ATI RN Quick COMPREHENSIVE REVIEW

Cervical lacerations are common complications from vacuum-assisted birth is rare but can include perineal, vaginal, or cervical lacerations When a client is experiencing a wound evisceration... the nurse should init ...

Cervical lacerations are common complications from vacuum-assisted birth is rare but can include perineal, vaginal, or cervical lacerations When a client is experiencing a wound evisceration... the nurse should initially stay with the client and call for help. Next, the nurse should place saline-soaked gauze on the exposed bowels to keep the internal organs moist. The nurse should then place the client in a supine position with his hips and knees bent to relieve pressure from the open wound. Last, the nurse should take the client's vital signs to assess for changes in hemodynamics. Valproic acid can cause hepatic toxicity continuous passive motion (CPM) machine Turn of the CPM machine during meals to promote comfort and dietary intake. -The affected extremity should maintain neutral alignment. Heparin is an anticoagulant that inhibits the conversation of prothrombin to thrombin. Patients on an anticoagulant drug such as heparin are at an increased risk of bleeding. -Signs of bleeding: ecchymoses, tarry stools, mucosal bleeding, and pink/ red-tinged urine. Correct method for walking upstairs with crutches 1. Hold to rail with one hand and crutches with the other hand. 2. Push down on the stair rail and the crutches and step up with the "unaffected" leg. 3. If not allowed to place weight on the "affected" leg, hop up with the "unaffected" leg. 4. Bring the "affected" leg and the crutches up beside the "unaffected" leg. 5. Remember, the "unaffected" leg goes up first and the crutches move with the "affected" leg. DROPLET: "SPIDERMAn" Droplet precautions Airborne precautions: Contact precautions -Sepsis -Scarlet Fever -Strep -Pertussis -Pneumonia -Parvovirus -Influenza -Diphtheria -Epiglottitis -Rubella AIRBORNE: "My Chicken Hez TB" -Measles -Chicken pox -Herpes zoster -TB Management: neg. pressure room, private room, mask, n-95 for TB. -A private room -Masks or respiratory protection devices for caregivers and visitors. -An N95 or high-efficiency particulate air (HEPA) respirator is used i f the client is known or suspected to have TB. -Negative pressure airflow exchange in the room of at least six exchanges per hour -MRSA -RSV -Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies, and staff) -Wound infections -Enteric infections (C-Diff) -Eye infections (conjunctivitis) Management: gown, gloves, goggles, private room VRSA - contact and airborne precautions (private room, door closed, negative pressure) -A private room or a room with other clients with the same infection. -Gloves and gowns worn by the caregivers and visitors Stage I pressure ulcer Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple. Stage II pressure ulcer Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. Stage III pressure ulcer Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. Stage IV pressure ulcer Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material) is calculated by using appropriate stimuli (a painful stimulus may be necessary) and then assessing the clients response in three areas. Glasgow Coma Score When verifying NG tube placement, the pH of aspirated gastric fluid should Eye opening (E) - The best eye response, with responses ranging from 4 to 1 4 = Eye opening occurs spontaneously. 3 = Eye opening occurs secondary to voice. 2 = Eye opening occurs secondary to pain. 1 = Eye opening does not occur. Verbal (V) - The best verbal response, with responses ranging from 5 to 1 5 = Conversation is coherent and oriented. 4 = Conversation is incoherent and disoriented. 3 = Words are spoken but inappropriately A good indication of appropriate placement is obtaining gastric contents with a pH between 0 and 4. Sodium 136-145 Potassium 3.5-5 Total Calcium 9.0-10.5 Magnesium 1.3-2.1 Phosphorus 3.0-4.5