NUR2755 / NUR 2755 Multidimensional Care IV Final Exam Review | Rated A | LATEST 2021/2022 | Rasmussen College

NUR2755 / NUR 2755 Multidimensional Care IV Final Exam Review | Rated A | LATEST 2021/2022 | Rasmussen College 1. After drop: continue  in body temp after the victim is removed from the cold - Warm IV fluids, heated O2, heated peritoneal/pleural/gastric/bladder lavage 2. Frostbite: occurs when body tissue freezes & causes damage to tissue integrity • 1st: hyperemia ( blood flow), edema • 2nd: clear to milky fluid-filled blisters, partial-thickness skin necrosis • 3rd: small blisters w/ dark fluid, affected body part is cool/numb/blue/red, non-blanchable. Full-thickness & subq necrosis, requires debridement • 4th: no blisters/edema, the part is numb/cold/bloodless. Full-thickness necrosis extends to muscle & bone. May require amputation • Inter: opioids, IV rehydration, ibuprofen 400-800 PQ q8h (reduces secondary tissue injury). - After rewarming, elevate above heart level, splint PRN - Assess for compartment syndrome 3. Frostnip: superficial cold injury that may produce pain, numbness, pallor, waxy appearance. Relieve by applying warmth 4. High altitude ds (HAD): body’s response to exposure to low partial pressure of O2 at high elevations - Descent pt to lower altitude - Give PO acetazolamide (Diamox) 5. Drowning: Risk for pulmonary infection, ARDS, CNS impairment - Remove from water, CPR PRN, give O2, intubation - DO NOT try to get water out of the lungs 6. Pulmonary Embolism (PE): - Most PE occurs d/t inappropriate blood clotting forms a VTE (aka DVT) • Risk Factors: dehydration, prolonged immobility/travel, central venous catheters, Sx, obesity, advanced age,  blood clotting, Hx of thromboembolism - Smoking, pregnancy, estrogen therapy, HF, CVA, Ca (lung/prostate), trauma  risk for VTE/PE • S/S: dyspnea, acute confusion,  HR, pleuritic cx pain on inspiration (sharp/stabbing). Tachycardia, distended neck vein, syncope, cyanosis, hypotension, feeling of impending doom, hemoptysis • Dx: CT pulmonary angiography (CT-PA) of the chest, D-dimer • Inter: elevate HOB, O2 via NC, high-Fowler’s, telemetry, assess pulse, O2, LOC, distended neck veins, ABGs, administer heparin/lovenox 7. Safety issues in the ED: Pt identification, fall risk, skin breakdown, HAIs, med errors and adverse events. 8. Triage: sorting & classifying patients into priority levels depending on illness/injury severity - Triage nurse: gatekeeper in the emergency care system - 3 levels: Emergent, Urgent, Nonurgent