client interviewing considerations - Quiet room, explain plan, allow older adults more time to respond, use approved interpreter, Breast self-exam - Both Male and female, In front of mirror, Arms up, self aware of own breast tissue, , Weber Test - Place Fork on top of the head, ask clinet if they hear the vibration on both ears, or one ear, Breast examination techniques - Client lay arms above head, use pad of three middle fingers, circular, vertical or wedge motion, from sternum to axillary , Age related cognitive changes - Delirium (acute, temp), dementia(progressive, permanent), depression, Age related skin changes - thin skin, thin hair, loss of subcutaneous tissue, thickened nails, Seizure precaution - Highest priority- padding bed rails, airway equipment, bed alarm, Home oxygen safety - check equipment daily, upright, no smoking sign, check , electrical equipment well repair and grounded, Client belonging disposal-Safe - Keep jewels, money, precious items and document, Client belonging disposal-bedside - Glasses, cane, cell phone, dentures, cloths. and document, Client belonging disposal-Home/pharmacy - Home medications not to be left with client and document, Commonly used abbreviations - always use abbreviations approved by your facility-BID, TID,QID PRN, STAT,Ad lib, PM, AM, AC,Q6H,, Telephone orders - IN emergencies: Have second nurse listen, Repeat back, Spell out words, Question any prescription that seems off, make sure provider signs order asap (24hrs), Incident reports - NEVER document in client medical records examples(falls, injury, medication errors, omission of prescription, needlesticks), Hygiene for client with delirium - They may refuse hygiene and become agitated, offering frequent break may distract the client, thus able to complete the hygiene, Protective isolation - For immunocompromised- client on chemo, transplant- no live plants, no uncooked food, wear masks, hand hygiene, Droplet isolations - For influenza, pertussis, diphtheria, -mask, gown, goggles , Informed consent - Nurse witness, Ensure client questions are answered to satisfaction, support client decision making. Do not advice, Advocacy - Act on behalf of client, support client autonomy, call provider for information beyond scope of practice e.g explaining procedure., Veracity - Be truthful to client of what one does not know and promise to inquire and get back to client. e.g. about procedure or critical lab results.,
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ATI Proctor Concepts Mastery 1
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Olengiges
Higher Education
Nursing
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