ATI Engage Fundamentals and Mobility/Documentation Comprehensive Notes

Client Education

  • Client education: an ongoing, goal-driven, interactive process that provides clients with new information and is a fundamental element of a nurse’s scope of practice.
  • Goals of client education:
    • Health promotion: any activity that works to improve a client’s health.
    • Restoration of health: any activity that works to improve the health of a client with an illness or injury.
    • Adaptation to permanent illness or injury: assisting a client to adapt their life to accommodate permanent health alterations.
  • Domains of learning (domains of development/learning):
    • Cognitive: thinking domain – thinking through information and being able to comprehend it.
    • Affective: feeling domain – client’s feelings regarding values, attitudes, and beliefs.
    • Psychomotor: doing domain – the physical or mental activities required to learn skills.
  • Example domain application:
    • Cognitive: teaching a diabetic client about carbohydrate counting.
    • Affective: helping a newly diagnosed diabetic patient cope with lifestyle changes.
    • Psychomotor: demonstrating and supervising insulin self-administration.
  • Relevance and motivation in learning:
    • Relevance is the client’s understanding of why they should learn the information.
    • Key aspects of relevance:
    • Personal connection to health outcomes: how information applies to their condition.
    • Immediate and long-term benefits: short-term benefits and long-term health improvements.
    • Tailoring education to client needs: using client-specific examples.
    • Use of real-life scenarios and analogies: motivation through relatable context.
    • Motivation and readiness:
    • Client autonomy in learning: clients should have a say in when, where, and how they learn.
    • Readiness to learn: motivation fluctuates based on emotional, physical, and cognitive state.
    • Incorporating individual learning preferences.
    • Creating a conducive learning environment.
    • Enhancing motivation through nurse–client communication.
  • Factors that promote learning:
    • Perceived benefit.
    • Enhanced health literacy.
    • Ongoing client participation.
    • Nonjudgmental support.
    • Quiet, low-stimulus environment.
    • Repetition.
  • Factors that hinder learning:
    • Fear, anxiety, depression.
    • Lack of motivation.
    • Environmental distractions.
    • Psychomotor deficits.
    • Physical discomfort (fatigue, pain).
    • Timing factors.
  • Health literacy:
    • Health literacy is the client’s ability to obtain, read, and understand basic health information.
    • On average, health information is presented at a high school or college reading level.
  • Feedback in client education:
    • Feedback: helpful information provided to the learner to aid in improvement.
    • Nurses must provide feedback during and after educational sessions so the client knows they understand the information.
  • Types of feedback (summary):
    • Positive feedback: reinforces correct understanding or skill.
    • Corrective feedback: helps correct mistakes in a supportive way.
    • Guided feedback: encourages self-reflection by asking the client to identify their own mistakes.
    • Neutral feedback: encourages continued learning without judgment.
  • Teach-back strategy:
    • Teach-back is conducted by asking the client to repeat or demonstrate educational information back to you.
    • Purpose: confirms the client received information accurately and correctly.
  • How to use the Teach-Back Method effectively
    1) Explain information clearly: use plain language; avoid medical jargon.
    2) Ask the client to Teach Back: for example, ask how they will take medication, demonstrate insulin dosing, or what they will do if blood sugar drops.
    3) Clarify and re-educate as needed: rephrase teaching and try again if recall is difficult.
    4) Repeat until understanding is confirmed: reassess and have the client teach back again if needed; adjust teaching methods if necessary (e.g., visual aids, written instructions).
  • Examples of Teach-Back in nursing practice
    • Traditional approach vs Teach-Back approach in scenarios:
    • Post-surgery wound care: traditional: “Do you understand how to change your dressing?” Teach-back: client demonstrates cleaning and redressing wound at home.
    • Diabetes management: traditional: “You need to check your blood sugar before meals and at bedtime.” Teach-back: asks client when they plan to check glucose and to demonstrate the process.
    • Heart failure education: traditional: “Limit your sodium intake.” Teach-back: asks client to identify foods to avoid to control salt intake.
    • Medication administration: traditional: “Take this pill twice a day.” Teach-back: asks when they will take it and how they will remember.
  • Elements of an effective teaching plan
    • Similar to the nursing process: Assessment – Analysis – Planning – Implementation – Evaluation.

Documentation and Charting

  • PIE Model (Problem, Intervention, Evaluation)
    • Problem: nursing diagnosis or issue identified from assessment data.
    • Intervention: nursing actions taken to address the problem.
    • Evaluation: client’s response to the intervention and further plan of care.
    • Example PIE notes: e.g., P: Acute pain related to surgical incision; I: Administered acetaminophen 650 mg PO; E: Pain decreased to 3/10 after 30 minutes; plan to reassess in 1 hour.
  • SOAP Note structure
    • Subjective: symptoms described by client.
    • Objective: observable findings (vital signs, exam, measurements).
    • Assessment: nursing diagnosis or professional interpretation combining subjective and objective data.
    • Plan: steps to treat and any referrals or testing.
  • Source-Oriented Medical Record (SOMR)
    • Traditional format with sections such as History and Physical (H&P), Physician’s Orders, Progress Notes, Nurses’ Notes, Laboratory Reports, Diagnostic Testing, Consultation Reports, Discharge Planning.
  • DAR Focus Charting
    • Focuses on data, action, and response:
    • Data: objective and subjective information (assessment findings, vitals, concerns).
    • Action: nursing interventions taken.
    • Response: client’s reaction to intervention and further plan.
  • Example DAR note for shortness of breath scenario provided.
  • Charting by Exception (CBE)
    • Documents routine, normal findings; exceptions are documented in detail.
    • Example: routine postop assessment would state no new pain or abnormal findings; unexpected findings documented with details and provider notification.
  • Problem-Oriented Medical Records (POMR)
    • Focus on problems rather than solely on disciplines:
    • Database: initial assessment data.
    • Problem List: active and resolved problems with a plan for each.
    • Plan of Care: interdisciplinary interventions.
    • Progress Notes (SOAP notes): ongoing documentation.
  • FACT acronym for charting
    • Factual – objective, unbiased language; do not insert opinions.
    • Accurate – correct details (times, dates, measurements, patient responses).
    • Complete – include necessary details, interventions, and responses.
    • Timely – chart as soon as possible after care is provided.
  • Correcting errors in documentation
    • Keep the original entry; draw a single line through the error and write “error” with your initials.
    • Record the date and time of the correction.
    • Do not obscure the original entry (no white-out, etc.).
    • Document the correct information.
  • Late charting entries
    • Identify as a late entry; tie the entry to the event or date.
    • Sign and date the new entry and indicate which event or previous note it references.
    • Do not leave blank lines.
  • Electronic Health Records (EHRs)
    • A systemic, digitized documentation system to improve client care.
    • Provides comprehensive records of health history and serves as a communication tool among providers.
    • Includes all treatments, diagnoses, and visits; essential for billing; can be used in court.
  • Electronic Documentation Guidelines
    • Never share login information; use strong, unique passwords and change them regularly.
    • Log off when documentation is complete; never leave a station without logging off.
    • Protect monitors to maintain client confidentiality.
    • If using an electronic signature, ensure the name and credentials are correct and professional.
  • ISMP and documentation abbreviations
    • Institute for Safe Medication Practices (ISMP) compiles a list of appropriate abbreviations to reduce confusion and errors in documentation.
  • Informatics
    • Informatics: use of information and technology to communicate, manage knowledge, mitigate error, and support decision making.
    • Nursing informatics: integration of technology and devices with nursing knowledge and clinical decision-making.
    • In 1992, the American Nurses Association designated nursing informatics as its own specialty practice.
    • Bar code scanning in nursing:
    • Benefits: reduces medication errors (Five Rights: right patient, right drug, right dose, right route, right time), enhances documentation accuracy (auto-records administration time in eMAR), improves patient safety (alerts about allergies, missed doses), increases efficiency (real-time updates), supports regulatory compliance (TJC, CMS, FDA).
    • Challenges/limitations not enumerated in detail.
  • Health Literacy (additional emphasis in informatics context)
    • Health literacy impacts patient safety, disease management, self-care, prevention, and effective communication.
  • Simulation in nursing education
    • Benefits: enhances critical thinking and decision-making; improves clinical confidence; provides immediate feedback; promotes patient safety; fosters interdisciplinary collaboration; accommodates diverse learning styles.

Mobility and the Musculoskeletal System

  • Mobility definition and nursing goal
    • Mobility means motion or movement; bodies are designed for motion and require muscles, skeleton, and nerves to function in unison.
    • Nursing goal: preserve, maintain, and restore mobility and function as much as possible.
    • Ambulation: the ability to walk from place to place independently.
  • Musculoskeletal overview
    • Musculoskeletal: muscles and skeleton.
    • The muscular system:
    • More than 600600 muscles in the human body.
    • Muscles account for about half of body weight.
    • Muscles contract across joints to pull on the skeleton; muscles are always active and require oxygen and glucose.
    • The four properties of a muscle (CEEE):
    • C: Contractibility – ability to shorten (contract) and relax.
    • E: Excitability – muscle fibers respond to nerve or hormone stimulation; resting muscle is negatively charged; stimulation makes it positively charged and active.
    • E: Extensibility – ability to stretch while other fibers contract.
    • E: Elasticity – ability to recoil to original state after contraction/extension.
    • Muscle types:
    • Cardiac: found only in the heart; involuntary.
    • Smooth: in blood vessels and visceral organs; involuntary.
    • Skeletal: attached to bones by tendons; voluntary.
    • Mnemonic for muscle function: M – muscles; C – contract; P – pull; G – generate; M – movement.
  • The skeletal system
    • Made up of $206$ bones.
    • Bones provide rigid structure, support internal organs, store minerals, and are weight-bearing.
    • Bones comprise layers, not solid; protection and movement depend on bones in coordination with muscles.
  • Bone classifications
    • Long bones; Short bones; Flat bones; Irregular bones; Sesamoid bones (e.g., patella, carpals).
  • Remodeling and cartilage
    • Remodeling: mature bone is constantly replaced; resorption followed by deposition of new bone material.
    • Cartilage: firm yet flexible connective tissue found in ears, nose, larynx, ribs, intervertebral discs, knees, and ankles.
  • Types of movements
    • Flexion, Extension, Abduction, Adduction, Pronation, Supination, Circumduction, Rotation, Inversion, Eversion, Dorsiflexion, Plantarflexion.
  • Body mechanics
    • Definition: coordinated effort of musculoskeletal and nervous systems to maintain posture, alignment, and balance in daily life.
    • Correct use: maximize strength and minimize strain; good posture in motion.
  • Postural misalignments (examples)
    • Lordosis: excessive inward curvature of the lower back; anterior pelvic tilt.
    • Kyphosis: excessive outward curvature of the upper back; forward pelvis.
    • Flat back: loss of spinal curvature (straight back).
    • Sway back: pelvis tilts forward; head anterior to pelvis; loss of abdominal/lower back tone.
    • Scoliosis: C- or S-shaped spine.
    • Diagram reference lists Balanced Lordosis, Kyphosis, Flat Back, Sway Back, Scoliosis.
  • Immobility and its impact
    • Immobility: inability to move one or more body parts.
    • Prolonged immobility leads to systemic cascades of decline; joints: stiffness, pain, limited ROM; risk of fibrofatty tissue and adhesions; venous stasis increases clot risk.
  • Mobility assessment and ADLs
    • Activity intolerance: insufficient energy for activity.
    • Activity tolerance: ability to complete activities without distress.
    • Activities of Daily Living (ADLs): basic self-care tasks.
  • Proper positioning
    • Positioning: intentional placement of the body to align with natural curves and avoid pressure points.
    • Goals: Promotion and Prevention.
  • Stages of pressure injury (1–2 of 2)
    • Stage 1: intact skin with nonblanchable redness (no maroon/purplish discoloration).
    • Stage 2: partial-thickness skin loss; pink/red wound bed; moist; may include blister.
    • Stage 3: full-thickness skin loss; adipose and granulation tissue visible; possible rolled edges, slough, eschar; no bone/muscle visible.
    • Stage 4: full-thickness loss with exposure of fascia, muscle, ligaments, cartilage, or bone; possible tunneling/undermining.
    • Unstageable: slough/eschar conceal extent of tissue loss; stage cannot be determined.
    • Deep tissue pressure injury: localized area with deep red, maroon, or purple discoloration; nonblanchable; may include a blister or exposed wound bed.
  • Appendix imagery and descriptions (contextual references)
    • Appendix 1a: Muscular System – major muscles described (head/neck region).
    • Appendix 1b: Muscular System Continued – additional muscles listed (limbs).
    • Appendix 2: Types of Bones – cross-section of bone showing compact bone and spongy bone; examples of bone types.
    • Appendix 3: Bone Diagram – features such as epiphysis, diaphysis, growth plate, periosteum, articular cartilage, and bone sections.
    • Appendix 4: Sleeping Positions – correct vs incorrect sleeping alignment.
  • Sleeping position guidance (application in mobility/staging)
    • Correct: side-lying with aligned spine, a small head pillow, and a knee-between-pillow alignment.
    • Incorrect: head propped on a large pillow causing spinal misalignment.

Additional topics touched in the slides

  • Copyright and licensing notes (ATI Engage materials)
    • ATI materials are copyrighted by ATI; posted for the licensed institution on LMS; not for individual use; must include ATI marks and not be shared outside the institution; do not post on social media; termination of license ends access.
  • Health informatics and bar-code scanning details
    • Bar-code scanning supports accuracy, safety, and regulatory compliance; helps in medication administration, eMAR updates, allergy checks, and dose verification; mention of challenges but not enumerated here.
  • Sleep positions and sleeping posture references (Appendix 4)
    • Visual references depicting correct vs incorrect spine alignment during sleep.
  • Educational strategies recap
    • Teach-back as a core method for validating understanding; reinforcement of the core nursing process in education planning; focus on readability and client-centered teaching.
  • Quick recall formulas and numbers
    • Muscular system scale: >600600 muscles; skeletal system: 206206 bones.
    • Pain example in teaching scenarios: 7/107/10 (as a reference point in case examples).
    • Acetaminophen dose example: 650extmg650 ext{ mg} PO (example in PIE/interventions).
  • Key nursing documentation concepts (quick glossary)
    • PIE: Problem, Intervention, Evaluation.
    • SOAP: Subjective, Objective, Assessment, Plan.
    • SOMR: Source-Oriented Medical Record structure.
    • DAR: Data, Action, Response.
    • CBE: Charting by Exception.
    • POMR: Problem-Oriented Medical Records with Database, Problem List, Plan of Care, and Progress Notes.
    • FACT: Factual, Accurate, Complete, Timely.
  • ISMP guidance
    • ISMP provides a list of approved abbreviations to reduce documentation errors.
  • Simulation in nursing education
    • Benefits include development of clinical decision-making, confidence, feedback, patient safety, teamwork, and adaptability to different learning styles.
  • Key cautionary notes
    • Ensure patient confidentiality and secure login/logout procedures when using electronic systems.
    • Maintain professional standards in all narrative and objective descriptions; avoid nonessential or biased language.