ATI Fundamentals Protcored Exam Review.

ATI Fundamentals Proctored Exam Review Nursing Process- ATI Fundamentals Ch. 7 Assessment/ Data Collection ▪ Pt. interview ▪ Medical history ▪ Physical assessment ▪ Lab reports ▪ S/S, feelings ▪ Objective data VS Analysis ▪ ID pt. health status ▪ Recognize trends and patterns Planning ▪ Nurse initiated/Independent Interventions ▪ Provider-Initiated/Dependent interventions ▪ Collaborative interventions ▪ Establish priorities Implementation ▪ Base care according to data and plan of care ▪ Use problem-solving and critical thinking ▪ Minimize risks ▪ Implement nursing action based on delegation Evaluation ▪ Evaluate client responsesto interventionsfor form clinical judgement ▪ See if goals are met ▪ Determine effectiveness of nursing care plan Practice Question: A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? A. “I will determine the most important client problems that we should address.” B. “I will review the past medical history on the client’s record to get more information.” C. “I will go carry out the new prescriptions from the provider.” D. “I will ask the client if his nausea hasresolved.” Practice Question: By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassessthe client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain Medical and Surgical Sepsis- ATI Fundamentals Ch. 10 Hand Hygiene PRIMARY BEHAVIOR!!!!!! 3 essential components (at least 15 seconds and up to 2 minutes if more soiled) ▪ Soap ▪ Water ▪ Friction Must perform hand hygiene with eithersoap and water or alcohol-based product Alcohol based amount- usually 3-5mLs (rub until completely dry) If visible soiled= soap and water (2 min) Perform hand hygiene using recommended antiseptic solutionsfor immunocompromised or multi-drug resistant micro-organisms Personal Protective Equipment (PPE): ▪ Put on (or Don): Gown Mask Googles Gloves ▪ Take off (or Doff): Gloves Googles Gown Mask Physical Environment: ▪ Do not place items on the floor (even soiled laundry) ▪ Do not shake linens can spread microorganisms in the air • Keep from touch clothing keep away from you ▪ Clean LEAST soiled areas FIRST ▪ Use plastic bags for moist, soiled items ▪ Place specimensin biohazard containers Maintaining a Sterile Field: ▪ Prolonged exposure to airborne micro-organisms can make sterile items nonsterile. • Avoid coughing, sneezing, and talking directly over a sterile field. • Ask patientsto refrain from touching supplies ▪ Only sterile items may be in a sterile field. • The outer wrappings and 1-inch edges of packaging that contains sterile items are not sterile. • Touch sterile materials only with sterile gloves ▪ Microbes can move by gravity from nonsterile item to a sterile item. • Do not reach across or above a sterile field. • Do not turn your back on a sterile field. • Hold items to add to a sterile field at a minimum of 6 inches above the field. ▪ Any sterile, non-waterproof wrapper that encounters moisture becomes nonsterile • Keep allsurfaces dry. • Discard any sterile packagesthat are torn, punctured, or wet. Sterile Filed set up: ▪ First open flap or wrapper of packaging AWAY from you ▪ Next open SIDE flaps ▪ Last open last flap TOWARD your body Practice Question: A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. a bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand Infection Control- ATI Fundamentals Ch. 11 Modes of transmission ▪ Contact • Direct contact- person to person • Indirect contact- inanimate object to person • Fecal-oral transmission- handling food without washing hands after using a restroom and failing to wash hands ▪ Droplet • Sneezing, coughing, and talking ▪ Airborne • Sneezing and coughing ▪ Vector-borne • Animal or insects (such as ticks with Lyme disease, mosquitos with West Nile Virus and Malaria) Chain of Infection ▪ Causative Agent Reservoir Portal of Exit Mode of Transmission Portal of entry Susceptible host Stages of Infection ▪ Incubation interval b/w pathogen entering the body and presentations of first finding ▪ Prodromal interval of onset of general findings to more distinct findings; pathogen multiplies ▪ Illness interval when findings specific to the infection occur ▪ Convalescence recovery Isolation Precautions ▪ Change PPE after contact with each client and between procedures with the same client Standard Precautions (Tier 1) ▪ Applies to all body fluids (except sweat), non-intact skin, and mucous membranes ▪ Perform hand hygiene ALWAYS!!!! Transmission Precautions(Tier 2) ▪ Airborne precautions • Private room, masks and respiratory devices, negative pressure airflow exchange • T- N95 or high-efficiency particulate air(HEPA) respirator • Wear mask while outside of room ◆ Measles, Varicella, TB ▪ Droplet precautions • Droplets larger than 5 mcg and travel 3-6 ft ◆ Haemophilusinfluenzae B, Rubella, Pertussis, Scarlet fever, mumps, mycoplasma pneumonia, sepsis • Private room with client with same infection • Masksfor providers and visitors • Wear mask outside of room ▪ Contact precautions • Within 3 ft of client against direct and environmental contact • RSV, Shigella, Herpessimplex, impetigo, Scabies, multi-drug resistant organisms-MRSA, enteric organisms- C-Diff (From GI) • Private room with other clients with same infection • Gloves and gown worn by caregivers and visitors ▪ Protective precautions • To protect clients who are immunocompromised: stem cell transplant, chemo • Private room • Positive airflow 12 or more air exchanges/hr. • HEPA filter for incoming air • Mask for when patient is out of the room Multidrug-resistant Infection: ▪ Methicillin- resistant Staphylococcus aureus- MRSA • Resistantto many antimicrobials • Vancomycin and linezolid are used to treat MRSA ▪ Vancomycin-resistant Staphylococcus aureus- VRSA • Resistantto Vancomycin • Other antimicrobials will work based on the specific strain Herpes Zoster (Shingles) ▪ Viral Infection ▪ Initially produced by chicken pox after which the virusremains dormant ▪ Re-activated as Shingles later in life ▪ Has a prodromal period: • Pain- unilateral and extends horizontally along a dermatome • Tingling • Burning ▪ Shingles may be very debilitating and painful ▪ Older adults are more susceptible to herpeszoster ▪ Nursing Care: • Assess pain, lesions, presence of fever, neuro. complications,signs of infection • Use air mattress or bed cradle for pain prevention to affected areas • Isolate the client until the vesicles have crusted over • Maintain strict wound care precautions • Avoid exposing client to infants, pregnant women who have not had chicken pox, immunocompromised clients • Anyone who has not had chicken pox and have not been vaccinated is at risk • Administer analgesics- NSAIDS, narcotics ▪ Administer antiviral agents- acyclovir can shorten the course ▪ Monitor for complications of Postherpetic neuralgia- pain lasting longer than 1 month Isolation Guidelines- ATI Fundamentals Ch. 11 Isolation guidelines are a group of actions that include hand hygiene and the use of barrier precautions Must be used whenever there is anticipation of contacting infectious material Change PPE: ▪ After contact with each client ▪ In between procedures with the same client ▪ If in contact with large amounts of blood and body fluids Clients in isolation are at higher risk for depression and loneliness- provide sensory stimulation Health Care Associated Infections- ATI Fundamentals Ch. 11 HAI’s are infections acquired while receiving care in the health care setting. Formerly called “Nosocomial Infections” Often occurs in the ICU Best way to prevent HAIsisfrequent and effective handwashing Common sites: ▪ UTI- E-Coli, Staph aureus, enterococci ▪ Surgical wounds ▪ Respiratory tract ▪ Blood stream Practice Question: A client is 2 days postoperative following an appendectomy. While changing the linens on the client’s bed, the nurse notes drainage from an infected wound has soiled the bed sheet. The appropriate nursing action is to: A. carefully place the soiled sheet in a moisture-resistant plastic bag B. Spray the soiled sheet with a bleach solution C. Roll up the soiled sheet and toss it directly into the laundry chute D. Discard the sheet in an impervious trash bag Safe Medication Administration and Error Reduction- ATI Fundamentals Ch. 47 Providers Responsibilities: ▪ Obtain pt. medical history ▪ Perform physical exam ▪ Diagnosing ▪ Prescribe medication ▪ Monitor response to therapy ▪ Modify medication prescription to therapy Nomenclature: ▪ Chemical Name chemical composition ▪ Generic Name official or nonproprietary name ▪ Trade Name brand name Unsafe prescription Appropriate/ priority actionsfollowing a medication error Routes of administration- intradermal, Z-track, TB test: ▪ IV Intermittent IV bolus IV catheter insertion: ▪ Selecting an IV site Medication reconciliation Manifestations of allergic reactions Mixing insulin Evaluating appropriate use of herbalsupplements Priority action for handling defective equipment Client Safety – ATI Fundamentals Ch. 12 Fall precautions: ▪ Complete fall risk assessment on admission and regular intervals ▪ Adequate lighting ▪ Call light within reach ▪ Assistive devices, if needed ▪ Assign to nurses’station ▪ Hourly rounding ▪ Frequently used item within reach ▪ Bed in lowest position with brakes locked ▪ Keep side rails up ▪ Nonskid footwear and bathmats ▪ Use gait belts ▪ Keep clear path to bathroom Seizure precautions: ▪ Make sure equipment is at bedside ▪ Maintain airway patency ▪ Inspect environment and remove items that can harm patient ▪ Assist with ambulation ▪ DO NOT PUT ANYTHING IN CLIENTS MOUTH!! ▪ Do not restrain patient ▪ Lower to floor, put them on one side with head flexed ▪ Wrap a blanket on all 4 sides of patient’s bed ▪ Stay with client and call for help ▪ Administer medication ▪ Determine mental status ▪ Measure VS and oxygenation ▪ Document seizure Home safety hazards ▪ Place “No Smoking” sign ▪ No smoking near oxygen Do it outside ▪ Ensure electrical equipment is in good repair and well grounded ▪ Keep oxygen 8 feet away from gasstove ▪ Replace bedding that can generate static electricity w/items made from cotton ▪ Keep flammable materials away from oxygen Ergonomics- prevention of injury when lifting ▪ Avoid injury when turning patients Needle disposal Handling defective equipment Home safety ▪ Older adult ▪ Teaching client about home safety ▪ Evaluating client understanding of home safety Seclusion and restraints- in general use seclusion or restraints for the shortest duration necessary and only if less restrictive measures are not sufficient ▪ Possible complicationsinclude- pneumonia, incontinence and pressure ulcers Fire safety ▪ R (rescue client), A (Alarm), C (Contain Fire), E (Extinguish) Fire Extinguishers: ▪ P (pull the pin), A (aim), S (squeeze), S (Sweep) Classes of fire extinguishers: ▪ Class A: combustibles such as paper, wood- trash fires ▪ Class B: for flammable liquids and gas fires ▪ Class C: electrical fires Seclusion/Restraints- ATI Fundamentals Ch. 12 Can be physical (vest, belt, etc.) or chemical (sedatives) Use only if less restrictive measures are not effective Inappropriate use ofseclusion or restraints: ▪ Convenience ofstaff ▪ Client extremely physically or mentally unstable ▪ Punishment for the client ▪ Clients who cannot tolerate the decreased stimulation of a seclusion room Restraintsshould: ▪ Never interfere with treatment ▪ Restrict movement as little as necessary ▪ Fit properly and be discreet ▪ Be easily removed or changed Alternativesto restraints: ▪ Orientation to the environment ▪ Supervision of a family member orsitter ▪ Diversional activities ▪ Electronic devices Planning care for a client with a prescription for restraints: ▪ Provider must complete a face to face assessment ▪ Order must include reason, type, location, how long to use, type of behavior needing the restraints. ▪ 4hr of restraints Adult ▪ 2hr 9-17 years of age ▪ 1hr 9 years of age ▪ May renew these orders with a MAXIMUM of 24 consecutive hours ▪ CANNOT have a PRN restraint order ▪ In an emergency, nurses may place restraints but MUST get an order from provider ASAPusually within 1 hr. Nursing Responsibilities: ▪ Explain the need to client ▪ Aske client or guardian for consent ▪ Assessskin integrity every 2 hr., offer food and fluid, hygiene, elimination, monitor vitals, offer range of motion of extremities ▪ Pad bony prominences prevent skin breakdown ▪ QUICK-RELEASE knot to movable part of bed frame ▪ Fit 2 fingers between restraints and client ▪ Remove or replace restraints frequently to ensure good circulation ▪ Ongoing evaluation for the need for restraints ▪ Never leave the client alone without the restraints ▪ Document all the above Practice Question: A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. “I will place the client on his side.” B. “I will go to the nurses’ station for assistance.” C. “I will administer his medications.” D. “I will prepare to insert an airway.” Practice Question: A nurse is caring for a client who fell at a nursing home. the client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client’s call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment. Home Safety- ATI Fundamentals Ch. 13 Infants and toddlers: ▪ Aspiration • Keep small objects out of reach • Check toys/objects for loose orsharp edges • Do not feed infant hard candy, peanuts, popcorn, sliced pieces of hot dog • Do not place infant in supine position wile feeding • Pacifier should only be one piece (no string or ribbon attached) ▪ Suffocation • Teach “back to sleep” mnemonic • Keep plastic bags out of reach • Make sure crib mattress fit snugly • Do not place anything in the crib with infant • Remove crib toys • Fence swimming pools, begin swim lessons • CPR/Heimlich training • Keep toilet lids down ▪ Poisoning • Keep houseplant/cleaning agents out of reach • Inspect/remove sources of lead (paint chips) • Have poison control hotline number available • Place poisons, paint, gasoline in locked cabinet • Lock up medications using child-proof containers • Dispose expired meds ▪ Falls • Keep crib/playpen rails up • Never leave infant unattended on high surfaces (changing tables) • Use gates on stairs, windows have screens • Place in low bed when toddler starts to climb ▪ Motor vehicle injury • Place infants/toddlersin a rear-facing carseat until 2 y/o • Car seat should have a 5-point harness • Place car seat in the back seat of car (safest) ▪ Burns • Test temperature of formula and bath water • Place pots on back burner, turn handle away • Supervise use of faucets • Keep matches/lighters out of reach • Cover electrical outlets • Apply sunscreen SPF 30 or higher or protective clothing Preschoolers and school-age: ▪ Drowning • Be sure child knows how to swim • Wear life jacket • Implement buddy system • Have locked fences around pools • Supervision near pools and water ▪ Motor vehicle injury • Use booster seats for children who are 4 ft • Air bag in passenger seat 12 y/o in back seat • Use seat belts • Wear protective equipment (riding a bike, sports) • Road safety • Play in safe areas ▪ Firearms • Keep firearms unloaded, locked up, and out of reach • Teach to never touch and gun • Store bulletsin different location ▪ Play injury • Teach not to run with candy or objects in mouth • Ensure bikes are appropriate size • Teach playground safety • Never swim alone • Wear protective helmets • Avoid strangers ▪ Burns • Reduce setting of water heater to no higher than 120 F • Teach dangers of matches, fireworks, and firearms • How to use a microwave • Apply SPF 30 or higher sunscreen ▪ Poisons • Teach about hazards of alcohol, cigarettes, illicit drugs • Keep potentially dangeroussubstances out of reach • Have the poison control hotline number available ▪ Begin sex education forschool-aged child Adolescents: ▪ Motor vehicle injury • Complete driver’s education course • Educate on hazards of driving while distracted • Watersafety • Protective equipment in sports • Be alert for manifestations of depression, anxiety, other behavioral changes ▪ Burns • Sunscreen (SPF 30 or higher) • Dangers of tanning beds and sunbathing ▪ Social Media • Discuss, monitor, and limit exposure to social networking and the Internet Young and middle adults: ▪ MVA most common ▪ Adults- occupational injuries, alcohol, and suicide Older adults (cognitive, physical, and sensory changes) ▪ Falls, burns, home hazards(need modificationssuch as grab bars, etc.) ▪ Electrical cords behind furniture ▪ Monitor gait and balance ▪ Use nonskid mat in bathtub or shower ▪ Ensure adequate lighting ▪ Remove item that could cause client to trip Emergency Care- ATI Fundamentals Ch. 13 ABCDE Principle ▪ A – Airway/Cervical Spine ▪ B – Breathing ▪ C – Circulation ▪ D – Disability ▪ E – Exposure Basic first aid ▪ Bleeding • External bleeding- apply direct pressure to wound site • DO NOT remove impaling objects, instead stabilize the object • Internal bleeding will require IV volume replacement with fluid or blood products, or surgical interventions ▪ Fractures and splinting • Assess for swelling, deformity and skin integrity • Assess temperature, distal pulses and mobility • Apply splint to immobilize the fracture. • Cover open areas with sterile dressing • Reassess neurovascular status(5 Ps) ▪ Sprains • RICE • Refrain from weight bearing • Apply ice to decrease inflammation • Apply compression dressing to minimize swelling • Elevate the extremity ▪ Heatstroke • Body temperature greater than 104F- treat aggressively • S/S- hot dry skin, hypotension, tachypnea, tachycardia, anxiety, confusion,seizures, coma. • Client DOES NOT sweat • Rapid cooling- ice packs over major arteries • Cold water bath • Do not allow client to shiver- if so, cover with a blanket ▪ Frostnip and frostbite • Common sites earlobes, tip of nose, fingers, and toes • Frostnip no tissue injury, just treat by warming • Frostbite tissue injury, white waxy areas • Warm the affected area in 98.6-108F water bath • Pain medication and tetanus ▪ Burns • Can be from electrical current, chemicals, radiation, or flames • Remove the agent (electrical current,radiation and chemical) • Smother flames and perform primary survey • Cover the client and maintain NPO • Elevate extremitiesif not contraindicated (like Fracture) • Assess thickness and areas of burns • IV fluids and tetanus ▪ Altitude-Related Illnesses • Client becomes hypoxic • Can progress cerebral and pulmonary edema – immediate treatment!!! • S/S: ◆ Throbbing HA, N/V, Dyspnea, Anorexia • Nursing Interventions: ◆ Administer O2 ◆ Descend to lower altitude ◆ Provide steroids and diuretics ◆ Promote rest CPR CAB Assess for response and breathing: ▪ If no breathing (or gasping)- call for help ▪ If alone activate emergency response system and get AED if available ▪ If a second person is there,send them for activate the emergency response system (911) ▪ Check pulse and begin CPR and alternate wit breaths if pulse not detected Practice Question: A nurse is caring for a client who 1-day postoperative following abdominal surgery. What isthe first action the nurse should take after discovering that a client’s wound has eviscerated? A. Cover the incision with a moist sterile dressing. B. Have the client lie on his back with his knees flexed. C. Call the client’s surgeon D. Measure the client’s vitalsigns. Ergonomic Principles – ATI Fundamentals Ch. 14 Body mechanics: ▪ Center of gravity • To lower center of gravity, bend hips and knees • Spread feet apart to broaden base of support ▪ Pushing or pulling • Widen base of support • Pull objects to center of gravity instead of pushing away • If Pushing move front foot forward • If Pulling move your rear leg back to promote stability • Face the direction of movement ▪ Lifting • Flex hips, knees and back • Bring object to thigh level, bending knees and keeping back straight • Hold object as close to you as possible • Do not twist while pushing – risk for injury Positioning – ATI Fundamentals Ch. 14 Frequent position changes prevent discomfort, contractures, pressure on tissues and nerve and circulatory damage, and they stimulate postural reflexes and muscle tone. Use of transfer devices: ▪ transfer belt, hydraulic lift,sliding board, canes, crutches, walkers Determine the client’s ability to assist with transfers: ▪ Balance, muscle strength, endurance Evaluate the need for additionalstaff or assistive devices Assess and monitor the use of mobility aids (canes, walkers, etc.) Positions: ▪ Semi-fowler’s: 15-45 degrees (typically 30) • Preventsregurgitation of enteral feedings, prevents aspiration, lung expansion, mechanical ventilation, dysphagia ▪ Fowler’s: 45-60 degrees • NG tube insertion, suctioning, better chest expansion, ventilation ▪ High fowler’s: 60-90 degrees • prevention of aspiration, promoteslung expansion, relievessevere dyspnea ▪ Supine or dorsal recumbent • foot support can help prevent foot drop • client lies on their back, spine in proper alignment ▪ Prone: • Patient lies flat on their abdomen and chest • Prevents hip flexion contractures afterlower extremity amputation ▪ Lateral orside-lying • prevention of pressure ulcers ▪ Sims’ orsemi-prone • promotes oral drainage ▪ Orthopneic • allows for chest expansion- COPD ▪ Trendelenburg • facilitates postural drainage • HOB lower than foot of bed ▪ Reverse Trendelenburg • promotes gastric emptying and prevents esophageal reflux • Foot of bed lower than HOB ▪ Modified Trendelenburg • client is flat with legs elevated above the level of the heart • Treats hypovolemia Practice Question: A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? A. supine B. semi-Fowler’s C. semi-prone D. Trendelenburg Security and Disaster Plans – ATI Fundamentals Ch. 15 A disaster is a mass casualty or intra-facility event that at least temporarily overwhelms or interrupts the normal flow of services of a hospital Internal emergencies(within the facility) ▪ Loss of electricity or water ▪ Explosion ▪ Terrorist act External emergencies ▪ Hurricanes ▪ Floods ▪ Volcano eruptions ▪ Earthquakes ▪ Disease epidemics ▪ Major transportation accidents Triage Categories: ▪ Emergent (Class 1) • Highest priority is given to clients with life-threatening injuries but also have a high possibility of survival once stabilized ▪ Urgent (Class II) • Major injuriesthat are not yet life-threatening and can usually wait 30 min-2 hr. for treatment ▪ Nonurgent (Class III) • Minor injuries that are not life-threatening and do not need immediate attention ▪ Expectant (Class IV) • Clients who are not expected to live and can die naturally. Comfort care only Discharge/Relocation of Clients ▪ During a disaster, decisions must be made regarding discharging and moving clients so their beds can be given to more high priority clients ▪ Ambulatory clients are discharged or relocated first ▪ Clients requiring assistance are next and arrangements are made for their assistance at home ▪ Unstable clients are not discharged or relocated unlessthey are in imminent danger Fire ▪ Use R.A.C.E mnemonic Severe thunderstorms/Tornados ▪ Close drapes protect against shattering glass ▪ Lower bed to lowest position ▪ Move away from windows ▪ Close doors ▪ Do not use elevators Biological pathogens ▪ Be alert for appearance of disease that does not usually occur at a specific time or place ▪ Use recommended isolation measures ▪ Take measuresto protect yourself and others ▪ Recognize indications of infection/poisoning Chemical Incidents ▪ Occur of an accident or due to a purposeful action (terrorism) ▪ Avoid contact ▪ Maintain ABCs ▪ Remove offending chemical – undress client Hazardous material Incident ▪ Contain material in one place ▪ Don PPE ▪ Water Universal Antidote ▪ Place contaminated material into plastic bags and seal them ▪ Wash skin with water and antibacterialsoap Radiological Incidents ▪ Wear water-resistant gown, double gloves, body fully cover Bomb Threat ▪ Listen for distinguishing background noises ▪ Bomb located – do not touch it ▪ Keep elevators available ▪ Remain calm and alert – try not to alarm the patient Active Shooter Situation: ▪ RUN • Evacuate • Leave belongings behind • Instruct others to follow ▪ HIDE • Stay out of shooters sight • Find a protective area • Block or lock doors • Silence phone and remain quiet ▪ FIGHT • If unable to run and hide, throw items, yell shooter to stop, wound the shooter Health Promotion/Disease Prevention – ATI Fundamentals Ch. 16 Screenings are for baseline and for clients who are asymptomatic: ▪ Routine physical q 1-3 years (females), q 5 years (males) _ 20-40 years ▪ Dental q 6 months ▪ TB screening q 2 years ▪ BP q 2 years, annually of elevated ▪ BMI each routine visit ▪ Cholesterol starting at age 20, min. q 5 years ▪ Glucose starting at age 45, min. q 3 years ▪ Skin assessment q 3 years (ages 20-40), annually 40 years ▪ Digital rectal exam during routine physical exam, continue after age 76 ▪ Colorectal screening (every year between 50 and 75) ▪ Cervical cancer screening (PAP) Ages 21-29 q 3 years, 30-65 q 5 years ▪ Breast cancer screening (20-39 years, clinical exam q 3 years, mammogram annually after 40) ▪ Testicular exam (start at age 20) ▪ Prostate specific antigen (PSA) starting at 50 Primary: decreases risk of exposure ▪ Immunization programs ▪ Child carseat education ▪ Nutrition, fitness activities ▪ Health education in schools Secondary: prevent worsening of health ▪ Communicable disease screenings ▪ Early detection, treatment of DM ▪ Exercise programs for older adults who are frail Tertiary: prevent long term consequences of illness ▪ Begins after an injury or illness ▪ Prevention of pressure ulcers afterspinal cord injury ▪ Promoting independence after traumatic brain injury ▪ Rehabilitation centers Client Education – ATI Fundamentals Ch. 17 Domains of learning: ▪ Cognitive- focuses on thinking • Client learns manifestations of hypoglycemia and can verbalize when to notify the HCP ▪ Affective- feelings, beliefs, and values • New diabetic discusses her feelings about her new diagnosis and the life changes necessary ▪ Psychomotor-require mental and physical activity • When client practices preparing insulin injections Factor that enhance learning: ▪ Perceived benefit ▪ Cognitive and physical ability ▪ Health and cultural beliefs ▪ Active participation ▪ Age and educational level appropriate methods Barriers to learning ▪ Fear, anxiety, and depression ▪ Physical discomfort, pain, and fatigue ▪ Environmental distractions ▪ Health and cultural beliefs ▪ Sensory and perceptual deficits ▪ Psychomotor deficits Health Assessment – ATI Fundamentals Ch. 26 Assessment Techniques ▪ 4 basic assessment techniques • Inspection, palpation, percussion, Auscultation • In the above order except where? Abdomen ▪ Equipment ▪ Older adult considerations ▪ Focused assessment: • focused assessment a highly specific assessment focusing on the system orsystems involved in the patient's problem. Generalsurvey: appraisal of overall health ▪ Physical appearance • Ex: age, gender, LOC, color ofskin,signs of distress ▪ Body structure • Ex: height,stature, nutritionalstatus, symmetry of body parts, posture, gross abnormalities ▪ Mobility • Ex: gait, movements (tremors), ROM, motor activity ▪ Behavior • Ex: facial expressions, mood and affect, speech, dress, hygiene, grooming ▪ Vital signs • Temperature, Pulse, Respirations, BP, O2 Components: ▪ Patient ID ▪ Past Medical History ▪ Medications ▪ Allergies ▪ Social History ▪ Immunizations/Travel ▪ Family History ▪ Review of Systems (subjective) ▪ Physical examination (objective) System Assessment Neurological ▪ Alert/Orientation x4 ▪ Communication/Speech ▪ Pupils (dilated or constricted) ▪ Glasgow Coma Scale ▪ Muscle Tone/Strength/Sensation/Tremor Respiratory ▪ Pulse oximetry ▪ Cough/Sputum ▪ Oxygen ▪ Respiratory effort ▪ Respiratory rhythm ▪ Breath sounds • Resonant sounds are low pitched, hollow sounds heard over normal lung tissue. • Flat or extremely dull sounds are normally heard over solid areas such as bones. • Dull or thud like sounds are normally heard over dense areas such as the heart or liver. ◆ Dullness replacesresonance when fluid orsolid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors. • Hyper resonant sounds that are louder and lower pitched than resonant sounds are normally heard when percussing the chests of children and very thin adults. ◆ Hyper resonant sounds may also be heard when percussing lungs hyperinflated with air, such as may occur in patients with COPD, or patients having an acute asthmatic attack. ◆ An area of hyperresonance on one side of the chest may indicate a pneumothorax. • Tympanic sounds are hollow, high, drum like sounds. ◆ Tympany is normally heard over the stomach but is not a normal chestsound. ◆ Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax. Cardiovascular ▪ Skin ▪ Cap refill ▪ Apical pulse rhythm ▪ Heart sounds ▪ Peripheral pulses ▪ Edema ▪ ECG assessment Genitourinary ▪ Genitalia ▪ Assessment of urination ▪ Continent/Incontinent ▪ Urine amount/color/characteristics ▪ Urostomy/stoma status ▪ Urinary stents ▪ Urinary catheter Gastrointestinal ▪ Oral mucosa ▪ Abdomen (distended, taut, ascites, incision, girth) ▪ Pain ▪ Bowel movements (diarrhea –what else should I assess for the possibility of?) ▪ Last BM ▪ Continent/Incontinent ▪ Nausea/vomiting ▪ Bowel sounds ▪ Tubes/Insertion site/tube feeding ▪ Stoma/stoma status Skin Integrity ▪ Skin color ▪ Intactskin ▪ Signs/symptoms of inflammation/infection. Isit localized orsystemic? ▪ Contusion/Ecchymosis Wounds ▪ Location/type/size/tunneling/undermining/surrounding tissue/ drainage ▪ Pressure reduction/relief measures Pain Pain Assessment ▪ P = What precipitated the pain? What is the pattern? ▪ Q = quality and quantity ▪ R = Region and radiation ▪ S = Severity/Intensity ▪ T = Timing Vital Signs – ATI Fundamentals Ch. 27 Temperature ▪ Oral 96.8 – 100.4 F – anything 100.4 F indicates fever (infection) ▪ Rectal 0.9 F or higher ▪ Axillary 0.9 F or lower ▪ Temporal 1- 2 F Pulse ▪ Pulse strengths (look at Ch. 28-31 points) ▪ Assessfortachycardia and bradycardia ▪ Normal 60-100 bpm Respirations ▪ Normal 12-20 breaths/min ▪ Assessfor respiratory complicationslike: • Tachypnea, Bradypnea, Apnea, Hyper/Hypoventilation • Kussmaul respiration increases RR, regular pattern, but abnormally deep • Cheyne-Strokes respiration irregular rate and depth, apnea period Pulse Oximetry (SaO2) ▪ Normal 95%-100% Blood Pressure ▪ Normal less than 120/80 ▪ Assess complication and contributing factors ▪ BP CANNOT be less than 100/70 Physical Assessment – ATI Fundamentals Ch. 28-31 Head/Neck: Check for ▪ Head bumps, lesion, alopecia, dry scalp ▪ Face symmetry, color ▪ Neck ROM, JVD, swollen lymph nodes goiter, trachea midline ▪ Eyes visual acuity, PERRLA, double/blurred/no vision ▪ Ears alignment, drainage deformities ▪ Nose midline, patent naris, assess smell ▪ Mouth cracked lips, bleeding gums, dry/moist mucus membranes, swollen tongue, ability the swallow, gag reflex, slurred speech ▪ Teeth shiny, white, and smooth Thorax, Heart, and Abdomen: Check for ▪ Thorax and Lungs • Inspect (shape,symmetry,surgery scars, skin color) • Palpation (edema, masses, bulges) • Percussion (dullness or tympanic sounds) • Auscultation (abnormal respiratory patternslike crackles, wheezes, etc., assessfor bronchial, bronchovesicular, and vesicular lungs sounds) ▪ Heart • S1 “lub” (contraction) • S2 “dub” (relaxation) • S3 ventricular gallop; in children and young adults, occurs after S2 • S4 atrial gallop, in athletes, occurs after S1 • Murmurs ◆ Systolic occurs after S1 ◆ Diastolic occurs after S2 • Thrills palpable vibration • Bruit Blowing, swishing sounds • Auscultatory sites of Heart: ◆ Aortic Right 2 nd ICS ◆ Pulmonic Left 2 nd ICS ◆ Erb’s Point Left 3 rd ICS ◆ Tricuspid Left 4 th ICS ◆ Apical/Mitral/PMI Left midclavicular line 5th ICS - (closure of mitral valve) ▪ Abdomen • Inspection (lesion,scars, color, bruising, distention) • Auscultation (Bowelsounds_5-35 [hypo or hyper} start in RLQ • Percussion (high pitched tympany sounds) • Palpation (light or deep varies on tenderness) Skin ▪ Assess temperature – use dorsal part of hand ▪ Assess skin integrity – Braden scale ▪ Assess skin turgor – indication of dehydration if tenting occurs ▪ Color of skin: • Pallor (white appearance) • Cyanosis (Blue color – loss of O2) • Jaundice (yellow pigment – liver problems) • Erythema (redness) ▪ Nails • Check for clubbing – respiratory insufficiency • Capillary refill (3 seconds) – greater than 3 seconds indicates arterial insufficiency ▪ Hair • Alopecia (bald spots) • Distribution • Hirsutism – hair growth on faces for females ▪ Peripheral Arteries Strength Pulses(carotid, radial, brachial, femoral, popliteal, posterior tibial, and dorsalis pedis) • 0 = Absent, unable to palpate • +1 = diminished, weaker than expected • +2 = brisk, expected – NORMAL!! • +3 = increased • +4 = Full volume, bounding ▪ Edema • 1+ = Trace, 2mm, rapid skin response -- NORMAL!! • 2+ = Mild, 4mm, 10-15 second skin response • 3+ = Moderate, 6mm, prolonged skin response • 4+ = Severe, 8mm, prolonged skin response ▪ Lesions • Primary: ◆ Macule freckles, petechiae ◆ Papule elevated nevus ◆ Nodule wart ◆ Vesicle blister, varicella, herpes zoster ◆ Pustule acne ◆ Tumor Epithelioma ◆ Wheal insect bite • Secondary: ◆ Erosion ruptured vesicle ◆ Crust scab ◆ Scale dandruff, moist surface, no bleeding ◆ Fissure tinea pedis ◆ Ulcer pressure ulcer, venous stasis ulcer ▪ Use A (asymmetry) B (Border) C (Color) D (Diameter) E (Evolving) system Musculoskeletal ▪ Assess: • Gait • Alignment (Kyphosis, Lordosis, Scoliosis) • Symmetry, muscle mass • Muscle tone ▪ Range of Motion • Flexion, extension, hyperextension,supination, pronation, abduction, adduction, etc. Neurologic ▪ Mentalstatus • Alert responsive • Lethargic drowsy but able to open eyes • Obtunded responds to light shaking but confused • Stuporous requires painful stimuli • Comatose no response ▪ Sensory function light touch, temperature, pain sensation ▪ Motor Function Romberg test, Heel-to-toe walk ▪ Cranial Nerves: • 1 olfactory (smell) • 2 Optic (sight) ◆ Snellen chart – visual acuity ◆ Rosenbaum – near vision or farsightedness ◆ Ishihara test - Color vision • 3 Oculomotor, 4 trochlear, 6 Abducens (PERRLA, 6 cardinal positions of gaze) • 5 Trigeminal (light touch sensation, jaw clench, chewing) • 7 Facial (taste 2/3 thirds of tongue, facial movements) • 8 Auditory (hearing and balance) ◆ Whisper test, Rinnestest, Weber tests • 9 Glossopharyngeal (taste 1/3 thirds of tongue, swallow, gag reflex) • 10 Vagus (gag reflex, speech) • 11 Spinal accessory (turning head, shrug shoulders) • 12 Hypoglossal (tongue movement) Therapeutic Communication -ATI Fundamentals Ch. 32 Levels of basic communication ▪ Intrapersonal communication “self-talk” ▪ Interpersonal communication b/w 2 people ▪ Public communication b/w large groups of people ▪ Transpersonal communication spiritual ▪ Small group communication committees, research teams, support groups Non Verbal Communication: Nurses should be aware of how they communicate nonverbally and should determine the meaning of the clients’ nonverbal communication as well. ▪ Appearance, posture, gait ▪ Facial expression, eye contact, gestures ▪ Sounds ▪ Territoriality, personalspace Essential Components ▪ Time ▪ Attentive behavior or active listening ▪ Caring attitude – show concern, emotional connection ▪ Honesty – be open, direct, truthful, and sincere ▪ Trust ▪ Empathy – awareness and understanding ▪ Nonjudgmental attitude – displaying acceptance Effective Skills and Techniques ▪ Silence – allow time for meaningful reflection ▪ Presenting reality – distinguish reality ▪ Active listening – hear, observe, and understand ▪ Open-ended questions – facilitatesspontaneousresponses ▪ Clarifying techniques • Restating, reflecting, paraphrasing, exploring ▪ Offering general leads, broad opening statements ▪ Showing acceptance and recognition ▪ Focusing ▪ Giving information ▪ Summarizing ▪ Offering self ▪ Touch Barriersto effective communication ▪ Asking irrelevant personal questions ▪ Offering personal opinions ▪ Stereotyping ▪ Giving advice ▪ Giving false reassurance – “Don’t worry” or “everything will be ok” ▪ Minimizing feelings ▪ Changing the topic ▪ Asking “why” questions – asking for explanation ▪ Challenging ▪ Offering value judgments ▪ Being defensive ▪ Offering sympathy ▪ Arguing Coping- ATI Fundamentals Ch. 33 Stress ▪ Changes in an individual’sstate of balance in response to stressors, the internal or external forces that disrupt that state of balance. ▪ Can be situational and developmental ▪ Caused by sociocultural factors(lack of education, prolonged poverty) • Encourage relaxation techniques • Training to manage stress • Use effective communication Coping ▪ How an individual deals with problems or issues. • Be empathetic • Coping skills • Encourage client’s autonomy and decision-making Adaptation ▪ Alarm reaction stage: increased body functions (hormones, VS) ▪ Resistance stage: body functions normalize (stabilize VS) ▪ Exhaustion stage: body functions are no longer able to maintain a response and the client cannot adapt. Adherence ▪ Commitment and ability of the client and family to follow a given treatment regimen • Allow client to give input • Follow up with any questions Types of Role Problems ▪ Role conflict person must assume opposing roles with incompatible expectation • Ex: mother wants to stay home with her infant, but her family finances require her to work ▪ Sick role expectations of others and society regarding how one should behave when sick • Ex: caring for self while sick and continuing to provide childcare to grandchildren ▪ Role ambiguity uncertainty about what is expected when assuming a role; creates confusion ▪ Role strain frustration and anxiety that occurs when a person feels inadequate for assuming a role • Ex: caring for a parent with dementia ▪ Roles overload more responsibility and roles than are manageable, very common • Ex: assuming the role of student, employee, and parent Cultural and Spiritual Nursing Care – ATI Fundamentals Ch. 35 Culture ▪ Involves similarities shared among members of a group through: • Race • Ethnicity • Influences ▪ Evolution of Culture • Knowledge • Values • Beliefs Morals and Laws • Customs Buddhism ▪ Vegetarians ▪ Avoid alcohol and tobacco ▪ Might fast on holy days ▪ Bran death – requirement ▪ Death is seen as a stage of life to occur at home ▪ Body prepared by male ▪ May use cremation Christianity ▪ Common belief – faith healing ▪ Organ donation generally allowed ▪ Practice holy communion Sikhism ▪ Female client often checked by other females ▪ Remove undergarments – can be distressing ▪ Use religioussymbols or devotional prayer ▪ Might not permit cutting orshaving of the hair Navajo ▪ Correct poor health by stories, songs, rituals, prayers and paintings Hinduism ▪ Illness can be caused by past sins ▪ Clients want to lie on the floor while dying ▪ Care of body should those of same gender ▪ Cremation ▪ Use ritualsfor purity and prayer ▪ Use amulets or other symbols Islam ▪ Avoid alcohol and pork Jehovah witness ▪ Not accept blood transfusion ▪ Avoid foods prepared with blood Grief, Loss, and Palliative Care – ATI Fundamentals Ch. 36 Advanced Directives ▪ Living Will – document stating clients wishes ▪ Health Care Proxy aka Durable Power of Attorney -makes decision for client on their behalf Types of loss ▪ Necessary loss related to a change that is part of the cycle of life and is anticipated but still cam be intensely felt ▪ Actual loss of a valued person, item, or status ▪ Perceived loss anything client defined as loss but that is not obvious or verifiable to others ▪ Maturational or developmental loss any loss normally expected due to developments of life • Ex: a child leaving for college ▪ Situational loss any anticipated loss caused by external event • Ex: a family loses their home during tornado ▪ Anticipatory loss experienced before loss has happened Kubler-Ross Model of Grief ▪ Denial difficulty believing in an expected or actual loss ▪ Anger directs anger toward self and others ▪ Bargaining negotiates for more time or a cure ▪ Depression overwhelming saddened ▪ Acceptance acknowledges what is happening and plans by moving forward Manifestations of Grief Reactions ▪ Normal grief • Considered “uncomplicated” • Some acceptance should be evident by 6 months • May have somatic complaints: chest pain, palpitations, headaches, change in sleep patterns ▪ Anticipatory grief • “letting go of an object the person before the loss” ▪ Complicated grief • Difficult progression through the expected stages of grief ▪ Disenfranchised grief • Experienced loss that cannot be publicly stated • Ex: suicide or abortion Postmortem Care ▪ Maintain privacy ▪ Remove all tubes (unless organs are to be donated) ▪ Remove personal belongings and give to the family ▪ Cleanse and align the body supine with a pillow under head, arms with palms down outside of the sheet, dentures in place and eyes closed. ▪ Apply fresh linens with absorbent pads ▪ Brush and comb the client’s hair- replace hair pieces if necessary. ▪ Remove excess equipment and supplies and soiled linensfrom room. ▪ Dim the lights to minimize noise and provide a calm environment ▪ Allows family to visit ▪ Put ID tag Hygiene – ATI Fundamentals Ch. 37 Bathing ▪ Assign to AP ▪ Allow rest periods ▪ Partial baths cannot tolerate but cleaning of in uncomfortable areas ▪ Therapeutic baths promote comfort Oral hygiene ▪ Place client head to the side ▪ Use soft toothbrush Foot care ▪ Preventskin breakdown, pain, infection ▪ Caution with diabetic neuropathy Perineal care ▪ Maintain skin integrity and relive discomfort Cultural and social practices Bathing a client with Dementia Oral care for a client who is unconscious ▪ Place client head to the side Foot care for a client who has DM Practice Question: A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client’s head to the side. B. Place two fingers in the client’s mouth to open. C. Brush the client’s teeth once per day. D. inject a mouth rinse into the center of the client’s mouth. Practice Question: A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client’s plan of care? A. Schedule rest periods during morning care. B. Discontinue morning care for 2 days. C. Perform all care as quickly as possible. D. Ask a family member to come in to bathe the client. Rest and Sleep – ATI Fundamentals Ch. 38 Stages of Sleep ▪ Stage 1 NREM • Light sleep; few minutes • Muscle relaxes • Loss of awareness • VS/metabolism decrease • Awakens easily • Feelsrelaxed and drowsy ▪ Stage 2 NREM • Deeper sleep; 10-20 minutes • VS decrease • Requiresstimulation to wake ▪ Stage 3 NREM • Slow wave sleep or delta sleep • VS decrease • More difficult to awake ▪ STAGE 4 REM • Vivid dreaming; 90 minutes and recurring • Longer with each sleep cycle • Avg. length 20 min Sleep duration ▪ Infants and toddlers: 9-15 hours per day ▪ Adolescents: 9-10 hours per day ▪ Adults: 7-8 hours per day Common sleep disorders ▪ Insomnia • Acute – few days due to stressor • Chronic – a month or longer ▪ Sleep apnea • Central- CNS problem • Obstructive-structural ▪ Narcolepsy • Sudden attacks of excessive sleepiness during waking hours • Begin REM sleep within 15 min of going to sleep • Hallucination on onset ▪ Hypersomnolence disorder • Excessive daytime sleepiness lasting @ 3 months Factorsthat can interfere with sleep ▪ Illness ▪ Current life events ▪ Emotionalstress or mental illness ▪ Diet ▪ Exercise ▪ Fatigue ▪ Sleep environment ▪ Medications Client Education ▪ Exercise regularly at least 2 hr before bedtime. ▪ Establish a bedtime routine and a regular sleep pattern. ▪ Arrange the sleep environment for comfort. ▪ Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime. ▪ Limit fluids 2 to 4 hr before bedtime. ▪ Engage in muscle relaxation if anxious orstressed. Practice Question: A nurse is talking with a client about ways to help him sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (select all that apply.) A. practice muscle relaxation techniques. B. exercise each morning. C. take an afternoon nap. D. alter the sleep environment for comfort. E. limit fluid intake at least 2 hr. before bedtime Nutrition and Oral Hydration – ATI Fundamentals Ch. 39 Eating Disorders ▪ Anorexia nervosa significantly low body weight for gender, age, developmental level, and physical health ▪ Bulimia nervosa cycle of binge eating flowed by purging ▪ Binge-eating disorder repeated episodes of binge eating Obesity ▪ BMI of 25 is upper boundary of healthy weight ▪ BMI of 25-25.9 is considered overweight for a adult ▪ BMI of 30 or greater is considered obese Nursing considerations ▪ Record I & O ▪ Weigh client same scale, same time, after voiding ▪ Assess for S/S of poor nutrition ▪ Educate clients on medicationsthat can affect nutritional intake ▪ Assist in preventing aspiration: • Fowlers’ position • Tuck chin when swallowing • Avoid using a straw • Observe for pocketing food in cheeks • Assess for dysphagia- choking, gagging, drooling • Semi-fowlers’ for at least 1 hour after meals • Oral hygiene after meals Therapeutic Diets ▪ Clear liquid clear juices, broth, gelatin ▪ Full liquid purred veggies ▪ Pureed purred meats, fruits, and scrambled eggs ▪ Mechanical soft diced or ground foods ▪ Soft/low residue dairy products, eggs, ripe bananas ▪ High fiber whole grains, raw and dried fruits ▪ Low sodium no added salt or 1-2 g sodium ▪ Low cholesterol no more than 300 mg/day ▪ Diabetic balanced intake of protein, fat, and carbohydrates about 1800 calories ▪ Dysphagia purred foods and thickened liquids ▪ Regular no restrictions Mobility/Immobility – ATI Fundamentals Ch. 40 Maintaining Skin Integrity ASSESSMENT ▪ Observe the skin for breakdown, warmth, and change in color. ▪ Look for pallor or redness in fair-skinned clients, and purple or blue discoloration in dark-skinned clients. ▪ Observe bony prominences. ▪ Check skin turgor. ▪ Use a pressure ulcer risk scale such as Norton or Braden. ▪ Assess at least every 2 hr. ▪ Observe for urinary or bowel incontinence. NURSING INTERVENTIONS ▪ Identify clients at risk for pressure ulcer development. ▪ Position using corrective devicessuch as pillows, foot boots, trochanter rolls, splints, and wedge pillows. ▪ Turn every 1 to 2 hr. and use devicesforsupport or per protocol. ▪ Teach clients who can move independently to turn at least every 15min. ▪ Provide clients who are sitting in a chair with a device to decrease pressure. ▪ Limit sitting in a chair to 1 hr. Instruct clients to shift their weight every 15 min. ▪ Use a therapeutic bed or mattress for clients in bed for an extended time. ▪ Monitor nutritional intake. ▪ Provide skin and perineal care. ▪ Preventing skin breakdown in immobile patients ▪ Assessing skin condition for immobile patients ▪ Evaluating a client use of a walker ▪ Application of anti-embolic stockings ▪ Preventing complications of immobility ▪ Presenting plantar flexion Crutches ▪ Do not alter crutches ▪ Hand grips with elbows flexed at 20-30 degrees ▪ Tripod position (6 inches in front) ▪ 2-3 finger-widths in axilla space • 2-point partial weight bearing on both feet • 3-point bear all weight on 1 foot (unaffected) while using both crutches • 4-point bear weight on both legs, alternate with each crutch ▪ Going upstairs(Ascending) • Move unaffected leg up first moves affected leg and crutches up ▪ Going downstairs (Descending) • Move crutches and affected leg down first moves unaffected leg down Cane ▪ Maintain 2 points ofsupport ▪ Keep cane on stronger side of body ▪ Move cane forward move weaker leg advance stronger leg Walker ▪ Put all 4 points on the floor before to putting weight on hand pieces ▪ Move walker forward affected or weaker foot move unaffected leg Airway Management- ATI Fundamentals Ch. 53 Monitoring O2 Saturation Labs to report Teaching tracheostomy care at home Positioning for postural drainage Nasotracheal suctioning technique Teaching the use of the incentive spirometer Other Skillsto Review Facilitating urinary catheter insertion Maintaining urinary catheter insertion ▪ Promoting voiding in a client postop ▪ Condom catheter NG tube insertion and preparing to administer feeding Verifying NG tube placement Central line dressing change Sterile technique Assisting the client to use a fracture pan Ear irrigation Obtaining a capillary blood glucose Cleaning a wound site Incentive spirometer