202 Flashcards
Difference between Low flow oxygen and High flow oxygen?
Low flow - Measured in L/ min titrated 1-2L, inspiratory flow not met, and uses Nasal prongs, simple mask, non-rebreather
High flow - Measured in % titrated 5-10% at a time air needs to humidified, inspiratory flow met/exceeded
What is an AquaPak Humidified O2 system? And when does the tubing need to be changed?
An attachment that contains sterile water that humidifies the air and is an AGM not a medication. Tubing needs to be changed every 7 days
What are the three parts of a trach tube?
Outer cannula with flange
Inner Cannula
Obturator
What are the most important safety equipment for a trach tube?
Suction equipment
Oxygen equipment with humidification
Two replacement tracheostomy tubes (one the same size and one smaller)
Obturator and spare inner cannula
10 ml syringe
Less important
Tracheal tube exchanger
tracheal dilator or forceps
Sterile gloves
Water soluble lubricant
spare ties
Normal saline nebule
Manual resuscitation device with appropriate size airway and mask
What does the placement of the chest tube mean?
Upper chest tube means its draining air
Lower chest tube is draining fluid
Is a PICC a Peripheral line or a Central line?
Central line
What size is a CVAD with multiple lumens? and do you have to flush each line?
18 gage with one that is different
Yes
When would you need a PICC?
Administering IV fluids and blood products quickly
Administering Vaso medication
Chemotherapy
Administer medications with extreme PH values like cloxacillin
Obtain venous blood samples
How many ml’s do you need to flush a Central line?
10 mls before
20mls after
How many ml’s do you need to flush a peripheral line?
3mls before
10 ml’s after
Do you need a Heparin flush for Valved PICC line?
No
Why do you need to aspirate a central line?
Because a fibrin sheath can form
How often does a transparent dressing, Securement device, Needless cap need to be changed?
Every 7 days and prn
Transparent dressing- gauze needs to be changed every 2 days
Needless cap should be changed when blood is unable to clear from the needless cap
How often does a transparent dressing, Securement device, Needless cap need to be changed?
Every 7 days and prn
Transparent dressing- gauze needs to be changed every 2 days
Needless cap should be changed when blood is unable to clear from the needless cap
What to do if the external line is different by at least 2 cms?
Report to IV team and document
Complication of a CVAD?
Infection
Occlusions
Phlebitis, thrombophlebitis, infiltration, extravasation
Catheter migration
Air embolism
Catheter embolism
Pneumothorax/ hemothorax
Arrhythmia
How to deal with a venous air embolism?
Lean the patient on the left side and in Trendelenburg position to move air bubble into right right atrium.
If it is an arterial air embolism should be kept in supine position
What ml syringe is the smallest you can use with a peripheral line and why?
10 ml due to the idea it can only exert 8 PSI anything smaller is too much pressure
What to do if an IV push med is incompatible with the IV solution?
Stop IV line, pinch the line, aspirate, flush with 10ml, administer the medication abiding my the time required to administer, and 10 ml post med flush.
What causes a catheter Occlusion? S&S? Interventions?
Clamped or kinked catheter, Tip against wall of vessel, Thrombosis, Precipitate build up in lumen
S&S- Sluggish infusion or aspiration, unable and/or aspirate
Intervention - Check IV line, flush with saline, anticoagulant or thrombolytic agent
What causes an Embolism? S&S? Interventions?
Catheter breaking, Dislodgement of thrombus, entry of air into circulation
S&S - Chest pain, Respiratory distress (dyspnea, tachypnea, hypoxia, cyanosis), hypertension, tachycardia
Interventions - Clamp catheter, place patient on left side with head down( if suspect or emboli), Administer oxygen, notify physician
What is the cause of pneumothorax? S&S? and Interventions?
Inadvertent puncture of the lung at the time of inserting needle in vein
Decreased or absent breath sounds, respiratory distress (cyanosis, dyspnea, tachypnea), chest pain, distended unilateral chest
Interventions - Position in semi Fowler’s position, administer O2, administer analgesic if ordered, Prepare for xray/chest tube insertion
What causes Catheter migration? Signs and Symptoms? Intervention?
Improper suturing, insertion site trauma pressure, changes in intrathoracic pressure, forceful catheter flushing, spontaneous
Sluggish infusion or aspiration, edema of chest for neck during infusion, Client complaint of gurgling sound in ear, Dysrhythmias, Increased external catheter length
Fluoroscopy to verify position, assist with removal and new CVAD placement
Where are Non tunneled CVAD’s located?
Jugular, femoral, and subclavian
When would you want to use a non tunneled CVAD?
Short term emergency therapy, external jugular, or subclavian vein
Requires a sterile dressing
Non valved
Only good for 7 days or less due to risk of infections
When would you use a CVAD?
Used for long term intermittent or continuous access
to Administer …
- Chemo therapy, Vasopressors or dilator, give large volumes of IV and normal IV, irritant medications, Extreme PH values, hypertonic solutions, obtain venous blood samples, and monitor central venous pressure
Proximal end is tunneled subcutaneously from the insertion site 10-15 cm
Have a Dacron Cuff on the tunneled portion of the catheter 3-4 weeks so granulation tissue can form around it
When would you use an IVAD (Implanted Vascular Access device?
Located in the upper chest that connects to the distal third vena cava of superior vena cava
Used for chemo therapy (aka people who need a port very long term outside the hospital)
Requires heparin flush every 8 weeks to maintain patency
When would a hemodialysis cuff would need a cuff?
Uncuffed - used for an emergency or less than 3 months
Cuffed - longer than 3 months
Things to know if giving TPN through CVAD
Total parenteral nutrition is given through CVAD and Partial parenteral nutrition is given with PVAD
Needs a dedicated line and an inline filter
What happens when there is Unilateral dilation in the eyes?
Brain hematoma
Brainstem herniation
Migraine
Compressed cranial nerve 3
Why is there Bilateral Dilation with fixed versus sluggish pupils?
Mid brain injury
Poor prognosis if GCS less than 3
Patient is approaching death
Sluggish -
Eye disease
Illicit substances
Post seizure
What does bilateral Constriction mean?
Brain trauma (pons CVA)
opioids/ narcotics
Medication
Environmental toxins
eye trauma
Diseases (diabtes, MS, Neuro-syphillis)
heat stroke
Unilateral constriction mean?
Horner’s syndrome
Iris inflammation
Adhesion
Medication
Which cranial nerve number is responsible ears?
8 the acoustic
Right now identify where the cranial nerves are
Refer to the first neuro pp
How many pairs of dermatomes are there?
31 pairs of spinal nerves only 30 dermatomes
How many cervical, thoracic, lumbar, Sacral, and coccygeal nerves are there?
7 Cervical C1 is not a dermatome so it starts at C2
12 Thoracic
5 lumbar
5 Sacral
1 Coccyx numbered as zero
How do dermatomes run?
Bilaterally across horizontally
Are there Dermatomes on your face?
No cause Cranial nerves
Describe where the cervical nerves are?
Back of head to Lower back, inner arms, ring fingers (back of head to mid shoulder blades)
Describe where the thoracic dermatomes are
Upper back/ back of arms to Lower abdomen and mid back
Describe where the Lumbar dermatomes are
Lowe back/ hip and goin to Lower back, front and outside of calf
Sacral Dermatomes location?
Lower back to perianal region and next to anus
Methods to assess motor functions?
Gait
Romberg test
finger to finger test
heel to shin test
Strength
Symmetry
Difference between Cerebellar ataxia versus Sensory ataxia?
Cerebellar - uncoordinated muscle movement
Sensory - Impaired feeling
Ataxia - without coordination
What does DTR stand for?
Deep tissue reflex
What can cause abnormal reflexes?
Peripheral Neuropathy
Nerve compression
Trauma or Lesions
Medications
Hormone imbalances
Electrolyte imbalances
Nutrient deficiencies
Disease
Ischemic versus Hemorrhagic stroke?
Ischemic - blood clot stops the flow of blood to an area
Hemorrhagic stroke- Weakened/ diseased blood vessels rupture
Acronym for stroke?
FAST VAN
Face
Arm
Speech
Time
Vision
Aphasia
Neglect
What is an extracranial cause of a siezure?
Excess/ Deficit- Glucose, electrolytes, triglycerides
Toxins - Internal (kidney or live or metabolic disease)
External poisons
What is an intracranial cause
Primary epilepsy (idiopathic)
Secondary epilepsy - Progressive brain disease (tumor) Static brain disease (scar after trauma)
Three key features of seizures
Where the seizure began in the brain
Level of awareness
Describing the other features
What is a focal, generalized, and focal to bilateral seizures?
Focal - onset in one care on one side of the brain
Generalize seizure - Involves both sides of the brain at the onset
Focal to bilateral - one side to both
What are the levels of awareness during a seizure?
Focal aware - awareness remains intact, even if the person is unable to talk or respond during a seizure
Focal impaired awareness - Awareness is impaired or affected at anytime during the seizure
Awareness unknown - Not always possible to know f a person is aware or not
Generalized - presumed to affect the person’s awareness or consciousness
What are the other features of the seizures?
Focal motor seizure - body movement occurs (Twitching, jerking, or stiffening) or automatisms (lip licking, rubbing hands, walking/running, laughing/crying)
Focal non-motor seizure: Changes in sensation, emotions, thinking, or experiences
Generalized motor seizure: Tonic and clonic (tonic stiffening and jerking)
Generalized non-motor seizure: primarily absence seizures involve brief changes in awareness, staring, and may present with automatisms
What are the phases of a seizure?
Prodromal - signs a seizure could be happening (confusion, headache, mood/behavior’s changes)
Early Ictal/ Aural phase - Sensory warnings prior
Ictal phase - Seizure acting, loss of awareness, repeated movements, convulsions, tachycardia, trouble breathing
Postictal phase - Rest and recovery
What is status epilepticus?
A state of constant seizure or when seizures recur in rapid succession without return to consciousness between seizures (neurological emergency)
Uses more energy than is supplied - neurons become exhausted and cease to function and can cause permanent brain damage
What is a tonic-clonic epilepticus seizure?
Most dangerous as it can cause ventilatory insufficiency, hypoxia, cardiac arrythmias, hyperthermia, and systemic acidosis
What can trigger a seizure?
Stress
excessive excitement
Excessive fluid in take
Extremely low blood sugar
sunlight, heat, humidity
Flickering lights
SKipping meals
Illness, fever, allergies
Lack of sleep
Withdrawal form medications, illicit drugs, alcohol
Missing medications
Things to do and do not with seizures?
Remove hazards
ensure patient safety and airway
stay with client until seizure has passed and time and observe activity
Turn the patient on their side if possible
apply oxygen if needed
suction if needed
Assist with ventilation if patient does not breath
Call a code blue if warranted
DO NOT Restrain or insert anything into their mouth.
Symptoms of short term alcohol on CNS
Initial relaxation
Decreased inhibition (drive faster)
Lack of coordination
Impaired judgement
Slurred speech
Anxiety or agitation
Hypotension
Bradycardia
Bradypnea
Long term symptoms of alcohol
Wernicke’s encephalopathy
Korsakoff’s syndrome
Impaired cognition
Decreased psychomotor skills
Impaired abstract thinking and memory
Sleep disturbances
Depression/labile mood
Attention deficit
Seizures
What is the CAGE tool?
A tool to ask about alcohol use
Have you thought of CUTTING down?
Have people ANNOYED you by criticizing your drinking?
Have you ever felt bad or GUILTY about your drinking?
Have you ever had in the morning (EYE OPENER) to steady your nerves or get rid of a hangover
What is CIWA used for?
To assess alcohol withdrawal
Clinical Institute Withdrawal Assessment
What is the 10 categories of AWS?
Nausea/ vomiting
Tremor
Tactile disturbances
Auditory disturbances
Paroxysmal sweats
Visual disturbances
Anxiety
Headache
Agitation
Orientation
Stages of alcohol withdrawl over 3 days?
6-12 hours - Minor withdrawal symptoms: insomnia, tremors, anxiety, gastrointestinal upset, headache, diaphoresis, palpitations, anorexia, nausea, tachycardia, hypertension
12-24 hours-Alcoholic hallucinosis: visual, auditory, or tactile hallucinations
24-48 hours -Withdrawal seizures: generalized tonic-clonic seizures
48-72 hours - Alcohol withdrawal delirium (delirium tremens): hallucinations (predominately visual), disorientation, agitation, diaphoresis
What is the kindling phenomenon?
The severity of each attempted to withdrawal gets more severe each time consecutive time they are withdrawing
Other issues with alcohol withdrawal
Alcohol is a diuretic
N/V
Poor appetite due to gastritis
Not drinking enough water
alcohol can cause pancreatitis
malnourished and at risk for refeeding syndrome
Gastritis caused by lack of Thiamine
Why is thiamine deficiency associated with alcohol withdrawal?
Thaimine is essential for energy metabolism. it converts cards into glucose
BeriBeri -
Dry beriberi: effects the CNS and Peripheral nervous system - Wernicke’s encephalopathy (fluid on the brain)
Acute/sudden syndrome requiring urgent treatment
Swelling causes damage to nerves and blood vessels in the brain
Ataxia, Confusion, Nystagmus (uncontrolled eye movement vibration)
If untreated can lead to Korsakoff’s Syndrome
Korsakoff’s Syndrome (second step from the one above)
Irreversible, significant short-term memory impairment
Inability to learn new things or retain new information
Some loss of long-term memory
Aphasia
Lack of insight
Confabulation
Wet: effects the heart and circulatory system -
What makes up most of spinal injury accidents?
Motor vehicle (35%)
Falls (17%)
Degrees of injury
Complete - spinal cord is completely severed, Complete loss of mobility and sensation below the injury
Incomplete - Incomplete or partial cord severance, Some movement and/or sensory below the level of injury
What is the difference between primary injury and secondary injury?
Primary is the initial contact
Secondary is the inflammation that forms later
What is the difference between primary injury and secondary injury?
Primary is the initial contact
Secondary is the inflammation that forms later
Collaborative care goals for spinal injury
Patient airway needs to be maintianed along with adequate ventilation, adequate circulating blood volume
treat systemic and neurologic shock to maintain BP
In the assessment check for motor and sensory tests, spontaneous movements, signs of ICP and LOC
Clinical manifestations of an injury above C4
Total loss of respiratory muscles
Mechanical ventilation is required
Artificial airway
Paralysis of abdominal and intercostal muscles
pulmonary edema
Clinical manifestations below C4?
Diaphragmatic breathing if phrenic nerve functional
Hypoventilation common with diaphragmatic breathing
Paralysis of abdominal and intercostal muscles
Clinical manifestations of T5 or higher
Neurogenic shock
Bradycardia under 40 (administer atropine)
Peripheral vasodilation
Cardiac monitoring is necessary
Clinical manifestations under T5
Problems associated with hypomotility (bowels are slower)
Constipation
Paralytic ileus
Gastric distension
Medications such as metoclopramide may help with motility
Stress ulcers are common
Clinical manifestations T12 or above and below T12
Reflex (spastic) bowels
Cannot voluntarily relax the anal sphincter
may have constipation
Signals between the colon and the brain become distupted
The reflex that triggers a BM still works but may not be felt
Areflexic (flaccid bowel)
Decreased peristalsis
Loose sphincter
Risk for constipation with bowel incontinence
Clinical manifestations of ICP
Changes in LOC
Ocular signs
Headache
Vomiting
Late signs
Changes in vitals (Decreased HR, Irregular respirations, and widened BP)
Decreased motor function
What should you monitor with ICP?
Fluid and electrolyte balance
Monitor ICP should be between 5-15 mm Hg
protect from injury
consider of psychological considerations
Ranges for GCS
13-15 is mild brain injury
9-12 Moderate injury
3-8 Severe brain injury
What is a coup contrecoup injury?
Primary (coup) the first impact
Contre coup or the secondary is when the brain hits the opposite side of impact after first
