ATI remediation-principles PDF

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ATI remediation for principles of intervention, ...

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ATI remediation: Sara Kahler Practice A: Client Rights: Ethical responsibilities: - Autonomy-- The right to make one’s own personal decisions, even when those decisions might not be in that person’s own best interest - Beneficence—positive actions to help others - Fidelity—agreement to keep promises - Justice—Fairness in care delivery and use of resources - Nonmaleficence—avoidance of harm or injury --Ethical dilemmas when, not enough scientific data to solve, conflict between moral imperatives, the answer will have a profound effect on the situation and the client -- How to make ethical decisions: identify whether the issue is a dilemma, state ethical dilemma all issues and who is involved, list/analyze all possible options for resolving, select option that is in concert with the ethical principle that applies to this situation decisions makers values/beliefs and the professions values for client care, do this action. -- principles: Advocacy(support client’s health/safety/rights), Responsibility (willingness to respect obligations and follow through on promises), Accountability(ability to answer for one’s own actions) Confidentiality (protection of privacy without diminishing access to quality care) Continuity of care: Safe med administration—accurate documentation: -- Know before giving: medication class, action, therapeutic effect, side effects, adverse effects, toxic effects, interaction, precaution/contraindications, prepration/doseage/adminstration, nursing imp. -- Do NOT use: naked decimal ie “.5”, “U”, “cc”, “QD/i/d” “Tiw”, “HS”, “SC, SQ, Sub qu”, “IN”, “ss” “D/C”, “OD” “SSRI”, “SSI”, “HCL” -- Complete prescription: client’s name, date, time, name of md, dosage, route, time and frequency, signature -- educate pt what taking and why, teach them so they’re part of the safety net -- report all errors—complete unusual occurrence report in 24 hrs—does NOT become part of the client’s permanent record. -- only give med personally prepared Cultural and spiritual nursing care: --Spirituality—transpersonal—with an unseen higher power -- Buddhism—may refuse care on holy days, may refuse analgesic/strong sedatives, some are veg heads, avoid alcohol/tobacco, may fast on holy days, request priest prior to death, chanting normal, brain death not requirement for death -- Hinduism—personal hygiene valued, some veg head, death- may want to lie on floor, thread around neck/wrist, family pours water into mouth, bathes body—cremation -- Islam-Birth must have a female provider, head coverings, hand hygiene imperative, pray 5x/dayMecca, avoid alcohol/pork, fast during Ramadan. Death—faces Mecca, confess sins, washed enveloped in white cloth, prayer

-- Jehovah’s Witness: may avoid blood transfusions even in critical situations, avoid food’s having/prepared with blood, death-burial/cremation Judism—8th day circumcision, may be kosher, death—someone stays with body Mormonism: baptize at 8, avoid alcohol tobacco caffeine, death-communion, burial, last rites -- assessment—first self reflection(nurse’s) person beliefsidentify client’s religion, focused ongoing as nurse identify clients at risk for spiritual distress -- If pt is reading a devotional and crying don’t ask why, provide privacy and time for reading -- Jehovah’s witness needs blood transfusion—involve pt’s religious/spiritual leaders is a culturally responsive action, alternative forms of blood products can be discussed and a plan acceptable to all can be reached Assistive devices: Assess ROM capability, muscle tone/mass, observe for contractures(shortening of muscle/tendon), monitor gait, monitor nutritional intake of Ca, -- repo pt every 2 hrs in wheelchair every 15min -- Cane: -maintain TWO points of support on the ground at all times, -keep cane on stronger side of body, -support body weight on both legs, -move the cane forward 6-10” THEN move WEAKER leg, next advance stronger leg past cane. -- Crutches: -Don’t alter crutches after fitting, -follow the prescribed crutch gait, -support body weight at the hand grips with the elbows flexed at 30º, -position the crutches on the UNAFFECTED side when sitting/rising from chair Practice B: Delegation and supervision: --Predictability of outcome—will the completion of the task have a predictable outcome?, Routine tx? Is it a new tx? -- to LPN—can monitoring findings, reinforcing teaching, trach care, suction, check ng patency, administer enteral feedings, cath, administer meds -- AP- ADLs,, feeding w/o swallowing precautions, specimen collection, I/O, vitals if stable -- delegate factors—consider for selection of an appropriate ap/lp- education, training, experience, critical thinking needed? Ability to communicate w/ others, is competent, -- rights of delegation—supervision/evaluation, right direction/communication, task, person, right circumstances Legal responsibilities: right to refuse: -- Ask why refusing -- determine reason for refusal

-- Provide info regarding risk of refusal -- notify appropriate health care personnel --Document the refusal and actions taken Safe medication administration and error reduction: accurate transcription: -- Complete prescription: client’s name, date, time, name of md, dosage, route, time and frequency, signature -- only transcribe phone orders in emergent, needs to be signed in 24 hours Airway mgt: Trach suctioning: --hypoxemia early signs: tachypnea, tachycardia, restlessness, anexiety, confusion, pale skin, elevated accessory muscles, nasal flaring, accessory muscles, adventitious lung sounds. Late: stupor, cyanotic, bradypnea, bradycardia, hypotension, cardiac dysrhythmias -- outer cannula fits into the stoma and keeps airway open -- inner cannula fits snugly into the outer cannula, locks into place -- Nursing: have two extra tracheotomy tubes at bedside(pt sz and smaller incase accidental decannulation), have dry erase/paper to communicate -- oral care every 2 hrs -- trach care every 8 hrs reduce risk of infection and skin breakdown -- use sterile technique --surgical asepsis to remove clean inner cannula --repo every 2hr Legal responsibilities: interventions within nursing scope of practice: -negligence—nurse fails to implement safety measures for pt at risk for falls ie NOT - follow professional standards of care -use equipment in a responsible knowledgeable manner - communicate effectively and thoroughly with clients -documentation care nurse provided --malpractice(professional negligence) nurse administers large dose of med due to calculation error, pt dies --breech of confidentiality—tell press diagnosis --defamation of character—tells coworker gossip

Data collection/general survey: Assessment technique: --Explain various assessment tecniques you will use --Inspect, palpate, percuss

--allow more time for older adult --Health history can come from pt, family, med records, other providers(how reliable is source?) -- Clarify—Back Channeling “go on, tell me more” Probing(ask open ended questions) closed ended questions require yes/no answer ie do you have any pain when you cannot sleep? Therapeutic communication: appropriate nur response: ch 32 -be aware of how you communicate nonverbally --elicit and attend to client’s thoughts/feelings/concerns needs --express empathy and genuine concern for the pt/family’sissues --be open, direct, truthful,sincere -- display a nonjudgemental attitude Therapeutic communication: long term care 32 --recognize client may require amplicfication --minimize distractions and face pt when speaking --allow plenty of tieme for pt to respond -- when impaired communication is assessed ask for imput from caregivers/family to determine the extent of deficits and how to best communicate

Assessing for Dysphagia: -- have pt tuck chin when swallowing --support upper back, neck head --semi fowlers --observe for s/sx dysphagia (choking, gagging/drooling food) --keep in semifowlers 1hr post meal Clear liquid diet: --clear fruit juices --gelatin --broth -- “see through” liquids --liquids that leave little residue Rest and sleep: --small snack of carbs prior to bed --guided imagery --comfortable room temperature -- limit caffeine/nicotine --engage in muscle relaxation if anxious/stressed IV: priority interventions for complications-

-- do not stop continuous infusion or allow blood to back up into catheter for any length of time, clot form at the tip of the needle or catheter and can be lodged against vein wall, blocking the flow of fluid -- tell client not to manipulate flow rate, change settings, lie on tubing --Mark sure IV site isn’t too tight --Flush intermittent IV caths w/ appropriate solution after every medication administration 8-12 hr --monitor site and infusion every hour Mixing insulin: --Clear  cloudy --gently roll vials -Regular “clear” -NPH ‘Cloudy” 24 hr urinary collection: 44 --discard first voidance -- collect all other voidings --follow facility policy on appropriate refrigerated storage/labeling/transport -- discard urine voided w/ stool -- give container(catheter, urinal, hat, commode) Pressure ulcer: expected findings 55 --Stage II --partial thickness loss involving epidermis and dermis --ulcer is visible and superficial, may appear as an abrasion/blister/shallow crater --edema persists -- ulcer may become infected possibly with pain and scant discharge Thorax/heart/abdomen :cardiac assessment 29 -- Inspect jugular veins with HOB at 30 degrees -- apical pulse for PMI at fourth/fifth ICS -- heaves/lifts are unexpected --thrills—do you feel a vibration? Not normal -- “do you have any problems with your heart? Do you take any meds for your heart?” Pressure ulcers: procedure for wound irrigation: -- use piston syrindge -- Use sterile straight cath for deep wounds w/ small openings --do not use cotton balls/products that shed fibers -- use NS, lactated ringsers, or antibiotic solution - dress with woven gauze...