exam 2 Flashcards
Neuro: Describe the characteristics of Cushing’s Triad
Cushing’s triad refers to a set of signs that are indicative of increased intracranial pressure (ICP), or increased pressure in the brain. Cushing’s triad consists of bradycardia, irregular respirations, and a widened pulse pressure
Describe early and late signs of increased intracranial pressure
Early: Restlessness, agitation, change in level of consciousness, mental status change, vomiting without nausea
Late: irregular breathing, seizures, posturing, fixed & dilated pupils, coma, cushing’s triad
Neuro: Describe Cheyne Stokes respirations
A respiratory pattern that involves a period of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all
Cheyne Stokes is a late sign of increased intracranial pressure
Neuro: Explain the ICPS acronym for use of a patient with an ICP monitor
ICPS is the acronym used to remember ways to prevent spikes in intracranial pressure
I- immobilize the C-spine
C- keep CO2 low in order to prevent vasodilation
P- keep head of bed 30-45 degrees
S- limit the amount of times you suction, hyperventilate when you do suction, and limit attempt to less than 10 seconds.
Neuro: Describe levels of consciousness using the Glascow Coma Scale (GCS)
The higher the score on the GCS, the less severe the impact of an injury.
13-15 = mild
9-12 = moderate
3-8 = severe
A decrease in the GCS score is a priority for reporting to the doctor because it indicates a decrease in level of consciousness
Neuro: Describe the use of Mannitol for management of ICP including side effects
Mannitol is an osmotic diuretic that elevates blood plasma osmolality, resulting in enhanced flow of water from tissues, including the brain and cerebrospinal fluid, into interstitial fluid and plasma. However, it can also cause fluid to shift into the interstitial space leading to peripheral edema and if not treated, heart failure
Neuro: Describe the rationale for slowly decreasing blood pressure of a hypertensive patient who is recovering from a stroke
Patients who experience a hypertensive stroke should have careful management of their blood pressure so that a pseudo hypotensive state is not induced. This is done by slowly decreasing the systolic pressure over a period of 24-48 hours.
Neuro: Describe the goal times for tPA treatment for an embolic stroke
The goal for treating an embolic stroke with tPA are time oriented. Best practice is to start tPA within 4 hours of last known well time and within 60 minutes of arrival at treatment center
Neuro: Describe autonomic dysreflexia and the priority actions for treatment
Autonomic dysreflexia is a emergent condition that occurs in people with a spinal cord injury occurring at level T5-T6 who are experiencing a stimulus somewhere below the level of injury. Patients present with a sudden increase in blood pressure, decreased heart rate, anxiety, headache, diaphoresis, and skin flushing above the injury site.
The priority action is to eliminate the source of stimuli and then treat the symptoms caused by the condition.
Common stimuli include a blocked urinary catheter, full bladder, urinary tract infection, fecal impaction, tight clothing, and many other possible stimuli.
Neuro: Describe the priority for caring for patients with known seizure disorder
Patient safety is the priority for seizure patients. This includes padded bedrails, bed in lowest position, suction set up, side-lying position
Cardiac: Describe the primary causes of decreased cardiac output
Anything that disrupts normal circulating volume causing hypovolemia; and conditions that compromise cardiac muscle function or electrical function.
Cardio: Explain why defibrillation takes priority over any other intervention when a patient is in ventricular fibrillation
The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm.
Cardio: Describe the characteristics of Atrial Fibrillation
In A. Fib, there are multiple foci of electrical stimulation in the atria which makes the isometric line of the ECG appear squiggly and without a visible P wave. The QRS complex is present because occasional beats are fully conducted.
Describe the process of using a central line for medication delivery or blood draw.
When using a central line, you must use aseptic technique, check that the dressing is pristine and the site is free of signs of infection. Before using the line, scrub the hub for at least 15 seconds, use a 10cc syringe, and change the cap if blood is drawn.
Cardiac: Describe Mean Arterial Pressure and how to calculate it
MAP is the average arterial pressure during one cardiac cycle and is an indicator of tissue perfusion. Normal MAP is 70-100 and is calculated by taking SBP (+) 2 (DBP) divided by 3.
Cardio: Describe the appearance of ventricular tachycardia
Rate: fast
Rhythm: Regular
P wave: no
QRS: wide and bizarre
T: no
Cardio: Describe the characteristics of endocarditis
Endocarditis is an infection on the inner layer of the heart. Often it will manifest as vegetation on the valves. It can be caused bacteria, virus, or fungus. People experience fever, chills, weakness, fatigue, malaise, and anorexia.
Cardio: Describe why Amiodarone is the treatment of choice for a patient who converts into ventricular tachycardia but has a pulse
Ventricular tachycardia with a pulse is not defibrillated nor is CPR started. Pacing is not indicated. The rhythm will be treated with antiarrhythmics
Lines: Describe a normal assessment of an arterial line
The extremity distal to the arterial line should be warm to the touch and have sensation that is baseline for the patient. The site should be visible without excessive drainage and the surrounding tissue should be soft. Any altered findings should be reported immediately
Lines: Describe a normal assessment of an arterial line
The extremity distal to the arterial line should be warm to the touch and have sensation that is baseline for the patient. The site should be visible without excessive drainage and the surrounding tissue should be soft. Any altered findings should be reported immediately
Lines: State the concept of the transducer used in arterial line pressure measurement.
The transducer is the part of the arterial line that ensures proper pressure readings through its connection to the closed pressure system. In order for accurate pressures to be seen, the transducer must remain at the phlebostatic axis located at midaxillary, 4th intercostal space of the patient.
Cardio: State the arrhythmias that are shockable and describe why defibrillation is the priority action
Ventricular Fibrillation and Pulseless Ventricular Tachycardia
Both of these are incompatible with life because there is virtually no cardiac output due to the left ventricle not squeezing efficiently.
Discuss the relationship between cardiac arrhythmias and tissue perfusion
Cardiac arrhythmias can impact cardiac output due to the fast or slow rate or the disrupted electrical conduction
Cardiac: Describe the mechanism of action for Adenosine and what it is used for.
Adenosine slows the conduction through the AV and SA nodes, thereby disrupting erratic cardiac electrical activity. It is used in the treatment of SVT that is unresponsive to other methods of conversion. Adenosine must administered with consent from the patient, a physician at the bedside, and defibrillation pads in place.
Cardiac: Describe pericarditis with clinical manifestations and complications
Clinical manifestations of pericarditis may include sharp pain in the chest, anxiety, dyspnea, a friction rub, and fever. Complications that should be reported immediately may be cardiac tamponade, low blood pressure, muffled heart sounds.
Cardiac: Describe the mechanism of action for Atropine and what is is used for
Atropine increases the sympathetic nervous system drive and depresses the parasympathetic drive thereby increasing the heart rate. Atropine can be used to treat symptomatic bradicardia.
CVC: Describe nursing measures to prevent CLABSI (central line associated blood stream infection)
Scrub the hub for at least 15 seconds and allow to dry for 15 seconds before administering medications or drawing blood
Assess site for any sign of warmth, redness, or drainage
Practice excellent hand hygiene
Check the dressing and keep it pristine
Art. Line: Describe the purpose of the transducer used with a radial arterial line
when a patient has an arterial line, the transducer should be placed at the phlebostatic axis, which is approximated at the 4th intercostal space and midaxillary line. The purpose of the transducer is to provide an interface between the a.line catheter and the monitor using pressure. A misplaced transducer will not give accurate data for intravascular and intracardiac pressure.
CVC: Explain a pneumothorax as a complication of a subclavian central line insertion
The location of a subclavian central line present a high risk for lung puncture during the insertion process. In this instance, the patient would demonstrate diminished breath sounds on the affected side
