Summary RN ATI Capstone Proctored Comprehensive Assessment

Cancer disorders: Planning discharge teaching for a client who is postoperative following a modified radical mastectomy-AMS Chapter 92 • Modified radical mastectomy: lymph nodes removed • Nursing Actions: Have the client sit with the head of the bed elevated 30° when awake and support her arm on a pillow. Lying on the unaffected side can relieve pain. Have the client wear a sling while ambulating (to support arm). Avoid administering injections, taking blood pressure, or obtaining blood from the client’s affected arm. Please a sign above the client’s bed regarding these precautions. Emphasize the importance of well-fitted breast prosthesis for a client who had a mastectomy. Provide emotional support to the client and her family Encourage the client to express feelings related to perception of sexuality and body image. • Client education: Teach the client how to care for her incision and drainage tubes (drains are usually left in for 1 to 3 weeks) Advise the client to avoid placing her arm in a dependent position. This position will interfere with wound healing. Encourage early arm and hand exercises (squeezing a rubber ball, elbow flexion and extension), and hand-wall climbing to prevent lymphedema and to regain full range of motion Teach the client not to wear constrictive clothing and to avoid cuts and injuries on the affected arm. Continuity of care: Interventions promoting independence- CH Chapter 7 • Community health nurses play a large role in maintaining continuity of care for clients as they transition from acute to outpatient settings and promote independence. • Group partnering to elicit needed change in the community are more powerful than a nurse working independently with an individual. • Nursing interventions: Initiate necessary consults, or notify the provider of the client’s needs so the provider can initiate a consult. Seek expertise from health care professionals representing a variety of disciplines. The nurse educates clients about community resources and self-care measures Coordinate all health care services and resources. Crisis management: Crisis intervention for intimate partner-MH Chapter 29 • A crisis is an acute, time-limited (usually lasting 4 to 6 weeks) event during which a client experiences an emotional response that cannot be managed with the client’s normal coping mechanisms. • Maturational/internal crisis: Achieving new developmental stages, which requires learning additional coping mechanism • Crisis intervention is designed to provide rapid assistance for individuals or groups who have an urgent need Promote a sense of safety by assessing the client’s potential for suicide or homicide Identifying the current problem and directing interventions for resolution Helping the client to set realistic, attainable goals Strategies to decrease anxiety Critical Incident Stress Debriefing is a group approach that can be used with a group of people who have been exposed to a crisis situation Facility protocols: Discovering a medication error- Leadership Chapter 5 • Incident reports are records of unexpected or unusual incidents that affected a client, employee, volunteer, or visitor in a health care facility. In most states, as long as proper safeguards are employed, incident reports cannot be subpoenaed by clients or used as evidence in lawsuits. • Medication errors, procedures/treatment errors, equipment-related injuries/errors, needle stick injuries, client falls/injuries, visitor/volunteer injuries, threat made to client or staff, loss of property. • In the event of an incident that involves a client, employee, volunteer, or visitor, the nurse’s priority is to assess the individual for injuries and institute any immediate care measures necessary to decrease further injury. If the incident was client-related, notify the provider and implement additional tests or treatment as prescribed. ...................................................................................................CONTINUE.