A nurse educator is reviewing with a group of nursing students the actions and thought processesnurses use during the steps of the nursing process. Use the ATI Active Learning Template: Basic Concept tocomplete this item to include the following:A. Nursing Interventions: List at three actions to take during the analysis or data collection step. List four factors to consider during the evaluation step when clients have not achievedtheir goals.

Using ATI Active Learning Template: Basic ConceptA. Nursing Interventions Analysis/data collection Recognize patterns or trends. Compare the data with expected standards or reference ranges. Arrive at conclusions to guide nursing care. Factors to consider during evaluation for unmet goals An incomplete database Unrealistic client outcomes Nonspecific nursing interventions Inadequate time for the client to achieve the outcomes

6. Using the ATI Active Learning Template: Basic Concept Nursing Interventions on client safety

Nursing responsibilities include knowing how often the client should be. Assessed Including neurosensory checks of affected extremities (circulation, sensation,mobility). These checks are usually done at least every 2 hr.. Offered food and fluid.. Provided with means for hygiene and elimination.. Monitored for vital signs.. Offered range of motion of extremities. Frequency of client assessments in regard to food, fluids, comfort, and safety should beperformed and documented every 15 to 30 min. Other responsibilities include the following:. Explaining the need for the restraint to the client and family, emphasizing that the restraint isneeded to ensure the safety of the client and will be used only as long as it is necessary.. Obtaining signed consent from client or guardian, if required.. Reviewing the manufacturers instructions for correct application.. Removing or replacing restraints frequently to ensure adequate circulation to the area andallowing for full range of motion to the restricted limb.. Padding bony prominences.. Using a quick-release knot to tie the restraint to the bed frame where it will not tighten whenthe bed is raised or lowered.. Ensuring that the restraint is loose enough for range of motion and with enough room to fittwo fingers between the device and the client to prevent injury.. Regularly assessing the need for continued use of the restraints to allow for discontinuation ofthe restraint or limiting the restraint at the earliest possible time.. Never leaving the client unattended without the restraint.. Completing documentation to include the following:. Precipitating events and behavior of the client prior to seclusion or restraint. Alternative actions taken to avoid seclusion or restraint. The time restraints were applied and removed (if discontinued). Type of restraint used and location. Clients behavior while restrained. Type and frequency of care (range of motion, neurosensory checks, removal,integumentary checks). Condition of the body part being restrained. Clients response when the restraint is removed. Medication administration

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 weight on both legs, move the cane forward 6 to10 inches, then move the weaker leg forward toward the cane...Next, advance the stronger leg past the cane.

Crutch instructions..Do not alter crutches after fitting...Follow the prescribed crutch gait...Support body weight at the hand grips with the elbows flexed at 30...Position the crutches on the unaffected side when sitting or risingfrom a chair.

Closed Intermittent Irrigation

Prepare a sterile syringe with irrigant.

Clamp the catheter between the injection port and the extension tubing.Cleanse the injection port with an antiseptic swab or wipe.

Insert the needle of the syringe with irrigant into the injection port.

Slowly inject the irrigant into the catheter.

Withdraw the syringe and remove the clamp.

Allow the irrigant to drain into the drainage bag

Subjective and objective data indicating poor nutrition: Nausea, vomiting, diarrhea, constipation Flaccid muscles Mental status changes Loss of appetite Change in bowel pattern Spleen, liver enlargement Dry, brittle hair Loss of subcutaneous fat Dry, scaly skin Inflammation, bleeding of gums Poor dental health Dry, dull eyes Enlarged thyroid Prominent protrusions over bony areas Weakness Change in weight

Nursing Interventions To promote sleep Help clients establish and follow a bedtime routine. Limit waking clients during the night. Help with personal hygiene needs or a back rub prior to sleep to increase comfort. Instruct clients to: Exercise regularly at least 2 hr before bedtime. Arrange the sleep environment for comfort. Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime. Limit fluids 2 to 4 hr before bedtime. Engage in muscle relaxation if anxious or stressed. Instruct clients with narcolepsy to: Exercise regularly. Eat small meals that are high in protein. Avoid activities that increase sleepiness (sitting too long, warm environments, drinking alcohol). Avoid activities that would cause injury should the client fall asleep (driving, heights). Take naps when drowsy or when narcoleptic events are likely. Take stimulants the provider prescribes. Consider continuous positive airway pressure (CPAP) devices for clients who have sleep apnea. Consult the provider about trying sleep-promoting, over-the-counter products (melatonin,valerian, chamomile). As a last resort, suggest that the provider prescribe a pharmacological agent. Medications of choicefor insomnia are benzodiazepine-like medications, which include the sedative-hypnotics zolpidem(Ambien), eszopiclone (Lunesta), and zaleplon (Sonata).

Pulse pressure is the difference between the systolic and the diastolic pressure readings.

Factors Affecting Wound Healing An increase in age delays healing because of: Loss of skin turgor. Skin fragility. A decrease in peripheral circulation and oxygenation. Slower tissue regeneration. A decrease in absorption of nutrients. A decrease in collagen. Impaired function of the immune system. Overall wellness A compound fracture of the femur in a client who has a chronic illness can bedifficult to heal. Immune function is the bodys ability to fight infection by destroying invading pathogens.A decrease in leukocyte count will delay healing. Some medications (anti-inflammatory and antineoplastic) interfere with the bodys ability torespond to and prevent infection. Nutrition provides energy and elements for wound healing. Tissue perfusion provides circulation that delivers nutrients for tissue repair and infection control. Adequate Hgb levels are essential for oxygen delivery to healing tissues. Obesity Fatty tissue lacks blood supply. Chronic diseases, such as diabetes mellitus and cardiovascular disorders, place additional stress onthe bodys healing mechanisms. Chronic stress further impedes healing. Smoking impairs oxygenation and clotting. Wound stress, such as from vomiting