ATI
RN MEDSURG ATI Remediation
Polycystic Kidney Disease, AKI and CKD: Clinical Manifestations of Nephrotic Syndrome
o Alteration in glomerular membrane allowing proteins (typically albumin) to pass in the
urine causing decreased serum osmotic pressure
o Findings: weight gain over days/weeks, facial/periorbital edema that decreases
throughout the day, ascites, anorexia, diarrhea, decreased frothy urine and normal BP or
slightly low
Respiratory Failure: Manifestations of ARF
o Findings: Rapid shallow breathing, cyanotic, tachycardia, hypotension, decreased
oxygenation level, wheezing or rales, cardiac arrhythmias, confusion, lethargy, substernal
or suprasternal retraction
o Nursing care: Maintain a patent airway, monitor respiratory status every hour or more as
needed, mechanical ventilation, monitor for pneumothorax if a PEEP is used, obtain
ABGs, continuous ECG monitoring, position, prevent infection, promote nutrition
Hemodialysis and peritoneal dialysis: proper administration of peritoneal dialysis
o Preprocedure: Assess dry weight (obtained when dialysate is drained), serum
electrolytes, creatinine, BUN, and blood glucose.
o Determine the client's ability to perform self-peritoneal dialysis and follow sterile
technique.
Level of alertness
Past experience with dialysis
Understanding of procedure
o Intraprocedure: Monitor the client's vital signs frequently during initial dialysis of clients
in a hospital setting.
Monitor the client's serum glucose level (dialysate contains glucose, a
hypertonic solution).
Record the amount of inflow compared to outflow of dialysate.
Monitor the color (clear, light yellow is expected) and amount (expected to
equal or exceed amount of dialysate inflow) of outflow.
Monitor for signs of infection (fever; bloody, cloudy, or frothy dialysate return;
drainage at access site) and for complications (respiratory distress, abdominal
pain, insufficient outflow, discolored outflow).
Check the access site dressing for wetness (risk of dialysate leakage) and exit site
infections.
Warm the dialysate prior to instilling. Avoid the use of microwaves, which cause
uneven heating.
Follow prescribed times for infusion, dwell, and outflow.
Maintain surgical asepsis of the catheter insertion site and when accessing the
catheter.
Keep the outflow bag lower than the client's abdomen (drain by gravity, prevent
reflux).
Reposition the client if inflow or outflow is inadequate.
Carefully milk peritoneal dialysis catheter if fibrin clot has formed.
This study source was downloaded by 100000830772748 from CourseHero.com on 03-12-2022 09:00:24 GMT -06:00
https://www.coursehero.com/file/45949646/RN-MEDSURG-ATI-Remediationdocx/
, Provide emotional support to the client and family.
o Post procedure: Monitor weight, serum electrolytes, creatinine, BUN, and blood glucose.
Cancer Treatment Options: Teaching About Skin Care Following Radiation Treatment
o Gently wash the skin over the radiated area with mild soap and water; dry area
thoroughly using patting motions.
o Do not remove or wash radiation tattoos
o Do not apply powders, ointments, lotions, deodorants or perfumes to irritated skin.
o Wear soft clothing; avoid tight or constricting clothes
o Do not expose irritated skin to sun or a heat source
Burns: Assessment Findings of Early Phase of Injury
o Emergent (resuscitative phase)
Begins with injury and continues for 24 to 48 hours
Priority: securing airway, supporting circulation and organ perfusion by fluid
replacement, managing pain, preventing infection through wound care,
maintaining body temperature and providing emotional support.
Intravenous Therapy: Priority Action for Central Venous Device Complication
o Infiltration or extravasation : pallor, local swelling, decrease skin temperature around
site, damp dressing, slowed rate of infusion
Stop infusion and remove catheter
Elevate extremity
Encourage rapid ROM
Apply warm or cold compress
Restart infusion proximal to the site or in another extremity
o Thrombophlebitis: edema, throbbing, burning pain, increased skin temperature,
erythema, red line up am with palpable ban at vein site
d/c infusion and remove catheter
elevate extremity
apply warm compress 3 to 4 times
restart infusion in different site
obtain specimen for culture and prepare the catheter for culture if drainage is
present
o hematoma: ecchymosis at the site
do not apply alcohol
apply pressure after IV catheter removal
use warm compress and elevate after bleeding stops
o fluid overload: distended neck veins, increased BP, tachycardia, SOB, crackles in lungs
stop infusion
raise HOB
measure vitals and O2 sat
adjust the rate after correcting FVO
administer diuretics
o cellulitis: pain, warmth, edema, induration, red streaking, fever, chills, malaise
d/c infusion and remove catheter
Elevate extremity
This study source was downloaded by 100000830772748 from CourseHero.com on 03-12-2022 09:00:24 GMT -06:00
https://www.coursehero.com/file/45949646/RN-MEDSURG-ATI-Remediationdocx/
RN MEDSURG ATI Remediation
Polycystic Kidney Disease, AKI and CKD: Clinical Manifestations of Nephrotic Syndrome
o Alteration in glomerular membrane allowing proteins (typically albumin) to pass in the
urine causing decreased serum osmotic pressure
o Findings: weight gain over days/weeks, facial/periorbital edema that decreases
throughout the day, ascites, anorexia, diarrhea, decreased frothy urine and normal BP or
slightly low
Respiratory Failure: Manifestations of ARF
o Findings: Rapid shallow breathing, cyanotic, tachycardia, hypotension, decreased
oxygenation level, wheezing or rales, cardiac arrhythmias, confusion, lethargy, substernal
or suprasternal retraction
o Nursing care: Maintain a patent airway, monitor respiratory status every hour or more as
needed, mechanical ventilation, monitor for pneumothorax if a PEEP is used, obtain
ABGs, continuous ECG monitoring, position, prevent infection, promote nutrition
Hemodialysis and peritoneal dialysis: proper administration of peritoneal dialysis
o Preprocedure: Assess dry weight (obtained when dialysate is drained), serum
electrolytes, creatinine, BUN, and blood glucose.
o Determine the client's ability to perform self-peritoneal dialysis and follow sterile
technique.
Level of alertness
Past experience with dialysis
Understanding of procedure
o Intraprocedure: Monitor the client's vital signs frequently during initial dialysis of clients
in a hospital setting.
Monitor the client's serum glucose level (dialysate contains glucose, a
hypertonic solution).
Record the amount of inflow compared to outflow of dialysate.
Monitor the color (clear, light yellow is expected) and amount (expected to
equal or exceed amount of dialysate inflow) of outflow.
Monitor for signs of infection (fever; bloody, cloudy, or frothy dialysate return;
drainage at access site) and for complications (respiratory distress, abdominal
pain, insufficient outflow, discolored outflow).
Check the access site dressing for wetness (risk of dialysate leakage) and exit site
infections.
Warm the dialysate prior to instilling. Avoid the use of microwaves, which cause
uneven heating.
Follow prescribed times for infusion, dwell, and outflow.
Maintain surgical asepsis of the catheter insertion site and when accessing the
catheter.
Keep the outflow bag lower than the client's abdomen (drain by gravity, prevent
reflux).
Reposition the client if inflow or outflow is inadequate.
Carefully milk peritoneal dialysis catheter if fibrin clot has formed.
This study source was downloaded by 100000830772748 from CourseHero.com on 03-12-2022 09:00:24 GMT -06:00
https://www.coursehero.com/file/45949646/RN-MEDSURG-ATI-Remediationdocx/
, Provide emotional support to the client and family.
o Post procedure: Monitor weight, serum electrolytes, creatinine, BUN, and blood glucose.
Cancer Treatment Options: Teaching About Skin Care Following Radiation Treatment
o Gently wash the skin over the radiated area with mild soap and water; dry area
thoroughly using patting motions.
o Do not remove or wash radiation tattoos
o Do not apply powders, ointments, lotions, deodorants or perfumes to irritated skin.
o Wear soft clothing; avoid tight or constricting clothes
o Do not expose irritated skin to sun or a heat source
Burns: Assessment Findings of Early Phase of Injury
o Emergent (resuscitative phase)
Begins with injury and continues for 24 to 48 hours
Priority: securing airway, supporting circulation and organ perfusion by fluid
replacement, managing pain, preventing infection through wound care,
maintaining body temperature and providing emotional support.
Intravenous Therapy: Priority Action for Central Venous Device Complication
o Infiltration or extravasation : pallor, local swelling, decrease skin temperature around
site, damp dressing, slowed rate of infusion
Stop infusion and remove catheter
Elevate extremity
Encourage rapid ROM
Apply warm or cold compress
Restart infusion proximal to the site or in another extremity
o Thrombophlebitis: edema, throbbing, burning pain, increased skin temperature,
erythema, red line up am with palpable ban at vein site
d/c infusion and remove catheter
elevate extremity
apply warm compress 3 to 4 times
restart infusion in different site
obtain specimen for culture and prepare the catheter for culture if drainage is
present
o hematoma: ecchymosis at the site
do not apply alcohol
apply pressure after IV catheter removal
use warm compress and elevate after bleeding stops
o fluid overload: distended neck veins, increased BP, tachycardia, SOB, crackles in lungs
stop infusion
raise HOB
measure vitals and O2 sat
adjust the rate after correcting FVO
administer diuretics
o cellulitis: pain, warmth, edema, induration, red streaking, fever, chills, malaise
d/c infusion and remove catheter
Elevate extremity
This study source was downloaded by 100000830772748 from CourseHero.com on 03-12-2022 09:00:24 GMT -06:00
https://www.coursehero.com/file/45949646/RN-MEDSURG-ATI-Remediationdocx/
