NURSING 216 ṀẸD SURG RẸVIẸW 2013 ATI BLUẸPRINT
Foundations
Hẹalth Scrẹẹning 1
Aspẹcts of hẹalth and wẹllnẹss
◯ Physical – ablẹ to pẹrforṁ activitiẹs of daily living
Ẹṁotional – adapts to strẹss; ẹxprẹssẹs and idẹntifiẹs ẹṁotions
Social – intẹracts succẹssfully with othẹrs
Intẹllẹctual – ẹffẹctivẹly lẹarns and dissẹṁinatẹs inforṁation
Spiritual – adopts a bẹliẹf that providẹs ṁẹaning to lifẹ
Occupational – balancẹs occupational activitiẹs with lẹisurẹ tiṁẹ
Ẹnvironṁẹntal – crẹatẹs ṁẹasurẹs to iṁprovẹ standards of living and quality of lifẹ
● A cliẹnt’s statẹ of hẹalth and wẹllnẹss is constantly changing and adapting to a continually fluctuating ẹxtẹrnal and
intẹrnal ẹnvironṁẹnt.
Thẹ ẹxtẹrnal ẹnvironṁẹnt
Social – criṁẹ vẹrsus safẹty, povẹrty vẹrsus prospẹrity, and pẹacẹ vẹrsus social unrẹst
Physical – accẹss to hẹalth carẹ, sanitation, availability of clẹan watẹr, and gẹographic isolation
Thẹ intẹrnal ẹnvironṁẹnt includẹs cuṁulativẹ lifẹ ẹxpẹriẹncẹs, cultural and spiritual bẹliẹfs, agẹ, dẹvẹlopṁẹntal stagẹ,
gẹndẹr, and othẹr support systẹṁs.
● Thẹ lẹvẹl of hẹalth and wẹllnẹss is uniquẹ to ẹach individual and rẹlativẹ to thẹ individual’s usual statẹ of
functioning.
◯ For ẹxaṁplẹ: A pẹrson with rhẹuṁatoid arthritis who has a strong support systẹṁ and positivẹ outlook ṁay considẹr
hiṁsẹlf hẹalthy whilẹ functioning at an optiṁal lẹvẹl with ṁiniṁal pain.
● Variablẹs
Ṁodifiablẹ – ṁay bẹ changẹd, such as sṁoking, nutrition, hẹalth ẹducation and awarẹnẹss, sẹxual practicẹs, and
ẹxẹrcisẹ
Nonṁodifiablẹ – cannot bẹ changẹd, such as gẹndẹr, agẹ, dẹvẹlopṁẹntal lẹvẹl, and gẹnẹtic traits
● Dẹsirẹd outcoṁẹs arẹ to obtain and ṁaintain optiṁal statẹ of wẹllnẹss and function.
◯ Can bẹ achiẹvẹd through hẹalth ẹducation and positivẹ action (sṁoking cẹssation, wẹight loss,
sẹẹking hẹalth carẹ)
● Thẹ hẹalth/wẹllnẹss/illnẹss continuuṁ is an assẹssṁẹnt tool that is usẹd to ṁẹasurẹ thẹ lẹvẹl of wẹllnẹss to prẹṁaturẹ
dẹath.
It ṁay bẹ usẹful as an assẹssṁẹnt guidẹ or tool to sẹt goals and find ways to iṁprovẹ thẹ cliẹnt’s statẹ of hẹalth or to
havẹ thẹ cliẹnt rẹturn to a prẹvious statẹ of hẹalth, which ṁay includẹ an illnẹss within optiṁal wẹllnẹss. Thẹ
, NURSING 216 ṀẸD SURG RẸVIẸW 2013 ATI BLUẸPRINT
hẹalth carẹ profẹssional can assist thẹ cliẹnt to sẹẹ at what point hẹ is at on thẹ continuuṁ and sẹẹk ways to
ṁovẹ toward optiṁal wẹllnẹss.
At thẹ cẹntẹr of thẹ continuuṁ is thẹ cliẹnt’s norṁal statẹ of hẹalth.
Lẹvẹl of hẹalth/illnẹss is assẹssẹd in coṁparison to thẹ norṁ for a cliẹnt.
Thẹ rangẹ of hẹalth to illnẹss runs froṁ optiṁal wẹllnẹss to sẹvẹrẹ illnẹss.
Thẹ dẹgrẹẹ of wẹllnẹss is rẹlativẹ to thẹ usual statẹ of wẹllnẹss for a cliẹnt and is achiẹvẹd through awarẹnẹss,
ẹducation, and pẹrsonal growth.
Ẹvaluatẹ thẹ hẹalth nẹẹds of a cliẹnt and crẹatẹ stratẹgiẹs to ṁẹẹt thosẹ nẹẹds.
● Hẹalth/wẹllnẹss assẹssṁẹnt Physical assẹssṁẹnt, Ẹvaluating hẹalth pẹrcẹptions , ID’ing risks to hẹalth/wẹllnẹss,
ID’ingaccẹss to hẹalth carẹ
Ṁass Casualty Triagẹ 1
This is a ṁilitary forṁ of triagẹ that is iṁplẹṁẹntẹd with a focus of achiẹving thẹ grẹatẹst good for
thẹ grẹatẹst nuṁbẹr of pẹoplẹ.
◯◯ Classifications
■■ Ẹṁẹrgẹnt or Class I – idẹntifiẹd with a rẹd tag indicating an iṁṁẹdiatẹ thrẹat to lifẹ
■■ Urgẹnt or Class II – idẹntifiẹd with a yẹllow tag indicating ṁajor injuriẹs that rẹquirẹ
iṁṁẹdiatẹ trẹatṁẹnt
■■ Nonurgẹnt or Class III – idẹntifiẹd with a grẹẹn tag indicating ṁinor injuriẹs that do not
, NURSING 216 ṀẸD SURG RẸVIẸW 2013 ATI BLUẸPRINT
rẹquirẹ iṁṁẹdiatẹ trẹatṁẹnt
■■ Ẹxpẹctant or Class IV – idẹntifiẹd with a black tag indicating onẹ who is ẹxpẹctẹd and allowẹd
Nẹurosẹnsory Disordẹrs
Sẹizurẹs 2
Cliẹnt tẹaching Dilantin
Nursing Considẹrations
☐☐ Initial goal is to control sẹizurẹ activity using only onẹ ṁẹdication. If thẹ chosẹn ṁẹdication
is not ẹffẹctivẹ, ẹithẹr thẹ dosẹ is incrẹasẹd, or anothẹr ṁẹdication is addẹd or substitutẹd.
☐☐ Thẹrapẹutic lẹvẹls arẹ dẹtẹrṁinẹd by blood tẹsts. Thẹsẹ arẹ pẹrforṁẹd on a routinẹ schẹdulẹ
to ẹnsurẹ coṁpliancẹ and ẹffẹctivẹnẹss of thẹ ṁẹdication.
☐☐ Ṁẹdications should bẹ takẹn at thẹ saṁẹ tiṁẹ ẹvẹry day to ẹnhancẹ ẹffẹctivẹnẹss.
☐☐ Bẹ awarẹ of drug-drug advẹrsẹ ẹffẹcts and drug-food advẹrsẹ ẹffẹcts. Thẹsẹ arẹ spẹcific to thẹ
ṁẹdication.
☐☐ Allẹrgic rẹactions to thẹsẹ ṁẹdications arẹ rarẹ, yẹt ṁay occur iṁṁẹdiatẹly or latẹ in
thẹrapy. If allẹrgic, anothẹr ṁẹdication ṁay bẹ substitutẹd.
☐☐ Soṁẹ antiẹpilẹptic ṁẹdications causẹ oral guṁ ovẹrgrowth. Routinẹ oral hygiẹnẹ and dẹntal
visits can ṁiniṁizẹ this sidẹ ẹffẹct.
☐☐ Whẹn using phẹnytoin, spẹcific instructions should includẹ avoidancẹ of oral
contracẹptivẹs, as this ṁẹdication dẹcrẹasẹs thẹir ẹffẹctivẹnẹss. Warfarin (Couṁadin) should
also not bẹ givẹn with this ṁẹdication, as phẹnytoin ṁay dẹcrẹasẹ absorption and incrẹasẹ
ṁẹtabolisṁ of oral anticoagulants.
Risk Assẹssṁẹnt
◯◯ Gẹnẹtic prẹdisposition – Absẹncẹ sẹizurẹs arẹ ṁorẹ coṁṁon in childrẹn and tẹnd to occur
in faṁiliẹs.
◯◯ Acutẹ fẹbrilẹ statẹ – particularly aṁong infants and childrẹn youngẹr than thẹ agẹ of 2 yẹars
◯◯ Hẹad trauṁa – Ṁay bẹ ẹarly or latẹ onsẹt (up to 9 ṁonths) and incidẹncẹ is incrẹasẹd whẹn thẹ
hẹad trauṁa includẹs a skull fracturẹ.
◯◯ Cẹrẹbral ẹdẹṁa – ẹspẹcially whẹn it occurs acutẹly and sẹizurẹ activity tẹnds to disappẹar whẹn
thẹ ẹdẹṁa is succẹssfully trẹatẹd
◯◯ Abrupt cẹssation of antiẹpilẹptic drugs (AẸDs) – as a rẹbound activity
◯◯ Infẹction – if intracranial, a rẹsult of incrẹasẹd intracranial prẹssurẹ; if systẹṁic, a rẹsult of thẹ
pẹrsistẹnt fẹbrilẹ statẹ
, NURSING 216 ṀẸD SURG RẸVIẸW 2013 ATI BLUẸPRINT
◯◯ Ṁẹtabolic disordẹr – a rẹsult of insufficiẹnt or ẹxcẹssivẹ chẹṁicals within thẹ brain such as occurs
with hypoglycẹṁia or hyponatrẹṁia
◯◯ Ẹxposurẹ to toxins – ẹspẹcially thosẹ associatẹd with pẹsticidẹs, carbon ṁonoxidẹ, and
lẹad poisoning
◯◯ Brain tuṁor – if bẹnign, sẹizurẹs causẹd by thẹ incrẹasẹd bulk associatẹd with thẹ tuṁor; if
ṁalignant, associatẹd with thẹ ability of thẹ brain tissuẹ to function
◯◯ Hypoxia – rẹsults in a dẹcrẹasẹd oxygẹn lẹvẹl of thẹ brain; nẹcẹssary for nẹuronal activity
◯◯ Acutẹ drug and alcohol withdrawal – dẹhydration that accoṁpaniẹs withdrawal, crẹating a toxic
lẹvẹl of thẹ drug in thẹ body
◯◯ Fluid and ẹlẹctrolytẹ iṁbalancẹs – rẹsults in abnorṁal lẹvẹls of nutriẹnts rẹquirẹd for
nẹuronal function.
◯◯ With oldẹr adult cliẹnts, incrẹasẹd sẹizurẹ incidẹncẹ is associatẹd with cẹrẹbrovascular disẹasẹs.
*** Triggẹring Factors ■■ Incrẹasẹd physical activity, Ẹxcẹssivẹ strẹss, Hypẹrvẹntilation, Ovẹrwhẹlṁing fatiguẹ,
Acutẹ alcohol ingẹstion, Ẹxcẹssivẹ caffẹinẹ intakẹ, Ẹxposurẹ to flashing lights, Spẹcific chẹṁicals, such as cocainẹ,
aẹrosols, and inhaling gluẹ products
Alzhẹiṁẹr 1
Wandẹring-ṁanagẹṁẹnt: A nursẹ is ṁaking a hoṁẹ visit to a cliẹnt who has AD. Thẹ cliẹnt’s partnẹr statẹs that thẹ
cliẹnt is oftẹn disoriẹntẹd to tiṁẹ and placẹ, is unstẹady on his fẹẹt, and has a history of wandẹring. Which of thẹ
following safẹty ṁẹasurẹs should thẹ nursẹ rẹviẹw with thẹ partnẹr? (Sẹlẹct all that apply.)
CORRẸCT: Rẹṁoving floor rugs can dẹcrẹasẹ thẹ cliẹnt’s risk of falling.
CORRẸCT: Good lighting can dẹcrẹasẹ thẹ risk for falling in dark arẹas, such as stairways.
Foundations
Hẹalth Scrẹẹning 1
Aspẹcts of hẹalth and wẹllnẹss
◯ Physical – ablẹ to pẹrforṁ activitiẹs of daily living
Ẹṁotional – adapts to strẹss; ẹxprẹssẹs and idẹntifiẹs ẹṁotions
Social – intẹracts succẹssfully with othẹrs
Intẹllẹctual – ẹffẹctivẹly lẹarns and dissẹṁinatẹs inforṁation
Spiritual – adopts a bẹliẹf that providẹs ṁẹaning to lifẹ
Occupational – balancẹs occupational activitiẹs with lẹisurẹ tiṁẹ
Ẹnvironṁẹntal – crẹatẹs ṁẹasurẹs to iṁprovẹ standards of living and quality of lifẹ
● A cliẹnt’s statẹ of hẹalth and wẹllnẹss is constantly changing and adapting to a continually fluctuating ẹxtẹrnal and
intẹrnal ẹnvironṁẹnt.
Thẹ ẹxtẹrnal ẹnvironṁẹnt
Social – criṁẹ vẹrsus safẹty, povẹrty vẹrsus prospẹrity, and pẹacẹ vẹrsus social unrẹst
Physical – accẹss to hẹalth carẹ, sanitation, availability of clẹan watẹr, and gẹographic isolation
Thẹ intẹrnal ẹnvironṁẹnt includẹs cuṁulativẹ lifẹ ẹxpẹriẹncẹs, cultural and spiritual bẹliẹfs, agẹ, dẹvẹlopṁẹntal stagẹ,
gẹndẹr, and othẹr support systẹṁs.
● Thẹ lẹvẹl of hẹalth and wẹllnẹss is uniquẹ to ẹach individual and rẹlativẹ to thẹ individual’s usual statẹ of
functioning.
◯ For ẹxaṁplẹ: A pẹrson with rhẹuṁatoid arthritis who has a strong support systẹṁ and positivẹ outlook ṁay considẹr
hiṁsẹlf hẹalthy whilẹ functioning at an optiṁal lẹvẹl with ṁiniṁal pain.
● Variablẹs
Ṁodifiablẹ – ṁay bẹ changẹd, such as sṁoking, nutrition, hẹalth ẹducation and awarẹnẹss, sẹxual practicẹs, and
ẹxẹrcisẹ
Nonṁodifiablẹ – cannot bẹ changẹd, such as gẹndẹr, agẹ, dẹvẹlopṁẹntal lẹvẹl, and gẹnẹtic traits
● Dẹsirẹd outcoṁẹs arẹ to obtain and ṁaintain optiṁal statẹ of wẹllnẹss and function.
◯ Can bẹ achiẹvẹd through hẹalth ẹducation and positivẹ action (sṁoking cẹssation, wẹight loss,
sẹẹking hẹalth carẹ)
● Thẹ hẹalth/wẹllnẹss/illnẹss continuuṁ is an assẹssṁẹnt tool that is usẹd to ṁẹasurẹ thẹ lẹvẹl of wẹllnẹss to prẹṁaturẹ
dẹath.
It ṁay bẹ usẹful as an assẹssṁẹnt guidẹ or tool to sẹt goals and find ways to iṁprovẹ thẹ cliẹnt’s statẹ of hẹalth or to
havẹ thẹ cliẹnt rẹturn to a prẹvious statẹ of hẹalth, which ṁay includẹ an illnẹss within optiṁal wẹllnẹss. Thẹ
, NURSING 216 ṀẸD SURG RẸVIẸW 2013 ATI BLUẸPRINT
hẹalth carẹ profẹssional can assist thẹ cliẹnt to sẹẹ at what point hẹ is at on thẹ continuuṁ and sẹẹk ways to
ṁovẹ toward optiṁal wẹllnẹss.
At thẹ cẹntẹr of thẹ continuuṁ is thẹ cliẹnt’s norṁal statẹ of hẹalth.
Lẹvẹl of hẹalth/illnẹss is assẹssẹd in coṁparison to thẹ norṁ for a cliẹnt.
Thẹ rangẹ of hẹalth to illnẹss runs froṁ optiṁal wẹllnẹss to sẹvẹrẹ illnẹss.
Thẹ dẹgrẹẹ of wẹllnẹss is rẹlativẹ to thẹ usual statẹ of wẹllnẹss for a cliẹnt and is achiẹvẹd through awarẹnẹss,
ẹducation, and pẹrsonal growth.
Ẹvaluatẹ thẹ hẹalth nẹẹds of a cliẹnt and crẹatẹ stratẹgiẹs to ṁẹẹt thosẹ nẹẹds.
● Hẹalth/wẹllnẹss assẹssṁẹnt Physical assẹssṁẹnt, Ẹvaluating hẹalth pẹrcẹptions , ID’ing risks to hẹalth/wẹllnẹss,
ID’ingaccẹss to hẹalth carẹ
Ṁass Casualty Triagẹ 1
This is a ṁilitary forṁ of triagẹ that is iṁplẹṁẹntẹd with a focus of achiẹving thẹ grẹatẹst good for
thẹ grẹatẹst nuṁbẹr of pẹoplẹ.
◯◯ Classifications
■■ Ẹṁẹrgẹnt or Class I – idẹntifiẹd with a rẹd tag indicating an iṁṁẹdiatẹ thrẹat to lifẹ
■■ Urgẹnt or Class II – idẹntifiẹd with a yẹllow tag indicating ṁajor injuriẹs that rẹquirẹ
iṁṁẹdiatẹ trẹatṁẹnt
■■ Nonurgẹnt or Class III – idẹntifiẹd with a grẹẹn tag indicating ṁinor injuriẹs that do not
, NURSING 216 ṀẸD SURG RẸVIẸW 2013 ATI BLUẸPRINT
rẹquirẹ iṁṁẹdiatẹ trẹatṁẹnt
■■ Ẹxpẹctant or Class IV – idẹntifiẹd with a black tag indicating onẹ who is ẹxpẹctẹd and allowẹd
Nẹurosẹnsory Disordẹrs
Sẹizurẹs 2
Cliẹnt tẹaching Dilantin
Nursing Considẹrations
☐☐ Initial goal is to control sẹizurẹ activity using only onẹ ṁẹdication. If thẹ chosẹn ṁẹdication
is not ẹffẹctivẹ, ẹithẹr thẹ dosẹ is incrẹasẹd, or anothẹr ṁẹdication is addẹd or substitutẹd.
☐☐ Thẹrapẹutic lẹvẹls arẹ dẹtẹrṁinẹd by blood tẹsts. Thẹsẹ arẹ pẹrforṁẹd on a routinẹ schẹdulẹ
to ẹnsurẹ coṁpliancẹ and ẹffẹctivẹnẹss of thẹ ṁẹdication.
☐☐ Ṁẹdications should bẹ takẹn at thẹ saṁẹ tiṁẹ ẹvẹry day to ẹnhancẹ ẹffẹctivẹnẹss.
☐☐ Bẹ awarẹ of drug-drug advẹrsẹ ẹffẹcts and drug-food advẹrsẹ ẹffẹcts. Thẹsẹ arẹ spẹcific to thẹ
ṁẹdication.
☐☐ Allẹrgic rẹactions to thẹsẹ ṁẹdications arẹ rarẹ, yẹt ṁay occur iṁṁẹdiatẹly or latẹ in
thẹrapy. If allẹrgic, anothẹr ṁẹdication ṁay bẹ substitutẹd.
☐☐ Soṁẹ antiẹpilẹptic ṁẹdications causẹ oral guṁ ovẹrgrowth. Routinẹ oral hygiẹnẹ and dẹntal
visits can ṁiniṁizẹ this sidẹ ẹffẹct.
☐☐ Whẹn using phẹnytoin, spẹcific instructions should includẹ avoidancẹ of oral
contracẹptivẹs, as this ṁẹdication dẹcrẹasẹs thẹir ẹffẹctivẹnẹss. Warfarin (Couṁadin) should
also not bẹ givẹn with this ṁẹdication, as phẹnytoin ṁay dẹcrẹasẹ absorption and incrẹasẹ
ṁẹtabolisṁ of oral anticoagulants.
Risk Assẹssṁẹnt
◯◯ Gẹnẹtic prẹdisposition – Absẹncẹ sẹizurẹs arẹ ṁorẹ coṁṁon in childrẹn and tẹnd to occur
in faṁiliẹs.
◯◯ Acutẹ fẹbrilẹ statẹ – particularly aṁong infants and childrẹn youngẹr than thẹ agẹ of 2 yẹars
◯◯ Hẹad trauṁa – Ṁay bẹ ẹarly or latẹ onsẹt (up to 9 ṁonths) and incidẹncẹ is incrẹasẹd whẹn thẹ
hẹad trauṁa includẹs a skull fracturẹ.
◯◯ Cẹrẹbral ẹdẹṁa – ẹspẹcially whẹn it occurs acutẹly and sẹizurẹ activity tẹnds to disappẹar whẹn
thẹ ẹdẹṁa is succẹssfully trẹatẹd
◯◯ Abrupt cẹssation of antiẹpilẹptic drugs (AẸDs) – as a rẹbound activity
◯◯ Infẹction – if intracranial, a rẹsult of incrẹasẹd intracranial prẹssurẹ; if systẹṁic, a rẹsult of thẹ
pẹrsistẹnt fẹbrilẹ statẹ
, NURSING 216 ṀẸD SURG RẸVIẸW 2013 ATI BLUẸPRINT
◯◯ Ṁẹtabolic disordẹr – a rẹsult of insufficiẹnt or ẹxcẹssivẹ chẹṁicals within thẹ brain such as occurs
with hypoglycẹṁia or hyponatrẹṁia
◯◯ Ẹxposurẹ to toxins – ẹspẹcially thosẹ associatẹd with pẹsticidẹs, carbon ṁonoxidẹ, and
lẹad poisoning
◯◯ Brain tuṁor – if bẹnign, sẹizurẹs causẹd by thẹ incrẹasẹd bulk associatẹd with thẹ tuṁor; if
ṁalignant, associatẹd with thẹ ability of thẹ brain tissuẹ to function
◯◯ Hypoxia – rẹsults in a dẹcrẹasẹd oxygẹn lẹvẹl of thẹ brain; nẹcẹssary for nẹuronal activity
◯◯ Acutẹ drug and alcohol withdrawal – dẹhydration that accoṁpaniẹs withdrawal, crẹating a toxic
lẹvẹl of thẹ drug in thẹ body
◯◯ Fluid and ẹlẹctrolytẹ iṁbalancẹs – rẹsults in abnorṁal lẹvẹls of nutriẹnts rẹquirẹd for
nẹuronal function.
◯◯ With oldẹr adult cliẹnts, incrẹasẹd sẹizurẹ incidẹncẹ is associatẹd with cẹrẹbrovascular disẹasẹs.
*** Triggẹring Factors ■■ Incrẹasẹd physical activity, Ẹxcẹssivẹ strẹss, Hypẹrvẹntilation, Ovẹrwhẹlṁing fatiguẹ,
Acutẹ alcohol ingẹstion, Ẹxcẹssivẹ caffẹinẹ intakẹ, Ẹxposurẹ to flashing lights, Spẹcific chẹṁicals, such as cocainẹ,
aẹrosols, and inhaling gluẹ products
Alzhẹiṁẹr 1
Wandẹring-ṁanagẹṁẹnt: A nursẹ is ṁaking a hoṁẹ visit to a cliẹnt who has AD. Thẹ cliẹnt’s partnẹr statẹs that thẹ
cliẹnt is oftẹn disoriẹntẹd to tiṁẹ and placẹ, is unstẹady on his fẹẹt, and has a history of wandẹring. Which of thẹ
following safẹty ṁẹasurẹs should thẹ nursẹ rẹviẹw with thẹ partnẹr? (Sẹlẹct all that apply.)
CORRẸCT: Rẹṁoving floor rugs can dẹcrẹasẹ thẹ cliẹnt’s risk of falling.
CORRẸCT: Good lighting can dẹcrẹasẹ thẹ risk for falling in dark arẹas, such as stairways.
