Exam 4 Flashcards
(371 cards)
1
Q
What organ are we worried about when dealing with electrical burns?
A
heart (dysrhythmias)
2
Q
What kind of precautions are electrical burn pts on?
A
C-spine precautions because bone could be fractured
3
Q
What is a 1st degree burn?
A
effects the epidermis
4
Q
What is a 2nd degree burn?
A
effects the dermis
5
Q
What does a 2nd degree burn look like?
A
shiny, moist, blistered
6
Q
What is a 3rd degree burn?
A
total skin destruction
7
Q
What does a 3rd degree burn look like?
A
black eschar, more white than level above
8
Q
What is a 4th degree burn?
A
bones, muscles, tendons
9
Q
What does a 4th degree burn look like?
A
dead tissue (don’t feel pain)
10
Q
What is priority with emergent care of burns?
A
personal safety
11
Q
When might care involve decontamination of the burn?
A
with chemical burns
12
Q
What are two major risks for people with burns?
A
hypothermia
infection
13
Q
Emergent care of wounds?
A
cool, lukewarm water and cover
14
Q
Why does the nurse elevate extremities with burns?
A
to counteract inflammation
15
Q
What is a major predictor of mortality in burn victims?
A
inhalation injuries
16
Q
What two side effects can quickly develop with inhalation injuries?
A
airway compromise
pulmonary edema
17
Q
What are the 3 types of inhalation injuries?
A
upper airway injury
lower airway injury
metabolic asphyxiation
18
Q
What is a key finding with carbon monoxide poisoning?
A
cherry-red facial color
19
Q
How does carbon monoxide poisoning work?
A
chemical binds with Hgb to decrease O2 carrying capacity
20
Q
What are S/S of an inhalation injury? (10)
A
soot in mouth/nose
AMS
pale skin
decreased O2 sat
productive cough
increased work of breathing
hoarseness
stridor
wheezy/crackly lung sounds
burnt nasal hairs or eyebrow hairs
21
Q
What is the duration of the resuscitation/emergent phase of a burn injury?
A
from onset of injury to completion of fluid resuscitation (72hrs)
22
Q
What is the focus during the resuscitation/emergent phase of a burn injury?
A
ABCs and hemodynamic stabilization
23
Q
What is the duration of the acute phase of a burn injury?
A
from beginning of diuresis to wound closure (72hrs)
24
Q
What is the focus during the acute phase of a burn injury?
A
maintenance of cardiovascular and pulmonary systems
25
When is fluid resuscitation present?
when pts start to diuresis
26
What is the duration of the rehab phase of a burn injury?
from wound closure to optimal physical mobility
27
What is the focus during the rehab phase of a burn injury?
psychosocial adjustment - return to society
28
What are complications during the emergent phase of burn injuries? (5)
electrolyte imbalances
hypovolemic shock
third spacing
inflammation
immune changes
29
What is third spacing?
inflammation makes capillaries permeable which causes the movement of fluid into interstitial spaces
30
What is the sodium imbalance with major burns?
hyponatremic (Na going into cell)
31
What assessment is priority with hyponatremia?
neuro assess
32
What is the potassium imbalance with major burns?
hyperkalemic (K going out of cell)
33
What assessment is priority with hyperkalemia?
cardiac assess
34
What infusion restores vasculature and fluid volume?
albumin
35
What is the isolation protocol with major burns?
reverse isolation
36
What do nurses use the Parkland Formula for?
fluid resuscitation
37
How much of total fluid vol does the nurse administer over the 1st 8hrs?
1/2
38
How much of total fluid vol does the nurse administer over the next 8hrs?
1/4
39
How much of total fluid vol does the nurse administer over the last 8hrs?
1/4
40
What are the goals to maintain during fluid resuscitation?
SBP >90
HR <120
MAP >65
Urine output 0.5mL/kg/hr
(30-50mL/hr)
41
Under what circumstances will a burn pt be transferred to a burn center? (6)
face, hands, feet, genitalia, major joints
partial thickness burns >10% TBSA
3rd degree burns
electrical or chemical burns
inhalation injury
circumferential
42
What does circumferential mean?
burns are all the way around extremities, thorax, or neck
43
What is a high risk for circumferential burns?
compartment syndrome
44
With what type of burn injury is the development of compartment syndrome common?
full thickness injury; leathery eschar appearance
(3rd/4th degree burns)
45
What are S/E of compartment syndrome? (3)
lack of pulse in distal extremities
absence of movement
deep, aching pain
46
What is a escharotomy?
longitudinal incisions to relieve pressure from edema
47
What does cleaning the burn wound stimulate?
granulation and revascularization
48
What are 3 interventions for managing burn wounds?
debridement
hydrotherapy
dressings
49
How often are dressing changes with burn wounds?
daily
50
How often are dressing changes with skin grafts for burn wounds?
occlusive; changed q3-5 days
51
When can a nurse begin caring for a skin graft?
after the surgeon inspects it
52
What are 3 disorders of wound healing?
scars/keloids
contractures
failure to heal
53
What is autograft?
receiving a graft from your own tissue
54
What is allograft?
receiving a graft from another living thing
55
What interventions are included in nursing management of burns? (7)
PPE
airway management
fluid therapy
pain management
wound care
nutrition therapy
tetanus shot
56
Which meds are used IV during the emergent and acute phases of burn injuries?
morphine
fentanyl
57
Which meds are used for anxiety and pain management for burn injuries?
Lorazepam (ativan)
Midazolam (versed)
58
What are priority nursing management interventions during the acute phase of burn injuries? (5)
labs
infection
mobility
GI system
excision & grafting
59
What can happen to the GI system after a burn injury?
paralytic ileus, stress ulcers
intervention: NG tube
60
What kind of diet is recommended to a burn pt?
high calorie, high protein, high carbohydrate diet
61
Amount and frequency of meals for burn pt?
small portions, frequently
62
What meds are prescribed to burn pts to provide nutritional support?
insulin
carafate
histamine blockers
63
5-12 days after a traumatic injury what might happen to calorie needs?
double or triple
up to 5,000kcal
64
What is a nutritional high risk for burn pts?
hyperglycemia bc of insulin resistance
65
What is the MOA of Carafate?
coats lining of esophagus to prevent ulcers from forming
66
What are interventions for maintaining mobility with burn pts?
positioning
ROM exercises
ambulation
compression dressings
67
What is included in home care instructions for burn pts? (7)
skin & wound care
exercise & activity
physical & occupational therapies
nutrition
pain management
thermoregulation & clothing
mental health counseling
68
What is the exocrine function of the pancreas?
manufactures and secretes digestive enzymes
69
What enzyme breaks apart carbohydrates?
amylase
70
What enzyme breaks apart fats?
lipase
71
What enzymes break apart protein?
trypsin
chymotrypsin
72
What is the endocrine function of the pancreas?
manufactures and secretes insulin and glucagon
73
Pathophysiology of pancreatitis?
enzymes that are usually inactive until they reach the small intestine are activated in the pancreas and prompts inflammation
74
What is a hallmark sign of acute pancreatitis?
lipolysis
75
What occurs during lipolysis to the pancreas?
auto-digestion of pancreas (fibrosis)
76
Proteolysis may lead to...
thrombosis & gangrene of pancreas
77
What electrolyte imbalance is common with lipolysis?
hypercalcemia
78
What are pts at a high risk for because of proteolysis & necrosis of the pancreas?
risk for bleeding because of vasodilation
79
What might inflammation look like with acute pancreatitis?
pus formation, lesions
80
What are signs of acute pancreatitis?
lipolysis
proteolysis
necrosis of blood vessels
inflammation
81
How is chronic pancreatitis diagnosed?
repeated episodes (flare ups) of acute pancreatitis
82
What is the pathophysiology of chronic pancreatitis?
pancreatic secretions precipitate and plug pancreatic ducts leading to inflammation, fibrosis, ulcer formation, and the destruction of the secreting cells
83
What is the etiology of chronic calcifying pancreatitis?
alcoholism
84
What is the etiology of chronic obstructive pancreatitis?
inflammation, cholelithiasis
85
What is the etiology of autoimmune/genetic chronic pancreatitis?
immunoglobulins invade pancreas
86
What are pts with autoimmune/genetic chronic pancreatitis at a high risk of developing?
pancreatic cancer
87
What is the most common risk factor for pancreatitis?
gallstones
88
What are risk factors for developing pancreatitis? (7)
middle-aged man
alcoholism
trauma
smoking
familial
viral infection/abscesses
hyperlipidemia
89
What medications can cause pancreatitis? (3)
thiazides
NSAIDS
salicylates
90
If the cause of pancreatitis is related to alcoholism what is the prognosis?
poor
91
During what times of the year is pancreatitis most common?
during the holidays and vacation times
92
Manifestations of acute pancreatitis? (8)
N/V
Fever
Jaundice
Confusion & agitation
Ecchymosis in the flank or umbilical area
Hypovolemia & shock
Renal failure
Ascites
93
What is the key manifestation of acute pancreatitis?
severe abdominal pain
94
Manifestations of chronic pancreatitis?
Recurrent attacks of intense abdominal pain & back pain
Vomiting
Wt loss
Jaundice; dark urine
Foul smelling fatty stools (Steatorrhea)
S/S of diabetes
95
What are the 3 P's of diabetes?
polyphagia
polydipsia
polyuria
96
What assessments are important for the nurse to perform on pts with pancreatitis?
GI & Skin assessments
97
What is Grey-Turner's sign?
flank bruising indicating acute pancreatitis
98
What is Cullen's sign?
bruising around the umbilicus indicating acute pancreatitis
99
What is a lab result that is highly indicative of acute pancreatitis?
elevated amylase within 12-24hrs
100
Which lab results are elevated with pancreatitis?
amylase
lipase
glucose
WBC
101
Which lab results are decreased with pancreatitis?
calcium & magnesium
102
What is ERCP?
Endoscopic Retrograde Cholangiopancreatography: invasive procedure where they inset stents or remove cysts
103
What two radiology diagnostics are utilized to diagnose pancreatitis?
CT
ultrasound
104
What is the primary nursing diagnosis associated with pancreatitis?
acute pain related to inflammation & enzyme leakage
105
What opioid medications are often prescribed to help manage acute pain related to pancreatitis?
morphine
dilaudid
fentanyl
(PCA pump)
106
What histamine receptor antagonists is often prescribed to help manage pancreatitis?
ranitidine
107
What PPI is often prescribed to help manage pancreatitis?
prilosec
108
What nursing intervention is often performed to manage pancreatitis?
NG tube insertion to decompression the stomach
109
What position often provides the most comfort to pts with pancreatitis?
fetal position
110
Why are PPI's prescribed to pts with pancreatitis?
decreasing gastric acid production can promote enzyme replacement
111
What are secondary and tertiary nursing diagnoses for pancreatitis?
risk for fluid volume deficit related to fluid shifts
imbalanced nutrition less than body requirements
112
What are 3 nursing interventions for the risk for fluid vol deficit associated with pancreatitis?
IVF- isotonic solution (NS 150mL/hr)
NPO during acute period
I & O
113
What are 3 nursing interventions for imbalanced nutrition less than body requirements associated with pancreatitis?
NPO
antiemetics
enteral tube feeding
114
When is enteral feeding often initiated?
if NPO for 24-48hrs & no ileus
115
What must pts recovering from pancreatitis avoid when they return home?
alcohol & high fat foods
116
How many kcal may a pt with pancreatitis need a day?
4,000-6,000
117
What are 10 complications of pancreatitis?
death
infection (shock)
decreased CO (hypovol shock)
AKI
paralytic ileus
pleural effusion (L)
ARDS
DIC
MODS
DM type II
118
When can a pancreatitis pt discontinue the NPO status?
when serum amylase is normal, active bowel sounds, and no pain
119
What is pt education the nurse should provide when the pancreatitis pt is beginning to eat and drink again?
moderate to high carb, high protein, low fat diet
small, frequent, bland meals
avoid caffeine products
eliminate alcohol
may need pancreatic enzyme supplements
120
What additional pt education points may the nurse provide to the pancreatitis pt?
relaxed atmosphere
smoking cessation
121
What are S/S of pancreatitis complications? (8)
anorexia
n/v
abdominal distention with increasing fullness
persistent wt loss
severe epigastric or back pain
frothy/foul smelling BM
irritability, confusion
persistent fever
122
Because of hyperthyroidism what state does the body enter?
hyper-metabolic state
123
What hormones does the thyroid produce?
calcitonin
T3
T4
124
What are two risk factors for developing hyperthyroidism?
graves disease (autoimmune)
thyroiditis
125
What is the role of the pituitary gland?
promotes secretion and regulation of thyroid
126
What diagnostics are preformed to diagnose hyperthyroidism?
ultrasound
EKG
thyroid scan
127
In hyperthyroidism, the blood TSH level is
decreased
128
In hyperthyroidism, the T3 & T4 level is
elevated
129
What is a thyroid scan?
nuclear medicine
administer radioactive isotope day before scan and if there is elevated uptake of the isotope, hyperthyroidism can be diagnosed
130
What are nursing interventions for hyperthyroidism?
calm environment/safety
nutrition support, I & O, wt
eye protection (eye drops)
lower room temp (cold showers)
131
What medications are used to help manage hyperthyroidism?
thionamides (methimazole, propylthiouracil)
beta blockers
iodine solutions
132
What is the MOA of thioamides for hyperthyroidism?
inhibit the production of thyroid hormones by decreasing iodine use
133
What is the indication of beta blockers for hyperthyroidism?
palpitations
tachycardia
134
What is the MOA of iodine for hyperthyroidism?
short-term use
inhibit production of thyroid hormones
135
What are the treatments for hyperthyroidism?
iodine therapy
thyroidectomy
136
What are complications associated with a thyroidectomy? (5)
hemorrhage
thyroid storm/crisis
airway obstruction
hypocalcemia
nerve damage (vocal cords)
137
What is the MOA of iodine therapy?
destroys some thyroid producing cells
138
When is iodine therapy contraindicated?
pregnancy
139
What does iodine administration decrease?
size of thyroid gland
bleeding
140
What position should the pt be in after a thyroidectomy?
semi-folwers
141
What is a thyroid storm?
Common with graves disease and involves increased circulation of thyroid hormones in the blood.
142
What can be the result of thyroid storm?
high mortality rate
hypermetabolic state
143
What are S/S of thyroid storm? (6)
hyperthermia
HTN
SOB
delirium
vomiting
abdominal & chest pain
144
What are S/S of hypocalcemia? (3)
tetany
tingling of fingers/toes
convulsions
145
What condition can onset rapidly with hypothyroidism?
myxedema
146
What state does the body enter with hypothyroidism?
hypometabolic state
147
Why does hypothyroidism often go unnoticed?
can mimic normal aging process
148
What are risk factors for hypothyroidism? (3)
female (30-60 years)
inadequate intake of iodine
radiation therapy to head/neck
149
What area experiences hair loss with hypothyroidism?
eyebrows
150
What is myxedema?
swelling of face, tongue, hands
151
What diagnostics are performed to diagnose hypothyroidism?
thyroid scan
EKG
152
In hypothyroidism, the T3 and T4 level are
decreased
153
In hypothyroidism, the TSH level is
increased
154
In hypothyroidism, the cholesterol level is
increased
155
What are nursing interventions for managing hypothyroidism? (5)
monitor cardiac and respiratory systems
monitor wt, dietician consult
skin care
warming measures
stool softeners
156
What kind of diet is recommended with hypothyroidism?
low calorie/high bulk diet
157
What should the nurse refrain from administering to pts with hypothyroidism?
fiber laxatives
158
What is the treatment for hypothyroidism?
thyroid hormone replacement therapy
159
What is a possible complication of untreated hypothyroidism?
myxedema coma
160
What are S/S of myxedema coma? (5)
cold
respiratory failure
low BP
low BS
low HR
161
What kind of metabolism produces a build-up of lactic acid?
anaerobic
162
What are the 4 types of shock?
distributive
hypovolemic
cardiogeneic
obstructive
163
What are the 2 subcategories of hypovolemic shock?
absolute & relative
164
What is absolute hypovolemic shock?
external loss of whole blood or bodily fluids
165
What is relative hypovolemic shock?
fluid volume moves out of intravascular spaces and into interstitial spaces
166
What is obstructive shock?
there is a physical obstruction distrupting the heart's functioning
167
What kind of complications can cause obstructive shock?
tension pneumothorax
cardiac tamponade
PE
168
What is cardiogenic shock?
the heart's fault
169
What kind of complications can cause cardiogenic shock?
MI
dysrhythmias
170
What are the 3 types of distributive shock?
anaphylactic
neurogenic
septic
171
What is distributive shock?
excessive vasodilation that impairs blood flow
172
What are cardiovascular manifestations of shock?
tachycardia
hypotension
decreased cap refill
173
What is a cardiovascular manifestation unique to neurogenic distributive shock?
bradycardia
174
What are respiratory manifestations of shock?
tachypnea
175
What are respiratory manifestations specific to anaphylactic distributive shock?
wheezing
stridor
SOB
176
What are renal manifestations associated with shock?
decreased urinary output
177
What is a renal manifestation unique to neurogenic distributive shock?
bladder dysfunction
178
What are integumentary manifestations of shock?
pallor
cool, clammy skin
179
What are integumentary manifestations unique to septic distributive shock?
flushed skin
high temp
180
What are neurological manifestations associated with shock?
anxiety
confusion/agitation
AMS
181
What neurological manifestations are unique to neurogenic distributive shock?
flaccid paralysis
loss of reflexes
182
What are GI manifestations associated with shock?
hypoactive or no bowel sounds
183
What are GI manifestations unique to neurogenic distributive shock?
bowel dysfunction
184
What are GI manifestations unique to anaphylactic distributive shock?
n/v
185
What is involved in the initial stage of shock?
no manifestations except a build-up of lactic acid
186
What is involved in the compensatory stage of shock?
body is mounting measures to increase CO to restore tissue perfusion and oxygenation
187
What is involved in the progressive stage of shock?
compensatory mechanisms begin to fail
188
What is involved in the refractory stage of shock?
irreversible: total body failure
MODS
189
What are the 4 stages of shock?
initial
compensatory
progressive
refractory
190
What is the overall goal of treatment for cardiogenic shock?
restore blood flow to myocardium by restoring balance between O2 supply/demand
191
What is a priority nursing intervention for cardiogenic shock?
provide supplemental O2
192
What is the medical treatment for cardiogenic shock?
minimal fluid replacement
193
What pharmaceuticals may be prescribed with cardiogenic shock?
nitrates (nitro)
diuretics (furosemide)
dopamine/dobutamine
194
What should the nurse be cautious of when administering nitrates?
hypotensive manifestations
195
What is the MOA of diuretics?
decrease preload
196
What is the MOA of dopamine?
increase myocardial contractility
197
What is the MOA of dobutamine?
vasopressor
increase myocardial contractility
198
What are diagnostics utilized for cardiogenic shock?
CXR
EKG
lactic acid
199
What is the overall goal for hypovolemic shock?
stop the cause/bleeding/injury
200
What is the treatment for hypovolemic shock?
rapid fluid replacement
201
What is the 3:1 rule?
3mL of isotonic solution for every 1mL of estimated blood loss
202
What medications may be utilized with hypovolemic shock?
vasopressors (norepinephrine) Levophed
203
What is the positioning for optimal venous return?
supine w/ legs elevated
204
When would the nurse move to blood infusion when initiating fluid replacement?
after 500mL (1L) of fluids
205
What could happen to blood vessels if the nurse implements the use of vasopressors without initiating rapid fluid replacement?
they could collapse
206
What are the priority nursing interventions for hypovolemic shock?
providing supplemental O2
IV fluid bolus
bedrest while supine w/ legs elevated
207
What is the first manifestation the nurse will notice with a pt experiencing hypovolemic shock?
tachycardia
208
What is the overall goal of obstructive shock?
manage the obstruction
209
What interventions may be implemented to treat obstructive shock?
mechanical decompression
anticoagulation therapy
radiation, debulking, or removal of the mass/cause
210
What are 2 common causes of neurogenic shock?
SCI
spinal anesthesia
211
What is the patho of neurogenic shock?
loss of SNS vasoconstrictor tone = blood pooling & tissue hypoperfusion
212
What are manifestations associated with neurogenic shock?
hypotension
bradycardia
temperature dysregulation
213
What is poikilothermic?
the pt's temperature matches that of the room's
214
What medication can be used to treat hypotension?
vasopressor (Phenylephrine)
215
What is the difference btw neurogenic & spinal shock?
neurogenic shock is a hemodynamic condition
216
What does an allergic reaction cause systematically?
massive vasodilation
217
What is the patho of septic shock?
vasodilation = maldistribution of blood flow
218
What is the integumentary response during the progression of septic shock?
warm/flushed initially then progresses to cool/clammy
219
What lab values are elevated with septic shock?
lactic acid
BG
220
What is the treatment for septic shock?
the 1hr bundle
221
What diagnostics are utilized with the 1hr bundle?
CBC/CMP
blood cultures
lactate
blood coag studies
ABGs
222
What are the steps of the 1hr bundle?
1. draw lactic acid level
2. draw blood cultures
3. admin broad spectrum antibiotics
4. admin 1,000mL NS bolus
5. If pt remain hypotensive, admin Levophed
223
What is an elevated lactic acid level?
>2
224
What is a very elevated lactic acid level?
>4
225
What is the standard fluid replacement rate?
30mL/kg
226
What must be present to diagnose as MODS?
failure of 2 or more organ systems
227
What occurs to the pt's metabolism when experiencing SIRS?
hypermetabolic
228
SIRS?
systemic inflammatory response syndrome
229
What body system is the first to demonstrate MODS?
respiratory
230
MODS?
multiple organ dysfunction syndrome
231
What are respiratory findings associated with MODS?
alveolar edema (crackly)
ARDS (intubation)
232
What are cardiac findings associated with MODS?
decreased cap refill
dysrhythmias
233
What are neurologic findings associated with MODS?
comatose (extreme hypoxia)
234
What are renal findings associated with MODS?
AKI (accumulation of toxins)
235
What are metabolic findings associated with MODS?
hyperglycemia
insulin resistance
236
What are hepatic findings associated with MODS?
cannot covert lactic to glucose therefore the pt becomes hypoglycemic
237
What symptoms can indicate SIRS?
abnormal temp
increased RR
increased HR
abnormal WBC
decreased PCO2
238
What is WBC range?
4,000-12,000
239
How many symptoms must the pt exhibit to classify as SIRS?
2
240
What are the qualifications for classification of sepsis?
2 sirs
+
confirmed or suspected infection
241
What are the qualifications for classification of severe sepsis?
sepsis
signs of end organ damage
hypotension
lactate >4
242
What are the qualifications for classification of MODS?
presence of altered organ function
high levels of toxins
243
What are the qualifications for classification of septic shock?
severe sepsis w/ persistent hypotension
lactate >4
end organ damage
244
What are the 7 complications of shock?
MODS
ARDS
AKI
GI distress
hypermetabolic/catabolic
clotting issues
electrolyte imblances (acidotic)
245
What is DIC?
thousands of small clots form within organ capillaries, creating hypoxia & anaerobic metabolism = platelets and other clotting factors to be depleted = hemorrhage?
246
What happens to the platelet count with DIC?
decreases
247
What happens to the D-dimer with DIC?
increases
248
What happens to fibrinogen with DIC?
decreases
249
What happens to PT/aPTT with DIC?
increases
250
What is the nurse's priority with DIC?
watch for excess bleeding
251
What should the nurse be prepared to admin for DIC treatment?
heparin
platelets
clotting factors
PRBC's
252
PAWP value?
6-12mmHg
253
MAP value?
>65mmHg
254
CVP value?
2-8mmHg
255
What does the CVP tell you?
how well blood is being pumped back to the heart
256
What does a high CVP indicate?
cardiogenic shock
257
What does a low CVP indicate?
hypovolemic shock
258
SV value?
60-160mL/beat
259
CO value?
4-8L/min
260
Alpha receptors MOA?
increase vasoconstriction
261
Beta 1 receptors MOA?
increase myocardial contractility
262
Beta 2 receptors MOA?
vasodilation of bronchi
263
What are the 3 vasopressors?
epinephrine (adrenaline)
norepinephrine (levophed)
dopamine
264
What are low doses of EPI used for?
code symptoms
anaphylactic shock
(cardiac stimulation & bronchodilation)
265
What are high doses of EPI used for?
IV drip
(peripheral vasoconstriction)
266
What is the gold standard med for treatment of septic shock?
norepinephrine (Levophed)
267
With what shock subcategories is dopamine utilized more often?
cardiogenic shock
septic shock
268
Why are vasopressors high risk meds?
they need to be administered with a central line because they can damage tissue
269
Dobutamine MOA?
positive inotropic med
270
What does a positive inotropic med do?
increased cardiac contractility
271
Why is dobutamine often administered with a vasopressor?
because it can cause vasodilation
272
With which type of shock is dobutamine most often utilized?
cardiogenic shock
273
What is vasopressin?
synthetic ADH (antidiuretic hormone)
274
What is the MOA of vasopressin?
ADH: Adds Da H2O to the body
(retain fluid, increase BP)
275
Nursing considerations for vasopressin?
monitor I & O
high risk med (central line)
276
Equation for CO?
HR x SV
277
SVR when vessels dilate?
decreases
278
SVR when vessels constrict?
increases
279
What is CO?
amount of blood pumped through the heart each miin
280
What is SV?
amount of blood pumped through the heart with each beat
281
Preload?
how much vol is pumping through system
282
Afterload?
forces opposing ejection
283
What is the trauma triad of death?
hypothermia
acidosis
coagulopathy
284
What are the 3 points after injury that a head injury could cause death?
immediately after
within 2hrs
about 3 weeks after
285
What are the 2 biggest causes of TBI?
falls and MVA
286
What are the 2 types of head injuries?
scalp lacerations
skull fractures
287
What are the 2 major complications associated with scalp lacerations?
blood loss
infection
288
What are the 3 major complications associated with skull fractures?
infection
hematoma
tissue damage
289
What are 2 signs of TBI?
raccoon eyes
battle's sign
290
What is battle's sign?
bruising behind ear
291
When present what indicates the presence of CSF leakage?
glucose
292
What are the tests for CSF leaks?
dextrostix
tex-tape
B2 transferrin
halo sign
293
If there is CSF leakage what is a possible complication?
meningitis
294
What is the gold standard test for CSF leak?
B2- Transferrin
295
What are 2 examples of diffuse head injuries?
concussion
diffuse axonal injury
296
What is a minor diffuse head injury GCS score?
13-15
297
What is a severe diffuse head injury GCS score?
3-8
298
What are 2 examples of focal head injuries?
contusion
hematoma
299
What are unique S/S of focal head injuries?
headache & pupillary effects on affected side
S/S on opposite side of injury
300
What does the GCS assess?
eyes
voice
motor
301
What are early signs of increased ICP?
decreased LOC
irritability
sleepiness
flat affect
headache
vomiting
302
What are late signs of increased ICP?
cushing's triad
seizures
coma
abnormal posturing
pupillary changes
303
What is Cushing's Triad?
HTN (wide pulse pressure)
bradycardia
cheyenne-stokes respirations
304
What are S/S of post-concussion syndrome?
persistent headache
lethargy
personality changes
shortened attention span
decreased short-term memory
changes in intellectual ability
305
What TBI has the highest mortality rate?
diffuse axonal injury
306
Who is at high risk for developing a contusion head injury?
elderly pts on anticoagulants
307
Which hematoma type is a medical emergency and why?
epidural bc it develops quickly
308
When does an intracerebral hematoma occur?
2-14 days
309
When does a subarachnoid hematoma occur?
weeks-months after injury
310
At what pressure does the nurse want to maintain SBP at with head injury pts?
>100mmHg
311
What is the best diagnostic test to evaluate for head trauma?
CT scan
312
What does a transcranial doppler measure?
cerebral blood flow velocity
313
If a pt loses consciousness for greater than ____min more severe complications?
30
314
What factors make up content of brain?
CSF
intravascular blood
brain tissue
315
What factors influence ICP?
intrabdominal & intrathoracic pressure
posture
temp
CO2 levels
316
What kind of relationship does CSF, intravascular blood, and brain tissue have?
inverse
317
What is the Monro-Kellie Doctrine?
compensatory mechanisms to maintain normal ICP
*after injury, initially no increase in ICP
318
What is the normal ICP?
5-15mmHg
319
What ICP value requires treatment?
>20mmHg
320
What is the normal CPP value?
80-100mmHg
321
What CPP value causes cerebral ischemia?
<60mmHg
322
What CPP value indicates brain death?
<30mmHg
323
How is CPP calculated?
MAP-ICP
324
What are the first 2 symptoms noticed with decreasing CPP?
dizzy
blurred vision
325
What meds do nurses use to manipulate MAP?
pressors
326
What meds do nurses use to manipulate ICP?
mannitol/hypertonic solutions
327
How many stages of increased ICP are there?
4
328
What is involved in the 3rd stage of increased ICP?
failing compensation
(Cushing's triad)
329
If ICP is elevated for too long what is the result?
brain herniation (respiratory changes)
330
When auto-regulation of cerebral blood flow fails what is the result?
cerebral edema
331
What is the normal PCO2 level?
35-45
332
What is the result of increased CO2 on cerebral blood flow?
dilates cerebral blood vessels and increases ICP
333
What is the result of decreased CO2 on cerebral blood flow?
severe vasoconstriction resulting in severe hypoxia
334
What does the pupillometer do?
measures pupil at peak dilation
335
When does the RN need to report to the provider a pupillary change?
>1mm
336
What is the normal pupil exam?
3-4mm
337
With an EVD the transducer must be level with the?
tragus of the ear
338
What increases the risk of infection with EVD?
in place more than 5 days
CSF leak
systemic infection
339
What cleaning technique is used when working with EVD?
aseptic
340
When might the provider instruct the RN to remove CSF from EVD?
>20
341
How long must the EVD be clamped for an accurate reading of CSF vol drained?
at least 6min
342
What is the time frame for intermittent drainages of CSF with an EVD?
30-120 sec
343
What is a possible complication if more than 20mL of CSF is drained in a hr?
ventricles could collapse
344
What kind of drug is mannitol?
osmotic diuretic
345
Route of admin for mannitol?
IV
346
How does mannitol decrease IVP?
plasma expansion
osmotic effect
347
What does the RN monitor with the admin of mannitol or hypertonic solutions?
serum electrolytes
BP
348
What are 2 examples of hypertonic solutions?
3% NaCl
D5W
349
What medication is given as a prophylactic for GI bleeds and gastric ulcers?
H2 Receptor Antagonists
Ranitidine (Zantac)
350
What medication is given to pts with increased ICP as antiseziure?
phenytoin (Dilantin)
351
What can be a S/E of propofol?
hypotension
352
What are the 3 main nursing interventions for increased ICP?
maintain patent airway
ICP within normal limits
normal fluid & electrolytes
353
What can raise abdominal pressure?
hip flexion
354
What are nursing considerations with suctioning?
maximum of 2 passings
maximum of 10sec
oxygenate before and after
355
Why might a pt with increased ICP have an NG tube?
nutrition and prevent abdominal distension
356
Diabetes Insipidus is caused by
decrease of ADH (hypernatremia)
357
What is the treatment for Diabetes Inspidus?
fluid replacement
358
SIADH is caused by
excess ADH (hyponatremia)
359
At what temp does the RN want to maintain a pt with increased ICP?
96.8-98.6
360
What opioids are commonly used with increased ICP pts?
fentanyl & morphine
361
MOA of propofol (Diprivan)?
used to manage anxiety & agitation (sedation)
* doesn't control pain
362
MOA of Precedex (Dexmedetomedine)?
sedation
*no pain control
363
MOA of Nimbex (Cisatracuriu m)?
sedation
* no pain control
364
Why might benzos not be used with treatment of increased ICP?
longer effects
hypotension
365
Urinary output with diabetes insipidus?
high
366
Urinary output with SIADH?
low
367
Specific gravity of diabetes insipidus urine?
low (dilute urine)
368
Specific gravity of SIADH urine?
high (concentrated urine)
369
What is the treatment for SIADH?
diuretics, fluid restriciton
370
What kind of disorders of TBI pts most at risk for developing?
seizure disorders
371
Personality changes are expected after pt is comatose for?
6hrs or more
