Do not delegate - ✔✔ What you can EAT E-evaluate A-assess T-teach
Addison's & Cushings - ✔✔ Addison's = down down down up down
Cushings=
... [Show More] up up up down up
hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia
Better peripheral perfusion? - ✔✔ EleVate Veins, DAngle Arteries
APGAR - ✔✔ Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)
Airborne precautions - ✔✔ MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB
Airborne precautions protective equip - ✔✔ private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB
Droplet precautions - ✔✔ spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
(Private room and mask)
Contact precaution - ✔✔ MRS WHISE
protect visitors & caregivers when 3 ft of the pt.
Multidrug-resistant organisms
RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff),
Gloves and gowns worn by the caregivers and visitors
Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag
PMGG= Private room/ share same illness, mask, gown and gloves
Skin infection - ✔✔ VCHIPS
Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies
Air or Pulmonary Embolism - ✔✔ S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.)
Woman in labor (un-reassuring FHR) - ✔✔ (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids!
Tube feeding with decreased LOC - ✔✔ Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration)
After lumbar puncture and oil based myelogram - ✔✔ pt is flat SUPINE (prevent headache and leaking of CSF)
Pt with heat stroke - ✔✔ flat with legs elevated
during Continuous Bladder Irrigation (CBI) - ✔✔ catheter is taped to the thigh. leg must be kept straight.
After Myringotomy - ✔✔ position on the side of AFFECTED ear, allows drainage.
After Cateract surgery - ✔✔ pt sleep on UNAFFECTED side with a night shield for 1-4 weeks
after Thyroidectomy - ✔✔ low or semi-fowler's position, support head, neck and shoulders.
Infant with Spina Bifida - ✔✔ Prone so that sac does not rupture
Buck's Traction (skin) - ✔✔ elevate foot of bed for counter traction
After total hip replacement - ✔✔ don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows.
Prolapsed cord - ✔✔ Knee to chest or Trendelenburg
oxygen 8 to 10 L
Cleft Lip - ✔✔ position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position.
To prevent dumping syndrome - ✔✔ (post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals.
AKA (above knee amputation) - ✔✔ elevate for first 24 hours on pillow. position prone daily to maintain hip extension.
BKA (below knee amputation) - ✔✔ foot of bed elevated for first 24 hours. position prone to provide hip extension.
detached retina - ✔✔ area of detachment should be in the dependent position
administration of enema - ✔✔ pt should be left side lying (Sim's) with knee flexed.
After supratentorial surgery - ✔✔ (incision behind hairline on forhead) elevate HOB 30-40 degrees
After infratentorial surgery - ✔✔ (incision at the nape of neck) position pt flat and lateral on either side.
During internal radiation - ✔✔ on bed rest while implant in place
Autonomic Dysreflexia/Hyperreflexia - ✔✔ S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST!
Shock - ✔✔ bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg)
Head Injury - ✔✔ elevate HOB 30 degrees to decrease ICP
Peritoneal Dialysis (when outflow is inadequate) - ✔✔ turn pt from side to side BEFORE checking for kinks in tubing
Lumbar Puncture - ✔✔ After the procedure, the pt should be supine for 4-12 hours as prescribed.
Myesthenia Gravis - ✔✔ worsens with exercise and improves with rest
Myesthenia Gravis - ✔✔ a positive reaction to Tensilon---will improve symptoms
Cholinergic Crisis - ✔✔ Caused by excessive medication ---stop giving Tensilon...will make it worse.
Liver biopsy (prior) - ✔✔ must have lab results for prothrombin time
Myxedema/ hypothyroidism - ✔✔ slowed physical and mental function, sensitivity to cold, dry skin and hair. [Show Less]