Retake 2 ATI RN Medical Surgical

GI Diagnostics Procedure: Plan of Care for a Client Who Has Gastroenteritis (Ch.46)  A positive finding for clostridium difficile is indicative of this opportunistic infection, which usually becomes established secondary to use of broad-spectrum antibiotics.  Medications: Some medications ( NSAIDs, warfarin, aspirin) place the client at risk for complications. Notify the provider if medication restrictions were not followed.  Blood Test: Interpretations of Findings o Aspartate aminotransferase/ Alanine Aminotransferase: Elevation occurs with hepatitis or cirrhosis. o Alkaline Phosphatase- Elevation indicates liver damage o Amylase/ Lipase- Elevation occurs with pancreatitis o Total Bilirubin- Elevation indicate altered liver function, bile duct obstruction, or other hepatobiliary disorder. o Albumin- Decrease can indicate hepatic disease. o Alpha-fetoprotein- Elevated in liver cancer, cirrhosis and hepatitis. o Ammonia- Elevated in liver disease. Tuberculosis: Appropriate Interventions for a Client Who Has Tuberculosis(Ch.23)  TB diagnosis should be considered for any client who has a persistent cough, chest pain, weakness, weight loss, anorexia, hemoptysis, dyspnea, fever, night sweats, or chills.  Mantoux Test o An intradermal injection of an extract of the tubercle bacillus is made. o A positive Mantoux test indicates that the client has developed an immune response to TB. o Individuals who have latent TB can retain positive MT test and can receive treatment.  Educate the client and family to continue medication therapy for its full duration of 6 to 12 months, even up to 2 years for multi-drug resistant TB.  Airborne precautions are NOT needed in the home setting because family members have already been exposed. Medical and Surgical Asepsis: Maintaining a Sterile Field ( Ch. 10)  The outer wrapping and 1-inch edge 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 edge the sterile field to which other sterile items may be added.  Consider any object held below the waist or above the chest contaminated.  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 the body. o Next, open the side flaps, using the right hand for the right flap and the left hand for the left flap. This study source was downloaded by from CourseH on :01:03 GMT -05:00 . o Grasp the last flap and turn it down toward the body. Diagnostic and Therapeutic Procedures for Female Reproductive Disorders: Client Teaching about Genital Herpes ( Ch. 62)  Diagnosis of genital herpes can be based on the client history and physical.  Laboratory test o Herpes viral culture: fluid from a lesion is obtained using a swab and placed in a cup for culture. o Polymerase chain reaction: identifies genetic material of the virus. Cells from a lesion, blood, or other body fluids can be tested. o Antibody test: blood is tested for antibodies to the virus.  HerpeSelect Immunoblot, HerpeSelect ELISA, Western Blot Postoperative Nursing Care : Preventing Complications (Ch.96)  Report a blood pressure difference of 25% from baseline, a drop to 15 to 20 mmH in diastolic or systolic pressures, or a trending decrease in diastolic or systolic pressures by 5 mmHg at each 15 minute sign assessment.  Extubating of endotracheal tube is based on client’s response to commands, ability to elevate head and use of thoracic breathing.  If the client responds to verbal stimuli, gradually elevate the head of the bed to semi-fowlers position, if not contraindicated, to facilitate chest expansion. Stroke: Caring for a Client Who has Left-sided Hemiplegia(Ch.15)  Left sided hemiplegia o Right extremity hemiplegia (paralysis) or hemiparesis (weakness) o Visual changes, such as hemianopsia (loss of visual field in one or both eyes).  Right sided hemiplegia o Unilateral neglect syndrome: ignore left side of the body: cannot see, feel or move affected side, so client unaware of its existence). Can occur when left hemispheric strokes, but is more common with right hemispheric strokes. o Left hemiplegia or hemiparesis o Poor impulse control and judgement Polycystic Kidney Disease, AKI and CKI: Dietary Recommendations for a Client who Has Nephrotic Syndrome (Ch. 59)  Restrict dietary sodium, potassium, phosphorous and magnesium.  Provide a diet that is high in carbohydrates and moderate in fat.  Restrict intake of fluids (based on urinary output).  Instruct the client to monitor the daily intake of carbohydrates, proteins, sodium, and potassium according to the providers prescription.  Instruct the client to avoid antacids containing magnesium. Antibiotics Affecting the Bacterial Cell Wall: Manifestations to Report to the Provider (Pharm Ch.44) This study source was downloaded by from CourseH on :01:03 GMT -05:00 o If indications of allergy appear (urticaria, rash, hypotension, dyspnea), stop the cephalosporin immediately, and notify the providers. o Monitor the infusion site for redness, swelling and inflammation. o Instruct clients to notify the provider if changes in hearing acuity develop. Nonopioid Analgesic: Medication Interactions (Ch. 35)  Acetaminophen o Acute toxicity : Results in liver damage with early manifestations of nausea, vomiting, diarrhea, sweating, and abdominal discomfort progressing to hepatic failure, coma and death  NSAID o Damage to gastric mucosa can lead to gastrointestinal (GI) bleeding and perforation, especially with long term use. o Observe for indications of GI bleeding (passage of black or dark colored stools, severe abdominal pain, nausea, vomiting).  Advise clients to notify providers if manifestations of salicylism occur. The medication should be discontinued until manifestations are resolved. The medication can be restarted at a lower dose. Blood and Blood Product Transfusions: Initiating a Transfusion of Packed RBC’s (Ch.40).  Prime the blood administration set with 0.9% sodium chloride only. Never add medications to blood products. Y-tubing with a filter is used to transfuse blood.  Initiate large bore IV access. An 18-20 gauge need is standard for administering blood products.  Acute Hemolytic Reaction o Findings include chills, fever, low back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom. Cardiovascular Diagnostics and Therapeutic Procedures: Flushing and Implanted Port (Ch.27)  Apply topical anesthetic cream to skin if indicated.  Palpate skin to locate the port body septum to ensure proper insertion of the needle.  Access with a noncoring (Huber) needle  Check for blood return prior to medication administration to confirm patency and placement.  Flush with 5 mL Heparin 100 units/ml after every use and at least once per month (NS Recommendation) Hematological Diagnostics Procedures: Evaluating Client Understanding of Anticoagulant Therapy ( Ch. 39).  Platelets : 150,000-400,000 mm o Increased: malignancy, polycythemia vera and rheumatoid arthritis o Decreased: enlarged spleen, hemorrhage, leukemia  WBC: 5,000-10,000 This study source was downloaded by from CourseH on :01:03 GMT -05:00 o Elevated: Infection or inflammation o Decreased: Immunosuppression, autoimmune disease  RBC: Females ( 4.2-5.4) Males ( 4.7-6.1) o Elevated: Erythocytosis, polycythemia vera, severe dehydration o Decreased: Anemia, hemorrhage, kidney disease TB: Teaching About Medication Therapy ( Ch.23)  Broad Spectrum Antimycobacterial –Rifampin o Three negative sputum culture for TB usually taking 3-6 months to achieve o Inform client regarding manifestations of anorexia, fatigue, and malaise and instruct them to notify the provider if they occur. o 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 to TB. Gastrointestinal therapeutic procedures: calculating protein requirements ( Ch. 47)  Never abruptly stop TPN. Speeding up/slowing down the rate is contraindicated. An abrupt rate change can alter blood glucose levels significantly.  Do not use TPN line for other IV bolus fluids and medications (repeated access increases the risk for infection).  If the stoma appears black, or purple in color, this indicates a serious impairment of blood flow and requires immediate intervention. Electrocardiography and dysrhythmia monitoring: analyzing a cardiac rhythm strip (Ch. 28)  Dysrhythmias are classified by the following: site of organ : SA node, atria, AV node or ventricle. o Effect on the rate and rhythm of the heart: bradycardia, tachycardia, heart block, premature beat, flutter, fibrillation or asystole.  Digoxin is held for 48 hr prior to elective cardioversion. Neurologic Diagnostic Procedures: Preparing a Client for Lumbar Puncture (Ch.3)  Lumbar puncture position—side lying in the fetal position. The client should remain lying for several hours to ensure that the site clots and to decrease the risk of a post lumbar puncture headache caused by CSF leakage.  Encourage the client to lie flat in bed. Provide fluids for hydration, and administer pain medication.  Instruct the client to void prior to the procedures. Client should be positioned to stretch the spinal canal. This be done by having the client assume a “cannonball” position while on the side by having the client stretch over an overbed table if sitting is preferred. GI Therapeutic Procedures: Caring for a Client Receiving Enteral Feeding (Ch.47)  If a bag is unavailable and administered late, do not attempt to catch up by increasing the infusion rate because the client can develop hyperglycemia.  Older adult clients have increased incidence of glucose intolerance. This study source was downloaded by from CourseH on :01:03 GMT -05:00  Assess every 4 to 8 hours.  Follow sterile procedures to minimize the risk of sepsis. o Change tubing and solution bag (even if not empty) every 24 hours. o DO not use the line for other IV bolus solutions (prevents contamination and interruption of the flow rate.) Hepatitis Therapeutic Procedures: Client Positioning Following a Biopsy (Ch.55)  Assist the client into the supine position with the upper risk quadrant of the abdomen exposed.  Instruct the client exhale and hold for at least 10 seconds while the needle is inserted.  Assist the client to a right side lying position and maintain for several hours. Renal Diagnostic Procedures: Caring for a Client Following a Kidney Biopsy (Ch.56)  Monitor vital signs following sedation.  Assess dressing and urinary output (hematuria).  Review Hgb and Hct values.  Administer PRN pain medication.  Complications o Hemorrhage, infection, cloudy, foul smelling urine, urgency, urine positive for leukocyte esterase, and nitrites, sediment and RBC’s.  Review anticoagulant studies. Cushing’s Disease/ Syndrome: Ongoing Assessment to Detect Abnormal Findings (Ch.80)  Labs o Potassium and Calcium Levels: Decreased o Glucose and Sodium Levels: Increased  Assess for indication of hypervolemia ( edema, distended neck veins, SOB, adventitious breath sounds, hypertension, tachycardia.)  Maintain a safe environment to minimize the risk of pathological fractures and skin trauma. Polycystic Kidney Disease, AKI and CKI : Expected Findings ( Ch. 59).  AKI o Fluid overload (dependent and generalized edema, hyperkalemia, crackles, decreased oxygenation, SOB, scant to normal or excessive UOP, hematuria, lethargy, muscle twitching, seizures, dry skin and mucous membrane.  CKI o HTN, kussmaul respirations, crackles, pleural friction rub, increased creatinine, decreased sodium and calcium, decreased H & H  Polycystic Kidney Disease o Hyponatremia, nocturia, enlarged abdominal girth, HTN, headache, constipation, blood and cloudy urine Asthma: Using a Peak Flow Meter (Ch. 18)  Use at the same time each day. This study source was downloaded by from CourseH on :01:03 GMT -05:00 o Ensure that marker is zeroed. o Have the child stand up straight. o Remove gum or food from mouth. o Close lips tightly around the mouthpiece (ensure tongue is not occluding). o Blow out as hard and as quickly as possible. o Read the number on the meter. o Repeat three more times (Wait at least 30 seconds between attempts). o Record the highest number. o Repeat three more times ( Wait at least 30 seconds between attempts). o Record the highest number. Hemodialysis and Peritoneal Dialysis: Interventions for Decreased Dialysate Flow Rate (Ch.57)  Compare the client’s preprocedural weight with the postprocedural weight as a way to estimate the amount of fluid the procedure removed. o 1 L fluid equals 1 kg (2.2 lbs)  Avoid invasive procedures for 4 to 6 hours after dialysis due to the risk of bleeding as a result of anticoagulation.  Check the graft for patency by checking for a thrill or bruit.  Discuss with the provider medications to withhold until after dialysis. Withhold any dialyzable medications and medications that lower blood pressure. Complications of DM: Priority Interventions for DKA (Ch. 83)  Administer regular insulin 0.1 to 0.15 unit/kg as an IV bolus dose and then follow with a continuous IV infusion of regular insulin at 0.1 unit/kg/hr  The client who has DKA will absorb subcutaneous insulin slowly and erratically, making it difficult to adjust dosage of insulin appropriately. Monitor blood glucose hourly. Blood glucose of less than 200 mg/dL is the goal for resolution.  Teach older adult clients to monitor blood glucose every 1 to 4 hours when ill. Head Injury: identification of Altered Respiratory Patterns (Ch.14).  Changes in level of consciousness, using the GCS, provide the earliest indication of neurological deterioration.  Untreated hypoxia leads to brain injury or death if the brain has been denied adequate oxygenation for 3 to 5 minutes.  Maintain a patent airway. Provide mechanical ventilation. Hypothyroidism: client Teaching (Ch. 79)  Instruct the client that treatment begins slowly and that the dosage is increased every 2 to 3 weeks until the desired response is obtained.  Remind the client to take the dose prescribed. Do not stop taking medication or change dose.  Avoid fiber laxatives, which interfere with absorption of levothyroxine.  Caution the client against using electrical blankets or other electric heating devices because the combination of vasodilation, decreased sensation, decreased alertness can result in unrecognized burns. This study source was downloaded by from CourseH on :01:03 GMT -05:00 Preoperative Nursing Care: Recognizing Deviations in Lab Values (Ch. 95)  UA—renal function/ rule infection  CBC—fluid status/ anemia/ infection/immune response  Allergies to banana or kiwi can be indicate the client is at risk for a reaction to latex.  Allergy to eggs or soybeans oil is a contraindication to the use of Propofol for anesthesia. Pressure Ulcers, Wounds, and Wound Management: Wound Care Following an Open Cholecystectomy (Ch.55)  For clean wounds, such as surgical incision, cleanse from the least contaminated (the incision) toward the most contaminated (the surrounding skin).  Use gentle friction when cleansing or applying solutions to the skin to avoid bleeding or