ATI Topic Descriptors STUDY GUIDE

ATI Topic Descriptors STUDY GUIDE Basic Care and Comfort (13) Plan A Hygiene Care: Evaluating Appropriate Use of Assistive Devices Cane instructions: Maintain two points of support on the ground at all times Keep the cane on the stronger side of the body Support body wt on both legs, move cane forward 6-10 inches, then move the weaker leg forward toward the cane. Next, advance the stronger leg Dentures: Clients who have fragile oral mucosa require gentle brushing and flossing. Perform denture care for the client who is unable to do it himself Remove dentures with a gloved hand, pulling down and out at the front of the upper denture, and lifting up and out at the front of the lower denture. Place dentures in a denture cup or emesis basin Brush them with a soft brush and denture cleaner Rinse them with water Store the dentures, or assist the client with reinserting the dentures Complimentary and Alternative Therapies: Appropriate Use of Music Therapy for Pain Management Music decreases physiological pain, stress and anxiety by diverting the personʼs attention away from the pain and creating a relaxation response. let client select the type of music music produces an altered state of consciousness through sound, silence, space and time must be listened to for 15-30 minutes to be therapeutic earphones help client concentrate on music while avoiding other clients or staff highly effective in reducing postop pain if pain acute, increase volume of music Prostate Surgeries: Calculating a Clientʼs Output When Receiving Continuous Bladder Irrigations purpose: to maintain the patency of indwelling urinary catheters (bec blood, pus, or sediment can collect within tubing resulting in bladder sistention and buildup of stagnant urine) Med-Surg p. 1443 after prostate surgery, irrigation is typically done to remove clotted blood from the bladder and ensure drainage of urine. if bladder manually irrigated, 50ml of irrigating soln should be instilled and then withdrawn with a syringe to remove clots that may be in bladder and catheter. with CBI, irrigating soln is continuously infused and drained from the bladder. The rate of infusion is based on the color of drainage. Ideally the urine drainage should be light pink without clots. The inflow and outflow of irrigant must be continuously monitored. If outflow is less than inflow, the catheter patency should be assessed for clots or kinks. If the outflow is blocked and patency cannot be reestablished by manual irrigation, the CBI is stopped and the physician notified. Record amount of urine output and character of urine every eight (8) hours or as per physicianʼs orders. (To obtain urine output, subtract amount of fluid instilled into bladder from total output.) intermittent irrigation dorsal recumbent or supine position avoid cold solution bec may result in bladder spasm clamp cath just below soft injection port cleanse injection port with antiseptic swab (same port as specimen collection) insert needle through port at 30degree angle slowly inject fluid into cath and bladder withdraw syringe remove clamp and allow solution to drain into drainage bag if ordered by MD, keep clamped to allow solution to remain in bladder for short time (20-30min) Closed continuous irrigation Recording and Reporting Record type and amt of irrigation soln used, amt returned as drainage and the character of drainage Record and report any findings such as complaints of bladder spasms, inability to instill fluid into bladder and/or presence of blood clots. Urinary Elimination: Kegel Exercises for Urinary Incontinence sits on toilet with knees far apart and tightens muscle to stop the flow of urine ( to learn the muscle) then practiced at nonvoiding times instruct client to contract muscle for a count of 3, hold and release for a count of 3, and repeat this 10x. Client should repeat these cycles for 25-30x 3x/day for 6 months. Client should do this Bowel Elimination Needs: Client Education Regarding Colostomy Care Stoma s/b pink. Dusky blue stoma---ischemia Brown-black stoma---necrosis mild to moderate swelling for 1st 2-3 weeks after surgery intact skin barriers with no evidence of leakage do not need to be changed daily and can remain in place for 3-5 days. skin should be washed with mild soap, warm water and dried thoroughly before barrier applied pouch must fit snugly to prevent leakage around stoma. The opening around the appliance should be no more than 1/16 inch larger than the stoma. Stoma shrinks and does not reach usual size for 6-8 weeks empty pouch before it is 1/3 full to prevent leakage cleanse skin and use skin barriers and deodorizers to prevent skin breakdown and malodor apply skin barrier and pouch. if creases next to stoma occur, use barrier paste to fill in; let dry 1-2 min apply non-allergic paper tape around the pectin skin barrier in a picture frame method. Burns: Non-pharmacologic Comfort Interventions for Dressing Changes Med/Surg p. 534-535 Distractions Relaxation tapes visualization guided imagery biofeedback meditation used as adjuncts to traditional pharmacologic txs of pain Visualization and guided imagery can be helpful to the nurse as well as the pt nurse ask the pt about a favorite hobby or recent vacation nurse can explore these areas further by asking questions that make the pt visualize and describe a favorite hobby or recent vacation by using this method, both the nurse and the pt must focus on things besides the task at hand. (ie dressing change) to keep the conversation flowing Relaxation tapes can be helpful when played at night to help the pt fall asleep. Application of Heat and Cold: Assess Need for Heat/Cold Applications Application of Cold: Ensure Safe Use of Cold Applications Potter/Perry p. Cold and heat applications relieve pain and promote healing. selection varies with clientʼs conditions. moist heat can help relieve the pain from a tension HA cold heat can reduce the acute pain from inflamed joints avoid injury to skin by checking the temp and avoiding direct application of the cold or hot surface to the skin esp at risk: spinal cord or other neuro injury, older adults, confused clients Ice massage or cold therapy are particularly effective for pain relief. Ice massage: apply the ice with firm pressure followed by slow steady, circular massage Cold may be applied to pain site on the opposite side of the body corresponding to the pain site or on a site located between the brain and the pain site. takes 5-10 minutes to apply cold each client responds differently to the site of the application that is the most effective application near the actual site of pain tends to work best a client feels cold, burning and aching sensations and numbness. When numbness occurs, the ice should be removed. cold is particularly effective for tooth or mouth pain when ice is place on the web of the hand between the thumb and index finger cold applications are also effective before invasive needle punctures Heat application donʼt lay on heating element bec burning could occur Assessment for Temperature Tolerance (P/P p. 1549) before applying either, the nurse should assess the clientʼs physical condition for signs of potential intolerance to heat and cold first observe the area to be txʼd alterations in skin integrity, such as abrasions, open wounds, edema, bruising, bleeding or localized areas of inflammation increase the clientʼs risk of injury. baseline skin assessment provides a guide for evaluating skin changes that might occur during therapy assessment includes id of conditions that contraindicate heat or cold therapy: an active area of bleeding should not be covered by a warm application bec bleeding will continue warm applications are contraindicated when client has an acute, localized inflammation such as appendicitis bec the heat could cause the appendix to rupture. if client has CV problems, it is unwise to apply heat to large portions of the body bec the resulting massive vasodilation may disrupt blood supply to vital organs. cold is contraindicated if the site of injury is already edematous cold furth retards circulation to the area and prevents absorption of the interstitial fluid. if client has impaired circulation (arteriosclerosis), cold further reduces blood supply to affected area cold contraindicated in presence of neuropathy (client unable to perceive temp changes) cold contraindicated in shivering (intensifies shivering and dangerously increase body temp) If MD orders cold therapy to lower extremity, assess for cap refill, observing skin color and palpating skin temp, distal pulses and edematous areas if signs of circulatory inadequacy, question order if confused or unresponsive, make freq observations of skin integrity after therapy begins assess condition of equip used before applying heat and cold, understand normal body responses to local temp variations, assess the integrity of the body part, determine the clientʼs ability to sense temp variations and ensure proper operation of equipment. Crohnʼs Disease: Selecting a Low-Fiber, Low-Residue Diet No raw vegetables, vegs not strained, dried beans, peas, and legumes No raw fruits, fruits with skins, seeds No nuts, raisins, rich desserts no whole grain breads or cereals no fried, smoked, pickled or cured meats, no alcohol, fruit juices with pulp Dumping Syndrome: Client Education Regarding Dietary Interventions meal size must be reduced accordingly (6 small feedings) no drinking fluids with meals (30-45 min before or after meals) helps prevent distention or a feeling of fullness dry foods with low-carb content and moderate protein and fat content proteins and fats are increased promotes rebuilding of body tissues and to meet energy needs specifically meat, cheese, eggs and mild products no concentrated sweets (honey, sugar, jelly, jam) cause dizziness, diarrhea, a sense of fullness short rest period after each meal Cholecystitis: Dietary Restrictions Low in fat, and sometimes a wt reduction diet is also recommended (4-6 weeks take fat soluble vit supplements Palliative Care: Client/ Family Teaching caring interventions rather than curing interventions for any age, diagnosis, any time, and not just during the last few months of life preservation of dignity becomes the goal of palliative care allows clientʼs to make more informed choices, achieve better alleviation of sx and have more opportunity to work on issues of life closure establish a caring relationship with both client and family management of sx of disease and therapies Preparing the Dying Clientʼs Family (P/P 588) Objectives: family will be able to provide appropriate physical care for the dying client in home family will be able to provide appropriate psychological support to the dying client. Describe and demonstrate feeding techniques and selection of foods to facilitate ease of chewing and swallowing Demonstrate bathing, mouth care, and other hygiene measures and allow family to perform return demo show video on simple transfer techniques to prevent injury to themselves and client, help family to practice instruct family on need to enforce rest periods teach family to recognize s/s to expect as the clientʼs condition worsens and provide info on who to call in an emergency discuss ways to support the dying person and listen to needs and fears solicit questions from family and provide info as needed. Evaluation: Have the family members demo physical care techniques ask family members to describe how they vary approaches to care when the client has sx such as pain or fatigue ask the family to discuss how they feel about their ability to support the client . Cognitive Disorders: Promoting Independence in Hygiene for A Client with Alzheimerʼs Disease Stage S/S Stage 1, Forgetfulness Short term memory loss Decreased Attn Span Subtle Personality Changes Mild cognitive deficits Difficulty with depth perception Stage 2, Confusion Obvious memory loss Confusion, impaired judgement, confabulation Wandering behavior Sundowning (more confusion in late afternoon/early evening) Irritability and agitation Poor spatial orientation, impaired motor skills Intensification of sx when the client is stressed, fatigued, or in an unfamiliar environment Depression r/t awareness of reduced capacities Stage 3, Ambulatory dementia loss of reasoning ability Increasing loss of expressive language Loss of ability to perform ADLs More Withdrawn Stage S/S Stage 4, End Stage Impaired or absent cognitive, communication and/or motor skills Bowel and bladder incontinence Inability to recognize family members or self in mirror Assess teaching needs for the client and especially for the family members when the clientʼs cognitive ability is progressively declining. Review the resources avail to the family as the clientʼs health declines. A wide variety of home care and community resources may be avail to the family in many areas of the country, and these resources may allow the client to remain at home rather than in an institution Perform self assessment regarding possible feelings of frustration, anger, or fear when performing daily care for clients with progressive dementia NCP Med/Surg 1592 Monitor ptʼs ability for independent self-care to plan appropriate interventions specific to pt unique problems Use consistent repetition of daily health routines as a means of establishing them bec memory loss impairs ptʼs ability to plan and complete specific sequential activities assist pt in accepting dependency to ensure that all needs are met. teach family to encourage independence and to intervene only when the pt is unable to perform to promote independence Bathing/Hygiene provide desired personal articles, such as bath soap and hairbrush, to enhance memory and provide care facilitate ptʼs bathing self as appropriate to facilitate independence and provide appropriate help in hygiene Dressing/Grooming provide ptʼs clothes in accessible area to facilitate dressing Be available for assistance in dressing as necessary to facilitate independence and provide appropriate help in dressing Toileting Assist pt to toilet as specified intervals to promote regularity facilitate toilet hygiene after completion of elimination to prevent discomfort and skin breakdown. Rest and Sleep: Recognizing and Reporting Sleep Disorders (P/P 1203) If untreated lead to three problems insomnia abnormal movements or sensation during sleep or when awakening at night, or excessive daytime sleepiness. Four categories Dyssomnias (origins in body systems ) Intrinsic (initiating and maintaining sleep) psychophysiological insomnia narcolepsy periodic limb movement disorders sleep apnea syndromes Extrinsic (outside the body) inadequate sleep hygiene insufficient sleep syndrome hypnotic dependent sleep disorders alcohol dependent sleep disorders Circadian Rhythm Sleep Disorders (misalignment of timing and what is desired) Time Zone Change Shift work sleep disorder Delayed sleep phase syndrome Parasomnias (undesirable behaviors that occur during sleep) Arousal Disorders Sleepwalking Sleep terrors Sleep-Wake Transition Disorders Sleeptalking Sleep starts