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Adult Med-Surg ATI Study Guide
Learn/Master the BASIC principles and PROCEDURES of NURSING o Critical Thinking o Evidence-based Practice o Patient-centered Care o Clinical Application o Nursing Process (A.D.P.I.E.) o Therapeutic Communication When in doubt, the correct answer may be the low urine output (Urine output less than 30 mL/hr) Strong indication of a hematologic disorder = Absence of hair on the legs Rationale: Thinning or absence of hair on the extremities indicates poor arterial circulation to that area Brachytherapy Treatment (ATI Chapter 92: Cancer treatment options) What is Brachytherapy? o Type of radiation therapy that provides internal radiation to target tissues and destroy cells Ex. providing radiation to the tumor directly and the surrounding noncancerous area o Procedure that involves placing radioactive material inside of the body (Vagina or abdomen) Also can be absorbed by the thyroid when delivered via IV with radionuclide iodine Indication of Brachytherapy Treatment o Commonly used to treat prostate cancer o Cervical cancer o Uterine (endometrial) cancer o Brest cancer, lung cancer, eye cancer, and skin cancer Note: o Ensure no one touches the client’s excretions Rationale: due to excretions being radioactive until the isotope are eliminated from the body
Nursing Consideration o Ensure client receiving this kind of therapy is placed within a private room with the door kept closed as much as possible Rationale: Due to client being immunocompromised because of radiation therapy (meaning their body is more susceptible to contracting something o Sign should be placed on the door outside of the client’s room that warns people of the radiation source o Using a dosimeter film badge that’s responsible for recording personal amount of radiation exposure Rationale: Too high of a recording on the badge increases the client’s risk getting cancer o Nurse should wear a lead apron when providing direct care to provide protection from radiation source and not turn their back toward the client o Limit each of the client’s visitors to 30 minutes per day o Instruct visitors to remain at least 6 feet from client receiving radiation at all times o The following should remain from entering the room of radiation treatment: Pregnant women Women trying to conceive Individuals under the age of 16 o Keeping a lead container in the client’s room (for delivery method that allows spontaneous loss of radioactive material) Rationale: Container provides a safe place to put radioactive material to prevent people from people being exposed to it In addition, use tongs/forceps to place radioactive material into the lead container Rationale: Using tongs prevents healthcare provider from using their hands (which helps prevent exposure to the radiation) Note: Keep tongs/forceps in the room as well o Keep all linens and dressings should be kept in client’s room until the radiation source is removed
type of blood cancer that causes bone marrow to make too many red blood cells. Nursing Interventions o Patient should elevate their legs when sitting Rationale: to avoid venous pooling with subsequent clot formation o Patient should drink at least 3 Liters of fluid per day to help lower blood viscosity o Patient should wear support hose/TED hose/SCD when awake o Patient should use a soft toothbrush to clean their teeth (avoid flossing or anything that increasing the risk for bleeding) Pyelonephritis A bacterial infection of the kidney and renal pelvis Nursing consideration o The nurse should instruct the client about the importance of wiping from front to back following fecal elimination to avoid introducing bacteria into the urinary tract Dumping Syndrome information: Preventing Dumping Syndrome Eliminate/avoid simple sugars and sugar alcohols from the client’s diet to prevent dumping syndrome o Sugar, honey, and sugar alcohols increase hypertonicity and propel food through the intestines faster than food without sweeteners The client should ingest protein at every meal to slow gastric emptying (preventing dumping syndrome) The client should drink beverages between meals ONLY (about 1 hour after eating solid foods) o Rationale: Mixing food and fluids propels the mixture through the gastrointestinal tract faster than solid food alone). Electroencephalogram (EEG) Nursing Consideration o Pre-Operative care Thoroughly shampoo the client’s hair prior to the EEG o Instruct the client to be sleep-deprived prior to the EEG to increase the likelihood of recording seizure activity
o Instruct client to lie still in reclining chair or bed and to keep their eyes closed (for the initial recording) o EEG takes 45 minutes to 2 hours o EEG documents brain activity How to Avoid Sickle Cell Crisis Avoid strenuous physical activities that cause overexertion Drinking 3 to 4 liters of fluid per day Avoid traveling to high altitudes and in airplanes (since passenger cabins are non-pressurized) Avoid recreational activities that require persistent exposure to cold weather EKG/ECG/Telemetry Reading A flattened T wave or the development of U waves is indicative of Hypokalemia Elevated ST Segment = Hyperkalemia Widen QRS = Hyperkalemia Prolonged QT Intervals = Hypocalcemia o Manifestations of Hypocalcemia Tingling & numbness Tetany Seizures Shorten QT intervals = Hypercalcemia Diabetes Insipidus Treatment o Chlorpropamide Antidiabetic agent with antidiuretic effects o Vasopressin An exogenous form of antidiuretic hormone o Desmopressin Synthetic form of antidiuretic hormone SIADH Treatment o Tolvaptan
Expected findings o Triad of neurological changes o Petechial rash o Hypoxemia Risk factors o Multiple fractures o Fracture of a long bone Increased Intracranial Pressure (ICP) Manifestation o Widened Pulse Pressure o Sleepiness o Bradycardia o Severe hypertension o pupil changes o Change in the level of consciousness o Nausea and Vomiting o Seizures o Alterations in breathing pattern o Distended jugular veins o Decerebrate posturing o Decorticate posturing Nursing Consideration (for Increased Intracranial Pressure) o Monitor vital signs every 2 hours o Assess neurological status every 4 hours o Keep the client’s room darkened o Maintain client’s bed at 30 to 45 degrees LASIK Surgery indication o procedure to correct nearsightedness, farsightedness, and astigmatism by changing the shape of the cornea
Adverse effects of LASIK Surgery o Dryness of the eyes o Blurred vision Hodgkin’s Lymphoma Early manifestation o Enlarged lymph nodes o Night sweats o Unexplained weight loss o fevers o pruritus (itching) ATI Chapter 70: Amputations Nursing care for clients with Amputations o Primary focus is on preventing postoperative complications such as: Hypovolemia (increased risk of hypovolemia due to bleeding/excessive bleeding from the surgical site) Pain Infection (increased risk of infection due to surgical procedure) o Assessing the client’s surgical site for bleeding Rationale: continuous bleeding or excessive bleeding will lead to further complications o Monitor the client’s vital signs frequently Rationale: Changes in vitals signs (ex. elevated heart rate/tachycardia, low blood pressure/hypotension) may indicate postoperative complications due to amputation procedure o Monitor tissue perfusion of end of residual limb Nursing action: Palpate residual limb for warmth o Rationale: warmth may indicate blood flow; however, HEAT may indicate infection During assessment of limb, compare pulse most proximal to incision with pulse in other extremity o Avoid placing pillow under residual/amputated limb o Monitor the client for manifestations of infection and non-healing of incision. Infection can lead to osteomyelitis
Nursing consideration o Assist the client into a prone position (on their stomach) for 20 to 30 minutes every 3 to 4 hours following an amputation Rationale: to reduce the risk of flexion contractures What is an Electromyogram (EMG)? A procedure shows electrical activity within the muscles during contraction It is useful for discriminating between muscular dysfunction and nerve dysfunction Receptive aphasia vs Expressive aphasia Receptive aphasia o When the client cannot understand words or sentences they hear Expressive aphasia o Clients who cannot name simple objects or formulate sentences or phrases Heart Failure related to Mitral Stenosis Expected finding o Increased pulmonary congestion o Increased pulmonary artery pressure o Increased left atrial pressure o Decreased cardiac output Cardiac Catheterization Nursing consideration o Educate patient on lying flat for several hours after the procedure should remain flat or head of the bed elevated to no more than 30 degrees for 2 to 6 hours after the procedure Amount of time depends on the type of closure device the provider uses o Client will receive medication to relax before the procedure mild sedative for relaxation and comfort prior to the procedure o Educate client to keep their leg straight after the procedure
Blood Transfusion Nursing consideration o Check to determine the packed RBC’s are less than 1 week old o Ask another nurse to check the packed RBC’s label against the medical record o Prime the transfusion tubing with 0.9% sodium chloride o Use an angiocatheter that is 18 to 20 gauge (to allow the packed RBCs to flow easily) o Ensure pack of blood is infused slowly over 2 to 4 hour period (to decrease the risk of bacterial contamination) Hypervolemic reaction due to circulatory overload (ex. a person getting a blood transfusion) manifestations o Tachycardia o Dyspnea o Coughing o Distended neck veins Herpes Zoster (Shingles) vs Herpes Simplex Virus (Genital Herpes) Herpes Zoster (Shingles) manifestation o Unilateral, localized, nodular skin lesions Herpes Simplex Virus (Genital Herpes) manifestation o Fluid-filled vesicular rash in the genital region Urinary Tract Infection (UTIs) Manifestations o Back pain and flank pain o frequency of urination o Urgency of urination o Cloudy urine o Foul-smelling urine Pan-hysterectomy for Uterine Cancer Discharge teaching
ATI Chapter 16: Stroke – Nursing care and Client education Monitor client for increased ICP (intracranial pressure) o This may indicate client is having changes in level of consciousness o Nursing action: Elevate the client’s head of the bed to 30 degrees in order to reduce ICP and to promote venous drainage Frequent neurological checks Performing the following screening assessments: o National Institute of health stroke scale (NIHSS) Helps to determine deficits the client is experiencing and the need for thrombolytic therapy o The Glasgow Coma Scale Used for whenever the client has decreased level of consciousness or orientation Assisting client with communication skills (if their speech is impaired) o Implement using a communication board with the client Client should remain NPO until thorough screening for swallowing is performed Monitor client for signs of Dysphagia (trouble swallowing) such as the following: o Drooling o Choking o Coughing o Pocketing their food (saving the food to eat later) due to them taking longer than normal to eat (taking longer than 10 seconds to swallow food) Ensure client eats in an up-right position o Client head and neck should be flexed slightly forward to assist with eating/swallowing Instruct client to avoid using straws while drinking o Rationale: straws increase risk for aspiration Nursing care for complications of immobility (such as atelectasis, pneumonia, pressure injury, and DVT) o Help client with ambulation as soon as possible Rationale: doing so helps to reduce risk for complications or further complications developing o Offering client SCDs, antiembolism, and stockings o Assist client with elevating the affected extremities
Rationale: Doing so helps to promote venous return and reduce swelling o Encourage client to perform range of motion exercises at least every 2 hours. Nursing care for reducing the risk of falls and injuries o Using assistive devices during transferring the client Examples of transferring devices Transfer belts Sliding boards Sit-to-stand lifts (used to help reduce the strain put on your back when assisting the client) o Educate client on the importance of protecting and caring for the affected extremity to avoid injury o Encourage client to support their arm (affected arm) while doing the following: While in bed While ambulating with an arm sling While in the wheelchair Supporting it while placed on pillows Nursing care for providing assistance with ADLs (activities of daily living) as needed o Instruct the client to dress their affected side first while sitting in a supportive chair that aids in balancing. o In addition, teach client about using the unaffected side to exercise the affected side of the body Hypertonic Dehydration Expected finding o Urine specific gravity greater than 1.030 (ex. 1.045 Urine Specific Gravity) o Sodium level greater than 145 mEq/L o Increased respiratory rate Acute Cholecystitis Expected finding o Tachycardia (priority finding) o Abdominal pain radiating to the right shoulder
o Metabolic acidosis o Decreased RBC production o Hyperphosphatemia Frequency of Migraine headaches Foods to avoid o Foods that contain tyramine (aged cheese, sausage) o Yeast o Chocolate o Smoked fished o Fermented or pickled foods Components of Cushing’s triad Bradycardia Hypertension Irregular respirations Widen Pulse Pressure Cushing Syndrome (Hypercortisolism) Expected Finding/Manifestations o Weakness, fatigue, sleep disturbances o Back and joint pain o Altered emotional state (irritability, depression) o Decreased libido Addison’s Disease Expected Finding/Manifestations o Weight loss o Craving for salt o Hyperpigmentation of the skin and mucous membranes o Weakness and fatigue o Nausea, anorexia, and vomiting o Abdominal pain o Constipation or diarrhea o Dizziness with orthostatic hypotension o Severe Hypotension o Dehydration o Hyponatremia
o Hyperkalemia o Hypoglycemia o Hypercalcemia Total Knee Arthroplasty (will most likely be on the final exam) Nursing consideration o Instruct the patient to flex their foot every hour when awake Rationale: To reduce the risk for thromboembolism and promote venous return o Avoid placing pillows under the knee to prevent flexion contractures o Instruct client to elevate the leg when sitting in a chair to reduce edema and pain o Instruct the patient to remain their legs in a neutral position when resting in bed to prevent dislocation of the knee Chest Tube/Atrium System Bubbling in the water seal chamber ceases when the lung re-expands Nursing Consideration o Instruct the client to perform the Valsalva maneuver during removal o Nurse should provide the client with pain medication prior to the procedure to promote comfort during the removal of the chest tube o The nurse should cover the insertion site with an occlusive dressing to prevent air entry into the pleural space Pressure injury Nursing consideration o Change position every 1 to 2 hours (to decrease pressure on bony prominences) o Instruct client to keep the skin clean and to dry and to moisturize the skin with a cream or lotion o avoid massaging or rubbing the affected area (can cause further skin breakdown)
o instruct client to take Verapamil with meals or milk (to decrease gastric irritability) o Increase fiber intake to avoid constipation o Instruct the client to monitor blood pressure weekly o Instruct the client to report manifestations of hypotension to the provider Autonomic Dysreflexia Manifestations o Bradycardia /heart rate below 60 BPM (ex. HR 52/min) o Severe headache (reportable finding) o Flushing (above the level of the injury and pallor below the level of the injury) o Sudden, significant rise in systolic and diastolic pressures (hallmark manifestation) o Hypertension o Anxiety (which can lead to patient becoming tachypnea) Thoracentesis Nursing consideration o Encourage the client to take deep breaths after the procedure Rationale: helps to re-expand the lung o Assist a client who cannot sit up into a side-lying position with the affected side up during the procedure o Client will receive a local anesthetic for the procedure o Client will not require an NPO status after midnight prior to the procedure o Instruct client can resume activity within 1 hour following the procedure Rheumatoid Arthritis Nursing Consideration o Alternate application of heat and cold to the affected joints (to decrease joint inflammation and pain) Rationale: Cold helps to relieve joint swelling; Heat helps to decrease joint stiffness and pain
o Regular exercise is important to prevent stiffness (however, it may be painful) Modified Radical Mastectomy Nursing consideration o Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period o Instruct the client to start exercising the right arm 24 hour after surgery o Nurse should elevate the arm of the affected side on a pillow to promote lymphatic fluid return o Nurse should elevate the head of bed to at least 30 degrees (to promote drainage from the surgical site and facilitate breathing) Client Education for Modified Radical Mastectomy o Instruct client that numbness can occur near the incision and along the inside of the affected arm due to nerve injury o Instruct client to stand upright and avoid flexing the affected arm when ambulating (to reduce risk for elbow contracture) o Instruct the client to begin active range-of-motion exercises 1 week after surgery (to increase mobility without causing stress on the incision) o Instruct client to dress loose-fitting clothing (to reduce the risk of stress on the incision) Diabetes Insipidus Expected findings o Low urine specific gravity o Hypotension (due to dehydration caused by excessive excretion of urine) o Weak peripheral pulses Manifestation o polydipsia (excess thirst) o polyuria (excess urination)
