Rasmussen College:NUR 2755 MDC4 Final Exam Multidimensional Care IV _LATEST 2021/2022,100% CORRECT

Rasmussen College:NUR 2755 MDC4 Final Exam Multidimensional Care IV _LATEST 2021/2022 MDC4 Final Exam Why teach patient to deep breath and cough after surgery - prevent pneumonia Normal drainage for surgical site? - Clear (serous) or pale/red/watery (serosanguineous) Worrisome sign of post op patient?? - Restlessness Clearly if patient is presenting to ER with heat exhaustion, what is the priority action of the nurse? - IV Fluids Action is patient has bee sting. . if available? - Epi Community disaster preparedness, what would be an organization to help? - *Medical Reserve Corporation* FEMA Red Cross DMAT?? - Disaster Medical Assistance Team Federal employees License is good in ALL 50 states How many days of medical supplies should you have if needed for a disaster, just making a disaster plan? - 3 days Cimetidine for burn patients?? Why?? - Help with gastric ulcers Triage tags. . . what would we put on them to help?? - Name Age Injury (Anything to help identify) Any treatments we did Who we can contact/who has been contacted. Triage colors Gave double dose of medication, what to do first? - Assess patient What to do when patient comes back from surgery, and they're declining (rapid, shallow respirations, elevated heart rate, blood pressure dropping), what do you do?? - Call rapid response team Allergy exposure situation - more exposure to allergen the more risk to developing a reaction Patient in lithotomy position for surgery, where would their experience post op discomfort?? - Shoulders Why do we have drainage tubes/what's the purpose?? - To help prevent infection Why do we give a patient with multiple sclerosis Baclofen?? - To treat muscle spasms Patient with Parkinson's, when should you schedule their most demanding activities??? - When the drug therapy/medication peaks for them. Somebody that has a thrombotic stroke, what is important assessment item, especially in the first 24 hours?? - Pupil response to light/size Someone had an ischemic stroke and getting thrombolytic treatment, what are we trying to control in the first 24 hours?? - Blood pressure How to determine if patient can have tPA after stroke AFTER CT?? - Onset of symptoms within 3 hours. Long term Phenytoin therapy (seizures), what do we expect to see/a side effect, but we wouldn't stop the medication? (Expected side effect) - Excessive gum tissue growth *DO NOT STOP MEDICATION SUDDENLY* What would be a potential finding in postical phase of a generalized tonic clonic seizure what we would want to monitor for?? - Drowsiness Priority intervention in postical phase of tonic clonic seizure?? - Airway - assess breathing pattern Prep for an EEG?? They know they'll have one in the morning, so what prep do they need to do or not do beforehand?? - Can eat NO Caffeine What do you expect to see in a patient in ictal phase of generalized tonic clonic seizure?? - Jerking Stiffness Loss of consciousness Loss of bowel/bladder What to do when someone is coming out of a coma - had head injury and they're starting to wake up now after a few days what would we want to do??? - Orient them Decerebrate assessment - rigid arms, wrists/hands c shaped & flexed outward possible arched back Patient is getting IV heparin for a PE, what would PTT be at for therapeutic levels?? - Higher -- like if its at 25, we would want to increase the rate of heparin Gene Alteration CYP2C19 and history of PE, what to do to prevent further issues? - IVCF - Inferior Vena Cava Filter Mean Arterial Pressure, how to correlate with blood loss?? - Lower blood volume = lower MAP How to calculate MAP?? - Double the bottom number of blood pressure, add that to the top number and then divide by 3. Example: BP is 120/80, 80+80 = 160 160 + 120 = 280 280/3= 93.333 MAP would be 93. What to educate elderly patients on about rehydration to prevent shock?? - Increase fluids, drink on a regular schedule What lab value will be off in a patient with shock, septic shock? - Lactic Acid What to remember when determining triage or prioritization of patients?? - ABCs Sick calls and tension with staff after a long week of critical care patients, what is important to remember in this aspect - Debriefing External disaster examples - Tornado Flooding Hurricane When we see a patient passed out/unconscious at home, with cherry red skin color, what do we assume??? - Carbon monoxide poisoning Make sure that if a patient we did Parkland Formula, and still low urine output, what else can we do?? - Increase fluid rate Monitor urine output Check electrolytes Parkland formula - 4 mL x TBSA (%) x body weight (kg). 50% given in first 8 hours, 50% given over the next 16 hours. Patient with a burn, what electrolyte would we typically initially see with 3rd spacing of fluid?? - High potassium What patient would be at high risk for developing a PE?? - Hx of DVT Smoking Oral birth control Pregnancy Immobility Major long bone fracture Hx of falls Post Op patients How would you determine if patient is receiving good ventilation?? - Equal chest rise Stable vitals Skin color Capillary Refill What type of alarm would you hear if patient has mucous plug and needs suctioning?? - High pressure alarm initial phase of shock - MAP decreased by 10 mmHg from baseline. Mild vasoconstriction. Increased heart rate. Vital organ function is NOT disrupted. Indicators of shock are difficult to detect at this stage. THIS STAGE IS STILL REVERSIBLE. Nonprogressive phase of shock - MAP decreases by 10-15 mmHg from baseline. Moderate vasoconstriction. Increased heart rate and decreased pulse pressure. Chemical compensation. Decreased urine output, stimulation of thirst reflex, mild acidosis, mild hyperkalemia. Tissue hypoxia occurs in nonvital organs and in the kidneys but is not great enough to cause permanent damage. Restlessness, tachycardia, increased respiratory rate, falling systolic blood pressure, narrowing pulse pressure, cool extremities, and a 2%-5% change in oxygen saturation. THIS STAGE IS STILL REVERSIBLE. Progressive phase of shock - Decrease of more than 20% MAP. Anoxia of nonvital organs, hypoxia of vital organs. Moderate acidosis, moderate hyperkalemia, tissue ischemia. Some tissues die. Patient may have a sense of impending doom or "something bad". Patient may become confused and thirst increases. Rapid weak pulse, low blood pressure, pallor to cyanosis of oral mucosa and nail beds, cool and moist skin, anuria, and 5%-20% decrease in oxygen saturation. Refractory phase of shock - FINAL PHASE Final stage and also irreversible stage. Occurs when too much cell death and tissue damage has happened. Vital organs have extensive damage and cannot respond effectively to interventions, so shock continues. Severe tissue hypoxia with ischemia and necrosis. Buildup of toxic metabolites. MODS. Death. When patient presents to ER with suspicion of sepsis, what to do in the first few hours?? - Lactic acid Blood cultures Antibiotics AFTER blood cultures How to calculate TBSA? - A&P head: each 4.5% (9% entire head) A&P chest: 18% each A&P arm: 4.5% each side on each arm (9% entire each arm) A&P leg: 9% each side, each leg. (18% entire each leg) Groin: 1% Deep partial thickness burns - Red to white Moderate Edema Yes pain Blisters are rate Yes eschar (its soft and dry) Healing time is 2-6 weeks Grafts can be used in prolonged healing time What happens to a patient that has drowned? - Alveoli are collapsing, and pulmonary edema occurs What kind of scenarios would we see hospital disaster plan activated?? - Large influx of patients Example: explosion Wellness for nurses to prevent burn out and PTSD - Counseling Encourage & Support coworkers Monitor each other's stress levels Take breaks when needed Talk about feelings Drink plenty of water Healthy snacks for energy Keep in touch with family, friends and SO Do not work more than 12 hours How do we treat frostbite? - rapid rewarming: bath with warm water, pain management What are some concerns with frostbite? - Edema and swelling -- elevation above level of heart. Patient has overheated, hot to touch, flushed face and passed out at a sporting event. (Heat Stroke). What do we do? - Get out of the sun, hydration (sips), cool them down - get clothes wet. The priority is to get them out of the sun and into the shade and cool them down! With overheating/heat stroke, do we want to cause shivering?? Why or why not? - No! Shivering is the body's was of warming the body. What other symptoms (objective findings) would you see in a patient that overheated/heat stroke? - Sweating lightheaded/dizzy confusion/hallucinations elevated heart rate (could be irregular) elevated blood pressure decreased urine output Come upon a car crash with multiple victims, what is priority/what patient is at biggest risk? - Airway/breathing issue first Term for initial surveillance of injury - triage How to teach CNA easiest way to cool down a patient? - Remove clothing & blankets Frost bite 2nd degree - large clear-to-milky fluid filled blisters develop with partial thickness skin necrosis. *Redness and blisters filled with fluid* In a patient with hypothermia what are we concerned about with the heart? and why do we monitor the heart? - To watch for serious arrhythmias What causes serious arrhythmias in patients with hypothermia?? - Blood pooling in the extremities, blood is shunted from getting to the heart. Therefore, lactic acid lab will be abnormal. This will cause the arrhythmias. What will we HEAR with a pneumothorax? Expected finding - Diminished breath sounds What do you see with a flail chest? The most distinctive sign?? - Paradoxical chest movements What is the initial reaction for a low-pressure alarm, what would you check first?? - low pressure alarm = not getting enough oxygen. Bag the patient manually. High pressure alarm, absent breath sounds in right upper chest what is it likely to be?? - Pneumothorax Patient has head to toe trauma and at risk for developing ARDS, what is the earliest sign? - Increased respiratory rate What is the most common first symptom with a patient with a PE? - Chest pain Pain response in an unconscious patient? (peripheral pain response) - Squeezing the nail beds What are measures for a patient with a head injury, how do we prevent increase intracranial pressure? - Decrease stimulus Slow movements Don't cough hard or blow nose Deep Breaths Slow exhale to help with pain control Patient has clear fluid coming from nose, what tests would we do or see? - Positive for glucose Yellow halo on white linen or filter paper Patient with spinal cord injury, how to lessen change of AD? - Bowel/Bladder Program How to know if spinal shock is still continuing in a spinal cord injury patient? - Absent/decreased reflexes **Protect the head! Patient is having a seizure, what would you do? - Left side Lay flat loosen clothing padded side rails protect head suction at bedside SAFETY! Patient had a stroke and having homonymous hemianopsia after, how do we help them? - Check all fields (turn head side to side) Myasthenia Gravis: how do we prevent chlorogenic crisis? - Medication regimen Parkinson's: how to help maintain mobility?? - encourage mobility Bradykinesia (Slow Movement) - rocking back and forth to get up helps with this Gillian Barre Syndrome: what would be something that could have happened in the recent history that you would want to ask that happened?? - Infections/Virus in the last month What can you do for a Gillian Barre Syndrome patient?? - Active listening Support System Encourage/Positive Feedback How does paralysis occur with Gillian Barre Syndrome?? - Ascending (bottom up) First signs of meningitis? - Positive Kernig sign Positive Nuchal rigidity Positive Brudzinski sign Halo device: should a patient drive? - NO- patient should NOT drive