ATI capstone Fundamentals Study Guide (2023) (Graded A+)

ATI capstone Fundamentals Study Guide (2023) (Graded A+) FUNDAMENTALS Laboratory Values Albumin: 3.5-5 Sodium 136-145 mEq/L Potassium 3.5-5.0 mEq/L Total Calcium 9.0-10.5 mg/dL Magnesium 1.3-2.1 mg/dL Phosphorus 3.0 –4.5 mg/dL BUN 10-20 mg/dL Creatinine 0.6 – 1.2mg/dL males, 0.5 – 1.1 mg/dL females Glucose 70 -105 mg/dL HgbA1c 6.5% WBC 5,000-10,000/mm3 RBC Men 4.7-6.1 million/mm3, Women 4.2-5.4 million/mm3 Hemoglobin Men 14-18g/100 mL, Women 12-16 g/100 mL Hematocrit Men 42-52%, Women 37-47% Platelet 150,000-400,000/mm3 pH 7.35-7.45 pC02 35 to45 mm Hg p02 80-100 mmHg HCO3 21-26mmol/L Normal PT = 11-12.5 sec, Normal INR = 0.7-1.8 (Therapeutic INR 2-3) Normal PTT = 30-40 sec (Therapeutic PTT 1.5 – 2 x normal or control values) Digoxin 0.5 to 2.0ng/mL Lithium 0.8 to 1.4 mEq/L Dilantin 10-20 mcg/mL Theophylline 10 to 20mcg/mL Urine specific gravity: 1.010-1.03 Latex Allergies: Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well. Order of assessment: I-inspection P-palpation P-percussion A-auscultation Except with abdomen it is IAPP-inspect, auscultate, percuss and palpate. Cane walking: C-cane O-opposite A-affected L-leg Proper use: ensure the cane has a rubber cap hold the cane on the stronger side flex the elbow slightly when using the cane use a quad cane for increased support Cane instructions - Always maintain 2 points of support on the ground - Keep the cane on the stronger side - Support body weight on both legs - Move the cane forward 6-10 in - Move the weaker leg forward toward the cane - finally advance stronger leg past the cane Crutch walking: Remember the phase “step up” when picturing a person going up stairs with crutches. The good leg goes up first followed by the crutches and the bad leg. The opposite happens going down the stairs….OR “up to heaven…down to hell” Delegation: RNs DO NOT delegate what they can EAT - evaluate, assess, teach Dysrhythmia What indicates ineffective cardiac contractions: comparing apical and radial pulses at the same time can help detect pulse deficit* indicating ineffective cardiac contraction and presence of cardiac dysrhythmias Measure apical and radial simultaneously to determine if there is a deficit Helpful tool to remember Isolation Precautions: AIRBORNE: "My Chicken Hez TB" -Measles -Chicken pox -Herpes zoster -TB Management: neg. pressure room, private room, mask, n-95 for TB. DROPLET: "SPIDERMAn" -Sepsis -Scarlet Fever -Strep -Pertussis -Pneumonia -Parvovirus -Influenza -Diphtheria -Epiglottitis -Rubella -Mumps -Adenovirus Management: Private room/mask CONTACT: "MRS WEE" -MRSA -VRSA -RSV -Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies, and staphylococcus) -Wound infections -Enteric infections (Clostridium difficile) -Eye infections (conjunctivitis) Management: gown, gloves, goggles, private room BMI’S Underweight- less than 18.5 Healthy weight is indicates by a BMI of 18.5-24.9. Overweight is indicated by a BMI of 25-29.9. Obesity is indicated by a BMI greater than or equal to 30. NG tube placement -pH of aspirated gastric fluid Indication of good placement includes pH b/w 0-4 Glasgow Coma Scale/Scoring Mediterranean diet for hypertension Following the Mediterranean diet, red meat should be limited to two times monthly. The client should have dairy in moderate portions daily to weekly. The intake of fish and seafood is at least two times per week. Drinking wine is acceptable in moderation. Low fat diet for cholecystitis Roast turkey, rice pilaf, green beans- Roast turkey is a low-fat protein option that would be an excellent choice for a low-fat diet. High calorie-low protein diet for encephalopathy 2ndry to liver failure Chicken breast, mashed potatoes, spinach. Heart failure dietary recommendations It is encouraged to stop smoking, reduce sodium intake, monitor fluid intake, restricting intake to 2 L per day. It is also encouraged to increase protein intake to 1.12 g/kg and consume small, frequent meals that are soft, easy-to-chew foods. There are no recommendations on calcium intake associated with heart failure. Cystocele When the wall between the bladder and the vagina weakens Use pelvic floor exercises (Kegel exercises*) to strengthen muscle which results in reduction or prevention of pelvic prolapse and stress urinary incontinence Cholecystitis Inflammation of the gallbladder, a small, digestive organ beneath the liver. Cholecystitis is often caused by stones that block the tube leading from the gallbladder to the small intestine. Severe pain in the upper right belly and bloating are symptoms. Treatment includes a hospital stay and surgical removal. Delirium- how to reduce falls Hourly rounding by the nurse - hourly rounding by the nurse significantly reduces the occurrence of client falls as well as reducing call light usage and increasing client satisfaction. Demonstrating how to use a call light does not decrease risk of falls for these patients* Furosemide- strong *potassium-wasting* diuretic (water pill) Used to treat fluid retention- can cause dehydration & electrolyte imbalance Client prescribed potassium-wasting diuretics should be encouraged to eat foods high in potassium. Oranges*, dried fruits, tomatoes, avocados, dried peas, meats, broccoli, and bananas are all good sources of potassium. Table salt is not a good source of potassium. Measures that promote sleep Limit alcohol and nicotine prior to bedtime - Limit alcohol, caffeine (stimulant), and nicotine (stimulant) at least 4 hr before bedtime. Exercise regularly; limit exercise at least 2 hr before bedtime. (Do not take an evening walk before bedtime) Limit fluids 2 to 4 hr before bedtime. (Do not consume a warm drink at bedtime) Pressure ulcer staging Stage 1: Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple. Stage 2: Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. Stage 3: Full-thickness tissue loss with damage to or necrosis of subQ tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. Stage 4: Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets or infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material). Chemo pt experiencing neutropenia Avoid crowded events* Clients with neutropenia do not have enough circulating neutrophils to fight off infections. This client should avoid crowds to prevent exposure to colds/viruses. The client should monitor their temperature daily to track trends that could indicate infection. Gardening would expose the client to microbes in the soil that could cause illness. Fresh fruits and vegetables are covered with microbes that while not normally harmful to nonimmunocompromised clients can cause infection in clients with myelosuppression. These foods should be cooked before the client ingests them. Hearing aid teaching points Use mild soap and water to clean the ear mold. * - To clean the ear mold, use mild soap and water while keeping the hearing aid dry. Use the lowest setting that allows hearing without feedback. When the hearing aid is not in use, turn it off or remove the batteries to conserve battery power (not just during sleep hours) Keep replacement batteries on hand. Parkinson’s manifestations Bradykinesia- slow movement or difficulty moving Oily skin NOT pruritis Ortho hypo Uncontrolled drooling NOT xerostomia Celiac Disease – gluten free diet NO: Tortillas, wheat, barley, rye, malt, brewer’s yeast YES: Corn bread, mashed potatoes, lentils, rice, cheese, butter, milk, grilled meat/fish, gluten free flours like corn, soy, rice & potato flour Signs of dehydration Fever (102 F) Elevated Urine specific gravity (1.010-1.025) Elevated hematocrit (37-64%) Elevated BUN Radiation – how to treat dry, red, scaling skin Apply px lotion to the area* - Hydrating lotions are commonly prescribed to treat irradiated areas. Antimicrobial soaps can be harsh and further traumatize new epidermal cells. The client should avoid applying other lotions not prescribed by the radiologist to affected areas. Clients receiving radiation therapy should avoid exposing irradiated areas to sun. Moist heat should be avoided over irradiated areas. Heat/cold therapies – risk for injury from therapy? The nurse should use extreme caution with clients who are very young, an older adult, fair-skinned, impaired cognition, and have comorbidities because they are at higher risk for fragile skin. *attorney not needed to sign off on adv. Directives Living will: a legal document that specifically outlines a client wishes regarding life-sustaining treatment. DNR order: written by the provider when the client requests not the be resuscitated in the event of cardiac arrest. Informed consent: a consent to surgery or a procedure and is obtained after a client received complete disclosure of all pertinent information regarding the surgery or procedure to be performed. A durable power of attorney for health care: a legal document that designates another person to make health care decisions for the client when the client becomes unable to make decisions independently.