NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
Foundations
Health Screening 1
Aspects of health and wellness
◯ Physical – able to perform activities of daily living
Emotional – adapts to stress; expresses and identifies emotions
Social – interacts successfully with others
Intellectual – effectively learns and disseminates information
Spiritual – adopts a belief that provides meaning to life
Occupational – balances occupational activities with leisure time
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.
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
The internal environment includes cumulative life experiences, cultural and spiritual beliefs, age, developmental stage,
gender, and other support systems.
● The level of health and wellness is unique to each individual and relative to the individual’s usual state of
functioning.
◯ For example: A person with rheumatoid arthritis who has a strong support system and positive outlook may consider
himself healthy while functioning at an optimal level with minimal pain.
● Variables
Modifiable – may be changed, such as smoking, nutrition, health education and awareness, sexual practices, and
exercise
Nonmodifiable – cannot be changed, such as gender, age, developmental level, and genetic traits
● Desired outcomes are to obtain and maintain optimal state of wellness and function.
◯ Can be achieved through health education and positive action (smoking cessation, weight loss,
seeking health care)
● The health/wellness/illness continuum is an assessment tool that is used to measure the level of wellness to premature
death.
It may be useful as an assessment guide or tool to set goals and find ways to improve the client’s state of health or to
have the client return to a previous state of health, which may include an illness within optimal wellness. The
, NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
health care professional can assist the client to see at what point he is at on the continuum and seek ways to
move toward optimal wellness.
At the center of the continuum is the client’s normal state of health.
Level of health/illness is assessed in comparison to the norm for a client.
The range of health to illness runs from optimal wellness to severe illness.
The degree of wellness is relative to the usual state of wellness for a client and is achieved through awareness,
education, and personal growth.
Evaluate the health needs of a client and create strategies to meet those needs.
● Health/wellness assessment Physical assessment, Evaluating health perceptions , ID’ing risks to health/wellness,
ID’ingaccess to health care
Mass Casualty Triage 1
This is a military form of triage that is implemented with a focus of achieving the greatest good for
the greatest number of people.
◯◯ 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
■■ Nonurgent or Class III – identified with a green tag indicating minor injuries that do not
, NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
require immediate treatment
■■ Expectant or Class IV – identified with a black tag indicating one who is expected and allowed
Neurosensory Disorders
Seizures 2
Client teaching Dilantin
Nursing Considerations
☐☐ Initial goal is to control seizure activity using only one medication. If the chosen medication
is not effective, either the dose is increased, or another medication is added or substituted.
☐☐ Therapeutic levels are determined by blood tests. These are performed on a routine schedule
to ensure compliance and effectiveness of the medication.
☐☐ Medications should be taken at the same time every day to enhance effectiveness.
☐☐ Be aware of drug-drug adverse effects and drug-food adverse effects. These are specific to the
medication.
☐☐ Allergic reactions to these medications are rare, yet may occur immediately or late in
therapy. If allergic, another medication may be substituted.
☐☐ Some antiepileptic medications cause oral gum overgrowth. Routine oral hygiene and dental
visits can minimize this side effect.
☐☐ When using phenytoin, specific instructions should include avoidance of oral
contraceptives, as this medication decreases their effectiveness. Warfarin (Coumadin) should
also not be given with this medication, as phenytoin may decrease absorption and increase
metabolism of oral anticoagulants.
Risk Assessment
◯◯ Genetic predisposition – Absence seizures are more common in children and tend to occur
in families.
◯◯ Acute febrile state – particularly among infants and children younger than the age of 2 years
◯◯ Head trauma – May be early or late onset (up to 9 months) and incidence is increased when the
head trauma includes a skull fracture.
◯◯ Cerebral edema – especially when it occurs acutely and seizure activity tends to disappear when
the edema is successfully treated
◯◯ Abrupt cessation of antiepileptic drugs (AEDs) – as a rebound activity
◯◯ Infection – if intracranial, a result of increased intracranial pressure; if systemic, a result of the
persistent febrile state
, NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
◯◯ Metabolic disorder – a result of insufficient or excessive chemicals within the brain such as occurs
with hypoglycemia or hyponatremia
◯◯ Exposure to toxins – especially those associated with pesticides, carbon monoxide, and
lead poisoning
◯◯ Brain tumor – if benign, seizures caused by the increased bulk associated with the tumor; if
malignant, associated with the ability of the brain tissue to function
◯◯ Hypoxia – results in a decreased oxygen level of the brain; necessary for neuronal activity
◯◯ Acute drug and alcohol withdrawal – dehydration that accompanies withdrawal, creating a toxic
level of the drug in the body
◯◯ Fluid and electrolyte imbalances – results in abnormal levels of nutrients required for
neuronal function.
◯◯ With older adult clients, increased seizure incidence is associated with cerebrovascular diseases.
*** Triggering Factors ■■ Increased physical activity, Excessive stress, Hyperventilation, Overwhelming fatigue,
Acute alcohol ingestion, Excessive caffeine intake, Exposure to flashing lights, Specific chemicals, such as cocaine,
aerosols, and inhaling glue products
Alzheimer 1
Wandering-management: A nurse is making a home visit to a client who has AD. The client’s partner states that the
client is often disoriented to time and place, is unsteady on his feet, and has a history of wandering. Which of the
following safety measures should the nurse review with the partner? (Select all that apply.)
CORRECT: Removing floor rugs can decrease the client’s risk of falling.
CORRECT: Good lighting can decrease the risk for falling in dark areas, such as stairways.
Foundations
Health Screening 1
Aspects of health and wellness
◯ Physical – able to perform activities of daily living
Emotional – adapts to stress; expresses and identifies emotions
Social – interacts successfully with others
Intellectual – effectively learns and disseminates information
Spiritual – adopts a belief that provides meaning to life
Occupational – balances occupational activities with leisure time
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.
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
The internal environment includes cumulative life experiences, cultural and spiritual beliefs, age, developmental stage,
gender, and other support systems.
● The level of health and wellness is unique to each individual and relative to the individual’s usual state of
functioning.
◯ For example: A person with rheumatoid arthritis who has a strong support system and positive outlook may consider
himself healthy while functioning at an optimal level with minimal pain.
● Variables
Modifiable – may be changed, such as smoking, nutrition, health education and awareness, sexual practices, and
exercise
Nonmodifiable – cannot be changed, such as gender, age, developmental level, and genetic traits
● Desired outcomes are to obtain and maintain optimal state of wellness and function.
◯ Can be achieved through health education and positive action (smoking cessation, weight loss,
seeking health care)
● The health/wellness/illness continuum is an assessment tool that is used to measure the level of wellness to premature
death.
It may be useful as an assessment guide or tool to set goals and find ways to improve the client’s state of health or to
have the client return to a previous state of health, which may include an illness within optimal wellness. The
, NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
health care professional can assist the client to see at what point he is at on the continuum and seek ways to
move toward optimal wellness.
At the center of the continuum is the client’s normal state of health.
Level of health/illness is assessed in comparison to the norm for a client.
The range of health to illness runs from optimal wellness to severe illness.
The degree of wellness is relative to the usual state of wellness for a client and is achieved through awareness,
education, and personal growth.
Evaluate the health needs of a client and create strategies to meet those needs.
● Health/wellness assessment Physical assessment, Evaluating health perceptions , ID’ing risks to health/wellness,
ID’ingaccess to health care
Mass Casualty Triage 1
This is a military form of triage that is implemented with a focus of achieving the greatest good for
the greatest number of people.
◯◯ 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
■■ Nonurgent or Class III – identified with a green tag indicating minor injuries that do not
, NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
require immediate treatment
■■ Expectant or Class IV – identified with a black tag indicating one who is expected and allowed
Neurosensory Disorders
Seizures 2
Client teaching Dilantin
Nursing Considerations
☐☐ Initial goal is to control seizure activity using only one medication. If the chosen medication
is not effective, either the dose is increased, or another medication is added or substituted.
☐☐ Therapeutic levels are determined by blood tests. These are performed on a routine schedule
to ensure compliance and effectiveness of the medication.
☐☐ Medications should be taken at the same time every day to enhance effectiveness.
☐☐ Be aware of drug-drug adverse effects and drug-food adverse effects. These are specific to the
medication.
☐☐ Allergic reactions to these medications are rare, yet may occur immediately or late in
therapy. If allergic, another medication may be substituted.
☐☐ Some antiepileptic medications cause oral gum overgrowth. Routine oral hygiene and dental
visits can minimize this side effect.
☐☐ When using phenytoin, specific instructions should include avoidance of oral
contraceptives, as this medication decreases their effectiveness. Warfarin (Coumadin) should
also not be given with this medication, as phenytoin may decrease absorption and increase
metabolism of oral anticoagulants.
Risk Assessment
◯◯ Genetic predisposition – Absence seizures are more common in children and tend to occur
in families.
◯◯ Acute febrile state – particularly among infants and children younger than the age of 2 years
◯◯ Head trauma – May be early or late onset (up to 9 months) and incidence is increased when the
head trauma includes a skull fracture.
◯◯ Cerebral edema – especially when it occurs acutely and seizure activity tends to disappear when
the edema is successfully treated
◯◯ Abrupt cessation of antiepileptic drugs (AEDs) – as a rebound activity
◯◯ Infection – if intracranial, a result of increased intracranial pressure; if systemic, a result of the
persistent febrile state
, NURSING 216 MED SURG REVIEW 2013 ATI BLUEPRINT
◯◯ Metabolic disorder – a result of insufficient or excessive chemicals within the brain such as occurs
with hypoglycemia or hyponatremia
◯◯ Exposure to toxins – especially those associated with pesticides, carbon monoxide, and
lead poisoning
◯◯ Brain tumor – if benign, seizures caused by the increased bulk associated with the tumor; if
malignant, associated with the ability of the brain tissue to function
◯◯ Hypoxia – results in a decreased oxygen level of the brain; necessary for neuronal activity
◯◯ Acute drug and alcohol withdrawal – dehydration that accompanies withdrawal, creating a toxic
level of the drug in the body
◯◯ Fluid and electrolyte imbalances – results in abnormal levels of nutrients required for
neuronal function.
◯◯ With older adult clients, increased seizure incidence is associated with cerebrovascular diseases.
*** Triggering Factors ■■ Increased physical activity, Excessive stress, Hyperventilation, Overwhelming fatigue,
Acute alcohol ingestion, Excessive caffeine intake, Exposure to flashing lights, Specific chemicals, such as cocaine,
aerosols, and inhaling glue products
Alzheimer 1
Wandering-management: A nurse is making a home visit to a client who has AD. The client’s partner states that the
client is often disoriented to time and place, is unsteady on his feet, and has a history of wandering. Which of the
following safety measures should the nurse review with the partner? (Select all that apply.)
CORRECT: Removing floor rugs can decrease the client’s risk of falling.
CORRECT: Good lighting can decrease the risk for falling in dark areas, such as stairways.
