NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
Foundations
HealthJScreening 1
AspectsJofJhealthJandJwellness
◯JPhysicalJ–
ableJtoJperformJactivitiesJofJdailyJlivingJEmotionalJ–
J
adaptsJtoJstress;JexpressesJandJidentifiesJemotionsJSocialJ–
J
interactsJsuccessfullyJwithJothers
J
IntellectualJ–
effectivelyJlearnsJandJdisseminatesJinformationJSpiritualJ–
J
adoptsJaJbeliefJthatJprovidesJmeaningJtoJlifeJOccupationalJ–
J
balancesJoccupationalJactivitiesJwithJleisureJtime
J
EnvironmentalJ–JcreatesJmeasuresJtoJimproveJstandardsJofJlivingJandJqualityJofJlife
● AJclient’sJstateJofJhealthJandJwellnessJisJconstantlyJchangingJandJadaptingJtoJaJcontinuallyJfluctuatingJexternalJandJinte
rnalJenvironment.
TheJexternalJenvironment
SocialJ–JcrimeJversusJsafety,JpovertyJversusJprosperity,JandJpeaceJversusJsocialJunrest
PhysicalJ–JaccessJtoJhealthJcare,Jsanitation,JavailabilityJofJcleanJwater,JandJgeographicJisolation
TheJinternalJenvironmentJincludesJcumulativeJlifeJexperiences,JculturalJandJspiritualJbeliefs,Jage,JdevelopmentalJstage,Jge
nder,JandJotherJsupportJsystems.
● TheJlevelJofJhealthJandJwellnessJisJuniqueJtoJeachJindividualJandJrelativeJtoJtheJindividual’sJusualJstateJofJfun
ctioning.
◯JForJexample:JAJpersonJwithJrheumatoidJarthritisJwhoJhasJaJstrongJsupportJsystemJandJpositiveJoutlookJmayJconsiderJhimse
healthyJwhileJfunctioningJatJanJoptimalJlevelJwithJminimalJpain.
● Variables
ModifiableJ–JmayJbeJchanged,JsuchJasJsmoking,Jnutrition,JhealthJeducationJandJawareness,JsexualJpractices,JandJexercise
NonmodifiableJ–JcannotJbeJchanged,JsuchJasJgender,Jage,JdevelopmentalJlevel,JandJgeneticJtraits
● DesiredJoutcomesJareJtoJobtainJandJmaintainJoptimalJstateJofJwellnessJandJfunction.
◯JCanJbeJachievedJthroughJhealthJeducationJandJpositiveJactionJ(smokingJcessation,JweightJloss,Jseeki
ngJhealthJcare)
● TheJhealth/wellness/illnessJcontinuumJisJanJassessmentJtoolJthatJisJusedJtoJmeasureJtheJlevelJofJwellnessJtoJprematureJdea
th.
ItJmayJbeJusefulJasJanJassessmentJguideJorJtoolJtoJsetJgoalsJandJfindJwaysJtoJimproveJtheJclient’sJstateJofJhealthJorJtoJhaveJ
, NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
theJclientJreturnJtoJaJpreviousJstateJofJhealth,JwhichJmayJincludeJanJillnessJwithinJoptimalJwellness.JTheJhealthJca
reJprofessionalJcanJassistJtheJclientJtoJseeJatJwhatJpointJheJisJatJonJtheJcontinuumJandJseekJwaysJtoJmoveJtowardJo
ptimalJwellness.
AtJtheJcenterJofJtheJcontinuumJisJtheJclient’sJnormalJstateJofJhealth.JLevelJo
fJhealth/illnessJisJassessedJinJcomparisonJtoJtheJnormJforJaJclient.
TheJrangeJofJhealthJtoJillnessJrunsJfromJoptimalJwellnessJtoJsevereJillness.
TheJdegreeJofJwellnessJisJrelativeJtoJtheJusualJstateJofJwellnessJforJaJclientJandJisJachievedJthroughJawareness,Jedu
cation,JandJpersonalJgrowth.
EvaluateJtheJhealthJneedsJofJaJclientJandJcreateJstrategiesJtoJmeetJthoseJneeds.
● Health/wellnessJassessmentJPhysicalJassessment,JEvaluatingJhealthJperceptionsJ,JID’ingJrisksJtoJhealth/wellness,JID’i
ngaccessJtoJhealthJcare
MassJCasualtyJTriage 1
ThisJisJaJmilitaryJformJofJtriageJthatJisJimplementedJwithJaJfocusJofJachievingJtheJgreatestJgoodJforJtheJ
greatestJnumberJofJpeople.
◯◯ JClassifications
■■JEmergentJorJClassJIJ–JidentifiedJwithJaJredJtagJindicatingJanJimmediateJthreatJtoJlife
■■JUrgentJorJClassJIIJ–
identifiedJwithJaJyellowJtagJindicatingJmajorJinjuriesJthatJrequireJimmediateJtreatment
J
■■JNonurgentJorJClassJIIIJ–JidentifiedJwithJaJgreenJtagJindicatingJminorJinjuriesJthatJdoJnot
, NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
requireJimmediateJtreatment
■■JExpectantJorJClassJIVJ–
J identifiedJwithJaJblackJtagJindicatingJoneJwhoJisJexpectedJandJallowedJNeurosensoryJDisorders
Seizures 2
ClientJteachingJDilantin
NursingJConsiderations
☐☐ JInitialJ goalJ isJ toJ controlJ seizureJ activityJ usingJ onlyJ oneJ medication.J IfJ theJ chosenJ medicationJisJn
otJeffective,JeitherJtheJdoseJisJincreased,JorJanotherJmedicationJisJaddedJorJsubstituted.
☐☐ JTherapeuticJ levelsJ areJ determinedJ byJ bloodJ tests.J TheseJ areJ performedJ onJ aJ routineJ scheduleJtoJe
nsureJcomplianceJandJeffectivenessJofJtheJmedication.
☐☐ JMedicationsJ shouldJ beJ takenJ atJ theJ sameJ timeJ everyJ dayJ toJ enhanceJ effectiveness.
☐☐ J BeJ awareJ ofJ drug-drugJ adverseJ effectsJ andJ drug-
foodJ adverseJ effects.J TheseJ areJ specificJ toJ theJmedication.
☐☐ JAllergicJ reactionsJ toJ theseJ medicationsJ areJ rare,J yetJ mayJ occurJ immediatelyJ orJ lateJ inJthe
rapy.JIfJallergic,JanotherJmedicationJmayJbeJsubstituted.
☐☐ J SomeJ antiepilepticJ medicationsJ causeJ oralJ gumJ overgrowth.J RoutineJ oralJ hygieneJ andJ dentalJvisitsJ
canJminimizeJthisJsideJeffect.
☐☐ JWhenJ usingJ phenytoin,J specificJ instructionsJ shouldJ includeJ avoidanceJ ofJ oralJcontraceptives,
J asJthisJmedicationJdecreasesJtheirJeffectiveness.JWarfarinJ(Coumadin)JshouldJalsoJnotJbeJgivenJ
withJthisJmedication,JasJphenytoinJmayJdecreaseJabsorptionJandJincreaseJmetabolismJofJoralJant
icoagulants.
RiskJAssessment
◯◯ J GeneticJ predispositionJ –
J AbsenceJ seizuresJ areJ moreJ commonJ inJ childrenJ andJ tendJ toJ occurJinJfamilies.
◯◯ JAcuteJ febrileJ stateJ –J particularlyJ amongJ infantsJ andJ childrenJ youngerJ thanJ theJ ageJ ofJ 2J years
◯◯ JHeadJ traumaJ –
J MayJ beJ earlyJ orJ lateJ onsetJ (upJ toJ 9J months)J andJ incidenceJ isJ increasedJ whenJ theJheadJtraumaJincludesJaJs
kullJfracture.
◯◯ JCerebralJ edemaJ –
J especiallyJ whenJ itJ occursJ acutelyJ andJ seizureJ activityJ tendsJ toJ disappearJ whenJtheJedemaJisJsuccessfullyJtre
ated
◯◯ JAbruptJ cessationJ ofJ antiepilepticJ drugsJ (AEDs)J –J asJ aJ reboundJ activity
, NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
◯◯ JInfectionJ –
J ifJ intracranial,J aJ resultJ ofJ increasedJ intracranialJ pressure;J ifJ systemic,J aJ resultJ ofJ theJpersistentJfebrileJstat
e
◯◯ J MetabolicJ disorderJ –
J aJ resultJ ofJ insufficientJ orJ excessiveJ chemicalsJ withinJ theJ brainJ suchJ asJ occursJwithJhypoglycemiaJorJhyponatr
emia
◯◯ JExposureJ toJ toxinsJ –
J especiallyJ thoseJ associatedJ withJ pesticides,J carbonJ monoxide,J andJleadJpoisoning
◯◯ JBrainJ tumorJ –
J ifJ benign,J seizuresJ causedJ byJ theJ increasedJ bulkJ associatedJ withJ theJ tumor;J ifJmalignant,JassociatedJwith
J theJabilityJofJtheJbrainJtissueJtoJfunction
◯◯ JHypoxiaJ –J resultsJ inJ aJ decreasedJ oxygenJ levelJ ofJ theJ brain;J necessaryJ forJ neuronalJ activity
◯◯ J AcuteJ drugJ andJ alcoholJ withdrawalJ –
J dehydrationJ thatJ accompaniesJ withdrawal,J creatingJ aJ toxicJlevelJofJtheJdrugJinJtheJbody
◯◯ JFluidJ andJ electrolyteJ imbalancesJ –
J resultsJ inJ abnormalJ levelsJ ofJ nutrientsJ requiredJ forJneuronalJfunction.
◯◯ J WithJ olderJ adultJ clients,J increasedJ seizureJ incidenceJ isJ associatedJ withJ cerebrovascularJ diseases.
***JTriggeringJFactorsJ■■JIncreasedJphysicalJactivity,JExcessiveJstress,JHyperventilation,JOverwhelmingJfatigue,JAc
uteJalcoholJingestion,JExcessiveJcaffeineJintake,JExposureJtoJflashingJlights,JSpecificJchemicals,JsuchJasJcocaine,Jaeros
ols,JandJinhalingJglueJproducts
Alzheimer 1
Wandering-
management:JAJnurseJisJmakingJaJhomeJvisitJtoJaJclientJwhoJhasJAD.JTheJclient’sJpartnerJstatesJthatJtheJclientJisJoftenJdi
sorientedJtoJtimeJandJplace,JisJunsteadyJonJhisJfeet,JandJhasJaJhistoryJofJwandering.JWhichJofJtheJfollowingJsafetyJmeas
uresJshouldJtheJnurseJreviewJwithJtheJpartner?J(SelectJallJthatJapply.)
CORRECT:JRemovingJfloorJrugsJcanJdecreaseJtheJclient’sJriskJofJfalling.
CORRECT:JGoodJlightingJcanJdecreaseJtheJriskJforJfallingJinJdarkJareas,JsuchJasJstairways.
Foundations
HealthJScreening 1
AspectsJofJhealthJandJwellness
◯JPhysicalJ–
ableJtoJperformJactivitiesJofJdailyJlivingJEmotionalJ–
J
adaptsJtoJstress;JexpressesJandJidentifiesJemotionsJSocialJ–
J
interactsJsuccessfullyJwithJothers
J
IntellectualJ–
effectivelyJlearnsJandJdisseminatesJinformationJSpiritualJ–
J
adoptsJaJbeliefJthatJprovidesJmeaningJtoJlifeJOccupationalJ–
J
balancesJoccupationalJactivitiesJwithJleisureJtime
J
EnvironmentalJ–JcreatesJmeasuresJtoJimproveJstandardsJofJlivingJandJqualityJofJlife
● AJclient’sJstateJofJhealthJandJwellnessJisJconstantlyJchangingJandJadaptingJtoJaJcontinuallyJfluctuatingJexternalJandJinte
rnalJenvironment.
TheJexternalJenvironment
SocialJ–JcrimeJversusJsafety,JpovertyJversusJprosperity,JandJpeaceJversusJsocialJunrest
PhysicalJ–JaccessJtoJhealthJcare,Jsanitation,JavailabilityJofJcleanJwater,JandJgeographicJisolation
TheJinternalJenvironmentJincludesJcumulativeJlifeJexperiences,JculturalJandJspiritualJbeliefs,Jage,JdevelopmentalJstage,Jge
nder,JandJotherJsupportJsystems.
● TheJlevelJofJhealthJandJwellnessJisJuniqueJtoJeachJindividualJandJrelativeJtoJtheJindividual’sJusualJstateJofJfun
ctioning.
◯JForJexample:JAJpersonJwithJrheumatoidJarthritisJwhoJhasJaJstrongJsupportJsystemJandJpositiveJoutlookJmayJconsiderJhimse
healthyJwhileJfunctioningJatJanJoptimalJlevelJwithJminimalJpain.
● Variables
ModifiableJ–JmayJbeJchanged,JsuchJasJsmoking,Jnutrition,JhealthJeducationJandJawareness,JsexualJpractices,JandJexercise
NonmodifiableJ–JcannotJbeJchanged,JsuchJasJgender,Jage,JdevelopmentalJlevel,JandJgeneticJtraits
● DesiredJoutcomesJareJtoJobtainJandJmaintainJoptimalJstateJofJwellnessJandJfunction.
◯JCanJbeJachievedJthroughJhealthJeducationJandJpositiveJactionJ(smokingJcessation,JweightJloss,Jseeki
ngJhealthJcare)
● TheJhealth/wellness/illnessJcontinuumJisJanJassessmentJtoolJthatJisJusedJtoJmeasureJtheJlevelJofJwellnessJtoJprematureJdea
th.
ItJmayJbeJusefulJasJanJassessmentJguideJorJtoolJtoJsetJgoalsJandJfindJwaysJtoJimproveJtheJclient’sJstateJofJhealthJorJtoJhaveJ
, NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
theJclientJreturnJtoJaJpreviousJstateJofJhealth,JwhichJmayJincludeJanJillnessJwithinJoptimalJwellness.JTheJhealthJca
reJprofessionalJcanJassistJtheJclientJtoJseeJatJwhatJpointJheJisJatJonJtheJcontinuumJandJseekJwaysJtoJmoveJtowardJo
ptimalJwellness.
AtJtheJcenterJofJtheJcontinuumJisJtheJclient’sJnormalJstateJofJhealth.JLevelJo
fJhealth/illnessJisJassessedJinJcomparisonJtoJtheJnormJforJaJclient.
TheJrangeJofJhealthJtoJillnessJrunsJfromJoptimalJwellnessJtoJsevereJillness.
TheJdegreeJofJwellnessJisJrelativeJtoJtheJusualJstateJofJwellnessJforJaJclientJandJisJachievedJthroughJawareness,Jedu
cation,JandJpersonalJgrowth.
EvaluateJtheJhealthJneedsJofJaJclientJandJcreateJstrategiesJtoJmeetJthoseJneeds.
● Health/wellnessJassessmentJPhysicalJassessment,JEvaluatingJhealthJperceptionsJ,JID’ingJrisksJtoJhealth/wellness,JID’i
ngaccessJtoJhealthJcare
MassJCasualtyJTriage 1
ThisJisJaJmilitaryJformJofJtriageJthatJisJimplementedJwithJaJfocusJofJachievingJtheJgreatestJgoodJforJtheJ
greatestJnumberJofJpeople.
◯◯ JClassifications
■■JEmergentJorJClassJIJ–JidentifiedJwithJaJredJtagJindicatingJanJimmediateJthreatJtoJlife
■■JUrgentJorJClassJIIJ–
identifiedJwithJaJyellowJtagJindicatingJmajorJinjuriesJthatJrequireJimmediateJtreatment
J
■■JNonurgentJorJClassJIIIJ–JidentifiedJwithJaJgreenJtagJindicatingJminorJinjuriesJthatJdoJnot
, NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
requireJimmediateJtreatment
■■JExpectantJorJClassJIVJ–
J identifiedJwithJaJblackJtagJindicatingJoneJwhoJisJexpectedJandJallowedJNeurosensoryJDisorders
Seizures 2
ClientJteachingJDilantin
NursingJConsiderations
☐☐ JInitialJ goalJ isJ toJ controlJ seizureJ activityJ usingJ onlyJ oneJ medication.J IfJ theJ chosenJ medicationJisJn
otJeffective,JeitherJtheJdoseJisJincreased,JorJanotherJmedicationJisJaddedJorJsubstituted.
☐☐ JTherapeuticJ levelsJ areJ determinedJ byJ bloodJ tests.J TheseJ areJ performedJ onJ aJ routineJ scheduleJtoJe
nsureJcomplianceJandJeffectivenessJofJtheJmedication.
☐☐ JMedicationsJ shouldJ beJ takenJ atJ theJ sameJ timeJ everyJ dayJ toJ enhanceJ effectiveness.
☐☐ J BeJ awareJ ofJ drug-drugJ adverseJ effectsJ andJ drug-
foodJ adverseJ effects.J TheseJ areJ specificJ toJ theJmedication.
☐☐ JAllergicJ reactionsJ toJ theseJ medicationsJ areJ rare,J yetJ mayJ occurJ immediatelyJ orJ lateJ inJthe
rapy.JIfJallergic,JanotherJmedicationJmayJbeJsubstituted.
☐☐ J SomeJ antiepilepticJ medicationsJ causeJ oralJ gumJ overgrowth.J RoutineJ oralJ hygieneJ andJ dentalJvisitsJ
canJminimizeJthisJsideJeffect.
☐☐ JWhenJ usingJ phenytoin,J specificJ instructionsJ shouldJ includeJ avoidanceJ ofJ oralJcontraceptives,
J asJthisJmedicationJdecreasesJtheirJeffectiveness.JWarfarinJ(Coumadin)JshouldJalsoJnotJbeJgivenJ
withJthisJmedication,JasJphenytoinJmayJdecreaseJabsorptionJandJincreaseJmetabolismJofJoralJant
icoagulants.
RiskJAssessment
◯◯ J GeneticJ predispositionJ –
J AbsenceJ seizuresJ areJ moreJ commonJ inJ childrenJ andJ tendJ toJ occurJinJfamilies.
◯◯ JAcuteJ febrileJ stateJ –J particularlyJ amongJ infantsJ andJ childrenJ youngerJ thanJ theJ ageJ ofJ 2J years
◯◯ JHeadJ traumaJ –
J MayJ beJ earlyJ orJ lateJ onsetJ (upJ toJ 9J months)J andJ incidenceJ isJ increasedJ whenJ theJheadJtraumaJincludesJaJs
kullJfracture.
◯◯ JCerebralJ edemaJ –
J especiallyJ whenJ itJ occursJ acutelyJ andJ seizureJ activityJ tendsJ toJ disappearJ whenJtheJedemaJisJsuccessfullyJtre
ated
◯◯ JAbruptJ cessationJ ofJ antiepilepticJ drugsJ (AEDs)J –J asJ aJ reboundJ activity
, NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
◯◯ JInfectionJ –
J ifJ intracranial,J aJ resultJ ofJ increasedJ intracranialJ pressure;J ifJ systemic,J aJ resultJ ofJ theJpersistentJfebrileJstat
e
◯◯ J MetabolicJ disorderJ –
J aJ resultJ ofJ insufficientJ orJ excessiveJ chemicalsJ withinJ theJ brainJ suchJ asJ occursJwithJhypoglycemiaJorJhyponatr
emia
◯◯ JExposureJ toJ toxinsJ –
J especiallyJ thoseJ associatedJ withJ pesticides,J carbonJ monoxide,J andJleadJpoisoning
◯◯ JBrainJ tumorJ –
J ifJ benign,J seizuresJ causedJ byJ theJ increasedJ bulkJ associatedJ withJ theJ tumor;J ifJmalignant,JassociatedJwith
J theJabilityJofJtheJbrainJtissueJtoJfunction
◯◯ JHypoxiaJ –J resultsJ inJ aJ decreasedJ oxygenJ levelJ ofJ theJ brain;J necessaryJ forJ neuronalJ activity
◯◯ J AcuteJ drugJ andJ alcoholJ withdrawalJ –
J dehydrationJ thatJ accompaniesJ withdrawal,J creatingJ aJ toxicJlevelJofJtheJdrugJinJtheJbody
◯◯ JFluidJ andJ electrolyteJ imbalancesJ –
J resultsJ inJ abnormalJ levelsJ ofJ nutrientsJ requiredJ forJneuronalJfunction.
◯◯ J WithJ olderJ adultJ clients,J increasedJ seizureJ incidenceJ isJ associatedJ withJ cerebrovascularJ diseases.
***JTriggeringJFactorsJ■■JIncreasedJphysicalJactivity,JExcessiveJstress,JHyperventilation,JOverwhelmingJfatigue,JAc
uteJalcoholJingestion,JExcessiveJcaffeineJintake,JExposureJtoJflashingJlights,JSpecificJchemicals,JsuchJasJcocaine,Jaeros
ols,JandJinhalingJglueJproducts
Alzheimer 1
Wandering-
management:JAJnurseJisJmakingJaJhomeJvisitJtoJaJclientJwhoJhasJAD.JTheJclient’sJpartnerJstatesJthatJtheJclientJisJoftenJdi
sorientedJtoJtimeJandJplace,JisJunsteadyJonJhisJfeet,JandJhasJaJhistoryJofJwandering.JWhichJofJtheJfollowingJsafetyJmeas
uresJshouldJtheJnurseJreviewJwithJtheJpartner?J(SelectJallJthatJapply.)
CORRECT:JRemovingJfloorJrugsJcanJdecreaseJtheJclient’sJriskJofJfalling.
CORRECT:JGoodJlightingJcanJdecreaseJtheJriskJforJfallingJinJdarkJareas,JsuchJasJstairways.
