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Levels of cognitive ability (Bloom’s taxonomy), from the lowest to highest, include:​

Remembering – recalling basic concepts or facts​

Understanding – explaining concepts and making sense of information​

Applying – using information in new situations​

Analyzing – exploring relationships or drawing connections between ideas​

Evaluating – critically examining information and making judgements​

Creating – using information to produce new or original work ​

We can also categorize these different levels of cognitive ability further into foundational thinking and critical thinking. Foundational thinking requires remembering and understanding. Critical thinking requires you to first remember and understand information but then apply that information to a complex clinical situation.

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The subject of the question is the specific topic of the scenario and what the inquiry is about. Identifying the subject is essential to eliminating incorrect answer options. ​

Strategies!​

If the scenario includes a medication name, then that medication is important to the answer.​

If the scenario provides clinical manifestations, then the symptoms or assessment findings are essential.​

If the scenario identifies a client's age, gender, or culture, then that information is key to selecting the correct answer. ​

If the scenario involves communication, then the nurse must use therapeutic techniques to respond. Do not ask a client “why” as this is considered non-therapeutic. ​

Tips!​

All clients are considered a full code status unless otherwise stated.​

Provider orders will be called prescriptions.​

If there is an answer option requiring the nurse to administer a medication, the prescription can be assumed.​

All medications will be presented using generic, not brand, names.

When delegating tasks, the unlicensed assistive personnel (UAP) has no additional training or certification.

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Unstable v. stable​

Unexpected v. Expected​

Actual v. Potential​

ABCs​

Acute v. Chronic

Unstable clients are prioritized over stable clients.​

Example: A client with difficulty breathing takes priority over a client in need of discharge teaching. ​

Acute conditions take priority over chronic conditions.​

Example: An acute asthma exacerbation takes priority over a client with diabetes mellitus type 2. ​

Unexpected assessment findings are more concerning and take priority over expected (anticipated) clinical manifestations.​

Example: You must differentiate abnormal expected findings from abnormal unexpected findings. A client who is 2 hours postoperative from an open cholecystectomy will have decreased bowel sounds (abnormal but expected). However, vomiting blood (abnormal unexpected) is the priority. ​

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Airway is always the priority, followed by adequate ventilation and oxygen, then circulation. The only exception to this rule is during cardiopulmonary resuscitation (CPR) in which circulation (compressions) are the priority, followed by airway and breathing.

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Physiologic needs must be prioritized, followed by safety and security needs, then psychological needs. If a physical need is not addressed in one of the answer options, always look for an option that addresses safety. ​

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The National Council of State Boards of Nursing (NCSBN, 2019) defines clinical judgment as “the observed outcome of critical thinking and decision making; an iterative process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern and generate the best possible evidenced-based solutions in order to deliver safe client care” (p. 1). ​

“Clinical judgment” is simply a conclusion about a client’s needs or health problems and the decision to take or avoid action. When you apply critical thinking as a professional nurse, the end result is clinical judgment.​

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RECOGNIZE

determine which data elements are relevant (directly related to the priority client need) and which are irrelevant (unrelated to the priority client need). From the relevant data, the nurse must decide which cues are the most important and of immediate concern. ​

This step occurs during the assessment phase of the nursing process.

ANALYZE

The nurse must be able to organize and link relevant and recognized cues to the client’s clinical presentation and determine what the data means. ​

This step occurs during the assessment phase and continues into the diagnosis phase of the nursing process. ​

HYPOTHESES

interpret the relevant cues and consider all possibilities to determine what is occurring in the client's situation (analysis), then rank the hypotheses (client needs) by priority. The nurse must consider which client needs are most likely and most serious and why. When ranking client needs according to priority, consider urgency, risk, difficulty, likelihood, and time. ​

This step occurs during the diagnosis phase and continues into the planning phase of the nursing process.

GENERATE SOLUTIONS

Use the hypotheses and identify goals and expected outcomes as well as interventions to incorporate into the plan of care. The nurse must consider actions to be taken and actions to be avoided or that are contraindicated. Consider what must be done, could be done, and should not be done in the care of the client. ​

This step occurs during the planning phase of the nursing process.

TAKE ACTION

identify and implement the generated solutions (appropriate nursing actions) based on understanding the rationale for the action. Actions taken must address the highest priorities (hypotheses) of care based on the client's presentation. Interventions may include things to be performed, requested, administered, communicated, taught, and/or demonstrated.​

This step occurs during the implementation phase of the nursing process.

EVALUATE

Nurses must evaluate actual observed client outcomes and compare them to expected outcomes after interventions have been implemented. ​

Ask yourself these questions: ​

Did the client improve, decline, or experience no change in condition? ​

Were the actions taken effective, ineffective, or unrelated to the client’s condition?​

This step occurs during the evaluation phase of the nursing process. ​

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Physiological Adaptation is one of the eight client needs that you will encounter when taking the NCLEX-RN® examination. This category accounts for approximately 11-17% of the exam content. Physiological adaptation requires the nurse to manage and provide care for clients with acute, chronic, or life-threatening physical health conditions (NCSBN, 2023). ​

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Safe and Effective Care Environment

Management of Care 15–21%

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The NCLEX-RN® client needs category Management of Care is a subcategory of Safe and Effective Care Environment. Management of care requires the nurse to provide and direct nursing care that enhances the care delivery setting to protect the client and healthcare personnel (NCSBN, 2023)​.

integrate advance directives into client plan of care​

delegate and supervise care of client provided by others (e.g., LPN/VN, assistive personnel, other RNs)​

organize workload to manage time effectively​

practice and advocate for cost-effective care​

initiate, evaluate, and update client plan of care​

provide education to clients and staff about client rights and responsibilities​

advocate for client rights and needs​

collaborate with multidisciplinary team members when providing client care (e.g., physical therapist, nutritionist, social worker)​

manage conflict among clients and healthcare staff​

maintain client confidentiality and privacy​

provide and receive hand-off of care (report) on assigned clients​

use approved terminology when documenting care​

perform procedures necessary to safely admit, transfer, and/or discharge a client​

prioritize the delivery of client care based on acuity​

recognize and report ethical dilemmas​

practice in a manner consistent with the nurses’ code of ethics​

verify the client receives education and patient consent for care and procedures​

receive, verify, and implement healthcare provider orders​

utilize resources to promote quality client care (e.g., evidence-based research, information technology, policies, and procedures)​

recognize limitations of self and others and utilize resources​

report client conditions as required by law (e.g., abuse/neglect and communicable diseases)​

provide care within the legal scope of practice​

participate in performance improvement projects and quality improvement processes​

assess the need for referrals and obtain necessary orders​

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●Advocacy: support and defend clients’ health, wellness, safety, wishes, and personal rights, including privacy

● Responsibility: willingness to respect obligations and follow through on promises.

● Accountability: ability to answer for one’s own actions.

● Confidentiality: protection of privacy without diminishing access to high-quality car

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ETHICAL PRINCIPLES FOR CLIENT CARE ● Autonomy: the right to make one’s own personal decisions, even when those decisions might not be in that person’s own best interest.

● Beneficence: action that promotes good for others, without any self-interest. ● Fidelity: fulfillment of promises.

● Justice: fairness in care delivery and use of resources.

● Nonmaleficence: a commitment to do no harm.

● Veracity: a commitment to tell the truth

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ETHICAL DECISION‑MAKING

Ethical decision-making is a process that requires striking a balance between science and morality. When making an ethical decision:

● Identify whether the issue is indeed an ethical dilemma.

● Gather as much relevant information as possible about the dilemma.

● Reflect on your own values as they relate to the dilemma.

● State the ethical dilemma, including all surrounding issues and the individuals it involves.

● List and analyze all possible options for resolving the dilemma, and review the implications of each option.

● Select the option that is in concert with the ethical principle that applies to this situation, the decision maker’s values and beliefs, and the profession’s values for client care. Justify selecting that one option in light of the relevant variables.

● Apply this decisionto the dilemma, and evaluate the outcomes

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ETHICAL DILEMMAS

● Ethical dilemmas are problems that involve more than one choice and stem from differences in the values and beliefs of the decision makers. These are common in health care, and nurses must apply ethical theory and decision-making to ethical problems.

● A problem is an ethical dilemma when:

◯ A review of scientific data is not enough to solve it.

◯ It involves a conflict between two moral imperatives.

◯ The answer will have a profound effect on the situation and the client.

Moral distress occurs when the nurse is placed in a difficult situation where the actions taken are different from what the nurse feels is ethically correct

Ethics committees generally address unusual or complex ethical issues. Examples of ethical guidelines for nurses are the American Nurses Association’s Code of Ethics for Nurses With Interpretive Statements (2015) and the International Council of Nurses’ The ICN Code of Ethics for Nurses (2012).

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Unintentional torts

NEGLIGENCE: A nurse fails to implement safety measures for a client at risk for falls.

MALPRACTICE (PROFESSIONAL NEGLIGENCE): A nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies. Quasi‑intentional torts

BREACH OF CONFIDENTIALITY: A nurse releases a client’s medical diagnosis to a member of the press.

DEFAMATION OF CHARACTER: A nurse tells a coworker that they believe the client has been unfaithful to their partner.

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Intentional torts

ASSAULT The conduct of one person makes another person fearful and apprehensive A nurse threatens to place an NG tube in a client who is refusing to eat.

BATTERY Intentional and wrongful physical contact with a person that involves an injury or offensive contact A nurse restrains a client and administers an injection against their wishes.

FALSE IMPRISONMENT A person is confined or restrained against their will A nurse uses restraints on a competent client to prevent their leaving the health care facilit

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Professional negligence

The failure of a person who has professional training to act in a reasonable and prudent manner. The terms “reasonable” and “prudent” generally describe a person who has the average judgment, intelligence, foresight, and skill that a person with similar training and experience would have.

● Negligence issues that prompt most malpractice suits include failure to:

◯ Follow professional and facility-established standards of care.

◯ Use equipment in a responsible and knowledgeable manner.

◯ Communicate effectively and thoroughly with clients. ◯ Document care the nurse provided.

◯ Notify the provider of a change in the client’s condition. ◯ Complete a prescribed procedure.

***************STUDENT NURSE LIABILITY**************

● Nursing students face liability if they harm clients as a result of their direct actions or inaction. They should not perform tasks for which they are not prepared, and they should have supervision as they learn new procedures. If a student harms a client, then the student, instructor, educational institution, and facility share liability for the wrong action or inaction. (4.2)

● Nurses can avoid liability for negligence by:

◯ Following standards of care.

◯ Giving competent care.

◯ Communicating with other health team members and clients.

◯ Developing a caring rapport with clients.

◯ Fully documenting assessments, interventions, and evaluations.

◯ Being familiar with and following a facility’s policies and procedures

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INFORMED CONSENT

● Informed consent is a legal process by which a client or the client’s legally appointed designee has given written permission for a procedure or treatment. Consent is informed when a provider explains and the client understands:

◯ The reason the client needs the treatment or procedure. ◯ How the treatment or procedure will benefit the client. ◯ The risks involved if the client chooses to receive the treatment or procedure.

◯ Other options to treat the problem, including not treating the problem.

● The nurse’s role in the informed consent process is to witness the client’s signature on the informed consent form and to ensure that the provider has obtained the informed consent responsibly.

INFORMED CONSENT GUIDELINES

Clients must consent to all care they receive in a health care facility.

● For most aspects of nursing care, implied consent is adequate. Clients provide implied consent when they adhere to the instructions the nurse provides. For example, the nurse is preparing to perform a tuberculosis skin test, and the client holds out their arm for the nurse.

● For an invasive procedure or surgery, the client must provide written consent.

● State laws prescribe who is able to give informed consent. Laws vary regarding age limitations and emergencies. Nurses are responsible for knowing the laws in the state(s) in which they practice

WHO CAN SIGN

● A competent adult must sign the form for informed consent. The person who signs the form must be capable of understanding the information from the health care professional who will perform the service (a surgical procedure) and the person must be able to communicate with the health care professional. When the person giving the informed consent is unable to communicate due to a language barrier or a hearing impairment, a trained medical interpreter must intervene. Many health care facilities contract with professional interpreters who have additional skills in medical terminology to assist with providing information.

● Individuals who can grant consent for another person include the following.

◯ Parent of a minor

◯ Legal guardian

◯ Court‑specified representative

◯ An individual who has durable power of attorney authority for health care

● Emancipated minors (minors who are independent from their parents [a married minor]) can consent for themselves. ● Include a mature adolescent in the informed consent process by allowing them to sign an assent as a part of the informed consent document. (4.3) ● The nurse must verify that consent is informed and witness the client signing the consent form

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ADVANCE DIRECTIVES

The purpose of advance directives is to communicate a client’s wishes regarding end-of-life care should the client become unable to do so.

******An advance directive is a broad category of legal instructions that outlines your healthcare wishes (e.g., cardiopulmonary resuscitation [CPR], mechanical ventilation) ahead of time. It is used when severe medical situations occur and you are not able to communicate your wishes. Unlike a living will, however, an advance directive is not limited to terminal illness. It may also include medical events such as dementia, stroke, or coma. Many types of documents fall under the category of advanced directives, and one is called a living will. With an advance directive in place, the client's wishes are followed, even if they conflict with the wishes of loved ones.

● The PSDA requires asking all clients on admission to a health care facility whether they have advance directives.

● Staff should give clients who do not have advance directives written information that outlines their rights related to health care decisions and how to formulate advance directives.

● A health care representative should be available to help with this process.

Types of advance directives

Living will

● A living will is a legal document that expresses the client’s wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues.

*****A living will is a written document that outlines your healthcare wishes for end-of-life care if you become terminally ill and cannot make these decisions on your own. It tells your medical providers the medical treatments you may or may not want if you are permanently unconscious or at the end of a terminal illness, including how long you want your life prolonged. It might also include your religious preferences.​

● Most state laws include provisions that protect health care providers who follow a living will from liability.

Durable power of attorney for health care

POWER OF ATTORNEY - FINANCIAL AND LEGAL DECISIONS ONLY

A durable power of attorney for health care is a document in which clients designate a health care proxy to make health care decisions for them if they are unable to do so. The proxy can be any competent adult the client chooses.

A healthcare proxy, or agent, is a person who can make healthcare decisions. For the healthcare agent to act, the client’s provider must first certify that the client is not able to make medical decisions.

HEALTH CARE PROXY MAKES HEALTHCARE DECISIONS ONLY

Provider’s orders

Unless a provider writes a “do not resuscitate” (DNR) or “allow natural death” (AND) prescription in the client’s medical record, the nurse initiates cardiopulmonary resuscitation (CPR) when the client has no pulse or respirations. The provider consults the client and the family prior to administering a DNR or AND.

NURSING ROLE IN ADVANCE DIRECTIVES

Nursing responsibilities include the following.

● Provide written information about advance directives.

● Document the client’s advance directives status.

● Ensure that the advance directives reflect the client’s current decisions.

● Inform all members of the health care team of the client’s advance directives. MANDATORY REPORTING Health care providers have a legal obligation to repor

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REFUSAL OF TREATMENT

● The PSDA stipulates that staff must inform clients they admit to a health care facility of their right to accept or refuse care. Competent adults have the right to refuse treatment, including the right to leave a facility without a discharge prescription from the provider.

● If the client refuses a treatment or procedure, the client signs a document indicating that they understand the risk involved with refusing the treatment or procedure and that they have chosen to refuse it.

● When a client decides to leave the facility against medical advice (without a discharge prescription), the nurse notifies the provider and discusses with the client the risks to expect when leaving the facility prior to discharge.

● The nurse asks the client to sign an Against Medical Advice form and documents the incident

MANDATORY REPORTING Health care providers have a legal obligation to report their findings in accordance with state law in the following situations. ABUSE Nurses must report any suspicion of abuse (child or elder abuse, adult violence, HARM TO SELF OR OTHERS ) following facility policy.

The Patient Self Determination Act of 1990 requires that healthcare providers must inform clients of their right to accept or refuse care. Competent adults have the right to refuse care or treatment, including the right to leave a healthcare facility without a discharge prescription from the provider.​

If a client refuses treatment or a procedure and/or wishes to leave the facility against medical advice (AMA), the following must occur:​

The nurse must notify the provider.​

The client must sign a document stating that they understand the risk involved with refusing the treatment or procedure and that they have chosen to refuse it.​

The client must be explained the risks of leaving prior to discharge.​

The client must sign an Against Medical Advice (AMA) form.​

The nurse must document the incident.

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MANDATORY REPORTING Health care providers have a legal obligation to report their findings in accordance with state law in the following situations. ABUSE Nurses must report any suspicion of abuse (child or elder abuse, adult violence, HARM TO SELF OR OTHERS ) following facility policy.

COMMUNICABLE DISEASES Nurses must report communicable disease diagnoses to the local or state health department. For a complete list of reportable diseases and a description of the reporting system, go to the Centers for Disease Control and Prevention’s website, www.cdc.gov. Each state mandates which diseases to report in that state.

● Reporting allows officials to:

◯ Ensure appropriate medical treatment of diseases (tuberculosis).

◯ Monitor for common-source outbreaks (foodborne, hepatitis A).

◯ Plan and evaluate control and prevention plans (immunizations).

◯ Identify outbreaks and epidemics.

◯ Determine public health priorities based on trends

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When it comes to client advocacy, the nurse should:

Protect and support the client’s rights.

Establish their primary commitment is to the client, not family or friends.

Support the client’s right to self-determination—the client makes the decision.

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There are four rights to effective communication for delegation, which include the following​ Four Cs:​

clear: understood by the listener​​
concise: right amount of direction given​​
correct: information follows policy​​
complete: no question left unanswered​​

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● RNs cannot delegate the nursing process, client education, or tasks that require nursing judgment to PNs or to APs.

CONSIDER:

● Education, training, and experience

● Knowledge and skill to perform the task

● Level of critical thinking the task requires

● Ability to communicate with others as it pertains to the task ● Demonstration of competence

● The facility’s policies and procedures ● Licensing legislation (state’s nurse practice acts)

5 RIGHTS OF DELEGATION

Right task

● Identify which tasks are appropriate to delegate for each specific client.

● A right task is repetitive, requires little supervision, and is relatively noninvasive for the client.

● Delegate activities to appropriate levels of team members (RN, PN, AP) according to professional standards of practice, legal and facility guidelines, and available resources.

RIGHT TASK: Delegate an AP to assist a client who has pneumonia to use a bedpan.

WRONG TASK: Delegate an AP to administer a nebulizer treatment to a client who has pneumonia.

Right circumstances

● Determine the health status and complexity of care the client requires.

● Match the complexity of care demands to the skill level of the delegatee.

● Consider the workload of the delegatee.

RIGHT CIRCUMSTANCE: Delegate an AP to measure the vital signs of a client who is postoperative and stable. WRONG CIRCUMSTANCE: Delegate an AP to measure the vital signs of a client who is postoperative and required naloxone to reverse respiratory depression.

Right person

● Determine and verify the competence of the delegatee. ● The task must be within the delegatee’s scope of practice or job description.

● The delegatee must have the necessary competence and training. ● Continually review the performance of the delegatee and determine care competence.

● Evaluate the delegatee’s performance according to standards, and when necessary, take steps to remediate any failure to meet standards.

RIGHT PERSON: Delegate a PN to administer enteral feedings to a client who has a head injury.

WRONG PERSON: Delegate an AP to administer enteral feedings to a client who has a head injury. Right direction and communication in writing, orally, or both ● Communicate what data to collect.

● Provide a method and timeline for reporting, including when to report concerns and assessment findings.

● Communicate specific task(s) to perform and client‑specific instructions.

● Detail expected results, timelines, and expectations for follow-up communication.

RIGHT DIRECTION AND COMMUNICATION: Delegate an AP to assist Mr. Martin in room 312 with a shower before 0900.

WRONG DIRECTION AND COMMUNICATION: Delegate an AP to assist Mr. Martin in room 312 with morning hygiene. Right supervision and evaluation

● Provide supervision, either directly or indirectly (assigning supervision to another licensed nurse).

● Monitor performance.

● Intervene if necessary (for unsafe clinical practice).

● Provide feedback:

◯ Did the delegatee complete the tasks on time?

◯ Was the delegatee’s performance satisfactory?

◯ Did the delegatee document and report unexpected findings?

◯ Did the delegatee need help completing the tasks on time?

● Evaluate the client and determine the client’s outcome status.

● Evaluate task performance and identify needs for performance-improvement activities and additional resources. RIGHT SUPERVISION: Delegate an AP to assist with ambulating a client after the RN completes the admission assessment.

WRONG SUPERVISION: Delegate an AP to assist with ambulating a client prior to the RN

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ASSESS/COLLECT DATA

Baseline data: Vital signs, height, weight, allergy status Biographical information Client’s reason for seeking health care Present illness and findings Health history ● Current illness

● Current medications (prescription, over-the-counter [including dietary or herbal supplements])

● Prior illnesses, chronic diseases

● Surgeries

● Previous hospitalizations

● Other relevant data Family history (hypertension, cancer, heart disease, diabetes mellitus) Psychosocial assessment

● Alcohol, tobacco, recreational drugs, caffeine use ● History of mental illness ● History of abuse or homelessness ● Home situation/significant others Nutrition ● Current diet, any chewing or swallowing problems ● Recent weight gain/loss ● Use of nutritional or herbal supplements ● Dentures Spiritual health/quality-of-life concerns ● Religion

● Advance directives, living will

● Collect subjective data about each body system (changes, altered function). ● Collect objective data with a head-to-toe physical examination. Safety assessments

● History of falls ● Sensory deficits (vision, hearing) ● Use of assistive devices (walker, cane, crutches, wheelchair) Discharge information ● Family members in the home ● Transportation for discharge ● Relevant phone numbers ● Medical equipment needs at home ● Home health care needs at home ● Stairs in the home INVENTORY PERSONAL ITEMS Examples are clothing, jewelry, money, credit cards, assistive devices (eyeglasses, contacts, hearing aids, cane, dentures), medications, cell phones and other technology devices, and religious articles. ● Discourage keeping valuables at the bedside. ● Document communication with client related to items left within the room, and valuables locked in the facility’s safe. ORIENTATION Orient the client and family to the room and the facility. Share information, including the following. ● Call light operation ● Electric bed operation ● Telephone services/television controls ● Overhead lighting operation ● Smoking policy ● Restroom locations ● Waiting areas ● Meal times ● Usual time for providers’ visits ● Dining/vending services ● Visiting policies

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INDICATIONS FOR TRANSFER AND DISCHARGE

● The level of care changed (health status improved so a client no longer needs intensive care).

● Another setting is required to provide necessary care (transfer from medical unit to surgical suite).

● The facility does not offer the type of care a client now requires (after the acute phase of a stroke, the client requires care in a skilled facility).

● The client no longer needs inpatient care and is ready to return home. DISCHARGE PLANNING

This should begin on admission for every client.

● Assess whether the client will be able to return to their previous residence.

● Determine whether the client needs or has someone to assist them at home.

● Assess the residence to see if the client needs adaptations or specific equipment. ● Make a referral to the social worker to arrange for community services.

● Communicate health status and needs to community service providers.

● The provider documents that the client can be discharged. However, a client who is legally competent has the right to leave the facility at any time. The nurse notifies the client’s provider, has the client sign the proper forms if possible, and provides discharge teaching.

● Involve the client and family as much as possible in the discharge planning. DISCHARGE EDUCATION

The nurse discusses the discharge instructions with the client and provides a printed copy.

● Instructions should use clear, concise language that the client will understand.

● The nurse should verify understanding of the instructions by the client. Standards for discharge education

● Identify safety concerns at home.

● Review manifestations of potential complications and when to contact emergency care or the provider.

● Provide the phone number of the provider.

● Provide names and phone numbers of community resources that give care at the client’s residence.

● Provide step-by-step instructions for performing continuing treatments (dressing changes).

● Enforce dietary restrictions and guidelines, including those that pertain to medication administration.

● Enforce the amount and frequency of therapies to perform to support continued independence at home.

● Provide directions regarding how to take medications, potential interactions, and why adherence is important

DISCHARGE DOCUMENTATION

● Type of discharge (provider prescription or against medical advice [AMA])

● Date and time of discharge, who went with the client, and transportation (wheelchair to car, gurney to ambulance) ● Where the client went (home, long-term care facility)

● Summary of the client’s condition at discharge (steady gait, ambulating independently, in no apparent distress)

● Description of any unresolved difficulties and procedures for follow-up

● Disposition of valuables, medications brought from home, and prescriptions DISCHARGE INSTRUCTIONS Documentation of understanding of instructions by the client

● Written instructions in the client’s language

● Diet at home

● Step-by-step instructions for procedures at home

● Precautions to take when performing procedures or administering medications ● Manifestations of complications to report

● Names and numbers of providers and community services to contact

● Plans for follow-up care and therapie

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INDICATIONS FOR TRANSFER AND DISCHARGE

● The level of care changed (health status improved so a client no longer needs intensive care).

● Another setting is required to provide necessary care (transfer from medical unit to surgical suite).

● The facility does not offer the type of care a client now requires (after the acute phase of a stroke, the client requires care in a skilled facility).

● The client no longer needs inpatient care and is ready to return home. DISCHARGE PLANNING

This should begin on admission for every client.

● Assess whether the client will be able to return to their previous residence.

● Determine whether the client needs or has someone to assist them at home.

● Assess the residence to see if the client needs adaptations or specific equipment. ● Make a referral to the social worker to arrange for community services.

● Communicate health status and needs to community service providers.

● The provider documents that the client can be discharged. However, a client who is legally competent has the right to leave the facility at any time. The nurse notifies the client’s provider, has the client sign the proper forms if possible, and provides discharge teaching.

● Involve the client and family as much as possible in the discharge planning.

DISCHARGE EDUCATION

The nurse discusses the discharge instructions with the client and provides a printed copy.

● Instructions should use clear, concise language that the client will understand.

● The nurse should verify understanding of the instructions by the client. Standards for discharge education

● Identify safety concerns at home.

● Review manifestations of potential complications and when to contact emergency care or the provider.

● Provide the phone number of the provider.

● Provide names and phone numbers of community resources that give care at the client’s residence.

● Provide step-by-step instructions for performing continuing treatments (dressing changes).

● Enforce dietary restrictions and guidelines, including those that pertain to medication administration.

● Enforce the amount and frequency of therapies to perform to support continued independence at home.

● Provide directions regarding how to take medications, potential interactions, and why adherence is important

DISCHARGE DOCUMENTATION

● Type of discharge (provider prescription or against medical advice [AMA])

● Date and time of discharge, who went with the client, and transportation (wheelchair to car, gurney to ambulance) ● Where the client went (home, long-term care facility)

● Summary of the client’s condition at discharge (steady gait, ambulating independently, in no apparent distress)

● Description of any unresolved difficulties and procedures for follow-up

● Disposition of valuables, medications brought from home, and prescriptions DISCHARGE INSTRUCTIONS Documentation of understanding of instructions by the client

● Written instructions in the client’s language

● Diet at home

● Step-by-step instructions for procedures at home

● Precautions to take when performing procedures or administering medications ● Manifestations of complications to report

● Names and numbers of providers and community services to contact

● Plans for follow-up care and therapie

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RESPONSIBILITIES OF THE NURSE-Transferring/discharging a client

● On the day and time of transfer, confirm that the receiving facility or unit is expecting the client, and that the room or bed is available.

● Communicate the time the client will transfer to the receiving facility or unit.

● Complete documentation (medical records, transfer form).

● Give a verbal transfer report in person or via telephone.

● Confirm the mode of transportation the client will use to complete the transfer or discharge (car, wheelchair, ambulance).

● Make sure the client is dressed appropriately if going outside the facility.

● Account for all the client’s valuables. Receiving a transferred client

● Have any specialized equipment ready.

● If appropriate, inform the client’s roommate of the impending admission or transfer.

● Inform other health care team members of the client’s arrival and needs.

● Meet with the client and family on arrival to complete the admission process and orient the client and family to the new facility or unit.

● Assess how the client tolerates the transfer. ● Review transfer documentation.

● Implement appropriate nursing interventions in a timely manner

TRANSFER DOCUMENTATION

● Medical diagnosis and care providers ● Demographic information

● Overview of health status, plan of care, recent progress ● Alterations that can precipitate an immediate concern

● Notification of assessments or care essential within the next few hours

● Most recent vital signs and medications, including PRN

● Allergies

● Diet and activity orders

● Specific equipment or adaptive devices (oxygen, suction, wheelchair)

● Advance directives and emergency code status

● Family involvement in care and health care proxy, if applicable

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RN Responsibilities​ (cannot be delegated)

Clinical assessment​

Initial client education​

Discharge education​

Clinical judgment​

Planning​

Evaluation​

Implementation of complex care​

Initiating blood transfusion

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Tasks which can be delegated to LPN

Stable or chronic clients​

24-hour post-op clients​

Wound care​

Monitoring RN findings​

Reinforcing education​

Routine procedures (e.g., catheterization)​

Most medication administrations (PO, SQ, IM, most IV meds are typically reserved for the RN)​

Ostomy care​

Tube patency & enteral/parenteral feeding​

Specific limited assessments (e.g., lung sounds, bowel sounds, neurovascular checks)

Do NOT Delegate to the LPN/LVN

New admissions​

Clients being discharged​

Transfers in or out​

Education of clients​

Unexpected outcomes​

Clients with potential problems

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Tasks which can be delegated to UAP

Activities of daily living​

Hygiene- including oral and perineum care (but not ostomy or wound care)​

Linen change​

Routine, stable vital signs (no admission vitals)​

Documenting input/output​

Positioning​

Reinforce safe transfer​

Unsterile care​

Remind client to do something but not how to do it​

Detach suction/remove a urinary catheter​

Weighing a client​

Ambulating a client to the restroom, down the hallway, and even using crutches after education

Do NOT delegate to the UAP

Assessment​

Teaching​

Medication​

Evaluation​

Unstable clients

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Begin each entry with the date and time.​​

Record all data factually and objectively.​​

This includes observations of a client’s behavior and the actions of another health professional.​​

Use complete descriptions of assessments and care in an objective manner, avoiding generalizations.​​

Use the client’s words, in quotes, to record what they have said.​​

This is most important when the client is expressing emotions or thoughts of harming themselves or someone else.​​

Document consultations with providers that seek to clarify a prescribed intervention.​​

Document only what you have observed or done yourself. ​​

Document as care is provided, rather than waiting for the end of the shift. This increases the accuracy of documentation.​​

If a late entry is needed, document the time the charting was completed, then note the time care was provided at the start of the note.​​

Correct all errors when discovered. The process for making a correction in an electronic health record (EHR) may vary by software.​​

End each entry with your signature and role abbreviation (registered nurse [RN]; licensed vocational nurse [LVN]; nursing assistant [NA]; medical doctor [MD]; occupational therapist [OT]). This step is often completed by the EHR and is linked to your login credentials.​​

First initial, last name, SN. (e.g., C. Simpson, RN)​​

Document using correct medical terminology, spelled correctly.​​

It is not necessary to use correct grammar and punctuation, though entries should be clear and concise.​​

Be aware of who is around you when documenting the EHR. ​​

Shield the monitor from the line of sight of others, including colleagues whose access may differ from yours.​​

Do not leave the computer with the screen active, even for a short time. ​​

Finally, always protect your computer password.​

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The transfer process should include:​

use of a communication hand-off tool (e.g., ISBAR)​

written and verbal report of the client’s status and care needs​

client’s medical diagnosis and healthcare providers​

client’s demographic information​

overview of health status, plan of care, and recent progress​

potential alterations in health that can be concerning​

most recent set of vital signs and medications and when they were last given​

allergies​

notification of client care needs within the next few hours​

diet and activity prescriptions​

specific equipment of adaptive devices currently in use or may be needed (e.g., oxygen, suction, and wheelchair)​

advanced directives​

family involvement and healthcare proxy (if applicable)​

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Content tested in this client needs category includes but is not limited to:

aging process

antepartum, intrapartum, and postpartum care

newborn care

developmental stages and transitions

health promotion and disease prevention

health screening

high-risk behaviors

lifestyle choices

self-care

techniques of physical assessment

he NCLEX-RN® test plan (NCSBN, 2023) further explains that the candidate should be able to:

Provide care and education for the newborn, infant, and toddler client from birth through 2 years.

Provide care and education for the preschool, school age, and adolescent clients ages 3 through 17 years.

Provide care and education for the adult client ages 18 through 64 years.

Provide care and education for the adult client ages 65 years and over.

Provide prenatal care and education.

Provide care and education for an antepartum client or a client in labor.

Provide postpartum care and education.

Assess and educate clients about health risks based on family, population, and community.

Assess the client’s readiness to learn, learning preferences, and barriers to learning.

Plan and/or participate in community health education.

Educate clients about preventative care and health maintenance recommendations.

Provide resources to minimize communication barriers.

Perform targeted screening assessments (e.g., vision, nutrition, and depression).

Educate clients about prevention and treatment of high-risk health behaviors.

Assess the client’s ability to manage care in the home environment and plan care accordingly.

Perform comprehensive health assessments.

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Birth: Hepatitis B (“Bee”)

Two months: Hepatitis B (“Bee”), DTap, RV, Hib, IPV, PCV (“Dr. Hip”)

Three months: DTap, RV, Hib, IPV, PCV (“Dr. Hip”)

Six months: Hepatitis B (“Bee”), DTap, RV, Hib, IPV, PCV (“Dr. Hip”), Influenze (“In”)

12-18 months: MMR, Hepatitis A, DTAP, Hib, PVC, Varicella (“MAD HPV”)

4-6 years: Varicella, DTaP, IPV, MMR (“Very Dim”)

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Primordial prevention is the most recent addition to preventive strategies and precedes primary prevention. It involves risk factor prevention and is the earliest prevention modality (Kisling & Das, 2021). Strategies are often aimed at children to decrease as much risk exposure as possible. Activities focus on social and environmental conditions that promote disease onset (Kisling & Das, 2022).

Example of primordial prevention: Improving access to safe playgrounds and sidewalks in an urban community may promote physical activity which decreases risk factors for obesity, cardiovascular disease, and diabetes mellitus type 2.

PRIMARY

Primary prevention addresses the needs of healthy clients to promote health and PREVENT disease with specific protections. It decreases the risk of exposure individual/ community to disease.Primary prevention focus on activities the client can do to avoid disease or injury before it happens

● Immunization programs

● Child car seat education

● Nutrition, fitness activities

● Health education in schools SECONDARY

Additional Examples : smoking cessation, using an infant car seat properly, and immunizations

SECONDARY

Secondary prevention focuses on identifying illness, providing treatment, and conducting activities that help prevent a worsening health status.

● Communicable disease screening, case finding

● Early detection, treatment of diabetes mellitus

● Exercise programs for older adults who are frail

Additional Examples: annual mammogram screening for all women over age 45 years, monitoring blood glucose in clients diagnosed with diabetes, and treating hypertension to prevent cardiovascular disease

TERTIARY

Tertiary prevention aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functioning.

● Begins after an injury or illness

● Prevention of pressure ulcers after spinal cord injury

● Promoting independence after traumatic brain injury

● Referrals to support groups

● Rehabilitation center

Additional Examples: breathing training for chronic obstructive pulmonary disease (COPD), cardiac rehabilitation after myocardial infarction, rehabilitation after spinal cord injury to learn how to use a wheelchair.

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The registered nurse must assess a client’s readiness to learn, learning preferences, and barriers to learning.

COGNITIVE DOMAIN

Cognitive learning requires intellectual behaviors and focuses on thinking. The nurse will assist the client with learning physical skills. This involves strategies such as demonstration and return demonstration as well as practice. It involves knowledge (learning the new information), comprehension (understanding the new information), application (using the new information in a concrete way), analysis (organizing the new information), synthesis (using the knowledge for a new outcome), and evaluation (determining the effectiveness of learning the new information).

discussion (one-on-one or group)​

allowing verbalization of feelings and support from others​

lecture​

question and answer session​

role play​

computer-assisted instruction​

Example, cognitive learning takes place when clients learn the manifestations of hypoglycemia and then can verbalize when to notify the provider.

Example 2: Helping a client learn more about a new diagnosis of heart failure

PSYCHOMOTOR DOMAIN

Psychomotor learning is gaining skills that require mental and physical activity. Psychomotor learning relies on perception (or sensory awareness), set (readiness to learn), guided response (task performance with an instructor), mechanism (increased confidence allowing for more complex learning), adaptation (the ability to alter performance when problems arise), and origination (use of skills to perform complex tasks that require creating new skills).

demonstration​

practice​

return demonstration​

independent games​

For example, psychomotor learning takes place when clients practice preparing insulin injections ​

Example2: Helping a client learn to eat using utensils following a stroke

AFFECTIVE DOMAIN

The nurse will assist the client in processing attitudes, feelings, enthusiasms, and motivations. This involves strategies such as role-play and discussion. ​

Affective learning involves feelings, beliefs, and values. Hearing the instructor’s words, responding verbally and nonverbally, valuing the content or believing that it is worth learning, creating a method for identifying values and resolving differences, and employing values consistently in decision-making are all characteristics of affective learning.

role-play​

discussion (one-on-one or group) ​

allowing verbalization of feelings and support from others​

Example: Helping a client become willing to learn more about smoking cessation

Example 2 Affective learning takes place when clients learn about the life changes necessary for managing diabetes mellitus and then discuss their feelings about having diabetes.

LEARNING PRINCIPLES:

MOTIVATION:

Motivation to learn is an internal state that is influenced by the belief in the need to know something. Clients who need knowledge for survival will have stronger motivation to learn. Teaching needs to be focused on how the information meets the client’s own goals or values. Motivation to learn can be influenced by cultural factors and active participation of the client.

READINESS:

Readiness to learn is based on the client’s wiliness to engage in learning. Readiness to learn is most affected by stages of grief. Stages of grief not only apply to death, but also to illness. Clients must accept their illness and be ready to learn how to manage the illness. A client in the grief stages of adapting to illness is unlikely to be ready to learn. ​

ABILITY:

The ability to learn is influenced by developmental level, health literacy, and physical capabilities.

ENVIORMENT:

Environment can play a role in successful teaching. Ensure a quiet, distraction-free environment. Also, consider room temperature, lighting, furniture, and have all the equipment available. Keep teaching sessions short to ensure the client retains interest.​

​

FACTORS AFFECTING LEARNING FACTORS THAT ENHANCE LEARNING ● Perceived benefit ● Cognitive and physical ability ● Active participation ● Age- and education level-appropriate methods

BARRIERS TO LEARNING

● Fear, anxiety, depression

● Physical discomfort, pain, fatigue

● Environmental distractions

● Sensory and perceptual deficits

● Psychomotor deficits

Much of health promotion and disease prevention involves client education. Many factors influence client education, including:

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health care access and quality

neighborhood and built enviornment

social and community context

economic stability

education access and quality

current health status​

education level/health literacy level

socioeconomic status

culture, race, ethnicity

spiritual beliefs

emotional status

health perception

willingness to learn

fear, anxiety

physical discomfort, fatigue

environmental distractions

sensory, perceptual, or psychomotor deficits

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The neonatal period is from birth to 28 days of life. During this time, the newborn’s behavior is reflexive, and stabilization of body systems is the primary task. Behavior is largely influenced by contact with caregivers and the environment.

The average newborn weighs 2700–8000 grams, is 48–53 cm in length, and has a head circumference of 33–35 cm. It is not uncommon for a newborn to lose up to 10% of birth weight during the first few days of life, due to fluid loss through respirations, urination, and defecation, as well as low fluid intake. Birth weight should be regained by 2 weeks of age.

Normal newborn behavior includes crying, sucking, sleeping, and periods of reactivity. Movement is sporadic but symmetrical and should involve all four extremities. Crying is the primary means of communication. Caregivers should be taught to recognize crying patterns and respond appropriately. Stimulation is important and is achieved by talking to the newborn and holding the newborn face-to-face.

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EXPECTED GROWTH AND DEVELOPMENT FOR NEWBORNS

PHYSICAL DEVELOPMENT

● Lose 5% to 10% body birth weight in first few days, but should regain it by the second week.

● Weight gain is about 150 to 210 g (5 to 7 oz) per week in the first 6 months.

● Measurements of crown-to-rump length, head-to-heel length, head circumference, and chest circumference are key indicators of appropriate growth.

● Head molding (overlapping of skull bones) present; fontanels are palpable. REFLEXES

● Include startling, sucking, rooting, grasping, yawning, coughing, plantar and palmar grasp, and Babinski.

● Confirm presence or absence of expected reflexes to monitor for appropriate neurological development. BODY POSITION

● Generally flexed at rest.

● Movement should involve all four extremities equally, but can be sporadic.

SLEEP

● Sleep patterns can be reversed for several months (daytime sleeping and nighttime wakefulness).

● Average 15 hr of sleep time each day. COGNITIVE DEVELOPMENT

● Learn to respond to visual stimuli.

● Use cry as a form of communication.

● Cry patterns can change to reflect different needs.

PSYCHOSOCIAL DEVELOPMENT

● Interactions with caregivers affect psychosocial development. Positive interactions promote nurturing and attachment. Negative experience or lack of interaction hinders appropriate attachment.

● Most newborns can mimic the smile of the caregiver by 2 weeks of life. EXPECTED GROWTH AND DEVELOPMENT FOR INFANTS PHYSICAL DEVELOPMENT

● Posterior fontanel closes by 2 to 3 months of age.

● Anterior fontanel closes by 12 to 18 months of age.

Tracking parameters

WEIGHT: Birth weight should double by 4 to 6 months and triple by the end of the first year. HEIGHT: Infants grow about 2.5 cm (1 in) per month in the first 6 months, and then about 1.25 cm (0.5 in) per month until the end of the first year.

HEAD CIRCUMFERENCE: The circumference of infants’ heads increases approximately 2 cm (0.8 in) per month during the first 3 months, 1 cm (0.4 in) per month from 4 to 6 months, and then approximately 0.5 cm (0.2 in) per month during the second 6 months.

DENTITION: Six to eight teeth erupt in the infant’s mouth by the end of the first year.

● Use cold teething rings, over-the-counter teething gels, and acetaminophen or ibuprofen.

● Use a cool, wet washcloth to clean the teeth.

● Do not give infants a bottle when they are falling asleep. Prolonged exposure to milk or juice can cause dental caries (bottle-mouth caries).

Motor skill development found in photo chart

Piiaget: Sensorimotor stage (birth to 24 months)

● Separation is the sense of being distinct from other objects in the environment.

● Object permanence develops at about 9 months. This is the process of knowing that an object still exists when it is hidden from view. ● Mental representation is the recognition of symbols. Language development

● Responds to noises ● Vocalizes with “oohs” and “aahs” ● Laughs and squeals ● Turns head to the sound of a rattle ● Begins to comprehend simple commands

● Pronounces single-syllable words

● Begins speaking two- and then three-word phrases PSYCHOSOCIAL DEVELOPMENT Erikson: Trust vs. mistrust (birth to 1 year)

● Infants trust that others will meet their feeding, comfort, stimulation, and caring needs.

● Infants’ reflexive behavior (attachment, separation recognition/anxiety, and stranger fear) influences their social development.

● Attachment, when infants begin to bond with their parents, develops within the first month, but actually begins before birth. The process is optimal when the infant and parents are in good health, have positive feeding experiences, and receive adequate rest.

● Separation recognition occurs during the first year as infants recognize the boundaries between themselves and others. Learning how to respond to people in their environment is the next phase of development. Positive interactions with parents, siblings, and other caregivers help establish trust.

● Separation anxiety develops between 4 and 8 months of age. Infants protest loudly when separated from parents, which can cause considerable anxiety for the parents.

● Stranger fear becomes evident between ages 6 to 8 months, when infants are less likely to accept strangers. Self‑concept development By the end of the first year, infants distinguish themselves as separate from their parents. Body‑image changes

● Infants discover that the mouth is a pleasure producer.

● Hands and feet are objects of play.

● Smiling makes others react. AGE‑APPROPRIATE ACTIVITIES

● Infants have a short attention span and do not interact with other children during play (solitary play). Age-appropriate activities can promote cognitive, social, and motor development.

● Appropriate toys and activities that stimulate the senses and encourage development include rattles, mobiles, teething toys, nesting toys, playing pat-a-cake, playing with balls, and reading books. HEALTH PROMOTION FOR NEWBORNS AND INFANTS SCREENINGS

● Newborn screenings for metabolism disorders can be repeated in early weeks of life (phenylketonuria, galactosemia).

● Developmental milestone screenings occur ongoing as part of routine well checkups with the provider at 2 weeks, and 2, 4, 6, 9, and 12 months. IMMUNIZATIONS Follow the latest Centers for Disease Control and Prevention (CDC) immunization recommendations (see www.cdc.gov) for healthy infants. During the first year, these generally include immunizations against hepatitis B, diphtheria, tetanus, pertussis, rotavirus, polio, influenza, and pneumococcal pneumonia. The recommendations change periodically, so check them often.

NUTRITION

● Breastfeeding provides optimal nutrition during the first 12 months.

● Feeding alternatives:

◯ Iron‑fortified formula is an acceptable alternative to breast milk.

◯ Cow’s milk is inadequate and should not be given before 1 year of age.

● Weaning from the breast or bottle can begin when infants can drink from a cup (after 6 months).

◯ Replace a single bottle- or breast-feeding with breast milk or formula in a cup.

◯ Every few days, replace another feeding with a cup.

◯ Replace the bedtime feeding last.

● Solid food is appropriate around 6 months.

◯ Indicators for readiness include voluntary control of the head and trunk and disappearance of the extrusion reflex (pushing food out of the mouth).

◯ Introduce iron‑fortified rice cereal first.

◯ Start new foods one at a time over a 5- to 7-day period to observe for signs of allergy or intolerance (fussiness, rash, vomiting, diarrhea, constipation). Vegetables, fruits, and meats follow, generally in that order.

◯ Do not give honey to infants until after 12 months of age because it can cause infant botulism

. ◯ Appropriate finger foods to introduce around 9 months include ripe bananas, toast strips, graham crackers, cheese cubes, noodles, and peeled chunks of apples, pears, and peaches.

◯ Remind parents that solid food is not a substitute for breast milk or formula until after 12 months.

◯ Fluoridated water or supplemental fluoride is recommended after 6 months to protect against dental caries.

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EXPECTED GROWTH AND DEVELOPMENT PHYSICAL DEVELOPMENT

The anterior fontanel closes by 18 months.

WEIGHT: Toddlers grow approximately 1.8 to 2.7 kg (4 to 6 lb) per year.

HEIGHT: Toddlers grow approximately 7.5 cm (3 in) per year.

CONTRIBUTION TO SELF-CARE ACTIVITIES: dressing, feeding, toilet-training

COGNITIVE DEVELOPMENT

Piaget: Sensorimotor transitions to preoperational

● The concept of object permanence is fully developed.

● Toddlers have and demonstrate memories of events that relate to them.

● Domestic mimicry is evident (playing house).

● Preoperational thought does not allow toddlers to understand other viewpoints, but it does allow them to symbolize objects and people in order to imitate activities they have seen.

Language development

● By 24 months, most toddlers understand about 300 words, and can speak in two- to three-word phrases.

● Ability to comprehend speech outweighs the number of words and phrases spoken.

PSYCHOSOCIAL DEVELOPMENT

Erikson: autonomy vs. shame and doubt

● Independence is paramount as toddlers attempt to do everything for themselves.

● Separation anxiety continues when parents leave.

● A toddler might show regression (bed-wetting, thumb sucking) as a response to anxiety or separation.

● Engages in parallel play, but by age 3 begins to play and communicate with others.

Moral development

● Moral development parallels cognitive development.

● Egocentric: Toddlers are unable to see another’s perspective; they can only view things from their point of view.

● Punishment and obedience orientation begins with a sense that others reward good behavior and punish bad behavior.

Self-concept development: Toddlers progressively see themselves as separate from their parents and increase their explorations away from them.

Body-image changes: Toddlers appreciate the usefulness of various body parts.

AGE‑APPROPRIATE ACTIVITIES

● Solitary play evolves into parallel play where toddlers observe other children and then engage in activities nearby. ● Temper tantrums result when toddlers are frustrated with restrictions on independence. Providing consistent, age-appropriate expectations helps them work through their frustration.

● Offer choices (juice or milk) instead of providing an opportunity for a yes/no response from the toddler.

● Toilet training can begin with awareness of the sensation of needing to urinate or defecate. The toddler should show indications of readiness and parents should demonstrate patience, consistency, and a nonjudgmental attitude with toilet training. Nighttime control can develop last.

● Discipline should be consistent with well‑defined boundaries that help develop acceptable social behavior. Appropriate activities

● Filling and emptying containers

● Playing with blocks

● Looking at books

● Playing with push and pull toys

● Tossing a ball

PROMOTION IMMUNIZATIONS

Generally include immunizations against :

hepatitis A and B,

diphtheria,

tetanus,

pertussis,

measles, mumps, rubella,

varicella,

polio,

influenza,

haemophilus influenza type B

pneumococcal pneumonia.

Recommendations change periodically.

NUTRITION

● Toddlers are picky eaters with repeated requests for favorite foods.

● Toddlers should consume 2 to 3 cups (16 to 24 oz) per day and can switch from drinking whole milk to drinking low-fat or fat-free milk at 2 years of age.

● Limit juice to 4 to 6 oz a day.

● Food serving size is 1 tbsp for each year of age.

● Toddlers can be reluctant to try or accept foods new to them.

● As toddlers become more autonomous, they tend to prefer finger foods.

● Regular meal times and nutritious snacks best meet nutrient needs.

● Avoid snacks and desserts that are high in sugar, fat, or sodium.

● Avoid foods that pose choking hazards (nuts, grapes, hot dogs, peanut butter, raw carrots, tough meats, popcorn).

● Supervise toddlers during snacks and mealtimes.

● Cut food into small, bite-sized pieces to make it easier to swallow and to prevent choking.

● Do not allow toddlers to eat or drink during play activities or while lying down.

● Do not use food as a reward or punishment.

●Do not allow child to use a bottle during naps or bedtime to reduce the risk for dental caries.

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ASSOCIATIVE PLAY  |   4 YRS ( CAN ONLY SEE FROM THIER POINT OF VIEW) | 

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EXPECTED GROWTH AND DEVELOPMENT

PHYSICAL DEVELOPMENT

● Development occurs at a more gradual rate than cognitive and psychosocial development.

● Preschoolers evolve from the characteristically unsteady wide stance and protruding abdomen of toddlers to the more graceful, posturally erect, and sturdy physicality of this age group.

● Male preschoolers have a tendency to appear larger with more muscle mass. WEIGHT: Preschoolers gain about 2 to 3 kg (4.5 to 6.5 lb) per year. HEIGHT: Preschoolers grow about 6.2 to 9 cm (2.4 to 3.5 in) per year.

Piaget: preoperational phase

● Preschoolers are still in the preoperational phase of cognitive development. They participate in preconceptual thought (from 2 to 4 years of age) and intuitive thought (from 4 to 7 years of age).

● Preconceptual thought: Preschoolers make judgments based on visual appearances.

Misconceptions in thinking during this stage include:

◯ Artificialism: Everything is made by humans.

◯ Animism: Inanimate objects are alive.

◯ Imminent justice: A universal code exists that determines law and order.

● Intuitive thought: Preschoolers can classify and begin to question information and become aware of cause‑and‑effect relationships.

Time concepts:

Preschoolers begin to understand the concepts of past, present, and future. By the end of the preschool years, they can comprehend days of the week. Language development: Vocabulary continues to increase, and by age 6 contains 8,000 to 14,000 words. Desires and frustrations are more verbally articulated, and a need to learn information is expressed through questioning. Phonetically similar words (eye and I) are difficult to comprehend at this age. Preschoolers speak in sentences, identify colors, and enjoy talking. Children who speak more than one language reach language milestones at the same time as peers who speak one language.

PSYCHOSOCIAL DEVELOPMENT

Erikson: Initiative vs. guilt:

Preschoolers take on many new experiences, despite not having all of the physical abilities necessary to be successful at everything. When children are unable to accomplish a task, they can feel guilty and believe they have misbehaved. Guide preschoolers to attempt activities within their capabilities while setting limits. Moral development: Preschoolers continue in the good-bad orientation of the toddler years but begin to understand behavior in terms of what is socially acceptable. Self-concept development: Preschoolers feel good about themselves for mastering skills (dressing and feeding) that allow independence. During stress, insecurity, or illness, they tend to regress to previous immature behavior or develop habits (nose picking, bed wetting, or thumb sucking).

Body-image changes

● Mistaken perceptions of reality coupled with misconceptions in thinking lead to active fantasies and fears. Preschoolers fear bodily harm, the dark, ghosts, animals, inclement weather, and medical personnel.

● Sex‑role identification is typical. Social development

● During the preschool time period, children generally do not exhibit stranger anxiety and have less separation anxiety. This leads to exploring their neighborhood environment and making new friends. However, prolonged separation (during hospitalization) can provoke anxiety. Favorite toys and play help ease fears.

● Pretend play is healthy and allows children to determine the difference between reality and fantasy.

● Sleep disturbances are common during early childhood, and problems range from difficulties going to bed to night terrors.

Advise parents to: ◯ Assess whether the bedtime is too early for children who still take naps. Preschoolers average about 12 hr of sleep a day. Some still require a daytime nap. ◯ Keep a consistent bedtime routine, and help children slow down in preparation for bedtime. Avoid media use or other stimulation before bed.

◯ Use a night light.

◯ Reassure children who are frightened.

◯ Ensure media content the child views is age appropriate and nonviolent.

AGE‑APPROPRIATE ACTIVITIES

Parallel play shifts to associative play during the preschool years.

Play is not highly organized, and preschoolers do not cooperate during play.

Activities include the following.

● Playing ball

● Putting puzzles together

● Riding tricycles

● Pretend and dress-up activities

● Musical toys

● Painting, drawing, and coloring

● Sewing cards

● Cooking and housekeeping toys

● Looking at illustrated books

● Technology (video and computer programs) to support development and learn new skills HEALTH PROMOTION IMMUNIZATIONS

● These generally include immunizations against diphtheria, tetanus, pertussis, measles, mumps, rubella, varicella, seasonal influenza, and polio.

HEALTH SCREENINGS :

Vision screening is routine in the preschool population as part of the prekindergarten physical examination. It is essential to detect and treat myopia and amblyopia before poor visual acuity impairs the learning environment.

NUTRITION

● Preschoolers who are mildly active, require an estimated caloric intake range from 1200 to 1400 calories per day.

● Picky eating remains a problem for some preschoolers, but often by age 5 they become a bit more willing to sample different foods.

● Preschoolers age 3 need 13 to 19 g of protein daily and 25 g are needed for ages 4 to 5 (2 to 4 oz-equivalents) in addition to adequate calcium, iron, folate, and vitamins A and C.

● Parents should provide a balance of nutrients. See www.choosemyplate.gov for nutritional guidelines for preschoolers.

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EXPECTED GROWTH AND DEVELOPMENT

PHYSICAL DEVELOPMENT

WEIGHT: Gain about 1.8 to 3.2 kg (4 to 7 lb) per year HEIGHT: Grow about 5 cm (2 in) per year FINE AND GROSS MOTOR DEVELOPMENT:

Coordination continues to improve and movements become more refined.

● Females can exceed the height and weight of males near the end of school-age years.

● Permanent teeth erupt.

● Visual acuity improves to 20/20.

● Auditory acuity and sense of touch fully develop. CHANGES RELATED TO PUBERTY BEGIN:

● Females ◯ Budding of breasts.

◯ Appearance of pubic hair

◯ Menarche

● Males

◯ Enlargement of testicles with changes in the scrotum

◯ Appearance of pubic hair

COGNITIVE DEVELOPMENT

Piaget: Concrete Operations

● See weight and volume as unchanging.

● Understand simple analogies and relationships between things and ideas.

● Understand time (days, seasons).

● Classify more complex information.

● Understand various emotions.

● Become self-motivated.

● Solve problems and understand cause and effect. Language development

● Define many words and understands rules of grammar.

● Understand that a word can have multiple meanings.

● Increased ability to connect words into phrases.

● Reason about a word’s meaning rather than the literal translation. ● Understands jokes and riddles. PSYCHOSOCIAL DEVELOPMENT

Erikson: industry vs. inferiority School-age children’s stage of psychosocial development, according to Erikson, is industry vs. inferiority.

● School-age children develop a sense of industry through advances in learning.

● Tasks that increase self-worth motivate them.

● Stress is increasingly common in this age group from parental and peer expectations, their environment, or observed violence.

● Fears of ridicule by peers and teachers over school-related issues are common. Some children manifest nervous behavior to deal with stress (nail biting).

Moral development ● Early on, school-age children might not understand the reasoning behind many rules and will try to find ways around them. Instrumental exchange is in place (“I’ll help you if you help me.”). They want to make the best deal and do not consider elements of loyalty, gratitude, or justice when making decisions.

● In the latter part of the school years, they move into a law-and-order orientation, placing more emphasis on justice.

Self-concept development

● Strive to develop healthy self‑respect by finding out in what areas they excel

● Need parents to encourage them in educational or extracurricular successes

● Self-esteem developed based on interactions with peers and perceived self-concept Body-image changes

● Body image solidifies.

● Education should address curiosity about sexuality, sexual development, and the reproductive process.

● School-age children are more modest than preschoolers and place more emphasis on privacy

. ● School-age children develop concern about appearance and hygiene. Social development

● Social environment can expand to include school, community, and church.

● Peer groups play an important part in social development. However, peer pressure begins to take effect.

● Friendships begin to form among same-gender peers. Clubs and best friends are popular.

● Most relationships come from school associations.

● Children at this age can rival the same-gender parent.

● Conformity becomes evident.

● School-age children become more independent from parents.

Competitive and cooperative play predominates.

6- TO 9-YEAR-OLDS

● Play board, video, and number games.

● Play hopscotch. ● Jump rope. ● Collect rocks, stamps, cards, coins, or stuffed animals. ● Ride bicycles. ● Build simple models. ● Artistic activities (painting and drawing). ● Play team sports: skill building.

9- TO 12-YEAR-OLDS

● Make crafts. ● Read books. ● Build models. ● Develop in hobbies. ● Assemble jigsaw puzzles. ● Play video games. ● Play team sports. ● Learn to play musical instruments.

HEALTH PROMOTION IMMUNIZATIONS Follow the latest . These generally include immunizations against diphtheria, tetanus, pertussis, human papillomavirus, hepatitis A and B, measles, mumps, rubella, varicella, seasonal influenza, polio, meningococcal infections, and for some high-risk individuals, pneumococcal infections.

● Scoliosis: Screening for idiopathic scoliosis, a lateral curvature of the spine with no apparent cause, is essential, especially for females, during the school-age stage.

● Health promotion and maintenance education is essential to promote healthy choices and prevent illness. NUTRITION

● By the end of the school-age stage, children eat adult servings of food and also need nutritious snacks.

● Obesity predisposes school-age children to low self-esteem, diabetes mellitus, heart disease, and high blood pressure.

Advise parents to:

◯ Not use food as a reward.

◯ Emphasize physical activity.

◯ Provide a balanced diet

◯ Teach children to make healthy food selections for meals and snacks.

◯ Avoid eating meals at fast-food restaurants.

◯ Avoid skipping meals.

DENTAL HEALTH ● Have the child brush and floss daily.

● Ensure the child get regular check-ups EVERY 6 MONTHS

# data[].attributes.body
EXPECTED GROWTH AND DEVELOPMENT

PHYSICAL DEVELOPMENT

● Adolescents gain the final 20% to 25% of height during puberty.

● Sleep habits change with puberty due to increased metabolism and rapid growth during the adolescent years. Adolescents stay up late, sleep later in the morning, and perhaps sleep longer than they did during the school-age years.

FEMALES ● Grow 5 to 20 cm (2 to 8 in) and gain 7 to 25 kg (15.5 to 55 lb) during the prepuberty growth spurt

● Stop growing around 16 to 17 years of age

● Mature sexually in the following order:

◯ Appearance of breast buds

◯ Growth of pubic hair (can have hair growth prior to breast bud development)

◯ Onset of menstruation

MALES

● Grow 10 to 30 cm (4 to 12 in) and gain 7 to 29 kg (15 to 65 lb) during the prepuberty growth spurt

● Stop growing at around 18 to 20 years of age

● Mature in the following order:

◯ Increase in the size of the testes and scrotum

◯ Appearance of pubic hair

◯ Rapid growth of genitalia

◯ Growth of axillary hair

◯ Appearance of downy hair on upper lip

◯ Change in voice

COGNITIVE DEVELOPMENT

Piaget: Formal operations

● Think at an adult level.

● Think abstractly and deal with principles and hypothetical situations.

● Evaluate the quality of their own thinking.

● Have a longer attention span.

● Are highly imaginative and idealistic.

● Make decisions through logical operations.

● Are future-oriented.

● Are capable of deductive reasoning.

● Understand how actions of an individual influence others. Language development Adolescents communicate one way with the peer group and another way with adults. Use open-ended questions to communicate and discuss sensitive issues.

PSYCHOSOCIAL DEVELOPMENT

Erikson: identity vs. role confusion

● They develop a sense of personal identity that family expectations influence.

● Adolescents strive for independence from guardians and identify more with peers.

Group identity: They become part of a peer group that greatly affects behavior.

Vocationally: Work habits and plans for college and career begin to solidify.

Sexuality: Sexual identity develops during adolescence, with increasing interest in the opposite gender, the same gender, or various genders, according to self‑identification with sexuality. Self‑identification can shift as sexual maturity progresses.

Health perceptions: Adolescents often feel invincible to bad outcomes of risky behaviors.

Moral development: conventional law and order. Adolescents do not see rules as absolutes, instead looking at each situation and adjusting the rules. Not all adolescents attain this level of moral development during these years. Self-concept development: Adolescents develop a healthy self-concept by having healthy relationships with peers, family, and teachers while striving for emotional independence. Identifying a skill or talent helps them maintain a healthy self-concept. Participation in sports, hobbies, or the community can have a positive outcome. Body-image changes: Adolescents seem particularly concerned with the body images the media portray. Changes during puberty result in comparisons between adolescents and peers. Guardians also give their input for hair styles, dress, and activity. Adolescents require interventions if depression or eating disorders result from poor body image.

Social development

● Group relationships are important, as they lead to personal acceptance, approval, and learned behaviors.

● Peer relationships develop as a support system.

● Best-friend relationships are more stable and long-lasting than in previous years.

● Guardian-child relationships change to allow more independence.

AGE‑APPROPRIATE ACTIVITIES

● Nonviolent video games, music, movies

● Sports, social events

● Caring for a pet

● Career-training programs ● Reading

HEALTH PROMOTION IMMUNIZATIONS

These generally include immunizations against diphtheria, tetanus, pertussis, human papillomavirus, hepatitis A and B, measles, mumps, rubella, varicella, seasonal influenza, meningococcal and polio, and for some high-risk individuals, pneumococcal infections. HEALTH SCREENINGS

Provide health promotion and maintenance education related to illness prevention.

SCOLIOSIS: Screening for idiopathic scoliosis, a lateral curvature of the spine with no apparent cause, is essential, especially for females, during the adolescent growth spurt because it is most evident at that time.

NUTRITION

● Rapid growth and high metabolism require increases in high-quality nutrients.

Nutrients that tend to be deficient during this stage of life are iron, calcium, and vitamins A and C.

● Eating disorders commonly develop during adolescence (more in females than in males) due to a fear of being overweight, fad diets, or as a mechanism of maintaining control over some aspect of life.

◯ Anorexia nervosa

◯ Bulimia nervosa

◯ Overeating

● Advise guardians to: ◯ Not use food as a reward. ◯ Emphasize physical activity.

◯ Provide a balanced diet. See www.choosemyplate.gov for nutritional guidelines for adolescents.

◯ Teach adolescents to make healthy food selections for meals and snacks.

DENTAL HEALTH

● Brush daily. ● Floss daily. ● Get regular check-ups

# data[].attributes.body
EXPECTED GROWTH AND DEVELOPMENT '

PHYSICAL DEVELOPMENT

● Growth has concluded around age 20.

● Physical senses peak.

● Cardiac output and efficiency peak.

● Muscles function optimally at ages 25 to 30.

● Time for childbearing is optimal.

● Pregnancy-related changes occur.

COGNITIVE DEVELOPMENT

Piaget: Formal operations

The young adult years are an optimal time for education, both formal and informal.

● Critical thinking skills improve.

● Memory peaks in the 20s.

● Ability for creative thought increases.

● Values/norms of friends (social groups) are relevant.

● Decision‑making skills are flexible with increased openness to change.

PSYCHOSOCIAL DEVELOPMENT

Erikson, young adults must achieve intimacy vs. isolation. ● Young adults can take on more adult commitments and responsibilities.

● Young adults’ occupational choices relate to:

◯ High goals/dreams. ◯ Exploration/experimentation.

Moral development

● Young adults can personalize values and beliefs.

● They can base reasoning on ethical fairness principles (justice).

Self-concept development: Influences on the formation of a healthy self-concept during the young adult years include: ● Avoidance of substance use disorders

● Formation of a family

● Frequency of interactions with family and friends

● Personal choice and response to ethical situations Body-image changes

● Changes are affected by diet and exercise patterns. ''

● Pregnancy-related body image changes can also occur. Social development Young adults might: ● Leave home and establish independent living situation.

● Establish close friendships (intimacy).

● Transition from being single to being a member of a new family.

● Question their ability to parent.

● Experience increased anxiety and/or depression, especially after the birth of a child.

HEALTH PROMOTION Young adults are especially at risk for alterations in health from:

● Substance use disorders

● Periodontal disease due to poor oral hygiene

● Unplanned pregnancies: a source of high stress

● Sexually transmitted infections (STIs)

● Infertility

● Work-related injuries or exposures

● Violent death and injury

IMMUNIZATIONS

Primary vaccinations for young adults include annual influenza, as well as tetanus, diphtheria, and pertussis. Other vaccines are given to “catch up” the young adult for incomplete immunization series, or to provide additional protection to high-risk individuals. These include immunizations against hepatitis A and B, measles, mumps, rubella, varicella, human papillomavirus, and pneumococcal and meningococcal infections.

HEALTH SCREENINGS

● Young adults should follow age-related guidelines for screening.

● Encourage selecting a primary care provider for ongoing, routine medical care.

● Provide education about contraception and regular physical activity.

ROUTINE HEALTH CARE VISITS Should include obtaining height, weight, vital signs, and family history; screening for stress; education related to STIs and substance use disorders; and encouragement of good nutrition. NUTRITION

● Monitor for adequate nutrition and proper physical activity. ● Monitor calcium intake in females. ● See choosemyplate.gov for nutritional recommendations

# data[].attributes.body
EXPECTED GROWTH AND DEVELOPMENT

PHYSICAL DEVELOPMENT

Decreases in the following:

● Skin turgor and moisture

● Subcutaneous fat

● Melanin in hair (graying)

● Hair

● Visual acuity, especially for near vision

● Auditory acuity, especially for high-pitched sounds

● Sense of taste '

● Skeletal muscle mass

● Height

● Calcium/bone density

● Blood vessel elasticity

● Respiratory vital capacity

● Large intestine muscle tone

● Gastric secretions

● Decreased glomerular filtration rate

● Estrogen/testosterone

● Glucose tolerance COGNITIVE DEVELOPMENT Piaget: Formal operations

● Reaction time and speed of performance slow slightly.

● Memory is intact.

● Crystallized intelligence remains (stored knowledge).

● Fluid intelligence (how to learn and process new information) declines slightly.

PSYCHOSOCIAL DEVELOPMENT

According to Erikson, middle adults must achieve generativity vs. stagnation.

Middle adults strive for generativity.

● Use life as an opportunity for creativity and productivity. ● Have concern for others.

● Consider parenting an important task.

● Contribute to the well-being of the next generation.

● Strive to do well in one’s own environment.

● Adjust to changes in physical appearance and abilities. Moral development

● Religious maturity

● Spiritual beliefs and religion taking on added importance ● Become more secure in their convictions

● Often have advanced moral development

Self-concept development:

Some middle adults have issues related to: ● Menopause ● Sexuality ● Depression ● Irritability ● Difficulty with sexual identity ● Job performance and ability to provide support ● Marital changes with the death of a spouse or divorce Body image changes ● Sex drive can decrease as a result of declining hormones, chronic disorders, or medications. ● Changes in physical appearance can raise concerns about desirability.

● FEMALES: Response to menopausal changes can cause role confusion for some clients or a sense of excitement related to sexual freedom.

● MALES ◯ Decreasing strength can be frustrating or frightening. ◯ Climacteric occurs. Social development ● Need to maintain and strengthen intimacy

● Empty nest syndrome: experiencing sadness when children move away from home

● Provide assistance to aging parents, adult children, and grandchildren, giving this stage of life the name “sandwich generation”

HEALTH PROMOTION

Especially at risk for alterations in health due to: ● Obesity, type 2 diabetes mellitus ● Cardiovascular disease ● Cancer ● Substance use disorders (alcohol use disorder) ● Psychosocial stressors

IMMUNIZATIONS

Primary vaccinations for middle adults include annual influenza immunization, as well as tetanus, diphtheria, zoster, pneumococcal, and pertussis. Other vaccines are given to “catch-up” the middle adult for incomplete immunization series, or to provide additional protection to high-risk individuals.

These include immunizations against hepatitis A and B, measles, mumps, rubella, varicella, and pneumococcal and meningococcal infections.

SCREENINGS

● Dual-energy x-ray absorptiometry (DXA) screening for osteoporosis

● Eye examination for glaucoma and other disorders every 2 to 3 years or annually depending on provider

● Mental health screening for anxiety and depression

NUTRITION

Nutrition counseling for middle adults generally includes:

● Obtaining adequate protein.

● Increasing the consumption of whole grains and fresh fruits and vegetables.

● Limiting fat and cholesterol.

● Increasing vitamin D and calcium supplementation (especially for females). See www.choosemyplate.gov for nutritional recommendations

# data[].attributes.body
Older Adults (65 Years and Older)

EXPECTED GROWTH AND DEVELOPMENT

PHYSICAL DEVELOPMENT

Integumentary

● Decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which leads to wrinkles and dry, transparent skin

● Loss of subcutaneous fat, which makes it more difficult for older adults to adjust to cold temperatures

● Thinning and graying of hair, as well as a more sparse distribution

● Thickening of fingernails and toenails Cardiovascular/pulmonary

● Decreased chest wall movement, vital capacity, and cilia, which increases the risk for respiratory infections

● Reduced cardiac output

● Decreased peripheral circulation

● Increased blood pressure Neurologic

● Slower reaction time

● Decreased touch, smell, and taste sensations

● Decline in visual acuity

● Decreased ability for eyes to adjust from light to dark, leading to night blindness, which is especially dangerous when driving

● Inability to hear high-pitched sounds (presbycusis)

● Reduced spatial awareness

Gastrointestinal

● Decreased production of saliva

● Decreased digestive enzymes

● Decreased intestinal motility, which can lead to increased risk of constipation

● Increased dental problems

Musculoskeletal

● Decreased height due to intervertebral disk changes

● Decreased muscle strength and tone

● Decalcification of bones

● Degeneration of joints

Genitourinary

● Decreased bladder capacity

● Prostate hypertrophy in males

● Decline in estrogen or testosterone production ● Atrophy of breast tissue in females

Endocrine

● Decline in triiodothyronine (T3) production, yet overall function remains effective

● Decreased sensitivity of tissue cells to insulin

Immune

● Decreased production of antibodies by B cells

● Increased production of autoantibodies (antibodies against the host’s body) with increased autoimmune response

● Decreased core body temperature

● Decreased T-cell function

● Decreased stress response

● Decreased response to immunizations

COGNITIVE DEVELOPMENT

Piaget: Formal operations

● Many older adults maintain their cognitive function. There is some decline in speed of the cognitive function versus cognitive ability.

● A number of factors influence older adults’ abilities to function (overall health, the number of stressors, and lifelong mental well-being).

● Slowed neurotransmission, vascular circulation impairment, disease states, poor nutrition, and structural brain changes can result in the following cognitive disorders.

◯ Delirium: Acute, temporary, and can have a physiologic source (infection, sleep deprivation, or pain) or related to a change in surroundings (being in an unfamiliar or new environment); delirium is often the first manifestation of infection (urinary tract infection) in older adults.

◯ Dementia: Chronic, progressive, and possibly with an unknown cause (Alzheimer’s disease, vascular dementia). ◯ Depression: Chronic, acute, or gradual onset (present for at least 6 weeks); depression is often due to loss of a loved one, feelings of isolation, or chronic disease. PSYCHOSOCIAL DEVELOPMENT

Erikson: Integrity vs. despair

Older adults need to: ● Adjust to lifestyle changes related to retirement (decrease in income, living situation, loss of work role).

● Adapt to changes in family structure (can be role reversal in later years).

● Adapt to changes in living environment.

● Deal with multiple losses (death of a spouse, friends, siblings). ● Face death.

Self-concept development: Older adults face difficulties in the area of self-concept.

● Seeing oneself as an aging person

● Finding ways to maintain a good quality of life

● Becoming more dependent on others for activities of daily living

Body image changes: An adjustment to decreases in physical strength and endurance is often difficult, especially for older adults who are cognitively active and engaged. Many older adults feel frustrated that their bodies are limiting what they desire to do.

Social development

● Find ways to remain socially active and to overcome isolation.

● Maintain sexual health.

HEALTH PROMOTION

HEALTH RISKS

Cardiovascular diseases

● Coronary artery disease ● Hypertension Factors affecting mobility● Arthritis ● Osteoporosis ● Falls Mental health disorders ● Depression ● Dementia ● Suicide ● Alcohol use disorder ● Tobacco use disorder Other disorders ● Stroke ● Diabetes mellitus ● Cancer ● Incontinence ● Abuse and neglect ● Cataracts ● Chronic pain ● Issues related to poor dental hygiene (gingivitis, missing teeth, gum disease)

IMMUNIZATIONS

● Immunizations against diphtheria, tetanus, pertussis, varicella, seasonal influenza, herpes zoster, and pneumococcal infections

● Immunizations against, hepatitis A and B, haemophilus influenzae type b, and meningococcal infections for high-risk individuals HEALTH SCREENINGS Older adults should follow age-related guidelines for screening.

ANNUAL SCREENINGS ● Hearing

● Fecal occult blood test

● Digital rectal and prostate‑specific antigen (males)

● Dual-energy x-ray absorptiometry (DXA) scanning for osteoporosis

● Eye examination for glaucoma and other disorders PERIODIC SCREENING

● Mental health screening for depression ● Cholesterol and diabetes screening every 3 years

NUTRITION

● In addition to gastrointestinal alterations, other factors influence nutrition in older adults.

◯ Difficulty getting to and from the supermarket to shop for food

◯ Low income

◯ Impaired mobility

◯ Depression or dementia

◯ Social isolation (preparing meals for one person, eating alone)

◯ Medications that alter taste or appetite

◯ Prescribed diets that are unappealing

◯ Incontinence that can cause the person to limit fluid int

ake

◯ Constipation

● Metabolic rates and activity decline as individuals age, so total caloric intake should decrease to maintain a healthy weight. With the reduction of total calorie intake, it becomes even more important that the calories older adults consume be of good nutritional value. Go to www.choosemyplate.gov for nutritional recommendations.

NUTRITIONAL RECOMMENDATIONS

● Increase intake of vitamins D, B12, E, folate, fiber, and calcium.

● Increase fluid intake to minimize the risk of dehydration and prevent constipation.

● Take a low-dose multivitamin along with mineral supplementation.

● Limit sodium, fat, refined sugar, and alcohol intake. RECOMMENDATIONS FOR IMPROVING NUTRITIONAL INTAKE DURING ACUTE OR LONG-TERM CARE

● Allow the client to eat with others, when possible. Socialization can make the meal more enjoyable.

● Make sure food is accessible throughout the day and nutritional supplements between mealtimes.

● Provide medication or address other physical needs before the meals so the client can be comfortable.

● Allow the client to wash the hands and clean the mouth before meals.

● Avoid mealtime interruptions.

● Make sure the client has glasses, dentures, or other assistive devices prior to meals.

● Consult the provider and dietitian about including client-preferred foods that might be outside the restrictions of the therapeutic diet, if the client is not eating enough.

● Promote physical activity (walking, range-of motion exercises) to increase the appetite.

PSYCHOSOCIAL INTERVENTIONS

To improve self-concept and alleviate social isolation: ● Therapeutic communication ● Touch ● Reality orientation ● Validation therapy ● Reminiscence therapy ● Attending to physical appearance ● Assistive devices (canes, walkers, hearing aids)

# data[].attributes.body
INJURY PREVENTION 2 DAYS - 1 YEAR

Aspiration

● Avoid small objects (grapes, coins, and candy), which can become lodged in the throat.

● Provide age-appropriate toys.

● Check clothing for safety hazards (loose buttons). Bodily harm

● Keep sharp objects out of reach.

● Keep infants away from heavy objects they can pull down.

● Do not leave infants alone with animals.

● Monitor for shaken baby syndrome. Burns ● Check the temperature of bath water.

● Turn down the thermostat on the hot water heater to 49° C (120° F) or below.

● Have smoke detectors in the home and change their batteries regularly.

● Turn handles of pots and pans toward the back of the stove.

● Apply sunscreen when outdoors during daylight hours.

● Cover electrical outlets. Drowning: Do not leave infants unattended in the bathtub. Falls

● Keep the crib mattress in the lowest position with the rails all the way up.

● Use restraints in infant seats.

● Place infants seat on the ground or floor, and do not leave them unattended or on elevated surfaces.

● Use safety gates across stairs. Poisoning ● Avoid lead paint exposure. ● Keep toxins and plants out of reach. ● Keep safety locks on cabinets that contain cleaners and other household chemicals.

● Keep a poison control number handy or program it into the phone.

● Keep medications in childproof containers and out of reach.

● Have a carbon monoxide detector in the home. Motor-vehicle injuries: Use an approved rear-facing car seat in the back seat, preferably in the middle (away from air bags and side impact). Infants should sit in a rearfacing position at least until age 2 or until they reach the maximum height and weight for their car seat (as long as the top of the head is below the top of the seat back). Convertible restraints should have a five‑point harness or a T-shield. Suffocation ● Keep balloons and plastic bags away from infants.

● Be sure the crib mattress is firm and fits tightly.

● Ensure crib slats are no farther apart than 6 cm (2.4 in). ● Remove crib mobiles or crib gyms by 4 to 5 months of age.

● Do not use pillows in the crib.

● Place infants on the back for sleep.

● Keep toys that have small parts out of reach.

● Remove drawstring clothing

INJURY PREVENTION 1-3 YEARS

Aspiration

● Avoid small objects (grapes, coins, candy) that can lodge in the throat.

● Keep toys with small parts out of reach.

● Provide age-appropriate toys.

● Check clothing for safety hazards (loose buttons).

● Keep balloons away from toddlers. Bodily harm

●Keep sharp objects out of reach.

● Keep firearms in a locked box or cabinet.

● Do not leave toddlers unattended with animals present.

● Teach stranger safety.

Burns

● Check the temperature of bath water.

● Turn down the thermostat on the water heater.

● Have smoke detectors in the home and replace their batteries regularly.

● Turn pot handles toward the back of the stove.

● Cover electrical outlets.

● Use sunscreen when outside. Drowning

● Do not leave toddlers unattended in the bathtub.

● Keep toilet lids closed.

● Closely supervise toddlers at the pool or any other body of water.

● Teach toddlers to swim.

Falls

● Keep doors and windows locked.

● Keep the crib mattress in the lowest position with the rails all the way up.

● Use safety gates across stairs. Motor-vehicle injuries

● Use an approved car seat in the back seat, away from air bags.

● Toddlers should be in a rear-facing car seat at least until age 2 or until they exceed the height and weight limit of the car seat. They can then sit in an approved forward‑facing car seat in the back seat, using a five‑point harness or T-shield until they exceed the manufacturer’s recommended height and weight for the car seat.

● Prior to installation, read all car seat safety guidelines.

● Teach toddler not to run or ride a tricycle into the street. ● Never leave a toddler alone in a car, especially in

INJURY PREVENTION 6-12

Bodily harm

● Keep firearms in a locked cabinet or box.

● Assist with identifying safe play areas.

● Teach stranger safety.

● Teach children to wear helmets and pads when roller skating, skateboarding, bicycling, riding scooters, skiing, and during any other activities that increase injury risk.

● Teach children to wear light reflective clothing at night. Burns

● Teach fire safety and elimination of potential burn hazards.

● Have working smoke and carbon monoxide detectors in the home.

● Promote sunscreen use.

Drowning

● Supervise children when swimming or near a body of water.

● Teach swimming skills and safety. Motor-vehicle injuries ● Have children use a car or booster seat until adult seat belts fit correctly.

● Children younger than 13 years of age are safest in the back seat. Substance abuse/poisoning

● Keep cleaners and chemicals in locked cabinets or out of reach.

● Teach children to say “no” to use of illicit drugs,

INJURY PREVENTION 12-20

Bodily harm ● Keep firearms in a locked cabinet or box. ● Teach proper use of sporting equipment prior to use.

● Insist on helmet use and/or pads when roller skating, skateboarding, bicycling, riding scooters, skiing, and during any other activities that increase injury risk.

● Avoid trampolines.

● Be aware of changes in mood and monitor for self-harm in at-risk adolescents.

◯ Poor school performance

◯ Lack of interest in things of previous interest

◯ Social isolation

◯ Disturbances in sleep or appetite

◯ Expression of suicidal thoughts Burns

● Teach fire safety.

● Promote sunscreen use. Drowning: Teach swimming skills and safety.

Motor-vehicle injury

● Encourage attendance at drivers’ education courses. ● Emphasize seat belt use.

● Discourage use of cell phones, including texting, while driving.

● Teach the dangers of combining substance use with driving. Substance use

● Monitor at-risk adolescents.

● Teach adolescents about the dangers of smoking

● Teach adolescents to say “no” to drugs and alcohol.

● Present a no-tolerance attitude. Sexually transmitted infections (STIs)

● Identify risk factors through the assessment and interview process.

● Provide education about prevention of STIs and resources for treatment. Pregnancy prevention

● Provide education.

● For pregnant adolescents, provide resources for supervision of pregnancy, nutrition, and psychological support.

INJURY PREVENTION 20-35

● Avoiding alcohol, tobacco products, and illicit drugs, which can lead to substance use disorders ● Avoiding driving a vehicle during or after drinking alcohol or taking substances that impair sensory and motor functions ● Wearing a seat belt when operating a vehicle ● Wearing a helmet while bike riding, skiing, and other recreational activities that increase head-injury risk ● Installing smoke and carbon monoxide detectors in the home ● Securing firearms in a safe location

INJURY PREVENTION 35-65

● Avoid substances, including alcohol, that can lead to substance use disorders. ● Avoid driving a vehicle during or after drinking alcohol or taking substances that impair sensory and motor functions. ● Wear a seat belt when operating a vehicle. ● Wear a helmet while bike riding, skiing, and other recreational activities that increase head-injury risk. ● Install smoke and carbon monoxide detectors in the home. ● Secure firearms in a safe location.

INJURY PREVENTION 65 AND OLDER

● Install bath rails, grab bars, and handrails on stairways. ● Remove throw rugs. ● Eliminate clutter from walkways and hallways. ● Remove extension and phone cords from walkways and hallways. ● Properly use mobility aids (walkers, canes). ● Practice safe medication use. ● Ensure adequate lighting. ● Wear eyeglasses and hearing aids if needed. ● Prevent substance use disorders. ● Avoid driving a vehicle during or after drinking alcohol or taking substances that impair sensory and motor functions. ● Wear a seat belt when operating a vehicle. ● Wear a helmet while bike riding, skiing, and other recreational activities that increase the risk of head injury. ● Install smoke and carbon monoxide detectors in the home. ● Secure firearms in a safe location.

# data[].attributes.body
G: Gravida, the number of pregnancies the woman has had

Para-the number of births the woman has had:

T: the number of term births  (37 weeks to 42 weeks gestation)

P: the number of preterm births ( between 20 and 37 weeks)

A: the number of spontaneous and/or elective abortions

L: the number of living children the woman has birthed

The estimated date of delivery -Nagele’s rule-

(EDD) is calculated using the first day of the last menstrual period. Nagele’s rule begins by subtracting 3 months from the date the last menstrual period began, then adding 7 days, and finally, correcting the year, if necessary.

Example: The first day of the last menstrual period is December 8, 2022.

#1 December 8 – 3 months = September 8

#2 September 8 + 7 days = September 15

#3 Adjust the year as pregnancy is 40 weeks = September 15, 2023

The EDD for this client is September 15, 2023.

# data[].attributes.body
The registered nurse must provide care and education to the pregnant client from antepartum through postpartum. The nurse must:

Assess the client’s psychosocial response to pregnancy.

Assess the client for symptoms of postpartum complications.

Calculate the expected delivery date.

Check fetal heart rate during routine prenatal exams.

Assist the client with learning and performing newborn care.

Provide prenatal care and education.

Evaluate the client’s ability to care for the newborn.

# data[].attributes.body
Antepartum care begins at conception and continues throughout pregnancy until birth.

The schedule of prenatal visits for an uncomplicated pregnancy is:

Conception to 28 weeks—every 4 weeks

29–36 weeks—every 2 weeks

37 weeks to birth—weekly

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Breasts​​​​​​: At the time of delivery, they have enlarged, the nipples have areolas that have darkened and become more pronounced in response to hormonal changes in preparation for breastfeeding. In supine position, palpate both breasts for engorgement, inspect nipples for soreness or skin breakdown. Assessment of the breasts also occurs when assisting with breastfeeding, which includes determining if the woman is producing early milk which is thin, watery and slightly yellow (colostrum) or if she has begun producing true milk. ​

Uterus: After delivery, the uterus gets smaller and smaller, receding to the level of the umbilicus and eventually back under the symphysis pubis. This is called involution. Natural oxytocin hormone and oxytocin administered intravenously cause contractions that compress blood vessels at the open venous site of placental attachment on the uterine wall. The uterine lining is also shed out through the vagina, and this material is called lochia. In supine position, with the bladder empty, use deep palpation to determine the location of the firm uterine fundus. It should be midline and somewhere between 2 fingerbreadths above, at, or below the umbilicus. Fundal massage should firm up a boggy uterus and may elicit a flow of lochia. Breastfeeding should also stimulate contractions. A firm uterus feels like a grapefruit. Upon palpating the abdomen to assess the uterus, it may be observed that the rectus muscles are not present anteriorly as in a male or a pre-pregnant woman or male. The large uterus separates these muscles laterally as pregnancy progresses. ​

Bladder: Postpartum assessment of bladder status is considered the “new vital sign” to prevent complications associated with retained urine and a full bladder. This will cause the uterus to deviate, contributing to subinvolution, increasing the risk of hemorrhage, or contributing to the development of a urinary tract infection. Monitor for pain with urination that may indicate structural damage, infection, or an unnoticed laceration. Monitor for difficulty urinating, particularly after an epidural, so that the bladder does not fill up. Whenever possible, have her empty her own bladder, but empty the bladder by catheterization if necessary. Women who have had a cesarean section (C/S) will have an indwelling catheter in place until they can ambulate, and after removal they may initially have difficulty emptying their bladder.​

Bowel: The bowel becomes an important assessment of the postpartum woman in both vaginal and C/S deliveries. Although it does not seem an important component of delivery, consider the hormonal influence (progesterone), medication administration for pain, dehydration (blood loss), decreased maternal activity, and surgical interventions that may be part of the delivery process. These can lead to constipation during the postpartum period. It is not uncommon for the woman to be discharged with a stool softener medication and without having had a bowel movement if bowel sounds are active and flatulence is present. Provide education regarding constipation prevention with ambulation, adequate fluid intake and a fiber-rich diet.

Lochia​​​​​​: The fluid that is shed from the uterus through the vagina consisting of uterine blood and tissue is called lochia. It has a distinct odor, similar to menstrual flow, but should not be foul-smelling. A steady flow is normal, and a stream of lochia with small clots with ambulation or uterine palpation is normal as the blood pools in the uterus. ​

Assess how many peripads she is filling in an hour. One pad saturated every 30 minutes is cause for concern and further assessment of the uterus and perineum. The best way to document assessment of the normal progression of vaginal discharge, otherwise known as lochia, is by using the acronym COAT (color, odor, amount, and time).​

COAT​

Days 1–3 lochia is known as rubra, appearing bright red, dark red or reddish brown in color. ​

Days 3–10 lochia is known as serosa, appearing pink or brown-tinged in color. Over time, lochia thins and becomes dark brown. ​

Days 10–14 lochia is known as alba, appearing white, cream, or light yellow in color. ​

Excessive amounts of bright red (lochia rubra) may be indications of a retained placental fragment or other issue. With excessive blood loss, sanitary pads should be weighed to determine accurate blood loss. This can be done by first weighing the sanitary pad when dry and then weighing the pad again after it has been used. This number is then documented as output in the appropriate column of the medical record.

Episiotomy (and lacerations: perineum assessment): Episiotomy and lacerations are common following labor and delivery. Recall that an episiotomy is performed by the healthcare provider to make more room for the fetus, reduce stage 3, and prevent lacerations. It is repaired under local anesthetic with sutures following placenta delivery. ​

Lacerations in the cervix, vagina and perineum can also occur during delivery and can cause postpartum hemorrhage and negatively impact future sexual intercourse and deliveries. Lacerations are characterized as first-degree (superficial) through fourth-degree (laceration goes into the rectal wall). Third- and fourth-degree lacerations may impact the woman’s ability to have a bowel movement. Hematomas can occur in this area as well and are silent causes of postpartum hemorrhage. ​

In supine position with adequate lighting, ask the mother to relax her knees then inspect the perineum. Episiotomy and laceration repairs should be well approximated and remain intact, free of hematomas and drainage. Assess for the presence of hemorrhoids, common particularly after a long 3rd stage (pushing). Assess whether the woman is performing peri care appropriately (is the area clean, peripads being changed). ​

The best way to document perineal assessment of an episiotomy or laceration is by using the acronym REEDA.​

REEDA​

R is redness

E is edema

E is ecchymosis

D is drainage

A is approximation

Initially, ice packs are recommended for swelling, vasoconstriction, and comfort. Other assistive measures, such as a peri-donut, witch hazel pads, anesthetic sprays, sitz bath, and use of the peri-bottle, should be taught to the mother for comfort and cleanliness. It is important to teach the mother to pat the area dry after voiding rather than wiping. In addition, women should be reminded to always change sanitary peripads from front to back in order to avoid cross-contamination from the rectal area.

Hematoma & Hemorrhoids​​​​​​: Additional risks for postpartum mothers include hematoma vulvar and hemorrhoids​

Hemotoma vulvar is caused by rapid bleeding into soft tissue causing severe pain. This pain is often described as “pressure” and may be associated with a precipitous delivery or vacuum or forceps delivery. It is not uncommon for a hematoma vulvar to require surgical intervention in order to ligate the bleeding vessel. ​

Hemorrhoids are varicosities of the rectum which often result from straining to have a bowel movement when constipated or from the pressure placed on the pelvic blood vessels by the enlarged pregnant uterus. These usually resolve themselves after delivery but can be treated during this time to relieve the pain and pressure. ​

Extremities​​​​​​​: The woman’s blood during the postpartum period is hypercoagulable and, in combination with inactivity following delivery, she is at risk for deep vein thrombosis (DVT). The lower extremities are assessed for the presence of localized redness, warmth, edema, and tenderness, all findings that may indicate a DVT in the affected extremity. Weak pedal pulses in the affected extremity may indicate obstruction due to the thrombus formation and, therefore, pedal pulses should also be assessed bilaterally. Encouraging early ambulation can prevent deep vein thrombosis (DVT).​

A Homan's sign is one way to gauge the presence of a DVT, although not used as often or at all due to being nonspecific and not sensitive (meaning that a positive sign may be present with no DVT or DVT may be present with a negative Homan's sign). Homan's sign is positive when discomfort is present in the calf upon dorsiflexion of the foot. It is important to remember that a DVT may not always cause pain and that all assessment findings should be reported to the healthcare provider.

Emotional Status​​​​​​: Women go through a rush of emotions and acceptance during the postpartum period, and everyone is different. Assess for signs of bonding with the newborn, engagement in parenting skills, and the relationship with her partner. Postpartum depression is not uncommon. ​

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Nuclear Family​

Consists of two adults and sometimes one or more children ​

Extended Family​

Consists of relatives (aunts, uncles, grandparents, and cousins) in addition to the nuclear family​

Example: Joan and Jacob live with their two children and Joan’s parent

Single Parent Family

Formed when one parent leaves the nuclear family because of death, divorce, desertion or when a single person decides to have or adopt a child​

Example: Tom lives alone with his daughter, Samara, after the death of his partner. ​

Blended Family​

Formed when parents bring children from previous relationships into a new joint-living situation​

Example: Sally and Jamal live together with Sally’s son, Timmy, and Jamal’s son, Michael. ​

Alternative Family​

May include multi-adult households, grand families (grandparents caring for grandchildren), communal groups with children, adults living alone, and cohabitating partners​

Example: Sandy and Jennifer live together with their adopted son, Dakota.

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BSE is best performed 3 to 5 days after the beginning of the menstrual period; however, post-menopausal women should examine their breasts at the same time every month. The client should begin by visualizing the breasts in front of a mirror, looking at size, shape, and color. The client should compress both nipples to assess for discharge. Then, the client should lie on the bed or floor and raise the arm above the head to examine the breast on the same side of the body. The breast should be examined using the pads of the middle three fingers to palpate the entire breast in a systematic fashion.

Once complete, the client should raise the opposite arm above the head and examine the other breast (Breastcancer, 2022).

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How to do a breast self examination

Step 1: In front of a mirror

Examine your breasts with arms down

Examine breast and armpit with raised arms

Place your hands on your hips to engage the muscles

Step 2: In the shower

Raise your left arm above your head

Examine your left breast with your right hand

Repeat the same procedure for the right breast

Step 3: on the bed

Place a pillow under your right shoulder and right hand behind your head

Press your left fingers pad on the breast in a circular direction

Check your nipple, switch to the other breast from the start

When to see a doctor

If you feel any lumps or skin dimpling

A breast differs in size or shape from the other

Discharge from nipples without squeezing

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Testicular self-exam (TSE) is best performed while standing after a shower. Teach the client to use both hands with fingers under the scrotum and thumbs on top to gently roll the testicle to feel for lumps. Feel up the spermatic cord on the back side of the testicle. The client should feel for hard lumps, painful areas, or any change in the size or consistency of the testicle. ​

Check your testicles at least once a month

Perform the test in the shower

Soap yourself up

Check one testicle at the time

Gently roll it between the fingers

Feel up the spermatic cords on the back of the testicles

Look for hard lumps, smooth or rounded bumps

Changes in size, shape or consistency​

Or any painful areas

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GENERAL SURVEY

The general survey is a written summary or appraisal of overall health. Gather this information from the first encounter with the client and continue to make observations throughout the assessment process. (26.2) Assess/collect data about the following.

PHYSICAL APPEARANCE

● Age

● Sex

● Race and/or ethnicity

● Level of consciousness

● Color of skin

● Facial features

● Indications of distress (pallor, labored breathing, guarding, anxiety)

● Indications of possible physical abuse or neglect

● Indications of substance use disorders

BODY STRUCTURE

● Body build, stature, height, and weight

● Nutritional status

● Symmetry of body parts

● Posture and usual position

● Gross abnormalities (skin lesions, amputations) MOBILITY

● Gait

● Movements (purposeful, tremulous)

● Range of motion

● Motor activity

BEHAVIOR

● Facial expression and mannerisms

● Mood and affect

● Speech

● Dress, hygiene, grooming, and odors (body, breath)

VITAL SIGNS

Temperature (T) reflects the balance between heat the body produces and heat lost from the body to the environment.

Pulse (P) is the measurement of heart rate and rhythm.

Pulse corresponds to the bounding of blood flowing through various points in the circulatory system. It provides information about circulatory status.

RESPIRATIONS (RR)

the body’s mechanism for exchanging oxygen and carbon dioxide between the atmosphere and the blood and cells of the body, which is accomplished through breathing and recorded as the number of breaths per minute.

Blood pressure (BP)

Reflects the force the blood exerts against the walls of the arteries during cardiac muscle contraction (systole) and relaxation (diastole).

Systolic blood pressure (SBP) occurs during ventricular systole, when the ventricles force blood into the aorta and pulmonary artery, and it represents the maximum amount of pressure exerted on the arteries when ejection occurs. Diastolic blood pressure (DBP) occurs during ventricular diastole, when the ventricles relax and exert minimal pressure against arterial walls, and represents the minimum amount of pressure exerted on the arteries

● Pain (often considered an additional vital sign

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REVIEW OF SYSTEMS, QUESTIONS TO ASK DURING A PHYSICAL ASSESSMENT AND SCREENINGS 

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REVIEW OF SYSTEMS, QUESTIONS TO ASK DURING A PHYSICAL ASSESSMENT AND SCREENINGS 

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REVIEW OF SYSTEMS An extensive review of systems ascertains information about the functioning of all body systems and health problems

QUESTIONS TO ASK

Integumentary system

● Do you have any skin diseases? ● Do you have any itching, bruising, lumps, hair loss, nail changes, or sores? ● Do you have any allergies? ● How do you care for your hair, skin, and nails? ● Do you use lotions, soaps, or sunscreen or wear protective clothing?

Head and neck

● Do you get headaches? If so, how often? (Ask about and note onset, precipitating factors, duration, character, pattern, and presence of other manifestations.) ● What do you do to relieve the pain? ● Have you ever had a head injury? ● Can you move your head and shoulders with ease? ● Are any of your lymph nodes swollen? (If so, ask about recent colds or viral infections.) ● Have you noticed any unusual facial movements? ● Does anyone in your family have thyroid disease?

Eyes

● How is your vision? ● Have you noticed any changes in your vision? ● Do you ever have any fluid draining from your eyes? ● Do you wear eyeglasses? Contact lenses? ● When was your last eye examination? ● Does anyone in your family have any eye disorders? ● Do you have diabetes?

Ears, nose, mouth, and throat

● How well do you hear? ● Have you noticed any changes in your hearing? ● Have other people commented that you aren’t hearing what they say? ● Do you wear hearing aids? ● Do you ever have ringing or buzzing in your ears, drainage, dizziness, or pain? ● Have you had ear infections? ● How do you clean your ears? ● Are you having any pain, stuffiness, or fluid draining from your nose? ● Do you have nosebleeds? ● Do you have any difficulty breathing through your nose? ● Have you noticed any change in your sense of smell or taste? ● How often do you go to the dentist? ● Do you have dentures or retainers? ● Do you have any problems with your gums, like bleeding or soreness? ● Do you have any difficulty swallowing or problems with hoarseness or a sore throat? ● Do you have allergies? ● Do you use nasal sprays? ● Do you know if you snore?

Breasts

● Do you perform breast self-examinations? How often, and when do you perform them? ● Do you have any tenderness, lumps, thickening, pain, drainage, distortion, or change in breast size, or any retraction or scaling of the nipples? ● Has anyone in your family had breast cancer? ● Are you aware of breast cancer risks?

● For clients over 40: How often do you get a mammogram?

Respiratory system

● Do you have any difficulties breathing? ● Do you breathe easier in any particular position? ● Are you ever short of breath? ● Have you recently been around anyone who has a cough, cold, or influenza? ● Do you receive an influenza vaccine every year? ● Have you had the pneumonia vaccine? ● Do you smoke or use other tobacco products? If yes, for how long and how much? Are you interested in quitting? ● Are you around second-hand smoke? ● Do you have environmental allergies? ● Has anyone in your family had lung cancer or tuberculosis? ● Have you ever been around anyone who has tuberculosis? ● Have you had a tuberculosis test?

Cardiovascular system

● Do you have any problems with your heart? ● Do you take any medications for your heart? ● Do you ever have pain in your chest? Do you also feel it in your arms, neck, or jaw? ● Do you know if you have high cholesterol or high blood pressure? ● Do you have any swelling in your feet and ankles? ● Do you cough frequently? ● Are you familiar with the risk factors for heart disease?

Gastrointestinal system

● Do you have any problems with your stomach (nausea, vomiting, heartburn, or pain)? ● Do you have any problems with your bowels (diarrhea or constipation)? ● When was your last bowel movement? ● Do you ever use laxatives or enemas? ● Have you had any black or tarry stools? ● Do you take aspirin or ibuprofen? If so, how often? ● Do you have any abdominal or lower back pain or tenderness? ● Have you had any recent weight changes? ● Do you have any swallowing difficulties? ● Do you drink alcohol? If so, how much?

● For clients over 50: Have you had a colonoscopy? If so, when was your last one? ● Do you know the indications and manifestations of colon cancer? ● What is your typical day’s intake of food and fluid? ● Do you have any dietary restrictions, food intolerances, or special practices?

Genitourinary system

● Do you have any difficulties with urination (burning, leakage or loss of urine, urgency, frequency, waking up at night to urinate, or hesitancy)? ● Have you noticed any change in the color of your urine? ● Have you noticed any changes in your menstrual cycle? ● Have you had pain during intercourse? ● Have you had any sexual problems? ● Have you had any pain in your scrotum or testes?

Musculoskeletal system

● Have you noticed any pain in your joints or muscles? ● Do you have any weakness or twitching? ● Have you had any recent falls? ● Are you able to care for yourself? ● Do you exercise or participate in sports? ● For postmenopausal clients: What was your maximum height? ● For postmenopausal clients: Do you take calcium supplements?

Neurologic system

● Have you noticed any change in your vision, speech, ability to think clearly, or loss of or change in memory? ● Do you have any dizziness or headaches? ● Do you ever have seizures? If so, what triggers them? ● Do you ever have any weakness, tremors, numbness, or tingling anywhere? If so, where

Mental health

● What are the sources of stress in your life (family, career, school, peers) and what stresses do you deal with? ● Are you having any problems with depression or changes in mood? ● Have you had any recent losses? ● Are you having any problems concentrating?

Endocrine system

● Have you noticed any change in urination patterns? ● Have you noticed any change in your energy level? ● Have you noticed any change in your ability to handle stress? ● Have you had any change in weight or appetite? ● Have you had any visual disturbances? ● Have you had any palpitations?

Allergic/immunologic system

● Do you have any allergies to medications, foods, or environmental substances? ● Have you ever received a blood transfusion? If so, did you have any adverse reactions?

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Temperature

ORAL, RECTAL,TYMPANIC,TEMPORAL AND AXILLARY

PHYSIOLOGIC RESPONSES

● The neurologic and cardiovascular systems work together to regulate body temperature. Disease or trauma of the hypothalamus or spinal cord will alter temperature control.

● The rectum, tympanic membrane, temporal artery, pulmonary artery, esophagus, and urinary bladder are core temperature measurement sites.

● The skin, mouth, and axillae are surface temperature measurement sites.

HEAT PRODUCTION AND LOSS

Heat production results from increases in basal metabolic rate, muscle activity, thyroxine output, testosterone, and sympathetic stimulation, which increases heat production. Heat loss from the body occurs through:

● Conduction: Transfer of heat from the body directly to another surface (when the body is immersed in cold water). ● Convection: Dispersion of heat by air currents (wind blowing across exposed skin).

● Evaporation: Dispersion of heat through water vapor (perspiration).

● Radiation: Transfer of heat from one object to another object without contact between them (heat lost from the body to a cold room).

● Diaphoresis: Visible perspiration on the skin.

ASSESSMENT/DATA COLLECTION EXPECTED TEMPERATURE RANGES

● An oral temperature range of 36° to 38° C (96.8° to 100.4° F) is acceptable. The average is 37° C (98.6° F).

● Rectal temperatures are usually 0.5° C (0.9° F) higher than oral and tympanic temperatures.

● Axillary temperatures are usually 0.5° C (0.9° F) lower than oral and tympanic temperatures.

● Temporal temperatures are close to rectal, but they are nearly 0.5° C (1° F) higher than oral, and 1° C (2° F) higher than axillary temper

Age

● Newborns have a large surface-to-mass ratio, so they lose heat rapidly to the environment. A newborn’s temperature should be between 36.5° and 37.5° C (97.7° and 99.5° F). By age 5, children should be able to maintain an average temperature of 37° C (98.6° F).

● Older adult clients experience a loss of subcutaneous fat that results in lower body temperatures and feeling cold. Their average body temperature is 35° to 36.1° C (95.9° to 99.5° F). Older adult clients are more likely to develop adverse effects from extremes in environmental temperatures (heat stroke, hypothermia). It also takes longer for body temperature to register on a thermometer due to changes in temperature regulation.

Hormonal changes can influence temperature. In general, temperature rises slightly with ovulation and menses. At ovulation, body temperature can increase by 0.3° to 0.6° C (0.5° to 1.0° F) above the client’s baseline. During menopause when the client is experiencing a hot flash, skin temperature can increase up to 4° C (7.2° F).

Recent food or fluid intake and smoking can interfere with accurate oral measurement of body temperature, so it is best to wait 20 to 30 min before measuring oral temperature.

Pulse temporal, carotid, brachial, femoral, popliteal, posterior tibial or dorsal pedal pulses

PHYSIOLOGIC RESPONSES

Autonomic nervous system controls the heart rate. Parasympathetic nervous system lowers the heart rate. Sympathetic nervous system raises the heart rate.

ASSESSMENT/DATA COLLECTION EXPECTED

HEART RATE RANGE

The expected reference range for an adult client’s pulse is 60 to 100/min at rest.

● Assess the wave-like sensations or impulses you feel in a peripheral arterial vessel or over the apex of the heart as a gauge of cardiovascular status.

Rate: The number of times per minute you feel or hear the pulse.

Rhythm: The regularity of impulses. A premature, late, or missed heart beat can result in an irregular interval between impulses and can indicate altered electrical activity of the heart. A regular pulse is the expected finding. Strength (amplitude or pulse volume): Reflects the volume of blood ejected against the arterial wall with each heart contraction and the condition of the arterial vascular system. The strength of the impulse should be the same from beat to beat.

Grade strength on a scale of 0 to 4.

● 0 = Absent, unable to palpate

● 1+ = Diminished, weaker than expected

● 2+ = Brisk, expected

● 3+ = Increased, strong

● 4+ = Full volume, bounding

Equality: Peripheral pulse impulses should be symmetrical in quality and quantity on both sides of the body at the same location. Assess strength and equality to evaluate the adequacy of the vascular system. An inequality or absence of pulse on one side of body can indicate a disease state (thrombus, aortic dissection). Unequal pulses from apical to radial is a pulse deficiet.

RESPIRATIONS

Chemoreceptors in the carotid arteries and the aorta primarily monitor carbon dioxide (CO2) levels of the blood. Rising CO2 levels trigger the respiratory center of the brain to increase the respiratory rate. The increased respiratory rate rids the body of excess CO2. For clients who have chronic obstructive pulmonary disease (COPD), a low oxygen level becomes the primary respiratory drive.

PROCESSES OF RESPIRATION

Ventilation: The exchange of oxygen and carbon dioxide in the lungs through inspiration and expiration. Measure ventilation with the respiratory rate, rhythm, and depth. Diffusion: The exchange of oxygen and carbon dioxide between the alveoli and the red blood cells. Measure diffusion with pulse oximetry.

Perfusion: The flow of red blood cells to and from the pulmonary capillaries. Measure perfusion with pulse oximetr

EXPECTED RESPIRATORY RATE RANGE

● The expected reference range for an adult client’s respiratory rate is 12 to 20/min

● Accurate assessment of respiration involves observing the rate, depth, and rhythm of chest-wall movement during inspiration and expiration. Do not inform the client that you are measuring respirations so the client will remain relaxed and not alter the breathing pattern.

Rate: The number of full inspirations and expirations in 1 min. Determine this by observing the number of times the client’s chest rises and falls.

Depth: The amount of chest wall expansion that occurs with each breath. Altered depths are deep or shallow.

Rhythm: The observation of breathing intervals. For adults, expect a regular rhythm (eupnea) with an occasional sigh.

PULSE OXYGENATION MOINTORING AND READING
Pulse oximetry - digit probe, earlobe probe, or disposable sensor pad

This is a noninvasive, indirect measurement of the oxygen saturation (SaO2) of the blood (the percent of hemoglobin that is bound with oxygen in the arteries is the percent of saturation of hemoglobin).

ASSESSMENT/DATA COLLECTION EXPECTED PULSE OXIMETRY RANGE

The expected reference range is 95% to 100%, although clients who have chronic lung disease might tolerate a level as low as 85%. The provider can prescribe an acceptable range for the client.

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PHYSICAL ASSESSMENT TECHNIQUES

Preparation/Preparing

● Provide adequate lighting.

● Keep the fingernails nails short.

● Ensure a quiet, private environment.

◯ Have necessary equipment ready.

◯ Invite the client to use the bathroom before beginning the physical examination. Collect urine or fecal specimens at this time.

During

● Maintain a comfortable environment.

● Provide privacy, using a gown or draping the client with a sheet and visualizing only one section of the body at a time. ● Explain the various assessment/data collection techniques you will use.

● Look and observe before touching.

● Keep hands and stethoscope warm.

● Do not feel or listen through clothing. (Clothing can obscure or create sounds.)

● Use standard precautions when in contact with body fluids, wound drainage, and open lesions. ADDITIONAL GUIDELINES FOR OLDER ADULT CLIENTS

● Allow adequate time for the interaction. Mobility issues can increase the time required for some older adults to change positions. Older adult clients have more information to relay regarding their history because of having lived longer. For some clients, cognitive issues can lengthen the time required for communication.

● Watch for indications the client is getting tired (slumped shoulders, grimacing or sighing, or leaning against object for support.

● Be aware that topics of conversation related to a loss or possible loss of independence might be difficult for the client to discuss.

● Make sure older adults who use sensory aids (eyeglasses, hearing aids) have them available for use.

PHYSICAL ASSESSMENT SEQUENCE

For most body systems, follow the sequence of

1. inspection

2. palpating

3. percussion

4. auscultation.

The exception is the abdomen;

inspect, auscultate, percuss, and palpate in that order to avoid altering bowel sounds.

Inspection

Inspection begins with the first interaction and continues throughout the examination.

● A penlight, an otoscope, an ophthalmoscope, or another lighted instrument can enhance the process.

● Inspection involves using the senses of vision, smell (olfaction), and hearing to observe and detect any expected or unexpected findings. Inspect for size, shape, color, symmetry (comparing both sides of the body), and position. ● Validate findings with the client.

Palpation

Palpation is the use of touch to determine the size, consistency, texture, temperature, location, and tenderness of the skin, underlying tissues, an organ, or a body part. Palpate tender areas last.

● Use light palpation (less than 1 cm [0.4 in]) for most body surfaces. Use deeper palpation (4 cm [1.6 in]) to evaluate abdominal organs or masses.

● Various parts of your hands detect different sensations. ◯ The dorsal surface is the most sensitive to temperature. ◯ The palmar surface and base of the fingers are sensitive to vibration.

◯ Fingertips are sensitive to pulsation, position, texture, turgor, size, and consistency.

◯ The fingers and thumb are useful for grasping an organ or mass.

● Starting with light palpation, be systematic, calm, and gentle. Proceed to deep palpation if necessary unless contraindicated. Percussion Percussion involves tapping body parts with fingers, fists, or small instruments to vibrate underlying tissues to determine the size and location; detect tenderness or abnormalities, and to check for the presence or absence of fluid or air in the tissues. The denser the tissue, the quieter the sound. An understanding of the effect of various densities on sound can help you locate organs or masses, find their edges, and estimate their size. TECHNIQUES FOR PERCUSSION

● Direct percussion

which involves striking the body to elicit sounds

● Indirect percussion which involves placing your hand flatly on the body, as the striking surface, for sound production

● Fist percussion, which helps identify tenderness over the kidneys, liver, and gallbladder

Auscultation

Auscultation is the process of listening to sounds the body produces to identify unexpected findings. Some sounds are loud enough to hear unaided (speech and coughing), but most sounds require a stethoscope or a Doppler technique (heart sounds, air moving through the respiratory tract, blood moving through blood vessels). Learn to isolate the various sounds to collect data accurately.

● Evaluate sounds for amplitude or intensity (loud or soft), pitch or frequency (high or low), duration (time the sound lasts), and quality (what it sounds like).

● Use the diaphragm of the stethoscope to listen to high-pitched sounds (heart sounds, bowel sounds, lung sounds). Place the diaphragm firmly on the body part.

● Use the bell of the stethoscope to listen to low-pitched sounds (unexpected heart sounds, bruits). Place the bell lightly on the body part.

EQUIPMENT FOR SCREENING EXAMINATION

● Gown ● Drapes ● Scale with height measurement device ● Thermometer ● Stethoscope with diaphragm and bell ● Sphygmomanometer ● Reading/eye chart ● Otoscope, ophthalmoscope, nasal speculum ● Penlight or ophthalmoscope ● Cotton balls ● Sharp and dull objects ● Tuning fork ● Glass of water ● Items to test smell and taste ● Clean gloves ● Tongue depressor ● Reflex hammer ● Pulse oximeter ● Marking pen ● Measuring tape and clear, flexible ruler with measurements in centimeters ● Watch or clock to measure time in seconds

Sample documentation of physical Assessment on a Client: 16‑year‑old male, alert and oriented x 3. No distress. Personal hygiene and grooming slightly unkempt but appropriate for age. Weight appropriate for height, erect posture, and steady gait. Full range of motion. Does not maintain eye contact. Volunteers no information but answers questions appropriately. No gross abnormalities.

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THERAPUTIC COMMUNICATION DO'S AND DONTS 

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THERAPUTIC COMMUNICATION DO'S AND DONTS 

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DO'S

DONT'S

providing false assurance​

giving unwanted advice​

using authority​

using avoidance language​

distancing​

using professional jargon​

using leading or biased questions​

talking too much​

interrupting​

using “why” questions​

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AIDET

GENERAL SURVEY INSPECTION

PAIN ASSESSEMENT

ONSET: When did you initially feel this pain?

LOCATION: where do you feel the pain?

DURATION: How long does it last?

CHARCTER: is it stinging, achy, burning?

AGGERVATING FACTORS: What makes it worse?

RELIEVING FACTORS: What makes it better?

TIME: whemn does you pain occur, am, pm, thorough the day?

SEVERITY- On a scale of 1- 10 how sever is the pain

-SKIN-

INSPECT:

PALPATE:

-NAILS-

INSPECT:

PALPLATE:

+-HEAD AND NECK -

ASSESS: skull, face, hair, neck, shoulders, lymph nodes, thyroid gland, trachea position, carotid arteries, and jugular veins.

- Skull -

EXPECTED FINDINGS

● Size (normocephalic)

● No depressions, deformities, masses, tenderness

● Overall contour and symmetry

-Face -

EXPECTED FINDINGS

● Symmetry of facial features (If there is asymmetry, note if all features on one side of face are affected, or only some of the features)

● Symmetry of expressions

● No involuntary movements

● Proportionate features (no thickening as with acromegaly)

-EYES-

External and internal anatomy of the eye, visual pathways, fields, visual acuity, extraocular movements, and reflexes.

Visual acuity

■ Distant vision: Snellen and Rosenbaum charts, eye cover, Ishihara test for color blindness

■ Near vision: hand-held card

Eyes parallel to each other without bulging (exophthalmos) or crossing (strabismus)

● Eyebrows symmetric from the inner to the outer canthus: can raise and lower symmetrically

● Eyelids closing completely and opening to show the lower border and most of the upper portion of the iris without ptosis (the upper eyelid covering the pupil)

● Eyelashes curving outward with no inflammation around any of the hair follicles ● No edema or redness in the area of the lacrimal glands.

● Conjunctiva-Pink moist and intact

● The sclerae will be white in those who have fair skin and light yellow with possible brown macules in clients who have a dark complexion. ● Corneas clear, shiny, and smooth. ● Lenses clear, cloudy with cataracts

● Irises round and illuminating fully when you shine a light across from the side. A partially illuminated iris indicates glaucoma. Note the color of the irises

● P: Pupils clear

● E: Equal and between 3 to 7 mm in diameter

● R: Round

● RL: Reactive to light both directly and consensually when you direct light into one pupil and then the other

● A: Accommodation of the pupils when they dilate to look at an object far away and then converge and constrict to focus on a near object

PALPATION

Palpate the lacrimal apparatus to assess for tenderness and to express any discharge from the lacrimal duct. Expected findings include no tenderness, no discharge, and clear fluid (tears)

-Neck-

EXPECTED FINDINGS

● Muscles of the neck symmetric.

● Shoulders equal in height and with average muscle mass. ◯ RANGE OF MOTION (ROM): Moving the head smoothly and without distress in the following directions:

■ Chin to chest (flexion).

■ Ear to shoulder bilaterally (lateral flexion).

■ Chin up (hyperextension

Lymph nodes

● Chains of lymph nodes extend from the lower half of the head down into the neck. Palpate each node for enlargement, in the following sequence.

◯ Occipital nodes: Base of the skull

◯ Postauricular nodes: Over the mastoid

◯ Preauricular nodes: In front of the ear

◯ Tonsillar (retropharyngeal) nodes: Angle of the mandible ◯ Submandibular nodes: Along the base of the mandible ◯ Submental nodes: Midline under the chin

◯ Anterior cervical nodes: Along the sternocleidomastoid muscle

◯ Posterior cervical nodes: Posterior to the sternocleidomastoid muscle

◯ Supraclavicular nodes: Above the clavicles

● Lymph nodes are usually difficult to palpate and not tender or visible.

● Use the pads of the index and middle fingers and move the skin over the underlying tissue in a circular motion to try to detect enlarged nodes. Compare from side to side.

● Evaluate any enlarged nodes for location, tenderness, size, shape, consistency, mobility, and warmth

Thyroid gland

The thyroid gland has two lobes and is fixed to the trachea. It lies in front of the trachea and extends to both sides. Examine the gland by

● Inspecting the lower half of the neck to see any enlargement of the gland. An average-size thyroid gland is not visible. Having the client hyperextend the neck helps makes the skin taut and allows better visualization. Have the client to take a sip of water and feeling the thyroid gland as it moves up with the trachea.

● Palpating the thyroid gland on both sides of the trachea for size, masses, and smoothness.

AUSCULTATION: If the thyroid is enlarged, auscultate the gland using a stethoscope. A bruit indicates an increase in blood flow to the area, possibly due to hyperthyroidism. Trachea Inspect and palpate the trachea for any deviation from midline above the suprasternal notch. Masses in the neck or mediastinum

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EARS NOSE MOUTH AND THROAT

-EARS-

EXTERNAL EAR EXPECTED FINDINGS

● Alignment: The top of the auricles meeting an imaginary horizontal line that extends from the outer canthus of the eye. The auricles should be of equal size and level with one another.

● Ear color matching face color

● No lesions, deformities, or tenderness

● No foreign bodies or discharge

● Presence of a small amount of cerumen

INTERNAL EAR

Straighten the ear canal by pulling the auricle up and back for adults and older children, and down and back for younger children. Using the otoscope, insert the speculum slightly down and forward 1 to 1.5 cm (0.4 to 0.6 in) following, but not touching, the ear canal to visualize:

● Tympanic membranes that are pearly gray and intact, taut, and free from tears.

● A light reflex that is visible and in a well‑defined cone shape.

● Umbo and manubrium landmarks are readily visible.

● External ear canal color can vary but is consistent with the client’s skin color.

● Cerumen might be present in the ear canal. Moist cerumen is light brown to gray. Asian or Native American heritage is associated with dry cerumen.

AUDITORY SCREENING TESTS

● Whisper test (CN VIII)

◯ TECHNIQUE

■ Occlude one ear and test the other to see if the client can hear whispered sounds without seeing your mouth move.

■ Repeat with the other ear.

◯ EXPECTED FINDING: The client can hear you whisper softly from 30 to 60 cm (1 to 2 ft) away.

● Rinne test (28.2)

◯ TECHNIQUE

■ Place a vibrating tuning fork firmly against the mastoid bone. Have the client state when he can no longer hear the sound. Note the length of time that the client heard the sound (bone conduction).

■ Then move the tuning fork in front of the ear canal. When the client can no longer hear the tuning fork sound, note the length of time the sound was heard (air conduction).

◯ EXPECTED FINDING: Air conduction (AC) sound longer than bone conduction (BC) sound; 2:1 ratio.

● Weber test (28.3)

◯ TECHNIQUE: Place a vibrating tuning fork on top of the client’s head. Ask whether the client can hear the sound best in the right ear, the left ear, or both ears equally.

◯ EXPECTED FINDING: The client hears sound equally in both ears (negative Weber test).

-NOSE-

EXPECTED FINDINGS :

The nose is midline, symmetrical, and the same color as the face. Observe for tenderness, swelling, masses, or deviations.

● Each naris (nostril) is patent without excessive flaring. The structure of the nose is firm and stable.

● To examine internal structures, insert a nasal speculum just barely into each naris as the client tips their head back. ◯ Septum is midline and intact.

◯ Mucous membranes are redder than the oral mucosa and moist with no discharge or lesions.

● Assess smell (CN I) by asking the client to close their eyes, occlude one naris at a time, and identify a familiar smell with the eyes closed.

-MOUTH-

EXPECTED FINDINGS

● Lips: Darker pigmented skin than the face and are moist, symmetric, smooth, soft with no lesions, and nontender. Lip color can range from pink in clients who have pale skin to plum for clients who have dark skin.

● Gums: Tight against the teeth with no bleeding on gloves from palpation. Uniform in pink color; dark skinned clients can have bluish or brown patches of pigmentation.

● Mucous membranes: Pink and moist with no lesions and some freckled brown pigmentation for dark skinned clients. Hyperpigmentation can occur after age 50 years.

● Tongue: Use a gauze pad to hold the tip and move the tongue from side to side. The dorsal surface is pink, with the presence of papillae, and symmetric. The underside of the tongue is smooth with a symmetric vascular pattern. Assess taste (CN VII, CN IX) by having the client close their eyes and identify foods you place on the tongue. Ask the client to move the tongue up, down, and side to side. Test strength (CN XII) by applying resistance against each cheek while the client sticks the tongue into each cheek. The tongue is midline, moist, free of lesions, and moves freely.

● Teeth: Shiny, white, and smooth. Check for malocclusions by asking the client to clench their teeth. Note any missing or loose teeth, as well as any discoloration. Yellow or darkened teeth are common in older adults because of long-term wear.

MUCOUS MEMBRANES

● Hard palate: Whitish, intact, symmetric, firm, and concave. ● Soft palate: Light pink, intact, smooth, symmetric, and moves with vocalization (CN IX, CN X).

● Uvula: Pink, midline, intact, and moves with vocalization. ● Tonsils: The same color as the surrounding mucosa and vary in size and

vsibility.

◯ +1: Barely visible

◯ +2: Halfway to the uvula

◯ +3: Touching the uvula

◯ +4: Touching each other or midline

● Gag reflex: Elicit by using a tongue blade to stimulate the back of the throat (CN IX, CN X). Explain the procedure to the client prior to performing this assessment.

● Speech: Clear and articulate

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First-level priority problems are those that are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing. Often considered to be threats to the ABCs: airway, breathing, circulation.​​

Examples: cardiac arrest; loss of consciousness; difficulty breathing; choking​

Second-level priority problems are those that are next in urgency—those requiring your prompt intervention to prevent further deterioration.​​

Examples: mental status change; acute pain; risk to safety; active bleeding​

Third-level priority problems are those that are important to the client’s health but can be attended to after more urgent health problems are addressed. Interventions to treat these problems are long term, and the response to treatment is expected to take more time. These problems may require a collaborative effort between the client and healthcare professionals.​​

Examples: homelessness; affording medications; knowledge deficits

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Functional assessment is a measure of a person’s self-care ability. A functional assessment will focus on the client’s ability to dress, bathe, toilet, and ability to manage a household independently. ​

Functional assessment consists of:​

self-esteem, self-concept​

activity/exercise​

sleep/rest​

nutrition/elimination​

interpersonal relationships/resources​

spiritual resources​

coping and stress management​

personal habits​

alcohol use​

illicit or street drug use​

environment/hazards​

intimate partner violence​

occupational health​

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Toddler​

Use play to teach a procedure or activity (e.g., handling examination equipment and applying a bandage to a doll). Offer picture books that describe stories of children in a hospital or clinic. Use simple words such as “cut” instead of “laceration” to promote understanding.

Preschooler​

Use role-play, imitation, and play to make learning fun. Encourage questions and offer explanations. Use simple explanations and demonstrations. Encourage children to learn through pictures and short stories about how to perform hygiene.​

School-Aged Child​

Teach psychomotor skills needed to maintain health (complicated skills such as learning to use a syringe takes considerable practice). Offer opportunities to discuss health problems and answer questions.

Adolescent​

Help adolescents learn about feelings and the need for self-expression. Use teaching as a collaborative activity. Allow adolescents to make decisions about health and health promotion (e.g., safety, sex education, and substance abuse). Teach problem-solving skills to help adolescents make the right choices.

Young or Middle Adult​

Encourage participation in the teaching plan by setting mutual goals. Encourage independent learning. Offer information so adult understands the effects of health problems.

Older Adult​

Teach when the client is alert and rested. Involve the adult in discussion or activity. Focus on wellness and the person’s strength. Use approaches that enhance the client’s reception of stimuli when there is a sensory impairment. Keep teaching sessions shorter than the ones for younger clients.

TEACHING GROUPS

Teaching in small groups (six people or fewer) often increases learning and learner satisfaction.

● The nurse is able to teach more than one client or family at a time.

● The nurse can use several types of learning strategies at once.

● Learners can interact and learn from each other.

● Group settings do not work for all clients, especially if physical or emotional barriers are present

TEACH BACK

The teach-back method is an evidence-based health literacy intervention that promotes client engagement, safety, adherence, and quality. The goal of the teach-back method is to ensure that you have explained medical information clearly, so that clients and their families understand what you communicated to them. ​

Teach-back in action:​

1. “Tell me in your own words how you will take this medication at home.”​

2. “Tell me some of the side effects that you should watch for.”​

3. “When will you call the healthcare provider regarding your blood pressure?”​

4. “Please show me how to draw up insulin into a syringe.”​

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Additional educational opportunities for nurses surround health promotion and complementary therapies. Complementary therapies can help with pain, stress management, and sleep. The nurse can teach the client about different therapies. Some examples may include:​

Yoga and exercise: Yoga helps calm the mind, but also improves strength, balance, and flexibility. Yoga can help with back pain, arthritis, heart health, sleep, energy, and stress reduction. ​

Massage: A massage can help promote relaxation, ease sore muscles, and provide increased blood supply to tissues. It can reduce stress and assist with back pain, anxiety, and migraines.​

Aromatherapy: Aromatherapy is the use of scents which can induce feelings of calmness or help the client reminisce about happy memories to improve mood or distract from pain.​

Acupressure: Acupressure is the application of pressure on certain body points (similar to acupuncture). Those points are thought to affect different body systems and bring symptom improvement (such as reduction in nausea or pain).​

Mindfulness: Mindfulness is about self-care. Caring for self (e.g., exercise, healthy eating, and sleep) is a way to maintain health. Exercise can increase endorphins, which improves mood.​

Use of Supplements: Various supplements can aid with various health conditions. However, it is important to understand potential interactions between supplements and prescribed medications. Some examples of supplements include melatonin (for sleep), St. John’s wort (for depression), probiotics (for diarrhea), ginger (for gastrointestinal upset), echinacea (immune system stimulation), aloe (promotes wound healing), and valerian root (sleep aid).

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Capillary hemangiomas are a normal integumentary variation in newborns.

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Childhood BMI

Body mass index (BMI) is interpreted differently for children even though it is calculated with the same formula. Due to changes in weight and height with age, BMI levels among children are expressed relative to other children of the same sex and age. After BMI is calculated, it is expressed as a percentile obtained from either a graph or a percentile calculator. The BMI-for-age percentile growth charts are the most used indicator to measure the size and growth patterns of children and teens in the United States

Adulthood BMI

A healthy diet and regular physical exercise are necessary throughout the adult years to maintain a healthy weight and prevent future health-related issues. A healthy body mass index (BMI) is between 18.5 and 24.9. BMI is calculated in one of two ways:​

BMI = weight (kg) / [height (m) x height (m)​]

BMI = 703 x weight (lbs) / [height (in) x height (in)]

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Infancy

By the end of the first year of life, infants view themselves as separate from the caregiver. ​

Toddlerhood

The toddler refers to body parts by name and recognizes gender differences. Adults should avoid negative descriptions of physical appearance as the toddler will begin to use words heard in conversation. ​

Preschooler

The preschooler recognizes that individuals have desirable and undesirable appearance characteristics. They are vulnerable to prejudice and bias. Modesty becomes a concern. Sexual exploration is more pronounced, including genitalia manipulation and questions about sexual reproduction. ​

School-aged

In general, children like their physical appearance less are they age. Body image is influenced by others. A positive self-concept leads to feelings of self-respect, self-confidence, and overall happiness. ​

Adolescence

Adolescents are acutely aware of appearance and often compare themselves to others. Any blemish or defect is often magnified disproportionately. Feelings of confusion regarding self-concept are common in early and middle adolescence. ​

Young Adulthood

Body image is affected by diet and exercise. Pregnancy can lead to body image changes as well. Self-concept is influenced by:​

avoiding excessive substance use​

forming a family​

interacting with close friends​

responding to ethical situations

Middle Adulthood

Middle adults may struggle to adapt to biological signs of aging, including changes in appearance. Sex drive may decline due to the loss of estrogen and testosterone or due to physical appearance changes. Females must cope mentally and physically with menopause. Males must adapt to decreasing physical strength and climacteric (age-related decrease in testosterone). ​

Self-concept is influenced by menopause, sexuality, depression, job performance, and marital changes. Clients with high self-esteem, a favorable body image, and a positive attitude toward physiological changes are those who engage in physical activity, eat healthy meals, obtain adequate sleep, and follow good hygiene practices. ​

Older Adulthood

Older adults must adjust to decreasing physical strength and endurance and often feel frustrated by physical limitations. Self-concept is influenced by finding ways to maintain the quality of life and increasing dependence on others. Overall health, number of stressors, and lifelong mental well-being impact self-concept.

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ANTEPARTUM:THINGS TO REMENER MOM AND BABY

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ANTEPARTUM:THINGS TO REMENER MOM AND BABY

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The normal baseline fetal heart rate is 110–160 beats per minute.

Bradycardia of less than 110 beats per minute can be caused by fetal heart block, cardiac conduction abnormalities, umbilical cord prolapse, maternal hypoglycemia, hypothermia, viral infection (cytomegalovirus), or beta blocker use.

Tachycardia of greater than 160 beats per minute can be caused by fetal anemia, fetal sepsis, maternal dehydration, maternal fever, or cocaine use.​

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THINGS TO FOCUS ON:

lthough teaching topics will vary based on caregiver needs and previous knowledge, some major newborn teaching topics include:

use of a bulb syringe​

Position the infant on the back with the head in a neutral position. Compress the bulb syringe. Suction the mouth first, since the newborn may gasp when the nose is suctioned, causing aspiration of mucus or fluid in the mouth. Then suction the nose gently and only if necessary. Clean the bulb syringe with warm soapy water and rinse thoroughly.

umbilical cord care​

circumcision care​

bathing and skin care​

temperature management​

use of an infant car seat ​

The car seat should be positioned at a 45-degree angle, which prevents the infant from slumping and airway obstruction occurring.

The car seat should use a 5-point harness with the retainer clip at the level of or slightly below the infant’s shoulders.

The safest place for an infant is rear-facing in the back seat of the vehicle.

Only two fingers should fit between the harness and the infant. No thick blankets or clothing should be in-between the infant and the restraint.

breastfeeding​

the newborn should be encouraged to latch to the breast at least 8–12 times in 24 hours. In the first few days, this encourages milk production.

The postpartum client should hold the breast in a “C” hold with fingers back from the areola. Aim the breast toward the newborn’s upper lip and encourage the newborn to take as much of the lower part of the areola as possible.

Proper latch on the breast can prevent nipple soreness and breakdown as well as ensure the newborn gets an adequate supply of milk from the breast.

newborn gets enough milk if they have 6–8 wet diapers daily, 3–4 soft bowel movements every 24 hours, and they seem content after feeding. The breasts should feel soft after feeding. Gently burp the newborn when finished feeding from each breast.

formula feeding​

holding and positioning​

sleep pattern and position

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Asepsis is the absence of illness‑producing micro‑organisms. Hand hygiene is the primary behavior

MEDICAL

Always use hand hygiene.

Wash hands with an antimicrobial or plain soap and water, using alcohol-based products (gels, foams, and rinses; or performing a surgical scrub).

● The three essential components of handwashing are the following.

◯ Soap

◯ Running water

◯ Friction

Perform hand hygiene using recommended antiseptic solutions when caring for clients who are: immunocompromised or have infections with multidrug-resistant or extremely virulent micro-organisms.

● Perform hand hygiene after contact with anything in clients’ rooms and after touching any contaminated items, whether or not gloves were worn, and before putting gloves on and after taking them off.

Performing hand hygiene might be necessary between tasks and procedures on the same client to prevent cross‑contamination of different body sites

When hands are visibly soiled, after contact with body fluids, before eating, and after using the restroom, wash them with a nonantimicrobial or antimicrobial soap and water.

Surgical asepsis refers to the use of precise practices to eliminate all micro‑organisms from an object or area and prevent contamination (“sterile technique”). It applies to parenteral medication administration, insertion of urinary catheters, surgical procedures, sterile dressing changes, and many other common nursing procedures.

Setting up a sterile field​

1. Perform hand hygiene before setting up a sterile field.​

2. Don a surgical mask to avoid breathing onto the open sterile field.​

3. Open the outermost flap of a sterile kit first, away from the body. Then, open the flap closest to the top, pulling to the side. Open the second side flap, pulling to the other side. Finally, open the last and innermost flap toward the body.​

4. The arms must be kept to the side and not over the sterile surface.

Prolonged exposure to airborne microorganisms can make sterile items non-sterile.​

Avoid coughing, sneezing, and talking directly over a sterile field​

Nurses and clients should avoid sudden movements

Avoid touching sterile supplies, drapes, gowns, and gloves

Only sterile items can be in a sterile field.​

Touch sterile materials only with sterile gloves​

Any object held below the waist or above the chest is considered contaminated​

Sterile materials can touch other sterile surfaces or materials, but any contact with non-sterile materials contaminates the sterile area no matter how short the contact​

Outer 1-inch edges of sterile packaging are not sterile; discard any object that comes into contact with the 1-inch border​

Microbes can move in the environment from a non-sterile item to a sterile item.​

Do not reach across or above a sterile field​

Do not turn your back on a sterile field​

Hold any items that need to be added to the sterile field at least 6 inches above the sterile field​

Keep all surfaces dry​

Discard any sterile packages that are torn, punctured, or wet

Perform hand hygiene using recommended antiseptic

When hands are visibly soiled, after contact with body fluids, before eating, and after using the restroom, wash them with a nonantimicrobial or antimicrobial soap and water

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PERSONAL PROTECTIVE EQUIPTMENT AND WHEN TO WEAR 

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PERSONAL PROTECTIVE EQUIPTMENT AND WHEN TO WEAR 

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STANDARD

RUBBER GLOVES AND HANDWASHING

ISOLATIONS:

CONTACT -

GOEN AND GLOVES

MUST USE SOAP AND WATER WHEN LEAVING CONTACT PT'S

Diseases:​

M – Multi-drug (MRSA, VRE)​
R – Respiratory infection (RSV)​
S – Skin infection (impetigo, scabies)​
W – Wound infection​
E – Enteric infection* (Clostridium difficile)​
E – Eye infection (Conjunctivitis)​

AIRBORNE-

N95 REPIRATOR

NEGATIVE PRESSURE ROOM

MEASEALS, T.B, VARICELLA , HERPES ZOSTER(SHINGLES) AND SARS(COVID 19)

DROPLET- SURIGAL MASK ONLY BUT USE GOGGLES IF NEEDED

Diseases:​

S – Sepsis, scarlet fever, streptococcal pharyngitis, SARS​
P – Parovirus B19, pneumonia, pertussis​
I – Influenza​
D – Diptheria​
E – Epiglottitis​
R – Rubella​
M – Mumps, meningitis, mycoplasma, meningeal pneumonia​
An – Adenovirus​

Neutropenic Isolation

Authorized personnel only!

All visitors must check with the nurse before entering!

Everyone must:

Enter with no infection

Keep door closed

Wash hands before entering or leaving rooms

Follow standard procedures

No flowers, fresh fruits, or vegetables

Wear a gown and gloves before entering the room

Care providers and staff must:

Wear a mask, a gown, and gloves before entering the rooms

Use patient dedicated or disposable equipment

DONNING - ON

1. HAND HYGIENE

2. MASK

3. GOGGLES

4. GOWN

5. GLOVES

EDAPT-

1. Perform hand hygiene​

2. Put on gown​

3. Put on mask to cover nose and mouth​

4. Place goggles over eyes​

5. Don gloves​

GOWN MASK GOGGLES GLOVES

DOFFING

1. GLOVES

2. GOOGLES,

3. GOWN

4. MASK

5. HAND HYGIENE

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Standard precautions (tier one)

This tier of standard precautions applies to all body fluids (except sweat), non-intact skin, and mucous membranes. A nurse should implement standard precautions for all clients.

● Hand hygiene using an alcohol-based waterless product is recommended after contact with the client when the hands are not visibly soiled or contaminated with blood or body fluids and after the removal of gloves.

● Alcohol-based waterless antiseptic is preferred unless the hands are visibly dirty, because the alcohol-based product is more effective in removing micro‑organisms.

● Wash hands with soap and water if contamination with spores is suspected.

● Hand hygiene using nonantimicrobial soap or an antimicrobial soap and water is recommended when visibly soiled or contaminated with blood or body fluids. ● Use soap and water (not alcohol) for C. difficile.

● Remove gloves and complete hand hygiene between each client.

● Masks, eye protection, and face shields are required when care might cause splashing or spraying of body fluids.

● Clean gloves are worn when touching anything that has the potential to contaminate the hands of the nurse. This includes body secretions, excretions, blood and body fluids, non-intact skin, mucous membranes, and contaminated items.

● Hand hygiene is required after removal of the gown. Use a sturdy, moisture-resistant bag for soiled items and tie the bag securely in a knot at the top.

● Properly clean all equipment for client care; dispose of one-time use items according to facility policy.

● Bag and handle contaminated laundry to prevent leaking or contamination of clothing or skin.

● Enable safety devices on all equipment and supplies after use; dispose of all sharps in a puncture-resistant container.

● A client does not need a private room unless they are unable to maintain appropriate hygienic practices. Transmission precautions (tier two) Airborne precautions

Use airborne precautions to protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary or laryngeal tuberculosis).

Airborne precautions require:

● A private room.

● Masks and respiratory protection devices for caregivers and visitors.

Use an N95 or high‑efficiency particulate air (HEPA) respirator if the client is known or suspected to have tuberculosis

. ● Negative pressure airflow exchange in the room of at least six to 12 exchanges per hour, depending on the age of the structure.

● If splashing or spraying is a possibility, wear full face (eyes, nose, mouth) protection.

● Clients who have an airborne infection should wear a SURGICAL while outside of the room/home.

Droplet precautions

Droplet precautions protect against droplets larger than 5 mcg and travel 3 to 6 ft from the client (streptococcal pharyngitis or pneumonia, Haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague).

Droplet precautions require:

● A private room or a room with other clients who have the same infectious disease. Ensure that clients have their own equipment.

● Masks for providers and visitors.

● Clients who have a droplet infection should wear a mask while outside of the room/home.

Contact precautions

Contact precautions protect visitors and caregivers when they are within 3 ft of the client against direct client and environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, impetigo, scabies, multidrug-resistant organisms).

Contact precautions require:

● A private room or a room with other clients who have the same infection.

● Gloves and gowns worn by the caregivers and visitors.

● Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag.

Protective environment

Protective environment is an intervention (not type of precautions) to protect clients who are immunocompromised. This includes clients who have had an allogeneic hematopoietic stem cell transplant.

A protective environment requires:

● Private room.

● Positive airflow 12 or more air exchanges/hr.

● HEPA filtration for incoming air.

● Mask for the client when out of room.

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Modes of Disease Transmission​

Direct​

Direct Contact: Skin-to-skin contact through blood or body fluids (Example: C. difficile)​

Droplet Spread: Sneezing, coughing, or talking (Example: Influenza)​

Indirect​

Airborne: Inhalation of suspended infectious particles (Example: Tuberculosis)​

Vehicle borne: Contaminated materials such as food, water, clothes (Example: E. coli)​

Vector borne​

Mechanical: Agent undergoes maturation in an intermediate host before it can be transmitted to humans (Example: Malaria)​

Biological: Bite from mosquitoes, fleas, and ticks (Example: Lyme disease)

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sexually transmitted diseases (e.g., chlamydia, gonorrhea, syphilis, acquired immunodeficiency syndrome [AIDS] but not human immunodeficiency virus [HIV]) ​

hepatitis A, B, C ​

tuberculosis ​

measles ​

mumps ​

rubella ​

varicella ​

pertussis

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Chain of infection

Causative agent (bacteria, virus, fungus, prion, parasite)

TYPES OF PATHOGENS

Pathogens are the micro-organisms or microbes that cause infections.

● Bacteria (Staphylococcus aureus, Escherichia coli, Mycobacterium tuberculosis)

● Viruses: Organisms that use the host’s genetic machinery to reproduce (HIV, hepatitis, herpes zoster, herpes simplex virus [HSV])

● Fungi: Molds and yeasts (Candida albicans, Aspergillus)

● Prions: Protein particles (new variant Creutzfeldt-Jakob disease)

● Parasites: Protozoa (malaria, toxoplasmosis) and helminths (worms [flatworms, roundworms], flukes [Schistosoma])

Virulence is the ability of a pathogen to invade and injure a host. Herpes zoster is a common viral infection that erupts years after exposure to chickenpox and invades a specific nerve tract

Reservoir (human, animal, food, organic matter on inanimate surfaces, water, soil, insects)

Portal of exit from (means for leaving) the host

● Respiratory tract (droplet, airborne): Mycobacterium tuberculosis and Streptococcus pneumoniae

● Gastrointestinal tract: Shigella, Salmonella enteritidis, Salmonella typhi, hepatitis A

● Genitourinary tract: Escherichia coli, hepatitis A, HSV, HIV

● Skin/mucous membranes: HSV and varicella

● Blood/body fluids: HIV and hepatitis B and C ●

Transplacental Mode of transmission

● Contact

◯ Direct physical contact: Person to person

◯ Indirect contact with an inanimate object: Object to person

◯ Fecal-oral transmission: Handling food after using a restroom and failing to wash hands

● Droplet: Sneezing, coughing, and talking

● Airborne: Sneezing and coughing

● Vector borne: Animals or insects as intermediaries (ticks transmit Lyme disease; mosquitoes transmit West Nile and malaria)

Portal of entry to the host: Might be the same as the portal of exit

Susceptible host: Compromised defense mechanisms (immunocompromised, breaks in skin), leaving the host more susceptible to infections

Stages of an infection

Incubation: interval between the pathogen entering the body and the presentation of the first finding

Prodromal stage: interval from onset of general findings to more distinct findings; during this time, the pathogen multiplies

Illness stage: interval when findings specific to the infection occur

Convalescence: interval when acute findings disappear, total recovery taking days to month

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Key strategies to prevent injury include:​​

Stay close to the person or object when lifting.​​

Face the person or object when lifting​​.

Keep the spine, neck, and back straight and aligned throughout the lift​​.

Tuck the chin to the chest during lifting​​.

Maintain a wide stance by keeping feet apart​​.

Pivot in the direction of the move.​​

Use leg muscles to lift; do not use back muscles​​.

Use slow, smooth movements​​.

Use assistive devices, such as mechanical lifts, gait belts, and slide boards, when available​.

● Have one or more staff members assist with positioning clients. Moving them up in bed is a significant cause of back pain and injury.

● Plan ahead for activities that require lifting, transfer, and ambulation of a client, and ask others to be available to assist.

● Prepare the environment by removing obstacles prior to the procedure.

● Explain the process to the client and assistants to clarify their roles.

● Be aware that the safest way to lift a client is with assistive equipment.

● Rest between heavy activities to decrease muscle fatigue.

● Maintain good posture and exercise regularly to increase the strength of your arms, legs, back, and abdominal muscles, so these activities will require less energy.

● Keep your head and neck in a straight line with your pelvis to avoid neck flexion and hunched shoulders, which can cause impingement of nerves in your neck.

● Use smooth movements when lifting and moving clients to prevent injury from sudden or jerky muscle movements. ● When standing for long periods of time, flex your hips and knees by using a footrest. When sitting for long periods of time, keep your knees slightly higher than your hips.

● Avoid repetitive movements of the hands, wrists, and shoulders. Take a break every 15 to 20 min to flex and stretch joints and muscles whenever possible.

● Avoid twisting your spine or bending at the waist (flexion) to minimize the risk for injury

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Victim Triage

ASSESS FIRST (Emergent)​

Life-threatening injury requiring immediate intervention​

Severe alteration in breathing, circulation, and/or neurological status​

Immediate care is needed​

Examples: Severe internal or external bleeding, burns over high percentage of the body, major respiratory trauma, shock​

ASSESS SECOND (Urgent)​

Urgent but not life-threatening injury​

Breathing, circulation, and neurological status are within normal limits but could change​

Care can be somewhat delayed until the red group's needs are addressed​

Examples:  Open bone fractures with palpable distal pulses, integumentary damage​​

WALKING WOUNDED (Nonurgent)​

Minor injuries when treatment can be delayed several hours​

Breathing, circulation, and neurological status are normal and not expected to change​

Care can be delayed until the red and yellow group’s needs are addressed​

Examples: Minor burns, closed fractures​​

MORTALLY WOUNDED (Expectant)​

Injuries are extensive and chance of survival is unlikely, or the client is already deceased​

Absence of breathing and/or circulation​

Severely impaired neurological status​

Comfort care only is provided until all red and yellow tagged client’s needs are addressed​

Examples: Severe neurological trauma, absence of breathing or circulation​

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Radiation safety is based on three principles: time, distance, and shielding. The risk of exposure is decreased when personnel minimize the amount of time they are near radiation. Shielding from radiation using a lead apron and gloves protects as well. ​

External ionizing radiation is used for diagnostic testing and therapeutic care. Internal radiation, brachytherapy, involves placing radioactive material into or near a client’s tumor. Special internal radiation precautions include: ​

Minimize time in the client’s room and cluster care.

Prohibit client activities outside of the room.

Initiate bedrest until client treatment is discontinued.

Limit visitation to less than 1 hour while remaining 6 feet away from the client.

Prevent visitation of young children and women who are pregnant or caregivers.

Nursing assignments should be rotated to limit exposure.

Nurses should wear a dosimeter film badge to measure radiation exposure.

Any hospital employee (i.e., nurse, respiratory therapist, housekeeping) who is pregnant should not be assigned to this client. ​

The client should be placed in a private room with a private bath and farthest from the nurses’ station to limit the risk of exposure to others.

A radiation precaution sign should be placed on the door.

Biohazardous waste is biological waste that must be handled carefully. This type of waste includes any item contaminated with blood or other body fluids, such as feces. Ways to prevent biohazardous exposures include: ​

single-use disposable client supplies ​

needleless systems ​

handwashing ​

red biohazardous waste containers ​

personal protective equipment ​

sharps disposal containers

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The provider must prescribe restraint use in writing after a face-to-face assessment of the client (Crisis Prevention Institute [CPI], 2009).

****In an emergency when there is an immediate risk to the client or staff, the nurse may implement restraints without a prescription but must obtain a prescription within 1 hour. ​

A prescription for restraints allows 4 hours of use for an adult

2 hours of use for clients 9 to 17 years,

1 hour of use for clients younger than 9 years.

Providers can renew prescriptions for a maximum of 24 consecutive hours.

Providers CANNOT prescribe restraints as needed (PRN) (CPI, 2009).​

NURSING RESPONSIBILITIES FOR CLIENTS IN RESTRAINTS

● Explain the need for the restraints to the client and family, emphasizing that the restraints keep the client safe and are temporary.

● Ask the client or guardian to sign a consent form.

● Review the manufacturer’s instructions for correct application.

◯ Assess skin integrity, and provide skin care according to the facility’s protocol, usually every 2 hr.

◯ Offer food and fluid.

◯ Provide a means for hygiene and elimination.

◯ Monitor vital signs.

◯ Offer range‑of‑motion exercises of extremities.

● Pad bony prominences to prevent skin breakdown.

● Secure restraints to a movable part of the bed frame. If restraints with a buckle strap are not available, use a quick-release knot to tie the strap.

● Make sure the restraints are loose enough for range of motion and that there is enough room to fit two fingers between the restraints and the client.

● Remove or replace restraints frequently to ensure good circulation to the area and allow for full range of motion to the limbs.

● Conduct an ongoing evaluation of the client.

● Regularly determine the need to continue using the restraints.

● Never leave the client alone without the restraints.

● Check facility policy regarding types of restraints. Many facilities no longer use vest restraints due to the risk for strangulation.

DOCUMENT

● Precipitating events and behavior of the client prior to seclusion or restraints

● Alternative actions to avoid seclusion or restraints

● Time of application and removal of the restraints

● Type of restraints and location

● The client’s behavior while in restraints

● Type and frequency of care (range of motion, neurologic checks, removal, integumentary checks)

● Condition of the body part in restraints

● The client’s response at removal of the restraints

● Medication administratio

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HOSPITAL SAFETY

Complete a fall-risk assessment for each client at admission and at regular intervals.

Be sure the client knows how to use the call light (by giving a return demonstration), that it is in reach, and to encourage its use.

● Respond to call lights in a timely manner.

● Use fall-risk alerts (color-coded wristbands).

● Provide regular toileting and orientation of clients who have cognitive impairment.

● Provide adequate lighting.

● Orient clients to the setting to make sure they know how to use all assistive devices (grab bars) and can locate necessary items.

● Place clients at risk for falls near the nurses’ station.

● Provide hourly rounding.

● Make sure’ bedside tables, overbed tables, and frequent-use items (telephone, water, facial tissues) are within reach. ● Keep the bed in the low position and lock the brakes.

● For clients who are sedated, unconscious, or otherwise compromised, keep the side rails up.

● Avoid the use of full side rails for clients who get out of bed or attempt to get out of bed without assistance.

● Provide nonskid footwear and nonskid bath mats for use in tubs and showers.

● Use gait belts and additional safety equipment when moving clients.

● Keep the floor clean, dry, and free from clutter with a clear path to the bathroom (no scatter rugs, cords, or furniture)

HOME SAFETY

Age-related changes vary greatly among this age group​.

Prevention is important as older clients have longer recovery times from injuries and an increased risk of complications​.

A decrease in tactile sensitivity can be a risk factor for burns and other tissue injuries​.

Remove items that could cause a fall (loose carpets and throw rugs)​.

Place electrical cords behind furniture​.

Place grab bars near the toilet and in the tub/shower​.

Use non-skid mats in the tub/shower​.

Ensure that lighting is adequate inside and outside of the home​.

Remove clutter​.

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IF NEEDLE STICK OCCURS

1. Wash the site with soap and water​.

2. Report the incident to the supervisor​.

3. Immediately seek medical treatment​.

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Seven Rights of Medication Administration ​

1. The Right Medication - Review the medication order, compare the healthcare provider's medication order to the MAR (or eMAR, and then use the MAR to prepare and administer medication(s). Use the three checks system. ​

2. The Right Dose - Confirm appropriateness of dose using drug reference. Check dese and verify math calculation or conversions with another nurse; prepare dose using standards of measurement. ​

3. The Right Patient - Check the name on the order and the patient. Use at least 2 identifiers. Ask patient to identify themselves. ​

4. The Right Route - Check the order and appropriateness of the route ordered. Confirm the patient can take or receive the medication by the ordered route. ​

5. The Right Time - Check the frequency of the ordered medication and that you are giving the ordered dese at the correct time. Confirm when the last dose was given, if applicable, prior to administration. ​

6. The Right Documentation - Immediately document after administering the medication per agency policy. Make sure to document any preassessment data that is required of certain medications. ​

7. The Right Indication - Confirm the rationale for the ordered medication. Does the medication correlate with the patient's history?

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SIEZURE PRECAUTIONS AND SAFETY MEASURES 

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SIEZURE PRECAUTIONS AND SAFETY MEASURES 

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SEIZURE PRECAUTIONS

Seizure precautions (measures to protect clients from injury during a seizure) are imperative for clients who have a history of seizures that involve the entire body and/or result in unconsciousness.

● Make sure rescue equipment is at the bedside, including oxygen, an oral airway, suction equipment, and padding for the side rails. Clients at high risk for generalized seizures should have a saline lock in place for immediate IV access. ● Ensure rapid intervention to maintain airway patency.

● Inspect the client’s environment for items that could cause injury during a seizure, and remove items that are not necessary for current treatment.

● Assist clients at risk for seizures with ambulation and transferring to reduce the risk of injury.

● Advise all caregivers and family not to put anything in the client’s mouth (except an airway for status epilepticus) during a seizure.

● Advise all caregivers and family not to restrain the client during a seizure but to lower the client to the floor or bed, protect their head, remove nearby furniture, provide privacy, put them on one side with the head flexed slightly forward if possible, and loosen their clothing.

DURING A SEIZURE

Stay with the client, and call for help.

Assist seated or standing clients to the floor while protecting the head​.

Maintain airway patency and suction PRN.

Position the client on their side to maintain a patent airway and prevent aspiration​.

Loosen restrictive clothing and clear the area near the client to prevent injury​.

Administer medications.

Administer oxygen as needed if hypoxia is present (e.g., cyanosis, pallor)​.

Note the duration of the seizure and the sequence and type of movements.

Record and document the time and duration of the seizure​.

● After a seizure, determine mental status and measure oxygenation saturation and vital signs. Explain what happened, and provide comfort, understanding, and a quiet environment for recovery.

● Document the seizure with any precipitating behavior and a description of the event (movements, injuries, duration of seizures, aura, postictal state), and report it to the provider

During seizure activity, the priority is client safety. Nursing actions during a seizure include:​

Assist seated or standing clients to the floor while protecting the head​.

Position the client on their side to maintain a patent airway and prevent aspiration​.

Loosen restrictive clothing and clear the area near the client to prevent injury​.

Administer oxygen as needed if hypoxia is present (e.g., cyanosis, pallor)​.

Record and document the time and duration of the seizure​.

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FIRE SAFETY

Fires in health care facilities are usually due to problems with electrical or anesthetic equipment, or from smoking. All staff must:

● Know the location of exits, alarms, fire extinguishers, and oxygen shut‑off valves.

● Make sure equipment does not block fire doors.

● Know the evacuation plan for the unit and the facility.

Fire response follows the RACE sequence

R: Rescue and protect clients in close proximity to the fire by moving them to a safer location. Clients who are ambulatory can walk independently to a safe location.

A: Alarm: Activate the facility’s alarm system and then report the fire’s details and location.

C: Contain/Confine the fire by closing doors and windows and turning off any sources of oxygen and any electrical devices. Ventilate clients who are on life support with a bag-valve mask.

E: Extinguish the fire if possible using the appropriate fire extinguisher.

FIRE EXTINGUISHERS

To use a fire extinguisher, use the PASS sequence.

P: Pull the pin.

A: Aim at the base of the fire.

S: Squeeze the handle.

S: Sweep the extinguisher from side to side, covering the area of the fire.

Classes of fire extinguishers

Class A is for combustibles (paper, wood, upholstery, rags, other types of trash fires).

Class B is for flammable liquids and gas fires.

Class C is for electrical fires

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HAS A SIDE EFFECT THAT TURNS URINE BRON TO BLACK. APPARENTLY IT IS HARMELESS

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Signs and Symptoms of Active TB:​

Chest pain, or pain with breathing or coughing​

Loss of appetite​

Chills​

Unintentional weight loss​

Fatigue​

Night Sweats​

Fever​

Coughing up blood​

Coughing that lasts three or more weeks​

Use Airborne precautions to prevent transmission​

N95 HEPA filter mask for all healthcare providers providing care to the client​

Client can wear a surgical mask when being transported to another department​

Place client in negative-airflow room​

Use barrier protection when the risk of contamination exists​

Administer prescribed medications (think of the acronym RIPE)​

Rifampin (RIF)​

Isoniazid (INH)​

Pyrazinamide (PZA)​

Ethambutol (EMB)​

Administer heated and humidified oxygen therapy as prescribed​

Promote adequate nutrition- a well-balanced diet for adequate caloric intake and foods rich in protein, iron, and vitamins C and B​

Provide emotional support

Clients should be educated on the following:​

Airborne precautions not needed in the home because family members have already been exposed​.

Exposed family members should be tested for TB​.

Medication therapy must be continued until complete which can be 6-12 months and maybe even up to 2 years for drug resistant TB​.

Follow-ups are needed for 1 full year​.

Sputum samples required every 2-4 weeks to monitor for medication effectiveness. Clients are no longer considered infectious after 3 consecutive negative sputum cultures.​

Practice proper hand hygiene at all times​.

Cover your mouth and nose when coughing or sneezing​.

Contaminated tissues should be disposed of in plastic bags​.

Masks should be worn in public places when TB is active.