Integumentary
Which 2 types of burns do not have pain associated with them?
3rd & 4th degree
Name 3 s/s that may indicate your pt is experiencing anaphylaxis
Flushing, urticaria/itching, angioedema, hypotension, weak pulse, bronchoconstriction, congestion, rhinorrhea, dyspnea, laryngeal edema, wheezing, diminished breath sounds
In CPR: how many compressions per minute? What is the rate of compressions to breaths if an advanced airway is not in place? How often should you switch out compressors?
100-120 compressions per minute
30 compressions: 2 breaths
Switch q2minutes
What is the difference between hospice and palliative care?
Palliative: Goal is to improve quality of life for the patient
Name the 7 Ps of compartment syndrome
Pain, pallor, paralysis, paresthesia, poikilothermia, pulselessness, and pressure
Describe the appearance of a superficial 2nd degree burn
Moist, red, blanching, blistering
Name 3 s/s you may see in a patient with Systemic Lupus Erythematosus (SLE)
Fever, fatigue, "butterfly" rash, discoid rash, photosensitivity post sun exposure, oral ulcers, joint discomfort, osteoporosis, pericarditis, pericardial friction rub, raynauds, vasculitis, nephritis, psychosis, cognitive impairment, seizures
What are the treatments for V-Tach, V-fib, and A-fib?
V-tach: stable - continuous EKG, antidysrythmics, cardioversion; unstable - CPR until defibrillation is available
V-fib: CPR until defibrillation is available, epinephrine & amiodarone
A-fib: drugs to treat rapid ventricular rate & anticoagulants, synchronized cardioversion, MAZE procedure
What are some complementary treatments that may help comfort a patient at end of life?
Massage, music therapy, therapeutic touch, guided imagery, aromatherapy
How are the types of hepatitis spread?
A: fecal-oral route
B: blood borne
C: blood borne
D: only people with B are at risk
E: fecal-oral route
Name 2 s/s and the treatment for Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TENS)
S/S: fever, malaise, myalgia, sore throat, conjunctivitis, rash, mucositis
Treatment: discontinue the drug, supportive care
Name 3 s/s you may see in a pt experiencing hypovolemic shock
Low MAP/SBP, high HR, thready pulses, low O2, decreased UO (< 30 mL/hr), low perfusion, increased thirst, changes in LOC, weakness, pain
Name 3 s/s you may see in a pt experiencing a myocardial infarction (MI).
Chest pain/pressure, radiating pain to jaw or left arm, diaphoresis, crackles/wheezes, JVD, peripheral edema, N/V, anxiety
Name 5 s/s you may see in a pt approaching end of life.
Cold/cyanosis/mottling, Cheyenne-Stokes breathing, decreasing LOC, weakness, anorexia, VS changes, restlessness, grimacing, moaning
Name 3 s/s and treatments for hypothyroidism & hyperthyroidism
Hypothyroidism s/s: obesity, cold intolerance, depression, hair loss, bradycardia, constipation, menstrual changes, fatigue, joint pain
Hypothyroidism tx: lifelong levothyroxine
Hyperthyroidism s/s: exophthalmos, goiter, nervousness, tremors, anxiety, mood swings, rapid pulse, elevated SBP, cardiac dysrythmias, heat intolerance, increased appetite, weight loss, increased bowel movements
Hyperthyroidism tx: nonsurg - Methimazole or propylthiouracil, iodine, propanolol, RAI; surgical - thyroidectomy
Name 5 signs of smoke inhalation
Shortness of breath, hoarse voice/cough, stridor/wheezing, facial burns, singed facial/nasal hair, presence of carbonaceous sputum
Differentiate between hypovolemic, cariogenic, distributive, and obstructive shock
Hypovolemic: loss of vascular volume resulting in decreased MAP
Cardiogenic: heart muscle is unhealthy & pumping is impaired
Distributive: characterized by widespread vasodilation, leading to a relative hypovolemia and inadequate tissue perfusion despite normal or high cardiac output
Obstructive: caused by problems that impair the ability of the normal, healthy heart to pump effectively
What is Beck's Triad a sign of and what are the 3 components of it?
Classic sign of cardiac tamponade
1. JVD
2. Muffled heart sounds
3. Hypotension
Describe Cheyne-Stokes respirations
Alternating apnea & rapid breathing
Differentiate between a left and right sided stroke
Left-sided: paralysis/weakness of right side, speech/language/thinking impaired, altered intellectual ability, aphasia, slow or cautious behavior
Right-sided: paralysis/weakness of left side, spatial and perceptual deficits, proprioception, unaware of deficits, disoriented to time and place, impulsivity and poor judgement
Using the rule of 9s & the Parkland formula: a pt sustained burns to their chest, anterior of both legs and arms, and face. They weigh 150 lbs. How much fluid should be given in the first 8 hours? Round to the nearest whole number
6,750 mL
List the steps of the 1-hour sepsis bundle
1. Measure lactate level
2. Obtain blood cultures before administering antibiotics
3. Administer broad-spectrum antibiotics
4. Begin rapid administration of 30 mL/kg of crystalloid for hypotension or lactate > or = 4 mmol/L
5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP > or = 65 mmHg
What murmurs would you expect to hear in mitral valve stenosis, prolapse, and regurgitation and aortic valve regurgitation and stenosis?
Mitral valve stenosis: Diastolic murmur at apex
Mitral valve prolapse: Mitral "click"
Mitral valve regurgitation: Systolic murmur
Aortic valve regurgitation: Diastolic murmur
Aortic valve stenosis: Harsh systolic murmur
If a pt may be a candidate for organ donation, what are the nurse's priorities?
Maintain a patent airway, adequate tissue & organ oxygenation, normothermia, hydration, and electrolyte balance, prevent infection and coagulopathy
What are 3 s/s of a pneumothorax and how is it treated?
S/S: sudden chest pain, SOB, rapid & shallow breathing, fast HR, hypoxia
Tx: chest tube