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FINAL- Test 1

Blood/TPN/CVAD/Fluids/Pain/Hospice/Brain Injury/SCI

Procedure for Blood Administration is verify order, consent, pre-vitals Prime ytube w/0.9% NS, warm blood, Hang within 30 min, verify w/2 nurses IV-access catheter is an 18-gauge or larger needed, 2ml/min 1st 15, vitals q15 and post, can't exceed 4 hrs, monitor for reactions.
What is TPN and what is it used for long-term support or when the patient has high protein and caloric requirements
TPN is composed of *FEAST* fat, electrolytes, amino acid, sugar, trace elements
TPN nursing management Admin central line like picc cvad, check bag for contaminants, refrigerate, never add to, Accucheck qshift, daily weights, I & O- changed q24hs, watch for refeeding syndrome, hyper/hypoglycemia. In emergency hand 10% dextrose
What is CVAD nursing care Infection, aseptic, long term antibiotics, chemo, blood, watch for air embolism, tips cultured for bacteria, flush with 10ml syringe push pause method, dsg change 3-7 days, cxr t confirm placement before using line.
Hypertonic fluid are and used for... dextrose 10% in water (D10W) and dextrose 5% in 0.9% sodium chloride (D5NS)- treats hyponatremia, pulm edema. Causes cells to shrink. goes back into intravascular.
Hypotonic are and used for.... 0.45% Saline (1/2 NS) 0.225% Saline (1/4 NS) 0.33% saline (1/3 NS)- causes cells to swell- from intravascular to the extracellular.
Isotonic Fluids are and used for..... 0.45% Saline (1/2 NS) 0.225% Saline (1/4 NS) 0.33% saline (1/3 NS)- stays in the intravascular system directly, due to blood loss, surgery, dehydration, Doesn't move fluid.
Monitor blood transfusion for (improvement in complete blood count, increased blood pressure, improved patient color, decreased bleeding). • Monitor for signs of circulatory overload (such as shortness of breath) if the transfusion must be given rapidly.
3 kinds of transfusion reactions are Acute hemolytic reaction: within first 15 minutes- blood in urine Febrile reaction: leukocyte incompatibility- acetaminophen and diphenhydramine given 30 minutes before the transfusion Allergic: to plasma proteins of the donor- corticoids and benadryl
Acute hemolytic s/s and tx are Chills, fever, low back pain, flushing, tachycardia, dyspnea, tachypnea, hypotension, hematuria- stop infusion run NS diuretics and foley catheter, watch BP.
Febrile reaction s/s and tx are Sudden chills and fever (rise in temperature of >1° C), headache, flushing, anxiety, vomiting, muscle pain- Give anti-pyretics, stop infusion.
Circulatory overload s/s and tx Cough, dyspnea, pulmonary congestion, headache, hypertension, tachycardia- sit up, diuretics, morphine, o2, phlebotomy.
Indications for TPN Chronic severe diarrhea and vomiting • Complicated surgery or trauma • Gastrointestinal obstruction • Intractable diarrhea • Severe anorexia nervosa • Severe malabsorption • Short bowel syndrome • Gastrointestinal tract anomalies and fistulae
SCI nursing interventions are Ensure patent airway, stabilizer spine, o2, large bore 2 ivs, ns or lactated, assess for other injuries, control bleeding, obtain xrays ct mri, admin methylprednisolone.
Tetraplegia is c1-8 neck down loss- arms and legs
Cervical injuries effect,,, respiratory- c1-3 absence of independent respiratory function, c-4 may be able to breathe without ventilator, c-5-8 decreased resp reserve
Paraplegia t1-6, wheelchair arms are mobile
Spinal shock is a temporary neurologic syndrome of decreased reflexes, loss of sensation, and flaccid paralysis below the level of the injury. syndrome lasts days to months.
Neurogenic shock t6 or higher is due to the loss of vasomotor tone caused by injury and is hypotension and bradycardia, peripheral vasodilation, venous pooling, and a decreased cardiac output occurs.
Autonomic dysreflexia is is a massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system in response to visceral stimulation once spinal shock is resolved in patients with spinal cord lesions
Spinal cord injury is due to cord compression by bone displacement, interruption of blood supply to the cord, or traction resulting from pulling on the cord
Complications of SCI are Spinal Shock, Neurogenic Shock, Respiratory Failure, Autonomic Dysreflexia, Deep vein Thrombosis, Impaction, UTI, Decubiti, Contractures, Postural Hypotension, Sexual Dysfunction
Secondary injury symptoms are ischemia, hypoxia, hemorrhage, and edema that progress over 72 hrs or more happens after the injury.
Poikilothermism is is the adjustment of the body temperature to the room temperature. Inability to shiver and sweat below the injury level occurs too.
s/s Autonomic dysreflexia are most common precipitating cause is a distended bladder or rectum- HTN (up to 300 mm Hg systolic), headache, diaphoresis, bradycardia 30-40, piloerection (erection of body hair), flushing, blurred vision, nasal congestion, anxiety, and nausea.
Treatment for autonomic D head of the bed 45 degrees or sitting the patient upright, Remove the noxious stimulus (fecal impaction, kinked urinary catheter, tight clothing).notification of the physician. Most common cause is bladder irritation.
Neurogenic bladder problems are urgency, frequency, incontinence, inability to void, and high bladder pressures resulting in reflux of urine into the kidneys. Happens after spinal shock resolves per text.
The initial mechanical disruption of axons as a result of stretch or laceration is referred to as the Primary injury
What is the ongoing, progressive damage that occurs after the initial injury Secondary injury
During the acute phase following the SCI, what should be the nurse’s highest priority when planning care for the client? preventing further damage to the spinal cord injury
Classification of spinal cord injury *Mechanism of Injury *Level of Injury *Degree of Injury --Complete Total loss of sensory and motor functions below the level of injury --Incomplete Mixed loss of voluntary motor activity and sensation Leaves some tracts intact
Physiologic mechanisms that maintain intracranial pressure are Arterial or Venous Pressure, Intraabdominal and Intrathoracic Pressure, Posture, Temperature, Blood Gases (CO2)
An increase in ICP leads to decreased cerebral perfusion pressure (CPP) which worsens cerebral ischemia. ICP >20 leads to fatality
Normal ICP is 0-15 mmHg
How to calculate CPP **CPP= MAP-ICP **MAP= 1(sys) + 2(dia)
Normal CPP = 70-100 and must maintain at least 70 for adequate perfusion
Cushings triad a late sign of ICP is Increasing systolic, Widening pulse pressure, Bradycardia, bounding pulse, Irregular, slow respiration. ****Early sign is change in LOC
Signs of increasing ICP Change in LOC, Change in Vitals, change in body temperature, Headache, n/v, Changes in Pupil Response, Decrease in motor function, Decorticate/Decerebrate Posturing
Ongoing treatment for ICP Osmotic Diuretic, Hypertonic Saline, Antiseizure Drugs, Corticosteroids for Tumors, H2 receptor antagonists- prevention of GI ulcer, HOB 30 degrees, Mechanical ventilation if GCS less than 8, ICP monitoring, SBP 100-160, CPP >60
A diffuse head injury is a concussion- Retrograde amnesia, HA, Post concussion syndrome
A focal head injury is contusion, laceration, hematoma
Brain tumors are primary if they originate from brain tissue and secondary if they originate from a lesion- all deadly if not treated- rarely metastasize- Glioblastoma is the worst.
What are your emergent 1st priorities in managing SCI Respiratory- patent airway. Then Stabilize c-spine. Admin O2. Establish 2 lg bore iv sites.
The focus of palliative care is to reduce the severity of disease symptoms. The goals of palliative care are to prevent and relieve suffering and to improve quality of life for patients with serious, life-limiting illnesses.
Goal of hospice is to Provide comfort and support for dying patients and their families.
If a pt is unable to make decisions for themselves and have no family , how is a DNRO facilitated? A DNR order can be entered only if two physicians conclude that CPR would be medically useless or if a court approves the DNR order.
If the pt is of sound mind and requests a DNRO what is the process? patient and a physician signs
Advanced directive is.. signed by 2 witnesses, a surrogate is appointed, and patient signs.
In order to be eligible for hospice.... First, the patient must wish to receive it, and second, the physician must certify that the patient has a prognosis of 6 months or less to live.
The family attorney informed a patient’s children and wife that he did not have an advance directive after he suffered a serious stroke. Who is responsible for identifying end-of-life (EOL) measures to be instituted when the patient cannot communicate? Wife and adult children
Consequences of untreated pain include suffering, physical and psychosocial dysfunction, impaired recovery, immunosuppression, and sleep disturbances
If no healthcare surrogate has been appointed then who makes decisions for the patient who is unable to make the choice? Next of Kin immediate family
Created by: matthew0116