Category 1: Safe and Effective Care

Environment
The Safe and Effective Care Environment consists of the Management of Care and the Safety and
Infection Control subcategories.

I) Management of Care
The registered nurse provides and directs nursing care that enhances the care delivery setting to
protect the client and health care personnel.
RN's must be able to:

 Integrate advance directives into client plan of care

 Assign and supervise the care provided by others (e.g., LPN/LVN, assistive personnel, other RNs)
 Organize workload to manage time effectively
 Participate in providing cost-effective care
 Initiate, evaluate, and update the plan of care (e.g., care map, clinical pathway)
 Provide education to clients and staff about client rights and responsibilities
 Advocate for client rights and needs
 Collaborate with health care members in other disciplines when providing client care
 Manage conflict among clients and health care staff
 Maintain client confidentiality and privacy
 Provide and receive a report on assigned clients (e.g., standardized handoff communication)
 Use approved abbreviations and standard terminology when documenting care
 Perform procedures necessary to safely admit, transfer or discharge a client
 Prioritize the delivery of client care
 Recognize ethical dilemmas and take appropriate action
 Practice in a manner consistent with a code of ethics for registered nurses
 Verify that the client comprehends and consents to care and procedures
 Receive and/or transcribe health care provider orders
 Utilize information resources to enhance the care provided to a client (e.g., evidenced-based research,
information technology, policies, and procedures)
 Recognize the limitations of self/others and seek assistance
 Report client conditions as required by law (e.g., abuse/neglect, communicable disease, gunshot wound)
 Report unsafe practice of health care personnel and intervene as appropriate (e.g., substance abuse,
improper care, staffing practices)
 Provide care within the legal scope of practice
 Participate in performance improvement/quality improvement process and
 Recognize the need for referrals and obtain necessary orders

Related content includes, but is not limited to:

 Advance Directives
 Advocacy
 Assignment, Delegation, and Supervision
 Case Management
 Client Rights
 Collaboration with Interdisciplinary Team
 Concepts of Management
 Confidentiality/Information Security
 Continuity of Care
 Establishing Priorities
 Ethical Practice
 Informed Consent
 Information Technology
 Legal Rights and Responsibilities
 Performance Improvement & Risk Management (Quality Improvement)
 Referrals

Advance Directives:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of advance directives in order to:

 Assess client and/or staff member knowledge of advance directives (e.g., living will, health care proxy,
Durable Power of Attorney for Health Care [DPAHC])
 Integrate advance directives into the client plan of care
 Provide the client with information about advance directives

Assessing the Client and/or Staff

Members' Knowledge of Advance
Directives
When a learning need in respect to advance directives is assessed by the registered nurse, education
should be planned to correct any identified knowledge deficits in reference to all aspects of advance
directives including living wills, health care proxies, and durable power of attorney for health care
[DPAHC] .
For example, when a client asks the registered nurse if they can change their advance directives, the
registered nurse should know that the client has a knowledge deficit relating to the fact that advance
directives can be changed at any time and when the supervising registered nurse manager audits
client medical records and documentation and learns that the staff are not including complete
information about whether or not the clients have or do not have advance directives, the supervising
registered nurse manager should know that the staff have a knowledge deficit relating to the fact that
the presence or absence of advance directives must be assessed and documented.
When such learning needs are identified, appropriate patient or staff education should be planned,
implemented, evaluated and documented as was previously discussed and detail with the Integrated
Process of Teaching and Learning.
The registered nurse is responsible and accountable for assessing educational needs in respect to
advance directives and to insure that the clients and staff members have the sufficient knowledge to
make sound and knowledgeable decisions relating to these important aspects of client care. This
knowledge enables the clients to make knowledgeable decisions about their own advance directives
and it enables other members of the nursing team to integrate the principles of advance directives
into the care that they provide to their clients.

Integrating Advance Directives into

the Client Plan of Care
Advance Directives are integrated into the client's plan of care by nurses and other healthcare
professionals. Any and all information about advance directives is also documented and
communicated with other members of the healthcare team so that all of these client's choices are
upheld in all aspects of care and all clients should be encouraged to initiate advance directives
whenever they have failed to generate these important documents in the past.
The ultimate purpose of advance directives is to guide professional decision making and direct the
client's care and treatments at the end of life. Advance directives also provide the legal basis for all
clients to accept or reject care as they wish because they have the innate right to autonomous
decision making without coercion and self-determination even when they are no longer competent
to do so.
Nurses must review and verify the patient's advance directive status with their first patient contact
because an emergency life threatening situation like a cardiac or respiratory arrest can occur at any
time with little or no time to review these documents at that time. If, for example, the patient has an
advance directive to NOT have CPR, the nurse may administer CPR because they have failed to
review the client's advance directive. This CPR, then, is contrary to the patient's wishes.

The Elements and Components of

End of Life Decisions and Advance
Directives
The elements and components of The Patient Self Determination Act, which was passed by the US
Congress in 1990, gives Americans the right to make decisions relating to future care and treatments
when the person is no longer able to give informed consent and/or the refusal of care and
treatments because the person is incapacitated to do so. These decisions are documented with an
advance directive and/or made by the legally appointed health care proxy or surrogate according to
this national law.
The Patient Self Determination Act also mandates public education about advance directives and the
fact that all hospitals, including psychiatric facilities, and all health insurance plans have to follow
and adhere to state law specific relating to advance directives.
The Uniform Determination of Death Act, approved by most states in our nation, also provides
healthcare facilities and healthcare professionals with some guidance and direction relating to end of
life decisions. The Uniform Determination of Death Act defines death as either the irreversible
cessation of respiratory and circulatory functions OR the irreversible cessation of all brain functions
including brain stem function.
The elements and components of end of life choices and advance directives can include:

 An election to donate some or all bodily organs according to the US Uniform Anatomical Gift Act
 A living will
 A health care proxy
 A durable power of attorney for health care (DPAHC) which is separate and distinct from a durable
power of attorney relating to financial and monetary decisions
The Uniform Anatomical Gift Act of the United States, simply stated, sets the regulations revolving
around organ donations and organ transplantations, including prohibitions against the sale and
trafficking of human organs. According to this law of the land, living people can elect to donate one
or more of their bodily parts; and it also contains mechanisms that enable surviving spouses and
other relatives to donate organs after the loss of love of a loved one when that person has not made
a decision about whether or not they want to participate in an organ donation.
A living will, which is often referred to as an advance directive, is a well thought out document that
lists the types of things and interventions that the client wants and does not want at the end of life
when they are no longer able to give knowledgeable consent or reject these things and interventions
as the result of their loss of their legal ability to consent to or reject these things. It should be as
specific and as detailed as necessary. Treatments and aspects of care that were not anticipated and
included in the living will then become the responsibility of the surrogate health care proxy to make.
Some of the most commonly aspects of care that are addressed in living wills are choices relating to
whether or not the client wants CPR, tube feedings, surgeries and other invasive procedures. Many
living wills also address the client's desire to have comfort and pain relief interventions at the end of
life.
The health care proxy, or surrogate, is also referred to as the health care power of attorney and the
durable power of attorney for healthcare. The durable power of attorney for healthcare is separate
and distinct from any durable power of attorney for financial matters.
People with a legal power of attorney for healthcare can make decisions relating to healthcare
decisions when the client is no longer able to make these decisions and these decisions were not
anticipated and documented in the person's living will.
Despite the fact that all of these end of life decisions and documents can be acceptably and legally
done and executed by the client themselves or by the client and their family members, some elect to
have an attorney at law to perform this role.

Providing the Client With Information

About Advance Directives
Clients should be provided with complete information about advance directives and they should also
have the opportunity to discuss all of their alternatives and options. This education should also
include the benefits and risks associated with their choices in the same manner that is done with all
informed consent.
Some of the specific information that should be provided to the client, in writing and/or orally
include understandable information about:

 The Patient Self Determination Act

 The Uniform Determination of Death Act
 The Uniform Anatomical Gift Act
 Living wills
 Health care proxies and surrogates
 Durable powers of attorney for health care (DPAHC)

Another piece of useful information for both the client/family members and healthcare providers in
terms of advance directives is the Five Wishes which was developed with a Robert Wood Johnson
Foundation grant. The Five Wishes, which can and should be considered and addressed in the
client's advance directive, include the client's choices in respect to:

1. Who they desire to make healthcare related decisions for them about their care when they are no longer
able to make these important decisions
2. All medical care and treatments that the patient ELECTS TO HAVE and all of those that the client does
NOT want
3. How the client wants to be treated and cared for by others at the end of life
4. Decisions relating to the promotion of comfort and the relief of pain
5. Things that they want their loved ones to know

Another decision and document that may be highly useful to clients and their healthcare decisions
makers is a values history. Although not mandated by law, value histories are recommended and
highly beneficial when it comes to end of life care and decision making, particularly when a person is
appointed as a health care proxy or durable power of attorney for healthcare.
Values histories contain and consist of the client's general basic beliefs, values, opinions and
principles relating to these principles and beliefs in addition to others:

 The quality of life versus the quantity of life

 The management of pain even if it may shorten the duration of life
 Surgical procedures and associated alterations of the body image
 "Being a guinea pig"
 Dignity and maintaining dignity at the end of life

Advocacy: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of advocacy in order to:

 Discuss identified treatment options with client and respect their decisions
 Provide information on advocacy to staff members
 Act in the role of client advocate
 Utilize advocacy resources appropriately (e.g., social worker, chain of command, interpreter)

The roles and responsibilities of registered nurses are vast and diverse. Some of the many nursing
roles and responsibilities include advocate, teacher, change agent, care giver, researcher and manager
of care.

Discussing Identified Treatment

Options with the Client and
Respecting Their Decisions
Nurses consistently advocate for the client and significant others, as based on their intrinsic rights
and individual needs, by discussing the client's identified treatment options in an unbiased manner
including, but not limited to:

 The identified treatment itself

 How the identified treatment or procedure is done
 How the identified treatment or procedure works
 The benefits of the identified treatment
 The possible risks and side effects of the identified treatment
 Who will perform or provide the identified treatment or procedure
 Alternatives to the identified treatment or procedure
 The procedure, the benefits and risks of possible alternatives to the identified treatment or procedure

Providing Information on Advocacy to

Staff Members
Registered nurses, as teachers and managers of care, are expected to assess and fulfill the identified
educational and competency needs of clients as well as staff in terms of advocacy.
In this role, the registered nurse provides complete information to staff members, as indicated,
about client advocacy and ways that this advocacy role and responsibility can be fulfilled and
integrated into their practice.
This education should include:

 The role of the nursing care team members as client advocates

 The inalienable rights of the client in terms of autonomy, self-determination and autonomous,
independent decision making
 The intrinsic and legal right of clients to accept and reject any and all treatments
 The identification and utilization of resources that can facilitate and enhance advocating for the
individual client, significant others, families, groups and populations.

Acting in the Role of Client Advocate

As the nurse advocates for clients and significant others, the nurse consistently and respectfully
communicates and collaborates with the client and other healthcare professionals to promote,
uphold, and protect the client's rights, their interests and their choices even when the nurse and/or
other members of the healthcare team may not agree with these choices.
Registered nurses advocate for individual clients, families, local, national and global groups in all
settings including the government and the community.

Utilizing Advocacy Resources

Appropriately
Registered nurses manage and coordinate care as a member of the multidisciplinary team and the
center of care. Making referrals and seeking out and utilizing appropriate resources within and
outside of one's facility are intrinsic to this professional registered nursing role.
When clients have needs that the nurse cannot be fulfilled and met by the registered nurse in
collaboration with other members of the nursing care team, the registered nurse should then utilize
and employ different internal or external resources such as a social worker, a physical therapist, an
occupational therapist, a clergy member or a home health care agency in the community and external
to the nurse's healthcare agency.
Professional interpreters are also helpful in terms of communicating with clients who do not speak
English. These interpreters facilitate the fulfillment of the role and responsibility of the nurse when
advocacy collaboration and communication are necessary and the client does not have a sufficient
level of comprehension with the nurse's native, spoken language.
Many facilities have formal processes, including referral forms and policies/procedures associated
with following the chain of communication and command, referring to the utilization of available
internal and external resources. It is the responsibility of the nurse to know about and follow these
formal procedures when they exist.
Assignment, Delegation and
Supervision: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of assignment, delegation, and supervision in order to:

 Identify tasks for delegation based on client needs

 Ensure appropriate education, skills, and experience of personnel performing delegated tasks
 Assign and supervise care provided by others (e.g., LPN/VN, assistive personnel, other RNs)
 Communicate tasks to be completed and report client concerns immediately
 Organize the workload to manage time effectively
 Utilize the five rights of delegation (e.g., right task, right circumstances, right person, right direction or
communication, right supervision or feedback)
 Evaluate delegated tasks to ensure correct completion of activity
 Evaluate the ability of staff members to perform assigned tasks for the position (e.g., job description,
scope of practice, training, experience)
 Evaluate the effectiveness of staff members' time management skills

The assignment of care to others, including nursing assistants, licensed practical nurses, and other
registered nurses, is perhaps one of the most important daily decisions that nurses make.
Proper and appropriate assignments facilitate quality care. Improper and inappropriate assignments
can lead to poor quality of care, disappointing outcomes of care, the jeopardization of client safety,
and even legal consequences.
For example, when a registered nurse delegates aspects of patient care to a licensed practical nurse
that are outside of the scope of practice of the licensed practical nurse, the client is in potential
physical and/or psychological jeopardy because this delegated task, which is outside of the scope of
practice for this licensed practical nurse, is something that this nurse was not prepared and educated
to perform. This practice is also illegal and it is considered practicing outside of one's scope of
practice when, and if, this licensed practical nurse accepts this assignment. All levels of nursing staff
should refused to accept any assignment that is outside of their scope of practice.
RELATED:

 How is the Scope of Practice Determined for a Nurse?

 Scope of Practice vs Scope of Employment
 RN Scope of Practice
Delegation, simply defined, is the transfer of the nurse's responsibility for the performance of a task
to another nursing staff member while retaining accountability for the outcome. Responsibility can
be delegated. Accountability cannot be delegated. The delegating registered nurse remains
accountable for all client care despite the fact that some of these aspects of care can, and are,
delegated to others.

Identifying Tasks for Delegation

Based on Client Needs
Appropriate decisions relating to the successful assignment of care are accurately based on the needs
of the patient, the skills of the staff, the staffs' position description or job descriptions, the
employing facility's policies and procedures, and legal aspects of care such as the states' legal scopes
of practice for nurses, nursing assistants and other members of the nursing team.
The "Five Rights of Delegation" that must be used when assigning care to others are:

 The "right" person

 The "right" task
 The "right" circumstances
 The "right" directions and communication and
 The "right" supervision and evaluation

In other words, the right person must be assigned to the right tasks and jobs under the right
circumstances. The nurse who assigns the tasks and jobs must then communicate with and direct the
person doing the task or job. The nurse supervises the person and determines whether or not the
job was done in the correct, appropriate, safe and competent manner.

The "Right Task" and The "Right

Person": Identifying Tasks for
Delegation Based on Client Needs
The client is the center of care. The needs of the client must be competently met with the
knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who
delegates aspects of care to other members of the nursing team must balance the needs of the client
with the abilities of those to which the nurse is delegating tasks and aspects of care, among other
things such as the scopes of practice and the policies and procedures within the particular healthcare
facility.
Some client needs are relatively predictable; and other patient needs are unpredictable as based on
the changing status of the client. Some needs require high levels of professional judgment and skill;
and other patient needs are somewhat routinized and without the need for high levels of
professional judgment and skill. Some client needs are acute, ever changing and/or rarely
encountered; and other patient needs are chronic, relatively stable, more predictable, and more
frequently encountered.
Based on these characteristics and the total client needs for the group of clients that the registered
nurse is responsible and accountable for, the registered nurse determines and analyzes all of the
health care needs for a group of clients; the registered nurse delegates care that matches the skills of
the person that the nurse is delegating to.
For example, a new admission who is highly unstable should be assigned to a registered nurse; the
care of a stable chronically ill patient who is relatively stable and more predictable than a serious ill
and unstable acute client can be delegated to the licensed practical nurse; and assistance with the
activities of daily living and basic hygiene and comfort care can be assigned and delegated to an
unlicensed assistive staff member like a nursing assistant or a patient care technician. Lastly, the care
of a client with chest tubes and chest drainage can be delegated to either another registered nurse or
a licensed practical nurse, therefore, the registered nurse who is delegating must insure that the nurse
is competent to perform this complex task, to monitor the client's response to this treatment, and to
insure that the equipment is functioning properly.

Ensuring the Appropriate Education,

Skills, and Experience of Personnel
Performing Delegated Tasks
The staff members' levels of education, knowledge, past experiences, skills, abilities, and
competencies are also evaluated and matched with the needs of all of the patients in the group of
patients that will be cared for. Some staff members may possess greater expertise than others. Some,
such as new graduates, may not possess the same levels of knowledge, past experiences, skills,
abilities, and competencies that more experienced staff members possess. Some may even be more
competent in some aspects of client care than other aspects of client care. For example, a licensed
practical nurse on the medical surgical floor may have more knowledge, skills, abilities, and
competencies than a registered nurse in terms of chest tube maintenance and care because they may
have, perhaps, had years of prior experience in an intensive care area of another healthcare facility
before coming to your nursing care facility.
Delegation should be done according to the differentiated practice for each of the staff members. A
patient care technician, a certified nursing assistant, a licensed practical nurse, an associate degree
registered nurse and a bachelor's degree registered nurse should not be delegated to the same aspects
of nursing care. Based on the basic entry educational preparation differences among these members
of the nursing team, care should be assigned according to the level of education of the particular
team member.
Also, staff members differ in terms of their knowledge, skills, abilities and competencies. A staff
member who has just graduated as a certified nursing assistant and a newly graduated registered
nurse cannot be expected to perform patient care tasks at the same level of proficiency, skill and
competency as an experienced nursing assistant or registered nurse. It takes time for new graduates
to refine the skills that they learned in school.
Validated and documented competencies must also be considered prior to assignment of patient
care. No aspect of care can be assigned or delegated to another nursing staff member unless this
staff member has documented evidence that they are deemed competent by a registered nurse to do
so. For example, a newly hired certified nursing assistant cannot perform bed baths until a
supervising registered nurse has observed this certified nursing assistant provide a bed bath and has
decided that they are now competent to do this task without direct supervision.
All healthcare facilities and agencies must assess and validate competency before total care or any
aspect of care is performed by an individual without the direct supervision of another, regardless of
their years of experience. Competency checklists are used to document the competency of the staff;
they must be referred to as assignments are made. Care can be delegated to another only when that
person is deemed competent to perform the role or task and this competency is documented.
Scopes of practice are also considered prior to the assignment of care. All states have scopes of
practice for advanced nurse practitioners, registered nurses, licensed practical nurses and unlicensed
assistive personnel like nursing assistants and patient care technicians.

Assigning and Supervising the Care

Provided by Others
The job of the registered nurse is far from done after client care has been delegated to members of
the nursing team. The delegated care must be followed up on and the staff members have to be
supervised as they deliver care. The registered nurse remains responsible for and accountable for the
quality, appropriateness, completeness, and timeliness of all of the care that is delivered.
The supervision of the care provided by others includes the monitoring the care, coaching and
supporting the staff member who is providing the care, assisting the staff member with priority
setting and time management skills, as indicated, educating the staff member about the proper
provision of care, as indicated by a knowledge or skills deficit, and also praising and positively
reinforcing the staff for a job well done.
Remember, the delegating registered nurse is still responsible and accountable for all of the client
care that is delegated to others.
Communicating Tasks to be
Completed and Report Client
Concerns Immediately
Registered nurses who assign, delegate and/or provide nursing care to clients and groups of clients
must report all significant changes that occur in terms of the client and their condition. For example,
a significant change in a client's laboratory values requires that the registered nurse report this to the
nurse's supervisor and doctor.
They must also communicate and document all tasks that were completed and the client's responses
to this treatment. As the old adage says, "If it wasn't documented, it wasn't done."

Organizing the Workload to Manage

Time Effectively
Time is finite and often the needs of the client are virtually infinite. Time management, organization,
and priority setting skills, therefore, are essential to the complete and effective provision of care to
an individual client and to a group of clients.
Priorities of care, as previously discussed, are established using a number of methods and
frameworks including the ABCs, Maslow's Hierarchy of Needs and the ABCs/MAAUAR method
of priority setting.
Some time management techniques, in addition to priority setting, that you may want to consider
using to insure that you manage your workload and time effectively include:

 Clarifying your assignment as necessary

 Planning your work in an orderly and systematic manner knowing that priorities and clients' status
change frequently
 Avoiding all unnecessary interruptions
 Learning how to say no to others when they ask you for help and you have priority patient needs that
would not be addressed if you helped another
Utilizing the Five Rights of
Delegation
As previously discussed, all delegation may be based on the "Five Rights of Delegation" which are:

 The "right" person

 The "right" task
 The "right" circumstances
 The "right" directions and communication
 The "right" supervision and evaluation

Evaluating Delegated Tasks to Ensure

the Correct Completion of the Activity
or Activities
In addition to the supervision of delegated tasks in terms of quality, appropriateness, and timeliness,
the registered nurse who has delegated tasks must insure that the assigned activities have been
correctly completed.
When assignments are made, the registered nurse must insure that the staff member will have ample
time during the shift to complete the assignment and, then, the registered nurse must monitor and
measure the staff members' progress toward the completion of assigned tasks throughout the
duration of the shift.
This monitoring must be done in an ongoing and continuous manner and not at the end of the shift
when it is too late to make corrections.

Evaluating the Ability of Staff

Members to Perform the Assigned
Tasks for the Position
As previously discussed, staff members should have documented competency for all tasks that are
assigned to them. All nursing team members have the responsibility, however, to refuse an
assignment if they believe that they cannot do it properly. When this occurs, the registered nurse
should either teach the staff member how to perform the task and then document their competency
in terms of this assigned task or assign the task to another nursing team member who has
documented competency and is sure that they can perform the task in a correct manner.
Part of supervision entails the ongoing evaluation of staff's ability by the registered nurse to perform
assigned tasks using direct observations and with indirect observations of patient safety, the quality
of the care provided, the appropriateness of care provided, and the timeliness of care provided. For
example, the registered nurse can directly observe the performance of the nursing assistant while the
client is being transferred from the bed to the chair; and the registered nurse can review the
medication administration record to determine if the licensed practical nurse has administered
medications in a timely manner which is an example of indirect observation.
The ability of a staff member to perform a specific task is not only based on their competency but it
is also based on their:

 Legal scope of practice,

 Documented competency,
 Education and training,
 Past experiences,
 Position description which is also referred to as the job description and
 Healthcare facility specific policies and procedures.

All states throughout our nation have legally legislated scopes of practice for registered professional
nurses, licensed practical or vocational nurses, and advanced nursing practice nurses; and they also
have legal guidelines related to what an unlicensed, assistive staff member, such as a student nurse
technician, patient care aide, patient care technician or nursing assistant, can and cannot legally
perform regardless of whether or not the healthcare provider or the delegating nurse believes that
they are competent to do.
Although these legal, legislated scopes of practice may vary a little from state to state, they share a lot
of commonalities and similarities. For example:

 The scope of practice for the registered nurse will most likely include the legal ability of the registered
professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis,
planning, implementation and evaluation.

 The scope of practice for the licensed practical or vocational nurse will most likely include the legal ability
of this nurse to perform data collection, plan, implement and evaluate care under the direct supervision
and guidance of the registered nurse.

 The scope of practice for an advanced practice nurse, such as a nurse practitioner, will most likely include
the legal ability of the advanced practice registered professional nurse to perform all phases of the
nursing process including assessment, nursing diagnosis, planning, implementation and evaluation in
addition to prescribing some medications.
Nurses violate scope of practice statutes, or laws, when they function in roles and aspects of care
that are above, beyond and/or not included in their scope of practice. Permanent license revocation
may occur when a nurse practices outside of the legally mandated scope of practice. Additionally,
licensed nurses who have failed to either reapply for their license or have had it revoked as part of a
state disciplinary action cannot and continue to practice nursing are guilty of practicing nursing
without a license.
Among the tasks that CANNOT be legally and appropriately delegated to nonprofessional,
unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and
personal care aides, include assessments, nursing diagnosis, establishing expected outcomes,
evaluating care and any and all other tasks and aspects of care including but not limited to those that
entail sterile technique, critical thinking, professional judgment and professional knowledge.
Some examples of tasks and aspects of care that can be delegated legally to nonprofessional,
unlicensed assistive nursing personnel, provided they are competent in these areas, under the direct
supervision of the nurse include:

 Assisting the client with their activities of daily living such as ambulation, dressing, grooming, bathing
and hygiene
 Measuring and recording fluid intake and output
 Measuring and recording vital signs, height and weight
 The provision of nonpharmacological comfort and pain relief interventions such as establishing and
maintaining an environment conducive to comfort and providing the client with a soothing and
therapeutic back rub
 Observation and reporting changes in and the current status of the patient's condition and reactions to
care
 The transport of clients and specimens and other errands and tasks such as stocking supplies
 Assistance with transfers, range of motion, feeding, ambulation, and other tasks such as making beds and
assisting with bowel and bladder functions

In addition to the legally mandated state scopes of practice, the registered nurse must also insure
that the delegated tasks are permissible according to the nursing team members' position description
which is also referred to as the job description, and the particular facility's specific policies and
procedures relating to client care and who can and who cannot perform certain tasks.
For example, intravenous bolus and push medications may be permissible for only licensed
registered nurses in certain areas of the healthcare facility such as the intensive care units; the
administration of blood and blood components may be restricted to only registered nurses; and the
care of a client who is receiving conscious sedation may be restricted to only a few registered nurses
in the particular healthcare facility, according to these job descriptions, policies and procedures.
Evaluating the Effectiveness of Staff
Members' Time Management Skills
As previously mentioned, the registered nurse must allot a reasonable amount of time for staff
members to complete their assignments when care and tasks are delegated. The staff should be able
to complete their assignments within the allocated period of time. When an assignment is not done
as expected, the delegating nurse should determine why this has occurred and they must take
corrective actions to insure task completion.
One of the things that the delegating nurse will want to consider when an assignment is not
completed within the allotted time frame is determining whether or not the staff member is
organizing their work and using effective time management skills. If the staff member is not using
effective time management skills, the nurse must teach and assist the staff member about better time
management and priority setting skills.

Case Management: NCLEX-

RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of case management in order to:

 Explore resources available to assist the client with achieving or maintaining independence
 Assess the client's need for materials and equipment (e.g., oxygen, suction machine, wound care supplies)
 Participate in providing cost effective care
 Plan individualized care for client based on need (e.g., client diagnosis, self-care ability, prescribed
treatments)
 Provide client with information on discharge procedures to home, hospice, or community setting
 Initiate, evaluate, and update plan of care (e.g., care map, clinical pathway)

The definition of case management and the role of the "case manager" vary greatly in the
professional literature. As discussed with critical pathways in the integrated process entitled
"Communication and Documentation", case management is method of nursing care delivery,
however, case management can also be used to describe the roles of people who work in health
insurance companies, the roles of people, like social workers, who work in healthcare facilities to
move clients along the continuum of care, and as of the many roles of that nurses have.
The registered nurse as a case manager entails the coordination of care, resource identification, the
planning of services, referrals, and linking clients to the services that they need as based on their
biological, emotional, and social needs as well as their spiritual and cultural preferences.
Registered nurses, as case managers of care:

 Insure that client care is of high quality, effective, timely, complete and cost effective
 Insure that all clients are provided with the care and services offered by not only the appropriate
members of the nursing care team but, also, with members of the multidisciplinary healthcare team such
as a physical rehabilitation team or a community home care team, for example. This aspect of case
management is accomplished by connecting, referring and linking clients to the services that they need as
based on the kinds of care and the levels of care that they need according to their current assessed needs.
 Insure that all clients are provided with the material resources that they need to meet their current
assessed needs. For example, the client may need a CPAP machine, a sequential pressure device, oxygen
therapy and oxygen supplies, a suctioning machine and/or sterile wound care supplies including sterile
dressings
 Coordinate and continuously evaluate the timeliness, effectiveness and appropriateness of client care
 Identify and implement immediate and effective actions if, and when, any deviations from the plan of
care and/or poor patient outcomes occur
 Insure that the client is at, or moved to, the appropriate level of care, as indicated by the current client's
status, so that appropriate care at the appropriate level of care can be provided and also to insure that
insurance reimbursement for their necessary care and services is done

Case management, as previously mentioned, is also a formal method of nursing care delivery. In this
context, case management can employ a number of different frameworks and models. These
possible case management models used for patient care delivery systems include:

 The ProACT Model

 The Collaborative Practice Model
 The Case Manager Model
 The Triad Model of Case Management

The Professionally Advanced Care Team, abbreviated as and referred to as the ProACT Model, of
patient care delivery was developed at the Robert Wood Johnson University Hospital. This model,
simply described, assigns and addresses the registered nurses' role as both a primary nurse providing
clinical care and a clinical case manager with additional formal functions such as those related to
personnel, fiscal and budgeting responsibilities and administration/management functions.
The Collaborative Practice Model of case management entails the role of some registered nurses in a
particular healthcare facility to manage, coordinate, guide and direct the complex care of a
population of clients throughout the entire healthcare facility who share a particular diagnosis or
Diagnostic Related Group, referred to as a DRG, such as chronic obstructive pulmonary disease, an
acute myocardial infarction or the Tetralogy of Fallot.
The Collaborative Practice Model of case management uses the critical pathways, also referred to as
clinical pathways, as were previously discussed. This model also identifies, monitors, tracks, trends
and documents all variances including patient related variances, healthcare provider variances and
system variances.
The Case Manager Model or The Beth Israel Multidisciplinary Patient Care Model is quite similar to
the Collaborative Practice Model with the exception of the fact that this model, unlike the
Collaborative Practice Model, is unit based and not organization wide. For example, a registered
nurse on a particular nursing care unit may be assigned to take care of all of the clients on that unit
who share a particular diagnosis or Diagnostic Related Group; these nurses remain on their unit
rather than having clients throughout the particular facility like the nurses using the Collaborative
Practice Model do.
The Triad Model of Case Management, also referred to as the Collaborative Care Model of
Vanderbilt University Medical Center in Nashville, Tennessee creates, maintains and focuses on the
close interdisciplinary collaboration of the social worker, the nursing case manager, and the
utilization review team member throughout the course of care.

Exploring the Resources Available to

Assist the Client with Achieving or
Maintaining Independence
All available resources, including available human, material and financial resources, must be
explored, identified and garnered in order to promote optimal patient care outcomes and to assist
the client with achieving and maintaining their highest possible level of independence.
Nurses manage client care, as a case manager; strive to insure that the client receives the correct
resources at the correct time and in a timely manner. When goal is not accomplished in an effective
and timely manner, the healthcare facility loses money and/or optimal outcomes are not achieved.
All possible resources that could possibly assist the client with achieving and maintaining
independence, as based on the assessment of the client and their current needs, are explored, after
which the best possible and most feasible alternative(s) is (are) selected and employed. After this
intervention, the registered nurse evaluates the successes or failures of these interventions in terms
of how well they have facilitated client independence or any other expected or desired client
outcome or goal or they have failed to do so. When expected outcomes are not achieved, the
registered nurse determines the reason(s) behind this failure.
Assessing the Client's Need for
Materials and Equipment
After the client is fully assessed initially and then also reassessed in an ongoing manner, the nurse, as
the manager of care determines which supplies, materials and equipment the client needs to meet
their needs.
After this assessment and determination, the registered nurse then Insures that the client is provided
with the material resources, including supplies and equipment that they need to meet their current
assessed needs. For example, the client may need a CPAP machine, a sequential pressure device,
oxygen therapy and oxygen supplies, a suctioning machine and/or sterile wound care supplies
including sterile dressings

Participating in Providing Cost

Effective Care
Nurses and other members of the healthcare team, often in a collaborative manner, plan care as
based on is appropriateness, its cost effectiveness and its cost/benefit benefit ratio without
compromising the quality of care and/or optimal positive outcomes of care. The challenge lies
within. The nurse, and others, must select the treatments, interventions, and human and material
resources that are the least costly and ALSO the most beneficial and the most appropriate.
Cost effective is defined as "giving the most profit or advantage in exchange for the amount of
money that is spent" and the cost-benefit ratio is defined as the "comparison of the likely costs of a
plan or project with the benefit it will bring, done in order to help make a decision". Cost effective
care and the care and services provided to clients with a good cost-benefit ratio is NOT always the
least expensive and the least costly. Nonetheless, this care and services must be the least costly
possible while still high quality and effective in terms of meeting the clients' needs.
According to the US Centers for Medicare and Medicaid Services (CMS), "In 2014, U.S. health care
spending increased 5.3 percent following growth of 2.9 percent in 2013 to reach $3.0 trillion, or
$9,523 per person. The faster growth experienced in 2014 was primarily due to the major coverage
expansions under the Affordable Care Act, particularly for Medicaid and private health insurance.
The share of the economy devoted to health care spending was 17.5 percent, up from 17.3 percent
in 2013." Health care is costly and its costs continue to rise.
In the not too distant past, healthcare facilities, including hospitals and medical centers, were
reimbursed for the services and care that they provided based on the cost associated with these
services. This type of healthcare reimbursement was referred to as retrospective reimbursement.
Under retrospective reimbursement, there was little or no reason or incentive to control and contain
costs because insurance companies paid for all the provided care and services regardless of their
associated costs. As healthcare costs continued to rise and spiral out of control, cost containment
efforts led to the discontinuation of the retrospective reimbursement system and the rise of the
prospective reimbursement system.
As the result of prospective reimbursement, healthcare facilities and healthcare providers no longer
got reimbursed for all the care and services provided. Instead, they got, and remain to be,
reimbursed at a fixed amount as determined by the client's specific diagnosis related group (DRG).
As a result of this retrospective reimbursement system, healthcare facilities that can successfully and
effectively provide quality care that insures optimal outcomes with shortest possible lengths of stay
and the fewest possible resources and care make more money than those with extended and
prolonged lengths of stay and the use of unnecessary, abundant, and unlimited resources. Cost
containment became, and remains to be, a high priority for healthcare organizations and healthcare
providers.
Healthcare insurance companies, also referred to as third party payers, in our nation include
governmental health care insurance and private healthcare insurance companies.
The United States Medicare program and the states' administered Medicaid programs are the two
governmental reimbursement programs. Medicaid reimburses healthcare costs for low income
individuals, low income families, and chronically ill and disabled children. Medicaid is administered
by the states. Medicare, under the U. S. Social Security Act, reimburses healthcare costs for older
adults who are 65 years of age and older, as well as permanently disabled people and their
dependents.
Private insurance companies differ in terms of their monthly premiums, their annual deductibles
which the healthcare insurance policy holder must pay, their copayments which the healthcare
insurance policy holder must pay, their covered services, and reimbursement rates.

Planning Individualized Care for the

Client Based on Need
All care is planned as based on the needs of the unique individual and their needs, their diagnosis,
their level of self care abilities, their strengths, their weaknesses, and treatments that are ordered and
prescribed.
The planning process was previously detailed and discussed with the "Integrated Process: The
Nursing Process".
Providing the Client with Information
on Discharge Procedures to the
Home, Hospice, or Community
Setting
Like initial planning, discharge planning should, and must, begin, as previously stated, at the time of
the first client contact and/or immediately upon admission to a healthcare facility.
Discharge planning must reflect the needs of the client at the appropriate level of care along the
continuum of care. For example, a discharge plan may include a discharge to the client's personal
home, to a physical rehabilitation center or a discharge to the client's personal home with the
services of a home health company. This planning can also include other discharges in the
community such as a hospice and palliative care center, a long term care nursing home or an assisted
living facility.
Failures to effectively plan discharges along the continuum of care fragment and jeopardize the well-
being of the client. They are also quite costly and highly avoidable when continuous, ongoing
assessments and discharge planning is complete and accurate.
As part of the discharge planning process, registered nurses in collaboration with others, use
established medical necessity criteria to determine and to confirm that the client is being moved
along the continuum of care at the appropriate level of care and also to confirm that the client is
being provided with only those services and care that are consistent with these established criteria.
Only care that meets these criteria will be paid for and reimbursed for.

Initiating, Evaluating, and Updating

the Plan of Care
As previously stated, the purpose of a plan of care is to insure that the client is getting appropriate,
complete and timely care as based on the current needs and status of the client. For this reason, all
clients must have a current plan of care that is initiated, evaluated in terms of its appropriateness,
effectiveness, completeness and timeliness.
The plan of care, or care plan, whether or not it is a traditional care plan, a care map, or a critical
pathway, MUST be updated and remain current as based on the client's current needs.
Client Rights: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of client rights in order to:

 Recognize the client's right to refuse treatment/procedures

 Discuss treatment options/decisions with client
 Provide education to clients and staff about client rights and responsibilities
 Evaluate client/staff understanding of client rights
 Advocate for client rights and needs

The American Hospital Association's Bill of Rights (replaced by the AHA's - Patient Care
Partnership) includes the fact that all clients and patients have
According to the American Hospital Association, all patients have the right to:

 Privacy
 Confidentiality
 Respect and dignity
 Select and choose their own doctor(s)
 Fully know about their medical condition and treatments without any withholding of information
 Make autonomous decisions about their medical care including their right to accept and reject any
treatments
 Complete freedom from abuse and neglect
 Access to emergency services
 Manage and control their finances and personal property
 Competent and compassionate care
 Religious freedom
 Social freedom
 Accurate bills for the care and services that are given to the person
 Express their complains and have these complaints and concerns addressed
Recognizing the Client's Right to
Refuse Treatments and Procedures
Some of these American Hospital Association's Bill of Rights are further amplified and clarified with
the Patient Self Determination Act and the Health Insurance Portability and Accountability Act
(HIPAA).
As previously mentioned, the Patient Self Determination Act upholds and emphasizes the person's
right to make decisions relating to current and future care and treatments. Legally, all patients and
clients must be told about their right to accept or reject all treatments upon admission and with their
first contact with a healthcare agency or provider.
The Health Insurance Portability and Accountability Act (HIPAA) supports and upholds the clients'
rights to confidentially and the privacy of their medical related information regardless of its form. It
covers hard copy and electronic medical records.

Discussing Treatment Options and

Decisions with the Client: Informed
Consent
Informed consent is defined as the patient's election of a treatment or procedure which is based on
their full understanding of the treatment or procedure, its benefits, its risks, and any alternatives to
the particular treatment or procedure. All clients have the legal right to autonomy and self-
determination to accept or reject all treatments and interventions.
With the exception of emergencies, all aspects of nursing care and interventions must be explained
to the patient. When legal informed consent is not given by the patient, any treatments and
procedures that are done without the client's consent are considered illegal, assault and/or battery.
There are three basic types of consent. These types of consent are implicit consent, explicit consent
and opt out consent. This type of consent is indirect and not direct like explicit consent. For
examples, clients who consent and agree to hospitalization are implicitly consenting to the nursing
care by the nature of their hospitalization.

 Explicit consent: Explicit consent entails the expression of a direct and formal consent to agree to or
not to agree to any and/or all treatments. These consents can be verbal or in writing. Most, if not all,
invasive procedure consents are explicit consents that are done in writing and documented in the client's
medical record, sometime using a facility specific consent form. The components of this type of consent
are discussed below.
 Implicit consent: An implicit or implied consent, in contrast to an explicit consent, is indirect rather
formal and direct. For example, a patient gives implicit consent to nursing care when they have simply
agreed to and consented to be hospitalized.

 Opt out consent: Opt out consent is passive and indirect. This type of consent is given when a patient
does NOT refuse a treatment. The lack of objections by the patient indicate that the person has
consented to the treatment or procedure with an opt out consent.

Informed consents can only be obtained from an adult patient who is mentally competent to do so
except under some circumstances and situations. When consent, for any reason including the lack of
majority, mental incompetence and unconsciousness, cannot be obtained, other people can provide
legal consent for the patient.
Some of these people are:

 A legally appointed representative for a developmentally disabled adult, for example

 The parent or legal guardian of a minor and unemancipated minor child
 An emancipated minor who is independent of their parents and
 The durable power of attorney for healthcare decisions or the health care surrogate or proxy

The physician, or other licensed independent provider, the nurse and the client have roles and
responsibilities in terms of informed consent.
The nurse is responsible and accountable for the verification of and witnessing that the patient or
the legal representative has signed the consent document in their presence and that the patient, or
the legal representative, is of legal age and competent to provide consent. They also confirm that the
patient has sufficient knowledge to make a knowledgeable decision.
The physician provides the client with complete information about the treatment or procedure, the
potential risks including pain and complications, the benefits of the treatment or procedure, who will
perform the planned treatment or procedure, and any possible alternatives to the treatment or
procedure including their benefits and risks.
The patient or their legal representative must give consent voluntarily and without any coercion by
others. They must also ask questions and clarify things until they are certain about the procedure, the
benefits, the risks and possible alternatives.
The components of informed consent, as discussed immediately above, include the provision of
complete and unbiased information about the treatment, the purpose of the treatment, the risks,
benefits, which will perform the proposed treatment or procedure, alternatives, and options.
Additional components include the verification that the client fully understands this information and
their right in terms of refusing the treatment or procedure.
The nurse's recognition that informed consent was obtained is based on the legality and
completeness of the written consent and the required process for obtaining a consent including the
client's legal ability to sign it and the client's understanding of the procedure or treatment that they
are consenting to. For example, during the preoperative period of time, nurses must recognize,
identify and confirm that a complete surgical consent was obtained and placed in the patient's
medical record.

Providing Education to Clients and

Staff about Client Rights and
Responsibilities
Registered nurses are responsible and accountable for insuring that all clients and staff members are
knowledgeable about clients' rights and responsibilities and they must also insure that this
knowledge is applied and integrated into staff practice and that all of the clients are exercising their
rights and also fulfilling their responsibilities in terms of healthcare and the healthcare providers and
facility.
When an educational need is assessed in terms of clients' rights and responsibilities, the registered
nurse must plan, implement and evaluate an educational activity that meets this need, as fully
discussed previously with the Integrated Process of Teaching and Learning.
Some of the components of this education can include the elements associated with the American
Hospital Association's Bill of Rights, the Patient Self Determination Act and the Health Insurance
Portability and Accountability Act (HIPAA) in addition to the components of the American
Hospital Association's patient responsibilities. For example, patients have the responsibility to:

 Provide healthcare providers with complete information relating to their signs, symptoms, health related
concerns, and their past and current medical conditions
 Report any safety issues and concerns
 Report any lack of understanding relating to their care, treatments and procedures
 Actively and collaboratively participate in all their care, treatments and procedures
 Be considerate of others
 Follow all the healthcare organization's policies and procedures related to patient behavior, demeanor
and other patient related issues and behaviors such as cigarette smoking and illicit drug use

Evaluating the Client and Staff

Understanding of Client Rights
Client and staff understanding of client rights can be measured and evaluated indirectly and directly.
The registered nurse can directly or indirectly observe the staff member's interactions with the client
and the education that the nurse provides to the client in terms of their rights either with direct
observation or by reviewing the medical record for documentation that the client understands and
exercises their rights during the course of their care.

Advocating for Client Rights and

Needs
Nurses consistently advocate for the client and significant others, as based on their intrinsic rights
and individual needs in an ongoing manner and in all aspects of care.

Collaboration with
Interdisciplinary Team:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of collaboration with interdisciplinary teams in order to:

 Identify the need for interdisciplinary conferences

 Identify significant information to report to other disciplines (e.g., health care provider, pharmacist, social
worker, respiratory therapist)
 Review plan of care to ensure continuity across disciplines
 Collaborate with healthcare members in other disciplines when providing client care
 Serve as a resource person to other staff

Identifying the Need for

Interdisciplinary Conferences
Healthcare and the provision of healthcare services are highly complex with a vast number of
disciplines or professions that contribute to the total care of the patient. For this reason,
interdisciplinary, or multidisciplinary, client care conferences are a highly effective way for all these
interacting professions and departments to come together in order to discuss and solve complex
patient care problems in hopes that this collaboration will lead to high quality outcomes for the
patient.
Interdisciplinary, or multidisciplinary, client care conferences also give the registered nurse the
opportunity to advocate for the client, to serve as the leader of an interdisciplinary group, to serve as
a member of an interdisciplinary group, to enhance the nurse's commitment to clients and client
care, to employ group skills such as negotiation, compromise, conflict resolution, and achieving
consensus, and to utilize creative problem solving and decision making skills to achieve desired
patient outcomes and goals.
Registered nurses identify patient cases that could potentially benefit from an interdisciplinary client
care conference, they plan and arrange for these conferences and they participate in them.
Planning interdisciplinary client care conferences is often challenging. An agenda is developed,
information is collected for presentations, healthcare team members are invited, a time, a date and a
room is decided upon and the client and significant others are encouraged to attend.
Participating in groups, including an interdisciplinary client care conference, requires preparation;
therefore, nurses should be prepared for these meetings. They should have data and information
readily accessible to discuss and they should also have some recommendations for future care that
may enhance the client's outcomes of care.
In addition to expressing their own thoughts, nurses should listen attentively to the thoughts and
suggestions of others in a respectful manner and also be able to compromise and negotiate the best
plan of care for the patient.

Identifying Significant Information to

Report to Other Disciplines
Nurses assess and reassess clients throughout the continuum of their care and they also
communicate and report significant information to other disciplines when the occasion arises.
For example, the nurse will report changes in the client‘s arterial blood gases or oxygen saturation
levels to the respiratory therapist when a client is being weaned off mechanical ventilation; a nurse
will report significant change in the client's psychological or emotion status after the administration
of a new psychotropic medication and they will also report significant changes in terms of the
client's vital signs after a diagnostic test or treatment, to the client's attending physician; the nurse
will report adverse reactions to medications to the pharmacist; and they will report a client's change
in their social support systems to the social worker, a discharge planner and/or a case manager.
This reporting is done in order to insure unfragmented, timely and appropriate care to the client or
groups of clients that meet their current, and often changing, needs as the result of significant
changes in terms of their biological, emotional, and social status.
Reviewing the Plan of Care to Ensure
Continuity Across Disciplines
Nurses, as the collaborator, the manager and the coordinator of client care, consistently and
continuously review the plan of care to insure that all of the appropriate disciplines within the
multidisciplinary team are contributing their services according to the plan of care and that this care
seamlessly moves the client toward their expected outcomes and goals.

Collaborating with Healthcare

Members in Other Disciplines When
Providing Client Care
Broadly described, collaboration is working with others in a collegial and mutually respectful
manner.
Nurses collaborate with patients, significant others, families, other nurses and other healthcare
providers to solve patient care problems and to provide the optimal quality level of care to the
patient or group of patients.
Some of the skills that the nurse must possess in order to be an effective and credible collaborator
include superior interpersonal and communication skills, respect for others, the ability to establish
and maintain trust, critical thinking skills, problem solving skills, decision making skills, and the
ability to understand and be able to identify the contributions of others that can improve the quality
of the patient's care.
The titles and numbers of the many different healthcare team members that nurses collaborate with
are vast and diverse.
Now, you will learn about some of these team member roles and responsibilities so you can identify
and utilize their distinct and unique perspectives and contributions to the plan of care and patient
problem solving.
RELATED:

 How is the Scope of Practice Determined for a Nurse?

 Scope of Practice vs Scope of Employment
 RN Scope of Practice
Nursing Assistants, Patient Care Technician and
Other Titles
These members of the nursing team are unlicensed assistive personnel who assist nurses in the
provision of direct and indirect care under the direct supervision of the nurse. They perform
nonsterile functions like the provision of and assistance with the patient's activities of daily living,
measuring and recording urinary output and oral intake, helping the patient with exercises such as
range of motion exercises, taking and documenting vital signs, measuring patients' height and
weight, collecting some specimens, the provision of comfort measures like a back rub, patient
transport, and clerical duties including running errands.
They work under the direct supervision and guidance of the nurse.

Licensed Practical / Vocation Nurses

Licensed practical / vocational nurses are licensed healthcare providers who provide a wide range of
nursing services to patients in all kinds of healthcare settings.
They work under the supervision of a registered nurse and they perform nonsterile and sterile
procedures. They work in structured settings with patients who have predictable and relatively
noncomplex healthcare problems including chronic disorders such as heart disease and chronic
obstructive pulmonary disease.
PLEASE NOTE: Vocational nurses are only called such in California and Texas.

Registered Nurses
Registered nurses are licensed healthcare providers who, unlike licensed practical nurses, are
independent practitioners who render nursing care services in a wide variety of healthcare settings.
They can work in unstructured environments and with patients who have unpredictable and
complex healthcare problems and concerns.
See a list of RN careers and specialties.

Nursing Supervisors
Nursing supervisors supervise patient care and the quality of care that is delivered to groups of
patients. Depending on the size and complexity of the healthcare setting, supervisors can have many
titles and they may or may not also provide direct nursing care in addition to their supervision of
care.
Nurses report to their nursing supervisors according to the facility's chain of communication and
command. For example, they report to their "supervising registered nurse/charge nurse/head
nurse", then their "nursing supervisor" and then to the "assistant director of nursing" and then "the
director of nursing or vice president of nursing."
Vice President for Nursing Services/The Director of
Nursing
The Vice President for Nursing Services, also referred to as the Director of Nursing or the Director
for Nursing Services in some facilities, is the chief nursing officer of the healthcare setting. They are
ultimately accountable for all aspects of patient care, the adherence to regulations and a wide variety
of other responsibilities.
At times, this Vice President for Nursing Services may have one or more Assistant or Associate
Directors of Nursing.

Nurse Clinical Specialists

Nurse Clinical Specialists are mastered prepared advanced practice registered nurses with an area of
specialty who have successfully passed and maintained their American Nurses Credentialing Center's
(ANCC) certification as a clinical nurse specialist in a specialty area of practice. Some possible
specialty areas of practice are pediatrics, psychiatric mental health, adult health and community
health.

Nurse Practitioners
Nurse Practitioners, similar to Nurse Clinical Specialists, are mastered prepared advanced practice
registered nurses with an area of specialty who have successfully passed and maintained their
American Nurses Credentialing Center's (ANCC) certification as a nurse practitioner in a specialty
area of practice. Some possible specialty areas of practice are pediatrics, psychiatric mental health,
family health and community health.

Nurse Midwives
A Member of the Nursing Team and the Obstetrics Team
Nurse midwives are advanced practice registered nurses who work with nonrisk pregnant women
during the pregnancy under the supervision of an obstetrician.

Nurse Anesthetists
A Member of the Nursing Team and the Anesthesia Team
Nurse Anesthetists are advanced practice registered nurses who work under the supervision of a
anesthetist in the provision of all types of anesthesia.

Medical Doctors
Medical doctors are licensed professionals who provide medical care. Many doctors serve as primary
care doctors but there is a wide variety of medical doctors who perform different roles and who
have a specialty area of practice such as cardiology, endocrinology, pulmonary medicine, gastrology,
neurology, dermatology, pediatrics, gerontology, ophthalmology, nephrology, psychiatry and other
specialized practices.
Physician Extenders
Physician extenders work under the direct supervision of a medical doctor and they provide care
that is based on protocols and their state legal scopes of practice. They are not, like nurse
practitioners, independent practitioners. A physician's assistant is an example of a physician
extender.

Doctors of Osteopathy (DOs)

Although doctors of osteopathy are, in some respects, similar to medical doctors, they are also
different. The educational preparation is different, their licensing examination and their scopes of
practice are different, but they can be found in acute care, long term care and community based
healthcare settings. Doctors of osteopathy may also have specialty areas of practice, but most
function as primary care doctors. Additionally, they can also provide care, write prescriptions, and
perform surgeries.

Doctors of Chiropractic Medicine

Chiropractors work primarily in the community setting and they focus their nonpharmacological
treatments of musculoskeletal and neuromuscular disorders such as scoliosis, chronic headaches,
back pain, and neck pain. They too are licensed professionals who have their own state mandated
scope of practice.

Dieticians
Dieticians assess, plan, implement and evaluate interventions including those relating to dietary
needs of those patients who need regular or therapeutic diets. They also provide dietary education
and work with other members of the healthcare need when a client has dietary needs secondary to
physical disorders such as dysphagia.

Physical Therapists
Physical therapists are licensed healthcare professionals who assess, plan, implement and evaluate
interventions including those related to the patient's functional abilities in terms of their strength,
mobility, balance, gait, coordination, and joint range of motion. They also provide patients with
assistive aids like walkers and canes and exercise regimens.
Physical therapists practice in all healthcare environments including the home and the community
and, similar to occupational therapists, physical therapists are often found in the rehabilitation and
restorative care area of a large acute care or long term care facility.

Occupational Therapists
Occupational therapists assess, plan, implement and evaluate interventions including those that
facilitate the patient's ability to achieve their highest possible level of independence in terms of their
activities of daily living such as bathing, grooming, eating and dressing.
They also give patients adaptive devices like special long shoe horns so the patient can put their
shoes on, sock pulls so they can independently don socks, special adaptive cutlery to facilitate
independent eating, grabbers so the patient can pick items up from the floor, special mouth care
tools, and special devices to manipulate buttoning so the person can dress and button their clothing
independently.
Occupational therapists also assess the home for safety and the need for assistive devices when the
patient returns to the home. They may recommend modifications to the home environment such as
ramps, grab rails and handrails to insure safety and independence.
Like physical therapists, occupational therapists practice in all healthcare environments including the
home and the community and, similar to physical therapists, they are often found in the
rehabilitation and restorative care area of a large acute care or long term care facility.

Speech Therapists
Speech pathologists or therapists assess, diagnose and treat primarily communication disorders such
as aphasia and swallowing disorders such as dysphagia. For example, speech therapists may help
patients with the formation of words and speaking when they have an impaired ability to
communicate with others using words. This deficit is referred to as expressive aphasia. They also
assist the patient with word boards and other electronic devices to facilitate communication.
Dysphagia and other swallowing disorders are also assessed, diagnosed and treated in collaboration
with other members of the healthcare team like nurses, dietitians and medical doctors.

Respiratory Therapists
Respiratory therapists, like other members of the healthcare team, collaborate with other discipline
in solving respiratory related healthcare problems.
They draw arterial blood gases, maintain patient with mechanical ventilation, provide CPAP, Bi
PAP, incentive spirometry and intermittent respiratory treatments like IPPB, they administer
respiratory medications, they intubate patients, assist with bronchoscopy and other respiratory
related diagnostic tests, perform pulmonary hygiene measures like chest physiotherapy and serve an
integral role during cardiac and respiratory arrests.

Social Workers
Social workers have a number of different roles in the healthcare environment. They counsel
patients and provide psychological support, they liaison with the community in terms of patients'
financial needs, they serve as part of the team that insures care along the continuum of care after the
person is discharged, and they sometimes serve as case managers.

Psychologists and Psychiatrists

Psychologists and psychiatrists provide mental health and psychiatric services to those with
psychiatric mental health disorders both long term and acute. They also provide psychological
support family members and significant others as indicated.
Podiatrists
Podiatrists provide care and services to patients who have foot problems. They often work with
diabetic patients to assess the feet to prevent diabetic foot complications. They recommend special
footwear, they often clip toe nails and they also treat other non-diabetic patients with disorders of
the foot.

Prosthetists
Prosthetists, in collaboration with other members of the healthcare team, assess patients and then
design, fit and supply the patient with an artificial body part such as a leg or arm prosthesis. They
also follow-up with patients who have gotten a prosthesis to check and adjust it in terms of proper
fit, patient comfort and functioning.

Serving as a Resource Person to Other

Staff
Nurses are the center of care that is provided. Registered nurse have the professional responsibility
to serve as a resource person within their areas of expertise to other staff including those in other
disciplines in order to increase their understanding of nursing, nursing care, the needs of the clients,
and how the nursing staff interact and collaborate with them.

Concepts of Management:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of concepts of management in order to:

 Identify roles/responsibilities of health care team members

 Plan overall strategies to address client problems
 Act as liaison between client and others (e.g., coordinate care, manage care)
 Manage conflict among clients and health care staff
 Evaluate management outcomes

Many people think that leadership and management are the same thing but they are not, they are
different.
Supervision, as discussed somewhat before, is the oversight and evaluation of care, aspects of care
and other nursing functions that have been delegated and assigned to others.
Management, on the other hand, is meeting established goals and objectives by planning, organizing
and directing actions and efforts towards established goals.
Registered nurses serve in both management and supervision functions.
Nurses, as managers, serve as a collaborator with others, a priority setter, a decision maker, a
problem solver, and coordinator of care; they have the knowledge, skills and abilities relating to
these functions which facilitate the movement towards established goals, as well as clinical skills and
abilities.

Identifying the Roles and

Responsibilities of Health Care Team
Members
As the manager of client care, registered nurses must be able to identify the functions, roles and
responsibilities of the other members of the multidisciplinary health care team members in order to
correctly garner these services. The roles and responsibilities of a wide variety of other members of
the multidisciplinary health care team were described and discussed above under "Collaborating with
Healthcare Members in Other Disciplines When Providing Client Care".

Planning Overall Strategies to Address

Client Problems
Registered nurses must be able to identify and employ overall strategies to address client problems
and healthcare concerns.
Some of these strategies can include:

 Supervision and delegation to insure that all client care is done in a complete, effective, proper and timely
manner
 The complete, effective, proper and timely execution of the Nursing Process including assessments,
planning, implantation and evaluation
 Collaboration and communication with other members of the multidisciplinary health care team when
the need arises
 Actively engaging and involving the client in all aspects of care
 Providing education and training to clients and staff when the need arises
Acting as a Liaison Between the Client
and Others
As previously discussed, registered nurses coordinate and manage care as they serve and act as the
liaison between the client and others as they advocate for the client and the fulfillment of their
needs.
Often, the registered nurse serves and acts as the liaison between the client and family members,
significant others, other members of the multidisciplinary team, upper healthcare facility
administrators and even healthcare insurance companies to negotiate care that is medically necessary
and to obtain reimbursement for the necessary care and treatments that the client needs.

Managing Conflict Among Clients and

Health Care Staff
One of the most upsetting and distressing things that occur when people work together is conflict.
One thing that we must understand, however, is that conflict can be beneficial and it is a natural
process that will occur and one that cannot be prevented among members of a group.
Simply stated, conflicts arise when two or more people have differences in terms of their beliefs or,
opinions. Conflicts can be readily identified when arguments, a lack of trust among those involved in
the conflict arise, when the flow of work is disrupted, when interpersonal relationships are impaired,
when criticism of others and frustration occur.
Conflicts can be beneficial when they are resolved in a healthy, mutually satisfying manner so that all
involved in the conflict can "win". Conflicts and healthy conflict resolution can lead to and promote
personal and group growth and development, creativity, innovation and innovate thought, the free
expression of one's beliefs and opinions, and lead to divergent thinking.
Conflict resolution and "win-win" conflict resolution is facilitated when group members and group
leaders focus on the issues at hand rather than differences between and among people with diverse
opinions and beliefs, when opinions and beliefs are presented in a clear, understandable manner
after some research, when all maintain respect for others and their diverse opinions and beliefs, and
when the conflicting parties are open to the viewpoints of others.
Ineffective conflict resolution and "win-lose" conflict resolution is destructive; it can lead to anger,
frustration, a lack of commitment to common goals, disputes, struggles for power and control, and
impaired thinking processes.
Registered nurses, therefore, must be able to recognize, identity, and report conflicts so that
conflicts do not tatter the team when they are not identified and resolved. Ignoring conflicts will
cause problems; resolving and addressing conflicts can lead to personal and group growth.
The stages of conflict and conflict resolution are:

 Frustration: Frustration occurs when those involved in the conflict believe that their goals and needs are
being blocked and not met.

 Conceptualization: Conceptualization occurs when those involved in the conflict begin to understand
what the conflict is all about and why it has occurred. This understanding often varies from person to
person and this personal understanding may or may not be accurate. The conflict continues.

 Taking action: Those involved in the conflict act. Some act in an active manner and others act in a
passive manner. For example, one person affected by the conflict may act out with anger, hostility and
even physical force; and another may just withdraw from the situation because they simply cannot
tolerate the feelings that the conflict evokes.

 Resolution: Resolution occurs when the group is able to come to some agreement with mediation,
negotiation or another method. This resolution is done with the participation of all of those who are
involved in the conflict.

Conflicts, according to Lewin who also developed a theory of planned change, include these four
basic types of conflict:

 Avoidance-Avoidance Conflicts: Avoidance-Avoidance conflicts occur when none of the people

involved in the conflict do NOT want any of the possible alternatives that could resolve the conflict.

 Approach- Approach Conflicts: Approach- Approach conflicts, in sharp contrast to Avoidance-

Avoidance conflicts, occur when the people involved in the conflict want more than one alternatives or
actions that could resolve the conflict.

 Approach-Avoidance Conflicts: Approach-Avoidance conflicts occur when the people involved in the
conflict see all of the alternatives or actions as NEITHER completely satisfactory and acceptable or
completely dissatisfactory and unacceptable.

 Double Approach - Avoidance Conflicts: Double Approach - Avoidance conflicts occur when the
people involved in the conflict are forced to choose among alternatives and actions, all of which have
BOTH positive and negative aspects to them.

Conflicts can be effectively resolved using a number of different strategies and techniques. These
strategies include those below:
 Collaboration and Open Communication: Collaboration and open communication within a trusting
and supportive environment can resolve conflicts in a beneficial manner. Collaboration and open
communication foster good working relationships among group members, it promotes the active
participation between and among conflicting parties, and it facilitates a deeper understanding of the issue
at hand.

 Compromise and Negotiation: Compromise and negotiation facilitates the conflicting parties to be
and remain to be assertive, rather than aggressive and cooperative; it also promotes a balance of power
between and among the conflicting parties.Negotiation consists of focusing on common goals and
interests rather than individuals and their different and disparate opinions, clearly separating the
conflicting parties from the conflict and problem, exploring options and alternatives in an open and
trusting environment, and using objective characteristics and criteria to describe and define the problem
and the alternative solutions.

 Mediation: This strategy includes one-to-one communication with each of the conflicting parties to
learn about each person's concerns, beliefs and opinions after which members of the group can explore
and employ mutually beneficial actions to resolve the conflict.

Ineffective and unhealthy methods of conflict resolution include those below.

 Avoiding and Withdrawing: Avoiding and withdrawing is a form of passivity. Although a temporary
avoidance can give the conflicting party some time to cope with and think about the conflict and possible
resolutions, prolonged avoidance and withdrawal can lead the lack of conflict resolution. Sticking one's
head into the sand is not helpful in terms of conflict resolution.

 Competition: Competition thwarts conflict resolution because it is not consistent with group goals and
progress towards a shared mission or goal. Competition can lead to power and control struggles,
coercion, manipulation of others and an unhealthy desire of one or more of the conflicting parties to
"win" at all costs at the expense of others.

 Accommodating Others: The sacrificial accommodation of others is also detrimental to good conflict
resolution. Accommodating others is not assertive, it does not promote negotiation, compromise or
mediation, and it does not meet the needs of the person who is accommodating others.

Evaluating Management Outcomes

The outcomes of effective management can be measured and ascertained by scrutinizing the effects
of management in terms of a number of different outcomes and variables including but not limited
to staff satisfaction, staff productivity, and the provision of high quality effective, cost effective, and
timely nursing care and services. It can also be measured and ascertained by evaluating the outcomes
of client care and their level of satisfaction with the care and services that were provided to them,
for example.

Confidentiality and
Information Security:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of confidentiality and information security in order to:

 Assess staff member and client understanding of confidentiality requirements (e.g., HIPAA)
 Maintain client confidentiality and privacy
 Intervene appropriately when confidentiality has been breached by staff members

According to the United States Department of Health & Human Services, the Health Insurance
Portability and Accountability Act (HIPAA) and the HIPAA Privacy Rule provides federal
protections for individually identifiable health information and gives patients an array of rights with
respect to that information.
At the same time, the Privacy Rule is balanced so that it permits the disclosure of health information
needed for patient care and other important purposes such as health insurance reimbursement and
quality improvement activities.
The Security Rule of HIPAA has administrative, physical, and technical safeguards to insure the
confidentiality, integrity, and availability of electronic protected health information. This rule relates
to electronic information security as well as other forms of information.
Our nation's Health Insurance Portability and Accountability Act (HIPAA) protects the patients'
rights to the privacy and confidentiality of all medical information, including written, oral electronic
information, unless the client has expressly consented to it in writing.

Maintaining Client Confidentiality and

Privacy
The HIPAA Privacy Rule legally limits access to medical records and information to only those who
have a NEED to know. Those who have the need to know have this need because they need some
data and information about the patient so that they can perform some indirect or direct patient care.
For example, nurses have a need to know information about the patient so that they can provide the
patient with quality care. Dietitians have to need to know some information about the patient so that
they can assess and plan care for the patient as based on their nutritional needs and status, and,
those who provide indirect care, such as the director of nursing, the infection control nurse, the
wound care nurse and the members of the quality assurance department, also have a need to know
about patients and groups of patients so that they can perform their roles even though they are not
providing any direct patient care to the patient. Others who have a need to know are health
insurance companies and students including student nurses.
All nurses must be aware of the implications of and the possible consequences for violations relating
to the Health Insurance Portability and Accountability Act and the HIPAA Privacy Rule.
Few nurses violate patient confidentiality intentionally. It is often momentary lacks of judgment that
lead to these breaches so nurses must consciously think before they act or speak.
Nurses should never discuss patients with others who do not have the "need to know". They must
protect and secure client written records and they must also secure electronic records by protecting
and not sharing their password and logging off after each entry.
Other things that protect patient privacy and confidentiality include not responding to any telephone
or email inquiries about patients unless the inquiring person states a unique identifier for the patient
such as a secret code number or word. Lastly Facebook, and other forms of social media, and
photos using a cell phone are strictly prohibited.
All healthcare facilities have regulations, policies and procedures related to confidentiality and
accessing client records. All nurses, and other healthcare providers, have the responsibility to be
knowledgeable about these regulations, policies and procedures and adhering to them at all times
without any breaches.
Personal privacy, including privacy during visits and during conversations as well as when they are
getting personal care such as hygiene must also be upheld and maintained.

Assessing Staff Members' and Client

Understanding of Confidentiality
Requirements
The best way to know whether or not staff members understand and apply the requirements
associated with confidentiality and privacy is to observe the staff member as they perform their roles
and uphold these rights.
For example:
 Are all staff members knowledgeable about the Health Insurance Portability and Accountability Act
(HIPAA)?
 Is the staff member carrying on idle conversations in the cafeteria about patients?
 Is the staff member logging off the computer before leaving the screen unattended?
 Is the staff member securing medical records so that anyone without the need to know has no access to
them?

Clients must also know their rights and the rights of others in terms of medical information. Nurses
can identify a knowledge deficit in this area when a patient asks a nurse a question like "What is
wrong with that patient who is always screaming out?" or a similar question. Nurses should inform
this inquisitive patient that you cannot share any information with them that relates to other
patients.

Intervening Appropriately When

Confidentiality Has Been Breached by
Staff Members
The registered nurse has the professional, ethical and legal responsibility to insure that all client
rights, including the clients' rights to privacy and confidentiality, are upheld, supported and
advocated for.
Whenever a nurse witnesses any breach of confidentiality and privacy including, but not limited to,
any unauthorized access to medical records by those without the need to know, idle discussions that
violate HIPAA regulations, a failure to log off the computer when done, and the lack of privacy
during change of shift reports, the nurse must intervene immediately by correcting the situation and
not allowing it to continue.

Continuity of Care: NCLEX-

RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of continuity of care in order to:

 Provide and receive report on assigned clients (e.g., standardized hand off communication)
 Use documents to record and communicate client information (e.g., medical record, referral/ transfer
form)
 Use approved abbreviations and standard terminology when documenting care
 Perform procedures necessary to safely admit, transfer or discharge a client
 Follow up on unresolved issues regarding client care (e.g., laboratory results, client requests)

Simply defined, the continuity of care is defined as the sound, timely, smooth, unfragmented and
seamless transition of a client from one area within the same healthcare facility, from one level of
care to a higher and more intense level of care or to a less intense level of care based on the client's
status and level of acuity, from one healthcare facility to another healthcare facility and also any
discharges to the home in the client's community.
Maintaining the continuity of care requires that the nurse, and other members of the healthcare
team, identify current client needs and then move the client to the appropriate clinical area, to the
appropriate level of care, and to the appropriate healthcare facility in a timely and effective manner.
Communication, collaboration and cooperation among and between appropriate healthcare team
members and the client are essential components of the continuity of care.

Providing and Receiving Report on

Assigned Clients
Reports at the end of a shift insure a seamless, unfragmented transition from one shift of nursing
staff to the next. These "Hand off", or change of shift, reports are a critical component of nursing
care.
These reports must minimally include:

 The patient's name, their doctor's name, the date of admission and diagnosis
 All unresolved issues and uncompleted tasks
 Priorities of care
 Significant data and information about the patient's status and condition
 Abnormal diagnostic testing results
 The patient's responses to care and treatment(s)
 Fluid status including all intake and output
 Any unusual occurrences, variances, incidents and accidents
 Special treatments and patient responses such as the administration of blood
 Any consults and referrals and
 Changes in the plan of care and/or doctor's orders

Facilities use standardized methods of reporting to insure the completeness of these end of shift
reports, as well as patient transfer reports and patient discharge reports.
Some standardized change of shift "hand off" reports, as recommended by the Joint Commission on
the Accreditation of Healthcare Organization, include:

 SBAR
 ISBAR
 BATON
 The Five Ps and
 IPASS

SBAR stands for:

 S: Situation: The patient's diagnosis, complaint, plan of care and the patient's prioritized needs
 B: Background: The patient's code or DNR status, vital Signs, medications and lab results
 A: Assessment: The current assessment of the situation and the patient's status and
 R: Recommendations: All unresolved issues including things like pending diagnostic testing results and
what has to be done over the next few hours

ISBAR stands for:

 I: Introduction: The introduction of the nurse, the nurse's role in care and the area or department that
you are from
 S: Situation: The patient's diagnosis, complaint, plan of care and the patient's prioritized needs
 B: Background: The patient's code or DNR status, vital Signs, medications and lab results
 A: Assessment: The current assessment of the situation and the patient's status and
 R: Recommendations: All unresolved issues including things like pending diagnostic testing results and
what has to be done over the next few hours

BATON stands for:

 B: Background: Past and current medical history, including medications

 A: Actions: What actions were taken and/or those actions that are currently required
 T: Timing: Priorities and level of urgency
 O: Ownership: Who is responsible for what? and
 N: Next: The future plan of care

The Five Ps are:

 P: Patient: The patient's name, age, gender, location and other demographic data
 P: Plan: Patient diagnosis and plan of care
 P: Purpose: The rationale for the care plan
 P: Problems: Things that are different, abnormal or unusual and
 P: Precautions: Risks and things that may change and/or become unusual for the patient

IPASS stands for:

 Introduction: The introduction of the nurse, the nurse's role in care and the area or department that you
are from
 P: Patient: The patient's name, age, gender, location and other demographic data
 A: Assessment: The current assessment of the situation and the patient's status
 S: Situation: The patient's diagnosis, complaint, plan of care and the patient's prioritized needs and
 S: Safety concerns: Physical, mental and social risks and concerns

Using Documents to Record and

Communicate Client Information
Documentation is a form of written communication. A wide variety of documentation forms exist.
Some of these forms include progress notes, admission forms, transfer forms to another level of
care or service, referral forms, discharge forms, daily care flow sheets, graphic charts for vital signs,
blood glucose level forms, intake and output forms, assessment forms, falls risk and skin breakdown
assessment forms, narcotic records, patient teaching records, and other documents that are primarily
used by other disciplines such as laboratory and diagnostic imaging reports.
Regardless of the differences among healthcare facilities in terms of the provision of care along the
continuum of care and their specific documentation methods and forms, nurses must follow their
own facility's policies, procedures and guidelines. For example, some facilities use problem oriented
charting and others may use source oriented medical records; some may use multidisciplinary critical
pathways or care maps and others may use discipline specific care plans like nursing care plans.
More extensive information about documentation was previously discussed with the "Integrated
Process of Communication and Documentation" section.

Using Approved Abbreviations and

Standard Terminology When
Documenting Care
As previously detailed with the Integrated Process of Communication and Documentation, there are
a number of abbreviations that can jeopardize client safety because they can be interpreted
differently among healthcare providers, therefore, the Joint Commission on the Accreditation of
Healthcare Organizations and common sense mandates that only accepted and approved
abbreviations and terminology are used for documentation. For example, the abbreviation "MS" is
NOT an approved abbreviation because "MS" can be interpreted as multiple sclerosis, morphine
sulfate and magnesium sulfate. All healthcare facilities are required to have a formalized list of
unacceptable abbreviations that cannot be used because they are problematic and can lead to errors
and confusion.

Performing Procedures Necessary to

Safely Admit, Transfer or Discharge a
Client
The continuity of care is facilitated with the safe admission, transfer and discharge of clients.
An admission is defined as the first, initial client contact. A transfer, in the context of this review, is
defined as the movement of the client from one area to another area within the same healthcare
facility; and a discharge is defined as the cessation of care and services to a client. For example, a
client can be discharged to another healthcare facility or to the community.
Admissions, transfers and discharges of clients require that the sending and receiving persons, such
as a registered nurse, communicate in writing and orally at times about the client and their current
status.
Upon admission and transfer, the client will be assessed and planning will begin and done by the
person receiving the client. The admission process typically includes orienting the client and/or the
significant others to the healthcare setting, a complete review of the client's bio-psycho-social status
and needs, medication reconciliation, a complete and thorough assessment, and giving the client or
significant other information such as HIPAA information, patient rights and responsivities, and the
complaint process in addition to other admission essentials.
Upon admission and transfer, the sending area will provide the receiver of the patient with complete
information about the client and their needs. Some of this information can be done by the sending
on an established form like a transfer form or the complete medical record to the receiving area or
person.
Discharges, similar to transfers, involve the sender's communication and collaboration with the
receiver of the client to insure that the particular discharge is appropriate for the client and meeting
their needs and also to facilitate a smooth and seamless transition with the sharing of the client's
medical information.
Following Up on Unresolved Issues
Regarding Client Care
Unresolved issues can never be left unattended. The "loop" must be closed.
Nurses must report all unresolved issues up the chain of command and communication until
resolution occurs. At times, unresolved issues can be followed up by the next shift of nursing team
members and at other times they can be resolved with a simple telephone call. For example, nurses
report unresolved issues during the change of shift report and they can also call the patient's doctor
when laboratory values reveal significant changes and abnormalities.

Establishing Priorities:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of establishing priorities in order to:

 Apply knowledge of pathophysiology when establishing priorities for interventions with multiple clients
 Prioritize the delivery of client care
 Evaluate the plan of care for multiple clients and revise plan of care as needed

Actual needs and problems take priority over wellness, possible risk and health promotion problems
and short term acute patient care needs and problems typically take priority over longer term
chronic needs.

Applying a Knowledge of
Pathophysiology When Establishing
Priorities for Interventions with
Multiple Clients
As previously mentioned with the "Integrated Process related to the Nursing Process", priorities are
established using a number of methods and frameworks including the ABCs, Maslow's Hierarchy of
Needs and the ABCs/MAAUAR method. Knowledge of these frameworks and an in-depth
knowledge about pathophysiology facilitate the proper establishment of priorities relating to the
interventions that are then provided to individual clients and groups of clients with diverse needs of
varying acuity and differing priorities.
The ABCs identifies the airway, breathing and cardiovascular status of the patient as the highest of
all priorities in that sequential order.
Maslow's Hierarchy of Needs identifies the physiological or biological needs, including the ABCs,
the safety/psychological/emotional needs, the need for love and belonging, the needs for self-
esteem and the esteem by others and the self-actualization needs in that order of priority.
Some examples of each of these needs according to Abraham Maslow's Hierarchy of Needs are:

Physical and Biological Needs

 Some physical needs include the need for the ABCs of airway, breathing and cardiovascular function,
nutrition, sleep, fluids, hygiene and elimination.

Safety and Psychological Needs

 The psychological or emotional, safety, and security needs include needs like low level stress and anxiety,
emotional support, comfort, environmental and medical safety and emotional and physical security.

Love and Belonging

 The love and belonging needs reflect the person's innate need for love, belonging and the acceptance of
others including a group.

Self Esteem and Esteem by Others

 All people have a need to be recognized and respected as a valued person by themselves and by others.
People have a need self-worth and self-esteem and they need the esteem of others.

Self Actualization
 Self-actualization needs motivate the person to reach their highest level of ability and potential.

The ABCs / MAAUAR method, which was previously detailed, places the ABCs as the highest and
greatest priorities which are then followed with the 2nd and 3rd priority level needs.
The 2nd priority needs include MAAUAR which is mental status, acute pain, acute impaired urinary
elimination, unresolved and unaddressed needs, abnormal diagnostic test results, and risks. The
3rd level priorities include all concerns and problems addressed with the 2nd level priority needs.
Prioritizing the Delivery of Client Care
The delivery of client care is prioritized as just discussed above.
In addition to prioritizing and reprioritizing, the nurse should also have a plan of action to
effectively manage their time; they should avoid unnecessary interruptions, time wasters and helping
others when this helping others could potentially jeopardize their own priorities of care.

Evaluating the Plans of Care for

Multiple Clients and Revising the Plan
of Care as Needed
In addition to providing guidance and direction in terms of nursing care delivery, plans of care,
including nursing care plans and other systems like a critical pathway, provide the mechanism with
which the outcomes of the care can be measured and evaluated.
Appropriate and effective client care is dependent on the accuracy and appropriateness of the
client's plan of care. For this reason, reasessments and updating and revising a plan of care as based
on the client's current status is necessary.

Ethical Practice: NCLEX-

RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of ethical practice in order to:

 Recognize ethical dilemmas and take appropriate action

 Inform client/staff members of ethical issues affecting client care
 Practice in a manner consistent with a code of ethics for registered nurses
 Evaluate outcomes of interventions to promote ethical practice

Ethics, simply defined, is a principle that describes what is expected in terms of right and correct
and wrong or incorrect in terms of behavior. For example, nurses are held to ethical principles
contained within the American Nurses Association Code of Ethics. Ethics and ethical practice are
integrated into all aspects of nursing care.
The two major classifications of ethical principles and ethical thought are utilitarianism and
deontology. Deontology is the ethical school of thought that requires that both the means and the
end goal must be moral and ethical; and the utilitarian school of ethical thought states that the end
goal justifies the means even when the means are not moral.
The ethical principles that nurses must adhere to are the principles of justice, beneficence,
nonmaleficence, accountability, fidelity, autonomy, and veracity.

 Justice is fairness. Nurses must be fair when they distribute care, for example, among the patients in the
group of patients that they are taking care of. Care must be fairly, justly, and equitably distributed among
a group of patients.

 Beneficence is doing good and the right thing for the patient.

 Nonmaleficence is doing no harm, as stated in the historical Hippocratic Oath. Harm can be intentional
or unintentional.

 Accountability is accepting responsibility for one's own actions. Nurses are accountable for their nursing
care and other actions. They must accept all of the professional and personal consequences that can
occur as the result of their actions.

 Fidelity is keeping one's promises. The nurse must be faithful and true to their professional promises and
responsibilities by providing high quality, safe care in a competent manner.

 Autonomy and patient self-determination are upheld when the nurse accepts the client as a unique
person who has the innate right to have their own opinions, perspectives, values and beliefs. Nurses
encourage patients to make their own decision without any judgments or coercion from the nurse. The
patient has the right to reject or accept all treatments.

 Veracity is being completely truthful with patients; nurses must not withhold the whole truth from clients
even when it may lead to patient distress.

The most commonly occurring ethical issues and concerns in healthcare include the allocation of
scarce resources and end of life issues.
Bioethics is a subcategory of ethics. Bioethics addresses ethical concerns like those that occur as the
result of advancing science and technological advances. Some of the most common, current
bioethical issues revolve around stem cells, cloning, and genetic engineering.
Recognizing Ethical Dilemmas and
Taking Appropriate Action
Nurses have the responsibility to recognize and identify ethical issues that affect staff and patients.
For example, providing nursing care for clients undergoing an abortion may raise ethical and moral
concerns and issues for some nurses; and some patients may be affected with a liver transplant
rejection because donor livers are not abundant enough to meet the needs of all patients who
request it.
Many hospitals, medical centers and other healthcare facilities have multidisciplinary ethics
committees that meet as a group and resolve ethical dilemmas and conflicts. Nurses should avail
themselves to ethicists and ethical committees within their facility when such ethical resources and
mechanisms are present in order to resolve ethical concerns and ethical dilemmas.
In addition to utilizing these resources, the nurse can take appropriate actions when faced with an
ethical dilemma by understanding and applying the ethical guidelines provided in the American
Nurses Association's Code of Ethics, the American Medical Association's Code of Ethics, the World
Medical Association's Code of Ethics, the American Nurses Association's Standards of Care and
Standards of Practice, American Nurses Association's position papers such as that which describes
the ethical use of narcotic analgesics at the end of life even if this medication hastens death, state
board of nursing declaratory statements, and the International Nurses Association's Code of Ethics.
The steps of the ethical decision making process, like the problem solving process, are:

 Problem Definition. Problem definition is the clear description of the ethical dilemma and the
circumstances revolving around it.

 Data Collection. During this phase of the ethical decision making process includes a review of ethical
codes, published evidence based practices, declaratory statements, professional position papers and the
professional literature.

 Data Analysis. The collected data is then organized and analyzed.

 The Identification, Exploration and Generation of Possible Solutions to the Problem and the
Implications of Each. All possible solutions and alternatives to resolve the ethical dilemma are explored
and evaluated.

 Selecting the Best Possible Solution. All potential solutions and alternatives are considered and then the
best and most ethical action is taken.

 Performing the Selected Desired Course of Action to Resolve the Ethical Dilemma
 Evaluating the Results of the Action. Like the evaluation phase of the Nursing Process, actions to resolve
ethical issues are evaluated and measured in terms of their effectiveness to resolve the ethical dilemma.

Informing the Client and Staff

Members of Ethical Issues Affecting
Client Care
Nurses have the responsibility to identify ethical issues that affect staff members and patients; and
they also have the responsibility to inform staff members and affected clients of ethical issues that
can and do affected client care. For example, providing nursing care for clients undergoing an
abortion may raise ethical and moral concerns and issues for some nurses; and some patients may be
affected with a liver transplant rejection because donor livers are not abundant enough to meet the
needs of all patients who request it.
Although a rare occasions, a patient may, at times, ask you to do something that is not ethical. For
example, a patient may ask a nurse to assist in their suicide at the end their life or they may inquire
about another patient in terms of their diagnosis. When something like this occurs, the nurse must
inform the client that they cannot do it for ethical and legal reasons.
Clients may also need information about ethics can affect the care that they choose or reject. For
example, a client may ask the nurse about whether or not it is permissible ethically and legally to
reject CPR at the end of life or to take pain medications even if it hastens their death.

Practicing In a Manner Consistent

with The American Nurses
Association's Code of Ethics and
Other Ethical Codes
As previously discussed, nurses are expected to apply the ethical guidelines provided in the
American Nurses Association's Code of Ethics, the American Medical Association's Code of Ethics,
the World Medical Association's Code of Ethics, the American Nurses Association's Standards of
Care and Standards of Practice, American Nurses Association's position papers such as that which
describes the ethical use of narcotic analgesics at the end of life even if this medication hastens
death, state board of nursing declaratory statements, and the International Nurses Association's
Code of Ethics.
The American Nurses Association's Code of Ethics, for example, contains elements that emphasize
and speak to advocacy, collaboration with others, the maintenance of client safety, the dignity and
worth of all human beings, the prohibition of any discrimination, accountability, the preservation of
patient rights, such as dignity, autonomy and confidentiality, and the provision of competent, safe
and high quality care of nursing care.

Evaluating the Outcomes of

Interventions to Promote Ethical
Practice
As with all other aspects of nursing care, the outcomes of the interventions to promote ethical
practice are evaluated and measured.
Some of the evaluation criteria that can be used to determine and evaluate the outcomes of the
interventions to promote ethical practice can include one or more of the following:

 Is staff knowledgeable about ethics and ethical practice?

 Is staff effectively applying ethical principles to their daily practice?
 Are clients and staff fully knowledgeable and informed about ethics and ethical practice?
 Were all appropriate professional resources, including codes of ethics and the professional literature,
employed to resolve the ethical dilemmas?

Informed Consent: NCLEX-

RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of informed consent in order to:

 Identify an appropriate person to provide informed consent for the client (e.g., client, parent, legal
guardian)
 Provide written materials in the client's spoken language, when possible
 Describe components of informed consent
 Participate in obtaining informed consent
 Verify that the client comprehends and consents to care and procedures
As previously discussed with the section "Client Rights", all clients have the right to be fully
informed about their medical condition and they also have the innate right to knowledgeably
consent to or reject all care and proposed treatments.

What is Informed Consent?

Informed consent is defined as the patient's choice to have a treatment or procedure which is based
on their full understanding of the treatment or procedure, its benefits, its risks, and any alternatives
to the particular treatment or procedure. All clients have the legal right to autonomy and self-
determination to accept or reject all treatments and interventions.
The three basic types of consent are implicit consent, explicit consent and opt-out consent, as
previously detailed with Client Rights.
RELATED: What Does it Mean for a Nurse to Sign a Consent for Surgery Form?

Identifying the Appropriate Persons to

Provide Informed Consent
Informed consent can only be obtained from an adult patient who is mentally competent to do so
except under some circumstances and situations. When consent, for any reason including the lack of
majority, mental incompetence, and unconsciousness, cannot be obtained, other people can provide
legal consent for the patient.
These people include the parent or legal guardian of a minor and unemancipated minor child, a
legally appointed representative for a developmentally disabled adult, for example, an emancipated
minor, and the person who has been appointed as the client's durable power of attorney for
healthcare decisions or their health care surrogate or proxy.
In other situations, the courts have guardianship and the right to give informed consent for a client
who is not able to consent on their own.
With the exception of emergencies, informed consent must be obtained.
Providing Written Materials in the
Client's Spoken Language, When
Possible
As more fully discussed and described with the "Integrated Process of Teaching and Learning",
clients must be given oral and written educational material and content at the level with which the
client can understand this education. At times, written material in the client's spoken, the native
language is beneficial for patients and significant others and, at other times, the assistance and
services of a professional translator may be indicated.

Describing the Components of

Informed Consent
The components of informed consent include the person's knowledgeable consent to a treatment or
procedure after they have been given, and understand, complete, unbiased information about:

 The proposed treatment or procedure

 Who will perform the treatment or procedure
 The purpose of the proposed treatment or procedure
 The expected outcomes of the proposed treatment or procedure
 The benefits of the proposed treatment or procedure
 The possible risks associated with the proposed treatment or procedure
 The alternatives to the particular treatment or procedure
 The benefits and risks associated with alternatives to the proposed treatment or procedure
 The client's right to refuse a proposed treatment or procedure

Again, all clients have the legal right to autonomy and self-determination to accept or reject all
treatments, procedures, and interventions without any coercion or the undue influence of others.

Participating in Obtaining Informed

Consent
The physician, or other licensed independent providers, the nurse and the client have roles and
responsibilities in terms of informed consent.
The nurse is responsible and accountable for the verification of and witnessing that the patient or
the legal representative has signed the consent document in their presence and that the patient, or
the legal representative, is of legal age and competent to provide consent. They also confirm that the
patient has sufficient knowledge to make a knowledgeable decision.
The physician, or another licensed independent practitioner such as a nurse practitioner or a
physician's assistant, provides the client with complete information about the treatment or
procedure, the potential risks including pain and complications, the benefits of the treatment or
procedure, who will perform the planned treatment or procedure, and any possible alternatives to
the treatment or procedure including their benefits and risks.
The patient or their legal representative must give consent voluntarily and without any coercion by
others. They must also ask questions and clarify things until they are certain about the procedure, the
benefits, the risks, and possible alternatives.

Verifying that the Client or

Representative Comprehends and
Consents to Care and/or Procedures
The recognition that informed consent was obtained is based on the legality and completeness of
the written consent and the required processes for obtaining consent including the client's legal
ability to sign it and the client's understanding of the procedure or treatment that they are
consenting to.
There are also times, such as during the preoperative period of time, which nurses must recognize,
identify and confirm that a complete surgical consent was obtained and placed in the patient's
medical record.

Information Technology:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of information technology in order to:

 Receive and/or transcribe health care provider orders

 Apply knowledge of facility regulations when accessing client records
 Access data for client through online databases and journals
 Enter computer documentation accurately, completely and in a timely manner
 Utilize information resources to enhance the care provided to a client (e.g., evidenced-based research,
information technology, policies and procedures)

Information technology (IT), simply defined, is the use of electronic technological advances such as
computers, remote telehealth, and telecommunication within the healthcare environment to capture,
store, maintain and preserve health and medical information and data, to transmit data and
information to others within and outside of the particular healthcare setting, and to facilitate the
ability of healthcare providers, including nurses, to retrieve data and information that can be used
for research and the education of the nurse as well as the clients that they care for.
Information technology has endless possibilities for use in terms of patient care and healthcare.
Some of these uses include:

 Bar codes with unique patient identifiers that can prevent and avoid medical errors secondary to the poor
identification of a patient before treatments, including, medication errors and wrong procedure errors
 Bar codes that can be used for the billing of patient care supplies and equipment
 Automated doctors' ordering systems
 Electronic medical records
 Instantaneous access to information including a particular facility's policies and procedures
 The analysis of data including patient related and aggregated data, performance improvement data and
risk management data. The aggregation and analysis of data enables healthcare providers to identify
patterns and trends relating to client care.
 Current and valid information on the internet such as standards of care, ethical codes, evidence based
practices, professional healthcare databases, professional journals, patient education materials and
continuing education for healthcare providers, including nurses

Despite the many benefits of information technology exist, information technology is, however, a
double edged sword. Information technology is of great benefit to healthcare, healthcare agencies,
healthcare providers and patients but it is not without its perils and pitfalls. Some of the risks and
perils of information technology include breaches of patient privacy and confidentiality, computer
hacking, and crashes that delete data.

Receiving and/or Transcribing Health

Care Provider Orders
Nurses, including registered nurses and licensed practical nurses, perform independent and
dependent nursing interventions. Independent nursing interventions are those things that nurses can
provide to the patient without a doctor's order and dependent nursing interventions are those things
that nurses can provide to the patient only with a doctor's order. The administration of medications
and the application of a restraint, for example, are dependent nursing functions that require an order
from the doctor or another independent licensed practitioner.
Many healthcare facilities have abandoned hard copy, paper medical records and have opted to
maximize their use of technological advances with such advances like electronic medical records and
automated orders for patient care procedures and interventions. The use of these technological
advances not only facilitates ready access to these orders but it also eliminates or minimizes some of
the commonly occurring medical and medication errors that plagued hard copy, paper medical
records such as illegible handwriting.
Whenever a handwritten order or an automated order is done, it is the nurse's responsibility to
insure that the order is complete and appropriate and that orders are carried out in a timely manner.
All questionable orders must be followed up on by the nurse.
For example, a complete order for restraints must minimally include the reason for it, the type of
restraint to be used, how long the restraint can be used, the client behaviors that requires the use of
the restraint and the signature of the person ordering the restraint; and a complete medication order,
for example, must contain the name, dose, form, route and frequency of the medication in addition
to the signature of the person ordering and, ideally, also the rationale for the use of this ordered
medication.
Nurses are responsible for receiving and processing physician provider orders. Some of the specific
aspects of this responsibility include the nurse's review of an order for completeness, questioning
orders that a patient questions, questioning orders that do not seem to be appropriate for the
patient, and questioning orders that are incomplete, illegible and /or not clear.
Telephone orders and other verbal orders are strongly discouraged. They can lead to serious errors.
When it is necessary to call a provider to get an order, the nurse must fully document the order and
the circumstances that necessitated the telephone order. The nurse will then read the order back to
the ordering physician to confirm its correctness. Some facilities also require that two nurses hear
and confirm the order.

Applying a Knowledge of Facility

Regulations When Accessing Client
Records
All healthcare facilities must have policies, procedures and educational activities, as mandated by law
and external regulatory and credentialing bodies, related to the accessing, viewing and use of clients'
medical records and medical information.
The Security Rule of HIPAA mandates administrative, physical, and technical safeguards to insure
the confidentiality, integrity, and availability of electronic protected health information. This rule
relates to electronic information security as well as other forms of information.
The HIPAA Privacy Rule legally limits access to medical records and information to only those who
have a NEED to know during their provision of direct and indirect care to the client. Those who
have the need to know include clinical staff and students of nursing who provide patient care
services in addition to those who provide indirect care, such as the director of nursing, the infection
control nurse, the wound care nurse and the members of the quality assurance department, and
health insurance companies and students including student nurses.

Accessing Data for Clients and

Through Online Databases and
Journals
Some information and resources online are reliable and accurate and others are not. It is up to the
nurse to identify and scrutinize online information and resources in a complete and accurate manner
before using it for and with clients and staff.
Generally speaking, websites online that have a url with ".org", ".edu" and ".gov "are reliable and
accurate but they may not be as current as you want.
Some of the reliable online resources and information that can be helpful in terms of client
education include nonprofessional patient related materials like the online Merck Manual for Home
Use, health related information specific to diseases such as that which is made accessible online by
major national associations and organization such as the American Cancer Society and the American
Heart Association, governmental agencies and bodies such as the US Centers for Disease Control
and Prevention and the National Institutes of Health.

Entering Computer Documentation

Accurately, Completely and in a
Timely Manner
Documentation is defined as the recording of patient related events and activities associated with
client care; this documentation is a form of written communication and the purpose of it is to
communicate client related data in an accurate, complete and timely manner, as more fully discussed
and described with the "Integrated Process of Communication and Documentation".
Utilizing Information and Resources
to Enhance the Care Provided to a
Client
Some of the databases that nurses can use for research and evidence based practice, for example,
are:

 PubMed
 The Cumulative Index to Nursing and Allied Health Literature (CINAHL)
 The Cochrane Library
 Ovid's Evidence Based Medicine Reviews (EBMR)
 Medlars
 The Joanna Briggs Institute
 Medline Plus (An International nursing index and Index Medicus is also included)
 The Directory of Open Access Journals
 The Nursing Center for Lippincott Williams & Wilkins

Some of the resources that are useful to clients include, but are not limited to, patient educational
materials for their specific disease or healthcare problem.

Legal Rights and

Responsibilities: NCLEX-
RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of legal rights and responsibilities in order to:

 Identify legal issues affecting the client (e.g., refusing treatment)

 Identify and manage the client's valuables according to facility/agency policy
 Recognize limitations of self/others and seek assistance
 Review facility policy and state mandates prior to agreeing to serve as an interpreter for staff or primary
health care provider
 Educate client/staff on legal issues
 Report client conditions as required by law (e.g., abuse/neglect, communicable disease, gunshot wound)
 Report unsafe practice of health care personnel and intervene as appropriate (e.g. substance abuse,
improper care, staffing practices)
 Provide care within the legal scope of practice

Some of the legal terms that you must be familiar with include these:

 Common Law: Common law is law that results from previous legal decisions. They are based on legal
precedent. (Berman and Synder, 2012)

 Statutory Law: Statutory law is law that is passed by a legislative body such as the state's legislature or
the US Congress. (Berman and Synder, 2012)

 Constitutional Law: Constitutional law is law that is included in the Constitution of the United States of
America and its amendments. (Berman and Synder, 2012)

 Administrative Law: Administrative law is rules and regulations that are legally enacted to support some
statutory law. For example, nursing boards enact administrative rules and regulations relating to state
enacted laws such as the state's nurse practice act and legislated continuing education requirements for
the relicensure of nurses. (Berman and Synder, 2012)

 Criminal Law: Criminal law, part of public law, covers acts that are illegal and against the law. Criminal
law includes felony and misdemeanor infractions of the law. (Berman and Synder, 2012)

 Civil Law: Civil law, also part of public law, covers torts and contract laws. (Berman and Synder, 2012)

 Torts: Torts are civil laws that address the legal rights of patients and the responsibilities of the nurse in
the nurse patient relationship. Some torts specific to nursing and nursing practice include things like
malpractice, negligence and violations relating to patient confidentiality. (Berman and Synder, 2012)

 Unintentional Torts: Unintentional torts include things like malpractice and negligence.

 Intentional Torts: Intentional torts include things like false imprisonment, assault, battery, breaches of
privacy and patient confidentiality, slander and libel.

 Liability: Liability is vulnerability and legal responsibility, simply stated. For example, nurses are liable
when they fail to carry out doctor's orders. (Berman and Synder, 2012)
 Respondeat Superior: Respondeat Superior is the legal doctrine or principle that states that employers
are legally responsible for the acts and behaviors of its employees. Respondeat Superior does not,
however, relieve the nurse of legally responsibility and accountability for their actions. They remain liable.
(Berman and Synder, 2012)

 Negligence: Negligence is a nonintentional tort. Negligence occurs when the nurse fails to follow
established policies, procedures and standards of care in the same manner that another "reasonable"
nurse would do in the same situation. (Berman and Synder, 2012)

 Malpractice: Malpractice, also a nonintentional tort, has six elements. The elements of malpractice
include a duty, a breach of duty as a nurse, reasonable foreseeability that the nurse's act has a connection
with the patient injury that occurred, the patient was harmed, the link that act directly led to the harm and
the patient has the right to financial compensation or damages. (Berman and Synder, 2012)

 Assault: Assault, an intentional tort, is threatening to touch a person without their consent. (Berman and
Synder, 2012)

 Battery: Battery, another intentional tort, is touching a person without their consent. (Berman and
Synder, 2012)

 False Imprisonment: False imprisonment is restraining, detaining and/or restricting a person's freedom
of movement. Using a restraint without an order is considered false imprisonment. (Berman and Synder,
2012)

 Defamation: Defamation is making false statements about a person in writing or orally that leads to the
destruction of a person's reputation. (Berman and Synder, 2012)

 Slander: Slander is oral defamation of character using false statements.

 Libel: Libel is written defamation of character using false statements.

Identifying Legal Issues Affecting

Staff and Clients
Some of the most commonly occurring legal issues that impact on nursing and nursing practice are
those relating to informed consent and refusing treatment as previously detailed, licensure, the
safeguarding of clients' personal possessions and valuables, malpractice, negligence, mandatory
reporting relating to gunshot wounds, dog bites, abuse and unsafe practices, for example, informed
consent, documentation, accepting an assignment, staff and client education relating to legal issues,
and strict compliance with and adherence to all national, state, and local laws and regulations.

Licensure
All registered and licensed practical, or vocational, nurses must be currently licensed to practice
nursing in their state of practice. Licensure protects the consuming public and insures that the nurse
has completed a state approved nursing school, has successfully passed their licensure examination
and has also continuously met the requirement(s) for relicensure each biennium without any
suspensions or revocations of their license.
Practicing without a current and valid license is illegal and it amounts to practicing without a license.

The Safeguarding of Clients' Personal Possessions

and Valuables
Nurses are responsible for the safeguarding and respecting the clients' personal possessions and
valuables; they must also NOT, under any circumstances, borrow or steal their personal possessions
and valuables.
Although policies and procedures relating to the safeguarding of clients' personal possessions and
valuables may vary a little from one healthcare facility to another, these policies and procedures
typically include discouraging clients to retain personal possessions and valuables while hospitalized,
and then securing maintained and retained personal possessions and valuables in a locked and secure
safe using an envelope that fully documents the client's name, room number and the contents of the
envelope, including things like jewelry, cash and credit cards, that were collected from the client with
their permission.
Items that are placed in this envelope are itemized and listed using a description such as a "ring with
a purple stone", a "yellow metal bracelet" or a "white metal necklace" rather than an amethyst ring,
14 carat gold bracelet or a sterling silver necklace because the nurse cannot determine and confirm
that indeed these items are anything more than inexpensive costume jewelry.
Items are listed on the envelope. What appears to be gold, sterling silver or a ruby may indeed be
only an inexpensive gold, silver or ruby look alike and the nurse may have no idea whether it is real
gold, silver or a ruby or not. For this reason these items are listed as "yellow metal", "silver metal"
and a "red stone", respectively. In addition to jewelry, other valuable items that must be secured
include cash, credit cards and legal documents.
When the client is discharged from the facility or they choose to have their personal possessions and
valuables returned to them, the nurse and the client check and confirm that all of the items listed on
the envelope are indeed still in this envelope. The client also signs a statement that documents that
they have been given back their personal possessions and valuables.

Malpractice
Malpractice is an act of omission or commission that does not meet established standards of care
and causes some injury. Nurses, therefore, must provide all aspects of nursing care according to
established standards of care, in a safe and competent manner, and also done in a complete,
appropriate and timely manner.
The six essential components of malpractice include causation, foreseeability, damages to the
patient, a duty that was owed to the client and this duty was breached, and, lastly, this breach of duty
led to direct and/or indirect harm to the client.
Actions of omission and commission that lead to client injury place the nurse in jeopardy for
malpractice.

Negligence
Negligence is also an act of omission or commission that does not meet established standards of
care. It differs from malpractice because it lacks one or more of the six elements of malpractice that
are essential to be considered malpractice.
Actions of omission and commission that lead to client injury place the nurse in jeopardy for
negligence.

Mandatory Reporting
Nurses are legally mandated to report abuse, neglect, gunshot wounds, dog bites, some
communicable diseases and any unsafe and/or illegal practices done by another health care provider.
Informed Consent and Refusals of Treatment which was fully detailed previously.

Documentation
All documentation and all forms of documentation are considered legal documents. Some of the
legal aspects of documentation, in addition to the legal mandates associated with confidentiality,
include the strict legal prohibitions against altering a record, obliterating entries in the medical
record, and falsifying documentation.
Other guidelines for documentation include the use of permanent ink, the use of only accepted
terms and abbreviations, legible writing, accurate spelling, proper grammar, accurate dating and time
of the entry, the signature and title of the person who documented the entry, and a professional
tone. If an error in documentation occurs, a thin line that does NOT obliterate the entry is drawn
through the erroneous entry, the notation "Error" is written above the entry and the nurse signs this
notation with their name and title.

The Acceptance of an Assignment

Nurse are legally accountable to accept only those assignments that are appropriate in terms of their
nurse practice act and their scope of practice, and only those that the nurse believes that they are
competent to perform.
RELATED:

 How is the Scope of Practice Determined for a Nurse?

 Scope of Practice vs Scope of Employment
 RN Scope of Practice

The Provision of Staff and Client Education

Relating to Legal Issues
As with other educational needs, nurses assess client and staff member educational deficits and
educational needs relating to the legal issues that impact on their care and the care that nurses
provide, respectively. After this assessment, educational activities to meet identified educational
needs are planned, implemented and evaluated in terms of their effectiveness in meeting the
educational need that was identified.

Compliance With and Adherence to Other Laws

Nurses are also expected to comply and adhere to other national, state, and local laws and
regulations. For example, the compliance with the Centers for Medicare and Medicaid Services must
be adhered to, state laws relating to professional licensure and mandatory reporting must be
complied with, and local laws relating to the disposal of biohazardous waste must also be followed
without fail.

Recognizing the Limitations of

Self/Others and Seeking Assistance
When Needed
Nurse are legally accountable to accept only those assignments that are appropriate in terms of their
nurse practice act and their scope of practice, and only those that the nurse believes that they are
competent to perform.

Reviewing the Facility Policy, Federal

Mandates and State Mandates Prior to
Agreeing to Serve as an Interpreter for
Staff or Primary Health Care Providers
In addition to following the policies and procedures of the particular employing healthcare
organization, nurses must also follow and comply with any federal and state laws relating to
interpreters and serving as an interpreter.
Some of these laws include:

 The Americans with Disabilities Act of 1990 and the Rehabilitation Act of 1973 which forbid and
prohibit any discrimination against people with disabilities including those who are deaf. Sign language
interpreters could be used in healthcare facilities to comply with these laws.

 The Civil Rights Act of l964 and Title VI of this law states that "No person in the United States shall, on
ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or
be subjected to discrimination under any program or activity receiving Federal assistance."

 Title VI Prohibition Against Discrimination on the Basis of National Origin- Persons with Limited
English Proficiency states that, "Because of these language barriers, LEP (limited English proficiency)
persons are often excluded from programs or experience delays or denials of services from recipients of
Federal assistance. Such exclusions, delays or denials may constitute discrimination on the basis of
national origin, and in violation of Title VI".

Since the year 1999, all healthcare organizations and agencies that get federal funding must provide
interpreter services to those that need it.

Educating Clients and Staff on Legal

Issues
As with other educational needs, nurses provide educational activities to clients, significant others,
and other staff members about legal issues that can impact on the care that they provide.

Reporting Client Conditions as

Required by Law
Some of the conditions that nurses are mandated by law to report some communicable diseases,
gunshot wounds, and child and/or elder abuse or neglect.
Reporting Any Unsafe Practice by
Health Care Personnel and Intervene
as Appropriate
As previously mentioned, nurses are legally mandated to report any and all unsafe and inappropriate
practices of healthcare staff and personnel. Once identified, the nurse must attempt to cease the
unsafe and/or inappropriate practices and immediately report it.
Some examples of these practices and behaviors include improper client care, narcotic diversion,
unsafe staffing practices and substance abuse by a member of the healthcare team.

Providing Care That is Within the

Legal Scope of Practice
Legally, nurses can only accept assignments and provide patient care that is appropriate in terms of
their nurse practice act and their scope of practice, and only those that the nurse believes that they
are competent to perform. These legal issues were extensively described and detailed previously.

Performance Improvement &

Risk Management: NCLEX-
RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of performance improvement and risk management in order to:

 Define performance improvement/quality assurance activities

 Participate in performance improvement/quality improvement process
 Report identified client care issues/problems to appropriate personnel (e.g., nurse manager, risk
manager)
 Utilize research and other references for performance improvement actions
 Evaluate the impact of performance improvement measures on client care and resource utilization
Measuring the quality has evolved, further developed, and become more regulated and refined over
the last decades. It has transitioned and transformed from quality control, to quality assurance, to
quality improvement, to performance improvement and continuous quality improvement. It has also
transitioned from an emphasis on structures, to an emphasis on process, and now to an emphasis on
outcomes, including patient outcomes.
The goal of performance improvement and performance improvement studies is to enhance and
improve the outcomes of care, to insure client safety, to increase the efficiency of patient care and
related processes, to reduce costs and to reduce risks and liability.
Additionally, performance improvement activities are mandated by external regulatory and
credentialing agencies and bodies like the state departments of health, the Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO), and the Centers for Medicare and Medicaid
(CMS).
Performance improvement activities include the:

 Identification of an opportunity for improvement

 Convening and organizing a group or team to work on the quality improvement activity. This team
should have members who are close to the process under study.

 Collection and analysis of data and information including, but not limited to, individual client data,
aggregated data for populations of clients, best practices, standards of care, evidence based practices,
research studies and the professional literature

 Close and collaborative examination and exploration of the process at hand that is being explored

 Elimination of variances that adversely affect client care and the quality of the client care provided

The most effective quality improvement activities should focus on areas that have the greatest risk,
the greatest costs in terms of both human and monetary costs, the greatest volume, and/or the most
problem prone.

Defining Performance
Improvement/Quality Assurance
Activities
Some of the terms and concepts relating to performance improvement that you should be familiar
with and able to apply for your NCLEX-RN examination include:
The Culture of Safety
The healthcare organization must establish and maintain a culture of safety within it in order for the
organization to benefit from effective performance improvement activities to promote high quality
and safe care for its clients. This culture and the associated values and beliefs must be integrated into
all of the healthcare organization's staff members from upper management to the front line
employees.

A Blameless Environment
Performance improvement and risk management activities must be conducted in a blame free
environment that focuses on the issues and ways to improvement processes and NOT who made
the mistake. Errors and problems in a blameless and blame free environment are viewed as
opportunities for improvement and not opportunities to blame and punish those who erred. These
activities aim to prevent problems and concerns by making all processes fail safe and NOT subject
to human error.

Root Cause Analysis and A Blame Free

Environment
Root cause analysis, a process that is used with and for performance improvement activities, within
the blame free environment of the healthcare organization and in keeping with its philosophy and
culture of safety, explores and digs down to the roots of the problem, its root causes and the things,
not people, that are the real reasons why medical errors and mistakes are made.
These root causes are typically faulty processes and processes and procedures that have some points
of risk and vulnerability and that place the healthcare organization at risk for errors and future
errors. For this reason, the question "Why", rather than "Who", is asked repeatedly during root
causes analyses to dig down to the root causes of the problem to find out why and NOT to find out
who is the source of the problem.

Sentinel Events
A sentinel event is an event or occurrence, incident or accident that has led to or may possibly lead
to client harm. Even near misses, that have the potential for harm, are considered sentinel events
because they have the potential to cause harm in the future.
Some sentinel events, like the suicidal death of a client, are legally mandated to be reported to the
state; other sentinel events should additionally be reported to the Joint Commission on the
Accreditation of Healthcare Organizations. All sentinel events, however, should be studies, explored
and investigated in order to prevent future events, occurrences, incident or accident.
Some of the most commonly occurring medical error sentinel events that affect healthcare
organizations can include medical errors such as falls, adverse drug reactions, medication errors,
suicide, infant abduction, the retention of a foreign body when surgery has been done, wrong
patient, wrong site and wrong procedures and treatments, treatment delays, and complications like
infections and other unanticipated events that can occur after a treatment or procedure.
Variance Tracking
Identifying variances and analyzing variances are integral to performance improvement and
performance improvement activities. As previously mentioned, variances can include patient related,
healthcare provider and organizational variances from the expected.
Variances are also described as "specific" or "random". Random variances happen when the process
is faulty and/or prone to human error; and random variances occur when one part of the process is
faulty and/or prone to human error. Specific variances occur whenever the faulty process is carried
out; and random variances occur at sporadic, unpredicted and random times when the faulty process
is carried out.

Performance and Quality Indicators

Core Measures: Quality indicators can be classified as core measures and outcome measures. Core
measures are standardized measures of quality put forward by the Joint Commission on the
Accreditation of Healthcare Organizations' (JCAHO) ORYX National Hospital Quality Measures
that address populations of clients such as the geriatric and pediatric populations, diseases such as
pneumonia, sepsis and heart failure and pneumonia, and also organizational measures like those
used in the intensive care areas and the emergency departments

Performance and Quality Indicators

Outcome Measures: Outcomes measures explore and study the outcomes of client care. For
example, lengths of stay, MRSA infection rates, the effectiveness of falls risk screening in terms of
identifying clients at risk of falls, the effectiveness of falls risk interventions to prevent falls,
mortality rates, morbidity rates, infection rates related to healthcare acquired infections, and
readmissions may be explored and studied as an outcome measure.

Risk Management
Risk management focuses on decreasing and eliminating things that are risky and place the
healthcare organization in a position of liability.
Risk management activities focus on healthcare related hazards and adverse events such as patient
falls, infant abduction, medication errors, healthcare acquired infections, wrong site/wrong person
surgeries and other invasive treatments and tests. identifies and eliminates hazards relating to basic
safety such as falls, hospital acquired infections and infant abduction, a wide variety of medical
errors such as wrong site surgery, wrong patient surgery and medication errors.
JCAHO has requirements relating to medical errors in terms of reporting sentinel events and the
elimination of hazards using root cause analysis. Risk assessments of the client, their condition, and
the environment of care are done to decrease liabilities and potential lawsuits. A falls risk assessment
and a risk assessment for skin breakdown are two mechanisms that decrease liabilities and risks
associated with the client and their condition.
Participating in Quality Improvement
(QI) Activities
Registered nurses are often asked to participate in performance improvement/quality improvement
activities.
Often, nurses participate in quality improvement activities as part of a team. A team is a group of
people who work together to achieve a common goal. Some of the professional roles and
responsibilities that a nurse can assume in terms of quality improvement include identifying and
reporting problems and opportunities for improvement, collecting performance improvement
related data, serving on a performance improvement/quality improvement group or team,
implementing performance improvement/quality improvement recommended corrective actions
into their nursing practice, and measuring and collecting data that evaluates the outcomes of
performance improvement activities and corrective actions.
Teams and group work are highly beneficial to performance improvement and performance
improvement activities, particularly when those closest to the process under study are included as
valued members of the group.
These group or team members have the most knowledge about the process under study and how
and when it negatively impacts on client care. Unlike members of upper level management and
administration, these group members at the front line are exposed to the issue at hand on a regular
and frequent basis, and its nuances within the context of care. They are also highly skilled in terms
of their abilities to clearly identify not only established discrepancies in the formalized, and
documented, process and procedure but also able to identify discrepancies and inconsistency in
terms of how people execute and deviate from the formalized, and documented, process and
procedure.
The seventeen characteristics that effective team members possess, according to Maxwell, include:

1. Dependability: They can be counted on to participate and contribute to the group and their group work
without fail.

2. Adaptability: Group members must be flexible, able to adapt to changing situations and circumstances
and achieve the group's goals and fulfill its mission.

3. Awareness of the Mission: Members must be motivated by and thoroughly knowledgeable about the
mission of the group.

4. Superior Communication Skills: Effective and respectful communication and active listening without
any judgments are essential to group success.
5. Effective Collaboration Abilities: Cooperation is not enough; active and effective collaboration is
essential to group success.

6. Self – Discipline: Teams members must be disciplined enough to want to succeed and produce the
expected goals of the group.

7. Selflessness: The team member values and has loyalty to the group and its work despite the fact that
they have personal goals and interests.

8. Commitment: Group members must be committed to the mission, goals and work of the group despite
potential barriers such as interpersonal conflicts.

9. Enthusiasm: Effective group members are not only committed to the group and its work, but they are
also energized with their participation and enthusiastic about the group and its work.

10. Competency: The person has the knowledge, skills and abilities to perform both clinically and as a
group member who has had some formal or informal education relating to groups, group development
and how to function as a group member and group leader.

11. The Ability to Add Value: Group members are effective when they have the knowledge, skills and
abilities to add value to the group and the work of the group.

12. The Ability to Be Prepared: Team members must be prepared and ready to serve as a member of the
group, attend all meetings and to perform their assigned tasks in relationship to the group's mission and
goals.

13. Intention: All team members must be able to do the right thing in all aspects of group work.

14. The Ability to Improve Self and Self-Reflect: Self-reflection entails the constructive criticism of self
and changing oneself when this self-reflection indicates the need to do so. These actions promote and
facilitate not only individual growth but also group growth and development.

15. The Ability to Focus: Group members must be able to focus and maintain focus on the mission and
the goals of the group without distraction. Team members must be able to maintain their focus on the
group and its work, and NOT on people that may have led to the problem or concern that is being
explored by the group.

16. Perseverance and Tenaciousness: Members of the team must persevere and be tenacious when they
act as a member of a team.
17. The Ability to Form and Maintain Relationships: Lastly, effective team members must be able to
form and maintain interpersonal relationships with others inside and outside of the group in order to
achieve group goals.

Although there are several different types of teams, all effective teams, including performance
improvement teams, have several common characteristics including:

 A mission or charter that is clear and not ambiguous

 A common shared mission that is bought into by all team members
 Formal and informal roles within the team such as a group leader or facilitator
 The ability to access data and information
 Open communication and the free expressions of members' perspectives, thoughts, beliefs and opinions
 An open environment of trust, mutual support, cooperation, respect and respect
 An environment and norms that promote divergent thought and differences of opinions without any
judgements

Teams are synergistic; the group as a whole has collective wisdom, powerful and additive
interactions, and the ability to produce more than one individual alone. The whole is greater than the
sum of the parts.
Although teamwork and group work are more time consuming than solo work, teams maximize the
many and diverse skills of different healthcare disciplines, especially when teams are used for
performance improvement activities.
Performance improvement activities can follow several methods including the PDCA cycle which is
Planning, Doing, Checking and Acting, Six Sigma method that includes definition of the problem,
measurements, analysis, improvements and control to achieve zero defects, and any other currently
popular "method de jour", however, all performance improvement activities have these general
steps:

 The definition of the problem or opportunity for improvement

 The collection of data and information relating to the problem or opportunity for improvement

 The organization and analysis of the collected data and information that includes, but is not limited to,
the comparison and contrasting of this data to standards of care, best practices, benchmarks, legal
mandates and the recommended standards put forth by agencies such as the Joint Commission on the
Accreditation of Healthcare Organizations.

 Root cause analysis to dig down to the possible causes of the problem
 Generating a list of possible solutions and alternatives of action to solve the problem and/or improve the
quality of care

 Selecting the solution or alternative of action that is not only feasible but also the one that has the
greatest possibility of success

 Initiating and implementing the best solution or corrective action

 Measuring the effectiveness of the implemented solution or corrective action in terms of its success.

All performance improvement/ quality improvement activities are documented. For example, data is
collected and documented, the minutes of committee meetings and corrective action plans are
documented.

Reporting Identified Client Care

Issues and Problems to Appropriate
Personnel
Nurses must immediately report a client care issue, concern or problem to the supervising nurse, the
charge nurse and/or the performance improvement or risk management department according to
the reporting policies and procedures of the particular facility.
Although the formal mechanisms that can be used by nurses to report identified client care issues,
problems, sentinel events that have caused harm in addition to "near misses", may vary somewhat
among different healthcare facilities, however, they are many commonalities. Most facilities have
mechanisms that define and describe:

 The channels of oral communication through which client care issues, concerns or problems are orally
communicated as soon as they are discovered.

 The forms and the other documents that are used to formally document and report client care issues,
concerns or problems

 The names of and/or the departments that will receive oral and written notification and reporting of
client care issues and problems. Some of these people and departments are the nursing supervisor, the
quality assurance staff, the risk management department and the nurse manager.
Utilizing Research and Other
References for Performance
Improvement Actions
Some of the pertinent research and other references that nurses, and other healthcare providers,
utilize include:

 Published articles in the professional literature

 Valid and sound research studies
 Benchmarks
 Standards of practice
 Standards of care
 Published evidence based practices
 Pertinent laws
 Pertinent ethical codes
 Pertinent standards and regulations such as those of the Joint Commission on the Accreditation of
Healthcare Organizations

Evaluating the Impact of Performance

Improvement Measures on Client Care
and Resource Utilization
The impact of performance improvement activities and performance improvement measures to
increase the quality of care can be measured using a number of different measurement techniques
and strategies including:

 The comparison of pre and post corrective action data

 A determination of whether or not action plans were effective in terms of client safety, increasing levels
of effectiveness and timeliness of care and services to the individual client or groups of clients, decreasing
levels cost, a decrease in terms of patient related incident and accidents such as healthcare acquired
infection rates and falls that result in injury.
 A determination of whether or not action plans were effective in terms of eliminating waste, decreasing
the use of unnecessary services, and properly using the appropriate resources at the appropriate level of
care

Referrals: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of referrals in order to:

 Assess the need to refer clients for assistance with actual or potential problems (e.g., physical therapy,
speech therapy)
 Recognize the need for referrals and obtain necessary orders
 Identify community resources for the client (e.g., respite care, social services, shelters)
 Identify which documents to include when referring a client (e.g., medical record, referral form)

Referrals, simply defined, are contacts that are initiated by the nurse and other members of the
healthcare team in order to meet the needs of the client at the appropriate level of care and in the
appropriate setting. Registered nurses manage and coordinate care along the continuum of care.

Assessing the Need to Refer Clients

for Assistance with Actual and
Potential Problems
Nurses and the entire healthcare team assess clients and determine their need for referrals relating to
actual and potential problems.

Recognizing the Need for Referrals

and Obtaining Necessary Orders
When clients have assessed needs that cannot be fulfilled and met by the registered nurse in
collaboration with other members of the nursing care team, the registered nurse should then seek
out resources, as well as utilize and employ different internal or external resources such as a physical
therapist, a clergy member or a home health care agency in the community and external to the
nurse's healthcare agency.
These resources are tapped into and, when considered appropriate for the client and their needs.
Identifying Community Resources for
the Client
Common referral needs include resources and/or assistance in the community in respect to:

 Crisis intervention
 Anger management programs for perpetrators of abuse for example
 Social work services for uninsured clients and those in need of assistance such as Meals on Wheels
 Respite care for burdened caregivers
 Community self-help groups
 Housing, including emergency shelters, for victims and children affected with abuse
 Transportation to and from medical appointments
 Elder day care and in home care of an elderly patient
 Parenting resources for fathers, young mothers and others who an assessed need for the same

Identifying and Using Appropriate

Documents When Referring a Client
Medical data and information including referral forms and the client's medical record are shared with
the person, department or community resource that is accepting the client according to their legal
need to know this information in order to provide the client with their necessary care and
treatments.
 II) Safety and Infection Control
The registered nurse protects clients and health care personnel from health and environmental
hazards.
They must be able to:

 Assess the client for allergies and intervene as needed (e.g., food, latex, environmental allergies)
 Protect client from injury (e.g., falls, electrical hazards)
 Ensure proper identification of client when providing care
 Verify appropriateness and/or accuracy of a treatment order
 Implement emergency response plans (e.g., internal/external disaster)
 Use ergonomic principles when providing care (e.g., assistive devices, proper lifting)
 Follow procedures for handling biohazardous materials
 Educate client on home safety issues
 Acknowledge and document practice error (e.g. incident report for medication error)
 Facilitate appropriate and safe use of equipment
 Participate in institution security plan (e.g., newborn nursery security, bomb threats)
 Apply principles of infection control (e.g., hand hygiene, surgical asepsis, isolation, sterile technique,
universal/standard precautions)
 Educate client and staff regarding infection control measures
 Follow requirements for use of restraints and/or safety device (e.g., least restrictive restraints, timed
client monitoring)

Related content includes, but is not limited to:

 Accident/Error and Incident Prevention

 Emergency Response Plans
 Ergonomic Principles
 Handling Hazardous and Infectious Materials
 Home Safety
 Reporting Incident / Event / Irregular Occurrence / Variances
 Safe Use of Equipment
 Security Plans
 Standard Precautions/Transmission Based Precautions/Surgical Asepsis
 Use of Restraints/Safety Devices
Accident/Error and Incident
Prevention: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of accident / error and incident prevention in order to:

 Assess clients for allergies and intervene as needed (e.g., food, latex, environmental allergies)
 Determine client/staff member knowledge of safety procedures
 Identify factors that influence accident/injury prevention (e.g., age, developmental stage, lifestyle, mental
status)
 Identify deficits that may impede client safety (e.g., visual, hearing, sensory/perceptual)
 Identify and verify prescriptions for treatments that may contribute to an accident or injury (does not
include medication)
 Identify and facilitate correct use of infant and child car seats
 Provide the client with appropriate method to signal staff members
 Protect the client from injury (e.g., falls, electrical hazards)
 Review necessary modifications with client to reduce stress on specific muscle or skeletal groups (e.g.,
frequent changing of position, routine stretching of the shoulders, neck, arms, hands, fingers)
 Implement seizure precautions for at-risk clients
 Make appropriate room assignments for cognitively impaired clients
 Ensure proper identification of client when providing care
 Verify appropriateness and/or accuracy of a treatment order

Patient, resident safety is a major concern in healthcare organizations. The Joint Commission on the
Accreditation of Healthcare Organization (JCAHO) publishes patient safety goals on an annual basis
to facilitate client safety.
The Hospital Patient Safety Goals for 2016 include the goals to:

 Identify patient safety risks

 Identify patients correctly
 Improve staff communication
 Use medications correctly
 Use patient safety alarms correctly
 Prevent infections
 Prevent errors and mistakes relating to surgery, other invasive procedures, and treatments
More information about the current Patient Safety Goals put forth by the Joint Commission on the
Accreditation of Healthcare Organization (JCAHO).

Assessing the Client for Allergies and

Intervening as Needed
Upon first contact with the client, the nurse thoroughly assesses the client for any known allergies,
in addition to many other bio-psycho-social-spiritual data. These allergies can be related to
medications and other substances such as contrast media that is used for many diagnostic tests,
foods, environmental factors like pet dander and air pollution and other things like an allergy to latex
and products containing latex.
Nurses determine, identify and document client allergies to medications, contrast media used for
diagnostic tests, foods, and environmental sources including latex.
Nurses observe for and identify any possible allergies to the medications. For example, nurses
collect data relating to past medication allergic responses and they also observe patients throughout
the course of care to determine if the patient is experiencing an allergic response to a new
medication. For this reason, nurses must be fully informed about the signs and symptoms of an
allergic response to all medications that they administer.
All allergies to medications are documented in the nursing assessment and also on the medication
administration record in addition to other areas in the medical record, according to the facility's
policy and procedure. Many healthcare agencies also use allergy bands and/or bar codes with
embedded allergy information to enable nurses to readily identify any allergies to medications.
Similar to latex allergic responses, the degree, intensity and seriousness of allergic responses to
medications can be moderate or severe.
Commonly occurring medication allergies include allergies to penicillin which can be particularly
dangerous and life threatening, allergies to sulfonamides, and allergic reactions to cephalosporin
medications.
Commonly occurring allergies to radiocontrast media include allergies to ionic high osmolality
contrast media and nonionic low osmolality contrast media. Some of the risk factors associated with
allergies to radiocontrast media include beta blocker antihypertensive medications, the elder years,
female gender, and a history of renal disease and/or heart disease.
It is estimated that nearly 10% of people have a reaction to penicillin. Some of these reactions are an
allergic response and others are simply a side effect. The first exposure to penicillin, referred to as
the "sensitizing dose", sensitizes and prepares the body to respond to a second exposure or dose. It
is then the second exposure or dose that leads to anaphylaxis, or anaphylactic shock.
The signs and symptoms of anaphylaxis and anaphylactic shock, a type of distributive shock, are the
massive collapse of venules and arterioles in the body's circulatory system, decreased cardiac output,
histamine release, a drop in blood pressure, pooling of venous blood, laryngeal edema, respiratory
distress, a rash, a rapid bounding heart beat, and death unless it is immediately treated.
Like a penicillin allergy, allergies to latex and its effects on the body can vary among individuals in
terms of its severity. For example, some clients may only be affected with an immediate local contact
dermatitis, the least severe of all the allergic reactions to latex, others can be affected with a delayed
contact dermatitis, and still move can respond with a life threatening allergic reaction which can be
signaled with itching and flulike symptoms and progress to tachycardia, hypotension, dyspnea, chest
pain tremors, and anaphylactic shock.
The signs and symptoms of immediate and delayed contact dermatitis to latex include itching and
burning of the skin and skin scaling that can extend the area of contact such as the hands when latex
gloves are used.
Allergies to latex can occur after long use and they can also occur with the first contact with latex.
Some of the patients at greatest risk for latex allergies are those with some immunosuppressive
disorder such as HIV/AIDS, those with asthma and eczema. It is also believed that those who are
allergic to some foods, like avocados, are more at risk for latex allergies than others without these
food allergies.
Learn more about the role of HIV/AIDS nurses.
In summary, nurses must be knowledgeable about assessing known and possible client allergies
including those to medication, other medical substances such as latex and contrast media, foods and
environmental factors, the signs and symptoms of an allergic response, and interventions that must
be done when the client is affected with an allergic response. Some of these interventions can
include reporting, documentation and interventions to correct any allergic responses and changes
that can impact on the client's healthcare status. For example, CPR and other life saving measures
may be indicated when the client is affected with life threatening anaphylactic shock; and the nurse
may have to administer corticosteroid medications with a doctor's order after an allergic response
was communicated to the client's physician.

Determining Client and Staff

Knowledge of Safety Procedures
Staff is required to have the knowledge, skills and abilities to identify safety risks, to intervene
appropriately to prevent and correct safety hazards and to act accordingly when a client, family
member, visitor or another staff member is actually or potentially affected by a safety hazard.
When a staff educational need related to these or other aspects of safety, the registered nurse, will
plan, implement and evaluate education to meet these needs. After education is provided, the staff
member will be assessed for their competency.
Some safety skills, such as using a fire extinguisher, are rarely used skills and others, such as daily
surveillance of the patient care area for safety hazards and risks, are frequently used skills. Both,
rarely used and frequently used safety skills, however, are associated with high risk, therefore, rarely
used skills must be assessed and staff must be deemed competent on a frequent basis with
observation; and frequently used safety skills can be validated for competent performance with the
indirect observation of the application of these skills and the identification of any issues or
discrepancies in the performance of these skills. For example, the staff member should actually
demonstrate the correct use of a fire extinguisher in a planned manner and at least on an annual
basis and the competency levels of staff related to frequently used safety skills can be determined
and validated indirectly by observing the correct application of these skills in the area of
employment.
Clients also may have safety educational needs. For example, clients at risk for incidents, accidents,
and errors should be instructed about safety procedures and measures that they can use to prevent
them. For example, some clients may need frequent reminders to call for help before getting out of
bed to prevent a fall, and others may need the nurse to educate them for the need for grab rails and
to have a carbon monoxide alarm in the home.

Identifying Factors that Influence

Accident/Injury Prevention
Some of the factors that can positively impact on and influence injury and accident prevention
include an age and developmental stage at which the person is able to understand safety and safe
behavior; a normal, alert and awake level of consciousness, a level of cognitive ability and mental
status that enables the person to have insight into safety and safe behaviors and fully aware and
cognizant of their own limitations, strengths and weaknesses; and a lifestyle including exercise and
an adequate diet that can enhance their health, well-being and level of safety.
In terms of age, infants, toddlers, young children and the elderly very young are at greater risk for
accidents and injuries than other age groups; people with poor consumption patterns, such as illicit
drug and/or alcohol abuse, are more prone to injuries and accident than those who have healthy
lifestyle choices that increase their strength, stamina, agility and nutritional status.

Identifying Deficits That May Impede

Client Safety (e.g., visual, hearing,
sensory/perceptual)
Physical deficits like sensory losses and alterations, impaired mobility, an altered mental and
emotional state, and other factors can negatively impact on the safety of the client.

Sensory and Perceptual Deficits

Physical deficits like a sensory losses and alterations can affect client safety. For example, clients
with a visual impairment may trip over objects that they cannot see and they can also fail to see a
sign that indicates that a floor is wet; and patients with a hearing deficit may not hear a fire or smoke
alarm.

Impaired Mobility
Patients affected with permanent or temporary losses of mobility are more prone to injuries and
accidents than other patients without these deficits. For example, a client with left sided paralysis as
the result of a cerebrovascular accident and a client who has become weak as the result of prolonged
complete bed rest are at greater risk for injuries and accident than those without these conditions.

An Altered Mental and Emotional State

High levels of stress, fatigue, the effects of some medications like sedating medications, the effects
of anesthesia, and depression are risk factors associated with a greatest risk for client injuries and
accidents than other clients with intact and unimpaired mental and emotional states.

A Lack of Safety Insight

A lack of good judgment and insight into safety risks place clients at risk for safety concerns.

Identifying and Verifying

Prescriptions for Treatments That
May Contribute to An Accident or
Injury, Not Including Medications
An essential component of injury and accident protection entails the ability of the nurse to identify
and verify all treatment orders and prescriptions to insure that they are not placing the client at risk
for any injury or accident. When the nurse receives an order or prescription for a treatment or
procedure that is questionable in terms of client appropriateness and safety, the nurse, as the nurse
does with questionable medication orders, contacts the person who has prescribed the treatment or
procedure and verifies the order before carrying this order out.
The treatments and procedures that are most prone to client risk, injuries and accidents and the
most risky are invasive procedures including surgery and invasive diagnostic tests. It is, therefore,
essential that nurses exercise extreme caution and apply their knowledge of the client's status and the
risks associated with the particular treatment to the particular order to insure that undue risks are not
associated with the invasive treatment or procedure that has been ordered.
Some of the procedures associated with high degrees of risk intraprocedure or treatment and after
the treatment or procedure include all surgical procedures, invasive cardiac catheterizations,
intubation, peripheral venous catheters, central venous catheters, chest tubes, mechanical ventilation,
the administration of contrast media for diagnostic tests and other procedures and treatments, some
of which will be discussed in a later section entitled The Reduction of Risk Potential.

Identifying and Facilitating the

Correct Use of Infant and Child Car
Seats
When properly used and fitted, infant and child death and injury secondary to motor vehicle
accidents can be significantly, according to the National Highway Traffic Safety Administration
(NHTSA). It is estimated that infant and child car seats prevent death among infants by 71% and
among toddlers and young children under 3 years of age by 54%.
Infant seats and car seats must be properly sized and properly installed in order for them to be
effective against injures and death. For example, rears facing infant seats are always installed in the
back seat facing the rear of the car when the infant or baby is less than about 2 years of age and
about 20 to 30 pounds. Convertible safety seats can be both rear facing and front, or forward,
facing. Regular car seat belts can be typically used when the child is at least 40 pounds and about 4
years of age.

Providing the Client with An

Appropriate Method to Signal Staff
Members
Many accidents and client injuries can be prevented when the client has access to a device that
enables them to signal staff and when these calls to staff members are responded to in a timely
manner. Nurse call bells that continue ringing for minutes without being responded to by staff can,
and do, lead to unnecessary injuries and accidents that could have been prevented by a prompt staff
response. Regardless of the method for alerting staff is used, calls for help and assistance must be
immediately responded to.
At times the method to signal and alert nursing staff members must be modified according to the
client's characteristics and needs and at other times the method to signal and alert nursing staff
members must be modified according to a situation or circumstance in the environment that is not
related to the client and their abilities.
Most clients are able to signal staff with a call bell and light. Others may only be able to verbally call
out for help, and others may not be able to signal staff members. Clients unable to use a call bell
should be placed near the nursing station or another area with high activity so the client's verbal calls
for help can be heard and attended to by staff; clients unable to call for help using a call signal or
verbal calls for help should not only be placed in a room near the nursing station or another area
with high activity so that they can be monitored and observed on a frequent basis.
When there is a utility failure, or another environmental factor such as the malfunction of the
facility's call bell system, that disrupts the use of call bells, hand held bells or buzzers should be
provided to the clients so they can communicate with nursing staff despite this electrical power loss
or system malfunction.

Protecting the Client from Injury

Healthcare providers and healthcare facilities are mandated to protect clients, visitors and staff from
injury. Some of the commonly occurring injuries in healthcare facilities include burns, falls, electrical
shock, accidental poisoning and events occurring from internal and external disasters.
Thermal injures can occur as the result of faulty warming and cooling devices and also with the
improper application of heat and cold to the client, particularly when the client has a sensory and/or
neurological deficit that impairs their ability to sense and feel skin damage resulting from the heat or
cold application. More information about the safe and correct application of heat and cold will be
discussed later in this NCLEX-RN review.
Falls a major, commonly occurring and costly accident, with or without injury, plague virtually all
health care facilities. For this reason, all clients should be screened and assessed for falls risk upon
admission, upon our first client contact and, also, whenever the client's condition is marked with
significant physical and/or psychological or cognitive changes.
When a client is screened and assessed as a falls risk client, special interventions to prevent falls must
be immediately initiated, communicated and documents.
Some of the risk factors associated with falls that are typically included in a falls risk screening and
assessment are:

Incontinence
Patients who are incontinent of feces and/or urine are at greater risk for falls than clients who are
not affected with these elimination problems. Incontinent patients may leave feces and/or urine of
the floor which they may slip on and/or they may be in such a hurry to get to the toilet that they fail
to use proper lighting and other safety measures to prevent a fall.

Confusion
Confusion can lead to poor judgment and a lack of awareness of environmental factors that can lead
to a fall. People who are confused may lack good judgment and they may not be aware of any
hazards.
Poor vision
People who are visually impaired can trip over things they cannot see, particularly in a strange, or
new, environment. Clients should be given their eyeglasses and encouraged to use them.

A delayed and slow reaction time

A delayed and slow reaction time, a normal change associated with the aging process, places clients
at greater risk than others, and often younger, clients. They may not react quickly enough to avoid a
hazard, such as a wet floor, that they see. This can lead to a slip and fall.

Age
The aging population, infants and young children are the age groups that are at greatest risk for falls.

Medications
Sedating medications and other medications with some side effects, such as fatigue, muscular
weakness, dizziness, and orthostatic hypotension, for example, increase a client's vulnerability to
falls.

Poor muscular strength, balance, coordination, gait

and range of motion (ROM)
When a client has poor balance, coordination, proper gait, and full range of motion for one reason
or another, they are at greater risk for falls than other clients without these deficits. One of the most
effective interventions to address these deficits is to employ the services of the physical therapist to
increase the client's muscular strength, balance, coordination, gait and range of motion in order to
prevent falls.

Environmental hazards
Patient rooms and client areas that have clutter, poor lighting, high glare, wet floors and/or an
absence of nurse call bells are not safe. The nurse is responsible to keep the client environment safe
and without any hazards.

Past falls
A history of falls in the past, particularly more recent and frequent falls, place a client at future risk
for falls because many of the same conditions that were present in the past, particularly the recent
past, may continue to the current time. For example, paralysis secondary to a cerebrovascular
accident persists over time.

Fear of falling
A client's fear of falling has been shown to be positively correlated with falls risk.
Some diseases and disorders
Some diseases and disorders, particularly those that adversely affect the client's musculoskeletal
and/or neurological status, place a client at risks for falls. For example, diseases and disorders like
muscular dystrophy, Parkinson's disease and a seizure disorder place a client at risk for falls.
In addition to intrinsic, patient related factors that place clients at risk for falls, there are also a
number of extrinsic and environmental factors that place clients at risk for falls.
Some of these factors, all of which must be immediately corrected, include:

Inadequate patient foot wear

Poorly fitting, nonskid proof and simply dangerous shoes and slippers place clients at risk for falls.
Patient footwear should be skid proof, sturdy, properly fitted and safe. Skid proof socks are highly
effective in terms of fall prevention.

Broken equipment and the inappropriate use of

patient equipment
Broken patient equipment such as a broken wheelchair or cane can lead to falls. All broken
equipment must be reported and immediately removed from service and not used until they are
repaired and deemed safe to use. All patient equipment must also be used correctly. When a staff
member improperly uses a mechanical lift, for example, to move the client from the bed to the chair
and the patient falls as the result of this improper use, an accident and injury has occurred as the
result of this improper use of the mechanical lift.

No answers to calls for help

As previously stated, all calls from clients must be responded to promptly in order to prevent falls as
well as other incidents and accidents, many of which can lead to patient injury.
In addition to assessing clients for falls risk, some of the special interventions that can prevent falls
or lessen the degree of injury that a client can sustain after a fall include the following:

 The use of patient assistive devices such as walkers and canes

 Padded briefs to decrease the extent of an injury when a client does fall despite preventive measures

 The use of padded gym mats on the floor next to a bed can also decrease the extent of an injury when a
client does fall despite preventive measures

 The use of low beds to decrease the extent of an injury when a client does fall despite preventive
measures

 The use of bed and chair alarms to alert staff that the client is rising from the bed or the chair
 More frequent patient monitoring and observation

 The use of high toilet seats and grab bars

Electrical Safety
Like other safety hazards, health care facilities are subject to incidents and accidents associated with
things and practices that are contrary to good electrical safety. For example, frayed electrical cords
and using extension cords that can overwork electrical outlets and also cause client tripping and
falling can occur in health care facilities unless they are eliminated from the environments within
which clients receive services and staff members work.
All electrical client equipment is routinely and predictably inspected for safety, and preventive
maintenance is also done and documented on these pieces of electrical equipment. When a piece of
equipment is overdue for this electrical inspection and maintenance and also when it is
malfunctioning and/or with a frayed wire, this piece of electrical equipment must be immediately
taken out of service and sent to the appropriate department for inspection, preventive maintenance
and repair. Under NO circumstances should such equipment be used even on a very temporary
basis. More about the safe use of equipment will be discussed below.
Client's personal electrical equipment, such as televisions, radios, electrical razors and computers,
must also be inspected and approved as safe, by a person competent to do so, before it can be used
by the client in the health care environment. For this reason, patients are discouraged from bringing
personal electrical equipment into the health care facility for their personal use.

Reviewing Necessary Modifications

with the Client to Reduce Stress on
Specific Muscle or Skeletal Groups
Some of the things that nurses can facilitate and do in order to reduce stress on specific muscle and
skeletal groups include encouraging clients to perform routine stretching, range of motion exercises
and also frequently changing positions into those which place the body in a safe position.
Clients who are not able to do this must be positioned and repositioned every two hours into a
position that will not cause any harm such as any stressors on the muscle groups, and that prevent
skin breakdown and other complications associated with immobility such as contractures.
The client positions that are used for maintaining good bodily alignment and optimal physiological
functioning include the Sim's or semi prone position, the Fowler's position, the dorsal recumbent
position, the prone position and the lateral position. These positions are supported and maintained
with pillow, bolsters and wedges when necessary to maintain correct bodily alignment.
Routine stretching and exercising the body's full range of motion should be strongly encouraged
among all clients that are able to do so and passive or assisted range of motion should be provided
to the client when they are not able to perform these exercises on their own. These exercises
maintain the body's ability to remain strong and mobile. Routine stretching of the shoulders, neck,
arms, hands, and fingers should also be encouraged.

Implementing Seizure Precautions for

At-Risk Clients
Nurses must implement seizure precautions for at-risk clients to protect them from injury. Seizures,
which can be a primary diagnosis or a condition that results from another medical condition such as
hypoglycemia, increased intracranial pressure and cerebrovascular accidents, result from abnormal
electrical activity in the brain.
Some of the risk factors that can place a client at risk for seizures include:

 Alzheimer's disease
 The use of illicit drugs
 Some prescription drugs
 An overdose of an illicit drug
 A personal history of prior seizures
 A family history of seizures
 Cerebral tumors and infections
 Alcohol withdrawal
 Hepatic failure
 Renal failure
 Exposures to toxins
 Hypertension
 Hypoglycemia
 Extreme stress
 Some diseases such as syphilis, sickle cell anemia, Whipple's disease etc.
 Abnormal hormonal changes

The client is assessed for the presence of any seizure risk factors and when a seizure disorder is
suspected the client will receive diagnostic tests such as an electroencephalogram (EEG) to assess
the client's electrical activity of the brain and to determine whether or not epilepsy is the cause of the
seizure activity, a MRI and CT scan to determine if there are any structural brain abnormalities like a
tumor, a lumbar puncture to determine whether or not the client has an infection or cerebral
bleeding, and PET imaging to determine the specific location that is causing the seizure activity.
Most seizures are short lived and they typically persist for only a few minutes; when seizures last
more than 3 or 5 minutes they can be life threatening. It is also potentially life endangering when a
client has several seizures in rapid succession.
When a seizure is witnessed by the nurse, the nurse must remain with the client, call for the help and
assistance of others, and observe and assess the client's physical status, like their cardiac and
respiratory functioning, and also implement emergency measures when they are indicated. The client
should also be protected from physical injury during the seizure.
All observations and assessments of the client prior to the seizure, such as an aura, during the
seizure and after the seizure are fully documented. It is also reported to the client's physician.
Clients who are at risk for seizures and a seizure disorder should be taught and educated about the
need to avoid hazardous activities such as climbing to high heights with a ladder because a seizure
can occur suddenly and without any warning, the warning signs of a seizure, the risk factors
associated with seizures, and to wear a medical emergency tag or bracelet that alerts others to the
fact that the person has a seizure disorder.

Making Appropriate Room

Assignments for Cognitively Impaired
Clients
In addition to more frequent monitoring, clients with a cognitive impairment should be placed in a
room near a hub of activity near the nursing station, for example, to prevent injuries and accidents.

Ensuring the Proper Identification of

the Client When Providing Care
Proper patient identification must be done before anything is done for or with a patient. As we
previously discussed, accurate identification is necessary during all aspects of nursing care. At least
two unique identifiers, other than room number, must be used.
Some examples of unique identifiers include a unique code number, the person's first, middle and
last name and/or complete date of birth including year, an encoded bar code bracelet with at least
two unique identifiers imbedded into it and a photograph. Room numbers are never used as unique
identifiers. Patients and residents often enter the rooms of other patients and residents, particularly
when they are confused.
Patients at greatest risk for identification errors are patients who are confused, comatose, have a
primary language other than English, and those patients who have an identical name or a similar
name to another patient in the health care facility. For example, Mr. Smith and Mr. Smyth are at risk
for identification errors when they are in the same facility.
The proper identification of patients prevents many medical errors, including wrong patient surgery,
medication errors and the provision of incorrect treatments and procedures to a patient.
Health care facilities have formalized policies, procedures and mechanisms for patient identification.
In addition to the use of two unique identifiers, some health care facilities also have bar coded
patient identification bands, patient identification wrist bands that include any patient allergies and
even wristbands to alert staff that the client is a do not resuscitate client.

Verifying the Appropriateness and/or

Accuracy of a Treatment Order
An essential component of injury and accident prevention, as previously detailed with the section
above entitled "Identifying and Verifying Prescriptions for Treatments That May Contribute to An
Accident or Injury, Not Including Medications", nurses must not only identify and verify all
treatment orders and prescriptions to insure that they are not placing the client at risk for any injury
or accident and also to verify that the order is appropriate for the client and that it is accurate and
transcribed in an accurate manner.
When the nurse receives an order or prescription for a treatment or procedure that is questionable in
terms of client appropriateness and safety, the nurse as the nurse manager of care, contacts the
person who has prescribed the treatment or procedure, and they also clarify and verify all
questionable orders.

Emergency Response Plans:

NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of emergency response plans in order to:

 Determine which client(s) to recommend for discharge in a disaster situation

 Identify nursing roles in disaster planning
 Use clinical decision-making/critical thinking for emergency response plan
 Implement emergency response plans (e.g., internal/external disaster)
 Participate in disaster planning activities/drills
One of the major roles of health care facilities entails the authorship, review and implementation of
emergency response plans for all possible and anticipated circumstances. Many components of these
internal and external disaster plans are driven by the regulations and requirements of external
regulatory bodies such as the US government, the states and the Joint Commission on the
Accreditation of Health care Organizations.
The two major categories of disasters that require an emergency response plan are internal disasters
and external disasters.
Internal disasters are events within the facility that jeopardize the health and safety of patients, staff,
visitors and others. Examples of internal disasters include:

 Fires
 Utility failures
 Workplace violence
 Tornados, cyclones, hurricanes and other severe storms and flooding
 Explosions and bomb threats
 Radiation contamination and
 Acts of terrorism and bioterrorism in the health care facility

External disasters are serious events which occur in the nearby community that leads to mass
causalities and people in need of medical attention and care. A crash of a jumbo jet and a major train
derailment are examples of external disasters.
Tornados, cyclones, hurricanes and other severe storms and flooding are examples of both internal
and external disasters. For example, Hurricane Katrina is an example of a catastrophic event that can
be considered both an internal disaster and an external disaster. It was an internal disaster because
many health care facilities in New Orleans were adversely affected with flooding and power losses. It
was also an external disaster because there were many injured and ill patients in the community that
required the care and services of the health care system.
Other examples of external disasters include acts of terrorism and bioterrorism in the community,
such as the Boston Marathon terrorist bombing and radiation spills and accidents.

Determining Which Client(s) to

Recommend for Discharge in a
Disaster Situation
Nurses use their critical thinking and triage techniques to determine which clients they should
recommend for discharge in the event of an internal disaster and in the event of an external disaster
that will require the reallocation of staff, client beds, and clinical care areas.
In descending order of priority from the most severe to the least severe type of client, the following
clients should be selected for discharge and relocation during an external disaster when unexpected
admissions of victims with varying degrees and severity of injury occur as a result of the massive
casualty event in the community.

 Unstable clients: Unstable clients are the most severe and, as such, are not candidates for discharge or
transfer to another nursing care unit or relocation.

 Stable clients: Stable clients who continue to need nursing and medical care and assistance are the second
priority and, therefore, should not discharged until the lowest priority clients are discharged or
transferred and there is a continued need for more reallocation of resources because higher acuity and
higher priority clients need necessary care and services during the disaster.

 Ambulatory clients and self care clients: Ambulatory clients and self care clients who need little or no
assistance are the first clients to be safely discharged, transferred or relocated.

Identifying Nursing Roles in Disaster

Planning
Nurses, assistive personnel and all other personnel in health care facilities have specific roles in
internal and external disasters, as outlined and detailed in the health care facility's emergency
preparedness and emergency response plans. It is highly important that all staff know their roles and
responsibilities before a disaster occurs because there is little time to read a policy and procedure
when a disaster actually does occur. Immediate and competently executed actions are necessary.
Actions that must be taken for various internal disasters will be discussed now:

Fires and Fire Prevention

Fire prevention in health care facilities includes the education and training of staff, smoke detectors,
sprinkler systems, fire doors and policies and procedures relating to fires and fire threats including
no smoking policies, oxygen and medical gases use, maintenance and storage policies and
procedures, and electrical safety policies and procedures.
The procedure for dealing with and managing patients during a fire is easily remembered with the
acronym RACE. You MUST RACE when a fire starts. RACE includes these elements in correct
sequential order of priority

 R: Step number one is rescue everyone in danger; get all clients and visitors out of danger by following
the fire plan set up and established by the facility you work in.
 A: Step number two is pull the fire alarm
 C: Step number three is to contain the fire in the smallest possible area by closing all windows and
doors. This prevents the fire from spreading to other areas of the health care facility.
 E: Step number four is extinguishing the fire when it is small enough to do so safely.

Step one, which is rescuing everyone in danger, may mean that nurses and other members of the
nursing team must follow instructions for a vertical or horizontal evacuation of patients. When
patients are moved from one level or floor of the health care facility to another floor, it is referred to
as a vertical evacuation; and when you move patients from one area of the floor to another area on
the same floor, it is referred to as a horizontal evacuation. Elevators are never used to evacuate
because elevators are for the exclusive use of fire fighters and the equipment that is necessary to
extinguish the fire.
All medical facilities and households must have fire extinguishers. The different type of fire
extinguishers and their uses will now be discussed.

 A Type A fire extinguisher: A Type A fire extinguisher is used to put out fires on common solid things
like paper, mattresses and cloth including clothing. This type of fire extinguisher is somewhat limited.

 A Type B fire extinguisher: A Type B fire extinguisher is used to fight oil, gasoline and grease fires,
including kitchen grease fires. It too is limited in terms of its use. For example, a Type B fire extinguisher
cannot be used to combat an electrical fire.

 A Type C fire extinguisher: A Type C fire extinguisher is used to extinguish electrical fires

 Type AB fire extinguishers: Type AB fire extinguishers combine the uses of a type A and type B fire
extinguishers. They can be used on solids, like paper, wood, cloth as well as oil, gasoline and grease.

 Type ABC fire extinguishers: Type ABC fire extinguishers are a combination of A, B, and C uses.
They are used for all types of fires. They are the ideal choice for home and in most areas of a health care
facility.

It is required for all fire extinguishers to be checked regularly to insure that they are fully charged
and ready to use in an emergency.
Using a fire extinguisher is quite simple if you remember and use the acronym PASS which is:

 Pull the pin on the fire extinguisher.

 Aim at the bottom of the fire.
 Squeeze the trigger on the fire extinguisher to release the spray and then
 Sweep the spray from side to side over the base of the fire until it is extinguished.
When a person has clothing that has caught on fire, the person should STOP, DROP AND ROLL.
Tell the person, to STOP, DROP, and to not run, and as you also cover the person with a blanket to
smother the fire.
GET LOW AND GO if a room fills with smoke. Smoke and heat rise so get to the floor and crawl
out.

Utility Failures
The major complications of utility failures are the abrupt cessation of electrical power to essential
medical equipment such as a mechanical ventilator, suctioning apparatus and oxygen
supplementation systems as well as a disruption of communication systems. Telephone, fax and
computer abilities are hampered and even the patients' ability to communicate with staff using their
bedside intercom system and their call bell is inactivated when a power outage and electrical systems
fail. When this occurs, the nursing team must continuously visually monitor patients by walking up
and down the hallways and also providing patients with other forms of communication such as a
mechanical bell so that they can continue to alert staff about their needs.

Workplace Violence
Workplace violence can occur among and between workers, patients and visitors. Disturbed,
aggressive behaviors that threaten others must be addressed by deescalating the situation whenever
possible and by preventing these episodes of violence with security measures such as deterring video
surveillance and security guards.
When an episode of workplace violence is possible or actually occurring, the nurse must follow the
procedures that address this internal disaster. The prevention and management of disturbed
behavior will be discussed later in this course with the section entitled "Psychological Integrity".

Weather Related Emergencies

Generally speaking, severe storms such as tornados and cyclones are addressed by moving the
clients and staff to the center of the area away from windows, by closing windows, curtains, and
blinds, by closing interior doors to protect patients from flying debris and by evacuating the area
and/or building when you are officially told to do so.

Explosions
Explosions can occur as the result of both nefarious and accidental means. For example, terrorists
may plant a bomb in the facility and an accidental explosion of a medical gas can also occur.

Bomb Threats
Additionally, bomb threats can be called into the facility. If you receive a bomb threat by telephone,
stay on the line with the person as long as possible while you are alerting others to this threat.
Staying on the line gives you time to collect data and information about the person including their
gender, where and when the bomb is to be detonated, and any background noises that may lead to
the location of the caller.
Radiation Contamination
Radiation contamination can also occur as the result of a nefarious act of terrorism or by accidental
means such as those that may occur in areas such as the nuclear medicine department. All facilities
have policies and procedures relating to exposures to radiation, including those recommended by the
Centers for Disease Control and Prevention (CDC).
The CDC recommends that everyone evacuate the area, remove outer clothing, place clothes in a
plastic bag to contain the radiation, and wash or shower all exposed bodily parts.
Many health care facilities have decontamination areas with showers in the nuclear medicine
department and/or the emergency departments to use in the case of radiation contamination.

Acts of Terrorism
Terrorism, such as what happened with the World Trade Center and the Boston Marathon, is
described as the purposeful and terroristic use of violence and force against people and property.
Terrorism can be done with mechanical means like an airliner or bomb, with chemical, nuclear and
radiological weapons and also with biological pathogens. The latter is referred to as bioterrorism.

Bioterrorism
Agents of bioterrorism, their signs, symptoms and treatments are too complex and extensive to
cover in this review, however, you should be familiar with those that are the most likely. Some of
these agents include anthrax, botulism, plague, smallpox, tularemia and viral hemorrhagic fevers like
yellow fever and Ebola.
General guidelines in terms of responding to a bioterrorism attack include the basic principles of
isolation, standard precautions, cleaning, disinfection and sterilization, as indicated by the
bioterrorist microbe.

The Nurse's Role in Responding to External

Disasters
Health care facilities respond to internal disasters and external disasters that occur as the result of a
mechanical, chemical, nuclear, radiological and biological means. Physical injuries that affect large
numbers of people are triaged according to the severity of their injuries and their prognosis in terms
of certain death or the possibility of sustaining life with treatment. Triage is a method of prioritizing
care during massive external and internal disasters. Color coded tags are often used; these tags alert
the staff to the severity of all arriving victims and their potential for survival.
Triage colored tags that are black identify the expectant group of victims that is expected to die. This
group of victims is given pain medications to provide comfort at the moment and no other further
treatments until the red colored tagged clients' needs are addressed. Red colored triaged tags are the
immediate care group that requires immediate medical attention for life threatening injuries. This
group has a greater possibility of survival than the black tagged group. The yellow triage color
indicates that treatment can be somewhat delayed until the red group's needs are addressed. This
group is referred to as the yellow tagged group. Lastly, the green triage group, referred to as the
minimal care group, has only minor injuries. Like the yellow group, their needs can be delayed until
clients with greater needs have been treated.

Using Clinical Decision Making and

Critical Thinking for Emergency
Response Plans
Professional judgment, critical thinking and sound decision making are some of the essential skills
that the registered nurse must readily and competently use in terms of their responses to internal and
external disasters.
For example, the registered nurse utilizes professional judgment, critical thinking and sound decision
making when they:

 Triage clients
 Recommend the transfer or discharge of clients during an emergency
 Lead and direct others with authoritarian leadership to insure the safety of clients, staff and visitors
 Perform their other roles and responsibilities relating to internal and external disasters

Implementing Emergency Response

Plans
Nurses must be highly prepared to fulfill their roles and responsibilities in terms of all internal and
external disasters including those just discussed.
One way to prepare is to review the policies and procedures relating to your role on a regular basis
and another way to prepare is by participating in mock drills and practices within the organization.
Some facilities have secret code names for disasters and other emergencies. These secret code
names, like Code Blue for a cardiac arrest, communicate the nature of the emergency or disaster to
staff without alarming patients, visitors and others who are not staff. Whenever you hear this
announcement you must act as if it is a real emergency rather than taking it lightly. If you learn later
that it was a drill, you have gotten the opportunity to practice and if you later learn that this
announcement indicated a real emergency, you have acted in a way that you should have to fulfill
your assigned roles and responsibilities.
In addition to Code Blue for a cardiac arrest, many facilities also use Code Red for fire, Code Gray
for a severe weather storm, cyclone or hurricane, Code Orange for a chemical spill and Code Pink
for an infant abduction.
Participating in Disaster Planning
Activities and Drills
All nurses, including registered nurses, and other health care professionals play an important role in
internal and external disasters and emergency preparedness. Registered nurses are also frequently
asked to participate as a member of a work group or committee in order to generate, evaluate and
revised internal and external disaster plan and also to:

 Educate staff and clients in relationship to their roles during a disaster or emergency
 Participate in ALL disaster and emergency practice drills
 Participate in the planning. Implementation and evaluation of disaster and emergency practice drills

The Joint Commission on the Accreditation of Health Care Organizations and other regulatory
bodies mandate that all health care facilities have emergency response plans and that these plans are
taught and evaluated with drills and testing at least twice a year.

Ergonomic Principles:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of ergonomic principles in order to:

 Assess client ability to balance, transfer and use assistive devices prior to planning care (e.g., crutches,
walker)
 Provide instruction and information to client about body positions that eliminate potential for repetitive
stress injuries
 Use ergonomic principles when providing care (e.g., assistive devices, proper lifting)

Ergonomics is a scientific discipline that addresses the human being in the environment to facilitate
human wellbeing. For example, an ergonomically designed computer mouse and ergonomically and
anatomically correct chairs that curve to conform to our normal lumbar curve are examples of
ergonomic principles applied to products that are used in the home and the workplace.
Body mechanics is the safe use of the body using the correct posture, bodily alignment, balance and
bodily movements to safely bend, carry, lift and move objects and people. An example of a good
body mechanics principle is to push rather then pull objects and people.
Nurses must apply the principles of ergonomics and well as body mechanics in their personal and
professional life.

Assessing the Client Ability to

Balance, Transfer and Using Assistive
Devices Prior to Planning Care
Upon admission, and whenever a significant client change occurs, the client's ability to balance,
safely transfer and use assistive devices is assessed and then incorporated into the client's plan of
care. As previously discussed in terms of falls and fall prevention, the nurse assessing the client may
determine that the client is at risk for falls because they lack the muscular strength, coordination,
and/or balance to do so in a safe manner and without injury to self and the staff that are performing
care.
In addition to increasing the client's muscular strength, coordination, and/or balance, nurses, often
in collaboration with a physical therapist and other health care providers, nurses assess the client's
ability to safely use an assistive device such as a walker or a cane to facilitate their movement and
ambulation.

Providing Instruction and

Information to Client about Body
Positions that Eliminate the Potential
for Repetitive Stress Injuries
In addition to the fact that health care staff must be knowledgeable about and use good body
mechanics and ergonomic principles, clients also need knowledge and skill in content areas including
body position, proper bodily alignment and ways to prevent repetitive stress injuries.
Some of the common used, anatomically correct positions that are used by patients in bed are the
Fowler's position which is a sitting position with the head of the bed elevated, the dorsal recumbent
position and supine positions which are lying on the back with or without a pillow for the head, the
prone position on the stomach, the lateral position which is a side lying position with the upper
most knee bent and often maintained in that position with a pillow, and the Sim's position which is a
semi prone position.
Repetitive stress injuries, simply defined, are injuries that lead to muscular and neurological pain and
discomfort, stiffness, and cramping as the result of repeated and repetitive movements and other
things that lead to the overuse of a muscle or muscle group. The most often affected muscles and
muscle groups include those of the wrist, forearm, elbow, fingers, hands, neck and shoulders.
Some of the activities and conditions associated with repetitive stress injuries include:

 Prolonged and intense activity without taking a break from it

 Poor posture and poor bodily alignment
 Stress
 Cold ambient temperatures

Using Ergonomic and Body

Mechanics Principles When Providing
Care
Body mechanics is the safe use of the body using the correct posture, bodily alignment, balance and
bodily movements to safely bend, carry, lift and move objects and people.
Safe patient handling and the application of the principles of body mechanics protect the patient and
they also protect the nurse. Patients benefit because they are being lifted and transferred by one or
more people who are using the strongest muscles of the body and nurses benefit because they have
avoided patient injury and they have also protected themselves from sometimes severe and
permanent injuries, particularly to their back, which can sometimes cease the nurse's ability to return
to nursing.
In addition to getting the assistance of another or using a mechanical life, nurses should follow these
principles of safe patient handling and body mechanics.

 Take the time to do a little bit of muscular warmup and stretching before you attempt to lift or transfer a
person or object.
 Think about and plan your approach before you attempt to do it.
 Explain what you will be doing and how you will perform the lift or transfer to the client. Instruct the
patient about what you and they will be doing. For example, tell the patient to bend their knees and press
their feet into the mattress and, then on the count of three, tell the patient that they should push up to
the top of the bed as you assist them. Even very weak patients can help you with a lift or transfer when
they know what you are about to do and how they can help you.
 Remain as close to the person or the object, such as a large box, when you are about to lift it and while
you are lifting.
 Face the person or object that you are about to lift.
 Keep your spine, neck and back straight and aligned throughout the lift or transfer. Do not twist.
 Tuck your chin in and keep your neck and head aligned.
 Maintain a wide and secure base of support by keeping your feet apart.
 Pivot on your feet in the direction of the move and not against it.
 Get a secure and good grip on the object or person that you are about to lift.
 Use the long and strong muscles of your arms and legs to lift. Do NOT use back muscles and.
 Use slow, smooth and non-jerky movements.

If your facility requires the use of a back support and/or you choose to use it, please understand that
these back supports are useful, however, they will not protect you unless you also use good body
mechanics.
There are a number of assistive devices that can be used to safely lift and transfer patients.
Mechanical lifts are used mostly for patients who are obese and cannot be safely moved or
transferred by two people, and also for patients who are, for one reason or another, not able to
provide any help or assistance with their lifts and transfers, such as a person who is paralyzed.
A gait or transfer belt is also used to assist with transfers and lifting. These wide and sturdy belts are
placed around the patient's waist when they stand, transfer and ambulate. They are very often also
used for physical therapy.
Slide boards are particularly useful to move a patient from one flat surface to another. These boards
reduce friction and, therefore, make the move easier and less irritating to the patient's skin.

Handling Hazardous and

Infectious Materials:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of handling hazardous and infectious materials in order to:

 Identify biohazardous, flammable and infectious materials

 Follow procedures for handling biohazardous materials
 Demonstrate the safe handling techniques to staff and client
 Ensure safe implementation of internal radiation therapy

Hazardous materials are defined as those things that are not biological but still remain hazardous to
human beings including patients and staff. Examples of hazardous materials are chemicals and
radiation.
The US Occupational Safety and Health Administration mandates that information about all
hazardous materials is readily accessible to workers including those who work in the health care
environment. Information about hazardous materials is found on Material Safety Data Sheets which
are published and distributed to the users of their products to fulfill the mandates of OSHA and to
protect workers.
Material Safety Data Sheets (MSDS) include the name of the product, information about the
product's risks, measures, such as washing the skin, that must be taken when a person has been
exposed to some risk relating to the product and information about the procedures for using,
handling, disposing of and storing the particular product.
Biohazardous waste is defined as biological waste that can be hazardous to humans. Items such as
sharps and bed linens that are contaminated with blood or other bodily fluids, such as feces, are
considered biohazardous medical waste.
The careful handling and disposal of all hazardous materials protects staff, clients, and visitors from
harm.

Identifying Hazardous Biohazardous,

Flammable and Infectious Materials
Biohazardous Materials
Biohazardous materials are heavily regulated at the national, state and local levels. All health care
facilities, therefore, are legally mandated to have complete and appropriate policies and procedures
relating to the labelling, storage, use and disposal of biohazardous, or biomedical, materials.
Biohazardous materials place clients, staff and visitors at risk for exposures to bloodborne
pathogens and pathogens transmitted with bodily fluids.

Flammable and Combustible Materials

Examples of some of the flammable and combustible materials that are commonly used within
health care settings and facilities are medical gases, such as oxygen and nitrous oxide, flammable and
combustible liquids such as those contained in some cleaning fluids and aerosol cans.

Following Procedures for Handling

Biohazardous Materials
Biohazardous materials threats can be decreased and eliminated with a combination of
administrative controls, work related controls and engineering controls.
Established policies and procedures are examples of administrative controls to decrease the dangers
associated with biohazardous materials risk; the utilization of proper and safe practices such as
handwashing is an example of a work related control that decreases the threats associated with
biohazardous materials; and engineering controls aim to decrease the dangers associated with
biohazardous materials and these controls include such things like the selection of and placement of
impervious red containers in all client rooms to collect disposable, contaminated sharps.
Some of the other preventive measures relating to biohazardous exposures include:

 The use of single patient disposal supplies and equipment such as a disposable, single use blood pressure
cuffs
 Needleless systems
 Proper handwashing
 Standard and special transmission precautions
 Red biohazardous waste containers and bags
 The use of personal protective equipment
 The use of a neutral zone in surgical areas and other areas where invasive procedures are done
 The safe disposal of sharps not only in health care facilities but also in the client's home and their
community

The U.S. Environmental Protection Agency mandates the safe disposal of needles, syringes and
other sharps in all areas of the community, in addition to their proper and safe disposal by health
care facilities.
The proper and safe disposal of biohazardous material in the community includes:

 Community Drop Boxes and Supervised Collection Sites: The client can dispose of used needles in
many doctors' offices, hospitals, pharmacies, health departments, and fire stations.

 At-Home Needle Destruction Devices: At home needle destruction devices destroy used needles and,
as such, make them safe for household disposal. Clients in the home should be instructed to contact their
solid waste disposal company for specific local information and resources relating to sharps disposal.

 Syringe Exchange Programs: Sharps users can also safely exchange used needles for new needles by
contacting the North American Syringe Exchange Network at (253) 272-4857 for no cost. The site
is www.nasen.org

 Mail-Back Programs: Sharps can also be disposed of by mailing them in a special container to a
collection center for a fee.
Following Procedures for Handling
Flammable and Combustible
Materials
Flammable and combustible medical gases can be stored in individual canisters or provided to the
client care area with a centralized medical gas delivery system. Emergency shut off valves are
mandated for centralized medical gas delivery system in the case of an emergency.
Medical gas containers must be designed, constructed, and labeled according to OSHA regulations.
The following color labels are used for the following gas canisters.

 White: The international color for oxygen

 Yellow: Air
 Green: Oxygen
 Light Blue: Nitrous oxide
 Red: Ethylene
 Orange: Cyclopropane
 Brown: Helium
 Brown and Green: Helium and oxygen
 Gray: Carbon dioxide
 Gray and Green: Carbon dioxide and oxygen

Oxygen Safety
Oxygen safety in the health care setting and within the home environment includes the use of a "No
Smoking" signs, avoiding all synthetic fibers and fabrics near the oxygen because fabrics and fibers
other than cotton can create static electricity, and not using any flammable liquids like acetone near
the oxygen source.
In the health care facility and also within the home oxygen canisters must be safely secured and
transported.
Educating and Demonstrating Safe
Handling Techniques to Staff and
Clients
The registered nurse, as an educator, must assess the learning needs of clients and staff members in
terms of their ability and competency related to the safe handling and management of biohazardous
materials and materials that are flammable or combustible.
For example, clients and staff should have a thorough understanding of and knowledge about types
of things that are considered biohazardous and they should also demonstrate the proper, safe and
correct techniques related to the correct handling and disposal of sharps and other biohazardous
waste.

Ensuring the Safe Implementation of

Internal and External Radiation
Therapy
Radiation therapy can be broadly categorized as external and internal radiation therapy.
Radiation safety is based on the three safety principles of time, distance and shielding. In other
words, the risk of exposure to internal and external radiation can be decreased when the nurse, and
other health care personnel such as an X ray technician, minimize and decrease the amount of time
that they are exposed to and in close proximity with radiation; they must also maximize the distance
between themselves and the source of the radiation, and, they must also shield themselves from the
radiation using things like a lead apron and gloves when they are near the source of radiation.
The risk for exposures to radiation decreases when the duration of the time exposed to the radiation
is decreased and when the distance from the radiation and the shielding is maximized.
External ionizing radiation is used for diagnostic testing and also for therapeutic care. For example, a
chest x ray uses radiation for diagnosis and therapeutic external radiation, sometimes referred to as
teletherapy, is done by using a linear accelerator that delivers electron and gamma ionizing radiation
for a minute or so to treat and reduce the size of a tumor.
Therapeutic internal radiation, which is also referred to as brachytherapy, internal radiation,
interstitial radiation and intracavity radiation, is a therapeutic procedure that entails the internal
placement of some radioactive material into or near the client's tumor. Therapeutic internal radiation
entails the delivery of high doses of radiation using a needle, wire or radioactive seed.
Brachytherapy is most often delivered to clients who are affected with tumor and cancer of the
prostate, lungs, esophagus, cervix, endometrium, rectum, breast, head and neck.
Special radiation precautions are initiated when a client is receiving brachytherapy in order to protect
visitors and health care staff from the harmful effects of the radiation. Some of these special internal
radiation precautions include:

 The minimization of the duration of time that health care providers are in the client's room to deliver
care and services to the client

 The placement of the client receiving internal radiation in a private room

 The prohibition of the client's activities outside of their room

 The initiation of complete bed rest for the client until the treatment is discontinued

 The provision of education to the family members and other visitors that includes information about
their need to limit the time of their visits to at least less than 1 hour, to stay at least 6 feet away from the
client and to not enter the room if a visitor or family member is pregnant.

 The need for health care staff to minimize the amount of time spent in the room, to decline to enter the
room if they are pregnant, to retain all supplies and equipment including things like bed linens in the
client's room until they are deemed safe for disposal by a person who is competent to make this decision,
and how and when to report concerns about the client's treatment such as when implanted seeds
inadvertently leave the client's body.

Home Safety: NCLEX-RN

In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of home safety in order to:

 Assess the need for client home modifications (e.g., lighting, handrails, kitchen safety)
 Apply knowledge of client pathophysiology to home safety interventions
 Educate client on home safety issues
 Encourage the client to use protective equipment when using devices that can cause injury (e.g., home
disposal of syringes)
 Evaluate the client care environment for fire/environmental hazard
Assessing the Need for Client Home
Modifications
Registered nurses and other health care providers such as physical therapists and discharge planners
are responsible for and accountable for a complete, timely and accurate assessment and reassessment
of the home relating to safety concerns. When a safety concern is assessed, these health care
providers must recommend corrective actions, some of which can include recommendations to
modify and change the home environment.
Nurses must insure the safety of all clients regardless of the setting where health care services are
rendered to the client.
Some of the assessed safety needs and concerns arise from extrinsic, environmental factors and
forces, and others arise as the result of the client's intrinsic characteristics and needs. For example,
environmental factors and forces that impact on patient safety can include the lack of adequate
lighting and grab bars in the home, and intrinsic factors and forces that impact on patient safety can
include the client's pathophysiology and the client's decreased level of awareness and insight into
safety and their safety needs.
Other intrinsic factors that can impact the client's safety in the home include the client's age, the
client's level of growth and development, the client's sensory and perceptual abilities, the client's
compromised level of functioning and independence, and the client's level of cognitive functioning.
In addition to being aware of these intrinsic and extrinsic factors and forces and assessing the client's
safety needs, nurses who provide care in the home must ensure that emergency phone numbers are
readily accessible.
Some of the most commonly identified safety needs of clients in the home are things that will be
assessed

 The level of lighting

 Food safety
 Oxygen use
 Carbon monoxide
 Emergency alert systems
 Household cleanliness and sanitation
 Electrical safety
 Emergency evacuation
 The presence of handrails and other assistive hardware
 Other environmental hazards
The Level of Lighting
The adequacy of lighting is assessed in order to determine whether or not the lighting within the
client's home and in its exterior areas are safe and conducive to safety particularly in areas such as
the bathroom, the client's bedroom and the exterior exits and driveway, for example.

Food Safety
Food borne illnesses are a safety risk to clients, particularly when the client is adversely impacted
with a physical pathophysiologic disorder such as immunocompromised, a normal development
deficit such as an undeveloped immune system among infants, a normal developmental condition
such as pregnancy, and a normal age related change related to the elderly population such as a
diminished immune system. The most commonly occurring pathogenic microorganisms associated
with food borne illnesses are Escherichia coli and salmonella.
Some of the preventive measures to insure food safety in the home include:

 Proper handwashing when handling food and when preparing meals

 Discarding all expired food products including fresh, frozen and canned foods
 Handling raw meats and fish separately. For example, different cutting boards and utensils should be
used for fish and meats.
 Cooking meat and fish to the proper temperature
 Following FIFO rule which is First In is First Out. In other words, the first foods in the pantry or
refrigerator are the first foods that should be consumed or discarded.

Oxygen Safety
Oxygen use and oxygen therapy safety were previously discussed above with the section entitled
"Following Procedures for Handling Flammable and Combustible Materials".

Carbon Monoxide
Carbon monoxide poisoning can occur when a person is exposed to an excessive amount of this
odorless and colorless gas. Carbon monoxide poisoning severely impairs the body to absorb life
sustaining oxygen. This oxygen absorption deficit can lead to serious tissue damage and death.
The greatest risk factors associated with carbon monoxide poisoning are automobiles that are
running in an enclosed area such as a garage and buildings including private homes, and the absence
of relatively inexpensive carbon monoxide alarms that detect high levels of carbon monoxide in the
environment.
The signs and symptoms of carbon monoxide poisoning include weakness, a dull headache,
shortness of breath, confusion, blurred vision, nausea, vomiting, dizziness, and loss of
consciousness. People who are sleeping or otherwise unaware of these symptoms and their causes
are in the greatest danger.
The treatment for carbon monoxide poisoning can include the removal of the person to an outdoor
space that is not affected with the carbon monoxide, the administration of pure oxygen through a
face mask or a mechanical ventilator, and hyperbaric oxygen therapy depending on the extent of the
poisoning and the condition of the client.

Emergency Alert Systems

Emergency alert systems including the appropriate number and placements of smoke alarms and,
ideally, a carbon monoxide alarm, should be in the client's home. Batteries for smoke alarms and
carbon monoxide detection devices must be changed at least every six months. Many people are
reminded to do so when the clock moves forward or backward one hour during the spring and the
fall.

Household Cleanliness and Sanitation

Household cleanliness and sanitation are assessed and addressed in order to protect the client from
commonly occurring infections and disorders that can occur when the home is dusty, dirty, filled
with grime and affected with insect and/or vermin infestation.

Electrical Safety
The home is assessed for frayed wires, overloading of electrical sockets and other electrical hazards
such as electrical items in the presence of water, the absence of ample and working smoke alarms
and the absence of a fire extinguisher. The Immediate correction of all electrical hazards must be
implemented as soon as they are discovered.

Emergency Evacuation
Emergency evacuation plans and the preparedness of clients and their family members to evacuate
are assessed by the nurse. Clients and family members must be knowledgeable about an emergency
evacuation when the interior of the home is adversely affected with smoke, a fire or the presence of
carbon monoxide, for example; and they should also be knowledgeable about an emergency
evacuation should an event such as a tornado, hurricane, flooding, and a utility failure threaten their
level of safety. For these circumstances, the client and family members must be thoroughly
knowledgeable about emergency evacuation shelters that meet their needs. For example, clients who
perform home peritoneal dialysis need a special emergency evacuation shelter that has the electricity
needed to continue these lifesaving treatments when emergency evacuation from the home is
necessary.

The Presence of Handrails and Other Assistive

Hardware
Many home care clients have weakness and functional impairments so the home is assessed for the
presence of the necessary assistive devices and hardware such as raised toilet seats, handrails, grab
rails, and other devices, to promote safety and prevent falls. Additionally, a falls alert system should
be worn by clients who are at risk for fails, particularly when they live in the home alone and without
a care giver.
Other Environmental Hazards
Other environmental safety hazards include clutter, obstructed areas, the use of unsafe scatter rugs,
and the presence of chemicals and poisons that could accidentally be consumed by unaware young
children and adults who are affected with a cognitive deficit.

Applying a Knowledge of Client

Pathophysiology to Home Safety
Interventions
As the home is being assessed, the registered nurse will apply their professional judgment, their
critical thinking and decision making skills to the safety needs of the client, some of which result
from some client pathophysiology such as diseases, disorders and disabilities that impact on home
safety and the safety of the client.
For example, chemicals such as those contained in many cleaning solutions and medications are
particularly dangerous to clients in the home who are affected with a developmental or cognitive
deficit; clients with impaired auditory senses or perceptual deficits may need an additional visual alert
for smoke alarms over and above the sound of an alarm, and clients with visual impairments and
deficits need a large print list of emergency contact telephone numbers.

Educating the Client on Home Safety

Issues
As with all aspects of care, nurses must determine the client's level of understanding in terms of
home safety needs. Teaching should occur when a learning need has been identified.
For example, when a home care patient tells you that he warms his car up in the garage for a half
hour before getting into it so it will not be cold, it is apparent that this client is not knowledgeable
about the dangers of carbon monoxide and how it builds up in garages when cars are left running in
this enclosed place.
Nurses educate clients and family members about home safety concerns and recommend and/or
assist the client in correcting all safety hazards in the home. It is also helpful to provide the client
with
written/printed home safety instructions. Some of the information that you provide to the client, in
addition to the safety hazards just discussed, includes community specific information about such
things as the local evacuation route and emergency shelters that can be utilized by the patient as
based on their health care needs.
Encouraging the Client to Use
Protective Equipment When Using
Devices That Can Cause Injury
Some examples of these techniques and protective equipment when using devices that can cause
injury include the safe disposal of sharps when the client is taking injections in the home, such as
insulin, using clean medically aseptic gloves when changing a wound dressing, and wearing safety
googles when mowing the law or performing another task that could lead to eye injuries.

Evaluating the Client Care

Environment for Fire and
Environmental Hazards
Some of the elements that are assessed and evaluated for fire and environmental hazards, as more
fully discussed above, include:

 Smoke alarms
 Carbon monoxide alarms
 Electrical hazards, such as frayed electrical cords
 The level of lighting
 Food safety
 The safe use of oxygen
 Household cleanliness and sanitation
 The presence of handrails and other assistive hardware
 The absence of tripping hazards such as clutter and scatter rugs
Reporting Incident, Event,
Irregular Occurrence,
Variances: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of reporting incident, event, irregular occurrence, and variance in order to:

 Identify need/situation where reporting of incident/event/irregular occurrence/variance is appropriate

 Acknowledge and document practice error (e.g. incident report for medication error)
 Evaluate responses to error/event/occurrence

Identifying the Need or Situation

Where Reporting of an Incident,
Event, Irregular Occurrence or
Variance is Appropriate
All incidents, events, irregular occurrences, and variances must be identified and reported according
to the particular health care facility's policies and procedures. The purpose of this reporting is to give
the health care facility and the health care professionals the opportunity to address the issue and
prevent the occurrence of future incidents, events, irregular occurrences, and variances. The data
collected on these reports is analyzed, tracked and trended over time in a blame free environment
that is consistent with the health care facility's culture of safety.
Nurses must immediately report all client care issue, concern or problem to the supervising nurse,
the charge nurse and/or the performance improvement or risk management department according
to the reporting policies and procedures of the particular facility.
Generally speaking, all incidents, accidents, adverse events, irregular occurrence and variances
require the completion of a written report that will be sent to the risk management and/or
performance improvement department as per the specific facility's established policies and
procedures.
Simply stated, incidents, accidents and events that must be reported and documented include
occurrences that are not expected, not normal, irregular and potentially or actually harmful to the
patient, staff, visitors and others.
Variances, or deviations from practice, that lead to a quality defect or problem are reported.
Variances can be classified as a practitioner variance, a system/institutional variance, a patient
variance, a random variance and a specific variance.
A practitioner variance is an irregularity that is associated with the care and/or service provided by a
health care provider. For example, an untimely medical assessment upon admission is considered a
practitioner variance.
A system/institutional variance is an irregularity that is associated with the care and/or service given
by the facility. For example, the lack of necessary supplies and equipment to adequately and safely
care for patients and the lack of staff education and competency validation are considered
system/institutional variances.
A patient variance is an irregularity that is associated with the patient themselves and not the health
care provider or the facility. For example, the development of a pressure ulcer secondary to the
patient's immobility and poor nutritional status is an example of a patient related variance.
Information that is typically reported on a formal incident or accident report includes:

 The date, time and place of the incident or accident

 Clear, concise and objective data about the occurrence and any surrounding factors, like a wet floor, that
may have led to the incident or accident
 The name of the person or persons who was affected with the incident or accident
 The names of any witnesses
 Any injuries that were sustained as a result of the incident or accident
 All care and treatment s that were provided to the person who was adversely affected with an incident or
accident
 The names of people, such as the client's doctor, that were contacted and notified about the incident or
accident

These reports are forwarded to the correct person, as indicated in the facility's policies and
procedures. They are not put in the client's medical record nor mentioned in the client's medical
record. These legal documents are considered confidential.
Acknowledging and Documenting a
Practice Error
As previously discussed with "Performance Improvement", all medical errors and "near misses", or
sentinel events, such as wrong site surgery, wrong patient surgery and medication errors must be
recognized, documented and reported.
Historically, incidents and accidents are under reported. This under reporting results from a number
of factors including the fact that the nurse, or another practitioner, does not know that they have
performed a practice error, or the person fails to report the practice error because they have a fear of
being blamed and penalized for the error, or they simply just do not want to take the time to follow
the health care facility's policies and procedures relating to the reporting of incidents, accidents and
practice errors.
In addition to reporting all medical errors, the nurse must assess the client's condition, render the
care that the client needs as the result of the injury or accident, and also document the client's
responses to these interventions.

Evaluating The Client Responses to

An Error, Event or Occurrence
Whenever an error, event or irregular occurrence occurs, the nurse must immediately assess the
client and their responses to it and provide the care that is indicated by the client's condition. For
example, the client will be assessed for their neurological status and level of consciousness after a fall
when it is possible that the client hit their head on the floor as a result of the fall.
The priority when an error, adverse event, occurrence or variance occurs is the patient and their
physical as well as psychological health and wellbeing. After the priority needs of the affected patient
are addressed, the nurse should complete the necessary reporting and documented. The priority is
the patient at the time of an error, adverse event, occurrence or variance that leads to harm and/or
potential harm.

Safe Use of Equipment:

NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of safe use of equipment in order to:
 Inspect equipment for safety hazards (e.g., frayed electrical cords, loose/missing parts)
 Teach client about the safe use of equipment needed for health care
 Facilitate the appropriate and safe use of equipment
 Remove malfunctioning equipment from client care area and report the problem to appropriate
personnel

Inspecting Equipment for Safety

Hazards
Equipment safety and the safe use of equipment is dependent upon both user safety and equipment
safety.
User safety can be insured when all users of equipment, including nurses, are instructed on proper
use and all pieces of equipment and then they are then deemed and validated as competent to
correctly and safely use a piece of equipment PRIOR to using it without direct supervision and
guidance.
User safety is also insured when the health care provider asks for the assistance of another and their
reinstruction when they believe that they are not competent to use a specific piece of equipment as
well as when they inspect the equipment prior to using it with a patient.
Some of the safety inspection components include the inspection of the piece of equipment for
frayed cords, malfunctioning, missing and/or loose parts, and documented evidence of preventive
maintenance and safety inspections by those who perform these tasks.
All equipment that is even possibly unsafe or questionably safe must be immediately taken out of
service and sent to the department that is responsible for insuring its safety.
All health care facilities have established protocols and procedures for the safe use of equipment
which include staff education, competency validation, preventive maintenance, and safety
inspections.
Most health care facilities prohibit the patient's use of their own equipment like a radio, television or
electric razor; others permit it but only after it has been inspected and deemed safe by personnel
who have the knowledge and skills to do so. These personnel do not include nurses. This inspection
is typically done by the maintenance or equipment department.
Teaching the Client About the Safe
Use of Equipment Needed for Health
Care
Clients, in addition to staff, must be educated about the safe use of equipment, particularly when
they are performing self care in the home using medical equipment.
Safe and effective equipment such as electrical oxygen supplementation therapy and continuous
passive motion devices, in addition to nonelectrical equipment such as walkers, canes and other
mobility aids, must be safe and deemed safe prior to use.
The rubber tips on a walker, cane and crutches should be inspected often. All tips that are uneven or
worn out must be replaced immediately; preventive maintenance is done by replacing all tips at least
one a month even when they are not worn out.
Clients, in addition to staff, must also be educated about the safe use of equipment, particularly
when they are performing self care in the home.

Facilitating the Appropriate and Safe

Use of Equipment
The appropriate and safe use of equipment can be facilitated with:

 The complete education and training of all users

 Validated and documented competency to use any and all pieces of equipment by a person qualified to
do so
 Preventive maintenance
 The removal of all unsafe equipment from service
Removing Malfunctioning Equipment
from the Client Care Area and
Reporting the Problem to the
Appropriate Personnel
As stated immediately above, unsafe items must be immediately removed from the client care area
and then reported and returned to the department, such as the biomedical department, that ensures
equipment safety. It is also recommended that items that are questionably safe also removed and
returned so that those who are more knowledgeable than the nurse can inspect them and validate
their safety.

Security Plans: NCLEX-RN

In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of security plans in order to:

 Use clinical decision making/critical thinking in situations related to security planning

 Apply principles of triage and evacuation procedures/protocols
 Participate in institution security plan (e.g., newborn nursery security, bomb threats)

Using Clinical Decision

Making/Critical Thinking in
Situations Related to Security
Planning
Clinical decision making and critical thinking skills are utilized by the registered nurse who
participates in security plans, the execution of security drills, and the evaluation of the successes, or
the lack thereof, associated with security plans and responses to security threats and breaches.
Safety and security are closely aligned. Health care facilities have security plans, as mandated, similar
to the necessity for emergency preparedness plans. Security plans are consistent with the regulations
and recommendations of the Joint Commission On the Accreditation of Health care Organizations,
The Centers for Medicare and Medicaid and the International Association for Health care Security
and Safety.
Some of the most commonly occurring security risks in health care facilities include infant
abduction, client elopement, the entry of dangerous and violent people into the health care setting,
computer hacking and information/data theft.
Although health care facilities can vary somewhat in terms of their security and security plans, some
of the commonly used security measures that are used in health care facilities include:

 Security alert systems to alert staff to a security breach such as code pink when an infant abduction has
occurred
 The use of staff identification badges and visitor identification badges that identify people who are
authorized to be in a facility
 Closed circuit monitoring and alarm systems in high risk areas such as the emergency care area
 Security doors
 Special assignments and training for a group of people so that this specially trained group can act when a
security breach occurs. For example, a psychological crisis team may be trained and assigned to act when
a psychologically impaired person is violent towards other clients, staff or visitors
 Electronic methods and devices, such as an electronic wristband, for the newborn and the mother to
prevent successful infant abductions
 Procedures to follow in the event of a security threat such as a bomb threat or an active shooting event
that may lead to the evacuation of clients and others

Nurses must be fully knowledgeable about security plans and their assigned responses to security
threats so that they can act rapidly and with delay.
Even though preventive security measures, such as secured and alarmed doors and staff
identification badges, are routinely used, there are times that these serious and dangerous events
occur.
Similar to emergency preparedness plans, all nurses must be prepared to act with security threats and
security breaches. One way to prepare is to review the policies and procedures relating to your role
on a regular basis and another way to prepare is by participating in mock drills and practices within
the organization.

Applying the Principles of Triage and

Evacuation Procedures/Protocols
In descending order of priority from the most severe to the least severe type of client, the following
clients should be selected for discharge and relocation. The need for this may occur, for example,
when a shooter is loose in the building and on a rampage.
 Medical unstable and unpredictable critical care patients are the most severe of all patients. They are not
candidates for discharge and relocation except under highly severe and threatening intra facility crises.

 Stable clients who need assistance are the second priority and, therefore, not discharged until the lowest
priority clients are discharged

 Ambulatory clients who need no assistance are the first clients to be safely discharged and relocated.

Participating in the Institution's

Security Plans
Similar to emergency preparedness plans, all nurses must be prepared to act with security threats and
security breaches. One way to prepare is to review the policies and procedures relating to your role
on a regular basis and another way to prepare is by participating in mock drills and practices within
the organization.

Standard Precautions,
Transmission Based,
Surgical Asepsis: NCLEX-
RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills standard precautions, transmission-based, and surgical asepsis in order to:

 Assess client care area for sources of infection

 Understand communicable diseases and the modes of organism transmission (e.g., airborne, droplet,
contact)
 Apply principles of infection control (e.g., hand hygiene, surgical asepsis, isolation, sterile technique,
universal/standard precautions)
 Use an appropriate technique to set up a sterile field/maintain asepsis (e.g., gloves, mask, sterile supplies)
 Follow correct policy and procedures when reporting a client with a communicable disease
 Educate client and staff regarding infection control measures
 Utilize appropriate precautions for immunocompromised clients
 Evaluate infection control precautions implemented by staff members
 Evaluate whether the aseptic technique is performed correctly

Some of the commonly used terms and terminology associated with infection control include those
relating to the chain of infection, the modes of transmission of infectious microorganisms, asepsis,
types of infection, and personal protective equipment. Read more about cleaning, disinfection, and
sterilization.

 The chain of infection includes the infectious microorganism, the reservoir or location where the
pathogen lives, the port of exit from the reservoir, the mode of transmission from the reservoir, the
portal of entry into the person, or host.

 Airborne transmission is defined as the mode or means with which a microorganism is moved and
transmitted via air and inhaled into the respiratory tract by the susceptible host. These infections are
found in droplets and dust in the air. Airborne precautions are indicated in the presence of a pathogen
that is transmitted via the airborne mode of transmission.

 Contact transmission is defined as the mode or means with which a microorganism is moved and
transmitted via direct or indirect contact with the infected person or an object that has been
contaminated with the pathogen, respectively. Indirect contact transmission is sometimes referred to as
vehicle-borne transmission. Contact precautions are indicated in the presence of a pathogen that is
transmitted via contact transmission.

 Vector-borne transmission is defined as the transmission of a pathogen from an animal or insect to a

human being.

 Transmission based precautions are special measures that are put in place to prevent the spread of
infection. Transmission based precautions are based on the pathogens mode of transmission. Examples
include contact and airborne precautions.

 Standard precautions are measures that are used to prevent the spread of infection among all patients
whether or not they have a known infection. Standard precautions protect health care workers and
patients from the spread of infection secondary to contaminated blood and other bodily fluids.

 Asepsis is defined as not septic, that is, asepsis is the absence of disease-causing organisms. The two
types of asepsis are medical asepsis and surgical asepsis.
 Medical asepsis is defined as the absence of disease-causing microorganisms. Medical asepsis is often
referred to as clean which is more than sanitary. Medically aseptic techniques are used to maintain
medical asepsis.

 Surgical asepsis is defined as the absence of all microorganisms. Surgical asepsis is often referred to as
sterile. Surgically aseptic techniques are used to maintain sterile asepsis.

 Contaminated is defined as some contact with a microorganism. Sterile items and clean or medically
aseptic items are contaminated differently. A medically aseptic item is contaminated with it comes in
contact with pathogenic microorganisms and sterile items become infected when they are touched with
any item that is not sterile.

 Decontamination, according to OSHA, is defined as "the use of physical or chemical means to remove,
inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer
capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or
disposal."

 Disinfection is defined as the destruction of pathogens, but not spores, using a chemical or physical
means of disinfection.

 Sterilization is defined as the process with which all pathogens including spores are destroyed.
Sterilization can be done with moist heat, a combination of heat and pressure, gas, radiation, and boiling
water.

 An antiseptic is a germicidal solution that inhibits the growth of some microorganisms. Examples of
antiseptics include hexachlorophene, iodine, alcohol, and antiseptic hand washes. Many can be used
directly on the skin.

 Healthcare-associated infection is any infection that occurs during the time that the patient is being cared
for in a health care facility. Most of these infections are infections of the urinary tract.

 Iatrogenic infections are those that occur as the result of some diagnostic test or therapeutic procedure.
For example, atelectasis after a diagnostic bronchoscopy is an iatrogenic infection.

 Occupational exposure is an exposure to a pathogen by a health care worker during their course of work.

 Post-exposure prophylaxis is the prevention of an infection after an individual has been exposed to it.
 Personal protective equipment (PPE) is specialized equipment and attire that is used by employees in
health care to protect against infections. Examples of personal protective equipment include gowns,
gloves, masks, goggles, and respirators.

Assessing the Client Care Area for Sources of

Infection
Throughout the delivery of patient care, nurses must constantly and continuously monitor and
surveil the patent care environment for possible and likely sources of infection. Like all other safety
concerns, nurses must report and correct all sources of infection in the patient care area. Health
care-acquired infections are costly and highly concerning events.
Technically speaking, healthcare-acquired infections are those infections that were contracted after
the first health care contact or admission. Health care-acquired infections, sadly, are primarily passed
along with the hands of the health care provider, therefore, proper handwashing is one of the
primary things that the entire health care team can do to prevent them.
Some of the risk factors that impact on the frequency and occurrence of healthcare-acquired
infections include immunosuppression, the close living quarters that clients and residents share, the
prolonged state of illness that many patients have, surgeries, and some of the treatments that clients
get such as the placement of an indwelling urinary catheter, chemotherapy, or the placement of an
intubation tube.
The most commonly occurring pathogenic microorganisms that lead to healthcare-acquired
infections are E.coli, staphylococcus aureus, pseudomonas aeruginosa, candida albicans, and
enterococcus. The primary locations of these healthcare-acquired infections are surgical wounds, the
urinary tract, the respiratory tract, and the bloodstream.
Understanding Infections and
Communicable Diseases and the
Modes of Organism Transmission

Source: Centers for Disease Control and Prevention. Principles of epidemiology, 2nd ed. Atlanta:
U.S. Department of Health and Human Services; 1992.
The chain of infection includes:

 The pathogenic infectious microorganism

 The mode of transmission
 The reservoir
 The portal of exit
 The susceptible host
 The portal of entry

Communicable diseases and infections occur as the result of many pathogenic disease-causing fungi,
bacteria, viruses, parasites, and prions. Prions are protein particles without nucleic acid that can
cause neurological diseases like Creutzfeldt-Jakob disease and scrapie.
The Infectious Agent
Bacteria
Bacteria differ in terms of their morphology or shape, their actions, and their reactions to some
laboratory diagnostic tests. Bacteria can be shaped like a rod, a circular cell, a sphere, or a spiral;
some pathogenic bacteria lead to infection by releasing toxins into human tissue and some are gram-
positive and others are gram-negative when they are tested in the laboratory, for example.
Rod-shaped bacteria are referred to as bacilli; round-shaped bacteria are referred to as cocci, and
spiral-shaped bacteria are referred to as spirochetes. An example of bacillus is Bacillus anthracis
which causes anthrax. Bacilli are gram-positive aerobic microorganisms. Examples of a coccus are
staphylococcus and streptococcus, and examples of spirochetes are those that cause syphilis and
Lyme disease.
Different bacteria react differently to diagnostic laboratory testing. Some bacteria are gram-positive
and others are gram-negative, and some are characterized by their ability to change color, and others
are characterized as resistant to color changes.
Gram-positive bacteria react to the introduction of a gram stain because they, anatomically, have a
thick wall which contains peptidoglycan and teichoic acid; gram-negative bacteria do not react to a
gram stain because these bacteria have thin walls that are comprised of a lipid membrane holding
endotoxins such as lipoproteins and lipopolysaccharides. Gram-negative bacteria are more common
than gram-positive bacteria.
Bacteria are also differentiated by their ability to resist color changes when subjected to a staining
procedure in the laboratory. Acid-fast bacteria resist decolorization when stained with a Ziehl-
Neelsen or Kinyoun stain.
The four phases of bacterial growth in the correct sequential order are:

 The lag phase: The lag phase is characterized by the bacteria's acclimation and adaptation to their
environment; the bacteria mature but they are not ready for division and growth. RNA synthesis occurs,
and the rate of biosynthesis is high because the bacteria need these proteins for the future, rapid growth.

 The log phase: The log phase, often referred to as the exponential phase and the logarithmic phase of
growth is characterized by the bacteria's rapid and continuous growth until the nutrients, necessary for
growth, no longer exist.

 The stationary phase: The stationary phase, which results from the depletion of the nutrients that are
necessary for the continued growth of the bacteria, is characterized by the cessation of growth and the
bacteria's metabolic activity.

 The death phase: The death phase is the end of the bacteria's life.
Viruses
Viruses are comprised of RNA, DNA, and long molecules; and they have an outer coat of protein
that consists of lipids. They are also smaller than bacteria. Some viruses have a wide host range and
others have a narrow and low host range. Viruses with a wide host range can infect and impact on
multiple species, including human beings, and others with a narrow and low host range can impact
on and infect as few as one species.
Viruses, like bacteria, come in several shapes including icosahedral and helical shapes, and they can
be differentiated from each other in terms of their specific host cells. For example, some viruses are
plant viruses and others can be categorized as fungal viruses or animal viruses. Lastly, they can also
be according to their method of replication and their nucleic acid composition in terms of RNA and
DNA.
The six stages of virus growth in correct sequential order are attachment, penetration, uncoating,
replication, self-assembly, and release.

 The attachment stage: This stage is characterized by the virus attaching to a receptor on the host's cells.
Some viruses are highly limited in terms of their ability to attach to host cells and others have a great
ability to attach to host cells.

 The penetration stage: The penetration stage occurs with viral entry when the virus enters the host's
cell.

 The uncoating stage: This stage entails the removal and destruction of the virus' coating; this action
allows the virus to deposit its nucleic material into the host cell.

 The replication stage: The replication stage is characterized by the replication and multiplication of the
virus.

 The self-assembly stage: The self-assembly stage is the stage with which the virus mature.

 The release stage: During the release stage the virus is released from the host cells and the virus dies as
the result of its lysis.

RELATED: How Do Nurses Protect Themselves from Highly Infectious Patients?

Fungi
Fungi are found in the soil, on plant life, and on human beings. Most are harmless; however, there
are some that can lead to serious infections among humans, particularly when the client is
immunocompromised for one reason or another.
Fungi have what is referred to as a mutualistic symbiotic relationship, an antagonistic relationship,
and a commensal symbiotic relationship with humans and also other organisms. These relationships
with other organisms benefit both the host and the fungus, causing harm to the host of the fungus,
and neither benefit or harm the host and fungus, respectively.
Humans, including our clients in the health care environment, can get superficial, cutaneous,
subcutaneous, and systemic fungal infections. Systemic fungal infections are typically highly virulent
and they have the capability of spreading the infection to virtually all bodily organs. Candidiasis,
aspergillosis, and cryptococcosis are examples of systemic fungal infections. Cutaneous fungal
infections include those that infect the cutaneous tissue including the hair and the nails; athlete's
foot, or tinea pedis, is an example of cutaneous fungal infection. Superficial fungal infections affect
the host's epidermis; an example of a superficial fungal infection is tinea capitis which is often
referred to as a ringworm. Lastly, subcutaneous fungal infections infect all layers of the skin down to
the fascia and the muscles such as occur as the result of a deep traumatic puncture wound.

Parasites
Parasites live on or in a host and they get their nutrition from the host. Parasitic infections are most
common in tropical third world nations, but they can also occur in some developed countries such
as America. Some examples of parasitic infections include pinworms, giardia, tapeworms, lice,
maggot infestations, and scabies.

Prions
A prion is not a living organism, instead, it is the abnormal folding of cellular proteins. Prions and
prion diseases most often adversely affect the host's brain and neural tissue. Hardy prions, which can
only be destroyed with sterilization, are associated with high mortality and high morbidity rates.
Some of the prion diseases include several forms of encephalopathy, including "mad cow" disease,
Creutzfeldt-Jacob disease, and other rare diseases such as kuru.
The ability of a pathogenic microorganism to cause infections and diseases and the ability of these
microorganisms to cause various degrees of severity depends on a number of factors including a
person's physiological condition and susceptibility and the characteristics of the pathogen in terms
of its pathogenicity, virulence, and the infective dose.
Pathogenicity is defined as the ability of the pathogenic causative microorganism to actually cause
disease. Some pathogens have greater pathogenicity than others. For example, when 1,000 people
with the same physiological level of health are exposed to the same pathogen but only 1 develops a
disease or infection secondary to this exposure, this pathogen has a lower degree of pathogenicity
than when 1,000 people with the same physiological level of health are exposed to the same
pathogen and 200 exposed people develop an infectious disease as the result of this exposure.
Virulence is defined and described as how powerful a pathogenic causative microorganism is in
terms of its ability to cause disease with a level of severity. Some pathogenic causative
microorganisms are more virulent than other pathogenic causative microorganisms.
An infective dose, simply defined, is the amount of the pathogenic causative microorganism that is
needed in order to lead to disease and infection. Some pathogenic causative microorganisms need a
higher dose than others to cause disease.
In summary, pathogenic causative microorganisms with high levels of virulence, high levels of
pathogenicity, and a low infective dose are more threatening than pathogenic causative
microorganisms with low levels of virulence, low levels of pathogenicity and a high infective dose.

The Reservoir
The reservoir is the environment within which the pathogen lives, grows, and reproduces.
Reservoirs can include humans, animals, water, soil, and insects.

Human Reservoirs
Humans who serve as reservoirs may or may not be adversely affected with infection despite the fact
that they serve as the environment within which the pathogenic microorganisms lives, grows, and
reproduces as the habitat for the pathogen. For example, asymptomatic carriers like "Typhoid
Mary", a cook, was believed to be the first asymptomatic carrier of typhoid, and, as such, it is
believed that she infected some 50 plus people. On the other hand, people, including our health care
clients, who have active, symptomatic infections, such as influenza, can and do spread and transmit
it to others. Additionally, infections can also be spread by an infected person during the incubation
period for the specific infection and by convalescent carriers who have recovered from the infection.

Water Reservoirs
Contaminated water is often the reservoir for a number of parasites and other infections like
Legionnaires disease, amebiasis, cryptosporidiosis, schistosomiasis, and giardiasis.

Animal Reservoirs
Some animal reservoirs and the infectious disease that they spread include:

 Pigs: Trichinosis
 Cows: Brucellosis
 Rodents: Plague
 Rabbits: Tularemia
 Birds: West Nile encephalitis
 Sheep: Anthrax
 Bats and Dogs: Rabies

Additionally, some diseases such as HIV/AIDS, severe acute respiratory syndrome (SARS), and
Ebola have originated in animal reservoirs but now harbor in human reservoirs.

Soil Reservoirs
Many fungal agents, such as those that cause histoplasmosis, live, and multiply in contaminated soil.
Modes of Transmission
Modes of transmission, or transportation, are the part of the cycle of infection that moves a
pathogen from its reservoir to its susceptible host. There are several modes of transmission
including direct, indirect, airborne, vehicle, and vector modes of transmission.
Direct transmission occurs when a pathogen comes in direct contact with the susceptible host's skin
or mucous membrane. Indirect transmission is the movement of an infectious agent from the
reservoir to an object which is then passed to the susceptible host when the host touches the object.
Droplet transmission occurs when a pathogen is spread with a spray or splash of infectious
microorganisms which can occur with coughing and sneezing for example.
Airborne transmission occurs when the pathogen is carried in dust or droplets in the air. Measles is
an example of a virus that is transmitted with the airborne mode of transmission.
Vehicle transmission is defined as contact with an infection in things like contaminated soil and
water. Vector transmission is the movement of the pathogen with live things like insects that infect
humans with their sting or bite.

The Portal of Exit

The portal of exit is how the pathogenic microorganism leaves the reservoir. For example, influenza
leaves the human reservoir with a cough or a sneeze, and Lyme's disease leaves the tick with its
infectious bite.

The Susceptible Host

Some patients are more susceptible to and at higher risk of infection than others. Some of the things
that increase the patient's or host's susceptibility to infection are high levels of stress, high cortisol
levels, old age, infancy, genetics, poor nutrition particularly when the patient is affected with a
protein deficit, the presence of physical disorders and diseases, immunosuppression, some
medications such as and steroids, and some treatments like radiation therapy and chemotherapy for
cancer.
Briefly stated, people get infections when their natural bodily defenses against infection fail. The
human body's first line of defense against infection is intact skin. Other bodily defenses include the
inflammation process and antibody-mediated defenses including active and passive immunity.
Active immunity is present as a response to an antigen, and passive immunity is present when
antibodies to an antigen are present. Both active and passive immunity can be either natural or
artificial.
Artificial active and passive immunity is given with an injection of an antibody-like immune globulin
which produces artificial passive immunity and the injection of an antigen which reacts with the
formation of antibodies against the infection. This is artificial active immunity.
Natural active and passive immunity occurs when the person gets the infection and later produces
antibodies against it which prevents future occurrences of this specific infection and when the
neonate naturally gets antibodies in utero during pregnancy. These immunities are naturally active
and natural passive immunity, respectively.

Periods of Communicability
The period of communicability is defined as the duration of time that a pathogen can indirectly or
directly transmit the infection to another. This period of time varies according to the
microorganism. Some pathogens are associated with brief periods of communicability and others are
characterized with longer periods of communicability.

The Pathogen's Incubation and Latent Periods

The incubation period is the duration of time between the entry of the pathogenic organism into the
body upon initial exposure until the signs and symptoms of the infection begin. Pathogens establish
themselves in their new environment, they grow, they proliferate and go to their target area during
the incubation period of time. All pathogenic microorganisms have incubation periods. Some
incubation period is quite long and extended, as is the case with HIV, and others, such as influenza,
have a brief incubation period.
Incubation periods vary among pathogenic microorganisms and also among clients. For example,
some of the factors that can impact on the duration of the incubation period include the client's
physiological state and their level of susceptibility, the microorganism's portal of entry, the dose of
the infectious agent, and the speed at which the microorganism replicates. Incubation periods are
typically shorter among infants and children and longer among the members of the adult population.
In contrast to incubation periods, which mark the time from initial exposure to signs and symptoms,
the latent period of time for pathogenic microorganisms is the period of time between infection and
infectiousness, which is the time at which transmission to others is possible.
When the body's defenses against infection are not sufficient to combat it, infections occur. The
signs and symptoms of infection, generally speaking, are local and also systemic.
The local signs of infection, like the signs and symptoms of the protective inflammatory process, are
site pain, redness, heat, swelling, and some bodily part dysfunction.
The inflammatory process is a protective response that protects and defends us against tissue
damage and harm; the inflammatory process and its mechanisms eliminate damaged tissue and
promote the restoration of normal bodily tissue.
In the correct sequential order, the phases or stages of this process are:

 The initial tissue injury which can result from an infection or a traumatic cause
 The vascular response. The release of histamine, prostaglandins, and kinins. These substances lead to
vasodilation which increases the necessary blood supply to the injured tissue and the area surrounding it.
 The exudate response. The release of leukocytes, including macrophages and neutrophils, to the injured
area to combat the infection.
The systemic signs and symptoms of infection include fatigue, chills, hyperthermia, prodromal
malaise, tachypnea, tachycardia, nausea, vomiting, anorexia, confusion, incontinence, abdominal
cramping, and diarrhea, among other signs and symptoms as based on the infection. For example,
urinary infection signs and symptoms can include urgency, dysuria, urinary frequency, and
hematuria; and respiratory infections lead to coughing, dyspnea, and adventitious breath sounds.

The Portal of Entry

The portal of entry is the internal or exterior part of the human body that permits the infectious
microorganism to enter the human body. For example, many E. coli infections occur when this
pathogen enters the susceptible host's mouth. This is called fecal-oral transmission because the
pathogen exits via the feces and it enters into the mouth of the susceptible host.
In summary, the chain of infection includes:

 The pathogenic microorganism

 The mode of transmission
 The reservoir
 The portal of exit
 The susceptible host
 The portal of entry

And, the stages of infection are, in correct sequential order:

 The incubation period as discussed above

 The prodromal phase is characterized by fatigue and generalized feelings of malaise and the period of
time during which the pathogenic microorganism reproduces.
 The illness stage during which time the client has the symptoms and signs specific to the particular
infection
 The convalescence stage which is characterized by the client's recovery from the infection and the
cessation of its signs and symptoms

Applying the Principles of Infection

Control
The principles of infection control that will be discussed in this section include:

 Asepsis
 Medical asepsis
 Surgical asepsis
 Hand hygiene
 Universal / Standard precautions
 Special transmission precautions and isolation
 The use of personal protective equipment

Asepsis
Asepsis prevents the spread of infection. The two types of asepsis are medical asepsis, or clean
procedure, and surgical, or sterile, asepsis.
Some of the basic principles relating to asepsis are:

 Some treatments and procedures require surgical asepsis and others only require medical asepsis.
 Skin, including that on the hands, cannot be sterilized; they can only be sanitized.
 Nurses and other health care providers must stop all procedures and treatments and then begin all over
again whenever a break in surgical asepsis or medical asepsis occurs.
 Nurses, including licensed practical and registered nurses, can perform treatments and procedures that
require surgical and/or medical asepsis. Nursing assistants and other unlicensed assistive staff cannot
perform treatments or procedures that require surgical asepsis; these unlicensed staff can only perform
treatments or procedures that require medical asepsis.

Medical Asepsis
Medical asepsis also referred to as a clean technique, is the infection control principle and practice
that decreases the spread of infection. Medical asepsis reduces the number of pathogenic
microorganisms and it also impairs the proliferation and growth of microorganisms.
Hand hygiene, skin preparation prior to the injection of a subcutaneous medication, and the
administration of all medications except those given intravenously are examples of the application of
medical asepsis principles into nursing care practices.

Surgical Asepsis
Unlike medical asepsis, surgical asepsis, also referred to as surgical technique, eliminates all
microorganisms.
The principles and techniques of surgical asepsis are applied when the skin is not intact and also
when internal areas of the body are being entered, cared for, or treated. Surgical asepsis is used
for wound care, during all invasive procedures including surgical procedures and other invasive
procedures such as endoscopy, for the administration of intravenous medications, for wound care,
and for the insertion of an indwelling urinary catheter as well as other internally placed tubes like
central lines and peripheral intravenous lines.
Hand Hygiene
Handwashing is the best and most effective way to prevent the spread of infection when it is done
correctly and properly. Proper handwashing can be done with friction and regular soap and water or
special alcohol-based hand sanitizing antimicrobial solution, for at least 20 seconds.
Handwashing is particularly important in the health care environment for many reasons including
the fact that health care facilities are highly prone and susceptible to many healthcare-acquired
infections, including those such as like methicillin-resistant staphylococcus aureas (MRSA),
vancomycin-resistant enterococcus (VRE), and penicillin-resistant Streptococcus pneumoniae, which
are highly resistant to antimicrobial treatment. Please note, although special alcohol-based hand
sanitizing antimicrobial solutions are effective against most pathogenic microorganisms, they are not
effective against Clostridium difficile (C. diff).
Handwashing is done using friction for a minimum of twenty seconds before and after each client
contact, in addition to other times such as before and after donning and removing gloves.
Alcohol-based hand cleansers are not a substitute for good handwashing, however, they can be used
when running water and soap are not accessible. Alcohol-based handwashing products are liberally
applied to the entire hand after which the hands are rubbed until the entire hand is dried completely.

Universal / Standard Precautions

Universal and standard precautions are infection control measures that are used to prevent the
spread of infection among ALL patients whether or not they have a known infection. Standard
precautions protect health care workers and patients from the spread of infection secondary to
contaminated blood and other bodily fluids.

Special Transmission Precautions and Isolation

Contact precautions prevent direct and indirect contact transmissions of infectious pathogens like
those found in infected wounds, infectious diarrhea, and infections such as herpes simplex; droplet
precautions are used to prevent the transmission of pathogens that are transmitted with a cough or
sneeze, therefore, face masks are indicated for these precautions; and airborne precautions are used
for airborne transmission microbes like tuberculosis which requires a negative pressure private room
and a HEPA mask.

Personal Protective Equipment

The use of personal protective equipment protects the health care staff, clients, and visitors against
infections. Personal protective equipment (PPE) is specialized equipment and attire that is used by
employees in health care to protect against infections. Examples of personal protective equipment
include gowns, gloves, masks, goggles, and respirators.
Some basic principles for donning and removing personal protective equipment include donning
sterile gowns and gloves using the surgical technique by touching only the sterile surfaces of these
items with sterile hands. For example, the first sterile glove is applied by touching the inside of the
glove with the bare hand after which the second sterile glove is donned by holding the glove with
the sterile gloved hand without touching any skin surfaces.
Another basic principle includes removing used personal protective equipment by folding the item
inside out and disposing of it in the proper receptacle.

Using Appropriate Technique to Set

up a Sterile Field and Maintaining
Asepsis
These basic sterile asepsis procedures are followed for setting up and maintaining a sterile field.

 Sterile items ONLY are placed on the sterile field.

 The nurse must NEVER turn their back to a sterile field.
 The nurse must NEVER lean over a sterile field.
 The nurse must NEVER have the sterile field below the waist level.
 Coughing or sneezing over the sterile field contaminates the sterile field.
 The nurse must maintain a one-inch border around the sterile field that is not sterile.
 All sterile items and supplies are put inside of this one-inch border.
 The sterile field must remain dry; any wetness or moisture contaminates the sterile field.
 Sterile liquids must be poured carefully into sterile containers on the sterile field without the solution
running over and obliterating the label on the bottle.
 Sterile gowns and gloves are used by staff that is working with and/or setting up a sterile field.
 Sterile masks are also indicated, particularly when there is a possibility that a person will be working with
or near the sterile field.

Whenever these things are NOT done and maintained continuously throughout the treatment or
procedure, the entire sterile field and its contents are promptly discarded because the sterile field is
no longer sterile. The entire set up must be redone from the very beginning.

Following the Correct Policy and

Procedures When Reporting a Client
With a Communicable Disease
All states have laws and regulations that mandate the reporting of communicable diseases, most of
which must also be reported to the Centers of Disease and Prevention. The purpose of this
reporting is to facilitate the tracking and trending of communicable diseases and epidemics in order
to reverse the threat and to prevent future outbreaks. It is the responsibility of health care to report
communicable diseases and not the responsibility of the client or the family member.
Some of this mandatory reporting can be done with a telephone call and other communicable
disease occurrences must be reported with a written report.
Some of the communicable diseases that must be reported include anthrax, salmonella, gonorrhea,
pertussis, and rubella.

Educating the Client and Staff

Regarding Infection and Infection
Control Measures
As with other education, registered nurses assess the educational needs of both staff and clients, they
plan educational activities to meet these assessed needs, they provide the education and they also
evaluate the outcomes of these educational activities in terms of their effectiveness.
The assessment of these needs can be direct or indirect. For example, a registered nurse may directly
observe improper handwashing being done by another staff member and they can indirectly assess
educational needs when they collect, aggregate, and analyze data relating to the frequency of
infections.
Some of these educational needs are within the cognitive domain of learning and others are within
the psychomotor domain of learning. For example, a client may indicate that they have a cognitive
learning need when they ask why they are isolated into a private room; and a visitor may indicate
that they have a psychomotor learning need when you observe the discarding of their gown and
mask outside of the client room.
Once educational needs are assessed, educational activities are planned and implemented in order to
meet these needs.
Some of the content that is typically presented to clients and staff members and according to their
level of understanding can include:

 The chain of infection

 Ways to prevent infection by breaking the chain of infection
 Surgical and medical asepsis
 The use of personal protective equipment (PPE)
 Handwashing
 Standard/Universal precautions
 Special transmission-based precautions and practices
 The handling and disposal of biohazardous waste
 Immunity and immunization schedules

Utilizing Appropriate Precautions for

Immunocompromised Clients
The client's immune system protects it from infection. Immunocompromise, in addition to the other
intrinsic risk factors, such as a very young age and advancing years, some medications, some
disorders such as HIV/AIDS, poor nutritional status, and therapeutic interventions such as radiation
therapy and chemotherapy, place clients in varying degrees of risk in terms of contracting an
infection.
Protective precautions, in addition to standard/universal precautions, may be necessary when a
client is significantly and adversely affected with immunocompromised and/or a circumstance such
as being an organ transplantation recipient. Protective precautions reduce the risk of infection by
separating the immunocompromised client from microorganisms including those that do not
normally affect a person without immunocompromise. For example, clients with HIV/AIDS are
protected from microorganisms that do not normally affect a person without immunocompromised.
Protective isolation prevents these opportunistic infections among clients affected by HIV/AIDS.

Evaluating Infection Control

Precautions That Are Implemented
by Staff Members
Nurses, directly and indirectly, evaluate staff competency in terms of their utilization of infection
control measures and precautions, such as those within the cognitive domain of learning and the
psychomotor domain of learning as listed above under the topic "Educating the Client and Staff
Regarding Infection and Infection Control Measures".

Evaluating Whether Aseptic

Technique is Performed Correctly
Again, nurses, directly and indirectly, evaluate staff competency in terms of their utilization of
infection control measures and precautions including their correct performance of the aseptic
technique.
Use of Restraints and Safety
Devices: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of use of restraints and safety devices in order to:

 Assess the appropriateness of the type of restraint/safety device used

 Follow requirements for use of restraints and/or safety device (e.g., least restrictive restraints, timed
client monitoring)
 Monitor/evaluate client response to restraints/safety device

The most common reasons for restraints in health care agencies are to prevent falls, to prevent
injury to self and/or others and to protect medically necessary tubes and catheters such as an
intravenous line and a tracheostomy tube, for example.
All health care environments adopt the philosophy and goal of a restraint free environment;
however, it is not often possible to prevent the use of restraints and seclusion. There are rare
occasions when the use of restraints is not preventable because the restraints have become the last
resort to protect the client and others from severe injuries.

Commonly Used Terms Associated

With Restraints and Restraint Use
 A "restraint" is defined as any physical or chemical means or device that restricts client's freedom to and
ability to move about and cannot be easily removed or eliminated by the client.

For example, a vest restraint to prevent a patient fall is an example of a physical restraint and a
sedating medication to control disruptive behavior is considered a chemical restraint. Both restrict
the person's ability to move about freely. Other examples of physical restraints are soft padded wrist
restraints, a sheet tied around a person to keep them from falling out of a chair, side rails that are
used to stop a person from getting out of bed, a mitten to stop a person from pulling on their
intravenous line, arm and leg restraints, shackles, and leather restraints.

 A "physical restraint" is defined as "any manual method or physical or mechanical device, material, or
equipment attached to or adjacent to the resident's body that the individual cannot remove easily which
restricts freedom of movement or normal access to one's body", according to the Centers for Medicare
and Medicaid Services.
 A "chemical restraint" is defined as "any drug used for discipline or convenience and not required to treat
medical symptoms", according to the Centers for Medicare and Medicaid Services.

 A "safety device", also referred to as a protective device, is defined as a device that is customarily used for
a particular treatment. Safety devices are not considered a restraint, even though they limit freedom of
movement, because they are a device that is customarily and traditionally used for a particular treatment.
An intravenous arm board that is used to stabilize an intravenous line is an example of a safety device
which is not considered a restraint.

 "Preventive measures" is defined as those things that are done to prevent the use of restraints.

 The "least restrictive restraint" is defined as the restraint that permits the most freedom of movement to
meet the needs of the client. For example, mittens are the least restrictive device or restraint that can be
used to prevent dislodging of catheters and medically necessary lines such as an intravenous line or a
central venous device.

Assessing the Appropriateness of the

Type of Restraint Used
Nurses assess and determine the need for a client to be restrained or secluded and they also assess
the appropriateness of the type of restraint/safety device that is used in context with the client's
current condition and behaviors; they assess and reassess the client in a regular and ongoing basis to
insure that the client is safe and that their needs have been met when the use of restraints or
seclusion cannot be avoided.
These assessments also explore the client's condition within the context of the appropriateness of
the restraint in terms of its being the least restrictive alternative and being used for the shortest
possible period of time.

Following the Requirements For the

Use of Restraints and Safety Devices
According to the Joint Commission on the Accreditation of Health care Organizations and the
Centers for Medicare and Medicaid Services, there are many regulations and requirements that
address restraints and restraint use including:

 The initiation and evaluation of preventive measures that can prevent the use of restraints
 The use of the least restrictive restraint when a restraint is necessary
 Monitoring the client during the time that a restraint has been applied
 The provision of care to clients who are restrained

Alternative Preventive Measures

Some of the preventive, alternative measures that can decrease the need for restraints to prevent a
fall include:

 Accurate client assessment for the risk of falls

 The immediate initiation of special falls risk interventions when a client is assessed as "at risk" for falls
 More frequent monitoring
 Providing frequent reminders to the client to call for help before arising from the bed or chair
 Using bed and chair alarms
 Using a companion, sitter, etc.
 Reorienting the person
 Placing the client near an activity hub such as the nursing station so that the falls risk client gets more
monitoring and observation

Some of the preventive, alternative measures that can decrease the need for restraints in order to
prevent the dislodgment of medical tubes, lines and catheters include:

 Discontinuing or changing the treatment as soon as medically possible

 More frequent monitoring
 Using a companion, sitter, etc.
 Distraction
 Providing constant reminders about the importance of not touching the tube, line or catheter
 Keeping the tube, line or catheter out of view
 Reorienting the person

Some of the preventive, alternative measures that can decrease the need for restraints in order to
prevent violent behaviors that place self and/or others at risk for imminent harm include:

 Behavior management techniques

 Behavior modification techniques
 Keeping the client away from triggers
 Stress management and relaxation techniques
 Positive and negative reinforcements
Restraint Orders
A complete doctor's order is needed to initiate the use of restraints except under extreme emergency
situations when a registered nurse can initiate the emergency use of restraints using an established
protocol until the doctor's order is obtained and/or the dangerous behaviors no longer exist.
Restraints without a valid and complete order are considered false imprisonment.
The minimal components of orders for restraint include the reason for and rationale for the use of
the restraint, the type of restraint to be used, how long the restraint can be used, the client behaviors
that necessitated the use of the restraints, and any special instructions beyond and above those
required by the facility's policies and procedures.

The Least Restrictive Restraint

The least restrictive restraint to correct the problem like falls and the dislodgment of tubes, lines and
catheters is used when restraints are necessary. Restraints, from the least restrictive to the most
restrictive, are:

 Mitten restraints that are used to prevent the dislodgment of tubes, lines and catheters
 Wrist restraints that are used to prevent the dislodgment of tubes, lines and catheters
 A vest restraint that is used to prevent falls as well as disturbed violent behavior
 Arm and leg restraints that are used to prevent violent behavior
 Leather restraints that are also used to prevent violent behavior

Restraints should NEVER be used for staff convenience or client punishment.

Monitoring the Client During Restraint

When you monitor the patient or resident who is restrained, you must observe and monitor the
patient's physical condition, the patient's emotional state, and the patient's responses to the restraint
or seclusion.
Is the patient safe? Are the restraints still in place and safely applied? Are the patient's vital signs
normal? Are the skin color, intactness of the skin, and circulation good? Is the restraint too tight? Is
the patient comfortable and without any physical needs that you can attend to like toileting, food
and/or fluids? Is the person confused? Is the patient or resident angry, upset or agitated? Is the
person afraid or fearful?
After the restraint is applied, initial monitoring is done whenever necessary but at least every 15
minutes for the first hour by a licensed independent practitioner (LIP) or the qualified registered
nurse (RN). When the patient or resident is stable and without significant changes, the monitoring
and correlate documentation is then done at least every 4 hours for adults, every 2 hours for children
from 9 to 17 years of age, and at least every hour for those less than 9 years of age.
The scope of monitoring must include an evaluation or reassessment of the patient's:
 Physical status, including vital signs, any injuries, nutrition, hydration, circulation, range of motion,
hygiene, elimination and physical comfort

 Psychological and emotional status, including psychological comfort and the maintaining of dignity,
safety and patient rights

 Restraint need, discontinuation readiness and how the patient or resident acts and reacts when the
restraint is temporarily removed for ongoing care. Does the patient's or resident's condition justify the
need for the continuation of the current restraint device, a less or more restrictive restraint or the
discontinuation of restraints?

 The correct and safe application, removal and reapplication of the restraint

The Provision of Care to Restrained Clients

The following aspects of care must be provided as needed to a restrained patient or resident and
documented at least every two (2) hours when the person is restrained for non behavioral reasons,
and at least every four (4) hours when the person is restrained for behavioral reasons and more often
for children (every two (2) hours for those 9 to 17 years of age, and at least every hour for those less
than 9 years of age, unless the person needs more frequent care.
The components of this care are based on the client's needs and it typically includes:

 Range of motion exercises to the restrained body part unless the person is sleeping
 Turning and repositioning the individual
 Skin care if the skin assessment indicates a need to do so
 Checking the circulatory status of the affected body part
 Providing for all other physical needs such as toileting, hydration, nutrition, etc.
 Providing for the patient's psychological needs, such as their need for as much independence as possible,
the need for dignity and respect and freedom from anxiety

Some facilities use restraint flow sheets to document and record the use of restraints, the monitoring
of the client, the care provided and the responses of the patient who is restrained or in seclusion.
When these flow sheets are not used, the nurse must document all monitoring and care elements in
the progress notes.
Monitoring and Evaluating Client
Response to Restraints and Safety
Devices
When the registered nurse monitors and evaluates the client's responses to the restraints or safety
device, the nurse will assess and evaluate the client and their:

 Mental Status. Is the person afraid or fearful? Is the person confused? Is the patient or resident angry,
upset or agitated?
 Physical Status. Is the person safely restrained and safe from strangulation from a vest restraint, for
example? Are the client's respiratory and circulatory systems normal? Is the person clean, comfortable,
and dry? Is the skin showing any signs of irritation or breakdown?
 Response to the Restraint. Has the person improved to the point where they may no longer need of the
restraint?

Trial releases from restraints and attempts to control the behavior with appropriate alternatives to
restraint provides the registered nurse and/or licensed independent practitioner (LIP) with
reassessment data that guides the decision-making process in terms of the:

 Continuing the use of restraints because the clinical justification and the patient/resident behavior
remains the same, or
 Moving to a less restrictive method, or
 Using a preventive alternative strategy rather than the restraint, or
 The discontinuation of the restraint