HS 323 cheat sheet

Scope of practice is defined by state nurse practice acts, licensure, employer policy, and specialty certification; when these conflict, the most restrictive applicable limit governs the individual clinician.

Standard of care = what a reasonably prudent clinician with similar training would do in similar circumstances; it is established by evidence-based guidelines, professional standards, and expert testimony, not by institutional convenience.

The nursing process sequence is assessment, diagnosis (clinical problem identification), planning with measurable outcomes, implementation, and evaluation; evaluation findings loop back into reassessment.

Evidence hierarchy from strongest to weakest for therapy questions: systematic reviews/meta-analyses of randomized trials, individual randomized trials, cohort studies, case-control studies, case series, expert opinion.

Beneficence (act in the patient's interest), nonmaleficence (avoid harm), autonomy (respect informed choice), justice (fair distribution of resources), and fidelity (keep promises) are the five core ethical principles applied to clinical decisions.

Delegation rules: the delegating clinician retains accountability; tasks delegated to assistive personnel must be predictable, require no clinical judgment, and carry low risk (e.g., vital signs on stable patients, ambulation, intake/output).

Professional development mechanisms include continuing education units, peer review, reflective practice, and certification; licensure renewal requirements vary by jurisdiction and are set by the licensing board.

Cardiac output = heart rate × stroke volume; normal adult CO ≈ 4–8 L/min. Stroke volume depends on preload, afterload, and contractility, so any change in these three alters CO.

Normal adult vital sign ranges: temperature 36.1–37.2 °C oral, pulse 60–100/min, respirations 12–20/min, blood pressure <120/<80 mmHg, SpO2 ≥95% on room air.

Acid–base interpretation: pH <7.35 = acidosis, >7.45 = alkalosis; respiratory disorders change PaCO2 in the opposite direction to pH; metabolic disorders change HCO3− in the same direction as pH.

Renal regulation: kidneys adjust HCO3− reabsorption and H+ excretion over hours to days; the lungs adjust PaCO2 within minutes, making respiratory compensation fast and renal compensation slow.

Left-sided heart failure produces pulmonary congestion (dyspnea, crackles, orthopnea, pink frothy sputum); right-sided failure produces systemic congestion (JVD, peripheral edema, hepatomegaly, ascites).

Signs of inadequate perfusion: altered mentation, urine output <0.5 mL/kg/h, capillary refill >3 s, cool mottled extremities, narrowing pulse pressure, rising lactate.

Electrolyte red flags: potassium >6.0 mEq/L or <2.5 mEq/L risks dysrhythmia; sodium change faster than 8–10 mEq/L per 24 h risks cerebral edema or osmotic demyelination.

Assessment sequence: airway, breathing, circulation, disability (neuro), exposure - performed first in unstable patients; full head-to-toe history and physical follows once stabilized.

Pain assessment tools by population: 0–10 numeric rating scale for adults, Wong-Baker FACES for children, PAINAD or Abbey for patients with advanced dementia who cannot self-report.

Pulse quality graded 0 (absent) to 4+ (bounding); 2+ is normal. Compare bilateral pulses and check capillary refill, color, temperature, and sensation distally.

Mental status: Glasgow Coma Scale 3–15 (eye 1–4, verbal 1–5, motor 1–6); score ≤8 generally indicates need for airway protection.

Orthostatic hypotension = drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing; indicates volume depletion or autonomic dysfunction.

Abnormal breath sounds: crackles (fluid in alveoli), wheezes (lower airway narrowing), stridor (upper airway obstruction - emergency), pleural friction rub (inflammation of pleura).

Lab reference anchors: hemoglobin 12–17 g/dL, WBC 4,000–11,000/µL, platelets 150,000–400,000/µL, glucose 70–100 mg/dL fasting, creatinine 0.6–1.2 mg/dL, INR 0.8–1.1 off anticoagulation.

Trend data over single values: a falling blood pressure with rising heart rate and narrowing pulse pressure suggests compensated shock; reassess after each intervention.

SMART outcome criteria: specific, measurable, attainable, relevant, and time-bound (e.g., 'patient will ambulate 50 feet with a walker by day 3').

Medication rights: right patient, drug, dose, route, time, documentation, reason, and response; verify two patient identifiers before every administration.

High-alert medications (insulin, heparin, opioids, concentrated electrolytes, chemotherapy) require independent double-check and standardized dosing to prevent harm.

Therapeutic drug monitoring: measure trough levels just before the next dose (e.g., vancomycin, aminoglycosides); measure peak levels at a defined interval after infusion per protocol.

Isotonic fluids (0.9% NaCl, lactated Ringer's) expand intravascular volume; hypotonic (0.45% NaCl) shifts water intracellularly; hypertonic (3% NaCl) pulls water out of cells and requires close sodium monitoring.

Oxygen delivery: nasal cannula 1–6 L/min (≈24–44% FiO2), simple mask 5–10 L/min, nonrebreather 10–15 L/min (≈80–95% FiO2); titrate to target SpO2, generally 92–96% for most adults.

Postoperative priorities: airway and ventilation, pain control adequate for deep breathing, early ambulation, incentive spirometry, wound assessment, and prevention of venous thromboembolism.

Chain of infection: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host; break any link to prevent transmission.

Standard precautions apply to all patients: hand hygiene, gloves, gown, mask, eye protection based on anticipated exposure, and safe sharps handling.

Transmission-based precautions: contact (MRSA, C. difficile, scabies) requires gown and gloves; droplet (influenza, pertussis, meningococcus) requires a surgical mask within 3 feet; airborne (TB, measles, varicella) requires an N95 or PAPR and negative-pressure room.

Hand hygiene is the single most effective infection prevention measure; use alcohol-based rub unless hands are visibly soiled, then soap and water (also required for C. difficile and norovirus).

The Joint Commission National Patient Safety Goals include correct patient identification, improved communication (read-back of verbal orders), safe medication use, and reducing health care–associated infections.

Root cause analysis is a retrospective, systems-focused method for sentinel events; failure mode and effects analysis (FMEA) is prospective and identifies risks before harm occurs.

Fall prevention: Morse Fall Scale or similar risk scoring, bed in lowest position, call light in reach, nonskid footwear, hourly rounding, and toileting schedules for high-risk patients.

Sharps injury response: wash the site with soap and water, report immediately, and follow post-exposure prophylaxis protocol (e.g., HIV PEP started as soon as possible, ideally within hours).

Informed consent requires capacity, disclosure of risks/benefits/alternatives, comprehension, and voluntariness; the provider performing the procedure obtains consent, and the nurse witnesses the signature and verifies understanding.

HIPAA permits disclosure of protected health information for treatment, payment, and operations without authorization; minimum necessary standard applies to all other disclosures.

Mandatory reporting duties typically include suspected child abuse, elder abuse, certain communicable diseases, and gunshot wounds; specific requirements are set by state law.

Patient Self-Determination Act requires health care facilities to inform patients of their right to make advance directives; a durable power of attorney for health care designates a surrogate decision-maker.

SBAR (Situation, Background, Assessment, Recommendation) structures handoff and escalation communication to reduce omissions and delays.

An incident report documents facts about an unexpected event for quality improvement; it is not part of the medical record and is not referenced in the patient's chart.

Cultural humility in communication: use qualified medical interpreters for patients with limited English proficiency; family members, especially minors, should not serve as interpreters for clinical discussions.

Documentation must be timely, accurate, complete, objective, and legible; record only care performed and observations made - never pre-chart interventions not yet done.

Late entries are made with the current date/time and labeled as a late entry with the date/time of the original event; never backdate or alter an existing entry.

Corrections: draw a single line through an error, write 'error' and initials, and enter the correct information; electronic records use addendum functions and preserve audit trails.

The medical record is a legal document and may be subpoenaed; document in objective terms (e.g., '2 cm × 3 cm reddened area on sacrum') rather than conclusions ('looks bad').

Confidentiality: access only records needed for care; unauthorized access, even by employees, is a privacy breach subject to discipline and legal penalty.

Handoff documentation should include current condition, recent changes, pending results, treatments in progress, and specific concerns, using a standardized format.

Retention and destruction of records follow state law and facility policy; release of records generally requires a signed authorization except for treatment, payment, and operations.

Levels of prevention: primary (prevent disease before it occurs - immunization, seat belts), secondary (early detection - screening), tertiary (limit disability from existing disease - rehabilitation).

Screening recommendations vary by age and risk; examples include colorectal cancer screening beginning at 45, cervical cancer screening from 21, and annual influenza vaccination for persons ≥6 months.

Herd immunity threshold depends on pathogen transmissibility (R0); measles R0 ≈ 12–18 requires roughly 92–95% population immunity to interrupt transmission.

Social determinants of health include income, education, housing, food security, transportation, and neighborhood environment; they drive a large share of health outcomes and must be assessed in care planning.

Epidemiologic measures: incidence = new cases ÷ population at risk per time period; prevalence = all existing cases ÷ total population at a point in time.

Health literacy strategies: teach-back method, plain language, limiting to three key points, and written materials at or below a sixth-grade reading level.

Screening test properties: sensitivity = true positives ÷ all with disease; specificity = true negatives ÷ all without disease; positive predictive value depends on prevalence.

Prioritization frameworks: Maslow's hierarchy (physiologic needs first), ABCs (airway, breathing, circulation), and safety/risk potential before psychosocial or educational needs.

Acute versus chronic: address the most unstable or life-threatening problem first, even if a chronic issue is more distressing to the patient.

Delegation decision rule: use the five rights of delegation (right task, circumstance, person, direction/communication, supervision) and verify the delegate's competence.

Escalation criteria: any deterioration in airway, breathing, circulation, or neurologic status warrants immediate provider notification using SBAR and rapid response activation.

Time-critical interventions: chest pain with suspected MI - aspirin and ECG within 10 minutes; suspected stroke - CT and thrombolytic decision within the treatment window.

Clinical judgment model: notice cues, interpret them, respond with an action, and reflect on the outcome; document the reasoning that supported each decision.

Resource stewardship: choose the least invasive, least costly intervention that achieves the outcome, and involve the interprofessional team early to prevent duplication.

Pharmacokinetics: absorption, distribution, metabolism (mostly hepatic), excretion (mostly renal); half-life determines time to steady state (≈4–5 half-lives) and dosing interval.

High-risk drug classes requiring monitoring: anticoagulants (INR, aPTT, platelets), insulin (glucose, potassium), opioids (respiratory rate, sedation scale), digoxin (level 0.5–2 ng/mL, potassium).

Adverse drug event reporting goes to the facility's safety system and, for serious events, to the national reporting program; reporting is nonpunitive and intended for system learning.

Antibiotic stewardship: prescribe only when indicated, obtain cultures before the first dose, choose the narrowest effective agent, and reassess at 48–72 hours for de-escalation.

Anticholinergic and sedative medications increase fall and delirium risk in older adults; Beers criteria identify potentially inappropriate medications for this population.

Patient education on new prescriptions should cover purpose, dose and timing, expected effects, serious adverse effects to report, and interactions with food or other drugs.

Look-alike/sound-alike drug names and unclear abbreviations (e.g., 'U' for units, trailing zeros) are leading causes of medication errors; use standardized, unambiguous notation.

Adult chain of survival: early recognition and activation, high-quality CPR, rapid defibrillation, advanced life support, post-arrest care.

High-quality CPR: compression rate 100–120/min, depth at least 2 inches (5 cm) in adults, full chest recoil, minimize interruptions to <10 seconds, and change compressor every 2 minutes.

Defibrillation for shockable rhythms (ventricular fibrillation, pulseless ventricular tachycardia) as early as possible; each minute of delay reduces survival by roughly 7–10%.

Nonshockable rhythms (asystole, pulseless electrical activity) are treated with CPR and epinephrine; reversible causes are sought using the H's and T's.

Rapid response team activation criteria commonly include respiratory rate <8 or >28, SpO2 <90%, systolic BP <90, heart rate <40 or >130, and acute change in mental status.

Anaphylaxis: epinephrine intramuscularly into the anterolateral thigh is first-line; antihistamines and corticosteroids are adjuncts, not initial treatment.

Post-resuscitation care includes targeted temperature management, avoiding hypotension and hypoxia, glucose control, and neurologic prognostication no earlier than 72 hours.

Normal fetal heart rate is 110–160 beats/min; late decelerations indicate uteroplacental insufficiency, variable decelerations suggest cord compression, and early decelerations are benign head compression.

Newborn transition: first breath expands lungs and drops pulmonary vascular resistance; APGAR is scored at 1 and 5 minutes for appearance, pulse, grimace, activity, and respiration.

Pediatric weight-based dosing uses mg/kg; verify calculated doses against a maximum adult dose and use a length-based tape or double-check for emergencies.

Pediatric assessment differs by age: for infants and toddlers, observe first, then auscultate and palpate; obtain history from the caregiver.

Normal pediatric vital signs vary widely by age; heart rate and respiratory rate are higher in infants and decline with age, so use age-specific reference ranges.

Older adults have reduced renal and hepatic clearance, lower total body water, and polypharmacy risk; start low and titrate slowly.

Pregnancy physiologic changes include increased blood volume and heart rate, decreased blood pressure, and a hypercoagulable state; interpret labs and vital signs accordingly.

Daily fluid requirement estimate: 30 mL/kg/day for adults, or 4-2-1 mL/kg/h rule for children (4 mL/kg/h for first 10 kg, 2 for next 10, 1 for each kg thereafter).

Signs of hypovolemia: thirst, decreased skin turgor, dry mucous membranes, oliguria, orthostatic changes, and elevated BUN-to-creatinine ratio.

Signs of hypervolemia: weight gain, edema, crackles, JVD, and dyspnea; daily weights are the most reliable indicator of fluid status.

Hypokalemia causes muscle weakness, ileus, and U waves on ECG; hyperkalemia causes peaked T waves, widened QRS, and risk of ventricular fibrillation.

Hypocalcemia signs: perioral numbness, Chvostek sign (facial twitch with tapping), Trousseau sign (carpal spasm with blood pressure cuff inflation).

Hyponatremia symptoms progress from confusion and headache to seizures and coma; correct slowly (≤8–10 mEq/L per 24 h) to avoid osmotic demyelination.

Nutrition screening should occur within 24 hours of admission; albumin and prealbumin are affected by inflammation and are not reliable single markers of nutritional status.

Donabedian model evaluates quality through structure (resources), process (what is done), and outcomes (results achieved).

Common quality measures: readmission rates, hospital-acquired infection rates, patient experience scores (HCAHPS), mortality, and adherence to evidence-based bundles.

PDSA (plan-do-study-act) cycles drive rapid tests of change; benchmark comparisons and run charts track whether improvement is real or random variation.

Pay-for-performance and value-based purchasing tie reimbursement to quality measures, which can create pressure to improve documentation as well as care.

Interprofessional team roles: physicians diagnose and prescribe, nurses assess and coordinate, pharmacists optimize medications, therapists restore function, social workers address resources.

Patient-centered care requires shared decision-making, respect for preferences, and coordination across transitions of care, including discharge planning and follow-up.

Health care–associated harm is often preventable; reporting near misses and using checklists during high-risk procedures reduce error rates.

Study designs: randomized controlled trials establish causation; cohort studies measure association and relative risk; case-control studies estimate odds ratios for rare outcomes.

Validity types: internal validity concerns whether the study measured what it intended; external validity concerns generalizability to other populations.

Levels of evidence: level I systematic reviews of RCTs, level II RCTs, level III controlled trials without randomization, level IV case-control/cohort, level V expert opinion.

Statistical significance (p < 0.05) does not equal clinical significance; effect size and confidence intervals describe the magnitude and precision of the result.

Informatics: standardized terminologies (SNOMED CT, LOINC, ICD-10) enable data exchange; computerized provider order entry with clinical decision support reduces medication errors.

Ethical research protections: institutional review board approval, informed consent, voluntariness, and special protections for vulnerable populations (children, prisoners, pregnant women).

Critical appraisal questions: Was the sample representative? Were groups comparable? Were outcomes measured objectively? Were confounders addressed?

Cultural assessment domains: health beliefs, communication preferences, family decision-making roles, religious practices, dietary restrictions, and experiences of bias.

Use teach-back to confirm understanding: ask the patient to explain in their own words what they will do, rather than asking 'Do you understand?'

Health literacy prevalence is substantial; use plain language, chunk information, and avoid jargon, and confirm with written or visual materials when helpful.

Language access: use qualified interpreters, avoid ad hoc interpreters, and provide translated written materials at appropriate reading levels.

Motivational interviewing uses open questions, affirmations, reflective listening, and summarizing to build intrinsic motivation for behavior change.

Stages of change model: precontemplation, contemplation, preparation, action, maintenance, and relapse; interventions should match the patient's stage.

Religious and spiritual needs may affect treatment decisions (e.g., blood products, fasting, end-of-life rituals); ask and document preferences.

Leadership styles: transformational (inspires shared vision), transactional (rewards and consequences), laissez-faire (minimal direction), and situational (adapts to context).

Conflict resolution approaches: competing, collaborating, compromising, avoiding, and accommodating; collaboration is preferred for important, complex issues.

Delegation accountability remains with the delegating clinician; the delegate is responsible for the task performed and must report findings and changes.

Just culture distinguishes human error (console), at-risk behavior (coach), and reckless behavior (sanction) to encourage reporting without blame.

Staffing and assignment decisions should match patient acuity and staff competence, not only ratios; escalate unsafe assignments through the chain of command.

Performance improvement feedback should be specific, timely, behavior-focused, and paired with a plan for correction.

Incivility and disruptive behavior harm patient safety and team communication; address directly and document per policy.

Palliative care focuses on symptom relief and quality of life at any stage of serious illness; hospice care begins when life expectancy is generally ≤6 months and curative treatment is forgone.

Advance directives include living wills (treatment preferences) and durable power of attorney for health care (surrogate decision-maker); a POLST or MOLST records specific orders for seriously ill patients.

Pain management at end of life: opioids titrated to effect, with bowel regimen to prevent constipation; addiction concerns should not prevent adequate symptom control.

Signs of imminent death: decreased intake, Cheyne-Stokes respirations, mottling, cool extremities, terminal secretions, and decreased responsiveness; these are expected, not emergencies.

Family support includes education about what to expect, permission to stop aggressive interventions, and bereavement resources.

Ethical principles at end of life: respect autonomy, avoid futile treatment, provide comfort, and honor cultural and spiritual practices.

Documentation of goals-of-care conversations should include who was present, what was discussed, the patient's stated preferences, and any resulting orders.

Pressure injury staging: stage 1 = intact skin with nonblanchable erythema; stage 2 = partial-thickness loss; stage 3 = full-thickness loss; stage 4 = full-thickness with exposed muscle, bone, or tendon; unstageable = obscured by slough or eschar.

Braden Scale assesses pressure injury risk across sensory perception, moisture, activity, mobility, nutrition, and friction/shear; lower scores indicate higher risk.

Wound assessment: measure length, width, and depth; describe tissue type (granulation, slough, eschar), drainage amount and character, and periwound skin.

Moist wound healing supports epithelialization; choose dressings based on exudate (foam for moderate exudate, hydrocolloid for low, alginate for heavy).

Infection signs: increasing pain, redness, warmth, purulent drainage, odor, fever, and elevated WBC; obtain culture from clean tissue, not from surface exudate.

Repositioning every 2 hours for at-risk patients, offloading heels, and keeping skin clean and dry reduce pressure injury incidence.

Venous ulcers typically occur near the medial malleolus with edema and are treated with compression; arterial ulcers occur on toes or lateral ankle and require revascularization evaluation.

Oxygenation targets: SpO2 92–96% for most adults; 88–92% for those at risk of hypercapnic respiratory failure (e.g., COPD).

Signs of hypoxia: restlessness, confusion, tachycardia, tachypnea, cyanosis (late sign), and use of accessory muscles.

Acid–base: respiratory acidosis (low pH, high PaCO2) from hypoventilation; respiratory alkalosis (high pH, low PaCO2) from hyperventilation.

Airway management: suction only when indicated, limit to 10–15 seconds, preoxygenate, and monitor for bradycardia and hypoxia.

Incentive spirometry and early mobilization reduce postoperative atelectasis; teach slow deep breaths with sustained inhalation.

Asthma exacerbation: short-acting beta-agonist bronchodilators, systemic corticosteroids, and oxygen; reassess after each treatment.

COPD exacerbation: controlled oxygen, bronchodilators, corticosteroids, antibiotics if indicated, and noninvasive ventilation for respiratory acidosis.

Shock types: hypovolemic, cardiogenic, distributive (septic, anaphylactic, neurogenic), and obstructive (tension pneumothorax, tamponade, pulmonary embolism).

Early septic shock: fluids 30 mL/kg crystalloid for hypotension or lactate ≥4, broad-spectrum antibiotics within 1 hour, and vasopressors if MAP <65 after fluids.

Cardiogenic shock: low cardiac output with elevated filling pressures; treat with inotropes and cautious fluid, not large fluid boluses.

Tension pneumothorax: tracheal deviation, absent breath sounds, hypotension, and JVD; treat with immediate needle decompression.

Cardiac tamponade: Beck triad (hypotension, muffled heart sounds, JVD) and pulsus paradoxus; treat with pericardiocentesis.

Pulmonary embolism: sudden dyspnea, chest pain, tachycardia, and hypoxia; treat with anticoagulation and consider thrombolysis if hemodynamically unstable.

Fluid resuscitation monitoring: reassess perfusion (mentation, urine output, capillary refill, lactate) after each bolus to avoid overload.

Pupillary assessment: size, symmetry, and reactivity; fixed and dilated pupils suggest brainstem herniation, pinpoint pupils suggest opioid effect or pontine injury.

Stroke recognition: FAST (face droop, arm weakness, speech difficulty, time to call); thrombolytic window is generally up to 4.5 hours from symptom onset.

Increased intracranial pressure signs: decreasing level of consciousness, headache, vomiting, Cushing triad (hypertension, bradycardia, irregular respirations).

Seizure first aid: protect from injury, do not restrain or place objects in the mouth, time the event, and position for airway protection after it ends.

Delirium versus dementia: delirium has acute onset, fluctuating course, and inattention; dementia is chronic and progressive.

Sensory assessment: test visual acuity and fields, hearing, and sensation; document baseline and changes, especially after neurologic injury or surgery.

Post–head injury monitoring: neurologic checks every 15 minutes initially, watch for vomiting, severe headache, and changes in level of consciousness.

Diabetic ketoacidosis: hyperglycemia, ketosis, metabolic acidosis with anion gap, and dehydration; treat with isotonic fluids, insulin infusion, and potassium replacement.

Hyperosmolar hyperglycemic state: marked hyperglycemia, high osmolality, minimal ketosis, and severe dehydration; treat with fluids and insulin.

Hypoglycemia: glucose <70 mg/dL with symptoms; give 15 g fast-acting carbohydrate if alert, glucagon or IV dextrose if unresponsive, and recheck in 15 minutes.

Thyroid storm: fever, tachycardia, agitation, and altered mental status; treat with beta-blockers, thionamides, iodine, and supportive care.

Myxedema coma: hypothermia, bradycardia, altered mental status, and hypoventilation; treat with thyroid hormone replacement and supportive care.

Adrenal crisis: hypotension unresponsive to fluids, hyperkalemia, and hyponatremia; treat with IV hydrocortisone and volume resuscitation.

Sick-day rules for diabetes: continue basal insulin, monitor glucose more often, and seek care for persistent vomiting or glucose extremes.

Acute kidney injury staging uses serum creatinine rise and urine output; oliguria is <0.5 mL/kg/h for 6 hours.

Prerenal AKI: decreased perfusion (hemorrhage, dehydration, heart failure); intrinsic: tubular damage (ischemia, nephrotoxins); postrenal: obstruction (stones, BPH, tumor).

Hyperkalemia in renal failure is a medical emergency; treat with calcium gluconate, insulin with glucose, beta-agonists, and dialysis as needed.

Chronic kidney disease: monitor creatinine, eGFR, potassium, phosphorus, and hemoglobin; limit sodium, potassium, and phosphorus as indicated.

Dialysis access care: assess thrill and bruit for AV fistula or graft, avoid blood pressure and venipuncture on the access arm.

Urinary tract infection signs: dysuria, frequency, urgency, suprapubic pain, and fever; confusion may be the presenting sign in older adults.

Urinary catheter care: use only when indicated, maintain closed drainage, keep bag below bladder, and remove as soon as possible to prevent CAUTI.

Bowel sounds: hypoactive suggests ileus or obstruction; hyperactive suggests gastroenteritis or early obstruction; absent sounds are an emergency finding.

Signs of bowel obstruction: abdominal pain, vomiting, distension, and inability to pass gas or stool; treat with NPO, nasogastric decompression, and fluids.

Enteral feeding: elevate head of bed 30–45 degrees, verify tube placement per policy, check residual volume if ordered, and monitor for aspiration.

Parenteral nutrition: requires central access, dedicated line, and monitoring of glucose, electrolytes, and triglycerides; taper to prevent refeeding syndrome.

Refeeding syndrome: hypophosphatemia, hypokalemia, and hypomagnesemia after rapid reintroduction of nutrition; start feeding slowly in high-risk patients.

GI bleeding signs: hematemesis, melena, hematochezia, and signs of hypovolemia; monitor hemoglobin and prepare for endoscopy.

Liver failure: monitor for ascites, jaundice, coagulopathy, hepatic encephalopathy, and esophageal varices.

Fracture care: immobilize, assess neurovascular status distally (pulse, color, temperature, sensation, motion), and elevate to reduce edema.

Compartment syndrome: severe pain out of proportion, pain with passive stretch, paresthesia, pallor, and pulselessness (late); treat with immediate fasciotomy.

Fat embolism signs after long bone fracture: sudden dyspnea, petechiae, confusion, and hypoxia.

Osteoporosis prevention: weight-bearing exercise, adequate calcium and vitamin D, and bone density screening for at-risk adults.

Hip precautions after arthroplasty depend on surgical approach; teach avoid crossing legs, bending >90 degrees, and internal rotation if posterior approach.

Mobility assessment: assess gait, balance, strength, and fall risk before ambulation; use assistive devices fitted to the patient.

Deep vein thrombosis prevention: early ambulation, compression devices, and anticoagulation when ordered; monitor for unilateral leg swelling and pain.

Burn depth: superficial (epidermis, painful, red), partial thickness (blistering, painful), full thickness (white or charred, insensate), and deep tissue involvement.

Rule of nines for adults: head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%.

Parkland formula for fluid resuscitation: 4 mL × body weight (kg) × %TBSA burned, with half given in the first 8 hours from injury.

Burn care priorities: airway (inhalation injury), fluid resuscitation, pain control, wound coverage, and infection prevention.

Inhalation injury signs: facial burns, singed nasal hairs, soot in sputum, hoarseness, and stridor; prepare for early intubation.

Wound infection signs: increasing pain, redness, warmth, purulent drainage, and fever; obtain cultures and treat per protocol.

Pressure injury prevention: risk assessment on admission and regularly, repositioning, moisture management, nutrition support, and offloading devices.

Suicide risk assessment: ask directly about thoughts, plan, intent, and access to means; do not leave a high-risk patient alone and follow safety protocols.

Depression signs: persistent low mood, anhedonia, sleep and appetite changes, fatigue, and suicidal ideation; screen with validated tools such as PHQ-9.

Anxiety and panic: assess for physiologic causes (hypoxia, hypoglycemia, arrhythmia) before attributing symptoms to anxiety.

Delirium prevention: orient the patient, promote sleep, maintain hydration and nutrition, mobilize early, and minimize restraints and sedating medications.

Substance withdrawal: alcohol and benzodiazepine withdrawal can be life-threatening; monitor vital signs and use CIWA or similar protocols.

Therapeutic communication: use open-ended questions, reflection, and silence; avoid false reassurance, advice-giving, and changing the subject.

Restraint use requires a provider order, time-limited duration, frequent monitoring, and documentation of the least restrictive alternative tried first.

Preoperative assessment: verify consent, allergies, NPO status, medications, and baseline vital signs; mark the surgical site per policy.

Time-out before procedures confirms patient identity, procedure, site, and team roles; it is a required safety step.

Postoperative complications: atelectasis, pneumonia, wound infection, DVT, hemorrhage, and urinary retention; monitor vital signs and surgical site.

Malignant hyperthermia: hyperthermia, muscle rigidity, tachycardia, and elevated end-tidal CO2 after anesthetic exposure; treat with dantrolene.

Anesthesia recovery: monitor airway, breathing, circulation, level of consciousness, pain, and temperature per protocol.

Postoperative nausea and vomiting: assess hydration, pain, and medications; provide antiemetics as ordered.

Discharge teaching after surgery: wound care, activity restrictions, medication schedule, signs of complications, and follow-up appointments.

Verify blood product with a second clinician: patient identity, blood type, unit number, and expiration; discrepancies must be resolved before transfusion.

Transfusion reaction signs: fever, chills, rash, dyspnea, hypotension, and back pain; stop the transfusion, maintain IV access with normal saline, and notify the provider.

Acute hemolytic reaction is the most serious; it occurs from ABO incompatibility and requires immediate cessation and supportive care.

Transfusion thresholds vary; restrictive strategies generally use hemoglobin <7 g/dL for stable adults, with higher thresholds for cardiac disease.

Monitor vital signs before, 15 minutes after starting, and at intervals during transfusion; most reactions occur in the first 15 minutes.

Blood product administration must be completed within the time frame specified by policy (often 4 hours) and never with medications in the same line.

Documentation includes product type, unit number, start and stop times, vital signs, and patient response.

Key legislation: EMTALA requires emergency screening and stabilization regardless of ability to pay; HIPAA protects health information; the ACA expanded coverage and preventive services.

Nurses advocate for patients at the individual, unit, organizational, and policy levels; professional organizations provide policy engagement channels.

Social determinants of health are addressed through screening, referral to community resources, and care coordination.

Health equity requires identifying disparities by race, ethnicity, income, geography, and disability, and targeting resources accordingly.

Public health surveillance detects outbreaks and tracks trends; reportable diseases are defined by state and local health departments.

Quality reporting programs publicly report measures such as readmissions and infections, influencing reimbursement and reputation.

Advocacy skills: present evidence, build coalitions, communicate with policymakers, and document patient stories with consent.

Triage in mass casualty: use color-coded systems such as START (simple triage and rapid treatment) to prioritize by likelihood of survival with available resources.

START categories: green (minor, walking), yellow (delayed, serious but stable), red (immediate, life-threatening but treatable), black (deceased or expectant).

Disaster phases: mitigation, preparedness, response, and recovery; each phase has distinct planning and resource requirements.

Surge capacity involves staff, supplies, space, and systems; plans should address communication, evacuation, and alternate care sites.

Personal and family preparedness improves workforce availability during disasters; facilities should address staff safety and support.

Decontamination precedes treatment for hazardous material exposure; protect responders with appropriate PPE.

Post-disaster mental health effects are common; provide psychological first aid and connect people with resources.

Inspection, palpation, percussion, and auscultation are the core assessment techniques; for the abdomen, auscultate before palpating and percussing to avoid altering bowel sounds.

Percussion sounds: resonance (normal lung), hyperresonance (hyperinflation), dullness (fluid or solid), tympany (gas-filled bowel).

Auscultation of lungs: compare bilaterally, listen to at least one full breath in each field, and note adventitious sounds.

Heart sounds: S1 and S2 are normal; S3 may indicate heart failure in adults; murmurs are graded 1–6 by intensity.

Vital sign technique: measure blood pressure with the arm at heart level, correct cuff size, and both feet flat; confirm abnormal readings.

Neurologic assessment: level of consciousness, orientation, pupils, motor strength, and sensation; use a consistent scale.

Documentation of assessment findings should be objective, specific, and comparable over time to detect trends.

Pain is subjective; use the patient's self-report as the primary source and a validated tool for those unable to report.

Multimodal analgesia combines nonopioid and opioid agents to reduce opioid requirements and side effects.

Opioid side effects: respiratory depression, sedation, constipation, nausea, and pruritus; monitor sedation and respiratory rate.

Opioid-induced respiratory depression: decreasing respiratory rate and sedation; treat with naloxone and supportive care.

Nonpharmacologic interventions include positioning, heat or cold, relaxation, distraction, and music therapy.

Assess pain characteristics: location, quality, intensity, timing, aggravating and relieving factors, and effect on function.

Documentation should include the assessment, intervention, and reassessment of response.

Document objectively and avoid conclusory or judgmental language; record facts, observations, and interventions.

Never alter a record after the fact; use addenda and follow policy for corrections.

Informed refusal: document the patient's decision, the information provided, and the provider notification.

Incident reports are for internal quality improvement and are not referenced in the medical record.

Risk management includes identifying hazards, reporting near misses, and participating in safety huddles.

Confidentiality breaches include unauthorized access, lost devices, and discussing patient information in public areas.

Consent for minors generally requires a parent or guardian, with exceptions defined by state law (e.g., emergency care, certain reproductive health services).

TeamSTEPPS core skills: communication, leadership, situation monitoring, and mutual support.

Structured communication tools include SBAR, CUS (concerned, uncomfortable, safety issue), and closed-loop communication.

Handoffs should be standardized and include current condition, recent changes, pending results, and action items.

Role clarity and respect for each team member's expertise improve outcomes and reduce errors.

Conflict should be addressed directly and escalated when it affects patient safety.

Shared mental models and briefings improve coordination during high-risk events.

Patient and family are members of the care team; include them in goals and decisions.

Infancy: well-child visits, immunizations, safe sleep, and developmental screening.

Childhood: injury prevention, nutrition, physical activity, and school readiness.

Adolescence: mental health screening, substance use prevention, sexual health education, and safety counseling.

Adulthood: cardiovascular risk screening, cancer screening, and workplace safety.

Older adulthood: fall prevention, polypharmacy review, cognitive screening, and advance care planning.

Health coaching and goal setting support behavior change; use motivational interviewing and small, achievable steps.

Community resources and social support enhance health promotion efforts.

Electronic health records support documentation, order entry, results review, and clinical decision support.

Clinical decision support can improve adherence to guidelines but may cause alert fatigue if overused.

Barcode medication administration reduces errors by matching patient and medication.

Data security requires strong passwords, access controls, and reporting of breaches.

Telehealth expands access but requires attention to privacy, consent, and appropriate use.

Standardized terminologies enable interoperability and data exchange.

Technology failures require downtime procedures and manual documentation per policy.

PDSA cycles test changes on a small scale before spread.

Root cause analysis examines system factors after a sentinel event.

Failure mode and effects analysis identifies risks prospectively.

Run charts and control charts distinguish common from special cause variation.

Benchmarking compares performance with peers or standards.

Engaging frontline staff in improvement increases buy-in and sustainability.

Measurement and feedback are essential to sustain improvement.

Maintain professional boundaries; avoid dual relationships and personal involvement that could harm care.

Recognize signs of burnout and compassion fatigue; seek support and use healthy coping strategies.

Follow policies on social media and patient privacy.

Report impaired colleagues through appropriate channels.

Engage in continuing education and reflective practice.

Use available employee assistance and peer support resources.

Model healthy behaviors for patients and colleagues.