General Nursing PDF

General Nursing #1 Priority- ABC’s 1. Airway 2. Breathing 3. Circulation Maslow’s Hierarchy ABC’s Safety Comfort (Pain) Psychological Social Spiritual When in distress, DO NOT ASSESS! Fire Safety RACE - rescue patients at risk, activate alarm, contain fire by closing doors and...

General Nursing #1 Priority- ABC’s 1. Airway 2. Breathing 3. Circulation Maslow’s Hierarchy ABC’s Safety Comfort (Pain) Psychological Social Spiritual When in distress, DO NOT ASSESS! Fire Safety RACE - rescue patients at risk, activate alarm, contain fire by closing doors and windows, extinguish fire if able Prevention Types Primary Preventing disease or injury Ex: educating on first aid Secondary Treating patients who are injured Ex: emergency department, triage Tertiary Follow-up care Nursing Process: 1. Assessing - gather information 2. Diagnosing - name the problem 3. Outcome/Planning - develop plan of care 4. Implementing - perform nursing interventions 5. Evaluating - did interventions work? Order of Assessment *In kids, go from least to most invasive Pulse Strength 0 absent, 1+ weak, 2+ normal, 3+ bounding Arterial Blood Gases Before drawing an ABG, perform the Allen’s Test to check for sufficient blood flow ABG needs to be in a heparinized tube (blocks clotting cascade) Put on ice immediately after drawing  General Nursing Burns #1 priority: Maintain a patent airway Rule of 9s 9= head 18= arms 36= torso 36= legs 1= perineum Parkland Formula Calculation for the total fluid requirement 24 hours after a burn 4ml x Total Burn Surface Area x body weight (kg) = Total fluid pt will receive in 24 hrs 50% given in the first 8 hours 50% given in the next 16 hours 1st Degree- red and painful 2nd Degree- blisters and edema 3rd Degree- no pain due to nerve damage Burn Types NI: airway patency (intubation may be necessary), give O2, assess vital signs, give IV fluids, assess for paralytic ileus, pain management, assess for s/sx of infection Glasgow Coma Scale  General Nursing Cranial Nerves Cultural Jewish: no meat and milk together Greek: puts protective charms on baby’s neck to avoid eny from others Blood O- universal donor AB + is the universal recipient Patients who are Rh negative should NOT receive Rh positive blood Blood Transfusions Stay with pt for first 15 minutes Multiple blood transfusions = risk for hyperkalemia Transfusion reactions s/sx: fever, SOB, hypotension, fever, dizziness If reaction occurs: STOP transfusion, start IV line with NS, call MD and blood bank, monitor pt for s/sx Compartment Syndrome Emergency situation caused by increased pressure and restricted blood flow to an extremity, which results in pain and paresthesia Requires immediate action, as damage is irreversible after 4-6 hours 5 P’s: pain, paresthesia, paralysis, pallor, pulselessness NI: notify MD, fasciotomy to relieve pressure, loosen cast Sucking stab wound Dress wound and tape it on 3 sides so air can escape Do NOT use occlusive dressing Next steps: get chest tube tray, labs, and start an IV Chest Tube If it is accidently removed, use occlusive dressing taped on 3 sides (allows air to escape and prevents tension pneumothorax) If it becomes disconnected, do NOT clamp Place the end of the tube in a container of sterile saline (or water if saline not available) Fluctuations = good (fluid moves up with each inspiration and down with expiration) mean the chest tube is working No fluctuations → check for kinked tubing, occlusions, or ask patient to change position Continuous bubbling when the chest tube is connected to suction → air leak Safety in the patient’s room Ensure all the wheels are locked and bed is in lowest position Having all 4 side rails up is a form of restraint (even in patients who are considered a fall risk)  General Nursing Pressure Ulcer Stages Don and Doff Order Precautions Contact Gloves, gown *water and soap for c. diff Mrs. Wee M - multidrug resistant organism R - respiratory infection S - skin infections (herpes simplex, impetigo, scabies) W - wound infections E - enteric infection (c. diff) E - eye infection Droplet Gloves, gown, face mask, eye shield Spiderman S - Sepsis, streptococcal pharyngitis, scarlet fever P - Pneumonia, pertussis, parovirus B19 I - Influenza D - Diphtheria E - Epiglottitis R - Rubella M - Meningitis, meningeal pneumonia, mumps An - Adenovirus Airborne Standard Precautions + gloves, N95 mask MTV M - Measles T - Tuberculosis V - Varicella Zoster