CMSRN cheat sheet

Sepsis screen: suspected infection plus qSOFA ≥2 (respiratory rate ≥22, altered mentation, systolic BP ≤100 mm Hg) signals high risk and prompts escalation.

Hypoglycemia protocol in a conscious patient: 15 g fast-acting carbohydrate, recheck glucose in 15 minutes, and repeat until glucose is above 70 mg/dL.

Pressure injury staging is based on depth: stage 1 intact non-blanchable erythema; stage 2 partial-thickness dermal loss; stage 3 full-thickness tissue loss without fascia exposure; stage 4 exposed fascia, muscle, or bone.

Moisture-associated skin damage has irregular borders and spares bony prominences; pressure injuries occur over bony prominences.

Postoperative fever timing: within 24 hours suggests atelectasis; 24-72 hours suggests pneumonia; after 72 hours consider urinary or wound infection.

Restraint monitoring: circulation, skin, and respiratory checks at least every 15 minutes; release and reposition every 2 hours.

Blood transfusion reaction: stop the transfusion, maintain IV access with normal saline, assess vital signs, and notify the provider and blood bank.

Fall precautions: bed low, brakes locked, call light within reach, non-skid footwear, and assist first ambulation after sedation.

Postoperative atelectasis prevention includes incentive spirometry, deep breathing, coughing, and early ambulation.

Teach-back: ask the patient to restate or demonstrate the information and re-teach until accurate.

Health literacy universal precautions: plain language, three key points, pictures, and confirmation of understanding for every patient.

Heart failure: report weight gain of 2-3 lb overnight or 5 lb in one week; weigh daily at the same time, on the same scale, in similar clothing.

Warfarin teaching: consistent vitamin K intake, INR monitoring, soft toothbrush, and reporting bleeding or dark stools.

Diabetes sick-day rule: continue insulin, check glucose every 4 hours, check ketones if glucose is above 240 mg/dL, and maintain hydration.

Smoking cessation 5 A's: Ask, Advise, Assess, Assist, Arrange.

Motivational interviewing uses open questions, reflection, and affirmation to explore ambivalence about behavior change.

Discharge medication teaching: use a reconciled list, explain purpose and timing, and observe patient or caregiver administration.

Delegation five rights: right task, circumstance, person, direction/communication, and supervision.

Nurse's role in informed consent: verify the provider discussed the procedure, assess understanding, and witness signature; the nurse does not obtain consent.

Incident reports document facts for quality improvement and are not filed in the medical record.

Chain of command: charge nurse, then nursing supervisor, then administrator or medical director when safety concerns are unresolved.

Just culture: human error is consoled, at-risk behavior is coached, and reckless behavior is disciplined.

Scope of practice is set by the state nurse practice act, facility policy, and individual competence.

Prioritization: airway, breathing, and circulation first; unstable before stable; acute before chronic.

Social media boundary: no posting patient identifiers or initiating personal contact with patients.

SBAR: Situation, Background, Assessment, Recommendation for handoff and escalation.

Medication reconciliation at admission, transfer, and discharge identifies omissions, duplications, and interactions.

Discharge planning begins at admission with assessment of home support, function, equipment, transportation, and follow-up.

The interdisciplinary team includes nursing, medicine, pharmacy, therapy, social work, nutrition, and case management.

Case management coordinates resources and transitions to promote timely, safe discharge.

Conflict resolution: address privately, use I-statements, focus on patient goals, and escalate if unresolved.

Family meeting: clarify goals of care, share information, build consensus, and document decisions.

Transitional care: timely follow-up, medication access, and a contact number reduce readmission risk.