ATI Med Surg Critical Points,100% CORRECT

ATI Med Surg Critical Points Topics to Review Safety and Infection Control (4 items) Accident/Error/Injury Prevention (1 item) Seizures and Epilepsy: Implementing Precautions (RN QSEN - Safety, Active Learning Te ...

ATI Med Surg Critical Points Topics to Review Safety and Infection Control (4 items) Accident/Error/Injury Prevention (1 item) Seizures and Epilepsy: Implementing Precautions (RN QSEN - Safety, Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 6) • Seizures are abrupt, normal, excessive, and uncontrolled electrical discharge of neurons within the brain that can cause alterations in the level of consciousness and changes in motor and sensory ability and/or behavior. Epilepsy is the term used to define chronic recurring abnormal brain electrical activity resulting in 2 or more seizures. • Precautions include knowing the risk factors related to seizures and epilepsy; genetic predisposition, acute febrile state, head trauma, cerebral edema, abrupt cessation of antiepileptic drugs. • There are triggering factors of seizures and epilepsy; increased physical activities, excessive stress, hyperventilation, alcohol, caffeine, flashing lights, substance abuse, aerosols, stress, and fatigue. It is important for nurses to know these factors in an order to implement precautions. Home Safety (1 item) Musculoskeletal Trauma: Discharge Teaching About an External Fixation Device (RN QSEN - Safety, Active Learning Template - Basic Concept, RM AMS RN 10.0 Chp 71) • External fixation involves fracture immobilization using percutaneous pins and wires that are attached to a rigid external frame. • For care of the device: clean the external fixation pins one to two times each day to remove exudate that can harbor bacteria, using a separate cotton swab on each pin will decrease the risk of cross-contamination, which could cause pin site infection. • Advise the client that they should report redness, heat, and drainage at the pin sites, which can indicate an infection that can lead to osteomyelitis. Discuss clothing and other materials that can be used to cover the device. If activity is restricted, advise the client to perform deep breathing and leg exercises and other techniques to prevent complications to immobilization, such as pneumonia or thrombus formation. Standard Precautions/Transmission-Based Precautions/Surgical Asepsis (2 items) Infection Control: Teaching About Isolation Precautions (RN QSEN - Safety, Active Learning Template - Basic Concept, RM FUND RN 9.0 Ch 11) • Infection occurs when the presence of a pathogen leads to a chain of events, all components of chain must be present and intact for the infection to occur. Nurses use infection control practices to break the chain and thus stop the spread of infection. • Isolation guidelines are a group of actions that include hand hygiene and the use of barrier precautions which intend to reduce the transmission of infectious organisms. Precautions apply to every client, regardless of the dx and implementation of them must occur whenever there is anticipation of coming into contact with infectious material. • Clients in isolation are at high risk for depression and lonliness, assist client and their family to understand the reason for isolation and provide sensory simulation. Health Promotion and Maintenance (2 items) Health Promotion/Disease Prevention (1 item) Health, Wellness, and Illness: Identifying Risk Factors for Atherosclerosis (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 1) • Atherosclerosis is caused by gradual thickening of the intima and media of the arteries, it results in the progressive narrowing of the lumen. • Plaques may form on the walls of the arteries, making them rough and fragile. • Familial predisposition, High blood pressure, smoking, diabetes, obesity, unhealthy cholesterol levels are some major risk factors for atherosclerosis. Basic Care and Comfort (6 items) Elimination (4 items) Postoperative Nursing Care: Urinary Retention (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 96) • Monitor fluid and electrolyte balance following surgery. Monitoring can help determine if there is an issue of urinary retention. • Nursing care related to input and output should include: Palpate bladder for distention. Monitor urinary catheters for patency. Observe color, consistency, odor, and amount of urine. Urine output less than 30 mL/hr can indicate hypovolemia. • Urine output of at least 30 ml/hr is part of the criteria for discharge from PACU. Urinary Elimination: Teaching a Client to Manage Stress Incontinence (RN QSEN - Patient- centered Care, Active Learning Template - System Disorder, RM FUND RN 9.0 Ch 44) • Stress incontinence is loss of small amounts of urine from increased abdominal pressure without bladder muscle contraction with laughing, sneezing, or lifting. • A therapeutic procedure related to the treatment of stress incontinence is a bladder- retraining program. Urinary bladder retraining increases the bladders ability to hold urine and clients’ ability to suppress urination. • Nurses can teach the client how to perform Kegel exercises: tighten pelvic muscles for a count of 10, relax slowly for a count of 10 and repeat in sequences of 15 in the lying- down, sitting and standing positions. Mobility/Immobility (1 item) Mobility and Immobility: Climbing Stairs With Crutches (RN QSEN - Safety , Active Learning Template - Nursing Skill, RM FUND RN 9.0 Ch 40) • Maintain or regain body alignment and stability, decrease skin and musculoskeletal system changes, achieve full or optimal ROM, and prevent contractures. • Nurse should assist the client with ambulation. Use assistive devices such as gait belts, walkers, canes, or crutches as needed. • Crutch instructions: do not alter crutches after fitting, follow the prescribed crutch gait, support body weight at the hand grips with elbows flexed at 30 degrees, and position the crutches on the unaffected side when sitting or rising from a chair. Non-Pharmacological Comfort Interventions (1 item) Vitamins, Minerals, and Supplements: Medication Interaction With Feverfew (RN QSEN - Safety , Active Learning Template - Medication, RM Pharm RN 7.0 Chp 30) • Feverfew is used to decrease the frequency of migraine headaches, but it has not been proven to relieve an existing migraine headache. • Feverfew can cause increased risk of bleeding in clients taking NSAIDs, heparin, and warfarin. Discontinue 2 weeks before elective surgery. • Question clients about concurrent use of NSAIDs, heparin, and warfarin. Pharmacological and Parenteral Therapies (23 items) Adverse Effects/Contraindications/Side Effects/Interactions (6 items) Medications Affecting Blood Pressure: Adverse Effects of Enalapril (RN QSEN - Safety , Active Learning Template -Medication, RM Pharm RN 7.0 Chp 20) • Blood pressure is controlled in a variety of ways with many meds that are used alone or in combination. • Enalapril is a medication for hypertensive crisis. It is an ACE inhibitor. • Enalapril should be administered slowly because rapid administration will cause blood pressure to go down rapidly. Blood and Blood Products (2 items) Blood and Blood Product Transfusions: Steps in the Administration Process (RN QSEN - Safety , Active Learning Template - Nursing Skill, RM AMS RN 10.0 Chp 40) • Clients can receive transfusions of whole blood or components of whole blood for replacement due to blood loss or blood disease. • Explain the procedure to the client. Assess vital signs and the client’s temperature prior to transfusion. Remain with the client for the first 15-30 min of the infusion (reactions occur most often during the first 15min) and monitor vital signs and rate of infusion per facility policy. • Assess laboratory values (e.g., platelet count less than 20,000 and hemoglobin less than 6 g/dL). Verify the prescription for a specific blood product. Obtain consent for procedure if required. Obtain blood samples for compatibility determination, such as type and cross-match. Rheumatoid Arthritis: Caring for a Client Receiving Plasmapheresis (RN QSEN - Safety , Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 88) • Rheumatoid arthritis is a chronic, progressive inflammatory disease that can affect tissues and organs but principally attacks the joints, producing an inflammatory synovitis. it involves joints bilaterally and symmetrically, and typically affects several joints at one time. Ra usually affects upper joints first. • Plasmapheresis removes circulating antibodies from plasma, decreasing attacks on the client’s tissues. This may be done for severe, life-threatening exacerbation. • Ra is an autoimmune disease that is precipitated by WBCs attacking synovial tissue. the WBCs cause the synovial tissue to become inflamed and thickened. Expected Actions/Outcomes (2 items) Chronic Obstructive Pulmonary Disease: Identifying Greatest Risk for Infection (RN QSEN - Safety , Active Learning Template - Basic Concept, RM AMS RN 10.0 Chp 22) • Copd encompasses two disease: emphysema and chronic bronchitis. Most clients who have emphysema also have chronic bronchitis. Copd is irreversible. • Use sputum cultures and WBC counts to dx acute respiratory infections. Encourage immunizations, such as influenza and pneumonia, to decrease the risk of infection. • Respiratory infections result from increased mucus production and poor oxygenation levels. Clients should advised to avoid people who have respiratory infections. Medication Administration (9 items) Antibiotics Affecting Protein Synthesis: Adverse Effects of Aminoglycosides (RN QSEN - Safety , Active Learning Template - Medication, RM Pharm RN 7.0 Chp 45) • Antibiotics affecting protein synthesis are bacteriostatic, such as tetracyclines and macrolides, or bactericidal, such as aminoglycosides. • Aminoglycosides are bactericidal antibiotics that destroy micro-organisms by disrupting protein synthesis. Clients who have kidney impairment should receive lower doses of aminoglycosides. • Most aminoglycosides, such as gentamicin and streptomycin (IM only), are parenteral. Neomycin also has oral and topical formulations; tobramycin also has an inhalation formulation Diabetes Mellitus Management: Client Teaching About Insulin Lispro (RN QSEN - Safety, Active Learning Template - Medication, RM AMS RN 10.0 Chp 82) • Diabetes mellitus is a metabolic disorder resulting from either an inadequate production of insulin (type 1) or an inability of the body’s cells to respond to insulin that is present (type 2). • Insulin regimens are established for clients who have type 1 dm. More than 1 type of insulin: rapid, short, intermed, and long acting. Given one or more times a day based on blood glucose results. • Insulin lispro is a rapid acting insulin, onset is rapid (10-30 min). Should be administered before meals to control postprandial rise in blood glucose. Administer in conjunction with intermediate- or long acting insulin to provide glycemic control between meals and at night. Diabetes Mellitus: Teaching About Metformin (RN QSEN - Patient-centered Care, Active Learning Template - Medication, RM Pharm RN 7.0 Chp 39) • Exenatide is prescribed along with an oral antidiabetic medication, such as metformin or a sulfonylurea medication, for clients who have type 2 diabetes mellitus to improve diabetes control. • Metformin is contraindicated for clients who have severe infection, shock, and any hypoxic condition. The medication should not be used by clients who have alcohol use disorder. • Instruct clients to take immediate release tablets two times per day with breakfast and dinner and to take sustained-release tablets once daily with dinner. Seizures and Epilepsy: Client Teaching About Phenytoin (RN QSEN - Safety , Active Learning Template - Medication, RM AMS RN 10.0 Chp 6) • Administer prescribed antiepileptic drugs (AEDs), such as phenytoin. Administer diazepam or lorazepam IV push followed by IV phenytoin or fosphenytoin. • When using phenytoin, specific instructions should include avoidance of oral contraceptives, as this medication decreases their effectiveness. Warfarin should also not be given with this medication, as phenytoin can decrease absorption and increase metabolism of oral anticoagulants. • The nurse should not instruct the client to take oral contraceptives, because contraceptive effectiveness is decreased when taking phenytoin. The nurse should instruct the client that phenytoin causes overgrowth of the gums. The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness. Urinary Tract Infections: Teaching About Ciprofloxacin (RN QSEN - Patient-centered Care, Active Learning Template - Medication, RM Pharm RN 7.0 Chp 46) • Instruct clients to observe for and report pain, swelling, and redness at the Achilles tendon site. Tell clients to stop taking ciprofloxacin and avoid exercise until the inflammation subsides. • Pain and swelling of the achilles tendon indicate an adverse effect of ciprofloxacin to report to the provider. Vaginal yeast infection is an overgrowth of Candida albicans, which commonly occurs when taking ciprofloxacin. • Cottage cheese-like lesions in the mouth indicate an overgrowth of Candida albicans, a common adverse effect when taking ciprofloxacin. Milk and other dairy products contain calcium ions that reduce the effect of ciprofloxacin. The client should take the medication 6 hr before or 2 hr after ingesting dairy products. Parenteral/Intravenous Therapies (1 item) Medications Affecting Coagulation: Nursing Actions for Enoxaparin Administration (RN QSEN - Safety , Active Learning Template - Medication, RM Pharm RN 7.0 Chp 25) • Pharmaceutical agents that modify coagulation are used to prevent clot formation or break apart an existing clot. These meds work in the blood to alter the clotting cascade, prevent platelet aggregation, or dissolve a clot. They all carry a significant risk of bleeding. • Monitor vital signs. Advise clients to observe for bleeding: increased heart rate, decreased blood pressure, bruising, petechiae, hematomas, black tarry stools. Monitor platelet count. Instruct client to avoid aspirin. • Monitor platelets. Discontinue medication for platelet count less than 100,000/mm3. In clients who have spinal or epidural anesthesia: Assess insertion site for indications of hematoma formation, such as redness or swelling. Monitor sensation and movement of lower extremities. Notify provider of abnormal findings. Pharmacological Pain Management (1 item) Pain Management: Opioid Education for an Older Adult Client (Active Learning Template - Medication, RM AMS RN 10.0 Chp 4) • Opioid analgesics, such as morphine, fentanyl, and oxycodone, are appropriate for treating moderate to severe pain. Nociceptive pain typically responds to opioids and nonopioid medications. • Older adults, especially those with cognitive impairment are at risk for undertreatment of pain. It is a serious complication and can lead to increased anxiety with acute pain and depression with chronic pain. • It is important to educate clients about the adverse effects of taking opioids. Urinary retention, respiratory depression, dizziness, nausea, vomiting, and lightheadedness are some common adverse effects of opioid analgesia. Total Parenteral Nutrition (TPN) (2 items) Dosage Calculation: Calculating an Infusion Rate (Active Learning Template - Basic Concept, RM FUND RN 9.0 Ch 48) • It is extremely important for nurses to have knowledge of dosage calculations. Proper dosage calculations for med administration can serious affect med errors. Iv infusion rates is one of the many calculations it is important for nurses to know. • If an electronic infusion pump is not available, regulate the IV flow rate using the roller clamp on the IV tubing. When setting the flow rate, count the number of drops that fall into the drip chamber over 1 min. • Then calculate the flow rate using the drop factor on the manufacturer’s package containing the administration set. The drop factor is the number of drops per milliliter of solution. Gastrointestinal Therapeutic Procedures: Administering Total Parenteral Nutrition (RN QSEN - Safety , Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 47) • Gastrointestinal therapeutic procedures are performed for maintenance of nutritional intake, and treatment of gastrointestinal obstructions, obesity, and other disorders. • Gastrointestinal therapeutic procedures nurses should be knowledgeable about include TPN. • TPN admin is usually through a central line, such as a tunneled triple lumen or a single or double lumen peripherally inserted central picc line. You should first determine the clients’ readiness for TPN. Obtain laboratory values, including electrolytes. Solutions are customized for each client according to daily lab results. Reduction of Risk Potential (21 items) Diagnostic Tests (1 item) Musculoskeletal Trauma: Monitoring Laboratory Values (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 71) • Monitoring for manifestations of infection include: monitoring laboratory values (WBC, ESR). • A fracture is a break in a bone secondary to trauma or a pathological condition. Fractures cause by trauma are the most common type of bone fracture. Pathological fractures can be caused by metastatic cancer, osteoporosis, or Paget’s disease. • Osteomyelitis is an infection of the bone that begins as an inflammation within the bone secondary to penetration by infectious organisms (virus, bacteria, or fungi) following trauma or surgical repair of a fracture. Laboratory Values (4 items) Anemias: Laboratory Findings for a Client Who Has Aplastic Anemia (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 41) • Anemia is an abnormally low amount of circulating RBCs, Hgb concentration, or both. It is an indicator of an underlying disease or disorder. Anemia results in diminished oxygen- carrying capacity and delivery to the tissues and organs. The goal of treatment is to restore and maintain adequate tissue oxygenation. • Aplastic anemia results in a decreased number of red blood cells as well as decreased platelets and white blood cells. • Bone-marrow aspiration/biopsy is used to diagnose aplastic anemia. Chronic Obstructive Pulmonary Disease: Interpreting ABG Results (Active Learning Template - Diagnostic Procedure, RM AMS RN 10.0 Chp 22) • COPD encompasses two diseases: emphysema and chronic bronchitis. Most clients who have emphysema also have chronic bronchitis. Copd is irreversible. • Expected findings of laboratory tests of patients of copd include ABGs: hypoxemia (decreased Pa02 less than 80 mm Hg) and hypercarbia (increased PaC02 greated than 45 mm Hg). • The nurse should observe for hypokalemia, fluid retention, and black tarry stools these are adverse effect of prednisone. Infections of the Renal and Urinary System: Manifestation of Chronic Glomerulonephritis (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 60) • the function of the renal system includes maintaining fluid volume, removing waste, regulating blood pressure, maintaining acid-base balance, producing erythropoietin, and activating vitamin D. The function of the urinary system is to store and remove urine. • Glomerulonephritis is an immunologic kidney disorder that can start in the kidneys (genetic basis and immune-inducing inflammation) or be a result of other health disorders (lupus erythematosus, diabetic nephropathy) and results in glomerular injury. • Chronic glomerulonephritis develops over a period of 20-30year. Postoperative Nursing Care: Laboratory Findings to Report (Active Learning Template - Basic Concept, RM AMS RN 10.0 Chp 96) • Initial postoperative care involves making assessments, administering medications, managing pain, preventing complications, and determining when a client is ready to be discharged from the PaCu. • Postop diagnostic procedures include CBC, metabolic profile, ABGs, additional laboratory tests. • Nurses should be familiar with lab values and be able to recognize findings that are not normal so that they can report them when necessary. They should review post op lab findings potassium, sodium, creatinine and BUN, hemoglobin and hematocrit. Potential for Complications from Surgical Procedures and Health Alterations (3 items) Cholecystitis and Cholelithiasis: Providing Preoperative Teaching (RN QSEN - Patient-centered Care, Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 53) • Cholecystitis is an inflammation of the gallbladder wall. Cholelithiasis is the presence of stones in the gallbladder related to the precipitation of either bile or cholesterol into stones. • Teach clients to report abdominal pain, diarrhea, or vomiting. The medication is limited to 2 years of administration and requires a gallbladder ultrasound every 6 months during the first year to determine effectiveness. • Teach the client to report indications of bile leak (pain, vomiting, abdominal distention) to the provider. Teach the client to resume activity gradually and as tolerated, and to resume the preoperative diet System Specific Assessments (3 items) Noninflammatory Bowel Disorders: Assessing a Client for Inguinal Hernia (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 51) • Noninflammatory bowel disorders can cause pain, changes in pattern, bleeding, and malabsorption. This group of disorders includes hemorrhoids, cancer, hernia, IBS and intestinal obstruction. • A bowel hernia is the displacement of the bowel through a weakness of the abdominal muscle into other areas of the abdominal cavity. Incisional hernias can occur as a postsurgical complication due to inadequate healing of the incisional site from malnutrition, infection, or obesity. • In a hernia that is strangulated, blood supply is cut off to a portion of the bowel, increasing the risk for obstruction, necrosis, and perforation. In males and indirect inguinal hernia can be large and descend into the scrotum. Therapeutic Procedures (8 items) Cancer Disorders: Caring for a Client Who Is Postoperative Following a Mastectomy (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 92) • Surgical procedures include lumpectomy (breast-conserving), wide excision or partial mastectomy, total mastectomy, modified radical mastectomy (lymph nodes removed), radical mastectomy (lymph nodes and muscle removed), and reconstructive surgery. • Have the client sit with the head of the bed elevated 30 degrees when awake and support her arm on a pillow. Lying on the unaffected side can relieve pain. • Avoid administering injections, taking bp, or obtaining blood from the clients affected arm. Place a sign above the clients’ bed regarding these precautions. Cancer Disorders: Teaching About Ureterostomy (RN QSEN - Patient-centered Care, Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 92) • Colon resection, involves the removal of a portion of the colon to excise the tumor. Colectomy is the removal of the colon with a temporary or permanent colostomy or ileostomy. • Provide ostomy teaching (findings of ischemia to be reported to the provider, expected output, appliance management) if applicable. • Educate the client regarding the care of the incision, activity limits, and ostomy care, if applicable. Growth Factors: Evaluating Understanding of Erythropoietin (Active Learning Template - Medication, RM Pharm RN 7.0 Chp 26) • Erythropoietin, a substance that stimulates bone marrow to produce red blood cells, is produced by the kidney. In clients who have chronic kidney disease, erythropoietin is no longer present and anemia results. Epoetin alfa stimulates production of red blood cells in these clients. • Monitor iron levels, and implement measures to ensure an iron level that is within the expected reference range. RBC growth depends on adequate quantities of iron, folic acid, and vitamin B12. Without adequate levels of these, erythropoietin is significantly less effective. Monitor Hgb & Hct twice per week until the target range is reached. • Blood cells and platelets are produced in the body by the biological process hematopoiesis. In the body, this process is naturally controlled by hormones, also known as hematopoietic growth factors. Intravenous Therapy: Client Positioning for Nontunneled Percutaneous Central Venous Catheter Insertion (RN QSEN – Safety, Active Learning Template - Therapeutic Procedure, RM FUND RN 9.0 Ch 49) • Iv therapy involves infusing fluids via an Iv catheter to administer medications, supplement fluid intake, or provide fluid replacement, electrolytes, or nutrients. • A safety positioning device is part of the equipment in the IV starter kit. You should position the client in a comfortable position. • To prevent IV infections, you should never disconnect tubing for convenience or to reposition the client. Physiological Adaptation (34 items) Alterations in Body Systems (8 items) Airway Management: Monitoring for Hypoxia During Suctioning (RN QSEN - Safety, Active Learning Template – Nursing Skill, RM FUND RN 9.0 Ch 53) • Suctioning orally, nasally, or endotracheally when clients have early signs on hypoxemia, such as restlessness, confusion, tachypnea, tachycardia, decreased Sp02 levels, adventious breath sounds, audible or visible secretions. Cyanosis. And absence of spontaneous cough. • Managing airway compromise includes respiratory assessment and measuring vital signs, including oxygen sat with a pulse ox and administration of oxygen. Pulse ox should remain on client during suctioning. • Hyperoxygenate the client using a bag-valve-mask or specialized ventilator function with an Fi02 of 100%. Arthroplasty: Postoperative Care (RN QSEN - Patient-centered Care, Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 68) • Arthroplasty refers to the surgical removal of a diseased joint due to osteoarthritis, osteonecrosis, ra, trauma, or congenital abnormalities, and replacing it with prosthetics or artificial components made of metal and/or plastic. • Client requires extensive physical therapy to regain mobility. Care for incision and clean daily. Also monitor for evidence of infection: fever, increased redness, swelling, purulent drainage. • Postop the nurse should; Monitor for DVT: swelling, redness, pain in calf. Pulmonary embolism: shortness of breath, chest pain, and bleeding if the client it taking an anticoagulant. Hyperthyroidism: Priority Action Following a Parathyroidectomy (RN QSEN - Safety , Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 78) • Hyperthyroidism is a clinical syndrome cause by excessive circulating thyroid hormones. Because thyroid activity affects all body systems, excessive thyroid hormone exaggerates normal body functions and produces a hypermetabolic state. • Thyroidectomy is a surgical removal of part or all of the thyroid gland. In a total thyroidectomy the client will need thyroid hormone replacement therapy. A subtotal thyroidectomy can be performed for the treatment of hyperthyroidism when medication therapy fails or radiation therapy is contraindicated. • Postop care includes: keeping the client in semi-fowlers position, supporting head and neck, avoiding neck extension. Monitoring vital signs every 15 min then 30 when stable. Assisting with deep breathing exercises every 30-60 min. checking surgical dressing for excessive bleeding. These are just a few. Respiratory Management and Mechanical Ventilation: Recognizing Potential Complications (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 19) • Oxygen is administered in an attempt to maintain a Sa02 of 95-100% by using the lowest amount of oxygen without putting the client at risk for complications. Supplemental oxygen can be delivered by a variety of methods based on the client’s particular circumstances. • Complications include; oxygen toxicity: which can result from high concentrations of oxygen typically above 50%, long durations of oxygen therapy, and the client’s degree of lung disease. Manifestations include a nonproductive cough, substernal pain, nasal stiffness, nausea, vomiting, fatigue, headache, sore throat, and hypoventilation. • Other complications oxygen-induced hypoventilation: which can develop in clients who have COPD and chronic hypoxemia with hypercarbia. And Combustion is also a risk because oxygen is combustible. Tuberculosis: Discharge Instructions (Active Learning Template - System Disorder, RM AMS RN Chp 23) • TB is an infectious disease caused by Mycobacterium tuberculosis. TB is transmitted through aerosolization (airborne route). Preventing infection transmission is important. • Educate the client and family to continue medication therapy for its full duration of 6 to 12 months, even up to 2 years for multidrug-resistant TB. Emphasize that failure to take the medications can lead to a resistant strain of TB. • Provide the client and family education because TB is often treated in the home setting. Airborne precautions are not needed in the home setting because family members have already been exposed. Exposed family members should be tested for TB. Fluid and Electrolyte Imbalances (2 items) Electrolyte Imbalances: Manifestations of Hypokalemia (Active Learning Template - System Disorder, RN QSEN - Patient-centered Care, RM AMS RN 10.0 Chp 44) • Hypokalemia is a result of an increased loss of potassium from the body or movement of potassium into the cells, resulting in serum potassium less than 3.5 meq/L. • Expected findings of hypokalemia: decreased blood pressure, thread weak pulse, orthostatic hypotension, altered mental status, anxiety, lethargy, hypoactive bowel sounds, nausea, vomiting, and constipation, are just a few. • Expected findings of ECG are: flattened T wave, prominent U waves, ST depression prolonged PR interval. Muscular weakness, and deep tendon reflexes can be reduced also. Fluid Imbalances: Findings Related to Dehydration (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 43) • Mild to moderate dehydration may include; increased thirst, dry mouth, tired of sleepy, decreased urine output, dry skin, dizziness, urine is low volume and more yellowish than normal are just a few clinical manifestations. • Assessing skin turgor on older adults hand can give a false impression of dehydration, you should instead assess skin turgor on their forearm or just above clavicle. • Fluid volume deficit is a serious problem and can affect a persons health seriously. It is important to assess a person and recognize clients at risk for dehydration. Hemodynamics (6 items) Cardiovascular Diagnostic and Therapeutic Procedures: Managing an Arterial Line (RN QSEN - Patient-centered Care, Active Learning Template - Diagnostic Procedure, RM AMS RN 10.0 Chp 27) • Cardiovascular diagnostic procedures that nurses should be familiar with include cardiac enzymes and lipid profile, echocardiogram, stress testing, hemodynamic monitoring, angiography, and vascular access. • Arterial lines are placed in the radial (most common), brachial, or femoral artery. Arterial lines provide continuous information about changes in blood pressure and permit the withdrawal of samples of arterial blood. Intra-arterial pressures can differ from cuff pressures. • The integrity of the arterial waveform should be assessed to verify the accuracy of blood pressure readings. Monitor circulation in the limb with the arterial line (capillary refill, temperature, color). Arterial lines are not used for IV fluid administration. Hemodialysis and Peritoneal Dialysis: Priority Finding (RN QSEN - Safety , Active Learning Template – Therapeutic Procedure, RM AMS RN 10.0 Chp 57) • Hemodialysis shunts blood from the body through a dialyzer and back into circulation. Hemodialysis requires vascular access. Peritoneal dialysis involves instillation of hypertonic dialysate solution into the peritoneal cavity and subsequent dwell times. • Peritoneal dialysis is the treatment of choice for the older adults who require dialysis. • The nurse should recognize and report any abnormal findings while caring for the client. Pacemakers: Rhythm Strip Interpretation (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 29) • A pacemaker is a battery-operated device that electrically stimulates the heart when the natural pacemaker of the heart fails to maintain an acceptable rhythm. They can be temporary or permanent. • Document the time and date of insertion, model (permanent pacemaker), settings, rhythm strip, presence of adequate pulse and blood pressure, and client response. • Nurses should be familiar with different types of pacemakers, how they function and the care involved. Pneumothorax, Hemothorax, and Flail Chest: Nursing Actions for a Flail Chest (Active Learning Template – Therapeutic Procedure, RM AMS RN 10.0 Chp 25) • Pneumothorax is the presence of air or gas in the pleural space that causes lung collapse. A hemothorax is an accumulation of blood in the pleural space. • A flail chest occurs when at least two neighboring ribs, usually on one side of the chest, sustain multiple fractures causing instability of the chest wall and paradoxical chest wall movement. This results in significant limitation in chest wall expansion. Flail chest is the inability of the injured side of the chest to expand adequately upon inhalation and contract upon exhalation. One side of the chest is typically affected due to multiple rib fractures. Illness Management (6 items) Hyperthyroidism: Assessing a Client for Thyroid Storm (RN QSEN - Safety , Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 78) • Thyroid storm/crisis results from a sudden surge of large amounts of thyroid hormones into the bloodstream, causing an even greater increase in body metabolism. This is a medical emergency with a high mortality rate. • Precipitating factors include uncontrolled hyperthyroidism occurring most often with Graves ’ disease, infection, trauma, emotional stress, diabetic ketoacidosis, and digitalis toxicity, all of which increase demands on body metabolism. It can also occur following a surgical procedure or a thyroidectomy as a result of manipulation of the gland during surgery. • Findings include: hyperthermia, hypertension, delirium, vomiting, abdominal pain, tachydysrhtmias, chest pain, dyspnea, and palpitations. Medical Emergencies (5 items) Burns: Priority Intervention (RN QSEN - Safety, Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 75) • Dry heat, moist heat, direct contact with hot surfaces, chemicals, electricity, and ionizing radiation can cause burns, which result in cellular destruction of the skin layers and underlying tissue. The type of burn affect the treatment plan. • Emergent (resuscitative phase) begins with the injury and continues for 24-48 hour. Priorities include securing the airway, supporting circulation and organ perfusion by fluid replacement, managing pain, preventing infection through wound care, maintaining body temperature, and providing emotional support. • Acute phase begins 36-48h, priorities include assessment and maintenance of the cardiovascular, respiratory, and gastrointestinal systems, wound care and pain control. Rehabilitative begins when most of the burn area has healed, priorities include psychosocial support, prevention of scars and contractures, and resumption of activities, including work, family and social roles. Emergency Nursing Principles and Management: Priority Action During an Anaphylactic Reaction (RN QSEN – Safety, Active Learning Template - Basic Concept, RM AMS RN 10.0 Chp 2) • Anaphylaxis is a life-threatening allergic reaction that can cause shock, a sudden drop in bp and trouble breathing. • Calling for help or calling a code should be done before any other action upon discovery of a patient experiencing an anaphylactic reaction. • Establishing a patent airway and ventilation is essential. Early endotracheal intubation is essential to preserve airway patency. Pressure Ulcers, Wounds, and Wound Management: Priority Action for Management of Evisceration (Active Learning Template - System Disorder, RM FUND RN 9.0 Ch 55) • Dehiscence is a partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers. Evisceration is a dehiscence that involves the protrusion of visceral organs through a wound opening. • In the event of an evisceration, the nurse should first all for help. Notify the provider immediately due to the need for surgical intervention. Stay with the client, cover the wound and any protruding organs with sterile towels or dressings soaked with sterile normal saline solution to decrease the chance of bacteria invasion and drying of the tissue. Do not attempt to reinsert the organs. • Next position the client supine with the hips and knees bent. Observe for indications of shock, maintain a calm environment, and keep the client NPO in preparation for returning to surgery. Respiratory Management and Mechanical Ventilation: Priority Finding to Report Following Extubation (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 19) • It is an important role of the nurse to find and report any abnormal finding when caring for a patient following extubation. • It is important to maintain a patent airway, have a resuscitation bag with a face mask available at the bedside at all times in case of ventilator malfunction or accidental extubation. • Following extubation, monitor for signs of respiratory distress or airway obstruction, such as ineffective cough, dyspnea, and strictor. Unexpected Response to Therapies (2 items) Blood and Blood Product Transfusions: Caring for a Client Who Is Experiencing a Febrile Reaction (RN QSEN – Safety, Active Learning Template - Therapeutic Procedure, RM AMS RN Chp 40) • Complications of blood transfusions may relate to your patient’s physical ability to tolerate the procedure or to the blood product or administration process. • First stop the transfusion and maintain IV access by infusing normal saline solution through new tubing at a slow rate. For any suspected reaction, perform a physical assessment. Many reactions have similar symptoms or mimic the symptoms of other acute or chronic conditions. • Febrile non-hemolytic transfusion reactions account for about 90% of all reactions. Most common in patients who are immunosuppressed or pregnant, these reactions develop as the recipient’s antibodies react to the antigens contained in donor blood, usually to leukocytes or plasma proteins. Renal Calculi: Identifying Nephrostomy Tube Complications (RN QSEN - Safety, Active Learning Template – System Disorder, RM AMS RN 10.0 Chp 61) • The majority of calculi are composed of calcium phosphate or calcium oxalate, but they can contain other substances. Flank pain suggests calculi are located in the kidney or ureter, pain intensifies as the calculus moves through the ureter. • Calculus can be removed by open surgery. A surgical incision is used for large or impacted calculi or for calculi not removed by other approaches. • Expected findings of renal calculi are; fever, diaphoresis, pallor, nausea/vomiting, tachycardia, tachypnea, increased blood pressure (pain), or decreased blood pressure.