Renal Calculi - Pain: Flank pain → Kidney or Ureter (if pain radiates → stones in ureter or bladder)
Performing Ear Irrigation: Sterile technique, warm meds, pull up & back, tilt toward affected ear
Thrombolytic Ther
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Renal Calculi - Pain: Flank pain → Kidney or Ureter (if pain radiates → stones in ureter or bladder)
Performing Ear Irrigation: Sterile technique, warm meds, pull up & back, tilt toward affected ear
Thrombolytic Therapy (Stroke): Reteplase recombinant (rTPA – clot buster) w/ in 4.5 hours of initial symptoms
Trach care: Dressing ∆, inner cannula ½ hydrogen peroxide, & stoma □ knot
Head injury ( changes in LOC): Length of time unconscious & GCS
General anesthesia (post-op): ABC’s – full body assessment, Vitals every 15 minutes, Lateral position (if unresponsive or unconscious
- monitor LOC), Fluids/Electrolytes
Superficial Burns: Painful, pink, red, mild edema (3-6 day healing), damage to epidermis
Dialysis (reporting unexpected findings): Temp of 100 degrees, ↓ BP, bleeding, 1 L of fluid = 1Kg, clotting, H/A, Nausea,
Disequilibrium syndrome (rapid ↓ BUN & Fluid volume), anemia, peritonitis, ↑ BG, ↑ cholesterol
Pacemaker (complications ): Infection, hematoma, pneumothorax, hemo-thorax, arrhythmias, pacer spikes before P or QRS,
hiccups / muscle twitching
Magnesium (Mg) Sulfate → Increase Mg+ > 1.3 Mg/dL
↑ Mg foods = (Dairy, dark leafy greens veges)
↓ Mg causes → Hyperactive deep tendon reflexes
* Paresthesia’s, muscle tetany, positive chvostek’s & Trousseau’s sign, hypoactive bowels, constipation,
abdominal distention, paralytic Ileus.
TPN Admin: (Total parenteral nutrition) -feeding that bypasses the GI tract. Fluids are given into a vein to provide most of the
nutrients the body needs. Given when person cannot/ should not receive feedings or fluids by mouth.
Hypertonic (20-50% dextrose), Used in chronic pain, peritonitis, burns, Infection, etc
No more than 10% hourly, ↑ in rate for body adjustment, check BG
Hyperglycemia, hypoglycemia, vitamin deficiencies, air embolism (clamp, place in Trendelenburg pos., O2)
Fluid imbalance → Fluid volume excess
Wound Culture specimen: Sterile field, press / rotate over wound surface inside the wound (center) in drainage
Diabetes Mellitus ( Nephropathy ): Kidney damage d/t prolonged ↑ BG & dehydration
Monitor I & O, Creatinine, BP
Avoid Soda, alcohol, acetaminophen/NSAIDS / 2 – 3 L fluid from food / beverages
Kidney Biopsy ( Post op ):
Monitor VS → Client receives sedation
Assess dressings & urinary output (hematuria-blood in urine)
Labs: HgB & Hct values, Admin PRN pain meds, Complications hemorrhage / infection
Thyroidectomy ( Post Op ): Needs Thyroid hormone replacement
Client in high fowler’s position, Respiratory (trach supplies) present, Check for laryngeal nerve damage
Pain management, Hypocalcemia / Tetany can occur
Prioritization: Apply knowledge to Standards to determine priority action
Systemic before Local – “Life before Limb”
Acute before Chronic
Actual Problems before Potential Future
Listen carefully to clients & Don’t Assume
Recognize & Respond - Trends vs. Transien
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