Summary NURSING 2020 MODULES 2,3,4,5

Here are some key focus areas for Exam 2 which covers Modules 3, 4, & 5. Review course modules for information. You are responsible for all content in the chapters, power points, lecture notes, tables, red flags, figures, boxes, with special focus points on the following topics: Module 3 Tissue Integrity • Relate principles of triage to prioritize care delivery in a disaster situation. • Appraise the roles of the nurse in emergency preparedness and response. • Prioritize nursing care for the patient during the acute phase of burn injury. • Develop a comprehensive plan of care for a patient with alteration in tissue integrity. • Describe the physiological process involved in the maintenance and restoration of health and wellness, across the lifespan, as it relates to tissue integrity. o Burns Review RN delegation of tasks Infection prevention Hand washing and perform sterile dressing changes (LPNs can do dressing changes just reinforce that they have to be sterile) They also must have their PPEs on Understand how to support severely burned patients from resuscitation to discharge/rehab; identify priority actions in each phase Adequate fluid status during resuscitation phase by checking urine output; Priority for burn patient coming to ED are fluids; priority for patient that has been electrocuted make sure these patients are on a cardia monitor; what are potential consequences of burns are self-image and depression Treatment for patient that develops loud, brassy cough – what is going on here inhalation injury (They are about to lose their airway, so we want to get ready to intubate) You would do the same for a person who is having difficulty swallowing or drooling. Understand common medications administered to burn patients and why the medications are given i.e. for pain drug of choice is morphine, prevention of ulcers use Tagamet, famotidine, or ranitidine Understand nursing assessment of burn patient – what is continuously monitored – s/s to watch for i.e. drooling, difficulty swallowing-what does the nurse do first? Assess their airway and listen to their lungs; psychosocial impact of sever burn- would depression be normal? Yes Parkland Formula Parklands 4mlx Body Space Affects x kg, remember 1st half goes in the first 8 hrs. 2nd half goes in over the next 16 hrs. Use Lactated Ringer How to calculate BSA% Understand lab/ABG values for a burn patient i.e. what is typically seen in burn patients? Hyperkalemia, hyponatremia, and edema Describe the different layers of burns r/t involvement of dermis/epidermis Superficial Partial-Thickness Burn effects epidermis and superficial dermis. They are very painful and blister formation is common. o Disaster preparedness Understand colored tags and how would you educate others Yellow tag example: open fracture Red tag example: chest pain, suspected stroke/MI Green tag example: simple fracture Black tag example: agonal respirations, open head wound Understand personal preparedness plan – what do you include or consider? How many days should you pack for yourself? 3 What do you need to consider? Food, medication, water, non-perishable foods, pets, childcare, and older adults What does the RN need to do to be prepared on the floo Gather supplies Organize Move stable patients Know the chain of command Module 4 Gas Exchange • Develop a comprehensive plan of care for a patient with alteration in Gas Exchange. • Describe the physiological process involved in the maintenance and restoration of health and wellness, across the lifespan, as it relates to Gas Exchange. • Evaluate laboratory data and clinical manifestations to determine the adequacy of oxygenation and ventilatory interventions. • Plan nursing care for the patient being mechanically ventilated. o Emergency Nursing/Mass casualty/Trauma Nursing Role of RN in ED when there is a mass casualty? Triage- The most experienced nurse should do this Understand critical incident stress debriefing? Process what they just went though (destress) How to prevent PTSD as a nurse? Exercise, stay hydrated, eat healthy, get enough sleep, avoid caffeine, and talk to someone Understand how you would triage incoming patients from mass casualty – examples know the difference between traditional and mass casualty Traditional, you would take care of the most critical first. Mass casualty, take care of the most viable (most likely to live with the least resources)