VATI RN 2ND COMPREHENSIVE PREDICTOR FOCUSED REVIEW

VATI RN 2ND COMPREHENSIVE PREDICTOR FOCUSED REVIEWVATI RN 2ND COMPREHENSIVE PREDICTOR FOCUSED REVIEW Management of Care – (5) Case Management – (1) Cardiovascular Disorders: Tetralogy of Fallot (RM NCC RN 10.0 Chp 20) • Defects that decreases pulmonary blood flow have an obstruction of pulmonary blood flow and an anatomic defect (ASD or VSD) between the right and left sides of the heart. In these defects, there is a right to left shift allowing deoxygenated blood to enter the systemic circulation. Hypercyanotic spells (blue, or “Tet,” spells) manifest as acute cyanosis and hyperpnea • Tetralogy of fallot – four defects that result in mixed blood flow: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy Cyanosis at birth: progressive cyanosis over the first year of life Systolic murmur Episodes of acute cyanosis and hypoxia (blue or “Tet” spells) • Surgical procedures – shunt placement until able to undergo primary repair; complete repair within first year of life Collaboration with Interdisciplinary Team – (1) Communicable Diseases, Disasters, and Bioterrorism: CDC Reportable Diagnoses (RM CH RN 7.0 Chp 6) • Anthrax, Botulism, Cholera, Congenital rubella syndrome (CRS), Diphtheria, Giardiasis, Gonorrhea, Hepatitis A, B, C, HIV infection, influenza-associated pediatric mortality, Legionellosis/Legionnaires’ disease, Lyme disease, Malaria, Meningococcal disease, Mumps, Pertussis (whooping cough), Poliomyelitis, paralytic, Poliovirus infection, nonparalytic, Rabies (human or animal), Rubella (German measles), Salmonellosis, Severe acute respiratory syndrome-associated coronavirus disease (SARS-CoV), Shigellosis, Smallpox, Syphillis, Tetanus/C. Tetani, Toxic Shock Syndrome (TSS) (other than streptococci), Tuberculosis (TB), Typhoid fever, Vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus (VISA/VRSA) Concepts of Management – (1) Managing Client Care: Conflict Management Between Health Care Workers (RM Leadership 7.0 Chp 1) 1 | P a g e• Conflict is the result of opposing thoughts, ideas, feelings, perceptions, behaviors, values, opinions, or actions between individuals. Conflict is an inevitable part of professional, social, and personal life and can have constructive or destructive results. Nurses must understand conflict and how to manage it. Nurses can use problem-solving and negotiation strategies to prevent a problem from evolving into a conflict. Lack of conflict can create organizational stasis, while too much conflict can be demoralizing, produce anxiety, and contribute to burnout. Conflict can disrupt working relationships and create a stressful atmosphere. If conflict exists to the level that productivity and quality of care are compromised, the unit manager must attempt to identify the origin of the conflict and attempt to resolve it. Continuity of Care – (1) Information Technology: Change-of-Shift Report (RM FUND 9.0 Chp 5) • Nurses give this report at the conclusion of each shift ot the nurse assuming responsibility for the clients. Formats include face to face, audiotaping, or presentation during walking rounds in each client’s room (unless the client has a roommate or visitors are present). An effective report should: include significant objective information about the client’s health problems, proceed in a logical sequence, include no gossip or personal opinion, and relate recent changes in medications, treatments, procedures, and the discharge plan. Establishing Priorities – (1) Managing Client Care: Prioritizing Care of Postoperative Clients (RM Leadership 7.0 Chp 1) • Prioritize systemic before local (“life before limb”) • Prioritize acute (less opportunity for physical adaptation) before chronic (greater opportunity for physical adaptation) • Prioritize actual problems before potential future problems • Listen carefully to clients and don’t assume • Recognize and respond to trends vs. transient findings • Recognize indications of medical emergencies and complications vs. expected findings • Apply clinical knowledge to procedural standards to determine the priority actions Safety and Infection Control – (8) Accident/Error/Injury Prevention – (1) Seizures: Maintaining Seizure Precautions (RM NCC RN 10.0 Chp 13) • Maintain seizure precautions, including placing the bed in the lowest position and padding the side rails to prevent future injury. Emergency Response Plan – (1) Client Safety: Priority Action for Fire (RM FUND 9.0 Chp 12)• R: rescue and protect clients in close proximity to the fire by moving them to a safer location. Clients who are ambulatory may walk independently in a safe location • A: alarm: activate the facility’s alarm system and then report the fire’s details and location • C: contain/confine the fire by closing doors and windows and turning off any sources of oxygen and any electrical devices. Ventilate clients who are on life support with a bag valve mask • E: extinguish the fire is possible using the appropriate fire extinguisher Handling Hazardous and Infectious Materials – (1) Cancer Treatment Options: Implanted Internal Radiation Device (RM AMS RN 10.0 Chp 91) • Brachytherapy describes internal radiation that is placed close to the target tissue. This is done via placement in a body orifice (vagina) or body cavity (abdomen) or delivered via IV such as with radionuclide iodine, which is absorbed by the thyroid. Brachytherapy provides radiation to the tumor and a limited amount to surrounding normal tissues. Waste products are radioactive until the isotope has been completely eliminated from the body. Waste products should not be touched by anyone. Nursing considerations: Place the client in a private room away from other clients when possible. Keep door closed as much as possible. Place a sign on the door warning of the radiation source. Wear a dosimeter film badge that records personal amount of radiation exposure. Limit visitors to 30-min visits, and have visitors maintain a distance of 6 feet from the source. Visitors and health care personnel who are pregnant or under the age of 18 should not come into contact with the client or radiation source. Wear a lead apron while providing care keeping the front of the apron facing the source of radiation. Keep a lead container in the client’s room if the delivery method could allow spontaneous loss of radioactive material. Tongs are available for placing radioactive material into this container. Follow protocol for proper removal of dressings and bed linens from the room. Client education: Inform the client of the need to remain in an indicated position to prevent dislodgement of the radiation implant. Instruct the client to call the nurse for assistance with elimination. Instruct the client and family about radiation precautions needed in health care and home environments. 3 | P a g eHome Safety – (1) Home Safety: Identifying Potential Hazards in the Home (RM FUND 9.0 Chp 13) Remove items that could cause the client to trip, such as throw rugs and loose carpets. Place electrical cords and extension cords against a wall behind furniture. Monitor gait and balance, and provide aids as needed. Make sure that steps and sidewalks are in good repair. Place grab bars near the toilet and in the tub or shower, and install a stool riser. Use a nonskid mat in the tub or shower. Place a shower chair in the shower and provide a bedside commode if needed. Ensure that lighting is adequate inside and outside the home. Standard Precautions/Transmission-Based Precautions/Surgical Asepsis – (3) Acute Neurological Disorders: Priority Intervention for Meningitis (RM NCC Rn 10.0 Chp 12) The presence of petechiae or a purpuric-type rash requires immediate medical attention. Isolate the client as soon as meningitis is suspected, and maintain droplet precautions per facility protocol. Droplet precautions require a private room or a room with clients who have the same infectious disease, ensuring that each client has his or her own designated equipment. Providers and visitors should wear a mask. Maintain respiratory isolation for a minimum of 24 hr after initiation of antibiotic therapy. Cancer Treatment Options: Neutropenia Precautions (RM AMS RN 10.0 Chp 91) Precautions: Have the client remain in the room unless he needs to leave for a diagnostic procedure or therapy. In this case, place a mask on him during transport. Protect the client from possible sources of infection (plants, change water in equipment daily) Have client, staff, and visitors perform frequent hand hygiene. Restrict visitors who are ill. Avoid invasive procedures that could cause a break in tissue (rectal temperatures, injections, indwelling urinary catheters) unless necessary. Keep dedicated equipment (blood pressure machine, thermometer, stethoscope) in the client’s room. Administer colony-stimulating factors (filgrastim) as prescribed to stimulate WBC production Client Education: Encourage the client to avoid crowds while undergoing chemotherapy. Take temperature daily. Report elevated temperature to the provider. Avoid food sources that could contain bacteria (fresh fruits and vegetables; undercooked meat, fish, and eggs; pepper and paprika) Avoid yard work, gardening, or changing a pet’s litter box Avoid fluids that have been sitting at room temperature for longer than 1 hr.Wash all dishes in hot, soapy water or a dishwater. Wash glasses and cups after each use. Wash toothbrush daily in the dishwater or rinse in a bleach solution. Do not share toiletry or personal hygiene items with others. Report fever greater than 37.8’C (100’F) or other manifestations of bacterial or viral infections immediately to the provider. Infection Control: Appropriate Actions for a Client Who Has Methicillin- Resistant Staphylococcus Aureus (MRSA) (RM FUND 9.0 Chp 11) • Use frequent and effective hand hygiene before and after care. • Educate the client about the required and recommended immunizations and where to obtain them. The target groups include children, older adults, those with chronic disease, and those who are immunocompromised and their families and contacts. • Educate the client and ask for a return demonstration of good oral hygiene. Good oral hygiene decreases the protein (which attracts micro- organisms) in the oral cavity, which thereby decreases the growth of micro-organisms that can migrate through breaks in the oral mucosa. 5 | P a g e• Encourage the client to consume an adequate amount of fluids. Adequate fluid intake prevents the stasis of urine by flushing the urinary tract and decreasing the growth of micro-organisms. Adequate hydration also keeps the skin from breaking down. Intact skin prevents micro-organisms from entering the body. • For immobile clients, ensure that pulmonary hygiene (turning, coughing, deep breathing, incentive spirometry) is done every 2 hr, or as prescribed. Good pulmonary hygiene decreases the growth of micro-organisms and the development of pneumonia by preventing stasis of pulmonary excretions, stimulating ciliary movement and clearance, and expanding the lungs. • Use of aseptic technique and proper personal protective equipment (such as gloves, masks, gowns, and goggles) in the provision of care to all clients prevents unnecessary exposure to micro-organisms. • Teach and use respiratory hygiene/cough etiquette. It applies to anyone entering a health care setting (clients, visitors, staff) with signs or symptoms of illness, whether diagnosed or undiagnosed. This includes cough, congestion, rhinorrhea, or an increase in the production of respiratory secretions. The components of respiratory hygiene and cough etiquette include: Covering the mouth and nose when coughing and sneezing Using facial tissues to contain respiratory secretions and disposing of them promptly into a hands-free receptacle Wearing a surgical mask when coughing to minimize contamination of the surrounding environment Turning the head when coughing and staying a minimum of 3 ft away from others, especially in common waiting areas Performing hand hygiene after contact with respiratory secretions and contaminated objects/materials Use of Restraints/Safety Devices – (1) Client Safety: Appropriate Use of Physical Restraints (RM FUND 9.0 Chp 12) • Restraints can be either physical (devices that restrict movement: vest, belt, mitt, limb) or chemical, such as sedatives and neuroleptic or psychotropic medications to calm the client • Restraints can cause complications, including pneumonia, incontinence, and pressure ulcers • It is inappropriate to use seclusion or restraints for: convenience of the staff, punishment for the client, clients who are extremely physically or mentally unstable, clients who cannot tolerate the decreased stimulation of a seclusion room • Restraints should: never interfere with treatment, restrict movement as little as is necessary, fit properly and be as discrete as possible, and be easy to remove or changeIn an emergency situation when there is immediate risk to the client or others, nurses may place restraints on a client. The nurse must obtain a prescription from the provider as soon as possible according to the facility’s policy (usually within 1 hr). • The prescription must include the reason for the restraints, the type of restraints, the location of the restraints, how long to use the restraints, and the type of behavior that warrants using the restraints. • The prescription allows only 4 hr of restraints for an adult, 2 hr for clients ages 917, and 1 hr for clients younger than 9 years of age. Providers may renew these prescriptions with a maximum of 24 consecutive hours. • Providers cannot write PRN prescriptions for restraints. Health Promotion and Maintenance – (5) Ante/Intra/Postpartum and Newborn Care – (1) Newborn Nutrition: Effective Breastfeeding (RM MN RN 10.0 Chp 25) Place the newborn skin-to-skin on the mother’s chest immediately after birth. Initiate breastfeeding as soon as possible or within the first 30 min following birth. Have the mother wash her hands, get comfortable, and have caffeine-free, nonalcoholic fluids to drink during breastfeeding. Explain the let-down reflex (stimulation of maternal nipple releases oxytocin that causes the let-down of milk). Reassure the mother than uterine cramps are normal during breastfeeding, resulting from oxytocin, which also promote uterine involution. Express a few drops of colostrum or milk and spread it over the nipple to lubricate the nipple and entice the newborn. Show the mother the proper latch-on position. Have her support the breast in one hand with the thumb on top and four fingers underneath. With the newborn’s mouth in front of the nipple, the newborn can be stimulated to open his mouth by tickling his lower lip with the tip of the nipple. The mother pulls the newborn to the nipple with his mouth covering part of the areola as well as the nipple. Explain to the mother than when her newborn is latched on correctly, his nose, cheeks, and chin will be touching her breast. Hunger cues include hand to mouth or hand to hand movements, sucking motions, and rooting reflex. Demonstrate the four basic breastfeeding positions: football hold (under the arm), cradle (most common) or modified cradle (across the lap), and sidelying. Encourage the mother to breastfeed at least 15-20 min per breast to ensure that her newborn receives adequate fat and protein, which is richest in the breast milk as it empties the breast. Newborns need to breastfed at least 8-12 times in a 24 hr period. Explain to the mother that newborns will niurse on demand after a pattern is established. Show the mother how to insert a finger in the side of the newborn’s mouth to break the suction from the nipple prior to removing the newborn from the breast to prevent nipple trauma. Tell the mother to begin the newborn’s next feeding with the breast she stopped feeding him with in the previous feeding. Tell the mother how to tell if her newborn is receiving adequate feeding (gaining weight, voiding 6-8 diapers per day, and contentedness between feedings). Explain to the mother that the newborncan have loose, pale, and/or yellow stools during breastfeeding, and that this is normal. Tell the mother to avoid nipple confusion in the newborn by not offering supplemental formula, pacifier, or soothers until breastfeeding has been established typically 2-3 weeks. Tell the mother to always place her newborn on his back after feedings. Herbal products, such as fenugreek or blessed thistle, and prescription medications, such as metoclopramide, have been reported to increase breast milk production. There is insufficient data to confirm or deny their effect on lactation. Mothers should check with the provider before taking over-the-counter or prescription medications. Developmental Stages and Transitions – (1) Burns: Dressing Change on a School-Age Child (RM NCC RN 10.0 Chp 32) • The nurse should premedicate the child before performing a dressing change. Use nonpharmacologic methods for pain control (guided imagery, music therapy, therapeutic touch) to enhance the effects of analgesics and promote improved pain management. Health Promotion/Disease Prevention – (2) Infections: Client Assignment for Pregnant Personnel (RM MN RN 10.0 Chp 8) • Brachytherapy involves the implantation of a sealed radiation source within the targeted tumor tissue. A client who is wearing a solid implant emits radiation as long as the implant is in place; however, the client’s excreta is not radioactive. Pregnant nurses should not care for such clients. There are no contraindications to having a pregnant nurse care for a client under enteric precautions, a client with cancer who is receiving a continuous infusion or intravenous therapy, or a client who requires frequent wound irrigation. Prenatal Care: Risks for the Adolescent Client (RM MN RN 10.0 Chp 4) • Preterm births, low-birth weight infants, cephalopelvic disproportion, iron deficiency anemia, and preeclampsia-eclampsia and its sequelae. In the adolescent age group, prenatal care is the critical factor that most influences pregnancy outcome. Lifestyle Choices – (1) Contraception: Triage Clients on Different Types of Birth Control Methods (RM MN RN 10.0 Chp 1) • Abstinence: if complete abstinence is maintained there are no risks • Coitus interruptus (withdrawal): depends on a man’s ability to control ejaculation. Leakage of fluid that contains spermatozoa prior to ejaculation can be deposited in vagina. Risk of pregnancy • Calendar method (Rhythm method): various factors can affect change, the time of ovulation and cause unpredictable menstrual cycles. Risk of pregnancy.• Basal body temperature (BBT): Risk of pregnancy • Billings Method (Cervical Mucus Method): Assessment of cervical mucus characteristics may be inaccurate if mucus is mixed with semen, blood, contraceptive foams, or discharge from infections. Risk of pregnancy. Condoms: condoms can rupture or leak potentially resulting in an unwanted pregnancy. Condoms have a one-time usage, which creates a replacement cost. Only water-soluble lubricants should be used with latex condoms to avoid condom breakage. • Diaphragm and spermicide: not recommended for clients who have a history of toxic shock syndrome (TSS) or frequent, recurrent urinary tract infections. Increased risk of acquiring TSS. Proper hand hygiene aids in prevention of TSS as well as removing diaphragm promptly at 6 hours following coitus. • Combined oral contraceptives: oral contraceptive effectiveness decreases when taking medications that affect liver enzymes such as anticonvulsants and some antibiotics. Psychosocial Integrity – (5) Abuse/Neglect – (1) Family Violence: Evaluating Child Abuse (RM MH RN 10.0 Chp 32) • Risk factors for abuse toward a child: the child is under 3 years of age; a perpetrator perceives the child as being different (the child is the result of an unwanted pregnancy, is physically disabled, or has some other trait that makes him particularly vulnerable). • Infant assessment – shaken baby syndrome (shaking can cause intracranial hemorrhage. Assess for respiratory distress, bulging fontanels, and an increase in head circumference. Retinal hemorrhage can be present). Any bruising on an infant before age 6 months is suspicious. • Preschoolers to adolescents assessment – assess for unusual bruising, such as on abdomen, back, or buttocks. Bruising is common on arms and legs in these age groups. Assess the mechanism of injury, which might not be congruent with the physical appearance of the injury. Numerous bruises at different stages of healing can indicate ongoing beatings. Be suspicious of bruises or welts that resemble the shape of a belt buckle or other object. Assess for burns. Burns covering “glove” or “stocking” areas of the hands or feet can indicate forced immersion into boiling water. Small, round burns can be from lit cigarettes. Assess for fractures with unusual features, such as forearm spiral fractures, which could be a result of twisting the extremity forcefully. The presence of multiple fractures is suspicious. Assess for human bite marks. Assess for head injuries: level of consciousness, equal and reactive pupils, and nausea or vomiting. Behavioral Interventions – (1) Anxiety Disorders: Planning Care for a Client who has Obsessive CompulsiveDisorder (RM MH RN 10.0 Chp 11) • Provide a structured interview to keep the client focused on the present. Assess for comorbid condition of substance use disorder. Provide safety and comfort to the client during the crisis period of these disorders, as clients in severe- to paniclevel anxiety are unable to problem solve and focus. Clients experiencing paniclevel anxiety benefit from a calm, quiet environment. Remain with the client during the worst of the anxiety to provide reassurance. Perform a suicide risk assessment. Provide a safe environment for other clients and staff. Provide milieu therapy that employs the following: a structured environment for physical safety and predictability; monitoring for, and protection from, self-harm or suicide; daily activities that encourage the client to share and be cooperative; use of therapeutic communication skills, such as open-ended questions, to help the client express feelings of anxiety, and to validate and acknowledge those feelings; client participation in decision making regarding care. Use of relaxation techniques with the client as needed for relief of pain, muscle tension, and feelings of anxiety. Instill hope for positive outcomes (but avoid false reassurance). Enhance client self- esteem by encouraging positive statements and discussing past achievements. Assist the client to identify defense mechanisms that interfere with recovery. Postpone health teaching until after acute anxiety subsides. Clients experiencing a panic attack or severe anxiety are unable to concentrate or learn. Mental Health Concepts – (3) Anxiety Disorders: Expected Findings for a Client who has Social Anxiety Disorder (RM MH RN 10.0 Chp 11) • Social anxiety disorder (social phobia) – the client experiences excessive fear of social or performance situations • The client reports difficulty performing or speaking in front of others or participating in social situations due to an excessive fear of embarrassment or poor performance. • The client might report physical manifestations (actual or factitious) in an attempt to avoid the social situation or need to perform Eating Disorders: Short-Term Goal for Client who have Anorexia Nervosa (RM MH RN 10.0 Chp 19) • Provide a highly structure milieu in an acute care unit for the client requiring intensive therapy. Develop and maintain a trusting nurse/client relationship through consistency and therapeutic communication. Use a positive approach and support to promote client self-esteem and positive self-image. Encourage client decision making and participation in the planof care to allow for a sense of control. Use behavioral contracts to modify client behaviors. Reward the client for positive behaviors, such as completing meals or consuming a set number of calories. Personality Disorders: Antisocial Personality Manifestations (RM MH RN 10.0 Chp 16) • Antisocial – characterized by disregard for others with exploitation, lack of empathy, repeated unlawful actions, deceit, and failure to accept personal responsibility; sense of entitlement, manipulative, impulsive, and seductive; nonadherence to traditional morals and values; verbally charming and engaging. Basic Care and Comfort – (4) Assistive Devices – (2) Ergonomic Principles: Use of a Standard Walker (RM FUND 9.0 Chp 14) The walker and affected leg move forward, then the patient should move the unaffected leg parallel to the affected leg. Sensory Perception: Speaking to a Client Who Has a Hearing Impairment (RM FUND 9.0 Chp 45) • Sit and face the clients. Avoid covering your mouth while speaking. Encourage the use of hearing devices. Speak slowly and clearly. Do not shout. Try lowering vocal pitch before increasing volume. Use brief sentences with simple words. Write down what clients do not understand. Minimize background noise. Ask for a sign-language interpreter if necessary. Elimination – (1) Urinary Elimination: Three-Way Indwelling Catheter (RM FUND 9.0 Chp 44) Continuous bladder irrigation. Prostate issues. Nutrition and Oral Hydration – (1) Renal Disorders: Dietary Prevention of Nephrolithiasis (RM Nutrition 6.0 Chp 14) • Excessive intake of protein, sodium, calcium, and oxalates (rhubarb, spinach, beets) can increase the risk of stone formation Pharmacological and Parenteral Therapies – (12) Adverse Effects/Contraindications/Side Effects/Interactions – (3) Chronic Neurologic Disorders: Teratogenic Risks to the Fetus (RM Pharm RN 7.0 Chp 13) • Minor anomalies, major congenital malformations, intrauterine growth retardation, cognitive dysfunction, low IQ, microcephaly, and infant mortality. Medications for Psychotic Disorders: Screening for Extrapyramidal Adverse Effects (RM MH RN 10.0 Chp 24)• Extrapyramidal symptoms associated with antipsychotics: first generation (conventional): Acute dystonia Manifestations: severe spasm of the tongue, neck, face, and back; crisis situation that requires rapid treatment Nursing considerations: begin to monitor for acute dystonia anywhere between 1-5 days after administration of first dose. Treat with an antiparkinsonian agents such as benztropine. IM or IV administration diphenhydramine can also be beneficial. Stay with the client and monitor the airway until spasms subside (usually 5-15 min). Pseudoparkinsonism Manifestations: bradykinesia; rigidity; shuffling gait; drooling; tremors Nursing considerations: observe for pseudoparkinsonism for the first month after the initiation of therapy. Can occur in as little as 5 hr following the first dose. Treat with an antiparkinsonian agent, such as benztropine or trihexyphenidyl. Implement interventions to reduce the risk for falling. Akathisia Manifestations: inability to sit or stand still; continual pacing and agitation Nursing considerations: observe for akathisia for the first 2 months after the initiation of treatment. Can occur in as little as 2 hr following the firstdose. Manage with antiparkinsonian agents, beta blockers, or lorazepam/diazepam. Monitor for increased risk for suicide in clients who have severe akathisia. Tardive dyskinesia (TD) Manifestations: late EPS, which can require months to years of medication therapy for TD to develop. Involuntary movements of the tongue and face, such as lip smacking and tongue fasciculations. Involuntary movements of the arms, legs, and trunk. Nursing considerations: evaluate the client every 3 months, if TD appears, dosage should be lowered, or the client should be switched to another type of antipsychotic agent. Once TD develops, it usually does not decrease, even with discontinuation of the medication. There is not a treatment for TD. Teach client that purposeful muscle movement helps to control the involuntary TD. Neuroendocrine effects Manifestations: gynecomastia; weight gain; menstrual irregularities Nursing considerations: monitor weight. Some clients gain 100 lb or more. Advise the client to observe for these manifestations and to notify the provider if they occur. Neuroleptic malignant syndrome Manifestations: sudden high fever; blood pressure fluctuations; diaphoresis; tachycardia; muscle rigidity; drooling; decreased level of consciousness; coma; tachypnea Nursing considerations