Ss chills or fever low bp tachycardic shakiness

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S/S : chills or fever, low BP, tachycardic, shakiness, hyperglycemia and/or insulin resistance ****decreased SVR, flushing, oliguria!!!! Common cause of SIRS and MODS Snake bites - The first priority for a client bitten by a snake is to move the client to a safe area away from the snake and encourage rest to decrease venom circulation. Priority nurs. Intervention (immobilizing affected extremity with a splint) Extremity is immobilized and kept below the level of the heart. The digital photographs of the snake are taken to identify the snake after the client is moved to a safe area. Emergency assistance is called after the client is safe. The client’s jewelry and constrictive clothing is removed before swelling starts but is not the priority, do not ice the area or suck venom, can use tourniquet to cut off circulation of blood if pt is not tx to the ER right away. Subdural hematoma - vein is torn around cerebral cortex. Develops slowly, people at risk are on warfarin or Plavix like drugs s/s -dec. LOC, hemiparesis, possible ICP, pupils dilated or fixed tx: craniotomy
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Pneumonia w/ ventilators - main cause is aspiration, poor oral hygiene, contaminated equipment. strategies to reduce VAP: - elevated HOB 30-45 degrees, hand hygiene and gloves when suctioning, suction above cuff before deflation, oral hygiene Q2 !!!! meticulous oral care, HOB 35-40, PPI, DVT/PUD prophylaxis, sedation vacation (daily), condensation, suction every 4 hrs (pneumonia-s/s dec. breath sounds, resp alkalosis, consolidation) Ventilators -pt should not be able to speak, if they’re speaking over ventilator access cuff for possible air leak, Empty the ventilator tubing when moisture collects, Turn the client at least every 2 hours or get the client out of bed, as prescribed, to prevent complications of immobility, Have resuscitation equipment available at the bedside. s/s Hypotension, Pnemothorax or subcutaneous emphysema (a.k.a. crepitus), Gastrointestinal alterations (e.g., stress ulcers), Malnutrition, Infection, Muscle deconditioning, Ventilator dependence or inability to be weaned. The only time you cannot use a vent is when a pt has a “DNR” Control mode-breaths for you Assisted control-finishes the breath for you SIMV-for weaning High pressure-obstruction Low pressure-leak/disconnected tube PEEP-if above 15 can cause barotrauma & pneumothorax, observe for s/s of asymmetric chest wall movements, & dec. UO, dec. BP Air embolism-s/s dyspnea, tachypnea, cyanosis, hypotension, & chest pain Nurs. Interventions : clamp catheter, place pt in left lateral Trendelenburg Hemo/pneumothorax-agitation, hypotension, tachycardia, & absent breath sounds JVD-retention of blood in the right side of heart increases rt. atrial pressure which leads to JVD as a result of backflow through the vena cava
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