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ATI RN COMPREHENSIVE EXIT EXAM

Terms in this set (1858)

End Stage Renal Disease (ESRD):
ESRD, or chronic renal failure, occurs when the glomerular filtration rate (GFR) is less than 25 mL/min, the serum creatinine level steadily rises, or dialysis or transplantation is required.

The goal of nutritional therapy is to maintain appropriate fluid status, blood pressure, and blood chemistries.

A high-protein, low-phosphorus, low-potassium, low-sodium, fluid restricted diet is recommended.

Calcium and vitamin D are nutrients of concern.

Protein needs increase once dialysis is begun because protein and amino acids are lost in the dialysate.

Fifty percent of protein intake should come from biologic sources (eggs, milk, meat, fish, poultry, soy).

Adequate calories (35 cal/kg of body weight) should be consumed to maintain body protein stores.

Phosphorus must be restricted.

The high protein requirement leads to an increase in phosphorus intake.

Phosphate binders must be taken with all meals and snacks.

Vitamin D deficiency occurs because the kidneys are unable to convert it to its active form.

This alters the metabolism of calcium, phosphorus, and magnesium and leads to hyperphosphatemia, hypocalcemia, and hypermagnesemia.

Calcium supplements will likely be required because foods high in phosphorus (which are restricted) are also high in calcium.

Potassium intake is dependent upon the client's laboratory values, which should be closely monitored.

Sodium and fluid allowances are determined by blood pressure, weight, serum electrolyte levels, and urine output.

Achieving a well-balanced diet based on the above guidelines is a difficult task. The National Renal Diet provides clients with a list of appropriate food choices.
Prioritization includes clinical care coordination such as clinical decision making, priority setting, organizational skills, use of resources, time management, and evaluation of care.

Clinical decisions are made by completing a thorough assessment which will help you make good judgments later when you see a changing clinical condition. A poor initial assessment can lead to missed findings later on.

Priority setting refers to addressing problems and prioritizing care. It is critical for efficient care. The RN uses his/her knowledge of pathophysiology when prioritizing interventions with multiple clients.

Orders of prioritization:

1. Treat first any immediate threats to a patient's survival or safety.

Ex. obstructed airway, loss of consciousness, psychological episode or anxiety attack.

ABC's.

2. Next, treat actual problems. Ex. nausea, full bowel or bladder, comfort measures.

3. Then, treat relatively urgent actual or potential problems that the patient or family does not recognize. Ex. Monitoring for post-op complications, anticipating teaching needs of a patient that may be unaware of side effects of meds.

4. Lastly, treat actual or potential problems where help may be needed in the future.

Ex Teaching for self-care in the home.

Here are some great principles to help you as you prioritize:

Systemic before local

Acute before chronic

Actual before potential

Listen don't assume

Recognize first then apply clinical knowledge

Maslow's Hierarchy of Needs:

Prioritize according to Maslow with physiological and safety issues before psychological esteem issues.
Admittance of a pregnant client to a medical-surgical unit:

You may have a pregnant client admitted with a diagnosis unrelated to her pregnancy and, therefore, she may be admitted to a general medical-surgical floor. A mnemonic to assist you in performing important assessment elements for these clients is FETUS.



* F: Document fetal heart tones every shift. To assess fetal heart tones, use a handheld Doppler ultrasound and place it in an area corresponding to uterine height. For example, for a client who's less than 20 weeks' pregnant, the most likely area to find fetal heart tones is at the pubic hairline or the symphysis pubis. For a client whose pregnancy is more advanced, such as at 24 weeks, the fetal heart rate can most probably be heard midline between the symphysis pubis and the umbilicus. As the pregnancy advances in weeks, fetal heart tones can be heard closer to and possibly above the umbilicus.



* E: Provide emotional support. Pregnant women who are experiencing unexpected medical conditions are at a high level of anxiety related to how the current medical problem may affect the fetus. You should take extra care to alleviate and reduce your client's anxiety by explaining all medications and treatments. Additionally, be prepared to listen for fetal heart tones anytime the client requests it to further reduce her worry of the fetus' well being.



* T: Measure maternal temperature. Because your client's core body temperature is higher than you can detect through oral or tympanic thermometers, be alert to the presence of a fever. A high maternal temperature can lead to fetal tachycardia and distress. An order for antipyretics on admission to ensure their quick availability will be a prudent request you should make to the admitting physician.



* U: Ask about uterine activity or contractions. Make it a normal part of your routine to ask about any type of uterine pain, tightening, or discomfort throughout your shift. Be aware that early contractions often present as lower back pain. Don't attribute complaints of lower back pain to the hospital bed. If your client reports any unusual activity, take care to softly palpate the lower abdomen for periods of greater than 2 minutes while conversing with her. Watch for subtle changes of facial expression while simultaneously detecting a change in uterine tone. If contractions are suspected, your client will need to be monitored with continuous fetal monitoring in the labor and delivery unit.



* S: Assess for the presence of and changes in sensations of fetal movement. After 20 weeks' gestation, all women should be able to report feeling the fetus move. This is an important assessment to perform and document at least every shift, easily accomplished by asking "How often are you feeling the baby move?" By asking this as an open-ended question, you'll receive more information about the quantity of fetal movement such as, "I haven't felt the baby move as much as usual today."
There are times when a woman may be hospitalized during the postpartum period for a medical condition. When this occurs, she'll most likely be placed on a general medical-surgical unit. Her admission will cause you to ask: "What's normal during the weeks following the birth of a baby?"



* Breasts. Within the first 24 hours postpartum, colostrum appears and is followed by breast milk within the first 72 hours. Breast engorgement is most likely to occur around day 4 postpartum. The engorged breast will appear full, taut, and even shiny. Although this is normal, it may be very uncomfortable for your client. In contrast, a woman with mastitis will usually run a fever higher than 100° F, report feeling "ill," and have one breast that's affected (firm, inflamed, swollen, and exquisitely tender to touch). If your client is breastfeeding her newborn, she'll require a breast pump. Depending on the medications ordered, the milk may need to be disposed of and not used for the baby.



* Lochia. Sometimes women will experience lochia (vaginal discharge) until the time of their 6-week postpartum visit. Immediately after delivery, the lochia is red and heavy enough to require a pad change every 1 to 2 hours. By 7 days postpartum, the lochia should be lighter in color (pink to red) and amount, requiring a pad change every 4 hours. Lochia that becomes heavier, has a foul odor, and is accompanied by pelvic pain isn't a normal finding and requires immediate intervention.



* Perineal care. For the first 2 weeks following delivery, clients will need to perform perineal hygiene as taught during the immediate postpartum period. This may include perineal water rinses following elimination using warm water or medicinal rinses, use of sitz baths, and comfort medications to the perineal and anal area.



* Cesarean section. If your client delivered her baby via cesarean section, continued assessment of the surgical incision is warranted for the first 2 to 3 weeks postpartum. Redness and warmth around the incision, excessive bruising around the incision, or incisional drainage requires immediate intervention. If the surgeon used staples to close the incision, they're usually removed approximately 5 days post-delivery.



Remember, the hospitalized postpartum client is likely to be very emotional. Not only will she be experiencing the normal hormonal fluctuations of the postpartum period, she'll may also be distraught leaving her newborn at home and feeling that she's missing bonding time with her child. Visitation between the mother and her infant may be very limited to minimize the infant's risk of infection, but visits should be arranged if at all possible.