Med Surg ATI Review
Ch. 1 Health, Wellness, and Illness Variables o Modifiable= can be changed, smoking, nutrition, health edu, sex practices, exercise o Non modifiable= sex, age, developmental level, genetics
Ch. 2 Emergency Nursing Principles and Management Triage Resuscitation= level one Emergent= level two Urgent= level 3 Less urgent= level four O Nonurgent= level five, non life threatening condition require simple eval and care management ABCDE Airway= maintain airway, head tilt/chin lift (do NOT perform if pt has spine injury-> do modified jaw thrust maneuver), bag valve mask w/ 100% O2, nonrebreather w/ 100% 02 use for spontaneous breathers Breathing Circulation Disability= loc Exposure= clothing Poisoning= use activated charcoal, gastric lavage (done w/I 1hr) aspiration Rapid response team= respond to emergency when pt has indications of rapid decline Cardiac emergency Vfib= defibrillate, CPR, admin IV antidysrhythmic (epi, amiodarone, lidocaine, magnesium sulfate) Vtach Epi= s stimulate alpha 1 (vasoconstrict), beta 1 (increase hr), beta 2 (bronchodilate), good for superficial bleeding, increase bp, AV block and cardiac arrest and asthma o s/e= htn crisis, dysrhythmias, angina Dopamine= renal blood vessel dilation, beta 1 increase hr, good for shock, hf o s/e= dysrhythmias, angina Dobutamine= beta 1 increase hr, good for hr Ch. 3 Neurologic Diagnostic Procedures Cerebral angiography= visualization of cerebral blood vessels, assess blood flow within brain, id aneurysms Do NOT perform if pregnant, don't eat food or fluids for 4-6hrs prior to procedure assess for allergy to shellfish or iodine b/c require use of contrast media, ask about anticoag, assess BUN and creatinine; monitor area for clotting after procedure CT= cross section image EEG= id seizure activity and sleep disorder o Wash hair b/f procedure, be sleep deprived, expose to flashing lights, hyperventilate for 3-4 min
Glasgow coma scale= determine loc, b best score is 15, score less than 8 is associate w severe head injury and coma Eye open (E) 4= eye open spontaneously : 3= eye open to sound 2= eye open to pain 1= eye does not open o Verbal (V) 5= conversation is coherent and oriented 4= conversation is incoherent and disoriented 3= words are spoken but inappropriate 2= sound made 1= no sound Motor (M) 6= commands followed 5= local reaction to pain 4= general w/drawal to pain decorticate posture (adduction of arms, flexion of elbows and wrists 2= decerebrate posture (extension of elbows and wrists) : no motor response ICP monitoring= performed by neurosurgeon in operating room, used for GCS score of 8, complication of infection Intraventricular catheter o Subarachnoid screw/bolt Epidural or subdural sensor Increased ICP (normal 10-15)= IRRITABILITY first sign, severe headache, decrease loc, dilated/ pinpoint pupils, altered breathing pattern (Cheyne-stokes), hyperventilation, apnea, abnormal posturing Lumbar puncture= w/draw CSF to diagnose MS, syphilis, meningitis, void b/f procedure assume cannonball position, monitor puncture site, remain lying still on back after procedure Complication= headache from leaking csf, give opioids/pain meds, increase fluid intake MRI= remove jewelry, not claustrophobic, give earplugs o w/ contrast dyes: assess for allergies for shellfish o no jewelry