Nursing Foundations and Scope of Practice & Professionalism and Leadership

Novice to Expert (Patricia Benner’s Model)

Patricia Benner’s Novice to Expert theory describes how nurses develop skills and knowledge
over time through education and experience. It consists of five stages:
Novice – Beginner with little or no experience; follows rules and procedures rigidly.
Advanced Beginner – demonstrates basic skills but continues to need guidance.
Competent – 2-3 years of experience; individual can plan, make decisions, and perform job
responsibly and efficiently.
Proficient – Sees the bigger picture; demonstrates advanced decision making, knowledge,
resourcefulness, flexibility, and problem solving.
Expert – deep knowledge and skills, teaches others, and multitasks effortlessly & fluently.
Example: A novice nurse follows a checklist for wound care, while an expert nurse adapts the
process based on patient-specific needs.
THINK: “NURSES ALWAYS CARE FOR PATIENTS EXPERTLY”

Guidelines for Nursing Practice

Nursing practice is guided by ethical, legal, and professional standards:
ANA (American Nurses Association) establishes ETHICAL standards for nursing profession.
ANA Code of Ethics (Key principles: Autonomy, Beneficence, Nonmaleficence, Justice,
Fidelity, Veracity)
Autonomy- the patients right to make their own decisions.
Beneficence-to promote good
Nonmaleficent- to avoid causing harm
Justice- to treat fairly and equally
Fidelity- to keep promises
Advocacy- standing up for your patient
Veracity- to tell the truth (honesty)

Texas Board of nursing: to protect and promote the welfare of the people of Texas by ensuring
each person holding a license is competent to practice safely. Can take disciplinary action.

State Nurse Practice Acts (NPA):

-Define nursing scope of practice.
-Govern licensure requirements.
-Protect public health and safety.
Example: A nurse following the ANA Code of Ethics ensures patient confidentiality (HIPAA)
when discussing a case.

Nursing Process (ADPIE)

A systematic problem-solving approach for patient-centered care:
Assessment – Collect data (subjective & objective).
Diagnosis – Identify nursing problems (not medical).
Planning – Set SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound).
Implementation – Perform interventions.
Evaluation – Assess effectiveness and adjust as needed.
Example: A nurse assessing a patient with pneumonia collects respiratory rate, breath sounds,
and oxygen levels (Assessment), diagnoses "Ineffective Airway Clearance," plans to improve
oxygenation, implements repositioning and deep breathing, and evaluates by reassessing
oxygenation.

Nursing Organizations
American Nurses Association (ANA) – Establishes practice standards, ethics, and advocacy.
National League for Nursing (NLN) – Focuses on nursing education and faculty development.
National student Nurses association (NSA) - focused on students
The Joint Commission (TJC)- Accredits hospitals

QSEN (Quality and Safety Education for Nurses):

Developed to improve patient safety and quality of care. Six core competencies:
Patient-Centered Care – Respect patient preferences and values.
Teamwork & Collaboration – Communicate effectively within healthcare teams.
Evidence-Based Practice (EBP) – Integrate research into clinical practice.
Quality Improvement (QI) – Use data to enhance care processes.
Safety – Minimize risk and prevent harm.
Informatics – Use technology for patient care and documentation.
Example: A nurse scans a barcode before medication administration to ensure patient safety
(informatics).

Consent & Advance Directives

Informed Consent – Patient must understand risks, benefits, and alternatives before procedures.
Nurse's Role: Witness consent, ensure understanding (but NOT obtain consent).
Physicians Role: explain to the patient the risks and benefits of the procedure, the alternatives,
risks, and benefits of procedure. KEY: Answers all patients questions

Advance Directives: Legal documents outlining healthcare preferences.

Living Will – Specifies interventions a patient wants or refuses if incapacitated.
Durable Power of Attorney– Appoints a decision-maker if the patient is incapacitated.
DNR (Do Not Resuscitate) / DNI (Do Not Intubate) – Orders for end-of-life care.
Example: A patient with terminal cancer signs a DNR, meaning the nurse should not perform
CPR if the patient’s heart stops.

Decision-Making in Nursing
Critical Thinking in Nursing Decisions:
Analyze information.
Apply nursing knowledge.
Evaluate outcomes.
Ethical Decision-Making Framework:
Identify the problem.
Gather relevant information.
Consider ethical principles.
Make a decision/Evaluate the decision’s impact
Delegation Principles (Five Rights of Delegation):
Right Task – Appropriate for delegation?
Right Circumstance – Patient’s condition stable?
Right Person – Qualified personnel?
Right Directions– Clear instructions?
Right Supervision/Evaluation – Follow-up and evaluation?
Example: A nurse delegates vital sign monitoring to a CNA but retains responsibility for
evaluating abnormal results.

Components of Professionalism
Professionalism in nursing includes behaviors, values, and responsibilities:
Knowledge & Competence – Maintain skills and continuing education.
Autonomy & Accountability – Take responsibility for actions.
Advocacy – Protect patient rights and well-being.
Ethical & Legal Practice – Follow ANA Code of Ethics and Nurse Practice Act.
Communication & Collaboration – Work with interdisciplinary teams.
Leadership & Commitment to Excellence – Engage in lifelong learning.
Respect & Compassion – Treat patients and colleagues with dignity.
Example: A professional nurse maintains patient dignity by closing the curtain before a physical
assessment.

Health Promotion, Wellness, and Disease Prevention

Modifiable and Non-Modifiable Risk Factors

Modifiable Risk Factors (Can be changed through lifestyle choices or interventions)
Diet & Nutrition – Poor diet increases risk for obesity, diabetes, cardiovascular diseases.
Physical Activity – Sedentary lifestyle contributes to chronic illnesses.
Smoking & Substance Use – Increases risk of cancer, heart disease, and lung disease.
Stress & Coping Mechanisms – Chronic stress affects immune function and heart health.
Sleep Patterns – Sleep deprivation can lead to metabolic disorders.
Environmental Exposure – Pollution, second-hand smoke, and occupational hazards.
Example: A nurse educates a patient with hypertension on reducing salt intake to lower blood
pressure.

Non-Modifiable Risk Factors (Cannot be changed, but awareness can guide prevention
strategies)
Age – Risk for chronic diseases increases with age.
Genetics & Family History – Some diseases, like diabetes and breast cancer, have hereditary
links.
Sex – Certain conditions affect males and females differently (e.g., osteoporosis is more common
in women).
Ethnicity/Race – Some ethnic groups have higher predispositions to conditions like sickle cell
anemia or hypertension.
Example: A nurse screens a patient for colon cancer earlier because of a strong family history.
EMTALA (Emergency Medical Treatment and Active Labor Act)
A federal law that requires hospitals to treat and stabilize all patients in an emergency, regardless
of their ability to pay, citizenship, or legal status.
Applies to all hospitals that receive Medicare funding.
Requires hospitals to:
Provide a medical screening exam (MSE) to determine if an emergency condition exists.
Stabilize the patient or transfer them to an appropriate facility if needed.
Not "dump" (refuse or transfer) uninsured or Medicaid patients for financial reasons.
Example: A hospital cannot deny care to an uninsured patient experiencing a heart attack.

Levels of Prevention
1. Primary Prevention (Prevention before disease occurs – promotes wellness & healthy
behaviors)
Immunizations (e.g., flu shots, HPV vaccine)
Health education (e.g., smoking cessation, nutrition counseling)
Exercise programs to prevent obesity
Safe sex practices, contraceptive counseling
Environmental sanitation (e.g., clean water initiatives)
💡 Example: A nurse conducts a smoking cessation class for teenagers to prevent future lung
disease.

2. Secondary Prevention (Early detection and prompt treatment to prevent complications)

Screenings (e.g., mammograms, Pap smears, colonoscopies)
Regular blood pressure & cholesterol monitoring
Diabetes screening for at-risk patients
TB testing for healthcare workers
Early interventions (e.g., administering low-dose aspirin to prevent heart attacks)
💡 Example: A nurse schedules routine mammograms for women over 40 to catch breast cancer
early.

3. Tertiary Prevention (Managing existing disease to prevent worsening & maximize

function/quality of life)
Rehabilitation (e.g., physical therapy after a stroke)
Support groups (e.g., cardiac rehab, Alcoholics Anonymous)
Chronic disease management (e.g., insulin therapy for diabetes)
Assistive devices (e.g., prosthetics, hearing aids, wheelchairs)
💡 Example: A nurse teaches a diabetic patient how to monitor blood sugar and prevent foot
ulcers.

Medicare & Medicaid

Medicare (Federal Program) Eligibility:
Age 65 and older
Certain disabilities (e.g., ALS, ESRD requiring dialysis)
Medicaid (State & Federal Program) Eligibility:
Low-income individuals & families
Children (CHIP – Children's Health Insurance Program)
Pregnant women
Disabled individuals
Covers hospital stays, doctor visits, long-term care, and some home health services.
💡 Example: A single mother with low income qualifies for Medicaid to cover prenatal care.

Nursing Interventions for Health Promotion & Disease Prevention

Primary Prevention Interventions
Educate about healthy eating and exercise to prevent obesity.
Encourage smoking cessation to prevent lung disease.
Advocate for vaccinations (e.g., flu shots, HPV vaccine).
Provide mental health support to prevent stress-related conditions.
💡 Example: A nurse at a community health fair provides free blood pressure checks and health
education.

Secondary Prevention Interventions

Screening & early detection (e.g., teaching self-breast exams, BP screenings).
Encouraging compliance with routine health exams (e.g., yearly Pap smears).
Administering medications to manage early-stage conditions (e.g., statins for high cholesterol).
💡 Example: A school nurse conducts annual vision and hearing tests to identify issues early.

Tertiary Prevention Interventions

Rehabilitative care (e.g., helping stroke patients regain mobility).
Patient education on managing chronic diseases (e.g., insulin injection training for diabetes).
Support groups for chronic conditions (e.g., heart failure support, cancer survivors).
💡 Example: A nurse teaches a newly diagnosed diabetic how to check blood sugar and
administer insulin.

Health Care Delivery

Health Care Settings

Healthcare is delivered in various settings, depending on the level of care required. These
settings are categorized based on the complexity and urgency of services provided.

1. Primary Care (Preventive & Routine Care)

Focus: Health promotion, disease prevention, early detection, and treatment of common
illnesses.
Examples:
Family doctor’s office
Community health centers
Urgent care clinics (for minor illnesses like colds, infections)
School-based health clinics
💡 Example: A patient visits a primary care provider for an annual physical exam and flu shot.

2. Secondary Care (Specialist & Acute Care)

Focus: More specialized treatment than primary care but not as intensive as tertiary care.
Examples:
Specialist care (e.g., cardiologists, dermatologists)
Outpatient surgery centers (e.g., cataract surgery, endoscopies)
Emergency departments (non-life-threatening issues like fractures, infections)
💡 Example: A patient is referred to a cardiologist for evaluation after an abnormal ECG.

3. Tertiary Care (Highly Specialized & Advanced Care)

Focus: Treatment of complex conditions requiring highly specialized knowledge, technology, or
intensive care.
Examples:
ICU (Intensive Care Units) – Life-support care for critically ill patients.
Specialty hospitals – Burn centers, cancer hospitals, neurosurgery units.
Advanced surgeries – Heart bypass surgery, organ transplants.
💡 Example: A patient undergoes open-heart surgery at a cardiac center.

4. Quaternary Care (Experimental & Uncommon Treatments)

Focus: Highly specialized procedures, often experimental or limited to major research hospitals.
Examples:
Clinical trials (e.g., experimental cancer treatments)
Rare procedures (e.g., face transplants)
💡 Example: A patient participates in an experimental gene therapy trial for a rare genetic
disorder.

5. Long-Term Care (Chronic & Ongoing Support)

Focus: Managing chronic illnesses, disabilities, or rehabilitation after major medical events.
Examples:
Nursing homes – 24/7 medical supervision for elderly or disabled patients.
Assisted living facilities – Residential support with personal care.
Home health care – Skilled nursing, therapy, or hospice care at home.
💡 Example: A stroke patient moves into a rehabilitation center to regain motor function.

6. Palliative & Hospice Care (End-of-Life & Comfort Care)

Palliative Care: Supports patients with serious illnesses (cancer, COPD, heart failure) to improve
comfort, regardless of life expectancy.
Hospice Care: Focuses on comfort, dignity, and pain relief for terminally ill patients with less
than 6 months to live.
💡 Example: A nurse provides pain management and emotional support for a terminally ill patient
in hospice care.

Social Determinants of Health (SDOH)

Social determinants of health are non-medical factors that affect health outcomes. They shape the
conditions in which people live, work, and grow.

Five Key Social Determinants of Health (SDOH)

1. Economic Stability
Impact: Financial insecurity leads to difficulty affording healthcare, nutritious food, or stable
housing.
Examples:
Low-income status → increased risk of chronic diseases.
Unemployment → lack of health insurance → limited access to care.
Example: A nurse connects a low-income patient to Medicaid services for affordable healthcare.

2. Education Access & Quality

Impact: Higher education levels correlate with better health literacy, employment, and access to
healthcare.
Examples:
Limited education → difficulty understanding medication instructions.
Lack of health education → poor nutrition choices.
Example: A public health nurse teaches high school students about safe sex practices.

3. Healthcare Access & Quality

Impact: Limited access to care leads to untreated health conditions and worse health outcomes.
Examples:
Lack of health insurance → skipping medical appointments.
Provider shortages in rural areas → delays in care.
Example: A nurse in a rural clinic uses telemedicine to connect patients with specialists.

4. Neighborhood & Built Environment

Impact: Unsafe living conditions, lack of access to healthy food, and poor air quality contribute
to chronic disease.
Examples:
Living in a food desert → higher rates of obesity and diabetes.
Unsafe housing → increased risk of asthma, lead poisoning.
Example: A nurse advocates for safer playgrounds and more grocery stores in low-income
neighborhoods.

5. Social & Community Context

Impact: Support systems and community involvement affect mental and physical health.
Examples:
Social isolation → increased risk of depression and cognitive decline.
Discrimination → stress-related health issues (hypertension, anxiety).
Example: A nurse refers an elderly patient to a local senior center to combat loneliness.

Nursing Role in Addressing Social Determinants of Health

✔ Screening patients for food insecurity, housing instability, and financial barriers to care.
✔ Providing health education to improve literacy and disease prevention.
✔ Connecting patients to resources like Medicaid, food banks, and community health programs.
✔ Advocating for policy changes that address systemic health disparities.
Ethical and Legal Considerations in Nursing

Torts in Nursing
A tort is a civil wrong that results in harm to another person, leading to legal liability. In nursing,
torts can be intentional or unintentional.

Intentional Torts (Deliberate Actions)- occur when a nurse deliberately harms a patient or
violates their rights.
-Assault – Threatening a patient with harm without making physical contact. Example: A nurse
raises a hand and threatens to slap a patient.
-Battery – Unwanted physical contact without consent. Example: Administering an injection to a
competent patient who refused it.
-False Imprisonment – Restraining a patient without legal justification. Example: Applying
restraints without a doctor’s order.
-Invasion of Privacy – Disclosing a patient’s private health information without permission.
-Defamation (Slander & Libel) – Spreading false information that damages a person’s reputation.
-Slander is spoken (e.g., falsely accusing a patient of drug abuse), while libel is written (e.g.,
documenting false statements in a patient’s chart).

Unintentional Torts (Negligence & Malpractice)- happens when a nurse fails to meet the
standard of care, resulting in patient harm.
-Negligence – Failure to provide proper care, leading to harm. Example: Forgetting to lower a
patient’s bed, causing them to fall.
-Malpractice – Professional negligence, where the nurse knew better but failed to act
appropriately. Example: Administering the wrong medication and causing harm.

Code of Ethics for Nurses

The American Nurses Association (ANA) Code of Ethics guides nurses in making ethical
decisions and providing high-quality care

Core Values in Nursing

Nurses are guided by several core values:
Altruism – Putting patient needs before personal gain.
Autonomy – Respecting a patient’s right to make their own decisions.
Human Dignity – Treating all patients with respect and worth.
Integrity – Being honest and ethical in all actions.
Social Justice – Advocating for fair treatment and equal access to healthcare.

Sentinel Events
A sentinel event- is a serious, unexpected occurrence that results in severe harm or death and
requires immediate investigation.
Adverse event- is a situation or circumstance that caused unexpected harm to the client.
Near-Miss event- a potential error or close call that could have caused harm but was caught and
avoided.
Common examples of sentinel events in nursing include:
Medication errors – Administering the wrong drug or dose, leading to harm.
Surgical errors – Performing surgery on the wrong site or leaving surgical instruments inside a
patient.
Patient falls – Falls that lead to fractures or brain injury.
Delayed treatment – Failing to recognize and address life-threatening conditions in time.
Suicide – A patient committing suicide while under hospital care.
Elopement – A confused patient leaving the hospital and getting injured.
Example: If a nurse administers an excessive dose of insulin, causing fatal hypoglycemia, this
would be classified as a sentinel event requiring a root cause analysis.

Ethical Dilemmas in Nursing

An ethical dilemma arises when a nurse faces a difficult decision with conflicting moral
principles, where there is no clear right or wrong answer.

Common ethical dilemmas in nursing include:

End-of-life decisions – Deciding whether to withdraw life support.
Patient autonomy vs. beneficence – Balancing a patient’s right to refuse treatment with the desire
to provide beneficial care.
Resource allocation – Determining who should receive limited ICU beds or organ transplants.
Truth-telling vs. nonmaleficence – Deciding whether to withhold distressing medical news to
prevent emotional harm.
Refusing care based on personal beliefs – A nurse deciding whether to participate in procedures
like abortion due to personal or religious reasons.
Steps to Resolve Ethical Dilemmas
Identify the problem – Determine the ethical conflict.
Gather information – Understand the patient’s wishes and legal rights.
Examine ethical principles – Consider autonomy, beneficence, nonmaleficence, and justice.
Consider alternatives – Explore all possible solutions.
Make a decision – Choose the best ethical action.
Evaluate the outcome – Reflect on whether the decision upheld ethical nursing care.
Example: A terminal cancer patient refuses artificial nutrition and hydration, but their family
insists on tube feeding. The nurse must balance autonomy (respecting the patient’s right to refuse
treatment) with family concerns.

Evidence-Based Practice
- clinical expertise (what clinician knows), Best research Evidence (what’s in literature), patient
values (what patient wants).
Sources of information:
-PEER REVIEWED- examined by experts for accuracy/ authentication
-Governmental agencies/ Dept. of health and human services/ American heart association/ .org,
. Gov
-databases/ agencies for healthcare research and quality (AHRQ)
Types of research methods:
Quantitative research- uses numerical data to evaluate outcomes of interventions/ counts
Qualitative research- participants feelings and dialogue
Patient-Centered Care

Preferences in Patient-Centered Care

Patient-centered care involves respecting and incorporating a patient’s individual preferences,
values, and cultural beliefs into their care plan.
Key aspects include:
Respect for autonomy: Patients have the right to make their own healthcare decisions.
Cultural competence: Nurses should acknowledge and integrate cultural beliefs into care (e.g.,
dietary restrictions, religious practices).
Informed consent: Patients must understand their treatment options and risks before making
decisions.
Shared decision-making: Nurses work collaboratively with patients and families to develop care
plans.

Therapeutic Communication in Nursing

Therapeutic communication is a key nursing skill used to build trust and provide emotional
support to patients.
Key Techniques:
Active Listening: Making eye contact, nodding, and providing verbal affirmations.
Clarification: Asking questions to ensure understanding (e.g., "Can you explain what you
mean?").
Paraphrasing: Restating what the patient says to confirm understanding.
Empathy: Acknowledging the patient’s emotions (e.g., "I can see this is difficult for you.").
Silence: Allowing time for the patient to process thoughts before responding.
Open-Ended Questions: Encouraging discussion (e.g., "How are you feeling today?").
Avoid:
Giving false reassurance ("Everything will be fine.")
Offering personal opinions ("If I were you...")
Using medical jargon that the patient may not understand.
Patient Education
Effective patient education ensures that patients understand their condition, treatment plan, and
self-care practices.

Key Principles of Patient Teaching:

Assess the patient’s learning needs and preferred learning style (visual, auditory, kinesthetic).
Use simple language and avoid medical jargon.
Utilize teach-back method (ask the patient to repeat instructions in their own words).
Provide written materials or visual aids when necessary.
Encourage family involvement for additional support.
Consider health literacy and tailor education accordingly.
Example: Teaching a diabetic patient how to monitor blood sugar using a glucometer and
demonstrating insulin injection techniques.
Vital Signs
Normal Ranges for Vital Signs
Temperature: 96.8-100.4°F (36°C – 38°C)
Heart Rate: 60 – 100 bpm (tachycardia >100 bpm, bradycardia <60 bpm)
Respiratory Rate: 12 – 20 breaths per minute (Bradypnea <12 bpm, Tachypnea >20 bpm)
Blood Pressure: 120/80 mmHg (hypertension >140/90, hypotension <90/60)
Oxygen Saturation (SpO₂): 95 – 100% (hypoxia <90%)

Priority Nursing Actions for Unstable Vital Signs

Fever/hyperthermia: above 100.4 F *commonly caused by infection
Symptoms: flushed face, diaphoresis (sweating), “Hot skin”, Tachycardia, increased RR
Nursing intervention: cool fluids, remove excess clothing, administer medications as ordered,
Cooler environment, Tepid bath
Treatment: if fever is caused by bacterial or microbial infection the appropriate antibiotic or anti-
infective may be prescribed. (Antipyretics-fever reducing, modification of ext. environment)

Tachycardia (>100 bpm):

Assess for pain, fever, dehydration, anxiety, or hypoxia.
Administer oxygen if hypoxic.
Encourage rest and hydration.

Bradycardia (<60 bpm):

Assess for dizziness, fatigue, or hypotension.
Monitor for signs of heart block (ECG changes).
Administer atropine if symptomatic (per provider’s order).

Hypertension (>140/90 mmHg):

Assess for headache, blurred vision, and dizziness.
Encourage lifestyle modifications (low-sodium diet, exercise).
Administer antihypertensive medication if ordered.

Hypotension (<90/60 mmHg):

Assess for dizziness, confusion, and shock.
Position the patient supine with legs elevated.
Administer IV fluids as prescribed. (stay hydrated)

Low Oxygen Saturation (<90%):

Administer oxygen as needed.
Encourage deep breathing and coughing.
Assess for respiratory distress or obstruction.

Clinical Decision Making

Delegation in Nursing- involves assigning tasks to other healthcare personnel while maintaining
accountability.

What RNs Can Delegate:

To LPNs:
Medication administration (except IV push meds in some states).
Wound care and dressing changes.
Reinforcing patient education.

To UAPs (Unlicensed Assistive Personnel):

Vital signs, bathing, feeding, and ambulation.
Measuring intake and output.
Assisting with toileting.

What RNs CANNOT Delegate:

Assessment, planning, teaching, evaluation, and complex clinical judgment.

Assessment: Subjective vs. Objective Data

Subjective Data: Information reported by the patient (e.g., pain level, nausea, dizziness).
Objective Data: Measurable data observed by the nurse (e.g., blood pressure, lab values, wound
drainage).

Prioritization in Nursing (ABCs and Maslow’s Hierarchy)

Airway: Ensure the patient’s airway is open and unobstructed.
Breathing: Assess oxygenation and respiratory status.
Circulation: Check for adequate perfusion and blood pressure.
Disability: Assess neurological status (LOC, stroke symptoms).
Exposure: Prevent hypothermia or injuries.

Maslow’s Hierarchy of Needs (from highest to lowest priority):

Physiological needs (airway, breathing, circulation, food, water).
Safety and security (fall prevention, infection control).
Love and belonging (emotional support).
Self-esteem (encouraging independence).
Self-actualization (achieving full potential).

Planning and Interventions

Planning: Setting realistic, measurable goals for patient care.
Interventions: Actions taken to meet the goals (e.g., repositioning an immobile patient every 2
hours to prevent pressure ulcers).
Evaluation:
Determines if the interventions were effective.
If goals are not met, the care plan is adjusted accordingly.

Perineal Care
Perineal care involves cleansing the genital and anal areas to prevent infections, odors, and skin
breakdown.

Steps for Female Perineal Care:

Provide privacy and explain the procedure.
Position the patient in the dorsal recumbent or side-lying position.
Use warm water and mild soap; avoid harsh chemicals.
Clean from front to back to prevent urinary tract infections (UTIs).
Use a different section of the washcloth for each stroke.
Dry the area thoroughly to prevent moisture buildup.

Steps for Male Perineal Care:

If the patient is uncircumcised, gently retract the foreskin.
Clean the tip of the penis first in a circular motion, then the shaft.
Clean the scrotum and perineal area.
Dry thoroughly and return the foreskin to its natural position.

Foot, Hair, Scalp, and Nail Care

Foot Care:
Assess for cuts, ulcers, or signs of infection, especially in diabetic patients.
Wash with warm water and mild soap; avoid soaking for prolonged periods.
Moisturize but avoid applying lotion between the toes to prevent fungal infections.
Trim nails straight across to prevent ingrown nails.
Encourage proper-fitting shoes and daily foot inspections.

Hair and Scalp Care:

Brush hair daily to prevent tangles and scalp irritation.
Shampoo hair at least twice a week or as needed.
For immobile patients, use a no-rinse shampoo cap or dry shampoo.
Monitor for dandruff, lice, or scalp lesions.

Nail Care:
Trim nails straight across (unless contraindicated, such as in diabetic patients).
Clean under nails and file rough edges to prevent injury.
Diabetic and immunocompromised patients should have their nails trimmed by a podiatrist to
prevent complications.

Bed Bath
A bed bath is given to patients who are bedridden or unable to bathe themselves.

Types of Bed Baths:

Complete bed bath: Nurse washes the entire body.
Partial bed bath: Nurse washes only areas prone to odor or discomfort (e.g., face, axilla, perineal
area).
Assist bath: Patient can do some of the washing with assistance.

Steps for a Complete Bed Bath:

Gather supplies (basin, washcloths, soap, towels, clean gown).
Provide privacy and adjust the room temperature.
Wash from clean to dirty areas (face first, perineal area last).
Use separate washcloths for different areas to prevent cross-contamination.
Change water if it becomes cold or soapy.
Dry skin thoroughly and apply lotion if needed except for TOES

Infection Control

Stages of Infection:
Incubation Period: Time between exposure to the pathogen and the onset of symptoms. The
patient may not show signs of illness yet.
Prodromal Stage: Early symptoms appear (mild fever, fatigue, malaise). The patient is most
contagious during this phase.
Illness Stage: Full symptoms develop; the patient experiences the highest level of discomfort.
Decline Stage: Symptoms begin to resolve as the immune system or treatment fights the
infection.
Convalescence Stage: Recovery phase; the patient regains strength, and the infection is
eliminated.

Hand Hygiene
Hand hygiene is the most effective way to prevent healthcare-associated infections (HAIs).

Handwashing with Soap and Water:

Use when hands are visibly soiled, after contact with bodily fluids, or before eating.
Wash for at least 20 seconds (sing "Happy Birthday" twice).
Scrub all areas, including between fingers and under nails.
Dry hands completely and use a paper towel to turn off the faucet.

Alcohol-Based Hand Sanitizer:

Use when hands are not visibly soiled, and soap/water is unavailable.
Apply 3-5 mL (dime-sized amount) and rub hands together until dry.
Not effective against C. difficile—use soap and water instead.

Isolation Precautions and Considerations

Isolation precautions prevent the spread of infections based on transmission routes.

Standard Precautions:
Used for all patients.
Includes hand hygiene, gloves for potential contact with bodily fluids, and proper sharps
disposal.

Transmission-Based Precautions:
Contact Precautions (e.g., MRSA, C. difficile, VRE, RSV, scabies):
Wear gloves and gown before entering the room.
Use dedicated equipment (e.g., stethoscope, BP cuff) for the patient.
C. difficile requires soap and water handwashing (sanitizer is ineffective).
Droplet Precautions (e.g., influenza, pertussis, rubella, meningitis): Spread through respiratory
droplets (droplets are larger than airborne so they fall to the floor faster.
Wear a surgical mask within 3-6 feet of the patient, gown
Patient should wear a mask when leaving the room.

Airborne Precautions (e.g., TB, measles, varicella/chickenpox, COVID-19): conditions that

spread through aerosolized particles.
Requires N95 respirator and negative pressure room.
Patient must remain in isolation, and the door should stay closed.
If transporting the patient, they should wear a surgical mask.

Protective/Neutropenic Precautions (e.g., chemotherapy patients, immunocompromised patients):

Private room with HEPA filtration.
No fresh flowers, plants, or raw foods (risk of infection).
Visitors must wear masks and perform strict hand hygiene.

Styles of Communication
Verbal Communication – Spoken or written language, clarity and tone are important.
Nonverbal Communication – Body language, facial expressions, gestures, and posture.
Aggressive Communication – Dominating, forceful, often disregards others’ opinions.
Passive Communication – Avoiding conflict, failing to express needs or concerns.
Passive-Aggressive Communication – Indirectly expressing anger or frustration.
Assertive Communication – Clear, respectful expression of thoughts and needs.

SBAR (Situation, Background, Assessment, Recommendation)

Situation – Briefly describe the current problem.
Background – Relevant history, diagnosis, treatments.
Assessment – What is happening now? (Vitals, symptoms).
Recommendation – What should be done next? (Orders, interventions).

Therapeutic Communication
Active Listening – Giving full attention, nodding, using verbal affirmations.
Open-ended Questions – Encouraging detailed responses (e.g., "Tell me more about...").
Clarification – Ensuring understanding by restating (e.g., "Are you saying that...?").
Reflection – Repeating back what the patient says to encourage more expression.
Silence – Allowing the patient time to process and respond.
Empathy – Understanding and sharing feelings appropriately.

Barriers to Communication
Language Differences – Use interpreters when needed.
Cultural Barriers – Understanding differing health beliefs.
Sensory Impairments – Visual/hearing impairments, use of aids.
Emotional Distress – Anxiety, depression, fear, anger.
Cognitive Impairment – Dementia, delirium, learning disabilities.
Conflict Resolution
Avoiding – Ignoring the conflict; may be useful for minor issues.
Accommodating – Giving in to maintain harmony.
Compromising – Each party gives up something to reach a resolution.
Collaborating – Working together to find a mutually beneficial solution.

Documentation
Guidelines for Documentation
¸-must be clear, accurate and concise
-used by interprofessional team, billing and payment, research, accreditation, and legal
proceedings.
FACT: Factual, Accurate, Complete, and Timely

Legal Components
ANA standards require nurses to document care accurately and completely.
HIPAA Compliance – Protecting patient privacy.
CPOE systems (computerized provider order entry): allows providers to write and transmit
prescriptions, consults, tests, and procedures electronically.

Charting Methods
Narrative Charting – Free-text descriptions of patient status and interventions.
SOAP Notes – Subjective, Objective, Assessment, Plan.
PIE Charting – Problem, Intervention, Evaluation.
DAR (Focus) Charting – Data, Action, Response.
Charting by exception- focuses on documenting only unexpected or unusual findings

Informatics
Electronic Health Records (EHR): digital documentation system used to improve medical
records. Real-time form of a chart that can be shared among authorized users. Includes medical
history, diagnosis, allergies, and diagnostic testing results.

Medical Records
Include history, diagnoses, treatments, test results.
Legal document subject to audits and reviews.

Collaboration & Teamwork

Discharge Planning
Begins at admission, ensuring a smooth transition home or to another facility.
Involves patient education on medications, follow-up care, and symptoms to monitor.
Interdisciplinary Communication
Nurses, physicians, therapists, social workers, and other healthcare professionals work together.
Includes handoffs, team meetings, and care conferences to ensure continuity of care.
Client Education
Domains of Learning
Cognitive – Understanding facts and knowledge (e.g., disease process).
Affective – Emotions, values, and attitudes (e.g., coping strategies).
Psychomotor – Learning physical skills (e.g., insulin injection technique).
Education Considerations
Health Literacy – Adjusting materials to the patient’s reading level.
Cultural Sensitivity – Respecting beliefs about health.
Readiness to Learn – Motivation and emotional state.
Teaching Strategies – Using videos, demonstrations, or return demonstrations (tesachback)

Health Policy
HIPAA (Health Insurance Portability and Accountability Act)
Protects patient health information (PHI).
Prevents unauthorized access to records.
Policies & Procedures
Hospital policies ensure patient safety and compliance.
Includes infection control, medication administration, and emergency procedures.

Mobility
Positioning
Supine – Lying on the back.
Prone – Lying on the stomach.
Lateral – Side-lying position.
Fowler’s – Sitting up at 45-90 degrees (used for dyspnea).
Trendelenburg – Head lower than feet (used for shock).
Body Mechanics & Ergonomics
Lift with legs, not back
Keep objects close to the body when lifting
Use assistive devices whenever possible
Assistive Devices
Canes – cane is used on the stronger side, handle of cane should be held at wrist level, move
weak leg first then strong leg.
TIP: use “COAL”- Cane Opposite Affected Leg
Walkers – Move walker forward, step forward with the weaker leg, then step forward with the
stronger leg
Crutches:
2-point Gait- Move one crutch and the opposite leg at the same time. Then move the other
crutch and opposite leg at the same time.
3-point Gait- Move both crutches forward, then hop forward with the unaffected leg (keeping
the injured leg off the ground)
4-point Gait- Move one crutch forward, move the opposite leg forward, move the other
crutch forward, move the opposite leg forward.
Tip: everything moves separately in a 4-step pattern
Swing-to Gait (used when both legs are week)- move both crutches forward, then swing both
legs forward to the crutches (not past them)
Swing-through Gait- Move both crutches forward, then swing both legs forward past the
crutches.
Stairs with crutches- “Up with the good, down with the bad”
Going up: step up with the strong leg first, then bring up the weak leg and crutches.
Going down: Move the crutches and weak leg first, then step down with the strong leg.

Braden Scale
Assesses pressure ulcer risk (Score ≤18 = at risk) low number= lower risk
Fall Risk Assessment (Morse Scale, Hendrich II Scale)
Evaluates history of falls, gait, medications, mental status.

Safety
Patient Identifiers
Name and DOB, wristband verification, hospital id number, telephone number, or alternate
client-specific documentation.
Suicide Precautions- after being screened and testing positive a detailed assessment is conducted,
needs round the clock care/ surveillance, remove potentially harmful items from the room, use
an environmental checklist to identify risk, Search/limit items brought by visitors, manage
visitation by nonhospital staff.

Environmental Safety
Clear pathways, adequate lighting, bed in lowest position.

Fall & Seizure Precautions

Fall precautions: remove scatter rugs, ensure good lighting, Mark step edges with colored tape,
remove clutter, Tape down electrical cords, or place against wall/behind furniture (don’t just put
under rug), install grab bars in showers/bathtubs, place non-slip mats on shower floor, ensure
proper use of assistive devices.
Seizure precautions: pad the side rails of the bed, have oxygen in the room w/ a delivery
device, suction and vital sign equipment set up, check for pre-seizure aura (remove dentures if
applicable)
During a seizure: if patient is standing lower then controlled, turn patient to LEFT side, loosen
restrictive clothing/ move anything out the way, Never restrain a patient/ NEVER put anything in
their mouth, note when seizure started and stopped, vital signs, neuro exam, reassurance, gag
reflex
Sentinel Events
Unexpected occurrences leading to serious injury or death.
Healthcare-Associated Infections (HAIs)
Hand hygiene, PPE use, sterile technique to prevent infections.
Iatrogenic- coming from a procedure or intervention
Nosocomial- originating in the hospital
(CLABSI, CAUTI, CDI, HAP, VAP, SSI, HAPI)
Procedure Time-outs
Pre-procedure verification to ensure correct patient, site, procedure.
RACE, PASS, Fire Safety
RACE – Rescue, Alarm, Contain, Extinguish.
PASS – Pull, Aim at base, Squeeze, Sweep (for fire extinguishers).

Medication Administration
Pharmacodynamics
How drugs affect the body at a cellular and systemic level.
Agonists – Activate receptors (e.g., morphine binds to opioid receptors).
Antagonists – Block receptors (e.g., naloxone reverses opioid effects).
Half-life – Time for drug concentration to decrease by half.
Therapeutic Index (TI) – Measures drug safety (narrow TI drugs require close monitoring).

Evaluation of Medication Response

Assess for therapeutic effects – Is the medication working as intended?
Monitor for side effects and adverse reactions – Nausea, dizziness, allergic reactions.
Lab values – e.g., warfarin requires INR monitoring.
Vital signs – e.g., beta-blockers lower blood pressure and heart rate.
Routes of Administration
Oral (PO) – Swallowed, slower onset due to digestion.
Sublingual (SL) – Under tongue; fast absorption (e.g., nitroglycerin).
Buccal – Between cheek and gum; rapid absorption.
Topical – Applied to skin (e.g., creams, patches).
Parenteral – IV (fastest), IM (muscle), Subcutaneous (fatty tissue).
Inhalation – Directly into lungs (e.g., inhalers, nebulizers).
Rectal/Vaginal – Alternative when oral is not possible.
Client Medication Rights- 10
Right Patient – Verify with two identifiers.
Right Medication – Check label three times before administration.
Right Dose – Confirm dose calculation and safe range.
Right Route – Administer as prescribed.
Right Time – Follow scheduled timing.
Right Documentation – Record immediately after administration.
Right to Refuse – Respect the patient’s decision.
Right Education – Explain medication use, side effects, and precautions.
Right assessment
Right evaluation/response
Reducing Medication Errors
Use electronic MAR (Medication Administration Record).
Check patient allergies before giving meds.
Avoid distractions during med prep.
Use barcode scanning when available.

Client Education for Medications

Teach proper medication use, side effects, and adherence.
Warn about drug interactions
DO NOT CRUSH ENTERIC-COATED and EXTENDED-RELEASE medications
1. Inhalation medications (inhalers)
-MDI (Metered-dose inhaler): shake inhaler, breathe out fully, place inhaler in mouth, hold your
breath for 10 seconds, then exhale.
- DPI (dry powder inhaler)- requires a forceful, deep inhalation (rapid breathing)
-Rectal suppositories- place client on left lateral or sims position
Pain
Types of Pain Medications
Non-opioids – Acetaminophen, NSAIDs (ibuprofen, aspirin).
Opioids – Morphine, fentanyl, oxycodone (risk of dependency).
Side Effects of Pain Medications
NSAIDs – GI bleeding, kidney damage, dizziness, nausea, heartburn, stomach upset
Opioids – Respiratory depression, constipation, drowsiness.
Acetaminophen – Liver toxicity at high doses.
ADPIE on Pain
Assessment – Pain level, characteristics.
Diagnosis – “Acute pain related to surgical incision.”
Planning – Goal: Reduce pain to tolerable level.
Implementation – Administer pain relief, reposition, distraction.
Evaluation – Reassess pain level and effectiveness.
PQRST Pain Assessment
P – Provocation (What causes/worsens pain?).
Q – Quality (Sharp, dull, throbbing?).
R – Region/Radiation (Where is it? Does it spread?).
S – Severity (Pain scale 0-10).
T – Timing (When did it start? Constant or intermittent?).
Alternatives to Analgesics (pain medications)
Heat/cold therapy, massage, guided imagery, acupuncture, laughing, humor, hypnosis, animal
therapy
Therapeutic Communication for Pain
Acknowledge pain – "I understand that you’re in pain."
Encourage expression – "Can you describe the pain?"
Offer non-pharmacologic interventions.

End-of-Life Care
Palliative Care
Focuses on symptom relief for chronic/terminal conditions.
Not limited to end-of-life; can be used alongside curative treatment.
Hospice Care
For terminally ill patients with <6 months prognosis.
Comfort-focused, no curative treatments.
Therapeutic Communication in End-of-Life Care
Use open-ended questions ("How are you feeling about this transition?").
Acknowledge emotions – "It’s okay to feel scared."
Caregiver Support
Offer respite care, counseling, emotional support.
Client Assessment in End-of-Life Care
Monitor for pain, dyspnea, agitation, skin breakdown.
Effects of Spirituality
Religious beliefs may influence end-of-life decisions (e.g., refusal of blood transfusions).
Physical Manifestations of Grief
Withdrawal, irregular breathing, cold extremities, mottling of skin.
Organ Donation
Requires consent from patient/family unless donor registry exists.
Postmortem Care
Washing the body, accounting for clients’ possessions, removing invasive devices such
intravenous catheters, and placing identification tags in at least two places.
Surgical Client
Preoperative, Intraoperative, and Postoperative Phases
Preoperative – begins with decision to have surgery, lasts until patient is transferred to
operating room or procedural bed. Initial phase of care before surgery. (identification of patient,
interview, assessment, consent etc.)
Intraoperative – begins when the patient is transferred to the OR bed until transfer to the post
anesthesia care unit (Sterile field maintenance, anesthesia monitoring.)
Postoperative – lasts from admission to the PACU or other recovery area to complete recovery
from surgery and last follow-up health care provider visit (Monitor vitals, assess for pain,
manage airway.)
Informed Consent
Must be obtained before surgery, patient must be competent.
Surgical Asepsis vs. Medical Asepsis
Surgical Asepsis – Sterile technique (e.g., in OR, wound dressing).
Medical Asepsis – Reducing microorganism spread (hand hygiene, PPE).
Complications & Nursing Interventions
Hemorrhage – Monitor BP, HR, bleeding; replace fluids.
Infection – Monitor incision site, fever, WBC count.
DVT (Deep Vein Thrombosis) – Early ambulation, compression devices.
Postoperative Pain Management
Administer analgesics as ordered.
Non-pharmacologic measures (e.g., repositioning, ice/heat).
Sensory Deficits-refers to impaired or absent functioning in one or more senses
Hearing loss – Use hearing aids, speak clearly.
Vision loss – Large-print materials, adequate lighting. (Cataracts, glaucoma, macular
degeneration, presbyopia)
Touch impairment – Assess for skin breakdown. (diabetic neuropathy)
Taste/smell loss – Monitor nutrition.
Sensory Overload & Deprivation
Overload – Too much stimulation (ICU psychosis).
Deprivation – Lack of sensory input (isolation, blindness).
Nursing Interventions for Sensory Impairments
Provide adaptive devices (glasses, hearing aids).
Enhance communication strategies (writing boards, interpreters).
Modify the environment (reduce noise for sensory overload, increase stimuli for deprivation).