Med surg ati study GUIDE

Med surg ati study • Accident/Error/Injury Prevention - (1) o Spinal Cord Injury: Care of a Client who has a Halo Device (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 16) o The purpose is to provide traction and/or immobilize the spinal column ▪ Do not use the halo device to turn or move a client ▪ If the client goes home with a halo fixation device on, provide instruction on pin and vest care. ▪ Teach the client signs of infection and skin breakdown. ▪ Maintain body alignment and ensure cervical tong weights hang freely. ▪ Monitor skin integrity by providing pin care and assessing the skin under the halo fixation vest as appropriate. • Standard Precautions/Transmission-Based Precautions/Surgical Asepsis - (1) o Bacterial, Viral, Fungal, and Parasitic Infections: Isolation Precautions for Client Who Has Influenza (Active Learning Template - Basic Concept, RM FUND RN 9.0 Ch 56) ▪ Contact: Clostridium difficile, herpes simplex virus, impetigo, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Staphylococcus aureus (VRSA) ▪ Airborne: Measles, varicella, tuberculosis ▪ Droplet (3-6 ft): Haemophilus influenzae type B (Hib), pertussis, mumps, rubella, plague, streptococcal pneumonia, meningococcal pneumonia • Tuberculosis: Priority Action for a Client in the Emergency Department (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 23) ▪ Administer heated and humidified oxygen therapy as prescribed ▪ 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 into provided plastic bags or no-touch receptacles ▪ Clients are no longer considered infectious after three consecutive negative sputum cultures • Adverse Effects/Contraindications/Side Effects/Interactions - (1) o Electrolyte Imbalances: Manifestations of Hypokalemia (Active Learning Template - Medication, RM AMS RN 10.0 Chp 44) ▪ VITAL SIGNS: ▪ Decreased blood pressure, thready weak pulse, orthostatic hypotension ▪ NEUROLOGIC: ▪ Altered mental status, anxiety, and lethargy that progresses to acute confusion and coma ▪ ECG: ▪ Flattened T wave, prominent U waves, ST depression, prolonged PR interval ▪ GASTROINTESTINAL: ▪ Hypoactive bowel sounds, nausea, vomiting, constipation, abdominal distention. Paralytic ileus can develop. ▪ MUSCULAR: ▪ Weakness. Deep-tendon reflexes can be reduced. ▪ RESPIRATORY: Shallow breathing • Blood and Blood Products - (1) o Blood and Blood Product Transfusions: Steps to Administer a Blood Transfusion (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 40) ● Verify the prescription for a specific blood product. ● Obtain consent for procedure if required. ● Obtain blood samples for compatibility determination, such as type and cross-match. ● Assess for a history of blood-transfusion reactions. ● Initiate large-bore IV access. An 18- or 20-gauge needle is standard for administering blood products. ● Obtain blood products from the blood bank. Inspect the blood for discoloration, excessive bubbles, or cloudiness. ● Prior to transfusion, two RNs must identify the correct blood product and client by looking at the hospital identification number (noted on the blood product) and the number identified on the client’s identification band to make sure the numbers match. ● The nurse completing the blood product verification must be one of the nurses who administers the blood product. ………………………………………..CONTINUED…………………………………………………