Summary Med surg ATI (study guide; latest Fall , A+ help

Summary Med surg ATI (study guide; latest Fall

2020, A+ help

 Accident/Error/Injury Prevention - (1)

o Spinal Cord Injury: Care of a Client who has a Halo Device (Active Learning Template - Therapeutic Procedure, RM

AMS RN 10.0 Chp 16)

o The purpose is to provide traction and/or immobilize the spinal column

 Do not use the halo device to turn or move a client

 If the client goes home with a halo fixation device on, provide instruction on pin and vest care.

 Teach the client signs of infection and skin breakdown.

 Maintain body alignment and ensure cervical tong weights hang freely.

 Monitor skin integrity by providing pin care and assessing the skin under the halo fixation vest as

appropriate.

 Standard Precautions/Transmission-Based Precautions/Surgical Asepsis - (1)

o Bacterial, Viral, Fungal, and Parasitic Infections: Isolation Precautions for Client Who Has Influenza (Active Learning

Template - Basic Concept, RM FUND RN 9.0 Ch 56)

 Contact: Clostridium difficile, herpes simplex virus, impetigo, methicillin‑resistant

Staphylococcus aureus (MRSA), vancomycin‑resistant Staphylococcus aureus (VRSA)

 Airborne: Measles, varicella, tuberculosis

 Droplet (3-6 ft): Haemophilus influenzae type B (Hib), pertussis, mumps, rubella, plague,

streptococcal pneumonia, meningococcal pneumonia

 Tuberculosis: Priority Action for a Client in the Emergency Department (Active Learning Template - System

Disorder, RM AMS RN 10.0 Chp 23)

 Administer heated and humidified oxygen therapy as prescribed

 The client should be transported using the shortest and least busy route

 cough and expectorate sputum into tissues that are disposed of by the client into provided plastic

bags or no‑touch receptacles

 Clients are no longer considered infectious after three consecutive negative sputum cultures

 Adverse Effects/Contraindications/Side Effects/Interactions - (1)

o Electrolyte Imbalances: Manifestations of Hypokalemia (Active Learning Template - Medication, RM

AMS RN 10.0 Chp 44)

 VITAL SIGNS:

 Decreased blood pressure, thready weak pulse, orthostatic hypotension

 NEUROLOGIC:

 Altered mental status, anxiety, and lethargy that progresses to acute confusion and coma

 ECG:

 Flattened T wave, prominent U waves, ST depression, prolonged PR interval

 GASTROINTESTINAL:

 Hypoactive bowel sounds, nausea, vomiting, constipation, abdominal distention.

Paralytic ileus can develop.

 MUSCULAR:

 Weakness. Deep‑tendon reflexes can be reduced.

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 RESPIRATORY: Shallow breathing

 Blood and Blood Products - (1)

o Blood and Blood Product Transfusions: Steps to Administer a Blood Transfusion (Active Learning

Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 40)

● Verify the prescription for a specific blood product.

● Obtain consent for procedure if required.

● Obtain blood samples for compatibility determination, such as type and cross‑match.

● Assess for a history of blood‑transfusion reactions.

● Initiate large‑bore IV access. An 18‑ or 20‑gauge needle is standard for administering blood products.

● Obtain blood products from the blood bank. Inspect the blood for discoloration, excessive bubbles, or cloudiness.

● Prior to transfusion, two RNs must identify the correct blood product and client by looking at the hospital identification

number (noted on the blood product) and the number identified on the client’s identification band to make sure the numbers

match.

● The nurse completing the blood product verification must be one of the nurses who administers the blood product.

● Prime the blood administration set with 0.9% sodium chloride only. Never add medications to blood products. Y‑tubing

with a filter is used to transfuse blood.

● Begin the transfusion, and use a blood warmer if indicated. Initiate the transfusion within 30 min of obtaining the blood

product to reduce the risk of bacterial growth.

 Central Venous Access Devices - (2)

o Cardiovascular Diagnostic and Therapeutic Procedures: Administering Medication Through a Nontunneled

Percutaneous Central Catheter (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0

Chp 27)

 Insertion location:

 subclavian vein, jugular vein; tip in the distal third of the superior vena cava

 Indications: Short-term use only

 administration of blood, long‑term administration of chemotherapeutic agents,

antibiotics, and total parenteral nutrition

o Cardiovascular Diagnostic and Therapeutic Procedures: Removing a Peripherally Inserted Central Catheter

(Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 27)

 Length of use: up to 12 months

 Assess Picc line every 8 hrs

 Change tubes and caps every 3 days

 Follow facility protocol for dressing changes, usually every 7 days and when indicated (wet, loose,

soiled).

 Expected Actions/Outcomes - (1)

o Electrolyte Imbalances: Effective Action of Magnesium Sulfate (Active Learning Template - Medication,

RM AMS RN 10.0 Chp 44)

 IV route is used because IM can cause pain and tissue damage

 Oral magnesium can cause diarrhea and increase magnesium depletion

 Monitor Deep Tendon Reflex (DTR) hourly during administration of magnesium sulfate.

 IV magnesium sulfate is given via an infusion pump not to exceed 150 mg/min, or 67 mEq over an

8‑hr period

 Clients receiving digitalis should be monitored closely if magnesium is low because it predisposes

the client to digitalis toxicity.

 Medication Administration - (1)

o Heart Failure and Pulmonary Edema: Client Teaching on Use of Furosemide (Active Learning Template -

Medication, RM AMS RN 10.0 Chp 32)

 Use to decrease preload

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 Teach clients taking loop or thiazide diuretics to ingest foods and drinks that are high in

potassium to counter the effects of hypokalemia.

 Total Parenteral Nutrition (TPN) - (1)

o Electrolyte Imbalances: Adequate Nutritional Status with Total Parenteral Nutrition (Active Learning

Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 44)

 The purpose of TPN administration is to prevent or correct nutritional deficiencies and minimize

the adverse effects of malnourishment.

 Hypertonic IV bolus solution.

 TPN contains complete nutrition, including calories in a high concentration (10% to 50%) of

dextrose, lipids/essential fatty acids, protein, electrolytes, vitamins, and trace elements.

INDICATIONS

Any condition that

 ●● Affects the ability to absorb nutrition.

 ●● Has a prolonged recovery.

●● Creates a hypermetabolic state.

 ●● Creates a chronic malnutrition.

 Diagnostic Tests - (1)

o Neurologic Diagnostic Procedures: Preparing a Client for a Lumbar Puncture (Active Learning Template -

Diagnostic Procedure, RM AMS RN 10.0 Chp 3)

 The risks versus benefits of a lumbar puncture should be discussed with the client prior to this

procedure. DO NOT perform when pt has ICP or bleeding disorder or on anticoagulant

Nursing Actions

 Ensure that all of the client’s jewelry is removed and that the client is wearing only a

hospital gown

 Void prior to procedure

 Position Pt in “cannonball while on one side” or “stretch over an overbed table when

sitting”

 System Specific Assessments - (1)

o Burns: Priority Action During Resuscitation Phase (Active Learning Template - System Disorder, RM

AMS RN 10.0 Chp 75)

Emergent (resuscitative phase)

 Begins with the injury and continues for 24 to 48 hr.

 Priorities include securing the airway, supporting circulation and organ perfusion by

fluid replacement, managing pain, preventing infection through wound care,

maintaining body temperature, and providing emotional support.

 Alterations in Body Systems - (4)

o Respiratory Management and Mechanical Ventilation: Caring for a Client Who Has an Endotracheal Tube

(Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 19)

 Use caution when moving the client

 Apply protective barriers (soft wrist restraints) according to hospital protocol to prevent self‑

extubation

 Use two staff members for repositioning and to resecuring the tube.

 Suction oral and tracheal secretions to maintain tube patency

 Have a resuscitation bag with a face mask available at the bedside at all times in case of ventilator

malfunction or accidental extubation

 Support ventilator tubing to prevent mucosal erosion and displacement.

 Document tube placement in centimeters at the client’s teeth or lips.

 Assess respiratory status every 1 to 2 hr:

 Monitor and document ventilator settings hourly