CM/ss Flashcards
Hope fostering activities
Spirituality
Relationships
Humor
Positive memories
Hope hindering activities
Isolation
Uncontrollable pain and discomfort
Abandonment
Double effect criteria
Action itself is good/neutral
Intends good, not evil
Good is not achieved by evil effect
Favorable balance of good over evil
Maslow hierarchy
Physiological needs
Safety and security
Belonging
Esteem
Self actualization
4 components of wellness
Capacity to perform
Adaptable
Feeling of well being
Harmony and balance
Aspects of critical thinking
Interpretation, Analysis, Evaluation
Inference
Explanation
Self reflection
Self regulation
Priorities
Validate info
Draw from past XP
Flexibility (outside the box)
Consider alternatives
Teleologic/consequentialism/utilitarianism
Greatest good for greatest number
Deontologic/formalist
Independent of consequence
Sense of duty
New grad competencies
Management of care
Safety and infection
Health promotion and maintenance
Psychosocial integrity
Basic care and comfort
Pharm and parenteral
Risk management
Physiological adaptation
Employer expectations
Theory
ADPIE
Know abilities and limitations
Communication
Delegation
Documentation
Basic skills
Information technology
Work ethics
Acceptable speed
Stages of Kubler Ross grief
Denial
Anger
Bargain
Depression
Acceptance
Principles of Kurt Lewin’s Force Field Theory of Change
Driving and restraining forces of change
3 phases: unfreezing (plan), movement (implement), refreeze (integration)
Neuro assessment: health hx
Pain
Seizures
Dizziness and vertigo
Visual
Weakness
Abnormal sensations
General hx
Complications for altered LOC
Respiratory
PNA
Aspiration
Pressure injury
DVT
Contractures
Early CM increased ICP
Altered LOC
Restless, confusion, drowsy, increased respiratory effort, purposeless movements
Pupils
Weakness at one side
HA
Late CM increased ICP
Cushing (high systolic BP, low HR, low RR)
Projectile vom
Respiratory and vasomotor
Hemiplegia, decorticate, decerebrate, flaccid
Respiratory
Loss of brainstem reflexes
Hyperthermia
Intracranial surgery complications
ICP
Bleeding, hypovolemic shock
Fluid and lytes
Infection
CSF leak
Seizures
Basilar skull fracture
Bleeding from nose, pharynx, ears
Battle sign (bruised behind ears)
CSF leak (halo sign around blood)
Epidural hematoma
Brief loss of consciousness
Then lucid
Then back to stupor
Concussion
Dizzy, vom
Lethargy, Hard to arouse
Changes in LOC, Confusion
Anxiety, Irritable
HA
Speech and movement difficulty
TBI complications
Decreased cerebral perfusion
Cerebral edema and herniation
Impaired O2 and vent
F lyte and nutrition
Seizures
Spinal shock
Sudden decrease in reflexes below SCI
Flaccid
Low reflexes
Decreased sensation
Can lead to paralytic ileus
May be hypotension and bradycardic
Neurogenic shock
Due to ANS dysfunction
Decreased BP, HR, CO
Resp issues (hypercap, hypoxia, p edema)
Secretion retention
Syncope
Warm dry skin
Pooling of blood increases DVT risk
Autonomic dysreflexia
Pounding HA
Increase BP
Diaphoresis
Nasal congestion
Bradycardia
Nausea
SCI complications
DVT
Ortho hypo
Autonomic dysreflexia
Death is most commonly associated with PE, PNA, and sepsis
Tetra/paraplegia comps
Spasticity
Infection and sepsis
MS
Relapsing and recurring
Fatigue
Weakness
Numbness
Impaired coordination
Loss of balance
Pain
Visual
Depression
Constipation and UTIs
Contractures/spasticity, PNA, edema, pressure injuries (bed bound stuff)
Risk for osteoporosis
Myasthenic crisis
Severe weakness
Resp and bulbar weakness
Can lead to respiratory failure
Cholinergic crisis
Severe weakness
Resp and bulbar weakness
Increase secretions: SLUDGE
Saliva
Lacrimation
Urine
Defecation
Gastro
Emesis
GBS
Ascending paralysis
Impaired reflexes
Weak
CN demyelination
May alter HR and BP (hyper or hypo)
CSF has increased proteins but normal WBC
Paresthesias and pain
Sympathetic storm syndrome
Loss of consciousness
VS unstable
Diaphoresis
Agitation
Brain changes with older folks
Decreased volume and weight of brain
Decreased NTs
Decreased cerebral blood flow
Decreased metabolism
In coma, abnormal pupil and motor=
Neuro disease
In coma, normal pupil=
Toxic or metabolic disorder
DI
Increased dilute urine output
Increased serum OSM
SIADH
Hypervolemia and hyponatremia
Decreased UOP
SCI
Retention and distention
Decreased sweating
Hypotension
Acute pain back and neck
Decreased resp func
Meningitis
HA
Fever and chills
Stiff neck
Kernig and Brudzinski
Photophobia
Rash
LOC and seizure
ICP and hydrocephalus
MG
Ptosis
Vision
Facial weakness
General weakness
Dysphonia
Dysphagia
Signs of imminent death
Mottling of skin
Weak and irregular pulse
Can’t swallow secretions
May or may not have bowel incontinence
Compensatory shock
BP WNL
Tachycardia
Tachypnea
Hypoperfusion
Anxiety
Confusion
Cold, cool, clammy
Deceased GI motility
Decreased UOP
Progressive stage shock (overall ss and patho)
BP drop 40 from baseline or <100
MAP <65
Rapid shallow resp, crackles
Chest pain
Mental status
AKI
Liver failure
GI bleeding
Patho: HF, decreases cell perfusion, interstitial edema, anaerobic metabolism, increased clotting cascade/DIC/bruising
Increase capillary permeability
Increased lactic
Hypovolemic shock
Pale
Cold
Low BP
Clammy
Weak
Fatigue
Dizzy
Thirst
Cardiogenic shock
Angina
Arrhythmias, ECG
Fatigue
Doom
Cardiac labs - BNP, CK, troponin
Low CO, low BP
Fluid in lungs/crackles
Septic shock
Hyperthermia
Tachycardia
Bounding pulses
Hypotension
Decreased UOP
NV
Decreased GI motility
Warm flushed skin progresses into cool pale mottled skin
Hepatic
Hypercoagulation, increased CRP/procalcitonin/lactic
Anaphylactic shock
Acute onset
Respiratory distress - dyspnea and bronchospasm
GI distress
Skin/mucosa irritation (pruritis and uticaria)
CV compromise - arrhythmias, vasodilation, hypotension
HA, flushing
Decreased LOC
Facial edema
Electrical burns
Dysrhythmia, cardiac arrest
Myoglobinuria
ATN and AKI
Possible spinal injury - always C spine!
Increased CK
Inhalation injury
Carbonaceous sputum
Facial burns, redness, blistering, edema
Singed nasal hair
Hoarseness
Painful swallow
Dark oral and nasal membranes
Clothing burns around neck and chest
Major burn injury complications
Fluid shift leading to shock
F and lytes
CV
Hypermetabolic
Pulmonary- airway, carbon monoxide
Renal and GI
Immunological
Thermoregulation
Low platelets - bleeding risk
(In the hospital stuff) - PNA, UTI, respiratory failure, sepsis, cellulitis, wound infection, AKI, arrhythmias, HAI/CLABSI
Complications during emergent phase of burn injury
ARF
Distributive shock
AKI
Compartment
Paralytic ileus
Curling’s ulcer
CV alterations in burn injuries
Immediate decreased CO
Loss of fluid volume
Compensatory vasoconstriction leads to increased workload and O2 demands
Hypoperfusion and decreased O2 to body
Low BP
HF and pulmonary edema if too much fluid is infused
Fluid and electrolyte imbalances with burns
Rapid edema
Fluid shifts, hypovolemia
Hyperkalemia initially
Hyponatremia
Decreased peripheral circulation due to edema and eschar - need an escharotomy
Dehydration
Low blood volume/hemoconcentration
Decreased UOP
Metabolic acidosis
GI alterations in burn injuries
Paralytic ileus
Curling’s ulcer
Translocation of bacteria
Vomiting and aspiration- need an NGT
Decreased absorption
Thermoregulatory changes in burns
Skin loss
Hypothermia
(Need to prevent heat loss)
Temp will rise during recovery
Complications in acute/intermediate phase burn injury (thermal and electrical)
ARF, ARDS
HF, pulmonary edema
Sepsis
Delirium
Visceral damage from electrical
F and lyte shifts in acute/intermediate phase burn injury
Hemodilution
Increased UOP
Hyponatremia due to diuresis
Hypokalemia
Metabolic acidosis
Respiratory ss with progressive shock
Acidotic
Shallow and rapid
Crackles, pulmonary edema
Decreased surfactant/alveolar collapse
ARDS
CV ss with progressive shock
Arrhythmias
Ischemia
Chest pain
Tachycardia
MI
Increased troponin
Renal ss with progressive shock
AKI
High BUN and Cr
F and lyte and acid base
Hepatic ss with progressive shock
Jaundice
Increased labs
Increased waste
Increased risk infection
Hyperglycemia
GI ss with progressive shock
Stress ulcers
GI bleed
Bacterial translocation
SIRS
“Cytokine storm” in septic shock
High or low WBC
High HR
High or low temp
High RR
What is a negative Nikolsky sign
No separation from dermis when rubbing first degree burn
Burn patho
Decreased CO
Capillary permeability leads to edema
Increase SNS
Vasoconstriction and decreased perfusion
Hypovolemia and low BP
Kidney ss with burn injuries
Hypovolemia leads to injury
Heme in urine due to RBC destruction
Myoglobinuria due to muscle breakdown
Normal CPP
70 to 100
Normal ICP
0 to 15
