Universal Principles of NCM

7/21/2019 Universal Principles of NCM

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CONTENTS

Message from the National Student Nurses

Association ivContributors xi

Preface xvii

List of Abbreviations xix

Understanding the NCLEX Examination 2The Test plan 2How the Test Is Constructed 2How the Test Is Scored 3How Candidates Are Notified of Results 3

Preparation and Test Taking 3Using the Test Plan to Your Best Advantage 3Final Preparation for Test Taking 4Taking the Test 5How to Use this Book 6

References and Suggested Readings 6

Analysis 10

Planning and Implementation 10Techniques of Drug Administration 10Medication Calculations 18

Central Nervous System Drugs 23Local Anesthetics 23Nonnarcotic Analgesics and Antipyretics 25Narcotic Analgesics 27Narcotic Antagonists 28Sedatives and Hypnotics 29Anticonvulsants 31Muscle Relaxants 32Antipsychotic Agents 32

Autonomic Nervous System Drugs 37Adrenergic Drugs 37Adrenergic Blocking Agents 41Cholinergics 42Anticholinergics 43Antiparkinson Agents 44

Drugs Affecting the Endocrine System 46Antidiabetic Agents 46Pituitary Hormones 48Corticosteroids 49Thyroid Hormones 50Thyroid Antagonists 50Womens and Mens Health Agents 51

Oxytocics 52

Eye Drugs 53Mydriatics and Cycloplegics 53Miotics 54

Cardiovascular Drugs 55Cardiac Glycosides 55Antianginal Drugs 57

UNIT 1PREPARING FOR THE NCLEXEXAMINATION 1

UNIT 2DRUGS AND NURSING

IMPLICATIONS 7

Factors Affecting Drug Action 8Definition of a Drug 8Factors Affecting Drug Action 8

Drug Administration 10Assessments Appropriate to All Medication

Administration 10


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Peripheral Vasodilators 59Antidysrhythmics 59Cardiac Stimulants 62Anticoagulants 62Thrombolytic Drugs 64Antilipemic Agents 65Antihypertensives 65

Renal Drugs 69Diuretics 69Potassium-Removing Resin 72

Respiratory Drugs 72Antiasthmatic Drugs 72Antihistamines 74Mucolytics 74Expectorants and Antitussives 75

Gastrointestinal Tract Drugs 76Histamine (H2) Antagonists 76Gastrointestinal (GI) Anticholinergics 77Antacids 77Antidiarrheal Agents 78Laxatives 79Antiemetics 81Emetics 81Sucralfate (Carafate) 82

Arthritis Drugs 83Arthritis Drugs 83Antigout Drugs 84

Antimicrobials 85General Information 85Aminoglycosides 86Penicillins 86

Cephalosporins 87Macrolides 89Tetracyclines 89Chloramphenicol 90Sulfonamides 91Urinary Anti-Infectives 91Vancomycin Hydrochloride (Vancocin) 92Fluoroquinolones 93Antitubercular Drugs 93

Antiviral Agents 95Acyclovir (Zovirax) 95

Antifungal Agents 95

Antifungals 95

Anthelmintic Agents 96Anthelmintics 96

Antineoplastic Agents 97Antineoplastic Agents 97Alkylating Agents 97Antimetabolites 98Antibiotic Antineoplastic Agents 99

Antineoplastics Affecting Hormonal Balance 100Mitotic Inhibitors 102Miscellaneous Antineoplastic Agents 102

Immunosuppressants 103Azathioprine (Imuran) 103Cyclosporine (Sandimmune) 104

Vitamins and Minerals 104Vitamins 104Minerals 105Heavy Metal Antagonists 105

Herbs and Herbal Health Products 106History 106Source and Use 106Natural Pharmacy 106Complications 106Professional Responsibilities 106

Vaccines and Toxoids 108Vaccines and Toxoids 108Immune Serums 109


vi CONTENTS

UNIT 3UNIVERSAL PRINCIPLES OFNURSING CAREMANAGEMENT 111

Nursing Practice Standards 112Nursing: Scope & Standards of Practice (2004) 112Standards of Practice 112

Standards of Professional Performance 114

Legal and Ethical Aspects of Nursing 116Overview 116Guide to the Code of Ethics for Nurses: Interpretation

and Application (ANA, 2001) 116

Managing Client Care 118Priorities of Client Care 118Assignment Methods for Delivery of Care 119

Safety 121Fire Safety/Preparedness Practices 121Equipment 122

Restraints 122Principles and Interventions for Specific Aspects of

Care 122Universal/Clinical Issues 128

Cultural Diversity in Health Practices 130



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CONTENTS v

Multisystem Stressors 144Stress and Adaptation 144Inflammatory Response 144

Immune Response 144Nutrition 146Infection 155Pain 155Fluids and Electrolytes 158Acid-Base Balance 161Intravenous Therapy 162Shock 164Multiple Trauma 166

Aging 173General Information 173Patterns of Health and Disease in the Older Adult 176Assessment 176

Analysis 177Planning and Implementation 177Interventions 177Evaluation 178Conditions 178Elder Mistreatment 179Osteoporosis 180Cerebral Vascular Accident 180Benign Prostatic Hypertrophy 180Cataracts 180Glaucoma 180

Perioperative Nursing 182Overview 182

Preoperative Period 183Intraoperative Period 184Postoperative Period 186

Oncologic Nursing 191Pathophysiology and Etiology of Cancer 191Diagnosis of Cancer 192Treatment of Cancer 192

The Neurosensory System 199Overview of Anatomy and Physiology 199Assessment 203Analysis 207Planning and Implementation 207

Evaluation 210Disorders of the Nervous System 210Disorders of the Eye 224Disorders of the Ear 227

The Cardiovascular System 236Overview of Anatomy and Physiology 236Assessment 238Analysis 240Planning and Implementation 240

Evaluation 241Disorders of the Cardiovascular System 242

The Hematologic System 264Overview of Anatomy and Physiology 264Assessment 268Analysis 269Planning and Implementation 269Evaluation 270

Disorders of the Hematologic System 271

The Respiratory System 283Overview of Anatomy and Physiology 283Assessment 286Analysis 286Planning and Implementation 286Evaluation 291Disorders of the Respiratory System 292

The Gastrointestinal System 307Overview of Anatomy and Physiology 307Assessment 310Analysis 312

Planning and Implementation 312Evaluation 314Disorders of the Gastrointestinal System 314Disorders of the Liver 326Disorders of the Gallbladder 331Disorders of the Pancreas 332

The Genitourinary System 341Overview of Anatomy and Physiology 341Assessment 343Analysis 345Planning and Implementation 345Evaluation 348Disorders of the Genitourinary System 348

The Musculoskeletal System 361Overview of Anatomy and Physiology 361Assessment 362Analysis 363Planning and Implementation 363Evaluation 366Disorders of the Musculoskeletal System 366

The Endocrine System 381Overview of Anatomy and Physiology 381Assessment 383Analysis 384Planning and Implementation 385

Evaluation 385Disorders of the Endocrine System 386

The Integumentary System 406Overview of Anatomy and Physiology 406Assessment 407Analysis 407Planning and Implementation 408Evaluation 408Disorders of the Integumentary System 408

UNIT 4ADULT NURSING 143


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CONTENTS

Special Structures of Pregnancy 539Physical and Psychologic Changes of

Pregnancy 541

The Antepartal Period 543Assessment 543Analysis 544Planning and Implementation 544Evaluation 547Complications of Pregnancy 547Pre- and Coexisting Diseases of Pregnancy 551

Labor and Delivery 560Overview 560Assessment during Labor 564First Stage of Labor 565Second Stage of Labor 567Third Stage of Labor 568Fourth Stage of Labor 568Complications of Labor and Delivery 569Analgesia and Anesthesia 573Operative Obstetrical Procedures 575

The Postpartum Period 581Overview 581Postpartal Psychosocial Changes 582Assessment 583Analysis 583Planning and Implementation 583Evaluation 585Complications of the Postpartum Period 585

The Newborn 590Physiologic Status of The Newborn 590Assessment 592Analysis 593

Planning and Implementation 593Evaluation 594Variations from Normal Newborn

Assessment Findings 594

The High-Risk Infant 599Overview 599Assessment 599Analysis 599Planning and Implementation 599Evaluation 599High-Risk Disorders 599Special Conditions in the Neonate 601

Conditions of the Female Reproductive System 607Infertility and Fertility 607Menstrual Disorders 610Infectious Disorders 612


Overview of Psychiatric-Mental Health Nursing 623Theoretical Basis 623Nursing Process 626Analysis 627Planning and Implementation 627Evaluation 630Behaviors related to Emotional Distress 630

Psychiatric Disorders (DSM-IV-TR) 638Disorders of Infancy, Childhood, and Adolescence 63Pervasive Developmental Disorders 640Delirium, Dementia, and other Cognitive Disorders 64Substance Use Disorders 642Psychoactive Substance-Induced Organic Mental

Disorders 642Schizophrenia and other Psychotic Disorders 647Mood Disorders 649

Neurotic Disorders 653Anxiety Disorders 653Somatoform Disorders 655Dissociative Disorders 656Personality Disorders 656

Psychologic Aspects of Physical Illness 674Stress-Related Disorders 674Victims of Abuse 674Critical Illness 677Chronic Illness 677AIDS 678Death and Dying 679Grief and Mourning 679


UNIT 7PSYCHIATRIC-MENTAL HEALTHNURSING 621

Diabetic Diet and Exchange Lists 686

Renal Diet 690

Bariatric Diet 691

High-Fiber Diet 692

1500-Kilocalorie Diet 692

1000-MilIigram Sodium-Restricted Diet 694

Bland Diet 695

Low-Residue Diet 695

20-Gram Fat-Restricted Diet 696

Fat-Controlled Diet 697

APPENDIX 685


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xv

P R E F A C E

Endorsed by the National Student Nurses Association

(NSNA), the NCLEX-RN

Review, Sixth Edition hasbeen developed expressly to meet your needs as youstudy and prepare for the all-important NCLEX-RN

licensure examination. Taking this exam is always astressful event in the best of circumstances; itconstitutes a major career milestone and NCLEXsuccess is the key to your future ability to practice as aregistered nurse.

NEW TO THIS EDITIONThe NCLEX-RNReview, Sixth Edition has been revisedto meet the standards set by the National CouncilsState Boards of Nursings (NCSBN) most current test

plan. More than 3000 unique and challenging NCLEXquestions have been included. Additionally, eachquestion is followed by a comprehensive rationale foreach answer given as well as the identifying areas ofcognitive level, client need, nursing process, andsubject area. Additional emphasis on pharmacologyand delegation in the form of 500 new questionshas been added throughout the practice materialsince these areas have a greater emphasis on theactual exam.

Alternative format questions are throughout thepractices tests and include the newest addition to theexam: the charting question. These new questionshave been added to the test-taking software included

with the book.New content currently being tested on the exam is

included in the text such as conscious sedation,complementary and alternative medicine (CAM), andherbal medicines.

More user-friendly charts and images have beenincluded throughout the review content, followed bydiet and nutrition appendices and eleven 100-questionpractice tests.

Test-Taking Software

The CD-ROM included with this text holds a pool ofover 3000 questions (2000 new, 1100 from text) in anenvironment that simulates the test taking experienceTests are downloaded in varying lengths just like theactual exam. You can test your knowledge and testtaking skills in two ways: learning and test modes. Inlearning mode, the rationale for correct and incorrectresponses are immediately given after each question.In test mode, you will receive a score after completina test. Questions answered incorrectly may bereviewed after completing the exam.

In either mode, once the test is completed, you havthe option to view and print the results displayed as

bar-graph percentages that represent the areas of thetest plan, cognitive levels, subject area, and nursingprocess. This element gives you a clear and concisevisual presentation of the results that further enhanceand maximize study time.

Free PDA Downloads

Practice for the exam on-the-go with PDA portabilityDownloads can be accessed from the CD-ROMproviding over 500 practice questions with rationalesPractice tests are downloaded in tests of varyinglengths just like the actual examination. Test andlearning modes are available in both Windows andPalms operation systems.

Organization, Content, and Features

Unit 1, Preparing for the NCLEX Examination is anintroductory unit that covers:

Explanation of the test plan Test construction How computerized adaptive testing (CAT) works Study tips and techniques


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Unit 2, Drugs and Nursing Implications groupsdrugs by classifications and similarities to help you inconsolidating this important but sometimesoverwhelming information. Unit 2 includes:

Drug classification prototypes Related drug variances from the prototype Drug action mechanisms Drug uses and adverse effects Nursing implications and discharge teachingUnit 3, Universal Principles of Nursing Care and

Management includes: Nursing practice standards Legal and ethical aspects of nursing Delegation Prioritization Coordinating the health care team and client careUnits 4 through 7 cover adult, pediatric, maternity,

and psychiatric-mental health nursing. Each of theseunits covers a systematic approach to review thesubject matter:

Introductory review of anatomy and physiologyalong with basic theories and principles

The Nursing Process integrated with a bodysystems approach: Assessment: review of both history and

physical examination Analysis: includes appropriate NANDA nursing

diagnoses Planning: discusses client goals Implementation: identifies the interventions to

achieve client goals Evaluation: lists outcome criteria

Review of the pertinent disorders for each systemthat includes: General characteristics Pathophysiology Psychopathology Medical/surgical management Assessment data Nursing interventions and client education

The concept, scope, and design of this text representthe commitment of the author and publishing team tohelp the graduate nurse reach full professional potential.

Good luck on your NCLEX-RN examination!

xviii PREFACE


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x

L I S T O F

A B B R E V I A T I O N S

AA Alcoholics Anonymous

ABGs arterial blood gasesABE acute bacterial endocarditisac before mealsACOA Adult Children of AlcoholicsACE angiotensin-converting enzymeACh acetylcholineACTH adrenocorticotropic hormoneADA American Dietetic AssociationADH antidiuretic hormoneADL activities of daily livingAFB acid-fast bacillusAIDS acquired immune deficiency syndromeAKA above the knee amputationALG antilymphocytic globulinALL acute lymphocytic leukemiaALT alanine aminotransferase

An analysisANA American Nurses Association or antinuclearantibodies

ANLL acute nonlymphocytic leukemiaANS autonomic nervous systemAp applicationA-P anterior-posteriorAPTT activated partial thromboplastin timeARC AIDS-related complexARDS adult respiratory distress syndromeAs assessmentASA acetylsalicyclic acid (aspirin)ASD atrial septal defectASO antistreptolysinAST aspartate aminotransferaseATG antithymocytic globulinATN acute tubular necrosisATP adenosine triphosphateAV atrial-ventricularBCG Bacillus Calmette-GurinBID twice a dayBKA below the knee amputationBMR basal metabolic rateB&O suppositories containing belladonnaBP blood pressureBPD bronchopulmonary dysplasiaBPH benign prostatic hypertrophyBSE breast self-examination

BUN blood urea nitrogen

CABG coronary artery bypass graftC CelsiusCa calciumCAD coronary artery diseaseCAT computerized adaptive testingCBC complete blood countCCK-PZ cholecystokinin and pancreozyminCCU coronary care unitCDC Centers for Disease Control and PreventionCEA carcinoembryonic antigenCF cystic fibrosisCHD congenital heart diseaseCHF congestive heart failureCHO carbohydrateCI chlorideCL cognitive level

cm centimeterCN client needCNM certified nurse midwifeCNS central nervous systemCo comprehensionCO2 carbon dioxideCOPD chronic obstructive pulmonary diseaseCP cerebral palsyCPAP continuous positive airway pressureCPD cephalopelvic disproportionCPK creatine phosphokinaseCPR cardiopulmonary resuscitationC&S culture and sensitivityCSF cerebrospinal fluidCST contraction stress testCT computed tomographyCTZ chemoreceptor trigger zoneCV cardiovascularCVA cerebrovascular accidentCVP central venous pressureCVS chorionic villi samplingD&C dilatation and currettageDDAVP desmopressinDDST Denver Developmental Screening TestDES diethylstilbestrolDIC disseminated intravascular coagulationdL deciliterDMT a hallucinogen


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xx LIST OF ABBREVIATIONS

DNA deoxyribonucleic acidDPT diphtheria, pertussis, and tetanus toxoiddr dramDT diphtheria and tetanus toxoidDTs delirium tremensDTaP diphtheria-tetanus-acellular pertussis vaccineDTP diphtheria, tetanus, and pertussis toxoidDVT deep venous thrombosisECG electrocardiogramECT electroconvulsive therapy

ED Emergency departmentEDC estimated date of confinementEEG electroencephalogramEMG electromyographyENT ear, nose, throatEP erythrocyte protoporphyrinERT estrogen replacement therapyESR erythrocyte sedimentation rateETOH ethyl alcoholEv evaluationfl dr fluid dramfl oz fluid ounceF FahrenheitFAD flavin adenine dinucleotideFDA Food and Drug AdministrationFHT fetal heart ones

FHR fetal heart rateFSH follicle-stimulating hormoneFSP fibrin split productsft feetFTT failure to thriveg gauge or gramGI gastrointestinalgr graingtt(s) drop(s)GTT glucose tolerance testGU genitourinaryGVHD graft versus host diseaseh hourHA headacheH2 histamine 2HBIG hepatitis B immunoglobulin

HBV hepatitis B vaccineHCG human chorionic gonadotropinHGI hydrochloric acid or hydrochlorideHCO3 bicarbonateHCS/HPL human chorionic somatomammotropin/

human placental lactogenHe health promotion/maintenanceHELLP hemolysis, elevated liver enzymes, lowered

plateletsHct hematocritHg mercuryHgb hemoglobinHbA1c hemoglobin A1cHgbS abnormal hemoglobin seen in sickle-cell

anemiaHib Haemophilus influonzae type B

HIV human immunodeficiency virusHLA human leukocyte antigenHMD hyaline membrane diseaseHNP herniated nucleus pulposusH2O waterH2O2 hydrogen peroxidehr(s) hour(s)HSV2 herpes simplex virus type 2I & O intake and outputI & Os intake and outputsIA intra-arterial

ICP intracranial pressureICU intensive care unitID identificationIDDM insulin-dependent diabetes mellitusIDM infant of diabetic motherIgG immunoglobulin GIM intramuscularIm implementationIMV intermittent mandatory ventilationin inch

IPPB intermittent positive pressure breathingIQ Intelligence quotientISG immune serum globulinITP idiopathic thrombocytopenic purpuraIUD intrauterine deviceIUGR intrauterine growth retardationIV intravenousIVP intravenous pyelogramJRA juvenile rheumatoid arthritisK potassium or knowledge (in question code for

comprehensive practice tests)kcal kilocaloriesKCL potassium chloridekg kilogramKUB kidney, ureter, bladderL liter

lb poundLDH lactic dehydrogenaseLE lupus erythematosusLGA large for gestational ageLH luteinizing hormoneLOA left occiput anteriorLOC level of consciousnessLOP left occiput posteriorLP lumbar punctureLPN licensed practical nurseL/S lecithin/sphingomyelinLSD lysergic acid diethylamideLVN licensed vocational nursem meter or minimmin minim orminutesMAO monamine oxidase

MAOI monamine oxidase inhibitorsMAR medication administration recordmcg microgramMCT medium chain triglyceridesMD medical doctormEq milliequivalentmg milligramMI myocardial infarctionmL milliliterMLC mixed leukocyte culturemm millimeterMMR measles, mumps, rubellaMRI magnetic resonance imagingMSH melanocyte-stimulating hormonemU milliunitNa sodium

NANDA North American Nursing DiagnosisAssociation

NEC necrotizing enterocolitisng nanogramsNG nasogastricNIDDM non-insulin-dependent diabetes mellitusNP nursing processNPO nothing by mouthNS normal salineNSAIDs nonsteroidal anti-inflammatory drugsNSS normal saline solution


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LIST OF ABBREVIATIONS x

NST nonstress testO2 oxygenOB-Gyn obstetrics-gynecologyOBS organic brain syndromeOCD obsessive-compulsive disorderOCT oxytocin challenge testOD right eyeOMD organic mental disorderOOB out of bedOPV oral polio vaccine

OR operating roomOS left eyeOTC over-the-counterOU both eyesoz ounceP pulsePA pulmonary arteryPABA para-aminobenzoic acidPACU postanesthesia care unitPAP pulmonary artery pressurePap PapanicolaouPCA patient-controlled analgesiapCO2 partial pressure of carbon dioxidePCP Pneumocystis cariniipneumonia or

phencyclidinePCWP pulmonary capillary wedge pressure

PDA patent ductus arteriosusPEEP positive-end expiratory pressurePG phosphatidylglycerolPGE2 prostaglandin E2Ph physiological integrityPICCs peripherally implanted central cathetersPID pelvic inflammatory diseasePIH pregnancy-induced hypertensionPKU phenylketonuriaPl planningPMI point of maximal impulsePND paroxysmal nocturnal dyspneaPNS parasympathetic nervous system or

peripheral nervous systemPO by mouthPO2 partial pressure of oxygen

post-op postoperative (after surgery)PPD purified protein derivativePPN peripheral parenteral nutritionpre-op preoperativeprep preparationPRN as neededPs psychosocial integrityPSA prostate-specific antigenPT prothrombin timePTCA percutaneous transluminal coronary

angioplastyPTH parathormonePTSD post-traumatic stress disorderPTT partial thromboplastin timePTU propylthiouracilPUBS percutaneous umbilical blood sampling

PUC pediatric urine collectorPVC premature ventricular contraction or

polyvinyl chloridePVD peripheral vascular diseaseq everyQID four times a day

R respirationsRA rheumatoid arthritisRAIU radioactive iodine uptakeRBC red blood cellRDA recommended daily allowancesRDS respiratory distress syndromeRF rheumatic feverRIA radioimmunoassayRN registered nurseRNA ribonucleic acid

ROA right occiput anteriorROM range of motionROP right occiput posteriorS3 third heart soundSA sinoatrialSa safe, effective care environmentSBE subacute bacterial endocarditisSub-Q subcutaneousSGA small for gestational ageSGOT serum glutamic-oxylacetic transaminaseSGPT serum glutamic-pyruvic transaminaseSIDS sudden infant death syndromeSL sublingualSLE systemic lupus erythematosusSTD sexually transmitted diseaseT temperature or thoracic

TB tuberculosisTBI total body irradiationtbsp tablespoonTCAs tricyclic antidepressantsTd adult tetanus toxoid and diphtheria toxoidTEF tracheoesophageal fistulaTENS transcutaneous electrical nerve stimulatorTET tetralogyTHC tetrahydrocannabinolTIA transient ischemic attackTID three times a dayTPN total parenteral nutritionTPP thiamin pyrophosphateTSE testicular self-examinationTSH thyroid-stimulating hormonetsp teaspoon

TUR transurethral resectionTURP transurethral prostatectomyug microgramUC ulcerative colitisURI upper respiratory infectionUTI urinary tract infectionVBAC vaginal birth after cesareanVDRL Venereal Disease Reactive LaboratoryVER visual evoked responseVF ventricular fibrillationVMA vanillylmandelic acidVS vital signsVSD ventricular septal defectVT ventricular tachycardiaWBC white blood count or white blood cellWBCs white blood cells

wk weekWNL within normal limits< less than> greater than


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11

U N I T 3

U N I V E R S A LP R I N C I P L E S O F N U R S I N G C A R EM A N A G E M E N T

UNIT OUTLINE112 Nursing Practice Standards

116 Legal and Ethical Aspectsof Nursing

118 Managing Client Care

121 Safety

130 Cultural Diversity in Health

Practices

Nurses must frequently apply various management principles

while caring for their clients in various health care settings. This

unit has been crafted to clarify these issues. It begins with a

comprehensive view of nursing practice standards as well as

legal and ethical aspects of nursing.

Client care management issues such as determining priorities,

working with the health care team, making assignments,delegating to unlicensed assistive personnel, and coordinating

client care as the client progresses from admission through

discharge have been described along with valuable principles

to facilitate the nurses application of this information.

Safety considerations regarding fire, disaster management,

electricity, equipment, and the use of physical restraints have

been incorporated.

This unit also includes selected principles and interventions

related to specific aspects of care such as body mechanics,transfer techniques, positioning, the hazards and prevention of

immobility, application of cold and heat, asepsis, and the care

of clients who develop or are at risk for pressure ulcers.

Additionally, a section on cultural diversity in health practices

explores key issues related to cultural, religious, food, and death

practices in the process of nursing care delivery.


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3112 NCLEX-RN Review

NURSING: SCOPE & STANDARDSOF PRACTICE (2004)

Standards are authoritative statements by which thenursing profession describes the responsibilities forwhich its practitioners are accountable. Consequently,standards reflect the values and priorities of theprofession. Standards provide direction for professionalnursing practice and a framework for the evaluation ofpractice. Written in measurable terms, standards alsodefine the nursing professions accountability to thepublic and the client outcomes for which nurses areresponsible.

Nursing: Scope & Standards of Practice describes acompetent level of nursing practice and professionalperformance that is common to all registered nurses.

The scope of the practice statement articulates thewho, what, when, where, and how of practice, fornursing organizations, policy makers and the nursesaccountability to the public. The practice part of thestatement consists of 2 components: Standards ofPractice, which contains 6 standards and Standardsof Professional Performance, which contains9 standards. These are presented in the followingsection (ANA, 2004).

Nursing: Scope & Standards of Practice is used inconjunction with Nursings Social Policy Statement(ANA, 2003) and the Guide to the Code of Ethics forNurses: Interpretation and Application (ANA, 2008).Together these resources provide a complete anddefinitive description that best serves the publicshealth and the nursing profession. There areadditional scope of practice statements specific tothose registered nurses in the specialty practices, buthave been omitted from this text because the emphasisof this text is preparation of the nurse generalist (onewho has graduated from a diploma, associates or

baccalaureate level program).

STANDARDS OF PRACTICE

(Reprinted with permission from American Nurses

Association, Nursing: Scope and Standards of Practice,2004 nursebooks.org, American Nurses Association,Silver Spring, MD)

Standard 1. AssessmentRegistered nurse collects comprehensive datapertinent to the clients health or the situation.

Measurement Criteria

A. Data collection process:1. Systematic2. Ongoing

B. Holistic data collection involves:1. Client2. Family3. Other health care providers as appropriate4. Environment

C. Priority of data collection activities determined by:1. Clients immediate condition2. Anticipated needs of the client or situation

D. Uses appropriate evidence-based:1. Assessment techniques2. Instruments

E. Uses analytical models and problem-solving toolsF. Synthesizes available relevant data, information,

and knowledge to identify patterns and variancesG. Relevant data documented in a retrievable format

Standard 2. DiagnosisRegistered nurse analyzes the assessment data todetermine the diagnoses or issues.


A. Diagnoses or issues from assessment dataB. Diagnoses are validated with:

1. Client

2. Family3. Other health care providers, when possible

and appropriateC. Diagnoses or issues documented to facilitate

determination of:1. Expected outcomes2. Plan of care

Standard 3. Outcomes IdentificationRegistered nurse identifies expected outcomes for aplan individualized to the client or the situation.


A. Outcomes are formulated with:1. Client2. Family3. Other health care providers, when possible

and appropriateB. Culturally appropriate expected outcomes derived

from diagnosesC. Considers associated risks, benefits, costs, current

scientific evidence, and clinical expertise

Nursing Practice Standards


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3UNIVERSAL PRINCIPLES OF NURSING CARE MANAGEMENT 11

D. Defines expected outcomes considering associatedrisks, benefits and costs, and current scientificevidence, in terms of:

1. Client2. Client values3. Ethical considerations4. Environment5. Situation

E. Outcomes include a time estimate for attainmentF. Outcomes provide direction for continuity of careG. Modifies outcomes based on:

1. Changes in the status of the client2. Evaluation of the situation

H. Documents expected outcomes as measurable goals

Standard 4. PlanningRegistered nurse develops a plan that prescribesstrategies and alternatives to attain expected outcomes.


A. Develops individualized plan considering client

characteristics or the situation, including:1. Age2. Culturally appropriate3. Environmentally sensitive

B. Plan is developed with:1. Client2. Family3. Others, as appropriate

C. Plan includes strategies that address:1. Each of identified diagnoses or issues2. Promotion and restoration of health3. Prevention of illness, injury, and disease

D. Provides for continuity within the planE. Incorporates a time line within the plan

F. Establishes the plan priorities with:1. Client2. Family3. Others, as appropriate

G. Utilizes the plan to provide direction to healthcare team

H. Plan reflects current statutes, rules andregulations, and standards

I. Integrates current trends and research affecting careJ. Considers the economic impact of the planK. Plan uses standardized language/recognized

terminology

Standard 5. ImplementationRegistered nurse implements the identified plan.


A. Implements plan in safe and timely mannerB. Documents implementation of the identified plan,

including:1. Any modifications2. Changes3. Omissions

C. Uses evidence-based interventions and treatmentspecific to the diagnosis or problem

D. Uses community resources and systems toimplement plan

E. Collaborates with nursing colleagues and others

Standard 5a. Coordination of CareRegistered nurse coordinates care delivery.


A. Coordinates implementation of the planB. Employs strategies to promote health and a safe

environmentC. Documents the coordination of the care

Standard 5b. Health Teachingand Health PromotionRegistered nurse employs strategies to promote healtand a safe environment.

Measurement CriteriaA. Provides health teaching that addresses:

1. Healthy lifestyles2. Risk-reducing behaviors3. Developmental needs4. Activities of daily living5. Preventive self-care

B. Uses health promotion and health-teachingmethods appropriate to:

1. Situation2. Clients developmental level3. Learning needs4. Readiness

5. Ability to learn6. Language preference7. Culture

C. Seeks opportunities for feedback/evaluation ofeffectiveness of strategies

Standard 6. EvaluationRegistered nurse evaluates progress towardattainment of outcomes.


A. Evaluation of outcomes is:

1. Systematic2. Ongoing3. Criterion-based4. Related to structures and processes in the pla

and time lineB. Client and other care providers are involved

in process, as appropriateC. Effectiveness of planned strategies evaluated by:

1. Client responses2. Attainment of expected outcomes


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D. Documents the results of the evaluationE. Uses ongoing assessment data to revise (as

needed):1. Diagnoses2. Outcomes3. Plan4. Implementation

F. Disseminates results (as appropriate, in accordancewith state and federal laws and regulations) to:1. Client2. Others involved in the care or situation

STANDARDS OF PROFESSIONALPERFORMANCE

Standard 7. Quality of PracticeRegistered nurse systematically enhances the qualityand effectiveness of nursing practice.


A. Documents application of the nursing process in aresponsible, accountable, and ethical manner

B. Uses the results of quality improvement activitiesto initiate changes in:1. Nursing practice2. Health care delivery system

C. Uses creativity and innovation in nursing practiceto improve care delivery

D. Participates in activities to improve quality andeffectiveness of nursing practice. May include:1. Identifying aspects of practice important for

monitoring2. Using indicators for monitoring

3. Collecting data to monitor quality andeffectiveness

4. Analyzing quality data to identifyopportunities for improvement

5. Making recommendations to improve nursingpractice or outcomes

6. Implementing activities to enhance the qualityof nursing practice

7. Developing, implementing, and evaluatingpolicies, procedures, and/or guidelines toimprove the quality of practice

8. Participating on interdisciplinary teams toevaluate clinical care or health services

9. Participating in efforts to minimize costs and

unnecessary duplication10. Analyzing factors related to safety, satisfaction,

effectiveness, and cost/benefit options11. Analyzing organizational systems for

barriers12. Implements processes to remove or decrease

barriers within organizational systems13. Incorporates new knowledge to initiate changes

in nursing practice if desired outcomes notachieved

Standard 8. EducationRegistered nurse attains knowledge and competencythat reflects current nursing practice.


A. Participates in ongoing educational activitiesrelated to knowledge bases and professional issues

B. Demonstrates a commitment to lifelong learning:1. Self-reflection2. Inquiry to identify learning needs

C. Seeks experiences that reflect current practice tomaintain skills and competence in clinical practiceor role performance

D. Acquires knowledge and skills appropriate to thespecialty area, practice setting, role, or situation

E. Maintains records that provide evidence ofcompetency and lifelong learning

F. Seeks experiences and formal and independentlearning activities to maintain and develop clinicaland professional skills and knowledge

Standard 9. Professional PracticeEvaluationRegistered nurse evaluates ones own nursing practicein relation to professional practice standards andguidelines, relevant statutes, rules, and regulations.


A. Provides age-appropriate care in a culturally andethnically sensitive manner

B. Engages in self-evaluation on a regular basis byidentifying:

1. Areas of strength2. Areas for further professional development

C. Obtains informal feedback regarding own practicefrom clients, peers, colleagues, and others

D. Participates in systematic peer review, as appropriateE. Takes action to achieve goals identified during the

evaluation processF. Provides rationales for practice beliefs, decisions,

and actions as part of the informal and formalevaluation processes

Standard 10. CollegialityRegistered nurse interacts with and contributes to theprofessional development of peers and colleagues.

Measurement CriteriaA. Shares knowledge and skills with peers and

colleagues (i.e., client care conferences,presentations, or formal or informal meetings)

B. Provides peers with feedback regarding theirpractice/role performance

C. Interacts with peers and colleagues to enhance ownprofessional nursing practice/role performance

D. Maintains compassionate and caring relationshipswith peers and colleagues


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E. Contributes to an environment conducive toeducation of health care professionals

F. Contributes to a supportive and healthy workenvironment

Standard 11. CollaborationRegistered nurse collaborates with client, family, andothers in the conduct of nursing practice.


A. Communicates with client, family, and health careproviders regarding client care and the nurses rolein the provision of that care

B. Collaborates with appropriate individuals increating a documented plan focused on outcomeswith decisions related to care and delivery ofservices that indicate communication

C. Partners with others to effect change and generatepositive outcomes through knowledge of the clientor situation

D. Documents referrals, including provisions forcontinuity of care

Standard 12. EthicsRegistered nurse integrates ethical provisions in allareas of practice.


A. Uses current Code of Ethics for Nurses withInterpretive Statements (ANA) to guide practice

B. Delivers care in a way that preserves and protectsclient autonomy, dignity, and rights

C. Maintains client confidentiality within regulatoryparameters

D. Serves as a client advocate and fosters skills forself-advocacy

E. Maintains a therapeutic/professional client-nurserelationship with appropriate role boundaries

F. Demonstrates commitment to practicing self-care,managing stress, and connecting with self and others

G. Contributes to resolving ethical issues of clients,colleagues, or systems (i.e., ethics committees)

H. Reports illegal, incompetent, or impaired practices

Standard 13. ResearchRegistered nurse integrates research findings intopractice.


A. Utilizes the best available evidence, includingresearch findings, to guide practice decisions

B. Actively participates in research activities at variouslevels appropriate to the nurses level of educationand position. Such activities may include:

1. Identifying clinical problems specific to nursinresearch (client care and nursing practice)

2. Participating in data collection (surveys, piloprojects, formal studies)

3. Participating in a formal committee or progra4. Sharing research activities and/or findings

with peers and others5. Conducting research6. Critically analyzing and interpreting research

for application to practice7. Using research findings in development of

policies, procedures, and standards of practicin client care

8. Incorporating research as a basis for learning

Standard 14. Resource UtilizationRegistered nurse considers factors related to safety,effectiveness, cost, and impact on practice in theplanning and delivery of nursing services.


A. Evaluates factors such as safety, effectiveness,availability, cost and benefits, efficiencies, andimpact on practice when choosing practice optionthat would result in the same expected outcome

B. Assists client and family to identify and secureappropriate/available services to address health-related needs

C. Assigns or delegates tasks, based on needs andcondition of the client, potential for harm, stabilitof the clients condition, complexity of the task,and predictability of the outcome

D. Assists client and family to become informedconsumers about options, costs, risks, and benefitof treatment and care

Standard 15. LeadershipRegistered nurse provides leadership in theprofessional practice setting and the profession.


A. Engages in teamwork as a team player and a teambuilder

B. Works to create and maintain healthy workenvironments in local, regional, national, orinternational communities

C. Displays ability to define a clear vision, associate

goals, and a plan to implement and measureprogress

D. Demonstrates a commitment to continuous,lifelong learning for self and others

E. Teaches others to succeed by mentoring and othestrategies

F. Exhibits creativity and flexibility through times ochange

G. Demonstrates energy, excitement, and a passion fquality work


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H. Accepts mistakes by self and others to create a culturewhere risk-taking is not only safe but expected

I. Inspires loyalty through valuing people as themost precious asset in organization

J. Directs coordination of care across settings andamong caregivers, including oversight of licensed

and unlicensed personnel in any assigned ordelegated tasks

K. Serves in key roles in work setting (committees,councils, and administrative teams)

L. Promotes advancement of profession viaparticipation in professional organizations

Legal and Ethical Aspects of Nursing

OVERVIEW

It is important for nurses to recognize that nursing practiceis guided by legal restrictions and professional obligations.Legal responsibilities are regulated by state nurse-practiceacts and may vary from state to state. In addition, generalstandards for the practice of nursing have been developed

and published by the American Nurses Association,which has also developed a code of ethics.

Nurses need to be aware of these standards, as wellas legal and ethical concepts and principles, becausenurses are accountable for their actions in all theseareas in their professional role.

Ethical Concepts That Applyto Nursing PracticeA. Ethics: rules and principles that guide nursing

decisions or conduct in terms of therightness/wrongness of that decision or action.

B. Morals: personally held beliefs, opinions, andattitudes that guide our actions.C. Values: appraisal of what is good.

1. Dilemmas may occur when different valuesconflict.

2. Example: clients right to refuse treatment maybe in conflict with nurses obligation to benefitclient and to carry out treatment.

D. Ethical dilemma: a problem in making a decisionbecause there is no clearly correct or right choice.This may result in having to choose an action thatviolates one principle or value in order to promoteanother.

E. Autonomy: an individual has the right to make his

or her own decision regarding treatment and care.F. Paternalism: another person makes decisions

about what is right or best for the individual.G. Beneficence: promoting good or doing no harm to

another.H. Right to know: right to knowledge necessary or

helpful in making an informed decision.I. Principle of double effect: promoting good may

involve some expected harm, such as adverse sideeffects of medication.

J. Distributive justice: allocation of goods andservices and how or to whom they are distributed.1. Equality: everyone receives the same.2. Need: greater services go to those with greater

needs (e.g., critically ill client receives moreintensive nursing care).

3. Merit: services go to more deserving (used as a

criterion for transplant recipients).

GUIDE TO THE CODE OF ETHICSFOR NURSES: INTERPRETATIONAND APPLICATION (ANA, 2001)*

The Guide to the Code of Ethics for Nurses:Interpretation and Application contains the full textof the Code of Ethics for Nurses with InterpretativeStatements (ANA, 2001), in addition to a history,purpose, application, case studies and examples.This guide is used as a tool for teaching employeesand students how to apply the values in the Code ofEthics.

The Code of Ethics for Nurses serves the followingpurposes:

It is a succinct statement of the ethical obligationsand duties of every individual who enters thenursing profession.

It is the professions non-negotiable ethical standard. It is an expression of nursings own understanding

of its commitment to society.

Code of Ethics for NursesA. The nurse, in all professional relationships,

practices with compassion and respect for theinherent dignity, worth, and uniqueness of everyindividual, unrestricted by considerations of socialor economic status, personal attributes, or thenature of health problems.

*Reprinted with permission from American Nurses Association, Guide tothe Code of Ethics for Nurses: Interpretation and Application, 2001.nursebooks.org, American Nurses Association, Silver Spring, MD.


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B. The nurses primary commitment is to the client,whether an individual, family, group, or community.

C. The nurse promotes, advocates for, and strives toprotect the health, safety, and rights of the client.

D. The nurse is responsible and accountable forindividual nursing practice and determines theappropriate delegation of tasks consistent with thenurses obligation to provide optimum client care.

E. The nurse owes the same duties to self as to others,including the responsibility to preserve integrityand safety, to maintain competence, and tocontinue personal and professional growth.

F. The nurse participates in establishing,maintaining, and improving health careenvironments and conditions of employmentconducive to the provision of quality health careand consistent with the values of the professionthrough individual and collective action.

G. The nurse participates in the advancement of theprofession through contributions to practice,education, administration, and knowledgedevelopment.

H. The nurse collaborates with other healthprofessionals and the public in promotingcommunity, national, and international efforts tomeet health needs.

I. The profession of nursing, as represented byassociations and their members, is responsible forarticulating nursing values, for maintaining theintegrity of the profession and its practice, and forshaping social policy.

Legal Concepts That Applyto Nursing PracticeA. Standards: identify the minimal knowledge and

conduct expected from a professional practitioner.Standards are applied as they relate to a practitionersexperience and educational preparation. Forexample, any nurse would be expected to be certainthat an ordered medication was being given to thecorrect client. However, more complex nursingactions, such as respirator monitoring, would requiresupervised experience and/or continuing education.

B. Negligence: lack of reasonable conduct or care.Omitting an action expected of a prudent person ina particular circumstance is considered negligence,as is committing an action that a prudent personwould not.

C. Malpractice: professional negligence, misconduct,or unreasonable lack of skill resulting in injury orloss to the recipient of the professional services.

D. Competence: ability or qualification to makeinformed decisions.

E. Informed consent: agreement to the performance ofa procedure/treatment based on knowledge offacts, risks, and alternatives.1. Simple: having capacity to give consent for the

treatment or procedure.

2. Valid: having capacity to give consent and alsdemonstrating an understanding of the natureof the treatment, expected effects, possible sideffects, and alternatives to treatment.

F. Assault: unjustifiable threat or attempt to touch oinjure another.

G. Battery: unlawful touching or injury to another.H. Crime: act that is a violation of duty or breach of

law, punishable by the state by fine orimprisonment (see Table 3-1).

I. Tort: a legal wrong committed against a person, hor her rights, or property; intentional, willfullycommitted without just cause (see Table 3-1). Theperson who commits a tort is liable for damages ia civil action.

1. Negligence and malpractice are torts.2. Victims of malpractice are entitled to receive

monetary awards (damages) to compensate fotheir injury or loss.

J. Good Samaritan doctrine: rescuer is protectedfrom liability when assisting in an emergencysituation or rescuing a person from imminent and

serious peril, if attempt is not reckless andpersons condition is not made worse.K. Licensure: Granted by states to protect public

1. Purposesa. Standards for entry into practiceb. Defines what licensed person can do (e.g.

Nurse Practice Acts)2. License revocation/suspension

a. Criteria vary in each state.b. Licensed nurses should be aware of their

states Nurse Practice Act.c. Nurses who are disciplined in one state

may also be disciplined in another state inwhich they hold a license.

Table 3-1 Examples of Crimes and Torts

Crimes Torts

Assault and battery Assault and battery Involuntary manslaughter: False imprisonment: intentiona

committing a lawful act confinement of a clientthat results in the death without consentof a client Fraud

Illegal possession or sale Negligence/malpractice:of a controlled substance Medication errors

Carelessness resultingin loss of clients property

Burns from hot water bottleheating pads, hot soaks Failure to prevent falls by

not using bed rails Incompetence in assessing

symptoms (shock, chest pairespiratory distress)

Administering treatmentto wrong client


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Legal Concepts Related to Psychiatric-MentalHealth Nursing

A. Voluntary commitment: client consents to hospitaladmission.1. Client must be released when he no longer

chooses to remain in the hospital.2. State laws govern how long a client must

remain hospitalized prior to release.3. Client has the right to refuse treatment.

B. Involuntary commitment: client is hospitalizedwithout consent.1. Most states require that the client be mentally

ill and be a danger to others/self (includesbeing unable to meet own basic needs such aseating or protection from injury).

2. In most states the client who has beeninvoluntarily committed may notrefusetreatment.

C. Insanity: a legal term for mental illness in whichan individual cannot be held responsible for ordoes not understand the nature of his or her acts.

D. Insanity defenses: not guilty by reason of insanity.1. MNaghten rule (right and wrong test): the

accused is not legally responsible for an act if,at the time the act was committed, the persondid not, because of mental defect or illness,know the nature of the act or that the act waswrong.

2. Irresistible impulse: the accused, because ofmental illness, did not have the will to resistan impulse to commit the act, even thoughable to differentiate between right and wrong.

3. Individuals who commit crimes andsuccessfully plead insanity defenses may beinvoluntarily committed to psychiatric

hospitals under civil commitment laws. Thereis presently a trend toward finding individualsinsane and guilty.

E. Rights of clients: rights that each state may grant toits residents committed to a psychiatric hospital.

1. Right to receive treatment and not just be confined2. Right to the least restrictive alternative (locked

vs unlocked units, inpatient vs outpatient care)3. Right to individualized treatment plan and to

participation in the development of that planand to an explanation of the treatment

4. Right to confidentiality of records5. Right to visitors, mail, and use of telephone6. Right to refuse to participate in experimental

treatments7. Right to freedom from seclusion or restraints8. Right to an explanation of rights and assertion

of grievances9. Right to due process

Legal Responsibilities of the NurseA nurse is expected to:A. Be responsible for his or her own actsB. Protect the rights and safety of patientsC. Witness, but not obtain, informed consent for

medical proceduresD. Document and communicate information

regarding client care and responsesE. Refuse to carry out orders that the nurse

knows/believes are harmful to the clientF. Perform acts allowed by that nurses state nurse

practice actG. Reveal clients confidential information only to

appropriate personsH. Perform acts for which the nurse is qualified by

either education or experienceI. Witness a will (this is not a legal obligation, but

the nurse may choose to do so)

J. Restrain clients only in emergencies to preventinjury to self/others. Clients have the right to befree from unlawful restraint.

Managing Client Care

PRIORITIES OF CLIENT CARE

For One ClientA. Maslows Hierarchy of Needs (1954) (see

Table 3-2)1. Principles

a. An individuals needs are depicted inascending levels on the hierarchy.

b. Needs on one level must be (at leastpartially) met before one can focus on ahigher-level need

Table 3-2 Maslows Hierarchy of Needs

Maturity

Self-Actualization

Self-Esteem/Respect Needs

Affection or Belonging Needs

Safety and Security Needs

Physiologic/Survival Needs

Adaptation based on Maslows Hierarchy of Needs.

Grow

ingTo

ward


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2. Levels of Maslows Hierarchya. Physiologic/survival needs: basic human

needs (e.g., oxygen, water, food, elimination,physical and mental rest, activity, andavoidance of pain)

b. Safety and security needs1) Protection from physical harm (e.g.,

mechanical, thermal, chemical, orinfectious)

2) Interpersonal, economic, andemotional security

c. Affection or belonging needs1) Giving and receiving of affection2) Sense of belonging (e.g., including

client/family in planning of care)d. Self-esteem/respect needs

1) Feeling of self-worth2) Need for recognition

e. Self-actualization1) Highest level: not reached by all2) Independence3) Feeling of achievement or competency

B. Application of Maslows Hierarchy in health care1. Client carea. Basic physiologic needs should take

precedence over higher-level needs and onup the continuum accordingly.

b. Professional nurse often delivers care atmultiple levels simultaneously (e.g., whilefeeding a client, you position them toprevent aspiration and converse with them).

c. Tool to guide decision making of priorities inemergencies and time management of care.

2. Also applies to families, staff, and yourself

For Multiple Clients

A. Maslows Hierarchy applies (e.g., more critically illclients will require more care to meet theirphysiologic/survival needs)

B. Organizing multiple client assignments1. Analyze and plan for entire shift.2. Develop a working plan so that priorities get

accomplished and all clients receive optimal care.3. First consider schedules for nursing activities

(e.g., meds, treatments, VS, mealtimes, clientappointments, I&Os, etc.).

4. Then work in the nonscheduled activities thatneed to be accomplished to meet care plan goals(e.g., supporting family, teaching client, meetingwith other departments about scheduling,writing care plan, discharge planning).

ASSIGNMENT METHODSFOR DELIVERY OF CARE

PrinciplesA. Registered nurse (RN) is the decision maker/delegator

1. Assesses each client. Determines appropriateplan of care.

2. Assesses available staff and their jobdescriptions. Decides how to use humanresources to accomplish care.

B. Typical levels of staff1. Nursing Assistants

a. Unlicensed assistive personnel (UAP)b. Assign to majority of the routine

procedures (e.g., baths, bed making,routine VS, etc.)

2. Licensed Practical Nurse (LPN)/LicensedVocational Nurse (LVN)a. LPN/LVNs work under the direction of a

registered nurse or a physician.b. Performs most patient care except in som

specialty areas.c. Some states prohibit IV push medications

or to hang the first unit of blood.3. Registered Nurse (RN)

a. Performs the most complex procedures(e.g., starting IVs, developing the plan ofcare, interpreting ECGs, correlatinglaboratory results with client status)

b. Applies the nursing process for each clienc. Coordinates the medical plan with thenursing care plan

d. Coordinates client activities1) Other departments2) Health care workers3) Community

e. Performs client/family teachingf. Ensures documentation of care and outcomg. Directs and supervises care given by LPN

and ancillary personnelh. Acts as a client advocate; supporting,

pleading, or arguing in favor of the clientregarding:

1) Client rights2) Facility policy3) Treatment/care issues4) Personnel issues

Delegation to Unlicensed AssistivePersonnel (UAP)A. Delegation is the transfer of authority to a

competent individual to perform a selectednursing task in a selected situation.1. Based on principle of public safety.2. RN has ultimate accountability for the

provision and management of nursing care(includes delegation decisions).

3. When done correctly, it allows more care to bprovided in a given time period by distributinthe workload and allowing better use of theRNs time.

B. Five Rights of Delegation1. Right Task

a. Often defined by states Nurse Practice Acb. Facility policy


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c. Job description of UAP, or specific roledelineation for a specific UAP

d. Tasks appropriate for consideration:1) Repetitive custodial nature2) Not require UAP to make clinical

judgment3) Not require complex steps or decisions4) Results predictable5) Potential risk is minimal6) Uses standard unchanging procedure

2. Right Circumstancesa. Assess the clients condition and stability.b. Identify the environment/setting (e.g., ICU

vs. long-term care).c. Identify the collective nursing care needs

of the whole assignment.d. Assess the clients plan of care and goals.e. Provide the appropriate skill-mix and lines

of reporting.f. Provide the needed supplies and equipment.g. Match complexity of the task with the

UAPs competence and level of

supervision available.h. Identify any infection control or safety issues.3. Right Person

a. Organizations standards for competency ofUAPs.

b. Instruct or assess the UAPs competence ona client-specific basis.

c. Perform UAP evaluations based on thestandards.

4. Right Direction/Communicationa. Communicate the task(s) clearly and on

client-specific and UAP-specific bases.b. Use oral and/or written vehicles to

communicate, depending on the

circumstances.c. Communicate specific information to bereported, specific data to collect, and timelines for reporting.

d. Communicate specific tasks to beperformed and any client-specificinstruction or limitations.

e. Expected outcomes or potentialcomplications and when to communicatethis information.

f. What signs and symptoms to be alert forand how to report it.

g. Communicate availability of support.h. Verify understanding.

5. Right Supervision/Evaluationa. Supervision may be provided by thedelegating nurse or other designated staff.

b. Supervising nurse must know the expectedmethod for supervision (direct or indirect),the competency of the UAP, nature of thedelegated tasks, and the stability of theclient condition.

c. Ensure adequate time is allotted to providingneeded supervision.

d. Supervise or assign supervision to otherappropriate licensed nurses.

e. Monitor performance, and get and providefeedback as indicated (check intermittently).

f. Intervene as needed.g. Provide education as needed.h. Ensure clear documentation.i. Evaluate the client outcome.

j. Evaluate your delegation practice.C. Other considerations1. Plan and start delegating before you get too busy.2. The delegation relationship takes time to build.3. Select the UAP for the task, if possible (e.g.,

one UAP might do best with a large, faster-paced assignment, while another may do

better with clients who can benefit by a slowerconversational approach).

4. Allow flexibility where possible.5. Use positive feedback.6. Give credit.

Admission of Client to HospitalA. Room assignment

1. Check available data (e.g., diagnosis, age,pertinent history)

2. Does client need to be close to nurses stationfor optimal monitoring?

3. Does client need isolation or specialprecautions?

4. Who will be the clients roommate?5. Consider the physical layout of available rooms

and bathrooms. What would be best for theclient based on his or her functional status?

B. Perform a baseline admission assessment perfacility procedure.

C. Obtain needed equipment (e.g., urinal, denturecup, etc.).D. Explain and document the disposition of valuables

per facility policy.E. Orient to facility/policies (e.g., visiting hours,

parking, telephone, chaplaincy services, TV,mealtimes, electrical equipment, etc.).

F. Orient to unit (e.g., layout, lounges, smokingpolicy, activities, menu selection, medicationtimes, straight vs. prn orders, mealtimes, unitpersonnel, etc.).

G. Orient to room (e.g., roommate; bedside stand,table, and closet; call light, bathroom call system,

bed operation, TV, telephone, etc.).

Caring for the ClientWho Leaves the UnitA. Coordinate scheduling to consider clients

diagnosis, activity/test to be performed, andclients other therapeutic goals.

B. Prepare client physically and psychologically asindicated.


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C. Consider the clients condition; medication, diet, andtreatment regimes; as well as specific precautionsand adjust the clients schedule as needed.

D. Communicate pertinent information to otherdepartments/personnel.

Discharge of Client from the HospitalA. Discharge to home

1. Begin discharge plan on admission.2. Teach client/significant other about disease

process, needed precautions, restrictions,treatments, and medications.

3. Assess and document knowledge of disease andhome-care regimen and ability to perform safely.

4. Make referrals as needed for added supportand care (e.g., community/home health nurses,home health aide, community support groups,social worker, physical therapist, etc.).

5. Arrange for client to obtain neededequipment/supplies (e.g., bedside commode,ostomy supplies, dressings, etc.).

6. Ensure that client has needed prescriptions.7. Provide written/audio/visual educational

materials at the level of the clients ability andappropriate community resource contactinformation.

8. Schedule or direct client to arrange forappropriate follow-up.

9. Communicate with individuals/agency(ies)responsible for follow-up care.

B. Discharge of client to long-term care facility:communicate with facility nursing staff

1. Clients functional abilities and limitations2. Present medical regime and schedule3. Mental and behavioral status4. Family support/involvement5. Nursing care plan and response6. Existing advance directives7. Recent medication administration records8. History and physical9. Pertinent diagnostic reports

10. Other: requirements per insurance

Safety

FIRE SAFETY/PREPAREDNESSPRACTICES

A. Be aware of hazards and report immediately.B. Locate and remember:

1. Escape routes2. Fire drill procedures3. Use of available equipment

a. Fire escapesb. Fire doorsc. Fire alarmsd. Fire sprinkler controlse. Fire extinguishersf. Shut-off valves for O2 and/or medical air

4. Keep fire exits clear.C. Fire safety

1. Prevention is everyones responsibility.2. Three elements needed for a fire to start

a. Fuel: substance that will burnb. Heat: flame or sparkc. Oxygen: room air contains 21% O2

3. See Table 3-3.D. In the event of a fire:

1. Follow the RACE acronym:R 5Remove all persons in immediate danger

to safetyA5Active alarm and have someone call 911

Table 3-3 Fire Hazards and Prevention

Fire Hazards Fire Prevention

Faulty electrical Report frayed or exposed electrical wiresequipment Report sparks or excessive heatand wiring coming from electrical equipment

Overloaded Avoid overloaded circuitscircuits Dont use adaptors or extension cords

Plugs that are Use only 3-pronged grounded plugsnot properly Do not allow electrical equipment fromgrounded outside the institution to be used until it

checked by the maintenance departmeClutter Avoid clutterUnsafe practices No open flames or smoking in the area

when O2 Remove flammable liquids from the areain use Post Oxygen in Use signs as per

institutional policySecure O2 storage per institutional policy

Smoking Remove cigarettes and matches from roomReport suspicious odors of smoke or

burning immediatelyControl smoking practices per institution

policyLimit smoking to designated areasNo smoking in bedDirectly supervise smoking of selected clienEnsure use of safe ashtrays/metal receptacl

Spontaneous Dispose of chemicals, rags, and combustibcombustion substances in proper containers


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C 5Close doors to prevent spread of smokeand fire

E5Extinguish the fire using the PASSacronym:P 5Pull the pinA5Aim on the base of fireS 5Squeeze the handleS 5Sweep from side to side

2. Shut off piped-in O2

and/or medical air.3. Follow institutional policy concerning

announcing the fire and location and notifyingfire company.

4. Avoid use of elevators.5. Follow institutional evacuation plan as

needed.

EQUIPMENT

A. Follow facility procedure when using variousequipment.

B. Unfamiliar equipment

1. Contact your staff development department orsupervisor for information.2. Read available manufacturers literature.

C. Suspected malfunction (i.e., equipment thatdoes not do its task consistently or correctly,makes unusual noises, or gives off an unusual odoror extreme temperature)

1. Dont try to repair.2. Replace it immediately.3. Contact maintenance department so that it can

be checked out safely and repaired.

RESTRAINTS

A. Physical restraints should be used only ifnecessary to prevent injury to the client orothers.

1. Signed, dated, physicians order needs to bewritten specifying the form of restraint and atime limit for restraint use. (At that time theclient will be reevaluated for restraint need todetermine if a less restrictive method isappropriate.)

2. Least restrictive form of restraint should beuseda. Maintain functional abilitiesb. Decrease risk of complications

c. Minimize behavioral reaction3. Remove restraints for 10 min q2h for ROM,repositioning/ambulation, toileting, andpreventative skin care.

4. Document rationale for restraint, othermeasures tried in lieu of restraint (e.g.,distraction, family notification, environmentalmodifications), client response, andpreventative care.

PRINCIPLES AND INTERVENTIONSFOR SPECIFIC ASPECTS OF CARE

Body MechanicsA. Safe and efficient use of appropriate muscle

groups to do the jobB. Principles for the safe movement of clients

1. Keep your back straight.2. Ensure a wide base of support (keep your feet

separated).3. Bend from the hips and knees (not the waist).4. Use the major muscle groups (strongest).5. Use your body weight to help push or pull.6. Avoid twisting (pivot the whole body).7. Hold heavy objects close to your body.8. Push or pull objects instead of lifting.9. Ask for help as needed.

10. Synchronize efforts with client and other staff.11. Use turning or lifting sheets as needed.12. Use mechanical devices as needed.

Transfer and Movement Principlesand TechniquesA. From bed to chair or wheelchair

1. Identify clients strongest side.2. Place chair beside bed, on same side as clients

strongest side, so it faces the foot of bed.Stabilize chair and lock wheels.

3. Lower bed, lock wheels, and elevate head of bed.4. If assistance is needed:

a. Place one arm under clients shoulders.The other arm should be placed over andaround the knees.

b. Bring legs over the side of bed whileraising the clients shoulders off the bed.

c. Dangle client and watch for signs of faintingor dizziness. (Stand in front of client forprotection in case of balance problems.)

d. Protect paralyzed arm during transfer. (Usesling or clothing for support.)

e. Place clients feet flat on the floor. (If clienthas a weak leg, use your leg and foot to

brace the weak foot and knee.)f. Face the client and grasp firmly by placing

your arms under the armpits. Have clientlean forward so that your control of theclients upper body is stabilized.

g. Using a wide base of support and bendingat your knees, coach the client to assist asmuch as possible by using verbalinstruction and counting.

h. Stand client (if weight bearing ispermitted) by pivoting the feet, legs, andhips to a standing position.

i. Continue the slow pivotal movement untilclient is positioned over chair. Lowerclient into chair.


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B. Log rolling1. Performed when spinal column must be kept

straight (post-injury or surgery).2. Two or more persons needed

a. Both staff should be on side oppositewhere client is to be turned.1) One staff places hands under clients

head and shoulders.

2) One staff places hands under clientships and legs.3) Move client as a unit toward you.4) Cross arms over chest and place pillow

between legs.5) Raise side rail.

b. Both staff move to side of bed to whichclient is being turned.1) One staff should be positioned to keep

clients shoulders and hips straight.2) One staff should be positioned to keep

thighs and lower legs straight.3) At the same time the client is drawn

toward both staff in a single unified

motion. The clients head, spine, andlegs are kept in a straight position.c. Position with pillows for support and raise

side rails.

Positioning of the ClientA. General principles

1. Privacy/draping2. Universal precautions as needed3. Knowledge of clients condition when moving

client (e.g., paresis or paralysis of a limb; needto support joints or limbs in a specific manner;awareness of pressure points)

4. Good posture and body alignment5. Use of added supports as needed (e.g., pillows,

wedge cushions, handrolls, foot boards)6. Comfort: reduce pressure and strain on body

parts7. Safety8. Bed in a low position once repositioned9. Access to personal items and care (e.g., call

bell, drinking water, tissues, telephone, etc.)10. Clients should change position fairly

frequently (at least every 2 hours).B. Positions

1. Semi-Fowlers (see Figure 3-1A)a. Backrest elevated at 458 angle

b. Knees supported in slight flexionc. Arms rest at sides

2. High Fowlers (see Figure 3-1B)a. Backrest elevated at 908 angle (right angle)b. Knees slightly flexedc. Arms supported on pillows or bedside

tabled. Allows for good chest expansion in clients

with cardiac or respiratory problems

3. Supine (dorsal/horizontal recumbent)a. Client lies on back.b. Clients head and shoulders slightly

elevated with pillow (modified per clientcondition, physician order, or agencypolicy regarding spinal injury, surgery orpost spinal anesthesia)

c. Small pillow under lumbar curvatured. Prevent external rotation of legs with

supports placed laterally to trocanterse. Knees slightly flexedf. Prevent footdrop with foot board, rolled

pillow or high top sneakers (depends onpersistence of client condition)

4. Prone (see Figure 3-2)a. Client lies on abdomen.b. Head turned to one side on small pillow o

on flat surface.c. Small pillow just below diaphragm to

support lumbar curve, facilitate breathingand decrease pressure on female breasts.

d. Pillow under lower legs to reduce plantarflexion and flex knees.

e. May be modified in amputees whereflexion of hips and knees may becontraindicated.

Figure 3-1 (A) Semi-Fowlers position, (B) highFowlers position


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5. Trendelenburga. Client lies on back with head lower than

rest of body.b. Enhances circulation to the heart and brain.

Sometimes used when shock is present.c. In emergencies, the entire lower bed may

be elevated on shock blocks.

d. May be used for prolapsed cord outside ofthe hospital.6. Modified Trendelenburg

a. Client is positioned with legs elevated to anangle of approximately 208, knees straight,trunk horizontal, and head slightly elevated.

b. Used for persons in shock to improve cerebralcirculation and venous return to the heartwithout compromising respiration.(Contraindicated when head injury is present.)

7. Lateral (side-lying)a. Client lies on side.b. Pillow under head to prevent lateral neck

flexion and fatigue.

c. Both arms are slightly flexed in front of thebody. Pillow under the upper arm andshoulder provides support and permitseasier chest expansion.

d. Pillow under upper leg and thigh preventsinternal rotation and hip adduction.

e. Rolled pillow behind clients back.8. Sims (semiprone; see Figure 3-3)

a. Similar to lateral, but with weightsupported on anterioraspects of the ilium,humerus, and clavicle.

b. Used for vaginal and rectal exams, enemaadministration, and drainage of oralsecretions from the unconscious client.

Comfortable for the client in the lasttrimester of pregnancy.

c. Client placed on side (left side for enema orrectal exam) with head turned to side on apillow.

d. Lower arm is extended behind the body.e. Upper arm flexed in front of body and

supported by a pillow.f. Upper leg is sharply flexed over pillow

with the lower leg slightly bent.

9. Knee-chest (see Figure 3-4)a. Client first lies on abdomen with head

turned to one side on a pillow.

b. Arms flexed on either side of head.c. Finally the client is assisted to flex and

draw knees up to meet the chest.d. Difficult position to be maintaineddo not

leave client alone. Used for rectal andvaginal exams.

10. Dorsal lithotomy (see Figure 3-5)a. Used for female pelvic exam.b. Have client void before assuming this

position.

Figure 3-2 Prone position Figure 3-3 Sims position

Figure 3-4 The knee-chest position

Figure 3-5 Dorsal lithotomy position


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c. Client lies on back with the knees wellflexed and separated.

d. Frequently stirrups are used. (Adjust forproper feet and lower leg support.)

e. If prolonged use of stirrups, be alert tosigns of clot formation in the pelvis andlower extremities.

ImmobilityA. Definition: inability to move in environment freely

1. May be prescribed to limit movement ofbody/body part(s) as part of treatment/careplana. Bed rest objectives may be:

1) Reduce physical activity2) Allow rest3) Reduce oxygen needs4) Allow to regain strength5) Prevent further injury6) Promote healing7) Restrict movement of specific body

part(s)2. May be related to physical inactivity,cognitive, and/or emotional changes

B. Conditions that may require bed rest includecardiovascular, neurological, musculoskeletal,cancer, AIDS, etc.

C. Factors affecting immobility1. Length of immobility2. Severity of illness or injury3. Premorbid physical condition4. Emotional state

D. Hazards of immobility (see Table 3-4)

Cold ApplicationA. Systemic

1. Lowers metabolic ratea. Client lies on top of one, or between two,

cooling blankets. Blanket(s) are attached toa machine that circulate(s) coolantsolution.1) Follow agency policy/procedure for

care of client treated with hypothermiablanket(s).

2) Monitor VS (T, P, R, and BP) regularlyand frequently.

3) Attention to skin hygiene andprotection with oil as required.

4) Frequent repositioning and assessmentof body surface areas.5) Observe for signs of tissue damage and

frostbite (pale areas).6) Assist client in basic needs (e.g.,

hygiene, elimination, nutrition, etc.).7) Identify client temperature at which to

cease the treatment (temperature maycontinue to drift downward). MonitorVS frequently until stable for 72 hours.

2. Alcohol or sponge bath (tepid solutions,8581008 F)a. Alcohol bathcombination of alcohol an

water (alcohol has a drying effect on skinused less frequently). Alcohol increasesheat loss by evaporation.

b. Sponge bathcool or tepid (not cold) watec. Frequent and regular VS monitoring (T, P

R, and BP).d. Large areas sponged at one time allowing fo

transfer of body heat to the cooling solutione. Wet cloths applied to forehead, ankles,

wrists, armpits, and groin where bloodcirculates close to skin surface.

f. Identify temperature to cease treatmentdue to potential for continued downwardtemperature drift.

3. Discontinue systemic cold applications andreport and document findings if:a. Shivering occurs (this mechanism will

raise body temperature);b. Cyanosis of the lips or nails occurs; or

c. Accelerated weak pulse occurs.B. Local1. Purposes

a. Control bleeding by constriction of bloodvessels.

b. Reduce inflammation:1) Inhibit swelling.2) Decrease pain.3) Reduce loss of motion at site of

inflammation.c. Control accumulation of fluid.d. Reduce cellular activity (e.g., check

bacterial growth in local infections).e. Effective initialtreatment after trauma

(24-48 hours). This application of cold isthen frequently followed by a phase ofapplication of heat.

2. Ice caps or ice collarsa. Covered with cotton cloth, flannel, or

towel to absorb moisture fromcondensation. Change as needed.

b. Not left on for longer than 1 hour.c. Cease treatment and report if client

complains of cold or numbness, or if areaappears mottled.

3. Cold compressesa. Use sterile technique for open wounds.

Check site of application after 510

minutes for signs of intolerance (cyanosisblanching, mottling, maceration, orblisters).

b. Remove after prescribed treatment period(usually 20 minutes).

C. Special considerations1. Elderly clients and clients with impaired

circulation have decreased tolerance to cold.2. Moist application of cold penetrates better

than dry application.


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Table 3-4 Hazards of Immobility

Potential Negative Effects of Immobility Nursing Interventions

Cardiovascular:Orthostatic hypotension:

Impaired ability to equalize blood supply upon assuming Monitor VSan upright position (BP drop, weakness, dizziness, or Dangle clients legs 2-3 times/day, if appropriatefainting) Tilt tables

Encourage progressive weight-bearing, as indicated Monitor for change in lying and sitting/standing BP

Increased cardiac workload:Blood volume redistributes and increases circulating Monitor tolerance for various ADLsvolume (increased heart rate) Monitor characteristics of pulses

Valsalva maneuver:Holding breath and fixing thorax, breath forced against Teach to exhale rather than hold breath when moving in bedclosed glottis during movement Overhead trapeze for repositioning

Thrombus formation:Venous stasis, external pressure against veins Proper positioning

Assess for Homans sign Elastic stockings, sequential compression devices, etc. Ensure adequate hydration

AnticoagulantsRespiratory:

Limited chest expansion Monitor respiratory rate and depth Monitor for use of accessory muscles

Decreased movement and pooling of secretions Check breath sounds in all lobes and for degree of aeration Teach to perform deep breathing and coughing exercises

Impaired oxygen exchange Assess for effective cough Note any evidence of adventitious lung sounds

Metabolic:Reduced metabolic rate (except with fever) Encourage to be up and about during day, if possibleTissue atrophy and protein catabolism Provide diet with increased protein and calories

Nutritional supplements Check weights

Bone demineralization Watch for peripheral edemaFluid and electrolyte imbalances Monitor laboratory studies

Gastrointestinal:Slower peristalsis (risk for constipation/nausea and vomiting, Monitor frequency and consistency of BMsfecal impaction) Check for bowel sounds in all four quadrants of abdomen

Prevent or treat constipation Assess for signs of fecal impaction

Urinary Elimination:Stasis of urine (risk of infection) Monitor I&O

Assist client to empty bladderRenal calculi Assess for signs of urinary tract infection and renal calculi

Musculoskeletal:Decreased strength Consult PT and OT, as indicated and endurance

Rehab techniques as indicatedMuscle atrophy - Active and passive ROMContractures - Isokinetic/resistiveOsteoporosis - Stretch and flexibility

Change position at least q of 2 h Monitor height over time Restorative nursing care Check ROM

(continues)


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Application of External Heat

A. Rationale1. Relaxes muscles in spasm.2. Softens exudates for easy removal.3. Hastens healing due to vasodilation.4. Localization of infection. Note: Do not

apply heat to the abdomen with suspectedappendicitis as it may precipitaterupture.

5. Hastens suppuration.6. Warms a body part.7. Reduces congestion of an underlying

organ.8. Increases peristalsis.9. Reduces pressure from accumulated

fluids.10. Comforts and relaxes.B. Dry heat

1. Hot water bottle/bag, electric heating pad,lamp, cradle, or aquamatic pad.

2. Deeper tissue penetration modes: ultrasound,and shortwave and microwave diathermy(administered by Licensed PhysicalTherapist).

3. Follow agency policy for heat applicationmode ordered:a. Check temperature of water and machine

setting carefully;b. Assess site of application frequently for

signs of tissue damage or burns; andc. Be alert to potential bleeding resulting

from vasodilation.C. Moist heat

1. Soaks, compresses, hot packsa. Follow agency policy.b. Check temperature of application.c. Use sterile technique for open wounds.d. Assess skin condition after 5 minutes for

increased swelling, excessive redness,

blistering, maceration, pronounced palloror if the client reports pain or discomfort.

e. Remove the device after 1525 minutes oras ordered/necessary.D. Special considerations

1. Moist heat penetrates deeper than dry and isusually better tolerated.

2. The skin area involved may vary in anyindividual depending on the number of heatreceptors present.

3. Heat is less tolerated in the very young,elderly, and clients with circulatory problems

AsepsisA. Defined as the absence of disease-producing

organisms.B. Medical asepsis1. Practices to reduce the number of

microorganisms after they leave the body or treduce transmission.

2. Often referred to as clean technique.3. Includes:

a. Hand washing/decontaminationb. Standard precautionsc. Isolation technique (i.e., contact, droplet,

airborne)d. Cleaning/disinfecting of equipment

C. Surgical asepsis1. Practices aimed at destroying pathological

organisms before they enter the body throughan open wound.

2. Referred to as sterile technique.3. Includes:

a. Physical barriers: gloves, masks, gowns,drapes, protective eyewear

b. High-risk procedures:1) Catheter insertion2) Surgical wound dressing changes3) Administration of injections

Table 3-4 Hazards of Immobility (continued)

Pressure Ulcers:Prolonged pressure on area disturbs blood supply and nutrition Monitor skin conditionto a body part Use pressure reduction/relieving devices

Position to avoid injury to tissues and promote lung expansio Check intertriginous areas for accumulation of sweat andloss of fluid

Psychological:Depression, disorientation, social isolation, altered body concept, Provide educationanxiety, etc. Consult other interdisciplinary team members, as neededSleep disturbances- disrupted sleep and wake cycles Encourage participation as capable in ADLs

Provide emotional support Create pleasant environment Coordinate care to allow client to get through sleep cycles Provide orienting materials (e.g., clocks, newspapers,eyeglasses, hearing aids, etc.)


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c. Associated with populations with highrisk for infection. The clients in thiscategory are:1) Transplant recipients2) Burn victims3) Neonates4) Immunosuppressed/AIDS, clients

with cancer receiving chemotherapy

4. Principles of surgical asepsisa. Sterile field: area where sterile materialsfor a sterile procedure are placed (e.g., atable covered with sterile drape).

b. Sterile field remains sterile throughoutprocedure.

c. Movement in and around field must notcontaminate it.

d. Keep hands in front of you and above yourwaist (never reach across the field withunsterile items).

e. Barrier techniques (gown, gloves, masks,and drapes are used as indicated todecrease transmission).

f. Edges of sterile containers are not sterileonce opened.g. Dry field is necessary to maintain sterility

of field.

UNIVERSAL/CLINICAL ISSUES

Pressure Ulcer (Dermal Ulcer,Decubitis Ulcer)A. Any lesion caused by unrelieved pressure that

causes local interference with circulation andsubsequent tissue damage.

B. Risk factors1. Immobility (e.g., bed- and chair-bound clients

as well as those with impaired ability toreposition themselves)

2. Incontinence3. Impaired nutritional status/intake4. Impaired level of consciousness5. Impaired physical condition (e.g., stability of

condition, chronicity, and severity)6. Skin condition impaired (e.g., nourishment,

turgor, integrity)7. Predisposing conditions (e.g., diabetes

mellitus, neuropathy, vascular disease,anemia, cortisone therapy)

C. General prevention, care, and treatment1. Inspect skin and document status and

interventions daily.2. Cleanse when soiling occurs (e.g., avoid hot

water, harsh or drying cleansing agents).3. Minimize dry skin (e.g., avoid cold or dry air

and use moisturizers as needed).4. Minimize moisture from irritating substances

(e.g., urine, feces, perspiration, wounddrainage).

a. Cleanse immediately and apply protectivebarrier as indicated.

5. Avoid massage over bony prominences.(Massage around but not directly overpressure sites.)

6. Change position frequently, every 15 minutesto 2 hours, to decrease prolonged pressure.

7. Reduce friction and shearing (e.g., promote

lifting rather than dragging).8. Support surfaces:a. Pressure relieving: static surfaces (