11/15/23, 11:18 AM Galen College Nur 283 comp 1
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Galen College Nur 283
Comprehensive 1 Exam 1.Priority= ABC’s; safety ; who will die first!!!! a.Triage 1 client w/ multiple compound fractures and reporting chest painst b.Report to HCP pt who has drainage that has was serosanguineous and has not become sanguineous c.See patient first who polycystic fibrosis is bleeding with black tarry stool d.Pt w/ asthma suddenly stops wheezing e.Pancreatitis with pain upon inspiration 2.Delegation= LPN vs UAP within scope a.UAP- change linens, VS NOT NEW ADMIN, REMIND, administer tap water enema (NOT FLEET). Document drainage, Output i.UAP turns patient every 2 hours ; or can recheck VS 2 hours after kidney biopsy
b.LPN- Reinforce teaching, enteral feeding , PPN, Meds, PO SQ, IM, IV (isotonic) monitor , 24 hr post op, wound care 3.Unit assignment= related to nurses skill set if from MedSurg, ortho ect, a.OB nurse gets appendicitis patient 4.Management – use translator ...speak with eye contact patient NOT translator 5.Nurse suspect child abuse. Nurse should first a.Assess/ Obtain detail bruising 6.Signs of labor = a.True labor S/S= bloody show , water breaks, contractions increase freq, duration, intensity , Cervix dilated 10 cm , effacement 0-100% (cervix thinner shorter) i.Regular contractions= increase in freq , duration, intensity , DOES NOT decrease with rest b.False Labor – Braxton hicks= disappear with walking or position changes i.Irregular contractions alleviated with rest or position change, no changes to 7.Stage 1 of labor= Active, laten post labor expected ; Normal FHR 1 10-140 a.Late decelerations tell Dr as priority b.Pt is 2 stage of labor FHR decrease = turn patient to the left 1 ( least invasive)nd st c.Stage 1=contractions=cervix dilation i.1. Early/latent phase (early education 0-3 cm, dilation, monitor FHR) ii.2. active phase (breathing technique, pain management, cervix 4-7cm, continue, OXYTOCIN, EPIDURAL, IV narcotics slowly over peak of contractions), iii.3. transition phase (8-10cm, 100% effacement, ANXIETY & VOMITY , urge for BM, Push @ 10cm, BLOODY SHOW assess amniotic fluid, emotional support, breathing techniques ONL Y PUSH @ 10cm) d.Stage 2 delivery of baby (cervix 100% effaced 10cm dilated, urge to bear down, Fergueson reflex) position= high fowler's, lithotomy , side-lying (assess- FHR, freq, duration,) e.Stage 3 delivery of placenta= high risk for infection, uterine inversion (NEVER pull cord), give PITOCIN f.Stage 4 postpartum recovery (check bleeding peri pads (report fully saturated in 1 hr , infection over 100.4 report) 2-4 hours after birth= breastfeeding and skin to skin i.Interventions= check fundus 1st 3 times every 5 m ins then every 15 m ins , void (every 2-
3hrs) or use cath, Pitocin IV or IM, breast feeding, ii.Treatment for boggy fundus-fundal massage, void, oxytocin, methergine (increases BP) iii.Lochia= Rubra/ dark red 3-4 days; Serosa/ pink brown= 4-10 days; Alba/ white/yellow= 10-28 days iv.Peri-care- Squeeze peri-bottle with warm water , front to back wipe, blot area, v.Report bloody fluid should be clear vi.If FHR is 180 turn mom to left side vii.Report late deceleration 11/15/23, 11:18 AM Galen College Nur 283 comp 1
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8.Injections time frames a.Intradermal = can be delegated to LPN, forearm, return to office 48-72 hrs after injection; if date missed must receive again after 7 days; 25-27 gauge.25- .5 length, 5-15 needle angle; 0.1mL i.Positive TB induration 10mm Begin Airborne precautions ii.PPD- not 22 gauge should be 27 gauge b.SubQ - 26-30 gauge 1.5mL or less, pinch skin insulin or heparin ; obese 90 45 degree angle;
degrees; i.Insulin best absorbed thru abdomen c.IM- 22-25 length 0.5-1inches; 90 degrees, 1-2mL (in deltoid)= ventral gluteal, Dorso gluteal, deltoid; infants 0-12 months vastus lateralis; Z track
d.IV- immediate absorption 9.Ostomy care = bag and wafer; pat skin dry , apply barrier cream only 2cm from stoma; wafer should 1/8 cm larger than stoma; empty pouch 1/3 full; DO NOT empty 30 mins after eating a.NORMAL Red beefy = fresh new ostomy;OR pink moist normal; REPOR T: pale, gray , blue, dry stoma= no blood flow b.Teach – ileostomy watery stools; 10.NOT ready for discharge a.New med, unstable, acute S/S ect, 11.S/S MI = heart attack = unstable angina, chest pain, left substernal pain, sudden, crushing chest pain, left arm, jaw , heartburn, SOB, N/V abd pain, diaphoresis, dusky skin a.Risk factors-SODDA= stress, obesity (BMI over 25), Bad diet, Diabetes & HTN, African American males over 50 i.Is receiving treatment heparin; non-stemi = sent to cath lab b.Dx- EKG (within 10 mins), TROPONIN over 0.5, c.Treatment = Oxygen, A spirin, Nitro (no fils, sublingual, take while sitting), Morphine; CA TH LAB ;
angioplasty (stent; iodine CONTRAST (feels warm), lie flat/supine after), bypass, thrombolytics
TPA (2-6 hrs of initial MI) i.Home teaching after angio= NO heavy lifting, NO bath ( can shower), monitor redness, warm, drainage at incision report ; low Na diet, reduce stress, caffeine, cholesterol, exercise 5 days a week 30 mins; stop smoking, sex after 2 flight of stairs without SOB) ii.Heparin – PTT 46-70 antidote Protamine sulfate d.ST elevation = NO o2 hyperkalemia; major blockage, treatment: STEMI thrombolytic
e.ST depression aka NON STEMI= low o2= hypokalemia, mild blockage; NEVER THROMBOL YTIC; NON STEMI = cath LAB
i.If neg for MI = stress test w/ exercise (stop if chest pain or ST changes) or chemical
stress test ( 48-24hrs before caffeine/ decaff, no beta blockers, calcium channel blocker , theophylline ) no eating or drink 4hrs before and after 12.interventions burn patient-IV lactated ringer or IV 0.9% normal saline; (isotonic); (fluid resuscitation working if 30mL/hr or more, BP , HR), TPN (increase nutritional intake), prevent infection ( immunocompromised) a.Labs- high K over 5.0; (tall peaked t wave); low Na below 135, elevated H&H and hematocrit; dehydration low urine output under 30/ml per hour b.Rule of 9= front surface head/neck, left arm and right arm= 4.5% each; front surface of chest/ trunk, left leg and right leg 9% each, perineum 1% c.Parkland formula= 4mL x kg X TBSA%= within 1 24 hours st ( ½ in 8hrs ; ½ in 16hrs )
d.After burn teaching= water-based lotion, pressure garments, exercise daily ROMs, sunscreen ,
protective clothing e.Types of burns= i. 1st degree=superficial- dry blanchable ii.2nd degree-partial thickness-blisters , red moist, shiny filled vesicles 1.Treat=cool water , no ice, no creams to open skin, cover area clean dry cloth,
