Exam 1 Flashcards
‘/What is the CPOT?
Critical-Care Pain Observation Tool
What does the scoring indicate on the CPOT
0=no pain————4=some pain———-8=extreme pain
What are the four categories on the CPOT?
- Facial Expression 0=relaxed 1=tense 2=grimacing
- Body movements 0=no mvmt 1=protection 2-restless/agitated
- Compliance w ventilator or vocalization 10=tolerating/easy or talking normally 1= tolerating/coughing or sighing/moaning 2=fighting or sobbing
- Muscle Tension 0=Relaxed 1= Tense/rigid 2= very tense/rigid
Rules for CPOT
- pt must be observed at rest for one minute to obtain a baseline value
- Then, pt should be obs during nociceptive procedures (e.g. turning, wound care) to detect any changes in in response to pain.
- pt should be eval’d before and at peak effect of an analgesic agent to assess med effectiveness
- attribute the highest score obs during the obs period.
- muscle tension should be eval’d last, especially when the patient is at rest bc touch may lead to behavioral reactions.
Risk Factors of Delirium
- age
- post-op
- pain meds
- h/o dimentia
- male
- vent
What is CAM-ICU tool?
an acute confusion assessment method tool used in ICU to identify and recognize delirium quickly
What is the RASS tool?
Richmond Agitation-Sedation Scale
used to measure level of sedation in ICU pt’s
How is the Richmond measured?
-
(-3 to -5) Need to decrease sedation
- Unarousable -5, Deep Sedation-4, mod sed -3
-
(-2 to 0) Good! No intervention needed at this time!
- Light sed -2, drowsy -1, restless +1, alert & calm 0
-
(+2 to +4) Not enough sedation! Assess for pain, anxiety and delirium!
- Agitated +2, very agitated, +3 combative +4
pos 4, sedate the whore
neg 5, sedations high
Rich is hero, we want him at 0
Why would you give a paralytic to a pt on a ventilator?
Pt is very agitated and can’t be controlled with benzo’s or analgesics
Paralytics used for pt’s on ventilators
Succinylcholine or vecoronium
Additional interventions when giving a pt a paralytic to pt’s on ventilators
pain management and sedation
What is the Train of Four tool?
device that gives an electrical impulse to the ulnar or facial nerve to detect level of paralytic.
Train of Four (TOF) scale
Measuring paralytic effectiveness:
- attach electrodes to facial or ulnar nerve
- count muscle twitches
- 0 twitches = over paralyzed
- 2 twitches = Goal
- 4 twitches = not enough paralytic
What do you say to visitors of ICU patients?
Explain the situation
Paint a picture of what they will see
Universal visiting hours
What is terminal weaning?
Weaning off mechanical ventiliation in terminal pt’s
Extubation of the patient to allow them to die
use only pain management and sedation
Pt is going to die, no chance of recovery
What is the first thing you do when educating a patient/family on discharge info
assess prior knowledge
Pt changes that would require Rapid Response?
- Can’t keep sats above 90
- can’t keep systolic BP >90
- RR >30
- ALOC
- HR >130 (except w pain or fever)
- Can’t get blood sugar >40
What is the ABCDEF bundle?
a = assess pain
b= both completed spont awakenng and spont breathing
c= choice of analgesia
d= delirium assessment performed
e= early mobility (even intubated)
f= family involvement
What to look for in an ABG when determining which pt to see first?
- #1 PaO2 (who has the lowest needs seen first)
- the patient who is the most acidotic (resp. acidosis, low pH and Pa02)
Ways of calculating the rate on a 6 sec ECG strip, when it is regular
- count R waves and multiply X 10
- count large boxes between R waves and ÷ 300
- 2= 150 HR
- 3= 100 HR
- 4= 75 HR
P-wave represents
atrial depolarization
QRS complex represents
Normal measurements?
Ventrical depolarization
0.08-0.12 (2-3 sm boxes)
T wave represents
ventricular repolarization
PR interval represents
normal measurements?
mvmnt from SA node to AV node to bundle of his to perkinje fibers (before ventricals contract)
0.12-0.21 (3-5 small boxes)
QT interval represents
depolarization and repolarization of the ventricles
the time between the beginning of Q and the end of S
Prolonged QT can lead to what?
dysrhythmias
What does a widened QRS represent?
pt is havingk PVC’s, if ignored
can lead to v-tach
then v-fib
then asystole
What is a PVC?
What causes PVC’s
A ventricular contraction that happens at the wrong time
- Drugs
- caffeine
- post-op
- recent MI
Treatment for PVC’s, V-tach, and asystole
Antidysrhythmic
Amiodorone or Lidocaine
4 PVC’s in a row
V-tach
R on T phenomenon
When a PVC happens at the moment of ventricular refractory phase on the downslope of the preceding T wave, it can trigger V-tach or V-fib.
cardiovert vs. defib
- cardiovert- awake pt’s with consent, using less electricity, and sedated
- defib- pt’s who are pulseless, v-tach, and v-fib
Interventions for pt’s in v-tach with a pulse (stable)
- amiodorone 150
what is synchronized cardioversion
Why is it used?
The cardiovert machine synchronizes (press synchronize button) so that it delivers the shock at the highest point of the R wave.
To prevent the R on T phenomenon
interventions for v-fib
amiodorone
pulseless = cpr, amiodorone
interventions for V-tach with a pulse
Least invasive -> invasive
- Assess: BP, RR, chest pain?, pale? diaphoretic?,
- Amiodorone 150 over 10 minutes
- Still has a pulse and symptomatic =Cardiovert w sedation (diprovan)
Interventions for v-tach without a pulse
- Call for help
- CPR
- Epi q 3-5 mins
- shock
- CPR
- Amiodorone/lidocain/proconamide (enterchangeable) (1X)
what allergy is not compatable with diprovan (propofol)?
Eggs
interventions for Torsades
Mg+ push
Can you defib a pt in asystole/cardiac arrest
NO!
- CPR
- Epi
- Amiodorone
causes for cardiac arrest or PEA
H’s and T’s
- hydrogen prob. (acidotic)
- hypo-hyperthermia
- hypo/hyperkalemia
- hypoxia
- tension pneumo
- tamponade
- thrombus (PE or MI)
Rapid sequence intubation
When intubation is needed immediately due to ARDS, burns, etc
- sedate with versed or fentanyl
- paralyze
How to confirm ET tube placement
- bilateral chest expansion
- ascultate lungs
- C02 detector strip (gold)
- CXR
What causes the high pressure alarm to go off on a ventilator?
- check the tube for kinks etc
- pt is coughing
- pt bites the tube
- mucus plug
What causes the low pressure alarm to go off on a ventilator?
- the tubing is disconnected
- the patient pulled the tube out (extubation)
What do you do if you can’t find the cause of ventilator alarms going off?
Manually ventilate
Pneumonia symptoms
fever
increased HR
Increased WBC’s
crackles
sputum
PNU Patho
Bacterial, viral, or fungal infection of one or both lungs that cause the alveoli to fill with fluid or pus, causing them to stick together and not fill with air.
PE symptoms
Increased HR
Decreased BP
dyspnea
hemoptysis
fever
chest pain
Decreased 02
wheezing
crackles
blood in sputum
PE Patho
When a deep venous thrombi (DVT) detach and embolize to the pulmonary circulation, occluding the pulmonary arteries.
PE treatment
heparin or lovenox (sub-q)
DC’d on warfarin or apiciban
Labs for PE
D-dimer
ABG’s (hypoxia)
CT scan (dye –> shellfish allergy
VAP interventions
Bundle care:
- hand hygeine
- elevate HOB 30-45 (to prevent aspiration)
- reposition at least q 2hrs
- DVT prophylaxis - heparin and SCD’s
- Peptic ulcer prophylaxis - PPI’s and H2 blockers
- oral care with chlorahexadine
- sedation holiday
Causes of VAP
- hand hygeine
- cross contamination
- vent tubing ( drain away from pt)
- oral care
Signs of acute respiratory distress (ARDS)
Early:
- tachypnea –> resp alkalosis
- restlessness –> resp acidosis
- severe SOB
- labored breathing
- low BP
- confusion and extreme tiredness
Late:
- cyanosis
causes of ARDS
Sepsis
inhalants
severe pneumonia
head, chest, or other major injurt
Pancreatitis, massive blood transfusions, burns
Patho of ARDS
Inflammatory process destroys the alveoli epithelial lining making them more permeable. Fluid builds up in the alveoli, keeping lungs from filling with enough air, and less 02 reaches the bloodstream and to tissues and organs.
ARDS
- decreased compliance in alveoli - fibrotic and can’t stretch
- inadequate gas exchange
- chest white out (fluid build up that hardens)
- decreasing Pa02 despite increasing fiO2
- keep giving 02 and Pa02 still decreases
- refractory hypoxemia
ARDS treatment/interventions
- antibiotics
- increase peep
- prone position
- echmo
- fluid and electrolytes
- nutrition (TPN) (bc they are prone)
What is PEEP
Positive end-expiratory pressure
The pressure applied by the vent at the end of each breath that
keep alveoli from collapsing
What happens when there is too much PEEP
- it puts too much positive pressure into the lungs, increasing thoracic pressure, which can cause hypotension
- Can overinflate and explode alveoli
What position do you put a patient with ARDS with PEEP ventilation
Prone
* **when moving patient, always have one nurse watch the ET tube to prevent extubation
Haldol
med for dimentia
Haldol side effects
dysrhythmias
dry mouth
constipaiton
sedating
causes EPS
Medication for symptomatic bradycardia
Atropine
Atropine side efffects
anticholinergic
drys you out
increased HR
dilates pupils
