❖ Nursing Process- ATI Fundamentals Ch. 7
➢ Assessment/ Data Collection
▪ Pt. interview
▪ Medical history
▪ Physical assessment
▪ Lab
... [Show More] reports
▪ S/S, feelings
▪ Objective data VS
➢ Analysis
▪ ID pt. health status
▪ Recognize trends and patterns
➢ Planning
▪ Nurse initiated/Independent Interventions
▪ Provider-Initiated/Dependent interventions
▪ Collaborative interventions
▪ Establish priorities
➢ Implementation
▪ Base care according to data and plan of care
▪ Use problem-solving and critical thinking
▪ Minimize risks
▪ Implement nursing action based on delegation
➢ Evaluation
▪ Evaluate client responses to interventions for form clinical judgement
▪ See if goals are met
▪ Determine effectiveness of nursing care plan
Practice Question: A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process?
➢ A. “I will determine the most important client problems that we should address.”
➢ B. “I will review the past medical history on the client’s record to get more information.”
➢ C. “I will go carry out the new prescriptions from the provider.”
➢ D. “I will ask the client if his nausea has resolved.”
Practice Question: By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?
➢ A. Reassess the client to determine the reasons for inadequate pain relief.
➢ B. Wait to see whether the pain lessens during the next 24 hr.
➢ C. Change the plan of care to provide different pain relief interventions.
➢ D. Teach the client about the plan of care for managing his pain
➢
❖ Medical and Surgical Sepsis- ATI Fundamentals Ch. 10
➢ Hand Hygiene PRIMARY BEHAVIOR!!!!!!
➢ 3 essential components (at least 15 seconds and up to 2 minutes if more soiled)
▪ Soap
▪ Water
▪ Friction
➢ Must perform hand hygiene with either soap and water or alcohol-based product
➢ Alcohol based amount- usually 3-5mLs (rub until completely dry)
➢ If visible soiled= soap and water (2 min)
➢ Perform hand hygiene using recommended antiseptic solutions for immunocompromised or multi-drug resistant micro-organisms
➢ Personal Protective Equipment (PPE):
▪ Put on (or Don): Gown Mask Googles Gloves
▪ Take off (or Doff): Gloves Googles Gown Mask
➢ Physical Environment:
▪ Do not place items on the floor (even soiled laundry)
▪ Do not shake linens can spread microorganisms in the air
• Keep from touch clothing keep away from you
▪ Clean LEAST soiled areas FIRST
▪ Use plastic bags for moist, soiled items
▪ Place specimens in biohazard containers
➢ Maintaining a Sterile Field:
▪ Prolonged exposure to airborne micro-organisms can make sterile items nonsterile.
• Avoid coughing, sneezing, and talking directly over a sterile field.
• Ask patients to refrain from touching [Show Less]