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Complex II > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Mitigation phase of emergency nursing

A

planning phase
proactive rather than reactive

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2
Q

Preparedness phase of emergency nursing

A

practicing the plan
training a disaster team

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3
Q

Emergency response phase of emergency nursing

A

Implementation of the plans
assessing if the plan is working

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4
Q

Recovery phase of emergency nursing

A

returning everything to a new normal
PTSD may occur and should be assessed

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5
Q

What is the #1 priority of emergency nursing?

A

SAFETY
know where your exits are, put on PPE and know who is around you

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6
Q

What is trauma?

A

injury to any body part/wound or shock from sudden physical injury

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7
Q

How long should a rapid assessment take?

A

60 seconds or less

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8
Q

What should be gathered with your rapid assessment?

A

vitals signs
GCS
extent of injuries

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9
Q

Reverse/disaster triage is used in what situation?

A

mass casualty
>100 people

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10
Q

In what order do you assess with reverse/disaster triage?

A

treat less injured 1st and leave severely injured to die possibly
the greatest good for the greatest amount of people

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11
Q

What elements are involved with a primary survey?

A

Airway
Breathing
Circulation
Disability
Exposure

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12
Q

What is your priority when assessing airway?

A

are there any obstructions?
clear obstructions with suction, turn to side to expel vomit/blood and anticipate intubation

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13
Q

ONLY insert an oropharyngeal airway if the patient doesn’t have what?

A

Gag reflex
because otherwise, you will not be able to get the tube down and secure the airway

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14
Q

What does a C-collar do?

A

controls airway and CNS

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15
Q

What should not be done if they have a potential cervical spine injury?

A

Head tilt/chin lift

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16
Q

What should you do if the patient is unresponsive without trauma to the airway?

A

head tilt/chin lift

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17
Q

What should you do if the patient is unresponsive with trauma to the airway?

A

Jaw thrust

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18
Q

If you suspect they have blunt force trauma, what should you do?

A

Stabilize their spine and log roll

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19
Q

What should you look/listen for when assessing breathing?

A

symmetrical chest rise & fall
use of accessory muscles
listen to all 5 lung sounds
broken ribs

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20
Q

If 3 plus ribs have broken what has most likely happened?

A

Lung has collapsed

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21
Q

What may sub-q edema indicate?

A

flail chest
This is a medical emergency, and you should intervene immediately

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22
Q

What should you do if the patient has a flail chest?

A

raise HOB
apply O2 or Ambu bag for inadequate breathing
if the flail chest progresses into a collapsed lung then prepare of intubation

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23
Q

What should be assessed when looking at circulation?

A

HR
BP
Peripheral pulses (radial)
central pulses (carotid/femoral) (check this 1st)
cap refill
skin color
LOC
urine output

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24
Q

What is the priority action when assessing circulation?

A

Get 2 IV access points using large-bore IV caths in the antecubital fossa of both arms
Infuse isotonic IV fluids and or blood products

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25
Q

What should be assessed with disability?

A

LOC with GCS (less than 8, intibate)
AVPU
pupillary response

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26
Q

How should you assess exposure/environment?

A

expose & look at the patient (front/back/naked)
preserve evidence found
Priority is to maintain body heat and privacy/dignity

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27
Q

What is the trauma triad of death

A

Hypothermia (keep warm)
acidosis (replace volume loss)
coagulopathy (monitor for s/sx of shock)

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28
Q

Secondary survey includes…?

A

Full set of VS, 5 adjuncts, family presence
Give comfort measures
Head to toe
Inspect posterior

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29
Q

What are the 5 adjuncts?

A

Foley catheter
Full set of labs
cardiac monitor
NG or OG tube
some sort of radiology (x-ray or CT)

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30
Q

What does AMPLE stand for?

A

Allergies
meds
past medical hx/menstrual period
last intake & output
exposures

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31
Q

When inspecting posteriorly, what should you check for?

A

check rectal tone to assess for spinal cord injury
if there is no tone, assume spinal cord injury

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32
Q

What is pre-load?

A

amount of blood going into the right atrium
Involves central venous pressure (CVP)
& pulmonary artery wedge pressure (PAWP)

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33
Q

Central venous pressure

A

measures the right atrial pressure/the volume of blood going into the right atrium

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34
Q

How is CVP measured?

A

Central line
PA catheter

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35
Q

CVP range

A

2-6

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36
Q

if CVP is >6

A

There is too much fluid
pump problem
give diuretics

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37
Q

if CVP is <2

A

not enough fluid, need volume
give fluids

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38
Q

Pulmonary Artery wedge pressure

A

pressure generated by the left ventricle

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39
Q

What is after-load?

A

Pressure the ventricles have to pump against to move blood out of the heart & to the lungs or body
involves pulmonary vascular resistance (PVR) & systemic vascular resistance (SVR)

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40
Q

Pulmonary vascular resistance

A

pressure the RV must overcome to pump blood to the lungs

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41
Q

Systemic vascular resistance

A

Pressure the LV must overcome to pump blood to the body

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42
Q

Mean arterial pressure

A

> 65mmHG

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43
Q

PAWP

A

6-15

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44
Q

Cardiac output

A

3-6 L/min
amount of blood pumped in one minute
CO= SV x HR

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45
Q

PA pressure systole

A

15-28

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46
Q

PA pressure diastole

A

5-16

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47
Q

SVR

A

800-1200

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48
Q

stroke volume

A

50-100mL/sec

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49
Q

Ejection fraction

A

normal: 55-70%
acute heart failure: <40%
% of blood ejected with each beat

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50
Q

Elevated preload (CVP&PAWP) s/sx

A

crackles
JVD
hepatomegaly
peripheral edema
taut skin turgor
too much fluid

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51
Q

Decreased preload s/sx

A

poor skin turgor
dry mucous membranes
not enough fluid

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52
Q

Elevated afterload (PVR&SVR) s/sx

A

cool extremities
weak peripheral pulses
not enough fluid

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53
Q

Decreased afterload s/sx

A

warm extremities
bounding peripheral pulses
too much fluid

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54
Q

Pulmonary artery catheter (swan-ganz)

A

a catheter that is threaded into the RA, then RV, then into a branch of the PA
measures right atrial pressure, pulmonary artery pressure and left ventricle pressure
measures fluid INSIDE the heart

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55
Q

What happens if there is high PA pressure? why?

A

pulmonary HTN
pulmonary edema
RA is having to work hard bc the afterload is high
give sildenafil, even females

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56
Q

How do you measure PAWP/LV pressure?

A

Inflate the balloon!
You MUST deflate the balloon after bc it’s in the PA & is cutting off blood flow which could lead to massive PE or necrosis
high risks for clots with this procedure

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57
Q

Arterial lines are most commonly placed in what artery?

A

Radial

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58
Q

What are the indications for an arterial line?

A

pt needs a continuous BP reading
frequent ABGs
the patient is on vasopressors

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59
Q

What does an ART line measure?

A

continuous BP readings in the arteries leaving the heart
measures ABGs ( can draw blood from these lines for ABGs)

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60
Q

What should you not use the ART line for?

A

giving meds or IV fluids through the ART line

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61
Q

What is the biggest risk with this procedure?

A

cutting off the blood flow to the hand
before inserting, complete an Allen’s test
if the pt says their hand hurts, call dr!

62
Q

the art line is accurate when the _____ is level with the atrium of the heart

A

Transducer

63
Q

if the pt heart is higher than the transducer then

A

pressure is too high

64
Q

if the pt heart is lower than the transducer then

A

pressure it too low

65
Q

if the transducer is higher than the heart then

A

the pressure is low

66
Q

if the transducer is lower then the heart then

A

the pressure is high

67
Q

What is the first major sign of shock?

A

hypotension

68
Q

What is the priority for shock?

A

early detection

69
Q

Initial phase of shock

A

no visible changes
only at the cellular level

70
Q

Non-progressive (compensatory) of shock

A

the body compensates to perfuse organs
at 1st, BP increases but this can’t last long
CO & BP start to drop, so HR increases
no big changes bc the body can compensate
RR increase
cold and clammy
urine decreases

71
Q

Progressive phase of shock

A

Compensatory mechanisms fail

72
Q

S/sx of progressive shock

A

pale
poor skin turgor
cool skin
decreased cap refill
decreased peri pulses
restless/anxious
decreased LOC
pulmonary edema
lactic acid builds up

73
Q

Refractory stage of shock

A

irreversible & total system failure
the patient is going to die

74
Q

S/sx of refractory shock

A

rapid, shallow breaths
cyanotic skin
no urine output

75
Q

High CVP leads to

A

JVD

76
Q

Causes of hypovolemic shock

A

trauma
dehydration
hemorrhage

77
Q

What will be increased in hypovolemic shock?

A

HR
SVR
RR

78
Q

What will hypovolemic shock patients complain of feeling?

A

not being able to breathe

79
Q

What is the priority nursing intervention for hypovolemic shock?

A

replace fluids with normal saline or blood

80
Q

What is the first-line drug for hypovolemic shock?

A

Norepinephrine

81
Q

Whole blood is given when

A

the patient has lost a large amount of blood

82
Q

In what time frame must whole blood be transfused before the coagulation factors deteriorate?

A

within 24 hours of collection

83
Q

Fresh frozen plasma is used to treat

A

active bleeding
coagulation disorders
extensive burns
shock
replacement therapy for coagulation factors

84
Q

Albumin does what

A

expands blood volume and increases BP

85
Q

packed red blood cells are used when?

A

to restore or maintain adequate organ oxygenation and circulating blood volume

86
Q

Platelets are used for?

A

Thrombocytopenia
aplastic anemia
chemotherapy induced bone marrow suppression

87
Q

Cryoprecipitate

A

thawed frozen plasma that contains coagulation factors

88
Q

What should you do pre-procedure before admin blood products

A

obtain blood samples to determine compatibility
assess for hx of transfusion reactions
start large-bore IV access
2 RNs must verify product & pt within 30 min of transfusion

89
Q

How often should you monitor VS and reactions intra-procedure?

A

stay with the pt for the first 15-30 min
monitor VS at 15 min, 30 min, 1 hr, immediately after and 1 hour after transfusion

90
Q

What should you do post transfusion?

A

take VS
dispose of tubing
complete paperwork and document

91
Q

What should you consider when transfusion older adults?

A

assess VS q 15 min (at risk for fluid volume overload)
withhold IVF during transfusion
give furosemide/diuretics post transfusion

92
Q

If adverse reactions occur, what should you immediately do?

A

STOP transfusion
remove the tubing
remove blood products
start NS with new tubing
monitor VS
send blood & tubing to the blood bank for testing

93
Q

Acute hemolytic reaction onset

A

Immediately

94
Q

S/sx of acute hemolytic reaction

A

chills
fever
low back pain
flushing
Hemoglobinuria
impending sense of doom

95
Q

Nurse action for acute hemolytic reaction

A

monitor VS & fluid status

96
Q

Febrile reaction onset

A

within 2 hrs of starting infusion

97
Q

Febrile reaction S/sx

A

1-degree temp difference from pretransfusion temp

98
Q

febrile reaction nurse action

A

admin antipyretics

99
Q

Allergic reaction onset

A

up to 24 hours after transfusion

100
Q

allergic reaction s/sx

A

itching
flushing
Anaphylaxis

101
Q

Nurse actions for allergic reaction

A

admin antihistamine and may restart if ordered at a slower rate

102
Q

Anaphylactic reaction onset

A

up to 24 hours after transfusion

103
Q

Anaphylactic reaction s/sx

A

bronchospasm
laryngeal edema
shock

104
Q

Nurse action for anaphylactic reaction

A

admin epi, O2 and possible CPR

105
Q

Bacterial reaction onset

A

during or several hours after transfusion

106
Q

S/sx of bacterial reaction

A

wheezing
dyspnea
cyanosis
shock

107
Q

Nurse action for bacterial reaction

A

admin antibiotics

108
Q

Circulatory overload onset

A

any time during the transfusion

109
Q

S/sx of circulatory overload

A

crackles
dyspnea
cough
JVD
anxiety

110
Q

Nursing actions for circulatory overload

A

slow the transfusion
position the pt upright w/ feet lower than heart level
admin O2
Diuretics and morphine

111
Q

What is an infarction?

A

tissue has NO blood flow
irreversible

112
Q

what is ischemia?

A

tissue damage w/ little blood flow
reversible

113
Q

what is unstable angina?

A

increased chest pain that is not relieved by rest or the admin of nitroglycerine

114
Q

What labs should be monitored for AMI, UA & CAD?

A

Myoglobin
CK-MB
Troponin I or T

115
Q

What is the earliest marker of an MI?

A

Myoglobin
gone after 24 hours of potential MI

116
Q

What is the CK-MB level?

A

0.1-4.9
peaks around 24 hours after the onset of chest pain
specific for AMI, when elevated this indicates damage to the cardiac muscle

117
Q

What is the Troponin I or T range?

A

0.01-0.03
elevation indicates cardiac tissue damage
after 4-6 hrs w/ T
after 2-4 hrs w/ I

118
Q

What is involved with the PCI and Cardiac catheterization

A

the wire goes into the femoral or brachial artery, guided up through the aorta to the coronary arteries
an angiogram can be done to visualize blockages

119
Q

What are some precautions to take before and after an angiogram?

A

before: assess for shellfish & iodine allergy
after: load pt with fluids to flush out all of the dye and monitor BUN & creatinine closely, pt must also lay flat for 4 hours after

120
Q

Emergent interventions for AMI/ unstable angina

A

monitor for dysrhythmias, hypoTN, increased chest pain
ONAM

121
Q

Single chamber pacemaker (VVI)

A

sense & paces the right ventricle only
Will only see one pacemaker spike

122
Q

Dual chamber pacemaker (DDD)

A

senses & paces both right atria and right ventricle
will see 2 pacemaker spikes

123
Q

Who will need a pacemaker no matter what?

A

3rd degree heart block pts

124
Q

What should you teach your patient about their pacemaker?

A

minimize shoulder movement
carry a pacemaker ID card because it will set off airport security
take their pulses daily at the same time
microwaves are okay to be around but stay away from objects generating magnetic field
no heavy lifting or contact sports

125
Q

What are the most important things you should teach your patient about an angioplasty?

A

conscious sedation
the leg that is cannulated must remain straight for at least 4-6 hours following the procedure

126
Q

What are the complications associated with an angioplasty?

A

cardiac tamponade
hemorrhage at the insertion site
Acute kidney injury from IV contrast dye

127
Q

What is the backup procedure if the PCI does not work?

A

Coronary artery bypass graft (CABG)

128
Q

Who is indicated to receive CABG treatment?

A

unable to open the CA w PCI
3 vessel blockage
50% occlusion of the left main CA

129
Q

What are some complications of CABG?

A

hypovolemic shock
decreased cardiac output
Hypothermia
Electrolyte imbalance

130
Q

S/SX of cardiac tamponade?

A

JVD
muffled heart sounds
paradoxical pulses (10mmHg difference)
narrowing pulse pressure
tachypnea
Bradycardia
cardiac arrest (late sign)

131
Q

Nursing actions for cardiac tamponade?

A

notify dr immediately
treatment is pericardiocentesis

132
Q

S/sx of cardiomyopathy

A

decreased ejection fraction
decreased cardiac output
s/sx of right and left HF
S3 & S4
murmur
syncope after activity
cardiomegaly
fatigue, weakness, dysrhythmias

133
Q

Risk factors/ causes of cardiomyopathy

A

family hx
sudden cardiac arrest
endocrine/metabolic diseases
Alcoholism
HTN

134
Q

Nursing care for acute heart failure

A

daily weights & I&Os
oxygen
bed rest
restrict fluid & Na
if hemodynamically unstable, then give dobutamine
if BNP is increased, give diuretics and O2
put on a cardiac monitor
start large bore IV 16 or 18 gauge (centrally located)

135
Q

What is increased in cardiogenic shock?

A

HR
CVP
SVR

136
Q

S/sx of cardiogenic shock

A

resp distress-crackles
JVD
tachycardia w/ hypotension
altered LOC
decreased peripheral pulses
thermodynamically unstable

137
Q

nursing interventions for cardiogenic shock

A

apply oxygen and vent PRN
put pt on cardiac monitor
start a central line
ONAM

138
Q

Complications of cardiogenic shock

A

DIC
multiple organ dysfunction syndrome (MODS)

139
Q

What is the systolic BP for a hypertensive crisis?

A

180-240

140
Q

What is the diastolic BP for a hypertensive crisis?

A

> 100

141
Q

What are some s/sx of a hypertensive crisis?

A

severe HA
blurred vision
epistaxis
dizzy/disoriented

142
Q

What is the first-line medication for a hypertensive crisis?

A

Nitroprusside (vasodilator)

143
Q

How should you admin nitroprusside?

A

IV admin low dose initially so the BP doesn’t drop too fast and become hypotensive

144
Q

What are the nursing actions during a hypertensive crisis?

A

continuous BP monitoring (every 5-15min) but it is ideal to have an arterial line
assess neuro status

145
Q

Aortic aneurysm is weakness in what?

A

dilated section of the aorta
LIFE THREATENING

146
Q

Aortic dissection is what?

A

an accumulation of blood within the arterial wall

147
Q

what are some risk factors for an aortic aneurysm/ dissection?

A

male
uncontrolled HTN
atherosclerosis
old age

148
Q

S/sx of an abdominal aortic aneurysm (AAA)

A

constant gnawing pain in the abdomen radiating to flank or back
there will be a bruit over the aneurysm
AUSCULTATE 1ST!!! DO NOT PALPATE!!! YOU WILL KILL YOUR PT!!!

149
Q

S/sx of a thoracic aortic aneurysm

A

severe back pain
cough/SOB
Difficulty swallowing

150
Q

S/sx of a dissecting aneurysm

A

can occur with AAA or thoracic
if the pulse is lost, then the aneurysm has been dissected
sudden change in symptoms from AAA/thoracic to tearing, ripping, stabbing abdominal or back pain
see s/sx of hypovolemic shock (MEDICAL EMERGENCY, GO STRAIGHT TO THE OR)

151
Q

Nursing care for aortic aneurysms

A

control BP (goal is systolic 100-120)
give antihypertensive
assess pain, pulses, urine output
have one central line and 2 peripheral lines w/ large boreholes
keep warm
no smoking
for AAA, keep pt supine

Complex II (6 decks)

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