Ariana Melesio 1
ATI iRN iCOMPREHENSIVE iPREDICTOR i2016 iREMEDIATION
❖ Management iof iCare i– i(9)
➢ Advance iDirectives/Self-Determination/Life iPlanning i– i(1)
▪ Professional iResponsibilities: iClient iTeaching iAbout iDo-Not-Resuscitate iOrders
i(Active iLearning iTemplate i– iBasic iConcept, iRM iLeadership i7.0 iChp. i3)
• Unless ia ido inot iresuscitate i(DNR) ior iallow inatural ideath i(AND) iprescription iis
iwritten, ithe inurse ishould i initiate iCPR iwhen ia iclient ihas i no ipulse ior irespirations.
iThe iwritten iprescription i for ia iDNR ior iAND i must ibe iplaced i in ithe iclient’s i medical
irecord. iThe iprovider iconsults ithe iclient iand ithe i family iprior ito iadministering ia
iDNR ior iAND.
➢ Client iRights i– i(1)
▪ Coordinating iClient iCare: iAppropriate iAction iWhen ia iClient iLeaves iAgainst iMedical
iAdvice i(Active i Learning iTemplate i– iBasic iConcept, iRM iLeadership i7.0 iChp. i2)
• A iclient iwho ileaves ia ifacility iwithout ia iprescription ifor idischarge ifrom ithe
iprovider i is iconsidered i leaving iagainst i medical iadvice i(AMA). iA iclient iwho i is
i legally icompetent ihas ithe i legal iright ito ileave ithe i facility iat iany itime. iThe i nurse
ishould i immediately i notify ithe iprovider. iIf ithe iclient iis iat irisk i for i harm, i it i is
i imperative ithat ithe inurse iexplain ithe irisk i involved i in i leaving ithe i facility. iThe
i individual ishould isign ia i form irelinquishing iresponsibility i for iany i complications
it hat iarise i from idiscontinuing iprescribed icare. iThe i nurse ishould idocument iall
icommunication, ias iwell ias ithe ispecific iadvice ithat iwas iprovided i for ithe iclient. iA
inurse iwho itries ito iprevent ithe iclient i from i leaving ithe i facility ican i face i legal
icharges iof iassault, ibattery, iand i false i imprisonment.
➢ Collaboration iwith iInterdisciplinary iTeam i– i(1)
▪ Coordinating iClient iCare: iInformation ito iReport ito iOccupational iTherapist i(Active
iLearning iTemplate i– iBasic iConcept, iRM iLeadership i7.0 iChp. i2)
• Patient’s icondition iand icurrent istatus; iany imedications ithe ipatient iis ion; ipatient’s
itolerance i level i for ipain; iany iassistive idevices ithe ipatient iuses
➢ Confidentiality/Information iSecurity i– i(1)
▪ Professional iResponsibilities: iProtecting iConfidential iClient iInformation i(Active
iLearning iTemplate i– iBasic iConcept, iRM iLeadership i7.0 iChp. i3)
• It iis iessential ifor inurses ito ibe iaware iof ithe irights iof iclients iin iregard ito iprivacy
iand iconfidentiality. i Facility ipolicies iand iprocedures iare iestablished i in iorder ito
iensure icompliance iwith iHIPAA iregulations. iIt iis iessential ithat inurses iknow iand
iadhere ito ithe ipolicies iand iprocedures. iHIPAA iregulations ialso iprovide i for
ipenalties i in ithe ievent iof inoncompliance iwith ithe iregulations.
➢ Continuity iof iCare i– i(1)
▪ Information iTechnology: iPreparing ia iChange-of-Shift iReport i(Active iLearning
iTemplate i– iBasic iConcept, iRM iFUND i9.0 iCh i5)
• Nurses igive ithis ireport iat ithe iconclusion iof ieach ishift ito ithe inurse iassuming
iresponsibility i for ithe iclients. iFormats i include i face i to iface, iaudiotaping, ior
ipresentation iduring iwalking irounds i in ieach iclient’s iroom i(unless ithe iclient ihas ia
iroommate ior ivisitors iare ipresent). iAn ieffective ireport ishould: i include isignificant
, Ariana Melesio 2
objective iinformation iabout ithe iclient’s ihealth iproblems; iproceed iin ia ilogical
isequence; i include i no igossip ior ipersonal iopinion; irelate irecent ichanges i in
i medications, itreatments, iprocedures, iand ithe idischarge iplan
➢ Legal iRights iand iResponsibilities i– i(1)
▪ Professional iResponsibilities: iUnderstanding iRegulations ifor iNursing iScope iof
iPractice i(Active iLearning iTemplate i– iBasic iConcept, iRM iLeadership i7.0 iChp. i3)
• Standards iof icare iguide, idefine, iand idirect ithe ilevel iof icare ithat ishould ibe igiven iby
ipracticing i nurses. iThey ialso iare iused i in i malpractice i lawsuits ito idetermine i if ithat
ilevel iwas i maintained. iNurses ishould irefuse ito ipractice ibeyond ithe ilegal iscopeio f
ipractice iand/or ioutside iof itheir iareas iof icompetence iregardless iof ireason i(staffing
ishortage, ilack iof iappropriate ipersonnel). iNurses ishould iuse ithe i formal ichain iof
icommand ito iverbalize iconcerns irelated ito iassignment i in i light iof icurrent i legal
iscope iof ipractice, i job idescription, iand iarea iof icompetence.
➢ Performance iImprovement i(Quality iImprovement) i– i(1)
▪ Maintaining ia iSafe iEnvironment: iDemonstrating iQuality iand iSafety iEducation ifor
iNurses iCompetencies i(Active iLearning iTemplate i– iBasic iConcept, iRM iLeadership
7.0 iChp. i4)
• Safe iuse iof iequipment irefers ito iappropriate ioperation iof ihealth icare-related
iequipment iby itrained istaff. iEquipment-related i injuries ican ioccur ias ia iresult iof
i malfunction, idisrepair, ior imishandling iof i mechanical iequipment. iNurses i must
iensure ithat ithey i have ithe icompetence i necessary ito iuse i equipment ifor itasks ithat
i fall iwithin itheir iscope iof ipractice. iNurses ishould iuse iequipment ionly iafter
ireceiving isufficient i instruction. iEquipment ishould i be iregularly i inspected iby ithe
iengineering ior imaintenance idepartment iand i by ithe iuser iprior ito iuse. iFaulty
iequipment i(frayed icords, idisrepair) ican istart ia ifire ior icause ian ielectrical ishock iand
ishould ibe iremoved i from iuse iand ireported iimmediately iper iagency ipolicy.
➢ Referrals i– i(2)
▪ Alzheimer’s iDisease: iResources ifor iHome iCare i(Active iLearning iTemplate i– iSystem
iD isorder, iRM iAMS iRN i10.0 iChp i8)
• Refer ito isocial iservices iand icase imanagers ifor ilong-term/home imanagement,
iAlzheimer’s iAssociation, icommunity ioutreach iprograms, iand isupport igroups
▪ Nutrition iand iOral iHydration: iPriority iFinding iFollowing ian iIschemic iStroke i(Active
iLearning iTemplate i– iSystem iDisorder, iRM iFUND i9.0 iCh i39)
• Identify iif isomeone ihas idysphagia, ithis ipatient iwill ineed ipureed ifoods; iclear iand
i full i liquids iplus ipureed imeats, ifruits iand iscrambled ieggs, ilow iresidue: ilow i in i fiber
❖ Safety iand iInfection iControl i– i(6)
➢ Accident/Error/Injury iPrevention i– i(2)
▪ Adverse iEffects, iInteractions, iand iContraindications: iPriorityiAction ito ianiAllergic
iResponse i(Active iLearning iTemplate i– iMedication, iRM iPharm iRN i7.0 iChp i5)
• Treat iwith iepinephrine, ibronchodilators, iand iantihistamines. iProvide irespiratory
isupport iand i inform ithe iprovider.
▪ Health iPromotion iof iInfants i(2 iDays ito i1 iYear): iCar iSeat iSafety i(Active iLearning
iTemplate i– iBasic iConcept, iRM iNCC iRN i10.0 iChp i3)
ATI iRN iCOMPREHENSIVE iPREDICTOR i2016 iREMEDIATION
❖ Management iof iCare i– i(9)
➢ Advance iDirectives/Self-Determination/Life iPlanning i– i(1)
▪ Professional iResponsibilities: iClient iTeaching iAbout iDo-Not-Resuscitate iOrders
i(Active iLearning iTemplate i– iBasic iConcept, iRM iLeadership i7.0 iChp. i3)
• Unless ia ido inot iresuscitate i(DNR) ior iallow inatural ideath i(AND) iprescription iis
iwritten, ithe inurse ishould i initiate iCPR iwhen ia iclient ihas i no ipulse ior irespirations.
iThe iwritten iprescription i for ia iDNR ior iAND i must ibe iplaced i in ithe iclient’s i medical
irecord. iThe iprovider iconsults ithe iclient iand ithe i family iprior ito iadministering ia
iDNR ior iAND.
➢ Client iRights i– i(1)
▪ Coordinating iClient iCare: iAppropriate iAction iWhen ia iClient iLeaves iAgainst iMedical
iAdvice i(Active i Learning iTemplate i– iBasic iConcept, iRM iLeadership i7.0 iChp. i2)
• A iclient iwho ileaves ia ifacility iwithout ia iprescription ifor idischarge ifrom ithe
iprovider i is iconsidered i leaving iagainst i medical iadvice i(AMA). iA iclient iwho i is
i legally icompetent ihas ithe i legal iright ito ileave ithe i facility iat iany itime. iThe i nurse
ishould i immediately i notify ithe iprovider. iIf ithe iclient iis iat irisk i for i harm, i it i is
i imperative ithat ithe inurse iexplain ithe irisk i involved i in i leaving ithe i facility. iThe
i individual ishould isign ia i form irelinquishing iresponsibility i for iany i complications
it hat iarise i from idiscontinuing iprescribed icare. iThe i nurse ishould idocument iall
icommunication, ias iwell ias ithe ispecific iadvice ithat iwas iprovided i for ithe iclient. iA
inurse iwho itries ito iprevent ithe iclient i from i leaving ithe i facility ican i face i legal
icharges iof iassault, ibattery, iand i false i imprisonment.
➢ Collaboration iwith iInterdisciplinary iTeam i– i(1)
▪ Coordinating iClient iCare: iInformation ito iReport ito iOccupational iTherapist i(Active
iLearning iTemplate i– iBasic iConcept, iRM iLeadership i7.0 iChp. i2)
• Patient’s icondition iand icurrent istatus; iany imedications ithe ipatient iis ion; ipatient’s
itolerance i level i for ipain; iany iassistive idevices ithe ipatient iuses
➢ Confidentiality/Information iSecurity i– i(1)
▪ Professional iResponsibilities: iProtecting iConfidential iClient iInformation i(Active
iLearning iTemplate i– iBasic iConcept, iRM iLeadership i7.0 iChp. i3)
• It iis iessential ifor inurses ito ibe iaware iof ithe irights iof iclients iin iregard ito iprivacy
iand iconfidentiality. i Facility ipolicies iand iprocedures iare iestablished i in iorder ito
iensure icompliance iwith iHIPAA iregulations. iIt iis iessential ithat inurses iknow iand
iadhere ito ithe ipolicies iand iprocedures. iHIPAA iregulations ialso iprovide i for
ipenalties i in ithe ievent iof inoncompliance iwith ithe iregulations.
➢ Continuity iof iCare i– i(1)
▪ Information iTechnology: iPreparing ia iChange-of-Shift iReport i(Active iLearning
iTemplate i– iBasic iConcept, iRM iFUND i9.0 iCh i5)
• Nurses igive ithis ireport iat ithe iconclusion iof ieach ishift ito ithe inurse iassuming
iresponsibility i for ithe iclients. iFormats i include i face i to iface, iaudiotaping, ior
ipresentation iduring iwalking irounds i in ieach iclient’s iroom i(unless ithe iclient ihas ia
iroommate ior ivisitors iare ipresent). iAn ieffective ireport ishould: i include isignificant
, Ariana Melesio 2
objective iinformation iabout ithe iclient’s ihealth iproblems; iproceed iin ia ilogical
isequence; i include i no igossip ior ipersonal iopinion; irelate irecent ichanges i in
i medications, itreatments, iprocedures, iand ithe idischarge iplan
➢ Legal iRights iand iResponsibilities i– i(1)
▪ Professional iResponsibilities: iUnderstanding iRegulations ifor iNursing iScope iof
iPractice i(Active iLearning iTemplate i– iBasic iConcept, iRM iLeadership i7.0 iChp. i3)
• Standards iof icare iguide, idefine, iand idirect ithe ilevel iof icare ithat ishould ibe igiven iby
ipracticing i nurses. iThey ialso iare iused i in i malpractice i lawsuits ito idetermine i if ithat
ilevel iwas i maintained. iNurses ishould irefuse ito ipractice ibeyond ithe ilegal iscopeio f
ipractice iand/or ioutside iof itheir iareas iof icompetence iregardless iof ireason i(staffing
ishortage, ilack iof iappropriate ipersonnel). iNurses ishould iuse ithe i formal ichain iof
icommand ito iverbalize iconcerns irelated ito iassignment i in i light iof icurrent i legal
iscope iof ipractice, i job idescription, iand iarea iof icompetence.
➢ Performance iImprovement i(Quality iImprovement) i– i(1)
▪ Maintaining ia iSafe iEnvironment: iDemonstrating iQuality iand iSafety iEducation ifor
iNurses iCompetencies i(Active iLearning iTemplate i– iBasic iConcept, iRM iLeadership
7.0 iChp. i4)
• Safe iuse iof iequipment irefers ito iappropriate ioperation iof ihealth icare-related
iequipment iby itrained istaff. iEquipment-related i injuries ican ioccur ias ia iresult iof
i malfunction, idisrepair, ior imishandling iof i mechanical iequipment. iNurses i must
iensure ithat ithey i have ithe icompetence i necessary ito iuse i equipment ifor itasks ithat
i fall iwithin itheir iscope iof ipractice. iNurses ishould iuse iequipment ionly iafter
ireceiving isufficient i instruction. iEquipment ishould i be iregularly i inspected iby ithe
iengineering ior imaintenance idepartment iand i by ithe iuser iprior ito iuse. iFaulty
iequipment i(frayed icords, idisrepair) ican istart ia ifire ior icause ian ielectrical ishock iand
ishould ibe iremoved i from iuse iand ireported iimmediately iper iagency ipolicy.
➢ Referrals i– i(2)
▪ Alzheimer’s iDisease: iResources ifor iHome iCare i(Active iLearning iTemplate i– iSystem
iD isorder, iRM iAMS iRN i10.0 iChp i8)
• Refer ito isocial iservices iand icase imanagers ifor ilong-term/home imanagement,
iAlzheimer’s iAssociation, icommunity ioutreach iprograms, iand isupport igroups
▪ Nutrition iand iOral iHydration: iPriority iFinding iFollowing ian iIschemic iStroke i(Active
iLearning iTemplate i– iSystem iDisorder, iRM iFUND i9.0 iCh i39)
• Identify iif isomeone ihas idysphagia, ithis ipatient iwill ineed ipureed ifoods; iclear iand
i full i liquids iplus ipureed imeats, ifruits iand iscrambled ieggs, ilow iresidue: ilow i in i fiber
❖ Safety iand iInfection iControl i– i(6)
➢ Accident/Error/Injury iPrevention i– i(2)
▪ Adverse iEffects, iInteractions, iand iContraindications: iPriorityiAction ito ianiAllergic
iResponse i(Active iLearning iTemplate i– iMedication, iRM iPharm iRN i7.0 iChp i5)
• Treat iwith iepinephrine, ibronchodilators, iand iantihistamines. iProvide irespiratory
isupport iand i inform ithe iprovider.
▪ Health iPromotion iof iInfants i(2 iDays ito i1 iYear): iCar iSeat iSafety i(Active iLearning
iTemplate i– iBasic iConcept, iRM iNCC iRN i10.0 iChp i3)
