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RN ATI Capstone Adult Medical Surgical
Hematologic Diagnostic Procedures: Bone Marrow Biopsy (RM AMS RN 10.0 Chp 39, Active Learning Template - Diagnostic Procedure) - Bone biopsy takes a small sample of bone marrow removed by needle aspiration for cytological (histological) examination Performed with local anesthesia or conscious sedation. Used to diagnose blood disorders (anemia, thrombocytopenia) or diseases of bone marrow (leukemia, infection) or stage lymphoma or other forms of cancer. Teaching: teach client to report excessive bleeding and evidence of infection to provider Teach client to check the biopsy site daily, keep the dressing clean, dry, and intact If sutures in place, have client return in 7 days to have them removed Esophageal Disorders: Dietary Selections for a Client Who Has a Hiatal Hernia (Active Learning Template - System Disorder, RN QSEN - Patient-centered Care, RM AMS RN 10.0 Chp 48) - Avoid eating immediately prior to going to bed Avoid foods and beverages that decrease LES pressure (fatty and fried foods, chocolate, coffee, peppermint, spicy foods, tomatoes, citrus fruits, and alcohol) Musculoskeletal Trauma: Teaching Strategies to Prevent Carpal Tunnel Syndrome (RN QSEN - Safety , RM AMS RN 10.0 Chp 71, Active Learning Template - Basic Concept) - Avoid repetitive flexion of wrist Perform ROM Have item under wrists while using computer to prevent prolonged flexion Elevate hand above level of heart
Renal Calculi: Priority Intervention for a Client Who Has Renal Calculi (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp
- Report laboratory and diagnostic findings to the provider Strain all urine to check for passage of the calculus and save the calculus for laboratory analysis Encourage client to increase oral intake to 3L/day unless contraindicated Encourage ambulation to promote passage of the calculus Administer IV fluids as prescribed Asthma: Monitoring peak expiratory flow rates (AMS Ch. 21) - fastest airflow rate reached during exhalation. Urinary Elimination: Identifying Type of Urinary Incontinence (Active Learning Template - System Disorder, RM FUND 9.0 Ch 44) - Stress: loss of small amounts of urine from increased abdominal pressure without bladder muscle contraction with laughing, sneezing or lifting Urge: inability to stop urine flow long enough to reach the bathroom due to an overactive detrusor muscle with increased bladder pressure Overflow: urinary retention from bladder overdistention and frequent loss of small amounts of urine due to obstruction of the urinary outlet or an impaired detrusor muscle Reflex: involuntary loss of a moderate amount of urine usually without warning due to hyperreflexia of the detrusor muscle, usually from spinal cord dysfunction Functional: loss of urine due to factors that interfere with responding to the need to urinate, such as cognitive, mobility and environmental barriers Total: unpredictable involuntary loss of urine that generally does not respond to treatment
Cushing's Disease/Syndrome: Expected Laboratory Values (RM AMS RN 10.0 Chp 80, Active Learning Template - System Disorder) - Elevated plasma cortisol levels Elevated ACTH levels Hypokalemia Hypocalcemia Hypernatremia Decreased lymphocytes Actions for low-pressure alarms (AMS Ch. 19) - - check for cuff leaks, tube displacement Diagnostic and Therapeutic Procedures for Female Reproductive Disorders: Client Teaching Following Colposcopy and Cervical Biopsy (Active Learning Template - Diagnostic Procedure, RM AMS RN 10. Chp 62, RN QSEN - Patient- centered Care) - Nursing Considerations: Post-procedure care is the same as for a Pap test Provide client with perineal pad and tissues Instruct the client to rest for the first 24 hour after the procedure Instruct the client to abstain from sexual intercourse and avoid using a douche, vaginal creams, or tampons until all discharge has stopped (usually about 2 weeks). Instruct the client to avoid lifting heavy objects for approximately 2 weeks to allow time for the cervix to heal Instruct the client to use analgesics as directed by the provider, but to avoid the use of aspirin because it can cause bleeding Instruct the client to report excessive bleeding, fever, or foul-smelling drainage to the provider. Integumentary Diagnostic Procedures: Identifying Fungal Infections (Active Learning Template - Diagnostic Procedure, RM AMS RN 10. Chp 73) - Requires a sufficient quantity of scales collected using a wooden tongue depressor and placing the specimen in a clean container to be sent to the laboratory
If a fungal culture is needed because of inconclusive results due to a deeper fungal infection, a punch biopsy is performed Specimens must be properly labeled and delivered to the laboratory promptly for appropriate storage and analysis Osteoarthritis and Low-Back Pain: Expected Assessment Findings for a Herniated Lumbar Disk (RM AMS RN 10.0 Chp 72, Active Learning Template - System Disorder) - Expected findings: dull or sharp low back pain Pain aggravated by coughing, sneezing or straining Muscle spasms, cramping and stiffness Pain in the buttock Sciatic nerve compression causes severe pain when leg is straightened and held up Numbness/tingling of the leg (paresthesia); burning or stabbing pain in the leg or foot Report chills/fever, bowel or bladder incontinence, progression of decreased ability to move, and paresthesias to the provider promptly (can indicate a more serious condition) Herniated disk which can cause sciatic nerve involvement with burning or stabbing pain into one leg or foot Peripheral Vascular Diseases: Risk Factors for Deep-Vein Thrombosis (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp
- Associated with Virchow's triad (hypercoagulability, impaired blood flow, damage to blood vessels)
- hip surgery, total-knee replacement, open prostate surgery
- heart failure
- immobility
- pregnancy
- oral contraceptives
- active cancer
Coagulation Disorders: Laboratory Values Associated with Heparin- Induced Thrombocytopenia (RM AMS RN 10.0 Chp 42, Active Learning Template - System Disorder) - Decreased platelet levels Other s/s: redness, pain, warmth and swelling of lower extremities, excessive bleeding, tachycardia, hypotension, diaphoresis, oliguria, decreased LOC Kidney Transplant: Indications of Transplant Rejection (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 58) - Hyperacute: within 48 hr cause: small blood clots form in transplanted kidney that block vessels and lead to massive cellular destruction, irreversible s/s: fever, hypertension, pain at transplant site treatment: immediate removal of the donor kidney Acute: occurs 1 week - 2 years after surgery cause: vasculitis in the donor kidney and cellular destruction begins with inflammation that can cause lysis of the donor kidney s/s: oliguria, anuria, low-grade fever, hypertension, tenderness over the transplanted kidney, lethargy, azotemia, and fluid retention treatment: involves increased doses of immunosuppressive meds Chronic: occurs gradually over months to years cause: blood vessel injury from overgrowth of smooth muscles of the blood vessels causing fibrotic tissue to replace normal tissue resulting in a nonfunctioning donor kidney s/s: gradual return of azotemia, fluid retention, electrolyte imbalance, fatigue treatment: conservative (monitor kidney status, continue immunosuppressive therapy) until dialysis is required Multiple Sclerosis: Teaching Client About Visual Changes (RM AMS RN 10.0 Chp 10, Active Learning Template - System Disorder) - Patient may be double (diplopia)
Teach scanning techniques. Instruct client to visually can his environment by moving his head from side to side Pacemakers: Indication of Malfunction (RM AMS RN 10.0 Chp 29, Active Learning Template - Therapeutic Procedure) - Causes: insufficient pacemaker settings, lead wire placement and function, battery function, myocardial damage and electrolyte imbalance Monitor ECG to ensure heart rate is within programmed parameters. Pace spikes should be adequate in number and occur directly before P or QRS complexes Pacer spikes that occur on the T wave can cause life-threatening arrhythmias. Treatment of complications is related to identifying the cause Pacemaker settings should be manipulated only as prescribed Pneumothorax, Hemothorax, and Flail Chest: Clinical Manifestations of a Tension Pneumothorax (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 25) - Expected findings: anxiety, pleuritic pain Physical assessment findings: signs of respiratory distress (Tachypnea, tachycardia, cyanosis, dyspnea and use of accessory muscles)
- Tracheal deviation to the unaffected side
- Reduce/absent breath on affect side
- Asymmetrical chest wall movement
- Hyperresonance on percussion due to trapped air (pneumothorax) Polycystic Kidney Disease, Acute Kidney Injury, and Chronic Kidney Disease: Teaching About Polycystic Kidney Disease (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 59) - PKD - congenital disorder where clusters of fluid filled cysts develop in the nephrons. Healthy kidney tissue is replaced by multiple non-functioning cysts
valentpneumococcal conjugate vaccine (PCV-13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23).Follow recommendations for administration to adults who are immunocompromised, have specific chronic diseases, smoke cigarettes, or live in long-term care facilities.For adults 65 years and older who have not been immunized with PCV13 or PPSV23, administer PCV first and then give PPSV23 in 6 to 12 months; do not administer both during the same visit. For adults who received a dose of PPSV23 at age 65 or older, an additional dose is not indicated. Acid-Base Imbalances: Expected ABG Findings in a Client Who Has Renal Failure (RM AMS RN 10.0 Chp 45, Active Learning Template - System Disorder) - Metabolic Acidosis pH <7.35, HCO3 < Aneurysms: Postoperative Findings to Report to the Provider (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 38) - monitoring the arterial pressure, heart rhythm and hemodynamic finding. evidence of graft occlusion or rupture. monitor vs and circulation q 15 minutes. maintain head of bed below 45 degrees to prevent flexion of the graft.
- graft occlusion or rupture immediately (changes in pulse, coolness below graft), white or blue extremities or flanks, severe pain, abd. distention and decreased urine output. Gastrointestinal Diagnostic Procedures: Barium Swallow (Active Learning Template - Diagnostic Procedure, RM AMS RN 10.0 Chp 46, RN QSEN - Patient-centered Care) - Inform client to remain NPO after midnight pre procedure Assess client's understanding of bowel prep Barium enema schedule before procedure Assess for contraindication to bowel prep - > possible bowel perforation or obstruction, inflammatory disease
Instruct client ot monitor elimination of contrast and report retention (constipation) or diarrhea accompanied by weakness Discussed possible OTC for constipation Instruct client stool will be white for 24 to 72 hr until barium clears, report abdominal fullness, pain or delay in return to brown stool Respiratory Failure: Priority Findings of Guillain-Barre Syndrome (RN QSEN - Safety, Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 26) - Gullain-Barre Syndrome - > an autoimmune neuro condition where the immune system attacks the nerves in the peripheral nervous system and cranial nerves. Important to report symptoms within 2 weeks of starting for interventions to be effective Loss of muscle tone, parasthesia, absent reflexes, paralysis Amputations: Postoperative Care (RM AMS RN 10.0 Chp 69, Active Learning Template - Therapeutic Procedure) - Position extremity in dependent position Have client lie in prone position Monitor for signs of infection and non-healing incision Assess surgical site for bleeding, monitor vital signs frequently Palpate residual limb for warmth Compare pulse most proximal to incision with pulse in other extremity Administer antibiotics and change dressings as prescribed if open amputation was performed Record characteristics of drainage, such as amount, color and odor Endocrine Diagnostic Procedures: Priority Action Following a Pheochromocytoma Removal (RM AMS RN 10.0 Chp 76, Active Learning Template - System Disorder, RN QSEN - Safety) - Adrenalectomy: removing gland with the tumor
Loop (diuretics) and thiazide (hydrocholorthiazide) diuretics can cause hypokalemia, and potassium supplementation can be required Parkinson's Disease: Discharge Teaching About Carbidopa/Levodopa (Active Learning Template - Medication, RM AMS RN 10.0 Chp 7) - When given orally, medications such as levodopa are converted to dopamine in the brain, increasing dopamine levels in the basal ganglia Dopaminergics may be combined with cabidopa to decrease peripheral metabolism of levodopa, requiring a smaller dose to make the same amount available to the brain. Side effects are subsequently less Due to med tolerance and metabolism, the dosage, form of med, and administration times must be adjusted to avoid periods of poor mobility Nursing considerations: Monitor for the "wearing-off" phenomenon and dyskinesias (problems with movement), which can indicate the need to adjust the dosage or time of administration or the need for a medication holiday Cancer Disorders: Bone Marrow Harvesting (RM AMS RN 10.0 Chp 92, Active Learning Template - Therapeutic Procedure) - Expected findings:
- Large quantities of immature leukemic blast cells (confirms diagnosis)
- Typing of protein markers (to differentiate myeloid or lymphoid leukemia) Nursing actions: Administer pain medication as prescribed Apply pressure for 5 to 10 min, then a pressure dressing Monitor for bleeding and infection for 24 hr Cancer Treatment Options: Education Following Chemotherapy (Active Learning Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 91, RN QSEN - Safety) - Client Education: (ch 91)
- Prepare the client for extended treatment that will cause the lesion to weep, crust and erode
- Reassure the client that the appearance of the lesion will improve after treatment Ch 91 page 581 Instruct client about the administration of antiemetics and schedule them prior to meals Encourage the client to eat several small meals a day if better tolerated. Low-fat dry foods (Crackers, toast) and avoiding drinking liquids during meals can prevent nausea
- Suggest client select foods that are served cold and do not require cooking. Cooking food can emit odors that stimulate nausea
- Encourage consumption of high-protein, high-calorie, nutrient-dense foods. Use meal supplements as needed.
- Encourage the use of plastic eating utensils, sucking on hard candy, and avoiding red meats to prevent or reduce the sensation of metallic taste
- Teach the client to create a food diary to identify items that can trigger nausea Chronic Obstructive Pulmonary Disease: Priority Action for Dyspnea (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp
- (pg 130) - Position client to maximize ventilation (high-Fowler's) Other: Encourage effective coughing or suction to remove secretions Encourage deep breathing and use of an incentive spirometer Administer breathing treatments and meds Administer oxygen as prescribed Monitor for skin breakdown around the nose and mouth from the oxygen device Gastrointestinal Diagnostic Procedures: Using Fecal Occult Blood Testing to Screen for Colorectal Cancer (RM AMS RN 10.0 Chp 46, Active Learning Template - Diagnostic Procedure) - Nursing action:
Valvular Heart Disease: Discharge Teaching a Client Following a Mitral Valve Replacement (RN QSEN - Safety , RM AMS RN 10.0 Chp 33, Active Learning Template - Therapeutic Procedure) - - Stress the importance of taking prophylactic antibiotic before any invasive dental or respiratory procedure
- Notify doctor of 3lb gain in 1 day or 5 lb gain in one week
- Coodrinate planned rest periods
- Encourage client to follow the prescribed exercise program
- Encourage adherence to dietary restrictions (avoid alcohol and coffee)
- Teach energy conservation
- Open wounds need to be cleaned carefully and antibiotic ointment should be used
- Petechial rash or SOB should be reported to health care provider
- Avoid meds that have alcohol, ephedrine or epinephrine (dysrhythmias)
- Teach symptoms of HF; report to provider Diabetes Mellitus Management: Evaluating Understanding of Hypoglycemia Treatment (RM AMS RN 10.0 Chp 82, Active Learning Template - System Disorder) - Instruct the client who has hypoglycemia (glucose of 70 mg/dL or less) to take 15 to 20 g of a readily absorbable carbohydrate (4 to 6 oz of fruit juice or regular soft drink, 3 to 4 glucose tablets, 8 to 10 hard candies, or 1 tbsp of honey) and recheck blood glucose in 15 min. ☐ Repeat the administration of carbohydrates if not within normal limits, and recheck blood glucose in 15 min. ☐ If blood glucose is within normal limits, have a snack containing a carbohydrate and protein (if the next meal is more than 1 hr away). > Blood glucose increases approximately 40 mg/dL over 30 min following ingestion of 10 g of absorbable carbohydrate. ■ If the client is unconscious or unable to swallow, administer glucagon subcutaneous or IM (repeat in 10 min if still unconscious) and notify the provider.
■ In acute care, the nurse should administer 50% dextrose if IV access is available. Consciousness should occur within 20 min. ■ Once consciousness occurs and the client is able to swallow, have the client ingest oral carbohydrates. Electrocardiography and Dysrhythmia Monitoring: Pharmacologic Management of Symptomatic Bradycardia (RM AMS RN 10.0 Chp 28, Active Learning Template - System Disorder, RN QSEN - Safety) - Medication: atropine and isoprotenerol Electrical management: Pacemaker Hypertension: Dietary Teaching for a Client (RM AMS RN 10.0 Chp 36, Active Learning Template - System Disorder) - - Monitor for hyperkelmia with salt substitutes use
- Consume less than 2.3 g/day of sodium
- Consume a diet low in fat, saturated fat, and cholesterol
- Limit alcohol intake to 2 servings per day for men and 1 serving per day for women. A serving of alcohol is equivalent to 1.5 oz liquor, 5 oz wine, or 12 oz beer
- Dietary approaches to stop hypertension (DASH) are effective in the prevention and treatment of hypertension
- The DASH diets is high in fruits, veggies and low-fat dairy foods
- Avoid foods high in sodium and fat (trans and saturated fat)
- Consume foods rich in calcium and magnesium
- Client not taking a potassium-sparing med should increase potassium consumption Hyperthyroidism: Environmental Intervention (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 78) - - Promote a calm environment
- Reduce room temp
- Minimize the client's energy expenditure by assisting with activities as necessary and by encouraging the client to alternate periods of activity with rest
NG tube: gastric decompression
- No alcohol consumption
- No smoking
- Limit stress
- Pain mgmt
- Position for comfort (fetal, side-lying, head of the bed elevated, sitting up or leaning forward)
- Administer analgesics and other meds as prescribed
- Monitor blood glucose and provide insulin
- Monitor hydration status (orthostatic BP, I&O, lab values)
- Administer Iv fluids and electrolyte replacement as prescribed Peptic Ulcer Disease: Dietary Education (RM AMS RN 10.0 Chp 49, Active Learning Template - System Disorder, RN QSEN - Patient- centered Care) - Lying down after a meal slows the movement of food within intestines Limit the amount of fluid ingested at one time Eliminate liquids with meal, for 1 hr prior to and following meal Consume high protein, high fat, low fiber and low to moderate carb diet Avoid milk and sugars (sweets, fruit juice, sweetened fruit, milk shakes, honey, syrup, jelly) Consume small, frequent meals rather than large meals Pneumothorax, Hemothorax, and Flail Chest: Manifestations of Pulmonary Trauma (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 25) - Unequal chest expansion (unaffected side expands while affected side diminishes) Paradoxical chest wall movement (inward movement of segment during inspiration, outward movement of segment during expiration) Tachycardia Hypotension Dyspnea Cyanosis Anxiety Chest pain
Polycystic Kidney Disease, Acute Kidney Injury, and Chronic Kidney Disease: Evaluating Understanding of Nephrotic Syndrome (RM AMS RN 10.0 Chp 59, Active Learning Template - System Disorder) - - Instruct the client to monitor the daily intake of carbs, proteins, sodium and potassium, according to the provider's prescription
- Instruct the client to monitor fluid intake according to fluid restriction prescribed by the provider
- Instruct the client to avoid antacids containing mag
- Encourage client to take rest periods from activity
- Educate the client who is receiving hemodialysis or peritoneal dialysis on an outpatient basis
- Educate the client on how to measure BP and weigh at home
- Encourage client to ask questions and discuss fears
- Encourage the client to diet, exercise and take meds as prescribed
- Advise client to notify MD if she sees skin breakdown After discharge:
- Neprhology services is indicated if the client is to receive outpatient dialysis Refer the client to a community support group relating to the disease
- Consult nutritional services for the client's dietary needs
- Refer the client to a smoking-cessation support group and counseling if needed Skin Disorders: Providing Teaching About Contact Dermatitis (RN QSEN - Patient-centered Care, Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 74) - Caused by exposure to allergen, chemical or mechanical irritation Rash is well-demarcated Distribution varies depending upon the cause and the exposure to the allergen
