Triage in Mass Casualty Events
Triage Classes and Colors
Answer
Triage in Mass Casualty Events
System implemented to provide the greatest good to the greatest number of people in a mass casualty event.
Class I - Red: Severe life-threatening injury (e.g., hemorrhaging laceration, sucking chest wound, amputation). Treat first.
Class II - Yellow: Serious injury, not life-threatening (e.g., open fracture without hemorrhage, full thickness burn not affecting airway). Treatment can be delayed up to 60 minutes.
Class III - Green: Minor injuries, "walking wounded" (e.g., closed wrist fracture, sprain, abrasion, minor lacerations). Treatment can be delayed for several hours.
Class IV - Black: Mortal wounds (e.g., penetrating head wound with fixed/dilated pupils, unresponsive patient with agonal respirations). Expected and allowed to die.
Do not prioritize patients who are mortally wounded but still alive.
Card 2
Management of Disasters
Mitigation
Preparedness
Response
Recovery
Answer
Management of Disasters
Mitigation: Prevention or reduction of the cause, impact, or consequences of disasters (e.g., risk assessment, inspections, education).
Preparedness: Planning, training, and education for unavoidable disasters (e.g., create disaster action plan, identify evacuation routes, develop communication plan, execute disaster drills, create supply kit).
Response: Implementation of disaster action plan (e.g., implement evacuations, perform search and rescue operations, triage victims).
Recovery: Restoration efforts (e.g., rebuilding structures, ↓ vulnerability to future disasters).
Card 3
Bioterrorism
Anthrax
Smallpox
Other Potential Agents
Answer
Bioterrorism
Deliberate release of biological agents as weapons, with the intent to kill or disable those in the general population.
Anthrax: Deadly infectious disease caused by B. anthracis spores.
- S/S: Fever, shortness of breath, cough, N/V, diaphoresis.
- Tx: Antibiotics (e.g., ciprofloxacin, doxycycline), antitoxins.
Smallpox: Deadly infectious disease caused by variola virus. Eradicated since 1979 via immunizations, but viral stockpiles still exist.
- S/S: Fever, rash that starts in the mouth and spreads down the body.
- Tx: Smallpox vaccine (↓ severity of illness), antivirals.
Other Potential Agents: Botulism, plague, tularemia, hemorrhagic viruses (e.g., Ebola), food and water safety threats.
Nationally Notifiable Diseases
Diseases monitored by the National Notifiable Diseases Surveillance System (NNDSS) in order to prevent the occurrence and/or spread of these infections.
Key Diseases:
- Anthrax
- Botulism
- Chlamydia
- Cholera
- COVID-19
- Diphtheria
- Giardiasis
- Gonorrhea
- H. influenzae
- Hantavirus
- Hepatitis A/B/C
- Lead Poisoning
- HIV
- Lyme Disease
- Meningococcal disease
- Measles
- Mumps
- Pertussis
- Rabies
- Rubella
- Salmonella
- Shiga toxin- producing E. coli
- Smallpox
- Syphilis
- Tetanus
- Tuberculosis
- Varicella
- Viral hemorrhagic fevers
- Zika
Reporting: Local Departments of Health report notifiable communicable diseases to the State Departments of Health, which report them to the CDC.
A FULL list of nationally notifiable diseases can be found at CDC.gov.
Epidemiology
Incidence: Number of new cases of a disease/injury in a population during a specified time.
Prevalence: Number of current cases (new and pre-existing) of a disease/injury in a population during a specified time.
This figure does not include patients who have died from the disease/injury!
Attack Rate: Number of new cases divided by the total population.
Endemic: A disease that is typically present within a population or geographic area.
Epidemic: Increase in the number of cases of a disease above what is normally expected within a population or area.
Pandemic: The spreading of an epidemic to other countries and continents, affecting a large number of people (e.g., COVID-19).
Card 6
Epidemiology
Epidemiologic Triangle
Answer
Epidemiology
The study of the distribution, causes, and risk factors of health-related events in a specific population.
Epidemiologic Triangle: Model developed by scientists to study health problems.
- Agent: What causes the disease (e.g., bacteria, virus, pollutant).
- Host: Infected organism (e.g., human, animal).
- Environment: External factors that allow the disease to spread (e.g., dirty water, warm temperature).
Card 7
Community Assessment - Data Collection Methods
Informant Interviews
Direct Observation
Windshield Survey
Secondary Analysis
Surveys
Answer
Community Assessment
Informant Interviews: Gather data by interviewing selected members of the target community.
Direct Observation: Observe human activities at a chosen location over a period of time.
Windshield Survey: Drive around a community and make observations of what is seen through the car's windshield (e.g., housing, residents, open spaces, stores, businesses, schools, transportation services, medical facilities).
Secondary Analysis: Review existing data (e.g., vital statistics records, community health records, census data).
Surveys: Collect data from a sample of persons.
Card 8
Community Health Plan
Nursing Process
Answer
Community Health Plan: Nursing Process
Assessment: Identify aggregate to study, perform data collection. Identify community needs, problems, and strengths.
Diagnosis: Analyze and prioritize community health problems.
Planning: Identify specific, measurable goals to address the problems. Plan interventions to meet those goals.
Implementation: Execute interventions identified during the planning stage.
Evaluation: Assess effectiveness of the interventions and understand the factors that contributed to the success or failure of the intervention.
Card 9
Family Nursing
Family Systems Theory
Family Assessment Tools
Answer
Family Nursing
Family Systems Theory: Family is an interdependent unit. A change/stressor experienced by one family member affects the entire family.
Family Assessment Tools:
- Genogram: Graphic representation of a family tree (typically 3 generations). Can incorporate the family's medical/health history to identify patterns (e.g., "My Family Health Portrait" from the CDC).
- Ecomap: Diagram that highlights the relationships between the family and external systems (e.g., school, work, extended family).
Transitions are a time of ↑ risk for families. Transitions include normal life changes (e.g., birth of a child) and unexpected events (e.g., job loss, divorce, death of a family member).
Card 10
Health Risks Across the Lifespan
Adults:
- Health Risks
- Patient Teaching
Answer
Health Risks Across the Lifespan - Adults
Health Risks: Chronic diseases (e.g., CVD, diabetes, mental illness, cancer, obesity).
- Women: Reproductive health issues, menopause, breast cancer, osteoporosis.
- Men: Prostate and testicular cancer.
PT: Annual wellness examinations, self-examinations (e.g., breast self-examination, testicular self-examination), screenings (e.g., mammograms, pap tests, prostate cancer screening), healthy lifestyle choices (e.g., weight-bearing exercise to prevent osteoporosis).
Card 11
Health Risks Across the Lifespan
Infants, Children, Adolescents:
- Health Risks
- Family Teaching
Answer
Health Risks Across the Lifespan
Infants:
- Health Risks: Congenital defects, preterm and low birth weight, sudden infant death syndrome (SIDS), accidental injuries (e.g., suffocation).
- Family Teaching: Prenatal care, benefits of breastfeeding, sleep safety (e.g., place baby on back for all sleep).
Children:
- Health Risks: Accidental injuries (e.g., choking, drowning, bicycle or sports injuries), childhood obesity.
- Family Teaching: Car seat safety, protective equipment for sports, healthy eating, physical activity, immunizations.
Adolescents:
- Health Risks: Mental health disorders, substance use, smoking, motor vehicle accidents, STIs.
- Family Teaching: Safe sex practices/abstinence, motor vehicle safety (e.g., seat belts, no cell phone use, no drinking), monitor for substance abuse and mental health issues.
Card 12
Subsidized Health Insurance
Medicare
Medicaid
Answer
Subsidized Health Insurance
Medicare: Insurance program for individuals > 65 years old and younger people with End-Stage Renal Disease (ESRD), Amyotrophic Lateral Sclerosis (ALS), or receiving dialysis.
- Part A: Inpatient hospital, skilled nursing facility, home health.
- Part B: Outpatient care, medical supplies, preventative services.
- Part C: Part A and part B combined through private insurance. Can include vision, hearing, dental, and prescription coverage.
- Part D: Prescription drug coverage.
Part A is for Acute care.
Part B is for Basic medical care.
Part C is for Commercial insurance.
Part D is for Drug coverage.
Medicaid: Assistance program available for low income persons/families, based on taxable income and family size.
Care for the elderly, give aid to the poor.
Card 13
Violence in the Community
Community Risk Factors
Victim Risk Factors
Effects of Violence
Prevention
Answer
Violence in the Community
Community RF: Poverty, unemployment, substance abuse, mental illness, access to firearms, media influence.
Victim RF:
- Homicide: Males, African Americans, young adults.
- Suicide: Males, > 75 years old, Native Americans.
- Sexual Assault: Females, victims of intimate partner violence (IPV).
Effects of Violence: Witnessing and being the victim of violent acts may lead to poor long-term behavioral and mental health outcomes. Individuals exposed to violence (at any age) are more likely to experience or perpetrate IPV in the future.
Prevention: Education (e.g., parenting classes, life skills training, anger management), mentoring and peer programs, screening for abuse during all health care visits.
Card 14
Vulnerable Populations
Migrant Workers
Homeless
Veterans
LGBT+
People with Disabilities
Answer
Vulnerable Populations
Groups at higher risk of poor health outcomes due to societal barriers, lack of resources, or physical limitations.
Migrant Workers: Work injuries, pesticide/chemical exposure, sun exposure (↑ risk of skin cancer), dermatitis, communicable diseases (e.g. tuberculosis), dental problems.
Homeless: Trauma-related injuries, skin lesions (e.g., insect bites), infestations (e.g., lice, scabies), STIs, substance abuse, mental illness, communicable disease, dental problems.
Veterans: Mental health disorders (e.g., PTSD, depression), substance abuse, traumatic brain injury, amputations, chronic pain, suicide.
LGBT+: Substance use/abuse, suicide, homelessness, mental health disorders, victimization.
People with Disabilities: Chronic illness (e.g., obesity, hypertension), lack of preventative care, unhealthy behaviors (e.g., smoking).
Carbon Monoxide (CO) Poisoning
Toxicity from CO (a tasteless, odorless, and colorless gas). May lead to serious illness or death.
RF: Poor ventilation, malfunctioning heater, car exhaust, house fire.
PT:
- Install home CO detector, maintain functioning heating units, ensure adequate ventilation.
- Never use anything that burns gasoline or charcoal (e.g., generator, grill, camp-stove) inside home, garage, or basement.
- Be aware of signs/symptoms of CO poisoning: headache, dizziness, nausea, confusion.
Because CO binds to hemoglobin (in place of O2), patients with CO poisoning will have normal pulse oximetry readings!
Card 16
Lead Poisoning
Risk Factors
Nursing Care
Patient Teaching
Answer
Lead Poisoning
Excess lead exposure, causing damage to the nervous system and cognitive impairment.
RF: Pre-1978 housing and home renovation due to lead-based paint. Peeling/flaking paint contaminates soil surrounding the home and interior surfaces of the home.
NC: Conduct lead exposure screening, evaluate serum lead levels for at-risk individuals. Chelation therapy indicated for serum lead level > 45 mcg/dL.
PT: Check for peeling/chipped paint, wet mop floors (vs. vacuuming/sweeping), Frequently wash toys/pacifiers, children's hands/faces, and keep from playing in soil right outside home, ↑ child's intake of calcium and iron to ↓ lead absorption.
Card 17
Environmental Hazards
Air Pollution
Occupational Hazards
Water Contamination
Food Deserts
Answer
Environmental Hazards
Air Pollution: Motor vehicle and industry emissions (e.g., carbon monoxide, ground-level ozone, particulate matter), indoor air pollutants (e.g., tobacco smoke, asbestos, mold).
Occupational Hazards: Air contaminants (e.g., dust, fumes), chemical and biological hazards, machine operation risks, heat and/or radiation exposure, ergonomic risks (heavy lifting, repetition), excess noise.
Water Contamination: Wastewater treatment discharge, chemical contamination (e.g., fertilizers, pesticides), lead contamination from water pipes.
Food Deserts: Geographic areas that lack sufficient access to grocery stores and healthy food options.
Card 18
Determinants of Health
Environmental Factors
Social Factors
Answer
Determinants of Health
Environmental and social factors that profoundly affect health risks and outcomes.
Environmental Factors: Access to healthy food, clean water, and transportation. Infrastructure, environmental hazards (e.g., pollution, tobacco smoke), public safety (i.e., crime/violence).
Social Factors: Socioeconomic status, race, ethnicity, support system (e.g., friends, family), job opportunities, education, access to medical care.
Individuals with low socioeconomic status, minority populations, and socially isolated individuals have an ↑ risk for poor health outcomes.
Prevention Levels
Primary: Interventions aimed at preventing a disease from occurring in the first place (i.e., before a disease begins).
- Examples: Vaccinations, anti-smoking campaigns.
Secondary: Interventions focused on early detection of a disease.
- Examples: Screenings (e.g., annual mammograms, depression screening in the elderly, domestic violence screening).
Tertiary: Interventions aimed at slowing/stopping disease progress and prevention of complications after a disease is diagnosed.
- Examples: Rehabilitation, support groups (e.g., Alcoholics Anonymous).
Primary is aimed at Preventing illness. Secondary Screens for illness. Tertiary Treats existing illness!
Card 20
Community Health Nursing Roles
Home Health Nurse
Hospice Nurse
Occupational Health Nurse
Faith-Based (Parish) Nurse
School Nurse
Answer
Community Health Nursing Roles
Home Health Nurse: Provides care in the patient's residence. Responsibilities include patient assessment, treatment (e.g., wound care), education, and care coordination (e.g., communication w/provider, referrals).
Hospice Nurse: Provides palliative care and emotional support during the process of death.
Occupational Health Nurse: Provides screening, surveillance, and education to prevent workplace illness and injury.
Faith-Based (Parish) Nurse: Provides health education and promotion for a faith community or congregation, supports an individual's spiritual health.
School Nurse: Provides preventative care (e.g., vision and hearing screening), acute and emergency care, coordination of care for students with chronic illnesses.
Card 21
Community Health Terminology
Community
Aggregate
Community-Oriented Nursing
Community-Based Nursing
Answer
Community Health Terminology
Community: A group connected by social, personal, or geographical links.
- Example: People who live in the same neighborhood.
Aggregate: A subgroup or population that share characteristics or concerns (i.e., a community within a community).
- Example: LGBT+ residents of the same neighborhood.
Community-Oriented Nursing: Focus is on health promotion and disease prevention of the community or population (e.g., community education, screening, immunization clinics, outreach programs).
Public health nursing = Community-oriented nursing.
Community-Based Nursing: Focus is on illness care of individuals and families in the community (e.g., home health nursing).
Card 22
Patient Safety Events
Types of Patient Safety Events
Incident Reporting
Answer
Patient Safety Events
Event, condition, or incident that could or did result in harm to a patient.
Types:
- Near Miss: Error that did not result in patient harm (due to early detection or luck).
- Adverse Event: Results in patient harm (e.g., medication error, patient fall).
- Sentinel Event: Results in temporary severe harm, permanent harm, or death of a patient (e.g., amputation of the wrong leg).
Incident Reporting: Documentation of a patient safety event that is used for quality improvement. RN completes report within 24 hours (or per facility policy).
Do NOT include or mention the report in the patient's chart. This is an internal document, not a part of the medical record!
Card 23
Quality Improvement (QI)
QI Process
Best Practices
Answer
Quality Improvement (QI)
Ongoing process used to improve the quality and safety of health care.
QI Process:
- Establish standard of care (i.e., benchmark or best practice).
- Collect data and compare against benchmark/standard.
Audits are an effective way to measure/evaluate performance.
- If the standard was not met, perform a root cause analysis to understand the causative factors.
- Take corrective action(s) to address the gap.
- Re-evaluate to determine effectiveness of the solution.
Best Practices:
- Recognize QI as a continual process.
- Encourage employees to participate in the process and report unusual trends to the QI team.
Card 24
Disciplinary Action
Chemically-Impaired Employees
Progressive Approach to Discipline
Answer
Disciplinary Action
Chemically-Impaired Employees:
- Recognize signs/symptoms of chemical impairment:
- Personality changes (e.g., rapid mood swings, social isolation).
- Changes in physical appearance (e.g., red eyes, slurred speech).
- Job performance issues (e.g., ↑ med errors, excessive absences).
- Immediately remove employee from work setting, provide for safe transportation home, arrange formal meeting to discuss incident within 24 hours.
Nurses must report any suspicion of chemical impairment in coworkers to their supervisor.
Progressive Approach to Discipline:
Informal (verbal) reprimand → formal (written) reprimand → suspension from work → involuntary termination.
Card 25
Employee Performance Appraisal
Best Practices
Answer
Employee Performance Appraisal
- Collect data throughout the evaluation period (i.e., over time) to use for review.
- Allow employee to complete a self-appraisal before performance review.
- Include peer evaluations from professional staff.
- Compare employee performance against documented standards (i.e., performance checklist), NOT against other RNs.
- Set realistic, mutually agreeable goals for employee growth/improvement.
Conflict Management Strategies
Avoiding: Conflict is ignored by one or all parties. Conflict remains unresolved and grows.
Smoothing: One party compliments the other in order to gain agreement. Conflict is not resolved.
Competing: Win-lose solution. One party wins at the expense of the other party.
Accommodating: Lose-win solution. One party "gives in" and allows the other party to win.
Compromising: Lose-lose solution. Both parties make sacrifices. Conflict is resolved, but all parties are unsatisfied.
Collaborating: Win-win solution. Both parties put aside previous goals and work together towards a common goal. Produces the best outcome.
Card 27
Conflicts
Types of Conflict
Stages of Conflict
Answer
Conflicts
Types of Conflict:
- Intrapersonal: Individual's internal struggle.
- Interpersonal: Conflict between ≥ 2 people.
- Intergroup: Conflict between groups or departments.
Stages of Conflict:
- Latent: Individuals not aware of conflict yet, but it can occur at any time.
- Perceived: Individuals are aware of the conflict, but without an emotional response.
- Felt: Emotional response to the conflict (e.g., stress, anxiety).
- Manifest: Action begins to resolve the conflict.
- Aftermath: The conflict is resolved with positive and/or negative results.
Card 28
Best Practices for Efficiency
Efficient Nursing Practice
Critical Pathways
Answer
Best Practices for Efficiency
Efficient Nursing Practice:
- Identify and prioritize tasks for patients at the beginning of the shift.
- Cluster patient care (e.g., perform wound dressing change and give meds in one trip).
- Complete tasks for one patient before moving on to the next.
- Delegate tasks when appropriate (cards 163 - 165).
- Complete charting as soon as possible after performing a task/procedure. Do not wait until the end of the shift!
Critical Pathways: Multidisciplinary care plan which details the essential steps to care for patients with a common diagnosis.
- Goal = improve efficiency and ↓ patient's length of stay.
Card 29
Delegation
Practical Nurses (LVNs/LPNs):
- Tasks Within Scope of Practice
- Tasks Outside Scope of Practice
Answer
Practical Nurses (LVNs/LPNs)
Tasks Within Scope of Practice:
- Administration of most medications and enteral feedings.
- Wound dressing changes.
- Insertion, removal, and management of invasive items (e.g., catheter, enema, IV, NG tube).
- Tracheostomy care.
- Reinforcement of teaching after RN has done initial teaching.
Tasks Outside Scope of Practice:
- Initial patient assessment (e.g., new admission).
- Creation of nursing diagnosis or care plan.
- Administration of IV medications (depending on state laws).
- Administration of blood products or chemotherapy.
- Taking verbal orders from the provider.
Only RNs can EAT: Evaluate, Assess, Teach.
Card 30
Delegation
Unlicensed Assistive Personnel (UAPs):
- Tasks Within Scope of Practice
- Tasks Outside Scope of Practice
Answer
Unlicensed Assistive Personnel (UAPs)
Tasks Within Scope of Practice:
- Personal Care: Hygiene, bathing, dressing, feeding (without swallowing precautions), toileting needs, repositioning.
- Safety: CPR, fall prevention, ambulation.
- Basic Skills: Routine vital signs, obtaining weight and height, reporting changes to a licensed provider (RN), non-invasive specimen collection, charting I&Os.
Tasks Outside Scope of Practice:
- Medication administration.
- Wound care.
- Insertion, removal, or use of invasive items (e.g., catheter, enema, IV).
Card 31
Delegation
Five Rights of Delegation
Answer
Delegation
Right Task: Only delegate tasks allowed by state laws and workplace policies.
Right Circumstance: Consider the patient's status (e.g., do not delegate a task for an unstable patient).
Right Person: Ensure delegatee has the knowledge, experience, and qualifications/training to safely perform the task.
Right Direction: Communicate your expectations, when/what/how to report back, and a deadline for the task.
Right Supervision: The RN is accountable for evaluating the outcome of the task. Provide feedback as needed.
Patient Prioritization
Restrictive/Invasive Procedures: Begin with the least restrictive or invasive intervention(s) before progressing.
- Example #1: For a confused patient at risk for falls, provide a sitter for the patient (non-restrictive) instead of applying restraints (restrictive).
- Example #2: For a patient having difficulty urinating, try pouring warm water over the perineum (non-invasive) before inserting a urinary catheter (invasive).
Survivability Potential: In mass casualty events, priority is given to the seriously wounded who are likely to survive with intervention.
- Example: Prioritize a patient with an open femur fracture over an unresponsive patient with a penetrating head wound.
Card 33
Patient Prioritization
Acute vs. Chronic
Unexpected vs. Expected
Answer
Patient Prioritization
Acute vs. Chronic: New-onset symptoms take priority over symptoms associated with a chronic illness.
- Example: A patient with a long bone fracture with sudden onset of chest pain & dyspnea takes priority over a COPD patient with an SpO2 of 89% (common for this disorder).
Unexpected vs. Expected: Unexpected findings take priority over S/S that are expected for a patient's diagnosis.
- Example: A diabetic patient with a blood sugar reading of 40 mg/dL takes priority over a patient with appendicitis complaining of RLQ pain (expected with this diagnosis).
Card 34
Patient Prioritization
Nursing Process
Maslow's Hierarchy
ABCs
Answer
Patient Prioritization
Nursing Process: Assess, Diagnose, Plan, Implement, and Evaluate in that order. Always assess before taking any action!
- Example: Patient reports dyspnea. Assess first (e.g., listen to breath sounds, check O2 saturation) before determining next steps (e.g., notifying the provider).
Maslow's Hierarchy: Basic physiological needs must be met before addressing higher psychosocial concerns.
- Example: When prioritizing a nursing diagnosis for a patient with anorexia nervosa, "Imbalanced Nutrition" (physiological issue) takes priority over "Disturbed Body Image" (psychosocial issue).
ABCs: Airway, Breathing, Circulation priority is set in that order.
- Example: A patient experiencing an asthma attack (airway threat) takes priority over a patient complaining of severe chest pain (circulation threat).
Leadership Styles
Authoritarian/Autocratic: Decisions made with little input from the team, leader dictates instructions. Leads to mistrust and high turn-over.
This style may be useful in emergency situations.
Laissez-Faire: Hands-off approach. Leader allows team to make decisions for themselves with no direction. Leads to low productivity and frustration.
Laissez-Faire = Lazy.
Democratic: Leader and team work together towards goals and outcomes. Promotes group satisfaction, but may slow decision making.
Transactional: Focused on current work completion, rewards for finishing tasks, and consequences for delayed tasks. May lack big-picture thought.
Transformational: Promotes teamwork and shared decision making. Leader is respected and trustworthy. Ideal style.
Card 36
Elder Mistreatment
Signs/Symptoms
Nursing Care
Answer
Elder Mistreatment
S/S: Bruises and/or injuries in various stages of healing, treatment delays, dehydration, pressure injuries, poor hygiene, incompatibility between the injury and explanation, inconsistency between patient and caregiver explanations.
NC: Screen for elder abuse using an appropriate screening tool. Interview older adult and caregiver separately. Report any suspicion of abuse to Adult Protective Services!
Respite care (i.e., short-term relief of duties for primary caregivers) can ↓ caregiver burnout and help prevent abuse.
Elder Mistreatment
Victim RF: Dementia, physical dependency, social isolation.
Perpetrator RF: Caregiver strain, substance abuse, mental illness.
Types of Abuse:
- Physical abuse: Hitting, pushing, inappropriate restraints.
- Emotional abuse: Verbal threats, humiliation, harassment.
- Sexual abuse: Non-consensual sexual acts.
- Economic abuse: Withholding or misuse of funds.
- Neglect: Failure of caretaker to provide for basic needs (e.g., medical care, nutrition, hygiene).
- Abandonment: Leaving a vulnerable person alone.
Card 38
Medication Safety
BEERS List Criteria
Answer
BEERS List Criteria
The BEERS list is comprised of medications that should be avoided or used with caution in older adults due to increased risk of adverse effects.
Selected Examples of Included Drug Classes:
- Medications with anticholinergic effects (e.g., atropine, oxybutynin, benztropine).
- Antidepressants, including SNRIs and SSRIs (e.g., amitriptyline, sertraline, duloxetine).
- First generation antihistamines (e.g., diphenhydramine, hydroxyzine)
- Antipsychotics (e.g., chlorpromazine, olanzapine).
- Benzodiazepines (e.g., lorazepam, alprazolam).
- NSAIDs (e.g., ibuprofen, naproxen, ketorolac).
- Proton-pump inhibitors (e.g., omeprazole, pantoprazole).
Polypharmacy
Concurrent use of 5 or more medications, which ↑ the risk for falls, disability, and mortality.
RF: Use of OTC medications, multiple chronic conditions, transitions of care (i.e., from one facility/provider to another).
Prevention:
- Utilize Beers criteria to identify potentially harmful medications.
- Perform medication reconciliation during transitions of care.
- Assess pt's understanding of when/how to take their medications.
- Encourage patient to use one pharmacy for all prescriptions.
PT: Carry a complete list of all medications at all times. Bring all prescription and OTC medications in their original containers to each doctor's appointment.
Card 40
The 3 Ds
Dementia
Delirium
Depression
Answer
The 3 Ds
Dementia
Delirium
Depression
Gradual, progressive onset
Acute, sudden onset
Mood change lasting > 2 wks
Chronic, non-reversible
Transient, reversible
Treatable with psychotherapy and pharmacotherapy
Usually caused by neurodegenerative disease (e.g., Alzheimer's)
Causes include metabolic disorders, infections, toxins
Causes include neurotransmitter alterations, psychosocial factors
Unchanged LOC
Alterations in LOC usually present
Unchanged LOC
Normal behavior (until advanced stages)
Disturbed behavior, easily distracted, sleep/wake disturbances, hallucinations
Behavioral changes and somatic symptoms (e.g., pain, insomnia) often present
These are commonly misdiagnosed as each other!
Card 41
Alzheimer's Disease
Signs/Symptoms
Diagnostics
Nursing Care
Answer
Alzheimer's Disease
Gradual, non-reversible dementia resulting in memory problems, judgement issues, and changes in personality.
S/S:
- Stage I (mild): Forgetfulness, short-term memory loss.
- Stage II (moderate): Disorientation, agitation, incontinence, wandering, assistance with ADLs necessary.
- Stage III (severe): Bedridden, verbal/motor skills lost, dysphagia.
Dx: Symptom review, memory/thinking tests (e.g., mini-cog).
NC: Maintain structured environment. Provide short directions, repetition, frequent reorientation. Avoid overstimulation. Use a single-day calendar. Maintain routine toileting schedule. Provide secure environment (e.g., block access to exits/stairs), implement fall prevention measures (cards 75-76).
Sundowning (↑ confusion or agitation in the evening) is common.
Card 42
Parkinson's Disease
Signs/Symptoms
Diagnostics
Nursing Care
Answer
Parkinson's Disease
Progressive neurodegenerative disease causing muscle rigidity, akinesia, and involuntary tremor.
S/S: Muscle rigidity, tremor, slow/shuffling gait, postural instability, akinesia/bradykinesia, mask-like expression, drooling, dysphagia.
TRAP = Tremor, Rigidity, Akinesia/Bradykinesia, Postural instability.
Dx: Symptom review, rule out other causes.
NC: Monitor swallowing and food intake. Thicken food. Sit patient upright to eat. Have suction equipment available. Encourage ROM and exercise. Assist with ADLs, implement fall precautions.
Card 43
Effective Communication
Best Practices
Answer
Effective Communication
- Allow ample time for communicating and provide rest periods between sessions.
- Be aware of sensory deficits the patient may have, ensure assistive devices (e.g., hearing aids, glasses) are in place.
- Provide printed material with large fonts in well-lit room.
- Ask one question at a time, allow patient time to respond.
- For patients with hearing loss, ↓ background noise and turn off TV. Get patient's attention before speaking. Face patient so they can see your lips, do not shout, rephrase (do not repeat) if they do not understand.
Card 44
Effective Communication
Hearing/Balance
Other Changes
Answer
Effective Communication
Hearing/Balance:
- Presbycusis (bilateral hearing loss) starting with high-pitched frequencies.
- Tinnitus (ringing or buzzing in ears).
- ↑ Cerumen (ear wax).
- Altered equilibrium = difficulty maintaining balance.
Other Changes:
- ↓ Sense of smell.
- ↓ Sense of touch and pain = ↑ risk of injury (e.g., burns).
- ↓ Body temperature (average temp = 97.7°F).
- ↓ Ability to respond to temperature extremes = ↑ risk of hypothermia or heat stroke/exhaustion.
Card 45
Physiological Changes
Eye Health & Vision
Answer
Physiological Changes
Eye Health and Vision:
- Presbyopia (difficulty focusing on close-up objects).
- ↓ Visual field and peripheral vision.
- Issues w/ glare & darkness make driving at night difficult.
- Dry eyes (eye drops or ointments may be needed for stinging or discomfort).
- Yellowing of the lens = alterations in color perception.
- ↑ Risk of cataracts (opacity of the lens), glaucoma
(↑ fluid pressure inside the eye), and macular degeneration (loss of central vision).
Card 46
Physiological Changes
Immune System
Integumentary System
Answer
Physiological Changes
Immune System:
- ↓ Immune function = ↑ risk of infection and slower healing.
- ↑ Risk for cancer and autoimmune disorders.
Integumentary System:
- Thinner skin, ↓ skin elasticity and strength, ↑ risk of skin tears.
- Development of senile lentigines (i.e., age spots), paler skin.
- Fragile blood vessels = ↑ bruising and bleeding under skin.
- ↓ Oil production = dry, itchy skin.
- ↓ Subcutaneous tissue = ↑ risk of pressure injuries.
- ↓ Sweating = ↑ risk of overheating.
- Years of sun exposure = ↑ risk of skin cancer.
Card 47
Physiological Changes
Renal System
Reproductive System
Answer
Physiological Changes
Renal System:
- ↓ Nephrons, renal blood flow, and kidney function.
- Stiffening of the bladder and weakening of bladder muscles.
- ↑ Risk of incontinence, urinary retention, and urinary tract infections (UTIs).
Confusion/agitation is a common symptom of a UTI in an older adult.
Reproductive System:
- Women:↓ Estrogen and progesterone, cessation of ovulation, thinner/drier vaginal walls, menopause (S/S: hot flashes, mood swings, sleeping difficulties).
- Men: Prostatic enlargement (benign prostatic hypertrophy), ↓ testosterone, and ↑ risk for erectile dysfunction.
Card 48
Physiological Changes
Endocrine System
Gastrointestinal System
Answer
Physiological Changes
Endocrine System:
- ↓ Thyroid gland activity = ↓ basal metabolic rate (BMR).
- ↓ Insulin release and tissue sensitivity to insulin = ↑ blood glucose levels and ↑ risk of diabetes.
Gastrointestinal System:
- ↑ Fatty tissue in the abdomen.
- ↓ Salivation/mastication function and a weak gag reflex causes ↑ risk of dysphagia/aspiration.
- ↓ Appetite and taste sensation = ↑ risk of malnutrition.
- ↓ Thirst mechanism = ↑ risk for dehydration.
- ↓ Gastric emptying rate and bowel motility = ↑ risk of constipation.
Card 49
Physiological Changes
Musculoskeletal System
Answer
Physiological Changes
Musculoskeletal System:
- ↓ Bone density = ↑ risk of osteoporosis and fractures.
- ↑ Risk for falls due to: Prior falls, impaired vision, impaired balance, polypharmacy, incontinence, cognitive decline, pain, orthostatic hypotension.
- Muscle atrophy = ↓ strength and endurance.
- Stiffening of joints = ↓ ROM and ↑ risk of arthritis.
- Kyphosis (i.e., excessive outward curvature of the thoracic spine) and ↓ height.
Card 50
Physiological Changes
Nervous System
Answer
Physiological Changes
Nervous System:
- Cerebral atrophy (↓ in the size and number of neurons) and ↓ cerebral blood blow = ↓ cognitive function (e.g., forgetfulness, mild memory issues).
Dementia (card 155) is NOT an expected part of aging!
- ↓ Reflexes and delayed reaction time.
- ↓ Senses (vision, hearing, taste, smell, touch).
- Sleep-wake alterations = ↓ quantity and quality of sleep.
- ↑ Risk for chronic pain. Cognitive disorders may make pain assessment difficult. Assess facial expressions, appetite, sleep disturbances, and mood/behavior alterations.
Card 51
Physiological Changes
Respiratory System
Cardiovascular System
Answer
Physiological Changes
Respiratory System:
- ↓ Lung capacity and elasticity combined with weaker respiratory muscles leads to ↑ work of breathing.
- ↑ Anterior-posterior chest diameter.
- ↓ Cough reflex = harder to expel foreign material.
- ↑ Risk of respiratory infections (e.g., pneumonia) and abnormal breathing patterns (e.g., sleep apnea).
Cardiovascular System:
- ↓ Heart muscle efficiency and strength = ↓ cardiac output.
- Incomplete valve closure = ↑ risk of murmurs.
- Stiffening/calcification of blood vessels leads to atherosclerosis.
- ↑ Systolic blood pressure and ↑ risk for orthostatic hypotension.
Card 52
Psychosocial Changes
Common Changes Associated with Aging
Answer
Psychosocial Changes
- Loss of work role and interactions with coworkers related to retirement.
- Loss of loved ones (e.g., death of spouse, long term friends).
- Loss of independence (e.g., need for assisted living arrangements).
- Financial constraints (e.g., reduced or fixed income).
- ↑ Risk of social isolation, depression, suicide.
Older adults should be routinely screened for depression and suicidal ideation.
Card 53
Postoperative Nursing Care
Best Practices
Answer
Postoperative Nursing Care
- Monitor for S/S of hemorrhage and shock (e.g., hypotension, weak pulses, ↓ urine output).
- Prevent and assess patient for DVT, PE (card 70).
- Prevent postoperative pneumonia by encouraging early/frequent ambulation and techniques to improve oxygenation (card 132).
- Monitor for S/S of surgical site infection (pain, erythema, induration, purulent drainage).
In the immediate post-op period, slight edema, crusting along the incision line, and pink wound edges are expected.
Card 54
Perioperative Nursing Care
Intraoperative Care
Post-Anesthesia Care
Answer
Perioperative Nursing Care
Intraoperative Care:
- Participate in "time out" procedure (e.g., verification of patient identity, marking of surgical site).
- Aid with procedure (e.g., assist w/ patient positioning/preparation), monitor patient, assist surgical team, complete documentation).
Post-Anesthesia Care (in PACU):
- Ensure a patent airway and optimal oxygenation.
- Assess vital signs every 5 - 15 minutes per facility policy.
- Prevent hypothermia.
- Manage pain, nausea, and vomiting.
- Assess dressing over surgical site for signs of hemorrhaging.
- Keep patient NPO until gag reflex/swallowing ability returns.
- Once VS and LOC are stabilized and protective reflexes are active, patient is discharged from PACU.
Card 55
Preoperative Nursing Care
Pre-Admission
Day of Surgery
Answer
Preoperative Nursing Care
Pre-admission:
- Obtain health history, perform physical assessment, review allergies and medications.
- Obtain preoperative labs and screening tests.
- Provide teaching (e.g., pre-op preparation, post-op care).
Day of Surgery:
- Verify informed consent (cards 4 - 5) and advanced directives.
- Confirm adherence to food/fluid restrictions and discontinuation of specific meds as ordered (e.g., aspirin).
- Obtain vital signs.
- Administer pre-op medications as ordered (e.g., sedatives, anticholinergics, analgesics, antiemetics).
Card 56
Home Oxygen Safety
Patient Teaching
Answer
Home Oxygen Safety
- Do not smoke or have open flames near oxygen (it is combustible).
- Place "no smoking" sign visibly at front of home.
- Ensure the home has operational smoke detectors.
- Ensure oxygen tank remains upright, away from heat sources, and in a well-ventilated area.
- Use only water-based lubricants. Do not use oil-based products (e.g., petroleum jelly).
- Wear cotton clothes, avoid synthetic fabrics, wool, or nylon (these produce static electricity).
Card 57
Tracheostomy Care
Nursing Care
Answer
Tracheostomy Care
- Place patient in Semi-Fowler's position.
- Use clean gloves to remove inner cannula and remove site dressing.
- Using sterile gloves, insert new inner cannula.
- Clean around stoma under faceplate using cotton-tipped applicators and normal saline. Clean from stoma site outward, using each applicator only once. Gently dry.
- Place new pre-split gauze under faceplate. Do NOT cut gauze! (lint or fuzz created can enter tracheostomy).
- Leave old ties in place until new ties are secured. Ensure 1 finger fits between the neck and the tie.
Artificial Airways
Devices used to secure the patient's airway.
Oropharyngeal: Inserted into mouth, secures tongue to prevent occluding epiglottis.
Nasopharyngeal: Inserted into nose to posterior pharynx, does not stimulate gag reflex.
Endotracheal: Inserted orally through vocal cords into trachea.
Tracheostomy Tube: Surgically created opening in the anterior neck to insert tube directly into trachea.
Patients w/ artificial airways may be unable to speak. Use alternative communication methods (e.g., writing board, vocabulary cards) to allow patient to convey their needs.
Card 59
Chest Tubes
Nursing Care
Answer
Chest Tubes
- Obtain chest X-ray to verify tube position.
- Keep an occlusive dressing at the chest tube insertion site.
- Assess insertion site for subcutaneous emphysema (S/S: edema, crepitus) and infection.
- Only clamp when ordered. Do not "strip" the tube.
- Encourage patient to cough, breathe deeply, use an incentive spirometer to help with lung expansion.
- Keep padded clamps, sterile water, sterile gauze at bedside.
- If chest tube disconnects from drainage system, place end of tube in sterile water (to maintain water seal).
- If chest tube is accidentally removed, place dry sterile gauze over site, notify provider.
- Monitor for complications (e.g., tension pneumothorax).
Card 60
Chest Tubes
Chambers
Answer
Chest Tubes
Drains fluid, air, or blood from pleural space. Chest tube placed near lung apex for a pneumothorax, and near the base of the lung for a hemothorax or pleural effusion.
Chambers:
- Drainage Collection: Chart amount and color of drainage. Report drainage > 100 mL/hr to the provider.
- Water Seal: Fill with 2 cm of sterile fluid, check every 2 hrs. Chamber must be kept upright and below chest insertion site.
- Tidaling (↑/↓ movement of water) expected.
- Seals swim in the tides! Tidaling is expected in the water seal!
- Lack of tidaling = lung re-expansion or obstruction.
- Continuous bubbling = air leak.
- Suction Control: -20 cm H20 common for adults.
- Continuous bubbling expected.
Card 61
Suctioning
Nursing Care
Answer
Suctioning
- Position conscious patient in Semi-Fowler's position, unconscious patient in lateral position.
- Set the appropriate suction pressure on the wall unit:
- Preoxygenate patient with 100% O2 (as suctioning may cause hypoxemia).
- Do NOT apply suction while inserting catheter.
- Rotate the catheter and suction intermittently while withdrawing the catheter.
- Limit suctioning: 10 - 15 sec per pass and 3 total passes.
- Re-oxygenate patient, flush catheter with saline, and allow 30 - 60 seconds between suctioning attempts.
Therapeutic Interventions for Oxygenation
Chest Physiotherapy: Use of percussion, vibration, postural drainage, and breathing exercises to loosen respiratory secretions.
- Schedule treatments before meals or 1 - 2 hours after meals to avoid vomiting. Use bronchodilator 30 minutes - 1 hour before treatment.
Positive Airway Pressure: Use of air pressure to keep the airways open. Indicated for respiratory disorders (e.g., sleep apnea).
- Includes continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP).
Suctioning: Maintains patent airway through removal of pulmonary secretions, blood, or other materials from the respiratory tract.
For tracheal suctioning, use a suction catheter that is
Oxygen Delivery Devices
Device
Flow Rate
Considerations
Nasal Cannula
1 - 6 L/min
Water-based lubricant may be used in nares to prevent drying.
Simple Face Mask
5 - 8 L/min
Impairs patient's ability to eat, drink, & talk.
Partial Rebreather
10 - 15 L/min
Adjust flow rate to maintain bag ⅔ full.
Non-Rebreather
10 - 15 L/min
Inflate reservoir bag prior to applying.
Aerosol Mask/Face Tent
6 - 15 L/min
Good for patients with facial trauma or burns.
Venturi devices provide the most precise O2 delivery (up to 40%) without intubation. Flow rate is dependent upon the mask to which it is attached.
Card 64
Techniques to Improve Oxygenation
Deep Breathing
Coughing
Positioning
Incentive Spirometer
Other Techniques
Answer
Techniques to Improve Oxygenation
Deep Breathing: Allows movement in lung bases, which prevents alveolar collapse.
Coughing: Deep, productive coughing clears mucus.
Positioning: Semi-Fowler's and above ↑ lung capacity.
Incentive Spirometer: Mechanical device that promotes lung expansion and ↓ pulmonary complications. Teach patient proper technique before surgery and reinforce teaching after surgery:
- Inhale slowly and deeply with lips around mouthpiece. Don't blow into device.
- INcentive spirometer = breathe IN.
- Use ~ 10 times every hour while awake.
Other Techniques: Pursed-lip breathing and diaphragmatic breathing can ↓ dyspnea, especially in patients with COPD.
Card 65
Oxygenation
Hypoxemia
Hypoxia
Oxygen Toxicity
Answer
Oxygenation
Hypoxemia: Insufficient oxygen in arterial blood (
Hypoxia: Insufficient tissue oxygenation.
- Early S/S: Restlessness, irritability, abnormal breathing (e.g., use of accessory muscles, nasal flaring, adventitious lung sounds), tachycardia, tachypnea, hypertension, pallor.
- Late S/S: ↓ LOC, cyanosis,↑ lactic acid (lactic acidosis), dysrhythmias, bradycardia, bradypnea, hypotension.
Oxygen Toxicity: Exposure to above-normal O2 partial pressures with oxygen therapy.
- S/S: Non-productive cough, nasal congestion, substernal pain, headache, nausea, vomiting, fatigue, sore throat.
Use the lowest O2 liter flow needed to manage hypoxia.
Card 66
Oxygenation
Ventilation
Diffusion
Perfusion
Answer
Oxygenation
Ventilation: Flow of air into and out of the alveoli.
- Example: Asthma causes bronchoconstriction, which ↓ ventilation.
Diffusion: Exchange of O2 and CO2 between the alveoli and RBCs (in the bloodstream).
- Example: Pulmonary fibrosis causes thickening and scarring of the lungs, which ↓ diffusion.
Perfusion: Exchange of O2 and CO2 between the RBCs and the body tissues.
- Example: Peripheral arterial disease (PAD) restricts blood flow to the extremities, which ↓ perfusion.
Card 67
Fecal Occult Blood Test (FOBT)
Indications
Best Practices
Instructions
Answer
Fecal Occult Blood Test (FOBT)
Identifies blood in stool as blood may not be visible to the eye (occult means hidden).
Indications: Anemia, colon cancer screening, GI disorders.
Best Practices:
- Obtain samples from separate areas of a single bowel movement using applicator.
- Collect stool in a clean container free from urine.
Instructions:
- Use applicator to apply a small amount of stool onto testing card slots A and B. Apply reagent to card.
If Blood is present, the card turns Blue.
Presence of blood requires prompt evaluation (e.g., colonoscopy)!
Card 68
Enema Administration
Nursing Care
Answer
Enema Administration
- Have bedside commode, bedpan, or bathroom ready for use.
- Warm enema solution to room temperature.
- Elevate solution ≤ 18" above level of patient's anus.
- Position patient on left side w/ right leg flexed (Sims' position).
- Lubricate enema tip if not pre-lubricated.
- Insert tip into anus 3 - 4" (7.5 - 10 cm), angling the tip towards the umbilicus.
- Administer enema slowly over 5 - 10 minutes.
- If patient reports abdominal cramping, lower solution container.
- Once administration is complete, encourage patient to remain on side, retain contents, and resist toileting for ~ 10 minutes.
- Assist patient to bathroom or bedside commode.
Card 69
Promoting Bowel Elimination
Laxatives
Enemas
Rectal Suppositories
Digital Removal
Answer
Promoting Bowel Elimination
Laxatives: Medications that promote emptying of the intestinal tract (e.g., osmotic, bulk forming, and stimulant laxatives).
Enemas: Instillation of a solution via the rectum to remove feces.
- Cleansing Enemas: Stimulate the colon to contract and eliminate stool (e.g., large volume cleansing enemas, pre-packaged disposable enemas).
- Oil Retention Enemas: Lubricate feces in the rectum and colon, making it easier to pass.
Rectal Suppositories: Position patient in Sims' position (left side), insert about 1 inch into rectum.
Digital Removal: Manual removal of hardened stool in the rectum with a gloved, lubricated finger.
Card 70
Ostomies
Patient Teaching
Answer
Ostomies
- Assess stoma regularly, should be pink/moist. Pale or blue stoma indicates ischemia.
- Empty bag when it is ⅓ full. Change appliance immediately if leaking!
- Cut opening in skin barrier ≤ ⅛" bigger than measured stoma size to prevent skin damage from contact with ostomy output.
- Change ostomy appliance ~ 2x/week (more frequently for ileostomies).
- Chew foods thoroughly. Consume low-fiber diet for first 6 - 8 weeks. Avoid foods that cause gas/odor.
Card 71
Ostomies
Types
Answer
Ostomies
Surgical procedure that reroutes part of the intestine through the abdominal wall, forming a stoma.
Types:
- Ileostomy: Created from the ileum. Bowel movements are loose/watery.
- Colostomy: Created from the large intestine. Bowel movements vary in consistency.
- Ascending (right) colostomy = liquid stool.
- Transverse colostomy = semi-solid stool.
- Descending/Sigmoid (left) colostomy = formed stool.
Bowel Elimination
Constipation:
- RF: Insufficient fluid and fiber intake, physical inactivity, medications, older age.
- S/S: Hard/dry/lumpy stool, pain/difficulty passing stool.
Unresolved constipation can result in fecal impaction!
Diarrhea:
- RF: Infection, medications, food allergies, GI dysfunction (e.g., celiac disease).
- S/S: Loose/watery stool, abdominal cramping, urgency to defecate.
Diarrhea places the patient at ↑ risk for dehydration (S/S: ↑ HR & RR, dry mouth, fatigue) and perianal skin breakdown.
Card 73
Urinary Catheters
Indwelling Urinary Catheter Care
Answer
Indwelling Urinary Catheter Care
- Insert catheter using sterile technique and equipment.
- Hang bag below level of bladder on bed frame. Do not lay bag on floor.
- To avoid obstruction, frequently check tubing for kinks and dependent loops. Ensure patient is not lying on tubing.
- Clean around the meatus daily and after each bowel movement. Clean from the meatus outward.
- If leakage or disconnection occurs, replace catheter and collection system.
- Empty into a graduated container to accurately measure urine output.
- Remove as soon as appropriate.
Urinary Catheters
Suprapubic Catheters: Drainage tube inserted surgically into the bladder through a small incision above the pubic symphysis. Provides long-term continuous bladder drainage.
- Indications: Urethral stricture or injury, severe BPH.
External Urine Collection Devices: Includes condom catheters for males (i.e., rubber sheath rolled down penis shaft connected to a drainage bag) or wicking devices for females (i.e., tube placed between labia made of wicking material that is attached to suction).
- Indications: Incontinence. Not effective for obstruction or retention.
Urinary Catheters
Indwelling: Tube inserted into the urethra to allow for continuous drainage of urine from the bladder.
- ↑ Risk of CAUTI, pain, urethral injury.
- Indications: Urinary retention, urinary obstruction, strict output monitoring, bladder irrigation, severe perineal or sacral wounds.
Straight/Intermittent: Used to drain the bladder a single time or intermittently for chronic urinary retention.
- ↓ Risk of CAUTI compared to indwelling catheters.
- Indications: Chronic retention (e.g., neurogenic bladder, spinal cord injury), urine sampling (if unobtainable otherwise).
Card 76
Bladder Scanner
Indications
Instructions
Answer
Bladder Scanner
Portable ultrasound device used to measure volume of urine within the bladder.
Indications: Used to assess for urinary retention.
Instructions:
-
- Encourage patient to void (if possible) in order to assess the postvoid residual amount.
- Turn on scanner, select button indicating whether or not the patient has a uterus.
- Apply ultrasound gel to patient's abdomen. Place scanner 1" above symphysis pubis. Point scanner towards bladder.
- Press the scan button. Adjust the probe location to center the bladder image on the crosshairs shown on the scanner screen.
- Press DONE when satisfied with results, print results.
Card 77
Urinary Tract Infection (UTI)
Prevention
Answer
UTI Prevention
- Females, wipe front to back. Wear cotton underwear. Avoid bubble baths, sitting in wet bathing suits, tight clothing.
- Uncircumcised males, clean under foreskin.
- Empty bladder regularly.
- Avoid constipation.
- Urinate after intercourse.
- Drink ~ 3 L of fluid per day.
- Cranberry juice ↓ risk of UTIs.
Urinary Tract Infection
Infection in any part of the urinary tract. Most common type is a bladder infection (cystitis).
RF: Women (due to close proximity of urethral meatus to anus), foley catheters, uncircumcised males, menopause, frequent sexual intercourse, constipation.
S/S: Abdominal pain, dysuria, urinary frequency and urgency, nausea/vomiting, cloudy urine, foul-smelling urine, confusion (in older adults).
Dx: Urinalysis results positive for bacteria, WBCs, leukocyte esterase, nitrates, blood.
Card 79
Urinary Incontinence
Types
Risk Factors
Treatment
Answer
Urinary Incontinence
Stress Incontinence: Small urine loss with ↑ intra-abdominal pressure (e.g., sneezing, coughing, laughing). Caused by weakened pelvic floor.
- RF: Menopause, prior pregnancy/deliveries, obesity, pelvic surgeries.
Urge Incontinence: Inability to reach the bathroom in time due to overactive detrusor muscle.
- RF: Neurologic disorders (e.g., stroke), bladder irritation.
Tx: Behavioral therapy (e.g., toileting schedule, constipation management), Kegel exercises, weight loss, ↓ caffeine/alcohol intake.
- Pharmacological Therapy: Anticholinergics (e.g., oxybutynin), topical estrogen for women.
- Mechanical Devices: Cones or pessaries for stress incontinence.
Urine Sample Collection
Routine Urinalysis: Collect during normal voiding, avoid contamination w/ feces. If unable to be analyzed within 1 hr, refrigerate.
Clean Catch Urine Specimen: Clean with sterile moist wipes. Waste initial amount into toilet, then position sterile container into stream. Only 15 - 30 mL needed.
- Male: If uncircumcised, retract foreskin. Clean tip of penis starting at urethral meatus in concentric circles.
- Female: Cleanse labia front to back & hold apart during urination.
Sterile Specimen: Catheterize patient or collect from special sampling port on indwelling catheter. Do NOT collect from drainage bag!
24-Hour Urine Collection: Discard first void, then collect ALL urine voided in the next 24 hours. Container must be refrigerated.
Card 81
Urine Characteristics
Urine Output
Color
Appearance
Specific Gravity
Answer
Urine Characteristics
Urine Output:
- Daily output ≈ Daily fluid intake.
- Expected: 0.5 - 1.5 mL/kg/hr or approximately 1,500 mL/day.
Alert provider for urine output
Color: Light yellow (straw-colored) to amber.
Appearance: Clear, transparent.
Specific Gravity: Normal range = 1.005 - 1.030.
- ↑ Urine specific gravity = concentrated urine.
- ↓ Urine specific gravity = dilute urine.
DiLute = Low urine specific gravity.
Urine should be clear (NOT cloudy or malodorous) and should NOT contain: glucose, ketones, blood, protein, bilirubin, nitrates or leukocyte esterase.
Card 82
Parenteral Nutrition
Indications
Nursing Care
Answer
Parenteral Nutrition
Intravenous administration of nutrition outside the GI tract.
Indications: Malabsorption, hypermetabolic state, malnutrition, prolonged NPO.
NC:
- Confirm TPN ingredients on the label match the order.
- Gradually increase/decrease flow rate.
- Monitor I&Os, daily weights, electrolyte and glucose levels.
- Use IV tubing with a filter. Change tubing/bag every 24 hours.
- If the next TPN bag is unavailable on time, administer 10 - 20% dextrose/water until it arrives.
- Do not administer other fluids or meds through TPN line.
- Monitor central line insertion site for S/S of infection or infiltration.
Card 83
Enteral Nutrition
Tube Feeding Best Practices (2 of 2)
Answer
Tube Feeding
Flush with 30 mL water before and after feeding, medications, GRV check, or every 4 hours during continuous feeding.
Change delivery sets (e.g., bag and tubing) every 24 hours or per facility policy.
Clean opening and rim of formula cans before use.
Refrigerate opened cans, discard after 24 hours.
To prevent bacterial growth, limit hang time to 4 hours for open systems and 24 - 48 hours for closed systems (or per manufacturer guidelines).
Card 84
Enteral Nutrition
Tube Feeding Best Practices (1 of 2)
Answer
Tube Feeding
- Before feeding, perform abdominal assessment and confirm presence of bowel sounds.
- Keep HOB 30 - 45° during feeding and for ≥ 1 hr after feeding to ↓ aspiration risk.
- Confirm tube placement:
- Confirm INITIAL placement with X-ray!
- Measure length of exposed NG tube and confirm with documented length.
- Verify pH of aspirated contents.
Do not instill air into tube to check placement!
- Aspirate all gastric contents with syringe and measure gastric residual volume (GRV). Follow facility policy re: holding feeding for large GRV (e.g., > 500 mL) and returning residuals to the stomach.
Card 85
Enteral Nutrition
Indications
Types of Enteral Feeding Tubes
Administration Options
Answer
Enteral Nutrition
Obtaining nutrients via the GI tract (by mouth or feeding tube).
Indications: Disorders that prevent oral nutrition (e.g., dysphagia, coma, upper GI obstruction, severe anorexia, malnutrition).
Types of Enteral Feeding Tubes:
- Short-term use: Nasogastric tube.
- Long-term use (> 4 wks): Percutaneous endoscopic gastrostomy (PEG), or surgically placed gastrostomy tube.
Administration Options:
- Continuous feeding: Delivered via gravity or pump.
- Intermittent feeding: Delivered via gravity, pump, or bolus feeding with syringe.
SLOWLY increase feeding rate until ordered rate is achieved (per facility policy).
Card 86
Nasogastric Tube
Confirming Placement
Removal
Answer
Nasogastric Tube
Confirmation of Placement:
- Abdominal X-ray is the best way to confirm NG tube location.
- Do not begin feeds or connect to suction until placement is confirmed!
- At the bedside, NG tube location can be confirmed by aspirating (i.e., withdrawing) fluid and testing the pH. Gastric fluid pH is
Removal:
Cover patient's chest with towel.
Flush NG tube with water or air (optional, clears tubing).
Instruct patient to take a deep breath and hold it.
Remove tubing quickly and smoothly.
Offer patient oral care and tissue to blow nose.
Card 87
Nasogastric Tube
Insertion
Answer
Nasogastric Tube Insertion
Elevate head of bed, cover patient's chest with towel, provide basin (emesis may occur).
Estimate length of tube needed by measuring from the tip of the nose, to the earlobe, and then to the xiphoid process. Mark position on tubing with indelible marker or tape.
Lubricate tip of tube.
Gently insert tubing into the nostril towards the back of the patient's throat.
Encourage patient to sip water through a straw or swallow, which aids tube advancement into esophagus.
Advance firmly but do not push past extreme resistance.
Insert to predetermined length and secure to nose with tape.
Card 88
Nasogastric Tube
Indications
Types
Answer
Nasogastric Tube
Tube inserted through nare to access the stomach.
Indications: Decompression for bowel obstruction. Short-term nutritional support and administration of medications for patients unable to tolerate oral intake.
Types:
- Double-lumen tube (e.g., Salem Sump): Best for decompression. One lumen is for suction, the other lumen acts as a sump (i.e., allows air to enter in order to prevent the suction lumen from adhering to the gastric wall).
Do not insert water or aspirate from the air lumen.
- Small bore, single-lumen tube (e.g., Levin, Dobhoff): Best for nutrition or medication administration.
Card 89
Capillary Blood Glucose Measurement
Nursing Care
Answer
Capillary Blood Glucose Measurement
Measurement of blood glucose level using blood from a fingertip puncture.
- Clean site with alcohol swab. Allow skin to dry completely.
- Lower patient's hand to encourage bleeding.
- Hold lancet to the skin at the lateral, distal end of the fingertip (NOT the pad of finger).
- Wipe away first drop of blood with gauze.
- Gently touch test strip to drop of blood without smearing it.
- Apply pressure to puncture site with dry gauze.
- Dispose of test strip/lancet appropriately (e.g., sharps box).
Card 90
Prevention of Foodborne Illness
Patient Teaching
Answer
Prevention of Foodborne Illness
- Wash hands after using the bathroom and prior to food preparation.
- Wash fruits and vegetables thoroughly prior to preparing or eating.
- Use separate equipment to prepare raw meats and cooked foods.
- Use a meat thermometer to ensure meat is thoroughly cooked.
- Refrigerate perishables within 2 hours of purchasing or cooking (or within 1 hour for outside temp > 90°F).
- Ensure refrigerator is ≤ 40°F and freezer is ≤ 0°F.
Therapeutic Diet Types
NPO: Latin for "nil per os" = nothing by mouth, no oral intake. Pt may require diet advancement in stages after being NPO.
Clear Liquid: Transparent & liquid at room temperature (e.g., water, clear sodas, pulp-free fruit juice, popsicles, jello, tea, coffee without creamer, clear broth).
Full Liquid: Any liquid item (e.g., clear liquids, milk, ice cream, orange juice, pudding, strained creamy soups).
Soft: Soft, low-fiber, easily digested foods (e.g., low fat dairy, eggs, pudding, bland vegetables, tofu, lean skinless meats).
Dysphagia: Thickened liquids and moist/soft or puréed foods.
Regular: No dietary restrictions.
Card 92
Dysphagia
Risk Factors
Signs/Symptoms
Nursing Care
Answer
Dysphagia
Difficulty swallowing, resulting in ↑ risk of aspiration.
RF: Nervous system disorders (e.g., stroke, Parkinson's, dementia, ALS, cerebral palsy), head/neck/esophageal injury, GERD.
S/S: Coughing, clearing of the throat, difficulty eating and/or drinking, aspiration pneumonia.
NC: Assess patient for swallowing issues at admission (prior to providing any food/liquids). Coordinate referral to speech language pathologist and implement recommended interventions, which may include: thicken liquids, (up arrow) HOB (High-Fowler's), teach patient to tuck chin when swallowing.
Card 93
Body Mass Index (BMI)
BMI Interpretation
Answer
Body Mass Index
Measure of body fat based on height and weight.
Calculated by: weight (kg)/height(m)2.
BMI
Meaning
≤ 18.4
Underweight
18.5 - 24.9
Healthy
25 - 29.9
Overweight
≥ 30
Obese
Card 94
Micronutrients
Vitamins
Minerals
Answer
Micronutrients
Vitamins:
- Water-soluble Vitamins: B-complex vitamins and vitamin C.
Water-soluble vitamins require regular replacement in the body.
- Fat-soluble Vitamins: Vitamin A, D, E, K.
Fat-soluble vitamins are stored for long periods of time and have an ↑ risk for toxicity with excess consumption.
Think of A fat DEcK of cards.
Minerals:
- Major Minerals (electrolytes): Calcium, chloride, magnesium, phosphorus, potassium, sodium.
- Trace Minerals: Copper, fluoride, iodine, iron, selenium, zinc.
Card 95
Macronutrients
Carbohydrates
Fats
Proteins
Answer
Macronutrients
Carbohydrates: Main source of energy for the body.
- Recommended daily intake is 45 - 65% of calories/day.
- 1 gram carbohydrates = 4 calories.
Fats: Main source of stored energy. Important for cell structure/function, temperature regulation, protection of organs, and absorption of vitamins.
- Recommended daily intake is 20 - 35% of calories/day.
- 1 gram fat = 9 calories.
Proteins: Body's building blocks. Important for building and repair of tissues, immune system support, and energy.
- Recommended daily intake is 10 - 35% of calories/day.
- 1 gram protein = 4 calories.
Fluid Balance
Intake: Any fluid put into the body (e.g., oral fluid intake, IV fluids, fluids contained within foods, tube feedings, TPN, IV flushes, bladder irrigation).
Output: Any fluid that leaves the body (e.g. urine, fluid in stool, vomit, blood loss, chest tube drainage, wound drainage).
- Sensible losses: Measurable excretion (e.g., urination, defecation).
- Insensible losses: Other routes of fluid loss (e.g., sweat, respiration).
Measurement of I&Os: Document in milliliters at least once every 8 hours.
- 1 cc = 1 mL
- 1 oz = 30 mL
- 1 cup = 8 oz (which = 240 mL)
- 1 tsp = 5 mL
- 1 Tbsp = 15 mL
- 1 Tbsp = 3 tsp
Ice chips should be recorded as half their volume (e.g., 8 oz of ice chips is worth 4 oz of water, or 120 mL).
Card 105
Solution Osmolarity
Illustration
Answer
Solution Osmolarity
Card 106
Solution Osmolarity
Hypertonic
Isotonic
Hypotonic
Answer
Solution Osmolarity
Hypertonic: Water moves out of a cell and it shrivels.
- Examples: Dextrose 10% in water (D10W), 3% sodium chloride, 5% sodium chloride.
Isotonic: The volume of the cell does not change with fluid movement.
- Examples: 0.9% sodium chloride (normal saline), Lactated Ringer's (LR), dextrose 5% in water (D5W).
Hypotonic: Water moves into a cell and it swells.
- Examples: 0.45% sodium chloride (half normal saline), 0.225% sodium chloride (quarter normal saline).
Card 107
Diabetic Foot Care
Patient Teaching
Answer
Diabetic Foot Care
- See a podiatrist regularly. Get professionally fitted shoes.
- Inspect feet daily using a mirror. Check shoes for objects before putting them on.
- Apply moisturizer to feet, but not between toes.
- Do not go barefoot or wear open-toe shoes. Wear socks that fit well, without uncomfortable seams.
- Cut nails straight across, file away sharp corners. Do not use OTC products (e.g., corn/callus removal agents).
- Do not use heating pads on feet.
- Check water temperature with elbow before stepping into a tub or shower. Do not soak feet.
Card 108
Wound Care
Drains:
- Types
- Care of a Closed Drain
Answer
Drains
Tubing inserted into wound or cavity to remove blood and fluid. Promotes healing and ↓ risk of infection.
Types:
- Open: Tubing without collection device, deposits fluid onto surface of skin/dressing (e.g., Penrose drain).
- Closed: External tubing ends in a container that uses negative pressure (i.e., suction) to collect fluid (e.g., Jackson-Pratt/JP drain, Hemovac).
Care of Closed Drain:
- Secure device to clothing to prevent pulling at insertion site.
- Empty before half full. Open cap, pour contents into measuring canister, note amount and color. Fully compress container and replace cap.
- Change dressing daily. Clean site around drain using a new cotton swab for each swipe. Assess for S/S infection (redness, purulent or odorous discharge, swelling).
Card 109
Wound Care
Removing Sutures
Removing Staples
Answer
Wound Care
Removing Sutures: Utilize sterile suture removal kit. Grasp the knot of the suture with forceps and gently lift. Cut one side of the suture below the knot (close to the skin). Pull the cut suture through the skin.
Removing Staples: Utilize sterile staple removal kit. Place lower jaw of staple remover under the CENTER of the staple and squeeze the handles together.
Suture/staple removal requires a provider order. Clean incision before and after removal. Count and chart the number of sutures/staples removed. Remove alternate sutures/staples to assess for wound dehiscence.
Card 110
Wound Care
Sterile Dressing Change
Answer
Sterile Dressing Change
- Using clean gloves, carefully remove soiled dressing.
- Note wound appearance and drainage.
- Perform hand hygiene, prepare sterile field, don sterile gloves.
- Clean the wound. Moisten gauze with sterile saline or wound cleanser. Gently clean from top to bottom and/or from the center of the wound moving outward. Use a new piece of gauze for each stroke.
- Remove gloves, perform hand hygiene, don sterile gloves.
- Apply prescribed topical medications and dry/sterile dressing over wound. Secure with tape or gauze wrap.
- Label dressing with date, time, initials.
Clean (vs. sterile) gloves may be appropriate for cleaning chronic wounds or pressure injuries.
Card 111
Wound Care
Culture
Irrigation
Answer
Wound Care
Culture:
- Obtain before beginning antibiotic therapy.
- Irrigate wound with normal saline (DO NOT use wound cleanser).
- Swab a 1 cm area of viable tissue in the wound bed for ~ 5 seconds with enough force to produce exudate.
- Do NOT swab necrotic/avascular tissue.
- Do NOT touch the skin surface with the swab.
Irrigation:
- Wear gown, gloves, and eye protection.
- Use a 35 mL piston syringe with a 19 gauge catheter/needle.
- Use an irrigation force of ~ 8 - 15 psi. Irrigate wound with NS or prescribed solution.
Card 112
Wound Healing
Drainage
Wound Appearance
Answer
Wound Healing
Drainage:
- Types: Serous (clear, watery), serosanguineous (light pink, blood tinged), sanguineous (bright red), or purulent (white/yellow/beige, malodorous).
- Amount: Scant, small, moderate, large, or copious.
Wound Appearance:
- Red = Healthy Tissue. Wound has a "beefy" red color. Protect and provide a moist wound healing environment.
- Yellow = Needs Cleaning. Wound contains slough (necrotic tissue, looks like "chicken fat") and/or has purulent drainage. Irrigate and clean wound!
- Black = Needs Debridement. Wound contains eschar (hard or rubbery black/brown necrotic tissue). Needs autolytic, enzymatic, chemical, or sharp debridement.
Card 113
Wound Healing
Complications
Barriers to Healing
Answer
Wound Healing
Complications: Hemorrhage, infection, dehiscence (total/partial separation of wound layers), evisceration (dehiscence with protrusion of internal organs).
For evisceration, do not try to reinsert organs. Place saline-moistened gauze over the open area, lower HOB, notify the provider immediately, keep patient NPO in anticipation of surgical repair.
Barriers to Healing: Chronic illnesses (e.g., diabetes), smoking, malnutrition (especially insufficient protein!), older age, impaired circulation (e.g., peripheral arterial disease), immunosuppression, corticosteroids.
Wound Healing
Primary Intention: Wound edges are approximated (i.e., brought together) with staples or sutures.
Secondary Intention: Wound is left open to heal through granulation, contraction, epithelization. ↑ Risk of infection, longer healing time.
Tertiary Intention: Closure of wound is intentionally delayed. Wound is irrigated, debrided, observed for ~ 1 week, then surgically closed.
Wound Healing Phases
Hemostasis: GOAL = stop bleeding.
- Vasoconstriction allows for hemostasis. Platelets are activated and trigger the clotting cascade.
Inflammatory: GOAL = clean wound. Lasts several days.
- Vasodilation allows for influx of white blood cells (neutrophils, macrophages) to eliminate bacteria.
Proliferation: GOAL = fill and cover wound. Lasts several weeks.
- Fibroblasts arrive and form granulation tissue.
- New blood vessels develop (angiogenesis).
- Wound contracts.
- Epithelial cells migrate to cover the wound bed.
Maturation: GOAL = remodeling of scar tissue. Lasts up to 12 mos.
- Collagen (type 3) is replaced by stronger collagen (type 1).
Card 116
Pressure Injuries
Staging
Answer
Pressure Injury Staging
Stage and Depth of Injury
Description
Stage I: Damage limited to epidermis.
Non-blanchable, intact, red skin (erythema).
Stage II: Damage into dermis.
Open, shallow wound with a red/moist wound base.
Stage III: Damage into subcutaneous tissue.
Open wound, visible adipose tissue. Muscle, tendon, bone NOT visible.
Stage IV: Damage extends beyond subcutaneous tissue.
Deep wound with exposed muscle, tendon, and/or bone.
Unstageable: Unknown depth.
Wound base is covered in slough and/or eschar (i.e., necrotic tissue).
Deep Tissue Injury: Damage at bone/muscle interface.
Intact or non-intact skin with non-blanchable purple/maroon discoloration.
Card 117
Pressure Injuries
Risk Factors
Prevention
Answer
Pressure Injuries
Damage to the skin and underlying tissue due to intense and prolonged pressure. Leads to inadequate perfusion/oxygenation and cell death.
RF: Immobility, older age, incontinence, poor nutrition, perfusion issues, diabetes, smoking, corticosteroids, Braden scale score ≤ 18.
Prevention:
- Place at-risk patients on a bed that provides pressure redistribution. Keep HOB ≤ 30°.
- Reposition patient every 2 hrs.
- Utilize waffle seat cushion while the patient is chair-sitting or in a wheelchair. Advise patient to shift weight every 15 minutes.
- Elevate heels with pillows or heel elevation boots.
- Utilize padded dressings over bony prominences.
- Ensure patient receives adequate nutrition (especially protein).
Card 118
Restraints
Nursing Care
Answer
Restraints
- Try deescalation techniques first (e.g., use simple, nonthreatening language, set clear boundaries, reduce stimuli, provide diversion, offer PRN medications).
- Use the least restrictive method to correct issue.
- In an emergency, nurse can apply restraints. Order needs to be obtained from the provider ASAP after application.
- Tie restraint to unmoving part of bed FRAME (NOT side rail) using a quick-release knot (slip knot). Two fingers should fit between the restraint and patient.
- Place belt restraints over the patient's gown/clothing.
- Patients in violent restraints require continuous observation.
- Perform patient assessments per facility policy (e.g., q15 min for violent patients, q2h for non-violent patients). Provide care (e.g., ROM exercises, toileting) q2h or per facility policy.
- Remove restraints immediately once the patient is no longer a danger to themselves or others.
- Document rationale for restraints/seclusion, time in restraints/seclusion, patient assessment findings, patient care offered and provided.
Card 119
Restraints
Order Requirements
Answer
Restraints
Order Requirements:
-
- Provider must do an in-person assessment within 24 hours of initiation of restraints or seclusion.
- For non-violent restraints, a new order is required every 24 hours if restraints are still required.
- Violent restraint orders must be renewed within the following time limits for a maximum of 24 hrs:
- ≤ 4 hrs for adults (≥ 18 yrs).
- ≤ 2 hrs for older children and adolescents (9 - 17 yrs).
- ≤ 1 hr for younger children (
- PRN orders are NOT allowed!
Card 120
Restraints
Indications
Types
Answer
Restraints
Indications:
- Non-Violent Restraint Order: Indicated for patients who are pulling at lines, tubes, and drains (e.g., an intubated and sedated patient).
- Violent Restraint Order: Indicated for patients who pose an imminent risk of harm to self or others (e.g., violent behavior).
Types:
- Physical: Hand mitts (least invasive), limb restraints, belts, vests.
- Chemical: Benzodiazepines (e.g., lorazepam), antipsychotics (e.g., haloperidol).
Card 121
Fall Prevention
Patient Teaching to Prevent Falls at Home
Answer
Fall Prevention - Home
- Remove scatter rugs.
- Ensure good lighting (especially over stairs) and encourage use of nightlights.
- Mark step edges with colored tape. Remove clutter.
- Tape down electrical cords, or place against a wall/behind furniture.
- Install grab bars in showers/bathtubs.
- Place non-slip mat on the shower floor.
- Ensure proper use of assistive devices (e.g., grab bars, railings, walkers, canes).
Card 122
Fall Prevention
Best Practices in Acute Care Settings
Answer
Fall Prevention - Acute Care
- Round hourly on patients. Provide regular opportunities for toileting and nutrition.
- Move patients that are unable to follow instructions or call for assistance near the nurses' station.
- Keep floors clean, dry, and uncluttered.
- Ensure bed is locked and in the lowest position.
- Set bed alarm for patients at risk for falls.
- Keep patient's possessions, overbed table, and call light within patient's reach.
- Ensure patient wears non-slip, well-fitting footwear.
- Encourage patient to sit on the edge of the bed and dangle their legs before standing up.
Use of Stairs with Crutches
Climbing Stairs:
- Position unaffected leg next to the stair railing, hold the handrail on that side. Position crutch under axilla on the other (affected) side.
- Step up with the unaffected leg, then bring the affected leg and crutch to the step.
Descending Stairs:
- Position affected leg next to the stair railing, hold the handrail on that side. Position crutch under axilla on the other (unaffected) side.
- Lower crutch one step, then move affected leg down, then move unaffected leg down.
Up with the good, down with the bad!
Card 124
Mobility Devices
Crutches:
- Best Practices
- Crutch Gaits
Answer
Crutches
Best Practices: The underarm pad should sit 2" below the axilla when the shoulder is at rest. Adjust hand grips to allow elbow flexion of 30°.
Crutch Gaits:
- Two-point: Move the opposite crutch and leg together (e.g., left leg/right crutch) followed by the other crutch and leg (right leg/left crutch).
- Three-point: Move both crutches with the injured leg, next advance the uninjured leg.
- Four-point: One crutch is moved, then the opposite leg, then the second crutch, then the last leg (e.g., left crutch, right leg, right crutch, left leg).
- Swing-through: Both crutches are advanced, then both legs are moved at the same time.
- One Crutch: Crutch is used on the strong/uninjured side. Move the crutch forward with the injured leg, then move the uninjured leg forward.
Card 125
Mobility Devices
Canes
Walkers
Answer
Mobility Devices
Canes:
- The cane should be held on the strong side.
- Handle of the cane should be at the level of the wrist (or the greater trochanter). Elbow should be slightly bent.
- Two points of support should be on the ground at all times.
- Place cane 6 - 10" forward, move weak leg forward to the cane, advance stronger leg past cane.
Walkers:
- Top of the walker should reach the crease of the wrist when the patient has their arms relaxed at their side.
- Elbows should be flexed ~ 30 degrees.
- When rising from a chair, use chair arms for support (not walker).
- Push walker forward, move weak leg inside walker, step forward with strong leg into walker.
Card 126
Combating Effects of Immobility
Nursing Care
Answer
Combating Effects of Immobility
- Encourage coughing, deep breathing, and incentive spirometry.
- Apply TED hose or SCDs to promote blood return.
- Provide anticoagulation as ordered.
- Reposition patient every 2 hours, keep skin clean/dry.
- Help patient perform active/passive ROM exercises.
- Encourage ↑ fiber and fluid intake.
- Encourage movement as allowed/tolerated.
- Coordinate referrals to physical therapy and occupational therapy.
Card 127
Deep Vein Thrombosis (DVT)
Prevention
Signs/Symptoms
Nursing Care
Answer
Deep Vein Thrombosis (DVT)
Thrombus (blood clot) forms in a deep vein in an extremity (usually in the lower leg).
Prevention:
- Early and frequent ambulation.
- Compression stockings (e.g., TED hose).
- Sequential compression device (SCD).
- Prophylactic medications (heparin, enoxaparin).
S/S: Calf/thigh pain, edema, erythema over the affected vein.
NC: Elevate extremity (no pillow or knee gatch under knee), warm/moist compresses, do NOT massage the limb.
Monitor for & report S/S of pulmonary embolism (PE): Shortness of breath, chest pain, tachycardia, hypotension.
Card 128
Immobility
Effects on Function
Answer
Immobility
Function: Immobility, illness, or hospitalization may affect a patient's ability to perform ADLs and Instrumental ADLs (IADLs).
- ADLs: Basic tasks necessary for living (e.g., ambulating, bathing, dressing, eating, toileting).
- IADLs: More complex, but still important for functioning (e.g., transportation, finances, shopping).
NC: Encourage patients to participate in their own care as much as possible to maintain function, independence, and dignity.
Patients may not report ↓ ability to perform ADLs, as this may be embarrassing or upsetting. The best way to assess a patient's ability to perform ADLs is by observing them.
Card 129
Immobility
Effects on Body Systems
Answer
Immobility
System
Effects
Respiratory
↓ Lung expansion, ↑ risk of atelectasis (lung collapse), respiratory infections (e.g., pneumonia).
Cardiovascular
↑ Risk of blood clots, orthostatic hypotension.
Musculoskeletal
Muscle atrophy, bone demineralization, ↑ risk for contractures, osteoporosis.
Gastrointestinal
↓ GI motility, ↑ risk of constipation.
Renal
Urinary stasis leads to ↑ risk of UTIs, kidney stones.
Integumentary
↑ Risk for pressure injuries.
Psychosocial
Isolation, depression, ↓ self esteem & sleep quality.
Card 130
Comfort Care
Palliative Care
Hospice Care
Answer
Comfort Care
Palliative Care: Management and treatment of symptoms (e.g., pain, shortness of breath) with focus on ↑ quality of life and ↓ suffering.
- Palliative care can be provided along WITH interventions aimed at curing a disease.
Hospice Care: Symptom management for life-limiting illness. Includes emotional support and bereavement services for families. Can be provided at home or in a facility. Care is NOT focused on curing a disease.
- Medicare requires
- Does not require DNR status.
- Patients can be discharged from hospice if their prognosis improves.
Card 131
Types of Grief
Anticipatory
Normal
Complicated
Disenfranchised
Answer
Types of Grief
Anticipatory: Response to an impending loss.
- Example: Family and individual's response to a diagnosis of a terminal illness.
Normal: Experienced following a loss. Generally resolves independently in 6 months - 1 year.
Complicated: Intense, prolonged sorrow for more than a year. Grief interferes with the individual's daily functioning.
- Example: Two years after a woman's husband left her, she rarely leaves her house and still blames herself for the loss.
Disenfranchised: Experience of a loss that is not publicly acknowledged.
- Example: Miscarriage, death of an extramarital lover.
Card 132
Stages of Grief
Denial
Anger
Bargaining
Depression
Acceptance
Answer
Grief
Denial: Shock, numbness, and disbelief.
Anger: Feeling of abandonment, blaming others for the injustice (healthcare provider, family member, higher power).
Bargaining: Negotiation with self, higher power, etc. Pondering "what if" scenarios.
Depression: Post-denial emptiness, sadness, and withdrawal.
Acceptance: Acknowledgement of new reality and the fact that life must go on. Does not mean they are okay with the loss.
Card 133
General Adaptation Syndrome (GAS)
Stages of GAS
Answer
General Adaptation Syndrome (GAS)
Physiologic changes that occur during periods of stress.
Stages of GAS:
- Alarm Reaction: "Fight or flight" response to a stressful event.
- S/S: ↑ Cortisol levels, BP, and HR.
- Resistance: After the initial shock of the stressful event has subsided, body attempts to normalize vitals & hormone levels.
- S/S: Poor concentration, irritability, and frustration.
- Exhaustion: Prolonged stress depletes the body's resources and weakens the immune system.
- S/S: Fatigue, depression, anxiety, and disease (related to impaired immunity).
Card 134
Sleep
Common Sleep Disorders
Sleep Hygiene
Answer
Sleep
Common Sleep Disorders:
- Insomnia: Difficulty falling or staying asleep.
- Sleep Apnea: Breathing repeatedly stops/starts during sleep.
- Narcolepsy: Excessive daytime sleepiness.
Sleep Hygiene (i.e., practices that promote improved sleep):
- Follow a regular sleep schedule (go to bed and wake up around the same time each day).
- Sleep in a cool, dark, quiet room.
- Avoid naps in the late afternoon/evening.
- Avoid alcohol and caffeine later in the day.
- Exercise regularly, but not within 3 hours of bedtime.
- Avoid large meals and use of electronics before bed.
Card 135
Sleep
Circadian Rhythm
Stages of Sleep
Answer
Sleep
Circadian Rhythm: Internal biological clock that regulates our sleep/wake cycle. Affected by light, environment, age.
Stages of Sleep:
- Stage 1: Transition from wakefulness to sleep, lasts several minutes, vitals decrease.
- Stage 2: Light sleep before deep sleep begins, vitals continue to decrease.
- Stage 3: Deep sleep, vitals are at their lowest, difficult to awaken, allows you to feel refreshed in the morning.
- Rapid Eye Movement (REM): Occurs about 90 minutes after falling asleep, eyes move side to side rapidly, vital signs increase, vivid dreaming occurs.
Patient-Controlled Analgesia
Device that delivers individualized analgesia (most commonly opioid analgesics) for pain control.
PCA Programming:
- Program the pump w/ dose and lockout interval (i.e., minimum time between doses) per provider orders.
- When the patient presses the button, a bolus (i.e., demand dose) of pain medication is delivered.
- PCA can also be programmed to provide a continuous infusion (basal dose) of pain medication.
- Second RN usually required to confirm settings when the pump is programmed and when changing the medication syringe.
ONLY the patient should press the button, NOT nurses/visitors.
Pain Management
Pharmacological Therapies:
- Nonopioid Analgesics: (e.g., acetaminophen, NSAIDs, aspirin). Use for mild to moderate pain.
- Opioid Analgesics: (e.g., fentanyl, morphine, dilaudid, oxycodone). Use for moderate to severe pain.
- Adjuvant Analgesics: Antidepressants (e.g., amitriptyline), anticonvulsants (e.g., carbamazepine), topical analgesics (e.g., lidocaine).
Non-Pharmacological Therapies: Physical therapy, massage, guided imagery, distraction, biofeedback, acupuncture (card 29).
Card 138
Types of Pain
Etiology:
- Nociceptive, Neuropathic, Idiopathic
Location:
- Cutaneous, Somatic, Visceral, Referred
Answer
Types of Pain
Etiology of Pain:
- Nociceptive: Pain caused by injury to tissue. Often described as aching, throbbing.
- Neuropathic: Pain caused by injury to nerves. Often described as burning, shooting, "pins and needles".
- Idiopathic: Pain from an unknown cause.
Location of Pain:
- Cutaneous: Pain involving the skin (e.g., paper cut).
- Somatic: Pain involving the deeper tissues (e.g., joint, tendon, bone).
- Visceral: Organ-related pain (e.g., intestinal pain).
- Referred: Originates at one site, but felt at another site (e.g., shoulder pain following a heart attack).
Card 139
Types of Pain
Acute
Chronic
Breakthrough
Cancer
Answer
Types of Pain
Acute: Sudden onset, resolves when cause of pain is addressed. Causes alteration in vital signs (e.g., ↑ HR and BP).
Chronic: Persistent, > 3 months. May impact psychological status and quality of life (e.g., sleep, appetite, work). Vitals may not be impacted.
Breakthrough: Intense transient pain despite taking pain medications.
Cancer: Related to both the cancer itself and cancer treatment. May be acute and/or chronic.
Card 140
Seizures
Seizure Precautions
Nursing Care
Answer
Seizures
Seizure Precautions: Pad bed side rails. Ensure oxygen, suction, and vital signs equipment is in patient's room.
Nursing Care During a Seizure:
- Lower patient to the floor on their left side. If already lying down, turn patient to the left to decrease risk of aspiration.
- Loosen restrictive clothing, ensure airway is patent.
- Remove items and possible hazards from surrounding area (e.g., furniture).
- Do NOT put anything in the patient's mouth.
- Do not restrain the patient.
- Note time of onset and duration of the seizure.
Nursing Care After a Seizure:
- Record vital signs, perform neurological exam.
- Reassure and reorient the patient.
Card 141
Oral Care & Denture Care
Best Practices
Answer
Basic Care & Comfort
Oral Care:
- For alert patients, place emesis basin under patient's chin, or provide cup for rinsing and spitting.
- For unconscious patients, angle patient's head ≥ 45° and turn to side to prevent aspiration.
- Do not place fingers in mouth.
Denture Care:
- Place towels in sink to prevent damage if dentures fall during cleaning.
- Brush with toothbrush and toothpaste or denture cleaner.
- Rinse with cool water and store in labeled denture cup with denture solution or water.
Card 142
Bed Bath & Bed Making
Best Practices
Answer
Basic Care & Comfort
Bed Bath:
- Use basin with warm water or disposable bath wipes.
- Provide patient privacy, cover areas not currently being washed with a bath sheet.
- Wipe eyes first without soap. Then wash the face, chest, arms, abdomen, legs, feet, back.
- Wash perineum last. Change water before washing perineum.
Females wipe Front to back.
Bed Making:
- Raise bed to waist height.
- Do not shake linen (disperses skin cells).
- Immediately place soiled linens in appropriate bin, not on floor.
Card 143
Sterile Fields
Sterile Field Preparation
Pouring Sterile Solutions
Answer
Sterile Fields
Sterile Field Preparation:
Position package so top flap will open away from your body.
Open top flap away from you.
Open flap on right side with your right hand and left side with your left hand (so you do not reach over sterile field).
Open last flap towards your body.
Add items by opening package and dropping item from 6" above field.
Pouring Sterile Solutions:
Open cap and place it so the inside of the cap is facing up on a non-sterile surface.
Hold the bottle such that the label is in the palm of your hand.
Pour slowly at a height that does not result in splashing (e.g., 4 - 6").
Card 144
Sterile Fields
Indications
Best Practices
Answer
Sterile Fields
Indications: Surgical procedures, central line dressing changes, tracheostomy care, insertion of a urinary catheter, arterial line, or CVC.
Best Practices:
- Never turn your back or leave field unattended.
- Do not reach over sterile field.
- Do not talk, cough, or sneeze over sterile field.
- Check integrity of all packaged items for holes, damage, or moisture prior to dropping onto field.
- The 1" border of the field is considered non-sterile.
- Objects held below the waist are considered non-sterile.
- A sterile item that becomes wet is no longer sterile.
Card 145
Protective Isolation
Nursing Care
Patient Teaching
Answer
Protective Isolation
Precautions used to protect immunocompromised patients from infection ("reverse" isolation). Also referred to as neutropenic precautions.
NC:
- Provide a private room with positive-pressure airflow.
- Leave equipment in the patient's room (e.g., stethoscope, BP cuff).
- Wear appropriate PPE: mask, gloves, gown.
- Do not allow flowers and live plants into the patient's room.
- Screen all visitors for illness.
PT:
- Perform frequent and thorough hand hygiene.
- Avoid crowds and contact with people who are sick.
- Do not share personal items (e.g., toothbrush) or utensils with others.
- Avoid raw foods, including raw fruits and vegetables.
- Cook meats thoroughly.
- Avoid live plants and gardening.
Card 146
Transmission Precautions
Droplet
Airborne
Answer
Transmission Precautions
Droplet: Used for infections spread via respiratory droplets.
- Infections: Influenza, pertussis, group A strep, mumps, diphtheria, rubella, bacterial meningitis.
- PPE required: Gown, gloves, and surgical mask (for contact
Airborne: Used for infections suspended in air. Provide private room with negative-pressure airflow.
- Infections: Varicella (chickenpox), measles, tuberculosis.
- PPE required: Gown, gloves, N95 mask or respirator.
Patient should wear a surgical mask any time they must leave their room.
Transmission Precautions
PPE and infection prevention practices utilized during patient care to ↓ the spread of infectious agents.
Standard/Universal: Used with all patients. Includes hand hygiene, clean gloves, safe injection practices, cough etiquette, and use of additional PPE (e.g., gown, mask, eye protection, face shield) when splashing of bodily fluids is possible (e.g., wound irrigation).
Contact: Used for infections spread by touching the patient or the patient's environment.
- Infections: C. difficile, multidrug resistant organisms (e.g., MRSA, VRE), RSV, major wound infections, impetigo, lice, scabies.
- PPE required: Gown and gloves.
C. difficile requires soap and water (NOT hand sanitizer).
Card 148
Personal Protective Equipment (PPE)
Donning Sequence
Doffing Sequence
Answer
Personal Protective Equipment
Equipment used to reduce exposure to unsafe matter.
Don (Put on)
Hand hygiene
Gown - tie to secure
Mask - cover nose and chin
Eye protection
Gloves - cover cuff of gown
GMEG: "Gee Meg, my patient is on isolation precautions!"
Doff (Take off)
Gloves
Eye protection
Gown
Mask
Hand hygiene
Avoid touching the outside of all PPE during removal (it is contaminated).
Card 149
Hand Hygiene
Soap and Water
Hand Sanitizer
Answer
Hand Hygiene
Most important step in preventing infection. Wash before and after touching a patient or their surroundings.
Soap and Water: Keep hands lower than elbows. Rub vigorously with soap for at least 15 - 20 seconds, rinse thoroughly. Turn off faucet w/ paper towel AFTER drying hands.
Hand Sanitizer: Use one that contains at least 60% alcohol. Apply enough (~ 3 - 5 mL) to cover hands. Rub together vigorously until completely dry.
Use soap and water (vs. hand sanitizer) when hands are visibly dirty, before eating, after using the bathroom, and after caring for a patient with infectious diarrhea.
Card 150
Hospital-Acquired Infections (HAIs)
Best Practices for Prevention
Answer
HAI Prevention
- Perform proper hand hygiene.
- Room cohorting (i.e., group patients with same diagnosis/infection together).
- Post sign on room door and keep PPE cart outside room for patients on isolation precautions.
- Keep disposable stethoscope and equipment at bedside for patients with transmission precautions.
- Cluster care to limit exposure.
- Limit invasive procedures, remove lines/tubes/drains as soon as possible.
- Perform line/tube/drain care per evidence-based facility policy (e.g., dressing changes).
Card 151
Hospital-Acquired Infections (HAIs)
Types of HAIs
Answer
Hospital-Acquired Infections (HAIs)
Nosocomial (i.e, originating in the hospital) infections not present at time of admission. May be iatrogenic (i.e., caused by a procedure or therapy). Associated with morbidity, mortality, longer stays, and ↑ care costs.
Types of HAIs:
- Central line-associated bloodstream infection (CLABSI)
- Catheter-associated urinary tract infection (CAUTI)
- Clostridium difficile infection (CDI)
- Hospital-acquired pneumonia (HAP)
- Ventilator-associated pneumonia (VAP)
- Surgical site infection (SSI)
- Hospital-acquired pressure injury (HAPI)
Card 152
Continuity of Care
Admission
Transfer
Discharge
Answer
Continuity of Care
Admission: Confirm advanced directive status, assess for allergies, determine fall risk. Assess for swallowing issues prior to allowing the patient to eat or drink. Perform head-to-toe assessment. Begin discharge planning!
Transfer: Provide details to the receiving nurse using SBAR format handoff (card 44).
Discharge: Provide instruction on diet/activity restrictions, prescribed medications, follow-up appointments, and provider contact information.
A medication reconciliation should be done during admission, upon transfer to another floor/unit/facility, and at discharge.
Card 153
SBAR Communication
Situation
Background
Assessment
Recommendation
Answer
SBAR Communication
Technique to organize and facilitate communication with interdisciplinary team members.
Situation: Introduce yourself, provide the patient name, and briefly describe the specific problem/concern.
Background: Provide the patient's admitting diagnosis and relevant history.
Assessment: Share relevant assessment findings (e.g., vital signs, signs/symptoms, labs, or diagnostics).
Recommendation: Provide suggestions for next steps.
Card 154
Interdisciplinary Team Members
Provider
Occupational Therapist
Physical Therapist
Speech Language Pathologist
Respiratory Therapist
Social Worker
Case Manager
Answer
Interdisciplinary Team Members
Provider: Examines, diagnoses, and treats injuries/illnesses (e.g., doctor, nurse practitioner).
Occupational Therapist: Helps patients regain or maintain their ability to perform activities of daily living (ADLs).
Physical Therapist: Works with patients to improve mobility, range of motion (ROM), and endurance.
Speech Language Pathologist: Assists with speech, language, and swallowing issues.
Respiratory Therapist: Manages airway and breathing issues.
Social Worker: Provides psychosocial support and appropriate referrals for patients and families.
Case Manager: Assists with discharge planning, arranges for medical equipment/services required by patient.
Card 155
The Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
Answer
The Nursing Process
Systematic approach used to guide patient care.
Assessment: Use critical thinking to collect data (subjective & objective).
Diagnosis: Formulate a nursing diagnosis using data collected to address an actual or potential health problem.
Planning: Create patient-centered SMART goals (Specific, Measurable, Attainable, Realistic, Timely) and outcomes.
- Poorly written goal: "Patient's blood pressure will decrease."
- SMART goal: "Patient's systolic blood pressure will decrease by 10 mmHg by (date)."
Implementation: Execute nursing interventions to meet planned goal(s).
Evaluation: Reassess patient to evaluate if goals/outcomes have been met. Adapt plan of care based on new assessment.
These steps are sequential! Always start by assessing.
Card 156
Internal Radiation (Brachytherapy)
Nursing Care
Answer
Internal Radiation (Brachytherapy)
Sealed radioactive item implanted into a patient for short-term targeted radiation therapy.
- Patient should be kept in a private room w/ door closed.
- Cluster care in order to minimize time spent in the room.
- Care providers should wear dosimeter badge and lead apron while facing the patient at all times.
- Pregnant employees & visitors should not enter the room.
- Visitors must remain > 6 feet away from patient. Limit visits to ≤ 30 min.
- If the implant becomes dislodged, use tongs to place it in a lead container and then call the provider.
Card 157
Body Mechanics
Prevention of Caregiver Injury
Answer
Body Mechanics - Prevention of Injury
- Stand with feet shoulder width apart.
- Raise the bed to waist level when providing care, and hip level when repositioning or transferring patient.
- Avoid twisting spine.
- Bend using knees, not waist (lift with legs, not back).
- Hold object close to your body when lifting.
- Use assistive devices as needed (e.g., lift equipment, transfer belt).
- Ensure the appropriate number of caregivers are available to assist with patient transfer.
Card 158
Sharps Injury
Prevention
Nursing Care
Complications
Answer
Sharps Injury
Accidental puncturing of self with a needle.
Prevention:
- Use needleless systems when possible.
- Avoid recapping needles. If unavoidable, use scoop method.
- Deploy safety feature(s) immediately after use.
- Place used needle immediately in sharps container.
- Report full sharps container.
NC: Thoroughly rinse site with normal saline or water. Report needlestick injury to charge nurse and follow up with post-exposure prophylactic measures (e.g., bloodwork).
Complications: Transmission of blood-borne pathogens (e.g., Hepatitis B and C, HIV).
Card 159
Safety & Security
Equipment Malfunction
Chemical Exposure
Tornado
Bomb Threat
Answer
Safety & Security
Equipment Malfunction: Tag faulty equipment, take out of use, notify appropriate department (e.g., engineering). Ensure equipment is inspected regularly.
Chemical Exposure: Brush dry chemicals off skin and clothing. Remove clothing, flush skin with water. Locate Material Safety Data Sheet (MSDS).
Tornado: Avoid windows, move patients to the middle of the building (e.g., hallway). If patient is unable to be moved, place blanket over patient for protection.
Bomb Threat: If threat made via phone call, keep the caller talking and do not hang up, write down as much as possible about the call (e.g., exact wording of threat, voice, behavior).
Card 160
Fire Safety
RACE Sequence
PASS Sequence
Answer
Fire Safety
RACE Sequence:
- R: Rescue anyone in immediate danger.
- A: Activate the alarm for help.
- C: Contain fire by closing fire doors.
- E: Extinguish and Evacuate if safe to do so.
PASS Sequence:
When using a fire extinguisher:
- P: Pull the pin.
- A: Aim at the base of the fire.
- S: Squeeze the handle.
- S: Sweep from side to side.
Card 161
Illnesses
Acute vs. Chronic Illness
Modifiable vs. Non-Modifiable Risk Factors
Answer
Illnesses
Classification:
- Acute Illness: Sudden onset, limited duration, responds well to treatment (e.g., medication, surgery).
- Examples: Appendicitis, influenza.
- Chronic Illness: Slower onset, may not respond to treatment, requires long-term care and management. Persists > 1 year.
- Examples: Diabetes, arthritis.
Risk Factors:
- Modifiable: Can be decreased or removed with lifestyle adjustments (i.e., obesity, smoking, stress).
- Non-modifiable: Nothing can change them (i.e., age, ethnicity, genetics).
Card 162
Types of Immunity
Active Natural
Active Artificial
Passive Natural
Passive Artificial
Answer
Types of Immunity
Active Natural: Exposure to a pathogen triggers the immune system to produce antibodies.
Active Artificial: Vaccination triggers the immune system to produce antibodies.
Passive Natural: Antibodies are passed through the placenta or breastmilk from mom to baby.
Passive Artificial: Immune globulin (antibodies) administered to the patient for immediate protection.
Passive immunity protection is immediate, but may only last a few weeks or months. Active immunity can take several weeks to develop, but is long-lasting.
Card 163
Stages of Infection
Incubation
Prodromal
Illness
Convalescence
Answer
Stages of Infection
Incubation: Time period after the initial entry of a pathogen into the host until the appearance of general signs/symptoms. Pathogen multiplies within the host, patient unaware of the disease.
Prodromal: Appearance of general, non-specific signs/symptoms (e.g., fever, fatigue, malaise).
Illness: Appearance of infection-specific S/S.
Convalescence: Recovery from infection. Patient generally returns to normal functioning, but permanent damage may remain.
Card 164
Chain of Infection
Illustration
Answer
Chain of Infection
Card 165
Chain of Infection
Infectious Agent
Reservoir
Portal of Exit
Mode of Transmission
Portal of Entry
Susceptible Host
Answer
Chain of Infection
Epidemiological model that describes the spread of infection/disease.
Infectious Agent: Organism capable of causing infection/disease (e.g., bacteria, viruses, fungi, parasites).
Reservoir: Where the agent lives and multiplies (e.g., humans, animals, soil).
Portal of Exit: The way the agent leaves the reservoir (e.g., nose/mouth, urine, blood).
Mode of Transmission: How the agent goes from the reservoir to the new host. Includes direct contact, droplet, airborne, vehicles (e.g., water, food), or vectors (e.g., mosquitoes, fleas, ticks).
Portal of Entry: How the agent enters the new host. May be the same as the portal of exit.
Susceptible Host: Recipient of infection. Susceptibility influenced by immune status, genetics, age, etc.
Patient Positions
Lateral: "Side-lying," weight is on the hip and shoulder.
Modified Left Lateral Recumbent: Previously known as "Sims' position". Mix of lateral and prone. Patient lies on left side, with left leg extended and right leg flexed at hip. Used for enema administration.
Trendelenburg: Bed flat, tilted backward so HOB is lower than foot of bed. ↑ Venous return. Not for long time use (can ↑ intracranial pressure and obstruct airway).
Reverse Trendelenburg: Bed flat, tilted forward so foot of bed is lower than HOB. ↓ Risk of gastroesophageal reflux.
Lithotomy: Patient supine w/ knees flexed, legs abducted. Used for gynecologic, rectal, or urologic procedures.
Patient Positions
Supine: Patient lying on back in neutral position.
SUPine - patient is facing UP.
Prone: Patient lying on stomach in neutral position. Improves oxygenation in respiratory distress syndrome. Prevents hip flexion contractures after lower extremity amputation.
Semi-Fowler's: Sitting with head of bed (HOB) at 30 - 45°.
Fowler's: Sitting with HOB at 45 - 60°.
High-Fowler's: Sitting with HOB at 60 - 90°. Ideal to help with difficulty breathing.
Card 168
Complementary & Alternative Medicine (CAM)
Types of Therapy
Possible Contraindications
Answer
Complementary & Alternative Medicine
Practices and products that are not a typical part of conventional medical care (allopathic).
Therapy
Possible Contraindications
Acupuncture
Needle phobia, bloodborne pathogens
Herbal Supplements
Concurrent prescription drug use, coagulation disorders
Massage
DVT, psychosis
Hypnosis & Meditation
Psychosis (current or previous)
Chiropractic Adjustments
Fractures, bone cancers
Ask about a patient's use of CAM during the patient intake/assessment.
Card 169
Cultural Considerations
Jehovah's Witnesses
Islam
Judaism
Mormonism
Catholicism
Answer
Cultural Considerations
Jehovah's Witnesses: May refuse blood products.
Islam: Pork, alcohol, shellfish are prohibited. Fasting during month of Ramadan. Prayer 5 times a day. Female patients may request female providers/caretakers.
Judaism: May be Kosher-observant (no pork products, shellfish, or meat with dairy).
- Example: Hamburger is ok, cheeseburger is not.
Mormonism: Alcohol, tobacco, coffee/tea discouraged.
Catholicism: Some may avoid meat on Fridays during Lent.
Regardless of stated religion, everyone practices differently. Ask about individual cultural practices.
Card 170
Cultural Considerations
Language & Interpreter Use
Answer
Cultural Considerations
- Patients with limited English proficiency have a legal right to appropriate language services (e.g., medical interpreters and printed material in their preferred language).
- Qualified interpreters require knowledge of medical terminology. Use of patient's family members or friends is NOT recommended!
- Speak directly to patient, not the interpreter.
- Ask one question at a time and do not use supplemental hand gestures.
Card 171
Cultural Considerations
Culture
Culturally Competent Care
Cultural Assessment
Ethnocentrism
Answer
Cultural Considerations
Culture: Shared beliefs, values, and/or customs influenced by race, ethnicity, language, or geographic location.
Culturally Competent Care: Care that meets religious/cultural/social needs of the patient. Improves quality of care & patient outcomes.
Cultural Assessment: Identification of patient's cultural and spiritual beliefs, practices, and preferences regarding medical interventions, illness, family, diet, pregnancy, death, and postmortem care.
Ethnocentrism: The belief that the views and practices of one's own culture is superior to other cultures. Nurses should NOT demonstrate ethnocentrism.
Culturally competent care begins with identifying your own cultural beliefs and values!
Card 172
Nursing Documentation
Objective
Subjective
Best Practices
Answer
Nursing Documentation
Objective: Observable and tangible data, facts (e.g., vital signs).
Subjective: Things reported by the patient that cannot be verified independently (e.g., nausea or pain). Document as a direct quote.
Objective data is observed.
Subjective is what the patient says.
Best Practices:
- Document immediately after but not before doing something.
- Use approved abbreviations.
- Do not include slang, humor, or negative descriptions of patients or coworkers.
- For written records, cross errors out with one line and add initials, date, and time. Do not use correction tape/fluid.
Patient Education
Instructional Methods:
- Written Materials: In the patient's primary language using layman's terms and an appropriate reading level.
- Demonstration: Showing a patient how a skill is performed.
- Others: Simulation/training devices, videos, books, websites.
Evaluation Methods:
- Teach Back: After the nurse explains/demonstrates something, the patient explains/demonstrates it back to ensure full comprehension. This is the best way to assess patient comprehension of teaching!
- Example: After being shown how to draw up and inject insulin, the nurse watches the patient self-administer their next insulin dose.
Providing ONLY written materials is not sufficient education!
Card 174
Patient Education
Health Literacy
What Aids Learning
What Hinders Learning
Answer
Patient Education
Health Literacy: Ability to learn, gather, process, and understand health information.
What Aids Learning:
- Intrinsic motivation (wanting to change behaviors to benefit self, not because they feel others think they "should").
- A quiet teaching environment free from distractions.
What Hinders Learning:
- ↓ Physical strength, coordination, dexterity.
- Medical jargon or educational materials above patient's reading and/or education level.
- Visual or hearing deficits.
- Presence of symptoms (e.g., pain, fatigue, moderate/severe anxiety).
Card 175
Patient Education
Domains of Learning
Answer
Patient Education
Cognitive: Involves intellect/thinking.
- Example: A patient learning the recommended eating plan for blood sugar control.
Psychomotor: Involves physicality/action.
- Example: A patient practicing administering their own insulin injections.
Affective: Involves emotions/feelings.
- Example: A patient eager to learn as they realize how diabetes could affect their life.
Card 176
Communication
Nontherapeutic Communication Techniques
Answer
Nontherapeutic Communication Techniques
Technique
Example
False reassurance
"Everything will be fine."
Passing judgement (approving or disapproving)
"Yes, you did the right thing."
Giving advice
"You should..." or "You shouldn't…"
Closed-ended questions
(e.g., yes/no questions)
"Are you feeling sad?"
"Why" questions
"Why are you so angry?"
Leading/Biased questions
"You don't smoke, do you?"
Changing the subject
"Let's talk about something else..."
AVOID using these techniques.
Card 177
Communication
Therapeutic Communication Techniques
Answer
Therapeutic Communication Techniques
Technique
Example
Open-ended questions
"Tell me more about..."
Clarification/Validation: Seek understanding for something that is unclear.
"Do I understand you correctly when you say…?"
Reflection: Refer questions back to the patient.
Pt: "Do you think I should try this medication?"
Nurse: "What are your thoughts about it?"
Offering self: Make yourself available to the patient.
"I can sit with you until your family arrives."
Restating: Repeat what patient said to confirm understanding.
Pt: "I am so anxious that I can't get to sleep."
Nurse: "Your anxiety is keeping you awake."
Card 178
Communication
Forms of Nonverbal Communication
Answer
Forms of Nonverbal Communication
Posture: The way one sits, stands, and moves.
Expression: The way one's face conveys emotions/thoughts.
Eye Contact: Depending on one's culture, eye contact may be respectful or could be threatening.
Gestures: Meaning depends on culture/country (e.g., nodding in the U.S. means yes, in Greece it means no).
Touch: May be therapeutic at times. Ask patient before using.
Silence: May be therapeutic and encourage reflection.
For effective nonverbal communication, remember your ROLES: Relaxed body language, Open posture, Lean in, Eye contact, sit Squarely toward patient.
Card 179
Communication
Communication Process
Communication Levels
Answer
Communication
Communication Process:
- Sender: Person expressing information (verbal or nonverbal).
- Receiver: The recipient of the information.
- Message: The information being sent.
- Channel: The format in which the information is sent (e.g., spoken words, facial expressions).
- Feedback: Receiver's response to sender to acknowledge message.
Communication Levels:
- Intrapersonal: One's inner thoughts, "self-talk".
- IntrApersonal has an A for Alone.
- Interpersonal: Interaction with one other person.
- Small-group: Interaction with a few people (e.g., a floor/unit meeting).
- Public: Interaction with a large audience (e.g., speaking at a conference).
Card 180
Models
Transtheoretical Model
Answer
Transtheoretical Model
Theory that describes the six stages associated with health behavior changes.
Stage
Definition
Precontemplation
Not aware of a change needing to be made, unlikely to make change in the next 6 months.
Contemplation
Thinking of making a change, likely within 6 months.
Preparation
Small steps taken; change likely within 30 days.
Action
Change made within the past 6 months and is ongoing.
Maintenance
Change has persisted for 6+ months and is continuing.
Termination
Desire to return to previous behaviors is gone. Behavior change believed to be permanent.
Card 181
Models
Health Belief Model
Answer
Health Belief Model
Theoretical model used to explain and predict an individual's health-related behaviors.
Key Factors:
- Perceived severity of the potential illness (e.g., how bad is it?).
- Perceived susceptibility to the illness (e.g., how likely am I to get it?).
- Perceived benefits of/barriers to taking preventative action.
Other Factors:
- Modifying factors (e.g., age, gender, ethnicity, race).
- Cues to action (e.g., advice of others, media campaigns).
- Self-efficacy (i.e., individual's confidence in their ability to be successful).
Card 182
Theoretical Foundations
Piaget's Theory of Cognitive Development
Answer
Piaget's Theory of Cognitive Development
Theory that describes perception and cognition across the lifespan.
Stage
Age Range
Key Characteristics
Sensorimotor
Birth - 2 years
Learn through senses and movement. Develop object permanence (things continue to exist when out of sight).
Preoperational
2 - 7 years
Magical thinking (thoughts or wishes cause events to occur), animism (treat inanimate objects as alive).
Concrete Operational
7 - 11 years
Have a better understanding of cause and effect. Learn conservatism (matter does not change when its form is altered).
Formal Operational
≥ 11 years
Engage in abstract thought, deductive reasoning, logic based problem-solving.
Card 183
Theoretical Foundations
Erikson's Stages of Psychosocial Development
Answer
Erikson's Stages of Psychosocial Development
Theory that describes key stages in human development and the psychosocial crisis encountered during each stage.
Stage
Age Range
Psychosocial Crisis
Infancy
Birth - 1 year
Trust vs. Mistrust
Toddler
1 - 3 years
Autonomy vs. Shame and Doubt
Preschooler
3 - 6 years
Initiative vs. Guilt
School Age
6 - 12 years
Industry vs. Inferiority
Adolescence
12 - 18 years
Identity vs. Role Confusion
Young Adulthood
18 - 40 years
Intimacy vs. Isolation
Adulthood
40 - 65 years
Generativity vs. Stagnation
Older Age
≥ 65 years
Integrity vs. Despair
Card 184
Theoretical Foundations
Maslow's Hierarchy of Needs
Answer
Maslow's Hierarchy of Needs
Card 185
Theoretical Foundations
Kohlberg's Theory of Moral Development
Answer
Kohlberg's Theory of Moral Development
Theory that focuses on thinking, reasoning, and decision-making across the lifespan.
Stage
Age Range
Decision Making
Preconventional
≤ 5 years
Decisions are made with the goal of avoiding consequences or to get rewards.
Conventional
6 - 12 years
Decisions are made while considering impact on other people and following social norms. Approval is desired.
Postconventional
≥ 13 years
Abstract ideas and other perspectives begin to impact decisions.
Card 186
Mandatory Reporting
Nurse's Responsibilities
Answer
Mandatory Reporting
- Report suspected abuse of a child, elder, or vulnerable adult. This is required as a mandated reporter.
- Nurse does not have the burden of providing proof - just the requirement to report the facts/circumstances that led the nurse to suspect abuse/neglect. Priority nursing action is always to protect patient from immediate harm.
- Interview patient separately from suspected abuser.
- Collect and prepare evidence for legal purposes.
- Develop a safety plan with the patient (i.e., plan for escape if abuse reoccurs).
- Provide information on shelters and safe houses.
Unintentional Torts
Unintended acts against a patient that cause harm.
Negligence: Failure to provide care that a reasonably prudent person would in a similar situation.
Malpractice: Negligence by a professional (e.g., licensed nurse). With nursing malpractice, the nurse had a duty to the patient and failed to provide the standard of care required, resulting in patient harm.
- Example: Nurse failed to check the labeling on a medication vial, which resulted in a medication error and patient harm.
Abandonment: Desertion of a patient by anyone who has assumed the responsibility for care/custody of that patient.
Card 188
Intentional Torts
Assault
Battery
False Imprisonment
Invasion of Privacy
Defamation of Character
Answer
Intentional Torts
Willful acts that violate a patient's rights.
Assault: Any threat made against a patient that makes them fearful (e.g., "If you don't settle down, I'm going to tie you down.").
Battery: Touching of a patient without consent that causes harm (e.g., nurse injects a medication into a patient despite the patient's refusal).
A before B: Assault (threat) before Battery (harm).
False Imprisonment: Inappropriate confinement of a patient with restraints, seclusion, or a medication acting as a "chemical restraint."
Invasion of Privacy: Violating a patient's right to confidentiality (e.g., sharing patient information to a family member without patient consent).
Defamation of Character: Making derogatory remarks that harm a patient's reputation. Includes slander (verbal statements) and libel (written statements).
Slander is spoken but libel is written, like a book in the library.
Card 189
Health Insurance Portability & Accountability Act (HIPAA)
Key Provisions
Best Practices
Answer
HIPAA
Law that protects a patient's right to privacy and regulates how their health care information is used and disclosed.
Key Provisions:
- Patient information may NOT be disclosed to anyone that is not directly involved in the care of the patient without patient consent.
- Patients have a right to receive a copy of their health records.
Best Practices:
- Log off computer when stepping away. Use secure, unique passwords and change them frequently. Never share passwords.
- Only discuss patient information in a secure environment (e.g., nurses' station) instead of public places (e.g., elevator, cafeteria).
- Do not access information or charts not needed for work.
- Report any breach of confidentiality.
Card 190
Advance Directives
Patient Self-Determination Act (PSDA)
Types of Advance Directives
Answer
Advance Directives
Legal documents that communicate preferences regarding medical care if the patient becomes incapacitated and/or is unable to verbalize their wishes.
PSDA: Ensures a patient's right to to self-determination in health care decisions, including advanced directives.
Types of Advance Directives:
- Living Will: Indicates desired or prohibited medical interventions including code status, level of intervention, or life-sustaining measures (e.g. ventilation, tube feeding).
- Do Not Resuscitate (DNR): No CPR or resuscitative actions taken.
- Physician's Orders for Life-Sustaining Treatment (POLST): Medical orders that summarize the patient's wishes regarding medical care.
- Durable Power of Attorney (DPOA):Identifies another person(s) responsible for medical decision-making. This person does not have to be related to the patient.
Card 191
Refusal of Treatment
Right to Refuse
Leaving Against Medical Advice (AMA)
Nursing Actions for AMA
Answer
Refusal of Treatment
Right to Refuse: Patients who are competent to provide consent have the right to refuse medications or other therapies EVEN if they were involuntarily admitted (except in emergency).
Leaving Against Medical Advice (AMA): Patient chooses to leave the hospital before the treatment team recommends discharge. Places patient at ↑ risk for readmission and morbidity/mortality.
Nursing Actions for AMA:
- Notify the provider.
- Discuss risks associated with leaving AMA with the patient.
- Have patient sign AMA form (or document patient's refusal to sign form).
- Remove any IV catheters and apply dressing.
- Do NOT call security!
Card 192
Informed Consent
Key Points
Answer
Informed Consent
- If a patient is not oriented (i.e., dementia, delirium, under the influence of drugs/alcohol) they may NOT be competent to provide consent.
- Many states give minors (
- If a patient has questions about the procedure (before or after providing consent), the provider must be contacted to answer them.
- A patient who does not speak English can not consent without a medical interpreter available to translate.
- After consent has been obtained, the patient still has the right to change their mind and decline treatment!
Card 193
Informed Consent
Provider's Role
Nurse's Role
Documentation
Answer
Informed Consent
Process that confirms a patient's voluntary decision to undergo a procedure or intervention.
Provider's Role: Explain the nature, risks, and benefits of the procedure, alternatives to the procedure, risks and benefits of the alternatives. Assess the patient's understanding of the information and answer all patient questions.
Nurse's Role: Sign consent form as witness, confirm patient received and understands above information, ensure patient is competent, and gave consent voluntarily.
Documentation: All elements of informed consent must be documented on a form or in the patient's medical record.
Ethical Principles
Principle
Example
Autonomy: The patient's right to make their own healthcare decisions.
Respect a patient's right to refuse a treatment.
Beneficence: To promote good.
Take a patient outside to get fresh air.
Nonmaleficence: To avoid causing harm.
Perform multiple checks to avoid a medication error.
Justice: To treat fairly and equally.
Distribute care equitably among assigned patients.
Fidelity: To be faithful/loyal.
Keep promise to a patient.
Advocacy: To promote/protect the patient's rights, health, and safety.
Notify provider of concerning change in patient's condition.
Veracity: To tell the truth.
Be honest with patient about possible side effects of a medication.
Card 195
Ethics of Care
American Nurses Association (ANA)
Ethical Dilemma
Ethics Committee
Answer
Ethics of Care
American Nurses Association (ANA): Establishes ethical standards for the nursing profession.
Ethical Dilemma: Conflicting values that cause distress and controversy.
- Example: Daughter of an intubated patient with terminal cancer does not want her mother to have opioid pain medication due to religious reasons even though she is in severe pain.
Ethics Committee: Interdisciplinary team (e.g., nurse, physician, social worker) that provides guidance in the face of an ethical dilemma. Assists in mediation between the patient, family, and treatment team.
Provides recommendations, does NOT impose decisions.
Card 196
The Profession of Nursing
State Boards of Nursing (BON)
Nursing Practice Act (NPA)
Evidence-Based Practice (EBP)
Answer
The Profession of Nursing
State Boards of Nursing (BON): Manage nursing licensure, testing requirements, and nursing education program standards.
Nursing Practice Act (NPA): Legal document that governs nursing practice in each state. Defines nursing scope of practice with clear definitions of roles. Nurses who violate the defined standard of care face discipline (e.g., fines, supervised practice, mandatory education, suspension).
Be familiar with the laws affecting your practice (as defined in your state's NPA)!
Evidence Based Practice (EBP): Utilizing the best evidence from research to guide nursing practice.