NURSING > STUDY GUIDE > NURSING CORE NURS 222 EXAM 3 STUDY GUIDE. LATEST SOLUTION 2020. (All)

NURSING CORE NURS 222 EXAM 3 STUDY GUIDE. LATEST SOLUTION 2020.

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RASS (Richmond Agitation Sedation Scale) +4: Combative: overly combative, violent, immediate danger to staff +3: Very agitated: removes/ pulls catheter or tube(s); aggressive +2: Agitated: frequent non-purposeful movement, fights ventilator +1: Restless: Anxious but movements not aggressive vigorous 0: Alert and calm Verbal Stimulation ver v (eye-opening/eye contact) to voice (>10 seconds) -2: Light sedation: Briefly awaken with eye contact to voice (<10 seconds) -3: Moderated sedation: Movement or eye opening to voice (but no eye contact) Physical Stimulation -5: Unarousable: No response to voice or physical stimulation Procedure for RASS Assessment 1. Observe patient. a. Patient is alert, restless, or agitated. (score 0 to +4) 1. If not alert, state patient’s name and say to open eyes and look at speaker. a. Patient awakens with sustained eye opening and eye contact. (score -1) b. Patient awaken with eye opening and eye contact, but not sustained. (score - 2) c. Patient has any movement in response to voice but no eye contact. (score - 3) 1. When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing sternum. a. Patient has any movement to physical stimulation (score -4) b. Patient has no response to any stimulation. (score -5) Differences between TOXICITY and WITHDRAWALS CENTRAL NERVOUS SYSTEM DEPRESSANTS: Produce physiological and psychological dependence and may have crosstolerance, cross-dependency, and an additive effect when take concurrently. 1. ALCOHOL Lab: blood alcohol concentration (BAC): 0.08% (80 g/dL) legally intoxicated Acute toxicity level greater than about 0.35% (350 g/dL) Intended Effects: relaxation, decreased social anxiety, stress reduction TOXICITY NP DR MADS WITHDRAWALSVI FART a. Nystagmus a. Vomiting b. Peripheral collapse b. Insomnia c. Decrease motor skills/LOC c. Fine tremors d. Respiratory arrest d. Anxiety e. Memory impairment e. Restlessness f. Altered judgement f. Tonic clonic seizure/Transient g. Death f. Restlessness hallucination or illusion h. Slurred speech g. constrict pupil i. Dilation pupil CHRONIC SALTED a. Sexual dysfunction b. Acute pancreatitis c. Liver damage (ranging from fatty liver to cirrhosis) d. Thiamine deficiency cause Wernicke-Korsakoff syndrome (confusion, recent memory loss, and confabulation of lost memories) e. Erosive gastritis/gastrointestinal bleeding f. Direct cardiovascular damage Effect usually start: within 4-12 hr of the last intake of alcohol, Peak after: 24-48 hr Alcohol withdrawal delirium: 2-3 days after stop of alcohol and may last 2-3 days. (48-72hr)

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