READ THE LAST PART OF THE QUESTION

THE METHOD

• READ THE LAST PART OF THE QUESTION

• PUT IT IN YOUR OWN WORDS

• FIGURE OUT THE SITUATION

• START WITH THE LAST ANSWER, COMPARE IT TO ELIMINATE ONE ANSWER

• SATA: EACH ONE OF THE SATA IS A CONCEPT, AND AN ANSWER CHOICE OF ITS OWN

PRIORITIZATION

• ASK GRAPH:

• AIRWAY, SEPSIS, K+, HYPOGLYCEMIA, LETHARGY OR GRUNTING, ALTERED LOC, PERITONITIS, HEMORRHAGE

• STABLE VERSUS STABLE

• EXPECTED VERSUS UNEXPECTED

• BRAIN >> LUNGS >> HEART >> LIVER >> KIDNEY >> PANCREAS

• MASLOW’S HIERARCHY: (MENTAL HEALTH)

o PHYSIOLOGICAL: OBJECTIVE (K+ 2.8)

o SAFETY: FALL RISK, SUICIDAL

o COMFORT: SUBJECTIVE & “I” STATEMENTS (PAIN)

• PSYCH/EMOTION

o SOCIAL: MARITAL STATUS, ETC.

o SPIRITUAL: HOPE

CHEST TUBE

• WATER SEAL CHAMBER:

o INTERMITTENT: GOOD

o CONTINUOUS: BAD

• SUCTION CONTROL CHAMBER:

o INTERMITTENT: BAD

o CONTINOUS: GOOD

VENTILATOR PRESSURE ALARMS

• HIGH PRESSURE ALARM

• OBSTRUCTION, KINK, INCREASED SECRETIONS

• LOW PRESSURE ALARM

• DISCONNECTION, CUFF LEAK, LOSS OF AIRWAY

GAIT

• “UP WITH THE GOOD, DOWN WITH THE BAD.”

• CANE IS HELD ON THE STRONG SIDE, AND ALWAYS MOVES BEFORE THE WEAKER LEG

• CRUTCHES ARE HELD ON THE BAD SIDE

• FLEXION AT 30 DEGREES

• TYPE OF GAIT CRUTCHES WALKING PATTERN: REVIEW VIDEOS ON REGISTEREDNURSERN

▪ 2 POINT – MOST CLOSELY RESEMBLES NORMAL WALKING

▪ 3 POINT

▪ 4 POINT

5 D’S LAB VALUES

• K+ = > 6 • PH = 6 & > 6

• CO2 IN THE 60S

• PO2 IN THE 60S

• PLATELET BELOW 40K

FOOD CONTRAINDICATIONS

• MAOI—AVOID TYRAMINE; BAR (BANANAS, AVOCADO, RAISINS) + DRY FOOD

• CELIAC DISEASE—AVOID BROW (BARLEY, RYE, OATS, WHEAT)

• PKU—AVOID HIGH PROTEIN AND HIGH-PHENYALANINE FOOD (MEAT, DAIRY, EGGS)

• GRAPEFRUIT—CONTRAINDICATED IN STATINS AND CA-CALCIUM BLOCKERS (NIFEDIPINE)

HERBAL SUPPLEMENTS

• GINGKO BILOBA, GARLIC, GINSENG, & FEVERFEW--INCREASES THE RISK FOR BLEEDING • ST. JOHN’S WORT—COMMONLY USED FOR DEPRESSION/MOOD DISORDERS; IT MAY CAUSE HTN & SEROTONIN SYNDROME WHEN USED WITH

OTHER ANTIDEPRESSANTS

• SAW PALMETTO—USED TO TREAT BENIGN PROSTATIC HYPERPLASIA

• BLACK COHOSH—USED BY PERIMENOPAUSAL CLIENTS EXPERIENCING HOT FLASHES

• ECHINACEA—HELP BOOST IMMUNE SYSTEM AND FIGHT OFF INFECTIONS

PPE/ISOLATION PRECAUTIONS – HANDWASHING!

• STANDARD/UNIVERAL PRECAUTION -- ANTHRAX 1 / 2

• GLOVES

• CONTACT – ENTERIC, VRE, MRSA, C.DIFF, HEPATITIS A, GI NOROVIRUS, GI ROTAVIRUS

• PRIVATE ROOM, GLOVES, GOWN

• RSV = CONTACT + MASK

• DROPLET – “PIMP” = PERTUSSIS, INFLUENZA, MENINGITIS, PNEUMONIA, VIRUSES, RUBELLA

• PRIVATE ROOM, GLOVES, SURGICAL MASK, PT WEARS SURGICAL MASK WHEN LEAVING THE ROOM

▪ IF THERE IS A RISK OF CONTACT WITH BODY FLUIDS DURING PROCEDURE GOWN & FACE SHIELDS ARE USED.

• AIRBONE—“MTV” = MEASLES (RUBEOLA), MUMPS, TB, VARICELLA, SARS, MERS

• N95, NEGATIVE AIRFLOW ROOM, PT WEARS SURGICAL MASK WHEN LEAVING THE ROOM

PROPER ORDER FOR PPE

• DONNING: GOWN >> MASK >> GOGGLES >> GLOVES

• DOFFING: GLOVES >> GOGGLES >> GOWN >> MASK

PHLEBITIS INFILTRATION EXTRAVASATION

• INFLAMMATION OF THE VEIN

• PAIN, INCREASED TEMPERATURE, REDNESS

• D/C IV LINE + WARM COMPRESS

• COMPLICATION THAT OCCURS WHEN

SOLUTION INFUSES INTO THE SURROUNDING

TISSUES OF THE INFUSION SITE.

• LEAKAGE OF IV SOLUTION/MEDICATION (NON-

VESICANT/IV SOLUTIONS) INTO THE

EXTRAVASCULAR TISSUE

• PAIN, DECREASED TEMPERATURE, EDEMA,

PALLOR

• D/C IV LINE + WARM COMPRESS, ELEVATE

EXTREMITY

• IV CATHETER BECOMES DISLODGED AND

(VESICANT/MEDICATION) INFUSES INTO THE

TISSUES

• PAIN, STINGING, BURNING, SWELLING,

REDNESS

• D/C IV LINE + COOL COMPRESS, ADMINISTER

ANTIDOTE IF EXIST

• AVOID WARM COMPRESS

EXTRAPYRAMIDAL SYMPTOMS

• SIDE EFFECTS OF ANTIPSYCHOTIC MEDICATIONS

• -ZINES + HALOPERIDOL

• INCLUDE MOVEMENT OF DYSFUNCTION SUCH AS:

• DYSTONIA (CONTINOUS SPASMS/MUSCLE CONTRACTIONS)
• AKATHISIA (MOTOR RESTLESSNESS)
• PARKINSONISM (RIGIDITY)
• BRADYKINESIA (SLOWNESS OF MOVEMENT)
• TREMOR

DUCHENNE MUSCULAR

DYSTROPHY (DMD)

AMYOTROPHIC LATERAL

SCLEROSIS

(ALS)

“LOU GEHRIG DISEASE”

GUILLAIN BARRE SYNDROME

(GBS)

MULTIPLE SCLEROSIS

(MS)

MYASTHENIA GRAVIS

• MOST COMMON • DEBILITATING, • ASCENDING MUSCLE • PROGRESSIVE, • AUTOIMMUNE DISEASE

FORM OF CHILDHOOD PROGRESSIVE WEAKNESS AND DEMYELINATING INVOLVING A DECREASED

MD NEURODEGENERATIVE ABSENT DEEP TENDON DISEASE OF THE CNS NUMBER OF

• X-LINKED RECESSIVE DISEASE WITH NO CURE REFLEXES • MUSCLE WEAKNESS, ACETYLCHOLINE

• DUE TO LACK OF A • CLIENTS DEVELOP • HX OF RESPIRATORY SPASTICITY, RECEPTORS AT THE

PROTEIN CALLED FATIGUE AND MUSCLE TRACT INFECTION / GI INCOORDINATION, NEUROMUSCULAR

“DYSTROPHIN” WEAKNESS THAT INFECTION LOSS OF BALANCE, JUNCTION.

NEEDED FOR MUSCLE PROGRESSES TO • POTENTIAL AND FATIGUE ARE • AS A RESULT, THERE IS A

STABILIZATION PARALYSIS, DYSPHAGIA, COMPLICATION: PRESENT—CAUSING FLUCTUATING WEAKNESS

• DISEASE ONSET IS 2-5 DIFFICULTY SPEAKING, PROGRESSING IMPAIRED OF SKELETAL MUSCLES,

YEARS OF AGE AND RESPIRTATORY PARALYSIS & MOBILITY/RISK FOF MOST OFTEN PRESENTED

• PROXIMAL LOWER

EXTREMITIES AND

FAILURE.

• RILUZOLE IS THE ONLY

RESPIRATORY DISTRESS

• MEASUREMENT OF

FALL & INJURY.

• GAIT TRAINING AND

AS PTOSIS/DIPLOPIA,

BULBAR SIGNS

PELVIS ARE AFFECTED MEDICATION APPROVED SERIAL SPIROMETRY ASSISTIVE DEVICES (DIFFICULTY

FIRST FOR ALS TREATMENT—IT (FVC) IS GOLD CAN HELP PREVENT SPEAKING/SWALLOWING)

• GOWER SIGN – USE OF

ONE’S HANDS TO RISE

FROM A SQUAT THERE

IS THOUGHT TO SLOW

NEURON

DEGENERATION.

STANDARD FOR

ASSESSING

VENTILATION IN

FALLS, INJURY AND

PRESERVE

INDEPENDENCE AS

AND DIFFICULTY

BREATHING.

• MUSCLES ARE STRONGER

IS NO EFFECTIVE CURE;

GOAL IS TO AVOID

MUSCLE ATROPHY

CLIENTS WITH GBS LONG AS POSSIBLE. IN THE MORNING, AND

BECOME WEAKER WITH

THE DAY’S ACTIVITY AS

THE SUPPLY OF

AVAILABLE

ACETYLCHOLINE IS

DEPLETED.

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