ATI Comprehensive
REMINDER - ANSABCS
Assess first!!
Least invasive first!!
Protect your self and the affected person first!!
Urine Specific Gravity - ANS1.0.5-1.030
If incr *dehydration*
Sodium Level - ANS136-one hundred forty five
hypotonic dehydration : low
Magnesium Level - ANS1.Five-2.5
hyper : dysrhythmias
hypo : weak muscle tissue and absent DTR
foods excessive in magazine : legumes, nuts, and green greens
Calcium Level - ANS9-10.Five mg/dL
Platelets - ANS150,000-400,000
WBCS - ANS5,000-10,000
Defense Mechanisms - ANSDisplacement - when a patron transfers feelings of a particular
scenario to any other nonthreatening scenario
Regression - occurs whilst a purchaser reverts to a childlike pattern of behavior that might
have been exhibited previously
Suppression - denial of a demanding feeling or scenario
Sublimation - exhibiting behaviors regular with sublimation, that's displayed whilst a
consumer substitutes socially unacceptable conduct for proper conduct
*"My boss accused me of stealing yesterday. I changed into so irritated I went to the gym
and worked out"*
,Denial - specializing in disbelieving the news
This simply is not feasible
Rationalization - By justifying the adolescent's diagnosis by way of attempting to find a more
individually suited reason for the impending loss
*Maybe this is better for our child because we dont need any suffering thru chemo*
Suppression - "Let's move on that circle of relatives excursion we've got got deliberate. We
will address this when we return."
Displacement - "Our infant would not have this terminal analysis if the health practitioner had
diagnosed the most cancers sooner."
Benzodiazepines - ANSdrugs that lower tension and reduce pressure
Examples : Alprazolam
*Initiate fall precautions for this consumer*
Common adverse results : ortho hypo, dizziness, confusion, lethargy, constipation (incr
fluids)
Overdose : *give flumazenil*
guide customers RR with a bag mask
How does a nurse verify knowledgeable consent? - ANSThe purchaser is able to as it should
be describe the imminent manner
Turning a customer - ANSUse a draw sheet
Raise the mattress to running peak
Place a pillow under the arm of the opposite side the pt is being became
Lower one side rail (opposite side desires to be up)
Dietary Teaching for a 6 Month Old - ANSIntroduce new meals separately over five-7 days
Infant element sizes are 1 Tbsp consistent with year of age. For toddlers below 12 month
half of Tbsp or 3/four a Tbsp are suitable
100% fruit juice, no longer to exceed a hundred and twenty-a hundred and eighty mL (four-6
oz.) according to day
Do now not provide entire milk, majority of energy should come from breast milk or
formulation
Airborne Precautions - ANSMy chook hez tb
,- measles
- chickenpox (varicella)
- Herpes zoster/shingles
- TB
non-public room, neg strain with 6-12 air exchanges/hr masks & respirator N95 for TB
Droplet Precautions - ANSspiderman!
Sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
Private room and mask
Contact Precautions - ANSMRS WHISE
Multidrug-resistant organisms
RSV,
Shigella,
Wound infections,
Herpes simplex,
Impetigo,
Scabies,
Enteric sicknesses resulting from micro-organisms (C diff),
defend traffic & caregivers when three feet of the pt.
Gloves and robes worn through the caregivers and site visitors
Disposal of infectious dressing cloth into a single, nonporous bag with out touching the
outdoor of the bag
PMGG= Private room/ percentage same infection, mask, gown and gloves
Boggy Uterus - ANSFIRST ACTION : Massage the uterus to expel clots
Admin 02, oxytocin, CBC
Car Seat Safety Guidelines - ANSSecure the retainer clip at the level of your babys armpits
, You can region a blanket over the newborn once cozy within the seat
Newborn should continue to be rear-facing within the back seat of the vehicle till the age of
two or till achieving the age and weight the auto seat manufacturer recommends. In a
collision, this role decreases the pressure at the new child's head and neck
Place seat at a forty five degree attitude
"Im involved about being discharged due to the fact I stay alone, and my coverage would not
cowl ostomy elements" - ANSRefer the customer to a network based social employee
Initiate a domestic health consult
Give customer info about neighborhood aid businesses
The steps of a root purpose analysis are: - ANSCollect all data surrounding occasion,
thoroughly analyze information, pick out in all likelihood causes, define corrective moves
Responsibility of the nurse concerning residing wills - ANSThe nurse's duty is to offer the
consumer with statistics approximately precise instructions for addressing clinical remedy in
a residing will. The nurse need to help the customer whilst they are capable of make choices
for themself by means of providing data approximately what end-of-lifestyles options to
report.
Delirium - ANSan acutely disturbed country of mind that occurs in fever, intoxication, and
different issues
*Rapid, inappropriate, incoherent, rambling speech styles*
Paranoid Personality Disorder - ANStype of character ailment characterised through
excessive suspiciousness or distrust of others
*Projecting Blame*
Dependent Personality Disorder - ANSA persona disease characterized with the aid of a
sample of clinging and obedience, fear of separation, and an ongoing want to be sorted.
*Excessive clinging*
Schizotypal Personality Disorder - ANSa mental sickness characterized through numerous
traits that reason troubles interpersonally, along with constricted or irrelevant affect; magical
or paranoid questioning; and unusual ideals, speech, conduct, appearance, and perceptions
*Social awkwardness*
Postpartum Period - ANSRequires instant intervention by means of the nurse : boggy uterus
Cramping is anticipated, to ease the cramping observe warmth or lie prone