ATI-3 -ATI Topic Descriptors

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 ATI-3 -ATI Topic Descriptors Basic Care and Comfort (13) Plan A 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 if bladder manually irrigated, 50ml of irrigating soln should be instilled and then withdrawn with a syringe to remove clots that may be in bladder and catheter.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