NCLEX Review Guide: Fundamentals - Comfort, Safety & Mobility, Hygiene, Skin Integrity

Pain Assessment and Management

• Pain is the 5th vital sign and should be assessed using appropriate scales (0-10 numeric scale for adults, FACES scale for children).
• Chronic pain differs from acute pain in that it persists beyond expected healing time and may not respond to traditional pain relief methods.
• Never assume a patient isn't in pain based on their appearance or behavior - pain is subjective and individual.

Fall Prevention and Mobility Assessment

• Fall risk assessment tools like the Morse Fall Scale help identify patients at high risk for falls based on factors like history of falling, secondary diagnosis, and ambulatory aids.
• Proper body mechanics include maintaining wide base of support, keeping back straight, and lifting with legs rather than back to prevent injury.

Safe Patient Transfer Steps:

1. Assess patient's ability to assist and cognitive status
2. Obtain adequate help and appropriate equipment
3. Explain procedure to patient
4. Use proper body mechanics throughout transfer
5. Ensure patient safety and comfort post-transfer

Basic Hygiene Principles

• Personal hygiene promotes physical and psychological well-being while preventing infection and maintaining skin integrity.
• Bathing frequency depends on patient's condition, activity level, and personal preferences - daily bathing isn't always necessary for all patients.

Pressure Injury Prevention and Management

• Pressure injuries develop when sustained pressure compromises blood flow to tissues, typically over bony prominences like sacrum, heels, and elbows.
• The Braden Scale assesses six risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear with scores ranging from 6-23.