BEFAST
These 5 parts make the anacronym BEFAST (must be able to describe how to assess for each of the 5 parts)
What are:
Balance
Eyes
Face
Speech
Time
In this orthopedic condition, the priority is to given to hanging antibiotics and the patient may need prolonged home IV antibiotics to cure the infection.
What is Osteomyelitis?
Your patient is on Phenytoin (Dilantin). You educate your patient on this important self-care related to this medication to manage seizures.
What is regular oral hygiene and dental checkups due to the gingival hyperplasia?
Your patient states that when she overexerts herself, especially since she moved to Arizona, it tends to trigger an exacerbation of this disease.
What is Multiple Sclerosis?
Your patient presents to the ED c/o SOB, petechiae. He states he fractured his leg 48 hours ago. You recognize this complication and prioritize this intervention. (Name both the complication and the prioritization).
Fat embolism
Administer Oxygen
This must be done within twenty minutes of realizing your patient may be having a stroke.
What is a noncontrast CT exam.
Your patient has been diagnosed with an hemorrhagic stroke. Your first priority is to assess this.
What is blood pressure?
Your 78yo female patient has Kyphosis and complains she has lost some of her height. You anticipate that the provider may place her on this medication for this condition. (Name both the medication and medical condition).
Alendronate (Bisphosphonate) - sit up straight to take!
Osteoporosis
Your patient with Parkinson's exhibits these 4 symptoms.
What are:
Tremors
Rigidity
Akinesia
Postural Instability
You are on the Stroke Alert Team and you respond to a possible stroke on a med/surg unit. When you arrive and perform #4 of the NIHSS assessment tool and realize that the patient is not having a stroke. What did the nurse do to determine it was not a stroke but actually this temporary ailment. (Name the test and what the ailment actually is).
What is raise the eyebrows.
This is Bell's Palsy.
Your patient has Dysarthria and receptive Aphasia, you understand that this means this.
What is they have slurred speech and difficulty understanding what you are saying?
Your client states that her chronic, neurological condition started with ptosis and double vision. You understand that she probably has this disease and need to help to minimize this common complaint. (Name the disease and the common complaint that affects their ADLs).
What are:
Myasthenia Gravis
Fatigue
You are looking at the medication list of your client with Parkinson disease. What are two teaching points you can make sure the client knows about the drug used to treat his disease. (List 2 teaching points specifically about this medication).
Protein ingestion may impair the absorption of levodopa.
Rise slowly from a lying to a sitting and then standing position.
You know that this is the 'sweet spot' in terms of HOB for any patient with a neurological issue.
What is 30 degrees?
You provide education to your patient recovering from a hip fracture and include these 5 things to prioritize to prevent dislocation.
What are:
No flexion >90 degrees
No crossing legs
Use hip abductor pillow
Avoid low chairs/toilets
No internal rotation of the affected leg
You understand that it is important to use these assistive devices to prevent contractures and non-alignment in your patient with hemiparesis. (Name at least 3 things).
What are:
Trochanter roll
Hand roll
High-top tennis shoes
Your patient complains of sudden pressure in the area of their repaired open fracture. You assess for these other signs of compartment syndrome. (Name the other 5).
What are:
Pressure
Pain
Paresthesia
Pallor
Pulselessness
Paralysis
Your client has a swollen, red, and extremely painful right great toe. Based on this information, you understand that this medication is most likely to be ordered now and this medication will he be prescribed as a maintenance medication once this flare has passed. (Name the disease and the two medications)
What are:
Gout
Colchicine
Allopurinol.
Your post-stroke client is constantly trying to get out of bed by himself and won't wait for you to help him to the bathroom. You understand this is an effect of which side of the brain stroke.
What is right side?
You see the UAP doing these two interventions to your patient with compartment syndrome and stop her immediately.
What is applying ice and elevating the extremity?
This is done to prevent skin breakdown in your patient with deficits related to a stroke. You also know that the patient shouldn't be left on the affected side for more than this amount of time.
What are:
Turn Q 2h
Do not leave on affected side >30min.
Your patient begins show signs of Tonic seizure activity and you know to mark the time of this phase of a seizure.
What is the Ictal phase.
Your patient with RA is prescribed this DMARD and you know that this will need to be monitored. Name the medication and the side effect to monitor for.
What are:
Methotrexate
Liver function tests
CBC
You are an ICU nurse and your patient asks you why are his clothes hanging from the ceiling. You understand that he has developed this.
What is Delirium?
With this medication, whether it is for your client with SLE or RA, you know that this is a priority to protect. (Name this medication and the priority to protect.)
What are:
Hydroxychloroquine
Eyes