ATI Topic Descriptors
Basic Care and Comfort (13) Plan A
Hygiene Care: Evaluating Appropriate Use of Assistive Devices
Cane instructions:
Maintain two points of support on the ground at all times Keep the cane on
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ATI Topic Descriptors
Basic Care and Comfort (13) Plan A
Hygiene Care: Evaluating Appropriate Use of Assistive Devices
Cane instructions:
Maintain two points of support on the ground at all times Keep the cane on the stronger side of the body
Support body wt on both legs, move cane forward 6-10 inches, then move the weaker leg forward toward the cane.
Next, advance the stronger leg
Dentures:
Clients who have fragile oral mucosa require gentle brushing and flossing. Perform denture care for the client who is unable to do it himself
Remove dentures with a gloved hand, pulling down and out at the front of the upper denture, and lifting up and out at the front of the lower denture.
Place dentures in a denture cup or emesis basin Brush them with a soft brush and denture cleaner Rinse them with water
Store the dentures, or assist the client with reinserting the dentures
Complimentary and Alternative Therapies: Appropriate Use of Music Therapy for Pain Management
Music
decreases physiological pain, stress and anxiety by diverting the personʼs attention away from the pain and creating a relaxation response.
let client select the type of music
music produces an altered state of consciousness through sound, silence, space and time
must be listened to for 15-30 minutes to be therapeutic
earphones help client concentrate on music while avoiding other clients or staff highly effective in reducing postop pain
if pain acute, increase volume of music
Prostate Surgeries: Calculating a Clientʼs Output When Receiving Continuous Bladder Irrigations
purpose: to maintain the patency of indwelling urinary catheters (bec blood, pus, or sediment can collect within tubing resulting in bladder sistention and buildup of stagnant urine)
Med-Surg p. 1443
after prostate surgery, irrigation is typically done to remove clotted blood from the bladder and ensure drainage of urine.
if bladder manually irrigated, 50ml of irrigating soln should be instilled and then withdrawn with a syringe to remove clots that may be in bladder and catheter.
with CBI, irrigating soln is continuously infused and drained from the bladder. The rate of infusion is based on the color of drainage. Ideally the urine drainage should be light pink without clots. The inflow and outflow of irrigant must be continuously monitored. If outflow is less than inflow, the catheter patency should be assessed for clots or kinks. If the outflow is blocked and patency cannot be reestablished by manual irrigation, the CBI is stopped and the physician notified.
Record amount of urine output and character of urine every eight (8) hours or as per physicianʼs orders.
(To obtain urine output, subtract amount
of fluid instilled into bladder from total output.)
intermittent irrigation
dorsal recumbent or supine position
avoid cold solution bec may result in bladder spasm clamp cath just below soft injection port
cleanse injection port with antiseptic swab (same port as specimen collection) insert needle through port at 30degree angle
slowly inject fluid into cath and bladder
withdraw syringe remove clamp and allow solution to drain into drainage bag
if ordered by MD, keep clamped to allow solution to remain in bladder for short time (20-30min)
Closed continuous irrigation Recording and Reporting
Record type and amt of irrigation soln used, amt returned as drainage and the character of drainage
Record and report any findings such as complaints of bladder spasms, inability to instill fluid into bladder and/or presence of blood clots.
Urinary Elimination: Kegel Exercises for Urinary Incontinence
sits on toilet with knees far apart and tightens muscle to stop the flow of urine ( to learn the muscle)
then practiced at nonvoiding times
instruct client to contract muscle for a count of 3, hold and release for a count of 3, and repeat this 10x.
Client should repeat these cycles for 25-30x 3x/day for 6 months. Client should do this 5x.day
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