Flashcards.

WHAT IS IT?

A colostomy is a stoma (opening on the abdomen) where stool exits into an appliance (bag). This card covers how to care for the stoma, the skin, and the appliance, plus diet teaching.

NURSING CONSIDERATIONS

• •Assess stoma appearance. Normal color is pink to red.
• •Report a stoma that is pale, dark, purple, or brown.
• •Cut the stoma appliance (bag) 1/16 to 1/8 inch larger than the stoma.
• •Cleanse the stomal area and keep it dry.
• •Apply skin barrier before applying the appliance.
• •Empty the appliance frequently to avoid complications, generally when 1/3 full.
• •A small needle-sized hole can be made in the pouch to let flatus (gas) escape. Seal it with a bandaid.

Diet teaching:

• •Foods that increase gas: beer, broccoli, brussel sprouts, cabbage, carbonated drinks, beans, dairy, spinach
• •Foods that thicken stool: applesauce, banana, bread, cheese, yogurt, rice, pasta

WHAT IS IT?

Hepatitis is inflammation of the liver, usually from a virus. Different types spread in different ways. As the liver is damaged, bilirubin and liver enzymes rise, which leads to jaundice and other symptoms.

Types and transmission:

• •Hepatitis A (HAV): health care workers are at risk; spreads by fecal-oral route, person-to-person, and poorly washed hands or utensils. Most contagious 10 to 14 days before symptoms start and is self-limiting (resolves on its own). Prevention: strict hand washing, standard precautions, hepatitis A vaccine.
• •Hepatitis B (HBV): spreads by blood or body fluids through IV drug use, sexual contact, or needle stick. Prevention: standard precautions, hand washing, blood screening, hepatitis B vaccine, needle precautions, safe sex practices.
• •Hepatitis C (HCV): blood-borne, IV drug users, needle stick. Prevention: standard precautions, needle safety, blood screening. NO vaccine available.
• •Hepatitis D (HDV): opportunistic infection associated with hepatitis B virus (HBV).
• •Hepatitis E (HEV): fecal-oral route, common in underdeveloped countries.

ASSESSMENT

Preicteric stage:

• •Flu-like symptoms, pain, low-grade fever

Icteric stage:

• •High bilirubin causes jaundiced (yellow) skin and eyes, dark urine, and pruritus (itching)
• •Clay-colored stool (from lack of bile secretion)
• •Elevated liver function tests (LFTs): AST, ALT, ALP, and ammonia

Posticteric stage:

• •Recovery phase, lab values return to normal, pain relief, increased energy

MANAGEMENT

Supportive therapy to address symptoms:

• •Lactulose for high ammonia levels
• •Antiemetics (anti-nausea medications)
• •Antihistamines (can help treat hepatitis C virus)
• •Antiviral therapy

WHAT IS IT?

Dialysis uses a semipermeable membrane to do many of the jobs the kidneys can no longer do. This includes clearing waste and toxins, removing urea, creatinine, and uric acid, and regulating electrolytes and acid-base balance.

TABLE

Hemodialysis:

• •Pulls blood from the patient through a machine that acts as the semipermeable membrane, then returns the blood to the patient
• •Requires vascular access
• •Risk for hypovolemic shock

Hemodialysis safety:

• •Protect vascular access (limb alert: no BP or sticks on that arm)
• •Pharmacologic considerations
• •Monitor vital signs closely

Peritoneal dialysis:

• •The peritoneum acts as the semipermeable membrane
• •Can be done at home
• •Risk for peritonitis

Peritoneal dialysis safety:

• •Prevent infection (hand hygiene and sterile technique)
• •Monitor for infection (peritonitis)

WHAT IS IT?

Leukemia is the overgrowth of abnormal, undeveloped WBCs (white blood cells). WBCs are needed for infection control and immunity. It is diagnosed by blood tests and a bone marrow biopsy.

TYPES (by WBC affected)

• •ALL (acute lymphocytic leukemia): 2 to 4 years of age
• •CLL (chronic lymphocytic leukemia): 50 to 70 years of age
• •AML (acute myelogenous leukemia): peaks at 60 years of age
• •CML (chronic myelogenous leukemia): incidence increases with age

ASSESSMENT

• •Weight loss
• •Fever
• •Infections
• •Pain in bones and joints
• •Night sweats
• •Aplastic anemia: pallor (pale skin), fatigue, easy bleeding and bruising
• •Increased WBC in CLL and CML
• •Decreased WBC in ALL and AML
• •Philadelphia chromosome in the majority of CML clients
• •Mouth sores from chemotherapy

MANAGEMENT

• •Chemotherapy and radiation
• •Bone marrow biopsy: apply pressure to the biopsy site
• •Initiate neutropenic precautions: strict handwashing, limit visitation, no fresh fruits or flowers
• •Plan activities to provide time for rest
• •Instruct the client on oral hygiene: rinse mouth with saline, avoid lemon or alcohol-based mouthwashes

WHAT IS IT?

Shingles is a viral infection caused by the herpes zoster virus. It is most common in elderly clients with a history of chickenpox or the chickenpox vaccine. It is highly contagious.

ASSESSMENT

• •Vesicular rash that follows the dermatome and is usually unilateral (on one side)
• •Painful and itchy
• •Fever, malaise, fatigue

MANAGEMENT

• •Contact isolation, or airborne isolation if the rash is disseminated (widespread)
• •Assess neurological status and signs of infection
• •Medications: antivirals, NSAIDs, and the shingles vaccine (for prevention)

WHAT IS IT?

A pressure ulcer is skin and tissue damage caused by pressure and/or shear (skin sliding against a surface), usually over a bony area. Nursing care focuses on prevention and treatment based on the stage.

NURSING CARE

• •Identify at-risk patients and start precautions and assessments
• •Keep skin dry and sheets wrinkle-free; turn and reposition frequently
• •Assess and document the status of the ulcer
• •Treatment may include creams, dressings, debridement (removing dead tissue), grafting, and vacuum-assisted suction

STAGING

• •Stage I: intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not show visible blanching.
• •Stage II: partial thickness loss of dermis, presenting as a shallow open ulcer with a red-pink wound. Presents as a shiny or dry shallow ulcer without slough or bruising.
• •Stage III: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
• •Stage IV: full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
• •Unstageable: full thickness tissue loss where the actual depth is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and stage cannot be determined.
• •DTI (deep tissue injury): damage of underlying soft tissue from pressure and/or shear
• •[source fragment unclear, verify at source]

WHAT IS IT?

This card covers nursing care before, during, and after a seizure to keep the client safe.

MANAGEMENT

Before:

• •Give all medications on time
• •Use seizure precautions if at risk
• •Verify the order for PRN (as-needed) dosing and ensure medication is readily available

During (maintain airway):

• •Turn the client to the side in case of vomit
• •Have oxygen and suction equipment available
• •DO NOT force anything into the mouth during a seizure (including a bite block)

During (protect from injury):

• •Lower the bed to the lowest position
• •Use padded side rails
• •Loosen restrictive clothing
• •DO NOT try to restrain the client
• •Notify the MD of type, onset, and duration

After:

• •Keep the client safe while postictal (the recovery period after a seizure)

WHAT IS IT?

Influenza is a virus with multiple strains and increasing severity. It is spread through droplet contact.

ASSESSMENT

Symptoms:

• •Sudden onset
• •Lasts 6 to 7 days
• •Aches in the head, muscles, and body
• •Fatigue
• •Runny nose, sore throat, cough
• •Vomiting
• •High fever (102 to 104 degrees F)

MANAGEMENT

Vaccine, indicated annually for:

• •Healthcare workers
• •Elderly
• •Children over 6 months
• •Pregnant clients
• •Immunocompromised clients: do NOT give the nasal spray vaccine to immunocompromised clients

Vaccine contraindications:

• •Severe allergy to the flu vaccine, eggs, or latex
• •History of Guillain-Barre
• •Recent bone marrow or organ transplant (less than 6 months)

Anti-virals:

• •Oseltamivir (Tamiflu): within 48 hours of onset, best within 24 hours

WHAT IS IT?

Cognitive impairment disorders include autism-spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD), dementia, and Alzheimer's disease. Dementia is a broad category of brain diseases that are gradual and long-term and result in self-care deficits, largely affecting the client's ability to function. It causes judgment impairments and problems with problem solving and behavior. Alzheimer's disease is a TYPE of dementia and is an irreversible form caused by nerve cell deterioration, with a steady, progressive decline in functional capacity.

ASSESSMENT

• •Apraxia: difficulty performing motor tasks
• •Aphasia: difficulty progressing to inability to speak and understand what is being said
• •Agnosia: does not recognize familiar people or objects
• •Amnesia: memory loss

MANAGEMENT

Caregiver stress:

• •Role strain, for example a child caring for a parent
• •Sadness due to the loved one not recognizing them

Safety:

• •Wandering can be an issue; units should be locked/secured and clients supervised
• •Watch water temperature, as clients may burn themselves
• •Remove anything toxic or hazardous from easy access
• •Watch for agitation and remove things that increase it
• •Decrease stimuli and reassure the client
• •Never argue
• •Use a calm, reassuring voice with gentle touch when appropriate
• •Watch for sundowning (increased confusion at night)

Communicate:

• •Maintain eye contact
• •Stand in front of them; be calm, firm, and direct
• •Give simple one-step tasks/directions
• •Use short, simple words
• •Always identify them and yourself
• •Reorient as needed, which may be frequent

Promote their current abilities:

• •Keep familiar things around them
• •Continually reinforce what they know and can do at this point in time
• •Promote independence and supervise to ensure ADLs (activities of daily living) are taken care of

WHAT IS IT?

Hemophilia is an impaired ability to control blood clotting due to a deficiency in specific clotting proteins. It is an X-linked recessive disorder (hereditary). Carrier females pass it to a male child.

Quick Concept: Missing coagulation factors prevent fibrin formation, so the person bleeds for a long time because they cannot clot.

Types:

• •Hemophilia A (deficiency of factor VIII)
• •Hemophilia B (deficiency of factor IX)
• •Hemophilia C (deficiency of factor XI)

ASSESSMENT

• •Epistaxis (nose bleeds) and prolonged bleeding from trauma
• •Frequent bruising
• •Bleeding in the brain: visual changes, headaches, change in LOC (level of consciousness), slurred speech
• •GI (gastrointestinal) bleed: hematemesis (throwing up blood), melena (black stools = upper GI bleed)
• •Normal PT and thrombin time, prolonged PTT

MANAGEMENT

Goals:

• •Replace missing clotting factors
• •Prevent bleeding
• •Prevent long-term joint problems

Medications:

• •Replace the missing factor by slow IV push
• •DDAVP increases the body's production of clotting factor and is ONLY used in mild Hemophilia A

Access:

• •Many clients have a metaport for access
• •Maintain sterility when accessed
• •Only access when following policies or orders

TEST-TAKING TIPS

• •Deal with patients rather than with machines.
• •Avoid answers with: never, always, must, "why?", "I understand".
• •If two answers are opposites (for example hyper- vs. hypo-), one is usually correct.
• •Do not leave the patient alone.
• •Choose physical over psychological.
• •If you do not know the answer, pick the one with the most information.
• •Use ABC (Airway, Breathing, Circulation) except in emergencies, distress situations, and CPR.

PRIORITIZATION COMPARISONS

• •Assessment vs. Implementation
• •Acute vs. Chronic
• •Stable vs. Unstable
• •Expected vs. Unexpected
• •Real vs. Potential
• •Odd man out

DELEGATION

Do not delegate (PACET):

• •Planning
• •Assessment (initial)
• •Collaboration
• •Evaluation
• •Teaching

UAPs cannot be delegated:

• •"EAT" tasks, medication, and unstable patients

LPNs:

• •Cannot be delegated anything related to blood
• •Are assigned the most stable patients

CONVERSIONS

• •1 tsp = 5 mL
• •1 tbsp = 3 tsp (15 mL)
• •1 oz = 30 mL
• •1 cup = 8 oz
• •1 pint = 2 cups (16 oz)
• •1 quart = 2 pints (32 oz)
• •1 gr (grain) = 60 mg
• •1 kg = 2.2 lbs
• •1 g = 1 mL (diapers)
• •F = (C x 1.8) + 32

NORMAL VALUES

• •Temperature normal range: 98.6 F plus or minus 1 (37 C plus or minus 0.5)
• •MAP (mean arterial pressure): (systolic + 2 x diastolic) / 3; normal 70 to 105 mmHg (greater than 60 mmHg)
• •CVP (central venous pressure): 2 to 8 mmHg; CVP can indicate right ventricular failure or fluid volume overload

WHAT IS IT?

This card defines key ethics and legal terms in nursing.

TABLE

• •Veracity: truth, an essential part of a therapeutic relationship between a health care provider and patient
• •Beneficence: the duty to do good; an obligation to help the patient
• •Nonmaleficence: the duty to do no harm
• •Tort: litigation where one person asserts that an injury (physical, emotional, or financial) occurred because of another's actions or failure to act
• •Negligence: harm that results because a person did not act reasonably
• •Malpractice: professional negligence
• •Slander: character attacked and spoken in the presence of others
• •Assault: an act in which there is a threat or attempt to do bodily harm
• •Battery: unauthorized physical contact

WHAT IS IT?

This card covers the Parkland formula for fluid resuscitation in burns and a reference table of the cranial nerves.

PARKLAND FORMULA

• •Total fluid: 4 mL/kg/% body burned
• •1st 8 hours: 1/2 of total volume
• •2nd 8 hours: 1/4 of total volume
• •3rd 8 hours: 1/4 of total volume

CRANIAL NERVES (S = Sensory, M = Motor, B = Both)

• •I Olfactory: smell test
• •II Optic: visual acuity and visual fields
• •III Oculomotor: pupil constriction and extraocular movements
• •IV Trochlear: extraocular movements, inferior adduction
• •V Trigeminal: clench teeth and light touch
• •VI Abducens: extraocular movements, lateral abduction
• •VII Facial: facial movement, close eyes, smile
• •VIII Auditory: hearing and Romberg test
• •IX Glossopharyngeal: gag reflex
• •X Vagus: say "ah", uvular and palate movement
• •XI Accessory: turn head and lift shoulders to resistance
• •XII Hypoglossal: stick out tongue

WHAT IS IT?

This card is a memory aid for how hepatitis spreads and which infections are airborne.

HEPATITIS TRANSMISSION

• •Consonants (B, C, D): blood and body fluids
• •Vowels (A, E): fecal and oral

AIRBORNE (MTV)

• •Measles
• •TB (tuberculosis)
• •Varicella (chicken pox / herpes zoster, also called shingles)

WHAT IS IT?

This card covers Erikson's developmental stages plus several memory aids (cranial nerves, PPE order, and isolation precautions).

DEVELOPMENTAL STAGES (Erikson)

• •Infancy (0-18m): Trust vs. Mistrust. Development of trust based on caregivers.
• •Early childhood (18m-3yrs): Autonomy vs. Shame & Doubt. Development of a sense of personal control.
• •Preschool (3-5yrs): Initiative vs. Guilt. Development of a sense of purpose and direction.
• •School age (6-11yrs): Industry vs. Inferiority. Development of pride in accomplishments.
• •Adolescence (12-18yrs): Identity vs. Role Confusion. Exploration of independence and development of self.
• •Early adulthood (18-40yrs): Intimacy vs. Isolation. Development of personal relationships and love.
• •Adulthood (40-65yrs): Generativity vs. Stagnation. Fulfilling goals and building career and family.
• •Older adult (over 65yrs): Integrity vs. Despair. Looking back on life with acceptance.

CRANIAL NERVES (mnemonic)

• •Oh (Olfactory I), Oh (Optic II), Oh (Oculomotor III), To (Trochlear IV), Touch (Trigeminal V), And (Abducens VI), Feel (Facial VII), A (Auditory VIII), Girls (Glossopharyngeal IX), Vagina (Vagus X), And (Accessory XI), Hymen (Hypoglossal XII)
• •Function mnemonic: Some Say Marry Money But My Brother Says Big Bras Matter More

PPE (personal protective equipment) ORDER

• •Don PPE: 1. Hand hygiene 2. Gown 3. Mask 4. Goggles 5. Gloves
• •Remove PPE: 1. Gloves 2. Goggles 3. Gown 4. Mask 5. Hand hygiene

ISOLATION PRECAUTIONS

• •Droplet (SPIDERMAN): Sepsis, Scarlet fever, Streptococcal pharyngitis, Parvovirus B19, Pneumonia, Pertussis, Influenza, Diphtheria (pharyngeal), Epiglottitis, Rubella, Mumps, Meningitis, Mycoplasma or meningeal pneumonia, Adenovirus
• •Contact (MRS. WEE): Multidrug resistant organisms, Respiratory infection, Skin infections (VCHIPS), Wound infection, Enteric infection (C. difficile), Eye infection (conjunctivitis)

WHAT IS IT?

The APGAR score rates a newborn's condition right after birth. The five parts are Appearance, Pulse, Grimace, Activity, and Respiration.

SCORE INTERVENTIONS

• •8 to 10: no intervention required; support the newborn's spontaneous efforts
• •4 to 7: stimulate, rub the newborn's back, administer oxygen, rescore at specific intervals
• •0 to 3: requires full resuscitation, rescore at specific intervals

WHAT IS IT?

This card uses the memory aid CORBIN to list signs of a possible heart defect.

ASSESSMENT (CORBIN)

• •Color: bluish skin or extremities
• •O2: low pulse oximetry percentage
• •Rhythm: abnormal heart rate
• •Breathing: heavy or labored
• •Increase in sweat, especially on the forehead
• •Nursing: trouble feeding and breathing at the same time, or poor appetite

WHAT IS IT?

Each role on the care team has a legal limit to what it can do. The RN (registered nurse) does the work that needs judgment. The LPN/LVN (licensed practical nurse / licensed vocational nurse) does stable, routine care. The UAP (unlicensed assistive personnel) does basic tasks.

RN (registered nurse):

• •Does the nursing assessment (the first full look at the patient).
• •Makes the care plan and the nursing diagnosis.
• •Teaches the patient and family.
• •Gives IV (intravenous, into the vein) push medications and blood.
• •Cares for the unstable patient.

LPN/LVN (licensed practical/vocational nurse):

• •Gives most oral and intramuscular medications.
• •Does routine, stable tasks like dressing changes and tube feedings.
• •Reinforces teaching the RN already started.
• •Collects focused data, but does not do the first full assessment.

UAP (unlicensed assistive personnel):

• •Helps with bathing, feeding, walking, and toileting.
• •Takes routine vital signs on stable patients.
• •Measures intake and output (fluids in and out).

Quick Concept: RN = assess, teach, plan, judge. The RN keeps these and does not give them away.

WHAT IS IT?

Delegation is giving a task to another worker while the RN (registered nurse) keeps responsibility for the outcome. Some duties belong only to the RN and can never be handed off.

KEY POINTS

• •The RN cannot delegate the initial assessment (the first full evaluation of a patient).
• •The RN cannot delegate nursing judgment, planning, or evaluation of care.
• •The RN cannot delegate patient teaching.
• •The RN cannot delegate care of an unstable or unpredictable patient.
• •A helpful memory tool is the four words you never delegate: assess, teach, plan, evaluate.

NURSING CONSIDERATIONS

• •You may delegate a task, but you never delegate accountability for it.
• •When unsure, ask if the task needs nursing knowledge or judgment. If yes, the RN keeps it.
• •Delegate stable, routine, predictable tasks with clear outcomes.

WHAT IS IT?

Before the RN (registered nurse) hands a task to another worker, the RN checks five things. This framework comes from the NCSBN (National Council of State Boards of Nursing) and keeps delegation safe.

KEY POINTS

• •Right task: the job is appropriate to delegate (routine, stable, low risk).
• •Right circumstance: the patient and setting are stable and fit the task.
• •Right person: the worker is trained and allowed to do this task.
• •Right direction and communication: clear instructions, with the expected result and limits.
• •Right supervision and evaluation: the RN monitors, follows up, and checks the outcome.

NURSING CONSIDERATIONS

• •Skipping any one of the five rights makes the delegation unsafe.
• •The RN still answers for the result even after delegating.
• •Give specific instructions, such as what to report and when to report it.

WHAT IS IT?

When more than one patient needs help, treat the most life-threatening problem first. The ABCs put the airway, breathing, and circulation in order of urgency.

KEY POINTS

• •A = Airway: a blocked airway kills fastest, so it always comes first.
• •B = Breathing: after the airway is open, check that the patient can breathe and get oxygen.
• •C = Circulation: then check the pulse, blood pressure, and any bleeding.
• •Some sources add D = Disability (neurological status) and E = Exposure.

NURSING CONSIDERATIONS

• •A patient who cannot keep an open airway or breathe is the top priority.
• •Choking, no breath sounds, and severe bleeding all jump to the front of the line.
• •After the ABCs are stable, move on to other needs.

Quick Concept: Airway before breathing before circulation. Open the airway first, always.

WHAT IS IT?

Maslow's hierarchy of needs ranks human needs from most basic to highest. In nursing, meet the lower (physical) needs before the higher (emotional) ones when setting priorities.

KEY POINTS

• •Physiological needs come first: airway, breathing, food, water, sleep, elimination.
• •Safety and security come next: fall prevention, infection control, a safe environment.
• •Love and belonging: support, family, relationships.
• •Self-esteem: respect, dignity, confidence.
• •Self-actualization: reaching one's full potential, sits at the top.

NURSING CONSIDERATIONS

• •Always meet a physical need before a psychosocial (emotional or social) need.
• •The ABCs (airway, breathing, circulation) are the most urgent physiological needs.
• •Example: oxygen need comes before a patient's worry about going home.

Quick Concept: Physical before psychosocial. The body before the feelings.

WHAT IS IT?

To prioritize, compare how new and how stable each problem is. Acute means new or sudden. Chronic means long-lasting. Unstable means changing fast and at risk.

Acute vs chronic:

• •Acute problems are new, sudden, and often more urgent.
• •Chronic problems are long-standing and usually more predictable.
• •A sudden change in a chronic patient becomes acute and rises in priority.

Stable vs unstable:

• •Stable patients have steady vital signs and predictable needs.
• •Unstable patients have changing vital signs or new symptoms.
• •The unstable patient is the higher priority and needs the RN (registered nurse).

NURSING CONSIDERATIONS

• •See the acute, unstable patient before the chronic, stable one.
• •Expected findings for a known condition are lower priority than unexpected ones.
• •A new or worsening symptom always raises the priority.

Quick Concept: Acute and unstable beat chronic and stable.

WHAT IS IT?

Triage is sorting patients so the sickest are seen first. In the emergency department, a common system rates urgency as emergent, urgent, or non-urgent.

KEY POINTS

• •Emergent: life-threatening, must be seen now. Examples include chest pain, trouble breathing, active heavy bleeding.
• •Urgent: serious but not immediately life-threatening, should be seen soon. Examples include a simple fracture or moderate abdominal pain.
• •Non-urgent: not serious, can safely wait. Examples include a sprain, a rash, or a cold.

NURSING CONSIDERATIONS

• •Many emergency departments use a 5-level scale called the ESI (Emergency Severity Index), where level 1 is the most urgent and level 5 the least; verify the exact scale at your source.
• •The patient who waits the least is the one whose airway, breathing, or circulation is most at risk.
• •Triage is ongoing. Recheck waiting patients because their status can change.

WHAT IS IT?

START stands for Simple Triage And Rapid Treatment. It is used in a mass-casualty event (many victims at once). The goal shifts to doing the most good for the most people, so resources go where they will save lives.

Color categories:

• •Red (immediate): life-threatening but survivable with quick care. Treated first.
• •Yellow (delayed): serious injuries that can wait a short time without dying.
• •Green (minor): the walking wounded, minor injuries, can wait the longest.
• •Black (expectant): dead or injuries so severe that survival is unlikely. They receive comfort care, not the first resources.

NURSING CONSIDERATIONS

• •In a disaster, priority goes to those most likely to survive with treatment, not always the most injured.
• •This is different from daily triage, where the sickest patient is treated first.
• •A patient who is not breathing even after the airway is opened is tagged black in START.

Quick Concept: Red first, then yellow, then green. Black is last for resources.

WHAT IS IT?

Standard precautions are the basic infection-control steps used for every patient, every time. You assume any patient's blood and body fluids could carry infection, even if they look healthy.

KEY POINTS

• •Use them for all patients regardless of diagnosis.
• •Perform hand hygiene before and after every patient contact.
• •Wear gloves when you may touch blood, body fluids, mucous membranes, or broken skin.
• •Add a gown, mask, or eye protection when splashing is possible.
• •Handle sharps safely and never recap needles.

NURSING CONSIDERATIONS

• •Standard precautions are the foundation; transmission-based precautions are added on top when needed.
• •Body fluids include blood, urine, stool, saliva, wound drainage, and vomit.
• •Hand hygiene is the single most important way to prevent the spread of infection.

WHAT IS IT?

Contact precautions prevent the spread of germs passed by touch, either directly to the patient or to items in the room. They are added on top of standard precautions.

KEY POINTS

• •Wear a gown and gloves when entering the room.
• •Place the patient in a private room when possible.
• •Use dedicated equipment for that patient (own blood pressure cuff, thermometer).
• •Clean shared equipment between patients.

Example diseases:

• •MRSA (methicillin-resistant Staphylococcus aureus, a resistant skin bacterium).
• •VRE (vancomycin-resistant Enterococcus).
• •C. difficile (Clostridioides difficile, a gut infection causing diarrhea).
• •Scabies and other draining wound or skin infections.

NURSING CONSIDERATIONS

• •For C. difficile, wash hands with soap and water; alcohol gel does not kill its spores.
• •Remove the gown and gloves and wash hands before leaving the room.

Quick Concept: Contact means gown and gloves. The germ spreads by touch.

WHAT IS IT?

Droplet precautions stop germs that travel in large respiratory droplets when a person coughs, sneezes, or talks. These droplets fall quickly and travel only a short distance (about 3 to 6 feet).

KEY POINTS

• •Wear a surgical mask when within about 3 to 6 feet of the patient.
• •Place the patient in a private room when possible.
• •Put a surgical mask on the patient during transport.
• •A special air-handling room is not required.

Example diseases:

• •Influenza (the flu).
• •Pertussis (whooping cough).
• •Bacterial meningitis (Neisseria meningitidis).
• •Mumps and rubella.

NURSING CONSIDERATIONS

• •A regular surgical mask is enough; droplet does not need an N95 respirator.
• •Droplets do not stay in the air for long, so no special ventilation is needed.

Quick Concept: Droplet = surgical mask within a few feet.

WHAT IS IT?

Airborne precautions stop tiny germs that float in the air for long periods and travel long distances. These particles can be inhaled even after the patient leaves the area.

KEY POINTS

• •Place the patient in an AIIR (airborne infection isolation room), a negative-pressure room.
• •Keep the door closed at all times.
• •Wear a fitted N95 respirator (or higher), not just a surgical mask.
• •Put a surgical mask on the patient during any transport.

Example diseases:

• •Tuberculosis (TB).
• •Measles (rubeola).
• •Varicella (chickenpox), which also needs contact precautions.
• •Disseminated herpes zoster (widespread shingles).

NURSING CONSIDERATIONS

• •A memory tool for airborne diseases is My (measles), Chicken (varicella), Hez (herpes zoster), TB.
• •Negative pressure pulls room air out and filters it so germs do not escape to the hallway.

Quick Concept: Airborne = N95 plus a negative-pressure room with the door shut.

WHAT IS IT?

Donning means putting on PPE (personal protective equipment), the gear that protects you from infection. There is a set order so each piece covers the one before it.

STEPS

1. Perform hand hygiene first.

2. Put on the gown and tie it.

3. Put on the mask or respirator and fit it to the face.

4. Put on the goggles or face shield.

5. Put on the gloves last, pulling them over the gown cuffs.

NURSING CONSIDERATIONS

• •A memory tool for the order is Gown, Mask, Goggles, Gloves.
• •Gloves go on last so they seal over the gown sleeves.
• •For an N95 respirator, check the seal after putting it on.

Quick Concept: Don in this order: gown, mask, goggles, gloves.

WHAT IS IT?

Doffing means taking off PPE (personal protective equipment). The dirtiest items come off first so you do not touch contaminated surfaces and spread germs to yourself.

STEPS

1. Remove the gloves first; they are the most contaminated.

2. Perform hand hygiene.

3. Remove the goggles or face shield by the side or back, not the front.

4. Remove the gown, rolling it inside out.

5. Remove the mask or respirator last, touching only the ties or straps.

6. Perform hand hygiene again as the final step.

NURSING CONSIDERATIONS

• •Remove the mask or respirator only after you have left the patient's room (airborne rooms: remove outside the room).
• •Never touch the front of any item; the outside is dirty.
• •Hand hygiene is always the very last action.

Quick Concept: Doff dirtiest first: gloves, goggles, gown, mask. Wash hands last.

WHAT IS IT?

Hand hygiene means cleaning your hands with soap and water or with an alcohol-based hand rub. It is the single most effective action to prevent the spread of infection.

KEY POINTS

• •Clean hands before and after every patient contact.
• •Clean hands before putting on gloves and after taking them off.
• •Wash with soap and water when hands are visibly dirty or after caring for a patient with C. difficile (Clostridioides difficile) or norovirus.
• •Alcohol-based rub is fine when hands are not visibly soiled.
• •Scrub for at least 20 seconds with soap and water.

NURSING CONSIDERATIONS

• •Alcohol gel does not kill C. difficile spores, so use soap and water in that case.
• •Wearing gloves does not replace hand hygiene.

Quick Concept: When in doubt with spores or visible dirt, use soap and water.

WHAT IS IT?

Falls are a common and serious safety risk in hospitals, especially for older adults. The nurse screens for fall risk and puts simple safeguards in place.

KEY POINTS

• •Identify high-risk patients: older adults, confused patients, those on sedatives or diuretics, and those with poor mobility.
• •Keep the bed in the lowest position with wheels locked.
• •Keep the call light, water, and personal items within reach.
• •Use nonskid socks and make sure walkways are clear and well lit.
• •Answer call lights quickly and do hourly rounding.

NURSING CONSIDERATIONS

• •Keep two side rails up for safety; raising all four can count as a restraint.
• •Assist high-risk patients to the bathroom on a schedule.
• •A bed or chair alarm can alert staff but does not replace checking on the patient.

WHAT IS IT?

A restraint is any device or method that limits a patient's free movement. Restraints are a last resort and are tightly regulated to protect the patient.

KEY POINTS

• •Always try the least restrictive option first, such as distraction, family at the bedside, or moving the patient closer to the nurses' station.
• •A provider's order is required; it must state the type, reason, and time limit.
• •An order cannot be PRN (as needed); it must be specific to one episode.
• •Renew the order within set time limits (often every 24 hours for nonviolent and shorter for violent; verify at source).

NURSING CONSIDERATIONS

• •Tie the restraint to the bed frame with a quick-release knot, never to the side rail.
• •Check circulation, skin, and the need to continue often, and release to check skin and offer food, fluids, and toileting on a schedule.
• •In a true emergency, a nurse may apply a restraint and get the order right after.

Quick Concept: Least restrictive first, real order, never PRN, monitor closely.

WHAT IS IT?

Before giving any medication, the nurse checks a set of rights to prevent errors. The core list has five, with more added over time.

KEY POINTS

• •Right patient: confirm with two identifiers.
• •Right medication: match the drug to the order.
• •Right dose: confirm the amount is correct and safe.
• •Right route: confirm how it is given (by mouth, IV, and so on).
• •Right time: give it at the scheduled time.
• •Added rights often include: right documentation, right reason, right response, and the patient's right to refuse.

NURSING CONSIDERATIONS

• •Check the medication label three times against the order.
• •Document only after giving the medication, never before.
• •If anything does not match, stop and clarify before giving the drug.

Quick Concept: Patient, medication, dose, route, time. Five core rights every time.

WHAT IS IT?

Before care, medications, or procedures, the nurse confirms the right patient using two separate identifiers. This prevents giving care to the wrong person.

KEY POINTS

• •Use two identifiers, such as the patient's full name and date of birth.
• •The room number or bed number is never an acceptable identifier.
• •Check the identification band against the order and the patient's answer.
• •Ask the patient to state their name and birth date rather than asking yes or no questions.

NURSING CONSIDERATIONS

• •This is a National Patient Safety Goal from The Joint Commission.
• •For a confused patient, confirm with the band and a caregiver.
• •Always re-identify before each medication pass and each blood transfusion.

Quick Concept: Two identifiers, never the room number.

WHAT IS IT?

Informed consent is the patient's agreement to a treatment after understanding it. The provider and the nurse have different jobs in this process.

Provider's role:

• •Explains the procedure, its benefits, and its risks.
• •Describes the alternatives and what happens without treatment.
• •Answers the patient's medical questions.

Nurse's role:

• •Witnesses the patient's signature.
• •Confirms the patient understands and is signing freely.
• •Makes sure the form is complete and notifies the provider if the patient has questions or doubts.

NURSING CONSIDERATIONS

• •The nurse does not obtain consent or explain the procedure; that is the provider's duty.
• •If the patient is confused, sedated, or unsure, stop and call the provider.
• •Consent must be voluntary, informed, and given by a competent adult.

Quick Concept: Provider informs, nurse witnesses.

WHAT IS IT?

An advance directive is a legal document that states a patient's wishes for care if they cannot speak for themselves. It guides the team when the patient cannot decide.

KEY POINTS

• •It is created while the patient is competent and able to choose.
• •It takes effect only when the patient can no longer make decisions.
• •The patient can change or cancel it at any time while competent.
• •Common types include the living will and the durable power of attorney for health care.

NURSING CONSIDERATIONS

• •Ask about advance directives on admission and document the answer.
• •Place a copy in the medical record.
• •The nurse supports the patient's wishes and does not push a personal opinion.

WHAT IS IT?

These are two kinds of advance directive. One states the wishes; the other names a decision maker. They work together.

Living will:

• •A written statement of what care the patient does or does not want.
• •Often covers wishes about life support, feeding tubes, and resuscitation.
• •Speaks for the patient when they cannot speak.

Durable power of attorney for health care (DPOA):

• •Names a person (the health care proxy or agent) to make decisions.
• •The agent decides only when the patient cannot.
• •The agent should follow the patient's known wishes.

NURSING CONSIDERATIONS

• •A living will says what; the DPOA says who.
• •The DPOA agent speaks for the patient, but not while the patient can still decide.
• •Keep both documents in the chart and follow the facility policy.

Quick Concept: Living will = the wishes. DPOA = the person who carries them out.

WHAT IS IT?

HIPAA stands for the Health Insurance Portability and Accountability Act. It is a federal law that protects the privacy of a patient's health information.

KEY POINTS

• •Share patient information only with those involved in that patient's care.
• •Do not discuss patients in public areas like elevators or hallways.
• •Do not post any patient information on social media.
• •Patients have the right to see and get a copy of their own records.
• •Release information to others only with the patient's written permission.

NURSING CONSIDERATIONS

• •Log off the computer and keep paper charts out of public view.
• •Confirm who you are speaking with before sharing information by phone.
• •A breach of privacy can lead to fines and loss of license.

Quick Concept: Need to know only. If a person is not part of the patient's care, do not share.

WHAT IS IT?

Nurses are mandatory reporters. By law, they must report certain situations to the proper authorities to protect patients and the public.

KEY POINTS

• •Report suspected abuse or neglect of children, older adults, and dependent adults.
• •Report certain communicable diseases to public health authorities.
• •Report gunshot wounds, stab wounds, and suspected domestic violence per state law.
• •You report a reasonable suspicion; you do not need proof.

NURSING CONSIDERATIONS

• •Document the facts you observed in objective terms, not opinions.
• •Reporting in good faith protects the nurse from liability.
• •Failing to report when required can lead to legal penalties; verify exact rules at your source because they vary by state.

WHAT IS IT?

Scope of practice is the set of actions a nurse is legally allowed to perform. Each state defines it through its Nurse Practice Act, the law that governs nursing.

KEY POINTS

• •The Nurse Practice Act is a state law, so the exact scope can differ by state.
• •The state board of nursing enforces it and issues licenses.
• •Working outside your scope can mean losing your license.
• •A nurse must refuse a task that is unsafe or outside their scope, even if a provider orders it.

NURSING CONSIDERATIONS

• •If an order is unclear or unsafe, clarify it before acting.
• •Know your facility policy as well; it can be stricter than the law but not looser.
• •Doing something you are not trained or licensed for is negligence.

Quick Concept: The Nurse Practice Act is state law and sets the limits of what you can do.

WHAT IS IT?

SBAR is a standard way to hand off or report patient information clearly and quickly. It keeps the message organized so nothing important is missed.

STEPS

1. S = Situation: state who you are, the patient, and the current problem.

2. B = Background: give the relevant history and context.

3. A = Assessment: share your findings and what you think is going on.

4. R = Recommendation: say what you need or suggest next.

NURSING CONSIDERATIONS

• •Use SBAR when calling a provider or handing off to another nurse.
• •It reduces communication errors, a leading cause of patient harm.
• •Have the chart and recent vital signs ready before you call.

Quick Concept: Situation, Background, Assessment, Recommendation. Say it in that order.

WHAT IS IT?

The Universal Protocol is a set of steps from The Joint Commission used before surgery and invasive procedures to prevent mistakes. The time-out is the final check done just before the procedure starts.

STEPS

1. Verify the correct patient, procedure, and site before the procedure.

2. Mark the surgical site, usually by the person doing the procedure.

3. Perform the time-out: the whole team pauses right before starting.

4. During the time-out, confirm correct patient, correct procedure, and correct site, and resolve any disagreement before going on.

NURSING CONSIDERATIONS

• •The time-out involves the entire team and everyone must agree.
• •Its goal is to prevent wrong-patient, wrong-site, and wrong-procedure errors.
• •If anything does not match, stop and clarify before the procedure begins.

Quick Concept: Right patient, right procedure, right site. The whole team pauses to confirm.

WHAT IS IT?

Never events are serious, largely preventable errors that should never happen in care. They signal a major safety problem and often are not reimbursed by insurers.

KEY POINTS

• •Surgery on the wrong patient, wrong site, or wrong procedure.
• •A foreign object, such as a sponge, left inside a patient after surgery.
• •A severe pressure injury (bedsore) that develops in the hospital.
• •A patient fall or medication error causing serious harm.
• •A mismatched blood transfusion.

NURSING CONSIDERATIONS

• •These events are reported and reviewed to find the root cause.
• •Prevention relies on checklists, time-outs, two identifiers, and safe handoffs.
• •The focus is on fixing the system, not blaming one person.

Quick Concept: Never events are serious, preventable, and should never occur.

WHAT IS IT?

The UAP (unlicensed assistive personnel) supports the team with basic tasks that are stable, routine, and need no nursing judgment. Knowing what fits the UAP helps you delegate safely.

Can delegate to UAP:

• •Bathing, feeding, and helping a stable patient walk.
• •Taking routine vital signs on a stable patient.
• •Measuring intake and output and weighing the patient.
• •Helping with hygiene, positioning, and toileting.

Cannot delegate to UAP:

• •The initial assessment or any nursing judgment.
• •Patient teaching.
• •Giving medications (in most settings).
• •Care of an unstable patient or a first feeding for a patient at risk of choking.

NURSING CONSIDERATIONS

• •Give clear instructions and tell the UAP exactly what to report back.
• •The RN (registered nurse) keeps accountability and checks the result.

Quick Concept: Stable, routine, no judgment goes to the UAP.

WHAT IS IT?

When you have several patients, you must decide who to see first. Combine the ABCs, stability, and what is expected versus unexpected to make the call.

KEY POINTS

• •See the patient with an airway, breathing, or circulation problem first.
• •See the unstable patient before the stable one.
• •An unexpected or new symptom outranks an expected finding.
• •A problem that could become life-threatening soon outranks a steady, chronic one.

NURSING CONSIDERATIONS

• •Ask which patient is least stable and most likely to get worse fast.
• •Expected findings for a known diagnosis are lower priority.
• •Reassess often because priorities change as patients change.

Quick Concept: Sickest and least stable first, using the ABCs to break ties.

WHAT IS IT?

Protective precautions, also called neutropenic precautions, protect a patient who has a very weak immune system from catching infection. Here the goal is to keep germs away from the patient, not to contain a germ.

KEY POINTS

• •Used for patients with a low white blood cell count, such as those on chemotherapy or after a transplant.
• •Place the patient in a private room, often with positive-pressure airflow.
• •Limit visitors and screen out anyone who is sick.
• •Do not bring fresh flowers, fresh fruit, or standing water that can grow germs.
• •Stress strict hand hygiene for everyone entering.

NURSING CONSIDERATIONS

• •This is the opposite direction of airborne isolation: positive pressure keeps room air clean by pushing outside air away.
• •Avoid raw or undercooked foods for these patients.

Quick Concept: Protective precautions guard the patient, not the room.

WHAT IS IT?

An incident report, also called an occurrence report, is an internal record of an unexpected event such as a fall, a medication error, or an injury. It helps the facility improve safety.

KEY POINTS

• •Complete it as soon as possible after the event.
• •Write only objective facts, what you saw and did, not opinions or blame.
• •It is a confidential quality tool, used to improve systems.
• •Do not mention the incident report in the patient's chart.

NURSING CONSIDERATIONS

• •Still chart the patient's condition, assessment, and care in the medical record.
• •Notify the provider and follow up on the patient's status.
• •The report is for the facility; it is not part of the legal medical record.

Quick Concept: Facts only, file it separately, never reference it in the chart.

WHAT IS IT?

Sharps are needles, scalpels, and other items that can pierce the skin. Safe handling prevents needlestick injuries, which can spread bloodborne infections.

KEY POINTS

• •Never recap a used needle.
• •Drop sharps directly into a puncture-proof sharps container.
• •Do not overfill the container; replace it when it reaches the fill line.
• •Use safety-engineered devices with built-in needle guards.
• •Keep the sharps container close to where you give the injection.

NURSING CONSIDERATIONS

• •If a needlestick happens, wash the area, report it at once, and follow the exposure protocol.
• •Bloodborne risks include hepatitis B, hepatitis C, and HIV (human immunodeficiency virus).

Quick Concept: Never recap, dispose right away, do not overfill.

WHAT IS IT?

The ESI (Emergency Severity Index) is a common 5-level emergency triage tool. It sorts patients by how urgent they are and how many resources they will likely need.

KEY POINTS

• •Level 1: needs immediate life-saving care (for example, not breathing).
• •Level 2: high risk, should not wait (for example, severe chest pain or confusion).
• •Level 3: needs many resources but is stable.
• •Level 4: needs one resource.
• •Level 5: needs no resources, the least urgent.

NURSING CONSIDERATIONS

• •Levels 1 and 2 are decided by how sick and unstable the patient is.
• •Levels 3 to 5 are decided by how many resources are expected, such as labs, imaging, or procedures.
• •Verify the exact decision points at your source, since facilities apply the tool with their own guidance.

Quick Concept: Sicker patients get a lower number; level 1 is the most urgent.

WHAT IS IT?

A competent adult has the legal right to make decisions about their own body, including the right to refuse treatment. The nurse respects and supports that choice.

KEY POINTS

• •A competent adult may refuse any treatment, even a life-saving one.
• •The patient has the right to clear information to make the choice.
• •Forcing care on a competent adult who refuses can be battery.
• •The patient also has the right to dignity, privacy, and respectful care.

NURSING CONSIDERATIONS

• •If a patient refuses, make sure they understand the risks, then document the refusal.
• •Notify the provider when a patient refuses important care.
• •Never threaten or pressure a patient into a treatment.

Quick Concept: A competent adult can refuse care; your job is to inform, document, and respect.

WHAT IS IT?

A handoff is the moment one nurse transfers responsibility for a patient to another nurse or unit. Most communication errors happen here, so a clear, structured report is essential.

KEY POINTS

• •Give a complete report covering the patient's status, recent changes, and pending tasks.
• •Use a structured format such as SBAR (Situation, Background, Assessment, Recommendation).
• •Do the handoff at the bedside when possible so both nurses can see the patient.
• •Allow time for questions and a read-back of key information.

NURSING CONSIDERATIONS

• •Include allergies, code status, lines, drains, and any safety concerns.
• •Confirm pending labs, medications due, and follow-ups.
• •A good handoff prevents missed care and errors after the shift change.

Quick Concept: Structured, two-way, at the bedside when possible.