Ryca Shared "NUR 202 Exam 2" - 50 Picmonics
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NUR 202 Exam 2
Traumatic Brain Injury Assessment
- Assessment
- Change in LOC
- Personality Changes
- Amnesia
- Increased Intracranial Pressure
- Diplopia
- Posturing
- Location of Injury
- Basilar Skull Fracture
- Halo or Ring Sign
- Considerations
- Intracranial Bleeding
2 mins
Flail Chest
- Cause/Mechanism
- Trauma
- Assessment
- Shallow Respirations
- Chest Pain
- Paradoxical Chest Movement
- Interventions
- Mechanical Ventilation
- Analgesics
- Intercostal Nerve Blocks
- Considerations
- Surgical Rib Fixation
- Monitor Pulmonary Contusion
2 mins
Concussion
- Cause
- Brain Trauma
- Pathophysiology
- Neurometabolic Cascade
- Signs & Symptoms
- Visual Disturbances
- Cognitive Dysfunction
- Sleep Disturbances
- Emotional Instability
- Diagnosis
- Sport Concussion Assessment Tool 5th Edition (SCAT5)
- Diagnostic Imaging
- Treatment
- Physical and Cognitive Rest
- Monitored Exercise
- Vestibular Rehabilitation
- Considerations
- Second Impact Syndrome
4 mins
Types of Head Injuries
- Open Head Injury
- Linear Fracture
- Comminuted Fracture
- Depressed Fracture
- Open Fracture
- Basilar Skull Fracture
- Closed Head Injury
- Coup and Contrecoup
- Brain Contusion
- Concussion
2 mins
Types of Shock
- Hypovolemic
- Depleted Volume
- Cardiogenic
- Pump Failure
- Obstructive
- Indirect Pump Failure
- Distributive
- Lost Vascular Tone
- Neurogenic
- Anaphylactic
- Septic
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
Sepsis Assessment
- Signs and Symptoms
- Systemic Infectious Process
- Fever
- Hypotension
- Change in LOC
- Increased WBC
- Shift to the Left
- Tachycardia
- Tachypnea
- Hyperglycemia
- Edema
2 mins
Pneumothorax
- Mechanism
- Air Enters Pleural Space
- Assessment
- Sudden Dyspnea
- Absent or Restricted Movement on Affected Side
- Decreased or Absent Breath Sounds on Affected Side
- Chest Pain
- Tracheal Deviation
- Vital Sign Changes
- Crepitus
- Considerations
- High Fowler's Position With Oxygen
- Prepare For Chest Tube Placement
- Educate High Risk Patients
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
Cardiac Tamponade
- Mechanism
- Fluid in the Pericardial Sac
- Pericarditis
- Decreased Cardiac Output
- Signs/Symptoms
- Beck's Triad
- Hypotension
- Jugular Venous Distention (JVD)
- Distant Heart Sounds
- Pulsus Paradoxus
- Electrical Alternans
- Treatment
- Pericardiocentesis
1 min
Cardiac Enzyme Evaluation: Creatine Kinase CK-MB
- Measures
- Skeletal or Cardiac Muscle Injury
- Time Ranges
- Onset: 4-8 Hours
- Peak: 12-24 Hours
- Return to Normal: 2-3 Days
1 min
Syndrome Of Inappropriate Antidiuretic Hormone (SIADH)
- Pathophysiology
- Hypersecretion of ADH
- Increased Sensitivity to ADH
- Signs & Symptoms
- Serum Hypoosmolality
- Coma and Seizure
- Dilutional Hyponatremia
- Cramps and Tremors
- Euvolemia
- Change in LOC
2 mins
Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Nonpharmacologic Interventions
- Monitor Serum and Urine Osmolality
- IandOs with Daily Weights
- Restrict Fluid Intake
- Monitor Cardiovascular and Neurological Status
- Seizure Precautions
2 mins
Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Pharmacologic Interventions
- Diuretics
- Hypertonic IV Fluids
- Demeclocycline
- Tolvaptan and Conivaptan
1 min
Diabetes Insipidus Assessment
- Polyuria
- Nocturia
- Low Specific Gravity (USG)
- Polydipsia
- Dehydration
- Hypotension
- Tachycardia
- Confusion
2 mins
Increased Intracranial Pressure (ICP) Assessment
- Change in LOC
- Headache
- Cushings Triad
- Irregular Respirations
- Widening Pulse Pressure
- Bradycardia
- Projectile Vomiting
- Abnormal Pupils
- Papilledema
- Posturing
2 mins
Increased Intracranial Pressure (ICP) Interventions
- Interventions
- Elevate Head Of Bed
- Foley Catheter
- Mannitol (Osmitrol)
- High Dose Barbiturates
- Passive Hyperventilation
- Dexamethasone (Neoplasm or Infection)
- Considerations
- Neuro Assessment
- Maintain Normal Temperature
- Avoid Activities That Increase ICP
- Intracranial Monitoring System
2 mins
Emphysema
- Mechanism
- Hyperinflation and Loss of Elasticity
- Assessment
- Pursed Lip Breathing
- Barrel Chest
- Dyspnea on Exertion
- Clubbing
- Depression and Anxiety
- Thin Appearance
- Nursing Considerations
- CO2 Retention
- Low Concentration of O2
- High Fowler's Position
- High Calorie, High Protein Diet
2 mins
Chronic Bronchitis Interventions
- Tripod Position
- Humidified Oxygen
- Pursed Lip Breathing
- Increase Fluid Intake
- ABGs
- Early Detection of Exacerbation
- Considerations
- Lowest O2 Therapy
- Assisted Ventilation
- Increased Infection Risk
2 mins
Chronic Bronchitis Assessment
- Clinical Findings
- Chronic Productive Cough
- > 3 Months for 2 Years
- Increased Mucus Production
- Dyspnea
- Cyanosis
- Wheezes
- Complications
- Right Side Heart Failure
- Jugular Venous Distention (JVD)
- Peripheral Edema
2 mins
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