ATI capstone Fundamentals PDF

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FUNDAMENTALS Laboratory Values Albumin: 3.5-5 Sodium 136-145 mEq/L Potassium 3.5-5.0 mEq/L Total Calcium 9.0-10.5 mg/dL Magnesium 1.3-2.1 mg/dL Phosphorus 3.0 –4.5 mg/dL BUN 10-20 mg/dL Creatinine 0.6 – 1.2mg/dL males, 0.5 – 1.1 mg/dL females Glucose 70 -105 mg/dL HgbA1c 1.010-1.025) Elevated hematocrit (>37-64%) Elevated BUN Radiation – how to treat dry, red, scaling skin Apply px lotion to the area* - Hydrating lotions are commonly prescribed to treat irradiated areas. Antimicrobial soaps can be harsh and further traumatize new epidermal cells. The client should avoid applying other lotions not prescribed by the radiologist to affected areas. Clients receiving radiation therapy should avoid exposing irradiated areas to sun. Moist heat should be avoided over irradiated areas. Heat/cold therapies – risk for injury from therapy? The nurse should use extreme caution with clients who are very young, an older adult, fair-skinned, impaired cognition, and have comorbidities because they are at higher risk for fragile skin. *attorney not needed to sign off on adv. Directives Living will: a legal document that specifically outlines a client wishes regarding life-sustaining treatment. DNR order: written by the provider when the client requests not the be resuscitated in the event of cardiac arrest. Informed consent: a consent to surgery or a procedure and is obtained after a client received complete disclosure of all pertinent information regarding the surgery or procedure to be performed.

A durable power of attorney for health care: a legal document that designates another person to make health care decisions for the client when the client becomes unable to make decisions independently. Psychosocial stages of development Pre-schoolers 3-6 years: Take on new experiences and when unable to accomplish task may feel guilty or misbehave. Generally, do not exhibit stranger anxiety. Understand behavior in terms of what is socially acceptable School aged children 6-12 years: Develop a sense of industry through advances in learning. Strive to develop healthy self-respect by finding out in what areas they excel. Peer groups play important role in social development. Adolescents 12-20 years: Develop sense of personal identity that family expectations influence. Peer relationships develop as a support system. Concerned with body images that media portray. Young adults 20-35 years: Personalize values and beliefs and base reasoning on ethical fairness principles. Establish close relationships. Have influences that help with formation of healthy self-concept, such as family and friends. Encephalopathy a disease in which the functioning of the brain is affected by some agent or condition (such as viral infection or toxins in the blood). The causes of encephalopathy are numerous and varied; they include infections, anoxia, metabolic problems, toxins, drugs, physiologic changes, trauma, and other causes. Prevent aspirations for pt at risk for stroke To decrease the risk of aspiration for a stroke client, ensure the clients position is upright(fowlers), that the upper back and head are supported during meals. Remind the client to tuck their chin while swallowing, to guide the food's path. Avoid lowering the head of bed during feedings. Oral care can improve the client's well-being and increase the interest for eating but does not help prevent the potential for aspiration.

TPN A “cracked” TPN solution has an oily appearance or a layer of fat on top of the solution and should not be used.

Types of gait 2-point gait: A two-point gait requires at least partial weight bearing on each leg. The client moves a crutch at the same time as the opposite leg so the crutch movements are similar to arm motion during normal walking. 3-point gait: A three-point gait requires the client to bear all of his weight on one foot. With a three-point gait, the client bears weight on both crutches and then on the uninvolved leg, repeating the sequence. The affected leg does not touch the ground. 4-point gait: A four-point gait provides stability for the client but requires weight bearing on both legs. He moves each leg alternately with each opposing crutch, so four points of support are on the floor at all times. Always recheck* a pt’s bp if it is hypertensive before any other action Types of immunity: Acquired Passive Active Cellular

Macular degeneration Risk factors for pressure injury: -urinary incontinence Phlebitis: -d.c infusion, apply warm compress, if continued therapy req start new IV Skin marks Papule Macule: smaller than 1 cm- ex: freckle Nodule Vesicle First aid for wounds apply clean dressings over the top of blood saturated dressings and hold pressure - (to prevent disruption of wound tissue) do not take old dressings off risk for constipation (post abdominal sx) -urge suppression -hx or chronic use of stimulant laxative use -Inadequate fluid intake Sterile field during a wound dressing change: - restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray (if liquid comes in contact with the sterile field at any point it is considered contaminated and unsterile) Metered-dose inhaler Shake vigorously Hold breath for 10 seconds after inhaling med Hold mouthpiece 1-2 in away from mouth (which one do u have to rinse mouth for?) Older adult skin changes: Decrease in elasticity Indrease in pigment Dec in subq Dec in moisture levels Intolerance to enteral feedings: nausea/vomiting Fire/smoke hazard: (RACE) -evacuate the room (rescue) -pull alarm -close windows (contain) -extinguish Meningococcal meningitis: First action: initiate droplet precaution (private room mask within 3ft) Seizure: Nurse priority: lay on side with head forward Contributing factors to decrease in med effectiveness: Recurring bowel inflammation (GI issues decrease motility, decreasing med effectiveness, so oral meds should be avoided NG tube meds:

Give one at a time Flush in b/w with 10-15 mL Do not crush sublingual meds Crush and mix meds in sterile water 15-30 mL Foot care for pt with diabetes mellitus: Always wear slipper when out of bed Cut toenails straight across Avoid warm water soaks Avoid lotion between toes Infiltration: Causes edema  leakage of fluid into the extravascular tissue Phlebitis: inflammation of vein extravasation: iv cath becomes dislodged and med infuses into the tissues

Types of torts Negligence: Slander: Libel: Invasion of privacy What to include in transfer report: response to pain medication review of ongoing discharge plan recent physical changes (no need to include demographic information) Toddler ages gross motor skills: Dyspnea on COPD pt: Flaring of nostrils, increased RR, increased depth of respirations*, expected pulse O2 of...