Comp 2 September 2024 PDF

Comp 2 September 2024 Types of play and know appropriate toys Apical or point of Maximal impulse (PMI): Apical, at the apex of the heart, and PMI, at the 5 intercostal pace, midclavicular th line; used for infants and children up to 3 years of age, placed in the su...

Comp 2 September 2024 Types of play and know appropriate toys Apical or point of Maximal impulse (PMI): Apical, at the apex of the heart, and PMI, at the 5 intercostal pace, midclavicular th line; used for infants and children up to 3 years of age, placed in the supine position, to determine discrepancies with radial pulse, and used in adults with conjunction with some diseases and medications and during a head to toe assessment Lung Sounds: Restraints Round every hour and document in patient chart or Joint comm will have your license-Ask Potty, Pain, Position Restraints need to be undone and circulation and skin checked every 1-2 hours ▪ Restraints should be used as a last resort ▪ Used when less restrictive interventions have been determined to be ineffective to protect client, staff, or others from harm ▪ Must be discontinued at the earliest possible time ▪ Restraints are used for 2 situations: 1. Nonviolent, non-self-destructive behavior (pulling out IV, pulling on ventilator tubing) 2. Violent, self-destructive behavior (harm to self, staff, or others) ▪ If suicidal/homicidal= nothing allowed in room and patient must be a one to one observation. ▪ Quick release tie ONLY to nonmobile part of bed/All 4 side rails=restraint ▪ Blood Transfusion ▪ Assess patient's cardiovascular status prior to initiating blood transfusion. Vital signs must be checked ▪ After 15 minutes, 30 minutes, and one hour. Continue checking vital signs every hour to monitor for a reaction to the blood. ▪ Stop transfusion immediately if patient has an allergic reaction and start normal saline; blood can only be transfused with normal saline using Y-type tubing.  ▪ A unit of whole blood must be infused over 3.5 - 4 hours; never over 4 hours. ▪ Nursing intervention for O+ patient receiving A+ blood would be to discontinue the infusion. ▪ Fresh frozen plasma (FFP) is administered as rapidly as tolerated to treat bleeding associated with a raised PT(>1.5 times normal) or aPTT (>2 times normal). ▪ Monitor for signs and symptoms of infusion reaction: headaches, chills, shortness of breath, hives, warmth over the body, or generalized itching Use larger bore needle (i.e. 20-gauge, 1 to 1-1/4 inch length peripheral catheter). SUCTION- Most hospitals use in-line suction systems on ventilator patients. Suctioning should ALWAYS be a sterile technique Suction is not applied while the catheter is inserted and suction should be limited to no longer than 10-12 sec on withdrawing the catheter. Pre-oxygenate with 100% oxygen for 30 seconds - 3 minutes prior to suctioning Always observe for cardiac arrhythmias and reported cases of cardiac arrests during suctioning and well documented. HYPEROXYGENATE PRIOR TO SUCTIONING SUCTION PRESSURE SHOULD BE 80-120MMHG Changing Trach steps: 1. REMOVE OLD DRESSING AND EXCESS SECRETIONS 2. SET UP STERILE FIELD 3. REMOVE THE DISPOSABLE INNER CANNULA AND REPLACE WITH NEW 4. CLEAN STOMA SITE AND TRACH SITE 5. SECURE NEW TRACH TIES IN PLACE 6. REMOVE SOILED TRACH TIES 7. REMOVE GLOVES AND WASH HANDS Remember when you think of THYROID think CALCIUM (the divorced parents Ca goes opposite ways) PARATHYROID think CALCIUM (the good kids Ca goes same way) ADRENAL think Sugar, SALT, Sex= lots salt (cushing)/no salt(Addison) Pressure/Tumor on a glad makes it hypersecrete =Increase !! Cardiac Always check your patient first not the rhythm Is the patient symptomatic? See them first! Does the scenario say they have a pulse? If not go straight to CPR IF IT HAS A QRS(TREE) ITS ATRIAL---- LOOKS LIKE WINGS =A.FLUTTER TXT-SYNCHRONIZED CARDIO VERSION-PT MUST BE ON FULL CARDIAC MONIOR AND RESUS EQUIPMENT ON STAND BY IF IT HAS A QRS(TREE) ITS ATRIAL—LOOKS LIKE ITS VIBRATING=A.FIB TXT=SYNCHRONIZED CARDIOVERSION- PT MUST BE ON FULL CARDIAC MONIOR AND RESUS EQUIPMENT ON STAND BY SUPER FAST CANT SEE P=SVT= TXT=ADENOSINE PUSH IT HARD AND FAST/ YOU WANT AN IV SITE CLOSEST TO THE HEART (EX AC) PT WILL HAVE AYSTOLE THEN PRAY FOR NORMAL RHYTHM AFTER IF I DONT SEE QRS (TREE) IT HAS TO BE VENTRICULAR —LOTS OF V’S=V.TACH TXT=AMIODARONE- PT MUST BE ON FULL CARDIAC MONIOR AND RESUS EQUIPMENT ON STAND BY IF IT DONT SEE A QRS (TREE) THEN I HAVE TO BE VENTRICULAR-LOOKS LIKE ITS VIBRATING=V.FIB TXT-D.FIB Biologic= most like me- I dont last long and get sick easily so I need to be on ABX a lot of times Mechanical=machine man made-I last longer but I will get  stuck after awhile so I need anticoags= Monitor PT/INR/bleeding precautions Neuro IMPORTANT -HOW DO WE CARE TO DECREASED ICP -AVOID CLUSTER CARE -QUIET ENVIRONMENT-----NON STIMULATING -HYPEROXYGENATE PT PRIOR TO SUCTION -AVOID HIP FLEXION THERES THAT LOG ROLL AGAIN!!! THAT MUST BE IMPORTANT Spinal shock normal for 2-4 days after injury so injury will look different after inflammation goes down. Remember C1- C2=death, C2-C5 monitor Respiratory, T6 and up=Autonomic Dysreflexia Look and monitor for Halo sign=CSF leakage=Emergency - - - - - Wound Care - Risk for wounds-Elderly, Obesity, Nutrition deficiency, immobile, sedentary, immunocompromised (cancer) - Healing Process- Phase 1=inflammation 3-4 days, Phase 2=prolife/new cells create 1-2 weeks, Phase 3=scar phase - Wound Intentions-Primary is pretty=surgical wound, Secondary is scary=trauma wound, Tertiary think leave open to close later. - Braden=know what makes it up=20 is normal so lower the number higher the risk -sensory, moisture, activity, mobility, nutrition, friction - Pressure ulcers- Stage 1(superficial nonblanchable intact=sunburn) - Stage 2(partial fluid filled/ruptured blister=bad sunburn) - Stage 3(adipose tissue, start to form slough/eschar) - Stage 4-(full thickness can go down to bone=osteomyelitis o Dehiscence (POP OPEN) or Evisceration wound(POP OPEN WITH ORGANS)(OBESITY)(ABD SX)and interventions – SALINE SOAKED DRESSING held onto wound dont leave the patient. Call for help ====ABD Binder  o Applying Heat or Cold therapy---HEAT FOR CIRCULATION,/ COLD IS FOR SWELLING= NO LONGER THAN 20MIN/BARRIER/NO ONE WHO HAS COMPROMISED CIRCULATION o Types of Dressings for each type of wound-----IF IT SHOWS ADIPOSE TISSUE (WET 2 DRY/DAMP 2 DRY) o SURGICAL= NONADHERENT dressing- tefla pad o Stage 1 and 2 or superficial wound-clear tegaderm o H’s-honey/hydros(ONLY ADD ON WITH A WOUND THAT HAS SLOUGH/ESCHAR)=rehydration/Autolytic debridement o Foams-Absorption o Alginates-Absorption o Mechanical debridement=think machine or human machine-wet/dry, wet/moist, jet bath, any force, high force irrigation o Sharps debridement-scraping o Chemical debridement-enzymatic –and chemical is used o Tunneling=hole that drops down in wound=use clock method to doc o Undermining=qtip under first layer of skin=use clock method to doc - o Drain Care (Hemovac & JP)—KNOW I/O use critical thinking with output according to time--- NONE FOR YOUR SHIFT ALERT or OVER 100ML in small period =ALERT o Know safety=pin to patient gown/always compress/never hang free/1-2 suture at site monitor for infection/dislodgement  o Penrose- tube with needle=simply a drain careful not to dislodge-not sutured in place - o Promoting wound healing & normal wound healing – VIT C, PROTEIN-lean meats(lean part of cow, deer) (organ meats-kidney/liver)-(Nuts)---if you see orange juice with any of them pick FACTITIOUS= IS IT TO SELF OR TO ANOTHER- BOTH DOES IT FOR PERSONAL GAIN(MONEY,RESOURCES,ATTENTION,ETC)—GYPSEY ROSE MALINGERING=LIE AND FABRICATE INJURY OR ILLNESS FOR PERSONAL GAIN Monitor meal times and stay with patient for up to an Hour after. Monitor/Eval PT room for vomit bags/food Distraction, Journaling, Group therapy, Individual Therapy REFRESH PSYCH MEDS BENZOS(Anxiety)/ANTIDOTE=FLUMAZENIL DEPRESSANTS-SSRI(SERTONIN SYNDROME)/MAOI(HTN EPISODES/NO THYRAIME) PSYCHOTICS-MONITOR EPS MOST IMPORTANT TARDIVE DYSKINESIA(LIP/TONGUE) NMS-FEVER, MUSCLE TWITCHING,RESTLESS=FATAL SCHIZOPHRENIA