4.2 Basic Concepts
Open Resources for Nursing (Open RN)
Before learning how to use the nursing process, it is important to understand basic concepts concerning how critical thinking relates to nursing practice. Let’s take a deeper look at how nurses think.
Critical Thinking and Clinical Reasoning
Nurses make decisions while providing client care by using critical thinking and clinical reasoning. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[1] Using critical thinking means that nurses take extra steps to maintain client safety and don’t just “follow orders.” It also means the accuracy of client information is validated and plans for caring for clients are based on their needs, current clinical practice, and research.
“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:
- Independence of thought: Thinking on your own
- Fair-mindedness: Treating every viewpoint in an unbiased, unprejudiced way
- Insight into egocentricity and sociocentric: Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentric)
- Intellectual humility: Recognizing your intellectual limitations and abilities
- Nonjudgmental: Using professional ethical standards and not basing your judgments on your own personal or moral standards
- Integrity: Being honest and demonstrating strong moral principles
- Perseverance: Persisting in doing something despite it being difficult
- Confidence: Believing in yourself to complete a task or activity
- Interest in exploring thoughts and feelings: Wanting to explore different ways of knowing
- Curiosity: Asking “why” and wanting to know more
Clinical reasoning is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze client information, evaluate the significance of this information, and weigh alternative actions.”[2] To make sound judgments about client care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience.[3]
Inductive and Deductive Reasoning and Clinical Judgment
Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process.
Inductive reasoning involves noticing cues, generalizing, and creating hypotheses based on specific information or incidents. Cues are data that fall outside of expected findings that give the nurse a hint or indication of a client’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A generalization is a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes clearer. Based on generalizations created from patterns of data, the nurse creates a hypothesis regarding a client problem. A hypothesis is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored.
No one can draw conclusions without first noticing cues. Paying close attention to a client, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. A nurse is similar to the detective looking for cues in Figure 4.1.[4] Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to act quickly, especially in emergency situations. They can see how certain objects or events form a pattern (i.e., generalization) that indicates a common problem (i.e., hypothesis).
Example: A nurse assesses a client and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the client’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.
Deductive reasoning is another type of critical thinking that is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Deductive reasoning relies on a general statement or hypothesis – sometimes called a premise or standard – that is held to be true. The premise is used to reach a specific, logical conclusion. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about client care and solve problems.
Example: Based on research findings, hospital leaders determine clients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. (See Figure 4.2).[5] The nurse further implements this policy by organizing care for clients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking because the intervention is applied to all clients regardless if they have difficulty sleeping or not.
Clinical judgment is the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.”[6] The NCSBN administers the national licensure exam (NCLEX) that evaluates the decision-making ability of nursing graduates and sets a minimum standard for safe, competent nursing care by entry-level licensed nurses. The NCLEX uses the NCSBN Clinical Judgment Measurement Model (NCJMM) to measure clinical judgment.
Evidence-based practice (EBP) is defined by the American Nurses Association (ANA) as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and client, family, group, community, and population preferences and values.”[7]
Nursing Process
The nursing process is a critical thinking model based on a systematic approach to client-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing client care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses (RNs), regardless of role, population, specialty, and setting, are expected to perform competently.[8] The mnemonic ADOPIE is an easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.
The nursing process is a continuous, cyclical process that is constantly adapting to the client’s current health status. See Figure 4.3a[9] for an illustration of the nursing process.
The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.
Assessment
The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.”[10] A registered nurse uses a systematic method to collect and analyze client data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized client in pain includes recognizing cues such as the client’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff.[11]
Licensed practical/vocational nurses (LPN/VNs) assist with gathering data according to their state’s scope of practice, but do not analyze data because this is outside their scope of practice. The “Assessment” component of the nursing process is further described in the “Assessment” section of this chapter.
Diagnosis
The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.”[12] A nursing diagnosis is the nurse’s clinical judgment about the response from the client to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses.[13]
Analyzing assessment data and formulating a nursing diagnosis is outside the scope of practice for LPN/VNs, and as such, they do not assist with this phase of the nursing process. The “Diagnosis” component of the nursing process is further described in the “Diagnosis” section of this chapter.
Outcome Identification
The “Outcome Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”[14] The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the client based on their assessment data and nursing diagnoses.
Outcome identification is outside the scope of practice of LPN/VNs, and as such, they do not assist with this phase of the nursing process. The “Outcome Identification” component of the nursing process is further described in the “Outcome Identification” section of this chapter.
Planning
The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.”[15] Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each client’s needs in order to achieve their previously established goals and outcomes. Nursing interventions are planned and documented by the nurse in the client’s nursing care plan so that nurses, as well as other health professionals, can refer to it for continuity of care.[16]
The “Planning” component of the nursing process is further described in the “Planning” section of this chapter.
Nursing Care Plans
Creating nursing care plans is a part of the “Planning” step of the nursing process. A nursing care plan is a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific client using the nursing process. RNs create nursing care plans so that the care provided to the client across shifts is consistent among health care personnel. Some interventions can be delegated to LPN/VNs or trained Unlicensed Assistive Personnel (UAPs) with RN supervision.
Creating the nursing care plan is outside the scope of practice, and as such, the LPN/VNs do not perform this task, although they may contribute to it. Developing nursing care plans and implementing appropriate delegation are further discussed under the “Planning” and “Implementation of Interventions” sections of this chapter.
Implementation
The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.”[17] Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the client. Interventions are documented in the client’s electronic medical record as they are completed.[18] LPN/VNs implement interventions contained in the nursing care plan, provided they are within their scope of practice. The LPN/VN is responsible for documenting the interventions they perform in the client’s medical record.
The “Implementation” Standard of Professional Practice also includes the subcategories “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment.[19]
The “Implementation” component of the nursing process is further described in the “Implementation of Interventions” section of this chapter.
Evaluation
The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.”[20] During evaluation, nurses reassess the client and compare the findings against established outcomes to determine the effectiveness of the interventions and overall nursing care plan. During this phase, RNs ask, “Were outcomes met? Are any modifications required for the nursing care plan?” Both the client’s status and the effectiveness of the nursing care plan are continuously evaluated and modified as needed.[21]
Evaluating and modifying the nursing care plan is outside the scope of practice of LPN/VNs, although they can assist in gathering assessment data to assist the RN in performing this step of the nursing process. The “Evaluation” component of the nursing process is further described in the “Evaluation” section of this chapter.
Benefits of Using the Nursing Process
Using the nursing process has many benefits for nurses, clients, and other members of the health care team. The benefits of using the nursing process include the following:
- Promotes quality client care
- Decreases omissions and duplications
- Provides a guide for all staff involved to provide consistent and responsive care
- Encourages collaborative management of a client’s health care problems
- Improves client safety
- Improves client satisfaction
- Identifies a client’s goals and strategies to attain them
- Increases the likelihood of achieving positive client outcomes
- Saves time, energy, and frustration by creating a care plan that is accessible to all staff caring for a client
By using these components of the nursing process as a critical thinking model, nurses plan outcomes and interventions that are customized to the client’s specific needs, ensure the interventions are evidence-based, and evaluate the effectiveness of interventions in meeting the client’s needs.
NCSBN Clinical Judgment Measurement Model
The NCSBN Clinical Judgment Measurement Model (NCJMM) complements the nursing process, but it is a model that assesses an NCLEX candidate’s clinical judgment. Terminology used by this model includes recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes. See Figure 4.3b[22] and Table 4.2 for comparisons of NCJMM terms and the nursing process.[23],[24],[25]
Table 4.2 Comparison of the NCJMM to the Nursing Process
| NCSBN Clinical Judgment Skill | Description | Corresponding Step of the Nursing Process |
|---|---|---|
| Recognize Cues | What data is clinically significant?
Determining what client findings are significant, most important, and of immediate concern to the nurse (i.e., identifying “relevant cues”). |
Assessment |
| Analyze Cues | What does the data mean?
Analyzing data to determine if it is “expected” or “unexpected” or “normal” or “abnormal” for this client at this time according to their age, development, and clinical status. Making a clinical judgment concerning the client’s “human response to health conditions/life processes, or a vulnerability for that response”; also referred to as “forming a hypothesis.” |
Diagnosis
(Analysis of Data) |
| Prioritize Hypotheses | What hypotheses should receive priority attention?
Ranking client conditions and problems according to urgency, complexity, and time. |
Planning |
| Generate Solutions | What should be done?
Planning individualized interventions that meet the desired outcomes for the client; may include gathering additional assessment data. |
Planning |
| Take Action | What will I do now?
Implementing interventions that are safe and most appropriate for the client’s current priority conditions and problems. |
Implementation |
| Evaluate Outcomes | Did the interventions work?
Comparing actual client outcomes with desired client outcomes to determine effectiveness of care and making appropriate revisions to the nursing care plan. |
Evaluation |
Learning activities are incorporated throughout this book to help students practice answering NCLEX Next Generation-style test questions.
Review Scenario A in the following box for an example of a nurse using the nursing process and NCJMM skills while providing client care.
Client Scenario A: Using the Nursing Process[26]
A nurse is caring for a hospitalized client with a medical diagnosis of heart failure who has a prescription to receive furosemide 80mg IV every morning. The nurse uses critical thinking according to the nursing process and the NCJMM before administering the prescribed medication:
Assessment/Recognize Cues: During the morning assessment, the nurse notes that the client has a blood pressure of 98/60, heart rate of 100, respirations of 18, and a temperature of 98.7F.
Diagnosis/Analyze Cues: The nurse reviews the medical record for the client’s vital signs baseline and observes the blood pressure trend is around 110/70 and the heart rate in the 80s.
Planning/Prioritize Hypothesis: The nurse recognizes cues (assessment data) that form a pattern related to fluid imbalance and hypothesizes that the client may be dehydrated.
Planning/Generate Solutions: The nurse gathers additional information and notes the client’s weight has decreased four pounds since yesterday. The nurse talks with the client and validates the hypothesis when the client reports that their mouth feels like cotton, and they feel light-headed. By using critical thinking and clinical judgment, the nurse diagnoses the client with the nursing diagnosis Fluid Volume Deficit and plans interventions for reestablishing fluid balance.
Implementation/Take Action: The nurse withholds the administration of IV furosemide and contacts the health care provider to discuss the client’s current fluid status. After contacting the provider, the nurse initiates additional nursing interventions to promote oral intake and closely monitors hydration status.
Evaluation/Evaluate Outcomes: By the end of the shift, the nurse evaluates the client status and determines that fluid balance has been restored.
In Scenario A, the nurse is using clinical judgment and not just “following orders” to administer the Lasix as scheduled. The nurse assesses the client, recognizes and analyzes cues, creates a hypothesis regarding the fluid status, plans and implements nursing interventions, and evaluates outcomes. While performing these steps, the nurse promotes client safety by contacting the provider before administering a medication that could cause harm to the client at this time.
Holistic Nursing Care
Using the nursing process and clinical judgment while implementing evidence-based practices is referred to as the “science of nursing.” Before getting deeper into the science of nursing in the remainder of this chapter, it is important to discuss the “art of nursing” that relies on holistic care provided in a compassionate and caring manner using the nursing process.
The American Nurses Association (ANA) defines nursing as, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.”[27]
The ANA further describes nursing as a learned profession built on a core body of knowledge that integrates both the art and science of nursing. The art of nursing is defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.”[28]
Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. Review a scenario illustrating holistic nursing care provided to a client and their family in the following box.
Holistic Nursing Care Scenario
A single mother brings her child to the emergency room for ear pain and a fever. The physician diagnoses the child with an ear infection and prescribes an antibiotic. The mother is advised to make a follow-up appointment with their primary provider in two weeks. While providing discharge teaching, the nurse discovers that the family is unable to afford the expensive antibiotic prescribed and cannot find a primary care provider in their community they can reach by a bus route. The nurse asks a social worker to speak with the mother about affordable health insurance options and available providers in her community and follows up with the prescribing physician to obtain a prescription for a less expensive generic antibiotic. In this manner, the nurse provides holistic care and advocates for improved health for the child and their family.
Caring and the Nursing Process
The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.”[29] Successful use of the nursing process requires the development of a care relationship with the client. A care relationship is a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development of rapport and underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the client and family. Assessing and caring for the whole person considers the physical, mental, emotional, and spiritual aspects of being a human being.[30] Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, using therapeutic touch, and providing emotional support while respecting their cultural beliefs associated with caring behaviors.[31] See Figure 4.4[32] for an image of a nurse using touch as a therapeutic communication technique to communicate caring.
Dr. Jean Watson is a nurse theorist who has published many works on the art and science of caring in the nursing profession. Her theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and the public. Dr. Watson’s caring philosophy encourages nurses to be authentically present with their clients while creating a healing environment.[33]
Now that we have discussed basic concepts related to the nursing process, as well as the science and art of nursing, let’s look more deeply at each component of the nursing process in the following sections.
- Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41(4), 215-221. doi: 10.1097/01.NEP.0000000000000669. PMID: 32569111. https://pubmed.ncbi.nlm.nih.gov/32569111/ ↵
- Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41(4), 215-221. ↵
- Powers, L., Pagel, J., & Herron, E. (2020). Nurse preceptors and new graduate success. American Nurse Journal, 15(7), 37-39. https://www.myamericannurse.com/nurse-preceptors-and-new-graduate-success/ ↵
- “The Detective” by paurian is licensed under CC BY 2.0 ↵
- “In the Quiet Zone…” by C.O.D. Library is licensed under CC BY-NC-SA 2.0 ↵
- NCSBN. (n.d.). NCSBN clinical judgment measurement model. https://www.ncsbn.org/14798.htm ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- “The Nursing Process” by Kim Ernstmeyer at Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (3rd ed.). American Nurses Association. ↵
- American Nurses Association. (n.d.) The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ ↵
- “Nursing Process and NCJMM” by Tami Davis is licensed under CC BY 4.0 ↵
- NCSBN (n.d.) NCSBN Clinical Judgment Measurement Model. https://www.ncsbn.org/14798.htm ↵
- Ignativicius, V., & Silvestri, L. (2022). Preparing for the Next-Generation NCLEX (NGN): A “how-to” step-by-step faculty resource manual. Elsevier. https://evolve.elsevier.com/education/wp-content/uploads/sites/2/NGN_FacultyGuide_Final.pdf ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- “Patient Image in LTC.JPG” by ARISE project is licensed under CC BY 4.0 ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- Walivaara, B., Savenstedt, S., & Axelsson, K. (2013). Caring relationships in home-based nursing care - registered nurses’ experiences. The Open Journal of Nursing, 7, 89-95. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722540/pdf/TONURSJ-7-89.pdf ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- “hospice-1793998_1280.jpg” by truthseeker08 is licensed under CC0 ↵
- Watson Caring Science Institute. (n.d.). Watson Caring Science Institute. Jean Watson, PHD, RN, AHN-BC, FAAN, (LL-AAN). https://www.watsoncaringscience.org/jean-bio/ ↵
Reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.
To promote safety for clients of all ages, nurses should be knowledgeable about safety risks according to age and developmental stages because the types and frequencies of accidents vary among age groups. Information from the Centers for Disease Control (CDC) regarding safety tips for each age group is summarized in the following subsections.[1]
Infants and Preschoolers
Motor vehicle accidents, falls, choking, drowning, and accidental poisoning are safety concerns for this age group. Infants and toddlers are curious, but they lack the judgement to recognize the dangers of their actions, so childproofing the home and providing adult supervision are essential for this developmental age group.[2] See Figure 5.7[3] for an image of an infant car seat used to protect infants in the event of a motor vehicle accident. Nurses help educate parents about the proper use, positioning, and installation of car seats.
School-Aged Children
In children aged 4-11, motor vehicle injuries are a major cause of unintentional injury, along with drowning and poisoning. This age group is more aware of dangers and limitations, but adult supervision is still important. The nurse should educate parents of school-aged children about safety seats, booster seats, or shoulder seat belts while riding in the car.[4]
Bicycle accidents are also a common concern in this age group. Many bike accidents involve the head or face because of the lack of helmet use. Nurses provide health teaching to school-aged children regarding bicycle safety and helmet use. See Figure 5.8[5] for an image of a girl wearing a bike helmet.
Because this age group is beginning to enjoy more independence, basic instructions and education on how to recognize and respond to potentially dangerous situations with strangers should also be provided. Parents should also be educated about the AMBER alert system that can be activated if a child is missing and believed to be kidnapped or in danger. This AMBER alert system uses the resources of law enforcement and the media to notify the public about a possible abduction or a missing child in danger.[6]
Nurses must also be aware of signs of maltreatment and child abuse because millions of children are affected each year. Child abuse includes physical, sexual, emotional abuse, and neglect. According to the American Academy of Child and Adolescent Psychiatry (AACAP), after abuse or violence, many children develop mental health problems, including depression and post-traumatic stress disorder. These children may also have serious medical problems, learning problems, and problems getting along with friends and family members. Every state has laws that require health care professionals to report suspected child abuse no matter what form this abuse takes.[7]
Adolescents
Motor vehicle accidents are the number one cause of death for adolescents. Teens aged 16-19 are three times more likely to be in a fatal crash than drivers older than age 20. Adolescent males are twice as likely to die in a motor vehicle accident than females of the same age. Texting while driving is a common cause of distracted driving and accidents in adolescents. Because much of an adolescent’s time is spent away from the home, it is difficult for parents to control many of the decisions that adolescents make. Nurses educate teenagers to use seat belts, obey speed limits, and never use a cell phone or text while driving.[8] See Figure 5.9[9] for an image reminding teenage drivers to not text and drive.
Traumatic brain injuries (TBI) may occur in this age group due to participation in sports and recreation-related activities. TBI results from a blow, jolt, or hit to the head that causes a disruption in blood function or flow to the brain. Nurses should always be alert for indications of a concussion when a sports injury has occurred. Signs of a concussion requiring immediate medical attention include the following:
- Headache, vomiting, balance problems, fatigue, or drowsiness
- A dazed and confused appearance or difficulty concentrating or remembering; confusion
- Emotional irritability, nervousness, or a change in personality
The CDC has comprehensive information and education materials for parents, coaches, players, and healthcare providers as part of their “Heads Up” program.[10]
Substance abuse is another significant concern in the adolescent population and includes substances such as tobacco, alcohol, illicit drugs, prescription medication, over-the-counter medications, and bath salts. The National Institutes of Health provides many resources for educating teens and their parents about substance abuse.[11]
Adults
Intimate partner violence and substance abuse are common safety issues in the adult population.
Intimate Partner Violence
Intimate partner violence (IPV) is widespread in the United States and is the most prevalent adult safety issue. Intimate partner violence includes physical or sexual violence, stalking, and psychological or coercive aggression by current or former intimate partners. Victims can be female or male, and sexual orientation can be heterosexual or LGBTQ+. The nurse is often the initial health care professional in contact with a victim of IPV. Prompt recognition of a potential or actual threat to client and staff safety is crucial. It is often the nurse’s assessment that plays an important role in identifying a client experiencing IPV. Compassion and understanding are important to show to this vulnerable population. Effective communication is necessary to help victims come forward and share their experiences of abuse. IPV is a complex issue, and the client may not initially consider leaving the abuser as an option. See Figure 5.10[12] for an image of a sign in a community demonstrating support against domestic violence.
See the following tools and resources to share with clients experiencing IPV. For example, the Danger Assessment Tool is a self-administered survey that is free to use and is available in several languages.[13] Nurses can refer clients experiencing IPV to the National Center on Domestic Violence, the Trauma and Mental Health database for resources,[14] and the National Domestic Violence Hotline for free, confidential support.[15] Most importantly, nurses should assist clients experiencing IPV to create a safety plan.
View the tools and resources available at these hyperlinks to share with individuals experiencing intimate partner violence:
Substance Abuse
Substance abuse is defined by the World Health Organization (WHO) as a maladaptive pattern of using alcohol and/or drugs despite it causing persistent social, occupational, psychological, or physical problems that can be physically hazardous. Substance misuse continues to be a safety issue that affects adults across all socioeconomic levels. In 2022, over 108,000 people died in the United States as a result of an opioid overdose.[16] Misuse of prescription pain medication (such as oxycontin and fentanyl) and street drugs like heroin is a national crisis that plagues social and economic welfare. Substance misuse not only affects an individual but also causes harm to their family members. Early identification of substance use disorders, rehabilitation interventions, and continued support are key for helping the individual, as well as their family members, in the recovery process. See Figure 5.11[17] for an image of a heroin needle found in a community setting.
Older Adults
According to the Centers for Disease Control and Prevention, falls and motor vehicle accidents are leading causes of injury in older adults. However, several other issues pose significant hazards for this population, such as fires, accidental overdosing on medications, elder abuse, and financial exploitation. [footnote]Centers for Disease Control and Prevention (n.d.). Injury prevention and control. https://www.cdc.gov/injury/index.html[/footnote]
In most reported cases of elder abuse, a caregiver or a person in trusted relationship is the perpetrator. For various reasons such as fear and disappointment, most of these cases go unreported. Abuse, including neglect and exploitation, is experienced by about 1 in 10 people aged 60 and older who live at home. From 2002 to 2016, more than 643,000 older adults were treated in the emergency department for nonfatal assaults and over 19,000 homicides occurred.[18] Read an example of an older adult experiencing financial exploitation in the following box.
Consider the story of John, a 92-year-old male who lost his wife over a year ago and has been lonely ever since. He lives alone in a large home in the country. John hired a repairman to fix his roof. The repairman befriended John, bringing him homemade cookies and pies and even running errands for him. The repairman often stayed for coffee, and the two of them spent time talking about fishing and gardening. The repairman convinced John to take out a reverse mortgage to pay for additional improvements on his home. Then, knowing John’s bank account numbers and login information, the repairman stole $250,000 that John received for his reverse mortgage.
Most victims of elder abuse are frequently seen in the emergency department several times before they are admitted to the hospital. Nurses must be alert to any indications of elder abuse, such as suspicious injuries or behaviors, and report suspected incidents to local adult protective services agencies. Commons signs of elder abuse or maltreatment include the following[19]:
- Bruises, cuts, burns, or broken bones that are unexplainable or suspiciously explained
- Malnourishment or weight loss
- Poor hygiene, an unkempt appearance, unclean clothing, or dirty, matted hair
- Foul odor from clothing or body
- Anxiety, depression, or confusion
- Unexplained transactions or loss of money
- Withdrawal from family members or friends
View additional resources related to elder abuse in the following box.
Additional resources for older adults suspected as being victims of elder abuse:
In addition to promoting safety for clients and their families, it is important for nurses to be aware of safety risks in the environments and to take measures to protect themselves. Common safety risks to nurses include sharps injuries, exposure to blood-borne pathogens, lifting injuries, and lack of personal protective equipment (PPE).
Workplace Safety
The World Health Organization (WHO) defines a healthy environment as a place of physical, mental, and social well-being supporting optimal health and safety. The American Nurses Association (ANA) created the Nurses’ Bill of Rights, a document that sets forth seven basic principles concerning expectations for workplace environments. One of the ANA principles states, “Nurses have the right to a work environment that is safe for themselves and their patients.”[21] Environmental Health is also one of the ANA Standards of Professional Performance. This standard includes "creating a safe and healthy workplace and professional environment."[22]
Preventing Sharps Injuries and Blood-Borne Pathogen Exposure
Exposure to sharps and blood-borne pathogens is a critical safety issue that nurses face in the workplace.[23] Blood-borne pathogen exposure can cause life-threatening illnesses such as hepatitis B, hepatitis C, and HIV. Regulations and laws, such as the Blood-borne Pathogen Standard from the Occupational Safety and Health Administration (OSHA) and the Needlestick Safety and Prevention Act of 2002, have been effective in significantly reducing sharps injuries and blood exposures among health care workers. Areas covered by these regulations include sharps disposal practices, evaluation and selection of safety-engineered sharps devices and personal protective equipment (PPE), training, record keeping for needlestick injuries, hepatitis B vaccination, and post exposure follow-up. Medical device manufacturers have also played an important role in reducing sharps injury risks to health care workers by developing innovative safety-engineered technology, such as needleless IV access devices.[24] While substantial progress has been made to reduce injuries, preventable sharps injuries and blood exposures continue to occur in health care settings. According to the Centers for Disease Control and Prevention (CDC), around 385,000 sharps-related injuries occur annually among health care workers in hospitals, but it has been estimated that as many as half of injuries go unreported.[25] See Figure 5.12[26] for an image of a sharps container used to prevent sharps-related injuries.
If you do experience a sharps injury or are exposed to the blood or other body fluid of a client, follow agency and school policy and immediately follow these steps according to the injury site [27]:
- Wash puncture and small wounds with soap and water for 15 minutes.
- Apply direct pressure to lacerations to control bleeding and seek medical attention.
- Flush mucous membranes with water.
- Report the incident to your instructor or supervisor.
- Seek medical care to determine your risk associated with the exposure.
Safe Client Handling
Back injuries and other musculoskeletal disorders can be caused by one bad client lift or from the daily wear and tear of manually lifting clients. At least 56% of nurses have reported pain from musculoskeletal disorders that were exacerbated by requirements of their job. Consequences of these injuries can be devastating to nurses and their careers. Musculoskeletal injuries related to client handling are responsible for more lost work time, long-term medical care needs, and permanent disabilities than any other work-related injury. Even using proper body mechanics and the use of gait belts can result in client handling injuries in nurses and healthcare workers. The ANA has established safe patient handling and mobility initiatives with the goal of complete elimination of manual patient handling. [footnote]American Nurses Association. (2015, September). Safe patient handling & mobility: Understanding the benefits of a comprehensive SPHM program [Brochure]. https://www.nursingworld.org/~498de8/globalassets/practiceandpolicy/work-environment/health--safety/ana-sphmcover__finalapproved.pdf[/footnote] See Figure 5.13[28] for an example of safe client handling equipment.
View these videos on safe client handling and mobility from the ANA:
Personal Protective Equipment
The Occupational Safety and Health Administration (OSHA) requires employers to provide personal protective equipment (PPE) to their workers and ensure its proper use. [footnote]United States Department of Labor. (n.d.). Personal protective equipment. Occupational Safety and Health Administration. https://www.osha.gov/personal-protective-equipment[/footnote] In healthcare settings, the use of PPE includes gloves, gowns, goggles, face shields, and N95 respirators according to a client’s condition. Healthcare workers rely on personal protective equipment to protect themselves and their clients from being infected and infecting others. It is vital to follow agency procedures regarding PPE and transmission precautions to avoid exposure to infectious disease. See Figure 5.14[31] for an image of healthcare team members wearing PPE. Unfortunately, the COVID-19 pandemic created global shortages of PPE, resulting in many nurses and healthcare workers being exposed to the fatal disease. The ANA continues to advocate for adequate PPE for nurses in their work environments. Review additional information about PPE using the hyperlink below.
Fire Safety
Healthcare workers are required to understand fire safety in terms of what to do in the event of a fire, where fire alarms and fire extinguishers are located and how to access them, and where fire doors and fire exits are located. Fire safety is such a crucial aspect of safe client care that The Joint Commission and Centers for Medicare and Medicaid have mandated that all healthcare facilities receiving Medicare or Medicaid reimbursement must have a fire response plan, fire safety training for staff members, and functioning fire response equipment, such as fire alarms, fire extinguishers, overhead sprinkler systems, and clearly identified fire exit doors. The Joint Commission requires that facilities routinely conduct fire alarm drills as a means of practicing what to do in the event of a fire. These drills must be audited and documented with areas for improvements noted and addressed. [footnote]The Joint Commission. (2024). Fire protection: Clinical impact. https://www.jointcommission.org/resources/the-physical-environment/fire-protection/clinical-impact/[/footnote]
RACE and PASS
Fire safety revolves around the acronyms RACE and PASS. RACE is an acronym that tells people what to do in the event of a fire. PASS is an acronym that tells people how to use a fire extinguisher correctly. Both acronyms are described below.
RACE stands for Rescue, Activate, Confine, and Extinguish[32]:
- Rescue: Rescue anyone in immediate danger. This includes removing clients from the immediate vicinity of the fire, as well as yourself. Maintain your safety while rescuing clients so you do not become a fire victim. This becomes especially important to keep in mind if the fire is between you and the client.
- Activate: Activate the fire alarm. This allows others to realize there is a fire or potential fire so that safety measures can begin immediately. Sometimes the activate step is also stated as “Alarm.”
- Confine: Confine the fire by closing doors and windows. This includes closing fire doors to help prevent the fire from breaching one fire zone and encroaching on another.
- Extinguish or Evacuate: Extinguish small fires if possible. Again, maintain your safety before trying to extinguish a fire. If the fire cannot be easily extinguished, then evacuate the fire zone or the building if necessary.
PASS stands for Pull, Aim, Squeeze, and Sweep[33]:
- Pull: Pull the pin on the fire extinguisher handle. This action is necessary to allow the handle to be depressed and allow fire extinguisher contents to be released.
- Aim: Aim low towards the base of the fire with the fire extinguisher nozzle or hose. It is important to aim the fire extinguisher contents to the base of the fire because this is what will extinguish the fire through smothering. The top part of the fire will not be smothered by the fire extinguisher contents because it is too large and spread out
- Squeeze: Squeeze down on the handle of the fire extinguisher to depress it and allow contents to be released from the extinguisher.
- Sweep: Sweep the hose or nozzle from side to side as the fire extinguisher contents are being sprayed on the base of the fire. This helps to fully cover the base of the fire in the hope of extinguishing it. Continue sweeping the fire extinguisher nozzle, spraying contents at the base of the fire until the fire is extinguished, or the fire extinguisher is empty. If the fire reignites, begin the steps of RACE and PASS again.
Safety Data Sheets
Safety Data Sheets (SDS), formerly referred to as Material Safety Data Sheets (MSDS), are hazardous communication sheets that let workers know certain information about chemicals they encounter in the workplace. OSHA requires that SDS’s are readily available and easily readable for each chemical in the workplace. SDS include the following mandatory information[34]:
- Section 1: Identification of the chemical and recommended uses, along with the contact information of the supplier.
- Section 2: Hazard(s) identification, classification of the chemical, and warning information about the hazards present.
- Section 3: Composition and information about ingredients contained in the product, including the chemical name, concentration, and impurities or stabilizing additives that may be present in the product.
- Section 4: First aid measures, including initial care for individuals who have been exposed to the chemical by varying routes.
- Section 5: Firefighting measures, including type of extinguishing equipment required and hazardous combustion products produced if the chemical burns.
- Section 6: Accidental release measures, including and appropriate response to spills or leaks and associated cleanup recommendations.
- Section 7: Handling and storage recommendations for the chemical.
- Section 8: Exposure controls and personal protection required for the chemical.
- Section 9: Physical and chemical properties of the substance.
- Section 10: Stability and reactivity hazards of the chemical.
- Section 11: Toxicological information, including health effects of exposure to the chemical and whether these are immediate, delayed, or chronic effects. Symptoms associated with exposure are also included.
Read more about SDS requirements in this OSHA Brief.
Explore the Healthy Work Environment web page by the American Nursing Association (ANA) for additional strategies that promote safe work environments for nurses, including the Nurses' Bill of Rights and ways to put this plan into action.
In addition to promoting safety for clients and their families, it is important for nurses to be aware of safety risks in the environments and to take measures to protect themselves. Common safety risks to nurses include sharps injuries, exposure to blood-borne pathogens, lifting injuries, and lack of personal protective equipment (PPE).
Workplace Safety
The World Health Organization (WHO) defines a healthy environment as a place of physical, mental, and social well-being supporting optimal health and safety. The American Nurses Association (ANA) created the Nurses’ Bill of Rights, a document that sets forth seven basic principles concerning expectations for workplace environments. One of the ANA principles states, “Nurses have the right to a work environment that is safe for themselves and their patients.”[35] Environmental Health is also one of the ANA Standards of Professional Performance. This standard includes "creating a safe and healthy workplace and professional environment."[36]
Preventing Sharps Injuries and Blood-Borne Pathogen Exposure
Exposure to sharps and blood-borne pathogens is a critical safety issue that nurses face in the workplace.[37] Blood-borne pathogen exposure can cause life-threatening illnesses such as hepatitis B, hepatitis C, and HIV. Regulations and laws, such as the Blood-borne Pathogen Standard from the Occupational Safety and Health Administration (OSHA) and the Needlestick Safety and Prevention Act of 2002, have been effective in significantly reducing sharps injuries and blood exposures among health care workers. Areas covered by these regulations include sharps disposal practices, evaluation and selection of safety-engineered sharps devices and personal protective equipment (PPE), training, record keeping for needlestick injuries, hepatitis B vaccination, and post exposure follow-up. Medical device manufacturers have also played an important role in reducing sharps injury risks to health care workers by developing innovative safety-engineered technology, such as needleless IV access devices.[38] While substantial progress has been made to reduce injuries, preventable sharps injuries and blood exposures continue to occur in health care settings. According to the Centers for Disease Control and Prevention (CDC), around 385,000 sharps-related injuries occur annually among health care workers in hospitals, but it has been estimated that as many as half of injuries go unreported.[39] See Figure 5.12[40] for an image of a sharps container used to prevent sharps-related injuries.
If you do experience a sharps injury or are exposed to the blood or other body fluid of a client, follow agency and school policy and immediately follow these steps according to the injury site[41]:
- Wash puncture and small wounds with soap and water for 15 minutes.
- Apply direct pressure to lacerations to control bleeding and seek medical attention.
- Flush mucous membranes with water.
- Report the incident to your instructor or supervisor.
- Seek medical care to determine your risk associated with the exposure.
Safe Client Handling
Back injuries and other musculoskeletal disorders can be caused by one bad client lift or from the daily wear and tear of manually lifting clients. At least 56% of nurses have reported pain from musculoskeletal disorders that were exacerbated by requirements of their job. Consequences of these injuries can be devastating to nurses and their careers; musculoskeletal injuries related to client handling are responsible for more lost work time, long-term medical care needs, and permanent disabilities than any other work-related injury. Even using proper body mechanics and the use of gait belts can result in client handling injuries in nurses and health care workers. The ANA has established safe patient handling and mobility initiatives with the goal of complete elimination of manual patient handling.[42] See Figure 5.13[43] for an example of safe client handling equipment.
View these videos on safe client handling and mobility from the ANA:
Personal Protective Equipment
The Occupational Safety and Health Administration (OSHA) requires employers to provide personal protective equipment (PPE) to their workers and ensure its proper use.[46] In health care settings, the use of PPE includes gloves, gowns, goggles, face shields, and N95 respirators according to a client’s condition. Health care workers rely on personal protective equipment to protect themselves and their clients from being infected and infecting others. It is vital to follow agency procedures regarding PPE and transmission precautions to avoid exposure to infectious disease. See Figure 5.14[47] for an image of health care team members wearing PPE. Unfortunately, the COVID-19 pandemic created global shortages of PPE, resulting in many nurses and health care workers being exposed to the fatal disease. The ANA continues to advocate for adequate PPE for nurses in their work environments. Review additional information about PPE using the hyperlink below.
Fire Safety
Health care workers are required to understand fire safety in terms of what to do in the event of a fire, where fire alarms and fire extinguishers are located and how to access them, and where fire doors and fire exits are located. Fire safety is such a crucial aspect of safe client care that The Joint Commission and Centers for Medicare and Medicaid have mandated that all health care facilities receiving Medicare or Medicaid reimbursement must have a fire response plan, fire safety training for staff members, and functioning fire response equipment, such as fire alarms, fire extinguishers, overhead sprinkler systems, and clearly identified fire exit doors. The Joint Commission requires that facilities routinely conduct fire alarm drills as a means of practicing what to do in the event of a fire. These drills must be audited and documented with areas for improvements noted and addressed.[48]
RACE and PASS
Fire safety revolves around the acronyms RACE and PASS. RACE is an acronym that tells people what to do in the event of a fire. PASS is an acronym that tells people how to use a fire extinguisher correctly. Both acronyms are described below.
RACE stands for Rescue, Activate, Confine, and Extinguish[49]:
- Rescue: Rescue anyone in immediate danger. This includes removing clients from the immediate vicinity of the fire, as well as yourself. Maintain your safety while rescuing clients so you do not become a fire victim. This becomes especially important to keep in mind if the fire is between you and the client.
- Activate: Activate the fire alarm. This allows others to realize there is a fire or potential fire so that safety measures can begin immediately. Sometimes the activate step is also stated as “Alarm.”
- Confine: Confine the fire by closing doors and windows. This includes closing fire doors to help prevent the fire from breaching one fire zone and encroaching on another.
- Extinguish or Evacuate: Extinguish small fires if possible. Again, maintain your safety before trying to extinguish a fire. If the fire cannot be easily extinguished, then evacuate the fire zone or the building if necessary.
PASS stands for Pull, Aim, Squeeze, and Sweep[50]:
- Pull: Pull the pin on the fire extinguisher handle. This action is necessary to allow the handle to be depressed and allow fire extinguisher contents to be released.
- Aim: Aim low towards the base of the fire with the fire extinguisher nozzle or hose. It is important to aim the fire extinguisher contents to the base of the fire because this is what will extinguish the fire through smothering. The top part of the fire will not be smothered by the fire extinguisher contents because it is too large and spread out
- Squeeze: Squeeze down on the handle of the fire extinguisher to depress it and allow contents to be released from the extinguisher.
- Sweep: Sweep the hose or nozzle from side to side as the fire extinguisher contents are being sprayed on the base of the fire. This helps to fully cover the base of the fire in the hope of extinguishing it. Continue sweeping the fire extinguisher nozzle, spraying contents at the base of the fire until the fire is extinguished, or the fire extinguisher is empty. If the fire reignites, begin the steps of RACE and PASS again.
Safety Data Sheets
Safety Data Sheets (SDS), formerly referred to as Material Safety Data Sheets (MSDS), are hazardous communication sheets that let workers know certain information about chemicals they encounter in the workplace. OSHA requires that SDS’s are readily available and easily readable for each chemical in the workplace. SDS include the following mandatory information[51]:
- Section 1: Identification of the chemical and recommended uses, along with the contact information of the supplier.
- Section 2: Hazard(s) identification, classification of the chemical, and warning information about the hazards present.
- Section 3: Composition and information about ingredients contained in the product, including the chemical name, concentration, and impurities or stabilizing additives that may be present in the product.
- Section 4: First aid measures, including initial care for individuals who have been exposed to the chemical by varying routes.
- Section 5: Firefighting measures, including type of extinguishing equipment required and hazardous combustion products produced if the chemical burns.
- Section 6: Accidental release measures, including and appropriate response to spills or leaks and associated cleanup recommendations.
- Section 7: Handling and storage recommendations for the chemical.
- Section 8: Exposure controls and personal protection required for the chemical.
- Section 9: Physical and chemical properties of the substance.
- Section 10: Stability and reactivity hazards of the chemical.
- Section 11: Toxicological information, including health effects of exposure to the chemical and whether these are immediate, delayed, or chronic effects. Symptoms associated with exposure are also included.
Read more about SDS requirements in this OSHA Brief.
Explore the Healthy Work Environment web page by the American Nursing Association (ANA) for additional strategies that promote safe work environments for nurses, including the Nurses' Bill of Rights and ways to put this plan into action.
Client Scenario
Mr. Olson is a 64-year-old client admitted to the medical-surgical floor with a diagnosis of pneumonia. The client has severe macular degeneration and limited visual acuity. He is alert and oriented but notes that he has suffered a “few stumbles” at home over the last few weeks. He ambulates without assistance but relies heavily on tactile cues to help provide guidance.
Applying the Nursing Process
Assessment: The nurse notes that Mr. Olson’s macular degeneration and limited visual acuity pose a significant safety risk. He has reported “stumbling” at home and uses tactile cues to establish room boundaries.
Based on the assessment information that has been gathered, the following nursing care plan is created for Mr. Olson.
Nursing Diagnosis: Risk for Injury as evidence by altered visual acuity, stumbling at home, and using tactile cues to mobility.
Overall Goal: The client will be free from falls.
SMART Expected Outcome: Mr. Olson will be free from falls throughout his hospitalization.
Planning and Implementing Nursing Interventions:
The nurse will provide the client with education regarding the room layout and tactile boundary cues. The nurse will keep the client’s room free from clutter and provide appropriate lighting. The nurse will instruct the client to utilize the call light and request assistance when ambulating throughout the room. The nurse will provide the client with nonskid footwear to enhance safety during ambulation.
Sample Documentation:
Mr. Olson is at risk for falls as a result of his decreased visual acuity and hospitalization in an unfamiliar environment. The client has been provided education and safety equipment to decrease his risk of injury. The client has received education regarding the room layout and has been encouraged to request assistance when ambulating about the room.
Evaluation:
During the client's hospitalization, Mr. Olson utilizes the recommended safety equipment and requests assistance when ambulating and no falls occurred. SMART outcome was "met."
View a sample nursing care plan for this scenario that was created using the template found in Appendix B.
Client Scenario
Mr. Olson is a 64-year-old client admitted to the medical-surgical floor with a diagnosis of pneumonia. The client has severe macular degeneration and limited visual acuity. He is alert and oriented but notes that he has suffered a “few stumbles” at home over the last few weeks. He ambulates without assistance but relies heavily on tactile cues to help provide guidance.
Applying the Nursing Process
Assessment: The nurse notes that Mr. Olson’s macular degeneration and limited visual acuity pose a significant safety risk. He has reported “stumbling” at home and uses tactile cues to establish room boundaries.
Based on the assessment information that has been gathered, the following nursing care plan is created for Mr. Olson.
Nursing Diagnosis: Risk for Injury AMB altered visual acuity, stumbling at home, and using tactile cues to mobility.
Overall Goal: The client will be free from falls.
SMART Expected Outcome: Mr. Olson will be free from falls throughout his hospitalization.
Planning and Implementing Nursing Interventions:
The nurse will provide the client with education regarding the room layout and tactile boundary cues. The nurse will keep the client’s room free from clutter and provide appropriate lighting. The nurse will instruct the client to utilize the call light and request assistance when ambulating throughout the room. The nurse will provide the client with nonskid footwear to enhance safety during ambulation.
Sample Documentation:
Mr. Olson is at risk for falls as a result of his decreased visual acuity and hospitalization in an unfamiliar environment. The client has been provided education and safety equipment to decrease his risk of injury. The client has received education regarding the room layout and has been encouraged to request assistance when ambulating about the room.
Evaluation:
During the client's hospitalization, Mr. Olson utilizes the recommended safety equipment and requests assistance when ambulating and no falls occurred. SMART outcome was "met."
View a sample nursing care plan for this scenario that was created using the template found in Appendix B.
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
- You are providing care for Mrs. Jones, an 83-year-old female client admitted to the medical-surgical floor with worsening pneumonia. Upon auscultation of the client's lung fields, you note scattered crackles and diminished breath sounds throughout all lung fields. Mrs. Jones requires 4L O2 via nasal cannula to maintain an oxygen saturation of 94%. You have constructed a nursing care diagnosis of Ineffective Breathing Pattern. What nursing interventions might you consider to help improve the client's breathing pattern?
Test your knowledge using these NCLEX Next Generation-style questions. You may reset and resubmit your answers to these questions an unlimited number of times.[53]
Test your knowledge using these NCLEX Next Generation-style questions. You may reset and resubmit your answers to the questions in this assignment an unlimited number of times.[54]
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
Assessing a client’s risk for falls and planning interventions to prevent falls are common safety strategies completed by nurses. This section uses a client scenario to demonstrate how to use the nursing process to assess a client and then create a nursing care plan to prevent falls. Begin by reading the Handoff Report received from the nurse on the previous shift.
Handoff Report
Mr. Moore is a 72-year-old widower recovering in the hospital after sustaining injuries he received from a fall at home. See Figure 5.15 for an image of Mr. Moore.[55] He fractured his right hip and underwent surgical repair two days ago. He is receiving IV fluids and morphine for pain control. He has a history of hypertension and cardiovascular disease. He wears glasses and hearing aids. Per recommendations from the physical therapist, he is able to transfer with one assist with a walker but is weak on his right side. He has an order to ambulate at least 100 feet four times daily with a wheeled walker. He is 6 feet tall and weighs 165 pounds. Prior to the fall, he lived at home alone independently, and he is looking forward to returning home.
Assessment
The nurse collects the following assessment findings:
- Vital Signs: Blood pressure 90/60, heart rate 56, respiratory rate 18, temperature 37 degrees Celsius, pulse oximetry reading 92%, current pain level 0
- Alert and oriented x 3 to person, place, and time
- Lungs clear
- Cardiovascular Assessment: Heart rate is regular, capillary refill less than 3 seconds in fingers and toes, pedal pulses 2+
- Right lower extremity strength is 1+ (weak)
- Ambulates with walker with assistance; gait is unsteady
Critical Thinking Questions
1. Describe the fall risk factors for Mr. Moore.
2. Use the Morse Fall Risk Scale to assess Mr. Moore’s risk for falling.
Diagnosis
The NANDA-I nursing diagnosis is established: Risk for Falls as evidenced by lower extremity weakness and difficulty with gait.
Outcome Identification
Overall Goal: Mr. Moore will remain free from falls during his hospitalization stay.
SMART Expected Outcomes:
- Mr. Moore will not experience a fall during hospitalization.
- Mr. Moore will correctly use his assistive device (walker) every time he ambulates during hospitalization.
Planning Interventions
The following interventions are planned based on Mr. Moore’s fall risk factors.
- Remove clutter from the floor.
- Provide adequate lighting with a night-light at the bedside.
- Use half side rails to prevent falls from the bed.
- Monitor gait, balance, and fatigue with ambulation and encourage resting as needed.
- Place personal items within easy reach of the client at the bedside.
- Provide an elevated toilet seat.
- Encourage the use of prescribed glasses and hearing aids when walking.
- Obtain orthostatic blood pressures daily and notify the provider as indicated.
- Ensure the client wears shoes that fit properly, are fastened securely, and have no-skid soles.
- Suggest home adaptations to improve safety after discharge, such as adjusting the toilet seat height, installing grab bars in the bathroom, and using a rubber mat in the shower.
Critical Thinking Question
3. What additional interventions could be implemented for Mr. Moore to reduce his risk of falls that target his specific risk factors?
Implementation of Interventions
The following day, upon entering the room, you find Mr. Moore has climbed out of bed and is on his way to the bathroom. He states, “I need to go to the bathroom for a bowel movement and didn’t have time to ring the call light and wait.” You assist him with his walker, but he seems unsteady on his feet as he walks toward the bathroom. You’re not sure if he will make it to the toilet without falling. He says, “We need to hurry or I’m not going to make it.”
Critical Thinking Question
4. What is the best response?
Evaluation
The nurse evaluates Mr. Moore’s progress based on the established expected outcomes:
- Mr. Moore will not experience a fall during hospitalization: Outcome Met.
- Mr. Moore will use his assistive device (walker) correctly during hospitalization: Outcome Partially Met.
Mr. Moore forgets to call for assistance and uses a walker when he needs to go to the bathroom. A “stop” sign has been placed within client view to remind him to use the call light before getting up. In addition to hourly rounding, toileting will be performed at scheduled intervals every two hours. An icon has been posted on the doorframe to alert staff that the client is at high risk for falls. In addition to the bed being kept low and locked, a mat will be placed next to the bed at night. If Mr. Moore continues to forget to call for assistance, a bed alarm will be placed to alert staff of movement so that quick assistance can be offered.
Professional communication with other members of the health care team is an important component of every nurse’s job. See Figure 2.8[56] for an image illustrating communication between health care team members. Common types of professional interactions include reports to health care team members, handoff reports, and transfer reports. Reports may be verbal (e.g., reports given in person, by telephone, or recorded) or written (e.g., reports provided electronically or by fax).
Reports to Health Care Team Members
Nurses routinely report information to other nurses and health care team members, as well as urgently contact health care providers to report changes in client status.
Standardized methods of communication have been developed to allow information to be exchanged between health care team members in a structured, concise, and accurate manner to ensure safe client care. One common format used by health care team members to exchange client information is ISBARR, a mnemonic for the components of Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back or a simpler version called SBAR:
-
- Introduction: Introduce your name, role, and the agency from which you are calling.
- Situation: Provide the client’s name and location, why you are calling, recent vital signs, and the status of the client.
- Background: Provide pertinent background information about the client such as admitting medical diagnoses, code status, recent relevant lab or diagnostic results, and allergies.
- Assessment: Share abnormal assessment findings and your evaluation of the current client situation.
- Request/Recommendations: State what you would like the provider to do, such as reassess the client, order a lab/diagnostic test, prescribe/change medication, etc.
- Repeat back: If you are receiving new orders from a provider, repeat them to confirm accuracy. Be sure to document communication with the provider in the client’s chart.
Read an example of an ISBARR report in the following box. Information is provided to a printable ISBARR reference card.
Sample ISBARR Report From a Nurse to a Health Care Provider
I: “Hello Dr. Smith, this is Jane White, RN from the Med Surg unit.”
S: “I am calling to tell you about Ms. White in Room 210, who is experiencing an increase in pain, as well as redness at her incision site. The client has no known allergies and is a full code. Her recent vital signs were BP 160/95, heart rate 90, respiratory rate 22, O2 sat 96%, and temperature 38 degrees Celsius. She is stable but her pain is worsening.”
B: “Ms. White is a 65-year-old female, admitted yesterday post hip surgical replacement. She has been rating her pain at 3 or 4 out of 10 since surgery with her scheduled medication, but now she is rating the pain as a 7, with no relief from her scheduled medication of Vicodin 5/325 mg administered an hour ago. She is scheduled for physical therapy later this morning and is stating she won’t be able to participate because of the pain this morning.”
A: “I just assessed the surgical site, and her dressing was clean, dry, and intact, but there is 4 cm redness surrounding the incision, and it is warm and tender to the touch. There is moderate serosanguinous drainage. Otherwise, her lungs are clear, and her heart rate is regular. I am concerned her incision site may be becoming infected and that she will have difficulty with therapy if her pain remains uncontrolled.”
R: “I am calling to request an order for a CBC and increased dose of pain medication.”
R: “I am repeating back the order to confirm that you are ordering a STAT CBC and an increase of her Vicodin to 10/325 mg.”
View or print an ISBARR reference card
Handoff Reports
Handoff reports are defined by The Joint Commission as “a transfer and acceptance of client care responsibility achieved through effective communication. It is a real-time process of passing client specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the client’s care.”[57] In 2017, The Joint Commission issued a critical alert about inadequate handoff communication that has resulted in client harm such as wrong-site surgeries, delays in treatment, falls, and medication errors. Strategies for improving handoff communication have been implemented at agencies across the country.
Although many types of nursing shift-to-shift handoff reports have been used over the years, evidence strongly supports that bedside handoff reports increase client safety, as well as client and nurse satisfaction, by effectively communicating current, accurate client information in real time.[58] See Figure 2.9[59] for an image illustrating two nurses participating in a handoff report. Bedside reports typically occur in hospitals and include the client, along with the off-going and the oncoming nurses in a face-to-face handoff report conducted at the client's bedside. HIPAA rules must be kept in mind if visitors are present, or the room is not a private room. Family members may be included with the client’s permission. See a sample checklist for a bedside handoff report from the Agency for Healthcare Research and Quality in Figure 2.10.[60] Although a bedside handoff report is similar to an ISBARR report, it contains additional information to ensure continuity of care across nursing shifts. For example, the “assessment” portion of the bedside handoff report includes detailed pertinent data the oncoming nurse needs to know, such as current head-to-toe assessment findings to establish a baseline; information about equipment such as IVs, catheters, and drainage tubes; and recent changes in medications, lab results, diagnostic tests, and treatments.
Print a copy of the AHRQ Bedside Shift Report Checklist.
View a video on creating shift reports.[61]
Transfer Reports
Transfer reports are provided by nurses when transferring a client to another unit or to another agency. Transfer reports contain similar information as bedside handoff reports but are even more detailed when the client is being transferred to another agency. Checklists are often provided by agencies to ensure accurate, complete information is shared.
Conflict in the Workplace
Nurses encounter conflict in their daily work environment, such as misunderstandings or disagreements among staff, clients, providers, family members, or other individuals. Nurses must learn communication methods that lessen conflict and enhance interactions that lead to a better work environment.
Read additional information about "Conflict Resolution" in Open RN Nursing Health Alterations.
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
Assessing a client’s risk for falls and planning interventions to prevent falls are common safety strategies completed by nurses. This section uses a client scenario to demonstrate how to use the nursing process to assess a client and then create a nursing care plan to prevent falls. Begin by reading the Handoff Report received from the nurse on the previous shift.
Handoff Report
Mr. Moore is a 72-year-old widower recovering in the hospital after sustaining injuries he received from a fall at home. See Figure 5.15 for an image of Mr. Moore.[62] He fractured his right hip and underwent surgical repair two days ago. He is receiving IV fluids and morphine for pain control. He has a history of hypertension and cardiovascular disease. He wears glasses and hearing aids. Per recommendations from the physical therapist, he is able to transfer with one assist with a walker but is weak on his right side. He has an order to ambulate at least 100 feet four times daily with a wheeled walker. He is 6 feet tall and weighs 165 pounds. Prior to the fall, he lived at home alone independently, and he is looking forward to returning home.
Assessment
The nurse collects the following assessment findings:
- Vital Signs: Blood pressure 90/60, heart rate 56, respiratory rate 18, temperature 37 degrees Celsius, pulse oximetry reading 92%, current pain level 0
- Alert and oriented x 3 to person, place, and time
- Lungs clear
- Cardiovascular Assessment: Heart rate is regular, capillary refill less than 3 seconds in fingers and toes, pedal pulses 2+
- Right lower extremity strength is 1+ (weak)
- Ambulates with walker with assistance; gait is unsteady
Critical Thinking Questions
1. Describe the fall risk factors for Mr. Moore.
2. Use the Morse Fall Risk Scale to assess Mr. Moore’s risk for falling.
Diagnosis
The NANDA-I nursing diagnosis is established: Risk for Falls as evidenced by lower extremity weakness and difficulty with gait.
Outcome Identification
Overall Goal: Mr. Moore will remain free from falls during his hospitalization stay.
SMART Expected Outcomes:
- Mr. Moore will not experience a fall during hospitalization.
- Mr. Moore will correctly use his assistive device (walker) every time he ambulates during hospitalization.
Planning Interventions
The following interventions are planned based on Mr. Moore’s fall risk factors.
- Remove clutter from the floor.
- Provide adequate lighting with a night-light at the bedside.
- Use half side rails to prevent falls from the bed.
- Monitor gait, balance, and fatigue with ambulation and encourage resting as needed.
- Place personal items within easy reach of the client at the bedside.
- Provide an elevated toilet seat.
- Encourage the use of prescribed glasses and hearing aids when walking.
- Obtain orthostatic blood pressures daily and notify the provider as indicated.
- Ensure the client wears shoes that fit properly, are fastened securely, and have no-skid soles.
- Suggest home adaptations to improve safety after discharge, such as adjusting the toilet seat height, installing grab bars in the bathroom, and using a rubber mat in the shower.
Critical Thinking Question
3. What additional interventions could be implemented for Mr. Moore to reduce his risk of falls that target his specific risk factors?
Implementation of Interventions
The following day, upon entering the room, you find Mr. Moore has climbed out of bed and is on his way to the bathroom. He states, “I need to go to the bathroom for a bowel movement and didn’t have time to ring the call light and wait.” You assist him with his walker, but he seems unsteady on his feet as he walks toward the bathroom. You’re not sure if he will make it to the toilet without falling. He says, “We need to hurry or I’m not going to make it.”
Critical Thinking Question
4. What is the best response?
Evaluation
The nurse evaluates Mr. Moore’s progress based on the established expected outcomes:
- Mr. Moore will not experience a fall during hospitalization: Outcome Met.
- Mr. Moore will use his assistive device (walker) correctly during hospitalization: Outcome Partially Met.
Mr. Moore forgets to call for assistance and uses a walker when he needs to go to the bathroom. A “stop” sign has been placed within client view to remind him to use the call light before getting up. In addition to hourly rounding, toileting will be performed at scheduled intervals every two hours. An icon has been posted on the doorframe to alert staff that the client is at high risk for falls. In addition to the bed being kept low and locked, a mat will be placed next to the bed at night. If Mr. Moore continues to forget to call for assistance, a bed alarm will be placed to alert staff of movement so that quick assistance can be offered.
