JANE ASSESSMENT|UPDATED&VERIFIED|GUARANTEED SUCCESS

CHF Hallmark Signs -SOB, orthopnea, productive cough (pink frothy sputum) -JVD, crackles, edema, weight gain -anxiety, restlessness, oliguria, -Tachycardia, Tachypnea, HTN, -Nagging cough, increased Abd girth, ascites CHF interventions Focused cardiopulmonary assessment 1)Check VS ( HR, RR, BP, SpO2) 2) Supplemental O2 if needed 3) Elevate HOB 45-90 degrees 4) Elevated legs to promote venous return 5) IV access Strict Is and Os (monitor UOP) -Daily weight Call MD and anticipate orders for: CXR, diuretics, echo to evaluate EF (50%) , labs for Bmp, Cardiac enzymes. ICP Hallmark signs -Neuro changes: dec LOC, headaches, confusion, vision changes, seizures, changes in behavior -Cushing's triad: irregular breathing (describe), bradycardia, widened pulse pressure (systolic- diastolic) -Vomiting (could be projectile) -Babinski reflex, ICP interventions -Secure airway -Perform a focused neuro assessment a long with cardiopulmonary; VS (HR, RR, Spo2, BP and temp) and a GSC -HOB 30-45 degrees -Maintain adequate oxygenation/elevation (supplemental O2) -Temperature should be kept within certain limits. -Contact MD and anticipate orders for CT scan or MRI, CSF drainage if needed, osmotic diuretics, medications for blood pressure control. DKA Hallmark Signs -Polydipsia (excessive thirst), Polyuria (excessive urination), Polyphagia (appetite) - Metabolic acidosis, fast/deep breathing (kussmals), -Acetone breath, ketones -Hyperglycemia (300mg/dl) -Anion gap 12 -Decreased CO2 DKA interventions 1) Focus assessment; neuro status, LOC 2) Reassess VS including BG. -Establish IV access 3) Contact MD and anticipate orders for: -first; Fluid resuscitation (NS/LR), administration of insulin and K+, labs such as chemistry panel, BMP (K+, BUN, and creatine, VBG?), cardiac monitoring MI Hallmarks -Crushing chest pain, pain radiating from the left jaw, should and/or arm -Heartburn/ indigestion, n/v (women) -SOB, diaphoresis, pale cool skin, anxiety -ST elevation, High troponin (cardiac enzymes), high RR, high BP, and low O2 MI interventions -Perform a focused assessment; cardiopulmonary. -Recheck VS (HR, RR, BP, O2,) - 12 Lead EKG -Establish IV access -Follow ONAM (Oxygen, nitroglycerin, aspirin, morphine) -Contact MD and anticipate orders for labs; cardiac enzymes (CPK-MB) and troponin levels, an ECHO to check EF, CXR, check CBC. Sepsis hallmark signs Identified as 2 + of the following criteria PLUS a suspected infection: -Temperature 36.0C or 38.3 C -HR 90 -Respiration 20 -WBC 4,000 or 12,000 or BANDS 10% Blood sugar 140 in nondiabetic Others: Dec. BP, cool/clammy skin, dec. CO, oliguria Sepsis interventions -Focus assessment, VS (HR, RR, SpO2, BP, Temp) -Reassess BS -Establish IV access -Identify possible source of infection -Call MD and anticipate orders for sepsis BUNDLE, CXR Sepsis Bundle -Obtain initial lactate -Draw blood cultures, sart IV antibiotics (within first 60 minutes) -expect to start fluid resuscitation -Repeat serum lactate -Prepare for vasopressor (if fluids fail) -Continue assessment of patients for change in status