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0800: 62-year-old client brought to emergency department by spouse after tripping at home 6 hours ago. Right midfoot swollen with large amount of bruising on toes and sides of foot. Less swelling on ankle. No external bleeding or wounds. Reports pain 10/10 and unable to stand on foot, unable to move without difficulty, increased pain with palpation of superior aspect of foot. Able to move toes and dorsiflex foot, pedal pulse palpable, capillary refill delayed. Has history of hypertension, L meniscus repair 6 years ago, hepatitis A as a child.

3.For each potential nursing intervention, specify if the intervention is indicated or .For each potential nursing intervention, specify if the intervention is indicated or contraindicated for this client.

You got 5 correct point(s) minus 0 incorrect point(s) for a total score of 5 point(s) on this question.

Potential Intervention	Indicated	Contraindicated
Assess level of pain.
Teach to apply heat.
Elevate the foot above the level of the heart.
Assess ability to differentiate between sharp and dull touch.
Apply ice to swollen areas.

1.Marathon 아저씨 TKA(NGN) 상황 : TKA했고 드레싱 젖어있고 열이 38.1도 까지 RR 24 평소 마라톤 자주했다함.의심되는거 다골라

감염

MI

DVT

2.ngn은 열만 나고 v/s 멀쩡하고 hb하고 hct만 좀 떨어지고 나머지 lab은 다 정상인 헛소리하는 노인이었는데 추정 진단명

UTI

고관절 골절

알콜릭

3.op후 교육 문제

. THR 수술 후 옳은것은 SATA

3주후 tub bath 할 수 있다

may help device when pick up pet

3주후 driving할 수 있다

high raised toilet

⑤avoid across

⑥90도 sitting position

#You can usually drive a car after about 6 weeks, subject to advice from your

4.수술후 NGN

이사람 마라토너인데 TKR 수술함. V/S은 P만 120이고 나머지 정상. 시간당 50 수액맞는데 폴리 넣었더니 소변 70정도 나옴. Statin 약 복용중

제일 우려되는 것?

. 54세 남자 TKRA했고, 수술부위 깨끗, 근데 말초 쪽으로 edema랑 swelling있음 등등

다리수술한 마라토너 괜찮다가 맥박, 호흡 빨라지고(아주조금) 수술부위 거즈 위로 출혈보임 무슨 중재할래?

bleeding

dehydration

infection

pain

5.뭐부터 먼저 해줄거냐

IV drop increase

transfusion

antibiotic

pain med

출혈인지 RBC주고 호전됨. NGN

Mi, icu 보낸다

6.OA patient 교육잘된것

I will keep splint when I sleep.

아침에 대부분 exercise한다

aerobic and muscle strengthen exercise 하겠다

머리에 베개 대어주고 무릎밑에 베개대주기

#recommended to be encouraged to partake in a low-impact aerobic exercise program (walking, biking,

7.Naratriptan seizure 외 예전에는어떤약물로쓰이기도했는가?

Migraine headache

High blood pressure

anti imflammatory

prevention vomitting

8.알콜 abuse 환자 응급실 방문. 난 남편이 알콜 마시는게 두려워요. 지난밤에는 내 팔을 부러뜨렸여요.환자에게 적당한 말?

모두 leave. 떠나라는 말

너의 감정을 좀더 듣고 싶다 . 말해 줄래?

공감하고 사회지원?연결시켜줄게

9.quadriplegia환자 bed에서 어떻게 옮기나..?

어깨랑 무릎에 뭘 넣어서 든다..?

환자 돌려서 시트 넣는다

10.quadriplegia 환자 I'm trying to get you up on your bed. correct?

침대를 Trendelenburg 로 하고 환자를 위로 올린다

환자 밑에 깔린 sheet 를 이용하여 환자를 위로 올린다

Hammock sling 을 어깨부터 허리까지 착용시키고 mechanically 시행한다

Side rail 올린다

Wash your hands.

Approach and identify the patient (by checking the identification band) and explain the procedure (using simple terms and pointing out the benefits).

Provide privacy.

Position the bed.

The bed should be in the flat position at a comfortable working height.

Lower the side rail on the side of the body at which you are working.

Position yourself with your feet apart and your knees flexed close to the side of the bed.

Fold the patient's arms across his chest.

Place your arms under the patient so that a major portion of the patient's weight is centered between your arms. The arm of one nurse should support the patient's head and neck.

On the count of three, move the patient to the side of the bed, rocking backward on your heels and keeping the patient's body in correct alignment.

Raise the side rail on that side of the bed.

Move to the other side of the bed.

Place a pillow under the patient's head and another between his legs.

Position the patient's near arm toward you.

Grasp the far side of the patient's body with your hands evenly distributed from the shoulder to the thigh.

On the count of three, roll the patient to a lateral position, rocking backward onto your heels.

Place pillows in front of and behind the patient's trunk to support his alignment in the lateral position.

Provide for the patient's comfort and safety.

1 Position the call bell.

2 Place personal items within reach.

3 Be sure the side rails are up and secure.

Report and record as appropriate.

11. 사지마비 SCI환자 move out시 적절한 방법(sata)

①시트를 이용해 위로 올린다.

②mechanical device 사용

③side rail 올리고 position 할것이다.

④35kg이하면 혼자서도 옮길 수 있다.

⑤체위 변경시 환자의 침대를 나의 elbow 높이에서 시행할 것이다

11. Metamucil (Psyllium)복용법

이 약을 먹는 동안 fluid intake늘리겠다.

약과 물 6-8glass mix해서 30분동안 먹겠다.

먹고 full 로 물 한 컵

IBS 진단받으면 이 약 끊겠어요

Take Metamucil 30 minutes before meals to help you feel full faster

taking up to 10.2 g of psyllium before breakfast and lunch led to significant reductions in hunger, desire to eat, and increased fullness

low cholesterol. low sugar. relieve constipation. diarrhea treat.wt manage

12. Car seat, 틀린 것 ?

①아기의 seat 에 패딩을 해준다 옆, 뒤에

②convertible seat 는 good for

③snugly across thigh of toddler in boost seat

④school age who must sit in front of the car, air bag as back as possible.

Once your baby outgrows its infant seat, you'll need a convertible car seat as they grow.

13. infant car seat correct sata

cushion between back and baby

rolled blanket side of head due to minimize shaking head

may switch forward facing car seat when baby is 12m

back seat is the best place to place car seat for baby

position shoulder tip?line? so that car exit car seat at or below shoulder line?

#On rear-facing car seats, the shoulder straps should come through the car seat slots at or just BELOW your child's shoulders. On forward-facing seats, the shoulder straps should be at or just ABOVE the shoulders.

14.RSV precaution.:ribavrin(spray) 중재할 것?

사용 시 goggle 착용한다는 말

임상병리사가 blood drawn시 glove와 gown 입고 있다.

physician이 치료 후 청진기를 놓고 나온다

NA가 아무것도 하지 않고 방에서 부모와 이야기하고 있다