Nursing Fundamentals

🧭 Overview

🧠 One-sentence thesis

Scope of practice provides the legal framework that defines what nursing activities a licensed nurse is competent and permitted to perform, and nurses must always consider whether a requested task falls within their legal scope before acting.

📌 Key points (3–5)

• What scope of practice means: the services a trained health professional is deemed competent to perform and permitted to undertake according to their professional nursing license.
• Legal framework: scope of practice provides structured guidance for what practical nurses and registered nurses can perform based on their license type.
• Critical question for every task: nurses and nursing students must always ask whether they can legally perform a requested task or risk their education/license.
• Standards complement scope: nurses must follow standards set by the state Nurse Practice Act, ANA, agency policies, and federal regulators to ensure safe, competent care.
• Purpose of standards: these guidelines help direct nursing actions with the intent that safe, competent care is provided to the public.

🏛️ Core definition and legal framework

📜 What scope of practice is

Scope of practice: services a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional nursing license.

• This is a legal framework, not just a guideline or suggestion.
• It provides structured guidance for activities that different license types (practical nurses vs. registered nurses) can perform.
• The scope varies by license type—what one type of nurse can do may differ from another.

⚖️ The critical decision point

Every time a nurse or nursing student is asked to perform a task, they must consider:

• Can I legally do this based on my scope of practice?
• Am I putting my nursing education or nursing license at risk?

This is framed as an ongoing responsibility, not a one-time consideration.

Example: A nursing student is asked to perform a procedure. Before acting, they must verify whether their student status and training permit that activity, or whether it would violate their legal scope.

📏 Standards that govern nursing practice

🏢 Multiple sources of standards

Nurses must follow standards from several organizations and authorities:

Source	Role
State Nurse Practice Act	Legal state-level requirements
American Nurses Association (ANA)	Professional nursing standards
Agency policies and procedures	Facility-specific rules
Federal regulators	National-level requirements

🎯 Purpose of standards

• Intent: ensure that safe, competent care is provided to the public.
• Standards guide nursing actions—they tell nurses how to perform within their scope.
• Don't confuse: scope of practice defines what you can do; standards define how you should do it.

🏥 Context: nursing as a profession

📚 Chapter scope

The excerpt states this chapter will provide:

• An overview of basic concepts related to nursing scope of practice and standards of care.
• Coverage of learning objectives including:
  • Distinguishing levels of nursing education
  • Ethical and legal boundaries (Code of Ethics, Nurse Practice Act)
  • Client confidentiality
  • Health care team contributions
  • Evidence-based practice
  • Quality in client care
  • Various nursing work settings
  • Professional nursing organizations

🔍 Why this matters for students

• As a nursing student, understanding scope of practice is essential now, not just in the future.
• The excerpt emphasizes that students must consider scope of practice in their current role, highlighting that violations can affect both education and future licensure.

🧭 Overview

🧠 One-sentence thesis

Florence Nightingale transformed nursing from menial hospital tasks into a professional, educated practice grounded in evidence, environment, and holistic patient relationships—principles that remain foundational today.

📌 Key points (3–5)

• Nursing's origins: began in the 5th–6th centuries as religious charity; shifted to medical focus in the Middle Ages; professionalized in the mid-19th century.
• Florence Nightingale's breakthrough: used statistical evidence during the Crimean War to show that clean environments, water, and nutrition reduced soldier mortality from 60% to 2.2%.
• Core Nightingale principles: therapeutic environment, trusting nurse-patient relationships, confidentiality, and nursing knowledge distinct from medical knowledge.
• Common confusion: early nursing vs. modern nursing—before Nightingale, nursing was seen as menial work for lower classes; she established it as a professional, educated field.
• Modern nursing scope: over 4 million members in the U.S.; covers health promotion, disease prevention, care coordination, and holistic attention to physical, social, mental, emotional, and spiritual needs.

🕰️ Evolution of nursing before Nightingale

🕰️ Religious and charitable roots (5th–6th centuries)

• Nursing began as a charitable practice: caring for the sick, feeding and clothing the poor, and supporting widows and orphans.
• Foundations were religious; nuns often provided care.

⚕️ Shift to medical focus (Middle Ages)

• Medical and surgical treatments advanced; formal training began for medical practitioners.
• Care shifted from a religious perspective to a more medical one.

📉 Pre-Nightingale hospital nursing (mid-19th century)

• Nurses generally came from lower socioeconomic classes.
• Work focused on menial tasks: changing linens and other basic duties.
• Nursing was not seen as a professional or educated field.
• Don't confuse: this low-status image with the professional identity Nightingale later established.

🌟 Florence Nightingale's contributions

🌟 Who she was and her calling

• Florence Nightingale answered a religious calling to enter nursing, despite family opposition.
• She recognized the need for trained nurses and persisted in her vision.
• Result: she is considered the founder of modern nursing practice.

🏥 Crimean War breakthrough (1854)

• Nightingale's team discovered wounded soldiers were receiving poor care from overworked staff in dirty conditions.
• She documented the mortality rate and created statistical models.
• Key finding: 600 out of every 1,000 injured soldiers died from preventable communicable and infectious diseases.
• This statistical analysis became the early foundation of evidence-based practice used in nursing today.

🧼 Simple, powerful interventions

Nightingale's nursing interventions focused on:

• Providing a clean environment
• Ensuring clean water
• Promoting good nutrition (e.g., providing fruit to wounded soldiers)

Impact: mortality rate dropped from 60% to 2.2%.

Example: By simply improving hygiene and nutrition, the vast majority of preventable deaths were eliminated—demonstrating that nursing care, not just medical treatment, saves lives.

📚 Notes on Nursing (1859)

• Nightingale wrote this book, which became the cornerstone of the Nightingale School of Nursing curriculum (established 1860, the first nursing school in the world).
• She promoted the concept of nurses as a professional, educated workforce.

🧩 Foundational nursing principles from Nightingale

🧩 Therapeutic environment

Nightingale believed in placing a patient in an environment that promoted healing, allowing them to recover from disease.

• She emphasized that this knowledge was distinct from medical knowledge.
• Her focus on the healing power of the environment formed foundational principles still used in health care settings today.

🤝 Trusting relationships and presence

• Nightingale insisted on building trusting relationships with patients.
• She believed in the therapeutic healing that resulted from nurses' presence with patients.
• Don't confuse: nursing presence with passive observation—Nightingale saw it as an active, healing force.

🔒 Confidentiality

• Nightingale promoted confidentiality as a core principle.
• She stated a nurse "should never answer questions about her sick except to those who have a right to ask them."
• This principle remains central to nursing ethics today.

🏥 Modern nursing practice

🏥 Scope and scale

• Nursing has reinvented itself many times over the past 160 years as health care has advanced.
• Size: over 4 million members; the largest segment of the U.S. health care workforce.

🏥 Broad continuum of care

Modern nursing practice covers:

• Health promotion
• Disease prevention
• Coordination of care
• Palliative care when cure is not possible

🏥 Settings and roles

Nurses provide the majority of client assessments, evaluations, and care in:

• Hospitals
• Nursing homes
• Clinics
• Schools
• Workplaces
• Ambulatory settings

They are "at the front lines" ensuring care is delivered safely, effectively, and compassionately.

🧘 Holistic approach

• Nurses attend to patients and their families in a holistic way that often goes beyond physical health needs.
• They recognize and address:
  • Social needs
  • Mental needs
  • Emotional needs
  • Spiritual needs

Don't confuse: holistic care with "extra" care—Nightingale established that attending to the whole person is fundamental to nursing, not an add-on.

🧭 Overview

🧠 One-sentence thesis

Nursing practice is governed by multiple layers of standards—state Nurse Practice Acts, the American Nurses Association, employer policies, and federal regulations—all working together to ensure nurses deliver safe, competent, and ethical care to the public.

📌 Key points (3–5)

• Legal foundation: The Nurse Practice Act in each state defines scope of practice and is enforced by the state Board of Nursing, which can revoke licenses for violations.
• Professional standards: The ANA sets national standards through Nursing: Scope and Standards of Practice (defining the who/what/where/when/why/how of nursing) and the Code of Ethics for Nurses.
• Agency-level requirements: Nurses must follow employer-specific policies, procedures, and protocols, which supersede nursing school teachings but must still align with state scope of practice.
• Federal oversight: Organizations like The Joint Commission and CMS enforce safety goals and quality standards, often tying reimbursement to outcomes.
• Common confusion: Even if an agency asks you to do something, you must always stay within your state's Nurse Practice Act scope—protecting your license is your responsibility.

⚖️ State-level regulation

⚖️ Nurse Practice Act (NPA)

The Nurse Practice Act: enacted by a state's legislature, defines the scope of practice for nurses in that state, and establishes regulations for nursing practice.

• What it does: Sets legal boundaries for what nurses can and cannot do in that state.
• Enforcement: If a nurse violates the NPA's standards or scope, the state Board of Nursing can revoke their license.
• Why it matters: Nurses must legally follow the NPA in the state where they work, not just where they trained.
• Example: A nurse trained in one state must learn and follow the NPA of any new state they practice in.

🏛️ Board of Nursing

Board of Nursing: a licensing and regulatory body that issues nursing licenses to qualified candidates and provides discipline for nurses who do not follow standards and scope of practice.

• Two main roles:
  • Issues licenses to qualified candidates.
  • Disciplines nurses who violate the NPA.
• Student accountability: Nursing students are legally accountable for the quality of care they provide, just like licensed nurses.
• Students must recognize the limits of their knowledge and alert faculty or authority figures when situations exceed their competency.
• Violating standards of practice can result in the Board denying a license to a nursing graduate.

🎓 Student scope of practice

• Nursing students must understand their scope of practice as outlined in the NPA of the state where they complete clinical courses.
• Students are expected to recognize their limits and seek help appropriately.
• Don't confuse: Being a student does not exempt you from legal accountability—you are held to the same standards as nurses for the care you provide.

🇺🇸 National professional standards

🏥 American Nurses Association (ANA)

• Founded: 1896; represents nurses in all 50 states.
• Mission: "Lead the profession to shape the future of nursing and health care."
• Four pillars:
  • Fostering high standards of nursing practice.
  • Promoting a safe and ethical work environment.
  • Bolstering the health and wellness of nurses.
  • Advocating on health care issues affecting nurses and the public.

📘 ANA Scope and Standards of Practice

The ANA publishes Nursing: Scope and Standards of Practice, which describes:

Element	What it defines
Who	Nurses who are educated, titled, and maintain active licensure
What	Nursing integrates art and science of caring; focuses on protection, promotion, and optimization of health; prevention of illness; facilitation of healing; alleviation of suffering; diagnosis and treatment of human responses; advocacy
When	Anytime there is a need for nursing knowledge, wisdom, caring, leadership, practice, or education
Where	Any environment where there is a health care consumer in need of care, information, or advocacy
Why	Nursing's response to society's changing needs to achieve positive outcomes, in keeping with nursing's social contract
How	The ways, means, methods, and manners nurses use to practice professionally

• Simply put: Nurses treat human responses to health problems and life processes and advocate for the care of others.

🔄 Standards of Professional Nursing Practice

ANA Standards of Professional Nursing Practice: "authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently."

• Based on the nursing process: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.
• Define a competent level of nursing practice using critical thinking.
• All registered nurses must meet these standards.

🌟 Standards of Professional Performance

Twelve additional standards describing professional behavior:

1. Ethics: Integrates ethics in all aspects of practice.
2. Advocacy: Demonstrates advocacy in all roles and settings.
3. Respectful and Equitable Practice: Practices with cultural humility and inclusiveness.
4. Communication: Communicates effectively in all areas.
5. Collaboration: Collaborates with health care consumers and key stakeholders.
6. Leadership: Leads within the profession and practice setting.
7. Education: Seeks knowledge reflecting current practice and promotes futuristic thinking.
8. Scholarly Inquiry: Integrates scholarship, evidence, and research findings.
9. Quality of Practice: Contributes to quality nursing practice.
10. Professional Practice Evaluation: Evaluates one's own and others' nursing practice.
11. Resource Stewardship: Utilizes appropriate resources for safe, effective, financially responsible, and judicious services.
12. Environmental Health: Practices in a manner that advances environmental safety and health.

• Accountability: Nurses are accountable to themselves, health care consumers, peers, and society.
• Historical note: The Nightingale pledge historically emphasized nursing as a calling requiring dedication to serve the community according to standards of care and ethics.

🏢 Employer-level requirements

📋 Policies, procedures, and protocols

• In addition to ANA and state NPA standards, nurses must follow agency-specific policies, procedures, and protocols.
• Policy example: A hospital may require a thorough skin assessment documented daily on every client; failure to follow this can result in liability if a pressure injury develops.
• Procedure example: Each agency has specific steps for nursing skills (e.g., inserting urinary catheters).

📜 Protocol definition

Protocol: "a precise and detailed written plan for a regimen of therapy."

• Example: A hypoglycemia protocol automatically implemented when a client's blood sugar falls below a specific number (e.g., provide orange juice, recheck blood sugar).
• Superseding rule: Agency-specific policies, procedures, and protocols supersede information taught in nursing school.
• Nurses and students can be held legally liable if they don't follow them.

⚠️ Protecting your license

• Critical principle: You must continue to follow your state's Nurse Practice Act scope of practice even when following agency policies.
• Don't confuse: If an agency asks you to do something outside your defined scope of practice, you must refuse to protect your nursing license.
• It is always up to you to protect your license and follow the state's NPA when providing client care.

🏛️ Federal regulations and oversight

🏥 The Joint Commission (TJC)

• What it is: A national organization that accredits and certifies over 20,000 health care organizations in the U.S.
• Mission: Continuously improve health care by inspiring organizations to excel in providing safe and effective care of the highest quality and value.
• How it works: Sets standards for safe, high-quality health care; examples include National Patient Safety Goals and establishing a Safety Culture.

🎯 National Patient Safety Goals

The Joint Commission establishes annual goals for various agency types based on current national safety concerns.

Examples for hospitals:

• Identify Patients Correctly

• Improve Staff Communication

• Use Medicines Safely

• Use Alarms Safely

• Prevent Infection

• Identify Patient Safety Risks

• Prevent Mistakes in Surgery

• Implementation: Nurses, students, and staff incorporate actions related to these goals into daily client care.

• Examples: SBAR handoff reporting, barcode scanning equipment, perioperative team "time-outs" before surgery.

• Nursing programs use these goals to guide curriculum and clinical practice expectations.

🛡️ Safety Culture

Safety culture: empowers nurses, nursing students, and other staff members to speak up about concerns regarding client risks and to report errors and near misses, all of which drive improvement in client care and reduce incidences of client harm.

• Purpose: Encourages reporting to investigate system factors that contribute to errors, not to punish individuals.
• Example: A nurse or student creates an incident report when a medication error occurs; the agency uses it to investigate and improve systems.
• Many agencies have successfully reduced client harm by implementing a safety culture.

💰 Centers for Medicare & Medicaid Services (CMS)

• What it is: A federal agency that establishes and enforces regulations to protect client safety in hospitals receiving Medicare and Medicaid funding.
• Regulation example: Hospital policies must require confirmation of specific information before medication is administered (often called "checking the rights of medication administration").
• Quality standards: Organizations are reimbursed based on the quality of their client outcomes.
  • Example: Organizations with high rates of healthcare-associated infections (HAI) receive less reimbursement.
  • Result: Many agencies have reexamined policies, procedures, and protocols to promote optimal outcomes and maximum reimbursement.

💵 Reimbursement and health care funding

💼 Private health insurance

• Sources: Sponsored by employers or purchased privately by individuals from the Health Insurance Marketplace.
• Regulation: Private insurance programs must comply with state and federal regulations even though they are privately owned.

🏛️ Affordable Care Act (ACA)

• Also known as: "Obamacare" (2010).
• What it does: Created cost-reduction programs for private insurance through a public insurance marketplace.
• Subsidies: Insurance premiums are subsidized by taxpayer funds for incomes between 100% and 400% of the federal poverty level (e.g., in 2023, $30,000 to $120,000 for a family of four).
• Impact: Significantly decreased the number of uninsured individuals, but premiums can still be high.
• Remaining uninsured: Approximately 7.7% of individuals and families remain uninsured, leading to increased health risks due to lack of preventive services, well child care, dental care, and treatment of chronic disease.
• Consequence: Visits to the Emergency Room often increase when clients delay care due to cost concerns, further contributing to health care costs as hospitals are often not reimbursed for these visits.

🏥 Medicare

• Who it covers: Individuals aged 65 or older, individuals younger than 65 with certain disabilities, or those at any age with end-stage renal disease.
• Funding: Federally funded.

🏥 Medicaid

• Who it covers: Low-income adults, pregnant women, and children.
• Funding: Combination of state and federal funds.

📊 Diagnosis-Related Groups (DRGs)

• What they are: Medicare uses DRGs to classify clients with similar clinical characteristics (age, gender, severity of disease, comorbidities) with the rationale that these clients have similar care needs.
• Reimbursement: CMS sets reimbursement rates based on DRGs for qualifying services.
• Limitation: Differences between set reimbursement rates and actual charges cannot be passed on to the individual (though copays may apply).
• Financial impact: By accepting Medicare or Medicaid clients, organizations agree to accept these rates, which may be less than the actual cost of providing care (e.g., in 2017, Medicaid reimbursement was 89% of the cost of care).
• Compliance: Agencies receiving Medicare or Medicaid reimbursement must comply with state and federal regulations and meet established client outcomes, or their reimbursement rates are decreased or eliminated.

🧭 Overview

🧠 One-sentence thesis

Quality health care requires nurses to work collaboratively across primary, secondary, and tertiary care settings with a diverse interprofessional team, each member contributing specialized expertise to achieve holistic client outcomes.

📌 Key points (3–5)

• Three levels of care: primary (wellness/prevention), secondary (acute illness/injury), and tertiary (long-term/chronic management).
• Nursing roles by license level: LPNs provide basic nursing care under supervision; RNs use the nursing process and delegate; APRNs diagnose and prescribe.
• Team collaboration: nurses coordinate care with providers, UAPs, and interprofessional members (dieticians, PTs, OTs, social workers, etc.).
• Common confusion: secondary vs tertiary care—secondary treats the acute problem (e.g., setting a broken bone), while tertiary restores function after healing (e.g., regaining ability to walk).
• Chain of command: nurses consult hierarchically (charge nurse → supervisor → director) to address concerns and ensure accountability.

🏥 Levels of health care settings

🌱 Primary care

Primary care promotes wellness and prevents disease.

• What it includes: health promotion, education, immunizations, early disease screening, environmental considerations.
• Settings: physician offices, public health clinics, school nursing, community health nursing.
• Focus: keeping people healthy before illness occurs.

🚑 Secondary care

Secondary care occurs when a person has contracted an illness or injury and requires medical care.

• Also called acute care.
• Range of complexity: from simple repairs (small laceration, strep throat) to emergent care (head injury from accident).
• Settings: physician offices, clinics, urgent care, hospitals; specialized units include critical care, burn units, neurosurgery, cardiac surgery, transplant services.
• Goal: return the client to health and wellness.

🔄 Tertiary care

Tertiary care addresses the long-term effects from chronic illnesses or conditions with the purpose to restore a client's maximum physical and mental function.

• Goal: achieve the highest level of functioning possible while managing chronic illness.
• Example: a client who fractured their hip needs secondary care to set the bones, but tertiary care to regain strength and walking ability after bones heal.
• Another example: clients with incurable diseases (e.g., dementia) need specialized tertiary care for daily functioning support.
• Settings: rehabilitation units, assisted living, adult day care, skilled nursing units, home care, hospice centers.
• Don't confuse: tertiary care is not just "long-term hospital stay"; it focuses on restoring function and managing chronic conditions, not just treating the acute event.

👥 Health care team roles

🩺 Health care providers

A health care provider is "a physician, podiatrist, dentist, optometrist, or advanced practice nurse."

• Responsibilities: order diagnostic tests (blood work, X-rays), diagnose medical conditions, develop medical treatment plans, prescribe medications.
• In hospitals: the treatment plan is documented in the "History and Physical" section; prescriptions are called "orders."
• Provider rounds: providers visit hospitalized clients daily; nurses and students should attend rounds for their assigned clients to understand goals, clarify orders, and minimize follow-up calls.
• Nurse's role: respectfully clarify prescriptions when questions or concerns arise to ensure safe client care.

👩‍⚕️ Licensed Practical/Vocational Nurses (LPN/LVN)

A licensed practical nurse (LPN) is "an individual who has completed a state-approved practical or vocational nursing program, passed the NCLEX-PN examination, and is licensed by a state board of nursing to provide client care."

• Supervision: typically work under the supervision of an RN, APRN, or physician.
• Scope: provide "basic nursing care" to stable and/or chronically ill populations.
• Basic nursing care definition: "care that can be performed following a defined nursing procedure with minimal modification in which the responses of the client to the nursing care are predictable."
• Typical tasks: collect client assessment information, administer medications, perform nursing procedures according to state scope of practice.

📋 Wisconsin LPN scope highlights

• Accept only assignments the LPN is competent to perform.
• Provide basic nursing care.
• Record care given and report changes in client condition.
• Consult with a provider if a delegated act may harm a patient.
• Assist with data collection, care plan development/revision, reinforce teaching, participate with the health team.

🩺 Registered Nurses (RN)

A Registered Nurse (RN) is "an individual who has graduated from a state-approved school of nursing, passed the NCLEX-RN examination and is licensed by a state board of nursing to provide client care."

• Critical thinking model: use the nursing process (assessment, planning, intervention, evaluation) to make decisions and use clinical judgment.
• Delegation: may be delegated tasks from providers; may delegate tasks to LPNs and UAPs with supervision.
• Accountability: the RN remains accountable that delegated tasks are completed and documented.

🔄 Wisconsin RN scope highlights: the nursing process

Step	What it means
Assessment	Systematic and continual collection and analysis of data about health status, culminating in a nursing diagnosis.
Planning	Developing a nursing plan of care with goals and priorities derived from the nursing diagnosis.
Intervention	Nursing action to implement the plan by directly administering care or directing/supervising delegated acts.
Evaluation	Determining patient progress toward goal achievement; may lead to modification of the nursing diagnosis.

• Delegated acts: accept only those for which there are protocols or orders, and for which the RN is competent; consult provider if an act may harm a patient.
• Supervision: delegate tasks commensurate with educational preparation and abilities of the person supervised; provide direction, observe, monitor, and evaluate.

🎓 Advanced Practice Registered Nurses (APRN)

Advanced Practice Registered Nurses (APRN) are RNs who have a graduate degree and advanced knowledge.

Four categories:

Role	Abbreviation	Key functions
Nurse Practitioner	NP	Physical exams, diagnose/treat acute illness, manage chronic illness, order tests, prescribe medications/therapies, health teaching, prevention emphasis. May function independently or require physician supervision depending on state. Certifications: Family Practice, Adult-Gerontology Primary/Acute Care, Psychiatric/Mental Health.
Clinical Nurse Specialist	CNS	Mentor nurses, case management, research, design/conduct quality improvement programs, serve as educators and consultants. Specialties: Adult/Gerontology, Pediatrics, Neonatal.
Certified Registered Nurse Anesthetist	CRNA	Administer anesthesia and related care before/during/after procedures; provide airway management during emergencies. Deliver >65% of all anesthetics in the U.S. Settings: operating rooms, dental offices, outpatient surgical centers.
Certified Nurse Midwife	CNM	Gynecological exams, family planning, prenatal care, low-risk labor/delivery management, neonatal care. Settings: hospitals, birthing centers, community clinics, client homes.

• Key authority: APRNs can diagnose illnesses and prescribe treatments and medications.

🤝 Unlicensed Assistive Personnel (UAP)

Unlicensed Assistive Personnel (UAP) are "any unlicensed person, regardless of title, who performs tasks delegated by a nurse."

• Titles include: certified nursing aides/assistants (CNAs), patient care assistants (PCAs), patient care technicians (PCTs), state tested nursing assistants (STNAs), nursing assistants-registered (NA/Rs), certified medication aides/assistants (MA-Cs).
• Settings: hospitals and long-term care facilities in Wisconsin.
• Typical tasks: assist clients with daily tasks (bathing, dressing, feeding, toileting); collect client information (vital signs, weight, input/output) as delegated.
• Accountability: the RN remains accountable that delegated tasks have been completed and documented by the UAP.

🤝 Interprofessional team members

🍎 Dieticians

• Assess, plan, implement, and evaluate interventions related to dietary needs (regular or therapeutic diets).
• Provide dietary education.
• Work with the team when clients have dietary needs secondary to physical disorders (e.g., difficulty swallowing).

🧩 Occupational Therapists (OT)

• Facilitate the client's highest possible level of independence in activities of daily living (bathing, grooming, eating, dressing).
• Provide adaptive devices: long shoehorns, sock pulls, adaptive silverware, grabbers, buttoning devices.
• Assess the home for safety and need for assistive devices (ramps, grab rails, handrails).
• Practice in all health care environments: home, hospital, rehabilitation centers.

💊 Pharmacists

• Ensure safe prescribing and dispensing of medication.
• Vital resource for nurses with medication questions or concerns.
• Ensure clients get correct medication/dosing and guidance for safe, effective use.

🏃 Physical Therapists (PT)

• Assess, plan, implement, and evaluate interventions related to functional abilities: strength, mobility, balance, gait, coordination, joint range of motion.
• Supervise prescribed exercise activities.
• Provide and teach use of assistive aids (walkers, canes) and exercise regimens.
• Practice in all health care environments: home, hospital, rehabilitation centers.

🦶 Podiatrists

• Provide care and services for clients with foot problems.
• Often work with clients who have diabetes to clip toenails and provide foot care to prevent complications.

🦾 Prosthetists

• Design, fit, and supply artificial body parts (leg or arm prosthesis).
• Adjust prosthesis to ensure proper fit, comfort, and functioning.

🧠 Psychologists and Psychiatrists

• Provide mental health and psychiatric services to clients with mental health disorders.
• Provide psychological support to family members and significant others as indicated.

🫁 Respiratory Therapists

• Treat respiratory-related conditions.
• Specialized care includes: manage oxygen therapy, draw arterial blood gases, manage mechanical ventilators/CPAP/Bi-PAP, administer respiratory medications (inhalers, nebulizers), intubate clients, assist with bronchoscopy, perform chest physiotherapy, provide respiratory support.

🏠 Social Workers

• Counsel clients and provide psychological support.
• Help set up community resources according to clients' financial needs.
• Serve as part of the team ensuring continuity of care after discharge.

🗣️ Speech Therapists

• Assess, diagnose, and treat communication and swallowing disorders.
• Example: help clients with expressive aphasia; assist with word boards and electronic communication devices.
• Assess clients with dysphagia (swallowing disorders) and treat in collaboration with nurses, dieticians, and providers.

🔬 Ancillary department members

Department	Role
Clinical laboratory	Provide laboratory procedures to aid diagnosis, treatment, and management. Staffed by medical technologists who test biological specimens. Examples: blood tests, blood banking, cultures, urine tests, histopathology.
Radiology	Use imaging to assist in diagnosing and treating diseases. Perform X-rays, CTs, MRIs, nuclear medicine, PET scans, ultrasound scans.

🔗 Chain of command and coordination

🪜 Chain of command

Chain of command refers to a hierarchy of reporting relationships—from the bottom to the top of an organization—regarding who must answer to whom.

• Purpose: establishes accountability and lays out lines of authority and decision-making power.
• Example in a hospital: registered nurse → charge nurse → nurse supervisor → director of nursing → vice president of nursing.
• Example in long-term care: licensed practical/vocational nurse → registered nurse/charge nurse → director of nursing.
• For nursing students: always consult with your nursing instructor regarding questions or concerns about client care before going up the chain of command.

🧭 Nurse as coordinator

• Nurses continuously review the plan of care to ensure all contributions of the multidisciplinary team are moving the client toward expected outcomes and goals.
• Don't confuse: the nurse does not make all decisions alone; instead, the nurse consults with other nurses and interprofessional team members and coordinates their contributions.

🏅 Nurse specialties and certifications

Certification is the formal recognition of specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty.

🏥 Common nurse specialties

Specialty	Focus	Setting
Critical Care Nurses	Care for clients with serious, complex, acute illnesses/injuries requiring close monitoring and extensive medication protocols/therapies.	Intensive care units of hospitals.
Public Health Nurses	Promote and protect the health of populations based on nursing, social, and public health sciences.	Municipal and state health departments.
Home Health/Hospice Nurses	Provide nursing services for chronically ill clients and caregivers in the home, including end-of-life care.	Client homes.
Occupational/Employee Health Nurses	Health screening, wellness programs, health teaching, minor treatments, disease/medication management in the workplace. Focus on promotion, restoration, prevention, and protection from work-related/environmental hazards.	Workplaces.
Oncology Nurses	Care for clients with cancer, administer chemotherapy, provide follow-up care, teaching, and monitoring.	Hospitals, outpatient clinics, clients' homes.
Perioperative/Operating Room Nurses	Provide preoperative and postoperative care; assist with surgical procedures (select/handle instruments, control bleeding, suture incisions).	Hospitals and outpatient surgical centers.
Rehabilitation Nurses	Care for clients with temporary and permanent disabilities.	Inpatient and outpatient settings (clinics, home health care).
Psychiatric/Mental Health Nurses	Specialize in mental and behavioral health problems; provide nursing care to individuals with psychiatric disorders.	Hospitals, outpatient clinics, private offices.
School Nurses	Health assessment, intervention, follow-up to maintain school compliance with health care policies; ensure health and safety of staff and students. Administer medications, refer students for additional services (hearing, vision).	Schools.

📱 Telenursing

• Not a specialty, but a method of providing nursing care remotely using information and communication technology.
• May include: client education, support, health assessment/evaluation, triage.
• Provided in: several specialty areas (Critical Care, Emergency Departments), outpatient environments.
• Benefit: encourages increased client interactions, especially in underserved rural areas.

👶👴 Life span specialties

• Other common specialty areas use a life span approach across health care settings.
• Examples: maternal-child, neonatal, pediatric, and gerontological nursing.

🧭 Overview

🧠 One-sentence thesis

To become a nurse, candidates must graduate from a state-approved nursing program and pass the National Council Licensure Examination (NCLEX), with multiple educational pathways available depending on the desired nursing role.

📌 Key points (3–5)

• Two mandatory requirements: graduation from a state-approved nursing program and passing the NCLEX exam.
• Multiple educational pathways: LPN/VN requires one year; RN requires either a two-year ADN, four-year BSN, or three-year diploma program.
• NCLEX structure: adaptive, variable-length online test that measures knowledge, skills, and abilities essential for safe entry-level nursing practice.
• Common confusion: NCLEX-RN vs NCLEX-PN—RNs take NCLEX-RN (75-265 items, 6 hours), LPNs/LVNs take NCLEX-PN (85-205 items, 5 hours).
• Advanced degrees expand opportunities: MSN and doctoral degrees (PhD, DNP) allow specialization in education, advanced practice, research, or clinical leadership.

📚 Pathways to becoming a nurse

🩺 Licensed Practical Nurse/Vocational Nurse (LPN/VN)

• Complete a one-year nursing program.
• Pass the NCLEX-PN exam.
• Apply to the state Board of Nursing to receive an LPN license.

🏥 Registered Nurse (RN) pathways

Three main routes to become an RN:

Pathway	Duration	Notes
Associate Degree (ADN)	2 years	Many hospitals require BSN completion within a specific timeframe
Baccalaureate (BSN)	4 years	Required for military nursing, case management, public health, school nursing
Hospital-based diploma	3 years	Historically the most common route; lesser-known today

• After completing any of these programs, graduates must pass the NCLEX-RN to apply for RN licensure from their state Board of Nursing.
• Many ADN graduates enroll in BSN or higher degree programs after graduation.

📝 The NCLEX examination

🖥️ Exam format and structure

The NCLEX tests knowledge, skills, and abilities essential to the safe and effective practice of nursing at the entry level.

Key characteristics:

• Online, adaptive tests taken at specialized testing centers.
• Variable length—adapts as you answer items.
• Continually reviewed and updated based on surveys of newly graduated nurses every three years.

NCLEX-RN specifics:

• 75 to 265 items (15 are unscored test items).
• Six-hour time limit.

NCLEX-PN specifics:

• 85 to 205 items (25 are unscored items).
• Five-hour time limit.

🆕 Next Generation NCLEX (NGN)

Implemented in April 2023, the NGN introduced significant changes:

Framework:

• Uses the NCSBN Clinical Judgment Measurement Model.
• Measures prelicensure nursing graduates' clinical judgment and decision-making.
• Still based on the "Nursing Process" critical thinking model but uses new terminology.

New terminology candidates will encounter:

• "Recognize cues"
• "Analyze cues"
• "Create a hypothesis"
• "Prioritize hypotheses"
• "Generate solutions"
• "Take actions"
• "Evaluate outcomes"

New question types:

• Case studies
• Enhanced hot spots
• Drag and drop ordering of responses
• Multiple responses
• Embedded answer choices within paragraphs of text

Rationale: To measure nursing clinical judgment and decision-making ability to protect public health and welfare by ensuring safe and competent nursing care.

🗺️ Nurse Licensure Compact (NLC)

The Nurse Licensure Compact allows a nurse to have one multistate nursing license with the ability to practice in their home state, as well as in other compact states.

• As of 2023, 41 states have implemented NLC legislation.
• Enables nurses to practice across state lines without obtaining multiple licenses.

🎓 Advanced nursing degrees

📖 Master of Science in Nursing (MSN)

• Requires additional credits and years beyond the BSN.
• Variety of potential focuses including Nurse Educator and Advanced Practice Registered Nurse (APRN).

Associated certifications:

• Certified Nurse Educator (CNE)
• Nurse Practitioner (NP)
• Clinical Nurse Specialist (CNS)
• Certified Registered Nurse Anesthetist (CRNA)
• Certified Nurse Midwife (CNM)

Certification requirements:

• Successful completion of a certification exam.
• Continuing education requirements to maintain certification.
• Scope of practice defined by each state's Nurse Practice Act.

🔬 Doctoral degrees in nursing

Degree	Focus	Typical work roles
Doctor of Philosophy (PhD)	Research	Teaching or conducting research in universities or other settings
Doctor of Nursing Practice (DNP)	Clinical nursing practice	Advanced nursing practice, clinical leadership, or academic settings

🔄 Lifelong learning requirement

📚 Commitment to ongoing education

• Nursing practice changes rapidly and is continually updated with new evidence-based practices.
• Nurses must commit to lifelong learning to continue providing safe, quality care.

State requirements vary:

• Many states require continuing education credits to renew RN licenses.
• Others rely on health care organizations to set education standards and ongoing educational requirements.

Why it matters: No matter what nursing role or level of education you choose, staying current with evidence-based practices is essential for safe, quality client care.

🧭 Overview

🧠 One-sentence thesis

Nurses can be held legally liable for negligence or malpractice when they fail to follow the standard of care, and avoiding liability requires adherence to the Nurse Practice Act, professional standards, and employer policies.

📌 Key points (3–5)

• Negligence vs malpractice: negligence is general carelessness and deviation from reasonable care; malpractice is negligence judged against a professional standard of care.
• Six elements required to prove: duty owed, breach of duty, foreseeability, causation, injury, and damages must all be established in court.
• How to avoid liability: follow the Nurse Practice Act, ANA standards, and employer policies/procedures/protocols.
• Common confusion: negligence is broader (any carelessness); malpractice is specific to professionals and their standard of care.
• Consequences: nurses can be reprimanded, lose their license, or face legal action for breaches of duty.

⚖️ Legal liability in nursing

⚖️ What negligence means

Negligence: conduct lacking in due care, carelessness, and a deviation from the standard of care that a reasonable person would use in a particular set of circumstances.

• It is a general term applicable to anyone, not just professionals.
• The key is comparing behavior to what a "reasonable person" would do in the same situation.
• Example: failing to take basic precautions that any reasonable person would take.

⚖️ What malpractice means

Malpractice: a more specific term that looks at a standard of care, as well as the professional status of the caregiver.

• Malpractice applies specifically to professionals (like nurses, doctors).
• It judges conduct against the professional standard of care, not just general reasonableness.
• Don't confuse: all malpractice involves negligence, but not all negligence is malpractice—malpractice requires professional status and a professional standard.

🧱 Six elements to prove negligence or malpractice

🧱 What must be established in court

To prove negligence or malpractice, all six of the following elements must be established:

Element	What it means
Duty owed the client	The nurse had a professional obligation to the client
Breach of duty owed the client	The nurse failed to meet that obligation
Foreseeability	The harm was predictable
Causation	The breach directly caused the harm
Injury	The client suffered actual harm
Damages	The harm resulted in measurable losses

• All six must be present; if any element is missing, negligence/malpractice cannot be proven.
• Example: if a nurse breaches duty but no injury occurs, there is no malpractice case.

🛡️ How to avoid liability

🛡️ Follow established standards

To avoid being sued for negligence or malpractice, nurses and nursing students must follow:

• State Nurse Practice Act: defines scope and standards of practice for that state.
• American Nurses Association standards: national professional guidelines.
• Employer policies, procedures, and protocols: specific rules for the workplace.

🛡️ Consequences of breach

• Nurses can be reprimanded by their state Board of Nursing.
• Licenses can be revoked for not following the Nurse Practice Act.
• Nurses can be held legally liable for negligence, malpractice, or breach of client confidentiality.
• Risk of losing the nursing license if standards are not followed.

🚨 Examples of breach of duty

🚨 Failure to assess

Failure to Assess: Nurses should assess for all potential nursing problems/diagnoses, not just those directly affected.

• The excerpt emphasizes that nurses must assess all potential problems, not only the obvious or primary ones.
• Example: a nurse focuses only on a client's wound but fails to assess for pain, infection risk, or mobility issues—this could be viewed as negligence.
• Why it matters: incomplete assessment can lead to missed problems, harm to the client, and legal liability.

🚨 Other breaches mentioned

The excerpt begins to list examples of breach of duty but is incomplete. The key principle is:

• Any failure to meet the duty owed to the client (assessment, intervention, documentation, etc.) can be viewed as negligence if it deviates from the standard of care.

🧭 Overview

🧠 One-sentence thesis

Nurses must commit to lifelong learning because nursing practice changes rapidly with new evidence-based practices, and many states require continuing education to maintain licensure.

📌 Key points (3–5)

• NCLEX exams: variable-length, adaptive tests (NCLEX-RN: 75–265 items; NCLEX-PN: 85–205 items) that assess entry-level nursing competency.
• Next Generation NCLEX (NGN): introduced in April 2023, uses the NCSBN Clinical Judgment Measurement Model with new terminology like "recognize cues," "analyze cues," and "evaluate outcomes."
• Nurse Licensure Compact (NLC): allows one multistate license to practice in home state and other compact states (41 states as of 2023).
• Advanced degrees: MSN and doctoral degrees (PhD, DNP) expand opportunities; MSN includes roles like Nurse Practitioner, Clinical Nurse Specialist, and Nurse Educator.
• Lifelong learning requirement: many states require continuing education credits to renew RN licenses; organizations also set ongoing educational standards.

📝 NCLEX Examinations

📝 What NCLEX tests

NCLEX exams assess knowledge, skills, and abilities essential to the safe and effective practice of nursing at the entry level.

• The exams are continually reviewed and updated based on surveys of newly graduated nurses every three years.
• Both NCLEX-RN and NCLEX-PN are variable-length tests that adapt as you answer items.

🔢 NCLEX-RN structure

• Item range: 75 to 265 items, depending on how quickly you demonstrate proficiency.
• Unscored items: 15 of the items are unscored test items.
• Time limit: six hours.

🔢 NCLEX-PN structure

• Item range: 85 to 205 items.
• Unscored items: 25 of the items are unscored.
• Time limit: five hours.

🆕 Next Generation NCLEX (NGN)

🆕 When and why it changed

• The Next Generation NCLEX went into effect in April 2023.
• NCSBN's rationale: to measure nursing clinical judgment and decision-making ability of prospective entry-level nurses to protect the public's health and welfare by assuring safe and competent nursing care.

🧠 Clinical Judgment Measurement Model

• The NGN uses the NCSBN Clinical Judgment Measurement Model as a framework to measure prelicensure nursing graduates' clinical judgment and decision-making.
• The critical thinking model called the "Nursing Process" continues to underlie the NGN, but candidates will notice new terminology.
• New terminology examples: "recognize cues," "analyze cues," "create a hypothesis," "prioritize hypotheses," "generate solutions," "take actions," or "evaluate outcomes."

📋 New question types

The NGN includes new types of questions:

• Case studies
• Enhanced hot spots
• Drag and drop ordering of responses
• Multiple responses
• Embedded answer choices within paragraphs of text

Don't confuse: The Nursing Process still underlies the exam; the NGN adds new terminology and question formats, but the foundation remains the same critical thinking model.

🗺️ Nurse Licensure Compact (NLC)

🗺️ What the NLC allows

Nurse Licensure Compact (NLC): allows a nurse to have one multistate nursing license with the ability to practice in their home state, as well as in other compact states.

• As of 2023, 41 states have implemented NLC legislation.
• This means nurses can practice across state lines without obtaining separate licenses in each state.

🎓 Advanced Nursing Degrees

🎓 Master's Degree in Nursing (MSN)

• Requires additional credits and years of schooling beyond the BSN.
• Variety of focuses: Nurse Educator and Advanced Practice Registered Nurse (APRN).

Certifications associated with MSN:

Certification	Full Name
CNE	Certified Nurse Educator
NP	Nurse Practitioner
CNS	Clinical Nurse Specialist
CRNA	Certified Registered Nurse Anesthetist
CNM	Certified Nurse Midwife

• Certifications require successful completion of a certification exam and continuing education requirements to maintain the certification.
• Scope of practice for advanced practice nursing roles is defined by each state's Nurse Practice Act.

🎓 Doctoral Degrees in Nursing

Two types of doctoral nursing degrees:

Degree	Focus	Typical Work Roles
PhD (Doctor of Philosophy in Nursing)	Research	Teaching or conducting research in universities or other settings
DNP (Doctor of Nursing Practice)	Clinical nursing practice	Advanced nursing practice, clinical leadership, or academic settings

📚 Lifelong Learning

📚 Why lifelong learning is essential

• Nursing practice changes rapidly and is continually updated with new evidence-based practices.
• Nurses must commit to lifelong learning to continue to provide safe, quality care to their clients.

📚 Continuing education requirements

• Many states require continuing education credits to renew RN licenses.
• Other states rely on health care organizations to set education standards and ongoing educational requirements.
• Example: An organization might require nurses to complete a certain number of hours of continuing education annually to maintain competency in current evidence-based practices.

Key point: No matter what nursing role or level of nursing education you choose, the commitment to ongoing learning is necessary because practice standards evolve continuously.

🧭 Overview

🧠 One-sentence thesis

Nurses must understand legal and ethical considerations—including negligence, malpractice, and scope of practice—to protect their licenses and provide safe care, while committing to lifelong learning as evidence-based practices continually evolve.

📌 Key points (3–5)

• Lifelong learning is mandatory: nursing practice changes rapidly with new evidence-based practices, requiring ongoing education to maintain safe, quality care.
• Legal liability risks: nurses can face license revocation, negligence claims, or malpractice suits if they deviate from the Nurse Practice Act, standards of care, or breach confidentiality.
• Common confusion—negligence vs malpractice: negligence is general carelessness and deviation from reasonable care; malpractice is a more specific legal standard tied to professional status and duty.
• Six elements must be proven: to establish negligence or malpractice in court, all six elements (duty, breach, foreseeability, causation, injury, damages) must be shown.
• Prevention strategy: following state Nurse Practice Acts, ANA standards, and employer policies protects nurses from legal action and license loss.

📚 Advanced nursing education pathways

🎓 Master's degree options (MSN)

• Requires additional credits and years beyond the BSN.
• Potential focuses: Nurse Educator, Advanced Practice Registered Nurse (APRN).
• Associated certifications:
  • Certified Nurse Educator (CNE)
  • Nurse Practitioner (NP)
  • Clinical Nurse Specialist (CNS)
  • Certified Registered Nurse Anesthetist (CRNA)
  • Certified Nurse Midwife (CNM)
• All certifications require passing an exam and ongoing continuing education.
• Scope of practice for advanced roles is defined by each state's Nurse Practice Act.

🎓 Doctoral degrees in nursing

Degree	Focus	Typical roles
PhD (Doctor of Philosophy in Nursing)	Research	Teaching or conducting research in universities or other settings
DNP (Doctor of Nursing Practice)	Clinical nursing practice	Advanced nursing practice, clinical leadership, or academic settings

• Don't confuse: PhD emphasizes research; DNP emphasizes clinical practice.

🔄 Lifelong learning requirement

📖 Why continuous education matters

• Nursing practice changes rapidly and is continually updated with new evidence-based practices.
• Nurses must commit to lifelong learning to continue providing safe, quality care.
• This requirement applies regardless of nursing role or education level.

📜 State and organizational requirements

• Many states require continuing education credits to renew RN licenses.
• Other states rely on health care organizations to set education standards and ongoing educational requirements.
• Example: An organization may mandate annual training on new protocols even if the state does not require continuing education credits.

⚖️ Legal considerations in nursing practice

🔍 Negligence vs malpractice—key distinctions

Negligence: a general term that denotes conduct lacking in due care, carelessness, and a deviation from the standard of care that a reasonable person would use in a particular set of circumstances.

Malpractice: a more specific term that looks at a standard of care, as well as the professional status of the caregiver.

• How to distinguish: negligence applies to anyone (general carelessness); malpractice is specific to professionals and their duty of care.
• Both can result in legal liability when providing client care.
• Example: A reasonable person failing to clean up a spill (negligence) vs. a nurse failing to assess a client's condition (malpractice).

⚖️ Six elements required to prove negligence or malpractice

To establish negligence or malpractice in court, all six of the following elements must be proven:

1. Duty owed the client: the nurse had a professional obligation to the client.
2. Breach of duty owed the client: the nurse failed to meet that obligation.
3. Foreseeability: the harm was predictable.
4. Causation: the breach directly caused the harm.
5. Injury: actual harm occurred to the client.
6. Damages: measurable losses resulted from the injury.

• All six must be present; missing even one element means the case cannot be proven.
• Example: A nurse fails to assess a client (breach of duty), the client's condition worsens (injury), and the worsening was predictable and directly caused by the failure to assess (foreseeability and causation), resulting in extended hospitalization (damages).

🛡️ How to avoid legal liability

Prevention strategies:

• Follow the scope and standards of practice set forth by your state's Nurse Practice Act.
• Adhere to American Nurses Association (ANA) standards.
• Comply with employer policies, procedures, and protocols.
• Avoid breaches of client confidentiality.

Consequences of non-compliance:

• Nurses can be reprimanded.
• Licenses can be revoked.
• Legal action for negligence or malpractice can be taken.

⚠️ Examples of breach of duty (negligence)

The excerpt provides one specific example:

• Failure to Assess: Nurses should assess for all potential nursing problems/diagnoses, not just those directly affected [by the presenting issue].

• Don't confuse: assessing only the obvious problem is insufficient; comprehensive assessment is required to meet the standard of care.

• Example: A client presents with a broken arm, but the nurse fails to assess for other injuries or complications—this could constitute negligence if harm results.

🔐 Additional legal risks

🔐 Breach of client confidentiality

• Nurses can be held legally liable for breaching client confidentiality.
• This is a separate legal risk beyond negligence and malpractice.
• Protecting client information is a fundamental duty in nursing practice.

🌐 Nurse Licensure Compact (NLC)

🗺️ Multistate practice privilege

Nurse Licensure Compact (NLC): allows a nurse to have one multistate nursing license with the ability to practice in their home state, as well as in other compact states.

• As of 2023, 41 states have implemented NLC legislation.
• This simplifies licensure for nurses who work across state lines.
• Don't confuse: NLC does not override individual state Nurse Practice Acts; scope of practice is still defined by each state.

🧭 Overview

🧠 One-sentence thesis

Strong communication skills are essential for nurses to provide safe, quality, client-centered care by establishing therapeutic relationships and ensuring effective information transfer within the multidisciplinary team.

📌 Key points (3–5)

• Why communication matters: If communication breaks down, information exchange stops and client needs go unidentified.
• Two communication channels: Nurses must optimize communication with clients/families (through trust and active listening) and with the healthcare team (through professional, organized, accurate, complete, and concise communication).
• Core skill set: Effective communication includes assessing one's own skills, demonstrating cultural humility and respect, using therapeutic techniques, and adapting to the client and situation.
• Common confusion: Communication is not just talking—it requires the receiver to hear and understand the message, which must be confirmed.
• Foundation for care: Nurses develop therapeutic relationships daily to ensure health care concerns and needs are addressed.

🎯 Learning objectives and scope

🎯 What nurses must be able to do

The excerpt lists specific competencies nurses need to develop:

• Assess their own communication skills and effectiveness
• Demonstrate cultural humility, professionalism, and respect
• Use communication styles that show caring, respect, active listening, authenticity, and trust
• Maintain communication with interprofessional team members for safe transitions and continuity
• Confirm the recipient heard and understands the message
• Use therapeutic communication techniques
• Adapt communication to the client, audience, and situation
• Verify information sources are reliable and current
• Use correct medical terminology and abbreviations
• Describe ways to report client information
• Describe legal and standard documentation guidelines

📚 What this chapter covers

The chapter reviews methods for establishing good communication, including both client-facing and team-facing communication strategies.

💔 What happens when communication fails

💔 The breakdown cascade

If communication breaks down, information exchange stops and needs go unidentified.

• Communication failure is not neutral—it has direct consequences for client care.
• The excerpt emphasizes that unidentified needs cannot be addressed.
• Example: A client's concern that is not heard or understood cannot be acted upon by the healthcare team.

✅ How nurses prevent breakdown

• With clients and families: Establish trust and actively listen to health care concerns.
• With the team: Ensure information transfer occurs within the multidisciplinary team.
• Don't confuse: These are two different communication channels requiring different approaches (therapeutic vs. professional/organized).

🤝 Two modes of nursing communication

🤝 Client and family communication

Characteristic	What it requires
Goal	Ensure health care concerns and needs are addressed
Relationship type	Therapeutic relationships
Key methods	Establishing trust, active listening
Frequency	Daily interactions

👥 Interprofessional team communication

Characteristic	What it requires
Goal	Ensure information transfer occurs
Relationship type	Professional collaboration
Key qualities	Professional, organized, accurate, complete, and concise
Nurse's role	Vital for ensuring information transfer

🔄 Why both matter

• Nurses serve as a bridge: they gather information from clients through therapeutic communication and transfer it to the team through professional communication.
• The excerpt positions the nurse as "vital" for team information transfer, suggesting a central coordinating role.

🧭 Foundation: Empathy and human connection

🧭 The invisible dimension

The excerpt directs readers to reflect on "the often invisible needs of those around us and the difference we can make by creating caring human connections."

• Communication is not just information transfer—it includes recognizing needs that may not be explicitly stated.
• Example: A client may have emotional or social needs beyond their stated medical concerns.
• The emphasis on "caring human connections" suggests that technical accuracy alone is insufficient; the relational quality of communication matters for client-centered care.

🧭 Overview

🧠 One-sentence thesis

Effective nursing communication requires integrating verbal clarity, nonverbal awareness, assertive style, appropriate personal space, and strategies to overcome common barriers in order to build professional caring relationships with clients.

📌 Key points (3–5)

• Communication model: Every interaction needs a sender, a clear message, and a receiver who decodes it and provides feedback.
• Nonverbal dominance: Up to 80% of communication is nonverbal (body language, tone, pace), making it more powerful than words alone.
• Three communication styles: Passive (puts others first), aggressive (violates others' rights), and assertive (respects both self and others)—nurses should use assertive communication.
• Common confusion: Personal vs social zones—nurses typically stay in the social zone (4–10 feet) to maintain professional boundaries but must enter the personal zone (18 inches–4 feet) during assessments and procedures.
• Barriers require active management: Jargon, noise, stress, cultural differences, and physiological states all distort messages; nurses must continually seek feedback to verify understanding.

💬 The communication process

💬 Core elements of effective communication

Effective communication: an interaction that includes a sender of the message, a clear and concise message, and a receiver who can decode and interpret that message.

• The receiver provides feedback back to the sender in response to the received message.
• This is a two-way process, not one-directional.
• Example: A nurse (sender) explains a medication schedule (message) to a client (receiver), who then asks a clarifying question (feedback).

🗣️ Verbal communication

Effective verbal communication: an exchange of information using words understood by the receiver in a way that conveys professional caring and respect.

• More than just talking—it requires words the receiver can understand.
• Avoid jargon and slang: Using extensive medical terminology creates unintended barriers.
• Adapt to the receiver: Assess preferred communication method and individual characteristics (e.g., developmental level).
• Example: Postsurgical instructions for a pediatric client vs. an adult client may cover similar content (infection signs, pain management) but must be delivered differently based on developmental level.
• Always verify understanding: Regardless of adaptations made, the nurse must confirm the client understood the message.

🤐 Nonverbal communication

Nonverbal communication: includes facial expressions, tone of voice, pace of the conversation, and body language.

• More powerful than verbal messages: Up to 80% of communication is nonverbal.
• The breakdown is often described as 55% body language, 38% tone of voice, and only 7% the actual words spoken.
• Nurses must be purposeful: Nonverbal cues should convey professional caring.
• Example: A nurse directly facing the client at eye level, leaning slightly forward, and making eye contact communicates full attention and caring.
• SOLER mnemonic: Sit with open posture, lean in with good eye contact in a relaxed manner.

Don't confuse: The words you say with the message you send—if your nonverbal cues (hurried pace, lack of eye contact, short tone) contradict your words, the receiver will believe the nonverbal message.

🎯 Communication styles and assertiveness

🎯 Three communication styles

Style	Definition	Characteristics
Passive	Puts the rights of others before their own	Apologetic, tentative, does not speak up when wronged
Aggressive	Advocates for own rights while possibly violating others' rights	Tells others their feelings don't matter, insulting or offensive
Assertive	Respects others' rights while standing up for own ideas and rights	Direct but not insulting, deals with issues not attacks

✅ Assertive communication

Assertive communication: a way of conveying information that describes the facts and the sender's feelings without disrespecting the receiver's feelings.

• Use "I" messages: "I feel…," "I understand…," "Help me to understand…"
• Avoid "you" messages: These can feel like verbal attacks rather than addressing the issue.
• Example: Instead of "Why is it always so messy in your clients' rooms? I dread following you on the next shift!" (aggressive), say "I feel frustrated spending the first part of my shift decluttering our clients' rooms. Help me understand why it is a challenge to keep things organized during your shift?" (assertive).
• Why it matters: Assertive communication is an effective way to solve problems with clients, coworkers, and health care team members.

📏 Personal space and proxemics

📏 Understanding personal space zones

Proxemics: the study of personal space and provides guidelines for professional communication.

Zone	Distance	Typical use
Public zone	Over 10 feet	Generally avoids physical contact
Social zone	4–10 feet	Social interactions and business settings
Personal zone	18 inches–4 feet	Reserved for friends and family
Intimate zone	Less than 18 inches	Close relationships (may be invaded in crowds or sports)

🏥 Nursing implications

• Typical practice: Nurses usually communicate within the social zone to maintain professional boundaries.
• During care: When assessing clients and performing procedures, nurses often move into the client's personal zone.
• Be aware: Clients may experience psychological discomfort when this zone is invaded.
• Cultural considerations: The appropriateness of personal space varies by culture when providing client care.

Don't confuse: Professional distance with coldness—nurses must balance maintaining appropriate boundaries with conveying warmth and caring through nonverbal cues.

🚧 Common barriers and how to overcome them

🚧 Language and attention barriers

Jargon

• Problem: Medical terminology, complicated, or unfamiliar words create confusion.
• Solution: Explain information in plain language easy to understand by those without a medical or nursing background.

Lack of attention

• Problem: Nurses are busy with multiple tasks and clients; easy to focus on tasks instead of the person.
• Solution: When entering a client's room, pause, take a deep breath, and mindfully focus on the client to give them your full attention.

Language differences

• Problem: English may not be the client's primary language.
• Solution: Seek a medical interpreter and provide written handouts in the client's preferred language when possible.

🔊 Environmental barriers

Noise and distractions

• Problem: Health care environments are noisy (people talking, TV, alarms, overhead pages).
• Solution: Create a calm, quiet environment by closing doors, reducing TV volume, or moving to a quieter area if possible.

Light

• Problem: A room that is too dark or too light creates communication barriers.
• Solution: Ensure lighting is appropriate according to the client's preference.

Physical barriers for nonverbal communication

• Problem: E-mail or text lacks nonverbal cues (tone, facial expressions, body language), causing misinterpretation.
• Solution: Deliver important information face-to-face when possible so nonverbal communication is included.

🧠 Psychological and physiological barriers

Psychological barriers

• Problem: The sender's and receiver's psychological states affect how messages are sent, received, and perceived.
• Example: A stressed nurse's nonverbal communication (lack of eye contact, hurried pace, short tone) affects how the client perceives the message; a stressed client may not "hear" the message or may perceive it differently than intended.
• Solution: Be aware of signs of the stress response in yourself and clients; implement strategies to manage it (see stress management strategies below).

Physiological barriers

• Problem: Pain, sedatives, or certain pain medications impair the client's ability to receive and perceive messages.
• Solution: Provide pain relief before client education; remember that clients cannot sign health care documents after receiving sedatives or certain pain medications.

🌍 Cultural and perceptual barriers

Differences in cultural beliefs

• Problem: Norms of social interaction and emotional expression vary greatly across cultures (e.g., personal space, pain expression).
• Solution: Be aware of cultural variations and adapt communication accordingly.

Differences in perception and viewpoints

• Problem: When clients feel their beliefs or perspectives are not valued, they become disengaged.
• Solution: Provide health care information in a nonjudgmental manner, even if the client's perspectives differ from your own.

Hearing and speech problems

• Problem: Clients with hearing or speech impairments face communication challenges.
• Solution: Implement strategies to enhance communication (the excerpt references an "Adapting Your Communication" subsection for specific strategies).

🧘 Managing the stress response

Why it matters: The stress response is a common psychological barrier affecting both senders and receivers of messages.

Symptoms: Irritability, sweaty palms, racing heart, difficulty concentrating, impaired sleep.

Strategies to manage stress:

1. Relaxation breathing: Become aware of your breathing; take a deep breath in through your nose and blow it out through your mouth; repeat at least three times.
2. Healthy diet choices: Avoid caffeine, nicotine, and junk food, which can increase anxiety.
3. Exercise: Stimulates natural endorphins that reduce stress and improve sleep.
4. Adequate sleep: Set aside at least 30 minutes before bed to wind down; avoid electronic devices before bedtime.
5. Progressive relaxation: Lie down comfortably, breathe deeply, and systematically clench and relax each muscle group (feet, calves, thighs, buttocks, stomach, arms, hands, shoulders, face).

Don't confuse: Short-term stress (normal reaction to life events) with chronic stress—both require management, but the excerpt focuses on recognizing and addressing stress in the moment to improve communication.

🔑 Key takeaway for practice

🔑 Continual feedback is essential

• Many factors can distort messages so they are not perceived as intended.
• Core practice: Continually seek feedback and check understanding.
• Reflect on personal factors that influence your ability to communicate effectively.
• Be aware of potential barriers and actively work to reduce their impact.

🧭 Overview

🧠 One-sentence thesis

The nurse-client relationship evolves through distinct phases and relies on therapeutic communication techniques that build trust, encourage client-centered dialogue, and avoid communication blocks to promote holistic, compassionate care.

📌 Key points (3–5)

• The nurse-client relationship is professional and purposeful: it builds rapport and trust to engage clients in discussing feelings, care processes, and decision-making.
• Four phases structure the relationship: preinteraction, orientation, working, and termination—each with specific goals and communication strategies.
• Therapeutic communication uses specific techniques: active listening, open-ended questions, reflection, and empathy encourage clients to explore feelings and solve problems.
• Common confusion—therapeutic vs nontherapeutic responses: therapeutic techniques focus on the client's feelings and autonomy; nontherapeutic responses (giving personal opinions, false reassurance, asking "why" questions) block communication and impose the nurse's views.
• Effective communication requires adaptation: nurses must adjust their approach based on the client's age, developmental level, cognitive abilities, and language differences.

🤝 The nurse-client relationship

🤝 What it is and why it matters

The nurse-client relationship (also called a helping relationship): a professional relationship in which the nurse builds rapport and establishes trust with the purpose of actively engaging the client in discussions about their feelings, emotions, care process, and decision-making.

• It is not a personal friendship; it is a professional connection focused on the client's needs.
• The relationship facilitates therapeutic communication and engages the client in decision-making about their plan of care.
• The nurse practices the "art of nursing"—an abstract connection between the client's needs, expressed behaviors, and the nurse's perceptions and exploration of these concepts.
• Establishing rapport is of the utmost importance because it facilitates open and honest dialogue.

🔄 Four phases of the relationship

The nurse-client relationship evolves through four phases (described by nurse theorist Hildegard Peplau and others):

Phase	When it occurs	Key activities	Why it matters
Preinteraction	Before meeting the client	Review medical record or other data; identify and acknowledge preconceived notions to avoid biases	Preparation helps the nurse approach the client without bias
Orientation	Brief initial encounter	Address client by name; introduce self, role, and time frame; explain what will occur; ensure privacy; begin to establish trust and rapport	Failure to establish rapport and trust during this phase will block communication and make therapeutic communication difficult
Working	Majority of nurse's time with client	Focus on what is important to the client; recognize cues (body language, emotional statements); encourage discussion of feelings; use therapeutic communication techniques; help client gain awareness of feelings, coping mechanisms, and goals	If rapport and trust were successfully developed during orientation, the client is more likely to engage in therapeutic communication and perceive the nurse as educator and counselor
Termination	End of communication session	Inform the client that termination is approaching (don't end abruptly); review goals, achievements, and other sources of support; avoid terms like "I'll see you later" that insinuate temporary termination	Abruptly ending the conversation can lead to negative feelings and can be perceived as uncaring; termination should be a concrete occurrence

Don't confuse: The orientation phase is not just a quick hello—it is the foundation for trust. Without successful orientation, the working phase will be blocked.

🎯 Client-centered focus

• The nurse must realize the client is a unique individual with distinct needs, priorities, values, and belief systems.
• The nurse may not agree with the client's values and beliefs, but must respect them.
• During the working phase, the conversation should be focused on the client's feelings and thought processes, not the nurse's feelings and thoughts.
• The nurse should remain nonjudgmental while providing feedback and reflection.

Example: A nurse who respects a client's cultural beliefs about treatment options (even if the nurse personally disagrees) maintains trust and keeps communication open.

💬 Therapeutic communication

💬 What it is

Therapeutic communication: "The purposeful, interpersonal information-transmitting process through words and behaviors based on both parties' knowledge, attitudes, and skills, which leads to client understanding and participation."

• It is a type of professional communication used by nurses with clients.
• It has roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships and believed in the therapeutic healing that resulted from nurses' presence with clients.
• Several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing.

👂 Active listening and attending behaviors

Three main types of listening:

Type	Description	Therapeutic?
Competitive	Focused on sharing our own point of view instead of listening	❌ No
Passive	Not interested; assume we understand correctly without verifying	❌ No
Active	Communicating verbally and nonverbally that we are interested; actively verifying understanding with the speaker	✅ Yes

Active listening: communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with the speaker.

• The feedback process is the main difference between passive and active listening.
• An active listening technique is to restate what the person said and then verify our understanding is correct.

Example: A nurse says, "So you're saying the pain is worse at night—is that correct?" This restates the client's message and verifies understanding.

🤲 Therapeutic use of touch

• Touch is a powerful way to professionally communicate caring and empathy if done respectfully and with awareness of the client's cultural beliefs.
• Nurses commonly use professional touch when assessing, expressing concern, or comforting clients.
• Simply holding a client's hand during a painful procedure can be very effective in providing comfort.

Don't confuse: Therapeutic touch is not always appropriate. Nurses must respect personal boundaries and avoid touch if:

• The client is not receptive
• Cultural beliefs view touch by a member of the opposite sex as inappropriate
• The client has previously experienced trauma that causes touch to be uncomfortable or trigger negative emotions

🛠️ Therapeutic techniques

🛠️ Core principles

Therapeutic communication techniques are specific methods used to provide clients with support and information while focusing on their concerns. They:

• Encourage clients to explore their feelings, solve problems, and use coping responses
• Assist clients to set goals and select strategies for their plan of care based on their needs, values, skills, and abilities
• Recognize the autonomy of the clients to make their own decisions
• Maintain a nonjudgmental attitude and avoid interrupting
• Use appropriate terminology based on the client's developmental stage and educational needs to promote understanding and rapport
• Often use open-ended statements and questions, repeat information, or use silence to prompt clients to work through problems on their own

🗣️ Key techniques

Technique	What it is	Example or key phrase
Active listening	Using nonverbal and verbal cues (nodding, saying "I see") to encourage clients to continue talking; offering general leads	"What happened next?"
Providing silence	Not speaking at all; giving both nurse and client time to think and process	The nurse does not verbally respond after a client makes a statement (may nod or use other nonverbal communication)
Acceptance	Acknowledging a client's message and affirming they've been heard (not necessarily agreement)	"Yes, I hear what you are saying."
Giving recognition	Acknowledging a client's behavior without giving an overt compliment	"I noticed you took all of your medications today."
Offering self	Being present with the client; offering to sit with them	Offering to simply sit with clients for a few minutes creates a caring connection
Giving broad openings / open-ended questions	Allowing clients to direct the flow of conversation and decide what to talk about	"Tell me about your concerns."
Seeking clarification	Asking clients for clarification when they say something confusing or ambiguous	"I'm not sure I understand. Can you explain it to me?"
Placing the event in time or sequence	Asking questions about when certain events occurred in relation to other events	Helps clients and nurses get a clearer sense of the whole picture
Making / sharing observations	Observations about the appearance, demeanor, or behavior of clients	"You look tired." (May prompt them to explain why they haven't been getting much sleep)
Encouraging descriptions of perception	Asking about sensory issues or hallucinations in an encouraging, nonjudgmental way	"It looks like you may be hearing something. What do you hear now?"
Encouraging comparisons	Encouraging clients to make comparisons to situations they have coped with before	"How did you cope with that?" (Helps clients discover solutions to current problems)
Summarizing	Summarizing what clients have said to demonstrate listening and verify information	"You haven't been taking your medications this month because of the side effects of fatigue and weight gain. Is that correct?"
Reflecting	Asking clients what they think they should do (encourages accountability and problem-solving)	"What do you think are the pros and cons for the new treatment plan?"
Focusing	Focusing on a particularly important statement the client mentioned	"You're feeling anxious about going home, tell me more about that."
Confronting	Presenting reality, challenging assumptions, or pointing out inconsistencies (only during working phase after trust is established)	"Yesterday you told me that every weekend you go out and drink so much that you don't know where you are when you wake up."
Voicing doubt	A gentler way to call attention to incorrect or delusional ideas	Expressing doubt forces clients to examine their assumptions
Offering hope	Sharing hope that the client can persevere (must avoid false reassurance)	"I remember you shared with me how well you have coped with difficult situations in the past."
Using humor	Lightening the mood (must be tailored to the client's sense of humor)	Helps establish rapport and promote positive state of mind
Offering empathy	Recognizing, understanding, and sharing feelings with another person	Enables helping behaviors
Paraphrasing	Rephrasing the client's words and key ideas to clarify their message	"Participating in physical and occupational therapy today has kept you busy."
Presenting reality	Restructuring the client's distorted thoughts with valid information	"I see no evidence of spiders on the walls."
Restating	Using different word choices for the same content stated by the client	"You feel as though the nurses dislike you?"

Don't confuse: Offering hope vs. false reassurance. Saying "You'll be fine" to a terminally ill client is false reassurance and not therapeutic. Saying "I remember how well you have coped with difficult situations in the past" is therapeutic because it offers hope without making unrealistic promises.

💖 Empathy and unconditional positive regard

Empathy: the ability to recognize, understand, and share feelings with another person. Empathy involves showing understanding of another's situation or perspective and enables helping behaviors.

• Communicating honestly, genuinely, and authentically is powerful and opens the door to creating true connections.
• Communicating with empathy has also been described as providing "unconditional positive regard."
• Research has demonstrated that when health care teams communicate with empathy, there is improved client healing, reduced symptoms of depression, and decreased medical errors.

Example: A nursing student who treats clients professionally by respecting boundaries, listening in a nonjudgmental manner, addressing communication barriers, and respecting cultural beliefs builds trust. Clients feel she cares about them and feel comfortable sharing their health care needs.

🚫 Nontherapeutic responses

🚫 What they are

Nontherapeutic responses (also called communication blocks/barriers): responses that often block the client's communication of their feelings or ideas.

Nurses and nursing students must be aware of these potential barriers to communication and avoid them.

🚧 Common nontherapeutic responses

Response	Why it's nontherapeutic	Nontherapeutic example	Therapeutic alternative
Asking personal questions	Not relevant to the situation; not professional or appropriate; satisfies curiosity only	"Why have you and Mary never married?"	"How would you describe your relationship with Mary?"
Giving personal opinions	Takes away decision-making from the client; effective problem-solving must be accomplished by the client, not the nurse	"If I were you, I'd put your father in a nursing home."	"Let's talk about what options are available to your father."
Changing the subject	Demonstrates lack of empathy and blocks further communication; implies you don't care	"Let's not talk about your insurance problems; it's time for your walk now."	"After your walk, let's talk some more about what's going on with your insurance company."
Stating generalizations and stereotypes	Preconceived assumptions about clients that may or may not be true	"Older adults are always confused."	"Tell me more about your concerns about your father's confusion."
Providing false reassurances	Discourages further expressions of feelings; may not present reality; minimizes the client's situation	"You'll be fine," or "Don't worry; everything will be alright."	"It must be difficult not to know what the surgeon will find. What can I do to help?"
Showing sympathy	Focuses on the nurse's feelings rather than the client; shows pity rather than helping the client cope	"I'm so sorry about your amputation; I can't imagine losing a leg."	"The loss of your leg is a major change; how do you think this will affect your life?"
Asking "what" or "why" questions	Clients and family members may interpret these as accusations and become defensive	"Why are you so upset?"	"You seem upset. Tell me more about how you are feeling."
Showing approval or disapproval	Imposes the nurse's own attitudes, values, beliefs, and moral standards; judgmental messages contain terms like "should," "ought to," "good," "bad," "right," or "wrong"	"You shouldn't consider elective surgery; there are too many risks involved."	"So you are considering elective surgery. Tell me more about the pros and cons of surgery."
Giving defensive responses	Defensive or accusatory; does not listen to criticism	"No one here would intentionally lie to you."	"You believe people have been dishonest with you. Tell me more about what happened."
Providing passive or aggressive responses	Passive responses avoid conflict or sidestep issues; aggressive responses provoke confrontation	"It's your fault you are feeling ill because you don't take your medication."	"Taking your prescribed medications every day can prevent symptoms from returning." (Use assertive communication)
Arguing	Challenging or arguing against client perceptions denies that they are real and valid; implies the other person is lying, misinformed, or uneducated	"How can you say you didn't sleep a wink when I heard you snoring all night long!"	"You don't feel rested this morning? Let's talk about ways to improve your rest."

Don't confuse: Empathy vs. sympathy. Empathy focuses on understanding the client's feelings and helping them cope. Sympathy focuses on the nurse's feelings and shows pity, which is not therapeutic.

📝 Process recordings

Process recordings: reflective learning activities with an objective to improve a student's therapeutic communication skills. They include a transcript of the verbal and nonverbal responses between a student and a client during a therapeutic communication session.

• After the session, the transcript is analyzed by the student to identify:
  • Therapeutic techniques
  • Communication barriers or blocks
  • The phases of the nurse-client relationship
• The student evaluates the interaction to determine if the overall client-centered goal was met or not met, what went well, and what they could improve.
• As a result, the student gains self-awareness regarding the effectiveness of their communication and sets goals for self-improvement in future therapeutic communication sessions.

🎯 Strategies for effective communication

🎯 Specific questions to ask clients

• What concerns do you have about your plan of care?
• What questions do you have about your medications?
• Did I answer your question(s) clearly or is there additional information you would like?

Why this matters: These questions invite feedback, which provides an opportunity to improve client understanding, improve the client-care experience, and provide high-quality care.

📋 Additional strategies for hospitalized clients

• Round with the providers and read progress notes from other health care team members to ensure you have the most up-to-date information about the client's treatment plan and progress. This helps you provide safe client care as changes occur and accurately answer the client's questions.
• Review information periodically with the client to improve understanding.
• Use client communication boards in their room to set goals and communicate important reminders with the client, family members, and other health care team members. This can reduce call light usage for questions related to diet and activity orders and gives clients and families the feeling that they always know the current plan of care. (Keep client confidentiality in mind—the board can be seen by anyone entering the room.)
• Provide printed information on medical procedures, conditions, and medications. It helps clients and family members by providing information in multiple ways.

🔄 Adapting communication

When communicating with clients and family members, take note of your audience and adapt your message based on their characteristics such as age, developmental level, cognitive abilities, communication disorders, and language differences.

👶 Adapting for age and developmental level

Audience	Strategy
Children	Speak calmly and gently; demonstrate what will be done during a procedure on a doll or stuffed animal; use play or drawing pictures to establish trust
Adolescents	Give freedom to make choices within established limits
Older adults	Be aware of potential vision and hearing impairments that commonly occur and address these barriers accordingly

Don't confuse: Adapting communication is not "dumbing down" or being condescending. It is tailoring your approach to the client's needs and abilities to promote understanding and respect.

🧭 Overview

🧠 One-sentence thesis

Standardized communication methods like ISBARR and bedside handoff reports ensure safe, accurate information exchange among health care team members to maintain continuity of client care.

📌 Key points (3–5)

• Structured communication formats: ISBARR and SBAR provide a standardized framework for exchanging client information concisely and accurately.
• Handoff reports at bedside: Evidence supports bedside handoff reports increase client safety and satisfaction by communicating real-time information with the client present.
• Transfer reports: More detailed reports are required when moving clients between units or agencies to ensure complete information transfer.
• Common confusion: Handoff reports vs. ISBARR reports—handoff reports contain additional detailed assessment data and equipment information beyond the basic ISBARR structure.
• Why it matters: Inadequate handoff communication has resulted in client harm including wrong-site surgeries, treatment delays, falls, and medication errors.

📋 ISBARR Communication Framework

📋 What ISBARR stands for

ISBARR: a mnemonic for Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.

• A structured method to exchange client information between health care team members
• Ensures communication is concise, accurate, and complete
• A simpler version called SBAR omits the Introduction and Repeat back components
• Used for routine reports and urgent communications about client status changes

🔤 The six ISBARR components

Component	What to include	Purpose
Introduction	Your name, role, and agency	Establishes who is communicating
Situation	Client name/location, reason for call, recent vital signs, client status	States the immediate concern
Background	Admitting diagnoses, code status, recent lab/diagnostic results, allergies	Provides context
Assessment	Abnormal findings and your evaluation of the situation	Shares clinical judgment
Request/Recommendations	What you want the provider to do (reassess, order tests, change medication)	Makes specific asks
Repeat back	Confirm new orders by repeating them	Ensures accuracy

💬 Example scenario breakdown

The excerpt provides a sample ISBARR report for Ms. White, a 65-year-old post-hip surgery patient:

• Situation: Pain increased to 7/10, redness at incision site
• Background: Admitted yesterday, usually rates pain 3-4/10, scheduled for physical therapy
• Assessment: 4 cm redness around incision, warm and tender, moderate drainage, concern for infection
• Request: Order CBC and increased pain medication dose
• Repeat back: Confirms STAT CBC and Vicodin increase to 10/325 mg

Don't confuse: ISBARR is not just listing facts—the Assessment component requires the nurse to share their clinical evaluation and concerns.

🤝 Handoff Reports

🤝 What handoff reports are

Handoff reports: "a transfer and acceptance of client care responsibility achieved through effective communication...a real-time process of passing client specific information from one caregiver to another...for ensuring the continuity and safety of the client's care." (The Joint Commission)

• Occur during shift changes when care responsibility transfers between nurses
• The Joint Commission issued a critical alert in 2017 about inadequate handoffs causing client harm
• Harm examples: wrong-site surgeries, treatment delays, falls, medication errors

🛏️ Bedside handoff reports

• Evidence strongly supports this approach increases client safety and satisfaction
• Conducted face-to-face at the client's bedside
• Participants: the client, off-going nurse, and oncoming nurse
• Family members may be included with client permission
• HIPAA rules must be considered if visitors are present or the room is shared

📊 What makes bedside handoffs different from ISBARR

Bedside handoff reports contain additional detailed information beyond ISBARR:

• Detailed head-to-toe assessment findings to establish a baseline for the oncoming nurse
• Information about equipment: IVs, catheters, drainage tubes
• Recent changes in medications, lab results, diagnostic tests, and treatments
• Real-time verification with the client present

Don't confuse: While bedside handoffs are similar to ISBARR, they are more comprehensive because they ensure continuity across entire nursing shifts, not just communicate a single concern.

🚑 Transfer Reports

🚑 When transfer reports are used

• When moving a client to another unit within the same facility
• When transferring a client to another agency entirely

📝 Content requirements

• Contain similar information as bedside handoff reports
• Even more detailed when transferring to another agency
• Agencies often provide checklists to ensure accurate, complete information sharing
• Must ensure all pertinent client information travels with the client to maintain continuity of care

⚠️ Professional Communication Considerations

🔒 Confidentiality requirements

• Client information should only be shared with those directly involved in client care
• HIPAA rules must be kept in mind during bedside reports if visitors are present or rooms are not private
• The excerpt references the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for more information

📞 Communication formats

Reports may be delivered in multiple formats:

• Verbal: in person, by telephone, or recorded
• Written: electronically or by fax
• All formats must maintain the same standards of accuracy and completeness

🔧 Documentation requirement

• When receiving new orders from a provider during an ISBARR report, the nurse must document the communication in the client's chart
• This creates a permanent record of the interaction and orders received

🧭 Overview

🧠 One-sentence thesis

Nursing documentation is a legally required, multi-purpose activity that ensures continuity of care, supports reimbursement, and serves as evidence in legal proceedings, requiring accuracy, timeliness, and adherence to specific formats.

📌 Key points (3–5)

• Legal requirement: All documentation is a legal document; "if it wasn't documented, it wasn't done" is the standard in court.
• Multiple purposes: Documentation ensures continuity of care, monitors quality, supports reimbursement, and may be used for research or legal purposes.
• Core principles: Documentation must be objective, factual, timely, accurate, and completed only after tasks are performed—never in advance.
• Common confusion: Do not confuse different note types—DAR notes focus on one problem (Data-Action-Response), while SOAPIE notes organize information across six categories (Subjective-Objective-Assessment-Plan-Interventions-Evaluation).
• Technology and access: Most clinical settings use electronic health records (EHRs) on secure intranets, giving authorized users instant access to client information.

📱 Electronic health records and information access

📱 What is an EHR

Electronic health record (EHR): a real-time, client-centered record that makes information available instantly and securely to authorized users.

• EHRs use intranet technology (a private computer network within an institution) to maintain client confidentiality.
• Computers for accessing EHRs can be in client rooms, on wheeled carts, at workstations, or on handheld devices.

🗂️ Key sections nurses access in the EHR

Section	What it contains	Why nurses use it
History and Physical (H&P)	Reason for admission, health/surgical history, allergies, current medications, physical exam findings, diagnoses, treatment plan	Concise overview of client's current status and plan
Provider orders	Prescriptions and medical orders	Nurses must legally implement or communicate these orders per agency policy
Medication Administration Records (MARs)	Medication orders interfaced with pharmacy; location where nurses document medications given	Documents what medications were administered
Treatment Administration Records (TARs)	Documentation of treatments like wound care	Tracks non-medication treatments
Laboratory results	Blood work and other lab test results	Monitors client status
Diagnostic test results	X-rays, ultrasounds, etc.	Monitors client status
Progress notes	Notes by nurses and other health care providers about client care	Ensures continuity of care across team members

• Nurses should review daily progress notes by all team members to ensure continuity of care.

⚖️ Legal documentation requirements

⚖️ Core legal principles

• Any documentation in the EHR is considered a legal document.
• The standard in court: "If it wasn't documented, it wasn't done."
• Documentation is used for continuity of care, quality assurance, reimbursement (insurance, Medicare, Medicaid), research, and legal concerns.

📝 Documentation guidelines

• Objectivity and professionalism: Documentation should be objective, factual, and professional. Only document what you personally assessed, observed, or performed.
• Language: Use proper medical terminology, grammar, and spelling.
• Required elements: All documentation must include date, time, and signature of the person documenting.
• Avoid abbreviations: Abbreviations should be avoided in legal documentation.
• Timeliness: Documentation must be completed in an accurate and timely manner after the task is performed. Do not document in advance of completing a task.
• Never falsify: Assessments, interventions, medications, or treatments that were not completed should never be charted as completed. This is considered falsification and can present serious legal ramifications for the nurse and the health care facility.

✏️ Correcting errors

• Paper documentation: Avoid leaving blank lines to prevent others from adding to your documentation. In the event of a charting error, draw a single line through the error and write "mistaken entry" above the line with your initials. Errors should never be erased, scribbled out, or covered with white-out.
• Electronic documentation: If charted in error, it should be corrected with the details of the error and the correction noted in the background should the need arise to review the documentation.

🩺 What nurses document

• Recording client assessments
• Writing progress notes
• Creating or addressing information in nursing care plans

📋 Common documentation formats

📋 Charting by exception (CBE)

Charting by exception (CBE) documentation: designed to decrease the amount of time required to document care by containing a list of normal findings.

• After performing an assessment, nurses confirm normal findings on the list and write only brief progress notes for abnormal findings or to document communication with other team members.
• Saves time by focusing on deviations from normal.

🎯 Focused DAR notes

DAR: stands for Data, Action, and Response.

• Commonly used in combination with charting by exception.
• Each note is focused on one client problem for efficiency in documenting and reading.

Three components:

• Data: Information collected during client assessment (vital signs, physical exam findings) during the Assessment phase of the nursing process. Think of this as describing the main problem.
• Action: Nursing actions planned and implemented for the client's focused problem (correlates to Planning and Implementation phases). Think of this as describing what was done about the problem.
• Response: Client's response to nursing actions and evaluation of whether planned care was effective (correlates to Evaluation phase). Think of this as describing the result of what happened after performing the actions.

Example (from the excerpt):

• D: Client reports increasing pain at the incisional site, rated as 7/10, increased from 4/10 despite receiving oral Vicodin 5/325 at 1030. Vital Signs: BP 160/95, HR 90, RR 22, O2 sat 96%, and temperature 38 degrees C. There is 4 cm of redness surrounding the incision that is warm and tender to touch with moderate serosanguinous drainage. Lung sounds are clear, and HR is regular.
• A: Dr. Smith was notified at 1210 and orders received for CBC STAT and increased Vicodin dose to 10/325 mg.
• R: Lab results pending. Additional Vicodin administered per order at 1215. At 1315, client reported decreased pain level of 3/10. Will notify provider of results when they become available. -J. White, RN

📖 Narrative notes

Narrative notes (also called summary notes): a type of progress note that chronicles assessment findings and nursing activities for the client that occurred throughout the entire shift or visit.

• Provides a comprehensive summary of the shift or visit.
• Example (cardiac narrative note from the excerpt): Client denies chest pain or shortness of breath. Vital signs are within normal limits. Point of maximum impulse palpable at the fifth intercostal space of the midclavicular line. No lifts, heaves, or thrills identified on inspection or palpation. JVD absent. S1 and S2 heart sounds in regular rhythm with no murmurs or extra sounds. Skin is warm, pink, and dry. Capillary refill is less than two seconds. Color, movement, and sensation are intact in upper and lower extremities. Peripheral pulses are present (+2) and equal bilaterally. No peripheral edema is noted. Hair is distributed evenly on lower extremities.

🧩 SOAPIE notes

SOAPIE: a mnemonic for a type of progress note organized by six categories: Subjective, Objective, Assessment, Plan, Interventions, and Evaluation.

• Written by nurses and other members of the health care team.

Six components:

• Subjective: What the client said (e.g., "I have a headache"). Can also contain pertinent medical history and why the client is in need of care.
• Objective: Observable and measurable data collected during assessment (vital signs, physical exam findings, lab/diagnostic test results).
• Assessment: Interpretation of what was noted in Subjective and Objective sections (e.g., nursing diagnosis in a nursing progress note or medical diagnosis in a provider's progress note).
• Plan: Outlines the plan of care based on the Assessment section, including goals and planned interventions.
• Interventions: Describes the actions implemented.
• Evaluation: Describes the client response to interventions and if the planned outcomes were met.

Example (same scenario as DAR note):

• S: Client reports having incisional pain of 6/10, increased from 4/10 despite receiving oral Vicodin 5/325 at 1030.
• O: Vital Signs: BP 160/95, HR 90, RR 22, O2 sat 96%, and temperature 38 degrees C. There is 4 cm of redness surrounding the incision that is warm and tender to touch with moderate serosanguinous drainage. Lung sounds are clear, and HR is regular.
• A: Dr. Smith was notified at 1210.
• P: New orders received for CBC STAT to check for infection and increased Vicodin dose to 10/325 mg for pain management.
• I: Additional Vicodin administered per order at 1215.
• E: At 1315, client reported decreased pain level of 3/10. Will notify provider of results when they become available. -J. White, RN

Don't confuse: DAR focuses on one problem with three steps (Data-Action-Response), while SOAPIE organizes the same information into six categories that separate subjective from objective data and explicitly state the assessment and plan.

🚪 Specialized documentation types

🚪 Discharge summary

• Documented when a client is discharged from an agency.
• Includes clear verbal and written client education and instructions provided to the client.
• Frequently provided in a checklist format to ensure accuracy.

Information included:

• Time of departure and method of transportation out of the hospital (e.g., wheelchair)

• Name and relationship of person accompanying the client at discharge

• Condition of the client at discharge

• Client education completed and associated educational materials or other information provided to the client

• Discharge instructions on medications, treatments, diet, and activity

• Follow-up appointments or referrals given

• Discharge teaching typically starts at admission and continues throughout the client's stay because this allows for reinforcement of teaching topics.

Example (from the excerpt): Client discharged home at 1645 with Sarah Jones, his wife, in a wheelchair to their car. Client was in stable condition with the following vital signs: BP 124/76, HR 76, RR 16, O2 sat 98%. Dressing over surgical incision site was dry and intact. Client education was provided on wound care at home and the "Caring for Your Incision" handout was provided. The Discharge Instructions sheet was reviewed with orders for a regular diet and no heavy lifting until follow-up appointment with Dr. Singer on 8/26/2024. Referral completed with ACME Home Health for wound care with the initial home visit scheduled for tomorrow.

🏥 Minimum Data Set (MDS) charting

Minimum Data Set (MDS): a federally mandated assessment tool created by registered nurses in skilled nursing facilities to track a client's goal achievement and coordinate the efforts of the health care team to optimize the resident's quality of care and quality of life.

• Used in long-term care settings.
• Provides information for reimbursement by private insurance, Medicare, and Medicaid.
• Guides nursing care plan development.

🚨 Incident reports

Incident reports (also called variance reports): a specific type of documentation completed when there is an unexpected occurrence, such as a medication error, client injury, client fall, or a near miss (where an error did not actually occur but was prevented from occurring).

Who completes them:

• Completed by the staff member involved in the occurrence.

What to include:

• Date and time of the event
• Client involved (if applicable)
• What occurred
• What was done in response to the event
• What else was happening at the time the incident occurred
• Other facility-specific required data
• Avoid abbreviations, assumptions, or interpretations.

Purpose:

• Intended to be used as a safety tool to identify system issues and process problems that could benefit from quality and safety improvements.
• Should be used as a component of a safety culture, not punitively.
• If used punitively, staff become reluctant to report errors or suggest process improvements for fear of "getting in trouble."

Relationship to medical record:

• Incident reports are not a part of the medical record and should not be mentioned in the medical record.
• However, the specific event should be documented in the medical record, along with health care provider notification and interventions provided.

🧭 Overview

🧠 One-sentence thesis

Culturally responsive care integrates clients' cultural beliefs into health care through a lifelong process of cultural competence and humility, ultimately reducing health disparities and improving outcomes.

📌 Key points (3–5)

• What culturally responsive care is: intentional, client-centered care that integrates cultural beliefs into health care and promotes trust and rapport.
• Cultural competence vs cultural humility: competence is applying evidence-based nursing aligned with clients' cultural values to improve outcomes; humility is a humble, respectful attitude that challenges one's own biases and treats learning as lifelong.
• Holism in nursing: incorporating clients' physical, mental, spiritual, cultural, and social needs into care.
• Common confusion: cultural competence is not a one-time achievement but a lifelong process of learning and adaptation.
• Why it matters: understanding and respecting cultural values, beliefs, and preferences improves care quality and helps reduce health disparities.

🌍 Core concepts of culturally responsive care

🌍 What culturally responsive care means

Culturally responsive care: integrates cultural beliefs into an individual's health care.

• It is intentional—not accidental or passive.
• It promotes trust and rapport with clients.
• At its heart, it is client-centered care.
• The excerpt emphasizes that culture profoundly affects health beliefs, including perceived causes of illness, ways to prevent illness, and acceptance of medical treatments.

🤝 The ANA's perspective on nursing care

• The American Nurses Association states that the art of nursing is demonstrated by:
  • Unconditionally accepting the humanity of others.
  • Respecting their need for dignity and worth.
  • Providing compassionate, comforting care.
• This foundation supports the idea that culturally responsive care is central to nursing practice.

🧩 Two key frameworks: competence and humility

🧩 Cultural competence

Cultural competence: a lifelong process of applying evidence-based nursing in agreement with the cultural values, beliefs, worldview, and practices of clients to produce improved client outcomes.

• It is not a fixed skill but an ongoing process.
• It requires aligning nursing practice with clients' cultural frameworks.
• The goal is to produce improved client outcomes.
• Example: A nurse learns about a client's cultural beliefs regarding medication and adapts the care plan to respect those beliefs while maintaining evidence-based practice.

🙏 Cultural humility

Cultural humility: a humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot know everything about other cultures, and approach learning about other cultures as a life-long goal and process.

• Key elements:
  • Challenge your own biases: actively question assumptions.
  • Acknowledge limits: accept that you cannot know everything about other cultures.
  • Commit to lifelong learning: treat cultural understanding as an ongoing journey.
• Don't confuse: cultural humility is not about mastering all cultures; it's about maintaining a respectful, learning-oriented attitude.

🏥 Holistic care and its components

🏥 What holism means in nursing

Holism: incorporating clients' physical, mental, spiritual, cultural, and social needs into their health care.

• Nurses provide holistic care when they address all these dimensions, not just physical symptoms.
• The excerpt lists five aspects:
  • Physical
  • Mental
  • Spiritual
  • Cultural
  • Social
• Example: A nurse caring for a client considers not only their medication needs (physical) but also their emotional state (mental), religious practices (spiritual), cultural food preferences (cultural), and family support (social).

🌱 The journey of developing cultural competency

• As a nursing student, you are undertaking a journey of:
  • Developing cultural competency.
  • Maintaining an attitude of cultural humility.
  • Learning how to provide holistic care to clients.
• This journey is framed as ongoing and developmental, not a one-time training.

📊 Why culturally responsive care matters

📊 Impact on health disparities

• Nurses improve the quality of health care by:
  • Understanding clients' cultural values, beliefs, and preferences.
  • Respecting these cultural elements.
  • Incorporating them into care.
• This approach can ultimately help reduce health disparities.
• The excerpt emphasizes that culture's impact on health is profound because it affects many health beliefs.

🎯 Learning objectives for nursing students

The excerpt lists several learning objectives that frame the chapter's goals:

Objective	What it means
Reflect on personal values and biases	Examine your own cultural background and assumptions
Embrace diversity and equity	Support health care for individuals of diverse backgrounds across the life span
Demonstrate respect, equity, and empathy	Show these qualities in all actions and interactions with clients
Participate in lifelong learning	Continuously learn about cultural preferences, worldviews, and decision-making processes
Adapt care considering diversity	Modify nursing care to respect all aspects of diversity
Identify principles of dignity, holistic care, advocacy, and spirituality	Understand key principles that support culturally responsive care

• Don't confuse: these are not one-time tasks but ongoing commitments throughout a nursing career.

🧭 Overview

🧠 One-sentence thesis

Developing cultural competence requires nurses to understand that culture is a dynamic, multifaceted identity shaped by many overlapping factors, and to approach each patient with humility rather than assumptions about their cultural group.

📌 Key points (3–5)

• Culture is dynamic and multidimensional: it includes nationality, language, religion, gender, age, geography, and many other intersecting factors—not just ethnicity.
• Subcultures exist within larger cultures: people belong to multiple overlapping groups (occupation, hobbies, geography) that shape their identity.
• Cultural humility over assumptions: nurses must recognize diversity within every culture and avoid stereotyping individuals based on group membership.
• Common confusion: culture vs. subculture—subcultures are smaller groups within a parent culture; people can belong to many subcultures simultaneously (intersectionality).
• Why it matters: culture influences health beliefs, pain expression, family roles, communication styles, treatment acceptance, and decision-making in healthcare.

🧩 Core definitions

🧩 What culture means

Culture: a set of beliefs, attitudes, and practices shared by a group of people or community that is accepted, followed, and passed down to other members of the group.

• Culture is sometimes used interchangeably with ethnicity, nationality, or race, but it is broader.
• It binds group members together and helps form a cohesive identity.
• Culture has an enduring influence on worldview, expressed through language, family connections, religion, cuisine, dress, and other customs.
• Culture is not static—it is dynamic and ever-changing as members encounter beliefs from other cultures.
• Example: sushi is a traditional Asian dish that has become popular in America in recent years.

🔍 What subculture means

Subculture: a smaller group of people within a culture, often based on a person's occupation, hobbies, interests, or place of origin.

• Members may identify with some, but not all, aspects of their larger "parent" culture.
• Subcultures share beliefs and commonalities that set them apart and do not always conform with the larger culture.

Category	Examples
Age/Generation	Baby Boomers, Millennials, Gen Z
Occupation	Truck Driver, Computer Scientist, Nurse
Hobbies/Interests	Birdwatchers, Gamers, Foodies, Skateboarders
Religion	Hinduism, Baptist, Islam
Gender	Male, Female, Nonbinary, Two-Spirit
Geography	Rural, Urban, Southern, Midwestern

🌐 Intersectionality

Intersectionality: the many ways in which a person expresses their cultural identity are not separated, but are closely intertwined.

• People typically belong to more than one culture simultaneously.
• These cultures overlap, intersect, and are woven together to create a person's cultural identity.
• Culture is expressed in many ways: language(s) spoken, religion, gender identity, socioeconomic status, age, sexual orientation, geography, educational background, life experiences, living situation, employment status, immigration status, ability/disability.

🔄 Assimilation

🔄 What assimilation is

Assimilation: the process of adopting or conforming to the practices, habits, and norms of a cultural group.

• As a result, the person gradually takes on a new cultural identity and may lose their original identity in the process.
• Example: a newly graduated nurse, after several months of orientation on the hospital unit, offers assistance to a colleague who is busy—the new nurse has developed self-confidence and understands that helping others is a norm for the nurses on that unit.

⚠️ Involuntary assimilation

• Assimilation is not always voluntary and may become a source of distress.
• Historic examples: authorities in the United States and Canadian governments required indigenous children to attend boarding schools, separated them from their families, and punished them for speaking their native language.
• Don't confuse: voluntary adoption of new cultural practices (e.g., a new nurse learning unit norms) vs. forced assimilation that causes loss of original identity.

🌍 How culture influences health and healthcare

🌍 Cultural values and beliefs

• Culture provides an important source of values and comfort for clients, families, and communities.
• Think of culture as a thread woven through a person's world that impacts choices, perspectives, and way of life.
• It plays a role in all life events and threads through the development of self-concept, sexuality, and spirituality.
• It affects lifelong nutritional habits, as well as coping strategies with death and dying.

🏥 Impact on health perceptions

• Culture influences how a client interprets "good" health, as well as their perspectives on illness and the causes of illness.
• The manner in which pain is expressed is also shaped by a person's culture.
• Example: one culture may encourage open expression of pain, while another may value stoicism.

🗣️ Cultural concepts in healthcare

The excerpt provides examples of how culture impacts common values and beliefs:

Cultural Concept	Examples of Culturally Influenced Values and Beliefs
Family Patterns	Family size; views on contraception; roles of family members; naming customs; value placed on elders and children; discipline/upbringing of children; rites of passage; end-of-life care
Communication Patterns	Eye contact; touch; use of silence or humor; intonation, vocabulary, grammatical structure; topics considered personal (i.e., difficult to discuss); greeting customs (handshakes, hugs)
Space Orientation	Personal distance and intimate space
Time Orientation	Focus on the past, present, or future; importance of following a routine or schedule; arrival on time for appointments
Nutritional Patterns	Common meal choices; foods to avoid; foods to heal or treat disease; religious practices (e.g., fasting, dietary restrictions); foods to celebrate life events and holidays

🩺 Impact on healthcare encounters

Culture can affect encounters with health care providers in other ways:

• Level of family involvement in care
• Timing for seeking care
• Acceptance of treatment (as preventative measure or for an actual health problem)
• The accepted decision-maker (i.e., the client or other family members)
• Use of home or folk remedies
• Seeking advice or treatment from nontraditional providers
• Acceptance of a caregiver of the opposite gender

💡 Nurses' own cultural beliefs

• Nurses and other health care team members are impacted by their own personal cultural beliefs.
• Example: a commonly held belief in American health care is the importance of timeliness—medications are administered at specifically scheduled times, and appearing for appointments on time is considered crucial.
• Most cultural beliefs are a combination of beliefs, values, and habits that have been passed down through family members and authority figures.
• The first step in developing cultural competence is to become aware of your own cultural beliefs, attitudes, and practices.

🙏 Cultural diversity and cultural humility

🙏 Cultural diversity

Cultural diversity: a term used to describe cultural differences among people.

• While it is useful to be aware of specific traits of a culture or subculture, it is just as important to understand that each individual is unique.
• There are always variations in beliefs among individuals within a culture.
• Nurses should refrain from making assumptions about the values and beliefs of members of specific cultural groups.

🙏 Cultural humility

Cultural humility (American Nurses Association definition): "A humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot possibly know everything about other cultures, and approach learning about other cultures as a lifelong goal and process."

• A better approach than making assumptions: recognize that culture is not a static, uniform characteristic.
• Realize there is diversity within every culture and in every person.
• Don't confuse: cultural competence (knowing about cultures) vs. cultural humility (recognizing you cannot know everything and approaching learning as lifelong).

📊 Changing demographics

• Current demographics in the United States reveal that the population is predominantly white.
• People who were born in another country, but now live in the United States, comprise approximately 14% of the nation's total population.
• However, these demographics are rapidly changing.
• The United States Census Bureau projects that more than 50 percent of Americans will belong to a minority group by 2060.
• With an increasingly diverse population to care for, it is imperative for nurses to integrate culturally responsive care into their nursing practice.

⚠️ Barriers to culturally responsive care

⚠️ Concepts that hinder care

The excerpt defines several concepts that can impact a nurse's ability to provide culturally responsive care:

Concept	Definition	Example
Stereotyping	The assumption that a person has the attributes, traits, beliefs, and values of a cultural group because they are a member of that group.	The nurse teaches the daughter of an older client how to make online doctor appointments, assuming that the older client does not understand how to use a computer.
Ethnocentrism	The belief that one's culture (or race, ethnicity, or country) is better and preferable than another's.	The nurse disparages the client's use of nontraditional medicine and tells the client that traditional treatments are superior.
Discrimination	The unfair and different treatment of another person or group, denying them opportunities and rights to participate fully in society.	A nurse manager refuses to hire a candidate for a nursing position because she is pregnant.
Prejudice	A prejudgment or preconceived idea, often unfavorable, about a person or group of people.	The nurse withholds pain medication from a client with a history of opioid addiction, assuming they are engaging in drug-seeking [behavior].

🚫 How to avoid these barriers

• Recognize that these concepts represent assumptions and judgments that prevent individualized, respectful care.
• Challenge your own cultural biases (part of cultural humility).
• Approach each patient as a unique individual rather than a representative of a cultural group.
• Don't confuse: awareness of cultural traits (helpful background knowledge) vs. stereotyping (assuming an individual fits the group profile).

🧭 Overview

🧠 One-sentence thesis

The Patient's Bill of Rights safeguards clients' rights to accurate information, fair treatment, and self-determination in health care decisions, with principles that underscore the importance of cultural competency and respectful care.

📌 Key points (3–5)

• Origin and evolution: Adopted by the American Hospital Association in 1973, the bill has been updated, revised, and adapted worldwide for all health care settings.
• Core purpose: Safeguards a client's right to accurate and complete information, fair treatment, and self-determination when making health care decisions.
• Cultural competency foundation: Clients should expect to be treated with sensitivity, dignity, and respect for their cultural values.
• Scope beyond culture: While the bill extends beyond cultural considerations alone, its basic principles underscore the importance of cultural competency when caring for people.
• Common confusion: The Patient's Bill of Rights is not a static document—different versions exist, but all share general principles of informed consent, privacy, and respectful care.

🏥 Historical context and purpose

📜 Origin and development

• The American Hospital Association (AHA) adopted the Patient's Bill of Rights in 1973.
• The bill is described as "an evolving document related to providing culturally competent care."
• It has been updated, revised, and adapted for use throughout the world in all health care settings.
• Different versions exist, but they share general principles.

🎯 Core mission

The Patient's Bill of Rights safeguards a client's right to accurate and complete information, fair treatment, and self-determination when making health care decisions.

• Clients should expect to be treated with sensitivity and dignity.
• Respect for cultural values is explicitly emphasized.
• The bill's basic principles underscore the importance of cultural competency when caring for people.

🤝 Respect and information rights

🤝 Right to considerate and respectful care

• The patient has the right to considerate and respectful care (Right #1).
• This is the foundational principle that frames all other rights.

📋 Right to understandable information

• Patients are encouraged to obtain relevant, current, and understandable information concerning diagnosis, treatment, and prognosis from physicians and other direct caregivers (Right #2).
• Information must be accessible and comprehensible, not just technically available.

🔍 Right to know caregivers' identities

• Patients have the right to know the identity of physicians, nurses, and others involved in their care (Right #4).
• This includes knowing when those involved are students, residents, or other trainees.
• Example: A patient should be informed if a medical student will be participating in their procedure.

💰 Right to financial information

• The patient has the right to know the immediate and long-term financial implications of treatment choices, insofar as they are known (Right #5).
• This enables informed decision-making that considers both medical and economic factors.

🗣️ Decision-making and autonomy rights

🗣️ Right to make care decisions

• The patient has the right to make decisions about the plan of care prior to and during the course of treatment (Right #6).
• Patients can refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy.
• They must be informed of the medical consequences of refusal.
• In case of refusal, the patient is entitled to other appropriate care and services or transfer to another hospital.

📝 Right to discuss procedures and alternatives

• Except in emergencies when the patient lacks decision-making capacity and the need for treatment is urgent, the patient is entitled to the opportunity to discuss and request information related to specific procedures and/or treatments (Right #3).
• This includes:
  • The risks involved
  • The possible length of recuperation
  • The medically reasonable alternatives and their accompanying risks and benefits

📄 Right to advance directives

• The patient has the right to have an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decision-maker (Right #7).
• The hospital is expected to honor the intent of that directive to the extent permitted by law and hospital policy.
• Health care institutions must:
  • Advise patients of their rights under state law and hospital policy to make informed medical choices
  • Ask if the patient has an advance directive
  • Include that information in patient records
• Patients have the right to timely information about hospital policy that may limit its ability to implement fully a legally valid advance directive.

🔒 Privacy and confidentiality rights

🔒 Right to privacy

• The patient has the right to every consideration of privacy (Right #8).
• Case discussion, consultation, examination, and treatment should be conducted so as to protect each patient's privacy.

🗂️ Right to confidential records

• The patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential by the hospital (Right #9).
• Exceptions exist in cases such as suspected abuse and public health hazards when reporting is permitted or required by law.
• The patient has the right to expect that the hospital will emphasize the confidentiality of this information when it releases it to any other parties entitled to review information in these records.

📖 Right to review medical records

• The patient has the right to review the records pertaining to his/her medical care and to have the information explained or interpreted as necessary, except when restricted by law (Right #10).
• This supports transparency and patient understanding of their own care.

🏢 Institutional transparency and research rights

🏢 Right to appropriate care and transfer

• The patient has the right to expect that, within its capacity and policies, a hospital will make a reasonable response to the request of a patient for appropriate and medically indicated care and services (Right #11).
• The hospital must provide evaluation, service, and/or referral as indicated by the urgency of the case.
• When medically appropriate and legally permissible, or when a patient has so requested, a patient may be transferred to another facility.
• Requirements for transfer:
  • The institution to which the patient is to be transferred must first have accepted the patient for transfer
  • The patient must have the benefit of complete information and explanation concerning the need for, risks, benefits, and alternatives to such a transfer

🔗 Right to know business relationships

• The patient has the right to ask and be informed of the existence of business relationships among the hospital, educational institutions, other health care providers, or payers that may influence the patient's treatment and care (Right #12).
• This transparency helps patients understand potential conflicts of interest.

🔬 Right to consent or decline research participation

• The patient has the right to consent to or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement (Right #13).
• Studies must be fully explained prior to consent.
• A patient who declines to participate in research or experimentation is entitled to the most effective care that the hospital can otherwise provide.
• Don't confuse: declining research participation does not mean forfeiting quality care—patients are still entitled to the best available standard treatment.

🔄 Right to continuity of care

• The patient has the right to expect reasonable continuity of care when appropriate (Right #14).
• Patients should be informed by physicians and other caregivers of available and realistic patient care options when hospital care is no longer appropriate.

📢 Right to know policies and resources

• The patient has the right to be informed of hospital policies and practices that relate to patient care, treatment, and responsibilities (Right #15).
• This includes:
  • Available resources for resolving disputes, grievances, and conflicts (such as ethics committees, patient representatives, or other mechanisms available in the institution)
  • The hospital's charges for services and available payment methods

🔄 Current status

🔄 Evolution to Patient Care Partnership

• The excerpt notes that a current version of the "Patient Care Partnership" brochure from the American Hospital Association has replaced the Patient's Bill of Rights.
• This reflects the ongoing evolution of the document to meet contemporary health care needs.

🧭 Overview

🧠 One-sentence thesis

Cultural competence is a lifelong nursing process that combines knowledge, awareness, and sensitivity about clients' cultural beliefs to improve health outcomes and build trusting relationships with culturally diverse clients.

📌 Key points (3–5)

• What cultural competence is: applying evidence-based nursing in agreement with clients' cultural values, beliefs, worldview, and practices to produce improved outcomes.
• Why it matters: culturally competent care improves quality of care, health outcomes, and builds supportive, trusting relationships; it is an ethical and moral obligation.
• How to develop it: through cultural awareness (self-reflection), cultural knowledge (seeking information), cultural sensitivity (nonjudgmental respect), cultural skill (synthesizing information while planning care), and cultural encounters (direct engagement with diverse clients).
• Common confusion: cultural competence is not just awareness of other cultures' existence—it requires intrinsic motivation (cultural desire), active learning, and ongoing self-examination of one's own biases and assumptions.
• Foundation: rooted in Dr. Madeleine Leininger's transcultural nursing theory, which emphasizes "culturally congruent practice" (care aligned with clients' preferred values and practices).

🌱 Origins and foundations

🌱 Transcultural nursing theory

Transcultural nursing: incorporates cultural beliefs and practices of individuals to help them maintain and regain health or to face death in a meaningful way.

• Developed by Dr. Madeleine Leininger (1925–2012), the first professional nurse with a PhD in anthropology.
• She combined "culture" (from anthropology) with "care" (from nursing) into "culture care."
• In the mid-1950s, no cultural knowledge base existed to guide nursing decisions or understand cultural behaviors.
• Leininger coined the term culturally congruent practice.

Culturally congruent practice: nursing care that is in agreement with the preferred values, beliefs, worldview, and practices of the health care consumer.

• She developed and taught the first transcultural nursing course in 1966; master's and doctoral programs followed.
• Honored as a Living Legend of the American Academy of Nursing in 1998.

📜 Ethical and professional standards

• Nurses have an ethical and moral obligation to provide culturally competent care.
• ANA "Respectful and Equitable Practice" Standard: nurses must practice with cultural humility and inclusiveness.
• ANA Code of Ethics: nurses must collaborate to protect human rights, fight discriminatory practices, and reduce disparities.
• Nurses are expected to be aware of their own cultural identifications to control personal biases that may interfere with the therapeutic relationship.
• Self-awareness involves examining one's own culture and perceptions/assumptions about the client's culture, as well as understanding how oppression, racism, discrimination, and stereotyping affect them personally and in their work.

🪞 Self-examination and cultural desire

🪞 Beginning with self-reflection

• Developing cultural competence begins in nursing school.
• Culture is an integral part of life, but its impact is often implicit.
• It is easy to assume others share the same cultural values, but each individual has their own beliefs, values, and preferences.
• Nurses should reflect on questions such as:
  • Who are you? With what cultural group or subgroups do you identify?
  • When you meet someone from another culture/country/place, do you try to learn more about them?
  • Do you notice instances of bias, prejudice, discrimination, and stereotyping in your environment?
  • Have you reflected on your own upbringing and childhood to better understand your own implicit biases?
  • Do you consider your use of language to avoid terms or phrases that may be degrading or hurtful?
  • When other people use biased language and behavior, do you feel comfortable speaking up?
  • How ready are you to give equal attention, care, and support to people regardless of their culture, socioeconomic class, religion, gender expression, sexual orientation, or other "difference"?

💡 Cultural desire

Cultural desire: the intrinsic motivation and commitment on the part of a nurse to develop cultural awareness and cultural competency.

• Although cultural diversity training is typically a requirement for health care professionals, cultural desire refers to the nurse's own internal drive.
• It is not just completing a training—it is a personal commitment to ongoing learning and growth.
• Don't confuse: cultural desire is intrinsic (from within), not just external compliance with training requirements.

🧩 The five characteristics of cultural competence

🧩 Cultural awareness

Cultural awareness: a deliberate, cognitive process in which health care providers become appreciative and sensitive to the values, beliefs, attitudes, practices, and problem-solving strategies of a client's culture.

• To become culturally aware, the nurse must undergo reflective exploration of personal cultural values while also becoming conscious of the cultural practices of others.
• The culturally competent nurse seeks to reverse harmful prejudices, ethnocentric views, and attitudes they have.
• Cultural awareness goes beyond simple awareness of the existence of other cultures—it involves interest, curiosity, and appreciation.
• Example: A nurse reflects on their own upbringing and realizes they hold certain assumptions about family roles; they then actively work to understand how other cultures view family differently.

📚 Cultural knowledge

Cultural knowledge: seeking information about cultural health beliefs and values to understand clients' world views.

• The nurse actively seeks information about other cultures, including common practices, beliefs, values, and customs, particularly for cultures prevalent within the communities they serve.
• Cultural knowledge also includes understanding:
  • Historical backgrounds of culturally diverse groups in society.
  • Physiological variations and the incidence of certain health conditions in culturally diverse groups.
• Cultural knowledge is best obtained through cultural encounters with clients from diverse backgrounds to learn about individual variations within cultural groups and to prevent stereotyping.
• Don't confuse: cultural knowledge is not about memorizing stereotypes—it is about understanding general patterns while recognizing individual variation.

🤝 Cultural sensitivity

Cultural sensitivity: being tolerant and accepting of cultural practices and beliefs of people.

• Demonstrated when the nurse conveys nonjudgmental interest and respect through words and action.
• Includes understanding that some health care treatments may conflict with a person's cultural beliefs.
• Implies a consciousness of the damaging effects of stereotyping, prejudice, or biases on clients and their well-being.
• Nurses who fail to act with cultural sensitivity may be viewed as uncaring or inconsiderate, causing a breakdown in trust for the client and their family members.
• When a client experiences nursing care that contradicts their cultural beliefs, they may experience moral or ethical conflict, nonadherence, or emotional distress.
• Example: A nurse recognizes that a client's religious beliefs may influence their dietary preferences and works with the dietary team to provide culturally appropriate meals, rather than dismissing the client's concerns.

🛠️ Cultural skill

Cultural skill: reflected by the nurse's ability to gather and synthesize relevant cultural information about their clients while planning care and using culturally sensitive communication skills.

• Nurses with cultural skill provide care consistent with their clients' cultural needs.
• They deliberately take steps to secure a safe health care environment that is free of discrimination or intolerance.
• Example: A culturally skilled nurse will make space and seating available within a client's hospital room for accompanying family members when this support is valued by the client.
• Cultural desire, awareness, sensitivity, and knowledge are the building blocks for developing cultural skill.

🌍 Cultural encounters

Cultural encounter: a process where the nurse directly engages in face-to-face cultural interactions and other types of encounters with clients from culturally diverse backgrounds in order to modify existing beliefs about a cultural group and to prevent possible stereotyping.

• Direct engagement is essential—reading about cultures is not enough.
• Cultural encounters help the nurse learn about individual variations within cultural groups.
• They prevent the nurse from relying on stereotypes or generalizations.
• Example: A nurse who has only read about a particular cultural group's health beliefs meets several clients from that group and learns that individuals within the group have diverse perspectives and practices.

🔄 The lifelong process

🔄 Ongoing development

• Cultural competence is a lifelong process that evolves throughout a nursing career.
• It takes motivation, time, and practice to develop.
• By developing the characteristics of cultural awareness, cultural knowledge, cultural skill, and cultural encounters, a nurse develops cultural competence.
• Culturally competent nurses have the power to improve the quality of care leading to better health outcomes for culturally diverse clients.
• Nurses who accept and uphold the cultural values and beliefs of their clients are more likely to develop supportive and trusting relationships with their clients.
• In turn, this opens the way for optimal disease and injury prevention and leads towards positive health outcomes for all clients.

🧭 Overview

🧠 One-sentence thesis

Health disparities—differences in health outcomes driven by social determinants—persist in the U.S. health care system despite decades of promoting culturally competent care, and nurses play a critical role in reducing these disparities through culturally responsive care.

📌 Key points (3–5)

• What health disparities are: differences in health outcomes caused by entrenched economic, sociopolitical, or environmental factors (social determinants of health), not just individual choices.
• Who is affected: vulnerable populations experience increased disease burden and access problems based on ethnicity, gender, age, disability, socioeconomic status, geographic location, and other characteristics historically linked to discrimination.
• Evidence of ongoing disparities: the 2022 National Healthcare Quality and Disparities Report shows continued gaps—especially for poor, uninsured, rural, Hispanic, and Black populations—despite improvements since the Affordable Care Act.
• Common confusion: health disparities vs. health care disparities—health disparities refer to differences in health outcomes; health care disparities refer specifically to differences in access to care and insurance coverage.
• Why nurses matter: nurses are uniquely positioned to reduce disparities by providing culturally sensitive environments, performing cultural assessments, and delivering culturally responsive care.

🏥 Origins and persistence of disparities

🏛️ Historical roots in the U.S. health care system

• The U.S. health care system was shaped by mainstream white culture values and originally designed to serve primarily English-speaking clients with financial resources.
• Most health care professionals in the U.S. are members of white culture, and medical treatments tend to arise from that perspective.
• The 2003 Institute of Medicine report Unequal Treatment provided evidence that "bias, prejudice, and stereotyping on the part of health care providers may contribute to differences in care."
• Don't confuse: the problem is not just individual provider bias—it is also systemic design that embedded inequities from the start.

📉 Current state despite progress

• Although access and quality have improved since 2000 following the Affordable Care Act, the 2022 report shows continued disparities.
• Vulnerable populations continue to experience increased prevalence and burden of diseases, as well as problems accessing quality health care.
• Example: Gains in insurance coverage vary by race and ethnicity, with Hispanic groups and Non-Hispanic American Indian or Alaska Native groups significantly less likely to be insured.

🔍 Defining key terms

🩺 Health disparities

Health disparities: differences in health outcomes resulting from entrenched economic, sociopolitical, or environmental factors, referred to as social determinants of health.

• These are not random variations—they result from systemic factors, not individual behavior alone.
• Health disparities negatively impact groups based on ethnicity, gender, age, mental health, disability, sexual orientation, gender identity, socioeconomic status, geographic location, or other characteristics historically linked to discrimination or exclusion.

🏥 Health care disparity

Health care disparity: differences in access to health care and insurance coverage.

• This is a narrower term than health disparities—it focuses specifically on access and insurance, not all health outcomes.
• Example: rural counties are disproportionately designated as primary care shortage areas compared to metropolitan counties.

🌍 Social determinants of health

Social determinants of health: conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes.

• Resources that enhance quality of life can significantly influence population health outcomes.
• Examples include:
  • Safe and affordable housing
  • Access to education
  • Public safety
  • Availability of healthy foods
  • Local emergency/health services
  • Environments free of life-threatening toxins

📊 Evidence of ongoing disparities

📉 Key findings from the 2022 National Healthcare Quality and Disparities Report

The Agency for Healthcare Research and Quality (AHRQ) releases an annual report describing quality in terms of client safety, person-centered care, care coordination, effective treatment, healthy living, and care affordability.

Finding	Details
Life expectancy decline	Overall health expectancy declined in 2022 due to COVID, with a greater decline for Hispanic and non-Hispanic Black groups compared to non-Hispanic White groups.
Insurance coverage gaps	Percentage of people with health insurance has increased greatly in the past decade, but gains vary by race and ethnicity; Hispanic and Non-Hispanic American Indian or Alaska Native groups are significantly less likely to be insured.
Rural access problems	Disproportionately more rural counties than metropolitan counties are designated as primary care shortage areas.
Maternal health disparities	The U.S. has worse maternal health and health care than other industrialized nations, with suboptimal outcomes for multiple measures and considerable racial disparities.

💰 Broader consequences

• Health disparities and health care disparities can lead to:
  • Decreased quality of life
  • Increased personal costs
  • Lower life expectancy
• These disparities also translate to greater societal costs, such as the financial burden of uncontrolled chronic illnesses.

🛠️ Resources and initiatives to combat disparities

🏛️ Federal and national agencies

Agency/Initiative	Role
Agency for Healthcare Research and Quality (AHRQ)	Publishes the National Healthcare Quality and Disparities Report on measures related to access, affordability, coordination, treatment, healthy living, safety, and person-centered care.
Healthy People 2030	A new initiative launched every ten years to guide national health promotion and disease prevention efforts.
Office of Minority Health (OMH)	Works to improve the health of minority populations; provides resources on Cultural and Linguistic Competency, including national standards for Culturally and Linguistically Appropriate Services (CLAS).
REACH-US	Centers for Disease Control initiative to remove barriers to health linked to race, ethnicity, education, income, location, or other social factors.
National Partnership for Action to End Health Disparities (NPA)	Raises awareness and increases effectiveness of programs targeting health disparities; offers a Toolkit for Community Action.

🤝 Nonprofit and professional organizations

Organization	Mission
Robert Wood Johnson Foundation (RWJF)	Philanthropic organization identifying root causes of health disparities and removing barriers to improve health outcomes.
The Sullivan Alliance	Nonprofit strengthening the capacity and quality of the nation's health workforce by increasing the number of historically marginalized people in every area of health care.
Transcultural Nursing Society (TCNS)	Improves the quality of culturally congruent and equitable care worldwide by promoting cultural competence in nursing practice, scholarship, education, research, and administration.

🩺 The nurse's role in reducing disparities

🎯 Why culturally responsive care matters

• Providing culturally responsive care is a key strategy for reducing health disparities.
• While there are multiple determinants contributing to a person's health, nurses play an important role by:
  • Providing a culturally sensitive environment
  • Performing a cultural assessment
  • Providing culturally responsive care
• Nurses are uniquely positioned to directly impact client outcomes as we work together to overcome health disparities.

⚠️ Consequences of lack of culturally responsive care

• A lack of culturally responsive care potentially contributes to miscommunication between the client and the nurse.
• The client may experience:
  • Distress
  • Loss of trust in the nurse or the health care system as a whole
  • Nonadherence to prescribed treatments
• Don't confuse: this is not just about being polite—lack of cultural responsiveness has measurable negative health outcomes.

🌟 Real-world example: Flint, Michigan water crisis

Background: In 2014 the water system in Flint, Michigan, was discovered to be contaminated with lead. The city's children were found to have perilously elevated lead levels. Children from poor households were most affected by the crisis.

Health impact: Lead is a dangerous neurotoxin. Elevated lead levels are linked to:

• Slowed physical development
• Low IQ
• Problems with cognition, attention, and memory
• Learning disabilities

Nursing response: Approximately 150 local nurses and nursing students answered the call by:

• Organizing and arranging educational seminars
• Setting up lead testing clinics to determine who had been affected by the water contamination
• A nursing student involved noted that this situation illustrated "the need for health care, the need for nursing, goes way outside the hospital walls."

Key insight: This example shows how social determinants (contaminated water, poverty) create health disparities, and how nurses can advocate for community health beyond traditional hospital settings.

🧭 Overview

🧠 One-sentence thesis

Nurses reduce health disparities and improve client outcomes by creating culturally sensitive environments, performing cultural assessments, and integrating clients' cultural beliefs into their care.

📌 Key points (3–5)

• Why culturally responsive care matters: lack of cultural sensitivity leads to miscommunication, distrust, and poor adherence to treatment; nurses are uniquely positioned to overcome health disparities.
• How to convey cultural sensitivity: introduce yourself formally, observe nonverbal cues, use inclusive language, adopt a nonjudgmental approach, and prioritize cultural considerations.
• When to use medical interpreters: required when clients have limited English ability; trained interpreters reduce errors, shorten hospital stays, and improve satisfaction—family members should not interpret.
• Common confusion: it's acceptable to admit limited knowledge of a culture and politely ask questions; being open and honest prevents misunderstandings and shows respect.
• Sensitive topics like sexuality: nurses should initiate conversations in private, non-judgmental settings, provide normalcy without minimizing concerns, and recognize when to seek additional resources.

🤝 Building a culturally sensitive environment

👋 First contact and introductions

• Introduce yourself by name and role when meeting the client and family for the first time.
• Address the client formally using their title and last name until you know their preference.
• Ask how they wish to be addressed and record this in the chart.
• Respectfully acknowledge family members and visitors at the bedside.
• Example: A nurse meets a new client and says, "Hello, I'm Nurse Smith. How would you like me to address you?" rather than assuming a first-name basis.

🧭 Observing and following nonverbal cues

• Begin by standing or sitting at least arm's length from the client.
• Observe eye contact, space orientation, touch, and other nonverbal behaviors and follow the client's lead.
• Why this matters: different cultures have different norms for personal space and physical contact; imposing your own norms can cause discomfort or distrust.
• Don't confuse: "following their lead" means adapting to the client's behavior, not assuming all members of a culture behave identically.

🗣️ Language and inclusive communication

• Note the client's preferred language and record it in the chart.
• Determine if a medical interpreter is required before proceeding with interview questions if English is not the client's primary language.
• Use inclusive, culturally sensitive language:
  • Say "a person who uses a wheelchair" instead of "wheelchair bound."
• Why: language shapes perception and respect; inappropriate terms can alienate clients.

🙏 Honesty, respect, and nonjudgment

• Be open and honest about the extent of your knowledge of the client's culture.
• Politely ask questions about their beliefs and seek clarification to avoid misunderstandings.
• Adopt a nonjudgmental approach and show respect for cultural beliefs, values, and practices.
• Attempt to integrate cultural expressions into care as long as they are not unsafe for the client or others.
• Assure the client that cultural considerations are a priority in their care.
• Example: A nurse says, "I'm not familiar with this practice. Can you help me understand so I can support you better?" rather than dismissing or ignoring the client's beliefs.
• Don't confuse: you may not personally agree with a client's cultural expressions, but the client's rights must be upheld.

🌐 Using medical interpreters

🏥 Why trained interpreters are required

Medical interpreters are trained professionals who facilitate communication when clients have limited ability to speak, read, write, or understand English.

• Health care facilities are mandated by The Joint Commission to provide qualified medical interpreters.
• Benefits of trained interpreters:
  • Fewer communication errors
  • Shorter hospital stays
  • Reduced 30-day readmission rates
  • Improved client satisfaction

❌ Why family members should not interpret

• The client may withhold sensitive information from family members.
• Family members may edit or change information provided.
• Unfamiliarity with medical terminology causes misunderstandings and errors.
• Don't confuse: family members can provide cultural context, but they should not replace trained interpreters for medical communication.

📋 Guidelines for working with interpreters

• Allow extra time for the interview or conversation.
• Meet with the interpreter beforehand to provide background whenever possible.
• Document the interpreter's name in the progress note.
• Always face and address the client directly using a normal tone of voice; do not direct questions to the interpreter.
• Speak in the first person (using "I").
• Avoid idioms, abbreviations, slang, jokes, and jargon:
  • Example: Don't say "Are you feeling under the weather today?"—this idiom may not translate clearly.
• Speak in short paragraphs or sentences; ask only one question at a time.
• Allow sufficient time for the interpreter to finish before beginning another statement or topic.
• Ask the client to repeat instructions and explanations to verify understanding.

🧑‍🤝‍🧑 Cultural and gender considerations

• Consider coordinating conversations with other health care team members to streamline communication.
• Be aware of cultural implications: who can discuss what health care topics and who makes decisions.
• Obtain an interpreter of the same gender as the client when possible to prevent potential embarrassment if sensitive matters are discussed.

💬 Discussing sexuality sensitively

🔍 What sexuality encompasses

Sexuality encompasses sex, sexual orientation, gender identity, gender roles, among other topics.

• Why these discussions arise:
  • Medication sexual side effects
  • Disease processes affecting sexuality
  • Surgical procedures affecting sexuality
  • Sexually transmitted infections
  • Sexual trauma
  • Health needs of LGBTQAI+ and straight clients
• Why clients may hesitate: embarrassment or social stigmas about certain topics; they may feel they cannot initiate the conversation.

🛡️ Creating a safe environment for discussion

• Provide a private area free of interruptions for the conversation.
• Do not appear hurried; give the client your undivided attention.
  • Why: clients may be reluctant to open up if they feel the nurse is too busy.
• Provide a sense of normalcy without minimizing concerns; ask permission before further discussing sexuality.
  • Example: "Some clients taking this medication experience erectile dysfunction. Is this something that you would like to talk about?"
• Remain nonjudgmental and respectful even if you may not agree with the client's sexuality.
• Recognize your limitations as a nurse; it's acceptable not to have all the answers—seek additional referrals and information as necessary.

🚨 When to use additional resources

• Be aware of situations that warrant using other staff:
  • Example: If a female client has experienced sexual trauma by a male perpetrator, she likely will not be comfortable with a male RN performing her assessment.
  • It may be necessary to confer with the charge RN to change client assignments to allow the client to be cared for by female staff.
• Why: trauma-informed care requires sensitivity to past experiences that may affect comfort and trust.

🩺 Cultural assessment tools

🔤 The Four Cs of Culture model

A quick cultural assessment tool that asks what the client Considers to be a problem, the Cause of the problem, how they are Coping, and how Concerned they are.

Question	Example client response
What does the client Consider the problem and what they Call it?	A client diagnosed with pneumonia believes his body is "unbalanced."
What does the client think Caused this problem?	The client believes the illness is punishment for a misdeed; avoids certain foods and uses herbal tea as home remedies.
How Concerned is the client about this problem?	The client views the illness as "God's will" and states, "It's in God's hands."

• Why this tool helps: it reveals the client's perspective, which may differ significantly from the biomedical model, and guides culturally responsive care planning.

📝 Comprehensive cultural assessment (Spector's Heritage Assessment)

A more detailed interview adapted from Spector's Heritage Assessment Tool includes questions such as:

• Where were you born? Where were your parents born?
• What pronoun do you use (he, she, they)?
• In what language are you most comfortable speaking and reading?
• Did you grow up in a city, town, or rural setting?
• When you were growing up, who lived with you and your family?
• Are your friends from the same cultural background as you?
• What is your religious preference?
• Do you have any dietary preferences related to your religious or cultural beliefs?
• In your culture, how do you celebrate the birth of a baby? A wedding?
• When a woman is pregnant, are there any special customs she needs to follow? Any special foods?

Why these questions matter: they help the nurse understand the client's cultural context, family structure, language needs, religious practices, and health-related customs, enabling integration of cultural beliefs into care.

⚠️ Consequences of lacking culturally responsive care

📉 Impact on communication and trust

• Miscommunication between the client and the nurse.
• Client distress or loss of trust in the nurse or the health care system as a whole.
• Non-adherence to prescribed treatments.
• Why nurses are uniquely positioned: nurses work directly with clients and can directly impact client outcomes by overcoming health disparities.

🧭 Overview

🧠 One-sentence thesis

Cultural assessment tools help nurses systematically gather information about clients' cultural beliefs, practices, and concerns to provide care that respects and accommodates their cultural needs.

📌 Key points (3–5)

• When to assess: After establishing a culturally sensitive environment, nurses should incorporate cultural assessment when caring for all clients.
• Quick tool—Four Cs: Asks what the client Considers the problem, what Caused it, how they are Coping, and how Concerned they are.
• Comprehensive tool—Heritage Assessment: Covers birthplace, language, religion, dietary practices, family structure, illness customs, death rituals, and decision-making patterns.
• Purpose: These tools facilitate understanding and communication and are adaptable to a variety of health care settings.
• Common confusion: Assessment is not a one-time checklist—it should inform ongoing culturally responsive care, including cultural negotiation and creating a culturally safe environment.

🔍 Quick cultural assessment: The Four Cs

🔍 What the Four Cs model asks

The Four Cs of Culture model is a quick cultural assessment tool that focuses on four key questions:

• Consider/Call: What does the client think is the problem? What do they call it?
• Caused: What does the client believe caused this problem?
• Coping: How is the client coping with the problem?
• Concerned: How serious does the client think this problem is?

🩺 Example scenario from the excerpt

The excerpt provides a pneumonia example to illustrate the Four Cs:

Four C	Client's perspective
Consider	Client believes his body is "unbalanced" (not "pneumonia")
Caused	Client believes the illness is punishment for a misdeed
Coping	Client avoids certain foods, uses home remedies like herbal tea
Concerned	Client views illness as "God's will" and states "It's in God's hands"

• This shows how a client's cultural framework can differ significantly from the biomedical diagnosis.
• The nurse learns what matters to the client and how they are already managing the problem.

📋 Comprehensive cultural assessment: Heritage Assessment

📋 What the Heritage Assessment covers

Inspired by R. E. Spector's Heritage Assessment interview, this tool gathers detailed cultural background through open-ended questions:

Background and identity:

• Birthplace (client and parents)
• Preferred pronoun (he, she, they)
• Language comfort for speaking and reading
• Urban, town, or rural upbringing
• Household composition during childhood

Social and religious context:

• Friends' cultural backgrounds
• Religious preference
• Dietary preferences related to religion or culture

Life events and customs:

• Birth and wedding celebrations
• Pregnancy customs and special foods
• Illness care practices (who cares, what foods, what to avoid)
• Home remedies for illness
• Comforting actions when someone is dying
• Death rituals

Family structure and beliefs:

• Who makes family decisions
• How elders are viewed
• Beliefs about organ donation or blood transfusions
• Special customs (rites of passage, foods, holidays)

🎯 Why this depth matters

• The excerpt emphasizes that these tools are "designed to facilitate understanding and communication."
• By asking about specific life events (birth, illness, death), nurses learn how cultural beliefs shape health behaviors, not just what the beliefs are.
• Example: Knowing that a client's culture designates a specific family member to make decisions helps the nurse include the right people in care planning.

🚫 Don't confuse with...

• This is not a checklist to "complete" and file away—it informs ongoing care decisions.
• The excerpt notes these tools are "adaptable to a variety of health care settings," meaning nurses should select relevant questions for the context, not rigidly follow every item.

🔗 Connection to culturally responsive care

🔗 Assessment as a foundation

The excerpt places cultural assessment as the second step in a sequence:

1. Establish a culturally sensitive environment (covered in prior section)
2. Perform cultural assessment (this section)
3. Provide culturally responsive care (next section)

🔗 What comes after assessment

The excerpt briefly introduces concepts that follow from assessment:

Culturally safe environment: A safe space for clients to interact without judgment or discrimination, where the client is free to express their cultural beliefs, values, and identity.

Cultural negotiation: Both the client and nurse seek a mutually acceptable way to deal with competing interests of nursing care, prescribed medical care, and the client's cultural needs.

• Example from the excerpt: A nurse asks a client to take medication "every day when he awakens" rather than "every morning at 0800" to accommodate a culture that views time as relative rather than fixed.
• Example from the excerpt: A nurse arranges for a client to keep her hijab during surgery, covering it with a surgical cap, rather than requiring removal.

🔗 Decision-making and self-determination

The excerpt introduces a potential cultural conflict:

Self-determination: A person's right to determine what will be done with and to their own body.

• U.S. health care culture emphasizes individuality and self-determination.
• Some clients' cultures value group decision-making and decisions made to benefit the group, not necessarily the individual.
• Example from the excerpt: The 2019 film The Farewell depicts a Chinese-American family deciding not to tell the matriarch she is dying of cancer—a group decision that conflicts with U.S. norms of patient autonomy.
• Don't confuse: The excerpt does not resolve this tension; it highlights that assessment must uncover who makes decisions in the client's culture so the nurse can navigate these differences respectfully.

🧭 Overview

🧠 One-sentence thesis

Culturally responsive care requires nurses to create safe environments, negotiate competing cultural and medical needs, and accommodate clients' cultural preferences regarding decision-making, space, eye contact, and food while maintaining effective treatment.

📌 Key points (3–5)

• Culturally safe environment: a space free from judgment where clients can express cultural beliefs, values, and identity without discrimination.
• Cultural negotiation: a reciprocal, collaborative process where nurse and client find mutually acceptable ways to balance nursing care, medical treatment, and cultural needs.
• Cultural influences on care: time orientation, space/touch preferences, eye contact norms, and food choices all vary by culture and must be accommodated when feasible.
• Common confusion: U.S. healthcare emphasizes individual self-determination, but some cultures prioritize group decision-making—nurses must recognize and respect this difference.
• Practical accommodation: when cultural needs don't adversely affect treatment, they should be honored (e.g., keeping a hijab during surgery, adjusting medication timing to daily routines rather than clock time).

🏥 Creating a Culturally Safe Environment

🛡️ What makes an environment culturally safe

Culturally safe environment: a safe space for clients to interact with the nurse, without judgment or discrimination, where the client is free to express their cultural beliefs, values, and identity.

• This is both an individual nurse responsibility and an organizational responsibility.
• Safety means freedom from judgment and discrimination.
• Clients must feel free to express their cultural identity openly.

🤝 Why safety matters for care

• Without cultural safety, clients may withhold information or disengage from care.
• Trust and the nurse-client relationship depend on this foundation.
• The environment must support the client's cultural expression, not suppress it.

🔄 Cultural Negotiation in Practice

🤝 What cultural negotiation means

Cultural negotiation: both the client and nurse seek a mutually acceptable way to deal with competing interests of nursing care, prescribed medical care, and the client's cultural needs.

• It is reciprocal and collaborative—not one-sided.
• When cultural needs don't significantly or adversely affect treatment, they should be accommodated when feasible.
• The goal is to balance medical requirements with cultural preferences.

💊 Medication timing example

• The conflict: Healthcare culture values punctuality and fixed schedules; some cultures view time as relative (day/night, wake/eat/sleep cycles).
• The negotiation: Instead of "take medication at 0800," teach "take medication when you awaken each day."
• This respects the client's cultural view while maintaining treatment effectiveness.

🧕 Surgical hijab example

• The conflict: Preoperative protocol requires removing personal items; client wishes to keep hijab for religious/cultural reasons.
• The negotiation: Nurse arranges with surgical team to keep hijab in place, covered by a surgical cap.
• This shows respect for cultural beliefs while meeting surgical requirements.

⚠️ When to negotiate

• Don't confuse accommodation with compromising safety: negotiate when cultural needs don't adversely affect treatment.
• The excerpt emphasizes "when feasible" and "do not significantly affect treatment plan."

🧠 Decision-Making and Self-Determination

🇺🇸 U.S. healthcare cultural norms

Self-determination: a person's right to determine what will be done with and to their own body.

• U.S. healthcare mirrors American cultural norms: individuality, personal freedom, self-determination.
• Emphasis is on the individual making their own healthcare decisions.

🌏 Collectivistic vs individualistic cultures

• Some cultures value group decision-making and decisions made to benefit the group, not necessarily the individual.
• Example: The excerpt references the film The Farewell, where a Chinese-American family decides not to tell the matriarch she is dying of cancer, believing the family should bear the emotional burden—a collectivistic viewpoint contrasting with American individualism.
• Don't confuse: Individual autonomy is not universal; some clients expect and prefer family-centered decision-making.

🧭 Space, Touch, and Eye Contact

📏 Space orientation

• The amount of personal space a person needs to feel comfortable is culturally influenced.
• For some, standing four inches away feels awkward; for others, small personal space is expected during conversation.
• Nurses must often enter a client's intimate or personal space, which can cause emotional distress.

Best practices:

• Always ask permission before entering personal space.
• Explain why close contact is necessary and what will happen.
• Watch for cues: client removing themselves, pulling away, or closing eyes signals discomfort.
• Allow the client to assume a comfortable position or distance.

🤚 Touch considerations

• Touch is culturally determined.
• It may be inappropriate for a male nurse to care for a female client (or vice versa) in some cultures.
• In some cultures, touching a person's head without permission is considered rude.
• Modesty and exposure concerns vary by culture.

👁️ Eye contact norms

• In the U.S., direct eye contact is valued when communicating.
• In some cultures, direct eye contact is interpreted as rude or bold.
• Clients may avert their eyes or look down to show deference and respect.
• Nurse response: Notice these cultural cues and mirror the client's behaviors when possible.

🍽️ Food Choices and Dietary Practices

🌾 Cultural significance of food

• Culture plays a meaningful role in dietary practices and food choices.
• Food is used to celebrate life events and holidays.
• Most cultures have staple foods (bread, pasta, rice) and particular preparation methods.
• Special foods are prepared to heal, cure, or demonstrate kinship, caring, and love.

🍲 Examples across cultures

• U.S.: Chicken noodle soup is often prepared for family members who are ill.
• Asian cultures: Individuals prefer "heating" or "cooling" foods depending on the illness, believing specific foods bring balance back to their system.
• Certain foods and beverages (meat, alcohol) are forbidden in some cultures.

🍴 Common food choices by culture/religion

Culture/Religion	Common Dietary Choices	Other Considerations
Buddhist & Hindu	Lentils, tofu, vegetables, spices, rice	May practice vegetarianism and mindful eating
Christian	Varies by denomination; some eat fish on Friday instead of meat	During Lent, may fast or avoid certain foods
Hispanic	Rice, beans, pork, beef, chicken, goat, eggs, corn, avocado, tropical fruits	Diet blends tradition and modern cuisine from Mayan & Aztec agricultural communities
Hmong	Pho, laab, spring rolls, sticky rice, pork, chicken, beef, fish, tofu, leafy greens, tropical fruits	During postpartum period, may choose boiled chicken, rice, warm/hot water for 30 days
Jewish	Kosher diet includes preparation of meat and dairy, kosher-certified foods	During Yom Kippur, may fast for 24 hours

🤝 Nurse accommodation

• Nurses should accommodate or negotiate dietary requests of clients.
• Food holds important meaning to many people—respecting this supports culturally responsive care.

📋 Summary of Cultural Competency Development

🎯 Key principles for nurses

• Cultural competence is an ongoing process requiring dedication, time, and practice.
• It is a key strategy in reducing health care disparities.
• Culture functions as a source of values and comfort for clients, families, and communities.

🚫 What interferes with care

• Misunderstandings, prejudices, and biases on the part of the healthcare provider interfere with client health outcomes.
• Nurses must examine their own biases, ethnocentric views, and prejudices.

✅ What promotes effective care

• Intentionally provide client-centered care with sensitivity and respect for culturally diverse populations.
• Negotiate care so it is congruent with clients' cultural beliefs and values.
• Respect and understand cultural values and beliefs to develop positive, trusting relationships.

🧭 Overview

🧠 One-sentence thesis

The nursing process serves as a critical thinking road map that enables nurses to analyze information, prioritize care, and provide safe, client-centered interventions even for clients they have just met.

📌 Key points (3–5)

• What the nursing process is: a professional standard and critical thinking model that guides nurses in providing safe, client-centered care.
• Why nurses can act quickly: they use the nursing process to analyze pertinent information and prioritize actions systematically.
• Critical thinking vs clinical reasoning: critical thinking is broader (includes teamwork, workflow, safety); clinical reasoning is the cognitive process of gathering/analyzing client data and weighing alternative actions.
• Inductive reasoning in nursing: noticing cues → recognizing patterns (generalizations) → forming hypotheses about client problems.
• Common confusion: critical thinking attitudes (independence, humility, curiosity) are not the same as clinical reasoning skills (gathering data, evaluating significance, choosing actions).

🧠 How nurses think: Critical thinking and clinical reasoning

🧠 Critical thinking defined

Critical thinking: a broad term in nursing that includes "reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow."

• It means nurses do not just "follow orders"—they take extra steps to maintain client safety.
• Nurses validate the accuracy of client information and base care plans on client needs, current clinical practice, and research.
• Example: A nurse receives a prescription but first checks whether it matches the client's current condition and allergies before administering it.

🎯 Attitudes of critical thinkers

Critical thinkers possess specific attitudes that foster rational thinking:

Attitude	What it means
Independence of thought	Thinking on your own
Fair-mindedness	Treating every viewpoint in an unbiased, unprejudiced way
Insight into egocentricity and sociocentricity	Thinking of the greater good, not just yourself; knowing when you are acting for yourself vs. the greater good
Intellectual humility	Recognizing your intellectual limitations and abilities
Nonjudgmental	Using professional ethical standards, not basing judgments on personal or moral standards
Integrity	Being honest and demonstrating strong moral principles
Perseverance	Persisting despite difficulty
Confidence	Believing in yourself to complete a task or activity
Interest in exploring thoughts and feelings	Wanting to explore different ways of knowing
Curiosity	Asking "why" and wanting to know more

🔍 Clinical reasoning defined

Clinical reasoning: "A complex cognitive process that uses formal and informal thinking strategies to gather and analyze client information, evaluate the significance of this information, and weigh alternative actions."

• To make sound judgments, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action.
• Clinical reasoning develops over time and is based on knowledge and experience.
• Don't confuse: clinical reasoning is more specific than critical thinking—it focuses on the cognitive process of analyzing client data and deciding on actions.

🧩 Inductive reasoning: From cues to hypotheses

🔎 What inductive reasoning involves

Inductive reasoning: noticing cues, making generalizations, and creating hypotheses based on specific information or incidents.

• The nurse organizes cues into patterns and creates a generalization.
• Based on generalizations, the nurse creates a hypothesis regarding a client problem.
• This process is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes clear.

🧩 Key terms in inductive reasoning

Cues

Cues: data that fall outside of expected findings that give the nurse a hint or indication of a client's potential problem or condition.

• No one can draw conclusions without first noticing cues.
• Paying close attention to the client, the environment, and interactions with family members is critical.
• Use your five primary senses: hear, feel, smell, taste, and see.

Generalization

Generalization: a judgment formed from a set of facts, cues, and observations.

• The nurse organizes cues into patterns to form a generalization.
• Example: noticing redness, warmth, and tenderness together forms a pattern.

Hypothesis

Hypothesis: a proposed explanation for a situation; it attempts to explain the "why" behind the problem that is occurring.

• If a "why" is identified, then a solution can begin to be explored.
• Example: the hypothesis "the incision has become infected" explains why the site is red, warm, and tender.

💡 Example of inductive reasoning in practice

Example: A nurse assesses a client and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection (generalization) and creates a hypothesis that the incision has become infected. The provider is notified of the client's change in condition, and a new prescription is received for an antibiotic.

• Cues: red, warm, tender incision site
• Generalization (pattern): signs of infection
• Hypothesis: the incision has become infected
• Action: notify provider, receive antibiotic prescription

🚨 Why inductive reasoning matters in emergencies

• Nurses need strong inductive reasoning patterns and must be able to take action quickly, especially in emergency situations.
• They can see how certain objects or events form a pattern (generalization) that indicates a common problem (hypothesis).
• The nurse is similar to a detective looking for cues—be mindful and observant.

🗺️ The nursing process as a road map

🗺️ What the nursing process provides

• The nursing process is a critical thinking model that guides client care.
• It becomes a road map for the actions and interventions that nurses implement to optimize clients' well-being and health.
• It is a standard of professional nursing practice for providing safe, client-centered care.

❓ How nurses can act immediately after handoff

• Nurses can receive a quick handoff report from another nurse and immediately begin providing care for a client they previously knew nothing about.
• They know what to do because they use the nursing process to analyze pertinent information, prioritize, and make a plan.
• The nursing process provides a systematic framework for decision-making.

🧭 Overview

🧠 One-sentence thesis

Nurses use critical thinking attitudes and clinical reasoning (both inductive and deductive) to make clinical judgments through the systematic nursing process, which is a continuous cycle of assessment, diagnosis, outcome identification, planning, implementation, and evaluation.

📌 Key points (3–5)

• Critical thinking attitudes: Independence, fair-mindedness, intellectual humility, integrity, perseverance, confidence, curiosity, and other attitudes foster rational thinking in nursing.
• Inductive vs deductive reasoning: Inductive reasoning moves from specific cues to generalizations and hypotheses; deductive reasoning applies general standards/rules to specific situations.
• Clinical judgment definition: The observed outcome of critical thinking and decision-making that uses nursing knowledge to assess situations, prioritize concerns, and generate evidence-based solutions.
• Common confusion: Inductive reasoning (bottom-up: cues → patterns → hypothesis) vs deductive reasoning (top-down: general standard → specific application).
• The nursing process (ADOPIE): A continuous, cyclical framework—Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation—based on ANA Standards of Professional Nursing Practice.

🧠 Critical Thinking Attitudes

🧠 What critical thinkers possess

Critical thinkers have specific attitudes that support rational thinking and ensure care plans are based on client needs, current clinical practice, and research.

Key attitudes include:

• Independence of thought: Thinking on your own
• Fair-mindedness: Treating every viewpoint in an unbiased, unprejudiced way
• Insight into egocentricity and sociocentricity: Thinking of the greater good, not just yourself; recognizing when you are thinking for yourself vs. for the greater good
• Intellectual humility: Recognizing your intellectual limitations and abilities
• Nonjudgmental: Using professional ethical standards, not personal or moral standards
• Integrity: Being honest and demonstrating strong moral principles
• Perseverance: Persisting despite difficulty
• Confidence: Believing in yourself to complete a task
• Interest in exploring thoughts and feelings: Wanting to explore different ways of knowing
• Curiosity: Asking "why" and wanting to know more

🔍 Why these attitudes matter

These attitudes help nurses validate information and base care plans on client needs rather than personal biases or assumptions.

🔄 Clinical Reasoning and Judgment

🔄 Clinical reasoning defined

Clinical reasoning: "A complex cognitive process that uses formal and informal thinking strategies to gather and analyze client information, evaluate the significance of this information, and weigh alternative actions."

• To make sound judgments, nurses must generate alternatives, weigh them against evidence, and choose the best course of action.
• Clinical reasoning develops over time based on knowledge and experience.

⚖️ Clinical judgment defined

Clinical judgment (NCSBN definition): "The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care."

• Clinical judgment is the result of critical thinking and clinical reasoning using both inductive and deductive reasoning.
• The NCSBN administers the NCLEX exam using the NCSBN Clinical Judgment Measurement Model (NCJMM) to measure clinical judgment.

📚 Evidence-based practice (EBP)

Evidence-based practice (ANA definition): "A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer's history and condition, as well as health care resources; and client, family, group, community, and population preferences and values."

🔍 Inductive Reasoning (Bottom-Up)

🔍 What inductive reasoning involves

Inductive reasoning involves noticing cues, making generalizations, and creating hypotheses based on specific information or incidents.

Key terms:

• Cues: Data that fall outside expected findings that give the nurse a hint or indication of a client's potential problem or condition
• Generalization: A judgment formed from a set of facts, cues, and observations (similar to gathering puzzle pieces into patterns until the whole picture becomes clear)
• Hypothesis: A proposed explanation for a situation; attempts to explain the "why" behind the problem

🕵️ How inductive reasoning works

The process flows: Cues → Patterns → Generalization → Hypothesis

• No one can draw conclusions without first noticing cues.
• Paying close attention to the client, environment, and interactions with family is critical.
• Nurses need strong inductive reasoning to take action quickly, especially in emergencies.
• Be mindful of your five primary senses: hear, feel, smell, taste, and see.

💉 Example: Infection detection

A nurse assesses a client and finds the surgical incision site is red, warm, and tender to the touch. The nurse:

1. Recognizes these cues
2. Forms a pattern of signs of infection
3. Creates a hypothesis that the incision has become infected
4. Notifies the provider and receives a prescription for an antibiotic

This demonstrates inductive reasoning in nursing practice.

📏 Deductive Reasoning (Top-Down)

📏 What deductive reasoning involves

Deductive reasoning: "Top-down thinking" that relies on using a general standard or rule to create a strategy.

• Relies on a general statement or hypothesis (premise or standard) held to be true
• The premise is used to reach a specific, logical conclusion
• Nurses use standards from: state Nurse Practice Act, federal regulations, American Nursing Association, professional organizations, and employers

🏥 Example: Quiet zone policy

Hospital leaders determine (based on research) that clients recover more quickly with adequate rest. The hospital creates a quiet zone policy:

• No overhead paging at night
• Low-speaking voices by staff
• Reduced lighting in hallways

The nurse implements this policy by organizing care to promote uninterrupted rest at night for all clients regardless of whether they have difficulty sleeping.

This is deductive thinking because the intervention is applied universally based on a general standard.

🔀 Don't confuse: Inductive vs Deductive

Aspect	Inductive Reasoning	Deductive Reasoning
Direction	Bottom-up (specific → general)	Top-down (general → specific)
Starting point	Specific cues and observations	General standard or rule
Process	Cues → patterns → hypothesis	Standard → application to all cases
Example	Noticing infection signs → hypothesis of infection	Research-based policy → apply to all clients

🔄 The Nursing Process (ADOPIE)

🔄 Overview of the nursing process

The nursing process is a critical thinking model based on a systematic approach to client-centered care. Nurses use it to perform clinical reasoning and make clinical judgments.

• Based on ANA Standards of Professional Nursing Practice
• Authoritative statements of actions and behaviors all RNs must perform competently, regardless of role, population, specialty, or setting
• Mnemonic: ADOPIE = Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation
• The process is continuous and cyclical, constantly adapting to the client's current health status

📋 Assessment

"The registered nurse collects pertinent data and information relative to the health care consumer's health or the situation."

• RNs use a systematic method to collect and analyze client data
• Includes: physiological, psychological, sociocultural, spiritual, economic, and lifestyle data
• Example: Assessing a hospitalized client in pain includes recognizing cues like inability to get out of bed, refusal to eat, withdrawal from family, or anger directed at staff

Scope note: LPN/VNs assist with gathering data according to their state's scope of practice but do not analyze data (outside their scope).

🩺 Diagnosis

"The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues."

• A nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs
• Nursing diagnoses are the bases for the care plan
• Nursing diagnoses differ from medical diagnoses

Scope note: Analyzing assessment data and formulating nursing diagnoses is outside the scope of practice for LPN/VNs.

🎯 Outcome Identification

"The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation."

• The nurse sets measurable and achievable short- and long-term goals
• Sets specific outcomes in collaboration with the client
• Based on assessment data and nursing diagnoses

Scope note: Outcome identification is outside the scope of practice for LPN/VNs.

🔁 Continuous cycle

The nursing process is not linear but cyclical—each phase informs the others, and the process repeats as the client's condition changes.

🧭 Overview

🧠 One-sentence thesis

The nursing process is a systematic, cyclical approach to client-centered care that guides registered nurses through six continuous steps—Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation—to deliver competent, evidence-based nursing care.

📌 Key points (3–5)

• What the nursing process is: a critical thinking model based on ANA Standards of Professional Nursing Practice, using the mnemonic ADOPIE (Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation).
• How it works: a continuous, cyclical process that constantly adapts to the client's current health status, not a one-time linear sequence.
• Common confusion—RN vs LPN/VN scope: RNs perform all six steps; LPN/VNs assist with Assessment data collection and Implementation within their scope, but do not analyze data, diagnose, identify outcomes, create care plans, or evaluate/modify plans.
• Why it matters: ensures consistent, individualized care across shifts and health professionals; integrates evidence-based practice with clinical expertise and client preferences.
• Key tool: the nursing care plan documents individualized planning and interventions so all personnel can provide continuity of care.

🔄 What the nursing process is and how it works

🔄 Definition and foundation

The nursing process: a critical thinking model based on a systematic approach to client-centered care, used by nurses to perform clinical reasoning and make clinical judgments.

• Based on the ANA Standards of Professional Nursing Practice—authoritative statements of actions and behaviors all RNs must perform competently, regardless of role, population, specialty, or setting.
• The mnemonic ADOPIE helps remember the six components: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation.

🔁 Continuous and cyclical nature

• The process is not linear; it is a continuous cycle that constantly adapts to the client's current health status.
• Nurses reassess, modify interventions, and re-evaluate outcomes as the client's condition changes.
• Example: if outcomes are not met during Evaluation, the RN returns to Assessment or Planning to adjust the care plan.

📋 The six components of the nursing process

📋 Assessment

"The registered nurse collects pertinent data and information relative to the health care consumer's health or the situation."

• Uses a systematic method to collect and analyze client data.
• Includes physiological, psychological, sociocultural, spiritual, economic, and lifestyle data.
• Example: assessing a hospitalized client in pain includes recognizing cues like inability to get out of bed, refusal to eat, withdrawal from family, or anger directed at staff.
• Scope note: LPN/VNs assist with gathering data according to their state's scope but do not analyze data (analysis is outside their scope).

🩺 Diagnosis

"The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues."

• A nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs.
• Don't confuse: nursing diagnoses are the bases for the nurse's care plan and are different from medical diagnoses.
• Scope note: analyzing assessment data and formulating nursing diagnoses is outside the scope of practice for LPN/VNs; they do not assist with this phase.

🎯 Outcome Identification

"The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation."

• The nurse sets measurable and achievable short- and long-term goals and specific outcomes.
• Done in collaboration with the client based on assessment data and nursing diagnoses.
• Scope note: outcome identification is outside the scope of practice for LPN/VNs; they do not assist with this phase.

📝 Planning

"The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes."

• Uses assessment data, diagnoses, and goals to select evidence-based nursing interventions customized to each client's needs.
• Interventions are planned and documented by RNs in the client's nursing care plan so nurses and other health professionals can refer to it for continuity of care.
• Scope note: creating the nursing care plan is outside the scope of practice for LPN/VNs, although they may contribute to it; some interventions can be delegated to LPN/VNs or trained UAPs with RN supervision.

🛠️ Implementation

"The nurse implements the identified plan."

• Nursing interventions are implemented or delegated with supervision according to the care plan to ensure continuity of care across multiple nurses and health professionals.
• Interventions are documented in the client's electronic medical record as they are completed.
• Includes subcategories: Coordination of Care and Health Teaching and Health Promotion to promote health and a safe environment.
• Scope note: LPN/VNs implement interventions contained in the nursing care plan, provided they are within their scope of practice; they are responsible for documenting the interventions they perform.

✅ Evaluation

"The registered nurse evaluates progress toward attainment of goals and outcomes."

• Nurses reassess the client and compare findings against established outcomes to determine the effectiveness of interventions and the overall nursing care plan.
• RNs ask: "Were outcomes met? Are any modifications required for the nursing care plan?"
• Both the client's status and the effectiveness of the nursing care plan are continuously evaluated and modified as needed.
• Scope note: evaluating and modifying the nursing care plan is outside the scope of practice for LPN/VNs, although they can assist in gathering assessment data to help the RN perform this step.

📄 Nursing care plans

📄 What a nursing care plan is

Nursing care plan: a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific client using the nursing process.

• Created by RNs so that care provided to the client across shifts is consistent among health care personnel.
• Part of the Planning step of the nursing process.

🤝 Who creates and uses care plans

• RNs create nursing care plans.
• Some interventions can be delegated to LPN/VNs or trained Unlicensed Assistive Personnel (UAPs) with RN supervision.
• Scope note: creating the nursing care plan is outside the scope of practice for LPN/VNs; they do not perform this task, although they may contribute to it.

🔍 Scope of practice distinctions

🔍 RN responsibilities

Component	RN role
Assessment	Collects and analyzes data
Diagnosis	Analyzes data and formulates nursing diagnoses
Outcome Identification	Identifies expected outcomes and goals
Planning	Develops care plan and selects interventions
Implementation	Implements or delegates interventions with supervision
Evaluation	Evaluates progress and modifies care plan

🔍 LPN/VN responsibilities

Component	LPN/VN role
Assessment	Assists with gathering data (does not analyze)
Diagnosis	Does not assist (outside scope)
Outcome Identification	Does not assist (outside scope)
Planning	May contribute but does not create care plans
Implementation	Implements interventions within their scope of practice; documents interventions
Evaluation	Assists in gathering assessment data for RN; does not evaluate or modify care plan

⚠️ Common confusion: analyzing vs collecting

• Don't confuse: LPN/VNs can collect assessment data, but they cannot analyze data or formulate diagnoses—analysis is outside their scope.
• Example: an LPN/VN can measure vital signs and report them, but the RN interprets the data and decides on nursing diagnoses.

🌐 Connection to evidence-based practice

🌐 ANA definition of evidence-based practice

Evidence-based practice (per ANA): "A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer's history and condition, as well as health care resources; and client, family, group, community, and population preferences and values."

• The nursing process embodies this approach by combining:
  • Best evidence from research and theories
  • Clinical expertise (the nurse's judgment and skills)
  • Client assessment data and health care resources
  • Client and family preferences and values

🌐 How the nursing process integrates evidence-based practice

• During Planning, RNs select evidence-based nursing interventions customized to each client's needs.
• The process ensures that care is not based solely on tradition or intuition but on the best available evidence, clinical expertise, and client preferences.

🧭 Overview

🧠 One-sentence thesis

The Diagnosis phase of the nursing process involves analyzing assessment data to identify the client's human response to health conditions or vulnerability for that response, forming the basis for individualized care planning.

📌 Key points (3–5)

• What Diagnosis means: analyzing data to determine what is "expected" or "unexpected" for this specific client at this time, then making a clinical judgment about their human response to health conditions or life processes.
• RN vs LPN/VN scope: creating diagnoses is within the RN scope of practice; LPN/VNs do not perform this task but may contribute assessment data.
• NCJMM parallel: the "Analyze Cues" skill in the Clinical Judgment Measurement Model corresponds to the Diagnosis step—asking "What does the data mean?"
• Common confusion: Diagnosis is not just labeling a medical condition; it is identifying the client's human response or vulnerability to health conditions/life processes (also called "forming a hypothesis").
• Why it matters: accurate diagnosis ensures that subsequent planning, interventions, and evaluation are tailored to the client's actual needs and responses.

🔍 What the Diagnosis phase involves

🔍 Analyzing assessment data

• The nurse reviews collected data to determine whether findings are "expected" or "unexpected," "normal" or "abnormal" for this particular client.
• Context matters: the nurse considers the client's age, development, and current clinical status.
• Example: In Scenario A, the nurse notes a blood pressure of 98/60 and heart rate of 100, then reviews the client's baseline vital signs to determine if these values are unexpected for this client with heart failure.

🧩 Making a clinical judgment

Diagnosis (Analysis of Data): Making a clinical judgment concerning the client's "human response to health conditions/life processes, or a vulnerability for that response"; also referred to as "forming a hypothesis."

• This is not simply repeating a medical diagnosis (e.g., "heart failure").
• It is identifying how the client is responding to their condition or what they are vulnerable to.
• The excerpt emphasizes that this step is also called "forming a hypothesis" in the NCJMM framework.

🧷 Scope of practice distinctions

🧷 RN responsibility

• Creating nursing diagnoses is within the RN scope of practice.
• RNs analyze data, form hypotheses, and document diagnoses that guide the care plan.

🧷 LPN/VN role

• LPN/VNs do not create nursing diagnoses; this task is outside their scope of practice.
• They may contribute by providing assessment data to assist the RN in performing this step.
• Don't confuse: LPN/VNs can gather data and implement interventions, but they do not analyze data to form nursing diagnoses.

🔗 Connection to the NCJMM

🔗 "Analyze Cues" skill

The NCJMM uses the term "Analyze Cues" to describe the same cognitive work as the Diagnosis phase:

NCJMM Skill	Question it answers	Nursing Process step
Analyze Cues	What does the data mean?	Diagnosis (Analysis of Data)

• The nurse determines whether data is expected or unexpected for this client at this time.
• The nurse makes a clinical judgment about the client's human response or vulnerability.
• This skill is assessed on the NCLEX as part of clinical judgment measurement.

🔗 "Forming a hypothesis"

• The excerpt states that making a nursing diagnosis is "also referred to as 'forming a hypothesis.'"
• This language bridges the traditional nursing process and the newer NCJMM framework.
• Example: After recognizing that the client's blood pressure is lower than baseline, the nurse forms a hypothesis about what this means for the client's current condition and response to treatment.

📊 How Diagnosis fits into the nursing process

📊 Sequential relationship

1. Assessment/Recognize Cues: gather clinically significant data.
2. Diagnosis/Analyze Cues: analyze what the data means and identify the client's human response or vulnerability.
3. Planning/Prioritize Hypotheses & Generate Solutions: use diagnoses to select interventions and set goals.
4. Implementation/Take Action: carry out the plan.
5. Evaluation/Evaluate Outcomes: compare results to expected outcomes and revise as needed.

📊 Why this step cannot be skipped

• Without accurate diagnosis, the nurse cannot select appropriate interventions or establish meaningful goals.
• The diagnosis phase ensures that care is individualized to the client's actual responses, not just their medical diagnosis.
• Example: Two clients with the same medical diagnosis (heart failure) may have different nursing diagnoses based on their unique responses (e.g., one may have fluid overload, another may have activity intolerance).

🧭 Overview

🧠 One-sentence thesis

Outcome identification is a critical step in the nursing process that bridges assessment and intervention by establishing measurable, client-centered goals that guide care planning and enable evaluation of nursing effectiveness.

📌 Key points (3–5)

• What outcome identification does: translates assessment data and nursing diagnoses into specific, measurable goals that define what the client should achieve.
• Why it matters: outcomes provide direction for interventions, ensure all staff work toward the same goals, and create benchmarks for evaluating whether care was effective.
• How it fits the process: occurs after assessment/diagnosis and before planning interventions; corresponds to "prioritize hypotheses" and "generate solutions" in the NCJMM model.
• Common confusion: outcomes are not the same as interventions—outcomes describe the result you want the client to achieve, while interventions are the actions nurses take to help achieve those results.
• Key principle: outcomes must be individualized to the client's specific needs, realistic, and aligned with evidence-based practice.

🎯 Purpose and placement in the nursing process

🎯 What outcome identification accomplishes

Outcome identification: the phase where nurses establish specific, measurable goals that define what the client should achieve as a result of nursing care.

• This step transforms assessment findings and nursing diagnoses into concrete targets.
• It answers the question: "What do we want to happen for this client?"
• Example: A client diagnosed with Fluid Volume Deficit (from Scenario A in the excerpt) would have an outcome such as "Client will achieve fluid balance as evidenced by stable vital signs and weight within 24 hours."

🔗 How it connects to other nursing process steps

• After assessment/diagnosis: You must first identify the problem (e.g., fluid imbalance) before you can set a goal for resolving it.
• Before intervention planning: Outcomes guide what interventions to choose—you select actions that will help achieve the stated goal.
• Enables evaluation: At the end, you compare actual client outcomes with the desired outcomes you identified here.
• The excerpt emphasizes that the nursing process "identifies a client's goals and strategies to attain them" and "increases the likelihood of achieving positive client outcomes."

🧩 Relationship to NCJMM

NCJMM Skill	Nursing Process Step	What happens
Prioritize Hypotheses	Planning (includes outcome identification)	Ranking problems by urgency and deciding which goals to address first
Generate Solutions	Planning (includes outcome identification)	Planning individualized interventions that meet the desired outcomes; may include gathering more data

• The excerpt shows that outcome identification spans both "prioritize hypotheses" (deciding which client conditions need attention first) and "generate solutions" (defining what should be done).
• Don't confuse: prioritizing hypotheses is about ranking problems, while generating solutions includes both setting goals and choosing interventions.

📋 Characteristics of effective outcomes

📋 Client-centered and individualized

• The excerpt repeatedly emphasizes that the nursing process "customizes" care to "the client's specific needs."
• Outcomes must reflect the individual client's situation, not generic textbook goals.
• Example: In Scenario A, the nurse's outcome for fluid balance was tailored to that specific client's baseline vital signs (blood pressure trend around 110/70, heart rate in the 80s) and current status.

📏 Measurable and specific

• Outcomes must be concrete enough to evaluate whether they were achieved.
• The excerpt states that evaluation involves "comparing actual client outcomes with desired client outcomes to determine effectiveness of care."
• This comparison is only possible if the desired outcome was stated in measurable terms (e.g., vital signs, weight, client-reported symptoms).
• Example: "Client reports mouth no longer feels like cotton" and "weight returns to baseline" are measurable indicators that fluid balance was restored.

⏱️ Realistic and evidence-based

• The excerpt notes that nurses "ensure the interventions are evidence-based" and that the nursing process "increases the likelihood of achieving positive client outcomes."
• Outcomes should be achievable given the client's condition, resources, and timeframe.
• They should align with current best practices and research.

🤝 Collaborative and holistic considerations

🤝 Team collaboration

• The excerpt lists benefits of the nursing process including "encourages collaborative management of a client's health care problems" and "provides a guide for all staff involved to provide consistent and responsive care."
• Outcome identification ensures everyone on the healthcare team is working toward the same goals.
• Clear outcomes "save time, energy, and frustration by creating a care plan that is accessible to all staff caring for a client."

🌐 Holistic perspective

• The excerpt defines nursing as addressing "the whole person," including "physical, mental, emotional, and spiritual aspects."
• Outcomes should reflect this holistic view, not just physical symptoms.
• Example: In the Holistic Nursing Care Scenario, outcomes would include not only the child's ear infection resolving but also the family's ability to access affordable medication and follow-up care.
• The ANA definition emphasizes "protection, promotion, and optimization of health and human functioning" and "alleviation of suffering"—outcomes should address these broader dimensions.

💙 Caring relationship

• The excerpt states that "successful use of the nursing process requires the development of a care relationship with the client."
• Outcomes should be developed with the client when possible, respecting their "beliefs, values, and attitudes."
• This mutual relationship and trust (rapport) ensures outcomes are meaningful to the client and more likely to be achieved.
• Dr. Watson's caring philosophy encourages nurses to be "authentically present" and create a "healing environment"—outcomes should support this therapeutic relationship.

🔍 Distinguishing outcomes from related concepts

🔍 Outcomes vs. interventions

• Outcome: the result or goal you want the client to achieve (e.g., "fluid balance restored").
• Intervention: the action the nurse takes to help achieve that result (e.g., "promote oral intake," "monitor hydration status").
• The excerpt shows this distinction in Scenario A: the nurse's interventions (withholding furosemide, contacting the provider, promoting oral intake) were chosen to achieve the outcome of restoring fluid balance.
• Don't confuse: outcomes describe the destination; interventions describe the journey.

🔍 Outcomes vs. nursing diagnoses

• Nursing diagnosis: identifies the problem or "human response to health conditions" (e.g., Fluid Volume Deficit).
• Outcome: defines the desired state after the problem is resolved (e.g., adequate hydration, stable vital signs).
• The excerpt describes diagnosis as "analyzing data" and "forming a hypothesis," while outcomes are part of "generate solutions"—what should be done about the hypothesis.

🔍 Expected vs. actual outcomes

• Expected (desired) outcomes: what you identify during the planning phase as the goal.
• Actual outcomes: what really happened, assessed during the evaluation phase.
• The excerpt defines evaluation as "comparing actual client outcomes with desired client outcomes to determine effectiveness of care."
• If actual outcomes don't match expected outcomes, the nurse makes "appropriate revisions to the nursing care plan."

🧭 Overview

🧠 One-sentence thesis

Planning is the collaborative fourth step of the nursing process where registered nurses develop individualized, evidence-based interventions to achieve expected client outcomes identified in the previous step.

📌 Key points (3–5)

• What planning is: the RN develops a collaborative, holistic plan with strategies to achieve expected outcomes, documented using standardized terminology.
• Three types of interventions: independent (nurse performs without orders), dependent (requires prescription/order), and collaborative (performed with other health team members).
• Direct vs indirect care: direct care involves personal client contact (e.g., wound care); indirect care occurs away from the client (e.g., documentation, care conferences).
• Common confusion: not all nursing actions require a prescription—independent interventions can be performed based on nursing judgment alone, while dependent interventions need provider orders.
• Individualization is essential: interventions must be customized to each client's preferences and needs to be effective, not just copied from standardized lists.

🎯 What planning involves

📋 Definition and scope

Planning: "The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes."

• Planning is the fourth Standard of Practice by the American Nurses Association.
• The RN creates an individualized, holistic, evidence-based plan in partnership with the client, family, significant others, and interprofessional team.
• Elements are prioritized for client safety and optimal outcomes.
• The plan is modified based on ongoing assessment of the client's response.
• Documentation uses standardized language or terminology.
• Scope limitation: Planning is outside the scope of practice for LPN/VNs, though they may assist in implementing planned interventions.

🔧 Nursing interventions defined

Nursing interventions: evidence-based actions that the nurse performs to achieve client outcomes.

• Just as providers make medical diagnoses and write prescriptions, nurses formulate nursing diagnoses and plan nursing interventions.
• Interventions should focus on eliminating or reducing the related factors (etiology) of the nursing diagnoses when possible.
• Interventions, goals, and expected outcomes are written in the nursing care plan for continuity of care across shifts, nurses, and health professionals.

📚 Sources for selecting interventions

Nurses can use several sources to identify evidence-based interventions:

• Care planning tools and references in the electronic health record
• Care planning books
• Nursing Interventions Classification (NIC) system: categorizes and describes nursing interventions based on research and nursing profession input; regularly evaluated and updated; considered evidence-based nursing practices.
• The RN uses clinical judgment to decide which interventions best suit an individualized client's needs.

🔀 Types of nursing interventions

🩺 Independent nursing interventions

Independent nursing intervention: any intervention the nurse can independently provide without obtaining a prescription or consulting another health care team member.

• The nurse performs these based on nursing knowledge and judgment alone.
• Example: monitoring the client's 24-hour intake/output record for trends due to risk for imbalanced fluid volume.
• Example: using therapeutic communication to assist clients coping with a new medical diagnosis.
• Scenario application: For a client with Excess Fluid Volume, an evidence-based independent intervention is "The nurse will reposition the client with dependent edema frequently, as appropriate," individualized to "The nurse will reposition the client every two hours."

💊 Dependent nursing interventions

Dependent nursing interventions: require a prescription or order before they can be performed.

Key terms:

• Prescriptions: interventions specifically related to medication as directed by an authorized primary health care provider.

• Order: an intervention, remedy, or treatment as directed by an authorized primary health care provider.

• Primary health care provider: a member of the health care team (usually a physician, advanced practice nurse, or physician's assistant) licensed and authorized to formulate prescriptions on behalf of the client.

• Example: administering medication is a dependent nursing intervention.

• The nurse incorporates dependent interventions into the overall care plan by associating each with the appropriate nursing diagnosis.

• Scenario application: For a client with Excess Fluid Volume, a dependent intervention is "The nurse will administer scheduled diuretics as prescribed."

🤝 Collaborative nursing interventions

Collaborative nursing interventions: actions the nurse carries out in collaboration with other health team members.

• Collaborators include physicians, social workers, respiratory therapists, physical therapists, and occupational therapists.
• These actions are developed in consultation with other health care professionals and incorporate their professional viewpoint.
• Scenario application: For a client with Excess Fluid Volume and deteriorating oxygen saturation, the nurse consults with a respiratory therapist who plans oxygen therapy and obtains a provider prescription; documented as "The nurse will manage oxygen therapy in collaboration with the respiratory therapist."

🎭 Direct vs indirect care

Care Type	Definition	Examples
Direct care	Interventions carried out by having personal contact with clients	Wound care, repositioning, ambulation
Indirect care	Interventions performed in a setting other than with the client	Attending care conferences, documenting, communicating about client care with other providers

🎨 Individualization and care plan creation

🧩 Why individualization matters

• Planned interventions must be individualized to the client to be successful.
• Example: Adding prune juice to breakfast for a client with constipation only works if the client likes prune juice; if not, this intervention should not be included.
• Collaboration with the client, family members, significant others, and the interprofessional team is essential for selecting effective interventions.
• There is no set number of interventions required; instead, the number is based on what is needed to meet the specific, identified outcomes for that client.
• Don't confuse: Quality and individualization matter more than quantity of interventions.

📝 Who creates nursing care plans

• Nursing care plans are created by registered nurses (RNs).
• Documentation of individualized nursing care plans is legally required:
  • In long-term care facilities by the Centers for Medicare and Medicaid Services (CMS)
  • In hospitals by The Joint Commission

👥 Client participation requirements

CMS guidelines emphasize client involvement:

• Residents and their representatives must be afforded the opportunity to participate in their care planning process.
• This applies to initial decisions and refusal of care or treatment.
• Facility staff must support and encourage participation by:
  • Ensuring clients, families, or representatives understand the comprehensive care planning process
  • Holding meetings when the client is functioning at their best and representatives can be present
  • Providing sufficient advance notice
  • Scheduling to accommodate representatives (in-person, conference call, or video conferencing)
  • Planning enough time for information exchange and decision-making
• A resident has the right to select or refuse specific treatment options before the care plan is instituted.

📋 Care plan formats

• Many facilities have standardized nursing care plans with lists of possible interventions that can be customized for each specific client.
• Other facilities require the nurse to develop each care plan independently.
• Whatever the format, nursing care plans should be individualized to meet the specific and unique needs of each client.
• Nursing school care plans can be in various formats: concept maps, tables, creative formats, or formal formats.
• The Joint Commission conceptualizes the care planning process as the structuring framework for coordinating communication that results in safe and effective care.

🧭 Overview

🧠 One-sentence thesis

Implementation is the fifth step of the nursing process where the registered nurse executes the identified care plan using critical thinking and clinical judgment, while prioritizing interventions, ensuring client safety, delegating appropriately, and documenting all actions performed.

📌 Key points (3–5)

• What implementation means: executing the care plan through interventions, requiring continual reassessment to detect changes in the client's condition.
• How to prioritize interventions: use Maslow's Hierarchy, ABCs (airway, breathing, circulation), least invasive options, and consider timing impacts on future events.
• Client safety is paramount: nurses must use clinical judgment to stop planned interventions when the client's condition changes, preventing errors before they reach the client.
• Common confusion about delegation: RNs can delegate tasks but retain accountability for outcomes; they cannot delegate responsibilities requiring clinical judgment and must follow state Nurse Practice Acts.
• Documentation requirement: interventions must be documented in a timely manner—if not documented, legally considered not done.

🎯 Core definition and dynamic nature

🎯 What implementation involves

Implementation: The fifth step of the nursing process and fifth Standard of Practice by the American Nurses Association, defined as "The registered nurse implements the identified plan."

• The RN uses critical thinking and clinical judgment throughout implementation.
• After the initial care plan is developed, continual reassessment is necessary to detect changes requiring plan modification.
• The dynamic nature of the nursing process is crucial to providing safe care.

🔄 Key activities during implementation

The nurse performs four main activities:

• Prioritizes planned interventions
• Assesses client safety while implementing interventions
• Delegates interventions as appropriate
• Documents interventions performed

LPN/VNs have an active role provided interventions fall within their scope of practice.

🚦 Prioritizing interventions

🚦 Methods for prioritization

Prioritization follows similar methods as prioritizing nursing diagnoses:

• Maslow's Hierarchy of Needs: address basic physiological needs first
• ABCs: airway, breathing, and circulation establish top priority
• Least invasive first: preferred when possible due to lower risk of injury

⏰ Timing and future impact

Consider the potential impact on future events, especially if a task is not completed at a certain time.

Example: A client is scheduled for surgery later in the day. The nurse prioritizes initiating NPO (nothing by mouth) prescription before completing pre-op education. Rationale: if the client eats or drinks, surgery time will be delayed.

• Knowing the client's purpose for care, current situation, and expected outcomes is necessary to accurately prioritize.

🛡️ Client safety considerations

🛡️ When planned interventions become unsafe

Clients may experience condition changes that make planned interventions no longer safe to implement.

Example: A care plan states "The nurse will ambulate the client 100 feet three times daily." During morning assessment, the client reports feeling dizzy and blood pressure is 90/60. Using clinical judgment, the nurse decides not to ambulate the client.

• This decision and supporting assessment findings must be documented in the client's chart.
• Communicate during shift handoff report.
• Notify the provider of the client's change in condition.

🚨 Historical context of safety focus

The excerpt describes two landmark Institute of Medicine (IOM) reports:

Year	Report	Key Finding
2000	To Err Is Human	As many as 98,000 people die in U.S. hospitals yearly from preventable medical errors
2007	Preventing Medication Errors	More than 1.5 million Americans injured yearly; average hospitalized client experiences at least one medication error daily

🎓 Quality and Safety Education for Nurses (QSEN)

• Began in 2005 to prepare nurses to continuously improve quality and safety.
• Vision: "inspire health care professionals to put quality and safety as core values to guide their work."

Quality improvement: "The combined and unceasing efforts of everyone—health care professionals, clients and their families, researchers, payers, planners and educators—to make the changes that will lead to better client outcomes (health), better system performance (care), and better professional development (learning)."

Nurses are expected to identify gaps where change is needed and assist in implementing quality improvement initiatives.

👥 Delegation of interventions

👥 Definition and accountability

Delegation: "The assignment of the performance of activities or tasks related to client care to unlicensed assistive personnel or licensed practical nurses (LPNs) while retaining accountability for the outcome."

RNs are accountable for:

• Determining appropriateness of the delegated task according to client condition and circumstance
• Communication provided to appropriately trained LPN or UAP
• Level of supervision provided
• Evaluation and documentation of the task completed

⚖️ Legal requirements for delegation

The RN must consider before delegating:

• State Nurse Practice Act
• Federal regulations
• Agency policy

Critical limitation: The RN cannot delegate responsibilities requiring clinical judgment.

📋 Wisconsin Nurse Practice Act requirements

The excerpt provides specific Wisconsin requirements:

RN responsibilities during delegation:

• Delegate tasks matching educational preparation and demonstrated abilities
• Provide direction and assistance
• Observe and monitor activities
• Evaluate effectiveness of acts performed

LPN responsibilities under general RN supervision:

• Accept only patient care assignments the LPN is competent to perform
• Provide basic nursing care (care following defined procedures with minimal modification where patient responses are predictable)
• Record nursing care and report changes in patient condition
• Consult with provider when a delegated act may harm a patient
• Assist with data collection, care plan development/revision, reinforce RN teaching, participate in meeting basic patient needs

📊 General delegation guidelines by role

Activity	RN	LPN	CNA
Assessment	Complete client assessment	Assist with data collection for stable clients	Collect measurements (weight, I/O, vital signs) in stable clients
Diagnosis	Analyze data and create nursing diagnoses	Not applicable	Not applicable
Outcome Identification	Identify SMART client outcomes	Not applicable	Not applicable
Planning	Plan nursing interventions	Assist with care plan development	Not applicable
Implementation	Implement independent, dependent, collaborative interventions; delegate with supervision; document	Participate in meeting basic client needs; reinforce RN teaching; provide basic health instruction; document	Implement delegated interventions for basic nursing care (e.g., ambulation assistance); document
Evaluation	Evaluate outcome attainment; revise care plan	Contribute data on client outcomes; assist in care plan revision	Not applicable

Don't confuse: LPNs can assist with care planning and data collection, but only RNs can complete full assessments, create nursing diagnoses, and evaluate outcomes independently.

📝 Documentation requirements

📝 Timely documentation mandate

• Interventions must be documented in the client's record in a timely manner.
• Lack of documentation is considered failure to communicate and a basis for legal action.

Basic rule of thumb: If an intervention is not documented, it is considered not done in a court of law.

⏱️ Why timing matters

Document administration of medication and other interventions promptly to prevent errors that can occur due to delayed documentation time.

🤝 Coordination and health teaching

🤝 ANA Standard 5A: Coordination of Care

Competencies include:

• Organizing components of the plan
• Engaging the client in self-care to achieve goals
• Advocating for dignified and holistic care by the interprofessional team

📚 ANA Standard 5B: Health Teaching and Health Promotion

Health Teaching and Health Promotion: "Employing strategies to teach and promote health and wellness."

• Client education is an important component of nursing care.
• Should be included during every client encounter.

Example: Teaching about medication side effects while administering medications, or teaching clients how to self-manage conditions at home.

🔗 Putting it together: implementation scenario

The excerpt references Scenario C (from the Assessment section):

• Interventions related to breathing were prioritized.
• Diuretic medication administered first.
• Lung sounds monitored frequently throughout the shift.
• Weighing the client before breakfast delegated to the CNA.
• Client educated about medications and methods to reduce peripheral edema at home.
• All interventions documented in the electronic medical record (EMR).

This demonstrates the integration of prioritization, delegation, client education, and documentation in real practice.

🧭 Overview

🧠 One-sentence thesis

Evaluation is the continuous process of determining whether nursing interventions have helped clients achieve expected outcomes within specified time frames, and revising the care plan when outcomes are not met.

📌 Key points (3–5)

• What evaluation measures: whether expected outcomes were met, partially met, or not met by the indicated time frames.
• When to evaluate: every time the nurse interacts with a client, discusses the care plan with the team, or reviews updated test results.
• What happens when outcomes aren't met: the care plan must be revised with new or different interventions.
• Common confusion: evaluation is not a one-time final step—it requires continuous reassessment and care plan updates as higher priority goals emerge.
• Scope distinction: evaluation is outside the scope of practice for LPN/VNs, though they may assist in collecting reassessment data for the RN.

🎯 What evaluation is and when it happens

🎯 Definition and standard

Evaluation: "The registered nurse evaluates progress toward attainment of goals and outcomes."

• This is the sixth step of the nursing process and the sixth Standard of Practice by the American Nurses Association.
• Both client status and the effectiveness of nursing care must be continuously evaluated.
• The care plan is modified as needed based on evaluation findings.

⏰ Timing of evaluation

Reassessment should occur:

• Every time the nurse interacts with a client
• When discussing the care plan with the interprofessional team
• When reviewing updated laboratory or diagnostic test results
• As higher priority goals emerge

Don't confuse: Evaluation is not just a final step at discharge—it is an ongoing, continuous process throughout care.

📝 Documentation requirement

• Results of the evaluation must be documented in the client's medical record.
• This creates a legal record of care effectiveness and plan revisions.

🔍 How to evaluate outcomes

🔍 Three possible results

For each expected outcome, the nurse determines if it was:

Result	Meaning	Action
Met	Outcome achieved within time frame	Continue current plan or discontinue if goal complete
Partially met	Some progress but outcome not fully achieved	Revise care plan with additional interventions
Not met	No progress toward outcome	Revise care plan; may need different interventions

🧠 Critical thinking in evaluation

• Nurses use critical thinking to analyze reassessment data.
• Compare current client status to the expected outcomes and time frames established in the planning phase.
• Example: If the outcome was "clear lung sounds within 24 hours" and crackles are still present, the outcome is not met.

🔄 Revising the care plan

🔄 When revision is needed

• When interventions do not help the client progress toward expected outcomes.
• When the care plan must be updated to more effectively address client needs.
• When ongoing assessment data indicates changes are necessary.

❓ Key questions for revision

The excerpt provides a guide of questions to ask:

• Did anything unanticipated occur?
• Has the client's condition changed?
• Were the expected outcomes and their time frames realistic?
• Are the nursing diagnoses accurate for this client at this time?
• Are the planned interventions appropriately focused on supporting outcome attainment?
• What barriers were experienced as interventions were implemented?
• Does ongoing assessment data indicate the need to revise diagnoses, outcome criteria, planned interventions, or implementation strategies?
• Are different interventions required?

🛠️ What can be revised

Any component of the care plan may need updating:

• Nursing diagnoses (may no longer be accurate)
• Outcome criteria (may have been unrealistic)
• Planned interventions (may need to be changed or added)
• Implementation strategies (may need adjustment)
• Time frames (may need extension or adjustment)

📋 Example application

📋 Scenario: Excess Fluid Volume

The excerpt describes evaluating four expected outcomes for a client with excess fluid volume:

Day 1 evaluation data:

• Client reported decreased shortness of breath ✓
• No longer crackles in lower lung bases ✓
• Weight decreased by 1 kg (partial progress)
• 2+ edema continued in ankles and calves (not resolved)

Evaluation result: Partially Met

Revision action: Two new interventions added:

1. Request prescription for TED hose from provider
2. Elevate client's legs when sitting in chair

📋 Scenario: Risk for Falls

Evaluation data:

• Client verbalizes understanding
• Client appropriately calling for assistance when getting out of bed
• No falls have occurred

Evaluation result: Met

Action: Continue to reassess according to care plan; no revision needed at this time.

Don't confuse: Even when outcomes are met, the nurse continues reassessment—evaluation is ongoing throughout hospitalization, not a one-time check.

🧭 Overview

🧠 One-sentence thesis

The nursing process is a systematic, client-centered approach that integrates critical thinking, clinical reasoning, and clinical judgment across all phases—assessment, diagnosis, outcome identification, planning, implementation, and evaluation—to deliver safe, individualized care and achieve expected client outcomes.

📌 Key points (3–5)

• The nursing process uses ADOPIE: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation work together as an iterative cycle.
• Critical thinking and clinical judgment are essential: These cognitive processes are applied throughout every step to observe, analyze, prioritize, and revise care.
• The client remains central: Individualized, client-centered care is the cornerstone; the client's progress toward expected outcomes drives all nursing actions.
• Frequent reassessment and revision are required: The care plan must be updated as needed based on evaluation of whether outcomes are met, partially met, or not met.
• Common confusion: Evaluation is not a one-time endpoint—it is continuous and triggers revisions to diagnoses, outcomes, or interventions when goals are not fully achieved.

🔄 The iterative nature of the nursing process

🔄 Continuous cycle, not linear steps

• The nursing process is described as iterative, meaning it repeats and loops back on itself.
• After evaluation, the nurse may need to revise diagnoses, outcome criteria, planned interventions, or implementation strategies.
• Example: If expected outcomes are only "partially met," the nurse adds new interventions and continues reassessing.

🧠 Integration of cognitive skills

• Critical thinking, clinical reasoning, and clinical judgment are used when:
  • Assessing the client
  • Creating a nursing care plan
  • Implementing interventions
• These skills are not isolated to one phase; they are woven throughout the entire process.

📋 Evaluation and revision in practice

📋 What evaluation determines

• The nurse evaluates whether expected outcomes were achieved within the specified time frames.
• Outcomes are categorized as:
  • Met: The client achieved the goal.
  • Partially Met: Some progress was made, but the goal is incomplete.
  • Not Met: The goal was not achieved.

🔧 Revising the care plan

• When outcomes are partially met or not met, the nurse must ask:
  • Do diagnoses need revision?
  • Are different interventions required?
  • Do outcome criteria need adjustment?
• Example: A client with Excess Fluid Volume showed decreased dyspnea and clear lung sounds (outcomes met), but edema persisted (outcome partially met). The nurse added two new interventions: requesting TED hose and elevating the client's legs.

📝 Documentation of evaluation

• Evaluation of the care plan is documented in the client's medical record.
• This ensures continuity of care and accountability.

🎯 Client-centered care as the foundation

🎯 The client is the cornerstone

• Throughout the entire nursing process, the client always remains the cornerstone of nursing care.
• This means:
  • Care is individualized to the client's unique needs, preferences, and responses.
  • The nurse does not apply a generic template but tailors every step to the specific client.

🤝 Providing individualized care

• Individualized, client-centered care involves:
  • Assessing the whole person (physical, emotional, social).
  • Setting outcomes that matter to the client.
  • Implementing interventions that respect the client's dignity and preferences.
• Evaluating whether care has been successful in achieving client outcomes is essential for safe, professional nursing practice.

🏥 Example: Applying the nursing process

🏥 Scenario: Excess Fluid Volume

• Nursing diagnosis: Excess Fluid Volume
• Expected outcomes (with time frames):
  1. Client will report decreased dyspnea within 8 hours.
  2. Client will have clear lung sounds within 24 hours.
  3. Client will have decreased edema within 24 hours.
  4. Client's weight will return to baseline by discharge.

📊 Evaluation on Day 1

Outcome	Evaluation data	Status
Decreased dyspnea	Client reported decreased shortness of breath	Met
Clear lung sounds	No crackles in lower lung bases	Met
Decreased edema	2+ edema continues in ankles and calves	Partially Met
Weight return to baseline	Weight decreased by 1 kg	In progress

🔧 Revisions made

• Because edema outcome was partially met, the nurse revised the care plan with two new interventions:
  1. Request prescription for TED hose from provider.
  2. Elevate client's legs when sitting in chair.
• The nurse will continue to reassess and revise as needed during hospitalization.

🎯 Second diagnosis: Risk for Falls

• Expected outcome: Client verbalizes understanding and calls for assistance when getting out of bed; no falls occur.
• Evaluation: Outcome met—client is appropriately calling for assistance, and no falls have occurred.
• The nurse continues to monitor according to the care plan.

✅ Standards and professional practice

✅ ANA Standards alignment

• The nursing process follows the ANA Standards of Professional Nursing Practice.
• Each step (Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation) corresponds to a professional standard.

✅ Safe, professional nursing practice

• Providing individualized care and evaluating its success are essential for safe, professional nursing practice.
• Don't confuse: Safety is not just about preventing physical harm—it also includes ensuring that care is effective, respectful, and aligned with the client's goals.

🧭 Overview

🧠 One-sentence thesis

A national focus on reducing medical errors since 1999 has driven the establishment of safety initiatives and standards that make safety a foundational priority in all nursing care.

📌 Key points (3–5)

• Safety as a basic need: Safety is a foundational human need that always receives priority in client care, intertwined with basic physiological needs in Maslow's Hierarchy.
• National safety movement: The 1999 IOM report To Err is Human broke the silence on health care errors and led to multiple safety initiatives by The Joint Commission and QSEN.
• Never events and sentinel events: Certain serious, preventable adverse events are now publicly reported and no longer reimbursed by insurers to increase accountability.
• Root cause analysis: Investigations focus on system factors (not individual blame) to identify hidden problems and prevent future harm.
• Common confusion: Near misses vs. actual errors—near misses have the potential to cause harm but are intercepted or fail by chance; both require investigation to improve safety.

🏥 The national safety movement

📜 Historic turning point (1999)

• The Institute of Medicine (IOM) released To Err is Human: Building a Safer Health System in 1999.
• This report broke the silence surrounding health care errors and encouraged building safety into care processes.
• It marked the beginning of a sustained national focus on reducing medical errors.

🎯 Major safety initiatives that followed

Initiative	What it does
The Joint Commission National Patient Safety Goals	Annual goals released to promote specific safety practices
Quality and Safety Education for Nurses (QSEN) Institute	Promotes emphasis on high-quality, safe client care in nursing education and practice

• These initiatives aim to create a culture of safety across all health care settings.

🛡️ Safety as a foundational need

🔺 Maslow's Hierarchy and safety

Safety is a basic foundational human need and always receives priority in client care.

• Nurses use Maslow's Hierarchy of Needs to prioritize urgent client needs.
• The bottom two rows of the pyramid receive top priority: physiological needs and safety.
• Safety is intertwined with basic physiological needs—you cannot address one without considering the other.

🚗 Scenario: safety first

• Example: At a fiery car crash, you find a person not breathing inside the burning car.
• Your first priority is not to start rescue breathing inside the car.
• Instead, move the person to a safe place where you can safely provide CPR.
• Why: Safety must be established before other interventions can be effective.

🏥 Safety in nursing practice

• Client safety is central to everything nurses do in all health care settings.
• Nurses play a critical role in:
  • Promoting client safety while providing care
  • Teaching clients and caregivers how to prevent injuries at home and in the community
  • Keeping themselves safe (if you become ill or injured, you cannot effectively care for others)

💔 When safety fails: the Josie King story

• In 2001, 18-month-old Josie King died from medical errors at a well-known hospital.
• Causes: a hospital-acquired infection and an incorrectly administered pain medication.
• Her mother, Sorrel King, has worked to improve client safety in hospitals everywhere.
• Key lesson: Medical errors can be devastating to clients and families; preventable deaths highlight the need for systemic safety improvements.
• Don't confuse: This was not a single person's mistake but a failure of multiple system factors.

🚨 Categories of serious safety events

❌ Never events

Never events: Adverse events that are clearly identifiable, measurable, serious (resulting in death or significant disability), and preventable.

• In 2007, CMS discontinued payment for costs associated with never events; most private insurers adopted this policy.
• Never events are publicly reported to increase accountability and improve quality of care.
• Seven categories of never events:

Category	Example
Surgical or procedural	Surgery performed on the wrong body part
Product or device	Injury or death from a contaminated drug or device
Client protection	Client suicide in a health care setting
Care management	Death or injury from a medication error
Environmental	Death or injury from using restraints
Radiologic	Metallic object in an MRI area
Criminal	Death or injury from physical assault on health care grounds

🔔 Sentinel events

Sentinel events: A client safety event that reaches a client and results in death, permanent harm, or severe temporary harm requiring interventions to sustain life.

• Defined by The Joint Commission.
• Called "sentinel" because they signal the need for immediate investigation and response.
• Difference from never events: Sentinel events may not be entirely preventable.
• Organizations are strongly encouraged (but not required) to report sentinel events to The Joint Commission.
• Why report: Self-reporting allows other facilities to learn and prevent future events through knowledge sharing and risk reduction.

⚠️ Near misses

Near misses: An error that has the potential to cause an adverse event (client harm) but fails to do so because of chance or because it is intercepted. (WHO definition)

• Near misses do not result in harm, but they reveal vulnerabilities in the system.
• They are investigated using root cause analysis to prevent future actual errors.
• Common confusion: Near miss vs. actual error—a near miss could have caused harm but didn't; an actual error did cause harm or reach the client.

🔍 Root cause analysis and human factors

🔎 What is root cause analysis

Root cause analysis: A structured method used to analyze serious adverse events to identify underlying problems that increase the likelihood of errors, while avoiding the trap of focusing on mistakes by individuals.

• A multidisciplinary team analyzes the sequence of events leading up to the error.
• Goals:
  • Identify how and why the event occurred
  • Prevent future harm by eliminating hidden system problems
• Used to investigate sentinel events, never events, and near misses.

🧩 Beyond individual blame

• Root cause analysis goes beyond focusing on the individual who made the mistake.
• It looks at system factors that contributed to the error.
• Example: When a medication error occurs, the analysis examines:
  • Similar-looking drug labels
  • Placement of similar-looking medications next to each other in a dispensing machine
  • Vague instructions in a provider order
• Why this matters: Errors are rarely due to poor motivation or incompetence; they are often caused by system design flaws.

🧑‍🔧 Human factors science

Human factors: Focus on the interrelationships among humans, the tools and equipment they use in the workplace, and the environment in which they work.

• Safety in health care is ultimately dependent on humans—doctors, nurses, and health care professionals—providing the care.
• Key contributing factors to errors:
  • Poor communication
  • Less-than-optimal teamwork
  • Memory overload
  • Reliance on memory for complex procedures
  • Lack of standardization of policies and procedures
• Root cause analysis uses human factors science to understand these interrelationships.

📋 Incident reports and safety culture

📝 What is an incident report

• An incident report is specific documentation performed when there is an error, near miss, or other unexpected occurrence during client care.
• Not included in the client's medical record.
• Used to identify process problems or areas that could benefit from safety and quality improvement.

🏛️ Part of a culture of safety

• Incident reports are a component of an agency's culture of safety.
• They are used during investigations like root cause analysis.
• Goal: Help improve the safety and quality of client care by learning from errors and near misses.

🧭 Overview

🧠 One-sentence thesis

Safety strategies—including medication error prevention initiatives, checklists, and structured team communication tools—reduce the likelihood of errors and establish safe standards of care.

📌 Key points (3–5)

• What safety strategies are: research-based initiatives designed to reduce errors and create safe standards of care.
• Three main categories: medication error prevention (lists and checks), checklists (to overcome memory limitations), and structured team communication (ISBARR and handoff reports).
• Why checklists matter: humans are prone to short-term memory loss, especially when multitasking or under stress; checklists reduce reliance on fallible memory.
• Common confusion: team communication is not just talking—it requires standardized methods to ensure accurate, complete, and timely information exchange.
• Real-world impact: initiatives like the WHO surgical checklist have significantly decreased injuries and deaths by focusing on teamwork and communication.

💊 Medication error prevention

💊 National safety initiatives

Multiple initiatives have been developed nationally to prevent medication errors:

• "Do Not Use List of Abbreviations": standardized list to avoid misinterpretation.
• "List of Error-Prone Abbreviations": identifies abbreviations that commonly lead to mistakes.
• "Frequently Confused Medication List": highlights drugs with similar names or packaging.
• "High-Alert Medications List": flags medications that carry higher risk of harm if used incorrectly.
• "Do Not Crush List": specifies medications that should not be crushed (to preserve efficacy or safety).

✅ Three checks standard

Standard of care: nurses perform three checks of the rights of medication administration whenever administering medication.

• This is not a suggestion; it is considered a standard of care.
• The "rights" refer to verifying correct patient, drug, dose, route, time, etc.
• Example: a nurse checks the medication label three separate times—when retrieving it, when preparing it, and before administering it—to catch any discrepancy.

📋 Checklists to overcome memory limits

📋 Why checklists are needed

Performance of complex medical procedures is often based on memory, even though humans are prone to short-term memory loss, especially when multitasking or under stress.

• Memory is fallible, particularly in high-pressure or multitasking situations.
• Checklists reduce reliance on memory by providing a point-of-care reference.
• Example: during a busy shift, a nurse may forget a step in a complex procedure; a checklist ensures every step is completed.

🏥 WHO surgical checklist

• Developed by the World Health Organization (WHO).
• Adopted by most surgical providers worldwide as a standard of care.
• Impact: significantly decreased injuries and deaths caused by surgeries.
• How it works: focuses on teamwork and communication, ensuring all team members verify critical steps before, during, and after surgery.
• The Association of PeriOperative Registered Nurses (AORN) combined WHO and Joint Commission recommendations to create a specific surgical checklist for nurses.

Don't confuse: a checklist is not just a formality—it is a proven safety tool that addresses human cognitive limitations.

🗣️ Structured team communication

🗣️ Why standardized communication matters

Serious client harm can occur when client information is absent, incomplete, erroneous, or delayed during team communication.

• Nurses routinely communicate with multidisciplinary teams and report changes in client status.
• Unstructured communication increases the risk of missing or misinterpreting critical information.
• Standardized methods ensure accurate information is exchanged in a structured and concise manner.

📞 ISBARR reports

ISBARR is a mnemonic for the components of Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.

Component	What it includes
Introduction	Identify yourself and the patient
Situation	State the current problem or concern
Background	Provide relevant history and context
Assessment	Share your clinical assessment
Request/Recommendations	State what you need or suggest
Repeat back	Confirm understanding by repeating key information

• Example: a nurse calls a provider to report a patient's worsening condition, using ISBARR to ensure all critical details are communicated clearly and nothing is missed.

🤝 Handoff reports

Handoff reports: a transfer and acceptance of client care responsibility achieved through effective communication. It is a real-time process of passing client-specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the client's care. (The Joint Commission)

• Handoff reports are a specific type of team communication that occurs when care is transferred.
• Key feature: real-time, client-specific information exchange.
• Purpose: ensure continuity and safety of care.
• Example: at shift change, the outgoing nurse gives a handoff report to the incoming nurse, covering the patient's current status, recent changes, and pending tasks.

Don't confuse: a handoff is not just a summary—it is a structured communication process designed to prevent information loss during care transitions.

🏛️ Culture of safety (introduction)

🏛️ What a culture of safety is

A culture of safety reflects the behaviors, beliefs, and values within and across all levels of an organization.

• Beyond individual safety strategies, health care agency leaders must establish a culture of safety.
• This culture encompasses the entire organization, not just individual practices.
• The excerpt introduces the concept but does not elaborate further on specific behaviors or implementation.

🧭 Overview

🧠 One-sentence thesis

Standardized communication methods and a culture of safety—especially Just Culture—reduce client harm by ensuring accurate information exchange and encouraging error reporting without wrongful blame.

📌 Key points (3–5)

• Standardized team communication: ISBARR and handoff reports prevent harm from absent, incomplete, or delayed information.
• Culture of safety components: Just Culture (distinguishing human error from reckless behavior), Reporting Culture (errors and near-misses are reported), and Learning Culture (drawing conclusions and implementing reforms).
• Just Culture model: categorizes errors into simple human error (console and fix system), at-risk behavior (coaching), and reckless behavior (punitive action).
• Common confusion: "no blame" vs. Just Culture—Just Culture does not tolerate conscious disregard of risks or gross misconduct; it distinguishes system failings from individual recklessness.
• Leadership accountability: without adequate leadership and a culture of safety, adverse events increase; leaders must support reporting, respond to vulnerabilities, and address burnout.

🗣️ Team communication methods

🗣️ Why standardized communication matters

• Serious client harm can occur when information is absent, incomplete, erroneous, or delayed during team communication.
• Nurses routinely communicate with multidisciplinary teams and report changes in client status to health care providers.
• Standardized methods ensure accurate information is exchanged in a structured and concise manner.

📋 ISBARR

ISBARR: a mnemonic for Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.

• Used to structure team communication.
• Ensures all essential information is conveyed clearly.
• Example: a nurse uses ISBARR to report a client's sudden change in vital signs to the provider, ensuring nothing is missed.

🤝 Handoff reports

Handoff reports: "A transfer and acceptance of client care responsibility achieved through effective communication. It is a real-time process of passing client specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the client's care." (The Joint Commission)

• A specific type of team communication as client care is transferred.
• Real-time, client-specific information exchange.
• Purpose: continuity and safety of care.

🏛️ Culture of safety foundations

🏛️ What is a culture of safety

Culture of safety: reflects the behaviors, beliefs, and values within and across all levels of an organization as they relate to safety and clinical excellence, with a focus on people.

• Established by health care agency leaders.
• The Joint Commission (2021): leadership has an obligation to protect the safety of clients, employees, and visitors.
• Without adequate leadership and an effective culture of safety, there is higher risk for adverse events.

⚠️ How inadequate leadership contributes to adverse events

Inadequate leadership can contribute to adverse effects in the following ways:

• Insufficient support of client safety event reporting
• Lack of feedback or response to staff who report safety vulnerabilities
• Allowing intimidation of staff who report events
• Refusing to consistently prioritize and implement safety recommendations
• Not addressing staff burnout

🧩 Three components of a culture of safety

Component	Definition
Just Culture	People are encouraged, even rewarded, for providing essential safety-related information, but clear lines are drawn between human error and at-risk or reckless behaviors.
Reporting Culture	People report errors and near-misses.
Learning Culture	The willingness and the competence to draw the right conclusions from safety information systems, and the will to implement major reforms when their need is indicated.

🌟 Additional characteristics (American Nurses Association)

A culture of safety includes:

• Openness and mutual respect when discussing safety concerns and solutions without shifting to individual blame
• A learning environment with transparency and accountability
• Reliable teams

🚧 Barriers to a culture of safety

Examples of barriers that do not promote a culture of safety:

• Complexity
• Lack of clear measures
• Hierarchical authority
• The "blame game"
• Lack of leadership

Don't confuse: If staff fear reprisal for mistakes and errors, they will be less likely to report errors, processes will not be improved, and client safety will continue to be impaired.

🎯 Safety themes in practice

🎯 Kaiser Permanente's six strategic themes (2001)

An example of how one health care institution implemented a culture of safety:

Theme	Focus
Safe culture	Creating and maintaining a strong safety culture, with client safety and error reduction embraced as shared organizational values.
Safe care	Ensuring that actual and potential hazards associated with high-risk procedures, processes, and client care populations are identified, assessed, and managed in a way that demonstrates continuous improvement and ultimately ensures that clients are free from accidental injury or illness.
Safe staff	Ensuring that staff possess the knowledge and competence to perform required duties safely and contribute to improving system safety performance.
Safe support systems	Identifying, implementing, and maintaining support systems—including knowledge-sharing networks and systems for responsible reporting—that provide the right information to the right people at the right time.
Safe place	Designing, constructing, operating, and maintaining the environment of health care to enhance its efficiency and effectiveness.
Safe clients	Engaging clients and their families in reducing medical errors, improving overall system safety performance, and maintaining trust and respect.

⚖️ Just Culture model

⚖️ Why Just Culture is needed

• Nurses have been traditionally trained to believe that clinical perfection is attainable, and that "good" nurses do not make errors.
• Errors are perceived as being caused by carelessness, inattention, indifference, or uninformed decisions.
• Expecting high standards can become counterproductive if it creates an expectation of perfection that impacts the reporting of errors and near misses.
• If employees feel shame when they make an error, they may feel pressure to hide or cover up errors.
• Evidence indicates that approximately three of every four errors are detected by those committing them, as opposed to being detected by an environmental cue or another person.
• Therefore, employees need to be able to trust that they can fully report errors without fear of being wrongfully blamed.
• For many organizations, the largest barrier in establishing a culture of safety is the establishment of trust.

📜 ANA endorsement and definition

The American Nurses Association (ANA) officially endorses the Just Culture model.

ANA 2019 position statement:

• "Traditionally, healthcare's culture has held individuals accountable for all errors or mishaps that befall clients under their care."
• "By contrast, a Just Culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control."
• "A Just Culture also recognizes many individual or 'active' errors represent predictable interactions between human operators and the systems in which they work."
• "However, in contrast to a culture that touts 'no blame' as its governing principle, a Just Culture does not tolerate conscious disregard of clear risks to clients or gross misconduct (e.g., falsifying a record or performing professional duties while intoxicated)."

Don't confuse: Just Culture is not "no blame"—it does not tolerate conscious disregard of clear risks or gross misconduct.

🔍 Three categories of human behavior

🔍 Simple human error

Simple human error: occurs when an individual inadvertently does something other than what should have been done.

• Most medical errors are the result of human error due to poor processes, programs, education, environmental issues, or situations.
• These errors are managed by correcting the cause, looking at the process, and fixing the deviation.
• Example: A nurse appropriately checks the rights of medication administration three times, but due to the similar appearance and names of two different medications stored next to each other in the medication dispensing system, administers the incorrect medication to a client. Root cause analysis reveals a system issue (e.g., change the labelling and storage of look alike-sound alike medication).

Manager response: Console the individual and consider changes in training, procedures, and processes. Make system-wide changes to prevent future errors.

🔍 At-risk behavior

At-risk behavior: an error that occurs when a behavioral choice is made that increases risk where the risk is not recognized or is mistakenly believed to be justified.

• Example: A nurse scans a client's medication with a barcode scanner prior to administration, but an error message appears on the scanner. The nurse mistakenly interprets the error to be a technology problem and proceeds to administer the medication instead of stopping the process and further investigating the error message, resulting in the wrong dosage of a medication being administered to the client. Ignoring the error message can be considered "at-risk behavior" because the behavioral choice was considered justified by the nurse at the time.

Manager response: Hold individuals accountable for their behavioral choice; often require coaching with incentives for less risky behaviors and situational awareness. In the example above, mandatory training on using a barcode scanner and responding to errors would be implemented, and the manager would track the employee's correct usage for several months following training.

🔍 Reckless behavior

Reckless behavior: an error that occurs when an action is taken with conscious disregard for a substantial and unjustifiable risk.

• Example: A nurse arrives at work intoxicated and administers the wrong medication to the wrong client. This error is considered due to reckless behavior because the decision to arrive intoxicated was made with conscious disregard for substantial risk.

Manager response: Remedial action and/or punitive action is taken. In the example above, the manager would report the nurse's behavior to the state's Board of Nursing with mandatory substance abuse counseling to maintain their nursing license. Employment may be terminated with consideration of patterns of behavior.

🎓 Just Culture in nursing education

🎓 Shared accountability model

Principles of culture of safety, including Just Culture, Reporting Culture, and Learning Culture are also being adopted in nursing education.

• Mistakes are part of learning.
• A shared accountability model promotes individual- and system-level learning for improved client safety.

🎓 Student responsibilities

Under a shared accountability model, students are responsible for:

• Being fully prepared for clinical experiences, including laboratory and simulation assignments
• Being rested and mentally ready for a challenging learning environment
• Accepting accountability for their part in contributing to a safe learning environment
• Behaving professionally
• Reporting their own errors and near mistakes
• Keeping up-to-date with current evidence-based practice
• Adhering to ethical and legal standards

🎓 How student errors are addressed

• Students know they will be held accountable for their actions, but will not be blamed for system faults that lie beyond their control.
• They can trust that a fair process will be used to determine what went wrong if a client care error or near miss occurs.
• Student errors and near misses are addressed based on an investigation determining if it was simple human error, an at-risk behavior, or reckless behavior.
• Example: A simple human error by a student can be addressed with coaching and additional learning opportunities to remedy the knowledge deficit.
• However, if a student acts with recklessness (for example, repeatedly arrives to clinical unprepared despite previous faculty feedback or falsely documents an assessment or procedure), they are appropriately and fairly disciplined, which may include dismissal from the program.

🎯 Benefits of Just Culture

🎯 Outcomes

A Just Culture in which employees aren't afraid to report errors is a highly successful way to:

• Enhance client safety
• Increase staff and client satisfaction
• Improve outcomes

🎯 How success is achieved

Success is achieved through:

• Good communication
• Effective management of resources
• An openness to changing processes to ensure the safety of clients and employees

🧭 Overview

🧠 One-sentence thesis

Nursing education is adopting a shared accountability model where students are responsible for their preparation and professional behavior while not being blamed for system-level faults, with errors addressed through fair investigation rather than automatic punishment.

📌 Key points (3–5)

• Shared accountability framework: Students accept responsibility for their actions (preparation, professionalism, reporting errors) while the system acknowledges that some failures lie beyond individual control.
• Fair investigation process: Errors are categorized as simple human error, at-risk behavior, or reckless behavior, with consequences matched to the type of mistake.
• Learning from mistakes: Errors are viewed as learning opportunities rather than automatic grounds for punishment, promoting both individual and system-level improvement.
• Common confusion: Accountability vs. blame—students are accountable for their actions but not blamed for system faults; a fair process determines what went wrong.
• Professional standards: Students must maintain evidence-based practice, report errors, behave professionally, and adhere to ethical/legal standards.

🎓 Student Responsibilities Under Shared Accountability

📚 Preparation and Readiness

Students must ensure they are ready for clinical experiences:

• Be fully prepared for clinical, laboratory, and simulation assignments
• Arrive rested and mentally ready for challenging learning environments
• Keep current with evidence-based practice standards

Why this matters: Preparation directly affects client safety; unprepared students pose risks to patients and themselves.

🤝 Professional Conduct and Safety Contribution

Students contribute to a safe learning environment through:

• Behaving professionally at all times
• Accepting accountability for their role in safety
• Adhering to ethical and legal standards

Example: A student who arrives on time, reviews patient charts beforehand, and asks clarifying questions demonstrates professional accountability.

📢 Error Reporting Obligation

Students are responsible for:

• Reporting their own errors
• Reporting near misses (incidents that almost caused harm)

Don't confuse: Reporting an error with being punished—the shared accountability model separates honest reporting from automatic blame.

⚖️ Fair Process for Addressing Errors

🔍 Three Categories of Errors

The investigation determines which type of error occurred:

Error Type	Definition	Response
Simple human error	Unintentional mistake due to knowledge deficit	Coaching and additional learning opportunities
At-risk behavior	Actions that increase risk but without malicious intent	(Not detailed in excerpt)
Reckless behavior	Deliberate disregard for safety or standards	Appropriate discipline, possibly including program dismissal

🛡️ Protection from System-Level Blame

Students can trust that:

• They will not be blamed for faults beyond their control
• A fair process will investigate what went wrong
• System failures are distinguished from individual failures

Example: If a student administers the wrong medication because the pharmacy labeled it incorrectly and the student followed proper checking procedures, this would be investigated as a system fault, not solely student error.

⚠️ When Discipline Is Appropriate

Reckless behavior warrants fair discipline:

• Repeatedly arriving unprepared despite faculty feedback
• Falsely documenting assessments or procedures
• Deliberately ignoring safety protocols

Why severity matters: Reckless behavior shows disregard for client safety and professional standards, justifying stronger consequences including possible dismissal.

🌱 Learning Culture Philosophy

🧠 Mistakes as Learning Opportunities

The culture recognizes that:

• Mistakes are part of the learning process
• Errors provide opportunities for individual growth
• System-level learning improves overall client safety

Don't confuse: Learning from mistakes with excusing carelessness—the model still holds students accountable but uses errors constructively.

🔄 Individual and System Improvement

The shared accountability model promotes:

• Individual learning through coaching and remediation
• System-level improvements by identifying patterns and structural problems
• Continuous improvement in client safety

Example: If multiple students make the same medication calculation error, the system might improve by adding more calculation practice to the curriculum, while individual students receive targeted coaching.

🧭 Overview

🧠 One-sentence thesis

The Joint Commission publishes annual National Patient Safety Goals tailored to different healthcare settings to systematically reduce client harm through evidence-based interventions targeting the most common safety risks.

📌 Key points (3–5)

• What they are: Evidence-based goals and recommendations updated yearly for seven healthcare setting types, based on safety data from experts and stakeholders.
• Core goal categories for nursing care centers: Identify residents correctly, use medicines safely, prevent infection, prevent falls, and prevent pressure injuries.
• Two-identifier rule: At least two ways (e.g., name and date of birth) must be used to confirm client identity before medication or treatment.
• Common confusion: "Bed sores" is an outdated term; the current clinical term is "pressure injuries."
• Why it matters: Nurses and nursing students must know and apply the goals specific to their practice setting to deliver safe, standardized care.

🎯 Purpose and scope of National Patient Safety Goals

🎯 What the goals are

National Patient Safety Goals: goals and recommendations tailored to seven different types of health care agencies based on client safety data from experts and stakeholders.

• Published annually by The Joint Commission.
• Seven healthcare areas covered: ambulatory health care, behavioral health care, critical access hospitals, home care, hospital settings, laboratories, nursing care centers, and office-based surgery.
• Each setting receives customized goals relevant to its specific safety risks.

🔄 Annual updates

• Goals are revised every year based on new safety data.
• Include evidence-based interventions proven to reduce harm.
• Nurses must stay current with the goals for their specific practice setting.

🏥 Goals for nursing care centers (long-term care)

🆔 Identify residents correctly

The goal: Use at least two identifiers to ensure each client receives the correct medication and treatment.

• How: Use the client's name and date of birth (not just one).
• Why: Prevents medication errors and wrong-patient procedures.
• Example: Before administering medication, verify both the resident's full name and birth date match the medication order.

💊 Use medicines safely

Three key components:

Component	What to do	Rationale
Blood thinners	Take extra care with anticoagulant medications	High risk for serious bleeding complications
Medication reconciliation	Record and pass along correct information; compare current medications to new prescriptions	Prevents drug interactions and duplications
Client education	Give written medication lists; instruct clients to bring updated lists to every doctor visit	Empowers clients to participate in safety

🧼 Prevent infection

• Follow hand hygiene guidelines from CDC or WHO.
• Set institutional goals for improving hand-cleaning compliance.
• Why: Hand hygiene is the single most effective infection prevention measure.

🚶 Prevent residents from falling

• Risk assessment: Identify which clients are most likely to fall.
• Key risk factors: Medications causing weakness, dizziness, or sleepiness.
• Action: Implement fall precautions for at-risk clients.
• This goal connects directly to detailed fall prevention protocols covered in subsequent sections.

🛏️ Prevent bed sores (pressure injuries)

• Terminology note: "Bed sores" is the historic term; "pressure injuries" is the current clinical term.
• Process:
  • Identify clients at highest risk for pressure injuries.
  • Take preventive action for at-risk clients.
  • Assess frequently per agency protocol.
• Don't confuse: Prevention (proactive measures) vs. treatment (after injury occurs); the goal emphasizes prevention.

🔗 Integration with nursing practice

📚 Related nursing skills

The excerpt directs nurses to additional resources for implementing these goals:

• Client identification: covered in "Initiating Patient Interaction"
• Infection prevention: covered in "Aseptic Technique Basic Concepts"
• Medication safety: covered in "Basic Concepts of Administering Medications"
• Pressure injury prevention: covered in the "Integumentary" chapter

🎓 Student and nurse responsibility

• Must be aware of current goals for their practice setting.
• Must use the associated recommendations in daily practice.
• Goals provide a standardized framework for safe care delivery across institutions.

🧭 Overview

🧠 One-sentence thesis

Fall prevention in healthcare settings requires systematic risk assessment and tailored interventions that address each client's specific risk factors, because falls are very common and can cause serious injury and death, especially in older adults.

📌 Key points (3–5)

• Why falls matter: Each year, 3 million older adults are treated in emergency departments for fall injuries, and over 800,000 are hospitalized for head injuries or hip fractures from falls.
• Multiple risk factors combine: Most falls result from a combination of risk factors—lower body weakness, medications, vision problems, environmental hazards—and the more risk factors a person has, the greater their chance of falling.
• Two-tier prevention approach: Universal fall precautions apply to all clients all the time, while individualized interventions target each client's specific assessed risk factors.
• Common confusion: Universal precautions vs. risk-based interventions—universal precautions are baseline safety measures for everyone, whereas risk-based interventions are added based on individual assessment findings.
• Ongoing assessment is key: Fall risk assessment is an ongoing process performed every shift, not a one-time event, because client conditions and risk factors change.

🎯 Why falls are a critical safety issue

📊 Impact on older adults

• Injury and death: Falls are very common and can cause serious injury and death, with older adults having the highest risk.
• Emergency care burden: 3 million older people are treated in emergency departments for fall injuries each year.
• Hospitalization: Over 800,000 clients per year are hospitalized because of head injury or hip fracture resulting from a fall.

🔄 The fear-weakness cycle

• Many older adults who fall become afraid of falling, even if they're not injured.
• This fear may cause them to limit their everyday activities.
• When a person is less active, they become weaker.
• Weakness further increases their chances of falling, creating a downward spiral.

Don't confuse: The problem is not just the physical injury from a fall—the psychological fear of falling can itself create conditions that make future falls more likely.

🔍 Identifying who is at risk

🧪 Quick screening questions (STEADI)

The Centers for Disease Control developed "STEADI – Stopping Elderly Accidents, Deaths & Injuries" to help reduce the risk of older adults falling at home. Three screening questions determine risk:

• Do you feel unsteady when standing or walking?
• Do you have worries about falling?
• Have you fallen in the past year? If yes, how many times? Were you injured?

If the individual answers "Yes" to any of these questions, further assessment of risk factors is performed.

🏥 Fall assessment tools for hospitalized clients

By virtue of being ill, all hospitalized clients are at risk for falls, but some clients are at higher risk than others.

Assessment is an ongoing process with the goal of identifying a client's specific risk factors and implementing interventions in their care plan to decrease their risk of falling.

Commonly used fall assessment tools:

• Morse Fall Scale
• Hendrich II Fall Risk Model
• Hester Davis Scale for fall risk assessment

🚩 Key risk factors in hospitalized clients

Risk Factor	Why It Increases Fall Risk
History of falls	All clients with a recent history of falls (e.g., in the past three months) should be considered at higher risk for future falls
Mobility problems and assistive devices	Clients who have problems with their gait or require an assistive device (cane or walker) are more likely to fall
Medications	Clients taking several prescription medications or those taking medications that could cause sedation, confusion, impaired balance, or orthostatic blood pressure changes are at higher risk
Mental status	Clients with delirium, dementia, or psychosis may be agitated and confused, putting them at risk
Continence	Clients who have urinary frequency or frequent toileting needs are at higher fall risk
Equipment	Clients tethered to equipment such as an IV pole or Foley catheter are at higher risk of tripping
Impaired vision	Clients with impaired vision or those who require glasses but are not wearing them have decreased recognition of environmental hazards
Orthostatic hypotension	Clients whose blood pressure drops upon standing often experience light-headedness or dizziness that can cause falls

🧩 Understanding combined risk

Most falls are caused by a combination of risk factors. The more risk factors a person has, the greater their chances of falling.

Many risk factors can be changed or modified to help prevent falls.

Common contributing conditions:

• Lower body weakness
• Vitamin D deficiency
• Difficulties with walking and balance
• Medications (tranquilizers, sedatives, antihypertensives, antidepressants)
• Vision problems
• Foot pain or poor footwear
• Environmental hazards (throw rugs, clutter that can cause tripping)

🛡️ Universal fall precautions

🏗️ What makes them "universal"

Universal fall precautions are called "universal" because they apply to all clients, regardless of fall risk, and revolve around keeping the client's environment safe and comfortable.

Falls are the most commonly reported client safety incidents in the acute care setting. Hospitals pose an inherent fall risk due to the unfamiliarity of the environment and various hazards in the hospital room.

During inpatient care, nurses assess their clients' risk for falling during every shift and implement interventions to reduce the risk of falling.

✅ Universal fall precautions checklist

Environment and orientation:

• Familiarize the client with the environment
• Have the client demonstrate call light use
• Maintain the call light within reach
• Keep the client's personal possessions within safe reach
• Have sturdy handrails in client bathrooms, rooms, and hallways
• Use night lights or supplemental lighting
• Keep floor surfaces clean and dry; clean up all spills promptly
• Keep client care areas uncluttered

Equipment safety:

• Place the hospital bed in the low position when a client is resting; raise the bed to a comfortable height when the client is transferring out of bed
• Keep the hospital bed brakes locked
• Keep wheelchair wheels in a "locked" position when stationary

Client safety:

• Keep non-slip, comfortable, and well-fitting footwear on the client
• Follow safe client handling practices

Example: A nurse caring for any client—even one with no identified fall risk factors—must still keep the bed in the low position when the client is resting and ensure the call light is within reach.

🎯 Individualized interventions based on risk factors

🧠 Altered mental status

• Clients with new altered mental status should be assessed for delirium and treated by a trained nurse or physician.
• For cognitively impaired clients who are agitated or trying to wander, more intense supervision (e.g., sitter or checks every 15 minutes) may be needed.
• Some hospitals implement designated safety zones that include low beds, mats for each side of the bed, nightlight, gait belt, and a "STOP" sign to remind clients not to get up.
• Clients with altered mental status should also have their medications reviewed, as medications can both contribute to agitation as well as help calm patients whose agitation is a threat to themselves or others or is interfering with the delivery of necessary care.

🚶 Impaired gait or mobility

• Clients with impaired gait or mobility will need assistance with mobility during their hospital stay.
• All clients should have any needed assistive devices (canes or walkers) in good repair at the bedside and within safe reach.
• If clients bring their assistive devices from home, staff should make sure these devices are safe for use in the hospital environment.
• Even with assistive devices, clients often need staff assistance when transferring out of bed or walking.
• Use a gait belt when assisting clients to transfer or ambulate per agency policy.

🚽 Frequent toileting needs

Clients with frequent toileting needs should be taken to the toilet on a regular basis via a scheduled rounding protocol.

👓 Visual impairment

Clients with visual impairment should have clean corrective lenses easily within reach and applied when walking.

💊 High-risk medications

High-risk medications: medications that could cause sedation, confusion, impaired balance, orthostatic blood pressure changes, or cause frequent urination.

Interventions:

• Clients on high-risk medications should have their medications reviewed by a pharmacist with fall risk in mind.
• Recommendations should be made to the prescribing provider for discontinuation, substitution, or dose adjustment when possible.
• If a pharmacist is not immediately available, the prescribing provider should carry out a medication review.
• Clients taking medications that can cause orthostatic hypotension should have their orthostatic blood pressure routinely monitored.
• The client and their caregivers should be educated about fall risk and steps to prevent falls when the client is taking these medications.

📉 Frequent falls

Clients with a history of frequent falls should have their risk for injury assessed, including checking for a history of osteoporosis and use of aspirin and anticoagulants.

🕐 Scheduled hourly rounding

🔄 What it is and why it works

Scheduled hourly rounds: scheduled hourly visits to each client's room to integrate fall prevention activities with client care.

Scheduled hourly rounds have been found to greatly decrease the incidence of falls because the client's needs are proactively met, reducing the motivation for the client to get out of bed unassisted.

These activities can be completed by unlicensed assistive personnel, nurses, or nurse managers.

✅ Hourly rounding protocol activities

Pain and comfort:

• Assess client pain levels using a pain-assessment scale (if staff other than a nurse is doing the rounding and the client is in pain, contact the nurse immediately so the client does not have to use the call light for pain medication)
• Put pain medication that is ordered "as needed" on an RN's task list and offer the dose when it is due
• Ask if the client needs to be repositioned and is comfortable

Toileting:

• Offer toileting assistance

Safety checks:

• Ensure the client is using correct footwear (e.g., specific shoes/slippers, no-skid socks)
• Check that the bed is in the locked position
• Place the hospital bed in a low position when the client is resting

Access to essentials:

• Make sure the call light/call bell button is within the client's reach and the client can demonstrate accurate use
• Put the telephone within the client's reach
• Put the TV remote control and bed light switch within the client's reach
• Put the bedside table next to the bed or across the bed
• Put the tissue box and water within the client's reach
• Put the garbage can next to the bed

Communication:

• Prior to leaving the room, ask, "Is there anything I can do for you before I leave?"
• Tell the client that a member of the nursing staff (use names on whiteboard) will be back in the room in an hour to round again

💊 Medication-related fall risk evaluation

📋 When to evaluate

Evaluate medication-related fall risk for clients on admission and at regular intervals thereafter.

🧮 Scoring system

Add up the point value (risk level) for every medication the client is taking. If the client is taking more than one medication in a particular risk category, the score should be calculated by (risk level score) × (number of medications in that risk level category).

Point Value (Risk Level)	Medication Class	Fall Risks
3 (High)	Analgesics, antipsychotics, anticonvulsants, benzodiazepines	Sedation, dizziness, postural disturbances, altered gait and balance, impaired cognition
2 (Medium)	Antihypertensives, cardiac drugs, antiarrhythmics, antidepressants	Induced orthostasis, impaired cerebral perfusion, poor health status
1 (Low)	Diuretics	Increased ambulation and induced orthostasis

Action threshold:

• Score ≥ 6: Elevated risk for falls; ask pharmacist or prescribing provider to evaluate medications for possible modification to reduce risk

🔄 Pharmacist review

For a client at risk, a pharmacist should review the client's list of medications and determine if medications may be tapered, discontinued, or changed to a safer alternative.

Example: A client taking two benzodiazepines (3 × 2 = 6 points), one antihypertensive (2 points), and one diuretic (1 point) has a total score of 9, which is ≥ 6, triggering a pharmacist review for possible medication changes.

🔗 Care planning process

🗺️ Translating assessment into action

Fall prevention care planning is a process where the client's risk assessment information is translated into an action plan to specifically address the identified client needs, in addition to universal fall precautions.

There are many interventions available to prevent falls and fall-related injuries based on the client's specific risk factors.

Don't confuse: Care planning is not choosing between universal precautions OR individualized interventions—it is universal precautions (for everyone) PLUS individualized interventions (based on each client's specific risk factors).

🧭 Overview

🧠 One-sentence thesis

Restraints should only be used as a last resort when alternative interventions fail to prevent harm, because they violate client autonomy and dignity and can cause serious physical and psychological harm.

📌 Key points (3–5)

• What restraints are: devices, methods, or processes that restrict a client's freedom of movement without their permission, including mechanical devices, chemical restraints, and seclusion.
• Why restraints are problematic: they violate autonomy and dignity, cause psychological harm (humiliation, fear, anger), and create physical risks (falls, entanglement, pressure injuries, contractures, muscle loss, and death).
• ANA standard: a restraint-free environment is the standard of care; restraints may only be justified when no viable alternative exists and client/staff safety is in jeopardy.
• Common confusion: side rails and hand mitts are not always restraints—it depends on the purpose (preventing voluntary exit vs. preventing inadvertent falls or helping with repositioning).
• Two categories: medical restraints (for nonviolent behaviors like removing tubes) vs. behavioral restraints (for violent, self-destructive behaviors requiring special training and stricter time limits).

🚫 What counts as a restraint

🚫 Core definition

Restraint: a device, method, or process used for the specific purpose of restricting a client's freedom of movement without the person's permission.

• The key is purpose and restriction of voluntary movement.
• Restraints include:
  • Mechanical devices (e.g., wrist ties, vest restraints, roll belts)
  • Chemical restraints
  • Seclusion

💊 Chemical restraint

Chemical restraint: a drug used to manage behavior, restrict freedom of movement, or impair interaction with surroundings that is not standard treatment or dosage for the client's condition.

• The definition emphasizes "not standard treatment or dosage."
• It is not simply giving medication; it is using medication specifically to restrict movement or behavior outside normal treatment.

🚪 Seclusion

Seclusion: confinement of a client in a locked room from which they cannot exit on their own.

• Used as discipline for harmful behavior or to decrease environmental stimulation.
• Limits freedom of movement even though the client is not mechanically restrained.

⚠️ Harms and risks of restraints

⚠️ Physical dangers

• Struggle and entanglement: restrained people naturally try to remove the restraint, which can lead to falls or fatal entanglement.
• Immobility complications: pressure injuries, contractures, and muscle loss.
• Death: restraints can cause fatal outcomes.

😔 Psychological and ethical harms

• Emotional toll: humiliation, fear, anger, and damage to self-esteem.
• Violation of rights: restraints violate the fundamental client rights of autonomy and dignity.
• The excerpt emphasizes that restraining or secluding clients is "contrary to the goals and ethical traditions of nursing."

📋 Guidelines and regulations

📋 ANA position

• Standard of care: a restraint-free environment.
• When restraints may be justified:
  • Acute psychotic episode with aggression or assault threatening client and staff safety.
  • Severe dementia or delirium with high risk for serious injury (e.g., hip fracture from falling).
• Requirements when restraints are used:
  • Documentation by more than one witness.
  • Humane care that preserves human dignity.
  • RNs with necessary knowledge and skills must be actively involved in assessment, implementation, and evaluation.
  • Adherence to federal regulations and Joint Commission standards.

📝 Typical nursing documentation

• Client behavior necessitating the restraint
• Alternatives to restraints that were attempted
• Type of restraint used
• Time and location of application
• Client education regarding the restraint

🩺 Medical restraints

🩺 What they are

Medical restraints: restraints used to manage nonviolent, non-self-destructive behaviors.

• Common uses:
  • Preventing removal of life-sustaining tubes, drains, IV catheters, urinary catheters, or endotracheal tubes.
  • Preventing high-risk clients from getting out of bed and falling.
• Types: hand mitts, soft wrist restraints, siderails, vest restraints, roll belts.

📜 Policy requirements for medical restraints

• Documentation of reason, alternatives tried, type applied, behavioral criteria for removal, range of motion and cares while in restraints, date and time applied or removed.
• RN role: must apply or supervise application.
• Order requirements:
  • New order every 24 hours.
  • May never be issued as an "as needed" (PRN) order.
  • If the primary care provider did not order it, they should be notified as soon as possible.
• More commonly encountered in general hospital settings.

🧤 Hand mitts

• Large, soft glove covering a confused client's hand to prevent inadvertent dislodging of medical equipment.
• Considered a restraint by The Joint Commission if:
  • Pinned or attached to the bed or bedding.
  • Applied so tightly that hands or fingers are immobilized.
  • So bulky that ability to use hands is significantly reduced.
  • Cannot be easily removed intentionally by the client in the same manner staff applied it (considering the client's physical condition and ability).

🤲 Soft limb restraints

• Designed to immobilize one or both arms or legs through application around wrist(s) or ankle(s).
• Made of soft material to minimize risk of pressure injuries or other injuries.
• Implemented to prevent inadvertent removal of tubes, drains, catheters, or other medical equipment.

👕 Vest restraints

• Mesh or cloth vest applied over the client's chest and tied to an immovable part of each side of the bed.
• Purpose: prevent a client from getting out of bed and injuring themselves.
• Should only be used for impulsive or confused clients when other alternatives are not effective, and not as a means of convenience.

🔥 Behavioral restraints

🔥 What they are

Behavioral restraints: restraints used to manage violent, self-destructive behaviors.

• Used when clients exhibit:
  • Hitting or kicking staff or other clients.
  • Physically harming themselves or others.
  • Threatening to do so.
• Used in emergency situations where safety concerns need to be immediately addressed to prevent harm.

🎓 Special training required

• RNs need special training to apply behavioral restraints, including:
  • Safe application of the restraint.
  • Maintaining personal safety.
  • Techniques to de-escalate violent or aggressive behavior.
• Typically used in mental health units, emergency departments, or critical care units.

📜 Federal guidelines for behavioral restraints

Facilities accepting Medicare and Medicaid reimbursement must follow these guidelines:

• Discontinuation: must be discontinued at the earliest possible time.
• No standing or PRN orders: orders for seclusion or restraint can never be written as standing or PRN (as needed).
• Physician consultation: treating physician must be consulted as soon as possible if restraint or seclusion is not ordered by the client's treating physician.
• One-hour evaluation: a physician or licensed independent practitioner must see and evaluate the need within one hour after initiation.
• Monitoring and care: nurse must follow agency policy for frequent monitoring, regularly changing position to prevent complications, and ensuring basic needs (hydration, nutrition, toileting) are met; some agencies require a 1:1 client sitter.
• Time limits per order:
  • 4 hours for adults
  • 2 hours for children and adolescents ages 9 to 17
  • 1 hour for clients under 9
  • Original order may only be renewed in accordance with these limits for up to a total of 24 hours.
  • After the original order expires, a physician or licensed independent practitioner must see and assess the client before issuing a new order.

🛏️ Side rails and enclosed beds

🛏️ When they are restraints

• Considered a restraint if: the purpose is to prevent a client from voluntarily getting out of bed or attempting to exit the bed.
• Example: raising side rails to stop a confused client from getting up.

🛏️ When they are NOT restraints

• Not a restraint if:
  • The purpose is to prevent the client from inadvertently falling out of bed.
  • The purpose is to help the client with repositioning.
  • The client does not have the physical capacity to get out of bed, regardless of whether side rails are raised or not.

Don't confuse: the same device (side rails) can be a restraint or not a restraint depending on the purpose and the client's capacity.

🔄 Alternatives to restraints

🔄 Individualized care interventions

Many alternatives focus on individualization of client care and elimination of medications with side effects that cause aggression:

• Routine daily schedules
• Regular feeding times
• Intentional rounding
• Frequent toileting
• Effective pain management

🎵 Diversionary techniques

• Television, music, games, or looking out a window to calm a restless client.
• Encouraging restless clients to spend time in a supervised area (dining room, lounge, near nurses' station) to prevent their desire to get up and move around.

🔔 Technology and supervision

• Bed and chair alarms
• Use of a sitter at the bedside

📌 Evolving best practices

• The excerpt notes that guidelines are continuously changing.
• Example: meal trays on chairs were previously used in long-term care to prevent residents from getting out of the chair and falling, but by the definition of a restraint, this action is now considered a restraint and is no longer used.

🧭 Overview

🧠 One-sentence thesis

Nurses must tailor safety interventions to each developmental stage because accident types, frequencies, and risk factors vary significantly across age groups from infancy through older adulthood.

📌 Key points (3–5)

• Age-specific risks: Each life stage has distinct safety concerns—infants face choking and drowning, adolescents face motor vehicle accidents and TBI, adults face intimate partner violence and substance abuse, and older adults face falls and elder abuse.
• Developmental awareness: Younger children lack judgment to recognize danger, adolescents spend time away from parental supervision, and older adults may be vulnerable to exploitation by trusted individuals.
• Nurse's role: Nurses educate families, recognize signs of abuse or injury, and connect victims to resources and protective services.
• Common confusion: Not all age groups need the same type of supervision—infants require constant adult supervision and childproofing, while adolescents need education about independent decision-making and risk recognition.
• Reporting obligations: Every state requires health care professionals to report suspected child abuse, and nurses must also report suspected elder abuse to adult protective services.

👶 Infants, Preschoolers, and School-Aged Children

👶 Infants and preschoolers: curiosity without judgment

• Main risks: Motor vehicle accidents, falls, choking, drowning, and accidental poisoning.
• Why these risks occur: This age group is curious but lacks the judgment to recognize dangers.
• Key interventions:
  • Childproofing the home
  • Providing constant adult supervision
  • Proper use, positioning, and installation of infant car seats
• Example: An infant car seat protects infants during motor vehicle accidents; nurses educate parents on correct installation.

🚸 School-aged children (4–11 years): emerging independence

• Main risks: Motor vehicle injuries, drowning, poisoning, and bicycle accidents.
• Developmental shift: This age group is more aware of dangers and limitations, but adult supervision is still important.
• Key interventions:
  • Education about safety seats, booster seats, or shoulder seat belts
  • Bicycle safety and helmet use (many bike accidents involve head or face injuries due to lack of helmet use)
  • Basic instructions on recognizing and responding to dangerous situations with strangers
• AMBER alert system: Parents should be educated about this system, which uses law enforcement and media resources to notify the public about possible abductions or missing children in danger.

🛡️ Recognizing and reporting child abuse

Child abuse includes physical, sexual, emotional abuse, and neglect.

• Impact: After abuse or violence, many children develop mental health problems (depression, post-traumatic stress disorder), serious medical problems, learning problems, and problems getting along with friends and family.
• Legal obligation: Every state has laws requiring health care professionals to report suspected child abuse in any form.
• Don't confuse: Reporting is mandatory regardless of the type of abuse—physical, sexual, emotional, or neglect.

🚗 Adolescents: Independence and Risk-Taking

🚗 Motor vehicle accidents: the leading cause of death

• Statistics:
  • Motor vehicle accidents are the number one cause of death for adolescents
  • Teens aged 16–19 are three times more likely to be in a fatal crash than drivers older than 20
  • Adolescent males are twice as likely to die in a motor vehicle accident than females of the same age
• Common cause: Texting while driving (distracted driving).
• Challenge: Much of an adolescent's time is spent away from home, making it difficult for parents to control decisions.
• Nurse education: Teach teenagers to use seat belts, obey speed limits, and never use a cell phone or text while driving.

🏈 Traumatic brain injuries (TBI) from sports

TBI results from a blow, jolt, or hit to the head that causes a disruption in blood function or flow to the brain.

• When to suspect: TBI may occur due to participation in sports and recreation-related activities.
• Signs of concussion requiring immediate medical attention:
  • Headache, vomiting, balance problems, fatigue, or drowsiness
  • A dazed and confused appearance or difficulty concentrating or remembering
  • Emotional irritability, nervousness, or a change in personality
• Resource: The CDC's "Heads Up" program provides comprehensive information and education materials for parents, coaches, players, and health care providers.

💊 Substance abuse concerns

• Substances of concern: Tobacco, alcohol, illicit drugs, prescription medication, over-the-counter medications, and bath salts.
• Significance: Substance abuse is a significant concern in the adolescent population.
• Resources: The National Institutes of Health provides many resources for educating teens and their parents.

🩹 Adults: Violence and Substance Misuse

🩹 Intimate partner violence (IPV): the most prevalent adult safety issue

Intimate partner violence (IPV) includes physical or sexual violence, stalking, and psychological or coercive aggression by current or former intimate partners.

• Scope: IPV is widespread in the United States and is the most prevalent adult safety issue.
• Who is affected: Victims can be female or male; sexual orientation can be heterosexual or LGBTQ+.

🔍 The nurse's role in identifying IPV

• Why nurses matter: The nurse is often the initial health care professional in contact with a victim of IPV; prompt recognition of potential or actual threats to client and staff safety is crucial.
• Assessment importance: It is often the nurse's assessment that plays an important role in identifying a client experiencing IPV.
• Communication approach:
  • Show compassion and understanding to this vulnerable population
  • Use effective communication to help victims come forward and share their experiences
• Don't confuse: IPV is complex, and the client may not initially consider leaving the abuser as an option—nurses should not pressure immediate action.

🛠️ Tools and resources for IPV victims

Resource	Description
Danger Assessment Tool	Self-administered survey, free to use, available in several languages
National Center on Domestic Violence, Trauma & Mental Health	Database for resources
National Domestic Violence Hotline	Free, confidential support
Safety plan	Most important: nurses should assist clients to create a safety plan

💉 Substance abuse in adults

Substance abuse is defined by the World Health Organization (WHO) as a maladaptive pattern of using alcohol and/or drugs despite it causing persistent social, occupational, psychological, or physical problems that can be physically hazardous.

• Scope: Substance misuse continues to be a safety issue that affects adults across all socioeconomic levels.
• Statistics: In 2022, over 108,000 people died in the United States as a result of an opioid overdose.
• Substances of concern: Prescription pain medication (such as oxycontin and fentanyl) and street drugs like heroin.
• Impact: Substance misuse affects not only the individual but also causes harm to their family members.
• Key interventions: Early identification of substance use disorders, rehabilitation interventions, and continued support for the individual and family members in the recovery process.

👴 Older Adults: Falls, Accidents, and Abuse

👴 Leading causes of injury

• Main risks: Falls and motor vehicle accidents are leading causes of injury in older adults (according to the CDC).
• Other significant hazards: Fires, accidental overdosing on medications, elder abuse, and financial exploitation.

🚨 Elder abuse: a hidden crisis

• Prevalence: Abuse (including neglect and exploitation) is experienced by about 1 in 10 people aged 60 and older who live at home.
• Statistics (2002–2016): More than 643,000 older adults were treated in the emergency department for nonfatal assaults, and over 19,000 homicides occurred.
• Perpetrators: In most reported cases, a caregiver or a person in a trusted relationship is the perpetrator.
• Underreporting: For various reasons such as fear and disappointment, most cases go unreported.

🔎 Recognizing signs of elder abuse

• Common signs:
  • Bruises, cuts, burns, or broken bones that are unexplainable or suspiciously explained
  • Malnourishment or weight loss
  • Poor hygiene, an unkempt appearance, unclean clothing, or dirty, matted hair
  • Foul odor from clothing or body
  • Anxiety, depression, or confusion
  • Unexplained transactions or loss of money
  • Withdrawal from family members or friends
• Pattern: Most victims are frequently seen in the emergency department several times before they are admitted to the hospital.

📋 Nurse's responsibility in elder abuse cases

• What to watch for: Nurses must be alert to any indications of elder abuse, such as suspicious injuries or behaviors.
• Reporting obligation: Report suspected incidents to local adult protective services agencies.
• Assessment tool: The Elder Mistreatment Assessment tool is available from The Hartford Institute for Geriatric Nursing.

💰 Financial exploitation example

Example: John, a 92-year-old male living alone, hired a repairman who befriended him by bringing homemade cookies and pies and running errands. The repairman convinced John to take out a reverse mortgage for home improvements, then stole $250,000 from John's bank account after obtaining his account numbers and login information.

• This illustrates how trusted individuals can exploit vulnerable older adults.
• Don't confuse: Financial exploitation is a form of elder abuse, not just theft—it involves a breach of trust by someone in a relationship with the victim.

🧭 Overview

🧠 One-sentence thesis

Nurses must protect themselves from workplace hazards—including sharps injuries, blood-borne pathogens, lifting injuries, and inadequate PPE—by following safety regulations and using proper equipment to maintain a healthy work environment.

📌 Key points (3–5)

• Core workplace hazards: sharps injuries, blood-borne pathogen exposure, musculoskeletal disorders from lifting, and lack of personal protective equipment.
• Regulatory framework: OSHA standards, the Needlestick Safety and Prevention Act, and ANA principles establish the right to a safe workplace.
• Fire safety protocols: RACE (Rescue, Activate, Confine, Extinguish/Evacuate) and PASS (Pull, Aim, Squeeze, Sweep) are mandatory response procedures.
• Common confusion: proper body mechanics and gait belts are not sufficient to prevent lifting injuries—complete elimination of manual patient handling is the goal.
• Chemical safety: Safety Data Sheets (SDS) must be readily available for every workplace chemical and include 11 mandatory sections.

🏥 Workplace safety foundations

🏥 Healthy work environment definition

A healthy environment is a place of physical, mental, and social well-being supporting optimal health and safety (WHO definition).

• The ANA Nurses' Bill of Rights establishes seven basic principles for workplace expectations.
• One principle states: "Nurses have the right to a work environment that is safe for themselves and their patients."
• Environmental Health is an ANA Standard of Professional Performance requiring nurses to create safe and healthy workplace environments.

💉 Sharps and blood-borne pathogen safety

💉 The hazard and its scope

• Blood-borne pathogen exposure can cause life-threatening illnesses: hepatitis B, hepatitis C, and HIV.
• Approximately 385,000 sharps-related injuries occur annually among health care workers in hospitals.
• As many as half of injuries go unreported, meaning the actual number is likely much higher.

🛡️ Regulatory protections

Key regulations that have significantly reduced sharps injuries:

Regulation/Law	Coverage areas
OSHA Blood-borne Pathogen Standard	Sharps disposal, safety-engineered devices, PPE, training, record keeping, hepatitis B vaccination, post-exposure follow-up
Needlestick Safety and Prevention Act (2002)	Evaluation and selection of safety-engineered sharps devices

• Medical device manufacturers have developed innovative safety-engineered technology, such as needleless IV access devices.
• Despite progress, preventable sharps injuries and blood exposures continue to occur.

🚨 Immediate response to exposure

If you experience a sharps injury or blood/body fluid exposure, follow these steps immediately:

• Puncture/small wounds: Wash with soap and water for 15 minutes.
• Lacerations: Apply direct pressure to control bleeding and seek medical attention.
• Mucous membranes: Flush with water.
• Always: Report the incident to your instructor or supervisor and seek medical care to determine exposure risk.

Don't confuse: These are immediate first-response steps; they do not replace the need for medical evaluation and potential post-exposure prophylaxis.

🏋️ Safe client handling and mobility

🏋️ The injury problem

• At least 56% of nurses have reported pain from musculoskeletal disorders exacerbated by job requirements.
• Musculoskeletal injuries related to client handling cause more lost work time, long-term medical care needs, and permanent disabilities than any other work-related injury.
• Back injuries can result from one bad lift or from daily wear and tear of manually lifting clients.

❌ Why traditional methods fail

• Even using proper body mechanics and gait belts can result in client handling injuries.
• These methods are insufficient to prevent injury.

Common confusion: Many believe proper body mechanics alone will prevent injury, but the ANA has established that manual patient handling must be completely eliminated.

✅ The ANA solution

• The ANA has established safe patient handling and mobility initiatives.
• Goal: Complete elimination of manual patient handling.
• Employers must provide safe patient handling equipment (e.g., mechanical lifts, transfer devices).

Example: Instead of manually lifting a client from bed to chair, use a mechanical lift device that bears the weight and reduces physical strain on the nurse.

🦺 Personal protective equipment (PPE)

🦺 OSHA requirements

• OSHA requires employers to provide PPE to workers and ensure its proper use.
• In health care settings, PPE includes: gloves, gowns, goggles, face shields, and N95 respirators (according to client condition).

🔄 Purpose and proper use

• PPE protects health care workers from being infected.
• PPE protects clients from being infected by health care workers.
• It is vital to follow agency procedures regarding PPE and transmission precautions to avoid exposure to infectious disease.

⚠️ Supply challenges

• The COVID-19 pandemic created global shortages of PPE.
• Many nurses and health care workers were exposed to the fatal disease due to inadequate PPE.
• The ANA continues to advocate for adequate PPE for nurses in their work environments.

🔥 Fire safety protocols

🔥 Regulatory requirements

The Joint Commission and Centers for Medicare and Medicaid mandate that facilities receiving reimbursement must have:

• A fire response plan
• Fire safety training for staff
• Functioning fire response equipment (alarms, extinguishers, overhead sprinkler systems, clearly identified exit doors)
• Routine fire alarm drills that are audited and documented

🏃 RACE: What to do in a fire

RACE stands for Rescue, Activate, Confine, and Extinguish/Evacuate.

Step	Action	Key point
Rescue	Rescue anyone in immediate danger	Maintain your own safety; do not become a victim yourself
Activate	Activate the fire alarm	Allows others to realize there is a fire so safety measures can begin
Confine	Confine the fire by closing doors and windows	Close fire doors to prevent fire from breaching one zone and encroaching on another
Extinguish or Evacuate	Extinguish small fires if possible; otherwise evacuate	Maintain your safety before trying to extinguish; evacuate if fire cannot be easily extinguished

Don't confuse: The "E" can mean either Extinguish or Evacuate depending on the situation—small, manageable fires can be extinguished, but larger fires require evacuation.

🧯 PASS: How to use a fire extinguisher

PASS stands for Pull, Aim, Squeeze, and Sweep.

• Pull: Pull the pin on the fire extinguisher handle (necessary to depress the handle and release contents).
• Aim: Aim low towards the base of the fire with the nozzle or hose (the base must be smothered; the top is too large and spread out).
• Squeeze: Squeeze down on the handle to depress it and release contents.
• Sweep: Sweep the hose or nozzle from side to side while spraying (helps fully cover the base of the fire).

Continue sweeping until the fire is extinguished or the extinguisher is empty. If the fire reignites, begin RACE and PASS again.

📋 Safety Data Sheets (SDS)

📋 What SDS are

Safety Data Sheets (SDS), formerly called Material Safety Data Sheets (MSDS), are hazardous communication sheets that inform workers about chemicals they encounter in the workplace.

• OSHA requires that SDS are readily available and easily readable for each chemical in the workplace.

📋 Eleven mandatory sections

Every SDS must include:

1. Identification: Chemical name, recommended uses, supplier contact information
2. Hazard identification: Classification and warning information
3. Composition: Chemical name, concentration, impurities, stabilizing additives
4. First aid measures: Initial care for individuals exposed by varying routes
5. Firefighting measures: Type of extinguishing equipment required, hazardous combustion products
6. Accidental release measures: Appropriate response to spills/leaks and cleanup recommendations
7. Handling and storage: Recommendations for safe handling and storage
8. Exposure controls: Personal protection required
9. Physical and chemical properties: Characteristics of the substance
10. Stability and reactivity: Hazards of the chemical
11. Toxicological information: Health effects (immediate, delayed, or chronic), symptoms of exposure

Example: If a nurse spills a cleaning chemical, the SDS provides immediate information about whether to evacuate, what PPE to wear during cleanup, and what first aid to provide if someone is exposed.

🧭 Overview

🧠 One-sentence thesis

The excerpt does not contain substantive content about cognitive impairments; it consists of learning activities for fall prevention and glossary entries unrelated to the chapter title.

📌 Key points (3–5)

• The provided text does not match the chapter title "Cognitive Impairments Introduction."
• The excerpt contains a nursing case study about fall risk assessment for Mr. Moore, a 72-year-old patient recovering from hip surgery.
• The material demonstrates the nursing process (assessment, diagnosis, outcome identification, planning, implementation, evaluation) applied to fall prevention.
• No information about cognitive impairments, their types, assessment methods, or management is present in this excerpt.

📋 Content mismatch note

📋 What the excerpt actually contains

The provided text includes:

• Learning activities from Chapter 5.11 focused on fall prevention strategies
• A client scenario (Mr. Moore) demonstrating fall risk assessment
• Glossary entries defining terms like "at-risk behavior" and "behavioral restraints"
• No discussion of cognitive impairments, cognitive assessment, or related nursing interventions

⚠️ Missing expected content

Based on the chapter title "Cognitive Impairments Introduction," one would expect:

• Definitions and types of cognitive impairments
• Assessment tools for cognitive function
• Common causes and risk factors
• Nursing considerations for cognitively impaired clients

None of this content appears in the provided excerpt.

📝 Note to reader

This excerpt does not provide material suitable for creating review notes about cognitive impairments. The text appears to be from a different chapter section focused on fall prevention and safety protocols in nursing care.

🧭 Overview

🧠 One-sentence thesis

Effective fall prevention requires identifying individual risk factors, implementing targeted interventions, and continuously evaluating whether the client remains safe and uses assistive devices correctly.

📌 Key points (3–5)

• Risk assessment drives planning: Fall risk factors (weakness, gait difficulty) are identified first, then assessed with tools like the Morse Fall Risk Scale to guide intervention selection.
• Interventions target specific risks: Environmental modifications (lighting, clutter removal), assistive devices (walkers, elevated toilet seats), and monitoring (orthostatic blood pressures, gait observation) address identified vulnerabilities.
• Outcome evaluation is two-part: Success is measured both by whether falls occur and by whether the client correctly uses safety measures (e.g., calling for help, using walker).
• Common confusion: A client may remain fall-free but still not meet all outcomes—partial success (no falls but inconsistent device use) requires additional interventions like reminders, scheduled toileting, or alarms.
• Adaptive response to partial success: When outcomes are only partially met, interventions are escalated (visual cues, scheduled toileting, bed alarms) rather than simply repeated.

🔍 Assessment and Diagnosis

🔍 Identifying fall risk factors

The excerpt presents a client (Mr. Moore) with specific vulnerabilities:

• Lower extremity weakness
• Difficulty with gait
• Unsteadiness when walking

These factors form the evidence base for the nursing diagnosis.

📋 Nursing diagnosis structure

Risk for Falls: A NANDA-I diagnosis established when a client has identifiable vulnerabilities that increase fall likelihood.

The diagnosis is stated as:

• Diagnosis label: Risk for Falls
• Evidence: "as evidenced by lower extremity weakness and difficulty with gait"

Example: A client who forgets to call for help and walks unsteadily to the bathroom demonstrates both physical risk factors (gait problems) and behavioral risk factors (not waiting for assistance).

🧪 Use of assessment tools

The excerpt mentions the Morse Fall Risk Scale as a formal tool to quantify fall risk, though specific scoring is not detailed. This structured assessment translates observations into a risk level that guides intervention intensity.

🎯 Planning: Goals and Interventions

🎯 Goal structure

The excerpt distinguishes between an overall goal and specific measurable outcomes:

Goal Type	Statement	Characteristics
Overall Goal	"Mr. Moore will remain free from falls during hospitalization"	Broad, safety-focused
SMART Expected Outcomes	1. "Will not experience a fall"<br>2. "Will correctly use assistive device every time"	Specific, measurable, time-bound (during hospitalization)

Don't confuse: The overall goal is the desired end state; SMART outcomes are the measurable checkpoints that show whether the goal is being met.

🛡️ Environmental interventions

Interventions that modify the physical space:

• Remove clutter from the floor (reduces tripping hazards)
• Provide adequate lighting with night-light at bedside (improves visibility)
• Use half side rails (prevent rolling out of bed without creating entrapment risk)
• Place personal items within easy reach (reduces need to stretch or get up)

🚶 Mobility and assistive device interventions

Interventions that support safe movement:

• Monitor gait, balance, and fatigue with ambulation; encourage resting as needed
• Ensure shoes fit properly, are fastened securely, and have no-skid soles
• Encourage use of prescribed glasses and hearing aids when walking (sensory support)
• Provide elevated toilet seat (reduces distance to sit/stand)

Example: A client who needs to hurry to the bathroom may skip using the walker; ensuring the walker is always within reach and providing scheduled toileting reduces this urgency.

🩺 Physiological monitoring interventions

• Obtain orthostatic blood pressures daily and notify provider as indicated (detects dizziness risk from position changes)

🏠 Discharge planning interventions

Suggested home adaptations:

• Adjust toilet seat height
• Install grab bars in the bathroom
• Use rubber mat in the shower

These extend fall prevention beyond hospitalization.

🚨 Implementation Challenges

🚨 Real-time decision-making scenario

The excerpt describes a critical moment:

• Client climbs out of bed without calling for help
• States urgency: "I need to go to the bathroom for a bowel movement and didn't have time to ring the call light and wait"
• Appears unsteady with walker
• Says "We need to hurry or I'm not going to make it"

This scenario illustrates the gap between planned interventions (use call light, use walker) and actual behavior under urgency.

Key question posed: "What is the best response?" (The excerpt does not provide the answer, leaving it as a critical thinking exercise.)

⚖️ Balancing safety and dignity

The client's urgency is real (bowel movement cannot wait), but fall risk is high (unsteady gait). The nurse must:

• Assist immediately (not delay for ideal conditions)
• Use the walker despite time pressure
• Stay close to provide physical support
• Consider whether the client can safely reach the toilet or needs a bedside commode

📊 Evaluation and Adaptive Interventions

📊 Outcome evaluation results

Expected Outcome	Evaluation Result	Evidence
Will not experience a fall	Outcome Met	No falls occurred
Will correctly use assistive device (walker)	Outcome Partially Met	Forgets to call for assistance when needing bathroom

Don't confuse: "Outcome Met" does not mean the client is now safe indefinitely—it means the outcome was achieved during the evaluation period. Partial success on the second outcome indicates ongoing risk.

🔄 Escalated interventions after partial success

When the client continues to forget to call for help, additional layers are added:

🔄 Visual and cognitive cues

• "Stop" sign placed within client view to remind him to use call light before getting up
• Icon posted on doorframe to alert staff that client is at high risk for falls

🔄 Proactive scheduling

• Scheduled toileting every two hours (in addition to hourly rounding) reduces urgency that leads to unsafe behavior

🔄 Environmental safeguards

• Bed kept low and locked
• Mat placed next to bed at night (cushions impact if client does get up)

🔄 Technology-assisted monitoring

• Bed alarm will be placed if client continues to forget to call for assistance
• Alarm alerts staff of movement so quick assistance can be offered

Why this matters: The excerpt demonstrates that fall prevention is iterative—when behavioral interventions (reminders) are insufficient, environmental and technological safeguards are added without waiting for a fall to occur.

🧠 Proactive vs reactive approach

The excerpt emphasizes adding the bed alarm if the client continues to forget, not after a fall happens. This is proactive risk management: recognizing that partial outcome achievement signals the need for stronger interventions before harm occurs.

🧭 Overview

🧠 One-sentence thesis

Nursing evaluation of fall-prevention interventions requires ongoing adjustment of strategies when outcomes are only partially met, using layered safeguards like environmental cues, scheduled rounding, and alarms to compensate for client memory deficits.

📌 Key points (3–5)

• Evaluation tracks outcome achievement: outcomes can be fully met, partially met, or unmet; partial achievement triggers plan revision.
• Layered fall-prevention strategies: combine environmental reminders (signs, icons), scheduled interventions (hourly rounding, toileting), physical safeguards (low bed, mats), and technology (alarms).
• Common confusion: a client using an assistive device correctly does not mean the outcome is fully met if they forget to call for help first—partial achievement requires additional interventions.
• Scheduled rounding integrates prevention: hourly visits and two-hour toileting schedules proactively address needs before the client attempts unsafe movement.
• Escalation of interventions: strategies progress from passive reminders to active alarms if the client continues at-risk behavior.

📋 Evaluation process and outcome measurement

📊 Outcome status categories

The excerpt demonstrates three outcome states:

• Met: the client did not fall during hospitalization.
• Partially Met: the client uses the walker correctly but forgets to call for assistance.
• Unmet: (not illustrated in this case, but implied by the framework).

🔍 What "partially met" means

Outcome Partially Met: Mr. Moore uses his assistive device (walker) correctly during hospitalization.

• The client performs part of the desired behavior (correct walker use) but not all components (calling for help before getting up).
• Partial achievement signals the need for additional interventions, not abandonment of the goal.
• Don't confuse: using equipment correctly ≠ safe behavior if other fall-risk actions (e.g., getting up alone) persist.

🛡️ Layered fall-prevention interventions

🪧 Environmental cues and alerts

• "Stop" sign placed within client view: reminds the client to use the call light before getting up.
• Icon posted on doorframe: alerts staff that the client is at high risk for falls.
• These passive reminders compensate for memory deficits without restricting movement.

⏰ Scheduled rounding and toileting

In addition to hourly rounding, toileting will be performed at scheduled intervals every two hours.

• Hourly rounding: scheduled visits integrate fall prevention with other care activities.
• Two-hour toileting schedule: proactively addresses bathroom needs, reducing the client's impulse to get up alone.
• Rationale: Mr. Moore forgets to call for assistance when he needs to use the bathroom; scheduled toileting prevents the triggering situation.

🛏️ Physical safeguards

• Bed kept low and locked: reduces fall distance and prevents bed movement.
• Mat placed next to the bed at night: cushions impact if the client does get up.
• These measures mitigate injury risk even if the client bypasses other safeguards.

🔔 Technology escalation

If Mr. Moore continues to forget to call for assistance, a bed alarm will be placed to alert staff of movement so that quick assistance can be offered.

• Bed alarms are a conditional escalation: implemented only if passive and scheduled strategies fail.
• Purpose: detect movement in real time, enabling staff to intervene before a fall occurs.
• Don't confuse with restraints: alarms alert staff but do not restrict the client's freedom of movement (see glossary definition of restraint: "restricting a client's freedom of movement without the permission of the person").

🔄 Continuous evaluation and plan revision

🔄 Iterative adjustment

The case illustrates the nursing process cycle:

1. Evaluate against established outcomes.
2. Identify gaps: Mr. Moore forgets to call for help.
3. Revise the plan: add stop sign, scheduled toileting, mat, and conditional alarm.
4. Re-evaluate: if forgetting persists, escalate to bed alarm.

🎯 Why multiple strategies matter

• No single intervention addresses all fall-risk factors.
• Combining reminders (cognitive support), schedules (proactive need fulfillment), and alarms (real-time detection) creates redundancy.
• Example: if Mr. Moore ignores the stop sign, scheduled toileting reduces bathroom urgency; if he still gets up, the alarm alerts staff immediately.

🧭 Overview

🧠 One-sentence thesis

The excerpt provides a glossary of safety and cognitive impairment terms used in nursing practice, establishing foundational vocabulary for understanding client care protocols and risk management.

📌 Key points (3–5)

• Glossary structure: Definitions cover safety culture, restraints, communication tools, and cognitive impairment concepts across multiple chapters.
• Safety terminology: Includes error classification (near misses, never events, sentinel events) and institutional culture qualities (Just Culture, Learning Culture, Reporting Culture).
• Restraint distinctions: Chemical vs. medical restraints serve different purposes; seclusion is a separate confinement method.
• Common confusion: Simple human error vs. reckless behavior—the Just Culture model distinguishes inadvertent mistakes from conscious disregard of risk.
• Cognitive impairments introduction: Cognition involves thinking and decision-making that develops continuously from infancy through adulthood.

📚 Safety terminology and error classification

🔍 Types of adverse events

The excerpt defines three levels of safety events based on severity and outcome:

Term	Definition	Key characteristic
Near misses	Error with potential to cause harm but doesn't	Intercepted or fails by chance
Never events	Clearly identifiable, measurable adverse events	Serious, preventable, results in death or significant disability
Sentinel event	Client safety event that reaches the client	Results in death, permanent harm, or severe temporary harm requiring life-sustaining interventions

• Don't confuse: Near misses could have caused harm but didn't; sentinel events did cause serious harm.

🏥 Institutional safety culture qualities

Culture of safety: The behaviors, beliefs, and values within and across all levels of an organization as they relate to safety and clinical excellence, with a focus on people.

Three specific culture types are defined:

• Just Culture: Encourages reporting safety information and rewards it, but distinguishes between human error and reckless behavior with clear boundaries.
• Learning Culture: Shows willingness and competence to draw conclusions from safety information systems and implement major reforms when needed.
• Reporting Culture: People report errors and near misses openly.

🧩 Error classification in Just Culture model

Simple human error: An error that occurs when an individual inadvertently does something other than what should have been done.

• Most errors result from poor processes, programs, education, environmental issues, or situations—not individual fault.
• Management approach: correct the cause, examine the process, fix the deviation.

Reckless behavior: An error that occurs when an action is taken with conscious disregard for a substantial and unjustifiable risk.

• Key distinction: Inadvertent (human error) vs. conscious disregard (reckless behavior).

🔬 Analysis tools

Root cause analysis: A structured method used to analyze serious adverse events to identify underlying problems that increase the likelihood of errors, while avoiding the trap of focusing on mistakes by individuals.

• Focus is on systems and processes, not blaming individuals.

Human factors: A science that focuses on the interrelationships between humans, the tools and equipment they use in the workplace, and the environment in which they work.

🔒 Restraints and confinement

🛑 General restraint definition

Restraint: A device, method, or process that is used for the specific purpose of restricting a client's freedom of movement without the permission of the person.

💊 Chemical restraint

Chemical restraint: A drug used to manage a client's behavior, restrict the client's freedom of movement, or impair the client's ability to appropriately interact with their surroundings that is not a standard treatment or dosage for the client's condition.

• Key qualifier: "not a standard treatment or dosage"—distinguishes restraint from legitimate medication.

🏥 Medical restraints

Medical restraints: Restraints used to manage nonviolent, non-self-destructive behaviors such as the client attempting to remove life-sustaining tubes, drains, IV catheters, urinary catheters, or endotracheal tubes.

• Purpose: protect medical equipment and treatment integrity, not manage violence.

🚪 Seclusion

Seclusion: The confinement of a client in a locked room from which they cannot exit on their own.

• Used for behavior that can cause harm to self or others, or to decrease environmental stimulation.
• Don't confuse: Seclusion is confinement in a locked room; restraints restrict movement but don't necessarily involve a locked room.

🗣️ Communication and handoff tools

📋 ISBARR mnemonic

ISBARR: A mnemonic for the components of health care team member communication that stands for Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.

• Structured communication tool to ensure complete information transfer.

🤝 Handoff reports

Handoff reports: A transfer and acceptance of client care responsibility achieved through effective communication. It is a real-time process of passing client specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the client's care.

• Emphasizes real-time and client-specific information.
• Goal: continuity and safety.

🧠 Cognitive impairments introduction

🧩 What cognition means

Cognition: The term used to describe our ability to think.

• Involves receiving input from the environment and making decisions about responses.
• Some decisions are conscious; others are reflexive.

📈 Cognitive development across the lifespan

• Infants: Cognitive development based on experiences with their environment.
• Throughout life: Cognitive processes continue developing through childhood, adolescence, and adulthood.
• Purpose: learning to adapt and use knowledge to solve problems and reach desired outcomes.

🔄 Continuous evolution

• The excerpt emphasizes that cognitive function is "continuously evolving."
• Many factors can influence cognitive function throughout life (the excerpt cuts off before listing these factors).

🛡️ Fall prevention and safety protocols

🔄 Scheduled hourly rounds

Scheduled hourly rounds: Scheduled hourly visits to each client's room to integrate fall prevention activities with the rest of a client's care.

🌐 Universal fall precautions

Universal fall precautions: A set of interventions to reduce the risk of falls for all clients and focus on keeping the environment safe and comfortable.

• Applied to all clients, not just high-risk individuals.

🔥 Emergency response mnemonics

🧯 RACE for fires

RACE: A mnemonic for actions to immediately take during a fire, standing for Rescue, Activate, Confine, and Extinguish.

🔥 PASS for fire extinguishers

PASS: A mnemonic for actions to take when using a fire extinguisher, including Pull, Aim, Squeeze, and Sweep.

🏥 Additional safety and health concepts

🎯 National Patient Safety Goals

National Patient Safety Goals: Annual safety goals and recommendations tailored for seven different types of health care agencies based on client safety data from experts and stakeholders.

🌿 Healthy environment

Healthy environment: A place of physical, mental, and social well-being supporting optimal health and safety.

📄 Safety Data Sheets

Safety Data Sheets (SDS): Hazardous communication sheets that let workers know certain information about chemicals they encounter in the workplace. OSHA requires that SDS's are readily available and easily readable for each chemical in the workplace.

• Formerly called Material Safety Data Sheets (MSDS).

💔 Intimate Partner Violence

Intimate Partner Violence (IPV): Physical or sexual violence, stalking, and psychological or coercive aggression by current or former intimate partners.

💊 Substance abuse

Substance abuse: A maladaptive pattern of continued use of alcohol or a drug despite it causing persistent social, occupational, psychological, or physical problems that can be physically hazardous.

🧭 Overview

🧠 One-sentence thesis

Nurses identify clients' sensory impairments and implement interventions to improve their safety, functioning, and quality of life by using strategies and resources that help them engage with their surroundings and others.

📌 Key points (3–5)

• Five basic senses: sight (vision), hearing (auditory), touch (tactile), smell (olfactory), and taste (gustatory) help us perceive and act in the world around us.
• Nurses rely on sensory input: nurses use their own senses when gathering assessment data—listening to heart and lung sounds, evaluating skin appearance, smelling infectious processes, and feeling pulses.
• Sensory impairment impacts safety: when an individual experiences sensory impairment due to loss of one or more senses or altered stimuli (too much or too little), their ability to safely function is impacted.
• Nursing goal: provide support and dignity to individuals and their families by using strategies and resources that help them engage with their surroundings and others to the best of their ability.

🧩 Core concepts

🧩 What sensory impairments are

Sensory impairment: any type of difficulty that an individual has with one of their five senses.

• When an individual experiences loss of a sensory function (such as vision), the way they interact with the environment is affected.
• Example: when an individual gradually loses their vision, their reliance on other senses to receive information from the environment is often enhanced.

🧩 The five basic senses

The excerpt identifies five basic senses:

Sense	Type	Function
Sight	Vision	Helps perceive visual information
Hearing	Auditory	Helps perceive sounds
Touch	Tactile	Helps perceive physical contact
Smell	Olfactory	Helps perceive odors
Taste	Gustatory	Helps perceive flavors

• These senses help us perceive and act in the world around us.
• We may not often consider the importance of our sensory input until it is impaired.

🩺 Nursing role and sensory function

🩺 How nurses use their senses in care

Nurses especially rely on their senses when providing client care as they gather assessment data:

• Hearing: ask questions and listen to client responses; listen to heart and lung sounds.
• Vision: evaluate the appearance of skin.
• Smell: may smell an infectious process when changing a wound dressing.
• Touch: feel the sensation of pulses when assessing circulation.

🩺 Nursing responsibilities with sensory impairments

• Identify clients' sensory impairments.
• Implement interventions to improve safety, functioning, and quality of life.
• Provide support and dignity to individuals and their families.
• Use strategies and resources to help clients engage with their surroundings and others to the best of their ability.

⚠️ Safety considerations

⚠️ Why safety is a priority

• Safety is always a nursing consideration for a client with a sensory impairment.
• Intact senses are required to make decisions about functioning safely within the environment.

⚠️ Safety example

Example: an individual who has impaired hearing may not be able to hear a smoke alarm and requires visual indicators when the alarm is triggered.

• This illustrates how sensory impairments require environmental adaptations to maintain safety.
• The nurse must consider how each sensory loss affects the client's ability to detect and respond to hazards.

📚 Chapter scope

📚 What this chapter covers

The excerpt states that this chapter will review:

• Common sensory impairments
• Related nursing care

The learning objectives listed include:

• Identifying risk factors for sensory impairments
• Identifying cues related to sensory impairments across the life span
• Identifying interventions to support diverse clients (individual, family, or group) with sensory impairments
• Contributing to a plan of care for clients with sensory impairments
• Detailing support for family/significant others caring for clients with a sensory impairment
• Including community resources available for clients and families with a sensory impairment
• Including adaptations to the environment to maintain safety for the client with a sensory impairment
• Outlining evidence-based nursing interventions for specific sensory disorders

🧭 Overview

🧠 One-sentence thesis

Nurses must implement individualized, evidence-based interventions to help clients with sensory impairments communicate effectively, remain safe from injury, and maintain quality of life, while also understanding how the body's natural defenses protect against infection.

📌 Key points (3–5)

• Sensory impairment interventions must be customized: Each client requires tailored nursing actions based on their specific sensory deficit (vision, hearing, tactile, etc.).
• Safety is the primary goal: Expected outcomes focus on keeping clients free from injury and able to navigate their environment.
• Communication adaptations are essential: Nurses must identify and document each client's preferred communication method and use appropriate techniques (facing client, adequate lighting, simple language).
• Common confusion: Sensory overload vs. sensory deprivation—overload requires reducing stimuli (closing doors, combining activities), while deprivation requires adding meaningful stimuli (photos, conversation, calendars).
• Natural body defenses work in layers: Physical barriers (skin, mucous membranes), mechanical actions (cilia, peristalsis), chemical mediators, and normal flora all contribute to nonspecific innate immunity.

👁️ Vision impairment interventions

👓 Ensuring access to corrective devices

• Clients must have clean, current-prescription glasses or contacts available.
• Provide magnifying glasses when needed.
• Apply labels to frequently used items using high-contrast colors (e.g., medication bottles).

🏠 Environmental modifications

• Provide adequate room lighting; minimize glare (offer sunglasses, draw window coverings).
• Do not rearrange the environment—consistency helps clients navigate safely.
• Maintain an uncluttered space; remove hazards like scatter rugs and oxygen tubing.
• Describe the environment to the client as needed.
• Identify food tray items using clock positions (e.g., "Your coffee is at 2 o'clock").

🔍 Safety and assessment

• Monitor functional implications of diminished vision.
• Identify yourself when entering the client's space.
• Encourage and arrange routine vision assessments and screenings.
• Provide reading materials in large print.

👂 Hearing impairment interventions

🔊 Assistive devices and maintenance

• Perform or arrange routine hearing assessments.
• Assist the client in acquiring hearing aids or assistive devices.
• Ensure appropriate use; maintain batteries and cleanliness.

💬 Communication techniques

Technique	Why it matters
Gain attention before speaking	Ensures client is ready to receive information
Avoid noisy backgrounds	Reduces competing sounds
Stay within 2–3 feet	Optimizes sound transmission
Face client directly in good lighting	Facilitates lipreading
Use low, deep voice	Easier to hear than high-pitched sounds
Avoid turning away while speaking	Client cannot lipread if they can't see your mouth
Use short, simple sentences	Easier to process; avoid slang
Use gestures when necessary	Provides visual cues

📋 Documentation and planning

• For severe hearing impairment, document the client's preferred method of communication (verbal, written, lipreading, American Sign Language) in the care plan.

🤲 Other sensory impairments

👃 Impaired sensitivity to odor

• Advise checking pilot lights visually (cannot rely on smell for gas leaks).
• Encourage checking expiration dates on food and marking dates on leftovers.

🌡️ Impaired tactile sensation

• Maintain water heater temperature at a safe range to avoid burns.
• Check bath water temperature with a thermometer (client cannot rely on touch).

🗣️ Impaired oral communication

• Listen and provide sufficient time for the client's answer.
• Avoid childlike phrases and words.
• Ask questions requiring short or "yes/no" answers for clients with expressive aphasia.
• Keep explanations simple.
• Provide a communication board or alternative methods as appropriate.
• Collaborate with a speech therapist.
• Provide education to family/caregivers to facilitate communication.

🔄 Sensory overload vs. sensory deprivation

🚨 Sensory overload interventions

Sensory overload: A condition that occurs when an individual receives too many stimuli or cannot selectively filter meaningful stimuli.

• Plan and combine nursing activities to avoid interrupting rest time.
• Decrease noise level in the room and hallway (medical devices, conversations).
• Close the room door if possible.
• Example: A client in a busy ICU with constant alarms, bright lights, and frequent interruptions may become confused and agitated—reducing these stimuli helps restore calm.

🌱 Sensory deprivation interventions

Sensory deprivation: A condition that occurs when there is a lack of sensations due to sensory impairments or when the environment has few quality stimuli.

• Provide meaningful stimuli: client's choice of television, radio, reading material, calendars, photos of family members, pets.
• Provide social interaction as appropriate.
• Encourage family members/caregivers to engage in meaningful conversations.
• Example: An isolated client with hearing loss may withdraw—adding visual stimuli (family photos) and encouraging visits helps maintain engagement.

🔀 Don't confuse

• Overload = too much input → reduce stimuli, create quiet, consolidate care.
• Deprivation = too little input → add meaningful stimuli, encourage interaction.

🛡️ Natural defenses against infection

🧱 Physical barriers (nonspecific innate immunity)

Nonspecific innate immunity: A system of defenses in the body that targets invading pathogens in a nonspecific manner; present from birth.

Skin:

• Three layers of closely packed cells; topmost layer (epidermis) contains keratin.
• Keratin makes the surface mechanically tough and resistant to bacterial degradation.
• Infections occur when the skin barrier is broken, allowing opportunistic pathogens to enter.

Mucous membranes:

• Line the nose, mouth, lungs, urinary and digestive tracts.
• Consist of epithelial cells bound by tight junctions.
• Secrete mucus that traps debris and microbes; mucus also contains antimicrobial peptides.

Endothelia:

• Tightly packed cells lining urogenital tract, blood vessels, lymphatic vessels.
• Blood-brain barrier protects the CNS from microorganisms; keeps cerebrospinal fluid sterile.

⚙️ Mechanical defenses

• Mucociliary escalator: Cilia in the respiratory tract propel mucus (with trapped microbes) upward to be coughed, sneezed, or swallowed.
  • Smoking disrupts this system → increased bacterial colonization and frequent infections.
• Flushing actions: Urine and tears physically remove microbes.
  • Urinary tract is normally sterile due to flushing.
  • Eyelashes and eyelids prevent dust from reaching the eye; blinking bathes the eye in tears.
• Peristalsis: Involuntary muscle contractions in the intestine push digested content (and trapped microbes) forward.
  • Feces can contain microorganisms → good hand hygiene prevents fecal-oral transmission.

🦠 Microbiome as defense

• Normal flora compete with pathogens for nutrients and cellular-binding sites.
• Example: In the vagina, normal flora limits Candida albicans growth, preventing yeast infections.
• Disruption risk: Antibiotics can deplete normal flora → opportunistic infections like Clostridium difficile (C-diff) can colonize.
  • C-diff causes severe, potentially lethal diarrhea.
  • Fecal transplantation (transferring fecal material from a donor) can restore normal flora and treat recurrent C-diff.

🧪 Chemical defenses

• Chemical mediators in body fluids and tissues inhibit microbial invaders.
• Example: Sebaceous glands in the dermis secrete oil (details cut off in excerpt).

🩺 Applying the nursing process: Mr. Mitchell case

📊 Assessment findings

• 87-year-old male, increasingly withdrawn, difficulty answering questions appropriately.
• Whisper test: unable to report any of six words whispered behind him.
• Ear canals clear without cerumen.
• Embarrassed about asking people to repeat; avoids social situations.
• Interested in improving hearing and communication.

🎯 Nursing diagnosis and outcomes

• Diagnosis: Readiness for Enhanced Communication as evidenced by expressed desire to enhance hearing and communication.
• Overall goal: Client will experience enhanced communication with improved hearing.
• SMART outcome: Mr. Mitchell will attend an appointment with an audiologist within two weeks.

🛠️ Interventions implemented

• Provided education about available hearing devices.
• Used communication techniques: faced client directly, provided good lighting for lipreading, shut door for quiet environment, used short simple sentences.
• Did not interpret nodding as understanding.
• Shared assessment findings with provider; requested audiologist referral.
• Assisted client in making the appointment.

✅ Evaluation

• At next appointment (two weeks later): Mr. Mitchell wearing hearing aid, answers questions appropriately.
• Reports attending more social events "now that I can hear better."
• SMART outcome: met.

🦠 Pathogens overview

🧬 Four common types

Type	Description	Treatment
Viruses	Genetic code (DNA/RNA) with protein coating; invade cells to replicate	Antiviral medications; antibiotics do NOT work
Bacteria	Single-celled; diverse shapes; some strains resistant (e.g., MRSA)	Antibiotics; resistance is a growing concern
Fungi	Thick cell wall makes them harder to kill; e.g., Candida albicans (oral thrush, yeast infections)	Antifungal medications
Parasites	Protozoa (single-celled), helminths (worms), ectoparasites (ticks, mosquitos)	Antihelmintics

⚠️ Don't confuse

• Antibiotics kill bacteria, not viruses or fungi.
• Normal flora are microorganisms that live on/in the body without causing infection unless the host becomes susceptible.
• Pathogens are microorganisms that cause disease.

---

Note: The excerpt provided contains nursing textbook content focused on sensory impairments, infection basics, and natural defenses. All information above is derived solely from the source material.

🧭 Overview

🧠 One-sentence thesis

The body employs a layered defense system—physical barriers, normal flora, chemical mediators, inflammation, fever, and adaptive immunity—that works together to prevent pathogen invasion and eliminate infections when they occur.

📌 Key points (3–5)

• Nonspecific innate immunity provides immediate, broad-spectrum defense through physical barriers, normal flora, chemical mediators, inflammation, and fever.
• Specific adaptive immunity activates when innate defenses are insufficient, using B cells (antibodies) and T cells to target specific pathogens and create immunological memory.
• Normal flora prevents infection by occupying binding sites and competing for nutrients, but disruption (e.g., antibiotics) can allow opportunistic pathogens to flourish.
• Common confusion: Inflammation is often perceived negatively, but it is a necessary process that recruits defenses to eliminate pathogens—excessive inflammation, however, can cause tissue damage.
• Cytokine storm occurs when too many cytokines are released too quickly, potentially causing multi-organ failure and death.

🛡️ Physical and mechanical defenses

🛡️ Skin and mucous membranes

• The skin and mucous membranes form the first line of defense by creating physical barriers.
• Eyelashes prevent dust and debris from reaching the eye surface.
• Tears wash debris away from the eye.
• These mechanical defenses block pathogen entry at portals where the body contacts the external environment.

🦠 Normal flora (microbiome)

Normal flora: microorganisms that naturally inhabit the body and contribute to the microbiome, serving as an important first-line defense against invading pathogens.

• Normal flora occupies cellular binding sites and competes for nutrients, preventing pathogen attachment and proliferation.
• Example: In the vagina, normal flora competes with Candida albicans, preventing yeast infections by limiting nutrient availability and inhibiting Candida growth.
• Similar competition occurs on the skin, in the upper respiratory tract, and in the gastrointestinal tract.

Why disruption matters:

• When the microbiome is disrupted (e.g., by antibiotics), susceptibility to infection increases.
• Example: Antibiotic treatment can deplete gastrointestinal normal flora, allowing Clostridium difficile (C-diff) to colonize and cause severe, potentially lethal diarrheal infection.
• Fecal transplantation is a recent strategy for treating recurrent C-diff by restoring normal flora.

🧪 Chemical defenses

🧪 Sebum and skin defenses

• Sebaceous glands in the dermis secrete sebum (oil) onto the skin surface through hair follicles.
• Sebum seals off hair follicle pores and prevents bacteria from invading sweat glands and surrounding tissue.
• Environmental factors affect these defenses: low humidity in winter makes skin drier and more susceptible to pathogens normally inhibited by the skin's low pH.
• Application of moisturizer restores moisture and essential oils, helping prevent infection.

🧪 Enzymes and pH

• Digestive tract: Enzymes in saliva and the digestive tract eliminate most pathogens that survive the stomach's acidic environment.
• Urinary tract: Slight acidity of urine inhibits growth of potential pathogens.
• Respiratory tract: Various chemical mediators in nasal passages, trachea, and lungs have antibacterial properties.

🧪 Plasma protein mediators

Plasma protein mediators: nonspecific innate immune factors in plasma (the fluid portion of blood) that contribute to the inflammatory response, including acute-phase proteins, complement proteins, and cytokines.

Acute-phase proteins:

• Example: C-reactive protein—high levels indicate inflammation caused by serious infection or other medical conditions.

Complement proteins:

• Always present in blood and tissue fluids, allowing quick activation.
• Aid in pathogen destruction by piercing outer membranes (cell lysis) or making pathogens more attractive to phagocytic cells like macrophages.

Cytokines:

• Proteins that affect interaction and communication between cells.
• The first immune cell to detect a pathogen acts like a conductor, creating and sending cytokine messages to direct other immune cells and initiate inflammation.

⚠️ Cytokine storm

Cytokine storm: a severe immune reaction in which the body releases too many cytokines into the blood too quickly.

• Can occur as a result of infection, autoimmune condition, or other disease.
• Signs and symptoms: high fever, inflammation, severe fatigue, nausea.
• Can be severe or life-threatening, leading to multiple organ failure.
• Example: Many COVID-19 complications and deaths were caused by cytokine storm.

🔥 Inflammation

🔥 Purpose and process

Inflammation: a response triggered by a cascade of chemical mediators when pathogens breach the nonspecific innate immune system or when injury occurs.

Why inflammation is necessary:

• Recruits cellular defenses to eliminate pathogens.
• Removes damaged and dead cells.
• Initiates repair mechanisms.
• Don't confuse: Although often perceived negatively, inflammation is necessary—but excessive inflammation can cause local tissue damage or, in severe cases like sepsis, become deadly.

🔥 Acute inflammation sequence

1. Vasoconstriction occurs first to minimize blood loss if injury has occurred.
2. Vasodilation follows, with increased blood vessel permeability due to histamine release by mast cells.
3. Five observable signs result from histamine:
   • Erythema (redness)
   • Edema (swelling)
   • Heat
   • Pain
   • Altered function

🔥 Cellular response

• Phagocytes influx at the site of injury/infection.
• Neutrophils are recruited to fight pathogens.
• As the fight continues, pus forms from accumulation of neutrophils, dead cells, tissue fluids, and lymph.
• After a few days, macrophages typically clear out the pus.
• If this nonspecific inflammatory process does not successfully kill pathogens, infection occurs.

🌡️ Fever

🌡️ Systemic inflammatory response

• Fever extends beyond the infection site and affects the entire body, resulting in overall increased body temperature.
• Enhances nonspecific innate immune defenses by stimulating white blood cells to kill pathogens.
• Rise in body temperature inhibits growth of many pathogens.

🌡️ Physiological mechanisms

During fever:

• Skin may appear pale due to vasoconstriction of blood vessels in the skin.
• Blood flow diverted away from extremities to minimize heat loss and raise core temperature.
• Hypothalamus stimulates muscle shivering to generate heat and raise core temperature.

When fever breaks:

• Hypothalamus stimulates vasodilation, returning blood flow to the skin and releasing heat.
• Hypothalamus stimulates sweating, which cools the skin as sweat evaporates.

🌡️ Benefits and risks

• Low-level fever is thought to help overcome illness.
• Risk: Immune response can be too strong, causing tissue and organ damage or death.
• Example: Staphylococcus aureus and Streptococcus pyogenes can produce superantigens causing toxic shock syndrome and scarlet fever, with fevers exceeding 42°C (108°F) that must be managed to prevent tissue injury and death.

🎯 Specific adaptive immunity

🎯 When adaptive immunity activates

Specific adaptive immunity: the immune response activated when the nonspecific innate immune response is insufficient to control an infection.

Two types of adaptive responses:

• Cell-mediated immune response: carried out by T cells
• Humoral immune response: controlled by activated B cells and antibodies

🎯 B cells

• Mature in the bone marrow.
• Make Y-shaped proteins called antibodies that are specific to each pathogen.
• Antibodies lock onto the pathogen's surface and mark it for destruction by other immune cells.
• Five classes of antibodies: IgG, IgM, IgA, IgD, and IgE.
• Turn into memory B cells that are stored and released if the specific antigen reappears in the future.
• Memory B cells allow the immune system to mount a quick defense because of previously created memory.

🎯 T cells

• Mature in the thymus.
• Three classes:
  • Helper T cells: stimulate B cells to make antibodies and help killer cells develop
  • Regulatory T cells: (mentioned but not detailed in excerpt)
  • Cytotoxic T cells (Killer T cells): directly kill cells already infected by a pathogen
• Use cytokines as messenger molecules to send chemical instructions to the rest of the immune system to ramp up response.

🎯 Immunological memory

• Adaptive immunity creates memory cells for each specific pathogen.
• Provides long-term protection from reinfection with that pathogen.
• On reexposure, memory cells facilitate an efficient and quick immune response.
• Example: After recovering from chicken pox, the body develops memory of the varicella-zoster virus that specifically protects against reinfection.
• Vaccines are administered to enhance specific adaptive immunity by creating this memory without causing disease.

🔄 Cooperation between innate and adaptive immunity

Defense Type	Timing	Specificity	Memory	Key Components
Nonspecific innate immunity	Immediate	Broad-spectrum	None	Physical barriers, normal flora, chemical mediators, inflammation, fever
Specific adaptive immunity	Delayed (days)	Pathogen-specific	Yes (memory cells)	B cells (antibodies), T cells

How they work together:

• Innate immunity provides immediate defense while adaptive immunity develops.
• When a pathogen enters the body (e.g., through the nose), innate defenses respond first.
• If innate defenses are insufficient, adaptive immunity is activated.
• Adaptive immunity creates targeted, long-lasting protection through memory cells.

🧭 Overview

🧠 One-sentence thesis

Nurses must systematically assess clients for infection risk and signs of sepsis, implement evidence-based interventions including aseptic technique and monitoring, and evaluate outcomes to prevent healthcare-associated infections and life-threatening complications.

📌 Key points (3–5)

• White blood cell differential interpretation: Different WBC types respond to different threats—neutrophils fight bacteria, eosinophils respond to parasites/allergies, lymphocytes produce antibodies and attack infected cells, and monocytes handle chronic infections.
• Inflammation markers: ESR and CRP are nonspecific tests that indicate inflammation presence but don't diagnose the specific cause; CRP rises within hours and can increase a thousand-fold with severe bacterial infection.
• Sepsis recognition is time-critical: Lactate levels and blood cultures help diagnose sepsis early; nurses must draw blood cultures before administering antibiotics to avoid false results and ensure proper treatment.
• Common confusion—timing matters: Blood cultures must be drawn before antibiotics are given, and peak/trough levels affect when antibiotics can be administered.
• Risk-based nursing diagnoses: "Risk for Infection" applies to vulnerable clients (e.g., impaired skin integrity), while "Risk for Shock" applies to clients with existing infections who may develop sepsis.

🔬 Diagnostic tests for infection

🩸 White blood cell differential

A differential count breaks down the types of white blood cells to help identify the nature of an infection.

Key cell types and their roles:

WBC Type	Primary Function	What elevation suggests
Neutrophils	Engulf and destroy bacteria/fungi at infection sites	Bacterial infection (neutrophilia); severe infection can deplete them
Eosinophils	Respond to parasites, allergic reactions, control inflammation	Parasitic infections or allergic responses (eosinophilia)
Basophils	Involved in allergic reactions	Allergic processes
Lymphocytes (B cells, T cells, NK cells)	Produce antibodies, distinguish self/non-self, attack infected/cancer cells	Acute viral infections (lymphocytosis)
Monocytes	Engulf bacteria, tissue repair, immune functions	Chronic rather than acute infections

Interpretation caution:

• Context matters: a severe infection like sepsis can use up available neutrophils, causing a falsely low count.
• Providers consider signs, symptoms, and medical history—not just numbers.

🧪 Inflammation markers

🔴 ESR (Erythrocyte Sedimentation Rate)

An indirect measure of inflammation based on how quickly red blood cells settle in a test tube.

• Red cells settle faster when inflammatory proteins (like CRP) are elevated.
• Nonspecific: indicates inflammation is present but doesn't identify the cause or location.

🔥 CRP (C-Reactive Protein)

A sensitive acute phase reactant released within hours of infection or inflammation onset.

• Can increase up to a thousand-fold with severe bacterial infection.
• Rise may precede fever or pain symptoms.
• More sensitive than ESR for detecting early inflammation.

🩺 Lactate and sepsis detection

💉 Serum lactate

Lactate accumulates when cells switch from aerobic to anaerobic metabolism due to insufficient oxygen.

Why it matters for sepsis:

• Normally lactate levels in blood are low.
• Excess production occurs when tissues don't receive enough oxygen (sepsis, shock, heart attack, respiratory distress).
• Lactate accumulates faster than the liver can break it down → lactic acidosis.
• Critical for early sepsis recognition because sepsis can quickly progress to septic shock and multi-organ failure.

🧫 Blood cultures and timing

Blood cultures identify bacteria (bacteremia), fungi, or viruses in the bloodstream.

Critical nursing considerations:

1. Timing is everything: When orders for both antibiotics and blood culture arrive, draw the blood culture first—antibiotics given beforehand will compromise results and harm the treatment plan.

2. Multiple samples: Often 3+ cultures from different veins are drawn because pathogens may only appear intermittently in blood.

3. Incubation time: Cultures are incubated for several days; some organisms grow slowly.

4. Positive results: When bacteria are found, susceptibility testing identifies which antibiotics will be most effective.

Example scenario: A client with suspected sepsis has new orders for vancomycin and blood cultures. The nurse must draw the blood cultures immediately and hold the antibiotic until after the draw is complete.

🎯 Other diagnostic tests

• Site-specific cultures: Nasal swab, nasopharyngeal swab, sputum culture, urine culture, wound culture.
• Imaging: Chest X-ray for suspected lower respiratory tract infection.
• Therapeutic drug monitoring: Peak and trough levels ensure antibiotic concentrations stay within therapeutic ranges; nurses must time administration accordingly.

🩺 Nursing diagnoses for infection

🎯 Risk for Infection

Susceptibility to invasion and multiplication of pathogenic organisms.

Risk factors from the excerpt:

• Impaired skin integrity
• Inadequate vaccination
• Malnutrition / Obesity
• Dysfunctional gastrointestinal motility
• Smoking
• Stasis of body fluid

Example PES statement: "Risk for Infection as evidenced by alteration in skin integrity and insufficient knowledge to avoid exposure to pathogens."

⚠️ Risk for Shock

Susceptibility to inadequate blood flow that may lead to life-threatening cellular dysfunction.

Risk factors:

• Deficient fluid volume
• Hypoxia
• Ineffective medication self-management
• Unstable blood pressure

Associated conditions:

• Infections
• SIRS (Systemic Inflammatory Response Syndrome)
• Sepsis

Example PES statement: "Risk for Shock as evidenced by the associated condition of infection."

Don't confuse: Risk diagnoses have no etiological factors because they reflect potential problems, not actual ones.

🎯 Outcomes and interventions

📋 SMART outcomes

Broad goal example: "The client will remain free from infection during their health care stay."

SMART outcome example: "The client will demonstrate how to perform dressing changes using aseptic technique prior to discharge from the hospital."

🛡️ Infection prevention interventions

Monitoring:

• Monitor preexisting conditions that increase infection risk
• Watch for early signs of localized/systemic infection
• Monitor WBC results
• Inspect skin and mucous membranes for redness, warmth, tenderness, drainage
• Obtain cultures as needed
• Monitor for malaise or decreased energy

Technique and precautions:

• Maintain aseptic technique during procedures
• Use sterile technique for invasive procedures or open wounds
• Use universal precautions with all clients
• Initiate transmission-based precautions when needed
• Screen visitors for communicable disease

Supportive care:

• Promote sufficient nutrition and fluid intake
• Encourage rest
• Ensure hygienic care (hand hygiene, daily bathing, oral care, perineal care)
• Moisturize dry skin to keep it intact
• Prevent respiratory infection: incentive spirometry, coughing/deep breathing, position changes, early ambulation
• Prevent wound infection: change saturated dressings to reduce bacterial reservoirs

Education:

• Teach signs/symptoms of infection and when to report them
• Teach importance of nutrition, exercise, adequate rest
• Encourage up-to-date vaccinations
• Encourage smoking cessation (smoking damages the mucociliary escalator)

Special populations:

• Suspect infection in older adults with new lethargy or confusion

🌡️ Hyperthermia interventions

For clients with fever:

• Assess for diaphoresis, shaking chills (rigors)
• Monitor level of consciousness
• Adjust room temperature without inducing chilling
• Administer antipyretics (acetaminophen, ibuprofen) as appropriate
• Apply external cooling methods as needed (cold packs, cool sponge bath)
• Encourage fluid intake
• Monitor for dehydration

🚨 Implementing care for active infection

💊 Medication management

• Administer antibiotics/antimicrobials as prescribed
• Instruct clients to complete the full course even if they feel better (prevents antibiotic resistance)
• Monitor culture results and report to provider to ensure prescribed therapy matches susceptibility results

🔍 SIRS/sepsis monitoring

Immediately notify provider for 2+ of these SIRS indicators:

• Heart rate >90 bpm
• Temperature >38°C or <36°C
• Systolic BP <90 mm Hg
• Respiratory rate >20
• WBC >12,000 or <4,000

When SIRS is suspected:

• Anticipate orders for lactate level and blood cultures for early sepsis diagnosis

Additional monitoring:

• Watch for new decreased mental status (especially in older adults)—indicates decreased oxygenation or tissue perfusion
• For early shock signs: administer oxygen immediately to maintain O₂ sat >90%
• Administer prescribed antibiotics within one hour of diagnosis for improved survival
• Be prepared for IV fluids and vasopressor medications to treat shock

Don't confuse: SIRS indicators with normal variation—two or more abnormal values together signal a systemic problem requiring immediate action.

📊 Evaluation

✅ Effectiveness assessment

• Determine whether established outcomes have been met
• Assess if planned interventions are still appropriate at the time of implementation
• If outcomes are not met, add or revise interventions to help the client meet goals

Example from case study:

• Diagnosis: Ineffective Airway Clearance related to excessive mucus
• Outcome: Client will effectively clear secretions throughout hospitalization
• Evaluation: Client maintained patent airway and effectively cleared secretions → outcome "met"

---

Key takeaway for nursing practice: Infection management requires vigilant assessment, timely diagnostic testing with proper sequencing (cultures before antibiotics), early recognition of sepsis warning signs, and systematic evaluation of intervention effectiveness.