Final Exam Flashcards
How should all hemodynamic measurements be taken?
At phlebostatic axis with the HOB 45 degrees
PVR (Pulmonary Vascular Resistance): Value
37 - 250 dynes
Right Afterload
SVR (Systemic Vascular Resistance): Value
800 - 1,400 dynes
Left Afterload
Cardiac Output (CO)
4 - 8 L/min
Stroke Volume (SV)
50 - 100 ml/beat
RA/CVP
2 - 6 mmHg
Right Preload
Wedge Pressure
8 - 12 mmHg
Left Preload
*If unavailable, check PA diastolic
Ejection Fraction
60 - 70%
Monro-Kellie Hypothesis
3 components in the skull: CSF, brain, blood
Increases in any one, increases ICP
ICP: Normal Value
5 - 15
Intracranial HTN: Value
> 20
High ICP: S/S
- LOC change**
- Pupillary changes
- Papilledema
- Motor changes (decorticate, decerebrate, flaccid)
- Headache
- Projectile Vomiting
High ICP: Treatment
-Hypertonic Saline (3% NaCl)*
-Osmitrol (Mannitol)*
Use a filter d/t crystallization possibility
Bolus is best method
-Dexamethasone, Solumedrol (steroids)
No hypotonic fluids (D5W or 1/2 NS) -> causes swelling
HOB >30 degrees
Spinal Shock: Definition
Temporary loss of all motor and sensory function BELOW LOI - immediately after injury
Gradual return of function: 4-6 weeks
Spinal Shock: S/S
- Complete loss of motor reflexes
- Flaccid paralysis
- Loss of Bowel and Bladder control (retention)
Assess for (+) anal wink at onset = incomplete injury (good sign)
Neurogenic Shock: Definition
Temporary loss of SNS innervation (often SCI above T6) - immediately after injury
Without SNS, PNS takes over (vagal nerve)
Neurogenic Shock: S/S
- Vasodilation
- Hypotension (treat with vasopressors and volume)
- Bradycardia (treat with Atropine if bpm 40s-50s)
- Skin, warm and dry
Neurogenic Shock: Care
- Ace wraps, compression boots (to circulate perfusion centrally)
- Vasopressors and volume
- Atropine
Autonomic Dysreflexia: Definition
Overstimulation of SNS below LOI - a few weeks after the injury
Common cause: Bowel and Bladder
Autonomic Dysreflexia: S/S
- HA
- Facial flushing and warmth
- Nasal congestion
- # 1 HTN
- Bradycardia
- Anxiety/impending doom
Below Injury: cold skin with goosebumps
Autonomic Dysreflexia: Interventions
- Sit patient up, elevate HOB to lower BP
- Identify and remove stimulus
- Treat BP if remaining high
Stroke: Presentation
GFAST
Gaze Facial Droop Arm Weakness Speech Difficulty Time of Onset
Basilar Artery Syndrome: S/S
Basilar Artery supplies 95% of blood to brain stem
- Dizziness
- Ataxia (loss of body control)
- Tinnitus
- N/V
- One sided weakness
Right MCA Stroke: S/S
Most common
- Left weakness
- Head/eyes turn to stroke side (right)
- “Let side neglect”
- Disoriented
- Impulsive
- Poor judgement
- Lack of proprioception
Left MCA Stroke: S/S
- Right sided weakness
- Altered intellectual ability
- Slow
- Cautious
- Anxious
- Depressed
- Dyslexia
- Aphasia
Expressive Aphasia
Affects Broca’s Area (frontal lobe)
Understand language, but can’t communicate/talk/write
Use a picture board
Receptive Aphasia
Affects Wernicke’s Area (temporal lobe)
Unable to understand language
Make up new words
Ischemic Stroke: Meds
Fibrinolytic/Thrombolytic Therapy
TPA (must meet criteria)
- No acute hemorrhage
- Tx sooner than 4.5 hours after onset
- BP <185/110 (use Labetalol and Nicardipine)
- Neuro assessment after admin
NO TPA IF RECENT BLEED OR RISK FOR BLEEDS
Stroke: Nursing Care
-Determine time of onset
-Urgent non-contrast CT (determines stroke type)
-Prioritize ABC
-Impaired swallowing
-Impaired communication
-Clothe weak side first
-If Blind on one side:
Rotate Tray
Neglect Syndrome (use mirror for self care)
Meningitis: Definition
Infection of the meninges surrounding the brain and spinal cord
Meningitis (Bacterial): Presentation
MOST LETHAL
- Brain damage
- Hearing loss
- Epilepsy
- Death
- Meningococcal may cause death in 24 hr
Meningitis (Viral): Presentation
Self-limiting
Sometimes herpes can cause rapid brain tissue necrosis
Meningitis: General S/S
- Photophobia
- Nuchal Rigidity
- Brudzinski’s Sign & Kernig’s Sign
- HA
- Weakened immune system
- N/V, fever, chills, generalized muscle aches and pain
- Red macular skin rash (meningococcal)
Meningitis: Diagnosis
Lumbar puncture and analyze CSF
Cloudy, low glucose: Bacterial
Clear, normal glucose: Viral
Meningitis: Nursing Care
-Droplet and Standard Precautions (until abx 24-48 hr)
Regular room
Don’t have to close door
Surgical mask within 3 ft.
Mask on patient when out of room
-Abx, anti-seizure, analgesic, anti-pyretic, corticosteroids
Pulmonary Embolism
Obstruction of pulmonary artery (most commonly a clot)
Large emboli can impair circulation and gas exchange
PE common in hospitalization (can cause death with 1 hr)
Pulmonary Embolism: Risk Factors
- Prolonged immobility (venous stasis)
- CVC
- Surgery (vessel damage and clot formation)
- Obesity
- Advancing age
- Conditions that increase clotting (pregnancy, sickle cell, estrogen tx)
- History of thromboembolism
Pulmonary Embolism: Classic S/S
- Sudden dyspnea
- Pleuritic chest pain
- Tachypnea
- Anxiety
- Cough
- Hemoptysis
- Feeling of impending doom/anxiety
Massive Pulmonary Embolism: S/S
- Tachycardia
- JVD
- Hypotension
Pulmonary Embolism: Prevention
- DVT prophylaxis
- Passive and Active ROM
- SCDs. TEDs
- Anticoagulants/Antiplatelets
- Avoid smoking
Pulmonary Embolism: Diagnosis
- CT scan (check kidney function: BUN/Cr, UOP)
- Multidetector or CT angiography
- D Dimer assay
- Ventilation perfusion scan (VQ scan)
Pulmonary Embolism: Drug Therapy
-Draw coagulation studies first**
-Anticoagulants
Heparin (PTT: 40-90)
Warfarin/Coumadin (INR: 2-3)
Lovenox (Enoxaparin)
Xarelto (Rivaroxaban)
-Thrombolytic if ordered (“-ase”
Acute Respiratory Distress Syndrome (ARDS): Criteria
-Onset <7 days
-Refractory hypoxemia (doesn’t respond to non-invasive O2 tx)
-Bilateral chest infiltrates (“white out” on X-Ray)
-No Left HF evidence
Normal Wedge: 8-12
ARDS: Precipitating Factors
- Shock
- Trauma
- Pancreatitis
- Sepsis
- Pulmonary Aspiration
- Toxin Inhalation
- Multiple Blood Transfusions
ARDS: Manifestations
- Rapid onset dyspnea**
- Increased alveolar dead space**
- Refractory hypoxemia (needs intubation)**
- Abnormal lung sounds
- Cyanosis
- Intercostal/substernal retractions
- Tachycardia
- Hypotension
ARDS: Nursing Implications
-Intubation and Mechanical Vent
-Corticosteroids (anti-inflammatory)
-Nutritional support
-Fluids per protocol
-Inhaled nitric oxide (vasodilator)
-Surfactant Replacement
-ECMO
Re-oxygenates blood
Allows lungs to rest and heal
Laryngeal Trauma
Ensure patent airway
May have to prep for total laryngectomy (teach patient they won’t be able to speak after)
Laryngeal Trauma: Presentation
- Hoarse
- Swelling
- Dyspnea
- Hemoptysis
- Hematoma/Edema of neck
Laryngeal Trauma: Interventions
- Monitor Airway
- Trach kit and emergency equipment at bedside
- Provide humidified air
- HOB >45 degrees
- Aspiration precautions
- Voice Rest
Chest Trauma: Primary Survey
ABCDE
-Airway - C Spine (C4 and C5 innervate the diaphragm)
-Breathing - equality/quality of breath sounds
-Circulation - Pulse, HR, skin, BP, bleeding signs, IVF
-Disability - GCS or AVPU (alert, voice, pain, unresponsive)
-Expose (remove clothing for complete emergency assessment)
Cover with warm blanket
Chest Trauma: Nursing Interventions (order)
- Open airway under C-Spine precautions
- Provide oxygen
- Prepare for ETT
- Establish IV access
- Fluids as ordered (warmed)
- Monitor temp
Chest Trauma: Secondary Survey
AMPLE
Allergies Medication use Past medical hx Last meal Events leading to injury
Assessment Findings for clues of injury
Pneumothorax - diminished breath sounds
Ruptured Diaphragm - Breath sounds in lower mid chest
Vascular Injury - bruit
Cardiac Tamponade or Pericardial Bleed - muffled heart sounds
Tension Pneumothorax or Cardiac Tamponade - Distended neck veins
Hypovolemia - flat jugulars
Tension Pneumothorax or Massive Hemothorax - tracheal shift
Trauma Triad of Death
Coagulopathy
Hypothermia
Metabolic Acidosis
Pneumothorax
Air in the pleural space
Pneumothorax: Types
Closed - spontaneous after respiratory disorders (Thomas)
Open - wound opens pleural cavity to the outside
Pneumothorax: S/S
- Dyspnea
- Tachycardia
- Hyper resonance on affected side
- Decreased breath sounds on affected side
- Pleuritic chest pain
- SubQ Emphysema/Crepitus
Pneumothorax: Implications
- Prep for Chest Tube
- For open pneumo, non-porous dressing taped on 3 sides
Tension Pneumothorax
Air enters on inspiration, can’t leave on expiration
Decreased CO
Tension Pneumothorax: S/S
- Increased HR
- Severe respiratory distress
- JVD
- Angina
- Tracheal shift
- Cyanosis
Tension Pneumothorax: Implications
Needle decompression
2nd intercostal at midclavicular
Prep for chest tube
Hemothorax
Blood in the pleural space
Hemothorax: S/S
- Dyspnea, Tachycardia, chest pain, tracheal shift
- Dullness on percussion of affected side
Hypovolemic Shock
- Tachycardia
- Hypotension
- Tachypnea
- Decreased LOC
- Decreased UOP
- Cold, clammy skin
Hemothorax: Implications
-Chest tube
-Replace volume lost
-Open thoracotomy (if severe)
Immediate drainage of 20 mL/kg
Accumulation of >3mL/kg/hr
ABGs
pH: 7.35 - 7.45
CO2: 35 - 45
HCO3: 22 - 26
Chest Tube Placement
Pneumothorax: 2nd/3rd intercostal at midclavicular
Hemothorax: 4th-8th intercostal at midaxillary
Ventilator: Monitor
For changes in:
- VS
- S/S of hypoxia or hypoxemia
- Dysrhythmias
- Aspiration
Ventilator: Clinical Assessment
-Watch for chest rise
-Listen for breath sounds
-Check placement for gurgling in stomach (indicates esophagus instead of trachea)
Capnography can assess too
-Stabilize and mark tube at incisor or naris
Proper CO2 Capnography: Value
35 - 45 mmHg
Ventilator: Low Pressure Alarm
- Leakage
- Patient stopped breathing if on CPAP or SIMV
Ventilator: High Pressure Alarm
- Blockage
- Biting, coughing, mucus plug, kink, water collection
Suction to resolve
Ventilator: Complications
-Hypotension (Increased intrathoracic pressure = decreased CO)
-Aspiration (epiglottis issues)
-Infection
-Ventilator Associated Pneumonia (VAP)
48+ after intubation
Prevent with daily “Chlorhexidine”
-Barotrauma (alveolar rupture)
Increased positive pressure
Overdistention of alveoli
Friable lung tissue
ETT Patient Care
-HOB 30-45 degrees
-Monitor respiratory status
-Check ETT placement and vent settings
-Mouth care (“Chlorhexidine”)
Reduces VAP
-Monitor for S/S infection
VAP, aspiration pneumonia
-NPO, TPN/tube feeds
-Chemical sedation or restraints
-DVT prophylaxis
-Peptic ulcer prophylaxis
Weaning Off a Ventilator: Criteria
- Ability to breathe spontaneously
- Ability to support adequate O2
- Ability to maintain adequate hemodynamic stability
Weaning Off a Ventilator: Nurse Responsibilities
- DC Sedation
- Assess for respiratory distress
- Evaluate LOC
- ABGs
Tidal Volume: Value
500
FiO2: Value
~30%
SaO2: Value
> 90%
PaO2: Value
80 - 100 mmHg (>60 mmHg if acute care)
PEEP: Value
5 - 15 cmH2O
PEEP: S/E
- Additional thoracic pressure
- Risk for pneumo, barotrauma, and low CO
5 P’s for Monitoring Distal to ABG site
- Pain
- Paresthesia
- Pulse
- Paralysis
- Pallor
GCS
15: normal
<8: need to be intubated
3: comatose
What drugs slow healing?
Corticosteroids
Acute Pancreatitis: Etiology
-ETOH
-Bile duct obstruction
-Other
Abd surgery
Trauma
Infection
Drug use
Idiopathic
Acute Pancreatitis: S/S
- LUQ severe pain**
- N/V
- Abd Distention
- Jaundice
- Low grade fever
- Hypovolemic Shock: tachycardia and hypotension
- Grey Turner’s Sign: flank
- Cullen’s Sign: belly button
Acute Pancreatitis: Complications
-Jaundice
-Hyperglycemia (can’t make insulin)
-Hypocalcemia (r/t fat/pancreatic necrosis)
Tetany and seizures
-Pulmonary (ARDS, atelectasis)
-Paralytic Ileus
-Hypovolemic shock d/t fluid shift and hemorrhage
-DIC
-Renal failure r/t hypovolemia
Acute Pancreatitis: Diagnostic Tests
WBC: >10,000
H&H: <12; 36%
ALT: >20 = gallstones
Glucose: increased d/t insulin production stopped
E-lytes:
Potassium (3.5 - 5.0)
Calcium (8.5 - 10.5)Acute Pancreatitis: Interventions
- PRIORITY: replace fluids**
- ABC
- Pain control (morphine, Dilaudid, Demerol)
- Input and Output
- Monitor labs
- Nutrition
- H2 blockers, PPI
Gallstone Removal Procedure
ERCP
Hep A: Transmission
Fecal –> Oral
Hep A: Labs
IgM: current infection
IgG: immunity/recovery
Hep A: Nursing Care
Post-Exposure:
Healthy- vaccine only
Unhealthy- vaccine + immunoglobulin
Hep B: Transmission
Blood and Body Fluids
Mother -> child at birth
Hep B: Labs
HBcAB/Core Antibody: exposure (presumptive infections)
HBsAG/Surface Antigen: currently infected
HBsAB: Immunity
Hep B: Nursing Care
Most develop immunity after exposure
If becomes chronic (>6 mo) = liver cirrhosis and cancer risk
Post-Exposure: Vaccine + immunoglobulin
Hep C: Transmission
Blood
Mainly IV drug abuse
Hep C: Labs
HCV antibody: exposure/past infection
HCV RNA: current active infection
Hep C: Nursing Care
Breastfeeding is ok if nipples not cracked/bleeding
No vaccine, but there is a cure
Liver Cirrhosis: Types
- Laennec’s: ETOH
- Post Necrotic: r/t infection (MOST COMMON)***
- Biliary Cirrhosis: biliary obstruction or destruction
- Cardiac Cirrhosis: secondary to CHF
Liver Cirrhosis: Presentation
- Jaundice
- Ascites
- Edema
- Vitamin Deficiency
- Petechiae
- Ecchymosis
Liver Cirrhosis: Complications
-Portal hypotension
-Bleeding Esophageal varices
Rupture Causes: cough, strenuous exercise, trauma
-Coagulation defect
-Jaundice
-Ascites
-Gynecomastia
Hepatic Encephalopathy: Precipitating Factors
- Excessive protein intake
- GI bleed*
- Constipation
- Drugs (opioids, sedatives, analgesics)
- Infection
- Hypokalemia
Variceal Hemorrhage: Emergency Care
- Maintain airway
- Replace volume (not LR = increased ammonia = decreased LOC)
- Prep for emergency endoscopy
- Insert NGT
- Reduce hepatic blood flow (vasopressin)
- Watch for Projectile Vomiting
