NLE Fundamentals of Nursing & the Nursing Process — Asepsis, Infection Control & Patient SafetyRevision Notes

Exam Tips

• NLE stem clue: 'Which is the SINGLE MOST EFFECTIVE measure to prevent infection?' → Answer: Hand hygiene / handwashing.
• Remember: You can break the chain at ANY link, but the nurse's primary tool is hand hygiene.
• Chain of infection order is a favorite fill-in or sequencing question — memorize: Agent → Reservoir → Exit → Transmission → Entry → Host.
• Philippine-context scenario: A patient returns from a rural barangay with fever and rash after a mosquito bite — chain involves vector-borne transmission (vector = mosquito).

Key Points

• Infection requires six sequential links: (1) Infectious agent → (2) Reservoir → (3) Portal of exit → (4) Mode of transmission → (5) Portal of entry → (6) Susceptible host.
• Breaking ANY ONE link in the chain stops infection transmission — this is the foundation of all infection control measures.
• Hand hygiene is the SINGLE MOST EFFECTIVE intervention to break the chain of infection.
• Modes of transmission: Contact (direct/indirect), Droplet, Airborne, Vehicle (contaminated water/food/equipment), and Vector-borne (mosquitoes, ticks).
• Portals of exit include: respiratory tract, GI tract, GU tract, skin/wounds, and blood.
• High-risk portals of entry: broken skin, mucous membranes, invasive lines, urinary catheters, and surgical incisions.
• Most susceptible hosts: immunocompromised patients (chemotherapy, HIV, corticosteroid use), malnourished, very young (neonates), elderly, and those with invasive devices.
• Filipino context: Dengue (vector-borne), TB (airborne), Cholera (vehicle) are common chains encountered in Philippine community and hospital settings.

Definitions

Section Title

The Chain of Infection

Common Mistakes

• Confusing direct contact (physical touch) with indirect contact (touching contaminated surfaces/equipment) — both are under 'contact transmission.'
• Forgetting that a VECTOR transmits an organism biologically (e.g., Aedes mosquito with dengue) — distinct from a vehicle (inanimate contaminated object).
• Assuming that only immunocompromised patients are susceptible — any patient with a broken skin barrier (IV line, wound) or urinary catheter is also at elevated risk.
• Thinking hand hygiene is only needed after patient contact — the WHO 5 Moments require it BEFORE contact as well.

Exam Tips

• NLE question: 'A patient with influenza says she feels tired and achy but has no cough yet. What stage is she in?' → Prodromal stage.
• Five signs of inflammation mnemonic: 'Really Hot, Swollen, Painful, Functionless' → Redness, Heat, Swelling, Pain, Loss of function.
• If the NLE asks about the MOST IMPORTANT nonspecific defense — answer is INTACT SKIN (first line of defense).
• Leukocytosis + fever + malaise in a post-op patient = systemic infection until proven otherwise — relevant for NCM 101/103 scenarios.

Key Points

• Four stages of infection: Incubation → Prodromal → Illness (Acute) → Convalescence.
• Prodromal stage: early, vague, nonspecific symptoms (malaise, low-grade fever) — patient is HIGHLY COMMUNICABLE during this stage.
• Illness (acute) stage: peak of specific signs and symptoms (e.g., high fever, purulent discharge, specific organ involvement).
• Convalescence: recovery phase; patient may still be a carrier.
• Local infection signs (classic signs of INFLAMMATION): Redness (rubor), Heat (calor), Swelling (tumor), Pain (dolor), Loss of function (functio laesa) — remember 'RSHPL' or classic Latin terms.
• Systemic infection signs: Fever (pyrexia), Leukocytosis (elevated WBC >10,000/mm³), Malaise, Lymphadenopathy, Anorexia.
• Nonspecific (innate) defenses: intact skin and mucous membranes, normal flora, gastric acid (pH 1.5–3.5), cilia, cough/sneeze reflex, inflammatory response, phagocytosis (neutrophils, macrophages).
• Specific (adaptive) immunity: Humoral immunity (B lymphocytes → antibodies/immunoglobulins) and Cell-mediated immunity (T lymphocytes).
• Skin is the FIRST and MOST IMPORTANT nonspecific defense barrier — ANY break in skin integrity increases infection risk.

Definitions

Section Title

Stages of Infection and Body Defenses

Common Mistakes

• Confusing the prodromal stage (vague symptoms, MOST contagious) with the illness stage (specific symptoms, peak of disease).
• Forgetting that normal flora is a DEFENSE mechanism — disrupting it (e.g., broad-spectrum antibiotics) can lead to opportunistic infections like Clostridioides difficile (C. diff).
• Mixing up humoral (B cells, antibodies) and cell-mediated (T cells) immunity — humoral targets extracellular pathogens; cell-mediated targets intracellular pathogens and cancer cells.
• Listing only 4 signs of inflammation — 'loss of function' (functio laesa) is the 5th sign and is sometimes omitted.

Exam Tips

• NLE pattern: 'While setting up a sterile field, you notice the drape became wet. What should you do?' → Discard the entire sterile field and set up a new one — wet = contaminated.
• Remember: DOUBT = CONTAMINATED. If an NLE option says 'when in doubt, consider it contaminated and replace' — that is always correct.
• Procedure categorization: Urinary catheter insertion = sterile technique; NG tube insertion = clean technique. Know the difference!
• The 1-inch border concept is tested in setup scenarios — items placed within 1 inch of the edge of a sterile drape are considered contaminated.

Key Points

• Medical asepsis (clean technique): REDUCES the NUMBER of microorganisms and prevents their spread. Used in routine care (bathing, oral care, wound irrigation with clean technique, NG tube insertion).
• Surgical asepsis (sterile technique): renders an area COMPLETELY FREE of ALL microorganisms INCLUDING spores. Required for invasive procedures (IV insertion into sterile sites, urinary catheterization, surgical wound care, injections into sterile body cavities).
• Key principle of medical asepsis: ALWAYS move from CLEAN to DIRTY (e.g., wipe wounds center outward, work from the cleanest area to the most contaminated).
• PRINCIPLES OF SURGICAL ASEPSIS (HIGH-YIELD — memorize all 8):
• 1. Only STERILE touches STERILE — never touch sterile items with non-sterile hands.
• 2. A sterile field is created JUST BEFORE USE and never left unattended.
• 3. The 1-INCH (2.5 cm) OUTER BORDER of any sterile field/drape is considered CONTAMINATED.
• 4. Anything BELOW WAIST LEVEL or below the table edge is CONTAMINATED — keep hands above waist and in view.
• 5. MOISTURE wicks microorganisms (strike-through contamination) — a WET sterile field is a CONTAMINATED field.
• 6. Do NOT reach ACROSS a sterile field; do not turn your BACK on it.
• 7. Sterile persons FACE EACH OTHER; the sterile gown is sterile FRONT from chest to waist and sleeves from cuff to ~5 cm above elbow. The BACK of the gown is NOT sterile.
• 8. When IN DOUBT about sterility — CONSIDER IT CONTAMINATED (golden rule).

Definitions

Section Title

Medical vs. Surgical Asepsis

Common Mistakes

• Pouring solutions INTO a sterile field by reaching over it — always pour from the SIDE, close to the container but without touching the sterile field.
• Forgetting the 1-inch border rule — students often place sterile items at the very edge of the drape, which is already contaminated.
• Allowing a sterile-gloved hand to drop below waist level — anything below waist = contaminated.
• Thinking a sterile gown is sterile ALL OVER — only the FRONT (chest to waist) and SLEEVE CUFFS to elbows are sterile; back is NOT sterile.
• Confusing medical asepsis with surgical asepsis in procedure-based NLE questions — key cue: 'sterile' or 'invasive' = surgical asepsis; 'clean' or 'routine' = medical asepsis.

Exam Tips

• Spaulding memory trick: 'Critical = Sterile; Semi-critical = High-level Disinfection; Non-critical = Clean and Low-level Disinfection.'
• NLE question: 'What level of reprocessing does a urinary catheter require?' → Sterilization (critical item).
• NLE question: 'What must the nurse do BEFORE sterilizing a surgical instrument?' → Clean it first (remove organic matter).
• The autoclave question: steam autoclave is the GOLD STANDARD — most common, reliable, economical.

Key Points

• The Spaulding Classification determines the LEVEL of reprocessing needed based on how the item contacts the patient.
• CRITICAL ITEMS (enter sterile tissue or vascular system — surgical instruments, urinary catheters, IV needles, cardiac catheters) → Must be STERILIZED.
• SEMI-CRITICAL ITEMS (contact mucous membranes or non-intact skin — endoscopes, laryngoscopes, respiratory therapy equipment, vaginal specula) → Require HIGH-LEVEL DISINFECTION (at minimum).
• NON-CRITICAL ITEMS (contact only intact skin — BP cuffs, stethoscopes, bedpans, bedside rails, hospital floors) → Require LOW- to INTERMEDIATE-LEVEL DISINFECTION or thorough CLEANING.
• CRITICAL RULE: CLEANING must ALWAYS come BEFORE disinfection or sterilization — organic matter (blood, mucus, feces) SHIELDS microorganisms from chemical and heat action.
• Most common, reliable, and economical sterilization method: STEAM AUTOCLAVE (moist heat, steam under pressure — 121°C at 15 psi for 15–30 minutes).
• Ethylene oxide (ETO) gas: used for heat-sensitive items (plastics, rubber, electronics).
• Hydrogen peroxide plasma: low-temperature sterilization for moisture-sensitive equipment.
• High-level disinfection agents: Glutaraldehyde, Orthophthalaldehyde (OPA), Hydrogen peroxide, Peracetic acid.
• Low/intermediate disinfection: Chlorine compounds (bleach), Alcohols (70% isopropyl/ethyl), Quaternary ammonium compounds (for surfaces).

Definitions

Section Title

Cleaning, Disinfection, and Sterilization (Spaulding Classification)

Common Mistakes

• Classifying stethoscopes and BP cuffs as semi-critical — they are NON-CRITICAL (contact intact skin only).
• Skipping cleaning before sterilization — a common error; organic material blocks effectiveness of heat and chemicals.
• Thinking endoscopes need sterilization — they contact mucous membranes, making them semi-critical requiring high-level disinfection (though sterilization is always acceptable if feasible).
• Confusing disinfection with sterilization — disinfection does NOT kill all spores; only sterilization does.

Exam Tips

• C. diff = SOAP AND WATER — this is an NLE-favorite question. Never use ABHR for C. diff isolation.
• Moment 2 (before aseptic procedure) is the MOST CRITICAL moment for protecting patients from HAIs during invasive procedures.
• 20 seconds of handwashing = roughly the time it takes to hum 'Happy Birthday' twice — a commonly cited mnemonic.
• NLE scenario: 'The nurse is about to insert an IV catheter. The previous task was charting on the computer. Which moment applies?' → Moment 1 (before touching the patient) AND Moment 2 (before an aseptic procedure) — document BOTH.

Key Points

• Hand hygiene is the #1 most effective, simplest, and most cost-effective infection control measure available to nurses.
• WHO 5 MOMENTS FOR HAND HYGIENE (must be memorized in sequence):
• Moment 1: BEFORE touching a patient.
• Moment 2: BEFORE a clean/aseptic procedure.
• Moment 3: AFTER body-fluid exposure risk.
• Moment 4: AFTER touching a patient.
• Moment 5: AFTER touching the patient's surroundings (even if you didn't touch the patient).
• ALCOHOL-BASED HAND RUB (ABHR): preferred for routine hand decontamination when hands are NOT visibly soiled. Faster, less skin-drying.
• SOAP AND WATER: required when hands are VISIBLY SOILED (blood, body fluids) AND for SPORE-FORMING organisms (especially Clostridioides difficile — C. diff) because ALCOHOL IS INEFFECTIVE AGAINST SPORES.
• Handwashing technique: wet hands → apply soap → rub all surfaces (palms, backs, between fingers, thumbs, nails, wrists) for at least 20 seconds → rinse under running water → dry with disposable paper towel → use towel to turn off tap.
• Keep hands LOWER THAN ELBOWS during handwashing so contaminated water runs from clean (forearms) to dirty (fingertips) — wait, actually: water runs from arms DOWN to fingertips then OFF into sink — hands held below elbows ensure contaminated water doesn't run back up the arm.
• Remove jewelry (rings, bracelets, watches) before handwashing — these harbor microorganisms.
• Artificial nails and chipped nail polish are NOT recommended in clinical settings — harbor organisms under nails.

Definitions

Section Title

Hand Hygiene – WHO 5 Moments

Common Mistakes

• Using ABHR for C. difficile — ALCOHOL DOES NOT KILL C. DIFF SPORES. Soap and water is mandatory for C. diff patients.
• Performing hand hygiene only after patient contact (Moments 4 and 5) and forgetting BEFORE contact (Moments 1 and 2) — protecting the patient from the nurse's own flora.
• Forgetting Moment 5 — after touching patient SURROUNDINGS, even without touching the patient (e.g., adjusting the bed rail or IV pole).
• Keeping hands HIGHER than elbows during handwashing — this allows contaminated water to run back down toward clean forearms. Hands should be BELOW elbows.

Exam Tips

• Classic NLE question: 'In what order should the nurse remove PPE after caring for a TB patient?' → Gloves → Goggles/face shield → Gown → Mask (remove mask outside the room).
• Donning vs. doffing: 'DON = Dress On (build protection layer by layer); DOFF = Discard Off (most contaminated first).'
• For airborne isolation scenarios (TB ward in a Philippine government hospital), the answer for mask type is ALWAYS N95 respirator, NOT surgical mask.
• NLE tip: The question 'What should the nurse do LAST when removing PPE?' → Remove the mask/respirator (outside the room).

Key Points

• PPE components: Gown, Mask (surgical mask or N95 respirator), Goggles/Face shield, Gloves.
• DONNING (PUTTING ON) SEQUENCE — most to least contaminated risk, from largest to smallest: GOWN → MASK/RESPIRATOR → GOGGLES/FACE SHIELD → GLOVES.
• Mnemonic for donning: 'GMGG' or 'Good Masks Guard Germs' → Gown, Mask, Goggles, Gloves.
• DOFFING (REMOVING) SEQUENCE — remove MOST CONTAMINATED items FIRST, to protect self from self-contamination; MASK removed LAST (outside the patient's room): GLOVES → GOGGLES/FACE SHIELD → GOWN → MASK/RESPIRATOR.
• Mnemonic for doffing: 'GGGM' → Gloves, Goggles, Gown, Mask.
• Perform HAND HYGIENE after each step of doffing and after all PPE is removed.
• Remove mask OUTSIDE the patient room (especially for airborne precautions) — this prevents exposure in the doorway.
• Gloves are the MOST contaminated item and are removed FIRST during doffing to prevent self-contamination of the face and mucous membranes.
• Gloves are SINGLE-USE: change between patients; change between dirty and clean tasks on the SAME patient (e.g., after perineal care, before IV care).
• Wearing gloves does NOT replace hand hygiene — perform hand hygiene even AFTER glove removal.
• N95 respirator must be FIT-TESTED to the individual nurse before use in clinical settings.

Definitions

Section Title

Personal Protective Equipment (PPE) – Donning and Doffing

Common Mistakes

• Removing the MASK first during doffing — the mask should be removed LAST, outside the room, because it protects the mucous membranes of the face.
• Confusing N95 respirator (airborne precautions) with surgical mask (droplet precautions) — a critical distinction in NLE questions.
• Forgetting hand hygiene after doffing — glove removal does not guarantee clean hands; ABHR or handwashing is still required.
• Reusing disposable gloves between patients — gloves are SINGLE-USE items.
• Skipping eye protection (goggles/face shield) when there is splash risk — standard precautions require eye protection when splashing of blood/body fluids is likely.

Exam Tips

• The NLE LOVES the 'MTV' mnemonic for Airborne: Measles, TB, Varicella — N95 + negative pressure room.
• Quick classification: 'Is it TB?' → Airborne (N95). 'Is it flu or meningitis?' → Droplet (surgical mask). 'Is it MRSA or C. diff?' → Contact (gown + gloves).
• Room pressure: TB patient = NEGATIVE pressure (sucks air in); Chemo patient (neutropenic) = POSITIVE pressure (pushes filtered air out).
• Scenario with immunocompromised patient: 'The nurse is caring for a post-BMT patient. A visitor arrives with a bouquet of fresh flowers. What should the nurse do?' → Ask the visitor to take the flowers home (no fresh flowers or standing water in protective isolation).
• In the Philippine public health setting: TB is a major concern; know that PTB patients in the community are managed under the DOTS (Directly Observed Treatment Short-course) program of the DOH.

Key Points

• STANDARD PRECAUTIONS: Apply to ALL patients regardless of diagnosis. Treat ALL blood, body fluids, secretions, excretions (EXCEPT sweat), non-intact skin, and mucous membranes as potentially infectious.
• Standard precautions include: Hand hygiene, PPE (gloves, gown, mask, eye protection as needed), Safe injection practices, Respiratory hygiene/cough etiquette, Safe handling of contaminated equipment and linen.
• TRANSMISSION-BASED PRECAUTIONS are used IN ADDITION to standard precautions for specific pathogens.
• CONTACT PRECAUTIONS: For organisms spread by direct or indirect contact. PPE = GOWN + GLOVES. Dedicated equipment. Single room preferred. Diseases: MRSA, VRE, C. difficile, scabies, wound infections.
• DROPLET PRECAUTIONS: For large respiratory droplets (>5 microns) that travel short distances (~1 meter). PPE = SURGICAL MASK. Private room or spatial separation (1 meter). Diseases: Influenza, Pertussis (whooping cough), Mumps, Rubella, Neisseria meningitidis (meningococcal disease).
• AIRBORNE PRECAUTIONS: For small airborne nuclei (<5 microns) that remain suspended in air and travel long distances. PPE = N95 RESPIRATOR + NEGATIVE-PRESSURE ROOM (Airborne Infection Isolation Room/AIIR) with door CLOSED. Diseases: Pulmonary Tuberculosis (PTB), Measles (Rubeola), Varicella (Chickenpox).
• AIRBORNE DISEASES MNEMONIC: 'MTV' → Measles, TB, Varicella. OR 'My Chicken Has TB.'
• PROTECTIVE (REVERSE) ISOLATION: Protects an IMMUNOCOMPROMISED patient (neutropenia, bone marrow transplant, organ transplant) FROM environmental organisms. Uses POSITIVE-PRESSURE room, NO fresh flowers/standing water, strict hand hygiene for all entering.
• Negative pressure (airborne) → sucks air IN from hallway to room → prevents airborne organisms from escaping the room.
• Positive pressure (protective) → pushes filtered air OUT from room to hallway → prevents environmental organisms from entering the room.

Definitions

Section Title

Standard and Transmission-Based (Isolation) Precautions

Common Mistakes

• Putting a TB patient in a POSITIVE-pressure room — TB requires NEGATIVE pressure (airborne precautions); positive pressure is for PROTECTIVE isolation.
• Using a SURGICAL MASK for TB/Measles/Varicella — ONLY an N95 RESPIRATOR provides adequate airborne protection.
• Forgetting that contact precautions require DEDICATED equipment (stethoscope, BP cuff, thermometer) for each patient.
• Confusing droplet (influenza, pertussis) with airborne (TB, measles, varicella) — key distinction is particle SIZE and DISTANCE of transmission.
• Applying ONLY transmission-based precautions without standard precautions — transmission-based precautions are ALWAYS in ADDITION to standard precautions, not a replacement.

Exam Tips

• CAUTI 'golden rule': drainage bag ALWAYS BELOW BLADDER LEVEL — a very common NLE question.
• VAP mnemonic: '30-45° + Oral care = VAP prevention' — remember the angle.
• CLABSI: 'maximal sterile barriers' means it's not enough to just wear gloves — you need full sterile gown, large drape, mask, and cap.
• NLE scenario: 'The nurse is ambulating a patient with a Foley catheter. Where should the bag be positioned?' → Below the level of the bladder, do not raise it above the patient's waist.

Key Points

• HAIs are largely PREVENTABLE; nurses are primary implementers of prevention bundles.
• CAUTI (Catheter-Associated Urinary Tract Infection) Prevention Bundle:
• - Insert urinary catheter ONLY when clinically indicated (not for convenience).
• - Use ASEPTIC technique during insertion.
• - Maintain a CLOSED drainage system — never disconnect tubing.
• - Keep drainage bag BELOW BLADDER LEVEL at all times (prevent backflow).
• - Remove catheter as EARLY as possible — daily necessity review.
• - Secure the catheter to prevent urethral traction.
• CLABSI (Central Line-Associated Bloodstream Infection) Prevention Bundle:
• - Hand hygiene before insertion and manipulation.
• - MAXIMAL STERILE BARRIERS during insertion (sterile gown, gloves, large drape, mask, cap).
• - CHLORHEXIDINE gluconate for skin antisepsis (preferred over povidone-iodine).
• - Optimal catheter site selection (subclavian vein preferred over femoral vein for adults).
• - Daily review of line necessity — remove line as soon as no longer needed.
• VAP (Ventilator-Associated Pneumonia) Prevention Bundle:
• - Elevate HEAD OF BED 30–45 degrees (semi-Fowler's).
• - Perform ORAL CARE with chlorhexidine regularly.
• - Daily sedation interruption and spontaneous breathing trials.
• - Subglottic secretion drainage.
• SSI (Surgical Site Infection) Prevention:
• - Appropriate PERIOPERATIVE ANTIBIOTICS (within 1 hour before incision).
• - Strict sterile technique in the operating room.
• - Blood glucose control (hyperglycemia impairs immunity).
• - Chlorhexidine or iodine skin preparation.
• Antimicrobial stewardship: Nurses support judicious antibiotic use by reporting cultures timely, questioning unnecessary orders, and educating patients about completing antibiotic courses.

Definitions

Section Title

Healthcare-Associated Infection (HAI) Prevention Bundles

Common Mistakes

• Placing the urine drainage bag ON THE BED or elevated above bladder level — ALWAYS keep the bag below the bladder to prevent urine backflow and CAUTI.
• Opening the closed catheter drainage system for 'routine' urine sampling — use the sampling port with aseptic technique; never disconnect the tubing.
• Forgetting to perform daily catheter necessity assessment — leaving catheters in longer than needed is a primary CAUTI risk factor.
• Using povidone-iodine instead of chlorhexidine for central line skin prep — current evidence supports chlorhexidine gluconate as the preferred agent.
• Positioning a ventilated patient flat (0°) — VAP prevention requires 30–45° head-of-bed elevation.

Exam Tips

• NLE question: 'When applying sterile gloves using the open method, which surface of the first glove may the nurse touch with bare hands?' → The INSIDE (cuff/inner surface) only.
• Remember: Bare → inside cuff only. Gloved → outside of second glove only.
• OR vs. bedside: CLOSED METHOD (OR with sterile gown); OPEN METHOD (bedside procedures).

Key Points

• TWO METHODS of sterile gloving:
• OPEN (CLOSED-HAND) METHOD: Used for bedside invasive procedures (catheter insertion, dressing changes, IV insertion into sterile fields). Hands emerge from gown cuffs BEFORE gloves are applied.
• CLOSED METHOD: Used in the OPERATING ROOM when wearing a sterile gown. Hands stay INSIDE the gown cuffs until gloves are pulled on over the cuffs. The sterile gown sleeve acts as a barrier.
• OPEN METHOD steps:
• Step 1: Open the sterile glove package without contaminating the inside. Place on a clean, dry, flat surface.
• Step 2: With the DOMINANT hand (bare), grasp the INSIDE CUFF (folded portion) of the FIRST GLOVE for the NON-DOMINANT hand and put it on.
• Step 3: With the GLOVED (dominant) hand, slide fingers UNDER THE OUTSIDE CUFF of the SECOND GLOVE and put it on the dominant hand.
• Step 4: Adjust both gloves; keep hands above waist and in view at all times.
• KEY RULE: Bare hand touches only the INSIDE (non-sterile surface) of the glove; gloved hand touches only the OUTSIDE (sterile surface) of the other glove.
• If a sterile glove tears, is punctured, or becomes contaminated during a procedure: STOP, remove the glove, perform hand hygiene, and apply a new sterile glove.
• Keep sterile-gloved hands above the waist and visible — if they drop below the waist or go out of sight, they are CONTAMINATED.

Definitions

Section Title

Sterile Gloving Techniques

Common Mistakes

• Touching the OUTSIDE of the first glove with a bare hand — the bare hand should ONLY touch the inner cuff (folded edge) of the first glove.
• Allowing sterile-gloved hands to fall below waist level after gloving — below waist = contaminated.
• Continuing a procedure with a torn or questionably contaminated glove — always stop and re-glove.

Exam Tips

• NLE question: 'The nurse is administering blood to a patient. Which identifiers should be verified?' → Full name AND date of birth/hospital number — NEVER room number.
• Fall prevention priority: 'Bed in lowest position with brakes locked' is the FIRST and most fundamental fall prevention measure.
• Restraint order: Time-limited (e.g., 24-hour order that must be renewed), least restrictive, and requires frequent monitoring documentation.
• Orthostatic hypotension prevention: 'Dangle the patient at the bedside before standing' — tested in post-operative and cardiac nursing scenarios.
• SBAR is the preferred communication tool for all Philippine hospitals adopting JCI or PhilHealth accreditation standards.

Key Points

• PATIENT IDENTIFICATION: Always use AT LEAST TWO IDENTIFIERS before any procedure, medication administration, or blood transfusion. Use: FULL NAME + DATE OF BIRTH or HOSPITAL NUMBER. NEVER use room number as an identifier.
• FALL PREVENTION — a priority nursing safety concern, especially for the elderly and post-operative patients:
• - Assess fall risk on ADMISSION and with every change in condition (use Morse Fall Scale or similar validated tool).
• - Keep BED in the LOWEST POSITION with BRAKES LOCKED at all times.
• - SIDE RAILS: Keep raised per policy — NOTE: raising all FOUR side rails simultaneously may constitute a RESTRAINT.
• - Keep CALL LIGHT, water, glasses, and personal items WITHIN PATIENT'S REACH.
• - Ensure ADEQUATE LIGHTING, DRY NON-SLIP FLOORS, clear pathways.
• - Use NON-SLIP FOOTWEAR (socks with grips or proper footwear).
• - Assist high-risk patients with AMBULATION and TOILETING — toileting needs are a common fall trigger.
• - Apply a FALL-RISK IDENTIFIER (e.g., yellow armband, bed sign) per institutional policy.
• - Address ORTHOSTATIC HYPOTENSION: instruct patients to RISE SLOWLY from lying to sitting to standing (dangle at bedside before full standing).
• RESTRAINTS — use as LAST RESORT only:
• - Requires a TIME-LIMITED PHYSICIAN'S ORDER (must be renewed periodically per institutional policy).
• - Use the LEAST RESTRICTIVE type of restraint appropriate for the situation.
• - Tie restraints to the MOVABLE PART OF THE BED FRAME, never to the side rails.
• - Use a QUICK-RELEASE KNOT (bow or clove hitch) for rapid removal in emergencies.
• - Monitor restrained patients frequently: skin integrity, circulation (check pulse distal to restraint), range of motion, nutrition, hydration, and toileting needs.
• - FOUR raised side rails = restraint → requires physician order.
• COMMUNICATION SAFETY — SBAR for structured handoff:
• - S = Situation (what is happening), B = Background (relevant history), A = Assessment (nurse's clinical assessment), R = Recommendation (what action is needed).
• SURGICAL SAFETY: Use WHO Surgical Safety Checklist; SITE MARKING to prevent wrong-site surgery; Time-out immediately before incision.

Definitions

Section Title

Patient Safety – Fall Prevention, Patient Identification, and Restraints

Common Mistakes

• Using room NUMBER as a patient identifier — room number alone is NEVER an acceptable identifier; always use name + DOB or hospital number.
• Tying a restraint to the SIDE RAIL — side rails move and can injure the patient. Always tie to the movable BED FRAME.
• Using a fixed knot (square knot) for restraints — always use a QUICK-RELEASE knot.
• Forgetting that 4 raised side rails = a restraint requiring a physician's order and monitoring.
• Only assessing fall risk on admission — fall risk must be reassessed with EVERY SIGNIFICANT CHANGE in patient condition (post-op, new medication, new neurological symptoms).

Exam Tips

• NLE question on waste segregation: 'Where does the nurse dispose of a blood-soaked gauze?' → YELLOW infectious waste bag.
• 'Where does the nurse dispose of a used needle and syringe?' → SHARPS container (puncture-proof).
• NEVER RECAP (two-handed) — if this appears as an NLE option, it is always WRONG.
• PEP for HIV: must start within 72 hours, ideally within 1–2 hours — a commonly tested fact.
• RA 9173 connection: Nurses are entitled to a safe work environment; employers who fail to provide sharps disposal systems violate occupational safety standards.

Key Points

• Philippine DOH Health Care Waste Management Manual mandates proper waste segregation:
• YELLOW bags: Infectious/hazardous waste (blood-soaked materials, body fluids, specimens, soiled dressings, cultures, isolation waste).
• BLACK bags: Non-infectious, non-hazardous waste (paper, packaging, food waste from non-infectious patients).
• PUNCTURE-PROOF SHARPS CONTAINERS: For needles, syringes, lancets, scalpel blades, glass ampoules, and other sharp objects.
• NEVER RECAP NEEDLES (using two hands) — single greatest cause of needlestick injuries.
• If recapping is absolutely necessary, use the ONE-HANDED SCOOP TECHNIQUE (lay cap flat on surface, scoop it up with the needle using one hand).
• Dispose of SHARPS IMMEDIATELY at the POINT OF USE — do not carry unprotected needles across the room.
• Sharps containers must be properly labeled, closed, and disposed of when 3/4 FULL — never overfill.
• NEEDLESTICK INJURY MANAGEMENT:
• 1. Remove glove(s) if worn.
• 2. Encourage BLEEDING by gently squeezing around the wound.
• 3. Wash with soap and running water for at least 20 seconds.
• 4. Do NOT apply bleach or scrub aggressively.
• 5. REPORT immediately to the supervisor and Employee Health/Infection Control.
• 6. Assess need for POST-EXPOSURE PROPHYLAXIS (PEP) — e.g., antiretrovirals for HIV exposure, HBV immunoglobulin for hepatitis B exposure.
• 7. Incident report documentation is required.
• Under RA 9173, nurses have the right to a safe working environment; employers are responsible for providing sharps safety devices and PPE.

Definitions

Section Title

Environmental and Waste Safety – Sharps and Segregation

Common Mistakes

• Using two hands to recap needles — the MOST dangerous sharps practice and the leading cause of needlestick injuries in healthcare settings.
• Placing sharps in regular waste bins or yellow infectious waste bags — sharps MUST go in PUNCTURE-PROOF sharps containers.
• Overfilling sharps containers (beyond 3/4 full) — increases risk of needlestick when disposing.
• Not reporting needlestick injuries — under-reporting is common but delays PEP, which must be started within 72 hours of exposure.
• Squeezing or applying suction to a needlestick wound — this does NOT remove the virus and can worsen tissue damage. Gently SQUEEZE to encourage bleeding, then wash with soap and water.