Staying Alive
Normal ranges for vital signs in an adult
What are the following: Temp 97-99 F; HR 60-100 bpm; BP 90/60-129/79 mm Hgl RR 12-20 bpm; O2 94ish -100%; except in COPD pts
See slide
(L to R): Serosanguineous, serous, purulent, sanguineous
Contact precautions
Gown/gloves; disposable equipment in room
Steps of Nursing Process
Assessment, Diagnosis, Plan (Goals), Implementation, Evaluation
Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis; amplitude (+2), rhythm (regular), symmetry (equal bilaterally)
Wound change preparation - before touching the patient
Assess patient readiness, medicate for pain if needed, gather supplies, etc.
Droplet precautions
Surgical mask; gown, eyewear if splashing/sneezing/coughing
SMART goals - SMART and statement beginning
Specific, Measurable, Achievable, Relevant, Time Frame; involve patient in decision-making process; The patient will...
Assessment of respirations
Quality - work of breathing, use of accessory muscles; Depth - shallow, deep; Respiratory rate - breaths per minute (eupneic/tachypneic/bradypneic); Rhythm (regular/irregular); if documenting, also include use of O2 method/amount
Stages of pressure injuries
1 - intact skin, nonblanchable erythema
2 - partial-thickness epidermis and/or dermis
3 - full-thickness into subcutaneous
4 - full-thickness to muscle, bone, or connective tissue
Unstageable - full-thickness with necrotic tissue (eschar)
Airborne precautions
N95 mask; negative pressure room
Collaborative interventions; nursing interventions beginning statement
Working with team (HCP, therapists, case management, social workers, dieticians, etc.). The nurse will...
Point of maximum impulse - location, name, and how long to auscultate
Apical pulse (mitral heart sound), apex of heart, 1 full minute
Wound assessment - what we are evaluating
location, size, presence of undermining or tunneling, drainage (COCA), wound edges/maceration/infection, wound bed, patient response
Transportation of patient on precautions
Droplet/airborne - have them wear surgical mask during transport
Define evaluation
Cyclical, evaluates if the patient met the goal
What is sepsis?
Braden scale categories
Sensory perception, moisture, activity, mobility, nutrition, friction/shear
Examples of contact, droplet, and airborne diseases
Contact - MRSA, RSV, VRE, impetigo, rotavirus, C. diff
Droplet - influenza, meningitis, diphtheria, pertussis, mumps
Airborne - TB, chickenpox, measles
Assessment includes...
subjective data, objective data, labs, diagnostic tests, x-rays, etc.