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NUR 418 > Exam III - Sepsis and Neuro > Flashcards

Exam III - Sepsis and Neuro Flashcards

1
Q

LOC is composed of _______ and _________

A

Alertness and Orientation

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2
Q

Lowest LOC

A

arousal/alertness

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3
Q

GCS stands for ______________

A

Glascow-Coma Scale

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4
Q

Lowest score on the GCS (even if dead)

A

3

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5
Q

GCS does not account for __________ or inability to ___________

A

Lateralization (one sided responses) or inability to speak

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6
Q

If you are assessing verbal commands, do NOT ________

A

Touch the patient (or model the command)

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7
Q

Two types of posturing are __________ and _________

A

Decerebrate and decorticate

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8
Q

Pupil function assesses both __________ and ________ pathways

A

Sympathetic and parasympathetic

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9
Q

“If you code me, ____ me”

A

cool

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10
Q

Cluster breathing

A

irregular, gasping

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11
Q

Cheyne-Stokes breathing

A

very fast then very slow (torsades of breathing)

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12
Q

Apneustic breathing

A

prolonged inhale/exhale with long pauses

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13
Q

Ataxic breathing

A

irregular deep then shallow with apneic periods

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14
Q

Cushing Triad

A

Increased pressure on the brainstem cause bradycardia, hypertension, and wide pulse pressure

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15
Q

CVA stands for ____________________ and is also known as _______

A

Cerebrovascular attack AKA stroke

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16
Q

TIA stands for __________________

A

Transient ischemic attack AKA “mini stroke”

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17
Q

Modifiable risk factors for stroke

A
  • Uncontrolled hypertension
  • (HTN)-single most modifiable factor
  • Obesity
  • Atrial fibrillation (25% of all strokes)
  • Hyperlipidemia
  • Smoking
  • Diabetes mellitus
  • Drug/alcohol abuse
  • Poor diet/exercise
  • Use of oral contraceptives
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18
Q

Non-modifiable risk factors for stroke

A
  • Age
  • Gender
  • Ethnicity/race
  • Heredity/family history
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19
Q

Types of stroke

A 
Ischemic
----Thrombotic
----Embolic
Hemorrhagic
----Intracerebral
----Subarachnoid
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20
Q

Ischemic stroke

A

Inadequate blood flow to brain
Subtypes: Thrombotic and Embolic
See slide 17

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21
Q

Hemorrhagic stroke

A

Bleeding into brain tissue
Subtypes intracerebral or subarachnoid
See slide 17

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22
Q

Right sided stroke patients are a ________ concern

A

SAFETY - typically unaware that they have a deficit

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23
Q

Left sided stroke patients are at greater risk for _______

A

Depression - typically aware of deficit

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24
Q

FAST - what if unknown time?

A

Ruled out for tPA

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25
Q

FAST

A

**Emphasized as test question

Face, arms (have them close their eyes), speech, time

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26
Q

Blood pressure and stroke

A

Allow BP to be high for perfusion to the brain

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27
Q

Stroke nursing care

A

Based on deficit:

  • maintain airway
  • aspiration prevention
  • elimination assistance
  • seizure precaution
  • promote communication
  • assist with mobility & ADLs
  • maintain skin integrity
  • referral to OT/PT/ST/rehabilitation
  • health promotion/education
  • emotional support (depression screening***)
  • monitor for impulsivity***

*** emphasized

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28
Q

Ischemic Stroke Tx

A

Stent
TPA – strict time rules & contraindications*
Long term anticoagulants*

***emphasized

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29
Q

Hemorrhagic Stroke Tx

A

Resection
Aneurysm clip
Evacuation of hematoma

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30
Q

Assessment of a stroke patient (head to toe)

A

Neuro:

  • Stroke Scale
  • LOC – Q1hr focused neuro assessment

Cardio:

  • Co-morbidities may increase incidence of cardiac dysfunction
  • Hypertension is common (and often preferred) to increase blood flow to the brain

Respiratory:
- Muscle weakness predisposes stroke patients to obstruction risk & aspiration pneumonia

GI / Nutrition:

  • Constipation is common – if stool is liquid assess for impaction
  • Additional tools for eating (other than a traditional fork)
  • Assessment by a ST if available & Nursing bedside swallow assessment
  • PEG tube if needed

Urinary:
- Loss of bladder control – inability to void or incontinence

Musculoskeletal System:
- ROM & positioning to prevent joint contractures and muscle atrophy

Integumentary:
- Increased risk of skin breakdown

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31
Q

What else can you do to help a stroke patient?

A

EMPATHY

  • Assess for coping
  • Ask what helps them
  • Try to stand where they can see you
  • Be patient and allow time for communication
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32
Q

Post-acute care

A

Begin planning transition early – as soon as patient is stable

Placements include:
Home (respite care may be available)
Rehab - intermediate or ambulatory ($$$)
LTC – may be permanent ($$$)

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33
Q

Monro-Kellie Doctrine/Hypothesis

A

Brain
Blood
CSF

If the VOLUME of 1 of one increases, then a reciprocal decrease in one or both of the others must occur (increase in ICP)

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34
Q

Using Monro-Kellie Hypothesis, what would happen in a hemorrhage?

A

Brain and CSF become compressed

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35
Q

Using Monro-Kellie Hypothesis, what happens if the brain swells?

A

Blood and CSF become compressed

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36
Q

What two things does the brain need?

A

Sugar and Oxygen

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37
Q

If no medical interventions are provided, the brain will __________

A

Herniate

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38
Q

Normal Intracranial Pressure

A

0-15 mm Hg

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39
Q

Diagnostic Criteria for ICP

A

20 mm Hg or > persisting for 5 minutes or longer

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40
Q

Cerebral Perfusion Pressure (CPP)

A

MAP - ICP = CPP

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41
Q

Normal CPP

A

60-100 mm Hg, keep at 70 or higher in those with abnormal brain pathology

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42
Q

If the brain herniates, this is an indicator of _____________

A

brain death

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43
Q

What is the single most important factor in maintaining brain health?

A

CPP

44
Q

An increase in ICP or decrease in CPP will result in decreased ________

A

Cerebral blood flow (cutting off sugar and oxygen)

45
Q

The EVD should be leveled (zeroed) to the _______

A

Tragus of the ear

*** Emphasized

46
Q

EVD uses Saline without _______

A

Preservatives

Must use sterile NS flush

*** Emphasized as test question

47
Q

Fluid filled EVD system

A
  • Absolute sterile setup
  • Most common
  • Similar to hemodynamic monitoring systems
48
Q

Increased ICP nursing care positioning

A

Positioning

  • HOB elevation supine and no more than 30 degrees
  • Neutral head position
  • Turn side to side
  • ——Watch for return to baseline CPP
49
Q

Mannitol

A
  • For edema
  • Bolus or push
  • Should see decrease in ICP within 15 minutes
    ——Side effects: MASSIVE diuresis (dehydration), tachycardia, hypotension
50
Q

Normal HR

A

60-100

51
Q

Normal BP

A

S: 100-130
D: 60-90

52
Q

Normal CO (cardiac output)

A

4-8 L/min

53
Q

Normal SVR

A

800-1200

54
Q

Normal PVR

A

<250

55
Q

Normal CVP

A

2-8 mmHg

56
Q

Normal SvO2

A

60-80%

57
Q

Define Sepsis

A

Systemic response to infection

58
Q

Define Severe Sepsis

A

Sepsis with organ dysfunction

59
Q

Define Septic Shock

A

Sepsis with marked hypotension despite adequate fluid resuscitation

60
Q

Sepsis from non-infection (SIRS)

A 
Pancreatitis
Tissue Ischemia
Trauma
Burn
Drug Reaction
Auto-immune
61
Q

SIRS

A

Systemic Inflammatory Response Syndrome

62
Q

Positive signs of SIRS

A 
Two of these:
Temp (fever or hypothermia)
HR above 90
RR above 20
WBC <4k or >12k
Glucose above 140 in non-diabetic

AND

A known source of infection or one of the non-infection criteria (pancreatitis, burn, auto-immune, etc)

***emphasized

63
Q

Blood cultures are drawn as ___ bottles, ___ sets and must be drawn from ___ site(s)

A

4 bottles, 2 sets (anaerobic and aerobic each set)
Must be from two sites
** Only one set can be taken from a central line

***emphasized as exam question

64
Q

How many mL of fluid do you give as resuscitation for someone with sepsis?

A

30mL/kg within 1 hour

65
Q

One hour bundle for sepsis

A
  • Measure Lactate (greater than 4 is critical)
  • Obtain Blood Cultures x2
  • Initial fluid resuscitation 30ml/kg
  • Begin brought spectrum antibiotics (Zosyn & Levaquin)
  • Closely monitor hemodynamics
  • Repeat Lactate at 2 hour mark

*** Emphasized

66
Q

Six hour bundle for sepsis

A
  • Vasopressors for hypotension persisting after fluids (titrate to maintain MAP above 65)
  • Place CVC with monitoring (keep CVP between 8 and 12 or 12 to 15 if vented, keep SCVO2 above 70%)
  • Keep urine output greater than 0.5ml/kg/hr
  • Redraw Lactate Q4 hrs
  • If vented, ensure Vt at 6ml/kg IBW, monitor FiO2/PaO2 ratio, assess for ARDS/abdominal compartment syndrome (3rd spacing)
67
Q

Define Shock

A
  • Life-threatening response to alterations in circulation
  • Inadequate tissue perfusion
  • Imbalance between cellular oxygen supply and demand
68
Q

Stages of shock

A

Shock is categorized into four overlapping stages:

  • Initial
  • Compensatory
  • Progressive
  • Refractory
69
Q

Stage I of Shock

A

Initial

  • Hypo-perfusion: inadequate delivery or extraction of oxygen
  • Metabolism changes at cellular level from aerobic to anaerobic
  • Lactic acid builds up and must be removed by liver
  • Process requires O2, unavailable due to decreased tissue perfusion
70
Q

Stage II of Shock

A

Compensatory

  • Sustained reduction in tissue perfusion
  • Initiation of compensatory mechanisms
  • If cause corrected, patient recovers, if not patient enters progressive stage
71
Q

Stage III of Shock

A

Progressive

  • Failure of compensatory mechanisms (leakage of protein into interstitial space, increase of systemic interstitial edema)
  • Distinguishing features of decreased cellular perfusion and altered capillary permeability
  • Profound cardiovascular effects (hypo-perfusion, vasoconstriction)
72
Q

Stage IV of Shock

A

Refractory

  • Prolonged inadequate tissue perfusion
  • Exacerbation of anaerobic metabolism
  • Accumulation of lactic acid and waste products
  • —-Unresponsive to therapy
  • —-MODS
73
Q

Accumulation of lactic acid and waste products results in:

A
  • Dysrhythmias
  • Pulmonary edema
  • Respiratory Distress Syndrome (RDS)
  • Cerebral changes
  • Renal decreased GFR
  • Contributes to multiple organ dysfunction and death
74
Q

Shock assessment initial stage v late stage

A

Initial stage: anxiety, restlessness, elevated BP, rapid and deep breaths (Kussmaul), decreased renal function, nausea, Decreased bowel sounds, distension, constipation

Late stage: Coma, loss of peripheral pulses, low BP, Shallow respirations, Poor gas exchange

75
Q

Absolute hypovolemic shock

A

Blood loss

76
Q

Relative hypovolemic shock

A

Dehydration

77
Q

Distributive Neurogenic Shock HR

A

Severe bradycardia and hypotension

78
Q

Risk factors for death by trauma

A
  • Co-morbities
  • Hemorrhage
  • Low initial GCS
  • Over age 60
  • Blood thinners
79
Q

Define Trauma

A

Injury to living tissue caused by extrinsic agent. Regardless of mechanism of injury (MOI).

80
Q

Blast trauma

A

Unique combination of blunt and penetrating trauma

81
Q

Primary Survey of trauma patient

A 
A—Airway (and alertness w/simultaneous cervical spinal stabilization
B—Breathing (and ventilation)
C—Circulation (and control hemorrhage
D—Disability (neurologic status)
E—Exposure (and environmental control)
F—Full set of VS (family presence)
G—Get adjuncts
----L—Lab studies (ABGs, Blood Type)
----M—Monitor (cardiac)
----N—Naso/Orogastric tube
----O—Oxygenation and Ventilation
----P—Pain assessment and management
82
Q

Secondary survey of trauma patient

A

H—History (and Head-to-toe)

I—Inspect posterior surfaces

83
Q

Triage for mass casualty (AVPU)

A

Awake - Green
Verbally responsive - Yellow
Painful responses - Orange
Unresponsive - Red

84
Q

Trauma Phases of Care

A
  • Resuscitation
  • Secondary Survey
  • OR (surgical)
  • ICU (CCU)
  • Ortho
85
Q

Trauma Triad of Death

A

Hypothermia
Metabolic Acidosis
Coagulopathy

86
Q

Criteria for brain death

A
  • No movement or posturing. Seizures, shivering or response of any sort
  • No pupillary reflex
  • No corneal, oculocephalic, cough or gag reflex
  • No oculovestibular reflex
  • No HR increase with atropine
  • No respiratory effort

Must be confirmed by two separate assessors 6 hours apart

87
Q

Types of trauma

A

Penetrating, blunt, and blast

***Emphasized as test question

88
Q

What percentage of strokes are caused by Afib?

A

25%

89
Q

Which statement by the nurse is INCORRECT about TIA - Transient Ischemic Attack?
1 - A TIA is a transient episode of neurologic dysfunction without acute infarction of the brain
2 - Symptoms usually last less than an hour
3 - S/S of TIA depend on location of dysfunction but mimic CVA
4 - 50 percent of patients who have a TIA will have a stroke

A

50 percent of patients who have a TIA will have a stroke

90
Q 
Which risk factor for stroke is not modifiable?
1 - Hypertension
2 - Alcohol Intake
3 - Family History
4 - High Fat Diet
A

3 - Family History

91
Q

The nurse explains to a TIA patient that he is scheduled for a CTA this afternoon, which statement best describes the rationale for the exam?
1 - The CTA will help predict Mr. Lewis’s risk for stroke
2 - The CTA will guide treatment with medications
3 - The CTA will determine if the cause of the TIA was a blockage in the cerebral arteries
4 - The CTA is the standard treatment for TIA

A

3 - The CTA will determine if the cause of the TIA was a blockage in the cerebral arteries

92
Q

What is the time limit for the administration of TPA?

A

4.5 hours

93
Q

Contraindications for the use of tPA does not include: *
1 - Suspected internal bleeding within 3 months
2 - Unknown symptom onset
3 - Surgery within 14 days
4 - Current or suspected infection

A

4 - Current or suspected infection

94
Q

At arrival to the unit, Mr. Lewis has a blood pressure of 178/100, the nurse understands which of the following is INCORRECT about BP in the acute phase of a CVA?
1 - Hypertension is not treated in the acute phase unless BP is above 220/120
2 - Patients must have BPs below 185/110 to receive fibrinolytics
3 - Hypotension in the acute phase of a CVA is more common than hypertension
4 - If warranted, IV antihypertensives are preferred treatments

A

3 - Hypotension in the acute phase of a CVA is more common than hypertension

95
Q

Which of the following medication orders would the nurse question for the patient in the acute phase of a CVA? *
1 - Heparin 18units/kg/hr IV infusion
2 - Labetalol 1mg/min for SBP above 220
3 - Normal Saline 0.9% IV infusion 50mL/hr
4 - Dextrose 50% IV Push for BG less than 50mg/dL

A

1 - Heparin 18units/kg/hr IV infusion

96
Q

Which of the following would NOT be included in the nurses plan of care for the patient having a CVA?
1 - Assessment and documentation of neurological status
2 - Assess patient’s ability to swallow
3 - Ensure positioning to reduce risk of aspiration
4 - Delegate regulation of IV fluids to the UAP based on output

A

4 - Delegate regulation of IV fluids to the UAP based on output

97
Q 
Mr. Lewis had a right sided stroke, in addition to left sided weakness, the nurse can expect all of the following except?
1 - Perceptual deficits
2 - Cautious and slow movements
3 - Impaired time judgement
4 - Minimization of problems
A

2 - Cautious and slow movements

98
Q

Increased ICP suctioning and oxygenation goals

A

Suctioning

  • Only when necessary
  • Preoxygenate
  • Limit suction to 10 seconds

Adequate Oxygenation

  • Goal: PaO2 > 80 mmHg
  • Airway vigilance
  • Mechanical ventilation
  • ——Positive end-expiratory pressure (PEEP) – use with caution
99
Q

Increased ICP CO2 management

A

Carbon Dioxide Management

  • PaCO2 35-45 mm Hg (changes in CO2 increase ICP)
  • Avoid hyperventilation
100
Q

Increased ICP Diuretics and Fluid management

A

Diuretics

  • Osmotic diuretics
  • ——Reduce brain tissue volume (Mannitol, Hypertonic saline)
  • Loop diuretics
  • ——Reduce brain tissue volume
  • ——Decrease CSF formation

Fluid Administration

  • Optimized fluid administration with isotonic solutions
  • Strict intake/output
  • Goal: serum osmolality less than 320 mOsm/L.
  • Colloids or blood products to restore volume
101
Q

Increased ICP blood pressure

A

Blood Pressure

  • Goal: MAP 70-90 mm Hg
  • CPP: at least 70 mm Hg
  • Avoid hypertension
  • —–Increases cerebral blood volume
  • —–Nicardipine
  • Avoid hypotension
  • —–Ischemia
  • —–Vasopressors
102
Q

Increased ICP metabolic demands

A

Metabolic Demands

  • Temperature control
  • ——Induced hypothermia (Goal: 34o – 35o C)
103
Q

Increased ICP sedation

A

Sedation

  • Benzodiazepines
  • Propofol
  • Analgesia
104
Q

Increased ICP seizure prophylaxis

A

Seizure prophylaxis

- Neuromuscular blockade

105
Q

Septic shock vitals

A 
HR - High
BP - Low
CO - initially high then very low
SVR - Very low
CVP - Low
O2 - Low
106
Q

Hypovolemic shock vitals

A 
HR - High
BP - Severely Low
CO - Low
SVR - Low
CVP - Low
O2 - Low
107
Q

Cardiogenic shock vitals

A 
HR - High
BP - Low
CO - Very Low (LV not pumping)
SVR - High
CVP - High
O2 - Low

NUR 418 (4 decks)

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