Medical-Surgical Nursing, 11th Ed., Harding, Kwong, Roberts, Hagler & Reinisch | Registered Nurse (RN) School Study Aid
Neurovascular Assessment 6 P's
- Pain
- Paresthesia
- Pulse
- Pallor
- Pressure
- Paralysis
Chest Tubes: Management and Care
- Confirm suction order
- Crepitus
- Kinking
- Shortness of Breath (SOB)
- Infection
- Excessive bubbling
- If tube dislodges from patient, use petroleum gauze taped 3 ways
- If drainage system is damaged, place disconnected drainage tube in sterile water
Glasgow Coma Scale
- LOC Assessment
- Score of 3 to 15
- 8 or Less = Coma
- Eye Opening
- Verbal Response
- Motor Response
Oxygen Delivery Methods
- Nasal Cannula
- Simple Face Mask
- Non-Rebreather Mask
- Venturi-Mask
- Oxygen In Use Sign
- No Electrical Sparks
- Six Feet Away from Open Flames
- Dry Nasal and Upper Airway Mucosa
- Skin Irritation
- Home Education
Tracheostomy Care
- Inner Cannula Removed and Cleaned
- Clean Q8 Hours Around Stoma
- One Finger Under Ties
- Speak with Deflated Cuff
- Can Eat with Tube in Place
- Keep Replacement Tube Nearby
- Immediately Replace if Dislodged
- Physician Does First Tube Change
Burns Assessment
- Stage and Extent of Burn
- Dyspnea
- Singed Nasal Hairs
- Pain
- Initial Decrease Urinary Output
- Paralytic Ileus
- Signs of Inadequate Hydration
- Shock
- Hypothermia
- Hyperkalemia
Burns Interventions
- Ensure Airway Patency
- O2
- IV Fluid Replacement
- Dry Sterile Dressing
- Debridement
- Elevate Burned Limbs
- Analgesics
- Silver Sulfadiazine
- Escharotomy
Rule of 9's for Burns
- Total Body Surface Area (TBSA)
- Head
- Chest
- Abdomen
- Upper Back
- Lower Back
- Posterior Leg (each)
- Anterior Leg (each)
- Each Arm
- Genitalia 1%
Parkland Formula
- Burn victims
- 24 hours
- TBSA %
- x Weight (kg)
- x 4
- = Fluid Requirement (in first 24 hrs)
- 1/2 of fluid given in first 8 hours
Burns Considerations
- Maintain Body Temperature
- Increased Risk of Infection
- Venous Thromboembolism (VTE) Prophylaxis
- Curling's Ulcer
- Excision and Grafting
- Adequate Nutrition
- Contractures
Wound Drainage Types and Devices
- Serous
- Serosanguineous
- Sanguineous
- Purulent
- T-tube
- Penrose
- Jackson-Pratt (JP)
- Hemovac
- Record Drainage Amounts
- Check Device Function
Parts of an ECG
- P Wave
- Atrial Depolarization
- QRS Complex
- Ventricular Depolarization
- T Wave
- Ventricular Repolarization
ECG Interpretation
- Rate
- Rhythm
- P Waves
- Upright, Rounded, Before Every QRS
- PR Interval (< 0.20 seconds)
- Normal QRS (< 0.12 seconds)
ECG: Sinus Bradycardia
- < 60 bpm
- Regular
- Present, Upright, Every QRS
- < 0.20 seconds
- < 0.12 seconds
- Atropine
ECG: Sinus Tachycardia
- > 100 bpm
- Regular
- Present, Upright, Every QRS
- < 0.20 seconds
- < 0.12 seconds
- Treat Underlying Cause
ECG: Atrial Fibrillation
- Variable Rate
- Irregular Rhythm
- No P Wave
- No PR Interval
- QRS < 0.12 Seconds
ECG: Atrial Flutter
- Variable
- Regular or Irregular
- Saw Tooth, Multiple Before Every QRS
- Non-measurable
- < 0.12 seconds
12 Lead Contiguous Leads - Anterior Wall MI
- Lead V3
- Lead V4
- Left Anterior Descending (LAD)
12 Lead Contiguous Leads - Septal Wall MI
- Lead V1
- Lead V2
- Left Anterior Descending (LAD)
12 Lead Contiguous Leads - Inferior Wall MI
- Lead II
- Lead III
- Lead aVF
- Right Coronary Artery (RCA)
12 Lead Contiguous Leads - Lateral Wall MI
- Lead I
- Lead aVL
- Lead V5
- Lead V6
- Circumflex
Obstructive Sleep Apnea (OSA)
- Narrowed or Obstructed Air Passage
- Apnea
- Loud Snoring
- Startle Response
- Daytime Drowsiness
- Positional Therapy
- Oral Appliance
- Continuous Positive Airway Pressure (CPAP)
- Surgery
- Weight Loss
Interventions for Impaired Skin Integrity
- Signs of Skin Breakdown
- Pain
- Redness
- Decreased Skin Turgor
- Bleeding
- Bony Prominences
- Reposition Q2H
- Pressure Relief
- Maintain Clean and Dry Skin
- Adequate Nutrition and Hydration
Types of Wound Healing
- Acute
- Chronic
- Primary Intention
- Approximated Edges
- Secondary Intention
- Edges Not Approximated
- Tertiary Intention
- Delayed Closure due to Infection and Necrosis
Patient Position Overview
- Trochanter Roll
- Trapeze Bar
- Ankle-Foot Orthotic (AFO) Devices
- Fowlers Position
- Supine Position
- Trendelenburg
- Side-Lying Position
- Prone Position
- Sims' Position
- Reposition q2 Hours/Prevent Skin Breakdown
- Confirm Body Alignment
Stages of Hypothermia
- 32 to 35°C (90 to 95°F)
- Shivering
- 28 to 32°C (82 to 90°F)
- Obvious Motor Impairment
- Slowed Thinking
- < 28°C (< 82°F)
- Shivering Stops
- Paradoxical Undressing
- Arrhythmias
Severe Sepsis and Septic Shock Assessment
- Microthrombi
- DIC
- Decreased Oxygen Saturation
- Decreased WBC
- Oliguria
- High Output Heart Failure
- Multiple Organ Failure
Hypothermia Interventions
- Remove From Environment
- Remove Wet Clothing
- Warm Clothing
- Heated Blankets
- Warm IV Solutions
- Heated Oxygen
- Warm Gastric Lavage
- Warm Trunk BEFORE Extremities