Adult Medical Surgical - Critical Points

       Ethical Responsibilities: Client Decision to Refuse Treatment (Active Learning Template - Basic Concept) 1. Autonomy: the right to make one’s own personal decisions, even when those decisions might not be in that person’s own best interest. 2. Beneficence: action that promotes good for others, without any selfinterest. 3. Fidelity: fulfillment of promises. Arthroplasty: Safety Considerations for Continuous Passive Motion Machine (Active Learning Template - Therapeutic Procedure) 1. CPM is usually placed and initiated immediately after surgery. 2. CPM provides a passive range of motion from full extension to the prescribed amount of flexion. 3. Follow the prescribed duration of use but turn it off during meals. Seizures and Epilepsy: Priority Intervention for a Client Experiencing a Seizure (Active Learning Template - System Disorder) 1. Protect the client’s privacy and the client from injury (move furniture away, hold head in lap if on the floor). 2. Position the client to provide a patent airway. 3. Be prepared to suction oral secretions. HIV/AIDS: Teaching Home Care (Active Learning Template - System Disorder) 1. Avoid crowded areas or traveling to countries with poor sanitation. 2. Avoid raw foods (fruits, vegetables) and undercooked foods (meat, fish, eggs). 3. Avoid cleaning pet litter boxes to reduce the risk of toxoplasmosis. Infection Control: Admitting a Client Who Has Pertussis (Active Learning Template - System Disorder) 1. A private room or a room with other clients who have the same infectious disease. Ensure that clients have their own equipment. 2. Masks for providers and visitors. 3. Clients who have a droplet infection should wear a mask while outside of the room/home. Musculoskeletal Trauma: Maintaining Traction (Active Learning Template Therapeutic Procedure) 1. Ensure that weights hang freely and are not resting on the floor. 2. If the weights are accidentally displaced, replace the weights. If the problem is not corrected, notify the provider. 3. Ensure that pulley ropes are free of knots, fraying, loosening, and improper positioning at least every 8 to 12 hr. Stroke: Evaluating Client's Mobility with Use of Quad Cane (Active Learning Template - Basic Concept) Physical therapy can be consulted for assistance with reestablishment of ambulation with or without assistive devices (single or quad cane, walker) or wheelchair support. 2. Wheelchair adaptations (an extended brake handle on the client’s affected side of the wheelchair) can be necessary. 3. Occupational therapy can be consulted for assistance with reestablishment of partial or full function of the affected hand and arm. Cancer Treatment Options: Planning Teaching for Client Who Has Mucositis (Active Learning Template - Basic Concept) 1. Avoid spicy, salty, acidic foods. 2. Try eating foods that are cold rather than hot. 3. Rinse the mouth with a solution of 0.9% sodium chloride, roomtemperature tap water, or salt and soda water. Frequency is guided by the intensity of the mucositis. Medications Affecting Blood Pressure: Identifying Manifestations of Anaphylaxis (Active Learning Template - Medication) 1. Skin reactions, including hives and itching and flushed or pale skin. 2. Low blood pressure (hypotension). 3. Constriction of the airways and a swollen tongue or throat, which can cause wheezing and trouble breathing. Dosage Calculation: Calculating a Dose of Ceftazidime (Active Learning Template - Basic Concept) 1. Nurses can use three different methods for dosage calculation: ratio and proportion, formula (desired over have), and dimensional analysis. 2. For dosages less than 1.0: Round to the nearest hundredth. 3. For dosages greater than 1.0: Round to the nearest tenth. Heart Failure and Pulmonary Edema: Client Teaching About Furosemide (Active Learning Template - Medication) 1. Furosemide and bumetanide are loop diuretics. 2. Administer furosemide IV no faster than 20 mg/min. 3. Loop and thiazide diuretics can cause hypokalemia, and potassium supplementation can be required. Pharmacokinetics and Routes of Administration: Client Teaching About Use of Metered-Dose Inhaler (Active Learning Template - Nursing Skill) 1. Tilt your head back slightly, press the inhaler, and, at the same time, begin a slow, deep inhalation breath. Continue to breathe slowly and deeply for 3 to 5 seconds to facilitate delivery to the air passages. 2. Hold your breath for 10 seconds to allow the medication to deposit in your airways. 3. Take the inhaler out of your mouth and slowly exhale through pursed lips. 1.            Head Injury: Early Manifestations of Increased Intracranial Pressure (Active Learning Template - Basic Concept) 1. Severe headache, nausea, vomiting. 2. Deteriorating level of consciousness, restlessness, irritability. 3. Close monitoring of vital signs and neurologic status allows early reporting of changes in the GCS score, an increase in the blood pressure, and an alteration in respiratory pattern and effort. Hyperthyroidism: Assessing a Client for Chvostek's Sign Following a Thyroidectomy (Active Learning Template - Nursing Skill) 1. This clinical sign presents after gently tapping over the cheek, two cm in front of the ear. 2. If the Chvostek sign is positive, ipsilateral twitching of the facial muscles occurs, whereas there is no movement when the sign is negative. 3. This clinical finding has become widely accepted in the medical community as a sign of hypocalcemia. Peptic Ulcer Disease: Reportable Findings for Nasogastric Output Following Abdominal Surgery (Active Learning Template - Therapeutic Procedure) 1. Scant blood can be seen in the first 12 to 24 hr. 2. Notify the provider before repositioning or irrigating the nasogastric tube (disruption of sutures). 3. Monitor and report bleeding such as black stools or coffee ground emesis. Peripheral Vascular Diseases: Arterial Revascularization (Active Learning Template - Therapeutic Procedure) 1. Used with clients who have severe claudication and/or limb pain at rest, or with clients who are at risk for losing a limb due to poor arterial circulation. 2. Bypass grafts are used to reroute the circulation around the arterial occlusion. 3. Grafts can be harvested from the client (autologous) or made from synthetic materials. Chest Tube Insertion and Monitoring: Teaching About Water-Seal Drainage (Active Learning Template - Therapeutic Procedure) 1. Tidaling (movement of the fluid level with respiration) is expected in the water seal chamber. 2. Cessation of tidaling in the water seal chamber signals lung re-expansion or an obstruction within the system. 3. Continuous bubbling in the water seal chamber indicates an air leak in the system. Diagnostic and Therapeutic Procedures for Reproductive Disorders: Client Teaching About Genital Herpes (Active Learning Template - System Disorder) 1. Fluid from a lesion is obtained using a swab and placed in a cup for culture. Low sensitivity especially for recurrent lesions that begin to heal; may need specific typing for HSV. 3. Polymerase chain reaction (PCR) test identifies type of virus (herpes simplex 1 [HSV 1] or herpes simplex 2 [HSV 2]). Gastrointestinal Diagnostic Procedures: Obtaining a Guaiac Smear Sample for Fecal Occult Blood Testing (Active Learning Template - Diagnostic Procedure) 1. Provide the client with cards impregnated with guaiac that can be mailed to provider or with a specimen collection cup. 2. If the cards are used, three samples obtained on different days are usually required. 3. At least three repeats of a positive guaiac FOBT confirms GI bleeding. Hyperthyroidism: Priority Finding Following Complete Thyroidectomy (Active Learning Template - Therapeutic Procedure) 1. Keep the client in a semi-Fowler’s position. Support head and neck with pillows or sandbags. Avoid neck extension. 2. Check the surgical dressing and back of the neck for excessive bleeding. 3. Respiratory distress can occur from compression of trachea due to hemorrhage, which is most likely to occur in the first 24 hr. Respiratory distress also can occur due to edema. Ensure that tracheostomy supplies are immediately available. Humidify air, assist to cough and deep breathe, and provide oral and tracheal suction if needed. Angina and Myocardial Infarction: Priority Intervention for Acute Angina (Active Learning Template - System Disorder) 1. The initial management includes the administration of Morphine, Oxygen, Nitrate, Aspirin 2. The administration of aspirin upon arrival, beta-blocker within 24 hours, and thrombolytic within 30 minutes 3. Administer oxygen via cannula or face mask Chronic Obstructive Pulmonary Disease: Caring for a Client Who Has Emphysema (Active Learning Template - Therapeutic Procedure) 1. Emphysema is characterized by the loss of lung elasticity and hyperinflation of lung tissue. 2. Emphysema causes destruction of the alveoli, leading to a decreased surface area for gas exchange, carbon dioxide retention, and respiratory acidosis. 3. Barrel chest or increased chest diameter (with emphysema) . Hyperresonance on percussion due to “trapped air” (with emphysema). Hemodialysis and Peritoneal Dialysis: Indications of Peritonitis (Active Learning Template - System Disorder) 1. Cloudy or opaque effluent is the earliest indication of peritonitis. 2.      Monitor for infection (fever, purulent drainage, redness, swelling, cloudy or discolored drained dialysate). 3. Infection at the access site can result from leakage of dialysate. Accesssite infections can cause peritonitis. Spinal Cord Injury: Actions to Take for Autonomic Dysreflexia (Active Learning Template - System Disorder) 1. Sit the client up to decrease blood pressure secondary to postural hypotension. 2. Distended bladder is the most common cause (kinked or blocked indwelling urinary catheter, urinary retention, urinary calculi). 3. Monitor vital signs for severe hypertension and bradycardia. Administer antihypertensives (nitrates or hydralazine). Burns: Expected Findings Following Full-Thickness Burns (Active Learning Template - System Disorder) 1. Sensation minimal or absent. 2. No blisters, severe edema, eschar hard and inelastic. 3. Damage to the entire epidermis and dermis, can extend into the subcutaneous tissue, nerve damage. Complications of Diabetes Mellitus: Identifying Manifestations of Diabetic Ketoacidosis or Hyperglycemic-Hyperosmolar State (Active Learning Template System Disorder) 1. HHS: Seizures, myoclonic jerking: Related to blood osmolarity greater than 350 mOsm/L. Reversible paralysis: Related to how elevated the blood osmolarity becomes (coma occurs once blood osmolarity is greater than 350 mOsm/L) 2. DKA: GI effects (nausea, vomiting, abdominal pain): Increased ketones and acidosis lead to nausea, vomiting, and abdominal pain. 3. Both: Polyuria, polyphagia, polydipsia. Angina and Myocardial Infarction: Identifying Indications of Potential Client Problems (Active Learning Template - System Disorder) 1. Troponin I or T: Any positive value indicates damage to cardiac tissue and should be reported. 2. Angina: ST depression and/or T-wave inversion indicates presence of ischemia. 3. MI: T-wave inversion indicates ischemia; ST-segment elevation indicates injury; abnormal Q-wave indicates necrosis. Complications of Diabetes Mellitus: Identifying Complications of DKA (Active Learning Template - System Disorder) 1. Fruity odor of breath: Elevated ketone bodies (small fatty acids) used for energy that collect in the blood, which leads to metabolic acidosis 2.           2. Kussmaul respirations: Deep rapid respirations occur in an attempt to excrete carbon dioxide and acid when in metabolic acidosis 3. Metabolic acidosis: Breakdown of stored glucose, protein, and fat to produce ketone bodies. Diabetes Mellitus Management: Identifying Potential Complications for a Postoperative Client (Active Learning Template - System Disorder) 1. Consistent maintenance of blood glucose within the expected reference range is the best protection against the complications of diabetes mellitus. Expected reference ranges can vary. 2. Peripheral neuropathy includes focal neuropathies, caused by acute ischemic damage or diffuse neuropathies, which are more widespread and involve slow, progressive loss. This can lead to complications (foot deformities, ulcers). 3. Periodontal disease, integumentary disorders (infections, patchy color changes, sclerosing). Complications of Diabetes Mellitus: Prescriptions for a Client Experiencing DKA (Active Learning Template - System Disorder) 1. Rapid IV infusion of 0.9% sodium chloride over the first hr. 2. Follow with IV infusion of 0.45% sodium chloride as maintenance fluids. 3. Monitor laboratory tests. Angina and Myocardial Infarction: Planning Care for a Client (Active Learning Template - System Disorder) 1. Vital signs every 5 min until stable, then every hour. Cluster nursing interventions. 2. Serial ECG, continuous cardiac monitoring 3. Location, precipitating factors, severity, quality, and duration of pain Angina and Myocardial Infarction: Actions to Take for Client Experiencing Myocardial Infarction (Active Learning Template - System Disorder) 1. Acute MI- Administer oxygen to maintain oxygen saturation of 90% or greater. 2. Heart failure- Administer IV morphine, diuretics, and/or nitroglycerin to decrease preload. 3. Heart failure- Administer IV vasopressors and/or positive inotropes to increase cardiac output and maintain organ perfusion. Gastrointestinal Therapeutic Procedures: Caring for Client Who Is Receiving Total Parenteral Nutrition (Active Learning Template - Therapeutic Procedure) 1. The flow rate is gradually increased and gradually decreased to allow body adjustment (usually no more than a 10% hourly increase in rate). 2. Never abruptly stop TPN. 3. Assess weights daily.   Angina and Myocardial Infarction: Evaluating a Client’s Condition (Active Learning Template - System Disorder) 1. Vital signs every 5 min until stable, then every hour. 2. Hourly urine output: greater than 30 mL/hr indicates expected kidney perfusion. 3. Laboratory data: cardiac enzymes, electrolytes, ABGs. Heart Failure and Pulmonary Edema: Monitoring Changes in Client Status (Active Learning Template - System Disorder) 1. Expected findings: Anxiety, tachycardia, acute respiratory distress, 2. Expected findings: Dyspnea at rest, change in level of consciousness, 3. Expected findings: An ascending fluid level within the lungs (crackles, cough productive of frothy, blood-tinged sputum).