HLTH 216 VATI RN 2ND COMPREHENSIVE PREDICTOR FOCUSED REVIEW Management of Care – (5) Case Management – (1) Cardiovascular Disorders: Tetralogy of Fallot (RM NCC RN 10.0 Chp 20) • Def... ects that decreases pulmonary blood flow have an obstruction of pulmonary blood flow and an anatomic defect ( ASD or VSD) between the right and left sides of the heart. In these defects, there is a right to left shift allowing deoxygenated blood to enter the systemic circulation. Hypercyanotic spells (blue, or “Tet,” spells) manifest as acute cyanosis and hyperpnea • Tetralogy of fallot – four defects that result in mixed blood flow: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy • Cyanosis at birth: progressive cyanosis over the first year of life • Systolic murmur • Episodes of acute cyanosis and hypoxia (blue or “Tet” spells) • Surgical procedures – shunt placement until able to undergo primary repair; complete repair within first year of life Collaboration with Interdisciplinary Team – (1) Communicable Diseases, Disasters, and Bioterrorism: CDC Reportable Diagnoses (RM CH RN 7.0 Chp 6) • Anthrax, Botulism, Cholera, Congenital rubella syndrome (CRS), Diphtheria, Giardiasis, Gonorrhea, Hepatitis A, B, C, HIV infection, influenza-associated pediatric mortality, Legionellosis/Legionnaires’ disease, Lyme disease, Malaria, Meningococcal disease, Mumps, Pertussis (whooping cough), Poliomyelitis, paralytic, Poliovirus infection, nonparalytic, Rabies (human or animal), Rubella (German measles), Salmonellosis, Severe acute respiratory syndrome-associated coronavirus disease (SARS-CoV), Shigellosis, Smallpox, Syphillis, Tetanus/C. Tetani, Toxic Shock Syndrome (TSS) (other than streptococci), Tuberculosis (TB), Typhoid fever, Vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus (VISA/VRSA) Concepts of Management – (1) Managing Client Care: Conflict Management Between Health Care Workers (RM Leadership 7.0 Chp 1) • Conflict is the result of opposing thoughts, ideas, feelings, perceptions, behaviors, values, opinions, or actions between individuals. Conflict is an inevitable part of professional, social, and personal life and can have constructive or destructive results. Nurses must understand conflict and how to manage it. Nurses can use problem-solving and negotiation strategies to prevent a problem from evolving into a conflict. Lack of conflict can create organizational stasis, while too much conflict can be demoralizing, produce anxiety, and contribute to burnout. Conflict can disrupt working relationships and create a stressful atmosphere. If conflict exists to the level that productivity and quality of care are compromised, the unit manager must attempt to identify the origin of the conflict and attempt to resolve it. Continuity of Care – (1) Information Technology: Change-of-Shift Report (RM FUND 9.0 Chp 5) • Nurses give this report at the conclusion of each shift ot the nurse assuming responsibility for the clients. Formats include face to face, audiotaping, or presentation during walking rounds in each client’s room (unless the client has a roommate or visitors are present). An effective report should: include significant objective information about the client’s health problems, proceed in a logical sequence, include no gossip or personal opinion, and relate recent changes in medications, treatments, procedures, and the discharge plan. Establishing Priorities – (1) Managing Client Care: Prioritizing Care of Postoperative Clients (RM Leadership 7.0 Chp 1) • Prioritize systemic before local (“life before limb”) • Prioritize acute (less opportunity for physical adaptation) before chronic (greater opportunity for physical adaptation) • Prioritize actual problems before potential future problems • Listen carefully to clients and don’t assume • Recognize and respond to trends vs. transient findings • Recognize indications of medical emergencies and complications vs. expected findings • Apply clinical knowledge to procedural standards to determine the priority actions Safety and Infection Control – (8) Accident/Error/Injury Prevention – (1) Seizures: Maintaining Seizure Precautions (RM NCC RN 10.0 Chp 13) • Maintain seizure precautions, including placing the bed in the lowest position and padding the side rails to prevent future injury. Emergency Response Plan – (1) Client Safety: Priority Action for Fire (RM FUND 9.0 Chp 12) • R: rescue and protect clients in close proximity to the fire by moving them to a safer location. Clients who are ambulatory may walk independently in a safe location • A: alarm: activate the facility’s alarm system and then report the fire’s details and location • C: contain/confine the fire by closing doors and windows and turning off any sources of oxygen and any electrical devices. Ventilate clients who are on life support with a bag valve mask • E: extinguish the fire is possible using the appropriate fire extinguisher Handling Hazardous and Infectious Materials – (1) Cancer Treatment Options: Implanted Internal Radiation Device (RM AMS RN 10.0 Chp 91) • Brachytherapy describes internal radiation that is placed close to the target tissue. This is done via placement in a body orifice (vagina) or body cavity (abdomen) or delivered via IV such as with radionuclide iodine, which is absorbed by the thyroid. • Brachytherapy provides radiation to the tumor and a limited amount to surrounding normal tissues. • Waste products are radioactive until the isotope has been completely eliminated from the body. Waste products should not be touched by anyone. • Nursing considerations: • Place the client in a private room away from other clients when possible. Keep door closed as much as possible. • Place a sign on the door warning of the radiation source. • Wear a dosimeter film badge that records personal amount of radiation exposure. • Limit visitors to 30-min visits, and have visitors maintain a distance of 6 feet from the source. • Visitors and health care personnel who are pregnant or under the age of 18 should not come into contact with the client or radiation source. • Wear a lead apron while providing care keeping the front of the apron facing the source of radiation. • Keep a lead container in the client’s room if the delivery method could allow spontaneous loss of radioactive material. Tongs are available for placing radioactive material into this container. • Follow protocol for proper removal of dressings and bed linens from the room. • Client education: • Inform the client of the need to remain in an indicated position to prevent dislodgement of the radiation implant. • Instruct the client to call the nurse for assistance with elimination. • Instruct the client and family about radiation precautions needed in health care and home environments. Home Safety – (1) Home Safety: Identifying Potential Hazards in the Home (RM FUND 9.0 Chp 13) • Remove items that could cause the client to trip, such as throw rugs and loose carpets. Place electrical cords and extension cords against a wall behind furniture. Monitor gait and balance, and provide aids as needed. Make sure that steps and sidewalks are in good repair. Place grab bars near the toilet and in the tub or shower, and install a stool riser. Use a nonskid mat in the tub or shower. Place a shower chair in the shower and provide a bedside commode if needed. Ensure that lighting is adequate inside and outside the home. Standard Precautions/Transmission-Based Precautions/Surgical Asepsis – (3) Acute Neurological Disorders: Priority Intervention for Meningitis (RM NCC Rn 10.0 Chp 12) • The presence of petechiae or a purpuric-type rash requires immediate medical attention. Isolate the client as soon as meningitis is suspected, and maintain droplet precautions per facility protocol. Droplet precautions require a private room or a room with clients who have the same infectious disease, ensuring that each client has his or her own designated equipment. Providers and visitors should wear a mask. Maintain respiratory isolation for a minimum of 24 hr after initiation of antibiotic therapy. Cancer Treatment Options: Neutropenia Precautions (RM AMS RN 10.0 Chp 91) • Precautions: • Have the client remain in the room unless he needs to leave for a diagnostic procedure or therapy. In this case, place a mask on him during transport. • Protect the client from possible sources of infection (plants, change water in equipment daily) • Have client, staff, and visitors perform frequent hand hygiene. Restrict visitors who are ill. • Avoid invasive procedures that could cause a break in tissue (rectal temperatures, injections, indwelling urinary catheters) unless necessary. • Keep dedicated equipment (blood pressure machine, thermometer, stethoscope) in the client’s room. • Administer colony-stimulating factors (filgrastim) as prescribed to stimulate WBC production • Client Education: • Encourage the client to avoid crowds while undergoing chemotherapy. • Take temperature daily. Report elevated temperature to the provider. • Avoid food sources that could contain bacteria (fresh fruits and vegetables; undercooked meat, fish, and eggs; pepper and paprika) • Avoid yard work, gardening, or changing a pet’s litter box • Avoid fluids that have been sitting at room temperature for longer than 1 hr. • Wash all dishes in hot, soapy water or a dishwater. Wash glasses and cups after each use. • Wash toothbrush daily in the dishwater or rinse in a bleach solution. • Do not share toiletry or personal hygiene items with others. • Report fever greater than 37.8’C (100’F) or other manifestations of bacterial or viral infections immediately to the provider. Infection Control: Appropriate Actions for a Client Who Has Methicillin-Resistant Staphylococcus Aureus (MRSA) (RM FUND 9.0 Chp 11) • Use frequent and effective hand hygiene before and after care. • Educate the client about the required and recommended immunizations and where to obtain them. The target groups include children, older adults, those with chronic disease, and those who are immunocompromised and their families and contacts. • Educate the client and ask for a return demonstration of good oral hygiene. Good oral hygiene decreases the protein (which attracts micro-organisms) in the oral cavity, which thereby decreases the growth of micro-organisms that can migrate through breaks in the oral mucosa. • Encourage the client to consume an adequate amount of fluids. Adequate fluid intake prevents the stasis of urine by flushing the urinary tract and decreasing the growth of micro-organisms. Adequate hydration also keeps the skin from breaking down. Intact skin prevents micro-organisms from entering the body. • For immobile clients, ensure that pulmonary hygiene (turning, coughing, deep breathing, incentive spirometry) is done every 2 hr, or as prescribed. Good pulmonary hygiene decreases the growth of micro-organisms and the development of pneumonia by preventing stasis of pulmonary excretions, stimulating ciliary movement and clearance, and expanding the lungs. • Use of aseptic technique and proper personal protective equipment (such as gloves, masks, gowns, and goggles) in the provision of care to all clients prevents unnecessary exposure to micro-organisms. • Teach and use respiratory hygiene/cough etiquette. It applies to anyone entering a health care setting (clients, visitors, staff) with signs or symptoms of illness, whether diagnosed or undiagnosed. This includes cough, congestion, rhinorrhea, or an increase in the production of respiratory secretions. The components of respiratory hygiene and cough etiquette include: • Covering the mouth and nose when coughing and sneezing • Using facial tissues to contain respiratory secretions and disposing of them promptly into a hands-free receptacle • Wearing a surgical mask when coughing to minimize contamination of the surrounding environment • Turning the head when coughing and staying a minimum of 3 ft away from others, especially in common waiting areas • Performing hand hygiene after contact with respiratory secretions and contaminated objects/materials Use of Restraints/Safety Devices – (1) Client Safety: Appropriate Use of Physical Restraints (RM FUND 9.0 Chp 12) • Restraints can be either physical (devices that restrict movement: vest, belt, mitt, limb) or chemical, such as sedatives and neuroleptic or psychotropic medications to calm the client • Restraints can cause complications, including pneumonia, incontinence, and pressure ulcers • It is inappropriate to use seclusion or restraints for: convenience of the staff, punishment for the client, clients who are extremely physically or mentally unstable, clients who cannot tolerate the decreased stimulation of a seclusion room • Restraints should: never interfere with treatment, restrict movement as little as is necessary, fit properly and be as discrete as possible, and be easy to remove or change • In an emergency situation when there is immediate risk to the client or others, nurses may place restraints on a client. The nurse must obtain a prescription from the provider as soon as possible according to the facility’s policy (usually within 1 hr). • The prescription must include the reason for the restraints, the type of restraints, the location of the restraints, how long to use the restraints, and the type of behavior that warrants using the restraints. • The prescription allows only 4 hr of restraints for an adult, 2 hr for clients ages 9-17, and 1 hr for clients younger than 9 years of age. Providers may renew these prescriptions with a maximum of 24 consecutive hours. • Providers cannot write PRN prescriptions for restraints. Health Promotion and Maintenance – (5) Ante/Intra/Postpartum and Newborn Care – (1) Newborn Nutrition: Effective Breastfeeding (RM MN RN 10.0 Chp 25) • Place the newborn skin-to-skin on the mother’s chest immediately after birth. Initiate breastfeeding as soon as possible or within the first 30 min following birth. Have the mother wash her hands, get comfortable, and have caffeine-free, nonalcoholic fluids to drink during breastfeeding. Explain the let-down reflex (stimulation of maternal nipple releases oxytocin that causes the let-down of milk). Reassure the mother than uterine cramps are normal during breastfeeding, resulting from oxytocin, which also promote uterine involution. Express a few drops of colostrum or milk and spread it over the nipple to lubricate the nipple and entice the newborn. Show the mother the proper latch-on position. Have her support the breast in one hand with the thumb on top and four fingers underneath. With the newborn’s mouth in front of the nipple, the newborn can be stimulated to open his mouth by tickling his lower lip with the tip of the nipple. The mother pulls the newborn to the nipple with his mouth covering part of the areola as well as the nipple. Explain to the mother than when her newborn is latched on correctly, his nose, cheeks, and chin will be touching her breast. Hunger cues include hand to mouth or hand to hand movements, sucking motions, and rooting reflex. Demonstrate the four basic breastfeeding positions: football hold (under the arm), cradle (most common) or modified cradle (across the lap), and side-lying. Encourage the mother to breastfeed at least 15-20 min per breast to ensure that her newborn receives adequate fat and protein, which is richest in the breast milk as it empties the breast. Newborns need to breastfed at least 8-12 times in a 24 hr period. Explain to the mother that newborns will niurse on demand after a pattern is established. Show the mother how to insert a finger in the side of the newborn’s mouth to break the suction from the nipple prior to removing the newborn from the breast to prevent nipple trauma. Tell the mother to begin the newborn’s next feeding with the breast she stopped feeding him with in the previous feeding. Tell the mother how to tell if her newborn is receiving adequate feeding (gaining weight, voiding 6-8 diapers per day, and contentedness between feedings). Explain to the mother that the newborn can have loose, pale, and/or yellow stools during breastfeeding, and that this is normal. Tell the mother to avoid nipple confusion in the newborn by not offering supplemental formula, pacifier, or soothers until breastfeeding has been established typically 2-3 weeks. Tell the mother to always place her newborn on his back after feedings. Herbal products, such as fenugreek or blessed thistle, and prescription medications, such as metoclopramide, have been reported to increase breast milk production. There is insufficient data to confirm or deny their effect on lactation. Mothers should check with the provider before taking over-the-counter or prescription medications. Developmental Stages and Transitions – (1) Burns: Dressing Change on a School-Age Child (RM NCC RN 10.0 Chp 32) • The nurse should premedicate the child before performing a dressing change. Use nonpharmacologic methods for pain control (guided imagery, music therapy, therapeutic touch) to enhance the effects of analgesics and promote improved pain management. Health Promotion/Disease Prevention – (2) Infections: Client Assignment for Pregnant Personnel (RM MN RN 10.0 Chp 8) • Brachytherapy involves the implantation of a sealed radiation source within the targeted tumor tissue. A client who is wearing a solid implant emits radiation as long as the implant is in place; however, the client’s excreta is not radioactive. Pregnant nurses should not care for such clients. There are no contraindications to having a pregnant nurse care for a client under enteric precautions, a client with cancer who is receiving a continuous infusion or intravenous therapy, or a client who requires frequent wound irrigation. Prenatal Care: Risks for the Adolescent Client (RM MN RN 10.0 Chp 4) • Preterm births, low-birth weight infants, cephalopelvic disproportion, iron deficiency anemia, and preeclampsia-eclampsia and its sequelae. In the adolescent age group, prenatal care is the critical factor that most influences pregnancy outcome. Lifestyle Choices – (1) Contraception: Triage Clients on Different Types of Birth Control Methods (RM MN RN 10.0 Chp 1) • Abstinence: if complete abstinence is maintained there are no risks • Coitus interruptus (withdrawal): depends on a man’s ability to control ejaculation. Leakage of fluid that contains spermatozoa prior to ejaculation can be deposited in vagina. Risk of pregnancy • Calendar method (Rhythm method): various factors can affect change, the time of ovulation and cause unpredictable menstrual cycles. Risk of pregnancy. • Basal body temperature (BBT): Risk of pregnancy • Billings Method (Cervical Mucus Method): Assessment of cervical mucus characteristics may be inaccurate if mucus is mixed with semen, blood, contraceptive foams, or discharge from infections. Risk of pregnancy. • Condoms: condoms can rupture or leak potentially resulting in an unwanted pregnancy. Condoms have a one-time usage, which creates a replacement cost. Only water-soluble lubricants should be used with latex condoms to avoid condom breakage. • Diaphragm and spermicide: not recommended for clients who have a history of toxic shock syndrome (TSS) or frequent, recurrent urinary tract infections. Increased risk of acquiring TSS. Proper hand hygiene aids in prevention of TSS as well as removing diaphragm promptly at 6 hours following coitus. • Combined oral contraceptives: oral contraceptive effectiveness decreases when taking medications that affect liver enzymes such as anticonvulsants and some antibiotics. Psychosocial Integrity – (5) Abuse/Neglect – (1) Family Violence: Evaluating Child Abuse (RM MH RN 10.0 Chp 32) • Risk factors for abuse toward a child: the child is under 3 years of age; a perpetrator perceives the child as being different (the child is the result of an unwanted pregnancy, is physically disabled, or has some other trait that makes him particularly vulnerable). • Infant assessment – shaken baby syndrome (shaking can cause intracranial hemorrhage. Assess for respiratory distress, bulging fontanels, and an increase in head circumference. Retinal hemorrhage can be present). Any bruising on an infant before age 6 months is suspicious. • Preschoolers to adolescents assessment – assess for unusual bruising, such as on abdomen, back, or buttocks. Bruising is common on arms and legs in these age groups. Assess the mechanism of injury, which might not be congruent with the physical appearance of the injury. Numerous bruises at different stages of healing can indicate ongoing beatings. Be suspicious of bruises or welts that resemble the shape of a belt buckle or other object. Assess for burns. Burns covering “glove” or “stocking” areas of the hands or feet can indicate forced immersion into boiling water. Small, round burns can be from lit cigarettes. Assess for fractures with unusual features, such as forearm spiral fractures, which could be a result of twisting the extremity forcefully. The presence of multiple fractures is suspicious. Assess for human bite marks. Assess for head injuries: level of consciousness, equal and reactive pupils, and nausea or vomiting. Behavioral Interventions – (1) Anxiety Disorders: Planning Care for a Client who has Obsessive Compulsive Disorder (RM MH RN 10.0 Chp 11) • Provide a structured interview to keep the client focused on the present. Assess for comorbid condition of substance use disorder. Provide safety and comfort to the client during the crisis period of these disorders, as clients in severe- to panic-level anxiety are unable to problem solve and focus. Clients experiencing panic-level anxiety benefit from a calm, quiet environment. Remain with the client during the worst of the anxiety to provide reassurance. Perform a suicide risk assessment. Provide a safe environment for other clients and staff. Provide milieu therapy that employs the following: a structured environment for physical safety and predictability; monitoring for, and protection from, self-harm or suicide; daily activities that encourage the client to share and be cooperative; use of therapeutic communication skills, such as open-ended questions, to help the client express feelings of anxiety, and to validate and acknowledge those feelings; client participation in decision making regarding care. Use of relaxation techniques with the client as needed for relief of pain, muscle tension, and feelings of anxiety. Instill hope for positive outcomes (but avoid false reassurance). Enhance client self-esteem by encouraging positive statements and discussing past achievements. Assist the client to identify defense mechanisms that interfere with recovery. Postpone health teaching until after acute anxiety subsides. Clients experiencing a panic attack or severe anxiety are unable to concentrate or learn. Mental Health Concepts – (3) Anxiety Disorders: Expected Findings for a Client who has Social Anxiety Disorder (RM MH RN 10.0 Chp 11) • Social anxiety disorder (social phobia) – the client experiences excessive fear of social or performance situations • The client reports difficulty performing or speaking in front of others or participating in social situations due to an excessive fear of embarrassment or poor performance. • The client might report physical manifestations (actual or factitious) in an attempt to avoid the social situation or need to perform Eating Disorders: Short-Term Goal for Client who have Anorexia Nervosa (RM MH RN 10.0 Chp 19) • Provide a highly structure milieu in an acute care unit for the client requiring intensive therapy. Develop and maintain a trusting nurse/client relationship through consistency and therapeutic communication. Use a positive approach and support to promote client self-esteem and positive self-image. Encourage client decision making and participation in the plan of care to allow for a sense of control. Use behavioral contracts to modify client behaviors. Reward the client for positive behaviors, such as completing meals or consuming a set number of calories. Personality Disorders: Antisocial Personality Manifestations (RM MH RN 10.0 Chp 16) • Antisocial – characterized by disregard for others with exploitation, lack of empathy, repeated unlawful actions, deceit, and failure to accept personal responsibility; sense of entitlement, manipulative, impulsive, and seductive; nonadherence to traditional morals and values; verbally charming and engaging. Basic Care and Comfort – (4) Assistive Devices – (2) Ergonomic Principles: Use of a Standard Walker (RM FUND 9.0 Chp 14) • The walker and affected leg move forward, then the patient should move the unaffected leg parallel to the affected leg. Sensory Perception: Speaking to a Client Who Has a Hearing Impairment (RM FUND 9.0 Chp 45) • Sit and face the clients. Avoid covering your mouth while speaking. Encourage the use of hearing devices. Speak slowly and clearly. Do not shout. Try lowering vocal pitch before increasing volume. Use brief sentences with simple words. Write down what clients do not understand. Minimize background noise. Ask for a sign-language interpreter if necessary. Elimination – (1) Urinary Elimination: Three-Way Indwelling Catheter (RM FUND 9.0 Chp 44) • Continuous bladder irrigation. Prostate issues. Nutrition and Oral Hydration – (1) Renal Disorders: Dietary Prevention of Nephrolithiasis (RM Nutrition 6.0 Chp 14) • Excessive intake of protein, sodium, calcium, and oxalates (rhubarb, spinach, beets) can increase the risk of stone formation Pharmacological and Parenteral Therapies – (12) Adverse Effects/Contraindications/Side Effects/Interactions – (3) Chronic Neurologic Disorders: Teratogenic Risks to the Fetus (RM Pharm RN 7.0 Chp 13) • Minor anomalies, major congenital malformations, intrauterine growth retardation, cognitive dysfunction, low IQ, microcephaly, and infant mortality. Medications for Psychotic Disorders: Screening for Extrapyramidal Adverse Effects (RM MH RN 10.0 Chp 24) • Extrapyramidal symptoms associated with antipsychotics: first generation (conventional): • Acute dystonia Manifestations: severe spasm of the tongue, neck, face, and back; crisis situation that requires rapid treatment Nursing considerations: begin to monitor for acute dystonia anywhere between 1-5 days after administration of first dose. Treat with an antiparkinsonian agents such as benztropine. IM or IV administration diphenhydramine can also be beneficial. Stay with the client and monitor the airway until spasms subside (usually 5-15 min). • Pseudoparkinsonism Manifestations: bradykinesia; rigidity; shuffling gait; drooling; tremors Nursing considerations: observe for pseudoparkinsonism for the first month after the initiation of therapy. Can occur in as little as 5 hr following the first dose. Treat with an antiparkinsonian agent, such as benztropine or trihexyphenidyl. Implement interventions to reduce the risk for falling. • Akathisia Manifestations: inability to sit or stand still; continual pacing and agitation Nursing considerations: observe for akathisia for the first 2 months after the initiation of treatment. Can occur in as little as 2 hr following the first dose. Manage with antiparkinsonian agents, beta blockers, or lorazepam/diazepam. Monitor for increased risk for suicide in clients who have severe akathisia. • Tardive dyskinesia (TD) Manifestations: late EPS, which can require months to years of medication therapy for TD to develop. Involuntary movements of the tongue and face, such as lip smacking and tongue fasciculations. Involuntary movements of the arms, legs, and trunk. Nursing considerations: evaluate the client every 3 months, if TD appears, dosage should be lowered, or the client should be switched to another type of antipsychotic agent. Once TD develops, it usually does not decrease, even with discontinuation of the medication. There is not a treatment for TD. Teach client that purposeful muscle movement helps to control the involuntary TD. • Neuroendocrine effects Manifestations: gynecomastia; weight gain; menstrual irregularities Nursing considerations: monitor weight. Some clients gain 100 lb or more. Advise the client to observe for these manifestations and to notify the provider if they occur. • Neuroleptic malignant syndrome Manifestations: sudden high fever; blood pressure fluctuations; diaphoresis; tachycardia; muscle rigidity; drooling; decreased level of consciousness; coma; tachypnea Nursing considerations: this life-threatening medical emergency can occur within the first week of treatment or any time thereafter. Stop antipsychotic medication. Monitor vital signs. Apply cooling blankets. Administer antipyretics. Increase the client’s fluid intake. Administer dantrolene or bromocriptine to induce muscle relaxation. Administer medication as prescribed to treat arrhythmias. Assist with immediate transfer to an ICU. • Orthostatic hypotension Nursing considerations: the client should develop tolerance in 1-2 weeks. Monitor blood pressure and heart rate for orthostatic changes. Hold medication until the provider is notified if systolic blood pressure is less than 80 mm Hg. Instruct clients about the indications of orthostatic hypotension (lightheadedness, dizziness). If these occur, advise the client to sit or lie down. Orthostatic hypotension can be minimized by getting up or changing positions slowly. Encourage the client to increase fluid intake to maintain hydration. • Sedation Nursing considerations: inform the client that effects should diminish after about 1 week. Instruct the client to take the medication at bedtime to avoid daytime sleepiness. Advise the client not to drive until sedation has subsided. • Seizures Indications: greatest risk in clients who have an existing seizure disorder. Nursing considerations: advise the client to report seizure activity to the provider. An increase in antiseizure medication can be necessary. • Severe dysrhythmias Nursing considerations: obtain baseline ECG and potassium level prior to treatment, and periodically throughout the treatment period. Avoid concurrent use with other medications that prolong QT interval. • Sexual dysfunction – common in both males and females Nursing considerations: advise the client of possible adverse effects. Encourage that the client report effects to the provider. The client can need dosage lowered or be switched to a high-potency agent. • Skin effects Manifestations: photosensitivity that can result in severe sunburn. Contact dermatitis from handling medications. Nursing considerations: advise clients to avoid excessive exposure to sunlight, to use sunscreen, and to wear protective clothing. Advise clients to avoid direct contact with the medication. • Liver impairment Nursing considerations: assess baseline liver function, and monitor periodically. Educate client to observe for indications (anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice) and to notify the provider. Nonopioid Analgesics: Laboratory Values for Acetaminophen Overdose (RM Pharm RN 7.0 Chp 35) • Acetaminophen slows the metabolism of warfarin, leading to increased levels of warfarin. This places clients at risk for bleeding. • Nursing considerations: instruct clients to observe for indications of bleeding (bruising, petechiae, hematauria). Monitor prothrombin time and INR levels and adjust dosages of warfarin accordingly. Blood and Blood Products – (1) Cancer Treatment Options: Outcomes of Platelet Transfusion (RM AMS RN 10.0 Chp 91) • Cancer patients may need platelet transfusions if their bone marrow is not making enough. This happens when platelet-producing bone marrow cells are damaged by chemo or radiation therapy or when they are crowded out of the bone marrow by cancer cells. Central Venous Access Devices – (1) Cardiovascular Diagnostic and Therapeutic Procedures: Care of the Nontunneled Percutaneous Central Venous Catheter (RM AMS RN 10.0 Chp 27) • Description: 18-25 cm (7-10 in) in length with one to five lumens • Length of use: short-term use only • Insertion locations: subclavian vein, jugular vein, tip in the distal third of the superior vena cava • Indications: administration of blood, long-term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition • Assess the site for redness, swelling, drainage, tenderness, and condition of the dressing. Clean the insertion port with alcohol for 15 seconds and allowing it to dry completely prior to accessing it. Valve disinfection caps which contain alcohol are available for single use. Use transparent dressing to allow for visualization. Follow facility protocol for dressing changes, usually every 7 days and when indicated (wet, loose, soiled). • Follow the Infusion Nurses Society (INS) practice recommendations for flushing – use a 10 mL syringe for flushing the PICC line. Do not apply force if resistance is met. Flush with 10 mL 0.9% sodium chloride after drawing blood. Flush with 5 mL heparin (10 units/mL) when the PICC is not actively in use. The frequency of the flush depends on the type of PICC. Expected Actions/Outcomes – (3) Medications for Psychotic Disorders: Nursing Actions for Antipsychotic Therapy (RM MH RN 10.0 Chp 24) • Antipsychotics: First-generation (conventional) – Use the Abnormal Involuntary Movement Scale (AIMS) to screen for the presence of EPS. Assess the client to differentiate between EPSs and worsening of psychotic disorder. Administer anticholinergics, beta-blockers, and benzodiazepines to control early EPS. If adverse effects are intolerable, a client can be switched to a low-potency or atypical antipsychotic agent. Advise clients that antipsychotic medications rarely cause physical or psychological dependence. Advise clients to take medication as prescribed and on a regular schedule. Advise clients that some therapeutic effects can be noticeable within a few days, but significant improvement can take 2-4 weeks, and possibly several months for full effects. Consider depot preparations (haloperidol decanoate, fluphenazine decanoate), administered IM once every 3-4 weeks, for clients who have difficulty maintaining a medication regimen. Inform the client that lower doses can be used with depot preparations, which will decrease the risk of adverse effects and the development of tardive dyskinesia. Begin administration with twice-daily dosing, but switch to daily dosing at bedtime to decrease daytime drowsiness and promote sleep. • Antipsychotics: Second- and third-generation (atypical) – Risperidone also is available as a depot injection administered IM once every 2 weeks, and the extended-release injection of paliperidone is administered every 28 days. Ariprprazole also has a long-acting injectable which is administered on a monthly basis. This method of administration is a good option for clients who have difficultly adhering to a medication schedule. Therapeutic effect occurs 2-6 weeks after first injection depot. Advise clients that low doses of medication are given initially, and dosages are then gradually increased (“Start low and go slow”). Use oral disintegrating tablets for clients who can attempt to “cheek” or “pocket” tablets, or for those who have difficulty swallowing them. Advise clients taking asenapine to avoid eating or drinking for 10 min after each dose. Administer lurasidone and ziprasidone with food to increase absorption. The cost of antipsychotic medications can be a factor for some clients. Assess the need for case management intervention. Osteoarthritis and Low-Back Pain: Dietary Supplements (RM AMS RN 10.0 Chp 72) • Glucosamine supplements • Glucosamine is a naturally occurring chemical involved in the makeup of cartilage. Glucosamine sulfate is believed to aid in the synthesis of synovial fluid and rebuild cartilage. • Glucosamine can decrease the cells that cause joint inflammation and degradation of cartilage. • Glucosamine is often takin in combination with chondroitin and might not have a pain reduction effect. • Client education – consult the provider regarding use and dosage. Contraindicated for clients who have hypertension or are pregnant or breastfeeding. Chondroitin can cause bleeding, especially for clients taking anticoagulants. Can cause mild GI upset (nausea, heartburn). Use with caution with shellfish allergy. Question clients about concurrent use of chondroitin, NSAIDs, heparin, and warfarin. Parkinson’s Disease: Effects of Levodopa (RM AMS RN 10.0 Chp 7) • Dizziness upon rising, confusion, movement disorders, nausea, and hallucinations Medication Administration – (2) Cystic Fibrosis: Client Teaching about Pancrelipase (RM NCC RN 10.0 Chp 19) • Pancrelipase treats pancreatic insufficiency associated with cystic fibrosis • Nursing considerations – monitor stools for adequate dosing (1-2 stools/day). Administer capsules with all meals and snacks. Client can swallow or sprinkle capsules on food. Increase dosage of enzymes when eating high-fat foods. Electrolyte Imbalances: Safe Potassium Administration (RM AMS RN 10.0 Chp 44) • Never give potassium via IM or subcutaneous route, which can cause necrosis of the tissues. • Replacement of potassium – encourage foods high in potassium: avocados, broccoli, dairy products, dried fruit, cantaloupe, bananas, juices, melon, lean meats, milk, whole grains, and citrus fruits. Provide oral potassium supplementation. • IV potassium supplementation – never administer by IV push (high risk of cardiac arrest). The maximum recommended rate is 10 mEq/hr. Parenteral/Intravenous Therapies – (2) Dosage Calculation: Calculating IV Rate Using Ratio and Proportion (RM Pharm RN 7.0 Chp 3) • Have / Quantity = Desired / X Intravenous Therapy: Assessing an IV Site (RM FUND 9.0 Chp 49) • Infiltration or extravasation – pallor, local swelling at the site, decreased skin temperature around the site, damp dressing, slowed rate of infusion • Treatment: stop the infusion and remove the catheter. Elevate the extremity. Encourage active range of motion. Apply a warm or cold compress depending on the solution infusing. Restart the infusion proximal to the site or in another extremity. • Prevention: carefully select the site and catheter. Secure the catheter. • Phlebitis or thrombophlebitis – edema; throbbing; burning; or pain at the site; increased skin temperature; erythema; a red line up the arm with a palpable band at the vein site; slowed rate of infusion • Treatment: promptly discontinue the infusion and remove the catheter. Elevate the extremity. Apply warm compresses three to four times/day. Restart the infusion in a different vein proximal to the site or in another extremity. Obtain a specimen for culture at the site and prepare the catheter for culture if drainage is present. • Prevention: rotate sites at least every 72 hr or sooner according to the facility’s policy. Avoid the lower extremities. Use hand hygiene. Use surgical aseptic technique. • Hematoma – ecchymosis at the site • Treatment: do not apply alcohol. Apply pressure after IV catheter removal. Use a warm compress and elevation after the bleeding stops. • Prevention: minimize tourniquet time. Remove the tourniquet before starting the IV infusion. Maintain pressure after IV catheter removal. • Catheter embolus – missing catheter tip on removal; severe pain at the site with migration; absence of findings if no migration • Treatment: place a tourniquet high on the extremity to limit venous flow. Prepare for removal under x-ray or via surgery. Save the catheter after removal to determine the cause. • Prevention: do not reinsert the stylet into the catheter. Reduction of Risk Potential – (4) Laboratory Values – (1) Fluid Imbalances: Anticipated Laboratory Findings for Dehydration (RM AMS RN 10.0 Chp 43) • Hematocrit (Hct) – increased in hypovolemia • BUN – increased (greater 25 mg/dL) due to hemoconcentration • Urine specific gravity – greater than 1.030 • Serum sodium – greater than 145 mEq/L • Serum osmolality – greater than 295 mOsm/kg Potential for Complications of Diagnostic Tests/Treatments/Procedures – (1) Disorders of the Eye: Identifying Postoperative Risk (RM AMS RN 10.0 Chp 12) • Cataracts Complications • Infection – can occur after surgery Client education – manifestations of infection that the client should report include yellow or green drainage, increased redness or pain, reduction in visual acuity, increased tear production, and photophobia • Bleeding – is a potential risk several days following surgery Client education – clients should immediately report any sudden change in visual acuity or an increase in pain • Glaucoma Complications • Blindness – is a potential consequence of untreated glaucoma Client education – encourage adults 40 or older to have an annual examination, including a measurement of IOP Potential for Complications from Surgical Procedures and Health Alterations – (1) Pituitary Disorders: Clinical Findings of Diabetes Insipidus (RM AMS RN 10.0 Chp 77) • Polyuria (abrupt onset of excessive urination, urinary output of 4-30 L/day of dilute urine): failure of the renal tubules to collect and reabsorb water. Polydipsia (excessive thirst, consumption of 2-20 L/day). Nocturia, Fatigue, Dehydration, as evidenced by extreme thirst, weight loss, muscle weakness, headache, constipation, and dizziness. • Physical assessment findings – sunken eyes; tachycardia; hypotension; loss or absence of skin turgor; dry mucous membranes; weak, poor peripheral pulses; decreased cognition Therapeutic Procedures – (1) Cancer Disorders: Client Discharge Education for Ileal Conduit (RM AMS RN 10.0 Chp 92) • Instruct the client to self-catheterize and plan procedure at timed intervals since there is no sensation of bladder fullness (neobladder, continent pouch) • Teach the client to monitor peristomal skin for redness, excoriation, or infection (ileal conduit, continent pouch). • Ileal conduit ureter diversion – ileum • Ileal conduit portal of exit – abdominal stoma • Ileal conduit urinary elimination – continuous drainage into external pouch Physiological Adaptations – (7) Alterations in Body Systems – (2) Chest Tube Insertion and Monitoring: Expected Findings (RM AMS RN 10.0 Chp 18) • Client presentation – dyspnea; distended neck veins; hemodynamic instability; pleuritic chest pain; cough; absent or reduced breath sounds on the affected side; hyperresonance on percussion of affected side (pneumothorax); dullness or flatness on percussion of the affected side (hemothorax, pleural effusion); asymmetrical chest wall motion • Postprocedure • Monitor chest tube placement and function – check the water seal level every 2 hr, and add fluid as needed. The fluid level should fluctuate with respiratory effort. • Document the amount and color of drainage hourly for the first 24 hr and then at least every 8 hr. Mark the date, hour, and drainage levels on the container at the end of each shift. Report excessive drainage (greater than 70 mL/hr) or drainage that is cloudy or red to the provider. Drainage often increases with position changes or coughing. • Check for expected findings of tidaling in the water seal chamber and continuous bubbling only in the suction chamber. • Monitor the chest tube insertion site for redness, pain, infection, and crepitus (air leakage in subcutaneous tissue) Pituitary Disorders: Client Comfort (RM AMS RN 10.0 Chp 77) • Acromegaly – encourage deep breathing exercises, but limit coughing as this increases intracranial pressure and can cause a leak of cerebrospinal fluid (CSF) • Diabetes insipidus – add bulk foods and fruit juices to the diet if constipation develops. A laxative might be needed. Provide skin and mouth care, and apply a lubricant to cracked or sore lips. Use a soft toothbrush and milk mouthwash to avoid trauma to the oral mucosa. Use alcohol-free skin care products, and apply emollient lotion after baths. Encourage the client to drink fluids in response to thirst. • SIADH – restrict oral fluids to 500-1000 mL/day to prevent further hemodilution (first priority). During fluid restriction, provide comfort measures for thirst, such as mouth care, ice chips, lozenges, and staggered water intake. Reduce environmental stimuli and position the client as needed. Hemodynamics – (1) Electrocardiography and Dysrhythmia Monitoring: Identifying the Need for Anticoagulation Therapy (RM AMS RN 10.0 Chp 28) • Bradycardia (any rhythm less than 60/min) – treat if the client is symptomatic • Medication – atropine and isoproterenol • Electrical management – pacemaker • Atrial fibrillation/Supraventricular tachycardia/Ventricular tachycardia with pulse • Medication – amiodarone, adenosine, and verapamil • Electrical management – synchronized cardioversion • Ventricular tachycardia without pulse or ventricular fibrillation • Medication – amiodarone, lidocaine, and epinephrine • Electrical management – defibrillation Medical Emergencies – (2) Emergency Nursing Principles and Management: Priority Assessment (RM AMS RN 10.0 Chp 2) • ABCDE Principle • Airway/Cervical Spine • Breathing • Circulation • Disability • Exposure Spinal Cord Injury: Emergency Management (RM AMS RN 10.0 Chp 16) • Respiratory status – monitoring respiratory status is the first priority. Involuntary respirations can be affected due to a lesion at or above the phrenic nerve or swelling from a lesion immediately below C4. Lesions in the cervical or upper thoracic area will also impair voluntary movement of muscles used in respiration (increase in depth or rate). Provide oxygen and suction as needed. Assist with intubation and mechanical ventilation if necessary. Assist the client to cough by applying abdominal pressure when attempting to cough. Teach the client about incentive spirometer use, and encourage the client to perform coughing and deep breathing regularly. • Tissue perfusion – neurogenic shock, which a complication of spinal trauma, causes a sudden loss of communication within the sympathetic nervous system that maintains the normal muscle tone in blood vessel walls. Neurogenic shock can occur within 24 hr of a SCI, resulting in peripheral vasodilation that leads to venous pooling in the extremities, a drop in cardiac output and heart rate, and a life-threatening decrease in blood pressure. This complication can last for a several days to weeks. • Monitor for hypotension, dependent edema, and loss of temperature regulation, which are common manifestations. When in an upright position, clients who are in neurogenic shock will experience postural hypotension. Transferring the client to a wheelchair should occur in stages. Raise the head of the bed and be ready to lower the angle if the client report dizziness. Transfer the client into a reclining wheelchair with the back of the wheelchair reclined. Be ready to lock and lean the wheelchair back onto the knee to a fully reclined position if the client reports dizziness after the transfer. Do not attempt the return the client to the bed. Monitor for manifestations of thrombophlebitis (swelling of extremity, absent/decreased pulses, and areas of warmth and/or tenderness). The client might be on anticoagulants to prevent development of lower extremity thrombi. • Intake and output – the client might be NPO for several days. Regulation of fluid balance and nutritional support is necessary. Maintain an adequate fluid intake for the client. Fluid will aid in preventing urinary calculi and bladder infections, and will maintain soft stools. • Neurological status – after determining the baseline, monitor for an increasing loss of neurological function • Muscle strength and tone – after determining the baseline, monitor for an increasing loss of muscle strength in the affected extremities. Clients who have upper motor neuron injuries (above L1 and L2) will convert to a spastic muscle tone after neurogenic shock. Clients who have lower motor neuron lesions involve the cauda equina, the motor and sensory deficits can be patchy, with some areas of innervation and others without. Encourage active range-of-motion (ROM) exercises when possible, and assist with passive ROM if the client lacks all motor function • Mobility – clients who have complete injuries will not regain mobility. Clients who have incomplete injuries can regain some function that will allow mobility with various types of braces. However, functional mobility can still be best attained through use of wheelchair. • Sensation – varying degrees of loss of sensation will be experienced depending on whether the lesion is complete or incomplete. Take care to prevent skin breakdown in both the bed and wheelchair. Various types of foam and air mattresses are available for beds and wheelchairs. • Bowel and bladder function • Spastic neurogenic bladder – clients who have upper motor neuron injuries develop spastic bladder after the neurogenic shock resolves. Bladder management options for male clients include condom catheters and stimulation of the micturition reflex by tugging on the pubic hair. Female clients need to use an indwelling urinary catheter due to the unpredictably of the release of urine. [Show More]
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