ATI MEDSURG FOCUSED REVIEW-Latest

ATI MEDSURG FOCUSED REVIEW CHAPTER 4 Pain Management: Use of Nonpharmacologic Methods of Pain Relief (RN QSEN - Patient-centered Care, Active Learning Template - Basic Concept, RM AMS RN 10.0 Chp 4) 1. relaxation 2. distraction 3. cutaneous stimulation (ie acupressure, massage, thermal therapy, contralat stimulation) 4. guided imagery 5. hypnosis 6. biofeedback 7. music therapy 8. exercise NSAIDS have analgesic, anti-inflammatory, antiplatelet, & antipyretic effects. - Be aware of Hepatotoxic effects of Acetiminophen. Pt w/ a healthy liver should take no more than 4g/day. - prevent GI upset in pt by admin the Rx w/ food or antacids. - Monitor pt for bleeding w/ long term NSAID use. - Monitor pt for "Salicylism" (tinnitus, vertigo, decreased hearing acuity). More notes on management of pain CHAPTER 16 Spinal Cord Injury: Care of a Client who has a Halo Device (RN QSEN - Safety , Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 16) - Application of Immobilization Devices & Traction - *Pts who have cervical fractures may be placed in a halo fixation device or cervical tongs. Purpose is to provide traction &/or immobilize the spinal column. - NURSING ACTIONS - *maintain body alignment & ensure cervical tong weights hang freely. *Monitor skin integrity by providing pin care & assessing the skin under the halo fixation vest as appropriate. - PT EDUCATION - *if the pt goes home w/ a Halo fixation device on, provide instruction on pin & vest care. *Teach the pt signs of infection & skin breakdown. Surgical Interventions CHAPTER 23 Tuberculosis: Priority Action for a Client in the Emergency Department (RN QSEN - Safety , Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 23) Tuberculosis: Priority Action for a Client in the Emergency Department • Heated humidified oxygen administration • N95 HEPA filtered mask for staff /transportation of client surgical mask • Negative pressure room. The client should be transported using the shortest and least busy route. Cough and expectorate sputum into tissues that are disposed of by the client should be put into provided plastic bags or no-touch receptacles. Clients are no longer considered infectious after 3 consecutive negative sputum cultures. CHAPTER 24 Pulmonary Embolism: Risk Factors for Deep-Vein Thrombosis (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 24) RISK FACTORS Long-term immobility Oral contraceptive use and estrogen therapy Pregnancy Tobacco use Hypercoagulability (elevated platelet count) Obesity Surgery (especially orthopedic surgery of the lower extremities or pelvis) Central venous catheters Heart failure or chronic atrial fibrillation Autoimmune hemolytic anemia (sickle cell) Long bone fractures Cancer Trauma Advanced age `` Electrocardiography and Dysrhythmia Monitoring: Analyzing ECG (Active Learning Template - Diagnostic Procedure, RM AMS RN 10.0 Chp 28) CHAPTER 36 Hypertension: Evaluating a Client Who Takes Lisinopril (RN QSEN - Safety , Active Learning Template - Medication, RM AMS RN 10.0 Chp 36) Beta blockers Metroprolol and atenolol. For patients with unstable angina or myocardial infarction. Decreases cardiac output and blocks the release of renin, subsequently decreasing vasoconstriction in the peripheral vasculature Side effects of beta blockers Fatigue, weakness, depression, sexual dysfunction. Stopping abruptly can cause rebound hypertension. Can mask hypoglycemia Adverse effect of Lisinopril is persistent dry cough. CHAPTER 40 Blood and Blood Product Transfusions: Treatment for Circulatory Overload (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 40) For blood transfusion on the elderly, use no larger than a 19-gauge needle is used Assess kidney function, fluid status, and circulation prior to blood product administration. Older adult patient are at an increased risk for fluid overload Use blood products that are less than 1 week old. Assess vital signs every 15 min throughout the transfusion for fluid overload Administer the blood transfusion over 2 to 4 hr for older adult clients. Without giving other IV fluid to prevent fluid overload Risk for HF and fluid overload 1.Stop transfusion immediately if reaction is suspected 2. Start infusion of NS with separate line 3. Save and send bag and lines of blood to testing lab 4. Maintain patent airway,administer oxygen 5. Give antibiotic and administer vasopressors (dopamine) 1. Monitor daily weights, I and O, edema- may be indication of worsening condition. 2. Monitor for cardiac output, blood pressure, and ejection fraction. 3. Hemodynamic monitoring using arterial line can tell us more about patient's condition. 4. Harder for heart failure patient to receive transfusions- worsening condition is manifested as dyspnea, chest tightness, tachycardia, tachypnea, headache, hypertension, jugular vein distention, peripheral edema, orthopnea, anxiety and crackles in the bases of the lungs 5. nursing interventions are to give O2, monitor VS, slow infusion, give diuretics and contact provider. CHAPTER 44 Electrolyte Imbalances: Effective Action of Magnesium Sulfate (Active Learning Template - Medication, RM AMS RN 10.0 Chp 44) • IV route is used because IM can cause pain and tissue damage. • Oral magnesium can cause diarrhea and increase magnesium depletion. • Monitor Deep Tendon Reflex (DTR) hourly during administration of magnesium sulfate. • IV magnesium sulfate is given via an infusion pump not to exceed 150mg/min or 67mEq over an 8 hr period. • Clients receiving digitalis should be monitored closely if magnesium is low because it predisposes the client to digitalis toxicity.  Electrolyte Imbalances: Adequate Nutritional Status with Total Parenteral Nutrition (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 44) • The purpose of TPN administration is to prevent or correct nutritional deficiencies and minimize the adverse effects of malnourishment. CHAPTER 47 Gastrointestinal Therapeutic Procedures: Total Parental Nutrition (RN QSEN - Safety , Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 47 1.TPN is a hypertonic IV bolus solution used to correct nutritional deficiencies. 2. TPN is usually administered through a PICC line 3. Daily lab values including electrolytes will need to be pulled for each patient and TPN will be individualized based on these values. 4. The flow rate is gradually increased and decreased to allow for body adjustment 5. change tubing and bag every 24 hours- if TPN not available when changing or empty, give 5% dextrose solution CHAPTER 55 Pressure Ulcers, Wounds, and Wound Management: Implementing Preventive Strategies (RN QSEN - Safety , Active Learning Template - Basic Concept, RM FUND 9.0 Ch 55) -Reposition the client in bed at least every 2 hr and every 1 hr in a chair. -Hydration, and nutrient -Provide a firm, wrinkle-free foundation with wrinkle-free linens -relieve pressure on the sacrum, buttocks, and heels -Instruct clients who are mobile to shift their weight every 15 min when sitting -Keep clients from sliding down in bed -Clean the skin with a mild cleansing agent -Apply dimethicone-based moisture barrier creams or alcohol-free barrier films clean from least contaminated to the most contaminated use gentle friction do not use cotton balls or other products that shed fibers document the location and type of wound and incision, the status of the wound, type of dressing and materials, client teaching, and how the client handled the procedure CHAPTER 70 Osteoporosis: Teaching Self-Administration of Alendronate (RN QSEN - Safety , Active Learning Template - Medication, RM AMS RN 10.0 Chp 70) • Take with 8oz water in the early morning before eating • Remain upright for 30 min after taking oral medication • Report early signs of indigestion, chest pain, difficulty swallowing, or bloody emesis. • Clients using IV preparations should have dental examinations and preventative treatment prior to starting therapy. Alendronate is an oral bisphosphonate used to treat postmenopausal osteoporosis, male osteoporosis, glucocorticoid-induced osteoporosis, and Paget’s disease of the bone. Although generally safe, esophagitis and esophageal ulceration are the most serious adverse effects. To minimize the risk of esophagitis and ulceration, the client should be instructed to remain upright (sitting or standing) for a minimum of 30 minutes (up to 1 hour) after administration. Other rare adverse effects are musculoskeletal pain, ocular inflammation, atypical femur fractures, and osteonecrosis of the jaw. CHAPTER 71 Musculoskeletal Trauma: Maintaining Proper Traction (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 71) Maintain body alignment and realign if the client seems uncomfortable or reports pain. Ensure that weights hang freely and are not resting on the floor. CHAPTER 85 `BBBBBBBBBBBB` For adults 65 years and older who have not been immunized with PCV13 or PPSV23, administer PCV13 first and then give PPSV23 in 6 to 12 months; do not administer both during the same visit. For adults who received a dose of PPSV23 at age 65 or older, an additional dose is not indicated. MPSV4 is preferred for adults who are 56 years of age or older, require a single dose, and have nothad MenACWY previously Zoster vaccine: Recommended as a one-time dose for all adults older than 60 years CHAPTER 93 Pain Management for Clients Who Have Cancer: Managing Breakthrough Pain (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 93) • Manage acute severe pain with short term (24 to 48 hr) around the clock administration of opioids rather than following a PRN schedule • The parenteral route is best for immediate, short-term relief of acute pain. The oral route is better for chronic, non-fluctuating pain. • Combinations such as hydrocodone and acetaminophen for breakthrough pain. CHAPTER 78 Hyperthyroidism: Assessing a Client for Chvostek's Sign Following a Thyroidectomy (Active Learning Template - Nursing Skill, RM AMS RN 10.0 Chp 78) CHAPTER 3 Neurologic Diagnostic Procedures: Preparing a Client for a Lumbar Puncture (Active Learning Template - Diagnostic Procedure, RM AMS RN 10.0 Chp 3) The risks versus benefits of a lumbar puncture should be discussed with the client prior to this procedure. DO NOT perform when patient has ICP or bleeding or on anticoagulant. NURSING ACTIONS: • Ensure that all of the client’s jewelry is removed and that the client is wearing only a hospital gown. • Void prior to procedure • Position patient in “cannonball while on one side” or “stretch over an overbed table when sitting.” CHAPTER 45 Acid-Base Imbalances: Interpreting ABG Results (Active Learning Template - Diagnostic Procedure, RM AMS RN 10.0 Chp 45) Acid-Base Imbalances: Identifying Clients at Risk for Imbalances (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 45) CHAPTER 14 Head Injury: Monitoring Neurological Status (RN QSEN - Patient-centered Care, Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 14) CHAPTER 80 Cushing's Disease/Syndrome: Priority Actions (RN QSEN - Safety , Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 80) CHAPTER 75 Burns: Assessment Findings of Early Phase of Injury (RN QSEN - Safety , Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 75) Inhalation damage findings include: • Singed nasal hair, eyebrows, and eyelashes; sooty sputum; hoarseness; wheezing; edema of the nasal septum; and smoky smelling breath. Carbon monoxide inhalation (from burns in an enclosed area) findings include: • Headache, weakness, dizziness, confusion, erythema (pink or cherry red skin) and upper airway edema Hypovolemic shock • Hypotension and tachycardia. Burns: Priority Action During Resuscitation Phase (RN QSEN - Safety, Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 75) Emergent (Resuscitative Phase): • Begins with the injury and continues for 24 to 48 hr. • Priorities include securing the airway, supporting circulation and organ perfusion by fluid replacement, managing pain, preventing infection through wound care, maintaining body temperature, and providing emotional support. CHAPTER 47 Gastrointestinal Therapeutic Procedures: Appropriate Actions for an Abdominal Paracentesis (RN QSEN - Safety , Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 47) • Goal: Relieve abdominal ascites pressure • Performed by inserting a needle or trocar through the abdominal wall into the peritoneal cavity Preprocedure • Consent sign • Have patient void prior • High fowler position, sit upright, edge of bed with feet support, • Restore fluids before or after • Assess lab (amylase, BUN, creatinine, albumin, protein, glucose) Intraprocedure • 4-6L drain from cavity. Monitor drainage. CHAPTER 45 Sensory Perception: Performing Ear Irrigation (Active Learning Template - Nursing Skill, RM FUND 9.0 Ch 45) Use a commercial ceruminolytic (ear drops that soften cerumen) for impactions and follow with warm water irrigation. CHAPTER 15 Stroke: Planning to Administer Thrombolytic Therapy (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 15) Medication: • Give within 4-5hr of initial symptoms. Catheter – directed thrombolytic therapy must be administered within 6 hr of the onset of symptoms • Contraindication Hemorrhagic stroke Anticoagulant takers (bleeders) CHAPTER 91 Cancer Treatment Options: Teaching About Skin Care Following Radiation Treatment (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 91) • Gently wash the skin over the radiated area with mild soap and water. Dry the area thoroughly using patting motions. • Do not remove or wash off radiation tattoos (markings) used to guide therapy. Do not apply powders, ointments, lotions, deodorants, or perfumes to the radiated skin. • Wear soft clothing. Avoid tight or constricting clothes. • Do not expose the radiated skin to sun or a heat source. • Inspect skin for evidence of damage and report to the provider. Cancer Treatment Options: Prioritizing Client Care (RN QSEN - Safety , Active Learning Template - Basic Concept, RM AMS RN 10.0 Chp 91) CHAPTER 18 Chest Tube Insertion and Monitoring: Clarifying Provider Prescription (RN QSEN - Safety , Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 18) CHAPTER 14 Head Injury: Administering Medications for Increased Intracranial Pressure (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 14) • Mannitol (first-line) – Draws fluids from the brain into blood. • Barbiturates (phenobarbital, thiopental) – decrease cellular metabolism demands. • Phenytoin – prevent and treat seizures. • Morphine – pain and restlessness. CHAPTER 60 Infections of the Renal and Urinary System: Assessment of Flank Pain (Active Learning Template - Nursing Skill, RM AMS RN 10.0 Chp 60) CHAPTER 5 Meningitis: Planning Interventions for Care (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 5) • Isolate the client in a private room as soon as meningitis is suspected (droplet precaution). • Continue droplet precautions till antibiotics have been administered for 24 hrs and secretions are no longer infectious. • Clients who have bacterial meningitis might need to remain on droplet precautions continuously. • Implement fever reduction measures such as a cooling blanket. • Decrease environmental stimuli (quiet). • Minimize exposure to bright light. • Head of bed 30 degrees. • Avoid coughing and sneezing. • Seizure precautions • Older adults at increased risk for pneumonia. CHAPTER 23 Tuberculosis: Discharge Teaching About Tuberculosis (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 23) • 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. • Instruct the client to continue with follow up care for 1 full year. • Instruct the client that sputum samples are needed every 2 to 4 weeks to monitor therapy effectiveness. • Advise clients who have active TB to wear a mask when in public places or in contact with crowds. CHAPTER 43 Fluid Imbalances: Clinical Manifestations of Dehydration (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 43 Chapter 59 Polycystic Kidney Disease, Acute Kidney Injury, and Chronic Kidney Disease: Findings to Report (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 59 CHAPTER 28 Electrocardiography and Dysrhythmia Monitoring: Priority Action for Sinus Bradycardia (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 28) • Atropine or Isoproterenol. Implantation of pacemaker CHAPTER 29 Pacemakers: Evaluating Client Understanding of Discharge Teaching (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 29) • Carry a pacemaker identification card at all times • Prevent wire dislodgement (wear sling when out of bed. Do not raise arm above shoulder for 1 to 2 weeks). • Take pulse daily at the same time. Notify the provider if heart rate is less than the pacemaker rate CHAPTER 45 Acid-Base Imbalances: Evaluating Arterial Blood Gas Results (Active Learning Template - Basic Concept, RM AMS RN 10.0 Chp 45) CHAPTER 9 Brain Tumors: Pharmacological Treatment of Diabetes Insipidus (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 9) • Treatment of DI consists of massive fluid replacement, careful attention to laboratory values, and replacement of essential nutrients as indicated. • Desmopressin. CHAPTER 86 HIV/AIDS: Priority Client Teaching (RN QSEN - Patient-centered Care, Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 86) • Teach the client how the virus is transmitted and ways to prevent infection, such as the use of condoms, abstinence, and avoiding sharing needles. • Encourage the client to maintain up to date immunizations, including yearly seasonal influenza and pneumococcal polysaccharide vaccine. • Instruct the client to avoid crowded areas or travelling to countries with poor sanitation. • Do not miss a dose. • Encourage the client to avoid raw foods, such as fruits or vegetables, and undercooked foods such as meat, fish or eggs. • Avoid cleaning pet litter boxes to reduce toxoplasmosis. • Avoid exposure to sick people (cold or flu). • Instruct the client to wash dishes in hot water using a dish washer if available. • Encourage the client to bathe daily using antimicrobial soap. CHAPTER 25 Pneumothorax, Hemothorax, and Flail Chest: Interventions for Flail Chest (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 25) • Cause- multiple rib fractures from blunt chest trauma. • Administer humidified oxygen • Promote lung expansion by encouraging deep breathing and proper positioning. • Usually stabilized by positive pressure ventilation. • Suction as needed. • Administer pain medication PCA or an epidural block commonly is used • Administer IV fluids. • Monitor I & O • Monitor vital signs and SaO2. CHAPTER 78 Hyperthyroidism: Client Teaching About Thyroid Storm (RN QSEN - Patient-centered Care, Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 78) ◯ Thyroid storm/crisis results from a sudden surge of large amounts of thyroid hormones into the bloodstream, causing an even greater increase in body metabolism. This is a medical emergency with a high mortality rate. ◯ Precipitating factors include infection, trauma, emotional stress, diabetic ketoacidosis, and digitalis toxicity, all of which increase demands on body metabolism. It also can occur following a surgical procedure or a thyroidectomy as a result of manipulation of the gland during surgery. ◯ Findings are hyperthermia, hypertension, delirium, vomiting, abdominal pain, hyperglycemia, and tachydysrhythmias. Additional findings include chest pain, dyspnea, and palpitations. ◯ Nursing Actions ■ Maintain a patent airway. ■ Provide continuous cardiac monitoring for dysrhythmias. ■ Administer acetaminophen to decrease the client's temperature. Caution - Salicylate antipyretics are contraindicated because they release thyroxine from protein-binding sites and increase free thyroxine levels. ■ Provide cool sponge baths, or apply ice packs to decrease fever. If fever continues, obtain a prescription for a cooling blanket for hyperthermia. ■ Administer thionamides - methimazole or propylthiouracil (PTU) - to prevent further synthesis and release of thyroid hormones. ■ Administer propranolol to block sympathetic nervous system effects. ■ Administer glucocorticoids to treat shock. ■ Administer IV fluids to provide adequate hydration and prevent vascular collapse. Fluid volume deficit may occur because of increased fluid excretion by the kidneys or excessive diaphoresis. Monitor intake and output hourly to prevent fluid overload or inadequate replacement. ■ Administer sodium iodide as prescribed, 1 hr after administering PTU. Caution - If given before PTU, sodium iodide can exacerbate manifestations in susceptible clients. ■ Administer small doses of insulin as prescribed to control hyperglycemia, which can occur because of the hypermetabolic state. ■ Administer supplemental O2 to meet increased oxygen demands. ◯ Client Education ■ Provide the client and family support and information about the client's condition and all procedures. Advise the client to notify the provider of fever, increased restlessness, palpitations, and chest pain. CHAPTER 71 Musculoskeletal Trauma: Assessing for Compartment Syndrome (RN QSEN - Safety , Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 71) CHAPTER 7 Parkinson¶s Disease: Teaching About Pathophysiology (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 7) • Parkinson’s Disease is a progressively debilitating disease that grossly affects motor function. 1. Identify three causes for hypokalemia • vomiting • diarrhea • failure to replace potassium losses • kidney disease • medication (Example is diuretics like lasix) 2. List three symptoms of hypokalemia • muscle weakness • fatigue • decreased GI motility • constipation • muscle cramps • arrhythmias, List three nursing implications • Monitor ECG • Administer K+ (I WILL NEVER give K+ IV bolus; I MUST dilute). • Teach dietary sources of K+ 1. Identify three causes for hyperkalemia • Tissue injury • K+-sparing diuretics • Renal failure • Adrenal insufficiency • Increased intake of potassium • Dehydration 2. List three symptoms of hyperkalemia • muscle weakness/paralysis • ventricular fibrillation/cardiac standstill • cardiac depolarization impaired • nausea • abdominal cramping • diarrhea 3. List three nursing implications • Monitor ECG • Kayexalate (I need to monitor BS ) • Calcium gluconate • Administer Loop diuretics as prescriped • Dialysis A nurse is teaching a group of nursing students about the National Pressure Ulcer Advisory Panel’s classification system for pressure ulcers. RELATED CONTENT: List the six pressure ulcer stages along with a brief description of the assessment 1. SUSPECTED DEEP TISSUE INJURY: Discolored but intact skin caused by damage to underlying tissue. The tissue in the area may be painful, firm, mushy, warmer or cooler when compared with adjacent tissue. 2. STAGE I: The skin is intact but the area has a persistent, non-blanchable redness, typically over a bony prominence. Compared to adjacent tissue, this area may feel painful, warm or cool to touch. The tissue in the area is swollen and congested with possible discomfort at the site. the area may appear blue or purple in darker skin tones. 3. STAGE II: This stage of pressure ulcer is characterized by shallow open ulcer with a red pink wound bed. It can also present as an intact or open/ruptured serum-filled blister. At this stage, there is a partial-thickness loss of dermis and the ulcer can appear as shiny or dry shallow slough. The ulcer at this stage may become infected, possibly with pain and scant drainage. 4. STAGE III: At this stage, the subcutaneous fat may be open, but the bone, tendon, or muscle are not exposed. This stage presents with a full-thickness tissue loss. This stage of pressure ulcer can look shallow in areas where there is no subcutaneous fat like the ear and nose. It’s depth usually depends on the anatomical location. Slough may be present but will not obscure the depth of tissue loss. The areas that are rich in subcutaneous tissue experience a deep and big damage to the subcutaneous tissue. Drainage and infection of the wound can occur at this stage. 5. STAGE IV: Unlike in stage III, bone, muscle, and tendon are exposed with full thickness tissue loss and tissue necrosis. This stage makes Osteomyelitis possible because the ulcer extends into the muscle and other supporting structures like tendon and fascia. There may be slough, eschar, tunneling, undermining, and infection. 6. UNSTAGEABLE: At this stage, the base of the ulcer is obscured by slough (can be yellow, tan, grey, green, or brown) and eschar (can be tan, brown, or black). The stage of the ulcer cannot be determined until the slough and eschar is removed to reveal the base of the wound. NURSING ACTIONS: List four nursing interventions to help prevent pressure ulcers. • Reposition clients every 2 hours while in bed and every 1 hour while sitting on a chair. This will help to relieve pressure on the bony prominences where pressure ulcer mostly occur. • Use pressure-relieving devices and implement pressure reduction surfaces like air mattress, foam mattress. • Keep clients clean, dry, well-nourished, and hydrated. • If possible, encourage ambulation and mobility of clients. TREATMENT OPTIONS: List two treatment options for pressure ulcers • Cleaning and dressing the wound as prescribed • Adequate nutrition can encourage wound healing. • Administer prescribed analgesics to relieve pain, antimicrobials, and antibiotics to prevent infection. • Surgical intervention and wound vac. RISK POTENTIAL: Discuss two indicators that increase a client’s risk for pressure ulcer • Limited mobility which can lead to poor blood flow and circulation thereby causing bedsores. • Incontinence which can lead to skin damage and may encourage pressure ulcer to develop. • Poor nutritional status: Patients with poor nutritional status have a higher chance of developing pressure ulcer • Pain can limit a client’s ability to reposition himself. A nurse is caring for a client who is receiving a blood transfusion. What nursing actions should the nurse anticipate if a transfusion reaction is suspected? • STOP THE INFUSION and maintain intravenous (IV) access by infusing normal saline solution through new tubing at a slow rate. INDICATIONS • Describe the four types of reactions and the time of onset. 1. Acute Hemolytic transfusion reaction: This kind of reaction is usually as a result of incompatibility which may have been caused by wrong blood-sample labelling, wrong blood-component labelling, and wrong patient identification. The reaction usually begins within 10 minutes of starting the transfusion. An osmotic diuretic like mannitol promotes urinary excretion of hemoglobin that results from this kind of reaction. 2. Febrile, Non-hemolytic transfusion reaction: This type of reaction usually start within 30 minutes to 6 hours after transfusion. This reaction can be accompanied with chills, fever and headache. A fever-reducing antipyretic or analgesic medication is usually administered to reduce the fever associated with this kind of reaction. 3. Allergic reaction: This type of reaction can start anytime during transfusion and up to 1 hour after completion. Allergic reaction differ from person to person. While some people may experience a minor rash, some others can experience anaphylactic reaction. Usually, antihistamines like Benadryl and vasopressor like Epinephrine are administered to subside allergic reaction. 4. Transfusion-related acute lung injury (TRALI): This type of reaction can occur at any time during the transfusion up till 6 hours after the transfusion is complete. Symptoms can include chills, respiratory distress (which can lead to respiratory failure), and onset of pulmonary edema. Clients with this type of reaction require oxygen and airway support. 5. Circulatory Overload: This type of reaction can occur during blood transfusion. Symptoms include ; dyspnea, tachycardia, tachypnea, crackles at base of lungs, JVD, headache, sudden anxiety, hypertension. Loop diuretics like Lasix can be administered to alleviate this kind of reaction. • What are the primary differences between the four types of blood reactions? The differences in the blood reactions are seen in the symptoms, causes, time of onset, and required intervention of each reaction type. • What are the similarities? Most reactions result in changes in vital signs, fever, chills, back/abdominal pain, and headache. • For each type of blood reaction, name a medication that can be administered and explain why that medication would be given. This question has been answered above. POTENTIAL COMPLICATIONS: Describe one nursing actions for each type of reaction : The first and priority nursing action for any kind of blood transfusion reaction is to STOP THE INFUSION. OUTCOMES: How do we identify improvement following blood administration? What blood type is considered the universal donor and why? people with type O blood are known as “universal donors” because anyone can receive type O red blood cells What blood type is considered the universal recipient and why? People with type AB blood are known as “universal recipients” because type AB individuals can receive red blood cells of any ABO type. Are the answers to these questions the same for all blood products? Give an example of any differences if there are any. The only difference I know is that for plasma blood product, AB plasma donors can give to all blood types. 1. Identify and discuss three risk factors that can result in heart failure. • Hypertension • Obesity • Coronary artery disease • Diabetes • smoking 2. Identify and discuss three types of medications that you might anticipate being prescribed for a client with heart failure. Discuss why these meds would be used. • Diuretics like Furosemide (Lasix) and chlorothiazide : These help to get rid of extra fluid and relieves symptoms like swelling on the leg. • Beta Blockers like metoprolol and carvedilol : These medications slow the heart rate. It can help the heart fill with blood more completely and also lowers the blood pressure. • Ace-Inhibitors like Lisinopril and Captopril : These medications relaxes and widens the blood vessels thereby making it easier for blood to flow. • Digoxin : This medication helps the heart pump more blood. 3. Discuss atrial fibrillation. Include risks posted to the client when in atrial fibrillation. Atrial fibrillation is a type of arrhythmia that is characterized by a fast rate and irregular rhythm of a person’s heartbeat. In Atrial fibrillation, the blood that pools in the atria isn't pumped completely into the heart's two lower chambers (ventricles) because the atria contracts (fibrillate) very fast and irregularly. This makes it difficult for the upper and lower chambers of the heart to work together as they are supposed to.While in atrial fibrillation, a patient has an increased risk of stroke, heart attack, and heart failure. Name three medications this client would be taking and why. • Sodium-channel blockers like quinidine slow electrical conduction in the heart. • Potassium channel blockers like Amiodarone (Cordarone) helps to control heart rhythm by interfering with conduction that occurs through the potassium channels in the cells • Beta blockers like metoprolol work by blocking the impulses that may cause an irregular heart rhythm and by interfering with hormonal influences on the heart’s cells. • Calcium channel blockers like verapamil (Calan) helps to slow down heart rate. • Anticoagulant like warfarin help to reduce risk of clots and stroke 4. Differentiate between right and left sided heart failure: Symptoms, assessment, pathophysiology, significance of identifying the differences. Left-sided heart failure is inadequate left ventricle cardiac output and consequently inadequate tissue perfusion. It is when the left side of the heart must work harder to pump the same amount of blood. Left sided heart failure can be grouped into 2 types. • Systolic failure is when the left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation. • Diastolic failure is when the left ventricle loses its ability to relax normally (because the muscle has become stiff). The heart can't properly fill with blood during the resting period between each beat. Right-sided heart failure usually occurs as a result of left-sided failure. When the left ventricle fails, increased fluid pressure is transferred back through the lungs. This leads to a damage to the heart's right side. When the right side loses pumping power, blood backs up in the body's veins. This usually causes swelling or congestion in the legs, ankles and swelling within the abdomen such as the GI tract and liver (causing ascites) SYMPTOMS OF HEART FAILURE INCLUDE: • Shortness of breath (also called dyspnea) • Persistent coughing or wheezing • Buildup of excess fluid in body tissues (edema) • Tiredness, fatigue • Lack of appetite, nausea • Confusion, impaired thinking • Increased heart rate. ASSESSMENT : • Check vital signs • Auscultate heart and lung sounds • Assess abdomen extremities for signs of edema/fluid retention. • Monitor intake and output • Check capillary refill (should be less than 3 seconds). • Laboratory values. Identifying the difference in the two kinds of heart failure is very important in carrying out assessment and right intervention measures.