name: Identify sexual behaviors that are unacceptable (e.g., makes inappropriate remarks in public places, says inappropriate things to people they know, makes unwanted advances to people they know or to strangers, kisses or hugs more than is appropriate, attempts to have sexual intercourse with others, masturbates in public) given the particular setting and patient population


name: Specify explicit expectations (based on developmental stage, level of cognitive functioning, and capacity for self-control) related to sexual behavior or verbalizations that might be directed toward others or objects in the environment


name: Provide parents information about age appropriate sexual behavior


name: Discuss with parents and children the importance of Internet safety and prevention of access to sexual material


name: Encourage parents to not punish or admonish the children for normative sexual behaviors


name: Instruct parents to use gentle distraction, such as asking the child to hold hands with them, to redirect the behavior


name: Discuss, based on the patient's developmental and cognitive ability, the negative effect that socially unacceptable sexual behavior may have on others, as appropriate


name: Avoid assigning roommates with communication difficulties, history of inappropriate sexual activity, or heightened vulnerabilities


name: Limit patient's physical mobility to decrease opportunity for socially unacceptable sexual behaviors, as needed


name: Provide appropriate level of supervision to monitor patient


name: Redirect from any socially unacceptable sexual behaviors or verbalizations


name: Discourage initiation of sexual or intimate relationships when under severe stress


name: Provide counseling for patient who has been sexually abused, as needed


name: Consider pharmacological treatment, as needed


name: Assist patient to identify strengths and reinforce these strengths


name: Ensure that the intervention is implemented consistently by all staff


name: Encourage the patient to participate in monitoring and recording behaviors


name: Discuss the behavior modification process with the patient and significant other(s)


name: Administer positive reinforcers on a predetermined schedule (continuous or intermittent) for desired behaviors


name: Withdraw positive reinforcers from undesired behaviors and attach reinforcers to a more desirable replacement behavior


name: Encourage the patient to participate in the selection of meaningful reinforcers


name: Determine changes in behavior by comparing baseline occurrences with postintervention occurrences of behavior


name: Document and communicate modification process to treatment team, as necessary


name: Consider using a standardized evidenced based interpersonal skills behavioral training program


name: Assist patient to identify possible courses of action and their social and interpersonal consequences


name: Identify specific social skills using guided discussion and examples that will be the focus of training


name: Assist patient to identify the behavioral steps for the targeted social skills


name: Provide models (e.g., role play, video presentation) demonstrating the behavioral steps in the context of situations that are meaningful to the patient


name: Provide feedback (e.g., praise or rewards) to patient about performance of targeted social skills


name: Identify the patient's emotional, cognitive, developmental, and situational needs


name: Determine ability for reading independently


name: Set therapy goals (e.g., emotional change; personality development; learn new values and attitudes)


name: Consult sources to recommend literature for therapy


name: Select stories, poems, essays, articles, self-help books, or novels that reflect the situation or feelings the patient is experiencing


name: Assist in helping the patient identify with the characters and emotional content in the literature


name: Examine and talk about the feelings expressed by the characters


name: Facilitate dialogue to help the patient compare and contrast the image, character, situation, or concept in the literature with his/her situation


name: Assist in helping the patient recognize how the situation in the literature can help with making desired changes


name: Interview patient to obtain a health history


name: Analyze nature of the specific health condition to be treated


name: Determine abilities and willingness for using the biobehavioral treatment


name: Discuss rationale for using biofeedback and type of feedback


name: Decide on the specific monitoring device to be used (e.g., thermal feedback; electrodermal response or galvanic skin response; electromyography feedback; finger pulse feedback; breathing biofeedback; electroencephalograph biofeedback)


name: Explain the procedure concerning the specific monitoring equipment used


name: Operate the biofeedback device according to instructions


name: Discuss timing, frequency, length, and setting for sessions with patient/family


name: Provide feedback of progress after each session


name: Identify potential types of biological agents that are likely terrorism agents (e.g., anthrax, smallpox, botulism, plague)


name: Integrate biological and chemical terrorism into agency disaster preparedness planning and evaluation


name: Consider current WHO and CDC recommended strategies to contain natural or deliberate disease and chemical events


name: Monitor clients with vague flu-like symptoms


name: Report suspicious symptoms to appropriate triage officers and health agencies


name: Maintain current knowledge of protective equipment, protective procedures, and isolation techniques


name: Ensure that protective equipment (e.g., hazmat suits, headgear, gloves, respirators) are available and in good working order


name: Familiarize and follow all decontamination policies, procedures, and protocols


name: Perform vaginal examination to determine fetal position and station


name: Apply controlled umbilical cord traction while guarding the fundus of uterus


name: Perform rectal examination to ensure tissue integrity


name: Maintain privacy and assure uninterrupted time during procedure


name: Position patient in comfortable, lying, semirecumbent posture


name: Cleanse site of entry or end of Y-connector with alcohol wipe before and after procedure


name: Instill irrigating fluids, per agency protocol


name: Keep patient fully informed of each irrigation, if repetition is necessary


name: Monitor patient level of comfort and ease of irrigation with each instillation, if repetition is necessary


name: Discontinue irrigations if procedure becomes too difficult or if it appears the catheter is obstructed


name: Notify physician if catheter is obstructed


name: Monitor and maintain correct flow rate with continuous infusions


name: Connect catheter to new drainage bag at end of irrigation


name: Assure patient comfort at end of procedure


name: Review patient history for specific risk factors (e.g., surgery, trauma, ulcers, hemophilia, poor clotting function, clotting inhibition from medication regime)


name: Monitor the patient closely for signs and symptoms of internal and external hemorrhage (e.g., distension or swelling of affected body part, change in type or amount of drainage from a surgical drain, bloody saturation of dressings, pooling of blood beneath patient)


name: Monitor for signs and symptoms of persistent bleeding (e.g., hypotension, weak and rapid pulse, cool and clammy skin, rapid breathing, restlessness, reduced urine output)


name: Monitor coagulation studies, including prothrombin time, partial thromboplastin time, fibrinogen, fibrin degradation and split products, and platelet counts, as appropriate


name: Avoid injections (IM or SQ), as appropriate


name: Avoid administering medications that will further compromise clotting times (e.g., clopidogrel, heparin, warfarin, or nonsteroidal antiinflammatory drugs [NSAIDs] such as aspirin)


name: Instruct patient to avoid medications that will further compromise clotting times (e.g., clopidogrel, heparin, warfarin, or nonsteroidal antiinflammatory drugs [NSAIDs] such as aspirin), as appropriate


name: Use electric razor, instead of straight edge, for shaving


name: Instruct patient to avoid invasive procedures; if they are necessary, monitor closely for bleeding


name: Instruct patient to avoid lifting heavy objects


name: Instruct patient to avoid constipation (e.g., encourage fluid intake and stool softeners), as appropriate


name: Apply ice pack to affected area, as appropriate


name: Note hemoglobin/hematocrit levels before and after blood loss


name: Monitor for signs and symptoms of persistent bleeding (i.e., check all secretions for frank or occult blood)


name: Hematest all excretions and observe for blood in emesis, sputum, feces, urine, NG drainage, and wound drainage, as appropriate


name: Instruct the patient and family on signs of bleeding and appropriate actions (i.e., notify the nurse), should further bleeding occur


name: Instruct the patient on activity restrictions


name: Obtain client history of vaginal bleeding (e.g., onset, amount, frequency of changing peri pads, color of bleeding, presence and location of pain, and presence of clots)


name: Review for risk factors related to late pregnancy bleeding (e.g., abruptio placentae, smoking, cocaine use, hypertension, diabetes, multiparity, previous cesarean birth, prior and current placenta previa, infertility treatment, multiple gestations, short interval between pregnancies, greater than 35 years of age)


name: Inspect perineum, clothing, sheets or pads for amount and characteristic of bleeding


name: Weigh blood soaked materials and clots to quantify blood loss


name: Continually monitor characteristic and amount of bleeding


name: Initiate continuous electronic fetal monitoring


name: Report client status and any changes in amount and frequency of bleeding, as appropriate


name: Initiate fetal resuscitation for abnormal (nonreassuring) signs of uteroplacental insufficiency


name: Delay digital cervical examination until location of placenta has been verified by ultrasound


name: Perform or assist with speculum examination to visualize blood loss and cervical status


name: Initiate IV access for fluid replacement


name: Obtain diagnostic blood studies (e.g., CBC, clotting studies, Rh, type and cross match, Kleihauer-Betke test), as ordered


name: Provide empathy, understanding and emotional support


name: Provide information on procedures, diagnostic tests, and treatments


name: Instruct woman to differentiate between old and fresh bleeding


name: Inform woman to monitor fetal movement to evaluate fetal well-being


name: Monitor for signs of hypovolemic shock (e.g., decreased blood pressure; rapid, thready pulse; increased respiratory rate; diaphoresis; restlessness; cool, clammy skin)


name: Monitor coagulation studies and complete blood count (CBC) with WBC differential, as appropriate


name: Avoid extremes in gastric pH level by administration of appropriate medication (e.g., antacids or histamine-2 blocking agent), as appropriate


name: Maintain pressure in cuffed/balloon nasogastric tube, if appropriate


name: Apply manual pressure over the bridge of the nose


name: Administer humidified oxygen, if appropriate


name: Place patient in mid-Fowler's position, as appropriate


name: Instruct patient to avoid traumatizing nares (e.g., avoid scratching, blowing, or touching nose)


name: Review obstetrical history and labor record for risk factors for postpartum hemorrhage (e.g., prior history of postpartum hemorrhage, over distention of the uterus, rapid labor, prolonged third stage, uterine infection, lacerations, retained placenta, labor, induction, use of anesthesia, preeclampsia, prolonged second stage, assistive birth, cesarean birth, or precipitous birth)


name: Perform fundal massage to ensure firm consistency


name: Increase frequency of fundal massage until the uterus becomes firm


name: Inspect placenta for intactness and missing fragments


name: Notify primary practitioner of excessive blood loss


name: Initiate IV infusion with needles suitable for blood transfusion


name: Administer a uterotonic drug, per protocol or order


name: Monitor maternal color, level of consciousness, pain, and anxiety level


name: Insert Foley catheter with urometer to monitor urine output, as appropriate


name: Order emergency laboratory tests or units of blood


name: Identify mother's beliefs about blood transfusions


name: Prepare the woman for transfer to the operating room for surgical intervention


name: Maintain continuous bladder irrigation, if appropriate


name: Verify that blood product has been prepared, typed, and crossmatched (if applicable) for the recipient


name: Verify correct patient, blood type, Rh type, unit number, and expiration date, and record per agency protocol


name: Instruct patient about signs and symptoms of transfusion reactions (itching, dizziness, shortness of breath and/or chest pain)


name: Monitor vital signs (e.g., baseline, throughout and after transfusion)


name: Notify laboratory immediately in the event of a blood reaction


name: Determine whether perceived dislike for certain physical characteristics creates a dysfunctional social paralysis for teenagers and other high-risk groups


name: Determine whether a recent physical change has been incorporated into patient's body image


name: Assist patient to discuss changes caused by puberty, as appropriate


name: Determine whether a change in body image has contributed to increased social isolation


name: Identify means of reducing the effect of any disfigurement through clothing, wigs, or cosmetics, as appropriate


name: Assist the hospitalized patient to apply cosmetics before seeing visitors, as appropriate


name: Determine patient's understanding of body mechanics and exercises (e.g., return demonstration of correct techniques when performing activities/exercises)


name: Use the principles of body mechanics in conjunction with safe patient handling and movement aids


name: Determine infant state before initiating feeding


name: Determine fluoride content of water used to dilute concentrated or powdered formula and refer for fluoride supplementation, if indicated


name: Determine onset and type of incontinence, frequency of episodes, and any related change in bowel function or stool consistency


name: Eliminate the cause of the incontinence (e.g., medication, infection, fecal impaction), if possible


name: Use nonionic detergent preparation (e.g., Peri-Wash) for cleansing, as appropriate


name: Protect the skin from excess moisture of urine, stool, or perspiration with a moisture barrier cream (e.g., petrolatum, lanolin, dimethicone), as needed


name: Monitor perianal skin for development of pressure ulcer and for infection


name: Schedule toileting with a commode at bedside or a bedpan, as appropriate


name: Administer prescribed medication for diarrhea (e.g., loperamide, atropine)


name: Use rectal tube, anal plug device, or fecal collection device (e.g., FlexiSeal Fecal Management System, Zossi Bowel Management System) with persons with intact skin, as appropriate


name: Perform rectal examination, as appropriate


name: Formulate a bowel retraining plan with the family (e.g., mineral oil, high fiber diet, regular toileting routine)


name: Encourage child to sit on toilet 10 to 15 minutes after meals for intervals of 10 minutes


name: Place a footstool below the feet to relax the abdomen


name: Provide positive reinforcement (e.g., stickers, praise, special activities) to encourage the child to participate in the bowel regime


name: Evaluate for fecal incontinence, as necessary


name: Note preexisting bowel problems, bowel routine, and use of laxatives


name: Teach patient about specific foods that are assistive in promoting bowel regularity


name: Individualize the bowel program with patient and appropriate others


name: Initiate an uninterrupted, consistent scheduled time for defecation


name: Use a bisacodyl suppository based in polyethylene glycol if tolerable


name: Instruct patient about digital rectal dilatation, as appropriate


name: Assess possible risk factors for the development of breast cancer, including age, age at first pregnancy, age at menarche, age at menopause, family history, history of breast disease, parity status, and history of breastfeeding


name: Ascertain whether or not patient has noticed any pain, lump, thickening, or tenderness of the breast, discharge, distortion, retraction, or scaling of the nipple


name: Assist patient to positions of comfort as examination proceeds, always allowing privacy and sensitivity, as needed


name: Explain specific steps of examination as you proceed


name: Conduct examination when patient is in upright then supine position


name: Instruct patient to utilize four different positions for visual inspection-arms at side, hands at waist and push inward toward hips, hands behind the head, and arms across waist with chest falling forward


name: Using a systematic approach, palpate breast tissue with the palmar surface of the first three fingers of the examiner's dominant hand


name: Instruct the patient about the importance of regular breast self-examination


name: Instruct patient on techniques to use to calm an infant (e.g., speak to infant, hand on belly, restraining arms, picking up, and holding and rocking)


name: Provide time and space to be alone, as appropriate


name: Select puncture site (e.g., outer lower aspect of heel, sides of distal phalanges of the fingers or toes, alternative sites such as the forearm)


name: Follow manufacturer's guidelines regarding timing on tests and preservation of blood sample (e.g., sealing blood tubes), as necessary


name: Label specimen according to agency protocol, as necessary


name: Monitor patient physically and psychologically per agency policy


name: Ensure activity level that does not compromise cardiac output or provoke cardiac events


name: Encourage gradual increase in activity when condition stabilized (i.e., encourage slower paced activities or shorter periods of activity with frequent rest periods after exercise)


name: Evaluate any episodes of chest pain (e.g., intensity, location, radiation, duration, and precipitating and alleviating factors)


name: Monitor ECG for ST changes, as appropriate


name: Perform a comprehensive appraisal of peripheral circulation (i.e., check peripheral pulses, edema, capillary refill, color, and temperature of extremity) per agency policy


name: Instruct the patient and family on treatment modalities, activity restriction and progression


name: Screen patients for anxiety and depression, encouraging treatment with suitable antidepressants, as indicated


name: Encourage noncompetitive activities for patients at risk for impaired cardiac function


name: Instruct patient and family on the aims of care and how progress will be measured


name: Ensure that all staff are aware of these goals and are working together to provide consistent care


name: Refer to heart failure program or cardiac rehabilitation program for education, evaluation, and guided support to increase activity and rebuild life, as appropriate


name: Offer spiritual support to the patient and family (e.g., contact a member of the clergy), as appropriate


name: Provide immediate and continuous means to summon nurse and let the patient and family know calls will be answered immediately


name: Perform a comprehensive appraisal of cardiac status including peripheral circulation


name: Monitor intake and output, urine output, and daily weight, as appropriate


name: Select best EKG lead for continuous monitoring, as appropriate


name: Draw serum, CK, LDH, and AST levels, as appropriate


name: Monitor renal function (e.g., BUN and Cr levels), as appropriate


name: Monitor liver function tests, if appropriate


name: Monitor laboratory values for electrolytes that may increase the risk of dysrhythmias (e.g., serum potassium and magnesium), as appropriate


name: Monitor trends in blood pressure and hemodynamic parameters, if available (e.g., central venous pressure and pulmonary capillary or artery wedge pressure)


name: Provide appropriate cardiac diet (i.e., limit intake of caffeine, sodium, cholesterol, and food high in fat)


name: Substitute artificial salt, if appropriate


name: Prevent peripheral thrombus formation (i.e., turn every 2 hours and administer low-dose anticoagulants)


name: Instruct the patient on self-care of chest pain (i.e., take sublingual nitroglycerine every 5 minutes three times; if chest pain is unrelieved, seek emergency medical care)


name: Instruct the patient and family on any special considerations with activities of daily living (e.g., isolate activities and allow rest periods), if appropriate


name: Screen patient for anxiety and depression, as appropriate


name: Screen patient for risk behaviors associated with adverse cardiac events (e.g., smoking, obesity, sedentary lifestyle, high blood pressure, history of previous cardiac events, family history of cardiac events)


name: Identify patient's readiness to learn lifestyle modification (e.g., diet, smoking, alcohol intake, exercise and cholesterol levels)


name: Instruct patient and family on signs and symptoms of early cardiac disease and worsening cardiac disease, as appropriate


name: Instruct patient and family on cardiac risk factor modification, as appropriate


name: Prioritize areas for risk reduction in collaboration with patient and family


name: Instruct patient and family to monitor blood pressure and heart rate routinely and with exercise, as appropriate


name: Encourage exercise, as indicated by patient cardiac risk factor


name: Instruct the patient on regular and progressive exercise, as appropriate


name: Encourage 30 minutes of exercise daily, as appropriate


name: Instruct patient on need to achieve exercise goals in incremental periods of 10 minutes multiple times daily, if intolerant to sustained 30 minute activities


name: Instruct patient and family on strategies for restricting or eliminating smoking


name: Instruct patient and family on strategies for a heart healthy diet (e.g., low sodium, low fat, low cholesterol, high fiber, adequate fluid, appropriate caloric intake)


name: Encourage patient to keep caloric intake at a level that achieves desired weight


name: Instruct patient and family on therapies to reduce cardiac risk (e.g., medication therapies, blood pressure monitoring, fluid restrictions, alcohol restrictions, cardiac rehabilitation)


name: Provide both verbal and written information to patient, family, and caregivers for all pertinent cares, as indicated


name: Focus care and treatment goals to enable the patient to maintain weight control, to remain a nonsmoker, and to remain as active as possible


name: Refer to heart failure program or cardiac rehabilitation program for lifestyle changes, as appropriate


name: Alleviate patient anxieties by providing accurate information and correcting any misconceptions


name: Monitor patient's progress at regular intervals


name: Revise interventions and goals to meet patient's needs, as necessary


name: Coordinate care with other pertinent health care providers (e.g., other nurses, physicians, social workers, third-party payers, physical therapists)


name: Modify care to increase cost effectiveness, as needed


name: Document cost effectiveness of case management


name: Monitor for signs of infection (foul-smelling cast, erythema, fever)


name: Monitor for signs of cast impairment of circulation or neurological function (e.g., pain, pallor, pulselessness, paresthesias, paralysis, and pressure) on affected extremity


name: Monitor circulation and neurological function of tissues above and below cast


name: Address compromised circulation and pain symptoms immediately (e.g., reposition cast, perform range of motion [ROM] to extremity, immediate cast pressure-relieving action)


name: Offer alternatives to scratching (e.g., cold air from a hair dryer)


name: Avoid getting a plaster cast wet (e.g., use appropriate protection for bathing or toileting, protective socks or gloves)


name: Position cast on pillows to lessen strain on other body parts with cast heel off pillow


name: Apply ice for first 24 to 36 hours to reduce swelling or inflammation


name: Elevate casted extremity at or higher than heart level to reduce swelling or inflammation


name: Pad rough cast edges and traction connections


name: Document cast care instructions given to patient and family


name: Document observations of patient ability to perform cast care


name: Address compromised circulation and pain symptoms immediately, to avoid permanent damage in neurovascular status (e.g., reposition cast, report unresolved symptoms as needing immediate cast pressure relieving action)


name: Handle the casted extremity with palms only until the cast is dry to avoid causing finger indentations that can lead to pressure sores


name: Explain the need for limited activity as cast dries


name: Apply ice for first 24 to 35 hours to reduce swelling or inflammation, as indicated


name: Elevate casted extremity at or higher than heart level to reduce swelling or inflammation, as indicated


name: Determine the type of Central Venous Access Device (CVAD) in place


name: Determine manufacturer and agency recommendations, guidelines, protocols, policies, and procedures related to the particular device


name: Determine patient's and/or family's understanding of the purpose, care, and maintenance of the CVAD


name: Provide information to patient and family related to the device (e.g., indications, functions, type of device to be used, care of device, potential complications) to reduce patient uncertainty, fear, and anxiety


name: Explain the entire procedure to patient when inserting, providing care for, accessing for medication or fluid therapy, or removing a device


name: Avoid use of the line until confirmation of tip placement postimplantation with baseline chest x-ray


name: Assure subclavian and jugular vein tips located within the lower third of the superior vena cava


name: Report catheter tips positioned within the heart as they have an increased risk of mortality


name: Report catheter tips positioned perpendicular to the vein wall as there is an increased risk of vessel erosion, hydrothorax, hydromediastinum, tamponade, and extravasation


name: Employ strict aseptic technique whenever device is handled, accessed or used to administer medications, to reduce potential for catheter-related bloodstream infections


name: Adapt care to the type of device (i.e., use clamp at all times with open-ended or midline CVADs; use Huber needles for port access; use saline flushes with nonreturn valves; use clear transparent dressing to anchor nontunneled, midline, and PICC CVADs)


name: Check patency of the CVAD immediately before administering prescribed medications/infusions


name: Aspirate blood from the device to check patency before administering prescribed therapy, as indicated per device type


name: Employ further actions to ensure patency if difficulty encountered with aspiration or no blood return, per manufacturer and agency protocol for occluded devices


name: Administer saline flush for valved catheter maintenance as valve prevents blood reflux into the lumen of the catheter, thus preventing thrombotic occlusion


name: Flush nonvalved (or open-ended) CVADs with heparinized saline weekly with the strength of heparin per agency policy


name: Flush implanted ports with heparinized saline monthly with the strength of heparin per agency policy


name: Flush PICCs weekly with heparinized saline if not in use, with the strength of heparin per agency policy


name: Employ needle-free devices to promote a closed system


name: Employ 10 cc syringes for access of CVADs as smaller gauge silastic catheters appear to create greater pressure of pounds/square inch which may result in the rupture of the catheter and clots forced into bloodstream


name: Assure that intravenous tubing line is securely taped into position


name: Assure tubing is lying on the bed or arm of the treatment chair; do not allow intravenous tubing to dangle or pull


name: Use self-adhesive anchoring devices, when appropriate or per agency policy


name: Change clear fluid administration sets every 72 hours, blood sets every 12 hours, and parenteral nutrition administration sets every 24 hours, or per agency policy


name: Use new IV solutions and administration sets for new CVADs


name: Discard existing infusion sets, assuring that infusion sets from old devices to new devices are not exchanged


name: Do not allow the CVAD to be inserted near to a stoma or to areas such as diapers in children in which contact with fecal material may occur


name: Apply gauze dressing for the first 24 hours after operative insertion


name: Apply a clear dressing under strict aseptic technique weekly thereafter or sooner if soiled, perforated, or the dressing is lifting off


name: Use transparent semipermeable dressings with nontunneled devices and change every 7 days or sooner if wet or dirty, or per agency policy


name: Use 2% chlorhexidine in 70% isopropyl alcohol solution for cleansing the exit wound and catheter at all dressing changes and to decontaminate the skin before CVAD insertion, unless patient has a known allergy to chlorhexidine


name: Decontaminate CVADs with 2% chlorhexidine gluconate in 70% isopropyl and allow to dry before accessing, unless contraindicated by the manufacturer


name: Obtain chest x-ray immediately in the event of suspected line infiltration, compromise, or migration


name: Monitor for arm swelling or increased warmth on side ipsilateral to implanted device


name: Monitor for complications of CVADs (e.g., pneumothorax, cardiac tamponade, arterial puncture, hemorrhage, hemothorax, hydrothorax, air embolus, brachial nerve plexus injury, thoracic duct injury, infection, misplacement)


name: Inspect entry site daily for redness, pain, tenderness, warmth, or swelling as devices are associated with increased risk of infection


name: Remove device if any signs of inflammation, leakage, or discharge from the entry site


name: Ensure any infusions attached to the CVAD have been switched off before removing a device


name: Position patient supine, head down for insertion and removal of nontunneled CVADs, if possible


name: Place gauze over the entry site and apply light to moderate pressure to remove CVAD to avoid catheter fracture, tearing, and/or embolization


name: Place CVAD tip in sterile container and send for culture if infection is suspected


name: Apply firm pressure to the puncture site after removing the CVAD for at least 2 minutes until hemostasis is achieved


name: Apply an airtight transparent dressing immediately after CVAD removal, ensuring a good seal is achieved, and keep in place for 72 hours


name: Monitor x-rays for pinch-off sign in catheters that are occluded or before removal as pinch-off catheters are more likely to tear or fracture


name: Use an antimicrobial-impregnated catheter for patients considered to be at-risk for catheter related sepsis


name: Consider length of time device is needed before recommending device (e.g., less than 7 days-use peripheral IV; 1 to 4 weeks-use midline catheter or PICC line; 1 month to 1 year-use PICC, tunneled CVAD, implantable port; longer than 1 year-use tunneled CVAD, implantable port)


name: Document pertinent data in patient permanent record for initial insertion of central venous access device (e.g., manufacturer, model number, serial number, implant date)


name: Instruct patient of the signs and symptoms of dysfunctional central venous access device (e.g., tachycardia, hypotension, dyspnea, agitation, independent filling of access needle with fluid or blood, shoulder or back pain, cardiac arrest)


name: Instruct patient to carry CVAD manufacturer identification card at all times


name: Instruct patient to wear a medical alert bracelet or necklace that identifies patient as a central venous access device patient


name: Monitor neurologic status closely and compare to baseline


name: Monitor patient's ICP and neurologic response to care activities


name: Position with head of bed up 30 degrees or greater


name: Encourage family/significant other(s) to talk to patient


name: Monitor laboratory values: serum and urine osmolality, sodium, potassium


name: Perform passive range-of-motion exercises


name: Titrate barbiturate to achieve suppression or burst suppression of EEG as ordered


name: Consult with physician to determine hemodynamic parameters


name: Administer and titrate vasoactive drugs, as prescribed, to maintain hemodynamic parameters


name: Monitor for anticoagulant therapy side effects (e.g., test stool and NG drainage for blood)


name: Administer rheologic agents (e.g., low-dose mannitol or low molecular weight dextrans), as prescribed


name: Draw blood to monitor hematocrit level, electrolytes, and blood glucose


name: Maintain hematocrit level for hypervolemic hemodilution therapy per protocol


name: Avoid neck flexion or extreme hip or knee flexion


name: Administer calcium channel blockers and vasopressors, as prescribed


name: Administer anticoagulant, antiplatelet, and thrombolytic medication, as prescribed


name: Monitor laboratory values for changes in oxygenation or acid-base balance, as appropriate


name: Monitor respiratory status (e.g., rate, rhythm, and depth of respirations; partial oxygen pressure, PCO2, pH, and bicarbonate levels)


name: Monitor for signs of fluid overload (e.g., rhonchi, jugular venous distention (JVD), edema, and increase in pulmonary secretions)


name: Discuss feelings, questions, and concerns patient has about surgery


name: Obtain necessary blood work and document results


name: Encourage intimate partner or support person to be present during delivery


name: Give information about events taking place and sensations patient may be experiencing during surgery


name: Transfer patient to recovery room or labor room


name: Monitor physiological aspects of recovery (e.g., pain, uterine changes, airway patency, and lochia)


name: Inspect condition of surgical incision and dressing


name: Assist in performing leg exercises, turning, coughing, and deep breathing


name: Provide adequate breastfeeding education and support, if appropriate (i.e., demonstrate infant positioning adaptations according to mobility limitations)


name: Facilitate family bonding and attachment by minimizing maternal-infant separation (e.g., present infant en face to mother, provide unobstructed view of infant, facilitate skin-to-skin contact, and transfer mother and infant together)


name: Provide divisional activities before the use of restraints (e.g., television, visitors)


name: Explain the procedure, purpose, and duration of the intervention to patient and significant other in understandable terms


name: Involve patient in making decisions to move to a more/less restrictive form of intervention, when appropriate


name: Monitor pretreatment screening workups for patients at risk for earlier onset, longer duration, and more distressing side effects


name: Promote activities to modify the identified risk factors


name: Monitor for side effects and toxic effects of treatment


name: Teach patient and family about the effects of therapy on bone marrow functioning


name: Instruct patient and family on ways to prevent infection, such as avoiding crowds, using good hygiene, and handwashing techniques


name: Administer medications to control side effects (e.g., antiemetics for nausea and vomiting), as needed


name: Administer chemotherapeutic drugs in the late evening so the patient may sleep at the time emetic effects are greatest


name: Encourage good oral hygiene with use of dental cleansing devices, such as unwaxed, nonshredding floss, sonic toothbrushes or water Pik, as appropriate


name: Initiate oral health restoration activities, such as use of artificial saliva, saliva stimulants, nonalcohol-based mouth sprays, sugarless mints, and fluoride treatments, as appropriate


name: Teach patient on self-assessment of oral cavity, including signs and symptoms to report for further evaluation (e.g., burning, pain, and tenderness)


name: Teach patient need for frequent dental follow-up care as dental caries form rapidly


name: Teach patient to avoid temperature extremes and chemical treatments of the hair when receiving treatment


name: Inform patient that hair loss is expected, as determined by type of therapy


name: Reassure patient that hair will grow back after treatment is terminated, as appropriate


name: Teach patient and family to monitor for organ toxicity, as determined by type of therapy


name: Discuss potential aspects of sexual dysfunction, as appropriate


name: Teach implications of therapy on sexual function, including the time frame for contraceptive use, as appropriate


name: Monitor fatigue level by soliciting the patient's description of fatigue


name: Teach patient and family techniques of energy management, as appropriate


name: Facilitate expression of fears about prognosis or success of treatments


name: Provide concrete objective information related to the effects of therapy to reduce patient uncertainty, fear, and anxiety about treatment-related symptoms


name: Determine presence of contraindications for use of chest physiotherapy (e.g., acute exacerbation of COPD, pneumonia without evidence of excess sputum production, osteoporosis, lung cancer, and cerebral edema)


name: Perform chest physiotherapy at least 2 hours after eating


name: Explain purpose and procedures used during chest physiotherapy to patient


name: Position any necessary equipment nearby (e.g., suctioning equipment, sputum container, and tissues)


name: Monitor respiratory and cardiac status (e.g., rate, rhythm, breath sounds, and depth of breath)


name: Monitor amount and character of secretions


name: Determine lung segment(s) containing excessive secretions


name: Position patient with the lung segment to be drained in uppermost position, making modifications for patients unable to tolerate prescribed position (i.e., avoid placing patient with COPD, acute head injury, and cardiac problems in Trendelenburg position as it can increase shortness of breath, intracranial pressure, and stress, respectively)


name: Strike chest rhythmically and in rapid succession using cupped hands over area(s) to be drained for 3 to 5 minutes, avoiding percussion over spine, kidneys, female breasts, incisions, and broken ribs


name: Apply pneumatic, acoustical, or electrical chest percussors


name: Rapidly and vigorously vibrate hands, keeping shoulders and arms straight and wrists stiff, on area(s) to be drained while patient exhales or coughs 3 to 4 times


name: Instruct patient to expectorate loosened secretions via deep breathing


name: Encourage coughing during and after procedure


name: Monitor patient tolerance during and after procedure (e.g., pulse oximetry, vital signs, and reported comfort level)


name: Teach the mother and partner about the physiology of labor and delivery


name: Explore childbirth plan for labor and delivery (e.g., the birthing environment, who will assist mother, who will be in attendance, what technology will be used, who will cut the cord, feeding preferences, and discharge plans)


name: Educate mother and partner about signs of labor


name: Inform mother about when to come to the hospital in preparation for delivery


name: Discuss pain control options with mother


name: Inform mother about delivery options if complications arise


name: Explain routine monitoring that may occur during labor and delivery


name: Teach mother and partner breathing and relaxation techniques to be used during labor and delivery


name: Review American Academy of Pediatrics recommendations for breastfeeding


name: Encourage mother to put the infant to breast after delivery


name: Provide opportunity for mother to be in close proximity to infant during postpartum hospitalization to facilitate bonding and breastfeeding


name: Promote parent's self-efficacy in taking on parental role


name: Discuss arrangements for sibling care during hospitalization


name: Assist parent(s) in planning strategies to prepare siblings for newborn


name: Assist parent to select a physician or clinic to receive child health supervision for newborn


name: Encourage mother to obtain an approved infant car safety seat to transport newborn home from hospital


name: Monitor degree of discomfort or pain with exercise, at night, or when resting


name: Instruct the patient on factors that interfere with circulation (e.g., smoking, restrictive clothing, exposure to cold temperatures, and crossing of legs and feet)


name: Observe for hemolysis, as indicated by blood in the urine, hemolyzed blood specimens, increase in daily serum hemoglobin, frank bleeding, and hyperkalemia


name: Collect blood, urine, sputum, and wound cultures for temperatures greater than 38 degrees C, as appropriate


name: Apply dressing for wound size and type, as appropriate


name: Elevate affected limb 20 degrees or greater higher than the level of the heart, as appropriate


name: Encourage passive or active range-of-motion exercises especially of the lower extremities exercises, during bed rest


name: Perform a comprehensive appraisal of peripheral circulation (i.e., check peripheral pulses, edema, capillary refill, color, temperature of extremity, and ankle brachial index, if indicated)


name: Target at risk patients (e.g., diabetics, smokers, elderly, hypertensive patients and those with elevated cholesterols levels) for comprehensive peripheral assessments and modification of risk factors


name: Encourage smoking cessation and regular exercise in patients with claudication


name: Encourage walking to the point of claudication and a little bit more each time to assist in the development of collateral circulation in the lower extremities


name: Instruct patient and family on medication therapies for blood pressure control, anticoagulation and reduction of cholesterol levels


name: Instruct patient on avoidance of beta blockers for blood pressure control, as they cause constriction of peripheral vessels and worsens claudication


name: Instruct patient on diet measures to improve circulation (e.g., diet low in saturated fat and good intake of omega 3 fish oils)


name: Instruct diabetic patients on the need for proper management of blood sugar


name: Instruct patient on proper skin care (e.g., moisturizing dry skin on legs, prompt attention to wounds and potential ulcers)


name: Provide patient and family with smoking cessation information, if applicable


name: Instruct patient on signs and symptoms indicating a need for emergent care (e.g., pain that does not go away upon rest, wound complications, loss of feeling)


name: Encourage patient participation in vascular rehabilitation programs


name: Verify that the surgical consent is properly signed


name: Administer preprocedure pain control approximately 1 hour before the procedure (e.g., acetaminophen)


name: Use a pacifier dipped in sucrose during the procedure and until the next feeding with permission from parent/guardian


name: Administer a topical local analgesia agent (e.g., eutectic mixture of local anesthetics [EMLA]), as ordered


name: Monitor for bleeding every 30 minutes for a least 2 hours post procedure


name: Provide post procedure pain control every 4 to 6 hours for 24 hours (e.g., acetaminophen)


name: Evaluate patient's responsiveness to determine appropriate action


name: Call for help if no breathing or no normal breathing and no response


name: Call a code according to agency standard when obtaining the automated external defibrillator (AED) or assuring that someone is obtaining the automated external defibrillator


name: Perform cardiopulmonary resuscitation that focuses on chest compressions in adults and compressions with breathing efforts for children, as appropriate


name: Deliver cardioversion or defibrillation as soon as possible


name: Minimize the interval between stopping chest compressions and delivering a shock, if indicated


name: Attach the cardiac monitor and determine the rhythm, assuring defibrillations will not be interrupted


name: Assure that someone is oxygenating the patient and assisting with intubation, as indicated


name: Ensure that someone is: (1) setting up medications; (2) delivering medications; (3) interpreting EKG and delivering cardioversion/defibrillation, as needed; and (4) documenting care


name: Remind personnel of current Advanced Cardiac Life Support protocols, as appropriate


name: Ensure that special resuscitation protocols (e.g., asthma, anaphylaxis, pregnancy, morbid obesity, pulmonary embolism, electrolyte imbalance, ingestion of toxic substances, trauma, accidental hypothermia, avalanche, drowning, electric shock or lightning strikes, percutaneous coronary interventions, cardiac tamponade, cardiac surgery) are instituted, when appropriate


name: Offer family members and significant other(s) opportunities to be present during resuscitation when in the best interests of the patient


name: Support family members who are present during resuscitation (i.e., ensure safe environment, provide explanations and commentary, allow appropriate communication with patient, continually assess needs, provide opportunities to reflect on resuscitation efforts after event)


name: Ensure that someone is coordinating care of other patients on the nursing unit


name: Terminate code by patient condition, as indicated


name: Assure organized post cardiac arrest care (e.g., cardiopulmonary and neurological support, therapeutic hypothermia, tapering of inspired oxygen concentration to avoid harmful hyperoxia, avoidance of hyperventilation)


name: Implement appropriate procedures for possible tissue and organ donation that are timely, effective, and supportive of the family members' and patient's desires


name: Review actions after code to identify areas of strength and those which need to be improved


name: Provide opportunities for team members to be involved in team debriefings or reflect on resuscitation efforts after event


name: Perform emergency cart check per agency protocol


name: Help patient understand the inability to attain desirable behaviors frequently results from irrational self-statements


name: Demonstrate caregiver sensitivity by responding promptly and appropriately to cues


name: Stimulate development by engaging in activities to enhance achievement and learning by being attuned to the patent's needs


name: Offer cognitive stimulation at work, such as training opportunities, cognitive richness to work content, opportunities for growth, and multitasking


name: Encourage cognitive stimulation outside of work, such as reading or active participation in cultural and artistic activities


name: Encourage the use of a multistimulation program (e.g., singing and listening to music, creative activities, exercise, conversation, social interactions, or problem solving) to promote and protect cognitive capacity


name: Ask for opinions and views rather than factual answers


name: Seek input and respect the contributions of others


name: Build teams of approximately 5 to 9 members


name: Design group work spaces that easily support 5 to 9 people with everyone having equal access to digital and analog information displays and being able to see each other eye to eye


name: Ensure that work spaces have easy projection and teleconferencing capabilities


name: Encourage group members to switch where they sit on a regular basis to build stronger networks


name: Provide individual workstations for private focused work with visual eyesight to others and a place for a visitor to sit (e.g., bench)


name: Provide a social space in which individuals can talk casually


name: Enable workers to have choice and control of where they work by providing a range of settings


name: Support programs of interdisciplinary education including interprofessional orientation days and social events, joint faculty appointments, and interdisciplinary coursework and clinic activities


name: Provide web-based tools (e.g., calendar, agendas, committee assignments, appropriate forms and documents) to help workers coordinate and communicate


name: Include the patient as a teammate, as appropriate


name: Use communication tools (e.g., daily huddles; repeat back; Situation, Background, Assessment, Recommendation [SBAR]; opportunity for questions), as needed


name: Continue dialogue of legal and ethical matters as they apply to the situation


name: Address misconceptions and stereotypes among team members


name: Use negotiation as a strategy for conflict resolution


name: Value the enhanced benefits of the collaborative efforts of the team


name: Recognize resourcefulness in coping with present situation


name: Assist individuals to realize their personal strengths, potential, and capacity


name: Demonstrate your valuing of individual or family


name: Build collaborative relationship with individual or family


name: Recognize individual's strength in modifying behavior to address the situation


name: Provide positive feedback to encourage and sustain new behavior


name: Acknowledge the capacity to live with chronic, long-term health issue or illness, as appropriate


name: Congratulate one in achieving improved outcome


name: Reinforce a behavior or outcome to increase the probability that it will be sustained


name: Facilitate motivation to continue with improved behavioral changes to attain the main goal


name: Apply strategies to reinforce learning and promote confidence and worth in learner


name: Write up statements of praise and send to individual or other persons (e.g., supervisor, award program), as appropriate


name: Promote legislation that ensures appropriate monitoring and treatment for communicable diseases


name: Perform or arrange for routine hearing assessments and screenings


name: Monitor for excessive accumulation of cerumen


name: Instruct patient not to use foreign objects smaller than patient's fingertip (e.g., cotton-tipped applicators, bobby pins, toothpicks, and other sharp objects) for cerumen removal


name: Remove excessive cerumen with twisted end of washcloth while pulling down the auricle


name: Consider ear irrigation for the removal of excessive cerumen if watchful waiting, manual removal, and ceruminolytic agents are ineffective


name: Note and document patient's preferred method of communication (e.g., verbal, written, lip reading, or American Sign Language) in plan of care


name: Gain patient's attention before speaking (e.g., obtain attention through touch)


name: Avoid noisy backgrounds when communicating


name: Avoid communicating more than 2 to 3 feet from patient


name: Listen attentively, allowing patient adequate time to process communication and respond


name: Facilitate lip reading by facing patient directly in good lighting


name: Ask patient to suggest strategies for improved communication (e.g., speaking toward better ear and moving to well-lit area)


name: Face the patient directly, establishing eye contact, and avoid turning away midsentence


name: Simplify language (i.e., do not use slang and use short, simple sentences), as appropriate


name: Avoid "baby talk" and exaggerated expressions


name: Verify what was said or written using patient's response before continuing


name: Facilitate use of hearing aids and assistive listening devices (e.g., phone amplifier, hardwire device, personal frequency modulation, and computers)


name: Remove hearing aid battery when hearing aid is not in use for several days


name: Clean detachable earmold using a mild soapy solution, removing moisture or debris with soft cloth, and avoiding isopropyl alcohol, solvents, and oil


name: Clean nondetachable earmold using a damp cloth, removing moisture or debris with soft cloth, and avoiding isopropyl alcohol, solvents, and oil


name: Check hearing aid batteries routinely, replacing, when necessary


name: Refer to manufacturer's guidelines on proper use of, care for, and maintenance of hearing aids and assistive listening devices


name: Instruct patient, nursing personnel, and family on use of, care for, and maintenance of hearing aids and assistive listening devices


name: Assist patient or family in acquiring hearing aid and assistive listening device


name: Refer to primary care provider or specialist for evaluation, treatment, and hearing rehabilitation


name: Monitor speech speed, pressure, pace, quantity, volume, and diction


name: Monitor cognitive, anatomical, and physiological processes associated with speech capabilities (e.g., memory, hearing, and language)


name: Instruct patient or family on cognitive, anatomical, and physiological processes involved in speech capabilities


name: Monitor patient for frustration, anger, depression, or other responses to impaired speech capabilities


name: Recognize emotional and physical behaviors as forms of communication


name: Provide alternative methods of speech communication (e.g., writing tablet, flash cards, eye blinking, communication board with pictures and letters, hand signals or other gestures, and computer)


name: Provide alternative methods of writing or reading, as appropriate


name: Adjust communication style to meet needs of client (i.e., stand in front of patient when speaking; listen attentively; present one idea or thought at a time; speak slowly but avoid shouting; use written communication; or solicit family's assistance in understanding patient's speech)


name: Maintain structured environment and routines (i.e., ensure consistent daily schedules; provide frequent reminders; and provide calendars and other environmental cues)


name: Modify environment to minimize excess noise and decrease emotional distress (i.e., limit visitors and excessive equipment noise)


name: Ensure call light is within reach and central call light system is marked to indicate patient cannot speak


name: Repeat what patient said to ensure accuracy


name: Phrase questions so patient can answer using a simple "yes" or "no," being aware that patient with expressive aphasia may provide automatic responses that are incorrect


name: Collaborate with family and speech language pathologist or therapist to develop a plan for effective communication


name: Provide one-way valve for patient with tracheostomy, replacing need for finger occlusion over tube


name: Instruct patient or family on use of speech aids after laryngectomy (e.g., esophageal speech, electrolarynges, tracheoesophageal fistulas)


name: Provide positive reinforcement, as appropriate


name: Refer patient to community support systems (e.g., The International Association of Laryngectomees and American Cancer Society)


name: Provide referral to speech language pathologist or therapist


name: Coordinate rehabilitation team activities


name: Perform or arrange for routine vision assessments and screenings


name: Monitor functional implications of diminished vision (e.g., risk of injury, depression, anxiety, and ability to perform activities of daily living and valued activities)


name: Identify yourself when entering the patient's space


name: Assist patient in enhancing stimulation of other senses (e.g., savoring aroma, taste, and texture of food)


name: Ensure that patient's eyeglasses or contact lens have current prescription, are cleaned, and stored properly when not in use


name: Minimize glare (i.e., offer sunglasses or draw window covering)


name: Avoid rearranging items in patient's environment without notifying patient


name: Provide daily living aids (e.g., clock and telephone with large numbers)


name: Apply labels to distinguish frequently used items (i.e., color-code dials on appliances, mark medication bottles using high-contrasting colors or rubber bands, and safety-pin labels on similar-colored clothing)


name: Use bright, contrasting colors in environment


name: Provide magnifying devices (e.g., handheld, stand, and video magnifier)


name: Provide sight substitutes (e.g., Braille materials, audio books, talking watches, and tactile markers)


name: Assist parents, family, educators, and caretakers involved with a child with diminished vision in meeting informational needs (e.g., how to teach child, anticipatory guidance, and developmental considerations)


name: Instruct parents, family, educators, and caretakers to recognize and respond to nontraditional expressive forms of communication (e.g., movements and facial expressions)


name: Assist parents, family, educators, and caretakers in developing reliable, functional communication systems (e.g., microswitches or speech-output devices)


name: Assist patient or family in identifying available resources for vision rehabilitation


name: Provide referral for the patient in need of surgical or other medical treatment


name: Provide referral for supportive services (e.g., social, occupational, and psychological)


name: Identify all community medical and social agency resources available to respond to a disaster


name: Encourage community members to have a personal preparedness plan (e.g., emergency telephone numbers, battery-operated radio, working flashlight, first aid kit, medical information, physician information, persons to be notified in an emergency)


name: Assist to prepare shelters and emergency aid stations


name: Define the objectives of the advocacy and the specific community to be assisted


name: Assist community members to navigate the health care system (e.g., to access low-cost or free care, to solve billing issues, to understand patient rights


name: Provide access to translation services, when needed


name: Work with lay community health workers and community leaders to identify needs and provide services


name: Assist community leaders to conduct a needs assessment whereby needs can be prioritized and activities to be identified


name: Understand the cultural health beliefs and practices of the identified community members


name: Help to mobilize resources in a community that will assist in achieving goals


name: Seek consultation, training and support for community advocacy efforts to build coalitions


name: Participate in media campaigns to increase public awareness


name: Attend school board meetings to share the negative effect of not having enough school nurses to monitor students' health statuses


name: Attend and speak at public forums about the positive effect of proposed health care services, projects, and legislation


name: Provide appropriate health care information and education to the public and legislators


name: Assist in the introduction and passage of health care legislation by finding sponsors and persuading potential cosponsors to sign on with their support


name: Use real-life examples from clinical practice to illustrate the needs of patients and the outcomes of public policy on patient care


name: Identify obstacles that prevent success and implement strategies to reduce barriers


name: Identify and develop potential community leaders


name: Provide an environment, creating situations in which individuals and groups feel safe expressing their views


name: Assure that community members maintain control of decision making


name: Identify own attitude toward the patient and situation; repeat as needed


name: Determine the ethical boundaries of the relationship, as needed


name: Deal with personal feelings evoked by the patient that may interfere with the effectiveness of therapeutic interactions


name: Discuss confidentiality of information shared


name: Return at established time to demonstrate trustworthiness and interest in the patient


name: Adjust physical distance between nurse and patient, as appropriate


name: Develop special ways of communicating (e.g., images, other words), as needed


name: Assist patient to identify areas of need to be addressed during meetings


name: Establish time of next interaction before ending the meeting each time


name: Summarize conversation at end of the discussion


name: Identify patient's readiness to explore identified problems and develop strategies for change


name: Encourage patient to take the time needed to express him/herself


name: Assist the patient to identify feelings that impede ability to interact with others (e.g., anger, anxiety, hostility, or sadness)


name: Collect data and identify problem which is focus of consultation


name: Monitor eyes and surrounding area for open lesions and ecchymosis


name: Determine patient's understanding of required lens care


name: Determine patient's physical and emotional capability to learn and perform required lens care


name: Instruct patient to perform hand hygiene before touching lenses


name: Instruct patient on proper care of contact lenses depending on type (e.g., hard or soft)


name: Instruct patient to remove lenses at appropriate interval (e.g., remove daily wear lenses at night and do not wear disposable lenses more than once)


name: Instruct patient wearing extended-wear contacts of increased risks (e.g., corneal ulcers and infection-caused eruptions)


name: Instruct patient wearing hard contacts of increased risks (e.g., corneal edema and corneal abrasions)


name: Instruct patient on symptoms to report to health care professional (e.g., eye and conjunctiva redness, discomfort or pain, excessive tearing, and visual changes)


name: Instruct patient to use recommended solutions to clean, moisten, rinse, and disinfect lenses


name: Instruct patient to rub and rinse lenses with recommended solution before and after storage


name: Instruct patient on importance of monitoring for and discontinuing use of recalled contact lens care products


name: Instruct patient not to use saliva, tap water, or sterile saline found in health care agencies for rinsing or storing lenses


name: Instruct patient to avoid exposing eyes to tap water, swimming pool water, or spa water when wearing lenses


name: Instruct patient to store lenses in lens container with recommended solution


name: Instruct on care of lens container (e.g., clean daily, leave open to air, and replace regularly)


name: Instruct the patient who wears eye cosmetics to use caution in their selection and application (i.e., choose cosmetics without irritating properties and apply before lens insertion)


name: Instruct patient to avoid exposure to or use of damaging or irritating environmental contaminants (e.g., dust, smoke, soaps, lotions, creams, and sprays)


name: Instruct patient to carry appropriate identification on type and care for lenses


name: Provide lens care for the patient unable to do so for self (e.g., removal, cleaning, storing, and insertion)


name: Account for access to controlled substances at all times


name: Follow agency protocol for resolving discrepancies


name: Keep abreast of federal and state regulations regarding the use of controlled substances


name: Monitor for evidence of misadministration or diversion of controlled substances (e.g., provider arriving early, staying late, coming to work on day off; volunteering to give medication to other's patients; frequent bathroom breaks; patients reporting unrelieved pain despite adequate prescription of pain medication)


name: Review computer reports, when available, to identify outliers regarding individual practitioners use of controlled agents


name: Assist the patient in identifying appropriate short-term and long-term goals


name: Appraise the effect of the patient's life situation on roles and relationships


name: Determine the risk of the patient's inflicting self-harm


name: Use supplies and equipment efficiently and effectively


name: Determine whether supplies should be disposable or reusable


name: Determine whether supplies should be purchased or leased


name: Use standardized documentation (e.g., critical paths) to contain costs and maintain quality, as appropriate


name: Evaluate services and programs for cost effectiveness on an ongoing basis


name: Inform patient of the cost and alternatives of when and where to acquire health care services


name: Compress abdomen below the xiphoid with the flat hand while assisting the patient to flex forward as the patient coughs


name: Provide factual information, as necessary and appropriate


name: Reveal selected aspects of one's own experiences or personality to foster genuineness and trust, as appropriate


name: Encourage new skill development, as appropriate


name: Discourage decision-making when the patient is under severe stress, when possible


name: Initiate necessary precautions to safeguard the patient or others at risk from physical harm


name: Encourage patient to focus on one implication at a time


name: Link the patient and family with community resources, as needed


name: Place relevant variables (e.g., outcomes, interventions, laboratory and diagnostic tests, consultations, patient and family education) sequentially on a decision tree


name: Keep the decision tree as simple as possible, even when the clinical events are complex (i.e., provide important details but minimize wordiness and length)


name: Include key decision points in which provider judgment is critical


name: Calculate variances and report through appropriate channels


name: Identify, with the patient, cultural practices that may negatively effect health so the patient can make informed choices


name: Negotiate, when conflicts cannot be resolved, an acceptable compromise of treatment based on biomedical knowledge, knowledge of the patient's belief systems, and ethical standards


name: Facilitate intercultural communication (e.g., use of a translator, bilingual written materials/media, accurate nonverbal communication, avoid stereotyping)


name: Provide information to the health care providers about the patient's culture


name: Determine newborn state before initiating feeding


name: Use clean cup without lid, spout, or lip


name: Pour expressed milk at room temperature or formula into cup


name: Hold swaddled newborn upright or semi-upright while supporting newborn's back, neck, and head


name: Hold cup to newborn's lip, resting slightly on the lower lip. with cup's edges touching outer parts of upper lip


name: Monitor for newborn signs of feeding readiness (e.g., increased alertness, open mouth and eyes, movements with mouth and face)


name: Tip cup so that milk touches newborn's lips


name: Monitor newborn's intake mechanism (i.e., preterm/low birth weight newborn tends to lap milk, whereas full term/older infant tends to sip or suck milk)


name: Burp the newborn frequently during and after the feeding


name: Monitor for newborn signs of fullness (e.g., closing mouth, not taking in more milk, change in infant state, infant not responding to verbal or tactile stimulation)


name: Discontinue feeding upon newborn sign of distress or infant sign of fullness


name: Measure newborn's milk intake over 24 hours


name: Instruct parent on cup feeding procedures


name: Instruct parent about feeding readiness, distress, and feeding termination signs


name: Select a specific cutaneous stimulation strategy based on the individual's willingness to participate, ability to participate, preference, support of significant others, and contraindications


name: Ensure that the electrical stimulation device is in good working order, as appropriate


name: Determine the individual's interest in the dance therapy


name: Inform the individual about purpose of the dance experience


name: Discuss with individual the desired goals (e.g., relaxation, stimulation, concentration, pain reduction)


name: Determine the individual's capabilities for movement


name: Identify preferences for the type of music and dance related to desired goals


name: Determine the time intervals between each session


name: Recommend the wearing of comfortable and appropriate clothing and shoes for dancing


name: Limit distracting visual and auditory stimuli


name: Select a suitable place and the necessary equipment (e.g., sound equipment, music selections, mirrors, chairs), as applicable


name: Plan sessions according to progress in the execution of movements


name: Allow time for pauses and breaks, if applicable


name: Instruct the individual to perform the dance therapy at home, if applicable


name: Incorporate family participation in the sessions, if applicable


name: Monitor continuously the achievement of the objectives and targets


name: Assist patient to clarify values and expectations that may assist in making critical life choices


name: Inform patient of alternative views or solutions in a clear and supportive manner


name: Use interactive computer software or web-based decision aides as an adjunct to professional support


name: Initiate cardiopulmonary resuscitation, as indicated


name: Prepare for immediate defibrillation of pulseless, unresponsive patient in conjunction with cardiopulmonary resuscitation


name: Maintain cardiopulmonary resuscitation when not administering external defibrillation


name: Determine type and operation techniques for available defibrillator


name: Apply pads or paddles according to machine recommendations (e.g., paddles need conduction agent; pads are ready-made with conduction agent)


name: Place appropriate monitoring devices on patients (automated external defibrillator pads or monitor leads)


name: Place paddles or pads to avoid clothing or bed linens, as appropriate


name: Determine need for shock per defibrillator instructions or interpretation of arrhythmia


name: Use safety precautions before discharging (e.g., call "clear" three times; ensure no one is touching the patient including self)


name: Monitor results and repeat, as indicated


name: Minimize interruptions to chest compressions in unresponsive patients


name: Assist in patient recovery (e.g., activate emergency medical systems when out of hospital for transport of patient to emergency care institution; arrange for transport within hospital to appropriate nursing unit for intensive cardiac care) as indicated


name: Instruct new nursing staff on type and operation techniques for available defibrillator


name: Assist in education of public related to proper use and indications of external defibrillation in cardiopulmonary arrest


name: Provide information to patient and family related to defibrillator implantation (e.g., indications, functions, cardioversion experience, required lifestyle changes, potential complications)


name: Provide concrete, objective information related to the effects of defibrillator therapy to reduce patient uncertainty, fear, and anxiety about treatment-related symptoms


name: Document pertinent data in patient's permanent record regarding initial insertion of defibrillator (e.g., manufacturer, model number, serial number, implant date, mode of operation, capability for pacing and/or shock delivery, delivery system for shocks, upper and lower rate limits for rate-responsive devices)


name: Confirm defibrillator placement postimplantation with baseline chest x-ray


name: Monitor for potential complications associated with defibrillator insertion (e.g., pneumothorax, hemothorax, myocardial perforation, cardiac tamponade, hematoma, PVCs, infections, hiccups, muscle twitches)


name: Observe for changes in cardiac or hemodynamic status, which indicate a need for modifications of defibrillator parameters


name: Monitor for conditions that potentially influence sensing (e.g., fluid status changes, pericardial effusion, electrolyte or metabolic abnormalities, certain medications, tissue inflammation, tissue fibrosis, tissue necrosis)


name: Monitor for arm swelling or increased warmth on side ipsilateral to implanted device and leads


name: Monitor for redness or swelling at the device site


name: Instruct patient to avoid tight or restrictive clothing that might cause friction at insertion site


name: Instruct patient on activity restrictions (e.g., initial arm movement restrictions for pectoral implantations, avoidance of heavy lifting, avoid contact sports, adhere to driving restrictions)


name: Monitor for symptoms of arrhythmias, ischemia, or heart failure (e.g., dizziness, syncope, palpitations, chest pain, shortness of breath) particularly with each outpatient contact


name: Instruct patient about emergent symptoms and what to do if symptoms occur (e.g., call emergency responders if dizzy)


name: Monitor drug and electrolyte levels for patients receiving concurrent antiarrhythmic medications


name: Monitor for metabolic conditions with adverse effects on defibrillators (acid-base disturbances, myocardial ischemia, hyperkalemia, severe hyperglycemia [greater than 600 mg/dL], renal failure, hypothyroidism)


name: Instruct patient about potential defibrillator complications from electromagnetic interference (inappropriate discharges, potential proarrhythmic effects of defibrillator, decreased defibrillator generator life, cardiac arrhythmia and arrest)


name: Instruct patient about basic safety in avoidance of electromagnetic interference (e.g., keep at least 6 inches away from sources of interference; do not leave cell phones in the "on" mode in a shirt pocket over the defibrillator)


name: Instruct patient about sources of highest electromagnetic interference (e.g., arc welding equipment, electronic muscle stimulators, radio transmitters, concert speakers, large motor-generator systems, electric drills, handheld metal detectors, magnetic resonance imaging, radiation treatments)


name: Instruct patient regarding special considerations at airport or government building security gates (e.g., always inform security guard of implantable defibrillator; walk through security gates; DO NOT allow handheld metal detectors near the device site; always walk quickly through metal detection devices or ask to be searched by hand; do not lean on or stand near detection devices for long periods)


name: Instruct patient that handheld metal detectors contain magnets that can reset the defibrillator and cause malfunction


name: Instruct patient to check manufacturer warnings when in doubt about household appliances


name: Instruct patient to carry manufacturer identification card at all times


name: Instruct patient to wear a medical alert bracelet or necklace that identifies defibrillator


name: Instruct patient about the need for regular checkups with primary cardiologist


name: Monitor for defibrillator problems that have occurred between scheduled checkup visits (e.g., inappropriate discharges, frequent discharges)


name: Instruct patient to keep a detailed log of all discharges (e.g., time, location, and activity of patient when discharge occurred; physical symptoms before and after discharge) to review with the physician


name: Instruct patient to consult primary cardiologist for all changes in medications


name: Instruct patient with new defibrillator to refrain from operating motor vehicles until permitted per primary cardiologist (usually 3 to 6 months after the last symptomatic arrhythmic event)


name: Instruct patient about the need for regular interrogation of defibrillator by cardiologist for routine maintenance


name: Instruct patient about the need to obtain chest x-ray annually for defibrillator placement confirmation


name: Avoid frightening family or friends about unexpected shocks


name: Instruct patient's family (particularly sexual partners) that no harm comes to a person touching a patient who is receiving a defibrillator discharge (e.g., may feel the shock, but it is not harmful)


name: Teach patient and family member(s) precautions and restrictions required


name: Explore psychological responses (e.g., changes in self-image, depression due to driving restrictions, fear of shocks, increased anxiety, concerns related to sexual activities, changes in partner relationships)


name: Encourage patient and family members to attend CPR classes


name: Encourage attendance at support group meetings


name: Estimate the effect on the nurse's time with the patient and subsequent development of a trusting relationship


name: Be familiar with the defined scope of practice, as outlined by state law and facility guidelines, of the health care provider that will assume the tasks, as appropriate


name: Explain the task to the health care worker


name: Ask questions to learn and clarify the other's understanding of the care to be provided


name: Identify etiological factors causing delirium (e.g., check hemoglobin oxygen saturation)


name: Recognize and document the motor subtype of the delirium (e.g., hypoactive, hyperactive, and mixed)


name: Increase surveillance with a delirium rating scale universally understood by nursing staff when confusion first appears so that acute changes can be easily tracked


name: Use family members or friendly hospital volunteers for surveillance of agitated patients instead of restraints


name: Acknowledge the patient's fears and feelings


name: Avoid demands for abstract thinking if patient can think only in concrete terms


name: Limit need for decision making if frustrating or confusing to patient


name: Administer PRN medications for anxiety or agitation, but limit those with anticholinergic side effects


name: Reduce sedation in general, but do control pain with analgesics, as indicated


name: Do not validate a delirium patient's misperceptions or inaccurate interpretations of reality (e.g., hallucinations or delusions)


name: Respond to the tone, rather than the content, of the hallucination or delusion


name: Remove stimuli that create excessive sensory stimuli (e.g., television or broadcast intercom announcements), when possible


name: Convey unconditional acceptance and support


name: Respond to the patient's delusions with calm, realistic statements


name: Encourage discussion of fears, anxiety, and anger without assuming that the delusion is right or wrong


name: Provide recreational, diversional activities that require attention or skill


name: Protect the patient and others from delusional behaviors that might be harmful


name: Provide appropriate level of surveillance and supervision to monitor patient


name: Administer antipsychotic and antianxiety medications on a routine and as needed basis


name: Provide illness teaching to patient and significant others, if delusions are illness-based (e.g., delirium, schizophrenia, or depression)


name: Determine type and extent of cognitive deficit(s) using standardized assessment tool


name: Address the patient distinctly by name when initiating interaction and speak slowly


name: Avoid touch and proximity if this causes stress or anxiety


name: Avoid unfamiliar situations (e.g., room changes and appointments without familiar people present), when possible


name: Select television or radio activities based on cognitive processing abilities and interests


name: Ask family members and friends to see the patient one or two at a time to reduce stimulation, if needed


name: Limit number of choices patient has to make so not to cause anxiety


name: Use symbols, other than written signs, to assist patient to locate room, bathroom, or other areas


name: Remove or cover mirrors if patient is frightened or agitated by them


name: Avoid terms "bath" and "shower" to reduce anxiety, if possible


name: Simulate homelike environment as much as possible (e.g., wall treatment, soft music, aromatherapy, soft lighting)


name: Give a reason for the bath (e.g., "Let's get your bath done before your daughter comes")


name: Reduce feelings of being cold by providing warm towels, washing feet first, washing face and hair last, or having beautician shampoo hair


name: Place warm towel over head and shoulders while washing lower extremities


name: Massage a soothing lotion into skin after bath


name: Respond accordingly to patient's perceptions (e.g., temperature, pain, and fear of drowning)


name: Give pain medication before bath if movement is painful


name: Remove dentures or offer something to eat to prevent biting during the bath


name: Identify usual patterns of wandering behavior


name: Modify unsafe aspects of patient's home (i.e., remove throw rugs, label rooms, and keep the house well lighted)


name: Alert neighbors about the patient's wandering behavior


name: Alert police and have current pictures taken


name: Provide patient with a medical alert bracelet or necklace


name: Monitor medication interactions, side effects, and desired therapeutic effects


name: Recommend medication adjustments, as needed


name: Assure the patient has adequate hydration


name: Install complex safety locks on doors to outside or basement


name: Install alarm and sensor devices on doors


name: Use technological electronic devices to locate and monitor wandering (e.g., GPS [Global Position Satellite], RFID [Radio Frequency Identification])


name: Provide a secure and safe place for wandering


name: Encourage physical activity during the daytime


name: Give patient a card with simple instructions (address and phone number) should the patient get lost


name: Provide caregivers that are familiar to the patient


name: Avoid taking any notes, documents, or reports into the deposition unless instructed by your attorney


name: Answer "I do not remember" or "I don't recall" if you do not remember a fact


name: Answer questions with a "yes" or "no" answer, if possible


name: Ask to talk with your attorney privately, if needed


name: Screen for health problems relevant to the adolescent and/or suggested by patient history (e.g., anemia; hypertension; hearing and vision disorders; hyperlipidemia; oral health problems; abnormal sexual maturation; abnormal physical growth; body image disturbances; eating disorders; poor nutrition; alcohol, tobacco, or drug use; unhealthy sexual behavior; infectious disease; poor self-concept; low self-esteem; depression; difficult relationships; abuse; learning problems; or work problems)


name: Facilitate caregiver's contact with community resources, as appropriate


name: Refer caregivers to support group, as appropriate


name: Monitor prescribed medication regime, as appropriate


name: Assure that medical tests and/or treatments are done in a timely manner, as appropriate


name: Instruct parent on what constitutes appropriate infant nutrition and nutritional habits


name: Discuss and support decision to breastfeed or bottle feed


name: Instruct on proper storage, preparation, and handling of breast milk or prepared infant formula


name: Introduce solid foods at approximately 6 months of age, instructing parent on the selection and preparation of foods, methods of introduction, and food storage


name: Instruct parent to avoid offering the infant a bottle containing juice or milk when in bed


name: Provide anticipatory guidance for infant weaning, including signs of readiness


name: Encourage establishment of bedtime rituals that reduce or eliminate disturbances in sleep-wake cycle


name: Assisting parent in identifying presence of sleep disturbance or disorder


name: Determine appropriate management technique for sleep disturbance or disorder


name: Discuss the risks and benefits of infant and caregiver cosleeping


name: Provide visual, auditory, tactile, and kinetic stimulation during play


name: Structure play and care around infant's behavioral style and temperament patterns


name: Provide developmentally appropriate, safe toys and activities


name: Explain the need for fluoride supplementation beginning at 6 months of age


name: Instruct parent to begin cleaning infant's oral cavity with damp cloth upon eruption of first tooth


name: Use soft-bristled toothbrush with water or nonfluoridated toothpaste once several teeth have erupted


name: Determine appropriate scheduling for initial and subsequent dental examinations


name: Perform recommended screenings (e.g., anemia, lead exposure, and vision)


name: Provide accurate information pertaining to risks, benefits, contraindications, and side effects of scheduled immunizations


name: Identify need for additional immunizations for selected groups of children


name: Provide anticipatory guidance concerning discipline, dependency, increased mobility, and safety


name: Discuss timeout versus corporal punishment strategies for discipline, encouraging the former


name: Instruct parent on injury prevention strategies tailored to child's specific developmental stage and curiosity level


name: Encourage provision of safe space for infant exploration


name: Discuss injury prevention strategies for fire and electrical burns, suffocation and aspiration, poisoning, falls, bodily injury, drowning, and motor vehicle injury


name: Instruct parent on prevention strategies for sudden infant death syndrome (SIDS)


name: Instruct parent about child temperament and its association with infant's interaction type with others


name: Promote and facilitate family bonding and attachment with infant


name: Support and praise parent skills and efforts


name: Discuss parent return to work and childcare options


name: Identify and address presence of family strife, lack of support, and pathology


name: Provide information to parent about child development and child rearing


name: Refer for parenting education, as needed


name: Monitor access site for redness, edema, heat, drainage, bleeding hematoma, and decreased sensation


name: Teach patient about how to care for dialysis access site


name: Avoid venipuncture and blood pressures in peripheral access extremity


name: Clamp nasogastric tube and monitor tolerance, as appropriate


name: Determine whether patient is passing flatus


name: Find ways to include patient preferences in the prescribed diet


name: Make the environment in which the meal is offered as pleasant as possible


name: Institute NPO or sips of water only for the first 24 to 48 hours after surgery, according to agency policy


name: Administer solutions of dextrose, saline, or lactated ringers to provide adequate nutrition in first 24 hours and until patient can tolerate a full liquid diet


name: Progress to a liquid diet that lasts 2 to 3 weeks


name: Instruct patient to sip room-temperature liquids (e.g., broth, unsweetened juice, milk) slowly, consuming between two to three ounces at a time


name: Instruct patients to carry with them sugar-free beverages and drink often


name: Incorporate pureed foods (e.g., broth blended with well-cooked beans, fish, or ground meats; yogurt; blended fruits) in diet once the patient's body has adjusted to liquids


name: Add mashed solid foods (e.g., finely diced meats, canned fruits, oatmeal, eggs) between 6 to 8 weeks postsurgery


name: Instruct patient to eat the protein foods on the plate first


name: Progress to firmer foods that are low in sugar, low in saturated and trans fat, and contain high-quality protein, maintaining this diet for life


name: Encourage patients to eat breakfast and at least four to five small meals daily


name: Instruct patients to take small bites, eat slowly, and chew solids that are well-cooked


name: Instruct patients to incorporate fresh fruits and vegetables in their fluid and food intake


name: Monitor for lactose intolerance as a possible postsurgical complication


name: Work with a dietitian after surgery to ensure that protein nutrition is optimal and to modify the diet as required


name: Instruct patient to avoid foods and beverages with large amounts of sugar (e.g., soda, juice drinks, milk shakes, regular ice cream) as these may cause a dumping syndrome


name: Instruct patient to avoid drinking approximately half an hour before eating, during the meal, and half an hour after the meal to reduce vomiting and diarrhea


name: Instruct patient about need to take an adult strength multivitamin with iron, a B-complex supplement, and added calcium


name: Encourage patients to keep a record of types and quantities of foods that cause discomfort, distress, or intolerance


name: Encourage patients to do at least 35 minutes of daily aerobic exercise with strength training three times per week to maintain a good metabolic rate


name: Encourage attendance at a support group for several months postsurgery


name: Assist patient/family/significant other(s) to prepare for discharge


name: Determine the patient's abilities for discharge


name: Collaborate with the physician, patient, family, significant others, and other health team members in planning for continuity of health care


name: Assist patient, family, and significant others in planning for the supportive environment necessary to provide the patient's posthospital care


name: Encourage the individual to choose the distraction technique(s) desired (e.g., music, engaging in conversation or telling a detailed account of event or story, recalling positive event, focusing on photo or neutral object, guided imagery, humor, or deep breathing exercises)


name: Use distraction techniques for children (e.g., play, activity therapy, reading stories, singing songs, or rhythm activities) that are novel, appeal to more than one sense, and do not require literacy or thinking ability


name: Identify with the patient a list of pleasurable activities (e.g., exercise, going for walks, bubble baths, talking to friends or family)


name: Instruct patient how to engage in the distraction (e.g., prompting neutral word, equipment, or materials) before the time needed, if possible


name: Use distraction alone or in conjunction with other measures or distractions, as appropriate


name: Use standardized forms for federal and state regulations and reimbursement as indicated


name: Chart baseline assessments and care activities using agency specific forms/flow sheets


name: Document evidence of client's specific claims (e.g., Medicare, workers compensation, insurance, or litigation-related claims)


name: Take minutes with a laptop or tablet in addition to any recording device used


name: Ensure that any electronic devices and media are connected and working well


name: Sit close to the officiating officer so you can easily ask questions and get clarification


name: Circulate an attendance list labeled with the meeting's name and date


name: Take advantage of name tags or placards if participants' names are unfamiliar


name: Begin the document with the name of the facility or organization committee as well as the meeting's location, time, place, and date


name: List names of those who are present and possibly the names of those absent or excused


name: Identify the purpose of the meeting and the officiating officer


name: Use the agenda as a structure for the minutes, but record the minutes to reflect the actual sequence of events (e.g., approval of minutes of previous meetings, approval of agenda, unfinished business, new business)


name: Record all motions and the outcomes of all votes


name: Include key discussion items and actions that have been agreed upon including assignments and timelines


name: Record any additional items, including announcements and adjournment of the meeting


name: Create an attachments list of any reports distributed for the meeting


name: Keep the writing clear, objective, and succinct


name: Finish the minutes as soon as possible while the details are fresh in mind


name: Include your name at the end as the minute's recorder


name: Proofread the document and send to the chair for approval


name: Distribute the minutes to the membership before the next meeting


name: File approved minutes according to organizational policy


name: Consult the most current edition of Robert's Rules of Order for information on meeting protocol and taking minutes


name: Dress patient after personal hygiene completed


name: Monitor signs and symptoms (e.g., redness, burning, itching, drainage, pain around and in the eye, difficulty in opening eyes on waking and moving lids, blurred vision) of dry eye


name: Identify personal characteristics (e.g., age, gender, hormones, autoimmune diseases, chemical burn) and environmental factors (e.g., dry air, air conditioning, sunlight) that may increase potential of dry eye


name: Monitor amount of tearing using tear strips


name: Screen the corneal epithelial damage using a standard test


name: Monitor patient's ability to wear, remove, and clean contact lenses, as appropriate


name: Instruct patient to avoid prolonged reading and lengthy computer use


name: Ensure the endotracheal bandages are not too tight in patients ventilated through an endotracheal tube


name: Monitor the mode and the pressure of the ventilator in mechanically ventilated patients


name: Identify the frequency and the type of the care according to the eyelid position in lagophthalmos (e.g., in comatose, under deep sedation and neuromuscular blockage, facial paralysis, Bell's palsy, thyrotoxic exophthalmos, paralytic ectropion)


name: Administer eye care at least twice a day, as appropriate


name: Apply lubricants (e.g., eye drops, ointments) to support tear production, as appropriate


name: Cover the eyes with effective devices (e.g., polyethylene cover, polyacrylamide gel, hypoallergenic tape), as appropriate


name: Prepare the patient for a tarsorrhaphy to protect the cornea


name: Inspect ocular surface and the cornea for effects of care and prophylactic treatment


name: Report abnormal signs and symptoms to the physician


name: Assist patient and family to identify a shared meaning of death


name: Seek to understand patient's actions, feelings, and attitudes


name: Facilitate care by others, as appropriate


name: Facilitate referral to hospice, as desired


name: Monitor for signs and symptoms of autonomic dysreflexia (e.g., paroxysmal hypertension, bradycardia, tachycardia, diaphoresis higher than the level of injury, facial flushing, pallor lower than the level of injury, headache, nasal congestion, engorgement of temporal and neck vessels, conjunctival congestion, chills without fever, pilomotor erection, and chest pain)


name: Investigate and remove offending cause (e.g., distended bladder, fecal impaction, skin lesions, constricting bed clothes, supportive stockings, and abdominal binders)


name: Place head of bed in upright position to decrease blood pressure and promote cerebral venous return, as appropriate


name: Apply electrocardiographic (ECG) "wireless" telemetry or "hardwired" electrodes and connect to a cardiac monitor, as indicated


name: Ensure appropriate lead selection in relation to patient needs


name: Ensure proper lead placement, and signal quality


name: Ensure ongoing monitoring of bedside ECG by qualified individuals


name: Monitor ECG changes that increase risk of dysrhythmia development (e.g., arrhythmia, ST-segment, ischemia, and QT-interval monitoring)


name: Facilitate acquisition of a 12-lead ECG, as appropriate


name: Ensure ready access of emergency dysrhythmia medications


name: Administer basic or advanced cardiac life support, if indicated


name: Instruct patient and family about the risks associated with the dysrhythmia(s)


name: Instruct patient and family about actions and side effects of prescribed medications


name: Instruct patient and family about self-care behaviors associated with use of permanent pacemakers and AICD devices, as indicated


name: Instruct patient and family about measures to decrease the risk of recurrence of the dysrhythmia(s)


name: Instruct patient and family about how to access the emergency medical system


name: Monitor anatomical structures for signs and symptoms of infection (e.g., inflamed tissue and drainage)


name: Instruct patient on the ear's anatomical structures and their function


name: Monitor for patient-reported signs and symptoms of dysfunction (e.g., pain, tenderness, itching, change in hearing, tinnitus, and vertigo)


name: Monitor episodes of chronic otitis media (i.e., ensure appropriate preventative measures and treatments are employed)


name: Instruct parent how to observe for signs and symptoms of auditory dysfunction or infection in child


name: Instruct patient on importance of annual hearing testing


name: Instruct women of childbearing age on importance of prenatal care (e.g., avoidance of ototoxic medications, adequate dietary intake, and strict control of alcoholism)


name: Inform parent about vaccinations which eliminate the possibility of sensorineural hearing loss (e.g., vaccination against rubella, measles, and mumps)


name: Cleanse external ear using washcloth-covered finger


name: Monitor for an excessive accumulation of cerumen


name: Instruct parent to ensure child does not place foreign objects into ear


name: Instruct patient how to monitor for persistent exposure to loud noise


name: Instruct patient on importance of hearing protection during persistent exposure to loud noise


name: Instruct parent to avoid bottle-feeding or allowing infant to bottle-feed when in supine position


name: Encourage use of earplugs for swimming if patient is susceptible to ear infections


name: Instruct patient on appropriate use of and care for assistive devices or treatments (e.g., hearing aids, medication regimen, and ear tubes)


name: Instruct patient on signs and symptoms warranting reporting to health care provider


name: Refer patient to ear care specialist, as needed


name: Collaborate with other members of health care team to develop a treatment plan; involve patient and/or significant others, as appropriate


name: Weigh on a routine basis (e.g., at same time of day and after voiding)


name: Accompany patient to bathroom during designated observation times after meals/snacks


name: Limit physical activity to promote weight gain, as needed


name: Provide a supervised exercise program, when appropriate


name: Assist patient to develop a self-esteem that is compatible with a healthy body weight


name: Encourage patient (and significant others, as appropriate) to express feelings regarding the prospect of ECT treatment


name: Confirm there is a written order and signed consent for ECT treatment


name: Discontinue or taper medications contraindicated for ECT as per physician order


name: Obtain a fasting blood glucose reading preprocedure and postprocedure for those patients who have insulin-dependent diabetes


name: Administer medications before and throughout the treatment as ordered by the physician


name: Verbally communicate unusual vital signs, physical complaints/symptoms, or unusual occurrences to the ECT nurse or ECT psychiatrist before the treatment


name: Assist the treatment team in placing leads for various monitors (e.g., EEG, ECG) and monitoring equipment (e.g., pulse oximeter, blood pressure cuff, peripheral nerve stimulator) on to the patient