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observe for what in basal skull fx?
bleeding from ears.
want to observe increased signs of bleeding.
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SCI. avoid what stimuli?
constipation
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ICU, care plan, contractures can be prevented by?
exercising 48 hours after injury, 5x a day. turning pt doesn't count.
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head injury pts, thrash around bed, what you wanna do?
pad side rails.
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C5 spinal cord injury, severe throbbing HA, what you wanna do?
Check indwelling catheter for patency
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assess SCI. injury. What you suspect?
spinal shock
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old female, decreased LOC, why did physician order, elevate HOB, avoid sharp hip flexion.
avoid impeding venous outflow.
anything that impedes venous outflow will increase ICP
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what you expect to observe with spinal shock?
absence of reflexes along extremities
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Glascow coma scale is measuring what?
LOC
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severe brain injury, what test is used to confirm brain death?
cerebral blood flow studies
first is EEG - then cerebral blood flow study
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you doing pin site care on traction. it comes off. what you do first?
notify surgeon.
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ED 6yo. MVI. vitals are normal. what you trying to do now?
preserve brain homeostasis.
so you're preventing secondary injuries from happening.
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diffuse axonal injury. what test can you do to observe brain structure?
MRI
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13yo, ED, baseball, child comes awake 5 hours after, he can't remember shit. MRI no injury. What you suspect?
classic concussion.
(no injury - won't be mild concussion bc he has been out for 5 hours)
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80yo male fell. he's most as risk for?
hematoma.
(what comes out of a hematoma? embolis...so it's a matter of "what comes first")
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Brain injury, what is a goal for this pt?
prevention of sleep deprivation.
sleep deprivation can irritate, increase ICP
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major cause of death with people with SCI?
P.E.
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highest risk for TBI is in what age group?
older people. 75 or older.
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spinal cord injury. you suspect muscle spasticity. What med can you expect to give?
baclofen
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ED, MVI, t1 spinal cord injruy. What is he at risk for d/t this?
Pulmonary edema
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decrease in BP and HR. You know it's neurogenic shock. What you wanna look out for?
abrupt onset of fever.
(think, they can't sweat either. SNS is damaged)
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Autonomic dsyreflexia. What are the obj when caring for this?
removing the triggering stimulus.
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burn pt, first systemic event after a burn injury is what?
hemodynamic instability....
then hypovolemia.
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burn victim, stabilized. If he has inadequate fluid resuscitation, what happens?
distributive shock.
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burn victim, 24% of body, pathopysiologic changes include what?
decrease CO
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male pt, 16yo, burn rt hand/arm, superficial burn, nurse teach pt what about dressing changes?
check cap refill for circulation
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burn unit, nurse has to monitor for what as the edema in the burns increases?
ischemia
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acute phase of burn, most important for nuse to monitor?
hypona+
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What occurs during the acute phase of a burn.
diuresis
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What is nursing goal during acute phase of burn?
to manage pain a proactive way for pt's comfort
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caring for pt during acute phase of burn. you are responsible for what?
observe for infection
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time to change dressings on burn pt. what can you do to reduce pain at this time?
go as fast as you can
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care plan, open fx, what is priority nursing goal?
risk for infection.
you have a bone sticking out, what you at risk for? osteomyelitis.
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hip fx, you tell pt to do what to prevent complications?
fluid intake.
(to prevent DVT, you increase fluid).
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nurse caring for pt with tibial fx. short leg cast is used for what?
knee motion.
-
amputation, when can pt stand up after surgery?
you can stand after the amputation. right after.
-
simple fx, teachings, what you tell pt?
do exercises of the unaffected muscles.
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long arm cast. 12 hrs, arms hurts, analgesics did not relieve pain, what next?
rid of cast as fast as you can.
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What situation is the family in when blaming each other about what happened to pt?
remorse and guilt
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gunshot wound, most common hollow organ injury is what?
small bowl
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multiple trauma, after threats to life are corrected (airway, etc) then what's next?
rapid physical assessment. (then you look at "what happened" to the pt. the wounds, the situation).
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rehab phase of burn injury.
patient and family education is priority in acute/rehab phase
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burn vic is transitioning from acute to rehab, pt tells the nurse, "I can't wait to have surgery so I can look normal again". What do you say to that?
we'll talk about it after the scars heal.
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high cervical spinal injury, what meds can you give to prevent further spinal cord damage?
solumedrol. corticos
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automic dysreflexia. What are they going to present?
brady and hypotention
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ICP, what symptoms would indicate increased ICP, leading to brain stem damage?
bradypnea
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person fell. hit head, feels fine after. now has HA. you suspect epidural hematoma. What you expect they do next?
emergency craniotomy.
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T2 SCI. neurogenic shock, you wanna monitor for what?
hypotention
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17 yo male, SCI, common cause is what?
MVI
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SCI, altered mobility, what can you do to prevent DVT?
apply thigh elastic socks
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discharge teaching, pt asks why autonomic dysreflexia is an emergency. Why?
Sudden increase in BP can increase ICP, bursting cerebral blood vessels
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SCI, autonomic dysreflexia, what is priority?
place pt in safe position
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SCI, prone to foot drop, use splints. splints are removed and reapplied how often?
every 2 hours
-
goal for quadriplegia include what?
maintain skin integrity.
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suspected brain injury pt. what might MD order to prevent secondary injury?
ABGs.
you want to prevent acidosis.
-
heat stroke. you expect to see what?
anhidrosis
(heat exhaustion - sweat. Heat stroke - no sweat)
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swallowed toilet bowl cleaner. What you want to do?
gastric lavage.
-
suspected alcohol intox. what condition can mimic this?
hypoglycemia.
-
sex assult vic. important for nurse to do what when assessing vic?
respect privacy and sensititvity.
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admitted for depression. What you want to do?
ask pt is they have thought about taking their own life
-
pt coughing forcefully, choking. What do you do?
watch pt. do not intervene at this time.
(no heimlich)
-
fx left femur. What signs for potential fat emboli?
cyanosis, decreased O2
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pt fell into hole. rt leg is shorter than lt leg, what you suspect?
dislocation of hip
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why are dislocations and subluxations medical emergencies?
vascular necrosis my develop
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hockey player. can't move left arm, arm looks longer than rt arm. What you suspect?
dislocated shoulder
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injury to wrist. 3rd degree strain. Why would MD order xray?
avulsion fx are associated with 3rd degree strains.
-
boy, bmx race, open fx, tibia. what grade is this?
grade 3.
-
pt has intra articular fx and MD splints injury. when man comes back, you want to let him know what?
post traumatic arthritis.
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fallen, injure ankle, trimalleolar fracture. What is used to hold that in place?
screws.
-
post op ORIF ankle. comes back, find out bones didn't heal together. What complication is this?
late complication.
-
neck of left femur fx. What is complication of that?
avascular necrosis
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resp insufficiency. you expect what to be inserted?
oral pharengeal airway.
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MVA, blunt trauma to abd. What action is appropriate.
immobilize on backboard.
What to immobilize until SCI is ruled out.
-
pt can't maintain patent airway d/t hemorrhage. What is nursing diagnosis?
ineffective airway clearance.
-
pt broken femur. cool moist skin, increased HR, falling BP. you suspect?
hemorrhage.
(hypovolemia through bleeding)
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discharge teaching. how you give instructions
verbal and written
-
Talking about pts that talk about suicide. What is it about crisis intervention?
is used to determine suicide potential.
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MVA, trapped burning vehicle. Est likelihood of survival. What is it based on?
age, depth, presence of inflammation
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acute phase of burn, caution of fluid and elecs is because of what?
- pt psycho resp. to burn injury
- shifts in fluid
- losses of fluid from large burn wounds
-
acute phase of burn. what intervention can you do to help pt cope more effectively?
- promote truthful communication
- assisting pt in practicing approp. strategies
- give positive reinforcement.
-
rehab phase. what goals are important at this time?
- increase understanding of follow up care
- increase control of care
- increase participation in daily living
- adjustment to alterations in lifestyle.
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school nurse. SPI. what are risk factors?
- young age
- driver
- african american
- male
- alchy use
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prevention of infection in burn pt. nurse instructor is discussing what phase of burn care
acute.
-
immediate resuscitative phase in burn injury. what does lab work look like?
hyperka+, hypona+, acidosis, increased HCT
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electrical burn. thick eschar. what abx would you use?
mafenide acetate
-
partial thickness. proper intervention of separation of burns.
trim away the whatever
-
what faactors does nurse use to determine depth of burn?
cause of burn
-
deep partial thickness. nursing diagnosis priority
acute pain
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baby, boil water on chest. what do i do?
cool bath
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teaching elastic garment. how do you wear it?
continously
-
partial thickness on chest and legs. smoke inhalation. what is priority
airway management
-
house fire. face, leftforearm
15%.
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What lab value you closely monitor in burn?
sodium deficit
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partial thickness. why do we keep alignment in pt?
to prevent contractures
-
something about fat, weight and fluids.
your reserve fat has been catabolized so it can be used for fluid because you haven't been eating.
-
-
neuro ICU. SCI. priority?
ineffective breathing patterns.
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fx of nose. skin tear, mucus membrane. what type of fx?
impacted.
-
long bone fx. careplan. what intervention to promote healing?
monitor color, temp,
-
edema, tenderness, muscle spasm, ecchymosis. ran 10 miles, now it hurts to stand. what is this?
2nd degree strain.
-
discharge after sprain to left ankle. what you tell him?
elastic bandage.
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AKA comes for post op check. phantom pain. what can you do?
apply hot compress.
-
BKA. how you measure proper positioning and prevent contrax?
encourage pt turn side to side/prone
-
sling. clavicle fx. what you teach?
encourage some light activity. raise it up a little bit. ROM. prevent contrax.
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What fx is at risk for volkmann's cx?
humerus
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soccer player. leg hit from side while foot is planted on ground.
lateral collateral ligament injury.
-
hip fx, chest pain, increase HR and RR. thick white, sputum. what is it?
fat embolism
-
fx humerus. tachy, pale, confused.
DIC.
-
something something fx.
place a pillow
-
broken hip. prevent complications. assess for what?
fat embolism
-
multi team do for amputees.
help achieve highest level of function
-
amputee. maintain what during care?
positive attitudes
-
amputee. least likely to perform what?
place residual limb on pillow.
-
BKA. discharge teaching. what you teach?
mobility aids.
-
amputee. discharged. assess for what?
pts, healed, nontender scar.
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alchy withdrawal. prevent hallucinations.
turn lights down low
-
known poison. assist with gastic lavage. what position?
semi fowlers.
-
rewarming hypothermic pt. what can you expect to do?
assess temp
-
you suspect internal bleeding when you see what?
increase pulse rate.
-
falling roof. test is see injury in peritoneal.
CT
-
no identification. how you get consent?
document LOC and status.
-
acute alchy intox,
hypoglycemia
-
rape trauma sysndrome
acute stress reactx to life threatening situation
-
rape vic. sate of shock. guilt, humilitation. what phase?
acute disorganization phase.
-
rape vic, interventions are aimed at what?
sense of control of his or her life
-
who is high risk for suicide?
elderly.
-
what do you document in relation to restraints?
pt's response to restraints.
-
ltc. weakness, lethargy. emergencies in elderly is different because?
altered response to treatment.
-
frostbite. homeless. rewarming.
place 100 degree circulation bath
-
stomach cramps, nausea, diarrhea. key to treatment of food poisoning.
determine source and type of food poisoning.
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