CRITICAL CARE: GENERAL OVERVIEW Flashcards

1
Q

Definition of Critical Care Nursing:

A

•Definition of Critical Care Nursing: Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems. A critical care nurse is a licensed professional nurse who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Definition of a Critically Ill Patient:

A

•Definition of a Critically Ill Patient: Critically ill patients are defined as those patients who are at high risk for actual or potential life-threatening health problems. The more critically ill the patient is, the more likely he or she is to be **highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care. **

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

ROLE of the Critical Care Nurse

  1. Assessment
  2. Continuous electronic monitoring (7)
  3. Titration of
  4. Communication
  5. Documentation
A
  1. •1:1 assessment
  2. •Complex to focus
  3. •Continuous electronic monitoring
  4. –ECG
  5. –Respiratory Rate
  6. –BP: NIBP or Arterial
  7. –Oxygenation: SpO2, SvO2
  8. –Temperature
  9. –Hemodynamic monitoring: PA, IABP
  10. –ICP monitoring
  11. •Titration of IV medications
  12. •Communication
  13. •Documentation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Critical Nurse Scope of Practice (7)

A
  1. •Assessment
  2. •Diagnosis
  3. •Outcomes Identification
  4. •Planning
  5. •Implementation
  6. •Evaluation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Impaired gas exchange

Nursing Interventions

A

Nursing Interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

**Altered Respiratory Pattern

Nursing Interventions**

A

Nursing Interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

**Impaired circulation

Nursing Interventions**

A

Nursing Interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

**Risk for hemodynamic instability

Nursing Interventions**

A

Nursing Interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Risk for infection

Nursing Interventions

A

Nursing Interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

**Risk for injury

Nursing Interventions**

A

Nursing Interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Knowledge deficit
Nursing Interventions

A

Nursing Interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

**Impaired neuro-sensory function

Nursing Interventions**

A

Nursing Interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Altered nutrition
Nursing Interventions

A

Nursing Interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Altered family processes

Nursing Interventions

A

Nursing Interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Pain
Nursing Interventions

A

Nursing Interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Fluid volume deficit

Nursing Interventions

A

Nursing Interventions

17
Q

Fluid volume excess

Nursing Interventions

A

Nursing Interventions

18
Q

Altered thermoregulation

Nursing Interventions

A

Nursing Interventions

19
Q

What will you do?

5 week old female

CC: N/V/D x 24 hours

B: five weeks normal delivery.

A: pale, good tone, alert, wet diaper, ST at 150, RR 32.

A

5 Week old:

  1. Assess
  2. IV
  3. Lumbar puncture
20
Q

What would you do?

56 yo female

CC: change in LOC +N/V in last 4 hours. Sent STAT from CT scan

B: Lung ca

A: somnolent, left side droop, LS course, Tachypnea,

Denies: CP

A

56 year old no meds why

21
Q

What would you do?

58 yo male

CC: frank blood in stool, hypotension

B: liver, heart failure, + BMI, HTN, DM, ETOH

A: yellow, somnolent, LS dim, Abdomen distended, firm, Denies N/V/CP. + SOB. Frank blood guiac +,

Radial 2+ B

4+ pitting edema to mid-thigh.

A

58 vasopressor…fluids?

22
Q

What would you do?

78 yo female

CC: leg pain

B: COPD, Sleep apnea, obesity. HTN.DM II

A: Bilateral cellulitic legs, rhonchi, Denies N/V/D/CP. + SOB

Pain 6/10

Radial 2+ B

Pedal 0 B

A

If pt is in shock you can’t give fluid continously

23
Q

Assessment of Critically Ill Patient

  1. Status (3)
  2. Head to toe, ALWAYS…
  3. Neuro use?
  4. Cardiac monitoring (6) /rhythm use lead?
  5. In ICU add ___?___ monitoring
  6. IV access consider (4)
  7. Labs? What kind?
A
  1. •Stable, Unstable Dieing
  2. Head to toe (physically all over ! **Turn the patient over **
  3. •Neuro..neuro..neuro. (GCS)
  4. •Cardiac monitor: rate, rhythm (lead II), BP, O2 Sat, RR
  5. –IN ICU add hemodynamic monitoring
  6. •IV access: how many, what size (or IO or Central Line)
  7. •Full sets of lab work
  8. •Heart sounds
  9. •LS
  10. •I & O/ hour or more frequently
  11. •Vital signs…q minute!
  12. •Document/communicate/assess/document
24
Q

Nursing Care

Always include (6)

A
  • Airway
  • Breathing
  • Circulation
  • Nursing interventions
  • Pain comfort
  • Family coping
25
**Circulation ** 3 ways to correct the situation?
1. –Fluids 2. –Blood 3. –Meds
26
1. Neuro Assessment: Use which tool?
1. Glasglow coma scale
27
1. Neuro Assessment: Why do the Glasgow Coma Scale? 2. Perfect score? 3. Less than 8? 4. What are you using to intubate?
1. GLASGOW HELPS TO DETERMINE HOW AIRWAY SHOULD BE MANAGED 2. 15 3. Less than 8 intubate 4. Endotracheal intubation
28
**ABCDEFGHI Trauma Assessment** ## Footnote The ABCDEFGHI mnemonic is used for a quick assessment of trauma patients. This is especially useful for emergency cases.
A Airway B Breathing C Circulation D Disability (neurologic status) E Expose (remove clothing, keep the patient warm) F Full set of vital signs G Give comfort measures H History/Head-to-Toe assessment I Inspect posterior surfaces
29
**Altered Breathing Patterns: Terminology** 1. **“DOE”** 2. **Kussmaul’s ** 3. **Hyperventiliation caused by?** 4. **Hypoventiliation caused by ?**
1. •Tachypnea - 2. •Bradypnea – 3. •Apnea 4. •Dyspnea - 5. •Hyperventilation - 6. •Hypoventilation – 7. •Kussmaul’s - 8. •Cheyne-stokes 9. •Orthopnea 10. •“DOE”: dyspnea on exertion 11. •“SOB” Short of breath
30
Biots Respiration
Regular breathing pattern followed by apena 10 seconds to 1 minute
31
Oxygen (1st drug of choice) 1. Assess: (3) 2. Interventions: 3. –Nasal cannual ___ to ___ L/mim (at \_**?\_\_** **add** H20) 4. –NRB: at least ___ to ___ L/min FLUSH, make sure to \_\_\_?\_\_\_ 5. –Cpap 6. –BiPap 7. –Intubation 8. •Sedation and BVM 9. •Ventilator
1. color, 02Sat on RA, ABG’s 2. Nasal cannual ___ to ___ L/mim (**at 4 liters add H20)** –NRB: at least ___ to ___ L/min FLUSH, make sure to inflate the bag –Cpap –BiPap 3. intubation 4. Sedation and BVM