name: Instruct patient on techniques for self-irrigation


name: Administer nasal medication, if necessary


name: Provide referral to health care provider


name: Verify that the patient has no contraindications for nasal placement (e.g., basilar skull fracture; facial, nasal or sinus trauma; esophageal varices or stricture; or clotting abnormalities)


name: Select type and size of tube to insert (i.e., small bore tubes are used for feeding and administering medications whereas large bore tube are used for gastric drainage; some have electromagnetic guidance systems)


name: Explain to the patient and family the rationale for using a nasogastric tube


name: Place patient in a supine position with head of bed elevated at least 30 degrees unless contraindicated


name: Determine the length of tube to be inserted into stomach by measuring the tube from the tip of the nose to the tip of the earlobe and to the bottom of the xiphoid process


name: Add additional length if the tube is to pass through the pyloric sphincter


name: Provide the patient with a glass of water to swallow during insertion, as appropriate


name: Lubricate the distal end of the tube with water or water soluble jelly


name: Insert the tube into the naris and advance along the base of the nostril to the posterior pharynx


name: Instruct patient to swallow and advance the tube to the predetermined marking


name: Apply skin preparation to the nose and securing surface of the face


name: Tape the tube securely to the nose so that the tube does not press against the skin of the naris


name: Label the tube with the date and time of placement


name: Obtain radiograph to confirm placement of the tube in the gastrointestinal tract


name: Encourage to monitor own nausea experience


name: Encourage to learn strategies for managing own nausea


name: Perform complete assessment of nausea, including frequency, duration, severity, and precipitating factors; use such tools as Self-Care Journal, Visual Analog Scales, Duke Descriptive Scales, and Rhodes Index of Nausea and Vomiting (INV) Form 2


name: Consider the cultural influence on nausea response when implementing intervention


name: Encourage not to tolerate nausea but to be assertive with health providers in obtaining pharmacological and nonpharmacological relief


name: Use frequent oral hygiene to promote comfort unless it stimulates nausea


name: Instruct in high carbohydrate and low fat food, as appropriate


name: Provide information about the nausea such as causes of the nausea and how long it will last


name: Monitor for visual disturbance (e.g., diplopia, nystagmus, visual-field cuts, blurred vision, visual acuity)


name: Monitor muscle tone, motor movement, gait, and proprioception, comparing both sides of body simultaneously


name: Monitor for pronator drift, comparing both sides of body simultaneously


name: Monitor grip strength, comparing both sides of body simultaneously


name: Monitor for tremor, comparing both sides of body simultaneously


name: Monitor vital signs (e.g., temperature, blood pressure, pulse, respirations)


name: Monitor respiratory status (e.g., ABG levels, pulse oximetry, depth, pattern, rate, effort)


name: Monitor speech characteristics (e.g., fluency, presence of aphasias, or word-finding difficulty)


name: Monitor response to stimuli (e.g., verbal, tactile, noxious)


name: Monitor sharp and dull or hot and cold discrimination


name: Monitor for Cushing response (i.e., rising systolic pressure with widening pulse and bradycardia)


name: Monitor craniotomy or laminectomy dressing for drainage


name: Increase frequency of neurological monitoring, as appropriate


name: Institute agency protocol for specific neurological condition (e.g., stroke, tumor, aneurism, trauma), as needed


name: Move infant's tongue rhythmically with the pacifier to encourage sucking, if needed


name: Provide pacifier to encourage sucking during tube feeding and for 5 minutes after the tube feeding


name: Rock and hold baby while infant sucks on pacifier when possible


name: Inform parent(s) on importance of meeting infant sucking needs


name: Encourage breastfeeding mother to allow nonnutritive sucking at breast after feeding complete


name: Inform parents of alternatives to nipple sucking (e.g., thumb, parent's finger, pacifier)


name: Assist the family in accepting the child's condition


name: Assist family to view the child as a child first, rather than as a chronically ill or disabled individual


name: Encourage interaction with healthy peers


name: Encourage the family to modify preconceived developmental expectations by focusing more on smaller unexpected achievements


name: Assist family in altering prescribed therapeutic regime to fit normal schedule, when appropriate


name: Encourage parents to have same parenting expectations and techniques for all children in family


name: Determine patient's nutritional status and ability to meet nutritional needs


name: Identify patient's food allergies or intolerances


name: Instruct patient about nutritional needs (i.e., discuss dietary guidelines and food pyramids)


name: Assist patient in determining guidelines or food pyramids (e.g., Vegetarian Food Pyramid, Food Guide Pyramid, and Food Pyramid for Seniors over 70) most suited in meeting nutritional needs and preferences


name: Determine number of calories and type of nutrients needed to meet nutrition requirements


name: Provide food selection, offering guidance toward healthier choices, if necessary


name: Adjust diet (i.e., provide high protein foods, suggest using herbs and spices as an alternative to salt, provide sugar substitute, increase or decrease calories, increase or decrease vitamins, minerals, or supplements), as necessary


name: Provide optimal environment for meal consumption (e.g., clean, well-ventilated, relaxed, and free from strong odors)


name: Perform or assist patient with oral care before eating


name: Ensure patient uses well-fitting dentures, if appropriate


name: Administer medications before eating (e.g., pain relief, antiemetics), if needed


name: Encourage patient to sit in upright position in chair, if possible


name: Ensure food is served in attractive manner and at temperature most suited for optimal consumption


name: Encourage family to bring patient's favorite foods while in hospital or care facility, as appropriate


name: Assist patient with opening packages, cutting food, and eating, if needed


name: Instruct patient on necessary diet modifications (e.g., NPO, clear liquid, full liquid, soft, or diet as tolerated), as necessary


name: Instruct patient on diet requirements for disease state (i.e., for patients with renal disease, restrict sodium, potassium, protein, and fluids)


name: Instruct patient on specific dietary needs based on development or age (e.g., increased calcium, protein, fluid, and calories for lactating women; increased fiber intake to prevent constipation among older adults)


name: Instruct patient to monitor calorie and dietary intake (e.g., food diary)


name: Assist patient in accessing community nutritional programs (e.g., Women, Infants, and Children, food stamps, and home-delivered meals)


name: Determine in collaboration with the dietitian, the number of calories and type of nutrients needed to meet nutrition requirements, as appropriate


name: Monitor laboratory values, as appropriate


name: Establish realistic short-term and long-term goals for change in the nutritional status


name: Discuss patient's knowledge of the basic four food groups, as well as perceptions of the needed diet modification


name: Discuss nutritional requirements and patient's perceptions of prescribed or recommended diet


name: Encourage use of the Internet to access useful information on diet, recipes, and lifestyle modification, as appropriate


name: Provide referral or consultation with other members of the health care team, as appropriate


name: Obtain anthropometric measurements of body composition (e.g., body mass index, waist measurement, and skinfold measures)


name: Monitor trends in weight loss and gain (i.e., in pediatric patients, plot height and weight on standardized growth chart)


name: Determine appropriate amount of weight gain during antepartum period


name: Identify abnormalities in skin (e.g., excessive bruising, poor wound healing, and bleeding)


name: Identify abnormalities in hair (e.g., dry, thin, course, and breaks easily)


name: Identify abnormalities in bowel elimination (e.g., diarrhea, blood, mucus, and irregular or painful elimination)


name: Identify recent changes in appetite and activity


name: Discuss role of social and emotional aspects of food consumption


name: Determine meal patterns (e.g., food likes and dislikes, overconsumption of fast food, missed meals, hurried eating, parent-child interaction during feeding, frequency and length of infant feedings)


name: Identify abnormalities in nails (e.g., spoon-shaped, cracked, split, broken, brittle, and ridged nails)


name: Perform swallowing evaluation (e.g., motor function of facial, oral, and tongue muscles, swallowing reflex, and gag reflex)


name: Identify abnormalities in oral cavity (e.g., inflammation; spongy, receding, or bleeding gums; dry, cracked lips; sores; scarlet, raw tongue; and hyperemic and hypertrophic papillae)


name: Monitor mental state (e.g., confusion, depression, and anxiety)


name: Identify abnormalities in musculoskeletal system (e.g., muscle wasting, painful joints, bone fractures, poor posture)


name: Conduct laboratory testing, monitoring results (e.g., cholesterol, serum albumin, transferrin, prealbumin, 24-hour urinary nitrogen, blood urea nitrogen, creatinine, hemoglobin, hematocrit, cellular immunity, total lymphocyte count, and electrolyte levels)


name: Determine energy recommendation (e.g., Recommended Dietary Allowance) based on patient factors (e.g., age, weight, height, gender, and physical activity level)


name: Determine factors affecting nutritional intake (e.g., knowledge, availability, and accessibility of quality food products in all food categories; religious and cultural influences; gender; ability to prepare food; social isolation; hospitalization; inadequate chewing; impaired swallowing; periodontal disease; poor-fitting dentures; decreased taste sensitivity; use of drugs or medications; and disease or postsurgical states)


name: Review other sources of data pertaining to nutritional status (e.g., patient food diary and written logs)


name: Initiate treatment or provide referral, as appropriate


name: Recommend the use of a soft-bristled toothbrush


name: Monitor condition of patient's mouth (e.g., lips, tongue, mucous membranes, teeth, gums, and dental appliances and their fit)


name: Provide oral health screening and risk assessment


name: Determine patient's usual dental hygiene routine, identifying areas to be addressed, if necessary


name: Instruct patient or patient's family on frequency and quality of proper oral health care (e.g., flossing, brushing, and rinsing; adequate nutrition; use of fluoride-containing water, supplement, or other preventive product; and other considerations based on patient's developmental level and self-care ability)


name: Assist patient in brushing (teeth, gums, and tongue), rinsing, and flossing, as needed


name: Assist patient wearing dentures in oral care, as needed (i.e., remove, cleanse, and reinsert dentures; brush gums, remaining teeth, and tongue; and massage gums with brush or fingers)


name: Provide oral care for unconscious patient using appropriate precautions (i.e., turn patient's head to side or place in side-lying position when possible, insert bite block or padded tongue blade, avoid putting fingers in mouth, use small amounts of liquid, and use bulb syringe or other suction device)


name: Cleanse infant's mouth using dry gauze or washcloth


name: Assist patient or patient's family in identifying and obtaining oral care products most suited to meet needs (e.g., toothbrush with easy-to-grasp handle, powered toothbrush, dental floss holder, immersion cleanser for dentures, and athletic mouthguard)


name: Discuss role of sugar in development of caries (i.e., encourage patient to limit natural sugar intake; suggest use of artificial sweeteners in diet, particularly xylitol; and instruct parent on appropriate use of bottles and sippy cups and their contents)


name: Discourage smoking and tobacco chewing (i.e., instruct patient on effects of tobacco use, implement tobacco-use prevention measures, and provide tobacco-cessation assistance)


name: Discuss importance of regular dental checkups, including timing of child's first visit to dental health professional


name: Provide community-level services (i.e., assist patient in meeting needs for transportation and translational services, use health fairs and cultural events as opportunities for education, and develop public service announcements)


name: Monitor condition of patient's mouth (e.g., lips, tongue, mucous membranes, teeth, gums, and dental appliances and their fit), including character of abnormalities (e.g., size, color, and location of internal or external lesions or inflammation, and other signs of infection)


name: Monitor changes in taste, swallowing, quality of voice, and comfort


name: Obtain order from health care provider to perform oral hygiene, if applicable


name: Determine necessary frequency for oral care, encouraging patient or patient's family to adhere to schedule, or assisting with oral care, as needed


name: Instruct patient to use soft-bristled toothbrush or disposable mouth sponge


name: Instruct patient on appropriate selection of floss use and type (i.e., avoid use if at-risk for bleeding; use waxed floss to prevent tissue trauma)


name: Administer mouth rinse to patient (e.g., anesthetic, effervescent, saline, coating, antifungal, or antibacterial solution)


name: Administer medication (e.g., analgesics, anesthetics, antimicrobials, and antiinflammatory agents), if needed


name: Remove dentures, encouraging patient to use only for meals


name: Instruct patient to avoid oral hygiene products containing glycerin, alcohol, or other drying agents


name: Instruct patient to keep toothbrushes and other cleaning equipment clean


name: Discuss importance of adequate nutritional intake (i.e., address malnutrition caused by deficiencies in folate, zinc, iron, and complex B vitamins; encourage consumption of high-protein, high vitamin C-containing foods)


name: Encourage avoidance of spicy, salty, acidic, dry, rough, or hard foods


name: Instruct patient to avoid foods causing allergenic response (e.g., coffee, cheese, nuts, citrus fruits, gluten, and potatoes), if applicable


name: Encourage patient to increase water intake


name: Instruct patient to avoid hot foods and liquids, preventing burns and further irritation


name: Instruct patient on signs and symptoms of stomatitis, including when to report to health care provider


name: Assist a physician who lacks computer skills with computerized order entry using the physician's log-in name and confirmation that the order is correct


name: Transfer order to appropriate electronic document, worksheet, medication form, laboratory slip, care plan, or Kardex


name: Participate in the development and improvement of a computerized order entry system for physicians and other providers who write orders


name: Review regulatory requirements and institutional policy and procedures for organ donation (i.e., in the United States, Center for Medicare and Medicaid Services and the Joint Commission mandate that every patient for whom death is imminent must be referred to the local Organ Procurement Organization (OPO) responsible for approaching the patient and family for possible organ donation)


name: Participate in health care team discussions concerning the patient's condition, prognosis, and plan of care so all can speak with uniformity


name: Verify that the OPO coordinator has been alerted if the patient has a life-threatening illness or injury


name: Obtain laboratory samples as prescribed (e.g., CBC, electrolyte levels, liver and renal function tests, hepatitis and HIV testing)


name: Assist with the determination of brain death, as appropriate


name: Ensure that brain death criteria have been met and documented


name: Realize that the OPO coordinator will make the request for donation and prescribe the appropriate testing for donation


name: Provide a private space where the OPO coordinator can approach the family to discuss organ donation


name: Obtain blood samples for blood and tissue typing as directed by the OPO coordinator


name: Administer IV fluids and vasoactive medications as prescribed


name: Prepare the family for what to expect during withdrawal of life-support therapy, as appropriate


name: Support the family through the end-of-life process


name: Assist with transfer of the patient to the operating room as directed by the OPO coordinator


name: Provide a mechanism for the family to obtain information about the organ recovery procedures


name: Offer family postmortem viewing of the body, when possible


name: Understand that ethical dilemmas may arise related to organ allocation, transplant candidacy, and available technologies


name: Help patients and families access quality health care information about organ donation and transplant


name: Conduct community education programs about organ donation and transplant


name: Monitor for postop complications, such as intestinal obstruction, paralytic ileus, anastomotic leaks, or mucocutaneous separation, as appropriate


name: Instruct patient to intubate and drain Indiana pouch whenever it feels full (every 4 to 6 hours)


name: Assure replacement of oxygen mask/cannula whenever the device is removed


name: Monitor patient's ability to tolerate removal of oxygen when eating


name: Provide information to patient and family related to pacemaker implantation (e.g., indications, functions, universal programming codes, potential complications)


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


name: Document pertinent data in patient permanent record for initial insertion of pacemaker (e.g., manufacturer, model number, serial number, implant date, mode of operation, programmed parameters, upper and lower rate limits for rate-responsive devices, type of lead fixation, unipolar or bipolar lead system, capability for pacing and/or shock delivery, delivery system for shocks)


name: Assure confirmation of pacemaker placement postimplantation in initial insertion with baseline chest x-ray


name: Monitor for signs of improved cardiac output at specified intervals after initiation of pacing (e.g., improved urine output, warm and dry skin, freedom from chest pain, stable vital signs, absence of JVD and crackles, improved level of consciousness), per facility protocol


name: Palpate peripheral pulses at specified intervals per facility protocol to ensure adequate perfusion with paced beats


name: Monitor for failure to pace and determine cause (e.g., lead dislodgement, fracture, or migration), as appropriate


name: Monitor for failure to capture and determine cause (e.g., lead dislodgement or malposition, pacing at voltage lower than capture threshold, faulty connections, lead fracture, ventricular perforation), as appropriate


name: Monitor for failure to sense and determine cause (e.g., sensitivity set too high, malposition of catheter lead, lead fracture, lead insulation break), as appropriate


name: Obtain chest x-ray immediately in the event of suspected lead fracture, patch crinkling, lead dislodgement, or lead migration


name: Monitor for pacemaker problems that have occurred between scheduled checkup visits


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


name: Perform a comprehensive appraisal of peripheral circulation (i.e., check peripheral pulses, edema, capillary refill, skin temperature. and diaphoresis) in any initial assessment of pacemaker patients and before initiating corrective actions


name: Determine type and mode of pacemaker, including universal pacemaker code information for the five positions, before initiating corrective actions


name: Gather additional data if possible from patient's permanent record (e.g., date of implantation, frequency of use, programming changes and parameters) before initiating corrective actions


name: Monitor heart rate and rhythm at specified intervals and with changes in patient condition


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


name: Instruct patient regarding the potential hazards for electromagnetic interference from outside sources (i.e., 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 pacemaker)


name: Instruct patient regarding the 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 the potential hazards from environmental interactions (e.g., inappropriate pacing or rhythm sensing, shortened generator life, cardiac arrhythmias, cardiac arrest)


name: Instruct patient regarding the potential hazards from metabolic disruptions (e.g., potential to increase pacer or capture thresholds)


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


name: Instruct patient with new pacemaker to refrain from operating motor vehicles until permitted, per primary cardiologist (usually 3 months minimally)


name: Instruct patient in the need for regular monitoring of pacemaker sensing and capture thresholds


name: Instruct patient in the need for regular interrogation of pacemaker by cardiologist for evidence of electromagnetic interference


name: Instruct patient in the need to obtain chest x-ray at least annually for continued pacemaker placement confirmation


name: Instruct patient of the signs and symptoms of dysfunctional pacemaker (e.g., bradycardia less than 30 beats per minute, dizziness, weakness, fatigue, chest discomfort, angina, shortness of breath, orthopnea, pedal edema, paroxysmal nocturnal dyspnea, dyspnea on exertion, hypotension, near-syncope, frank syncope, cardiac arrest)


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


name: Instruct patient on the special considerations at government security gates or the airport (e.g., always inform security guard of implantable pacemaker, 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 pacemaker and cause malfunction


name: Instruct patient's family that no harm comes to a person touching a patient who is receiving a pacemaker discharge


name: Determine indications for temporary pacing and duration of intended pacing support


name: Determine intended mechanics of pacing (e.g., internal or external, unipolar or bipolar, transthoracic, epicardial, or central venous catheter), including appropriateness of type of pulse generator selected


name: Perform a comprehensive appraisal of peripheral circulation (i.e., check peripheral pulses, edema, capillary refill), skin temperature, and diaphoresis


name: Instruct patient regarding the chosen pacemaker (e.g., purpose, indications, mechanics, duration)


name: Ensure externally paced patients are aware of possibility of discomfort and availability of sedation for comfort and/or relaxation


name: Obtain informed consent for insertion of the selected temporary pacemaker


name: Prepare the chosen pacemaker for use, per facility protocol (i.e., ensure battery is fresh, identify atrial and ventricular wire sets, identify positive and negative leads for each pair of wires, identification labels, as indicated/preferred)


name: Assist with insertion or placement of selected device, as appropriate


name: Apply external transcutaneous pacemaker electrodes to clean, dry skin on the left anterior chest and to the posterior chest, as appropriate


name: Provide sedation and analgesia for patients with external transcutaneous pacemaker, as indicated


name: Set rate according to patient need as directed by physician (general guidelines: 90 to 110 beats per minute surgical patients, 70 to 90 beats per minute medical patients, 80 beats per minute cardiac arrest patients)


name: Set the milliamperage according to patient (general adult guidelines: nonurgent 10 mA; emergent 15 to 20 mA); increase mA until capture is present


name: Monitor patient response to mA setting at regular intervals in anticipation of fluctuations resulting from endothelial sheath formation around electrode tips


name: Set the sensitivity (general adult guidelines: 2 to 5 millivolt, if failure to sense occurs, turn millivolt DOWN; if sensing beats not actually present, turn millivolt UP)


name: Initiate pacing by slowly increasing mA level delivered until consistent capture (capture threshold) occurs (general guidelines of mA output at 1.5 to 3 times higher than threshold, and minimally 15 to 20 mA in emergent conditions)


name: Obtain chest x-ray examination after insertion of invasive temporary pacemaker


name: Observe for changes in cardiac or hemodynamic status that indicate a need for modifications in pacemaker status


name: Monitor for failure to pace and determine cause (e.g., battery failure, lead dislodgement, wire fracture, disconnected wire or cable), as appropriate


name: Monitor for failure to capture and determine cause (e.g., lead dislodgement or malposition, battery failure, pacing at voltage lower than capture threshold, faulty connections, lead fracture, ventricular perforation), as appropriate


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


name: Perform capture and sensitivity threshold testing every 24 to 48 hours with newly inserted pacers to determine best generator settings (contraindicated in patients paced 90% or more of the time)


name: Perform threshold testing separately for atrial and ventricular chambers


name: Provide appropriate incisional care for pacemakers with insertion sites (e.g., dressing change, antimicrobial and sterile occlusive dressing per facility protocol)


name: Ensure that all equipment is grounded, in good working order, and carefully located (e.g., in a location from which it will not be dropped on the floor)


name: Ensure that wires are of a length to deter inadvertent dislodging of electrodes


name: Insulate electrode wires when not in use (e.g., cover unused thoracic wires with the fingertip of a disposable glove)


name: Teach patient and family member(s) precautions and restrictions required when temporary pacemaker is in place (e.g., limitation of movement, avoid handling the pacemaker)


name: Identify pain intensity during movements such as required recovery activities (e.g., coughing and deep breathing, ambulation, transfers to chair)


name: Explore patient's knowledge and beliefs about pain, including cultural influences


name: Monitor pain using a valid and reliable rating tool appropriate for age and ability to communicate


name: Question patient regarding the level of pain that allows a state of comfort and appropriate function and attempt to keep pain at or lower than identified level


name: Ensure that the patient receives prompt analgesic care before the pain become severe or before pain-inducing activities


name: Administer analgesics around-the-clock the first 24 to 48 hours after surgery, trauma, or injury except if sedation or respiratory status indicates otherwise


name: Monitor sedation and respiratory status before administering opioids and at regular intervals when opioids are administered


name: Follow agency protocols in selecting analgesic and dosage


name: Use combination analgesics (e.g., opioids plus nonopioids), if pain level is severe


name: Select and implement intervention options tailored to the patient's risks benefits and preferences (e.g., pharmacological, nonpharmacological, interpersonal) to facilitate pain relief, as appropriate


name: Avoid use of analgesics that may have adverse effects in older adults


name: Administer analgesics using the least invasive route available, avoiding the intramuscular route


name: Provide PCA and intraspinal routes of administration, when appropriate


name: Incorporate nonpharmacological interventions to the pain etiology and patient preference, as appropriate


name: Modify pain control measures on the basis of the patient's response to treatment


name: Prevent or manage medication side effects


name: Notify physician if pain control measures are unsuccessful


name: Provide accurate information to the family about the patient's pain experience


name: Use a valid and reliable chronic pain assessment tool (e.g., Brief Pain Inventory-Short Form, McGill Pain Questionnaire-Short Form, Fibromyalgia Impact Questionnaire)


name: Evaluate with patient the effectiveness of past pain control measures


name: Control environmental factors that may influence the patient's pain experience


name: Question the patient regarding pain at frequent intervals, often at the same time as checking vital signs or at every office visit


name: Instruct patient and family about principles of pain management


name: Encourage patient to monitor own pain and to use self-management approaches


name: Encourage appropriate use of nonpharmacological techniques (e.g., biofeedback, TENS, hypnosis, relaxation, guided imagery, music therapy, distraction, play therapy, activity therapy, acupressure, heat and cold application, and massage) and pharmacological options as pain control measures


name: Collaborate with patient, family, and other health professionals to select and implement pain control measures


name: Evaluate the effectiveness of pain control measures through ongoing monitoring of the pain experience


name: Watch for signs of depression (e.g., sleeplessness, not eating, flat affect statements of depression, or suicidal ideation)


name: Watch for signs of anxiety or fear (e.g., irritability, tension, worry, fear of movement)


name: Incorporate the family in the pain relief modality, when possible


name: Consider referrals for patient and family to support groups and other resources, as appropriate


name: Evaluate patient satisfaction with pain management at specified intervals


name: Understand the relationship between the parent's behavior and child's age appropriate goals


name: Identify personal factors that effect on the success of the educational program (e.g., cultural values, presence of any negative experiences with social service providers, language barriers, time commitment, scheduling issues, travel, and general lack of interest)


name: Identify the presence of family stressors (e.g., parental depression, drug addiction, alcoholism, low literacy, limited education, domestic violence, marital conflict, blending of families after divorce, and excessive punishment of children)


name: Instruct parent on normal physiological, emotional, and cognitive characteristics of adolescents


name: Provide online resources, books, and literature designed to teach parents about teen parenting


name: Instruct parents about essential communication skills that will increase their ability to empathize with their adolescent and assist their adolescent to problem solve


name: Instruct parents about methods of communicating their love to adolescents


name: Instruct parents to use reality and consequences to manage adolescent behavior


name: Ask parent to describe the behaviors of the child


name: Design an education program that builds on the family's strengths


name: Involve parents in the design and content of the education program


name: Identify personal factors that effect on the success of the education program (e.g., cultural values, presence of any negative experiences with social service providers, language barriers, time commitment, scheduling issues, travel, and general lack of interest)


name: Instruct parent on normal physiological, emotional, and behavioral characteristics of child


name: Provide online resources, books, and literature designed to teach parents about parenting


name: Instruct parents on the importance of a balanced diet, three meals a day, and nutritious snacks


name: Discuss approaches parents can use to assist children to express feelings positively


name: Discuss alternatives to a bedtime bottle to prevent nursing bottle caries


name: Reinforce ability of parent(s) to apply teaching to child care skills


name: Provide parent(s) with information about making home environment safe for infant


name: Place follow-up telephone call 1 to 2 weeks after encounter


name: Make home visits, as indicated by level of risk


name: Refer to male home visitors to work with fathers, as appropriate


name: Provide information on Medicare coverage for leave or "bedhold" fee, as appropriate


name: Discuss pass with responsible person describing nursing care and self-care, as needed


name: Obtain medications to be taken on pass and instruct responsible person


name: Provide assistive devices and equipment, as appropriate


name: Instruct appropriate person on the information that is needed about medication, food, alcohol intake, and activities when on pass


name: Document on sign-out form the date and time of departure; name, strength, dose, and quantity of medications provided; directions given; and other pertinent actions


name: Verify that medications were taken as instructed on return


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


name: Clarify with the individual the roles of the health care provider and the individual respectively


name: Assist the individual in identifying present circumstances in the environment, which may interfere with the achievement of goals


name: Specify with the individual the timing of delivery of reinforcers/rewards


name: Assist the individual in developing some form of flowchart to assist in tracking the progress toward goals


name: Explore with the individual reasons for success or lack of it


name: Recommend discontinuation of opioid administration by other routes


name: Avoid use of meperidine hydrochloride (Demerol)


name: Instruct patient and family to monitor pain intensity, quality, and duration


name: Instruct patient and family to monitor respiratory rate and blood pressure


name: Validate that the patient can use a PCA device (i.e., is able to communicate, comprehend explanations, and follow directions)


name: Instruct patient and family members how to use the PCA device


name: Instruct patient and family members about the action and side effects of pain-relieving agents


name: Monitor closely for respiratory depression in at-risk patients (e.g., older than 70 years; history of sleep apnea; concurrent use of PCA with a central nervous system depressant; obesity; upper abdominal or thoracic surgery and PCA bolus of greater than 1 mg; history of renal, hepatic, pulmonary, or cardiac impairment)


name: Explain to the patient the importance of proper identification throughout the health encounter


name: Ask the patient his/her first name, last name, and date of birth


name: Select the most appropriate location(s) for placing the identification device(s)


name: Ensure that identification devices are put in appropriate locations


name: Have on hand a number of replacement bands and an easy process for a new bracelet to be stamped and applied should a wristband be removed


name: Standardize the format of the wristbands across the health care institution


name: Compare the information provided by the patient with the information in the identification device before every administration of care (e.g., administering medications, performing invasive procedures, conducting diagnostic tests, transferring patient)


name: Use at least two patient identifiers when laboratory samples are obtained or when medications or blood products are administered


name: Conduct verification of patient at multiple points in time when procedure is complex and involves several stages


name: Use identification by family member or good friend when patient cannot provide information


name: Institute a "stop-the-line" policy if a misidentification error is suspected (i.e., do not carry out the intended action until positive identification is made)


name: Educate the patient about the risks related to an incorrect identification


name: Compare the information provided by a family member with the information in the identification device to confirm a patient's death


name: Ensure a best practice for patient identification by instituting a clearly written, easy to understand, agency policy


name: Honor written "Do Not Resuscitate" orders


name: Note on medical record any observable facts bearing on the testator's mental competency to make a will


name: Observe peer during performance of service as required for evaluation


name: Focus evaluation on quality, safety, and patient satisfaction outcomes


name: Consider the nurse's developmental stage (novice to expert) when conducting the evaluation


name: Instruct individual to tighten then relax the ring of muscle around urethra and anus, as if trying to prevent urination or bowel movement


name: Assure that the individual can differentiate between the desired drawing up-and-in muscle contraction and the nondesired bearing down effort


name: Provide cushion for chair, as appropriate


name: Inspect condition of incision or tear(s) (e.g., episiotomy, laceration, circumcision)


name: Provide and assist with sitz baths, as necessary


name: Apply protective barrier (e.g., zinc oxide, petrolatum), as appropriate


name: Apply prescribed medication (e.g., antibacterial, antifungal), as appropriate


name: Document characteristics of drainage, as appropriate


name: Instruct patient or significant other, as appropriate, regarding inspection of perineum for pathology (e.g., infection, skin breakdown, rash, abnormal discharge)


name: Monitor sharp or dull and hot or cold discrimination


name: Monitor for paresthesia (e.g., numbness, tingling, hyperesthesia, hypoesthesia, and level of pain), as appropriate


name: Encourage patient to use the unaffected body part to determine temperature of food, liquids, bathwater, etc


name: Instruct patient or family to monitor position of body parts when bathing, sitting, lying, or changing position


name: Monitor fit of bracing devices, prosthesis, shoes, and clothing


name: Administer analgesics, corticosteroids, anticonvulsants, tricyclic antidepressants, or local anesthesias, as necessary


name: Monitor for thrombophlebitis and venous thromboembolism


name: Identify the intended use of the catheter to determine the type needed (i.e., vesicants or potentially irritating drugs should be run through a centrally inserted line, not a peripheral line)


name: Obtain consent for the insertion procedure


name: Assure patient is appropriate candidate for insertion (i.e., veins must be visible or palpable; skin site should not have evidence of infection or bruising; patient should not have underlying sepsis, abnormal bleeding, history of noncompliance with previous line, or absence of proper consent)


name: Position patient supine for insertion with arm at a 90 degree angle to body


name: Flush with prepared heparin and saline, as appropriate and per agency protocol


name: Secure the catheter and apply a sterile transparent dressing, per agency protocol


name: Verify catheter tip placement by x-ray examination, as appropriate and per agency protocol


name: Monitor for immediate complications such as bleeding, nerve or tendon damage, cardiac decompression, respiratory distress, or catheter embolism


name: Flush the line after each use with an appropriate solution per agency protocol


name: Remove catheter according to manufacturer's instructions and per agency protocol


name: Obtain a skin culture and blood culture (sample from the line and other arm) if purulent drainage is noted


name: Draw laboratory samples and review blood chemistries (e.g., blood urea nitrogen, serum creatinine, and serum Na, K, and PO4 levels)


name: Monitor for signs of infection (e.g., peritonitis and exit site inflammation/drainage)


name: Review patient history for contraindications for pessary therapy (e.g., pelvic infections, lacerations, or space-occupying lesions; noncompliance; or endometriosis)


name: Discuss maintenance regimen with patient before fitting pessary (e.g., fit is trial and error; frequent follow-up visits are required; cleaning procedures)


name: Perform speculum examination to visualize status of vaginal mucosa


name: Insert pessary according to manufacturer's instructions


name: Perform second examination in upright position to verify fit


name: Recommend yearly Pap examinations, as appropriate


name: Insert needle directly over pulse at 45 degree to 60 degree angle


name: Arrange for immediate transport of specimen to laboratory


name: Obtain demographical information from donor


name: Cleanse skin with an iodine preparation before venipuncture, according to agency protocol


name: Instruct individual to elevate arm and apply firm pressure for 2 to 3 minutes after completion of blood or blood product donation process


name: Instruct individual to remain recumbent for another 1 to 2 minutes, or longer if faintness or weakness is experienced


name: Instruct individual to leave the pressure bandage on for several hours after donation


name: Stop any intravenous infusion that could contaminate the blood sample


name: Remove cap or tubing to access port, cleanse port with alcohol, and allow to dry


name: Review previous venipuncture experiences and patient preferences for venipuncture site


name: Avoid areas prone to nerve injury (e.g., 3 inch area above thumb or inner aspect of wrist just above the palm)


name: Position targeted extremity lower than level of heart


name: Avoid tourniquet application time of greater than 1 minute to minimize hemolysis of sample


name: Cleanse area with an appropriate solution, per agency protocol


name: Insert needle at a 20 to 30 degree angle in the direction of venous blood return


name: Remove needle from the vein and immediately apply pressure to the site with dry gauze for a minimum of 1 minute


name: Advise patient to leave dressing in place for at least an hour


name: Label specimen(s) with patient name, date and time of collection, and other information, per agency protocol


name: Supervise the patient during the treatment, as needed


name: Terminate the treatment if patient develops side effects


name: Order serum bilirubin levels, as appropriate per protocol or primary practitioner request


name: Report laboratory values to primary practitioner


name: Monitor vital signs, per protocol or as needed


name: Monitor serum bilirubin levels, per protocol or practitioner request


name: Obtain a physician's order or confer with a physician within 1 hour after the restraint is initiated


name: Renew orders for physical restraint according to state rules and regulations and professional standards of care


name: Ensure face to face evaluation is conducted by an appropriately credentialed provider within 1 hour of initiating use of physical restraints


name: Do not tie restraints to side rails of bed


name: Provide appropriate level of supervision to monitor patient and to allow for therapeutic actions, as needed


name: Provide for movement of extremities in patient with multiple restraints by rotating the removal and reapplication of one restraint at a time as safety permits


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


name: Implement alternatives to restraints, such as sitting in a geri-chair or close observation, as appropriate


name: Inform family about the risks and benefits of restraints and restraint reduction


name: Follow-up important electronic messages (e.g., texts, e-mails) with verbal contact


name: Encourage use of a structured communication tool (e.g., SBAR [Situation, Background, Assessment, and Recommendation]) to foster clear communication, as needed


name: Create and use a system to inform physicians of the specific nurse assigned to each of their patients


name: Participate in efforts to establish a comprehensive and easy to use communication system between physicians and nurses that might include handheld phones, text messaging, wireless voice-controlled electronic devices, a single page number


name: Participate in bedside medical rounds, multidisciplinary rounds, and interdisciplinary patient care teams, as appropriate


name: Use health history to determine the suitability of herbal or flower essence therapy


name: Instruct the patient about therapeutic use of herbs or flower essences (e.g., background, philosophy, modes of action, contraindications)


name: Select variety of plant indicated in relation to the individual's state of health


name: Obtain medicinal substances from reputable source


name: Consider using prepared stock flower essences such as the Bach collection of 38 flower essences


name: Prepare medicinal herbs or flowers (e.g., gather, wash, cut, cook), as indicated


name: Determine the form in which the medicinal plant or plant part is prepared (e.g., infusion, decoction, maceration)


name: Store preparations out of direct sunlight in a moderate environment


name: Determine dose and guidelines for the administration of herbal products


name: Assist the patient on the correct use of herbal products (e.g., preparation, time of administration, method of administration)


name: Explain the effects of interaction with other prescribed medicines, if necessary


name: Monitor for the expected response or potential adverse effects


name: Record in the clinical history the action and response to phytotherapy


name: Confirm the need for pneumatic tourniquet use in the physician's or anesthesia professional's plan of care


name: Verify that the entire tourniquet system is complete, clean, and functioning according to the manufacturer's instructions for use


name: Select a tourniquet cuff of appropriate width and length for extremity (e.g., as wide as possible without inhibiting surgical site exposure; use contoured cuffs for patient extremities that taper between the upper and lower edge of the cuff; cuff length should provide bladder overlap on limb and full engagement of hook-and-loop fasteners)


name: Evaluate patient for considerations related to tourniquet use (e.g., planned location of the tourniquet, condition of skin under and distal to the planned cuff site, size and shape of the extremity, peripheral pulses and sensation distal to the planned cuff site, ability to move digits in the involved extremity)


name: Screen for potential contraindications for tourniquet use (e.g., risk factors for deep vein thrombosis, ischemic extremities)


name: Assure that tourniquet tubing and connectors are incompatible with other tubing (e.g., IV tubing, vacuum system) or labeled to clearly identify that they are part of the tourniquet system


name: Label tourniquet tubing clearly to indicate that tubing belongs to which cuff and which is associated with which components of the tourniquet system(s) during procedures involving tourniquet control on two extremities


name: Position cuff tubing on or near the lateral aspect of the extremity


name: Verify the correct surgical site before application of tourniquet cuff


name: Wrap a low-lint, soft padding (e.g., limb protection sleeve, two layers of stockinet, cotton roll) around extremity under site of tourniquet cuff, ensuring that padding is wrinkle-free and does not pinch skin


name: Apply and secure tourniquet cuff snugly around the extremity, avoiding neurovascular sites and ensuring that skin is not pinched


name: Protect patient skin under the tourniquet cuff to prevent fluid accumulation (e.g., skin prep solutions, irrigation)


name: Protect reusable tourniquet cuffs from contamination by fluid, blood, and other potentially infectious material during surgery


name: Apply tourniquet protectors (e.g., U-shaped drapes, adhesive drapes, tourniquet covers) to minimize soiling, as indicated


name: Set the tourniquet pressure to maintain the minimum effective pressure as instructed by physician, anesthesia professional, or per agency policy and based on patient's systolic blood pressure and limb circumference


name: Alert anesthesia professional before wrapping the extremity


name: Inflate the cuff under the direction of physician or anesthesia professional


name: Monitor patient continuously during use and on deflation of tourniquet for physiological responses to tourniquet cuff inflation


name: Assure that activation indicators and pressure displays are visible and audible alarms sufficiently loud to be heard over other sounds in the operating room


name: Assure pneumatic tourniquet inflation time kept to a minimum


name: Inform physician of tourniquet inflation time at regular, established intervals


name: Confer with the surgeon and anesthesia professional about deflating the tourniquet for 10 to 15 minutes to allow tissue reperfusion when the duration of tourniquet inflation is longer than 2 hours


name: Verify the tourniquet inflation pressure during the time-out process


name: Avoid overheating patient when the tourniquet cuff is inflated, particularly in pediatric patients


name: Deflate the tourniquet cuff under the direction of the physician and anesthesia professional


name: Confirm sequence and timing of deflation of each tourniquet when tourniquets are used on two extremities


name: Document tourniquet equipment identification number, cuff site, pressure, inflation and deflation times, condition of skin under cuff, and peripheral circulatory and neurological evaluation, as per agency policy


name: Provide a report on pressure settings, duration of the pneumatic tourniquet inflation, and patient outcomes when transferring the care of the patient to other caregivers


name: Monitor patient for systemic responses and blood loss after cuff has been deflated


name: Report complications to the physician and anesthesia professional and to other caregivers when the patient care is transferred


name: Inspect and clean pneumatic tourniquet after use and according to manufacturer's written instructions


name: Clean reusable cuffs and bladders using a U.S. Environmental Protection Agency registered hospital disinfectant, per agency policy


name: Participate in proficiency testing programs as required by institution


name: Use appropriate specimen for the test being performed


name: Perform testing on collected specimens in a timely manner


name: Store reagents according to manufacturer's requirements or as stated in institution's procedure manual


name: Follow manufacturer guidelines and institutional procedures for instrument calibration


name: Document quality control checks as required


name: Perform test according to manufacturer directions or as stated in institutional procedures


name: Verify the results of the point of care test with use of a central laboratory when a critical clinical decision is to be made


name: Perform cleaning and maintenance of instruments according to manufacturer guidelines or as stated in institutional procedure


name: Document cleaning and maintenance as required


name: Establish a multidisciplinary team including representation from relevant laboratory groups to oversee appropriate resources (e.g., equipment, space available, documentation needs) and training of personnel, as needed in particular setting


name: Establish operational teams to oversee day to day operations, including training, proficiency testing, quality assurance, stock management, computer needs and Internet connectivity, and safety, as needed in particular setting


name: Incorporate preferred sleeping position into the plan of care if not contraindicated


name: Avoid placing the amputation stump in the flexion position


name: Turn the immobilized patient at least every 2 hours according to a specific schedule, as appropriate


name: Determine length and type of procedure, anesthesia requirements, patient's age, body weight, and current medication regime


name: Note nutritional status, presence of chronic illness, comorbidities, preexisting pressure ulcers, and at-risk conditions (e.g., obesity, diabetes, anemia, advanced age, demineralizing bone conditions, pediatric patients)


name: Identify high risk surgical situations (e.g., procedure greater than 2 hours, morbidly obese patients, vascular surgeries, excessive sustained pressure to certain body areas, cool environment with exposure of large body surfaces)


name: Determine patient's range of motion, stability of joints, or presence of prostheses or implants


name: Document specific risk factors that may predispose patient to position-related injuries


name: Check operating room table before patient transfer to ensure it is functioning, locked, and properly prepared with correct padded attachments


name: Assure all needed equipment is clean and in good working order


name: Assure a minimum of four persons to assist with transferring patient to the operating room table


name: Lock wheels of stretcher and operating room bed during transfer of patient


name: Document mode of operating room table transfer and number of persons assisting


name: Check with anesthesia before moving an anesthetized patient


name: Maintain body mechanics and employ ergonomic theory to prevent injury to self


name: Provide warmth, privacy, and reassurance, as needed


name: Protect all tubes, drains, lines, breathing circuits, and other devices


name: Use assistive devices for immobilization, securing patient to operating room bed without compromising circulation underneath any restraining straps


name: Employ restraining straps to prevent slippage of extremities


name: Support all body parts and maintain body alignment when moving an anesthetized patient


name: Avoid pulling or dragging patients during transfers


name: Maintain patient's proper body alignment at all times


name: Place on an appropriate therapeutic mattress or pad, as indicated


name: Position patient for comfort whether asleep or awake


name: Assure operative field adequately exposed


name: Assure no awkward position, undue pressure on a body part, or use of stirrups or traction will obstruct the vascular supply to any body part


name: Assure that respirations are not impeded by pressure of arms on the chest or by patient gown constricting neck or chest


name: Employ padded shoulder braces to prevent irreparable nerve injury when Trendelenburg position employed


name: Place in the proper surgical position for specific surgery (e.g., supine, prone, lateral chest, lithotomy, Kraske jacknife position)


name: Apply padding or position patient to avoid pressure to superficial nerves


name: Monitor physiological effects of positioning and traction devices, as appropriate


name: Intervene in situations in which position compromises patient outcomes


name: Ensure access to airway, intravenous catheters, and monitoring devices


name: Ensure that equipment or personnel do not create or impose pressure on patient during the procedure


name: Monitor position, straps, and padding to assure placement is maintained throughout procedure


name: Document all intraoperative assessments related to positioning and safety measures


name: Reposition patient slowly at procedure end to allow for adequate hemodynamic accommodation


name: Use appropriate body mechanics when positioning patient


name: Provide the patient with an adapted call system (e.g., low pressure, voice control, sip-and-puff straw like switch, chin movement switch) depending on level of motor function


name: Use heel boots to maintain ankles in neutral position


name: Position the head of bed as low as possible (measured by pulmonary function) to increase the surface area of the body and decrease pressure on bony prominences


name: Turn using the log roll technique every 2 hours or more frequently, as indicated


name: Stabilize the spine during position changes by keeping the spine in anatomical alignment (e.g., zero rotation)


name: Monitor brain tissue oxygen and intracranial pressure in critically ill patients during positioning changes, as appropriate


name: Monitor skin integrity under bracing device or orthosis collar


name: Brace traction weights when moving patient


name: Monitor for skin breakdown over bony prominences (e.g., sacrum, ischial tuberosities, heels)


name: Provide passive range of motion to affected limbs as determined by rehabilitation staff


name: Instruct family members on how to assist patient to turn in bed and how to provide range of motion, as appropriate


name: Encourage patient to participate in position changes (i.e., remind staff when it is time to be turned) as feasible


name: Instruct on ways (e.g., tilt, recline) to provide pressure relief to decrease potential for skin breakdown when using a wheelchair


name: Monitor for orthostatic hypotension when transferring to a sitting position in wheelchair


name: Use a slide board to assist transfer to a chair or wheel chair for those patients with fair balance


name: Select the appropriate wheelchair for the patient (e.g., standard adult, semi reclining, fully reclining, amputee, extra wide, narrow)


name: Select a wheelchair with seat low to floor for patient who will get around using foot propelling


name: Ensure that there is at least 2 to 3 inches of clearance on each side of the chair


name: Monitor for effects of prolonged sitting (e.g., pressure ulcers, skin tears, bruises, contractures, discomfort, incontinence, social isolation, falls)


name: Provide padding and other enhancements (e.g., contoured padded backs, padded leg rest panels, arm troughs, padded trays) for patients with special needs


name: Determine appropriate time frame for patient to remain in wheelchair based on health status


name: Provide trapeze or slide board to assist with transfer, as appropriate


name: Determine airway and circulatory adequacy


name: Obtain handoff report from the operating room nurse and anesthetist or anesthesiologist


name: Clarify any postoperative orders to be initiated in the post anesthesia care unit


name: Administer warming measures (e.g., warm blankets, convection blanket), as needed


name: Administer narcotic antagonists per agency protocol, as appropriate


name: Administer IV medication to control shivering, as per agency protocol


name: Remove external objects from body (e.g., clothing, tubes, monitors), as needed


name: Place incontinent pad under buttocks and between legs


name: Respect the family's religious beliefs and rituals


name: Monitor lochia for color, amount, odor, and presence of clots


name: Have patient empty bladder before postpartum check and frequently


name: Monitor fundal location, height, and tone, being sure to support the lower uterine segment during palpation


name: Monitor perineum or surgical incision and surrounding tissue (i.e., monitor for redness, edema, ecchymosis, discharge, and approximation of wound edges)


name: Encourage early and frequent ambulation, assisting patient, when needed


name: Encourage the postoperative patient to perform respiratory exercises, assisting patient, when needed


name: Comfort the patient experiencing shaking chills (i.e., provide warm blankets and offer beverages)


name: Instruct patient on nonpharmacological relief of pain (e.g., sitz baths, ambulation, massage, imagery, ice packs, witch hazel pads, and distraction)


name: Instruct patient on perineal care to prevent infection and reduce discomfort


name: Perform or assist with perineal care (i.e., apply ice pack, encourage patient to take sitz baths, and apply dry heat)


name: Monitor breasts for temperature and color and nipple condition


name: Monitor bladder, including intake and output (e.g., emptying of bladder, palpable, color, odor, input and output)


name: Facilitate return to normal urinary functioning (i.e., assist with sitz baths, promote hydration, pour warm water on perineum, and encourage ambulation)


name: Monitor bowels (e.g., date and time of last bowel movement, bowel sounds, presence of flatus)


name: Facilitate return to normal bowel functioning (i.e., administer stool softener or laxative, instruct patient to increase consumption of fluids and fiber, encourage ambulation)


name: Provide measures to reduce likelihood of deep vein thrombosis development (e.g., leg exercises and compression boot application)


name: Monitor legs for Homans' sign and arrange for further testing, if needed


name: Offer reassurance to patient on her ability to care for self and infant


name: Provide information about mood changes (e.g., postpartum "blues," depression, and psychosis), including symptoms warranting further evaluation and treatment


name: Monitor for symptoms of postpartum depression or psychosis


name: Provide anticipatory guidance on physiological and psychological changes and their management


name: Discuss sexuality and contraceptive choices


name: Monitor parent-infant attachment behaviors


name: Facilitate optimal parent-infant attachment


name: Instruct patient on nutritional needs, including the importance of a balanced diet and supplements, if indicated


name: Instruct patient on infant's nutritional needs


name: Provide adequate education and support on chosen feeding method


name: Refer patient to lactation consultant, if indicated


name: Instruct patient on danger signs that warrant immediate reporting (e.g., fever, depression)


name: Administer Rh immune globulin and Rubella vaccine, if indicated


name: Assist parent in scheduling newborn examination and postpartal examination


name: Refer to appropriate resources for community support or follow-up care


name: Describe clinical focus of the unit and agency


name: Communicate goals of the unit and agency


name: Display an accepting attitude to individual assigned to the unit and agency


name: Discuss clinical ladder and types of care providers and their specific responsibilities


name: Review emergency code procedures, as appropriate


name: Shape expectations for workload and scheduling


name: Be aware of own personality and how that affects teaching style


name: Be alert as to how generational differences may influence work attitudes and relationships


name: Share clinical stories and lessons learned to help shape clinical judgment


name: Provide emotional support, especially during highly stressful times


name: Determine student's knowledge and skill level before delegating a task


name: Provide as many opportunities as possible to practice complex skills (e.g., IV insertion, catheter insertion, leading team meetings, presentations to staff)


name: Ensure that students know and understand fire and disaster policies and emergency procedures


name: Discuss care plan for assigned patients, as appropriate


name: Facilitate student's communication with physicians and giving of patient reports


name: Establish and use electronic technologies (e.g., e-mail, text messages, social networks) to keep in touch with faculty member and students, as appropriate


name: Encourage student to work same days and same hours as preceptor


name: Discourage use of multiple preceptors per student


name: Develop a preconception, pregnancy-oriented, health risk profile based on history, prescription drug use, ethnic background, occupational and household exposures, diet, specific genetic disorders, and habits (e.g., smoking and alcohol and drug intake)


name: Obtain a thorough sexual history, including frequency and timing of intercourse, use of spermicidal lubricants, and postcoital habits such as douching


name: Refer for prenatal diagnostic tests for genetic, medical, or obstetrical risk factors, as needed


name: Counsel about avoiding pregnancy until appropriate treatment has been given (e.g., rubella vaccine, Rho[D] immune globulin, immune serum globulin, or antibiotics)


name: Screen individuals at risk or in populations at risk for tuberculosis, sexually transmitted disease, hemoglobinopathies, Tay-Sachs, and genetic defects


name: Support decision making about advisability of pregnancy based on identified risk factors


name: Evaluate the need for a screening mammogram based on the woman's age and desire for prolonged breastfeeding


name: Encourage dental examination during preconception to minimize exposure to x-ray examinations and anesthetics


name: Administer medication to terminate pregnancy, per protocol


name: Encourage significant other to support patient before, during, or after abortion, if desired or with consent from the patient


name: Provide information for referral to support groups (e.g., Resolve through Sharing, Compassionate Friends, SHARE Pregnancy and Infant Loss Support)


name: Refer for psychological support or counseling, as needed


name: Consider cultural and religious beliefs and values


name: Instruct individual in the prospective identification of the major premenstrual symptoms (e.g., bloating, cramping, irritability), use of a prospective calendar check list or symptom log, and the recording of timing and severity of each symptom


name: Collaborate with individual to prioritize most problematic symptoms


name: Prescribe symptom specific medication, as appropriate to practice level


name: Identify individual needs, concerns, and preferences, foster involvement in decision making, and identify and address barriers to care


name: Discuss importance of participating in prenatal care throughout entire pregnancy and encourage involvement of patient's partner or other family member


name: Monitor for hypertensive disorder (e.g., blood pressure, edematous ankles, hands, and face, and proteinuria)


name: Instruct patient on quickening and importance of monitoring fetal activity


name: Review with patient changes noted on fetal growth and status


name: Discuss nutritional needs and concerns (e.g., balanced diet, folic acid, food safety, and supplements)


name: Instruct patient on effects of exposure to or ingestion of harmful substances (e.g., alcohol, illicit drugs, teratogens, medications, herbs, and tobacco)


name: Discuss activity level with patient (e.g., appropriate exercise, activities to avoid, and importance of rest)


name: Provide genetic counseling and testing if indicated


name: Instruct patient on routine laboratory testing to occur throughout pregnancy (e.g., urinalysis, hemoglobin level, ultrasound, gestational diabetes, and HIV)


name: Instruct patient on nonroutine tests and treatments (e.g., nonstress test, biophysical profile, Rh-immune globulin, and stripping of membranes), if needed


name: Monitor psychosocial status of patient and patient's partner


name: Monitor for risk factors affecting patient or fetal health status (e.g., mental health disorder and intimate partner violence)


name: Offer support and counsel to the patient presenting with an unplanned or unwanted pregnancy


name: Offer anticipatory guidance about physiological and psychological changes and discomforts (e.g., nausea, vomiting, musculoskeletal changes, fears, and breast tenderness)


name: Assist patient in identifying strategies to cope with changes and relieve discomforts associated with pregnancy


name: Review safety precautions to be taken during pregnancy (e.g., seat belt use, avoidance of hot tubs and saunas, and travel restrictions)


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


name: Assist patient in preparing for labor and delivery (i.e., discuss pain management options, review labor signs and symptoms, discuss special circumstances requiring medical intervention, and encourage planned involvement of patient's partner or family)


name: Offer anticipatory guidance on infant care and considerations (e.g., circumcision, feeding, and selection of pediatric health care provider)


name: Discuss postpartal concerns and considerations (e.g., family planning and contraception, returning to work or school, and physiological and psychological changes)


name: Provide referral to appropriate service (e.g., supplemental food program, drug dependency treatment, and mental health counseling), if needed


name: Explain procedures in a way that the patient can understand


name: Communicate any concerns (e.g., abnormal laboratory or diagnostic test results, issues related to the patient's understanding of the planned procedure) to the surgeon


name: Involve patient in decisions related to surgery


name: Assure that patient has significant other for postoperative needs, such as transportation home as indicated


name: Link the sensations to their cause when it may not be self-evident


name: Consider the status of the existing chronic health condition


name: Review past medical history, medications, allergies, and past diagnostic testing pertinent to the presenting condition


name: Evaluate the diagnostic utility of the test in addressing the specific clinical question (i.e., understand sensitivity and specificity of the diagnostic test for the presenting condition)


name: Consult with accepted evidence-based practice guidelines, specialists, and other health care professionals, as appropriate


name: Provide the patient or family members with the rationale for the proposed testing, including how the information would benefit clinical decision making or continued monitoring


name: Allow for discussion and questions of the testing


name: Provide alternatives to diagnostic testing, as appropriate


name: Consider the availability and cost of the diagnostic testing and include the patient and family in the discussion


name: Instruct the patient and family on what to expect of the diagnostic test


name: Have a system in place to ensure test results are received when expected


name: Identify a method that ensures accurate communication of test date, time, and location to the patient or caregiver


name: Instruct the patient and family on the test date, time, location, and how to expect test results to be reported


name: Employ a system that provides for the timely return of diagnostic test results and assurance that missing or delayed reports are noted and pursued


name: Monitor for adverse effects of the diagnostic test


name: Maintain knowledge of diagnostic testing used in practice (e.g., sensitivity or specificity, rationale, alternatives, standards of care, evidence based practice, side effects, monitoring and state regulations or policy issues)


name: Determine signs and symptoms of current health problem


name: Review past and current therapeutic treatments tried for the health problem, including the reasons for stopping treatment


name: Document the effects of other treatments on the health problem


name: Identify nonpharmacological treatments (e.g., exercise, diet, physical therapy, occupational therapy, heat and cold treatment) that are indicated for current health problems


name: Consider the availability and cost of the recommended treatment and include the patient and family in the discussion


name: Provide the patient and family members with the rationale for the proposed treatment, expected outcome, and duration of the treatment


name: Allow for questions and discussion related to the diagnosis and treatment and provide alternatives to the treatment


name: Monitor for adverse effects of the treatment


name: Ensure for follow up to assess response to treatment


name: Maintain knowledge of treatments commonly used in practice, including rationale, alternatives, standards of care, evidence based practice, side effects, monitoring, and state regulations or policy issues


name: Touch patient to express concern, as appropriate


name: Offer to remain with patient during initial interactions with others on the unit


name: Help patient to realize that you are available but do not reinforce dependent behaviors


name: Offer to contact other support persons (e.g., priest/rabbi), as appropriate


name: Describe characteristics of the ulcer at regular intervals, including size (length × width × depth), stage (I-IV), location, exudate, granulation or necrotic tissue, and epithelization


name: Use a 19 gauge needle and a 35 cc syringe to clean deep ulcers


name: Utilize methods of measuring skin temperature to determine pressure ulcer risk, as per agency protocol


name: Avoid "donut" type devices to sacral area


name: Ensure the presence of a person dedicated to provide support to the infant


name: Evaluate the need for painful procedures


name: Separate the number and grouping of laboratory and diagnostic procedures according to infant's tolerance


name: Avoid painful procedures at the same time as nonemergency routine care


name: Use minimal amounts of tape or adhesives


name: Use noninvasive monitoring devices whenever possible


name: Instruct parents about signs and symptoms of pain and the comfort that they can provide


name: Reduce light and noise whenever possible during painful procedures


name: Use facilitated tucking (i.e., hand swaddle to hold extremities flexed and contained close to the trunk)


name: Use blanket swaddling after a painful procedure


name: Use nonnutritive sucking with a pacifier


name: Use sucrose solution with pacifier before and throughout painful procedures


name: Facilitate breastfeeding or feed breast milk during painful procedures


name: Facilitate kangaroo care (i.e., skin-to-skin contact) with parent during painful procedures, when possible


name: Facilitate holding by parent, when possible


name: Assemble a multidisciplinary product selection and evaluation team if change will affect other providers


name: Gather information on use of the existing product that is being replaced


name: Establish criteria for product selection


name: Decide on a disposable versus a reusable product


name: Strive for standardization of inventory when within and across facilities, when possible


name: Select a product that has an uncomplicated user interface


name: Solicit input from other health care providers (e.g., biomedical engineers, pharmacists, physicians, other agencies), as needed


name: Determine whether a higher cost product achieves better patient outcomes


name: Report significant medical device adverse events to the FDA (Food and Drug Administration) as well as to the manufacturer


name: Explain the purpose and process of the technique to the patient


name: Instruct patient to wear comfortable, unrestricted clothing


name: Screen for neck or back orthopedic injuries to which hyperextension of the upper spine would add discomfort and complications


name: Screen for increased intracranial pressure, capillary fragility, bleeding tendencies, severe acute cardiac difficulties with hypertension, or other conditions in which tensing muscles might produce greater physiological injury and modify the technique, as appropriate


name: Ask patient to loosen any tight clothing


name: Instruct the patient to sit in a reclining chair or lie down on a comfortable surface


name: Instruct the patient to assume a passive attitude by focusing on achieving relaxation in specific body muscles and refrain from focusing on any other thoughts


name: Instruct the patient to take a deep breath through the abdomen and hold for a few seconds and then exhale slowly


name: Have the patient repeat the deep breathing several times, asking the patient to imagine the tension being released from the body with each exhale


name: Have the patient tense systematically, for 5 to 10 seconds, each of 8 to 16 major muscle groups progressively from head to toe


name: Begin by asking the patient to take a deep breath and tighten the muscles in the forehead by raising the eyebrows as high as possible for 5 to 10 seconds and then release the tension, focusing on the feeling of the muscles relaxing as he/she exhales


name: Pause for 10 seconds before moving on to the next muscle group


name: Establish interval of initial prompted voiding schedule based upon voiding pattern


name: Establish beginning and ending time for the prompted voiding schedule if not for 24 hours


name: Prompt (maximum of three times) to use toilet or substitute regardless of continence status


name: Offer assistance with toileting regardless of continence status


name: Determine the cause of the pruritus (i.e., contact dermatitis, systemic disorder, medications)


name: Perform a physical examination to identify skin disruptions (i.e., lesions, blisters, ulcers, abrasions)


name: Administer opiate antagonists as indicated


name: Participate in selection and development of quality indicators appropriate to clinical setting and patient population


name: Include structure, process, and outcome quality indicators


name: Promote and use electronic health records for collection, exchange, and analysis of data


name: Negotiate solutions cognizant of local work loads


name: Participate on evidence based practice and quality improvement committees, as appropriate


name: Participate on intradisciplinary and interdisciplinary problem-solving teams


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


name: Provide information to patient and family regarding radiation effect on malignant cells


name: Utilize recommended radiation precautions in the management of patients with cardiac pacemakers


name: Provide special skin care to tissue folds that are prone to infection (e.g., buttocks, perineum, and groin)


name: Avoid application of deodorants and aftershave lotions to treated areas


name: Discuss the need for skin care, such as maintenance of dye markings, avoidance of soap, and other ointments, and protection during sunbathing or heat application


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


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


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


name: Promote therapeutic diet to prevent complications


name: Encourage rest immediately after treatments


name: Assist patient in achieving adequate comfort levels through the use of pain management techniques that are effective and acceptable to the patient


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


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


name: Institute neutropenic and bleeding precautions, as indicated


name: Initiate and maintain protection according to agency protocol for patient receiving internal radiation treatment (e.g., gold seed placement or radiopharmaceutical agents)


name: Explain protection protocols to patient, family, and visitors


name: Limit visitor time in room, as appropriate


name: Limit staff time in the room if patient is isolated for radiation precautions


name: Distance oneself from the radiation sources while giving care (e.g., stand at the head of the bed of patient with uterine implants), as appropriate


name: Document whether patient has showered, douched, or bathed after incident


name: Use a consistent approach (e.g., kind firmness, active friendliness, passive friendliness, matter-of-fact, and no demands) that reflects the particular needs and capabilities of the patient


name: Speak in a distinct manner with an appropriate pace, volume, and tone


name: Avoid frustrating the patient by demands that exceed capacity (e.g., repeated orientation questions that cannot be answered, abstract thinking when patient can think only in concrete terms, activities that cannot be performed, decision making beyond preference or capacity)


name: Present reality in manner that preserves the patient's dignity (e.g., provides an alternate explanation, avoids arguing, and avoids attempts to convince the patient)


name: Repeat patient's last expressed thought, as appropriate


name: Interrupt confabulation by changing the subject or responding to the feeling or theme rather than the content of the verbalization


name: Engage patient in concrete "here and now" activities (e.g., ADLs) that focus on something outside self that is concrete and reality oriented


name: Provide physical prompting and posturing (e.g., moving patient's hand through necessary motions to brush teeth), as necessary for task completion


name: Recommend patient wear personal clothing and assist, as needed


name: Provide objects that symbolize gender identity (e.g., purse or cap), as appropriate


name: Provide for adequate rest and sleep, including short-term, daytime naps, as needed


name: Encourage family to participate in care based on abilities, needs, and preferences


name: Modulate human and environmental sensory stimuli (e.g., visiting sessions, sights, sounds, lighting, smells, and tactile stimulation) based on patient's needs


name: Remove stimuli (e.g., pictures on the wall and television) that create misperception in a particular patient, when possible.


name: Provide psychoeducation to family and significant others regarding promotion of reality orientation


name: Monitor for changes in orientation, cognitive and behavioral functioning, and quality of life


name: Identify any deficits that may limit participation in recreational activities (e.g., mobility, cognitive, economic)


name: Assist patient to identify meaningful recreational activities (e.g., sports, drama, games, arts and crafts)


name: Monitor patient's physical and mental capacities while participating in recreational activities


name: Provide new recreational activities that are age and ability appropriate


name: Monitor emotional, physical, and social response to recreational activity


name: Place a warm water or saline soaked cloth over the protruding bowel to protect it from drying


name: Determine whether appropriate supportive care is available in the home or community


name: Evaluate accessibility of environmental needs for the patient in the home or community


name: Inform patient of appropriate Internet sites for use after discharge


name: Contact appropriate agency or health care provider


name: Minimize time between discharge and appointment with next provider


name: Send written referral and patient's plan of care electronically, as appropriate


name: Provide patient or family member with a copy of the referral information, as appropriate


name: Create a calm and comfortable environment


name: Use aroma or gentle music to create a healing atmosphere


name: Ask about the chief complaints, such as the presence of pain in certain areas or the presence of a particular illness


name: Have the Reiki receiver sit comfortably or lay down on a massage table, fully clothed, in a supine position


name: Relax your mind and take a few deep breaths to focus yourself


name: Remember: the Reiki does the work, not the practitioner


name: Begin by sending Reiki from about 3 feet away as a gentle way of beginning the session, if possible


name: Follow a specific series of hand placements: over eyes, over ears, one hand on forehead and one hand on top of head, hands under head, over the neck, upper chest, upper abdomen, lower abdomen, thighs (one at a time), knees (one at a time), lower legs, ankles, feet, bottoms of feet, have client roll over on to stomach, shoulders, waist area, lower back, backs of legs and front of legs


name: Draw or visualize Reiki symbols (e.g., power, mental or emotional, distance) as guided by your intuition


name: Allow your intuition to guide your movements by placing hands on (or a few inches over) the part of the body that most requires healing


name: Stay in each area for 5 to 15 minutes or until you feel the energy flow more slowly or your intuition informs you it is time to move hand position


name: Ask for specific permission during the session to work on sexual organs or parts of the body that would be considered inappropriate, if so guided


name: Move one hand at a time so that you maintain contact as much as possible


name: Note whether the patient has experienced a relaxation response and any related changes


name: Describe the rationale for relaxation and the benefits, limits, and types of relaxation available (e.g., music, meditation, rhythmic breathing, jaw relaxation, and progressive muscle relaxation)


name: Screen for current decreased energy level, inability to concentrate, or other concurrent symptoms that may interfere with cognitive ability to focus on relaxation technique


name: Use soft tone of voice with a slow, rhythmical pace of words


name: Provide undisturbed time because patient may fall asleep


name: Regularly evaluate individual's report of relaxation achieved, and periodically monitor muscle tension, heart rate, blood pressure, and skin temperature, as appropriate


name: Use relaxation as an adjuvant strategy with pain medication or in conjunction with other measures, as appropriate


name: Refer to religious advisor of the patient's choice


name: Make arrangements for individual's personal items to be in place before relocating


name: Monitor for physiological and psychological signs and symptoms of relocation (e.g., anorexia, anxiety, depression, increased demands, and hopelessness)


name: Assist the individual to grieve and work through the losses of home, friends, and independence


name: Evaluate the effect of disruption of lifestyle, loss of home, and adaptation to a new environment


name: Identify, with the patient, a theme for each session (e.g., work life)


name: Determine which method of reminiscence (e.g., taped autobiography, journal, structured life review, scrapbook, open discussion, and storytelling) is most effective


name: Introduce props (e.g., music for auditory, photo albums for visual, perfume for olfactory), addressing all five senses to stimulate recall


name: Encourage verbal expression of both positive and negative feelings of past events


name: Maintain focus of sessions, more on the process than on an end product


name: Assist the patient in creating or adding to a family tree, or to write his/her oral history


name: Use direct questions to refocus back to life events, as necessary


name: Instruct patient about ovulation prediction and detection techniques (e.g., basal temperature and urine testing)


name: Schedule tests based on the menstrual cycle, as needed


name: Collaborate with in vitro fertilization team in screening and selecting gamete donors


name: Draw specimens for endocrine determination


name: Perform ultrasound examinations to ascertain follicular growth


name: Inform about ectopic pregnancy precautions


name: Schedule follow-up medication, tests, and ultrasound examinations


name: Refer for genetic counseling related to maternal age at conception, as needed


name: Encourage the development and adherence to family routines and traditions (e.g., birthdays, holidays)


name: Encourage family involvement with child's schoolwork and activities


name: Assist youth in developing friendship-making skills


name: Monitor breathing patterns (e.g., bradypnea, tachypnea, hyperventilation, Kussmaul respirations, Cheyne-Stokes respirations, apneustic, Biot's respiration, ataxic patterns)


name: Monitor oxygen saturation levels continuously in sedated patients (e.g., SaO2, SvO2, SpO2), per agency policy and as indicated


name: Provide for noninvasive continuous oxygen sensors (e.g., finger, nose, or forehead devices) with appropriate alarm systems in patients with risk factors (e.g., morbidly obese, confirmed obstructive sleep apnea, history of respiratory problems requiring oxygen therapy, extremes of age), per agency policy and as indicated


name: Monitor for diaphragmatic muscle fatigue, as indicated by paradoxical motion


name: Note changes in SaO2, SvO2, end tidal CO2, and ABG values, as appropriate


name: Provide frequent intermittent monitoring of respiratory status in at-risk patients (e.g., opioid therapy, newborn, mechanical ventilation, facial or chest burns, neuromuscular disorders)


name: Establish a therapeutic relationship with patient and family


name: Inform patient and family of available state funding for respite care


name: Coordinate community support services (i.e., meals, day care, summer camp)


name: Monitor skill level of respite care provider


name: Provide a program of suitable activities, as appropriate


name: Evaluate unresponsiveness to determine appropriate action


name: Obtain the automated external defibrillator (AED)


name: Attach the AED and implement specified actions


name: Initiate 30 chest compressions at specified rate and depth, allowing for complete chest recoil between compressions, minimizing interruptions in compressions, and avoiding excessive ventilation


name: Provide two rescue breaths after initial 30 chest compressions completed


name: Tailor rescue actions to the most likely cause of arrest (e.g., cardiac or respiratory arrest)


name: Monitor patient response to resuscitation efforts


name: Clear oral, nasal, and tracheal secretions when possible and without interfering with chest compressions, as appropriate


name: Administer manual ventilation when possible and without interfering with chest compressions, as appropriate


name: Connect the person to an ECG monitor if needed when defibrillation is completed


name: Interpret ECG and deliver cardioversion or defibrillation, as needed


name: Assist with insertion of endotracheal tube (ET), as indicated


name: Assess lung sounds after intubation for proper ET position


name: Assure organized post cardiac arrest care (e.g., safe transport to appropriate nursing care unit)


name: Offer family members opportunities to be present during resuscitation when in the best interests of the patient


name: Support family members who are present during resuscitation (e.g., 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: Monitor fetal vital signs using auscultation and palpation or electronic fetal monitor, as appropriate


name: Discontinue syntocinon to decrease uterine activity


name: Reposition mother to left lateral or hands-and-knees position


name: Apply oxygen at 10 to 15 L/min if positioning is ineffective in correcting nonreassuring (abnormal) pattern of fetal heart rate


name: Give a bolus of 1 L crystalloid IV fluid


name: Administer IV vasopressor if blood pressure is low


name: Perform a vaginal examination with fetal scalp stimulation


name: Use fetal scalp electrode if fetal heart rate tracing is suboptimal


name: Perform amnioinfusion for nonreassuring (abnormal) variable decelerations in fetal heart rate or meconium-stained amniotic fluid


name: Coach to decrease pushing efforts for nonreassuring (abnormal) fetal heart signs to allow reestablishment of placental perfusion


name: Open the airway by slightly extending the neck, placing in the "sniffing" position


name: Monitor oxygen saturations by placing an oximeter probe on the right wrist


name: Initiate positive-pressure ventilation for apnea, gasping, or heart rate lower than 100 beats per minute


name: Set oxygen blender at 21% at 5 to 8 L to fill resuscitation bag and titrate based on oxygen saturations, as necessary


name: Give chest compression for heart rate of less than 60 beats per minute or if greater than 80 beats per minute with no increase


name: Continue compressions until heart rate is greater than or equal to 60 beats per minute


name: Prepare medications (e.g., narcotic antagonists, epinephrine, volume expanders, and sodium bicarbonate), as needed


name: Review past health history and documents for evidence of existing or previous medical and nursing diagnoses and treatments


name: Review data derived from routine risk assessment measures


name: Determine availability and quality of resources (e.g., psychological, financial, education level, family and other social, and community)


name: Identify biological, environmental, and behavioral risks and their interrelationships


name: Instruct on risk factors and plan for risk reduction


name: Consider criteria useful in prioritizing areas for risk reduction (e.g., awareness and motivation level, effectiveness, cost, feasibility, preferences, equity, stigmatization, and severity of outcomes if risks remain unaddressed)


name: Discuss and plan for risk reduction activities in collaboration with individual or group


name: Plan for long-term monitoring of health risks


name: Plan for long-term follow-up of risk reduction strategies and activities


name: Determine residential status of mother (e.g., place of residence, homelessness, living with someone, immigration status)


name: Determine outcomes of all prior pregnancies


name: Determine prior history of abuse and violence


name: Determine prior history of depression or other mental illness


name: Review, update, and complete information as pregnancy develops and at intrapartum, postpartum, and neonatal admissions, as needed


name: Review maternal history of chemical dependency, noting duration, type of drugs used (including alcohol), and time and strength of last dose before delivery


name: Document psychosocial adaptation to pregnancy by the patient, the father, other children and adults in the household, family members, and others in close relationship to the pregnant woman


name: Note presence of multiple gestation and consider challenges of raising multiples


name: Note any medications (e.g., sedative, anesthetic, or analgesic) administered to mother during intrapartal period


name: Note maternal morbidities that could delay attachment (e.g., prolonged labor, infection, sedating medications)


name: Note fetal and neonatal morbidities (e.g., fetal distress, hypoxia, oligohydramnios or polyhydramnios, hyperglycemia or hypoglycemia) that could delay its ability to interact with caretakers


name: Note attachment behaviors to multiples (e.g., twins, triplets)


name: Promote family attachment through patient education


name: Implement activities that promote attachment


name: Evaluate behavioral assessment of neonates during early pediatric visits for possible indications of parenting adjustment problems


name: Promote a postpartum maternal follow-up at 2 to 6 weeks to a qualified health care professional


name: Promote newborn follow-up at 2 and 6 weeks by a qualified health care professional


name: Prioritize areas for risk reduction in collaboration with the individual or family


name: Promote newborn safety by requiring newborn discharge into an approved car seat


name: Refer to the appropriate community agency for follow-up if risk of parenting problems or a lag in attachment has been identified


name: Obtain or review environment (e.g., potential teratogen and carcinogen exposures) and lifestyle (e.g., tobacco, alcohol, street, or prescription drug exposure) history


name: Discuss issues in testing other family members as relevant


name: Refer to genetic health care specialists for genetic counseling, as needed


name: Assist patient to identify various roles in life cycle


name: Assist patient to identify role transition periods throughout the lifespan


name: Assist patient to identify behaviors needed for role development


name: Remove all items from seclusion area that patient might use to harm self or others


name: Inform patient of video surveillance, as appropriate


name: Explain reasons for the video monitoring


name: Give careful consideration to who is responsible for watching the video monitor for changes in patient status


name: Reassure patient of safety within the seclusion area during monitoring


name: Distinguish direct visual inspection from checks performed through video monitoring and document appropriately


name: Reduce sensory stimuli around the seclusion area


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


name: Document rationale for restrictive intervention, patient's response to intervention, patient's physical condition, nursing care provided throughout intervention, and rationale for terminating the intervention


name: Ensure emergency resuscitation equipment is readily available, specifically a source to deliver 100% oxygen, emergency medications, and a defibrillator


name: Monitor the patient's level of consciousness and vital signs, oxygen saturation, and EKG, as per agency protocol


name: Determine whether the patient meets discharge or transfer criteria (i.e., Aldrete scale), as per agency protocol


name: Discharge or transfer patient, as per agency protocol


name: Provide written discharge instructions, as per agency protocol


name: Record seizure characteristics (e.g., body parts involved, motor activity, and seizure progression)


name: Assist patient to identify the effect of illness on self-concept


name: Consider the culture of the patient when promoting self-care activities


name: Provide a therapeutic environment by ensuring a warm, relaxing, private, and personalized experience


name: Place towels, soap, deodorant, shaving equipment, and other needed accessories at bedside or in bathroom


name: Provide desired personal articles (e.g., deodorant, toothbrush, bath soap, shampoo, lotion, and aromatherapy products)


name: Facilitate assistance of a barber or beautician as necessary


name: Ensure proper patient positioning to facilitate chewing and swallowing


name: Fix food on tray as necessary, such as cutting meat or peeling an egg


name: Provide preferred foods and drinks, as appropriate


name: Monitor patient's weight, as appropriate