Neuro
What are some nursing priority post op craniotomy?
Monitor drain( >50ml per shift notify MD)
Monitor BP
Frequent neuro check( at least every 1 hour)
Prevent seizure
reduce swelling
Your patient has a history of Myathenia Gravis and has prevented to the ER with c/o fatigue, and muscle weakness. As the nurse you know that a common cause of myathenia Gravis flare is :
Missing medication dose.
72 y/o patient admitted with Guillain Barre, the patient c/o weakness, hyporeflexia and some paresthesia. The patient is immobile and as such part of your nursing intervention is to :
Prevent complications of immobility:
have DVT prophylaxis in place to prevent blood clots: SCDs, anticoagulant agents
You are working the ER and has a patient that has come in with >50% of his body covered in burns, you suspect that that patient is going into shock based on his vital signs: Temp 95.4, pulse 120, RR 36, BP 70/44. As the primary nurse, you know the patient is in the emergent /resuscitative phase of burn care and you need to do what?
initiate fluids ( NS 0.9%)
this is where they need 2 large bore IVs for IVF
The patient with a blast injury should be positioned how?
Lateral trendelenburg, lay them on left side
Name two post op complications of head trauma:
SIADH and DI
** Monitor Urine output
Your patient that has missed their pyridostigmine has presented to the ER and appears to have a myathenia gravis flare up, given what you know about this condition, you know the patient is at risk for _____ and you prepare for -------
respiratory failure, possible intubation
Your patient has arrived on the unit after an escharotomy for a full thickness burn. As the nurse you are aware that the first and most important assessment that you will do is:
Neurovascular
( check pulses) diminshed or absent notify MD
Your patient has been admitted to the ER and suspected of having sepsis. Temp 101.0, pt has chills and limited urine output. The doctor has ordered IV zosyn to be started STAT as well as IVF NS @ 125cc/hr , lactate levels, cbc, urinalysis and blood culture. According to the sepsis bundle, what must you do first?
Draw a BLOOD CULTURES, LACTATE, and other labs BEFORE STARTING ANTIBIOTICS.
(IV fluids should be started- or be infusing) Second: Start broad spectrum antibiotics continue fluids.
Ebola is spread spread via direct contact with blood and body fluids. These patients are highly contagious and the nurse knows a PPE buddy is needed and they should wear which PPE
PPE level A
Your patient has arrived at the ER with a suspected head injury s/p motor vehicle crash. What assessment and tool would be your priority?
Neuro assessent
GCS- glasgow coma scale
Therapeutic outcome of pyridostigmine
increase muscle strength
Immediately after a burn injury, __________ results from massive cell destruction.
hyperkalemia
page 1871
During a mass casualty you are manning the doors of the ER. A patient has been brought in unresponsive with a penetrating head wound. As the triage nurse you will tag this patient with what color?
black -Not going to survive, expected to die or have died
What should you do if an area of your skin comes in contact with Botulism toxin?
wash with soap and water.
A fungal infection that causes neurological disease and is common among patients with AIDS.
cryptococcal meningitis.
Multiple sclerosis is a very slow progressive disease that can take on different patterns in different people, they can have relapses and remissions, these patients tend to fall often. As a nurse provide nursing education regarding prevention of injury to these patients.
walk with their feet widened apart, stare at their feet when they walk, go slow
This type of debridement is the use of surgical tools at the bedside to remove the nonviable tissue
mechanical
The patient has come in after a blast and has suspicions of a sucking chest wound. You would tag this patient as
RED- Life threatening injuries but thought to be survivable
true or false
Small pox is contagious via direct contact or droplet.
It is contagious during the fever and the rash.
True
62 y/o patient admitted with hx of Huntington disease and aspiration pneumonia. Pt is on O2 2 L via NC and has some shortness of breath, lungs are clear. Afebrile, RR 22. As a nurse you know that a important nursing priority for this patient would be:
Ensure humidification is added to O2
This condition is an autoimmune condition with a very poor prognosis. These patients have weakness and wasting of upper extremities usually occur first followed by impaired speech and trouble swallowing.
• Will end up with feeding tube and ventilator if that is their choice to do so.
ALS
This type of debridement is used much later in healing process and not used on large areas usually on pressure ulcers. (hint-Be sure not to put on viable tissue).
Enzymatic or Chemical debridement
During a mass casualty there is a standdown signal which is when you can eat and rest. Usually the nurses are encourage to _____
Restock meds and supplies.
Name 3 categories of triage:
emergent, urgent, non-urgent.
Emergent- life-threatening injuries and require immediate, life-saving intervention. Examples include cardiopulmonary arrest, severe respiratory distress, and major trauma.
Urgent- These patients have major injuries that are not immediately life-threatening but require prompt attention and treatment -stroke, head injuries, and asthma.
non-urgent - Examples include minor cuts, sprains, and some infections.