NUR 280 Comprehensive Review Comp 1 Comp 2 comp 3 2023.

NUR 280 Comprehensive Review Comp 1 Comp 2 comp 3 2023. Comp #1 Spinal Cord Injury/Surgery/Procedure - Expected finding: o Decreased reflexes o Numbness/tingling o Inability to urinate (from low spinal cord injury) - Not Expected: o Decreased RR. o Headache (increased ICP) o CSF halo (yellow fluid) - Post-Op: o Airway, circulation o Monitor for ICP, Neuro checks, VS closely - Complication: o Autonomic Dysreflexia. S/S:  Numbness & tingling (expected)  Severe hypotension  Cessation of breathing (not expected). Heparin/Enoxaparin (LMWH) - Anticoagulant that can be give IV or SQ o Labs:  aPTT 30-40 (WNL), while on Heparin should be 1.5-2x the normal value [aPTT on heparin 60-90]  Risk for bleeding (aPTT >70)  Warfarin & Heparin until Warfarin reaches therapeutic INR levels [2-3]  H&H (rule of thumb, hematocrit [37-52] will be 3x the amount of hemoglobin [12-18]) example: HgB 8 = Hct 24, or HgB 10 = Hct 30  Platelets 1.5-2.5x the normal (want them high not low)  Normal Platelets Range: 150-400 - Antidote: o Protamine Sulfate - Complication o HIT (Heparin Induced Thrombocytopenia)  Due to being on med for longer than a week  Monitor for s/s of bleeding  Lab: low platelet count (<150) o Interventions:  Stop heparin  Direct thrombin inhibitor  Lepirudin and Argatroban  Treat active and prevent any new thrombosis - SQ Administration o Don’t aspirate or expel the bubbles out of prefilled syringe Colostomy - Descending colostomy located on LLQ (involves the large intestines) - Stoma should be reddish pink, moist and shiny (Saunders pg. 688) o Call MD if stoma looks:  Pale/ Pink (low h&h levels)  Dark purple/ Black (compromised circulation)  Shrink in size/Dry  Small amount of mucous drain in the bag - Expect liquid stool in the immediate postop period but become mores more solid depending on location o Ascending Colon: liquid o Transverse Colon: loose to semi-formed o Descending Colon: close to normal - Empty pouch when 1/3 full - Monitor for dehydration & electrolyte imbalance - Avoid food that causes excess gas or odor o Give yogurt to help decrease smell - Avoid contact of skin with stool - Should start functioning 2-3 days after surgery Ventilator Associated Pneumonia (VAP) - Prevention o HOB elevated >30 degrees o ulcer prophylaxis (H2 blockers) o preventing aspiration o pulmonary hygiene (chest physiotherapy, postural drainage/percussion and turning/re-positioning Q2hours) o remove water from circuits, and suction PRN. o Vigilant, frequent oral care is key!  brushing teeth Q8hours, antimicrobial rinse and lip moisturizer Q2hours o Cough Sepsis: - Bloodstream infection/UTI, bacteria, fungi, vasodilation o considered a type of distributive shock, prevention is key. - Risk Factors: o cancer patients (highest risk) o malnutrition o immunocompromised o open wounds o DM, CKD, Hepatitis, HIV/AIDS - S/S: o DIC (disseminated intravascular coagulation) o low O2 o tachypnea o decreased/absent urine output o change in LOC o hypoxia o death/dysfunction of organs - Interventions: o Resuscitation oxygen therapy o Blood replacement therapy o Drug therapy - Identify early manifestations of infection o treat with antibiotics o strict aseptic technique o IV fluids o inotropic medications. Septic Shock - Caused by an infection o Medical emergency can happen to anyone who is a patient in the hospital. - Capillaries dilate o Fluid exits the vascular system and enters interstitial spaces. - S/S: o Hypotension o Tachycardia o Increased RR o Increased temp o cold and clammy skin. o Changes in LOC (earliest sign) - Treatment: o Fluids  Normal Saline and Lactated Ringers (Bolus) o Broad Spectrum antibiotics o Vasopressors A-Fib - Multiple Rapid impulses - Quivering atria - Irregular heart rhythm - HR 130-150+ - Treatments: o Oxygen o Amiodarone & Digoxin  With rapid ventricular response (RVR) o Calcium Channel Blocker (CCB)  Diltiazem o Beta Blocker (BB)  Metoprolol o Monitor electrolytes  Low potassium (increases risk for dig toxicity) o Anticoagulatory therapy  Warfarin  Prevents blood from clotting due to the quivering of the heart o Synchronized Cardioversion  When symptomatic and non-responsive to med Hyperbilirubinemia pg. 382 - Occurs when there is too much bilirubin in the blood. o Bilirubin is made by the breakdown of RBCs.  Indicates issues with the liver - Lab Value o Bilirubin: < 1  increased with impaired liver function. - S/S: o Jaundice o Poor sucking reflex o Enlarged liver o Lethargy o Poor muscle tone o Elevated bilirubin - Treatment: o Phototherapy  Used to reduce serum bilirubin levels  Adv. Rx.  Dehydration  Sensory deprivation  Eye damage  Bronze baby syndrome o Grayish brown skin Vital Signs (Peds) - Newborn/Infant (0-12mo) o BP: 60-80/40-50 o HR: 110-170 [2month old] o RR: 30-60 o Temp: 97.5-99.5 (Rectal) o O2: >95% - Toddler (1-3yrs) o BP: 90-105/ 50-70 o HR: 80-140 o RR: 22-37 o Temp: 97.6 to 99.5 (Axillary) - School Age (3-12yrs) o HR 70-100 [should not increase when child is eating] o BP 120/60 - High School (12+ yrs) o HR: 60-100 o BP: 125/65 - Take into consideration if patient is: o Sleeping, an athlete, running/any activity, age, resting ABGs - pH: 7-35-7.45 - HCO3: 22-28 - CO2: 45-35 - Respiratory Acidosis o Symptoms:  Hypoventilation (retains CO2)  Drowsiness/ Confusion  Hypoxia/ low RR o Risk Factors:  Hypoventilation  Respiratory failure  brain trauma  atelectasis  CNS depressants  Cystic Fibrosis - Respiratory Alkalosis: o Risk Factors:  Hyperventilation (getting rid of all CO2)  Kussmaul’s  hysteria, fever, pain, CAN stimulants, acute distress. o Symptoms:  Tachypnea  Dizziness/ lightheadedness  perioral numbness  paresthesia.