ATI Capstone Comprehensive
Assessment A
Assessing the Care Environment for a Client Who is Experiencing Suicidal
Ideations
-search the client's belonging with the client present. Remove all glass,
metal silverware, electrical cords, vases, belts, shoelaces, metal nail files,
tweezers, matches, razors, perfume, shampoo, plastic bags, and other
potentially harmful items from the client's room and vicinity
-allow the client to use only plastic eating utensils. Count utensils when
brought into and out of the client's room
-check the environment for possible hazards (windows that open, overhead
pipes that are easily accessible, non-breakaway shower rods, non-
recessed shower nozzles)
-ensure that the client's hands are always visible, even when sleeping
Caring for a Client Who Has Immunosuppression
monitor skin and mucous membranes for infection (breakdown, fissures,
and abscess)
,Developing an Emergency Preparedness Plan
The Hospital Incident Command System (HICS) for disaster management
offers a clear structure for disaster management at the facility level
Identifying Reportable Diseases
-Nurses are also mandated to report to the proper agency (local health
department, state health department) when a client is diagnosed with a
communicable disease
-a complete list of reportable diseases and a description of the reporting
system are available through the Centers for Disease Control and Prevent
Web site. Each state mandates which diseases must be reported in that
state. There are more than 60 communicable diseases that must be
reported to public health departments to allow officials to do the following:
ensure appropriate medical treatment of diseases (tuberculosis), monitor
for common-source outbreaks (foodborne: hepatitis A), plan and evaluate
control and prevention plans (immunizations for preventable diseases),
identify outbreaks and epidemics, determine public health priorities based
on trends, educate the community on prevention and treatment of these
diseases
,Nationally notifiable diseases: identified at the CDC website and include the
following
-anthrax, botulism, cholera, congenital rubella syndrome (CRS), diphtheria,
giardiasis, gonorrhea, hepatitis A, B, C, HIV, influenza-associated pediatric
mortality, legionellosis/legionnaires' disease, lyme disease, malaria,
meningococcal disease, mumps, pertussis (whooping cough), poliomyelitis,
paralytic, poliovirus infection, nonparalytic, rabies (human or animal),
rubella (german measles), salmonellosis, severe acute respiratory
syndrome-associated coronavirus disease (SARS-CoV), shigellosis,
smallpox, syphilis, tetanus/C. tetani, toxic shock syndrome (TSS) (other
than streptococcal), tuberculosis (TB), typhoid fever, vancomycin-
intermediate and vancomycin-resistant, viral hemorrhagic fever,
staphylococcus aureus (VISA/VRSA)
Identifying a Prescription to Clarify With the Provider
-caused by damage to sensory nerve fibers resulting in numbness and pain
**peripheral neuropathy includes focal neuropathies, caused by acute
ischemic damage or diffuse neuropathies, which are more widespread and
involve slow, progressive loss. This can lead to complications (foot
deformities, ulcers).
, **autonomic neuropathy can affect nerve conduction of the heart (exercise
intolerance, painless myocardial infarction, altered left ventricular function,
syncope), gastrointestinal system (gastroparesis, reflux, early satiety), and
urinary tract (decreased bladder sensation, urinary retention). It affects the
autonomic nervous system, which minimizes manifestations of
hypoglycemia (diaphoresis, tremors, palpitations), which can be dangerous
for the client
-clients who have impaired sensory perception might not feel numbness,
pain, or burning
managing adverse effects of risperidone
orthostatic hypotension
-nursing actions: monitor blood pressure and heart rate for orthostatic
changes
-client education: change position slowly
placing a client in side-lying position
Assessment A
Assessing the Care Environment for a Client Who is Experiencing Suicidal
Ideations
-search the client's belonging with the client present. Remove all glass,
metal silverware, electrical cords, vases, belts, shoelaces, metal nail files,
tweezers, matches, razors, perfume, shampoo, plastic bags, and other
potentially harmful items from the client's room and vicinity
-allow the client to use only plastic eating utensils. Count utensils when
brought into and out of the client's room
-check the environment for possible hazards (windows that open, overhead
pipes that are easily accessible, non-breakaway shower rods, non-
recessed shower nozzles)
-ensure that the client's hands are always visible, even when sleeping
Caring for a Client Who Has Immunosuppression
monitor skin and mucous membranes for infection (breakdown, fissures,
and abscess)
,Developing an Emergency Preparedness Plan
The Hospital Incident Command System (HICS) for disaster management
offers a clear structure for disaster management at the facility level
Identifying Reportable Diseases
-Nurses are also mandated to report to the proper agency (local health
department, state health department) when a client is diagnosed with a
communicable disease
-a complete list of reportable diseases and a description of the reporting
system are available through the Centers for Disease Control and Prevent
Web site. Each state mandates which diseases must be reported in that
state. There are more than 60 communicable diseases that must be
reported to public health departments to allow officials to do the following:
ensure appropriate medical treatment of diseases (tuberculosis), monitor
for common-source outbreaks (foodborne: hepatitis A), plan and evaluate
control and prevention plans (immunizations for preventable diseases),
identify outbreaks and epidemics, determine public health priorities based
on trends, educate the community on prevention and treatment of these
diseases
,Nationally notifiable diseases: identified at the CDC website and include the
following
-anthrax, botulism, cholera, congenital rubella syndrome (CRS), diphtheria,
giardiasis, gonorrhea, hepatitis A, B, C, HIV, influenza-associated pediatric
mortality, legionellosis/legionnaires' disease, lyme disease, malaria,
meningococcal disease, mumps, pertussis (whooping cough), poliomyelitis,
paralytic, poliovirus infection, nonparalytic, rabies (human or animal),
rubella (german measles), salmonellosis, severe acute respiratory
syndrome-associated coronavirus disease (SARS-CoV), shigellosis,
smallpox, syphilis, tetanus/C. tetani, toxic shock syndrome (TSS) (other
than streptococcal), tuberculosis (TB), typhoid fever, vancomycin-
intermediate and vancomycin-resistant, viral hemorrhagic fever,
staphylococcus aureus (VISA/VRSA)
Identifying a Prescription to Clarify With the Provider
-caused by damage to sensory nerve fibers resulting in numbness and pain
**peripheral neuropathy includes focal neuropathies, caused by acute
ischemic damage or diffuse neuropathies, which are more widespread and
involve slow, progressive loss. This can lead to complications (foot
deformities, ulcers).
, **autonomic neuropathy can affect nerve conduction of the heart (exercise
intolerance, painless myocardial infarction, altered left ventricular function,
syncope), gastrointestinal system (gastroparesis, reflux, early satiety), and
urinary tract (decreased bladder sensation, urinary retention). It affects the
autonomic nervous system, which minimizes manifestations of
hypoglycemia (diaphoresis, tremors, palpitations), which can be dangerous
for the client
-clients who have impaired sensory perception might not feel numbness,
pain, or burning
managing adverse effects of risperidone
orthostatic hypotension
-nursing actions: monitor blood pressure and heart rate for orthostatic
changes
-client education: change position slowly
placing a client in side-lying position
