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Rn ATI capstone Fundamentals Focused Review Management Care (1) -Integumentary and Peripheral Vascular Systems: Identifying Skin Lesions (Active Learning Template - Basic Concept, RM FUND 9.0 Ch 30)

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Rn ATI capstone Fundamentals Focused Review Management Care (1) -Integumentary and Peripheral Vascular Systems: Identifying Skin Lesions (Active Learning Template - Basic Concept, RM FUND 9.0 Ch 30) -... Equipment used to assess -adequate lighting, gloves, flexible ruler/tape measure, gown or drape to cover pt -Vascular Lesions -Spider Angioma- red center with radiating red legs, up to 2 cm, possibly raised -cherry Angioma- red 1 to 3cm, round and possibly raised -spider vein- bluish, spider shaped or linear up to several inches in size -petechiae/purpura- deep reddish/purple flat petechiae 1-3mm, purpura > 3mm -ecchymosis- purple fading to green or yellow over time, variable in size, flat -hematoma- raised ecchymosis Safety & Infection control (4) -Client Safety: Priority Action in a Fire Emergency (Active Learning Template - Basic Concept, RM FUND 9.0 Ch 12) -Know the location of exits, alarms, fire extinguishers, and oxygen shut-off valves. -Make sure equipment does not block fire doors. -Know the evacuation plan for the unit and the facility. R: Rescue and protect clients in close proximity to the fire by moving them to a safer location. Clients who are ambulatory may walk independently to a safe location. A: Alarm: Activate the facility’s alarm system and then report the fire’s details and location. C: Contain/Confine the fire by closing doors and windows and turning off any sources of oxygen and any electrical devices. Ventilate clients who are on life support with a bag-valve mask. E: Extinguish the fire if possible using the appropriate fire extinguisher -Home Safety: Teaching About Wound Care (Active Learning Template - Basic Concept, RM FUND 9.0 Ch 13) Burns -Test the temperature of formula and bath water. -Place pots on back burner and turn handle away from front of stove. -Supervise the use of faucets. -Keep matches and lighters out of reach. -Cover electrical outlets Play Injury -Teach to not run with candy or objects in mouth. -Remove doors from refrigerators or other potentially confining structures. -Ensure that bikes are the appropriate size for child. -Teach playground safety. -Teach to play in safe areas, and avoid heavy machinery, railroad tracks, excavation areas, quarries, trunks, and vacant buildings. -Teach to never swim alone and to wear a life jacket in boats. -Wear protective helmets and knee and elbow pads, when needed. -Teach to avoid strangers and keep parents informed of strangers. -Medical and Surgical Asepsis: Maintaining Surgical Asepsis While Performing a Sterile Dressing Change (Active Learning T-template - Nursing Skill, RM FUND 9.0 Ch 10) -The outer wrappings and 1-inch edges of packaging that contains sterile items are not sterile. ---The inner surface of the sterile drape or kit, except for that 1-inch border around the edges, is the sterile field to which other sterile items may be added. -To position the field on the table surface, grasp the 1-inch border before donning sterile gloves. Discard any object that comes into contact with the 1-inch border. -Touch sterile materials only with sterile gloves. -Consider any object held below the waist or above the chest contaminated. -Sterile materials may touch other sterile surfaces or materials; however, contact with nonsterile materials at any time contaminates a sterile area, no matter how short the contact. -Mobility and Immobility: Teaching Correct Use of a Cane (Active Learning Template - Nursing Skill, RM FUND 9.0 Ch 40) -Maintain two points of support on the ground at all times. -Keep the cane on the stronger side of the body. -Support body weight on both legs. -Move the cane forward 15 to cm (6 to 10 inches). -Then move the weaker leg forward toward the cane. -Next, advance the stronger leg past the can Health Promotion and Maintenance - (5) -Health Promotion and Disease Prevention: Teaching About Tertiary Prevention Programs (Active Learning Template - Basic Concept, RM FUND 9.0 Ch 16) -Tertiary prevention aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functioning. -Begins after an injury or illness -Prevention of pressure ulcers after spinal cord injury -Promoting independence after traumatic brain injury -Referrals to support groups -Rehabilitation center Infants (2 Days to 1 Year): Expected Findings for a Newborn (Active Learning Template - Growth and Development, RM FUND 9.0 Ch 18) -Posterior fontanel closes by 2 to 3 months of age. -Anterior fontanel closes by 12 to 18 months of age. -Birth weight should double by 4 to 6 months and triple by the end of the first year. -Infants grow about 2.5 cm (1 in) per month in the first 6 months, and then about 1.25 cm (0.5 in) per month until the end of the first year. -Head circumference increases about 1.25 cm (0.5 in) per month in the first 6 months and then about 0.5 cm (0.2 in) between 6 and 12 months. -Six to eight teeth erupt in the infant’s mouth by the end of the first year. -Use cold teething rings, over-the-counter teething gels, and acetaminophen or ibuprofen. -Use a cool, wet washcloth to clean the teeth. -Do not give infants a bottle when they are falling asleep. Prolonged exposure to milk or juice can cause dental caries (bottle-mouth caries) Infants (2 Days to 1 Year): Providing Nutritional Teaching to the Parent of an Infant (Active Learning Template - Basic Concept, RM FUND 9.0 Ch 18) -Breastfeeding provides optimal nutrition during the first 12 months. Feeding alternatives -Iron-fortified formula is an acceptable alternative to breast milk. -Cow’s milk is inadequate and should not be given before 1 year of age. -Weaning from the breast or bottle can begin when infants can drink from a cup (after 6 months). -Replace a single bottle- or breast-feeding with breast milk or formula in a cup. -Every few days, replace another feeding with a cup. -Replace the bedtime feeding last. -Solid food is appropriate around 4 to 6 months. -Indicators for readiness include voluntary control of the head and trunk and disappearance of the extrusion reflex (pushing food out of the mouth). -Introduce iron-fortified rice cereal first. -Start new foods one at a time over a 5- to 7-day period to observe for signs of allergy or intolerance (fussiness, rash, vomiting, diarrhea, constipation). Vegetables, fruits, and meats follow, generally in that order. Middle Adults (35 to 65 Years): Psychosocial Tasks for a Middle Adult Client (Active Learning Template - Growth and Development, RM FUND 9.0 Ch 24) According to Erikson, middle adults must achieve generativity vs. stagnation. Middle adults strive for generativity Use life as an opportunity for creativity and productivity. Have concern for others. Consider parenting an important task. Contribute to the well-being of the next generation. Strive to do well in one’s own environment. Adjust to changes in physical appearance and abilities.Moral development Religious maturity Spiritual beliefs and religion can take on added importance. Middle adults can become more secure in their convictions. Middle adults often have advanced moral development Self-concept development: Some middle adults have issues related to: Menopause, Sexuality, Depression, Irritability, Difficulty with sexual identity, Job performance and ability to provide support, Marital changes with the death of a spouse or divorce Body image changes Sex drive can decrease as a result of declining hormones, chronic disorders, or medications. Changes in physical appearance can raise concerns about desirability. WOMEN: Symptoms of menopause can represent as: Loss of the reproductive role or femininity. New interest in intimacy. MEN: Decreasing strength can be frustrating or frightening. Social development Need to maintain and strengthen intimacy. Empty nest syndrome: experiencing sadness when children move away from home. Provide assistance to aging parents, adult children, and grandchildren, giving this stage of life the name “sandwich generation.” Older Adults (65 Years and Older): Expected Assessment Findings for an Older Adult Client (Active Learning Template - Growth and Development, RM FUND 9.0 Ch 25) Integumentary Decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which leads to wrinkles and dry, transparent skin Loss of subcutaneous fat, which makes it more difficult for older adults to adjust to coldtemperatures Thinning and graying of hair, as well as a more sparse distribution Thickening of fingernails and toenails Cardiovascular/pulmonary Decreased chest wall movement, vital capacity, and cilia, which increases the risk for respiratory infections Reduced cardiac output Decreased peripheral circulation Increased blood pressure Neurosensory Slower reaction time Decreased touch, smell, and taste sensations Decreased production of saliva Decline in visual acuity Decreased ability for eyes to adjust from light to dark, leading to night blindness, which is especially dangerous when driving Inability to hear high-pitched sounds (presbycusis) Reduced spatial awareness Gastrointestinal Decreased digestive enzymes Decreased intestinal motility, which can lead to increased risk of constipation Increased dental problems Neuromuscular Decreased height due to intervertebral disk changes Decreased muscle strength and tone Decalcification of bones Degeneration of joints Genitourinary Decreased bladder capacity Prostate hypertrophy in men Decline in estrogen or testosterone production Atrophy of breast tissue in women Endocrine Decline in triiodothyronine (T3) production, yet overall function remains effective Decreased sensitivity of tissue cells to insulin Basic Care and Comfort - (2) Complementary and Alternative Therapies: Teaching a Client About Meditation (Active Learning Template - Basic Concept, RM FUND 9.0 Ch 42) Nursing interventions can provide some aspects of complementary alternative therapies, including the following. Guided imagery/visualization therapy: Encourages healing and relaxation of the body by having the mind focus on images Healing intention: Uses caring, compassion, and empathy in the context of prayer to facilitate healing Breathwork: Reduces stress and increases relaxation through various breathing patterns Humor: Reduces tension and improves mood to foster coping Meditation: Uses rhythmic breathing to calm the mind and body Simple touch: Communicates presence, appreciation, and acceptance Music or art therapy: Provides distraction from pain and allows the client to express emotions; earphones improve concentration Therapeutic communication: Allows clients to verbalize and become aware of emotions and fears in a safe, nonjudgmental environment Relaxation techniques: Promotes relaxation using breathing techniques while thinking peaceful thoughts (passive relaxation) or while tensing and relaxing specific muscle groups (progressive relaxation) Nutrition and Oral Hydration: Foods to Avoid on a Mechanical Soft Diet (Active Learning Template - Basic Concept, RM FUND 9.0 Ch 39) Mechanical soft: clear and full liquids plus diced or ground foods Reduction of Risk Potential - (2) Thorax, Heart, and Abdomen: Identifying Manifestations of Ineffective Cardiac Contractions (Active Learning Template - System Disorder, RM FUND 9.0 Ch 29) Systolic hypertension (widened pulse pressure) is a common finding with atherosclerosis. The PMI becomes more difficult to palpate because the AP diameter of the chest widens. Coronary blood vessel walls thicken and become more rigid with a narrowed lumen. Cardiac output decreases and strength of contraction leads to poor activity tolerance. Heart values stiffen due to calcification. The left ventricle thickens. Pulmonary vascular tension increases. Systolic blood pressure rises. Peripheral circulation diminishes Vital Signs: Obtaining a Client's Blood Pressure (Active Learning Template - Nursing Skill, RM FUND 9.0 Ch 27) Blood pressure (BP) reflects the force the blood exerts against the walls of the arteries during contraction (systole) and relaxation (diastole) of the heart. Systolic blood pressure (SBP) occurs during ventricular systole of the heart, when the ventricles force blood into the aorta and pulmonary artery, and it represents the maximum amount of pressure exerted on the arteries when ejection occurs. Diastolic blood pressure (DBP) occurs during ventricular diastole of the heart, when the ventricles relax and exert minimal pressure against arterial walls, and represents the minimum amount of pressure exerted on the arteries Physiological Adaptation - (2) Electrolyte Imbalances: Identifying Manifestations of an Electrolyte Imbalance (Active Learning Template - System Disorder, RM FUND 9.0 Ch 58) Hyponatremia PHYSICAL ASSESSMENT FINDINGS: Vary with a normal, decreased, or increased ECF volume VITAL SIGNS: Hypothermia, tachycardia, rapid thready pulse, hypotension, orthostatic hypotension NEUROMUSCULOSKELETAL: Headache, confusion, lethargy, muscle weakness with possible respiratory compromise, fatigue, decreased deep tendon reflexes (DTRs), seizures, com GI: Increased motility, hyperactive bowel sounds, abdominal cramping, anorexia, nausea, vomiting Hypernatremia VITAL SIGNS: Hyperthermia, tachycardia, orthostatic hypotension NEUROMUSCULOSKELETAL: Restlessness, disorientation, irritability, muscle twitching, muscle weakness, seizures, decreased level of consciousness, reduced to absent DTRs GI: Thirst, dry mucous membranes, dry and swollen tongue that is red in color, increased motility, hyperactive bowel sounds, abdominal cramping, nausea OTHER FINDINGS: Edema, warm flushed skin, oliguria Hypokalemia VITAL SIGNS: Hyperthermia, weak irregular pulse, hypotension, orthostatic hypotension, respiratory distress NEUROMUSCULOSKELETAL: Ascending bilateral muscle weakness with respiratory collapse and paralysis, muscle cramping, decreased muscle tone and hypoactive reflexes, paresthesias, mental confusion ELECTROCARDIOGRAM (ECG): Premature ventricular contractions (PVCs), bradycardia, blocks, ventricular tachycardia, flattening Twaves, and ST depression GI: Decreased motility, hypoactive bowel sounds, abdominal distention, constipation, ileus, nausea, vomiting, anorexia OTHER CLINICAL FINDINGS: Anxiety, which can progress to lethargy Hyperkalemia VITAL SIGNS: Slow, irregular pulse; hypotension NEUROMUSCULOSKELETAL: Irritability, confusion, weakness with ascending flaccid paralysis, paresthesias, lack of reflexes ECG: Ventricular fibrillation, peaked T waves, widened QRS, cardiac arrest GI: Increased motility, diarrhea, abdominal cramps, hyperactive bowel sounds Ergonomic Principles: Facilitating Drainage for a Client Who Has Pneumonia (Active Learning Template - System Disorder, RM FUND 9.0 Ch 14) Sims’ or semi prone The client is on his side halfway between lateral and prone positions, with his weight on his anterior ileum, humerus, and clavicle. His lower arm is behind him while his upper arm is in front. Both legs are in flexion but the upper leg is flexed at a greater angle than the lower leg at the hip as well as at the knee. This is a comfortable sleeping position for many clients, and it promotes oral drainage Liberal Education for Baccalaureate Generalist Nursing Practice Definition The need for an education that exposes nurses to multiple fields of study providing the foundation for a global perspective of society as well as high level thinking and acquisition of skills that can be applied to complex patient and system-based problems. Basic Organization and Systems Leadership for Quality Care and Patient Safety Definition The need for nurses to be able to understand power relationships and use decision-making and Scholarship for evidence-based practice Definition The need for nurses to be able to understand the research process and base practice and clinical judgments upon fact-based evidence to enhance patient outcomes. Inter professional communication and collaboration Definition The need for nurses to be able to function as a member of the healthcare team while promoting an environment that supports interprofessional communication and collaboration with the goal of providing patient-centered care. Clinical prevention and population health Definition The need for nurses to be able to identify health related risk factors and facilitate behaviors that support health promotion, and disease and injury prevention, while providing populationfocused care that is based on principles of epidemiology and promotes social justice. Baccalaureate generalist nursing practice Definition The need for nurses to be able to practice as a generalist using clinical reasoning to provide care to patients across the lifespan and healthcare continuum and to individuals, families, groups, communities, and populations. Foundational thinking in Nursing Definition Ability to recall and comprehend information and concepts foundational to quality nursing practice. Clinical judgement/critical thinking in Nursing Definition Ability to use critical thinking skills (interpretation, analysis, evaluation, inference, and explanation) to make a clinical judgment regarding a posed clinical problem. Includes cognitive abilities of application and analysis. RN Management of Care Definition The nurse coordinates, supervises and/or collaborates with members of the health care to provide an environment that is cost-effective and safe for clients. RN safety and infection control Definition The nurse uses preventive safety measures to promote the health and well-being of clients, significant others, and members of the health care team. RN health promotion and maintenance Definition The nurse directs nursing care to promote prevention and detection of illness and support optimal health. RN psychosocial integrity Definition The nurse directs nursing care to promote and support the emotional, mental and social wellbeing of clients and significant others. RN basic care and comfort Definition The nurse provides nursing care to promote comfort and assist client to perform activities of daily living. RN Pharmacological and parenteral therapies Definition The nurse administers, monitors and evaluates pharmacological and parenteral therapy. RN reduction of Risk Potential Definition The nurse directs nursing care to decrease clients’ risk of developing complications from existing health disorders, treatments or procedures. RN Physiological Adaptation Definition The nurse manages and provides nursing care for clients with an acute, chronic or life threatening illness. Human Flourishing Definition Human flourishing is reflected in patient care that demonstrates respect for diversity, approaches patients in a holistic and patient-centered manner, and uses advocacy to enhance their health and well-being. Nursing Judgement Definition Nursing judgment involves the use of critical thinking and decision making skills when making clinical judgments that promote safe, quality patient care. Proffesional Identitiy Definition Professional identity reflects the professional development of the nurse as a member and leader of the health care team who promotes relationship-centered care, and whose practice reflects integrity and caring while following ethical and legal guidelines. Spirit of Inquiry Definition A spirit of inquiry is exhibited by nurses who provide evidence based clinical nursing practice and use evidence to promote change and excellence. RN Assessment Definition The assessment step of the nursing process involves application of nursing knowledge to the collection, organization, validation and documentation of data about a client’s health status. The nurse focuses on the client’s response to a specific health problem including the client’s health beliefs and practices. The nurse thinks critically to perform a comprehensive assessment of subjective and objective information. Nurses must have excellent communication and assessment skills in order to plan client care. RN Analysis/ Diagnosis Definition The analysis step of the nursing process involves the nurse’s ability to analyze assessment data to identify health problems/risks and a client’s needs for health intervention. The nurse identifies patterns or trends, compares the data with expected standards or reference ranges and draws conclusions to direct nursing care. The nurse then frames nursing diagnoses in order to direct client care. RN Planning Definition The planning step of the nursing process involves the nurse’s ability to make decisions and problem solve. The nurse uses a client’s assessment data and nursing diagnoses to develop measureable client goals/outcomes and identify nursing interventions. The nurse uses evidenced based practice to set client goals, establish priorities of care, and identify nursing interventions to assist the client to achieve his goals. RN Implementation/Therapeutic Nursing intervention Definition The implementation step of the nursing process involves the nurse’s ability to apply nursing knowledge to implement interventions to assist a client to promote, maintain, or restore his health. The nurse uses problem-solving skills, clinical judgment, and critical thinking when using interpersonal and technical skills to provide client care. During this step the nurse will also delegate and supervise care and document the care and the client’s response. RN Evaluation Definition The evaluation step of the nursing process involves the nurse’s ability to evaluate a client’s response to nursing interventions and to reach a nursing judgment regarding the extent to which the client has met the goals and outcomes. During this step the nurse will also assess client/staff understanding of instruction, the effectiveness of interventions, and identify the need for further intervention or the need to alter the plan. Priority Setting Definition Ability to demonstrate nursing judgment in making decisions about priority responses to a client problem. Also includes establishing priorities regarding the sequence of care to be provided to multiple clients. Safety Definition The minimization of risk factors that could cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Patient-Centered Care Definition The provision of caring and compassionate, culturally sensitive care that is based on a patient’s physiological, psychological, sociological, spiritual, and cultural needs, preferences, and values. Evidence-Based Practice Definition The use of current knowledge from research and other credible sources to make clinical judgments and provide client-centered care. Informatics Definition The use of information technology as a communication and information gathering tool that supports clinical decision making and safe, scientifically based nursing practice. Teamwork and Collaboration Definition The delivery of client care in partnership with multidisciplinary members of the health care team, to achieve continuity of care and positive client outcomes. [Show More]

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