Union Test Prep Nclex Study Guide

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How to Prepare for Basic Care and Comfort

Questions on the NCLEX-RN® Exam
General Information
These questions represent one of four subdivisions of the topic Physiological
Integrity covered on the NCLEX-RN® exam. They examine the best practices for patient
care during daily living activities, such as hygiene, physical movement, and
obtaining nutrition. Here are some of the concepts you are likely to encounter in these
questions.
Assistive Devices
An important part of the basic care and comfort of your patients will involve your ability
to assess the need for assistive devices, provide instructions for their use, and evaluate
the patient’s ability to effectively use them.
Types of Assistive Devices

Assistive devices can include those for physical ambulation and safety, such as a
walker, cane, and/or crutches. It is also important to keep in mind that devices such as
hearing aids, sound amplifiers, and other alerting devices may be necessary for a
patient with a hearing deficit. Likewise, a service animal, walking cane, and Braille
devices may be utilized by patients with vision deficits or blindness. A patient with
a speech impairment (such as after a stroke, etc.) may require the use of wordboards,
pictureboards, or handheld speech-generating electronic devices to properly
communicate.
Assessing the Patient for Device Need

Each patient will need a full assessment to determine the proper assistive devices that
would be the most helpful. Just as two patients with the same medical condition may
require different therapies for optimal health and functioning, no two patients with the
same speech, auditory, physical, or communication deficits will need the same assistive
devices. You must individualize your recommendations based upon the specific needs
of each patient.
Assisting with Proper Use of Devices

Nurses play an important educational role for their patients who need to use assistive
devices. When the patient has been fully assessed and the correct assistive device
chosen, the nurse must ensure that the patient is able to use the device safely and in a
manner that allows the patient to efficiently and safely perform activities of daily
living while allowing for the maximum amount of independence possible.
Evaluating the Success of Device Use

Successful use of assistive devices can be determined by direct patient observation as
well as his or her ability to remain injury-free due to correct usage of the device. The
patient should also feel a sense of enhanced self-esteem and self-worth with proper
use. If adjustments to physical devices need to be made (cane length, height of
crutches, etc.), you will be responsible for helping the patient make this correction.
Likewise, if a particular assistive device does not seem to be allowing a patient to
perform to his or her full potential, discuss alternative choices and make arrangements
for the patient to try something new.
Elimination
Helping patients meet their elimination needs is central to their basic care and comfort.
Both bowel and bladder functions can become altered, which will require you to
provide appropriate nursing interventions for your patient’s health and well-being.
Assessment for Elimination Issues

A patient may develop an alteration of either bowel or bladder function (or both) for
many reasons. These reasons include, but are not limited to: age, decreased
muscular tone, physical disorders including anatomical structural disorders,
neurological disorders, and psychological problems. Medication use can also
affect your patient’s ability to properly void urine and/or feces. A full nursing assessment
is necessary to identify the proper interventions for each patient.
Common Terms Relating to Urination Problems

Urinary elimination is more commonly referred to as micturition. One of the most
common problems related to micturition is a urinary tract infection (UTI).
 Polyuria: excessive production of urine (>2.5 L in 24 hours). Normal output is
about 2 L a day. Nocturnal polyuria, or nocturia, occurs only during the night time
hours.
 Oliguria: less than normal urinary output (<400 mL in 24 hours).
 Anuria: lack of production of urine or severely scant amount of urine (<50 mL in
24 hours).
 Dysuria: painful or difficult urination.
 Urinary incontinence: the involuntary leakage of urine or loss of bladder control.
The five main types are: functional, reflex, stress, urge, and total.
 Urinary retention: the accumulation of urine in the bladder due to the inability to
completely empty it.
 Urgency: the strong, sudden, and uncontrollable urge to urinate.
Common Terms Relating to Bowel Problems

The passage of stool is referred to as defecation. You will need to identify potential
bowel problems based on the age and health of your patient.
 Constipation: less than three bowel movements a week.
 Diarrhea: watery or loose stool. The medical definition of diarrhea is three or
more loose stools over a 24-hour period.
 Fecal impaction: an accumulation of rock-hard stool inside the rectum that
cannot be passed.
 Flatulence: the expulsion of gastrointestinal gas.
Irrigations
At times, you will be responsible for performing irrigations of bodily orifices in order to
provide therapeutic intervention and maintain proper organ function. This may
include: bladder, eye, ear, and ostomy (urostomy for urinary diversion
and colostomy for fecal diversion). A gown should always be used to protect from
sprays and splashes in addition to goggles and protective masks when these
occurrences are expected, and gloves should always be worn. Sterile technique is
always used with the exception of fecal diversion irrigation in which you should use
clean technique.
Skin Care for Incontinent Patients

Providing constant and vigilant skin care is essential for an incontinent patient. Skin that
is exposed to urine and feces should be washed and dried. In addition, the use of
certain barrier products can help prevent skin breakdown and complications. These
may include solid skin barriers, moisture barrier ointments, moisture barrier pastes, and
skin sealants.
Alternative Therapies
Patients who cannot urinate on their own or who are unable to ambulate will need a
urinary catheter to promote urination. The most common of these is the Foley
catheter. The size of the catheter is referred to as the French or Fr. Men, women, and
children all require different sized catheters. Due to the high risk of infection, catheter
insertion is always performed under sterile technique and never delegated to unlicensed
medical personnel.
Evaluation of Restorative Methods

Successful management of bowel and bladder elimination issues should include (at the
very least):
 regular, painless, and nearly complete emptying of both urine and stool without
urgency
 the ability to recognize and respond to the need to urinate and defecate
 remaining infection-free
 good maintenance of skin integrity.
Patients with urinary or fecal incontinence may undergo bladder or bowel training to
develop better control over elimination. Also, be mindful of basic interventions that can
have a significant impact on a patient’s ability to properly urinate and defecate such as
diet, fluids, exercise, privacy, timing, and positioning if bedridden.
Mobility and Immobility

A nurse will need to assess a patient’s mobility, including strength, gait, motor skills,
coordination, and balance. Appropriate interventions are necessary to prevent
immobility, which carries the risk of complications such as skin breakdown and
contractures.
Mobility
Patients’ ability to be mobile is vital to their physical and psychological health. It is
defined as “the ability to move freely, easily, and purposefully in one’s environment.” It is
essential for life and plays a key function in one’s recovery and overall health. Your
assessment of mobility should uncover deficiencies that can be corrected with
appropriate nursing interventions to be implemented into the patient’s care plan.
Mobility Assessment
Direct visualization of the patients is the best way to assess their mobility. Standardized
tests may be used, but simply observing the way they move in bed, sit unassisted, rise
from sitting to standing, transfer from the bed to chair, or stand and walk can provide
good information. Observe the gait during walking. Gait can give valuable information
about balance, motor strength, joint mobility, and muscle coordination. Your
assessment should also test each of these factors individually as well.
Assistive Devices
In some cases, your patient will require the use of assistive devices including traction
devices, splints, braces, and casts. These will be applied, maintained, and removed by
you. You will need to be familiar with each, why they are used and be able to instruct
your patient on their use. The main function of these devices is to provide proper
alignment for healing, reduce pain, and prevent complications that may lead to future
immobility.
For immobile patients, you will likely need to apply and maintain assistive devices that
prevent venous thromboembolism. These may include compression stockings, anti-
embolism stockings or hose, and/or automatic sequential compression devices. All of
these promote improved venous return in an immobile patient and must be ordered by a
licensed practitioner.
Immobility
Immobility (especially complete bed rest) can lead to life-threatening complications that
are both physical and psychological. The nurse and the entire healthcare team must
take appropriate measures to both restore mobility and prevent complications. Be
familiar with the adverse consequences of immobility and measures to take to
intervene.
The main causes of immobility include: pain, motor/nervous system impairment,
functional problems, weakness, psychological problems, and medication-induced side
effects.
Skin Integrity
Completely immobile patients are at high risk of skin breakdown. Frequent
repositioning can help improve the skin’s turgor and perfusion as well as reduce the
pressure, shearing, and friction on localized areas. Keep in mind that a patient’s fluid
and nutritional needs are integral to skin health. You may also need to utilize
supportive and assistive devices such as a wedge, pillow, and pressure-relieving
mattress to prevent the formation of pressure ulcerations, and skin breakdown.
Circulation
The venous circulatory system is adversely affected by immobility as muscular
contractions help increase the flow of venous blood from the lower extremities to the
lungs and heart. Venous stasis, venous dilation, embolus
formation, and thrombophlebitis are among the most common
complications. Edema, orthostatic hypotension, and generalized hypotension may
also develop.
To promote proper circulation, anti-embolic devices may be used, such as those
described above. In addition, the nurse must implement active, active assisted, and
passive range of motion exercises, as well as positioning and repositioning to promote
proper circulation, and routine exercise and mobilization. This may include rehabilitative
exercise with both physical and/or occupational therapy.
Respiratory System
Immobility can lead to thickened respiratory secretions, pooling of secretions in the
lungs, and the inability to effectively clear them from the lungs and airways. Because of
this, patients are at risk for atelectasis, pneumonia, and other respiratory infections.
Immobility also leads to shallow, ineffective respirations, decreased airflow,
and decreased vital capacity of the lungs.
Immobile patients will need the incorporation of coughing, deep breathing, incentive
spirometry, and other inspiratory exercises in order to prevent these complications.
Some patients may also require postural drainage,
percussion, and vibration performed by the nurse or respiratory therapist following
these exercises to mobilize secretions.
Musculoskeletal System
Immobile joints **are at risk for developing stiffness, pain, decreased range of
motion, and contractures. Decreased weight-bearing movement leads to **muscle
atrophy and weakness. This also leads to loss of calcium **from the skeletal
system leading to osteoporosis, hypercalcemia, and fractures. These
complications can be avoided with the implementation of **range of motion
exercises and a variety of muscular exercises that can be done in bed. A tilt table can
be used to stimulate weight-bearing exercise in certain patients.
Other Potential Complications

Other physiologic changes due to immobility can include: urinary complications, bowel
alterations, weight gain, electrolyte imbalances (calcium, nitrogen, etc.), and
psychological problems including depression.
Body Alignment
Immobile patients will need special positioning to maintain proper body alignment and
optimal physiological functioning. Be familiar with the most commonly
used positions and assistive devices used to maintain positioning (bolsters, wedges,
etc.), and always be sure to educate the patient on the importance of positioning and
how he or she can assist in the process.
Traction
Some patients may require the use of traction devices to achieve and maintain
optimal positioning for healing. The most commonly used types include external
fixation devices, halo traction, and skeletal traction. The most common condition
requiring the use of these devices is a fracture, but other serious medical conditions
may require traction. The nurse may set up a patient’s traction and will be responsible
for maintaining it, ensure patient comfort and positioning during use, and perform
adjustments when necessary. Nursing assessments during the use of traction will
include frequent neurological and skin integrity exams of the affected limb/area.
Frequent repositioning will also be necessary.
Evaluation of Patient Response

Nurses will decide if their patients are meeting their expected goals with regard to
mobility and avoidance of complications. Several interventions such as those discussed
in the previous sections may be used simultaneously to ensure patients’ safety, health,
and expected recovery. Each patient should also be evaluated for psychological
effects of immobility that can affect his or her quality of life such as social isolation and
sensory deprivation. Adjustments to the care plan should include the proper
interventions to avoid these negative outcomes.
Non-Pharmacological Comfort Interventions

Patient comfort measures will often include the use of non-pharmacological
interventions. These techniques can range from the simple application of heat and cold
to hypnosis, biofeedback, and other complex mind-body exercises. Different
patients will have varying degrees of success with each. You will need to use your
knowledge of your patient’s pathophysiology and perceptions of pain to determine which
will be the most helpful.
Patient Assessment
Each patient should have a nursing assessment for the use of alternative and/or
complementary therapy. Depending on the specific needs and preferences of each
patient, these services may fit well with more traditional therapies. Examples can
include: meditation/relaxation therapy, aroma therapy, acupuncture, massage, mind-
body exercises, music therapy, herbs, and dietary supplements.
Determining the Need for Pain Management

Pain is a highly complex, subjective, and individualized sensation. Be familiar with the
numerous theories on the phenomenon of pain (Specificity Theory, Intensive,
Peripheral Pattern, etc.) as well as the four phases of pain and the varying types (acute,
chronic, neuropathic, visceral, localized, diffuse, etc.).
Proper pain management begins with your nursing assessment of a patient’s pain. The
most reliable indicator is the subjective description of the pain. Objective indicators
such as vital signs and behavior changes (crying, guarding, etc.) have been found to be
less reliable, but may be the only indicators in patients unable to communicate their
complaints of pain.
For adults, numeric or facial pain scales are useful, as is the “PQRST” method for
assessment. In children younger than age 3, observational behavioral pain assessment
scales may be used as well as a number of standardized pain assessment scales.
Other Alternative Therapies

Do not underestimate the importance of other non-pharmacological comfort
measures such as the use of music, warm blankets, and environmental controls such
as low lighting and relaxation sounds (white noise, water, etc.) on a patient’s overall
mood. Simple measures can often increase a patient’s sense of security and well-being.
Contraindications
Be aware of any contraindications to alternative therapies. Depending on a patient’s
diagnosis, condition (pregnancy, hypertension, age, etc.) or medication regimen,
therapies such as herbal supplementation, acupressure/acupuncture, and
aromatherapy may not always be appropriate or safe.
Palliative Care
Nurses will play an important role in the interdisciplinary team that oversees a patient’s
palliative care. Often, nurses serve as the coordinator of this care, but provide
assessments and close, physical care for patients at the end of life. The most important
aspects of palliative nursing care are symptom management, pain
control, and family support.
Your role will also require frequent discussions of the patient’s goals at the end of life
and execution of the corresponding intervention whether you agree with it or not. You
must focus your care to support the patient’s physical, emotional, psychosocial, and
spiritual needs at this critical time.
End-of-Life Support
Patients will undergo a number of physical, psychological, and emotional changes near
death. As expected, nurses must care for both the patients and their families during this
uncertain and difficult time.
Assisting Patients
Nursing interventions at the end of life will focus on comfort and will be guided
by individual patient needs. These may include: an increased need for sleep, a
decreased need for food and fluids, agitation and restlessness, incontinence of bowel
and bladder, respiratory secretions and congestion, change in breathing patterns,
decreased body temperature and skin pallor, disorientation and vision-like experiences,
social withdrawal, and expressing the need to have closure and say goodbyes. The goal
of care is for the patient to remain free of pain during this period.
Counseling Patients and Families

The nurse will play a critical role in helping the family members of a terminal loved one
understand and accept the changes they will see in the patient near the end of life. Both
patient and family members should be educated and counseled on these changes in
advance of their occurrence. Again, it is important to stress to family members that their
loved one will be made as comfortable as possible and free from pain and suffering
near the end of life.
Evaluating Outcomes
When evaluating the outcome of alternative therapies and comfort measures, it is
important to ask for, and incorporate, your patient’s feedback into your evaluation. In
addition to verbal feedback, pay attention to nonverbal body posturing and behaviors as
well. This evaluation is very similar to that for pharmacologic therapy.
When evaluating the outcome of palliative care interventions, it is important to consider
the patient’s stated goals. The goal of this type of care focuses on meeting the physical,
emotional, and spiritual needs of each individual patient. Pain and symptom control are
of utmost importance. With regard to the dying patient and family, you will need to
evaluate if there is understanding and acceptance of the present situation. Ideally,
family members should help take part (when appropriate) in end-of-life care.
Appropriate referrals may be necessary if grief counseling and other supportive
therapies are appropriate
Page 2 Basic Care and Comfort Study Guide for the NCLEX-RN exam ®
Nutrition and Oral Hydration

The intake of the proper amount of water—in addition to the various nutrients, vitamins,
and minerals required to maintain and promote health and wellness—will be a nursing
priority for every patient. This will require you to have working knowledge of the four
food groups (dairy, meat, fruits/vegetables, and grains) and the needs of your patients
based on their age, weight, condition, medications, and ability to eat and drink
independently. You should also be aware of cultural or religious considerations that play
a role in nutritional recommendations and choices.
Assessing the Patient

Each patient should have a nutritional assessment that includes a stated intake
history (subjective), one or more standardized tools (objective), anthropometric data like
height, weight, BMI, etc. (objective), clinical data like activity, skin condition, quality of
mucous membranes, etc. (objective), and biochemical data such as albumin, creatinine,
hemoglobin, and transferrin (objective) to screen for proper intake and potential
deficiencies.
Physical Ability
Paramount to a patient’s ability to have proper oral nutrition and hydration is an
assessment of his or her ability to eat independently, chew adequately,
and swallow properly. Poor dentition can also affect a patient’s ability to eat properly
so this should be included in your assessment as well. It is important to remember
that neurological conditions and side effects from therapies such as chemotherapy
and/or radiation may affect your patient’s physical ability to obtain proper hydration and
nutrition.
Nutritional Requirements
While most patients will simply require a well-rounded diet, some may have special
restrictions due to specific health conditions or personal beliefs. Health conditions such
as diabetes, hypertension, and high cholesterol mandate low-carbohydrate, low-sodium,
and low-cholesterol diets, respectively. Specific religious and cultural entities, such as
Jewish or Hindu populations, practice elimination of specific types of meat, particularly
pork and beef, respectively.
Food Restrictions
Be mindful that patients may also have certain food restrictions both due to allergies to
foods and potential medication interactions. Drugs can affect the digestive process
overall, but foods may also hinder or enhance the action of the drug. Examples would
include foods rich in vitamin K antagonizing the effects of warfarin and grapefruit juice
inhibition of the cytochrome P450 enzyme, one of the most important in the metabolism
of many different drugs.
Patient Preferences
Your patient’s preference for certain foods and quantities of food and water may depend
on several factors. Each should be discussed and taken into consideration when
developing the nutritional care plan. A few factors that may affect these preferences
may include: age, gender, ethnicity, culture, personal preferences, and personal beliefs
about food and food intake, as well as spiritual and religious practices and rituals.
Mathematical Calculations
The nurse will need to employ several mathematical calculations with regard to a
patient’s nutrition and hydration. Examples include calorie counts, body mass index
(BMI), and maintaining the daily intake and output record.
Managing Food Intake

It will be your responsibility to help your patient maintain, gain, or lose weight by
developing a dietary plan that meets his or her specific needs based on your
assessment. While most patients will likely need to lose weight, remember that those
suffering with chronic diseases or conditions that involve nausea, vomiting, or diarrhea
may need to gain weight. Regardless, all patients should have a balanced and healthy
diet that includes a variety of choices and appropriate preferred foods.
Calorie Counts
Diets intended to stimulate weight loss or gain will involve the use of calorie counts. This
will involve calculations of the number of calories in each gram of fat, protein, and
carbohydrate that is eaten. The quantity or weight of the food consumed is needed for
the calorie content of the food. Food labels provide this valuable information, and your
patient should be educated on their use as well as how to calculate the number of
calories consumed in both fresh and prepared foods.
Supplements
Despite a well-rounded diet, nutritional supplementation may be necessary. Examples
include drinks such as Ensure® and Boost®, which provide extra protein and some
essential vitamins and minerals.
Measuring BMI
To assist in understanding of how a patient’s nutritional status impacts his or her health,
simple calculations like body mass index (BMI) may be calculated. The formula for
measuring BMI is BMI= kg/m2 (body mass index = kilometers/meters squared). This
formula helps to determine the measure of body fat based on a patient’s height. A result
less than or equal to 18.5 indicates the patient is underweight, 18.5–24.9 normal weight,
25–29.9 overweight, and 30+ obese. Some patient’s results may be impacted by
increase in muscle mass, as muscle is heavier than fat.
Eating Independence
Just as in all other activities of daily living, nurses and all other members of the
healthcare team should encourage as much independence in eating as the patient can
manage. If assistive devices are needed for this process, they must be incorporated
into the patient’s care plan.
Alternative Feeding Methods

For patients unable to eat on their own or unable to get adequate amounts of food via
oral intake, enteral nutrition may be given. This may be given on a continuous basis,
intermittently, or in bolus form. Enteral feeding is done with a variety of different tubes;
nasogastric, gastrostomy, and percutaneous endoscopic gastrostomy (PEG) are a few
examples. Commercially prepared formulas are used for these feedings and are
selected based on the patient’s specific nutritional needs. Pureed foods may also be
used with some types of tube feedings.
Nurses must maintain the tubes and ostomy sites, maintain their correct positioning
and cleanliness, and ensure proper functioning and patency. Common complications to
watch for are aspiration, leakage, diarrhea, dehydration, nausea, vomiting, tube
displacement, nasal irritation (naso tubes only), and infection (ostomy sites).
Monitoring Intake and Output

Measuring a patient’s daily intake and output (I&O) is essential for proper management
and care. Intake includes calculation of all food and fluids consumed orally, given
intravenously, and through tube/enteral feedings per day. Output is calculated by the
volume of urine, vomitus, and wound/ostomy drainage that is produced per day and the
number of bowel movements or volume of diarrhea excreted in a day. These
calculations can be used (in part) to explain changes in a patient’s weight, hydration
status, laboratory values, and vital signs.
Hydration
Fluid imbalances can be in one of two categories: fluid excess (edema) or fluid deficits
(dehydration). Each will have distinguishing clinical features and corresponding
changes in a patient’s vital signs with which you should be familiar. Medications can
trigger imbalances as can the age, gender, and underlying medical condition of the
patient (diabetes, fever, etc.).
Personal Hygiene
Personal hygiene is considered an activity of daily living. Each patient will need
assessment of these functions and may need intervention if unable to properly or safely
perform hygiene activities independently.
Hygiene Assessment
Your assessment should include the patient’s ability to: bathe, wash, and shower;
perform foot, hair, nail, and perineal care; shave; and perform proper oral and mouth
care, including denture care when indicated. Remember that many
different influences (cultural, religious, energy level, underlying condition, etc.) will
impact a patient’s hygiene habits and routines. Just like any other aspect of patient
care, hygiene care should be tailored to your patient’s needs, practices, routines, and
preferences.
Daily Care Modification

Different patients will require different levels of nursing care and intervention for their
hygiene needs. As you assess each patient, be mindful of the established standards for
each task and provide proper education when necessary. Also incorporate assistive
devices such as shower chairs, handrails, back sponges, and special tools for nail care.
Remind patients to use devices consistently and demonstrate proper use to ensure their
safety while maintaining the maximum amount of independence.
Post-Mortem Care
Nurses will provide post-mortem care and prepare the deceased’s body for
viewing by the family and loved ones. This will include washing and drying the body,
removing all medical equipment (IV lines, catheters, etc.), placing the arms, hands, and
legs in good alignment, closing the eyes and jaw, and placing a shroud over the body.
An identification tag should be placed on the toe, outside of the shroud, prior to
transportation to the morgue.
Rest and Sleep

Rest and sleep are critical to overall health and recovery from an illness or acute stage
of a medical condition or disease. Sleep disorders and lack of rest can negatively
impact a patient’s physical and psychological health and well-being.
Assess for Patient Needs

Patients will vary in their individual needs for sleep and rest depending on their age,
developmental stage, level of wellness, and activity level. It is important to note that,
regardless of a patient’s baseline sleep needs, his or her needs will be increased
during the time of an illness or other health-related problem. Other factors that can
affect sleep include: medications, lifestyle choices, work schedules, sleep environment,
and emotional/psychological stress.
Proper nursing interventions can be tailored when a specific sleep disorder has been
identified. To determine this, a full physical examination, subjective sleep history, sleep
log, and polysomnography are useful tools.
Use Pathophysiology Knowledge

Based on the specifics of a patient’s sleep disorder, you can use your knowledge of the
associated pathophysiology to help your patient sleep and rest better. These
interventions may include pharmacologic measures (pain control and nocturnal
enuresis), non-pharmacological measures (stress/anxiety relief via relaxation
techniques), and assistive devices (continuous positive airway pressure/CPAP for sleep
apnea).
Adjust Patient Care Schedules Appropriately

Establishing a routine of good sleep hygiene will help your patients rest better while
under your care and provide a template for them to follow once they are back at home.
Regular bedtimes and wake times, regular physical activity, limiting daytime naps,
avoidance of heavy meals and alcohol later in the evening, and establishing a quiet,
calm, and relaxing sleep environment are just a few examples of this.
How to Prepare for Health Promotion and
Maintenance Questions on the NCLEX-RN®
Exam
General Information
Questions on this area of nursing competence are related to knowledge
of developmental milestones and stages throughout the human life cycle. Knowing
what is expected at various stages aids in the prevention and/or early detection of
health problems and the provision of optimal healthcare. ## The Aging Process
The aging process begins in infancy and progresses slowly through time to the elderly
years. Understanding the different stages of aging is essential. As a nurse, you will
need to use this knowledge to educate and care for patients of different ages through
your career.
The Stages
Each age range has a unique list of expected development milestones, warning
signs of deviation from the normal, and special needs to consider throughout a
patient’s nursing care. These categories will be highlighted later in this study guide. The
age range of each stage is listed below.
Infancy— 0 to 12 months
Preadolescent (in 2 stages)
 Preschool— 1 to 4 years
 School-age— 5 to 12 years
Adolescent— 13 to 18 years (beginning with puberty)

Adulthood (in three stages)
 Working years— 19 to 64 years

 Retirement years— 65 to 85 years
 Elderly— over 85 years
The Birth Process

Pregnancies are now monitored from the time a mother first learns she is expecting until
several weeks after the birth of the child. This type of care ensures the best health
outcomes for both the mother and infant.
Antepartum Care
Also known as prenatal care, antepartum care consists of gathering
information about and assessing the condition of the mother and her pregnancy prior
to the birth of the child. Information regarding the mother’s previous health history,
current state of health, critical health information, and counseling is collected by the
nurse and healthcare team during this time. This information, or lack thereof, can impact
the outcome of the mother’s pregnancy as well as indicate the need for several
important examinations of both the mother and child.
Delivery Date Calculation

Upon learning she is pregnant, a mother will often want to know when her baby will be
due. An estimated delivery date can be calculated by using Naegele’s Rule. This
calculation is based on the first day of the last menstrual period (LMP) and is
performed as follows: subtract three months from the first day of the LMP and then add
seven days. For example, if a woman’s LMP is January 23rd, her estimated delivery
date would be October 30th. Because the calculation is based on a 28-day menstrual
cycle and a 40-week gestation (pregnancy) period, it truly is an estimate. Only 4% of
babies are born on their estimated due date.
Full-term pregnancy is defined as birth between 37 and 42 weeks. Premature is any
birth before 37 weeks, and an infant is considered overdue when the pregnancy
extends past 42 weeks.
Mother’s Health
Proper and complete documentation of the mother’s current and past health history is
an important part of prenatal care. This should include information about: blood
pressure, weight, lifestyle, family history, genetic history, and medications. This includes
all prescription, alternative, and over-the-counter medications. There are several
medications that are considered Category X, or contraindicated, during pregnancy.
They can be harmful to the proper development of a fetus and/or cause miscarriage.
Medications in this category include: birth control pills, isotretinoin (Accutane), some
hyperlipidemia drugs, warfarin (Coumadin), and misoprostol (Cytotec). The vaccinations
for measles, mumps, and rubella (MMR) and smallpox can also be harmful to a
developing fetus.
It is helpful to ask about and document the mother’s perception of her pregnancy, her
support systems, and previous coping mechanisms. Nurses are frontline providers and
may assist in making a referral for prenatal support or other counseling if appropriate.
Rh Factor
Rh factor testing is another important piece of proper prenatal care. If the mother is Rh
positive (has the factor) or both parents are Rh negative (lacks the factor), then further
intervention is not necessary. However, if testing reveals that the mother is Rh
negative and the father is Rh positive or if the Rh status of the father is unknown, then
the mother will require a dose of Rho (D) immune globulin (RhoGAM) in the 28th
week of pregnancy to prevent immune-mediated complications later in the pregnancy
and at birth.
Tests
A number of tests may be done routinely during the prenatal period. Non-invasive
testing includes ultrasound that can confirm pregnancy and fetal viability as well as
provide information regarding gestational age, monitor fetal growth, and help identify
fetal anatomy. Ultrasound can also determine the location of the placenta.
Amniocentesis is an invasive prenatal test that can give detailed information
on genetic/chromosomal abnormalities of the fetus. While not routinely performed, it
may be indicated if the mother is over the age of 35 (advanced maternal age) or if
there is a positive family history of genetic or metabolic disorders.
Nutrition
Nutrition counseling is an essential part of prenatal care. Up to 50% of all pregnancies
are unplanned. Nurses can ensure that mothers are getting the proper nutrients they
need to promote the healthy development of their babies and reduce the risk of
intrapartum and postpartum morbidity. Pregnant teenagers will require greater
amounts of protein, calcium, and phosphorus as their bodies are still growing
throughout the pregnancy.
A mother’s average weight gain should be between 22 and 27 pounds during
pregnancy. Overweight mothers should gain less and underweight mothers more.
Substantial weight gain over this amount can increase the risk of preeclampsia, which
endangers both the mother and baby. If excess pregnancy weight is not lost after birth,
a mother’s risk of developing hypertension and Type II Diabetes increases as well.
Fetal Health
Nurses may educate mothers on normal pregnancy events. These events provide
quality information regarding the status and health of both the mother and fetus.
The first fetal movement or quickening should be felt around 17–19 weeks. In some
pregnancies, this movement may be felt as early as 15 weeks or as late as 25 weeks.
Mothers should take note of fetal movement and count kicks as they may provide
helpful information on fetal health in the later stages of pregnancy. At each prenatal
visit, a fetal heart rate will be taken. Normal range is between 120 and 160 beats per
minute.
Signs of Danger
As important as counseling a mother on ways to take care of herself and her child
during pregnancy, counseling her on what to look for if something is wrong is even more
so. The following are examples of signs of serious problems or life-threatening
conditions:
 Vaginal bleeding
 Severe, unrelenting abdominal pain
 Continuous headaches in the last trimester
 Sudden onset of swelling or severe swelling of the hands and feet in the last
trimester
 Blurred or dimmed vision in the last trimester
 Decreased fetal movement past 24 weeks
Cultural Considerations
It is important to get to know the religious and cultural backgrounds and practices of
pregnant patients. Different cultures have very different views regarding pregnancy and
the birthing process. Be familiar and accepting with any particular customs and
accommodate patients and their families in any way possible.
Intrapartum Care
Intrapartum care is defined as the nursing care provided from the onset of labor until
birth of the newborn.
Labor Onset
Three main factors trigger the onset of labor: the effect of hormones, the distension of
the uterus, and the effect of oxytocin. Two recognizable signs that labor will begin in
the near future include the loss of the cervical mucus plug and rupture of the
amniotic membranes. For a mother’s first pregnancy, the entire process from the
onset of labor to the birth of the baby may take anywhere between 12 and 14 hours.
With each subsequent pregnancy, this time frame tends to shorten unless there is an
extended period of time between pregnancies—usually more than several years.
Stages of Labor
Nurses must be able to identify the stages of labor and properly provide interventions
that are specific for each stage.
4 to 10 cm dilation— During this stage of labor, the cervix continues
to dilate and efface (soften/stretch/thin). The main nursing interventions during this time
will be monitoring and documenting this process and assessing the need for analgesia.
Full dilation to delivery— As the baby descends down the birth canal, the nursing
assessment grows to include noting changes in the perineum that signal birth is
imminent (bulging, increase in bloody show, crowning or visibility of other body parts of
the baby), recording vital signs of both mother and baby, and identifying the position of
the baby’s head in the birth canal.
Delivery of baby to delivery of placenta— The placenta is usually delivered within 5 to
20 minutes after the baby’s birth. The nurse should assess the umbilical cord for two
arteries and one vein.
Immediate recovery— A new mother’s uterus should be checked frequently for both
position and tone for the first hour after birth. Approximately 2 hours after birth, the
mother’s vital signs, fundal height, and vaginal bleeding/discharge should be assessed.
Her bladder should be checked for signs of distention and the nurse may assist the
mother with breastfeeding, if appropriate.
Postpartum Care
After the birth of the baby, the new mother will need to be continuously monitored for
and instructed on the signs of serious complications. These include:
Hemorrhage
Explain that it is normal to have some bleeding mixed with vaginal discharge for 3 to 6
weeks following delivery. Assess for and educate the patient on abnormal bleeding,
such as the passage of large clots or more intense spurts of bleeding.
Infection and Illness

New mothers need to be watched for an increased temperature (over 100.4ºF or
38ºC). Physical signs of infection can include: a sudden increase in perineal pain;
copious or smelly vaginal discharge; warm, red or tender breasts; pain with urination;
pain with or without swelling in the legs; and chest pain or cough.
Neonatal Care
Neonatal care is defined as the care that is given to a newborn infant. One minute
following birth, a newborn will be assessed on his or her appearance, vital signs, and
breathing. This helps guide appropriate interventions for the baby if indicated.
APGAR Score
The APGAR score is a number determined from the individual scores of five
assessments done at 1 minute and again at 5 minutes after birth. The five assessment
categories are: appearance (color), heart rate (pulse), grimace (reflex
irritability), activity (muscle tone), and respiration (respiratory effort). In each category, a
score of 0 to 2 is given where 0 is poor, 1 is okay, and 2 is good. A baby with a score of
7 or above is considered to be a healthy newborn. Scores lower than 7 may indicate the
newborn’s need for further medical support or intervention.
Complication Warning Signs

Infants must be carefully monitored for signs of distress or complications following birth.
Some warning signs or reasons for concern include: sunken-in or bulging cranial soft
spots, fever of greater than 100.4ºF or 38ºC, vomiting more than once in a 24-hour
period, the inability to keep food and water down, and labored and/or difficulty
breathing.
Newborn Care
Nurses must provide important information and education regarding the care of a
newborn. This may include answering questions on basic care, umbilical cord care,
bathing, feeding, and parent-child bonding. Nurses may also address safety concerns
such as car seats, preferred visitor policies, and sleep positioning.
Care of the Mother

It may be indicated for nurses to counsel postpartum women on their contraceptive
options. A woman’s menstrual cycle may return within 6 to 8 weeks of delivery. While
breastfeeding mothers may not see their menstrual cycle return until much later than
non-breastfeeding mothers, breastfeeding compatible (progestin-only) contraceptive
options should still be offered.
The postpartum period can be stressful for any new mother. Nurses should help
mothers recognize signs of postpartum depression and encourage mothers to seek
medical guidance if wide emotional swings are noted after the second or third
postpartum week.
Page 2 Health Promotion and Maintenance Study Guide for the NCLEX-
RN® exam
Developmental Transitions and Stages

In each developmental phase, there are normal expectations for physical, cognitive,
social, and emotional growth. This next section will include normal developmental
milestones, primary needs, and concerning deviations from the expected development
for each indicated group. ### Infants
Age: 1 month to 12 months
Developmental Expectations:
 Suckle reflex and rooting reflex

 Grasping reflex which develops into pincer grasp with thumb and finger
 Focus eyes on object (short period of time)
 Ability to vocalize, “coo”
 Respond to spoken words or loud noises (albeit sometimes selectively)
Normal Appearance Variations:
 Swollen breasts or genitalia—residual estrogen from mother during pregnancy or

with breastfeeding
 Milia (white acne bumps on face)
 Slightly misshapen heads that round with age
Needs:
 Forming bonds with parents and caregivers
Warning Signs:
 Not rolling from tummy to side by 10 months old

 Not transferring toys/objects from hand to hand by 9 months old
Preschool
Age: 1 to 4 years
 Dress and undress himself/herself

 Use and manipulate small objects with their hands and fingers
 Progressive control over bowel movements and bladder
 Increasingly aware of limits
 Voice opposition to activities by saying “no”
 Vocabulary of 500–3,000 words
 Short, 3–4 word sentences
 Draw with a pencil
 Eager to please
Needs:
 Consistency with environments and set boundaries

 Increased need to feel secure
 Close supervision to avoid dangerous settings
 Unstructured playtime
 Independence
Warning Signs:
 Not walking by 18 months

 Vocabulary less than 15 words
 Not able to follow simple commands, imitate words, or imitate simple actions
 Not interested in playing or engaging in “pretend” play
 Excessive focus on violence or other mature subject matter
School-age
Age: 5 to 12 years
 Coordination more advanced

 Perform activities that require a combination of motions (i.e., jumping rope, riding
a bicycle, skipping)
 Follow more complicated, multi-step commands
 Ability to retain information
 Recall their full name, their address, and how old they are (school-age children)
 Identify self as boy or girl
 Emulate their same-sex parent
Needs:
 Early intervention for those with vision and/or hearing problems

 Monitoring for scoliosis or lateral curvature of the spine
Warning Signs:
 Continued bed-wetting (nocturnal enuresis)

 Verbalization or showing signs of anxiety about school and/or home life
Adolescents
Age: 12 to 18 years
 Try to find self-identity

 Strong peer relationships
 Engage in somewhat risky behavior
 Natural sense of immortality
 Awareness and increasing concern with physical appearance
 Development of secondary sexual characteristics
 Increased hormone levels
 Growth spurts
Needs:
 Education and mental preparation for physical changes of puberty

 Guidance and discussions regarding sex, alcohol, and drugs
 Understanding and expectation of labial mood and personality shifts
Warning Signs:
 Excessive aggressiveness
 Persistent misbehavior, especially at school
 Monitor for dramatic changes including excessive weight gain or loss, changes in
behavior, changes in peer groups and how that may impact the adolescent
 Persistent depressed mood, despair, hopelessness, withdrawal, and comments
about suicide or suicide ideation
Adults (Working Adults)

Age: 19 to 64 years
 Erikson’s Theory of Psychosocial Development: (age 19–34 intimacy versus

isolation; age 35–64 generativity versus stagnation)
 Seek meaning or purpose in life
 Builds work, family and other relationships
 Prime age 25–35 years old
 As age increases, increase in chronic medical conditions
 Need for lifestyle modifications to address development of chronic concerns
Needs:
 Healthy coping mechanisms to manage demands of long-term relationships,

marriages, workplace relationships, and politics
 Preventative healthcare strategies to reduce the incidence of chronic illness as
age increases
Warning Signs:
 Substance abuse—alcohol, medication, or illicit drugs
 Feeling that life is meaningless or better without them in it
Older Adults (Retirement Aged)

Age: 65 to 85 years
 From Erikson’s Theory of Psychosocial Development: Resolve the conflict of ego

integrity versus despair. This means that they either look back on their lifetime and
accomplishments with a sense of satisfaction, or they feel despair if they don’t feel
a sense of meaning or purpose from their lives.
 Demonstrate slow decline in physical functioning
 Likely will retire from the workforce
 Reminiscent over life’s accomplishments or regrets
 Experience changes in interpersonal relationships
 Increasing incidence of illness, decline of function, and death
Needs:
 Support during difficult transitions to life away from the workplace

 Struggle with changes in loss of close personal relationships
Warning Sign:
Sense of despair or regret about life
Very Old Adults (Elderly)

Age: 85+ years
 Progressive decline of physical functioning

 Progressive decline of cognitive functioning
 Likely to experience heavy loss of interpersonal relationships
Needs:
 Need help learning to accept and find meaning in their lives

 Assistance in daily activities if unable to perform
 May need to change living environments to adapt to increasing needs
Warning Signs:
 Suicidal thoughts or behavior
RN® exam
Health Promotion and Disease Prevention

In the traditional medical model, health was defined as the absence of disease. Today,
we recognize that many people enjoy a high quality of life (healthy life) despite one or
more health challenges. The term health and wellness is a more encompassing term
that is used to represent a state of physical, social, and emotional well-being and the
pursuit of each. Nurses play a critical role in educating and empowering patients to take
control of their own health. They can help patients find the health resources they need
based on their specific health condition and/or disability. Be familiar with programs in
each of the following areas of health promotion and wellness.
Weight Management
Healthy weight management should focus on incremental changes to move patients
toward a desirable weight for their height and build. It is important to note that even a
modest weight loss of 10 to 20 pounds can significantly positively impact those with
chronic health conditions such as Type II Diabetes.
Smoking Cessation
The reasons people continue to smoke despite the known negative health effects, which
are numerous. Nicotine addiction, depression, anxiety, habit, and repeated exposure to
smoking-associated stimuli in both social and workplace settings all play a role. Often
those with low incomes, low education, and psychosocial problems find it difficult to quit.
More than one strategy will typically be necessary to achieve successful smoking
cessation.
Nutrition
Nutrition plays a large role in health and wellness. While good, sensible eating is
universally recommended, remember that special groups will need more specific
recommendations. Patients with hypertension should avoid excess sodium and
sodium-containing foods such as canned or processed foods. Patients at risk
for osteoporosis should be encouraged to increase their calcium intake. Those
with diabetes will need restricted carbohydrates, and those with high
cholesterol should avoid saturated fats like those in red/fatty meats and trans fats in
deep fried and fast foods.
Exercise
Exercise provides numerous health benefits for everyone at any age or activity level.
Exercise can help improve cardiovascular and respiratory function, assist in weight
control, stimulate metabolism, improve sleep, decrease the risk of
osteoporosis/strengthen bones, and improve overall strength, balance, flexibility, and
endurance. There is also good evidence to show that exercise can improve mental
health and positively impact a number of disorders such as depression and anxiety.
Exercise also decreases social isolation.
Other Therapies
Be aware that many patients will incorporate other alternative therapies with their
traditional western medical regimens. These may include massage, acupuncture,
hypnosis, and others. Patients often take over-the-counter medications, vitamins,
supplements, and homeopathic remedies such as herbs or essential oils. Some patients
may see alternative medical providers such as a shaman or chiropractor.
Breast Health
The importance of performing a breast self-examination (BSE) should be taught
to every female patient once they reach puberty. Women should do their BSE during
day 5 to 7 of their menstrual cycle on a monthly basis. Menopausal patients should also
continue to perform monthly BSEs.
Testicle Health
Testicular cancer is one of the most curable solid tumors. It is most common in men
ages 15 to 35 years. Male patients should be counseled on the importance
of testicular self-examination and should perform one regularly, preferably after
bathing when the scrotum is most relaxed. Any swelling, lumps, or other abnormalities
need to be reported immediately to the patient’s medical provider.
Hormone Replacement Therapy (HRT)

Perimenopausal and menopausal women may be candidates for hormone replacement
therapy (HRT) to help control the negative symptoms of their condition such as hot
flashes, sweating, and vaginal dryness. While HRT has protective effects against the
development of osteoporosis, it may increase the risk of the development of coronary
artery disease (CAD), breast cancer, deep vein thrombosis (DVT), and stroke.
Therefore, the risks and benefits of HRT need to be carefully weighed for each
individual patient.
Immunizations
Immunizations play an important part of overall health and wellness throughout a
patient’s lifetime. Generally, most immunizations are given to children aged 2 months to
12 months. The Hepatitis B vaccine is given to newborns shortly after birth with two
additional doses given at 1–2 months and 6–18 months of age. Rotavirus is given in 2–
3 doses at ages 2, 4, and 6 months. No Rotavirus vaccines are given after 8 months
and 0 days of age. DTaP is a five-dose series given at 2 months, 4 months, 6 months,
between 15 and 18 months, and between 4 and 6 years. Hib and Pneumococcal
conjugate (PCV-13) are given at 2, 4, 6 (sometimes for Hib) and 12–15 months.
The Hepatitis A vaccine is a two-dose series recommended at 12–18 months with a
second dose administered 6 months later. The annual influenza (flu) vaccine may be
given after 6 months of age. With the flu vaccine, two doses are required in the first year
to achieve immunity. After the first year, the child may return to once yearly dosing.
The MMR and Varicella vaccines are given between the ages of 12 and 15 months with
second doses given at 4–6 years. HPV vaccination is now recommended as a two dose
series for ages 9–14 and a three-dose series for those who start the series after age 15.
College freshmen who plan on living in dormitories who are previously unvaccinated
should receive the meningococcal vaccine. Adults over the age of 60 should all
receive the vaccination to prevent shingles (herpes zoster) as well as pneumococcal
pneumonia.
Oral Health
The importance of the connection between oral health and other physical disease
should be stressed from an early age. Gum disease or periodontal disease has been
linked to diabetes, heart disease, and other chronic, inflammatory conditions. Patients
should be counseled on the importance of dental visits and cleanings every six months
beginning at 2 years of age.
Mental Health
Nurses often interact more intimately with patients than any other member of the
healthcare team. They may be the first to identify a patient’s mental health issues or
those at risk for developing depression, anxiety, etc. Nurses can provide these
patients with helpful suggestions on how to effectively manage stress and assist with
arranging care for those who need intervention from a mental health specialist or
counselor.
Heart Disease and Stroke Prevention

High blood pressure is frequently associated with heart problems and strokes. Nurses
can identify blood pressure abnormalities and encourage patients to monitor their own
blood pressure at home, especially those who have a family history of hypertension.
Nurses can also help educate patients on worrisome symptoms and the normal
parameters for both systolic and diastolic blood pressures.
Skin Health
Nurses should counsel all patients on the dangers of excessive ultraviolet (UV)
exposure and the importance of regular skin cancer screenings. They can also
provide helpful information on sunscreen, protective clothing, and times of day to avoid
outdoor activities.
Health Screening
Knowledge of health screening requires a nurse to combine knowledge
of pathophysiology with known risk factors for certain ethnic and/or age groups of
patients. Below are descriptions of many routine health screening exams and, when
applicable, populations in which the screenings should take place.
Blood Sugar Check

Two types of blood sugar levels can be checked: fasting and non-fasting. For a
patient who is fasting (more than 8 hours), a level of greater than 125 mg/dL indicates
the need for further testing. A non-fasting patient should have a level less than 199
mg/dL.
Blood Pressure Check

Normal blood pressure is defined as anything less than 120/80 mmHg. While there
are several subcategories of hypertension (elevated, stage I, and stage II), severe
hypertension is defined as a blood pressure greater than 140/90 mmHg. Known as the
“silent killer,” hypertension, even when severe, may be completely asymptomatic.
Incidence of hypertension is higher in the southeastern U.S. and in African-Americans.
Other risk factors for hypertension include age over 60, inactive lifestyle, and
hyperlipidemia.
Fasting Lipid Profile

Every adult should have a fasting lipid profile done at least once every 5 years.
Following are the target results of such a screening.
 Total Cholesterol— < 200mg/dL

 Triglycerides— < 150ml/dL
 Low-density lipoprotein— < 100mg/dL (also known as LDL or “bad” cholesterol
and is closely linked to the development of atherosclerosis)
 High-density lipoprotein— > 40mg/dL for men; > 50mg/dL for women (also
known as HDL or “good” cholesterol and is cardioprotective)
Colorectal Screening
Every adult over the age of 50 should have regular colorectal screening. These tests
may include fecal occult blood testing (FOBT), sigmoidoscopy, colonoscopy,
double-contrast barium enema (DCBE), and/or digital rectal exam (DRE). In patients
with a positive family history of colorectal cancer, screenings should begin at an earlier
age and possibly be more frequent.
Prostate Screening
All men should be screened for prostate cancer starting at the age of 50. A blood test
measuring a man’s level of prostate-specific antigen (PSA) along with digital rectal
exam (DRE) are the tests that are used.
Mammogram
All women between the ages of 40 and 50 should have a baseline
mammogram. Annual screenings are generally indicated in most women until the age
of 55. They may be done biannually or continued annually. A positive family history of
breast cancer may dictate earlier screening mammograms for some women.
RN® exam
High Risk Behaviors

Detailed history-taking is essential as some patients may engage in certain high risk
behaviors or lifestyles that increase their risk for the development of disease, illness,
injury, or death. Many patients may not realize they’re at risk, so identification and
education of these is an essential part of comprehensive healthcare.
Sexually Related
Unprotected sexual activities (anal, vaginal, or oral) can increase the risk of sexually
transmitted diseases (STDs) as well as HIV/AIDs in certain populations. It may also
lead to unplanned pregnancy. Using contraception and/or barrier protection methods
can take planning and identification of resources for patients who need them. Nurses
are often well suited to give this direction and education.
Accident Avoidance
For many age groups, the number one cause of death is unintended injuries. Nurses
can provide counseling on ways to reduce risk such as seatbelt use while in the care
and the use of helmets or other protective equipment when biking, etc.
Lifestyle Choices
Lifestyle choices vary for each patient. They are a set of actions or characteristics that
range from habits to thoughtful, intentional decisions. Examples include remaining
single or child-free, living in a particular environment (rural versus urban), or engaging in
and practicing alternative healthcare (homeopathic, etc.). Each of these can impact a
patient’s health negatively or positively depending on his or her particular health
circumstances.
Self-Care
Self-care activities are those actions and practices that patients engage in to promote or
enhance their own health and well-being. They are not directed or overseen by medical
professionals. However, for some patients who have developmental/physical disabilities
or are elderly, there may be limited or curtailed abilities to perform self-care activities.
Nurses need to identify patients in need and utilize professional, institutional, and
personal (family/friends) resources to ensure a patient’s ability to live as independently
as possible.
Physical Assessment Techniques

Health histories and history of present illness (HPI) are subjective descriptions of a
patient’s symptoms and health circumstances. Physical assessment of the patient
provides objective information about a patient’s physical condition. The combination of
the two helps guide decision-making and planned intervention. There are four main
physical assessment techniques: inspection, palpation, percussion, and auscultation.
Inspection
Inspection, or purposeful observation, can provide a wealth of information about a
patient’s general health. Posture, body habitus, movements, and speech indicate
information about a patient’s nutritional status, personal care habits (dental care,
exercise, etc.), as well as provide as an alert for deviations from the expected
developmental phase. Vital signs are also part of inspection. In some cases,
personalization of assessment techniques may be required. For instance, a child will
require a small/child-sized blood pressure cuff to obtain accurate information.
Palpation
Palpation is using both the fingertips and palms to apply light to deep pressure to
certain internal structures to gather information regarding their function and state.
Palpation is used to assess pulse rate, rhythm, and quality. It is also used to note
a cardiac thrill (a palpable heart murmur) as well as tender, swollen, or displaced bones
or internal organs such as the liver, spleen, etc. Palpation can indicate a patient’s
hydration or fluid status by assessing skin turgor and signs of edema.
Percussion
Percussion techniques provide information regarding the levels of air and fluid within an
organ or body cavity. To perform percussion, the middle finger of one hand presses
over the structure while the index and middle finger of the other hand lightly taps on
the pressed finger. The returned sound will be dull (soft) if there
is fluid/exudate present and hollow (loud) if there is air. Percussion is most used to
assess conditions of the chest cavity (i.e., lungs) and the abdomen.
Auscultation
Auscultation is the technique of using a stethoscope to listen to the movement of air
and fluid inside of the body. The stethoscope has two sides that are useful for the
assessment of different sounds: the bell (smaller, hollow cup) picks up very low
frequency sounds (heart murmurs, some bowel sounds, arterial bruits, etc.), while
the diaphragm (larger, flat) is better for high frequency sounds (breath sounds, normal
heart sounds, blood pressure, etc.).
Teaching Patients Effectively

Nurses are invaluable sources of information and education. They need to understand
the principles of teaching and learning to effectively communicate this information
with patients.
Know About the Patient

Take the time to learn more about the patients and assess each patient’s ability and
readiness to learn. Ask about and identify how a patient likes to learn or learns best and
make accommodations for this to help ensure that the information is received,
processed, and understood. It is helpful to have a consistent, organized approach to
clearly deliver medical information.
Age and development— Consider the age and development of the patient. Tailor the
message as appropriate. Examples would be using small, simple words for younger
patients, and allowing older/adolescent patients learn more independently through the
use of trusted Internet-based websites.
Living situation— A patient who is socially isolated due to physical limitations
(decreased sight or hearing) or geographically isolated from family and friends will likely
need special accommodations for the learning process to be effective.
Learning preference— Different people learn differently. Visual learners may prefer
diagrams, handouts, or pamphlets. Auditory learners will prefer face-to-face
discussions or group meetings. Tactile (kinesthetic) learners will want to touch, feel,
and move a model or device to better “experience” what they are learning.
Know About Possible Barriers to Learning

A critical part of effective teaching is ensuring that the material received is understood.
A nurse must identify any potential barriers to learning prior to teaching to ensure that
the process is effective and produces the desired effect.
Physical condition— Consider a patient’s ability to hear and see during
communication. Adjust tone and rate of speech or use materials with enlarged print or
braille if indicated.
Financial concerns— Consider a patient’s financial ability to pay for a procedure,
surgery, medication, or other treatment. Discussing strategies or resources to help
ease these concerns will help build rapport and trust with patients.
Absence of support systems— Patients may feel isolated and alone if they lack the
proper support systems. Be available to these patients and guide them to the proper
resources to help them find the support they need.
Literacy skills and comprehension— Patients with low literacy skills and decreased
ability to comprehend will need special accommodation. A balance of
proper tone and delivery is necessary to avoid sounding condescending or belittling.
Cultural background— Cultural beliefs need to be considered when teaching patients.
Be sensitive to and respectful of certain ethnic traditions and practices.
Language barriers— Language barriers need to be identified and professional,
medically trained translators should be used whenever possible.
Attitude and motivation— An unmotivated patient is unlikely to put forth the effort
required to learn. Identify the reasons behind a poor attitude and make efforts to
remedy them whenever possible.
Acceptance of responsibility— Patients must recognize and accept personal
responsibility over their health and circumstances and take initiative to make the
necessary changes to get better.
Environment— Patients need the proper environment to receive information and learn
effectively. Minimize distractions and ensure proper measures are taken to respect
the patient’s privacy.
Teaching Strategies
A nurse can use many teaching techniques and strategies to ensure patients
understand and can perform the actions identified throughout the medical information
teaching.
Let the patient help establish and evaluate own goals.— Encourage patients to take an
active part in getting better. Helping them establish and evaluate their own goals makes
them part of the treatment team and motivates them to adhere to a treatment regimen.
In this way, patients take more ownership over their condition, healing, and wellness.
Have patient demonstrate understanding.— Asking patients if they understand or have
any questions allows an opportunity to identify gaps in learning. If they seem reluctant to
ask questions, the nurse can also ask them to repeat back what they understood in
their own words. For procedures or self-care that necessitate learning a new skill, ask
them to perform the task to ensure they understand.
Evaluate and modify the plan.— Despite the nurse’s best efforts, effective patient
education can sometimes be difficult. Be flexible and ready to try multiple strategies if
the teaching efforts are not producing the intended results.
How to Prepare for Management of Care
General Information
This category of questions falls under the broader umbrella of Safe and Effective Care
Environment and asks you to make relevant decisions about nursing care. Your
objective should be to determine the most effective way to deliver optimal care that
preserves the health and safety of patients and personnel. These are some of the
concepts you will need to know in order to make the appropriate decision(s) when
questioned by NCLEX.
Advance Directives
Advance directives are legal documents that specify the wishes of patients regarding
their care if they were to become incapacitated and unable to communicate on their
own. Examples of advance directives include:
* Living wills—written statements by a person with their desires regarding medical
treatment in the event they will no longer be able to express their informed consent
 Health care proxy—document that names a trusted individual as proxy or agent
to act on a person’s behalf in the event they are rendered incapable of
expressing their wishes
 Power of Attorney for Health Care—legal document that allows a person to
designate another person to make medical decisions for them in the event the
person cannot make medical decisions for himself or herself
Self-Determination
In 1990, Congress passed the Patient Self-Determination Act. This bill requires that
upon admission to a hospital, nursing home, home health agency, or other healthcare
institution, patients must be advised of the right to accept or refuse care as well as
their options for advance directives. If a patient already has an advance directive, the
nurse should help document this in the patient’s chart. If not, the nurse may be involved
in educating the patient on what advance directives are and discuss the patient’s
healthcare goals for the future. This may also include the patient’s wishes for organ
donation or making an anatomical gift as specified in the Uniform Anatomical Gift Act.
Life Planning
Advance directives help ensure that a patient’s wishes are carried out by the healthcare
team. As a nurse, you will need to incorporate advance directives into your patient’s
care plan. This may include determining if a patient needs an advance directive,
facilitating conversations with family members, and educating staff members who may
not be familiar with the document. You must also ensure that copies of advance
directives are placed in the patient’s chart.
Advocacy
Advocacy is at the heart of nursing. Advocacy is promoting or acting on behalf of the
interests of another. Nurses are advocates for their patients. Their duties can be
varied and diverse. These duties include providing patients and their families education
and explanation of various diagnoses, tests, and results; making sure the care plan is
executed in a timely and safe manner; and serving as a source of information and
communication between various members of the healthcare team. At times, you may
need to seek the opinion of those involved in patient care, but with expertise outside of
medicine, such as a social worker, dietician, or chaplain.
Assignment, Delegation, and Supervision

Delegation is an essential nursing skill. No matter how efficient you are as a nurse, you
will need help to complete all aspects of patient care. The key to delegating success is
finding the appropriate person to help, clearly explaining the assignment, and
maintaining responsibility for the outcome while providing proper support and
supervision.
Tasks for Professional Staff Only

Some tasks should never be delegated to non-professional staff. These include: nursing
assessment, examination, diagnosis, care goals or progress plans, and interventions
that require advanced knowledge, training, and skills.
Five Rights of Delegation

Prior to delegating a task, it is helpful to consider the five “rights” of delegation:
 Right task—Should the task be delegated?
 Right person—Is the person being asked qualified to perform the task?
 Right circumstance—Is the patient stable and the outcome of the task
predictable?
 Right communication—Has the task been clearly explained and proper
direction been given?
 Right supervision—Will the nurse retain responsibility and ultimately be
responsible for the outcome of the task?
Other Things to Consider
Tasks that are usually acceptable to delegate are those with unchanging protocols,
such as feeding, bathing, transferring, and dressing. Delegation should only be
considered in stable patients. Never delegate tasks when the patient is unstable, when
the outcome is uncertain or unpredictable, or when the tasks require complex or
complicated knowledge or technical skills.
As a nurse, you are a leader. Being a good leader means that you have the ability to
unite a team of caregivers to complete tasks to reach an overall goal— to provide
exceptional care to your patients.
Being a Good Supervisor

As a nurse, you may be asked to supervise a variety of nursing staff members. These
may include other RNs, licensed practical nurses (LPNs), licensed vocational
nurses (LVNs), and nursing assistive personnel (NAPs). You may be responsible
for coordinating the tasks of the nursing team. This will require clear communication,
adequate follow-up, active listening, technical knowledge of all aspects of the
supervised work, problem-solving, and conflict resolution skills when these needs arise.
A supervisor can evaluate the skills and abilities of each team member, especially with
regard to time management, and use this knowledge to more effectively and
appropriately delegate. Likewise, these skills will also be necessary and useful
for performance evaluations of those you supervise.
Case Management
Nurses are responsible for developing, implementing, and revising care plans that help
patients reach and maintain their independence after they are discharged from medical
care.
Things to Consider
Nursing case management not only involves patient care in your facility but also
includes helping patients find and utilize post-care resources. You will help your
patient do this by identifying his or her individual needs and discussing his or her goals.
Patient needs may include access to medical therapy and/or medical
devices following discharge from healthcare facilities. Commonly ordered medical
devices include oxygen machines, suction machine, wound care supplies, and
ambulatory assistive devices (braces, crutches, wheel chair, etc.). Effective case
management ensures the patient’s safety and the ability to care for himself or
herself while also considering options that are most cost-effective for the patient.
Additional Resources
When possible, incorporate evidence-based findings into your patient’s care plan.
Regularly review the research within medical literature to maintain the most current
level of knowledge and familiarize yourself with any newly advised standards of care.
Also, don’t hesitate to access local professionals who may have the knowledge you
need to manage a case.
Evolvement of Plan
In addition to initiating the care plan, it will also be your job to revise it at times.
Discussing the care plan with your patient will help you identify if changes are
necessary and evaluate his or her individual needs. You must also provide information
on medications that must be continued, repeat labs or imaging tests that are
necessary for care, and any follow-up visits that are needed after discharge.
Patient Rights
The nurse is responsible for not only explaining and educating patients on their
conditions and treatment options but also informing them of their rights as patients upon
admission to the hospital or other healthcare facility. The right to accept or refuse care
is specified in the Patient Self-Determination Act. The nurse needs to be familiar
with other healthcare laws that govern and protect a patient, as well.
HIPAA
HIPAA stands for the Health Insurance Portability and Accountability Act. It was
designed to protect a patient’s personal information such as his or her name, social
security number, birth date, and sensitive medical information, such as a diagnosis or
treatment received. Only those involved in direct patient care, insurance reimbursement,
or patient management can access and share this information.
Patients’ Bill of Rights

Adopted by the President’s Advisory Commission on Consumer Protection and
Quality in the Healthcare Industry, this document specifies what each patient’s rights
and responsibilities are as recipients of healthcare. It includes:
 Information disclosure—the right to accurate and easily understood information
about healthcare providers, facilities, and health plans
 Choice of providers and plans—the right to choose healthcare providers that
give high-quality care when needed
 Access to Emergency Services—the right to have evaluation and stabilization
by emergency services when and wherever needed (These services may be
given without authorization and must be given without financial penalty.)
 Participation in treatment decisions—the right to be informed of all treatment
options and make decisions about one’s care (This right also extends to other
healthcare proxies should the patient not be able to make decisions.)
 Confidentiality of health information—the right to speak privately with
healthcare providers and have all healthcare-related information kept private
(This also includes the right to access, read, and copy one’s own healthcare
record.)
 Complaints and appeals—the right to a fast, fair, and objective review of a
complaint against a healthcare plan, provider, care personnel, or facility
 Consumer responsibilities—specifies that a patient must disclose relevant
information about medications and past illnesses to his or her healthcare provider
Evaluating the Understanding of Rights

Your duty as a nurse is to ensure that your patient understands his or her rights and
responsibilities under the Patients’ Bill of Rights, including the right to informed
consent. You also are responsible for evaluating your patients’ understanding
of privileged communication and duty to disclose as it pertains to informed consent.
You must also assess other healthcare team members’ knowledge of patients’ rights
and provide education to them as needed.
Collaboration
Collaboration, in this case, is defined as the interdisciplinary interaction between the
various areas of healthcare. Nurses work with physicians, social workers, dieticians,
pharmacists, and many other healthcare specialties to achieve proper patient care.
Collaboration requires integration, cohesiveness, and teamwork. As a nurse, you will
often have the closest contact with the patient, and you must be ready to
initiate interdisciplinary discussions based on your observations and patient-given
information. In effect, you will serve as the central point of contact for your patient’s
collaborative healthcare team.
Management
A nurse often functions as the manager of the healthcare team. You must know
the roles and responsibilities of each team member, and you will serve as
a liaison between the team and the patient. You are a frontline problem-solver: you
will need to use conflict resolution skills to settle problems both between team members
and between your patient and the team. Developing an overall strategy for handling
problems is key to your success in this role. Supervision of properly delegated work is
also a key function of a nurse as a manager.
Confidentiality and Information Security

A nurse’s role includes both maintaining confidentiality and taking steps to ensure a
patient’s privacy is maintained. Understanding HIPAA (the Healthcare Insurance
Portability and Accountability Act) is crucial to this end. You should take steps to ensure
only authorized personnel have access to the medical record and that sensitive,
private patient information is kept out of public view. This also includes conversations
that may relay this type of information to unauthorized persons. Intervention may be
necessary if you observe these types of breaches from other healthcare team members.
Continuity of Care
Continuity of care refers to the proper communication of information between different
departments and agencies, from one agency to another, to ensure that all parties
(including the patient) agree upon and understand the patient’s healthcare goals. The
nurse must understand the proper procedures for admission, transfer,
and discharge to and from a facility, as well as the proper forms or referral paperwork
that is required in the patient’s medical record. You will also be responsible for
following up on any unresolved issues for your patient and forwarding this information
to the appropriate agency or department such as lab or imaging results. You may also
need to be prepared to give report to the patient’s new nursing staff.
Page 2 Management of Care Study Guide for the NCLEX-RN exam ®
Establishing Priorities
Each day in your nursing work, you will utilize your ability to prioritize. You will need to
establish care priorities for individual patients as well as prioritize your assigned patients
as a group.
Guidelines to Use
There are many frameworks that may be used in developing priorities. They may
include:
 ABCs—airway, breathing, and cardiovascular or circulatory system
 Maslow’s hierarchy—physiological needs, then safety and security, love and
belonging, self-esteem and self-actualization
 Agency policies—protocol dictated by the regulations of your facility
 Time—being efficient and delegating when appropriate
 Patient and family—taking the time to understand your patients and their
families in order to better assess individual needs and prioritize your care duties
for the day
 Patient activity—report, which can be a valuable tool in planning your priorities
for the day (Likewise, adjusting your priorities based on patient’s needs and
activities will help you get your work done most efficiently.)
 Medication priorities—managing care according to any strict schedule of
patient medication
Planning Care
Your assessment skills and ability to triage patients’ needs based on your findings will
help you prioritize appropriate interventions and give care to those who are unstable
and need immediate attention. This is especially true if you have multiple patients.
Patients demonstrating these conditions will have priority:
 Post-surgery—These patients require frequent monitoring of vital signs as well
as fluid and pain management.
 Baseline status deterioration—Any change from baseline requires immediate
life-sustaining intervention and assessment as to the underlying cause.
 Shock—Patients in shock require targeted intervention based on the underlying
cause and measures to reverse the physiologic changes triggered by shock.
 Allergic reaction—Immediate pharmacologic intervention is necessary for
patients exhibiting signs of allergic reaction.
 Chest pain—Patients with symptoms of chest pain need immediate cardiac
monitoring, pharmacologic intervention, and close monitoring for cardiovascular
deterioration.
 Post-diagnostic procedure—Some diagnostic procedures (i.e., cardiac or
vascular imaging) will require temporary but close, frequent monitoring.
 Unusual symptoms—Patients with unusual symptoms should be assessed
more frequently for worsening or change in their symptoms.
 Equipment malfunction—Patients with malfunctioning IVs, tubing, or other care
equipment will require immediate attention and more frequent follow-up.
Ethical Practice
Each day you work as a nurse, you will be required to use the basic principles of morals
and ethics to judge your actions and behavior as right or wrong. The American Nurses
Association (ANA) has developed a Code of Ethics for nurses to abide by. This code
provides the ethical guidelines that define the values and standards for the nursing
profession. Understanding these principles is essential to providing ethical nursing care:
 Autonomy—a person’s right to make his or her own decisions
 Beneficence—doing what is in the best interest of another
 Justice—providing equal, fair, and impartial treatment
 Nonmaleficence—acting in a manner that avoids harm
 Fidelity—maintaining faithfulness to ethical principles and to the ANA Code of
Ethics for Nurses
 Virtues—integrity, honesty, trustworthiness, and compassion, which are
standards of nursing
 Confidentiality—maintaining the privacy of another’s personal information
 Accountability—maintaining responsibility for one’s own actions
Informed Consent
Informed consent means that a patient has been appropriately counseled on all the
risks and benefits of a particular test or treatment before being asked to agree to it.
There are four main components of informed consent:
 a detailed explanation of the procedure or treatment
 a detailed explanation of the known risks and benefits of the procedure or
treatment (Specifically, the risk of death or potential serious injury should be
included if applicable.)
 a discussion of all possible alternative procedures or treatments
 a discussion of what the potential ramifications are if the patient refuses the
procedure or treatment being considered
Obstacles
As a nurse, you will facilitate the process of informed consent. This may include
evaluating whether or not the patient is capable of giving informed consent (mental
competency, minor, etc.) and identifying the proper person (parent, legal guardian, etc.)
to act on the patient’s behalf. You may also serve as a witness of informed consent,
and you must ensure that it occurs prior to the proposed treatment or procedure. You
must advocate for your patients by ensuring they have adequate information to give
informed consent. This may include providing a translator or written materials in the
patient’s native language. Despite all these responsibilities, the nurse is not responsible
for providing the information regarding the procedure(s) being performed. The nurse
must work with appropriate providers performing the interventions/procedures and
coordinate their conversation with the patient. Any refusal of care by the patient must be
properly documented in the medical record.
Information Technology
Information technology can improve patient care by allowing expedient access of
authorized providers to a patient’s entire medical record. It can improve patient safety
and health outcomes and may also be used to enhance patient education and care.
EHR
Electronic health records (EHRs) are computer-based versions of a patient’s paper
chart. They include all the personal information of the patient, demographics, insurance
information, medical notes, test results, past medical history, medications,
immunizations, and vital signs. EHRs can facilitate care between authorized
users involved in patient management because they allow instant access to all
necessary medical information. They may also be helpful either directly or indirectly to
other care-related activities such as quality management and outcomes reporting.
eMAR
Electronic medication administration records are systems that use electronic
tracking systems (i.e., barcodes, etc.) to track medications from order to patient
administration and integrate this information into the patient’s EHR. eMARs have been
shown to improve patient safety and outcomes by greatly reducing medication
administration errors.
Guidelines
Nurses working with these types of information technology systems will need to have a
thorough understanding of how each works in order to use them properly and efficiently.
The rules of patient confidentiality also apply to accessing and transmitting electronic
health records. You need to learn, understand, and maintain all the privacy
requirements for confidential patent information that are specific to the facility in which
you work.
Legal Rights and Responsibilities

As a nurse, you are responsible for understanding the legal limitations and scope of
practice of your nursing license. Many of these parameters are mandated by both
federal and state laws, as well as by general guidelines such as the Nurse Practice
Acts (NPAs). Each state will have a state Board of Nursing that will serve as your
credentialing body and source of information on the confines of laws applicable to the
state in which you practice.
Negligence
Negligence is an unintentional act or failure to act that results in harm to a patient. It
involves the failure to act in the same way that a reasonable person would, given the
same set of circumstances. Failure to give a medication, or give it in an untimely
manner, could be examples of negligence if the patient experiences a consequential
adverse reaction. In each case, the nurse exhibits a breach of duty of care that is an
essential component of negligence.
Malpractice
Malpractice differs from negligence in that malpractice includes the element of intent.
Often, the individual state Boards of Nursing set the requirements for determining
malpractice. In general, malpractice occurs when a nurse fails to competently perform
his or her duties and the patient suffers harm as a result. Examples include giving the
wrong medication to the wrong patient or giving an incorrect medication dosage.
A Nurse’s Role
The nurse is responsible for proper, timely care of patients. Any incorrect, inappropriate,
or lack of action (as set by the standard of care) could result in legal action against the
nurse if the patient suffers harm as a result. Be familiar with your legal rights and
responsibilities.
 Response to legal issues—You must be able to identify and respond
appropriately to legal issues relating to patient care. Examples include a patient’s
refusal of care and privacy rights of minors.
 Seeking assistance—You must be able to identify tasks and assignments that
you are not qualified to perform and seek help or guidance when necessary.
 Patient valuables—Your facility or practice will have specific guidelines to know
and follow with regard to handling valuables. Many facilities offer lock boxes and
security regulations concerning patient valuables.
 Patient and staff education—Participating in required and elective education
events helps ensure you understand and are prepared to respond appropriately
to potential legal and ethical issues.
 Regulations for reporting—Certain health conditions (communicable disease,
dog bites, etc.) have both state and federal regulations that must be followed.
You will need to be familiar with regulations that apply to you as a mandated
reporter of suspected child abuse and other crimes.
Organ Donation
Organ donation is the process of harvesting on organ or tissue from one person
and transplanting it on or into another. Internal organs, skin, bone, bone marrow, and
corneas may all be donated/transplanted. While many organ donations take place after
the donor is deceased, some are done with a living donor (e.g., kidney, bone marrow).
Nurse Roles
Specialized nurses, called procurement nurses, are involved in the care of organ
donation/transplantation patients. Nurses who counsel patients and their families on the
specifics of organ donation must have special training under federal law. As an entry-
level nurse, your involvement in the process will likely be ensuring that your patients
over the age of 18 have copies of their advance directives in the medical record.
Advance Directives and Donation

Advance directives are legal documents that specify the patient’s wishes if he or she
should become incapacitated and not able to express them for him or herself. The
patient’s wishes for organ donation, specifically, should be obtained and documented
within the medical record if the patient is legally able to provide this information.
Performance Improvement
Different medical institutions each have specific definitions of quality, but generally the
term refers to meeting or exceeding the patient’s expectations, meeting or exceeding
the standards for care, and achieving the planned outcomes for all patients. Quality
improvement refers to the process of identifying and improving quality issues with
regard to nursing care. This may include:
 TQM (Total Quality Management)— a long-term management approach to
success that is centered on patient satisfaction
 CQI (Continuous Quality Improvement)— a management approach that is
centered on ongoing evaluation and improvement of the processes that lead to
success
 Evidence-based decision making—This approach focuses on adjusting
policies and processes according to the most recent research evidence.
 Quality management plan and benchmarks— This approach uses
performance measures to adjust processes accordingly. Benchmarks are points
of comparison that can be used to identify problems in the process. This
approach encourages competition as it typically seeks to identify the best
practices at the best cost.
 Reporting issues— Nurses play a critical role in quality improvement. By
reporting patient care problems or issues to the appropriate personnel, you
ensure proper management evaluation of why they occur and facilitate
correction.
 Resources— You may also serve as a quality improvement resource for your
institution, practice, or agency. You may be a source of data collection or
participate in a group or team that is involved in the performance improvement
process. You may also be asked to evaluate the impact of procedural or process
changes to your nursing practice.
 Nurse-sensitive indicators— Nurse-sensitive indicators are measurements of
patient care that are directly impacted by nursing interventions. Examples of
these are skin breakdown (decubiti), falls, and the use of restraints.
Referrals
As you care for your patients, you will often play a role in helping to coordinate care with
other healthcare providers or community agencies. This may be as simple as
recommending a particular provider (dietician, physical therapist, wound care center),
but it may also require you to obtain prior authorization for your patients via their
insurance company. Your job is to appropriately assess your patient’s needs and then
assist him or her in the referral process to get the care needed. You will also be
responsible for providing the appropriate documentation to the provider or facility your
patient has been referred to (i.e., referral form or copy of the medical record).
How to Prepare for Pharmacological and
Parenteral Therapies Questions on the NCLEX-
RN® Exam
General Information
This section of the NCLEX exam, Pharmacological and Parenteral Therapies, falls
under the umbrella category of Physiological Integrity. This section focuses on
medications and alternative therapies available in healthcare. You will need to know
about medication dosages, contraindications, administration routes, side effects, and
pain management. Other topics may include questions regarding blood
products and parenteral nutrition. Below are the listed major concepts covered in this
category.
Medication Effects
Administering medication is much more than “giving” clients medicine. It requires a
substantial amount of knowledge about each medication, including the potential effects
(both intended and otherwise), interactions with other medications, and a thorough
understanding of the patient’s health status, including the ability to tolerate each
medication.
Adverse Effects
Adverse effects are undesired, harmful reactions of medications that may occur after
a medication is given. These effects may be mild, moderate, or severe and can
significantly impact the client. Nurses are responsible for assessing and monitoring
clients, their medication regimen, and any adverse effects related to their medications or
other therapies. Common signs of adverse effects include allergic
reaction (anaphylaxis), skin, respiratory, gastrointestinal and/or circulatory changes.
Other, more severe adverse effects include birth defects, hospitalization, coma, and
even death. Nurses must know how to recognize these symptoms and initiate any
needed, appropriate treatment steps.
Contraindications
Every medication has a list of conditions in which its use is not acceptable or safe.
Common conditions that have medication contraindications include pregnancy, organ
dysfunction, and allergy/sensitivity. Some medication contraindications are indicated
by the category of medication, such as with the pregnancy categories: A, B, C, D, and
X. Some medications are contraindicated with foods, such as grapefruit, Vitamin K,
alcohol, and specific herbs (St. John’s Wort, Ginseng, Black Cohosh, Ginkgo Biloba).
Other medications are contraindicated when the client is already on a specific
medication regimen. The nurse must investigate the full medication list of the client,
communicate current and future medication plans with the provider, and provide ample
education to avoid medication contraindications.
Side Effects
Side effects are very similar to adverse effects. Side effects can occur in addition to the
main intended effect of a medication or therapy. Some of the most common side effects
for medications include headache, abdominal pain, nausea, vomiting, diarrhea,
constipation, dizziness, drowsiness, lethargy, insomnia, and dermatitis. Many
medications have very specific side effects and should be studied in preparation for
the NCLEX exam. Clients should be educated on the most common side effects to
increase their awareness and communication of these effects, should they occur. Some
side effects may be treated with counter therapies, such as prescribing an anti-nausea
medication with medications known to cause nausea or adding a probiotic supplement
to take with antibiotics to help prevent or lessen diarrhea. When clients experience side
effects, the nurse is responsible for discussing these changes with the ordering provider
to determine if supportive or alternative therapies need to be considered.
Interactions
A thorough medication history is necessary to fully assess for any unwanted medication
interactions. The nurse should discuss the usage of all prescription medications, over-
the-counter (OTC) therapies, and other natural or herbal supplements with the client.
Many clients unknowingly add incompatible complementary therapy, dietary
changes, over-the-counter medications, and/or herbal supplements to their normal
medication regimen, increasing their risk for adverse effects. In the hospital, some
intravenous fluids will interact with prescribed medications and any incompatibilities
should be identified and discussed with the ordering provider.
Nurse Responsibilities
The nursing responsibilities related to medication and fluid administration extend well
beyond those listed above. Nurses are key in discussing medication names, dosages,
rationales, intended effects, unintended effects, and contraindications with their clients.
Nurses also help educate patients on how to take their medications; which ones need to
be taken with or without food; how often to take their medications; and any additional
specific instructions. Patients should be instructed when to call to report adverse
reactions or concerns about side effects. Sometimes, because of the adverse effects,
clients struggle with medication compliance and may abruptly stop or change their
medications without medical orders to do so. The nurse should be aware of any
medication changes and have an open communication plan with the ordering provider
to help maximize the therapies of the client with minimal adverse reactions. Lastly,
nurses are responsible for documenting all the discussions with both the client and
ordering providers. Documentation is critical for any medical observations, client
interactions, adverse reactions, nursing interventions, and/or emergency interventions
performed.
Blood and Blood Products

The administration of blood and blood products is common in the hospital setting.
Patients may need blood and blood products for a variety of reasons
including hypovolemia, anemia, clotting disorders, platelet deficiencies,
and trauma. Broad knowledge of blood type, blood administration protocols, and blood
products is crucial.
Prior to Administration
The single, most important step of administering blood and blood products is proper
patient identification. Each facility will have specific guidelines to follow to reduce
errors in blood product administration. In general, the following steps should be taken:
1. Identify the proper patient and reconcile the patient’s name and medical record
with the information on the ordered blood product.
2. Confirm that the ordered blood product matches the actual blood product.
3. Check the blood type of the patient with the blood type of the product to be
infused to ensure compatibility. This is called cross-matching.
4. Verify that the blood product(s) is/are not expired.
5. Lastly, confirm that patient consent has been obtained and is properly
documented.
This entire process is usually completed by a two-nurse team to help prevent any
errors or missed steps.
Administration
After following the above steps for proper identification of patient, product, and consent,
the nurse should prepare for administration of the designated blood product.
Patient Evaluation
Appropriate venous access to receive the blood product(s) needs to be identified
and/or obtained. The ideal catheter gauge to deliver blood is an 18 gauge to 20 gauge.
Central venous access devices may also be used for blood product administration.
Larger bore or central intravenous catheters allow the blood product to be administered
without clumping, crushing, or shredding of any of the blood components. Always
ensure that any existing line is patent and functional prior to initiating an infusion.
Documentation
All aspects of the administration of blood and blood products will need to be
documented. This will include (at a minimum):
 All steps of the verification process
 The exact times of the infusion (starting and stopping)
 Vital signs of the patient at initiation of infusion and at set intervals throughout
the infusion
 All information on the blood product that was administered
 All information about the intravenous line that was used for the infusion
 All instructions given to the patient before, during, and after the procedure
Administration and Patient Response

There are a number of potential adverse patient reactions to the administration of blood
and blood products. Mild to moderate adverse reactions include localized reactions
around the intravenous line, urticaria, rash, pruritus, flushing, fever, restlessness,
tachycardia, palpitations, mild dyspnea, and headache. Severe, and potentially life
threatening, adverse reactions include rigors, severe hypotension, hematuria,
unexplained bleeding (disseminated intravascular coagulation - DIC), anxiety, chest
pain, respiratory distress, and anaphylaxis. The first step in any concern for a
transfusion reaction is to stop the blood product infusion. This step is then quickly
followed by interventions as designated by the protocols in place at individual facilities.
Central Venous Access Devices

Several types of central venous access devices are available for patients. Central lines
are used for direct administration of intravenous medications, intravenous fluids, and/or
blood products to the central venous system. Common locations for central venous
access devices include access to the superior vena cava, inferior vena cava, subclavian
vein, femoral vein, and internal jugular vein. Central venous access devices have
specific instructions for use, care, and maintenance of the devices.
Patient Education
Many patients will be familiar with peripheral venous access, where short-term
intravenous catheters are used to administer intravenous medications and fluids. Some
patients, though, will require longer-term access or have medications ordered that are
caustic to the peripheral venous paths. These patients qualify for the placement of
central venous access devices. Central venous access devices allow intravenous
medications, fluids, and blood products to release into the robust central venous
system, instead of the more delicate peripheral venous system. Common reasons for
needing a central venous access device include long-term intravenous antibiotic
therapy, chemotherapy, parenteral nutrition (TPN), and simultaneous intravenous
medication administration.
Access Devices
A tunneled catheter is placed in a central vein (usually the subclavian), then
“tunnelled” through the skin where it exits somewhere on the chest. The “tunnel”
provides stability and helps to provide an infection barrier for long-term use of this type
of device. Examples include a Hickman®, Groshong®, or Broviac® catheter.
An implanted port is also tunnelled beneath the skin, and a catheter is threaded into
the superior vena cava. The port can be placed subcutaneously and accessed as
needed. Examples of this type of device are the PowerPort®, Port-A-Cath®, and
SlimPort® Dual-Lumen Rosenblatt™.
A peripherally inserted central catheter (PICC) is usually placed above or below the
antecubital area on the non-dominant arm and then advanced through the peripheral
vein until the tip rests in the superior vena cava or cavoatrial junction. These lines may
be left in place for long periods.
Access Maintenance
Nurses caring for patients with these devices will need to know how to care for them.
Since these central venous access devices are in place long-term, cleaning and
maintenance of the line will be required. Strict sterile technique is always required
when accessing the line or changing the dressing of a central venous
device. Chlorhexidine solution is often used for cleaning the individual lumens and
insertion site of the device. Nurses and patients alike should wear a face mask when
accessing the line or changing the dressing. The device line(s) may need to be routinely
“locked” or flushed with normal saline or low-concentration Heparin when not in use to
prevent clotting of the catheter. Dressing changes should also be performed every 2–7
days, depending on the type of dressing used and protocol of the facility.
Dosage Calculation
Medication dosage calculation requires familiarity with basic arithmetic, ratio and
proportion, and algebra. Different measurements systems exist in the world, including
the metric system, household measurements (teaspoons, tablespoons, cups, etc.),
and apothecary measurements (ounce, minim, dram, etc.). In medicine,
most adult doses differ from pediatric doses for the same medication. While adult
medication follows a standard dosing guideline, most pediatric medications
follow weight-based dosing. It is critical for nurses to know and understand how
medications are dosed, which measurements to use, and provide the education needed
for patients to understand the same.
Calculations
Many medication dosages, especially in the pediatric population, are based on body
weight in kilograms (kgs). To convert weight from pounds to kilograms,
simply divide the weight in pounds by 2.2. To find the dose of a medication, take the
prescribed unit (mg, ml, cc, etc.) of the medication and multiply it by the patient’s weight
in kilograms.
Depending on whether the prescribed order is for a total daily dose or multiple timed
doses, the nurse will be responsible for making sure the right dose is given at the right
time, to the right patient. If trying to figure out how much of a medication to give at each
dose, the total daily dose should be divided by the number of times the dose is given
during the day. Doses may be given once daily (QD), twice daily (BID), three times a
day (TID), or four times a day (QID). If scheduled at specific times, doses may be given
at specific hourly intervals or before or after significant events, such as meals or before
bed (HS). The use of the abbreviations given in the previous two sentences are
generally not recommended. They are provided for informational purposes only. All
medication orders with confusing or unclear abbreviations should be questioned and
clarified with the ordering provider.
Intravenous fluids are given over a period of time. The rate of delivery must be
calculated in order to give the appropriate medication dosage in the ordered amount of
time. To calculate the amount of time in which an infusion should be given, take the total
volume of the solution divided by the total time in minutes in which it should be given
and multiplied by the drop/drip rate factor of the IV tubing being used. There are two
types of IV tubing: microdrip (60 gtts/mL) and macrodrip (10–20 gtts/mL).
Decision Making
When performing calculations for medication and solution dosage, critical
thinking skills are required to guide decision making. While calculation errors will
inevitably occur, calculation results should be critically analyzed to make sure they
make sense for the order and the client. Nurses need to carefully observe in which units
their medications are prescribed and maintain continuity of those units throughout the
medication calculation. Many medications and therapy calculations require an
independent two-nurse double check prior to medication administration. This helps to
eliminate many calculation errors and ensure appropriate wasting of specific products.
Independent double checks are required for high alert medications and infusions such
as narcotics, insulin infusions, heparin infusions, chemotherapy, blood products,
parenteral nutrition, and titrated infusions.
Pharmacological and Parenteral Therapies Study Guide for the NCLEX-
RN® exam
Expected Actions and Outcomes

Nurses are expected to know the expected action of, and intended outcomes of, any
medications given to patients. Not only should the nurse anticipate these outcomes for
their patients, they should also be able to educate and provide guidance to their patients
regarding these medications.
Information and Evaluation

Numerous resources are available to help nurses navigate medication education. Most
healthcare facilities have a drug formulary that nurses can reference. Pharmacists and
pharmacy staff are knowledgeable resources to discuss questions or concerns about
medications. Nursing handbooks, the Physician’s Desk Reference (PDR), or reliable
Internet resources may also be helpful.
Not only should nurses know where to gather unknown information about medications,
they should be aware of all the medications their patients may be taking, acutely or
chronically. Recognize that home remedies, herbal supplements, and apothecary are
common practices and should be appropriately documented if used by the patient. It is
important to understand each patient’s compliance with their prescribed regimen and if
they feel the medication is achieving the expected outcome. Patients should be
evaluated for adverse events, side effects, interactions or toxicity from any medication
(or combination of medications). It is also good practice to regularly reconcile the
patient’s actual use of medications with what is listed in the medical record.
Clinical Decision Making

Clinical decision making is required in all aspects of nursing. Nurses must anticipate the
needs of their clients in regard to taking, tolerating, and sustaining medication therapy.
Medications are administered in a number of ways. Depending on their administration,
nurses should monitor for specific events. The bullets below help identify common
expectations with each medication administration type.
Oral (PO)
 Formulations—liquid, tablet, capsule, chewable

 Identify which medications can be crushed or must be taken whole.
 Some medications may be prescribed for sublingual (under the tongue)
or buccal (between cheek and gum).
 Monitor for choking.
Intradermal (ID)
 Formulation—injection
 After cleansing the injection side, use a small gauge needle, position the needle
flush to near flush (5–15 degree angle) with the surface of the skin, bevel side up.
Insert the needle into the skin in the dermal layer, and inject the solution.
 Volume <0.5ml
 Intradermal administration is most commonly used for sensitivity testing, such as
allergy and tuberculosis (TB) testing.
 Monitor for injection site reaction.
Subcutaneous (SubQ, SQ)
 After washing hands, donning gloves, and cleansing the injection site, position
the needle at a 45–90 degree angle to the site, squeeze the skin together (to
ensure entering the subcutaneous, fatty layer, and not intramuscular layer), insert
the needle into the skin bevel up, and inject the medication.
 Volume 0.5–1 ml
 Common injection sites: upper and outer area of the arm, front and outer sides of
the thighs, abdomen (outside of 2 in around the navel), upper and outer area of the
buttocks, and outer hip
 Subcutaneous medication administration is used for insulin and heparin
administration.
 Educate clients to rotate their sites if chronically using subcutaneous injection
sites to avoid tissue damage.
 Monitor for intended effects of the medication (e.g., decreased glucose with
insulin administration, therapeutic lab levels, etc.).
Intramuscular (IM)
 After washing hands, donning gloves, and cleansing the injection site, position
the needle at a 90 degree angle to the skin, bevel up, and insert into the
intramuscular tissue. Aspirate the syringe to check for blood. If blood appears,
withdraw the needle and restart administration. If no blood is present in the needle,
inject the medication.
 Max volume to be injected into one muscle for adults is 3 mL; children under the
age of 2 have a maximum volume of 1 mL.
 Common injection sites: deltoid, vastus lateralis, ventrogluteal, gluteus medius,
dorsogluteal muscles
 For children under 3 years old, the anterolateral thigh muscle (vastus lateralis) is
preferred.
 Needles of at least 1 inch in length are required to deliver medication
intramuscularly.
 Medications requiring IM administration: antibiotics and most immunizations
 Monitor for effects of medication, anaphylaxis, and injection site changes.
Topical
 Formulation—cream, ointment, patch

 It can be applied to the skin.
 Creams and ointments may be applied to specific areas of concern or on the
whole body. Follow the prescription and directions given with the medication.
 Monitor for dermatitis, non-improved or worsening of the condition being treated.
Transdermal
 Formulation—patch
 The option allows slow, continuous administration of medication.
 Patches are changed every 24–72 hours.
 Wash hands and don gloves. Apply the patch to a clean, dry, hairless, unbroken
area of skin. Rotate sites with every patch change to avoid skin irritation.
 Common application sites: upper arm, chest, back, flank
 Examples of medications that are available as transdermal patches: Fentanyl,
Scopolamine, Nitroglycerine, Clonidine, Nicotine, Methylphenidate, Lidocaine
 Monitor for dermatitis surrounding the sites.
 Ensure proper disposal of patches, especially narcotic patches, to eliminate
unintended transmission of medication.
Intravenous (IV)
 Formulation—infusion
 Medications are required to be administered through a venous access point.
 Intravenous lines may be peripheral or central.
 Medications that require venous access: injectable antibiotics, continuous
sedation drips, IV fluids, injectable steroids, etc.
 See more information in the previous section regarding central venous access
devices.
 Monitor for IV site reactions, phlebitis, infiltration, and device malfunction.
While these are the most common routes for administration of medication, be aware
there are still other routes available. Intrathecal (around the spinal cord), rectal, vaginal,
ocular (in the eye), otic (in the ear), and inhaled medication routes are available for
specific medications. These routes will be further explained in any medical surgical
nursing text.
Medication Administration
Proper and appropriate medication administration is one of the most important jobs a
nurse will encounter. There are numerous steps to be taken before, during, and after
administration of medications. Checking clients’ rights and the rights of medication
administration are crucial to ensuring safe delivery of healthcare. Most facilities have
protocols nurses are required to follow to assist in minimizing errors of medication
administration.
Patient Education
Patients and their caregivers will need to be educated on every aspect of their
prescribed medications.This includes education on the name, dosage, intended
purpose, potential side effects, potential interactions, and administration. Some
medications require specific storage instructions. Certain medications, such as
reconstituted antibiotics, some IM injections, and vaccinations must be refrigerated.
Other medications must not be exposed to light. Many medications need to be
discarded after specific periods. All medications should be stored out of the reach of
children and be protected against unintended use by others. Instruct clients to take their
full dose of medication for the duration instructed by the healthcare provider. This is
especially important for antibiotics. Clients should also know the indications for which to
call their healthcare provider with questions or concerns.
If the patient is being educated on a self-administered medication (inhaler, injections,
etc.), the proper technique should be taught along with how to properly dispose of any
unused drug and/or biohazardous materials (e.g., syringes/needles).
Information Review
Prior to administering any medication, you will need to review several bits of essential
information:
Review the “rights” of administration
 Right client
 Right medication
 Right dose
 Right route
 Right time
 Right documentation (also known as the sixth right)
Review pertinent patient data
 Vital signs
 Labs
 Current medications
 Medication interactions
 Diagnosis/diagnoses
Review the patient’s medical history (for contraindications) and listed

medication allergies.
Administering Medication
Many aspects are involved in the administration of a medication. First, one must have a
working knowledge of pharmacological principles (pharmacokinetics, administration
route, distribution, metabolism, and excretion) and understand how these principles
apply to patients and their medications.
Understand the proper preparation and administration of each medication, and keep in
mind that pediatric and adult routes of administration may differ.
Mixing Medications from Two Vials

At times, it may be necessary to mix two, compatible medicines from different vials prior
to injection. Combining insulin NPH and regular insulin is an example of this practice.
When drawing up these different insulins, first draw up the cloudy, insulin NPH,
followed by the clear, regular insulin. Also remember that prior to drawing up either
medication, both vials will need be cleansed with alcohol and the vials injected with the
same amount of air as the dose without touching either medication with the needle.
Documentation
Documentation is known as the ‘sixth right’ of medication administration. Nurses are
responsible for documenting the patient’s choices regarding medication administration.
This includes route, whether the medication was omitted, held, or refused, interactions,
effects, and any other observations.
Medication Reconciliation
A large number of medical errors occur due to poor or incomplete communication
regarding a patient’s medications. A medication reconciliation is a process that can
be used to prevent medical errors. It is particularly useful for newly admitted patients
and those being transferred elsewhere or discharged. Here is the process:
1. Make a list of the patient’s current medications and a list of newly prescribed
medications.
2. Critically compare the two and note discrepancies or inconsistencies.
3. Report the findings to the appropriate healthcare provider and document the
nursing actions.
Remember that all over-the-counter medications, herbal or dietary supplements, blood
or blood products, vaccinations, contrast or other diagnostic agents, and radioactive
medications should be included on both of the lists.
Titration
A titration is an adjustment in the dosage of a given medication based upon certain
parameters or criteria. These will usually be defined in the healthcare provider’s
order for the medication. The two most common types of medications used in this way
are insulin and certain blood pressure medications.
Handling and Disposal

Each facility or agency will have its own specific guidelines as to the handling and
disposal of unused medication. They will also have specific guidelines on the handling
of specific medications such as narcotics and chemotherapy. Patients will need
education on the process of taking and managing medications at home. Nurses should
indicate which patients need specific supplies such as needles, syringes, sharps
containers, and information regarding community disposal sites/narcotic collection days.
Evaluation
Always verify the medication order for accuracy. Ensure that all aspects are correct and
that the order is valid and signed by the prescriber. The nurse will be held responsible if
medications are administered in an incorrect order, an incorrect dose, or on the
incorrect patient.
How to Prepare for Physiological Adaptation
General Information
Often, a patient will need some sort of physiological adaptation to preserve and
maximize physiological integrity. These questions deal with providing appropriate
care for patients with chronic, acute, or life-threatening health conditions and any
adaptations required to improve their situations.
Body System Alterations

A patient’s body undergoes numerous alterations in response to an illness, disease
process, intervention, and/or surgery. Recognizing these alterations help to implement
proper care to return the patient to a more “normal” state of health. Nurses must explain
these adaptations and resultant changes in patient care to help patients understand the
reason behind these interventions.
Patient Assessment
Every patient’s care begins with your assessment of the health and psychological status
of the patient. This includes not only alterations due to illness, disease,
or interventions/treatments, but also the patient’s ability to cope with his or her
health situation and adaptation to an altered (sometimes permanently) state of
impairment. Patient assessment may also extend to the patient’s family and
external support system as well.
Specific Situations
The following are some of the more important clinical scenarios in which you will be
required to perform these functions:
Drainage Tubes
Any wound or tube drainage must be closely monitored. Pertinent characteristics of
drainage assessment include monitoring for changes in color, consistency, and volume.
Common drainage sites include surgical wound drains, respiratory secretions, chest
tube drainage, and negative pressure wound therapy. Be familiar with the appropriate
care involved in monitoring each. Nurses must be able to perform
important interventions with drainage tubes including keeping dressings occlusive,
monitoring for leaks or damage to the drainage systems, maintaining the drains (i.e.,
stripping,emptying, maintaining suction), and changing of equipment.
Radiation Therapy
Patients undergoing radiation therapy will need to be closely monitored for systemic
and localized effects of treatment. Common adverse reactions can include: alopecia,
damage to the skin and mucosa, fatigue, immunosuppression, etc. Also be familiar with
appropriate lifestyle modifications to discuss with your patient such as proper dietary
modifications and sunlight exposure precautions.
Prenatal Conditions
Understand how to identify potential prenatal complications as well as give
appropriate intervention during complications from pregnancy, labor, and/or delivery.
Common prenatal complications include constant or excessive bleeding, chemical
pregnancy, or molar pregnancy. Complications of later pregnancy, labor, and/or delivery
include eclampsia, gestational diabetes, still-birth, birth positioning, and birth trauma.
This may also include complications from previous surgical cesarean sections. Nurses
should frequently monitor vital signs, especially heart rate and signs of fetal or maternal
distress.
Infectious Diseases
Be familiar with the signs and symptoms of infectious processes. This
includes localized findings (pustule, erythema, swelling, etc.) as well as systemic
signs (fever, chills, gastrointestinal changes, fatigue, etc.). Understand
common incubation periods for various infections, and be able to link a patient’s
history of exposure or contact with your clinical findings. Lastly, be familiar with
various treatments for infectious processes (bacterial, fungal, viral) as well as specific
interventions based on affected body systems (respiratory versus genitourinary versus
gastrointestinal, etc.)
Invasive procedures
Understand the role of the nurse during invasive procedures. Many of these are done
at the bedside, so a general, working knowledge is critical. Understand how to identify
the patient and verify the order, gather the supplies, and set up for the procedure (i.e.,
sterile field if necessary), assist and monitor the patient during the procedure, assess
and monitor the patient post procedure, and how to properly document the procedure in
the medical record. Examples of such procedures include a central line (know patient
positioning, preparation, monitoring, etc.); thoracentesis (patient positioning,
preparation, specimen care, post-procedural care, etc.); bronchoscopy (patient
preparation, sedation/general anesthesia, post-procedure monitoring, etc.), and lumbar
puncture (patient preparation, patient positioning, sedation if needed, vital signs, etc.).
Phototherapy
Be familiar with the uses of phototherapy for both adults and newborns. Phototherapy is
most commonly used for physiologic jaundice in neonates. Potential complications of
phototherapy include eye damage (all clients should wear protective eye gear while
under phototherapy), hyperthermia, and medication interaction (i.e., ibuprofen, diuretics,
specific antibiotics). Understand how to implement therapy per the practitioner’s order
as well as monitor for therapeutic effectiveness.
Hypo and Hyperthermia

Understand the risk factors for the development as well as the signs and symptoms of
both hypo- and hyperthermia. Hypothermia is defined as a core body temperature less
than 95 degrees. Hyperthermia is a core body temperature greater than 99.4
degrees. Nursing interventions to correct these conditions include correcting
underlying disorders; hydration and cooling; wet packs for hyperthermia; and warming
packs, warming blanket, and warm fluids for hypothermia.
Ventilator Use
Understand the indications for the use of a ventilator as well as the many potential
complications of their use (alveolar overdistension, cardiac complications, oxygen
toxicity, hypo/hyperventilation, infection, etc.). While many facilities have
specialized respiratory therapists who closely monitor these patients along with the
nurse, it is important to have a working knowledge of the care of the patient on a
ventilator.
Wound Care
Be familiar with the signs and symptoms of wound infections including
wound temperature changes, erythema, edema, and purulent drainage. Nurses should
educate patients on smoking cessation, improved dietary changes, proper wound
positioning, adequate hydration, dressing changes, wound care, and early signs of
wound deterioration to improve wound healing and early detection of concerns.
Understand how to monitor drainage devices in a postoperative patient.
Peritoneal Dialysis
Be familiar with the indications for and frequency of peritoneal dialysis. Know how to
monitor a patient before, during, and after this procedure, and be familiar with common
complications and troubleshooting measures used during the treatment to ensure its
safety and effectiveness. Nurses should especially monitor for fluid and electrolyte
imbalances, consistency and volume of drainage, and patient vital signs.
Suctioning
Know the proper procedures for performing suctioning of
an endotracheal and/or tracheostomy tube, and oral and nasal passages. This also
includes preoxygenation prior to and in between suctioning sessions when
indicated/necessary. Always remember that when performing deep suction, the nurse
should initiate suction while withdrawing the catheter, not during the insertion.
Alterations in Body Systems
Patients may experience alterations in bodily systems. This includes patients at risk
for aspiration, skin breakdown, insufficient vascular perfusion, complications from
disease, and any changes from baseline status. Nurses not only monitor their patients
for these risks, but also educate the patients and their caregivers how to manage these
changes. It is critical for a patient’s recovery to adapt to these alterations whether it is
thickening liquids to reduce aspiration after stroke or using a walker for stability after a
hip surgery.
Ostomy Care
Be familiar with the care of patient and patient education for all ostomies
including bowel diversion ostomies, tracheal ostomies (tracheostomy),
and enteral ostomies (gastrostomy tubes or buttons). Specifically, understand the
techniques used to maintain patency of each, prevent complications of each, monitor
intake and output (as appropriate) for each and to ensure proper placement and
functioning. Stomas of these diversions should be pinkish-red in color without skin
excoriation or breakdown.
Seizures
Understand the difference between primary and secondary seizure disorder as well
as the signs and symptoms of the many different types of seizures
(absence, tonic, clonic, grand mal, etc.). Be familiar with your responsibilities for
patient care during a seizure (patient safety, etc.) and proper postictal care, including
proper documentation of the seizure.
Pulmonary Care
Be familiar with all aspects of pulmonary hygiene care from simple techniques like
coughing and deep breathing to more complicated procedures like vibration,
percussion, and postural drainage for the removal of respiratory secretions. Understand
how to use and teach incentive spirometry. Specifically, understand proper patient
positioning during postural drainage, as well as proper technique and location for
percussion and vibration.
Increased Intracranial Pressure

Be familiar with the etiology, signs and symptoms, diagnosis, monitoring and care of
patients with increased intracranial pressure. This includes all invasive and non-invasive
monitoring (CT, ventriculostomy, etc.). Monitor for changes in consciousness, mental
awareness, and physical signs such as pupil size changes and changes in motor skill.
Also be familiar with treatments for increased intracranial pressure depending on the
underlying cause and severity (pharmacologic management, procedures/interventions,
etc.).
Post-Operative Care
Be familiar with the principles of postoperative care for patients who have
received conscious sedation and/or general anesthesia. Understand
common postoperative complications (bleeding, pain, infection, etc.) and how to
effectively monitor for them and intervene when appropriate to prevent them. Review
the procedures for removing sutures and/or staples. Educate patients and their
caregivers on any post-operative instructions such as signs of infection, wound
disruption, medications, and dressing changes as indicated.
Evaluation
Nursing care will always include an evaluation of the patient’s response to many of the
therapeutic interventions discussed above (surgery, radiation therapy, medications,
etc.). Evaluate the patient’s progress toward achieving his or her individual treatment
goals. This process typically has five steps: collection of data on the current health
status; analysis of the data; comparison of the analyzed data to the patient’s expected
outcome; determining the success/failure of specific interventions using critical thinking
and professional judgement; and deciding to continue.modify, or discontinue a specific
plan of care based on its effectiveness or lack thereof.
Patient Education
Also incorporate education into patient care to promote the patient’s progress toward his
or her health goals. Be mindful of all intrinsic and extrinsic factors that can help or
hinder the patient’s progress. For example, the presence of a complicating intrinsic
factor, such as diabetes, will require special education and attention to improve the
patient’s self-care and implementation of healthy lifestyle choices. Likewise, an
extrinsic factor, like a strong family support system, should be maximized to help
patients fully return to their optimal state of health. Educating patients on how
to maximize their strengths and minimize weaknesses is critical to improving their
overall outcome and health.
age 2 Physiological Adaptation Study Guide for the NCLEX-RN exam ®
Fluids and Electrolytes

Proper nursing care is essential with regard to a patient’s balance of fluid and/or
electrolytes.
Signs and Symptoms of Imbalance

Recognize the signs and symptoms associated with both excess and deficient fluid
volume (hypovolemia and hypervolemia) and important electrolytes (sodium,
potassium, calcium, magnesium, phosphate, and chloride). Understand the most likely
cause of these imbalances given the current health state of the patient as well as the
proper management of these conditions.
Fluid
Hypervolemia is an excess of body fluids (plasma). Underlying causes can vary.
Common causative factors include an increased sodium level (hypernatremia), the
inability to clear excessive fluids/supplementation effectively, and organ failure (heart,
renal, and/or hepatic). Hypervolemic patients may
demonstrate hypertension, dyspnea/shortness of breath,
abdominal ascites, peripheral edema, distended jugular veins, and tachycardia.
Monitor for bounding pulses and adventitious breath sounds (rales, crackles)
throughout the exam.
Hypovolemia is the deficit of body fluids and may occur in response to loss
via hemorrhage, dehydration, vomiting, and diarrhea. Clinical signs of hypovolemia may
include hypovolemic shock, decreased cardiac output, metabolic acidosis, multisystem
organ failure, coma and death, if uncorrected. Weak, thready pulses, shallow breath
sounds, sunken facial features, and poor skin turgor may be assessed during
episodes of hypovolemia.
Electrolytes
 Sodium: 135–145 mEq/L. Understand the most likely causes and manifestations
of excess sodium (hypernatremia) and sodium deficits (hyponatremia).
Understand the direct inverse relationship to fluid. Know the likely endocrine
disorders that primarily manifest with sodium imbalances (diabetes
insipidus, syndrome of inappropriate antidiuretic hormone/SIADH).
Symptoms of hypernatremia include thirst, confusion, neuromuscular excitability,
seizures, and coma. Symptoms of hyponatremia include nausea/vomiting,
headache, confusion, fatigue, restlessness/irritability, muscle weakness,
seizures, and coma.
 Potassium: 3.7–5.2 mEq/L. Understand the most likely causes and
manifestations of excess potassium (hyperkalemia) and deficits (hypokalemia).
Hypokalemia may occur in the event of diuretics, laxatives, corticosteroids,
vomiting/diarrhea, hypomagnesemia, dialysis, insulin overdose, alkalosis,
refeeding syndrome, and anorexia. Hyperkalemia may occur in the event of
acute/chronic kidney disease, heparin, lithium, congestive heart failure, cirrhosis,
sickle cell disease, insulin deficiency, acidosis, digoxin toxicity, and potassium
supplementation. Peaked T-waves are often noted with hyperkalemia,
whereas decreased T-wave amplitude is characteristic of hypokalemia.
Neuromuscular changes are also common in the event of either hypo or
hyperkalemia.
 Calcium: 8.5–10.6 mg/dL. Understand the endocrine feedback
system responsible for calcium regulation. Know the most common
pathophysiologic causes of calcium excess (hypercalcemia) and deficits
(hypocalcemia) as well as common medications that can trigger calcium
imbalance (thiazides, lithium, phenobarbital, corticosteroids, etc.). Symptoms of
hypercalcemia include fatigue, depression, confusion, anorexia, nausea,
constipation, renal tubular defects, polyuria, short QT interval, and arrhythmias.
Symptoms of hypocalcemia include fatigue, cramping, weakness, paresthesias,
altered mental status, hypotension, prolonged QT interval, and arrhythmias.
 Magnesium: 1.7–2.2 mg/dL. Understand the underlying endocrine and disease
processes that commonly affect magnesium levels along with medications that
can potentially trigger hypermagnesemia (antacids and laxatives) as well
as hypomagnesemia (diuretics, antibiotics, cisplatin, PPIs, etc.). Symptoms of
hypermagnesemia include neuromuscular symptoms, muscle weakness,
nausea/vomiting, shortness of breath, cutaneous flushing, hypotension,
bradycardia, and hypocalcemia. Symptoms of hypomagnesemia include muscle
cramps, hyperreflexia, depression, generalized weakness, anorexia, vomiting,
convulsions, apathy, hypertension, ventricular arrhythmia, and death.
 Phosphate: 0.81–1.45 mmol/L. Be able to identify the disease processes,
medications, and endocrine dysfunctions that produce phosphate
imbalances. Be able to identify the clinical manifestations of both hypo and
hyperphosphatemia. Symptoms of hyperphosphatemia include muscle cramps,
numbness around the mouth, bone and joint pain, weak bones, rash, and itchy
skin. Symptoms of hypophosphatemia include weakness, trouble breathing, bone
fractures, anorexia, tooth decay, and irritability.
 Chloride: 97–107 mEq/L. Understand the main metabolic causes for low
chloride levels or hypochloremia (metabolic alkalosis, respiratory
acidosis, hyponatremia, etc.), as well as disease processes that can produce it
(cystic fibrosis, etc.). Be able to recognize the clinical signs and symptoms
of hypochloremia including fluid loss, dehydration, weakness, fatigue, increased
work of breathing, and diarrhea or vomiting. Increased chloride levels,
or hyperchloremia, can be the result of numerous disease processes (renal
disease, diabetes, hyperparathyroidism, etc.) and through fluid losses (diarrhea,
dehydration, diuresis). Be familiar with the common clinical manifestations of
hyperchloremia such as fatigue, muscle weakness, excessive thirst, dry mucous
membranes, and hypertension l.
Pathophysiology Application
Caring for a patient with either fluid or electrolyte imbalances or both requires you to
carefully consider and anticipate both the pathophysiologic responses to the
condition and its treatment. In addition to recognizing the signs and symptoms of these
disorders, you must also be aware of the risk factors for their development. This should
be an important part of your overall assessment and evaluation.
Patient Care Management

Care of hypervolemia generally includes fluid/sodium restriction and diuretic
medications to clear excess fluid. In hypovolemia, treatment is directed at correction of
the underlying cause and is dictated by the patient’s severity. This may range from
intravenous fluid supplementation to proper patient positioning (Trendelenburg),
plasma expanders, and the administration of blood and blood products.
Management of a patient with electrolyte imbalance(s) will rely heavily on correcting the
underlying cause (when applicable) along with replacement of depleted
electrolytes when indicated and interventions to deplete excesses when applicable.
Some of these management scenarios can include emergent interventions, so be
familiar with these (cardiac manifestations, seizures, etc.).
Evaluation of Patient Response to Treatment

As with any treatment given, ongoing patient evaluation will be necessary to ensure
patient safety and effectiveness. This will include monitoring for clinical signs and
symptoms of normalization of fluids and electrolytes as well as over or
undercorrection. Serial lab draws and values will be utilized as well. Certain lifestyle
modifications (diet, fluid restriction, medications, etc.) may be necessary for long-term
maintenance.
Hemodynamics
The care of patients who require hemodynamic monitoring is complex. Understand the
unique pathophysiologic changes of each patient, as well as the basic aspects of care
for patients that require routine and advanced hemodynamic monitoring and
intervention.
Patient Assessment for Decreased Cardiac Output

Understand the physiological principle of: cardiac output (CO) = stroke volume (SV) x
heart rate (HR). Normal cardiac output of 4 to 8 L/min is necessary to meet the body’s
physiological demands. When this falls short, impairment (mild to severe) will occur. Be
familiar with the clinical signs of diminished cardiac output such as diminished
peripheral pulses, hypotension, hypoxia, and reduced organ/tissue perfusion (and
its sequelae).
Cardiac Rhythm Strip Abnormalities

Being able to read a cardiac rhythm strip and identify abnormalities is essential for
prompt identification and intervention of potentially fatal arrhythmias. Know the proper
steps for reading a rhythm strip and the proper timing for all of
the waveforms, intervals, and complexes. Understand how to interpret abnormalities
in sinus rhythms (tachycardia, bradycardia, etc.), atrial arrhythmias [atrial flutter,
atrial fibrillation, supraventricular tachycardia (SVT), and premature atrial
contractions/complexes (PACs)], and ventricular arrhythmias [idioventricular rhythm,
ventricular tachycardia, agonal rhythm, ventricular fibrillation, Torsades de Pointes,
premature ventricular contractions (PVCs), and asystole]. Also be able to recognize the
various types of heart block (first, second-type I and II, and third degree as well as
bundle branch).
Be able to recognize the common physical signs and symptoms of cardiac
abnormalities and correlate them with abnormal electrocardiogram (EKG) findings.
Also be able to describe the altered path of electrical impulse/cardiac
depolarization from normal in each of the above disorders and correlate that with the
findings on an EKG (missing P waves, wide QRS complexes, etc.). Understand and be
able to distinguish between potentially life-threatening arrhythmias and more benign
ones.
Patient Care
Nursing care of patients undergoing altered hemodynamics is usually specialized, but
every nurse must have a basic knowledge of the principles of cardiac care.
Providing Patient Strategies

Patients with decreased cardiac output will require physical and psychological
modifications to cope with their condition. Provide patients with the proper strategies
for activity modification, rest, diet, pain modification in addition to ways to deal with
cognitive/emotional changes that may result from impaired cardiac function. Also
remember that these patients may need proper planning for safety and reduction of
risk due to their condition.
Interventions
Be familiar with emergent intervention protocols for cardiac emergencies (CPR,
ACLS protocols, etc.) and be able to initiate them. Also be familiar with the monitoring
and maintenance of cardiac pacemakers/defibrillators for patients with chronic cardiac
arrhythmias. When caring for patients who have just undergone placement of a
pacemaker, be familiar with the common complications of pacemaker placement
including insertion site infection, swelling, bleeding, damage to the blood vessels or
nerves, and collapsed lung.
Managing Care of Patients in Special Circumstances

Some cardiac patients will require special care and management depending on their
specific care plan and/or condition.
Arterial lines— The most common vessels used for surgical placement of arterial lines
include the radial and femoral arteries. Indications for arterial lines include need for
continuous hemodynamic monitoring, frequent blood sampling, and arterial blood gas
sampling. Absolute contraindications to arterial lines include absent pulse, full-
thickness burns over the insertion site, inadequate circulation to the extremities, and
Raynaud syndrome. Risk versus benefit should be assessed in clients with
anticoagulation therapy, atherosclerosis, coagulopathy, infection at the insertion site,
partial-thickness burns, previous surgery in the area, and synthetic vascular graft.
Pacing device— There are numerous external cardiac pacing devices available to
patients. Some familiar types include transcutaneous, transvenous, and epicardial.
Indications for external cardiac pacing devices include symptomatic bradycardia, sinus
node or AV node dysfunction, and traumatic cardiac injury. Common problems with
pacing devices include failure to trigger the appropriate cardiac chamber,
underdetection or overdetection of cardiac signals, and unusual EKG findings due to
incorrect pacing. Pacing devices are programmed prior to and throughout therapy as
indicated and may need routine battery changes and software updates. Review other
interventions that may also be indicated in the management of pacing devices.
Telemetry— Care of patients on telemetry devices (i.e., continuous cardiac
monitoring) may be done solely by the nurse or in conjunction with a specially trained
technician. Ultimately, the nurse is responsible for the analysis, interpretation, and
intervention(s) provided based on the telemetry reading.
Hemodialysis or continuous renal replacement therapy (CRRT) — Understand and
be familiar with the various types of venous access that may be used for these patients
(arteriovenous shunt, fistula, dialysis catheter, or graft) and the care that they require
(anticoagulant therapy, careful fluid balance, central line management, etc.) as well as
how to properly monitor a patient before, during, and after therapy. Common
complications from hemodialysis and CRRT include hypovolemia, hypotension,
hypertension, infection, and electrolyte imbalance.
Alteration in hemodynamics, tissue perfusion, and hemostasis— Understand and
be able to recognize patients with impaired perfusion of the cerebral, cardiac, and
peripheral tissues/organs. Be able to identify the signs and symptoms for each and
properly intervene when necessary. Nurses must frequently assess skin turgor, capillary
refill and monitor clients’ intake and output. Understand and be able to recognize the
risk factors for cerebral, cardiac and peripheral hemostasis, and when it is a desired
outcome (i.e., hemorrhage prevention postoperatively). The goal of care of patients with
any of these issues is to correct and treat any identifiable, underlying cause and
promote good tissue perfusion.
Page 3 Physiological Adaptation Study Guide for the NCLEX-RN exam ®
Illness Management
Nursing care with regard to illness management often involves more than simply
“providing care.” Comprehensive management will include the following tasks, which
help patients better manage their own illness recovery.
Data Reporting
Certain pieces of patient data must be reported immediately to the patient’s managing
practitioner. This may include adverse reactions and/or complications as discussed in
previous review sections. It may also include the patient’s basic and essential needs
and/or problems (physical, psychological, safety, etc.), any unexpected outcomes or
responses, and any substantial change in status/condition.
All patient baseline data should be available and accessible for nurses and healthcare
providers. This data helps support the critical thinking skills necessary to evaluate,
interpret, and assess the continuous patient changes.
A deep understanding of the patient’s pathophysiology is crucial to helping them
effectively during illness. This includes understanding all risk factors, etiologies, clinical
signs and symptoms, and potential complications of specific conditions. Knowledge of
pathophysiology helps to effectively create a care plan that prevents setbacks in a
patient’s recovery process.
Patient Education
A crucial aspect of illness management is the ability to properly educate patients on the
nature of their acute or chronic conditions. By doing so, patients gain empowerment and
can make informed decisions about their health and care. Proper patient education
starts with an analysis of the patient’s needs, deficiencies, and goals. The nurse must
then design and implement the proper education activities based on this information.
This process may also involve the patient’s family and/or caregivers. Be familiar with
the most common components of this type of education.
In addition, be aware of implementing a plan for those with a lifelong or terminal
condition. This will include education on self-care, modifiable risk factors, and available
resources. For clients with acquired immune deficiency syndrome (AIDS), special
education needs include reduction of risk potential for infection and spread of infection.
Interventions
Understand that recovery from an illness involves both intrinsic and extrinsic factors.
Some of these factors are innate to the patient (intrinsic) and others are not (extrinsic).
Be mindful of both when planning interventions for recovery. Remember that the
patient’s wellness comprises many aspects: biological, psychological, environmental,
behavioral, sociocultural, and adequacy of healthcare (culturally competent, accessible,
etc.) can and will impact recovery.
Gastric Lavage
Nurses may be responsible for performing gastric lavage if indicated. Common
situations that require gastric lavage include drug overdose, poisoning, and
gastrointestinal bleeding. Review the process in performing gastric lavage.
Continuity of Care
Nurses are the most important provider of continuity of care during the course of a
patient’s illness or condition. Understand the proper ways to provide seamless,
effective, and efficient care that meets your patient’s ongoing and changing needs. This
may include education, coordination of care, identification of community resources,
ongoing follow-up and continual reassessment and adjustment of the care plan.
This also extends to emergency care nurses who must help their patients understand
important aspects of their condition, signs of problems, and how to properly follow up
with continued care in the community.
Ventilation/Oxygenation
Patients with impaired ventilation/oxygenation will require special nursing management.
Be familiar with many of the indices measured by an arterial blood gas (SaO2, PaO2,
PaCO2, pH, and HCO3), as well as components of pulmonary function testing, pulse
oximetry, and spirometry. Understand that these patients will and often do require
care from a multidisciplinary healthcare team.
Evaluation of Treatment
As with any other type of nursing care, nurses must provide continuous evaluation of
the effectiveness of illness management. Assess each patient’s progress and
achievements to ensure they are meeting the expected outcomes as outlined in their
planned goals.
Medical Emergencies
Nurses play an integral part of patient care during a medical emergency. Minimally,
knowledge of emergent patient care should include all of the following:
Application of Knowledge and Skills

When caring for a patient experiencing a medical emergency, nurses must know the
most effective way to intervene. This will involve assessment of the patient in a rapid
way and minute-to-minute interventions. Be aware that the patient’s status may change
rapidly and unpredictably.
Pathophysiology
Knowledge of the patient’s pathophysiology is paramount in an emergent situation. It is
essential to gather thorough details of the patient’s past medical history and current
medical status to determine the most appropriate intervention. Conversely, knowing this
information can also help to predict the possibility of inadvertently inducing a medical
emergency during a treatment or procedure.
Nursing Procedures
Specific nursing procedures in medical emergencies will depend on the emergency that
is being treated. Generally, procedures will be prioritized by ABCs (airway, breathing,
and circulation). There are a number of medical conditions that can predispose a
patient to a medical emergency that can involve the cardiovascular, respiratory,
gastrointestinal, renal, central and peripheral nervous system, musculoskeletal,
gynecological (including pregnancy), otorhinolaryngologic, ophthalmic, oral, and dental
systems.
Psychomotor Skills
Nursing psychomotor skills vary during a medical emergency, depending on the
patient’s needs. In general, nurses must know how to perform cardiopulmonary
resuscitation, assess and clear a blocked airway, and perform the Heimlich
maneuver, in order to (minimally) establish an airway and maintain breathing and
circulation if clinically indicated.
Emergency Care
Other aspects of emergency care that nurses should be familiar with are respiratory
support (bag-valve-mask, ventilator use, etc.), the use of an automated external
defibrillator, advanced cardiac life support protocols and procedures (ACLS), as well
as what steps to take in the event of an emergent wound disruption
(evisceration and/or dehiscence).
Patient Education
Even though a medical emergency does not easily lend itself to patient education,
nurses must do their best to reassure and inform patients of their current status,
planned interventions, and any other critical information throughout the emergency
situation.
Notification
Nurses will often be the first member of the medical team to notify a healthcare provider
if a client is experiencing an unexpected response and/or an emergency situation.
Unexpected responses may result in vital sign changes, changes in patient status, and
reactions or severe side effects of medical therapies.
Evaluation
With any emergency treatment and/or intervention, nurses are responsible for
evaluation and documentation of all events that occurred, including the patient’s
response. This includes the establishment of an airway, the restoration of breathing,
hemodynamic and peripheral pulses, and the re-establishment of the patient’s
physiological stability.
Pathophysiology
It cannot be overstated how important a nurse’s understanding of pathophysiology is to
the proper care and treatment of any patient with either an acute or chronic condition.
Identification
Nurses will need to be able to correlate all clinical signs, symptoms, diagnostic findings,
potential risk factors, complications, and expected outcomes for any pathophysiologic
disorder (acute and chronic) for all patients.
General Principles
The general principles of pathophysiology are:
 the four stages of infection

 the five signs of infection
 the four phases of bacterial growth
 the six stages of viral growth
Nurses should also be familiar with the phases of the inflammatory process as well
as the phases of wound healing. Understand the innate and adaptive immune
responses and when each occurs in the disease process. Also understand
the principles of active and passive immunity.
Response to Therapies
For most patients, the response to therapy is predictable and expected. However, there
are patients who may and do have unexpected responses to various therapies.
Patient Assessment
Be aware of the potential risks, complications, and adverse reactions of any
intervention, procedure and/or therapy that is given to the patient. Be able to discern
between inadvertent/accidental adverse responses (puncture of a vessel during a
surgical intervention, retained surgical sponge, etc.) and undesirable yet common
adverse events (catheter associated urinary tract infections, nosocomial infections,
etc.) and assess patients for both. Clients with concern for altered mental status, stroke,
or traumatic brain injury should be monitored for signs of increased intracranial
pressure. Hemorrhage may also occur in the event of surgery, postpartum recovery,
stroke, and trauma.
Complications
Be able to recognize the signs and symptoms of expected and unexpected
complications. Understand the risk factors that make them more likely and how and
when to appropriately intervene when caring for patients that have undergone a
particular therapy, intervention, or procedure. This includes emergency care as well.
Recovery
Complication recovery is very similar to recovery from a primary medical condition. If a
complication does occur, understand and be able to provide the appropriate nursing
care to promote your patient’s recovery. For example, a nurse would need to provide
interventions, care, and assessment for the expected outcome following a catheter
associated urinary tract infection (CAUDI) as you would for an infection that is not
associated with the use of a urinary catheter.
Page 1 Psychosocial Integrity Study Guide for the NCLEX-RN exam ®
How to Prepare for Psychosocial Integrity

General Information
While under nursing care, some patients will experience needs that are not physical.
Some patients react to the stress of medical treatments by exhibiting unusual emotional
and social behaviors and are in need of mental health as well as physical support. Other
patients present with acute or chronic mental illness that requires careful expertise and
nursing support. Assessing and caring for the patient’s psychosocial integrity will be
discussed throughout this document.
Abuse and Neglect

Abuse and neglect can take many forms. Abuse can be physical, sexual,
or emotional. Neglect is the absence of appropriate care, a form of abuse that often
manifests in physical and emotional ways. Both may affect patients of any age.
Reporting
All suspected cases of child abuse must be reported to the appropriate authorities or
government agency. Nurses are mandated reporters and may face legal action if they
fail to report suspected abuse. Many states have laws that mandate when and how to
report known or suspected cases of abuse and neglect. Nurses are responsible for
following the appropriate protocol for reporting these actions as well
as documenting the abuse and/or neglect in the patient’s chart. Patient findings should
be documented clearly and objectively in the medical record, as they may be used
during legal proceedings later.
Risk Factors
To be alert for and recognize potential cases of abuse and neglect, the nurse must be
aware of the risk factors for each type. Remember that risk factors are not a sign of guilt
on the part of the abuser. However, when more than one risk factor is present in any
case, the patient’s overall risk for abuse increases substantially.
Risk Factors for Child Abuse

These are risk factors for child abuse:
 Past or present spousal abuse

 Parental perception of stress
 Life changes in the family
 Young age at the birth of the first child
 Low education level
 Little to no prenatal care
 No phone or having an unlisted phone number
 Low income or current unemployment
 Evidence of harsh discipline
Elder Abuse
While elder abuse can affect both males and females, the most common victims
are women over the age of 75. Elder abuse also commonly occurs to patients with
physical and/or mental impairment and those who are dependent on their abuser for
daily care.
Risk Factors for Domestic Abuse

It is important to remember that domestic/spousal abuse can happen to anyone at any
socioeconomic level. These are risk factors for this type of abuse:
 Planning to leave or recently left an abusive relationship

 History of abusive relationship(s)
 Poverty, unemployment, and/or a poor living situation
 Separation or divorce
 History of abuse as a child
 Mental and/or physical disabilities
 Poor support system of family/friends or social isolation
 Witness to domestic violence as a child
 Pregnancy (especially unplanned)
 Age under 30
 Being stalked by a partner
Nursing Role
As a nurse working with a suspected or known case of abuse, it is important to
encourage open communication that allows victims to share their
problems. Educate them on what abuse and neglect is, and help them find resources
and information on their own. Nurses provide counseling and support as well as teach
coping strategies that victims can use. The nurse will often help plan interventions for
suspected or known abuse victims and be able to evaluate their response to
intervention.
In cases of elder abuse, the nurse should help caregivers understand the special needs
of older adults. This involves finding appropriate resources for support of the elder and
the caregiver. It is also important to note that a legally competent adult cannot be
forced to leave an abusive situation/relationship.
Behavioral Interventions
Nurses need to understand, recognize, and plan appropriate care when patients’ are
experiencing negative psychological effects due to stress, illness, or crisis. Intervention
is necessary when a patient is unable to or cannot properly evaluate reality. Nurses may
provide specific interventions to maintain a patient’s cognition.
Signs of Altered Mental Processes

Common signs of altered mental status include:
 Disorientation
 Altered mood
 Altered behavior pattern
 Inability to perform self-care activities
 Altered sleep pattern
 Altered perception of one’s surroundings
The patient’s treatment plan should be tailored to his or her specific needs and focus on
the structure, safety, and symptom relief/management that is needed in each individual
case. In addition, the nurse must be able to evaluate the patient’s response and adjust
nursing interventions as indicated.
Possible Interventions
Remember that each patient will have specific needs, depending on each individual
situation. In general, be familiar with all of the following interventions and be able to
incorporate them into the nursing treatment plan.
Interaction
Try to maintain and encourage the patient’s normal daily interactions and activities.
This normalcy helps develop more routine-based and structured behavior, which helps
maintain the patient’s functioning and provides a sense of purpose.
Observation
During the patient’s interactions and daily activities, maintain close observation of the
patient’s behaviors, attitudes, and responses. Evaluating and documenting reactions
to the plan can help in understanding what is working and where adjustments are
needed.
Relationship
It is important to develop an open and honest relationship with patients. Clearly
verbalize relationship expectations from the beginning to improve patient’s compliance
in formulating and progressing toward their goals.
Verbalizing
Patients need verbalized acceptance despite behavior that is inappropriate. This helps
build trust and understanding and will help as the nurse continues to remind them of
their individual goals for treatment.
Role-Modeling
Nurses must always role-model appropriate behavior and interaction around other
patients and staff members. This helps patients better understand what is expected
from them while reinforcing and supporting any discussions of behavior expectations.
Patient Responsibility
Encourage patients to accept responsibility for their own actions and behaviors. While
encouraging them, nurses must also show the patient support and guidance.
Therapeutic patient-nurse relationships naturally encourage this process.
Positive Reinforcement
Acknowledge and praise achievements. Additionally, discuss and analyze failures.
Nurses must show patients that they are involved and sincerely care about them.
Provide a source of accountability and support during the treatment process.
Patient Orientation
Orient and reorient patients so that they can be in touch with reality as much as
possible. Encourage family members, friends, and other visitors to do the same.
Group Therapy
For appropriate patients, group therapy can be a powerful treatment tool. Discuss this
with the patients, and encourage them to attend sessions. If patients are not receptive
at first, continue to provide gentle persuasion and encouragement to give it a try.
Patient Self-Control
Know and teach patients ways to achieve and maintain self-control over their behaviors.
If anxiety plays a role in acting out, provide appropriate coping strategies to help
control this as well.
Stress Management and Coping Mechanisms

A new medical diagnosis and/or undergoing a medical treatment
regimen (chemotherapy, surgery, etc.) will be stressful for most patients and their
families. Every patient has a unique set of coping mechanisms that he or she (and
family) will use to get through this time. Nurses play a critical role in this process.
Nurses need to be able to assess the level of stress, identify existing coping
mechanisms, teach or provide resources to learn necessary skills,
and evaluate whether or not a patient is coping well, intervening when necessary.
Human Responses to Stress

Every patient will react differently to stress. Some may verbalize their feelings while
others will not. Be able to identify the most common responses to stress to help patients
effectively deal with their situations.
Physical
The physiological effects of stress can produce an upset in the body’s equilibrium. The
increased demands placed on a patient’s body produce a “fight or flight”
response dominated by the sympathetic nervous system. Physical responses to
stress can increase a patient’s ability to recover from an illness and become more
susceptible to disease. Chronic stress can produce changes in certain organ
systems (ulceration in the gastrointestinal tract), atrophy of the lymphatic
system (thymus, spleen, and nodes), and adrenal enlargement. Nursing interventions
should focus on providing external adaptive resources such as supplemental O2O2,
proper nutrition, and increased physical activity to support a patient’s physical ability to
heal.
Psychological
Psychological changes produced by stress can alter or influence a patient’s emotions.
Patients may feel overwhelmed and become anxious. They may have drastic and/or
wide mood swings. Chronic states of stress may result in a depressive state. Patients
and their caregivers will often flow through stages of grief including rationalization,
hopefulness, anger, and despair. While the psychological response to stress is often
negative, occasionally a positive response, such as relief, may occur. Nursing
interventions should focus on ways to help reduce the psychological effects of stress
(anxiety reduction, relaxation techniques, anger management, etc.).
Cognitive
Some patients facing stressful situations may suffer cognitive problems as a result. The
disruption of daily life can leave them unable to process information about their
situations and environment and affect their decision-making ability. For patients
suffering with cognitive difficulties of stress, nursing interventions can focus on helping
patients think more clearly (organization, time management, etc.), which gives them a
sense of control over their situation.
Minimizing Stress
Nurses must identify ways to help their patients minimize the negative effects of stress.
It may be easier for some patients than for others, but it is important to understand that
stress will be present and may affect each patient.
Identify stressors— Talk with patients about what they perceive to be stressors.
Discuss which ones they may be able to modify and which are beyond their control.
Verbalization— Gently encourage patients to communicate their feelings regarding the
effects of stress.
Identify patient strengths— Help patients understand and utilize the resources they
do have, rather than focusing on what they lack.
Identify regular coping mechanisms— Discuss ways that a patient has successfully
dealt with stress in the past. Determine if his or her coping skills are adequate.
Find new coping strategies— Discuss other ways to deal with stress if a patient lacks
sufficient skills. Tailor the discussion and identify strategies that would most benefit the
patient’s situation.
Listen, support, and teach— Allow the patients to speak. Listen and acknowledge
their concerns. Provide support and encourage friends and family to do the same.
Teach new skills and strategies when able, or provide the proper resources to do so.
Recognition of the Inability to Cope

Again, each patient’s coping skills are different. Each will have a unique social support
system and set of problem-solving skills (or lack thereof) that influences his or her ability
to cope. Be alert for and recognize signs that a patient is not coping well.
Verbalization— Many patients will not volunteer that they are having difficulty coping.
Discuss this openly with them on a regular basis.
Decision-making problems— A patient that cannot make decisions or verbalize needs
will likely feel overwhelmed. Offer guidance to help the patient improve his or her ability
to function more normally.
Destructive behavior— Some patients will lash out or act aggressively when they are
overwhelmed. They may also engage in self-destructive behaviors such as self-harm or
even attempt suicide. Monitor these clients closely.
Physical signs— Anxiety, depression, gastrointestinal symptoms, headaches and
other vague, non-specific physical complaints may be physical signs of a patient’s
inability to properly cope.
Lack of emotional control— Patients may demonstrate emotional lability and have
erratic mood swings.
Irritability— General irritability is also a sign of poor coping. This may manifest as
complaints from everything from caretakers to meals and housekeeping.
Causes of Stress
Whenever a patient demonstrates the inability to cope, carefully consider the source(s)
of stress for each patient. This may help to identify and implement appropriate coping
interventions.
Serious illness diagnosis— conditions that are terminal, inoperable, or rare
Change in health— setbacks in treatment, nosocomial infections, complications from
medication or surgery
Support system problems— lack of social support or a dysfunctional support system
Lack of psychological resources— poor or inadequate coping mechanisms; lack of
knowledge or experience despite previous stressors or previous negative outcome with
a major life event/stressor
Situational crisis— a major life event that is viewed as a crisis to the particular
individual that is affected (loved one’s death, divorce, etc.)
Defense Mechanisms
Defense mechanisms are unconscious behaviors or reactions to a stressor or
stressful situation. Every patient will implement some sort of defense mechanism. The
nurse may become responsible for identifying these actions as well as determining if
they are helpful or harmful to the patient.
Denial— when a patient does not recognize or acknowledge a thought or feeling
Suppression— when a patient acknowledges a thought or feeling, but then ignores or
tries to hide it
Projection— when a patient believes that someone else has the same thought or
feeling
Acting out— when a patient uses disruptive or drastic behavior to express a thought or
feeling that he or she otherwise feels incapable of expressing.
Displacement— when a patient directs a thought or feeling to another, usually
powerless target
Isolation of affect— when a patient separates a thought or feeling from the rest of his
or her thoughts
Intellectualization— when a patient “rationalizes” a thought or feeling to avoid its
emotional impact
Regression— when a patient utilizes an immature behavior or reaction to deal with a
thought or feeling
Reaction formation— when a patient changes a thought or feeling to its exact opposite
and adopts that stance
Rationalization— when a patient denies his or her own personal thoughts and adopts
one or more explanations to justify the situation
Sublimation— when a patient turns a negative thought or feeling into an action that
produces a positive outcome
Dissociation— when a patient (in part) detaches him/herself from the current
situation/reality in order to avoid a thought or feeling
The Nurse’s Role

Provide plenty of opportunities for patients to express their thoughts, feelings, and
apprehensions. Discuss ways to set realistic goals for their health and learn
constructive methods of problem-solving. Alternatively, identify potential
helpful resources and discuss the importance of proper support systems to relieve
stress and improve coping skills.
Crisis Intervention
A crisis is a sudden, often unexpected, impactful event that has a significant
emotional effect on a patient and dramatically affects his or her daily life. Crises can be
a critical time where nurses can help patients effectively deal with multiple changes and
emotions to avoid a potentially negative health outcome.
Nursing Responsibilities
Nurses must first recognize when a patient is in crisis. When a crisis is determined, the
nurse should be able to handle these tasks:
Patient history with this problem— Identify all of the information contributing to the
current crisis situation.
Patient’s current feelings— Help the patient discuss and identify all of the emotions
present.
Current support systems— Assess the patient’s access to and functioning of his or
her available support systems.
Crisis intervention techniques— Protect the patient’s safety first, then provide
physical and emotional support to return them to pre-crisis functioning. Teach coping
skills when necessary.
Patient’s potential for harm or self-harm— Constant, sometimes one-on-one
supervision is often necessary to assess the potential for violent behavior that may be
self-directed (suicidal ideation, attempts, etc.) or toward others.
Crisis Intervention Goals

After gathering information regarding the situation, nurses should assess and develop
nursing diagnoses to implement an effective care plan. Goals should include:
Reducing stress— Teach effective coping skills such as relaxation, visualization, etc.
to help manage anxiety and stress. Encourage open communication about emotions,
and protect the patient from additional stress when possible.
Organizing a solution— Help the patient identify existing or find new support systems
and mobilize them based on his or her specific needs.
Returning to normal function— Ensure patients adhere to and follow the treatment
plan. This includes scheduling and attending regular follow-ups after the resolution of
the acute phase of the crisis.
Cultural Awareness and Influence on Health

Nurses must understand, evaluate, and respect the role of different cultural, ethnic, and
racial perspectives with regard to both health and the process of giving care. The
culturally competent nurse must recognize the patient’s world view in the context of his
or her own to provide care that is appropriate for the patient’s needs. Be flexible and
willing to incorporate new ideas and knowledge into the patient’s care plan.
Listening With Respect

Discuss with patients what their viewpoints, and listen carefully to what they say. Learn
more about their beliefs on both health and illness, doing so with tolerance and
understanding. Be open to incorporating potential non-traditional processes and
practices into your care plan at the patient’s request.
Surmounting Language Barriers
Identify language barriers and use medically-licensed interpreters to better gather
and understand information about the patient’s cultural practices and preferences. Be
sure to document how a patient’s individual language needs were met.
Providing Culturally Appropriate Care

Because a person’s culture is such an integral part of his or her overall health and
perception of care, it is essential to provide care and services that are in-line with a
patient’s cultural beliefs. Nurses must be culturally competent and respectful, even if a
patient’s beliefs do not coincide with their own. This type of care improves the patient’s
quality of care and outcome. Some examples of cultural competence include
allowing dietary restrictions based on faith (i.e., Hindu/beef, Jewish/kosher);
respecting family hierarchy (i.e., patriarchy, decisions made by elders); and
providing religious support (i.e., access to priest/chaplain, ability to perform prayer
positioning).
If a nurse’s personal beliefs are so drastically different than the patient’s and the nurse
does not believe that he or she can adequately care for the patient, the nurse is allowed
to speak with a supervisor to ask for a change of assignments. However, if no other
skilled, trained nursing staff is available or if the patient would be at a health
disadvantage with the nurse’s change in assignments, it is the assigned nurse’s
responsibility to provide the best care. Actions otherwise may be perceived as an
abandonment of the patient or neglect.
Evaluation of Effectiveness
Always evaluate the effectiveness of your care plan with your patients. Always take the
time to listen to the patients, their view of health, illness, and/or treatments. Remember
to use the resources available to the nurses and patients such as interpreting services,
support groups, and cultural education.
End-of-Life Care
Every patient will have a different view of end of life based on personal, religious, and
cultural backgrounds or experiences. Nurses tailor end-of-life care based upon these
individual factors.
Patient Rights
Nurses must impartially relay medical information and treatment options, provide
support, and educate patients or caregivers when necessary. It is important to
remember that every patient has the right to make an informed decision for treatment
as well as theright to refuse it altogether. Allowing patients some control in their
choices in how to spend their last days of life may reduce anxiety and fear with the
process. Discuss the patient’s individual goals and wishes with him or her (and family),
and then respect those wishes and priorities.
Communication with Patient and Family

Nurses help to prepare patients and families regarding end-of-life expectations. This will
include physical, emotional, and psychological changes; decline or deterioration; and
the act of dying itself. Also be prepared to help the patient’s family deal with increasing
anxiety as death approaches. This includes the expression that the healthcare team is
doing all it can to make the patient comfortable at the end of life.
Post-Death Responsibilities
After a patient dies, a nurse must acknowledge the loss, express sympathy to the
family, and then, only after asking if they wish to do so, provide an opportunity for the
family to view the patient’s body. Care of the deceased patient continues as nurses then
prepares the body, completes post-mortem washing, shrouding, and transporting to
appropriate facilities (i.e., morgue, funeral home, operating room if organ donation is
indicated).
Family Dynamics
Each family and family member will have unique strengths and weaknesses in the
setting of patient care. Ideally, a patient’s family should support, listen to, and empathize
with one another. However, most families will have some level of dysfunctional
communication. When this is severe, it can lead to impairment, which may require
nursing intervention such as care conferences, individual conversations, and
outsourcing to support teams/groups.
Causes and Signs of Dysfunctional Families

The reasons for family dysfunction are numerous and varied. They may include:
genetics, developmental stages of each family member, family history, composition of
family members (i.e., parents, children, grandparents, stepparents, stepchildren, etc.),
and the lifestyle of the family. Signs of dysfunction can include poor
communication (often resulting in anger, hostility, or silence), poor coping
mechanisms, and lack of or poor use of outside support systems.
The Nurse’s Role

The nurse must observe and assess for signs of family dysfunction. If present, this
needs to be incorporated into the patient’s treatment plan. Interventions may include
group or family therapy and single or multidisciplinary healthcare conferences if
indicated. Nurses should encourage participation and discuss realistic strategies to
help the family’s function improve. Discuss, teach, and model appropriate
communication skills and help to identify and utilize the appropriate support systems.
Grief and Loss
Grieving is a natural, human response to loss. Every person grieves in different ways.
Grief may have physical, mental, emotional, spiritual, and social impacts. As a nurse,
first recognize and analyze any personal feelings about death and dying before
assisting others through their grief and loss-processing.
Stages of Grief
A few different conceptual frameworks and theories describe the process of both normal
and unresolved/complicated grieving. The most popular is perhaps Elizabeth Kubler-
Ross’s Stages of Grieving. In her theory, a person moves through five different
stages during the grieving process: denial, anger, bargaining, depression,
and acceptance. These stages are considered fluid and do not always occur in order.
Patients may experience each stage once, skip stages along the way, or flow back and
forth between stages before finally achieving acceptance. Each stage is met with
nursing responsibilities unique to that grieving process. Monitoring and recognizing
where patients or their caregivers are at in the stages of grief can help to tailor
interventions to best support them.
Differences in Reaction
Grief reaction differs among all people. Factors, including age, developmental stage,
gender, cultural influences, personal strengths, and emotional and physical reserves,
influence how a person perceives grief. Grieving may also occur in anticipation of a
devastating health diagnosis or outcome. This is called anticipatory grief.
Legal Topics
In addition to the physical, emotional, and psychological support nurses provide during
end-of-life care, there are also numerous legal processes that nurses must follow prior
to and after a patient passes.
Advance directives— Be familiar with and respectful of a patient’s wishes. If no
advance directive exists, nurses must educate and discuss this with the patient and
family.
Autopsies— In some cases, autopsy after death is a legal requirement. In others, it
may be a specific wish of the patient and/or family.
Organ donation— The patient’s wishes for his or her physical remains after death can
be added to his or her advance directive.
DNR orders— “Do not resuscitate” orders are often part of a patient’s advance
directives. Ideally, the patient has discussed this previously with the family, but if unable
to do so, the nurse should do so.
Other Nurse Responsibilities
Nurses must support both patients and their families during the difficult time of end of
life. Be familiar with the following additional nursing responsibilities:
Ideas for relief— Patients and families will experience a range of emotions. Provide
active listening, guidance, and support through anxiety, fear, loneliness, and
exhaustion.
Patient sense of security— It is common for a patient to feel a loss of control during
this time. Optimize opportunities for control, give patients choices, and provide
reassurance when necessary.
Acceptance of loss— Encourage patients and family members to openly discuss their
feelings. Know of and refer family members to available outside support, counseling,
and bereavement groups.
Physical comfort— Measures can include pain control, sedation, positioning, etc.
Emotional support— Discuss emotional reactions and affirm if they are normal.
Educate and reassure that the grieving process needs to occur and is a healthy
response to what is happening.
Patient and family expression— Spend time with the patient and family, and listen to
them. Again, reassure that the grieving process is normal, and provide additional
support with outside referrals as indicated.
Mental Health Concepts

Mental health is a person’s emotional and psychological well-being. Good mental
health allows one the ability to function reasonably well in day-to-day life.
Mental Health
Good mental health includes the ability to act responsibly, be self-aware, remain in
a positive mood, be relatively worry-free, and have the proper coping skills to deal
with a variety of life situations.
In healthcare, the nurse will frequently assess a patient’s mental health status. Many
patients may experience memory loss, loss of interest in themselves or
their hygiene. This is especially common in the event of chronic illness or prolonged
hospitalization. Nurses should tailor interventions to communicate with
patients, remind them of details when they forget, reorient them frequently throughout
the day, and assist in performing or encouraging good hygiene practices. Interventions
may include writing the date and healthcare worker’s names in the patient’s room;
promoting day/night schedules with set sleep and awake schedules; providing patients
with appropriate bathing supplies, etc.
Influences on Mental Health

Genetic/inherited factors, childhood attachment/nurturing, and general life
circumstances are major factors that influence mental health. In addition, to maintain
good mental health, one must have good interpersonal communication skills, proper
use of ego defense mechanisms, and access to and proper use of available support
systems (family, friends, etc.).
Common Mental Health Disorders

Patients may be affected by acute and/or chronic mental illness. Common diagnoses
to review include schizophrenia, depression, and bipolar disorder. Many of these
diagnoses are chronic but may additionally present with acute symptoms. Depression
may be complicated by a suicide attempt. Patients may be hospitalized in the event of
mania related to their bipolar disorder. Nurses must provide safe environments for their
patients, provide support for patients struggling with poor mental health, and maximize
interventions to promote a return to a healthy state of mind.
Education is a key component in improving mental health. For patients struggling with
addictions/dependencies, depression, dementia, and eating disorders, nurses may need
to educate patients and caregivers on what to expect throughout the duration of the
illness, the ups and downs, recovery, and possible relapse. Understand that many of
these diseases have additional physical symptoms or complications that require nursing
attention. Remember to care for the whole patient and not just a singular aspect of a
patient’s illness.
The Nurse’s Role

The nurse must be able to analyze and assess the patient’s individual mental health
needs and implement appropriate interventions. Patients may experience alterations in
mood, judgment, cognition, and reasoning. Knowing a patient’s baseline helps the nurse
to appreciate changes the patient may be experiencing. Manage patient pain to reduce
adverse mental strain; encourage maintaining as much normalcy throughout the day as
possible; and provide choices in care when applicable to help patients regain some
control. Often, a combination of interventions will be required to optimize care of a
patient’s mental health. Apply knowledge of psychopathology to each individual
patient to provide appropriate mental health care.
Religious and Spiritual Influences

Religion is defined as an organized, formalized set of beliefs that is based on one or
more gods. Spirituality is defined as a “connectedness” to other individuals, the
environment or universe, a higher power (not a god), and one’s self (intrapersonal
connectedness).
Effects on Health
Both religion and spirituality can have major impacts on a patient’s physical and
psychosocial well-being and health outcomes. Patients may experience internal conflict
if their condition or treatment options are not supported by their beliefs. Spiritual distress
may also occur as patients process emotions regarding their health status. Maintaining
a balance of spiritual/religious well-being will improve nursing care and patient
participation in healthcare treatments and interventions. Understand how a patient’s
individual religious/spiritual beliefs will impact their perception of and reaction to clinical
care.
The Nurse’s Role

Listen respectfully and empathetically to patients’ religious/spiritual needs and be aware
of specific religious and spiritual traditions. Nurses must also have an understanding of
their own religion, beliefs, and spirituality to provide the best and appropriate care for
their patients. Even if the nurse’s beliefs differ from a patient’s beliefs, the nurse is
responsible for providing the best care possible while supporting the patient toward
his/her personal belief. In the event the nurse does not feel he/she can provide the best
care to the patient due to religious or spiritual conflict, the nurse should seek a different
assignment with the nursing supervisor. Likewise, nurses need to respect a patient’s
right to refuse care that does not align with his or her religious or spiritual beliefs.
Sensory and Perceptual Alterations

Sensory and perceptual alterations are disruptions in a patient’s cognitive functioning
that cause a distorted perception of his or her surrounding environment and interactions
with others. They ultimately lead to a patient’s inability to function properly. This, in turn,
may place a patient at risk for harm in the healthcare setting.
Precipitating Factors
A few factors can affect a patient’s sensory functioning, including:
Developmental stage— Age and general physical decline can affect a patient’s ability
to hear, see, etc.
Culture— Different cultures have different norms for sensory functioning (i.e., eye
contact, physical touch, personal space, etc.)
Stress— Stressors, both physical and emotional, can affect a patient’s cognition. Pain,
testing, hospitalization, surgery, excess noise, uncertainty of the future, and lack of
knowledge/education are examples of common stressors.
Medications— Medications such as benzodiazepines and opioids can affect a patient’s
sensory functioning. Some medications such as gentamicin and lasix can be ototoxic.
Illness— There are some illnesses and conditions that severely impact a patient’s
sensory and perceptual functioning. Critical illnesses such as cancer or stroke and
chronic illnesses such as diabetes, hypertension, circulation, and neurological disorders
can affect a patient’s ability to receive sensory stimuli.
Lifestyle— A patient who has recently had a change in lifestyle (loss of loved one,
change of residency, etc.) may also experience impaired sensory function.
Personality— Some patients may have difficulties if they are more introverted, aloof
and/or less likely to communicate.
Risk Factors
It is important to identify a patient at risk so that you may take preventive measures to
keep him or her safe. Always orient the patient to person, place, and time with each
encounter and explain your nursing care prior to giving it.
Environment— A patient with little sensory stimulation (confined in a room, etc.) may
exhibit negative cognitive effects.
Vision and hearing problems— Apply appropriate nursing interventions for these
patients including the use of assistive devices, sign language interpreters, etc.
Restricted mobility— Ensure these patients have access to activities, can get to
personal belongings, and have assistance to ambulate when needed.
Emotional disorders— Specific nursing interventions will need to be individualized for
these patients (decreased stimuli for mania and increased stimuli for depression, etc.).
Limited social contact— Patients with limited access to social stimuli will need
intervention to prevent sensory deprivation symptoms.
Pain and discomfort— Apply proper nursing interventions including medications,
positioning, and other techniques.
Acute illness— High fever, infections, seizures, and intoxication may require the use of
interventions for sensory alterations.
Close monitoring— Intensely monitored patients such as those in the ICU setting may
experience negative sensory alterations due to excessive stimuli.
Cognitive ability issues— Patients with conditions that result in cognitive disruptions
(i.e., head trauma, etc.) will require special interventions.

Dependencies
Addiction of any sort can be an impairment to a patient’s ability to function properly.
Unfortunately, addictions are common. They can also be extremely challenging to
treat effectively because of both the physical and psychological dependency they
produce.
Substance Use Disorder

Substance use disorder is defined as the recurrent use of either alcohol and/or drugs,
which produces clinical and/or functional impairment that manifests as chronic health
problems, physical disability, and/or failure to meet one’s responsibilities at work, home,
or school. It is usually classified as mild, moderate, or severe depending on how many
diagnostic criteria are met. The criteria include evidence of loss of control, risky
behaviors, social impairment, and pharmacological criteria.
Other Dependencies
In addition to substance abuse, patients may have addictions to gambling, sex, and
pornography in addition to others. These are defined as non-substance-related
disorders, but their treatments may be similar to that for substance abuse.
The Nurse’s Role

The nurse’s role in a patient’s treatment will be to provide support in the following areas:
Physiological stability— Provide physical symptom relief with appropriate measures
for withdrawal and/or toxicity. An example would be giving methadone for heroin
withdrawal.
Patient safety— Physical symptoms of withdrawal can be painful and difficult. At all
times, patients must be kept safe via the use of physical restraints, even when it goes
against their wishes.
Patient education— Be an educational resource on the potential health, social, and
occupational dangers of substance abuse and other forms of dependency.
Referral and follow-up— Patient recovery may include outside referrals and follow-up
visits to assess continued improvement and treatment success. Nurses are often
heavily involved in this process.
Intervention— Support and encourage patients to continue in various intervention
processes such as counseling and group therapy.
Friend and family education— Recovering addicts need strong social support to have
continued treatment success. Nurses can help friends and family understand ways they
can support the patient and encourage group therapy participation throughout their
recovery.
Evaluation of response— Take the time to discuss the outcome and effectiveness of
the treatment plan with the patient and help evaluate the need for changes, if indicated.
Support Systems
Support systems are a network of people that a patient uses when emotional, moral,
or other types of practical support are needed. Support systems have been shown to
improve patient recovery rates, allow improved communication and education, and
assist in the care of the patient. A support system can also help patients remain
accountable for maintaining any new lifestyle changes that their condition or treatment
requires. Support systems are critical in the care of patients with chronic illness,
especially in the event of illnesses that cause decreased mental cognition (i.e.,
Alzheimer’s disease).
A nurse may also have to ensure that all caregivers involved in their patient’s support
system have the access that they need to outside resources, such as support groups for
families caring for loved ones, those experiencing caregiver fatigue, and respite care.
Therapeutic Communication
Therapeutic communication is more than just talking. It is an interactive, planned,
and goal-oriented process that is tailored for each patient. The overall aim is to
establish an avenue of open, constructive communication by forming a trustful, positive,
and beneficial relationship with the patient. Therapeutic communication incorporates
listening to and understanding the patient and promotes better understanding by
providing necessary clarification and insight. Without therapeutic communication, a
patient’s healing can be impaired. The nurse should encourage the patient to verbalize
feelings such as fear, discomfort, and hope. Patients should also be allowed to openly
ask questions and participate in their plan of care.
It is also important to recognize that nonverbal communication is a part of this
process as well. Nonverbal communication is often more powerful than what is said
because it may reveal a person’s underlying feelings and attitudes. Signs of this type of
communication include movements, facial expressions, and body positioning.
Regardless of how a patient communicates, the nurse should regularly evaluate the
effectiveness of communications between the client, caregivers, and healthcare team.
Foundations
The foundations for a therapeutic relationship and therapeutic communication are:
Understanding communication factors— Understand the patient’s developmental
level, age, level of consciousness and understanding, ability to communicate effectively,
culture, values, perceptions and perspectives.
Nonverbal communication— Remember that body positioning, eye contact, and other
physical cues are more powerful than the spoken word.
Communication skills— Communication styles and skills vary. Assess the patient and
adjust message and communication sessions to best fit the patient’s needs.
Causes of ineffective communication— Be aware of and adjust accordingly to avoid
ineffective communication (language barriers, education level, distractions, etc.)
Ability to participate— Always ensure that the patient can participate in this process
as it is interactive. A patient with aphasia, for example, will need special considerations
and adjustment to ensure this happens.
Conditions
The following factors must be present in the therapeutic relationship:
Empathy— an understanding and sharing of someone else’s feelings
Respect— acceptance and regard for someone else, even if he or she has a different
viewpoint
Genuineness— showing and expressing honest, sincere concern for the concerns and
questions of another
Self-disclosure— sharing personal views and experiences in order to improve the
mental and/or emotional state of another person
Concreteness and specificity— using very specific and direct terms when
communicating rather than general or vague ones
Appropriate Confrontation— (Only in a long-established patient-nurse relationships)
Gently, and in an accepting way, discuss the patient’s need to deal with a specific issue
or problem.
Barriers
There are many potential barriers to a therapeutic relationship that will need to be
avoided. They may include:
Listening problems— Make the proper time to communicate and minimize potential
distractions. Listening problems include misinterpretation, distracted listening, and
failure to listen.
Improper decoding— This means failing to recognize the true, intended message of
the patient.
Nurse’s needs first— There is always too much to do and too little time. Consider the
patients’ needs as a priority to listen and communicate effectively.
Stereotyping, probing, challenging, or rejecting— These are all counterproductive to
the therapeutic relationship and show a lack of respect to the patient.
Being defensive— Being defensive may be perceived as a response to real or
perceived failures or shortcomings. It is not therapeutic or in the best interest of the
patient.
Changing the subject— Identify personal feelings about difficult subjects and cope
with them prior to attempting discussion. Changing the subject to deal with personal
stress or uneasiness is inappropriate.
Passing judgment— The nurse must listen and understand, not pass judgement. Do
not place a negative or positive value on the patient’s message.
Therapeutic Responses
The nurse’s response to the information or feelings that patients shares can be helpful
in building effective, therapeutic communication. Some techniques to use are:
Silence— Silence allows for the patient to speak while the nurse listens, considers, and
conveys acceptance of the message. It also allows the patient to take the lead in the
exchange of information.
Using leads— Broad opening statements can initiate discussions between the patient
and nurse. It allows the patient to feel the nurse is interested in the patient’s feelings,
concerns, and values. It also allows the patient to choose the direction of the
conversation.
Clarification— Specific techniques such as exploring, paraphrasing, reflecting, and
restating can help ensure that the patient’s message is being heard correctly and
understood. Clarification reduces nurse bias and false assumptions about the patient.
Reflecting— Reflecting is a specific technique where the nurse reflects the patient’s
emotions (not exact words) back to the patient in conversation. This allows the patient
to further explore specific feelings and express unspoken ones as well.
Therapeutic Environment
Provide care and interventions that help patients better adapt to their environment so
that they can make a full recovery to the best of their ability. This will require the nurse
to meet a variety of patient needs. Consider if patients can care for themselves, have
any unmet needs, or are having difficulty adapting to the care environment. Provide and
maintain a therapeutic milieu that is supportive and safe for your patient’s recovery.
This includes eliminating all extraneous and avoidable stressors.
Nursing and Psychosocial Integrity

The nurse will use the nursing process of assessment, diagnosis, planning,
implementation, and evaluation to support and care for the psychosocial integrity of
every patient. By doing this, the nurse will convey respect for, empathy toward, and
understanding of the patient’s experience with illness, injury, or crisis. Using the nursing
process in this way also allows the patient to maintain autonomy and take an active role
in his or her care plan.
Nurses are in a unique role as they use their knowledge of psychopathology,
observation skills, and close patient interaction to intervene and help their patients avoid
negative psychosocial reactions that the stressors of illness, disease, treatment, and
hospitalization can bring. In this way, nursing care protects the psychosocial integrity of
all patients.
How to Prepare for Reduction of Risk Potential
General Information
Under the umbrella of physiological integrity, risk reduction is critical to improving the
safety of patients and current health care practices. Test results, vital signs, and signs
of complications will modify courses of treatment to provide the least risk possible to the
patient. Below are the main topics covered in this question category.
Vital Signs
A patient’s vital signs are the most rapid assessment tool that one can use to monitor
for drastic changes in physiologic function as well as responses to interventions.
Changes and abnormalities in heart rate, respiration, blood pressure, temperature, and
oxygen saturation can all point to potential and underlying physiological problems.
Assess and Respond

Assessment of vital signs is a valuable tool to determine a patient’s basic physiologic
functioning. Because there is often a rapid change in vitals with abnormal physiologic
function, the nurse should be able to correlate these changes with knowledge of the
patient’s pathophysiology. For example, an increased temperature should alert the
nurse to a possible infection.
Basic Values
Temperature: Understand and execute the proper procedure to take a temperature
given the patient’s age and conditions. Temperatures may be taken via oral, rectal,
tympanic, axillary, or temporal contact depending on the equipment available. Be aware
of the impact of emotions, hormonal cycles, and environmental temperatures when
obtaining a final value. Normal body temperature is approximately 98.6 degrees
Fahrenheit (36.7–37 degrees Centigrade).
Respirations: Correctly assess the rate, quality, and depth of respirations. Know the
normal ranges and sounds for patients of different ages as well as different physiologic
changes that can cause a respiratory rate increase or respiratory depression (CNS
depression/damage, acidosis/alkalosis, fever, pain, etc.). Normal range of respiratory
rate depends on age:
 neonates and infants: 30–60 breaths per minute

 toddlers: 20–40 breaths per minute
 preschool age children: 22–30 breaths per minute
 school age children: 20–26 breaths per minute
 adolescents to adulthood: 16–22 breaths per minute.
Heart rate: Assess pulses with both palpation and stethoscope auscultation. Know

the normal range and how to assess pulse rate based on age specifications. Palpation
locations include the radial pulse, femoral pulse, popliteal pulse, dorsalis pedis pulse,
posterior tibial pulse, and apical pulse. More central pulse locations (such as the
brachial and femoral pulses) should be used to palpate pulses in children. The apical
pulse, the pulse point of maximum intensity for an adult, can be located on the left side
of the chest at the 5th intercostal space. Assess the quality, regularity, and physiologic
symptoms that may influence a pulse rate including cardiovascular changes and
autonomic or parasympathetic nervous system activation. Normal pulse ranges include:
 neonate 80–180 beats per minute

 infant 100–160 beats per minute
 toddler 90–140 beats per minute
 preschool child 80-110 beats per minute
 school age child 70–100 beats per minute
 adolescent and adult 60–100 beats per minute
Blood Pressure: Know how to properly measure blood pressure and what underlying
physiologic factors affect it (blood volume, cardiac function, the peripheral vascular
resistance, blood viscosity, etc.). Know the normal ranges for blood pressure in different
age groups along with what phase of the cardiac cycle corresponds with systolic and
diastolic pressures. Understand the physiologic systems that can affect or change a
patient’s blood pressure (cardiac rate, peripheral vascular resistance, venous return,
etc.). Normal blood pressure ranges per age include:
 neonate diastolic 40–50mmHg and systolic 60–80mmHg

 infant diastolic 50–70 mmHg and systolic 74–100 mmHg
 toddler diastolic 50–80 mmHg and systolic 80–110 mmHg
 preschool child diastolic 50–78 mmHg and systolic 82–110 mmHg
 school age child diastolic 54–80 mmHg and systolic 84–120 mmHg
 adolescent diastolic 60–80 mmHg and systolic 100–120 mmHg
 adult diastolic 80–90 mmHg and systolic 120–140 mmHg.
Oxygenation: Some patients will need additional monitoring of SpO2SpO2, or

percentage of oxygen saturated hemoglobin in the blood. Expected value of
oxygenation for all patients is between 95–100%. Oxygenation can be measured by
using a pulse oximeter machine. Levels lower than 95% may indicate deterioration of
organ and patient status. Monitor this vital sign as indicated.
Invasive Monitoring Data

The vital sign discussion above refers to non-invasive methods of monitoring.
Understand the use and rationale for invasive monitoring such as intracranial pressure
monitoring and invasive hemodynamic monitoring.
Clinical scenarios in which intracranial pressure monitoring may be required include
head trauma, tumor, intracranial bleeding, and stroke. External vital signs for intracranial
pressure monitoring include headache, vomiting, pupillary change, and decreased level
of consciousness.
Invasive hemodynamic monitoring includes measurements of pulmonary artery
pressure, continuous blood pressure monitoring, pulmonary artery wedge pressure,
central venous pressure, cardiac output, and intra-arterial pressure. Hemodynamic
monitoring is often indicated in any conditions that require close monitoring of
hemodynamic status such as septic shock, multiorgan failure, traumatic injury, and
cardiac disease exacerbation.
Diagnostic Tests
Diagnostic testing is an essential part of risk reduction, as it may indicate one or more
underlying problems that may be addressed with potentially life-saving intervention.
Both invasive and non-invasive diagnostic testing is involved in nursing care.
Testing Procedures
Regardless of the diagnostic test being used, the nurse should always employ a general
set of testing procedures prior to administering (or assisting with) any diagnostic test.
Among these are:
 verification of the test order

 verification of the correct patient using at least two unique identifiers
 providing an explanation and education on the purpose of the test to the
patient/family/caregivers along with special instructions (NPO, etc.)
 obtaining/verifying informed consent
 hand washing, universal precautions, aseptic technique, etc. depending on
the proper requirements for the test
 proper, complete, and accurate labeling of the specimens along with proper
care, storage, and transport
 proper cleanup and disposal of all materials used or collected during the test,
including biohazardous waste and proper disposal of other potentially dangerous
or caustic materials (preservatives, chemicals, anticoagulants, etc.)
Nursing Knowledge
Always apply knowledge of nursing procedures when administering a diagnostic test.
Each test will have a unique set of procedures to follow and psychomotor skills that
must be employed. Be familiar with what these are for a wide spectrum of diagnostic
testing.
Perform Tests
A nurse must be familiar with the purpose of and preparation for a number of medical
tests, including these:
 General tests: biopsies, computed tomography (CT scan), magnetic resonance

imaging (MRI), ultrasound, x-ray
 Respiratory tests: pulmonary function tests (PFTs), bronchoscopy, incentive
spirometry
 Cardiovascular tests: electrocardiogram (EKG), angiography
 Renal/urinary testing: cystoscopy, intravenous pyelography (IVP), bladder
pressure monitoring
 Neurological tests: electroencephalogram (EEG), myelography
 Musculoskeletal tests: bone densitometry, arthroscopy, etc.
 Gastrointestinal tests: colonoscopy, barium enema, glucose monitoring
 Reproductive tests: fetal heart monitoring, non-stress test, amniocentesis,
ultrasound, mammogram
 Integumentary tests: tuberculin skin test, allergy testing
Evaluation
Diagnostic test results provide signals for nurses to determine which patients
need rapid evaluation. Nurses must compare the newest laboratory or testing results
with previous studies to determine any alterations from the patient’s baseline status.
Examples of critical diagnostic testing include blood glucose monitoring, oxygen
saturation, fecal occult blood, and serum electrolytes. Be familiar with all testing
methods in which nursing evaluation is essential to proper care.
In other instances, nurses will be asked to monitor the ongoing results of diagnostic
testing. Such tests will likely include maternal-fetal tests such as a non-stress test,
amniocentesis, ultrasound, and fetal heart monitoring. Some of these may require you
to compare the findings to earlier test data.
Nurses are often the very first member of the healthcare team to become aware of an
abnormal result. In some cases, nurses may be able to intervene and/or modify the
plan of care to address the issue. On other occasions, they may need to inform the
treating practitioner of critical values that may pose an immediate risk of harm to the
patient.
Laboratory Values
Understanding the importance of laboratory values, normal laboratory ranges,
and proper collection and monitoring techniques is critical to taking proper care of
any patient.
Patient Education
Similar to diagnostic testing, nurses will usually prepare the patient for laboratory
testing. They will explain the purpose of the test, along with providing education as to
what to expect and how the patient should prepare for the test. Nursing education may
also involve instructing patients on which laboratory testing will be required with the
patient’s chronic illnesses and/or prescribed medications. Examples of this include
diabetic patients having daily glucose monitoring and routine A1C testing and patients
taking Coumadin (Warfarin) requiring regularly scheduled coagulation studies.
Obtaining Specimens
Be familiar with the proper technique and the steps to collect blood specimens from
both a peripheral vein and a central venous catheter. Know how to properly collect
specimens from a wound (generally a swab specimen), as well as stool (routine,
guaiac, and infectious) and urine (routine, clean catch, midstream and timed).
Specimen Values
While it may be impossible to memorize the normal ranges for every laboratory
specimen, it is very helpful to have knowledge of what the general, normal range is for
the most commonly ordered laboratory tests. The following lab tests are some of the
most commonly ordered tests:
 Arterial blood gas or ABG

(pHpH, PO2PO2, PCO2PCO2, SaO2SaO2, HCO3HCO3)
 Lipid levels (total cholesterol, triglycerides, high density lipoprotein or HDL, low
density lipoprotein or LDL)
 Glucose (fasting, random, glycosylated hemoglobin or HgbA1CHgbA1C)
 Complete blood count or CBC (white blood cells or WBCs, hematocrit,
hemoglobin, platelets)
 Basic metabolic or electrolyte panel (sodium, potassium, magnesium, chloride,
calcium, carbon dioxide, glucose, etc.)
 Renal indices (creatinine, blood urea nitrogen or BUN)
 Coagulation studies (prothrombin time or PT, partial thromboplastin time or PTT,
activated partial thromboplastin time or aPTT, international normalized ratio or
INR)
In addition to knowing the normal ranges for these tests, the nurse will need to critically
evaluate the patient’s laboratory values. Monitor every lab result, evaluate for changes,
and correlate the findings with the patient’s condition and any previous lab results
and/or interventions.
Notification
The nurse is often the first to receive and review laboratory results. The nurse must then
notify the ordering and primary care practitioners of any abnormal results.
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Body System Alterations

Identify patients at risk for potentially dangerous and life-threatening alterations to
various body systems. Good nursing care in this area plays a key role in the reduction
of risk potential.
Patient Potential
Numerous conditions may place a patient at increased risk of morbidity and mortality.
Identify patients at risk for aspiration such as patients on tube feedings, sedated
patients, and those with swallowing difficulties (i.e., developmental delay, stroke). Be
aware that several conditions can predispose a patient to skin breakdown and
decubitus ulcers such as immobility, fecal and/or urinary incontinence, poor neurologic
sensory function, and poor nutritional status. Be aware of the conditions that place
patients at increased risk for insufficient vascular perfusion such as diabetes,
hypotension, postoperative recovery, and decreased mobility.
This list of conditions is not exhaustive. Developing a nursing assessment that is
comprehensive and detailed will help to identify potential areas that may require
intervention. Be aware of specific treatments and care that nurses may be able to
provide for patients at risk.
Patient Education
An important part of nursing care plan for these patients will be to provide the proper
patient education and self-care strategies. Patient activity and ability to participate
impact nursing care plans. For example, an immobile patient should be educated on the
importance of passive range of motion exercises and frequent position changes to
prevent contractures.
The nurse should also be able to educate patients on specific methods to prevent
complications due to a particular disease process and or diagnosed illness. For
example, discussing the importance of proper foot care and how to perform it daily to a
patient with diabetes.
Patient Data Use

Remember that the nurse will not only need to compare current patient data with
baseline data to determine if therapeutic goals are being met, but will also need to
monitor data to assess for potential complications and side effects of therapy. The
ability to closely monitor data may also aid in the diagnosis of new conditions or illness
that may arise during the course of care. This applies to vital signs, laboratory testing,
imaging, other diagnostic testing and patient output measurements (nasogastric tube,
emesis, stool, and urine).
Complications
Patients are at risk for complications with almost any diagnostic test, treatment
and/or procedure. Generally speaking, the more invasive any of these are, the greater
the risk. Use nursing knowledge and develop a set of skills for caring for these patients.
Assessment of Patient
Always assess patients for abnormal responses to tests, treatments, or interventions.
This will require knowledge of the most common potential complications and vigilant
monitoring for more subtle signs of abnormalities or rare complications.
Complication Prevention
Many complications of therapy can be prevented by nursing intervention. For
example, if a patient is undergoing a tube feeding, the nurse should keep the head of
the bed elevated to the proper angle (>30 degrees) to reduce the risk of aspiration.
Another example, if a patient has an immobile extremity that is casted, the nurse should
perform schedule assessments of the limb for appropriate circulation and neurologic
function to monitor for changes such as compartment syndrome. Nurses are
responsible for educating patients on signs and symptoms of potential complications
and when to report them.
Patient Care
Another important piece of complication prevention includes understanding the basic
principles of nursing care for those at risk for complications. For example, using proper
aseptic technique when caring for peripheral and central venous access lines
or raising the side rails of the bed for a patient who may be at an increased risk of
falls, etc. In most cases, the nurse will need to apply knowledge of nursing procedures
to take the proper precautions.
Monitoring
The nurse will need to focus the assessment on the potential complications following
diagnostic testing, procedures, or treatments. If the patient has had an invasive test or
surgery, the nurse should frequently monitor for signs of bleeding (hemodynamics,
urinary output, shock) and wound site changes (drainage, infection, closure). If the
patient has tubing, such as nasogastric tube, chest tube, or artificial airway, know the
proper schedule of assessment to maintain patency and proper placement. In the
case of endotracheal tubing, this may include performing suctioning.
Procedures
Often, the nurse is responsible for performing procedures that help reduce the risk of
complications. This may include placement and removal of nasogastric tubes, urinary
catheters, and peripheral venous access line.
In some cases, maintenance of external tubing may include additional nursing
intervention. Nasogastric tubes, urinary catheters, and peripheral venous access may
need routine or interventional flushing with appropriate solutions (normal saline, sterile
water, etc.) to maintain patency. Chest tubes may need to be stripped to maneuver
drainage and avoid blockage.
Special Circumstances
Some procedures, such as electroconvulsive therapy (ECT), require special nursing
precautions to protect a patient from dangerous complications. In ECT, the nurse will
need to be prepared to teach the patient about these special considerations and
implement them while monitoring the patient for potential complications that may occur
during and after the procedure. The nurse should assess the patient’s airway (ensure
patency) and understand side effects such as confusion, memory loss, nausea,
headache, jaw pain, and muscle aches.
Intervention
In many cases, the nurse will need to provide direct intervention in order to prevent and
treat potential medical complications. Common complications a nurse may see include
issues within the circulatory system (thrombosis, hemorrhage, all forms of shock,
etc.), concerns for aspiration (bottle feeding, foreign bodies, swallowing disorders, tube
feedings, etc.), and neurologic complications due to tight dressings/casts or foot drop
due to immobility.
Evaluation
Lastly, the nurse will need to evaluate and document a patient’s response to any
procedure and/or treatment. This includes the intended effect as well as unintended
side effects or complications. Objective data, such as laboratory results and imaging,
along with the patient’s subjective reports are both required in a thorough assessment.
Surgical Procedures and Health Alterations
Patients undergoing a surgical procedure will require special consideration and nursing
care to minimize, prevent, and respond to common complications.
Monitoring
Apply knowledge of pathophysiology when caring for the post-surgical patient. Know the
signs of thrombocytopenia, infection, inadvertent puncture of a major blood
vessel, pneumothorax, and hemorrhage. This will require the nurse to understand
the etiology of potential complications and the specific risk factors for
development.
Evaluation
Post-operative nursing care begins prior to surgery. Patients will require special
education and instruction on proper postoperative care and interventions to prevent
complications. Nursing interventions, such as preventing aspiration (elevated head of
bed, monitoring diet orders), preventing venous stasis (Ted hose and sequential
devices), and increasing mobility and activity to prevent immobility, should be
addressed in all patients. Always document the nursing interventions provided and their
effectiveness.
System-Specific Assessments
Be familiar with several system-specific assessments for patients that have undergone
procedures. Understand the importance of how abnormalities may affect healing or
patient outcomes, so that appropriate care plans and interventions can be implemented.
Types of Assessments
System-specific assessments are crucial to understanding expectations, changes, and
management of patients health needs. Here is a list of some of the more important
assessments:
Abnormal Peripheral Pulses— Assess the major peripheral pulses and note their
strength, fullness, and regularity. Be familiar with the appropriate rating scale for
documentation. Also know when and how to use a Doppler system to aid in pulse
assessment.
Abnormal Neurological Status— Assess the level of consciousness, mobility, muscle
strength, deep tendon reflexes, and cranial nerve function. Be familiar with the proper
documentation for each.
Peripheral Edema— Understand the physiologic settings in which peripheral edema
occurs as well as how to properly assess it and document the findings.
Hypoglycemia or Hyperglycemia— Be able to recognize and understand the clinical
signs and symptoms of hypo and hyperglycemia,
including ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome (HHNS).
Factors of Delayed Wound Healing— Be able to identify potential factors that may
impact or delay wound healing including: age, nutrition, cigarette/alcohol use,
medications, and chronic health conditions.
Trends and Changes in Condition— Use ongoing assessments to monitor for trends
or changes in the patient’s condition. Be able to identify appropriate times to intervene
and with which specific intervention. An example of this includes deciding between
notifying the attending practitioner versus performing a more focused assessment for
more information versus applying an appropriate nursing intervention.
Risk Assessment— Performing assessments and making nursing diagnoses are an
essential part of the risk assessment process. For example, patient findings of reduced
muscle strength and mobility with impaired sensory function alert the nurse to a
potentially increased risk of falls. Likewise, a patient with limited mobility will be at an
increased risk of skin breakdown. Nursing assessment will directly shape the plan of
care and guide interventions to prevent further illness or morbidity.
Focused Assessment— Be able to perform, interpret, and act upon a more focused
assessment. An example would be a patient with a cardiac condition who requires a
more extensive exam of heart sounds,as well as evaluation of EKG findings and
pertinent laboratory findings (cardiac enzymes, etc.).
Always remember to perform careful reassessment of patient conditions/status when
indicated.
Therapeutic Procedures
Apply nursing knowledge to the care of patients undergoing various therapeutic
procedures in order to reduce the risk of potential negative outcomes.
Anesthesia Recovery Assessment

Know how to assess patients recovering from local, regional, and/or general anesthesia.
This also includes conscious sedation. Understand how these various types of
anesthesia are employed (intravenously, inhaled, IM, etc.) and when they are used. Be
familiar with the unique risks that each presents and what tools are used
to continuously monitor a patient undergoing each type. Collect vital signs and
perform assessments to determine the level of consciousness, cognition, and
orientation. Nurses should monitor for common effects of anesthesia including nausea
and vomiting, sore throat, postoperative delirium, muscle aches, itching, hypothermia,
difficulty urinating, hematoma. More severe complications of anesthesia include
postoperative delirium/cognitive dysfunction and malignant hyperthermia (general
anesthesia) and pneumothorax and nerve damage (intravenous, local, or regional
anesthesia). Be able to recognize these potential complications and identify
when urgent intervention is required.
Patient Education
Patient education consists of informing patients of all planned procedures and
treatments; ensuring that informed consent is obtained for appropriate therapies;
identifying healthcare proxies; and providing instructions for pre/post procedure care,
care after discharge, and coordination of home care.
Before, During, and After Procedure

Nursing care before the procedure ensures that a patient is
both physicallyand psychologically prepared to undergo the planned treatment. The
nursing assessment helps to determine the appropriateness of the treatment for the
patient’s condition. During a procedure or treatment, continuous monitoring of a
patient’s physiologic status(vitals, blood pressure, pulse oximetry, etc.) is important.
These physical assessments will continue after the conclusion of the procedure along
with more focal assessments involving the treated organ system.
About Aftercare at Home

Specific instructions and education should be given to all patients upon discharge after
a procedure and/or treatment. This should begin as soon as the patient is admitted to
the facility. Verbal discussions, visual learning aids, written materials and step-by-step
instructions are just a few of the methods nurses should be familiar with to accomplish
this teaching. Examples include teaching/showing a patient how to care for a
tracheostomy (suctioning, hygiene, etc.) or properly care for an ostomy (bag
emptying/changes, skin care, etc.). Tailoring the educational approach based on each
patient’s cognitive needs and abilities is required in every patient encounter.
Patient Monitoring
In addition to the topics in the discussion above, the nurse will need to perform a variety
of patient monitoring assessments specific to the patient’s needs. For example, a
patient with a fracture will need evaluation of alignment, intact circulatory and neurologic
function prior to, during, and after the application of a cast.
For a patient undergoing conscious sedation, a registered nurse who is specially trained
(a nurse anesthetist) will be responsible for the administration, monitoring, and recovery
phases of patient care as is specified by the institution’s policies and governing bodies
that oversee this specialized form of nursing (JCAHO, AAMSN, etc.).
Monitoring patients during and after procedures requiring moderate sedation may
involve a little more attention from the nurse. Patients should have frequent monitoring
of vital signs, side effects (described earlier in this document), as well as level of
cognition to assess when the patient can return to normal activities. Patients with
continued effects from sedation, including delirium and muscle weakness, should be
monitored closely for injury, such as falling. Assess the patient closely to monitor for
subtle changes in vital signs or mental status that may indicate more serious
complications (delirium, hyperthermia, hypotension, etc.).
Precautions
Be familiar with special nursing care and interventions that involve precautions against
further injury or illness. This is especially important when caring for patients with
musculoskeletal injuries. Often, special techniques or assistive devices are used, such
as the log-rolling technique to maintain spinal alignment or an abduction pillow to
prevent further injury in a patient with a hip fracture.
Device Monitoring
The nurse will need to know how to continuously monitor various therapeutic devices for
effective functioning. These may include chest tubes, drainage tubes, various wound
drainage devices, and continuous bladder irrigation. Be familiar with common problems
associated with each, and understand how to troubleshoot to determine the underlying
cause of a malfunction. Know when it is appropriate to remove and replace a device
all together.
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How to Prepare for Safety and Infection Control

General Information
Safety and Infection Control, a key subpart of Safe and Effective Care Environment,
addresses the nurse’s ability to manage care with the best practices of reducing
hazards while providing both emergent and non-emergent responses to numerous
situations.
Prevention
Nurses are key players in the prevention of hazards to patient care including infection,
accidents, injuries, and medical errors. In addition, nurses must know and practice
principles that ensure the safety of healthcare personnel such as proper ergonomics,
safe use of all equipment and technology, and proper handling of infectious and
hazardous materials.
Promoting safe measures begins prior to a patient’s admission. This
includes inspecting the environment, planning for potential scenarios,
and anticipating where errors may occur. Nurses should understand their role in an
emergency response or security emergency situation. When the patient is admitted, the
nurse must immediately identify any patient-specific risk factors that may increase
the chances of error. Developmental factors, as well as a patient’s lifestyle and
knowledge of safety precautions, will factor into this assessment. Finally, nurses should
investigate future safety concerns that may impact patients after discharge, in their
homes and in the community. Taking measures at every step of the patient admission
process helps to prevent catastrophic safety events from occurring.
Age-Related Safety Factors

Nursing review of patient safety issues should begin with knowledge of the age-specific
or developmental risks associated with each of these age groups:
Infants— Parental safety education and implementation are the core of infant
safety. Nurses must educate parents on safety measures to take in order to protect their
infants. This includes instructing parents on proper carseat placement/strapping, child-
proofing homes, and safe sleep. The American Academy of Pediatrics recommends
that infants stay in a rear facing car seat until age 2. State law may vary and nurses
should know the laws for their state. Nurses and parents alike should monitor infants
closely to avoid contact with choking hazards, falling hazards, and hot items or liquids.
Toddlers— Fully mobile and curious about the world around them, toddlers are at
increased risk for poisoning, choking, and drowning. Inform parents and caregivers
about proper safety precautions including child-proofing cabinets and drawers where
hazardous medications or potential poisonous cleaners are kept. Car seats should be
rear-facing in the back seat of the vehicle until age 2. Toddlers should also remain in a
5-point harness until the child reaches the top height or weight limit allowed by the seat
(generally ages 4–7 years). Be sure to follow specific car seat standards in your state.
School-age children— Independence grows as more time is spent at school and with
friends. This age group needs education and guidance on water, fire, and traffic
safety as well as the dangers of strangers. Car seats and/or boosters are typically
required by law until the child is 4’9” or 80 pounds (whichever comes first). Although this
is usually between the ages of 8 and 12, requirements vary by state. Know the laws that
are applicable to the geographic location of practice.
Adolescents— Independence, impulsivity, and a sense of invincibility create many
risks in this age group. Motor vehicle safety (both as driver and passenger) should be
reviewed as well as the dangers of alcohol and substance abuse. Sexual
health information and safe sex practices should also be discussed.
Adults— Many different risks exist for this group that relate to home, workplace,
and leisure activities. In general, review the specific risks as they relate to motor
vehicles, fire, and the use of firearms.
Older adults— Declines in physical and cognitive abilities increase the risks of falls as
well as side effects with medications. In the older population, reaction times become
delayed increasing the risk of car accidents, falls, and burns. If caregivers are used or
present in the home, the risk of elder abuse must be discussed with the patient to
promote awareness and safety.
Environmental Considerations
Regardless of patient age, nurses must be familiar with the safety risks and principles
of accident prevention relative to the patient’s care environment.
Allergies— Patients of all ages can have allergies. Common allergy categories
include environmental allergies, medication allergies, food allergies, and latex.
Inquire about patient allergies when working with patients to ensure appropriate
documentation and avoidance of any possible triggers. Anaphylactic reactions provide
serious bodily reactions in response to allergen exposure. If not treated correctly and
immediately, these reactions may lead to death. Nurses must learn to recognize early
signs of allergic and anaphylactic reactions, including numbness or tingling around a
body part (especially lips, mouth, or tongue are extremely serious), swelling, increased
work of breathing, tachycardia, and hypotension.
Assistive equipment— Nurses will likely encounter patients with medical, assistive
equipment, such as hearing aids, visual aids, braces, or other medical aids (i.e.,
medicine pumps, oxygen, feeding tubes, etc.). Nurses should thoroughly document
and support the patient’s equipment as reasonable as possible. Patients able to see,
hear, and ambulate safely are less likely to be at risk for injury.
Fall prevention program— In the hospital, falls are most common among infants and
the elderly. Know the elements of such a program and the steps that are taken based
on the age of the patient. Common prevention strategies include clearing any
obstacles in the room (i.e., power cords, unnecessary equipment, and trash),
placing infants in high-sided cribs with rails fully elevated, and cleaning up spills
and trash from all walkways.
Seizure precautions— For those at risk, know the proper steps to ensure patient
safety during and after a seizure. Remember to assist patients into a side-lying
position if they are seizing to avoid aspiration of secretions or vomit.
Suction and oxygen equipment— Ensure that there is proper access to suction and
oxygen in every hospital room. Many non-hospital facilities have designated ports for
oxygen and suction to support their patients as needed. Patients that may require
suctioning or oxygen support include those with seizure disorders, swallowing
disorders, respiratory illnesses, artificial airways, and/or cardiac insufficiency.
Use of restraints— Restraints may be used to limit mobility in those at increased risk of
falls and seizures as well as in those who pose a safety threat to themselves, other
patients, or medical staff. In the event of all preventative interventions or therapies,
ensure that actions taken have been appropriately documented; the actions
are appropriate for the patient population intended; and the actions do not increase
the risk of other harmful situations.
Infection Control
The definition of an etiologic agent is any pathogen that is capable of causing
infection. These may include: bacteria, fungi, protozoa, rickettsiae, and helminths,
among others. Understanding the chain of infection or how infection is spread is
critical to understanding the methods and precautions used to prevent it. This involves
the following six elements:
Pathogen— An infection-causing agent, such as a bacteria or a virus.
Reservoirs— An animate or inanimate environment that provides a favorable place for
pathogens to grow and reproduce. Examples of human systems that serve as reservoirs
include the blood, respiratory, gastrointestinal, reproductive, and/or urinary systems.
Portal of exit— Any place where an infectious agent leaves a host. The above-named
human systems may also serve as portals of exit for the organisms they harbor.
Method of transmission— The way that an infectious organism is transferred from the
reservoir to another susceptible host. There are three main methods of
transmission: direct contact, indirect contact with a vector (carrier item), or via the
air (airborne).
Portal of entry— The place where an infectious agent enters a susceptible host.
Portals of entry may also be systems that act as reservoirs for pathogens.
Susceptible host— A patient, medical staff member, or other person who is at risk for
infection.
Emergency Response Plan

Every healthcare facility is required by the Joint Commission to have an emergency
response plan. Every facility and its staff will be required to periodically
perform emergency drills to assess the efficacy of the response teams. Fire
safety, natural disasters, and mass casualty events are some of the possible
scenarios where nurses will need to know their designated emergency response
roles. Nurses may also be involved in community outreach and planning of
emergency preparation such as natural disaster, bomb threat, and mass casualty.
Nurse Responsibilities
Nursing responsibilities in the emergency response plan will vary, but most likely
include ensuring the safety of the patients, securing the facility, and/or helping to
eliminate the threat of further harm or danger to the patients and staff. Nurses may be
assigned to triage, treatment, or discharge roles to ensure appropriate flow and care of
patients.
Patient safety should always be the priority. Nurses must determine how many and
what types of interventions their patients will need. Patients should be identified from
most critical to least critical. The least critical patients may be able to ambulate, have
decreased equipment needs, and may even heed early discharge in the event of
opening bed space for new admissions.
Fire Safety
In the event of a fire, patients must first be moved out of harm’s way. After the patients
are relocated to a safe space, the nurse may then contain the fire and evacuate patients
out of the facility, if necessary. Nurses will need to assess which patients will require
bed/stretcher evacuation (horizontal transfer) as well as those who will be able to
ambulate or use wheelchairs. A nurse will also be expected to educate and counsel
patients on fire safety in the home, including important emergency numbers,
installing/maintaining smoke alarms, and acquiring fire extinguishers.
Ergonomic Principles
Nurses must utilize proper ergonomic principles when assisting patients to protect
themselves from injury. Patients should also be educated on proper ergonomic
principles to prevent injury while ambulating or transferring from different surfaces.
These principles will be heavily incorporated into the nursing care plan for each patient.
Protecting Patients
Assessment of the patient’s baseline abilities will help the nurse design a proper care
plan that includes the use of assistive devices such as walkers, crutches, and canes. If
the patient has a repetitive stress injury, the nurse will need to instruct him or her as to
the proper body positions to help prevent aggravation or reinjury. For more targeted
conditions that involve single skeletal or muscular groups, the nurse can provide
instruction on proper positioning and stretches that help relieve stress on the area.
Protecting Yourself
Using proper lifting techniques (lifting from the legs and not overextending the body)
and assistive devices (gait belts, thera bands, crutches, electronic transfer devices,
etc.) for patients will help the patient, nurse, and support staff avoid injury. Be aware of
and utilize proper postures and body positions when performing daily functions at
technology-based workstations (desktop and/or mobile computers).
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Hazardous Materials
Nurses have a responsibility to practice safe and proper handling of patient care
equipment, potentially infectious/biohazardous materials, as well as hazardous
chemicals that are present in the workplace setting.
Identifying Hazardous Materials

Prior to handling or disposing of any material, the nurse must first determine if the
material is hazardous. Common hazards include biohazardous, flammable, and
infectious materials. Biohazardous material includes human body fluids, microbiological
waste (lab waste contaminated with concentrated, infectious agents), animal waste, and
pathological waste. Flammable items may include equipment, frayed electrical cords,
specific medications, oxygen and oxygen tubing. Infectious agents are often also
biohazardous and may include human bodily fluids, materials in contact with ill patients,
and cross contamination of materials.
OSHA
The Occupational Safety and Health Administration (OSHA) is an organization that
focuses on work-place safety and health. One of their jobs is to regulate written
standards that discuss the proper standard precautions that should be taken to
protect against blood-borne pathogen exposure. For example, OSHA has determined
protocols for workplaces to follow in the event of patient infection, isolation precautions,
standards of environmental infection control, nurse injury (i.e., needle stick), and latex
allergy.
OSHA also has developed a system of Safety Data Sheets (SDS, previously Material
Safety Data Sheets or MSDS) that describe the nature and potential hazards of all
chemical agents present in an employment setting. These threats include chemical,
environmental, or viral exposures that may increase the risk of specific health concerns
or illnesses.The nurse should be aware of their existence and how to access them in
the event of an exposure.
CDC and Standard Precautions

Part of OSHA’s written standards include the Centers for Disease Control and
Prevention (CDC) recommendations for the use of standard precautions. These are
patient care standards that detail how to protect staff from blood-borne pathogens. The
use of personal protective equipment (PPE), such as gloves as well as face and eye
protection, should be utilized and followed in every patient encounter and especially in
emergency/disaster response. OSHA also mandates that certain infectious diseases—
such as sexually transmitted infections, vaccine-preventable illness, international
outbreaks (Ebola, Zika, Yellow Fever, etc.), and others—be reported to the CDC to
track concerns for outbreaks, incidence, and prevalence of infection in the population.
Needlestick Safety and Prevention Act

The Needlestick Safety and Prevention Act is an important piece of legislation that
was enacted to protect workers in the healthcare setting. Safe disposal of all sharps
materials should be practiced with the use of mandated, marked biohazardous sharps
containers in patient care areas and medication preparation stations. Never recap
needles, and avoid bending or breaking them prior to disposal.
Internal Radiation Therapy

Internal radiation therapy may increase the risk of radiation exposure to those near to
and caring for the patient. This type of therapy is most often used in oncology for the
treatment of cancers of the prostate, rectum, or uterus. Internal radiation is a form of
implantable therapy where activated pellets, seeds, ribbons, wires, needles, capsules,
balloons, and/or tubes are used to slowly administer radiation to the area intended. It
helps to provide closer management of cancerous lesions that are difficult to externally
radiate. After implantation of the radiated objects, the patient’s body may release low
doses of radiation through the duration of therapy. Nurses should educate patients
undergoing internal radiation therapy to limit visitors, stay a distance away from others,
and avoid pregnant women and children until the implants are removed. The effects
of radiation will slowly dissipate over a few weeks to months, and after the removal of
the implants, the patient will no longer emit radiation.
Home Safety
Nurses play an important role in the identification, recommendation, and implementation
of safety practices and equipment that are necessary for patient safety in the home
environment. Patients and their families will often be involved in and work with the nurse
in this process. Nurses also implement home safety by teaching patients proper self-
care and reviewing issues relating to the safe care of children. In the home, nurses
should assess the need for walkway lighting, fire alarm maintenance, handrails, safe
kitchen tools, and reduction of fall hazards (i.e., power cords, floor pillows, rugs, etc.).
Preventive home safety measures can also include the patient’s use of protective
equipment when using potentially dangerous devices at home such as using oven mitts
to avoid burns, donning eye protection goggles when using power tools, and wearing
helmets when riding bicycles or ATVs.
Reporting Incidents
Incident reporting is another responsibility of nursing staff. Skills of accurately and
objectively reporting the events leading up to, during, and resulting from the incident
are required to properly document it. Common incidents to report include near
misses, medication error, substance abuse, improper care, staffing practices, and other
treatment errors. The overall goal of incident reporting is to prevent further injury and
repetition of the event in the future. Each facility will likely have its own procedures for
this process. Copies of the incident report are never included in the medical record.
However, the nurse should still document the simple facts of an incident in the patient’s
chart.
Unsafe practice reporting— When a nurse witnesses unsafe practices of other
healthcare personnel, he or she is responsible for reporting it to the appropriate
overseeing agency, both at the nurse’s individual facility and to the state’s credentialing
board.
Intervention during unsafe practices— To keep patients from harm, the nurse must
identify and intervene appropriately when witnessing potentially unsafe actions of other
healthcare team members. This may include confronting an individual and/or involving
management nursing staff in the event.
Equipment Use
Nurses must ensure the safe and proper usage of all equipment involved in patient
treatment and care. The nurse may be responsible for regular inspections as well as
proper patient instruction if he or she needs to use the equipment at home. Monitor for
fraying electrical cords, loose or missing parts on equipment, and broken equipment. If
the equipment is found to be unsafe or malfunctions, the nurse must immediately stop
using it, label it unsafe to use, and make sure it is placed in a location inaccessible to
patient care. If possible, put it in a specially designated area for malfunctioning
equipment and notify the proper personnel of the problem.
Security Plan
A nurse will be asked to perform the critical task of identifying patients in need of urgent
care in the event of a natural disaster or emergency.
The Triage Exam

The purpose of the triage exam is to identify patients who need life-saving care and
ensure they are the first patients to receive further evaluation and treatment. It will focus
on the following areas in order of their importance:
1. Airway— Ensure the patient’s airway is clear and open if necessary.
2. Respiration— Assess for signs and symptoms of respiratory distress.
3. Quality of respiration— Assess the rate and effort of breathing and check for
signs of adequate air exchange (capillary refill, color of skin, and lips). Auscultate
for breath sounds.
4. Pulse— Identify a pulse and note its rate and strength.
5. External bleeding— Look for signs of significant wounds or injuries in areas with
major blood vessels.
6. Blood pressure— Obtain a blood pressure.
7. Consciousness, pupillary response, and state of extremities— Assess the
patient’s neurological status with his or her level of consciousness, pupillary
response to light and signs of paralysis, or posturing of the extremities.
Specific Emergency Plans

Nurses will also have critical roles in the event of facility evacuations, newborn
nursery security events/lockdowns, and violence threats or controlled access
limitations. Routine drilling may be available at facilities to practice initiating the
protocols in place in these events. Nurses must know how to lock down their units; use
facility-based policies such as implementing “code-words” given to the patient to share
with those people allowed to have access to his or her critical healthcare information;
safely alert the appropriate hierarchy in the event of violence threats; and respecting
visiting hour policies. Clinical decision making and critical thinking skills often play
important parts in both the development and implementation of such plans.
Precautions
Many precautions are used in medicine to prevent the spread of infection. Standard
precautions, the most frequent of the precautions, used in every patient encounter.
Transmission-based precautions help to prevent the spread of pathogenic
microorganisms. Surgical asepsis, or sterile technique, is used in invasive and surgical
procedures.
Standard Precautions
Standard precautions, or universal precautions, including the use of personal
protective equipment or PPE (gloves, gowns, face shields, masks, and goggles),
should be used in situations where there is potential exposure to blood or other bodily
fluids, secretions, and/or excretions. Handwashing and the use of gloves are vital in
the prevention of the transmission of infectious pathogens. When donning (putting on)
PPE, always start with handwashing. Then, preferably outside the patient’s room,
always don in the following order: gown, mask, eye protection, and, lastly, gloves.
The reverse order should be used when doffing (taking off) PPE with handwashing as
the final step.
Transmission-based Precautions
Pathogenic microorganisms are spread in various ways. The specific transmission-
based precautions (also known as isolation precautions) are airborne,
contact, and droplet.This will necessitate the nurse to become familiar with
various infectious agents and their modes of transmission. Additionally, understand
specific precautions needed when caring for those with drug-resistant infections. Below
is a brief outline of the appropriate PPE and most common infectious agents in each
precaution category.
 Contact precautions— PPE required includes gown and gloves. Diseases
requiring this level of isolation include C difficile, norovirus, open wounds (burns),
respiratory syncytial virus (RSV), methicillin-resistant staphylococcus aureus
(MRSA), and vancomycin-resistant enterococci (VRE)
 Droplet precautions— PPE required includes gown, gloves, and mask.
Respiratory illnesses such as rhinovirus/enterovirus or adenovirus, pneumonia,
influenza, pertussis, mumps, and bacterial meningitis.
 Airborne precautions— PPE required includes gown, gloves, and N95
respirator mask. Diseases requiring this level of isolation include measles, severe
acute respiratory syndrome (SARS), varicella (chickenpox), and mycobacterium
tuberculosis.
Immunocompromised patients may additionally require isolation precautions to protect
the patient from externally transmitted infection. Due to their weakened immune system,
these patients benefit from decreasing any additional exposure to infection. Another
term for this type of isolation is reverse isolation. Generally, a minimum of contact
precautions is recommended/required throughout the care of immunocompromised
individuals.
Reporting Communicable Disease
Some diseases are so significant to public health that they must be reported to
the Centers for Disease Control and Prevention (CDC). This reporting allows
statistical analysis of the disease to determine how often it is occurring and any trends
or outbreaks. The following are the most common diseases that require CDC reporting:
chlamydia, gonorrhea, salmonellosis, rubeola (measles), pertussis, varicella, anthrax,
botulism, diphtheria, giardiasis, hepatitis (A, B, C), leprosy, lyme disease, malaria,
meningitis, mumps, poliomyelitis, Rocky Mountain spotted fever, rubella, smallpox,
syphilis, tetanus, tuberculosis, typhoid fever, antibiotic resistant infections, and yellow
fever.
Surgical Asepsis
These precautions are the practices necessary to keep areas and objects free from
microorganisms. Sterile technique is the term that is often used in place of surgical
asepsis. These techniques are used both in surgical procedures and other invasive
therapies and treatments such as IV therapy, suturing, and the placement of urinary
catheters.
These are the eight basic principles of sterile technique:
 Every object used in a sterile field must be sterile.

 If a sterile object touches an unsterile object, it is no longer sterile.
 A sterile object that is out of view or below waist level is considered unsterile.
 A sterile object can become unsterile through exposure to airborne pathogens.
 Fluids flow in the direction of gravity.
 Moisture or fluids passing through a sterile object can draw pathogens from
unsterile surfaces above or below via capillary action.
 The edges of a sterile field are unsterile.
 The skin cannot be sterilized.
The nurse must always monitor for and evaluate the sterility of procedures and the
equipment being used. When necessary “stop the line”, stopping all further activity
due to a break in protocol/sterility. The break in sterility must be addressed prior to
continuing on with the procedure. Nurses play a critical role in preventing patient harm
by maintaining an honest, sterile environment during aseptic procedures and surgery.
Restraints and Safety Devices

Restraints and safety devices are tools that can be used to keep both patients and
medical staff safe. A prescribing provider’s orders are required to initiate the use of
restraints. This only varies in emergent situations where restraints may be placed
initially and an order obtained shortly thereafter. There are chemical
restraints (medications) as well as physical restraints (bedside rails, mits, extremity
strap restraints,jackets, etc.). Be familiar with the use of all of these, when they are
indicated, and the safest/most effective way to use each.
Nurses must frequently assess restrained patients and ensure their needs are met.
Assessment and care measures include monitoring vital signs, signs of injury, nutrition,
hydration, circulation, providing range of motion, hygiene, elimination, comfort, and
safety. Patients are still entitled to maintain their dignity, safety, and patient rights while
being restrained. Always use the least restrictive restraint possible for the least amount
of time that ensures patient and staff safety. Each facility will have specific instructions,
indications of use, and frequency of assessments clearly outlined. If restraints are
inappropriately used, there are legal implications that will ensue. .
Restraints are never to be used for convenience or patient punishment. Keep in mind
that some medical conditions, such as seizures, will often include the use of restraints
for the safety of the patient. Restraints for these patients follow the same guidelines as
the rules listed previously.

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What are some common assistive devices mentioned and what are their purposes?

What are some common assistive devices mentioned and what are their purposes?

What are the principles of surgical asepsis?

What are the principles of surgical asepsis?

UNION TEST PREP NCLEX STUDY GUIDE

Flashcards available at https://uniontestprep.com/nclex-rn-exam/flashcards

Practice tests at https://uniontestprep.com/nclex-rn-exam/practice-test

How to Prepare for Basic Care and Comfort

Types of Assistive Devices

Assessing the Patient for Device Need

Assisting with Proper Use of Devices

Evaluating the Success of Device Use

Assessment for Elimination Issues

Common Terms Relating to Urination Problems

Common Terms Relating to Bowel Problems

Skin Care for Incontinent Patients

Evaluation of Restorative Methods

Mobility and Immobility

Other Potential Complications

Evaluation of Patient Response

Non-Pharmacological Comfort Interventions

Determining the Need for Pain Management

Other Alternative Therapies

Counseling Patients and Families

Nutrition and Oral Hydration

Assessing the Patient

Managing Food Intake

Alternative Feeding Methods

Monitoring Intake and Output

Daily Care Modification

Rest and Sleep

Assess for Patient Needs

Use Pathophysiology Knowledge

Adjust Patient Care Schedules Appropriately

Adolescent— 13 to 18 years (beginning with puberty)

 Working years— 19 to 64 years

The Birth Process

Delivery Date Calculation

Infection and Illness

Complication Warning Signs

Care of the Mother

Developmental Transitions and Stages

 Suckle reflex and rooting reflex

Normal Appearance Variations:

 Swollen breasts or genitalia—residual estrogen from mother during pregnancy or

 Forming bonds with parents and caregivers

 Not rolling from tummy to side by 10 months old

 Dress and undress himself/herself

 Consistency with environments and set boundaries

 Not walking by 18 months

 Coordination more advanced

 Early intervention for those with vision and/or hearing problems

 Continued bed-wetting (nocturnal enuresis)

 Try to find self-identity

 Education and mental preparation for physical changes of puberty

Adults (Working Adults)

 Erikson’s Theory of Psychosocial Development: (age 19–34 intimacy versus

 Healthy coping mechanisms to manage demands of long-term relationships,

Older Adults (Retirement Aged)