Verified Solutions.
Delegation to UAP - Answer: Transfer a duty.
they can get V/S, after RN has gotten initial set.
ambulate as long as pt has been cleared for weight bearing status.
re-ENFORCE education that RN has taught
assist with ADL's
CPR
document I&O's
glucose check, finger stick, per facility protocol
12 lead EKG, per facility protocol
turn & reposition
Delegation to LPN - Answer: med administration, enteral feedings, urinary Cath
insertion, suctioning, tracheostomy care, reinforcement of pt education
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,RN job duties remember neumonic - Answer: ADPIE
A-assessment
D-diagnosis
P-planning
I-implementation
E-evaluation
NG tube placement - Answer: pH paper.
xray is GOLD STANDARD to confirm proper placement, monitor NG output (color
and amt), monitor nasal skin around tube, monitor tubing for kinks & "plugs",
continue to assess BS's and abdominal girth, pain, **aspirate contents & irrigate
the tube w/ 30 mL of NS q 4 hrs or as ordered by hcp
NG assessment - Answer: 1st turn OFF suction
verify placement
can irrigate with sterile saline
SCD's on (high risk for clots and pneumonia)
turn & reposition
Peptic Ulcer Disease - Answer: A break or ulceration in the protective mucosal
lining of the lower esophagus, stomach, or duodenum
coffee ground emesis (old blood)
NPO, NG tube
triple therapy 2 antibiotics and 1 PPI
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,could have an active bleed
H. pylori
early stage cirrhosis - Answer: enlarged liver
jaundice
GI disturbances
weight loss
increase protein
late stage cirrhosis - Answer: liver becomes smaller and nodular
splenomegaly
ascites, distended abdominal veins, increased pressure in portal system
bleeding tendancies, decreased vitamin K and prothrombin, anemia
esophageal varices, internal hemorrhoids
dyspenia (from ascites and anemia)
pruritis from dry skin
clay colored stools; no bile in stool
tea colored urine; bile in urine
End stage cirrhosis - Answer: hepatic encephalopathy/coma
portal hypertension - Answer: A potential complication of chronic alcoholism
resulting in liver damage and obstruction of venous blood flow through the liver.
The rising blood pressure in the veins between the gastrointestinal tract and liver
causes engorgement of veins around the umbilicus (navel). The characteristic
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, radiating pattern of veins is called a "caput medusae" (head of Medusa). Medusa
was the "snake-haired lady" in Greek mythology.
end-stage cirrhosis
self breast exam - Answer: Monitor for any change in size, contour, dimpling.
Perform exam every month, 7 days after your period. Use finger pads of the three
middle fingers.; lay down arm up, or stand in front of mirror
postmenopausal (or MEN) - pick same day every month
self testicular exam - Answer: Looking for lumps that may be the first sign of
cancer common in men ages 15-35
perform in shower, roll 'ball' between fingers
Addison's disease - Answer: A rare, chronic endocrine disorder in which the
adrenal glands do not produce sufficient steroid hormones.
s/s fatigue, weakness, hypotension, crave salty food (hyponatremia)
need life long cortisol replacement
Monitor for addisonian crisis
Addisonian crisis - Answer: N/V confusion, abdominal pain, extreme weakness,
hypoglycemia, dehydration, EXTREME decreased BP
triggered by stress or infection
MEDICAL EMERGENCY
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