ATI Topic Descriptors
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
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if bladder manually irrigated, 50ml of irrigating soln should be instilled and then withdrawn with a syringe to remove clots that may be in bladder and catheter.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 5x.day
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. 1253-1254
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
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
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
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
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
Nocturnal leg cramps REM Sleep disturbances
nightmares
REM Sleep behavior disorder sleep paralysis
Other Parasomnias
sleep bruxism (teeth grinding) sleep enuresis (bed-wetting)
SIDS
Sleep Disorders associated with Med-Psych Disorders Psych Disorders Mood disorders Anxiety disorders Psychoses Alcoholism Neurologic Disorders Dementia Parkinsonism
Central degenerative disorders Other Med Disorders
Nocturnal cardiac ischemia
COPD
PUD
Proposed sleep Disorders
Menstruation-associated sleep disorders Sleep choking syndrome
Pregnancy associated sleep disorders Questions to Ask to Assess for Sleep Disorders Insomnia
How easily do you fall asleep
Do you fall asleep and have difficulty staying asleep? How many times do you awaken Do you awaken early from sleep
What time do awaken for good? What causes you to awaken early? What do you do to prepare for sleep? To improve you sleep?
How often do you have trouble sleeping Sleep Apnea
Do you snore loudly?
Has anyone ever told you that you often stop breathing for short periods during sleep? (Spouse or bed partner/roommate report this)
Do you experience HAs after awakening
Do you have difficulty staying awake during the day
Does anyone else in your family snore loudly or stop breathing during sleep? Narcolepsy
Are you tired during the day
Do you fall asleep at inopportune times?
Do you have episodes of losing muscle control or falling to the floor
have you ever had the feeling of being unable to move or talk just before falling asleep Do you have vivid lifelike dreams when going to sleep or waking up?
Basic Care and Comfort (13) Plan B
Mobility and Immobility: Recognizing Proper Use of Crutches
Crutch instructions
Do not alter crutches after proper fit has been determined Follow crutch gait prescribed by physical therapy
support body wt at hand grips with elbows flexed 30 degrees
position crutches on unaffected side when sitting or rising from chair. Elkin---pg 135
Use of crutches may be a temporary aid for persons with strains, in a cast or following surgical treatments
crutches may be routinely and continuously used for those with congenital or acquired MS abnormalities, neuromuscular weakness, or paralysis or they may be used after amputations.
clientʼs height
distance between crutch pad and axilla angle of elbow flexion
[make sure shoes are on before measuring] Standing
crutches 4-6 in in front of feet and side of feet Crutch pads
two to three fingers between top of crutch and axilla Elbow
should be flexed (30 degrees ATI)
***any tingling in torso means crutches are used incorrectly or wrong size
if crutch too long---pressure on axilla causing paralysis of elbow and wrist (crutch palsy) if crutch too short---bent over and uncomfortable
low handgrips cause radial nerve damage
high handgrips cause clientʼs elbow to be sharply flexed and strength and stability are decreased
4-point gait
requires wt bearing on both legs
often used when client has paralysis, as in spastic children with CP may also be used for arthritic clients
improves balance by providing wider base of support R crutch, L foot, L crutch, R foot
3 point gait
requires wt bearing on 1 foot affected leg does not touch ground
may be useful for client with broken leg or sprained ankle R/L crutches, unaffected foot, R/L crutches, unaffected foot 2-point gait
requires partial wt bearing on each foot faster than 4-point gait
requires more balance
crutch movements are similar to arm movements while walking L crutch and R foot together, R crutch and L foot together. Swing to gait
freq used by clients whose lower extremities are paralyzed or who wear wt-supporting braces on their legs
easier of the two swing gaits
requires ability to bear body wt partially on both legs Swing through gait
requires client have ability to sustain partial wt bearing on both feet Stairs
( up) unaffected leg on step, both crutches come to step, repeat
(down) move crutches to stair below, move affected leg forward, then unaffected
leg
Pain Management: Nonpharmacological Pain Management P/P---ch 42
P/P---pg 1250
Nonpharmacological interventions include cognitive-behavioral and physical approaches
best if taught when not experiencing pain Goals of cognitive-behavioral interventions change clientʼs perceptions of pain alter pain behavior
provide clients with greater sense of control Goals of physical approaches
providing comfort
correcting physical dysfunction altering physiological responses
reducing fears associated with pain-related immobility Relaxation and Guided Imagery
Relaxation
mental and physical freedom from tension or stress provide self control when discomfort or pain occurs reverse physical and emotional stress of pain can be used at any phase of health or illness
not taught when client is in acute discomfort bec inability to concentrate describe common sensations client may feel
decrease in temp
numbness of a body part
use as feedback
free of noise
light sheet or blanket
progressive takes about 15 min
pay attn to body noting areas of tension, tense areas replaced with warmth and relation
some times better if eyes closed background music can help
combination of controlled breathing exercises and a series of contractions and relaxation of muscle groups.
Guided Imagery
client creates an image in the mind, concentrate on that image and gradually becomes less aware of pain
Distraction
RAS (reticular activating system) inhibits painful stimuli if a person receives sufficient or excessive sensory input
directs attention to something else and reduces awareness of pain even increases tolerance
1 disadvantage
if works, may question the existence of pain works best for short, intense pain lasting a few minutes
ex: invasive procedure or while waiting for analgesic to work RN assesses activities enjoyed by client that may act as distractions
singing
praying
describing photos or pictures aloud
listening to music
playing games
may include ambulation, deep breathing, visitors, television, and music 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 minutes to be therapeutic
highly effective in reducing postop pain if pain acute, increase volume of music Biofeedback
behavioral therapy that involves giving individuals information about physiological responses (BP and tension) and ways to exercise voluntary control over those
responses
used to produce deep relaxation and is effective for muscle tension and migraine
HA
Cutaneous stimulation
stimulation of the skin to relieve pain
massage
warm bath
ice bag
for inflammation
transcutaneous electrical nerve stimulation (TENS) (also called counter stimulation)
causes release of endorphins thus blocking transmission of painful stimulation advantage: measures can be used in the home
reduce pain perception and help reduce muscle tension
RN eliminates sources of environmental noise, helps client to assume a comfortable position, explains purpose of therapy
Acupressure/Acupuncture
vibration or electrical stimulation via tiny needles inserted into the skin and subcutaneous tissues at specific points
elevation of edematous extremities to promote venous return and decrease swelling
Urinary Elimination Needs: Preventing Incontinence
Use timed voidings to increase intervals between voidings/decrease voiding frequency perform pelvic floor (Kegel) exercises
perform relaxation techniques
offer undergarments while client is retraining teach client not to ignore urge to void
Urinary Elimination: Providing Catheter Care Prevent infection
Maintain unobstructed flow of urine through the cath drainage system Perineal Hygiene
perineal hygiene 2x/day or prn for client with retention cath soap and water are effective
can be delegated to AP Catheter care
assess urethral meatus and surrounding tissue for inflammation, swelling and
discharge. Note amt, color, odor, and consistency of discharge. Ask client if any burning or discharge is felt
with towel, soap and water, wipe in a circular motion along length of catheter for 4 inches
apply an abx ointment at urethral meatus and along 1 inch of cath if ordered by MD Mobility and Immobility: Evaluating for Complications of Immobility
Complications of Immobility
Integumentary--Maintain intact skin turn the client q 1-2 hr decrease pressure
limit sitting in chair to less than 2 hr Respiratory--maintain patent airway,
achieve optimal lung expansion and gas exchange and mobilize airway secretions
teach the client to turn, cough and deep breath q 1-2 hr
yawn every hour
use incentive spirometer CPT
Integumentary--Maintain intact skin turn the client q 1-2 hr decrease pressure
limit sitting in chair to less than 2 hr Cardiovascular---maintain CV fx, increase
activity tolerance and prevent thrombus formation
increase activity
avoid valsalva maneuver stool softener
ROM
avoid pillows under knees use elastic stockings SCD
give low dose heparin Metabolic---decrease injuries to skin and
maintain metabolism within normal fxing
provide high calorie high protein diet with additional vits B and C
monitor oral intake Elimination--maintain or achieve normal
urinary and bowel elimination patterns
maintain hydration (at least 2000 mL stool softener
bladder and bowel training insert cath if bladder distended
Musculoskeletal--maintain or regain body alignment and stability decrease skin and MS system changes, achieve full or optimal ROM and prevent contractures
change position in bed q 2 hrs ROM
nutritional intake CPM
Psychosocial--maintain normal sleep/wake patter, achieve socialization and achieve independent completion of self care
coping skills
maintain orientation develop schedule
Gastroenteral Feedings: Monitoring Tube Feedings Monitoring for tube placement
initial placement is confirmed with xray
monitor gastric contents for pH. A good indication of appropriate placement is obtaining gastric contents with a pH between 0-4
Aspirate for residual volume---note: intestinal residual < 10 mL, gastric residual < 100mL
return aspirated contents or follow protocol Flush tubing with 30-60 mL of H20
Acute Glomerulonephritis: Dietary Choice
Acute Glomerulonephritis: insoluble immune complexes develop and become trapped in the glomerular tissue producing swelling and capillary cell death
Maintain prescribed dietary restrictions Fluid restriction (24 hr output + 500 mL) Sodium restriction
Protein restriction (if azotemia is present)
Edema is treated by restricting sodium and fluid intake
Dietary protein intake may be restricted if there is evidence of nitrogenous wastes. Varies with degree of proteinuria.
Low protein, low sodium, fluid restricted diet
Rest and Sleep: Interventions to Promote Sleep for Hospitalized Clients Assist the client in establishing and following a bedtime routine
Attempt to minimize the number of times the client is awakened during the night while hospitalized
Offer to assist the client with personal hygiene needs and/or a back rub prior to sleep to increase comfort
Instruct the client to:
Exercise regularly at least 2 hr before bed time
Arrange the sleep environment to what is comfortable
Limit alcohol, caffeine, and nicotine in the late afternoon and evening Engage in muscle relaxation before bedtime
As a last resort, provide a pharmacological agent as prescribed.
ATI Topic Descriptors Plan A
Health Promotion and Maintenance (13)
Uterine Atony: Performing Appropriate Assessment (Murray/Mckinney p. 734-736) Atony: lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly around the blood vessels when the placenta separates
relaxed muscles allow rapid bleeding from the endometrial arterieries at the placental site
bleeding continues until uterine muscle fibers contact to stop the flow of blood.
retention of a large segment of the placenta does not allow the uterus to contract firmly and therefore can cause uterine atony
Major signs of uterine atony include: fundus that is difficult to locate
a soft or boggy feel when the fundus is located
a uterus that becomes firm as it is massaged byt loses its tone when massage is stopped
a fundus that is located above the expected levels which is at or near the umbilicus excessive lochia especially if it is bright red
excessive clots expelled
if a peripad is saturated in an hour, a lg amt of blood is considered to have been lost saturation in 15 min represents an excessive loss of blood in the early PP period a constant steady trickle is just as dangeiours
if uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus
one hand is placed just above the symphysis pubis o support the lower uterine segment while the other hand getnly but firmly massages the fundus in a cirucular motion
clots are expressed by applying firm but gently pressure on the fundus in the direction of the vagina
critical that uterus is contracted firmly before clots are expressed
pushing on an uncontracted uterus could invert the uterus and cause massive hemorrhage and rapid shock.
ATI book p.304
uterine atony is hypotonic uterus that is not firm described as boggy.
if untreated will result in postpartum hemorrhage and may result in uterine inversion Nursing assessments
monitor for s/s of uterine atony which include
a uterus that is larger than normal and boggy with possible lateral displacement on pelvic exam
prolonged lochia discharge irregulaor or excessive bleeding
Assessments for uterine atony include: fundal height, consistency and location lochia quantity, color, and consistency
Normal Physiological Changes of Pregnancy: Calculating the clientʼs delivery date
ATI p. 34 Nageleʼs rule:
take the first day of the last menstrual period, subtract 3 months and add 7 days and 1 year.
McDonaldʼs method
measure uterine fundal height in centimeteres from the symphysis pubis to the top of the uterine fundus (between 18 to 30 weeks gestation age). The calculation is as follows the gestational age is estimated to be equal to fundal height.
Positioning the client in a supine position with a wedge under one hip to laterally tilt her and keep her off her vena cava and descending aorta. This will help maintain optimal perfusion of oxygenated blood to the fetus during the procedure.
Antepartum Diagnostic Interventions: Monitoring during a Nonstress Test ATI p. 85
Nonstress Test
monitor the response of the FHR to fetal movement
client pushes a button attached to the monitor whenever she feels a fetal movement that is noted on the paper tracing.
NST Reactive : FHR accelerates to 15 beats/min for at least 15 sec and occurs 2 or more times during a 20 min period
placenta is adequately perfused and the fetus is well-oxygenated
NST Nonreactive: FHR does not accelerate adequately with fetal movement or no fetal movements occur in 40 min.
if so, further assessment such as a contraction stress test or biophysical profile is indicated
Disadvantages: high rate of false nonreactive results with the fetal movement response blunted by fetal sleep cycles, chronic tobacco smoking, meds, and fetal immaturity client should be in a reclining chair or in a semi-fowlersʼ or left lateral position
if there are no fetal movements (fetal sleeping), vibroacoustic stimulation (sound source, usually laryngeal stimulator) may be activated for 3 sec on the maternal abdomen over the fetal head to awaken a sleeping fetus
If still nonreactive, anticipate a CST or a BPP
Newborn Hypoglycemia: Identify Appropriate Interventions ATI p. 424 Hypoglycemia : serum glucose level of less than 40mg/dL
Hypoglycemia occurring in the 1st 3 days of life in the term newborn is defined as a blood glucose level of <40 mg/dL. In the preterm newborn, hypoglycemia is defined as a blood glucose level of < 25 mg/dL
Untreated hypoglycemia can result in mental retardation S/S
poor feeding jitteriness. tremors hypothermia diaphoresis weak shrill cry lethargy
flaccid muscle tone seizures/coma assessments:
monitoring BG level closely
monitoring IV if unable to orally feed monitoring for signs of hypoglycemia monitoring VS and temp
Nursing interventions
obtaining blood per heel stick for glucose monitoring
freq oral and/or gavage feeding or continuous parenteral nutrition is provided early after birth to treat hypoglycemia (untreated can lead to seizures, brain damage, and death)
Labor and Birth Processes: Assess for True Labor vs. False Labor ATI p. 136 True Labor
Contractions
regular frequency
stronger, last longer and are more freq felt in lower back, radiating to abdomen walking can increase contraction intensity continue despite comfort measures
Cervix
progressive change in dilation and effacement moves to anterior portion
Fetus
presenting part engages in pelvis False Labor
Contractions
painless, irregular freq, and intermittent
decrease in freq, duration, and intensity with walking or position changes felt in lower back or abdomen above umbilicus
often stop with comfort measures such as oral hydration Cervix (assessed by vaginal exam)
no significant change in dilation or effacement often remains in posterior position
no significant bloody show Fetus
presenting part is not engaged in fetus
Bonding: Promoting Maternal Psychosocial Adaptation During the Taking-In Phase ATI p. 290
Taking In Phase--begins immediately following birth lasting a few hours to a couple of days. Characteristics include passive-dependent behavior and relying on others to meet needs for comfort, rest, closeness, and nourishment. the client focuses on her own needs and is concerned about the overall health of her newborn. She is excited and talkative, repeatedly reviewing the labor and birth experience.
Facilitate the bonding process by placing the infant skin-to-skin wiht the mother soon after birth in an en face position
Encourage the parents to bond with the infant through cuddling, feeding, diapering and inspecting the infant
provide a quiet and private environment that enhances the family bonding process. provide frequent praise, support and reassurance to the mother during the taking-hold phase as she moves toward independence in care of the newborn and adjusts to the maternal role
encourage the mother/parents to discuss their feelings, fears, and anxieties about caring for their newborn
Toddler: Recognizing Expected Body-Image Changes ATI
the toddler appreciates the usefulness of various body parts toddlers develop gender identity by age 3
Wongʼs Nursing Care of Children (p. 608) Growth slows considerably during toddlerhood. avg wt @ 2 years is 12 kg.
head circumference slows and is usually equal to chest circumference by 1-2 years. Chest circumference continues to increase and exceeds head circumference during the toddler years.
After the 2nd year the the chest circumference exceeds the abdominal measurement which in addition to the growth of the lower extremities, gives the child, a taller leaner appearance.
However, the toddler retains a squat, “pot-bellied” appearance bec of less well-developed abdominal musculature and short legs.
Legs retain a slightly bowed or curved appearance during the second year form the weight of the relatively large trunk.
Adolescent (12-20 years): Planning Age-Appropriate Health Promotion Education Substance abuse:
Drug Abuse Resistance Education (DARE) and other similar programs provide assistance in preventing experimentation
Abstinence is highly recommended. if sexually activity is occurring the use of birth control is recommended
Sexually Transmitted Diseases:
Adolescents should undergo external genitalia exams, PAP smears, and cervical and urethral cultures (specific to gender).
Rectal and oral cultures may also need to be taken
The adolescent should be counseled about risk taking behaviors and their exposure to STDs as well as AIDS, hepatitis. The use of condoms will decrease the risk of STDs Pregnancy
identification of pregnant adolescents should be done to ensure that nutrition and
support is offered to promote the health of the adolescent and the fetus. Following infant delivery, education should be given to prevent future pregnancies.
Injury prevention
encourage attendance at driverʼs ed courses. Emphasize the need for compliance with seat belt use
teach the dangers of combining substance abuse with driving (MADD)
Insist on helmet use with bicycles, motorcycles, skateboards, roller blades and snowboards
screen for substance abuse
teach the adolescent not to swim alone teach proper use of sporting equipment Age-appropriate activities:
nonviolent video games nonviolent music
sports
caring for a pet
reading social events
Contraception: Recognizing Correct Use of Condoms ATI p. 6
Condoms: a thin flexible sheath worn on the penis during intercourse to prevent semen from entering the uterus
Client Instruction
man places condom on his erect penis, leaving an empty space at the tip for a sperm reservoir
following ejaculation, the man withdraws his penis from the womanʼs vagina while holding condom rim to prevent any semen spillage to vulva or vaginal area
may be used in conjunction with spermicidal gel or cream to increase effectiveness. only water soluble lubricants should be used with latex condoms to avoid condom breakage.
Immunizations: Recognizing Complications to Report ATI p. 279 anaphylaxis
review sx with parents
prodromal sx--uneasiness, impending doom, restlessness, irritability, severe anxiety, HA, dizziness, parethesia, disorientation
cutaneous signs are the most common initial sign,child may complain of feeling warm. angioedema is most noticeable in the eyelids, lips, tongue, hands, feet and genitalia
cutaneous manifestations are often followed by bronchiolar constriction-- narrowing of the airway, dilated pulmonary circulation causes pulmonary edema and hemorrhages and there is often life- threatening laryngeal edema
instruct parents to call 991 or other emergency number and to keep the child quiet until help arrives
Encephalitis, seizures, and.or neuritis
review sx with parents. instruct parents when to seek medical care teach parents to prevent injury during a seizure
Thrombocytopenia
usually associated with measles vaccination teach parents to observe for bleeding
instruct the parents to call the primary care provider if bleeding, bruising, or re dot-like rash occurs.
Older Adult (0ver 65 years): Assessing Risk for Social Isolation Two forms of isolation
may be a choice, the result of a desire not to interact with others
may be a response to conditions that inhibit the ability or the opportunity to interact wiht others.
vulnerable to its consequences
vulnerability increased in the absence of the support of other adults as may occur with loss of the work role or relocation to unfamiliar surroundings.
impaired hearing, diminished vision, and reduced mobility all contribute to reduced interaction with others and isolation
the loss of the ability to drive may limit older adultsʼ ability to live independently as well as contributing to isolation
some withdraw bec of feelings of rejection
older adults see themselves as unattractive and rejected bec of changes in their personal appearance due to normal aging
nurse can assist lonely older adults to rebuild social networks and reverse patterns of isolation
outreach programs meals on wheels socialization needs
daily telephone call by volunteers need for activities such as outings
Spinal Cord Injury: Promoting Independence In Self-Care
Spinal cord injuries involve losses of motor fx, sensory, fx, reflexes, and control of elimination
The level of cord involved dictates the consequences of spinal cord injury. For example, injury at C3 to C5 poses a great risk for impaired spontaneous ventilation bec of
proximity of the phrenic nerve.
Tetraplegia/paresis = 4 extremities. Paraplegia/paresis= 2 lower extremities Tetraplegia
C1-C8 Paraplegia T1-L4
Level of Injury Movement Remaining Rehab Potential C1-C3
Often fatal injury, vagus nerve domination of heart, respiration, blood vessels, and all organs below injury
movement in neck and above, loss of innervation to diaphragm, absence of independent respiratory fx
ability to drive electric wheelchair equipped with portable ventilator by using chin control or mouth stick, headrest to stabilize head; computer use with mouth stick, head wand, or noise control; 24 hr attendant care, able to instruct others
C4
vagus nerve domination of heart, respirations and all vessels and organs below injury
sensation and movement in neck and above; may be able to breathe without a ventilator
Same as C1-C3
C5
vagus nerve domination of heart, respirations, and all vessels and organs below the injury
full neck, partial shoulder, back, biceps; gross elbow, inability to roll over or use hands; decreased
respiratory reserve
Ability to drive electric
wheelchair with mobile hand supports; indoor mobility in manual wheelchair; able to feed self with setup and adaptive equipment; attendant care 10 hrs per day
C6
vagus nerve domination of heart, respirations, and all vessels and organs below the injury
shoulder and upper back abduction and rotation at shoulder, full biceps to elbow flexion, wrist extension, weak grasp of thumb, decreased
respiratory reserve
ability to assist with transfer and perform some self-care; feed self with hand devices; push wheelchair on smooth, flat surface; drive adapted van from wheelchair; independent computer use with adaptive equipment; attendant care 6 hrs per day
Level of Injury Movement Remaining Rehab Potential C7-C8
vagus nerve domination of heart, respirations, and all vessels and organs below the injury
All triceps to elbow
extension, finger extensors and flexors, good grasp with some decreased strength, decreased respiratory reserve
ability to transfer self to wheelchair; roll over and sit up in bed; push self on most surfaces; perform most self-care; independent use of wheelchair; ability to drive care with powered hand controls (in some pts); attendant care 0-6 hrs per day
T1-T6
Sympathetic innervation to heart, vagus nerve
domination of all vessels and organs below injury
full innervation of upper extremities, back essential intrinsic muscles of hand; full strength and dexterity of grasp; decreased trunk stability, decreased respiratory reserve
full independence in self-care and in wheelchair ability to drive car with hand controls (in most patients); independent standing in standing frame
T6-T12
Vagus nerve domination only of leg vessels, GI and genitourinary organs
Full stable thoracic muscle and upper back; functional intercostals, resulting in increased respiratory reserve
Full independent us of wheelchair; ability to stand erect with full leg brace, ambulate on crutches with swing (although gait difficult); inability to climb stairs
L1- L2
Vagus nerve domination of leg vessels
Varying control of legs and pelvis, instability of lower back
Good sitting balance; full use of wheelchair;
ambulation with long leg braces
Level of Injury Movement Remaining Rehabilitation Potential L3-L4
Partial vagus nerve
domination of leg vessels, GI and genitourinary organs
Quadriceps and hip flexors, absence of hamstring function, flail ankles
Completely independent ambulation with short leg braces and canes; inability to stand for long periods
• level and severity of the SCI
• type and degree of resulting impairments and disabilities • overall health of the patient
• family support
It is important to focus on maximizing the patient's capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence.
The goal of SCI rehabilitation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life - physically, emotionally, and socially.
Health Promotion and Maintenance Plan B
Antepartum Diagnostic Interventions: Prenatal Fetal Heart Rate Monitoring
Nonstress Test (see below)
Contraction Stress test (CST) an assessment performed to stimulate contractions (which decrease placental blood flow) and analyze the FHR in conjunction with the contractions to determine how the fetus will tolerate the stress of labor.
A pattern of at least 3 contractions within a 10 min time period with duratio of 40-60 sec each must be obtained to use for assessment data
Nipple stimulated CST consists of the woman lightly brushing her palm across the nipple for 2 or 3 min, which causes the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins The same process is repeated after a 5 min rest period
Hyperstimulation of the uterus (uterine contraction longer than 90 sec or more freq than q 2 min) should be avoided by stimulating the nipple intermittently with rest periods in between and avoiding bimanual stimulation of both nipples unless stimulation of one nipple is uncuccessful
Oxytocin admin CST is used if nipple stimulation fails and consists of IV admin of oxytocin to induce uterine contractions
Contractions started with oxytocin may be difficult to stop and can lead to preterm labor
A negative CST (normal finding) is indicated if within a 10 min period, with 3 uterine contractions, there are no late decels of the FHR
A positive CST (abnormal finding) is indicated with persistent and consistent late decels on more than half of the contractions. This is suggestive of uteroplacental insufficiency. Variable decels may indicate cord compression and early decls may indicate fetal head compression.
Nursing Management
For a CST, the nurse should
Obtain a baseline of the FHR, fetal movement and contractions for 10-20 min and document
Complete an assessment without artificial stimulation if contractions are occurring spontaneously
Initiate nipple stimulation if there are no contractions. Instruct the client to roll a nipple between her thumb and fingers or brush her palm across her nipple. the client should stop when a uterine contraction occurs.
Monitor and provide adequate rest periods for the client to avoid hyperstimulation of the uterus.
Initiate IV oxytocin admin if nipple stimulation fails to elicit a sufficient uterine contraction pattern
Complications
Hyperstimulation of the uterus Preterm labor
Monitor for contractions lasting longer than 90 sec and/or occurring more freq than q 2 min
Biophysical Profile (BPP)
uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli.
Five variables
Fetal breathing movements: at least 1 episode of 30 sec in 30 min = 2, absent or less than 30 sec duration = 0
Gross body movements: at least 3 body or limb extensions with return to flexion in 30 min = 2, less than 3 episodes = 0
Fetal tone: at least 1 episode of extension with return to flexion = 2; slow extension and flexion, lack of flexion, or absent of movement = 0
Amniotic fluid volume: at least 1 pocket of fluid that measures at least 1 cm in 2 perpendicular planes = 2; pockets absent or less than 1 cm = 0
For BPP the nurse should
follow the same management as ultrasound
Complications of Pregnancy: Recognizing Abnormal Findings Bleeding during Pregnancy
vaginal bleeding during pregnancy is always abnormal and must be carefully investigated in order to determine the cause
Spontaneous Abortion
when a pregnancy is terminated before 20 weeks gestation (the point of fetal viability) or fetal wt less than 500 g.
Assessments
vaginal spotting or moderate to heavy bleeding with or without pain in early pregnancy
passage of tissue (products of conception) mild to severe uterine atony
backache
rupture of membranes dilation of the cervix fever
abdominal tenderness
s/s of hemorrhage such as hypotension
abnormal implantation of the fertilized ovum outside of the uterine cavity. The implantation is usually in the fallopian tube, which can result in a tubal rupture causing a fatal hemorrhage.
Assessments
one or two missed menses
unilateral stabbing pain and tenderness in the lower abdominal quadrant
scant, dark red or brown vaginal spotting if tube ruptures (bleeding may be into intraperitoneal area).
referred shoulder pain from blood irritation of the diaphragm or phrenic nerve (common sx)
N/V freq after tube rupture sx of hemorrhage and shock
Gestational Trophoblastic Disease
proliferation and degeneration of trophoblastic villi in the placenta which becomes swollen, fluid-filled and takes on the appearance of grape-like clusters. the
embryo fails to develop beyond a primitive start and these structures are associated with choriocarcinoma which is a rapidly metastasizing malignancy. Two types of molar growths are identifies by chromosomal analysis Assessments
rapid uterine growth larger than expected for the duration of the pregnancy due to the overproliferation of trophoblastic cells
vaginal bleeding at approximately 16 wks gestation. Bleeding is often dark brown resembling prune juice, or bright red that is either scant or profuse and continues for a few days or intermittently for a few weeks
bleeding accompanied by discharge from the clear fluid-filled vesciles excessive vomiting (hyperemesis gravidarum) due to elevated hCG levels
sx of pregnancy-induced HTN (PIH), including HTN, edema, and proteinuria that occur prior to 20 weeks gestation (PIH usually does not occur until after 20 wks gestation)
Incompetent Cervix
painless, passive dilation of the cervix in the absence of uterine contractions. The cervix is incapable of supporting the wt and pressure of the growing fetus and results in expulsion of the products of conception during the second trimester of pregnancy. This usually occurs around week 20 of gestation.
Assessments
pink stained vaginal discharge or bleeding increase in pelvic pressure
possible gush of fluid (rupture of membranes) uterine contractions with the expulsion of the fetus
postop (cerclage) monitoring for uterine contractions, rupture of membranes and signs of infection
Placenta Previa
when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus. The abnormal implantation results in bleeding during the third trimester of pregnancy as the cervix begins to dilate and efface
Assessments
painless, bright red vaginal bleeding that increases as the cervix dilates a soft relaxed, nontender uterus with normal tone
a fundal ht greater than usually expected for gestational age a fetus in a breech, oblique or transverse position
a palpable placenta
VS that are usual and within normal limits Abruptio Placenta
the premature separation of the placenta from the uterus, which can be a partial or complete detachment. This separation occurs after 20 wks gestation, which is usually in the third trimester. It has significant maternal and fetal morbidity and mortality and is a leading cause of maternal death
Assessments
sudden onset of intense localized uterine pain vaginal bleeding that is bright red or dark A board like abdomen that is tender
a firm rigid uterus with contractions (uterine hypertonicity) fetal distress
sx of hypovolemic shock Hyperemesis Gravidarum
excess N/V (r/t elevated HcG levels) that is prolonged past 12 weeks gestation and results in a 5% wt loss form prepregnancy wt, dehydration, electrolyte imbalance, ketosis, and acetonuria.
Assessments
excessive vomiting for prolonged periods
dehydration with possible electrolyte imbalance wt loss
decreased blood pressure increased pulse rate
poor skin turgor
Gestational Hypertension/Pregnancy Induced Hypertension begins after the 20th wk of pregnancy,
woman has an elevated BP at 140/90 mmHg or greater, or a systolic increase of 30 mmHg or diastolic increase of 15 mmHg from the prepregnancy state
Mild preeclampsia is GH with the addition of proteinuria of 1 - 2+ and a wt gain of more than 2 kg per wk in the 2nd and 3rd trimesters.
Severe preeclampsia consists of BP that is 160-100 mmHg or greater, proteinuria 3-4+, oliguria, elevated serum creatinine greater than 1.2 mg/dL, cerebral or visual disturbances (HA and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and RUQ pain.
Eclampsia is severe preeclampsia sx along with the onset of seizure activity or
coma.
Assessments
progression of hypertensive disease with indications of worsening liver
involvement, renal failure, worsening HtN, cerebral involvement, and developing coagulopathies
rapid wt gain 2 kg per wk in the second and third trimester fetal distress
Gestational Diabetes
an impaired toleratnce to glucose with the first onset or recognition during pregnancy. The ideal blood glucose level should fall between 60-120 mg/dL Assessments
hunger and thirst freq urination blurred vision
excess wt gain during pregnancy
TORCH infections
group of infections that can negatively affect a woman who is pregnant. These infections can cross the placenta and have teratogenic affects on the fetus. TORCH does not include all the major infections that present risks to the mother and fetus
infection sign/symptom
T-toxoplasmosis influenza sx or lymphadenopathy
O-other infection dependent on infection
R-rubella (german measles) rash, muscle aches, joint pain, mild
lymphedema, fetal consequences including miscarriage, congenital anomalies and death
C-cytomegalovirus (member of Herpes virus family)
asymptomatic or mononucleosis-like sx
H-Herpes simples virus (HSV) lesions initial outbreak
Circumcision: Evaluating Effectiveness of Discharge Teaching Postop parent teaching:
Teach the parents to keep the area clean. Change the infantʼs diaper at least every 4 hr and clean the penis with warm water with each diaper change.
With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper from adhering to the penis. The diaper should be fan folded to prevent pressure on the circumcised area
Avoid wrapping the penis in tight gauze, which can impair circulation to the glans. A tub bath should not be given until the circumcision is completely healed. Until then, warm water should be gently trickled over the penis
Notify the PCP if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from the infant.
Tell the parents a film of yellowish mucus may form over the glans by day 2 and it is important not to wash this off
Teach the parents to avoid using premoistened towelettes to clean the penis bec they contain alcohol.
Inform the parents that the newborn may be fussy or may sleep for several hrs after the circumcision
Inform the parents that the circumcision will heal completely within a couple of weeks.
Discharge Teaching: Evaluating Clientʼs Understanding of Bulb Syringe Use Oral and Nasal Suctioning
teach the parents to use a bulb syringe to suction any excess mucus from the nose and mouth
parents should suction the mouth first and then the nose, one nostril at a time the bulb should be compressed before inserting it into the infantʼs mouth or nose when suctioning the infantʼs mouth, always insert the bulb on the sides of the infantʼs mouth not in the middle and do not touch the back of the throat to avoid the gag reflex
Postpartum Physiological Changes and Nursing Care: Performing Fundal Assessment
Document the fundal height, location and uterine consistency
Determine the fundal ht by placing fingers on the abdomen and measuring how many fingerbreadths (cm) fit between the fundus and the umbilicus above, below, or at the umbilical level
Determine if the fundus is midline in the pelvis or displaced laterally (caused by a full bladder)
Determine if the fundus is firm or boggy. If the fundus is boggy (not firm), lightly massage the fundus in a circular motion.
Toddler: Provide Education on Age-Specific Growth and Development Stages of Development
Theorist Type of Development Stage
Erickson Psychosocial Autonomy vs Shame
Theorist Type of Development Stage
Piaget Cognitive Sensorimotor Transitions to
preoperational
Physical Development
anterior fontanel close by 18 months of age
Wt: At 30 months the toddler should weigh 4x his birth wt. Ht: the toddler grows by 7.5 cm (3 in) per year
Developmental Skills development of steady gait climbing stairs
jumping and standing on one foot for short periods stacking blocks in increasingly higher numbers drawing stick figures
undressing and feeding self toilet training
Cognitive Development
concept of object permanence is fully developed
Toddlers demonstrate memory of events that relate to them
language increase to about 400 words with the toddler speaking in 2-3 word phrases pre-operational thought does not allow for the toddler to understand other viewpoints, but it does allow toddlers to symbolize objects and people in order to imitate activities they have seen previously
independence is paramount for the toddler who is attempting to do everything for himself
separation anxiety continues to occur when a parent leaves the child Moral Development
Moral development is closely associated with cognitive development
Egocentric--toddlers are unable to see anotherʼs perspective; they can only view thing from their point of view.
the toddlerʼs punishment and obedience orientation begins with a sense of good behavior is rewarded and bad behavior is punished.
Self Concept Development
toddlers progressively see themselves as separate from their parents and increase their explorations away from them
Age Appropriate Activities
Solitary play evolves into parallel play where the toddler observes other children and then may engage in activities nearby
filling and emptying containers playing with blocks
reading books
playing with toys that can be pushed and pulled tossing a ball
Infant (Birth to 1 yr): Identifying Normal Physical Assessment Findings
Physical Development
The infantʼs posterior fontanel closes at 2-3 months of age The infantʼs size is tracked by wt, ht, and head circumference
Wt: the infant gains 0.7 kg (1.5 lb) per month the first 6 months and 0.3 kg (0.75 lb) per month the last 6 months. The infant triples birth wt by the end of the first year
Ht: The infant grows 2.5 cm (1 in) per month the first 6 month and then 1.25 cm (0.5 in) per month the last 6 months.
Head Circumference: The circumference of the infantʼs head increases 1.25 cm (0.5 in) per month the first 6 months
Following size, the infant develops gross motor skills Holds head up at 3 months
Rolls over at 5-6 months
Holds head steady when sitting at 6 months
Gets to sitting position alone and can pull up to a standing position at 9 months Stand hold on at 12 months
Stands alone at 12 months
Fine motor development follows next in the sequence Brings hans together
grasps rattle
looks for items that are dropped from view
transfers an object from one hand to the other (6 months) rakes finger food with hand ( 6 months)
uses thumb-finger to grasp items (9 months) Bangs two toys together (9 months)
Can nest one object inside another (12 months)
Scoliosis: Recognizing Signs During Routine Screening
School age children should be screened for scoliosis by examining for a lateral curvature of the spine before and during growth spurts.
Marked curvatures in posture are abnormal.
A slight limp, a crooked hemline, or ℅ a sore back are other s/s of scoliosis
inspect the back for any tufts of hair, dimples, or discoloration. Mobility of vertebral column is easily assessed in children bec of their propensity for constant motion durin exam
ATI Topic Descriptors Management of Care (24) Plan A
Advance Directives: Recognize Purpose (ATI)
Advance directive are written instructions that allow a client to convey his wishes regarding medical tx for situations when those wishes can no longer be personally communicated.
All clients admitted to a health care facility be asked if they have an advance directive. The client without an advance directive must be given written information that outlines his rights r/t health care decisions and how to formulate an advance directive.
A health care representative should be available to help with this process Living wills
allows the client to specify end of life decisions she does or does not sanction when unable to speak for herself. For example, the client can specify use or refusal of: CPR, if cardiac or respiratory arrest occurs
Artificial nutrition through IV or tube feedings
Prolonged maintenance on a respirator if unable to breathe adequately alone Living wills must be specific and be signed by two witnesses.
They can minimize conflict and confusion regarding health care decisions that need to be made
A durable power of attorney for health care (health proxy) is an indiv designated to make health care decisions for a client who is unable based upon the clientʼs living will Based upon the clientʼs advance directives, the physician writes orders for
life-sustaining tx. Examples include: DNR
Medical interventions (eg comfort measures only, IV fluids but no intubation, full tx) Use of ABX
Artificially administered nutrition through a tube.
Nursing responsibilities regarding advance directives include: provide written information regarding advance directives document the clients advance directive status
ensure that the advance directive is current and reflective of the clientʼs current decisions.
inform all members of the health care team of the clients advance directive.
(P/P)
Two basic advance directives living will
written documents that direct tx in accordance with a clientʼs wishes in the event of a terminal illness or condition.
may be difficult to interpret
two witnesses, neither of whom can be a relative or physician, are needed when the client signs the document
if health care workers follow the directions of the living will, they are immune from liability
designates an agent, surrogate, or proxy to make health care decisions if and when the client is no longer able to make decisions on his or her own behalf. In order for living wills or durable powers of attorney for health care to be enforceable, the client must be legally incompetent or lack decisional capacity to make decisions regarding health care treatment
The determination of legal competency is made by a judge, and the determination of decisional capacity is usually made by the physician and family.
The implementation of the advance directive is done within the context of the health care team and the health care institution.
When clients are legally incompetent and are unable to make health care decisions, the courts balance the stateʼs interest with what the client would have wanted.
Client Advocacy: Intervening on behalf of the Client
As an advocate, nurses must ensure that clients are informed of their rights and have adequate information on which to base health care decisions
Nurses must be careful to “assist” clients with health care decisions and not “direct” or “control” their decisions
Situations in which the nurse may advocate for the client or assist the client to advocate for herself include:
End of life decisions Access to health care Protection of client privacy Informed consent
Substandard practice
Skills risk taking vision self-confidence Articulate communication assertiveness Values caring autonomy respect empowerment
The nurse protects the clientʼs human and legal rights and provides assistance in asserting those rights if the need arises
keep in mind the clientʼs religion and culture
Discharge Planning: Interventions to Promote Timely Client Discharges The process begins at time of admission
Plans are developed with client and family input, focusing on active participation by the client to facilitate a timely discharge
Serves as a starting point for continuity of care for the client by the caregiver, home health nurse, or receiving facility.
The need for additional client or family support is included with recommendations for support services such as home health, outpatient therapy and respite care.
Discharge Summary includes:
Step by step instructions for procedures to be done at home
Precautions to take when performing procedures or administering meds S/s of complications that should be reported
Names and numbers of health care providers and community services the client/family can contact.
Time of discharge, mode of transportation, and who accompanied the client.
This should begin when the client is admitted to the facility unless the facility is to be the clientʼs permanent residence
assess whether or not the client will be able to return to his previous residence
determine whether or not the client will nee and/or have someone to assist him at home assess the residence to see if adaptations are required to accommodate the client prior to discharge
make a referral to the social worker to arrange for community services required by the client at discharge
communicate client health status and needs to community service providers. Clients Rights: Recognizing Client Rights Regarding Review of Records Only health care team members directly responsible for the clientʼs care should be allowed access to the clientʼs records. The client has the right to review his medical record and request information as necessary for understanding.
Clientʼs rights
To inspect and copy PHI
To ask the health care agency to amend the PHI that is contained in a record if the PHI is inaccurate
To request a list of disclosures made regarding the PHI as specified by HIPAA
To request to restrict the way the health care agency uses or discloses PHI regarding tx, payment or health care operations unless info is needed to provide emergency tx
To request that the healthcare agency communicates with the client in a certain way or at a certain location ; the request must specify how or where the clientʼs wishes to be contacted.
Collaboration with Interdisciplinary Team: Methods for Collaboration An interdisciplinary team is a group of health care professionals from different disciplines
Collaboration is used by interdisciplinary teams to make health care decisions about clients with multiple problems. Collaboration, which may take place at team meetings, allows the achievement of results that the participants would be incapable of
accomplishing if working alone.
Effective communication skills Mutual respect and trust Shared decision making The nurse contributes
Knowledge of nursing care and its management
A holistic understanding of the client, her health care needs,and health care systems
Nurse-primary care provider collaboration should be fostered to create a climate of mutual respect and collaborative practice
Collaboration can occur among different levels of nurses and nurses with different areas of expertise.
Nursing Interventions:
Use effective communication skills
Participate in client rounds and interdisciplinary team meetings Present info relevant to the clientʼs health status and tx regimen Attend interdisciplinary clinical conferences/case presentations.
COPD: Planning Strategies for Fatigue
ATI---determine the clientʼs physical limitations and structure activity to include periods of rest
promote adequate nutrition
increased work of breathing increases caloric demands Med-Surg
Energy Conservation Techniques
