Truam Flashcards
What are some teaching your would give to a pt for skin graft instructions?
- keep on for 24 hrs
- wash hands
- call provider if it doesn’t fit and keep u w/appointment
-don’t wring it out - lotion + creams rubbed in correctly
for a 50% burn, what is essential care for client when documenting?
- where the burns are
- how it happened
- any other injuries
- type of burn
- how long ago
- tetanus shot how long ago or if they have it
What are early signs of sepsis?
-Reduced MAP
-Extreme temp difference elevated/decreased
- elevated serum glucose
- increased HR
- hypotension
Caring partial thickness and full thickness sin house burn, day one client brought my ambulance toal 27% back of torso and arm, 2nd degree on arms and back, indwelling Cath inserted, iv on jugular vein, 76.2kg, burn assertion, 4500 lactate riggers in 24 hrs, slow cap refill, lung clear, oriented to person not place and event, client receiving morphine I’ve, dressing, day 3, o2 15l per min high nasal cannula, pain. reviewing plan of care, compare condition from day 1-3, day 3 client is in what phase of burn care, urine output is 50ml pale urine color:
Acute intermediate as evidenced by improved by urinary output
Look at hematocrit levels as hydration increases, hematocrit will decrease.
Nurse caring for 24 yr client with right tibial fracture, cast 2 hrs ago, pain 7/10 despite pain med, nursing assessment is cool and pale than left foot an delayed cap refill and pulse, what is nursing action priority?
notify doctor
Nurse caring for 24 yr client with right tibial fracture, cast 2 hrs ago, pain 7/10 despite pain med, nursing assessment is cool and pale than left foot an delayed cap refill and pulse, what is nursing action priority:
Notify the doctor
After notifying the doctor you would prepare the patient for what? (clinical manifestations are)
bivalve of the cast
CM: loss of sensation, weak pulses, paresticia, complain about pain unrelieved by pain
What is internal fixation?
screws/plates and external fixation: pins/cages, come through the skin and held outside of the skin, cast and skin
Internal fixation as cast splint r external pins. Nurse caring for a team of clients, indicate what interventions are required for orthopedic repair:
Administer non-opioid PRN: both
Administer antibiotic: both
Complete pain care for prescribed guideline: external
Provide assistance for physical therapy: both
Encourage exometric muscle exercise: both
Encourage LDLs: both
Wait bairing: internal
ER nurse, caring for 22yr old in motor vatical accident, internal bleeding and fracture rib, at 9p lethargic opens eyes with name, hr 120, rr 32 shallow bp 92/64, t 98. Rlung clear in all fields, lung left diminished, bruising in ribs 5-7, distending of abdomen, bowel in 4, fully Cath pale yellow urine, ABG drawn , mechanical vent. 11pm chest X-ray has left pneumothorax, chest tune insert at 10pm, 110/68 bp, ABG drawn, ER nurse giving report to icu abs represent
respiratory acidosis evidenced by ph, co2 acidic and normal bicarb
ED from 2300 represent: corrected because it’s normal ph
Nurse in er 66 tibial fracture left due to accident, 11 LOC normal, 6/10 pain, more meds of pain 1000 iv morphine, HR 80 RR18 BP 142/86 T 98.2 o2 98 ROOM AIR, give another morphine at 1100 and increase pain 8/10 on left, diaphysis, moaning, she says I’m in main and just got med but it hurts, drowsy, opens eyes to name, response to time, give 5mg of morphine, 7/10 pain, patient sleeping, drift to sleep, flutter eyes, HR 92 RR20 shallow breathing 142/96 98.2 90% o2 room air, past medical history obstructive sleep apnea, drinks wine, BMI 32 obese, reviewing client assessment from times, what actions would you take:
- Apply O2
- Check IV site
- Don’t allow her to sleep because she is drifting to sleep
- Don’t give more morphine because she will be sedated.
- Prepare to administer narcan (naloxone)
- Take deep breaths
- Contact health care provider for order of naloxone
21yrs old female clarinet, office for allergy testing, nurse injected in arm, she has sensual allergy cytrazine 10mg daily, vital T 97 HR 56 RR 28 labored 88/50 O2 89% RA, assessment 4x, congestive watering reddened, dark eyes underneath, stridor and wheezing, excesory muscle, sinus Brady, generalized itching, hives, hypoactive bowels, faint pulses, Which of those finessing acquire emirate fallowup :
- angioedema
- Bradycardia
- Hypotension
- O2 stats
ER nurse caring for a twenty year old client open fracture of ulna and radius, after riding a scale board, labs pic 2, nurses notes 1500 clarinet present to ED after college classes, left risk fall open fracture forearm, 4+ edema, diminished sensation posterior/anterior, prolonged cap refill, HR 102 98% RA RR 21 T98.7 pain 8/10, scheduled for oped reduction in OR at 2300 client can’t recall last tetanus booster, discharged after education of signs and symptoms, few days later client came back with pain worth, swelling, redness, 6/10 pain +4 edema and ecchymosis, bloods draw, BP 126/78 98 RA RR 18 T101.1 ORAL, prolonged cap refill, you are creating plan of care based on updated assessment:
AT high risk for infection (sepsis) evidenced by abc count
Education and halo system
Clean the pins regularly to avoid any chance of infection
Only sponge baths or at best bathe in shallow water. It’s important to clean the skin under the vest to prevent sores and irritation.
Avoid strenuous exercise, but try and walk a little each day.
Sleeping can be a major issue when wearing a halo brace and it can be difficult to get into a comfortable routine. The individual wearing the halo brace with generally have to sleep on their back but taking naps in a reclining chair may also help.
It can be surprisingly difficult to eat and drink or take medication when wearing a halo vest. Experts suggest using straws to drink and cutting food into small pieces or having soft food and juices.
Nurse providing care for client, diagnosis for pneumonia possible shock, t 102.2, warm flush skinned. What is clinet at high risk for?
client is at highest risk for septic shock by evidence by altered mentation
Nurse assessing client with stress due to septicemia, what should the nurse do?
monitor temperature, lactate levels, oxygen
