ATI Topic Descriptors
Basic Care and Comfort (13)
Plan A
. Use of Assistive Devices
Hygiene Care: Evaluating Appropriate
Cane instructions:
Maintain two points of support on the ground at all times
Keep the cane on the stronger side of the body
Support body wt on both legs, move cane forward 6-10 inches, then move the weaker
leg forward toward the cane.
Next, advance the stronger leg
Dentures:
Clients who have fragile oral mucosa require gentle brushing and flossing.
Perform denture care for the client who is unable to do it himself
Remove dentures with a gloved hand, pulling down and out at the front of the upper
denture, and lifting up and out at the front of the lower denture.
Place dentures in a denture cup or emesis basin
Brush them with a soft brush and denture cleaner
Rinse them with water
Store the dentures, or assist the client with reinserting the dentures
Complimentary and Alternative Therapies: Appropriate Use of Music Therapy for
Pain Management
Music
decreases physiological pain, stress and anxiety by diverting the personʼs
attention away from the pain and creating a relaxation response.
let client select the type of music
music produces an altered state of consciousness through sound, silence, space
and time
must be listened to for 15-30 minutes to be therapeutic
earphones help client concentrate on music while avoiding other clients or staff
highly effective in reducing postop pain
if pain acute, increase volume of music
,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withdrawn with a syringe to remove clots that may be in bladder and catheter.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
esp at risk: spinal cord or other neuro injury, older adults, confused clients
Basic Care and Comfort (13)
Plan A
. Use of Assistive Devices
Hygiene Care: Evaluating Appropriate
Cane instructions:
Maintain two points of support on the ground at all times
Keep the cane on the stronger side of the body
Support body wt on both legs, move cane forward 6-10 inches, then move the weaker
leg forward toward the cane.
Next, advance the stronger leg
Dentures:
Clients who have fragile oral mucosa require gentle brushing and flossing.
Perform denture care for the client who is unable to do it himself
Remove dentures with a gloved hand, pulling down and out at the front of the upper
denture, and lifting up and out at the front of the lower denture.
Place dentures in a denture cup or emesis basin
Brush them with a soft brush and denture cleaner
Rinse them with water
Store the dentures, or assist the client with reinserting the dentures
Complimentary and Alternative Therapies: Appropriate Use of Music Therapy for
Pain Management
Music
decreases physiological pain, stress and anxiety by diverting the personʼs
attention away from the pain and creating a relaxation response.
let client select the type of music
music produces an altered state of consciousness through sound, silence, space
and time
must be listened to for 15-30 minutes to be therapeutic
earphones help client concentrate on music while avoiding other clients or staff
highly effective in reducing postop pain
if pain acute, increase volume of music
,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
esp at risk: spinal cord or other neuro injury, older adults, confused clients
