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Healthcare Facility Organization and Services Study Guide

Learn essential nursing skills for safely moving and positioning clients. This guide covers body mechanics, therapeutic positions, and techniques to prevent immobility complications like pressure wounds and contractures. Essential for patient safety and nurse well-being.

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Introduction to the Nursing Process

Introduction to the Nursing Process

The nursing process is a systematic, client-oriented, and goal-oriented framework that combines critical thinking and scientific problem-solving to provide quality nursing care.

  • nursing process
  • critical thinking
  • scientific problem-solving
  • trial and error problem-solving
  • nursing assessment
  • nursing diagnosis
  • planning
  • implementation
  • evaluation
  • nursing care plan
  • prioritization
  • short-term goal
  • long-term goal

Nursing Process and Documentation Fundamentals

This content details the systematic steps of the nursing process including assessment, nursing diagnosis, planning, implementation, and evaluation, alongside methods of health record documentation.

  • Nursing assessment
  • Data collection
  • Subjective and objective data
  • Nursing diagnosis
  • Medical diagnosis
  • Nursing care plan
  • Setting priorities
  • Expected outcomes
  • Nursing interventions
  • Independent, interdependent, and dependent actions
  • Nursing implementation
  • Nursing evaluation
  • Discharge planning
  • Health record documentation
  • Accountability
  • Electronic medical records
  • Manual health records

Principles of Clinical Documentation

Guidelines for documenting client statements, medications, treatments, and the use of 24-hour clock and standard abbreviations.

  • documenting client statements
  • late entries
  • clear and consistent documentation
  • 24-hour clock
  • military time
  • standard abbreviations
  • medical acronyms
  • medication error prevention

Therapeutic Communication Skills and Principles

Nursing Assessment and Data Collection

The systematic and continuous collection and analysis of objective and subjective data through observation, interview, and physical examination.

  • Nursing assessment
  • Objective data
  • Subjective data
  • Data collection methods
  • Observation
  • Health interview
  • Nursing history
  • Physical examination
  • Data analysis
  • Congruence
  • Data clusters
  • Prioritization
  • Validation
  • Nursing diagnosis

Nursing Diagnosis and Planning Care

This topic covers the second and third steps of the nursing process, focusing on identifying nursing diagnoses and developing a nursing care plan through setting priorities, establishing expected outcomes, and selecting nursing interventions.

  • Nursing diagnosis
  • Medical diagnosis
  • Nursing process
  • Diagnostic statement components
  • Problem
  • Etiology
  • Signs and symptoms
  • Independent nursing interventions
  • Collaborative problems
  • Nursing care plan
  • Setting priorities
  • Expected outcomes
  • Short-term goals
  • Long-term goals
  • Nursing interventions

Implementing, Evaluating, and Documenting Nursing Care

This content covers the implementation of nursing care plans through independent, interdependent, and dependent actions, the evaluation of client responses, and the legal and professional requirements of documentation and reporting.

  • nursing implementation
  • independent actions
  • interdependent actions
  • dependent actions
  • intellectual skills
  • interpersonal skills
  • technical skills
  • nursing evaluation
  • discharge planning
  • accountability
  • documentation
  • health record
  • communication
  • accountability measures

Health Record Formats and Documentation

This text examines various health record systems, documentation formats, and guidelines for accurate nursing assessment and progress recording.

  • Manual health records
  • Electronic medical records (EMRs)
  • Medical information systems (MIS)
  • Assessment documents
  • Plans for care and treatment
  • Progress records
  • Plans for continuity of care
  • Narrative–chronological charting
  • Problem-oriented (focus) documentation
  • SOAP, SOAPIER, APIE, PIE, DAPE, DARP, and DARE acronyms
  • Charting by exception (CBE)
  • Discipline area (multidisciplinary) documentation
  • Case management
  • Graphic flow sheets
  • Medication administration record (MAR)
  • Objective vs. subjective documentation

Guidelines for Accurate Health Record Documentation

Documenting client information requires being prompt, clear, and consistent while using standard abbreviations and the 24-hour clock.

  • Prompt documentation
  • Late entries
  • Clear and consistent charting
  • 24-hour clock and military time
  • Standard medical abbreviations and acronyms
  • Joint Commission "do not use" list
  • Medication error prevention
  • Chronological documentation
  • Confidentiality and communication

Nursing Documentation and Client Confidentiality

This text covers the importance of accurate documentation, maintaining client confidentiality, and effective reporting to ensure continuity of care.

  • Client confidentiality
  • Documentation errors
  • Electronic Medical Records (EMR)
  • Change-of-shift reporting
  • Walking rounds
  • Nursing care plans
  • Health records
  • Accountability
  • Communication among caregivers

Safety and the Healthcare Facility Environment

This content describes the components of the basic client unit, nursing care guidelines, and various healthcare personnel and services.

  • basic client unit
  • hospital bed
  • overbed table
  • bedside stand
  • client privacy
  • nursing care guidelines
  • client identification
  • medical asepsis
  • 24-hour clock
  • diagnostic and treatment departments
  • radiology department
  • neurodiagnostic department

Healthcare Facility Departments and Support Services

Healthcare facilities offer direct client care departments, specialized client care departments, and support services to meet the needs of clients.

  • Physical Therapy
  • Occupational Therapy
  • Nursing Care Units
  • Pediatrics Unit
  • Obstetrics Department
  • Medical/Surgical Care Units
  • Burn Center
  • Geriatric Units
  • Dialysis Unit
  • Mental Health Unit
  • Chemical Dependency Unit
  • Rehabilitation Unit
  • Outpatient Department
  • Emergency Department
  • Intensive Care Unit
  • Coronary Care Unit
  • Decision Unit/Observation Unit
  • Intermediate Care Unit
  • Self-Care Unit
  • Dietary Department

Introduction to Microbiology and Pathogens

This text introduces microbiology by discussing the characteristics, growth, and classification of microorganisms including bacteria, viruses, fungi, and protozoa, as well as the chain of infection and antimicrobial resistance.

  • microorganism characteristics
  • microbial growth factors
  • culture and sensitivity (C&S) procedures
  • bacterial classification
  • prokaryotes vs eukaryotes
  • gram stain reaction
  • bacterial shapes
  • spore formation
  • viral structure and reproduction
  • antimicrobial-resistant microorganisms (AMR)
  • healthcare-associated infections (HAI)
  • chain of infection
  • modes of disease transmission

Pathogen Entry and Infection Prevention

Pathogens require a portal of entry to gain access to a person's body, which can be prevented through Standard Precautions and skin care.

  • Portals of entry
  • Standard Precautions
  • Susceptible host
  • Nonspecific defenses
  • Specific defenses
  • Chain of infection
  • Pathogenic microorganisms
  • Local destruction of tissue

Pathogenic Microorganisms and Infection Processes

Pathogenic microorganisms cause damage to host tissues through toxins and follow a progressive course of infection including incubation, prodromal, full illness, and convalescence stages.

  • endotoxins
  • exotoxins
  • incubation period
  • prodromal stage
  • full stage of illness
  • convalescence stage
  • portal of entry
  • virulence
  • symbiosis
  • antibiosis
  • opportunistic infections
  • communicable diseases

Documentation Standards and Nursing Process

Healthcare Documentation and Medical Abbreviations

Guidelines for using medical abbreviations, symbols, and acronyms while maintaining accurate, chronological, and confidential healthcare documentation.

  • Medical abbreviations and acronyms
  • Joint Commission Do Not Use List
  • Medication documentation safety
  • Clinical documentation standards
  • Patient confidentiality and privacy
  • Correcting errors in health records
  • Electronic Medical Record (EMR) entries
  • Medical symbols and terminology

Nursing Documentation and Change-of-Shift Reporting

Accurate documentation and efficient reporting ensure continuity of client care, facilitate communication among caregivers, and provide evidence of accountability.

  • Change-of-shift reporting
  • Walking rounds
  • Continuity of care
  • Nursing care plan
  • Client confidentiality
  • Health record purposes
  • Medical information systems
  • Nursing progress notes
  • Documentation accuracy
  • Reporting techniques

The Nursing Process and Assessment

A systematic method combining critical thinking and scientific problem-solving to identify client problems, collect data, and determine nursing diagnosis.

  • Nursing process
  • Critical thinking
  • Scientific problem-solving
  • Nursing assessment
  • Data collection
  • Objective data
  • Subjective data
  • Nursing history
  • Physical examination
  • Data analysis
  • Validating observations
  • Nursing diagnosis
  • Medical diagnosis

Nursing Documentation and Healthcare Facility Environment

This content covers healthcare accountability, documentation systems, health record contents, nursing procedure guidelines, and the organization of healthcare facility departments and client units.

  • Accountability
  • Health record documentation
  • Electronic medical records
  • Manual records
  • Documentation formats
  • Charting by exception
  • Narrative documentation
  • Problem-oriented medical records
  • Case management
  • Continuity of care
  • Guidelines for documentation
  • Confidentiality
  • Change-of-shift reporting
  • Client unit components
  • Nursing procedure guidelines
  • Client identification
  • 24-hour clock
  • Diagnostic and treatment departments
  • Direct client care departments
  • Support services

Introduction to Microbiology and Infection Control

The scientific study of microorganisms including pathogens, their metabolism, growth requirements, and the chain of infection.

  • Microbiology
  • Pathogens
  • Microorganism characteristics
  • Metabolism and growth
  • Culture and sensitivity testing
  • Classification of microorganisms
  • Eukaryotes
  • Prokaryotes
  • Fungi
  • Protozoa
  • Bacteria
  • Viruses
  • Antimicrobial resistance
  • Healthcare-acquired infections
  • Chain of infection
  • Infection transmission vehicles

Pathogen Actions and Infection Stages

Pathogens cause harmful effects through toxins and progress through stages including incubation, prodromal, full stage of illness, and convalescence.

  • Endotoxins
  • Exotoxins
  • Incubation period
  • Prodromal stage
  • Full stage of illness
  • Convalescence stage
  • Portal of entry
  • Virulence
  • Host resistance

Medical Asepsis and Infection Control

Guidelines for medical asepsis, standard precautions, and transmission-based precautions to prevent healthcare-associated infections.

  • Medical asepsis
  • Surgical asepsis
  • Standard precautions
  • Transmission-based precautions
  • Airborne precautions
  • Droplet precautions
  • Contact precautions
  • Healthcare-associated infections (HAIs)
  • Chain of infection
  • Hand hygiene
  • Personal protective equipment (PPE)
  • Protective (neutropenic) isolation
  • Biohazardous waste disposal
  • Antimicrobial-resistant organisms
  • Barrier techniques

Microbiology and the Chain of Infection

Therapeutic Communication Skills in Nursing

This topic covers the components of the communication process, therapeutic communication techniques, and factors influencing verbal and nonverbal interactions between nurses and clients.

  • Therapeutic communication
  • Components of communication
  • Verbal communication
  • Nonverbal communication
  • Rapport
  • Kinesics
  • Aphasia
  • Open-ended questions
  • Closed-ended questions
  • Clarification
  • Reflection
  • Paraphrasing
  • Summarizing
  • Assertiveness
  • Cultural considerations in communication

Nursing Communication, Data Collection, and Client Care

This content covers therapeutic communication skills, data collection processes, physical examination techniques, and methods for moving and positioning clients.

  • Therapeutic communication
  • Verbal and nonverbal communication
  • Nursing process
  • Data collection
  • Nursing diagnosis
  • Physical examination techniques
  • Diagnostic tests
  • Body mechanics
  • Client positioning
  • Range of motion
  • Mobility devices
  • Safety devices
  • Bed making
  • Nursing assessment

The Nursing Process and Problem-Solving

The nursing process is a systematic, client-oriented, and goal-oriented framework that combines critical thinking with scientific problem-solving methods to identify and treat client care problems.

  • Nursing process
  • Critical thinking
  • Scientific problem-solving
  • Trial and error
  • Nursing assessment
  • Nursing diagnosis
  • Planning
  • Implementation
  • Evaluation
  • Nursing care plan (NCP)
  • Prioritization
  • ABC (airway, breathing, circulation)
  • Subjective and objective data
  • Short-term and long-term goals

Introduction to Microbiology and Pathogenic Microorganisms

Medical Asepsis and Standard Precautions

Practicing techniques of medical asepsis and following Standard Precautions helps protect healthcare personnel and clients from the transmission of infectious microorganisms.

  • Medical asepsis
  • Standard Precautions
  • Healthcare-associated infections (HAIs)
  • Chain of infection
  • Endogenous microorganisms
  • Exogenous microorganisms
  • Personal protective equipment (PPE)
  • Hand hygiene
  • Sharps safety
  • Biohazardous material disposal
  • Antibiotic resistance
  • Immunizations for healthcare personnel

Infection Control and Transmission-Based Precautions

Healthcare professionals use standard precautions, personal protective equipment, and transmission-based precautions to prevent the spread of infectious diseases and break the chain of infection.

  • Standard Precautions
  • Transmission-Based Precautions
  • Airborne precautions
  • Droplet precautions
  • Contact precautions
  • Medical asepsis
  • Handwashing
  • Hand sanitization
  • Personal protective equipment (PPE)
  • Gloves
  • Masks
  • Eye protection
  • Gowns
  • Antimicrobial agents
  • Biohazardous waste disposal
  • Sharps disposal
  • Latex sensitivity
  • Healthcare-associated infections (HAIs)
  • Chain of infection

Infection Control and Transmission Precautions

Healthcare facilities utilize airborne, droplet, and contact precautions to prevent the transmission of microorganisms through air, droplets, or direct and indirect contact.

  • Airborne transmission
  • Airborne precautions
  • Special respiratory precautions
  • Respirator
  • Powered air-purified respirator (PAPR)
  • Droplet transmission
  • Droplet precautions
  • Contact transmission
  • Direct contact
  • Indirect contact
  • Colonization
  • Personal protective equipment

Transmission-Based Precautions and Isolation Nursing

Nursing measures for implementing standard and transmission-based precautions, including personal protective equipment, isolation settings, and protective isolation for immunosuppressed clients.

  • Standard Precautions
  • Transmission-Based Precautions
  • Airborne precautions
  • Contact precautions
  • Droplet precautions
  • Personal protective equipment (PPE)
  • Protective isolation
  • Neutropenic isolation
  • Double-bagging procedure
  • Vancomycin-Resistant Enterococcus (VRE)
  • Infection control protocols
  • Barrier techniques
  • Pediatric infection control

Data Collection in Client Care

The process of collecting data about the client’s condition, combined with the physical examination, identifies and clarifies a client’s health status.

  • Role of the practical/vocational nurse in data collection
  • Risk factors for disease and illness
  • Acute and chronic illness
  • Primary and secondary illness
  • Effects of inflammation and infection
  • Medical diagnosis versus nursing diagnosis
  • Physical examination techniques: observation, inspection, palpation, percussion, and auscultation
  • COLDSPA mnemonic for symptom assessment
  • Subjective and objective data
  • Laboratory tests and diagnostic procedures
  • Signs and symptoms of disease
  • Client and family teaching for diagnostic preparation

Diagnostic Procedures and Physical Examination Techniques

Healthcare providers use various diagnostic procedures and physical examination techniques to distinguish between normal and abnormal body structure and function.

  • Endoscopy
  • Biopsy
  • X-ray
  • Fluoroscopy
  • Ultrasonography
  • CT scan
  • Magnetic resonance imaging (MRI)
  • Positron emission tomography (PET) scan
  • Electroencephalogram (EEG)
  • Spirometry
  • Electrocardiogram (ECG/EKG)
  • Lumbar puncture
  • Arteriography
  • Informed consent
  • Observation
  • Inspection
  • Auscultation
  • Palpation
  • Percussion

Physical Examination and Data Collection

Guidelines for performing physical examination using head-to-toe and systems approaches to assess body structures and functions.

  • Head-to-toe method
  • Systems approach
  • Focused physical examination
  • General survey
  • Vital signs
  • Integumentary system assessment
  • Skin turgor
  • Capillary refill
  • Edema types
  • Primary skin lesions
  • Level of consciousness
  • Cognitive functioning
  • Pupillary assessment (PERRLA + C PE)
  • Musculoskeletal range of motion
  • Muscle strength assessment
  • Respiratory and cardiovascular assessment
  • Lung sounds
  • Peripheral pulses
  • Bowel sounds

The Nursing Process and Assessment

Nursing Care Plan for Ineffective Airway Clearance

A nursing care plan utilizes subjective and objective data to address ineffective airway clearance related to pneumonia through planning, implementation, and evaluation.

  • Nursing Care Plan (NCP)
  • Nursing Diagnosis
  • Ineffective Airway Clearance
  • Pneumonia
  • Planning
  • Implementation
  • Evaluation
  • Short-Term Goals
  • Long-Term Goals
  • Oxygen Saturation
  • Arterial Blood Gases (ABGs)
  • Supplemental Oxygen Therapy
  • Lung Auscultation
  • Vital Signs Assessment
  • Incentive Spirometer
  • Nebulizer Therapy

Comprehensive Nursing Health History Assessment

Essential questions and methods for collecting biographical data, medical history, psychosocial information, and activities of daily living during a nursing interview.

  • Biographical data
  • Chief complaint
  • Medical history
  • Allergies and sensitivities
  • Medication and supplement use
  • Psychosocial information
  • Activities of daily living
  • Review of systems
  • Data collection methods
  • Observation
  • Interview
  • Physical examination

Data Collection in Client Care

Physical Assessment of Skin and Integumentary Findings

This document illustrates techniques for inspection and palpation of the skin, hair, scalp, nails, and pupils to identify normal and abnormal findings.

  • Skin inspection and palpation
  • Skin color and warmth
  • Skin turgor
  • Capillary refill
  • Skin lesions
  • Macules
  • Wheals
  • Pustules
  • Ulcers
  • Papules
  • Vesicles
  • Fissures
  • Malignant melanoma
  • Alopecia
  • Pupillary reaction to light
  • Accommodation

Physical Examination and Data Collection

Healthcare providers perform data collection, assessment, and physical examination of clients to identify abnormal findings and develop the nursing care plan.

  • Physical examination formats
  • Head-to-toe examination
  • Body systems examination
  • Data collection in children
  • Musculoskeletal assessment
  • Skin assessment
  • Head and neck assessment
  • Auscultation of lung sounds
  • Palpation of peripheral pulses
  • Range of motion of the spine
  • Nerve assessment
  • Fontanelles inspection
  • Scoliosis screening
  • Nursing care plan development

Moving and Positioning Clients

Principles of body mechanics and techniques for moving, positioning, and maintaining client alignment to prevent injuries and complications of immobility.

  • body mechanics
  • center of gravity
  • base of support
  • line of gravity
  • body alignment
  • client positioning
  • supine position
  • prone position
  • lateral position
  • Sims position
  • Fowler position
  • orthopneic position
  • knee-chest position
  • lithotomy position
  • reverse Trendelenburg position
  • logroll turn
  • active and passive range of motion
  • contracture prevention
  • footdrop prevention

Range of Motion and Mobility Assistance

Nursing procedures for managing client range of motion, preventing contractures, and assisting mobile or partially mobile clients with movement and fall prevention.

  • Range of motion (ROM)
  • Active range of motion (AROM)
  • Passive range of motion (PROM)
  • Continuous passive motion (CPM) machine
  • Isometric exercises
  • Contracture prevention
  • Joint movements (flexion, extension, abduction, adduction, rotation, etc.)
  • Fall risk evaluation
  • Transfer belt (gait belt) use
  • Dangling procedure
  • Orthostatic hypotension
  • Body mechanics
  • Assisting clients with ambulation

Mobility Devices and Client Transfers

Using mobility devices and mechanical lifts to assist clients with walking, transfers, and movement.

  • Wheelchairs
  • Wheeled stretchers
  • Crutches
  • Slings
  • Motorized scooters
  • Mechanical client lifts
  • Sling lifts
  • Supine lifts
  • HoverMatt
  • Stand-assist lifts
  • Transfer boards
  • Crutch-walking gaits
  • Weight-bearing restrictions
  • Paraplegia transfers
  • Hemiplegia transfers

Moving and Positioning Clients

Client Transferring and Safety Device Management

Procedures for moving immobile clients using mechanical devices, transfer boards, and lifting sheets, alongside the application and monitoring of client safety devices and restraints.

  • Mechanical lift use
  • Transfer board application
  • Lifting sheet and glide sheet procedures
  • Wheeled stretcher safety
  • Body mechanics for nurses
  • Client positioning and skin integrity
  • Client reminder and protective devices
  • Restraint classifications
  • Posey jacket application
  • Wrist protective devices and netted mitts
  • Lap belt usage
  • Chemical restraints
  • Alternatives to safety devices
  • Pediatric protective devices

Beds and Bed Making in Healthcare

Purposes of bed making, types of hospital beds, and procedures for making unoccupied, occupied, and postoperative beds.

  • unoccupied bed
  • occupied bed
  • postoperative bed
  • closed bed
  • open bed
  • Gatch bed
  • bed cradle
  • side rails
  • mitered corners
  • incontinence pads
  • draw sheet
  • body mechanics
  • specialized hospital beds

Nursing Procedures for Bed Making

Procedures for making occupied, open, and postoperative beds using linens, specialized equipment, and safety measures to promote client comfort and skin integrity.

  • Occupied bed making
  • Open bed making
  • Postoperative bed preparation
  • Mitered corners
  • Toe pleats
  • Bed cradle use
  • Side rail safety protocols
  • Footboard application for footdrop prevention
  • Trapeze usage
  • Therapeutic beds and mattresses
  • Bariatric bed requirements
  • Infection control with soiled linens
  • Body mechanics for nurse safety

Personal Hygiene and Oral Care

This topic describes how to assist clients with personal hygiene including mouth care, denture care, and routine eye care to promote well-being, comfort, and dignity.

  • Mouth care
  • Flossing the teeth
  • Denture care
  • Mouth appliances
  • Dependent client mouth care
  • Routine eye care
  • Contact lens care
  • Halitosis
  • Periodontitis
  • Dental caries
  • Sordes
  • Lacrimal glands

Nursing Care for Eyes, Ears, and Extremities

Procedures and rationales for maintaining hygiene and safety for the eyes, ears, hearing aids, fingernails, toenails, and feet.

  • Contact lens care
  • Eye care for clients who cannot blink
  • Cerumen removal
  • Hearing aid maintenance
  • Fingernail and cuticle care
  • Toenail care and ingrown toenail prevention
  • Hand massage techniques
  • Foot soak procedures
  • Skin integrity assessment

Nursing Care for Shaving, Hair, and Skin

Procedures and rationales for assisting clients with shaving, hair care, shampooing, and skin protection.

  • Shaving with electric and blade razors
  • Standard Precautions during shaving
  • Disposal of sharps
  • Daily hair care for different hair types
  • Shampooing ambulatory and immobile clients
  • Use of a Shampoo Cap
  • Bed shampoo procedure
  • Skin integrity and assessment
  • Prevention of skin breakdown
  • Protective devices for bony prominences
  • Backrub techniques and effleurage

Personal Hygiene and Oral Care

Nursing Procedures for Bathing and Backrubs

This text outlines nursing procedures for providing various types of baths, backrubs, and perineal care to promote client comfort and hygiene.

  • Backrub
  • Kneading (pétrissage)
  • Tapping (tapotement)
  • Friction
  • Brushing (frôlement)
  • Vibration
  • Backrub techniques
  • Complete bed bath
  • Partial bath
  • Sponge bath
  • Shower and tub bath safety
  • Perineal care (peri care)
  • Sitz bath
  • Therapeutic baths
  • Towel bath
  • Lotion bath
  • Bag Bath
  • Skin breakdown prevention
  • Body mechanics

Personal Hygiene and Skin Care

Nursing care involves maintaining client cleanliness through mouth, eye, ear, hair, and skin hygiene while managing parasitic skin infestations.

  • Pediculosis
  • Scabies
  • Bedbugs
  • Mouth care
  • Eye care
  • Ear care
  • Hair care
  • Hand and foot care
  • Shaving
  • Bathing types
  • Skin inspection
  • Backrub techniques
  • Parasitic skin infestations

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