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Comprehensive Nursing Care: A
Multifaceted Approach
Comprehensive ATI NCLEX Predictor Study
Notes
Pain: Flank Pain
Flank pain can indicate issues with the kidney or ureter, such as kidney stones in the ureter or bladder. If the pain radiates, it may be a sign of stones in the ureter or bladder.
Performing Ear Irrigation
Use a sterile technique. Use warm medications. Pull up and back on the ear. Tilt the head toward the affected ear.
Thrombolytic Therapy (Stroke)
Reteplase recombinant (rTPA - clot buster) is administered within 4. hours of initial stroke symptoms.
Tracheostomy Care
Change the dressing as needed. Clean the inner cannula with 1/2 hydrogen peroxide. Secure the tracheostomy tube with a square knot.
Head Injury (Changes in Level of Consciousness)
Monitor the length of time the client is unconscious and their Glasgow Coma Scale (GCS) score.
General Anesthesia (Post-Op)
Perform a full body assessment, including the ABCs (airway, breathing, circulation). Monitor vital signs every 15 minutes. Place the client in a lateral position if they are unresponsive or unconscious, and monitor their level of consciousness. Monitor fluid and electrolyte balance.
Renal Calculi (Kidney Stones)
Superficial burns are painful, pink or red, with mild edema, and heal within 3-6 days. They involve damage to the epidermis.
Dialysis (Reporting Unexpected Findings)
Monitor for a temperature of 100 degrees, decreased blood pressure, bleeding, fluid imbalance (1 L of fluid = 1 Kg), clotting, headache, nausea, and disequilibrium syndrome (rapid decrease in BUN and fluid volume). Also monitor for anemia, peritonitis, increased blood glucose, and increased cholesterol.
Pacemaker Complications
Potential complications include infection, hematoma, pneumothorax, hemothorax, arrhythmias, and pacemaker spikes before the P or QRS wave. Increased magnesium (Mg) levels above 1.3 mg/dL can cause hiccups and muscle twitching.
Magnesium (Mg) Sulfate
Foods high in magnesium include dairy and dark leafy green vegetables. Decreased magnesium can lead to hyperactive deep tendon reflexes, paresthesias, muscle tetany, positive Chvostek's and Trousseau's signs, hypoactive bowels, constipation, abdominal distension, and paralytic ileus.
Total Parenteral Nutrition (TPN) Administration
TPN is a method of feeding that bypasses the gastrointestinal tract, providing most of the body's nutritional needs through intravenous fluids. TPN is used when a person cannot or should not receive feedings or fluids by mouth, such as in chronic pain, peritonitis, burns, or infection. No more than 10% of the total TPN volume should be administered hourly, and the rate can be increased for body adjustment. Monitor for hyperglycemia, hypoglycemia, vitamin deficiencies, air embolism, and fluid imbalances.
Wound Culture Specimen Collection
Collect the specimen using a sterile field and press or rotate the swab over the wound surface, focusing on the center of the wound and any drainage.
Ensure the client voids before the procedure.
Bariatric Surgery
Clients undergoing bariatric surgery should be positioned in a semi- Fowler's position, consume 6 small meals per day, and consume liquid or pureed food for the first 6 weeks (not to exceed 1 cup). Provide vitamin and mineral supplements, and ensure the client consumes 2 servings of protein daily.
Ostomy Care
Advise the client to avoid odorous and gas-producing foods, such as dark green vegetables, dairy, fish, eggs, beans, and corn. Recommend the client consume yogurt to help reduce gas. Avoid high-fiber foods for the first 2 months and encourage increased fluid intake.
Dumping Syndrome
Dumping syndrome can occur within 15 minutes of eating in clients who have undergone bariatric surgery. Symptoms include cramps, diarrhea, tachycardia, dizziness, fatigue, and hypoglycemia. Interventions include consuming small, frequent meals and drinking liquids 1 hour before or after meals.
Parkinson's Disease
Parkinson's disease is characterized by tremor, muscle rigidity, bradykinesia (slowness of movement), and postural instability. The disease progresses through 5 stages, with the final stage resulting in an inability to stand or walk and the need for full care.
Assault vs. Battery
Assault is a threat, while battery is the actual touching of another person.
Hypoglycemia Symptoms
Symptoms of hypoglycemia include shakiness, confusion, sweating, tachycardia, diaphoresis, palpitations, headache, lack of coordination, blurred vision, seizures, and coma.
Oral Hypoglycemic Agents
Oral hypoglycemic agents, such as glipizide, chlorpropamide, glyburide, and metformin, promote insulin release from the pancreas in clients with type 2 diabetes.
Glucagon is the medication used to treat insulin overdose.
Radiation Adverse Effects
Adverse effects of radiation therapy include skin changes, hair loss, and debilitating fatigue. Clients receiving radiation therapy should have 30-minute visits, maintain a distance of 6 feet from others, and be placed in a private room.
Infection Control in the Client's Home
Advise the client to maintain good hygiene, avoid crowded areas, avoid raw foods (vegetables and meats), avoid cleaning litter boxes, and clean the home.
Client Evacuation in Response to Fire
In the event of a fire, the priority is to evacuate the greatest number of people for the greatest good.
Seclusion
The maximum time for seclusion is 4 hours for clients 18 years and older, 2 hours for clients 9-17 years old, and 1 hour for clients 8 years and younger.
Conduct Disorders
Characteristics of conduct disorders include lack of remorse, bullying, threatening, low self-esteem, temper tantrums, physical cruelty, property destruction, truancy, and shoplifting.
Manic Phase (Bipolar Disorder)
The manic phase of bipolar disorder is characterized by an elevated mood, irritability, euphoria, agitation, restlessness, increased talking, flight of ideas, grandiose self-view, impulsivity, and poor judgment.
Personality Disorders
Paranoid personality disorder involves distrust and suspiciousness. Schizoid personality disorder involves emotional detachment and disinterest in relationships. Schizotypal personality disorder involves odd beliefs, eccentric appearance, magical thinking, and perceptual distortions. Antisocial personality disorder involves disregard for others, lack of empathy, unlawful behavior, and failure to accept responsibility.
Allergic Response Management
For mild rashes or hives, administer Benadryl. For anaphylaxis, treat with epinephrine, bronchodilators, and antihistamines, and provide respiratory support.
Losartan (Angiotensin II Receptor Blocker)
Losartan is an antihypertensive medication used for hypertension and kidney disease. Side effects include angioedema, hypotension, and dizziness.
Tracheostomy Care
Maintain adequate humidification, perform oral care every 2 hours, and perform tracheostomy care every 8 hours using sterile suctioning and surgical asepsis. Have two extra tracheostomy tubes available, and secure the tracheostomy tube with a square knot before removing the old one.
Documentation
Documentation should be subjective and objective, accurate and concise, complete and current, and organized with the date, time, and written in black ink.
Crutch Safety
When using crutches, the client should support their body weight at the hand grips with the elbows at a 30-degree angle. Position the crutches on the unaffected side when sitting or rising from a chair.
Varicella (Chickenpox)
Varicella is transmitted through direct contact, droplets, and from a person with shingles. The incubation period is 10-21 days, and the client is contagious 1- days before the lesions appear and until all lesions have scabs.
Scoliosis
Scoliosis is a lateral curvature of the spine with spinal/truncal rotation, causing rib asymmetry. Screening for idiopathic scoliosis during pre-adolescence involves observing the child from the back, bending at the waist with arms hanging down, and measuring truncal rotation with a scoliometer. The Cobb technique is used to determine the degree of curvature, and the Risser scale is used to determine skeletal maturity.
Interventions for Decreased Cardiac Output
Maintain bed rest, position the client in a semi-Fowler's or Fowler's position while awake, and have the client sleep with pillows. Optimal cardiac output positioning includes the left lateral side, semi- Fowler's, and supine with a wedge under one hip.
Infant Car Seat Positioning
Position the infant in the car seat at a 45-degree angle, with the safety restraints loose and low on the abdomen.
Correct Use of Condoms
Place the condom on the erect penis, leaving space at the tip for a sperm reservoir. Condoms may be used with spermicidal gel to increase effectiveness, and they protect against sexually transmitted infections. Only use water-soluble lubricants with latex condoms.
Amnio-Infusion for Oligohydramnios
Amnio-infusion involves infusing normal saline or lactated Ringer's solution into the amniotic cavity to reduce the severity of variable decelerations caused by cord compression. This procedure is performed when there is a scant amount or absence of amniotic fluid, and the membranes have ruptured.
Rhogam for Rh-Negative Clients
Rhogam is the administration of antibodies from human plasma to an Rh-negative mother to protect the fetus. Chadwick's sign is a violet or blue color of the cervix and vaginal mucosa, and Goodell's sign is the softening of the cervical tip.
Herpes Simplex Virus (HSV)
HSV can be transmitted directly to the fetus during vaginal birth if the mother has active lesions. Obtain cultures from women who have HSV or are at or near term.
Urinary Frequency Interventions
Advise the client to decrease fluid intake before bedtime, use perineal pads, and perform Kegel exercises to reduce stress incontinence.
Buddhist Dietary Practices
Buddhist dietary practices include vegetarianism, consuming nuts and legumes, and avoiding eggs and dairy products.
Placenta Previa
Placenta previa is a condition where the placenta is implanted low in the uterus, covering the cervix. This can cause painless, bright red vaginal bleeding. If placenta previa is suspected, the mother should be placed on bed rest in a side-lying position. Perineal pads should be weighed to monitor the amount of bleeding.
Abruptio Placenta
Abruptio placenta is the premature separation of the placenta from the uterine wall. This can cause dark red vaginal bleeding, which may or may not be present, along with sharp, stabbing pain. Fluid replacement, oxygen administration, fetal heart rate monitoring, and lateral positioning are important interventions. The pregnancy must be terminated, either through birth or cesarean section.
Endocrine Agents
Thyroid Hormones
Hypothyroidism is treated with synthetic thyroxine (T4), which increases metabolic rate, body temperature, oxygen use, renal perfusion, blood volume, and growth processes. Medications used include levothyroxine, thyroid, liothyronine. Hyperthyroidism is treated with anti-thyroid medications like propylthiouracil (PTU).
Gallbladder Inflammation (Cholecystitis)
Dietary recommendations include reduced fat intake and avoidance of coffee, broccoli, cauliflower, cabbage, onions, and legumes.
Compartment Syndrome
Symptoms include pain, pallor, decreased pulse, increased blood pressure, and paresthesia (tingling in the hands and feet).
Acute Renal Failure
Can cause electrolyte imbalances like hyponatremia, hyperkalemia, hypocalcemia, and hyperphosphatemia.
Shock
Symptoms include cold, clammy skin; hypotension; oliguria; drowsiness; rapid, shallow breathing; irritability; and tachycardia. Elevated or reduced central venous pressure and multi-organ damage may also occur.
Anti-Platelet Medications
Aspirin and clopidogrel (Plavix) are anti-platelet medications used to prevent myocardial infarction and stroke. They increase the risk of bleeding and should be used cautiously with other medications that affect coagulation, such as NSAIDs, heparin, warfarin, and corticosteroids.
Herbal and Botanical Therapies
Echinacea is used for the common cold. Ginger root can help reduce nausea and rheumatoid arthritis symptoms. Ginkgo biloba may improve vasodilation and be beneficial for dementia and Alzheimer's disease. Valerian can increase GABA to prevent insomnia, but should not be used in mental health conditions, convulsions, arrhythmias, tetany, or stridor/spasms. Black cohosh may have estrogen-like effects and be helpful for hypertension and hypoglycemia.
Nephrotic Syndrome
Characterized by the presence of serum proteins in the urine. Dietary management includes sufficient protein intake and sodium restriction.
Peptic Ulcer Disease
Dietary recommendations include avoidance of frequent meals/snacks, alcohol, smoking, NSAIDs, coffee, spicy foods, and caffeine.
Nephrolithiasis (Kidney Stones)
Increased fluid consumption is the primary intervention.
Lactose Intolerance
Symptoms include distention, cramps, flatus, and diarrhea.
Medication Considerations
Anti-Emetics
Can cause sedation. Metoclopramide (Reglan) should be monitored for extrapyramidal side effects.
Proton Pump Inhibitors (PPIs)
Can cause vitamin B12 deficiency.
Erectile Dysfunction Agents
Can cause headache, flushing, back pain, muscle aches, and temporary vision changes. Contraindicated in patients with heart problems, blood pressure issues, or history of stroke.
Oral Iron Supplements
Can cause teeth staining. Should be taken with water or juice, and avoided with antacids and meals. Encourage intake of high-iron foods.
Anti-Coagulants
Heparin sodium is administered intravenously or subcutaneously. Protamine sulfate is the antidote. Enoxaparin (Lovenox) is administered subcutaneously and has a longer half-life. Coumadin (warfarin) is administered orally. Vitamin K is the antidote. Increased bleeding risk. Avoid use with corticosteroids, NSAIDs, vitamin K, and oral hypoglycemics.
Electrolyte Imbalances
Hyponatremia
Symptoms include confusion, restlessness, lethargy, seizures, and coma. Treated with fluid restriction.
Hypokalemia
Symptoms include poor muscle strength, slow reflexes, and flat T waves (cardiac dysrhythmias). Treated with oral or intravenous potassium supplements.
Hypernatremia
Symptoms include postural hypotension. Treated with fluids (oral or intravenous).
Hyperkalemia
Symptoms include twitching, contraction, paralysis, and peaked T waves (cardiac dysrhythmias). Treated with kayexalate, loop diuretics, and insulin.
Hypocalcemia
Symptoms include twitching, muscle cramps, Trousseau's sign, and Chvostek's sign. Treated with dietary supplements, antacids, and vitamins.
Hypercalcemia
Symptoms include muscle weakness, fatigue, and slow gastrointestinal function. Treated with diuretics, increased fluid intake, weight-bearing exercises, and calcitonin.
Antidotes
Bethanechol/Neostigmine for atropine Atropine for physostigmine Digibind for digoxin Vitamin K for warfarin Protamine sulfate for heparin Glucagon for insulin-induced hypoglycemia Acetylcysteine (Mucomyst) for acetaminophen
Cardiovascular Medications
ACE Inhibitors
Used for heart failure, hypertension, myocardial infarction, and diabetic neuropathy. Side effects include orthostatic hypotension, dry cough, and hyperkalemia. NSAIDs can reduce the therapeutic effects.
Alpha-Adrenergic Blockers
Dilate veins and arteries, such as prazosin and doxazosin.
Panicked: Use gentle reality orientation. Confused: Provide reality orientation. Delusions/Hallucinations/Paranoia: Acknowledge but do not reinforce. Obsessive Compulsive Behavior: Communicate after the behavior. Personality/Cognitive Disorder: Be calm and matter-of-fact. Aggressive/Violent: Set boundaries, use short, simple sentences.
Psychiatric Medications
SSRIs: Citalopram, fluoxetine, sertraline (avoid St. John's Wort). TCAs: Amitriptyline (anticholinergic effects). MAOIs: Phenelzine (risk of hypertensive crisis). Atypical: Bupropion (appetite suppression, headache, dry mouth). SNRIs: Venlafaxine, duloxetine (nausea, weight gain, sexual dysfunction).
Nursing Responsibilities
RNs can delegate surgical asepsis responsibilities to unlicensed assistive personnel (UAPs) under RN supervision. Traditional handwashing should be used when hands are visibly soiled, when touching bodily fluids, before/after applying sterile gloves, and after using alcohol-based sanitizer 10 or more times. Factors that contraindicate good hand hygiene include nail polish, long nails, use of lotions, and wearing jewelry. Potential routes of entry for bloodborne pathogens include mucous membranes, puncture wounds, and burns on the hands. Personal protective equipment (PPE) is the single most effective way to prevent the transmission of infection. Nosocomial infections can occur in both the hospital and home care settings, often due to a suppressed immune system, failure to follow isolation precautions or aseptic technique, or hospital errors. For a suspected case of bacterial meningitis, standard precautions are needed during a lumbar puncture procedure.
Suspected Cause of Diarrhea
The male patient in the hospital recovering from MV Replacement surgery, who has developed new diarrhea and a high WBC count while being bed- bound and incontinent of stool, is suspected to have a bacterial, nosocomial infection as the cause of his diarrhea.
Bedrest and Hygiene Care
Complete Bedrest (CBR, BR)
Complete bedrest is a medical abbreviation that indicates the patient is confined to bed.
Frequent Bathing for Older Clients
Frequent bathing is necessary for older clients to prevent skin breakdown.
Sitz Bath
A sitz bath, where the patient's pelvic area is soaked in warm water, can be helpful in decreasing inflammation.
Guidelines for Patient-Centered Hygiene Care
Be respectful to the patient's cultural values. Ask the patient in what order they would like to complete their hygiene routine. Provide hygienic care as often as necessary (but not too often) and as gently as necessary.
Documentation of a Bath
The documentation of a bath should include the date, time, type of bath, and any abnormal findings or patient reactions.
Collaboration for Personal Care
The nurse may need to collaborate with a colleague for personal care if the patient is not ambulatory and is too heavy to be moved alone.
Pressure Ulcer Risk Assessment
Braden Scale Components
The Braden scale assesses the patient's sensory perception, moisture, activity, mobility, nutrition, and friction & shear. A high score indicates low risk of pressure ulcer development.
Trochanter Roll
A trochanter roll is used to keep the hips in a neutral position.
Hemiparesis and Hemiplegia
Hemiparesis is weakness on one side of the body, while hemiplegia is paralysis on one side of the body.
Prone and Sims' Positions
The prone position is lying on the abdomen, while the Sims' position is lying on the left side with the left leg straight and the right knee bent.
Integumentary System
Hazards: Skin breakdown Interventions: Repositioning, monitor nutrition status, reduce moisture, provide hygiene care
Musculoskeletal System
Hazards: Stiff joints, muscle atrophy, calcium imbalance Interventions: Range of motion exercises, ambulation, nutrition measures
Skin Breakdown Risk Factors
Poor nutrition, bedrest, obesity, using a specialty pressure-relieving mattress, increased friction and shear
Areas Prone to Skin Breakdown
Tailbone, heels, elbows, hips
Preventing Flaccidity
The most effective intervention in preventing flaccidity in a hospitalized patient is early ambulation after surgery.
Sequential Compression Devices (SCDs)
After applying SCDs, the essential assessment finding for the nurse to document is the lower extremity circulatory status.
Morse Fall Scale Components
The Morse Fall Scale assesses history of falls, secondary diagnosis, ambulatory aid, IV/heparin lock, gait/transferring, and mental status. Scores of 45+ indicate high risk, 25-44 indicate moderate risk, and 0-24 indicate low risk.
Injection Techniques
Tuberculin (TB) Injection
Maximum amount: 0.1 cc Site: Forearm Angle: 15-20 degrees Length: 1/4 - 1/2 inch Aspiration: No
Subcutaneous (SQ) Injection
Maximum amount: 2 cc Usual site: Upper arm, stomach Angle: 45 degrees Length: 1/2 - 1 inch Aspiration: Yes
Intramuscular (IM) Injection
Maximum amount: 5 cc Usual sites: Deltoid (1 cc), gluteus medius/maximus or vastus lateralis (5 cc) Angle: 90 degrees Length: 1 - 1.5 inches Aspiration: Yes
Blood Glucose Factors
Factors that can affect a blood glucose result include fasting/eating, time of day, level of activity, stress, illness, and menstruation.
Hypoglycemia Risk
The client most at risk for hypoglycemia is in the morning before breakfast.
Considerations for Patients on Blood Thinners
Monitor platelet levels, watch for bleeding/reduce bleeding risks, monitor vitals, and assess mobility status.
Benzodiazepines and Older Adults
Benzodiazepines should not be given to older adults, as they increase the risk of accidents and mental deficits.
Abbreviations
FUO - Fever of unknown origin qhs - At bedtime ac - Before meals
Medication Administration Considerations
Contraindications for Opening Capsules and Mixing with
Food
Enteric-coated (EC) and extended-release (ER) medications should not be opened or mixed with food.
Insulin Types
Rapid-acting insulin (onset 15 min, peak 30-90 min, duration 3-5 hr) Short- acting insulin (onset 30-60 min, peak 2-4 hr, duration 5-8 hr) Intermediate- acting insulin (onset 1-3 hr, peak 8 hr, duration 12-16 hr) Long-acting insulin (onset 1 hr, no clear peak, duration 20-26 hr)
