ATI Comprehensive Notes PDF

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Advanced Directives Living will can be part of advance directive/durable power of attorney. Responsibility of the nurse is confirming and providing information about the Advance Directive. Review the client's understanding about the advance directive. No nurse, doctor, family can be the witness to a patient signing their advanced directive. Stranger only. Social worker. Health proxy is another word for durable power of attorney. Patients can assign durable power of attorney, but the family cannot be a witness. Only a patient can change the durable power of attorney. *MAKE SURE ADVANCE DIRECTIVES ARE IN PLACE*

Advanced directive is end of life care. DPOA cannot make the decisions if the patient is well. WHO MAY GIVE CONSENT? TYPES:

GENERAL (SIGNED ON ADMISSION) IMPLIED (LIFE OR LIMB) INFORMED (SURGERY) Language Barrier: Language barrier, if a patient speaks another language, you can get a translator or someone in the healthcare team who speaks the same language. Advanced care nurses can answer allergy questions. Restraints: There is no such thing as a PRN order for restraints. Renewal prescription is every 24 hours Check every 15 minutes for children and every 30 min for adult Remove restraints every 2hr for thirty minutes If the situation is dangerous to a patient or other, you can apply restraints without order but you have 24 hours to get a prescription for restraint. Most important assessment is neurovascular. Types of restraints are slipknot, half knot and quick release. Use sheepskin inside the restraints. Tie the restraints to the frame of the bed or any part of the moving bed.

Therapeutic Response: No WHAT OR WHY. For schizophrenia do not deny or confirm. Breach of confidentiality We cannot use WIFI unless it is a VPN. Encryption. Not sharing username or password.

Change of Shift Report

New medication, appointments, change of condition, pending results, discharge and admission, death on floor, isolation precautions. Neutropenic precaution (most asked) patient risk for infection, avoid fresh foods, flowers drink water from bottle water never pick anything that says restrict. Limit is better. (patients visitors) Infection Control Handwashing, PPE, different types of isolation precautions.

MRSA of wound, contact precaution. PPE GLOVES (BEST) DROPLET: PPE, MASK (BEST) Any hand that is visibly soiled you need to wash hands (no hand sanitizer) Return demonstrating with teaching, if its not a option assign another AP, LVN should never follow uap. You should change gloves when caring for the same patient if caring for different area parts.

1 water 10 bleach to clean c diff spill (also blood spill) is 1-10 is not there use 1-9 Airborne, droplet, contact, negative pressure, positive pressure precautions (neg and airborne are the same) (positive is neutropenic precautions and Reversed Isolation precaution.

DON: GOWN, MASK, GOGGLES, GLOVES. DOFF: GLOVES, GOGGLES, GOWN, MASK. If the gown has a tie in the front, untie it first!!!!

TB, RUBELLA, MEASLES, VARICELLA. (AIRBORNE) Meningitis is a droplet.

AIDS/ HIV, HEP B, HEP C, HERPES SIMPLEX: standard precautions.

C DIFF PATIENT CAN GO OUT AS LONG AS THE DIARRHEA IS CONTROLLED (BRIEF) Toxoplasmosis aka TORCH: (domestic cats feces, especially the litter box) When pregnant, it can cause abnormalities to the baby. Not even with gloves.

Russell Skeleton Traction: Doesn’t have any pins. When providing care it's from head to foot, slowly and carefully. Compartment syndrome (main manifestation) is unrelieved pain, early manifestation is pallor. Don’t turn patient to the side Check for skin breakdown on the boot Check for DVT on unaffected legs. Saline for pin care, clean from insertion site going away, from the bottom of the pin to the outside. If there is a scab, leave it alone, don’t take it off. Monitor patients for purulent drainage, foul smell. (serosanguinous is normal, don’t need to report) 10/02 review: Autonomy: Patient makes their own decision and nurse supports Postmortem care, sputum, stool and UA collection is appropriate for AP Cannot use a double knot for restraints, retie to a half bow not(same)/ slip knot and 2 fingers. Advocacy: Nurse encourages patient to ask questions. Advanced directive include: enteral feeding, CPR, and DPA. For patient privacy when bed bath, close the curtains. Oliguria has little to no urine. Exm. 100 ml per day Planning ahead of time for the day and assigned tasks to the AP is good time management, prioritize easy patient first and the harder ones later so you can get help. Witness and verify consent for surgeries. Restraints: Document every 15 minutes, ensure that they are padded, check the client for slip knot/ bow knot. Padding on bony prominences^^^

Medications Hydromorphone, Fentanyl, Meperidine, Methadone, Codeine, Oxycodone: Assess LOC, vital signs. Rehab meds for addiction are methadone. Naloxone/ Narcan antidote. IV OR PCA route is less addictive. Respiratory distress beware. Orthostatic hypotension and urinary retention to monitor. High risk for falls. Warfarin: This means your blood will be less likely to make a dangerous blood clot. Warfarin is used to treat people who have had a previous blood clot, such as: a blood clot in the leg (deep vein thrombosis, or DVT) a blood clot in the lungs (pulmonary embolism) Antidote is Vitamin K Acetaminophen: Can cause liver toxicity, no Tylenol for patients with liver issues. Can cause kidney damage. Not be taken by pregnant women. Observe bruising, petechiae, hematuria (blood in urine) and jaundice. Antidote for Tylenol is Acetylcysteine Methylergonovine: It can treat severe bleeding from the uterus after childbirth. (contraindicated for pt. With high blood pressure 140/90) therapeutic effects =Increase feeling of contractions work. Clopidogrel: Take no more than 100 mg of aspirin with ticagrelor. Notify the provider if fever, chills, sore throat, or unusual bleeding or bruising occurs. Monitor client for signs of thrombotic thrombocytic purpura. Prolonged bleeding time is expected. Black stools is a adverse effect. Oxytocin: Induction or augmentation of labor at term. Postpartum control of bleeding. ( side effects nausea ,vomiting, headache) Phytonadione: Vitamin K. Prevention of hypoprothrombinemia, which may be associated with excessive doses oral anticoags. Prevention of hemorrhagic disease in newborns. Given 6 hrs after birth. Ritalin: This medication is used to treat attention deficit hyperactivity disorder - ADHD. It works by changing the amounts of certain natural substances in the brain. Methylphenidate belongs to a class of drugs known as stimulants. Given in the morning before food, monitor for suicide ideation. Adderall: Central nervous system stimulant. Management of ADHD. Insulin Blood trans reaction: acute hemolytic = chills flank pain (STOP TRANSFUSION) Anaphylactic schock = urticaria (itching)

Alcohol withdrawal: Antabuse makes them vomit, patients should wait 2 weeks after stopping antabuse it will still cause them to vomit. Ativan to prevent delirium when alcohol withdrawal. Tremors, increased hr, hallucination, anxiety, seizure, Alcohol withdrawal delirium: Visual hallucinations, paranoid delusion, tremors. Preventing delirium LORAZEPAM AND DIAZEPAM. Chlordiazepoxide.

Dilantin: Phenytoin, Anticonvulsant. Do not drive until clearance has been given based on control of seizure. Avoid alcohol or other CNS depressants. Side effects such as urine discoloration and unwanted hair growth may occur. Flossing and brushing carefully are recommended. Maintain a well-balanced diet. May cause drowsiness. Side effects are dyskinesia and slurred speech Ibuprofen: Analgesic. Treatment for mild to moderate pain. Take with food or milk and remain upright for 30 minutes. Report abdominal stomach pain or black red stools, odorous stools. Magnesium sulfate = given to stop premature labor side effects diarrhea,coma Antidote Calcium gluconate. Furosemide: (Lasix) Change slowly in position to minimize orthostatic hypertension. Consume foods high in potassium. Use sunscreen, report any unusual bleeding, bruising, sore throat, or SOB. Report allergy to sulfa. Ciprofloxacin: Drink plenty of fluids, do not take with antacids, may cause dizziness and drowsiness. Use sunscreen and protection clothing. Use for C-diff traits a wide variety of microorganisms. Digoxin: Antiarrhythmic agent. Take as directed. Report nausea, vomiting and anorexia. Digoxin level to be 0.5-2. Measure apical pulse 1 whole minute before. Side effects are yellow vision, blurry vision, anorexia, GI symptoms, CNS, dysrhythmias. Monitor for signs and symptoms of CHF, apical pulse, K+, and toxicity. Montelukast/ Singulair: Give at nighttime as maintenance to prevent asthma. Albuterol for asthma attacks Otic drops: warm the suspension before giving it, affecting the ear up when lying down. Kids back and down ear, Adults up and back.

Beta Blockers (olol): HF, Asthma, Pneumonia, DM is contraindicated. They will have a hard time breathing since these meds constrict. Dangerous effect: heart rate can go into cardiac arrest.

Propranolol =used for hypertension, caution on pt. w/diabetes and hypotension COPD and heart failure. manifestations of hypoglycemia include nervousness, dizziness, tachycardia, and sweating, irritable blurry vision, cool and clammy skin. Hyperthyroidism manifestations in pregnancy: vomiting, tachycardia, restlessness, blurred vision, moist skin, insomnia. Hypothyroidism: Bradycardia, MI manifestation: nausea, tachycardia, and diaphoresis

Antiplatelet agents: Resveratrol and saw palmetto can also have antiplatelet effect. (aspirin, nsaids, and other coags risk for bleeding) Garlic, ginger, glucosamine, ginkgo biloba, feverfew risk for bleeding Monitor bleeding.

Calcium channel blockers – Increase heart failure Ace Inhibitors – can cause angioedema Beta blockers – caution use with asthma Vasodilators – rapidly drop BP Alpha Agonists – Act in the brain NITROGLYCERIN ACTION: preload and afterload ROUTES: sublingual, translingual spray, transmucosal tab, topical ointment, transdermal patch (wear gloves, do not massage or rub area, apply to an area without hair (chest, flank, or upper arm), PO, IV MONITOR SE: hypotension, tachycardia, headache, tolerance ANTILIPEMIC MEDICATIONS (statins) -monitor HDL, LDL, Cholesterol, triglycerides Monitor liver function; muscle aches (rhabdomyolysis) NO GRAPEFRUIT

ANALGESICS – acetaminophen, nsaidsm opioids Antipyretic – acetaminophen, nsaids Anti-inflammatory – nsaids Antiplatelet – nsaids Side effects: renal damage and liver (acetaminophen) Liver (acetaminophen)

Cushing Triad: increased intracranial pressure. s/s: low RR, wide pulse pressure, take 3 blood pressure. Systolic goes up or stays the same while dystolic drops) 3 sets of blood pressure if the diastolic is greater than 60 in all 3 then it’s a sign of elevated ICP. Position for increased ICP: Fowlers position. No aspirin for kids less than 3, can cause damage to circulation system (Reye-syndrome) Aspirin: ringing in the ear (tinnitus) Adverse effect. Bronchoscopy: Before procedure, NPO for 6 hours. Check for bleeding PTT PT & INR. / During: Supine position with head extended/ After procedure NPO until gag reflex returns EGD: left Side lying head flexed. Best time to collect sputum is in the morning, NOT SALIVA!!!!!!!!!!!!! ABG: acidosis < 7.35-7.45 > alkalosis PaCO2 35-45 HCO3 22-28 ROME – RESP, OPPOSITE, MET, EQUAL. Opposite arrows means respiratory Is the arrows are same its metabolic

RESP ACIDOSIS: COPD, BRADYPNEA, RESP FAILURE, LATE PNEUMONIA RESP ALKALOSIS: TACHYPNEA, OXYGEN TOXICITY, VENTILATOR TOXICITY, ANXIETY META ACIDOSIS: DIARRHEA, HEART FAILURE, RENAL FAILURE, LIVER FAILURE, DKA, TOXICITY TO ASPIRIN. MET ALKALOSIS: DIURESIS, NAUSEA AND VOMITING, EXCESSIVE ANTACIDS, EXCESSIVE BICARBONATE COPD: Only need a nasal cannula 1-2 liters. HOME SAFETY: No open flames, electric stove, no smoking sign, smoke detectors (change battery 1 time a year at least), no oil-based lubricants only water based, best material to wear is

cotton, Oxygen that needs more than 4 liter needs humidification, nasal cannula secure with prongs pointing inside nose, portable fire extinguisher and fire blanket. Steps for suctioning: Raise head of the bed, listen to the lungs, hyper oxygenate, check suction machine before, lubricate catheter, (INTERMITTENT SUCTIONING) NO MORE THAN 3 SUCTIONS. Diagnostic Tests and therapies: Monitoring Collection chamber: Amount and character of the drainage, if there’s more than 100mL of drainage that could mean bleeding. Drainage should change sanguineous, serosanguineous to serous, if it continues to be sanguineous after 24 report to the MD ASAP. Water Seal/ Pleural vac: Height of sterile water, water height should be 2cm. Fluctuation (goes up and down) if it stops check the patient ASAP. If the patient is not better yet check for kink or obstruction. Monitor for bubbling intermittently, if the bubbling is vigorous check it because it can be a air leak/ disconnect. Height of water needs to be equal to the water. Nursing care for chest tubes: Keep at bedside. Keep a bottle of sterile water, pressure gauze (only tape 3 sides of the gauze) clamp (hemostat). If for some reason the cords get disconnected, get the end of the tube and put that into the sterile water bottle so the patient's bottle doesn’t collapse. Always check patients first!!!!!!!!!!! COPD DIET: High proteins and high calories from carbs for energy. (Easy digestible carbs) Avoid salt when there are signs of Cushing’s. Make sure they have their bronchodilators first before steroids. Monitor dry eyes, dry mouth, tachycardia, urinary retention and constipation. (Adverse effect of bronchodilators) Mucolytic agents help loosen secretions. Steroids: Can develop Cushing’s, weight gain and water retention , moon face, risk for infection and hyperglycemia. ß Monitor Stop smoking and increase fluids. Small frequent meals. Flu shot every year and pneumonia every 5 years. Pursed lips when breathing. No more than 2 liters of oxygen unless their o2 sats are below 88%. Pneumonia: Droplet precaution: Manifestation: Fever, tachypnea, Use of accessory muscle during respiration, crackles and bronchi, productive cough, shallow resp, nasal flaring, rib retractions, rales, dullness, chest pain, malaise. Management: Oxygen, semi upright to promote expansion, hydrate to loosen secretions, antibiotics, antitussive, antipyretics. Don’t restrict visitors, LIMIT.

Tuberculosis: Isolate if suspected TB. Manifestations: cough with bloody sputum (HEMOPTYSIS), chest pain, anorexia with weight loss, malaise and fatigue, fever pattern. Lab test for TB is QUANTIFERON. Fevers afternoon or evenings. Induration (red on skin): is the center, need to measure the hard center, 10mm is the induration for TB 72 hours to measure induration. .1 ml of medication. MOST ACCURATE IS SPUTUM (ACID FAST BACILLI TEST) Once a patient starts antibiotics, 3 weeks treatment, 3 negative tests, the patient can come out and have to take medications for about 6 months. Cipro antibiotic. Need to report muscle spasms, needs to be reported because it can cause damage. Review for resp test 10/05/2021 Thoracentesis position: sitting, leaning forward over the bedside table. (Orthopneic position) High Fowlers is a position only for alert and oriented patients. Bronchoscopy: Local anesthesia, NPO by midnight, neck will be hyperextended. Post Bronchoscopy: Remain NPO until gag reflex returns. Maintain the drainage container below the level of the client's chest. Report to charge nurse continuous bubbling in the water seal chamber. Three chamber closed chest tube, water rise and fall (suppose to) continue to monitor. COPD patient should drink 8 glasses of water a day. COPD patient should be encouraged to cough every 1-2 hours. Dumping syndrome: lay down after eating to prevent diarrhea. COPD should increase protein and calories. COPD bronchodilators before meals. COPD pursed lips breathing. COPD if a patient tells you that they are having issues breathing, evaluate the clients RR. COPD has barrel chest COPD is respiratory acidosis, high co2. COPD raise head first if o2 is 85% Meningococcal pneumonia is a droplet. Pneumonia and coughing up secretions encourage the client to cough and deep breathe. Suspected TB placed the client in a private room with a special ventilation system. Pulmonary TB is fatigue, fever at night and night sweats. TB with cough airborne.

Rapid breathing is alkalosis, slow breathing is acidosis.

Falls: First identify the patients that are at risk for fall. Create an incident report after assessment. (Morse scale) Immobilize if manifestations of fracture. When documenting an incident report it has to FACTS (witness) do not speculate or witness. You can use patient statements as long as it's in quotes. SS: Swelling, loss of power/ sensation, irregularity, pain, deformity, unnatural movement crepitus, tenderness, if possible fracture its adduction. Interventions for fall: Low bed, personal belongings at bedside table with the patient, bed alarm, night light, non-slip socks, fall precaution bracelet, call light within reach, place patient near nurses station, eliminate clutter in the room, keep patients' environment clear, toileting schedule, bedside commode, two side rails up. Meningitis (bacterial or viral): Droplet precaution, private room. Patients should be away from windows or doors and more towards the wall so droplets don't escape. Suspected meningitis, isolate patient.Sputum test to confirm (c&s). SS: Fever and vomiting, altered level of consciousness, disorientation, lethargy, difficulty to arouse, rashes. Nuchal rigidity (stiff neck) and headache: common sign of meningitis, they don't like bright lights and can develop seizures. Kernig's sign: lay flat, elevate the leg, the moment the leg straightens up and the patient has a headache that is a positive sign of meningitis. Brudzinski’s: Support the head from the back and slowly lift it up, if it causes a severe headache. Only way for pain to go away patient will need to bend their knees (another positive sign of meningitis) Meningitis can cause increased intracranial pressure. (monitor signs) Position for spinal tab (cerebral spinal fluid): side lying, or orthopneic if it's not available. After the procedure the patient should be on supine to prevent cerebral spinal fluid from coming out. The more pressure the better. Seizure: Warning signs of seizure → aura (seeing stuff that aren't there) If a patient is in the wheelchair and seizing, lock the wheels and leave them in the wheelchair. Recovery position: Left side lying sims position. Status epilepticus: Seizure that lasts more than 5 minutes. How to prevent: By giving the client diazepam to prevent status epilepticus.

Med surg: Dehiscence: Surgical wound opened but no guts sticking out. Lower head of bed, bend the knee, cover the surgical wound with warm moist sterile dressing and call for help. Evisceration: Guts popping out. Cover the part of the organ with warm moist dressing, put the head of the bed down, and then bend the knee, call for help. Knee Arthroplasty: A continuous passive motion machine. Patients should be premedicated before CPM because of pain. CPM machine is used at least bid. No pillow behind the knee because the knee can lock. Spinal deformity: Lordosis of the lumbar (common in pregnant women). Kyphosis: Thoracic curvature. Scoliosis: Middle school 10-12 year girls, this is common. TURP (Transurethral Resection) of the prostate: BPH or Prostate Cancer Enlarged prostate can lead to urinary retention and possible renal failure. Continuous bladder irrigation: monitor amount and character. (IMPORTANT TO MONITOR) Increase the flow of irrigation if there is a blockage, if it doesn't remove the blockage, manually irrigate. ^^If a patient starts complaining saying that their bladder is full. (Patient should not be feeling that with CBI) Mental health: Family and community violence: A female partner is the vulnerable person in the majority of the family violence when trying to stop the relationship. Risks: ...