ATI MEDSURG study guide *graded A*

(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 ..............................................CONTINUED.......................................................