ATI Remediation A

MANAGEMENT OF CARE:

- Pressure Injury, Wounds, and Wound Management: Selecting a Dressing for a Stage 2 Pressure
Injury
o Hydrocolloid: occlusive dressing that swells in the presence of exudate; seals the
wound’s surface and prevents evaporation of moisture from the skin
o Maintains a granulating wound bed
o Can stay in place for 3-5 days
- Delegation and Supervision: Tasks to Assign to Assistive Personnel
o Tasks to assign to Aps include ADLs (examples: bathing, grooming, dressing, toileting,
ambulating, feeding if without swallowing precautions, positioning), and routine tasks
(examples: bed making, specimen collection, I/Os, V/S for stable patients)
o The rights of delegation include: risk task, right circumstances, right person, right
direction/communication, right supervision/evaluation
o Determining the right circumstance of evaluation is critical. While a task may be within
an AP’s scope of practice, it may be more appropriate for the nurse to handle the task
depending on circumstance and client’s condition.
- Legal Responsibilities: Teaching About Declining Resuscitation
o A living will is a legal document that expresses the patient’s wishes regarding medical
treatment in the event that the patient becomes incapacitated and is facing end-of-life
issues
o Nurses are responsible for providing written information about advance directives,
document the client’s advance directives status, ensure that the advance directives
reflect the client’s current decisions, and inform all members of the health care team of
client’s advance directives
o Nasal cannula are not considered a resuscitation device but for comfort.
- Admissions, Transfers, and Discharge: Initiating Discharge Planning
o Discharge planning should begin on admission for every client
o Assess whether the patient will be able to return to their previous residence
o Assess the residence to see if patient needs adaptations or specific equipment.

SAFETY AND INFECTION CONTROL

- Sensory Perception: Assessing Safety Risks

o Older adult patients can be increased fall risks because of decreased strength, impaired
mobility and balance, improper use of mobility aids, unsafe clothing, environmental
hazards, endurance limitations, and decreased sensory perception.
o Other patients at increased risk: those with decreased visual acuity, generalized
weakness, urinary frequency, gait and balance problems (i.e. cerebral palsy, injury,
multiple sclerosis), and cognitive dysfunction
o Adverse reactions from meds (orthostatic hypotension, drowsiness, ototoxic) also
increases risk for falls.

HEALTH PROMOTION AND MAINTENANCE

 - Home Safety: Assessing Home Safety for a Client Who Is Receiving Oxygen Therapy
o Use and store oxygen equipment according to the manufacturer’s recommendations
o Place a “no smoking” sign in a conspicuous place near the front door of the home or
door of patient’s bedroom.
o Replace bedding that can generate static electricity (wool, nylon, synthetics) with items
made from cotton

BASIC CARE AND COMFORT

- Nasogastric Intubation and Enteral Feedings: Identifying Potential Causes of Diarrhea for a Client
Who Has a Gastrostomy Tube
o Flush enteral tubing with at least 30 mL water every 4-6 hours, and check tube
placement again.
o Refrigerate unused formula and discard after 24 hours.
o Diarrhea three times or more in a 24-hour period is a complication – slow instillation
rate, notify provider, and confer with dietitian.

PHARMACOLOGICAL AND PARENTERAL THERAPIES

- Pharmacokinetics and Routes of Administration: Administering an Otic Medication

o Aseptic technique
o Have the pt sit upright or lie on their side. Have them remain in position if possible for 2-
3 minutres after installation of ear drops.
o Straighten the ear canal by pulling auricle upward and outward for adults, down and
back for children less than 3 years of age
- Pharmacokinetics and Routes of Administration: Administration of Enoxaparin Subcutaneously
o Use for small doses of non-irritating, water-soluble meds (i.e. insulin and heparin)
o Use 3/8-5/8 inch, 25 to 27 gauge needle or 28-31 gauge insulin syringe. Inject no more
than 1.5 mL of solution
o Select sites that have adequate fat-pad size (i.e. abdomen, upper hips, lateral upper
arms, and thighs)
- Safe Medication Administration and Error Reduction: Performing Medication Reconciliation
o Medical reconciliation – process of creating the most accurate list of possible meds that
a patient is taking – including drug name, dosage, frequency, and route – and comparing
that list against the physician’s admission, transfer, and/or discharge orders, with the
goal of providing correct medications.
o This process takes place at admission, when transferring clients between units/ facilities,
and at discharge.
o Joint Commission requires policies and procedures for this.

REDUCTION OF RISK POTENTIAL

- Fluid Imbalances: Evaluating the Effectiveness of Corrective Measures

o Expected findings during hypovolemia – hyperthermia, tachycardia (to maintain a
normal BP), thready pulse, hypotension, orthostatic hypotension, decreased central
venous pressure, tachypnea, hypoxia
 o Causes of isotonic FVD (hypovolemia) – excessive GI loss, excessive skin loss (diaphoresis
without replacement), excessive renal system losses, burns, hemorrhage, altered intake
o Causes of dehydration – hyperventilation/excessive perspiration, prolonged fever, DKA,
insufficient water intake, diabetes insipidus, osmotic diuresis, excessive intake of salt
- Nasogastric Intubation and Enteral Feedings: Inserting an NG Tube for Stomach Decompression
o Assist client to high-fowler’s position if possible
o If client vomits, clear the airway, and provide comfort prior to continuing.
o Ask patient to drink water with straw at the end? TO ensure lubrication or patency?
(test question, but could not find reasoning in the book)
- Airway Management: Teaching About Tracheostomy Care at Home
o Keep following at bedside: 2 extra tracheostomy tubes, the obturator for the existing
tube, an oxygen source, suction catheters and a suction source, and a BVM.
o provide tracheostomy care every 8 hours to reduce risk of infection and skin
breakdown. ASEPTIC PROCEDURE AT HOME.
o Give oral care every 2 hours.

PHYSIOLOGICAL ADAPTATION

- Airway Management: Nasotracheal Suctioning

o Insert catheter into naris during inhalation
o DO NOT apply suction while inserting the catheter. Apply suction only while
withdrawing the catheter and rotating it with the thumb for 10-15 seconds
o Don’t perform more than 2 passes with the catheter. Allow at least 1 min between
passes for ventilation and oxygenation.
- Electrolyte Imbalances: Manifestations of a Sodium Imbalance
o Hyponatremia expected findings – VS with hypovolemia
o Neuromuscular findings – headache, confusion, lethargy, muscle weakness to the point
of possible respiratory compromise, fatigue, decreased DTR, seizures, lightheadedness,
dizziness
o GI: increased motility, hyperactive bowel sounds, abdominal cramping, nausea.