RN Adult Medical Surgical Online Practice A

RN Adult Medical Surgical Online Practice A Remediation Time: 04:40:00 Safety and Infection Control Emergency Nursing Principles and Management: Expected Prescription for a Rattlesnake Bite o Administer opioid medications for pain due to snake or spider bite o Monitor ABGs, blood glucose levels, coagulation profile o Monitor blood pressure, cardiac monitoring, ECG. Cancer Treatment Options: Safe Handling of a Radioactive Implant o Wear a lead apron while providing care, keeping the front of the apron facing the source of the radiation. o Keep a lead container in the client’s room if the delivery methods could allow spontaneous loss of radioactive material. Tongs are available for placing radioactive material into this container. o Follow protocol for proper removal of dressings and bed linens from the room. In most cases, all linens and dressings are kept in the client’s room until the radiation source is removed, to ensure it is not lost in the trash or laundry. Burns: Preventing Pseudomonas Aeruginosa Infection o Restrict plants and flowers due to the risk of contact with pseudomonas aeruginosa. o Check facility policy regarding consumption o fresh fruits and vegetables, which can be restricted. o Limit visitors: do not allow sick individuals, small children or other clients to visit. Management of Care Legal Responsibilities: Teaching About Client Rights o Informed consent is a legal process by which a client or the client’s legally appointed designee has given written permission for a procedure or treatment. Consent is informed when a provider explains, and the client understands:  The reason the client needs the treatment or procedure.  How the treatment or procedure will benefit the client.  The risks involved if the client chooses to receive the treatment or procedure.  Other options to treat the problem, including not treating the problem. o The nurse’s role in the informed consent process is to witness the client’s signature on the informed consent form and to ensure that the provider has obtained the informed consent responsibly. Informed consent guidelines: Clients must consent to all care they receive in a health care facility. o For most aspects of nursing care, implied consent is adequate. Clients provide o o o o o o o implied consent when they adhere to the instructions the nurse provides. For example, the nurse is preparing to perform a tuberculosis skin test, and the clients holds out their arm for the nurse. For an invasive procedure or surgery, the client must provide written consent. State laws prescribe who is able to give informed consent. Laws vary regarding age limitations and emergencies. Nurses are responsible for knowing the laws in the states in which they practice. A competent adult must sign the form or informed consent. The person who signs the form must be capable of understanding the information from the health care professional who will perform the service (a surgical procedure) and the person must be able to communicate with the health care professional. When the person giving the informed consent is unable to communicate due to a language barrier or a hearing impairment, a trained medical interpreter must intervene. Many health care facilities contracts with professional interpreters who have additional skills in medical terminology to assist with providing information. Individuals who can grant consent for another person include the following:  Parent of a minor  Legal guardian  Court-specified representative  An individual who has durable power of attorney authority for health care. Emancipated minors (minors who are independent from their parents [a married minor]) can consent for themselves. Include a mature adolescent in the informed consent process by allowing them to sign an assent as part of the informed consent document. The nurse must verify that the consent is informed and witness the client signing the consent form. Angina and Myocardial Infarction: Prioritizing Client Assessment at a Change of Shif o Acute vs. chronic, urgent vs. nonurgent, stable vs. unstable  A client who has an acute problem takes priority over a client who has a chronic problem.  A client who has an urgent need takes priority over a client who has a nonurgent need.  A client who has unstable findings takes priority over a client who has stable findings. o Nitroglycerin: Therapeutic Uses  Treatment of acute angina attack  Prophylaxis of chronic stable angina or variant angina o Nitroglycerin: Complications  Headache: Educate client to use aspirin or acetaminophen to relieve pain. Notify the provider if the headache does not resolve in a few weeks. Dosage can be reduced. Basic Care and Comfort Infections of the Renal and Urinary System: Preventing Urinary Tract Infections o Drink cranberry juice to decrease the risk of infection.  The compound in cranberries might stop certain bacteria from adhering to the mucosa of the urinary tract.  Clients who have chronic cystitis should avoid cranberry juice, which irritates the bladder. o Empty the bladder as soon as there is an urgency to void. o Urinate before and afer intercourse. o Empty bladder every 3-4 hours instead of waiting until bladder is completely full. Pressure Injury, Wounds, and Wound Management: Wound Irrigation for a Pressure Injury o Perform wound cleansing and irrigation  For clean wounds (a surgical incision), cleanse from the least contaminated (the incision) to the most contaminated (the surrounding skin).  Use gentle friction when cleansing or applying solutions to the skin to avoid bleeding or further injury to the wound.  Although the provider might prescribe other mild cleansing agents, isotonic solutions remain the preferred cleansing agents.  Never use the same gauze to cleanse across an incision or wound more than once.  Do not use cotton balls and other products that shed fibers.  If irrigating, use a piston syringe or a sterile straight catheter for deep wounds with small openings. Apply 5-8 psi of pressure. A 30-60 mL syringe with a 19-gauge needle provides approximately 8 psi. Use normal saline, lactated ringers, or an antibiotic/antimicrobial solution. Hold the tip 2.5 cm (1 in) above the wound. Use continuous pressure to flush the wound, repeating the procedure until the irrigant flowing out of the wound is cleaner. o Remove sutures and staples. o Administer analgesics and monitor for effective pain management. o Administer antimicrobials (topical, systemic) and monitor for effectiveness (reduced fever, increase in comfort, decreasing WBC count). o Document the location and type of wound and incision, the status of the wound and type of drainage, the type of materials, client teaching, and how the client tolerated the procedure. Mobility and Immobility: Climbing Stairs with Crutches o Do not alter crutches afer fitting o Follow the prescribed crutch gait. o Support body weight at the hand grips with elbows flexed at 20-30 degrees. o Hold the crutches in one hand and grasp the arm of the chair with the other hand for balance while sitting and rising from a chair. o The tripod position is the basic crutch stance. The client should place the crutches 15 cm (6in) in front of and 15 cm (6in) to the side of each foot to provide a wide base of support. o Crutch gait: client alternates weight from one leg to the other as well as on the crutches. o The client should stand with a straight back, hips, head and neck and should not place any weight on the axillae. o Types of gaits  Four-point gait requires the client to bear weight on both legs. The client alternates each leg with the opposite crutch so three points of support are on the floor at all time.  Three-point gait requires the client to bear all weight on one foot while using both crutches. The affected leg should never bear weight or touch the ground.  Two-point gait requires the client to have partial weight bearing on both feet. The client moves a crutch while moving the opposite leg at the same time. This is to mirror the movements of normal arm and leg motion during walking. o Order for going up stairs:  Places body weight on the crutches.  Advances the unaffected leg onto the stair.  Shifs weight from the crutches to the unaffected leg.  Brings the crutches and effected leg up to the stair. Cancer Disorders: Dietary Alterations for Reducing Colorectal Cancer Risk o Consume diet low in fat and simple carbohydrates but high in fiber. Fluid Imbalances: Hypertonic Dehydration o Laboratory Tests:  With fluid loss due to hemorrhage, hemoconcentration does not occur.  Hematocrit: increased in hypovolemia.  BUN: Increased (greater than 25 mg/dL) due to hemoconcentration.  Urine specific gravity: Greater than 1.030  Blood sodium: Greater than 145 mEq/L with dehydration. Complementary, Alternative, and Integrative Therapies: Medication Interaction with Feverfew o Supplements (feverfew, garlic, ginger) can increase the risk of bleeding in clients who are taking NSAIDs o The supplement gingko biloba can suppress coagulation and is used with caution in clients who are taking NSAIDs. Physiological Adaptation Seizures and Epilepsy: Priority Nursing During a Seizure o Safety/risk Reduction  Look first for a safety risk. For example, is there a finding that suggests a risk for airway obstruction, hypoxia, bleeding, infection, or injury?  Next ask, “What’s the risk to the client?” and “How significant is the risk compares to other posed risks?”  Give priority to responding to whatever finding poses the greatest (or most imminent) risk to the client’s physical well-being. o Turn the client to the side to decrease the risk of aspiration. o Turn child to a side0lying position (decreases risk of aspiration). o Maintain the child in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions. Fluid Imbalances: Findings Related to Dehydration o Vital signs: Hypothermia, tachycardia (in an attempt to maintain a normal blood pressure), thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea (increased respirations to compensate for lack of fluid volume within the body), hypoxia. Electrolyte Imbalances: Expected Findings Based on Potassium Level o Hypokalemia: potassium less than 3.5 mEq/L o Gastrointestinal: hypoactive bowel sounds, nausea, vomiting, constipation, abdominal distention. Paralytic ileus can develop. o Vital signs: decreased blood pressure, thready weak pulse, orthostatic hypotension. o Neurologic: Altered mental status, anxiety, and lethargy that progresses to acute confusion and coma. o ECG: Flattened T-wave, prominent U waves, ST depression, prolonged PR interval. o Muscular: Weakness, deep-tendon reflexes can be reduced. o Respiratory: shallow breathing. Pressure Injury, Wounds, and Wound Management: Priority Action for Management of Evisceration o Evidenced-based practice  Use current data to make informed clinical decisions to provide the best practice. Best proactive is determined by current research collected from several sources that have desirable outcomes.  Use knowledge of evidenced-based practice to guide prioritization of care and interventions (responding to clients experiencing wound dehiscence or crisis). For example, initiating CPR in the proper steps for a client experiencing cardiac arrest.  Methods to promote evidenced-based practice: Use a variety of sources of research. Keep current on new research by reading professional journals and collaborating with other nurses and professionals in other disciplines. Change traditional nursing practice with new research-based practices. o Nursing interventions: Evisceration and dehiscence require emergency treatment  Call for help. Notify the provider immediately due to the need for surgical intervention.  Stay with the client.  Cover the wound and any protruding organs with sterile towels or dressings soaked with sterile normal saline solution to decrease the chance of bacteria invasion and drying of the tissues. Do not attempt to reinsert the organs.  Position the client supine with the hips and knees bent.  Maintain a calm environment.  Keep the client NPO in preparation for returning to surgery. Hyperthyroidism: o Dietary Teaching Following Thyroidectomy with Parathyroid Removal  Major sources of calcium include dairy, broccoli, kale, fortified grains. o Manifestations of thyroid storm/ Assessment  Findings are hyperthermia, hypertension, delirium, vomiting, abdominal pain, tachydysrhythmias, chest pain, palpitations. o Nursing Management:  Report a temperature increase of 1 degree F or more to the provider immediately, because this is indicative of impending thyroid crisis. Reduction of Risk Potential Pancreatitis: Expected Laboratory Findings o Blood amylase: increases within 24 hr, and remains increased for 2 to 3 days (continued elevation can indicate pancreatic abscess or pseudocyst), Blood lipase increases slowly and can remain increased for days longer than amylase.  Urine amylase remains increased for up to 1 week.  Increases in enzymes indicate pancreatic cell injury.  MEMORY AID; In pancreatitis, the "ases" (aces) are high. o WBC count: Increased due to infection and inflammation o Platelets: Decreased o Blood calcium and magnesium: Decreased due to fat necrosis with pancreatitis o Blood liver enzymes and bilirubin: Increased with associated biliary dysfunction o Serum glucose: increased due to a decrease in insulin production by the pancreas. o Erythrocyte sedimentation rate: Elevated Stroke: Assessing for Neurological Deficits o Manifestations vary based on the area of the brain that is deprived of oxygenated blood. o The lef 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 (hemianopsia [loss of visual field in one or both eyes]). o The right cerebral hemisphere is responsible for visual and spatial awareness and proprioception.  Altered perception of deficits (overestimation of abilities)  Unilateral neglect syndrome (ignore lef side of the body: cannot see, feel, or move affected side, so client unaware of its existence). Can occur with lef-hemispheric strokes but is more common with right-hemispheric strokes.  Loss of depth perception  Poor impulse control and judgment  Lef hemiplegia or hemiparesis  Visual changes (hemianopsia) Noninflammatory Bowel Disorders: Assessing a Client for Inguinal Hernia o Bowel herniation: the displacement of the bowel through a weakness of the abdominal muscle into other areas of the abdominal cavity. o Expected findings: Protrusion or lump at involved site (groin area, umbilicus, healed incision) o Valvular Heart Disease: Priority Assessment Following a Myocardial Infarction o Interventions: Least restrictive/ least invasive  Select interventions that maintain client safety while posing the least amount of restriction to the client. For example, if a client who has a high fall risk index is getting out of bed without assistance, move the client closer to the nurses' work area rather than choosing to apply restraints.  Select interventions that are the least invasive. For example, bladder training for the incontinent client is a better option than an indwelling urinary catheter. o Assessment: Auscultation of the heart  Positioning the client in three different ways allows for optimal assessment of heart sounds, as some positions amplify extra or abnormal sounds. Sitting, leaning forward Lying supine Turned toward the lef side (best position for auscultating extra heart sounds or murmurs)  Use both the diaphragm and the bell of the stethoscope in a systematic manner to listen at all of the auscultatory sites.  To measure the heart rate, listen and count for 1 min.  Determine if the rhythm is regular. If a dysrhythmia exists, check for a pulse deficit (radial pulse slower that apical pulse). Report a difference in pulse rates to the provider immediately. Pressure Ulcers, Wounds, and Wound Management: Factors for Delayed Wound Healing o Nursing interventions: provide adequate hydration and meet protein and calorie needs  Encourage an intake of at least 2,500 mL/day of fluid from food and beverage sources if no contraindications (heart and chronic kidney disease),  Provide education about good sources of protein (meat, fish, poultry, eggs, dairy products, beans, nuts, whole grains).  Note if blood albumin levels are low (below 3.5 g/dL), because a lack of protein increases the risk for a delay in wound healing and infection.  Provide nutritional support (vitamin and mineral supplements, nutritional supplements, and enteral and parenteral nutrition). Most adult clients need at least 1,500 kcal/day for nutritional support. Cardiovascular Diagnostic and Therapeutic Procedures: Intervening to Manage Complications Following Cardiac Catheterization o Safety/Risk Reduction  Look first for a safety risk. For example, is there a finding that suggests a risk for airway obstruction, hypoxia, bleeding, infection, or injury?  Next ask, “What’s the risk to the client?” and “How significant is the risk compares to other posed risks?”  Give priority to responding to whatever finding poses the greatest (or most imminent) risk to the client’s physical well-being. o Hematoma formation: blood clots can form near the insertion site.  Nursing Actions Monitor for sensation, color, capillary refill, and peripheral pulses in the extremity distal to the insertion site. Assess the groin at prescribed intervals and as needed. Hold pressure for uncontrolled oozing/bleeding. Monitor peripheral circulation. Notify the provider. Burns: Discharge Teaching for Wound Management o Restoration of mobility  Maintain correct body alignment, splint extremities, and facilitate position changes to prevent contractures.  Maintain active and passive range of motion.    Assist with ambulation as soon as the client is stable. Apply pressure dressings to prevent contractures and scarring. Monitor areas at high risk for pressure sores (heels, sacrum, back of the head). Growth Factors: Evaluating Understanding for Erythropoietin o Expected Pharmacologic Action  Hematopoietic growth factors act on the bone marrow to increase production of red blood cells. o Therapeutic uses: Epoetin alfa  Anemia related to chronic kidney disease  For clients who have anemia caused by chemotherapy (nonmyeloid cancers)  To increase erythrocyte counts in clients who will undergo elective surgery  For clients who have anemia caused by taking zidovudine for HIV/AIDS Electrocardiography and Dysrhythmia Monitoring: Medications to Withhold Prior to a Cardioversion o Nursing Actions for elective cardioversion  Explain the procedure to the client and obtain consent.  Administer oxygen.  Document preprocedural rhythm  Have emergency equipment available.  Digoxin is held for 48 hr prior to elective cardioversion. Acute Respiratory Disorders: Caring for a Client Who Has Pneumonia o Airway breathing circulation (ABC) framework  The ABC framework identifies, in order, the three basic needs for sustaining life An open airway is necessary for breathing, so it is the highest priority. Breathing is necessary for oxygenation of the blood to occur. Circulation is necessary for oxygenated blood to reach the body's tissues. o The severity of manifestations should also be considered when determining priorities. A severe circulation problem can take priority over a minor breathing problem. o Some frameworks also include a "D" for disability and "E" for exposure. Pharmacological and Parenteral Therapies Integumentary Diagnostic Procedures: Contraindication for Allergy Skin Testing o Prior to testing, withhold corticosteroids and antihistamines for 48 hours to 2 weeks, as instructed by provider. o Prepare the skin on the client’s back or forearm for application of various allergens using soap and water. o Use alcohol to remove any oil. o Have equipment available to treat anaphylaxis. Hypertension: Recognizing Adverse Effects of Propranolol o Propranolol, beta blocker o Uses: hypotension, bradycardia, heart failure, AV block, sinus arrest, fatigue, bronchospasm in clients who have asthma. o Nursing actions:  Monitor blood pressure and heart rate. Monitor for chest pain, dyspnea, crackles, weight gain, or edema. Check apical pulse prior to dosage.  Monitor breathing and for evidence of bronchospasm.  Notify provider for pulse rate less than 50/min, or another prescribed rate. Heart Failure and Pulmonary Edema: Evaluating the Effects of Treatments o Inotropic agents (digoxin, dopamine, dobutamine, milrinone, levosimendan) are used to increase contractility and thereby improve cardiac output. o Nursing Actions:  For a client taking digoxin, take the apical heart rate for 1 min. Hold the medication is apical pulse is less than 60/min, and notify the provider. For some clients, the provider might allow the heart rate to be as low as 50/min.  Observe the client for nausea and vomiting. Pain Management: Opioid Education for an Older Adult Client o Opioid agonists: Morphine o Therapeutic uses:  Relief of moderate to severe pain (postoperative, myocardial infarction, following childbirth, cancer)  Sedation  Reduction of bowel motility  Cough suppression (codeine). o Complications: Urinary retention  NURSING ACTIONS Monitor 1&0. Assess the bladder for distention by palpating the lower abdominal area every 4 to 6 hr because opioid medication can suppress; awareness that the bladder is full.  CLIENT EDUCATION Void every 4 hr. Medications with anticholinergic properties (tricyclic antidepressants, antihistamines) can increase manifestations. Diabetes Mellitus: Teaching About Metformin o Take with food to decrease adverse Gl effects o Take vitamin By and folic acid supplements o Contact the provider if manifestations of lactic acidosis develop (myalgia, sluggishness, somnolence, and hyperventilation). Anemias: Teaching About Epoetin Alfa o Epoetin Alfa: a hematopoietic growth factor used to increase production of RBCs. o Nursing Actions:  Monitor for an increase in blood pressure.  Monitor Hgb and Hct twice per week.  Monitor for a cardiovascular event if Hgb increases too rapidly (greater than 1 g/dL in 2 weeks). o Client Education:  Understand the importance of having Hgb and Hct evaluated on a twiceper-week basis until targeted levels are reached. Endocrine Disorders: Interaction with Levothyroxine o Levothyroxine: thyroid hormone replacement therapy. o Nursing Actions:  Monitor for cardiovascular compromise (chest pain, palpitations, rapid heart rate, shortness of breath).  Inform the client that fiber supplements, calcium, iron, and antacids interfere with absorption. Before taking any over-the-counter medications, the client must consult with the provider. o Client Education:  Treatment begins slowly and the dosage will be increased every 2 to 3 weeks until the desired response is obtained. Blood TSH is monitored at scheduled times to ensure correct dosage.  Take the dose prescribed. Do not stop taking the medication or change the dose or brand name.  Take the medication on an empty stomach, typically 30-60 minutes before breakfast  Monitor for and report manifestations of hyperthyroidism (irritability, tremors, tachycardia, palpitations, heat intolerance, rapid weight loss).  Treatment is considered to be lifelong, requiring ongoing medical assessment of thyroid function. Medications Affecting Coagulation: Nursing Actions for Enoxaparin Administration o Enoxaparin: Low molecular weight heparin. o Therapeutic uses:  Prevent deep-vein thrombosis (DVT) in clients who are postoperative.  Treat DVT and PE.  Prevent complications in angina, non-Q wave MI, and ST elevation MI. o Nursing actions:  Rotate sites between right and lef anterolateral and posterolateral abdominal walls at least 2 inches from umbilicus. Pinch up an area of skin, inject at a 90-degree angle, and insert needle completely. Do not aspirate. Inject entire contents of syringe. Psychosocial Integrity Polycystic Kidney Disease, Acute Kidney Injury, and chronic kidney disease: Educating a Client About Psychosocial Issues o Nurses work with clients to identify goals and outcomes  Goals identify optimal status, whereas outcomes identify the observable criterion that will determine success or failure of the goal.  Ofen these terms are interchangeable. With any format, the goal/outcome must be client-centered, singular, observable, measurable, time-limited, mutually agreeable and reasonable.  Concise, measurable goals help nurses and clients evaluate progress:  Nurses use short- and long-term goals to guide the client toward the planned outcome and determine the effectiveness of nursing care.