A Nurse is caring for a clients on the med-surg unit. Which client is most at risk to develop a nosocomial infection?
A- client with alcohol abuse
... [Show More] admitted for detox
B- Client with Type I diabetes and peripheral neuropathy
C- Client recovering from a cholecystectomy
D- Client with full thickness burns, an NG tube and a Foley - D- Full thickness burn, NG tube and Foley
Think immunosuppression and avenues for infection
Adult vital signs - Temp: 97.5 99.5F
HR: 60-100
BP: Systolic 90/140 Diastolic 60/80
Resp: 12-20
o2 95%-100%
Celsius to Fahrenheit - (C x 1.8) + 32
Fahrenheit to Celsius - (F-32)/1.8
grading scale for pulses - 4+ = strong and bounding
3+ = full pulse, increased
2+ = normal, easily palpable
1+ = weak, barely palpable
0 = absent, not palpable
What type of information is Pain? - Subjective
When measuring an apical pulse you should count for a... - A full minute
Heart rate slows with ______, ________. _____________. and body temperature will ______ the heart rate - 1. age
2. emotions
3. pain
4. Increase
What is all included in a set of vital signs? - Heart rate, Blood pressure, Respiration rate, Oxygen saturation, Temperature, And pain
What is sodium level? - 135-145
What is potassium level? - 3.5-5
What is digoxin level? - 0.5-2
What is magnesium level? - 1.5-2.5 mEq/L
What is calcium level? - 9-10.5
What is phosphorus level? - 3.5-4.5
What is the normal WBC range? - 5,000-10,000/mm3
What is the normal platelet range? - 150,000-400,000/mm3
What is the normal Hemoglobin range? (male and female) - Male- 14-18
Female- 12-16
What is the normal hematocrit range? (male and female)
(always get male wrong) - Male- 45-52%
Female- 37-47%
what is the normal creatinine range? - 0.5-1.2 mg/dl
What is the normal BUN range? - 10-20 mg/dL
Cardiac Labs - CK
LDH = 140 - 280 (signifies MI
Myoglobin = <90 (elevation could indicate MI)
Troponin T: <0.2 (↑ = MI)
What is the normal APTT, PT, INR - APTT- 30-60 seconds
PT- 11-12.5 seconds
INR 0.81-1.20
What does the HgbA1c test for? - 3 months average blood sugar
Signs and Symptoms of Metabolic Acidosis - - headache
- decreased BP
- *hyperkalemia*
- *muscle twitching*
- warm, flushed skin (vasodilation)
- nausea, vomiting, diarrhea
- *Kussmal respirations (compensatory hyperventilation)*
Respiratory Alkalosis Signs/Sx - -seizures
-deep, rapid breathing
-hyperventilation
-tachycardia
-hypokalemia
-nausea, vomiting
Metabolic Alkalosis Signs and Symptoms - -dysrhythmias (tachycardia)
-hypoventilation
-nausea/vomiting/diarrhea
-tremors, muscle cramps
-hypokalemia
Normal PH level? - 7.35-7.45
Normal PaCO2 - 35-45
Normal HCO3 - 22-26
Respiratory acidosis - pH down PaCO2 up
Respiratory alkalosis - pH up PaCO2 down
metabolic acidosis - pH down HCO3 down
Metabolic alkalosis - pH up HCO3 up
PaCO2 involves what acid base imbalance? - Respiratory
HCO3 involves what acid base imbalance? - Metabolic
Common problems involved with respiratory acidosis - HYPOventilation
CNS depressant
bronchitis
pulmonary edema/emboli
Common problems involved with Metabolic acidosis - Diabetes
excessive intake of antacid
kidney injury
Diarrhea
Common problems involved with respiratory acidosis - HYPERventilation
fever
hypoxia
pain
anxiety [Show Less]