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mobility notes medsurg, Cheat Sheet of Nursing

alterations in molbility notes medsurg

Typology: Cheat Sheet

2024/2025

Uploaded on 05/09/2025

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ATI Medical-Surgical: Musculoskeletal – Subscale Topics and
Subtopics
1 Fractures and Immobilization Devices
Types of fractures (open vs. closed, comminuted, greenstick, pathologic, stress)
Priority assessments (neurovascular checks – 6 Ps)
Traction care (skin vs. skeletal traction)
Cast care and patient teaching
External and internal fixation devices
Complications:
Compartment syndrome
Fat embolism syndrome
Infection
DVT
Delayed union or malunion
2 Amputations
Types (AKA, BKA, upper extremity)
Pre- and postoperative nursing care
Prevention and management of complications:
Hemorrhage
Infection
Phantom limb pain
Flexion contractures
Priority assessments:
Skin flap integrity
Circulation and perfusion
Psychological support and body image
Limb shaping and prosthesis prep
3 Osteoarthritis vs. Rheumatoid Arthritis
Etiology and pathophysiology (OA = wear and tear; RA = autoimmune)
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🦴 ATI Medical-Surgical: Musculoskeletal – Subscale Topics and

Subtopics

1 ⃣ Fractures and Immobilization Devices

● Types of fractures (open vs. closed, comminuted, greenstick, pathologic, stress) ● Priority assessments (neurovascular checks – 6 Ps) ● Traction care (skin vs. skeletal traction) ● Cast care and patient teaching ● External and internal fixation devices ● Complications: ○ Compartment syndromeFat embolism syndrome ○ Infection ○ DVT ○ Delayed union or malunion

2 ⃣ Amputations

● Types (AKA, BKA, upper extremity) ● Pre- and postoperative nursing care ● Prevention and management of complications: ○ Hemorrhage ○ Infection ○ Phantom limb pain ○ Flexion contractures ● Priority assessments: ○ Skin flap integrity ○ Circulation and perfusion ● Psychological support and body image ● Limb shaping and prosthesis prep

3 ⃣ Osteoarthritis vs. Rheumatoid Arthritis

● Etiology and pathophysiology (OA = wear and tear; RA = autoimmune)

● Joint manifestations and deformities (RA: swan neck, boutonnière deformity) ● Medication management: ○ NSAIDs (e.g., celecoxib) ○ DMARDs (methotrexate, hydroxychloroquine) ○ Steroids (prednisone) ● Nonpharmacological interventions: ○ Heat/cold therapy ○ Rest vs. activity ○ Assistive devices

4 ⃣ Osteoporosis

● Risk factors (postmenopausal women, smoking, low Ca++/Vit D) ● Diagnostic testing (DEXA scan) ● Medication management: ○ Bisphosphonates (alendronate) ○ Calcium and Vitamin D supplements ● Fall prevention strategies ● Lifestyle modifications (weight-bearing exercise, smoking cessation)

5 ⃣ Back Pain and Herniated Disks

● Acute vs. chronic back pain ● Herniated intervertebral disks: ○ S/S of nerve compression ○ Diagnostic imaging (MRI) ○ Conservative treatment vs. surgical (laminectomy, discectomy) ● Body mechanics education ● Post-op spinal surgery care: ○ Logrolling technique ○ Neuro checks ○ Drain assessment

6 ⃣ Musculoskeletal Trauma and Emergency Care

● Strains vs. sprains ● RICE protocol (rest, ice, compression, elevation)

● Ankylosing spondylitis ● Paget’s disease ● Carpal tunnel syndrome ● Bursitis and tendinitis

🌬 ATI Medical-Surgical: Respiratory – Subscale Topics and

Subtopics

1 ⃣ Respiratory Assessment

● Anatomy and physiology review (upper/lower airway) ● Normal vs. abnormal breath sounds (crackles, wheezes, rhonchi, stridor) ● Pulse oximetry interpretation ● Arterial blood gases (ABGs) – interpretation of PaO₂, PaCO₂, HCO₃⁻, pH ● Sputum culture collection ● Early vs. late signs of hypoxia ● Assessing for respiratory distress: use of accessory muscles, cyanosis, nasal flaring

2 ⃣ Oxygen Therapy

● Nasal cannula, simple face mask, Venturi mask, nonrebreather mask ● High-flow vs. low-flow oxygen systems ● Humidification with oxygen ● Complications of oxygen use: oxygen toxicity, CO₂ retention ● Patient education for home oxygen use

3 ⃣ Airway Management

● Suctioning techniques (oral, nasal, tracheal) ● Tracheostomy care and suctioning ● Endotracheal intubation – nursing role during intubation/extubation ● Mechanical ventilation: ○ Settings (FiO₂, PEEP, rate)

○ Alarms (high pressure = obstruction, low pressure = disconnection/leak) ○ Complications: barotrauma, VAP (ventilator-associated pneumonia)

4 ⃣ Acute Respiratory Disorders

Pneumonia : ○ Risk factors (aspiration, elderly, immunocompromised) ○ Manifestations: fever, crackles, productive cough ○ Treatment: antibiotics, oxygen, fluids ● Asthma : ○ Triggers, bronchodilators (albuterol), corticosteroids ○ Status asthmaticus (life-threatening) ● COPD : ○ Emphysema and chronic bronchitis ○ Manifestations: clubbing, barrel chest, dyspnea ○ Medications: bronchodilators, corticosteroids, mucolytics ○ Oxygen therapy: target SpO₂ 88–92%, avoid high O₂ flow ● Pulmonary embolism : ○ S/S: sudden dyspnea, chest pain, tachypnea ○ Diagnostic: D-dimer, CT scan, V/Q scan ○ Prevention: anticoagulants, mobility ● Pneumothorax/Hemothorax : ○ Manifestations: tracheal deviation, absent breath sounds ○ Chest tube management and troubleshooting

5 ⃣ Chronic Respiratory Disorders

Tuberculosis (TB) : ○ Airborne precautions (N95, negative pressure) ○ Symptoms: night sweats, hemoptysis, weight loss ○ Medications: isoniazid, rifampin, ethambutol ○ DOT (directly observed therapy) for compliance ● Cystic fibrosis : ○ Respiratory & GI implications ○ Chest physiotherapy, enzyme replacements ● Sleep apnea : ○ CPAP use, lifestyle modifications

○ Pulmonary hygiene (incentive spirometer, deep breathing) ○ Early ambulation ○ Monitoring for respiratory complications (atelectasis, pneumonia)

🔟 Patient Education & Health Promotion

● Smoking cessation ● Use of incentive spirometer ● Flu and pneumonia vaccines ● Inhaler use (MDI vs. DPI technique) ● Breathing techniques: pursed-lip, diaphragmatic breathing ● Energy conservation techniques

Would you like this turned into a color-coded study guide, NCLEX-style cheat sheet , or test-ready chart with prioritization cues and red flags for each subtopic?

4o

You said:

test-ready chart with prioritization cues and red flags for each subtopic? also nursing process stops and nursing interventions in order of priority.

ChatGPT said:

Absolutely! Here's your test-ready respiratory system chart for ATI/NCLEX prep , organized by subtopic with:

Prioritization cues 🚨 Red flags 🧠 Nursing process steps (ADPIE) 󰟻 Priority interventions (in order)

🫁 Respiratory Subscale – NCLEX/ATI Test-Ready Chart

Subtopic Red Flags 🚨 Prioritization Cues

Nursing Process (ADPIE) 🧠

Priority Interventions 󰟻

Pneumonia Confusion in older adults, O2 sat < 90%, ↑ RR, crackles

Impaired gas exchange, ineffective airway clearance

A: Breath sounds, VS, ABGs, WBC D: Impaired gas exchange, risk for sepsis P: Maintain oxygenation, infection control I: O2, antibiotics, fluids, IS E: O2 sat > 92%, clear breath sounds

  1. Administer O
  2. Collect sputum culture
  3. Start IV antibiotics
  4. Encourage fluids/IS
  5. Position upright

COPD Wheezing, cyanosis, confusion, CO2 retention

Chronic hypoxia, risk for exacerbation

A: SpO2, ABGs, respiratory effort D: Ineffective breathing pattern P: Improve ventilation, prevent complications I: O2 (88–92%), bronchodilators, corticosteroids E: Decreased dyspnea, stable ABGs

  1. Apply low-flow O
  2. Administer bronchodilator
  3. Elevate HOB
  4. Encourage pursed-lip breathing
  5. Monitor for CO2 narcosis

Pneumothorax / Chest Tube

Tracheal deviation, absent breath sounds, sudden dyspnea

Impaired ventilation, tension pneumothorax risk

A: Breath sounds, chest expansion, O D: Impaired gas exchange P: Re-expand lung, prevent recurrence I: Chest tube care, monitor drainage E: Lung sounds return, O2 stable

  1. Monitor chest tube function
  2. Keep system below chest
  3. Report >70 mL/hr drainage
  4. Seal any disconnection with sterile dressing
  5. Monitor for subcutaneous emphysema

Mechanical Ventilation

High-pressure alarm, decreased breath sounds, agitation

Risk for VAP, impaired spontaneous breathing

A: VS, breath sounds, tube placement D: Risk for infection, ineffective breathing P: Maintain airway, prevent complications I: HOB >30°, suction, sedation, oral care E: Stable ABGs, no VAP

  1. Check alarm cause (obstruction/disconnection)
  2. Elevate HOB ≥ 30°
  3. Oral care Q2H with chlorhexidine
  4. Sedation protocol/PRN suctioning
  5. Daily sedation vacation

Tuberculosis (TB)

Night sweats, hemoptysis, weight loss, persistent cough

Airborne transmission risk

A: TB skin test, sputum AFB, chest X-ray D: Risk for infection transmission P: Isolate, initiate drug therapy I: N95 mask, airborne isolation, 4-drug therapy E: Negative cultures x

  1. Airborne precautions/N mask
  2. Private negative-pressure room
  3. Start RIPE therapy (rifampin, isoniazid, etc.)
  4. Educate on medication compliance
  5. DOT if needed

Oxygen Therapy

Confusion, O sat < 90%, restlessness

Hypoxia, risk for oxygen toxicity (esp. in COPD)

A: SpO2, respiratory effort, skin breakdown D: Impaired gas exchange P: Increase oxygenation safely I: Choose correct delivery device, humidify PRN E: SpO2 ≥ 92%, normal RR

  1. Apply appropriate device
  2. Titrate to order (watch for O2 toxicity in COPD)
  3. Assess skin under device
  4. Monitor SpO continuously
  5. Encourage coughing/deep breathing

Topic Key Nurse Teaching Points for New Nurses

Oxygen Therapy - Know each oxygen delivery device and its FiO₂ range (e.g., NC: 24–44%)

  • Always humidify O₂ >4 L/min
  • Watch for skin breakdown under mask/nose
  • In COPD, keep SpO₂ between 88–92%

Airway Management - Suction only when needed (gurgling, low SpO₂)

  • Keep suction sterile
  • Limit suction time to 10–15 sec
  • Monitor for hypoxia/bradycardia during suctioning

Tracheostomy Care - Use sterile technique

  • Keep extra trach, obturator, and ambu bag at bedside
  • Assess for signs of infection or displacement
  • Never change trach ties for first 24–48 hrs post-op

Chest Tubes - Always keep system below chest level

  • Monitor for continuous bubbling in suction chamber
  • Report output >70 mL/hr
  • Tape connections, check for leaks

Mechanical Ventilation - Know vent settings and alarms (high = blockage; low = disconnect)

  • HOB ≥30° to prevent VAP
  • Oral care q2h with chlorhexidine
  • Perform sedation vacations & assess readiness to wean

Pneumonia & COPD - Know difference between early/late hypoxia

  • In COPD, never give high-flow O₂ (can suppress drive)
  • Promote pursed-lip breathing, small frequent meals

Emergency Signs - Tracheal deviation = medical emergency

  • Silent chest in asthma = status asthmaticus
  • Sudden dyspnea + chest pain = suspect PE

ABG Interpretation - Know basic ranges: pH: 7.35–7. PaCO₂: 35–45 mmHg HCO₃⁻: 22–26 mEq/L PaO₂: 80–100 mmHg

  • Recognize signs of respiratory vs metabolic acidosis/alkalosis

󰰁 II. Teaching for Clients & Family Members (Simple, Safe, Empowering)

Topic Key Teaching Points for Clients & Families

Oxygen Use at Home - No smoking near oxygen

  • Store oxygen upright and secured
  • Avoid petroleum-based products on face
  • Check tubing for kinks; clean nasal cannula regularly

Inhaler Use (MDI/DPI) - Shake MDI before use

  • Exhale, then inhale slowly and deeply while pressing inhaler
  • Hold breath for 10 sec
  • Rinse mouth after steroid inhalers to prevent thrush

Breathing Techniques - Pursed-lip breathing : Inhale through nose, exhale slowly through pursed lips

  • Diaphragmatic breathing : Focus on belly rising
  • Use during dyspnea episodes

Signs to Report Immediately - Blue lips or fingers

  • Increased shortness of breath
  • High fever or productive cough
  • Sudden chest pain or confusion

Chest Tube Care at Home (if applicable)

  • Keep tubing coiled and below chest
  • Do not strip or milk the tubing
  • If tube disconnects: clamp briefly or place end in sterile water
  • Monitor for drainage changes

Preventing Infection (e.g., TB, pneumonia)

  • Cough/sneeze into tissue
  • Avoid crowds during flu season
  • Stay up to date on flu and pneumococcal vaccines
  • Complete full course of prescribed antibiotics

Lifestyle Modifications - Smoking cessation is the most important intervention

  • Eat small, high-protein meals if fatigued
  • Avoid extreme temperatures and strong scents
  • Use energy conservation techniques

Pulmonary Rehabilitation - Encouraged for COPD and chronic lung disease

  • Includes exercise, breathing training, and counseling
  • Helps improve quality of life and reduce hospital visits

O2 Sat < 90% Despite Oxygen

Even with oxygen therapy Indicates oxygenation failure

Stridor or "Silent Chest" No audible air movement in asthma or stridor post-extubation

Sign of complete airway obstruction

Restlessness, Confusion, Irritability

Especially in elderly or postop Early sign of hypoxia

Sudden Chest Pain + Dyspnea

Especially with tachycardia or hemoptysis Suspect pulmonary embolism (PE)

Post-Thoracentesis SOB or Chest Pain

With absent breath sounds Could indicate collapsed lung (pneumothorax)

New Onset Confusion in Elderly

Especially in patients with pneumonia or UTI

Can be a sign of hypoxia or sepsis

👣 Who Should the Nurse See First?

Use ABC , Maslow , and Safety First prioritization models:

Client Presentation See First?/

Why

Client with tracheal deviation & dyspnea

✅ YES – first Tension pneumothorax – life-threatening

Post-op client with SpO₂ 85% on room air

✅ YES –

second

Hypoxia – address breathing

Client with chest pain and tachypnea ✅ YES Suspect PE – high risk for sudden death

Client with asthma using accessory muscles

✅ YES Status asthmaticus can rapidly worsen

Client due for PRN pain med, stable vitals

❌ NO Comfort issue, not urgent

Client who needs assistance with ambulation

❌ NO Fall risk, but not life-threatening

Client scheduled for discharge teaching

❌ NO Can be deferred if others are unstable

Client who is confused but stable VS ❌ Maybe wait

Assess soon but not before respiratory distress cases

Client with cough and SpO₂ 94% ❌ No Mild symptoms – not priority

🧠 Nurse Test Tips – Prioritization Rules

Airway obstruction = first every timeO₂ sat < 90% = red flagThink: Airway > Breathing > Circulation > Safety > Comfort > TeachingConfusion + low SpO₂ = early hypoxia — act fastUse clinical judgment language from ATI: “First,” “Next,” “Immediate,” “Priority”

Would you like a printable prioritization decision tree or a set of NCLEX-style practice questions using these examples?

4o

You said:

nurse is discussing the greatest risk factors

ChatGPT said:

Absolutely! Here's a test-ready guide to help you discuss and identify the greatest risk factors —especially useful for ATI/NCLEX questions where you must recognize what puts a client at the highest risk for complications, decline, or mortality.

🧠 "Greatest Risk Factors" – Nursing Exam Strategy Guide

🔑 How to Approach These Questions:

  1. Use Clinical Judgment — Consider who has the greatest likelihood of harm or deterioration.
  2. Apply Maslow’s Hierarchy & ABCs — Prioritize Airway > Breathing > Circulation.

Condition Greatest Risk Factors Why it Matters

Tuberculosis - Homelessness

  • Incarcerated individuals
  • HIV or immunosuppressed clients
  • Foreign-born individuals

These groups have higher exposure and poor treatment access

Pneumothorax - Chest trauma

  • Tall, thin males (spontaneous)
  • Central line insertion
  • Mechanical ventilation

Risk for tension pneumothorax = medical emergency

ARDS - Sepsis

  • Trauma
  • Aspiration
  • Multiple blood transfusions

Causes refractory hypoxemia and multisystem failure

Mechanical Ventilation Complications

  • Sedation
  • Long intubation period
  • Improper oral care
  • Supine positioning

Risk for VAP and ventilator dependency

󰳋 When Teaching New Nurses: Focus on High-Risk Identification

Teach them to ask:

● Who is most likely to crash? ● Who has an unstable airway or breathing? ● Who has the most risk factors stacked together? ● What intervention could save a life?

🧩 Red Flag Risk Combinations to Teach Nurses to Watch For:

Combo Risk

Age > 65 + recent surgery + immobility Risk for PE or pneumonia

Confusion + low SpO₂ + COPD Early hypoxia – respiratory failure risk

Long-term steroid use + diabetes Infection risk (e.g., TB, pneumonia)

Central line + mechanical ventilation Sepsis or pneumothorax

Aspiration + dysphagia + altered LOC Aspiration pneumonia or ARDS

Airway swelling + stridor Obstructed airway (EMERGENCY)

Would you like me to turn this into a risk-factor flashcard deck , a bedside prioritization cheat sheet , or build scenario-based NCLEX questions from this content?

4o

You said:

which of the following is true manifestations

ChatGPT said:

Great! When you see a question that says "Which of the following is a true manifestation..." , it's testing your knowledge of expected signs and symptoms (S/S) for a condition.

Here’s how to approach this kind of question using the Respiratory system as an example:

🧠 Strategy for “Which of the Following is a True Manifestation?”

  1. Recall hallmark or textbook signs for that specific disease.
  2. Watch for distractors that are either opposite , not associated , or rare.
  3. Eliminate mild , nonspecific , or atypical symptoms unless the question stem is detailed.

🌬 Examples – True Manifestations by Respiratory Condition

Condition True ManifestationsNot True (Distractors)