Leadership Proctored study guide Recent Update

ATI Leadership Proctored Study Guide Chapter One: Managing Client Care Prioritization of Patient Care ABCDE Principle - A: Airway – Ensure patient’s airway is patent. At the same time secure the cervical spine if head or neck injury is suspected. No injury: head-neck, chin lift to secure airway. Injury: Use modified jaw-thrust maneuver - B: Breathing – Assess respiratory status. The rate, depth, etc. - C: Circulation – Assess HR, BP, cap refill, adequate circulation throughout the body - D: Disability: Assess LOC - E: Exposure – Assess body for trauma, or exposure to heat or cold Prioritization: - Always assess before taking action (Dyspnea: assess patient before taking further action, insulin: assess blood sugar before giving) - Unstable patients before stable patients (patients with findings that are expected for their medical diagnosis). COPD patient expected to have low SpO2 whereas patient. Patient with stroke with facial drooping expected, patient with other diagnosis having facial drooping unexpected, Albuterol side effects: tachycardia, tremors, restlessness (EXPECTED) - Acute over chronic: Patient with abnormal vital signs, low urinary output are acute situations and need attention before patients with stage 4 pressure injury (not developed over night) - Systemic issues over local issues. Systemic: fever, hypotension, tachycardia (infection or sepsis). Local: bad skin tear, erythema on the foot (need to address but others are priority) - ABCDE: Administering pain medication is RARELY an answer. - Maslow’s Hierarchy of Needs: Physiological, safety, love and belonging, self-esteem, self-actualization - Least invasive interventions before more invasive interventions. (move near nursing station, sitter, distractions before restraints. Patient difficulty urinating – run water in room before catheter Efficient Nursing Practice and Delegation Efficient Nursing Practice - Take time at the beginning of sift to plan and prioritize day - Always chart interventions and nursing care as soon after completing the task as possible. Throughout the day best practice - Group tasks for a single patient as much as possible. Get as much supplies for all patients at once if possible. - Do time consuming and challenging tasks earlier in the day, nurse has more energy during the day making it easier to get it done. Do non-essential tasks for later in the day (patient room is cluttered is non-essential task) Delegation vs. Asking for help Delegation (IMPORTANT): RN role: - Patient education - Tasks with nursing judgement - Patient assessment - Blood transfusion Delegate to LPN: - Administer medications - Administer enteral feedings (NG tube or gastric tube) - Insert foley catheter - Perform suctioning and trach care - Wound care - Reinforce education Delegate to CNA: - Bathing - Clothing - Ambulating - Toileting - Help feed a patient without swallow precautions - Positioning - Vitals, I&O’s, collect specimens - Make bed - Basic CPR Five Rights of Delegation: - Right task: repetitive, noninvasive, doesn’t require much supervision - Right Circumstance: Stable patient - Right Person: Within scope of practice and competent - Right direction and communication: Provide timeline and what communication you expect back to them (please take vitals in room in the next 30 minutes and report if BP is under ). - Right supervision and evaluation: provide feedback, assess self if unstable or change reported