SUMMARY
NUR 280
COMPREHEN
SIVE 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
, o Don’t aspirate or expel the bubbles out of prefilled syringe
v v v v v v v v v
Colostomy
- Descending colostomy located on LLQ (involves the large intestines)
v v v v v v v v
- Stoma should be reddish pink, moist and shiny (Saunders pg. 688)
v v v v v v v v v v
o Call MD if stoma looks: v v v v
▪ Pale/ Pink (low h&h levels) v v v v
▪ Dark purple/ Black (compromised circulation) v v v v
▪ Shrink in size/Dry v v
▪ Small amount of mucous drain in the bag v v v v v v v
- Expect liquid stool in the immediate postop period but become mores more solid depending
v v v v v v v v v v v v v
on location
v
o Ascending Colon: liquid v v
o Transverse Colon: loose to semi-formed v v v v
o Descending Colon: close to normal v v v v
- Empty pouch when 1/3 full
v v v v
- Monitor for dehydration & electrolyte imbalance
v v v v v
- Avoid food that causes excess gas or odor
v v v v v v v
o Give yogurt to help decrease smell v v v v v
- Avoid contact of skin with stool
v v v v v
- Should start functioning 2-3 days after surgery
v v v v v v
Ventilator Associated Pneumonia (VAP)
v v v
- Prevention
o HOB elevated >30 degrees v v v
o ulcer prophylaxis (H2 blockers) v v v
o preventing aspiration v
o pulmonary hygiene (chest physiotherapy, postural drainage/percussion and
v v v v v v
turning/re-positioning Q2hours)
v v
o remove water from circuits, and suction PRN. v v v v v v
o Vigilant, frequent oral care is key! v v v v v
▪ brushing teeth Q8hours, antimicrobial rinse and lip moisturizer Q2hours v v v v v v v v
o Cough
Sepsis:
- Bloodstream infection/UTI, bacteria, fungi, vasodilation
v v v v
o considered a type of distributive shock, prevention is key. v v v v v v v v
- Risk Factors:
v
o cancer patients (highest risk) v v v
o malnutrition
o immunocompromised
o open wounds v
o DM, CKD, Hepatitis, HIV/AIDS v v v
- S/S:
, o DIC (disseminated intravascular coagulation)
v v v
o low O2 v
o tachypnea
o decreased/absent urine output v v
o change in LOC v v
o hypoxia
o death/dysfunction of organs v v
- Interventions:
o Resuscitation oxygen therapy v v
o Blood replacement therapy v v
o Drug therapy v
- Identify early manifestations of infection
v v v v
o treat with antibiotics v v
o strict aseptic technique v v
o IV fluids v
o inotropic medications. v
Septic Shock
v
- Caused by an infection
v v v
o Medical emergency can happen to anyone who is a patient in the hospital.
v v v v v v v v v v v v
- Capillaries dilate v
o Fluid exits the vascular system and enters interstitial spaces.
v v v v v v v v
- S/S:
o Hypotension
o Tachycardia
o Increased RR v
o Increased temp v
o cold and clammy skin. v v v
o Changes in LOC (earliest sign) v v v v
- Treatment:
o Fluids
▪ Normal Saline and Lactated Ringers (Bolus) v v v v v
o Broad Spectrum antibiotics v v
o Vasopressors
A-Fib
- Multiple Rapid impulses
v v
- Quivering atria v
- Irregular heart rhythm
v v
- HR 130-150+
v
- Treatments:
o Oxygen
o Amiodarone & Digoxin v v
▪ With rapid ventricular response (RVR) v v v v
o Calcium Channel Blocker (CCB) v v v
NUR 280
COMPREHEN
SIVE 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
, o Don’t aspirate or expel the bubbles out of prefilled syringe
v v v v v v v v v
Colostomy
- Descending colostomy located on LLQ (involves the large intestines)
v v v v v v v v
- Stoma should be reddish pink, moist and shiny (Saunders pg. 688)
v v v v v v v v v v
o Call MD if stoma looks: v v v v
▪ Pale/ Pink (low h&h levels) v v v v
▪ Dark purple/ Black (compromised circulation) v v v v
▪ Shrink in size/Dry v v
▪ Small amount of mucous drain in the bag v v v v v v v
- Expect liquid stool in the immediate postop period but become mores more solid depending
v v v v v v v v v v v v v
on location
v
o Ascending Colon: liquid v v
o Transverse Colon: loose to semi-formed v v v v
o Descending Colon: close to normal v v v v
- Empty pouch when 1/3 full
v v v v
- Monitor for dehydration & electrolyte imbalance
v v v v v
- Avoid food that causes excess gas or odor
v v v v v v v
o Give yogurt to help decrease smell v v v v v
- Avoid contact of skin with stool
v v v v v
- Should start functioning 2-3 days after surgery
v v v v v v
Ventilator Associated Pneumonia (VAP)
v v v
- Prevention
o HOB elevated >30 degrees v v v
o ulcer prophylaxis (H2 blockers) v v v
o preventing aspiration v
o pulmonary hygiene (chest physiotherapy, postural drainage/percussion and
v v v v v v
turning/re-positioning Q2hours)
v v
o remove water from circuits, and suction PRN. v v v v v v
o Vigilant, frequent oral care is key! v v v v v
▪ brushing teeth Q8hours, antimicrobial rinse and lip moisturizer Q2hours v v v v v v v v
o Cough
Sepsis:
- Bloodstream infection/UTI, bacteria, fungi, vasodilation
v v v v
o considered a type of distributive shock, prevention is key. v v v v v v v v
- Risk Factors:
v
o cancer patients (highest risk) v v v
o malnutrition
o immunocompromised
o open wounds v
o DM, CKD, Hepatitis, HIV/AIDS v v v
- S/S:
, o DIC (disseminated intravascular coagulation)
v v v
o low O2 v
o tachypnea
o decreased/absent urine output v v
o change in LOC v v
o hypoxia
o death/dysfunction of organs v v
- Interventions:
o Resuscitation oxygen therapy v v
o Blood replacement therapy v v
o Drug therapy v
- Identify early manifestations of infection
v v v v
o treat with antibiotics v v
o strict aseptic technique v v
o IV fluids v
o inotropic medications. v
Septic Shock
v
- Caused by an infection
v v v
o Medical emergency can happen to anyone who is a patient in the hospital.
v v v v v v v v v v v v
- Capillaries dilate v
o Fluid exits the vascular system and enters interstitial spaces.
v v v v v v v v
- S/S:
o Hypotension
o Tachycardia
o Increased RR v
o Increased temp v
o cold and clammy skin. v v v
o Changes in LOC (earliest sign) v v v v
- Treatment:
o Fluids
▪ Normal Saline and Lactated Ringers (Bolus) v v v v v
o Broad Spectrum antibiotics v v
o Vasopressors
A-Fib
- Multiple Rapid impulses
v v
- Quivering atria v
- Irregular heart rhythm
v v
- HR 130-150+
v
- Treatments:
o Oxygen
o Amiodarone & Digoxin v v
▪ With rapid ventricular response (RVR) v v v v
o Calcium Channel Blocker (CCB) v v v
