Class notes ATI MED SURG 1: (NURSING221) NURSING221 ATI MED SURG 1: Safety and Infection Control / ATI remediation notes (spring 2021)

ATI MED SURG 1: Safety and Infection Control [2/4] - Bacterial, viral, fungal, and parasitic infections: isolation precautions for client who has influenza 1. A nurse is caring for a client who has Haemophilus influenza type B. Which of the following types of isolation should the nurse implement? a. Airborne b. Droplet c. Contact d. Protective - Seizures and Epilepsy: priority interventions for a client experiencing a seizure  Tonic clonic: May be preceded by aura.  3 phases:  Tonic episode: stiffening of muscles, loss of consciousness  Clonic episode: 1-2 min of rhythmic jerking of extremities  Postical phase: confusion, sleepiness  Absence: loss of consciousness for a few seconds. Key features: blank staring, eye fluttering, lip smacking, picking at clothes  Myoclonic: brief stiffening of extremities  Atonic: loss of muscle tone, results in falling  Status epilepticus: repeated seizure activity within 30 min or a single seizure lasting more than 5 min:  Epilepsy = chronic seizures (2 or more) • Diagnosis: EEG to identify origin of seizure • Nursing care • During seizure: Turn patient to the side, loosen restrictive clothing, do not insert airway or restrain patient, document onset/duration of seizure • Surgeries: Vagal nerve stimulatory, craniotomy to remove brain tissue causing seizures. • Meds: • Antiepileptics: Phenytoin (Dilantin) • Lamotrigine, carbamazepine, valproic acid  Indications: seizures  Side effects: gingival hyperplasia, diplopia, nystagmus, rash, ataxia, hypotension  Key points: serum phenytoin levels need to be monitored routinely d/t narrow therapeutic range. Decreases effectiveness of oral contraceptives Physiological adaptation [27/34] - Respiratory management and mechanical ventilation: caring for a client who has an endotracheal tube – therapeutic procedure - Polycystic kidney disease, acute kidney injury and chronic kidney disease: findings to report – system disorder - Pacemakers: evaluating client understanding of discharge teaching – therapeutic procedure - Electrocardiography and dysrhythmia monitoring: identifying first-degree heart block – diagnostic procedure - Musculoskeletal trauma: assessing for compartment syndrome – system disorder - Emergency nursing principles and management: emergency illness management – therapeutic procedure - Cancer treatment options: prioritizing client care – basic concept Health promotion and maintenance [1/2] - Immunization: recommended vaccinations for older adult clients – growth and development Pharmacological and parenteral therapies [14/23] - Pain management for clients who have cancer: managing breakthrough pain—system disorder - Dosage calculations: Calculating IV infusion rate – basic concept - Electrolyte imbalances: adequate nutritional status with TPN – therapeutic procedure  Total Parenteral Nutrition (TPN) → Indicated for malabsorption, hypermetabolic states (i.e. burns), chronic malnutrition, and prolonged NPO a. Administration → Via central line (i.e. PICC line) i. Do not use TPN line for other fluids or meds!! b. Nursing considerations → Gradually increase/decrease flow rate i. Change tubing and bag q24h and use micron filter on tubing ii. If next TPN bag is unavailable, administer 10% dextrose in water until it arrives because it prevents a precipitous drop in the client’s blood glucose levels iii. Monitor I&O, daily wt, electrolytes, and blood glucose (q4-6h for first 24h) o TPN -- Indications: Malabsorption, hypermetabolic state, chronic malnutrition, prolonged NPO ▪ Administration: Through central or peripheral IV-line (Ex. PICC) Infusion pump is always used for PN ▪ Nursing care: ● Gradually increase/decrease flow rate, Change tubing and bag every 24 hours, Use micron filter on tubing, Monitor I&O, daily weights, electrolyte levels, blood glucose (every 4-6 hours for the first 24 hours),If the next TPN bag is unavailable, administer 10% dextrose in water until it arrives, Do not use TPN line for other fluids or meds! Monitor central line insertion site for s/s of infection (erythema, pain, exudate) Monitor blood glucose, VS q4hrs - Medications affections coagulation: heparin contraindications – medication - Heparin subcutaneously  Use an electric shaver because they are less likely to get cuts from shaving  Avoid actions that may cause bleeding such as flossing. Do not massage site after injection, firm pressure is okay. Report signs of bleeding in urine. - Electrolyte imbalances: Manifestations of hypokalemia – medication - Heart failure and pulmonary edema: client teaching on use of furosemide – medication - Gastrointestinal therapeutic procedures: central venous access device care – therapeutic procedure - Electrolyte imbalances: effective action of magnesium sulfate – medication - Blood and blood produce transfusions: Indications of a transfusion reaction – therapeutic procedure Basic care and comfort [5/6] - Pressure ulcers, wounds, and wound management: methods of debridement Reduction of risk potential [14/21] - Cushing’s disease/ syndrome: priority action – system disorder - Burns: Priority action during resuscitation phase – system disorder - Alzheimer’s Disease: short term memory loss – system disorder - Alzheimers: Non-reversible dementia, resulting in memory loss, problems with judgment and changes in personality - Stages: - Stage 1: No impairment - Stage 2: Forgetfulness, no memory problems - Stage 3: mild cognitive deficits, short term memory loss noticeable to family members - Stage 4: Personality changes” obvious memory loss - Stage 5: Assistance with ADL’s necessary - Stage 6: Incontinence (fecal, urinary), wandering - Stage 7: impaired swallowing, ataxia, no ability to speak - Nursing care: maintain structured environment. Provide short directions, repetition. Avoid overstimulation. Use single-day calendar. Provide frequent reorientation. Maintain routine toileting schedule - Home safety: Remove scatter rugs. Install door locks, good lighting (particularly on stairs), Mark step edges with colored tape, remove clutter Meds: - Donepezil (prevents breakdown of Ach, improves ability to do ADL’s, other meds to manage symptoms (anti-psychotics, antidepressants, anti-anxiety meds) - Head injury: monitoring neurological status – system disorder - First priority: Stabilize cervical spine - Signs of increased ICP: irritability (early sign!), HA, decreased LOC, pupil abnormalities, abnormal breathing (Ex. Cheyne Stokes), abnormal posturing, Cushing’s triad (severe hypertension, wide pulse pressure, bradycardia) - Interventions to decrease ICP: Reduce hypercarbia, (hyperventilate patients), avoid suctioning, maintain HOB more than 30 degrees. Teach patient to avoid coughing, blowing nose, extreme neck flexion/extension, restrictive clothing - Medications  Mannitol: osmotic diuretic to treat cerebral edema  Phenobarbital: Induces coma, decreases metabolic demands ......................continues