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Acute Care > Acute Care 3 > Flashcards

Acute Care 3 Flashcards

1
Q

WBC

A

Normal 5-10 x 10^9 /L

Trending upward:
Leukocytosis > 11 x 10^9/L
Bacteria infection, stress/trauma, allergy, smoking, pneumonia, neoplasm

Trending downward:
Leukopenia < 4 x 10^9/L
Bone marrow failure (aplastic anemia), radiation/chemo, HIV, viral disease

< 5 with fever : HOLD PT
> 5 light exercise, progress as tolerated

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2
Q

CPAP

A

Constant airway pressure
Spontaneous ventilation

Indications:
Mild/moderate sleep apnea
Cardiogenic APE
PO abdominal surgery

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3
Q

Droplet precautions

A

Transmission involves contact of conjunctiva or mucous membranes in nose or mouth w/ large-particle droplets

Influenza, meningitis, mumps, rubella, certain types of pneumonia

STD precautions + mask w/ or w/o face shield

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4
Q

Hospital- code silver

A

Active shooter

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5
Q

ICU PT indications

Goals to determine…

A

Goal to determine stability for ambulation, transfers, stairs, ADLs, assistive device needs, tolerance to activity, PLOF

D/C planning - asking Q (live alone, stairs, etc) - May ask family if pt on vent

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6
Q

ICU - PT indications

Getting pt movement prevents:

A

Prevents deconditioning
Reduces risk of atelectasis-> consolidation-> pneumonia
Reduces risk of bed sores and DVT

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7
Q

FiO2 of room/ambient air is __%

Each liter increase with supplemental O2 increases FiO2 by appx __%

Low flow FiO2 …
High flow FiO2….

Maximum of __% used for vents to avoid O2 toxicity

A

20.9% (78% nitrogen; 1% CO2)

Each liter of supplemental O2 increases FiO2 by ~ 4%

Low flow is approximation- varies with RR and TV
High flow is precise delivery, does NOT vary with RR and TV

Max 60%

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8
Q

Type III

Respiratory failure

A

Perioperative

Atelectasis
Often results in Type I or II

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9
Q

If MI diagnosed must wait for 2 consecutive downtrending values before initiating PT

A 
Cardiac troponin (cTn) 
Cardiac creatine kinase (CK-MB or CPK-MB)
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10
Q

PaO2

A

75-100 mmHg
Normal value changes with age

70-70 rule
After 70- each decade value decreases by 10

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11
Q

Neurological considerations
Red/Yellow/Green
Delirium

A

Delirium tool (CAM-ICU)….

(-) = green

(+) and able to follow simple commands-
Green: in-bed
Yellow: out-bed

(+) and unable to follow commands = yellow

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12
Q

Respiratory acidosis

A

Reduction in alveolar ventilation
Results in more CO2 in blood
Body compensates by producing more HCO3 (bicarbonate)

pH =< 7.35
PaCO2 => 45 mmHg

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13
Q

Alkalemia

A

pH > 7.45

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14
Q

Anesthesia- Effects by system

Respiratory

A

Hypoventilation
Decreased ventilation drive
Aspiration
PE

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15
Q

Hospital codes that can be initiated by therapy team

A

Code blue
Rapid response
Stroke alert

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16
Q

Na+

A

Regulates fluid volume and impt in nerve conduction

Normal 134-142 mEq/L

Hyponatremia: low Na+
< 130
Monitor vitals 2ndary to risk for orthostatic hypotension

Hypernatremia: common in elderly who don’t drink enough water
> 145
Seizure precautions for pt w/ past hy

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17
Q

Acute care exam - initiation

A

Always check w/ nurse about any new developments or info on the pt that may not have been in your chart review

Survey the room during introduction

Subjective info:
PLOF and work/school/activity- fall history
Caregiver support and availability
Home situation and barriers- stairs, where bedroom and full bathroom
Availability of AD
Pt/caregiver d/c plans (may not match w/ each other or yours)

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18
Q

Hypoglycemia s/s

A 
Clammy skin/Sweating 
Shaking
Delirium 
Vision changes 
HA
Tachycardia
Weakness 
Lightheaded 
LOC 
Seizures
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19
Q

Neurological considerations
Red/Yellow/Green
Spinal precautions (pre-clearance or fixation)

A

Red

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20
Q

A disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time

A

Delirium

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21
Q

IABP- considerations and safety measures

A

Limit shoulder flexion on side of IABP placement to 90* or level of comfort (<90*)

Leveling the arterial line connected to IABP when ambulating

Ensure that the PT has training to leave ICU with patient

Never take patient to area where there are no outlets if battery starts to die (check battery frequently)

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22
Q

If you pull out a line…

A

Apply pressure
Have patient sit
Call nurse

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23
Q

Home with referral to outpatient therapy

A

Can the pt drive?
What kind of assistance still needed?
Often, a significant gap exists between hospital d/c and start of care in OP- HEP/education critical!

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24
Q

Rapid response

A

Goal: intervene before onset of injury, respiratory arrest or cardiac arrest

HR > 140 or HR < 40 
RR > 28   or RR < 8
Systolic BP > 180 or < 90 
Urine output < 50 cc over 4 hours
Staff, family or visitor has significant concern about pt condition
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25
Q

Respiratory parameters-
Red/Yellow/Green
Percutaneous Oxygen Saturation

A

=> 90% green

< 90% yellow: in-bed /red: out-bed

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26
Q

Hct

A

Hematocrit- % by volume RBC

Trending downward (anemia)
Low critical value (<15-20%) Cardiac failure or death
< 25% symptom based approach
< 25% HOLD PT- essential daily activity only
< 25-35 PT permitted- ambulation and stairs, light aerobics, light weights (1-2 lbs)
> 35% resistance and moderate aerobic exercise

Trending upward (polycythemia) 
High critical value (>60%) spontaneous blood clotting 
heart defects, severe dehydration, hypoxia, smoking
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27
Q

CPAP

A

Continuous positive airway pressure

Weaning mode
Completely spontaneous
Positive pressure maintained to prevent alveolar collapse

Usually 5-7 cmH2O

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28
Q

Cardiovascular considerations
Red/Yellow/Green
Stable tachyarrhythmia

A

Ventricular rate > 150 bpm
Yellow: in-bed
Red : out-bed

Ventricular Rate 120-150 bpm
Yellow

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29
Q

Chest tube- air bubbles in tank

A

Stop treatment and notify nurse

Bubbles = air leak

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30
Q

Inspiratory muscle training is contraindicated during ___.

At this juncture resting the respiratory muscles indicated.

A

Acute respiratory failure

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31
Q

B of SBAR

A

Background

Pt reason for and date of admit
Significant medical hy
Impt meds

(Admit 5/20/19 w/ chest pain and decreased mobility)

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32
Q

Respiratory acidosis
pH?
PaCO2?
HCO3-?

A

pH decrease < 7.35
PaCO2 increase > 45
HCO3- normal

Increased H+ due to excessive CO2 and decreased alveolar ventilation

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33
Q

Anesthesia- Regional

A

Pt is awake, usually given additional drugs to decrease awareness
Ex: spinals or epidurals

Epidurals fall into “local” category- lidocaine

Often delivered in combo with opioids/narcotics (such as fental) to decrease required dose of local anesthetic

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34
Q

Effects of general anesthesia

A 
Side effects:
Nausea 
Vomiting
Sore throat
Confusion 
Muscle aches 
Itching
Hypothermia

Serious complications:
Delirium, Cognitive dysfunction, Malignant hyperthermia

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35
Q

Orthostatic intolerance

A

Hypotension associated with a change in position, typically when moving supine to stand

Symptoms may include: dizziness, change in mentation, postural instability, and possibly loss of consciousness

Causes: depletion of blood volume; impairment of baroreflex-mediated vasoconstriction

Early mobility will reduce the risk of it
PT may be 1st to identify it- alert med team

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36
Q

Ca2+ levels tending down

What expect?

A

Confusion
Seizure
Fatigue

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37
Q

Considerations and safety measures when mobilizing on ECMO

A

Ambulatory/mobility team (PT, RT, RN, ECMO clinician, cardiologist m, surgeon, and any extra hands)

Cannulation sites
Equipment
Unexpected outcomes
Center specific protocols

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38
Q

Other considerations
Red/Yellow/Green
Patient febrile with temp exceeding acceptable max despite active physical or pharmacological cooling mgmt

A

Yellow

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39
Q

Hyperchloremia

A

Causes: dehydration, kidney disease

S/S: can cause metabolic acidosis

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40
Q

CMV : Controlled mandatory ventilation

A

Ventilator has total control of FiO2, tidal volume, flow rate

Patients likely sedated/pharmacologically paralyzed

No respiratory effort by pt

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41
Q

Doppler MAP

A

Due to pump being continuous not pulsatile
Difficult to get accurate pulse or cuff BP

MAPs should be between 60-80 mmHg

When taking MAP with Doppler you hear 1 sound that is the MAP (mean arterial pressure)

(LVAD)

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42
Q

Hypermagnesemia

A

Typically renal insufficiency
Normally kidneys excrete large amounts

> 2 mmol/L vasodilation and NM blockade
4 mmol/L nausea, lethargy, weakness, respiratory failure, paralysis, coma, hypoactive tendon reflex

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43
Q

DIC

A

Disseminated intravascular coagulopathy

Overactive proteins/clotting factors

Causes: severe trauma, liver failure, transfusion failure, sepsis, venom poisoning, cancer

Small clots form - can block vessels supplying organs, leading to failure
Also clotting factors get “used up” and can have serious uncontrolled bleed

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44
Q

MIP

A

Maximum inspiratory pressure

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45
Q

Hyperglycemia s/s

A

Frequent urination
Increased thirst
Severe fatigue

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46
Q

Respiratory alkalosis
pH?
PaCO2?
HCO3-?

A

pH increases > 7.45
PaCO2 decreases < 35 mmHg
HCO3- normal

Decreased H+ due to decrease CO2 when too much blown off

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47
Q

Step down units that bridge between ICU and general

Patient to nurse ratio between ICU and general care

A

Transitional units

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48
Q

SIMV : Synchronous intermittent mandatory ventilation

A

Rate and tidal volume set by RRT
Ventilator assists pt w/ breath of needed
Pt can breathe spontaneously on own between ventilator breaths

Used as a weaning mode
SIMV 2 = pt almost breathing independently
SIMV 15 = mostly relying on ventilator

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49
Q

Low flow O2 delivery-

Simple face mask

A

35-55% FiO2 at 5-10 min/flow
Easily portable w/ portable O2
Makes talking/eating difficult

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50
Q

Respiratory alkalosis

A

Elevation in alveolar ventilation
Results in less CO2 in blood
Body compensates by producing less HCO3 (bicarbonate)

pH => 7.45
PaCO2 =< 35 mmHg

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51
Q

Cardiovascular considerations
Red/Yellow/Green
Bradycardia

A

Red : if requires pharmacological treatment OR awaiting emergency pacemaker insertion

Yellow : not requiring pharmacological treatment and Not awaiting emergency pacemaker insertion

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52
Q

ICU delirium and mortality

A

Independent predictor of higher 6-month mortality and longer hospital stay

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53
Q

Hypokalemia

A

Trending downward < 3.5 mEq/Lm

Causes: NG suctioning, diuretics, diarrhea, Cushing’s

S/S: flattened T-wave, arrhythmias, clammy skin, muscle tetany, weakness, abdominal distention, respiratory failure

<2.5 collaborate with inter professional team on proceeding

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54
Q

Possible discharge dispositions

A

Home with no further therapy needed

Home with home health PT

Home with referral to outpatient therapy

Post-acute facility placement
(IRF, SNF, LTAC, nursing home/LTCF)

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55
Q

Wells DVT score

A

> 2.0 : High probability
1.0-2.0 : moderate probability
< 2.0 : low probability

1 point each:

  1. Active cancer
  2. Calf swelling >=3 cm (10 cm below tibial tuberosity)
  3. Swollen unilateral superficial veins
  4. Unilateral pitting edema
  5. Previous DVT
  6. Swollen leg
  7. Tenderness along deep venous system
  8. Paralysis, paresis, or immobilization of LE
  9. Bedridden >=3 days; major surgery 12 weeks
    - 2 points for : alternative diagnosis at least as likely
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56
Q

DNR

A

Usually only applicable to hospital
Usually has s colored bracelet to identify
No CPR etc - don’t initiate code blue

Some new terminology proposed to avoid confusion:
AND- allow natural death
AND-I allows specified interventions that can be performed

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57
Q

Chest tube

A

Reservoir must be kept lower than insertion site

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58
Q

Respiratory parameters-
Red/Yellow/Green
Respiratory Rate

A

=< 30 bpm: green

> 30 bpm: yellow

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59
Q

PPN- partial parenteral nutrition

A

Peripheral veins

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60
Q

Neurological considerations
Red/Yellow/Green
Vasospasm post-aneurysmal clipping

A

Green- in-bed

Yellow: out-bed

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61
Q

4 lab values indicating pt not ready for PT

A
  1. Hematocrit <25%
  2. Hemoglobin <8 g/dL
  3. Platelets <20,000/mm^3
  4. Anticoagulation INR >=2.5-3.0
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62
Q

Anesthesia- Effects by system

Psychomotor function

A

Time to regain consciousness
Delirium
Personality changes
Memory loss

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63
Q

HbA1C

A

Glycated hemoglobin

Based on attachment of glucose to HgB within RBC

RBC lives ~3 months- so A1C reflects average blood glucose levels over past 3 months

Normal <5.7%
Pre-diabetic 5.6-6.4%
Diabetic > 6.5%
Well controlled DM is at least 7%

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64
Q

Increased H+ due to excessive CO2 and decreased alveolar ventilation

A

Respiratory acidosis

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65
Q

Anesthesia- general

A

Propofol is one of most commonly used

Pt unconscious with no awareness and no sensation

Majority of effects gone within 24 hours, however complete resolution can take week(s)

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66
Q

Other considerations
Red/Yellow/Green
Femoral sheaths

A

Yellow: in-bed
Red: out-bed

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67
Q

Hospital- code pink

A

Abducted child/baby

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68
Q

Mechanical ventilation
Terms
PEEP

A

Positive end-expiratory pressure

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69
Q

Metabolic acidosis
pH?
PaCO2?
HCO3-?

A

pH decreases < 7.35
PaCO2 normal
HCO3- decreases < 22

Increased H+ due to a drop in HCO3-

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70
Q

Cardiovascular considerations
Red/Yellow/Green
IV antihypertensive therapy for hypertensive emergency

A

Red

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71
Q

Neurological considerations
Red/Yellow/Green
Level of consciousness

A

Drowsy, calm or restless (RASS -1 to +1) = green

Lightly sedated or agitated (RASS -/+ 2) = yellow

Unrousable or deeply sedated (RASS < -2)
Yellow: in-bed
Red: out-bed

Very agitated or combative (RASS >+2) = red

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72
Q

Hospital- code gray

A

Severe weather

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73
Q

Mg2+

A

Magnesium

Crucial for normal NM activity
Normal 0.7-1.0 mmol/L

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74
Q

ICUAW: ICU-acquired weakness

A

Muscle weakness that develops during ICU stay
Other items include critical illness myopathy/polyneuropathy

33% of all pt on ventilators
50% of all pt admitted w/ severe infection (sepsis)
Up to 50% of pt who stay in ICU for at least 1 week

May take more than a year to fully recover, making ADLs difficult and increasing burden of care

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75
Q

Anesthesia- Effects by system

Cardiovascular

A 
Hypotension 
Hypertension 
Dysarrhyrhmia 
Increased risk for MI
DVT
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76
Q

pH

A
  1. 4

7. 35-7.45

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77
Q

Main components of EMCO circuit

A

Tubing
Blood pump
Gas exchange
Heat exchange

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78
Q

Oxygen toxicity

A

Occurs when partial pressure of alveolar O2 remains elevated above normal levels prolonged periods of time (> 24 hours)

Supraphysiologic concentration of O2 can cause a state of hyperoxia
Development of reactive O2 species (ROS) - damaging cells/tissues; inflammation w/ diffuse alveolar damage
Absorption atelectasis

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79
Q

Highest patient to nurse ratio

A

General care (Acute)

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80
Q

PT- prothrombin time

A

Time it take plasma to clot
Normal range 11-12.15 sec

1-2x normal = therapeutic
2-3x normal = “risk of bleeding”

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81
Q

Nasogastric rube

A

Drain
Feeding tube

Head at 45* or greater to prevent aspiration

(Ask nurse if can be turned off during intervention)

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82
Q

Hyperkalemia

A

Trending upward > 5.5 mEq/L

> 5 pt at risk for cardiac issues
Might exhibit muscle weakness

Causes: severe cell destruction, redistributes K+ from ICF->ECF

S/S: flaccid paralysis m, peaked T-waves, shortened Q-T wave intervals

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83
Q

Arterial blood gases

A

Measure acidity and levels of oxygen, CO2, and bicarbonate within blood

Qualifies magnitude of gas exchange abnormalities

Identify type of respiratory failure

pH 7.35-7.45
PaO2 75-100
PaCO2 35-45
HCO3- 22-26

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84
Q

Glucose

A

Normal 70-100 mg/dL for non-diabetics
Glucose target 140-180 for most pt in non critical care while hospitalized

Hypoglycemia <70 mg/dL
Hyperglycemia > 200 mg/dL

Failure to correct hyperglycemia (> 240) can result in life threatening ketoacidosis

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85
Q

Low flow O2 delivery-

Non-rebreather

A

80-90% FiO2 10-15L/min

Works similar to partial rebreather- but one-way valve that exhalation onto bag- resulting in higher concentration in bag

Only used in seriously ill pts, and possibly during exercise in pt with ESLD

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86
Q

Hospital- code red

A

Fire

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87
Q

Safety in acute care - establish appropriateness of care

A
  • verify order and precautions
  • chart review to determine preliminary precaution list and plan
  • VITALS
  • key discussion w/ other providers - esp nursing and MD
  • anticipate difficulties/challenges in patient mobility/status, and plan accordingly

Assemble require assistance and items
Two patient identifiers (name and DOB)

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88
Q

Other considerations
Red/Yellow/Green
Suspicion of active bleeding or increased bleeding risk

A

Green: in-bed
Yellow: out-bed

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89
Q

Hospital- code black

A

External emergency

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90
Q

Low flow O2 delivery-

Partial-rebreather

A

40-60%FiO2 10-15L/min flow
Reservoir attached to mask

Air entering bag from trachea and primary bronchi, where no gas exchange occurs
Pt rebreathes O2 “just expired”

Easily mobile

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91
Q

Other considerations
Red/Yellow/Green
Active hypothermia management

A

Yellow

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92
Q

RASS

A

Richmond agitation-sedation scale

Response to verbal and physical stimuli

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93
Q

Post-op activities/exercise should…

A

Promote confidence in you
Don’t hurt
Give pt some control
Promote upright posture

Consider the incision
Avoid stretching/stressing incision
Avoid unilateral stress especially with abdominal and thoracic incisions

Offer incentives- ice chips, warm blanket, etc

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94
Q

Creatinine

A

Waste product of muscle metabolism of creatine

Usually relatively constant and related to muscle mass

Filtered but not reabsorbed by kidneys

Elevation can indicate kidney issues, dehydration or rhabdo

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95
Q

Code blue vs Rapid response

A

Code blue = resuscitation goal

Rapid response = goal is prevention of decline

96
Q

ABCDEF Bundle

A

A- assess, prevent and manage pain

B- both SAT and SBT (breathing)

C- choice of analgesia and sedation

D- delirium: assess, present and manage

E- early mobility and exercise

F- family engagement and empowerment

97
Q

Acidemia

98
Q

Mechanical ventilation
Settings
Ventilator rate

A

Breaths/minute

Set at lowest rate to keep PaCO2 between 35-45 mmHg

99
Q

Acute care exam - tests and measures

A

VITALS - before, multiple times during if need, after activity
Pain is part of vital assessment

As Applicable:
Cognition, speech/language ability, general appearance, CVP, MSK (functional mobility if unable to assess via traditional), Neuro (screen vs full exam), integumentary, pain, functional mobility, std measures

100
Q

Delirium in the ICU

A

Up to 80% of mechanically ventilated ICU patients

3 types:

  1. Hyperactive (ICU psychosis)
  2. Hypoactive
  3. Mixed
101
Q

Home with no further therapy needed

A

Pt may not even need therapy in the hospital or have no other needs after initial treatments

102
Q

BUN

A

Blood urea nitrate

Increases: kidney disease/dysfunction, excessive protein intake, excessive tissue destruction, HF, dehydration, shock, GI bleeds

Decreases: low-protein diet, muscle wasting, starvation, liver failure, cirrhosis, high urine flow

103
Q

Mechanical ventilation
Settings
FiO2

A

Fraction of inspired oxygen
Lowest value to meet satisfactory O2

(75-100)

104
Q

VIDD: ventilator-induced diaphragmatic dysfunction

A

Prolonged controlled mechanical ventilation (CMV) results in a rapid diaphragmatic atrophy

In as few as 12-18 hrs of CMV, significant fiber atrophy in both slow and fast muscle fibers of diaphragm
Occurs before skeletal muscle atrophy
CMV-induced atrophy exceeds rate reported for diaphragm after denervation

Diaphragm recovery- returns to near normal levels w/in 24 hrs after return to spontaneous breathing

105
Q

Balance and falls
Functional measures
Acute care

A

TUG
Berg
Forward reach
Single limb support

106
Q

Mechanical ventilation
Settings
Tidal volume

A

Usually set 400-1200 cc

Dependent on body mass

107
Q

Long-term Acute Carr hospital

A

Pts with multiple co-morbidities who need a long stay of hospital care

Still need daily medical management by a physician
Average LOS > 25 days

Provide: ventilator weaning, IV antibotics, dialysis, rehab services, wound care services

108
Q

Cardiovascular considerations
Red/Yellow/Green
Transvenous or epicardial pacemaker

A

Dependent rhythm:
Yellow: in-bed
Red: out-bed

Stable underlying rhythm = green (both: in and out bed)

109
Q

Anesthesia- conscious sedation

A

Midazolam and propofol are most commonly used sedatives
Fentanyl most frequent analgesic

Help relax and block pain while pt remains awake but unable to speak and won’t remember much about procedure

Colonoscopy, breast biopsy, Minor surgical procedures

110
Q

Standard precautions- infection control

A

Treat all pt as if they are infectious

Wash hands before and after, new gloves- every pt

PPE if contact w/ bodily fluids possible

Respiratory hygiene and cough etiquette

Aseptic technique

111
Q

HCO3-

A

Bicarbonate

Critical in maintaining acid-base balance
Mediated by kidneys

112
Q

Inpatient rehab facility criteria

A

Pt who needs intensive rehab services
Must be able to tolerate 3 hours therapy 5-7 days/week (includes PT, OT, ST- must have AT LEAST 2 disciplines on board)

Length of stay determined by diag - typically 10-12 days

Rehab is main focus, medically stable
No qualifying length of stay required in acute care hospital- patients can be referred from home or ED

“60% rule” for Medicare pts

113
Q

HgB

A

Hemoglobin - Indicator of severity of anemia or polycythemia

Trending downward (anemia):
Low critical (<5-7) can lead to HF or death
< 8 = essential daily activity only- HOLD PT
> 8 : ambulation permitted
8-10 :stairs,light aerobics,light weights(1-2 lbs)
> 10 : resistive exercise permitted

Trending upward (polycythemia):
COPD, altitude 
High critical (>20) can lead to clogged capillaries
114
Q

5 cardiovascular measures indicating lack of readiness for PT

A
  1. MAP <65 or >120 mmHg
    OR >=10 mmHg lower than normal SBP or DBP for pt receiving renal dialysis
  2. RHR <50 or >140 bpm
  3. SBP <90 or >200 mmHg
  4. New arrhythmia
  5. New onset angina-Type chest pain
115
Q

PVC limit of ___ to stop exercise and have patient sit, if worsens ____. If patient rhythm deteriorated into arrhythmia _____.

A

PVC limit of 6

If worsens return to bed

If arrhythmia return to room

116
Q

Other considerations
Red/Yellow/Green
Uncontrolled active bleeding

117
Q

Type II

Respiratory failure

A

Failure to exchange or remove CO2

Hypoxia with hypercapnea

Low PaO2 (< 55 mmHg) 
High PCO2 (>45 mmHg) 
Low pH (< 7.3)
118
Q

Central line - possible locations

A

Central central line:
Subclavian
Internal jugular
External jugular

Peripheral central line:
Basilic
Cephalic
Femoral

119
Q

Cardiovascular considerations
Red/Yellow/Green
Known/Suspected pulmonary hypertension

120
Q

Weaning criteria

A

Mode: spontaneously breathing w/ natural RR (<25 breaths/min)

PaCO2: 35-44 mmHg
FiO2: less than 40-50% w/ a PaO2 > 60 mmHg
PEEP: < 5-7 cmH2O
MIP at least -20 cmH2O

121
Q

Neurological considerations
Red/Yellow/Green
Uncontrolled seizures

122
Q

SaO2

A

88% or greater when measured with ABG

Is SpO2 when measured by pulse oximeter

123
Q

Anesthesia- local/peripheral

A

Injected into tissue to temporarily numb

124
Q

PICS: post-intensive care syndrome

Cognitive dysfunction

A

Problems connecting w/ remembering, paying attention, solving problems, and organizing and working on complex tasks

30-80% ICU pts
In some cases this may be permanent

May affect when pt can return to work, balance a checkbook, or perform other tasks that involve organization and concentration

125
Q

Decreased H+ due to decreased CO2 when too much blown off

A

Respiratory alkalosis

126
Q

aPTT

A

Time for blood to clot
Normal range 30-40 sec

Values 1-2x normal- May need to hold exercise due to risk of bleeding

127
Q

Neurological considerations
Red/Yellow/Green
Acute spinal cord injury

A

Green: in-bed
Yellow: out-bed

128
Q

Pulmonary artery pressure monitors

A

AKA Swan-Ganz catheter

Inserts directly into pulmonary artery at R side of heart

Measures arterial pressure, normal = 8-20 mmHg at rest
If > 25 mmHg at rest or >30 with physical activity…pulmonary HTN

Check with nursing prior to mobilization

129
Q

4 possible effects of anesthesia

A

General
Regional
Local/Peripheral
Conscious sedation

130
Q

Lowest patient to nurse ratio

A

Intensive care

May be general ICU or specialty (trauma, cardio, neuro, pediatric etc)

131
Q

Ca2+

A

Normal 8.5-10.5 mg/dL

Hypocalcemia: most often impaired PTH (parathyroid hormone)

Hypercalcemia: excessive PTH production, hyperthyroidism and malignancy

Severe > 12-13: lethargy, stupor, coma, bradycardia, AV block, shorter QT interval

132
Q

4 pulmonary measures indicating lack of readiness for PT

A
  1. SaO2 < 88%
    OR pt experiences a 10% oxygen desaturation below resting SaO2
  2. RR > 35 breaths per minute
  3. PEEP > 10 cmH2O
  4. FiO2 >= 0.6
133
Q

PICS: post-intensive care syndrome

A

Collection of Heath problems that remain after critical illness- can involve body, thoughts, feelings, or mind and may affect the family

ICU-acquired weakness
Cognitive or brain dysfunction
Other mental health problems

134
Q

Cardiovascular considerations
Red/Yellow/Green
Known/Suspected severe aortic stenosis

A

Green: in-bed
Yellow: out-bed

135
Q

Cardiovascular considerations
Red/Yellow/Green
MAP

A

Below target range- causing symptoms or despite support
Yellow: in-bed
Red : out-bed

Below target range - no/low support
Green (both)

Greater than lower limit w/ moderate support-
Yellow (both)

Greater than lower limit w/ high support-
Yellow: in-bed
Red: out-bed

136
Q

Ketoacidosis

A

Hyperglycemia >240 mg/dL uncorrected

Can be life threatening

S/S: SOB, nausea, vomiting, dry mouth, fruity breath

137
Q

Exercise considerations and glucose

A

Can be too low or too high

<70 give pt carb snack before exercise

> 250 EXERCISE typically CONTRAINDICATED

Exercise can make hyperglycemia worse

138
Q

IABP

Placed?
Indications?

A

Intra-Aortic balloon pump

Typically placed in femoral artery- requires bed rest and significant risk for lower extremity ischemia

Indications:
Refractory angina pectoris
Post-cardiopulmonary bypass shock
Temporizing complications of Percutaneous coronary intervention
Complications of MI refractory to pharmacologic therapy

139
Q

ACV : Assist control ventilation

A

Rate and tidal volume set by RRT
Pt controls respiratory rate but ventilator assists every breath
Once pt initiated breath, preset volume or pressure flow rate is delivered by ventilator

Can be set so machine will initiate breath if pt initiated respiratory rate is too low to meet rate set by therapist

Machine does 90-100% of work
Risk of hyperventilation and barotrauma

140
Q

High flow O2 delivery-

Transtrachael catheters “Trach mask”

A

May reduce work of breathing and augment CO2 removal

Pts who have been extubated and taken off ventilators May benefit from an interim of this to ensure weaning success

141
Q

CAM-ICU

A

Confusion assessment method for the ICU

Good for screening/detecting delirium in critically ill pts

142
Q

Respiratory parameters-
Red/Yellow/Green
Rescue therapies- prostacyclin

143
Q

TPN- total patenteral nutrition

A

Central line- vena cava

Bypasses GI tract

144
Q

Femoral IABP need to avoid…

A

Avoid flexion >30* at hip

They can walk - the challenge is getting them up with this restriction

Can get up with catalyst bed or tilt table

145
Q

Cardiovascular considerations
Red/Yellow/Green
ECMO

A

Femoral or Subclavian:
Green: in-bed
Red: out-bed

Single bicaval dual lumen inserted into central vein:
Green: in-bed
Yellow: out-bed

146
Q

Respiratory parameters-
Red/Yellow/Green
PEEP

A

=< 10 cmH2O: green
> 10 : yellow

Ventilator dysynchrony : yellow

147
Q

PPC

A

Post-op Pulmonary complications

Age > 60
Decreased mobility 
Malnourished 
Past respiratory ds 
Prolonged procedure 
Expected intubation
148
Q

Metabolic alkalosis
pH?
PaCO2?
HCO3-?

A

pH increases > 7.45
PaCO2 normal
HCO3- increases > 26

Decreased H+ due to increased renal absorption of HCO3-

149
Q

Low flow O2 delivery -

Nasal canula

A 
Nasal canula: 
Easily portable 
Only 22-44% FiO2 
Don’t use > 6 L
Can dry nasal passages; often humidified when > 3 L
150
Q

Neurological considerations
Red/Yellow/Green
Craniectomy

A

Green: in-bed
Yellow: out-bed

151
Q

Risk factors for HAI (healthcare associated infections)

A 
Age 
Immunodeficiency 
Immunosuppression 
Misuse of antibiotics 
Use of invasive diagnostic or therapeutic procedures 
Agitation 
Surgery 
Burns 
Length of hospitalization
152
Q

BiPAP

A

Two pressure levels:
IPAP
EPAP

Indications:
Acute hypercapnea- respiratory muscle rest;
Cardiogenic APE;
Immunosuppressed pt w/infection

153
Q

Ventricular assistive devices

A

Mechanical device that augments pumping capability of heart providing circulatory support necessary to sustain life
Most commonly used = LVAD
But can be for R, L or both

154
Q

Indications for VA ECMO

A

Cardiogenic shock with inability to oxygenate, due to…
Acute MI, Cardiac arrest, decompensated HF, post-partum cardiomyopathy

Post-cardiotomy shock

Bridge to durable VAD/TAH support or transplant

Absence of non-reversible organ failure

155
Q

Types of ECMO support

A

Veno-arterial (VA) ECMO-
Blood removed from vein, circulated through pump and artificial lung, and returned to artery
Supports heart and lungs

Veno-venous (VV) ECMO-
Blood removed from vein, circulated through pump and artificial lung, and returned to vein
Supports lungs only

156
Q

Respiratory parameters-
Red/Yellow/Green
Rescue therapies: Nitric Oxide

157
Q

Hand hygiene

A

Wet hands -> soap -> front/back/under nails ***scrub at least 20 sec (“Happy birthday song” twice) -> rinse -> dry and turn off water with towel

Alcohol based sanitizer at least 60% alcohol
If soap/water unavailable
Isn’t as effective

“Foam in, Foam out” - be visible using it.

158
Q

How to choose functional measures in acute care

A

Applicable to pt
Practical for use in acute care (time, cost, feasibility)
Assistance w/ d/c planning and pt safety
Acceptability of test to the individual (tolerance for test, positioning)
Appropriateness of test for application to the pathology or health condition, body function or status, activity or participation

159
Q

BUN:Creatinine ratio

A

Used to determine cause of acute kidney injury or dehydration

Normal ratio 10:1

10-20:1 = likely kidney dysfunction
> 20:1 = likely due to dehydration

160
Q

ICU delirium and cost

A

Higher severity and duration were associated with incrementally greater costs

29% higher ICU costs
31% higher hospital costs

Efforts to prevent or treat ICU delirium have potential to improve pt outcomes and reduce cost of care

161
Q

DNI

A

Do not intubate

Resulted from separating wishes of no CPR from no mechanical ventilation (MV)

162
Q

PICS: post-intensive care syndrome

Other mental health problems

A 
Critically ill pt may develop:
Problems falling asleep/staying asleep 
Nightmares or unwanted memories 
Anxiety/Depression 
Can be similar to PTSD

May benefit from psychotherapy and/or psychiatry following ICU discharge
Speech therapy can also assist with strategies to deal with impaired memory and attention

163
Q

Assisted living facility -

Discharge disposition requirements

A

Pt who need housing, support services, and health care

Services/Amenities (facility dependent):
3 meals/day in common dining area
Housekeeping, laundry, transportation, assistance with ADLs, medication assistance, rehab services (HH vs OP)

NOT to be confused with senior independent living apartment communities
Often hour ALFs
Some offer continuum of care

164
Q

Indications for VV EMCO

A

Potential reversible lung insult

Condition consistent with ARDS

Mechanical ventilation <7 days

Profound hypoxemia or hypercapnea

Bridge to lung transplant

Absence of non-reversible organ failure

165
Q

Metabolic measure indicating patient not ready for PT

A

Glucose <70 or >=200 mg/dL

166
Q

Cardiovascular considerations
Red/Yellow/Green
Cardiac ischemia

A

Yellow: in-bed
Red: out-bed

167
Q

Skilled nursing facility criteria

A

Pt who needs daily skilled care under direction of skilled nursing or rehab staff for a hospital related medical condition
Rehab services, nursing services (IV injections etc), Activities

Billed under Part A Medicare for those 65+
Otherwise private insurance

Requires 3 midnight stay I acute care hospital (Medicare)
Length of stay: up to 100 days

Can be within a longterm facility or a free standing facility (often combo with inpatient rehab services)

168
Q

PaCO2

A

35-45 mmHg

169
Q

BMP

A

Basic metabolic panel

Na+, Cl-, K+, HCO3-, BUN, creatinine, glucose

170
Q

Cardiovascular considerations
Red/Yellow/Green
Known/Suspected DVT/PE

171
Q

Ambulation with femoral IABP

A

Using catalyst bed or tilt table to get them up because can’t hip flex >30*

172
Q

PT and the post-op patient

These items should be addressed with every visit.

A

Assess cough- teach splinted breathing; teach airway clearance

Teach diaphragmatic breathing

Teach incentive spirometry

Teach frequent position changes

And education on all the above

173
Q

Cl-

A

Works w/ Na+, K+ and bicarbonate to regulate acid-base balance

Hyperchloremia - can cause metabolic acidosis

Hypochloremia- rarely occurs in isolation; can cause metabolic alkalosis
Monitor level of consciousness and motor function

174
Q

Code blue

A

Goal: perform resuscitation efforts after a person has stopped breathing or after heart stopped beating

Initiated by anyone with CPR certification or can verify person stopped breathing or has no pulse - or unresponsive and unable to determine if pulse/breathing

Can also initiate if unsure what to do and have dire concern for life of person

175
Q

Neurological considerations
Red/Yellow/Green
Subarachnoid hemorrhage with unclipped aneurysm

A

Green: in-bed
Yellow: out-bed

176
Q

Cardiovascular considerations
Red/Yellow/Green
Femoral IABP

A

Green : in-bed

Red: out-bed

177
Q

Cardiovascular considerations
Red/Yellow/Green
Pulmonary artery catheter or other continuous cardiac output monitoring device

A

Green: in-bed
Yellow: out-bed

178
Q

High flow O2 delivery -

Venturi mask

A

Mixes O2 with room air

Accurate constant FiO2
Typically: 24, 28, 31, 35 and 40% oxygen

Often used when concern about CO2 retention

179
Q

Ventricular assist device

A

Can support either R, L, or both

180
Q

Contact precautions

A

MRSA
Shingles
VRE
C-diff

STD precautions +
Gown and gloves req’d

In the case of c-diff, MUST use soap and water bc alcohol does NOT kill the bacteria

181
Q

PCA pump

A

Pt controlled analgesic

182
Q

Hypernatremia s/s

A

Swelling, increased thirst, lack of urination, cramps/spasms, weakness

Seizure precautions for patient with past hy

183
Q

A of SBAR

A

Assessment

Medical assessment findings/concerns

Ex: MI
PT: slow progress, only to toilet and back

184
Q

Home health homebound criteria

A

1: the patient MUST EITHER:
- bc of illness/injury, need aid of supportive devices (AD); special transportation; or assistance of another person in order to leave their place of residence
OR
- have a condition such that leaving his/her home is medically contraindicated

AND
2: A normal inability to leave home AND leaving home must require a considerable and taxing effort

185
Q

BNP

Levels indicate…

A

< 100 pg/mL NO HF
100-300 HF present
> 300-600 mild HF
> 600 moderate to severe HF

186
Q

Other considerations
Red/Yellow/Green
Large open surgical wound (chest/sternum, abdomen)

A

Green: in-bed
Red: out/bed

187
Q

Type I

Respiratory failure

A

Hypoxemic

Failure of oxygen exchange
Hypoxia without hypercapnea

Low PaO2 (< 55 mmHg) 
Normal PCO2 (35-45 mmHg)
188
Q

What does an IABP do?

A

Increases myocardial oxygen perfusion while increasing CO

Increasing CO therefore increases coronary blood flow which increases myocardial oxygen delivery

Balloon sits in aorta:
Deflates during systole- increases forward blood flow by decreasing afterload
Inflates during diastole- increases blood flow to coronary arteries via retrograde flow

189
Q

Coagulability tests

A

PT- prothrombin time
aPTT- activates partial thromboplastin time (heparin)”/lovenox)
INR - international normalized ratio (warfarin/Coumadin)

190
Q

Home with home health PT

A

“Home bound” status
Does pt need supervision or assistance?
Pt’s own home, family/caregiver home, assisted-living facility?

191
Q

SBAR

A

Situation
Background
Assessment
Recommendations

Situational briefing guide for staff and provider communication
Re: pt status or needs for non-emergent events, related issues, events in unit, lab or within health team

Does NOT become part of medical record- is to communicate to other providers with same pt

192
Q

External ventricular drain (EVD)

A

Monitors and alleviates swelling and increased pressures in the ventricles of the brain

Must keep head at 30* when drain is open

Always check with nursing before working with these pt

Common dx: CVA, TBI, Hydrocephalus

193
Q

R of SBAR

A

Recommendation

Suggestion for treatment
Referral to social work for revision of care; est d/c date

Ex:
OT referral
Contact SW for d/c dispo, social concerns
EDD 5/25/19

194
Q

PLT

A

Platelets
Normal 140-400 k/uL

Trending upward:
Thrombocytosis: >450 ;iron deficiency, cancer, infection and inflammation
Elevated levels can lead to venous thromboembolism

Trending downward:
Thrombocytopenia <150 ; liver disease, aplastic anemia, viral infection, radiation/chemo
Fall risk awareness (risk of spontaneous hemorrhage)

< 100 and/or temp >100.5 = HOLD PT
100-200 : PT permitted, exercise/bike w/o resistance
> 200 : Therapeutic exercise/bike with or without resistance

195
Q

1-to-1 supervision

A

Medical, mental health or behavioral conditions necessitate 1-on-1 care

Can be situational- like during meals bc aspiration precaution
Danger to self or others
Extreme fall risk
Delirium, extreme confusion

NEVER leave pt alone

196
Q

INR

A

International normalized ratio

INR > 3 : risk for bleeding

INR < 4 : PT indicated; light exercise, hold progressions until INR at therapeutic levels
INR > 5 : HOLD exercise- can perform PT eval in room
INR > 6: PT CONTRAINDICATED, 2 days bed rest likely, possible transfers OOB to chair only

197
Q

Stroke alert

A

Timely CT scan
Neuro eval
Determining need to admin tPA and/or surgical interventions

Call if pt exhibits signs of acute stroke (FAST)
F- face : look for uneven smile 
A- arm: check if 1 arm weak
S- speech: slurred?
T- time: 911/call code right away
198
Q

Advanced directives

A

Specify decisions about end-of-life care

Living will- outlines what treatment wants in event I life threatening conditions and/or inability to express those desires themself- May also contain info regarding organ/tissue donation

Durable power of attorney for health care- names a trusted health care proxy to make decisions when pt unable

199
Q

Cardiovascular considerations
Red/Yellow/Green
Tachyarrythmia with ventricular rate < 120 bpm

200
Q

LVAD

A

Implanted in patients with end stage heart failure

Bridge to recovery, transplantation, or for patients not eligible for transplant

Can aid to restore adequate CO and help recovery from 2ndary organ dysfunction

201
Q

Cardiovascular considerations
Red/Yellow/Green
Shock of any cause with lactate >4 mmol/L

202
Q

Decreased H+ due to increased renal absorption of HCO3-

A

Metabolic alkalosis

203
Q

Hypochloremia

A

Causes: NG suction, diarrhea, cystic fibrosis vomiting

Usually occurs with metabolic alkalosis

Rarely occurs in isolation

204
Q

Contraindications for mobilization

ICU/Acute

A
  1. Significant doses of vasoactives for hemodynamic stability (maintain MAP > 60)
  2. Mechanically ventilated and require FiO2 80% and/or PEEP > 12, OR have acutely worsening respiratory failure
  3. Maintained on NM paralytics
  4. Neurologic instability or acute event (< 24 hrs)
  5. Unresponsive/Unable to reduce sedation
  6. Unstable spine or extremity fractures
  7. Transitioning to comfort care
  8. Rigid femoral catheters
  9. Open abdomen, at risk for dehiscence
  10. Recent autograft or flap placement (plastic surgery)
205
Q

S of SBAR

A

Situation

Current situation
Ongoing investigation, family situation, how much pt knows about condition

Can be as simple as “take patient to therapy”

206
Q

Nosocomial infection

A

AKA HAI

Healthcare associated infection

207
Q

Wells score PE

A

> 4 PE likely

3 points each:
Suspected DVT
Alternative diag less likely than PE

1.5 points each:
Immobilization >=3 days; surgery in prev 4 weeks
History of PE or DVT
HR >100

1.0 points each:
Hemoptysis
Malignancy within past 6 months

208
Q

Catheter

A

Keep collection bag lower than bladder

209
Q

Other considerations
Red/Yellow/Green
Unstable major fracture (pelvic, spinal, lower limb long bone)

A

Yellow: in/bed
Red: out-bed

210
Q

CBC

A

Complete blood cell count

WBC
HCT - hematocrit
Hbg- hemoglobin
Platelets

211
Q

Orthostatic intolerance vs Normal

HR and Systolic

A

Normal:
HR: increase of 5 bpm
Systolic BP: decrease of 10 mmHg

Abnormal:
HR : increase of 20 or more bpm
Systolic BP: decrease of 20 or more mmHg

212
Q

Hypomagnesemia

A

Malabsorption; protracted vomiting, diarrhea, or intestinal drainage; defective renal tubular reabsorption; Cyclosporine

S/S: generalized alterations in NM function, depression, irritability, delirium, tachycardia

213
Q

Post-acute facility placements

A

IRF (inpatient rehab)
SNF (skilled nursing)
LTAC (longterm acute care
LTCF (longterm care facility/nursing home)

214
Q

____ can reduce atelectasis and should be instructed on every post-op with abdominal or thoracic incision

A

Diaphragmatic breathing

215
Q

Hyponatremia s/s

A

Confusion, weakness, cramps/spasms, HA, convulsions, irritability
< 130 mEg/L

Water moves into cells to balance, brain cells especially sensitive to swelling- Can be fatal

Dehydration or over-hydration

Can be fatal
Monitor vitals 2ndary to risk for orthostatic hypotension

216
Q

RBC

A

Normal

  1. 7-6.1 x10^6/uL male
  2. 2-5.4 x10^6/uL female

Decrease: anemia, cancer, blood loss, malnutrition

Increase (polycythemia): dehydration, R HF, COPD, smoking

217
Q

NPO

A

Nothing by mouth - NO food or drink

Safety -
Minimize aspiration
Protect pt from dangerous swallowing condition
Enforce bowel rest (GI system)

218
Q

Impella and IABP

A

Impella: Inserts into L side of heart to pump

IABP: Intra-aortic balloon pumps

219
Q

Type IV

Respiratory failure

220
Q

Respiratory parameters-
Red/Yellow/Green
Fraction of inspired oxygen (FiO2)

A

=< 0.6 green

> 0.6 yellow

221
Q

Airborne precautions

A

Contagious pathogens transmitted by airborne droplet nuclei that have ability to remain suspended in air for extended time

Measles, varicella (until dry/crusted), TB

STD precautions + N95 respirator mask or positive air purifying respirator (PAPR); eye protection; airborne isolation room required

222
Q

Neurological considerations
Red/Yellow/Green
Subgaleal drain

A

Green: in-bed
Yellow: out-bed

223
Q

D-dimer test

A

Ordered when DVT or PE suspected, and to confirm DIC

Measures degradation levels of fibrin

Positive > 500 ug/L

224
Q

K+

A

Affects excitability of heart, muscles and nerves

Normally excreted in urine
Normal 3.7-5.1 mEg/L

Hypokalemia
Hyperkalemia

225
Q

Increased H+ due to a drop in HCO3-

A

Metabolic acidosis

226
Q

ECMO/ECLS

A

Extracorporal membrane oxygenatio/life support

Mechanical devices to temporarily support heart and/or lung function during cardiopulmonary failure, allowing organ recovery or replacement

227
Q

Neurological considerations
Red/Yellow/Green
ICP

A

Active mgmt of intracranial hypertension w/ ICP not in desired range = red

Intracranial monitoring w/o active mgmt of intracranial hypertension-
Green: in-bed
Yellow: out-bed

228
Q

PSV : Pressure support ventilation

A

PF initiated breaths are augmented by ventilator to maintain a certain inspiratory pressure and tidal volume

The greater the PSV the less effort by pt
Usual range 5-25 cmH2O

Used as a weaning mode
Can reduced pressure support volume
Can increase time spent with this reduced assistance to address impaired endurance

229
Q

Neurological considerations
Red/Yellow/Green
Open lumbar drain (not clamped)

A

Green: in-bed
Red: out-bed

230
Q

Patient selection for ambulatory IABP

A

Used in patients who benefit from IABP but need ambulatory and long-term support

Requires ICU setting

Used as bridge to: transplant, MCS, determination, recovery (post MI or post ECMO; after high-risk surgery)

231
Q

Respiratory parameters-
Red/Yellow/Green
Rescue therapies- Prone Positioning

232
Q

Functional strength
Functional measures
Acute care

A

Chair rise test (quad strength)
30 sec, timed 5 reps

Arm curl

Supine hip extension

Heel rise

Toe tap

233
Q

PT and the post-op patient

Observation/Assessment with every visit.

A

Edema
Assess for DVT
Look at incision if possible- at least look for drainage
Assess orientation and ability to follow commands
Involve family if possible (but if they are getting in the way- suggest they take a break and go get a cup of coffee or something)

234
Q

General functional mobility and endurance
Functional measures
Acute care

A

Functional test (AMPAC 6-clicks)

Cardiovascular endurance (6MWT, 2MWT, 400m walk test, 2 min step test)

Walking speed

RPE during functional activities

235
Q

Respiratory parameters-
Red/Yellow/Green
Ventilation- HFOV

A

Yellow- in-bed

Red- out-bed

Acute Care (4 decks)

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