ATI Guide MedSurg

ATI Guide MedSurg (Safety) Seizure precautions Epilepsy During Protect the client’s privacy and the client from injury (move furniture away, hold head in lap if on the floor). Position the client to provide a patent airway. (Remember aspiration, turn head to side) Be prepared to suction oral secretions. Turn the client to the side to decrease the risk of aspiration. Loosen restrictive clothing. Do not attempt to restrain the client. Do not attempt to open the jaw or insert airway during seizure activity (can damage teeth, lips, and tongue). Do not use padded tongue blades. Document onset and duration of seizure and findings (level of consciousness, apnea, cyanosis, motor activity, incontinence) prior to, during, and following the seizure Post Seizure This is the postictal phase of the seizure episode. Maintain the client in a side‑lying position to prevent aspiration and to facilitate drainage of oral secretions. Check vital signs. Assess for injuries. Perform neurological checks. Allow the client to rest if necessary. Reorient and calm the client, who might be agitated or confused. Determine if client experienced an aura, which can indicate the origin of seizure in the brain. Try to determine possible trigger (e.g., fatigue). (Precautions transmission): Tuberculosis Appropriate interventions • Prevent infection transmission. • Wear a N95 HEPA filter or powered air purifying respirator when caring for clients who are hospitalized with TB. (23.2) • Place the client in a negative‑airflow room, and implement airborne precautions. • Use barrier protection when the risk of hand or clothing contamination exists. • Have the client wear a surgical mask if transportation to another department is necessary. The client should be transported using the shortest and least busy route. • Teach the client to cough and expectorate sputum into tissues that are disposed of by the client into provided plastic bags or no‑touch receptacles. • Airborne precautions are not needed in the home setting because family members have already been exposed. Exposed family members should be tested for TB. • 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 • Sputum early AM (AFB, wear PPE) needed every 2 to 4 weeks to monitor Tx. After 3 consecutive negative, no longer consider infected • Dispose of tissues in plastic bag, wear mask in public • The client's infection is usually no longer contagious after taking TB medications for 2 to 3 weeks. Medical Surgical Asepsis: Maintain sterile field • Avoid coughing, sneezing, and talking directly over a sterile field. • Advice clients to avoid sudden movements, refrain from touching supplies, drapes, or the nurse’s gloves and gown, and avoid coughing, sneezing, or talking over sterile field • Only sterile items may be in a sterile field. • The outer wrappings and 1‑inch edges of packaging that contains sterile items are not sterile. The inner surface of the sterile drape or kit, except for that 1‑inch border around the edges, is the sterile field to which other sterile items may be added. To position the field on the table surface, grasp the 1‑inch border before donning sterile gloves. Discard any object that comes into contact with the 1‑inch border. • Touch sterile materials only with sterile gloves. • Consider any object held below the waist or above the chest contaminated. • Sterile materials may touch other sterile surfaces or materials; however, contact with nonsterile materials at any time contaminates a sterile area, no matter how short the contact. • Open drape furthest from body, then siders, than closest to body, grasp drape with finger tips and lay on surface • Cap off first, then glove non-dominant hand Microbes can move by gravity from a nonsterile item to a sterile item. • Do not reach across or above a sterile field. • Do not turn your back on a sterile field. • Hold items to add to a sterile field at a minimum of 6 inches above the field Any sterile, non-waterproof wrapper that comes in contact with moisture becomes nonsterile by a wicking action that allows microbes to travel rapidly from a nonsterile surface to the sterile surface. • Keep all surfaces dry. • Discard any sterile packages that are torn, punctured, or wet. PROCEDURE Perform hand hygiene. STERILE FIELD SETUP • Open the covering of the package per the manufacturer’s directions, slipping the package onto the center of the workspace with the top flap of the wrapper opening away from the body. • Grasp the tip of the top flap of the package, and with arm positioned away from the sterile field, unfold the top flap away from body. • Next, open the side flaps, using the right hand for the right flap and the left hand for the left flap. • Grasp the last flap and turn it down toward the body ADDITIONAL STERILE PACKAGES • Open next to the sterile field by holding the bottom edge with one hand and pulling back on the top flap with the other hand. Place the packages that will be used last furthest from the sterile field; open these first. • Add them directly to the sterile field. Lift the package from the dry surface, holding it 15 cm (6 in) above the sterile field, pulling the two surfaces apart, and dropping it onto the sterile field. POUR STERILE SOLUTIONS • Removing the bottle cap. • Placing the bottle cap face up on a clean (nonsterile) surface. • Holding the bottle with the label in the palm of the hand so that the solution does not run down the label. • First pouring a small amount (1 to 2 mL) of the solution into an available receptacle. • Pouring the solution (without splashing) onto the dressing or site without touching the bottle to the site. STERILE GLOVES • Once the sterile field is set up, don sterile gloves. • Sterile gloving includes opening the wrapper and handling only the outside of the wrapper. Don gloves by using the following steps. • With the cuff side pointing toward the body, use the nondominant hand and pick up the dominant‑hand glove by grasping the folded bottom edge of the cuff and lifting it up and away from the wrapper. While picking up the edge of the cuff, pull the dominant glove onto the hand. • With the sterile dominant‑gloved hand, place the fingers of the dominant hand inside the cuff of the nondominant glove, lifting it off the wrapper and putting the nondominant hand into it. • When both hands are gloved, adjust the fingers. • During that time, only a sterile gloved hand may touch the other sterile gloved hand. • At the close of the sterile procedure or if the gloves tear, remove the gloves. Take them off by grasping the outer part of one glove at the cuff area, avoiding touching the wrist and pulling the glove down over the fingers and into the hand that is still gloved. Then, place the ungloved hand inside the soiled glove and pull the glove off so that it is inside out and only the clean inside part is exposed. Discard into an appropriate receptacle. (Precautions transmission) Gastrointestinal Dx: Plan of care for Gastroenteritis Contact for viral Fecal-oral (Health promo) Hypertension prevention measures • BMI 30 • Crtl DM Blood Glucose • Limit Caffeine, ETOH (limit 2 servings men, 1 women 1.5oz licor, 5oz wine, 12oz beer) • MGMT Stress • Smoke Cessation • Aerobic Exercise x 3 week • Limit Sodium (1.5-2.3g/day), Fat less 20% to 35% daily Kcal, 10% Saturated Cholesterol 300mg/day. • DASH: High fruits veggies, low fat. Rich in Ca and Mg • (High risk behaviors)Female Client teaching of genital herpes • Dx can be based on Hx and CM and confirmed with • Herpes viral culture swab: A cotton–tipped applicator is used to obtain vesicle fluid from intact lesions for culture. • PCR: ID Herpes (HSV1 or HSV2) DNA/RNA from cells from lesions, blood or body fluids • ELISA HerpeSelect, HerpeSelect Immunoblit, Western Blot to Differentiate between antibodies to HSV1 & HSV2 • Acyclovir (AE Phlebitis, Nephrotoxicity), Famciclovir , Valacycolvir Use gloves for topical admin, relief but no cure • Wash tx area 3/4x day and keep dry. No sex w/ lesions present. Use condoms (Mobility immobility)Stroke care for left sided hemiplegia CM: • The left cerebral hemisphere is responsible for language, mathematics skills, and analytic thinking. • Expressive and receptive aphasia (inability to speak and understand language) • Agnosia (unable to recognize familiar objects) • Alexia (reading difficulty) • Agraphia (writing difficulty) • Right extremity hemiplegia (paralysis) or hemiparesis (weakness) • Slow, cautious behavior • Depression, anger, and quick to become frustrated • Visual changes, such as hemianopsia (loss of visual field in one or both eyes) Right side: visual and spatial awareness proprioception • Left Hemi-paresis, hemiplegia • Left hemianopsia • Overestimation of abilities • Unilateral neglect • Loss of depth perception • Poor judgment/impulse control Care: • Vitals Q1-2H Call Doc if BP 180/110 (CM ischemic stroke) Mon Temp (↑Temp =↑ICP) • O2 if SaO2 92% or ↓LOC • ECG, auscultate for murmurs or irregularities • HOB 30° Avoid extreme flexion or extension of the neck. Keep body midline neutral • ROM PROM Q2H • Dress affected side first. Counter leaning on affected side. Support affected arm to prev shoulder subluxation (Mobility immobility)Musculoskeletal trauma: Preventing complications • Provide emergency care at time of injury. • Maintain ABCs. • Monitor vital signs and neurological status because injury to vital organs can occur due to bone fragments (fractures of pelvis, ribs). • Stabilize the injured area, including the joints above and below the fracture, by using a splint and avoiding unnecessary movement. • Maintain proper alignment of the affected extremity. • Elevate the limb above the heart and apply ice. • Assess for bleeding and apply pressure, if needed. • Cover open wounds with a sterile dressing. • Remove clothing and jewelry near the injury or on the affected extremity. • Keep the client warm. • Assess pain frequently and follow pain management protocols, both pharmacological and nonpharmacological. • Initiate and continue neurovascular checks at least every hour. Immediately report any change in status to the provider. • Prepare the client for any immobilization procedure appropriate for the fracture. • Compartment Syndrome: Assess neuro Frequent, report pain unrelieved by meds, tingle, numb or change in color in extremity • Immobilize fractures, min manipulation to prevent fat embolism Casts • Monitor neurovascular (Pain, sensation, temp, cap refill, pulse, mov) status every hour for first 24 hr and assess pain. • Handle cast with palms, don’t set on sharp edges. Elevate above heart for 1st 24-48hrs. Should be room for 1 finger. Report CM of infections “hot spots” or immobility issues like SOB, skin breakdown and constipation. Traction • Neuro checks Q1h for 24hrs then 4hrs. • Keep body aligned • Weight should hang free, no fraying/knots, loosen of cords check Q8-12h • Pins may use chlorahexadine, 1 pin = Qtip 1-2 x per day Compartment syndrome IF UnTx =Necrosis, neuromusc dmg, need fasciotomy • Pain, paralysis(L), paresthesia(E), pallor, and pulselessness(L) • Pain unrelieved by elevation or meds. Intense pain with passive mov. • Paresthesia numb tingle burn early cm • Paralysis weakness =nerve damage late cm • Pallor w cyanotic nails • Pulseless Late CM • Palpated muscles hard from edema (Mobility immobility)Preventing postop complications • ABC, resp effort, SaO2 Vitals Q15 Mins • Yankauer suction for thick oral secretions or a large French suction catheter for nasopharyngeal or nasotracheal secretions • Report increases/decrease of 25% in BP, trending decrease • Prevent hypothermia • Lateral position (RorL) if unresponsive/unconscious. If responsive to stim, gradual elevation to semifowlers. No pillows or knee gatches in bed. Specifics • Airway obstructed: choking; noisy, irregular respirations; decreased oxygen saturation values; and cyanosis. Implement headtilt/chin lift to pull tongue forward and open airway. Have Res equipment. Elevate HOB if not contra. Give humid O2 and plan for reintubation. • Hypoxia: Mon oxygenation, cough deep breath, HOB elevated, turn Q2H • Hypovolemic shock: Mon BP, cap refill, narrowing pulse pressure, ↑ HR and Resp, place supine w legs elevated, admin fluids & vasopressors • Paralytic ileus: Mon bowel sounds, ambulate, advance diet when bowel sounds and flatus present, can empty stomach content with NG tube. • Deshicence /Eviseration: Mon for risk factors (steroid uses, DM, HTN, obese, no splintting when cough ambulate, infection, hematoma, malnutrition) Call for help, stay w pt, cover wound with sterile towel/dressing soaked in sterile saline, don’t reinsert organs, low fowlers with hips and knees bent. Monitor for shock and call doc. • DVT due to dehydration, immobility, obesity, trauma, malignancy, Hx, hormones, indwell venous cath. Heparin. TED hose/SCD, ROM, early ambulate. No pressure behind the knees with pillows or blankets, no dangling for long periods, hydrate with IV/PO fluids. (Nutrition/hydration) Care for receiving radiation • May have mucositis and xerostomia, dysphagia or gastroenteritis • Provide a well‑balanced diet that does not contain red meat. Radiation can cause dysgeusia (altered taste), making foods such as red meat unpalatable. • Avoid spicy, salty, acidic foods. Hot foods might not be tolerated (Nutrition/hydration) Heart Failure / PE Sodium restriction teaching Low Sodium diet low sat fat and fluid restrictions No more than 2,300 milligrams of sodium, Less than 1,500 mg a day is ideal (Nutrition/hydration) Diet recommendation for nephrotoxic syndrome Acute kidney injury: Implement potassium, phosphate, sodium, and magnesium restrictions, if prescribed (depending on the stage of injury). Restrict fluid intake, if prescribed. High‑protein diet to replace the high rate of protein breakdown due to stress from the illness. Possible total parenteral nutrition (TPN). Chronic kidney Disease: diet that is high in carbohydrates and moderate in fat. Restrict potassium, phosphate, sodium, and magnesium. Restrict fluids based on urine output. Nephrotic syndrome (kidney failure) diet: Low fat/Sodium. Too much protein can dmg nephrons (Meds AE/SE/Contra/Interactions)Interactions of medications affecting blood pressure (Meds AE/SE/Contra/Interactions)Antibiotics Bactericidal: CM to report (Penicillins) • Allergies/anaphylaxis: report skin rash/hives hypotension, dyspnea • Renal impairment :Monitor Kidney Func and I/O • Hyperkalemia/dysrhitmias (penicillin G) • Hypernatremia (ticarcillin) • Bleeding (cegotetan/ceftriaxone) • Pseudomembranous colitis:diarrhea • GI symps Carbapenems • Suprainfection Carbapenems:Thrush, candidiasis • Otoxicity Vancomycin/azotronam/fosfomycin: tinnitus, hearin loss. • Rash/flush/tachycardia during infusion Vancomycin • Renal toxicity Vancomycin Mon I/O and kidney function (Meds AE/SE/Contra/Interactions)Rheumatoid arthritis: Labs to report • Methotrexate: CBC, Liver func, • Cyclosporine Kidney Func • Prednisone Blood Glucose, potassium (Meds AE/SE/Contra/Interactions)Non-opioid analgesics interactions • Aspirin affects coagulation (COX-2 irreversible inhibitor) • Avoid ETOH, increase risk bleed • NSAIDs (COX-2 reversible inhibitor) decrease antiplatelet effect of low dose aspirin • NSAIDs and ketorolac avoid concurrent use • Ketorolac avoid use for more than 5 days (Kidney Damage) • ETOH + Tylenol= Liver Damage • Tylenol slows metabolism of Warfarin (Blood products)Admin of packed RBCs (Blood products) Initiating a transfusion of packed RBCs