Priority Management
A patient with Hypertension reports a sudden, "worst headache of my life" and blurry vision. This is the first action the nurse should take.
What is elevating the Head of Bed (HOB) and notifying the provider (assessing for Hypertensive Crisis)?
what are the priority assessments for a patient with LeftCHF?
Auscultate lungs for crackles (left-sided) and check for jugular venous distension (JVD) or peripheral edema (right-sided).
what is the priority assessment for CAD/angina
Use PQRST to assess chest pain.'
what do these letters stand for?
what are priority assessments for DVT?
what is Check for unilateral calf swelling, warmth, and redness.
A patient with CHF is experiencing increased shortness of breath and a cough with frothy, pink-tinged sputum. This is the nurse's priority intervention.
What is administering Oxygen and placing the patient in High-Fowler's position?
what are priority interventions for a patient in LCHF?
Maintain Oxygen saturation and place in High-Fowler's to ease breathing.
what is the priority intervention for CAD?
If pain occurs, have the patient stop all activity and sit down.
What are nursing management for a DVT
Bed rest (initially), elevation of the extremity, and initiation of Heparin or Warfarin.
A patient with CAD reports chest pain that is not relieved by rest. The nurse should follow this specific priority sequence.
What is Stop activity, Administer Oxygen, and give Nitroglycerin?
what is the overall management for chronic CHF
Strict Daily Weights (report >2 lbs in 24 hours) and I&Os.
Mnemonic: UNLOAD FAST (Upright position, Nitrates, Lasix, Oxygen, ACE inhibitors, Digoxin...)
what medication used to treat CP or angina can cause headaches?
what is Nitroglycerin
what labs are required for a patient receiving treatment for a DVT?
Monitor aPTT for Heparin and PT/INR for Warfarin.
A patient with a suspected DVT in the left leg suddenly develops chest pain and shortness of breath. The nurse identifies this as the priority complication
What is a Pulmonary Embolism (PE)?
what position would be indicated for a patient with PVD
Elevate the legs (Venous = V-shape) to help blood get back to the heart.
what are the priority assessments for a patient believed to have a PE?
Watch for sudden-onset dyspnea, chest pain, and tachypnea. This is a medical emergency.
This is the priority "Never Event" nursing action for a patient with a confirmed DVT to prevent the clot from dislodging.
What is avoiding massage or compression of the affected limb?
what position would be indicated for a patient with PAD
Dangle the legs (Arterial = Angle down) to help blood get to the toes.
What would be immediate actions for a patient suspected of having a PE
Raise the Head of Bed (HOB) and apply Oxygen.