Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
ATI Topic DescriptorsBasic Care and Comfort (13)Plan AHygiene Care: Evaluating Appropriate Use of Assistive DevicesCane in...
Prostate Surgeries: Calculating a Clientʼs Output When Receiving ContinuousBladder Irrigationspurpose: to maintain the pat...
Record type and amt of irrigation soln used, amt returned as drainage and the characterof drainageRecord and report any fin...
apply skin barrier and pouch. if creases next to stoma occur, use barrier paste to fill in;let dry 1-2 minapply non-allergi...
Ice massage or cold therapy are particularly effective for pain relief.Ice massage: apply the ice with firm pressure follow...
if client has CV problems, it is unwise to apply heat to large portions of the body bec theresulting massive vasodilation ...
proteins and fats are increased      promotes rebuilding of body tissues and to meet energy needs      specifically meat, c...
teach family to recognize s/s to expect as the clientʼs condition worsens and provide infoon who to call in an emergencydi...
Stage                                          S/S Stage 4, End Stage                           Impaired or absent cogniti...
ToiletingAssist pt to toilet as specified intervals to promote regularityfacilitate toilet hygiene after completion of elim...
Nocturnal leg cramps     REM Sleep disturbances         nightmares         REM Sleep behavior disorder         sleep paral...
How often do you have trouble sleepingSleep ApneaDo you snore loudly?Has anyone ever told you that you often stop breathin...
clientʼs height     distance between crutch pad and axilla     angle of elbow flexion     [make sure shoes are on before me...
easier of the two swing gaits     requires ability to bear body wt partially on both legsSwing through gait     requires c...
progressive takes about 15 min            pay attn to body noting areas of tension, tense areas replaced with            w...
highly effective in reducing postop pain     if pain acute, increase volume of musicBiofeedback     behavioral therapy tha...
Urinary Elimination: Providing Catheter CarePrevent infectionMaintain unobstructed flow of urine through the cath drainage ...
Integumentary--Maintain intact skin         turn the client q 1-2 hr                                             decrease ...
Aspirate for residual volume---note: intestinal residual < 10 mL, gastric residual <100mLreturn aspirated contents or foll...
As a last resort, provide a pharmacological agent as prescribed.ATI Topic DescriptorsPlan AHealth Promotion and Maintenanc...
critical that uterus is contracted firmly before clots are expressedpushing on an uncontracted uterus could invert the uter...
Positioning the client in a supine position with a wedge under one hip to laterally tilt herand keep her off her vena cava...
Hypoglycemia occurring in the 1st 3 days of life in the term newborn is defined as ablood glucose level of <40 mg/dL. In th...
Fetus     presenting part engages in pelvisFalse LaborContractions     painless, irregular freq, and intermittent     decr...
Toddler: Recognizing Expected Body-Image ChangesATIthe toddler appreciates the usefulness of various body partstoddlers de...
Abstinence is highly recommended. if sexually activity is occurring the use of birthcontrol is recommendedSexually Transmi...
readingsocial eventsContraception: Recognizing Correct Use of Condoms ATI p. 6Condoms: a thin flexible sheath worn on the p...
instruct the parents to call the primary care provider if bleeding, bruising, or re      dot-like rash occurs.Older Adult ...
Level of Injury           Movement Remaining                  Rehab PotentialC1-C3                          movement in ne...
Level of Injury           Movement Remaining                   Rehab Potential C7-C8                          All triceps ...
• level and severity of the SCI • type and degree of resulting impairments and disabilities • overall health of the patien...
A negative CST (normal finding) is indicated if within a 10 min period, with 3 uterinecontractions, there are no late decel...
Fetal breathing movements: at least 1 episode of 30 sec in 30 min = 2, absent or lessthan 30 sec duration = 0Gross body mo...
abnormal implantation of the fertilized ovum outside of the uterine cavity. The     implantation is usually in the fallopi...
Incompetent Cervix      painless, passive dilation of the cervix in the absence of uterine contractions. The      cervix i...
the premature separation of the placenta from the uterus, which can be a partial     or complete detachment. This separati...
woman has an elevated BP at 140/90 mmHg or greater, or a systolic increase of     30 mmHg or diastolic increase of 15 mmHg...
infection                              sign/symptom T-toxoplasmosis                             influenza sx or lymphadenop...
Inform the parents that the circumcision will heal completely within a couple of weeks.Discharge Teaching: Evaluating Clie...
Theorist              Type of Development                    Stage Piaget                        Cognitive                ...
independence is paramount for the toddler who is attempting to do everything forhimselfseparation anxiety continues to occ...
Wt: the infant gains 0.7 kg (1.5 lb) per month the first 6 months and 0.3 kg (0.75 lb) permonth the last 6 months. The infa...
Marked curvatures in posture are abnormal.A slight limp, a crooked hemline, or ℅ a sore back are other s/s of scoliosisins...
A durable power of attorney for health care (health proxy) is an indiv designated tomake health care decisions for a clien...
designates an agent, surrogate, or proxy to make health care decisions if and      when the client is no longer able to ma...
Skills        risk taking        vision        self-confidence        Articulate communication        assertivenessValues  ...
Time of discharge, mode of transportation, and who accompanied the client.This should begin when the client is admitted to...
Effective communication skills      Mutual respect and trust      Shared decision makingThe nurse contributes      Knowled...
assuming the tripod position and a mirror placed on the table during use of an electricrazor or hair dryer conserves more ...
The desired goal in resolving conflict in both parties is to reach a satisfactory resolution.This is a win-win situationCon...
Strategy                              CharacteristicsSmoothing                                 One party attempts to “smoo...
Conflict Resolution                Advantages                  Disadvantages        Technique Compromising---each side     ...
this is especially important for a client using a bedpan. The call light and a supply oftoilet paper should be within easy...
Incorporate the consultantʼs recommendations into the clientʼs plan of careFacilitate coordination of the consultantʼs rec...
Request the clientʼs self-eval of progressObserve verbal and nonverbal communicationRevise the care plan as needed.Delegat...
Right Circumstance                        Wrong Circumstance    Delegate AP to take and record check-in    Delegate AP to ...
A clear, concise, description of the task, including its objective, limits, and expectationsis given. Communication must b...
Right Supervision                            Wrong Supervision An RN delegates to an LPN the task of        An RN delegate...
alway provide unambiguous and clear directions by describing a task, the desiredoutcome, time period within which the task...
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Ati bible
Upcoming SlideShare
Loading in …5
×

Ati bible

19,198 views

Published on

  • Be the first to comment

Ati bible

  1. 1. ATI Topic DescriptorsBasic Care and Comfort (13)Plan AHygiene Care: Evaluating Appropriate Use of Assistive DevicesCane instructions:Maintain two points of support on the ground at all timesKeep the cane on the stronger side of the bodySupport body wt on both legs, move cane forward 6-10 inches, then move the weakerleg forward toward the cane.Next, advance the stronger legDentures:Clients who have fragile oral mucosa require gentle brushing and flossing.Perform denture care for the client who is unable to do it himselfRemove dentures with a gloved hand, pulling down and out at the front of the upperdenture, and lifting up and out at the front of the lower denture.Place dentures in a denture cup or emesis basinBrush them with a soft brush and denture cleanerRinse them with waterStore the dentures, or assist the client with reinserting the denturesComplimentary and Alternative Therapies: Appropriate Use of Music Therapy forPain ManagementMusic decreases physiological pain, stress and anxiety by diverting the personʼs attention away from the pain and creating a relaxation response. let client select the type of music music produces an altered state of consciousness through sound, silence, space and time must be listened to for 15-30 minutes to be therapeutic earphones help client concentrate on music while avoiding other clients or staff highly effective in reducing postop pain if pain acute, increase volume of music
  2. 2. Prostate Surgeries: Calculating a Clientʼs Output When Receiving ContinuousBladder Irrigationspurpose: to maintain the patency of indwelling urinary catheters (bec blood, pus, orsediment can collect within tubing resulting in bladder sistention and buildup of stagnanturine)Med-Surg p. 1443after prostate surgery, irrigation is typically done to remove clotted blood from thebladder and ensure drainage of urine.if bladder manually irrigated, 50ml of irrigating soln should be instilled and thenwithdrawn with a syringe to remove clots that may be in bladder and catheter.with CBI, irrigating soln is continuously infused and drained from the bladder. The rateof infusion is based on the color of drainage. Ideally the urine drainage should be lightpink without clots. The inflow and outflow of irrigant must be continuously monitored. Ifoutflow is less than inflow, the catheter patency should be assessed for clots or kinks. Ifthe outflow is blocked and patency cannot be reestablished by manual irrigation, theCBI is stopped and the physician notified.Record amount of urine output andcharacter of urine every eight (8) hoursor as per physicianʼs orders.(To obtain urine output, subtract amountof fluid instilled into bladder from totaloutput.)intermittent irrigationdorsal recumbent or supine positionavoid cold solution bec may result in bladder spasmclamp cath just below soft injection portcleanse injection port with antiseptic swab (same port as specimen collection)insert needle through port at 30degree angleslowly inject fluid into cath and bladderwithdraw syringe remove clamp and allow solution to drain into drainage bagif ordered by MD, keep clamped to allow solution to remain in bladder for short time(20-30min)Closed continuous irrigationRecording and Reporting
  3. 3. Record type and amt of irrigation soln used, amt returned as drainage and the characterof drainageRecord and report any findings such as complaints of bladder spasms, inability to instillfluid into bladder and/or presence of blood clots.Urinary Elimination: Kegel Exercises for Urinary Incontinencesits on toilet with knees far apart and tightens muscle to stop the flow of urine ( tolearn the muscle)then practiced at nonvoiding timesinstruct client to contract muscle for a count of 3, hold and release for a count of 3, andrepeat this 10x.Client should repeat these cycles for 25-30x 3x/day for 6 months.Client should do this 5x.dayBowel Elimination Needs: Client Education Regarding Colostomy CareStoma s/b pink.Dusky blue stoma---ischemiaBrown-black stoma---necrosismild to moderate swelling for 1st 2-3 weeks after surgeryintact skin barriers with no evidence of leakage do not need to be changed daily andcan remain in place for 3-5 days.skin should be washed with mild soap, warm water and dried thoroughly beforebarrier appliedpouch must fit snugly to prevent leakage around stoma. The opening around theappliance should be no more than 1/16 inch larger than the stoma. Stoma shrinks anddoes not reach usual size for 6-8 weeksempty pouch before it is 1/3 full to prevent leakagecleanse skin and use skin barriers and deodorizers to prevent skin breakdown andmalodor
  4. 4. apply skin barrier and pouch. if creases next to stoma occur, use barrier paste to fill in;let dry 1-2 minapply non-allergic paper tape around the pectin skin barrier in a picture frame method.Burns: Non-pharmacologic Comfort Interventions for Dressing ChangesMed/Surg p. 534-535DistractionsRelaxation tapesvisualizationguided imagerybiofeedbackmeditationused as adjuncts to traditional pharmacologic txs of painVisualization and guided imagery can be helpful to the nurse as well as the ptnurse ask the pt about a favorite hobby or recent vacationnurse can explore these areas further by asking questions that make the pt visualizeand describe a favorite hobby or recent vacationby using this method, both the nurse and the pt must focus on things besides the task athand. (ie dressing change) to keep the conversation flowingRelaxation tapes can be helpful when played at night to help the pt fall asleep.Application of Heat and Cold: Assess Need for Heat/Cold ApplicationsApplication of Cold: Ensure Safe Use of Cold ApplicationsPotter/Perry p. 1253-1254Cold and heat applications relieve pain and promote healing.selection varies with clientʼs conditions.moist heat can help relieve the pain from a tension HAcold heat can reduce the acute pain from inflamed jointsavoid injury to skin by checking the temp and avoiding direct application of the cold orhot surface to the skinesp at risk: spinal cord or other neuro injury, older adults, confused clients
  5. 5. Ice massage or cold therapy are particularly effective for pain relief.Ice massage: apply the ice with firm pressure followed by slow steady, circular massageCold may be applied to pain site on the opposite side of the body corresponding to thepain site or on a site located between the brain and the pain site.takes 5-10 minutes to apply coldeach client responds differently to the site of the application that is the most effectiveapplication near the actual site of pain tends to work besta client feels cold, burning and aching sensations and numbness. When numbnessoccurs, the ice should be removed.cold is particularly effective for tooth or mouth pain when ice is place on the web of thehand between the thumb and index fingercold applications are also effective before invasive needle puncturesHeat applicationdonʼt lay on heating element bec burning could occurAssessment for Temperature Tolerance (P/P p. 1549)before applying either, the nurse should assess the clientʼs physical condition for signsof potential intolerance to heat and coldfirst observe the area to be txʼdalterations in skin integrity, such as abrasions, open wounds, edema, bruising, bleedingor localized areas of inflammation increase the clientʼs risk of injury.baseline skin assessment provides a guide for evaluating skin changes that might occurduring therapyassessment includes id of conditions that contraindicate heat or cold therapy:an active area of bleeding should not be covered by a warm application bec bleedingwill continuewarm applications are contraindicated when client has an acute, localized inflammationsuch as appendicitis bec the heat could cause the appendix to rupture.
  6. 6. if client has CV problems, it is unwise to apply heat to large portions of the body bec theresulting massive vasodilation may disrupt blood supply to vital organs.cold is contraindicated if the site of injury is already edematouscold furth retards circulation to the area and prevents absorption of the interstitial fluid.if client has impaired circulation (arteriosclerosis), cold further reduces blood supply toaffected areacold contraindicated in presence of neuropathy (client unable to perceive tempchanges)cold contraindicated in shivering (intensifies shivering and dangerously increase bodytemp)If MD orders cold therapy to lower extremity, assess for cap refill, observing skin colorand palpating skin temp, distal pulses and edematous areasif signs of circulatory inadequacy, question orderif confused or unresponsive, make freq observations of skin integrity after therapybeginsassess condition of equip usedbefore applying heat and cold, understand normal body responses to local tempvariations, assess the integrity of the body part, determine the clientʼs ability to sensetemp variations and ensure proper operation of equipment.Crohnʼs Disease: Selecting a Low-Fiber, Low-Residue DietNo raw vegetables, vegs not strained, dried beans, peas, and legumesNo raw fruits, fruits with skins, seedsNo nuts, raisins, rich dessertsno whole grain breads or cerealsno fried, smoked, pickled or cured meats,no alcohol, fruit juices with pulpDumping Syndrome: Client Education Regarding Dietary Interventionsmeal size must be reduced accordingly (6 small feedings)no drinking fluids with meals (30-45 min before or after meals) helps prevent distention or a feeling of fullnessdry foods with low-carb content and moderate protein and fat content
  7. 7. proteins and fats are increased promotes rebuilding of body tissues and to meet energy needs specifically meat, cheese, eggs and mild products no concentrated sweets (honey, sugar, jelly, jam) cause dizziness, diarrhea, a sense of fullnessshort rest period after each mealCholecystitis: Dietary RestrictionsLow in fat, and sometimes a wt reduction diet is also recommended (4-6 weekstake fat soluble vit supplementsPalliative Care: Client/ Family Teachingcaring interventions rather than curing interventionsfor any age, diagnosis, any time, and not just during the last few months of lifepreservation of dignity becomes the goal of palliative careallows clientʼs to make more informed choices, achieve better alleviation of sx and havemore opportunity to work on issues of life closureestablish a caring relationship with both client and familymanagement of sx of disease and therapiesPreparing the Dying Clientʼs Family (P/P 588)Objectives:family will be able to provide appropriate physical care for the dying client in homefamily will be able to provide appropriate psychological support to the dying client.Describe and demonstrate feeding techniques and selection of foods to facilitate easeof chewing and swallowingDemonstrate bathing, mouth care, and other hygiene measures and allow family toperform return demoshow video on simple transfer techniques to prevent injury to themselves and client,help family to practiceinstruct family on need to enforce rest periods
  8. 8. teach family to recognize s/s to expect as the clientʼs condition worsens and provide infoon who to call in an emergencydiscuss ways to support the dying person and listen to needs and fearssolicit questions from family and provide info as needed.Evaluation:Have the family members demo physical care techniquesask family members to describe how they vary approaches to care when the client hassx such as pain or fatigueask the family to discuss how they feel about their ability to support the client .Cognitive Disorders: Promoting Independence in Hygiene for A Client withAlzheimerʼs Disease Stage S/S Stage 1, Forgetfulness Short term memory loss Decreased Attn Span Subtle Personality Changes Mild cognitive deficits Difficulty with depth perception Stage 2, Confusion Obvious memory loss Confusion, impaired judgement, confabulation Wandering behavior Sundowning (more confusion in late afternoon/early evening) Irritability and agitation Poor spatial orientation, impaired motor skills Intensification of sx when the client is stressed, fatigued, or in an unfamiliar environment Depression r/t awareness of reduced capacities Stage 3, Ambulatory dementia loss of reasoning ability Increasing loss of expressive language Loss of ability to perform ADLs More Withdrawn
  9. 9. Stage S/S Stage 4, End Stage Impaired or absent cognitive, communication and/or motor skills Bowel and bladder incontinence Inability to recognize family members or self in mirrorAssess teaching needs for the client and especially for the family members when theclientʼs cognitive ability is progressively declining.Review the resources avail to the family as the clientʼs health declines. A wide variety ofhome care and community resources may be avail to the family in many areas of thecountry, and these resources may allow the client to remain at home rather than in aninstitutionPerform self assessment regarding possible feelings of frustration, anger, or fear whenperforming daily care for clients with progressive dementiaNCP Med/Surg 1592Monitor ptʼs ability for independent self-care to plan appropriate interventions specific topt unique problemsUse consistent repetition of daily health routines as a means of establishing them becmemory loss impairs ptʼs ability to plan and complete specific sequential activitiesassist pt in accepting dependency to ensure that all needs are met.teach family to encourage independence and to intervene only when the pt isunable to perform to promote independenceBathing/Hygieneprovide desired personal articles, such as bath soap and hairbrush, to enhance memoryand provide carefacilitate ptʼs bathing self as appropriate to facilitate independence and provideappropriate help in hygieneDressing/Groomingprovide ptʼs clothes in accessible area to facilitate dressingBe available for assistance in dressing as necessary to facilitate independence andprovide appropriate help in dressing
  10. 10. ToiletingAssist pt to toilet as specified intervals to promote regularityfacilitate toilet hygiene after completion of elimination to prevent discomfort and skinbreakdown.Rest and Sleep: Recognizing and Reporting Sleep Disorders (P/P 1203)If untreated lead to three problemsinsomniaabnormal movements or sensation during sleep or when awakening at night, orexcessive daytime sleepiness.Four categoriesDyssomnias (origins in body systems ) Intrinsic (initiating and maintaining sleep) psychophysiological insomnia narcolepsy periodic limb movement disorders sleep apnea syndromes Extrinsic (outside the body) inadequate sleep hygiene insufficient sleep syndrome hypnotic dependent sleep disorders alcohol dependent sleep disorders Circadian Rhythm Sleep Disorders (misalignment of timing and what is desired) Time Zone Change Shift work sleep disorder Delayed sleep phase syndromeParasomnias (undesirable behaviors that occur during sleep) Arousal Disorders Sleepwalking Sleep terrors Sleep-Wake Transition Disorders Sleeptalking Sleep starts
  11. 11. Nocturnal leg cramps REM Sleep disturbances nightmares REM Sleep behavior disorder sleep paralysis Other Parasomnias sleep bruxism (teeth grinding) sleep enuresis (bed-wetting) SIDSSleep Disorders associated with Med-Psych Disorders Psych Disorders Mood disorders Anxiety disorders Psychoses Alcoholism Neurologic Disorders Dementia Parkinsonism Central degenerative disorders Other Med Disorders Nocturnal cardiac ischemia COPD PUDProposed sleep Disorders Menstruation-associated sleep disorders Sleep choking syndrome Pregnancy associated sleep disordersQuestions to Ask to Assess for Sleep DisordersInsomniaHow easily do you fall asleepDo you fall asleep and have difficulty staying asleep? How many times do you awakenDo you awaken early from sleepWhat time do awaken for good? What causes you to awaken early?What do you do to prepare for sleep? To improve you sleep?What do you think about as you try to fall asleep
  12. 12. How often do you have trouble sleepingSleep ApneaDo you snore loudly?Has anyone ever told you that you often stop breathing for short periods during sleep?(Spouse or bed partner/roommate report this)Do you experience HAs after awakeningDo you have difficulty staying awake during the dayDoes anyone else in your family snore loudly or stop breathing during sleep?NarcolepsyAre you tired during the dayDo you fall asleep at inopportune times?Do you have episodes of losing muscle control or falling to the floorhave you ever had the feeling of being unable to move or talk just before falling asleepDo you have vivid lifelike dreams when going to sleep or waking up?Basic Care and Comfort (13)Plan BMobility and Immobility: Recognizing Proper Use of CrutchesCrutch instructionsDo not alter crutches after proper fit has been determinedFollow crutch gait prescribed by physical therapysupport body wt at hand grips with elbows flexed 30 degreesposition crutches on unaffected side when sitting or rising from chair. Elkin---pg 135Use of crutches may be a temporary aid for persons with strains, in a cast or followingsurgical treatmentscrutches may be routinely and continuously used for those with congenital or acquiredMS abnormalities, neuromuscular weakness, or paralysis or they may be used afteramputations.Crutch measurement includes three areas:
  13. 13. clientʼs height distance between crutch pad and axilla angle of elbow flexion [make sure shoes are on before measuring]Standing crutches 4-6 in in front of feet and side of feetCrutch pads two to three fingers between top of crutch and axillaElbow should be flexed (30 degrees ATI)***any tingling in torso means crutches are used incorrectly or wrong sizeif crutch too long---pressure on axilla causing paralysis of elbow and wrist (crutch palsy)if crutch too short---bent over and uncomfortablelow handgrips cause radial nerve damagehigh handgrips cause clientʼs elbow to be sharply flexed and strength and stability aredecreased4-point gait requires wt bearing on both legs often used when client has paralysis, as in spastic children with CP may also be used for arthritic clients improves balance by providing wider base of support R crutch, L foot, L crutch, R foot3 point gait requires wt bearing on 1 foot affected leg does not touch ground may be useful for client with broken leg or sprained ankle R/L crutches, unaffected foot, R/L crutches, unaffected foot2-point gait requires partial wt bearing on each foot faster than 4-point gait requires more balance crutch movements are similar to arm movements while walking L crutch and R foot together, R crutch and L foot together.Swing to gait freq used by clients whose lower extremities are paralyzed or who wear wt-supporting braces on their legs
  14. 14. easier of the two swing gaits requires ability to bear body wt partially on both legsSwing through gait requires client have ability to sustain partial wt bearing on both feetStairs ( up) unaffected leg on step, both crutches come to step, repeat (down) move crutches to stair below, move affected leg forward, then unaffected legPain Management: Nonpharmacological Pain Management P/P---ch 42 P/P---pg 1250Nonpharmacological interventions include cognitive-behavioral and physicalapproachesbest if taught when not experiencing painGoals of cognitive-behavioral interventions change clientʼs perceptions of pain alter pain behavior provide clients with greater sense of controlGoals of physical approaches providing comfort correcting physical dysfunction altering physiological responses reducing fears associated with pain-related immobilityRelaxation and Guided Imagery Relaxation mental and physical freedom from tension or stress provide self control when discomfort or pain occurs reverse physical and emotional stress of pain can be used at any phase of health or illness not taught when client is in acute discomfort bec inability to concentrate describe common sensations client may feel decrease in temp numbness of a body part use as feedback free of noise light sheet or blanket use with guided imagery or separate
  15. 15. progressive takes about 15 min pay attn to body noting areas of tension, tense areas replaced with warmth and relation some times better if eyes closed background music can help combination of controlled breathing exercises and a series of contractions and relaxation of muscle groups.Guided Imagery client creates an image in the mind, concentrate on that image and gradually becomes less aware of painDistraction RAS (reticular activating system) inhibits painful stimuli if a person receives sufficient or excessive sensory input directs attention to something else and reduces awareness of pain even increases tolerance 1 disadvantage if works, may question the existence of pain works best for short, intense pain lasting a few minutes ex: invasive procedure or while waiting for analgesic to work RN assesses activities enjoyed by client that may act as distractions singing praying describing photos or pictures aloud listening to music playing games may include ambulation, deep breathing, visitors, television, and musicMusic decreases physiological pain, stress and anxiety by diverting the personʼs attention away from the pain and creating a relaxation response. let client select the type of music music produces an altered state of consciousness through sound, silence, space and time must be listened to for 15 minutes to be therapeutic earphones help client concentrate on music while avoiding other clients or staff
  16. 16. highly effective in reducing postop pain if pain acute, increase volume of musicBiofeedback behavioral therapy that involves giving individuals information about physiological responses (BP and tension) and ways to exercise voluntary control over those responses used to produce deep relaxation and is effective for muscle tension and migraine HACutaneous stimulation stimulation of the skin to relieve pain massage warm bath ice bag for inflammation transcutaneous electrical nerve stimulation (TENS) (also called counter stimulation) causes release of endorphins thus blocking transmission of painful stimulation advantage: measures can be used in the home reduce pain perception and help reduce muscle tension RN eliminates sources of environmental noise, helps client to assume a comfortable position, explains purpose of therapy Acupressure/Acupuncture vibration or electrical stimulation via tiny needles inserted into the skin and subcutaneous tissues at specific points elevation of edematous extremities to promote venous return and decrease swellingUrinary Elimination Needs: Preventing IncontinenceUse timed voidings to increase intervals between voidings/decrease voiding frequencyperform pelvic floor (Kegel) exercisesperform relaxation techniquesoffer undergarments while client is retrainingteach client not to ignore urge to voidprovide positive reinforcement as client maintains continence
  17. 17. Urinary Elimination: Providing Catheter CarePrevent infectionMaintain unobstructed flow of urine through the cath drainage systemPerineal Hygieneperineal hygiene 2x/day or prn for client with retention cathsoap and water are effectivecan be delegated to APCatheter careassess urethral meatus and surrounding tissue for inflammation, swelling anddischarge. Note amt, color, odor, and consistency of discharge. Ask client if any burningor discharge is feltwith towel, soap and water, wipe in a circular motion along length of catheter for 4inchesapply an abx ointment at urethral meatus and along 1 inch of cath if ordered by MDMobility and Immobility: Evaluating for Complications of ImmobilityComplications of Immobility Integumentary--Maintain intact skin turn the client q 1-2 hr decrease pressure limit sitting in chair to less than 2 hr Respiratory--maintain patent airway, teach the client to turn, cough and deep achieve optimal lung expansion and gas breath q 1-2 hr exchange and mobilize airway secretions yawn every hour use incentive spirometer CPT 2000ml fluid
  18. 18. Integumentary--Maintain intact skin turn the client q 1-2 hr decrease pressure limit sitting in chair to less than 2 hr Cardiovascular---maintain CV fx, increase increase activity activity tolerance and prevent thrombus avoid valsalva maneuver formation stool softener ROM avoid pillows under knees use elastic stockings SCD give low dose heparin Metabolic---decrease injuries to skin and provide high calorie high protein diet with maintain metabolism within normal fxing additional vits B and C monitor oral intake Elimination--maintain or achieve normal maintain hydration (at least 2000 mL urinary and bowel elimination patterns stool softener bladder and bowel training insert cath if bladder distended Musculoskeletal--maintain or regain body change position in bed q 2 hrs alignment and stability decrease skin and ROM MS system changes, achieve full or nutritional intake optimal ROM and prevent contractures CPM Psychosocial--maintain normal sleep/wake coping skills patter, achieve socialization and achieve maintain orientation independent completion of self care develop scheduleGastroenteral Feedings: Monitoring Tube FeedingsMonitoring for tube placementinitial placement is confirmed with xraymonitor gastric contents for pH. A good indication of appropriate placement is obtaininggastric contents with a pH between 0-4Injecting air into the tube and listening over the abdomen is not an acceptable practice
  19. 19. Aspirate for residual volume---note: intestinal residual < 10 mL, gastric residual <100mLreturn aspirated contents or follow protocolFlush tubing with 30-60 mL of H20Acute Glomerulonephritis: Dietary ChoiceAcute Glomerulonephritis: insoluble immune complexes develop and become trapped inthe glomerular tissue producing swelling and capillary cell deathMaintain prescribed dietary restrictionsFluid restriction (24 hr output + 500 mL)Sodium restrictionProtein restriction (if azotemia is present)Edema is treated by restricting sodium and fluid intakeDietary protein intake may be restricted if there is evidence of nitrogenous wastes.Varies with degree of proteinuria.Low protein, low sodium, fluid restricted dietRest and Sleep: Interventions to Promote Sleep for Hospitalized ClientsAssist the client in establishing and following a bedtime routineAttempt to minimize the number of times the client is awakened during the night whilehospitalizedOffer to assist the client with personal hygiene needs and/or a back rub prior to sleep toincrease comfortInstruct the client to: Exercise regularly at least 2 hr before bed time Arrange the sleep environment to what is comfortable Limit alcohol, caffeine, and nicotine in the late afternoon and evening Engage in muscle relaxation before bedtimeApply CPAP devices as ordered by PCP for clients with sleep apnea
  20. 20. As a last resort, provide a pharmacological agent as prescribed.ATI Topic DescriptorsPlan AHealth Promotion and Maintenance (13)Uterine Atony: Performing Appropriate Assessment (Murray/Mckinney p. 734-736)Atony: lack of muscle tone that results in failure of the uterine muscle fibers to contractfirmly around the blood vessels when the placenta separatesrelaxed muscles allow rapid bleeding from the endometrial arterieries at the placentalsitebleeding continues until uterine muscle fibers contact to stop the flow of blood.retention of a large segment of the placenta does not allow the uterus to contract firmlyand therefore can cause uterine atonyMajor signs of uterine atony include:fundus that is difficult to locatea soft or boggy feel when the fundus is locateda uterus that becomes firm as it is massaged byt loses its tone when massage isstoppeda fundus that is located above the expected levels which is at or near the umbilicusexcessive lochia especially if it is bright redexcessive clots expelledif a peripad is saturated in an hour, a lg amt of blood is considered to have been lostsaturation in 15 min represents an excessive loss of blood in the early PP perioda constant steady trickle is just as dangeioursif uterus is not firmly contracted, the first intervention is to massage the fundus until it isfirm and to express clots that may have accumulated in the uterusone hand is placed just above the symphysis pubis o support the lower uterine segmentwhile the other hand getnly but firmly massages the fundus in a cirucular motionclots are expressed by applying firm but gently pressure on the fundus in the direction ofthe vagina
  21. 21. critical that uterus is contracted firmly before clots are expressedpushing on an uncontracted uterus could invert the uterus and cause massivehemorrhage and rapid shock.ATI book p.304uterine atony is hypotonic uterus that is not firm described as boggy.if untreated will result in postpartum hemorrhage and may result in uterine inversionNursing assessmentsmonitor for s/s of uterine atony which includea uterus that is larger than normal and boggy with possible lateral displacement onpelvic examprolonged lochia dischargeirregulaor or excessive bleedingAssessments for uterine atony include:fundal height, consistency and locationlochia quantity, color, and consistencyNormal Physiological Changes of Pregnancy: Calculating the clientʼs deliverydateATI p. 34Nageleʼs rule:take the first day of the last menstrual period, subtract 3 months and add 7 days and 1year.McDonaldʼs methodmeasure uterine fundal height in centimeteres from the symphysis pubis to the top ofthe uterine fundus (between 18 to 30 weeks gestation age). The calculation is as followsthe gestational age is estimated to be equal to fundal height.Cesarean Birth: Appropriate Client Positioning ATI p. 218
  22. 22. Positioning the client in a supine position with a wedge under one hip to laterally tilt herand keep her off her vena cava and descending aorta. This will help maintain optimalperfusion of oxygenated blood to the fetus during the procedure.Antepartum Diagnostic Interventions: Monitoring during a Nonstress Test ATI p.85Nonstress Testmonitor the response of the FHR to fetal movementclient pushes a button attached to the monitor whenever she feels a fetal movementthat is noted on the paper tracing.NST Reactive : FHR accelerates to 15 beats/min for at least 15 sec and occurs 2 ormore times during a 20 min period placenta is adequately perfused and the fetus is well-oxygenatedNST Nonreactive: FHR does not accelerate adequately with fetal movement or no fetalmovements occur in 40 min. if so, further assessment such as a contraction stress test or biophysical profile isindicatedDisadvantages: high rate of false nonreactive results with the fetal movement responseblunted by fetal sleep cycles, chronic tobacco smoking, meds, and fetal immaturityclient should be in a reclining chair or in a semi-fowlersʼ or left lateral positionif there are no fetal movements (fetal sleeping), vibroacoustic stimulation (sound source,usually laryngeal stimulator) may be activated for 3 sec on the maternal abdomen overthe fetal head to awaken a sleeping fetusIf still nonreactive, anticipate a CST or a BPPNewborn Hypoglycemia: Identify Appropriate Interventions ATI p. 424Hypoglycemia : serum glucose level of less than 40mg/dLdiffers from preterm and term newborn
  23. 23. Hypoglycemia occurring in the 1st 3 days of life in the term newborn is defined as ablood glucose level of <40 mg/dL. In the preterm newborn, hypoglycemia is defined as ablood glucose level of < 25 mg/dLUntreated hypoglycemia can result in mental retardationS/Spoor feedingjitteriness. tremorshypothermiadiaphoresisweak shrill crylethargyflaccid muscle toneseizures/comaassessments:monitoring BG level closelymonitoring IV if unable to orally feedmonitoring for signs of hypoglycemiamonitoring VS and tempNursing interventionsobtaining blood per heel stick for glucose monitoringfreq oral and/or gavage feeding or continuous parenteral nutrition is provided early afterbirth to treat hypoglycemia (untreated can lead to seizures, brain damage, and death)Labor and Birth Processes: Assess for True Labor vs. False Labor ATI p. 136True LaborContractions regular frequency stronger, last longer and are more freq felt in lower back, radiating to abdomen walking can increase contraction intensity continue despite comfort measuresCervix progressive change in dilation and effacement moves to anterior portion bloody show
  24. 24. Fetus presenting part engages in pelvisFalse LaborContractions painless, irregular freq, and intermittent decrease in freq, duration, and intensity with walking or position changes felt in lower back or abdomen above umbilicus often stop with comfort measures such as oral hydrationCervix (assessed by vaginal exam) no significant change in dilation or effacement often remains in posterior position no significant bloody showFetus presenting part is not engaged in fetusBonding: Promoting Maternal Psychosocial Adaptation During the Taking-InPhase ATI p. 290Taking In Phase--begins immediately following birth lasting a few hours to a couple ofdays. Characteristics include passive-dependent behavior and relying on others to meetneeds for comfort, rest, closeness, and nourishment. the client focuses on her ownneeds and is concerned about the overall health of her newborn. She is excited andtalkative, repeatedly reviewing the labor and birth experience.Facilitate the bonding process by placing the infant skin-to-skin wiht the mother soonafter birth in an en face positionEncourage the parents to bond with the infant through cuddling, feeding, diapering andinspecting the infantprovide a quiet and private environment that enhances the family bonding process.provide frequent praise, support and reassurance to the mother during the taking-holdphase as she moves toward independence in care of the newborn and adjusts to thematernal roleencourage the mother/parents to discuss their feelings, fears, and anxieties aboutcaring for their newborn
  25. 25. Toddler: Recognizing Expected Body-Image ChangesATIthe toddler appreciates the usefulness of various body partstoddlers develop gender identity by age 3Wongʼs Nursing Care of Children (p. 608)Growth slows considerably during toddlerhood.avg wt @ 2 years is 12 kg.head circumference slows and is usually equal to chest circumference by 1-2 years.Chest circumference continues to increase and exceeds head circumference during thetoddler years.After the 2nd year the the chest circumference exceeds the abdominal measurementwhich in addition to the growth of the lower extremities, gives the child, a taller leanerappearance.However, the toddler retains a squat, “pot-bellied” appearance bec of less well-developed abdominal musculature and short legs.Legs retain a slightly bowed or curved appearance during the second year form theweight of the relatively large trunk.Adolescent (12-20 years): Planning Age-Appropriate Health Promotion EducationSubstance abuse:Drug Abuse Resistance Education (DARE) and other similar programs provideassistance in preventing experimentationSexual Experimentation:
  26. 26. Abstinence is highly recommended. if sexually activity is occurring the use of birthcontrol is recommendedSexually Transmitted Diseases:Adolescents should undergo external genitalia exams, PAP smears, and cervical andurethral cultures (specific to gender).Rectal and oral cultures may also need to be takenThe adolescent should be counseled about risk taking behaviors and their exposure toSTDs as well as AIDS, hepatitis. The use of condoms will decrease the risk of STDsPregnancyidentification of pregnant adolescents should be done to ensure that nutrition andsupport is offered to promote the health of the adolescent and the fetus. Following infantdelivery, education should be given to prevent future pregnancies.Injury preventionencourage attendance at driverʼs ed courses. Emphasize the need for compliance withseat belt useteach the dangers of combining substance abuse with driving (MADD)Insist on helmet use with bicycles, motorcycles, skateboards, roller blades andsnowboardsscreen for substance abuseteach the adolescent not to swim aloneteach proper use of sporting equipmentAge-appropriate activities:nonviolent video gamesnonviolent musicsportscaring for a petcareer training programs
  27. 27. readingsocial eventsContraception: Recognizing Correct Use of Condoms ATI p. 6Condoms: a thin flexible sheath worn on the penis during intercourse to prevent semenfrom entering the uterusClient Instructionman places condom on his erect penis, leaving an empty space at the tip for a spermreservoirfollowing ejaculation, the man withdraws his penis from the womanʼs vagina whileholding condom rim to prevent any semen spillage to vulva or vaginal areamay be used in conjunction with spermicidal gel or cream to increase effectiveness.only water soluble lubricants should be used with latex condoms to avoid condombreakage.Immunizations: Recognizing Complications to Report ATI p. 279anaphylaxis review sx with parents prodromal sx--uneasiness, impending doom, restlessness, irritability, severe anxiety, HA, dizziness, parethesia, disorientation cutaneous signs are the most common initial sign,child may complain of feeling warm. angioedema is most noticeable in the eyelids, lips, tongue, hands, feet and genitalia cutaneous manifestations are often followed by bronchiolar constriction--narrowing of the airway, dilated pulmonary circulation causes pulmonary edema and hemorrhages and there is often life- threatening laryngeal edema instruct parents to call 991 or other emergency number and to keep the child quiet until help arrivesEncephalitis, seizures, and.or neuritis review sx with parents. instruct parents when to seek medical care teach parents to prevent injury during a seizureThrombocytopenia usually associated with measles vaccination teach parents to observe for bleeding
  28. 28. instruct the parents to call the primary care provider if bleeding, bruising, or re dot-like rash occurs.Older Adult (0ver 65 years): Assessing Risk for Social IsolationTwo forms of isolationmay be a choice, the result of a desire not to interact with othersmay be a response to conditions that inhibit the ability or the opportunity to interact wihtothers.vulnerable to its consequencesvulnerability increased in the absence of the support of other adults as may occur withloss of the work role or relocation to unfamiliar surroundings.impaired hearing, diminished vision, and reduced mobility all contribute to reducedinteraction with others and isolationthe loss of the ability to drive may limit older adultsʼ ability to live independently as wellas contributing to isolationsome withdraw bec of feelings of rejectionolder adults see themselves as unattractive and rejected bec of changes in theirpersonal appearance due to normal agingnurse can assist lonely older adults to rebuild social networks and reverse patterns ofisolationoutreach programsmeals on wheelssocialization needsdaily telephone call by volunteersneed for activities such as outingsSpinal Cord Injury: Promoting Independence In Self-CareSpinal cord injuries involve losses of motor fx, sensory, fx, reflexes, and control ofeliminationThe level of cord involved dictates the consequences of spinal cord injury. For example,injury at C3 to C5 poses a great risk for impaired spontaneous ventilation bec ofproximity of the phrenic nerve.Tetraplegia/paresis = 4 extremities. Paraplegia/paresis= 2 lower extremitiesTetraplegiaC1-C8ParaplegiaT1-L4
  29. 29. Level of Injury Movement Remaining Rehab PotentialC1-C3 movement in neck and ability to drive electricOften fatal injury, vagus above, loss of innervation to wheelchair equipped withnerve domination of heart, diaphragm, absence of portable ventilator by usingrespiration, blood vessels, independent respiratory fx chin control or mouth stick,and all organs below injury headrest to stabilize head; computer use with mouth stick, head wand, or noise control; 24 hr attendant care, able to instruct othersC4 sensation and movement in Same as C1-C3vagus nerve domination of neck and above; may beheart, respirations and all able to breathe without avessels and organs below ventilatorinjuryC5 full neck, partial shoulder, Ability to drive electricvagus nerve domination of back, biceps; gross elbow, wheelchair with mobile handheart, respirations, and all inability to roll over or use supports; indoor mobility invessels and organs below hands; decreased manual wheelchair; able tothe injury respiratory reserve feed self with setup and adaptive equipment; attendant care 10 hrs per dayC6 shoulder and upper back ability to assist with transfervagus nerve domination of abduction and rotation at and perform some self-care;heart, respirations, and all shoulder, full biceps to feed self with hand devices;vessels and organs below elbow flexion, wrist push wheelchair on smooth,the injury extension, weak grasp of flat surface; drive adapted thumb, decreased van from wheelchair; respiratory reserve independent computer use with adaptive equipment; attendant care 6 hrs per day
  30. 30. Level of Injury Movement Remaining Rehab Potential C7-C8 All triceps to elbow ability to transfer self to vagus nerve domination of extension, finger extensors wheelchair; roll over and sit heart, respirations, and all and flexors, good grasp with up in bed; push self on most vessels and organs below some decreased strength, surfaces; perform most self- the injury decreased respiratory care; independent use of reserve wheelchair; ability to drive care with powered hand controls (in some pts); attendant care 0-6 hrs per day T1-T6 full innervation of upper full independence in self- Sympathetic innervation to extremities, back essential care and in wheelchair heart, vagus nerve intrinsic muscles of hand; ability to drive car with hand domination of all vessels full strength and dexterity of controls (in most patients); and organs below injury grasp; decreased trunk independent standing in stability, decreased standing frame respiratory reserve T6-T12 Full stable thoracic muscle Full independent us of Vagus nerve domination and upper back; functional wheelchair; ability to stand only of leg vessels, GI and intercostals, resulting in erect with full leg brace, genitourinary organs increased respiratory ambulate on crutches with reserve swing (although gait difficult); inability to climb stairs L1- L2 Varying control of legs and Good sitting balance; full Vagus nerve domination of pelvis, instability of lower use of wheelchair; leg vessels back ambulation with long leg braces Level of Injury Movement Remaining Rehabilitation Potential L3-L4 Quadriceps and hip flexors, Completely independent Partial vagus nerve absence of hamstring ambulation with short leg domination of leg vessels, function, flail ankles braces and canes; inability GI and genitourinary organs to stand for long periodsThe success of rehabilitation depends on many variables, including the following:
  31. 31. • level and severity of the SCI • type and degree of resulting impairments and disabilities • overall health of the patient • family supportIt is important to focus on maximizing the patients capabilities at home and in thecommunity. Positive reinforcement helps recovery by improving self-esteem andpromoting independence.The goal of SCI rehabilitation is to help the patient return to the highest level of functionand independence possible, while improving the overall quality of life - physically,emotionally, and socially.Health Promotion and MaintenancePlan BAntepartum Diagnostic Interventions: Prenatal Fetal Heart Rate MonitoringNonstress Test (see below)Contraction Stress test (CST) an assessment performed to stimulate contractions(which decrease placental blood flow) and analyze the FHR in conjunction with thecontractions to determine how the fetus will tolerate the stress of labor.A pattern of at least 3 contractions within a 10 min time period with duratio of 40-60 seceach must be obtained to use for assessment dataNipple stimulated CST consists of the woman lightly brushing her palm across thenipple for 2 or 3 min, which causes the pituitary gland to release endogenous oxytocin,and then stopping the nipple stimulation when a contraction begins The same processis repeated after a 5 min rest period Hyperstimulation of the uterus (uterine contraction longer than 90 sec or morefreq than q 2 min) should be avoided by stimulating the nipple intermittently with restperiods in between and avoiding bimanual stimulation of both nipples unless stimulationof one nipple is uncuccessfulOxytocin admin CST is used if nipple stimulation fails and consists of IV admin ofoxytocin to induce uterine contractions Contractions started with oxytocin may be difficult to stop and can lead topreterm labor
  32. 32. A negative CST (normal finding) is indicated if within a 10 min period, with 3 uterinecontractions, there are no late decels of the FHRA positive CST (abnormal finding) is indicated with persistent and consistent late decelson more than half of the contractions. This is suggestive of uteroplacental insufficiency.Variable decels may indicate cord compression and early decls may indicate fetal headcompression.Nursing ManagementFor a CST, the nurse should Obtain a baseline of the FHR, fetal movement and contractions for 10-20 min and document Complete an assessment without artificial stimulation if contractions are occurring spontaneously Initiate nipple stimulation if there are no contractions. Instruct the client to roll a nipple between her thumb and fingers or brush her palm across her nipple. the client should stop when a uterine contraction occurs. Monitor and provide adequate rest periods for the client to avoid hyperstimulation of the uterus. Initiate IV oxytocin admin if nipple stimulation fails to elicit a sufficient uterine contraction patternComplications Hyperstimulation of the uterus Preterm labor Monitor for contractions lasting longer than 90 sec and/or occurring more freq than q 2 minBiophysical Profile (BPP)uses a real time ultrasound to visualize physical and physiological characteristics of thefetus and observe for fetal biophysical responses to stimuli.Five variablesReactive FHR: reactive nonstress test = 2, nonreactive = 0
  33. 33. Fetal breathing movements: at least 1 episode of 30 sec in 30 min = 2, absent or lessthan 30 sec duration = 0Gross body movements: at least 3 body or limb extensions with return to flexion in 30min = 2, less than 3 episodes = 0Fetal tone: at least 1 episode of extension with return to flexion = 2; slow extension andflexion, lack of flexion, or absent of movement = 0Amniotic fluid volume: at least 1 pocket of fluid that measures at least 1 cm in 2perpendicular planes = 2; pockets absent or less than 1 cm = 0For BPP the nurse should follow the same management as ultrasoundComplications of Pregnancy: Recognizing Abnormal FindingsBleeding during Pregnancy vaginal bleeding during pregnancy is always abnormal and must be carefully investigated in order to determine the causeSpontaneous Abortion when a pregnancy is terminated before 20 weeks gestation (the point of fetalviability) or fetal wt less than 500 g.Assessments vaginal spotting or moderate to heavy bleeding with or without pain in early pregnancy passage of tissue (products of conception) mild to severe uterine atony backache rupture of membranes dilation of the cervix fever abdominal tenderness s/s of hemorrhage such as hypotensionEctopic Pregnancy
  34. 34. abnormal implantation of the fertilized ovum outside of the uterine cavity. The implantation is usually in the fallopian tube, which can result in a tubal rupture causing a fatal hemorrhage.Assessments one or two missed menses unilateral stabbing pain and tenderness in the lower abdominal quadrant scant, dark red or brown vaginal spotting if tube ruptures (bleeding may be into intraperitoneal area). referred shoulder pain from blood irritation of the diaphragm or phrenic nerve (common sx) N/V freq after tube rupture sx of hemorrhage and shockGestational Trophoblastic Disease proliferation and degeneration of trophoblastic villi in the placenta which becomes swollen, fluid-filled and takes on the appearance of grape-like clusters. the embryo fails to develop beyond a primitive start and these structures are associated with choriocarcinoma which is a rapidly metastasizing malignancy. Two types of molar growths are identifies by chromosomal analysisAssessments rapid uterine growth larger than expected for the duration of the pregnancy due to the overproliferation of trophoblastic cells vaginal bleeding at approximately 16 wks gestation. Bleeding is often dark brown resembling prune juice, or bright red that is either scant or profuse and continues for a few days or intermittently for a few weeks bleeding accompanied by discharge from the clear fluid-filled vesciles excessive vomiting (hyperemesis gravidarum) due to elevated hCG levels sx of pregnancy-induced HTN (PIH), including HTN, edema, and proteinuria that occur prior to 20 weeks gestation (PIH usually does not occur until after 20 wks gestation)
  35. 35. Incompetent Cervix painless, passive dilation of the cervix in the absence of uterine contractions. The cervix is incapable of supporting the wt and pressure of the growing fetus and results in expulsion of the products of conception during the second trimester of pregnancy. This usually occurs around week 20 of gestation.Assessments pink stained vaginal discharge or bleeding increase in pelvic pressure possible gush of fluid (rupture of membranes) uterine contractions with the expulsion of the fetus postop (cerclage) monitoring for uterine contractions, rupture of membranes and signs of infectionPlacenta Previa when the placenta abnormally implants in the lower segment of the uterus nearor over the cervical os instead of attaching to the fundus. The abnormal implantationresults in bleeding during the third trimester of pregnancy as the cervix begins to dilateand effaceAssessments painless, bright red vaginal bleeding that increases as the cervix dilates a soft relaxed, nontender uterus with normal tone a fundal ht greater than usually expected for gestational age a fetus in a breech, oblique or transverse position a palpable placenta VS that are usual and within normal limitsAbruptio Placenta
  36. 36. the premature separation of the placenta from the uterus, which can be a partial or complete detachment. This separation occurs after 20 wks gestation, which is usually in the third trimester. It has significant maternal and fetal morbidity and mortality and is a leading cause of maternal deathAssessments sudden onset of intense localized uterine pain vaginal bleeding that is bright red or dark A board like abdomen that is tender a firm rigid uterus with contractions (uterine hypertonicity) fetal distress sx of hypovolemic shockHyperemesis Gravidarum excess N/V (r/t elevated HcG levels) that is prolonged past 12 weeks gestation and results in a 5% wt loss form prepregnancy wt, dehydration, electrolyte imbalance, ketosis, and acetonuria.Assessments excessive vomiting for prolonged periods dehydration with possible electrolyte imbalance wt loss decreased blood pressure increased pulse rate poor skin turgorGestational Hypertension/Pregnancy Induced Hypertension begins after the 20th wk of pregnancy,
  37. 37. woman has an elevated BP at 140/90 mmHg or greater, or a systolic increase of 30 mmHg or diastolic increase of 15 mmHg from the prepregnancy state Mild preeclampsia is GH with the addition of proteinuria of 1 - 2+ and a wt gain of more than 2 kg per wk in the 2nd and 3rd trimesters. Severe preeclampsia consists of BP that is 160-100 mmHg or greater, proteinuria 3-4+, oliguria, elevated serum creatinine greater than 1.2 mg/dL, cerebral or visual disturbances (HA and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and RUQ pain. Eclampsia is severe preeclampsia sx along with the onset of seizure activity or coma.Assessments progression of hypertensive disease with indications of worsening liver involvement, renal failure, worsening HtN, cerebral involvement, and developing coagulopathies rapid wt gain 2 kg per wk in the second and third trimester fetal distressGestational Diabetes an impaired toleratnce to glucose with the first onset or recognition duringpregnancy. The ideal blood glucose level should fall between 60-120 mg/dLAssessments hunger and thirst freq urination blurred vision excess wt gain during pregnancyTORCH infections group of infections that can negatively affect a woman who is pregnant. Theseinfections can cross the placenta and have teratogenic affects on the fetus. TORCHdoes not include all the major infections that present risks to the mother and fetus
  38. 38. infection sign/symptom T-toxoplasmosis influenza sx or lymphadenopathy O-other infection dependent on infection R-rubella (german measles) rash, muscle aches, joint pain, mild lymphedema, fetal consequences including miscarriage, congenital anomalies and death C-cytomegalovirus (member of Herpes asymptomatic or mononucleosis-like sx virus family) H-Herpes simples virus (HSV) lesions initial outbreakCircumcision: Evaluating Effectiveness of Discharge TeachingPostop parent teaching:Teach the parents to keep the area clean. Change the infantʼs diaper at least every 4 hrand clean the penis with warm water with each diaper change.With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hrafter the circumcision to keep the diaper from adhering to the penis. The diaper shouldbe fan folded to prevent pressure on the circumcised areaAvoid wrapping the penis in tight gauze, which can impair circulation to the glans.A tub bath should not be given until the circumcision is completely healed. Until then,warm water should be gently trickled over the penisNotify the PCP if there is any redness, discharge, swelling, strong odor, tenderness,decrease in urination, or excessive crying from the infant.Tell the parents a film of yellowish mucus may form over the glans by day 2 and it isimportant not to wash this offTeach the parents to avoid using premoistened towelettes to clean the penis bec theycontain alcohol.Inform the parents that the newborn may be fussy or may sleep for several hrs after thecircumcision
  39. 39. Inform the parents that the circumcision will heal completely within a couple of weeks.Discharge Teaching: Evaluating Clientʼs Understanding of Bulb Syringe UseOral and Nasal Suctioningteach the parents to use a bulb syringe to suction any excess mucus from the nose andmouthparents should suction the mouth first and then the nose, one nostril at a timethe bulb should be compressed before inserting it into the infantʼs mouth or nosewhen suctioning the infantʼs mouth, always insert the bulb on the sides of the infantʼsmouth not in the middle and do not touch the back of the throat to avoid the gag reflexPostpartum Physiological Changes and Nursing Care: Performing FundalAssessmentDocument the fundal height, location and uterine consistencyDetermine the fundal ht by placing fingers on the abdomen and measuring how manyfingerbreadths (cm) fit between the fundus and the umbilicus above, below, or at theumbilical levelDetermine if the fundus is midline in the pelvis or displaced laterally (caused by a fullbladder)Determine if the fundus is firm or boggy. If the fundus is boggy (not firm), lightlymassage the fundus in a circular motion.Toddler: Provide Education on Age-Specific Growth and DevelopmentStages of Development Theorist Type of Development Stage Erickson Psychosocial Autonomy vs Shame Freud Psychosocial Anal
  40. 40. Theorist Type of Development Stage Piaget Cognitive Sensorimotor Transitions to preoperationalPhysical Developmentanterior fontanel close by 18 months of ageWt: At 30 months the toddler should weigh 4x his birth wt.Ht: the toddler grows by 7.5 cm (3 in) per yearDevelopmental Skillsdevelopment of steady gaitclimbing stairsjumping and standing on one foot for short periodsstacking blocks in increasingly higher numbersdrawing stick figuresundressing and feeding selftoilet trainingCognitive Developmentconcept of object permanence is fully developedToddlers demonstrate memory of events that relate to themlanguage increase to about 400 words with the toddler speaking in 2-3 word phrasespre-operational thought does not allow for the toddler to understand other viewpoints,but it does allow toddlers to symbolize objects and people in order to imitate activitiesthey have seen previouslyPsychosocial Development
  41. 41. independence is paramount for the toddler who is attempting to do everything forhimselfseparation anxiety continues to occur when a parent leaves the childMoral DevelopmentMoral development is closely associated with cognitive developmentEgocentric--toddlers are unable to see anotherʼs perspective; they can only view thingfrom their point of view.the toddlerʼs punishment and obedience orientation begins with a sense of goodbehavior is rewarded and bad behavior is punished.Self Concept Developmenttoddlers progressively see themselves as separate from their parents and increase theirexplorations away from themAge Appropriate ActivitiesSolitary play evolves into parallel play where the toddler observes other children andthen may engage in activities nearby filling and emptying containers playing with blocks reading books playing with toys that can be pushed and pulled tossing a ballInfant (Birth to 1 yr): Identifying Normal Physical Assessment FindingsPhysical DevelopmentThe infantʼs posterior fontanel closes at 2-3 months of ageThe infantʼs size is tracked by wt, ht, and head circumference
  42. 42. Wt: the infant gains 0.7 kg (1.5 lb) per month the first 6 months and 0.3 kg (0.75 lb) permonth the last 6 months. The infant triples birth wt by the end of the first yearHt: The infant grows 2.5 cm (1 in) per month the first 6 month and then 1.25 cm (0.5 in)per month the last 6 months.Head Circumference: The circumference of the infantʼs head increases 1.25 cm (0.5 in)per month the first 6 monthsFollowing size, the infant develops gross motor skillsHolds head up at 3 monthsRolls over at 5-6 monthsHolds head steady when sitting at 6 monthsGets to sitting position alone and can pull up to a standing position at 9 monthsStand hold on at 12 monthsStands alone at 12 monthsFine motor development follows next in the sequenceBrings hans togethergrasps rattlelooks for items that are dropped from viewtransfers an object from one hand to the other (6 months)rakes finger food with hand ( 6 months)uses thumb-finger to grasp items (9 months)Bangs two toys together (9 months)Can nest one object inside another (12 months)Scoliosis: Recognizing Signs During Routine ScreeningSchool age children should be screened for scoliosis by examining for a lateralcurvature of the spine before and during growth spurts.
  43. 43. Marked curvatures in posture are abnormal.A slight limp, a crooked hemline, or ℅ a sore back are other s/s of scoliosisinspect the back for any tufts of hair, dimples, or discoloration. Mobility of vertebralcolumn is easily assessed in children bec of their propensity for constant motion durinexamATI Topic DescriptorsManagement of Care (24)Plan AAdvance Directives: Recognize Purpose(ATI)Advance directive are written instructions that allow a client to convey his wishesregarding medical tx for situations when those wishes can no longer be personallycommunicated.All clients admitted to a health care facility be asked if they have an advance directive.The client without an advance directive must be given written information that outlineshis rights r/t health care decisions and how to formulate an advance directive.A health care representative should be available to help with this processLiving wills allows the client to specify end of life decisions she does or does not sanctionwhen unable to speak for herself. For example, the client can specify use or refusal of:CPR, if cardiac or respiratory arrest occursArtificial nutrition through IV or tube feedingsProlonged maintenance on a respirator if unable to breathe adequately aloneLiving wills must be specific and be signed by two witnesses.They can minimize conflict and confusion regarding health care decisions that need tobe madevary from state to state
  44. 44. A durable power of attorney for health care (health proxy) is an indiv designated tomake health care decisions for a client who is unable based upon the clientʼs living willBased upon the clientʼs advance directives, the physician writes orders for life-sustaining tx. Examples include:DNRMedical interventions (eg comfort measures only, IV fluids but no intubation, full tx)Use of ABXArtificially administered nutrition through a tube.Nursing responsibilities regarding advance directives include:provide written information regarding advance directivesdocument the clients advance directive statusensure that the advance directive is current and reflective of the clientʼs currentdecisions.inform all members of the health care team of the clients advance directive. (P/P)Two basic advance directivesliving will written documents that direct tx in accordance with a clientʼs wishes in the event of a terminal illness or condition. may be difficult to interpret two witnesses, neither of whom can be a relative or physician, are needed when the client signs the document if health care workers follow the directions of the living will, they are immune from liabilitydurable power of attorney for health care
  45. 45. designates an agent, surrogate, or proxy to make health care decisions if and when the client is no longer able to make decisions on his or her own behalf.In order for living wills or durable powers of attorney for health care to be enforceable,the client must be legally incompetent or lack decisional capacity to make decisionsregarding health care treatmentThe determination of legal competency is made by a judge, and the determination ofdecisional capacity is usually made by the physician and family.The implementation of the advance directive is done within the context of the healthcare team and the health care institution.When clients are legally incompetent and are unable to make health care decisions, thecourts balance the stateʼs interest with what the client would have wanted.Client Advocacy: Intervening on behalf of the ClientAs an advocate, nurses must ensure that clients are informed of their rights and haveadequate information on which to base health care decisionsNurses must be careful to “assist” clients with health care decisions and not “direct” or“control” their decisionsSituations in which the nurse may advocate for the client or assist the client to advocatefor herself include:End of life decisionsAccess to health careProtection of client privacyInformed consentSubstandard practiceEssential Components of Advocacy
  46. 46. Skills risk taking vision self-confidence Articulate communication assertivenessValues caring autonomy respect empowermentThe nurse protects the clientʼs human and legal rights and provides assistance inasserting those rights if the need ariseskeep in mind the clientʼs religion and cultureDischarge Planning: Interventions to Promote Timely Client DischargesThe process begins at time of admissionPlans are developed with client and family input, focusing on active participation by theclient to facilitate a timely dischargeServes as a starting point for continuity of care for the client by the caregiver, homehealth nurse, or receiving facility.The need for additional client or family support is included with recommendations forsupport services such as home health, outpatient therapy and respite care.Discharge Summary includes:Step by step instructions for procedures to be done at homePrecautions to take when performing procedures or administering medsS/s of complications that should be reportedNames and numbers of health care providers and community services the client/familycan contact.Plans for follow up care and therapies
  47. 47. Time of discharge, mode of transportation, and who accompanied the client.This should begin when the client is admitted to the facility unless the facility is to be theclientʼs permanent residenceassess whether or not the client will be able to return to his previous residencedetermine whether or not the client will nee and/or have someone to assist him at homeassess the residence to see if adaptations are required to accommodate the client priorto dischargemake a referral to the social worker to arrange for community services required by theclient at dischargecommunicate client health status and needs to community service providers.Clients Rights: Recognizing Client Rights Regarding Review of RecordsOnly health care team members directly responsible for the clientʼs care should beallowed access to the clientʼs records. The client has the right to review his medicalrecord and request information as necessary for understanding.Clientʼs rightsTo inspect and copy PHITo ask the health care agency to amend the PHI that is contained in a record if the PHIis inaccurateTo request a list of disclosures made regarding the PHI as specified by HIPAATo request to restrict the way the health care agency uses or discloses PHI regarding tx,payment or health care operations unless info is needed to provide emergency txTo request that the healthcare agency communicates with the client in a certain way orat a certain location ; the request must specify how or where the clientʼs wishes to becontacted.Collaboration with Interdisciplinary Team: Methods for CollaborationAn interdisciplinary team is a group of health care professionals from differentdisciplinesCollaboration is used by interdisciplinary teams to make health care decisions aboutclients with multiple problems. Collaboration, which may take place at team meetings,allows the achievement of results that the participants would be incapable ofaccomplishing if working alone.Key elements of collaboration include:
  48. 48. Effective communication skills Mutual respect and trust Shared decision makingThe nurse contributes Knowledge of nursing care and its management A holistic understanding of the client, her health care needs,and health caresystemsNurse-primary care provider collaboration should be fostered to create a climate ofmutual respect and collaborative practiceCollaboration can occur among different levels of nurses and nurses with different areasof expertise.Nursing Interventions:Use effective communication skillsParticipate in client rounds and interdisciplinary team meetingsPresent info relevant to the clientʼs health status and tx regimenAttend interdisciplinary clinical conferences/case presentations.COPD: Planning Strategies for FatigueATI---determine the clientʼs physical limitations and structure activity to includeperiods of restpromote adequate nutrition increased work of breathing increases caloric demandsMed-SurgEnergy Conservation Techniquespacing and pursing (pacing activity and using pursed lip breathing with activities
  49. 49. assuming the tripod position and a mirror placed on the table during use of an electricrazor or hair dryer conserves more energy than when the pt stands in front of a mirror toshave or blow dry hair.use 02 during activities of hygiene bec these are energy consumingpt should be encouraged to make a schedule and plan daily and weekly activities so asto leave plenty of time for rest periodspt should also try to sit as much as possible when performing activitiesexhale when pushing, pulling or exerting effort during and activity and inhale during rest.walking is the best exercise for COPDcoordinated walking with slow, pursed-lip breathing without breath holding.breathe in and out through now while taking one step then to breathe out throughpursed lips while taking 2-4 stepswalk 15-20 minutes a day with gradual increasesuse MDI 10 minutes before exercisesConflict Resolution: Identify StrategiesConflict is the result of opposing thoughts, ideas, feeling, perceptions, behaviors,values, opinions, or actions between individuals.Conflict is an inevitable part of professional, social, and personal life and can result inconstructive or destructive consequences Constructive Consequences Destructive Consequences stimulates growth and open and honest can produce divisiveness communication may foster rivalry and compeitition increases group cohesion and commitment misperceptions, distrust, and frustration to common goals can be created facilitates understanding and problem group dissatisfaction with the outcome may solving occur motivates group to changeLack of conflict can create organizational stasis, while too much conflict can bedemoralizing, produce anxiety, and contribute to burnout
  50. 50. The desired goal in resolving conflict in both parties is to reach a satisfactory resolution.This is a win-win situationConflict Resolution Strategies Strategy Characteristics Compromising Each party gives up something To consider this a win-win solution, both parties must give up something equally valuable. If one party gives up more than the other it can become a win-lose situation Competing One party pursues a desired solution at the expense of others This is a win-lose solution Managers may use this when a quick or unpopular decision must be made The party who loses something may experience anger, frustration, and a desire for retribution Cooperating/Accommodating One party sacrifices something, allowing the other party to get what it wants. This is the opposite of competing. this is a lose-win solution. The original problem may not actually be resolved. The solution may contribute to future conflict
  51. 51. Strategy CharacteristicsSmoothing One party attempts to “smooth” other party, decreasing the emotional component of the conflict Often used to preserve or maintain a peaceful work environment The focus may be on what is agreed upon, leaving conflict largely unresolved This is usually a lose-lose solutionAvoiding Both parties know there is a conflict, but they refuse to face it or attempt to resolve it. May be appropriate for minor conflicts or when one party holds more power than the other party or if the issue may work itself out over time Since the conflict remains, it may surface again at a later date and escalate over time this is usually a lose-lose solution Conflict Resolution Advantages Disadvantages TechniqueAvoiding--ignoring the does not make a big deal conflict can become biggerconflict out of nothing; conflict may than anticipated be minor in comparison to other prioritiesAccommodating--- one side is more concerned one side holds more powersmoothing or cooperating. with the issue than the other and can force the other sideOne side gives in to the side to give inother sideCompeting---forcing; the two produces a winner; good Produces a loser; leavesor three sides are forced to when time is short and anger and resentment oncompete for the goal stakes are high losing sides
  52. 52. Conflict Resolution Advantages Disadvantages Technique Compromising---each side no one should win or lose may cause a return to the gives up something and but both should gain conflict if what is given up gains something something; good for becomes more important disagreements between than the original goal indiv Negotiating---high level stakes are high and solution agreements are permanent, discussion that seeks is rather permanent; often even though each side has agreement but not involves powerful groups gains and losses necessarily consensus Collaborating--both sides best solution for the conflict takes a lot of time; requires work together to develop and encompasses all the commitment to success optimal outcome goals to each side Confronting--immediate and does not allow conflict o may leave impression that obvious movement to stop take root; very powerful conflict is not tolerated conflict at the very startGenitalia and Rectum: Providing PrivacyPreparation of the client (for Female pelvic exam)Client is asked to empty her bladder so that urine is not accidently expelled during theexam.Client is assisted in assuming the lithotomy position in bed or on an exam table for anexternal genitalia assessment and is assisted in stirrups if a speculum exam is to beperformed.The nurse places a hand to the edge of the table and then instructs the client to moveuntil touching the hand. The clientʼs arms should be at her side or folded across thechest to prevent tightening of abdominal musclesA square drape or sheet is given to the client. She holds one corner over the sternum,the adjacent corners fall over each knee, and the fourth corner covers the perineum.Close the door, or pull room curtains around the bathing area. While bathing the client,expose only the areas being bathed.During bowel elimination, the nurse should maintain the clientʼs privacy.
  53. 53. this is especially important for a client using a bedpan. The call light and a supply oftoilet paper should be within easy reach. Respond immediately.Consultation: Referral in Response to a Client ConcernA consultant is a professional who provides expert advice in a particular area. Aconsultation is requested to determine what tx/services the client requires.Consultations provide expertise to clients who require a particular type of knowledge orservice (eg, a cardiologist for a client who had a myocardial infarction, a psychiatrist fora client whose risk for suicide needs to be assessed)Coordination of the consultantʼs recommendations with other health care providersʼrecommendations is necessary to protect the client form conflicting and potentiallydangerous orders.Consultation is a process in which a specialist is sought to identify methods of care or txplans to meet the needs of a client.Consultation is needed when the nurse encounters a problem that cannot be solvedusing nursing knowledge, skills, and available resourcesConsultation also is needed when the exact problem remains unclear; a consultant canobjectively and more clearly assess and identify the exact nature of the problemReferrals are made so that the client can access the care identified by the PCP orconsultantThe care may be provided in the inpatient setting (eg PT, OT) or outside the facility (eg,hospice care, home health aide)Discharge referrals are based on client needs in r/t actual and potential problems andmay enlist the aid of:social servicesspecialized therapists (eg PT,OT, speech)care providers (home health nurses, hospice nurse)Knowledge of community resources i necessary to appropriately link the client withneeded servicesConsultation (interventions)Initiate the necessary consults or notify the PCP of the clientʼs needs so the consult canbe initiated.Provide the consultant with all pertinent info about the problem
  54. 54. Incorporate the consultantʼs recommendations into the clientʼs plan of careFacilitate coordination of the consultantʼs recommendations with other health careproviders; recommendations to protect the client from conflicting and potentiallydangerous orders.Referrals (Interventions)To ensure continuity of care by the use of referrals, the nurse should:Initiate the discharge plan upon the clientʼs admission.Evaluate client/family competencies in r/t home care prior to discharge.Involve the client and family in care planningCollaborate with other health care professionals to ensure all health care needs are metComplete referral forms to ensure proper reimbursement for services ordered.Client Education: Document Client TeachingClient teaching documentationInformation presented, method of instruction (eg discussion, demonstration, videotape,booklet), client response, including questions and evidence of understanding such asreturn demo or change in behavior.Nursing documentation must be accurate to correctly record information regarding theclientʼs care.The purpose of reporting is to provide continuity of care for client when several nursesprovide care. Reporting should be conducted in a confidential manner.Evaluation of Client TeachingObserve the client demonstrating the learned activity (best for eval of psychomotorlearning)Ask questions.Listen to the client explain the info learneduse written tools to measure accuracy of information
  55. 55. Request the clientʼs self-eval of progressObserve verbal and nonverbal communicationRevise the care plan as needed.Delegation: Use of the Five Rights of DelegationRight TaskThe right task is one that is delegable for a specific client, such as tasks that arerepetitive, require little supervision and are relatively noninvasive.Identify what tasks are appropriate to delegate for each specific client.Delegate activities to appropriate levels of team members (eg LPN, AP) based onprofessional standards of practice, legal and facility guidelines, and available resources.Ex: Right Task Wrong Task Delegate LPN to perform a dressing Delegate LPN to develop the care plan for change on a client with cellulitis. a client with cellulitis. Delegate AP to assist a client with Delegate AP to administer a neb tx to a pneumonia to use a bedpan client with pneumonia.Right CircumstancesThe appropriate client, available resources, and other relevant factors are considered.In an acute care setting, clientʼs conditions can change quickly. good clinical decisionmaking is needed to determine what to delegate. If the circumstances have beenassessed or are deemed too complicated, the nurse takes the responsibility and doesnot delegate to the AP.Ex:
  56. 56. Right Circumstance Wrong Circumstance Delegate AP to take and record check-in Delegate AP to take VS on a client VS of office clients. receiving IV therapy for hypovolemic shock. Delegate AP to assist in obtaining VS from a stable postop client. Delegate AP to assist in obtain VS from a postop client who required naloxone (Narcan) for depressed respirations.Right personthe right person is delegating the right tasks to the right person to be performed on theright person.Assess and verify the competency of the health care team member. the task must be within the team memberʼs scope of practice the team member must have the necessary competence/trainingContinually review the performance of the team member and determine carecompetency.Assess team member performance based on standards, and when necessary, takesteps to remediate failure to meet standards.Ex: Right person Wrong Person Delegate an LPN to administer enteral Delegate an AP to administer enteral feedings to a client with a head injury. feedings to a client with a head injury. Delegate LPN to perform trach care on a Delegate an AP to perform trach care on a client client.Right Direction/ Communication
  57. 57. A clear, concise, description of the task, including its objective, limits, and expectationsis given. Communication must be ongoing between RN and AP during a shift of care.Communicate either in writing or orally:Data that need to be collectedMethod and timeline for reporting, including when to report concerns/assessmentfindingsSpecific task(s) to be performed; client specific instructionsExpected results, timelines, and expectations for follow-up communication.Ex: Right direction/communication Wrong direction/communication Delegate AP the task of assisting the client Delegate AP the task of assisting the client in room 312 with a shower, to be in room 312 with morning hygiene. completed by 0900. Delegate AP the task of obtaining a urine Delegate AP the task of obtaining a clean- specimen on a client in room 423, but not catch urine specimen from the client in informing her of what type of urine room 423, bed 2 specimen, or which specific client in the room needs the specimen.Right SupervisionAppropriate monitoring, evaluation, intervention as needed and feedback are provided.AP should feel comfortable to ask questions and seek assistance.Ex:
  58. 58. Right Supervision Wrong Supervision An RN delegates to an LPN the task of An RN delegates to an LPN the task of administering enteral feedings to a client providing client teaching to a client without (after the RN performs a physical a written care plan in place. assessment to evaluate the clientʼs tolerance to feedings thus far). An RN delegates an AP to ambulate a client prior to performing an admission An RN delegates to an AP the task of assessment. ambulating a client after completing the admission assessmentCare that cannot be delegated:Nursing process. Assessment Diagnosis Planning EvaluationNursing judgment.Delegation: Monitoring Outcomes of Delegated TasksAnother important step in delegation is evaluation of clientʼs outcomes. The RN mustgive constructive and appropriate feedback. The RN should always give specificfeedback in regard to any mistakes that were made, explaining how the mistakes couldhave been avoiding. Giving feedback in private is the professional way and preservesthe APs dignity. The RN may discover the need to review a procedure with staff andoffer demonstration or even recommend that additional training by scheduled with theeducation dept.Delegation: Assigning Tasks To AP Based On Role parameters and Skill RequiredAssess the knowledge and skills of the delegate open ended questionsMatch tasks to the delegateʼs skills know what skills are included in the training program of the facilityCommunicate clearly
  59. 59. alway provide unambiguous and clear directions by describing a task, the desiredoutcome, time period within which the task should be completed. never give task through another staff memberListen attentivelyProvide feedback.Roles/Tasks for AP/LPN Task AP LPN RN Developing a teaching plan for a client newly dxʼd with diabetes x mellitus Assessing a client admitted for surgery x Collecting VS q 30 min for a client who is 1 hr post cardiac cath x x x Calculating a clientʼs I/O x x x Administering blood to a client x Monitoring a clientʼs condition during blood transfusions and IV admin x x Providing oral and bathing hygiene to an immobilized client x x x Initiating client referrals x Dressing change of an uncomplicated wound x x Routine nasotracheal suctioning x x Receiving report from surgery nurse regarding a client to be admitted x to a unit from the PACU Initiating a continuous IV infusion of dopamine with dosage titration x based on hemodynamic measurements Administering subcutaneous insulin x x Assessing and documenting a clientʼs decubitus ulcer x x Evaluating a clientʼs advance directive status x

×