name: Monitor for complications of corrections of acid-base imbalances (i.e., rapid reduction in metabolic alkalosis results in metabolic acidosis)


name: Monitor for mixed acid-base derangements (e.g., primary metabolic alkalosis and primary respiratory acidosis) presenting as inappropriate metabolic compensations shrouding a primary respiratory disorder


name: Calculate differences in observed HCO3 and expected change in HCO3 to determine presence of mixed acid-base derangement


name: Monitor for associated excesses of bicarbonate (e.g., hyperaldosteronism, glucocorticoid excess, licorice abuse), as appropriate


name: Monitor for neurological and/or neuromuscular manifestations of metabolic alkalosis (e.g., seizures, confusion, stupor, coma, tetany, hyperactive reflexes)


name: Monitor for pulmonary manifestations of metabolic alkalosis (e.g., bronchospasm, hypoventilation)


name: Monitor for cardiac manifestations of metabolic alkalosis (e.g., arrhythmias, reduced contractility, decreased cardiac output)


name: Monitor for GI manifestations of metabolic alkalosis (e.g., nausea, vomiting, diarrhea)


name: Monitor for possible causes of carbonic acid excess and respiratory acidosis (e.g., airway obstruction, depressed ventilation, CNS depression, neurological disease, chronic lung disease, musculoskeletal disease, chest trauma, pneumothorax, respiratory infection, ARDS, cardiac failure, acute opioid ingestion, use of respiratory depressant drugs, obesity hypoventilation syndrome)


name: Monitor for signs and symptoms of carbonic acid excess and respiratory acidosis (e.g., hand tremor with extensions of arms, confusion, drowsiness progressing to coma, headache, slowed verbal response, nausea, vomiting, tachycardia, warm sweaty extremities, pH level less than 7.35, PaCO2 level greater than 45 mm Hg, associated hypochloremia, and possible HCO3 excess)


name: Administer medication therapy aimed at reversing the effects of inappropriate sedative drugs (e.g., naloxone to reverse narcotics, flumazenil to reverse benzodiazepines), as appropriate


name: Maintain caution when reversing the effects of benzodiazepines to avoid seizures if reversal is accomplished too vigorously


name: Administer low flow oxygen and monitor for CO2 narcosis in cases of chronic hypercapnia (e.g., COPD)


name: Administer noninvasive, positive-pressure ventilation techniques (e.g., nasal continuous positive-pressure ventilation, nasal bilevel ventilation) for hypercapnia related to obesity hypoventilation syndrome or musculoskeletal disease


name: Monitor for hypoventilation and treat causes (e.g., inappropriate low-minute mechanical ventilation, chronic reduction in alveolar ventilation, COPD, acute opioid ingestion, obstructive or restrictive airway diseases)


name: Monitor determinants of tissue oxygen delivery (e.g., PaO2, SaO2, hemoglobin levels, cardiac output) to determine the adequacy of arterial oxygenation


name: Position patient for optimum ventilation-perfusion matching (e.g., good lung down, prone, semi-Fowler's), as appropriate


name: Monitor work of breathing (e.g., respiratory rate, heart rate, use of accessory muscles, diaphoresis)


name: Provide low-carbohydrate, high-fat diet to reduce CO2 production, if indicated


name: Promote adequate rest periods (e.g., 90 minutes of undisturbed sleep, organize nursing cares, limit visitors, coordinate consults), as appropriate


name: Monitor for hyperventilation and treat causes (e.g., inappropriate high-minute mechanical ventilation, anxiety, hypoxemia, lung lesions, severe anemia, salicylate toxicity, CNS injury, hypermetabolic states, GI distention, pain, high altitude, septicemia, stress)


name: Reduce oxygen consumption by promoting comfort, controlling fever, and reducing anxiety to minimize hyperventilation, as appropriate


name: Provide rebreather mask for hyperventilating patient, as appropriate


name: Reduce high-minute ventilation (e.g., rate, mode, tidal volume) in mechanically overventilated patients, as appropriate


name: Promote adequate rest periods of at least 90 minutes of undisturbed sleep (e.g., organized nursing cares, limited visitors, coordinated consults), as appropriate


name: Administer parenteral chloride solutions to reduce HCO3 when correcting the cause of respiratory alkalosis, as appropriate


name: Monitor trends in arterial pH, PaCO2, and HCO3 to determine effectiveness of interventions


name: Monitor for symptoms of worsening respiratory alkalosis (e.g., alternating periods of apnea and hyperventilation, increasing anxiety, increased heart rate without increased blood pressure, dyspnea, dizziness, tingling in extremities, hyperreflexia, frequent sighing and yawning, blurred vision, diaphoresis, dry mouth, pH level of greater than 7.45, PaCO2 less than 35 mm Hg, associated hyperchloremia, HCO3 deficit)


name: Monitor for hypophosphatemia and hypokalemia associated with respiratory alkalosis, as appropriate


name: Monitor for mixed acid-base derangements (e.g., primary respiratory alkalosis and primary metabolic acidosis) presenting as inappropriate respiratory compensations shrouding a primary metabolic disorder


name: Calculate differences in observed PaCO2 and expected change in PaCO2 to determine presence of mixed acid-base derangement


name: Monitor for neurological and/or neuromuscular manifestations of respiratory alkalosis (e.g., paresthesias, tetany, seizures), as appropriate


name: Monitor for cardiopulmonary manifestations of respiratory alkalosis (e.g., arrhythmias, decreased cardiac output, hyperventilation)


name: Administer sedatives, pain relief, and antipyretics, as appropriate


name: Administer neuromuscular-blocking agents only if patient is mechanically ventilated, if indicated


name: Obtain ordered specimen for laboratory analysis of acid-base balance (e.g., ABGs, urine, and serum) in at-risk populations, as appropriate


name: Obtain sequential specimens to determine trends


name: Analyze trends in serum pH in the patient experiencing conditions with escalating effects on pH levels (e.g., hyperventilating patients, diabetic or alcoholic ketoacidosis patients, septic patients)


name: Analyze trends in serum pH in at-risk populations (e.g., patients with compromised respiratory status, renal impairment, diabetes mellitus, prolonged diarrhea or vomiting, Cushing's syndrome)


name: Note if arterial pH level is on the alkaline or acidotic side of the mean (7.35-7.45)


name: Examine trends in serum pH in conjunction with PaCO2 and HCO3 trends to determine whether the acidosis or alkalosis is compensated or uncompensated


name: Note if the compensation is pulmonary, metabolic, or is physiologically buffered


name: Identify potential etiologies before attempting to treat acid-base imbalances as it is more effective to treat etiology than imbalance


name: Identify the presence or absence of an anion gap (greater than 14 mEq/L) signaling an increased production or decreased excretion of acid products


name: Monitor for signs and symptoms of HCO3 deficit and metabolic acidosis (e.g., Kussmaul-Kien respirations, weakness, disorientation, headache, anorexia, coma, urinary pH level less than 6, plasma HCO3 level less than 22 mEq/L, plasma pH level less than 7.35, base excess less than -2 mEq/L, associated hyperkalemia, and possible CO2 deficit)


name: Monitor for causes of metabolic acidosis (e.g., methanol or ethanol ingestion, uremia, diabetic ketoacidosis, alcoholic ketoacidosis, paraldehyde ingestion, lactic acidosis, sepsis, hypotension, hypoxia, ischemia, malnutrition, diarrhea, renal failure, hyperalimentation, hyperparathyroidism, salicylate toxicity, ethylene glycol ingestion)


name: Monitor for signs and symptoms of HCO3 excess and metabolic alkalosis (e.g., numbness and tingling of the extremities, muscular hypertonicity, shallow respirations with pause, bradycardia, tetany, urinary pH level greater than 7, plasma HCO3 level greater than 26 mEq/L, plasma pH level greater than 7.45, BE greater than 2 mEq/L, associated hypokalemia, and possible CO2 retention)


name: Monitor for causes of metabolic alkalosis (e.g., diuretics, emesis, nasogastric tube, posthypercapnia, potassium deficiency, alkali ingestion, Cushing's syndrome, hyperaldosteronism, hypochloremia, excessive ingestion of medications containing HCO3)


name: Monitor for signs and symptoms of PaCO2 level deficit and respiratory alkalosis (e.g., frequent sighing and yawning, tetany, paresthesia, muscular twitching, palpitations, tingling and numbness, dizziness, blurred vision, diaphoresis, dry mouth, convulsions, pH level greater than 7.45, PaCO2 less than 35 mm Hg, associated hyperchloremia, and possible HCO3 deficit)


name: Monitor for causes of respiratory alkalosis (e.g., hyperventilation, mechanical overventilation, hepatic disease, pregnancy, septicemia, pain, CNS lesions, and fever)


name: Monitor for signs and symptoms of PaCO2 level excess and respiratory acidosis (e.g., hand tremor with extensions of arms, confusion, drowsiness progressing to coma, headache, slowed verbal response, nausea, vomiting, tachycardia, warm sweaty extremities, pH level less than 7.35, PaCO2 level greater than 45 mm Hg, associated hypochloremia, and possible HCO3 excess)


name: Monitor for possible causes of respiratory acidosis (e.g., airway obstruction, depressed ventilation, CNS depression, neurological disease, chronic lung disease, musculoskeletal disease, chest trauma, infection, ARDS, cardiac failure, acute opioid ingestion, and use of respiratory depressant drugs)


name: Initiate and/or change medical treatment to maintain patient parameters within limits ordered by the physician, using established protocols


name: Determine patient ability to participate in specific activities


name: Collaborate with occupational, physical, or recreational therapists in planning and monitoring an activity program, as appropriate


name: Determine patient's commitment to increasing frequency and range of activity


name: Assist patient to choose activities and achievement goals for activities consistent with physical, psychological, and social capabilities


name: Encourage creative activities, as appropriate


name: Assist patient to schedule specific periods for activities into daily routine


name: Assist patient and family to identify deficits in activity level


name: Identify strategies to promote patient participation in desired activities


name: Coordinate patient selection of age-appropriate activities


name: Provide activities to increase attention span in consultation with occupational therapist


name: Facilitate activity substitution when patient has limitations in time, energy, or movement, in consultation with occupational, physical, or recreational therapists


name: Encourage involvement in group activities or therapies, as appropriate


name: Refer to community centers or activity programs, as appropriate


name: Promote a physically active lifestyle to avoid unneeded weight gain, as appropriate


name: Suggest methods of increasing daily physical activity, as appropriate


name: Provide activities with implicit and emotional memory components (e.g., specially selected religious activities) for dementia patients, as appropriate


name: Employ animal-assisted activity programs, as appropriate


name: Instruct family to provide positive reinforcement for participation in activities


name: Allow for family participation in activities, as appropriate


name: Assist patient to develop self-motivation and reinforcement


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


name: Assist patient and family to monitor own progress toward goal achievement


name: Decide on purpose of acupressure for prevention or treatment of a particular individual (e.g., pain, headaches, nausea, asthma, colds and flu, arthritis, allergies, nervous tension, menstrual cramps, sinus problems, sprains, tennis elbow)


name: Describe the rationale, benefits, limits, and types of acupressure available (e.g., Shiatsu, Tui Na, Sujok, Jin Shin, Atmena)


name: Provide detailed description of chosen acupressure technique


name: Create a quiet, nondisrupting environment, when possible


name: Suggest that the individual assume a comfortable position with unrestricted clothing


name: Explain to individual that you will be searching for a tender area


name: Apply firm finger pressure in a slow, rhythmic manner to enable the layers of tissue to respond


name: Use thumbs, fingers, palms, the side of the hand, or knuckles to apply steady, stationary pressure at the pressure sensitive spot in the general location of the acupoint by using one's body weight to lean into the point to which pressure is applied


name: Apply pressure gradually and hold without any movement for several minutes at a time to relax an area or relieve pain


name: Observe verbal or postural cues (e.g., wincing, "ouch") to identify desired point or location


name: Instruct family/significant other(s) to provide acupressure treatments


name: Use personal protective equipment (PPE) (gloves, goggles, and mask), as appropriate


name: Position patient and head, as appropriate


name: Insert a laryngeal mask airway (LMA), as appropriate


name: Encourage physicians to place ETs via the oropharyngeal route, as appropriate


name: Hyperoxygenate with 100% oxygen for 3 to 5 minutes, as appropriate


name: Observe for systematic chest wall movement


name: Monitor oxygen saturation (SpO2) by noninvasive pulse oximetry and CO2 detection


name: Monitor respiratory status, as appropriate


name: Use personal protective equipment (e.g., gloves, goggles, and mask), as appropriate


name: Hyperoxygenate with 100% oxygen for at least 30 seconds, using the ventilator or manual resuscitation bag before and after each pass


name: Hyperinflate using tidal volumes that are indexed to the size of the patient, as appropriate


name: Use closed-system suctioning, as indicated


name: Use the lowest amount of wall suction necessary to remove secretions (e.g., 80-120 mm Hg for adults)


name: Monitor patient's oxygen status (SaO2 and SvO2 levels), neurological status (e.g., mental status, ICP, cerebral perfusion pressure [CPP]) and hemodynamic status (e.g., MAP level and cardiac rhythms) immediately before, during, and after suctioning


name: Vary suctioning techniques based on the clinical response of the patient


name: Monitor and note secretion color, amount, and consistency


name: Observe for signs of inadequate amniotic fluid volume (e.g., oligohydramnios, asymmetrical intrauterine growth retardation, postdatism, known fetal urinary tract abnormalities, prolonged rupture of membranes)


name: Recognize potential contraindications for amnioinfusion (e.g., amnionitis, polyhydramnios, multiple gestation, severe fetal distress, fetal scalp pH less than 7.20, known fetal anomaly, known uterine anomaly)


name: Observe for variable or prolonged fetal heart decelerations during intrapartal electronic monitoring


name: Obtain cord blood gas levels at time of delivery to evaluate effectiveness of intervention


name: Facilitate use of a pressure-relieving mattress


name: Monitor for phantom limb pain (i.e., check for burning, cramping, throbbing, crushing, or tingling pain where the limb was)


name: Administer pharmacological and nonpharmacological (e.g., TENS, phonophoresis, and massage) pain control, as needed


name: Monitor for psychological concerns (e.g., depression and anxiety) and adjustment related to change in body image


name: Place affected area in whirlpool bath, as appropriate


name: Monitor tissue for skin integrity (e.g., fungal infection, contact dermatitis, and scar management)


name: Instruct patient how to correctly perform postsurgical exercises (e.g., range of motion, endurance, and strengthening)


name: Encourage patient to perform range-of-motion, endurance, and strengthening exercises after surgery, providing assistance, when necessary


name: Instruct in transfer techniques and assistive devices (e.g., trapeze)


name: Facilitate the identification of needed modifications in lifestyle and assistive devices (e.g., home and car)


name: Instruct patient on signs and symptoms to be reported to health care provider (e.g., chronic pain, skin breakdown, tingling, absent peripheral pulse, cool skin temperature, and changes in functional needs or goals)


name: Discuss potential long-term goals for rehabilitation (e.g., walking without a support device)


name: Encourage and facilitate interaction with persons with similar amputations, as appropriate


name: Supervise initial use and care of the prosthesis


name: Instruct patient and family how to care for and apply the prosthesis


name: Assess prosthesis regularly for stability, ease of movement, energy efficiency, and gait appearance


name: Remove prosthesis before surgery, as appropriate


name: Refer to specialist for modification of prosthesis or treatment of complications related to its use


name: Establish effective communication patterns among patient, family, and caregivers to achieve adequate pain management


name: Ensure holistic approach to pain management (i.e., adequate consideration of physiological, social, spiritual, psychological, and cultural influences)


name: Adapt pain monitoring techniques to accommodate patients with communication impairments (e.g., pediatric, elderly, cognitively impaired, psychotic, critically ill, non-English speaking, dementia)


name: Determine pain onset, location, duration, characteristics, quality, intensity, pattern, relief measures, contributing symptoms, effects on patient, and severity before medicating patient


name: Determine patient's current level of comfort and desired level of comfort, using an appropriate pain rating scale


name: Determine patient's previous doses and routes of analgesic administration to avoid undertreatment or overtreatment


name: Involve patient in selection of analgesic, route, and dose, as appropriate


name: Assure that patient is not at risk for NSAID use (e.g., history of GI bleeding or renal insufficiency)


name: Assure that patient is not at risk for opioid use (e.g., history of obstructive or central sleep apnea)


name: Assure accurate 24-hour dosage is maintained (e.g., no more than 4000 mg acetaminophen and acetylsalicylic acid [ASA]; 3200 mg for ibuprofen)


name: Titrate opioid to desired effect or to uncontrollable side effects (e.g., comfort versus respiratory depression)


name: Adjust dosages for children and older adults, as appropriate


name: Account for narcotics and other restricted drugs, according to agency protocol


name: Record pain level using appropriate pain scale before and after administering analgesics


name: Attend to comfort needs and other activities that assist relaxation to facilitate response to analgesia


name: Assist patient in selecting nonpharmacological activities that have relieved pain in the past (e.g., distraction, music, simple relaxation therapy)


name: Give analgesics before pain-producing procedures or activities


name: Administer adjuvant analgesics and medications to potentiate analgesia, when needed


name: Instruct to request PRN pain medication before the pain is severe


name: Correct misconceptions and myths patient or family members may hold regarding analgesics, particularly opioids (e.g., addiction and risks of overdose)


name: Implement measures to reduce noxious stimuli in patient environment (i.e., keep patients clean, dry, correctly positioned, and turned regularly; prevent constipation and urinary retention; loosen constrictive bandages or clothing, as indicated; tighten and smooth wrinkled bed linens)


name: Evaluate the effectiveness of analgesic at regular, frequent intervals after each administration, but especially after the initial doses


name: Implement actions to decrease untoward effects of analgesics (e.g., respiratory depression, nausea and vomiting, dry mouth, constipation, gastric irritation)


name: Administer opioid reversal agents (e.g., naloxone) for respiratory depression or undesirable sedation, if indicated


name: Instruct patient and family about the use of analgesics, strategies to decrease side effects, and expectations for involvement in decisions about pain relief


name: Involve family/significant other(s) in pain control measures such as simple massage or heat/cold application techniques


name: Instruct patient and significant others about procedure


name: Check patency and function of intraspinal catheter, port, or pump


name: Label the intraspinal catheter and secure it appropriately


name: Ensure catheter site is visible and covered with a transparent dressing for monitoring purposes


name: Ensure that edges of site dressing are window-paned to prevent rolling of the dressing


name: Monitor catheter site and dressings to check for a loose catheter or wet dressing and notify appropriate personnel per agency protocol


name: Label tubing and site "Intraspinal Catheter-Do not Inject"


name: Avoid the use of alcohol on the catheter or connectors (i.e., alcohol is neurotoxic)


name: Start continuous infusion of analgesic agent after correct catheter placement has been verified and monitor rate to ensure delivery of prescribed dosage of medication


name: Monitor effectiveness of pain medication


name: Monitor respiratory status every hour for first 24 hours after catheter insertion, when patient is at highest risk for respiratory depression


name: Determine sensation every 2 hours using cold sensation with ice


name: Apply ice up from the toe and note where coldness is detected by the patient


name: Document numbness, tingling or normal sensation, and motor block using appropriate dermatomes


name: Determine the level of block to see if it is changing


name: Notify physician of sensation or motor block higher than the initial documented level


name: Identify weakness and sensation level for comparison (i.e., weakness should be correlated to the level of sensation)


name: Evaluate patient preoperatively in advance of the scheduled surgical procedure, preferably one or more days before procedure


name: Verify that the information provided by the patient is the same as the information in the identification device (e.g., wristbands, bed tag, fingerprint recognition software, palm vein scanner) and medical record


name: Examine patient and the patient's record to determine preexisting conditions, allergies, and contraindications for specific anesthetic agents or techniques


name: Document patient's readiness for anesthesia (e.g., preoperative fasting, medication regime, absence of upper respiratory tract infections, airway history)


name: Request appropriate consultations, including diagnostic and laboratory studies, based on the patient's health status and proposed surgery


name: Start appropriate intravenous and invasive monitoring lines and initiate noninvasive monitoring modalities, per the American Society of Anesthesiologists Standards for Basic Anesthetic Monitoring


name: Ensure positioning of patient to prevent peripheral nerve damage and pressure injuries


name: Deliver anesthetic consistent with each patient's physiological needs, patient's requests, clinical judgment, and the American Association of Nurse Anesthetists Scope and Standards for Nurse Anesthesia Practice


name: Monitor vital signs, respiratory and circulatory adequacy, response to anesthesia, and other physiological parameters


name: Measure and evaluate appropriate laboratory values


name: Manage emergence from anesthesia by administering indicated medications, fluids, and ventilatory support


name: Accompany patient to the postanesthesia or intensive care unit with appropriate monitoring and oxygen therapy


name: Encourage patient to seek assistance of nursing staff or responsible others during periods of increasing tension


name: Discourage intense activities (e.g., punching bag, pacing, excessive exercise)


name: Educate on methods to modulate experience of intense emotion (e.g., assertiveness training, relaxation techniques, writing in a journal, distraction)


name: Encourage use of collaboration to solve problems


name: Use external controls (e.g., physical or manual restraint, time outs, and seclusion) to calm patient who is expressing anger in a maladaptive manner, as needed (as last resort)


name: Assist the patient to identify possible upcoming, developmental, or situational crisis and the effects the crisis may have on personal and family life


name: Suggest printed literature and electronic sources for the patient to read, as appropriate


name: Schedule visits at strategic developmental or situational points


name: Include the family and significant others, when possible


name: Establish that the least restrictive measure is being initiated (if a lower level was used, establish that it was deemed ineffective before advancing to the next level of restriction)


name: Obtain a licensed independent practitioner (LIP) order as required by selection of measure based on institutional policy and state, federal, and regulatory agencies (e.g., Centers for Medicare & Medicaid Services, The Joint Commission)


name: Identify for the patient and significant others the appropriate behaviors necessary for termination of the intervention, repeat as needed


name: Restrict to designated area that is appropriate


name: Modulate human and environmental sensory stimuli (e.g., visiting sessions, sights, sounds, lighting, temperature, etc.) in the designated area, as needed


name: Use protective devices and measures (e.g., motion detectors, alarms, fences, gates, side rails, mitts, closed chairs, locked doors, restraints)


name: Administer PRN medications (e.g., anxiolytics, antipsychotics, sedatives), as appropriate


name: Provide for the patient's physical needs and safety (e.g., cardiovascular, respiratory, neurological, elimination, and nutrition, and skin integrity), as appropriate


name: Provide for the patient's psychological comfort and safety


name: Offer structured activities within the designated area, as appropriate


name: Provide positive reinforcement for appropriate behavior


name: Monitor the need for changes (e.g., lower/higher level measure, continue, or discontinue) to the restrictive measure at regular intervals


name: Involve patient in decision to change a restrictive measure (e.g., lower/higher level measure, continue, or discontinue), when appropriate


name: Hold a debriefing session (e.g., covering behaviors leading to the measures, and patient concerns about the intervention) with patient and staff after termination of the intervention


name: Document (e.g., rationale for the restrictive measure, patient's physical and psychological condition, nursing care provided, and the rationale for terminating the intervention) at appropriate points in care according to institutional policy, state, federal, and/or regulatory agency requirements


name: Identify form of art-based activity (e.g., preexisting, impromptu, directed, spontaneous)


name: Identify art medium to be used, such as drawings (e.g., self-portrait, human figure drawings, family kinetic drawings), photos and other media (e.g., photo journal, media journal), graphics (e.g., timeline, body maps), or artifacts (e.g., masks, sculpture)


name: Discuss with patient what to make, using direct or nondirect approach, as appropriate


name: Monitor patient's engagement during the art-making process, including verbal comments and behaviors


name: Record patient interpretation of drawings or artistic creation


name: Encourage patient to describe and talk about the art product and the art-making process


name: Incorporate patient's description and interpretation of the art activity into patient assessment data


name: Compare art product and art-making process to patient's developmental level and prior art making activities


name: Provide referral (e.g., social work, art therapy), as indicated


name: Provide 100% humidification of inspired air, oxygen, or gas


name: Inflate endotracheal/tracheostomy cuff using minimal occlusive volume (MOV) technique or minimal leak technique (MLT)


name: Maintain inflation of the endotracheal/tracheostomy cuff at 15 to 25 mm Hg during mechanical ventilation and during and after feeding


name: Monitor cuff pressures every 4 to 8 hours during expiration using a three-way stopcock, calibrated syringe, and manometer


name: Check cuff pressure immediately after delivery of any general anesthesia or manipulation of endotracheal tube


name: Suction the oropharynx and secretions from the top of the tube cuff before deflating the cuff


name: Change endotracheal tapes/ties every 24 hours, inspect the skin and oral mucosa, and reposition ET to the other side of the mouth


name: Loosen commercial endotracheal tube holders at least once a day and provide skin care


name: Assist with chest x-ray examination to monitor position of tube, as needed


name: Monitor secretions color, amount, and consistency


name: Perform oral care (e.g., use toothbrush, swabs, mouth and lip moisturizer), as needed


name: Monitor for decrease in exhale volume and increase in inspiratory pressure in patients receiving mechanical ventilation


name: Provide trachea care every 4 to 8 hours, as appropriate: clean the inner cannula, clean and dry the area around the stoma, and change tracheostomy ties


name: Inspect and palpate for air under skin every 8 hours


name: Tape the tracheostomy obturator to head of bed


name: Tape a second tracheostomy (same type and size) and forceps to head of bed


name: Elevate head of the bed equal to or greater than 30 degrees or assist patient to a sitting position in a chair during feedings, as appropriate


name: Minimize use of medications known to delay gastric emptying, as appropriate


name: Position upright equal to or greater than 30 (NG feedings) to 90 degrees or as far as possible


name: Keep tracheal cuff inflated, as appropriate


name: Supervise eating or assist, as necessary


name: Check NG or gastrostomy residual before feeding


name: Avoid feeding, if residuals are high (e.g., greater than 250 cc for feeding tubes or greater than 100 cc PEG tubes)


name: Use continuous NG pump feedings in place of gravity or bolus, if appropriate


name: Inspect oral cavity for retained food or medications


name: Determine barriers to assertiveness (e.g., developmental stage, chronic medical or psychiatric condition, lack of knowledge, and female socialization)


name: Differentiate between assertive, aggressive, passive, and passive-aggressive behaviors


name: Help to identify nonverbal communication (e.g., smiling, eye contact, tone and volume of voice) that will assist or hinder assertiveness


name: Help to build communication skills that will enable the patient to accurately articulate information


name: Encourage verbalization of feelings about diagnosis, treatment, and effect on lifestyle


name: Discuss with patient culture-based expressions of attachment before and after birth


name: Determine patient's image of unborn child


name: Discuss patient's experience of hearing fetal heart tones


name: Discuss patient's experience of viewing fetal ultrasound image


name: Discuss patient's experience of fetal movements


name: Encourage patient to attend prenatal classes


name: Instruct patient's partner on ways to participate during labor and delivery


name: Place newborn skin-to-skin with parent immediately after birth


name: Provide opportunity for parent to see, hold, and examine newborn immediately after birth (i.e., delay unnecessary procedures and provide privacy)


name: Facilitate eye contact between parent and newborn immediately after birth (i.e., demonstrate en face positioning; dim room lights; and provide a quiet, private environment)


name: Complete maternal and newborn assessments while allowing parent to hold newborn


name: Share information gained from physical assessments of infant with parent


name: Inform parent of care being given to infant


name: Encourage mother to breastfeed, if appropriate


name: Provide adequate breastfeeding education and support, if appropriate


name: Instruct parent on infant cues for feeding (e.g., rooting, sucking on fingers, crying)


name: Instruct parent on importance of feeding as nurturing activity, as it provides opportunity for extended eye contact and physical closeness


name: Assist parent in identifying infant's need when crying (e.g., hunger, pain, fatigue, fussiness)


name: Encourage consistent, prompt response to infant crying


name: Demonstrate infant soothing techniques to parent


name: Point out infant cues that show responsiveness to parent


name: Encourage frequent, sustained physical closeness between infant and parent (e.g., skin-to-skin contact, breastfeeding, child carrying, and sleeping in close proximity to infant)


name: Instruct parent on various ways of providing skin-to-skin contact (e.g., kangaroo care, massaging, and cobathing)


name: Instruct parent on infant cares (e.g., diaper changing, feeding, holding, massaging)


name: Encourage use of family members and friends for infant caregiving


name: Assist parent of multiples in recognizing individuality of each infant


name: Facilitate parent's complete access to and care of hospitalized infant


name: Explain equipment used to monitor hospitalized infant


name: Provide visual objects depicting infant (e.g., photograph of infant, infant footprint) to parent of hospitalized infant


name: Update parent frequently on status of hospitalized infant


name: Instruct parent on attachment development, emphasizing its complexity, ongoing nature, and opportunities


name: Provide anticipatory guidance on developmental milestones that will occur


name: Determine how family is coping with transitions


name: Provide opportunity for parent to discuss topics of concern (e.g., fears, questions pertaining to infant care, feelings of exhaustion, pain management, and ways to interact with and respond to infant)


name: Monitor factors that may interfere with optimal attachment (e.g., mental health disturbance in parent, financial strain, parent and child separation due to medical or surgical intervention, difficulties with breastfeeding, providing foster care, and adopting)


name: Provide referral to services (e.g., financial, pastoral care, and counseling), if appropriate


name: Use statements in the script, which elicit feelings of heaviness, lightness, or floating of specific body parts


name: Encourage patient to practice session three times a day


name: Instruct patient to keep a diary to document progress made with each session


name: Adhere to institutional policy for qualifications, training, and procedures to perform salvage and autotransfusion


name: Assure proper personnel are available before initiation of procedure


name: Screen for appropriateness of salvage (i.e., contraindications include sepsis, infection, tumor at the site, blood containing an irrigant that is not injectable, hemostatic agents, or microcrystalline collagen)


name: Use appropriate blood retrieval system per institutional policy


name: Monitor patient and blood retrieval system frequently during retrieval


name: Screen blood for appropriateness of reinfusion (i.e., contraindications include contaminants, pharmacologic agents, malignancy, hematologic disorders)


name: Place on an appropriate therapeutic mattress or bed


name: Use devices on the bed that protect the patient


name: Monitor for complications of bed rest (e.g., loss of muscle tone, back pain, constipation, increased stress, depression, confusion, sleep cycle changes, urinary tract infections, difficulty with urination, pneumonia)


name: Place in upright posture intermittently for patients unable to be out of bed every day to protect against orthostatic intolerance


name: Increase physical activity, as appropriate


name: Give any instructions or explanations slowly, using simple, concrete language


name: Demonstrate behavioral management techniques to significant others


name: Apply mitts, splints, helmets, or restraints to limit mobility and ability to initiate self-harm, if necessary


name: Communicate risk for self-harm to other care providers


name: Identify cues that precede self-mutilating behavior


name: Anticipate trigger situations that may prompt self-harm and intervene to prevent these


name: Explain and reinforce effective coping behaviors and appropriate expression of feelings


name: Use appropriate strategies of dialectical behavior therapy [DBT] (e.g., psychological education, problem solving, training in social skills, exercises in monitoring moods, modeling by therapist, homework assignments, meditation)


name: Administer medications to decrease anxiety, stabilize mood, and decrease self-stimulation, as appropriate


name: Avoid giving positive reinforcement to self-harmful behaviors


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


name: Provide parents information about age-appropriate sexual behavior


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


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


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


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


name: Provide appropriate level of supervision to monitor patient


name: Redirect from any socially unacceptable sexual behaviors or verbalizations


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


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


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


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


name: Determine ability for reading independently


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


name: Consult sources to recommend literature for therapy


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


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


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


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


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


name: Interview patient to obtain a health history


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


name: Determine abilities and willingness for using the biobehavioral treatment


name: Discuss rationale for using biofeedback and type of feedback


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


name: Explain the procedure concerning the specific monitoring equipment used


name: Operate the biofeedback device according to instructions


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


name: Provide feedback of progress after each session


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


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


name: Perform vaginal examination to determine fetal position and station


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


name: Perform rectal examination to ensure tissue integrity


name: Maintain privacy and assure uninterrupted time during procedure


name: Position patient in comfortable, lying, semirecumbent posture


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


name: Instill irrigating fluids, per agency protocol


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


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


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


name: Notify physician if catheter is obstructed


name: Monitor and maintain correct flow rate with continuous infusions


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


name: Assure patient comfort at end of procedure


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


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


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


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


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


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


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


name: Instruct patient to avoid lifting heavy objects


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


name: Apply ice pack to affected area, as appropriate


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


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


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


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


name: Instruct the patient on activity restrictions


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


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


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


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


name: Continually monitor characteristic and amount of bleeding


name: Initiate continuous electronic fetal monitoring


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


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


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


name: Initiate IV access for fluid replacement


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


name: Provide empathy, understanding and emotional support


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


name: Instruct woman to differentiate between old and fresh bleeding


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


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


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


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


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


name: Apply manual pressure over the bridge of the nose


name: Administer humidified oxygen, if appropriate


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


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


name: Perform fundal massage to ensure firm consistency


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


name: Inspect placenta for intactness and missing fragments


name: Notify primary practitioner of excessive blood loss


name: Initiate IV infusion with needles suitable for blood transfusion


name: Administer a uterotonic drug, per protocol or order


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


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


name: Order emergency laboratory tests or units of blood


name: Identify mother's beliefs about blood transfusions


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


name: Maintain continuous bladder irrigation, if appropriate


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


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


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


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


name: Perform rectal examination, as appropriate


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


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


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


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


name: Evaluate for fecal incontinence, as necessary


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


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


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


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


name: Monitor patient physically and psychologically per agency policy


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


name: Monitor liver function tests, if appropriate


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


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


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


name: Substitute artificial salt, if appropriate


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


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


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


name: Screen patient for anxiety and depression, as appropriate


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


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


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


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


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


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


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


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


name: Encourage 30 minutes of exercise daily, as appropriate


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


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


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


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


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


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


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


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


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


name: Monitor patient's progress at regular intervals


name: Document cost effectiveness of case management


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


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


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


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


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


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


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


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


name: Pad rough cast edges and traction connections


name: Document cast care instructions given to patient and family


name: Document observations of patient ability to perform cast care


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


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


name: Explain the need for limited activity as cast dries


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


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


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


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


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


name: Monitor neurologic status closely and compare to baseline


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


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


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


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


name: Perform passive range-of-motion exercises


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


name: Consult with physician to determine hemodynamic parameters


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


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


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


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


name: Maintain hematocrit level for hypervolemic hemodilution therapy per protocol


name: Avoid neck flexion or extreme hip or knee flexion


name: Administer calcium channel blockers and vasopressors, as prescribed


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


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


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


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


name: Obtain necessary blood work and document results


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


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


name: Transfer patient to recovery room or labor room


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


name: Inspect condition of surgical incision and dressing


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


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


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


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


name: Promote activities to modify the identified risk factors


name: Monitor for side effects and toxic effects of treatment


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


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


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


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


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


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


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


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


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


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


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


name: Discuss potential aspects of sexual dysfunction, as appropriate


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


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


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


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


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


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


name: Perform chest physiotherapy at least 2 hours after eating


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


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


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


name: Monitor amount and character of secretions


name: Determine lung segment(s) containing excessive secretions


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


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


name: Apply pneumatic, acoustical, or electrical chest percussors


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


name: Instruct patient to expectorate loosened secretions via deep breathing


name: Encourage coughing during and after procedure


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


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


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


name: Educate mother and partner about signs of labor


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


name: Discuss pain control options with mother


name: Inform mother about delivery options if complications arise


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


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


name: Review American Academy of Pediatrics recommendations for breastfeeding


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


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


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


name: Discuss arrangements for sibling care during hospitalization


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


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


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


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


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


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


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


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


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


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


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


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


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


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


name: Encourage patient participation in vascular rehabilitation programs


name: Evaluate patient's responsiveness to determine appropriate action


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


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


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


name: Deliver cardioversion or defibrillation as soon as possible


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


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


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


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


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


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


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


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


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


name: Terminate code by patient condition, as indicated


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


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


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


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


name: Perform emergency cart check per agency protocol


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


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


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


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


name: Ask for opinions and views rather than factual answers


name: Seek input and respect the contributions of others


name: Build teams of approximately 5 to 9 members


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


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


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


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


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


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


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


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


name: Include the patient as a teammate, as appropriate


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


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


name: Address misconceptions and stereotypes among team members


name: Use negotiation as a strategy for conflict resolution


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


name: Recognize resourcefulness in coping with present situation


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


name: Demonstrate your valuing of individual or family


name: Build collaborative relationship with individual or family


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


name: Provide positive feedback to encourage and sustain new behavior


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


name: Congratulate one in achieving improved outcome


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


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


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


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


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


name: Perform or arrange for routine hearing assessments and screenings


name: Monitor for excessive accumulation of cerumen


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


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


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


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


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


name: Avoid noisy backgrounds when communicating


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


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


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


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


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


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


name: Avoid "baby talk" and exaggerated expressions


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


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


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


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


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


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


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


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


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


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


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


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


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


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


name: Recognize emotional and physical behaviors as forms of communication


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


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


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


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


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


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


name: Repeat what patient said to ensure accuracy


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


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


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


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


name: Provide positive reinforcement, as appropriate


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


name: Provide referral to speech language pathologist or therapist


name: Coordinate rehabilitation team activities


name: Perform or arrange for routine vision assessments and screenings


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


name: Identify yourself when entering the patient's space


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


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


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


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


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


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


name: Use bright, contrasting colors in environment


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


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


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


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


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


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


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


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


name: Assist to prepare shelters and emergency aid stations


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


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


name: Provide access to translation services, when needed


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


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


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


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


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


name: Participate in media campaigns to increase public awareness


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


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


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


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


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


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


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


name: Summarize conversation at end of discussion


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


name: Determine patient's understanding of required lens care


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


name: Instruct patient to perform hand hygiene before touching lenses


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


name: Account for access to controlled substances at all times


name: Follow agency protocol for resolving discrepancies


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


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


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


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


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


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


name: Use supplies and equipment efficiently and effectively


name: Provide factual information, as necessary and appropriate


name: Encourage new skill development, as appropriate


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


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


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


name: Calculate variances and report through appropriate channels


name: Determine newborn state before initiating feeding


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


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


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


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


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


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


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


name: Burp the newborn frequently during and after the feeding


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


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


name: Measure newborn's milk intake over 24 hours


name: Instruct parent on cup feeding procedures


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


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


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


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


name: Inform the individual about purpose of the dance experience


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


name: Determine the individual's capabilities for movement


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


name: Determine the time intervals between each session


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


name: Limit distracting visual and auditory stimuli


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


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


name: Allow time for pauses and breaks, if applicable


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


name: Incorporate family participation in the sessions, if applicable


name: Monitor continuously the achievement of the objectives and targets


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


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


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


name: Initiate cardiopulmonary resuscitation, as indicated


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


name: Maintain cardiopulmonary resuscitation when not administering external defibrillation


name: Determine type and operation techniques for available defibrillator


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


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


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


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


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


name: Monitor results and repeat, as indicated


name: Minimize interruptions to chest compressions in unresponsive patients


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


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


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


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


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


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


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


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


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


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


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


name: Monitor for redness or swelling at the device site


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


name: Avoid frightening family or friends about unexpected shocks


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


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


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


name: Encourage patient and family members to attend CPR classes


name: Encourage attendance at support group meetings


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


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


name: Explain the task to the health care worker


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


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


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


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


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


name: Acknowledge the patient's fears and feelings


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


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


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


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


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


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


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


name: Convey unconditional acceptance and support


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


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


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


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


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


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


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


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


name: Give pain medication before bath if movement is painful


name: Identify usual patterns of wandering behavior


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


name: Monitor prescribed medication regime, as appropriate


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


name: Discuss and support decision to breastfeed or bottle feed


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


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


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


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


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


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


name: Determine appropriate management technique for sleep disturbance or disorder


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


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


name: Provide developmentally appropriate, safe toys and activities


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


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


name: Determine appropriate scheduling for initial and subsequent dental examinations


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


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


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


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


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


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


name: Encourage provision of safe space for infant exploration


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


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


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


name: Promote and facilitate family bonding and attachment with infant


name: Support and praise parent skills and efforts


name: Discuss parent return to work and childcare options


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


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


name: Refer for parenting education, as needed


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


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


name: Avoid venipuncture and blood pressures in peripheral access extremity