ATI Adult Medical Surgical Care Summary. STUDY GUIDE

ATI Medical Surgical Adult Nursing Chapters 1 Health, Wellness, and Illness 2 Emergency Nursing Principles and Management Unit 2 Nursing Care of Clients with Neurosensory Disorders 3 Neurologic Diagnostic Procedures 4 Pain Management 5 Meningitis 6 Seizures and Epilepsy 7 Parkinson’s Disease 8 Alzheimer’s Disease 9 Brain Tumors 10 Multiple Sclerosis, Amyotrophic Lateral Sclerosis, and Myasthenia Gravis 11 Headaches 12 Disorders of the Eye 13 Middle and Inner Ear Disorders 14 Head Injury 15 Stroke 16 Spinal Cord Injury 17 Respiratory Diagnostic Procedures 18 Chest Tube Insertion and Monitoring 19 Respiratory Management and Mechanical Ventilation 20 Acute Respiratory Disorders 21 Asthma 22 Chronic Obstructive Pulmonary Disease 23 Tuberculosis 24 Pulmonary Embolism 25 Pneumothorax and Hemothorax 26 Respiratory Failure 27 Cardiovascular Diagnostic and Therapeutic Procedures 28 Electrocardiography and Dysrhythmia Monitoring 29 Pacemakers 30 Invasive Cardiovascular Procedures 31 Angina and Myocardial Infarction 32 Heart Failure and Pulmonary Edema 33 Valvular Heart Disease 34 Inflammatory Disorders 35 Peripheral Vascular Diseases 36 Hypertension 37 Hemodynamic Shock 38 Aneurysms 39 Hematologic Diagnostic Procedures 40 Blood and Blood Product Transfusions 41 Anemias 42 Coagulation Disorders 43 Fluid Imbalances 44 Electrolyte Imbalances 45 Acid-Base Imbalances 46 Gastrointestinal Diagnostic Procedures 47 Gastrointestinal Therapeutic Procedures 48 Esophageal Disorders 49 Peptic Ulcer Disease 50 Acute and Chronic Gastritis 51 Noninflammatory Bowel Disorders 52 Inflammatory Bowel Disease 53 Cholecystitis and Cholelithiasis 54 Pancreatitis 55 Hepatitis and Cirrhosis 56 Renal Diagnostic Procedures 57 Hemodialysis and Peritoneal Dialysis 58 Kidney Transplant 59 Acute and Chronic Glomerulonephritis 60 Acute Kidney Injury and Chronic Kidney Disease 61 Infections of the Renal and Urinary System 62 Renal Calculi 63 Diagnostic and Therapeutic Procedures for Female Reproductive Disorders 64 Menstrual Disorders and Menopause 65 Disorders of Female Reproductive Tissue 66 Diagnostic Procedures for Male Reproductive Disorders 67 Disorders of the Male Reproductive System 68 Musculoskeletal Diagnostic Procedures 69 Arthroplasty 70 Amputations 71 Osteoporosis 72 Fractures and Immobilization Devices 73 Osteoarthritis 74 Integumentary Diagnostic Procedures 75 Chronic Skin Conditions 76 Burns 77 Endocrine Diagnostic Procedures 78 Posterior Pituitary Disorders 79 Hyperthyroidism 80 Hypothyroidism 81 Cushing’s Disease/Syndrome 82 Addison’s Disease and Acute Adrenal Insufficiency (Addisonian Crisis 83 Diabetes Mellitus Management 84 Complications of Diabetes Mellitus 85 Immune and Infectious Disorders Diagnostic Procedures 86 Immunizations 87 HIV/AIDS 88 Systemic Lupus Erythematosus 89 Rheumatoid Arthritis 90 General Principles of Cancer 91 Cancer Screening and Diagnostic Procedures 92 Cancer Treatment Options 93 Cancer Disorders 94 Pain Management for Clients with Cancer 95 Anesthesia and Moderate Sedation 96 Preoperative Nursing Care 97 Postoperative Nursing Care   Chapter 1- Health, Wellness, and Illness • Aspects of health and wellness o Physical – able to perform activities of daily living o Emotional – adapts to stress; expresses and identifies emotions o Social – interacts successfully with others o Intellectual – effectively learns and disseminates information o Spiritual – adopts a belief that provides meaning to life o Occupational – balances occupational activities with leisure time o Environmental – creates measures to improve standards of living and quality of life • A client’s state of health and wellness is constantly changing and adapting to a continually fluctuating external and internal environment. o The external environment  Social – crime versus safety, poverty versus prosperity, and peace versus social unrest  Physical – access to health care, sanitation, availability of clean water, and geographic isolation o The internal environment includes cumulative life experiences, cultural and spiritual beliefs, age, developmental stage, gender, and other support systems. Chapter 2- Emergency Nursing Principles and Management • Emergency nursing principles are the guidelines that nurses follow to assess and manage emergency situations for a client or multiple clients. • 7 Emergency nursing principles 1) Triage- ensures that clients with the highest acuity needs receive the quickest treatment 3 Categories:  Emergent- indicates a life- or limb-threatening situation.  Urgent- indicates that the client should be treated soon, but that the risk posed is not life-threatening.  Non-urgent- generally can wait for an extended length of time without serious deterioration. o Triage Under Mass Casualty Conditions a military form of triage that is implemented with a focus of achieving the greatest good for the greatest number of people 4 Classifications: • Emergent or Class I- identified with a red tag indicating an immediate threat to life • Urgent or Class II- identified with a yellow tag indicating major injuries that require immediate treatment • Non-urgent or Class III- identified with a green tag indicating minor injuries that do not require immediate treatment • Expectant or Class IV- identified with a black tag indicating one who is expected and allowed to die 2) Primary survey- a rapid assessment of life-threatening conditions. It should take no longer than 60 seconds to perform with use of ABCDE as a guideline wear standard PPE 3) Airway/cervical spine, breathing, circulation, disability, and exposure/environmental control (ABCDE) o Airway/Cervical Spine- the most important step in performing the primary survey. If a patent airway is not established, subsequent steps of the primary survey are futile.  Inspect for blood, broken teeth, vomit, or foreign materialsobstruction clear with finger sweep  If unresponsive without suspicion of trauma, open airway with a head-tilt/chin-lift maneuver. • Do NOT perform this technique on clients who have a potential cervical spine injury.  If the client is unresponsive with suspicion of trauma, open airway with a modified jaw thrust maneuver. o Breathing- Auscultation of breath sounds, observation of chest expansion and respiratory effort, notation of rate and depth of respirations, identification of chest trauma, note position of trachea, assess for jugular vein distention o Circulation- Nurses should assess heart rate, blood pressure, and perfusion. • CPR, assess for external bleeding, hemorrhage control, obtain IV access using large-bore IV catheters inserted into the antecubital fossa of both arms, infuse IV fluids (lactated Ringer’s and 0.9% normal saline and/or blood). o Disability quick assessment to determine the client’s level of consciousness (AVPU and Glasgow Coma Scale)  A- alert, V- responsive to voice, P- responsive to pain, U- unresponsive o Exposureremoves the client’s clothing for a complete physical assessment  Hypothermia (RISK)to preventRemove wet clothing from the client, cover the client with blankets or use a heat lamp to provide additional warmth, increase the temperature of the room, infuse warmed IV fluids as prescribed. 4) Poisoningassess for toxin originReverse heroin and other opiate toxicity with naloxone (Narcan) Administer IV diazepam (Valium) if seizures occurAssess for tissue edema every 15 to 30 min if bitten by a snake or spider 5) Rapid response teamA group of critical care experts (ICU nurse, respiratory therapist, a critical care provider, hospitalist) 6) Cardiac emergencyCardiac arrest (sudden cessation of cardiac function) Ventricular fibrillation (VF) Pulseless ventricular tachycardia (VT)(Irritable firing of ectopic ventricular beats at a rate of 140-180/min) Ventricular asystole (complete absence of electrical activity and ventricular movement of the heart) Pulseless electrical activity (PEA) o AHA ACLS Protocols  VF or pulseless ventricular tachycardia (VT)Initiate the CPR components of BLSDefibrillate according to BLS guidelinesEstablish IV accessAdminister IV antidysrhythmic medications according to ACLS guidelinesEpinephrine 1 mg IV push every 3 to 5 min or vasopressin 40 units IV x 1 only (switch to epinephrine if no response) • Consider the following medicationsAmiodarone hydrochloride (Cordarone), Lidocaine hydrochloride (Xylocaine), Magnesium sulfate, Procainamide (Procan SR), Vasopressin  Pulseless electrical activity (PEA)Initiate the CPR components of BLSDefibrillate according to BLS guidelinesEstablish IV accessConsider the most common causes. • 5 H’sHypovolemia, Hypoxia, Hydrogen ion accumulationacidosis, Hyper-/hypo-kalemia, Hypothermia • 5 T’sToxins (drugs), Tamponade (cardiac), Tension pneumothorax, Thrombosis (coronary or pulmonary) o Administer epinephrine 1 mg IV push every 3 to 5 min.  Asystole Initiate the CPR components of BLSDefibrillate according to BLS guidelinesEstablish IV accessBegin immediate transcutaneous pacingGive epinephrine 1 mg push every 3 to 5 min 7) Postresuscitation Medicate after resuscitationepinephrine, dopamine, and dobutamine Chapter 3- Neurologic Diagnostic Procedures **For all procedures if pregnant, determine if benefits outweigh risks** • Cerebral Angiogram- assesses the blood flow to and within the brain, identifies aneurysms, and defines the vascularity of tumors. Detects defects, narrowing, or obstruction of arteries or blood vessels in brainiodine-based contrast dye is injected into an artery during the procedure. o NPO 4-6 hours prior Assess allergies to shellfish or iodine Assess BUN and creatinine no jewelryDo not move during the procedurevoid before the test metallic taste in the mouth, a warm sensation over the face, jaw, tongue, lips, and behind the eyes from the dye injected during procedure o IntraprocedureA catheter is placed into an artery (groin or the neck), dye is injected, and x-ray pictures are taken o Postprocedurearea is closely monitored to ensure that clotting occurs movement is restricted o Complications Bleeding or hematoma formation at entry siteCheck the insertion site frequently, Check the affected extremity distal to the puncture site for adequate circulation (e.g., color, temperature, pulses, and capillary refill) • Cerebral Computed Tomography (CT) Scan- used to identify tumors and infarctions, detect abnormalities, monitor response to treatment, and guide needles used for biopsies. o NPO at least 4 hours prior Assess allergies to shellfish or iodine Assess BUN and creatinine no jewelryClient must lie supine with the head stabilized during the procedurepainlesssedate if needed • Electroencephalography (EEG)- most commonly performed to identify and determine seizure activity, but they are also useful for detecting sleep disorders and behavioral changes. o Preprocedure wash his hair prior to the procedure and eliminate all oils, gels, and sprays instruct the client to be sleep-deprived because this provides cranial stress, increasing the possibility of abnormal electrical activity, such as seizure potentials, occurring during the procedure. o Intraprocedure procedure takes 1 hr Electrical signals produced by the brain are recorded by the machine or computer in the form of wavy linesclient may resume normal activities after • Glasgow Coma Scale (GCS)- GCS scores are helpful in determining changes in the level of consciousness for clients with head injuries, space occupying lesions or cerebral infarctions, and encephalitis. o Interpretation of Findings The best possible GCS score is 15 9 to 12- Indicate a moderate head injury Greater than 13-Reflect minor head trauma Less than 8- Associated with severe head injury and coma • Intracranial Pressure (ICP) Monitoring- useful for early identification and treatment of increased intracranial pressureRisk for infection and bleeding • Lumbar Puncture (Spinal Tap)- used to detect the presence of certain diseases (multiple sclerosis, syphilis, meningitis), infection, and malignancies. o Needle is inserted and withdraws CSFsent to pathology dept.monitor puncture sitepatient to lie flathydratepain meds  Complications CSF leakagesevere headacheepidural blood patch to seal off leak • Magnetic Resonance Imaging (MRI) Scan- used to detect abnormalities, monitor response to treatment, and guide needles used for biopsies. Capable of discriminating soft tissue from tumor or bone. This makes the MRI scan more effective at determining tumor size and blood vessel location. o Assess for allergy to shellfish or iodine jewelry is removed priorNPO 408 hours prior history of claustrophobiaHx of any implants containing metal (e.g., pacemaker, orthopedic joints, artificial heart valves, intrauterine devices, aneurysm clips) • PET and SPECT Scans- useful in determining tumor activity and/or response to treatment. o Discuss radiation risk Assess for a Hx of DMmed alteration necessary to avoid hypo-/hyper-glycemia (tracer is glucose based) • Radiography (X-Ray)- reveals fractures, curvatures, bone erosion and dislocation, and possible soft tissue calcification Chapter 4- Pain Management • Nonpharmacological Pain Management skin stimulation (cold/hot), Distraction, Relaxation, Imagery, Acupuncture, Reduce environmental stimuli • Pharmacological Interventions- Analgesics: non-opioids, opioids, and adjuvants o Non-opioid acetaminophen (hepatotoxic), NSAIDs (tinnitus) mild to moderate pain Monitor for bleeding with long-term NSAID use o Opioid morphine sulfate, fentanyl (Sublimaze), and codeine moderate to severe pain parenteral best for immediate, short-term relief of acute pain. The oral route is better for chronic, non-fluctuating pain  Adverse effects: constipation, orthostatic hypotension, urinary retention, N/V, sedation, respiratory depression (Narcan) o Adjuvant enhances the effects of non-opioids Anticonvulsants: carbamazepine (Tegretol), Antianxiety agents: diazepam