HESI Remediation Info

  1. Arterial vs venous symptoms
    • Arterial: intermittent claudication, cramping, numbness, tingling
    • Aggravating symptoms: walking, elevation
    • Relieving factors: rest, or dangling.
    • Associated symptoms: cool pale skin-poor healing injuries to extremities
    • Venous: aching, tiredness, feeling of fullness
    • aggravating symptoms: prolonged standing, sitting.
    • relieving factors: elevation, lying, walking.
    • associated symptoms: edema, varicosities, weeping ulcers at ankles.
  2. Phases of burn patients nursing care
    • Resuscitative phase: Life threatening, airway or breathing problems, cardiopulmonary instability, hypovolemia, hypothermia-shock phase. Every organ is involved in this response with a TBSA burn of 20% or greater.
    • Acute Care phase: wound healing, wound closure prevention of infection.
    • Rehabilitation phase: support for adequate wound healing, prevention of scarring, contractures, and psychological support
  3. Critical care nursing management: Burns
    • Oxygen alterations: assess airway, breathing, administer O2. 
    • monitor HBCO levels-carbon monoxide
    • elevate HOB and implement HAP percautions
    • assist with pulmonary secretion suctioning
    • Observer for signs of airway obstructions
    • Intubation?
    • Maintain accurate documentation
    • Impaired gas exchange: High Flow Oxygen
    • Ineffective airway clearance: laryngeal swelling can occur at anytime during first 24 hours and up to 72 hours increased risk of edema. monitor for intubation
    • Fluid resuscitation: Parkland Burn Formula-(4ml X TBSA (%) X Weight (KG)) give 50% in first 8 hours. LR is the standard for the first 24-36 hours. Capillary Leak seals after 24 hours approx. which allows albumin to be given without leakage into the interstitium. 
    • Electrolytes: Potassium increased risk for hyper or hypo-due to cellular damage, kidney damage, metabolic acidosis. increased risk for hyponatremia as well
    • Ineffective kidney tissue perfusion: myoglobinuria(proteins)-port wine color in urine-leading to damage to glomerular apparatus-tubules. Fluids, forced diuresis with mannitol, osmotic diuretics-hourly urine output that is double recommended. UO every hour for first 48-72 hours.
    • Ineffective peripheral tissue perfusion: 6 P's (Pulselessness, pallor, pain, paraesthesia, paralysis, poikilothermia) 
    • Inflammatory phase: 3-5 days after injury.
    • Proliferative phase: 4-20 days after injury.-epithelization-cells begin to cover the wound and bring collagen to heal.
    • Maturation phase: 20-over a year-scar tissue begins to form.
    • Imbalanced nutrition: metabolism increases 40-100% depending on TBSA burned.
    • Topical antibiotic therapy is needed for burn injury. Silver sulfadiazine, mafenide acetate cream, bacitracin, pure silver.
    • Wound closure: Autografts, allografts (homografts), xenografts, synthetic skins
  4. Pediatric DKA
    • Type 1-absolute or relative insulin production:stress response, infection or missed insulin injection are some main causes of DKA in children or adolescence. 
    • S/S: BG elevated, ph low,urine ketonse, kussmaul respirations, WBC may be elevated.
    • Focused assessment: respiratory status, LOC, hydration status, electrolyte acid balance.
    • Treatment: hydration, insulin drip as ordered, continuous cardiac monitoring, monitor Potassium level, urine output >30ml/hr, neurological check every 1-2 hours-assess for signs of ICP due to increased risk of cerebral edema with re-hydration.
  5. HOT SPOT Heart Auscultations
    Image Upload 1
  6. rating pitting edema
    • +1: barely perceptible pit
    • +2: deeper pit-rebounds in a few seconds
    • +3: deep pit rebounds in 10-20 sec
    • +4: deep pit rebounds in >30 sec
  7. H2 receptor blockers ex
    • cimentidine (Tagamat)
    • ranitidine (Zantac)
    • famotidine (pepcid)
    • Pantoprazole
  8. Steps of IV and Tubing assessment
    IV site to bag
  9. mixing insulin RN (Regular to Nph)
    Most commonly ordered insulin that are mixed: NPH (intermediate-acting) and Regular  insulin (short-acting

    • Never mix Insulin Glargine “Lantus” with any other type of insulin.
    • Administer the dose within 5 to 15 minutes after drawing up because the regular insulin binds to the NPH and this decreases its action.
    • insert air into both vials than draw from CLEAR TO CLOUDY
Author
rmwartenberg
ID
330820
Card Set
HESI Remediation Info
Description
Weak subjects
Updated