ATI Comprehensive
Get a hin
Post operative care -Follow ABC post-op
-Make sure airway is clear and patient is able to breathe off of anesthesia
-Promote ambulation and anti-coags to prevent blood clots
-Monitor the surgery site to watch for infection
Managing Client Care: Implementing Change -Phases of making change:
-1st stage: unfreezing - Inform others about current issues
-2nd stage: moving - implementing change
-3rd: refreezing - solidifying change into a daily thing
Colostomy care -Teach about care inc caregivers if necessary
-Talk about self-esteem issues
-Often pts have a hard time accepting this change
Restraints: Mechanical -Assess client every 15-30 minutes
-Someone must be with patient at all times
-Check for new prescription q4 for> 18, q2 for 9-17 y, and q1 for <9 y
Neurocognitive Disorders: Delirium -Rapid speech
-Irritability
-Clouding of consciousness.
-Difficulty maintaining or shifting attention.
-Disorientation.
-Illusions.
-Hallucinations.
-Fluctuating levels of consciousness.
Disorders of the Eye: Macular Degeneration -Manifestations: Decrease or loss of central vision
d/t bleeding into the macula, yellow spots under retina
-Amsler grid can be used to help diagnose or test for this, grid with lines, pt with macular
degeneration may see blurred or twisted lines w/dark spots
-Lack of depth perception
-Objects appear distorted
-Blurred vision
-Loss of central vision
-Blindness
Mobility and Immobility: Developing a Plan of Care for a Client Who Is Immobile -
Consider how much the patient can move
-Work to their strengths
-Be considerate of their health needs
-Work on regaining strength and mobility if immobility is not related to paralysis
-Place trochanter rolls to prevent external rotation & abduction of the hips
-Encourage 2-3L consumption of water a day
-Do not massage lower extremities
Medications Affecting the Reproductive Tract -Meds:
*Estradiol
,-Adverse effects:
*htn
*HA (can cause thromboembolism which can result in stroke)
*swelling/tenderness of calf (can be indicative of DVT)
*gentinourinary candidiasis
Peptic Ulcer Disease (PUD): -Meds Used:
*Misoprostol
-Side Effects:
*uterine contractions
*reduces gastric acid secretions
*diarrhea
-Interventions:
*Notify provider if dysmenorrhea & spotting occur.
*Report diarrhea or abd pain; reduce dose if nec
-Administration:
*pregnancy test must be taken before starting*
*Take AC & HS
*don't take w/Mg containing antacids
Medication Administration: Ear Drop Administration *Administering ear drops:
-For child < 3, pull pinna back & down
-For person > 3, pull pinna up & back
-Warm to room temp
-Cold drops can cause n/v
Total Parenteral Nutrition (TPN) Infusion: Continuous -Cont. TPN can be given to pts who
don't meet adequate nutrient intake
-TPN should be given thru a pump
-TPN should only be given in a central line
blood glucose checks are needed
check for egg allergy bc this can cause interaction with tpn formula
take in oral nutrients as much as possible to allow for intestines to still digest as normal and work
Peripheral Vascular Diseases: Deep-Vein Thrombosis -encourage ambulation
-bed rest
-intermittent, continuous warm moist compress
-do not massage limb
-provide thigh high compression or stockings
-drink 2-3L per day
-place warm compresses on affected area
-elevate the affected leg above heart level
-watch for signs of an embolism
Hematologic Disorders: Stroke Stroke:
*Interventions to < Risk of ^ICP
-place client no more than 25*
-> or < than 25* can cause ^ ICP
-suction only when airway isn't clear
-unneccessary suctioning ^ risk for ^ ICP
-keep in quiet environment
,-avoid coughing, sneezing, or nose blowing
Hematologic Disorders: Manifestations of Vaso-Occlusive Crisis -hematuria: can be fatal d/t
renal ischemia
-visual disturbances
-Severe pain; usually in bones, joints, & abd
-swollen joints, hands, & feet d/t restricted vessels
-anorexia
-n/v
-^T
-obstructive jaundice
Pressure Ulcers, Wounds, and Wound Management: Identifying Risk Factors *Risk factors:
-Immobility
-Cognitive deficit
-Chronic illness (example diabetes)
-Steroid use
-Incontinence
-Malnutrition:
**^ risk for pressure ulcer d/t < tissue integrity
**slows healing process
*Stage I:
*Stage II: Partial thickness skin loss
*Stage III:
*Stage IV:
*Teaching home care to a family of a child who has a large wound?
-Provide a diet high in protein to promote tissue repair.
-Eat foods high in vitamin A
-do NOT cleanse with Betadine because it is toxic to open wounds.
Disorders of the Eye: Evaluating Teaching Following Cataract Extraction -Can continue aspirin
therapy
-Bend at the knee to pick things up
-Don't pick up more than 10lbs
-Use cool compress if feeling itchy
-Avoid activities that ^ intraocular pressure
-Avoid coughing, sneezing, bending at the waist straining at stool, rubbing or touching eyes,
rapid head movements
Tracheostomy Care -Teach how to clean trach
-Remove inner cannula, remove soiled dressing, clean stoma, change ties
-Teach to suction only when airway is not clear, not on a scheduled basis
-Only suction for 5-10 seconds to avoid hypoxia
-Insert suction catheter as far as safe suction is listed
-If you hit resistance, remove suction 2 cm & suction there to prevent tissue damage
-Use surgical asepsis
-Patient may still sound congested even after suctioning, that is normal
, Acute and Infectious Respiratory Illnesses: Caring for a Toddler Who Is Postoperative Following
a Tonsillectomy -Place patient in position with head lower than chest
-Avoid using straws
-Don't have patient cough or deep breathe
-Administer analgesics every 4 hrs
-Avoid activities that can hurt sutures or reopen surgery site
Electrolyte Imbalances: Clinical Manifestations of Hypokalemia -Decreased DTR
-Constipation.
-Feeling of skipped heart beats or palpitations.
-Fatigue.
-Muscle damage.
-Muscle weakness or spasms.
-Tingling or numbness.
Cancer Disorders: Manifestations of Ovarian Cancer -Abdominal bloating
-Increase in abdominal girth
-Early satiety
-Urinary frequency or urgency
-unexpected weight loss
-dyspepsia, gas, indigestion
Oxygen and Inhalation Therapy *Oxygen Toxicity
-Crackles and substernal chest pain
-Bradypnea d/t depression of respiratory drive
-Can result from high concentrations of O2
-Use lowest level of O2 necessary to maintain adequate SpO2.
-Monitor ABGs & notify provider if PACO2 levels rise outside of expected range.
*Contraindications:
-Petroleum & oil based products are combustible
-The pt should use a water-based lubricant.
*Educating Pt:
-check the functioning of the oxygen equipment daily.
-wear cotton fabrics rather than synthetic or woolen when the oxygen is in use.
-store full oxygen tanks in an upright position
*Testing:
-Oximetry: determination of the SpO2 of arterial blood using a photoelectric device called an
oximeter
-SpO2: a clinical msrmt of % of Hgb bound w/O2 in the blood
Spinal Cord Injury: Manifestations of Autonomic Dysreflexia -Facial flushing
-Nasal congestion
-Headache
Cardiovascular Disorders: Expected Findings of Kawasaki Disease -Early phases:
*High T unresponsive to abx or antipyretics
*tachycardia
-Later phases:
Get a hin
Post operative care -Follow ABC post-op
-Make sure airway is clear and patient is able to breathe off of anesthesia
-Promote ambulation and anti-coags to prevent blood clots
-Monitor the surgery site to watch for infection
Managing Client Care: Implementing Change -Phases of making change:
-1st stage: unfreezing - Inform others about current issues
-2nd stage: moving - implementing change
-3rd: refreezing - solidifying change into a daily thing
Colostomy care -Teach about care inc caregivers if necessary
-Talk about self-esteem issues
-Often pts have a hard time accepting this change
Restraints: Mechanical -Assess client every 15-30 minutes
-Someone must be with patient at all times
-Check for new prescription q4 for> 18, q2 for 9-17 y, and q1 for <9 y
Neurocognitive Disorders: Delirium -Rapid speech
-Irritability
-Clouding of consciousness.
-Difficulty maintaining or shifting attention.
-Disorientation.
-Illusions.
-Hallucinations.
-Fluctuating levels of consciousness.
Disorders of the Eye: Macular Degeneration -Manifestations: Decrease or loss of central vision
d/t bleeding into the macula, yellow spots under retina
-Amsler grid can be used to help diagnose or test for this, grid with lines, pt with macular
degeneration may see blurred or twisted lines w/dark spots
-Lack of depth perception
-Objects appear distorted
-Blurred vision
-Loss of central vision
-Blindness
Mobility and Immobility: Developing a Plan of Care for a Client Who Is Immobile -
Consider how much the patient can move
-Work to their strengths
-Be considerate of their health needs
-Work on regaining strength and mobility if immobility is not related to paralysis
-Place trochanter rolls to prevent external rotation & abduction of the hips
-Encourage 2-3L consumption of water a day
-Do not massage lower extremities
Medications Affecting the Reproductive Tract -Meds:
*Estradiol
,-Adverse effects:
*htn
*HA (can cause thromboembolism which can result in stroke)
*swelling/tenderness of calf (can be indicative of DVT)
*gentinourinary candidiasis
Peptic Ulcer Disease (PUD): -Meds Used:
*Misoprostol
-Side Effects:
*uterine contractions
*reduces gastric acid secretions
*diarrhea
-Interventions:
*Notify provider if dysmenorrhea & spotting occur.
*Report diarrhea or abd pain; reduce dose if nec
-Administration:
*pregnancy test must be taken before starting*
*Take AC & HS
*don't take w/Mg containing antacids
Medication Administration: Ear Drop Administration *Administering ear drops:
-For child < 3, pull pinna back & down
-For person > 3, pull pinna up & back
-Warm to room temp
-Cold drops can cause n/v
Total Parenteral Nutrition (TPN) Infusion: Continuous -Cont. TPN can be given to pts who
don't meet adequate nutrient intake
-TPN should be given thru a pump
-TPN should only be given in a central line
blood glucose checks are needed
check for egg allergy bc this can cause interaction with tpn formula
take in oral nutrients as much as possible to allow for intestines to still digest as normal and work
Peripheral Vascular Diseases: Deep-Vein Thrombosis -encourage ambulation
-bed rest
-intermittent, continuous warm moist compress
-do not massage limb
-provide thigh high compression or stockings
-drink 2-3L per day
-place warm compresses on affected area
-elevate the affected leg above heart level
-watch for signs of an embolism
Hematologic Disorders: Stroke Stroke:
*Interventions to < Risk of ^ICP
-place client no more than 25*
-> or < than 25* can cause ^ ICP
-suction only when airway isn't clear
-unneccessary suctioning ^ risk for ^ ICP
-keep in quiet environment
,-avoid coughing, sneezing, or nose blowing
Hematologic Disorders: Manifestations of Vaso-Occlusive Crisis -hematuria: can be fatal d/t
renal ischemia
-visual disturbances
-Severe pain; usually in bones, joints, & abd
-swollen joints, hands, & feet d/t restricted vessels
-anorexia
-n/v
-^T
-obstructive jaundice
Pressure Ulcers, Wounds, and Wound Management: Identifying Risk Factors *Risk factors:
-Immobility
-Cognitive deficit
-Chronic illness (example diabetes)
-Steroid use
-Incontinence
-Malnutrition:
**^ risk for pressure ulcer d/t < tissue integrity
**slows healing process
*Stage I:
*Stage II: Partial thickness skin loss
*Stage III:
*Stage IV:
*Teaching home care to a family of a child who has a large wound?
-Provide a diet high in protein to promote tissue repair.
-Eat foods high in vitamin A
-do NOT cleanse with Betadine because it is toxic to open wounds.
Disorders of the Eye: Evaluating Teaching Following Cataract Extraction -Can continue aspirin
therapy
-Bend at the knee to pick things up
-Don't pick up more than 10lbs
-Use cool compress if feeling itchy
-Avoid activities that ^ intraocular pressure
-Avoid coughing, sneezing, bending at the waist straining at stool, rubbing or touching eyes,
rapid head movements
Tracheostomy Care -Teach how to clean trach
-Remove inner cannula, remove soiled dressing, clean stoma, change ties
-Teach to suction only when airway is not clear, not on a scheduled basis
-Only suction for 5-10 seconds to avoid hypoxia
-Insert suction catheter as far as safe suction is listed
-If you hit resistance, remove suction 2 cm & suction there to prevent tissue damage
-Use surgical asepsis
-Patient may still sound congested even after suctioning, that is normal
, Acute and Infectious Respiratory Illnesses: Caring for a Toddler Who Is Postoperative Following
a Tonsillectomy -Place patient in position with head lower than chest
-Avoid using straws
-Don't have patient cough or deep breathe
-Administer analgesics every 4 hrs
-Avoid activities that can hurt sutures or reopen surgery site
Electrolyte Imbalances: Clinical Manifestations of Hypokalemia -Decreased DTR
-Constipation.
-Feeling of skipped heart beats or palpitations.
-Fatigue.
-Muscle damage.
-Muscle weakness or spasms.
-Tingling or numbness.
Cancer Disorders: Manifestations of Ovarian Cancer -Abdominal bloating
-Increase in abdominal girth
-Early satiety
-Urinary frequency or urgency
-unexpected weight loss
-dyspepsia, gas, indigestion
Oxygen and Inhalation Therapy *Oxygen Toxicity
-Crackles and substernal chest pain
-Bradypnea d/t depression of respiratory drive
-Can result from high concentrations of O2
-Use lowest level of O2 necessary to maintain adequate SpO2.
-Monitor ABGs & notify provider if PACO2 levels rise outside of expected range.
*Contraindications:
-Petroleum & oil based products are combustible
-The pt should use a water-based lubricant.
*Educating Pt:
-check the functioning of the oxygen equipment daily.
-wear cotton fabrics rather than synthetic or woolen when the oxygen is in use.
-store full oxygen tanks in an upright position
*Testing:
-Oximetry: determination of the SpO2 of arterial blood using a photoelectric device called an
oximeter
-SpO2: a clinical msrmt of % of Hgb bound w/O2 in the blood
Spinal Cord Injury: Manifestations of Autonomic Dysreflexia -Facial flushing
-Nasal congestion
-Headache
Cardiovascular Disorders: Expected Findings of Kawasaki Disease -Early phases:
*High T unresponsive to abx or antipyretics
*tachycardia
-Later phases:
