VATI RN 2ND COMPREHENSIVE PREDICTOR FOCUSED REVIEW
Management of Care – (5) Case Management – (1) Cardiovascular Disorders: Tetralogy of Fallot (RM
... [Show More] NCC RN 10.0 Chp 20) • Defects that decreases pulmonary blood flow have an obstruction of pulmonary blood flow and an anatomic defect (ASD or VSD) between the right and left sides of the heart. In these defects, there is a right to left shift allowing deoxygenated blood to enter the systemic circulation. Hypercyanotic spells (blue, or “Tet,” spells) manifest as acute cyanosis and hyperpnea
• 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 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, Syphillis, Tetanus/C. Tetani, Toxic Shock Syndrome (TSS) (other than streptococci), Tuberculosis (TB), Typhoid fever, Vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus (VISA/VRSA)
Concepts of Management – (1) Managing Client Care: Conflict Management Between Health Care Workers (RM Leadership 7.0 Chp 1) • Conflict is the result of opposing thoughts, ideas, feelings, perceptions, behaviors, values, opinions, or actions between individuals. Conflict is an
1 | P a g einevitable part of professional, social, and personal life and can have
constructive or destructive results. Nurses must understand conflict and
how to manage it. Nurses can use problem-solving and negotiation
strategies to prevent a problem from evolving into a conflict. Lack of conflict
can create organizational stasis, while too much conflict can be
demoralizing, produce anxiety, and contribute to burnout. Conflict can
disrupt working relationships and create a stressful atmosphere. If conflict
exists to the level that productivity and quality of care are compromised, the
unit manager must attempt to identify the origin of the conflict and attempt
to resolve it.
Continuity of Care – (1)
Information Technology: Change-of-Shift Report (RM FUND 9.0 Chp 5)
• Nurses give this report at the conclusion of each shift ot the nurse assuming
responsibility for the clients. Formats include face to face, audiotaping, or
presentation during walking rounds in each client’s room (unless the client
has a roommate or visitors are present). An effective report should: include
significant objective information about the client’s health problems, proceed
in a logical sequence, include no gossip or personal opinion, and relate
recent changes in medications, treatments, procedures, and the discharge
plan.
Establishing Priorities – (1)
Managing Client Care: Prioritizing Care of Postoperative Clients (RM Leadership
7.0
Chp 1)
• Prioritize systemic before local (“life before limb”)
• Prioritize acute (less opportunity for physical adaptation) before chronic
(greater opportunity for physical adaptation)
• Prioritize actual problems before potential future problems
• Listen carefully to clients and don’t assume
• Recognize and respond to trends vs. transient findings
• Recognize indications of medical emergencies and complications vs.
expected findings
• Apply clinical knowledge to procedural standards to determine the priority
actions
Safety and Infection Control – (8)
Accident/Error/Injury Prevention – (1)
Seizures: Maintaining Seizure Precautions (RM NCC RN 10.0 Chp 13)
• Maintain seizure precautions, including placing the bed in the lowest
position and padding the side rails to prevent future injury.
Emergency Response Plan – (1)
Client Safety: Priority Action for Fire (RM FUND 9.0 Chp 12)• R: rescue and protect clients in close proximity to the fire by moving them
to a safer location. Clients who are ambulatory may walk independently in a
safe location
• A: alarm: activate the facility’s alarm system and then report the fire’s
details and location
• C: contain/confine the fire by closing doors and windows and turning off
any sources of oxygen and any electrical devices. Ventilate clients who are
on life support with a bag valve mask
• E: extinguish the fire is possible using the appropriate fire extinguisher
Handling Hazardous and Infectious Materials – (1)
Cancer Treatment Options: Implanted Internal Radiation Device (RM AMS RN
10.0 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.
Wear 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.
3 | P a g eInstruct the client and family about radiation precautions needed in
health care and home environments.
Home Safety – (1)
Home Safety: Identifying Potential Hazards in the Home (RM FUND 9.0 Chp 13)
Remove items that could cause the client to trip, such as throw rugs and loose
carpets. Place electrical cords and extension cords against a wall behind
furniture. Monitor gait and balance, and provide aids as needed. Make sure
that steps and sidewalks are in good repair. Place grab bars near the toilet
and in the tub or shower, and install a stool riser. Use a nonskid mat in the
tub or shower. Place a shower chair in the shower and provide a bedside
commode if needed. Ensure that lighting is adequate inside and outside the
home.
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis – (3)
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.
Cancer Treatment Options: Neutropenia Precautions (RM AMS RN 10.0 Chp
91) Precautions:
Have the client remain in the room unless he needs to leave for a
diagnostic procedure or therapy. In this case, place a mask on him
during transport.
Protect the client from possible sources of infection (plants, change
water in equipment daily)
Have client, staff, and visitors perform frequent hand hygiene. Restrict
visitors who are ill.
Avoid invasive procedures that could cause a break in tissue (rectal
temperatures, injections, indwelling urinary catheters) unless necessary.
Keep dedicated equipment (blood pressure machine, thermometer,
stethoscope) in the client’s room.
Administer colony-stimulating factors (filgrastim) as prescribed to
stimulate WBC production Client Education:
Encourage the client to avoid crowds while undergoing chemotherapy.
Take temperature daily. Report elevated temperature to the provider.
Avoid food sources that could contain bacteria (fresh fruits and
vegetables; undercooked meat, fish, and eggs; pepper and paprika)
Avoid yard work, gardening, or changing a pet’s litter boxAvoid fluids that have been sitting at room temperature for longer than
1 hr.
Wash all dishes in hot, soapy water or a dishwater. Wash glasses and
cups after each use.
Wash toothbrush daily in the dishwater or rinse in a bleach solution.
Do not share toiletry or personal hygiene items with others.
Report fever greater than 37.8’C (100’F) or other manifestations of
bacterial or viral infections immediately to the provider.
Infection Control: Appropriate Actions for a Client Who Has Methicillin-
Resistant
Staphylococcus Aureus (MRSA) (RM FUND 9.0 Chp 11)
• Use frequent and effective hand hygiene before and after care.
• Educate the client about the required and recommended immunizations and
where to obtain them. The target groups include children, older adults,
those with chronic disease, and those who are immunocompromised and
their families and contacts.
• Educate the client and ask for a return demonstration of good oral hygiene.
Good oral hygiene decreases the protein (which attracts micro-organisms)
in the oral cavity, which thereby decreases the growth of micro-organisms
that can migrate through breaks in the oral mucosa.
5 | P a g e• Encourage the client to consume an adequate amount of fluids. Adequate
fluid intake prevents the stasis of urine by flushing the urinary tract and
decreasing the growth of micro-organisms. Adequate hydration also keeps
the skin from breaking down. Intact skin prevents micro-organisms from
entering the body.
• For immobile clients, ensure that pulmonary hygiene (turning, coughing,
deep breathing, incentive spirometry) is done every 2 hr, or as prescribed.
Good pulmonary hygiene decreases the growth of micro-organisms and the
development of pneumonia by preventing stasis of pulmonary excretions,
stimulating ciliary movement and clearance, and expanding the lungs.
• Use of aseptic technique and proper personal protective equipment (such as
gloves, masks, gowns, and goggles) in the provision of care to all clients
prevents unnecessary exposure to micro-organisms.
• Teach and use respiratory hygiene/cough etiquette. It applies to anyone
entering a health care setting (clients, visitors, staff) with signs or
symptoms of illness, whether diagnosed or undiagnosed. This includes
cough, congestion, rhinorrhea, or an increase in the production of
respiratory secretions. The components of respiratory hygiene and cough
etiquette include:
Covering the mouth and nose when coughing and sneezing
Using facial tissues to contain respiratory secretions and disposing of
them promptly into a hands-free receptacle
Wearing a surgical mask when coughing to minimize contamination of
the surrounding environment
Turning the head when coughing and staying a minimum of 3 ft away
from others, especially in common waiting areas
Performing hand hygiene after contact with respiratory secretions and
contaminated objects/materials
Use of Restraints/Safety Devices – (1)
Client Safety: Appropriate Use of Physical Restraints (RM FUND 9.0 Chp 12)
• Restraints can be either physical (devices that restrict movement: vest, belt,
mitt, limb) or chemical, such as sedatives and neuroleptic or psychotropic
medications to calm the client
• Restraints can cause complications, including pneumonia, incontinence, and
pressure ulcers
•
It is inappropriate to use seclusion or restraints for: convenience of the
staff, punishment for the client, clients who are extremely physically or
mentally unstable, clients who cannot tolerate the decreased stimulation of
a seclusion room
• Restraints should: never interfere with treatment, restrict movement as
little as is necessary, fit properly and be as discrete as possible, and be easy
to remove or changeIn an emergency situation when there is immediate risk to the client or
others, nurses may place restraints on a client. The nurse must obtain a
prescription from the provider as soon as possible according to the
facility’s policy (usually within 1 hr).
• The prescription must include the reason for the restraints, the type of
restraints, the location of the restraints, how long to use the restraints, and
the type of behavior that warrants using the restraints.
• The prescription allows only 4 hr of restraints for an adult, 2 hr for clients
ages 917, and 1 hr for clients younger than 9 years of age. Providers may
renew these prescriptions with a maximum of 24 consecutive hours.
• Providers cannot write PRN prescriptions for restraints.
Health Promotion and Maintenance – (5)
Ante/Intra/Postpartum and Newborn Care – (1)
Newborn Nutrition: Effective Breastfeeding (RM MN RN 10.0 Chp 25) Place the
newborn skin-to-skin on the mother’s chest immediately after birth. Initiate
breastfeeding as soon as possible or within the first 30 min following birth.
Have the mother wash her hands, get comfortable, and have caffeine-free,
nonalcoholic fluids to drink during breastfeeding. Explain the let-down reflex
(stimulation of maternal nipple releases oxytocin that causes the let-down of
milk). Reassure the mother than uterine cramps are normal during
breastfeeding, resulting from oxytocin, which also promote uterine involution.
Express a few drops of colostrum or milk and spread it over the nipple to
lubricate the nipple and entice the newborn. Show the mother the proper
latch-on position. Have her support the breast in one hand with the thumb on
top and four fingers underneath. With the newborn’s mouth in front of the
nipple, the newborn can be stimulated to open his mouth by tickling his lower
lip with the tip of the nipple. The mother pulls the newborn to the nipple with
his mouth covering part of the areola as well as the nipple. Explain to the
mother than when her newborn is latched on correctly, his nose, cheeks, and
chin will be touching her breast. Hunger cues include hand to mouth or hand to
hand movements, sucking motions, and rooting reflex. Demonstrate the four
basic breastfeeding positions: football hold (under the arm), cradle (most
common) or modified cradle (across the lap), and sidelying. Encourage the
mother to breastfeed at least 15-20 min per breast to ensure that her newborn
receives adequate fat and protein, which is richest in the breast milk as it
empties the breast. Newborns need to breastfed at least 8-12 times in a 24 hr
period. Explain to the mother that newborns will niurse on demand after a
pattern is established. Show the mother how to insert a finger in the side of the
newborn’s mouth to break the suction from the nipple prior to removing the
newborn from the breast to prevent nipple trauma. Tell the mother to begin the
newborn’s next feeding with the breast she stopped feeding him with in the
previous feeding. Tell the mother how to tell if her newborn is receiving
adequate feeding (gaining weight, voiding 6-8 diapers per day, andcontentedness between feedings). Explain to the mother that the newborn can
have loose, pale, and/or yellow stools during breastfeeding, and that this is
normal. Tell the mother to avoid nipple confusion in the newborn by not
offering supplemental formula,
pacifier, or soothers until breastfeeding has been established typically 2-3
weeks. Tell the mother to always place her newborn on his back after
feedings. Herbal products, such as fenugreek or blessed thistle, and
prescription medications, such as metoclopramide, have been reported to
increase breast milk production. There is insufficient data to confirm or
deny their effect on lactation. Mothers should check with the provider
before taking over-the-counter or prescription medications.
Developmental Stages and Transitions – (1)
Burns: Dressing Change on a School-Age Child (RM NCC RN 10.0 Chp 32)
• The nurse should premedicate the child before performing a dressing
change. Use nonpharmacologic methods for pain control (guided imagery,
music therapy, therapeutic touch) to enhance the effects of analgesics and
promote improved pain management.
Health Promotion/Disease Prevention – (2)
Infections: Client Assignment for Pregnant Personnel (RM MN RN 10.0 Chp 8)
• Brachytherapy involves the implantation of a sealed radiation source within
the targeted tumor tissue. A client who is wearing a solid implant emits
radiation as long as the implant is in place; however, the client’s excreta is
not radioactive. Pregnant nurses should not care for such clients. There are
no contraindications to having a pregnant nurse care for a client under
enteric precautions, a client with cancer who is receiving a continuous
infusion or intravenous therapy, or a client who requires frequent wound
irrigation.
Prenatal Care: Risks for the Adolescent Client (RM MN RN 10.0 Chp 4)
• Preterm births, low-birth weight infants, cephalopelvic disproportion, iron
deficiency anemia, and preeclampsia-eclampsia and its sequelae. In the
adolescent age group, prenatal care is the critical factor that most influences
pregnancy outcome.
Lifestyle Choices – (1)
Contraception: Triage Clients on Different Types of Birth Control Methods (RM
MN
RN 10.0 Chp 1)
• Abstinence: if complete abstinence is maintained there are no risks
• Coitus interruptus (withdrawal): depends on a man’s ability to control
ejaculation. Leakage of fluid that contains spermatozoa prior to ejaculation
can be deposited in vagina. Risk of pregnancy
• Calendar method (Rhythm method): various factors can affect change, the
time of ovulation and cause unpredictable menstrual cycles. Risk of
pregnancy.• Basal body temperature (BBT): Risk of pregnancy
•
Billings Method (Cervical Mucus Method): Assessment of cervical mucus
characteristics may be inaccurate if mucus is mixed with semen, blood,
contraceptive foams, or discharge from infections. Risk of pregnancy.
Condoms: condoms can rupture or leak potentially resulting in an unwanted
pregnancy. Condoms have a one-time usage, which creates a replacement
cost.
Only water-soluble lubricants should be used with latex condoms to avoid
condom breakage.
• Diaphragm and spermicide: not recommended for clients who have a
history of toxic shock syndrome (TSS) or frequent, recurrent urinary tract
infections. Increased risk of acquiring TSS. Proper hand hygiene aids in
prevention of TSS as well as removing diaphragm promptly at 6 hours
following coitus.
• Combined oral contraceptives: oral contraceptive effectiveness decreases
when taking medications that affect liver enzymes such as anticonvulsants
and some antibiotics.
Psychosocial Integrity – (5)
Abuse/Neglect – (1)
Family Violence: Evaluating Child Abuse (RM MH RN 10.0 Chp 32)
• Risk factors for abuse toward a child: the child is under 3 years of age; a
perpetrator perceives the child as being different (the child is the result of
an unwanted pregnancy, is physically disabled, or has some other trait that
makes him particularly vulnerable).
•
Infant assessment – shaken baby syndrome (shaking can cause intracranial
hemorrhage. Assess for respiratory distress, bulging fontanels, and an
increase in head circumference. Retinal hemorrhage can be present). Any
bruising on an infant before age 6 months is suspicious.
• Preschoolers to adolescents assessment – assess for unusual bruising, such
as on abdomen, back, or buttocks. Bruising is common on arms and legs in
these age groups. Assess the mechanism of injury, which might not be
congruent with the physical appearance of the injury. Numerous bruises at
different stages of healing can indicate ongoing beatings. Be suspicious of
bruises or welts that resemble the 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 lit 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.
Behavioral Interventions – (1)
Anxiety Disorders: Planning Care for a Client who has Obsessive CompulsiveDisorder (RM MH RN 10.0 Chp 11)
• Provide a structured interview to keep the client focused on the present.
Assess for comorbid condition of substance use disorder. Provide safety and
comfort to the client during the crisis period of these disorders, as clients in
severe- to paniclevel anxiety are unable to problem solve and focus. Clients
experiencing paniclevel anxiety benefit from a calm, quiet environment.
Remain with the client during the worst of the anxiety to provide
reassurance. Perform a suicide risk assessment. Provide a safe environment
for other clients and staff. Provide milieu therapy that employs the
following: a structured environment for physical safety
and predictability; monitoring for, and protection from, self-harm or suicide;
daily activities that encourage the client to share and be cooperative; use of
therapeutic communication skills, such as open-ended questions, to help
the client express feelings of anxiety, and to validate and acknowledge those
feelings; client participation in decision making regarding care. Use of
relaxation techniques with the client as needed for relief of pain, muscle
tension, and feelings of anxiety. Instill hope for positive outcomes (but avoid
false reassurance). Enhance client self-esteem by encouraging positive
statements and discussing past achievements.
Assist the client to identify defense mechanisms that interfere with
recovery. Postpone health teaching until after acute anxiety subsides.
Clients experiencing a panic attack or severe anxiety are unable to
concentrate or learn.
Mental Health Concepts – (3)
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
Eating Disorders: Short-Term Goal for Client who have Anorexia Nervosa (RM
MH
RN 10.0 Chp 19)
• Provide a highly structure milieu in an acute care unit for the client
requiring intensive therapy. Develop and maintain a trusting nurse/client
relationship through consistency and therapeutic communication. Use a
positive approach and support to promote client self-esteem and positive
self-image. Encourage client decision making and participation in the plan
of care to allow for a sense of control. Use behavioral contracts to modifyclient behaviors. Reward the client for positive behaviors, such as completing meals or consuming a set number of calories.
Personality Disorders: Antisocial Personality Manifestations (RM MH RN 10.0 Chp 16) • 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.
Basic Care and Comfort – (4) Assistive Devices – (2) Ergonomic Principles: Use of a Standard Walker (RM FUND 9.0 Chp 14) The walker and affected leg move forward, then the patient should move the unaffected leg parallel to the affected leg. Sensory Perception: Speaking to a Client Who Has a Hearing [Show Less]