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Safe and Effective Care Environment Management of Care (16-22%)

know all about informed consent. Who can sign for it, who cannot? and exceptions
Informed Consent
a legal document that gives permission to perform surgery, treatment, procedure,
or to give information to a third party
must be an adult over the age of 18
client may withdraw consent at any time
Who can sign a consent: legal/appointed guardian, durable power of attorney,
emancipated minor (a minor who has established independence through marriage,
pregnancy, served in the armed forces, or by a court order)
In general, there are two situations in which informed consents of an adult is not
needed: when an emergency is present and delaying treatment for the purpose of
obtaining informed consent would result in injury or death to the client. the
second is when the client waives the right to give informed consent
Remember: The HCP obtains the informed consent
The client gives permission of the informed consent
The nurse witnesses the informed consent
Client has the right to refuse treatment at any time w/o permission

know about the patients right to refuse treatment

Client's Rights
the client has the right to participate in his/her own healthcare with respect for the
individual's right to self determination (Autonomy)
Should the client refuse treatment or leave against medical advice, the nurse will
notify the HCP, explain the risks involved with leaving against medical advice,
and the nurse asks the client to sign an against medical advice form and
documents the incident

know the nurses role in advance directives

Advance Directives
purpose of advance directives is to communicate a clients wishes regarding end-of-life
care should the client become unable to do so
Types include: Living Will (expression of client's wishes), Durable Power of
Attorney (healthcare proxy)and Provider's Order (DNR or AND prescription)
Advance Directives must be documented and must be included in the clients
medical record

know the rules for restraints

Restraints (Physical and Chemical Safety devices)
must include a physician order, type, reason and timeframe
cannot be prescribed PRN
use quick release tie to secure restraint to bed frame or chair, do not tie to side rails
Assess restraints every 30 minutes and remove every 2 hours
Remember: Alternative measures for safety devices should always be used first such
as alarms sensors & restraints must be renewed every 24 hours
know about Malpractice, Defamation of Character, False Imprisonment, Assault and
Legal Responsibilities
Negligence- happens when a nurse fails to (unintentionally) implement safety measures for a
client (such as risk for falls)
Assault- an intentional threat made to a person
False Imprisonment- occurs when a client is not allowed to leave the health care facility when
there is no justification to detain the client. It can also occur when a restraining devices are used
without appropriate clinical need
Malpractice- failure to perform a duty and the client was injured because of it
Defamation of Character- a false communication that causes damage to someone's reputation
either in writing (libel) or verbally (slander)

Know what kind of task to delegate to RN, LPN's and UAP

Delegating and Supervision
In general, non-invasive interventions such as ADL's, skin care, range of motion
exercises, Vital signs for stable patients, specimen collections, positioning, feedings w/o
swallowing precautions, I & O, ambulation, grooming and hygiene measures, can be
assigned to the unlicensed assistant personnel (UAP)
In general, an LPN can perform all that a UAP can and invasive tasks such as dressing
changes, suctioning, inserting urinary catheters, tracheostomy care, administer enteral
feedings, check NG tube patency, reinforce client teachings, assist RN with ongoing care
plan assessments, medication administration (oral, subcutaneous, intramuscular and
selected piggyback medication) EXCLUDES IV MEDS IN SOME STATES
RN's are responsible for the nursing process, client education and tasks that require
nursing judgment to LPN or UAP

know what kind of patient to delegate to Float Nurses

Regulation of Nursing Practice
legally, the nurse cannot refuse to float unless a union contract guarantees that the nurse
can work only in a specified area or the nurse can prove lack of knowledge for the
assigned task
the nurse should inform supervisor of any lack of knowledge pertaining to the assigned
Know when to file an Incident Report
Incident Reporting
used as a means to identify risk situations and improve client care
incident report forms should not be copied or placed in client's medical record
Examples of when to file an incident report include:
medication errors, falls, needle-sticks, visitor/employee injures, procedure or equipment
Know how to identify ethical principles
Ethical Principles
ethical principles must be used to direct nursing actions
Autonomy- refers to the clients right to make own decisions
ex: the patient has the freedom of choice regarding treatment
Non-Maleficence- the obligation to do or cause no harm to another
Example: When this elderly person above received pain medication (an act of
beneficence) there are complications that could arise. Practitioners recognize
that using a narcotic may cause confusion. When obtaining the consent for her
hip surgery, we want to make certain that the patient is alert enough to
understand the risks and benefits of the procedure. We must balance the
beneficence of providing the medication quickly with the possible maleficence of
obtaining a consent when patient does not have the capacity to make the decision
for surgery.
Beneficence- relates to the quality of doing good for the benefit of the client
Example: An elderly patient falls at home and has a fractured hip. In the emergency
room, the nurse acts to provide pain medication as soon as possible in an act of
Justice- fair and equal treatment for all
Example: A hospital organization wishes to donate low or no-cost pediatric dental
services to the community. There are openings for 45 children per month. Justice
requires a fair method, that is free from bias, to determine who will receive these services
Veracity- being honest to tell the truth
Example: telling the client the truth about her terminal illness
Fidelity- to do what you promised to do!
Example: A patient asks the nurse not to reveal the fact that she is dying or give her
diagnosis to his family. The nurse asks why she does not want her family advised. The
patient explains that her family is very emotional and has stated they would do everything
to keep her alive, even if it required long-term mechanical ventilation. The patient has
explained multiple times that she does not want mechanical ventilation. The nurse
recognizes that keeping of this information in confidence, while supporting the family, is
an example of exercising fidelity.

Know the Do's and Don'ts of Documentation Guidelines

document subjective data as direct quotes such as the client stated, "the pain is
affecting my judgment"
document objective data as what the nurse sees, hears, feels(touch) and smells and
be precise in documenting accurately. ex: instead of saying the client appears
agitated, write the client is pacing back and forth in the room, yelling loudly.
NEVER pre-chart
do not leave blank spaces and use black ink for narrative documentation
when an entry error is made, draw a line through it and date & initial
do not use unacceptable abbreviation
document all care, responses, interventions, treatments, medications and calls
made to heath care team regarding patient treatments and questions
know how to take Telephone or Verbal Prescriptions
have a second nurse listen to a telephone prescription and sign
repeat it back , making sure to include the medications name, dosage, time
and route
question any prescription that may seem inappropriate for the client
Sign the prescription beginning w/ T.O, the HCP name and your name and
make sure the provider signs the prescription in person typically within 24

know the Roles of other Healthcare Team Members

Physical therapist- helps clients that express mobility concerns learning to
ambulate and regain strength
Occupational therapist helps clients that express ADL concerns concerning
adaptive devices that can be used such as eating utensils
Respiratory Therapist helps clients that express breathing treatment and
Social Worker- assists with continuation of healthcare services and family and
discharge planning
Nutrition Therapists assists clients with nutritional needs
Speech Therapist-assists clients with speech, language and swallowing

know about Time Management Techniques

Time Management
a technique designed to assist in completing tasks as quickly and as effectively as
possible in deciding on the most important tasks to do (prioritize) and doing it correctly
by: prioritizing client needs and keeping a log to assist with providing structure
Document medication/care as soon as completed

Know the Order of Priority in Assessing a Group of Clients

Prioritizing Care
priorities are classified as high, intermediate or low
life threatening or that could result in harm to the client if left untreated are high
Use ABC's (airway, breathing, circulation) as a guide when determining priority
Use Maslow's Hierarchy of Needs theory: Physiological needs, safety, love and
belonging, self esteem, self actualization
Use the nursing process ADPIE to determine priorities, remembering that
assessment is the FIRST step of the nursing process and Evaluation is the LAST

know what actions to take in the event of a Fire

remember the mnemonic RACE to setup priorities in the event of a fire and the
mnemonic PASS to use a fire extinguisher
Rescue the client
Activate the fire alarm
Confine the fire
Extinguish the fire
Pull the pin on the extinguisher
Aim at the base of the fire
Squeeze the extinguisher handle
Sweep the extinguisher from side to side

know what actions to take regarding ways to reduce exposure to Radiation

Radiation Safety
Remember : Time, Distance and Protective shield
monitor radiation exposure with a film (dosimeter) badge
place clients w/ radiation implants in a private room
keep all linen in the clients room until implant is removed

know practices that promote Medical and Surgical Asepsis

medical asepsis is "clean technique" that applies to administering medication,
managing NG tubes, providing personal hygiene and many other common nursing
Surgical asepsis is "sterile technique" applies to parenteral administration, urinary
catheter insertion, surgical procedures, sterile dressings and more

Infection Control (8-14%)

know how Health-care Associated (Nosocomial) Infections are acquired

HAI's are infections that the client acquires while receiving care in a hospital
the best way to prevent HAI's is through effective and frequent hand washing
most commons sites of HAI's is the urinary tract
most common causes are E.coli, S. auureus, and enterocci
An iatrogenic infection is a type of HAI resulting from a diagnostic or
therapeutic procedure
In older adults S/S could show confusion, agitation and incontinence
Common drug resistant HAI's: Vancomycin-enterocci, Methicillin-resistant S.
Aureus, and Multidrug-resistant Tuberculosis

know the mnemonics for Infection Control and what kind of precaution you have to take
for each one
Standard Precautions
must be practiced will ALL clients in any setting
includes hand washing, gloves, gown, mask and eye protection when appropriate
for client contact
Wash hands before and after client care
Wear gloves when touching blood, body fluids, secretions, non-intact skin,
mucous membrane, and contaminated items
Use alcohol based hand rubs when hands are not visibly soil
Wear masks, eye protection, or face shield for activities that may cause splashing
Wear gowns if soiling of clothing is likely
a client on standard precautions does not require a private room
Clean spills of blood or body fluid with diluted bleach and water or disinfectant

Transmission-Based Precautions include airborne, droplet, and contact precautions

Airborne Precautions
used for diseases or very small germs that are spread through the air from one
person to another.
Examples: Tuberculosis, measles, chickenpox (varicella)
precautions: require a private room (negative pressure airflow), N95 or HEPA
mask required. Mask required for visitors entering the room
Mask is placed on client when leaving the room

Droplet Precautions
used for diseases or germs that are spread in tiny droplets caused by coughing and
sneezing (examples: pneumonia, influenza, whooping cough, bacterial
meningitis). think of Spiderman!
precautions: private room or room with client that share the same infection
wear a surgical mask when within 3 feet of a client.
Place mask on client when the client needs to leave the room

Contact Precaution
used for infections, diseases, or germs that are spread by touching the patient or
items in the room
Precautions: require glove and gown, use precaution when within 3 feet of the
examples: C.difficile, RSV, wound infections, skin infections, eye infections, Flu
virus, multi-drug resistant infections
Know everything about Tuberculosis (TB)
contagiously airborne communicable and severe bacterial infection that usually
involves the lungs, but may spread to other parts of the body such as the brain,
kidneys, or the spine.
TB is spread through the airborne route
A client w/ TB needs to provide sputum sample every 2-4 weeks to monitor the
effectiveness of TB medication
Manifestations of TB include: persistent cough, fatigue, night sweats and purulent
Medications prescribed for TB: rifampin (causes yellowing of the skin, dark
orange urine, pain in the joints and loss of appetite) , ethambutol (causes vision
changes) and isoniazid (clients should take Vit B daily and observe signs for
TB regimen for 6-12 months
Intradermal injection, PPD 5 units, results 48-72 hours
Induration of >5 indicates positive for TB

know the differences between Hepatitis A, B and C

an inflammation of the liver
includes flu-like symptoms, jaundice, dark colored urine and stools and elevated
bilirubin, ALT, AST and ammonia level
Hep A- fecal-oral route through contaminated fruits vegetables and shellfish
Hep B and C- blood and body fluid contact
Preventions: Strict hand washing, needle precautions, and blood donor screenings

know all about HIV and AIDS, precautions, meds and treatment for it
HIV is a chronic illness that destroys T-cells
transmitted through blood and body fluids (semen and vaginal secretions)
use standard precautions when caring for a client with HIV
Disease prevention: condoms, abstinence and avoid sharing needles
encourage client to maintain up to date influenza and PPSV vaccine
S/S: chills, weight loss, night sweats, malaise, fever, diarrhea
Positive results of a Western Blot test and Indirect Immunofluorescence Assay
ELISA, confirms the presence of HIV infection
Positive CD4+ assists with the clarifying stage of HIV infection
Viral loading test determines how much of the HIV is in the blood
risk factors associated w/the virus: perinatal exposure, older adult women,
occupational exposure
avoid changing pet litter box to prevent getting toxoplasmosis
avoid raw fruits and veggies
Meds: antiretroviral therapy, NRTI such as Abacavir and Zidovudine
Know briefly about Lyme Disease
Lyme Disease
caused from a "tick bite"
ring-shaped rash
remove tick w/ tweezers, wash w/antiseptic, dispose by flushing or placing in a sealed jar
instruct client to avoid wooded grassy areas

Be able to differentiate between STI's. Mainly signs and symptoms of Syphilis, Gonorrhea,
Herpes, and Chlamydia
Chlamydia- causes a sharp pain at the base of the ribs that is sometimes referred to the
right shoulder and arm
a frequent cause of pelvic inflammatory disease and infertility

Gonorrhea- men have s/s of urethritis and yellow urethral discharge; women have
utheritis, sore throat or abnormal period
newborns born to mothers who have gonorrhea can develop opthalmia neoatorum

Syphilis- a painless red ulceration (chancre)

Trichomoniasis- painful w/ intercourse, burning at the genital site, frothy foul
smelling discharge
Herpes-painful vesicular outbreak

know what to do for poison ingestion

assess the person or child first before anything
remove exposure to the poison such emptying remaining pills from mouth or
flushing skin)
Identify the poison
Take measures to prevent absorption of the poison such as administering activated
lead posioning- Chelation therapy removes lead from the blood
Acetaminophen (Tylenol)- administer Acetylcysteine and dilute with juice or soda
because of its defensive odor
Aspirin poisoning- use activated charcoal
Corrosives such as bleach, household cleaners use no more than 4 ox of milk or
water, do not induce vomiting
Growth and Development
know specific age developments from infancy to adolescent
Infants (1 month to 1 year)
Trust vs Mistrust
age appropriate activities include playing w/ blocks and balls, reading
prevent aspiration, drowning, poisoning and suffocation

Toddlers (1 to 3 years)
Autonomy vs Shame and Doubt
punishment and obedience stage; parallel play
age appropriate activities include riding a tricycle, using blunt scissors, throw and
kick a ball
prevent self bodily harm, drowning, burns and falls

Preschoolers (3 to 6 years)
Initiative vs Guilt
pretend play stage; associative play
age appropriate play include riding a tricycle, hop on one foot, jump rope and
throw ball
over head, reading books, wading pools, skating and electronic games
Injury prevention include crossing the street

School-Aged Children (6 to 12 years)

Industry vs Inferiority
transitions into conceptual thinking such as able to tell time and solve problems
age appropriate activities include competitive play
Injury Prevention include wearing a helmet, use sunscreen when outdoors, motor
vehicle safety and poison/substance use

Adolescents (12 to 20 years)

Identity vs Role Confusion
uses logic to make decisions
be aware of mood changes and risk for self-harm
injury prevention include drinking, cell phone use while driving, enforcing seat
belt use