ATI RN Fundamentals 2016 Remediation
Management of Care:
Assignment, Delegation, and Supervision:
Delegating to Assistive Personnel: Nurses may
... [Show More] only delegate tasks appropriate for the skill and education level of the individual who is receiving the assignment (the delegate). RNs may not delegate the nursing process, client education, or tasks that require nursing judgement to PNs or to APs. Before delegating, nurses should consider the predictability of the outcome, the potential for harm, complexity of care, need for problem solving innovation, and level of interaction with the client. Use the five rights of delegation to decide: right task, right circumstances, such as setting and resources, right person, right direction and communication, right supervision and evaluation. Use professional judgement and critical thinking skills when delegating.
Tasks to Delegate to Assistive Personnel: Activities of daily living include bathing, grooming, dressing, toileting, ambulation, feeding (without swallowing precautions), and positioning. Routine tasks include bed making, specimen collection, intake and output, and vital signs (for stable clients).
Informed Consent:
Completing an Informed Consent Document: Informed consent is a legal process by which a client of the clients’ legally appointed designees has given written permission for a procedure or treatment. Consent is informed when a provider explains and the client understands: the reason the client needs the treatment or procedure, how the treatment of procedure will benefit the client, the risks involved if the client chooses to receive the treatment or procedure, other potions to treat the problem including not treating the problem. The nurse’s role in the informed consent process is to witness the client’s signature on the informed consent form and to ensure that the provider has obtained the informed consent responsibly. Clients must consent to all care they receive in a health care facility. The PSDA stipulates that staff must inform clients they admit to a health care facility of their right to accept or refuse care.
Legal Rights and Responsibilities:
Identifying an Intentional Tort: Types of intentional torts are assault, battery, and false imprisonment. Assault is the conduct of one person makes another person fearful and apprehensive. Battery is intentional and wrong physical contact with a person that involves an injury or offensive contact. False Imprisonment is a person confined or restrained against his will.
Safety and Infection Control:
Accident/Error/Injury Prevention:
Fall Risk Precautions: Complete a fall-risk assessment for each client at admission and at regular intervals. Individualize the plan for each client according to the results of the fall-risk assessment. For example, instruct a client who has orthostatic hypotension to avoid getting up too quickly, to sit on the side of the bed for a few seconds prior to standing, and to stand at the side of the bed for a few seconds prior to walking. Be sure the client knows how to use the call light (by giving a return demonstration) that it is in reach, and to encourage its use. Respond to call lights in a timely manner. Use fall-risk alerts, such as color-coded wristbands. Provide regular toileting and orientation of clients who have cognitive impairment. Provide adequate lighting. Orient clients to the setting to make sure they know how to use all assistive devices.
Planning Care for a Client Who Has a Latex Allergy: Before beginning any task or procedure that requires aseptic technique, health care team members must check for latex allergies. If the client or any member of the team has a latex allergy, the team must use latex-free gloves, equipment, and supplies.
Home Safety:
Teaching an Older Adult Client About Home Safety: Remove items that could cause the client to trip, such as throw rugs and loose carpets. Place electrical cords and extension cords against a wall behind furniture. Monitor gait and balance, and provide aids as needed. Make sure that steps and sidewalks are in good repair. Place grab bars near the toilet and in the tub or shower, and install a stool riser. Use a nonskid mat in the tub or shower. Place a shower chair in the shower and provide a bedside commode if needed. Ensure that lighting is adequate inside and outside the home.
Health Promotion and Maintenance:
Developmental Stages and Transitions:
Older Adult (65 Years or Older) Identify Expected Changes in Development: Integumentary: Decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which leads to wrinkles and dry, transparent skin. Cardiovascular/Pulmonary: Decreased chest wall movement, vital capacity, and cilia, which increases the risk for respiratory infections. Neurosensory: slower reaction time, decreased touch, smell, and taste sensations. Gastrointestinal: Decreased digestive enzymes, decreased intestinal motility, and increased dental problems. Neuromuscular: decreased height due to intervertebral disk changes, decreased muscle strength and tone. Genitourinary: Decreased bladder capacity, prostate hypertrophy in men, decline in estrogen or testosterone production, and atrophy of breast tissue in women. Endocrine: Decline in triiodothyronine (T3) production, yet overall function remains effective, decreased sensitivity of tissue cells to insulin.
Health Promotion/Disease Prevention:
Bathing a Client Who Has Dementia: Clients vary in their hygiene preferences and practices. These include bathing routines, oral care, grooming preferences, and health beliefs. Culture also plays an important role, because some cultures have unique hygiene practices. Be sure to be respectful and observant of each client’s specific cultural needs. Consider the client’s personal preference regarding hygiene practices. Socioeconomic status can affect clients’ hygiene status. If a client is homeless, alter discharge instructions and follow-up care accordingly. Respect each client’s dignity. Many clients are dealing with a loss of control when others must provide their hygiene care. Reassure clients and allow them to have as much control as possible.
Effects of Aging on Urinary Infections: Children achieve full bladder control by 4 to 5 years of age. The prostate enlarges after 40 years of age, leading to urinary frequency, hesitancy, retention, incontinence, and urinary tract infections (UTIs). Childbirth and gravity weaken the pelvic floor, putting clients at risk for prolapse of the bladder, leading to stress incontinence, which clients can help manage with pelvic floor (Kegel) exercises. Older Adult Clients have the following: Fewer nephrons, Loss of muscle tone of the bladder leading to frequency, Inefficient emptying of the bladder: residual urine increasing the risk for UTIs, Increase in nocturia.
Techniques of Physical Assessment:
Appropriate Technique for Abdominal Assessment: This examination includes observing the shape of the abdomen, palpating for masses, and auscultating for vascular sounds. Use the techniques of inspection, auscultation, percussion, and palpation. Note that this changes the usual order of assessment techniques. Auscultate just after inspection, because percussion and palpation can alter bowel sounds. Ask the client to urinate before the abdominal examination. Have the client lie supine with arms at sides and knees slightly bent. Imagine vertical and horizontal lines through the umbilicus to divide the abdomen into four quadrants with the xiphoid process as the upper boundary and the symphysis pubis as the lower boundary.
Basic Care and Comfort:
Assistive Devices:
Appropriate Use of Crutches: Do not alter crutches after fitting. Follow the prescribed crutch gait. Support body weight at the hand grips with elbows flexed at 20° to 30°. Position the crutches on the unaffected side when sitting or rising from a chair.
Elimination:
Preventing Skin Breakdown: Instruct clients to drink 2 to 3 L of fluid daily. Instruct clients to try to hold urine, and stay on schedule with bladder retraining. Advise clients to drink cranberry juice to decrease the risk of infection. Encourage clients who are obese to participate in a weight-reduction program to help resolve stress incontinence. Instruct clients to take medications to help resolve incontinence. Teach intermittent catheterization if necessary. Encourage clients to express their feelings about incontinence.
Mobility/Immobility:
Preventing Thrombus Formation: Elastic (antiembolic) stockings cause external pressure on the muscles of the lower extremities to promote blood return to the heart. SCDs and IPC have plastic or fabric sleeves that wrap around the leg and secure with hook-and-loop closures. The sleeves are then attached to an electric pump that alternately inflates and deflates the sleeve around the leg. These machines are set to cycle, typically a 10- to 15-second inflation and a 45- to 60-second deflation. Positioning techniques reduce compression of leg veins. ROM exercises cause skeletal muscle contractions, which promote blood return. Specific exercises that help prevent thrombophlebitis include ankle pumps, foot circles, and knee flexion. Antiembolic stockings, SCDs, and IPC require a prescription.
Nutrition and Oral Hydration:
Hyperosmolar Imbalance: N/A
Calculating Intake: Height, weight to calculate BMI and ideal body weight. BMI = weight (kg) ÷ height (m2). Step 1: Determine the client’s weight in kg and height in m. Step 2: Multiply the client’s height by itself to determine the m2 value. Step 3: Divide the weight in kg by the height value from step 2. The result is the client’s BMI. Take skinfold measurements. Check Laboratory values of cholesterol, triglycerides, hemoglobin, electrolytes, albumin, prealbumin, transferrin, lymphocyte count, nitrogen balance.
Pharmacological and Parenteral Therapies:
Medication Administration:
Administering a Medication via Intermittent Intravenous Bolus: The provider prescribes the type of IV fluid, the volume to infuse, and either the rate at which to infuse the IV fluid or the total amount of time it should take to infuse the fluid. The nurse regulates the IV infusion, either with an IV pump or manually, to be sure to deliver the right amount. Nurses administer large-volume IV infusions on a continuous basis, such as 0.9% sodium chloride IV to infuse at 100 mL/hr or 0.9% sodium chloride 500 mL to give IV over 3 hr. A fluid bolus is a large amount of IV fluid to give in a short time, usually less than 1 hr. A fluid bolus rapidly replaces fluid loss from dehydration, shock, hemorrhage, burns, or trauma. A large-gauge catheter (18-gauge or larger) is essential for maintaining the rapid rate necessary to give a fluid bolus to an adult. Nurses administer medications as an IV bolus, giving the medication in a small amount of solution, concentrated or diluted, and injecting it over a short time (1 to 2 min).
Administering Intradermal Tuberculin Test: Use for tuberculin testing or checking for medication or allergy sensitivities. Use small amounts of solution (0.01 to 0.1 mL) in a tuberculin syringe with a fine-gauge needle (26- to 27-gauge) in lightly pigmented, thin-skinned, hairless sites (the inner surface of the mid-forearm or scapular area of the back) at a 10° to 15° angle. Insert the needle with the bevel up. A small bleb should appear. Do not massage the site after injection.
Enteral Administration of Medications: Use liquid forms of medications; if not available, consider crushing medications if appropriate guidelines allow. Do not administer sublingual medications. Do not crush specially prepared oral medications (extended/time-release, fluid-filled, enteric-coated). Administer each medication separately. Do not mix medications with enteral feedings. Completely dissolve crushed tablets and capsule contents in 15 to 30 mL of sterile water prior to administration. To prevent clogging, flush the tubing before and after each medication with 15 to 30 mL water. Flush with another 15 to 30 mL sterile water after instilling all the medications.
Parenteral/Intravenous Therapies:
Catheter Insertion Procedure: Untie the tourniquet or deflate the blood pressure cuff. Cleanse the area at the site using friction in a circular motion from the middle and outwardly with chlorhexidine or the cleaning agent the facility’s protocol specifies. Allow it to air dry for 1 to 2 min. Remove the cover from the catheter, grasp the plastic hub, and examine the device for smooth edges. Retie the tourniquet or reinflate the blood pressure cuff. Anchor the vein below the site of insertion. Pull the skin taut and hold it. Warn the client of a sharp, quick stick. Use a steady, smooth motion to insert the catheter into the skin at an angle of 10° to 30° with the bevel up. Advance the catheter through the skin and into the vein, maintaining a 10° to 30° angle. A flashback of blood will confirm placement in the vein. Lower the hub of the catheter close to the skin to prepare for threading it into the vein approximately 0.6 cm (0.24 in). Loosen the needle from the catheter and pull back slightly on the needle so that it no longer extends past the tip of the catheter. Use the thumb and index finger to advance the catheter into the vein until the hub rests against the insertion site. Stabilize the IV catheter with one hand and release the tourniquet or blood pressure cuff with the other. Apply pressure approximately 3 cm (1.2 in) above the insertion site with the middle finger and stabilize the catheter with the index finger. Remove the needle and activate the safety device. Maintain pressure above the IV site and connect the appropriate equipment to the hub of the IV catheter. Apply a dressing and leave it in place until catheter removal, unless it becomes damp, loose, or soiled. Avoid encircling the entire extremity with tape and taping under the sterile dressing.
Reduction of Risk Potential:
Diagnostic Tests:
Monitoring Oxygen Saturation: A pulse oximeter is a device with a sensor probe that attaches securely to the fingertip, toe, bridge of nose, earlobe, or forehead with a clip or band. A pulse oximeter measures pulse saturation (SpO2) via a wave of infrared light that measures light absorption by oxygenated and deoxygenated hemoglobin in arterial blood. SpO2 reliably reflects the percent of saturation of hemoglobin (SaO2) when the SaO2 is greater than 70%. Oxygen is a tasteless and colorless gas that accounts for 21% of atmospheric air. Oxygen flow rates vary to maintain an SpO2 of 95% to 100% using the lowest amount of oxygen to achieve the goal without risking complications. The fraction of inspired oxygen (FiO2) is the percentage of oxygen the client receives.
Potential for Complications of Diagnostic Tests/Treatments/Procedures:
Preparing to Administer Feeding: Prepare the formula, tubing, and infusion device. Assist the client to Fowler’s position, or elevate the head of the bed to a minimum of 30°. Auscultate for bowel sounds. Monitor tube placement. Flush the tubing with at least 30 mL tap water. Administer the formula.
Therapeutic Procedures:
Teaching About Care of an Artificial Eye: N/A
Physiological Adaptation:
Alterations in Body Systems:
Teaching Incentive Spirometry: N/A
Dressings for Pressure Ulcers: Stage II pressure ulcers maintain a moist healing environment (saline of occlusive dressing). Apply hydrocolloid dressing. Stage III prescribed dressing. Stage IV prescribed dressing. Perform nonadherent dressing changes every 12 hrs. Do not use alcohol, Darkin’s solution, acetic acid, povidone-iodine, hydrogen peroxide, or any other cytotoxic cleansers on a pressure ulcer wound.
Performing a Dressing Change: Relieve pressure. Encourage frequent turning and repositioning. Use pressure-relieving devices, such as an air-fluidized bed. Implement pressure-reduction surfaces (air mattress, foam mattress). Keep the client dry, clean, well-nourished, and hydrated. Perform nonadherent dressing changes every 12 hr. Treatment can include skin grafts or specialized therapy such as hyperbaric oxygen. Provide nutritional supplements. Administer analgesics. Administer antimicrobials (topical and/or systemic). [Show Less]