*NURSING > STUDY GUIDE > Leadership Proctored Study Guide LATEST UPDATED VERSION A+ Guide (All)
Leadership Proctored Study Guide LATEST UPDATED VERSION A+ Guide/Leadership Proctored Study Guide LATEST UPDATED VERSION A+ Guide/Chapter One: Managing Client Care Prioritization of Patient Care ABCD... E Principle - A: Airway – Ensure patient’s airway is patent. At the same time secure the cervical spine if head or neck injury is suspected. No injury: head-neck, chin lift to secure airway. Injury: Use modified jaw-thrust maneuver - B: Breathing – Assess respiratory status. The rate, depth, etc. - C: Circulation – Assess HR, BP, cap refill, adequate circulation throughout the body - D: Disability: Assess LOC - E: Exposure – Assess body for trauma, or exposure to heat or cold Prioritization: - Always assess before taking action (Dyspnea: assess patient before taking further action, insulin: assess blood sugar before giving) - Unstable patients before stable patients (patients with findings that are expected for their medical diagnosis). COPD patient expected to have low SpO2 whereas patient. Patient with stroke with facial drooping expected, patient with other diagnosis having facial drooping unexpected, Albuterol side effects: tachycardia, tremors, restlessness (EXPECTED) - Acute over chronic: Patient with abnormal vital signs, low urinary output are acute situations and need attention before patients with stage 4 pressure injury (not developed over night) - Systemic issues over local issues. Systemic: fever, hypotension, tachycardia (infection or sepsis). Local: bad skin tear, erythema on the foot (need to address but others are priority) - ABCDE: Administering pain medication is RARELY an answer. - Maslow’s Hierarchy of Needs: Physiological, safety, love and belonging, self-esteem, self-actualization - Least invasive interventions before more invasive interventions. (move near nursing station, sitter, distractions before restraints. Patient difficulty urinating – run water in room before catheter [Show More]
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