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
,- 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:
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
,- 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:
