Introduction MayDay Staffing Solutions

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Introduction MayDay Staffing Solutions Powered By Docstoc
					                        MayDay Staffing Solutions
                   ―Responsive Business – Compassionate Nurses‖
                          16654 Soledad Canyon Rd. # 419
                              Santa Clarita, CA 91387

  Phone: (888) 640-7111      website:           Fax: (661) 309-9073


                                                     MayDay Staffing Solutions
                                                ―Responsive Business – Compassionate Nurses‖
                                                       16654 Soledad Canyon Rd. # 419
                                                           Santa Clarita, CA 91387

                             Phone: (888) 640-7111         website:              Fax: (661) 309-9073

                                        TABLE OF CONTENTS

BLOODBORNE PATHOGEN EXPOSURE------------------------------------------------------------------------- 3
LATEX SENSITIVITY AND ALLERGY ---------------------------------------------------------------------------10
FIRE SAFETY ------------------------------------------------------------------------------------------------------13
SAFETY -------------------------------------------------------------------------------------------------------------19
EMERGENCY PREPAREDNESS ----------------------------------------------------------------------------------25
TUBERCULOSIS ---------------------------------------------------------------------------------------------------31
PATIENT RIGHTS -------------------------------------------------------------------------------------------------41
AGE SPECIFIC COMPETENCY -----------------------------------------------------------------------------------46
CULTURAL COMPETENCY --------------------------------------------------------------------------------------- 55
RESTRAINTS AND SECLUSION ---------------------------------------------------------------------------------62
DOMESTIC VIOLENCE ------------------------------------------------------------------------------------------- 71
ELDER ABUSE -----------------------------------------------------------------------------------------------------73
SEXUAL HARASSMENT ------------------------------------------------------------------------------------------ 79
CONSCIOUS SEDATION ----------------------------------------------------------------------------------------- 91
ADVANCE MEDICAL DIRECTIVES ------------------------------------------------------------------------------99
ORGAN AND TISSUE DONATION ---------------------------------------------------------------------------- 103
PREVENTING MUSCULOSKELETAL DISORDERS----------------------------------------------------------- 109

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Bloodborne Pathogen Exposure


If you work in a Healthcare facility or any other setting where you may be exposed to blood or
body fluids, you are at risk for exposure to microscopic germs called pathogens. Certain pathogens
can cause serious and sometimes deadly illnesses. Some pathogens are carried in the blood and
transmitted from one person to another through blood or certain body fluids. These are called
bloodborne pathogens. There are many precautions that you can take to protect yourself from
these pathogens. In conjunction with the Occupational Safety and Health Administration (OSHA)‘s
Bloodborne Pathogens Standards, both your workplace and MayDay Staffing Solutions, have
prepared a Bloodborne Pathogen Exposure Control Plan. This explains how you can reduce or
eliminate the risk of contracting bloodborne diseases on the job. If you do experience an exposure
incident, this plan will also help you to know what to do next. It will be your responsibility to
determine where the exposure control plan is located in your workplace, and then become familiar
with it. You may obtain a copy of MayDay Staffing Solutions Exposure Control Plan through your
contact person at MayDay Staffing Solutions.

The most common bloodborne diseases that you may be exposed to on the job include:
• Hepatitis B virus (HBV)
• Human Immunodeficiency Virus (HIV)
• Hepatitis C Virus (HCV)
• Syphilis
• Malaria

Healthcare worker may be exposed to these pathogens from working with: blood, body fluids such
as saliva, amniotic fluid, semen, or from tissue or organs originated from a human being either
living or dead. The pathogens of greatest concern to Healthcare workers today are the Hepatitis B
Virus (HBV); the Human Immunodeficiency Virus (HIV); the virus that causes the disease known
as AIDS (Acquired Immunodeficiency Syndrome) and the Hepatitis C Virus. Once you have become
infected with any of these pathogens, you then put other people who come in contact with you at
risk of becoming infected; including your spouse or sexual partner, children, coworkers, or your
unborn child.


Hepatitis- inflammation of the liver.
There are different viruses that can cause Hepatitis and different ways that you can be exposed to
these viruses. On the job, the healthcare worker is particularly at risk of contacting the viruses that
cause Hepatitis B and Hepatitis C. Either virus can lead to cancer or severe liver damage
(Cirrhosis), which may become chronic. These viruses may also result in recurring illness, which
can cause you to feel sick or very tired, and can require hospitalization and may even lead to
death. Chronic liver disease is the tenth leading cause of death among adults in the United States.

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

With prompt treatment, most cases of Hepatitis B & C can be treated successfully. The best
treatment, however, is prevention. The Hepatitis B vaccine will help to prevent you from
contracting Hepatitis B. There is no vaccine for Hepatitis C.


At least 200,000 new Hepatitis B virus infections occur yearly in the US. Of these, approximately
15,000 result in hospitalization, and 350-450 result in death. In 1995, an estimated 800 Healthcare
workers became infected with HBV, representing a 95% decline from the 17,000 new infections
estimated in 1993. This decline was largely due to widespread immunization of healthcare workers,
the practice of universal precautions, and improved measures taken to prevent needle stick

Signs and Symptoms (approximately 30% of adults have no signs or symptoms)

•   Jaundice
•   Nausea and/or vomiting
•   Fatigue/ Loss of appetite
•   Abdominal pain/ Joint pain

Transmission — when blood or body fluids from an infected person enter the body of a person
who is not immune. Some ways for transmission to occur:

•   Through needle sticks or shams exposures on the job
•   Through sexual contact with an infected person
•   Sharing needles when shooting drugs
•   From an infected mother to her baby during birth


Hepatitis B vaccination (a series of 3 intramuscular injections were the second injection is given 1
month after initial vaccination and the third injection is given 6 months after the initial vaccination)
is the BEST protection. If you are a Healthcare worker, get vaccinated, follow routine use of barrier
protection and safely handle needles and sharps.

• Practice safe sex.
• Consider the risks before getting a tattoo or body piercing. If the artist or piercer does not clean
equipment carefully, you are at risk for contracting Hepatitis B.


An estimated 3.9 million people in the U.S. have been infected with the Hepatitis C virus. These
people may have a chronic infection but are not aware of it because they have no symptoms.
Infected individuals are the primary source of transmission to others. Forty percent of chronic liver

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

failure is related to Hepatitis C. While Hepatitis C is the most common chronic bloodborne
infection, the risk to Healthcare workers is no higher than that of the general public averaging 1-
2%. In the general population, transmission of the Hepatitis C virus is much the same as with
Hepatitis B. However, intravenous drug use accounts for 60% of the cases.

For the Healthcare worker, the primary mode of transmission is through needle stick injury. There
is no known vaccine for the prevention of Hepatitis C so it is imperative that Healthcare workers
follow strict precautions to prevent exposure.


HIV infection is a complex disease that can be associated with many symptoms. The virus attacks
part of the body‘s immune system, eventually leading to severe infections and other complications;
a condition known as AIDS. Despite current therapies that deal with the progression of HIV
disease, most healthcare workers who become infected with HIV are likely to eventually develop
AIDS. Most of the occupational exposures involve nurses or laboratory technicians. 39% of
occupational exposures are caused by needle stick injuries. There are drugs available which may
reduce the chance of becoming infected after an exposure to HIV; however, these drugs have
many adverse side effects. There is no vaccine to prevent HIV and there is no known treatment or
cure. The most common modes of transmission of HIV are: Unprotected sex, and using
intravenous drugs. In the U.S., better treatment of HIV-infected patients has caused an increase in
the number of people who are living and carrying the disease to 322,365 people. As a Healthcare
worker, you need to follow precautions with the blood of a patient who is HIV positive. HIV is not
transmitted by feeding or caring for the patient.


Where can bloodborne pathogens be found? The bloodborne pathogens you may be exposed
to in the workplace could be present in the following materials:

• Blood (including blood components and blood products)
• Body fluids including: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid,
pericardial fluid, peritoneal fluid, amniotic fluid, saliva, or any other body fluid contaminated with
• Tissue or organ (other than intact skin) from living or dead human
• HIV-containing cell or tissue/organ cultures and HIV & HBV containing culture medium
• Blood, organs or tissues from HIV- or HBV- infected experimental animals.

How can the Healthcare worker be exposed on the job? Bloodborne pathogens may enter
your body though:

• Puncturing the skin with a needle or ―sharp‖ (scalpel, broken glass, dental wire) that has been
contaminated with the blood of an infected person
• ―Non-intact skin,‖ such as abrasions, cuts, dermatitis, acne, or chapped skin
• Splashes to the mucous membranes of your eyes, mouth and nose

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

• Touching contaminated surfaces with your non-intact skin or transferring the contaminant by
hand to your mouth, eyes or nose. HBV can live in a dried state on surfaces for one month without
any visible signs.

What can be done to protect Healthcare workers who may be exposed?
Carefully following these Work Practice Controls will help to reduce or eliminate the possibility of
contracting a bloodborne infection while at work:

• HBV Vaccination is 80-100% effective in preventing Hepatitis B. The vaccine has little or no side
effects and should be offered to you at no charge by the facility where you are employed.
• If you have any problems with your immune system, you are more susceptible to contracting
HBV. It is even more important to receive the vaccine, but speak with your doctor first.
• You will need to sign a Hepatitis B Vaccination form indicating your vaccination status.
• You will need to have a Hepatitis B titer drawn before you can begin your assignment. Some
facilities will accept proof of vaccination instead of a titer.
• There is no known vaccination for Hepatitis C or HIV
• Practice universal precautions. This means assuming that all blood and body fluids are potentially
infectious and all precautions should be taken to avoid exposure.
• Engineering Controls are protective barriers that are put in place by the work facility to provide
for your safety. These engineering controls isolate or remove bloodborne pathogens from the
workplace. Some examples are: the autoclave, self-sheathing needles, needle less systems, sharps
disposal containers, bio-safety cabinets, biohazard labeling, readily accessible hand-washing
facilities, puncture-resistant and leak-proof containers for contaminated material. It is the
responsibility of the Healthcare worker to make proper use of the engineering controls provided
and to report any inconsistencies in their use or maintenance. If you are unclear as to how to use
any of the controls, it is your responsibility to find out.
• Personal Protective Equipment (PPE) refers to specialized clothing or equipment that the
Healthcare worker wears to provide protection from contact with bloodborne pathogens. Wear as
much or as little PPE as you will need for a given task in order to keep blood and other infectious
materials off your skin, mucous membranes and clothing. PPE will be provided, maintained and
disposed of by the work facility at no cost to the Healthcare worker. Always use protective
equipment each time you perform a task. Be sure you are familiar with the location of PPE and
know how to use it properly. Remove it before leaving the work area and dispose of it in the
proper container or area.

The following is a list of some of the PPE you may be using:

  • Gloves —Wear gloves any time you anticipate hand contact with blood, body fluids,
    contaminated surfaces, mucous membranes or whenever you have a non-intact skin cuts,
    chapped. abraded etc.)

Be sure:
 • Your gloves fit properly
 • To cover any non-intact skin with bandages before putting on gloves
  (in case a puncture or breakage occurs)

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

  • To remove gloves after removing all other PPE
  • To wash hands and replace gloves immediately if they break or are punctured
  • To wash your hands after removing gloves

Types of Gloves:

Single Use Gloves must be disposed of immediately after use, when torn or broken, and never re-
used. Utility Gloves are reusable after decontamination, but must be disposed of if they show any
signs of deterioration (cracks, punctures. etc.). Latex-Free Gloves will be provided if you have
sensitivity to latex.

Masks, Eye Protection, and Face Shields should be worn any time you anticipate there may be
splashes, spray, spatter, or droplets of blood or other infectious materials. You should ensure that
goggles or glasses with side walls, masks, and face shields fit you properly and are in good
condition before use.

Other Protective clothing:

Gowns, aprons, lab coats and surgical hoods, caps and shoe covers, should be worn when the task
and the degree of exposure warrant, and/or when there is a potential for a large exposure (e.g.,
surgery, autopsy).

• Hand-washing and Hygiene is one of the best ways to reduce your risk of infection on the job.
Always wash your hands between patients, upon completion of a task, if gloves break, and always
after removing gloves. Each work area should be supplied with a convenient hand-washing station
or another means of cleaning your hands until hand-washing facilities are available. When hand-
washing facilities are available, you should wash your hands as soon as possible. If your skin or
mucous membrane(s) makes contact with blood or potentially infectious material, you should
immediately wash the skin with soap and water or flush the mucous membrane with water.

There are two procedures described by CDC for good hand hygiene, hand washing and hand
decontamination. Good hand-washing techniques include:

• Using comfortably warm water
• Washing hands and wrists under running water for a full minute
• Using an antibacterial soap, which is non-abrasive and skin softening, if available
• Washing under fingernails and rings
• Rinsing thoroughly and drying carefully with paper towels. Discard paper towels, turning faucet
off with a clean paper towel
• Keeping fingernails to less than ¼ of an inch long when caring for patients at high risk of
acquiring infections. Avoid wearing artificial nails in the work setting

Hand Decontamination:

Hand decontamination is recommended for those clinical situations when your hands are not

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

visibly soiled with material such as blood, feces, or other body fluids. Hand decontamination
involves the use of a preparation with a concentration of 60 to 95 percent ethanol or isopropanol
alcohol. To effectively use decontaminants, vigorously rub the solution into your hands and
continue to rub until your hands are completely dry. The use of alcohol based hand rubs does not
eliminate the need for washing with soap and water, but is a convenient and safe way to eliminate
the transfer of infectious materials on the hands. The guidelines for the use of hand rubs

• Carefully washing hands with soap and water first if they are visibly soiled.
• Applying the product to the palm of one hand in the portion recommended by the manufacturer.
• Rubbing hands together, covering all surfaces of hands and fingers until dry.

Good hygiene practices include minimizing splashing, spraying, spattering, or generating droplets
of any potentially infectious material. In addition, it is important that you:

• Never eat, drink, smoke, apply cosmetics or lip balm, or handle contact lenses in work areas. Ask
your supervisor what areas have been set aside for these activities.
• Never mouth pipette/suction any blood or potentially infectious material.
• Never keep food or drink in refrigerators, freezers, shelves, cabinets, counters, or bench-tops
where blood or other potentially infectious materials are present.

Sharps injuries are one of the most common occupational injuries that Healthcare workers
experience. 80% are needle stick injuries are reported by nurses. ―Sharps‖ are any objects that
can penetrate the skin or mucous membrane and include needles, scalpels, broken glass, capillary
tubes, and exposed ends of dental wire. Introduction of bloodborne pathogens through piercing of
the skin or mucous membrane (perineal introduction) most commonly occurs when the Healthcare
worker is ―stuck‖ by one of these sharp objects but can also occur from a human bite. In order to
prevent sharps injuries on the job, you should:

• Never break, shear, bend or re-cap needles. If recapping is required, use a one-handed method
or mechanical device only
• Promptly dispose of used needle in an appropriate container. Never reach into one of these
containers for any reason. If it is full, notify your supervisor. Do not try to squeeze ―just another
one‖ into the container. Never place a used needle on the patient‘s bed, bedside tray or table, or
any other surface where you or anyone else may accidentally stick themselves.
• Never dispose of a used needle in a trash can or any other receptacle other than the
appropriately labeled, puncture-resistant, leak-proof, closeable container
• Plan for the safe handling and disposal of needles before using them.
• Do not remove a used needle from a syringe by hand.
• Use needleless systems, self-sheathing needles, or sharps with injury protection devices
whenever possible. Suggest to your supervisor any of these devices when they are appropriate but
not available.
• Report any sharps injury hazards in the work place and offer your suggestions.
• Volunteer to help evaluate and select any devices that your facility may be considering to help
reduce the risk of sharps injuries.

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

•If you experience a sharps injury, immediately wash the area with soap and water. If it is a
mucous membrane, flush with clear water.
• Immediately report any sharps injury to your supervisor and fill out an incident report. Report the
injury to MayDay Staffing Solutions by the end of your shift. Your Personal Placement Consultant
will assist you in completing a MayDay Staffing Solutions incident report. This is necessary for you
to receive your Workers Compensation benefits.
• Report any sharps injuries that you observe.
• Carefully clean up any contaminated broken glass using a dustpan and brush, tongs, forceps or
another mechanical device, never directly with the hands. Wear eye protection during clean up.
• Participate in any and all training in the use of needle stick prevention devices. Be sure you are
comfortable with the use of these devices already in practice at your facility.

Housekeeping‘s task is to maintain a clean, safe and sanitary environment are generally the
responsibility of the work facility. It is, however, a team effort and requires your participation. You

• Clean any equipment and work surfaces with the designated disinfectant immediately following
contact with blood or potentially infectious material.
• Place laundry in color coded, leak-proof containers without rinsing or sorting.
• Limit handling and agitation of laundry. Use gloves or other PPE if necessary.
• Carry laundry and trash bags away from your body.
• Never use your hands or feet to compact trash.
• Replace protective coverings on surfaces and equipment immediately following contamination or
at the end of the shift.
• Recognize biohazard signs as a warning of blood or potentially infectious material contamination.
You may see labels on bags or equipment.
• A fluorescent orange-red biohazard sign on a door indicates that handling of potentially infectious
pathogens takes place inside. Read the special requirements on the sign before entering.


If you do experience an exposure to bloodborne pathogens, don‘t panic. Follow the steps listed

1. Wash affected area with soap and water or flush mucous membrane with clear
2. Immediately report exposure to facility management and seek emergency
treatment with facility-appointed licensed Healthcare practitioner.
3. Begin treatment, if needed and chosen, within 1-2 hours of exposure, as per
facility protocol.
4. Document exposure for facility and MayDay Staffing Solutions by completing an incident report.
5. Notify MayDay Staffing Solutions Workers‘ Compensation at the number provided.
6 Notify MayDay Staffing Solutions Personal Placement Consultant.
7. Be sure to take advantage of all recommended follow-up care. Keep MayDay Staffing Solutions
   updated on a frequent basis as to the follow-up care.

                                                   MayDay Staffing Solutions
                                              ―Responsive Business – Compassionate Nurses‖
                                                     16654 Soledad Canyon Rd. # 419
                                                         Santa Clarita, CA 91387

                             Phone: (888) 640-7111      website:           Fax: (661) 309-9073


As your employer, MayDay Staffing Solutions cares about your health and safety. Bloodborne
pathogens do pose a real threat while on the job. Through reading and following the guidelines
that have been provided for you here and in the workplace, you will greatly reduce your risk of any
serious injury.

Now go to the Mandatory Test Booklet and complete the test for “Bloodborne Pathogens”
before moving on to the next section.

Latex Sensitivity and Allergy
Natural rubber is made from the milky substance of certain plants. This rubber is then made into
―natural rubber latex‖ (hereafter referred to as latex) and manufactured into tens of thousands of
medical products. The problem this may create is for those who have a predisposition to a latex
allergy or sensitivity either because of prior exposure to latex, or a genetic predisposition.
Healthcare workers are at an increased risk for developing or aggravating a predisposition to latex
sensitivity or allergy because they work closely with so many latex containing products. These
products include:

•   BP cuffs
•   Goggles
•   Stethoscopes
•   Respirators
•   Disposable Gloves
•   Rubber aprons
•   Oral and nasal airways
•   Anesthesia masks
•   Endotracheal tubes
•   Catheters
•   Tourniquets
•   Wound drains
•   IV tubing
•   Injection ports
•   Syringes
•   Rubber vial tops
•   Electrode pads
•   Dental dams
•   Surgical masks

                                                 MayDay Staffing Solutions
                                            ―Responsive Business – Compassionate Nurses‖
                                                   16654 Soledad Canyon Rd. # 419
                                                       Santa Clarita, CA 91387

                           Phone: (888) 640-7111      website:           Fax: (661) 309-9073

• Hot water bottles
• Condoms
• Diaphragms
• Balloons
• Pacifiers
• Baby bottle nipples
Limiting your latex exposure at home will help to decrease the overall latex exposure that you will

In addition to being aware of your own potential latex allergy, it is important to be aware of your
patients‘ allergy status with regards to Latex. While it is not as common for members of the
general public to have a Latex sensitivity/allergy (less than one percent do), those persons who
have experienced constant exposure to latex will be at a greater risk, such as children with spina
bifida, conditions that have involved multiple surgical procedures and indwelling catheters, and
people that have worked in latex manufacturing. People may have a latex cross-sensitivity if they
are allergic to certain foods such as bananas, chestnuts, avocados, and kiwi fruit. The Healthcare
professional maybe held liable for negligence if he/she exposes the patient to latex when that
Healthcare professional could or should have known of that patient‘s sensitivity/allergy. The
Healthcare professional should also be aware of the signs and symptoms of latex sensitivity/allergy
both for his/her own safety as well as that of the patient. Signs and symptoms of latex
sensitivity/allergy include:

•   Skin redness, cracking, peeling, chapping, fissures, thickening that stops at contact point
•   Pruritis, edema, eczema
•   Nasal/mucosal redness, swelling
•   Wheezing, asthma, hives, rhinitis 5-30 minutes after exposure
•   Conjunctivitis
•   Anaphylaxis

As of September 30, 1998 all products containing natural rubber latex are required to be labeled as
such. This helps to prevent unnecessary exposure. Other steps that you can take to avoid
latex exposure are:

• Use non-latex gloves when the task does not involve contact with infectious materials.
• If you choose latex gloves for barrier protection, use powder-free gloves with reduced protein
content. These gloves help reduce exposure to latex protein and therefore reduce the risk of
allergy. Hypoallergenic latex gloves do not reduce the risk of latex allergy, but reduce the risk of
contact dermatitis from chemical additives in latex.
• Use appropriate work practices to reduce the chance of latex reactions.
         o Do not use oil based hand creams or lotions (which can cause glove deterioration) unless
           they have been shown to reduce latex-related problems and maintain glove barrier
         o Wash hands with mild soap and dry thoroughly after removing gloves.
         o Remove latex-containing dust from the workplace by frequently cleaning areas
          contaminated with latex dust and frequently changing filters and vacuum bags used in

                                                  MayDay Staffing Solutions
                                             ―Responsive Business – Compassionate Nurses‖
                                                    16654 Soledad Canyon Rd. # 419
                                                        Santa Clarita, CA 91387

                            Phone: (888) 640-7111      website:           Fax: (661) 309-9073

           latex contaminated areas.

Take advantage of all latex allergy education and training offered by the facility. Become familiar
with procedures for preventing latex allergy. Learn to recognize the signs and symptoms of latex
allergy. If you develop symptoms of latex allergy, avoid direct contact with latex gloves and other
latex-containing products until you can see a physician experienced in treating latex allergy. If
you have a latex allergy, consult your physician regarding the following precautions:

•   Avoid contact with latex gloves and other latex containing products.
•   Avoid areas where you might inhale the powder from latex gloves worn by others.
•   Tell your employer and Healthcare providers that you have latex allergy.
•   Wear a medical alert bracelet.
•   Carefully follow your physician‘s instructions for dealing with allergic reactions to latex.

By following the recommended precautions above, you can help prevent potentially serious health
problems for yourself, co-workers and patients. By limiting latex exposure, you are helping to
protect those who may not even be aware of the risks involved. You should stay on top of current
information regarding latex allergy. Attend facility training, read current journals, and go to the
NIOSH (National Institute of Occupational Safety and I Health) on the web at

Go to the Mandatory Education Test booklet and complete the test for “Latex Sensitivity and
Allergy” before moving on to the next section.

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Fire Safety
There are many different causes of fire, because Healthcare facilities contain many potential
sources of fire, they are vulnerable and at risk. Patients are at risk for injury from fire because of
their limited mobility. As a Healthcare worker, your best defense against fire is prevention. If there
is a fire, it will be your responsibility to know the proper steps to take to protect your patients, co-
workers, and yourself. Be sure to attend the fire safety orientation at the facility and establish the
location of the facility‘s fire safety plan.

―Workplace fires and explosions kill 200 and injure more than 5,000 workers each year. In 1995,
more than 75,000 workplace fires cost businesses more than $2.3 billion. Fires wreak havoc
among workers and their families and destroy thousands of businesses each year, putting people
out of work and severely impacting their livelihoods. The human and financial toll underscores the
serious nature of workplace fires,‖ said Secretary of Labor Robert B. Reich.

The purpose of this module is to help you recognize various fire protection resources within the
workplace and to determine from the work facility how, and under which circumstances, to
operate alarms, extinguishers and fire hoses, quickly and efficiently evacuate buildings, and
participate in ―good housekeeping‖ practices which significantly reduced fire risk. Healthcare
workers should also be capable of recognizing potential fire hazards and know what must be done
to remedy any existing problems.


Fire is a chemical reaction that has four basic components: fuel, source of ignition, oxygen, and
the process of combustion. A fire protection program should be designed to control or eliminate
one or more of these components, thereby reducing the probability that fire will occur.
• Locate and read the Material Safety Data Sheets in your work areas. These forms describe the
hazards that a chemical may present, list precautions to take when handling, storing, or using the
substance, and outline emergency and first-aid procedures. Proper handling will prevent accidents.
• It is imperative that the fire doors remain closed AT ALL TIMES to be effective. Should you come
across a fire door that is ajar, remove the obstacle and the door will swing shut by itself.
• Extinguishers, hose cabinets, pull stations and ceiling sprinklers must be kept free of obstacles so
as to be highly visible, accessible and free flowing (sprinklers). Likewise, ceiling sprinkler beads
must not be used to hang decorations, balloons, plants. etc.


Listed below are the three classes of fire and methods for preventing each type of fire.

Class A: Ordinary Combustibles (wood, paper, smoking materials, vegetation, textiles, rubber,

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

• Materials should not be stored under or piled against buildings, doors, exits, or stairways.
• Materials should be stored in an area removed from any heat or electrical source.
• Smoking is the third leading cause of death from fires. Strictly adhere to your facility‘s policy on
designated smoking areas, and insist on compliance by patients and visitors. Be sure all smoking
materials are fully extinguished in a designated ash tray.
• Never allow smoking near oxygen, whether it is in use or in storage.

Class B: liquids and Gases (petroleum products, gasoline, oils, lubricants, paints, thinners)

• Cleaning rags, oily rags, and steel wool should be kept in separate metal containers with self-
closing lids and contents stenciled on the containers.
• Do not store these materials near any source of heat or electricity.
• Any spark-producing objects (including toys and games) should be removed from patient areas
and areas where there is oxygen.
• Many gases routinely used throughout healthcare facilities are both flammable and toxic, and
require specialized storage cabinets. The cabinets should be anchored to the wall to prevent
toppling. Cabinet doors should always be kept closed to Protect the contents from possible ignition

Class C: Electrical utilities, appliances. meters, motors, transformers, etc.

• The leading cause of fires in facilities that care for the sick is equipment.
• Do not overload electrical outlets. Wall outlets are designed to safely provide electricity for only
two appliances at the same time. DO NOT use adaptive devices which can cause serious
• Do not use more than one extension cord per piece of equipment and don‘t overload. An
extension cord may be used temporarily, but its diameter must be at least as large as the cord of
the device being plugged into it. All electrical cords should be periodically checked for cracked or
frayed insulation. Never run an extension cord under carpeting as it creates a fire hazard.
• Unplug electrical cord by grabbing the plug, not yanking on the cord. Pulling on the cord will
cause fraying of the cord and leave wires exposed.
• Immediately report any frayed cords and do not use equipment with exposed wires.
• Use only UL-rated equipment.
• Immediately report any strange odor coming from a piece of equipment. This could be the first
sign of a fire. Turn off equipment and discontinue use until it is examined or repaired.
• If you have any concerns about a piece of equipment that a patient has brought with them, have
it checked by the appropriate person at your facility before use.


It is important that all healthcare workers clearly understand their roles and responsibilities within
the facility‘s fire safety program. This section identifies various fire notification and suppression
devices typically found in the workplace. Notification systems alert personnel in the event of a fire.
Suppression systems are in place to extinguish a fire.

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You may be required to evacuate for emergencies such as bomb threats, weather conditions,
hazardous materials spill, violence, as well as fire. Learn to identify the various alarms or
personnel notification systems, which alert the building‘s occupants of an existing emergency
situation. The notification system may combine pull-stations, audio/visual indicating devices,
smoke and heat detectors, and emergency lighting to afford all building personnel the greatest
opportunity to safely evacuate the structure. You will also need to determine what to do if you
discover a fire. In most cases, you will need to know who to notify, which alarm to pull, and how
to proceed.


Your facility will appoint certain employees to use fire suppression equipment. If you are one of
these employees you must attend training to learn how to use the equipment correctly. In any
case, if there is a fire, you should:

• Try to contain the fire if it is safe to do so. Turn off or unplug the equipment. Turn off gas
supply, oxygen, etc if they are fueling the fire.
• Close doors and windows.
• Stuff wet towels under doors to keep out smoke.


Each extinguisher contains a ―letter‘ rating (A, BC or ABC) on its label which guides the user to the
proper class of fire for that specific extinguisher. Basically, water extinguishers are only to be used
on Class A‖ fires. C02 extinguishers can be used on ―B and C‖ fires, and some dry chemical types
can be used on all classes of fire. The most appropriate type of extinguisher should be available in
your department.


Water (APW) Extinguisher:
a) Pressurized Water: Use on Class A fires. DO NOT use on energized electrical equipment as
water is a conductor of electricity.

Carbon Dioxide Extinguisher:
b) Carbon Dioxide CO2 extinguishers are most effective on Class B and C (liquids and electrical)
fires. Since the gas disperses quickly, these extinguishers are only effective from 3 to 8 feet. Since
the fire could re-ignite, continue to apply the agent even after the fire appears to be out.

Dry Chemical Extinguisher (ABC):
c) Dry Chemical (ABC): Use on Class A, B, and C fires, depending on size. Installed around

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electrical equipment, computers, and PCB terminals. If used in a small unventilated area, visibility
may be reduced for a period of up to several minutes.

Visually check the following items on your extinguishers:

• Know where extinguishers are located on each unit to which you may be assigned.
• Make sure none of your departmental extinguishers are missing, obstructed or obviously

Examine the tag information to ensure that the extinguisher has been serviced within the last 12
months. Check the needle inside of the ―charge gauge.‖ The white or yellow needle should be
straight up pointing into the green ―good‘ zone. Any time the needle is pointing to a red area, the
extinguisher is faulty and must be immediately taken out of service for repairs.

• Finally, check for the presence of a plastic safety band which runs around the extinguisher‘s
handle and through a large steel pin also located in the handle. If the band is intact, the pin has
not been removed, and thus the extinguisher has not been discharged since the last servicing and
presumed to be fully operational.


Some facilities‘ fire safety plans may direct only certain employees to use extinguishers while other
employees evacuate the facility. It is your responsibility to learn what your specific duties are in
case of a fire.


An immediate readiness to evacuate is essential. Fire extinguishers should be used only by trained
personnel. Never enter a room that is smoke-filled. Never enter a room containing a fire without a
backup person. Never enter a room if the top half of the door is warm to the touch.
Although extinguishers can vary in size, color, and type of extinguishing agent, all devices operate
basically the same way. lf you have been trained, if the fire is small and heavy smoke is NOT
present, and if you have an exit open behind you, bring the fire extinguisher within six feet of the
fire and follow the PASS procedure:

P - Pull the pin located in the extinguishers handle.
A - Aim the nozzle, horn or hose at the base of the fire.
S - Squeeze or press the handles together.
S - Sweep from side to side at the base of the fire until it is out.

Continue spraying until the fire is completely out. It is better to spray longer than necessary than
not enough. Stay at the scene of the fire until the fire department arrives.

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Various locations in the facility may also have ―fixed or permanent extinguishing systems,‖
engineered into the facility to quickly dispense an appropriate extinguishing agent, should a fire
occur. These locations include cooking facilities, laboratory fume hoods, as well as some areas
where extensive electronic equipment is being used. Patient areas may also have ―sprinkler

Other areas such as hallways and stairwells may have fire hoses. They are intended for employee
use, recognizing that water may only be used safely on Class A fires. Be aware of areas which
have ―fixed‖ fire suppression systems and which have fire extinguishers.


• Fire evacuation plans will be posted in all buildings.
• Be aware of at least two means of exit from each unit or area where you work.
• All exits must be readily accessible, provide the best route to safety, and be suitably lighted.
Signs will indicate the direction of travel to exits not visible from any part of the floor area.
• Aisles, corridors, stairways, and passageways must be unobstructed at all times and must not be
used for storage.
• Do not lock exit doors while a facility is occupied. Doors must open in the direction of egress.
except where climatic conditions (such as accumulation of snow) preclude this practice. Some
facilities require ―locked units,‖ such as mental health facilities and correctional facilities. You must
be aware of the specific means of evacuation in these cases.
• For emergency evacuation, the use of floor plans or workplace maps that clearly show the
emergency escape routes and safe/refuge areas should be included in the plan. All employees
must be told what actions they are to take in emergency situations that may occur in the
workplace, such as a designated meeting location after evacuation.
• Do not use elevators during an evacuation. A sudden loss of electricity will leave you stranded.
• A method of communication will be in place to alert employees to the evacuation, or to take
other action as required in the plan. Alarms must be audible or visible to all people in the facility
and have an auxiliary power supply in the event electricity is affected. The alarm must be
distinctive and recognizable as a signal to evacuate the work area or perform actions designated
under the emergency action plan. The facility must explain to each employee the means for
reporting emergencies, such as manual pull box alarms, public address systems, or telephones.
Emergency phone numbers should be posted on or near telephones, on employee‘s notice boards,
or in other conspicuous locations. The warning plan should be in writing and management must be
sure each healthcare worker knows its meaning and proper actions to take.
• Know where you are to meet after an evacuation and who is responsible for accounting for each
person who has been evacuated.
• Know who you will assist and how you are to assist them in an evacuation. Depending on the
type of unit in which you are working, you may be responsible to assist patients out of the
building, move them to another area, or stay with them. Know the protocol for the unit where you
may be assigned. This protocol will vary from area to area
• Know when it is safe to return to the building after a fire or a drill

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Fires can be prevented and contained when everyone focuses on the mission of safety. Your task
is to identify and correct hazards. Know where fire alarms and extinguishers are and know how to
use them. Always take the time to investigate anything suspicious. Don‘t hesitate to initiate the
alarm. When you are attentive to fire hazards and know what steps to take towards prevention,
you can save lives.

Go to the Mandatory Education Test booklet and complete the test for “Fire Safety” before
moving on to the next section.

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                                           ―Responsive Business – Compassionate Nurses‖
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Healthcare professionals are exposed to many hazards while at work, regardless of the exact job
or the type of facility. This module will help to identify some of the hazards specific to the
Healthcare industry so that you can be aware of these hazards and learn how to protect yourself.


Electricity, while vitally important to our every day lives, can also cause serious injury or death.
Electrical current can pass through your body and cause injury or death from:

1. Burns
2. A physical injury from the body‘s reaction to the electrical current (shock), such as muscle
strain/sprain, a fall which causes broken bones, head injury etc.
3. Nervous system damage, such as the heart fibrillating and ceasing to create blood flow

In order to handle electricity safely and prevent injury:

• Refer to and follow the facility‘s policies and procedures with regards to electrical safety.
• Know and follow the facility‘s procedures for utility management during power outage, rolling
blackout, earthquake or any other emergency situation.
• Use equipment according to manufacturer‘s directions. If‘ needed, ask for training with any
electrical devices with which you are unfamiliar.
• Report and do not use any defective electrical devices including cords, plugs and switches.
Examine carefully for defects before using. If a plug, cord, switch or outlet should become hot,
discontinue use and report. Never use equipment with exposed wires (e.g. frayed/damaged cords).
• Prevent electrical overload and a potential fire by avoiding the use of:
 o Extension cords with two prongs
 o ―Cube taps‖ — devices that allow multiple connections in a single outlet
 o Multiple plugs collected to one another
 o Equipment that causes a circuit or fuse to ―blow‖
• Use power bars that have a fuse or a breaker.
• Use Ground Fault Circuit Interrupters (GFCI) in all wet locations such as bathrooms. Check the
GFCI by pushing the test button which should pop out the ―reset‖ button. Push the reset button to
• Use 3-prong extension cords that are UL listed. Never use a 2-prong plug with a 3-prong cord.
• Never break off the third prong of a plug to use in a 2-prong outlet.
• Do not disable electrical safety features or try to bypass them
• Use electrical equipment in areas that are clear from obstruction and away from flammable or
combustible materials. Never drape electrical equipment with combustible materials such as cloth
or paper.
• Do not lift or suspend an electrical device by its cord. Unplug the cord by the plug, not by

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yanking on the cord.
• Keep cords safely out of traffic areas, but never tack or staple the cord to a surface.
• Avoid working in wet areas with electrical equipment. Remove metal jewelry, such as
watchbands, bracelets, rings, necklaces and key chains.
• To prevent sparks from static electricity, clean computer monitors only when the computer is
turned off
• Be alert to areas that are marked ‗restricted‘ because of electrical danger. Do not enter unless
authorized to do so.
• Be attentive to equipment that must be left plugged in at all times. These pieces of equipment
should be clearly marked (e.g., ventilators. monitors. pumps).


Radiation occurs naturally as well as being man-made. Radiation is a byproduct of the radioactive
decay of atoms. These byproducts are in the form of alpha and beta particles, gamma rays and x-
rays. Natural sources of radiation include the sun, cosmic rays, radioactive elements in the earth‘s
crust and Radon. Man-made radiation comes from sources such as hospitals, laboratories, nuclear
reactors and their supporting facilities such as uranium mills and nuclear weaponry production.
Radioactive particles and rays (known as ionizing radiation or, simply radiation) may penetrate the
human body and deposit its energy in the tissue. Depending on the level of exposure, this
radiation may have no effect at all or can damage, change or even kill human cells. The extent of
damage depends upon the:

•   Total amount of energy absorbed
•   Time period of exposure
•   Dose rate of exposure
•   Particular organs exposed

Low or moderate doses of radiation may not produce evidence of injury until months or years after
the exposure. For example, leukemia has a two-year latency period between the time of exposure
and the emergence of the disease. Solid tumors have a five-year latency period. Types of health
effects and their probability depend also on whether the exposure has occurred over a long period
of time (chronic exposure) or a short period of time (acute exposure). It is also important to note
that the same health effects produced by radiation may occur in an individual from causes other
than radiation and when the individual has not been exposed to radiation. Cancers or genetic
defects caused by radiation have no detectable difference from those produced by other causes.


Everyone is continually exposed to radiation in the environment. This is considered a chronic
exposure. Some people also have additional chronic or acute exposures that may increase the risk
of health effects by radiation. These health effects include:
• Cancer
• Genetic mutations that may be passed to fixture generations

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• Massive tissue damage
• Death

Chronic Exposure

Chronic exposure refers to constant or intermittent exposure to low levels of radiation over a long
period of time. The health effects of this type of exposure include genetic effects, cancer,
precancerous lesions, benign tumors, cataracts, skin changes and congenital defects.

Acute Exposure

The term acute exposure refers to large, single doses or a series of doses of radiation over a short
period of time. Radiation therapy falls into this category, as do accidental and emergency
exposures. Large, acute exposures have two effects: immediate and delayed. The immediate
effects include symptoms of radiation sickness (with very large exposures) such as gastrointestinal
disorders, hemorrhaging, anemia, bacterial infections, loss of body fluids, and electrolyte
imbalance. Delayed effects would include cataracts, temporary sterility, cancer and genetic effects.
If the level of exposure is extremely high, death may result within hours, days or weeks.

Avoiding Radiation Exposure:

In order to avoid unnecessary exposure to radiation in the workplace, Healthcare professionals
should follow these guidelines:
External Radiation, Protection (external beam sources such as x-rays, gamma rays)
• Maximize distance from the source. The farther from the source of the radiation, the lower the
dose you will receive. Doubling the distance from the source will decrease the exposure to ½ of
the amount in the same time period.
• Minimize time of exposure. The less time you spend near the source of radiation, the lower the
dosage you will receive. Perform your task as quickly and safely as possible without increasing the
risk for accidents.
• Shield the radiation source. Placing a shield (lead, acrylic, etc) and/or protective clothing
between you and the radiation source will help to reduce or eliminate your exposure.
• Wear and monitor a dosimetric device when appropriate or required.

Internal Radiation Protection (radiopharmaceuticals, seeds, etc.)

• Dispose of syringes and other radioactive materials promptly and in the proper receptacle.
Carefully guard against any breakage of glass and puncture injuries.
• Never introduce any food or drink into an area posted ―Restricted,‖ even for a short time.
• Never eat or drink anything in an area where radioactive materials are being used
• Do not pipette by mouth.
• Do not put food or drink in a refrigerator designated for radioactive material storage.
• Prevent contamination of the skin and eyes.
• Remove potentially contaminated clothing promptly. Use goggles or a face shield (especially
when wearing contact lenses, which may absorb and concentrate radiochemical).

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• Wear protective gloves. Carefully wash hands after bridling radioactive materials, especially
before eating or smoking.
• Do not handle any radioactive materials that you have not been specifically trained or authorized
  to handle.
• Minimize the time spent with, and distance from, a patient being treated with radiation.
• Wear and monitor a dosimetric device when appropriate or required.


Many injuries can be prevented by eliminating the causes of slips and falls. Injuries from a slip and
fall can be minor, such as a bruise, or severe, as in the case of a fracture or head injury. Following
the guidelines below will help you to be more aware of the causes of slip and fall injuries and the
steps you can take to prevent them:

• Be aware of surroundings and watch where you are walking.
• Avoid walking on wet or slippery surfaces. If necessary, walk very slowly and carefully and take
  small steps.
• Wear well-fitting, supportive footwear with a solid, non-slip tread.
• Beware of obstacles in your path.
• Move carefully from areas of lightness to darkness (and vice versa), giving your eyes plenty of
   time to adjust to the light change.
• When entering a dark area, turn on lights.
• Keep traveling pathways clear of equipment, cords, and supplies.
• Be careful around uneven surfaces and buckled or un-tacked carpet. Use safety mats and non-
   skid mats under rugs when appropriate.
• Don‘t run. Running increases your chances of a slip and fall
• Avoid carrying heavy or oversized loads that can obscure your vision. If necessary to carry large
  loads, take less traveled routes and take wide corners.
• Report any unsafe conditions immediately.
• Use handrails on stairs and where available and necessary.
• Protect your patients from slips and falls in the same ways you protect yourself.


Healthcare facilities by nature contain many types of hazardous materials. As an employee at a
Healthcare facility, you are at risk for an exposure to these hazardous materials. It is the
responsibility of the facility to maintain current information about the hazardous materials in use at
the facility and to provide this information to its employees. It is your responsibility as an
employee to know where this information is located and to know how to use it.
Hazardous materials come in many forms, such as:

•   liquids
•   solids
•   gasses
•   vapors

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• fumes
• rusts

Hazardous materials may be grouped into categories based on the effects they have, both physical
(e.g., flammability) and health effects. Health effects are of great concern and include those
caused by ―acute exposure‖ (rapid and short term) and ―chronic exposure‖ (long term exposure
over a long period of time), The categories of health effects from hazardous materials are:

1 Carcinogen: a cancer causing agent
2. Corrosive: causes visible destruction of, or irreversible alteration in, living tissue by chemical
action at the site of contact
3. Highly toxic: lethal when taken by mouth, upon contact with bare skirt or inhaled at specified
4, Irritant: non-corrosive, causing reversible inflammatory effect on living tissue at site of contact
5. Sensitizer: causes development of allergic reaction after repeated exposure
6. Toxic: may be lethal when taken orally, upon contact with bare skin or inhaled in specified
7. Target organ effects, such as:

• Hepatotoxins - produce liver damage
• Nephrotoxins - produce kidney damage
• Neurotoxins - produce nervous system damage
• Blood or hematopoietic damage
• Pulmonary (lung) damage
• Reproductive Toxins - affect reproduction capability, produce chromosomal
(mutation) and fetal (teratogenic) damage.
• Cutaneous- affect dermal layer of the body
• Eye hazards

The facility where you work will be required to have a Hazard Communication Standard (HCS) in
place for your protection. This document satisfies the employee‘s need and right to know about
the identities and hazards of the materials in the work place. The HCS will inform you of:

•   the hazardous materials in use at the facility
•   the materials‘ physical hazards
•   the materials‘ health hazards
•   the materials' labeling and how to read it
•   the person in charge of maintaining the hazard communications program
•   where material safety data sheets (MSDS) are located and how to read them
•   training available when working with or around the hazardous materials in use

A valuable and required tool with regards to working with hazardous materials is the material
safety data sheet (MSDS). This is a document, provided by the manufacturer, describing the
material and its specific, potential hazardous effects, physical chemical characteristics and
recommendations for protective measures. The facility must provide MSDS for each one of the

                                                 MayDay Staffing Solutions
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hazardous materials that is present in the facility. The MSDS must be easily accessible to
employees, and employees must be told where and how to access this information, It is then your
responsibility to read the MSDS and apply the knowledge to your situation.


Correct handling of hazardous materials includes correct disposal. Besides chemical materials, any
materials that come in contact with patients must be considered to be potentially infectious. These
materials can be considered medical or infectious waste and include:

•   syringes and other sharps
•   blood and body fluids or material that has come in contact with blood or body fluids
•   linens and clothing
•   specimens

Be sure that you know where and how to dispose of medical waste properly in the facility where
you are working. Procedures for correct disposal may vary from one institution to the next.


• Healthcare professionals should be aware of the potential hazards present when oxygen is in
use. Although oxygen does not burn, it does support combustion and poses a serious threat to
healthcare workers as well as their patients and other facility employees. Care and caution must be
exercised around oxygen at all times.

• Teach your patients how to exercise caution while oxygen is in use.
• DO:
       Be sure oxygen is stored in a clean, dry location.
       Follow manufacturer‘s directions for use and maintenance.
       Be sure hands and any tools/equipment used with oxygen are free of grease or oil. Protect
       off duty oxygen from dust, dirt and greasy oils with designated plugs, caps, and covers.
       Open valves slowly to release pressure gently
       Momentarily open and close (―crack‖) the post valve to blow out debris prior to installing a
       Make sure that any cleaning, repair or transferring of oxygen equipment is performed by
       qualified, properly trained staff.
       Position the equipment so that valve is pointed away from the user and any other persons.
• DON‘T:
       Smoke around oxygen.
       Light matches, lighters or allow other open fire near oxygen.
       Use electrical equipment which may pose a ―sparking‖ hazard around oxygen (e.g. hair
       dryers. toaster).
       Use oxygen equipment if it is visibly dirty, in poor repair or damaged.
       Look at the regulator pressure gauge until the cylinder valve is filly opened.

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

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Go to the Mandatory Education Test booklet and complete the test for Safety before moving on to
the next section.

Emergency Preparedness
In addition to fire, there are other emergencies that healthcare workers should be prepared for in
the workplace. Different hazards may be present in different units, and some may be universal to
all areas. Its the facility‘s responsibility to orient you to the different hazards in each of your work
areas and what your response should be. Workplace emergencies may be natural or man-made
and include tile following:
• Floods
• Hurricanes
• Earthquakes
• Tornadoes
• Toxic gas releases
• Chemical spills
• Radiological accidents
• Explosions
• Terrorist Attacks
• Civil disturbances
• Workplace violence


Similar to a Fire Safety Plan, your workplace may also have an Emergency Action Plan in place.
This plan will instruct you in the following:

• The method for reporting emergencies
• An evacuation policy and procedure
• Emergency escape procedures
• Names, titles, departments, and telephone numbers of individuals both within and outside your
facility to contact for additional information or explanation of duties and responsibilities under the
emergency plan
• Procedure for employees who remain to perform shutdown of critical plant operation, operate
fire extinguishers, or perform other essential services that cannot be stopped before evacuating
• Rescue and medical duties for workers designated to perform them
• An assembly location and procedures to account for all those persons evacuated


Being prepared for an emergency includes recognizing the alert system in place at your facility.

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                                                  16654 Soledad Canyon Rd. # 419
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The emergency alert system should:

• Be distinctive and recognized by all employees (including disabled workers) as the signal to
either evacuate or perform specified actions.
• Make available an emergency communications system, such as a public address system portable
radio unit, or other means, to notify employees of the emergency and to contact local law
enforcement, fire department or others.
• Be able to be beard, seen or otherwise perceived by everyone in the workplace.


In an emergency, you may be required to evacuate the facility or remain to assist others. In the
case of an evacuation, the following considerations should be part of the evacuation plan:

•   Conditions under which an evacuation would be necessary
•   A clear chain of command
•   Specific routes and exits determined and posted
•   Procedures for assisting others, including patients and disabled personnel
•   Designation of who will shut down vital operations and at what point they should also evacuate
•   A system to account for patients and personnel following an evacuation


As part of your orientation, you will receive training regarding the types of emergencies that may
occur and the proper course of action. Emergency preparedness training should include:
• Your individual role and responsibilities
• Types of threats, hazards, and protective actions
• Notification, warning, and communications procedures
• Emergency response procedures
• Evacuation, shelter and accountability procedures
• Location and use of common emergency equipment
• Emergency shutdown procedures
Your emergency training should be documented in your and the facility‘s records.


Regardless of the type of facility you work in, you could potentially face an emergency involving
hazardous material, such as flammable, explosive, toxic, noxious, corrosive, biological, oxidizable,
or radioactive substances. The source may be external, such as a local chemical plant; or it may
come from within your facility. In any case, the facility‘s emergency action plan should address this
possibility. Most healthcare facilities use and store some of the above-mentioned hazardous
materials. They are therefore required by OSHA‘s Hazard Communication Standard (2 CFR
1910.1200) to inventory them, keep the manufacturer-supplied Material Safety Data Sheets
(MSDS) accessible to workers, label containers with their hazards, and train employees in ways to
protect themselves against those hazards. You may need to use personal protective equipment

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(PPE) during an emergency. Your facility will supply the PPE and training as to how and when to
use it. PPE may include:

•   Safety glasses, goggles, or face shields for eye protection
•   Hard hats and safety shoes for bead and foot protection
•   Proper respirators
•   Chemical suits, gloves, hoods, and boots for body protection from chemicals
•   Special body protection for abnormal environmental conditions such as extreme temperatures
•   Any other special equipment or warning devices necessary for hazards unique to your worksite

No one expects an emergency or disaster. However, it is a simple fact that they do occur and can
strike anyone, anywhere, at anytime. You may be called in to action when you least expect it. The
best way to protect yourself, your co-workers and your patients is to be familiar with your facility‘s
emergency action plan and to expect the unexpected. With training and a full understanding of the
emergency action plan, you will be well prepared to respond.

Go to the Mandatory Education Test booklet and complete the test for ―Emergency
Preparedness” before moving on to the next section.

Security and Violence Prevention; Non-Violent Crisis Intervention
Your safety and that of your patients and co-workers in and around the healthcare facility depends
upon your training and practice of the facility guidelines in order to prevent workplace violence.
Workplace violence consists of threats, verbal abuse, physical and sexual assaults and even
homicide that can occur either in or on the grounds of the workplace. Other acts may include
bomb or terrorist threats, harassment, stalking, theft and child abductions. There are increased
risks of violence in the healthcare setting because of:

• The increased prevalence of handguns and other weapons
• The free movement of the general public
• The use of hospitals as a ―holding area‖ for criminals, acutely-disturbed and violent individuals
• An increased number of chronically mentally ill patients who are released without follow up care
and who are no longer allowed to be held involuntarily
• The availability of drugs and money at hospitals, clinics, and pharmacies making them robbery
• The increased presence of gang members, drug and alcohol abusers and distraught family
members in clinics and hospitals where long waiting times, as well as other potentially volatile
circumstances, can quickly get out of control
• Low staffing levels, especially during high activity times, such as meals, visiting hours and patient
• Solo work, especially in high crime areas

                                                 MayDay Staffing Solutions
                                            ―Responsive Business – Compassionate Nurses‖
                                                   16654 Soledad Canyon Rd. # 419
                                                       Santa Clarita, CA 91387

                           Phone: (888) 640-7111      website:           Fax: (661) 309-9073

• Isolated work with clients during examinations or treatments
• Lack of staff training in the recognition and management of escalating hostile and aggressive
• Poorly lighted parking areas

These risk factors make it imperative for the Healthcare worker to be especially attentive to
potentially violent situations and the proper behavior should one arise. The keys are to attend the
facility‘s training sessions and to follow security protocols without exception. Should an incident
occur, it is imperative to report it according to the guidelines in the workplace. This is an important
tool in the prevention of future incidents. YOU are critical in the prevention of workplace violence
from the recognition of a potential incident, dismissing a violent situation, to the proper reporting
after an incident has occurred.


Knowing the facility‘s policies will improve your chances of a positive outcome should you find
yourself in a potentially dangerous situation. Take the facility's training seriously and participate in
practice drills and role-playing. Practice will increase your preparedness. You will learn to:

•AVOID and
•DIFFUSE potentially violent situations.


Be alert for signs that a person (patient, family member, visitor or co-worker) may be losing
control. Warning signs are a person who is:

•   Holding a weapon
•   Shouting, insulting, swearing or making verbal threats
•   Physically aggressive
•   Clenching fists, gritting teeth, pounding on objects
•   Acting restless, pacing
•   Making unrealistic demands
•   Appearing to be under the influence of drugs or alcohol
•   Suffering from certain brain disorders or mental illnesses

While the above risk factors may help to identify potentially dangerous people. you can never
judge on these things alone. Anyone can become violent at any time. Learn to stay alert and be
aware of your surroundings.


While nothing can guarantee that an employee will not become a victim of workplace violence,

                                                  MayDay Staffing Solutions
                                             ―Responsive Business – Compassionate Nurses‖
                                                    16654 Soledad Canyon Rd. # 419
                                                        Santa Clarita, CA 91387

                            Phone: (888) 640-7111      website:           Fax: (661) 309-9073

there are many steps that can be taken to prevent potentially violent acts from occurring. It is
important to review these steps at your facility as they may vary from place to place. You should:
• Safely store items that could become weapons (e.g., syringes. scissors. surgical instruments),
• Treat everyone courteously and with respect.
• Behave in a calm fashion and be proactive about long waiting times.
• Check records for previous violent history, if possible.
• Keep yourself from becoming entrapped with no exit.
• Learn the procedure for summoning help from security, emergency response team or police
when necessary.
• Enforce visiting hours and sign-in procedures (especially in nursery and pediatric areas).
• Be attentive to any ―restricted visitors‖ Don‘t be afraid to question unfamiliar people.
• Always wear your ID. badge and report anyone suspicious who does not have one.
• Be alert for and suggest surveillance in potentially dangerous areas where there is none.
• Promptly report any breaches in security, including items in need of repair such as locks. fences,
broken windows lighting, etc.
• Supervise the movement of psychiatric clients throughout the facility,
• Know the facility‘s procedure for moving violent clients from one area to another and follows that
procedure precisely.
• Supervise access to restricted areas such as nursery and pediatric units, drug storage areas. cash
storage, medical supply storage areas, etc.
• Know the facility‘s procedure for ―secured areas,‖ monitoring high risk patients at night. and
emergency evacuation.
• Avoid being alone with clients, especially those with a history of violent/aggressive behavior. t)o
not enter a seclusion room alone.
• Any intimate examinations or treatments must be done with a co-worker present. never alone
with the client.
• Avoid wearing, jewelry that could be a target of theft. used to strangulate or cause injury.
• Be aware of any tools or possessions left by visitors or maintenance staff that could be used
inappropriately by clients or others.
• Use security escorts or the ―buddy system‖ in parking areas, in the evenings or at night. Always
check in and around your car before getting in.
• Exercise caution in stairways. elevators or any unfamiliar areas. Request a security escort if
• Immediately report any suspicious activity, such as a person loitering, harassing or illegally


It may not always be possible to diffuse the anger someone is feeling. There are some techniques
that you may employ in an attempt to avoid an escalation of anger to the point of violence. Try to:

•   Stay calm.
•   Avoid being a hero and rushing into a judgment.
•   Use a soft but firm tone of voice.
•   Offer help and let the person talk while you listen.

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

•   Offer the person choices, avoid touching the person, and keep 2-3 arm lengths away.
•   Request assistance by alerting security or police according to protocol.
•   Give yourself an escape route.
•   Try to determine if the person has a weapon (without touching the person)
•   Use logic whenever possible.


You may receive a phone call which may threaten a bomb or other terrorist activity. If so, you
• Listen carefully and write down as much information as possible.
• Keep the person on the phone as long as you can. Use a checklist of questions to ask if the
facility provides one.
• Record the call it possible.
• Alert security as soon as possible. Take every threat seriously and report every one.
• If you receive a suspicious package or letter, alert security immediately.
• Know the facility‘s security systems regarding the prevention of infant/child abductions. Follow
the guidelines provided by the facility in case of abduction.


If you are involved in a violent incident, there are steps you should take afterwards. These steps
may vary depending on your actual situation however, the following are some general guidelines:

• All incidents should be reported and logged immediately
• You should receive prompt medical evaluation and treatment if necessary.
• Police should be notified.
• Ask about your legal rights to prosecute the perpetrator.
• In order to prevent similar incidents in the future, facility management may conduct meetings
regarding the incident.
• It is recommended that you receive post-incident counseling and guidance.
• Offer your input as to any improvements that could be made.


Not all violent situations can be avoided or controlled, by staying calm and following some basic
guidelines, you can help to prevent violent situations from the beginning and, in other
circumstances, bring a volatile situation under control. You are an essential component in
maintaining workplace safety and security.

Go to the Mandatory Education Test booklet and complete the test for “Security and Violence
Prevention in the Healthcare Setting” before moving on to the next section.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Tuberculosis (TB) is an airborne disease that has seen resurgence in the United States. Presently
the disease is on the decline, but because of outbreaks of multidrug-resistant Tb during the
resurgence, especially in hospitals and prisons, there was a high rate of death and transmission to
healthcare workers. 10-15 million persons in the United States are infected with the TB-causing
organism, Mycobacterium tuberculosis. Without intervention, about 10% of these people will
develop active TB at some point in life.

As a healthcare professional, not only can contract TB from your patients, but you may also
transmit it to others. Mycobacterium tuberculosis is spread by airborne particles called ―droplet
nuclei‖. These are released into the air from a person with active TB by:

•   Sneezing
•   Coughing
•   Speaking
•   Singing

Your job is to prevent exposure to droplet nuclei so as to avoid contracting TB and spreading it to
others. Prevention consists of following the facility‘s guidelines for the use of respiration and
isolation precautions. You should:

        • Understand isolation procedures and identifying marks for isolation patients.
        • Follow facility procedure in the use of masks and respirators (Personal Respiratory
        • Attend the facility‘s TB training and learn to properly fit and use various respirators
        available for your use.
        • Adhere to the facility policy on employee TB screening but, at the very least, have a PPD
        done yearly.
        • Participate in any educational offerings by the facility regarding TB
        • Use universal precautions when indicated.
        • Teach your patient with TB to always cover mouth and nose when sneezing or coughing
        with a disposable tissue and to discard appropriately.
        • Take special precautions with patients undergoing cough-producing procedures, such as
        bronchoscopy, administration of aerosolized medications, sputum collection, etc.
        • If you are exposed to TB, notify your supervisor, and then follow a licensed medical
        practitioner‘s advice for follow-up active infection prevention.


With the cooperation of well-trained and conscientious Healthcare workers, the spread of TB can
be properly controlled. It‘s up to you.

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Go to the Mandatory Education Test booklet and complete the test for “Tuberculosis” before
moving on to the next section.

HIPAA Privacy and Confidentiality Standards for Healthcare
The Health Insurance Portability & Accountability Act (HIPAA) is a comprehensive piece of
legislation that covers three areas:

       1. Insurance Portability- the ability for an individual to carry insurance coverage from one
       health plan to another without denial of coverage for a pre-existing condition
       2. Accountability- increases the government‘s fraud-enforcement authority significantly
       3. Administrative Simplification- reduces Healthcare costs and strengthens rules regarding
       patient privacy and security

The first two categories, Portability and Accountability, have already been put into effect, and as of
April 2003, the Administration Simplification component will be in force. The focus of this training
module will be on two of the new rules covered under the Administration Simplification: Privacy
and Security.

The Privacy rules protect an individual‘s health information and gives the patient certain rights.
The Security regulation requires organizations to protect individually identifiable electronic health
information. These rules help to protect a patient‘s privacy and confidentiality by careful
management of their protected health information (PHI). As a Healthcare professional, you must
be aware of, and comply with the new HIPAA standards regulating the use and release of an
individual's PHI. You must also be aware that since these regulations are now federal law, there
are both civil and criminal sanctions associated with their violation, and can carry penalties of
prison time and fines up to $250,000. For example, if you access a co-worker‘s medical record to
determine a birth date, or look up a neighbor‘s records out of curiosity, you have committed an
―inadvertent violation‖, which could result in a civil sanction and a fine.

In some cases, there may be a criminal sanction as well. ―Intended violations‖, such as selling
patient information for personal or financial gain, are more serious than inadvertent or accidental
release of information, and carry stiffer penalties. For instance, selling a celebrity‘s medical record
to a tabloid newspaper or selling health information to a marketing or pharmaceutical company for
personal profit, would be a direct violation, and could result in a 10-year jail sentence and a
$250,000 fine.

HIPAA calls on all ―covered entities‖ to learn the rules of privacy and confidentiality and to
conscientiously practice them. A covered entity is any person or organization that may come in
contact with PHI, including hospitals, nursing homes, physician‘s practices, laboratories,
pharmacies, insurance companies, payers, or other provider services. As a healthcare professional

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

working for one of these covered entities, you are the backbone of the facility‘s strength when it
comes to protecting patient‘s privacy and confidential PHI.


A patient‘s privacy and confidentiality are an integral part of the total satisfaction and dignity that
will be experienced while in your care.


       • Refers to a patient‘s right to decide what personal health information may be shared with
       • Allows the patient to decide with whom and how any information is shared.
       • Protects the patient from having his/her medical and personal information discussed in
       public, where it can be overheard (i.e., elevators, hallways, waiting areas).
       • Also includes the protection of physical privacy, such as during examinations, having a
       curtain around the bed during treatments, etc.

       •Limits access to a patient‘s personal and medical information to:
       1. Those who have a need to know (including the patient)
       2. Those who provide care to the patient

It is important for patients to be assured that their medical information will remain confidential. If
a patient feels in any way, that this confidentiality may be breached, that patient may withhold
vital information that could restrict his/her care. Helping your patient to understand his/her rights
and your facility‘s policies regarding privacy and confidentiality, will not only give your patient the
security needed, but will also ensure compliance with the new HIPAA standards. Should you have
any questions regarding patient privacy or confidentiality issues, you should seek the guidance of
the facility-appointed Privacy Officer. HIPAA standards require that a privacy officer be available to
answer any privacy concerns.


Unless you are new to healthcare, the issues of privacy and confidentiality are not new to you. We
are now living in a changing world where modes of communication and access to information are,
at the same time, easier and more complex. For these reasons, HIPAA standards were created to
protect individuals, not only because it is ethically correct, but to make it the law. The types of
information you are required to protect is defined by HIPPA as protected individually identifiable
health information (PHI), which is anything that can be used to identify an individual (including
demographic information) and meets the following criteria:

       • Is created or received by a Healthcare provider, health plan, employer, or healthcare

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       •Relates to the past, present, future physical/mental health, or condition of an
       • Describes the past, present, or future payment for the provision of health care to an

Some elements that make information individually identifiable are:

       •   Names
       •   Any other characteristics such as occupation, which may identify the individual
       •   Addresses
       •   Employers
       •   Relatives names
       •   Dates of birth
       •   Telephone and fax numbers
       •   E-mail addresses
       •   Social Security numbers
       •   Medical record numbers
       •   Member or account numbers
       •   Certificate numbers
       •   Voiceprints
       •   Fingerprints
       •   Photographs
       •   Codes

Releasing any PHI, other than for reasons that are permissible, is a direct violation of the HIPAA
privacy regulation. Remember that even if the patient‘s name is not mentioned, other information,
such as a date of surgery or the type of procedure that was done, may identify the patient, or can
help someone to guess at their identity.


It‘s important for patients to understand their rights and how they and their providers can protect
individual health information. HIPAA requires notices to be posted informing patients of how the
facility will use their PHI. HIPAA further requires that a reasonable effort is made to document that
the patient has received this information. You should locate and become familiar with your facility‘s
Notice of Privacy/Information Practices and be prepared to review it with your patients and answer
questions that they may have. The Notice of Privacy/Information Practices that your facility has
prepared will discuss the uses of PHI. This information is necessary for:

       • Treatment
       • Payment
       • Operations (teaching, training, medical staff/peer review, legal, auditing, customer
       service, and business management)
       • Hospital directory

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       • Public health safety reporting
       • Other required reporting, such as abuse, gunshot wounds
       • Subpoenas, trials, and other legal proceedings
Other situations require the authorized permission from the patient before PHI may be disclosed.
These situations include disclosures to employers, financial institutions, and the media. The
authorization must include the following elements:

       •   Description of the PHI to be released
       •   Identity of who may release and receive the PHI
       •   The purpose of the disclosure
       •   A date when authorization expires
       •   Name of patient
       •   Signature of patient

When disclosing PHI, HIPAA standards require that providers must disclose or access only the
minimum necessary amount of information to get the job done. Consider the following questions
when screening what PHI is necessary to disclose or withhold:

       •   Is this information necessary to perform my specific job?
       •   What is the likelihood that future disclosures could occur?
       •   What amount of information is necessary to provide quality care?
       •   How important is it to disclose/use this information?

―Incidental‖ issues and disclosures are permitted as long as reasonable safeguards are used to
protect PHI, and minimum necessary standards have been applied. Examples are: discussions
during teaching rounds, calling out a patient‘s name in the waiting room, sign-in sheets in clinics,
etc. And suppose you incidentally see information that you don‘t need. For example, if a patient is
placed in an isolation room, you may suspect or figure out why they are there. This information is
confidential, and should not be communicated to anyone else. You may see information about
patients on whiteboards throughout the hospital, but you are not at liberty to use this information
or disclose it to anyone, including coworkers, other patients, visitors, or anyone else.

HIPPA grants patients certain rights to privacy and confidentiality. Patients also have the right to
review and amend their own PHI. They have the right to request confidential forms of
communication (mail to a P.O. Box, not a street address; no message on answering machine. etc.)
and the right to restrict certain uses and disclosures. Patients also have the right to an accounting
of the disclosures of their PHI.


       1. The Federal Government, through the Department of Health and Human Services, has
       passed the Health Insurance Portability and Accountability Act (HIPAA). This is a set of
       standards, originally passed in 1996 and is now effective. As healthcare workers need to be
       familiar with the laws in their state, and are required to familiarize patients with facility

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       standards on privacy and confidentiality, it is the responsibility of the healthcare worker to
       document that the patient has received this information.

       2. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is an
       organization that accredits Healthcare facilities nationwide. JCAHO sets standards of patient
       care, including confidentiality. During an audit, JCAHO will expect you to know your
       organization‘s mission, its policies for protecting patient confidentiality and privacy, what
       efforts your department is making to improve confidentiality and privacy, and how your
       specific job relates to each of these items.

       3. National Committee for Quality Assurance (NCQA) is a national agency that accredits
       managed care organizations and evaluates managed care plans. In conjunction with
       JCAHO, NCQA developed recommendations to maintain patient privacy and confidentiality
       to include staff education, patient consent, and other systems to ensure confidentiality.

       4. Health Care Financing Administration (HCFA - now renamed The Centers for Medicare &
       Medicaid Services) is another part of the Department of Health and Human Services, and is
       specifically involved with Medicare, Medicaid, and the Child Health Insurance Program.
       Healthcare facilities must be in strict compliance with HCFA regulations, including those
       guidelines relating to patient privacy and confidentiality. If you are a healthcare worker
       involved in home health care, HCFA has developed guidelines for privacy and confidentiality
       when you use the OASIS evaluation tool.


Remember, security is the legitimate ability or inability to access information and confidetiality and
refers to the sharing of this information by authorized parties.


       > Determine what the state laws are with regard to ages of ―minors‖, ―elders‖, what types
       of information must remain confidential, and what information must be reported.
       >Learn and understand the facility‘s policies regarding confidentiality and privacy.
       > Be aware of who has access to what information and act accordingly.
       >Do not discuss patient information in public areas, such as the cafeteria, hallways &
       elevators, or outside of the workplace.
       > Ensure that the patient understands his/her rights and informed consent by discussing
       any questions, giving more verbal and written information if indicated, and asking the
       patient questions to determine the level of understanding.
       >Only answer questions regarding a patient with those co-workers who are authorized to
       >Evaluate your need to know before reading or discussing patient information.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073


       >Adhere to the facility policy regarding which types of information may be released over
       the phone, and to whom.
       > Never leave confidential information on voicemail or an answering machine.
       >Use the handset to listen to voicemail, not the telephone speaker.
       >Do not conduct a phone conversation involving confidential information when others can
       > Do not discuss confidential information while on a telephone speaker, unless you know
       who else is in the room and whether they are authorized to bear the conversation.


       > Follow facility policies on accessing and using email from the workplace.
       > Never share your password with anyone at any time.
       > Forward emails containing confidential information only when specifically authorized.
       > If you suspect or witness unauthorized access to secure information, you should notify
       your supervisor immediately.
       > Do not allow others to observe your computer screen while you are working.
       > When moving away from the computer, be sure no private information has been left on
       the screen.
       > Use a printer in close proximity to your computer, and retrieve printed material promptly.
       > If you use a PDA (or a card or piece of paper) to make notes of confidential information,
       destroy the information promptly when no longer needed.


       > Only authorized staff should make copies of, or fax, confidential information.
       > Check to be sure originals have not been left on the machine.
       > Making extra copies of confidential information is prohibited
       > Unsatisfactory or extra copies should be properly disposed.
       > Be sure the cover letter states that the information is confidential. Confirm fax number
       before sending confidential in formation.
       > If you must use a fax machine from another department, wait for confirmation and
       remove all materials before leaving the area.


In accordance with state and federal law, agency standards, and your facility, you should follow
policies regarding:

       >The destruction of unnecessary data and reports

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       > Information regarding mental health and substance abuse
       >The handling of HIV/AIDS status information
       >Informing patients of their test results


       > Be sure to use curtains, close doors and utilize other devices to ensure patient privacy
       and dignity.
       > When discussing confidential information with the patient, do so in a private location.
       > Use an appropriate voice volume.
       > Discuss patient rights and informed consent when the patient is calm and the ability for
       learning is appropriate and unhurried.
       > If a patient requests to review their own medical record, do so in a private location
       according to facility policy. A medical care provider should be available to answer questions
       at the time of the review.


One of the healthcare worker‘s responsibilities is to provide information to patients about their
medical care, so that they are able to make informed decisions about their care. This is called
―informed consent‖. Part of informed consent includes telling the patient:

       •   Who has requested information about them
       •   With whom the information will be shared
       •   How the information will be used
       •   How long their consent will be valid

The facility‘s informed consent policy should involve today‘s high-tech environment, such as the
storage of confidential information as an electric file, how it is accessed, and by whom.
Legally speaking, all adults are competent to make all of their own decisions, unless proven
otherwise by a court of law. If a patient has been proven incompetent, his/her proxy (surrogate)
must make decisions on behalf of the patient. When the patient is a minor, a parent or legal
guardian is asked for consent. There are exceptions to this, however, and these exceptions may
vary from state to state. Be sure you are familiar with the legalities in the state where you are
employed. When providing information and obtaining consent, Healthcare workers must:

       • Use non-technical language that the patient can understand
       • Provide an interpreter or speak the patient‘s language
       • Confirm that the patient has understood

Consent must be voluntary in order to be legally valid. This involves providing an atmosphere
where the patient is neither hurried nor pressured. If a patient feels that he/she would like to
review his/her own medical record, he/she has the right to do so. Patients also have the right to
have certain information changed or removed before giving consent. It is your responsibility to

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

seek information regarding the facility‘s policy and procedure in case this occurs.


There are exceptional situations where providers are required to release patient information.
Specific situations will vary from state to state, but generally include reporting:

       • Communicable diseases such as HIV, Hepatitis, Smallpox, TB, and Meningitis
       • Medical devices that malfunction or break
       • Child abuse or domestic violence
       • A suspected criminal or criminal activity, such as rape, violent crimes, suspected drug or
       alcohol abuse in the case of car accident victims
       • Court ordered information
       • Suspicious deaths or injuries (gun shot wounds)
       • Deaths (reported to funeral home)
       •Threats from patients to harm you or others

Conversely, there are situations which require consent when healthcare workers might think none
is necessary. These situations would involve minors (those under 18 years of age). In most states,
minors may give their own consent for care that involves contraception, pregnancy, sexually
transmitted diseases, and substance dependency. In most cases, these minors must give
permission for this information to be released to their parent or guardian. Again, it is imperative to
know the laws regarding minors and consent in the state where you work.


In today‘s high-tech world, there are more avenues for breaches in confidentiality. We not only
have a written medical record these days, but also electronic medical records (EMR) with many
routes to access these records; such as computer access, email, fax, microfilm, copiers and
printers. The telephone, which is a valuable tool in terms of transferring appropriate information to
an appropriate individual, has risen to a new level with the use of the cell phone. Healthcare
providers must be even more careful to avoid being overheard while using a cell phone because
they are able to use them increasingly in public areas. A conversation on a cell or cordless phone
may also be intercepted by someone using another cell phone or a scanner using the same

With regards to patient confidentiality and privacy, the following are some special areas of
concern. You must be aware of these situations and know what your responsibilities are:


       o While all states require HIV-positive status and AIDS cases to be reported, some also
       require the patient‘s name, address and other identifying information.

                                                  MayDay Staffing Solutions
                                             ―Responsive Business – Compassionate Nurses‖
                                                    16654 Soledad Canyon Rd. # 419
                                                        Santa Clarita, CA 91387

                            Phone: (888) 640-7111      website:           Fax: (661) 309-9073

          o You can face legal action if you handle HIV/AIDS information improperly.
          o Check with your supervisor to learn who informs whom about a patient‘s HIV/AIDS
          status. Then be sure of who needs to know.
          o Be exceptionally careful to not discuss the patient‘s HIV/AIDS status in public places
          o Be sure to get informed consent in writing.
          o If release of records is authorized, be sure the records are sent with a letter prohibiting
          further release.
•   Contracts with Third Parties
•   Electronic Medical Records
•   Medical Research
•   Pharmacy Practices
•   Mental Health and Substance Abuse Treatment


It is necessary to read and be familiar with your organization‘s Notice of Privacy/Information
Practices to best understand how it defines Healthcare operations. Additionally, you should be
familiar with the exceptional reasons for PHI disclosure in your state, and those allowed under the
HIPAA rules. You are not allowed to share patient information for any other reason, and doing so
is a violation of HIPAA regulations and can result in fines and jail time for you and your

HIPAA requires detailed policies and procedures to be in place that will spell out exactly how
patient information may be used, disclosed, and how it should be disposed. It is your responsibility
to understand these policies and to ask questions of your organization‘s privacy officer if you have
any issues, questions or concerns.

Go to the Mandatory Education Test booklet and complete the test for “HIPPA Standards for
Healthcare Professionals” before moving on to the next section.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Patient Rights

Satisfying and effective Healthcare is the desired outcome when patients, physicians, healthcare
workers, and facilities all work together. As a mechanism for ensuring quality patient care, the
American Hospital Association first adopted a ―Patient‘s Bill of Rights‖ in 1973. Revised in 1992,
this document sets the foundation for the understanding, respect, and assistance that patients
need in making their own health care choices. It emphasizes confidentiality, dignity, and education
on behalf of the patient. In order to achieve the optimal level of care, the patient also has their
own certain responsibilities, which will assist in reaching this goal.


As a healthcare worker, your responsibility is to respect the patient‘s rights and to educate your
patient about their rights. These rights may be exercised on behalf of the patient, by a designated
proxy, if the patient is legally incompetent, lacks decision making abilities, or is a minor.

The patient has the right to:

       • Care that is respectful, prompt, and considerate
       • Be given current and understandable information concerning their diagnosis, treatment
       and prognosis from any and all members of the health care team
       • Know the identity of all those involved in their care
       • Know the financial implications of treatment choices, both immediate and long-term, to
       the extent that they are known or can be predicted
       • Make decisions about his/her treatment plan before and during treatment and to refuse
       any treatment, with the medical consequences of refusal fully explained by the health care
       • To expect that an advance directive will be honored to the extent of the law and hospital
       policy. If there should be any reasons why the facility might limit implementation of a
       legally valid advance directive, the patient has the right to be informed of these limitations
       • Privacy. A patient‘s privacy is to be protected during examination, consultation, and
       treatment. All records and communications regarding the patient‘s care will be kept
       confidential, except where allowed or required by law
       • Review records pertaining to his/her own medical care and to have the contents
       explained and, if necessary, interpreted, except where restricted by law
       • Transfer to another facility when medically appropriate, legally permissible or when the
       patient requests, after receiving pertinent information including risks, benefits and
       alternatives of such a transfer
       • Refuse or accept participation in experimental treatment or research. If the patient

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       chooses to participate, the study must be fully explained prior to giving consent
       • Information regarding the availability of realistic care options when hospital care is no
       longer appropriate
       • Be informed of resources for resolving disputes, grievances, and conflicts
       • Information regarding hospital charges and payment methods, and any hospital policies
       that might pertain to care, treatment, and responsibilities.


Healthcare is a shared effort between patients, their families (or proxy), and the medical
Healthcare team. This collaboration necessitates cooperation on the part of the patient in order to
achieve effectiveness of care and patient satisfaction. Patients have an obligation to undertake
certain responsibilities in order to reach these goals. Patients have the responsibility to:

       • Provide information about past illnesses, hospitalizations, medications and other matters
       related to their health status
       • Request additional information or clarification about their health status or treatment in
       order to make informed decisions
       • Provide the hospital with written advance directives
       • Inform the Healthcare team if they anticipate problems in following the prescribed
       • Assist the hospital in its obligation to equitably provide care to other patients and the
       community. Patients must make reasonable accommodations with regard to the needs of
       other patients, medical staff, the hospital, and its employees
       • Provide insurance information
       • Realize no life style may impact his/her health status


As a member of the healthcare team, you have an obligation to inform patients of their rights as
well as implementing these rights while providing care. Examine the policies and procedures at
your facility so that you are able to provide accurate information or direct the patient to the
appropriate source of information. Establishing a respectful and cooperative partnership with your
patients, will enhance the quality of their healthcare experience.

Go to the Mandatory Education Test booklet and complete the test for “Patient Rights” before
moving on to the next section.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Documentation and Risk Management for Healthcare Workers

Complete and accurate documentation serves to communicate a patient‘s condition to other care
providers, risk management and quality assurance teams. It also serves as the main line of
defense should a lawsuit be filed. The same chart can also be used against the Healthcare worker
should the documentation be incomplete, inaccurate or lack the appropriate details.
Chart as promptly as possible to avoid ―forgetting‖ actions or assessments. This approach makes
for a more accurate account of events and chronological order. Remember, if it‘s not charted, it
wasn‘t done. Chart as if you will be reconstructing your actions of that shift for a jury some day in
the future. It may not be for another 5 or 6 years, so be sure to be concise, accurate and
complete. This document will serve as your memory.


       • Be precise about date and time.
       • Write legibly.
       • Use only facility approved abbreviations.
       • Be sure to sign each entry.
       • Be factual, clear and concise.
       • Note any change in patient status. If there is no change, notate ―no change in patient‘s
       • Document a patient‘s behavior objectively, especially non-compliant behavior.
       • Document facts, not judgments. For example, rather than charting ―the patient ―as
       aggressive and hostile,‖ chart ―the patient threw objects from bedside table at staff while
       • Quote patient directly.
       • Read previous notes before charting.
       • Chart only after event never before.
       • Use black ink (never a pencil or erasable pen).
       • Correct mistakes by putting one line through the entry, initial, date, and mark ―error‖
       near correction.
       • Make ―addendum entries‖ for notes that are out of sequence.
       • Chart patient and family education, including discharge instructions.
       • Be careful of word choices, avoiding words such as accidentally, unfortunately,
       unintentionally, somehow, etc.
       • Countersign another person‘s documentation only after carefully reading it in its entirety

       • Squeeze in a late entry
       • White out or erase an entry, leave spaces or blank lines between entries

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       • Chart that an incident report has been filed.
       • Leave loose ends. For example, follow up on lab reports even if only saving ―results
       not yet available.‖
       • Make statements casting blame, criticism, or intending to be gratuitous.
       • Tamper with or in any way alter the record.
       • Make an entry for someone else or ask them to make an entry for you.


Risk management is the process of reducing or eliminating incidents that may lead to injury, illness
or the dissatisfaction of clients and their families, visitors, and employees. Through risk
management, the facility and its employees can identify various potential risks and ways to
prevent incidents from occurring. Comprehensive risk management helps to protect the facility and
its employees from law suits, as well as providing safe, satisfying and cost-effective
healthcare to patients.

Healthcare workers are more likely to become involved in litigation because they provide hands-on
care. This leaves them open for liability because of their involvement in situations such as:

       •   Assessment that may be incorrect, incomplete or inappropriate
       •   Treatment that may be incorrect, incomplete or inappropriate
       •   errors in medication administration
       •   An adverse reaction to a procedure or medication
       •   A slip and NI incident
       •   Not providing safe and appropriate care
       •   Inadequate documentation
       •   Not reporting a change in patient status
       •   The use of faulty equipment

Other factors that may contribute to patient dissatisfaction and might be the fuel for litigation are:
poor communication, unrealistic expectations of healthcare providers and treatment outcomes, and
de-personalized service. Also, with shorter hospital stays and increased outpatient procedures,
there are increased family responsibilities needing to be addressed.


Should any incident occur which may affect the quality of care or safety, an incident report must
be filed. Your facility will supply you with guidelines for completing an incident report and to whom
the incident should be reported. Incident reports are a Legal component in the identification of
problems, and therefore help to prevent similar incidents from occurring in the future. They are
examined and reviewed in order to devise corrective actions. Incident reports also help to identify
any trends that may be affecting patient/employee care and safely.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073


In addition to filing incident reports, members of the Healthcare team can practice other risk-
reducing activities. Proper communication between Healthcare workers and their patients and
families is essential in establishing confidence and personalized service. Being a good listener,
providing compassionate understanding and presenting a pleasant bedside manner will add to a
patient‘s overall satisfaction. This will greatly help to reduce the likelihood of a law suit.


You are an essential part of risk management. Be sure that you report any potential problems that
you may encounter and follow hospital procedures should you be involved in an incident.
Go to the Mandatory Education test booklet and complete the test “Documentation and Risk
Management” before moving on to the next section.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Age Specific Competency

Requirements for accreditation with The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) include the education of healthcare workers regarding care of patients
based on their age. This education is vital for the practitioner‘s understanding of important growth
and development issues, and characteristic needs of specific age groups. Aspects of care should be
modified according to age-based characteristics, such as communication and education techniques,
ability to participate in one‘s own care, impact of illness and hospitalization, discharge planning,
and inclusion of family/primary caregiver/significant other in care and education.

As a healthcare professional, you are required to be competent in understanding and modifying
care for a specific patient population, including all age groups that apply. For example, a
practitioner providing care to children from birth to age twelve must not only be competent in
understanding the milestones, skills and development of children in that age group, but also the
age-specific considerations of their parents or other primary caregivers. A Healthcare
professional working in the Emergency Department should be trained in the characteristics and
needs of all age groups.

While sources vary in their opinion of exactly where one age group ends and another begins, it
must be taken into account that human characteristics will vary, regardless of ―age group‖. Age
groups should be considered and used as a guideline for assessment and the planning of patient
care to attain the optimal outcome for the patient.


After completing this self-learning module, the Healthcare professional will be able to:

• Identify characteristics of each age group including:
        o Name of age group
        o Psychosocial Achievements and Normal Growth and Development
        o Health Concerns
        o Unique Challenges
• Incorporate knowledge of age-specific competencies and plan of care, in order to provide the
patient with an optimal outcome
• Successfully complete the self test for this module

Age Specific Competency

Infancy (Birth - 1 year)
Psychosocial Achievements and Normal Growth and Development:

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      •   Builds motor skills, such as grasping, rolling, sitting, crawling, standing, walking
      •   Reflexive behaviors gradually replaced by voluntary movements
      •   Develops trust and a sense of being loved and cared for
      •   Simple communication such as crying and babbling
      •   Birth weight triples during 1st year of life
      •   Fears loss of support, loud noises, bright lights, sudden movements, strangers

Health Concerns:

      • Prematurity, infection, respiratory disease, cardiovascular disease, nutritional
      imbalances, accidents, disruption of family unit, delay in bonding, congenital malformations

Unique Challenges:

      • Weaning breast / bottle /cup, separation anxiety, teething, safety/injury prevention,
      parental/sibling adjustment, introduction to solid food, immature immune system

Age Specific Considerations for the Healthcare Professional:

      • Educate primary caregiver(s) regarding checkups, screening, and immunizations. Include
      primary caregiver(s) in child‘s care to decrease separation anxiety
      • Provide emotional support to family
      • Use calm, soothing voice when caring for child
      • Place infant on back to sleep
      • Assess for developmental milestones
      • Assess for abuse/neglect, report when indicated
      • Cuddle, rock, swaddle to comfort a child when possible/appropriate

Toddler (0-3 years)

Psychosocial Achievements and Normal Growth and Development:

      • Physical growth: 5 lbs/year; 3 inches/year
      • Molars and cuspids emerge
      • Walks, runs, balance improves, climbs stairs, Draws, toilet training (may be mastered or
      continuing), plays alone and parallel with others
      • Can feed self (hold bottle, finger foods)
      • Acquires language
      • Developing autonomy, shame and doubt, magical thinking, object permanence
      • Actively explores and discovers but with a short attention span
      • Cannot discern danger
      • Seeks positive reinforcement and approval from caregiver(s)
      • Concept of time is immediate only
      • Ritualistic/routine behaviors

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       • Fears separation from caregiver(s), but can tolerate short separation
       • Able to express emotions

Health Concerns:

       • Accidents, nutritional disturbances, contagious/infectious disease, dental health

Unique Challenges:

       • Toilet training, separation anxiety, stranger anxiety, communication (able to understand
       more than can communicate) asserting Independence (temper tantrums), sibling rivalry

Age Specific Considerations for the Healthcare Professional:

• Assess for developmental milestones
• Involve and educate family/primary caregiver(s) in caring for child
• Remind primary caregiver(s) regarding checkups, screening, and immunizations
• Monitor for abuse/neglect. Report when indicated
• Communicate with child at appropriate age level using appropriate learning materials (puppets,
dolls, videos, storybooks)
• Use firm, direct approach, distraction techniques, and give short, concrete instruction and
• Follow routines
• Use oral routes for medication administration when possible
• Keep medications out of child‘s reach
• Be alert to pediatric medication doses (usually based on child‘s weight)
• Use pediatric pain assessment tool
• Use appropriately-sized equipment pediatric BP cuff, electrodes, catheters, etc.)

Pre-school (4-6 years)

Psychosocial Achievements and Normal Growth and Development:

       • Gains less than 5 pounds/year; grows 2-2.5 inches/year
       • Begins to lose baby teeth
       • Develops coordination (e.g., runs, hops, throws, uses scissors)
       • Can dress self
       • Learns to use utensils, tie shoe laces, ride bike; can write name and copy letters of
       • Speech becomes more intelligible, speaks in sentences, vocabulary increases
       • Curious, imaginative and asks lots of questions
       • Develops sense of privacy
       • Becomes aware of others‘ feelings

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

      • Develops sense of time
      • Active fantasy life
      • Fear of separation and the supernatural (monsters, ghosts, animals, the dark)

Health Concerns:

      • Communicable diseases of childhood, accidents, dental health, poisoning
      • Hospitalization/illness may lead to regression
      • Nutritional Balance

Unique Challenges:

      • Maintaining a safe environment for child
      • Promoting close contact between caregiver(s) and child
      • Maintaining a healthy diet. Children often have specific likes and dislikes at this age.

Age Specific Considerations for the healthcare Professional:

      • Reassure child that illness and/or treatment are not punishment for misbehavior
      • Assess for developmental milestones
      • Monitor for abuse/neglect: report when indicated
      • Remind primary caregiver(s) regarding checkups, screening, and immunizations
      • Praise good behavior and offer small token rewards such as stickers
      • Encourage parental involvement and presence during hospitalization
      • Use clear, concise explanations that child can understand being attentive to vocabulary
      choices (e.g.. a child might believe they will be ―stretched‖ if they have to go on a
      • Give appropriate choices whenever possible (e.g. injection site)
      • Be alert to pediatric medication doses (usually based on child's weight)
      • Use appropriately sized equipment (pediatric BP cuff, electrodes, catheters, etc.)
      • Allow child some independence (self care, dressing, feeding) when appropriate
      • Use pediatric pain assessment tool

School Age (7-12 years)

Psychosocial Achievements and Normal Growth and Development:

      •   Gains 4-7 pounds/year, height increases at age 9, arms long in proportion to body
      •   Girls may begin menstruation and develop secondary sex characteristics
      •   Has 10-26 permanent teeth
      •   Improved balance and muscular strength, improved hand-eye coordination
      •   Can read, write, do math, and memorize
      •   Logical and deductive reasoning develop, understands past, present/future, can

                                             MayDay Staffing Solutions
                                        ―Responsive Business – Compassionate Nurses‖
                                               16654 Soledad Canyon Rd. # 419
                                                   Santa Clarita, CA 91387

                       Phone: (888) 640-7111      website:           Fax: (661) 309-9073

      understand death and dying
      • Assumes responsibility for chores and school related tasks
      • Begins to understand anatomy, bodily functions and illness
      • Can articulate some degree of discomfort, but may be reluctant to ask questions
      • Need to develop sense of adequacy about abilities involving social interaction and
      • Sex segregated ―play‖ with peers (athletics), development of personal interests/hobbies
      • Coping skills include, for example, doing nothing, acting impulsively, problem solving
      • Other adults beginning to have significant impact on behavior (teachers, coaches), but
      parents still considered primary adult authority

Health Concerns:

      • Communicable childhood diseases, accidents, dental health, behavior disorders
      • Nutrition
      • Vulnerable regarding drugs, alcohol, and sexual activity

Unique Challenges:

      • Peer pressure may lead to poor judgment
      • Prefers fast food dining with friends
      • Concerned with peer acceptance and appearance

Age Specific Considerations for the Healthcare Professional:

      • Remind primary caregiver(s) regarding checkups, screening, and immunizations
      • Continue to assess for developmental milestones
      • Monitor for abuse/neglect; report when indicated
      • Educate patient and caregiver(s), and promote parental involvement
      • Use age appropriate teaching materials and language. Be direct, use correct terminology,
      and encourage child to ask questions, participate in care, and make own decisions
      regarding care when appropriate
      • Be supportive of need for control and privacy
      • Support coping mechanisms and independence (e.g. ―Your job is to hold very still while I
      put these drops in your eye. It‘s OK if you‘re scared and want to grab your pillow‖)
      • Address fears, such as loss of control, supernatural tests, and failure in school, death
      • Provide for continued schooling
      • Educate in safe behaviors regarding drugs, alcohol, and sexual activity

Adolescence (13-20 years)

Psychosocial Achievements and Normal Growth and Development:

      • Secondary sex characteristics develop
      • Adult weight is achieved, some awkwardness may occur because of rapid growth

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

      • Variable appetite
      • Dentition complete, many adolescents have wisdom teeth extracted
      • Gross and fine motor control increases
      • Heightened emotionality because of hormonal changes
      • Capacity for abstract, symbolic, deductive and analytical thinking. Begin thoughts of
      • Critical of appearance and mood changes

Health Concerns:

      • Accidents, eating disorders, depression, substance abuse, acne, reproductive system
      problems (including adolescent pregnancy), STDs

Unique Challenges:

      • Identity, achievement, and autonomy may participate in impulsive and risk-taking
      • Is heavily influenced by peer opinion and judgments.
      • Attempts to identify factors necessary for self-growth

Age Specific Considerations for the Healthcare Professional:

      • Emphasize the continued need for checkups, screenings, and immunizations
      • Provide privacy for teaching and procedures
      • Provide increasingly more detailed information with the use of correct medical
      • Know the age at which an adolescent can legally authorize own treatment. Involve
      patient in treatment decisions and care
      • Encourage contact with family and friends while hospitalized
      • Reinforce knowledge of safe behaviors regarding drugs, alcohol, and sexual activity
      • Provide for continued schooling
      • Monitor for abuse
      • Assess for depression and encourage use of stress reduction
      • Refer to appropriate youth support groups, if needed

Young Adult (21-39)

Psychosocial Achievements and Normal Growth and Development:

      •   Physical and motor development complete
      •   At peak physical strength and prime reproductive capacity
      •   Continued development of intellectual abilities
      •   Develops intimate, long-term relationships

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

      • Struggles to form commitment without losing identity
      • Evaluates new information in terms of own experience

Health Concerns:

      • Pregnancy and childbirth, infertility, STDs, accidents, stress-related illness, substance

Unique Challenges:

      • Fears the loss of work and social relationships
      • Most significant relationships are with spouse, children, and coworkers
      • Most stressors include career, establishing family, balancing numerous roles and
      responsibilities at home/work/school community, and child rearing
      • Choice of alternative lifestyle (e.g., homosexuality)

Age Specific Considerations for the Healthcare Professional:

      • Assess for physical and mental health, self-esteem, family roles, support system
      • Emphasize the continued need for checkups, screenings, and immunizations
      • Use teaching methods that won‘t challenge self-concept
      • Explain the importance of compliance by relating to patient‘s life
      • Encourage family participation in patient care and education
      • Encourage expression of feelings and concerns
      • Educate in accident prevention and healthy lifestyle (e.g. weight control, exercise,
      nutrition, stress reduction) and explain benefits
      • Monitor for abuse

Middle Adult (40-64)

Psychosocial Achievements and Normal Growth and Development:

      •   Slow decline in body functions
      •   Degenerative changes (hair loss, eyesight, bearing), atrophy of reproductive system
      •   Menopause
      •   Develops concern for next generation
      •   May seek further education or career change
      •   Reflects on life and accomplishments

Health Concerns

      • Chronic disease (cardiovascular disease, arthritis, osteoporosis, diabetes, hypertension,
      lung disease), cancer, obesity may occur secondary to reduced metabolic rate, depression,
      substance abuse

                                                 MayDay Staffing Solutions
                                            ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111       website:           Fax: (661) 309-9073

Unique Challenges:

      • Making adjustments to middle age‘s physical changes
      • Maintaining satisfactory employment, then preparing for retirement and leisure
      • Maintaining satisfying relationships and social and civic responsibilities
      • May be caring for aging parents as well as children
      • Empty nest issues
      • Adjusting to being a grandparent

Age Specific Considerations for the Healthcare Professional:

      • Physical and mental health assessment to include physical changes/loss, family and social
      roles, career, self esteem
      • Continued monitoring for abuse
      • Encourage checkups, screenings, and immunizations
      • Promote as much self-care as possible and include significant other family in education
      and care when appropriate
      • Begin teaching about advance medical directives
      • Allow time to verbalize fears and concerns
      • Educate in accident prevention and healthy lifestyle (e.g. weight control, exercise,
      nutrition, stress reduction). safe use of medications
      • Assist in finding resources to meet Healthcare needs and costs

Older Adult (65-and older)

Psychosocial Achievements and Normal Growth and Development:

      •   Requires more sleep
      •   May have reduced attention span and memory
      •   May feel isolated or upset by loss (friends, family, sensory abilities or financial)
      •   Need for acceptance of their worth and satisfaction with accomplishments

Health Concerns:

      • Decreased mobility, joint pain, brittle bones
      • At greater risk for poor nutrition, dehydration, infections
      • Changes in skin, muscles, and sensory abilities
      • Chronic diseases as mentioned previously, but also including Alzheimer‘s, glaucoma,
      cataracts, and benign prostatic hypertrophy, fractures
      • Recovery from illness takes longer
      • More prone to adverse drug reactions
      • May present with atypical or vague symptoms making diagnosis difficult
      • Despair/depression

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Unique Challenges:

       •   May lose self-confidence as abilities decline
       •   Increased need for safety because of decreased cognition and mobility
       •   May need smaller, more frequent meals
       •   Maintaining leisure activities and social relationships
       •   Coming to terms with death

Age Specific Considerations for the Healthcare Professional:

       • Physical and mental health assessment to include screening for abuse and neglect,
       physical changes of aging, financial stability, loss & role changes, support system
       • May need to present information in a slower manner, in smaller segments, repeat a
       number of times, and avoid distractions
       • Use large print materials, simple pictures and medication dose calendars/aids
       • Encourage self-care and decisions
       • Ask questions to determine level of comprehension don‘t assume understanding
       • Involve family in education and care
       • Encourage checkups, screenings and immunizations
       • Ensure safety
       • Encourage physical and social activity and reminiscing


While it is not advised to stereotype patients, it is necessary to modify patient care based on
various characteristics These characteristics will include personal, cultural, religious and those
which are related to age. The guidelines given here should help the Healthcare professional to
provide individualized patient care based on the typical characteristics of the age group of the
patient and any significant others. In combination with other personal considerations, the
healthcare professional will be able to provide for the welfare of the total patient.

Go to the Mandatory Education Test booklet and complete the test for “Age Specific
Competency” before moving on to the next section.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Cultural Competency

Cultural Competency is achieved when the Healthcare professional employs a set of attitudes,
behaviors, policies, and skills in order to provide care in a cross-cultural environment. It is
reflective of the caregiver‘s ability to acquire and use knowledge of the clients preferred
communication method, healthcare beliefs and practices, and cultural attitudes and values.


It is imperative to become conscious of one‘s own cultural attitudes in order to begin to learn and
understand those of another culture. It is not an easy task to ask ourselves if we maintain
negative stereotypes and prejudices that might keep us from treating every individual with the
respect he or she deserves. However, it is necessary to be completely honest in order to
understand the possible biases we may be harboring, either intentionally or unintentionally. By
facing the positive and negative assumptions we may have made about those who are culturally
different from us, we are then free to move forward to learn about and care for our patients with
respect and understanding. It is difficult, if not impossible, to totally dismiss our deeply rooted
assumptions regarding race, ethnicity, culture, age, social and language skills, economic status,
gender, sexual orientation, and ability/disability. A conscientious Healthcare professional must first
learn to recognize his/her own assumptions and prejudices and then ensure that these
assumptions do not interfere with caring for the patient.


While it is important to recognize some of the cultural beliefs and practices of the population that
you regularly serve, it is impossible to know everything about every culture with which you may
come in contact. With today‘s mobile society, there is a real possibility of encountering persons
from anywhere around the globe. Healthcare professionals must be prepared to care for a refugee
from Bosnia with Post-traumatic Stress Disorder, an immigrant from China who speaks little or no
English, or a Native American who has been using traditional medicine to treat an illness. One
must also bear in mind that each patient comes from a unique background with his/her own
individual history, beliefs, health status, and communication style, regardless of any similarities to
a cultural group. The healthcare professional must be careful not to stereotype any one person
because of their cultural affiliation, but to treat each patient as an individual whose
understanding and practices may have been influenced by his/her culture In order to treat each
patient with respect and sensitivity, the Healthcare professional must learn ways to discover which
behaviors are acceptable to the patient and which are not, how best to communicate with the
patient, and what roles the family or a significant other play. For example, in some Asian cultures,
it is impolite to make eye contact with an elder or someone who is considered to be superior (such
as a doctor). In some Middle Eastern cultures, the husband speaks for the wife and tells her any

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

information given him by the Healthcare team. In either of these cases, it is important to take cues
from the patient or family member and/or ask respectfully to whom you should speak. It is also
important to be careful of body language and non-verbal hand signals, which may be interpreted
differently then the way they were intended. Some Chinese, for example, smile when they are
uncomfortable or discussing something sad. In other cultures, the widely used American ―OK‖ sign
can be highly offensive; for example, in Japan, it means money.

Again, take cues from your patient and be in tune to his/her body language and personal space.
Be attentive to greetings (some cultures may bow instead of shaking hands) and touching. You
may have found that while some patients are comforted by your touch, others may find it
uncomfortable or disrespectful. Many people from the Middle East and Western Asia do not like to
be touched on the head. Remember, cultural differences are not only found within populations
from other countries, but exist within religious, sexual, and economic communities within the US.
You must, for example, be sensitive to the efficacy of nutritional teaching within an impoverished
rural population, where there is limited Healthcare access and a low level of education.


1. Language and Communication

For non-English speaking patients, using an interpreter is the best possible solution (if one is
available). In such cases, it is important that he/she provide accurate, sensitive, two- way
communication and is able to uncover any areas of uncertainty or discomfort. An interpreter
should be knowledgeable in appropriate medical terminology and should not add his/her own
opinions. It is inappropriate to have a family member serve as an interpreter because they may be
too emotionally involved and may not have the technical knowledge to accurately convey the
provider‘s message. Also, some cultures prohibit the discussion of certain topics between parents,
children, or members of the opposite sex. It is often ―embarrassing‖ or simply disrespectful to
discuss these matters. It is important to understand that unspoken language is just as important
as verbal communication. As previously discussed, it is important to take cues from the patient:
when in doubt, ask appropriate questions such as: ―What would you like me to call you‘‖ or ―Is
there a family member we should include or speak with?‖ Respect the patient‘s personal space and
refrain from using hand signals that may have a different meaning in that person‘s culture.

2. Level of Education

The levels of education among members of the same cultural population can vary widely. The
Healthcare professional must be careful not to make assumptions based on other members of a
particular group who they may have encountered previously. The level of education may be
different based on age, geographical location, necessity, or other beliefs. A patient‘s level of
education will greatly influence the Healthcare provider‘s approach to assessment, treatment, and
overall care.

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3. Understanding the Causes of illness

Most people will accept treatment for health conditions based on their beliefs surrounding the
cause of the condition. Some members of a society, but not all, may adhere to traditional health
beliefs and practices. These beliefs and practices may be more common among those people who
have had little or no exposure to ―modern medicine.‖ Immigrants who have been in this country
for a long period of time may have experienced some of the health and medical practices used
here and may mingle them with their traditional practices. Some patients may feel more
comfortable if offered a combination of traditional practices and modern medicine. At the very
least, patients should be offered treatments that do not conflict with their traditional beliefs. The
following are some examples of traditional beliefs regarding the cause(s) of illness. Because these
are "traditional‖ beliefs and practices, it cannot necessarily be assumed that all members of a
given culture subscribe to all of the beliefs or practices.


       • In some Hispanic groups, it is believed that illness or disease is caused by an
       imbalance between hot and cold. In order to maintain good health, one must avoid
       exposure to extreme temperatures and consume appropriate foods and beverages
       Examples of ―cold‖ diseases include colic, menstrual cramps, and pneumonia: examples of
       ―hot‖ diseases/conditions would be pregnancy, diabetes, hypertension, and indigestion. The
       basis of treatment involves restoring balance, which is achieved by employing the
       appropriate ―hot‖ or ―cold‖ remedy. A ―hot‖ disease is counterbalanced by a ―cold‖ remedy
       and vice versa.

       • Some Chinese believe that illness stems from their ancestors or a divine being, in
       retribution for the person‘s wrongdoings or negligent behavior. Other beliefs include illness
       being caused by cosmic disharmony as a result of the poor combination of birth year,
       month, day, and time. A disharmony may also arise due to poor Feng Shui, which relates to
       the proper placement of objects within a room or house or the orientation (direction) of the
       house or room itself.

       • Individuals of Pacific Island origin believe in ―mana,‖ which describes the special life force
       or a special power that, when lost, can cause illness. In order to restore an imbalance of
       mana and attain healing, one must analyze damaged relationships within one‘s self,
       extended family, ancestors, environment, or spirituality

       • The ―evil eye‖ is recognized in many cultures as the cause of a variety of illnesses.

4. Treatments, Cures and Cultural Remedies for Illnesses and Injuries

The following are some examples of traditional belief regarding various traditional cures,
treatments and remedies for illnesses and conditions. Again, it cannot be assumed that all
members of a given society will subscribe to all of its practices.

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• Some members of the Middle Eastern culture are Muslims who, if devout, may pray five
times a day beginning before sunrise and ending after sundown. They may also fast, taking
no food or drink between sunrise and sunset during the holy month of Ramadan. This
practice may conflict with taking medications (including injections).

• Some Native American/Alaskan Natives practice sacred ceremonies for healing. These
ceremonies may include using plants and objects that are symbolic of the illness, the
person, or the treatment and often rely on having ―visions.‖ Chanting, prayer, sand
painting, dancing, and herbs are parts of traditional Navajo medicine. Many Native
American tribes cure a variety of physical and emotional ills by using a ―sweat lodge.‖

• Chinese medicine often combines Western medicine, dietary and supernatural healing
along with traditional therapies such as acupuncture, acupressure, and herbs. Some
Chinese patients fear disapproval by Western Healthcare professionals and fail to reveal the
use of such traditional practices.

• In some Pacific Island cultures, it is believed that using a traditional food called "taro‖ is
healthful because it holds great mana.

• Among some East African cultures, therapeutic burning maybe used to treat jaundice or
abdominal problems that may have been caused by the evil eye. These Burns often seen
on children, are administered along the abdomen, wrists, elbows and ankles, and if not
clearly understood and recognized, may be confused as being abuse injuries.

• Traditional folk remedies from many Hispanic countries include the use of herbs and
foods, such as the use of garlic to treat hypertension and cough; stomach massage and tea
to treat loss of appetite, stomach pain or diarrhea; chamomile tea for anxiety, colic, gas,
and nausea; and peppermint to treat gas

• Eastern Europeans eat honey and pollen to ensure longevity. Traditional healing
approaches include treatments using teas, herbs, grasses, and ointments

• In Cambodia, some people use the following techniques for healing a wide range of
ailments. ―Cupping‖ refers to placing a heated cup on the skin (usually the forehead or
abdomen) to draw out the evil energy or air into the cup as it cools. This practice will leave
some type of mark or scar. ―Pinching‖ produces a contusion at the base of the nose, on the
chest, neck or back, or between the eyes, where the skin has been squeezed tightly
between the thumb and forefinger. The rubbing of the side of a coin against the skin to
cause striations or ecchymosis is called "coining.‖ Sensitive investigation is necessary to
prevent labeling these remedies as abuse.

• Practices involving pregnancy and childbirth:

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               o The concept of the evil eye is a common part of the belief system of many African
               cultures. It is believed that by giving praise to a person, the evil eye can be either
               purposely or inadvertently directed to that person. The evil eye can then cause
               harm or illness. Somali women, for example, become fearful when comments are
               made regarding the beauty or size of their infants. They fear these compliments
               may bring on the evil eye, causing something had to happen to their child. Somali
               mothers much prefer to bear that their child looks ―healthy.‖

               o In 28 African countries, Female Genital Mutilation (FGM) is regularly practiced.
               This practice may cause a number of medical complications and many women
               who have experienced FGM do not want to speak about it.

               o Many Chinese women believe that they lose body heat giving birth and must
               replace it by eating hot soups for six weeks or more.

               o Hindus often feed a mixture of breast milk and cow‘s milk to their infants because
               cows are considered sacred.

5. The Role of Family, Friends, and Community

A patient may have certain beliefs and traditions when it comes to the people involved in their care
and treatment while ill or hospitalized. It is important that the Healthcare professional to be aware
of the social structure within the patient‘s culture in order to accommodate for appropriate family
and community support. For example, in South Asia, extended families traditionally live under one
roof. These close family members may be needed at the bedside to show their support, and the
patient may feel more comfortable with the family present and therefore recover more quickly.
Hispanic traditions are much the same, often relying on family members, godparents, and
―compadres‖ (close friends) to consult with the patient regarding illness or injury, as well as to
attend medical visits. Central Asians are very concerned with family honor and may not mention
what they consider to be a disgraceful condition, such as a pregnancy out of wedlock, mental
illness, or venereal disease. These conditions may go untreated if the caregiver is not a savvy
interviewer. Culturally sensitive Healthcare professionals should also make allowances in their
policies for family members being present and bringing important items including foods,
recognizing that this support is necessary in the healing process.

6. The Role Of a “Healer” or Spiritual Entity
Respecting the spiritual aspect of a patient‘s belief system is essential to the well-being of the
patient. Take the time to ask the patient if his/her spiritual needs are being met and how you can
assist in meeting those needs. Don‘t be afraid to ask questions but do be careful not to show any
personal judgment. An example of the spiritual traditions of the ill includes the Muslim tradition of
days of prayers for a sick and dying member of the family. When the family is able to be present,
a Muslim prayer leader, or Imam, is called in to be with the patient.

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7. Death and Dying

Two activities common to all humans and thus, all cultures, are birth and death. What is not
common is the concept of death itself and how a given culture may respond to it. Native
Americans and some Buddhists believe that there is a co-existence between the dead and the
living and that the dead have an influence over the well-being of the living. Hindus see death as
part of a cycle where the person is re-born into a new identity. The Trukese of Micronesia believe
that when a person reaches age 40, life is over and one must prepare for physical death from that
point on. From age 40 onwards the person is considered to be ―dead,‖ even though they are
physically alive. Christians believe that at the time of death, a persons‘ spirit leaves the body and is
either rewarded in heaven or suffers in hell, depending on that person‘s faithfulness or sinfulness
while on earth. In other cultures, death is an abrupt and final disengagement from this life. In still
other groups, talk of the deceased or even mentioning the person‘s name may endanger the
survivors‘ lives or prevent the deceased from leaving the earth and achieving peace.

It is important to be aware of the many concepts of death because this will shape how a person
behaves while alive. It will also determine how a person approaches Healthcare. It is necessary to
be sensitive to others‘ beliefs regarding death and dying in order to help patients and their families
through the bereavement process. This is important even before death occurs. Muslims spend
days in prayer prior to a person‘s death. After the person dies, the family washes the body and
buries it as soon as possible. In Islamic tradition, embalming and cremation are not allowed.
Patients and families must be allowed to grieve in their own unique way. Some cultures mourn
their dead by shaving their heads, wearing white or black clothing, and may show their grief for a
specific amount of time. Other cultures express their bereavement by dancing, drinking and, if
they are in a certain position of kinship, marrying the widowed spouse. And, in yet other cultures,
it is appropriate for the mourner(s) to wear certain clothing, perform rituals, and accept a new and
different status in the society. These are all normal ways for people within a cultural group to
understand and support each other following a death. What is considered ―normal‘ is based on the
standards of the culture. An Egyptian mother deeply mourning the death of a child for seven years
is normal if judged so by her society, while the same may be true for a Balinese person who
seemingly ―laughs off‖ a death because expressions of sorrow are forbidden in that culture. What
is considered normal or abnormal grief may only be judged by the standards of the grieving
person‘s cultural group.


Once a Healthcare professional recognizes and understands his/her own cultural beliefs, it is easier
to move forward in recognizing, accepting, and incorporating into healthcare, those beliefs and
practices of another culture. The following is a useful tool that may be helpful to gain appropriate
knowledge and effectively assess and treat a patient who is a member of another culture.


A framework for culturally competent clinical practice

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       • Explanation: What do you think may be the reason you have this problem? What do
       friends, family, and others say about your symptoms? Do you know anyone else who has
       had or who now has this kind of problem? Have you heard about/read about/seen it on
       TV/radio/newspaper? (If patients cannot offer an explanation, ask what most concerns
       them about their problems.)

       •Treatments: What kinds of medicines, home remedies, or other treatments have you
       tried? Is there anything you eat, drink, do or avoid on a regular basis to stay healthy? Tell
       me about it. What kind of treatment are you seeking from me?

       • Healers: Have you sought any advice from alternate or folk healers, friends, or other
       people who are not doctors for help with your problems? Tell me about it.

       • Negotiate: Try to find options that will be mutually acceptable to you and your patient
       and that incorporate the patient‘s beliefs, rather than contradicting them.

       • Intervention: Determine an Intervention with your patient that may incorporate alternate
       treatments, spirituality, and healers as well as other cultural practices (e.g. foods eaten or
       avoided in general and/or when sick).

       • Collaboration: Collaborate with the patient, family members, other Healthcare team
       members, healers, and community resources


It is extremely important to remember that there is not ―one way‖ to treat any cultural group. It is
imperative to develop a plan for individualizing healthcare based on a person‘s cultural heritage as
well as his/her individual thoughts and beliefs. Through culturally sensitive care, the healthcare
professional can provide an experience that is both comfortable and satisfying, while promoting
optimal health for the patient.

Go to the Mandatory Education lest booklet and complete the test for “Cultural Competency”
before moving on to the next section.

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Restraints and Seclusion
The use of restraints and seclusion can both help and harm a patient. Patients have specific rights
that protect them from the use of seclusion or restraint as a means of coercion, discipline,
convenience, or retaliation by staff. There are standards guiding the use of restraints and
seclusion that have been set forth by both the Health Care Financing Administration (HCFA) and
the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). These standards
include policy and protocol to be mandated by the individual institution and state. It is important
for healthcare professionals to be aware of these standards as well as the individual policies of the
institution and state in which they are working.


Restraint: Any method of physically restricting a person‘s freedom of movement, physical activity
or normal access to his or her body. A physical restraint is a device, material, or equipment
attached or adjacent to the patient‘s body, which he or she cannot easily remove. Restraints may
include medication that is used to control behavior or restrict freedom of movement that is not a
standard treatment for the patient‘s medical or psychiatric condition.

Seclusion: The involuntary, solitary confinement of a person in a room or an area from which the
person cannot physically leave.

Before restraints or seclusion may be initiated, careful assessment of the patient must be made in
order to determine the clinical appropriateness. All efforts to use other preventive strategies or
alternatives must be made first. The use of restraints and seclusion can potentially cause
physical and psychological harm, loss of dignity, violation of an individual‘s rights, and even death.
Appropriate use can prevent an individual from harming himself, herself, or others (including
staff), and may be justifiably employed as part of a patient‘s planned care.

Restraints and/or seclusion may be used:

       • To improve a patient‘s well-being
       • When less restrictive interventions are determined to be ineffective
       • To protect the patient from harm
       • To protect others from harm
       • In response to emergent and/or dangerous behavior
       • In patients with addictive disorders
       • As a part of planned care
       • As a pan of standard practice (such as to prevent a postoperative patient from
       removing an endotracheal tube, IV, or other medically necessary device)

Restraints and/or seclusion should not be used as a means of
• Coercion

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• Convenience to staff
• Retaliation
• discipline or punishment


All patients have the right to respectful care that maintains his or her dignity. Restraints and
seclusion can potentially have serious adverse effects on the patient by restricting these rights.
Each use of restraints and seclusion must consider whether:

       •   The   patient is respected as an individual
       •   The   environment is safe and clean
       •   The   patient is able to participate in his or her own care, and care is able to continue
       •   The   patient‘s modesty, visibility, and comfortable body temperature are maintained
       •   The   patient‘s needs are met, including adequate exercise, nourishment and personal care


Standards for the use of restraints and seclusion vary based on the patient‘s need. There are two
defined areas of usage for restraints and seclusion: Behavioral Health Patients and Acute
Medical Surgical (Non-psychiatric) Care.

Many of the rules are the same, but some rules do not apply to one situation or the other or are
specific rules needed for a unique situation. It is important to know the rules as they pertain to the
needs of the patient. For example, patients undergoing medical or surgical procedures may require
restraint to prevent harm. This would be considered Acute Medical Surgical (Non-psychiatric) care.
On the occasion when a patient‘s behavior becomes unexpectedly aggressive or destructive,
restraints or seclusion may be necessary as an emergency measure to protect the patient or
others. This emergency use would be considered ―behavioral‖ use of restraint or seclusion.

You will notice the terminology refers to restraints and seclusion for behavioral patients and
restraints for acute medical surgical patients. This is because seclusion would not be an effective
intervention for acute medical/surgical patients.

The following standards apply to the use of restraints for Acute Medical Surgical Patients and both
restraints and seclusion for Behavioral Patients:

       1. Choose when other less restrictive measures have been found ineffective in protecting
       the patient or others from harm.
       2. Use in accordance with the order of a physician or licensed independent practitioner (LP)
       that has been permitted by the facility and/or state to order restraints and/or seclusion.
       3. Never write orders as a standing order or on an as needed basis (PRN).
       4 Consult the patient‘s treating physician as soon as possible if ordered by a non-treating
       5. Use in accordance with a written modification of the patient‘s care plan.

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       6. Implement in the least restrictive manner possible.
       7. Use in accordance with safe and appropriate restraining techniques
       8. End at the earliest possible time.
       9. Continually assess, monitor, and reevaluate the patient.
       10 Train staff with direct patient contact in proper and safe use on an ongoing basis.
       11. Document use in the patient‘s medical record and reflect facility policy.


The following additional standards apply to restraints and seclusion for patients receiving
behavioral Healthcare:

1. Within 1 hour of initiation, a physician or LP must see the patient and evaluate the need for
restraints or seclusion.

2. Written orders for restraints and seclusion are limited to:
       • 4 hours for adults
       • 2 hours for children and adolescents ages 9-17
       • 1 hour for patients under age 9

3. Continuation of orders may be renewed for the same time periods as above, up to a total of 24
hours. A face-to-face reassessment by an LP is necessary after the original order expires, and if
necessary, the LP may write a new order to continue restraints or seclusion. The order and/or
facility policy will determine who (such as an RN) may reassess the patient and make a decision to
continue restraints or seclusion.

4. Monitoring of the patient is to be continuous or no less often than every 15 minutes.

5. Reassessment related to monitoring will determine the patient‘s well being.

6. Reassessment related to time-limited orders will determine the need for continued use.

 7. If staff has used appropriate criteria to terminate restraints or seclusion early, and the same
behavior is evident, the original order may be reapplied.

 8. Restraints and seclusion may only be used simultaneously if the patient is continuously
monitored by a staff member either face-to-face or by video and audio equipment that is close to
the patient.


The following standards apply to the use of restraints for patients receiving acute medical surgical
(non-psychiatric) care:

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1. An RN may initiate justifiable use of restraint but written or verbal order must be obtained from
a LP within 12 hours. A written order must be charted within 24 hours

2. Continued restraint must be authorized by an LP every 24 hours after examination of the

3. Monitoring occurs at a minimum of every 2 hours and is accomplished by observation,
interaction or direct examination of the patient. Monitoring will determine:

       • The patient‘s physical and emotional well-being
       • Maintenance of the patient‘s rights, dignity, and safety
       • Possible use of less restrictive methods
       • A change in behavior or clinical condition that nay indicate readiness for removal of
       • If restraints have been properly applied, removed, or re-applied

4. The facility may establish its own ―protocols‖ for certain specific conditions (e.g. intubation or
post-traumatic brain injury) where restraint may be necessary to prevent the patient from harming
themselves or interfering with lifesaving medical intervention. Such protocols will authorize a
certain staff member to initiate, maintain and terminate restraint without an order, but only when
the guidelines for clinical justification have been met. The protocol will also provide guidance with
regards to assessment of the patient, criteria for restraint application, criteria for monitoring and
reassessing the patient, and terminating the restraint. Initiating restraint without such a protocol
requires an order from an LP.

Documentation of the use of restraints and seclusion must be made in the patient‘s medical record
and must be consistent with the facility‘s policies. Typically, documentation will include:

       •   Documentation of each episode of use
       •   Clinical justification for use
       •   Results of patient monitoring and reassessment
       •   Significant changes in patient condition
       •   Adherence to facility policy and procedure
       •   Reference to the specific protocol when restraint is used as part of a protocol
       •   Measures taken to protect the rights of the patient

Many of the rules regulating restraints and seclusion will be specific to the facility in which you are
working and will affect your responsibilities in your specific Healthcare capacity. For
example, facilities will have a policy that has been constructed in conjunction with state law to
determine who is authorized to give, receive, and record verbal orders. Therefore, Healthcare
professionals (such as RNs, LPNs, and Mental Health Technicians) must determine whether they
are allowed to accept verbal orders for restraints and seclusion and from whom, the treating
physician, another LP, or a resident. Hospital policy will also define ―protocols‖ that contain

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restraint policies and do not call for a specific physician order. It is each Healthcare
professional‘s responsibility to know these protocols as they pertain to his or her own job duties.
Also, these protocols must be specifically referenced when documented in the patient‘s medical

Each facility will also have its preferences in the types of restraints used, and this will require
training. It is imperative for all Healthcare professionals to obtain training on a regular basis and to
be competent in the correct application method of the restraints they are using. JCAHO stipulates
that facilities provide staff orientation, which not only provides ongoing education in prevention
and appropriate use, but also encourages the use of alternatives to restraints and seclusion. You
may be able to avoid use of restraints and seclusion through use of other interventions. As
previously stated, these alternative methods should be exhausted before restraints and seclusion
are used.

As a member of a vital and dynamic Healthcare team, you should be prepared to assist in the
development of improved procedures and policies regarding the use of restraints and seclusion,
including minimizing their use and testing alternatives.


In summary, restraints and seclusion can be helpful tools in protecting patients and staff from
harm. They may be included in the patient‘s plan of care in order to bring about the best possible

Healthcare professionals must carefully assess an individual‘s condition and exhaust all other
alternatives before choosing to use restraints and/or seclusion. The use of restraints and seclusion
are a potential cause for harm, limitation of rights and dignity, and may cause the patient to
experience feelings of isolation and a decrease in well-being.

When clinically justifiable, the least restrictive methods of restraints and seclusion should be
selected first. The patient must be continuously monitored and reassessed, and the use of
restraints and seclusion must be discontinued at the earliest possible time.

Policy and protocols must be followed per each facility, and the Healthcare professional must
obtain ongoing training and be competent in the application, monitoring, and termination of
restraints and seclusion. The Healthcare professional must also be aware of the hospital policy
governing who may give, receive and record orders for restraints and seclusion. With these
standards in mind, patients will receive competent care that respects the rights and dignity of the

Go to the Mandatory Education Test booklet and complete the test for “Restraints and
Seclusion” before moving on to the next section.

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Abuse across the Lifespan: the Healthcare Professional’s Role
As a healthcare worker, you may be the first point of contact for a person suffering from abuse.
Abuse comes in many forms and affects all ages, and socio-economic and cultural groups. 95-98%
of abuse is directed against women and children, however, men may also be victims. Abuse
includes physical and emotional violence, sexual assault, and neglect. As a healthcare worker, you
need to be able to recognize the signs of abuse so that you can offer available resources, and in
cases where mandated by law, report your suspicion.

More than three million cases of alleged child maltreatment were reported in 1997. Child abuse is
most often inflicted by a parent or another relative. Child abuse is defined as -

A child who is less than 18 years of age whose parent or legal guardian has:

       • Inflicted or allowed infliction of physical injury that could cause death or impairment of
       • Created or allowed to be created a substantial risk of injury
       • Committed or has allowed to be committed a sex offense against the child or permits or
       encourages the child to engage in acts such as prostitution or incest.

Federal regulation defines abuse as the ―willful infliction of injury, unreasonable confinement,
intimidation or punishment with resulting physical harm, pain, or mental anguish.‖

Injuries are typical and normal in childhood; It is not always easy to discern an accidental injury
from an injury that has been intentionally inflicted. While there is no specific profile for an abused
child, there are some warning signs or ―red flags‖ that can signal the need for further assessment
and investigation. Some of these warning signs of child abuse are:

               • Shaken baby syndrome, which may be suspected in cases of subdural hematoma,
               neurological trauma, and retinal bleeding. Head injury is the number one cause of
               death in child abuse.

               • Parent‘s description of the incident does not match the injury or does not match
               the other parent‘s description. Description may be vague regarding circumstances of
               the accident.

               • Blame is placed on another person, such as a sitter, neighbor, or another child.

               • Parents claim the injury was self-inflicted (infant under 6 months of age).

               • A significant amount of time has passed before injury is reported.

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       • The same injuries or ingestion of toxins are repeated.

• A history of numerous accidents (treated by different doctors and hospitals).

• Fractures in multiple stages of healing are a classic injury of abuse.

• Bruises or contusions from objects that may leave an imprint, such as belt buckles, iron,
hands, cigarette burns, whip or loop bruises from electrical cords, grab marks on arms or
shoulders, absence of hair from pulling of hair, broken or loose teeth.

• Delineated burns such as a ―stocking" burn where the child‘s limbs are held in a scalding
hot liquid.

• Child‘s explanation of the incident is identical to parent/caretaker's, indicating ―coaching.‖

• Injuries due to sexual abuse such as anal fissures, perineal tears, or venereal disease.
There may also be a regression to bed-wetting, recurrent urinary tract and yeast infections,
pregnancy, bite marks or bruises, torn, stained or bloody underclothing.

• Signs of neglect such as poor hygiene, severe or chronic diaper rash, pale or
malnourished looking, consistent hunger, dehydration, child is well below normal height
and weight for age, lack of supervision, clothing inappropriate for the weather, unattended
medical/dental needs, alcohol or drug abuse.

• Signs of restraint such as bruises around the mouth from gagging, blisters or bruises
around the ankles or wrists caused by rope or wire.


The child may also be sending signals that can indicate abuse. An older child may exhibit
behavioral signs that are red flags. Some of these behaviors include:
       • Inappropriate behaviors for the child‘s age, lags in physical, mental or emotional

       • Wariness of contact with parent/caretaker (suspected abuser)

       • Anxious or fearful when hearing other children cry

       • Mood swings, depression, withdrawal, apathy, obsessions, phobias, compulsions,
       hypochondria, and/or suicidal thoughts mentioned

       • Fearful of adults, afraid to speak in their presence, afraid to go home

       • Sell-inflicted injuries

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               • Unwillingness to remove clothes; seductive or promiscuous behaviors

       As a direct result of abuse and neglect, children often may die at the hands of their
       caretakers. In most cases the abuser is a family member, and some children may be at a
       higher risk for abuse. For example, children of single parents have an 87% greater risk of
       being harmed by physical neglect. And while abusers come from all socioeconomic
       backgrounds, children in families with an income of below $15,000 were 22 times more
       likely to be abused than from those making over $30,000. Certain other factors may put
       adults at risk for becoming abusers. These following adult behaviors or indicators may merit
       further investigation:

       • The adult is or has been a victim of abuse. 50% of children are abused in households
       where the mother is a victim.

       • An adolescent parent with lack of parenting skills, immaturity, and unrealistic expectations
       of a child such as potty training, ability to stop crying, and/or feeding self.

       • Adult has unmet emotional needs, is isolated, and/or has poor impulse control.

       • Adult is experiencing a life crisis such as unemployment, death of a loved one, divorce, or
       housing problems.

       • Adult is involved in substance abuse.

       • The adult gives an improbable explanation of the cause of the injury, is vague, or
       changes the story.

       • The adult has mostly negative things to say about the child.

       • Refuses to give consent for further examination of the child.


Once the Healthcare worker suspects child abuse, the question is how and when to report it. Laws
vary from state to state and include different wording and descriptions of abuse. It is imperative
that you are familiar with the laws in the state in which you are working, as well as the policies of
your facility. Generally speaking, you will be required to report suspected abuse to a supervisor.
You will also be required to document your findings including to whom and when you made your
report. In most cases, you will need to make your report immediately. Many healthcare workers
fear that they may be held liable in reporting a suspected case of child abuse. In fact, good faith
reporting typically protects the Healthcare worker from prosecution. It is the case that should have
been reported, but wasn‘t, and that could lead to legal action against the Healthcare worker.

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Generally speaking, you are obligated to report the abuse if you have:
1) reasonable cause to suspect child abuse
2) a parent or legal guardian states to you that the child is being abused or
3) as a supervisor, you are notified by a staff member of suspected abuse.


Because abuse is cyclical, occurring in households where the adult abuser was also a victim, the
sooner the cycle is broken, the better the chance for the child and future generations. As a
Healthcare worker you can, and often are legally bound to, recognize abuse and report it. Make
sure that you fully understand the laws in the state of your employment and know the reporting
procedures at your facility. You must take your responsibility seriously, knowing that you might be
the one person who can stop the cycle of abuse.

Go to the Mandatory Education Test booklet and complete the test for “Child Abuse” before
moving on to the next section.

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
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It is estimated that every 15 seconds an incident of domestic violence occurs in the United States.
It is the leading cause of injury to women in a society that is family-centered, where the home is a
place of security and safety, it is a tragic fact that victims of domestic violence find the home a
place of danger. Violence by a stranger does not provoke the same feelings of fear, loyalty, love,
guilt and shame that domestic violence does. Adult victims are torn between the desire to shield
and help a loved one and the need to protect their own safety. Children are faced with the cold
fact that those who should protect them are in reality, a source of harm. These are reasons why
domestic violence is one of the most under-reported crimes in the country.


       • Domestic violence may focus on physical harm, but may include other forms of abuse
       such as isolation, intimidation, humiliation, criticism, derogatory remarks, withholding
       warmth, affection, and financial support. Sexual violence includes nonconsensual sex as
       well as harm inflicted by the partner during sex.

       • Yearly, 3-4 million women are abused by a partner.

       • Common among physically and mentally handicapped.

       • May occur in any age group from fetus to elderly.

       • 1 in 10 cases of sexual abuse are reported, perhaps because it is the only situation where
       the victim must prove innocence.


The healthcare worker is most often the first contact for a victim of domestic violence. While we
tend to think that a victim is most likely to seek help in an ER or clinic, many seek treatment for
injuries at a physician‘s office, especially an obstetrician‘s office. Routine screening of all patients
should be practiced in all Healthcare settings. You must learn the regulations for the state in which
you practice and also at the facility where you work. Screening all patients eliminates some of the
guesswork necessary in identifying victims of domestic violence. It is important to be able to
identify the signs of a person experiencing abuse which may include:

       • Trauma or burn inconsistent with explanation may be vague or evasive and protective of
       • Bruises in various stages of healing, multiple injuries
       • History of frequent ER visits or ―accident prone‖

                                               MayDay Staffing Solutions
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       • Chronic pain, psychosomatic, repetitive or vague complaints
       • Sleep/eating disorders
       • Pregnancy complications or early labor/miscarriage(s)
       • Suicide attempt or ideation; homicidal ideation
       • Substance abuse
       • Uncontrolled emotions, anxiety, depression, and/or emptiness
       • Passive behavior, poor self-esteem, and/or lack of eye contact
       • Noncompliance with medication or therapies (may not be permitted to obtain or go)
       • Delay in reporting injury (unable to seek medical attention)
       • Central injuries are more Common in abuse than ―peripheral‖ (arms and legs) injuries,
       which are more commonly accidental. 89% of injuries are to the head and face, followed
       by abdomen and chest at 32.5%.

You may be able to identity‘ an abusive situation by recognizing some common traits exhibited by
the abuser. These traits include:

       •   The need to gain and maintain power through control
       •   Violence in the family of origin
       •   Low tolerance for frustration
       •   Aggressive behavior
       •   Antisocial or sadistic behavior
       •   Domineering and/or meticulous behaviors; making unrealistic demands
       •   Refusal to leave victim alone

Screening for abuse should be accepting and empathetic. Provide privacy, even if this means
―assisting‖ the patient to the bathroom to separate her from a partner who refuses to leave.
Questions should be non-accusatory, simple. and direct. Let the patient know that these are
routine questions you ask of everyone and should not be misinterpreted as suspicion. Let the
patient know you are able to offer safety and resources for help should they be needed or
requested. Don‘t discount your questions by making statements such as, ―I know you don‘t have
this problem but I am required to ask everyone.‖

In most cases the victim will not admit to domestic violence for fear of retaliation and/or because
of the fusing of love, caring, and pain. In other cases, denial plays a big role as a result of fear,
guilt, shame, and hope for change or continued love of the abuser. As a therapeutic Healthcare
provider, you should incorporate the following into your screening:

       • Active listening skills; be nonjudgmental.
       • Communication with sensitivity.
       • Validation of the victim‘s experiences.
       • Encouragement to seek help.
       • Provide information as needed. Do not insist that the victim take information with them
       because if found by the abuser, it could create more problems.
       • Delay in reporting injury (unable to seek medical attention).
       • Central injuries are more common in abuse than "peripheral‖ (arms and legs) injuries,

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       which are more commonly accidental. 89% of injuries are to the head and face,
       followed by abdomen and chest at 32.5%.


Your goal is to identify and report domestic violence (as required by the law in your state of
employment). As Healthcare workers, we often seek to solve the problem as well. You can only be
expected to assess, screen, and supply information to the best of your ability. The average victim
of abuse leaves their relationship 2 - 5 times before ending it permanently. Most victims fear
retaliation or are unable to provide for themselves if they leave the relationship. Attempting to
leave an abusive situation has been identified as the most dangerous time for a victim. While this
may be frustrating to you as the Healthcare worker, you must support the patient‘s right to make
his or her own decisions.

Go to the Mandatory Education Test booklet and complete the test for “Domestic Violence”
before moving on to the next section.


Fortunately, older people in our population are healthier, more active and are living longer than
ever before. Unfortunately, as the number of elderly persons increases, so does the risk and
incidence of elder abuse. Elder abuse can be defined as the intentional or unintentional infliction of
harm; physical, psychological, or emotional. While exact classification may differ, generally
speaking an elder is considered to be a person aged 60 or older. Definitions of abuse will also vary
from state to state, but federal definitions include three basic categories of abuse. These
categories are:

       1. Domestic elder abuse refers to various forms of maltreatment that occur in the home
       of the patient or the home of the caregiver. The abuse is inflicted by someone who has a
       special relationship with the elder such as a spouse, a child, sibling, friend, or other

       2. Institutional elder abuse refers to maltreatment of an elderly person, which occurs in
       a residential facility for the elderly such as a nursing home, foster home, group home, care
       and board facilities, or a hospital or other treatment facility. In this situation, the abuse is
       inflicted by persons with a contractual obligation to provide care and protection to the elder
       and include paid caregivers such as nurses, nursing assistants, staff members, and

       3. Neglect or self-abuse refers to the elder who intentionally neglects or refuses self- care,

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       such as taking medications, personal hygiene, paying bills, and providing adequate shelter,
       food, and safety. The elder is mentally competent and able to understand the
       consequences of the neglectful behavior.

Domestic and institutional elder abuse may include the following types of abuse:

       • Physical abuse can be defined as the use of physical force to cause bodily injury, pain or
       impairment. Types of physical abuse include, but are not limited to; slapping, hitting,
       pinching, biting, kicking, and striking with an object, pushing/shoving, shaking, and
       burning. Additionally, the inappropriate use of drugs and physical restraint, force feeding,
       and physical punishment are considered types of physical abuse.

       • Psychological or emotional abuse occurs when fear, mental anguish, or emotional pain or
       distress has been inflicted. This would include such acts as intimidation, threats, insults,
       humiliation, and harassment. Behaviors such as name calling, giving the ―silent treatment,‖
       treating the elder as a child, and forced isolation are considered forms of psychological
       /emotional abuse.

       • Neglect is the failure or refusal to fulfill any part of one‘s obligations or duties to an elder.
       Typically, this would include failure to supply food, water, shelter, clothing, hygiene,
       comfort, safety, and financial services/responsibilities.

       • Exploitation is defined as the misuse of the resources (monetary or material) of the
       elderly for personal or monetary benefit. Types of exploitation include fraud, forgery, taking
       Social Security checks, removing property without consent, abusing a joint bank account,
       stealing money, purchasing large items with the elder‘s money without consent, cons or
       scams, and coercion to sign documents (contracts or wills for example). This type of abuse
       may also include improper use of guardianship power of attorney, or conservator ship

       • Sexual abuse may vary from exhibition to rape. This type of abuse is defined as any non-
       consensual sexual contact of any kind and includes acts against persons who are incapable
       of giving consent.


It is likely that no single factor is responsible for elder abuse. Elder abuse is a very complex issue,
like other types of domestic violence. Usually, a combination of factors contribute to the
mistreatment of our elderly and combine psychological, social, and economic factors with the
mental and physical condition of both the abuser and the abused. Some of the following risk
factors may be identified when assessing the elderly for abuse:

       • Aging Domestic Violence - This is a situation where the pattern of abuse, begun early
       in a relationship, has continued into old age. Spouses make up a large portion of elder

                                        MayDay Staffing Solutions
                                   ―Responsive Business – Compassionate Nurses‖
                                          16654 Soledad Canyon Rd. # 419
                                              Santa Clarita, CA 91387

                  Phone: (888) 640-7111      website:           Fax: (661) 309-9073

abusers, and it is believed that a large portion of these cases are the result of domestic
violence grown old.

• Vulnerability - The elderly are particularly vulnerable to exploitation, abuse, and neglect
because of the possibility of reduced cognition, reduced physical strength, financial
circumstances, and greater potential for isolation. Any of these situations leaves the elderly
person exposed to the possibility for abuse.

• New Living Arrangements - Living with someone else may be a new situation for an
elder who has lost a spouse or become dependant enough to require living with a caregiver
(usually a child). While it seems contradictory, social isolation may occur even while living
with someone. Because the caregiver is spending an increased amount of time caring for
the elder, the abuser becomes more isolated and this may lead to abusive behavior. While
further research is needed, it appears that abusers who live with an elder have a greater
opportunity to abuse, but also feel the need to isolate the elder to prevent discovery of the

• Abuser issues - Abuse may occur because of problems that the caregiver may be
experiencing such as stress, physical, mental or emotional illness, financial dependency on
the elder person, substance abuse, or ―burn out.‖ Cultural differences may be responsible
for elder abuse and for incidences where abuse is not identified or reported or is allowed to
continue because it is considered a ―family matter‘ and perhaps not actually seen as abuse.


As members of the Healthcare community, it is the responsibility of Healthcare
professionals to assess elderly patients for abuse and report abuse as necessary by state
law. Your supervisor and hospital policy will inform you of your specific responsibilities with
regards to reporting abuse or suspected abuse. The following is a description of some of
the warning signs of poor care and possibly abusive situations:

       • Signs of Physical Abuse
       Injury not properly treated
       Injury inconsistent with explanation
       Pain upon touching
       Bruises or ―grip marks‖ on arms or neck
       Repeated and unexplained injuries
       Attitude or statements about injuries are dismissive
       Poor personal hygiene
       Inappropriate medication administration
       Elder reports being hit, slapped, mistreated
       Signs of being restrained (e.g., rope burns on wrists/ankles, bruises etc)
       Bruising or bleeding around the genital or anal area, unexplained venereal disease

                                MayDay Staffing Solutions
                           ―Responsive Business – Compassionate Nurses‖
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                                      Santa Clarita, CA 91387

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or genital infection (signs of sexual abuse)
Broken glasses or other signs of punishment

•Signs of Psychological/Emotional Abuse
Emotional upset or agitation
Withdrawn or noncommunicative
Contradictory statements, Far- fetched stories
Confusion or disorientation
Behavior unusual to this person such as rocking, moaning, biting, and other
behaviors usually attributed to persons with dementia

• Signs of an Abusive Caregiver
History of mental illness, family violence, criminal behavior, and/or substance abuse
Anger, indifference, or aggressive behavior towards elder; withholds or lacks
affection for the elder
Refuses to allow elder to be seen alone

• Signs of exploitation
Circumstances and possessions don‘t match the size of the estate
Unusual banking transactions; e.g. large withdrawals, switching accounts, addition
of name(s)/signature(s) on elder‘s bank accounts
Many unpaid bills
A recent will when elder seems incapable of writing one
Frequent checks made out to ―cash‖
Frequent gifts to caregiver from elder
Frequent ATM withdrawals
Provision of substandard care especially when the elder has adequate resources
Refusal to spend money on elder
Provision of unnecessary services
Signature does not match elder‘s signature on checks or other documents
Elder unaware of own financial status

• Signs of neglect
Pressure sores
Poor nutritional status (in the absence of medical cause); weight loss, ill fitting
clothes/dentures, swallowing difficulties
Sunken eyes/cheeks
Poor color (pallor, cyanosis)
Unsanitary and/or unsafe living conditions (e.g. soiled bedding and clothing, fleas,
trash, dirt, urine/fecal odor, no heat or running water)

                                                 MayDay Staffing Solutions
                                            ―Responsive Business – Compassionate Nurses‖
                                                   16654 Soledad Canyon Rd. # 419
                                                       Santa Clarita, CA 91387

                           Phone: (888) 640-7111      website:           Fax: (661) 309-9073


It is estimated that between 50% and 85% of all elder abuse is perpetrated by family members
(adult children, a spouse, grandchildren, siblings, and other relatives). Most often these family
members are the spouse or children of the victim. Research indicates that these abusers are often
financially dependant on the elder and may also have substance abuse problems. Other abusers of
the elderly vary from home. Healthcare providers to nursing home staff, friends, other service
providers and scam artists. As Healthcare professionals, we have an obligation to provide
competent, safe and non-abusive care. We also have an obligation to recognize signs of
suspected abuse and to report the abuse. The reported abuse may have been perpetrated in
another setting, by a family member or it may have occurred in the facility where you are
working and may have been perpetrated by a fellow staff member.

Elder abuse may occur anywhere care is being provided to the elderly. This includes the elder‘s
home or the home of a caregiver. Other potential sites for abuse would naturally include
locations where the elderly reside or spend a great deal of time such as nursing homes. With
nearly 17,000 nursing homes in the US, there is a significant potential for abusive situations.
Nursing homes present a unique situation because of the large population of elderly residents,
differences in personalities, ages, and cultural backgrounds of the residents and their care givers,
overcrowding, lack of time for staff to sufficiently care for residents, and a multitude of other
problems. Indeed, the elderly can pose challenges when it comes to providing care because of the
amount of care required and the potential for the elderly patient to be aggressive or troublesome.
Burn out (described as progressive mental and physical exhaustion as a result of prolonged
involvement with people) is a very real threat in the nursing home setting and can be a risk factor
in abuse. Staff shortages and inadequate training may also add to a staff member‘s stress level
and increase the risk for abuse. Signs that we as Healthcare providers are putting our patients at
risk for abuse must be recognized and appropriately managed.


Recognition of the signs of abuse and reporting suspected abuse are necessary components of
quality care for the elderly. Prevention of abuse, however, is the most important step we can take
in protecting the elderly against abuse. The following tips and recommendations are for use by
Healthcare professionals in their personal practice, but are also useful as suggested methods of
prevention for the caregivers of the elderly that you may encounter.

Abuse Prevention Tips: (Both domestic and institutional caregivers)

       •   Get enough rest.
       •   Take care of your own health.
       •   Seek treatment for substance abuse problems.
       •   Examine your feelings for negativity towards the elderly person. Seek positive outlets for

                                                 MayDay Staffing Solutions
                                            ―Responsive Business – Compassionate Nurses‖
                                                   16654 Soledad Canyon Rd. # 419
                                                       Santa Clarita, CA 91387

                           Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       negative feelings such as support groups, exercise, and meditation.
       • Seek education about elder abuse on a regular, ongoing basis.
       • For assistance and information, contact appropriate associations or agencies such as
       Alzheimer‘s Association, AARP, American Cancer Society, American Society on
       Aging, Meals on Wheels, National Center on Elder Abuse, National Council on
       Aging, Adult Protective Services, and the Administration on Aging‘s Eldercare Locator

Domestic Caregivers

       • Seek financial counseling if monetary constraints are causing difficulties, inability to follow
       medical advice or an increased stress level.
       • Seek help with transportation matters if this is an issue.
       • Seek professional counseling for family problems that may be resurfacing as a result of
       your caregiving role.
       • Include your spouse in decisions and encourage the expression of his/her feeling
       regarding your role as caregiver.
       • Seek the help and advice of other helpful family members.
       • Increase social interactions and contacts.
       • Consider respite care.
       • Take a class and seek education in caregiving skills.

Institutional Caregivers
       • Give yourself a ―time out‖ if you feel tempted to strike out, physically or verbally against
       your patient. Seek a supervisor or co-worker for immediate support and resolution of
       frustration or anger.
       • Become involved with your facility/unit to improve conditions, policies and procedures in
       order to prevent ―bum out,‖ understaffing, stress, and other factors that may lead to elder
       • Attend training and educational sessions regarding elder abuse, stress management,
       problem solving skills, interpersonal care giving skills, dementia, and witnessing/reporting
       • Create and/or attend a support group for caregivers of elderly patients.


Elder abuse is an unfortunate problem that you have a high likelihood of encountering in the
Healthcare profession. Your ability to prevent, recognize and report elder abuse is paramount in
the protection and well being of our most vulnerable of patients.

Go to the Mandatory Education lest booklet and complete the test for “Elder Abuse” before
moving on to the next section.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Sexual Harassment

Sexual Harassment is a type of sexual discrimination which is illegal according to federal law.
Incidents that occur based on a person‘s gender can be considered sexual harassment and include
behaviors such as unwanted sexual advances, requests for sexual favors, and/or any type of
conduct either verbal, physical or visual that is of a sexual nature. These types of behaviors often
can be complicated by the abuser who makes the victim submit to the harassment as a condition
of employment, promotion, or evaluation. Sexual harassment occurs when unwanted sexual
conduct produces an environment which is hostile or offensive and therefore restricts the
employee‘s ability to perform.


Imagine yourself in a situation where you feel completely demoralized, embarrassed, intimidated
or frightened. Now try to imagine yourself performing your job in this type of environment. This is
what could happen if you were being sexually harassed. When the behavior of a fellow employee,
supervisor, client, or any other individual with whom you must come in contact while on the job is
sexually offensive or makes doing your job possible only if you submit to some type of sexual
conduct, this is sexual harassment. Sexual harassment limits employees‘ ability to function by
creating an environment that reduces morale and respect and can also affect successful
functioning as a team. Other problems that sexual harassment can produce are the loss of a good
reputation for the facility and possible legal action. Sexual harassment increases absenteeism,
employee turnover, and a loss in productivity. These problems, in turn, can lead to financial
disturbances. In short, sexual harassment can take a huge emotional, financial, and legal toll in
the workplace. Sexual harassment cannot be tolerated and you are protected against it by law.


Sexual harassment may take different forms. Commonly, it is quite clear that sexual harassment is
taking place because the abuser is either implicitly or explicit requiring that sexual favors are a
condition of employment, continued employment, promotion, or evaluation. In such a situation,
the victim is coerced into or required to, submit to unwanted sexual conduct in order to be hired,
maintain the position that s/he presently holds or move into another position. The cooperation of
the victim may also be required in order to receive a good performance evaluation. This type of
sexual harassment is labeled ―quid pro quo‖, literally meaning ―this for that‖. In other words,
sexual favors are given in return for certain terms of employment. Quid pro quo often involves a
person in a superior position to the employee, but may not necessarily be a direct supervisor.
Sexual harassment does not always involve someone in a superior position to the employee.
Sexual harassment can occur between any two employees from any department and is not limited
to men harassing women, but may involve women harassing men, or harassment between same
sex employees.

                                              MayDay Staffing Solutions
                                         ―Responsive Business – Compassionate Nurses‖
                                                16654 Soledad Canyon Rd. # 419
                                                    Santa Clarita, CA 91387

                        Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Another type of sexual harassment occurs when behaviors of an unwanted sexual nature cause the
work environment to become hostile. Some examples of this type of harassment include
inappropriate touching, the use of sexual innuendoes, jokes, anecdotes or graphic materials,
inappropriate comments related to one‘s body or clothing, cat calls or suggestive or insulting
gestures, and unwanted communications such as letters, phone calls or emails. These types of
behaviors are demoralizing and humiliating and create an environment which is hostile and very
difficult in which to perform one‘s duties.

Sometimes sexual harassment is subtle and sometimes it is blatant. It can be conveyed verbally,
non-verbally, or physically. Examples of these types of sexual harassment are:

       • Physical
       Any unwanted physical contact including touching, patting, grabbing, holding, hugging,
       brushing up against a person or blocking his/her path, and in the worst scenario physical or
       sexual assault.

       • Non-Verbal
       The display of sexually graphic materials such as nude calendars, pin-ups, cartoons, the
       use of offensive gestures, computer games, letters or pictures of a sexual nature, and
       staring at a person‘s body are all types of non-verbal harassment.

       • Verbal
       Verbal harassment includes lewd jokes, obscene or foul language, propositions of a sexual
       nature, sexual questioning, suggestive comments or conversations, threats, and comments
       about a person‘s body or clothing.


The following scenarios would be considered sexual harassment:

       • A manager tells one of his workers that a good performance evaluation and promotion is
       contingent on performing sexual acts with him.
       • An ICU nurse continues to ask one of the respiratory therapists at work to go out on a
       date with her. He has declined her invitation each time but she continues to ask him in
       person and through emails and letters.
       • A surgeon corners one of the OR nurses coming out of the dressing room and tells her he
       will let her pass if she kisses him.
       • A security guard stares at one of the female employee‘s legs, whistles and winks each
       time she passes by.
       • While in the cafeteria, a few employees at your table are describing some pornographic
       films loudly enough that you can hear every word. They laugh when you ask them to
       change the subject and continue their discussion.
       • A fellow employee has displayed sexually suggestive materials in the dressing area and

                                                 MayDay Staffing Solutions
                                            ―Responsive Business – Compassionate Nurses‖
                                                   16654 Soledad Canyon Rd. # 419
                                                       Santa Clarita, CA 91387

                           Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       on a locker.

       The following scenarios would NOT be considered sexual harassment:

       • An employee is told to discontinue playing a sexually explicit computer game while at
       work. The employee complies.
       • A discussion takes place amongst medical caregivers regarding potential sexual
       functioning of a patient undergoing prostate surgery.
       • A husband and wife working at the same facility, hold hands as they walk together from
       the parking lot to the building.


Sexual harassment is strictly prohibited according to title VII of the Civil Rights Act of 1964. All
employees are guaranteed freedom from sexual harassment under the law. Certain steps can be
taken to help prevent sexual harassment from occurring in the work place and may include
avoiding risky behaviors such as:

       • Unnecessary touching, hugging, back rubs
       • Staring at coworkers or looking them up and down
       • Sitting on someone's lap
       • Using any type of sexual reference either verbally (jokes, comments, innuendoes), or
       nonverbally (displaying sexually explicit materials e.g. calendars, posters, screen savers)
       • Using foul language
       • Avoiding sensitive topics and anything of a sexual nature
       • Keep conversation to professional and job related topics
       • Be respectful and considerate of fellow employees

       If you are the victim of sexual harassment, it may be helpful to express your feelings and
       discomfort with the situation, and request that the person stop the behavior. Sometimes
       people are not aware of the effect their behavior may be having on fellow employees. If
       the behavior continues, it is important to know the procedure at your facility to file a
       complaint. It is especially important to know to whom to report the harassment, especially
       if you are being harassed by an immediate supervisor. Some facilities have an officer who
       bears sexual harassment complaints and can assist with resolution. In any case, it is
       important for you talk about your situation and resolve it in the best way possible. It is
       important that you record important details regarding the harassment, such as:

               •   Date and time the incident(s) occurred
               •   Place the incident(s) occurred
               •   Description of the incident
               •   Names of any witnesses to the incident(s)

It is also important to support coworkers should they experience sexual harassment. Maintain
confidentiality at all times, and encourage reporting if requests to stop the behavior are ineffective.

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073


The following is Company Name. policy on Harassment. The facility where you are assigned will
have its own policy.

Harassment Policy

An important aspect of the Company‘s equal opportunity policy is made to ensure that all
individuals have the right and opportunity to work in an environment that is free from
harassment of any nature. Discriminatory harassment is unlawful and interferes with employees
job performance. Harassment in any form, from or against employees, applicants for
employment, temporary employees, temporary agency workers, vendors, maintenance workers, or
customers is unacceptable conduct which will not be tolerated by the company.

This policy applies to harassment on the basis of race, color, religion, gender or sex, national
origin, age, disability, sexual orientation, familial status or any other characteristic protected from
discrimination under law. Harassing behavior consists of discriminatory intimidation, ridicule, or
insult that has the purpose or effect of unreasonably interfering with an individual‘s work
performance or of creating an intimidating, hostile, or offensive work environment, as viewed from
the perspective of a reasonable person.

Sexual Harassment

We emphasize that sexual harassment in the workplace, like any other form of harassment, will
not be tolerated. Sexual harassment consists of unwelcome advances, requests for sexual favors,
and/or other verbal, visual or physical conduct of a sexual nature where:

       (1) Submission to such conduct is made, either explicitly or implicitly, a term or condition of
       an individual‘s employment
       (2) Submission to or rejection of such conduct is used as a basis for employment decisions
       (3) Such conduct has the purpose or effect of unreasonably interfering with an individual‘s
       work performance or of creating an intimidating, hostile or offensive work environment

Sexual harassment may include a range of subtle and not so subtle behaviors and may involve
individuals of the same or different gender. It is the Company‘s policy that no manager,
supervisor or other employee shall threaten or suggest, either explicitly or implicitly, that the
refusal of another employee or an applicant for employment to submit to sexual advances in any
form will adversely affect that person‘s employment, performance evaluation ratings, wages,
compensation, advancement, assigned duties, or any other term or condition of employment.
Furthermore, all employees are prohibited from offering, promising or granting preferential
treatment to any employee or applicant for employment as a result of that individual‘s engaging in

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

or agreeing to engage in sexual conduct. The following behavior is also prohibited; physical
assaults of a sexual nature; other unwanted and unnecessary physical contact with another
employee; unwelcome advances, propositions or sexual flirtations; subtle pressure or requests for
sexual activities; verbal abuse of a sexual nature, including but not limited to inappropriate verbal
comments about an individuals body or sexual activities; the inappropriate use of sexually explicit
or offensive language in discussions with or to describe an individual; sexually explicit or offensive
jokes; and the display in the workplace of sexually suggestive objects, pictures, publications, or
other materials.

Go to the Mandatory Education Test booklet and complete the test for “Sexual Harassment”
before moving on to the next section.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Pain Management

Pain is a very subjective experience that requires expertise on the part of the caregiver to
adequately teach, assess, and treat the patient based on the individuality of the patient‘s
circumstances. Pain is generally viewed as being either acute or chronic. Acute pain is both a
sensory and emotional reaction to the stimuli from sources such as trauma, medical procedures,
surgery, and other conditions such as migraine headaches, childbirth, and dental conditions. Acute
pain directly correlates with identifiable tissue damage; therefore, the pain decreases as the injury
or condition improves and is treated appropriately. Acute pain can be defined as pain that lasts
fewer than 3-6 months.

Acute pain is a type of pain called nociceptive. Nociceptive pain occurs when there has been injury
to muscle, soft tissue, bone, joints, or skin and messages about this injury are carried on the
nociceptor sensory fibers. Typically nociceptive pain is felt as a deep ache, throbbing, gnawing or
sore sensation. Postoperative pain is an example of nociceptive pain.

Chronic pain is persistent and does not subside. It persists longer than expected rather than
improving along with the somatic cause of the pain. Chronic pain arises from such conditions as
cancer, back pain, and arthritis. Chronic pain is considered to last longer than three to six months
or beyond the point of when tissue healing is complete. Treatment is more complex for chronic
pain than with acute pain because of the multidisciplinary treatment approach and the length of
time treatment may continue.

Neuropathic pain is a type of chronic pain and describes pain that has been caused by damage to
nerve tissue. Neuropathic pain is felt as a stabbing, burning, shooting sharp pain, and/or a
persistent numbness or tingling sensation. It is thought that neuropathy (another term for
neuropathic pain) may be caused by injury to the sensory or motor nerves in the peripheral
nervous system. Sciatica is an example of neuropathic pain.

Chronic pain may be further differentiated into two categories:

       • Identified Origin - this is chronic pain that has a clearly defined cause such as
       degenerative disk disease or a tumor.

       • Unidentified Origin - this type of chronic pain has no identifiable cause and lasts beyond
       initial tissue healing. This may also be termed ―chronic benign pain‖, psychogenic, or
       idiopathic pain. Fibromyalgia is an example of chronic pain with an unidentified origin.

It is believed that in chronic pain, there may actually be an ongoing pain signal, but an absence of

                                                 MayDay Staffing Solutions
                                            ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111       website:           Fax: (661) 309-9073

ongoing tissue damage. In cases of chronic pain, the pain itself has become the disease rather
than a symptom of an injury.


A large part of a Healthcare professional‘s job duties involves caring for patients who are
experiencing pain. Healthcare professionals have an obligation to minimize anything harmful and
to relieve patient suffering. Pain relief falls into this category and is further assured by the patient‘s
rights. Patient rights as they refer to pain include the right to:

       • Appropriate assessment and management of pain
       • Safe prescription of medications and ordering including appropriate education and use of
       patient-controlled analgesia (PCA), spinal/epidural or intravenous administration of pain
       medications, and other pain management techniques
       • Post-procedure monitoring, during which pain is assessed for intensity, quality (including
       character, frequency, location, and duration) and response to treatment
       • Education on pain management as a part of treatment and the importance of effective
       pain management
       • Discharge planning that includes pain management


Each person experiences pain differently. Two people with the same injury or disease process may
describe their pain in very different ways. Therefore, the goals of pain management must take into
account the individual patient‘s circumstances. The goals of pain management will also be different
depending on the type of pain the patient is experiencing. With this in mind, there are general
goals for a pain management program, including:

       • The reduction of the incidence and severity of pain
       • Patient education in communicating unrelieved pain in order to implement timely and
       effective relief
       • The enhancement of the patient‘s comfort and satisfaction
       • Effective pain relief that leads to fewer post-operative complications and
       consequently, shorter stays

Additional benefits to the achievement of these goals may be realized such as quicker return of
movement, a shorter hospital stay and reduced costs.


The American Pain Society (APS) suggests that pain is the fifth vital sign and should be assessed
and recorded at the same time as other vital signs. California state law designated pain as the fifth
vital sign in January 2000. Many institutions have followed the APS recommendation by including a

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

written record of a pain rating along with other vital signs in the patient‘s medical record.

All patients have the right to the assessment and treatment of pain. Pain is a personal experience
and cannot be measured like other medical problems such as with a blood test or an x-ray. Self-
reporting is the single most reliable method of assessing pain. An integral part of self reporting
depends on the positive and trusting relationship between the patient, the family (if appropriate),
and the caregiver making the pain assessment. Patient teaching is also vitally important. Each
organization has its own policy and procedure for pain assessment in place. It is imperative to
become familiar with and follow your organization‘s protocol for pain assessment including the:

       •   Initial assessment
       •   Frequency of assessment
       •   Recording of assessment and findings
       •   Effectiveness of the pain management techniques that have been implemented
       •   Specifics of the pain including:
                  • Location
                  • Quality
                  • Onset
                  • Frequency
                  • Intensity
                  • Personal meaning

The use of a pain rating scale is often helpful in assessing a patient‘s pain, such as with a
preoperative patient, it is helpful to review this tool with the patient before the patient experiences
pain. In any case, this tool has proven to be very effective in making an accurate assessment that
will assist in providing the information needed to manage a patient‘s pain. The pain scale tool will
give valuable information about the intensity of a patient‘s pain, but other parameters will still
need to be assessed such as the character of the pain and its location. The pain assessment tool is
generally a scale with either numerical values or facial expressions which help a patient to rank
their pain. These tools are helpful for all patients regardless of age, sex, language spoken and
cultural background. Some tools are better suited to some populations i.e., the tool with facial
expressions is particularly useful with children.


Patients‘ pain relief needs vary largely as a result of the origin of the pain, the patient‘s medical
condition, the specific procedure being performed, pain response and tolerance, types of pain
interventions available, personal preferences, cultural beliefs, age, and sex. Successful
management of pain includes control over the factors that initiate or maintain the pain. These
factors include physiologic, psychologic, pathologic, emotional, cognitive, environmental, and

The best strategy for successful pain relief is a flexible approach that includes:

       • A multidisciplinary approach, including all members of the Healthcare team as well as the

                                                 MayDay Staffing Solutions
                                            ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111       website:           Fax: (661) 309-9073

       patient, and family (when appropriate)
       • Proactive pain control that encompasses methods to prevent pain
       • Initial assessment and frequent re-assessment
       • The use of drug and nondrug therapies

Acute Pain Relief

It is well documented that preventive pain control is much more effective than trying to eliminate
or reduce pain once it has occurred. While aggressive pain prevention is not always possible, it
should be employed whenever the situation allows and should include pre-operative/procedure
patient/family teaching. Preventive pain management also includes the use of scheduled pain relief
rather than ―as needed‖ (PRN) medications. Often, patients will not request medication until the
pain level is too high. It is far easier to get control of pain and keep it at bay, than trying to control
it once it has gotten very intense. Scheduling postoperative/procedure pain medication helps to
prevent this problem and the patient always has the choice to refuse the medication if they so

There are many safe and effective methods of pain management for acute pain. Successful
administration depends upon the appropriate action of the Healthcare professional and patient
education. Some patients may have had negative experience with acute pain relief in the past and
this must be dealt with carefully. Another issue that may affect acute pain relief is a patient‘s fear
of addiction to medications such as opioids. Studies have shown that this fear is unfounded. One
study indicated that only 4 individuals out of 11,000 showed addiction one year after taking opioids
for acute pain.

Treatment options for acute pain include:

       • Acetaminophen
             • Safe and effective for lesser acute pain. May be purchased over the counter.

       • NSAIDs - Non-steroidal Anti-inflammatory Drugs; ibuprofen
             • Safe and effective for relief of most acute pain without opioid side effects.
             • Risk of gastric bleeding with long term use.

       • COX-2 Inhibitors - (Cyclooxygenase-2) celecoxib
             •Very useful for orthopedic surgery, dental surgery, dysmenorrhea
             • Fewer side effects than NSAIDs with equal efficacy.

        • Narcotics and Opioids- meperidine, propoxyphene, codeine, morphine
              • For moderate and severe pain
              •Side effects include respiratory depression, nausea, vomiting, constipation,

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Good nursing care, such as positioning the patient comfortably, attending to needs promptly,
attending to toileting needs, and patient teaching will also add to the comfort level of the patient
and are crucial to the success of a pain management plan. Alternative and adjunctive therapies,
such as relaxation, massage, hypnosis, acupuncture and acupressure, may also be successfully
employed. See details of other therapies under chronic pain below.

Chronic Pain Relief

Many of the same pain medications that are effective for acute pain are also useful for chronic
pain. There is much overlap and chronic pain medications may also include acetaminophen,
NSAIDS, narcotics, and opioids. Additionally, the use of topical preparations may aid in easing joint
pain, such as with arthritis or rheumatological disorders. The selection of the drug generally
depends on the severity of the pain, other conditions the patient may have, and takes into account
any other medications the patient may be taking. The following is a list of other therapies that may
be useful for chronic pain sufferers.

Cognitive Behavior Therapy

       • Further management of chronic pain may include the implementation of
       Cognitive Behavior Therapy. This is the use of patient education or other interventions used
       to assist the patient in coping with factors that may be affecting their pain, such as
       depression, anxiety, and fear. By weakening the connections between stressful and/or
       painful situations, the patient can learn to calm the mind and body and therefore change
       the behavioral response. The cognitive portion helps the patient to change the way certain
       thinking may affect the way they are feeling. This type of therapy may require a referral to
       a psychotherapist.

TENS (Transcutaneous Electrical Nerve Stimulation)
      •The use of TENS remains a popular option but research is not yet complete. It appears to
      be much more effective for chronic pain than acute, and necessitates careful
      implementation, patient instruction, and patience.

      •While the exact reason for efficacy is unknown, anticonvulsants have been used for the
      management of neuropathic pain for decades.

      • May be used for analgesia in neuropathic pain, but how it works is not known. Evidence
      dues not show if antidepressants should be favored over anticonvulsants or vice versa.

      • Aids in pain relief from bone metastasis.

Muscle relaxants
      • Particularly useful for chronic low back pain.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Bed rest
      • Some studies reveal that bed rest is the cause of adverse effects and is not as highly
      favored as it once was for herniated disk and sciatica.

Physical exercise
     • May be more favored for certain situations,
     •Can bring about the release of endorphins which help to reduce pain.

Weight loss
     • Obesity may aggravate or cause certain conditions and is linked to osteoarthritis of hip
     and knee.

     • Usually a last resort in chronic situations.

Dietary supplements
      • Omega-3 fatty acids can substitute for NSAIDs
      • Vegetarian Diet
      •Can reduce joint inflammation


Equally as important to the type of medication selected is the route which it is administered. The
patient‘s preferred method of administration should be taken into account whenever

Oral: Often preferred by patients, is convenient, less expensive and non-invasive,

Parenteral: Intramuscular or intravenous injections provide a more rapid onset of pain relief than
when taken orally.

PCA (Patient Controlled Analgesia): Gives the patient the control by allowing premeasured
medication doses to be infused at the patients command.

Suppositories: Very useful when GI function is compromised (nausea/vomiting dc).

Intrathecal: The uses of medications delivered into the spinal column have proven effective for
patients with severe pain.


Pain management is a major factor in a patient‘s well-being and satisfaction. Pain management is
also a patient‘s right. As Healthcare professionals, we are required to provide the patient with
accurate pain assessment and monitoring, competent and safe administration of medications and

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

other therapies we may be qualified to give, and education about pain and various types of pain
relief. Each patient must be treated as an individual, taking into account the specific pain-causing
condition, as well as factors which affect the patient‘s perception of pain, such as emotional state.
psychological coping mechanisms, and cultural/social background. Using a multidisciplinary
approach will afford the patient the most comprehensive care possible.

Go to the Mandatory Education Test booklet and complete the test for “Pain Management”
before moving on to the next Section.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Conscious Sedation

Conscious sedation describes the use of medication to minimally depress the level of
consciousness while allowing the patient to independently maintain his or her airway.
Additionally, the patient‘s protective reflexes and the ability to respond purposefully to verbal
commands and/or tactile stimulation are maintained. Medications given for pain control during
labor and delivery, pain relief during the post-operative period, and pre-medication for surgery or
procedures are not types of conscious sedation.

Conscious sedation is commonly used for various surgical and diagnostic procedures, including
closed reductions of fractures, endoscopy and radiological procedures. An important distinguishing
feature of conscious sedation is the ability of the patient to independently maintain a patent
airway. Conscious sedation is achieved when the patient experiences the onset of slurred speech,
but is still able to respond to a command such as ―open your eyes.‖

The administration of conscious sedation requires constant monitoring of the patient. Safe and
effective management of conscious sedation requires its administrator to be able to recognize and
respond immediately to any adverse reaction or complication. Requirements for practitioners who
administer conscious sedation include the ability to focus solely on the task at hand, and the ability
to recognize and intervene should complications occur.


Practitioners involved in administering conscious sedation are responsible for obtaining informed
consent prior to the procedure. Other responsibilities include patient preparation and monitoring of
the patient before, during, and after the procedure. In the case of an outpatient procedure,
discharge and follow up instructions should be given to the patient and/or the person responsible
for the patient‘s care before sedating the patient. Further responsibilities include:

       • The ability to assess care requirements of the patient before, during, and after the
       administration of conscious sedation
       • Assure that all equipment necessary for patient monitoring during conscious sedation is
       available and functioning properly
       • The ability to apply knowledge of anatomy, physiology, pharmacology, recognition of
       cardiac arrhythmia, and complications related to conscious sedation
       • A solid understanding of respiratory physiology and the use of oxygen delivery devices
       • The ability to recognize complications of each type of agent being administered for
       conscious sedation
       • Competent assessment, diagnosis, and intervention in the event of complications in
       accordance with appropriate institutional orders or protocols

                                                 MayDay Staffing Solutions
                                            ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111       website:           Fax: (661) 309-9073

       • Age-appropriate airway management competency as evidenced by certification
       (ACLS, PALS)


As with surgical procedures, prior to receiving conscious sedation patients will require a history and
physical on their medical record. Documented patient assessment prior to sedation should also
include (will vary by institution):

       •   NPO status
       •   vital signs
       •   weight
       •   airway status
       •   current medications
       •   allergies
       •   medical and anesthetic history
       •   mental status
       •   laboratory studies
       •   patient age

Some patients may not be candidates for conscious sedation. Careful assessment and screening of
the elderly or very young, patients with liver metabolism problems, kidney disease or patients that
have psychological or developmental disabilities may require other methods of sedation or possibly
anesthesia. Further, a patient‘s NPO status must be clearly assessed before receiving conscious
sedation. It is recommended that the patient has not consumed solid food or full liquids in the 6-8
hours prior and no clear liquids 3-4 hours prior to sedation. In a situation where conscious
sedation could be utilized for an emergency procedure, careful consideration must be given to the
risk of potential regurgitation or aspiration. It may be safer to delay the procedure (and sedation)
as long as doing so would not increase the patient‘s risk for a poor outcome. The facility should
have a protocol for aspiration prevention in such cases.


Healthcare professionals need to be familiar with and follow the facility‘s specific policies for the
management and monitoring of patients receiving conscious sedation. These procedures may

       • Reading, understanding, and following facility guidelines for patient monitoring, drug
       administration, and protocols for management of complications or emergencies.
       • Selection and ordering of agents being used to achieve conscious sedation are done by a
       qualified anesthesia provider or attending physician.
       • Agents classified as anesthetics, including but not limited to Ketamine, Propofol,
       Etomidate, Sodium Thiopental, Methohexital, Nitrous oxide and muscle relaxants should not

                                           MayDay Staffing Solutions
                                      ―Responsive Business – Compassionate Nurses‖
                                             16654 Soledad Canyon Rd. # 419
                                                 Santa Clarita, CA 91387

                     Phone: (888) 640-7111      website:           Fax: (661) 309-9073

be administered by Registered Nurses who are not qualified anesthesia providers.
• Administration of medications according to policy including validation of the physician's
order, obtaining medications, and following the five ‗Rights‖:

       1.   Right   medication
       2.   Right   dose
       3.   Right   patient
       4.   Right   time
       5.   Right   route

• Adherence to all national and state guidelines when administering any IV medication, any
discrepancy in the guidelines and what the physician has ordered must be resolved before
conscious sedation may begin.
• All medications must be documented on the patient‘s medical record.
• The healthcare professional monitoring the patient who is receiving conscious sedation
shall have no other responsibilities during the procedure. If the physician requires
assistance with the procedure, another healthcare professional must be called in to assist
the physician.
• Patients receiving conscious sedation shall have:

       o Vascular access maintained throughout the procedure
       o Supplemental oxygen available during and after conscious sedation
       o Monitoring and documentation of physiologic measurements before, during, and
       post procedure.

•Monitoring should include (at the least):

       o Baseline blood pressure, respiratory rate, oxygen saturation, cardiac rate and
       rhythm, and level of consciousness assessed and recorded
       o Assessment and recording (of the above) at least every 5 minutes during the
       procedure, then
       o Every 5-15 minute intervals during recovery, and
       o Every 15 minutes once…

                • at least 30 minutes have passed since administration of the last medication
                of sedation
                • the patient‘s vital signs are at baseline levels
                • the patient returns to pre-sedation level of consciousness and stability

• Any unexpected response by the patient such as dyspnea, cardiac dysrhythmias,
diaphoresis, inability to arouse the patient should be immediately reported to the
• An immediately accessible emergency cart should include emergency drugs, airway and
ventilatory equipment, a source of 100% oxygen and a defibrillator. Standard equipment
for rooms where conscious sedation is administered should include suction, oxygen, a

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       positive pressure breathing device, and appropriate airways.
       • The immediate availability of back-up personnel who can perform emergency airway
       management, intubations, advanced cardiopulmonary resuscitation, and reestablish venous
       access as needed whenever conscious sedation is being administered.
       • The patient must be discharged by a facility authorized licensed professional according to
       the guidelines established by the facility.


The following are some of the typical medications used by non-anesthesia personnel for conscious

Benzodiazepines produce muscle relaxation, sedative and amnesic effects as well as reducing
anxiety and convulsions. Slurred speech indicates an appropriate dose. If a patient is receiving
other narcotics, is debilitated, or is over age 60 the dosage will be less. The medications used in
this category are midazolam (Versed) and diazepam (Valium). Sedation usually occurs within 3 to 5
minutes after IV injection. Patients should be instructed to refrain from activities that require fine
motor or cognitive skills such as driving, infant care, or cooking.

Midazolam (Versed)
Is a short-acting benzodiazepine, which may be given alone or with a narcotic, and may result in
respiratory depression or arrest if given too rapidly or repeatedly. The most common route of
administration is IV; however, it may be administered IV, IM, P0, rectally, or nasally. Midazolam
must be given slowly and is contraindicated in patients with narrow-angle glaucoma or a known
sensitivity to benzodiazepines. Its effects last from 1 to 6 hours. Adverse reactions include nausea,
vomiting, over-sedation, amnesia, nystagmus, decreased respiratory rate, hiccups, and pain at the
injection site.

Diazepam (Valium)
Is no longer used as frequently as midazolam, but like midazolam may be used alone or with a
narcotic and is most commonly given by lV however, unlike midazolam, IM administration is not
recommended because it is very painful. Because diazepam is extremely irritating to the tissue, it
should not be injected into small veins. This drug precipitates when mixed with other drugs and,
therefore, should not be mixed. Adverse effects include tremor, amnesia, cardiovascular collapse,
nystagmus, nausea, respiratory depression, and phlebitis. Diazepam is contraindicated in patients
with a known sensitivity to the drug, which is hypersensitive to soy protein; experiencing shock,
coma or acute alcohol intoxication; or are under 6 months of age.

Narcotics are used for conscious sedation not only for their sedative effects but also to elevate the
patient‘s pain threshold and to provide analgesia. Fentanyl (sublimaze), meperidine (Demerol), and

                                                 MayDay Staffing Solutions
                                            ―Responsive Business – Compassionate Nurses‖
                                                   16654 Soledad Canyon Rd. # 419
                                                       Santa Clarita, CA 91387

                           Phone: (888) 640-7111      website:           Fax: (661) 309-9073

morphine are the most commonly used narcotics. Fentanyl is used most often and will be the only
narcotic described here.

Fentanyl (sublimaze)
Is a short and rapid acting synthetic opioid used for analgesia in procedures such as endoscopy. It
may be given in conjunction with a benzodiazepine. The duration of action is 2-4 hours; however,
patients should be instructed to refrain from activities that require fine motor or cognitive skills,
such as driving, infant care, or cooking. Fentanyl is contraindicated in patients with a known
intolerance. Adverse reactions include seizures, respiratory depression, apnea, arrhythmias, urine
retention, nausea, and vomiting.


Is a benzodiazepine antagonist and reduces or reverses the effects of benzodiazepines. The effect
of flumazenil lasts for about 1 hour, but the effects of the benzodiazepine can return because it
has a longer half life than flumazenil.

Extreme caution must be used when giving flumazenil to patients with a history of seizures or who
take benzodiazepines routinely. It must be administered very slowly, and the patient must be
closely monitored for seizure activity that could triggered by the flumazenil.

Naloxone (Narcan)
Is a narcotic antagonist that reverses the effect of a narcotic. When rapid injections of naloxone
are given, the narcotic‘s effects are reversed including respiratory depression, sedation and
analgesia. If the patient suddenly experiences a rapid onset of severe pain, careful observation
must occur to monitor for increased sympathetic and cardiovascular stimulation which may lead to
arrhythmias, pulmonary edema, congestive heart failure, and cardiac arrest.


The patient must meet specific discharge criteria in the recovery area before moving to another
location, such as Outpatient Recovery/Lounge (for outpatients), the floor (for inpatients), or home
(from ER). Meeting these criteria ensures that the patient has returned to a safe physiological level
of functioning.

Patients to be discharged should be:

       1.   Able to maintain a stable cardiovascular status.
       2.   Free of the need for airway support.
       3.   Without bleeding.
       4.   Under control with regards to pain.
       5.   Stable out of bed without dizziness or syncope.
       6.   Able to void

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       7. Able to retain oral fluids and experience no nausea or vomiting.
       8. Given a written physicians order for discharge with follow up instructions.
       9. If being discharged to home, leaving the facility under the observation of a
       responsible person and have transportation from the hospital.


The definition for conscious sedation for pediatric patients is the same as for adult patients.
Pediatric patients need to be evaluated for past medical history, ability to cooperate, psychological
or developmental disabilities, allergies, potential for unpredictable reactions to medication, NPO
status, and their ability to communicate. Prior to medication administration, informed consent must
be obtained from the parent or legal guardian of the child. Further education about conscious
sedation and follow up care needs to include both the child, at the appropriate level of
understanding, and the child‘s caregiver(s). Other variations in the judgment of conscious sedation
in the pediatric patient include:

       • Different parameters for NPO status (use facility guidelines)
       • Use of appropriately sized pediatric equipment
       • Proficiency in pediatric resuscitation (PALS)
       • Pediatric Code Cart available
       • Medication may include: Chloral hydrate (P0 or PR), diazepam (IV), Fentanyl (IV or IM),
       Midazolam (P0, IM, or IV), and morphine (lV or IM)
       • Accurate weight must be obtained prior to medication administration since dosage is
       calculated on body weight of patient.
       • Extreme care should be taken with dosage calculation. Monitoring, recovery,
       documentation, and discharge follow a similar protocol as for adults.

Go to the Mandatory Education Test Booklet and complete the test for “Conscious Sedation”
before moving on to the next section.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Discharge Planning
Over the course of a client‘s health care experience, an individual‘s treatment will likely involve
being relocated from one Healthcare setting to another. This transfer could be as simple as
sending a healthy newborn home with its parents or more complex as with a patient requiring
mechanical ventilation going from the hospital to a rehabilitation facility with the eventual goal of
going home. In any case, it is best to begin planning for a client‘s discharge as soon as possible.
Discharge planning is a multidisciplinary effort involving many different professionals working as a
team for the best possible outcome on behalf of the patient.

Discharge planning should include:

       1. Patient evaluation for the appropriateness of discharge
       2. Determination of site of discharge for best care and patient resources
       3. Financial resources available to patient
       4. The goals of care from the perspective of the patient and family, and all of the
       healthcare professionals who have and will be involved in the patient‘s care.

In helping to prepare and implement a written discharge plan Healthcare workers should
clearly define:

       • the educational materials, training aids, and assessment tools needed
       • the amount of time anticipated to complete the process and discharge the patient
       • team member access to patient and family for information gathering and training
       • the source and Limits of funds to implement the plan
       • physical and financial support adequate to implement the discharge plan
       • personnel needed for a successful discharge plan outcome. One member of the team with
       particular expertise should be designated to coordinate the efforts of all team members
       including the:

               o patient
               o family and/or caregiver (lay or professional)
               o physician
               o nurse
               o medical equipment provider
               o social worker
               o physical, occupational, speech therapist, and respiratory care practitioner as
               indicated by patient condition
               o case manager
               o nutritionist
               o representative of the discharge site
               o spiritual advisor

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Discharge planning begins as soon as the client has entered into your care. The more teaching.
understanding, and confidence you incorporate into your care, the easier the transition will be for
your client upon transfer to a new care setting. Begin your discharge teaching as much in advance
of the actual discharge date as possible. Involve family members that will be responsible for care
and allow them to ask questions and express any concerns or anxieties before the patient leaves
your care.

Patients and their families may have difficulty in understanding and remembering the details of the
plan of care they are to carry out once they are transferred from your facility. Patients should be
given a written plan and should be subsequently contacted by professionals to evaluate
compliance in the new came setting.


If you follow your facility‘s policy for discharge planning and provide valuable input as well as
implementation, your patient‘s transition from one care setting to the next should proceed as
smoothly as possible.

Go to the Mandatory Education Test booklet and complete the test for “Discharge Planning”
before moving on to the next section.

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111       website:           Fax: (661) 309-9073

Advance Medical Directives
Commonly referred to as ―Advance Directives‖ these are written documents that express a
patient‘s wishes regarding medical care decisions in the event that they are unable to speak for
themselves. These situations may arise when a patient is physically or mentally incapable of
making decisions and/or communicating their wishes. For example the patient may have:

       • Sustained brain damage that is irreversible
       • A coma that has been determined to be permanent
       • A terminal illness (patient is expected to die within a short period of time)


There are two types of advance directives. The patient may have one or both, and in some cases,
both may be contained in the same document.

       1. Living Will: A will is termed ―living‖ because it is in effect while the patient is alive. This
       document specifies the medical care a person either wanted does not want if they become
       terminally ill or debilitated and cannot communicate their wishes.
       2. Durable Power of Attorney for Health Care: Also known as a Medical Power of
       Attorney, this written document names another person (called a proxy or agent) to make
       medical care decisions if the patient becomes unable to do so.


As a Healthcare worker, you need to determine what your responsibilities are regarding advance
directives for each facility. Regulations vary from state to state and may change at any time. All 50
states and the District of Columbia have laws that recognize advance directives. Be sure to keep
current with this information.

You may be required to discuss advance directives with your patients. It is important to
understand that advance directives benefit:

       • Patients, by exercising their right in making their own Healthcare decisions
       • Families, in the event that they need to make decisions on behalf of a family member
       • The healthcare worker, by giving you a clear statement of the patient‘s wishes. Be aware
       of and understand the PSDA-The Patient Self Determination Act.
       It stipulates that all health care facilities receiving federal funds (Medicare, Medicaid) must:
       • Discuss advance directives with patients and give them written material in order for them
       to make informed decisions. You may be required to educate your patient about their rights
       to refuse medical care and to sign advance directives.
       • Comply with state regulations.
       • Determine whether or not the patient has an advance directive and enter this information

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       into the permanent record.
       • Maintain written policies and procedures regarding advance directives
       • Educate the staff and community in advance directives
       • Treat the patient the same whether or not they have executed advance directives.


Some Healthcare workers may hesitate to talk to their patients about advance directives. This is
often because talking about death or terminal illness openly is difficult for most people. As
healthcare workers, we fear that discussing advance directives will make our patients angry or
depressed. It may also bring to mind our own fears, therefore making it much easier to ignore the
topic altogether.

You can make talking about advance directives easier to both you and your patient by:

       • Timing your talk for a moment when your patient has settled in, is comfortable, and has
       • Reassuring the patient that everyone receives this information, and it is not a reflection of
       their condition.
       • Defining terminology to make it easier for your patient to understand. For example:
       Cardiopulmonary Resuscitation (CPR) An emergency procedure used to revive a person
       whose heart has stopped

              o Respirator a machine, also called a ventilator, that breathes for the patient
              when the ability to breathe has been lost.

              o DNR means Do Not Resuscitate. This should be noted in the patient‘s chart when
              the patient does not want to be revived by the medical team.

              o Total Parenteral Nutrition (TPN) A method of delivering loud and fluids to a
              patient who cannot eat or drink.

              o Terminal Illness - An illness that has no cure and is expected to cause death
              within one year.

              o Dialysis - The use of a machine to clean the blood of impurities when the kidneys
              are not able to do so.

       • Keep a positive attitude in your discussion by focusing on the fact that your patient is
       exercising his/her rights about their own medical care.
       • Listen carefully to what your patient has to say. Encourage them to discuss their feelings,
       but be sensitive to those patients who have difficulty with this topic. You may offer to leave
       written material and come back later.
       • Stress that while the patient may have an advance directive, this does not mean it will
       ever need to be used. They may of course change or revoke their choices at any time.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Most patients want to know what their rights are. With a clear and concise explanation, and
support and understanding from you, your patient should be able to approach advance directives
comfortably. When you assist your patient in preparing their own advance directives, help them to
understand the following:

       • Different medical situations that they may encounter such as the types of life
       sustaining measures that could be used, and some possible effects of terminal illness.
       • How important it is to involve family and loved ones in advance directives decisions.
       Some patients may want to involve clergy as well.
       • The difference between a living will and a durable power of attorney for healthcare.
       • That if you don‘t have all the information they desire, you can direct them to your
       facility‘s ethics committee or social services department, or the Partnership for Caring
       • Where they can obtain forms if your facility does not supply them. One resource is You can obtain state specific documents at this web site or
       you can obtain a printed set of documents by calling 1-800-989-9455. Partnership for
       Caring Publications,1620 Eye Street, N W, Suite 202,Washington. DC 20006

Once they have an advance directive, they should give copies to their health care provider,
attorney (if they have one) and family members, as well as carry a card in their wallet stating the
existence and location of the advance directive.


       1. How long is an advance directive in effect? Most states do not have any time limit on
       advance directives. Be sure by contacting a social worker or a hospital ethics committee in
       your state.
       2. Do I need to speak with a lawyer? Only if you feel you‘d like to. You can draw up and
       sign your own advance directive without a lawyer, but if you feel more secure, go ahead
       and have a lawyer review the document.
       3. If I‘m hospitalized in another state, are my advance directives legal? Since each state
       has its own laws governing advance directives, yours may or may not be honored in
       another state. If you spend much time in another state, you may want to consider
       preparing an advance directive for that Stale also.
       4. If I‘m in a lot of pain, but have an advance directive, can I still get treatment? By having
       an advance directive, you can spell out the exact types of treatment you do or do not want,
       including pain medication.
       5. Could my advance directives be prevented from taking effect by my family? As a general
       rule, no. Depending on the state however, if a family objects, hospital staff may need to
       help the family understand the right course of action in order to honor the patient wishes.
       6. What if I change my mind or want to make a change to my advance directive? Simply
       add or remove the items you want to change and initial them with the date. To cancel
       altogether, simply destroy the document and any copies.

                                              MayDay Staffing Solutions
                                         ―Responsive Business – Compassionate Nurses‖
                                                16654 Soledad Canyon Rd. # 419
                                                    Santa Clarita, CA 91387

                        Phone: (888) 640-7111      website:           Fax: (661) 309-9073


As a Healthcare worker, you may want to consider drawing up your own advance directives.
Besides protecting your own medical rights, this will improve your ability to empathize with
your patients. Having gone through the process yourself, you will:

       • Have greater knowledge of the process
       • Understand how your patients might feel
       • Allow you to speak more easily about advanced directives

Go to the Mandatory Education Test booklet and complete the test for “Advance Medical
Directives” before moving on to the next Section.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Organ and Tissue Donation

Did you know that 58 people could potentially benefit from the donation of vital organs such as a
heart, liver, kidneys, Lungs, cornea, skin (and more) from just one person? These organs may be
used for transplantation in order to save a life or for medical research to help prevent or cure
disease. Patients that you encounter may have already made the decision to become an organ
donor. In other cases, it may be the Healthcare professional who can share in the responsibility of
identifying potential organ donor patients and then notifying the physician. As a Healthcare
professional, you may encounter questions regarding organ donation. This information should help
you to discuss the topic knowledgeably and with compassion.


       • People 18 years or older of sound mind may become donors.
       • Minors may make their wishes known to become a donor with the consent of their
       parent(s) or guardian
       • The donation will not cost anything to the patient or their family.
       • No one, not a donor or a family member, may sell body tissue, organs, or a body.
       • Most major religions in the US are supportive of organ donation. Patients should be
       encouraged to discuss religious concerns and seek advice from a clergy member.
       • The donor should notify the family of their wishes. Generally, the family or durable
       medical power of attorney must give consent prior to any organs or tissues being
       removed, even if the donor has specifically conveyed the desire for donation.
       • An organ donor can carry a Uniform Donor Card, or in some states, this information is
       indicated on the driver‘s license.
       • A patient‘s Healthcare will not be affected by their donor status. There are strict medical
       guidelines before any patient can be pronounced medically and legally dead and his/her
       organs can be removed.
       • A patient‘s age and medical history should not influence his/her decision to become a
       donor. If the organs are deemed unsuitable for transplantation, they can be used for
       • A regional organ bank will match organs and tissues to recipients anywhere in the
       country and then take charge of distributing the gifts.
       • A donor may change his/her mind about donation at any time. Simply destroy the donor
       card or follow the local regulations to change the status on a driver‘s license. Be sure to tell
       family members about the change.
       • Donation does not disfigure the patient‘s body, so there is no disruption in funeral

A Healthcare professional should document any and all discussions about organ/tissue donation in
the patient‘s medical record, The following should be included:

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       1. Any communication with family and/or physician regarding possible organ or tissue
       2 Potential donor is identified as a ―donor‖ according to facility protocol for ―criteria for
       3. Documentation of brain death and the time the patient is pronounced dead by the
       4. Documentation of patient transfer to OR by writing "Transferred to OR" and signing

Other donor information that will be needed before actual donation takes place may include:

       •   Name, age, and sex
       •   Attending physician
       •   Date of admission
       •   Primary diagnosis and any recent surgery
       •   Medical history and cause of death
       •   Notification of transplant procurement team
       •   Location and description of any lacerations, fractures, or puncture wounds
       •   Notification of the coroner/medical examiner
       •   Pertinent lab results on chart

If the Patient would like further information, you could recommend the following sources:

       •   Personal healthcare provider
       •   Clergy member
       •   State or local medical association
       •   Local kidney, heart, lung, or liver foundation
       •   A regional transplant group/hospital, organ procurement organization, or tissue bank


Check with your facility‘s policy and procedure manual for specific responsibilities, and
consider becoming an organ donor yourself. You could save another life.

Go to the Mandatory Education Test booklet and complete the test for “Organ and Tissue
Donation” before moving on to the next section.

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

Medication Errors: What They Are, How They Happen, and How To
Prevent Them

A medication error is a preventable event that may cause or lead to incorrect medication use or
potential harm to the patient.


Medication errors include a multidisciplinary element which increases the possibility of an
occurrence. Errors may involve the manufacturer, prescriber, dispenser (e.g. pharmacist.
pharmacy technician), and administering individual (e.g. nurse, therapist). Places along the chain
of drug delivery where an error may occur are:

       •   Drug naming, labeling, packaging and distribution
       •   Prescribing and communicating orders
       •   Compounding
       •   Dispensing
       •   Administering
       •   Educating
       •   Monitoring
       •   Using


The purpose of drug therapy is to improve the quality of life for the patient. When a medication
error occurs, this goal is often unrealized, and there are many who suffer, including the Healthcare
professionals involved, the patient, and the patient‘s family. When an error is reported or
discovered, the facility‘s administration becomes involved as well as any agencies to which the
facility must report medication errors.


Because of the many components involved in delivering medication to a patient, there are many
different errors that may occur. Some examples of errors include:

       • A manufacturing defect with a drug or a drug delivery system (e.g., IV tubing, pump,
       • Ordering a medication in a dosage that is either too weak, too strong, or may react
       dangerously with another medication the patient is taking
       • Ordering or administering a drug to which the patient has an allergy
       • Dispensing or administering the wrong medication, wrong form or strength of the

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       medication, or the wrong dosage
       • Administering the medication by the wrong route, at the wrong time, or to the wrong

Errors may also be related to other sources because of a lack of:

       • Drug information (working knowledge and availability of information regarding drug being
       • Patient information, including allergies, medical status and any other medications being
       taken (including herbs, supplements and vitamins)
       • Effective communication such as the use of common and well-known abbreviations, clear
       handwriting, or where stray marks may be construed as decimal points, phone orders
       misunderstood, or sound alike drugs are misscommunicated
       • Well-rested, plentiful staff, practicing in a focused atmosphere
       • Properly stored medications (e.g. look-alike drugs stored in separate locations, dosages
       clearly identified)


The effect of a medication error on a patient may range from little or no effect to devastating
physiological and emotional repercussions and/or death. This impacts not only the patient, but the
family and significant others as well.

It is never easy to admit a mistake of any kind, but it is particularly difficult to report a mistake
where other people‘s lives and potentially one‘s livelihood are at risk. These are two reasons why
medication errors often go unreported. There is also a natural fear of blame and recrimination. No
one likes the notoriety of having made a mistake. That, subsequently, may make it difficult to
continue to work with other professionals who may question one‘s ability to perform competently.

Many professionals fear losing their job, notations on their personnel file, and potential legal
action. Often it seems easier and safer not to report the incident. This unfortunate choice makes
the process of eliminating medication errors even more difficult because the error cannot be
analyzed in order to prevent similar errors from occurring in the future.


No single strategy is enough to prevent medication errors. Much like a safety net, many layers of
prevention will help to ―catch‖ mistakes before they happen. You can help to prevent medication
errors by understanding the system of root cause analysis; a step-by-step method to understand
what went wrong, where improvements can be made, and how to monitor changes made. A root
cause analysis is NOT about placing blame, it is a matter of making improvements. In the case of
medication errors, JCAHO requires each root cause analysis to investigate:

       • Patient Identification procedures (e.g., checking patient I.D. bands routinely, scanning

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       bar codes if in use)
               • Is there enough staff for patient census?
               • Is overtime limited?
               • Is the patient assignment and/or unit suitably matched to staff?
               • Are supervisors available when needed?
               • Are policies and protocols understood and monitored on a daily basis?
       • Orientation and training:
               • Is it ongoing and always available to staff regarding new medications and
               methods of administration
       • Competency assessment:
       •Are prescriptions written and dispensed by properly credentialed professionals? Is
       orientation of staff completed and documented? Is the actual assessment of staff
       medication administration included as part of an employee‘s review.
       • Clear communication channels:
               •Are written instructions unambiguous and exchanges between staff non-

In order for a root cause analysis to take place, the error must be reported. You must be familiar
with the procedure for reporting errors at your facility and report any error as soon as possible.
Timely reporting will make it easer to reverse any negative effects and to determine what went
wrong while the event is still fresh in everyone's minds. This will greatly increase the effectiveness
of the root cause analysis. Your report should be kept confidential among only appropriate staff
that is made aware of the report, you should be treated fairly and your assistance should be

Utilizing the following strategies will also help to prevent errors:

       • Use a system of checkpoints along the medication delivery route. For example:
              □ A nurse is required to verify correct medication and dosage 3 times before
              □ A nurse double checks the order that was transcribed by the Unit secretary.
              □ The pharmacist double checks the pharmacy technician‘s transcription and any
              medications dispensed
              □ The patient, when capable, confirms his/her identify and the medication to be
       • Separate look-alike medications and store in well-lighted, non-distracting area away from
       toxic materials.
       • Remove dangerous or ―high alert‖ drugs from stock or label distinctly. Use a system of
       double checking before administration. Examples of high alert drugs are:

               *neuromuscular blocking agents
               *opioid narcotics
               *concentrated potassium chloride

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

                 * magnesium
                 * chemotherapy drugs
                 * heparin
                 * insulin
                 * warfarin
• Check expiration date and discard expired drugs
• Use unit dosing whenever possible. Avoid use of multiple dose vials
• Ensure that transcription and preparation areas are free from distraction. Take time to check and
re-check. Stay focused on the task and don‘t rush!
• Know everything possible about the drugs you handle, including attending seminars, reading
journals, reading reference material, and package inserts.
• Use the ―read back‖ method when taking verbal orders. Carefully read the order back to the
prescriber to verify it has been written correctly
• Have a colleague double-check calculations. When possible, use reference charts for infusion
calculations or allow an infusion pump to do the calculation.
• Set a standard routine when giving meds to include checking the patient‘s identity and allergies.
Review lab values and vital signs before administration.
• Use checklists and computer programs. Don't rely on memory.
• Utilize a set standard of abbreviations excluding look-alikes such as od, qd, and qid. When in
doubt, clarify! Type instructions whenever possible.
• Enlist the assistance of the patient! Good patient teaching -- especially drug name, dosage and
timing -- will help the patient to detect and prevent errors and omissions. Teach the patient to
state his/her name and present the l.D. band routinely before meds are given, teach them to
question the meds being given.


Being alert and aware of potential errors and their causes will help you to prevent making an error
yourself. By utilizing many strategies, working together with other healthcare professionals, and
educating the patient, you will be able to form the safety net that is so important in ―catching‖
mistakes before they happen.

Go to the Mandatory Education Test booklet and complete the test for “Medication Errors”
before moving on to the next section.

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111       website:          Fax: (661) 309-9073

Preventing Musculoskeletal Disorders
Using Ergonomics

Healthcare workers are particularly susceptible to back injuries because of the lifting and moving
they must do with and for their patients. Injuries of the musculoskeletal system are also a result of
repetitive use and may occur gradually over many years of use and abuse. In overcrowded and/or
understaffed facilities, it seems easier to go ahead and move a patient alone, rather than waiting
for help. This is one of the most common ways that Healthcare workers injure themselves.
Constant strain on muscles, ligaments, and other parts of the musculoskeletal system may lead to
disabling injuries, not necessarily today but sometime in the future. The proper use of ergonomics
can help to reduce and prevent injuries to which Healthcare workers are at an increased risk.


The types of musculoskeletal disorders (MSDs) that healthcare workers are at risk for include the

       •   Muscle pain, sprains, and strains
       •   Tendonitis: tenosynovitis
       •   Neck tension syndrome
       •   Bursitis
       •   Degenerated, bulging, or herniated discs
       •   Sciatica
       •   Degenerative arthritis
       •   Facet joint syndrome
       •   Slipped vertebrae
       •   Vertebral fracture
       •   Spinal stenosis

Areas of the body particularly affected are the back, neck, shoulder, hand, wrist, and knees. The
Healthcare worker should pay particular attention to the warning signs of MSDs, which may

       •   Tingling or numbness
       •   Burning sensation or swelling
       •   Aching or tightness
       •   Unusually fired or weak muscles
       •   Pain

Any of these signs or symptoms should be promptly reported to your supervisor, and you should
seek advice from your Healthcare provider.

                                                MayDay Staffing Solutions
                                           ―Responsive Business – Compassionate Nurses‖
                                                  16654 Soledad Canyon Rd. # 419
                                                      Santa Clarita, CA 91387

                          Phone: (888) 640-7111      website:           Fax: (661) 309-9073


Many work related injuries to the musculoskeletal system are a function of ergonomics.
Ergonomics is the science of adapting environment, procedures and equipment to the people
involved, in many cases of work-related MSDs, appropriate ergonomics have not been utilized. The
following are some of the reasons Healthcare workers become injured on the job. Many are a
result of using poor ergonomics. For example:

       •   Poor body mechanics
       •   Unsynchronized movements between staff members when transferring patients
       •   Twisting
       •   Lifting too much weight or lifting improperly
       •   Sudden movements
       •   Caring for uncooperative patients
       •   Reaching and bending
       •   Overcrowded or unwieldy areas
       •   Slips, trips, and falls
       •   Repetitive motions


Most Healthcare workers are required to lift/transfer/move patients. Healthcare workers are also
expected to ―catch‖ patients if they slip or fall. This may happen accidentally or while the patient is
being assisted with ambulation. Preparing for the correct movements beforehand is just as
necessary as advanced preparation is for any other task. Think the job through and plan out your
movements, as well as what other help you may need. Using proper body mechanics every day
will help to decrease the likelihood of injury. Good body mechanics include:

       • Receiving proper training and performing physical work for which training has been
       • Knowing one‘s own physical limits and not exceeding them
       • Maintaining balance by keeping feet apart to provide a stable base
       • Calling for assistance. If you need four people to make a transfer, schedule ahead of time
       if possible and wait until all people are there to help. Don‘t attempt the transfer alone or
       with fewer people than needed. Count to three, and all move in one synchronized motion
       • Getting as close to the person or object being lifted as possible. Reaching increases your
       risk of injury. Always face the patient
       • Pushing rather than pulling objects
       • Getting a firm and secure grasp. When moving patients, use a transfer belt. Give clear
       instructions to the patient so they can assist rather than hinder. Be sure the patient‘s hands
       are positioned on your arms or waist and NOT around your neck. When lifting objects, use
       both hands and, when necessary, wear properly fitted gloves
       • Carrying objects close to your body at waist level
       • Wearing non-slip, low-heeled shoes that offer good support

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

       • Bending at the knees, not the waist, and using your legs to lift
       • Turning your whole body or changing foot position rather than twisting, bending forward,
       or overreaching

Remember that while you may not feel an injury immediately, constant and repetitive use of your
body in the incorrect manner will eventually lead to problems. Be sure to use good body
mechanics every time you lift or move a patient or an object and when doing routine tasks that
require bending or stretching. Remember to keep your back straight and bend at the knees when
emptying a Foley bag and use a stool or lower the bed when reaching across the patient to adjust
IV tubing.


The following are guidelines to use when moving patients and objects and also in the use of
assistive equipment and devices. In any case, it important to prepare in advance for any kind of
mechanical tasks; It helps to warm up by doing some stretching exercises and warming exercises
such as walking in place. When possible, keep yourself in shape by exercising regularly (check with
your doctor first). This will strengthen muscles, as will maintaining good posture on a daily basis.
When seated, keep the small of your back against the chair back, and when standing keep your
shoulders back and hold abdominal muscles in. Practicing good body mechanics and using
ergonomics at home will help to prevent injuries. Carrying your groceries incorrectly time after
time can cause as much damage as moving one patient.

       • Moving and Lifting Patients
              o Prepare by arranging for needed help, assessing the patient‘s mental status and
              ability to move.
              o Be sure the route is free of hazards and plan for stops along the way
              o Use upright and neutral working postures.
              o Use slides and lateral transfers instead of lifting whenever possible
              o Use smooth movements and do not jerk. Return to an upright position as soon as
              possible. Bend at the knees, keeping your back straight.
              o Keep the patient and any equipment as close to you as possible. Keep handhold
              between your waist and shoulders.
              o Roll patient rather than reaching across them.
              o Adjust the bed to your center of gravity, lock the wheels, and put side rails up or
              down as needed
              o Adjust the receiving surface slightly lower than the surface the patient is on to
              take advantage of gravity
              o Use draw sheets, incontinence pads, and other friction-reducing devices (slide
              boards, slippery sheets, plastic bags, etc.). Get a good grip by rolling the sides of
              draw sheets or pads or by using the handles on other devices such as slippery
              o Kneel on the bed, floor, or stretcher to avoid reaching and bending.
              o Use the assistive devices for which you have received training such as Total-
              Body, Stand-Assist, and Ambulation lifts.

                                               MayDay Staffing Solutions
                                          ―Responsive Business – Compassionate Nurses‖
                                                 16654 Soledad Canyon Rd. # 419
                                                     Santa Clarita, CA 91387

                         Phone: (888) 640-7111      website:           Fax: (661) 309-9073

               o Become familiar with and use the equipment available to you at your facility, such
               as gait belts, transfer belts with handles, lift chairs, pivot blocks, push-up bars,
               range of motion machines, and trapeze bars. Take advantage of momentum by
               using a gentle rocking motion.
               o When performing stand-pivot type transfers, have the patient move as close to
               the edge of the bed or chair as possible. When medically appropriate, ask the
               patient to lean forward. Block the patient‘s weak leg with your knees by placing the
               weak leg between your two legs.

• Transporting Patients and Equipment

       o Decrease the weight or the load whenever possible. Make two trips if necessary.
       o Store items between shoulder and waist height.
       o Use sliding or lateral motions instead of lifting.
       o Push; don‘t pull.
       o Move down the center of corridors to avoid collisions.
       o Be cautious of uneven thresholds, door handles, and obstructive objects which may cause
       an abrupt stop.

 • Performing ADLS
        o Use long-handled extension tools, such as hand-held shower heads.
        o Wheel patient out of shower and turn them around to wash hard-to-reach places
        (rather than bending and overreaching)
        o Use shower and bathtub lifts and chairs.
        o Eliminate additional transfers by using toilet/shower chairs that are high enough
        to fit over toilets.
• When Standing for Prolonged Periods (e.g., assisting in surgery)
        o Position operating table, gurney, or other table at waist height.
        o To reduce reaching, stand on lifts or stools.
        o Frequently alternate feet on a lift or stool to reduce back strain.
        o Stretch and change position frequently during long procedures/operations.
        o Avoid repeatedly bending the neck or waist or bending for prolonged periods of
        o Store instruments in racks between shoulder and waist height to avoid bending
        and reaching.
        o To assist with holding extremities, use stands or fixtures. Get assistance from co-workers
        to position patients‘ extremities or to move heavy equipment.
        o To avoid extended periods of holding retractors, use retractor rings


       Practicing and following the guidelines outlined above will help you to prevent injuries in
       the workplace. These guidelines need to be practiced constantly in order for them to be
       effective. Practicing at home and on the job will help you to avoid painful and often
       debilitating problems. Be sure to take advantage of the training provided to you at your

                                       MayDay Staffing Solutions
                                  ―Responsive Business – Compassionate Nurses‖
                                         16654 Soledad Canyon Rd. # 419
                                             Santa Clarita, CA 91387

                 Phone: (888) 640-7111      website:           Fax: (661) 309-9073

facility and become familiar with the assistive devices available to you. Ultimately, the
prevention of musculoskeletal disorders is your responsibility. By taking precautions now
you can avoid pain and disability in the future.

Go to the Mandatory Education Test booklet and complete the test for “Preventing
Musculoskeletal Disorders.”


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