Full Course Guide – NURS 242 Med-Surg Nursing –
Complete and Correct Resources for Theory, Lab,
and Clinical Success
Exam 1: -
Cane: - -Appropriate height (at wrist level when arm is at side)
-Pt strong hand on cane
*MOVE CANE WITH WEAKER LEG*
At risk for falls due to: - incontenience
Transferring pt to WC: - -Place WC on strong side angled to bed
-Strong hand to armrest, then pivot
Safe pt handling: - -Keep pt directly in front of you and as close as possible to prevent
back injuries
Skin integrity: - -dont wear restrictive clothing
-WC pt lift themselves off buttock for 10 seconds q1hr
Pressure Ulcer stages: - *Stage 2- skin is not intact; open or fluid blister*
Wet-to-damp wound care: - mechanically removes necrotic tissue
does more damage than good bc it removes the good tissue as well
Informed consent: - -surgeon is responsible for having consent signed
-Pt who can not sign can sign with an "X" but must be witnessed by two people
-If the pt doesn't understand the surgery, the surgeon has to be notified
-A blind pt can sign the consent, has to be witnessed by 2 people
-Nurses DO NOT clarify orders/procedure/risks, must call the MD to explain to pt
Pre-OP: - -Report these to surgeon:
,-increased PT/INR/aPTT/Creatinine
-Verify operative permit is signed
-Side rails up, bed down, call light within reach
Intra-OP: - -Pts are lifted into position onto the OR table to prevent shearing
-Gel pads are placed on the OR table to prevent pressure ulcers
-Warming blankets are used
-Cover the pts head and feet (decrease hypothermia)
*If saving is necessary, hair should be removed using disposable sterile supplies immediately
before the start of the procedure*
-Sterile scrubbing from fingertips to elbow for 3-5 minutes
Post-OP: - -in PACU, nurse immediately assess pt airway, LOC
-RR <10 may indicate respiratory depression due to anesthesia
-Sanguineous to serosanguineous drainage is normal
-Crusting at incision line and swelling is normal
Malignant hyperthermia: - -life threatening
-you will see HIGH TEMPERATURE
-early sign is tachycardia, muscle rigidity
-Dantrolene is used to treat
Pain Management: - *Pain management referral for pts in chronic pain unrelieved*
-Pain after abdominal sx is from trapped carbon dioxide, ambulate pt as soon as possible
-Use FACES scale in pts with dementia
PCA Pump: - -Lockout interval of 5-15 minutes
-Pt cannot be cognitively impaired
-Only the pt can press the button
, If incision opens: - -cover with wet sterile gauze
-Do not try to reinsert protruding organ
-Reassure pt
-Supine position with knees bent
IV: - -20G 1-1.5" needle is adequate for most therapies
-Huber needle should be placed at 90 degree angle to access port (chemo pt)
TPN: - - Check each bag twice
-If TPN is unavailable, hang 10% dextrose/water or 20% D/W until TPN is available
-If TPN not administered on time, do not increase the rate
-Change IV tubing q24 hours when new bag is hung
-Dressing change around IV site changed 2 48-72 hours
Sickle Cell: - -Pain is the most common problem
-Requires large doses of opioid analgesics
-Hydrate with NS IV fluids, encourage oral fluids without caffeine
-Administer O2
-Remove restrictive clothing, No BP with external cuff
-Sickle Cell crisis: pain meds and IV fluids
Vitamin B12 Deficiency: - -Smooth, beefy red tongue
MRSA: - -Sleep in separate beds until infection clears
-Wash clothes in HOT water
Standard precautions: - -Hand hygiene
-Gloves
Contact precautions: - -Private room
-Wear gloves when entering room
Complete and Correct Resources for Theory, Lab,
and Clinical Success
Exam 1: -
Cane: - -Appropriate height (at wrist level when arm is at side)
-Pt strong hand on cane
*MOVE CANE WITH WEAKER LEG*
At risk for falls due to: - incontenience
Transferring pt to WC: - -Place WC on strong side angled to bed
-Strong hand to armrest, then pivot
Safe pt handling: - -Keep pt directly in front of you and as close as possible to prevent
back injuries
Skin integrity: - -dont wear restrictive clothing
-WC pt lift themselves off buttock for 10 seconds q1hr
Pressure Ulcer stages: - *Stage 2- skin is not intact; open or fluid blister*
Wet-to-damp wound care: - mechanically removes necrotic tissue
does more damage than good bc it removes the good tissue as well
Informed consent: - -surgeon is responsible for having consent signed
-Pt who can not sign can sign with an "X" but must be witnessed by two people
-If the pt doesn't understand the surgery, the surgeon has to be notified
-A blind pt can sign the consent, has to be witnessed by 2 people
-Nurses DO NOT clarify orders/procedure/risks, must call the MD to explain to pt
Pre-OP: - -Report these to surgeon:
,-increased PT/INR/aPTT/Creatinine
-Verify operative permit is signed
-Side rails up, bed down, call light within reach
Intra-OP: - -Pts are lifted into position onto the OR table to prevent shearing
-Gel pads are placed on the OR table to prevent pressure ulcers
-Warming blankets are used
-Cover the pts head and feet (decrease hypothermia)
*If saving is necessary, hair should be removed using disposable sterile supplies immediately
before the start of the procedure*
-Sterile scrubbing from fingertips to elbow for 3-5 minutes
Post-OP: - -in PACU, nurse immediately assess pt airway, LOC
-RR <10 may indicate respiratory depression due to anesthesia
-Sanguineous to serosanguineous drainage is normal
-Crusting at incision line and swelling is normal
Malignant hyperthermia: - -life threatening
-you will see HIGH TEMPERATURE
-early sign is tachycardia, muscle rigidity
-Dantrolene is used to treat
Pain Management: - *Pain management referral for pts in chronic pain unrelieved*
-Pain after abdominal sx is from trapped carbon dioxide, ambulate pt as soon as possible
-Use FACES scale in pts with dementia
PCA Pump: - -Lockout interval of 5-15 minutes
-Pt cannot be cognitively impaired
-Only the pt can press the button
, If incision opens: - -cover with wet sterile gauze
-Do not try to reinsert protruding organ
-Reassure pt
-Supine position with knees bent
IV: - -20G 1-1.5" needle is adequate for most therapies
-Huber needle should be placed at 90 degree angle to access port (chemo pt)
TPN: - - Check each bag twice
-If TPN is unavailable, hang 10% dextrose/water or 20% D/W until TPN is available
-If TPN not administered on time, do not increase the rate
-Change IV tubing q24 hours when new bag is hung
-Dressing change around IV site changed 2 48-72 hours
Sickle Cell: - -Pain is the most common problem
-Requires large doses of opioid analgesics
-Hydrate with NS IV fluids, encourage oral fluids without caffeine
-Administer O2
-Remove restrictive clothing, No BP with external cuff
-Sickle Cell crisis: pain meds and IV fluids
Vitamin B12 Deficiency: - -Smooth, beefy red tongue
MRSA: - -Sleep in separate beds until infection clears
-Wash clothes in HOT water
Standard precautions: - -Hand hygiene
-Gloves
Contact precautions: - -Private room
-Wear gloves when entering room
