PSB-RNSAE cheat sheet

Chain of command: unresolved concerns escalate nurse → charge nurse → supervisor → provider; never bypass a level while a patient is unstable.

Delegation to UAP: tasks must be predictable, with stable expected outcome, no ongoing assessment, no teaching, no judgment (vitals on stable patient, ambulation, intake/output).

Five rights of delegation: right task, right circumstance, right person, right direction/communication, right supervision/evaluation.

LPN/LVN scope: performs focused data collection, reinforces teaching initiated by RN, administers medications per state law; does not perform initial assessment or care planning.

Advance directives: living will states treatment wishes; durable power of attorney for health care names a surrogate; patient may revoke at any time, including while competent.

Informed consent elements: diagnosis, nature and purpose of procedure, risks and benefits, alternatives, right to refuse; the provider obtains consent, the nurse witnesses and verifies understanding.

Mandatory reporting: suspected abuse/neglect of children, older adults, and dependent adults; communicable reportable diseases; unsafe provider practice.

HIPAA: minimum necessary disclosure; patient may access records; breach notification required; incidental disclosure in care areas is permitted when reasonable safeguards used.

Prioritization: ABC (airway, breathing, circulation) before Maslow; acute before chronic; actual before potential; unstable patient over stable patient.

Standard precautions apply to all patients: hand hygiene, gloves for body fluids, gown/mask/eye protection when splash risk exists.

Hand hygiene: soap and water for 15–20 seconds; alcohol-based rub is ineffective against C. difficile spores and norovirus - use soap and water.

Transmission-based: contact (MRSA, VRE, C. diff, scabies) gown+gloves; droplet (influenza, pertussis, meningitis, mumps) mask within 3–6 feet; airborne (TB, measles, varicella, shingles disseminated) N95 plus negative-pressure room.

Neutropenic precautions: private room, no fresh flowers or standing water, no ill visitors, avoid rectal temperatures and suppositories; neutropenic diet per policy.

Fall risk: bed low and locked, call light within reach, nonskid footwear, hourly rounding; use belt or bed alarm for high-risk patients; no restraints without an order.

Restraint rules: provider order within 1 hour, time-limited (4 hours adults, 2 hours ages 9–17), face-to-face evaluation within 1 hour, release and circulation checks every 15 minutes, least restrictive device.

Fire response: RACE (rescue, alarm, contain, extinguish); PASS for extinguisher (pull, aim, squeeze, sweep); horizontal evacuation first.

Seizure safety: protect head, loosen clothing, turn to side, time the event, do not restrain or insert anything in the mouth; suction and oxygen at bedside.

Needlestick: wash with soap and water, report immediately, baseline HIV/hepatitis testing; post-exposure prophylaxis started as soon as possible, ideally within hours.

Growth and development: infants double birth weight by 5–6 months and triple by 12 months; birth length increases ~50% by 12 months.

Developmental milestones: sits unsupported 6–8 months, walks well 15 months, two-word phrases 18–24 months, parallel play toddlers, cooperative play preschoolers.

Erikson stages: trust vs mistrust (infant), autonomy vs shame (toddler), initiative vs guilt (preschool), industry vs inferiority (school age), identity vs role confusion (adolescent).

Prenatal screening: first trimester ultrasound for dating, 11–14 weeks nuchal translucency/cell-free DNA, 15–22 weeks maternal serum AFP for neural tube defects, 24–28 weeks glucose challenge test.

Expected weight gain in pregnancy: ~1–2 kg first trimester, ~0.4 kg/week thereafter; total 11–16 kg for normal BMI.

Screening schedule: Pap starting age 21, mammography from age 40–50 per guideline, colonoscopy at 45–50, bone density from 65 (younger with risk factors).

Newborn: vitamin K IM at birth, erythromycin eye ointment, hepatitis B vaccine within 24 hours; heel-stick newborn screen after 24 hours of feeding.

Immunizations: no live vaccines (MMR, varicella, LAIV) in pregnancy or immunocompromise; influenza inactivated vaccine is safe in any trimester.

Health literacy: teach-back confirms understanding; use plain language, limit to 3–5 key points, and provide written material at or below 6th-grade reading level.

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

Grief stages (Kübler-Ross): denial, anger, bargaining, depression, acceptance - not linear, and not required for a diagnosis.

Anxiety levels: mild (alert, perceptual field widened), moderate (narrowed perception, needs direction), severe (very narrow, needs guidance), panic (disorganized, unable to process).

Delirium vs dementia: delirium is acute, fluctuating, with altered attention and consciousness; dementia is chronic and progressive with intact consciousness until late.

Depression screening: PHQ-9; ask directly about suicidal ideation, plan, means, and intent; a contract for safety is not a substitute for observation and environment safety.

Alcohol withdrawal: monitor CIWA score; benzodiazepines are first line; watch for autonomic hyperactivity, tremor, hallucinations, and seizure risk.

Anorexia nervosa: highest mortality of psychiatric disorders; refeeding syndrome risk (hypophosphatemia, hypokalemia) with rapid reintroduction of calories.

Manifestations of lithium toxicity: coarse tremor, vomiting, diarrhea, ataxia, confusion; therapeutic level 0.6–1.2 mEq/L.

Abuse assessment: screen privately, use direct nonjudgmental questions, document with quotes and body-map diagrams, and provide resources before discharge.

Pressure injury staging: stage 1 intact skin with nonblanchable erythema; stage 2 partial-thickness dermis; stage 3 full thickness to subcutaneous; stage 4 to muscle/bone; unstageable when eschar obscures.

Repositioning: turn at least every 2 hours; use 30-degree lateral tilt; keep head of bed at or below 30 degrees when possible to reduce shear.

Nutrition: clear liquid (water, broth, gelatin), full liquid (adds dairy, custards), soft, and mechanical soft diets; NPO means nothing by mouth including medications unless ordered.

Bowel training: consistent schedule, privacy, upright position, fiber and fluid; constipation first-line measures before laxatives.

Urinary catheters: avoid routine use, remove as soon as possible; maintain closed drainage, bag below bladder, and perineal care daily.

Sleep hygiene: consistent schedule, limit naps, reduce light and noise, avoid caffeine and screens before bed; sleep cycle is roughly 90 minutes.

Pain assessment tools: numeric rating scale for adults, Wong-Baker FACES for children, PAINAD or FLACC for nonverbal or cognitively impaired patients.

Comfort measures: oral care every 2–4 hours for NPO or dying patients, dry linen, positioning, heat/cold application with skin checks every 15–20 minutes.

Six rights: right drug, dose, route, time, patient, documentation; add reason and to refuse when applicable.

IV flow rate (mL/hr) = total volume (mL) ÷ total time (hours); drip rate (gtt/min) = (volume × drop factor) ÷ minutes.

Dosage calculation: desired ÷ have × quantity; weight-based doses use kg (1 kg = 2.2 lb) and mg/kg/day divided per dose schedule.

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

Insulin: rapid-acting (lispro, aspart) peaks 1–3 hours, regular peaks 2–4 hours; give rapid-acting within 15 minutes of a meal; treat hypoglycemia with 15 g fast carbohydrate, recheck in 15 minutes.

Heparin: monitor aPTT; antidote protamine sulfate. Warfarin: monitor INR 2–3; antidote vitamin K. Opioids: antidote naloxone. Benzodiazepines: antidote flumazenil.

Digoxin: therapeutic 0.5–2 ng/mL; hold and notify for apical pulse below 60 in adults; early toxicity signs are anorexia, nausea, and visual halos.

Vancomycin and aminoglycosides: monitor trough levels and renal function; infuse vancomycin over at least 60 minutes to prevent red man syndrome.

Blood transfusion: verify with two licensed staff, use 0.9% sodium chloride only, start within 30 minutes and complete within 4 hours; stop and notify for fever, chills, or back pain.

Laboratory values: sodium 135–145, potassium 3.5–5.0, calcium 9–10.5, magnesium 1.3–2.1 mEq/L, glucose 70–110 mg/dL fasting, creatinine 0.6–1.2 mg/dL.

CBC: hemoglobin 12–18 g/dL, hematocrit 36–54%, platelets 150,000–400,000/mm³, WBC 5,000–10,000/mm³.

ABG: pH 7.35–7.45, PaCO2 35–45 mm Hg, HCO3 22–26 mEq/L, PaO2 80–100 mm Hg; respiratory opposite, metabolic equal in compensation.

Postoperative: monitor for hemorrhage, atelectasis, infection, and venous thromboembolism; early ambulation and incentive spirometry reduce risk.

Malignant hyperthermia: triggered by volatile anesthetics and succinylcholine; signs are rising temperature, muscle rigidity, tachycardia; treat with dantrolene.

Sepsis: qSOFA (respiratory rate ≥22, altered mentation, systolic BP ≤100); bundle includes cultures, broad-spectrum antibiotics within 1 hour, 30 mL/kg crystalloid for hypotension or lactate ≥4.

Tuberculosis: purified protein derivative read 48–72 hours; induration ≥5 mm positive in immunocompromise, ≥10 mm in high-risk, ≥15 mm in low-risk.

Fall and pressure risk scales: Braden for pressure injury, Morse for falls; reassess at least every shift and with change in condition.

Extravasation: stop infusion, aspirate per policy, remove catheter, apply cold or warm compress per drug, and notify provider.

Shock: tachycardia, tachypnea, narrow pulse pressure, cool clammy skin in hypovolemic and cardiogenic; warm flushed skin early in septic and neurogenic.

Hypovolemic shock: flat neck veins, decreased cardiac output; cardiogenic: jugular venous distention, crackles, S3 - treat with diuretics and inotropes, not fluid boluses.

Heart failure: left-sided causes dyspnea, orthopnea, crackles, pink frothy sputum; right-sided causes dependent edema, hepatomegaly, jugular venous distention.

Acute coronary syndrome: MONA is outdated as a blanket order; give aspirin, nitroglycerin if no contraindication, oxygen only if SpO2 <90%, and morphine for refractory pain.

Diabetic ketoacidosis: glucose >250, pH <7.3, bicarbonate <18, ketones, anion gap; treat with 0.9% sodium chloride, insulin infusion, and potassium replacement.

Increased intracranial pressure: early change in level of consciousness; late signs are fixed dilated pupils, decerebrate posturing, and Cushing triad (hypertension, bradycardia, irregular respirations).

Asthma exacerbation: wheezing, prolonged expiration, accessory muscle use; silent chest indicates severe obstruction and impending respiratory failure.

Chronic kidney disease: monitor potassium, phosphorus, and creatinine; restrict protein, potassium, and phosphorus; watch for fluid overload and metabolic acidosis.

Burns: Parkland formula 4 mL × kg × %TBSA for 24 hours, half in first 8 hours from burn time; use rule of nines for TBSA estimation.

Six rights: right drug, dose, route, time, patient, documentation; add reason and to refuse when applicable.

IV flow rate (mL/hr) = total volume (mL) ÷ total time (hours); drip rate (gtt/min) = (volume × drop factor) ÷ minutes.

Dosage calculation: desired ÷ have × quantity; weight-based doses use kg (1 kg = 2.2 lb) and mg/kg/day divided per dose schedule.

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

Insulin: rapid-acting (lispro, aspart) peaks 1–3 hours, regular peaks 2–4 hours; give rapid-acting within 15 minutes of a meal; treat hypoglycemia with 15 g fast carbohydrate, recheck in 15 minutes.

Heparin: monitor aPTT; antidote protamine sulfate. Warfarin: monitor INR 2–3; antidote vitamin K. Opioids: antidote naloxone. Benzodiazepines: antidote flumazenil.

Digoxin: therapeutic 0.5–2 ng/mL; hold and notify for apical pulse below 60 in adults; early toxicity signs are anorexia, nausea, and visual halos.

Vancomycin and aminoglycosides: monitor trough levels and renal function; infuse vancomycin over at least 60 minutes to prevent red man syndrome.

Blood transfusion: verify with two licensed staff, use 0.9% sodium chloride only, start within 30 minutes and complete within 4 hours; stop and notify for fever, chills, or back pain.