DO NOT delegate what you can...EAT (Acronym)
E
valuate,
A
ssess,
T
each
Addison's Disease
(Remember:
DOWN, DOWN, DOWN, UP, DOWN
)
- HYPOnatremia, HYPOtension, DECREASED blood volume, HYPERkalemia, and HYPOglycemia
Cushing's Disease
(Remember:
UP, UP, UP, DOWN, UP
)
- HYPERnatremia, HYPERtension, INCREASED blood volume, HYPOkalemia, HYPERglycemia
No PEE, No ??
K+; DO NOT give Potassium without adequate urine output.
Increased perfusion for VEINS and ARTERIES
Ele*V*ate
V
eins (*Think V,V*) and D*A*ngle *A*rteries.
V
*V*ate *V*eins (
Think V,V
) and D*A*ngle
A
A
*V*ate *V*eins (*Think V,V*) and D*A*ngle *A*rteries. (
Think A,A
)
APGAR: A (1st A)
Appearance - color pink/pink and blue/blue [pale]
APGAR: P
Pulse - >100/<100/Absent
APGAR: G
Grimace - cough/grimace/no response
APGAR: A (2nd A)
Activity - flexed/flaccid/limp
APAGR: R
Respirations - strong cry/weak cry/absent
AIRBORN Transmission Precautions: MTV
M
= Measles
T
= Tuberculosis
V
= Varicella (Chicken Pox)/Herpes Zoster (Shingles)
Remember: Private room w/ negative pressure w/ 6 - 12 air exchange/hr AND MASK.
N95
mask for TB.
DROPLET Precautions: SPIDERMAN (Some letters are repeated consecutively)
S
= Sepsis
S
= Scarlet Fever
S
= Streptococcal Pharyngitis
P
= Paravirus B19
P
= Pneumonia
P
= Pertussis
I
= Influenza
D
= Diptheria (Pharyngeal)
E
= Epiglottitis
R
= Rubella
M
= Mumps
M
= Meningitis
M
= Mycoplasma or Meningeal Pneumonia
AN
= Adenovirus
R
CONTACT Precautions: MRS WEE
M
= Multidrug Resistant Organism
R
= Respiratory Infection
S
= Skin Infections
W
= Wound Infections
E
= Enteric Infection (Clostridium Difficile)
E
= Eye Infections (Conjunctivitis)
SKIN Infections: V CHIPS
V
= Varicella
C
= Cutaneous Diptheria
H
= Herepes Zoster
I
= Impetigo
P
= Pediculosis
S
= Scabies
Air/Pulmonary Embolism: S&S and Care
S&S Include: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom.
Care: turn patient to the
LEFT SIDE
and
LOWER
the head of the bed
Woman in Labor w/ NON-Reassuring FHR: S&S and Care
S&S Include: late decelerations, decreased variability, fetal bradycardia, etc.
Care: turn on
LEFT SIDE
(also give O2, stop pitocin and increase fluids)
Tube Feeding w/ DECREASED LOC: Care
Care Includes: Position pt on
right side
(this promotes emptying of the stomach) with the HOB
elevated
(to prevent aspiration)
During Epidural Puncture: Care
Care Includes: position the patient
SIDE LYING
After a Lumbar Puncture (also an Oil Based Myelogram): Care
Care Includes: patient lies
FLAT/SUPINE
(This is done to prevent headache and leaking of CSF)
Heat Stroke: Care
Care Includes: Lie
FLAT
w/ legs
Elevated
After an Myringotomy: Care
Care Includes: Position patient on the side of the
affected
ear after surgery. (This allows drainage of secretions)
After Cataract Surgery: Care
Care Includes: The patient will sleep on the
unaffected
side with a night shield for 1 - 4 weeks.
After Thyroidectomy: Care
Care Includes: Position
LOW
or
semi - fowlers
, support the head, neck and shoulders.
Infant w/ Spina Bifidia: Care
Care includes: Position
prone
(on abdomen) so the sac does not rupture.
Buck's Traction (Skin Traction): Care
Care Includes: Elevate the foot of the bed for counter-traction.
After Total Hip Replacement: Care
Care Includes: Don't sleep on the operated side; don't flex hip for more than 45 - 60 degrees, don't elevate HOB more than 45 degrees. Also maintain hip
ABDUCTION
by separating thighs with pillows.
Prolapsed Cord: Care
Care Includes: Knee to Chest position OR Trendelenburg
Infant w/ Cleft Lip: Care
Care Includes: Position on the back or in an infant seat to prevent trauma to the suture line. While feeding, hold in the upright position.
To Prevent Dumping Syndrome: Care
(Post-Operatvie Ulcer/Stomach Surgeries)
Care Includes: Eat in the reclining position, lie down after meals for 20-30 minutes. Also
restrict fluids during meals, LOW CHO and fiber Diet
, and small frequent meals.
Above the Knee Amputation: Care
Care Includes: Elevate for the first 24 hours on a pillow, position prone daily to provide for hip extension.
Below Knee Amputation: Care
Care Includes: Foot of the bed elevated for the first 24 hours, position prone daily to provide for hip extension.
Detached Retina: Care
Care Includes: Area of detachment should be in the dependent position.
Administration of an Enema
Here, position the patient in
left side-lying
(Sims) w/ Knee Flexed.
After A Supratentorial Surgery (Incision Behind Hairline): Care
Care Includes: Elevate HOB 30-45 degrees
After A Infratentorial Surgery (Incision at the nape of the Neck): Care
Care Includes: Position the patient
FLAT
and lateral on either side.
During Internal Radiation: Care
Care Includes: On bedrest while implant is in place.
Autonomic Dysreflexia/Hyperflexia: S&S and Care
- Acutely, this is a reaction of the autonomic (involuntary) nervous system to overstimulation (due to lesions or injury of the spinal cord)
S&S Include: Pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia,
Hypertension
Care In
Shock: Care
Care Includes: Bed-rest w/ extremities elevated 20 degrees, knees straight, head slightly elevated (modified trendelenberg)
Head Injury: Care
Care Includes: Elevate the HOB 30 degrees to decrease ICP.
Peritoneal Dialysis w/ Inadequate outflow: Care
Care Includes: Turn patient from side to side
BEFORE
checking for kinks in the tubing (According to Kaplan)
Lumbar Puncture: Care After Procedure
Care Includes: Place the client in the supine position for 4 to 12 hours as prescribed.
Pain medication for Pancreantitis
With this, give
DEMEROL
not Morphine Sulfate.