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VATI RN COMPREHENSIVE PREDICTOR FOCUSED REVIEW, Exams of Nursing

Chamberlain College of NursingNursing

VATI RN COMPREHENSIVE PREDICTOR FOCUSED REVIEW VATI RN COMPREHENSIVE PREDICTOR FOCUSED REVIEW VATI RN COMPREHENSIVE PREDICTOR FOCUSED REVIEW

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VATI RN COMPREHENSIVE PREDICTOR FOCUSED REVIEW
❖
Management of Care – (9)
➢
Advance Directives – (1)
▪
Legal Responsibilities: Purpose of a Living Will (RM FUND 9.0 Chp 4)
• A living will is a legal document that expresses the client’s wishes regarding
medical treatment in the event the client becomes incapacitated and is facing end-
of-life issues. Most state laws include provisions that protect health care providers
who follow a living will from liability.
➢
Assignment, Delegation and Supervision – (2)
▪
Delegation and Supervision: Delegating Tasks to an Assistive Personnel (RM FUND
9.0 Chp 6)
• Examples of tasks nurses may delegate to Aps (provided the facility’s policy and
state’s practice guidelines permit)
◆
Activities of daily living (ADLs) – bathing, grooming, dressing, toileting,
ambulating, feeding (without swallowing precautions), positioning
◆
Routine tasks – bed making, specimen collection, intake and output, vital
signs (for stable clients)
▪
Managing Client Care: Delegation Strategy for Effective Task Management (RM
Leadership 7.0 Chp 1)
• Consideration for selection of an appropriate delegate include the following:
education, training, and experience; knowledge and skill to perform the task; level
of critical thinking required to complete the task; ability to communicate with
others as it pertains to the task; demonstrated competence; the delegatee’s culture;
agency policies and procedures and licensing legislation (state nurse practice acts)
➢
Case Management – (1)
▪
Cardiovascular Disorders: Tetralogy of Fallot (RM NCC RN 10.0 Chp 20)
• Tetralogy of Fallot – four defects that result in mixed blood flow: Pulmonary
stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
◆
Cyanosis at birth: progressive cyanosis over the first year of life. Systolic
murmur. Episodes of acute cyanosis and hypoxia (blue or “Tet” spells)
• Surgical procedures – shunt placement until able to undergo primary repair;
complete repair within the first year of life
➢
Collaboration with Interdisciplinary Team – (1)
▪
Communicable Diseases, Disasters, and Bioterrorism: CDC Reportable Diagnoses
(RM CH RN 7.0 Chp 6)
• Anthrax. Botulism. Cholera. Congenital rubella syndrome (CRS). Diphtheria.
Giardiasis. Gonorrhea. Hepatitis A, B, C. HIV infection. Influenza-associated
pediatric mortality. Legionellosis/Legionnaires’ disease. Lyme disease. Malaria.
Meningococcal disease. Mumps. Pertussis (whooping cough). Poliomyelitis,
paralytic. Poliovirus infection, nonparalytic. Rabies (human or animal). Rubella
(German measles). Salmonellosis. Severe acute respiratory syndrome-associated
coronavirus disease (SARS-CoV). Shigellosis. Smallpox. Syphilis. Tetanus/C.
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VATI RN COMPREHENSIVE PREDICTOR FOCUSED REVIEW

❖ Management of Care – (9) ➢ Advance Directives – (1) ▪ Legal Responsibilities: Purpose of a Living Will (RM FUND 9.0 Chp 4)

  • A living will is a legal document that expresses the client’s wishes regarding medical treatment in the event the client becomes incapacitated and is facing end- of-life issues. Most state laws include provisions that protect health care providers who follow a living will from liability. ➢ Assignment, Delegation and Supervision – (2) ▪ Delegation and Supervision: Delegating Tasks to an Assistive Personnel (RM FUND 9.0 Chp 6)
  • Examples of tasks nurses may delegate to Aps (provided the facility’s policy and state’s practice guidelines permit) ◆ Activities of daily living (ADLs) – bathing, grooming, dressing, toileting, ambulating, feeding (without swallowing precautions), positioning ◆ Routine tasks – bed making, specimen collection, intake and output, vital signs (for stable clients) ▪ Managing Client Care: Delegation Strategy for Effective Task Management (RM Leadership 7.0 Chp 1)
  • Consideration for selection of an appropriate delegate include the following: education, training, and experience; knowledge and skill to perform the task; level of critical thinking required to complete the task; ability to communicate with others as it pertains to the task; demonstrated competence; the delegatee’s culture; agency policies and procedures and licensing legislation (state nurse practice acts) ➢ Case Management – (1) ▪ Cardiovascular Disorders: Tetralogy of Fallot (RM NCC RN 10.0 Chp 20)
  • Tetralogy of Fallot – four defects that result in mixed blood flow: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy ◆ Cyanosis at birth: progressive cyanosis over the first year of life. Systolic murmur. Episodes of acute cyanosis and hypoxia (blue or “Tet” spells)
  • Surgical procedures – shunt placement until able to undergo primary repair; complete repair within the first year of life ➢ Collaboration with Interdisciplinary Team – (1) ▪ Communicable Diseases, Disasters, and Bioterrorism: CDC Reportable Diagnoses (RM CH RN 7.0 Chp 6)
  • Anthrax. Botulism. Cholera. Congenital rubella syndrome (CRS). Diphtheria. Giardiasis. Gonorrhea. Hepatitis A, B, C. HIV infection. Influenza-associated pediatric mortality. Legionellosis/Legionnaires’ disease. Lyme disease. Malaria. Meningococcal disease. Mumps. Pertussis (whooping cough). Poliomyelitis, paralytic. Poliovirus infection, nonparalytic. Rabies (human or animal). Rubella (German measles). Salmonellosis. Severe acute respiratory syndrome-associated coronavirus disease (SARS-CoV). Shigellosis. Smallpox. Syphilis. Tetanus/C.

tetani. Toxic shock syndrome (TSS) (other than Streptococcal). Tuberculosis

▪ Professional Responsibilities: Demonstration of Veracity (RM Leadership 7.0 Chp 3)

  • Veracity: the nurse’s duty to tell the truth ➢ Legal Rights and Responsibilities – (1) ▪ Professional Responsibilities: Rights of Clients (RM Leadership 7.0 Chp 3)
  • Client rights are the legal guarantees that clients have with regard to their health care ◆ Clients using the services of a health care institution retain their rights as individuals and citizens of the United States. The America Hospital Association (AHA) identifies client rights in health care settings in the Patient Care Partnership (www.aha.org) ◆ Residents in nursing facilities that participate in Medicare programs similarly retain resident rights under statutes that govern the operation of these facilities
  • Nurse are accountable for protecting the rights of clients. Situations that require particular attention include informed consent, refusal of treatment, advance directives, confidentiality, and information security. ❖ Safety and Infection Control – (5) ➢ Accident/Error/Injury Prevention – (2) ▪ Medications Affecting Urinary Output: Indications for the Use of a Diuretic (RM Pharm RN 7.0 Chp 19)
  • High-ceiling loop diuretics work in the ascending limb of loop of Henle – block reabsorption of sodium and chloride and prevent reabsorption of water. Causes extensive diuresis even with severe renal impairment
  • They are used when there is an emergent need for rapid mobilization of fluid – pulmonary edema caused by heart failure; conditions not responsive to other diuretics, such as edema caused by liver, cardiac, or kidney disease; or hypertension ◆ Unlabeled use – hypercalcemia ▪ Seizures: Maintaining Seizure Precautions (RM NCC RN 10.0 Chp 13)
  • Seizure precautions for any child at risk – pad side rails of bed, crib, and wheelchair; keep bed free of objects that could cause injury; have suction and oxygen equipment available ➢ Handling Hazardous and Infectious Materials – (1) ▪ Cancer Treatment Options: Implanted Internal Radiation Device (RM AMS RN 10. Chp 91)
  • Brachytherapy describes internal radiation that is placed close to the target tissue. This is done via placement in a body orifice (vagina) or body cavity (abdomen) or delivered via IV such as with radionuclide iodine, which is absorbed by the thyroid ◆ Brachytherapy provides radiation to the tumor and a limited amount to surrounding normal tissues. Waste products are radioactive until the Isotope has been completely eliminated from the body. Waste products should not be touched by anyone.
  • Nursing Considerations

◆ Place the client in a private room away from other clients when possible. Keep door closed as much as possible. Place a sign on the door warning of the radiation source. Wear a dosimeter film badge that records personal amount of radiation exposure. Limit visitors to 30-min visits, and have visitors maintain a distance of 6 feet from the source. Visitors and health care personnel who are pregnant or under the age of 18 should not come into contact with the client or radiation source. Weal a lead apron while providing care keeping the front of the apron facing the source of radiation. Keep a lead container in the client’s room if the delivery method could allow spontaneous loss of radioactive material. Tongs are available for placing radioactive material into this container. Follow protocol for proper removal of dressings and bed linens from the room.

  • Client Education ◆ Inform the client of the need to remain in an indicated position to prevent dislodgement of the radiation implant. Instruct the client to call the nurse for assistance with elimination. Instruct the client and family about radiation precautions needed in health care and home environments. ➢ Standard Precautions/Transmission-Based Precautions/Surgical Asepsis – (2) ▪ Acute Neurological Disorders: Priority Intervention for Meningitis (RM NCC RN 10.0 Chp 12)
  • The presence of petechiae or a purpuric-type rash requires immediate medical attention
  • Isolate the client as soon as meningitis is suspected, and maintain droplet precautions per facility protocol – droplet precautions require a private room or a room with clients who have the same infectious disease, ensuring that each client has his or her own designated equipment. Providers and visitors should wear a mask. Maintain respiratory isolation for a minimum of 24 hr after initiation of antibiotic therapy
  • Monitor vital signs, urine output, fluid status, pain level, and neurologic status
  • For newborns and infants, monitor head circumference and fontanels for presence of or changes in bulging
  • Correct fluid volume deficits and then restrict fluids until no evidence of increased ICP and serum sodium levels are within the expected range
  • Maintain NPO status if the client has a decreased level of consciousness. As the client’s condition improves, advance to clear liquids and then a diet the client can tolerate
  • Decrease environmental stimuli – provide a quiet environment; minimize exposure to bright light (natural and electric)
  • Provide comfort measures – keep the room cool; position the client without a pillow, and slightly elevate the head of the bed. The client can also be positioned side-lying to reduce neck discomfort
  • Maintain safety (keep the bed in a low position, implement seizure precautions)
  • Keep the family informed of the client’s condition

shape of a belt buckle or other object. Assess for burns. Burns covering “glove” or “stocking” areas of the hands or feet can indicate forced immersion into boiling water. Small, round burns can be from cigarettes. Assess for fractures with unusual features, such as forearm spiral fractures, which could be a result of twisting the extremity forcefully. The presence of multiple fractures is suspicious. Assess for human bite marks. Assess for head injuries, level of consciousness, equal and reactive pupils, and nausea or vomiting. ➢ Mental Health Concepts – (2) ▪ Anxiety Disorders: Expected Findings for a Client who has Social Anxiety Disorder (RM MH RN 10.0 Chp 11)

  • Social anxiety disorder (social phobia) – the client experiences excessive fear of social or performance situations ◆ The client reports difficulty performing or speaking in front of others or participating in social situations due to an excessive fear of embarrassment or poor performance ◆ The client might report physical manifestations (actual or factitious) in an attempt to avoid the social situation or need to perform ▪ Personality Disorders: Antisocial Personality Manifestations (RM MH RN 10.0 Chp
  • Antisocial – characterized by disregard for others with exploitation, lack of empathy, repeated unlawful actions, deceit, and failure to accept personal responsibility; sense of entitlement, manipulative, impulsive, and seductive, nonadherence to traditional morals and values; verbally charming and engaging ➢ Support Systems – (1) ▪ Neurocognitive Disorders: Planning Care for a Stage 2 Alzheimer’s Disease (RM MH RN 10.0 Chp 17)
  • Stage 2: Moderate ◆ Forgetting events of one’s own history. Difficulty performing tasks that require planning and organizing (paying bills, managing money). Difficulty with complex mental arithmetic. Personality and behavioral changes: appearing withdrawn or subdued, especially in social or mentally challenging situations; compulsive, repetitive actions. Changes in sleep patterns. Can wander and get lost. Can be incontinent. Clinical findings that are noticeable to others.
  • Nursing Care ◆ Perform self-assessment regarding possible feelings of frustration, anger, or fear when performing daily care for clients who have progressive cognitive decline. Nursing interventions are focused on protecting the client from injury, as well as promoting client dignity and quality of life. Provide for a safe and therapeutic environment – assess for potential injury, such as falls or wandering. Assign the client to a room close to the nurses’ station for close observation. Provide a room with a low level of visual and auditory stimuli. Provide for a well-lit environment, minimizing contrasts and shadows. Have

the client sit in a room with windows to help with time orientation. Have the client wear an identification bracelet. Use monitors and bed alarm devices as needed. Use restraints only as an intervention of last resort. Use caution when administering medications PRN for agitation or anxiety. Assess the client’s risk for injury and ensure safety in the physical environment, such as a lowered bed. ◆ Cognitive support – provide compensatory memory aids, such as clocks, calendars, photographs, memorabilia, seasonal decorations, and familiar objects. Reorient as necessary. Keep a consistent daily routine. Maintain consistent caregivers. Cover or remove mirrors to decrease fear and agitation. ◆ Physical needs – monitor neurological status. Identify disturbances in physiologic status which can contribute to the cause of delirium. Assess skin integrity which can be compromised due to poor nutrition, bed rest or incontinence. Monitor vital signs. Tachycardia, elevated blood pressure, sweating, dilated pupils can be associated with delirium. Implement measures to promote sleep. Monitor the client’s level of comfort and assess for nonverbal indications of discomfort. Provider eyeglasses and assistive hearing devices as needed. Ensure adequate food and fluid intake. Underlying causes of delirium can result in electrolyte imbalance. ◆ Communication – communicate in a calm, reassuring tone. Speak in positively worded phrases. Do not argue or question hallucinations or delusions. Reinforce reality. Reinforce orientation t time, place, and person. Introduce self to client with each new contact. Establish eye contact and use short, simple sentences when speaking to the client. Focus on one item of information at a time. Encourage reminiscence about happy times. Talk about familiar things. Break instructions and activities into short timeframes. Limit the number of choices when dressing or eating. Minimize the need for decision-making and abstract thinking to avoid frustration. Avoid confrontation. Approach slowly and from the front. Address the client by name. Encourage family visitation as appropriate. ❖ Basic Care and Comfort – (3) ➢ Assistive Devices – (1) ▪ Sensory Perception: Speaking to a Client Who Has a Hearing Impairment (RM FUND 9.0 Chp 45)

  • For clients who have hearing loss – sit and face the clients. Avoid covering your mouth while speaking. Encourage the use of hearing devised. Speak slowly and clearly. Do not shout. Try lowering vocal pitch before increasing volume. Use brief sentences with simple words. Write down what clients do not understand. Minimize background noise. Ask for a sign-language interpreter if necessary. Do not shout. ➢ Mobility/Immobility – (1) ▪ Musculoskeletal Trauma: Skeletal Traction (RM AMS RN 10.0 Chp 71)

▪ Medications for Psychotic Disorders: Screening for Extrapyramidal Adverse Effects (RM MH RN 10.0 Chp 24)

  • Acute dystonia – severe spasm of the tongue, neck, face, and back. Crisis situation that requires rapid treatment ◆ Nursing considerations – begin to monitor for acute dystonia anywhere between 1-5 days after administration of first dose. Treat with an antiparkinsonian agents such as benztropine. IM or IV administration diphenhydramine can also be beneficial. Stay with the client and monitor the airway until spasms subside (usually 5-15 min)
  • Pseudoparkinsonism – bradykinesia, rigidity, shuffling gait, drooling, tremors ◆ Nursing considerations – observe for pseudoparkinsonism for the first month after the initiation of therapy. Can occur in as little as 5 hr following the first dose. Treat with an antiparkisonian agent, such as benztropine or trihexyphenidyl. Implement interventions to reduce the risk for falling.
  • Akathisia – inability to sit or stand still. Continual pacing and agitation ◆ Nursing considerations – observe for akathisia for the first 2 months after the initiation of treatment. Can occur in as little as 2 hr following the first dose. Manage with antiparkinsonian agents, beta blockers, or lorazepam/diazepam. Monitor for increased risk for suicide in clients who have severe akathisia
  • Tardive dyskinesia (TD) – late EPS, which can require months to years of medication therapy for TD to develop. Involuntary movements of the tongue and face, such as lip smacking and tongue fasciculations. Involuntary movements of the arms, legs, and trunk ◆ Nursing considerations – evaluate the client every 3 months, if TD appears, dosage should be lowered, or the client should be switched to another type of antipsychotic agent. Once TD develops, it usually dose not decrease, even with discontinuation of the medication. There is not a treatment for TD. Teach client that purposeful muscle movement helps to control the involuntary TD.
  • Neuroendocrine effects – gynecomastia, weight gain, menstrual irregularities ◆ Nursing considerations – monitor weight. Some clients gain 100 lb or more. Advise the client to observe for these manifestations and to notify the provider if they occur.
  • Neuroleptic malignant syndrome – sudden high fever, blood pressure fluctuations, diaphoresis, tachycardia, muscle rigidity, drooling, decreased level of consciousness, coma, tachypnea ◆ Nursing considerations – this life-threatening medical emergency can occur within the first week of treatment or any time thereafter. Stop antipsychotic medication. Monitor vital signs. Apply cooling blankets. Administer antipyretics. Increase the client’s fluid intake. Administer dantrolene or bromocriptine to induce muscle relaxation. Administer medication as prescribed to treat arrhythmias. Assist with immediate transfer to an ICU.
  • Orthostatic hypotension

◆ Nursing considerations – the client should develop tolerance in 1-2 weeks. Monitor blood pressure and heart rate for orthostatic changes. Hold medication until the provider is notified if systolic blood pressure is less than 80 mm Hg. Instruct clients about the indications of orthostatic hypotension (lightheadedness, dizziness). If these occur, advise the client to sit or lie down. Orthostatic hypotension can be minimized by getting up or changing positions slowly. Encourage the client to increase fluid intake to maintain hydration.

  • Sedation ◆ Nursing considerations – inform the client that effects should diminish after about 1 week. Instruct the client to take the medication at bedtime to avoid daytime sleepiness. Advise the client not to drive until sedation has subsided.
  • Seizures – indications – greatest risk in clients who have an existing seizure disorder ◆ Nursing considerations – advise the client to report seizure activity to the provider. An increase in antiseizure medication can be necessary
  • Severe dysrhythmias ◆ Nursing considerations – obtain baseline ECG and potassium level prior to treatment, and periodically throughout the treatment period. Avoid concurrent use with other medications that prolong QT interval
  • Sexual dysfunction ◆ Nursing considerations – advise the client of possible adverse effects. Encourage that the client report effects to the provider. The client can need dosage lowered or be switched to a high-potency agent
  • Skin effects – photosensitivity that can result in severe sunburn. Contact dermatitis from handling medications ◆ Nursing considerations – Advise clients to avoid excessive exposure to sunlight, to use sunscreen, and to wear protective clothing. Advise clients to avoid direct contact with the education
  • Liver impairment ◆ Nursing considerations – assess baseline liver function, and monitor periodically. Educate clients to observe for indications (anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice) and to notify the provider ➢ Central Venous Access Devices – (1) ▪ Cardiovascular Diagnostic and Therapeutic Procedures: Care of the Nontunneled Percutaneous Central Venous Catheter (RM AMS RN 10.0 Chp 27)
  • Description 18 - 25 cm (7- 10 in) in length with one to five lumens. Length of use: short-term use only. Insertion location: subclavian vein, jugular vein, tip in the distal third of the superior vena cava. Indications: administration of blood, long- term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition. ➢ Expected Actions/Outcomes – (1) ▪ Parkinson's Disease: Effects of Levodopa (RM AMS RN 10.0 Chp 7)

▪ Brain Stimulation Therapies: Client Education About Electroconvulsive Therapy (RM MH RN 10.0 Chp 10)

  • Indication ◆ Major depressive disorder – clients whose manifestations are not responsive to pharmacological treatment. Clients from whom the risks of other treatments outweigh the risks of ECT, such as a client who is in her first trimester of pregnancy. Clients who are suicidal or homicidal and for whom there is a need for rapid therapeutic response. Clients who are experiencing psychotic manifestations ◆ Schizophrenia spectrum disorders – clients who have schizophrenia with catatonic manifestations. Clients who have schizoaffective disorder. Clients who are pregnant and have a schizophrenia spectrum disorder, therefore having an increased risk for adverse effects from medication therapy ◆ Acute manic episodes – clients who have bipolar disorder with rapid cycling (four or more episodes of acute mania within 1 year). Clients who are unresponsive to treatment with lithium and antipsychotic medications.
  • Considerations – procedural care ◆ The typical course of ECT treatment is two to three times a week for a total of six to 12 treatments. The provider obtains informed consent. If ECT is involuntary, the provider may obtain consent from the next of kin or a court order. ◆ Medication Management ➢ Thirty minutes prior to the beginning of the procedure, an IM injection of atropine sulfate or glycopyrrolate is administered to decrease secretions that could cause aspiration and to counteract any vagal stimulation effects, such as bradycardia ➢ At the time of the procedure, an anesthesia provider administers a short- acting anesthetic, such as methohexital or propofol, via IV bolus ➢ A muscle relaxant, such succinylcholine, is then administered to paralyze the client’s muscles during the seizure activity, which decreases the risk for injury ➢ Severe hypertension should be controlled because a short period of hypertension occurs immediately after the ECT procedure ➢ Any cardiac conditions, such as dysrhythmias or hypertension, should be monitored and treated before the procedure ➢ The nurse monitors vital signs and mental status before and after the ECT procedure ➢ The nurse assess the client’s and family’s understanding and knowledge of the procedure and provides teaching as necessary. Many clients and family have misconceptions about ECT due to media portrayals of the procedure. Due to the use of anesthesia and muscle relaxants, the tonic-clonic seizure activity associated with the procedure in the past is no longer an effect of the treatment.

➢ An IV line is inserted and maintained until full recovery. Electrodes are applied to the scalp for electroencephalogram (EEG) monitoring. The client receives 100% oxygen during and after ECT until the return of spontaneous respirations. Ongoing cardiac monitoring is provided, including blood pressure, electrocardiogram (ECG), and oxygen saturation. Clients are expected to become alert about 15 min following ECT. ▪ Cystic Fibrosis: Client Teaching about Pancrelipase (RM NCC RN 10.0 Chp 19)

  • Pancrelipase treats pancreatic insufficiency associated with cystic fibrosis ◆ Nursing considerations – monitor stools for adequate dosing (1-2 stools/day). Administer capsules with all meals and snacks. Client can swallow or sprinkle capsules on food. Increase dosage of enzymes when eating high-fat foods. ▪ Electrolyte Imbalances: Safe Potassium Administration (RM AMS RN 10.0 Chp 44)
  • IV potassium supplementation – never administer by IV push (high risk of cardiac arrest). The maximum recommended rate is 10 mEq/hr. ❖ Reduction of Risk Potential – (6) ➢ Potential for Complications of Diagnostic Tests/Treatments/Procedures – (2) ▪ Cardiovascular Diagnostic and Therapeutic Procedures: Priority Intervention Postangiography (RM AMS RN 10.0 Chp 27)
  • Nursing Actions – assess vital signs every 15 min x 4, every 30 min x 2, every hour x 4, and then every 4 hr (Follow facility protocol). Assess the groin site at the same intervals for: bleeding and hematoma formation. Thrombosis (Document pedal pulse, color, temperature). Maintain bed rest in supine position with extremity straight for prescribed time (a vascular closure device can be used to hasten hemostasis following catheter removal. Older adult clients can have arthritis, which can make lying in bed for 4-6 hr after the procedure painful. The provider can prescribe medication). Conduct continuous cardiac monitoring for dysrhythmias. (Reperfusion following angioplasty can cause dysrhythmias). Administer antiplatelet or thrombolytic agents as prescribed to prevent clot formation and restenosis (Aspirin, Clopidogrel, ticlopidine, Heparin, Low molecular weight heparin [enoxaparin], GP IIb/IIa inhibitors, such as eptifibatide). Administer anxiolytics and analgesics as needed. Monitor urine output and administer IV fluids for hydration (Contrast media acts as an osmotic diuretic). Perform/assist with sheath removal from vessel (Apply pressure to arterial/venous sites for the prescribed period of time [varies depending upon the method used for vessel closure], observe for vagal response [hypotension, bradycardia] from compression of nerves, apply pressure dressing)
  • Client education – instruct the client to do the following (leave the dressing in place for the first 24 hr following discharge; avoid strenuous exercise for the prescribed period of time; immediately report bleeding from the insertion site, chest pain, shortness of breath, and changes in the color or temperature of the extremity; restrict lifting to less than 10 lb (4.5 kg) for the prescribed period of time). Clients who have stent placement will receive anticoagulation therapy for

◆ Client education – encourage adults 40 or older to have an annual examination, including a measurement of IOP ➢ Potential for Complications from Surgical Procedures and Health Alterations – (1) ▪ Pituitary Disorders: Clinical Findings of Diabetes Insipidus (RM AMS RN 10.0 Chp

  • Polyuria (abrupt onset of excessive urination, urinary output of 4 - 30 L/day of dilute urine); failure of the renal tubules to collect and reabsorb water. Polydipsia (excessive thirst, consumption of 2 - 20 L/day). Nocturia. Fatigue. Dehydration, as evidenced by extreme thirst, weight loss, muscle weakness, headache, constipation, and dizziness.
  • Physical assessment findings – sunken eyes, tachycardia, hypotension, loos or absence of skin turgor, dry mucous membranes, weak, poor peripheral pulses, decreased cognition ➢ System Specific Assessments – (1) ▪ Head Injury: Assessing Decerebrate Posturing (RM AMS RN 10.0 Chp 14)
  • An abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward. The muscles are tightened and held rigidly. This type of posturing usually means there has been severe damage to the brain. ➢ Therapeutic Procedures – (2 ) ▪ Cancer Disorders: Client Discharge Education for Ileal Conduit (RM AMS RN 10. Chp 92)
  • Client Education – instruct the client to self-catheterize and plan procedure at timed intervals since there is no sensation of bladder fullness (neobladder, continent pouch). Teach the client to monitor peristomal skin for redness, excoriation, or infection (ileal conduit, continent pouch). ◆ Ureter diversion – ileum ◆ Portal of exit – abdominal stoma ◆ Urinary elimination – continuous drainage into external pouch ▪ Skin Infections and Infestations: Home Care of Pediculosis Capitis (RM NCC RN 10.0 chp 30)
  • Client education – teach the child and parents about medications; to avoid home remedies, as it can worsen infection; about correct laundering of potentially infected clothing, bedding; teach the parent to bag items that cannot be laundered into tightly sealed bag for 14 days; teach the parents to boil combs, brushes and hair accessories for 10 min or soak in lice-killing products for 1 hr; discourage sharing of personal items ❖ Physiological Adaptations – (5) ➢ Alterations in Body Systems – (1) ▪ Pituitary Disorders: Client Comfort (RM AMS RN 10.0 Chp 77)
  • Postoperative – monitor neurological status; drainage to mustache dressing (drip pad). Notify provider of the presence of glucose I the drainage (indication of leakage of cerebrospinal fluid). Maintain the client in a high-Fowler’s position.

Monitor fluid balance, especially greater output than intake (DI). Encourage deep breathing exercises, but limit coughing as this increases intracranial pressure and can cause a leak of cerebrospinal fluid (CSF). Assess for manifestations of meningitis. Administer replacement hormones. ➢ Hemodynamics – (1) ▪ Electrocardiography and Dysrhythmia Monitoring: Identifying the Need for Anticoagulation Therapy (RM AMS RN 10.0 Chp 28)

  • Clients who have atrial fibrillation of unknown duration must receive adequate anticoagulation for 4 - 6 weeks prior to cardioversion therapy to prevent dislodgement of thrombi into the bloodstream ➢ Medical Emergencies – (1) ▪ Emergency Nursing Principles and Management: Priority Assessment (RM AMS RN 10.0 Chp 2)
  • ABCDE Principle ◆ A = airway/cervical spine ◆ B = breathing ◆ C = circulation ◆ D = disability ◆ E = exposure ▪ Head Injury: Identifying Indications of a Skull Fracture (RM AMS RN 10.0 Chp 14)
  • Skull fractures can occur following forceful head injury. The brain might be damaged as a result. The client can have localized pain at the site of the fracture, and swelling can occur. The nurse should be alert for drainage from the ears or eyes (cerebral spinal fluid [CSF]) ➢ Unexpected Response to Therapies – (2) ▪ Assessment and Management of Newborn Complications: Neonatal Abstinence Syndrome (RM MN RN 10.0 Chp 27)
  • Long-term complications – feeding problems; central nervous system dysfunction (cognitive impairment, cerebral palsy); attention deficit disorder; language abnormalities; microcephaly; delayed growth and development; poor maternal- newborn bonding
  • Expected findings – monitor the neonate for abstinence syndrome (withdrawal) and increased wakefulness using the neonatal abstinence scoring system that assesses for and score the following: ◆ CNS: High-pitched, shrill cry; incessant crying; irritability; tremors; hyperactivity with an increased Moro reflex; increased deep-tendon reflexes; increased muscle tone; disturbed sleep pattern; hypertonicity; convulsions ◆ Metabolic, vasomotor, and respiratory findings: Nasal congestion with flaring, frequent yawning, skin mottling, retractions, apnea, tachypnea greater than 60/min, sweating, temperature greater than 37.2° C (99°F) ◆ Gastrointestinal: Poor feeding; regurgitation (projectile vomiting); diarrhea; excessive, uncoordinated, constant sucking ◆ OPIATE WITHDRAWAL: Manifestations of neonatal abstinence syndrome