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
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