───────────────────
── ASSESS · ANALYZE · PLAN ──
── IMPLEMENT · EVALUATE ──
── RECOGNIZE · ANALYZE ──
── PRIORITIZE · GENERATE ──
───────────────────
── TAKE ACTION · EVALUATE ──
── NCLEX · NGN · JUDGMENT ──
───────────────────
── ASSESS · ANALYZE · PLAN ──
── IMPLEMENT · EVALUATE ──
── RECOGNIZE · ANALYZE ──
── PRIORITIZE · GENERATE ──
───────────────────
── TAKE ACTION · EVALUATE ──
── NCLEX · NGN · JUDGMENT ──
───────────────────
mod 10
Clinical Judgment
From systematic process to informed decision — the thinking framework behind every nursing action.
Nursing Process
CJAM
Critical Thinking
Clinical Reasoning
Clinical Judgment
Delegation
The Nursing Process
Developed in 1958 by Ida Jean Orlando. A systematic, client-centered framework guiding nurses to deliver holistic care — physical, spiritual, and mental well-being in every decision. Nurses use critical thinking throughout each step.
RN — Full Nursing Process (5 Steps)
1
Assessment
Collect Data
Subjective + objective; health history; physical exam; labs/diagnostics.
›
2
Analysis
Identify Problems
Identify patterns/trends; compare to reference ranges; draw conclusions.
›
3
Planning
Set Goals
Measurable, time-bound goals; evidence-based interventions; plan of care.
›
4
Implementation
Carry Out Care
Apply plan; delegate & supervise; use clinical judgment; document.
›
5
Evaluation
Assess Outcomes
Evaluate effectiveness; continue, modify, or discontinue; document response.
⟲ The process is cyclical — steps may be repeated or revisited as the client's condition changes. The RN may return to any step at any point.
1. Assessment
- RN performs initial assessments on new & unstable clients
- PN may collect data on stable clients; RN determines if more assessment needed
- Objective: Measurable, observable via senses — VS, exam findings, facial expressions, I&O
- Subjective: Client/family self-report — documented in quotes
- Includes health history, PMH, medications, natural/herbal remedies, substance abuse, sexual history, support systems, and social/spiritual/cultural needs
2. Analysis
- RN reviews findings to identify client problems and formulate plan of care
- Identify patterns/trends; compare to expected reference ranges
- Draw conclusions to direct nursing care
- May need to reassess — assessment and analysis may repeat (especially in triage)
- Occurs in an ongoing manner throughout the nursing process
3. Planning
- Develop individualized, measurable goals with time frames
- Short-term: achieved within days; Long-term: weeks or months
- Interventions tailored — no two clients are alike
- Plan of care accessed/modified by all interprofessional team members
- RN updates plan whenever client condition changes
- May require consulting textbooks, internet, facility resources, and collaborating with other nurses and interprofessional team members
- For palliative/comfort care clients, goals may focus on improving pain enough that the client can visit with family or perform ADLs with assistance — not necessarily pain-free
4. Implementation
- Apply nursing knowledge with problem-solving & clinical judgment
- Delegate, supervise, and document care and client's response
- Implementation is continual — a single intervention is rarely enough (e.g., one dose of pain medication does not control ongoing pain)
5. Evaluation
- Determine if goals were met; continue, modify, or discontinue plan
- Client adherence: If the client will not or cannot follow the plan, the RN must investigate why — was the client in pain? Did they not understand the rationale? Intervene appropriately.
- Collaborate with other team members (e.g., physical therapist) to optimize timing — such as giving pain medication before a therapy session for maximum effect
PN — Modified Nursing Process (4 Steps)
PNs work under RN supervision. The PN collects data but cannot independently analyze or make nursing diagnoses — these remain the RN's responsibility. Always communicate changes to the supervising RN. Know your state's scope of practice.
Objective vs. Subjective Data
- Objective: Measurable, observable via senses — vital signs, facial expressions, intake/output, physical exam findings (inspection, auscultation, palpation)
- Subjective: Client or family self-report — pain description, reason for visit. Documented in quotes.
Plan of Care
- Documents: client problem, goals/plans, interventions, and responses
- Used & modified by all interprofessional team members (PT, OT, dietitian, etc.)
- Updated whenever client condition changes
- RN is responsible for keeping it current
Clinical Judgment Action Model (CJAM)
The NCSBN Clinical Judgment Action Model (CJAM) represents the process of making clinical judgments. It has 6 functions that directly map to nursing process steps. ⚡ The CJAM is the NCSBN's evidence-based model for clinical thinking and decision making.
Factors Shaping Clinical Judgment
Environmental Factors
- Setting and situation (safety, equipment, surroundings)
- Staffing levels and available support
- Supplies and health records availability
- Time pressures and cultural considerations
- Task complexity and risk assessments
Individual (Nurse) Factors
- Knowledge & skills
- Attitudes, prior experiences, level of experience
- Cognitive load — demands on nurse, stress, problem solving, memory
- Nursing fatigue increases risk of error
- Personal values and characteristics
Critical Thinking
Definition: An active, orderly, well-thought-out reasoning process guiding nurses to make nursing judgments by applying knowledge, experience, problem-solving, logic, reasoning, and decision-making. It is the foundation for clinical decision making — used both independently and with the interprofessional team. Critical thinking discourages quick judgments that lead to single-focused solutions. Nurses make inferences by pulling pieces of information together to determine a relationship between the data. CT requires lifelong learning and the ability to acquire relevant experiences that can be reflected on continuously to improve nursing judgment.
Three Core Elements
Element 1
Reflection
Purposefully thinking back on a situation to discover its meaning and gain insight. "Did my plan achieve optimal client outcomes? Which interventions were successful?"
Element 2
Language
Precise, clear language communicating unambiguous messages and expectations to clients and all healthcare team members.
Element 3
Intuition
An inner sensing that facts do not currently support something. Intuition should spark the nurse to search data to confirm or disprove the feeling.
Critical Thinking Competency Types
General Critical Thinking
- Scientific method
- Problem-solving
- Decision-making
- Diagnostic reasoning and inference
- Clinical decision-making; collaboration
Specific to Nursing
- The nursing process — applying critical thinking to client care
- Priority setting — determining which needs require immediate action
Three Levels of Critical Thinking
CT evolves through three distinct levels as a nurse gains knowledge and experience while maturing into a competent nursing professional.
Components of Critical Thinking
Knowledge
Nursing education, evidence-based practice, continuing ed, advanced degrees/certifications
Experience
Opportunities to observe, sense, and interact with clients — followed by active reflection. Builds intuition. An experienced nurse: understands clinical situations, recognizes and analyzes cues for relevance, and incorporates experience into intuition.
Competence
Applying the nursing process to make nursing judgments; proficient skill performance
Attitudes
Mindsets affecting how the nurse approaches a problem (see list below)
Standards
Intellectual: Ensure thorough CT application. Professional: Nursing judgment based on ethical criteria · Evaluation relies on EBP · Demonstrates professional responsibility · Promotes maximal level of nursing care
Critical Thinking Attitudes (11)
Confidence
Sure of abilities
Independence
Analyzes for logic
Fairness
Objective, nonjudgmental
Responsibility
Adheres to standards
Risk-taking
Calculated chances
Discipline
Systematic approach
Perseverance
Works until resolved
Creativity
Imagination for unique problems
Curiosity
Desires more information
Integrity
Truthful & ethical
Humility
Acknowledges weaknesses
Critical Thinking Skills — By Nursing Process Step
✓ Improve critical thinking: Find a mentor · Use a reflective journal on clinical judgment outcomes · Review evidence-based practice articles · Organize data with concept maps · Discuss client care with peers and colleagues
✗ Does NOT improve CT: Limiting consultations with other professionals involved in a client's care · Making quick decisions when unsure about a client's needs
Clinical Reasoning
Definition: The mental process used when analyzing all the data pertaining to a clinical situation. Takes into consideration nursing, scientific, and technological knowledge in client situations. It is a constant and repeated action nurses use in practice — not a one-time event.
Key Characteristics
- Guides nurses through assessing & compiling data
- Selecting and discarding pieces of information based on relevance
- Making decisions about client care based on nursing knowledge
- Clinical reasoning repeated across time = Clinical Judgment
- New graduates may lack this competency — it develops with practice
⚡ Complicated By
- Complex clinical situations — multiple comorbidities
- Ongoing client and family concerns
- Clients on multiple medications with adverse effects mimicking other conditions
- Staffing shortages and time pressure
- Nursing fatigue increases risk of error
⚡ NOT complicated by: Cost of health care · Decreased need for advanced practitioner intervention · Availability of computerized medical records (these simplify, not complicate clinical reasoning)
Clinical Judgment
Definition: Involves assessing and drawing conclusions about a patient's health requirements, issues, or concerns — and deciding whether to act, adhere to established methods, adjust them, or create new strategies based on the patient's reaction. The complexity stems from the specific circumstances of each patient, their individual reactions, and the dynamic between the nurse and the patient.
Shaped by: nurse's expertise, prior experience, personal values, and the context of the healthcare setting. The visible or observed outcome of critical thinking and decision making — develops through repeated use and increasing experience. On-the-job training is an effective way for nurses to develop the clinical judgment needed to keep clients safe.
The Thinking Hierarchy
Foundation
Critical Thinking
Higher-order reasoning
→
Applied to Practice
Clinical Reasoning
Data analysis in real situations
→
Observable Outcome
Clinical Judgment
Grows with experience
⚡ Factors Influencing RN Decision Making (Acute Care)
Awareness of client status
Goals / outcomes
Options to meet goals
Routines
Education
Nursing roles
Teamwork
Resources
Support from other staff
Patient education
Issues with communication and teamwork among healthcare professionals are the primary contributors to medical mistakes. Fostering collaboration is crucial for resolving issues and improving outcomes.
Prevention > Treatment: Prevention of a potential adverse situation is always better than having to treat an actual adverse situation. Early detection through nursing assessment is crucial — for example, recognizing a rising blood pressure before it escalates, or catching frequent post-op urination before bladder rupture.
Delegation
Definition (ANA/NCSBN): Assigning a nursing activity or procedure to another person who has the appropriate training for that activity. An RN cannot delegate activities requiring RN nursing judgment or decision-making to a PN or AP.
⚠️ Some states do NOT allow PNs to delegate. PNs must know and follow their state's delegation guidelines. Clinical reasoning and clinical judgment cannot be delegated to unlicensed staff — ever.
⚡ Delegation Types (Exam Terms)
- Wrong task: Activity outside AP's scope (e.g., asking AP to auscultate lungs)
- Right task: Appropriate for person's training (e.g., asking AP to take vital signs)
- Right person: Person has proper training for the assigned task
- Right circumstance: Appropriate setting/context for the delegation
Gatekeeping & Privacy
- Nurses are the gatekeepers ensuring clients' needs are met and optimal outcomes achieved
- Early assessment = early intervention = prevention of adverse events
- Private health info shared only at nurses' station or secure location — never in hallways or elevators
Exam High-Yield Summary
⚡ RN vs PN: first step
RN = Assessment · PN = Data Collection (reports changes to RN; cannot independently analyze)
⚡ NP order (RN)
Assessment → Analysis → Planning → Implementation → Evaluation — can cycle back
⚡ NCSBN model
The NCSBN Clinical Judgment Model (CJAM) assists with evidence-based critical thinking and decision making — not SMART goals or clinical reasoning alone
⚡ Critical thinking
Foundation for clinical decision making. NOT the same as clinical reasoning (which uses nursing/scientific/tech knowledge) or clinical judgment (which is the observable outcome)
⚡ CT skills (SATA)
Inference · Creativity · Inductive reasoning — Inspection = assessment; Implementation = NP step (neither are CT skills)
⚡ Developing a goal
Creating a client goal = Planning step. Carrying out the goal = Implementation. Assessing goal achievement = Evaluation.
⚡ Pain rating after meds
Asking client to rate pain after administering medication = Evaluation (assessing intervention effectiveness)
⚡ Auscultating lungs
Auscultating lung sounds = Assessment step (collecting data). Delegating this to AP = wrong task delegation (requires clinical reasoning)
⚡ Decision-making factors
Awareness of client status · Available resources · Support from other staff — NOT cost of care, NOT appropriate delegation
⚡ CR complicated by
Complex clinical situations · Ongoing client/family concerns — NOT cost, NOT decreased need for advanced practitioners, NOT computerized records
Clinical judgment
Observable outcome of critical thinking + decision making; develops with repeated practice and experience
Delegation rule
Cannot delegate clinical reasoning or clinical judgment to AP — ever. Some states don't allow PNs to delegate either.
CT levels
Basic (rules) → Complex (analyzes alternatives) → Commitment (expert, independent decisions)
CJAM → NP mapping
Recognize Cues = Assessment · Analyze/Prioritize = Analysis · Generate = Planning · Take Actions = Implementation · Evaluate Outcomes = Evaluation
PN supervision
PN plans and evaluates under RN supervision; RN retains overall accountability for nursing judgment
───────────────────
── MASLOW · ABCDE ──
── SAFETY · TRIAGE ──
── ACUTE · URGENT ──
───────────────────
── RED · YELLOW · GREEN ──
── BLACK · EXPECTANT ──
───────────────────
── MASLOW · ABCDE ──
── SAFETY · TRIAGE ──
── ACUTE · URGENT ──
───────────────────
── RED · YELLOW · GREEN ──
── BLACK · EXPECTANT ──
───────────────────
mod 11
Priority-Setting Frameworks
Organizing client care so the most critical intervention happens first — from individual assessments to mass casualty triage.
Maslow's HierarchyABCDE ApproachNursing ProcessSafety & RiskLeast RestrictiveTriageDelegation
Priority Setting — Overview
Priority setting = delivering nursing care based on the urgency or importance of client needs — completing the most critical intervention first. Applies to individual clients and to groups of clients. Nurses demonstrate prioritization skills when choosing interventions, revising care plans, and organizing shift care.
Group prioritization (change-of-shift): (1) First rank the order in which clients will be seen (most critical → least critical); (2) Then determine the order of care tasks for each individual client. Reprioritize multiple times throughout the shift as client needs change. Use clinical indicators to guide decision-making: LOC, skin tone changes, pain level, GI/renal function changes, trending vitals.
Which framework to use?
| Framework | Use When | Priority Goes To |
|---|---|---|
| Maslow's Hierarchy | Multiple competing needs | Lowest unmet level in pyramid |
| ABCDE | Multiple body system issues; clinical crisis ⚡ | Airway first, then sequence |
| Nursing Process | All clinical care situations | Assessment always first |
| Safety & Risk | Safety concerns; fall risk; medication risk | Greatest risk to physical/psychological well-being |
| Least Restrictive | Choosing between interventions | Least restriction while maintaining safety |
| Acute vs. Chronic | Conditions of different time courses | Acute over chronic |
| Urgent vs. Nonurgent | Needs with different harm potential if delayed | Urgent first |
| Unstable vs. Stable | Clients with different condition stability | Unstable (acute change) over stable |
| Survival Potential | Mass casualty; limited resources | Highest survival potential with available resources |
CURE task hierarchy: Critical (life-threatening → intervene immediately) → Urgent (harm if delayed) → Routine (scheduled care tasks) → Extra (comfort measures)
Maslow's Hierarchy of Needs
Developed by Abraham Maslow — five categories of human needs arranged as a pyramid. Lower levels must be met before higher levels can be pursued. Individuals may move back and forth between levels across the lifespan.
SELF-ACTUALIZATION
growth need · self-fulfillment
SELF-ESTEEM
confidence · achievement · respect from others
LOVE & BELONGING
friendships · family · intimacy · trust · connection
SAFETY & SECURITY
environment · employment · health · property · freedom from injury
PHYSIOLOGICAL ★ NURSING PRIORITY #1
air · water · food · shelter · sleep · warmth · reproduction · homeostasis
Level Details
- Physiological (L1): Essential for survival — oxygen, hydration, nutrition. Body maintains homeostasis via hunger, thirst. All other needs are secondary until these are met.
- Safety (L2): After physiology — security of environment, employment, health, freedom from accidents/injury. Children show this as fear and anxiety when threatened.
- Love & Belonging (L3): Social relationships, intimacy, friendships, work connections. The need to feel connected and belong.
- Self-Esteem (L4): Feeling good about oneself + being respected by others. Unmet → feelings of inferiority. ⚡
- Self-Actualization (L5): Reaching one's fullest potential. Growth need. Very few people reach this state according to Maslow.
Clinical Application
- Levels 1–4 = Deficiency needs — motivate action when unmet (felt as discomfort). Level 5 = Growth need.
- Address physiological needs first (O₂, circulation, hydration).
- Then safety — fall prevention, medication safety, environment.
- Then love & belonging — encourage social connections.
- Then esteem — promote confidence; avoid language that causes inferiority.
⚡ Maslow Order: Physiological → Safety → Love & Belonging → Self-Esteem → Self-Actualization
ABCDE Approach
A systematic approach to assess and treat critically ill clients. Used in any healthcare setting (not just acute care). Purpose: recognize and stabilize the most critical issue first, then move to the next system.
A — Airway
→
B — Breathing
→
C — Circulation ⚡
→
D — Disability
→
E — Exposure ⚡
The Nursing Process
A sequential framework guiding nurses in prioritizing care. Relies on critical thinking, client-centered care, evidence-based practice, and nursing instinct. Used regularly and continuously in all client care.
Step Details
- Assessment — ALWAYS FIRST ⚡: Gather objective (measurable — vitals, lung sounds) and subjective data (reported by client/caregiver) via physical exam, interviews, records, observations. Holistic approach.
- Analysis: Clinical judgment about actual/potential health conditions → nursing diagnosis. RN only — LPN does not perform this step.
- Planning: Evidence-based SMART goals (Specific, Measurable, Attainable, Realistic, Timely). Client-specific care plan. RN develops.
- Implementation: Perform nursing interventions. Direct care = at bedside (meds, procedures). Indirect care = away from bedside (documentation).
- Evaluation: Reassess — were desired outcomes met? If no → revise care plan, develop new goals/interventions.
RN vs. LPN
- RN — 5 steps: Assessment, Analysis, Planning, Implementation, Evaluation
- LPN — 4 steps: Data Collection, Planning, Implementation, Evaluation (no Analysis/nursing diagnosis step)
- LPN always works under supervision of RN or provider
Data Types
- Subjective: What the client or caregiver reports (symptoms, feelings, pain)
- Objective: Measurable and observable — vital signs, lung sounds, weight, lab values
Safety & Risk Reduction
Key Rule ⚡: Priority goes to the situation posing the greatest risk to the client's physical or psychological well-being. When multiple risks exist simultaneously, use Maslow's or ABCDE to determine which poses the highest risk.
Common Client Safety Issues
- Medication errors
- Surgical complications
- Device/equipment malfunctions
- Healthcare-associated infections (HAIs)
- Falls — fall risk = top safety priority ⚡
- Pressure injuries
- Environmental hazards (wet floors, loose electrical cords)
Proactive Risk Reduction
- Prevent harm before it reaches the client
- Example: dry a wet floor immediately → prevents slip/fall
- QSEN (Quality and Safety Education for Nurses): recommends individual + system-level safety interventions
- Strategies: use checklists; communicate hazards and concerns to team
- WHO defines client safety as "absence of preventable harm during healthcare and reduction of unnecessary risk to an acceptable minimum"
Least Restrictive / Least Invasive
Key Rule ⚡: Choose the intervention that is least restrictive and least invasive while still maintaining safety — for the client and those in the immediate surroundings. Both The Joint Commission and CMS have firm guidelines on this.
Restraints — Least Restrictive First
- Try alternatives before restraints: staff or family member sitting with client; distraction (music, TV); bed/chair alarms
- When restraints are necessary, use least restrictive type = allows greatest degree of movement
- Example: mitten > wrist restraint (mitten allows more movement) ⚡
- Restraints require provider prescription; monitor closely
Least Invasive Interventions
- Invasive procedures = more discomfort + greater infection risk
- Example: Post-op incontinence → implement toileting schedule + teach Kegel exercises before inserting urinary catheter
- Exam scenario ⚡: Confused client pulling at peripheral IV → cover IV site with elastic bandage (least restrictive) before applying wrist restraints or giving IM medication
Additional Priority Frameworks
Acute vs. Chronic
- Acute: sudden onset, severe, worsens rapidly — less time to adapt
- Chronic: progresses slowly; client has adapted over time
- Acute always takes priority over chronic
- Example: acute asthma attack (rapidly life-threatening) > chronic emphysema (slow deterioration over years)
- Note: asthma is chronic but an attack/exacerbation = acute
Urgent vs. Nonurgent
- Urgent: considerable probability of harm/discomfort if not addressed quickly (unanswered bed alarms, post-op pain)
- Nonurgent: low-risk; no immediate intervention needed (musculoskeletal aches, non-allergic itching, routine dietary questions)
- All nonurgent needs should still be addressed, just not first
Unstable vs. Stable
- Unstable: acute change in condition — uncontrolled bleeding, severe respiratory distress, frequently changing BP readings
- Stable: condition changes little over time — unchanged vitals within expected range, mildly elevated BP with history of HTN
- Unstable always takes priority over stable
CURE Task Priority Hierarchy
C — Critical
Intervene immediately — respiratory difficulty, chest pain, neurological changes
U — Urgent
Mild harm or discomfort if delayed — post-op pain, unanswered bed alarms
R — Routine
Scheduled care — routine meds, daily vitals, required shift tasks
E — Extra
Comfort measures — warm blanket, combing hair, reading to client
Survival Potential & Triage
Survival potential framework is used during mass-casualty incidents (natural disasters, major accidents, terrorism) when resources are limited. Goal: do the most good for the maximum number of clients.
Mass Casualty vs. ED Triage ⚡: In the ED, the most critical client receives most resources. In mass casualty, the most critically injured with minimal survival chance may receive no treatment — resources must save the most lives possible. Triage may be repeated upon arrival to a medical facility.
Disaster triage considerations: (1) Survival — likelihood of surviving the entire treatment process; (2) Quality of life — how the client's life will be affected if they survive their injuries; (3) Resource allocation — distributing scarce resources to save the maximum number of lives.
Disaster triage considerations: (1) Survival — likelihood of surviving the entire treatment process; (2) Quality of life — how the client's life will be affected if they survive their injuries; (3) Resource allocation — distributing scarce resources to save the maximum number of lives.
4 Triage Categories — Mass Casualty
🔴 RED — Emergent · 1st Priority ⚡
- Life-threatening + high survival chance with treatment
- Transport immediately
- Examples: major hemorrhage, active chest pain
🟡 YELLOW — Urgent/Delayed · 2nd Priority
- Serious but not immediately life-threatening
- Can wait 30 minutes to 2 hours
- Example: open fracture without major bleeding
🟢 GREEN — Nonurgent/Minimal · 3rd Priority
- "Walking wounded" — minor injuries only
- Can delay treatment hours to days
- Examples: sprained fingers, minor cuts
⚫ BLACK — Expectant · Lowest Priority
- Deceased or not expected to survive
- Examples: no spontaneous breathing, no pupil response, severe multi-system damage
- Provide comfort measures only; not transported
- Some systems: blue tag = still alive but expectant; black = already deceased
ED 5-Level Acuity System (ESI / CTAS)
| Level | Category | Description |
|---|---|---|
| 1 ⚡ | Most Urgent | Life-saving intervention needed immediately (cardiac/respiratory arrest, unresponsive, sepsis, anaphylaxis, shock) |
| 2 | Emergent | High-risk; could quickly deteriorate without prompt intervention |
| 3 | Urgent | Stable but needs prompt evaluation |
| 4 | Less Urgent | Stable; can wait longer for evaluation |
| 5 ⚡ | Least Urgent | Stable, non-emergency — safely waits the longest |
Systems: ESI (Emergency Severity Index) — US; CTAS (Canadian Triage Acuity Scale) — Canada. Both supported by the Emergency Nurses Association. No single globally agreed-upon system.
Resource Allocation & Delegation
Resource Allocation & Rationing
- Distributing materials, staff, time, equipment to meet client needs
- Priority setting = deciding how resources are distributed among clients each shift
- Rationing of care: care left undone, omitted, or missed due to limited resources (time, staffing level, skill mix, supply shortages)
- Missed nursing care = medical error — can negatively affect client safety ⚡
- Seek input from interprofessional team members when prioritizing allocations
- If urgent/life-threatening need identified → allot resources there first, before nonurgent needs
Delegation Rules ⚡
- Can delegate to nurses at or below licensure level AND assistive personnel (APs)
- Delegator remains responsible and accountable for ensuring the task is completed correctly
- CANNOT delegate: nursing judgment or critical decision making
- Only delegate if task is within the delegate's scope of practice AND they are competent
- Delegating routine tasks → nurse has more time for high-acuity clients
Exam High-Yield Summary
⚡ Safety/Risk → fall first
Dizziness when standing = greatest fall risk → priority under safety & risk reduction framework
⚡ Safety framework rule
Assigns highest priority to the situation posing the greatest threat to physical or psychological well-being
⚡ ABCDE Exposure (SATA)
DVT signs · temperature · bruising ✓ — RR = Breathing (B) · Blood pressure = Circulation (C) ✗
⚡ Mass casualty transport first
Actively bleeding abdominal wound = RED (life-threatening + high survival). RR 6 + no pupils = BLACK (expectant)
⚡ Digoxin + HR 48
HR 48/min after digoxin = bradycardia / digoxin toxicity — priority. Normal HR = 60–100/min
⚡ Maslow: inferiority feelings
"Feeling inferior / not good enough" = unmet self-esteem needs
⚡ Transfusion + urticaria
Hives during blood transfusion = anaphylaxis / allergic reaction — stop transfusion immediately; see this client first
⚡ ABCDE after A + B
After airway and breathing → next is C — Circulation → blood pressure. Temp/skin/abdomen = E (Exposure)
⚡ New abdominal pain
New onset abdominal pain = urgent (considerable harm potential if delayed); not chronic, not minimal, not expectant
⚡ Multi-system → ABCDE
Client with unexpected manifestations in several body systems → use ABCDE framework
⚡ Nursing process: first action
Assessment always first — perform physical assessment before nursing diagnosis, goals, or medications
⚡ Wheezing at change-of-shift
Audible wheezing = airway/breathing compromise → see this client first (ABCDE: A and B)
⚡ Confused client pulling IV
Least restrictive first: cover IV site with elastic bandage before wrist restraints or IM medication
⚡ New chest pain = priority
New chest pain is urgent/life-threatening — priority over yearly check-ups, arthritis stiffness, or dietary education
⚡ Maslow order
Physiological → Safety → Love & Belonging → Self-Esteem → Self-Actualization
───────────────────
── CARING · DIGNITY · TRUST ──
── EMPATHY · PRESENCE ──
── WATSON · SWANSON ──
───────────────────
── WHOLE · PERSON · CARE ──
── CULTURE · SPIRIT · VOICE ──
───────────────────
── CARING · DIGNITY · TRUST ──
── EMPATHY · PRESENCE ──
── WATSON · SWANSON ──
───────────────────
── WHOLE · PERSON · CARE ──
── CULTURE · SPIRIT · VOICE ──
───────────────────
mod 16
Patient-Centered Care
Delivering care that honors the whole person — values, culture, spirit, and human dignity.
PCCWatsonSwansonCaring PracticesClient PrefsCulture & GenerationsSpiritual CareAdvocacy
Patient-Centered Care & Caring
What is PCC?
- Puts the client at the center of all nursing care
- Incorporates caring, client preferences, and cultural considerations
- Evidence shows PCC ↑ client satisfaction
- Technology advances can distract from this — guard against task-only thinking
Caring — Core of Professionalism
- Nurturing another to whom one feels commitment or responsibility
- Holistic: physical, emotional, and spiritual needs
- Includes providing a healing environment, kindness, concern, empathy
- Nurses must care for themselves first before caring for others (Watson)
Watson's Theory of Human Caring
This theory suggests that to care for others, nurses must first care for themselves and attempt to achieve inner balance and spirituality. Nurses should establish a presence with clients, practice the act of "being," and work on developing trusting relationships.
The 10 Caritas Processes
Caritas 1
Sustaining humanistic-altruistic values through loving-kindness, compassion, and equanimity with self and other
Caritas 2
Being authentically present, enabling faith/hope/belief system, and honoring subjective inner, lifeworld of self and other
Caritas 3
Being sensitive to self and others by cultivating own spiritual practices; moving beyond ego to transpersonal presence
Caritas 4
Developing and sustaining loving, trusting-caring relationships
Caritas 5
Allowing for expression of positive and negative feelings; authentically listening to another person's story
Caritas 6
Creatively problem-solving/"solution-seeking" through caring process; full use of self and artistry of caring-healing practices via all ways of knowing
Caritas 7
Engaging in transpersonal teaching and learning within context of caring relationships; staying within other's frame of reference
Caritas 8
Creating healing environment at all levels whereby authentic caring presence potentiates wholeness, beauty, comfort, dignity, and peace
Caritas 9
Reverently assisting with basic needs as sacred acts; touching mind, body, spirit; sustaining human dignity
Caritas 10
Opening to spiritual mystery and unknowns; allowing for miracles
Key Questions Exemplifying the Caritas Processes
- Tell me about your health.
- What is it like to be in your situation?
- Tell me how you perceive yourself?
- What are your health priorities?
- How do you envision your life?
- What is the meaning of healing for you?
- What is the most important thing I can do for you?
- What is the most important thing you need right now?
Swanson's Theory of Caring
Five categories that improve client well-being by promoting empowerment, respect, and dignity. The nurse goes through these to demonstrate caring.
The Five Caring Behaviors
👂 Listening
- Active, not passive — focus on what, how, body language
- Allow pauses and silence — don't rush to next question
- Empathetic listening improves patient experience
- = Swanson's Being With
🤲 Touch ⚡
- Expressive touch = demonstrates caring; always get permission first
- Failure to get permission = grounds for battery charge
- Hand, shoulder, forearm = appropriate; side hug = acceptable for some; prolonged frontal hug = avoid (can be perceived as sexual)
- Cultural, gender, trauma history all affect appropriateness — some religions discourage touch by non-family members
- If client appears to withdraw → stop; do not use touch
- Decreases anxiety, ↑ well-being — even for clients in isolation
🧍 Being Present
- Gift of presence — clients miss friends and caregivers
- ↓ loneliness, ↑ well-being
- In both Watson & Swanson (= "being with")
- Must be conscious effort — being in the room ≠ being present
🛏️ Providing Comfort
- Non-pharm: warm blankets, water, hand/face wash, back rub, room temp, curtains
- Music therapy, pet therapy, virtual reality, acupressure
- = Swanson's Doing For
💛 Showing Compassion
- Recognize pain/suffering → take action to alleviate
- View client as individual, not a diagnosis ("the hip in 202")
- Nurse must evaluate own feelings before caring for difficult clients
- Requires adequate staffing — impossible when over-taxed
- Hindered when nurses focus on task of treatment "to" clients rather than the quality of the therapeutic relationship "with" them
- = Swanson's Being With
Client Preferences & Participation
Clients who feel their preferences are considered report feeling safe, cared for as a person, and show higher satisfaction and better outcomes. Client is viewed as a full member of the health care team — the expert on their own experience.
When client preferences are ignored, satisfaction drops. Example: a client who reads late at night being discouraged by staff — or a client who prefers to bathe in the evening but is made to bathe in the morning because more staff are available then. That reflects staff preference, not client preference.
Three Ways to Incorporate Preferences
1. Endorsing Participation
Use therapeutic communication; create safe space; invite client as full team member; empower to share needs and feelings
2. Promoting Client Understanding
Provide valid info; validate correct knowledge; correct inaccurate info (internet, acquaintances); discuss what client already knows
3. Sharing Information
Two-way street: nurse shares treatment info; client shares experience, perceptions, and preferred level of involvement
Barriers to Participation
- Power imbalance — being under care = real and perceived powerlessness
- Medical speak — unfamiliar language leaves clients reliant on others
- Illness, fatigue, weakness, altered cognition → limited ability to express preferences
- Team failure to recognize power imbalance or poor collaborative communication
- Language barriers
Client condition ↓ → nurse takes stronger advocate role. Condition ↑ → client participates more.
Cultural Competence & Generational Differences
Culturally competent nursing practice is defined by the ANA as "the application of evidence-based nursing that is congruent to the preferred cultural values, beliefs, worldviews, and practices of the client." Other factors impacting culture: socioeconomic status, health literacy, experience with racism, sexual orientation, and degree of acculturation (the process of sharing and learning the cultural traits/social patterns of another group). There may be substantial variation within the same religion or culture — never assume uniformity. Cultural competence is a continuous process, not a one-time achievement.
5 Elements of Cultural Competency
Awareness
Cultural Awareness
Self-assessment of own culture and biases toward individuals of other cultures
Knowledge
Cultural Knowledge
Willingness to learn about another's cultural values, beliefs, and activities
Skill
Cultural Skill
Ability to accurately assess client's cultural beliefs, values, and lifestyles
Encounters ⚡
Cultural Encounters
Interactions with clients from cultures different from one's own — enables nurse to interact with diverse clients
Desire
Cultural Desire
Commitment to become connected with clients' cultures
Cultural Assessment Questions
Identity
"Do you have any ethnic, spiritual, or racial affiliation with which you identify?"
Health Beliefs
"Do you have any beliefs and practices related to health or illness?"
Spiritual Practice
"What current spiritual beliefs or practices do you want to observe?"
Diet
"Do you follow any food preferences or prohibitions as part of your culture?"
Generational Communication Preferences ⚡ — generalized guidelines; may not apply to every individual
Spiritual Care & Pastoral Support
Spiritual Distress ⚡
- Uncomfortable feeling related to questioning life's meaning, belief system, or anger toward a higher power
- Manifestations: despair, anger, uncertainty, fear
- Not tied to a specific religion; expressions vary across cultures
- Signs: doubt, confusion, feeling alone, questioning God, simply stating "I feel alone"
- Nursing response: listen, sit with client, pray together, read spiritual texts, refer to pastoral care
Spiritual Well-Being
- Deep attachment to a higher power + acceptance of that power
- Associated with improved quality of life
- Nurse must examine own spiritual beliefs before providing spiritual care — identify personal biases first; if unable to overcome them, refer client to appropriate spiritual services
- Clients often want to discuss spiritual distress but wait for provider to initiate
- Addressing spiritual needs → ↑ client satisfaction
Spiritual Assessment Tools
Spiritual Assessment — Key Questions
- Where do you find spiritual strength?
- Do you have any concerns about the meaning of your life?
- Do you have questions about your relationship with God or a higher being?
- Do you have any questions about your spiritual practice?
- What kind of spiritual practices hold meaning for you?
- Do you have any concerns or fears about dying?
- Do you have any concerns about your relationships?
- Is there anything right now that is making you sad or feeling inadequate?
Pastoral Care ⚡ — Consult When:
⚡ Ethical dilemma
⚡ Terminal illness
⚡ Death of a client
⚡ Hardship
Injuries
- Chaplains may be pastors, rabbis, imams — also trained in humanism for non-religious clients
- Particularly vital at end of life: identifying beliefs, promoting autonomy, facilitating religious death rituals (e.g. baptism, sacrament of the sick)
- Available to nursing staff too — not only clients and families
- Spiritual support resources: dedicated prayer/reflection time, religious texts (Bible, Koran), pastoral visit, support group, palliative care, or referral to psychospiritual integrative therapy (CBT + mindfulness/meditation)
Client Advocacy, Access & End-of-Life Concepts
Client Advocacy
Protecting the client's rights of autonomy and self-determination; serving as their voice. Primary duty is always to the client — even when family conflicts.
Step 1
Determine client's needs — assess knowledge, rights, values, cognitive function
Step 2
Verify client's goals — motivational interviewing; discuss advance directives
Step 3
Implement plan — communicate needs to team; mediate conflicts; maintain focus on safety
Step 4
Ongoing evaluation — include client, caregivers, interprofessional team; clinical debriefing
End-of-Life & Treatment Terms
Medically Futile
Treatment with exceedingly low likelihood of working; will not cure or meaningfully extend life
Palliative Care ⚡
Multidisciplinary focus on managing symptoms of chronic or life-threatening illness; highest quality of life possible when a cure is not possible
Potentially Inappropriate Treatment
Treatment may technically work but won't improve quality/length of life or meet client's priorities and values
Quality of Life
Means something different to everyone — independence, life satisfaction, contact with family, or ability to function physically. Nurse helps client clarify priorities and advocates for those wishes.
Nurses must examine own feelings about medical futility and palliative care before providing care in these situations — seek support from colleagues, managers, pastoral care, or counselors as needed.
Telehealth & Access to Care
Telemedicine
- Health care including diagnostic testing and monitoring via internet-connected devices
- ECG, auscultation, diagnoses, prescriptions — across great distances
Telehealth
- Broader: both clinical and nonclinical health care delivery via telecom
- Behavioral health counseling, school health, long-term care, specialty consults
Healthy People 2030 goal: increase access to comprehensive, high-quality care. Key barriers: lack of insurance (~10% Americans), no primary care provider, transportation issues, limited rural facilities, incompatible office hours.
Exam High-Yield Summary
⚡ "God is so far away" → ?
Client experiencing spiritual distress — questioning life's meaning or connection to a higher power
⚡ Client refuses opioid
"I will speak to your provider to see if there is a different medication to treat your pain" — respects preference, advocates alternative
⚡ Nurse sits in silence w/ crying client
= Swanson's Being with — physically and emotionally present without needing to speak
⚡ Postop spiritual support request
"Tell me what I can do to help fulfill your need for support" — open-ended; lets client define their need
⚡ Baby Boomer teaching method
Talk in person — Baby Boomers prefer sincere, in-person communication; avoid screens; don't interrupt
⚡ Touch for emotionally distraught client
Briefly holding the client's hand — appropriate expressive touch; conveys caring
⚡ Pastoral consult (SATA)
Ethical dilemma · Terminal illness · Death of a client · Hardship
⚡ Cultural competency → interacts w/ other cultures
Cultural encounters — interactions with clients from cultures different from one's own
⚡ Religious belief vs family wishes
"You have the right to choose what treatments are best for you" — upholds client autonomy; primary duty is to client, not family
⚡ Comfort when cure not possible
Palliative care — symptom management for life-threatening illness; maintains highest quality of life possible
Swanson's 5 categories
Maintaining Belief · Knowing · Being With · Doing For · Enabling
Watson's Caritas
10 Caritas Processes; nurse must care for self first; goal = harmony of mind, body, spirit
Caring behaviors (5)
Listening · Touch · Being Present · Providing Comfort · Showing Compassion
Cultural competency (5)
Awareness · Knowledge · Skill · Encounters · Desire — continuous process
FICA
Faith · Importance · Community · Address in care
HOPE
Hope · Organized religion · Personal spirituality · Effects on care
Palliative vs medically futile
Palliative = manage symptoms when cure not possible · Futile = treatment has exceedingly low chance of working
Telehealth vs telemedicine
Telemedicine = clinical only (diagnostics, monitoring) · Telehealth = clinical + nonclinical (broader)
───────────────────
── URINARY · BOWEL · OSTOMY ──
── OUTPUT · INTAKE · ASSESS ──
── CONTINENT · INCONTINENT ──
───────────────────
── FOLEY · ENEMA · COLOSTOMY ──
───────────────────
── URINARY · BOWEL · OSTOMY ──
── OUTPUT · INTAKE · ASSESS ──
── CONTINENT · INCONTINENT ──
───────────────────
── FOLEY · ENEMA · COLOSTOMY ──
───────────────────
mod 32
Elimination
Urinary and bowel function, ostomy management, enemas, and diagnostic testing.
FactorsProblemsUrinaryOstomy CareEnemasDiagnostics
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
Common Bowel Elimination Problems
💊 Drugs → Constipation
(slow gastric motility)
Antacids
Anticholinergics & antispasmodics
Antiseizure medications
Calcium channel blockers
Diuretics
Iron supplements
Anti-Parkinson's meds
Narcotic pain medications
Antidepressants
Chronic GI Disorders
Urinary Elimination
Urinary Tract Pathway
🫘
Kidneys
Filter 120–150 qt blood/day → 1–2 qt urine
→
〰️
Ureters
Thin muscle tubes; one per kidney
→
🫙
Bladder
Fills & stretches; holds up to 2 cups
→
💧
Urethra
3 continence mechanisms: urethra · sphincter · pelvic floor
Primary Functions
- Eliminate waste & excess fluid as urine
- Regulate electrolyte levels
- Produce hormones for BP regulation
- Aid RBC development; keep bones strong
Diuretics vs. Antidiuretics
- Antidiuretics — prevent urine production → minimize fluid loss
- Diuretics — increase urine production → increase urination
Urinary Retention
- Bladder unable to fully empty
- Signs: unable to urinate, pain, distension, frequency, hesitancy, weak stream, leakage
Kidney Stones (Renal Calculi)
- Hard mineral/salt formations in the kidneys
- Also called nephrolithiasis or urolithiasis
Types of Urinary Incontinence
Stress
Leakage with coughing, sneezing, laughing, or activity that ↑ bladder pressure
Urge
Strong urge → leaks before reaching toilet
Reflex
Leakage from nerve damage
Overflow
Incomplete emptying → bladder overfills
Functional
Physical inability to reach the toilet in time
Nocturnal Enuresis
Involuntary urination during sleep
⚠️ UTI
- Bacteria enters urinary tract
- More common in women — shorter urethra
- Untreated → pyelonephritis (kidney infection)
- Symptoms: burning/painful urination, frequent urgency with little urine
- Risk factors: sexual activity, menopause, retention, obstruction, frequent catheter use, diabetes, abnormalities
Management of Alterations
- Urinary: lifestyle changes, bladder training, pelvic floor exercises, catheterization if needed
- Bowel: lifestyle changes, bowel training, stimulant agents
- Most alterations are treatable or manageable
Ostomy Types & Care
Types of Ostomies
- Colostomy — colon diverted to abdominal wall; stool varies by location
- Ileostomy — large intestine/rectum removed; small intestine to surface; reversible once colon heals
- Subtypes: 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 — Report Immediately
Blue · Purple · Dull · Dry · Black
🟡
Pouch Too Tight
Red, swollen, tender peristomal skin → need larger opening
Ostomy Care Procedure
1
Hand hygiene → gloves
2
⚡ Push skin AWAY from sticky area when removing pouch — prevents skin stripping
3
Cleanse stoma & peristomal skin with mild soap/water → dry completely (moisturizing soap interferes with adherence)
4
Measure stoma → cut opening 0.15–0.3 cm (⅛ in) larger than stoma — too big → leakage
5
Apply skin barrier and pouch → press seal 30 sec–1 min for adhesion
6
⚡ Empty bag when ⅓–½ full — waiting past ½ ↑ leakage risk (ileostomy effluent especially irritates skin)
Enemas
Procedure — High-Yield Steps ⚡
⚡ Position
Left lateral (Sims), right leg flexed forward — gravity flows solution into sigmoid/descending colon
⚡ Temp
Warm the solution — cold → cramping; too hot → mucosal injury
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 cramping or fluid leaks
Lubricate
Always lubricate rectal tube/nozzle before insertion
Diagnostic Procedures
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
Exam High-Yield Summary
Enemas
Position ⚡
Left lateral, right leg flexed (Sims)
Safest enema
Normal saline — isotonic
Oil retention
Retain ≥ 30 min
Cramping ⚡
Lower the container
Return-flow enema
Post-op flatus/distension
Ostomy
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
Urinary
UTI untreated
Progresses to pyelonephritis
UTI: women
Shorter urethra → easier bacterial entry
Low catheter output ⚡
Check for kinks first
Remove catheter
Deflate balloon completely first
Clean catch (female)
Wipe front to back
Bladder irritants
Alcohol · acidic fruits · chocolate · soda · spicy foods
Incontinence: stress
Leakage with coughing, sneezing, laughing, activity
Incontinence: urge
Strong urge but leaks before reaching toilet
Incontinence: overflow
Incomplete emptying → bladder overfills
Incontinence: functional
Can't reach the toilet in time
Incontinence: reflex
Leakage from nerve damage
Bowel
Constipation diet
High fiber
Narcotics → bowel
↑ constipation (slow motility)
Antibiotics → bowel
Kill GI flora → diarrhea
Vitamin K
Produced in large intestine
Constipation drugs
Narcotics · antacids · anticholinergics · Ca channel blockers · antidepressants · iron
IBS
Abdominal pain + altered bowel pattern (D, C, or mixed)
UC vs Crohn's
UC = large intestine · Crohn's = commonly small intestine
Diverticulitis
Food trapped in pouches → inflammation
Diagnostics
FOBT: avoid 72 hr
Red meat · citrus · Vit C · beets · raw veggies
FOBT: blue card
Positive for blood
NG placement ⚡
X-ray only for initial verification
───────────────────
── SKIN · ORAL · FOOT · HAIR ──
── INTEGRITY · HYGIENE ──
── BATHE · CLEAN · PROTECT ──
───────────────────
── PERINEAL · NAIL · SHAVE ──
───────────────────
── SKIN · ORAL · FOOT · HAIR ──
── INTEGRITY · HYGIENE ──
── BATHE · CLEAN · PROTECT ──
───────────────────
── PERINEAL · NAIL · SHAVE ──
───────────────────
mod 35
Hygiene
Personal care practices that preserve skin integrity, comfort, and client dignity.
BathingOral HygieneFoot & NailPerineal & SkinHair & Shaving
Bathing
🧬
Definition
Hygiene — actions and practices that decrease the spread or transmission of pathogens, lessening the occurrence of illness. Effective handwashing is necessary to prevent health care-associated infections (HAIs).
Types of Baths
Complete Bed Bath
Nurse gives bath entirely in bed — client cannot get out. Less effective than shower; use only when necessary.
Partial Bath
Client cannot tolerate complete bath, or can do part independently. Nurse assists with remaining areas.
Therapeutic Bath
Promotes comfort, soothes itchy skin. Ordered for specific skin conditions or wound care.
CHG Bath
Chlorhexidine gluconate — for ICU or high infection risk clients. Does not touch face.
⚡ Bed Bath Order — Clean to Dirty
1
Face
inner→outer
canthus
inner→outer
canthus
→
2
Neck &
Trunk
Trunk
→
3
Upper
Extremities
Extremities
→
4
Lower
Extremities
Extremities
→
5
Back &
Buttocks
Buttocks
→
6
Perineum
most contaminated
most contaminated
⚡ High-Yield Procedure Points
1Raise room temperature before bathing — client loses heat when body areas are exposed.
2Use long, firm strokes distal to proximal. Over lower extremities with DVT history → light strokes only (clot dislodgement risk).
3Eye care: clean moist cloth, NO soap, wipe from inner → outer canthus.
4Privacy: cover with bath blanket; expose only the area being washed; give client choices about bathing preference.
5Delegation: bathing can be delegated to AP — nurse remains responsible for data collection and client care.
6Linen: blanket/spread can be reused if not wet or soiled. Diaphoresis → frequent linen changes needed → moisture causes skin breakdown.
👴 Older Adults
- May resist bathing — determine reason, give choices
- Refusal is not abuse if client declines — nurse must address it
- Ask about preferred morning routine order before starting care
🧠 Hemiplegia — Dressing
- Dressing: use unaffected arm first → then place on affected side
- Undressing: remove unaffected side first
- Ask client to perform what they are able to do independently
Oral Hygiene
Frequency
2× / day
Brush for 2 minutes · soft-bristled toothbrush · fluoride mouthwash
Reduces Risk of
Pneumonia ⚡
Especially in long-term care — critical for infection prevention
Don't Skip NPO
Oral care ⚡
Bacteria present regardless of eating status
Poor Hygiene →
Gingivitis
Bleeding gums · metallic taste · yellow stain = early periodontal disease
⚡ Handwashing — Know When to Use Each
🧼 Soap & Water — REQUIRED
- Visibly soiled hands
- C. difficile exposure
- Infectious diarrhea
- Norovirus or suspected GI pathogen
💧 Alcohol Sanitizer — OK for
- Routine care between client contacts
- Rub all surfaces 15–20 sec until dry
- Clean least soiled areas first
- NOT effective against C. difficile
⚠️ Unconscious Client ⚡
- Suction apparatus at bedside — prevent aspiration
- Do NOT place fingers in mouth — biting risk
- Position: side-lying, head toward nurse — fluid drains out
- Chlorhexidine (CHG) — prevents microbial build-up ⚡
- Assess: impaired swallowing, decreased gag reflex
- Clean tongue with toothbrush or tongue scraper
🦷 Denture Care ⚡
- Dentures are very fragile — handle with care
- Remove upper: pull down and out · Lower: up and out
- Use denture cleaner — NOT regular toothpaste (damages)
- Rinse in tepid/cool water — hot water warps the denture
- Store in cup with cool water; label cup with client name
Foot & Nail Care
⚡ These Conditions Require a Podiatrist / Qualified Professional
⚡ DM / PVD Foot Care Rules
DO
- Inspect feet daily, including between toes
- Use lukewarm water only (impaired sensation → can't detect heat)
- File nails — never cut
- Dry feet thoroughly, especially between toes
- Apply moisturizer to the foot (not between toes)
- Refer to podiatrist for all nail and foot procedures
DO NOT
- Do NOT cut nails — file only
- Do NOT soak feet — infection risk
- Do NOT apply lotion between toes
- Do NOT self-treat corns or calluses
- Do NOT apply heat unless specifically prescribed
- Do NOT use hot water (neuropathy → temperature undetectable)
Standard Foot Care
- Trim nails straight across, file edges — reduces ingrown nails
- Wear clean cotton socks daily; check shoes for rough seams
- Nail care: after bath or soaking hands in warm soapy water for 10 min
- Longer nails conceal more pathogens than shorter nails
Nail Assessment & Anatomy
- Observe size, shape, condition of nail and nail beds; check for cracking, clubbing, fungus
- Cuticle forms a barrier to prevent infection — do not cut aggressively
- Check facility policy — some require a provider prescription for nail cutting
- Enamel = hardest substance in the body; first line of defense for teeth ⚡
Perineal Care & Skin Integrity
⚡ Cleansing Direction — Always Front to Back
Perineum
→
Labia / Meatus
→
Anus ⚠️
Front → Back · Prevents UTI
Female Perineal Care
- Cleanse labia → perineum to rectum using a clean section of cloth each pass
- Dry thoroughly
- Anus = most contaminated → cleanse last
- Maintains skin integrity, relieves discomfort, prevents infection (especially catheter care)
Male Perineal Care
- Uncircumcised: retract foreskin → clean meatus outward in circular motion
- Replace foreskin after cleaning — prevents swelling and circulation issues ⚡
- Dry thoroughly
- Anus = most contaminated → cleanse last
Skin Anatomy — Integumentary System
Epidermis
OUTERMOST LAYER
Lies upon the dermis · Composed of squamous epithelial cells · Contains Langerhans cells that sense and kill pathogens · First line of defense
Dermis
MIDDLE LAYER
Underlies the epidermis · Composed of connective tissue, nervous tissue, blood vessels · Gives skin its strength and elasticity
Hypodermis
SUBCUTANEOUS
Beneath the dermis · Separates dermis from underlying organs · Contains adipose tissue · Cushions physical trauma · Provides insulation and fat storage
Skin Integrity & Incontinence ⚡
- Urinary incontinence → yeast infection (excessive moisture)
- Incontinence → ↑ skin breakdown (hips, genitals, buttocks, perineum)
- Diaphoresis → skin breakdown → frequent linen changes required
- Bariatric clients: deep skin folds → assist with hygiene; ↑ BMI = physiological skin changes
Body Defenses & Special Sense Care
- Skin = largest organ · First line of defense against pathogens
- Mucous membranes (nose, mouth, respiratory tract) → cilia trap particles
- Eye care: moist cloth, no soap, inner → outer canthus
- Ear care: rotate cloth into canal · Drainage from ear = abnormal → possible infection
- Dementia: difficulty with hygiene = early/first sign ⚡
Hair Care & Shaving
Hair Care
- Brush/comb daily — removes tangles, stimulates circulation, distributes natural oils
- Soft-bristled brush; wide-toothed comb or pick for tightly curled hair
- Consider cultural and personal preferences
- 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
Cultural & Personal Considerations
- Discuss religious/cultural preferences before any care
- Many clients prefer nurse of same gender
- Expose only necessary body parts, as briefly as possible
Exam High-Yield Summary
Infection Control & Handwashing
Soap + water REQUIRED
Visibly soiled hands · C. difficile · Infectious diarrhea
Handwashing ↓ infections
Effective handwashing decreases hospital infection rates
Clean least soiled first
Reduce infection spread — always clean to dirty
Langerhans cells
Found in skin — sense and kill pathogens
Mucous membranes / cilia
Cilia trap particles in nose — prevent body invasion
Hygiene definition
Decreases spread of pathogens, lessening illness occurrence
Bathing & Procedures
Bed bath vs shower ⚡
Bed bath is less effective than shower — use only when necessary
Raise room temp ⚡
Raise room temperature before bathing — client loses heat when exposed
Reuse blanket/spread
Blanket and spread can be reused if not wet or soiled
Morning routine ⚡
Ask client about preferred morning routine before starting care
Older adults bathing ⚡
Give choices re: bathing preferences to encourage compliance
Hemiplegia dressing ⚡
Dress: unaffected arm first. Undress: remove unaffected side first
Delegation
Can delegate bathing to AP — nurse remains responsible
Bariatric → assist
Assist bariatric clients with hygiene — skin folds require special care
Oral & Dental
NPO → oral care ⚡
Still needed for NPO clients — bacteria present regardless of eating
Chlorhexidine ⚡
Oral care for unconscious clients — prevents microbial build-up
Clean tongue
Use toothbrush or tongue scraper during oral care
Gingivitis ⚡
Bleeding gums · metallic taste · yellow stain = early periodontal disease
Fluoride + brushing
2×/day for 2 min · soft bristle · fluoride mouthwash
Enamel ⚡
Protects teeth from pathogens — hardest substance in the body
Denture cleaner only
Regular toothpaste damages dentures — use denture cleaner
DM / PVD Foot Care
DM foot risk ⚡
DM + peripheral neuropathy + pale skin + ↓ pedal pulses = injury risk
Dry between toes ⚡
Completely dry between toes — infections develop in moist areas
Nail trim direction
Trim nails straight across to prevent ingrown nails
Cuticle function
Forms barrier to prevent infection of underlying tissue
No soaking — DM
Do NOT soak feet in DM/PVD — risk of infection
File only — DM ⚡
Do NOT cut nails in DM/PVD — file only
Skin Anatomy & Defense
Epidermis
Composed of squamous epithelial cells · Contains Langerhans cells
Dermis function
Gives skin strength and elasticity · connective tissue + blood vessels
Hypodermis
Beneath dermis · adipose tissue · cushions trauma + insulates body
Skin = largest organ ⚡
First line of defense; covers majority of outer body surfaces
Incontinence → yeast
Urinary incontinence → yeast infection from excessive moisture
Dementia + hygiene ⚡
Difficulty with personal hygiene = early/first sign of dementia
Religious preferences
Discuss individual perspective on health and hygiene before care
───────────────────
── 0 · 1 · 2 · 3 · 4 · 5 ──
── 6 · 7 · 8 · 9 · 10 ──
── ACUTE · CHRONIC · NEUROPATHIC ──
───────────────────
── ASSESS · TREAT · REASSESS ──
───────────────────
── 0 · 1 · 2 · 3 · 4 · 5 ──
── 6 · 7 · 8 · 9 · 10 ──
── ACUTE · CHRONIC · NEUROPATHIC ──
───────────────────
── ASSESS · TREAT · REASSESS ──
───────────────────
mod 37
Pain
The subjective fifth vital sign — assessment, pharmacologic and non-pharm management, and ethics.
Pain BasicsTypes of PainAssessmentPain ScalesNon-PharmPharmLegal / Ethical
Pain — The Basics
⚡ Pain is subjective. The client's self-report is the most reliable diagnostic indicator of pain. Always believe the client.
Pain Physiology — signal pathway
Stimulus
tissue damage
extreme temp
chemicals
extreme temp
chemicals
──▶
Nociceptors
peripheral
nerve endings
activated
nerve endings
activated
──▶
Spinal Cord
electrical
impulses travel
upward
impulses travel
upward
──▶
Brain
cortex processes
signal + context
signal + context
──▶
Perceived Pain
subjective
experience
unique to client
experience
unique to 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 shaped by all three
Biological
Disease severity
Inflammation
Tissue damage
Genetic sensitivity
Inflammation
Tissue damage
Genetic sensitivity
Psychological
Mood & anxiety
Stress
Catastrophizing
Prior pain experience
Stress
Catastrophizing
Prior pain experience
Social
Culture & religion
Support systems
Language barriers
Socioeconomic status
Support systems
Language barriers
Socioeconomic status
Types of Pain
By Duration
Acute
Chronic
⚡ Acute pain that is not treated can become chronic. Chronic pain is managed — not cured — and can be physically and emotionally debilitating.
By Origin
🔥
Nociceptive
aching · throbbing · localized
Felt in tissues or organs. Subtypes: somatic (skin/bones/muscles) and visceral (internal organs). Usually responds to standard analgesics.
tissue damage present
⚡
Neuropathic
burning · shooting · pins & needles
Nerve pain from somatosensory system — no tissue damage. Examples: diabetic neuropathy, phantom limb, spinal cord injury.
⚡ different meds required
🔬
Cancer Pain
tumor · bone · radiation · chemo
Newly recognized separate category. Includes tumor pressure, bone pain, radiation-induced pain, and chemo-related neuropathies.
own category
⚡ Nociceptive vs. Neuropathic: Medications that work for nociceptive pain are NOT effective for neuropathic pain — different treatment is needed.
Pain Assessment
⚡ PQRST Assessment Mnemonic
P
Precipitating
"What were you doing when it started?"
Q
Quality
"Describe what it feels like." Stabbing, burning, dull, throbbing
R
Region ⚡
"Can you point to where it hurts?"
S
Severity
"Rate it 0–10."
T
Timing
"When did it start? Constant or intermittent?"
Subjective vs. Objective
- Subjective — client's self-report: pain scale score, location, quality, timing, precipitating/relieving factors
- Objective ⚡ — nurse observes: grimacing, guarding, restlessness, diaphoresis, crying
- ⚡ Sweating (diaphoresis) = classic objective pain indicator
- Comfort-function goal — client and nurse together set a realistic pain level that allows functioning
- Hierarchy of Pain Measures — for clients unable to self-report; uses behavioral and physiological indicators
⚡ Special Populations
- For nonverbal/cognitively impaired → observe behavior: guarding, grimacing, restlessness, agitation
- Use FLACC or NVPS — select scale appropriate for cognitive ability
- Never assume no pain in a nonverbal client
- Older adults ⚡ — at risk for under-treatment; may under-report; nurses must proactively assess
- Watch for: RR trending down = too much opioid · anxiety can mimic pain; assess carefully
Pain Scales
Numeric Rating Scale (NRS) — 0 to 10
0
1
2
3
4
5
6
7
8
9
10
Mild
1 – 3
Non-pharm + NSAIDs
Moderate
4 – 6
Codeine / tramadol
Severe
7 – 10
Morphine / strong opioids
Numeric Rating Scale ⚡
≥ 8 years · verbal
Most frequently used. Reliable for clients ≥8 years. Most used for cancer pain.
⚡ default scale
Wong-Baker FACES ⚡
≥ 3 years · pediatric
Client selects a face. Three-in-one scale (faces + words + numbers). Client rates own pain only — not observer-rated.
⚡ self-report only
FLACC Scale ⚡
2 mo – 7 yr · cognitively disabled
Observational. 5 categories scored 0–2: Face, Legs, Activity, Cry, Consolability. Total 0–10.
⚡ also adults w/ cognitive disability
CRIES Scale
neonates ≥ 38 weeks
Crying, Requires O₂, Increased VS, Expression, Sleeplessness. Score >4 = further assessment. ≥6 = give analgesics.
Nonverbal Pain Scale (NVPS)
ICU · sedated · intubated
For clients who cannot verbalize pain — mechanically ventilated. Originally developed for burn units.
Visual Analog Scale (VAS)
language barrier
Client marks a point on a line representing pain intensity. Useful when language barrier exists or client cannot verbalize a number.
⚡ Choose the scale based on the client's age, cognitive ability, and communication capacity. Use cultural considerations when evaluating effectiveness.
Non-Pharmacological Interventions
Cutaneous Stimulation
Heat Therapy ⚡
Muscular pain, backache, menstrual discomfort.
⚡ max 20 min + 20-min break
Cold Therapy
Decreases swelling — orthopedic injuries, sprains.
20–30 min, check skin frequently
TENS Unit ⚡
Low-voltage electrical impulses. Adjustable intensity/pulse/duration. Client can use at home.
client-controlled
Massage
Decreases pain scores. Aromatherapy oils — check allergies; sit up slowly (orthostatic risk).
Acupuncture
Sterile needles into skin; stimulates CNS. Must be performed by experienced acupuncturist.
Acupressure
Similar to acupuncture without needles — pressure applied to body points.
Cognitive & Behavioral Strategies
- CBT — manages negative thoughts; includes distraction, relaxation, guided imagery, music therapy
- Distraction ⚡ — TV, virtual reality; effective in children for IM injections
- Music therapy — effective intraoperatively and postoperatively for reducing pain
- Biofeedback ⚡ — electrode sensors measure skin tension; teaches client 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.
Pharmacological Interventions
⚡ WHO 3-Step Pain Ladder — escalate as needed
1
Mild Pain — Nonopioids
NSAIDs (ibuprofen, aspirin, ketorolac) · Acetaminophen
2
Moderate Pain — Weak Opioids
Codeine · tramadol (± nonopioid adjuvants)
3
Severe Pain — Strong Opioids
Morphine · fentanyl · hydromorphone
Opioid Classification
Natural
Codeine
Morphine
Morphine
Semisynthetic
Oxycodone
Hydrocodone
Hydromorphone
Heroin
Hydrocodone
Hydromorphone
Heroin
Synthetic
Fentanyl
Tramadol
Tramadol
⚡ Opioid Safety
- Key adverse effects: sedation, respiratory depression, orthostatic hypotension, nausea/vomiting, constipation
- ⚡ Monitor: RR, depth, HR, BP, O₂ sat, capnography (CO₂)
- ⚡ Highest risk: first 4 hrs post-op; monitor closely for 24 hrs
- ⚡ Naloxone — opioid reversal for respiratory depression; have at bedside. NOT an analgesic — causes withdrawal in opioid-dependent clients.
Non-Opioids & Adjuvants
- NSAIDs — most prescribed worldwide; reduce inflammation and fever. Contraindicated in surgery and labor.
- Acetaminophen — nonopioid analgesic
- Adjuvants — corticosteroids (↑ glucose, fluid retention), antidepressants (nerve/migraine — takes weeks), botulinum toxin
- Gabapentin — anticonvulsant 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
- 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
⚡ 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.
⚡ Multimodal approach: Pain management involves a multimodal, multidisciplinary, and client-centered approach. Clients have a right to quality pain management and should be involved in discussions with the interprofessional team about how best to treat their pain.
Legal, Ethical & End-of-Life
⚡ Core Ethical Principles
Beneficence
do good
Relieve suffering. Nurses are obligated to provide effective pain relief as a fundamental component of care.
Nonmaleficence
do no harm
Untreated pain is harm. Withholding adequate pain management violates this principle.
Autonomy ⚡
right of self-determination
Client's right to choose. Offering IM vs. oral medication = example of autonomy in pain management.
Justice ⚡
treat all fairly
All clients treated fairly regardless of age, ethnicity, or substance use history.
⚡ Legal Principles
- Negligence ⚡ — failing to perform as a reasonable, prudent person. Forgetting to assess/administer prescribed pain medication = negligence.
- Malpractice — negligent act by a professional
- Opioids must be stored in locked cabinet, in original packaging, away from children
- ⚡ Advise client to keep a pain diary to track effectiveness of interventions
⚡ EOL Barriers to Pain Management
ASPMN + HPNA: Effective pain management = basic human right — even at end of life.
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.
───────────────────
── HOSPICE · PALLIATIVE ──
── DIGNITY · COMFORT · PEACE ──
── DENIAL · ANGER · BARGAINING ──
───────────────────
── ACCEPTANCE · GRIEF · LOSS ──
───────────────────
── HOSPICE · PALLIATIVE ──
── DIGNITY · COMFORT · PEACE ──
── DENIAL · ANGER · BARGAINING ──
───────────────────
── ACCEPTANCE · GRIEF · LOSS ──
───────────────────
mod 38
End of Life Care
Grief, loss, advance directives, compassionate care for dying clients and families — and supporting the nurse's own well-being.
Advance DirectivesGrief & LossNursing CareHospice CarePalliative CareDying ProcessSpiritual & CulturalPostmortem & OrganNurse Self-Care
Advance Directives
Legal documents that direct end-of-life care — established while client has decision-making capacity
Living Will
Directive document stating the client's wishes for specific medical treatments (e.g., CPR, mechanical ventilation, tube feeding) in the event they cannot communicate their own decisions.
Health Care Proxy
Also known as durable power of attorney for health care — appoints a designated person to make medical decisions on the client's behalf when they are no longer able to do so.
Purpose: Provide legal direction for EOL issues, reduce decision-making burden on families, and honor the client's wishes during a highly stressful time
Grief, Loss & Bereavement
Key definitions
Grief — the inner emotional response to loss, expressed through thoughts, feelings, and behaviors
Bereavement — includes both grief and mourning (the outward display of loss) as the individual deals with the death of a significant person
Mourning — the outward, behavioral expression of grief and loss
Types of Loss
Necessary Loss
Part of the normal cycle of life; anticipated but still intensely felt. Can be replaced by something different or better.
Actual Loss
Any loss of a valued person, item, or status (e.g., loss of a job) that others can recognize.
Perceived Loss
Client defines it as a loss, but it is not obvious or verifiable to others.
Maturational Loss
Expected loss from developmental processes; associated with normal life transitions that help build coping skills (e.g., child leaving for college).
Situational Loss
Unanticipated loss caused by an external event (e.g., family loses home in a tornado).
Anticipatory Loss
Grief experienced before the actual loss occurs, such as when a terminal diagnosis is given.
⚡ Kübler-Ross Model — five stages of grief
1
Denial
Difficulty believing in an expected or actual loss.
2
Anger
Directs anger toward self, others, a deity, objects, or circumstances.
4
Depression
Overwhelmingly saddened by inability to change the situation.
5
Acceptance
Acknowledges what is happening and makes plans for the future.
⚡ Important: Stages do not have to occur in order — clients may move back and forth, and the length of each stage varies person to person
Types of Grief Reactions
Normal (Uncomplicated) Grief
Considered uncomplicated; emotions may be negative but change to acceptance over time
Some acceptance should be evident by 6 months after the loss
Somatic complaints: chest pain, palpitations, headaches, nausea, sleep changes, fatigue
Anticipatory Grief
Grieving before the actual loss occurs (e.g., terminal illness)
Individuals begin grieving prior to the loss — "letting go" before death
Prolonged Grief Disorder (PGD) ⚡
Also called complicated grief; persists >6 months (children/adolescents) or >12 months (adults)
Intense yearning, longing, intrusive thoughts about the deceased
Significant impairment in social, occupational, or other areas of functioning
May develop: suicidal ideation, intense guilt, self-blame, lowered self-esteem
Persistent somatic complaints (fatigue, sleep disturbances, appetite changes)
Disenfranchised Grief
Loss that cannot be publicly shared or is not culturally acceptable
Examples: death of an incarcerated person, loss of a pet, suicide, miscarriage
Society regards the loss as unworthy of grief → social support is lacking
Factors Influencing Grief & Coping
Influencing Factors
Current age and stage of development
Interpersonal relationships and social support networks
Type and significance of the loss
Culture and ethnicity
Spiritual and religious beliefs and practices
Prior experience with loss
Socioeconomic status
Available coping strategies
⚡ Risk Factors for Dysfunctional Grieving
Being exceptionally dependent on the deceased
Unexpected death, especially at a young age, through violence, or in a socially unacceptable manner
Inadequate coping skills or lack of social support
Lack of hope or preexisting mental health issues (depression, substance use disorder)
Nursing Care: Facilitating Mourning
⚡ Therapeutic interventions to facilitate mourning
Allow time for the grieving process — do not rush the client through stages
Identify expected grieving behaviors (crying, somatic complaints, anxiety)
Use therapeutic communication: name the emotion — e.g., "You sound angry. Anger is a normal feeling for someone who has lost a loved one. Tell me how you're feeling."
Use active listening, open-ended questions, paraphrasing, clarifying, and summarizing
Use silence and personal presence to support the client through mourning
Avoid communication that inhibits expression — no false reassurance, advice-giving, subject-changing, or redirecting focus away from the grieving person
Avoid clichés (e.g., "They are in a better place now") — instead, encourage sharing memories about the deceased
Assist the grieving individual to accept the reality of the loss
Support efforts to "move on" and encourage building new relationships
Assess for evidence of ineffective coping (e.g., client refusing to leave home months after a partner's death)
Share information about the tasks and stages of mourning — normalize expected feelings such as anger toward the deceased
Provide continuing support; encourage the support of family and friends throughout the grieving process
Provide information about available community resources
Prevention of Abandonment & Isolation
Answer call lights timely and make frequent contact to reduce fear of dying alone
Keep the client informed of upcoming procedure and assessment times
Allow family members to stay overnight
Determine where the client is most comfortable — consider a room close to the nurses' station
If the client is at home, consider moving the bed to a central location rather than an isolated bedroom
Support for the Grieving Family
Suggest family members plan visits to promote the client's rest
Ensure family receives appropriate information as the treatment plan changes
Provide privacy so family can communicate and express feelings among themselves without including the client
Assess family's desire to provide physical care; be aware of possible caregiver fatigue — provide instruction as needed
Educate family about physical changes to expect as the client moves closer to death
Use therapeutic communication to encourage families to express feelings
Offer to contact a spiritual leader for spiritual support and guidance
Provide education about the grieving process and expected emotions to assist through mourning
Interprofessional Collaboration & Assessment
Encourage attendance at bereavement or grief support groups; provide community resource information
Initiate referrals for individual psychotherapy for clients with difficulty resolving grief
Offer to contact a spiritual advisor or encourage the client to do so
Participate in meetings with professional grief and mental health counselors
Determine which phase of grieving the client is experiencing; identify whether grieving is healthy or complicated
Determine the client's capacity to make decisions and reliability of the support system
Identify the client's sources of strength and hope
Identify desires and expectations of the client and family for end-of-life care
Hospice Care
⚡ Admission pathway — all four steps required
Life Expectancy
≤ 6 months
→
Dual Certification
Hospice provider
+ PCP both certify
+ PCP both certify
→
Client Agrees
Palliative care
not curative
not curative
→
Signed Statement
Chooses hospice
over curative Rx
over curative Rx
→
Enrolled
Recertify if lives
beyond 6 months
beyond 6 months
⚡ Interdisciplinary Team (IDG) — holistic care across all domains
Physician / PCP
Certifies illness, manages medical orders
Hospice Nurse
Meds, ADLs, family education, emotional support
Social Worker
Counseling, advance directives, resources
Chaplain
Spiritual & religious needs, in-depth counseling
Family / Caregivers
Core support; respite care available
Volunteers ⚡
Must = 5% of patient care hours. Housekeeping, transport, reading, music.
Respite care — brief caregiver break · client admitted to facility for max 5 days
Bereavement support — hospice supports family for up to 13 months after death
Settings: hospice may be provided at home, health care facility, or extended care facility
Palliative Care
⚡ The key comparison — frequently tested
Palliative Care
●Any age, any stage of serious illness
●Curative treatment CAN continue alongside ⚡
●No time constraints — starts at any point ⚡
●Holistic approach: physical + psychosocial ⚡
●Improves QOL, reduces hospital time, boosts satisfaction
●Nurse serves as advocate for client's dignity and self-esteem
●Team includes: physicians, nurses, social workers, PTs, OTs, massage therapists, music/art therapists, touch/energy therapists, spiritual support staff
●Examples: cancer, HF, renal/respiratory failure, Alzheimer's, Parkinson's
Hospice Care
●Life expectancy ≤ 6 months
●Curative treatment STOPS ⚡
●Requires dual certification + signed statement
●Client can withdraw from hospice at any time
●Recertification needed if client outlives 6-month window
●Any life-limiting illness (not just cancer)
⚡ WHO 3-Step Pain Ladder — escalate as needed
1
Mild Pain — Nonopioids
NSAIDs (ibuprofen, aspirin, ketorolac) · Acetaminophen
2
Moderate Pain — Weak Opioids
Codeine · Tramadol (± nonopioid adjuvants)
3
Severe Pain — Strong Opioids
Morphine · fentanyl · hydromorphone
⚡ Recommended approach: Combination of scheduled + PRN + non-pharm interventions
Physiological Changes While Actively Dying
Progressive signs — earliest at top, approaching death toward bottom
Cheyne-Stokes Respirations
within 3 days of death ⚡
Irregular cycle: rapid shallow breaths → deep breaths → apnea. Educate family this is expected and normal — not a sign of distress.
fan blowing lightly toward client
educate family — expected
Death Rattle
approaching death ⚡
Noisy, gurgling respirations from secretion accumulation. Client cannot clear secretions themselves ⚡ — do not expect them to cough or swallow. Deep suctioning is ineffective.
turn head/body to side for drainage ⚡
atropine drops ⚡
scopolamine patch ⚡
moist washcloth / oral suction
Dyspnea
shortness of breath ⚡
Sensation of breathlessness. First-line treatment is opioids (morphine) — vasodilate, reduce perceived breathing difficulty, decrease anxiety. Not the same as respiratory depression.
morphine — first line ⚡
oxygen therapy
fan blowing on face
positioning
benzodiazepines (anxiety)
Mottling
impending death ⚡
Purple, pale, or grey marbling of skin ⚡ — starts in the feet, moves up the legs. Occurs alongside cyanosis from poor circulation. Heart can no longer pump blood effectively. Client feels no discomfort but may feel cold to touch.
warm blankets ⚡
no painful interventions
educate family — expected
Hallucinations / Delirium
near death ⚡
Client may see or speak to deceased family members or describe peaceful places. Do NOT contradict or reorient — causes distress. Clients can still hear even in coma — continue talking to them with reassurance.
do NOT reorient ⚡
ensure safety, prevent injury ⚡
keep talking to client
reassure family
Temperature Dysregulation
late stage
Nervous system loses ability to regulate temperature. Causes include infection, cancer, opioids, anxiety, and hypoxia. May present as fever or hypothermia.
cold/hot compresses
warm sponge baths
hypothermia blanket
fan for cooling
antipyretics (acetaminophen, ibuprofen)
⚡ Consistently tested: Educate the family about ALL respiratory changes — they are expected and not a sign of distress
Additional manifestations of approaching death
Characteristics of discomfort — assess and manage
Pain
Anxiety
Restlessness
Dyspnea
Nausea / Vomiting
Dehydration
Diarrhea / Constipation
Urinary & Fecal Incontinence
Inability to Perform ADLs
⚡ Physical & Psychosocial Nursing Care for the Dying Client
🫀 Physical Care
Administer morphine for pain, air hunger, and anxiety
Perform ongoing assessment to determine medication effectiveness; adjust doses as needed
Manage adverse effects of medications
Reposition to maintain airway patency and comfort
Maintain integrity of skin and mucous membranes
Provide caring touch (hold the client's hand)
Remove products of elimination promptly; keep environment clean and odor-free
Provide comfortable clothing and careful grooming (hair, nails, skin)
Provide frequent oral care (swabs, mouth moisture); wipe face and eyes with warm wet cloth
Encourage family to bring comforting possessions
Encourage relaxation techniques (guided imagery, music) if appropriate
Promote client decision-making in food, activities, and health care to preserve control
Encourage ADLs as client is able and willing
🧠 Psychosocial Care
Use interprofessional approach; involve volunteers for nonmedical care
Use therapeutic communication to maintain nurse-client-family-provider relationships
Facilitate understanding of disease progression and treatment choices
Encourage participation in religious or comforting practices if appropriate
Assist client in clarifying personal values to support effective decision-making
Encourage use of past coping mechanisms that have worked
⚡ Hearing is the last sensation lost — be sensitive to all comments made near an unconscious client; continue talking to them with reassurance
Address specific concerns (financial, role changes); refer to social services as needed
Spiritual, Cultural & Dignity Care
Spirituality ⚡
Spirituality = significance and purpose of life; relationship with others, nature, higher power ⚡
Religion ≠ spirituality — religion = specific beliefs within a community
Always ask if client desires spiritual care before offering ⚡
In-depth counseling → refer to chaplain, not nurse
Benefits: improved QOL, better coping, prevents depression
🕊️
Cultural Competence ⚡
Some cultures: discussing impending death is culturally insensitive ⚡ — understand culture first
Language barrier → facility's official interpreter services ⚡ — NOT family, NOT housekeeping, NOT unauthorized apps
Many cultures distrust opioids — educate: not euthanasia, not addictive in dying context
Culture shapes pain management and EOL decisions
🌍
Dignity & Isolation ⚡
Dignity = everyday necessity; most EOL complaints relate to lack of caring
Illness causes loss of control → diminishes dignity
Involve client in all decision-making to preserve autonomy
Social isolation: schedule visitors when pain and symptoms are controlled
Resources: family visits ⚡, online support groups, hospice volunteers
💜
⚡ High-yield — the "good death" question
Always determine the client's own definition of a "good death" — do not impose the nurse's values.
A good death generally includes: pain management, planning ahead, closure, clear decision-making, and the ability to contribute to others.
Ask: "What can I do to help you feel more independent?" ⚡
Postmortem Care & Organ Donation
⚡ Nurse documentation after death — all four items required
✓
Date and time of death — exact, per facility policy
✓
Name of anyone notified — family, provider, chaplain
✓
Location of client's belongings — secured and accounted for
✓
Where body is moved — e.g., funeral home name
ID tags: minimum 2 locations — toe, arm, and outside of body bag · Remove invasive devices per facility policy · Provides nurse with opportunity for closure
⚡ Organ donation process — nurse role is strictly referral
✗
Nurse CANNOT initiate organ donation dialogue — direct-care nurse has a conflict of interest ⚡
↓ only if family/client voluntarily requests donation
1
Nurse makes referral to Organ Procurement Organization (OPO) ⚡
↓
2
OPO coordinator meets with client/family, answers all questions about donation
↓
3
Nurse facilitates: evaluates cultural/religious beliefs, provides time for feelings, uses chaplain if needed, gives accurate info
Donation is voluntary — donor authorizes before death or surrogate gives permission
Use private areas for family discussions concerning donation
Be sensitive to cultural and religious influences
Maintain ventilatory and cardiovascular support for vital organ retrieval until procurement is complete
⚡ Preparing the body for viewing — step by step
⚡ First action: Elevate the client's head immediately after death by raising the HOB and placing a pillow under the head and shoulders — prevents facial discoloration
1
Ask the family whether they want to be included in preparation of the body; maintain privacy throughout
2
Remove all tubes — unless autopsy is planned, organs are to be donated, or this is a medical examiner's case
3
Cleanse and align the body supine with pillow under head; arms with palms down outside the sheet; dentures in place; eyes closed
4
Remove all personal belongings; clarify with the family whether items should go with the body or to a designated person
5
Apply fresh linens with absorbent pads and a clean gown
6
Brush or comb the hair; replace any hairpieces
7
Remove excess supplies, equipment, and soiled linens from the room
8
Dim the lights and minimize noise to provide a calm environment for the family
After preparation, ask the family whether they would like to visit with the body — honor any decision
The provider (not the nurse) certifies death by pronouncing the time and documenting therapies used and actions taken prior to death
Remain aware of visitor and staff sensibilities during transport of the body from the room
⚡ Infant postmortem — special considerations
Swaddle the infant's body in a clean blanket
Transport in the nurse's arms or in an infant carrier based on facility protocol
Offer the family mementos of the infant — identification bracelets, footprints, the cord clamp, a lock of hair, photos
Autopsy Considerations
📋 Nurse's Role & Legal Requirements
The provider (not nurse) typically approaches the family about performing an autopsy
Nurse's role: answer family questions and support their choices
Purpose: advance scientific knowledge of disease processes and support development of new therapies
⚡ Law requires autopsy for: homicide, suicide, accidental death, or death occurring within 24 hr of hospital admission
⚡ Most facilities require all tubes remain in place when an autopsy is to be performed
Documentation must include: who pronounced death & time · organ donation consideration · tubes/lines left in place · disposition of personal articles · who was notified & decisions made · location of ID tags · time body left facility & destination
Managing Nurse Grief & Self-Care
How grief shows up in nurses
🫀 Physical
Chest tightness
Muscle discomfort & headaches
Sleep disturbances
GI problems
Palpitations
🧠 Psychological
Anger, irritability, sadness
Sleeplessness & exhaustion
Difficulty concentrating
Altered eating patterns
Feelings of helplessness
⚡ Self-care toolkit — exercise is the most-tested answer
Exercise Program
Most commonly tested self-care strategy
Balanced Nutrition
Well-balanced meals; avoid skipping
Set Boundaries
Take time for oneself; limit emotional spillover
Talk It Out
Talk to experienced nurses or seek professional help
Attend Funeral
Provides closure for the nurse
Journal & Hobbies
Process feelings; discover new interests
Sleep Routine
Establish consistent 6–8 hr schedule
Write to Family
Communicate in writing to the client's family after death
Attend Debriefing
Attend debriefing sessions with colleagues after a difficult loss
Note: All coping strategies should be used with consideration of professional boundaries
Exam High-Yield Hits
Hospice admission ⚡
Life expectancy ≤6 months. Both hospice provider AND PCP must certify. Client agrees to palliative — not curative — care.
Hospice = IDT ⚡
Interdisciplinary team effort — providers, nurses, social workers, chaplain. Holistic physical + psychosocial + spiritual care.
Palliative = holistic ⚡
Uses a holistic approach. Improves QOL. Can be given WITH curative treatment. No time constraints.
Palliative vs Hospice ⚡
Palliative: curative OK, any prognosis, no time limit. Hospice: curative stopped, ≤6 months, signed consent required.
Death rattle ⚡
Client CANNOT clear secretions. Turn head/body to side. Atropine or scopolamine patch. Deep suction = ineffective.
Noisy respirations ⚡
Educate family: expected respiratory changes are 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 discomfort. Warm blankets.
Hallucinations ⚡
Do NOT contradict or reorient. Ensure safety, prevent injury. Client can still hear in coma — keep talking.
Dyspnea Rx ⚡
First-line: opioids (morphine). Also: O₂, fan, positioning, benzodiazepines. Comfort focus over correction.
Good death ⚡
Determine the client's own definition — do not impose nurse's values. Includes pain control, closure, autonomy.
Culture & death ⚡
Some cultures: discussing 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.
Postmortem documentation ⚡
Document: date/time of death · who notified · where body moved · belongings location.
Dignified care ⚡
"What can I do to help you feel more independent?" Involve client in decisions. Preserves control and dignity.
Social isolation ⚡
Schedule family/friends to visit. Time visits when pain and symptoms are controlled for best interaction.
Spirituality ⚡
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 limits.
Respite care
Brief caregiver break. Client admitted to facility max 5 days. Provides needed rest for family caregivers.
Pain in EOL ⚡
Combination approach: scheduled + PRN + non-pharm. 3-step ladder: NSAIDs → codeine/tramadol → morphine.
Bereavement support
Hospice supports family/caregivers for up to 13 months after client's death.
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.
Advance directives ⚡
Living will = client's written treatment wishes. Health care proxy / durable POA = appoints someone to decide when client cannot.
Kübler-Ross stages ⚡
Denial → Anger → Bargaining → Depression → Acceptance. Stages do NOT have to occur in order. Length varies per person.
PGD timeframe ⚡
Prolonged Grief Disorder: >6 months (children/adolescents) or >12 months (adults). Suicidal ideation, intense guilt, functional impairment.
Disenfranchised grief ⚡
Loss that cannot be publicly shared or is not culturally acceptable (pet, miscarriage, suicide, incarcerated person). Social support is lacking.
Normal grief — 6 mo ⚡
Uncomplicated grief: some acceptance should be evident by 6 months after the loss. Somatic complaints are normal (chest pain, palpitations, headaches).
Grief — no clichés ⚡
Avoid false reassurance, advice, subject-changing, and clichés ("They are in a better place"). Instead: name the emotion, encourage sharing memories.
Dysfunctional grief risk ⚡
Dependent on deceased · unexpected/violent death at young age · inadequate coping skills · preexisting mental health issues (depression, SUD).
Anticipatory grief
Grieving before the actual loss (e.g., terminal illness). Client begins "letting go" prior to death. Begin supportive care early.
Hearing = last sense ⚡
Hearing is the last sensation lost. Be sensitive to ALL comments made near an unconscious client. Continue talking to them with reassurance.
Body prep — head ⚡
Elevate head immediately after death (HOB up + pillow under head/shoulders) to prevent facial discoloration. Do this ASAP.
Body prep — positions ⚡
Align body supine: pillow under head, palms down outside sheet, dentures in, eyes closed. Remove tubes unless autopsy/donation/medical examiner case.
Infant postmortem ⚡
Swaddle in clean blanket. Transport in nurse's arms or carrier. Offer family mementos: bracelets, footprints, cord clamp, hair lock, photos.
Autopsy — tubes ⚡
If autopsy is planned: leave ALL tubes in place. Autopsy legally required for: homicide, suicide, accidental death, or death within 24 hr of admission.
Abandonment prevention ⚡
Answer call lights promptly. Allow family overnight. Keep client informed of schedules. Place client near nurses' station or in central home location.
Caregiver fatigue ⚡
Determine family's desire and capacity to provide physical care. Monitor for caregiver fatigue. Provide instruction and respite options.
Nurse grief — debrief ⚡
Attend debriefing sessions with colleagues. Communicate in writing to family. Attend funeral. All strategies used with consideration of professional boundaries.
───────────────────
── REM · NREM · STAGE 1–4 ──
── SLEEP · REST · COMFORT ──
── CIRCADIAN · RHYTHM ──
───────────────────
── INSOMNIA · APNEA · NARCO ──
───────────────────
── REM · NREM · STAGE 1–4 ──
── SLEEP · REST · COMFORT ──
── CIRCADIAN · RHYTHM ──
───────────────────
── INSOMNIA · APNEA · NARCO ──
───────────────────
mod 30
Comfort, Rest, and Sleep
Sleep physiology, common disorders, and nursing interventions for rest and comfort.
Sleep StagesSleep DisordersInterventionsComfort
Sleep Physiology & Stages
☀️ Circadian Rhythm
Internal 24-hr clock synced to light/dark via the SCN in the hypothalamus. Controls when you sleep.
🌊 Sleep–Wake Homeostasis
Sleep pressure builds the longer you're awake. Controls how deeply you sleep. Resets during Stage 3.
🎯 High-Yield Brain Structures
Hypothalamus / SCN
Controls circadian rhythm via light exposure. Damaged SCN → erratic, unpredictable sleep.
Pineal Gland
Produces melatonin — the sleep hormone. First-line Rx for all ages.
Thalamus
Relays senses to cortex. Transmits images/sounds during REM → vivid dreams.
Brainstem (Pons)
Initiates REM. Paralyzes muscles (atonia) so you can't act out dreams.
🎯 Sleep Architecture — Most-Tested
Sleep Stage Depth Chart — One Typical Night (% of total sleep)
Wake / Transition
~8% · Alpha & Beta waves
N1 — Stage 1
~5% · Lightest
N2 — Stage 2 ⭐
~50% · Spindles
N3 — Stage 3 ⭐
~15% · Deepest
REM ⭐
20–25% · Dreams
Pattern across a full night — cycles repeat ~90 min, REM grows longer
NREM cycle
REM (grows longer each cycle)
N3 deep sleep (shrinks over night)
WAKE
Alpha (8–12 Hz) & Beta waves. Eyes closed, relaxed. Short transition into Stage 1.
N1
Lightest sleep. Easily awakened. Lasts 1–5 min. Hypnic jerks (muscle twitching) possible. Theta waves.
N2 ⭐ ~50%
Sleep spindles & K-complexes. HR & body temp decrease. Older adults spend MORE time here → frequent nighttime waking.
N3 ⭐ Deepest
Delta waves. Immune strengthens. Muscles/tissues/bones repair. Awakening from N3 → mental cloudiness 30–60 min. Lowest pulse & RR. Decreases with age.
REM ⭐ 20–25%
Dreaming stage. Beta waves (brain looks awake on EEG). Muscles atonic — can't act out dreams. Irregular breathing, elevated HR. Begins ~90 min after sleep onset. REM periods grow longer through the night.
Older Adults: ↑ Stage 2 (lighter sleep → frequent waking) · ↓ Stage 3 · ↓ REM · Takes longer to fall asleep. Extended bed time can worsen musculoskeletal weakness, arthritis, and pulmonary disorders.
⏰ Recommended Sleep Hours by Age Group
Newborns (0–28 d)
14–17 h
Infants (1 mo–1 yr)
12–15 h
Toddlers (1–3 yr)
11–14 h
Preschool (3–6 yr)
10–13 h
School-age (6–12 yr)
9–11 h
Adolescents (12–20 yr)
8–10 h
Young adults (20–35)
7–9 h
Middle adults (35–65)
7–9 h
Older adults (65+) ⭐
7–8 h
Newborn & Infant Sleep Patterns: NREM/REM cycles every 45–60 min; mostly in Stage 3. Until 3 months: ~50% REM. At 5–6 months: sleeps through night + daytime nap. After 1 year: progresses toward adult pattern.
⚠️ Sleep Deprivation Effects
Impaired judgment & ↓ response time
Triggers migraines, seizures
↑ Depression, stroke, obesity risk
Poorly controlled blood glucose (T2DM)
Shift workers: ↑ DM, obesity, CVD
Smartphone use at night → depression
💊 Sleep & Metabolic Hormones
Leptin ↑
Sleep increases leptin — the satiety hormone. Tells brain "you are full." Reduces hunger, prevents overeating.
Sleep
→
also ↓
cortisol
→
also ↓
cortisol
Ghrelin ↓
Sleep decreases ghrelin — the hunger hormone. Poor sleep → ↑ ghrelin → overeating → obesity & T2DM.
Sleep also ↓ cortisol → better insulin sensitivity → prevents T2DM.
Sleep Disorders
🎯 OSA vs. CSA — High-Yield Distinction
OSA — Obstructive ⭐
Upper airway physically collapses during sleep. Tissues obstruct the passage. Brain tries to send signals — the airway just can't open. Risk: obesity, enlarged tonsils, inactive tongue. Sx: loud snoring, daytime sleepiness, fatigue. Dx: polysomnography. Tx: CPAP (first-line).
CSA — Central ⭐
Brain fails to send signals to respiratory muscles → breathing simply stops. No airway obstruction. Causes: opioid overdose & heart failure. Key difference: it's a neurological signaling failure, not an anatomical block.
Insomnia
Ongoing inability to sleep despite opportunity — difficulty falling/staying asleep or waking too early. Associated with heart disease, hypertension, arthritis. Tx: CBT (first-line), medications, lifestyle.
Narcolepsy ⭐
Sudden uncontrollable sleepiness. NT1 = with cataplexy (brief involuntary muscle tone loss triggered by strong emotion/laughter) + lacks hypocretin (alertness hormone from hypothalamus). NT2 = without cataplexy.
Both types: nocturnal hallucinations · sleep paralysis · vivid dreams
Hypersomnia ⭐
Excessive daytime fatigue that does NOT improve with more sleep — the key differentiator. Not from disturbed circadian rhythm. Sx: poor memory, depression, short attention span, irritability.
RLS (Willis-Ekbom)
Uncontrollable urge to move legs — crawling/creeping sensation. Worsens at rest/bedtime, improves with movement. Associated with iron or vitamin deficiency. Avoid caffeine, nicotine, alcohol.
Night Terrors
vs nightmares
Night Terrors ⭐
NREM · First ⅓ of night · No dream recall · Mostly children · Do not wake
Nightmares
REM · Second half of night · Dream recalled · All ages
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 |
|---|---|---|
| Z-drugs ⭐ (nonbenzo hypnotics) |
Zolpidem · Zaleplon · Eszopiclone | Most commonly prescribed. Monitor for hallucinations, gastric discomfort, memory loss. Abuse potential. |
| Benzos (GABA agonists) |
Alprazolam · Clonazepam · Lorazepam | Retrograde amnesia, drowsiness, muscle relaxation. Use cautiously in older adults (↓ liver/kidney). NOT for long-term — physical dependence. |
| Melatonin ⭐ controlled-release |
Melatonin (OTC/Rx) | 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 ⭐ — triggers melatonin release
Acupuncture & thermotherapy ⭐ — evidence-based
Massage (caution: anticoagulants, open wounds, fever)
Guided imagery, meditation, music therapy
Yoga — reduces stress, muscle tension & pain
Sleep diary — track patterns to identify triggers
🌙 Sleep Hygiene — Bedtime Rules (Exam Staples)
4–6 HRS BEFORE BED
Avoid caffeine, alcohol, and nicotine. These disrupt sleep architecture and suppress REM.
≥3 HRS BEFORE BED
No vigorous exercise within 3 hours of bedtime — elevates core temp and arousal.
BEFORE 3 P.M.
Naps kept <30 min and taken before 3 p.m. — late naps reduce homeostatic sleep pressure.
AT BEDTIME
Establish a routine: warm shower/bath, dim lights. Keep room cool, dark, and quiet. Turn the clock away from view. Consistent sleep–wake time every day.
IF CAN'T SLEEP (~20 MIN)
Leave the bedroom. Read or listen to soft music elsewhere. Return only when sleepy. Bedroom = sleep and sexual activity only. Remove TVs and work items.
🏥 Hospital Sleep Promotion — Sensory Overload Prevention
✓Dim lights at night
✓Lower alarm volumes
✓Offer blindfolds & earplugs
✓Cluster / combine care tasks
✓Organize designated quiet time
✓Control pain & monitor meds
Promoting Comfort
"My health care team has helped me feel safe during my stay."— the client statement that signals comfort has been achieved
Comfort = Easing physical, mental, and emotional distress through warmth, empathy, and compassion. A comforted client feels safe, accepted, valued, and stronger.
🎯 Nursing Actions to Promote Comfort
▸
Encourage verbalization of needs and concerns ⭐
▸
Answer questions honestly ⭐
▸
Include client's concerns in the plan of care
▸
Respect cultural & spiritual beliefs
▸
Be present — practice active listening
▸
Allow informed choices — client feels in control
PN Nursing Process for Comfort: Data Collection → Planning → Implementation → Evaluation. Feeling safe, accepted, and valued = comfort achieved.
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
Recommended sleep hours
Newborns: 14–17 hr · Infants: 12–15 hr · Toddlers: 11–14 hr · Preschool: 10–13 hr · School-age: 9–11 hr · Adolescents: 8–10 hr · Young & Middle adults: 7–9 hr · Older adults: 7–8 hr
Infant sleep pattern
NREM and REM cycles every 45–60 min; ~50% REM until age 3 months. Begins sleeping through night at 5–6 months. Progresses toward adult pattern after age 1.
───────────────────
── PRE-OP · INTRA-OP · POST-OP ──
── CONSENT · PREP · ANESTHESIA ──
── PACU · RECOVERY · DISCHARGE ──
───────────────────
── SURGICAL · SAFETY · CHECKLIST ──
───────────────────
── PRE-OP · INTRA-OP · POST-OP ──
── CONSENT · PREP · ANESTHESIA ──
── PACU · RECOVERY · DISCHARGE ──
───────────────────
── SURGICAL · SAFETY · CHECKLIST ──
───────────────────
mod 39
The Surgical Client
Perioperative nursing care across all three phases — before, during, and after surgery.
Pre-OpIntra-OpPost-OpComplications
Preoperative Phase
🎯 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.
⚠ MH Family Hx
Notify intraop team. Life-threatening rxn to anesthesia meds.
Surgical Hx
Prior anesthesia response, complications.
⚖️ Risk Factors for Surgical Complications
Type 1 & 2 DM
Poor wound healing, infection risk
Smoking
↑ blood clots, slower healing, ↑ infection
Corticosteroids
Impair 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
✅ Who CAN Sign · ✗ Who CANNOT
✓ CAN SIGN
- ✓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
✗ CANNOT SIGN
- ✗Sedated or medicated clients
- ✗Unconscious (unless implied consent applies)
- ✗Non-emancipated minors
- ✗Client can change their mind at any point
Pregnancy Testing
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, incentive spirometry, coughing/deep breathing, splinting, early ambulation.
Intraoperative Phase
🎯 Surgical Team Roles
💉 Anesthesia Types — Depth of Effect
🧼 Skin Prep Sequence ⭐
1
Circular scrub,
center first
center first
→
2
Move outward
from center
from center
→
3
Discard sponge
at outer edge
at outer edge
→
4
Repeat with
new sponge
new sponge
→
5
Drape
the client
the client
🔥 Malignant Hyperthermia ⭐
Postoperative Phase
🫁
PACU Priority
ABCs First — O₂ Saturation is #1
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
💧 Fluid Imbalances
Post-Op Complications
Emergency
High Priority
Monitor
Safety Considerations for the Surgical Client
Key Safety Concerns
- Fall risks — anesthesia, opioids, and sedating medications impair balance and coordination post-op; assess fall risk before ambulation
- Aspiration precautions — keep head of bed elevated; sit upright to eat; remain upright at least 1 hour after meals; use thickened liquids if dysphagia is present
- Impaired cognition — post-op delirium and POCD affect safety; reorient frequently, ensure call light is within reach, use bed alarms as appropriate
Nursing Safety Interventions
- Apply non-slip footwear before ambulation
- Perform sit-to-stand assessment before first ambulation post-op
- Ensure adequate pain control — uncontrolled pain increases fall risk
- Educate client and family about call-for-assistance before getting up
- Monitor for orthostatic hypotension after prolonged bed rest or opioid use
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
───────────────────
── STAGE I · II · III · IV ──
── UNSTAGEABLE · DTPI ──
── BRADEN · NORTON · ASSESS ──
───────────────────
── WOUND · DRESS · HEAL ──
───────────────────
── STAGE I · II · III · IV ──
── UNSTAGEABLE · DTPI ──
── BRADEN · NORTON · ASSESS ──
───────────────────
── WOUND · DRESS · HEAL ──
───────────────────
mod 40
Tissue Integrity
Skin layers, pressure injury staging, wound management, and selecting the right dressing.
Skin Anatomy
Pressure Injuries
Dressings
Wound Care
Skin Anatomy & Function
Tissue integrity = ability to regenerate and maintain normal physiologic functioning. Skin accounts for 15% of total body weight and acts as the body's first line of defense.
🔬 Skin Layers — Cross-Section View
🔬 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
📊 Braden Scale
🛡️ 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
Moisture level spectrum
DRY →← HIGH EXUDATE
Rule: Moist (not wet) wound bed = optimal healing. Films → minimal exudate · Alginate/Hydrofiber → high exudate.
Wound Care, Healing & Drainage
💧 Drainage Types
📋 Acute vs. Chronic Wounds
Acute Wound
Develops from injury or trauma; follows a predictable healing timeline.
Chronic Wound
Develops over time from acute wounds that do not progress in healing; classified by origin.
🔄 Wound Healing Intentions
⏱️ Phases of Wound Healing ⭐
🔬 TIME Wound Assessment
T
Tissue
color, necrosis
I
Infection
redness, warmth, drainage
M
Moisture
dry/wet/maceration
E
Edge
describe wound edges
🧠 DIDN'T HEAL — Delayed Healing Factors
⚠️ Wound Complications
Infection
Redness, warmth, purulent drainage, fever
Dehiscence
Wound edges separate — reposition to reduce tension
Evisceration ⭐ EMERGENCY
Organs protrude. 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 → swab wound bed (not edges) → rotate swab → place in culture tube.
📐 Wound Measurement & Key Terms
- Method 1: Trace wound circumference with transparent tape — calculate surface area
- Method 2: Measure the length and width of the wound
- Nurse must use same method consistently throughout treatment to accurately track healing
- Blanching = skin whitens after pressure → intact microcirculation
- Non-blanchable erythema = redness persists under pressure → structural damage (Stage 1)
- Surgical debridement — removes biofilm/dead tissue; stimulates healing by contraction & epithelialization
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
───────────────────
── SENDER → MSG → RECEIVER ──
── ◁ FEEDBACK ▷ ──
── NOISE · NOISE · NOISE ──
───────────────────
── ENCODE · CHANNEL · DECODE ──
───────────────────
── SENDER → MSG → RECEIVER ──
── ◁ FEEDBACK ▷ ──
── NOISE · NOISE · NOISE ──
───────────────────
── ENCODE · CHANNEL · DECODE ──
───────────────────
mod 6
Communication
How information moves between nurse, client, and team — and what gets in the way.
4 Models
5 Forms · 4 Modes
Style Spectrum
Therapeutic vs. Non
OARS · Peplau
Communication Models
Shannon-Weaver
1948
⚡ exam
Sender
→
Encoder
→
Channel
→
Decoder
→
Receiver
⚡ Noise
Linear · one-way · no feedback. Nurse giving discharge instructions = Sender.
Schramm
1954
⚡ exam
Sender
⇄
Message
⇄
Receiver
Cyclical · feedback is the key component. No feedback → communication incomplete. "I understand now" = feedback.
Newcomb's ABX
Social model
A (sender)
↔
X (topic / person / object)
↔
B (receiver)
Social standpoint. X affects the A–B relationship. X can be a person, object, or topic.
Berlo's S-M-C-R
Sender
→
Message
→
Channel
→
Receiver
One-way · no feedback loop. Example: client instructional video.
⚡ Key principle: All models share at minimum a sender, receiver, and message. Feedback allows both parties to confirm understanding.
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
Style Spectrum — from avoidant to hostile
Passive
▲ Assertive ⭐
Pass-Aggressive
Aggressive
Passive
Avoids conflict
"I'll do whatever you want."
Agrees even when they don't want to. Fearful of being wrong. Common in novice nurses.
Assertive
Most effective ⭐
"I feel we should consider…"
Clear, honest, uses "I" statements. Advocates for rights without violating others'. Goal communication style.
Passive-Aggressive ⚡
Indirect anger
"Take your time." (then complains)
Appears passive but acts out indirectly. Sarcasm, ignoring, not following through.
Aggressive
Hostile
"It's your fault the client fell."
Blames with "you" statements. Interrupts. Controlling. Puts others on defense.
Factors & Barriers to Communication
Types of Factors ⚡
Strategies to Overcome ⚡
- Hearing impairment: move to quiet area, face client, slow pace, visual cues, write key info, ASL interpreter (Language Line)
- Vision impairment: ensure glasses are on; ensure room is well lit
- Language barrier: use facility's certified interpreter — never 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 before communicating
⚠️ Cultural factor influences client requests (e.g., last rites before death). Psychosocial + situational factors can co-exist (e.g., dialysis client worried about job, avoiding eye contact).
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 ⚡
01
Orientation
Client seeks help from nurse/provider. Initial meeting — nurse and client get acquainted.
02
Identification
Mutually respectful relationship is established. Client begins to trust the nurse.
03
Exploitation ⚡
Active phase — nurse educates client. Examples: teaching heart-healthy activities, wound care, medication regimen.
04
Resolution / Termination
Issue resolved; relationship ends until next encounter. Goals met, discharge occurs.
Therapeutic Techniques ⚡ vs. Nontherapeutic — Avoid
✓ Do — Therapeutic
●
Active Listening — nod, eye contact, open posture; attend to verbal & nonverbal cues
●
Open-Ended Questions — "Tell me more…" / "What is on your mind?"
●
Restating ⚡ — repeat client's message back to verify understanding "Is that correct?"
●
Reflection — mirrors feelings; when client asks for advice: "What do you think you should do?"
●
Summarizing / Paraphrasing — recaps to confirm understanding
●
Silence — allows reflection; let client break the silence
●
Accepting / Recognition — acknowledge without compliments: "I noticed you've been keeping your food diary."
●
Focusing — redirects disorganized thinking or delusional content
✗ Don't — Nontherapeutic
●
Giving advice — "If I were you, I would…" → belittling, undermines autonomy
●
False reassurance — "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 ⚡
- 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 empowers clients to make positive health behavior changes. Used for: diabetes, obesity, substance use disorder. Client-centered and non-judgmental. Key technique = OARS
O
Open-Ended Questions
Encourages disclosure without judgment.
"Tell me more about…" not "Why did you…"
A
Affirmations ⚡
Positive statements that build client confidence.
"I'm glad you decided to continue your fitness routine."
R
Reflective Listening
Restates & clarifies feelings behind the words.
"So you're worried you'll get diabetes like your mother."
S
Summarizing
Paraphrases the conversation to confirm understanding.
"Your mother also had diabetes."
⚡ Exam tip — MI 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 — "I understand now" = feedback
Shannon-Weaver: nurse provides discharge
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 — check first
Ensure client has glasses on
Teaching heart-healthy activities = phase?
Exploitation (active teaching phase)
Teaching AP: lecture + written steps
Modes: Verbal + Nonverbal + Written
Charge nurse: "take your time" then complains
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
───────────────────
── SOAP · PIE · DAR · CBE ──
── DATE · TIME · SIGN ──
── FACT · ACCURATE · COMPLETE ──
───────────────────
── EHR · HIPAA · LEGAL · SAFE ──
───────────────────
── SOAP · PIE · DAR · CBE ──
── DATE · TIME · SIGN ──
── FACT · ACCURATE · COMPLETE ──
───────────────────
── EHR · HIPAA · LEGAL · SAFE ──
───────────────────
mod 7
Documentation
Legal, accurate, and thorough recording of all client care and clinical decisions.
Records & EHRsDoc MethodsFACT & AbbreviationsHIPAA & LegalVerbal Rx & CPOE
Health Records & EHRs
EHR Timeline
60s
First utilization of EHRs
70s
Federal gov't (Dept. of Veteran Affairs) began using EHRs
80s
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
FACT Documentation & Abbreviations
FACT — Documentation Accuracy Guide
Abbreviations
ISMP — Institute for Safe Medication Practices: Devoted to preventing errors that occur within health care facilities. The ISMP compiles a list of abbreviations that are appropriate to use with documentation, helping to reduce confusion and errors. Each facility establishes its own approved list based on ISMP guidance.
✅ 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.
Correcting Errors in Documentation ⚡
How to Correct a Documentation Error
- Keep the original document — never destroy it
- Draw a single line through the entry and write "error" along with your initials
- Record the date and time of when the correction was entered
- Do not obscure the original entry with white out, black marker, pen, pencil, etc.
- Document the correct information
Guidelines for Late Charting Entries ⚡
- Identify the entry as a "late entry"
- Identify which event the late entry is for
- All new entries must be signed and dated
- Identify which event or previous note the new note is referencing
- Ensure there are no blank lines in documentation
Electronic Documentation Security Guidelines
- Never use anyone else's login information
- Password must be strong, unique, and changed frequently
- Log off when documentation is complete — never leave a computer station without logging off first
- Computer monitor/screen should be protected to avoid information being seen by others
- If an electronic signature is used, ensure your name is correct and professional credentials are noted
HIPAA, Privacy & Legal
Record Access Control — Without Special Consent ⚡
✓ Permitted
✓ Admitting provider
✓ Charge nurse on the unit
✓ The client themselves
✗ Denied Without Consent
✗ Family members
✗ 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 — Step by Step ⚡
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 ⚡
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
───────────────────
── ROM · AMBULATE · TRANSFER ──
── POSITION · TURN · REPOSITION ──
── BODY · MECHANICS · SAFETY ──
───────────────────
── SPLINT · CAST · IMMOBILIZE ──
───────────────────
── ROM · AMBULATE · TRANSFER ──
── POSITION · TURN · REPOSITION ──
── BODY · MECHANICS · SAFETY ──
───────────────────
── SPLINT · CAST · IMMOBILIZE ──
───────────────────
mod 22a
Mobility
Musculoskeletal health, safe movement, and preventing the complications of immobility.
MSK SystemBody MechanicsImmobilityMAT & AssessmentDevices & TransfersPositioning & ROM
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
- Mnemonic: Muscles Contract and Pull to Generate Movement (MCPGM)
🦾 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
- Made up of 206 bones; not solid — composed of layers
- Bones undergo remodeling once mature — old bone constantly replaced with new bone
🏋️ Four Properties of a Muscle — CEEE
C
Contractibility
Ability to shorten (contract) and then relax
E
Excitability
Muscle fibers receive and respond to nerve or hormone stimulation; resting = negatively charged, stimulated = positively charged
E
Extensibility
Ability to stretch (extend), occurring simultaneously as other muscles contract
E
Elasticity
Ability to recoil back to original state after being contracted or extended
🦴 Three Main Muscle Types
Cardiac
Only in the heart — functions involuntarily
Smooth
In blood vessels and visceral organs — functions involuntarily
Skeletal
Attached to bones by tendons — functions voluntarily
🦴 Classifications of Bones
Long
Weight-bearing; greater in length than width (e.g., humerus, femur)
Short
Small, cube-shaped — found in wrists and ankles
Flat
Thin, flat, slightly curved — skull, ribs, sternum, shoulder blades; protect brain and organs
Irregular
Unique shape — found in face, ears, vertebrae, sacrum, coccyx
Sesamoid
Formed within a tendon; protect tendon from joint stress — includes patella and carpals
🧠 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.
📐 Types of Postural Misalignments
Kyphosis ⚡
Upper back abnormally rounded with a forward tilt in the pelvis. Most common in older adult females due to vertebral weakening/fracture.
Lordosis
Lower back significantly curves inward with the pelvis tilting anteriorly (swayback of the lumbar spine)
Flat Back
Loss of the normal curvature of the spine — referred to as "straight back"
Sway Back
Back extends backward, lower back curves inward, pelvis tilts forward, head in front of pelvis — results from loss of muscle tone in abdomen and lower back
Scoliosis
C- or S-shaped lateral curvature of the spine
Cartilage
Firm yet flexible connective tissue found in ears, nose, larynx, ribs, intervertebral discs, knees, and ankles
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 ⚡
✅ 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
Mechanical lift
Slide boards
Staff
2 or more
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
Sit-to-stand lift
Ambulation devices
Staff
2 or more
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
Gait belt
Ambulation devices
Staff
1–2
1–2
Level
4
No Assist
March in place · Step forward & backward → if cannot or requires assistive device: assign Level 3 instead
Equipment
None
None
Staff
0–1
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 ⚡
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
───────────────────
── CODE BLUE · RRT · ICU ──
── TRIAGE · SIEVE · SORT ──
── ASSESS · INTERVENE · STABILIZE ──
───────────────────
── AIRWAY · BREATHING · CIRCULATION ──
───────────────────
── CODE BLUE · RRT · ICU ──
── TRIAGE · SIEVE · SORT ──
── ASSESS · INTERVENE · STABILIZE ──
───────────────────
── AIRWAY · BREATHING · CIRCULATION ──
───────────────────
mod 22b
Introduction to Critical Care and Emergency Nursing
High-acuity assessment, triage systems, code response, and disaster preparedness.
Assessment ToolsTriage SystemsCode Blue & RRTSpecial PopulationsDelirium & MobilityDisasters & ResourcesEnd of Life
Knowledge Acquisition & Critical Care Competence
Benner's Novice to Expert Model ⚡
01
Novice
No experience; follows rules rigidly
02
Adv Beginner
Pattern recognition; needs support
03
Competent
Goal-oriented; deliberate planning
04
Proficient
Holistic view; anticipates changes
05
Expert
Intuitive; situational mastery
Progression through experience, knowledge, and self-actualization — confidence develops at different rates. New nurse missing a skill: ask "What knowledge can I improve upon?"
Critical Care Foundation Skills
- The nursing process & decision-making
- Teamwork, collaboration, clinical judgment
- Client advocacy & client education
- Caring for a diverse group of clients
- One pathway into critical care: Emergency Department (ED)
- Key ED skills: assessment, triage, communication
Legal Aspects — EMTALA & Violence
- Nurses must abide by external and internal regulations
- EMTALA — prevents refusing care to uninsured clients
- ED = highest-risk area for violence against staff, family, clients, visitors
- Contributing factors: stress, anxiety, drugs/alcohol, mental illness, long wait times, fear of diagnosis
Assessment Tools — ABCDEF (ICU) · ABCDE (Trauma) · ESI (ED)
ABCDEF Bundle — ICU Daily Rounds ⚡
A
Assess Pain
Numerical scale, BPS, or CPOT. Assess, treat, evaluate response. Pain is underreported in ICU.
B
Breathing — SAT & SBT
SAT = stop sedatives. SBT = turn vent rate to zero. Goal: wean off ventilator ASAP.
C
Choice of Sedation
Assess ≥ 6×/day via RASS, SAS, or Ramsay. Client should be awake, calm, cooperative before weaning.
D
Delirium Assessment
Assess ≥ 2×/day via CAM-ICU or ICDSC. Incidence 20–80% in ICU. Turn lights off at night.
E
Early Mobility
Ambulate ASAP — prevents 40–58% muscle loss in 7 days. Sedation must be light or off first.
F
Family Engagement
Client & family at center of care. Invite to rounds, bedside procedures, CPR if desired.
RASS: −5 (unarousable) → +4 (combative). Weaning goal = 0 to −1. Paralytics (rocuronium) for acute lung injury/ARDS — nurse must be extremely vigilant; any disruption = respiratory arrest.
ABCDE — Trauma Primary Survey ⚡
Primary = ABCDE (immediate life threats). Secondary = head-to-toe after life-saving interventions. Tertiary = before discharge — catches missed injuries (e.g., hip fracture found during D/C teaching).
Emergency Severity Index (ESI) — Five-Tier ED Triage ⚡
Three-tiered system: Emergent (life-threatening) · Urgent (slightly delayed) · Delayed (stable) — Ex: 3 days of stable GI symptoms, no comorbidities = Delayed.
Triage Systems — SALT & START
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
SALT — Goal & Algorithm
- Greatest good for the greatest number
- Resources go to clients who can be saved
- Sort → Assess → Lifesaving Interventions → Treatment/Transport
- Mass casualty notification: type of incident · casualties · type of injuries expected
SALT Triage Tag Colors ⚡
🟢 Green · Minor
Can follow commands, peripheral pulse, no resp distress, no hemorrhage. Sprains, contusions, lacerations.
🟡 Yellow · Delayed
Meets green criteria + more than minor injuries. Fractures, open wounds, deep lacerations.
🔴 Red · Immediate
Does not meet green but may survive if treated. Neurological injury, shock, major burns.
⬛ Black · Expectant
Dead or not expected to live. Agonal respirations, unsurvivable injuries. Ex: burns + spinal cord injury.
START Algorithm — Decision Tree ⚡
Can the patient walk?
YES →
🟢 GREEN
NO ↓
Spontaneous breathing?
NO → open airway →
🔴 RED (resumes)
|
⬛ BLACK (apnea persists)
YES ↓
Respiratory rate >30/min?
YES →
🔴 RED
≤30 ↓
Perfusion OK? (radial pulse or cap refill ≤2s)
NO →
🔴 RED
YES ↓
Obeys commands?
NO →
🔴 RED
| YES →
🟡 YELLOW
Code Blue, RRT & Handoff Communication
Rapid Response Team (RRT)
- Called before full cardiac arrest — nurse identifies clinical deterioration early
- 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
Code Blue — Team Roles
First Responder
Calls code blue, starts compressions, leads until team arrives
Provider
Becomes team leader at the code cart
Nurse 1
Records all events throughout code
Nurse 2
IV access + medications
RT / Anesthesia
Ventilates the client
Client's Nurse
Manages environment + family communication
Code Cart Check ⚡
Every 24 hours + after every use. TJC requirement.
Code Cart Contents
Defibrillator · BVM · Epinephrine · Amiodarone · Sodium bicarb · Calcium · Glucose · IV supplies · Airway equipment
BLS/ACLS Renewal
Every 2 years. TNCC every 4 years.
Handoff ⚡
Both sending AND receiving nurse mutually responsible for completeness & accuracy. Tool: SBAR.
EMTALA ⚡
All ED pts must be evaluated and stabilized before transfer. COVID: permits transfer of unstabilized pts when ED overwhelmed.
Most Concerning ⚡
Chest pain unrelieved by nitroglycerin = most urgent finding in cardiac history patient
Cardiac key assessment: 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 — Care Phases ⚡
Human Trafficking — Red Flags ⚡
Companion Behavior
Companion refuses to leave patient alone with nurse; answers all questions; won't allow patient to use restroom alone
Physical Findings
Tattoo on inner thigh; bruises near groin/lower abdomen; multiple wounds in various healing stages; appears malnourished
History Clues
Multiple previous abortions; vague/inconsistent injury explanation; lives with many 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; obtain patient consent to intervene; contact social services + National Human Trafficking Hotline
Violence in ED
Fear of possible outcome of clinical situation → stress → aggression. 50%+ of ED nurses experience verbal or physical assault.
Delirium Prevention & Early Mobility
Delirium Facts ⚡
- Acute neurological disorder — 20–80% incidence in ICU
- 30% more common in patients >65
- Can be reversed (unlike dementia)
- Highest risk: elderly + sepsis/pneumonia
- Assess ≥ 2×/day — CAM-ICU or ICDSC tool
Hyperactive vs Hypoactive
Hyperactive
Agitation, restlessness, pulling at lines
Hypoactive ⚠️
Apathy, withdrawn — often missed, worse prognosis
Prevention Strategies ⚡
Early Mobility ⚡
Why ambulate early?
ICU patients lose 40–58% muscle mass within 7 days. Prevents long-term weakness and quality-of-life impact.
Goal ⚡
Ambulate as early as possible — tell family this is the reason.
Postpone When ⚡
On mechanical ventilation AND blood pressure is unstable (Next Gen answer)
Burns: CONTRAINDICATED
Ambulating in hallway is contraindicated. Indwelling catheter, mechanical vent, gastric intubation = indicated. Droplet isolation = unrelated.
Progression
Chair transfer → assisted ambulation. If unable: ROM exercises, neuromuscular electrical stimulation
Team Required
Nurse + RT + PT + pharmacist + provider. Sedation must be light or off before attempting.
Disasters, Chemical Emergencies & Resource Allocation
Chemical Emergency — Decontamination Pipeline ⚡
Chemical spill info → Safety Data Sheets (SDS) on hospital WiFi network. Use PPE until chemical identified.
Burns — Primary Survey Focus
- Assess: burns around mouth/nose, stridor, expectorant with charcoal material, O₂ sat <95%
- Determine % TBSA during primary survey
- Burns >15% TBSA → IV fluid resuscitation
- Smoke inhalation → airway edema → may need mechanical vent
- Give tetanus immunization for burn patients
Emergency Operation Plan (EOP)
- Prepare — stockpile, train, plan before disaster strikes
- Respond — activate plan during disaster
- Recover — restore normal operations after disaster
- Mitigate — reduce impact and risk of future disasters
- Hazard Vulnerability Analysis: facility proximity to hazards; past emergencies
Resource Allocation During Scarce PPE / Disaster ⚡
End of Life, Communication & Resilience
Terminal Patient — PREPARED Model ⚡
First action for life support removal: Prepare in advance how to discuss the situation with the family. Break bad news in small parts; nurse provides empathy, provider answers technical questions.
P
Prepare
for the discussion
R
Relate
to the family
E
Elicit wishes
of patient/family
P
Provide education
about condition/process
A
Acknowledge
emotions
R
Realistic hope
no false promises
E
Encourage
questions
D
Document
discussion & decisions
Dying Patient — Family Communication ⚡
- Work with provider to frequently update family compassionately
- Do not give false hope
- Family presence during resuscitation: allowed and encouraged
- Aid-in-dying (AID): nurse must know state laws — nurse spends most time with patient, best positioned to navigate
- Primary goal of nurse-family interaction: Creating a trusting relationship
Resilience & Professional Identity
- Mindfulness · Compassion for self · Diaphragmatic breathing
- Peer-support sessions · Balance work/life · Decrease social media
- Emotional intelligence
- Imposter syndrome: Belief that accomplishments are luck — self-assessment is key
- Professional autonomy: Independent decisions supported by leadership & 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).
───────────────────
── EQUITY · INCLUSION · JUSTICE ──
── DIGNITY · RESPECT · CULTURE ──
── LEININGER · SUNRISE ENABLER ──
───────────────────
── INTERPRET · ADVOCATE · INCLUDE ──
───────────────────
── EQUITY · INCLUSION · JUSTICE ──
── DIGNITY · RESPECT · CULTURE ──
── LEININGER · SUNRISE ENABLER ──
───────────────────
── INTERPRET · ADVOCATE · INCLUDE ──
───────────────────
mod 26
Inclusion, Equity, and Diversity
Culturally competent care that honors every client's identity and lived experience.
Key ConceptsVulnerable PopulationsEquity & LiteracyMarginalized GroupsSunrise EnablerInterpreters
Key Concepts — Culture, Bias & Competence
Types of Bias ⚡ — both contribute to health disparities
First step to cultural awareness ⚡ — conduct a self-assessment to identify your own biases before attempting to care for a client from a different culture.
Emic vs Etic Knowledge ⚡
🏠
EMIC
INSIDER PERSPECTIVE
Knowledge from a member of the culture — understanding the client's world from the inside out.
Emic = from inside
vs
🌍
ETIC
OUTSIDER VIEWPOINT
Knowledge from an observer outside the culture — a view of the culture from the outside.
Etic = outside
Having both → achieve cultural competence & holistic care
Cultural Awareness → Diversity → Competence (in order)
→
→
+
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.
immigrants
older adults
marginalized ethnic groups
individuals in poverty
chronic illness
veterans ⚡
Who Qualifies? ⚡
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 = higher infection risk
- Race/ethnicity — discrimination → stress → heart disease, DM, Alzheimer's
Health Status
- Chronic conditions (obesity, DM, HTN) → complex complications
- Disabilities → barrier to healthcare access and ADLs
Socioeconomic
- No health insurance = limited access to care
- Lower education → lower health literacy
- Unemployment/low income → choose between basic needs vs. medications
- Employer-based insurance = most common coverage; no job = no insurance
Intersectionality
Multiple simultaneous disparities → greater stress → lower self-esteem → risky behaviors (substance use). Vulnerability compounds when multiple risk factors overlap.
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 ⚡
Equality vs Equity — the key distinction
EQUALITY
Same resources for everyone
Equal ≠ always fair
≠
EQUITY
Resources based on individual need
Accounts for disparity
Factors Affecting Access (Health Disparities)
Transportation
Geographic location
Socioeconomic status
Health insurance
Limited education
Race · Ethnicity
Gender
Sexual orientation
Physical / cognitive 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): Easy-to-understand info · Collaborate · Trusted messengers · Certified interpreters for language barriers
Marginalized Groups — LGBTQ+ & Gender Identity
Marginalized sexual groups = lesbian, gay, bisexual, and those questioning their sexual orientation or gender identity.
Health Risks for LGBTQ+ Youth ⚡
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
🌅
Madeleine Leininger — part of the Theory of Culture Care Diversity and Universality. Developed in the 1950s, published in the 1980s. A visual portrayal of elements that help nurses provide culturally congruent care to enhance health and well-being at all stages of life.
All five categories are interrelated — cannot be separated.
Category 2 — The 8 Rays (Basic Elements) ⚡ — most tested; know all 8
🖥️
Technological
Phone, internet, computer → health communication & education
🕊️
Religious / Spiritual
Religion, spirituality, philosophical worldview → intersects with care needs
🌍
Cultural Values
Lifeways — how client spends their day, what is important, need for assistance
📚
Educational
Highest level of education → determines health literacy. Present info at ≤8th-grade level
⚡ TRICK
"Health disparity factors" is NOT one of the 8 rays. The 4 most tested factors are: Kinship/Social · Biological · Economic · Political/Legal
The 5 Categories of the Sunrise Enabler
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 (above)
Most tested — know all 8 and which are included vs. which are NOT (health disparity factors is the trick).
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
Support existing beliefs
Support existing beliefs
Accommodation
Adapt beliefs for safety
Adapt beliefs for safety
Repatterning
Change beliefs for better outcomes
Change beliefs for better outcomes
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 ⚡
Hearing Loss Communication
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)
Madeleine Leininger
Created the Theory of Culture Care Diversity & Universality (developed 1950s, published 1980s) and the Sunrise Enabler. All 5 categories are interrelated. Assists nurses in planning and providing culturally appropriate nursing care.
Three modes of care ⚡
Preservation (keep beliefs) · Accommodation/Negotiation (adapt beliefs) · Repatterning/Restructuring (change beliefs for better outcomes)
───────────────────
── BLOOD · URINE · STOOL ──
── WOUND · SPUTUM · THROAT ──
── COLLECT · LABEL · TRANSPORT ──
───────────────────
── STERILE · TECHNIQUE · TIMING ──
───────────────────
── BLOOD · URINE · STOOL ──
── WOUND · SPUTUM · THROAT ──
── COLLECT · LABEL · TRANSPORT ──
───────────────────
── STERILE · TECHNIQUE · TIMING ──
───────────────────
specimen
Specimen Collection
Correct technique and order of operations for collecting and handling clinical specimens.
BloodUrineStool / FOBTWound CultureSputum & Throat
Blood Specimens — Venipuncture & Capillary
Venipuncture procedure ⚡
01
Place tourniquet above the site to locate the vein — remove once vein is identified, before cleansing the site
02
Stroke arm gently distal → proximal to dilate the vein — avoid vigorous rubbing (injury risk)
03
Cleanse with approved antiseptic — allow to dry completely before inserting needle. Never puncture while antiseptic is still visible or wet
04
Insert needle → collect blood → withdraw → apply pressure with gauze
05
Document: method used, client tolerance, and pertinent findings
Capillary fingerstick — Do / Don't ⚡
✓ Correct technique
- Wrap finger in warm cloth to increase blood flow — heat causes vasodilation
- Pierce the side of the finger pad — fewer nerve endings, less pain
- Blood glucose 180 mg/dL → administer insulin per sliding scale orders
✗ Avoid these errors
- Elevate the hand — reduces blood flow to the site
- Pierce the middle of the finger pad — painful, more nerve-dense
- Firmly milk the puncture site — hemolyzes the sample
- Give OJ for a glucose of 180 — that raises blood glucose further
Urine Specimens
Collection types & 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 technique ⚡
01
Wash hands; part labia with one hand — maintain hold throughout entire collection
02
Wipe with antiseptic front to back — 3 strokes (left, right, center); new wipe for each stroke
03
Allow initial stream into toilet — flushes urethral meatus bacteria — then collect midstream portion
04
Do NOT hold cup against genitalia. Collect ~30–60 mL. Cap tightly and label immediately. Male: retract foreskin if uncircumcised, wipe center → outward circular, same stream sequence.
Urinalysis — reading the results ⚡
Leukocyte esterase
Positive
⚠ Indicates UTI — WBCs present in urine
Nitrites
Positive
⚠ Suggests bacterial infection
Glucose in urine
Present
⚠ Diabetes mellitus
Ketones
Present
⚠ DM or fat metabolism issue
Specific gravity
1.005 – 1.030
✓ Normal. SG 1.010 is NOT a UTI indicator
pH
4.6 – 8.0
✓ Normal range
Trace protein
Expected
✓ Normal finding — NOT a UTI indicator
Bilirubin / Urobilinogen
Elevated
Liver disease or RBC destruction
Stool Specimens & Fecal Occult Blood Test (FOBT)
What to avoid before FOBT ⚡
Avoid 3 days before & during
Red meat
Poultry
Fish / Seafood
Raw vegetables
Radishes / Turnips
Vitamin C supplements
These cause false positives
Avoid 7 days before ⚡
NSAIDs
Aspirin
Anticoagulants (warfarin)
Mineral oil / Laxatives
These irritate GI lining → GI bleeding
✓ Safe — no need to avoid
Yogurt
Calcium supplements
Vitamin E
FOBT key rules & stool collection procedure ⚡
FOBT (Guaiac) — Key Rules
- Screening tool for colorectal cancer, GI bleeding, ulcers, polyps
- Recommended age: >50 years old without symptoms
- Collect from 3 different stools — home testing is more accurate than one-time office test
- Positive result = blue color on test card → provider orders further diagnostics
Stool Collection Steps
01
Have client urinate first — prevents urine from contaminating the specimen
02
Collect in dry, clean container — not contaminated by water, urine, or toilet paper
03
Use tongue blade / wooden stick to transfer — sample size: walnut-sized or 15–30 mL liquid stool
04
Add preservative if required (keeps parasites alive). Label and send — C. difficile, O&P may need multiple samples
Wound Culture Specimen
Collection procedure ⚡
01
Hand hygiene → don clean gloves
02
Remove dressing; clean wound with sterile water or normal saline — NOT antiseptic
03
Use a sterile swab — collect from the center of the wound or area of drainage using a rotating motion over viable tissue
04
Place swab in sterile culturette — break ampule at bottom to activate transport medium. One swab per site.
05
Label and send promptly. Collect before starting antibiotics if possible — if already on antibiotics, note it on the lab requisition form
Where to swab — Do / Don't ⚡
✓ Correct swab sites
- Center of the wound bed
- Area of active drainage
- Viable tissue — rotating motion ensures organisms are captured
- Use a separate swab for each wound or wound site
✗ Never collect from
- Wound edges — colonized with external skin flora → misleading results
- Crusty area around the outside of the wound
- Pools of pus / pooled exudate
- Do NOT use the same swab on more than one location
Sputum & Throat Specimens
Sputum collection procedure ⚡
01
Rinse mouth with water before collection — reduces oral flora contamination
02
Instruct client to take several deep breaths and then cough deeply — sputum must come from the lungs, not saliva or postnasal drip
03
If client cannot produce sample → try chest physiotherapy first (loosens secretions). Nasotracheal suctioning = last resort
04
Nurse wears N95 respirator if TB is suspected — sputum collection is aerosolizing → requires airborne precautions
Sputum lab test types ⚡
Routine Culture
Sterile container
Identifies bacteria causing the lung infection
Identifies bacteria causing the lung infection
AFB — Acid-fast Bacilli
Sterile container
3 serial samples on separate days → detects TB
3 serial samples on separate days → detects TB
Cytology
Special preservative container
Identifies type of lung cancer — small cell, oat cell, large cell
Identifies type of lung cancer — small cell, oat cell, large cell
Culture & Sensitivity
Identifies bacteria + which antibiotic is most effective
Throat culture — swab technique
✓ Correct swab path
- Right tonsil → right arch → uvula → left arch → left tonsil in one continuous sweep
- Point-of-care tests are less accurate than lab culture — confirm positive POC results with lab
- Gum specimen: lightly scrape inside of cheek (separate procedure)
✗ Do NOT touch
- Gums — normal oral flora contaminates results
- Tongue — normal oral flora contaminates results
- Teeth — normal oral flora contaminates results
Exam High-Yield Summary
🩸 Blood
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 — never while visible/wet
🧪 Urine
Random urine: appropriate for
Routine urinalysis — NOT for culture & sensitivity or 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
UTI urinalysis finding
Leukocyte esterase — trace protein & SG 1.010 are normal, NOT UTI signs
Urine: if not sending immediately
Refrigerate — transport within 2 hours; unrefrigerated = invalid
Confirm urine pregnancy
Follow up with blood β-hCG test — urine can give false results
💩 Stool / FOBT
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
🩹 Wound Culture
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
🫁 Sputum & Throat
Sputum: best time to collect
Morning, before eating or drinking
Sputum: can't produce → do first
Chest physiotherapy — suctioning is last resort
AFB (TB) sputum test requires
3 serial samples in sterile containers on separate days
TB sputum: nurse PPE
N95 respirator — surgical mask is NOT adequate
───────────────────
── O₂ · CO₂ · VENTILATION ──
── PERFUSION · GAS EXCHANGE ──
── SpO₂ · PaO₂ · PaCO₂ ──
───────────────────
── HYPOXIA · HYPOXEMIA · COPD ──
───────────────────
── O₂ · CO₂ · VENTILATION ──
── PERFUSION · GAS EXCHANGE ──
── SpO₂ · PaO₂ · PaCO₂ ──
───────────────────
── HYPOXIA · HYPOXEMIA · COPD ──
───────────────────
mod 34
Gas Exchange and Oxygenation
Respiratory anatomy, physiology, oxygenation disorders, and airway management.
AnatomyVolumes & COPathophysiologyAssessmentO₂ TherapyInterventions
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
- O₂ transported by hemoglobin in RBCs
- Parasympathetic → bronchoconstriction · Sympathetic → bronchodilation ⚡
- ↑ airway resistance → ↑ work of breathing (asthma, COPD)
Pulmonary Circulation Pathway
- Deoxygenated blood: RV → tricuspid valve → pulmonary valve → pulmonary trunk → pulmonary arteries → lungs (CO₂ eliminated at alveoli)
- Oxygenated blood: pulmonary venules → pulmonary veins → left atrium → mitral (bicuspid) valve → LV → aortic valve → aorta → systemic circulation
- The pulmonary vein returns oxygenated blood to the left atrium
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
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
───────────────────
── AUTONOMY · BENEFICENCE ──
── NONMALEFICENCE · JUSTICE ──
── FIDELITY · VERACITY ──
───────────────────
── RIGHTS · CONSENT · ETHICS ──
───────────────────
── AUTONOMY · BENEFICENCE ──
── NONMALEFICENCE · JUSTICE ──
── FIDELITY · VERACITY ──
───────────────────
── RIGHTS · CONSENT · ETHICS ──
───────────────────
mod 8
Ethical and Legal Considerations
Professional obligations, client rights, and the legal boundaries of nursing practice.
Ethics & ValuesLegal FrameworkPractice Issues
What Is Ethics?
Ethics — the process of making decisions, choosing right from wrong, and acting within one's individual values. Each person has their own set of personal ethics and morals. Understanding personal values and those of clients provides clarification of each other's perceptions and plays an important role in professional nursing practice's ethical compliance.
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
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
ANA Social Media Principles (6)
1
Do not transmit/post identifiable client information
2
Maintain professional boundaries if communicating with client via social media
3
Expect posted info may be viewed by client, peers, supervisors
4
Use privacy settings; keep personal vs. professional accounts separate
5
Advocate for client rights; report social media violations
6
Work with employer to develop effective social media policies
Tort Law
Tort = act or omission causing legally cognizable harm
Unintentional Torts (no intent to harm)
Malpractice
Nurse fails to meet standards of care
Negligence
Breach of duty of care → client injury/suffering
Intentional Torts
⚡ Assault
Client made to feel fearful of harm/offensive contact (e.g., threatening with restraints)
⚡ Battery
Act resulting in harm/injury — illegal restraint, inappropriate touching, wrong body part operated on. Usually a criminal offense.
Defamation
False statements that damage reputation
Invasion of Privacy
Protect yourself: research malpractice coverage · follow facility rules · know your state Nurse Practice Act · put client first
Informed Consent & Advance Directives
Informed Consent
⚡ Provider's responsibility to obtain consent — NOT the nurse
Provider must disclose:
- Proposed procedure & who will perform it
- Purpose, expected outcomes, benefits, risks
- Alternatives & their benefits/risks
- Right to refuse
Nurse's role:
- ⚡ Witness client/legal rep signature
- Verify client has adequate knowledge to decide
Implied Consent
Client action implies consent (e.g., extending arm for BP). Can be withdrawn at any time. Client must have mental capacity. Emergency: if delay poses greater risk, consent implied.
Minor consent: Title X — sexual/reproductive health to adolescents without parental consent (varies by state)
Advance Directives
Written legal documents for client's healthcare decisions. Federal law requires facilities to provide forms.
Living Will
Documents specific life-sustaining treatment wishes if the client becomes incapacitated
Durable Power of Attorney for Health Care
Appoints individual (health care surrogate) to make decisions if client is unable
Key Facts
- ⚡ Client can choose ANY person as surrogate — not required to be a family member
- ⚡ Client can change advance directives at any time
- ⚡ No attorney required to complete
Nurse's role: promote development · discuss importance · determine literacy · coordinate referrals · communicate status to care team
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:
- Consult board of nursing and possibly legal counsel BEFORE reporting
- Gather all data and documentation
- 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
───────────────────
── RIGHT DRUG · DOSE · ROUTE ──
── RIGHT TIME · RIGHT PATIENT ──
── ASSESS · ADMINISTER · EVALUATE ──
───────────────────
── IV · IM · SQ · PO · SL ──
───────────────────
── RIGHT DRUG · DOSE · ROUTE ──
── RIGHT TIME · RIGHT PATIENT ──
── ASSESS · ADMINISTER · EVALUATE ──
───────────────────
── IV · IM · SQ · PO · SL ──
───────────────────
mod 21
Medication Administration
Safe drug delivery — from pharmacokinetics and the rights of medication to IV therapy and dose calculations.
PharmacokineticsDrug EffectsRights & SafetyRoutesInjectionsIV TherapyCalculations
Pharmacokinetics — ADME
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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)
- Displace skin & SubQ tissue 1–1.5 inches laterally with nondominant hand
- Insert needle at 90° — quick, darting motion
- Inject slowly and smoothly
- Hold 10 seconds to allow dispersal
- Withdraw needle; immediately release skin
- Activate safety device; cover with dry gauze
- 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 ⚡
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.
Dosage Calculations
📐 The Formula Method
Used when calculating the same units of measure for drug calculations. The volume or actual dose is calculated based on this formula; the dose equals the amount to be given.
Dose Ordered (desired) × Quantity (tablet or mL)
Available Dosage (what is on hand)
Convert units to the same measurement system before applying the formula. If units differ, convert first (e.g., g → mg: multiply × 1,000; mg → g: divide by 1,000).
Common Conversions ⚡
- 1 g = 1,000 mg — move decimal 3 places RIGHT to go g → mg
- 1 kg = 2.2 lb — divide lbs by 2.2 to get kg
- 1 oz ≈ 30 mL · 1 cup = 8 oz = 240 mL
- 1 tsp = 5 mL · 1 tbsp = 15 mL
Time-Critical vs. Non-Time-Critical
- Time-critical ⚡: administering ±30 min of scheduled time can cause harm or subtherapeutic effect
- Non-time-critical: can be given 1–2 hr early or late without causing harm or substandard pharmacological effect
- Each facility sets its own policy per CMS regulations
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
───────────────────
── HR · BP · RR · TEMP · SpO₂ ──
── SYSTOLIC · DIASTOLIC · MAP ──
── ASSESS · MEASURE · REPORT ──
───────────────────
── TACHYCARDIA · HYPERTENSION ──
───────────────────
── HR · BP · RR · TEMP · SpO₂ ──
── SYSTOLIC · DIASTOLIC · MAP ──
── ASSESS · MEASURE · REPORT ──
───────────────────
── TACHYCARDIA · HYPERTENSION ──
───────────────────
mod 24
Vital Signs & Patient Safety
Measuring and interpreting the body's key physiological indicators — and keeping clients safe.
OverviewCardiacBlood PressurePulseTemperatureRespirationsSpO₂Pain
Vital Signs — Quick Reference Dashboard
🩺 Blood Pressure
<120/80
mmHg · adult normal
90/60HypoCrisis
💗 Pulse
60–100
/min · adult
<60 bradynormal>100 tachy
🌡️ Temperature
36–38°C
96.8–100.4°F
HypoNormalFever
💨 Respirations
12–20
/min · adult
<12 bradynormal>20 tachy
🫁 SpO₂
95–100%
O₂ saturation
<90 critical<95 low100%
⚡ Delegation Rules — Know These Cold
✅ Delegate to AP
client conditionStable; condition established by RN
routine VSKnown stable clients
pulseRadial rate only
blood pressureElectronic BP · stable client · normal reading
🚫 RN Only
client conditionUnknown, unstable, or acute change
routine VSRechecking abnormal VS
pulseFull peripheral pulse assessment
blood pressureNew chest pain — nurse takes vitals ⚡
⚡ Documentation Requirements
🩺 Blood PressuremmHg · site (arm L/R or thigh) · client position (sitting / lying / standing)
💗 Pulserate · rhythm · strength · equality · site (radial or apical)
🫁 SpO₂% · site · O₂ source — room air or supplemental ⚡
🌡️ Temperature°C or °F · method and site used
💨 Respirationsrate · depth · rhythm · effort · client position
⚡ All VSdate · time · any interventions done · client response
Cardiac Physiology
Cardiac Output Formula
CO = SV × HR
Cardiac Output = Stroke Volume × Heart Rate
↑ CO→↑ Blood Pressure
↓ CO→↓ Blood Pressure
↓ SV or ↓ HR→↓ CO → ↓ BP
Cardiac Physiology Terms
Stroke Volume
SV
Blood ejected per ventricular contraction · ↓ SV → ↓ CO → ↓ BP
Preload
volume before contraction
Volume in ventricles before contraction · blood loss → ↓ preload → ↓ SV
⚡ Afterload
resistance to pump
Resistance heart must overcome · ↑ afterload → ↑ BP; HTN → hypertrophy → ↓ contractility
⚡ Contractility
force of contraction
Efficiency of heart contraction · ↓ O₂ or electrolyte imbalance → ↓ contractility → ↓ CO
BP Determinants
↑ Cardiac output→↑ BP
↑ Blood volume→↑ BP · hemorrhage → ↓ BP
↑ Blood viscosity→↑ resistance → ↑ BP
↓ Vessel elasticity→↑ rigidity → ↑ BP (atherosclerosis)
↑ Peripheral vascular resistance→↑ BP
⚡ Blood Flow Path — Memorize
Vena Cava
→
Right Atrium
→
Tricuspid Valve
→
Right Ventricle
→
⚡ Pulmonary Artery
→
Lungs (O₂ loaded)
→
Pulmonary Vein
→
Left Atrium
→
Mitral Valve
→
Left Ventricle
→
Aorta → Body
Right side = deoxygenated blood. Left side = oxygenated blood. Deoxygenated blood leaves right ventricle via pulmonary artery — high-yield.
Heart Sounds & Valve Sites
| Sound / Valve | What Closes | Location / Note |
|---|---|---|
| S1 "lub" | AV valves (mitral + tricuspid) | Start of systole · best with bell |
| ⚡ S2 "dub" | Semilunar valves (aortic + pulmonic) | Start of diastole · best with diaphragm |
| Aortic | — | 2nd ICS, right of sternum |
| Pulmonic | — | 2nd ICS, left of sternum |
| Tricuspid | — | 4th ICS, left of sternum |
| ⚡ Mitral (PMI) | — | 5th ICS, left midclavicular line |
⚡ SA Node — Pacemaker
Sets both rate & rhythm of the heartbeat — electrical impulse path:
⚡ SA Node
→
AV Node
(relays + delays)
→
Bundle of His
→
Ventricles contract
SA node located in right atrium; backup pacemaker = AV node if SA node fails.
Blood Pressure
Blood pressure spectrum — adult
90120130140160180+
Normal <120/80
Elevated 120–129/<80
HTN Stage 1 130–139/80–89
⚡ HTN Stage 2 ≥140/≥90
Crisis >180/>120
⚡ BP Classification — Adult
| Category | Systolic (mmHg) | And/Or | Diastolic (mmHg) |
|---|---|---|---|
| Normal | <120 | AND | <80 |
| Elevated | 120–129 | AND | <80 |
| HTN Stage 1 | 130–139 | OR | 80–89 |
| ⚡ HTN Stage 2 | ≥140 | OR | ≥90 |
| Hypertensive Crisis | >180 | AND/OR | >120 |
Diagnosis requires 2+ elevated readings on 2+ separate occasions. Hypotension = SBP <90 OR DBP <60.
Pediatric Blood Pressure Reference Values
| Age | Average (50th %ile) | HTN Threshold (95th %ile) |
|---|---|---|
| Newborn (full term) | 64/41 | N/A |
| Toddler | 85–91/37–46 (M) · 86–89/40–49 (F) | >103–109/56–65 (M) · >104–107/58–67 (F) |
| Preschooler | 91–98/46–53 (M) · 89–93/49–54 (F) | >109–112/65–72 (M) · >107–110/67–72 (F) |
| School-age | 96–106/55–62 (M) · 94–105/56–62 (F) | >114–123/74–81 (M) · >111–123/74–80 (F) |
| Adolescent | <120/80 | N/A (same criteria as adult) |
Pediatric HTN: BP at or above 95th percentile on 3 separate visits (healthy BMI).
⚡ Measurement Technique
Cuff size ⚡
Width = 40% of arm circumference · too narrow → falsely HIGH · too wide → falsely LOW
Arm position ⚡
At heart level · below = falsely high · above = falsely low · unsupported → falsely high
⚡ Sleeves
Do NOT roll up — constricts flow → falsely HIGH
⚡ Deflation rate
2 mmHg/sec correct · 5 mmHg/sec = too fast · common wrong-answer trap
Inflation
30 mmHg above expected systolic · wait ≥1 min between readings on same arm
Wait times
30 min after caffeine, nicotine, or exercise before assessing
Two-step method
Palpate brachial → estimate systolic → deflate → wait 1 min → auscultate
Palpation method
Inflate 30–50 mmHg above pulse disappearance · thrill returns = systolic
White coat syndrome
Clinical anxiety → temporary ↑ BP · build rapport, allow rest before reassessing
⚡ Korotkoff Sounds
K1
First thump
Clear, sharp tapping sound
⚡ Systolic BP
K2
Whooshing
Swooshing / swishing murmur
K3
Knocking
Crisper, louder knocking
K4
Muffled
Softer, fading
diastolic if K5 absent ⚡
K5
Silence
Sounds fully disappear
⚡ Diastolic BP
Pulse pressure = Systolic − Diastolic · normal 30–50 mmHg · e.g. 130/85 → PP = 45 mmHg
Site Selection
| Scenario | Action |
|---|---|
| Avoid | Mastectomy side · AV shunt · peripheral IV · acute injury · severe edema |
| ⚡ Both arms unavailable | Use thigh (popliteal artery) — reads 10–40 mmHg higher |
| Use manual method | Children · older adults · critical clients · abnormal readings |
| Electronic OK | Stable clients with normal readings only |
Orthostatic Hypotension
DefinitionSBP drop ≥20 mmHg OR DBP drop ≥10 mmHg within 1 min of standing
CausesDehydration · HF · CNS disorders · prolonged bed rest · medications
⚡ InterveneChange positions slowly · recheck at 3 min if symptoms persist
SequenceAssess: lying → sitting → standing
⚡ Hypertension — Lifestyle Interventions (NCLEX Favorite)
🥗 Low-sodium diet
High Na → fluid retention → ↑ BP
🚶 Daily exercise
Physical activity ↓ BP
🧘 Relaxation
↓ Stress → ↓ HR → ↓ BP
🚭 No nicotine
Stimulant → vasoconstriction → ↑ BP
❌ NOT: ↑ fluids
Increasing fluid intake is NOT a HTN intervention
HTN Complications
signsOften asymptomatic until organ damage occurs
organ targetsStroke · MI · kidney failure · retinopathy · atherosclerosis
interventionsLifestyle changes · antihypertensives · monitor for complications
educationDASH diet · exercise · medication adherence · provide info about antihypertensive medications including expected adverse effects and when to notify provider
Shock / Hypotension
signsDizziness · nausea · blurred vision · cold/pale skin · rapid breathing · weak & rapid pulse · fatigue
effects↓ CO → activity intolerance · chest pain on exertion
interventionsIncrease fluids · place in supine position (unless contraindicated) · evaluate current medications · IV fluids or blood products · vasopressors · compression stockings
educationChange positions slowly · stay well hydrated · avoid extremes in temperature · instruct about risk for dizziness and falling
Pulse
Expected Pulse Rates by Age
| Age Group | Normal (/min) | Tachycardia | Bradycardia |
|---|---|---|---|
| Newborn (0–28d) | 110–160 | >160 | <110 |
| Infant (1mo–1yr) | 90–160 | >160 | <90 |
| Toddler (1–3yr) | 80–140 | >140 | <80 |
| Preschooler (3–6yr) | 70–120 (75–129 ATI) | >120 | <70 |
| School-age (6–12yr) | 60–110 | >110 | <60 |
| Adolescent (12–20yr) | 50–100 | >100 | <50 |
| Adult (≥20yr) | 60–100 | >100 | <60 |
Tachycardia >100/min
causesExercise · anxiety · fever · caffeine · nicotine · blood loss · meds
symptomsPalpitations · anxiety · chest discomfort
⚡ priorityValsalva maneuver — "bear down" → stimulates vagus nerve → ↓ HR
otherRelaxation · limit caffeine · no nicotine · recheck 15–30 min
Bradycardia <60/min
causesHypothyroidism · HF · ↑ ICP · opioids · trained athletes (normal)
symptomsDizziness · fatigue · dyspnea · confusion · chest pain
⚡ priorityFall prevention first — instruct: call for help before getting up ⚡
otherChange positions slowly · medications as prescribed · notify provider
⚡ Apical Pulse Location
Adults & Children >7yr ⚡
5th ICS
Left midclavicular line (PMI)
Infants & Children <7yr ⚡
4th ICS
Left of sternum
Irregular / medsCount 1 full minute
Regular rhythmCount 30 sec × 2
Finding PMIAngle of Louis → 2nd ICS → down to 5th ICS → midclavicular
⚡ Pulse Strength Scale
0
Absent — nonpalpable; use Doppler (DUS)
+1
Weak / diminished — unexpected; assess further
+2
Normal — expected, easy to palpate
+3
Strong / full — increased; monitor
+4
Bounding — unexpected → report to provider
Pulse Deficit
MethodApical − radial, counted simultaneously by 2 nurses for 1 full minute
ExampleApical 106 − radial 93 = deficit 13/min
CausesAtrial fibrillation · coronary artery disease · aortic rupture
ActionDocument numeric deficit; notify provider
Peripheral Pulses & Assessment
Sites (8)Temporal · carotid · brachial · radial (most common) · femoral · popliteal · dorsalis pedis · posterior tibial
TechniquePads of 2–3 fingers; gentle pressure (too much obliterates pulse)
BilateralCompare both sides — should be equal in strength
⚡ NonpalpableUse Doppler ultrasound stethoscope (DUS)
TimingRest 15–30 min after activity before assessing
⚡ ↑ Pulse: fever, exercise, anxiety, pain, caffeine, nicotine, blood loss, ↓ O₂. | ↓ Pulse: opioids, sedatives, sleep, physical fitness, hypothyroidism, ↑ ICP.
Body Temperature
Thermoregulation
Heat production: metabolism, physical activity, shivering
Heat Loss Mechanisms
Conduction
Direct contact with cooler surface (ice pack)
Convection
Heat carried away by air currents (fan)
Evaporation
Sweat drying from skin lowers temperature
⚡ Radiation
Heat loss to cooler surface without direct contact (near cold window)
Temperature Alterations
🔥 Fever
>38°C (100.4°F)
Hypothalamus set point rises; client is "febrile." Most common cause: infection
Hyperthermia
uncontrolled rise
Hypothalamus unable to regulate · environmental heat or metabolic — NOT infection
🧊 Hypothermia
abnormally low core temp
Prolonged cold exposure or inadequate heat production
⚡ Older Adults
>37.2°C OR >1.1°C above baseline
Lower baseline temp; may not mount high fever even with significant infection
⚡ Temperature Sites — Know Advantages & Contraindications
| Site | Type | Advantages | Limitations / Contraindications |
|---|---|---|---|
| Oral | Surface | Easy access regardless of position | ⚡ Avoid within 30 min of eating, drinking, smoking; not for infants/young children |
| Tympanic | Core | Fast (<5 sec); core temp; unaffected by env. temp | ⚡ Pull pinna up & back (>3yr), down & back (<3yr); avoid with cerumen, ear infection |
| Temporal Artery | Core | Infrared scan; all ages; reflects rapid core temp changes; no injury risk | Moisture/sweat on skin → inaccurate; remove head covering/hair from forehead |
| Axillary | Surface (~0.5°C lower than oral) | Safe; all ages; no injury risk | Slower; does NOT reflect rapid core changes; affected by environmental temp |
| Rectal | Core (~0.5°C higher than oral) | Reliable; good for unconscious or diaphoretic | Avoid: diarrhea, hemorrhoids, rectal surgery, coagulopathy; ⚡ insert 1 inch adult, ½ inch infant/child |
Other Thermometer Types
| Type | Routes / Placement | Notes |
|---|---|---|
| Chemical Dot (Strip) | Oral · axillary · rectal (sheath required) | Plastic strip with chemical dots that change color; single- or multi-use; inexpensive, unbreakable — good for isolation rooms |
| Adhesive Patch / Tape | Forehead or abdomen | Liquid crystals change color; smart patches transmit wirelessly; ⚡ environmental temp alters reading — ensure neutral environment; inspect skin before & after |
⚡ Site Selection — Clinical Scenarios
| Condition | Avoid | Preferred Site |
|---|---|---|
| Diaphoretic + chewing ice | Tympanic / temporal / oral | Rectal |
| Ear infection or cerumen buildup | Tympanic | Oral · axillary · temporal |
| Post-hemorrhoidectomy | Rectal | Oral · tympanic · temporal |
| Infant < 3 yr | Tympanic (ear canal angle) | Axillary or temporal |
| Diaphoretic (moisture present) | Temporal artery | Rectal · oral |
| Mouth-breathing or oral surgery | Oral | Rectal · axillary · tympanic |
⚡ Fever Interventions
primaryAntipyretics (acetaminophen, ibuprofen) — first-line
clothingRemove excess clothing and blankets
environmentFan (convection); cool packs to neck, axillae, groin
sponge bathTepid — NOT alcohol (avoid isopropyl) ⚡
fluidsEncourage oral fluids; monitor frequently
🧊 Hypothermia Interventions
primaryWarming blanket or mat (forced air unit)
clothingAdd layers; cover head with cap
environmentIncrease room temperature
sponge bath—
fluidsWarmed IV fluids (if prescribed) · newborns → radiant warmer
Respirations
Expected Respiratory Rates by Age
| Age Group | Normal (/min) | Tachypnea | Bradypnea |
|---|---|---|---|
| Newborn (0–28d) | 30–60 | >60 | <30 |
| Infant (1mo–1yr) | 25–60 | >60 | <25 |
| Toddler (1–3yr) | 24–40 (ATI: 25–30) | >40 | <24 |
| Preschooler (3–6yr) | 22–34 (ATI: 20–25) | >34 | <22 |
| School-age (6–12yr) | 18–30 (ATI Engage) | >30 | <18 |
| Adolescent (12–20yr) | 16–20 | >20 | <16 |
| Adult (≥20yr) | 12–20 | >20 | <12 |
Respiratory Patterns — Waveform Reference
Eupnea
Normal
Normal RR 12–20/min, regular rhythm; silent, effortless breathing
Tachypnea
Fast + Shallow
RR above normal, often shallow; fever, pain, anxiety, pneumonia, asthma
Bradypnea
Slow
RR below normal; opioids, sedatives, ↑ ICP, hypothyroidism, alcohol
Apnea
⚠ Emergency
Complete cessation of breathing; persistent = respiratory arrest — medical emergency
Cheyne-Stokes
HF / ↑ ICP
Crescendo → deep hyperventilation → apnea cycle; HF, ↑ ICP, stroke; may precede death
Kussmaul
Acidosis/DKA
Deep, rapid, regular; no apnea; metabolic acidosis (DKA), severe kidney disease, sepsis
Biot's
CNS / Brainstem
Irregular clusters (slow + deep OR rapid + shallow) then apnea; brainstem injury/lesion
⚡ Assessment Technique — Key Rules
⚡ Conceal assessment
Never tell the client — they'll consciously alter breathing; keep fingers on wrist as if taking pulse
⚡ Position
Elevate HOB 45–60° — allows full chest expansion; reduces discomfort
Timing
30 sec × 2 regular · 1 full minute irregular / ill / respiratory infection
What to assess
Rate · depth (chest-wall movement) · rhythm · effort
Retractions
Accessory muscle use = ↑ work of breathing → report immediately
⚡ ↑ RR causes
Fever · pain · anxiety · nicotine · activity · ↑ ICP · infection
⚡ ↓ RR causes
Opioids · sedatives · brainstem injury
Oxygen Saturation (SpO₂ / SaO₂)
Key Facts
SaO₂O₂ bound to Hgb in arterial blood — actual invasive measurement
SpO₂Pulse oximetry estimate — non-invasive; reflects O₂ delivered to tissues
Normal95–100%
<95%Assess · intervene · notify provider
⚡ Pigmented skinMay affect accuracy; always correlate with other clinical data
Low SpO₂ — Causes & Signs
RespiratoryPneumonia · COPD · asthma · chronic lung disease
SystemicHypothermia · ↓ cardiac output
⚡ Key signDyspnea — key manifestation of low SpO₂
Other signsTachycardia · confusion · frequent cough
Hypoxia vs -emiaHypoxia = low O₂ in tissues · Hypoxemia = low O₂ in blood
⚡ Pulse Oximetry — Steps in Order
Step 1
Select site
Capillary refill <2 sec; finger most common in adults
Step 2
Apply probe
Remove dark nail polish; client must not move
Step 3 ⚡
Confirm radial pulse
Palpated rate must match oximeter; if not → move probe
Step 4
Wait 15–30 sec
Read consistent SpO₂ % on display
Interventions for Low SpO₂
⚡ FirstUpright position — increases thoracic expansion
AirwayDeep breathing + coughing (clears secretions)
O₂ / MedsSupplemental O₂ · bronchodilators (if prescribed)
MonitorContinuous SpO₂ if critically low; notify provider if persistent
Factors Affecting Accuracy
Dark nail polishChoose a different site
Poor perfusionHypothermia · vasoconstriction → correlate with clinical signs
MovementInstruct client to remain still
Hypotension / edemaReposition probe to a better site
⚡ VerifyOximeter rate must match palpated radial pulse
⚡ Document% · site · O₂ source (room air or supplemental)
Pain — The 5th Vital Sign
Key Concept
Pain is often considered a fifth vital sign, assessed alongside temperature, pulse, respiration, and blood pressure. Because pain affects clients' physical, emotional, and mental well-being, it must be managed immediately and effectively.
No pain
Mild (1–3)
Moderate (4–6)
Severe (7–10)
Acute Pain
Severe, rapid onset, short duration; resolves as healing occurs
→ Treat promptly; address underlying cause
Chronic Pain
Persists beyond expected healing, often >6 months
→ Regular schedule (not PRN only) is most effective
Cancer Pain
Acute, chronic, or intermittent; from tumor growth / tissue necrosis
→ Both pharmacological + nonpharmacological interventions
Manage on individual basis — each client's experience is unique. Use the same scale consistently for valid comparisons.
⚡ Pain Assessment Tools — by Age & Ability
Preterm & Term Neonates
CRIES
Behavioral + physiological indicators; 3-point scale
Pediatric
FACES / OUCHER
Client points to face matching their pain level
Teens & Adults — most common ⚡
Numerical 0–10
0 = no pain · 10 = worst possible pain
Older Adults
Descriptor
Verbal: mild / moderate / severe / none
Cognitively Impaired / Nonverbal
Nonverbal / Behavioral
Facial expressions · behavior · moaning · unexpected movements
Exam High-Yield Summary
ABC priority ⚡
SpO₂ 92% = see this client first — airway/breathing takes priority over elevated BP, pulse alone, or mildly low temp
Delegation ⚡
New chest pain → nurse takes vitals, not AP; acute change in condition is never delegated to AP
SpO₂ documentation ⚡
"SpO₂ 97% right index finger, room air" = complete; must include site AND O₂ source
BP documentation ⚡
Must include site (e.g., left arm) and client position; incomplete without site
Electronic BP ⚡
Abnormal reading → get manual BP first, then notify provider; electronic only for stable clients with normal readings
BP release rate ⚡
2 mmHg/sec is correct; 5 mmHg/sec = too fast → requires follow-up; common wrong-answer trap
Bradycardia + dizziness ⚡
Priority = fall prevention — instruct to call for help before getting up; comes before teaching or medication review
Valsalva maneuver ⚡
"Bear down" as if having a BM → stimulates vagus nerve → ↓ HR; used for tachycardia
Respiration count ⚡
Never tell client you are counting RR — they will alter breathing; count while appearing to take pulse
Tympanic thermometer ⚡
Pinna: up & back (>3yr) · down & back (<3yr); straightens ear canal for tympanic membrane access
Apical location ⚡
<7yr = 4th ICS left of sternum · ≥7yr = 5th ICS left midclavicular line (PMI)
S1 & S2 ⚡
S1 "lub" = AV valves close (mitral + tricuspid); S2 "dub" = semilunar valves close (aortic + pulmonic); bell for S1, diaphragm for S2
Pulse pressure ⚡
Systolic − diastolic; normal 30–50 mmHg; e.g., 130/85 → PP = 45; reflects cardiac function & blood volume
SA node ⚡
SA node = pacemaker of the heart; located in right atrium; impulse travels to AV node → ventricles contract
Blood flow ⚡
Deoxygenated blood: right ventricle → pulmonary artery → lungs; oxygenated blood: pulmonary vein → left atrium → mitral valve → left ventricle → aorta
CO & afterload ⚡
↑ afterload → ↑ BP · ↓ contractility → ↓ CO → ↓ BP · CO = SV × HR; ↓ preload (blood loss) → ↓ SV → ↓ BP
Orthostatic hypotension ⚡
SBP drop ≥20 mmHg OR DBP drop ≥10 mmHg within 1 min of standing; recheck at 3 min if symptoms persist
HTN diagnosis ⚡
Requires 2+ elevated readings on 2+ separate occasions; single reading does not diagnose HTN
HTN classification ⚡
Elevated: 120–129/<80 · Stage 1: 130–139 OR 80–89 · Stage 2: ≥140 OR ≥90 · Crisis: >180 and/or >120
Nicotine ⚡
Nicotine → ↑ HR + ↑ BP + vasoconstriction; also ↑ RR; wait 30 min before assessing VS after smoking
Fever effect ⚡
Fever → ↑ RR AND ↑ HR (↑ metabolic demand); fever >38°C (100.4°F); most common cause = infection
Respiratory patterns ⚡
Biot's = CNS anomaly (brainstem) · Cheyne-Stokes = HF / ↑ ICP · Kussmaul = metabolic acidosis (DKA)
Cuff size & technique ⚡
Cuff width = 40% of arm circumference; too narrow → falsely HIGH; too wide → falsely LOW; do not roll up sleeves
Palpation BP method ⚡
Inflate 30–50 mmHg above where pulse disappears; pulsatile thrill returns = systolic; used when auscultation is difficult
Pulse strength ⚡
+4 bounding = unexpected → report · +2 = normal · +1 = weak · 0 = absent → use Doppler (DUS)
Pulse deficit ⚡
Apical − radial, counted simultaneously by 2 nurses for 1 full minute; causes: A-fib, CAD, aortic rupture
Oral temperature ⚡
Probe in posterior sublingual pocket, lateral to midline; wait 30 min after eating, drinking, or smoking
Rectal temperature ⚡
Insert 1 inch (2.5 cm) for adults · ½ inch for infants/children; avoid with diarrhea, hemorrhoids, rectal surgery
Older adult temp ⚡
Lower baseline; fever threshold = >37.2°C OR >1.1°C above usual temp; may not mount high fever even with infection
SpO₂ steps ⚡
Select site → apply probe → confirm radial pulse matches oximeter → wait 15–30 sec for consistent reading
Pain — 5th vital sign ⚡
CRIES (neonates) · FACES/OUCHER (pediatric) · Numerical 0–10 (teens/adults) · Descriptor (older adults); manage on regular schedule, not PRN only
Cardiac valve sites ⚡
Aortic: 2nd ICS right · Pulmonic: 2nd ICS left · Tricuspid: 4th ICS left · Mitral (PMI): 5th ICS left midclavicular
White coat syndrome
Anxiety in clinical setting → temporary ↑ BP; build rapport and allow client to rest before reassessing
───────────────────
── CONTACT · DROPLET · AIRBORNE ──
── PPE · GLOVES · MASK · GOWN ──
── HAND HYGIENE · ASEPSIS ──
───────────────────
── ISOLATION · STANDARD · PLUS ──
───────────────────
── CONTACT · DROPLET · AIRBORNE ──
── PPE · GLOVES · MASK · GOWN ──
── HAND HYGIENE · ASEPSIS ──
───────────────────
── ISOLATION · STANDARD · PLUS ──
───────────────────
mod 19
Infection Control and Isolation
Breaking the chain of infection through precautions, PPE, and aseptic technique.
Chain of InfectionTransmission & PrecautionsPPEHand Hygiene & AsepsisBody DefensesStages of InfectionHAIs & MDROs
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
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 ⚡
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 |
| Neutrophils | First responders; "bands" (immature neutrophils) = left shift = ongoing infection | 55–70% |
| Lymphocytes | Fight chronic bacterial & acute viral infections; T & B cells | 20–40% |
| Monocytes | Clean up tissue damage, produce interferon | 2–8% |
| Eosinophils | Allergic reactions & parasitic infections | 1–4% |
| Basophils (Mast cells) | Release histamine, serotonin, heparin | 0.5–1% |
| 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
───────────────────
── NPSGS · FALLS · FIRES ──
── REPORT · DOCUMENT · ACT ──
── SAFE · ENVIRONMENT · CULTURE ──
───────────────────
── RESTRAINTS · RISK · PREVENT ──
───────────────────
── NPSGS · FALLS · FIRES ──
── REPORT · DOCUMENT · ACT ──
── SAFE · ENVIRONMENT · CULTURE ──
───────────────────
── RESTRAINTS · RISK · PREVENT ──
───────────────────
mod 18
Safety
Creating a safe care environment through national standards, event reporting, and fall prevention.
NPSGsCulture of SafetyUnexpected EventsEnvironmental SafetyAge-Based RisksFalls & RestraintsFire & Emergencies
National Patient Safety Goals (NPSGs)
The Joint Commission (TJC) — established in 1951 as an impartial national organization that accredits hospitals and other healthcare facilities based on safety performance, policy, procedures, practice, and outcomes. More than 22,000 health care institutions and programs are currently accredited by TJC. 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.
TJC Facility Evaluation: Facilities submit monthly safety and quality performance outcomes to an independent vendor that quantifies and identifies safety trends, both positive and negative. These quarterly performance measures can be tracked along with action plans specific to each outcome.
📋 Current NPSGs at a Glance
💉 HAI Quick Reference
| HAI Type | Definition |
|---|---|
| CLABSI | Pathogens enter bloodstream via central line (large vein, long-term) |
| CAUTI | Pathogens enter urinary system via catheter through urethra into bladder |
| SSI | Infection at the part of the body where surgery occurred |
| VAP | Pneumonia 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.
Root-Cause Analysis (RCA) ⚡
- Review process used to probe potential or actual errors
- Determines whether human error or systems failure led to the error
- Establishes a corrective action plan to address the problem or system error
- Administration, risk management, and nurse leaders should advocate that all team members report unexpected events and near misses
Barriers to Event & Near Miss Reporting ⚡
- Fear of repercussions or backlash to the reporting individual or team
- Lack of time to write the report
- Unclear facility policies and standards
- Bullying
- Insufficient education and training
- Lack of understanding of the roles and responsibilities of team members
- Favoritism and influence of some employees
🏥 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.
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 |
|---|---|---|
| A | Water | Paper, wood, plastics, rubber, cloth — general combustibles. ❌ Never on electrical or flammable liquids. |
| B | CO₂ | Oils, gasoline, paints, grease, caustic chemicals. Don't touch plastic horn (gets very cold). |
| C | Dry chemical | Electrical fires — wiring, fuse boxes, computers, electrical devices |
| D | Special dry powder | Metal fires — titanium, magnesium, potassium, sodium |
| K ⭐ | Wet chemical | Kitchen fires — flammable cooking oils and fats |
| A-B-C | Dry 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.