Fundamentals of Nursing

Fundamentals of Nursing is the body of knowledge and skill that underlies all nursing practice. This article covers the nursing process, basic care and comfort, and the safety principles that govern them. It is written for students preparing for the NCLEX-RN and NCLEX-PN examinations and for nurses reviewing core practice.

The nursing process

The nursing process is a five step, cyclical problem solving framework. It is the organizing structure for nursing care plans, for clinical documentation, and for the majority of licensure examination items. The steps are assessment, diagnosis (analysis), planning, implementation, and evaluation, commonly memorized as ADPIE.

Assessment

Assessment is the systematic, deliberate collection of data about the patient. It always comes first. When an examination item offers a plausible intervention and a plausible assessment, choose assessment unless the situation is an emergency with an obvious required action, such as an unwitnessed collapse or an airway obstruction.

• Subjective data are what the patient reports: pain, nausea, dizziness, fatigue, fear. Pain is always subjective and the patient's self-report is the single most reliable indicator.
• Objective data are what the nurse observes or measures: vital signs, wound appearance, gait, laboratory values, intake and output.
• Primary source is the patient. Secondary sources include family, the medical record, and other members of the health care team.
• Types of assessment include the comprehensive admission assessment, the focused assessment of a specific problem or body system, the ongoing or shift assessment, and the emergency assessment.

Techniques of physical assessment are inspection, palpation, percussion, and auscultation, performed in that order for every region except the abdomen. For the abdomen, auscultate before palpating, because palpation alters bowel sounds.

Scope note: in the registered nurse role, assessment means the comprehensive evaluation and the clinical interpretation of findings. The licensed practical nurse performs focused data collection, contributes findings to the assessment, and reports changes to the registered nurse. The initial and comprehensive assessment is a registered nurse responsibility and cannot be delegated.

Diagnosis and analysis

The nursing diagnosis is a clinical judgment about a human response to an actual or potential health problem that nurses are licensed and competent to treat independently. It differs from a medical diagnosis, which names a disease. A patient may carry the medical diagnosis of stroke and the nursing diagnoses of impaired physical mobility, impaired swallowing, and risk for aspiration.

Standard structures include:

• Actual problem (three part, PES): problem, related to etiology, as evidenced by signs and symptoms. Example: impaired skin integrity related to prolonged pressure over the sacrum as evidenced by a 2 cm stage 2 sacral pressure injury.
• Risk problem (two part): the risk label plus risk factors. Risk diagnoses have no signs and symptoms yet, because the problem has not occurred. Example: risk for falls as evidenced by unsteady gait, sedating medication, and history of two falls in six months.
• Health promotion diagnosis: a readiness for enhanced response in a patient who wishes to improve.

The etiology must be something nursing can address. Writing "related to congestive heart failure" is not useful, because a nurse cannot independently treat heart failure. "Related to decreased cardiac output and activity intolerance" points toward nursing action.

Planning

Planning sets priorities and writes measurable, patient centered outcomes.

Priority setting frameworks:

• Airway, breathing, circulation. Airway first, always. A patient who cannot maintain an airway outranks a patient who is hemorrhaging, who outranks a patient in pain.
• Maslow's hierarchy. Physiologic needs before safety, safety before love and belonging, then esteem, then self actualization. Use this when no ABC problem is present.
• Acute before chronic, unstable before stable, unexpected before expected. New onset confusion in an older adult is a priority. Chronic stable joint pain is not.
• Safety and risk of harm. A problem that will cause imminent injury outranks one that will not.

Outcome statements should be specific, measurable, attainable, realistic, and time limited. They describe the patient's behavior, not the nurse's action. "The patient will ambulate 50 feet with a walker and standby assistance by postoperative day two" is an outcome. "The nurse will ambulate the patient" is an intervention.

Care plan development, revision, and evaluation are registered nurse responsibilities. Licensed practical nurses contribute to and carry out the plan.

Implementation

Implementation is the performance of nursing interventions. Interventions are independent (nurse initiated, such as repositioning, teaching, or elevating an extremity), dependent (requiring a provider order, such as administering a medication), or collaborative or interdependent (carried out with other disciplines, such as a physical therapy mobility program).

Before any intervention, verify the patient with two identifiers, perform hand hygiene, explain the procedure, and provide privacy. After any intervention, document what was done, the patient's response, and any follow up needed.

Evaluation

Evaluation compares the patient's actual response with the expected outcome and determines whether the outcome was met, partially met, or not met. If the outcome is not met, the nurse reassesses, revises the diagnosis or the plan, and continues the cycle. Evaluation is a registered nurse responsibility.

Activities of daily living

Activities of daily living (ADLs) are the basic self care tasks: bathing, dressing, toileting, transferring, continence, and feeding. Instrumental activities of daily living (IADLs) are the more complex tasks required for independent community living: managing money, managing medications, using the telephone, shopping, preparing meals, housekeeping, laundry, and arranging transportation.

The distinction matters for discharge planning. A patient who is independent in ADLs but cannot manage medications or transportation is not safe to go home alone without support. Standardized tools include the Katz Index of Independence in Activities of Daily Living and the Lawton Instrumental Activities of Daily Living Scale.

Levels of assistance commonly documented: independent, setup or supervision, standby assist, minimal assist (patient performs about 75 percent), moderate assist (about 50 percent), maximal assist (about 25 percent), and total or dependent care.

Nursing application: promote the highest level of independence the patient can safely achieve. Doing a task for a patient who can do it slowly is faster for the nurse and harmful for the patient. Allow extra time, break tasks into steps, place items within reach on the patient's stronger side, and use adaptive equipment such as long handled reachers, sock aids, built up utensils, and elastic shoelaces.

Mobility, positioning, and safe patient handling

Hazards of immobility

Immobility harms every body system, and most complications are preventable by nursing action.

• Musculoskeletal: muscle atrophy, contractures, foot drop, disuse osteoporosis with hypercalcemia.
• Cardiovascular: orthostatic hypotension, increased cardiac workload, venous stasis and venous thromboembolism.
• Respiratory: decreased chest expansion, pooled secretions, atelectasis, hypostatic pneumonia.
• Integumentary: pressure injury.
• Gastrointestinal: decreased peristalsis, constipation, and fecal impaction.
• Genitourinary: urinary stasis, renal calculi, urinary tract infection.
• Psychosocial: depression, disorientation, sleep disturbance, learned helplessness.

Preventive nursing interventions: reposition on a schedule, range of motion exercises, early and frequent ambulation, incentive spirometry with deep breathing and coughing every one to two hours while awake, adequate fluid and fiber, sequential compression devices and prescribed anticoagulants, and a high protein diet to support tissue integrity.

Positions

• Supine (dorsal recumbent): flat on the back. Support the lumbar curve, place a small pillow under the head, and use a trochanter roll along the outer thigh to prevent external hip rotation. Foot supports prevent foot drop.
• Prone: on the abdomen, head turned to the side. Promotes hip extension. Poorly tolerated by patients with cardiac or respiratory compromise.
• Lateral (side lying): pillow between the knees and supporting the upper arm to prevent internal rotation and adduction.
• Sims: semiprone left side lying with the upper leg flexed. The position of choice for enema administration and rectal suppository insertion because it follows the natural curve of the sigmoid colon.
• Fowler variations: low or semi Fowler at 30 to 45 degrees, Fowler at 45 to 60 degrees, high Fowler at 60 to 90 degrees. High Fowler maximizes lung expansion and is used for dyspnea and for feeding.
• Trendelenburg: head lower than feet. Rarely used and contraindicated with increased intracranial pressure.
• Modified Trendelenburg: flat with legs elevated, sometimes used for hypotension or shock.
• Orthopneic: sitting up, leaning forward over a bedside table. Relieves severe dyspnea by allowing maximal chest expansion.

Position specific safety notes: elevate the head of the bed to at least 30 degrees for any patient receiving enteral feeding and keep it elevated for 30 to 60 minutes afterward to prevent aspiration. For pressure redistribution, however, avoid sustained head elevation above 30 degrees, because higher angles increase shear at the sacrum. Reposition patients in bed at least every two hours and patients sitting in a chair at least every hour, or teach chair bound patients to shift weight every 15 minutes.

Pressure injury prevention

Risk is assessed with the Braden Scale, which scores six subscales (sensory perception, moisture, activity, mobility, nutrition, and friction and shear). Lower scores mean higher risk, and a score of 18 or less generally indicates risk in adults.

Staging in brief:

• Stage 1: intact skin with nonblanchable erythema.
• Stage 2: partial thickness loss of dermis, shallow open ulcer or intact or ruptured serum filled blister. No slough or eschar.
• Stage 3: full thickness loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.
• Stage 4: full thickness loss with exposed bone, tendon, or muscle.
• Unstageable: the base is obscured by slough or eschar, so depth cannot be determined.
• Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration, or a blood filled blister, over intact or nonintact skin.

Prevention: repositioning schedule, pressure redistribution surfaces, heel offloading with pillows under the calves so the heels float, keeping skin clean and dry, moisture barrier products, adequate protein and calorie intake, and avoiding massage over bony prominences or reddened areas. Do not use donut or ring cushions, which concentrate pressure at the rim.

Ambulation and assistive devices

• Use a gait belt for any patient at risk of falling. Grasp the belt from underneath, keep the patient close to your center of gravity, and walk slightly behind and to the weaker side.
• Cane: hold on the strong or unaffected side. Advance the cane and the weak leg together, then step with the strong leg.
• Walker: a standard walker is lifted and set down about one step ahead, then the patient steps into it. The patient should not lean over the walker or pull up on it to stand.
• Crutches: the axillary pad should sit two to three finger widths below the axilla, and weight is borne on the hands, not the axillae, to prevent brachial plexus injury. A three point gait is used when one leg cannot bear weight.
• Stairs: the strong leg goes up first and the weak leg goes down first. A common memory aid is "up with the good, down with the bad."
• Transfers: move the patient toward the stronger side, lock the wheels, lower the bed, position the chair at a slight angle, and dangle the patient at the bedside first to check for orthostatic symptoms.

Body mechanics and safe handling

Widen the base of support, bend at the knees and hips rather than the waist, keep the load close to the body, avoid twisting by pivoting the feet, push rather than pull when possible, and raise the bed to waist height. Use mechanical lifts and additional staff for dependent patients. Injury prevention for the nurse is a patient safety issue as well, because a nurse who drops a patient causes harm.

Range of motion

Active range of motion is performed by the patient and maintains strength and joint flexibility. Active assistive range of motion is performed with partial help. Passive range of motion is performed by the nurse for a patient who cannot move the joint, and it maintains flexibility but does not build strength. Move joints slowly and smoothly to the point of resistance, never to the point of pain, support the joint above and below, and perform each movement approximately five times, generally two to three times daily.

Hygiene and personal care

Hygiene meets a physiologic need and, equally, a psychological one. Loss of the ability to bathe and groom independently is one of the most common sources of shame in hospitalized patients. Provide privacy, keep the patient covered except for the area being washed, and ask about personal and cultural preferences.

Bathing

• Test water temperature; approximately 43 to 46 degrees Celsius (110 to 115 degrees Fahrenheit) is a typical range for bathing, and it should always be verified against the patient's own tolerance. Older adults and patients with neuropathy or diabetes have reduced thermal sensation and are at high risk for burns.
• Wash from clean to dirty and from head to toe, saving the perineum for last.
• Eyes: wash from the inner canthus to the outer canthus using a separate portion of the washcloth for each eye, to avoid transferring organisms into the lacrimal duct or between eyes.
• Perineal care: clean from front to back. For an uncircumcised male, retract the foreskin, clean, and always return it to its natural position to prevent paraphimosis.
• Use gentle patting to dry, especially in skin folds and between the toes. Apply moisturizer to dry skin but not between the toes.
• Raise the side rails when leaving the bedside, and never leave a weak patient unattended in a tub or shower.

Oral care

Brush teeth twice daily and floss daily. For a patient who is unconscious or has an impaired gag reflex, place the patient in a side lying position with the head turned to the side, use minimal fluid, keep suction immediately available, and never place fingers in the mouth without a bite block. Dentures are removed, cleaned over a basin lined with a washcloth or filled with water to cushion a drop, and stored in a labeled container with water or denture solution. Avoid lemon glycerin swabs and alcohol based mouthwash, which dry and irritate the mucosa.

Foot and nail care

For a patient with diabetes or peripheral vascular disease: inspect the feet daily including between the toes and the soles, wash with lukewarm water and mild soap, dry thoroughly between the toes, do not soak the feet, do not use heating pads or hot water bottles, cut toenails straight across only if permitted by policy, and refer thickened nails, calluses, and corns to a podiatrist. Never allow the patient to walk barefoot. In many facilities nail trimming for patients with diabetes requires a provider order or podiatry referral.

Hair, shaving, and eyes

Shampooing may be done with a basin, an inflatable trough, or a no rinse cap. Use an electric razor for any patient with a bleeding risk, including patients on anticoagulants or with a low platelet count. For an unconscious patient, instill artificial tears as prescribed and consider protective shields, because the blink reflex may be absent and corneal drying can occur.

Elimination

Urinary elimination

Average adult urine output is roughly 1,500 mL per day. A minimum acceptable output is about 30 mL per hour, or 0.5 mL per kilogram per hour. Output below that threshold, sustained, must be reported.

Terms: dysuria (painful voiding), oliguria (diminished output), anuria (essentially absent output), nocturia (voiding at night), polyuria (excessive output), urinary frequency, urgency, hesitancy, and retention. Incontinence types include stress, urge, overflow, functional, and reflex.

Interventions: offer toileting on a schedule, provide privacy and unhurried time, position the patient as normally as possible (women sitting, men standing when able), run water or pour warm water over the perineum to stimulate voiding, ensure adequate fluid intake unless restricted, and perform bladder scanning for suspected retention rather than immediately catheterizing.

Catheter care and infection prevention: insert only when clearly indicated and remove at the earliest opportunity, since duration of catheterization is the single largest risk factor for catheter associated urinary tract infection. Insert using sterile technique, maintain a closed drainage system, secure the tubing to the thigh or abdomen to prevent traction, keep the collection bag below the level of the bladder at all times and off the floor, keep tubing free of dependent loops and kinks, perform routine perineal care with soap and water, and empty the bag with a separate clean container for each patient. Do not routinely irrigate. Do not disconnect the system to obtain a specimen; use the sampling port.

Bowel elimination

Normal frequency varies widely, from three times daily to three times weekly. Any change from the patient's own baseline is more meaningful than the absolute number.

• Constipation: hard, dry, difficult stool. Interventions include increased fluid, dietary fiber, activity, a regular toileting routine that takes advantage of the gastrocolic reflex after meals, and prescribed stool softeners or laxatives.
• Fecal impaction: a hardened mass in the rectum. A classic and easily missed sign is the passage of liquid stool around the impaction, which can be mistaken for diarrhea. Digital removal may be prescribed but carries a risk of vagal stimulation and bradycardia.
• Diarrhea: risks are dehydration, electrolyte loss, and perineal skin breakdown. Assess for infection, including Clostridioides difficile.
• Flatulence and distention: ambulation and left side lying may help.

Enema administration: place the patient in the left lateral Sims position, lubricate the tip, insert about 7.5 to 10 cm (3 to 4 inches) in an adult, directing the tip toward the umbilicus, and instill slowly. Solution containers for a cleansing enema are typically held about 30 to 45 cm (12 to 18 inches) above the anus; the higher the container, the faster and more forceful the flow. Stop and reassess if the patient reports cramping, dizziness, or palpitations. Never force the tubing against resistance.

Ostomy care: assess the stoma, which should be pink to red, moist, and slightly raised. A dusky, purple, or black stoma indicates compromised circulation and is an emergency to report. The peristomal skin should be intact. Cut the barrier opening no more than about one eighth inch larger than the stoma, empty the pouch when it is one third to one half full, and expect an ileostomy to drain liquid to pasty stool continuously while a descending or sigmoid colostomy produces more formed stool. Ileostomy patients are at particular risk for dehydration and electrolyte imbalance.

Rest and sleep

Sleep alternates between non rapid eye movement sleep (stages N1, N2, and N3) and rapid eye movement sleep, in cycles of roughly 90 minutes. N3 is deep, restorative slow wave sleep, greatest in the first half of the night, and it is when growth hormone is released and tissue repair is most active. Rapid eye movement sleep, greatest in the second half of the night, supports memory consolidation and is when most vivid dreaming occurs.

Age variation: newborns sleep 14 to 17 hours; school age children about 9 to 11 hours; adults 7 to 9 hours. Older adults need a similar total but obtain less N3 sleep, wake more often, and shift toward earlier sleep and wake times. Reduced deep sleep in older adults is a normal aging change, not automatically a disorder.

Common disorders: insomnia, obstructive sleep apnea, narcolepsy, restless legs syndrome, and circadian rhythm disruption from shift work or hospitalization.

Nursing interventions: cluster care to allow uninterrupted blocks of at least 90 minutes, dim lights and reduce noise and alarms at night, maintain a consistent schedule, encourage daytime light exposure and activity, limit daytime napping to short early afternoon naps, avoid caffeine for at least four to six hours before bed, avoid heavy meals and vigorous exercise close to bedtime, and reserve the bed for sleep. Teach that alcohol may shorten sleep onset but fragments sleep and suppresses rapid eye movement sleep later in the night. Sedative hypnotics are a short term measure and increase fall and confusion risk, especially in older adults.

Pain management

Pain is whatever the experiencing person says it is, existing whenever the person says it does. Self report is the gold standard. Vital signs may rise with acute pain but often normalize in chronic pain, so normal vital signs never disprove pain.

Classification:

• Acute pain has an identifiable cause and an expected resolution. Chronic or persistent pain continues beyond expected healing, generally longer than three months.
• Nociceptive pain arises from tissue damage and is somatic (sharp, well localized) or visceral (dull, cramping, poorly localized, often referred).
• Neuropathic pain arises from nerve damage and is described as burning, shooting, electric, or tingling. It responds better to adjuvants such as gabapentinoids and certain antidepressants than to opioids alone.
• Breakthrough pain is a transient flare over controlled baseline pain.
• Phantom limb pain is real neuropathic pain after amputation and must never be dismissed.

Assessment mnemonics: PQRST (provocation and palliation, quality, region and radiation, severity, timing) and OLDCART (onset, location, duration, characteristics, aggravating factors, relieving factors, treatment). Scales must match the patient: the 0 to 10 numeric rating scale for most adults, the Wong Baker FACES scale for children roughly three years and older, FLACC (face, legs, activity, cry, consolability) for infants and nonverbal children, and PAINAD or the Critical Care Pain Observation Tool for adults who cannot self report, such as those with advanced dementia or on mechanical ventilation.

Nonpharmacologic interventions: repositioning and splinting, heat for muscle spasm and stiffness, cold for acute injury, inflammation, and swelling, massage, distraction, guided imagery, relaxation breathing, music, and transcutaneous electrical nerve stimulation. Apply heat or cold with a barrier, limit application to roughly 15 to 20 minutes, and check the skin frequently, particularly in patients with impaired sensation.

Pharmacologic principles: use the least invasive effective route, dose around the clock rather than as needed for continuous pain, and medicate before pain becomes severe and before painful activities such as dressing changes or ambulation. For patient controlled analgesia, only the patient presses the button. Family members and staff must never press it for the patient, because the patient's own sedation is the built in safety mechanism.

Opioid adverse effects: constipation is the one effect to which tolerance does not develop, so start a bowel regimen with the opioid. Sedation reliably precedes respiratory depression, so a rising sedation score is the earliest and most useful warning sign. Naloxone reverses opioid induced respiratory depression, and the patient must be monitored afterward because naloxone has a shorter duration of action than many opioids. Pruritus, nausea, and urinary retention are also common. Physical dependence and tolerance are expected physiologic responses and are not the same as addiction.

Vital signs

Typical adult reference ranges:

• Temperature: about 36.5 to 37.5 degrees Celsius (97.7 to 99.5 degrees Fahrenheit) orally.
• Pulse: 60 to 100 beats per minute.
• Respirations: 12 to 20 breaths per minute.
• Blood pressure: normal is a systolic below 120 and a diastolic below 80 millimeters of mercury. Elevated is systolic 120 to 129 with diastolic below 80; stage 1 hypertension is 130 to 139 systolic or 80 to 89 diastolic; stage 2 is 140 or higher systolic or 90 or higher diastolic.
• Oxygen saturation: generally 95 to 100 percent on room air. Patients with chronic carbon dioxide retention may have an individualized lower target, often around 88 to 92 percent.
• Pain: documented as the fifth vital sign in many settings, though it is a symptom rather than a physiologic measurement.

Measurement technique:

• Temperature routes. Rectal readings approximate core temperature most closely but are contraindicated with rectal surgery, diarrhea, neutropenia, and clotting disorders. Wait 15 to 30 minutes after hot or cold liquids, smoking, or chewing gum before an oral reading. Tympanic and temporal artery readings are fast but technique dependent. Axillary readings are the least accurate. Document the route, because the route changes the interpretation.
• Pulse. The apical pulse is auscultated at the fifth intercostal space at the left midclavicular line. Count for a full minute if the rhythm is irregular or the patient is an infant. Assess the apical pulse for one full minute before giving digoxin and hold the dose for an adult apical rate below 60. A pulse deficit is the difference between simultaneously counted apical and radial rates and indicates ineffective contractions.
• Respirations. Count without telling the patient, ideally while appearing to take the pulse, because awareness alters the pattern.
• Blood pressure. The cuff bladder width should be about 40 percent of the arm circumference and the length about 80 percent. A cuff that is too narrow or applied over clothing gives a falsely high reading; a cuff that is too wide gives a falsely low reading. Support the arm at heart level; an arm below heart level reads falsely high. Avoid the arm with a dialysis access, mastectomy with lymph node dissection, intravenous infusion, or injury.
• Orthostatic vital signs. Measure supine, then sitting, then standing, waiting one to three minutes between positions. A drop of 20 millimeters of mercury or more in systolic pressure, or 10 or more in diastolic pressure, or symptoms of dizziness, is a positive finding and a fall risk.

Interpretation notes: fever raises the pulse and respiratory rate. A widening pulse pressure with bradycardia and irregular respirations suggests rising intracranial pressure and is an emergency. Pulse oximetry is unreliable with poor perfusion, hypothermia, vasoconstriction, motion, nail polish, and carbon monoxide poisoning, where the reading can be falsely normal. Always compare to the patient's own baseline and treat the patient, not the number.

Safety and infection prevention in basic care

Falls. Screen every patient with a validated tool such as the Morse Fall Scale or the Hendrich II Fall Risk Model. Interventions include the bed in the lowest position with wheels locked, the call light and personal items within reach, nonskid footwear, adequate lighting including night lighting, prompt response to call lights, hourly rounding addressing the four Ps (pain, position, personal needs or potty, and possessions), and toileting on a schedule for high risk patients. Four raised side rails are considered a restraint. If a patient begins to fall while you are assisting, do not try to hold them upright. Ease the patient to the floor while protecting the head, staying with the patient, and calling for help. After any fall, assess before moving the patient, notify the provider, complete an incident report, and document the objective findings in the medical record without referencing the incident report.

Restraints. Restraints are a last resort after less restrictive alternatives have failed. They require a provider order that specifies the type, the reason, and the duration, and they may never be ordered as needed. For nonviolent, nonbehavioral use, the order is generally renewed every 24 hours. For violent or self destructive behavior, orders are limited to 4 hours for adults, 2 hours for ages 9 to 17, and 1 hour for children under 9, with a face to face evaluation within 1 hour. Apply the least restrictive device, secure ties to the movable bed frame and never to the side rails, use a quick release knot, and assess circulation, sensation, motion, and skin every 15 to 30 minutes per policy, with release for range of motion, repositioning, toileting, and fluids at least every 2 hours.

Infection prevention. Hand hygiene is the single most effective measure. Use soap and water when hands are visibly soiled, after using the restroom, and when caring for a patient with Clostridioides difficile or another spore forming organism, because alcohol based rubs do not kill spores. Follow standard precautions for every patient, and add contact, droplet, or airborne precautions as indicated. Airborne precautions require an N95 or higher respirator and a negative pressure room. Maintain surgical asepsis for sterile procedures: keep sterile items above waist level and within sight, consider a one inch border of the sterile field contaminated, do not turn your back on the field, and treat any wet field as contaminated.

Aspiration prevention. Sit the patient fully upright for meals, allow rest before eating, avoid rushing, use small bites and a chin tuck when swallowing if recommended, avoid straws for patients with dysphagia unless specified, check for pocketing of food in the cheeks, and keep the patient upright for at least 30 to 60 minutes after eating. Refer any patient with coughing, choking, a wet or gurgly voice, or drooling to a swallowing evaluation.

Nutrition and hydration in basic care

Assess the patient's ability to feed themselves, dentition, appetite, cultural and religious preferences, and any therapeutic diet. Place the tray within reach, open packages, describe the tray as clock positions for a patient with visual impairment, and provide adaptive utensils as needed. Never rush feeding, and never blow on food. Monitor and record intake and output accurately, counting all fluids at room temperature including gelatin, ice cream, and ice chips (recorded as approximately half the volume of the melted ice). Signs of dehydration include dry mucous membranes, concentrated urine, poor skin turgor (assessed over the sternum or forehead in older adults, since hand turgor is unreliable with age), tachycardia, and orthostatic hypotension.

Documentation and communication

Document objectively, accurately, completely, and promptly. Chart what was observed and done, not conclusions or opinions about the patient. Never chart in advance. Correct an error by drawing a single line through it, writing the correction with your initials and the date, and never obliterating the original entry. Late entries are labeled as such.

Use SBAR (situation, background, assessment, recommendation) for handoff and for provider notification. A structured handoff at change of shift and at transfer reduces error, and the receiving nurse should have an opportunity to ask questions.

Report immediately to the provider or the charge nurse: a significant change from baseline, new or worsening pain, a fall, a medication error, unexpected bleeding, oxygen saturation below the ordered parameter, new confusion, chest pain, and urine output below the ordered minimum.

Delegation and scope of practice

The five rights of delegation are the right task, the right circumstance, the right person, the right direction and communication, and the right supervision and evaluation.

The registered nurse may not delegate assessment, nursing diagnosis, care plan development, evaluation of outcomes, initial patient teaching, or the care of an unstable patient. The registered nurse retains accountability for the outcome of any delegated task.

Licensed practical or vocational nurses generally may perform focused data collection, administer most medications within state scope, perform sterile dressing changes, insert catheters, provide tracheostomy and ostomy care, reinforce teaching already initiated by the registered nurse, and monitor stable patients with predictable outcomes. They report findings and any change in condition to the registered nurse. Specific scope varies by state and by facility policy, and the nurse is responsible for knowing the applicable nurse practice act.

Assistive personnel may perform standard, unchanging tasks with predictable outcomes: bathing, feeding a patient without swallowing difficulty, oral care, ambulating a stable patient, transferring, positioning, toileting, making beds, measuring and recording vital signs and intake and output on stable patients, and applying compression devices. They may not assess, teach, evaluate, or perform any task requiring nursing judgment, and any abnormal value they report must be verified by the nurse.

High yield points for the licensure examination

• Assess before you act, unless the situation is an emergency requiring immediate intervention.
• Airway, breathing, and circulation outrank everything else. Then use Maslow, then safety, then acute before chronic.
• The patient's self report is the most reliable indicator of pain.
• Sedation precedes respiratory depression in opioid therapy.
• Reposition at least every 2 hours in bed and every 1 hour in a chair, and never massage a reddened bony prominence.
• Keep the head of the bed elevated at least 30 degrees during and after enteral feeding.
• Keep the urinary drainage bag below the bladder and off the floor, and remove the catheter as early as possible.
• The cane goes on the strong side; the strong leg goes up the stairs first.
• Wash from clean to dirty and from the inner to the outer canthus of the eye.
• Use soap and water, not alcohol rub, for Clostridioides difficile.
• Only the patient presses the patient controlled analgesia button.
• Four raised side rails constitute a restraint.
• Compare every finding to the patient's own baseline.

This page is independent study material for nursing licensure exam preparation. NCLEX-RN® and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing (NCSBN). This content is not produced, reviewed, or endorsed by NCSBN. Always verify clinical information against current facility policy, drug references, and your nursing program's curriculum before applying it in practice.