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Do not delegate -ANSWER What you can EAT E-evaluate A-assess T-teach
Addison's & Cushings -ANSWER Addison's = down down down up down
Cushings= up up up down up
hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia,
hypo/hyperglycemia
Better peripheral perfusion? -ANSWER EleVate Veins, DAngle Arteries
APGAR -ANSWER Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)
Airborne precautions -ANSWER My chicken hez tb (measles, chickenpox (varicella)
Herpes zoster/shingles TB
Airborne precautions protective equip -ANSWER private room, neg pressure with 6-12 air
exchanges/hr mask N95 for TB
Droplet precautions -ANSWER spiderman! sepsis, scarlet fever, streptococcal
pharyngitis, parvovirus, pneumonia, pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room
or cohort mask!)
Contact precaution -ANSWER MRS WEE
Multidrug resistant organism
Rresiratory infection
Skin infection
Wound infection
Enteric infection (C diff)
Eye infection (conjunctivitis)
,Skin infection -ANSWER VCHIPS
Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies
Air or Pulmonary Embolism -ANSWER S/S chest pain, dyspnea, tachycardia,
pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of
bed.)
Woman in labor (un-reassuring FHR) -ANSWER (late decels, decreased variability, fetal
bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids!
Tube feeding with decreased LOC -ANSWER Pt on Right side (promotes emptying of the
stomach) Head of bed elevated (prevent aspiration)
After lumbar puncture and oil based myelogram -ANSWER pt is flat SUPINE (prevent
headache and leaking of CSF)
Pt with heat stroke -ANSWER flat with legs elevated
during Continuous Bladder Irrigation (CBI) -ANSWER catheter is taped to the thigh. leg
must be kept straight.
After Myringotomy -ANSWER position on the side of AFFECTED ear, allows drainage.
After Cateract surgery -ANSWER pt sleep on UNAFFECTED side with a night shield for
1-4 weeks
after Thyroidectomy -ANSWER low or semi-fowler's position, support head, neck and
shoulders.
Infant with Spina Bifida -ANSWER Prone so that sac does not rupture
Buck's Traction (skin) -ANSWER elevate foot of bed for counter traction
After total hip replacement -ANSWER don't sleep on side of surgery, don't flex hip more
than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip
abduction by separating thighs with pillows.
Prolapsed cord -ANSWER Knee to chest or Trendelenburg
, Cleft Lip -ANSWER position on back or in infant seat to prevent trauma to the suture line.
while feeding hold in upright position.
To prevent dumping syndrome -ANSWER (post operative ulcer/stomach surgeries) eat in
reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals,
low CHO and fiber diet. small, frequent meals.
AKA (above knee amputation) -ANSWER elevate for first 24 hours on pillow. position
prone daily to maintain hip extension.
BKA (below knee amputation) -ANSWER foot of bed elevated for first 24 hours. position
prone to provide hip extension.
detached retina -ANSWER area of detachment should be in the dependent position
administration of enema -ANSWER pt should be left side lying (Sim's) with knee flexed.
After supratentorial surgery -ANSWER (incision behind hairline on forhead) elevate HOB
30-40 degrees
After infratentorial surgery -ANSWER (incision at the nape of neck) position pt flat and
lateral on either side.
During internal radiation -ANSWER on bed rest while implant in place
Autonomic Dysreflexia/Hyperreflexia -ANSWER S/S pounding headache, profuse
sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting
position (elevate HOB) FIRST!
Shock -ANSWER bedrest with extremities elevated 20 degrees. knees straight, head
slightly elevated (modified Trendelenberg)
Head Injury -ANSWER elevate HOB 30 degrees to decrease ICP
Peritoneal Dialysis (when outflow is inadequate) -ANSWER turn pt from side to side
BEFORE checking for kinks in tubing
Lumbar Puncture -ANSWER After the procedure, the pt should be supine for 4-12 hours
as prescribed.
Myesthenia Gravis -ANSWER worsens with exercise and improves with rest
Myesthenia Gravis -ANSWER a positive reaction to Tensilon---will improve symptoms
Cholinergic Crisis -ANSWER Caused by excessive medication ---stop giving
Tensilon...will make it worse.