Danyell Shared "Exam 1 PNC IV" - 14 Picmonics
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Exam 1 PNC IV
Acute Respiratory Distress Syndrome (ARDS) Assessment
- Cause
- Damaged Alveolar-Capillary Membrane
- Assessment
- Restlessness
- Dyspnea
- Refractory Hypoxemia
- Decreased PaO2
- Diffuse Pulmonary Infiltrates
- Atelectasis
- Pulmonary Hypertension
2 mins
Acute Respiratory Distress Syndrome (ARDS) Interventions
- Interventions
- Closely Monitor Patient
- ABG's (Arterial Blood Gases)
- Oxygen
- Assess for O2 Toxicity
- Mechanical Ventilation
- PEEP
- Assess for Pneumothorax
- Permissive Hypercapnia
- Considerations
- High Mortality Rate
2 mins
Chest Tubes: Management and Care
- Confirm suction order
- Assessment
- Crepitus
- Kinking
- Shortness of Breath (SOB)
- Infection
- Excessive bubbling
- Quick Interventions
- If tube dislodges from patient, use petroleum gauze taped 3 ways
- If drainage system is damaged, place disconnected drainage tube in sterile water
1 min
Tracheostomy Care
- Inner Cannula Removed and Cleaned
- Clean Q8 Hours Around Stoma
- One Finger Under Ties
- Considerations
- Speak with Deflated Cuff
- Can Eat with Tube in Place
- Keep Replacement Tube Nearby
- Immediately Replace if Dislodged
- Physician Does First Tube Change
2 mins
Burns Assessment
- Stage and Extent of Burn
- Dyspnea
- Singed Nasal Hairs
- Pain
- Initial Decrease Urinary Output
- Paralytic Ileus
- Signs of Inadequate Hydration
- Shock
- Hypothermia
- Hyperkalemia
2 mins
Disseminated Intravascular Coagulation (DIC) Interventions
- Complications
- Risk for Shock
- Renal Failure
- Interventions
- Treat Underlying Cause
- Manage Bleeding
- Maintain Fluid and Hemodynamic Balance
- Transfusion
- Oxygenation
- Heparin Drip
2 mins
Severe Sepsis and Septic Shock Assessment
- Microthrombi
- DIC
- Decreased Oxygen Saturation
- Decreased WBC
- Oliguria
- High Output Heart Failure
- Multiple Organ Failure
2 mins
Types of Shock
- Hypovolemic
- Depleted Volume
- Cardiogenic
- Pump Failure
- Obstructive
- Indirect Pump Failure
- Distributive
- Lost Vascular Tone
- Neurogenic
- Anaphylactic
- Septic
2 mins
Burns Considerations
- Maintain Body Temperature
- Increased Risk of Infection
- Venous Thromboembolism (VTE) Prophylaxis
- Curling's Ulcer
- Excision and Grafting
- Adequate Nutrition
- Contractures
2 mins
Burns Interventions
- Ensure Airway Patency
- O2
- IV Fluid Replacement
- Dry Sterile Dressing
- Debridement
- Elevate Burned Limbs
- Analgesics
- Silver Sulfadiazine
- Escharotomy
2 mins
Types of Burns
- Superficial Thickness
- Sunburn
- Superficial Partial Thickness
- Blisters
- Blanching
- Deep Partial Thickness
- Little or Non-blanching
- Full Thickness
- Waxy White, Yellow or Black
- Decreased Pain
2 mins
Stages of Burn Care
- Phase / Stage 1
- Resuscitative/Emergent Phase
- Injury to Return of Capillary Permeability
- 48-72 hours
- IV Fluid Replacement
- Phase / Stage 2
- Acute Phase
- Diuresis to Near Wound Closure
- Phase / Stage 3
- Wound Closure to Return of Optimal Level
2 mins
Rule of 9's for Burns
- Total Body Surface Area (TBSA)
- Head
- Anterior Torso (18%)
- Chest
- Abdomen
- Posterior Torso (18%)
- Upper Back
- Lower Back
- Extremities
- Posterior Leg (each)
- Anterior Leg (each)
- Each Arm
- Genitalia 1%
2 mins
Disseminated Intravascular Coagulation (DIC) Assessment
- Mechanism
- Improper Initiation of Clotting Cascade
- Signs and Symptoms
- Systemic Bleeding
- Petechiae, Purpura, Ecchymosis
- Change in LOC
- Increased PT and PTT
- Cyanosis
- Increased Fibrin Degradation Products (FDP)
- Decreased Platelets and Fibrinogen
2 mins
