VATI RN 2ND COMPREHENSIVE PREDICTOR FOCUSED REVIEW | VATI RN COMPREHENSIVE PREDICTOR _ 100%

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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) • Defects ... 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 - - - - - - - - - - - - • 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. • Flaccid neurogenic bladder – clients who have lower motor neuron injuries develop a flaccid bladder. Bladder management options for males and females include intermittent catheterization and Crede’s method (downward pressure placed on the bladder to manually express the urine). • Neurogenic bowel functioning does not differ much between upper and lower motor neuron injuries. Daily use of stool softeners or bulk-forming laxatives is recommended to keep the stool soft. A bowel movement can be stimulated daily or every other day by administration of a bisacodyl suppository or digital stimulation (stimulation of the rectal sphincter with a gloved and lubricated finger) only if requested by the provider. Digital stimulation should b eused cautiously to avoid provoking a vagal response, which can result in bradycardia and syncope. • Development of a schedule as part of bladder and bowel training is critical in preventing complications related to immobility and promoting adequate nutrition and fluid balance. • Gastrointestinal function – an ileus can develop immediately after injury. Monitor for bowel sounds • Skin integrity – changing the client’s position every 2 hr (every 1 hr when in a wheelchair) is critical. Clients who have a SCI can neither move nor feel pain from prolonged pressure. Pressure-relief devices in both the bed and the wheelchair must be consistently used. • Sexual function – teach the client about alterations in sexual function and possible adaptive strategies. Clients who have quadriplegia and other clients who have upper motor neuron lesions are usually capable of reflexogenic erections (erections secondary to manual manipulation). Ejaculation coordinated with emission might not occur. Clients who have lower motor neuron injuries are less able to have reflexogenic erections, but clients who have incomplete injuries might be able to have a combination of reflexogenic and psychogenic erections (erections stimulated by sexual thoughts and images). Administer medications as prescribed.  Unexpected Response to Therapies – (2)  Assessment and Management of Newborn Complications: Neonatal Abstinence Syndrome (RM MN RN 10.0 Chp 27) • Long-term complications – feeding problems; central nervous system dysfunction (cognitive impairment, cerebral palsy); attention deficit disorder; language abnormalities; microcephaly; delayed growth and development; poor maternal-newborn bonding  Postoperative Nursing Care: Prioritizing Assessment Findings Following a Mastectomy (RM AMS RN 10.0 Chp 96) • Airway • Circulation • Vital signs • Positioning • Response to anesthesia (sedation, nausea, vomiting) • Input and output • Surgical wound, incision site, dressing • Pain • Mentition [Show More]

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