NUR2502 Multidimensional Care III Final Exam Outline MDC IV,100% CORRECT
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NUR 2502 NUR2502 Multidimensional Care III
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NUR 2502 NUR2502 Multidimensional Care III
NUR2502 Multidimensional Care III Final Exam Outline MDC IV
• Autonomic Dysreflexia:
S/S:
Sudden rise in BP with Bradycardia. Profuse sweating above Injury. flushing of skin. Blurred/Spots in vision. Nasal congestion
Causes:
Urine Retention!
Sympathetic Nervous System is Stimulated = Pa...
nur2502 multidimensional care iii final exam outline mdc iv
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NUR2502 Multidimensional Care III Final Exam Outline MDC
IV
• Autonomic Dysreflexia:
S/S:
Sudden rise in BP with Bradycardia. Profuse sweating above Injury.flushing of
skin. Blurred/Spots in vision. Nasal congestion
Causes:
Urine Retention!
Sympathetic Nervous System is Stimulated = Patient Goes into Overdrive
Straight Cath
Bladder Distention/UTI Constipation Pain, Temp Fluxuations GI, GUVascular
Stimulation
Interventions:
AD is neurologic emergency & must Be Promptly treated to prevent
Hypertensive Stroke!
If pt experiences AD, raise head of bed immediately to help reduce BP. Place
pt in a sitting position (First Priority!), or return to previous safe position.
Check for urinary retention or Catheter Blockage:
Check urinary catheter tubing (if Present) for Kinks or Obstruction.
1. If Urinary Catheter is not present, check for Bladder Distention &
Catheterize immediately if indicated:
2. Consider using anesthetic ointment on tip of catheter before catheter
insertion to ↓ urethral irritation.
Determine if Urinary tract infection or Bladder Calculi (Stones) are
contributing to genitourinary irritation.
Check pt for Fecal Impaction or other colorectal irritation, Using Anesthetic
Ointment at rectum. Disimpact if needed.
Examine skin for new or worsening pressure injury s/s. Monitor BP q 10-15Min.
Give Nifedipine or Nitrate to Lower BP. Paralytic Ileus may develop within72 hrs
of Hospital Admission.
• ARDS:
↑ Alveolar Permeability + Leaking of Fluid = Alveolar CollapseARDS
Causes:
,Systemic inflammatory response, more Edema, Surfactant going downafter
lung injury or illness
Intubated & Sedated, Antibiotics, Fluids
Sepsis. Burns. Pancreatitis. Transfusion. Trauma. Diffuse Pulmonary Infection -
Gastric Aspiration. O2 Toxicity. Lung Contusion
ARDS S/S:
Persistent Hypoxia (Even w/ O2 Therapy). Dyspnea. ↓ Pulmonary Compliance.
Non-Cardiac Pulmonary Edema
ARDS Diagnosis:
Refractory Hypoxia
Chest X Ray Shows Glossy + White out (Diffuse Patchy Infiltrates) Normal
Wedge Pressure
- pO2/FIO2 < 200
ARDS Phases:
Injury (Exudative) Phase = Alveolar Collapse. Early changes of dyspnea &
tachycardia. Alveoli fluid filled, pulmonary shunting, Atelectasis. Provide O2
Refractory = Hypoxemia
Reparative (Proliferative) Phase = Decreased Lung Compliance
Fibrotic Phase = Surfactant Cells Are Damaged
ARDS Treatment: Intubation/mechanical ventilation (PEEP high - monitorfor
tension pneumothorax) Treatment options do not reverse or treat the lung
damage that has occurred. Treatment is centered around preventingfurther
lung damage and treating underlying cause such as sepsis.
Positioning: prone to promote lung drainage. ↑nutrition to prevent
difficulties weaning from vent
• Assessing in emergencies
• Activation of HICS
• Bee sting:
1st aid for bee sting treatment-remove stinger-ice or cool water compress-
antihistamine (oral or topical) Epi, then O2
• Burns:
Management
1st hour is critical.
Airway & breathing is top priority, then circulation. Next is limiting extent ofinjury
& maintaining function of vital organs.
Resuscitation Phase
, Resuscitation phase is 1st intervention that takes place with victim.
begins at time of injury & can last up to 48 hrs.
Focus is on: Fluid imbalance (loss). Edema. Blood flow (perfusion). Priorities:
Airway. Provide oxygen therapy. Evaluate for direct airway injurythat occurs by
inhalation of smoke, heat, or chemicals.
Ask about: Source; Duration of exposure; Was fire in enclosed space? If hair is
singed off, or skin is burned further, assess inside of mouth for Debris;
evaluate inhalation injury by soot around nose
pt may become progressively hoarse/may drool or have difficulty breathing;
Listen for wheezing, stridor, crowing
BE ALERT FOR THESE AS IT INDICATES THAT THE CLIENT IS ABOUTTO LOSE THEIR
AIRWAY.
Support circulation & organ perfusion = accomplished by fluid replacement Be
alert for s/s of pulmonary edema; Be cautious with diuretics to ↑UO. Rather,
adjust fluids to ↑ UO.
Electrical burns can cause damage to muscles which can release
myoglobulin into bood which can cause acute renal failure.
Pain management
Prevent infection = wound care
Maintain body temp
Labs:
Hemoglobin/Hematocrit
Blood urea nitrogen
Glucose
Electrolyte panel
ABGs
Meds prophylaxis in burn pts: mafenide acetate, silver sulfadiazine, silver
nitrate solution, silver-impregnated dressings
Opioids- morphine, hydromorphone
Nonopioids – paracetamol, dipyrone, selective cyclooxygenase 2
inhibitors [COX 2 enzyme responsible for pain & inflammation], for
neuropathic pain gabapentin or pregabalin
Asepsis. Early detection. Minimize weight loss. Promote positive Self- image -
grieving process Kubler ross. Maintain mobility. Positioning. ROM.Ambulate. Wear
pressure garments 23 of 24 hrs-educate importance. electrolyte imbalances asoc
w/ burns:
Acid-base imbalances:
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