"Who Do You See First?" Flashcards Preview

HHS and DKA are extremely high blood sugar.

If not treated the client can go into a coma.  

Compartment syndrome is when there is too much pressure in a cast or enclosed space due to edema. 

The client will either get a fasciotomy (cut the skin open) or the cast will be cut off.

Hemorrhage is severe bleeding that causes the client to go into hypovolemic shock.

The client gets a very low blood pressure and tachycardia.

Severe fluid and electrolyte imbalances can cause life-threatening complications such as:

• dysrhythmias
• seizures
• respiratory depression
• coma

Septic shock is a systemic infection throughout the entire body.

It can cause very low blood pressure and tachycardia.

Peritonitis is when the bowel perforates causing infection and eventually septic shock if not treated.

The client gets a rigid, hard abdomen.

Acute angle-closure glaucoma is sudden eye pain and possible nausea and vomiting, resulting in blindness.

The client will receive antiglaucoma meds to lower the pressure. 

Interventions for a penetrating object in eye:

• DO NOT remove the object
• cover the eye with a cup and tape in place
• no bending, no straining
• surgery to remove object

Intervention for chemical eye burns:

• flush eyes with water for at least 15 to 20 minutes

An acid-base imbalance is a circulation or breathing issue where the client has a high risk of death if it becomes severe.

Autonomic dysreflexia is when the client with a spinal injury overreacts to stimuli such as unable to urinate or have a bowel movement.

It can cause a hypertensive crisis if it becomes severe.

A myasthenic crisis and cholinergic crisis is when the client with myasthenia crisis does not get the correct amount of medicine at the correct time.

This causes muscle weakness and respiratory muscle weakness if not treated. 

• myasthenic crisis is undermedicated
• cholinergic crisis is overmedicated

Increased intracranial pressure (ICP)

Increased pressure in the brain due to edema.

Steven's Johnson syndrome and toxic epidermal necrolysis are really bad adverse reactions of many meds that cause a severe rash all over the body.

Always let the HCP know if you notice a rash, especially after the client starts a new med.

• Dehiscence is when the surgical incision opens.
• Evisceration is when the abdominal organ comes out of the incision.

Immediate intervention is to put a sterile, saline-soaked dressing over site.

Signs and symptoms of a serious blood transfusion reaction:

• respiratory distress, dyspnea, dizziness, shortness of breath
• chills, diaphoresis
• back or chest pain

Antibodies are attacking the red blood cells causing decreased oxygen.

Steps to a blood transfusion reaction:

1. FIRST: stop the blood transfusion
2. change out the tubing, but keep the IV line in
3. start a new bag of normal saline, 0.9%
4. tell the HCP and blood bank
5. return the blood and tubing to the blood bank
6. stay with the client
7. may have to give epinephrine for severe symptoms such as difficulty breathing

Suicide is a psychological disorder when the client wants to kill themselves.

It is an emergency and someone needs to stay with the client at all times. 

Pinch the opening shut and apply an occlusive sterile dressing taped on 3 sides.

Call HCP about chest tubes if:

• drainage is >70 - 100 mL/hour
• drainage suddenly becomes bright red or increases in the amount
• chest tube comes out of client

For a client with chest tubes keep at the bedside:

• a clamp
  • to check for leaks
• sterile occlusive dressing
  • in case the tube comes out of the client​
• a bottle of sterile water
  • in case the tube comes out of the CDU

Put the chest tube in a bottle of sterile water to act as a water seal so air doesn't go into the client.

During a fire:

1. evacuate clients who can walk first
2. evacuate clients in wheelchairs next
3. evacuate bedridden clients last

3 adverse effects (reactions):

1. anaphylactic shock or difficulty breathing
2. rash
3. significant changes in vital signs or level of consciousness

Notify the HCP immediately.

Delirium tremens is withdrawal of alcohol that occurs 48 - 72 hours after stopping alcohol. 

With violent clients:

• approach the client calmly and communicate with a calm and clear tone of voice
• maintain a safe distance away from client
• maintain a non-aggressive posture
• listen actively and acknowledge anger
• determine what their need is
• call security if client does not calm down

Serotonin syndrome is when a client's serotonin level increases to dangerous levels.

It is caused by taking too many sedatives at once.

Neuroleptic malignant syndrome is a rare and fatal reaction to antipsychotics.

A positive/abnormal result indicates a bad finding and that late decelerations of the fetal heart rate were noted.

Late decelerations are never a good finding.

Disseminated intravascular coagulation is a serious bleeding and clotting complication in a pregnant client with eclampsia, placenta abruptio, a dead fetus, placenta retention or infection. 

The clotting factors are becoming over or underactivated. 

HELLP syndrome is a condition that can cause severe bleeding in a pregnant client.

The cause is not known but associated with gestational hypertension and preeclampsia. 

Eclampsia is the onset of seizures for a pregnant client with preeclampsia.

General interventions if mom or baby is having life-threatening distress during labor:

• put mom in Trendelenburg position
• give oxygen 8-10 liters by mask
• give IV fluids
• blood transfusion if needed
• prepare for cesarean delivery

A prolapsed umbilical cord is when the umbilical cord drops through the open cervix into the vagina ahead of the baby.

The cord can then become trapped against the baby's body during delivery. 

Abruptio placenta is when the placenta has separated off the uterine wall.

Amniotic fluid embolism is when there is an escape of amniotic fluid into maternal circulation which can lead to respiratory failure and bleeding. 

Signs and symptoms of fetal distress:

• fetal heart rate is < 110 or > 160 beats/minute
• meconium-stained amniotic fluids
• fetal hypo or hyperactivity
• severe variable or late decelerations

Late decelerations caused by placenta compression.

There is a gradual decrease in fetal heart rate. The lowest heart rate occurs after the contraction peak. 

Bleeding and Infection

Hemorrhage is:

• > than 1 pad per hour or
• one pad that gets saturated within 15 minutes

Blood loss and hemorrhage:

• Vaginal delivery: > 500 mL after delivery
• Cesarean delivery: > 1000 mL after delivery

Respiratory distress syndrome is caused by the newborn unable to produce enough surfactant. It can occur in preterm infants.

Surfactant helps open up the lungs to breathe better.

Pathological jaundice is an increase in bilirubin and yellowing of the skin. It is caused by a hemolytic disease such as Rh incompatibility or liver disease.

It occurs before 24 hours and is a serious life-threatening condition.

Meconium aspiration syndrome is when meconium gets into the lungs and causes respiratory distress and/or pneumonia.

Steps for a choking infant:

1. hold infant face down with head lower than feet
2. support head and jaw
3. give 5 back slaps
4. then put baby face up and give 5 chest thrusts
5. repeat until obstruction clears

Click HERE for a video on infant CPR and Choking treatment.

Steps for CPR on an infant:

1. check for pulse with brachial artery
2. use 2 fingers or 2 thumbs for chest compressions
3. go down 1 1/2 inches (2 cm) for compressions

• 1 rescuer: 30 compressions then 2 breaths
• 2 rescuers: 15 compressions and then 2 breaths

Click HERE for a video on infant CPR and choking treatment.

Esophageal atresia and tracheoesophageal fistula is when the esophagus forms an unnatural connection with the trachea causing food to enter the airway.

There is a high risk of aspiration.

Treatment for acetaminophen overdose:

• give acetylcysteine
• use activated charcoal with gastric lavage

Treatment for aspirin (acetylsalicylic acid) overdose:

• give activated charcoal

Treatment for corrosive poisoning:

• give water or milk
• don't induce vomiting as it can cause damage to the esophagus

A sickle cell anemia crisis is when RBCs clump together and block small blood vessels that carry blood to organs.

It causes severe pain.

Epiglottitis is an infection of the epiglottis which can be caused by Influenza type B or Strept.

There is a high risk of airway obstruction.

Status asthmaticus is a severe asthma attack that doesn't respond to inhalers.

Intubation and ventilator may be needed.