CRITICAL CARE: GENERAL OVERVIEW

Question 1

Definition of Critical Care Nursing:

Answer 1

•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.

Question 2

Definition of a Critically Ill Patient:

Answer 2

•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. **

Question 3

ROLE of the Critical Care Nurse

1. Assessment
2. Continuous electronic monitoring (7)
3. Titration of
4. Communication
5. Documentation

Answer 3

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

Question 4

Critical Nurse Scope of Practice (7)

Answer 4

1. •Assessment
2. •Diagnosis
3. •Outcomes Identification
4. •Planning
5. •Implementation
6. •Evaluation

Question 5

•Impaired gas exchange

Nursing Interventions

Answer 5

Nursing Interventions

Question 6

**Altered Respiratory Pattern

Nursing Interventions**

Answer 6

Nursing Interventions

Question 7

**Impaired circulation

Nursing Interventions**

Answer 7

Nursing Interventions

Question 8

**Risk for hemodynamic instability

Nursing Interventions**

Answer 8

Nursing Interventions

Question 9

Risk for infection

Nursing Interventions

Answer 9

Nursing Interventions

Question 10

**Risk for injury

Nursing Interventions**

Answer 10

Nursing Interventions

Question 11

Knowledge deficit
Nursing Interventions

Answer 11

Nursing Interventions

Question 12

**Impaired neuro-sensory function

Nursing Interventions**

Answer 12

Nursing Interventions

Question 13

Altered nutrition
Nursing Interventions

Answer 13

Nursing Interventions

Question 14

Altered family processes

Nursing Interventions

Answer 14

Nursing Interventions

Question 15

Pain
Nursing Interventions

Answer 15

Nursing Interventions

Question 16

Fluid volume deficit

Nursing Interventions

Answer 16

Nursing Interventions

Question 17

Fluid volume excess

Nursing Interventions

Answer 17

Nursing Interventions

Question 18

Altered thermoregulation

Nursing Interventions

Answer 18

Nursing Interventions

Question 19

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.

Answer 19

5 Week old:

1. Assess
2. IV
3. Lumbar puncture

Question 20

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

Answer 20

56 year old no meds why

Question 21

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.

Answer 21

58 vasopressor…fluids?

Question 22

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

Answer 22

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

Question 23

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?

Answer 23

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

Question 24

Nursing Care

Always include (6)

Answer 24

• Airway
• Breathing
• Circulation
• Nursing interventions
• Pain comfort
• Family coping

Question 25

**Circulation **

3 ways to correct the situation?

Answer 25

1. –Fluids
2. –Blood
3. –Meds

Question 26

1. Neuro Assessment: Use which tool?

Answer 26

1. Glasglow coma scale

Question 27

1. Neuro Assessment: Why do the Glasgow Coma Scale?
2. Perfect score?
3. Less than 8?
4. What are you using to intubate?

Answer 27

1. GLASGOW HELPS TO DETERMINE HOW AIRWAY SHOULD BE MANAGED
2. 15
3. Less than 8 intubate
4. Endotracheal intubation

Question 28

ABCDEFGHI Trauma Assessment

The ABCDEFGHI mnemonic is used for a quick assessment of trauma patients. This is especially useful for emergency cases.

Answer 28

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

Question 29

Altered Breathing Patterns: Terminology

1. “DOE”
2. **Kussmaul’s **
3. Hyperventiliation caused by?
4. Hypoventiliation caused by ?

Answer 29

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

Question 30

Biots Respiration

Answer 30

Regular breathing pattern followed by apena 10 seconds to 1 minute

Question 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

Answer 31

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