A
Interventions when a patient has paralytic ileus?
NPO
TPN
Suction PRN
PPI's
NG
Metoclopramide (reglan)
Nursing interventions for ICP
Monitor for decreased LOC, position head of bed 30 degrees, give mannitol admin IV
Primary intervention for a patient that has suffered from a severe burn injury in the acute phase.
IV rehydration to prevent massive volume depletion (hypovolemia)
Hyperkalemia
A 25 year old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
37%
Back of right arm (4.5%), posterior trunk (18%), front of left leg (9%), anterior head and neck (4.5%) and perineum (1%) which equals 37%.
Describe the phases of AKA.
Onset
Oliguria
Diuresis
Recovery
Oliguria: 1-7 days. Urine output will be less than 400mL/day. Monitor for hyperkalemia and hyponatremia and metabolic acidosis.
Diuresis: 2-6 weeks. Monitor for hypokalemia and hyponatremia.
Recover: Up to 12 months
A 35 year old male patient has full thickness burns to the anterior and posterior head and neck, front of left leg, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
19%
Anterior and posterior head and neck (9%), front of leg (9%), perineum (1%)
How do you assess when peristalsis is returning?
Patient reports flatus
A 66 year old female patient has deep partial-thickness burns to both of the legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
81%
Both of the legs on the back (18%), front and back of the trunk (36%), both arms on the front and back (18%), front and back of the head and neck (9%) which equals 81%.
What type of insulin do we use when we treat a patient with DKA?
A 68 year old male patient has partial thickness burns to the front and back of the right and left leg, front of right arm, and anterior trunk. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
58.5%
Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%.
Assess bowel sounds
If you have a peptic ulcer, what do you need to watch out for?
Hint: Sudden onset of abd. pain
Gastric perforation
Complications that can develop when a patient is in a myxedema coma?
Resp depression
Hypotension
Hypothermia
Seizures
Aspiration
Meningitis S&Sx and nuring interventions
High temp, excruciating headache, stiff neck, photophobia, fever and chills, N&V, alered LOC, positive Kernig's sign, positive Brudzinkis sign, hyperactive DTRs, tachycardia, seizures, restless.
DROPLET PRECAUTIONS, private room, continue until abx have been given for 24 hours, cooling blanket, bedrest, decrease environmental stimuli, minimize bright light, avoid coughing and sneezing (ICP)
Pt has a spinal cord injury at the level of T2/3. What kind of disability do they have?
A: Paresthesia
B: Quadriplegia
C: Hemiplegia
D: Paraplegia
D: Paraplegia
A 35 year old male patient has superficial partial-thickness burns to the anterior right arm, posterior left leg, and anterior head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
18%
Anterior right arm (4.5%), posterior left leg (9%), and anterior head and neck (4.5%) which equals 18%.
A patient has a cholangiogram done. What does that mean?
Assessing the blood vessels supplying the gallbladder
Assessing the bile ducts
What does sodium polystyrene (kayexalate) do?
Excretes potassium through feces
If a patient has DKA, what type of electrolyte imbalance do we have? And, how do you treat it?
Hyperkalemia
Insulin drip
A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
63%
Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.
S&Sx when a patient has a perforation of the bowel
Sudden onset of sharp pain
Rigid abdomen
Swelling
N&V
What is autonomic dysreflexia and what are nursing action items regarding patient care?
Stimulation of the sympathetic nervous system causes extreme HTN, sudden severe headache, pallor, below the level of the spinal cord's lesion, blurry vision, diaphoresis, nausea and goosebumps
Sit the patient up to decrease BP secondary to postural hypotension
Notify MD
Determine and treat the cause
-distended bladder it he most common cause (kinked or blocked cath)
-Remove fecal impaction
- Adjust room temp
- Remove tight clothing
-Assess for injury
Monitor vitals for severe HTN and bradycardia
Admin antihypertensives
What position do you place someone who is getting a paracentesis?
High fowlers (puts pressure on the stomach to expel more fluid)
What is the specific medication we use to achieve diuresis when it comes to ICP or cerebral edema?
Mannitol (watch out for lung edema!)
What is the Cushing's Triad and treatment?
Indicates increased ICP. S/S: Systolic hypertension, widening pulse pressure. Bradycardia with full and bounding pulse. Irregular respirations. Treatment: Mannitol, hyperventilation, elevate HOB, elevate BP, decompression (get the blood out of the head!).