Legal responsibilities: continuity of care
The purpose of reporting is to provide continuity of care and enhance communication among all team members who
... [Show More] provide care to the same clients, thus promoting client safety.
Nurses should use the formal chain of command to verbalize concerns related to assignment in light of current legal scope of practice, job description, and are of competence.
Nurses should refuse to practice beyond the legal scope of practice or outside of their areas of competence regardless of reason (staffing shortage, lack of appropriate personnel).
ATI Ch 5
Information technology: change-of-shift report
The purpose of reporting is to provide continuity of care and enhance communication among all team members who provide care to the same clients, thus promoting client safety.
Nurses should conduct reporting in a confidential manner.
An effective report should include significant objective information about the client's health problems, proceed in a logical sequence, include no gossip or personal opinion, and relate recent changes in medications, treatments, procedures, and the discharge plan.
ATI Ch 5
Admissions, transfers, and discharge: initiating discharge planning
Discharge planning is an inter professional process that starts at admission. Nurses conduct discharge planning with clients and families for optimal results.
Nurses use the nursing process as a guide to plan teaching and intervention for clients during discharge.
The nurse should assess whether the client will be able to return to his previous residence.
ATI Ch 9
Ethical responsibilities: the principle of veracity
Veracity is a commitment to tell the truth.
Ethical dilemmas are problems that involve more than one choice and stem from differences in the values and beliefs of the decision makers.
Nurses must apply ethical theory and decision-making to ethical problems.
Ethical decision-making is a process that requires striking a balance between science and morality.
ATI Ch 3
Legal responsibilities: who can give informed consent
Informed consent is a legal process by which a client or the client's legally appointed designee 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/procedure will benefit the client, risk involved if the client chooses to receive the treatment or procedure, and other options to treat the problem, including not treating the problem.
A competent adult must sign the form for informed consent. Medical interpreters might be necessary.
Emancipated minors (minors who are independent or married) may consent.
Mature adolescents may sign assent.
ATI Ch 4
Airway management: best practice for oxygen therapy
Provide oxygen therapy at the lowest liter flow that will correct hypoxemia.
Assess/monitor hypoxemia and hypercarbia (elevated CO2): restlessness, hypertension, and headache.
Encourage turning, coughing, deep breathing, and the use of incentive spirometry and suctioning.
Make sure all electric machinery (monitors, suction machines) is grounded.
ATI Ch 53
Airway management: use of home oxygen
Don't use volatile, flammable materials (alcohol, acetone).
Don't wear synthetic or wool fabrics.
Ensure that all electric devices (razors, hearing aids, radios) are working well.
Do not smoke.
Have fire extinguishers easily accessible.
ATI Ch 53
Infection control: precautions for shigella
Shigella's portal of exit (means of leaving the host) is the GI tract.
Standard precautions (tier one) are used for shigella. This includes hand hygiene. This also includes masks, eye protection, and face shields when care might cause splashing or spraying of body fluids.
The client doesn't need a private room.
ATI Ch 11
Infection control: planning a protective environment
A protective environment protect clients who are immunocompromised, such as those who have had an allogenic hematopoietic stem cell transplant.
A protective environment requires a private room, positive airflow with 12 or more air exchanges/hr, HEPA filtration for incoming air, and a mask for the client to wear when out of their room.
ATI Ch 11
Mobility and immobility: applying a sequential compression device
Use sequential compression devices to prevent thrombus formation.
Increase activity as soon as possible by dangling feet on side of bed or transferring to a chair.
Teach range of motion and antiembolic exercises such as ankle pumps, foot circles, and knee flexion.
ATI Ch 40
Pain management: priority action for dressing changes
Pain medication should be given prior to dressing changes if client reports that dressing changes are painful.
Infants, children, older adults, and clients who have substance use disorder are at risk for under treatment of pain.
Nonpharmacological pain management strategies include heat, cold, ambulation, deep breathing, acupuncture, and elevation of edematous extremities.
ATI Ch 41 [Show Less]