Nursing: Patient Care & Clinical Procedures

Core PT assessment begins w/ systematic head-to-toe eval. VS monitoring (HR, BP, RR, SpO2, Temp) forms baseline for all clinical decisions. ABN findings must be documented & escalated per facility PRO.

ADL assistance requires balancing PT autonomy w/ safety. Fall risk scoring (Morse scale) determines intervention level. High-risk PTs need bed alarm, non-slip footwear, & hourly rounding. Document all interventions in EHR w/ time stamps.

MED admin follows the 7 Rights: right PT, right MED, right dose, right route, right time, right reason, right documentation. Before any MED admin, verify allergies, check interactions via PHARM database, & confirm IDN w/ 2 identifiers (name + DOB). High-alert MEDs (insulin, heparin, opioids) require independent double-check by 2nd RN.

IV therapy management: assess site Q2H for signs of infiltration (swelling, coolness, pallor) or phlebitis (redness, warmth, cord-like vein). PIV replacement per facility PRO, typically Q72-96H. Central line care requires strict ASEP technique — CHG dressing changes Q7D or when soiled. Always scrub the hub 15sec before access.

Pain assessment uses validated tools: NRS (0-10) for verbal PTs, FLACC for pediatric/nonverbal, PAINAD for dementia PTs. Reassess pain 30min after IV MED, 60min after PO MED. Document response & notify HCP if pain uncontrolled. Non-PHARM interventions (repositioning, ice/heat, distraction, guided imagery) should complement MED mgmt.

Wound care follows TIME framework: Tissue assessment, Infection/inflammation control, Moisture balance, Edge advancement. Clean wounds w/ NS irrigation, debride necrotic tissue per scope of practice. Stage pressure injuries using NPUAP classification (Stage 1-4, unstageable, deep tissue injury). Reposition Q2H, use pressure-redistribution surfaces for at-risk PTs.

CARD monitoring: interpret basic rhythms — NSR, sinus TACHY/BRADY, AFIB, AFLUT, PVCs, VTACH, VFIB. Know ACLS algorithms for pulseless arrest (CPR, defib, epi Q3-5min). Recognize STEMI criteria on 12-lead ECG & activate cath lab protocol. Monitor troponin trends for ACS evaluation.

RESP care: assess breath sounds bilaterally (crackles=fluid, wheezing=bronchospasm, diminished=atelectasis/effusion). Incentive spirometry Q1H while awake post-op. Suction PRN for PTs w/ artificial airway — pre-oxygenate w/ 100% FiO2, limit suction pass to 10-15sec. Ventilator PTs: monitor for VAP bundle compliance (HOB 30-45°, daily sedation vacation, DVT PROPH, stress ulcer PROPH, oral care Q4H w/ CHG).

DM management: monitor BGL per HCP order (typically AC & HS). Sliding scale insulin admin based on facility PRO. Recognize hypo symptoms (tremor, diaphoresis, confusion, BGL <70) — treat w/ 15g fast-acting carbs, recheck in 15min (Rule of 15). Hyperglycemia w/ ketones may indicate DKA — check ABG, electrolytes, start IVF resuscitation per protocol.

Sepsis screening: use qSOFA (altered mentation, RR≥22, SBP≤100) or facility-specific screening tool. Hour-1 bundle: lactate level, blood CX before ABX, broad-spectrum ABX, 30mL/kg crystalloid for hypotension, vasopressors if MAP<65 after fluid resuscitation. Time to ABX is critical — every hour delay increases mortality.

Handoff communication uses SBAR: Situation (why calling), Background (relevant HX), Assessment (your clinical judgment), Recommendation (what you need). Bedside shift report includes PT in conversation, verifies lines/drains/equipment, reviews safety measures. Critical lab values require read-back confirmation from HCP.

Cultural competency in PT care: use certified interpreters (not family) for LEP PTs. Assess health literacy using teach-back method. Respect dietary restrictions, spiritual practices, & modesty preferences. Document advance directives & ensure POLST/MOLST forms are accessible.

Infection prevention: standard precautions for ALL PTs (hand hygiene, PPE as indicated). Transmission-based precautions: contact (gown+gloves for MDRO, C.diff), droplet (mask for flu, pertussis), airborne (N95+negative pressure for TB, measles, varicella). Hand hygiene w/ ABHR except for C.diff (soap & water only — spores resist alcohol). Monitor HAI rates & participate in unit-based quality improvement.

Discharge planning starts at admission. Assess PT/family readiness, home environment, support systems. Coordinate w/ SW for community resources, PT/OT for functional goals, PHARM for MED reconciliation. Teach-back on discharge MEDs, warning signs, follow-up appointments. Ensure PT has transportation & can access prescribed MEDs.

Scope of practice varies by licensure: RN can assess, plan, delegate, administer IV MEDs, interpret data. LPN/LVN performs focused assessment, administers PO/IM/SQ MEDs under RN supervision. CNA performs VS, ADLs, I&O documentation under RN delegation. Always delegate appropriately — never delegate assessment, teaching, evaluation, or unstable PTs to unlicensed personnel.

Documentation principles: if it wasn't documented, it wasn't done. Chart objectively using measurable terms. Avoid subjective language (not 'PT seems fine' but 'PT alert, oriented x4, denies pain, VS WNL'). Late entries clearly marked as such. Never alter existing documentation — addend only. EHR downtime procedures must be practiced regularly.

Quality measures: track nurse-sensitive indicators (falls, CAUTI, CLABSI, HAPI, restraint use). Participate in root cause analysis for sentinel events. Engage in evidence-based practice — appraise research, implement findings, evaluate outcomes. Maintain competency through CEU requirements & skills validation.