Exam 1
Triage, Heart, Shock
Triage, Heart, Shock
WHOS GETTING A RED TAG? (Triage)
1) Dislocated right hip and an open fracture of the right lower leg
2) Large contusion to the forehead and a bloody nose
3) Closed fracture of the right clavicle and arm numbness
4) Multiple fractured ribs and shortness of breath
PART 2
Which level trauma center can provide full continuum of trauma care for all clients?
4 - LIFE THREATENING: Possible Pneumo
1 & 4 Urgent - 30 minutes to 2 hours for definitive care
2 - Non urgent - walking wounded
Disaster Triage Tag System (Mass Casualty Conditions)
Emergent (Class I) Immediate threat to life/limb, Airway obstruction, shock
Urgent (Class II) Major injuries that require treatment (can wait a short time) Open fractures with distal pulse, large wounds requiring treatment within 30 min – 2 hours
Nonurgent (Class III) Minor injuries that do not require immediate treatment, (“walking wounded”) Closed fractures, sprains, strains, abrasions, contusions
Expectant (Class IV) Dead, Expected to/allowed to die Massive head trauma, extensive full-thickness body burns, high cervical spinal cord injury requiring mech. Vent.
LEVEL 1 - HIGHEST
Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients.
Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers
Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support then transfer
How is hepatitis B spread?
Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. (C is the same)
Hepatitis A is spread through ingestion of contaminated shellfish.
D - Need B first
E - international travelers/contamination
Identify the function of the following cells:
Suppressor T cells
Memory cells
Natural Killer cells
Suppressor T cells - prevent hypersensitivity
Memory cells - sensitized B cells to make immune response faster in re-exposure to pathogen
Natural Killer cells - seek and destroy
Signs of ovarian cancer and risk factors
"Think ovarian"
Vague GI symptoms
Mild symptoms for several months, abdominal pain or swelling, unexpected weight loss, vaginal bleeding
page 1461 middle to older age, BRAC mutations, nulliparity, hx endometriosis or breast CA
What is sickle cell disease
Nursing interventions for sickle cell crisis
Patient education to prevent crisis
Autosomal recessive inherited disease in which abnormal hemaglobin causes chronic anemia pain, disability, organ damage, increased risk for infection, and early death due to decreased perfusion
Page 796 - oxygen, pain, hydration, remove constricting clothing, room temp >72, no BP, check CMS
Page 797 - drink 3-4L/d, avoid alcohol, smoking, extreme hot/cold temperatures, strenuous physical activity
Name 3 risk factors for sepsis and septic shock
page 743
malnutrition, immunosuppression, large open wounds, HIV, age >80, DM, CKD
Prevention
Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change.
What is cholelithiasis?
AND
Nutrition education
GALLSTONES
Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods.
Cholecystitis - risk factors (PG 1178) 4 F's
S/S PG 1179 - pain radiating to right shoulder, anorexia/malabsorption of fats, flatulence, fullness, jaundice, clay colored stools, dark urine, steatorrhea
Identify who is at risk for stroke
AND
Health promotion to prevent strokes
Hypertension, atherosclerosis, cardiac disease, genetic factors
Table page 900
Aspirin when appropriate, blood pressure control, cholesterol management, and smoking cessation (ABC'S)
Risk factors for breast cancer
Page 1436
Genetic factors (family history)
age >65
breast density
nulliparity or first pregnancy after 30 years old
early menstruation (younger than 11) or late menopause (older than 55)
Hormone replacement therapy
obesity
Identify what each type of hypersensitivity is and an example of each
Type I, Type II, Type III, & Type IV
Type I - Anaphylaxis, characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse. Hay fever, asthma
Type II/BLOOD - Cytotoxic reaction, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign
Type III/Immune Complex hypersensitivity involves immune complexes formed when antigens bind to antibodies. Systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and bacterial endocarditis, autoimmune diseases.
Type IV/delayed, also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen - transplant rejection, TB testing, poison ivy
Differentiate signs and symptoms of left vs right sided heart failure
AND
Patient education for monitoring for worsening CHF
Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system.
Right-sided heart failure occurs with problems from the pulmonary vasculature onward including pulmonary hypertension. Signs will be noted before the right atrium or ventricle including dependent edema.
Heart healthy diet (low fat, low sodium), monitor intake and output to prevent dehydration and overload, and take medications as prescribed. Daily weights for fluid retention.
Ventilator Bundle - proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, frequent oral care, preventing aspiration, suctioning as needed
Tell us everything you can think of about HIV & AIDS
In HIV, CD4+ cells begin to create new HIV particles. "Hijack CD4 T cells as virus factories".
Macrophages also stop functioning properly.
Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection.
People infected with HIV are infectious in all stages of the disease. Only true prevention is abstinence.
CD4 cell count <200 = AIDS
Standard Precautions
AIDS wasting syndrome, diarrhea, AIDS dementia complex, immunocompromised, opportunistic infections
Needle sticks - go to ER, wash with soap and water, PEP (& PREP for at risk), incident report
Post-op care for patients after hysterectomy
AND
patient education
Page 1456
VS, temperature, Head to toe assessment, bleeding at the site, I&Os, perineal care, less than 1 saturated pad in 4 hours
Page 1457
No longer have a period, become pregnant, may experience s/s of menopause, no heavy lifting, no sexual intercourse, report fevers, pain or burning with urination
Provide patient education for a cerebral angiography and post procedure care
Cerebral angiography is performed by threading a catheter through the femoral or brachial artery to check the blood flow through the brain. The extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation by noting skin color and temperature, presence and quality of pulses distal to the injection site, and capillary refill. Clients usually are on bedrest. The client is not given general anesthesia
What is atrial fibrillation, who is at greatest risk, complications of afib and interventions to minimize complications
What is the Whipple procedure?
Why is it done?
AND
Post-op monitoring
To treat tumors and other disorders of the pancreas, intestine and bile duct.
Removal the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct.
Complications secretions that drain from a fistula and peritonitis.
Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.
Normal ICP range
How to calculate CPP
Ways to prevent increased ICP
Signs of increased ICP (Early and Late)
Normal ICP = 10-15
CPP =MAP (2x diastolic + systolic /3) - ICP
Stool softeners, quiet environment, do not cluster care, avoid flexing hips and neck , HOB elevated
Earliest sign = change in LOC, headache, N/V
Late = cushings triad (hypertension, bradycardia, widened pulse pressure), posturing (decebrate and decorticate)
Name the reportable STIs
(to local health authorities)
Chlamydia, gonorrhea, syphilis, chancroid, HIV/AIDS
Provide patient education on a Lumbar puncture and post procedure care
Used to diagnose serious infections like meningitis, disorders of the central nervous system, such as Guillain-Barre syndrome and multiple sclerosis; or cancers of the brain or spinal cord. Local anesthesia, side lying position, flat post procedure.
Monitor for a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased intracranial pressure. Drainage from the site. Clear fluid is cerebral spinal fluid leaking.
Name at least 3 signs of infective endocarditis and one cause
Clinical manifestations of infective endocarditis include fever with chills, night sweats, malaise and fatigue, anorexia and weight loss, cardiac murmur, and Osler’s nodes on palms of the hands and soles of the feet.
Valve disease, IV drug users, bacterial infection, viruses, fungi, staph or strep infections, dental procedures
Endocardium and valves are destroyed - valves can become damaged. Vegitations can become large that blood cannot flow through, embolisms form.
Common causes of AKI
Nutrition education for a patient with Kidney disease
Reduced kidney profusion (Decreased MAP & BP), damage to kidney tissue, and obstruction
(Pre-renal, intrarenal, post renal)
CKD - D/t HF, DM and HTN
Lower in sodium, potassium, and phosphorus, and higher in calories
Expected labs: Increased BUN/CR, high K, High Phos, Low Calcium, increased PTH, bone breakdown, decreased bicarb (possible acidosis), low H&H, low vit D, decreased Na, decreased albumin, increased lipids (cant metabolize), drug toxicity
Patient education for systemic lupus erythematosus (SLE) & preventing exacerbations
Page 357
Fatigue will be chronic, make rest periods, avoid smoke/smoking, avoid UV exposure/sunlight, wear protective clothing and sunscreen
systemic inflammation may cause vasculitis, muscle aches, bone necrosis due to lack of oxygen, Lupus nephritis due to autoantibodies attacking kidney tissues, butterfly rash
Priorities of care and patient education after diagnosed with STI
Page 1521
TREAT partner to prevent reinfection
Abstinence until infection cleared
Complete medication as prescribed
Drink fluids while on antibiotics
Follow up after treatment
Expected findings/drainage from a urinary catheter with continuous bladder irrigation after a prostatectomy
The urine drainage following prostatectomy usually begins as a reddish pink, then clears to a light pink color 24 hours after surgery.