Summary ATI PN Comprehensive Predictor Review

DO NOT delegate what you can...EAT (Acronym) - What you can *EAT* *E*-evaluate *A*-assess * T-*teach Addison's & Cushings - Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia Better peripheral perfusion? - Elevate veins, D-Angle Arteries APGAR - Appearance (all pink, pink and blue, blue (pale) Pulse (100, 100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) Airborne precautions - MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB Airborne precautions protective equip - private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB Droplet precautions - sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask) Contact precaution - MRS WHISE protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves Skin infection- *VCHIPS* - Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies Air or Pulmonary Embolism - S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.) Woman in labor (un-reassuring FHR) - (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! Tube feeding with decreased LOC - Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) LOC - Level of Consciousness After lumbar puncture and oil based myelogram - pt is flat SUPINE (prevent headache and leaking of CSF) Pt with heat stroke - flat with legs elevated during Continuous Bladder Irrigation (CBI) - catheter is taped to the thigh. leg must be kept straight. After Myringotomy - position on the side of AFFECTED ear, allows drainage. Myringotomy - surgical incision into the eardrum, to relieve pressure or drain fluid. After Cateract surgery - pt sleep on UNAFFECTED side with a night shield for *1-4 weeks* after Thyroidectomy - low or semi-fowler's position, support head, neck and shoulders. Infant with Spina Bifida - Prone so that sac does not rupture Buck's Traction (skin) - elevate foot of bed for counter traction After total hip replacement - don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows. Prolapsed cord - Knee to chest or Trendelenburg oxygen 8 to 10 L Cleft Lip - position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. To prevent dumping syndrome - (post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals. AKA (above knee amputation) - elevate for first 24 hours on pillow. position prone daily to maintain hip extension. BKA (below knee amputation) - foot of bed elevated for first 24 hours. position prone to provide hip extension. detached retina - area of detachment should be in the dependent position dependent position - supported administration of enema - pt should be left side lying (Sim's) with knee flexed. supratentorial - (incision behind hairline on forhead) e After supratentorial surgery - elevate HOB 30-40 degrees HOB - head of bed infratentorial - (incision at the nape of neck) After infratentorial surgery - position pt flat and lateral on either side. During internal radiation - on bed rest while implant in place