NCLEX A+ Fluid, acid, burn, misc.

You assess everything in a circulatory assessment except - pulse - skin color - skin temp - cap refill - turgor

- turgor turgor's for hydration not circulation

Fluid replacement supplies for burns?

2 large bore IVs LRs Albumin Give 1/2 of total fluid replacement during the 1st 8 hrs since time of burn occurrence not beginning of treatment

HCO3 normal range

22-26 mm Hg

PaCO2 normal range

35-45 mm Hg

Rule of Nines (adult)

9% per arm 9% for head 18% each leg 18% anterior trunk 18% posterior trunk 1% genitalia

You hear a pericardial friction rub which is

A sign of pericarditis

pH 6.8-7.35 (<7.35)

Acidotic

pH 7.45-7.8 (>7.45)

Acidotic

S&S of metabolic alkolosis

Altered LOC Decrease in serum K Muscle cramps Arrhythmia

S&S of metabolic acidosis

Altered LOC Increased serum K (Hyperkalemia) Muscle twitch, weakness, flaccid paralysis, arrhythmia Increased RR

Causes of respiratory acidosis

CO2 retention due to hypoventilation, sedation, pneumothorax

Emergency treatment for burns

Cool NOT ICE water for no more than 10 minutes Wrap in blanket to hold in body heat Remove jewelry ASAP Cover burn with clean, dry cloth Do not remove clothing that is stuck to the wound until later 100% O2 WATCH FOR CARBON MONOXIDE AND H CYANIDE POISONING

client diagnosed with rheumatoid arthritis has been prescribed dexamethasone orally as part of initial treatment therapy. What side effects should the nurse teach the client are expected?

Dexamethasone (Decadron) is a corticosteroid used short term to treat severe inflammation occurring in rheumatoid arthritis (RA). Expected side effects are associated with the body's response to excessive steroids in the system. Even short term use of corticosteroids will produce fatigue, secondary to insomnia, truncal obesity accompanied by thin extremities, and an increased appetite resulting in weight gain. Despite the short and intermittent use of corticosteroids for this auto-immune disease, some side effects remain permanently.

T/F amputation is usually not needed for electrical patients

F. Circulation is really bad.

How to combat skin infection in burn patient

Flush skin with sterile saline/cool H2O for 15-30 min to combat infection

1st thing to do for electrical burn patient

HIGH RISK FOR V FIB. START CONTINUOUS HEART MONITOR FOR 24 HRS.

SS of respiratory acidosis&

Headache Confusion Sleepiness/difficulty arousing —> coma Decreased LOC Hypoxia

Risk factors for further complications of a burn patient

Heart, lung, diabetic, or kidney diseases

Proper foot care and regular eye exams should be done to avoid complications caused by

Hyperglycemia

Drugs to flush out kidneys

IV Mannitol (osmitrol). Use in line filter and watch for clarity cause it may crystallize. DO NOT REFRIGERATE.

K should be in or out of cell?

In

Widening pulse pressure is a sign of

Increase ICP

S&S of Burns

Increased HR to pump fluid to vital organs Decreased cardiac output Decreased urine output Initial bottomed out BP but epi and norepi will kick in to jack BP back up ADH and aldosterone secretion to replenish and increase blood volume

Hallmark sign of cardiac tamponade

Increasing CVP with decreasing BP

Treatment for inhalation/smoke injury

Intubate/trach

renal care for burn patient with electrolyte imbalances

K increases in burn patients so monitor for hyperkalemia but later on they can develop hypokalemia. replace as needed

Care for cancer patients

Keep dedicated supplied in room Limit visitors Private room High calorie high protein diet Restrict tube placement

S&S of respiratory alkalosis

Light headed Fainting Numbness in mouth Tingling in fingers and toes

Treatment for respiratory acidosis

Liquify/mobilize secretion, percussion, postural drainage, suction, deep breathe exercising, fluids. Hey

pH 7.35-7.45

Normal

UAPs cannot

Observe, teach, evaluate, monitor, or administer but they can watch vitals

The son of an elderly diabetic client reports that his mother is frequently having low blood sugar. What should the nurse teach this family member about symptoms of hypoglycemia in the elderly?

Older clients are at risk for hypoglycemia unawareness. Blood sugar levels should be checked frequently. Some oral medications are more likely to cause hypoglycemia episodes. If the client has frequent episodes, perhaps a medication change is warranted. The elderly must maintain regular meal schedules and adequate food intake. This may present challenges for the elder who lives alone. If an elder develops unsteady gait, loss of concentration, and/or lightheadedness, the blood glucose levels should be checked. These symptoms are typical in a hypoglycemic episode.

What appears on a person's trunk when they have endocarditis

Petechiae

GI care for burn patient

Prevent Curling's stress ulcer: Observe for occult blood in stool, coffee brown vomit, bright red emesis. increased girth, NPO, suction NG tube in case of paralytic ileus development

2 earliest signs of hypoxia and acidosis

Restlessness & tachycardia

S&S of smoke/inhalation injuries

Singed nose/facial hair, soot , dark secretions, difficulty swallowing, wheezing, blistered oral/pharyngeal mucosa/lips, hoarseness, stridor, intercostal retraction, respiratory acidosis.

What is the priority nursing action for a client that was admitted with tingling of the toes and feet after having the flu for several days when the client begins to have numbness in the legs and hips?

Symptoms are classic for Guillain-Barre. The possibility of rapid progression and respiratory failure make this a medical emergency. The nurse's priority action is to notify the healthcare provider.

What signs and symptoms does the nurse expect a client diagnosed with bacterial pneumonia to exhibit?

The most common presenting signs and symptoms of pneumonia are cough, fever, chills, dyspnea, tachypnea, and pleuritic chest pain. If consolidation is present, increased tactile fremitus (vibration of the chest wall produced by vocalization) may be noted.

When you aspirate a patient's NG tube you pull back 75. Action?

Too low, so hold feeding and reinstill what you just took out

Integumentary care for burn patient

Use splints in a neutral position to prevent development of contractures but hyper-extend the neck and do not let them sleep on a pillow. Wrap finger wounds separately

When do you remove NG tube

When bowel sounds are heard

A client with acute renal failure will have

an increased (BUN). Significant elevation in BUN may result in nausea, vomiting, lethargy, fatigue, impaired thought processes, and headache.

Concern for baby if by 9 months

does not bear weight on legs with support, sit with help, babble ("mama", "baba", "dada"), play any games involving back-and-forth play, respond to own name, unable to recognize familiar people, look where you point, or transfer toys from one hand to the other.

Concern for baby if by 12 months

does not crawl, can't stand when supported, doesn't search for things that she sees you hide, doesn't say single words like "mama" or "dada", doesn't learn gestures like waving or shaking head, doesn't point to things, or loses skills he once had.

Concern for baby if by 18 months

doesn't point to show things to others, can't walk, doesn't know what familiar things are for, doesn't copy others, doesn't gain new words, doesn't have at least 6 words, doesn't notice or mind when a caregiver leaves or returns, or loses skills once obtained.

Symptoms of tension pneumothorax include

dyspnea, chest pain radiating to the shoulder, tracheal deviation, decreased or absent breath sounds on the affected side, neck vein distention and cyanosis

Signs and symptoms of ovarian cancer include

irregular menses, increasing premenstrual tension, menorrhagia with breast tenderness, early menopause, abdominal discomfort, dyspepsia, pelvic pressure and urinary frequency. Indigestion, flatulence, and fullness after a light meal, and increasing abdominal girth are significant symptoms.

Hyperkalemia may cause

muscle weakness, muscle twitching, and flaccid paralysis.

renal care for burn patient with red/brown urine

red/brown urine is expected after major burn but if found beware renal failure and notify primary provider to flush out kidneys and increase fluids.

If burn patient's circulatory check is bad you need to

restore circulation by relieving pressure via escharotomy (dead tissue removal)/fasciotomy (deep cut that cuts fascia)