ATI Comprehensive Predictor

ATI Comprehensive Predictor Do not delegate [ANS] - What you can *EAT* *E*-evaluate *A*-assess * T-*teach Addison's & Cushings [ANS] - Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia Better peripheral perfusion? [ANS] - Elevate veins, D-Angle Arteries APGAR [ANS] - Appearance (all pink, pink and blue, blue (pale) Pulse (100, 100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) Airborne precautions [ANS] - MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB Airborne precautions protective equip [ANS] - private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB Droplet precautions [ANS] - spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask) Contact precaution [ANS] - MRS WHISE protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves Skin infection- *VCHIPS* [ANS] - Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies Air or Pulmonary Embolism [ANS] - S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.) Woman in labor (un-reassuring FHR) [ANS] - (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! Tube feeding with decreased LOC [ANS] - Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) LOC [ANS] - Level of Consciousness After lumbar puncture and oil based myelogram [ANS] - pt is flat SUPINE (prevent headache and leaking of CSF) Pt with heat stroke [ANS] - flat with legs elevated during Continuous Bladder Irrigation (CBI) [ANS] - catheter is taped to the thigh. leg must be kept straight. After Myringotomy [ANS] - position on the side of AFFECTED ear, allows drainage. Myringotomy [ANS] - surgical incision into the eardrum, to relieve pressure or drain fluid. After Cateract surgery [ANS] - pt sleep on UNAFFECTED side with a night shield for *1-4 weeks* after Thyroidectomy [ANS] - low or semi-fowler's position, support head, neck and shoulders. Infant with Spina Bifida [ANS] - Prone so that sac does not rupture Buck's Traction (skin) [ANS] - elevate foot of bed for counter traction After total hip replacement [ANS] - don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows. Prolapsed cord [ANS] - Knee to chest or Trendelenburg oxygen 8 to 10 L Cleft Lip [ANS] - position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. To prevent dumping syndrome [ANS] - (post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals. AKA (above knee amputation) [ANS] - elevate for first 24 hours on pillow. position prone daily to maintain hip extension. BKA (below knee amputation) [ANS] - foot of bed elevated for first 24 hours. position prone to provide hip extension. detached retina [ANS] - area of detachment should be in the dependent position dependent position [ANS] - supported administration of enema [ANS] - pt should be left side lying (Sim's) with knee flexed. supratentorial [ANS] - (incision behind hairline on forhead) e After supratentorial surgery [ANS] - elevate HOB 30-40 degrees HOB [ANS] - head of bed infratentorial [ANS] - (incision at the nape of neck) After infratentorial surgery [ANS] - position pt flat and lateral on either side. During internal radiation [ANS] - on bed rest while implant in place Autonomic Dysreflexia/Hyperreflexia [ANS] - S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! Shock [ANS] - bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) Head Injury [ANS] - elevate HOB 30 degrees to decrease ICP Peritoneal Dialysis (when outflow is inadequate) [ANS] - turn pt from side to side BEFORE checking for kinks in tubing Lumbar Puncture [ANS] - After the procedure, the pt should be supine for 4-12 hours as prescribed. Myesthenia Gravis [ANS] - worsens with exercise and improves with rest Myesthenia Gravis [ANS] - a positive reaction to Tensilon---will improve symptoms Cholinergic Crisis [ANS] - Caused by excessive medication ---stop giving Tensilon...will make it worse. Liver biopsy (prior) [ANS] - must have lab results for prothrombin time Myxedema/ hypothyroidism [ANS] - slowed physical and mental function, sensitivity to cold, dry skin and hair. Grave's Disease/ hyperthyroidism [ANS] - accelerated physical and mental function. Sensitivity to heat. Fine/soft hair. Thyroid storm [ANS] - increased temp, pulse and HTN Post-Thyroidectomy [ANS] - semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside Hypo-parathyroid [ANS] - CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet Hyper-parathyroid [ANS] - fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet Hypovolemia [ANS] - increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity 1.030 Hypervolemia [ANS] - bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity 1.010. semi fowler's Diabetes insipidus (decreased ADH) [ANS] - excessive urine output and thirst, dehydration, weakness, administer Pitressin SIADH (increased ADH) [ANS] - change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics hypokalemia [ANS] - muscle weakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery) Hyperkalemia [ANS] - MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes Hyponatremia [ANS] - nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids Hypernatremia [ANS] - increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution. Hypocalcemia [ANS] - CATS Convulsions, Arrythmias, Tetany, spasms and stridor Hypercalcemia [ANS] - muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency! Hypo Mg [ANS] - Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity) Hyper Mg [ANS] - depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY Addison's [ANS] - Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress. Cushings [ANS] - Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump Addesonian crisis [ANS] - N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Pheochromocytoma [ANS] - hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor) Tetrology of Fallot [ANS] - DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) Autonomic Dysreflexia [ANS] - (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) FHR patterns for OB [ANS] - Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill what to check with pregnancy [ANS] - Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. Position of the baby by fetal heart sounds [ANS] - Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis. Ventilatory alarms [ANS] - HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc ICP and Shock [ANS] - ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp Cor pumonae [ANS] - Right sided heart failure caused by left ventricular failure (edema, jug