RN ATI Capstone Proctored Comprehensive Assessment: Form B Remediation
STUDY GUIDE
Management of Care: (3)
• Advance
... [Show More] Directive/Self-Determination/Life Planning (1)
o Professional Responsibilities: Admission requirement from the patient self- determination act
▪ PSDA-stipulates that on admission to a health care facility, all clients must be informed of their right to accept or refuse care
▪ Competent adults have the right to refuse treatment including
• Right to refuse treatment
• Right to leave a health care facility without a prescription for discharge from the provider
• Advocacy (1)
o Therapeutic Communication: Responding to a client who wants to discontinue treatment
▪ Refers to nurses’ role in supporting clients by ensuring that they are properly informed, that their rights are respected, and that they are receiving, and that they are receiving the proper level of care
• Advocacy is one of the most important roles of the nurse, especially when clients are unable to speak or act for themselves
• The nurse ensures that the client has the information they need to make decisions about health care
• Nurses must act as advocates even when they disagree with clients’ decisions
• The complex health care system puts clients voice when they system is not acting in their best interest
• Legal Rights and Responsibilities (1)
o Infection control: infectious diseases to report
▪ A complete list of reportable disease and the reporting system are available through the CDC
• Ensure appropriate medical treatment of diseases
• Monitor for common source outbreaks
• Plan and evaluate control and prevention plans
• Identify outbreaks and epidemics
• Determine public health priorities based on trends
Safety and Infection Control: (2)
• Home Safety (1)
o Family and Community violence: safety planning following partner violence
▪ All states have mandatory reporting laws that require nurses to report suspected child or vulnerable adult abuse; there are civil and criminal penalties for not reporting suspicions of abuse
• Document subjective and objective data obtained during assessment
• Provide basic care to treat injuries
• Make appropriate referral
• Help client develop a safety plan, identify behaviors and situations that might trigger violence, and prove information regarding safe
places to live.
• Use crisis intervention techniques to help resolve family or community situations where violence has been devastating
▪ Interventions for community-wide or mass casualty incidents (a school shooting or gang violence)
• Use of Restraints/Safety Devices (1)
o Anger Management: use of mechanical restraints
▪ New initiatives are being proposed to reduce or elevate the use of mechanical restraints
▪ National, state, and local initiatives advocate for restraint elimination
▪ Also heightened awareness of the damaging effects restraint can have on clients, health care professionals, and caretakers
▪ When it is deemed essential to use restraints, remove the client from seclusion or restraint as soon as the crisis is over when the clients attempts reconciliation and is no longer aggressive
Health Promotion and Maintenance: (1)
• Lifestyle Choices (1)
o Older Adults: Assessing a client for social isolation
▪ Social isolation is a state of complete or near-complete lack of contact between an individual and society. It differs from loneliness, which reflects temporary and involuntary lack of contact with other humans in the world.
▪ To improve self-concept and alleviate social isolation
• Therapeutic communication
• Touch
• Reality orientation
• Validation therapy
• Reminiscence therapy
• Attending to physical appearance
• Assistive devices
o Canes
o Walkers
o Hearing aids
Psychosocial Integrity: (3)
• Mental Health Concepts (1)
o Psychotic Disorders: Identifying speech alternations
▪ Positive symptoms:
• Manifestations of things that are not normally present. There are the most easily identified manifestations
o Hallucinations
o Delusions
o Alterations in speech
o Bizarre behavior
• Alterations in speech
o Associative looseness
▪ Unconscious inability to concentrate on a single thought. Can progress to flight of ideas in which the client’s speech moves so rapidly from on e thought to another that it is incoherent
o Neologisms
▪ Made-up words that have meaning only to the client
o Echolalia
▪ The client repeats the words spoken to him
o Clang association
▪ Meaningless rhyming of words, often forceful as, “OH FOX, BOX, AND LOX”
o Word Salad
▪ Word jumbled together with little meaning or significant to the listener
• Substance Use and Other Disorders and Dependencies (1)
o Substance use disorders: action for acute alcohol toxicity
▪ Effects and withdrawal usually start within 4 to 12 hours of the last intake of alcohol and can continue 5 to 7 days.
• Nausea
• Vomiting
• Tremors
• Restlessness
• Inability to sleep
• Depressed mood/irritability
• Increased heart rate, blood pressure, respiratory rate, and temperature
• Diaphoresis
• Tonic-colonic seizures
• Therapeutic Environment (1)
o Hospitalizations, illness, and play: actions to take for a preschooler who is in a acute care facility
▪ Level of Understanding
• Limited understanding of the cause of illness but knows what illness feels like
• Limited ability to describe manifestations
• Fears related to magical thinking
• Ability to understand cause and effect inhibited by concrete thinking
▪ Impact of hospitalization
• Can experience separation anxiety
• Can harbor of bodily harm
• Might believe illness and hospitalization are a punishment
Basic Care and Comfort: (2)
• Assistive Devices (1)
o Sensory Perception: Evaluating understanding of Hearing aid care
▪ Hearing Airds
• Amplify sounds, but do not help clients interpret what they hear
• Amplification of sound in a cloud environment can distracting and disturbing
• Client Education
o Use the lowest setting that allows hearing without feedback
o To clean the ear mold, use mild soap and water while keeping the hearing air dry
o When the hearing aid is not in use for an extended period, turn it off and removed battery to conserve battery power
• Nutrition and Oral Hydration (1)
o Bowel Elimination: Identifying an expected finding with dehydration
▪ Dehydration: fluid and electrolyte distrubances
• Metabolic acidosis from excessive loss of bicarbonate
o Weak, rapid pulse, hypotension, poor skin turgor, elevated
body temperature
o Hypernatremia
▪ Muscle weakness
▪ Lethargy
▪ Swollen red tongue
o Hypokalemia
▪ Leg cramps
▪ Muscle weakness
▪ Nausea
▪ Vomiting
▪ Cardiac dysrhythmias
• Monitor for manifestations of electrolyte imbalance
• Replace fluids and electrolytes as prescribed
Pharmacological and Parenteral Therapies: (6)
• Adverse Effects/Contraindications/Side Effects/Interactions (4)
o Endocrine disorders: Teaching about adverse effects of levothyroxine
▪ Monitor for therapeutic effects
▪ Dosages of levo might need to be increased
▪ Can increase the anticoagulant effects of warfarin by breaking down vitamin K
▪ Report
• Bleeding
• Petechiae
o Medications for Psychotic disorders: Priority finding to report for a client who is taking risperidone
o Medications for Psychotic disorders: Reportable finding for a client who is taking clozapine
▪ Complications that can occur
• Metabolic syndrome
• Orthostatic hypotension
• Anticholinergic effects
• Agitation, dizziness, sedation, and sleep disruption
• Mild EPS (tremor)
• Elevated prolactin levels
• Sexual dysfunction
▪ Contraindications
• Pregnancy risk cat. C
o Not recommended during pregnancy or breastfeeding
• Do not use in clients with dementia
• Avoid concurrent use of alcohol
o Renal Diagnostic Procedures: Medication to withhold prior to excretory urography
▪ Radiography
▪ CT Scan
▪ MRI
▪ Ultrasound
• Assess the size of kidneys; images the ureters, bladder, masses, cysts, calculi, and obstructions of the lower urinary tract
• Good alternative to excretory urography
• Nursing actions
o Provide skin care by removing gel after the procedure
• Complications
o Minimal risk for client [Show Less]