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Culture Documents
Definition:
Inability of the kidneys to perform vital functions including excretion of toxins,
electrolytes, fluids, and hydrogen ions.
Incidence:
Affects more than 2 out of a 1000 people in the U.S. annually.
Onset:
Gradual, over many years.
Etiology:
Diabetes and HTN are the primary causes of CRF, accounting for 40% and 25%,
respectively, of all cases. Other causes include trauma, autoimmune disorders, birth
defects, drug OD, and genetic diseases.
Clinical Findings:
Edema throughout the body, shortness of breath, fatigue, flank pain, oliguria (progressing
to anuria), elevated BP, and pale skin.
Nursing Focus
Patient Teaching
Findings
Best Verbal Response • Oriented: 5
• Confused: 4
• Inappropriate: 3
• Incomprehensible: 2
• Unresponsive: 1
Findings
Best Motor Response • Obeys commands: 6
• Localizes pain: 5
• Withdraws from pain: 4
• Abnormal flexion: 3
• Abnormal extension: 2
• Unresponsive: 1
Findings
Total .....................
Burn Assessment
• Depth of burn (1st; epidermis, 2nd; epidermis and partial dermis, or 3rd; penetrating
the dermis and underlying tissues).
• Percentage of TBSA involved.
• Age of the Pt (age + TBSA = % probability of mortality).
• Pulmonary injury (smoke inhalation, toxic fumes).
• Associated injuries (airway burns and other trauma).
• Special considerations (chemical/electrical burns, CO poisoning).
• Preexisting diseases (potential for exacerbation).
• Establish and manage ABCs and intubate if indicated. Use c-spine precautions if
traumatic injury is suspected.
• Administer 100% oxygen via NRB mask or use BVM if indicated.
• Obtain IV access and titrate to hemodynamic status.
• Attach ECG monitor and manage dysrhythmias per ACLS.
• Order and review labs (glucose, BUN, creatinine, CBC, electrolytes, PT, and PTT).
Rule of Nines
ABCDs of Melanoma
Definition:
Malignant neoplasia marked by the uncontrolled growth of cells, often with invasion of
healthy tissues locally or throughout the body (metastasis).
Incidence:
Second leading cause of death in the U.S., after cardiovascular (CV) disease.
Onset:
Varies with different types of cancer.
Etiology:
Varies with different types of cancer. Risk factors include tobacco use, sun exposure,
environmental/occupational exposure to carcinogens, poor nutrition, decreased level of
physical activity, and infectious diseases.
Clinical Findings:
Vary with different types of cancer. For a general overview of symptoms suggestive of
cancer, refer to CAUTION-7 Warning Signs of Cancer in this section.
Types of Treatments
• Surgery:
Removing cancerous tissue surgically or by means of cryosurgery (a technique for
freezing and destroying abnormal cells).
• Chemotherapy:
Treatment of cancer with drugs ("anticancer" drugs) that destroy cancer cells, or stop
them from growing or multiplying. Because some drugs work better together than alone,
two or more drugs are often given concurrently (combination therapy).
• Radiation Therapy:
Ionizing radiation (x-rays, gamma rays, or radioactive implants) deposits energy that
injures or destroys the cells in the target tissue by damaging their genetic material,
making it impossible for them to continue to grow.
Nursing Focus
• Nausea/vomiting:
Administer antiemetics as needed and before chemotherapy is initiated. Withhold foods
and fluids 4-6 hours prior to chemotherapy. Provide small portions of bland foods after
each treatment.
• Diarrhea:
Administer antidiarrheals. Monitor electrolytes. Give clear liquids as tolerated. Maintain
good perineal care.
• Stomatitis:
Avoid commercial mouthwash containing alcohol. Encourage good oral hygiene. Help Pt
rinse with viscous Lidocaine prior to eating to reduce discomfort, and again after meals.
Apply water-soluble lubricant to cracked lips. Popsicles provide a good source of
moisture.
• Itching:
Keep Pt's skin free of foreign substances. Avoid soap: wash with plain water and pat dry.
Use cornstarch or olive oil to relieve itching, and avoid talcum powder and powder with
zinc oxide.
Patient Teaching
• Inspect and palpate head and face for lacerations, contusions, fractures, or other
injuries.
• Eyes (injury, hemorrhage, contact lens, dislocation of lens).
• Ears and nose for CSF (cerebrospinal fluid).
• Mouth (blood, emesis, broken or missing teeth).
• Cranial nerves.
Chest
Abdomen
Extremities
Perineum
Fractures-Dislocation
Neurological