Accident/Error/Injury Prevention - (1)

o Spinal Cord Injury: Care of a Client who has a Halo Device (Active Learning Template - Therapeutic

Procedure, RM AMS RN 10.0 Chp 16)

o The purpose is to provide traction and/or immobilize the spinal column

 Do not use the halo device to turn or move a client

 If the client goes home with a halo fixation device on, provide instruction on pin and vest care.

 Teach the client signs of infection and skin breakdown.

 Maintain body alignment and ensure cervical tong weights hang freely.

 Monitor skin integrity by providing pin care and assessing the skin under the halo fixation vest as

appropriate.

 Standard Precautions/Transmission-Based Precautions/Surgical Asepsis - (1)

o Bacterial, Viral, Fungal, and Parasitic Infections: Isolation Precautions for Client Who Has Influenza

(Active Learning Template - Basic Concept, RM FUND RN 9.0 Ch 56)

 Contact: Clostridium difficile, herpes simplex virus, impetigo, methicillin-resistant

Staphylococcus aureus (MRSA), vancomycin-resistant Staphylococcus aureus (VRSA)

 Airborne: Measles, varicella, tuberculosis

 Droplet (3-6 ft): Haemophilus influenzae type B (Hib), pertussis, mumps, rubella, plague,

streptococcal pneumonia, meningococcal pneumonia

 Tuberculosis: Priority Action for a Client in the Emergency Department (Active Learning Template - System

Disorder, RM AMS RN 10.0 Chp 23)

 Administer heated and humidified oxygen therapy as prescribed

 The client should be transported using the shortest and least busy route

 cough and expectorate sputum into tissues that are disposed of by the client into provided plastic

bags or no-touch receptacles

 Clients are no longer considered infectious after three consecutive negative sputum cultures

 Adverse Effects/Contraindications/Side Effects/Interactions - (1)

o Electrolyte Imbalances: Manifestations of Hypokalemia (Active Learning Template - Medication, RM

AMS RN 10.0 Chp 44)

 VITAL SIGNS:

 Decreased blood pressure, thready weak pulse, orthostatic hypotension

 NEUROLOGIC:

 Altered mental status, anxiety, and lethargy that progresses to acute confusion and coma

 ECG:

 Flattened T wave, prominent U waves, ST depression, prolonged PR interval

 GASTROINTESTINAL:

 Hypoactive bowel sounds, nausea, vomiting, constipation, abdominal distention.

Paralytic ileus can develop.

 MUSCULAR:

 Weakness. Deep-tendon reflexes can be reduced.

 RESPIRATORY: Shallow breathing

 Blood and Blood Products - (1)

o Blood and Blood Product Transfusions: Steps to Administer a Blood Transfusion (Active Learning

Template - Therapeutic Procedure, RM AMS RN 10.0 Chp 40)

● Verify the prescription for a specific blood product.

● Obtain consent for procedure if required.

● Obtain blood samples for compatibility determination, such as type and cross-match.