ATI MEDSURG FOUNDATIONS OF NURSING CARE FOR ADULT CLIENTS

ATI MEDSURG FOUNDATIONS OF NURSING CARE FOR ADULT CLIENTSActual freezing of tissue fluid resulting in damage to the skin and underlying tissue 1st (superficial layers exposed) 2nd (blisters) 3rd (edema and blisters with no blanching) 4th (no blood supply with full necrosis) Frostbite Dopamine Heat Stroke Dobutamine 1 of 42 Definition respiratory support, circulation monitoring, IV fluids, assess tissue edema Q15-30 for bites, ABG's, glucose, coagulation, diazepam for seizures, reversing antidotes, dialysis Interventions to alleviate shock Interventions for client exposed to or who ingested a toxic agent Interventions for restoring effective circulation Influences to response to illness 2 of 42 Definition 1. Most important step in the primary survey 2. If clients are awake and responsive, airway is open 3. Head tilt chin lift maneuver is most effective technique; DO NOT perform if clients have a potential cervical spine injury 4. Modified Jaw Thrust maneuver if client is unresponsive with suspicion of trauma Ventricular Asystole Illness-Wellness Continuum Airway / cervical spine Poisoning management 3 of 42 Definition manual ventilation should be performed by a bag valve mask with supplemental oxygen or mouth-to-mask ventilation until a bag valve can be obtained Interventions to alleviate shock If client isn't breathing/breathing incorrectly Interventions for restoring effective circulation Pulseless Electrical Activity (PEA) interventions 4 of 42 Definition lightweight clothing, avoid excessive sun exposure, stay indoors, limit consumption of alcohol and caffeine, sunscreen, cold shower or bath Preventing Hyperthermia Disability Assessment Poisoning management Preventing Hypothermia 5 of 42 Definition BLS, ACLS, PALS Frostbite Nursing Actions Interventions to alleviate shock Emergency Nursing Principles Emergency Nurse Certifications