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Critical lab values to memorize?
- K+
- Na+
- Mg+
- H/H
- Ca++
- BUN/Cr
- WBC
- Glucose
- Platelets
- pH
- CO2
- O2
- HCO3 (bicarb)
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What is the 5 point physical assessment?
- For every new symptom, perform 5 point in under 2 minutes.
- 1) Central/Neural: make eye contact, ask how they're doing. Assess for eye contact, eye opening, and appropriate, timely response.
- 2) Central Cardiac: Listen to heart, listen for normalcy/ baseline. Look at ECG.
- 3)Peripheral cardiac: Feel pulses, strength, color, temp. Mottled knees = emergency. 10 seconds each pulse for each extremity.
- 4) Pulmonary: WOB, Resp Rate, even, PO2, follow tubes to equipment, lung sounds.
- 5) GI/GU if relevant: Distended,
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Independent vs. dependent nursing interventions?
- Dependent: requires IP order
- IV rate
- CXR
- Medications
- Independent:
- Assessment AND REASSESSMENT
- IV patency
- Ambulating
- Repositioning
- Oral care
- Teaching
- Bed change
- IV start
- Hand washing
- I/S
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