Med surg Ch 1

ABCDE Principle in Nursing

- A (Airway): ENSURE PATENT AIRWAY. Stabilize cervical spine if neck/head trauma is suspected - B (Breathing): Assess for respirations - C (Circulation): Check heart rate, blood pressure , capillary refill - D (Disability): Assess patient's level of consciousness - E (Exposure): Assess patient's body for trauma, exposure to heat/cold

How long does a pt have before brain injury or death occurs if the airway is not patent (hypoxia occurs)?

3 to 5 mins

when is antivenom most effective on a snakebite?

4 to 12hrs within bite

How should an obstruction be cleared in the airway?

Suction or the finger sweep method if the object is clearly visible

Ventricular asystole

a complete absence of electrical activity and ventricular movement of the heart. The client is in complete cardiac arrest and requires implementation of BLS and ACLS protocol. (not considered a shockable rhythm - no defibrillation)

primary survey

a rapid set of assessment of life-threatening conditions

what should a nurse do if a pt is asystole?

administer epinephrine bcs it increases heart rate, improves cardiac out, and promotes bronchodilation (widens airway)

what should a pt whit hyperthermia limit the consumption of?

alcohol and caffeine

What are the head-tilt/chin-lift maneuvers used to do?

clears the airway by lifting the tongue away from the laryngopharynx

manifestations of a heat stroke

elevated temperature (greater than 104F) lack of presipiration low blood pressure increased HR decreased urinary output alterations in mental status abnormal blood potassium or sodium levels

Manifestations of shock

hypotension, tachycardia, increased respiratory rate

Why would a nurse instill activated charcoal for a client who has ingested a toxic substance?

it adsorbs (individual molecules gather on surface of charcoal) the toxic substance and does not pass the blood stream

Why should a nurse notify a rapid response team for a pt who reports right calf pain and shortness of breath?

it is possible that the pt can be at risk for respiratory arrest due to a possible embolism and can lead to rapid decline in the pt's condition

Why shouldn't you induce vomiting in a pt who has injested a toxic agent?

puts pt at risk for aspiration

What guides the primary survey?

the ABCDE principle

shock

the body's response to inadequate tissue perfusion (circulation) and oxygenation

naxolone

used to reverse heroin and opiate toxicity and effects

diazepam

used to treat anxiety, muscle spasms, and seizures.

Gastric lavage and aspiration

when a large tube is placed orally into the gastrointestinal tract (stomach) to aspirate (suction) toxic contents, followed by flushing instilled fluid, usually water

When is the modified jaw thrust maneuver used?

when the pt is unresponsive with suspicion of trauma (neck injury)

When is the head-tilt/chin-lift maneuver used?

when the pt is unresponsive without suspicion of trauma