Acute Care 2 Flashcards
what are used to determine the functionality of a patient’s clotting ability
blood tests
measures platelet (PLT) functioning by determining the time it takes for a blood clot to form from a punctured capillary
bleeding time
what is normal bleeding time, what would indicate highly significant bleeding time
normal: 3-10 minutes
abnormal: > 15 minutes
tests for functioning of Factor I, fibrinogen Factor V, VII, X (all of which are extrinsic factors) that convert fibrin to stabilize clot)
prothrombin time (PT)
what is fibrin
a protein formed from fibrinogen during clot formation in blood
what happens if there is a malfunction in PT (prothrombin time)
blood will take longer to clot
what is normal prothrombin time
11-13 seconds
can also be used to determine functionality of the clotting cascade by evaluating clotting factors found in the intrinsic pathways (factors I, II, V, VIII, IX, X, XI, XII)
partial thromboplastin time (PTT)
how is PTT drawn and what does it separate
- drawn from venous blood
- separates into plasma and cells
what is PTT used to monitor dosages of
heparin (blood thinner)
what is normal value of PTT
30-45 seconds
if a substance is added to the blood, to activate _____ pathways, the time it takes to form a clot is measured in _____
intrinsic
seconds
test that is done when a substance is used to shorten the clotting time (reading it in less than one hour)
activated partial thromboplastin time (APTT)
what is normal APTT, what signifies spontaneous bleeding APTT
normal: 21-35 seconds
>70 seconds signifies spontaneous bleeding
used to correct for differences in the lab agents used to test the prothrombin time
international normalization ratio (INR)
what is used to monitory dosages of coumadin/warfarin
international normalization ratio (INR)
how is international normalization ratio calculated and what is the formula
patients PT value over control PT
INR = patient PT / control PT
produced by the action of plasma on cross-linked fibrin and the presence in the blood confirms that clotting has occurred
d-dimers
what are d-dimer blood tests used to screen for
DVT, PE, disseminated intravascular coagulation (DIC)
what tests are used to monitor the amount of anticoagulation therapies (heparin/coumadin) used to treat blood clots
PT, PTT, INR
what is important to remember when treating patients with impaired or enhanced clotting
they are at increased risk for bleeding (falls, running into things)
formation of blood clot in a deep vein; life threatening
venous thromboembolism (VTE)
what leads to DVT –> PE –> postthrombotic syndrome (PTS)
venous thromboembolism (VTE)
what percent of people die within 1 month of VTE diagnosis
10-30%
what is the 3rd most common CV illness following acute coronary syndrome and stroke
VTE
how many people die immediately with acute PE
what percent die within 3 months
1/5
40%
a patient dx with DVT is at significantly increased risk of developing
PE
what is the main intervention for DVT
anticoagulation therapy
for patients who are at increased risk of bleeding when dx with DVT, what is an alternative intervention instead of anticoagulants
surgery
when should mobility be started following DVT
started ASAP as immobility is a huge risk factor for developing more clots, but only once intervention has been initiated
what are anticoagulation medications
unfractionated heparin
low molecular weight heprin (LMWH)/fondaparinux
coumadin
new oral anticoagulation drugs (NOAC)
used with patients with high bleeding risk for renal disease
unfractionated heparin
most often used to treat LE DVT or PE
low molecular weight heparin (LMWH) or fondaparinux
used during DVT with pregnancy and patients with active cancer
low molecular weight heparin (LMWH)
primary choice for VTE in OP and home care settings
low molecular weight heparin (LMWH)
not usually the first choice in anticoagulation medication because it takes longer to achieve peak therapeutic levels, but can be used initially along with LMWH or UFH
coumadn
anticoagulation medication that requires no lab monitoring; has rapid time to peak therapeutic levels; less risk of cerebral hemorrhage
new oral anticoagulation drugs (NOAC)
what are NOAC commonly used in
TKA, THA
not yet tested for those with cancer or women who are pregnany
what are the risks for using anticoagulation medication
risk of active bleeding, acute stroke
what to watch for on anticoagulation medication for exercise and OOB activities
INR
range of INR for someone not on anticoagulation
0.8-1.2
typical INR range for someone on anticoagulaiton
2.0-3.0
INR of what indicates no resistive exercises, light exercise only with RPE < 11
what may be restricted
4-5
ambulation may be restricted if they are unsteady and may fall
INF > ____ - check with MD regarding activity
> 5.0
INR ____ may be on bed rest until corrects
> 6.0
a short-term catheter placed in a central vein by a physician or surgeon, usually for emergency access
non-tunneled temporary central catheters
these lines are usually stiffer material, may have 1 to 3 lumens, and are most commonly used in the intensive care areas (typically not a line you would see outside the ICU)
non-tunneled temporary central catheters
what are common placement sites for non-tunneled temporary central catheters
femoral, subclavian or jugular veins
how are non-tunneled temporary central catheters held in place
sutures or a securement device and covered with a transparent dressing
care needed for non-tunneled or percutaneous temporary central catheters
flushing
dressing changes
assessment for problems
what is the use for central venous access catheters
inserted for medications and parenteral nutrition
what are central venous access catheters intended to be for how long
intermediate to long-term
infusions that are hypertonic in nature and too irritating for peripheral veins
central venous access catheters
in many kids/adults, the __________ is a lifeline that is necessary for success in therapy
central venous access catheters
what does parenteral nutrition mean
receiving nutrients through the blood
another name for tunneled central catheters
broviacs
long-term catheters placed in a central vein by a interventional radiologist or surgeon
tunneled central catheters
tunneled catheters are usually inserted for intermittent or continuous treatments that will take _____ to ____ such as:
months to years
- chemotherapy in oncology patients
- TPN (total parental nutrition) with inflammatory bowel diseases
- neonates requiring months of care in NICU
where are the most common placements for central tunneled catheters
subclavian or jugular veins
after inserted into subclavian or jugular veins, tunneled central catheters are then tunneled under the skin to a distant exit site, usually where
mid-chest area
tunneled central catheters is sutured at first until the ______ located in a subcutaneous tunnel under the skin takes hold
Darcon cuff
why is a tunneled central catheter tunneled under the skin
to help keep microorganisms from migrating
where does the tip of a central venous catheter terminate
superior vena cava (or inferior vena cava) - the largest central veins
what occurs when medications/chemotherapy are administered into central venous access
hyperosmolar solutions (central strength TPN) and irritating medications (chemo) are quickly dispersed and diluted by the rapidly flowing large volume of blood in the vena cavas
long-term venous access devices placed in a central vein by interventional radiologist or surgeon; ports are usually inserted for intermittent long term therapy (chemo in oncology patients) and antibiotic therapy (cystic fibrosis)
totally implanted central catheters (implanted ports) - accessed (red) or not accessed (yellow)
difference between broviac catheters and implanted port
- Broviac: are external
- implanted port: placed under the skin and only a slight bump can be seen where the port body is implanted and sutured in a pocket under the skin of the chest or arm
how to access totally implanted ports
accessed with a needle through the skin into the port to use the device
if totally implanted ports have 2 lumens, can they both be accessed at the same time
yes
PICC
peripherally inserted central catheter
is an intermediate catheter that is placed in a peripheral vein and threaded into a central vein by IV team or interventional radiology
peripherally inserted central catheter (PICC)
where is peripherally inserted central catheter (PICC) usually inserted
antecubital area
what are common diagnoses of those who receive peripherally inserted central catheter (PICC)
CF, lyme disease, osteomyelitis, crohn’s disease
what holds peripherally inserted central catheter (PICC) in place
stat-lock and then covered with a transparent dressing
PT responsibilities for general assessment and care of central lines
- check site (dressing, dry, clean)
- secure line if you see it pulling or dragging
- NEVER thread IV tubing through bedrails (NO tension on central line)
CLABSI
central line associated blood stream infection
central venous catheter complications
infection
phlebitis
occlusion
air embolism
malposition
infiltration
catheter breakage/dislodgement
leakage
S/s: occurs when blood backfills at insertion site
occlusion
what to do when IV pump is alarming “occlusion” or “no upstream flow detected”
notify nursing
may occur if a central lines break (very rare); especially if line is located above the heart
air embolism
s/s of air embolism complication
sudden onset of pallor
cyanosis
dyspnea
cough
tachycardia
syncope
what should be done if patient experiences air embolism
- place patient on L side in Trendelenburg (head down)
- administer O2 and monitor pulse ox
- notify MD/RN stat to your location, do not move the patient
*** call for help/rapid response
s/s of malposition of CVC and what to do
neck/chest swelling, gurgling sound in ears, tachycardia
- notify MD/RN
signs of catheter breakage
leakage of infusate, bubbling or bulging of the catheter material, dressing is wet
what to do when notice catheter is broken
- IMMEDIATELY clamp catheter above the break using non-toothed clamp
- cover break with sterile gauze and hold onto the end going into the patient
- if not clamp, fold catheter onto itself, hold onto the end of the catheter, try not to move the catheter (end of catheter can actually get sucked into the vein, so hold on tight!) (you can tie a know in the end of the catheter and cover the end with a sterile gauze to keep it clean and prevent air from entering or blood from leaving
- stat page MD/RN
s/s of of dislodgement
external catheter length is longer than noted previously, Broviac cuff is visible
what to do when dislodgement occurs
page RN, they will stop infusion and notify MD
opening (stoma) for part of intestine or colon through abdomen; stool travels out opening, collected in bag
colonostomy
when is colostomy performed
injury, blockage, abscess
surgical opening of the bladder to the abdomen to allow for urine drainage; prevents UTIs and damage to kidneys
vesicostomy
vesicostomy seen in
children with bladder obstruction
children with spina bifida
a thin, sterile tube used to drain urine from the bladder; used if you aren’t able to use a catheter that is inserted into the urethra
suprapubic catheter
common populations for suprapubic catheters
seen in patients with SCI, spina bifida
prolonged hospitalization or ICU stay can cause alterations in mood and psychological functioning; anxiety, delirium, agitation, depression
ICU delirium
what can cause ICU delirium
alterations in sleep patterns/positions
noxious stimuli
noise
loss of circadian light patterns
contact precautions
- private room
- hand hygiene prior to glove application and after glove removal
- gloves and gown
don upon entering, doff before exiting - dedicated equipment
- transporting patient –> alert receiving department
droplet precautions
- private room
- hand hygiene prior to glove application and after glove removal
- gloves and possible gown
- don upon entering, doff before exiting
- face mask/googles
- transporting patient –> pt wear face mask and alert receiving department
airborne precautions
- private room required, negative air pressure
- hand hygiene prior to glove application and after glove removal
- don appropriate respirator - to be removed after exiting pt’s room
- visitors wear masks
- pt on isolation except for special tests or procedures
- if pt leaves room, needs to war a mask
- alert receiving department
