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PCC IV > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

What organ are we worried about when dealing with electrical burns?

A

heart (dysrhythmias)

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2
Q

What kind of precautions are electrical burn pts on?

A

C-spine precautions because bone could be fractured

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3
Q

What is a 1st degree burn?

A

effects the epidermis

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4
Q

What is a 2nd degree burn?

A

effects the dermis

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5
Q

What does a 2nd degree burn look like?

A

shiny, moist, blistered

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6
Q

What is a 3rd degree burn?

A

total skin destruction

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7
Q

What does a 3rd degree burn look like?

A

black eschar, more white than level above

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8
Q

What is a 4th degree burn?

A

bones, muscles, tendons

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9
Q

What does a 4th degree burn look like?

A

dead tissue (don’t feel pain)

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10
Q

What is priority with emergent care of burns?

A

personal safety

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11
Q

When might care involve decontamination of the burn?

A

with chemical burns

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12
Q

What are two major risks for people with burns?

A

hypothermia
infection

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13
Q

Emergent care of wounds?

A

cool, lukewarm water and cover

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14
Q

Why does the nurse elevate extremities with burns?

A

to counteract inflammation

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15
Q

What is a major predictor of mortality in burn victims?

A

inhalation injuries

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16
Q

What two side effects can quickly develop with inhalation injuries?

A

airway compromise
pulmonary edema

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17
Q

What are the 3 types of inhalation injuries?

A

upper airway injury
lower airway injury
metabolic asphyxiation

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18
Q

What is a key finding with carbon monoxide poisoning?

A

cherry-red facial color

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19
Q

How does carbon monoxide poisoning work?

A

chemical binds with Hgb to decrease O2 carrying capacity

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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

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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)

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22
Q

What is the focus during the resuscitation/emergent phase of a burn injury?

A

ABCs and hemodynamic stabilization

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23
Q

What is the duration of the acute phase of a burn injury?

A

from beginning of diuresis to wound closure (72hrs)

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24
Q

What is the focus during the acute phase of a burn injury?

A

maintenance of cardiovascular and pulmonary systems

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25
Q

When is fluid resuscitation present?

A

when pts start to diuresis

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26
Q

What is the duration of the rehab phase of a burn injury?

A

from wound closure to optimal physical mobility

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27
Q

What is the focus during the rehab phase of a burn injury?

A

psychosocial adjustment - return to society

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28
Q

What are complications during the emergent phase of burn injuries? (5)

A

electrolyte imbalances
hypovolemic shock
third spacing
inflammation
immune changes

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29
Q

What is third spacing?

A

inflammation makes capillaries permeable which causes the movement of fluid into interstitial spaces

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30
Q

What is the sodium imbalance with major burns?

A

hyponatremic (Na going into cell)

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31
Q

What assessment is priority with hyponatremia?

A

neuro assess

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32
Q

What is the potassium imbalance with major burns?

A

hyperkalemic (K going out of cell)

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33
Q

What assessment is priority with hyperkalemia?

A

cardiac assess

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34
Q

What infusion restores vasculature and fluid volume?

A

albumin

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35
Q

What is the isolation protocol with major burns?

A

reverse isolation

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36
Q

What do nurses use the Parkland Formula for?

A

fluid resuscitation

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37
Q

How much of total fluid vol does the nurse administer over the 1st 8hrs?

A

1/2

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38
Q

How much of total fluid vol does the nurse administer over the next 8hrs?

A

1/4

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39
Q

How much of total fluid vol does the nurse administer over the last 8hrs?

A

1/4

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40
Q

What are the goals to maintain during fluid resuscitation?

A

SBP >90
HR <120
MAP >65
Urine output 0.5mL/kg/hr
(30-50mL/hr)

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41
Q

Under what circumstances will a burn pt be transferred to a burn center? (6)

A

face, hands, feet, genitalia, major joints
partial thickness burns >10% TBSA
3rd degree burns
electrical or chemical burns
inhalation injury
circumferential

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42
Q

What does circumferential mean?

A

burns are all the way around extremities, thorax, or neck

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43
Q

What is a high risk for circumferential burns?

A

compartment syndrome

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44
Q

With what type of burn injury is the development of compartment syndrome common?

A

full thickness injury; leathery eschar appearance
(3rd/4th degree burns)

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45
Q

What are S/E of compartment syndrome? (3)

A

lack of pulse in distal extremities
absence of movement
deep, aching pain

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46
Q

What is a escharotomy?

A

longitudinal incisions to relieve pressure from edema

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47
Q

What does cleaning the burn wound stimulate?

A

granulation and revascularization

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48
Q

What are 3 interventions for managing burn wounds?

A

debridement
hydrotherapy
dressings

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49
Q

How often are dressing changes with burn wounds?

A

daily

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50
Q

How often are dressing changes with skin grafts for burn wounds?

A

occlusive; changed q3-5 days

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51
Q

When can a nurse begin caring for a skin graft?

A

after the surgeon inspects it

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52
Q

What are 3 disorders of wound healing?

A

scars/keloids
contractures
failure to heal

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53
Q

What is autograft?

A

receiving a graft from your own tissue

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54
Q

What is allograft?

A

receiving a graft from another living thing

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55
Q

What interventions are included in nursing management of burns? (7)

A

PPE
airway management
fluid therapy
pain management
wound care
nutrition therapy
tetanus shot

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56
Q

Which meds are used IV during the emergent and acute phases of burn injuries?

A

morphine
fentanyl

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57
Q

Which meds are used for anxiety and pain management for burn injuries?

A

Lorazepam (ativan)
Midazolam (versed)

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58
Q

What are priority nursing management interventions during the acute phase of burn injuries? (5)

A

labs
infection
mobility
GI system
excision & grafting

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59
Q

What can happen to the GI system after a burn injury?

A

paralytic ileus, stress ulcers
intervention: NG tube

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60
Q

What kind of diet is recommended to a burn pt?

A

high calorie, high protein, high carbohydrate diet

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61
Q

Amount and frequency of meals for burn pt?

A

small portions, frequently

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62
Q

What meds are prescribed to burn pts to provide nutritional support?

A

insulin
carafate
histamine blockers

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63
Q

5-12 days after a traumatic injury what might happen to calorie needs?

A

double or triple
up to 5,000kcal

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64
Q

What is a nutritional high risk for burn pts?

A

hyperglycemia bc of insulin resistance

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65
Q

What is the MOA of Carafate?

A

coats lining of esophagus to prevent ulcers from forming

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66
Q

What are interventions for maintaining mobility with burn pts?

A

positioning
ROM exercises
ambulation
compression dressings

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67
Q

What is included in home care instructions for burn pts? (7)

A

skin & wound care
exercise & activity
physical & occupational therapies
nutrition
pain management
thermoregulation & clothing
mental health counseling

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68
Q

What is the exocrine function of the pancreas?

A

manufactures and secretes digestive enzymes

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69
Q

What enzyme breaks apart carbohydrates?

A

amylase

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70
Q

What enzyme breaks apart fats?

A

lipase

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71
Q

What enzymes break apart protein?

A

trypsin
chymotrypsin

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72
Q

What is the endocrine function of the pancreas?

A

manufactures and secretes insulin and glucagon

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73
Q

Pathophysiology of pancreatitis?

A

enzymes that are usually inactive until they reach the small intestine are activated in the pancreas and prompts inflammation

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74
Q

What is a hallmark sign of acute pancreatitis?

A

lipolysis

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75
Q

What occurs during lipolysis to the pancreas?

A

auto-digestion of pancreas (fibrosis)

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76
Q

Proteolysis may lead to…

A

thrombosis & gangrene of pancreas

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77
Q

What electrolyte imbalance is common with lipolysis?

A

hypercalcemia

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78
Q

What are pts at a high risk for because of proteolysis & necrosis of the pancreas?

A

risk for bleeding because of vasodilation

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79
Q

What might inflammation look like with acute pancreatitis?

A

pus formation, lesions

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80
Q

What are signs of acute pancreatitis?

A

lipolysis
proteolysis
necrosis of blood vessels
inflammation

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81
Q

How is chronic pancreatitis diagnosed?

A

repeated episodes (flare ups) of acute pancreatitis

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82
Q

What is the pathophysiology of chronic pancreatitis?

A

pancreatic secretions precipitate and plug pancreatic ducts leading to inflammation, fibrosis, ulcer formation, and the destruction of the secreting cells

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83
Q

What is the etiology of chronic calcifying pancreatitis?

A

alcoholism

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84
Q

What is the etiology of chronic obstructive pancreatitis?

A

inflammation, cholelithiasis

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85
Q

What is the etiology of autoimmune/genetic chronic pancreatitis?

A

immunoglobulins invade pancreas

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86
Q

What are pts with autoimmune/genetic chronic pancreatitis at a high risk of developing?

A

pancreatic cancer

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87
Q

What is the most common risk factor for pancreatitis?

A

gallstones

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88
Q

What are risk factors for developing pancreatitis? (7)

A

middle-aged man
alcoholism
trauma
smoking
familial
viral infection/abscesses
hyperlipidemia

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89
Q

What medications can cause pancreatitis? (3)

A

thiazides
NSAIDS
salicylates

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90
Q

If the cause of pancreatitis is related to alcoholism what is the prognosis?

A

poor

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91
Q

During what times of the year is pancreatitis most common?

A

during the holidays and vacation times

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92
Q

Manifestations of acute pancreatitis? (8)

A

N/V
Fever
Jaundice
Confusion & agitation
Ecchymosis in the flank or umbilical area
Hypovolemia & shock
Renal failure
Ascites

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93
Q

What is the key manifestation of acute pancreatitis?

A

severe abdominal pain

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94
Q

Manifestations of chronic pancreatitis?

A

Recurrent attacks of intense abdominal pain & back pain
Vomiting
Wt loss
Jaundice; dark urine
Foul smelling fatty stools (Steatorrhea)
S/S of diabetes

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95
Q

What are the 3 P’s of diabetes?

A

polyphagia
polydipsia
polyuria

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96
Q

What assessments are important for the nurse to perform on pts with pancreatitis?

A

GI & Skin assessments

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97
Q

What is Grey-Turner’s sign?

A

flank bruising indicating acute pancreatitis

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98
Q

What is Cullen’s sign?

A

bruising around the umbilicus indicating acute pancreatitis

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99
Q

What is a lab result that is highly indicative of acute pancreatitis?

A

elevated amylase within 12-24hrs

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100
Q

Which lab results are elevated with pancreatitis?

A

amylase
lipase
glucose
WBC

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101
Q

Which lab results are decreased with pancreatitis?

A

calcium & magnesium

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102
Q

What is ERCP?

A

Endoscopic Retrograde Cholangiopancreatography: invasive procedure where they inset stents or remove cysts

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103
Q

What two radiology diagnostics are utilized to diagnose pancreatitis?

A

CT
ultrasound

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104
Q

What is the primary nursing diagnosis associated with pancreatitis?

A

acute pain related to inflammation & enzyme leakage

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105
Q

What opioid medications are often prescribed to help manage acute pain related to pancreatitis?

A

morphine
dilaudid
fentanyl
(PCA pump)

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106
Q

What histamine receptor antagonists is often prescribed to help manage pancreatitis?

A

ranitidine

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107
Q

What PPI is often prescribed to help manage pancreatitis?

A

prilosec

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108
Q

What nursing intervention is often performed to manage pancreatitis?

A

NG tube insertion to decompression the stomach

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109
Q

What position often provides the most comfort to pts with pancreatitis?

A

fetal position

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110
Q

Why are PPI’s prescribed to pts with pancreatitis?

A

decreasing gastric acid production can promote enzyme replacement

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111
Q

What are secondary and tertiary nursing diagnoses for pancreatitis?

A

risk for fluid volume deficit related to fluid shifts
imbalanced nutrition less than body requirements

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112
Q

What are 3 nursing interventions for the risk for fluid vol deficit associated with pancreatitis?

A

IVF- isotonic solution (NS 150mL/hr)
NPO during acute period
I & O

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113
Q

What are 3 nursing interventions for imbalanced nutrition less than body requirements associated with pancreatitis?

A

NPO
antiemetics
enteral tube feeding

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114
Q

When is enteral feeding often initiated?

A

if NPO for 24-48hrs & no ileus

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115
Q

What must pts recovering from pancreatitis avoid when they return home?

A

alcohol & high fat foods

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116
Q

How many kcal may a pt with pancreatitis need a day?

A

4,000-6,000

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117
Q

What are 10 complications of pancreatitis?

A

death
infection (shock)
decreased CO (hypovol shock)
AKI
paralytic ileus
pleural effusion (L)
ARDS
DIC
MODS
DM type II

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118
Q

When can a pancreatitis pt discontinue the NPO status?

A

when serum amylase is normal, active bowel sounds, and no pain

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119
Q

What is pt education the nurse should provide when the pancreatitis pt is beginning to eat and drink again?

A

moderate to high carb, high protein, low fat diet
small, frequent, bland meals
avoid caffeine products
eliminate alcohol
may need pancreatic enzyme supplements

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120
Q

What additional pt education points may the nurse provide to the pancreatitis pt?

A

relaxed atmosphere
smoking cessation

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121
Q

What are S/S of pancreatitis complications? (8)

A

anorexia
n/v
abdominal distention with increasing fullness
persistent wt loss
severe epigastric or back pain
frothy/foul smelling BM
irritability, confusion
persistent fever

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122
Q

Because of hyperthyroidism what state does the body enter?

A

hyper-metabolic state

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123
Q

What hormones does the thyroid produce?

A

calcitonin
T3
T4

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124
Q

What are two risk factors for developing hyperthyroidism?

A

graves disease (autoimmune)
thyroiditis

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125
Q

What is the role of the pituitary gland?

A

promotes secretion and regulation of thyroid

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126
Q

What diagnostics are preformed to diagnose hyperthyroidism?

A

ultrasound
EKG
thyroid scan

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127
Q

In hyperthyroidism, the blood TSH level is

A

decreased

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128
Q

In hyperthyroidism, the T3 & T4 level is

A

elevated

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129
Q

What is a thyroid scan?

A

nuclear medicine
administer radioactive isotope day before scan and if there is elevated uptake of the isotope, hyperthyroidism can be diagnosed

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130
Q

What are nursing interventions for hyperthyroidism?

A

calm environment/safety
nutrition support, I & O, wt
eye protection (eye drops)
lower room temp (cold showers)

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131
Q

What medications are used to help manage hyperthyroidism?

A

thionamides (methimazole, propylthiouracil)
beta blockers
iodine solutions

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132
Q

What is the MOA of thioamides for hyperthyroidism?

A

inhibit the production of thyroid hormones by decreasing iodine use

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133
Q

What is the indication of beta blockers for hyperthyroidism?

A

palpitations
tachycardia

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134
Q

What is the MOA of iodine for hyperthyroidism?

A

short-term use
inhibit production of thyroid hormones

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135
Q

What are the treatments for hyperthyroidism?

A

iodine therapy
thyroidectomy

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136
Q

What are complications associated with a thyroidectomy? (5)

A

hemorrhage
thyroid storm/crisis
airway obstruction
hypocalcemia
nerve damage (vocal cords)

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137
Q

What is the MOA of iodine therapy?

A

destroys some thyroid producing cells

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138
Q

When is iodine therapy contraindicated?

A

pregnancy

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139
Q

What does iodine administration decrease?

A

size of thyroid gland
bleeding

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140
Q

What position should the pt be in after a thyroidectomy?

A

semi-folwers

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141
Q

What is a thyroid storm?

A

Common with graves disease and involves increased circulation of thyroid hormones in the blood.

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142
Q

What can be the result of thyroid storm?

A

high mortality rate
hypermetabolic state

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143
Q

What are S/S of thyroid storm? (6)

A

hyperthermia
HTN
SOB
delirium
vomiting
abdominal & chest pain

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144
Q

What are S/S of hypocalcemia? (3)

A

tetany
tingling of fingers/toes
convulsions

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145
Q

What condition can onset rapidly with hypothyroidism?

A

myxedema

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146
Q

What state does the body enter with hypothyroidism?

A

hypometabolic state

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147
Q

Why does hypothyroidism often go unnoticed?

A

can mimic normal aging process

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148
Q

What are risk factors for hypothyroidism? (3)

A

female (30-60 years)
inadequate intake of iodine
radiation therapy to head/neck

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149
Q

What area experiences hair loss with hypothyroidism?

A

eyebrows

150
Q

What is myxedema?

A

swelling of face, tongue, hands

151
Q

What diagnostics are performed to diagnose hypothyroidism?

A

thyroid scan
EKG

152
Q

In hypothyroidism, the T3 and T4 level are

A

decreased

153
Q

In hypothyroidism, the TSH level is

A

increased

154
Q

In hypothyroidism, the cholesterol level is

A

increased

155
Q

What are nursing interventions for managing hypothyroidism? (5)

A

monitor cardiac and respiratory systems
monitor wt, dietician consult
skin care
warming measures
stool softeners

156
Q

What kind of diet is recommended with hypothyroidism?

A

low calorie/high bulk diet

157
Q

What should the nurse refrain from administering to pts with hypothyroidism?

A

fiber laxatives

158
Q

What is the treatment for hypothyroidism?

A

thyroid hormone replacement therapy

159
Q

What is a possible complication of untreated hypothyroidism?

A

myxedema coma

160
Q

What are S/S of myxedema coma? (5)

A

cold
respiratory failure
low BP
low BS
low HR

161
Q

What kind of metabolism produces a build-up of lactic acid?

A

anaerobic

162
Q

What are the 4 types of shock?

A

distributive
hypovolemic
cardiogeneic
obstructive

163
Q

What are the 2 subcategories of hypovolemic shock?

A

absolute & relative

164
Q

What is absolute hypovolemic shock?

A

external loss of whole blood or bodily fluids

165
Q

What is relative hypovolemic shock?

A

fluid volume moves out of intravascular spaces and into interstitial spaces

166
Q

What is obstructive shock?

A

there is a physical obstruction distrupting the heart’s functioning

167
Q

What kind of complications can cause obstructive shock?

A

tension pneumothorax
cardiac tamponade
PE

168
Q

What is cardiogenic shock?

A

the heart’s fault

169
Q

What kind of complications can cause cardiogenic shock?

A

MI
dysrhythmias

170
Q

What are the 3 types of distributive shock?

A

anaphylactic
neurogenic
septic

171
Q

What is distributive shock?

A

excessive vasodilation that impairs blood flow

172
Q

What are cardiovascular manifestations of shock?

A

tachycardia
hypotension
decreased cap refill

173
Q

What is a cardiovascular manifestation unique to neurogenic distributive shock?

A

bradycardia

174
Q

What are respiratory manifestations of shock?

A

tachypnea

175
Q

What are respiratory manifestations specific to anaphylactic distributive shock?

A

wheezing
stridor
SOB

176
Q

What are renal manifestations associated with shock?

A

decreased urinary output

177
Q

What is a renal manifestation unique to neurogenic distributive shock?

A

bladder dysfunction

178
Q

What are integumentary manifestations of shock?

A

pallor
cool, clammy skin

179
Q

What are integumentary manifestations unique to septic distributive shock?

A

flushed skin
high temp

180
Q

What are neurological manifestations associated with shock?

A

anxiety
confusion/agitation
AMS

181
Q

What neurological manifestations are unique to neurogenic distributive shock?

A

flaccid paralysis
loss of reflexes

182
Q

What are GI manifestations associated with shock?

A

hypoactive or no bowel sounds

183
Q

What are GI manifestations unique to neurogenic distributive shock?

A

bowel dysfunction

184
Q

What are GI manifestations unique to anaphylactic distributive shock?

A

n/v

185
Q

What is involved in the initial stage of shock?

A

no manifestations except a build-up of lactic acid

186
Q

What is involved in the compensatory stage of shock?

A

body is mounting measures to increase CO to restore tissue perfusion and oxygenation

187
Q

What is involved in the progressive stage of shock?

A

compensatory mechanisms begin to fail

188
Q

What is involved in the refractory stage of shock?

A

irreversible: total body failure
MODS

189
Q

What are the 4 stages of shock?

A

initial
compensatory
progressive
refractory

190
Q

What is the overall goal of treatment for cardiogenic shock?

A

restore blood flow to myocardium by restoring balance between O2 supply/demand

191
Q

What is a priority nursing intervention for cardiogenic shock?

A

provide supplemental O2

192
Q

What is the medical treatment for cardiogenic shock?

A

minimal fluid replacement

193
Q

What pharmaceuticals may be prescribed with cardiogenic shock?

A

nitrates (nitro)
diuretics (furosemide)
dopamine/dobutamine

194
Q

What should the nurse be cautious of when administering nitrates?

A

hypotensive manifestations

195
Q

What is the MOA of diuretics?

A

decrease preload

196
Q

What is the MOA of dopamine?

A

increase myocardial contractility

197
Q

What is the MOA of dobutamine?

A

vasopressor
increase myocardial contractility

198
Q

What are diagnostics utilized for cardiogenic shock?

A

CXR
EKG
lactic acid

199
Q

What is the overall goal for hypovolemic shock?

A

stop the cause/bleeding/injury

200
Q

What is the treatment for hypovolemic shock?

A

rapid fluid replacement

201
Q

What is the 3:1 rule?

A

3mL of isotonic solution for every 1mL of estimated blood loss

202
Q

What medications may be utilized with hypovolemic shock?

A

vasopressors (norepinephrine) Levophed

203
Q

What is the positioning for optimal venous return?

A

supine w/ legs elevated

204
Q

When would the nurse move to blood infusion when initiating fluid replacement?

A

after 500mL (1L) of fluids

205
Q

What could happen to blood vessels if the nurse implements the use of vasopressors without initiating rapid fluid replacement?

A

they could collapse

206
Q

What are the priority nursing interventions for hypovolemic shock?

A

providing supplemental O2
IV fluid bolus
bedrest while supine w/ legs elevated

207
Q

What is the first manifestation the nurse will notice with a pt experiencing hypovolemic shock?

A

tachycardia

208
Q

What is the overall goal of obstructive shock?

A

manage the obstruction

209
Q

What interventions may be implemented to treat obstructive shock?

A

mechanical decompression
anticoagulation therapy
radiation, debulking, or removal of the mass/cause

210
Q

What are 2 common causes of neurogenic shock?

A

SCI
spinal anesthesia

211
Q

What is the patho of neurogenic shock?

A

loss of SNS vasoconstrictor tone = blood pooling & tissue hypoperfusion

212
Q

What are manifestations associated with neurogenic shock?

A

hypotension
bradycardia
temperature dysregulation

213
Q

What is poikilothermic?

A

the pt’s temperature matches that of the room’s

214
Q

What medication can be used to treat hypotension?

A

vasopressor (Phenylephrine)

215
Q

What is the difference btw neurogenic & spinal shock?

A

neurogenic shock is a hemodynamic condition

216
Q

What does an allergic reaction cause systematically?

A

massive vasodilation

217
Q

What is the patho of septic shock?

A

vasodilation = maldistribution of blood flow

218
Q

What is the integumentary response during the progression of septic shock?

A

warm/flushed initially then progresses to cool/clammy

219
Q

What lab values are elevated with septic shock?

A

lactic acid
BG

220
Q

What is the treatment for septic shock?

A

the 1hr bundle

221
Q

What diagnostics are utilized with the 1hr bundle?

A

CBC/CMP
blood cultures
lactate
blood coag studies
ABGs

222
Q

What are the steps of the 1hr bundle?

A
  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
Q

What is an elevated lactic acid level?

A

> 2

224
Q

What is a very elevated lactic acid level?

A

> 4

225
Q

What is the standard fluid replacement rate?

A

30mL/kg

226
Q

What must be present to diagnose as MODS?

A

failure of 2 or more organ systems

227
Q

What occurs to the pt’s metabolism when experiencing SIRS?

A

hypermetabolic

228
Q

SIRS?

A

systemic inflammatory response syndrome

229
Q

What body system is the first to demonstrate MODS?

A

respiratory

230
Q

MODS?

A

multiple organ dysfunction syndrome

231
Q

What are respiratory findings associated with MODS?

A

alveolar edema (crackly)
ARDS (intubation)

232
Q

What are cardiac findings associated with MODS?

A

decreased cap refill
dysrhythmias

233
Q

What are neurologic findings associated with MODS?

A

comatose (extreme hypoxia)

234
Q

What are renal findings associated with MODS?

A

AKI (accumulation of toxins)

235
Q

What are metabolic findings associated with MODS?

A

hyperglycemia
insulin resistance

236
Q

What are hepatic findings associated with MODS?

A

cannot covert lactic to glucose therefore the pt becomes hypoglycemic

237
Q

What symptoms can indicate SIRS?

A

abnormal temp
increased RR
increased HR
abnormal WBC
decreased PCO2

238
Q

What is WBC range?

A

4,000-12,000

239
Q

How many symptoms must the pt exhibit to classify as SIRS?

A

2

240
Q

What are the qualifications for classification of sepsis?

A

2 sirs
+
confirmed or suspected infection

241
Q

What are the qualifications for classification of severe sepsis?

A

sepsis
signs of end organ damage
hypotension
lactate >4

242
Q

What are the qualifications for classification of MODS?

A

presence of altered organ function
high levels of toxins

243
Q

What are the qualifications for classification of septic shock?

A

severe sepsis w/ persistent hypotension
lactate >4
end organ damage

244
Q

What are the 7 complications of shock?

A

MODS
ARDS
AKI
GI distress
hypermetabolic/catabolic
clotting issues
electrolyte imblances (acidotic)

245
Q

What is DIC?

A

thousands of small clots form within organ capillaries, creating hypoxia & anaerobic metabolism = platelets and other clotting factors to be depleted = hemorrhage?

246
Q

What happens to the platelet count with DIC?

A

decreases

247
Q

What happens to the D-dimer with DIC?

A

increases

248
Q

What happens to fibrinogen with DIC?

A

decreases

249
Q

What happens to PT/aPTT with DIC?

A

increases

250
Q

What is the nurse’s priority with DIC?

A

watch for excess bleeding

251
Q

What should the nurse be prepared to admin for DIC treatment?

A

heparin
platelets
clotting factors
PRBC’s

252
Q

PAWP value?

A

6-12mmHg

253
Q

MAP value?

A

> 65mmHg

254
Q

CVP value?

A

2-8mmHg

255
Q

What does the CVP tell you?

A

how well blood is being pumped back to the heart

256
Q

What does a high CVP indicate?

A

cardiogenic shock

257
Q

What does a low CVP indicate?

A

hypovolemic shock

258
Q

SV value?

A

60-160mL/beat

259
Q

CO value?

A

4-8L/min

260
Q

Alpha receptors MOA?

A

increase vasoconstriction

261
Q

Beta 1 receptors MOA?

A

increase myocardial contractility

262
Q

Beta 2 receptors MOA?

A

vasodilation of bronchi

263
Q

What are the 3 vasopressors?

A

epinephrine (adrenaline)
norepinephrine (levophed)
dopamine

264
Q

What are low doses of EPI used for?

A

code symptoms
anaphylactic shock
(cardiac stimulation & bronchodilation)

265
Q

What are high doses of EPI used for?

A

IV drip
(peripheral vasoconstriction)

266
Q

What is the gold standard med for treatment of septic shock?

A

norepinephrine (Levophed)

267
Q

With what shock subcategories is dopamine utilized more often?

A

cardiogenic shock
septic shock

268
Q

Why are vasopressors high risk meds?

A

they need to be administered with a central line because they can damage tissue

269
Q

Dobutamine MOA?

A

positive inotropic med

270
Q

What does a positive inotropic med do?

A

increased cardiac contractility

271
Q

Why is dobutamine often administered with a vasopressor?

A

because it can cause vasodilation

272
Q

With which type of shock is dobutamine most often utilized?

A

cardiogenic shock

273
Q

What is vasopressin?

A

synthetic ADH (antidiuretic hormone)

274
Q

What is the MOA of vasopressin?

A

ADH: Adds Da H2O to the body
(retain fluid, increase BP)

275
Q

Nursing considerations for vasopressin?

A

monitor I & O
high risk med (central line)

276
Q

Equation for CO?

A

HR x SV

277
Q

SVR when vessels dilate?

A

decreases

278
Q

SVR when vessels constrict?

A

increases

279
Q

What is CO?

A

amount of blood pumped through the heart each miin

280
Q

What is SV?

A

amount of blood pumped through the heart with each beat

281
Q

Preload?

A

how much vol is pumping through system

282
Q

Afterload?

A

forces opposing ejection

283
Q

What is the trauma triad of death?

A

hypothermia
acidosis
coagulopathy

284
Q

What are the 3 points after injury that a head injury could cause death?

A

immediately after
within 2hrs
about 3 weeks after

285
Q

What are the 2 biggest causes of TBI?

A

falls and MVA

286
Q

What are the 2 types of head injuries?

A

scalp lacerations
skull fractures

287
Q

What are the 2 major complications associated with scalp lacerations?

A

blood loss
infection

288
Q

What are the 3 major complications associated with skull fractures?

A

infection
hematoma
tissue damage

289
Q

What are 2 signs of TBI?

A

raccoon eyes
battle’s sign

290
Q

What is battle’s sign?

A

bruising behind ear

291
Q

When present what indicates the presence of CSF leakage?

A

glucose

292
Q

What are the tests for CSF leaks?

A

dextrostix
tex-tape
B2 transferrin
halo sign

293
Q

If there is CSF leakage what is a possible complication?

A

meningitis

294
Q

What is the gold standard test for CSF leak?

A

B2- Transferrin

295
Q

What are 2 examples of diffuse head injuries?

A

concussion
diffuse axonal injury

296
Q

What is a minor diffuse head injury GCS score?

A

13-15

297
Q

What is a severe diffuse head injury GCS score?

A

3-8

298
Q

What are 2 examples of focal head injuries?

A

contusion
hematoma

299
Q

What are unique S/S of focal head injuries?

A

headache & pupillary effects on affected side
S/S on opposite side of injury

300
Q

What does the GCS assess?

A

eyes
voice
motor

301
Q

What are early signs of increased ICP?

A

decreased LOC
irritability
sleepiness
flat affect
headache
vomiting

302
Q

What are late signs of increased ICP?

A

cushing’s triad
seizures
coma
abnormal posturing
pupillary changes

303
Q

What is Cushing’s Triad?

A

HTN (wide pulse pressure)
bradycardia
cheyenne-stokes respirations

304
Q

What are S/S of post-concussion syndrome?

A

persistent headache
lethargy
personality changes
shortened attention span
decreased short-term memory
changes in intellectual ability

305
Q

What TBI has the highest mortality rate?

A

diffuse axonal injury

306
Q

Who is at high risk for developing a contusion head injury?

A

elderly pts on anticoagulants

307
Q

Which hematoma type is a medical emergency and why?

A

epidural bc it develops quickly

308
Q

When does an intracerebral hematoma occur?

A

2-14 days

309
Q

When does a subarachnoid hematoma occur?

A

weeks-months after injury

310
Q

At what pressure does the nurse want to maintain SBP at with head injury pts?

A

> 100mmHg

311
Q

What is the best diagnostic test to evaluate for head trauma?

A

CT scan

312
Q

What does a transcranial doppler measure?

A

cerebral blood flow velocity

313
Q

If a pt loses consciousness for greater than ____min more severe complications?

A

30

314
Q

What factors make up content of brain?

A

CSF
intravascular blood
brain tissue

315
Q

What factors influence ICP?

A

intrabdominal & intrathoracic pressure
posture
temp
CO2 levels

316
Q

What kind of relationship does CSF, intravascular blood, and brain tissue have?

A

inverse

317
Q

What is the Monro-Kellie Doctrine?

A

compensatory mechanisms to maintain normal ICP
*after injury, initially no increase in ICP

318
Q

What is the normal ICP?

A

5-15mmHg

319
Q

What ICP value requires treatment?

A

> 20mmHg

320
Q

What is the normal CPP value?

A

80-100mmHg

321
Q

What CPP value causes cerebral ischemia?

A

<60mmHg

322
Q

What CPP value indicates brain death?

A

<30mmHg

323
Q

How is CPP calculated?

A

MAP-ICP

324
Q

What are the first 2 symptoms noticed with decreasing CPP?

A

dizzy
blurred vision

325
Q

What meds do nurses use to manipulate MAP?

A

pressors

326
Q

What meds do nurses use to manipulate ICP?

A

mannitol/hypertonic solutions

327
Q

How many stages of increased ICP are there?

A

4

328
Q

What is involved in the 3rd stage of increased ICP?

A

failing compensation
(Cushing’s triad)

329
Q

If ICP is elevated for too long what is the result?

A

brain herniation (respiratory changes)

330
Q

When auto-regulation of cerebral blood flow fails what is the result?

A

cerebral edema

331
Q

What is the normal PCO2 level?

A

35-45

332
Q

What is the result of increased CO2 on cerebral blood flow?

A

dilates cerebral blood vessels and increases ICP

333
Q

What is the result of decreased CO2 on cerebral blood flow?

A

severe vasoconstriction resulting in severe hypoxia

334
Q

What does the pupillometer do?

A

measures pupil at peak dilation

335
Q

When does the RN need to report to the provider a pupillary change?

A

> 1mm

336
Q

What is the normal pupil exam?

A

3-4mm

337
Q

With an EVD the transducer must be level with the?

A

tragus of the ear

338
Q

What increases the risk of infection with EVD?

A

in place more than 5 days
CSF leak
systemic infection

339
Q

What cleaning technique is used when working with EVD?

A

aseptic

340
Q

When might the provider instruct the RN to remove CSF from EVD?

A

> 20

341
Q

How long must the EVD be clamped for an accurate reading of CSF vol drained?

A

at least 6min

342
Q

What is the time frame for intermittent drainages of CSF with an EVD?

A

30-120 sec

343
Q

What is a possible complication if more than 20mL of CSF is drained in a hr?

A

ventricles could collapse

344
Q

What kind of drug is mannitol?

A

osmotic diuretic

345
Q

Route of admin for mannitol?

A

IV

346
Q

How does mannitol decrease IVP?

A

plasma expansion
osmotic effect

347
Q

What does the RN monitor with the admin of mannitol or hypertonic solutions?

A

serum electrolytes
BP

348
Q

What are 2 examples of hypertonic solutions?

A

3% NaCl
D5W

349
Q

What medication is given as a prophylactic for GI bleeds and gastric ulcers?

A

H2 Receptor Antagonists
Ranitidine (Zantac)

350
Q

What medication is given to pts with increased ICP as antiseziure?

A

phenytoin (Dilantin)

351
Q

What can be a S/E of propofol?

A

hypotension

352
Q

What are the 3 main nursing interventions for increased ICP?

A

maintain patent airway
ICP within normal limits
normal fluid & electrolytes

353
Q

What can raise abdominal pressure?

A

hip flexion

354
Q

What are nursing considerations with suctioning?

A

maximum of 2 passings
maximum of 10sec
oxygenate before and after

355
Q

Why might a pt with increased ICP have an NG tube?

A

nutrition and prevent abdominal distension

356
Q

Diabetes Insipidus is caused by

A

decrease of ADH (hypernatremia)

357
Q

What is the treatment for Diabetes Inspidus?

A

fluid replacement

358
Q

SIADH is caused by

A

excess ADH (hyponatremia)

359
Q

At what temp does the RN want to maintain a pt with increased ICP?

A

96.8-98.6

360
Q

What opioids are commonly used with increased ICP pts?

A

fentanyl & morphine

361
Q

MOA of propofol (Diprivan)?

A

used to manage anxiety & agitation (sedation)
* doesn’t control pain

362
Q

MOA of Precedex (Dexmedetomedine)?

A

sedation
*no pain control

363
Q

MOA of Nimbex (Cisatracuriu m)?

A

sedation
* no pain control

364
Q

Why might benzos not be used with treatment of increased ICP?

A

longer effects
hypotension

365
Q

Urinary output with diabetes insipidus?

A

high

366
Q

Urinary output with SIADH?

A

low

367
Q

Specific gravity of diabetes insipidus urine?

A

low (dilute urine)

368
Q

Specific gravity of SIADH urine?

A

high (concentrated urine)

369
Q

What is the treatment for SIADH?

A

diuretics, fluid restriciton

370
Q

What kind of disorders of TBI pts most at risk for developing?

A

seizure disorders

371
Q

Personality changes are expected after pt is comatose for?

A

6hrs or more

PCC IV (4 decks)

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