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
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epidermis
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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
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
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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
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. Transient findings
Recognize indications - Emergencies vs. Expected
Delegate to LPN: Monitoring Findings, Reinforcing teaching, performing trach
care, suctioning, checking NG tube patency, administer tube feedings, inserting
urinary catheter, administering meds (No IV)
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