ATI Review – Flashcards

1, Perfrom hand hygiene 2, Assess skin and circulation in the legs. 3, Measure the calf and/or thigh circumference and the length of the leg to select the correct size stocking. 4, Turn the stocking inside to the heel 5, Put the stocking on the foot, 6, Pull the remainder of the stocking over the heels and up the leg. 7, Smooth any creases or wrinkles. 8, Remove the stockings and reapply them at least twice a day. 9, Make sure the stockings are not too tight over the toes. 10, Keep the stockings clean and dry. Clients who are postoperative or have special needs may need a second pair of hose. 11, Document the application and removal of the stockings

nose to earlobe to xyphoid

*The wound is cleaned with an antiseptic to remove encrusted blood and loosened scar tissue. *Sterile forceps (tongs or pincers) are used to pick up the knot of each suture, and then the surgical scissors or a small knife blade is used to cut the suture. *Forceps are used again to remove the loosened suture and pull the thread from the skin. *These relatively painless steps are continued until the sutures have all been removed. You may feel a tug or slight pull as a stitch is removed. *The wound is cleansed again. *Adhesive strips are often placed over the wound to allow the wound to continue strengthening.

Your pouch should be sealed well enough to prevent any odor from leaking out. You may notice more odor when you empty your pouch after you eat certain foods. Some of these foods are onions, garlic, broccoli, asparagus, cabbage, fish, some cheeses, eggs, baked beans, Brussels sprouts, and alcohol. Doing these things will keep down the odor: Eating parsley, yogurt, and buttermilk Keeping your ostomy devices clean Using special deodorants or adding vanilla oil or peppermint extract to your pouch before closing it. Ask your doctor or nurse about this. Before answering, a little background is needed. An ileostomy is when the part of the small intestine (called the ileum) is surgically connected to the abdominal wall to provide a way for stool to leave the body. This procedure is done when there is disease, blockage or other problems that don't allow stool to pass to the large intestine and exit as normal bowel movements. The small intestine is about 21 feet long and is responsible for breaking down food and absorbing nutrients. Each part of the small intestine absorbs certain nutrients. After part of the small intestine is removed, the remaining intestine adapts somewhat over time to compensate for the section that was removed. Why is this important? Your dietary needs and tolerances will depend on how much healthy small intestine remains and how much time has allowed it to adapt following surgery. In addition, the type of ileostomy will play a role — if your surgery created an ileostomy that is continent (no collection appliance is worn) or incontinent (an appliance is needed). With these points in mind, here are some general guidelines: Immediately after surgery (for about one month), you'll likely be advised to eat a diet that is low in roughage to allow the intestine time to heal and to prevent blockage due to swelling. Foods with roughage include whole grains, raw vegetables and fresh fruit. This is a temporary limitation. Eat meals at regular times, eat more slowly and chew well. Also, avoid skipping meals or overeating. These efforts help your remaining intestine digest and absorb food, reduce gas, improve "regularity" and control output. With time you will find that you can resume a more normal diet and you will learn which foods tend to be constipating, which may have more of a laxative effect, and which cause stool to change color, or cause gas or odor. This varies according to the individual and the length of small intestine remaining. If your stool is very thick (constipated), some dietary changes may help. Stool-thinning foods may include grape juice, apple juice and prune juice. Be cautious with foods that are constipating. For some people that includes apple, banana, cheese, potato, pasta, rice and peanut butter. Make sure to drink at least eight 8-ounce glasses a day. Water is best. Diluted electrolyte beverages, such Gatorade, Powerade or CeraLyte, contain sodium, are hydrating and are helpful immediately after surgery and during hot weather. Eating a lot of bread, especially whole grain bread, can increase your need for liquids.

Don't alter crutches after fitting. Follow the prescribed crutch gait. Support body weight at the hand grips with the elbows flexed at 30. Position the crutches on the unaffected side when sitting or rising from a chair. * Position crutch tips 6 in laterally and 6 in. in front of Pt's feet, and adjust per Pt comfort level * Adjust crutch height to accommodate 2 to 3 finger widths between crutch pad and axillae. * Elbows should be slightly flexed when Pt rests palms on hand grips. * Support weight with crutches. Repeat the following steps: 1, Advance both crutches and weaker leg to a comfortable distance (-12in) while supporting weight with hands. 2, Advance stronger leg until parallel to crutches.

Normal grief Anticipatory grief Complicated grief (unresolved or chronic grief is a type of complicated grief) Disenfranchised grief

* This grief is considered uncomplicated. *Emotions may be negative, such as anger, resentment, withdrawal, hopelessness, and guilt but should change to acceptance with time. *Some acceptance should be evident by 6 months after the loss. *Somatic complaints can include chest pain, palpitations, headaches, nausea, changes in sleep patterns, and fatigue.

*The grief implies the "letting go" of an object or person before the loss, as in a terminal illness. * Individuals have the opportunity to start the grieving process before the actual loss

This grief involves difficult progression through the expected stages of grief. Usually,the work of grief is prolonged, the manifestations of grief are more severe and they may result in depression or exacerbate a preexisting disorder. The client may develop suicidal ideation,intense feelings of guilt, and lowered self-esteem. Somatic complains persist for an extended period of time

The grief entails an experienced loss that cannot be publicly shared or is not socially acceptable, such as suicide.

Gown first Mask or respirator Goggles or face shield Gloves

1, Maintain surgical asepsis when performing any form of tracheal suctioning to avoid bacterial contamination of the airway. 2, Use surgical asepsis to remove and clean the inner cannula (with the facility-approved solution) Use a new inner cannula if it is disposable. 3, endotracheal suctioning requires sugical asepsis 4. requires obtaining a sterile specimen from a straight or indwilling catheter using surgical asepsis

*seclusion and/or restraints should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient. * Restraints should never interfere with treatment, restrict movement as little as is necessary to ensure safety, Fit properly and be as discreet as possible, be easily removed or changed to decrease the chance of injury and to provide for the greatest level of dignity. *In an emergency situation in which there is immediate risk to the client or others, the nurse may place a client in restraints. *The nurse must obtain a prescription from the provider as soon as possible in accordance with agency policy (usually with 1 h) * PRN restraints are not allowed.. Remove or replace restraints frequently to ensure good circulation to the area and allow for full ROM to the limb that has been restricted.

Shingles, chickenpox

administer antibiotic therapy after collecting the appropriate specimens for culture sensitivity testing

breach of confidentiality: a nurse releases a client's medical diagnosis to a member of the press

aspirate gently to collect gastric contents, testing PH (4 or less is expected), and assess odor, color, and consistency. confirm placement with an x-ray injecting air into the tube and then listening over the abdomen is not an acceptable practice.

OBJECTIVE: To ensure the patency of the nasogastric tube. INDICATION: Stomach contents fail to flow through tube. CONTRAINDICATION: Some tubes are maintained by airflow, not normal saline solution. NURSING ALERT: Connect proper end (main lumen) of double lumen tube to suction. The short lumen is an airway, not a suction-drainage tube. With double-lumen tube, if main lumen is probably blocked, clear the main lumen, then inject up to 60 cc of air through the short lumen above the level of the stomach where the end of the main lumen is located. EQUIPMENT: 1. Nasogastric tube connected to continuous or intermittent suction. 2. Irrigation or Toomey syringe and container for irrigating solution. 3. Normal saline for irrigation. 4. Disposable pad or bath towel 5. Disposable gloves (optional) 6. Stethoscope 7. Clamp ACTION 1. Check physician's order for irrigation. Explain procedure to client. Rationale: Clarifies schedule and irrigating solution. An explanation encourages client cooperation and reduces apprehension. 2. Gather necessary equipment. Check expiration dates on irrigating saline and irrigation set. Rationale: Provides for organized approached to task. Agency policy dictates safe interval for reuse of equipment. 3. Wash your hands. Rationale: Handwashing deters the spread of microorganisms. 4. Assist client to semi-Fowler's position unless this is contraindicated. Rationale: Minimizes risk of aspiration. 5. Check placement of NG tube; a. Attach Asepto or Toomey syringe to the end of tube and aspirate gastric contents. Rationale: The tube is in the stomach if its contents can be aspirated. b. Place 10mL-50ml of air in syringe and inject into the tube. Simultaneously, auscultate over the epigastric area with a stethoscope. Rationale: A whoosing sound can be heard when the air enters the stomach through the tube. c. Ask client to speak. Rationale: If tube is misplaced in trachea, client will not be able to speak. 6. Clamp suction tubing near connection site. Disconnect NG tube from suction apparatus and lay on disposasble pad or towel. Rationale: Protects client from leakage of NG drainage. 7. Pour irrigating solution into container. Draw up 30 ml of saline (or amount ordered by physician) into syringe. Rationale: Delivers measured amount of irrigant through NG tube. Saline compensates for electrolytes lost through NG drainage. 8 Place tip of syringe in NG tube. Hold syringe upright and gently insert the irrigant (or allow solution to flow in by gravity if agency or physician indicates). Do not force solution into NG tube. Rationale: Position of syringe prevents entry of air into stomach. Gentle insertion of saline (or gravity insertion) is less traumatic to gastric mucosa. 9 If unable to irrigate tube, reposition client and attempt irrigation again. Check with physician if repeated attempts to irrigate tube fail. Rationale: Tube may be positioned against gastric mucosa making it difficult to irrigate. 10. Withdraw or aspirate fluid into syringe. If no return, inject 20 ml of air and aspirate again. Rationale: Inject of air may reposition the end of tube. 11. Reconnect NG tube to suction. Observe movement of solution or drainage. Rationale: Determine patency of NG tube and correct operation of suction apparatus. 12. Measure and record amount and description of irrigant and return solution. Rationale: Irrigant placed in NG tube is considered intake: solution returned is recorded as output. 13. Rinse equipment if it will be reused. Rationale: Promotes cleanliness and prepares equipment for next irrigation. 14. Wash your hands Rationale: Handwashing deters the spread of microorganisms. 15. Record irrigation procedure, description of drainage and client's response. Rationale: Facilitates documentation of procedure and provides for comprehensive care.

Clear liquid-liquid that leave little residue (clear fruit juices, gelatin, broth) Full liquid-clear and full liquids dairy products, all juice, pureed vegetables Pureed-clear and full liquids plus pureed meats, fruits, scrambled eggs. Mechanical soft-clear and full liquids plus diced or ground foods Soft/low-residue: foods that are low in fiber and easy to digest High-fiber (Whole grains, raw and dried fruits) Low sodium-no added salt or 1 to 2 g of sodium Low cholesterol-no more than 300 mg/day of dietary cholesterol Diabetic-balanced intake of protein, fats, and carbohydrates of about 1800 calories Dysphagia-pureed food and thickeded liquids Regular-no restrictions

The nurse should determine that the client is experiencing a distorted grief reaction. The symptoms reported by the client are exaggerated and prolonged. In uncomplicated grief, the client's self-esteem remains intact with symptom resolution. Delayed grief reaction is expected. A depression disorder is a form of an exaggerated or distorted grief response.

collect for 24 hr or other prescribed duration. discard the first voiding collect all other voidings following facility policy on appropriate refrigerated storage, labeling, and transport of the specimen.

assess the ulcer frequently and report an increase in the size or depth of the lesion, change in granulation tissue (color, texture) and changes in exudates (color, quantity, odor.) follow the facility's protocol for ulcer treatment.

postoperative pain increase blood pressure

*Time-Plan for and allow adequate time to communicate with others. *Attentive behaviors or active listening-A means of conveying interest, trust, and acceptance. *Caring attitude-Show concern and facilitate an emotional connection and support between nurse and the client/family/significant other Honesty-Be open, direct, truthful, and sincere. *Trust-Demonstrate to the client/family/significant other that they can rely on the nurse without doubt, question, or judgment. *Empathy-Convey an objective awareness and understanding of the feelings, emotions, and behaviors of the client/family/significant other, including trying to envision what it must be like to be in the client/family/significant other's position. *Nonjudgmental attitude-a display of acceptance of the client/family/significant other will encourage open, honest communication.

* Wash hand *Roll the bottle between hands, never shake *Wipe the top alcohol *inject air into cloudy insulin first *inject air into clear insulin *pull clear insulin into syringe *pull cloudy insulin into syringe

*Removing staples *Staple removal is also a simple procedure and is similar to suture removal. Doctors use a special instrument called a staple remover. *After cleansing the wound, the doctor will gently back out each staple with the remover. The doctor applies pressure to the handle, which bends the staple, causing it to straighten the ends of the staple so that it can easily be removed from the skin. The staple backs out of the skin the very same direction in which it was placed. People *may feel a pinch or slight pull. *The process is repeated until all staples are removed. The wound is cleansed a second time, and adhesive strips are applied. This is also a relatively painless procedure.

*Removing staples *Staple removal is also a simple procedure and is similar to suture removal. Doctors use a special instrument called a staple remover. *After cleansing the wound, the doctor will gently back out each staple with the remover. The doctor applies pressure to the handle, which bends the staple, causing it to straighten the ends of the staple so that it can easily be removed from the skin. The staple backs out of the skin the very same direction in which it was placed. People *may feel a pinch or slight pull. *The process is repeated until all staples are removed. The wound is cleansed a second time, and adhesive strips are applied. This is also a relatively painless procedure.