Best reason to withdraw venous blood from CVC
Pt comfort
Include when utilizing standard/universal precautions
- hand hygiene
- ppe
- environmental cleaning/disinfection
- safe injection practice
Flush peripheral and central venous cath with
NS
Fall risk interventions:
- bed in low postion
- bed wheels locked
- hourly rounds
- call light and belongings in reach
Greatest risk for falling
- hip replacement
- oxycodone use
- L. hemis CVA
Contact isolation precautions leave in room:
- stethoscope
- isolation gowns
- thermometer
PCA pump used for what drugs?
- morphine
- dilaudid
- fentanyl
ET tube
- assess placement every shift
- replace change tape or fastener only when wet or soiled
- perform frequent skin assessment
PEEP
keep alveoli open
criteria to wean a pt off mechanical ventilation
- able to cough/remove secretions
- pain control
- adequate nutrition
low pressure alarm goes off, check:
- disconnection
- chest rise
ET tube remains in place for how many days?
14days
immediate response of chest tube pulled out
cover insertion site
pneumothorax
air in pleural space
Hemothorax, immediate action
- dependent loop hanging off edge
- drainage secured to head of bed
recommended suction setting
80-100
Glascow coma scale:
- eye
- motor
- verbal
consensual light reflex
constriction of opposite pupil when light stimulates the eye
Glascow Coma Scale (?BCA?) of 15
no head injury
ICP monitoring indicated
- an unconscious client w GCS <8
- client who is unable to open eyes and decorticate posturing
what can you do to Lower IVP
- hyperventilate
- IV sedation
- infuse osmotic diuretic
- mannitol
- open CSF drainage system
- elevate HOB
Conscious sedation recommended in these procedures:
- EGD/colonoscopy
- burn debreid
- removal implanted devices
- reduction and immobilization of fracture
reversal agent for Benzodiazepines
Romazicon
reversal agents for opiates
narcan
