ADULT ATI STUDY GUIDE

Health/Wellness Assessment 1. Physical Assessment 2. Evaluating health perceptions 3. Identifying risks for health/wellness 4. Identifying access to health care 2. Primary surveys rapid assessment of life-threatening conditions 3. ABCDE Airway/cervical spine Breathing Circulation Disability Exposure 4. With hypoxia, brain injury or death can occur within ____________ if airway is not patent. 3-5 minutes 5. Airway/cervical spine -Inspect for blood, broken teeth, vomit, foreign materials and clear with suction or finger sweep if clearly visible -If unresponsive without trauma= head tilt/chin lift maneuver -In unresponsive with trauma=modified jaw thrust maneuver -Bag valve with 100% oxygen for clients who need support or a nonrebreather mask with 100% oxygen for clients who breathe spontaneously 6. Head tilt/chin lift maneuver -position self at head of client -one hand on forehead, other on chin -tilt head while lifting chin upward and forward 7. Modified jaw thrust maneuver -position self as head of client -place both hands on either side of head -locate connection between maxilla and mandible 1 / 50 Adult ATI Study Guide -lift jaw superiorly while maintaining alignment of cervical spine 8. Breathing -auscultate breath sounds -observe chest expansion/respiratory effort -note rate/depth of respirations -identify chest trauma -assess tracheal position -assess for jugular vein distention 9. Circulation -HR, BP, peripheral pulses, and cap. refill -Isotonic IV fluids: LR or 0.9% sodium chloride -Blood products if needed -Shock can develop: oxygen, apply pressure on obvious bleeding, elevate LE, IV fluids/blood products, monitor VS, remain with client 10. Disability -determine LOC -AVPU mnemonic and Glasgow Coma Scale 11. AVPU mneumonic ALERT response to VOICE response to PAIN UNRESPONSIVE 12. Glasgow Coma Scale -Eye Opening (E): 4=spontaneously 3=to sound 2=to