fundamentals / mod 32
mod 32Elimination
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Factors Affecting Bowel Elimination
Physiological
Age · Diet · Fluid intake · Physical activity · Pregnancy · Surgery & anesthesia · Pain
Behavioral
Personal habits · Position during defecation · Psychological factors
Medical/Pharmacological
Medications · Diagnostic tests
⚠️ Narcotics/opioids slow gastric motility → ↑ constipation risk (high-yield exam point)
⚠️
Common Bowel Elimination Problems
Problem Description Key Causes / Notes
Constipation Dry, hard-to-pass stool; sensation of incomplete emptying Narcotics · Low fiber · Low fluid · Immobility → Tx: high-fiber diet
Paralytic Ileus Bowel obstruction from lack of intestinal activity Post-surgery · Anesthesia/meds · Electrolyte imbalance · Infection
Diarrhea Loose, watery stools Antibiotics (kill healthy GI flora) · Viral/bacterial infection · IBD · Crohn's · Ulcerative colitis
Flatulence Abdominal distension from gas Instruct patient to ambulate to help pass gas · Return-flow enema for post-op flatus
Hemorrhoids Swollen/inflamed rectal blood vessels → bloody stools, pain with defecation Causes: pregnancy, heart/liver failure · Tx: ointment, gentle wiping, sitz bath, ice pack
Incontinence Inability to control bowel movements Monitor skin integrity; keep area clean and dry
Diarrhea from antibiotics: Antibiotics eliminate healthy GI bacteria → allows harmful bacteria to grow → diarrhea. Risk factors for persistent diarrhea: frequent infections, large dairy intake, antibiotic use (e.g. cephalexin).
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Ostomy Types & Care

Types of Ostomies

  • Colostomy — colon diverted to abdominal wall; stool varies by location
  • Ileostomy — entire large intestine/rectum removed; small intestine to abdominal surface; can be reversed once colon heals
  • Types: end stoma · loop colostomy · double-barrel colostomy
  • Complications: hernia, electrolyte imbalance, blockage, prolapse, diarrhea, infection

Stoma Assessment — Know This!

  • ✅ Normal: moist, shiny, pink or reddish
  • 🚫 Abnormal: blue, purple, dull, dry, or black → report immediately
  • Red, swollen, tender peristomal skin → pouch may be too tight → need larger opening

Ostomy Care Procedure (Step-by-Step)

Step 1
Hand hygiene → gloves
Step 2 ⚡
Push skin AWAY from sticky area when removing pouch — prevents skin stripping
Step 3
Cleanse stoma and peristomal skin with mild soap/water first → dry completely (moisturizing soap interferes with adherence)
Step 4
Measure stoma → cut opening 0.15–0.3 cm (1/8 in) larger than stoma — if too big → leakage
Step 5
Apply skin barrier and pouch → press seal 30 sec–1 min for adhesion
Step 6 ⚡
Empty bag when ⅓–½ full — waiting until more than ½ full ↑ leakage risk (especially ileostomy — effluent irritates skin)

🍽️ Foods: Odor Control

  • ↑ Odor: Fish, garlic, beans
  • ↓ Odor: Buttermilk, cranberry juice, yogurt
  • Breath mint in pouch can help

🍽️ Foods: Gas Control

  • ↑ Gas: Beer, carbonated drinks, corn, dairy
  • ↓ Gas: Yogurt, crackers, toast
  • For loose stools (colostomy): low-fiber foods — rice, noodles, white bread, cheese
Colostomy irrigation = bowel training to prevent unplanned stool passage → allows client to go without a pouch. Ileostomy can allow colon time to heal and may be reversed.
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Enemas
Type How it works Key Notes
Tap water (hypotonic) Stimulates evacuation ⚠️ NEVER repeated — risk of water toxicity (fluid shift into interstitial spaces)
Soapsuds Irritant → promotes peristalsis; pure castile soap in tap water or NS Use cautiously: older adults & pregnant (↑ risk electrolyte imbalance & mucosa damage)
Normal saline ⭐ Volume stimulates peristalsis Safest — isotonic, equal osmotic pressure
Low-volume hypertonic Commercially prepared; draws fluid into colon ⚠️ Not for infants or dehydrated clients
Oil retention ⚡ Lubricates rectum/colon, softens stool Retain ≥ 30 minutes
Medicated Contains antibiotics or anthelmintics Retain 1–3 hours
Return-flow (flush) ⚡ Expels flatus, stimulates peristalsis Post-op abdominal distension/flatus

Enema Procedure — High-Yield Steps ⚡

Position ⚡
Left lateral (Sims) with right leg flexed forward — allows solution to flow by gravity into sigmoid/descending colon
Solution temp ⚡
Warm the solution — cold → abdominal cramping; too hot → mucosal injury
Insertion depth
Adults: 7.5–10 cm (3–4 in) · Children: 5–7.5 cm (2–3 in)
Bag height
Start at hip level → raise 30–45 cm (12–18 in) above anus
Cramping ⚡
Lower the container to slow flow if client reports cramping or fluid leaks
Lubricate
Always lubricate rectal tube/nozzle before insertion
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Diagnostic Procedures

Fecal Occult Blood Test (FOBT / Guaiac) ⚡

  • Used to detect blood in stool not visible to eye
  • Collect specimens from 3 different stools
  • Blue color on test card = positive for blood
  • Avoid for 72 hrs before test: red meat, citrus, Vitamin C, poultry, beets, raw vegetables (false positives)
  • Avoid NSAIDs for 7 days before testing

Stool Culture (parasites & ova)

  • Transfer stool with wooden tongue depressor to specimen container
  • Label container with client identifying info
  • Transport to lab in biohazard bag

NG Tube Placement ⚡

  • Initial placement verified by X-ray only (auscultation and pH NOT reliable for initial check)
  • First action: sit client upright before insertion
  • NG for decompression: post-op bowel obstruction
  • Coughing + SOB + crackles after NG = possible tube displacement or aspiration
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Exam High-Yield Summary
Enema position
Left lateral, right leg flexed (Sims position)
Safest enema
Normal saline — isotonic
Oil retention enema
Retain ≥ 30 min
Cramping during enema
Lower the container
Normal stoma
Moist, shiny, pink/red
Abnormal stoma
Blue, purple, dull, dry, or black → report!
Empty pouch when
⅓–½ full
Remove skin barrier
Push skin away from barrier (prevents stripping)
NG placement verify
X-ray only for initial verification
Constipation diet
High fiber diet
Narcotics → bowel
↑ constipation (slow gastric motility)
Antibiotics → bowel
Kill healthy GI flora → diarrhea
Return-flow enema
Post-op flatus/distension
FOBT: avoid for 72 hr
Red meat, citrus, Vit C, beets, raw veggies
Bladder irritants
Alcohol, acidic fruits, chocolate, soda, spicy foods
Urinary: UTI untreated
Can progress to pyelonephritis
Indwelling catheter: low output
Check for kinks first
Remove indwelling catheter
Deflate balloon completely first
Clean catch (female)
Wipe front to back
Vitamin K produced in
Large intestine
mod 35Hygiene
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Bathing

Purposes of Bathing

  • Cleanse the body, stimulate circulation, provide relaxation, enhance healing
  • Removes dirt, sweat, pathogens, dead skin
  • Opportunity for nurse to assess skin for redness or breakdown
  • Bed bath is less effective than shower — use only when no other option

Types of Baths

  • Complete bed bath — client cannot get out of bed
  • Partial bath — client cannot tolerate complete bath or can do part independently
  • Therapeutic bath — promotes comfort, soothes itchy skin
  • CHG (Chlorhexidine gluconate) bath — ICU/high-risk infection clients; does not touch face

Bed Bath Procedure — High-Yield ⚡

Prep ⚡
Raise room temperature before bathing — client loses heat when areas are exposed
Order ⚡
Face first → trunk/upper extremities → lower extremities → perineum (clean to dirty). Ask client to perform what they can.
Stroke direction
Long, firm strokes distal to proximal. Light strokes over lower extremities for clients with DVT history (clot can dislodge)
Eye care ⚡
Clean moist cloth, NO soap, wipe from inner to outer canthus
Privacy
Cover client with bath blanket; expose only the body part being washed; raise room temp; give client choices about bathing preference (older adults)
Delegation
Can delegate bathing to AP — nurse remains responsible for data collection and client care
Linen changes: Blanket/spread can be reused if not wet or soiled. Change linen when soiled. Diaphoresis (excessive sweating) → frequent linen changes needed → moisture causes skin breakdown.
Special populations: Older adults may resist bathing — determine reason, give choices (not abuse if client refuses, but nurse must address). Hemiplegia: dressing → use unaffected arm first, place on affected side. Undressing → remove unaffected side first.
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Oral Hygiene

Key Points ⚡

  • Decreases infection risk especially pneumonia in long-term care
  • Brush twice daily for 2 min, soft-bristled toothbrush
  • Use fluoride mouthwash to promote oral health
  • Poor oral hygiene → gingivitis (swollen, bleeding gums, metallic taste, yellow stain)
  • Clean the tongue with toothbrush or tongue scraper
  • NPO clients still need oral care — bacteria present regardless

Unconscious / High-Risk Clients ⚡

  • Suction apparatus at bedside to prevent aspiration
  • Do NOT place fingers in unconscious client's mouth (biting risk)
  • Position: side-lying, head turned toward nurse (semi-Fowler's or flat) — fluid drains out
  • Chlorhexidine (CHG) for unconscious clients — prevents microbial build-up
  • Check for aspiration risk, impaired swallowing, decreased gag reflex

Handwashing ⚡

  • Effective handwashing → decreases hospital infection rates
  • Soap and water REQUIRED when: hands visibly soiled, C. difficile, infectious diarrhea
  • Alcohol-based sanitizer: rub all surfaces for 15–20 seconds until dry
  • Clean least soiled areas first to reduce infection risk

Denture Care ⚡

  • Handle with care — very fragile
  • Remove upper denture: pull down and out; lower: up and out
  • Use denture cleaner NOT regular toothpaste (damages dentures)
  • Rinse in tepid/cool water (not hot — warps denture)
  • Store in cup with cool water to keep moist; label cup with client name
Gingivitis — Exam scenario: Swollen/bleeding gums, metallic taste, yellow stain, pain when brushing/eating → early periodontal disease. Caused by plaque and tartar build-up from poor oral hygiene.
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Foot & Nail Care

Standard Foot Care ⚡

  • Inspect feet daily — check between the toes
  • Use lukewarm water — dry feet thoroughly especially between toes (prevents fungal infection)
  • Apply moisturizer to feet — NOT between toes (moisture → infection)
  • Trim nails straight across, file edges — reduces ingrown toenail risk
  • Wear clean cotton socks daily; check shoes for rough seams
  • Do NOT self-treat corns/calluses; do NOT apply heat unless prescribed

Diabetes/PVD — CRITICAL ⚡

  • Podiatrist or qualified professional must perform foot/nail care for: diabetes mellitus, peripheral vascular disease, immunosuppression
  • Do NOT soak feet — risk of infection
  • Do NOT cut nails — file only
  • Do NOT apply lotion between toes
  • Risk factors for foot/nail injury: DM + peripheral neuropathy + pale skin + ↓ pedal pulses
  • Impaired sensation → cannot detect temperature → warm (not hot) water only

Nail Care

  • Observe size, shape, condition of nails and nail beds; check for cracking, clubbing, fungus
  • Cuticle forms a barrier to prevent infection — do not cut aggressively
  • Longer nails conceal more pathogens than shorter nails
  • Nail care: after bath or after soaking hands in warm soapy water for 10 min
  • Check facility policy before cutting nails — some require a provider prescription or podiatrist
  • Epidermis = squamous epithelial cells
  • Skin contains Langerhans cells that sense and kill pathogens
  • Enamel = first line of defense protecting teeth from pathogens (hardest substance in body)
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Perineal Care & Skin Integrity

Perineal Care Principles ⚡

  • Maintains skin integrity, relieves discomfort, prevents infection transmission (especially catheter care)
  • Cleanse front to back (perineum to rectum) — prevents UTI
  • Dry thoroughly
  • Female: cleanse labia → perineum to rectum with clean section of cloth each pass
  • Male uncircumcised: retract foreskin → clean meatus outward in circular motion → replace foreskin (prevents swelling/circulation issues)
  • Anus = most contaminated → cleanse last

Skin Integrity & Incontinence ⚡

  • Urinary incontinence → yeast infection (excessive moisture)
  • Incontinence → ↑ risk skin breakdown (hips, genitals, buttocks, perineum most affected)
  • Diaphoresis (moisture) → skin breakdown → frequent linen changes required
  • Skin = largest organ; first line of defense
  • Mucous membranes (nose, mouth, respiratory tract) → cilia trap particles preventing body invasion
  • Bariatric clients: deep skin folds → must assist with hygiene — hard to reach areas
Eye care: Clean moist cloth, NO soap, inner → outer canthus. Ear care: Rotate end of clean moist washcloth gently into ear canal. Drainage from ear = abnormal → possible ear infection.
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Hair Care & Shaving

Hair Care

  • Brush/comb daily — removes tangles, massages scalp, stimulates circulation, distributes natural oils
  • Soft-bristled brush; wide-toothed comb or pick for tightly curled hair
  • Consider cultural and personal preferences — ask client about their morning routine preference
  • Bed rest clients: dry/no-rinse shampoos or shampoo caps
  • Shampoo from hairline toward neck
  • Observe for: scalp pressure areas, dandruff, lice (notify provider immediately if lice found)

Shaving ⚡

  • Bleeding precautions → electric razor only
  • Soften skin with warm water first
  • Apply shaving cream or liquid soap; hold skin taut
  • Move in direction of hair growth; long strokes on face, short strokes on chin/lips
  • Ask about personal shaving preferences

Cultural Considerations

  • Discuss religious/cultural preferences before care
  • Many clients prefer nurse of same gender
  • Expose only necessary body parts, as briefly as possible
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Exam High-Yield Summary
Enamel
Protects teeth from pathogens — hardest substance in body
Older adults bathing ⚡
Give choices re: bathing preferences to encourage compliance
Handwashing ↓ infections
Effective handwashing decreases hospital infection rates
Oral hygiene — clean tongue
Use toothbrush or tongue scraper to clean tongue during oral care
Incontinence → yeast
Urinary incontinence → yeast infection from excessive moisture
Bariatric → assist
Assist bariatric clients with hygiene — cannot reach skin fold areas
Religious preferences
Discuss client's individual perspective on health/illness and hygiene
Epidermis
Consists of squamous epithelial cells
Soap + water REQUIRED
Visibly soiled hands · C. difficile · Infectious diarrhea
Cuticle
Forms barrier to prevent infection of underlying tissue
Dry between toes ⚡
Completely dry between toes — infections develop in moist areas
Langerhans cells
Found in skin — sense and kill pathogens
Nail trim direction
Trim nails straight across (prevents ingrown nails)
Glaucoma client
Educate client/caregivers about importance of routine dental visits
Fluoride + oral hygiene
Fluoride mouthwash · Brush 2×/day for 2 min · Soft bristle · Poor hygiene → gingivitis
Bed bath vs shower
Bed bath is less effective than shower — use only when necessary
Hemiplegia dressing ⚡
Dress: unaffected arm first → place on affected side. Undress: remove unaffected side first
NPO → oral care
Oral care still needed for NPO clients — bacteria present regardless of eating status
Raise room temp
Raise room temperature when giving a bath (client loses heat)
Chlorhexidine ⚡
Oral care for unconscious clients — prevents microbial build-up
Morning routine ⚡
Ask client about their preferred morning routine order before starting care
Clean least soiled first
Clean least soiled areas first to reduce infection spread (clean to dirty)
Reuse blanket/spread
Blanket and spread can be reused if not wet or soiled
Gingivitis ⚡
Early periodontal disease — swollen/bleeding gums, metallic taste, yellow stain from plaque/tartar
DM foot care ⚡
DM + peripheral neuropathy + pale skin + ↓ pedal pulses = risk for foot/nail injury
Mucous membranes / cilia
Cilia in nose trap particles, preventing them from invading the body
mod 37Pain
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Pain — The Basics
⚡ Pain is subjective. The client's self-report is the most reliable diagnostic indicator of pain. Always believe the client.

Key Definitions

  • Pain threshold — point at which a stimulus causes the client to perceive pain
  • Pain tolerance — how much of a stimulus the client is willing to accept
  • Nociceptors — sensory receptors for noxious stimuli; activated by tissue damage, extreme temps, chemicals
  • IASP definition — "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage"

⚡ Factors That Affect Pain Experience

  • Age & developmental stage
  • Fatigue & prior experiences with pain
  • Genetic sensitivity
  • Cognitive function
  • Anxiety & stress
  • Support systems & coping styles
  • Culture & religion
  • Disease severity
  • Language barriers
⚡ Biopsychosocial model: Pain is shaped by Biological (disease severity, inflammation), Psychological (mood, stress, catastrophizing), and Social (culture, support, SES) factors.
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Types of Pain

By Duration

  • Acute pain — sudden or slow onset; anticipated/predictable end; lasts <6 months. Examples: surgical incisions, trauma, burns.
  • Chronic pain — constant or recurring; lasts >6 months; no predictable end. Examples: arthritis, back pain, headaches. Can be physically and emotionally debilitating.
  • ⚡ If acute pain is not treated, it can become chronic.

By Origin

  • Nociceptive — felt in tissues, organs, or as referred pain. Usually localized, throbbing, or aching. Subtypes: somatic (skin/bones/muscles), visceral (internal organs).
  • Neuropathic — nerve pain from somatosensory system; no tissue damage. Described as intense, shooting, or burning; "pins and needles." Examples: diabetic neuropathy, phantom limb, spinal cord injury.
  • Cancer pain — newly recognized separate category; includes tumor pain, bone pain, radiation-induced pain, chemo-related neuropathies.
⚡ Nociceptive vs. Neuropathic: Medications that work for nociceptive pain are NOT effective for neuropathic pain — different treatment is needed.
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Pain Assessment

Subjective vs. Objective

  • Subjective — client's self-report: pain scale score, location, quality, timing, what precipitates/relieves it
  • Objective ⚡ — what the nurse observes: grimacing, guarding, restlessness, diaphoresis, crying
  • ⚡ Sweating (diaphoresis) = classic objective pain indicator
  • For nonverbal/cognitively impaired clients → observe behavior (guarding, grimacing, restlessness, behavioral changes)

⚡ PQRST Mnemonic

  • P — Precipitating cause: "What were you doing when it started?"
  • Q — Quality: "Describe what it feels like." (stabbing, burning, dull, throbbing)
  • R — Region/Location: "Can you point to where it hurts?" ⚡
  • S — Severity: "Rate it 0–10."
  • T — Timing: "When did it start? Is it constant or does it come and go?"

⚡ Special Population — Cognitively Impaired / Nonverbal Clients

Observe behavior ⚡
Guarding, grimacing, restlessness, agitation, behavioral changes
Objective signs ⚡
Grimacing, restlessness, increased diaphoresis
Use FLACC or NVPS
Select scale appropriate for cognitive ability — never assume no pain
Older adults ⚡
At risk for under-treatment. May under-report. Nurses must proactively assess.
⚡ Influencing factors: Client risk factors, medication trends (especially respiratory rate trending down = too much opioid), anxiety (can mimic pain — assess carefully), cultural/language differences.
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Pain Scales
Numeric Rating Scale (NRS) ⚡
0–10 scale. Most frequently used. Reliable for clients ≥8 years. 0=no pain, 1–3=mild, 4–6=moderate, 7–10=severe. Most used for cancer pain.
Wong-Baker FACES ⚡
For children ≥3 years. Client selects face. Three-in-one scale (faces + words + numbers). Client rates own pain only — not observer-rated.
FLACC Scale ⚡
For 2 months–7 years AND cognitively disabled adults. Observational. 5 categories scored 0–2: Face, Legs, Activity, Cry, Consolability. Total 0–10.
CRIES Scale
For neonates ≥38 weeks gestation. Crying, Requires O₂, Increased vital signs, Expression, Sleeplessness. Score >4 = further assessment. Score ≥6 = give analgesics.
Nonverbal Pain Scale (NVPS)
For clients who cannot verbalize pain — ICU, sedated, mechanically ventilated. Originally for burn units.
Visual Analog Scale (VAS)
Client marks a point on a line representing pain intensity. Useful when language barrier exists.
⚡ Choose the scale based on the client's age, cognitive ability, and communication capacity. Use cultural considerations when evaluating effectiveness.
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Non-Pharmacological Interventions

Cutaneous Stimulation ⚡

  • Heat therapy ⚡ — muscular pain, backache, menstrual discomfort. Apply max 20 min with at least 20-min break.
  • Cold therapy — decreases swelling (orthopedic injuries, sprains). Apply 20–30 min, check skin frequently.
  • TENS unit ⚡ — delivers low-voltage electrical impulses to skin. Adjustable intensity, pulse rate, duration. Client can be taught to use at home.
  • Massage — decreases pain scores; can use aromatherapy oils (check allergies first; sit up slowly after — orthostatic hypotension risk)
  • Acupuncture — sterile needles into skin; stimulates CNS. No contraindications generally. Must be performed by experienced acupuncturist.
  • Acupressure — similar to acupuncture without needles

Cognitive / Other Strategies

  • Cognitive Behavioral Therapy (CBT) — manages negative thoughts; includes distraction, relaxation, imagery, music therapy
  • Distraction ⚡ — TV, virtual reality; effective in children for IM injections
  • Music therapy — effective intraoperatively and postoperatively for reducing pain
  • Biofeedback ⚡ — measures skin tension using electrode sensors; teaches client techniques to control migraines and other pain
  • Therapeutic touch — nurse uses hands on or near body to balance energy; may help cancer/fibromyalgia
  • Positioning — reposition every 2 hrs; pad bony prominences (coccyx, sacrum, heels, scapula)
⚡ Mild pain (0–3): Ice packs + ibuprofen + distraction. Non-pharm can be used alone for chronic pain or combined with pharm for acute pain. After oral oxycodone — peak effect in 60–90 min; offer non-pharm while waiting.
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Pharmacological Interventions

Opioids ⚡

  • Most common pain medications; activate opioid receptors in brain/spinal cord/CNS
  • Natural: codeine, morphine. Semisynthetic: oxycodone, hydrocodone, hydromorphone, heroin. Synthetic: fentanyl, tramadol
  • Key adverse effects: sedation, respiratory depression, orthostatic hypotension, nausea/vomiting, constipation
  • ⚡ Monitor: respiratory rate, depth, HR, BP, oxygen saturation, capnography (CO₂)
  • ⚡ Highest risk: first 4 hrs post-op; monitor closely for 24 hrs
  • ⚡ Naloxone — opioid reversal agent for respiratory depression; have available at bedside

Non-Opioids & Adjuvants

  • NSAIDs (ibuprofen, aspirin, ketorolac) — most prescribed worldwide; effective for acute and chronic pain; reduce inflammation and fever. Contraindicated in surgery and labor.
  • Acetaminophen — nonopioid analgesic
  • Adjuvants — address underlying pain generators; used for mild pain, neuropathic pain, or to ↓ opioid dosage. Examples: corticosteroids (↑ glucose, fluid retention), antidepressants (nerve/migraine/arthritis pain — takes weeks to work), botulinum toxin
  • Gabapentin — anticonvulsant used for chronic pain; fewer side effects than carbamazepine
  • Sucrose — for infant pain during painful procedures

⚡ PCA Pump

  • Patient-controlled analgesia — client controls small bolus doses via button
  • Only RN programs and starts PCA pump; verifies settings
  • Monitor for OIVI: respiratory rate + capnography + pulse oximetry
  • Have naloxone at bedside

⚡ Range Orders

  • Start with the lowest dose when client is opioid-naïve or has never taken the medication
  • If first dose ineffective, increase incrementally up to maximum in range
  • Cannot split dose or give more frequently than prescribed — that is prescribing, outside scope of practice
  • Wait for medication to peak before reassessing and giving more
  • ⚡ Naloxone is NOT an analgesic — it is an opioid antagonist; giving it to an opioid-dependent client causes severe withdrawal
⚡ Nursing priorities: Administer pain meds before painful procedures. Use scheduled dosing for persistent pain + PRN for flare-ups. Advise clients to report pain early — before it peaks. Reassess after every intervention.
⚡
Exam High-Yield Hits
Pain is subjective ⚡
Client's self-report = most reliable diagnostic tool. Always believe the client.
FLACC used for ⚡
Children 2 months–7 years AND cognitively disabled. Face, Legs, Activity, Cry, Consolability — scored 0–2 each, total 0–10.
Heat therapy time ⚡
Max 20 minutes with at least 20-min break. Used for muscular pain, backache, menstrual pain.
Factors affecting pain ⚡
Stress, culture, social support, disease severity, age, fatigue, anxiety, prior experiences, language barriers
Cognitively impaired ⚡
Observe for grimacing, guarding, restlessness, diaphoresis. Cannot self-report — use behavioral observation.
TENS unit ⚡
Low-voltage electrical impulses to skin. Adjustable intensity/pulse rate/duration. Client can learn to use at home.
OIVI monitoring ⚡
Respiratory rate + capnography (CO₂) + pulse oximetry. First 4 hrs post-op = highest risk.
Naloxone ⚡
Reversal agent for opioid-induced respiratory depression. Keep at bedside for PCA clients. NOT an analgesic — causes withdrawal in opioid-dependent clients.
Range orders ⚡
Opioid-naïve = start lowest dose. Wait for peak before reassessing. Cannot change frequency — that's prescribing.
Negligence ⚡
Forgetting to assess and administer prescribed pain medication = negligence. Reasonable prudent person standard.
Objective pain signs ⚡
Diaphoresis (sweating) = objective. Grimacing, guarding, restlessness = objective. Pain scale score = subjective.
Autonomy example ⚡
Offering client choice of IM vs. oral medication = autonomy (right of self-determination).
Justice ⚡
All clients treated fairly for pain regardless of age, ethnicity, substance use history, or economics.
EOL barriers ⚡
Fear of addiction, belief pain is expected, inadequate assessment. Every client has RIGHT to effective pain management.
Neuropathic pain ⚡
Burning, shooting, intense. Diabetic neuropathy, phantom limb, spinal cord injury. Different meds than nociceptive pain.
PQRST — R ⚡
"R" = Region/Location. "Can you point to where you are having your pain?" Ask this to assess region.
Biofeedback ⚡
Uses electrode sensors to measure skin tension; teaches client techniques to relieve migraines/chronic pain.
Breakthrough pain ⚡
Control pain BEFORE it peaks. Advise clients to report pain as soon as they feel it — don't wait.
Older adults ⚡
Risk of under-treatment AND adverse effects from analgesics. Proactively assess — they may under-report.
Pain diary
Encourage client to track pain ratings before and after interventions to evaluate effectiveness over time.
Chronic pain >6 months
Constant or recurring. Arthritis, back pain, headaches. Managed — not cured. Anticonvulsants (gabapentin) often used.
Cutaneous stimulation ⚡
TENS unit, massage, acupuncture, cold therapy = all forms. Used for cutaneous/nonpharm pain relief.
Mild pain intervention ⚡
Pain rated 3/10 → ibuprofen + ice packs + distraction. Non-pharm first line for mild pain.
Oxycodone peak ⚡
Oral oxycodone peaks in 60–90 min. Offer non-pharm strategies while waiting — do not re-dose early.
Culture & pain ⚡
Culture affects reporting and perception. Language barriers → use FACES or VAS scales. Religious beliefs may affect response.
Respiratory depression risk ⚡
Highest in first 4 hrs post-op with IV opioids. Monitor RR, O₂ sat, capnography. Have naloxone ready.
mod 38End of Life Care
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Hospice Care
Hospice care = comfort, dignity, and support for clients with terminal illness when treatment will no longer cure or control the disease. Focus is quality of life, not prolonging it.

⚡ Admission Criteria

  • Life expectancy of 6 months or less
  • Both the hospice provider and primary care provider must officially state the client is terminally ill ⚡
  • Client must agree to palliative care (not curative treatment) ⚡
  • Client signs a statement choosing hospice in place of curative treatment ⚡
  • If client lives beyond 6 months → hospice provider must recertify
  • Client can stop hospice at any time (condition improves, remission)

⚡ Interdisciplinary Team (IDG)

  • Hospice care = interdisciplinary team effort ⚡ — providers, nurses, social workers, spiritual leaders
  • Holistic: physical, mental, social, and spiritual needs
  • Volunteers must account for 5% of total patient care hours
  • Volunteers: housekeeping, transport, childcare, sitting with client, reading, music
  • Nursing: medication administration, ADLs, education, emotional support
  • Respite care — brief break for caregivers; client admitted to facility for max 5 days
⚡ Nursing support in hospice: Assist with medication administration and ADLs · Educate family on what to expect as condition deteriorates · Provide emotional support · Bereavement support for up to 13 months after client's death.
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Palliative Care

What It Is

  • Holistic care for clients with severe medical illness — any age, any stage ⚡
  • Uses a holistic approach — treats whole person: physical and psychosocial ⚡
  • Improves quality of life, reduces hospital time, improves client satisfaction ⚡
  • Interprofessional team: providers, nurses, allied health
  • Examples: advanced cancer, heart failure, renal/respiratory failure, Alzheimer's, Parkinson's

⚡ Palliative vs. Hospice

  • Palliative care CAN be given while still receiving curative treatment ⚡
  • Palliative care has NO time constraints — can start at any stage ⚡
  • Hospice = curative treatment stopped; life expectancy ≤6 months
  • Any client with a life-limiting disease can receive palliative care regardless of prognosis

⚡ Pain: 3-Step Ladder

  • Step 1 — Mild pain: NSAIDs (nonopioids)
  • Step 2 — Moderate: codeine or tramadol
  • Step 3 — Severe: morphine
  • Combination of scheduled + PRN + non-pharm is recommended ⚡
🫁
Physiological Changes While Actively Dying
Cheyne-Stokes Respirations ⚡
Irregular breathing — rapid shallow breaths → deep breaths → apnea. Occurs within 3 days of death. Educate family it is expected. Intervention: fan blowing lightly toward client.
Death Rattle ⚡
Noisy respirations from secretion accumulation. Client cannot clear secretions themselves ⚡. Indication of approaching death ⚡. Interventions: turn head/body to side for drainage ⚡ · atropine drops or scopolamine patch to dry secretions ⚡ · moist washcloth / oral suction. Deep suctioning is ineffective.
Dyspnea ⚡
Shortness of breath. First-line Rx: opioids (morphine) — vasodilate, reduce breathing difficulty, decrease anxiety. Also: oxygen therapy, fan, positioning, relaxation, anxiolytics (benzodiazepines).
Mottling ⚡
Purple, pale, or grey marbling of skin ⚡ — starts in feet, moves up legs. Heart cannot pump blood effectively. Indication of impending death. Client feels no discomfort but may feel cold. Intervention: warm blankets.
Hallucinations ⚡
Seeing/hearing deceased family members or places. Do NOT contradict or reorient — causes distress. Clients can still hear even in coma — talk to them, provide reassurance. Priority: ensure client safety and prevent injury ⚡.
Temperature Changes
Nervous system loses ability to regulate temp. Causes: infection, cancer, opioids, anxiety, hypoxia. Management: cold/hot compresses, warm sponge baths, hypothermia blankets, fan, antipyretics (acetaminophen, ibuprofen, naproxen, aspirin).
⚡ Family education is key for ALL respiratory changes. Educate the family about expected changes — this is consistently tested. For noisy respirations: head/body to side, medications to dry secretions, cannot clear secretions themselves.
✝️
Spiritual, Cultural & Dignity Care

Spirituality ⚡

  • Spirituality = significance and purpose of life ⚡; relationship with others, nature, and higher power
  • Religion = specific beliefs/values shared within a community in worship of a higher power — NOT the same as spirituality
  • Spiritual care: ask if client desires spiritual care before offering it
  • In-depth spiritual counseling → refer to spiritual leaders/chaplain, not nurse
  • Benefits: improved quality of life, better coping, prevents depression/hopelessness
  • "Good death" — determine the client's own definition ⚡

Cultural Competence ⚡

  • In some cultures, talking about impending death is culturally insensitive ⚡ — understand culture before discussing prognosis
  • Language barrier → use health care facility's interpreter services ⚡ (NOT family members, NOT housekeeping, NOT apps unless employer-authorized)
  • Many cultures distrust opioids — educate on myths (opioids ≠ euthanasia, not addictive in dying context, can be increased)
  • Religion/culture affects pain management decisions and end-of-life preferences

Dignity & Social Isolation ⚡

  • Ask: "What can I do to help you feel more independent?" ⚡
  • Involve client in decision-making — preserves control and dignity
  • Social isolation → schedule visitors when pain and symptoms are controlled
  • Assist isolated clients: schedule family visits ⚡, online support groups, hospice volunteers
📋
Postmortem Care & Organ Donation

⚡ Postmortem Care

  • Physical care of body after death: washing, ID tags (min 2 locations: toe, arm, outside body bag), securing belongings
  • Nurse documents ⚡: date and time of death · name of anyone notified · location of belongings · where body is moved (e.g., funeral home)
  • Removal of invasive devices (IV, urinary catheter) — per facility policy
  • Provides nurse with opportunity for closure

⚡ Organ/Tissue Donation

  • Nurses providing direct care cannot initiate organ donation dialogue ⚡ — conflict of interest
  • When family/client voluntarily requests donation → nurse makes referral to Organ Procurement Organization (OPO) ⚡
  • OPC (coordinator) meets with client/family, answers questions
  • Nurse role: facilitate meeting, evaluate cultural/religious beliefs, allow time for family feelings, provide accurate information, use chaplain if needed
  • Donation is voluntary — donor must authorize before death or surrogate gives permission
🩺
Managing Nurse Grief & Self-Care

Grief Manifestations in Nurses

  • Physical: chest tightness, muscle discomfort, headaches, sleep disturbances, GI problems, palpitations
  • Psychological: anger, irritation, sadness, sleeplessness, exhaustion, difficulty concentrating, altered eating

⚡ Self-Care Strategies

  • Exercise program ⚡ (tested answer)
  • Eat well-balanced meals
  • Set boundaries, take time for oneself
  • Talk to experienced nurses / seek professional help
  • Attend the client's funeral (provides closure)
  • Journal feelings, discover a new hobby
  • Establish sleep routine (6–8 hours)
⚡
Exam High-Yield Hits
Hospice admission ⚡
Life expectancy ≤6 months. Both hospice provider AND PCP must certify terminal illness. Client agrees to palliative (not curative) care.
Hospice = IDT ⚡
Interdisciplinary team effort — providers, nurses, social workers, spiritual leaders. Holistic care.
Palliative = holistic ⚡
Uses a holistic approach. Improves quality of life. Can be given WITH curative treatment. No time constraints.
Palliative vs Hospice ⚡
Palliative: curative treatment still OK, any prognosis. Hospice: curative stopped, ≤6 months prognosis.
Death rattle ⚡
Client CANNOT clear secretions themselves. Turn head/body to side. Atropine drops or scopolamine patch. Indication of approaching death. Deep suction = ineffective.
Noisy respirations ⚡
Educate family about expected respiratory changes. Not a sign of distress in the client.
Cheyne-Stokes ⚡
Rapid breaths → deep breaths → apnea. Within 3 days of death. Expected and normal — educate family. Fan helps.
Mottling ⚡
Purple/grey marbling of skin. Starts in feet, moves up legs. Impending death sign. No client discomfort. Warm blankets.
Hallucinations ⚡
Do NOT contradict or reorient. Ensure client safety and prevent injury. Client can still hear in coma — talk to them.
Good death ⚡
Determine the CLIENT's own definition of a "good death." Do not impose nurse's definition.
Culture & death ⚡
Some cultures: talking about impending death is culturally insensitive. Understand culture before discussing prognosis.
Language barrier ⚡
Use facility's official interpreter services. NOT family members, NOT housekeeping, NOT unauthorized apps.
Organ donation ⚡
Nurse CANNOT initiate donation dialogue (conflict of interest). Family requests → refer to OPO (organ procurement organization).
Postmortem documentation ⚡
Document: date/time of death · who was notified · where body is moved · belongings accounted for.
Dignified care ⚡
"What can I do to help you feel more independent?" Involve client in decisions. Ask about their preferences.
Social isolation ⚡
Assist in scheduling family/friends to visit. Schedule when symptoms/pain are controlled for best interaction.
Spirituality ⚡
Focuses on significance and purpose of life. Ask if client DESIRES spiritual care before offering. Chaplain for in-depth counseling.
Nurse grief ⚡
Participate in exercise program. Talk to experienced nurses. Attend funeral. Journal. Sleep routine. Set boundaries.
Respite care
Brief caregiver break. Client admitted to facility max 5 days. Provides rest for caregivers.
Pain in EOL ⚡
Combination of approaches recommended: scheduled + PRN + non-pharm. 3-step ladder: NSAIDs → codeine/tramadol → morphine.
Dyspnea Rx
First choice: opioids (morphine). Also: O₂, fan, positioning, benzodiazepines for anxiety. Comfort focus.
Bereavement support
Hospice provides support for up to 13 months after client's death for family/caregivers.
Nurse cannot initiate
Nurse CANNOT start organ donation conversation. Must wait for family to voluntarily bring it up, then refer to OPO.
Postmortem ID tags
Minimum 2 locations: toe, arm, outside of body bag.
Volunteers 5%
CMS requires hospice volunteers account for 5% of total patient care hours provided by paid staff.
mod 30Comfort, Rest, and Sleep
🌙
Sleep Physiology & Stages
Two mechanisms regulate sleep: Circadian Rhythm — internal 24-hr clock synced to light/dark via the SCN in the hypothalamus  ·  Sleep–Wake Homeostasis — pressure to sleep increases the longer you are awake.

🎯 High-Yield Brain Structures

Hypothalamus / SCN
Controls circadian rhythm via light exposure. Damaged SCN → erratic sleep.
Pineal Gland
Produces melatonin — the sleep hormone. First-line Rx for all ages.
Thalamus
Relays senses to cortex. Transmits images/sounds during REM → dreams.
Brainstem (Pons)
Sends signals for REM. Relaxes muscles so you don't act out dreams.

🎯 Sleep Stages — Most-Tested

Stage Type % of Sleep Key Facts
Wake NREM — Alpha (8–12 Hz) & Beta (12–30 Hz) waves. Eyes closed, relaxed.
Stage 1 NREM ~5% Lightest sleep. Easily awakened. Lasts 1–5 min. Muscle twitching possible.
Stage 2 NREM ~50% Sleep spindles & K-complexes. HR & temp decrease. Older adults spend MORE time here → frequent waking.
Stage 3 ⭐ NREM ~15% Deepest sleep. Delta waves. Immune system strengthens. Muscles/tissues/bones repair. Awakening → mental cloudiness 30–60 min. Lowest pulse & RR.
REM ⭐ REM 20–25% Dreaming stage. Beta waves (looks awake on EEG). Muscles atonic (can't act out dreams). Irregular breathing, elevated HR. Begins ~90 min after sleep onset. Older adults have fewer REM cycles.
Older Adults: ↑ Stage 2 (lighter sleep → frequent waking) · ↓ Stage 3 · ↓ REM · Takes longer to fall asleep.

⚠️ Sleep Deprivation Effects

Impaired judgment & ↓ response time
Triggers migraines, seizures
↑ Risk: depression, stroke, obesity
Poorly controlled blood sugars (T2DM)
Shift workers: ↑ DM, obesity, CVD
Smartphone use at night → depression
Sleep & Weight: Sleep ↑ leptin (reduces hunger) & ↓ ghrelin (hunger hormone). Sleep also ↓ cortisol → better insulin sensitivity → prevents T2DM.
⚠️
Sleep Disorders
Insomnia
Ongoing inability to sleep despite opportunity. Difficulty falling/staying asleep or early waking. Associated with heart disease, hypertension, arthritis. Tx: CBT, medications, lifestyle changes.
OSA ⭐
Obstructive Sleep Apnea — recurrent upper airway collapse during sleep. Risk factors: obesity, inactive tongue, enlarged tonsils. Dx: polysomnography. Tx: CPAP (first-line). Symptoms: snoring, daytime sleepiness, fatigue.
CSA ⭐
Central Sleep Apnea — brain fails to send signals to respiratory muscles → breathing stops. Causes: opioid overdose & heart failure. (CSA ≠ OSA — no airway obstruction.)
Narcolepsy ⭐
Sudden uncontrollable sleepiness. NT1 = with cataplexy (brief involuntary muscle tone loss triggered by emotion/laughter) + lacks hypocretin (alertness hormone from hypothalamus). NT2 = without cataplexy. Both: nocturnal hallucinations, sleep paralysis, vivid dreams.
Hypersomnia ⭐
Excessive daytime fatigue that does NOT improve with more sleep (key differentiator). Not from disturbed circadian rhythm. Sx: poor memory, depression, short attention span, irritability.
RLS
Uncontrollable urge to move legs. Worsens at rest/bedtime. Also called Willis-Ekbom disease. Can occur with iron/vitamin deficiencies. Avoid caffeine, nicotine, alcohol.
Night Terrors
Occur during NREM (first ⅓ of night). No dream recall. Mostly in children. Don't wake the child — gently return to bed. Differs from nightmares (REM, dream recalled, second half of night).
OSA Dx = Polysomnography — records HR, BP, breathing, O₂ sat, brain waves, body movements, snoring. Done in a sleep lab. (Not ECG, not EEG alone.)
💊
Nursing Interventions for Sleep

💊 Pharmacologic — Know Adverse Effects

Class Examples Key Adverse Effects / Notes
Nonbenzodiazepine hypnotics ⭐ Zolpidem, Zaleplon, Eszopiclone (z-drugs) Most commonly prescribed. Monitor for hallucinations, gastric discomfort, memory loss. Abuse potential.
Benzodiazepines (GABA agonists) Alprazolam, Clonazepam, Lorazepam Retrograde amnesia, drowsiness, muscle relaxation. Use cautiously in older adults (↓ liver/kidney). NOT for long-term use — physical dependence.
Melatonin ⭐ Controlled-release melatonin First-line for older adults & all ages. Non-habit forming, cost-effective, few adverse effects.
OTC (Antihistamines) Doxylamine, Diphenhydramine Urinary retention, dry mouth, daytime drowsiness, visual disturbances, constipation.

🌿 Nonpharmacologic Interventions

Dim lights at bedtime ⭐
Acupuncture & thermotherapy ⭐
Massage (caution: anticoagulants, open wounds)
Guided imagery, meditation, music therapy
Yoga — reduces stress & pain
Sleep diary — identify patterns

🏥 Hospital Sleep Promotion (Sensory Overload Prevention)

Dim lights at night
Lower alarm volumes
Offer blindfolds & earplugs
Cluster/combine care tasks
Organize quiet time
Control pain & monitor meds
Sleep Hygiene Rules (Exam staples): Avoid caffeine/alcohol/nicotine 4–6 hrs before bed · Keep naps <30 min · Go to another room if not asleep in ~20 min (read/soft music) · Exercise ≥3 hrs before bed · Cool, dark, quiet room · Consistent sleep–wake time.
🤝
Promoting Comfort
Comfort = Easing physical, mental, and emotional distress using warmth, empathy, and compassion. A comforted client feels safe, accepted, valued, and stronger.

🎯 Nursing Actions to Promote Comfort

Encourage verbalization of needs/concerns ⭐
Answer questions honestly ⭐
Include client concerns in plan of care
Respect cultural & spiritual beliefs
Be present — active listening
Allow informed choices — client feels in control
Client is comforted when they say: "My health care team has helped me feel safe during my stay." — feeling safe, accepted, and valued = comfort achieved. PN Nursing Process: Data collection → Planning → Implementation → Evaluation.
⚡
Exam High-Yield Summary
Stage 3 sleep
Deepest — immune repair, delta waves, mental cloudiness if awakened
REM sleep
Dreaming, muscle atonia, beta waves, begins ~90 min after sleep onset
Older adults
↑ Stage 2, ↓ Stage 3, ↓ REM → melatonin first-line
Hypersomnia key
Fatigue does NOT improve with more sleep
Narcolepsy NT1
Cataplexy + no hypocretin; NT2 = no cataplexy
OSA dx
Recurrent airway collapse → polysomnography; Tx = CPAP
CSA causes
Opioids or heart failure (brain fails to signal muscles)
Night terrors
NREM, no recall, first ⅓ of night — do NOT wake child
Z-drugs adverse effect
Hallucinations; benzos → retrograde amnesia; OTC → urinary retention
Melatonin
First-line for older adults — non-habit forming
Sleep hormones
Sleep ↑ leptin, ↓ ghrelin, ↓ cortisol → prevents T2DM
Hospital sleep
Dim lights, earplugs, cluster care, lower alarms
RLS
Crawling sensation in legs, worsens at rest, improves with movement (Willis-Ekbom)
Sleep deprivation
Triggers migraines, seizures, ↑ depression, stroke, poorly controlled blood glucose
Shift work risks
↑ T2DM, cardiovascular disease, depression; immune function weakened
Stage 2 sleep
~50% of sleep; sleep spindles & K-complexes; older adults spend more time here
Comfort definition
Easing physical, mental, emotional distress — client feels safe, accepted, valued
mod 39The Surgical Client
📋
Preoperative Phase
Pre-op begins when client decides to have surgery → ends when transferred to surgical suite. Goals: establish baseline, identify risk factors, obtain consent, educate client.

🎯 Health History — What to Collect

Allergies
Apply allergy band. Report to team.
Medications
All Rx, OTC, herbals. Anticoagulants may need to stop.
Tobacco/Alcohol
↑ risk: blood clots, MI, bleeding, infection, longer stay.
Spiritual/Cultural
Document preferences. Affects consent and care.
Malignant Hyperthermia Hx
Family hx → notify intraop team. Life-threatening rxn to anesthesia meds.
Surgical Hx
Prior anesthesia response, complications.

⚖️ Risk Factors for Surgical Complications

Risk Factor Why It Matters
Type 1 & 2 DMPoor wound healing, infection risk
Smoking↑ blood clots, slower healing, ↑ infection
CorticosteroidsImpair wound healing, ↑ dehiscence risk
Age ≥65↑ delirium, POCD, comorbidities
Obesity (BMI >30)DVT/PE risk, difficult intubation, ↓ O₂
Anticholinergics + Dementia↑ postoperative delirium

📝 Informed Consent — Roles

Provider's Role
Explains procedure, risks, benefits, alternatives. Obtains consent. If client has questions → contact the doctor.
Nurse's Role ⭐
Verify signature · Confirm legal age · Confirm competence. Witness only — does not obtain consent.

✅ Who CAN Sign · ✗ Who CANNOT

✓ Alert & oriented adults
✓ Emancipated minors (married or pregnant by choice)
✓ History of mental illness does NOT prevent consent
✓ Implied consent — doctor only, unconscious emergency, no family/contact available
✗ Sedated or medicated clients
✗ Unconscious (unless implied consent applies)
✗ Non-emancipated minors
✗ Client can change their mind at any point
Pregnancy Testing Pre-Op: Required if LMP > 3–4 weeks ago or client requests it. Refusal is allowed — document it. Also document: allergies including latex and environmental allergens.
Pre-Op Teaching reduces hospital stay length. Topics: NPO timing, skin prep, med cessation, what to expect post-op, incentive spirometry, coughing/deep breathing, splinting, early ambulation.
🔪
Intraoperative Phase

🎯 Surgical Team Roles

Circulating Nurse
Coordinates care before/during/after procedure. Verifies ID, checks consent, allergy check, initiates time-out, maintains sterility for sterile team, documents care.
CST — Certified Surgical Technologist ⭐
Ensures instruments are sterile and ready. Hands tools to surgeon. Counts sponges, instruments, sharps. AKA "scrub tech."
Anesthesiologist / CRNA
Administers anesthesia, monitors cardiovascular and respiratory function throughout.

⏱️ Time-Out ⭐

Performed several times: before starting · before each additional procedure · at completion. Purpose: correct client, correct site, correct procedure. Initiated by circulating nurse.

💉 Anesthesia Types

Type What It Does Examples
LocalSmall area, client awakeLidocaine, benzocaine
Regional ⭐Temp loss of feeling in one area, client awake or sedated. Arm, leg, abd sx.Spinal/epidural block
GeneralCNS depressed, unconscious. CV and respiratory monitoring required.—
Moderate SedationDrowsy, pain-free, arousable, follows commands. No breathing support needed.Diazepam, lorazepam, midazolam

🧼 Skin Prep Sequence ⭐

1 Circular scrub, center first
2 Move outward from center
3 Discard sponge at outer edge
4 Repeat with new sponge
5 Drape the client

🔥 Malignant Hyperthermia ⭐

Life-threatening reaction to anesthesia. Triggered by: succinylcholine and volatile anesthetics (sevoflurane).
Early signs: muscle rigidity, jaw rigidity, tachycardia, tachypnea, ↑CO₂
Late signs: high fever, acidosis, hyperkalemia, dysrhythmias
Treatment: Stop triggering agent → Dantrolene → cooling measures → O₂ → correct acidosis
🛏️
Postoperative Phase
PACU Priority = ABCs. Monitor: O₂ sat (priority), airway, vitals, LOC, wound, pain, I&O.

✅ Post-Op Nursing Interventions

Incentive spirometry — 10×/hr, hold 3–5 sec. Prevents atelectasis.
Cough & deep breathe q2h. Splint incision with pillow.
Early ambulation — prevents atelectasis, PNA, DVT.
Reposition q1h — prevents clots, muscle weakness, lung infection.
SCDs while in bed — VTE prevention.
Sit upright to eat — prevents aspiration.

💊 Pain Management

Multimodal Approach
Combines opioids, NSAIDs, nonpharm methods to minimize opioid doses and side effects.
PCA Pump
Client self-administers IV pain med via button. Includes constant flow and/or PRN dosing.
Include client preferences ⭐
Ask what works. Review past analgesic responses. Include nonpharmacological options.
Nonpharm
Music therapy, distraction, breathing, heat/cold, repositioning.

💧 Fluid Imbalances

Hypovolemia
Causes: blood loss, NPO, anesthesia
Signs: hypotension, tachycardia, oliguria
Hypervolemia ⭐
Causes: CHF, renal failure, excess IV fluids
Signs: crackles, edema, hypertension
⚠️
Post-Op Complications
DVT / PE ⭐
DVT: clot in deep vein (extremities) → pain, redness, swelling, warmth. PE: clot travels to lungs → sudden chest pain + SOB + tachycardia. Prevention: SCDs, early ambulation, LMWH/warfarin.
Atelectasis
Collapsed alveoli from anesthesia (↓ surfactant). ↑ risk: smokers, COPD. Tx: incentive spirometry, coughing, early ambulation, supplemental O₂.
Ileus ⭐
Temporary cessation of peristalsis after abdominal surgery. Absent/minimal bowel sounds + nausea/discomfort. Tx: NPO + NG tube + IV fluids.
Dehiscence / Evisceration
Dehiscence = wound edges separate. Causes: infection, corticosteroids, injury. Evisceration = organs protrude through wound → EMERGENCY. Cover with sterile saline-moistened dressing, call provider immediately.
Wound Infection (SSI)
Redness · warmth · pain · fever · purulent/foul drainage · wound widening. Caused by: Staph, Strep, Pseudomonas. Tx: wound culture, antibiotics, debridement.
Aspiration / Pneumonia ⭐
Food/liquid enters airway → pneumonia. Risk: dysphagia, Parkinson's, stroke, dental problems. Prevention: sit upright to eat, stay upright 1 hr after, small bites, eat slowly.
Post-Op Delirium / POCD ⭐
Delirium: temporary confusion, older adults. ↑ risk: anticholinergics, benzodiazepines, opioids, dementia. Prevent: CGA, effective pain mgmt, avoid benzo + opioids. POCD: permanent long-term memory loss — Alzheimer's, stroke, Parkinson's hx.
Hypovolemia / Bleeding
Signs: hypotension, tachycardia, tachypnea, confusion, oliguria, ↓ cap refill. Monitor vitals closely. Tx: fluids, blood products.
⚡
Exam High-Yield Summary
Post-op priority
O₂ saturation — ABCs first
Bleeding sign
BP 88/60 = possible hemorrhage
PE post-op
Sudden chest pain + SOB = emergency
Poor wound healing
DM, smoking, steroids, age ≥65
VTE prevention
SCDs while in bed; tobacco → ↑ clot risk
Ileus
Absent bowel sounds + nausea → NPO + NG tube + IV fluids
Nurse consent role
Witness only — verify signature, age, competence
Time-out
Performed several times by circulating nurse
CST role
Ensures instruments sterile and ready
Malignant hyperthermia
Triggered by succinylcholine/sevoflurane → dantrolene
Evisceration
Sterile saline dressing — never push organs back
Urinary retention
No void 8 hr post-op → straight catheter
Reposition post-op
Every 1 hour — prevents clots, atelectasis
Aspiration → PNA
Sit upright to eat; risk: Parkinson's disease
Who can consent
Alert adults, emancipated minors (married/pregnant by choice); mental illness history ≠ prevents consent
Implied consent
Doctor only — unconscious emergency, no family/contact available
Pregnancy testing
Required if LMP >3–4 weeks; refusal allowed — document it
Latex allergy
Document with all allergies; use latex-free equipment perioperatively
Discharge priority
Meds that cause dizziness = greatest fall risk at discharge
Anticholinergics + dementia
↑ risk of postoperative delirium
Pre-op teaching
Reduces length of hospital stay and costs
Skin prep sequence
Circular, center outward, discard sponge at outer edge, new sponge each pass
Hypervolemia signs
CHF/renal failure/excess IV fluids → crackles, edema, hypertension
POCD
Long-term cognitive decline post-op — Alzheimer's, stroke, Parkinson's hx
mod 40Tissue Integrity
🧬
Skin Anatomy & Function
Layer What's in it Key Function
EpidermisKeratinocytes, melanocytes, Merkel cells, Langerhans cellsOuter barrier — protects from water loss, pathogens, UV
Dermis ⭐Collagen, elastin, fibroblasts, blood vessels, lymphaticsBlood vessels nourish the epidermis. Fibroblasts promote healing. Strength & elasticity.
SubcutaneousAdipose tissue, blood vessels, nervesInsulation, shock absorption, thermoregulation, sensation

🔬 Key Cells — Know These

Keratinocytes
Protect skin from water loss, pathogens, injury
Melanocytes
Produce melanin — skin color + UV protection
Merkel Cells
Detect light touch (palms, soles)
Langerhans Cells
Immune response in epidermis
Older Adults: ↓ collagen → thinner skin, less elasticity → ↑ skin tears & pressure injury risk. Less subcutaneous padding over bony prominences.
⚠️
Pressure Injuries
Caused by prolonged pressure + shearing over bony prominences. Shearing = layers slide opposite directions (e.g., high-Fowler's). Most common sites: heels, sacrum, hips, elbows, back of head.

🎯 Staging — Most Tested

Stage Tissue Key Feature
Stage 1Skin intactNon-blanchable erythema. Dressing: film or barrier cream.
Stage 2Partial-thicknessPink/red wound bed or ruptured serum blister. NO slough present. No deeper tissue visible.
Stage 3 ⭐Full-thicknessVisible adipose. Granulation tissue present. No bone/tendon/muscle. May have slough/tunneling.
Stage 4 ⭐Full-thicknessBone, tendon, muscle, or cartilage visible. Undermining/tunneling present.
UnstageableObscuredCovered by slough or eschar. Once removed = reveals Stage 3 or 4.
DTPIDeep tissueNon-blanchable deep red / maroon / purple. Skin may be intact.

📊 Braden Scale

6 Categories
Sensory perception · Moisture · Activity · Mobility · Nutrition · Friction & Shear
Score Interpretation ⭐
Range: 6–23. Lower = greater risk. Score 9 = highest risk of any listed.

🛡️ Prevention Interventions

Reposition — tilt 30° on side
HOB <30° — reduce sacral shear
Flex knees + pillows to prevent sliding
Wheelchair: shift weight at intervals ⭐
Pressure-relieving mattress
↑ Protein intake for wound healing
🩹
Wound Dressings — Match to Wound
Dressing Used For Key Note ⭐
Film (Transparent)Stage 1, superficial, minimal exudateVisualize wound without removal. NOT for wounds with significant exudate.
HydrocolloidSmall abrasions, Stage 2, post-opPromotes granulation. Do NOT use with infection, tunneling, undermining.
Alginate ⭐Moderate–high exudateRequires secondary dressing. Made from seaweed. High absorbency.
FoamMild–moderate exudateSilicone foam on sacrum within 24 hr of admission prevents HAPIs.
Hydrogel ⭐Dry wounds, necrosis/eschar, suspected infectionContains water — adds moisture to dry wounds. Soothing, minimal trauma.
HydrofiberModerate–high exudateLess maceration than alginate. Needs secondary dressing.
Barrier CreamStage 1, incontinence-prone skinProtects from moisture/pressure/shear.
Rule: Moist (not wet) wound bed = optimal healing. Dressings should absorb excess moisture while maintaining adequate moisture. Films → minimal exudate · Alginate/Hydrofiber → high exudate.
🔬
Wound Care, Healing & Drainage

💧 Drainage Types

Serous — clear, watery
Serosanguineous — thin, pink/light red
Sanguineous — bloody
Purulent — green/yellow = infection ⭐

🔄 Wound Healing Types

Primary (1st intention)
Clean wound sutured closed. Fastest. Minimal scarring.
Secondary (2nd intention) ⭐
Wound left open. Granulation tissue forms from wound bed upward. Prolonged healing. High infection risk. Moist wound bed required.
Tertiary / Delayed Primary (3rd intention)
Left open 5–10 days then sutured. Decreases infection risk in contaminated wounds.

⏱️ Phases of Wound Healing ⭐

1. Inflammatory / Hemostasis
Clotting occurs, swelling, defense response activated. Begins immediately after injury.
2. Proliferative
Collagen forms, granulation tissue develops, wound contracts and edges pull together.
3. Remodeling
Scar strengthens over months — but remains weaker than original skin.

🔬 TIME Wound Assessment

T = Tissue — color, necrosis
I = Infection/Inflammation — redness, warmth, drainage
M = Moisture — dry/wet/maceration
E = Edge — describe wound edges

🧠 DIDN'T HEAL — Delayed Healing Factors

Diabetes
Infection
Drugs (steroids)
Nutrition problems
Tissue necrosis
Hypoxia
Extensive tension
Another wound
Low temperature

⚠️ Wound Complications

Infection
Redness, warmth, purulent drainage, fever
Dehiscence
Wound edges separate — reposition to reduce tension
Evisceration ⭐
Organs protrude — emergency. Cover with sterile saline dressing, never push back.
Hematoma
Blood collects under wound — swelling, discoloration
Seroma
Serous fluid collects — clear/yellow pocket under wound
Fistula
Abnormal passage between two organs or to skin surface

🚰 Wound Drains

Penrose Drain
Passive, open, uses gravity. No collection chamber — drainage onto gauze.
Bulb Suction (JP) ⭐
Active, closed, negative pressure. Empty when ¾ full or q8h. Compress to reestablish suction.
Wound Culture: Clean wound with 0.9% sodium chloride first → then swab wound bed (not edges) → rotate swab → place in culture tube. Cleaning removes normal flora so culture is accurate.
⚡
Exam High-Yield Summary
Highest skin risk
Incontinent + diuretic
Braden scale
Lower = greater risk; score 9 = highest risk
Stage 2
Partial-thickness, NO slough, pink/red or blister
Stage 3 document
Full-thickness, visible adipose, no bone/tendon
Unstageable
Covered by slough or eschar — depth unknown
Alginate dressing
High exudate — requires secondary dressing
Hydrogel dressing
Dry wounds, necrosis, suspected infection
Wound culture
Clean with 0.9% NaCl first, then swab bed
Purulent drainage
Green/yellow = infection
Nutrition
Increase protein for wound healing
High-Fowler's risk
↑ shear on sacrum — keep HOB <30°
Bulb drain
Empty when ¾ full
Dermis function
Contains blood vessels that nourish epidermis
Remodeling phase
Scar strengthens but remains weaker than original skin
Stage 4
Full-thickness; bone, tendon, muscle, or cartilage visible
DTPI
Non-blanchable deep red/maroon/purple; skin may be intact
TIME mnemonic
Tissue · Infection · Moisture · Edge
DIDN'T HEAL
Diabetes · Infection · Drugs · Nutrition · Tissue necrosis · Hypoxia · Extensive tension · Another wound · Low temp
Wound healing phases
1 Inflammatory → 2 Proliferative (collagen/granulation) → 3 Remodeling (weaker than original)
Dehiscence vs evisceration
Dehiscence = edges separate; Evisceration = organs protrude (emergency)
Hematoma / Seroma / Fistula
Blood collects / serous fluid collects / abnormal passage between organs
Slough vs eschar
Slough = yellow/tan stringy; Eschar = black/hard → both = unstageable
Staple removal
Approximately 2 weeks (10–14 days)
7-day incision
Expect bright pink, absent exudate — normal
Sepsis sign
Post-op ↑ blood glucose = potential sepsis
Corticosteroids
Delay wound healing — prevent collagen and fibroblast formation
Infant diarrhea
Monitor for dermatitis (MASD)
Skin thermoregulation
Most tested skin function = temperature regulation
Pulsating lavage
Stage 4 mechanical debridement — dislodges exudate and necrotic tissue
mod 6Communication
📡
Communication Models
Model Components Key Points
Shannon-Weaver ⚡
(1948)		 Sender · Encoder · Channel · Decoder · Receiver · Noise Linear, one-way model. Noise = any environmental distractor. Exam tip: nurse as sender → correct answer is "sender"
Schramm ⚡
(1954)		 Sender · Receiver · Message Feedback is the key component — cyclical, back-and-forth. If no feedback → communication incomplete. Client saying "thank you, now I understand" = feedback
Newcomb's ABX
(Social model)		 A (sender) · B (receiver) · X (topic/subject) Social standpoint; X can be a person, object, or topic that affects the A–B relationship
Berlo's S-M-C-R Sender · Message · Channel · Receiver One-way, no feedback loop. Example: instructional client video
💬
Forms & Modes of Communication

5 Forms of Communication

  • Verbal — what is said (spoken word)
  • Nonverbal — body language, facial expressions, eye contact, posture (often more powerful than verbal)
  • Auditory — what the receiver hears; affected by tone, speed, disabilities, noise
  • Emotional — speaker's emotional state; empathy builds trust
  • Energetic — how the person projects themselves; caring presence matters

4 Modes of Communication

  • Verbal — face-to-face or phone; preferred by baby boomers
  • Nonverbal — eye contact, posture, appearance; can support or contradict verbal message
  • Electronic — email, text, video; must follow HIPAA security (secure messaging, auto-logoff, personal logins)
  • Written — letters, printed instructions; lacks nonverbal cues; affected by literacy & vision
⚠️ HIPAA & Electronic Communication: Cannot send discharge instructions via email unless secured. PHI sent electronically requires: personalized login, auto-logoff, and encrypted attachments. Use secure messaging only.
🗣️
Communication Styles
Passive
Avoids conflict
Agrees even when they don't want to. "I'll do whatever you want." Fearful of being wrong. Common in novice nurses.
Assertive ⭐ Best
Most effective
Clear, honest, uses "I" statements. Advocates for rights without violating others'. Confident and fair. Goal communication style.
Aggressive
Hostile
Blames with "you" statements. Interrupts, controlling. "It's your fault the client fell."
Passive-Aggressive ⚡
Indirect anger
Appears passive but acts out indirectly. Sarcasm, ignoring, not following through. E.g., charge nurse who says "take your time" then complains about lateness to staff.
🚧
Factors & Barriers to Communication

Types of Factors ⚡

  • Psychosocial — anxiety, fear, stress, emotional distress (e.g., worrying about dialysis while working 2 jobs)
  • Situational — fatigue, emergencies, new diagnosis, financial concerns
  • Cultural/Demographic — language, religion, age, gender, sexual orientation; false cultural assumptions → poor outcomes
  • Developmental/Cognitive — dementia, ASD, Down syndrome; use short, clear, directive instructions; avoid slang & medical jargon
  • Physiological — hearing loss, vision impairment, pain, disease (Parkinson's, MS)
  • Environmental — noise, poor lighting, temperature extremes, distractions (TV, phone)

Strategies to Overcome ⚡

  • Hearing impairment: move to quiet area, face the client, speak at slower pace, use visual cues, write key info, use ASL interpreter (Language Line)
  • Vision impairment: ensure glasses are on during teaching; ensure room is well lit
  • Language barrier: use facility's certified interpreter — never rely on family for medical interpretation
  • Dementia/altered LOC: speak clearly, slow pace, simple instructions
  • Pain/cannot communicate: use alternative pain assessment tool
  • Loud environment: lower TV volume or move client to quieter area before attempting communication
⚠️ Cultural factor influences client requests (e.g., last rites before death). Psychosocial + situational factors can co-exist in the same client (e.g., dialysis client avoiding eye contact, worried about job & family).
🩺
Therapeutic Communication
Jean Watson's Theory of Human Caring: Authentic presence · Protecting human dignity · Loving-kindness. Cornerstone = compassion, caring, empathy.

Peplau's 4 Phases of Nurse-Client Relationship ⚡

1. Orientation
Client seeks help from nurse/provider. Initial meeting.
2. Identification
Mutually respectful relationship established.
3. Exploitation ⚡
Active phase — nurse educates client (e.g., teaching heart-healthy activities, wound care)
4. Resolution/Termination
Issue resolved; relationship ends until next encounter.

Therapeutic Techniques ⚡

Technique What It Is Example
Active Listening Attending to both verbal & nonverbal cues; nod, make eye contact, minimize distractions "I see." + nodding + open posture
Open-Ended Questions Requires more than yes/no; encourages disclosure "Tell me more about that." / "What is on your mind?"
Restating ⚡ Repeats client's message back to verify understanding "You don't want the biopsy because you wouldn't seek treatment. Is that correct?"
Reflection Mirrors feelings behind the message; used when client asks for advice "What do you think you should do?"
Summarizing / Paraphrasing Recaps conversation to confirm understanding "You started feeling this way a few days ago and have had no relief. Does that sound correct?"
Silence Allows time for reflection; lets client lead and break the silence Pause after asking "How did that make you feel?"
Accepting / Recognition Acknowledge client was heard; recognize changes without compliments (avoids bias) "I noticed you've been keeping your food diary."
Focusing Gently redirects client who is jumping topics or expressing delusions Used for disorganized thinking or unlikely statements

❌ Nontherapeutic Techniques — Avoid These

  • Giving advice — "If I were you, I would…" → belittling
  • False reassurance / Minimizing — "Don't worry, you'll be fine." → dismisses concerns
  • Challenging / Dismissive — "Why did you do that?" → puts client on defense
  • Probing — pushing client to discuss topics they view as irrelevant
  • Changing subject — client perceives nurse doesn't care
  • Rejecting / Being critical — stops communication entirely

Best Practices for Enhancing Communication ⚡

  • Respect the client during conversation
  • Allow time for reflection
  • Show empathy
  • For important policy/announcements: schedule a face-to-face meeting
  • For a new AP learning a procedure: use verbal + nonverbal + written modes together
🎯
Motivational Interviewing (MI) — OARS
MI is a therapeutic communication method that empowers clients to make positive health behavior changes. Used for: diabetes, obesity, substance use disorder. Key technique = OARS
O — Open-Ended Questions
Encourages disclosure without judgment. "Tell me more about…" rather than "Why did you…"
A — Affirmations ⚡
Positive statements that build confidence. "I'm glad you decided to continue your fitness routine."
R — Reflective Listening
Restates & clarifies feelings. "So you're worried you'll get diabetes like your mother."
S — Summarizing
Paraphrases to confirm understanding. "Your mother also had diabetes."
⚡ Exam tip — Motivational Interviewing question format: "You said you're sad. What is making you feel sad?" = open-ended + reflective → this is MI. NOT advice-giving.
⚡
Exam High-Yield Summary
Schramm Model key component
Feedback — client saying "I understand now" = feedback
Shannon-Weaver: nurse providing discharge instructions
Nurse = Sender
Client refusing biopsy — nurse repeats back
Technique = Restating
MI: affirming fitness routine
Affirmation — "I'm glad you continued your fitness routine"
Last rites before death
Influenced by Cultural factor
Dialysis + 2 jobs + avoids eye contact
Psychosocial + Situational factors
Client drowsy, can't report pain
Use alternative pain assessment tool
Client requests email of discharge instructions
Cannot send — HIPAA violation
Client with hearing loss in ED
Move to quiet area · Slower pace · No medical jargon
Client with dementia
Speak clearly, slow pace
Teaching wound care — what to check first
Ensure client has glasses on
Teaching heart-healthy activities = which phase?
Exploitation (active teaching phase)
Teaching AP: 30-min lecture + written steps
Modes used: Verbal + Nonverbal + Written
Charge nurse: "take your time" then complains
Communication style = Passive-Aggressive
New scheduling policy announcement
Best method = Face-to-face meeting
Language barrier: medication reconciliation
Use facility's certified interpreter
Client watching TV at high volume
Lower TV volume first before communicating
Arms folded, no eye contact
Nonverbal communication
Assertive = best because
Uses "I" statements · Clear · Cooperative · Respects all parties
Presentation for older adults
Ensure room is well lit
mod 7Documentation
📁
Health Records & EHRs

What Is a Health Record? ⚡

  • Individualized collection of health information & data about a client's health
  • Identifies all health services provided (hospitalizations, procedures)
  • Components: demographics, vital signs, medical history, medications, allergies, immunizations, diagnoses, lab & radiology results
  • Clients can access their own records ⚡
  • Information can be shared with other providers and institutions

EHR — Key Facts ⚡

  • Real-time client records accessible by any authorized user — including the client
  • Complete information available instantly → faster care decisions
  • Legible documentation reduces prescription errors
  • Enables reliable billing & coding
  • Security: password protection, firewalls, encryption
  • EHR downtime = switch to paper documentation; safety features disabled
EHR Timeline
1960s First utilization of EHRs
1970s Federal gov't (Dept. of Veteran Affairs) began using EHRs
1980s Electronic technology became more widespread; EHR use increased
1997 IOM (Institute of Medicine) recommended nationwide adoption of EHRs ⚡
2009 HITECH Act encouraged facilities to install CPOE systems
⚡ Benefits of electronic documentation: Built-in clinical alerts prevent harm & duplicate tests · Real-time team access · Eliminates illegible records · Increases accuracy of coding · Client portals for direct provider interaction
📋
Documentation Methods
Method Key Feature Structure Watch Out
Source-Oriented Traditional; each discipline documents separately in narrative History & physical · Progress notes · Nurses' notes · Lab/diagnostic reports ⚠ Limits sharing among interdisciplinary team → fragmented care
POMR ⚡ Lawrence L. Weed; gathers all team members' data; promotes sharing ⚡ Database · Problem list · Initial plan · SOAP progress notes More organized; comprehensive; widely used
SOAP ⚡ Component of POMR; systematic & organized clinician notes Subjective (client's words) · Objective (nurse observes) · Assessment (analysis) · Plan (interventions) S = client's own statements ⚡ | O = measurable findings ⚡
PIE Model Simplified; focuses on nursing process; omits traditional plan of care Problem (nursing dx) · Intervention · Evaluation; uses flowsheets + progress notes Includes ongoing (not traditional) plan of care
Focus Charting Centers on specific problem, change in condition, or concern Data · Action · Response (DAR) Includes immediate AND future nursing actions
CBE ⚡ Documents only unexpected/unusual findings ⚡; uses standardized flowsheet Physical assessment flowsheet with expected findings; narrative if condition changes ⚠ Not most effective — assumes care was routine; can miss documentation gaps
SOAP — Component Examples ⚡
S — Subjective ⚡
Client's own words, feelings, views. From client, caregiver, or family.
"Client reports abdominal pain on exertion."
O — Objective ⚡
What nurse observes or measures. Vital signs, physical assessment.
"Rebound tenderness noted in RLQ of abdomen."
A — Assessment
Analysis of combined S + O data.
"Client's respiratory status is altered with productive cough."
P — Plan
Interventions to implement.
"Elevate HOB. Notify provider of change in status."
✔
FACT Documentation & Abbreviations
FACT — Documentation Accuracy Guide
F — Factual
Concrete
Objective, descriptive info from direct observation & measurement — what you see, hear, smell, feel.
"Head round, normocephalic. No nodules."
A — Accurate
Exact
Exact descriptions & measurements. Provides concrete data for comparing condition over time.
"Client voided 420 mL clear yellow urine at 0900."
C — Complete
What/When/Why
Contains what, when, where, why, and how. Nonbiased.
"JR, RN, administered Colace 100 mg PO at 1000. Client denied discomfort."
T — Timely ⚡
Chronological
Documented close to when care was performed — not at end of shift.
"BS 127 at 0732 → 2u Novolog SQ at 0745."
Abbreviations

✅ Commonly Used (Safe) — Full Reference

ABD abdomen
ac before meals ⚡
Ad lib at liberty (move freely)
BID twice a day ⚡
BK below the knee
BP blood pressure
cath catheter
CBC complete blood count
c/o complains of
CPR cardiopulmonary resuscitation
C&S culture and sensitivity
CXR chest x-ray
DNR do not resuscitate
DX diagnosis
FBS fasting blood sugar
GI gastrointestinal
gtt drop
H&H hemoglobin and hematocrit
HOB head of bed ⚡
hr hour
Hx history
ICU intensive care unit
I&O input and output
IV intravenous
LLE left lower extremity
LMP last menstrual period
LOC level of consciousness
LUE left upper extremity
MI myocardial infarction
MRSA methicillin-resistant S. aureus
NG nasogastric
NKA no known allergies
NKDA no known drug allergies
NPO nothing by mouth
N&V nausea and vomiting
O2 oxygen
OOB out of bed
per through or by
PO by mouth ⚡
PRN as needed ⚡
q every
r/o rule out
Rx prescription ⚡
Stat at once, immediately ⚡
TID three times a day
Tx treatment
UA urinalysis
Wt weight
Each facility establishes its own approved list — staff must be educated on use. Never use abbreviations in client-facing documents (informed consent, discharge instructions).

❌ Do Not Use (Joint Commission) ⚡

IU — mistaken for IV or 10. Write "International Unit"
MS / MSO4 / MgSO4 ⚡ — confused with each other. Write full name
qhs ⚡ — mistaken for "qhr" (every hour). Write "nightly"
qd / QD — mistaken for q.i.d. Write "daily"
qod / QOD — mistaken for q.i.d. Write "every other day"
TIW / tiw — mistaken for 3× a day or 2× a week. Write "three times weekly"
SC / SQ / sub q — multiple confusions. Write "subcut"
U / u (unit) — mistaken for 4, cc, or 0. Write "unit"
Trailing zero (X.0 mg) / No leading zero (.X mg) — decimal point missed. Write X mg / 0.X mg
per os — mistaken for "left eye." Write "PO," "by mouth," or "orally"
⚡ Correct medication entry example: "Synthroid 100 mg PO every morning ac" — uses full route, no trailing zeros, approved abbreviation ac (before meals). ANA standards require documentation to be factual, accurate, complete, timely, organized, and compliant.
🔒
HIPAA, Privacy & Legal

HIPAA Overview ⚡

  • Established 1996 by federal government — goal: make healthcare more efficient
  • Privacy Rule took effect 2003 — governs EHRs, protects consumer privacy
  • Nurses have a legal obligation to protect personal health information
  • Health info shared ONLY with those directly involved in client's care
  • Medical records can be used as evidence in court

Consequences of Violations ⚡

  • ⚡ Termination from health care facility
  • Financial fines
  • Imprisonment
  • Nursing license jeopardized
  • Unauthorized access to records = violation even without sharing
Who Can Access Records Without Special Consent? ⚡
✓ Admitting provider
✓ Charge nurse on the unit
✓ The client themselves
✗ Family (without consent)
✗ Staff not involved in care
Documentation & Legal: Medical records are legal documents. Nurses must follow ANA standards: factual, accurate, complete, timely, organized, compliant. Facilities can establish their own rules for documentation methods ⚡ — nurse who delegates a task will review the charting for that task ⚡.
📞
Verbal / Telephone Prescriptions & CPOE

Verbal Prescriptions — Rules ⚡

  • Reserved for emergency situations only — potential for error without CPOE safeguards
  • Received in person or via telephone by licensed personnel designated by facility
  • Write it down immediately in client's record as received, then read back ⚡
  • Exception — no need to write first: emergency or sterile environment → repeat back prior to implementation ⚡
  • Do NOT accept verbal prescriptions for chemotherapy (unless withholding/stopping)
  • Signed immediately by receiver; countersigned by prescriber per facility policy

Vulnerabilities (Why Verbal Is Risky)

  • Misinterpretation due to dialects or pronunciations
  • Background noise or poor reception
  • Confusion of clients with similar names
  • Medications with similar-sounding names
  • Provider's lack of familiarity with the client
Telephone Prescription Checklist ⚡
① Confirm client identity, allergies, age/weight if needed
② Ensure prescription is complete: med, dose, strength, route, frequency, indication, special instructions
③ Record prescription on designated area of chart
④ Read it back to the provider ⚡
⑤ Use clarifying techniques (spell meds, read numerals sequentially, distinguish similar terms)
⑥ Resolve discrepancies BEFORE implementing ⚡

CPOE — Computerized Provider Order Entry ⚡

HITECH Act (2009)

  • Federal government encouraged facilities to install CPOE systems
  • Minimizes medication errors & adverse drug events
  • Fewer transcription errors
  • Activates alert systems for potential client issues (drug reactions) ⚡
  • Can increase speed of care delivery ⚡

CDSS — Clinical Decision Support System

  • Feature within most CPOE systems
  • Recommends: doses, routes, frequencies of administration
  • Safety checks: allergy alerts, drug interactions, lab warnings
  • Eliminates errors from illegible handwriting & inconsistent abbreviations
  • Quicker transmittal of orders to appropriate department
⚡
Exam High-Yield Summary
Do Not Use abbreviations (3 from PT)
MSO4, IU, qhs — all on Joint Commission Do Not Use List
Who accesses records without special consent?
Admitting provider · Charge nurse on unit · The client themselves
Correctly written medication entry
"Synthroid 100 mg PO every morning ac" — full route, no trailing zero, correct abbrevs
HIPAA breach consequence
Personnel can be terminated for breaching client confidentiality
POMR key feature
Promotes information sharing among interdisciplinary team members
EHR — what can clients do?
Clients can track their own health information
"Client reports abdominal pain on exertion"
This is the S (Subjective) in SOAP — client's own words
Charting by Exception
Document only variations from expected findings
PRN means
As needed
Facility documentation rules
Facilities can establish their own rules for documentation methods
Nurse who delegates a task
Will review the charting for that task
CPOE benefit
Can increase speed of care delivery
Who advocated for nationwide EHR use?
Institute of Medicine (IOM) — 1997
Meets ANA documentation standards?
"Client vomited 240 mL of clear emesis but denies pain or nausea" — factual, complete, accurate
PO route =
By mouth
When is verbal Rx OK without writing first?
Emergency / sterile environment — repeat back before implementing. OK during code for unresponsive client ⚡
EHR alerts providers of
Possible actions that could cause client harm
Component of a health record
Immunization record (along with vitals, Hx, meds, allergies, diagnoses…)
"Rebound tenderness noted in RLQ"
Objective (O) SOAP data — observed/measured by nurse
Electronic documentation advantages (3)
Reduces medical errors · Makes medical history easily available · Increases accuracy of coding procedures
mod 22aMobility
🦴
Musculoskeletal & Neurological System

🔩 Connective Structures

Bone
Hard connective tissue — rigid framework, protects organs
Muscle
Soft tissue — motor power for movement & posture maintenance
Tendon ⚡
Non-flexible fibrous — connects muscle → bone
Ligament
Flexible fibrous — connects bone → bone
Cartilage
Flexible, coats bony areas — gliding & shock absorption
Synovial Joints
Fluid-filled capsules — connect bones, enable motion & flexibility

💪 Functions of Skeletal Muscle

  • Movement (main function) — walking, texting, dancing
  • Posture & positioning — maintains without conscious control ⚡
  • Thermoregulation ⚡ — contracting muscles generate heat; shivering = heat production

🦾 Functions of Skeletal System

  • Support — solid, stable framework
  • Protection — brain, spinal cord, heart, lungs
  • Production — red marrow → RBCs, WBCs, platelets, macrophages
  • Storage — calcium, phosphorus, magnesium, iron, lipids
  • Movement — works with muscular attachments
🧠 Neurological System — Movement & Proprioception
  • CNS: brain + spinal cord
  • PNS: thousands of nerves interfacing with spinal cord; communicate via neurotransmitters
  • Nerve cells fire → muscles contract → pull bones → movement (bones = levers; muscles = force)
  • Proprioception / kinesthesia ⚡ — sense of body position & balance; coordinates movement
  • Sensory receptor feedback → brain → fine-tune positioning
  • Stroke → difficulty with proprioception = diminished body position & balance awareness

👴 Age-Related Changes Affecting Mobility

Factor Change Effect on Mobility
Posture ⚡ ↑ thoracic spinal curvature; ↑ flexion in knees/hips Stooped posture, unsteady ambulation
Reflexes Poor balance — CNS dysfunction Unsteadiness, ↓ ability to right oneself
Joint mobility Slow movement, stiffness, ankle/foot weakness Slower steps, wider stance, varied length
Muscle mass ↓ endurance, ↓ strength ↑ fatigue with ambulation
Vision ↓ acuity, ↓ depth perception Hesitant ambulation, ↑ fall & tripping risk

🧒 Gross Motor Development — Life Span

Infancy → Childhood
Gross motor skills develop gradually. Gait fine-tuned between ages 5–7 — child learns to narrow base and lengthen stride.
Adolescence
Rapid growth; coordination refines. Muscle mass and strength approach adult levels by late adolescence.
Early Adulthood
Peak muscle mass and strength. Slight decline in mobility with challenging tasks begins — overall function remains maximal.
Older Adulthood
Sarcopenia, ↓ bone density, ↓ reflexes, ↓ vision — cumulative effects ↑ fall risk. Multicomponent programs (aerobic + strengthening + balance) maintain function.
Kyphosis ⚡
Outward curvature of thoracic spine — rounded upper back + pelvis tilted forward. Most common in older adult females due to vertebral weakening/fracture.
Sarcopenia ⚡
Loss of lean muscle mass — deterioration of twitch fibers. Lower extremities affected first (constant work against gravity). More noticeable in older adults.
⚖️
Body Mechanics & Ergonomics

3 Key Principles of Body Mechanics

📐
Body Alignment
Vertical line: ear → shoulder → trunk → hip → knee → ankle. Keep back straight, chin level, abdomen tight ⚡
⚓
Balance
Center of gravity just below umbilicus. Wider base + lower CoG = ↑ stability ⚡. Feet shoulder-width, knees flexed.
🔄
Body Movement
Face client face-to-face ⚡. Pivot feet — don't twist spine. Bend knees not back. Use quadriceps (largest muscles).

🏋️ Proper Lifting Sequence ⚡

①
Stand close to object
②
Contract abdomen, straight lower back
③
Head upright, shoulders raised
④
Bow hips slightly, squat
⑤
Push up from knees

✅ Correct Body Mechanics

  • Face client face-to-face during transfers ⚡
  • Wide base lowers center of gravity → ↑ stability ⚡
  • Stable CoG = ↑ balance ⚡; tighten abdomen ⚡
  • Raise bed to comfortable working height
  • Object/client as close to body as possible
  • Bend knees (not back) — use quadriceps
  • Pivot/side-step — never twist the torso

📊 Ergonomics

  • Study of body mechanics in relation to work environment & equipment design
  • ↑ Job satisfaction ⚡, ↑ productivity, ↓ injury & fatigue
  • Risk factors: lighting, noise, posture, force, repetition, workload hours
  • ANA Safe Patient Handling: "never lift alone" / "minimal lift" policies
  • Ergonomic tools: height-adjustable beds, transfer devices, shower chairs, 2-person lifts
⚠️
Effects of Immobility — System by System
🦴 Musculoskeletal
Disuse osteoporosis · Sarcopenia · Joint contractures · Foot drop
❤️ Cardiovascular
Cardiac deconditioning · Orthostatic hypotension · DVT → PE
🫁 Respiratory
Atelectasis · Pneumonia
🍽️ Gastrointestinal
Constipation · Fecal impaction · GERD · Malnutrition
💧 Genitourinary
Urinary retention · Renal calculi · UTI
🩹 Skin & Psych
Pressure injuries · Depression · Social isolation

🦴 Musculoskeletal

Disuse Osteoporosis
  • Bones thinner/weaker from bed rest (demineralization)
  • → fragility fractures (break under minor stress)
  • Rebuilding bone takes longer than muscle
Sarcopenia ⚡
  • Loss of lean muscle from deterioration of twitch fibers
  • Lower extremities first — always working against gravity
  • Nursing: encourage self-care activities, gradual activity increase
Joint Contractures
  • Abnormal joint fixation — stronger flexors pull joint into bent, nonfunctional position
  • Collagen → denser, less flexible over weeks
  • Nursing: ROM q8h, splints as prescribed, check alignment q2h
Foot Drop ⚡
  • Partial/total inability to dorsiflex (pull toes upward)
  • Foot arched, toes pointing down → toe dragging while walking
  • Nursing: splints, ambulation assist, notify provider

❤️ Cardiovascular

Orthostatic Hypotension ⚡

  • Dizziness on sitting/standing from lying
  • SBP ↓≥20 mmHg OR DBP ↓≥10 mmHg within 3 min of position change
  • Nursing: change positions slowly, HOB elevation, antiembolism stockings, fall precautions

DVT → Pulmonary Embolism ⚡

  • Immobility → ↑ blood viscosity + muscle atrophy → venous stasis → clot
  • Usually: arms, pelvis, thighs, lower legs
  • Worst complication: PE (clot → lungs)
  • Nursing: SCDs, antiembolism stockings, anticoagulants, ankle exercises, fluids
🩺 DVT Prevention Devices — Details
  • Antiembolism stockings: 12–20 mmHg compression; knee-high end 2 in below back of knee; thigh-high end 2 in below buttocks; assess circulation after 30 min
  • SCDs ⚡: Available in knee or thigh length (air pump + tubing + sleeves); assess skin every 8 h; remove if positive Homan's sign (DVT); contraindicated in severe arterial disease ⚡
  • Venous foot pumps: Intermittently compress foot/ankle → promotes venous return; alternative to SCDs
  • SCD fit: two fingers between sleeve and leg
  • SCD tubing: do NOT place under the leg — ↑ pressure ulcer risk & malfunction
  • Assess DVT history before applying SCDs (focused pre-application assessment)
  • Stocking too large → ↓ compression → ↑ DVT risk; too small → impairs circulation

🫁 Respiratory

Atelectasis ⚡

  • Partial/complete lung collapse from shallow breathing
  • ↓ alveoli available for gas exchange
  • Nursing: incentive spirometer ⚡, Fowler's ⚡, deep breathing & cough, turn q2h, O₂ as prescribed

Pneumonia ⚡

  • Infection — thick secretions + ↓ cough = can't clear pathogens
  • Supine → abdominal organs shift toward diaphragm → ↓ breath depth
  • Nursing: prone positioning for postural drainage ⚡, HOB ≥30–45°, fluids, deep breathing

🩹 Pressure Injury Stages

Stage 1 — Intact Skin
Persistent redness/discoloration · Temp difference · Firmness
Stage 2 — Into Skin ⚡
Lighter color than skin · Open/intact blister · Shallow wound with pink/red bed
Stage 3 — Beyond Skin
Open wound · Adipose or granulation tissue visible
Stage 4 — Deep
Exposed muscle, ligaments, or bone · Dead tissue
⚡ Reposition every 2 hours. Highest-risk bony prominences: occiput, shoulder blades, elbows, sacrum, ischium, heels. Moisture (incontinence, wound drainage, sweat) significantly ↑ breakdown risk.
📊
Mobility Assessment — MAT & TUG

Perform before initial mobilization, every 24 hours, and after any procedure altering mobility. Document and verbally communicate results to the team.

📋 Bedside Mobility Assessment Tool (MAT) — begin at Level 1, advance if tasks completed

Level
1
Maximum Assist
Shake hands across midline · Sit on edge of bed & hold ≥2 min ⚡ → if cannot do both: assign Level 1
Equipment
Mechanical lift
Slide boards
Staff
2 or more
Level
2
Moderate Assist
Feet on floor while seated · Extend leg, flex ankle & point toes; repeat other leg → if cannot do all: assign Level 2
Equipment
Sit-to-stand lift
Ambulation devices
Staff
2 or more
Level
3
Minimal Assist
Rise from seated using assistive device (cane/bed rail) · Maintain standing ≥5 sec → if cannot: assign Level 3
Equipment
Gait belt
Ambulation devices
Staff
1–2
Level
4
No Assist
March in place · Step forward & backward → if cannot or requires assistive device: assign Level 3 instead
Equipment
None
Staff
0–1

⏱️ Timed Up & Go (TUG)

  • Stand from chair → walk 10 ft → turn → return → sit
  • Comfortable pace; observe balance, stride, posture, gait
  • ⚡ >12 seconds = ↑ fall risk in older adults

🧹 ADLs & Occupational Therapy

  • ADLs = basic self-care: dressing, bathing, toileting ⚡, feeding
  • Client needing ADL assistance → refer to occupational therapist ⚡
  • Assistive devices for ADLs: commode chairs, toilet seat risers, shower chairs
  • Activity intolerance signs: weakness, fatigue, lightheadedness, diaphoresis, ↑ VS with activity

🏃 Exercise Recommendations & Activity Progression

📅 Weekly Target ⚡

  • 150 min/week of moderate-intensity aerobic activity — 30 min/day × 5 days
  • Examples: brisk walking (≥2.5 mph), water aerobics, swimming, slow cycling (~10 mph), ballroom dancing, hiking
  • Older adults: multicomponent programs — aerobic + muscle-strengthening + balance training
  • Adapted yoga and resistance bands improve muscle, bone density, and balance

📊 Borg RPE Scale ⚡

  • Rate of Perceived Exertion — range 6–20
  • Target exercise zone: 12–14 ("somewhat hard to strong effort")
  • Used when HR monitoring is impractical
  • Ambulation benefits: stimulates respiratory, circulatory, and GI systems — prevents paralytic ileus

🚶 Staged Ambulation Sequence ⚡

①
Sit up in bed — raise HOB
②
Dangle legs at edge of bed
③
Stand — assess tolerance
④
Ambulate with device if needed
Each step prevents orthostatic hypotension. Ambulate ASAP post-op or post-procedure.
🦯
Assistive Devices & Client Transfers

🚶 Ambulation Devices — Fit & Use

🦯 Cane
  • Height: top at wrist level ⚡
  • Elbow: 20–30° when gripping
  • Hold on stronger/unaffected side ⚡
  • When sitting: hold crutches/cane on unaffected side ⚡
  • Advance cane 6–10 in → then weaker leg → then stronger leg
  • Nurse stands on affected side, slightly behind
🚶 Walker ⚡
  • Height: top at wrist level ⚡
  • Elbow: ~15° when gripping
  • Move walker 6–8 in → all four legs down → step weaker leg → then stronger
  • NOT for stairs or escalators
  • Standard (no wheels) = most support; 2-wheel, 4-wheel = less support
🩼 Crutches
  • Pads 1–2 in below axilla ⚡ (NOT in axilla)
  • Hand grips at hip level
  • Elbow: 20–30°
  • Start position: 6 in front + 6 in to side of feet
  • Weight on HANDS, not axilla — axilla pressure = crutch palsy (numbness/tingling)
  • When sitting: hold on unaffected side ⚡
🩼 Crutch Gaits
4-Point Gait
R crutch → L foot → L crutch → R foot. Both legs bear weight. 3 contact points at all times. Most stable.
3-Point Gait
Both crutches + affected leg forward → then strong leg. One leg only. Strong leg bears full weight. For non-weight-bearing orders.
2-Point Gait
L crutch + R foot → R crutch + L foot. Partial weight bearing on both legs. Mimics normal walking pattern.

🔄 Transfer Devices

Device When to Use Key Notes
Gait Belt Client has some mobility — minimal assist At waistline; snug but fingers must slip under; pair with cane/walker/pivot disc
Slide Board Horizontal/lateral transfer (bed → gurney); immobile or acutely ill Minimum 3–4 staff; rigid slippery surface reduces friction
Pivot Disc Can stand but has difficulty moving feet; cooperative client Use with gait belt; allows easy rotation; requires weight-bearing capability
Sit-to-Stand Lift Moderate assist — has LE strength but cannot rise independently Client must be able to maintain standing once achieved
Mechanical Lift ⚡ Cannot bear weight — maximum/total assist ⚡ Inspect sling for wear; base at maximum open; raise bed to working height ⚡; 2+ staff; client must be calm & cooperative
➕ Additional Devices
  • Grab bars — fixed metal bars mounted on walls near tubs, showers, toilets; assist balance during transfers
  • Transfer/draw sheet — heavy half sheet folded and placed under client; used to reposition in bed and assist lateral transfers; use with slide board
  • Slide board gurney height: position gurney slightly higher than bed — uses gravity to assist lateral transfer
  • Mechanical lift types: ceiling-suspended OR wheeled-base floor lift; both have overhead bar + sling suspension
  • Operated by manual hydraulic pump or electric remote
  • Sling placement ⚡: position under client's center of gravity and greatest portion of body weight
🧦 Antiembolism Stocking — Application & Client Education
  • Inside-out technique ⚡ — eases application and improves comfort
  • Apply upon waking, before getting out of bed; remove at bedtime
  • Assess circulation & comfort 30 min after application
  • Knee-high: end 2 in below back of knee · Thigh-high: end 2 in below buttocks
  • Do NOT roll the top down — impedes circulation (tourniquet effect)
  • Do NOT pull toe opening back over foot — impedes circulation
  • Hand wash to maintain elasticity; use a clean pair daily
  • 12–20 mmHg compression for standard antiembolism stockings
⚡ Transfer Safety Checklist
  • Align nurse's knees with client's knees ⚡
  • Lock ALL wheels before transfer
  • Non-skid footwear before weight-bearing
  • Dangle legs before standing (prevents orthostatic hypotension)
  • Bed→chair: lowest position · Bed→stretcher: waist height
  • If client falls: extend one leg, let client slide to floor ⚡
  • Secure IV lines/drains/tubes before any move
  • Face direction of movement — never twist spine
  • Count audibly (1-2-3) to coordinate team
  • Antiembolism stockings: measure calf circumference + heel-to-knee length ⚡
🛏️
Client Positioning & Range of Motion

🛏️ Common Client Positions

Position Description Key Indication
Fowler's ⚡ HOB 45°; knees may flex. Semi (15–30°): used for NG tube clients ⚡; High (orthopneic): 60–90° ↑ Lung expansion, prevent atelectasis ⚡; post-op default; post-thoracic surgery; cardiovascular problems
Supine Flat on back (dorsal recumbent); knees may be bent Examination; applying stockings/SCDs
Prone ⚡ On abdomen, head turned; hips unflexed Postural drainage of secretions ⚡ (pneumonia); full hip/knee extension
Lateral Side-lying; hips & knees flexed; pillow between knees Spinal alignment; ↓ sacrum & heel pressure
Lateral Semi-Prone (Sims') Between prone & lateral; top leg flexed toward chest with pillow ↓ Sacrum/hip pressure; postural drainage; enema/perineal exams
Trendelenburg Head down, feet elevated ↑ Venous return; lower lobe lung drainage
Reverse Trendelenburg Head up, feet down GERD/gastroesophageal reflux; comfort for GI clients

🛏️ Positioning Support Devices

🦶 Footboard ⚡
Flat panel at foot of bed — keeps feet dorsiflexed, prevents foot drop. Client pushes feet against it.
🌀 Trochanter Roll
Bath blanket folded/rolled — placed at outer thigh; keeps hips in neutral position; used for one-sided weakness or paralysis.
✊ Hand Roll
Rolled washcloth placed in client's hand — maintains wrist/fingers in functional position; prevents flexion contractures.

🛏️ Pillow Placement by Position

Position Pillow / Support Placement Note / Caution
Supine Towel roll under small of back · Pillow under thighs (knees slightly flexed) · Forearms elevated ↑ Sacrum & heel pressure risk
Prone Pillow under head (turned to side) · Small pillow/towel roll under abdomen just below diaphragm · Pillow under lower legs (toes off bed) ↑ Lower back hyperextension · Difficulty breathing from chest pressure
Lateral Pillow under head/neck · Under upper arm (lower arm flexed forward) · Between knees/legs Check spinal alignment
Orthopneic (High Fowler's) ⚡ Client sits upright; overbed table in front with several pillows to rest/lean on → maximum chest expansion Used for severe dyspnea, COPD, HF

⬆️ Moving Client Up in Bed

  • Place draw sheet from shoulders to thighs
  • Place pillow between client's head and headboard (protection)
  • Lower HOB flat or Trendelenburg ⚡ — gravity assists moving client up
  • Roll sheet close to client; grasp at shoulders and hips (one person per side)
  • Ask client to bend knees and push on count
  • Count audibly (1-2-3) → lift and slide toward headboard simultaneously

🔄 Range of Motion — Movement Types

↙
Flexion
Bend, ↓ angle
↗
Extension
Straighten, ↑ angle
↩
Hyperextension ⚡
Beyond normal — leg behind body = hip hyperext.
←
Abduction
Away from midline
→
Adduction
Toward midline
↶
Pronation
Turn backward / downward
↷
Supination
Turn forward / upward
⭕
Circumduction ⚡
Full 360° circle
↔
Rotation
Side-to-side turning
↰↱
Inversion / Eversion
Turn inward / turn outward

Active ROM

  • Client voluntarily moves joints without assistance
  • Maintains AND increases muscle strength
  • Prevents contractures + bone demineralization
  • Each joint: at least every 8 hours ⚡
  • Full shoulder ROM ⚡ = flexion to 180° (arm fully overhead)

Passive ROM

  • Another person moves the joint for the client
  • Preserves flexibility but does NOT prevent muscle atrophy or bone demineralization
  • Muscles not contracting; bones not bearing weight
  • Support joint above AND below ⚡ when performing
  • Stop immediately if client reports pain
⚡
Exam High-Yield Summary
Sarcopenia ⚡
Older adult muscles smaller/weaker → loss of lean muscle mass; lower extremities affected first
ADL: toileting ⚡
Basic ADLs: dressing, bathing, toileting, feeding — refer to OT if assistance needed
Transfer mechanics ⚡
Proper body mechanics: face client face-to-face during transfer
Post-op position ⚡
Prevent atelectasis → position in Fowler's
Tendon ⚡
Connects muscle → bone; non-flexible fibrous tissue
Kyphosis ⚡
Rounded upper back + pelvis tilted forward; most common in older adult females
Incentive spirometer ⚡
Client at risk for atelectasis → remind to use incentive spirometer
Posture ⚡
Body posture maintained by muscles — without conscious control
Thermoregulation ⚡
Muscles help regulate temperature — contracting muscles generate heat; shivering = heat production
Stage 2 pressure injury ⚡
Blister or wound lighter than skin = Stage 2 (into skin layer)
Center of gravity ⚡
Stable CoG ↑ balance; wide base ↓ CoG = ↑ stability
Walker height ⚡
Top at wrist level when standing; elbow ~15° flexion
Maximum assist ⚡
Cannot bear weight → use mechanical lift (2+ staff required)
Age-related posture ⚡
↑ thoracic spinal curvature; ↑ flexion in knees/hips → stooped posture, unsteady gait
Proprioception + stroke ⚡
Stroke → difficulty with proprioception = ↓ body position & balance awareness
Muscle contraction ⚡
Muscle contraction results in flexion of a joint
Crutch fit ⚡
Pad placement: 1–2 in (5 cm) below axilla — NOT in axilla (→ crutch palsy)
ADL referral ⚡
Client needing ADL assistance → refer to occupational therapist
Ergonomics ⚡
↑ job satisfaction, ↑ productivity, ↓ injury and fatigue
Immobility → DVT ⚡
Immobile client → ↑ risk for DVT (→ PE if clot travels to lungs)
Foot drop ⚡
Foot drags during ambulation → foot drop (partial/total inability to dorsiflex)
MAT Level 1 task ⚡
Sit on edge of bed and hold ≥ 2 min — if cannot do both tasks: assign Level 1
Pneumonia position ⚡
Postural drainage for pneumonia → prone position
Crutches when sitting ⚡
When sitting to transfer: hold crutches on unaffected side
Antiembolic stockings ⚡
Measure calf circumference + heel-to-knee length
Hip hyperextension ⚡
Move leg BEHIND body = hip hyperextension
Client falling ⚡
Extend one leg → let client slide down to floor
Transfer knee alignment ⚡
Left-sided weakness: align nurse's knees with client's knees
Full shoulder ROM ⚡
Flexion to 180° — arm raised straight overhead
Mechanical lift bed height ⚡
AP leaves bed at lowest → intervene! Raise bed to working height
Passive ROM support ⚡
Support joint above AND below when performing passive ROM
SCD fit ⚡
Place two fingers between sleeve and leg — snug but not tight
SCD removal ⚡
Every 8 hours to assess skin integrity
Stocking too large ⚡
↓ compression → ↑ DVT risk
Stocking too small ⚡
Impairs circulation
Crutch palsy ⚡
Axilla pressure → nerve damage → numbness/tingling in arms — weight on HANDS, not axilla
TUG fall risk ⚡
>12 seconds = ↑ fall risk in older adults
Circumduction ⚡
Full 360° circle movement of a joint
Orthostatic hypotension ⚡
SBP ↓≥20 mmHg OR DBP ↓≥10 mmHg within 3 min of standing
Crutch pad placement ⚡
1–2 in below axilla — weight on hands; axilla pressure causes crutch palsy
Elbow angles ⚡
Cane/Crutch: 20–30° · Walker: ~15° when gripping
Reposition frequency ⚡
Every 2 hours; ROM: at least every 8 hours per joint
Fowler's angles ⚡
Semi: 15–30° · Standard: 45° · High (orthopneic): 60–90°
Cane advancement ⚡
Advance cane 6–10 in → weaker leg → stronger leg
Walker advancement ⚡
Move walker 6–8 in → all legs down → weaker leg → stronger leg
Borg RPE scale ⚡
Range 6–20; target exercise zone 12–14 ("somewhat hard to strong effort")
Exercise target ⚡
150 min/week moderate-intensity aerobic activity (30 min/day × 5 days)
Staged ambulation ⚡
Sit up → dangle legs → stand → ambulate — each step prevents orthostatic hypotension
Footboard ⚡
Keeps feet dorsiflexed — prevents foot drop; client pushes against panel at foot of bed
Trochanter roll
Rolled bath blanket placed at outer thigh — keeps hips in neutral position; used for one-sided paralysis
Hand roll
Rolled washcloth in client's hand — maintains wrist/fingers in functional position; prevents contractures
SCD contraindication ⚡
Contraindicated in severe arterial disease; remove if positive Homan's sign (DVT indicator)
Stocking: don't roll top ⚡
Do NOT roll the top down — acts as tourniquet, impedes circulation
Stocking application ⚡
Apply using inside-out technique; apply before getting out of bed in the morning; remove at bedtime
Venous foot pumps
Intermittently compress foot/ankle → promotes venous return; alternative to SCDs for DVT prevention
Sling placement ⚡
Position sling under client's center of gravity and greatest portion of body weight
Semi-Fowler's ⚡
HOB 15–30° — often optimal for clients with nasogastric tube in place
Moving up in bed ⚡
Lower HOB to Trendelenburg — gravity assists; client bends knees and pushes; draw sheet from shoulders to thighs
Paralytic ileus prevention
Ambulation stimulates GI, respiratory, and circulatory systems — prevents paralytic ileus post-op
mod 22bIntroduction to Critical Care and Emergency Nursing
📊
Assessment Tools — ABCDEF (ICU) & ESI (ED) & ABCDE (Trauma)

ABCDEF Bundle — ICU Daily Rounds ⚡

A
Assess Pain
Use numerical scale, BPS, or CPOT; assess, treat, evaluate response. Pain is underreported in ICU.
B
Breathing — SAT & SBT
Spontaneous Awakening Trial (SAT) = stop sedatives. Spontaneous Breathing Trial (SBT) = turn vent rate to zero. Goal: wean off ventilator ASAP.
C
Choice of Sedation
Assess sedation ≥ 6×/day using RASS, SAS, or Ramsay Scale. Client should be awake, calm, cooperative before weaning.
D
Delirium
Assess ≥ 2×/day with CAM-ICU or ICDSC. Incidence 20–80% in ICU. Turn lights off at night — delirium prevention.
E
Early Mobility
Ambulate ASAP — prevents muscle weakness (40–58% loss in 7 days). Sedation must be light or off before ambulating.
F
Family Engagement
Client & family at center of decision-making. Invite family to rounds, bedside procedures, CPR if desired.
RASS sedation scale: −5 (unarousable) to +4 (combative/violent). Goal for weaning = 0 (alert & calm) to −1. Paralytics (rocuronium) used for acute lung injury/ARDS — nurse must be extremely vigilant; any disruption = respiratory arrest.

ABCDE — Trauma Primary Survey ⚡

Letter Stands For Key Points
A Airway Assess mouth, larynx, trachea — foreign body, laryngotracheal trauma, allergic reaction
B Breathing Resp rate <12 or >20, O₂ sat <90%, stridor, asymmetrical chest rise — asthma, COPD, obstruction
C Circulation Heart & blood vessels — cardiac arrest, hemorrhage, myocardial dysfunction
D Disability ⚡ Neurological status via AVPU: Alert · Voice · Pain · Unresponsive. Causes: hypoxia, head injury, hypo/hyperglycemia
E Exposure Skin, wounds, infection, incontinence — preserve evidence (clothing, impaled objects). Assess for abuse/trafficking/assault
Survey types: Primary = ABCDE (immediate life threats). Secondary = head-to-toe after life-saving interventions. Tertiary = final sweep before discharge — catches missed injuries (e.g., hip fracture found during discharge teaching → tertiary survey).

Emergency Severity Index (ESI) — Five-Tier ED Triage ⚡

Level Name Description / Example
1 Resuscitation Life-saving intervention needed immediately — apneic, pulseless, severe resp distress, O₂ sat <90%, acute mental status change
2 High Risk ⚡ High-risk situation (chest pain, suicidal ideation), confused/lethargic, pain ≥7/10, severe distress (sexual assault, partner violence). Ex: anticoagulated pt with nasal bleeding that slowed = ESI 2
3 Two Resources Needs ≥ 2 resources (labs + IV fluids, x-ray + procedure, etc.)
4 One Resource Needs 1 resource only
5 No Resources Minor complaint, no resources needed
Three-tiered system: Emergent (life-threatening) · Urgent (can be slightly delayed) · Delayed (stable) — Ex: patient with 3 days of stable GI symptoms and no comorbidities = Delayed.
🏷️
Triage Systems — Disaster & SALT

Disaster Triage Locations

  • Primary — in the field; providers treat and prioritize evacuation
  • Secondary — ED; nurse categorizes using 3- or 5-tier tool
  • Tertiary — client moves to ICU/OR after ED

Goal of Disaster Triage

  • Greatest good for the greatest number
  • Resources go to clients who can be saved
  • SALT algorithm: Sort → Assess → Lifesaving Interventions → Treatment/Transport

SALT Triage Tag Colors ⚡

🟢 Green
Minor injuries — can follow commands, has peripheral pulse, no resp distress, no hemorrhage. Sprains, contusions, lacerations.
🟡 Yellow
Meets green criteria + more than minor injuries. Fractures, open wounds, deep lacerations.
🔴 Red
Does not meet green criteria but may survive if treated. Neurological injury, shock, major burns. CPR applied, hemorrhage controlled.
⬛ Black
Dead or not expected to live. Agonal respirations, unsurvivable injuries. Ex: burns + spinal cord injury.
Initial mass casualty notification includes: Type of incident · Estimated number of casualties · Type of injuries expected. Does NOT include traffic control plans or elective surgery rescheduling.
❤️
Code Blue, RRT & Handoff Communication

Rapid Response Team (RRT)

  • Called by nurse who identifies clinical deterioration before full cardiac arrest
  • Team: critical care nurse, pharmacist, respiratory therapist, provider
  • Common triggers: sepsis, respiratory failure, subtle mental status change
  • Clinical triggers: SBP <60 or >160, RR changes, HR changes, O₂ sat <90%, new confusion/restlessness

Code Blue Team Roles

  • First responder: calls code blue + starts chest compressions + leads until team arrives
  • Other staff: bring code cart, attach cardiac monitor
  • Provider becomes leader at code cart
  • One nurse: records events
  • One nurse: IV access + medications
  • Respiratory therapist/anesthesia: ventilates client
  • Client's nurse: manages environment + communicates with family
  • After code: transfer to CCU if not already there + debrief
Code Cart Check ⚡
Checked and documented every 24 hours. Replenished after every use. TJC requirement.
Code Cart Contents
Defibrillator · Bag-valve mask · Epinephrine · Amiodarone · Sodium bicarb · Calcium · Glucose · IV access supplies · Airway equipment · Specialty trays
BLS/ACLS Renewal
Every 2 years. TNCC every 4 years.
Handoff Responsibility ⚡
Both the sending AND receiving nurse are mutually responsible for completeness & accuracy. Tool: SBAR.
EMTALA ⚡
All ED patients must be evaluated and stabilized before transfer/discharge. COVID provision: permits transfer of unstabilized patients when ED is overwhelmed.
Cardiac: Most Concerning ⚡
Chest pain unrelieved by nitroglycerin = most urgent finding in cardiac history patient
Cardiac key assessment points: Previous chest pain episodes · Dyspnea · HR & rhythm · BP (both arms, lying & standing) · Carotid pulse · JVP · Mucous membrane color · Heart sounds · Peripheral pulses · Perfusion hands/feet.
🛡️
Special Populations — Sexual Assault & Human Trafficking

Sexual Assault ⚡

  • #1 reason not to report: Fear of being stigmatized
  • When possible, assign a SANE (Sexual Assault Nurse Examiner)
  • Obtain consent before forensic exam; explain all steps
  • Client should NOT change clothes or void before exam (preserve evidence)
  • Most important question to ask: "Were you exposed to HIV?"
  • If exposed: start PEP within 72 hours of assault
  • Emergency contraception (EC): ulipristal acetate 30mg × 1, effective up to 120 hrs (5 days)
  • Offer STI evaluation regardless of whether forensic exam is done

Sexual Assault — Discharge ⚡

  • First action before patient leaves: Ask if they want to return home (safety assessment)
  • Provide: bathing facility, food/beverages, grooming supplies, phone access, replacement clothing, follow-up instructions, law enforcement info, support services info
  • Law enforcement must take immediate custody of evidence after collection
  • Time is critical — collect evidence ASAP

Human Trafficking — Red Flags ⚡

Companion behavior
Companion refuses to leave patient alone with nurse; answers most/all questions for patient; won't allow patient to ambulate to restroom alone
Physical findings
Tattoo on inner thigh; bruises near groin and lower abdomen; multiple wounds in various stages of healing; appears malnourished/thin; afraid to answer specific questions
History clues
Multiple previous abortions; vague or inconsistent injury explanation; lives with multiple people; history of STIs, fractures
Imaging findings
Multiple healing fractures + hairline rib fracture = high-suspicion finding on x-ray
Nurse action
Get patient alone to assess; legally must obtain patient consent to intervene; contact social services + National Human Trafficking Hotline
Violence in ED
Patients may fear possible outcome of clinical situation → stress → aggression. 50%+ of ED nurses experience verbal or physical assault.
🧠
Delirium Prevention & Early Mobility

Delirium ⚡

  • Acute neurological disorder; 20–80% incidence in ICU
  • 30% more common in patients >65
  • Can be reversed (unlike dementia)
  • Hyperactive delirium: agitation, restlessness
  • Hypoactive delirium: apathy, withdrawn — often missed, worse prognosis
  • Assess ≥ 2×/day — CAM-ICU or ICDSC tool
  • Highest risk: elderly + sepsis/pneumonia

Prevention Strategies ⚡

  • Turn off lights at night (exam answer for delirium prevention)
  • Open blinds during day (sunlight exposure)
  • Minimize noise, answer alarms immediately
  • Ambulate client ASAP
  • Remove restraints; remove urinary catheters ASAP
  • Assist with eyeglasses and hearing aids
  • Wean from mechanical ventilation ASAP

Early Mobility ⚡

Why ambulate early?
ICU patients lose 40–58% muscle mass within 7 days. Ambulation prevents long-term weakness and quality-of-life impact.
Goal ⚡
Ambulate clients as early as possible to maintain muscle strength — family should be told this
When to POSTPONE ⚡
Postpone ambulation when patient is on mechanical ventilation AND blood pressure is unstable (Next Gen answer)
Burns: CONTRAINDICATION
Ambulating in hallway is CONTRAINDICATED for significant burn patients. Indwelling catheter, mechanical vent, gastric intubation = INDICATED. Droplet isolation = UNRELATED.
Progression
Chair transfer → assisted ambulation. If can't ambulate: ROM exercises, neuromuscular electrical stimulation
Team needed
Nurse, respiratory therapist, PT, pharmacist, provider — sedation must be light or off before attempting
🚨
Disasters, Chemical Emergencies & Resource Allocation

Chemical Emergency ⚡

  • Info about chemical spill: Safety Data Sheets (SDS) — found on hospital WiFi network
  • Use PPE (gown, gloves, mask) until chemical is identified
  • Priority action for A&O ambulatory patient: direct to decontamination area
  • Decontamination = copious amounts of water; remove/discard contaminated clothing; shower and dry; provide clean clothing
  • Hot zone → holding area → decontaminate → cold zone → evaluate for discharge

Burns — Primary Survey Focus

  • Assess: burns around mouth/nose, stridor/wheezing, expectorant with charcoal-like material, continuous coughing, O₂ sat <95%
  • Determine % TBSA during primary survey
  • Burns >15% TBSA: IV fluid resuscitation required
  • Smoke inhalation → airway edema → may need mechanical ventilation
  • Give tetanus immunization for burn patients

Resource Allocation During Scarce PPE / Disaster ⚡

Prepare
Stockpile items before disaster
Substitute
Use similar item (e.g., critical care nurse in place of ED nurse)
Adapt
Use not-equivalent but sufficient item (e.g., anesthesia machine instead of ventilator)
Conserve ⚡
Use less (e.g., prescribing 5mg morphine instead of 10mg = conserve)
Reuse ⚡
Reuse normally single-use items (e.g., sanitizing N95 masks instead of discarding) — PPE shortage during pandemic
Reallocate
Prioritize resources to clients with greater survival chance/greater need
Benner's Novice to Expert: Novice → Advanced Beginner → Competent → Proficient → Expert. New nurse lacking a skill (e.g., IV insertion) should ask: "What knowledge can I improve upon?" (self-assessment, not blame shifting).
🕊️
End of Life, Communication & Resilience

Terminal Patient — Life Support Removal ⚡

  • First action: Prepare in advance how to discuss the situation with the family (PREPARED model)
  • PREPARED: Prepare · Relate · Elicit wishes · Provide education · Acknowledge emotions · Realistic hope · Encourage questions · Document
  • Break bad news in small parts, leading the family gradually
  • Nurse + provider share news together — provider answers technical questions; nurse provides empathy & support
  • For dying patients who survive but don't improve: discuss removing equipment with family

Dying Patient Family Communication ⚡

  • Work with provider to frequently update family on status in a compassionate way
  • Do not give false hope
  • Family presence during resuscitation: allowed and encouraged — gives comfort, chance to say goodbye
  • Aid-in-dying (AID): nurse must know state laws; nurses spend most time with patient, best positioned to navigate

Trusting Relationship & ED Communication

Primary goal of nurse-family interaction ⚡
Creating a trusting relationship — allows patient to share info, family to receive updates, and builds foundation for care
Resilience strategies
Mindfulness · Compassion for self · Diaphragmatic breathing · Peer-support sessions · Balance work/life · Decrease social media · Emotional intelligence
Imposter syndrome
Belief that one is not competent; accomplishments are luck. Self-assessment is key — recognize it and continue learning.
Professional autonomy
Nurses making independent decisions; supported by leadership, collaborative decision making, comprehensive orientation
⚡
Exam High-Yield Summary
EMTALA — COVID provision
Permits transfer of unstabilized patients when ED overwhelmed by disaster/pandemic
Handoff responsibility
Both the ED nurse and the ICU nurse are responsible for completeness and accuracy
Code cart check
Every 24 hours + after every use (TJC requirement)
ESI Level 2 example
Patient on anticoagulants with nasal bleeding that slowed with pressure = high-risk situation → ESI 2
ABCDE "D"
Disability = check alertness + response to voice and pain (AVPU)
Chemical spill info
Find Safety Data Sheets (SDS) on hospital WiFi network
Chemical disaster: A&O patient
Priority: direct to decontamination area
Three-tiered: Delayed
Stable VS, no comorbidities — e.g., 3-day GI symptoms (N/V/D) with stable vitals
Tertiary survey
Injuries discovered during or before discharge (e.g., wrist fracture found at D/C teaching)
Ventilated patient: ambulate
Goal: ASAP to maintain muscle strength — tell family this is why
Postpone ambulation
Next Gen: postpone based on blood pressure (unstable BP = don't ambulate)
PPE shortage strategy
Reusing — e.g., sanitizing N95 masks rather than discarding
Lights off at night
Strategy to prevent delirium in older patients
Cardiac: most concerning
Chest pain unrelieved by nitroglycerin
Sexual assault: most important question
"Were you exposed to HIV?" → start PEP within 72 hrs if yes
Sexual assault: non-reporting
Most common reason = fear of being stigmatized
Sexual assault: discharge
Most important before leaving: ask if patient wants to return home (safety)
Terminal patient: first action
Life support removal: prepare in advance how to discuss with family
Dying patient: family update
Work with provider to frequently update family compassionately
New nurse/missing skill
Ask: "What knowledge can I improve upon?" = self-assessment (Benner's model)
Primary goal — nurse-family
Creating a trusting relationship
Violence in ED: why patients aggress
Fear of possible outcome of clinical situation → stress → aggression
Burns — INDICATED
Indwelling catheter · Mechanical ventilation · Gastric intubation
Burns — CONTRAINDICATED
Ambulating in hallway
Burns — UNRELATED
Droplet isolation
Human trafficking — red flags (Next Gen)
Companion answers questions · Bruising to arms/neck · Companion refuses patient restroom privacy · Multiple healing fractures + hairline rib fracture
SALT: black tag
Agonal respirations = black tag; burns + spinal cord injury = black tag
Conserve vs. Reuse
Conserve = use less of a resource (lower dose). Reuse = sanitize & use again (N95 during pandemic).
mod 26Inclusion, Equity, and Diversity
📖
Key Concepts — Culture, Bias & Competence

Culture — What It Is ⚡

Culture = learned, shared, transmitted values, beliefs, norms, and lifeways of a group. It includes language, communication practices, customs, religion, and health beliefs. Culture shapes how clients define health and illness — health and illness are defined differently by each individual client.

Types of Bias ⚡

  • Explicit (conscious) bias — deliberate, reportable attitudes; nurse is aware of them
  • Implicit (unconscious) bias — involuntary; affects perceptions & decisions without awareness; seen as gender, racial, or disability bias
  • Both types harm assessment & care → contribute to health disparities
  • First step to cultural awareness = conduct a self-assessment to identify your own biases ⚡

Emic vs Etic Knowledge ⚡

  • Emic = insider's perspective on a culture (from a member of that culture)
  • Etic = outsider's viewpoint of a culture
  • Gaining emic knowledge → understand client's cultural needs from their perspective
  • Having both → achieve cultural competence & holistic care
  • Memory trick: Emic = from inside; Etic = outside

Cultural Awareness → Diversity → Competence (in order)

Cultural Awareness
Investigating differences between your own culture and others. Requires examining self-bias first. Everyone has biases — acknowledging them is the starting point.
Cultural Diversity
Differences in age, ethnicity, gender identity, language, religion, socioeconomic status both within and among cultural groups. Nurses must embrace these to enhance care.
Cultural Competence ⚡
Appreciating, accepting, and respecting all individual cultural influences + integrating emic and etic knowledge into effective nursing care. Open communication and feedback are essential.
Inclusion
Environment that embraces individual differences so all can bring their whole selves and thrive. Everyone is welcomed, respected, and acknowledged.
Cultural practices affecting care: Who makes decisions (e.g., matriarch), food preferences, alternative treatments (e.g., cupping). Nurses who recognize these can incorporate them into the care plan → better outcomes. Nurses who ignore them may be overwhelmed by family involvement.
🛡️
Vulnerable Populations
Definition: Groups at higher risk for poor health outcomes due to barriers to social, economic, and environmental resources — including illness or disability. Examples: immigrants, older adults, marginalized ethnic groups, individuals in poverty, those with chronic illness, veterans.

Who Qualifies? ⚡

Vulnerable ✓
African American adolescent who is pregnant · Low-income family · Latina female with type 2 DM · Veterans · Undocumented immigrants · Clients with chronic illness or disability · Older adults
NOT Vulnerable ✗
White male with no chronic illness · Middle-class male in a large city (without other risk factors)

Three Factor Categories

Demographics

  • Age — older adults more vulnerable (physical disability, dependence)
  • Language — different language = decreased health literacy, communication barriers
  • Population density — living close together (nursing homes, shelters, dorms) = higher infection risk
  • Race/ethnicity — discrimination → stress → heart disease, DM, Alzheimer's
  • Intersectionality — multiple simultaneous disparities → greater stress → lower self-esteem → risky behaviors (substance use)

Health Status & Socioeconomic

  • Chronic conditions (obesity, DM, HTN) → complex complications
  • Disabilities → barrier to healthcare access and ADLs
  • No health insurance = limited access to care
  • Lower education → lower health literacy
  • Unemployment/low income → choose between basic needs vs. medications/healthcare
  • Employer-based insurance = most common coverage; no job = no insurance
Veterans ⚡ — Always considered a vulnerable population → increased risk for poor health outcomes. Do not assume they are guaranteed benefits or are unaffected by socioeconomic factors.
⚖️
Health Disparities, Equity, Equality & Literacy

Core Definitions ⚡

Health Disparities ⚡
Preventable differences in health outcomes among populations based on race, ethnicity, gender, age, or socioeconomic status. Factor impacting accessibility to healthcare services = health disparities.
Health Equity
Valuing all individuals equally + removing obstacles to achieve optimal health. Requires societal effort; not just equal distribution — accounts for individual needs.
Health Equality
Same resources distributed to everyone. Equal ≠ equitable. Example: new urgent care center = equal access for all, but those without transportation still can't access it (inequitable).
Health Literacy ⚡
Personal: individual's ability to obtain, process, and understand health info. Organizational: org's ability to equitably help individuals find and use health info. NIH recommends all health info at ≤8th-grade reading level.

Factors Affecting Access (Health Disparities)

  • Transportation · Geographic location · Socioeconomic status
  • Health insurance · Limited education
  • Race · Ethnicity · Gender · Sexual orientation
  • Physical, cognitive, sensory disabilities
  • Mental health · Religion

Healthy People 2030 Goals

  • Eliminate health disparities
  • Achieve health equity
  • Attain health literacy for all
  • National CLAS Standards = blueprint for healthcare orgs to advance health equity
Improving health literacy (CDC): Create easy-to-understand info · Collaborate to help individuals know their health info · Use trusted messengers · Use certified interpreters for language barriers.
🏳️‍🌈
Marginalized Groups — LGBTQ+ & Gender Identity

Key Definitions ⚡

  • Transgender = gender identity differs from sex assigned at birth. Focus: identity, not pronouns preference. ⚡ Correct answer = "Client associates their identity to something different from their sex assigned at birth."
  • Marginalized sexual groups = lesbian, gay, bisexual, and those questioning their sexual orientation or gender identity

Health Risks for LGBTQ+ Youth ⚡

  • Being bullied at school
  • Depression
  • Use of illicit substances
  • Increased risk for STIs
  • Suicide risk
  • Caused by: prejudice, social stigma, discrimination, physical and sexual violence
  • NOT associated: large friend group, working an after-school job
Long-term effects of marginalization: depression, PTSD, unemployment, poor relationships, chronic health outcomes. Youth impacts can carry into adulthood and affect schooling and employment performance.
🌅
Cultural Assessment — Leininger's Sunrise Enabler
Created by Madeline Leininger — part of the Theory of Culture Care Diversity and Universality. A visual portrayal of elements that help nurses provide culturally congruent care. All five categories are interrelated — can't be separated.

The 5 Categories

1 — Upper Level
Worldview and cultural/social structure dimensions — all other categories build up to this. Gives a complete picture of how culture shapes health and illness.
2 — Rays of the Sun ⚡
The 8 basic elements (see below). These are the most tested — know all 8 and which ones are included vs. which are NOT.
3 — Central Core
Interactions among basic elements → how they influence care reactions. Includes: influencers, care expressions/patterns, holistic health/illness/dying/death.
4 — Individual/Family/Community
Folk (generic) care · Integrative care · Professional care-cure practices. Nurse bridges folk medicine and Western medicine.
5 — Three Modes of Care
Preservation/Maintenance (support existing beliefs) · Accommodation/Negotiation (adapt beliefs for safety) · Repatterning/Restructuring (change beliefs for better outcomes)

Category 2 — The 8 Rays (Basic Elements) ⚡

Factor What to Assess
Technological Access to phone, internet, computer → affects health communication and education
Religious/Spiritual Religion, spirituality, philosophical worldview → intersects with health care needs
Kinship & Social ⚡ Marital status, family type, support systems, extended family and friends
Cultural Values/Beliefs Lifeways — how client spends their day, what is important, need for assistance from others
Biological ⚡ Personal/family history of physical illness, mental illness, hereditary/genetic conditions (added 2018)
Political & Legal ⚡ Political views → influence values/health behaviors. Legal status (e.g., undocumented = avoids care until emergent)
Economic ⚡ Education level, employment, income, poverty status, transportation, healthcare access
Educational Highest level of education → determines health literacy. NIH: present info at ≤8th-grade level
Trick question ⚡ — "Health disparity factors" is NOT one of the 8 rays of Leininger's Sunrise Enabler. The 4 tested factors are: kinship/social, biological, economic, political/legal.

Nursing Process & Cultural Assessment Order ⚡

Newly admitted client — do first ⚡
Perform a cultural health assessment at the beginning of the first encounter → enables open communication, client cooperation, accurate information → improves outcomes throughout all remaining nursing process steps.
Best care for client from different culture — do first ⚡
Conduct a self-assessment first (not the cultural assessment). You must examine your own biases before you can effectively assess and care for a client from a different culture.
Folk care + modern care ⚡
Coordinate folk care with modern medical treatments (culture care accommodation). Do NOT tell clients to stop folk care or that it can't be used. Bridge both approaches.
Client with cultural background (30 yrs in US) ⚡
Client born in India but lived in US 30 years → Inquire about special cultural beliefs or practices. Don't assume they have them; don't automatically get an interpreter.
🗣️
Communication & Interpreters

Certified Medical Interpreter ⚡

  • Required when there is a language barrier between client and nurse
  • Do NOT use family members — lack medical terminology → errors in translation + privacy violation risk
  • Do NOT use: talking slowly, repeating words, computer apps, AP staff learning the language
  • Maintain eye contact with the client (not the interpreter) during conversation → maintains open and positive communication
  • Use interpreter for discharge instructions, consent, and teaching

Hearing Loss Communication

  • Face the client when speaking ⚡
  • Do NOT use a loud tone of voice
  • Do NOT speak at a faster pace
  • Writing on paper is one option but not the primary approach
  • Other methods: speak clearly at normal pace facing client, use visual aids, ensure hearing aids are in place
Congruent communication: Nurses must ensure the communication techniques and words used are congruent between nurse, client, and family. Cultural differences in language affect how messages are received and interpreted.
⚡
Exam High-Yield Summary
Self-assessment first ⚡
To provide best care to a client from a different culture → conduct self-assessment FIRST (identify your own biases) before cultural assessment
Cultural awareness examines
Examine self-bias to enhance cultural awareness — not health disparities or nursing process
Newly admitted — do first
Perform cultural health assessment at the very start of the first encounter
Culture definition ⚡
Culture includes language and communication practices. Does NOT mean every client is treated the same. NOT every individual has cultural preferences.
Health & illness ⚡
Culture → health and illness defined differently by individual clients — not similarly for all
Emic = insider ⚡
List of health beliefs provided by cultural group members = emic knowledge (insider perspective)
Etic = outsider
Outside observation of a culture = etic knowledge
Health disparities
Factor impacting accessibility to health care services = health disparities (not cultural diversity or competence)
Vulnerable populations ⚡
African American adolescent pregnant · Low-income family · Latina female with T2DM · Veterans. NOT: white male no chronic illness, middle-class male in large city
Veterans ⚡
Always vulnerable → increased risk for poor health outcomes. Not guaranteed benefits; affected by socioeconomic factors
Lesbian/bisexual youth risks ⚡
Bullied at school · Depression · Illicit drugs · STIs · Suicide. NOT: large friend group, working after-school job
Transgender ⚡
"Client associates their identity to something different from their sex assigned at birth" — focus on identity, not assumption about pronouns or who they prefer as caregivers
Medical interpreter ⚡
Language barrier → use certified medical interpreter. NEVER family, NEVER talking slowly, NEVER AP staff, NEVER computer apps
Interpreter: eye contact
Maintain eye contact with the client, not the interpreter — promotes open positive communication
Hearing loss ⚡
Face the client when speaking. Do NOT use loud voice or faster pace
Folk care ⚡
Coordinate folk care with modern medical treatments — do not discourage or ban. Bridge both approaches (culture care accommodation).
India client (30 yrs US)
Don't assume cultural needs, don't automatically get interpreter → Inquire about special cultural beliefs or practices
Sunrise Enabler: 8 factors ⚡
Technological · Religious/Spiritual · Kinship/Social · Cultural Values · Biological · Political/Legal · Economic · Educational. "Health disparity factors" is NOT one of them.
Equality vs Equity
Equality = same resources for all. Equity = fair distribution based on individual needs. Equal ≠ always equitable (e.g., new clinic ≠ accessible for those without transport)
Madeline Leininger
Created the Theory of Culture Care Diversity & Universality and the Sunrise Enabler. All 5 categories are interrelated.
Three modes of care ⚡
Preservation (keep beliefs) · Accommodation/Negotiation (adapt beliefs) · Repatterning/Restructuring (change beliefs for better outcomes)
Specimen Collection
🩸
Blood Specimens — Venipuncture & Capillary

Venipuncture (Phlebotomy) ⚡

  • Place tourniquet above the site to locate vein — remove once site is identified, before cleansing
  • Stroke arm distal → proximal to dilate vein — avoid vigorous rubbing (risk of injury); gentle rubbing is correct
  • Cleanse with approved antiseptic — allow to dry completely before puncture
  • Do NOT puncture while antiseptic is still wet/visible on skin
  • For blood culture: rub the arm at selected site to dilate vein (gentle stroking = correct)
  • Butterfly needles = used for pediatric clients or needle-averse clients (smaller, less pain); not appropriate for all types — can lyse cells
  • Larger gauge # = smaller bore (e.g., 22G is smaller than 18G)
  • Document: method, tolerance, pertinent findings

Capillary Fingerstick (Point-of-Care Blood Glucose) ⚡

  • To increase blood flow to finger: wrap finger in a warm cloth — heat vasodilates
  • Do NOT elevate the hand (↓ blood flow), pierce the middle of the finger pad (more painful, nerve-dense), or firmly milk the puncture site (can hemolate sample)
  • Pierce the side of the finger pad — less painful
  • Blood glucose of 180 mg/dL → administer insulin per sliding scale orders — do not give OJ (that raises glucose), do not repeat test unnecessarily

Blood Culture Tips

  • Rub arm at selected site (distal → proximal) to dilate vein
  • Do NOT keep tourniquet on entire time — remove after site ID
  • Do NOT elevate arm above heart level
  • Do NOT puncture while antiseptic is still visible
🧪
Urine Specimens

Types of Urine Collection & When to Use ⚡

Collection Type Used For Key Notes
Random / Clean voided Routine urinalysis · Urine pregnancy test Voided into a clean cup — no special prep needed
Midstream Clean-Catch ⚡ Urine culture & sensitivity (UTI) Discard initial stream → collect midstream → reduces contamination
24-Hour Timed ⚡ Creatinine clearance · Protein · Hormone levels First void discarded → all subsequent voids collected on ice. If client misses a void → restart entire collection
Catheter specimen When client cannot void; straight cath for one-time sample Never collect from drainage bag — concentrated & contaminated. Use needleless port on tubing.

Midstream Clean-Catch — Female ⚡

  • Wash hands; part labia with one hand
  • Wipe with antiseptic front to back — 3 wipes (left, right, center), fresh wipe each time
  • Allow initial stream into toilet, then collect midstream
  • Do NOT hold cup against genitalia

Midstream Clean-Catch — Male

  • Uncircumcised: retract foreskin first
  • Wipe center → outward in circular motion
  • Direct initial stream into toilet → then collect

Urinalysis — What Results Mean ⚡

  • Leukocyte esterase → UTI (white cells in urine)
  • Nitrites → infection
  • Specific gravity 1.005–1.030 = normal; ↑ = concentrated/dehydrated
  • pH 4.6–8 = normal
  • Ketones → diabetes mellitus or fat metabolism issue
  • Glucose in urine → diabetes mellitus
  • Bilirubin/urobilinogen → liver disease or RBC destruction
  • Trace protein = expected finding; not a UTI indicator
  • Specific gravity 1.010 = within normal range — not a UTI indicator

Storage & Transport

  • Keep on ice or refrigerate; transport within 2 hours
  • Unrefrigerated urine becomes alkaline → bacterial growth → invalid results
⚡ Urine Pregnancy Test: First-voided morning sample (highest hCG). False positives and negatives possible. To confirm pregnancy → blood test, not just urine. Document last menstrual period.
💩
Stool Specimens & Fecal Occult Blood Test (FOBT)

FOBT (Guaiac Test) — Key Rules ⚡

  • Screening tool for colorectal cancer, GI bleeding, ulcers, polyps
  • Recommended for clients >50 years old without symptoms
  • Collect from 3 different stools (home testing more accurate than one-time office test)
  • Do NOT contaminate sample with water, urine, or toilet tissue
  • Positive result = blue color on test card → provider orders further diagnostics

What to AVOID Before & During Testing ⚡

  • Avoid 3 days before: Red meat, poultry, fish/seafood, raw vegetables (radishes, turnips, melons) → cause false positives
  • Avoid 7 days before: NSAIDs, aspirin, anticoagulants (e.g., warfarin)
  • Avoid Vitamin C supplements (false positive risk)
  • Do NOT collect during hemorrhoid flares or menstrual cycles
  • Do NOT collect after barium procedures or while using mineral oil/laxatives
  • ✅ Yogurt, calcium supplements, Vitamin E = okay (do NOT need to avoid)

Stool Collection Procedure

  • Have client urinate first to avoid contaminating specimen
  • Collect in dry, clean container — not contaminated by water, urine, or toilet paper
  • Use tongue blade / wooden stick to transfer to specimen container
  • Sample size: walnut-sized or 15–30 mL liquid stool
  • Add preservative fluid if required (keeps parasites alive for transport)
  • Label, send to lab or refrigerate — confirm timeline with lab

Lab Tests for Stool

  • C. difficile — bacterial culture (common cause of antibiotic-related diarrhea)
  • Ova & Parasites (O&P) — for suspected parasitic infection
  • Multiple samples often needed to confirm results
🩹
Wound Culture Specimen

Collection Procedure ⚡

  • Hand hygiene → clean gloves
  • Remove dressing; clean wound with sterile water or normal saline (NOT antiseptic — it kills organisms)
  • Use a sterile swab — collect from center of wound or area of drainage using a rotating motion
  • Never collect from: wound edges (colonized with skin flora → misleading), pus/pooled exudate
  • Never use same swab on more than one location
  • Place swab in sterile culturette — break ampule at bottom to activate transport medium
  • Label and send to lab promptly

Key Points to Remember ⚡

  • Rotate swab over viable tissue or drainage — ensures organisms are collected
  • Do NOT irrigate with antiseptic before collecting — kills organisms and ruins culture
  • Do NOT wipe crusty edges/outside of wound — results are misleading (external flora)
  • Culture and sensitivity → identifies bacteria + effective antibiotic
  • Gram's stain can be requested for faster preliminary results
  • Collect wound culture before starting antibiotics if possible; if already on antibiotics → note on lab requisition form
  • Multiple wounds or large wounds → separate swab per site
⚡ SATA Exam Tip — Wound Culture: Correct actions = Use a sterile swab + Use a rotating motion. Wrong: antiseptic irrigation, collecting from edges, aspirating exudate from pus pools.
🫁
Sputum & Throat Specimens

Sputum Collection ⚡

  • Best collected in the morning — before eating or drinking (highest concentration, least diluted)
  • Rinse mouth before collecting (removes normal oral flora → more accurate)
  • Client must cough deeply — sputum from lungs, NOT saliva
  • Target: 5–10 mL of sputum
  • If unable to produce: use chest physiotherapy first; suctioning/transtracheal aspiration = last resort
  • Nurse wears N95 respirator for suspected TB (airborne precaution)

Sputum Lab Tests

  • Routine culture — sterile container; identifies bacteria
  • Acid-fast bacilli (AFB) — sterile container; 3 serial samples collected to detect TB
  • Cytology — special preservative; identifies type of lung cancer (small cell, oat cell, large cell)
  • Culture & sensitivity — identifies bacteria + appropriate antibiotic

Throat & Gum Cultures

  • Use sterile swab
  • Throat: rub swab over tonsillar area right → right arch → uvula → left arch → left tonsil
  • Do NOT touch: gums, tongue, or teeth with swab (contamination)
  • Gum specimen: lightly scrape inside of cheek
  • Point-of-care tests less accurate than lab → confirmatory test recommended for positive findings

TB & Sputum — Key Points

  • Suspected TB → airborne precautions + N95 for nurse
  • AFB requires 3 separate samples on different days
  • Client should rinse mouth before each collection (not after)
  • If client can't produce sputum → chest physiotherapy → then suction if still inadequate
⚡
Exam High-Yield Summary
Wound culture — correct swab technique
Sterile swab + rotating motion over viable tissue or drainage area
Wound culture — do NOT collect from
Wound edges (skin flora = misleading), pus, pooled exudate
Do NOT irrigate wound with
Antiseptic before collecting culture — kills organisms
FOBT: how many samples
3 different stools — home testing more accurate than one-time office test
FOBT: foods to avoid (false +)
Red meat, poultry, seafood, fish, raw vegetables — avoid 3 days before
FOBT: meds to avoid
NSAIDs, aspirin, anticoagulants — avoid 7 days before
FOBT: safe (no need to avoid)
Yogurt · Calcium supplements · Vitamin E
UTI urinalysis finding
Leukocyte esterase — indicates infection. Trace protein & SG 1.010 are normal, NOT UTI signs
Random urine sample appropriate for
Routine urinalysis (not for culture & sensitivity, creatinine clearance)
Midstream clean-catch: first step
Urinate small amount into toilet first — flushes urethral bacteria
Clean-catch: female wipe direction
Front to back — prevents perineal/rectal contamination
24-hr urine: client misses a void
Restart the entire collection from the next urination
Never collect from indwelling catheter
Drainage bag — use needleless port on tubing instead
Capillary fingerstick: ↑ blood flow
Wrap finger in warm cloth — heat dilates vessels
Blood glucose 180 mg/dL → action
Administer insulin per sliding scale — do NOT give OJ
Blood culture: vein dilation technique
Gently rub/stroke arm distal → proximal — avoid vigorous rubbing
Venipuncture: when to puncture
Only after antiseptic has fully dried — do NOT puncture while still visible/wet
Sputum: best time to collect
Morning, before eating or drinking
Sputum: can't produce sample → do first
Chest physiotherapy — suctioning is last resort
AFB (TB) sputum test requires
3 serial samples in sterile containers
Confirm urine pregnancy
Follow up with blood test — urine can give false results
Urine: store if not sending immediately
Refrigerate — transport within 2 hours; unrefrigerated = bacterial growth, invalid
mod 34Gas Exchange and Oxygenation
🫁
Respiratory Anatomy & Gas Exchange
Nose/Mouth → Pharynx → Larynx → Trachea → Bronchi → Bronchioles → Alveoli ⚡
Upper Airway
  • Pharynx — cavity posterior to nose/throat; nasopharynx + oropharynx; warms, filters, humidifies air
  • Larynx — top of trachea; houses vocal cords
Lower Airway
  • Trachea → bronchi → bronchioles → alveoli
  • Right lung: 3 lobes · Left lung: 2 lobes
  • Alveoli — site of actual gas exchange ⚡
  • Pulmonary capillaries embedded in alveolar walls
Supporting Structures
  • Pleural cavity — visceral & parietal layers; pleural fluid enables smooth expansion
  • Diaphragm — separates chest from abdomen; autonomic NS control
  • Surfactant — prevents alveolar collapse on exhalation ⚡
  • Absent surfactant → atelectasis; most common post thoracic/abdominal surgery

Ventilation & Chemoreception

  • Inhalation: diaphragm + intercostals contract → negative pressure → thorax expands
  • Exhalation: muscles relax → gas expelled
  • Normal RR: 12–20 breaths/min · Brainstem monitors O₂ demand & CO₂
  • Peripheral chemoreceptors: aortic arch & carotid bodies
  • Central chemoreceptors: medulla oblongata

Perfusion & ANS Airway Control

  • RV → pulmonary artery → capillaries → O₂ exchange → pulmonary veins → LA → LV → aorta
  • O₂ transported by hemoglobin in RBCs
  • Parasympathetic → bronchoconstriction  ·  Sympathetic → bronchodilation ⚡
  • ↑ airway resistance → ↑ work of breathing (asthma, COPD)
📊
Lung Volumes, Cardiac Output & Conduction

Lung Volumes

TV — Tidal Volume
~500 mL
Air inspired & expired with each normal breath at rest
IRV — Inspiratory Reserve
~3,000 mL
Extra air breathed in after a typical inspiration
ERV — Expiratory Reserve
~1,100 mL
Air forcefully expelled after a normal breath out
RV — Residual Volume
~1,200 mL
Air remaining in alveoli after max expiration — cannot be exhaled
VC — Vital Capacity ⚡
~4,800 mL
Max air expelled after maximal inspiration = TV + IRV + ERV
TLC — Total Lung Capacity
~6,000 mL
All air in lungs after maximal inspiration = VC + RV
FVC — Forced Vital Capacity
in 1 sec
Air expelled in 1 second during forced expiration — used in spirometry
Lung Compliance
Distensibility
Extent lung expands with ↑ alveolar pressure · ↓ in emphysema, COPD, fibrosis, atelectasis
Cardiac Output ⚡
  • CO = HR × SV — volume of blood pumped by LV per minute
  • Normal resting: 3–6 L/min; athletes up to 35 L/min
  • Preload — EDV in LV; Frank-Starling: more stretch → stronger contraction → ↑ SV
  • Afterload — resistance LV works against; inversely related to SV
  • Contractility — force of LV ejection; ↓ in MI → ↓ CO
Electrical Conduction ⚡
⭐ SA Node
pacemaker
→
AV Node
→
Bundle of His
→
L & R Branches
→
Purkinje Fibers
contraction
  • Bradycardia <60 bpm · Tachycardia ≥100 bpm
Heart Sounds
S1
"lub"
Mitral & tricuspid close · systole onset
S2
"dub"
Aortic & pulmonic close · end systole
S3
"ken-tuck-y"
HF in adults · benign in kids/athletes
S4
"ten-nes-see"
Aortic stenosis · HTN · MI hx
  • Murmur — whooshing/blowing ⚡; backflow through incompetent valve
⚠️
Pathophysiology: Breathing & Cardiac Disorders

Ventilation Disorders

⬆️
Hyperventilation
↑ rate & depth → excess CO₂ exhaled
Respiratory Alkalosis
S/S: Dizziness · headache ⚡ · anxiety · ↑ HR · weakness · numbness/tingling fingers
Causes: Anxiety attacks ⚡ · pneumonia · COPD/asthma · DKA · brain injury
⬇️
Hypoventilation
Shallow/slow → CO₂ retained, O₂ drops
Respiratory Acidosis
S/S: Anxiety · dyspnea · confusion · disturbed sleep · weakness · impaired cough
Causes: Neuromuscular dx · barbiturates/narcotics/benzos · neurologic dx · trauma · COPD
Hypoxemia & Hypoxia
  • Hypoxemia — ↓ O₂ in blood · Hypoxia — ↓ O₂ at cellular level ⚡
  • S/S: confusion, irritability, restlessness, dyspnea, tachypnea, tachycardia or bradycardia, cyanosis, nasal flaring
  • Intercostal retractions → medical emergency
  • Causes: smoke inhalation ⚡, high altitude, COPD/pneumonia/asthma, anemia, meds ↓ RR
Heart Failure & Valves
  • Left HF → pulmonary vein backup → crackles, SOB, hypoxia ⚡
  • Right HF → systemic vein backup → peripheral edema
  • Stenosis — narrowed/stiff valve; ventricle hypertrophies ⚡
  • Regurgitation — leaky valve; backflow → murmur
  • A-fib — signals outside SA node ⚡; atria quiver → blood clots form
Ischemia & Perfusion
  • MI — irreversible; rest & nitro do NOT relieve pain ⚡
  • Angina pectoris — chest pain ≤5 min ⚡; relieved by rest + nitro + aspirin
  • Myocardial ischemia — ↓ blood supply → ↓ CO; angina, neck/jaw pain, fatigue, nausea, sweating
  • Hypoperfusion — hypotension, ↓ CO; syncope, arrhythmias, ↓ LOC, ↓ urine, lactic acidosis ⚡
  • V-tach — ventricular signals ⚡; chest pain, dizziness, SOB; with or without pulse

Modifiable Risk Factors ⚡

  • High-fat diet → ↑ BP & cholesterol ⚡
  • Sedentary lifestyle ⚡
  • Smoking (25+ yr hx) → vasoconstriction, ↓ O₂, ↑ BP & HR ⚡
  • Chronic stress → cortisol → ↑ BP, ↑ HR, ↑ weight gain
  • DASH diet → ↓ BP · Mediterranean diet → ↓ CVD, cancer, T2DM, dementia

Non-Modifiable & Environmental

  • Age · Family history (non-modifiable)
  • Pollution, second-hand smoke, vehicles → lung tissue damage
  • Occupational hazards: coal dust, grain, construction dust, chemical vapors
🔍
Cardiopulmonary Assessment
Inspection
  • Normal: regular, quiet breathing; no discomfort ⚡
  • Clubbing — enlarged fingertips; COPD, CF, lung cancer ⚡
  • Barrel chest — COPD
  • Tripod position — arms on legs/table → enhances respiratory effort
  • JVD: recline 30–45°; >1.5 in above sternal notch = abnormal → ↑ CVP
  • Cyanosis — bluish discoloration; late hypoxia sign
Palpation
  • Carotid + apical pulses simultaneously → rate/regularity comparison
  • Crepitus — bubbles/crackling under skin → subcutaneous air
  • Respiratory excursion — hands at 10th rib; thumbs separate evenly bilaterally
  • Tactile fremitus — chest wall vibration while speaking; ↓ in pleural effusion or pneumothorax
  • Pitting edema: 1+ (slight) to 4+ (deep, slow return)
  • CRT ≤3 sec normal; prolonged = impaired circulation/oxygenation
Percussion
  • Resonance → dullness at cardiac border
  • Resonance → dullness over lung = excess fluid (pleural effusion)

Adventitious Lung Sounds

Crackles ⚡
INHALATION
Popping / crackling sound from fluid in small airways
Inhalation
Pneumonia · left-sided HF
Wheezing
EXHALATION
Musical whistling from narrowed airways
Exhalation
Asthma · COPD
Rhonchi
EITHER
Rattling / gurgling from secretions in large airways
Inhale or Exhale
Airway obstruction · COPD
Stridor ⚡
INHALATION
High-pitched crowing from upper airway obstruction
Inhalation
🚨 Medical Emergency — epiglottitis · croup

Heart Auscultation Sites ⚡

Valve Location
Aortic 2nd ICS, right sternal border
Pulmonic 2nd ICS, left sternal border
Tricuspid 4th–5th ICS, left sternal border
Mitral 5th ICS, midclavicular line (left)
💨
Oxygen Therapy & Delivery Devices
O₂ is a medication — requires provider prescription · Healthy SpO₂: 95–100% · COPD SpO₂: 88–92% · Peds: SpO₂ <90% with distress · Humidify if flow >4 L/min

Delivery Devices

Low-Flow
Nasal Cannula ⚡
1–6 L/min 24–44% FiO₂
Most comfortable · COPD limit 2 L/min · skin breakdown at ears/nares
Simple Face Mask ⚡
5–10 L/min 35–60% FiO₂
Never <5 L/min (CO₂ buildup) · 7 L → simple mask ⚡ · ok for mouth breathers
Partial Rebreather
10–15 L/min 60–90% FiO₂
Reservoir bag — keep inflated · short-term acute illness
Nonrebreather
10–15 L/min 80–95% FiO₂
One-way valves · snug fit required · O₂ toxicity risk if prolonged
High-Flow & Precision
Venturi Mask ⚡
4–12 L/min 24–70% FiO₂
Most precise FiO₂ · preferred for COPD ⚡ · color-coded adapters · no humidification needed
High-Flow Nasal Cannula ⚡
Up to 60 L/min 21–100% FiO₂
Minimal gastric distension · may avoid intubation · peds: preferred for mod-severe bronchiolitis ⚡
Positive Pressure
CPAP ⚡
Continuous Variable FiO₂
Primary use OSA · covers nose ⚡ · keeps alveoli open
BiPAP
Continuous Variable FiO₂
Higher pressure inhale, lower exhale · COPD · HF · sleep apnea with muscle weakness
Special & Emergency
Manual Resuscitation Bag ⚡
10–15 L/min Up to 100% FiO₂
Cardiac/resp arrest · apex over nose, base over mouth · one-way valve ⚡
Aerosol Mask / Nebulizer
Variable
Delivers nebulized meds · mouthpiece for >5 yr ⚡ · face mask for <5 yr
Face Tent
≥10 L/min 24–100% FiO₂
Fits loosely under chin · imprecise FiO₂ · claustrophobic clients · post nasal/oral surgery
T-Piece
10 L/min Variable FiO₂
For artificial airways (ETT/trach) · used with nebulizer

O₂ Toxicity ⚡

  • Tinnitus (ringing in ears) ⚡, headache, muscle twitching, disorientation → acute CNS effects
  • Chronic: atelectasis, coughing, dyspnea, pleuritic chest pain; long-term → cataract formation
  • Cellular damage → alveolar collapse within 24 hrs of pure O₂
  • Without humidifier → cracks in oral/nasal mucosa ⚡

Home O₂ Safety ⚡

  • Post "No Smoking" signs inside AND outside ⚡
  • Attach containers to a fixed object ⚡
  • Notify fire dept & electric company ⚡
  • Tubing ≤ 50 feet (not 60 ft!) ⚡ · NOT in closed space (closet) ⚡
  • Away from heat, flames, aerosol sprays, petroleum products, hand sanitizer
  • Bedding: 100% cotton ⚡ · Flow meter knob all-right = stops O₂ flow ⚡

Home O₂ Systems

System Flow Electricity? Key Notes
Compressed Gas Up to 15 L/min No Inexpensive; bulky and heavy; careful storage required
Liquid Oxygen Up to 6 L/min No Portable tank fills from stationary vessel; expensive; evaporates if unused
O₂ Concentrator ⚡ 4–5 L/min Yes Least expensive long-term; not ambulatory ⚡; O₂ conc. ↓ as flow ↑ ⚡
🛠️
Therapeutic Interventions

Breathing Techniques

Incentive Spirometer ⚡
  • Promotes deep breathing; prevents atelectasis post-op ⚡
  • 10 reps/hour while awake ⚡; hold breath 3–5 sec each rep
Pursed-Lip Breathing
  • COPD, emphysema, pulmonary fibrosis; releases trapped air
  • Slow inhale through nose → slow exhale through pursed lips (2:1 ratio)
Coughing & Deep Breathing ⚡
  • Order: deep breath → hold → exhale slowly → brace with pillow → cough deeply ⚡
  • Every 1–2 hrs (5 reps); splint to prevent dehiscence

Secretion Clearance

Technique Key Steps / Facts Indication
CPT ⚡ Percussion + vibration + postural drainage; 20–30 min, up to 4×/day · Percussion → hollow sound ⚡ · Vibration = turbulence on exhale ⚡ · Avoid ribs, lower back, sternum, spine · Best before meals CF, bronchiectasis, excess secretions
Flutter Valve ⚡ Elbows on table, head up; tight seal · Exhale 2× normal rate ≥3–4 sec · 10 breaths then cough 3× CF, chronic bronchitis
Huff Coughing Inhale + hold → forceful exhale (less force than regular cough) · 4–5 huffs per cycle; less tiring Fatigue; post-op secretion clearance
Sputum Specimen Best AM before eating/drinking · 5–10 mL into sterile cup · Sputum (opaque/thick) ≠ saliva (thin/watery) Diagnosis (culture, cytology)
Suctioning ⚡ Oral → Yankauer (tonsil tip) ⚡ · Nasotracheal → sterile; suction mouth LAST · Adults: 80–140 mmHg; peds: 50–100 · ≤10–15 sec/pass; 1 min between passes ⚡ · 100% O₂ before & after each pass ⚡ · Insert without suction; apply while withdrawing with rotation Cannot cough/clear; artificial airway

Airway Devices

Oropharyngeal Airway
  • Hard plastic; size: corner of mouth to angle of jaw ⚡
  • Insert curved end toward cheek → rotate downward
  • Only altered LOC — stimulates gag; never in conscious client ⚡
Nasopharyngeal Airway
  • Soft rubber (nasal trumpet); size: tip of nose to earlobe ⚡
  • Does NOT stimulate gag reflex; safe for alert clients ⚡
Endotracheal Tube (ETT) ⚡
  • Mouth → past vocal cords → trachea; general anesthesia & mechanical ventilation
  • Not recommended >14 days ⚡; cuff inflated after insertion
  • Complications: bleeding, infection, hoarseness, vocal cord injury, esophageal placement ⚡
Tracheostomy ⚡
  • Long-term airway; surgical opening below vocal cords · care every 4–8 hrs
  • Fenestrated dressing only ⚡ (no cut gauze — fibers obstruct)
  • O₂: tracheostomy collar ⚡
  • Dislodged: ease back; if <72 hr (immature tract) → emergency
  • At bedside: resus bag, same-size tube, insertion tray, obturator
Chest Tubes ⚡
  • Drains blood/fluid/air from pleural/mediastinal space; restores normal intrapleural pressure
  • 3-chamber system: Collection → Water seal (air out on exhale, stops air in on inhale) → Suction control
  • Tidaling — fluid rises on inhale, falls on exhale = patent tube; absent = lung re-expanded or occluded
  • Continuous bubbling in water seal = air leak
  • Monitor for subcutaneous emphysema (dry crackling at site) ⚡
  • Keep system below chest level; upright when ambulating ⚡
  • No milking/stripping
  • Dislodged from system → exhale & cough → submerge in 2.5 cm sterile water ⚡
  • Dislodged from client → sterile non-occlusive gauze
  • High suction (−40 cm H₂O) → dry suction control system ⚡
  • Splint affected side when coughing ⚡ · Signed informed consent required ⚡
Tension Pneumothorax ⚡
  • Air enters pleural space but cannot escape → ↑ positive pressure → lung collapses
  • Mediastinal shift → tracheal deviation ⚡
  • S/S: hypotension, distended neck veins, absent breath sounds, hypoxemia ⚡
  • Medical emergency — needle decompression required
Heimlich Valve & Pleurodesis
  • Heimlich: one-way flutter valve for mobile drains · arrow points away from client ⚡ · small/partial pneumothorax; does not collect fluid
  • Pleurodesis: chemical/talc slurry via chest tube → scar tissue adhesion · clamp tube during; monitor for tension pneumothorax ⚡; unclamp immediately if signs develop
⚡
Exam High-Yield Summary
O₂ toxicity sign
Ringing in ears (tinnitus) + headache + muscle twitching
Hypoxia cause
Smoke inhalation — ↓ O₂ and ventilation
Surfactant absent →
Atelectasis — alveoli collapse on exhalation
Vital capacity
Max air expired after max inspiration
CPAP mask
Cover the nose to treat OSA
Cardiac conduction
SA → AV → Bundle of His → L/R bundles → Purkinje
Before trach suctioning
Administer 100% O₂ (open system)
Cardiac output
CO = HR × Stroke Volume
Normal breathing
Regular and quiet; no discomfort
Incentive spirometer
Every hour while awake; 10 reps; hold 3–5 sec
Gas exchange site
Alveoli
Correct CPT percussion
Hollow sound
Left HF finding
Crackles in lungs (blood backs up into pulmonary veins)
Priority: dyspnea
See dyspneic client first — hypoxia risk
1 L O₂ → device
Nasal cannula (1–6 L/min)
7 L O₂ → device
Simple face mask (5–10 L/min)
Murmur sound
Whooshing / blowing
Asthma + wheezing: first
Obtain O₂ saturation
Atrial fibrillation
Signals outside SA node; atria quiver → clots
Heart disease risk ⚡
High-fat diet · smoking hx · sedentary lifestyle (NOT overactive bladder; waist <33 in for men = not a risk)
Stenosis
Narrowed/stiff valve; ventricle hypertrophies
COPD finding
Clubbing of fingers
Chest tube: monitor for
Subcutaneous emphysema (dry crackling at insertion site)
Chest tube dislodged
Exhale & cough → submerge end in 2.5 cm sterile water
Flow meter all-right →
Stops O₂ flow
Oral suctioning device
Yankauer (tonsil tip) catheter
Long-term airway
Tracheostomy tube — only surgical airway device
−40 cm H₂O suction
Dry suction control system
Prolonged O₂ adverse Fx
Cracks in oral/nasal mucosa (drying effect)
Between suction passes
Wait 1 min to reoxygenate lungs
O₂ for trach client
Tracheostomy collar
O₂ mask: skin care
Reposition elastic band frequently
Trach dressing type
Commercially prepared fenestrated (no cut gauze — fibers obstruct)
CPT: exhaled turbulence
Vibration (not percussion)
Ambulate with chest tube
Keep collection device upright at all times
SpO₂ 90% →
Indication for O₂ therapy (early hypoxia)
Early hypoxia (not shock)
Elevated BP (late hypoxia → hypotension)
Chest tube comfort
Splint affected side during coughing
COPD precise O₂
Venturi mask
Home O₂ safety ⚡
"No Smoking" inside & out · fixed object · notify fire dept · ≤50 ft tubing · NOT in closet
mod 8Ethical and Legal Considerations
📜 Code of Ethics

ANA Code of Ethics — 9 Provisions

Applies to ALL nurses (RN, PN, students) in ALL settings including social media

Provisions 1–3

Fundamental values · compassionate care · respect for uniqueness/dignity · advocate for client rights & safety

Provisions 4–6

Duty to clients and self · accountability, responsibility, authority for best practices · competence · safe practice environment · adhere to ethical principles

Provisions 7–9

Duty to nursing profession · research · develop standards/policies · interprofessional collaboration · promote nursing integrity

Other Codes

ICN Code International Council of Nurses

Supranational scope. 2021 update added: equity & social justice, climate change, technology, sustainable development goals

NALPN Standards

Standards specific to practical nurses (LPN/LVN)

⚖️ The 6 Ethical Principles
🙋 1. Autonomy

⚡ Client's right to make own decisions including right to refuse

Nurse's obligation persists even if it differs from family/nurse preference. This is a legal obligation.

💚 2. Beneficence

Minimize harm; benefit the client

⚡ Goes above what's required: fall precautions, sitting with a scared client, meeting physical/social/emotional needs

🚫 3. Nonmaleficence

Do no harm

Ask: Will this action cause actual/potential harm? Do benefits outweigh the risks?

🗣️ 4. Veracity

Truthful and accurate information; builds trust

⚡ Disclose errors truthfully to client, provider, and supervisor

🤝 5. Fidelity

⚡ Loyalty; keep promises; uphold commitments

Follow through on agreements to build and strengthen the nurse-client relationship

⚖️ 6. Justice

⚡ Impartial, fair, equitable treatment

Regardless of age, sex, race, economic status — all clients receive same standards of safety & compassionate care

🔀 Ethical Dilemmas & Decision-Making

What is an Ethical Dilemma?

  • No clear right or wrong solution
  • Each option has advantages AND disadvantages
  • Occurs when personal values conflict with client values
  • Must follow the Code despite personal beliefs
  • Ethics committee may assist

8-Step Ethical Decision-Making Process

1

Is there an ethical dilemma? (conflict of values? no clear right/wrong?)

2

Clearly identify the dilemma (who is affected? what is the problem?)

3

Identify possible solutions (be open; don't eliminate any)

4

Apply ethical principles to each solution

5

Include all relevant individuals & factors (client, provider, family, social worker, legal, facility policy)

6

Decide on a solution (may not be unanimous; agree to work together)

7

Review the decision (has anything been overlooked or changed?)

8

Put decision into action (effective collaboration; evaluate effectiveness)

🌟 AACN Professional Values (5 Core)

Shared by all nurses across all practice settings

⚡ Altruism
Selfless concern/action for benefit of others. Advocacy is a component. Not done for reward or recognition.
⚡ Human Dignity
Every individual has intrinsic value regardless of race, religion, sex, gender, sexual orientation, culture, ethnicity, or socioeconomic status. Maintain privacy, respect, confidentiality, & culturally competent care.
⚡ Integrity
Honesty even when difficult. Upholding professional standards in challenging situations. Begins in prelicensure.
Autonomy
Right to self-determination. Legal obligation to respect client's decisions including refusal.
Social Justice
⚡ Basic right to health/well-being for every individual. Treating all clients fairly regardless of economic status, ethnicity, age, race, citizenship, disability, or sexual orientation. Nurses = largest global health worker group.
Value Clarification — process of identifying, assessing, and developing one's own values; helps navigate situations where client values differ from nurse values

Ethical Issues in Practice (examples)

Stem cell research · late termination of pregnancy · medically assisted death · refusal/termination of care · clients with substance use disorder · abuse victims · clients in legal custody · allocation of scarce resources

📣 Mandatory Reporting
Licensed nurses ARE mandatory reporters. Acting in good faith after an investigation reveals no maltreatment = no liability.

Maltreatment Types

Physical Neglect Verbal/Emotional Sexual Financial Exploitation Educational Lack of Protection from Harm

High-risk populations:

Older adults · children · those with mental/physical impairments

Reportable Diseases (examples)

Anthrax · botulism · chlamydia · foodborne disease · hepatitis A–C · HIV · influenza · measles · rubeola · ⚡ tuberculosis · Zika virus

Varies by state. STIs: agency responsible for contacting sexual partners.

📝 Incident Reporting (Occurrence Reports)

When to Report

  • Any event outside routine care
  • Medication errors
  • Workplace violence
  • Near-miss events
  • Adverse events
  • Sentinel events
Sentinel Event

Death, permanent disability, or temporary severe injury that should NEVER occur

Near-Miss

Incident where no harm occurred (e.g., expired med identified BEFORE administration)

Documentation Rules

  • Objective language; names of those involved; direct quotes
  • Report to supervisor immediately; complete ASAP
  • Filed by person who discovered the event

⚡ Critical Rule

Incident report is NOT part of the medical record. Do NOT reference it in the medical record — if you do, it becomes discoverable in court.

Document assessment, interventions, and outcomes in the medical record separately.

⚡ Just Culture — atmosphere of accountability; recognizes humanity and possibility of mistakes; nonpunitive toward error reporting; improves compliance
📊 Falsification of Records & Standards of Care

Falsification of Health Records

Documenting inaccurate, incomplete, or misleading data OR failing to document when required

Examples:

  • Not documenting an assessment
  • Not documenting interprofessional communication
  • ⚡ Documenting care that didn't occur
  • Documenting inaccurate findings

Consequences:

  • Incorrect/inadequate client care → negative outcomes
  • Disciplinary action by state BON
  • Warning to license revocation
  • Unprofessional conduct

Standards of Care (ANA)

Standards of Practice

Competent nursing care using the nursing process

Standards of Professional Performance

Ethics · culturally sensitive practice · communication · collaboration · leadership · continuing education · EBP · quality · self/peer evaluation · resource utilization · safe environment

Breach Example

⚡ Not reading back a verbal medication prescription. Breakdown in communication = leading cause of preventable harm

📤 Delegation — 5 Rights

1. Right Task

Within delegatee's job description per facility policy

2. Right Circumstance

Client condition is stable; delegatee can communicate changes

3. Right Person

Delegatee has the ability and knowledge

4. Right Directions & Communication

Specific instructions; delegatee clarifies if needed

5. Right Supervision & Evaluation

Nurse monitors completion; evaluates outcomes; ensures documentation

🧑‍⚕️ Workforce Issues

Client Abandonment

Deserting client without ensuring continuation of care

Examples:

  • Leaving unit without arranging replacement
  • Failing to give report
  • Sleeping during assignment

Moral/ethical obligation to stay when:

  • Client safety endangered
  • Nurse's actions responsible for client's health
  • Decreased risk of harm from nurse's actions
  • Benefit outweighs risk to nurse
Exception: When risk to nurse outweighs benefit (e.g., highly contagious infection + no PPE available) — must pass care to another nurse first

Staffing Ratios

Increased ratios → ↑ client mortality, length of stay, preventable incidents, burnout, job dissatisfaction

California is the only state with a law mandating minimum staffing ratios. ANA supports legislation for all states.

Nurse Fatigue

Physical & psychological exhaustion → unable to function safely

⚡ Effects: ↑ medication errors, communication breakdowns, poor judgment, ↓ client safety; ↑ risk for heart disease, cancer, diabetes, psychological disorders

Evidence-based strategies:

Limit shift lengths/hours per week · reduce night shifts to 8hr · rest periods every 2hr including naps · encourage physical activity · 7–9hr sleep per night · avoid distractions

Substance Use Disorder Among Nurses

Causes:

Genetic predisposition · mental/physical fatigue · pain control · personal/work stressors

Diversion

Self-use of controlled substances prescribed for a client

Manifestations:

  • Changes in job performance/appearance
  • Prolonged restroom trips · care errors
  • Narcotic count discrepancies
  • Volunteering to medicate other nurses' patients
  • Altered verbal/emotional responses
  • Frequent MAR alterations

⚡ Suspected impaired coworker → report to the charge nurse immediately

Many BONs now offer rehabilitation programs + return under supervision (vs. license revocation)

📢 Whistleblowing

Formally reporting illegal acts, wrongdoing, or unethical practice to a national/state regulatory agency

Federal and state safeguards protect the whistleblower from retaliation

ANA Recommends:

  1. Consult board of nursing and possibly legal counsel BEFORE reporting
  2. Gather all data and documentation
  3. Keep copies of everything
⚡
Exam High-Yield Summary
Falsification of records
Documenting care that did not occur — also includes NOT documenting when required
Social justice
"Health care should be a right for everyone" — equitable access regardless of status
PRN not given (client sleeping)
Document that the medication was NOT administered — never document "no pain" if you didn't assess
Nurse fatigue →
↑ medication errors, communication breakdowns, poor judgment, ↓ client safety
Equal care ∀ economic status
Ethical principle = Justice
Praying with scared client
Ethical principle = Beneficence (meeting emotional/social needs; going above what's required)
Mandatory reportable disease
Tuberculosis (TB) — football fracture, elder bruising from falls, and preschool enuresis are NOT reportable
Suspected impaired coworker
Tell the charge nurse — client safety first; do not confront coworker directly
Reporting own medication error
Professional value = Integrity (honesty even when difficult)
Privacy for incontinent client
Professional value = Human Dignity
"Wanted to help others"
Professional value = Altruism (selfless concern; not for reward or recognition)
Advance directives — surrogate
Surrogate makes decisions when client is unable. No attorney needed; can be changed; surrogate need NOT be family
Truthfully answering questions
Ethical principle = Veracity (builds trust; includes disclosing errors)
Respecting refusal of treatment
Ethical principle = Autonomy — a legal obligation for the nurse
Not reading back verbal order
Breach of standards of care — read-back/verify IS the standard; #1 cause of preventable harm = communication breakdown
Client doesn't understand consent
Nurse must ask the provider to re-discuss — obtaining informed consent is the provider's responsibility, not the nurse's
Refusing uninsured ED client
Violates EMTALA — all ED clients must receive a Medical Screening Evaluation regardless of insurance
Keeping promise to client
Ethical principle = Fidelity (loyalty; upholding commitments)
Blood product refusal form
Ethical principle = Autonomy (right to refuse; nurse must respect even if disagrees)
Roadside emergency care
Protected by Good Samaritan laws — requires: reasonable care, no prior knowledge of person, no compensation
Assault vs. Battery
Assault = threatening/fear of harm · Battery = actual harmful contact (illegal restraint, wrong body part operated on)
Incident report + medical record
Do NOT reference incident report in the chart — it is NOT part of the medical record (keeps it non-discoverable)
Nurse's role in informed consent
Witness the signature only — verify client has understanding; provider explains risks/benefits/alternatives
Just Culture
Nonpunitive accountability — nurses report errors to improve processes, not to be blamed
mod 21Medication Administration
💊
Pharmacokinetics — ADME
🍽️
Absorption
Drug → bloodstream
⚡ IV = fastest
⚡ PO = slowest
→
🌐
Distribution
Blood → tissues
Protein binding
Blood-brain barrier
→
🔥
Metabolism
Liver (CYP450)
First-pass effect
↓ liver → accumulate
→
🚽
Excretion
Kidneys (primary)
⚡ renal failure
= toxicity risk

Absorption Details

  • IV: no absorption barrier — direct to blood ⚡
  • PO: must pass GI + first-pass metabolism — slowest ⚡
  • Factors: route, solubility, blood flow at site, drug form
  • First-pass effect: oral drugs metabolized in liver before reaching systemic circulation → ↓ bioavailability
  • Liquid absorbs faster than tablet/capsule

Distribution Details

  • Transported via circulation to target tissues
  • Affected by: protein binding, lipid solubility, tissue perfusion
  • Only free (unbound) drug is active — bound drug is inactive reservoir
  • Blood-brain barrier: only lipid-soluble drugs can cross
  • Placental barrier: teratogenic drugs can cross to fetus

Metabolism

  • Primary site: liver (CYP450 enzyme system)
  • Converts drug to metabolites for excretion
  • Liver disease → ↓ metabolism → drug accumulation → toxicity
  • Geriatric: ↓ hepatic function → longer half-life → dose ↓ needed
  • Pediatric (neonates): immature liver → toxicity risk ↑
  • Drug-drug interactions often affect CYP450

Excretion ⚡

  • Primary route: kidneys → urine
  • Also: bile/feces, lungs (alcohol), sweat, breast milk
  • Impaired kidney function → greatest toxicity risk ⚡
  • Monitor: BUN, creatinine, GFR
  • Geriatric: ↓ GFR → dose reduction needed
  • Half-life: time for drug concentration to drop 50%

👶👴 Special Populations

Pediatric
  • Immature liver & kidneys → ↑ drug sensitivity
  • Weight-based dosing (mg/kg) — always convert lbs → kg
  • Higher body water % → altered distribution
  • Some drugs metabolized faster than adults
Geriatric
  • ↓ Renal & hepatic function → ↑ drug accumulation
  • ↓ Albumin → more free drug in circulation
  • Polypharmacy risk — monitor drug interactions
  • Start low, go slow — dose adjustments essential
⚗️
Pharmacodynamics & Drug Effects

📊 Types of Drug Effects

Therapeutic
Intended, desired effect — the goal of treatment
Side Effect
Predictable & unintended — usually tolerable; expected with the drug
Adverse Effect
Unintended & harmful — more serious; may require intervention
Idiosyncratic ⚡
Unexpected or opposite response — unpredictable, not dose-related (e.g., sedative causing hyperactivity)
Allergic
Immune-mediated hypersensitivity — mild (rash, urticaria) → anaphylaxis. First action: stop the drug.
Teratogenic
Causes fetal defects, loss, or prematurity — crosses placenta. Avoid in pregnancy.
Tolerance
Decreased response over time — higher dose required for same effect
Toxicity ⚡
Drug exceeds therapeutic range → organ damage. Risk ↑ with impaired kidneys, liver, or heart, and in older adults.

📈 Pharmacodynamic Concepts

Drug Levels & Timing

  • Therapeutic range: concentration that produces desired effects without toxicity
  • Peak level ⚡: highest drug concentration — drawn after absorption is complete
  • Trough level ⚡: lowest concentration — drawn before the next scheduled dose
  • Half-life: time for drug concentration to decrease by 50% — longer half-life = less frequent dosing
  • Onset: time from administration to first therapeutic effect
  • Duration: length of time the therapeutic effect is maintained
  • TDM (Therapeutic Drug Monitoring): blood sampling used for narrow therapeutic index drugs — digoxin, warfarin, lithium, phenytoin

Receptor Pharmacology & Mechanisms

  • Agonist: binds receptor → activates it, mimicking the natural ligand
  • Antagonist: binds receptor → blocks it, preventing activation
  • Therapeutic index (TI): toxic dose ÷ therapeutic dose — narrow TI = high risk (digoxin, warfarin, lithium, phenytoin)
  • Cumulative effect: drug accumulates with repeated doses → toxicity risk if clearance is impaired
  • First-pass effect: oral drugs are metabolized by the liver before reaching systemic circulation → reduced bioavailability; may require alternate route
  • Prodrug: inactive until metabolized (e.g., codeine → morphine)
  • CYP enzymes (cytochrome P-450): liver enzymes that metabolize most drugs — inhibited by grapefruit

🔗 Drug Interactions

💊 Drug – Drug
  • Synergism: combined effect > sum of parts
  • Additive: combined effect = sum of parts
  • Antagonism: one drug ↓ effect of another
  • Assess ALL medications — including OTC — for interactions
🍊 Drug – Food
  • Grapefruit: inhibits CYP3A4 → ↑ drug levels (dangerous with statins, etc.)
  • MAOIs + tyramine foods (aged cheese, wine) → hypertensive crisis
  • Iron + vitamin C → ↑ absorption; Iron + dairy/antacids → ↓ absorption
  • High-fat meals → slower intestinal absorption
  • "Empty stomach" = 1 hr before or 2 hr after a meal
🌿 Drug – Herbal
  • Can mimic drug–drug interactions (↑ or ↓ effects)
  • Always assess herbal supplement use before prescribing
  • Teach client which supplements to avoid based on their medications
  • Include herbals in medication reconciliation

⚠️ Adverse Reactions & Warnings

Allergic Reaction Spectrum

  • Mild: rash, urticaria (hives), pruritus
  • Moderate: swelling, wheezing, GI symptoms
  • Severe — Anaphylaxis ⚡: dyspnea, hypotension, tachycardia, circulatory collapse → life-threatening; requires immediate epinephrine
  • Stevens-Johnson Syndrome (SJS): onset 1–14 days post-dose; fever, chills, diffuse rash → blistering; respiratory distress — potentially fatal
  • First action for any allergic reaction: discontinue the medication immediately

Reporting & Black Box Warnings

  • Adverse Drug Event (ADE): life-threatening reaction requiring medical intervention — must be reported to the FDA
  • FDA uses ADE reports to revise labels, add warnings, or withdraw medications
  • Black Box Warning: placed on medications with potential for lethal or serious harm — highest level of FDA safety warning
  • Example: celecoxib (COX-2 inhibitor) → black box warning for fatal CV events and GI bleeding
  • Nurse's role: check allergies before every administration; document and notify provider of any reaction

👥 Special Populations

🧒 Pediatric
  • Immature liver → ↓ metabolism; immature kidneys → ↓ excretion until age 1
  • Higher rate of metabolism per kg → may need larger mg/kg doses or more frequent dosing
  • All doses are weight-based (kg) — recording lbs instead of kg is a common error
  • High toxicity risk in neonates — lack metabolizing enzymes
👴 Geriatric ⚡
  • ↓ liver, kidney, and heart function → slower clearance → high toxicity risk
  • ↓ muscle mass replaced by fat → alters drug distribution; ↓ plasma levels
  • Polypharmacy (≥5 medications) → ↑ risk of ADRs and drug interactions
  • May require lower doses; monitor closely for adverse effects
🤰 Pregnancy & Lactation
  • Delay medication therapy when possible; always weigh risk vs. benefit
  • Teratogens: cocaine, alcohol, ACE inhibitors, gentamycin, lithium, NSAIDs, tetracycline
  • ↓ GI motility → ↑ absorption → may need reduced oral doses
  • Codeine, morphine, alcohol cross the fetal–placental barrier
  • Some drugs excreted in breast milk — always check before prescribing to nursing clients
⚡ Red Man Syndrome (Vancomycin): Flushing and rash on the neck, chest, and back during rapid IV infusion — not a true allergic reaction (not immune-mediated). First action: STOP the infusion, then notify provider. If restarted, infuse more slowly.
✅
Rights of Medication Administration & Safety

🔟 The 10 Rights of Medication Administration

①
Right Patient ⚡
Two identifiers: name + DOB (or MRN, SSN, phone). Check ID band + MAR. Room number alone is never acceptable.
②
Right Drug
Verify name, form, and expiration date. Check label 3× (pull → prepare → bedside). Watch for LASA drugs; prefer generic name.
③
Right Dose
Check against MAR. Consider age, weight, condition. Double-check high-alert meds and weight-based calculations. Displaced decimal = common error.
④
Right Route
Confirm per provider order. Route affects onset, absorption rate, and side effects. Never assume — always verify.
⑤
Right Time ⚡
STAT = within 30 min. Urgent/ASAP = 30 min–1 hr. Late or missed dose = medication error. Check last dose time before giving.
⑥
Right Documentation
Chart on MAR immediately after giving — never before. PRN: document reason and effectiveness. Document refusals with date, time, and reason.
⑦
Right to Refuse ⚡
Client may refuse any medication. Investigate the reason, attempt to address concerns, notify provider, and document refusal in the medical record.
⑧
Right Education ⚡
Teach drug name, purpose, expected effects, adverse effects, and when to report. Use teach-back — ask client to explain in their own words.
⑨
Right Assessment
Check vitals, labs, allergies, and interactions before giving. e.g., BP before antihypertensive; apical pulse before digoxin; INR before warfarin.
⑩
Right Evaluation
Monitor response after giving. Was therapeutic effect achieved? Any adverse effects? Document PRN effectiveness (e.g., pain scale before and after).
⚡ Three-Check Rule: Verify right patient, drug, dose, route, and time at: (1) when pulling from drawer/AMDS → (2) during preparation → (3) at bedside before giving. Also apply teach-back for Right Education: ask the client to explain the medication in their own words.

📋 Complete Medication Order

A valid order must include ALL of the following:

01 Client name
02 Date & time written
03 Medication name — generic preferred
04 Dosage
05 Route
06 Frequency — write out fully; avoid unsafe abbreviations
07 Indication for use
08 Provider signature
⚡ If any component is missing, illegible, or unclear → contact the provider for clarification before administering.

🕐 Order Types & Timing

Order Types

  • Routine/Scheduled: regular intervals (e.g., q8h, daily, BID)
  • PRN (pro re nata): as needed for specific symptoms (pain, nausea, fever) — document reason + effectiveness
  • STAT ⚡: immediate, usually one dose — administer within 30 minutes of order
  • Urgent / ASAP / NOW: within 30 min–1 hr of order
  • Single/One-time: one dose only (e.g., preoperative)
  • Standing: active until provider discontinues

Time-Critical vs. Non-Time-Critical

  • Time-critical ⚡: giving ±30 min of scheduled time causes harm or subtherapeutic effect
    • Meds scheduled <4 hr apart
    • Meds around mealtimes (e.g., antidiabetics)
    • Meds that must be separated from others
  • Non-time-critical: safe to give 1–2 hr early or late — includes daily, weekly, monthly meds (scheduled ≥q4h)
  • Each facility sets its own policy per CMS regulations — always follow facility policy

🔄 Medication Reconciliation ⚡

Performed at every transition of care — admission, transfer (within or between facilities), and discharge. Goal: maintain an accurate, up-to-date medication list and prevent errors.

1 Document complete home med list on admission — name, dose, route, frequency, purpose
2 Compare home meds to newly prescribed meds — identify omissions, duplications, interactions, discrepancies
3 Update and re-reconcile at each care transition; communicate reconciled list to the next provider
4 At discharge: educate client and caregiver; provide written medication information; place reconciliation form with transfer documents
⚡ Include OTC medications and herbal supplements — not just prescriptions. Interprofessional team: nurse, provider, pharmacist, dietitian.

💻 Safety Technology

AMDS — Automated Medication Dispensing System

  • Nurse uses personal password + enters client name, drug, dose, route to dispense
  • Pharmacist reviews order before nurse can pull — generates alert if nurse attempts to pull before review
  • Override only in emergencies — workarounds bypass safety features and create error risk
  • AMDS reduces dispensing errors by ~31%

Barcode Medication Administration

  • At bedside: scan client's ID wristband + medication label
  • System alerts nurse if medication and client do not match — do not give until discrepancy is resolved
  • Reduces medication errors by ~41% and potential ADEs by ~51%
  • Never scan a medication for a client without physically checking the ID band

🔒 Error Prevention & Response

LASA Drugs ⚡
Look-Alike/Sound-Alike — e.g., dopamine/dobutamine, heparin/Hespan. Use Tall Man lettering (hydrOXYzine vs hydrALAzine). Store separately.
Preventing Interruptions ⚡
Mark the med prep area. Nurse may wear a vest during administration. Limit noise and cellphones. Do not interrupt unless critical.
No Workarounds
Never bypass AMDS, barcode alerts, or safety checks. Override only in a true emergency. Shortcuts = errors.
Stay at Bedside ⚡
Never leave meds at the bedside. Remain until client swallows all doses. If one pill at a time: wait.
No ID Bracelet ⚡
Ask client to state name + DOB. Verify against MAR. Replace smudged or missing bracelet immediately.
Return Demonstration
Best method to confirm self-administration skill (insulin, inhaler). Have client perform the procedure — not just describe it.
Medication Error Response
Assess client first → notify provider → notify supervisor → complete incident report. Incident report is a legal document but NOT placed in the chart.
Controlled Substances
Count with another nurse at every shift change. Witness and document waste immediately. Discrepancies must be reported.
Antibiotics ⚡
Complete the entire course even when symptoms resolve — stopping early promotes drug resistance.
Factors in Errors ⚡
Wrong dose/time/drug, missed dose, illegible Rx, failure to assess, giving before pharmacist review, interruptions, stressful conditions.

⚠️ High-Alert Medications — PINCH

High-alert medications cause significant harm when given in error. All PINCH drugs require an independent 2-nurse double-check before administration.

P
Potassium
Concentrated electrolyte — never give undiluted IV push (cardiac arrest risk)
I
Insulin
All types are high-alert — 2nd nurse confirms dose before drawing up ⚡
N
Narcotics
Controlled substances — count at shift change; witness waste
C
Chemo
Hazardous drugs — special PPE, independent double-check, safe handling required
H
Heparin
Anticoagulant — hemorrhage risk; verify dose, weight-based calculations
🗺️
Routes of Administration
ENTERAL — GI tract TOPICAL / SENSORY — skin, eyes, ears, mucosa INHALATION — respiratory tract PARENTERAL — injection (see Injections section)

🍊 Enteral Routes

Oral (PO) ⚡ by mouth
  • Slowest onset — must pass GI mucosa; first-pass hepatic metabolism ⚡
  • Most common, most convenient, least invasive route
  • Never crush sustained-release (SR/XR/ER) or enteric-coated tablets
  • Use scored tablet + cutter to split; mix crushed tabs with minimal food/fluid
  • Contraindicated: N/V, decreased GI motility, NPO, dysphagia
  • Empty stomach = 1 hr before or 2 hr after a meal when ordered
Sublingual (SL) / Buccal under tongue / cheek & gum
  • Rapid absorption — highly vascular mucous membranes
  • Bypasses first-pass effect — directly into systemic circulation
  • Let dissolve completely — do NOT swallow, eat, or drink until dissolved
  • SL: place under tongue; Buccal: place between cheek and gum
  • Classic example: nitroglycerin SL for angina
Enteral Tube ⚡ NG / G-tube
  • Verify tube placement before every use
  • Prefer liquid form — use solutions or suspensions when available ⚡
  • Never crush SR, XR, or enteric-coated tablets
  • Give each medication separately — do not mix together
  • Flush: 30–60 mL water before & after; 15–30 mL between each med ⚡
  • Infuse each med by gravity ⚡

🔮 Topical & Sensory Routes

Transdermal ⚡ patch / cream on skin
  • Wear clean gloves to apply and remove — nurse absorbs drug through skin ⚡
  • Remove and discard old patch before applying new one
  • Rotate sites; document site on patch (date, time, initials)
  • Slow, sustained systemic release — local AND systemic effects
  • Never cut a transdermal patch — alters dose delivery
  • Assess client's ability to apply and reading comprehension for self-care
Ophthalmic ⚡ eye drops / ointment
  • Tilt head back; look up
  • Pull down lower eyelid → instill drop into conjunctival sac ⚡ (not directly on cornea)
  • Apply gentle pressure to inner canthus (nasolacrimal duct) 1–2 min — prevents systemic absorption
  • Have client close eye gently for 1–2 min; blot excess
  • No contact lenses during treatment; tip of dropper must not touch eye
Otic ⚡ ear drops
  • Warm drops to body temperature — cold drops cause vertigo/dizziness
  • Adult / child >3 yr: pull pinna UP and BACK ⚡
  • Child <3 yr: pull pinna DOWN and BACK ⚡
  • Instill drops; place cotton ball loosely (do not pack)
  • Client lies on unaffected side; remain 2–5 min after instillation
Nasal drops / spray
  • Blow nose gently before instillation
  • Tilt head back slightly; insert nozzle without touching mucosa
  • Spray while inhaling through the nose; alternate nostrils
  • Do not blow nose for at least 5 minutes after
  • Prime new spray bottle before first use (pump until mist appears)
Rectal suppository / enema
  • Position: Sims' (left lateral)
  • Lubricate suppository; insert past internal anal sphincter (~2 in adult; 1 in child)
  • Client retains 15–30 min; if expelled within 15 min, may need re-insertion
  • Used when PO not possible (N/V, dysphagia, surgery)
  • Avoid if rectal surgery, rectal bleeding, or hard impacted stool
Vaginal suppository / cream / ring
  • Position: supine (dorsal recumbent) or lithotomy
  • Insert applicator or suppository ~2 inches into vaginal canal
  • Remain supine for at least 30 min after insertion
  • Perineal pad may be used to absorb drainage
  • Ensure privacy; provide clear instructions for self-administration

💨 Inhalation Routes

MDI — Metered Dose Inhaler
  • Shake canister; remove cap; prime if new (pump ×4 into air)
  • Exhale fully and completely before actuating
  • Seal lips around mouthpiece; press canister while inhaling slowly over 3–5 sec
  • Hold breath for 10 seconds; exhale slowly through nose
  • Wait 1–2 min between puffs
  • Use spacer if coordination is poor, or for children
  • After corticosteroid MDI: rinse mouth — prevents oral candidiasis (thrush) ⚡
DPI — Dry Powder Inhaler ⚡
  • Assess ability to inhale deeply before use — requires fast, forceful inhalation ⚡
  • Load dose per device instructions
  • Exhale fully — away from the device (moisture ruins the powder)
  • Seal lips tightly; inhale fast and forcefully
  • Hold breath 10 sec
  • Do NOT shake; no spacer — both alter powder delivery
  • After corticosteroid DPI: rinse mouth
Nebulizer
  • Place liquid medication in the nebulizer chamber
  • Attach to air or oxygen source; mist generated continuously
  • Client breathes normally through mouthpiece for full treatment (~10–15 min)
  • Use aerosol/face mask if client cannot hold mouthpiece
  • After corticosteroid nebulizer: rinse mouth — prevents thrush ⚡
  • Clean nebulizer equipment after each use
⚡ Speed of Onset (fastest → slowest): IV (no barriers) → Inhalation → Sublingual/Buccal → IM → SubQ → Oral (slowest — first-pass + GI absorption)

Common Route Abbreviations

  • PO — by mouth
  • SL — sublingual
  • ID — intradermal
  • IM — intramuscular
  • IV — intravenous
  • SubQ — subcutaneous
  • top — topical
  • NPO — nothing by mouth

Local vs. Systemic Effect

  • Local: effect confined to site of application (e.g., topical antibiotic on a wound, ophthalmic drops)
  • Systemic: absorbed into bloodstream and distributed to tissues (e.g., transdermal nitroglycerin, oral ibuprofen)
  • Most routes can produce both — apply pressure to nasolacrimal duct after eye drops to minimize systemic absorption
💉
Injection Techniques
Intradermal Subcutaneous Intramuscular Z-Track Sharps Safety
Intradermal (ID) ⚡
  • Angle: 5–15°, bevel UP
  • Needle: 25–27G, ¼–⅝ inch
  • Syringe: tuberculin (1 mL) ⚡
  • Volume: 0.01–0.1 mL
  • Site: inner forearm — free of lesions & hair ⚡
  • Insert ~⅛ inch; needle visible under skin
  • Inject slowly; watch for wheal/bleb ⚡ — no bleb = wrong layer
  • Withdraw slowly; apply dry gauze — do NOT massage
  • Uses: PPD/TB test, allergy skin testing
Subcutaneous (SubQ)
  • Angle: 45° if 1" pinch · 90° if 2" pinch ⚡
  • Needle: 25–27G, ⅜–⅝ in (45°) or ½ in (90°)
  • Volume: ≤1.5 mL
  • Sites: abdomen (≥2" from umbilicus), upper outer arm, anterior thigh, scapular area
  • Pinch tissue; inject slowly; release pinch after insertion
  • No aspiration required
  • Rotate sites — essential for insulin ⚡
  • Do NOT massage after heparin/enoxaparin ⚡
  • Uses: insulin, heparin, enoxaparin, some vaccines
Intramuscular (IM)
  • Angle: 90° — quick, darting motion
  • Needle: 18–25G, ⅝–1½ inch
  • Volume: up to 3 mL (site & age dependent)
  • Z-track method for all IM injections ⚡
  • Aspiration: NOT required (current evidence) ⚡
  • Inject slowly; hold 10 sec; withdraw at same angle
  • Cover with dry gauze; gentle pressure — do NOT massage
  • Rotate sites for scheduled injections
  • Avoid: lesions, inflammation, bony prominences
  • Uses: vaccines, hormones, antibiotics, irritating drugs
📐 Needle Angle at a Glance
5–15°
Intradermal
45°
SubQ (thin tissue)
90°
SubQ (avg tissue)
90°
IM (all sites)
Needle Selection Reference ⚡
Type Gauge Length Angle Max Vol
Intradermal 25–27G ¼–⅝ in 5–15° 0.1 mL
SubQ 25–27G ⅜–⅝ in 45° or 90° 1.5 mL
SubQ Insulin 25–31G 5/16–½ in 45° or 90° —
IM (avg adult) 18–25G ⅝–1½ in 90° 3 mL
IM Site Selection
Ventrogluteal ⚡ preferred
  • Palm on greater trochanter, index on AIIS; inject in the "V" between index & 3rd finger ⚡
  • No major vessels or nerves nearby — safest IM site
  • Adults: ≤3 mL, 1½ in needle
  • Preferred for irritating/oily solutions at any age
Deltoid
  • 2–3 finger widths below acromion process, midlateral arm ⚡
  • Risk: proximity to brachial artery & radial nerve
  • Adults/adolescents: ≤2 mL, 1–1½ in needle
  • Preschoolers & older: ½–1 in needle
  • Not for infants/toddlers <3 yr ⚡
Vastus Lateralis
  • Middle ⅓ anterolateral thigh: 1 hand width below greater trochanter, 1 hand width above knee ⚡
  • Adults: ≤3 mL; Infants: ≤1 mL — preferred infant site ⚡
  • Aqueous: 22–27G · Oily/viscous: 18–25G
  • Avoid dorsogluteal — risk of sciatic nerve injury ⚡

Z-Track Technique ⚡ (all IM)

  1. Displace skin & SubQ tissue 1–1.5 inches laterally with nondominant hand
  2. Insert needle at 90° — quick, darting motion
  3. Inject slowly and smoothly
  4. Hold 10 seconds to allow dispersal
  5. Withdraw needle; immediately release skin
  6. Activate safety device; cover with dry gauze
  7. Gentle pressure — do NOT massage
Seals drug in muscle — prevents tracking into SubQ. Required for iron dextran and all irritating/oily IM drugs.

SubQ Special Notes

Insulin ⚡
  • Insulin syringe only — unit-calibrated scale ⚡
  • Abdomen = fastest absorption; thigh = slowest
  • Rotate sites systematically within each area
  • Never mix without pharmacist confirmation
Heparin / Enoxaparin ⚡
  • Abdomen preferred (least tissue trauma)
  • Do NOT massage — causes hematoma ⚡
  • Apply gentle pressure with dry gauze only
  • Do not aspirate
⚠️ Sharps Safety
  • Place sharps container within arm's reach at eye level before giving any injection
  • Immediately engage needle safety device after withdrawal — never recap with two hands
  • One-handed scoop technique only if recapping a clean (unused) needle
  • Never recap contaminated needles; never force sharps into overfilled container
  • Filter needle required when drawing from ampule — change to injection needle before administering ⚡
  • Controlled substances: waste in front of a witness per agency policy
🩺
IV Therapy
Access Types Admin Methods Flow Rates Complications Safety
IV Access Types
Peripheral IV
  • Short catheter in peripheral vein; 20–24G most common
  • Assess q8h for infiltration & phlebitis
  • Change site q72–96h per agency policy
  • Inspect solution: clear, no particles, no leaks, not expired ⚡
  • Not for vesicants or vasopressors — use central access
PICC ⚡
  • Long catheter via antecubital fossa veins ⚡
  • Tip rests in superior vena cava (SVC) ⚡
  • Placement confirmed via chest X-ray before use
  • Long-term access (weeks–months); outpatient-friendly
  • Strict aseptic technique for all access & dressing changes
Central Venous (CVC)
  • Subclavian, internal jugular, or femoral vein
  • Multiple lumens — run several infusions simultaneously
  • Required for vesicants, vasopressors, TPN, concentrated meds
  • Strict aseptic technique; risk of CLABSI
Implanted Port
  • Reservoir surgically placed under skin
  • Access with non-coring (Huber) needle
  • Lowest infection risk — no external components
  • Common for chemo & long-term intermittent therapy
Administration Methods
IV Bolus (Push)
  • Concentrated med injected directly into bloodstream
  • Deliver over 3–5 minutes ⚡ (unless otherwise ordered)
  • Use injection port closest to the patient
  • Confirm IV compatibility with infusing fluid first ⚡
  • Saline-locked line: flush with NS before and after ⚡
  • Verify line placement & patency before giving
  • Ideal when client cannot tolerate large fluid volumes
IV Piggyback (IVPB)
  • Secondary bag connected via Y-port of primary tubing
  • Secondary bag hung higher than primary bag ⚡
  • Primary infusion resumes automatically when secondary is complete
  • Typical infusion time: 30–60 minutes
  • Verify compatibility with primary solution before connecting
Continuous Infusion
  • Large-volume fluid runs at a set rate around the clock
  • Used for maintenance fluids, pain management, vasopressors
  • IV pump required for accurate delivery ⚡
  • Assess infusion site & rate at least every hour
  • Compare infusing solution to MAR when assuming client care

Flow Rate Formulas ⚡

mL / hr (pump)
mL/hr = dose/time (hr) ÷ concentration/mL
gtt / min (gravity)
gtt/min = (mL/hr × drop factor) ÷ 60
Drop factors: macrodrip 10, 15, or 20 gtt/mL · microdrip 60 gtt/mL
Always verify tubing packaging for exact drop factor ⚡

Compatibility & Inspection ⚡

Inspect IV Bag Before Hanging
  • Clear color, no particles, no cloudiness, no precipitation ⚡
  • Check expiration date; check bag for cracks or leaks
  • Discard if any abnormality — do not use
Compatibility Rules
  • Check compatibility before mixing or co-infusing any two meds ⚡
  • If unsure → assume incompatible; give separately ⚡
  • Flush with ≥10 mL NS before & after each IV bolus ⚡
  • Incompatible signs: precipitate, haze, color change, gas
  • Use pharmacist or computerized compatibility program when in doubt
IV Complications
Infiltration
  • Non-vesicant leaks into surrounding tissue
  • Signs: swollen, pale, cool skin; no blood return; slowed drip
  • Action: stop infusion, remove catheter, elevate limb, apply warm compress
Extravasation ⚡
  • Vesicant leaks into tissue → severe damage / necrosis
  • Signs: burning, blistering, redness, induration at site
  • Action: stop immediately, leave catheter, aspirate if possible, antidote per protocol, notify provider
Phlebitis
  • Vein inflammation from chemical, mechanical, or bacterial cause
  • Signs: red, warm, tender, streak along vein track
  • Action: discontinue IV, restart at new site; warm compress for comfort
Air Embolism ⚡
  • Air enters bloodstream via IV line
  • Signs: sudden dyspnea, chest pain, cyanosis, hypotension
  • Action: clamp tubing immediately → position left lateral Trendelenburg ⚡ → notify provider → O₂
Fluid Overload ⚡
  • Excessive or too-rapid infusion
  • Signs: coughing, dyspnea, crackles (bilateral), ↑ BP, ↑ HR, bounding pulse, JVD
  • Action: slow rate (don't stop), elevate HOB, notify provider, monitor O₂ sat
Occlusion ⚡
  • IV not infusing; pump alarms "occlusion"
  • Action: check for kinked tubing first ⚡
  • Then: check clamp, reposition extremity, assess site; flush gently with NS
  • Do not force flush if resistance felt
⚡ IV route = no barriers to absorption — enters bloodstream immediately; effects begin within seconds. Monitor closely during the first 15 minutes of any new IV infusion. Central access is required for vesicants, vasopressors, and concentrated solutions. Always take vital signs before administering any IV medication.
⚡
Exam High-Yield Summary
Toxicity risk ⚡
Impaired kidney function = greatest toxicity risk — drug cannot be excreted
IV route ⚡
No barriers to absorption — fastest onset, enters bloodstream directly
Oral route ⚡
Slowest onset — must survive GI tract + first-pass hepatic metabolism
g → mg ⚡
Move decimal 3 places RIGHT (× 1,000) · 0.3 g = 300 mg
STAT order ⚡
Must be given within 30 minutes
Teach-back ⚡
Ask client to explain medication in their own words
Red Man Syndrome ⚡
Vancomycin infusion rash → STOP infusion FIRST, then notify provider
Idiosyncratic effect ⚡
Unexpected / opposite response to a medication
Intradermal angle ⚡
5–15° (bevel up) → must produce a wheal/bleb
IM angle ⚡
90°
Ventrogluteal ⚡
Palm on greater trochanter, index finger on AIIS
Eye drops ⚡
Pull down lower eyelid → place drop in conjunctival sac
Ear drops child <3 ⚡
Pull pinna DOWN and back
Ear drops adult ⚡
Pull pinna UP and back
DPI ⚡
Assess ability to inhale deeply before prescribing/teaching
Transdermal patch ⚡
Always wear clean gloves when applying or removing
Insulin ⚡
Second nurse verifies dose BEFORE giving — high-alert medication
No ID bracelet ⚡
Have client state name and DOB — do NOT use room number
PICC ⚡
Inserted via antecubital fossa veins; tip sits in superior vena cava
IV occlusion ⚡
Check for kinked tubing FIRST
Inspect IV bag ⚡
Check color, clarity, expiration date before hanging
Illegible Rx ⚡
Call the provider — never interpret or guess
Antibiotics ⚡
Complete the full course — prevents resistance and relapse
8 oz = 240 mL ⚡
1 cup = 8 oz = 240 mL · 1 oz ≈ 30 mL
Clindamycin ⚡
0.3 g from 150 mg/mL = 2 mL
Phenytoin ⚡
300 mg from 125 mg/5 mL = 12 mL
Acetaminophen ⚡
320 mg from 160 mg/5 mL = 10 mL
Amikacin ⚡
7 mg/kg, 165 lb pt, 250 mg/mL = 2.1 mL
First-pass effect
Oral drugs metabolized in liver before reaching systemic circulation → ↓ bioavailability
SubQ heparin
Do NOT massage after injection — increases bruising/bleeding risk
Z-track
Displace skin → inject at 90° → wait 10 sec → release — seals drug in muscle
Narrow therapeutic index
Digoxin, warfarin, lithium, phenytoin — small dose change → toxicity or failure
Polypharmacy (geriatric)
↓ renal/hepatic function + multiple meds → drug interactions and accumulation ↑
Fluid overload (IV) ⚡
Coughing, shortness of breath, crackles — complication of IV therapy
Intradermal syringe ⚡
Tuberculin syringe (1 mL), 25–27G, ¼–⅝ inch needle
Deltoid for preschoolers ⚡
Deltoid acceptable for IM in preschoolers & older children (not for infants/toddlers <3 yr)
Corticosteroid inhaler ⚡
After MDI or nebulizer corticosteroid: rinse mouth with water to prevent thrush
9 oz water ⚡
Exam uses 1 glass = 8 oz = 240 mL (1 oz ≈ 30 mL; 1 cup = 8 oz = 240 mL)
OTC in reconciliation ⚡
Include OTC medications and herbal supplements in medication reconciliation
Enteral tube flush ⚡
Flush with 30–60 mL water before and after medications; 15–30 mL between each med; infuse by gravity
Stay at bedside
Never leave meds at bedside — remain until all doses swallowed
mod 19Infection Control and Isolation
🔗
Chain of Infection

All 6 links must be present for infection to occur — break any one link to stop it.

1. Infectious Agent
Bacteria · Virus · Fungus · Parasite · Prion
Break by: disinfecting, sterilizing, antimicrobial Tx
→
2. Reservoir ⚡
Where agent lives & reproduces
Animate: people, animals, insects
Inanimate: soil, water, equipment, faucets
Break by: hand hygiene, proper skin prep, clean environment
→
3. Portal of Exit
How agent leaves reservoir
Ears, nose, mouth, skin, GI/respiratory/GU tracts, blood & body fluids
Break by: wound dressings, drainage containment
4. Mode of Transmission ⚡
Contact · Droplet · Airborne · Vehicle · Vector
Break by: hand hygiene, PPE, isolation precautions
→
5. Portal of Entry
How agent enters host
Same routes as exit (ears, nose, mouth, breaks in skin). IV lines, catheters = additional portals
Break by: sterile technique, intact skin care
→
6. Susceptible Host ⚡
Not everyone exposed gets ill
May be colonized (no symptoms) or become very ill. Host factors = immunity, nutrition, sleep, age, meds
Break by: immunizations, nutrition, hygiene, blood sugar control
Exam tip: A faucet an infected person touched = Reservoir. A client who acquired the infection = Susceptible Host. The susceptible host then becomes a new reservoir.

⚠️ Factors that ↑ Host Susceptibility

Age (very old or very young)
HIV/AIDS · malignancy · transplants
Immunosuppressants · corticosteroids · antineoplastics
Indwelling devices: ETT, Foley, central lines, implants
Surgical procedures · radiation therapy
Proton pump inhibitors (gastric suppressants)
💨
Transmission Modes & Precautions

Modes of Transmission

Mode How it spreads Examples ⚡
Direct Contact Infected person directly to another — no intermediary HSV, scabies, wound drainage touching nurse's abrasion
Indirect Contact Via contaminated object / surface between two people S. aureus on bedrail, door handle, shared equipment, contaminated PPE
Droplet ⚡ Large droplets travel ≤6 ft; land on mucosa Influenza ⚡, Pertussis (whooping cough) ⚡, rhinovirus, norovirus, meningitis, Mycoplasma pneumonia, RSV (also contact)
Airborne ⚡ Small particles stay suspended; travel long distances TB ⚡, Measles (rubeola) ⚡, Varicella (chickenpox) ⚡. Some conditions: influenza, rotavirus (but droplet precautions still adequate)
Vehicle Contaminated source to many people E. coli-contaminated produce, contaminated water supply
Vector-borne Insects/rodents carry organisms Mosquitoes, rats — not infected themselves, just carriers

Transmission-Based Precautions — Quick Reference ⚡

Standard (All Clients)
  • Applies to all clients regardless of diagnosis
  • Protects from blood, body fluids, nonintact skin, mucous membranes
  • PPE based on expected exposure
  • Hepatitis B → standard precautions only
Contact Precautions ⚡
  • PPE: Gown + gloves minimum to enter room
  • Private room preferred; cohorting if needed (≥3 ft separation)
  • Remove PPE inside room before exiting
  • Diseases: VRE ⚡, C. diff ⚡, MRSA, norovirus, RSV ⚡, scabies, wound drainage
Droplet Precautions ⚡
  • PPE: Surgical mask when entering or within 6–10 ft
  • Eye protection ⚡ — droplets can contact conjunctivae or mucous membranes of eyes
  • Private room preferred; cohorting ok (curtain drawn, ≥3 ft)
  • Client wears mask when leaving room; cough/sneeze into tissue → discard immediately (or into sleeve)
  • Diseases: Influenza ⚡, Pertussis ⚡, meningitis, Mycoplasma, SARS-CoV1, rhinovirus
Mnemonic ⚡
SPIDERMAN
Sepsis  ·  Pertussis  ·  Influenza  ·  Diphtheria  ·  Epiglottitis  ·  Rubella  ·  Mumps  ·  Adenovirus  ·  Neisseria meningitidis
Airborne Precautions ⚡
  • PPE: N95 or higher (fit-tested)
  • AIIR (negative pressure room) — door stays closed
  • 12 air exchanges/hr (new) · 6 (existing/renovated)
  • Client wears surgical mask when leaving AIIR
  • Diseases: TB ⚡, Measles (rubeola) ⚡, Varicella ⚡
Mnemonic ⚡
MTV
Measles (rubeola)  ·  TB (tuberculosis)  ·  Varicella (chickenpox)
Protective Isolation
  • For immunocompromised clients (e.g., post-HSCT)
  • Positive air pressure + HEPA filtration, ≥12 exchanges/hr
  • Well-sealed room, no plants (fresh or dried)
  • First ~100 days post-transplant (possibly longer)
AIIR vs Protective: Airborne = negative pressure (keeps bad air in). Protective = positive pressure (keeps bad air out). TB/Measles/Varicella → AIIR. Post-HSCT → Protective.
🧤
Personal Protective Equipment

Donning Order (Put On) ⚡

1 Gown
2 Mask (surgical or N95)
3 Eye goggles or face shield
4 Gloves LAST — over gown cuffs

Doffing Order (Remove) ⚡

1 Gloves FIRST — most contaminated ⚡
2 Face shield / goggles (by earpieces)
3 Gown (roll inside-out, don't touch outside)
4 Mask (by ties/bands, not front surface)
✓ Hand hygiene immediately after exiting

PPE Rules to Know ⚡

Gloves

  • Remove inside-out (contaminated surface stays inside)
  • Change when: between clients, after dressing change before computer, torn/punctured, between dirty/clean sites
  • Standard precautions: disinfect hands immediately after removing gloves ⚡ — cannot assume glove integrity was not breached
  • Do NOT wash/reuse gloves
  • Donned last (on top of gown cuffs)
  • Petroleum-based hand lotion ⚡ impairs integrity of latex gloves — weakens them, increases permeability

Masks

  • Surgical mask — droplet & standard precautions
  • N95 — airborne ONLY (must be fit-tested)
  • Remove mask outside room (after door is closed)
  • Do not touch front (contaminated surface)

Gowns

  • Single use only — never reuse
  • Cover entire torso + full-length sleeves
  • Discard inside room before exiting
  • If too small: second gown worn backwards over first
  • Sterile gown boundaries ⚡ — sterile zone = front chest to 2 in above elbows; axillae NOT sterile; back NOT sterile

Eye Protection

  • Eyeglasses/contacts do NOT replace goggles
  • Face shield provides more coverage than goggles + mask; mask still worn under face shield
  • Protect eyes from splashes of blood/body fluids
  • Wound irrigation ⚡ — expect splashing → wear face shield (covers face + eyes)
  • Face shield wrapping around sides = highest protection level

Sterile Gloving Techniques ⚡

Closed-Gloving Technique

  • Used when donning a sterile gown first (e.g., surgical scrub)
  • Hands remain inside gown cuffs throughout — hands never exposed
  • Sterile glove is handled through the fabric of the gown cuff
  • Preferred initial technique for surgical procedures

Open-Gloving Technique

  • Used when no sterile gown is worn (e.g., Foley insertion)
  • Hands come out of cuffs; gloves handled at wrist cuff only
  • Also used to replace a contaminated glove mid-procedure
  • Non-dominant hand gloved first
Needlestick Prevention ⚡: Engage safety device immediately after withdrawing needle · sharps container < ¾ full · no recapping · if stuck → wash with soap & water → report to supervisor immediately → complete incident report → follow-up per protocol. Prophylaxis must start within 24 hrs for HIV/Hep B.
🫧
Hand Hygiene & Asepsis

Soap & Water ⚡

  • Use when hands are visibly soiled
  • Use after caring for C. difficile (spores) — alcohol doesn't kill spores ⚡
  • Scrub for 15–30 seconds ("Happy Birthday" ×2)
  • Water temp: warm, not hot (hot → skin irritation)
  • Hands below elbows while rinsing (dirty water flows away)
  • Turn off faucet with paper towel ⚡ (prevents recontamination)

Alcohol-Based Sanitizer

  • Minimum 60% alcohol for effectiveness
  • Faster than soap/water — saves ~1 hr per 8-hr ICU shift ⚡
  • Rub all surfaces including between fingers until completely dry (~15–30 sec)
  • Must dry completely ⚡ — drying provides the full antiseptic effect; bacteria proliferate more easily on wet/moist hands
  • NOT effective on visibly soiled hands
  • NOT effective on C. difficile spores

Surgical Asepsis (Sterile Technique) ⚡

  • Remove all rings, watches, bracelets first — CDC has no specific ring policy ⚡; follow facility policy
  • Apply chlorhexidine + ethanol ⚡ (as effective as traditional scrub)
  • Scrub nails with sterile nail brush (subungual = highest bacteria)
  • Keep hands above elbows when rinsing
  • Fingernails ≤ ¼ inch · no artificial nails in high-risk areas
  • Nail polish: remove if chipped ⚡ (chipped areas harbor bacteria)

Sterile Field Rules ⚡

  • Open first flap away from body ⚡
  • Then sides, then flap toward body (last)
  • Outer 1-inch border is contaminated — items go in center
  • Anything below waist = contaminated
  • Never turn back on sterile field
  • If any doubt about sterility → start over
  • Prepare field as close to procedure time as possible

Adding Sterile Solution to a Sterile Field ⚡

1
Verify solution: correct, unopened, not expired, no client allergies
2
Remove cap without touching inside of cap or bottle rim → place cap upside down on nonsterile surface
3
Hold container with label facing palm of hand
4
Pour from 10–15 cm (4–6 in) above the sterile receptacle — pour carefully, do not splash
5
Remove bottle from over the field; replace cap without touching inside of cap or rim
Strikethrough ⚡ — if solution splashes or drips onto the sterile field, the field is wet = contaminated. Discard the entire field and start over.
Outside of container is not sterile — never place the bottle on the sterile field.
Gravity rule ⚡ — fluid flows downward. Tip of any wet object (e.g., forceps) must point down to prevent fluid traveling up and contaminating the sterile field.
If setting up field alone → pour liquids before donning sterile gloves.
Medical Asepsis
= Clean technique. Reduces number of organisms. Used for routine client care. Isolation precautions are an example.
Surgical Asepsis
= Sterile technique. Eliminates ALL organisms. Required for invasive procedures, OR, central line insertion.
Throat Culture ⚡: Swab posterior pharyngeal wall / tonsils / tonsillar pillars. Do NOT touch lips, teeth, tongue, uvula, or sides of oral cavity. Place swab in culture medium immediately. Use non-sterile gloves (not sterile). Don't take culture if epiglottis is severely inflamed (→ notify provider).
🛡️
Body Defenses & Inflammatory Response

Physical & Chemical Barriers

  • Skin — primary defense; intact stratum corneum (outer lipid layer)
  • Stratum corneum regenerates in 5–6 days; half restored within 6 hours ⚡
  • Detergents & adhesive tape can destroy stratum corneum → breaks barrier ⚡
  • Humectants (lotions, hand creams) promote skin hydration and improve integrity ⚡
  • Mucous membranes secrete mucus; humidification added to O₂ keeps nares/membranes moist ⚡
  • Respiratory cilia sweep particles out
  • GI acids/enzymes destroy invaders
  • Longer male urethra → fewer UTIs
  • Vaginal pH inhibits bacterial growth

Nonspecific Immunity

  • Neutrophils & Macrophages = phagocytes (eat & destroy micro-organisms)
  • First responders to injury
  • Released during inflammatory response
  • Neutrophils = 55–70% of WBCs

Specific Immunity

  • Antibodies (immunoglobulins) + lymphocytes
  • B cells produce antibodies; T cells are killer cells
  • Lymphocytes = 20–40% of WBCs

Inflammatory Response Steps

STEP 1
Pattern receptors recognize harmful stimuli
→
STEP 2
Inflammatory pathway activated
→
STEP 3
Inflammatory markers released (CRP ⚡)
→
STEP 4
Inflammatory cells recruited (leukocytes → monocytes → lymphocytes)

Manifestations of Inflammation

  • Heat
  • Redness
  • Swelling
  • Pain
  • Loss of function

Inflammatory Triggers

Infectious: Viruses, bacteria, fungi, parasites
Non-infectious Physical: Burns, frostbite ⚡, trauma, radiation ⚡, foreign bodies
Chemical: Glucose, alcohol, toxins, irritants (fluoride, nickel)
Biological: Damaged cells · Psychological: Excitement

Pharmacologic Response

  • Antihistamines ⚡ (e.g., diphenhydramine) — block histamine receptors → reduce allergic swelling, itching, and sneezing
  • NSAIDs ⚡ (e.g., ibuprofen) — inhibit prostaglandins → reduce inflammation, pain, and fever

Chronic Inflammation ⚡

  • Persistent, low-grade inflammatory response
  • Examples: asthma (ongoing bronchial swelling), GERD (repeated acid erosion cycle)
  • Can lead to tissue destruction and cancer over time ⚡

Lab Markers for Inflammation ⚡

Marker What it tells you Normal WBC Range
C-Reactive Protein (CRP) ⚡Nonspecific — elevated when inflammation is present—
ESR (Erythrocyte Sed. Rate)Nonspecific; varies by age & sex — can't compare between clients—
WBC (Total)↑ = infection/inflammation; ↓ = can't fight infection (neutropenia = dangerous)5,000–10,000/mm³
NeutrophilsFirst responders; "bands" (immature neutrophils) = left shift = ongoing infection55–70%
LymphocytesFight chronic bacterial & acute viral infections; T & B cells20–40%
MonocytesClean up tissue damage, produce interferon2–8%
EosinophilsAllergic reactions & parasitic infections1–4%
Basophils (Mast cells)Release histamine, serotonin, heparin0.5–1%
NLR (Neutrophil-to-Lymphocyte Ratio)Combines neutrophil + lymphocyte counts; useful for chronic inflammation, cancer, cardiovascular disease ⚡—
PLR (Platelet-to-Lymphocyte Ratio)Systemic inflammatory index; elevated in chronic conditions and cancer—
SII (Systemic Immune-Inflammation Index)Combines platelet, neutrophil, lymphocyte counts; useful in cancer and cardiovascular prognosis—
📈
Stages of Infection
1
Incubation
No symptoms. Exposure → first symptom. Duration varies (seconds to weeks). Lab changes may be detectable.
2
Prodromal ⚡
Vague, nonspecific symptoms: fever, aches, malaise, poor appetite as infectious agent replicates.
3
Acute Illness
Specific disease manifestations become obvious. Most severe stage.
4
Period of Decline
Symptoms subside as number of infectious agents decreases. Client begins to regain strength.
5
Convalescence ⚡
Returns to previous or new balanced state. Some infections may leave lasting effects.
Exam scenario clues: "Feeling better, fever gone, good appetite" = Convalescence ⚡. "Generalized aches, fever for 12 hrs" = Prodromal ⚡.

Local vs Systemic Infection

  • Local: confined to one area; treated with topical/oral antibiotics
  • Systemic: enters bloodstream; needs IV antibiotics + monitoring
  • Local → systemic if untreated

Lab Culture Tips

  • Urinalysis → if WBCs present → C&S to ID organism; UA + C&S sometimes ordered simultaneously ⚡
  • Chest x-ray confirms pneumonia but not the type
  • CRP, ESR, PCT are nonspecific — can't compare between labs or clients
  • "Bands" = immature neutrophils = left shift = active infection
🏥
HAIs, Infection Control Bundles & MDROs

The 4 Major HAIs (Health Care-Associated Infections)

CLABSI
Central Line-Associated Bloodstream Infection
CAUTI ⚡
Catheter-Associated Urinary Tract Infection
SSI
Surgical-Site Infection
VAP
Ventilator-Associated Pneumonia

CAUTI Bundle ⚡

  • Try alternatives first ⚡ (condom catheter, intermittent cath)
  • Use sterile technique for insertion
  • Check daily — remove ASAP when no longer needed
  • Maintain closed, aseptic drainage system
  • Do NOT disconnect system to obtain urine samples ⚡
  • Check every shift, not every 2 days ⚡

CLABSI Bundle (Insertion + Maintenance)

  • Hand hygiene before insertion
  • Maximal sterile barrier: sterile gloves, cap, gown, mask, full-body drape
  • Chlorhexidine >0.5% with alcohol at insertion site
  • Avoid femoral site (highest infection risk)
  • Dressing changes ⚡ — gauze: q2 days; semipermeable: q7 days (or sooner if wet/soiled/dislodged)
  • Chlorhexidine bath daily for ICU clients age >2 months ⚡
  • Scrub hub with friction before every access ⚡
  • Tubing changes ⚡ — propofol: q6–12h or when vial changed; fat emulsions/blood: q24h; other continuous infusions: q7 days (no more than q4 days)
  • Discontinue lines that aren't needed
VAP Bundle (Key Points) ⚡
  • Elevate head of bed 30–45°
  • Daily sedation vacation + assess readiness to extubate
  • Oral care with chlorhexidine
  • Avoid frequent ventilator circuit changes ⚡ — changes increase infection risk; change only when visibly soiled or malfunctioning
  • Peptic ulcer prophylaxis; DVT prophylaxis

Multidrug-Resistant Organisms (MDROs)

MRSA — methicillin-resistant S. aureus
VRE ⚡ — vancomycin-resistant Enterococcus
VRSA / VISA — vancomycin-resistant or intermediate S. aureus
ESBL — extended-spectrum beta-lactamase organisms
MDRSP — multidrug-resistant S. pneumoniae
MDRO precaution rule: All MDROs require Contact Precautions — gown + gloves to enter room. VRE → contact. MRSA → contact. C. diff → contact + soap & water (not alcohol-based hand rub).

Enhanced Barrier Precautions (Nursing Homes)

Designed to reduce MDRO transmission in nursing homes. Staff wear gown + gloves when engaging in:
Bathing/showering Hygiene/dressing Changing linens or briefs Toileting Wound care Transfers (bed → chair) Tubes, lines, ventilators, tracheostomies

COVID-19 Infection Control (WHO Recommendations)

  • Maintain ≥3 ft physical distance between clients, HCWs, staff, and visitors
  • HCWs caring for known/suspected COVID-19: don gloves + gown + eye shield + mask
  • Cohort HCWs to care exclusively for COVID-19 clients
  • For aerosolizing procedures (suctioning, nasopharyngeal/oropharyngeal specimen collection, CPR, manual ventilation, bronchoscopy) → don respirator mask

HCW Recommended Immunizations

Varicella Hepatitis B Influenza MMR (measles/mumps/rubella) Meningococcal meningitis Tdap (tetanus/diphtheria/pertussis) COVID-19

Sterilization vs Disinfection

Pre-cleaning is always step 1 ⚡ — remove visible soil/organic material before sterilization or disinfection. Methods: mechanical (hot water disinfectors) or ultrasonic devices for delicate instruments. Skipping pre-cleaning renders sterilization/disinfection ineffective.
Sterilization
Eliminates ALL micro-organisms including spores. Methods: thermal (autoclave), chemical (ethylene oxide, H₂O₂ gas), radiation. Required for surgical instruments.
Disinfection
High-level: only some spores remain — used for endoscopes; pasteurization is a high-level method ⚡. Low-level: most bacteria gone but some spores/fungi/viruses remain (bedrails, BP cuffs). Hospital-grade disinfectants. NOT for visible blood.
⚡
Exam High-Yield Summary
Pertussis transmission ⚡
Droplet — surgical mask, private room
TB transmission ⚡
Airborne — N95, negative pressure room, door closed
Measles (rubeola) ⚡
Airborne
Varicella (chickenpox) ⚡
Airborne
Influenza ⚡
Droplet
RSV ⚡
Contact precautions
VRE ⚡
Contact precautions — gown + gloves
C. diff hand hygiene ⚡
Soap & water only — alcohol doesn't kill spores
PPE removal — first ⚡
Gloves first — most contaminated
PPE donning — last ⚡
Gloves last — over gown cuffs
Faucet in chain of infection ⚡
Inanimate Reservoir
Client who got infected ⚡
Susceptible Host — becomes new reservoir
AIIR air exchanges
≥12/hr (new) · ≥6/hr (existing) — door stays closed
AIIR vs Protective pressure
Airborne = negative · Protective = positive
Mask: N95 for ⚡
Airborne precautions only — must be fit-tested
Contact precaution PPE removal ⚡
Gloves + gown removed inside room; mask removed in anteroom / hallway after door is closed — not inside room
Sterile field — first flap ⚡
Open away from body first
Sterile field — contaminated zone
Outer 1-inch border is non-sterile
Surgical asepsis hand product ⚡
Chlorhexidine + ethanol
Chipped nail polish ⚡
Remove it — chipped areas harbor bacteria
Faucet turn-off ⚡
Use paper towel to turn off — prevents recontamination
Prodromal stage ⚡
Vague symptoms: fever, aches, malaise → pathogen replicating
Convalescence ⚡
"Fever gone, feeling better" = convalescence
CAUTI — alternatives ⚡
Try alternatives before inserting Foley (e.g., condom catheter)
CAUTI — DO NOT ⚡
Never disconnect closed system to obtain urine sample
Needlestick — first action ⚡
Wash with soap & water → report immediately to supervisor
CRP as exam answer ⚡
Nonspecific marker of generalised inflammation
Throat culture swab site ⚡
Posterior pharyngeal wall, tonsils, tonsillar pillars — avoid all other surfaces
Bacteria as trigger ⚡
Infectious trigger of inflammatory response (burns, frostbite, radiation = noninfectious)
Glove change: dressing → computer ⚡
Change gloves after dressing change before documenting on computer ⚡
Alcohol gel advantage ⚡
Takes less time than soap/water — saves ~1 hr per shift in ICU
Gown: single-use ⚡
Discard every time — never reuse, even for same client
Nosocomial infection ⚡
= HAI — acquired while hospitalized
Contact precautions: infectious diarrhea ⚡
Infectious diarrhea, VRE, C. diff, MRSA → contact
Petroleum-based lotion + latex ⚡
Impairs glove integrity — weakens latex, increases permeability
Hand hygiene after glove removal ⚡
Standard precautions mandate it immediately — cannot assume glove integrity was not breached
Droplet → protect eyes ⚡
Droplets contact conjunctivae or mucous membranes of eyes, nose, mouth
Wound irrigation PPE ⚡
Expected splashing → face shield (covers face + eyes); mask still worn under it
Alcohol gel: dry completely ⚡
Drying = full antiseptic effect; bacteria proliferate more easily on wet/moist hands
Enhanced barrier precautions
Nursing homes: gown + gloves for bathing, wound care, toileting, transfers, device care
COVID-19: aerosolizing procedures
Suctioning, CPR, intubation, bronchoscopy → respirator mask (not just surgical mask)
Handwashing minimum time ⚡
15 seconds — rub all surfaces vigorously
Sterile solution: cap placement ⚡
Place removed cap upside down on nonsterile surface — never touch inside of cap or rim
Sterile solution: pour height ⚡
Pour from 10–15 cm (4–6 in) above the receptacle — do not splash
Strikethrough ⚡
Solution splashes onto sterile field = field is wet = contaminated → start over
Bottle on sterile field ⚡
Outside of container is not sterile — never place bottle on field
Gravity rule — wet instruments ⚡
Tip of wet object (forceps, etc.) must point down — fluid flows with gravity
Label facing palm ⚡
Hold bottle with label in palm when pouring sterile solution
Stratum corneum regeneration ⚡
Regenerates in 5–6 days; half restored within 6 hours; detergents and adhesive tape can destroy it
Humectants ⚡
Lotions/hand creams promote skin hydration and improve barrier integrity
O₂ humidification ⚡
Humidity added to oxygen therapy to keep nares and mucous membranes moist
Antihistamines ⚡
Diphenhydramine — blocks histamine receptors → reduces allergic swelling, itching
NSAIDs for inflammation ⚡
Ibuprofen — inhibits prostaglandins → reduces inflammation, pain, fever
Chronic inflammation → cancer ⚡
Persistent inflammation can lead to tissue destruction and cancer (e.g., asthma, GERD)
UA + C&S ordering ⚡
UA and culture & sensitivity may be ordered simultaneously — WBCs in UA confirm infection; C&S IDs organism
NLR / PLR / SII ⚡
New ratio-based inflammatory markers combining neutrophils, lymphocytes, platelets — useful in chronic inflammation, cancer, cardiovascular disease
Pre-cleaning before sterilization ⚡
Remove visible soil first — sterilization/disinfection is ineffective on soiled instruments
Pasteurization ⚡
High-level disinfection method — kills most organisms except some spores
CLABSI: dressing schedule ⚡
Gauze: q2 days; semipermeable: q7 days (or sooner if wet/soiled/dislodged)
CLABSI: chlorhexidine bath ⚡
Daily for ICU clients age >2 months — reduces bloodstream infection risk
CLABSI: tubing changes ⚡
Propofol: q6–12h; fat emulsions/blood: q24h; continuous infusions: q7 days (no more than q4 days)
VAP: ventilator circuits ⚡
Avoid frequent circuit changes — change only when visibly soiled or malfunctioning
Rings: CDC policy ⚡
CDC has no specific ring guideline — follow facility policy
Closed-gloving technique ⚡
Hands stay inside gown cuffs — used when sterile gown is worn (surgical scrub)
Open-gloving technique ⚡
Hands come out of cuffs — used when no sterile gown (e.g., Foley insertion) or replacing contaminated glove
Sterile gown boundaries ⚡
Sterile: front chest to 2 in above elbows. Axillae and back are NOT sterile
Mask removal — contact precautions ⚡
Gloves + gown removed inside room; mask removed in anteroom / hallway after door is closed
mod 18Safety
🎯
National Patient Safety Goals (NPSGs)
The Joint Commission (TJC) creates NPSGs annually to focus on client safety and safe healthcare delivery. Once consistently practiced nationwide, NPSGs become Standards of Compliance (retired goals — still required). Facilities risk losing accreditation if standards are not met. 250+ current standards include: medical error prevention · staff qualification verification · client rights & education · infection control · medication management · emergency preparedness.

📋 Current NPSGs at a Glance

NPSG 01 Identify Clients Correctly
Use 2 client identifiers before any medication, treatment, or procedure. Acceptable: name, DOB, hospital ID#, phone number. Room number is NEVER an identifier. Ask open-ended questions. Use barcode scanning. Verify with ID bracelet or EMR.
NPSG 02 Improve Staff Communication
Report critical results promptly — life-threatening values outside expected range. Convey directly to provider in person or by phone. Never by voicemail. Document: who received and communicated results, and the timeframe.
NPSG 03 Use Medications Safely
Label all meds (name, dose, date/time mixed) — discard unlabeled. Extra caution with anticoagulants (warfarin, heparin, enoxaparin): monitor weight, renal/hepatic labs, interactions. Medication reconciliation at admission, transfer, and discharge.
NPSG 06 Use Alarms Safely
Clinical alarm systems warn of serious events or equipment malfunction. Alarm fatigue = sensory overload from frequent false alarms → staff desensitization → delayed response → ↑ negative outcomes. ICUs have highest noise pollution. Staff learn which alarms need immediate attention.
NPSG 07 Prevent Hospital-Acquired Infections
4 CDC HAIs: CLABSI · CAUTI · SSI · VAP. MDROs: MRSA, VRE, C. diff. Hand hygiene = #1 prevention — historically <50% compliance; 1 in 31 clients gets an HAI. 500,000+ HAIs/year. Hospitals must have a performance action plan.
NPSG 15 Reduce Risk of Suicide
Screen all clients 12+ with behavioral health admitting dx using a validated screening tool. Positive screen → detailed assessment (plan? intent? self-injury?). At risk: 24/7 surveillance, remove harmful items, manage visitor items. Suicide = 10th leading cause of death; 2nd for ages 10–34.
UNIV PROTOCOL Prevent Adverse Events in Surgery
① Two identifiers
Verify client. Client verbalizes procedure.
② Mark site
Surgeon/APRN marks correct location. Not needed for bilateral organs.
③ Time-Out
All activity pauses — verify correct client, site, procedure. Confirm consent.
NEW 2024 Improve Health Care Equity
Assess social needs on admission: literacy, housing, transportation, food access. Continue assessment throughout hospitalization and during discharge planning. Leaders identify barriers to equity and patient safety.

💉 HAI Quick Reference

HAI Type Definition
CLABSIPathogens enter bloodstream via central line (large vein, long-term)
CAUTIPathogens enter urinary system via catheter through urethra into bladder
SSIInfection at the part of the body where surgery occurred
VAPPneumonia that develops while client is on a ventilator
💬
Culture of Safety & Communication

IOM: To Err Is Human (1999)

  • Goal: ↓ unexpected deaths, HAIs, surgical complications, nurse burnout; ↑ client satisfaction
  • Culture of safety = open communication, confidential reporting of safety issues, report near misses AND actual incidents
  • Nurses = most client contact on the team → key safety role
  • Staffing levels, resources, and management responsiveness all affect safety

Transforming Care at the Bedside — 4 Components ⚡

  • 70% bedside time for direct care (nurses currently spend ~33%)
  • Leadership development — team-building, hiring, coaching, evaluations
  • Rapid Response Team (RRT) — ICU nurse + respiratory therapist + critical care provider
  • ISBARR — standardized communication tool at bedside handoff
Hourly Rounding: Staff checks on clients every hour — address toileting, positioning, pain, safety (siderails, bed position, call light). ↓ fall rates, ↑ satisfaction. Handoff communication happens at the bedside.
AHRQ 10 Evidence-Based Safety Recommendations:
① Prevent infections② Simplify discharge instructions ③ Protocol to prevent VTE④ Improve medication education ⑤ Limit continuous work hours⑥ Work with a PSO ⑦ Improve facility design⑧ Survey safety culture ⑨ Create better teams⑩ Evidence-based protocol for invasive procedures
⑤ Nurse fatigue: <4 hrs sleep = 11.5× motor vehicle accident risk; ≥6 hrs sleep = 1.3× risk

🗣️ ISBARR — Know Each Component ⚡

I
Identity — Introduce yourself and where you are calling from
S
Situation — Client name, age, admitting diagnosis, chief complaint or urgent need for the RRT
B
Background — Medical history, current medications, advance directives
A
Assessment ⭐ — General impression + significant findings: diagnostic tests, lab results, vital signs
MOST TESTED
R
Recommendation — Treatment provided and client's response to the treatment
R
Read Back — Repeat provider's prescription back to clarify any miscommunication

🚨 When to Call the RRT ⚡

Sudden change in vital signs
Low O₂ sat despite oxygenation efforts
Chest pain despite nitroglycerine
Seizure
Deep concern about client condition
Sudden change in mental status
❌ NOT a trigger: One high blood glucose reading alone does not warrant an RRT call.
⚠️
Types of Unexpected Events & Occurrence Reporting

📊 Severity Spectrum — Most Tested ⚡

🟢
Near Miss
Error could have occurred but was caught and avoided before reaching the client
🟡
Client Safety Event
Unexpected event occurred — no harm, but potential for harm existed
🔴
Adverse Event
Unexpected event that caused harm to the client
⚫
Sentinel Event
"Never event" — severe harm, death, permanent/temporary injury. Must be reported to TJC.

Most Common Sentinel Events (US)

  • Wrong-site surgery ⭐
  • Surgical complications (intra- or postoperative)
  • Client suicide within facility
  • Client death while in restraints
  • Infant abduction · Falls with serious injury

Occurrence Report — Must File ⚡

  • Any fall — client, staff, or visitor
  • Unexpected vaccine or drug reaction
  • Wrong or incorrect medication administration
  • Lost items (e.g., dentures)
  • Exposure to blood or body fluids
  • Atypical behaviors against facility policy
Occurrence Report Process: Not punitive — used to investigate and prevent future incidents. Sequence: notify nurse leader/provider → ensure client safety → then file report. Risk management uses data to create action plans. Note: antibiotic given 30 min late is within the ±30 min acceptable window — not reportable.

🏥 Hospital-Acquired Injuries — Full Conditions List ⚡

TJC "Zero Harm" Policy: A hospital-acquired injury is harm that occurred during the hospital stay and was NOT present on admission. CMS will not reimburse hospitals for these preventable never events (falls, HAIs, hospital-acquired injuries).

Hospital-Acquired Conditions ⚡

  • CLABSI · CAUTI · SSI
  • Burn or electrical shock
  • Blood transfusion incompatibility ⚡
  • Injury related to fall or trauma
  • Ineffective or unsafe insulin usage ⚡
  • DVT — 50–60% of DVTs within 3–6 months post-hospitalization are hospital-acquired
  • Pressure injury (decubitus ulcer) acquired during the hospital stay

Clients at High Risk for Injury

  • Medical: stroke, MS, Parkinson's, fragility in older adults
  • Behavioral: schizophrenia, personality disorders, substance use disorders
  • Vision: cataracts and other eye conditions
  • Communication disability (hearing impairment, autism, aphasia) → 3× more likely to experience hospital adverse events
  • Cognitive: intellectual impairment, dementia, Alzheimer's disease
🏗️
Environmental Safety

⚡ Electrical Safety ⚡

  • Check cords — no fraying or severe creasing
  • All plugs must be 3-pronged (grounded)
  • GFCI outlets prevent electrocution
  • Hold plug to unplug — never pull the cord
  • Never plug/unplug with wet hands
  • Avoid extension cords; don't roll beds over cords
  • Defective: tag, remove, notify Clinical Engineering

🧪 Chemical Safety

  • Entry routes: inhalation · skin/eyes · ingestion · injection (needlestick)
  • SDS (Safety Data Sheet) — required for all chemicals; lists risks, first aid, disposal
  • PPE: gloves, gowns, masks, goggles based on chemical
  • Know eyewash station and emergency shower locations
  • Ventilation systems remove gases/fumes

☢️ Radiation Safety

  • Reduce Time — less time = lower dose
  • Increase Distance — step away when possible
  • Use Shielding — lead aprons, concrete walls
  • Children = greatest risk (rapidly dividing cells)
  • Always ask female clients: pregnant?
  • CT scan > x-ray in radiation dose

☢️ Radiation Types — Least to Most Dangerous ⚡

LOWEST RISK
Alpha (α)
Doesn't penetrate clothing. Travels only a few cm. Minor hazard.
MEDIUM RISK
Beta (β)
Travels small distance. Specialized clothing needed. Minimal hazard.
HIGHEST RISK
Gamma (γ)
Penetrates clothing AND body tissue. Lead shielding required. Risk: skin burns + internal injury.

🏠 Home Safety Key Points ⚡

Do These ✅

  • Mark stair edges with brightly colored tape
  • Secure cords to floor edges (not under rugs)
  • Set water heater to 49°C / 120°F
  • Install GCFIs in bathroom and kitchen
  • Add grab bars, non-slip mats, raised toilet
  • One solid paint color — better light reflection
  • Unplug small appliances when not in use
  • Electric razor for anticoagulant clients

Avoid These ❌

  • Extension cords across doorways or under rugs
  • Loose rugs and uneven flooring
  • Water heater above 120°F (scalding)
  • Multiple paint colors (harder to perceive depth)
  • Chairs with wheels or swivels
  • Cord loops near children (strangulation)
  • Leaving toaster plugged in unused
  • Manual razor if client is on anticoagulants

🔥 Home Fire Safety

Prevention Measures

  • Install smoke and CO detectors on every floor + outside sleeping quarters — test monthly, change batteries every 6 months
  • Place fire extinguishers on every level (especially basement, kitchen, garage)
  • Identify 2 exit points from each room; purchase rescue ladder for multilevel homes
  • Practice escape plan twice/year (one drill at night); designate central meeting area
  • Keep flammable items ≥3 feet from space heaters; inspect fireplace chimney annually
  • Only one appliance per outlet; replace all broken/exposed cords

Child Fire Safety

  • Teach Stop, Drop, and Roll (covering face) if clothing catches fire
  • Keep matches and lighters locked away from children
  • Teach children not to play near or touch space heaters
  • Cover available electrical outlets to prevent shock
👶
Age-Based Safety Risks
Age Group Primary Risks Key Interventions
0–4 yrs
Infants & Preschool		 Burns (hot liquids/steam), poisoning, choking, drowning, car safety Water heater ≤120°F · Lock toxic items · Fence pools · Rear-facing car seat until 2–4 yrs (max weight/height) · Never leave alone near water
5–12 yrs
School-Age		 Vehicle safety, sports injuries, drowning, firearms, internet exploitation/bullying Backseat until age 12 · Helmets & eye protection for sports · Supervise online activity · Firearms: unloaded, locked storage, ammo separate · ~20% accidental shooting deaths ≤14 yrs
13–19 yrs
Adolescents		 Speeding, alcohol/substances, unprotected sex, bullying, intimate-partner violence, suicide Open family communication · Take all suicide talk seriously · Screen for behavioral health · Healthy nutrition, sleep, exercise
19–64 yrs
Adults		 Stress, alcohol abuse, obesity, workplace accidents, mental disorders Middle-aged adults = highest risk of alcohol abuse + mental disorders + obesity. Workplace and leisure injury concerns.
65+ yrs ⭐
Older Adults		 Falls (1 in 3 fall annually; fatal every 20 min), chronic illness, impaired mobility, cognitive/sensory deficits, frailty Routine fall risk assessment · CDC STEADI program · Frailty evaluation on admission · Goals: mobility, function, cognition, pain control, social engagement
Frailty: Decline in function across multiple organ systems, linked to aging at different rates for different people. Clients at high frailty risk → poorer outcomes. Assess on admission. WHO defines older adults as ≥60; US standard is ≥65. Hospital stays can worsen conditions beyond the original illness.
🛡️
Falls, Restraints & Seizure Precautions

📉 Fall Risk Factors — Morse Fall Scale ⚡

PHYSICAL
  • Stroke, amputation, recent surgery
  • Multiple sclerosis, visual impairment
  • Weakness, unsteady gait, chronic pain
  • Malnutrition
COGNITIVE
  • Sleep disorders, impulsiveness
  • Disorientation, dementia, depression
ENVIRONMENTAL
  • Room clutter, poor lighting
  • Slippery floors
MEDICATIONS ⭐
  • Antidepressants
  • Antihypertensives
  • Anticonvulsants
  • Age, bathroom frequency, ↓ staffing

✅ Universal Fall Precautions — All Clients ⚡

Non-skid footwear
Bed in low position, wheels locked
Wheelchair brakes on
Clutter-free environment
Adequate lighting
Call light within reach
Belongings within reach
Orient to room + call system
Additional Fall Prevention: Fall safety champions promote strategies within the facility. High-risk clients may be placed closer to the nurses' station. Other tools: movement alarms, cognitive/physical activities for clients, virtual/physical sitter monitoring. Color-coded wristbands identify high-risk clients, but studies show they are not effective alone.
Movement alarms (bed, chair, person) ring when a client attempts to move — warning device, not a prevention tool. Useful for clients who forget to use the call light. Considered a form of restraint in long-term care facilities because they restrict mobility and independence.

Video Monitoring & Bedside Sitters

  • Video monitoring for: altered neurologic/cognitive status, agitated clients, impaired mobility
  • May include two-way intercom to redirect client; virtual privacy screen during personal care
  • Bedside sitter: useful for cognitively impaired + impulsive + mobile clients; helps prevent elopement; essential for clients with suicidal ideation
  • Elopement = client leaves/wanders away from the facility (usually due to cognitive deficit)

Siderails — Restraint vs. Safety ⚡

  • All 4 siderails raised = treated as a restraint per TJC — prevents client from exiting bed
  • 2 upper rails raised = NOT a restraint — client can still exit; prevents inadvertent rolling out
  • Exception: infants/toddlers — all siderails raised = safety measure, not restraint (developmental level)
  • Classification is based on intent: restraint vs. safety

🔒 Restraints — Last Resort ⚡

Try BEFORE restraints: social interaction · diversional activities · de-escalate · place near nurses' station · family at bedside · sitter · bed/chair alarms · remind/reorient client. Document all alternatives tried and their effectiveness.

🪜 5 Categories — Least to Most Restrictive

Physical (most temporary)
Manually holding/immobilizing client using physical strength. Short-term only (e.g., holding for injection, IV placement). Examples: swaddle wrap or immobilization board for infants during procedures. Can cause bruising/fractures — use with care.
Hand Mitten (mechanical — least restrictive)
Prevents removal of tubes/lines. Fingers can still move freely. Most commonly used first.
Wrist / Elbow Restraint
Limits flexion. Tie to BED FRAME — not siderail (siderail movement can injure). Use quick-release knot (not square knot). 2 fingers must fit between restraint and skin.
Belt / Lap Restraint
Prevents falling from bed/chair. Never over chest (impairs breathing). Open hand space at waist. Vest restraints → linked to fatal strangulation; many facilities eliminated them.
4-Point Extremity (most restrictive mechanical)
Aggressive/dangerous clients. Death in restraints = sentinel event. Must be reported.
Barrier Restraint
Limits movement through physical barriers: concave mattresses, lapboards on chairs, bed enclosures, all 4 siderails raised. Exception: infants/toddlers in cribs with all rails raised = safety, not restraint.
Chemical Restraint
Benzodiazepines, antipsychotics, or neuromuscular blockers to reduce movement or control behavior.
Seclusion
Client alone in securely locked room without consent. Used in psychiatric facilities for combative clients posing a risk to others.
Restraint Monitoring: Remove every 2 hours for 15 min — check circulation, skin integrity, ROM. Offer fluids, toileting, range-of-motion exercises. Only RN/PN can monitor — not AP. Provider must reassess need every 24 hours. Never use for punishment, convenience, or staffing shortages.

⚡ Seizure Precautions

Pre-Seizure Setup

  • Suction equipment at bedside
  • Oxygen at bedside
  • Establish 2 IV sites
  • Pad siderails
  • Remove constrictive clothing/jewelry
  • Ask about aura → remove dentures if yes

During Seizure ⚡

  • Call for help (RRT or 911)
  • Side-lying position — prevent aspiration
  • Protect head (folded towel/pillow)
  • Do NOT restrain extremities
  • Record time, duration, body parts involved
  • Observe eyes (open? twitching? pupil size?)
  • Administer benzodiazepine per order

Post-Seizure

  • Check gag reflex before giving anything by mouth
  • Toxicology screen / anticonvulsant level if ordered
  • Explain what happened; reassure client
  • EEG and imaging often ordered
  • Monitor glucose — treat if needed

💪 Lift Devices — Work-Related MSD Prevention ⚡

Safe Lift Device Use ⭐

  • Lock brakes of receiving furniture before transfer
  • Check max weight of the lift before use
  • Center client in sling — not at edge
  • Always 2 people to operate the lift
  • Safety check before lifting
  • Battery operated: verify charge first
  • Never leave client unsupervised in lift
  • Ceiling lifts > mobile lifts for back injury prevention

Lift Device Types

  • Mobile/Hoyer lift — locking wheels, sling
  • Ceiling lift — overhead mount; lowest back load on nurse
  • Turn/Slide sheet — frictionless material for repositioning in bed
  • PolyGlide sheet — smaller; moves body parts (e.g., obese extremities)
  • Sit-to-stand lift — seated → standing, mobile with locking brakes
🔥
Fire, Emergency Preparedness & Workplace Safety

🚨 R.A.C.E. — Fire Response ⚡

R
Rescue — move persons in immediate danger first
A
Alarm — activate fire alarm ⭐ NEXT step after rescue
C
Contain — close doors & windows (limits oxygen to fire)
E
Extinguish — attempt if fire is small and safe to do so

🧯 P.A.S.S. — Extinguisher Use ⚡

P
Pull — pull the pin (breaks tamper seal)
A
Aim — aim at the base of the fire
S
Squeeze — squeeze handle to release
S
Sweep — side-to-side at base until out
Fire needs: oxygen + heat + combustible material ⚡

🧯 Fire Extinguisher Classes ⚡

Class Agent Used For
AWaterPaper, wood, plastics, rubber, cloth — general combustibles. ❌ Never on electrical or flammable liquids.
BCO₂Oils, gasoline, paints, grease, caustic chemicals. Don't touch plastic horn (gets very cold).
CDry chemicalElectrical fires — wiring, fuse boxes, computers, electrical devices
DSpecial dry powderMetal fires — titanium, magnesium, potassium, sodium
K ⭐Wet chemicalKitchen fires — flammable cooking oils and fats
A-B-CDry chemical (multipurpose)Flammable materials, liquids, and electrical — most common all-purpose extinguisher

Evacuation Types

  • Lateral evacuation — same floor, preferred. Move those closest to fire first.
  • Vertical evacuation — different floor. Used only if lateral not possible.
  • Close all doors · Wrap clients in blanket with face covering · Stay low (smoke rises)
Facility fire alarms must be a distinct audible alarm different from all other alarm sounds (bell, siren, horn, or voice announcement). Visual alarms — flashing or strobe lights — are also present for notification. All alarms must be routinely tested and maintained.

Active Shooter — Run · Hide · Fight ⚡

  • Run — evacuate if safe path exists
  • Hide — secure location if can't run
  • Fight — last resort only
  • Validate knowledge: biannually (acute) / annually (long-term care)
  • CMS mandates emergency drills

☣️ Mass Casualty Decontamination

Radiation Exposure

  • Shower/rinse immediately
  • Cut off clothing, double-bag in biohazard bags
  • Scrub skin, wash hair, irrigate eyes liberally
  • Potassium iodide (oral/inhaled) — saturates thyroid to block radioactive iodine (given to victims, first responders, AND staff)
  • Symptoms: N/V/D, alopecia, burns, PTSD

Chemical Exposure

  • Quick shower + skin scrub immediately
  • Cut off clothing — don't pull over head
  • Double-bag in biohazard bags
  • Full PPE if toxin unknown
  • Short-term: blistering, resp. issues · Long-term: anxiety, depression

Biological Exposure

  • Multiple clients with same symptoms = suspect mass-casualty event
  • Full PPE if unknown (respirator + chem-resistant clothing)
  • Cut off clothing, double-bag
  • Onset: hours (botulinum) → months (anthrax ~2 mo)
  • Monitor mental status, breathing, vitals

Workplace Bullying

  • Repetitive harassment, isolation, belittlement
  • Effects: ↓ job satisfaction, ↑ medical errors, ↑ turnover, anxiety, exhaustion
  • Solution: relationship-oriented culture, positive communication, strong leadership, ↑ nurse confidence

Workplace Violence ⚡

  • Healthcare workers = 73% of all nonfatal workplace violence injuries (2018)
  • Warning signs: absenteeism, ↓ work quality, persistent complaints of not being treated fairly, mood swings, paranoia
  • Zero-tolerance policy required. Report to supervisor/HR.
  • OSHA: employee rights — can report hazards without retaliation; report to OSHA within 30 days

🏠 Home Oxygen Safety ⚡

  • Post "No Smoking" signs on outside doors and inside home
  • No smoking anywhere in home — even when oxygen is NOT in use
  • Do NOT wear oxygen appliance while cooking
  • Keep all flames, electrical appliances (hairdryers, electric razors), gas stoves ≥10 feet from oxygen exit point
  • No oil-based lotions, lipsticks, or aerosol sprays
  • Fire: turn off oxygen → exit → call 911

⚖️ Discrimination & Equity

  • Barriers to care: access, age, education, gender identity, race, ethnicity, language, religion, sexual orientation, economic status, disability
  • TJC standards mandate a bias-free, discrimination-free environment
  • Clients are entitled to: timely care, respectful treatment, interpreter when needed
  • Speak Up initiative (on TJC website) — for clients who experience discrimination

📋 Emergency Preparedness

  • CMS requires all hospitals receiving Medicare/Medicaid to establish an emergency preparedness plan
  • Training: new hire orientation AND annually; validate knowledge biannually (acute care) / annually (long-term care)
  • Emergency drills mandated by CMS — identify plan gaps
  • Nursing Compact: nurses can practice in any compact state → enables rapid cross-state disaster response
⚡
Exam High-Yield Summary
Home hazard — stair safety ⚡
Brightly colored tape on stair edges. Water heater ≤120°F/49°C. Cords along floor edges (never under rugs). Unplug small appliances when not in use.
Seizure — nursing action ⚡
Record time & duration. Do NOT restrain extremities. Position = side-lying (not prone). Monitor glucose, not hemoglobin.
Suicide risk — nursing actions ⚡
24/7 surveillance · Remove harmful objects · Search visitor items · Screen for ideation. Always ask the client directly — do NOT avoid the question.
HAI prevention — priority ⚡
Hand hygiene = #1 intervention. Outranks antiseptic wipes, auditing records, and client education for any HAI including CAUTI.
Near miss vs. other events ⚡
Near miss = caught before reaching client. Client safety event = no harm but occurred. Adverse = harm happened. Sentinel = severe/permanent/death.
Fire triangle ⚡
Fuel + Oxygen + Heat. CO₂ and nitrogen are non-flammable — NOT fire components. CO₂ actually extinguishes fires.
CDC HAI protocols ⚡
Evidence-based protocols for CAUTI · CLABSI · SSI. Influenza = droplet. TB = airborne. Neither is a CDC-tracked HAI type.
Workplace violence warning sign ⚡
Frequent reports of not being treated fairly. Also: mood swings, paranoia, emotional outbursts at criticism. Absenteeism alone is NOT a sign.
Electrical safety ⚡
Hold the plug, not the cord, when unplugging. Never plug/unplug with wet hands. No rolling bed over cords. No extension cords in patient areas.
Hospital-acquired injuries ⚡
Blood transfusion incompatibility · Wrong-site surgery · Ineffective insulin usage. Dysphagia after stroke = stroke complication, not hospital-acquired.
Occurrence report — required events ⚡
Visitor fall · Unexpected drug reaction · Lost dentures. Forgotten password = not reportable. Antibiotic 30 min late = within window, not reportable.
Client identifiers ⚡
Full name · Date of birth · Telephone number. Diagnosis = not unique. Room number = not unique (changes). Never use either.
Chemical toxin exposure ⚡
Rinse/shower skin with water immediately. Cut clothing off (never pull over head). Double-bag in biohazard bags. Potassium iodide = radiation only.
Lift device safety ⚡
Lock brakes · Check max weight · Safety check before lifting. Center client in sling. Always 2 people — never use alone.
Wrist restraints ⚡
Remove with every VS check (≥ q2h). Tie to bed frame (not siderail). Quick-release knot. 2 fingers between restraint and skin.
Transforming Care at Bedside ⚡
Standardized communication tool (ISBARR). Bedside time = 70%. Shift report at bedside. Hourly rounding (not q4h).
ISBARR — Assessment ⚡
Lab results · Diagnostic tests · Vital signs. Admitting diagnosis = Situation. Medical history = Background. Response to treatment = Recommendation.
RACE — after rescue ⚡
Activate the alarm (A = step 2). Order: Rescue → Alarm → Contain → Extinguish. Do not extinguish before alarming.
Fall risk screening variables ⚡
Fall history · Medical diagnosis · Assistive device use · Mental status. DNR status is NOT a fall risk variable.
Premixed medication label ⚡
Date mixed · Dose · Time mixed. Client age and room number are NOT required. Discard any unlabeled medication.
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