Final: lectures Flashcards
rule of nines
body is divided into areas that are multiples of 9% to calculate burn injury in adults
rule of nine: major sections
head
each arm
chest and back
each leg
rules of nine: head
-whole head: 9%
front: 4.5%
back: 4.5%
rules of nine: each arm
whole: 9%
front: 4.5%
back: 4.5%
rule of nine: chest and back
chest: 18%
back: 18%
rule of nine: each leg
whole: 18%
front: 9%
back:9%
Parkland/Consensus formula starts calculating at time of:
injury
Consensus formula:
1st half given:
2nd half given:
(2-4 mL)(kg)(TBSA%)
1st half: first 8 hrs
2nd: 16 hours
primary assessment of burn patients focuses on (5)
airway
breathing
circulation
disability
environment
secondary assessment of burn patients focuses on: (6)
total body scan to determine extent of burns
fluid resuscitation
labs (BMP, CBC, ABG)
Foley placement
Pain management
Administering tetanus/other necessary vaccines
pain management consideration w/ burn patients
higher dose/more frequent administration because metabolic rate will be higher
burn complications (circulatory) (5)
Massive edema
-electrolyte imbalances
-decreased cardiac output
-hypotension
-hypovolemic shock
burn complications (non circulatory) (5)
carbon monoxide impacts
impaired immunity/infection
impaired temperature regulation
decreased GI motility
stress/injury ulcers (GI)
burn is painful with mild edema
superficial
burn is painful with blisters and mild-moderate edema
partial-thickness burn
burn causes little to no pain and severe edema
full-thickness burn
burn is painless with little to no edema
deep-full thickness
burn effects only epidermis layer
superficial
burn effects epidermis and 1/3 of dermis
superficial partial thickness
burn effects epidermis and more than 1/3 (but not whole) dermis
deep partial thickness
burn effects epidermis and all of dermis
full-thickness
burn effects all skin layers
deep full-thickness
TBI priority action
apply C-collar and don’t remove until provider has assess and cleared patient
Glasgow coma scale:
less than 8:
9-12
more than 13:
<8: severe head injury/coma
9-12: moderate head injury
>13: minor head trauma
____________ pupils indicate severe brainstem injury and possible brain death
bilateral, fixed pupils
assessment for TBI (4)
Glasgow coma scale
cranial nerves
pupillary assessment
reflex assessment
_______ and _______ are both posturing indicating life-threatening brain damage with _________ being most severe
decorticate and decerebrate
decerebrate more severe
TBI monitoring: (5)
ICP
CPP
airway
circulation
neuro
Cerebral perfusion pressure formula
MAP - ICP
CPP should always be greater than _______, if less than, indicates _____________
60 mmHg
brain ischemia
normal CPP
60-100 mmHg
Normal ICP
10-15
________ and _______ indicates increased ICP and is a potential sign of brain __________
projectile vomiting and severe headache
brain herniation
TBI airway management: if GCS is 8 or less _______
intubate
With TBIs NEVER insert ____________
nasogastric tube
PaO2 should be over:
100 mmHg
_________ is one of the first signs of impending herniation
unilateral pupil dilation
Contraindication of HOB being elevated 30 degrees
spinal cord injury
_____________ is used if herniation is indicated as its a potent vasodilator and lowers CPP/ICP
hyperventilation
medications to reduce ICP (2)
Mannitol: osmotic diuretic
Vecuronium: neuromuscular blocking agent
_____ is the most common type of stroke (80-85%)
ischemic
ischemic strokes are caused by ________ generally coming from __________ following ___(3)_____
local thrombus/emboli
heart or large arteries
a-fib, acute MI, or surgery
Time goal for stroke management ED door - needle
60 minutes
NIHSS Score interpretation
0
1-4
5-15
16-20
21-42
no stroke
minor stroke
moderate to severe stroke
sever stroke
when to use NIHSS (4)
when patient arrives
following any intervention
when significant changes in pt status occurs
prior to discharge from ED
when to treat BP and BG before giving TPA:
-BG: <50mg/dL
-BP: S > 185; D>110 mmHg
Once TPA is initiated ________ can not be done
insertion of any tubes (foley, NG, IV, etc)
complications of thrombolytic therapy (4)
bleeding
angioedema
anaphylactic reaction
further deterioration in neurological status
assessment before/during/after TPA (6)
-Neuro assessment & vitals every 15 minutes for 2 hours than every 30 minutes for 4-6hrs
-Record I&Os
-Don’t administer any thrombotic for first 24 hours
-fall precautions
-telemetry
-monitor hemoglobin and platelets
TIA->stroke risk ABCD assessment
Age < or equal to 60
Blood pressure < or equal to 140/90
Clinical TIA features
Duration of symptoms (longer the symptoms, greater the risk of stroke
most common cause of hemorrhagic stroke
hypertension
s/s of autonomic dysreflexia (6)
sudden increase in BP
goodebumps
bradycardia
sense of anxiety
blurred vision
pain
hypovolemic shock results from
inadequate circulating volume
carcinogenic shock results from
pump failure
distributive shock results from
abnormal distribution of blood
obstructive shock results from
obstruction of blood flow
major intervention for cariogenic shock
position in semi-flowers or high fowlers
if cariogenic shock is caused by right sided pump failure, there is an increase in _______ and should be treated with _______
increased preload
isotonic fluids
Indicators of SIRS (7)
-fever + leukocytosis
-hyper/hypothermia
-HR > 90
-RR>20
-pCO2 < 32
WBC > 12000 or < 4000
10% immature neutrophils
client diagnosed with sepsis has a higher risk of developing _____ or ______
DIC or MODS
Risk factors of SEPSIS (6)
suppressed immune system
extreme age
people who have received an organ transplant
surgical procedure
indwelling device
sickness
Initial stage of septic shock (2)
Baseline MAP decreased by <10 mmHg
Vascular constriction and increased HR
in the initial stage of septic shock caused by bacterial sepsis, you will most likely see an elevated ____________ normal:
prolactin (normal: 0.01 ng/dL)
Compensatory phase of septic shock (6)
Map decreased by 10-15 mmHg
Urine output decreases
Blood vessel constriction increases
Tissue hypoxia occurs
Thirst and anxiety are subject to changes
in septic shock: a MAP <65 after fluid administration indicates:
condition is worsening
in septic shock, nurse should talk to provider about holding vasopressors if MAP is:
55 or less
Progressive stage of septic shock (7)
-sustained decreased MAP of more than 20 mmHg from baseline
-vital organs develop hypoxia; some tissues die
-rapid, low pulse
-low BP
-pallor; cool, moist skin
-anuria
-decrease in SpO2
Condition causing shock must be corrected within _______ of progressive stage onset
1 hour or less
refractory stage of septic shock (6)
-too little oxygen reaches tissues; cell death and tissue damage results
-MODS develops
-Rapid loss of consciousness
-nonpalpable pulse
-cold, dusky extremities
-slow, shallow respirations; unmeasurable SpO2
early s/s of septic shock (7)
warm flushed skin
hypotension
tachycardia
tachypnea
fever
high cardiac output
restless/anxiety
late s/s of septic shock (6)
cold and clammy skin
cardiac output decreases
oliguric
hypotension
decreased LOC
hypothermia
Treatment for septic shock (7)
start antibiotics within one hour
oxygenate
vasopressors
fluids
nutrition
corticosteroids
monitor BG for hyperglycemia
for a patient with septic shock, its important to review medications for:
diuretics- contraindicated
physiologic responses to all types of shocks include (3)
activation of inflammatory system
activation of coagulation system
hypoperfusion of tissues
patients receiving fluid replacement therapy for shock should be frequently monitored for (3)
adequate urinary output
changes in mental status
vital sign stability
the main goal of treating septic shock is
identification and elimination of infection
AKI is a rapid reduction in kidney function resulting in a failure to: (3)
maintain waste and elimination
fluid and electrolyte balance
acid-base balance
Labs indicating AKI (3)
-increase in serum creatinine by 0.3 mg/dL or more within 48 hrs
-increase in serum creatinine to 1.5x baseline in last 7 days
-urine volume less than 0.5mL/kg/hr for 6 hours
phase of AKI where patient is sickest
oliguric phase
phase of AKI that is most dangerous/life threatening
diuretic phase
phase of AKI where there’s a return to normal function while healing takes place
recovery phase
indications of CRRT (3)
-sepsis
-MODS
-clients aren’t able to tolerate intermittent dialysis
DKA is characterized by (4)
profound dehydration
electrolyte losses
ketonuria
acidosis
priority treatment of DKA (3)
potassium changes
fluid replacement (NS->D5W)
regular insulin drip
DKA is more common in type ____ and HHS is more common is type ____
DKA: type 1
HHS: type 2
treatment of HHS
Potassium changes
fluid replacement (NS-> D5W)
regular insulin drip
Type of insulin: lispro, aspart, glulisine
rapid-acting
peak of rapid-acting insulin
one hour
regular insulin peak
2-4 hours
what type of insulin: NPH, detemir
intermediate-acting
intermediate acting insulin peak
4-12 hours
what type of insulin: glargine, degludec
long-acting
long acting insulin starts working within ______ and lasts ______
2 hours, 24 hours
most common s/s of pulmonary embolism
coughing up blood
complications of PE (5)
cardiac arrest
arrhythmia
pulmonary effusion
pulmonary hypertension
pulmonary infarction
treatment of PE (5)
thrombolytics
anticoagulants
clot removal
inferior vena cava filter placement
balloon angioplasty
treatment of pulmonary hypertension (4)
anticoagulants
diuretics
oxygen
digoxin
procedure performed to remove fluid from the thoracic cavity; for both diagnostic and therapeutic purposes
thoracentesis
minimally invasive procedure that lets doctors look inside airways and lungs
bronchoscopy
common causes of type 1 respiratory failure (7)
trauma
pneumonia
lung disease
smoke, chemical, or water inhalation
blood clot
sepsis
heart attack
common causes of type II respiratory failure (5)
stroke
spinal cord injury
drug/alcohol overdose
sepsis
cardiac arrest
treatment of acute respiratory failure (4)
oxygen therapy
breathing treatments
fluid
ECLS
takes over the function of the heart and lungs, supplying oxygen and removing carbon dioxide
gives lungs a break, allows for time to recover
Extracorporeal life support (ECLS)
ventilator bundle (6)
oral care q2hrs
HOB 30 degrees
sedation holiday
GI prophylaxis
DVT prevention
daily assessment for extubation/weaing
complications of mechanical ventilation (6)
barotrauma
hemodynamic instability
Ventilator associated pneumonia (VAP)
aspiration
immobilization
anxiety/pain/delirium
degree of STRETCH of cardiac muscle fibers at end of diastole
preload
RESISTANCE to ejection of bleed from ventricle
afterload
STRENGTH/ABILITY of cardiac muscle to shorten in response to electrical impulse
contractility
percent of end diastolic volume ejected with each heart beat
ejection fraction
amount of blood pumped by ventricles in L/min
cardiac output
cardiac output formula
stroke volume x hr
normal cardiac output
4-8 L/min
normal cardiac index
2.5-4 L/min
normal central venous pressure
2-6 mmHg
central venous catheter contraindications (2)
recurrent sepsis
hypercoagulable state
MAP formula
(SBP + (DBPx2)) / 3
non-pharmacologic pain intervention (7)
ET suctioning
Repositioning
Oral Care
Reassurance/ family presence
Heat/Cold therapy
massage, acupuncture, relaxation
Music, low lights, adequate room temp
common sedatives (5)
dexmedetomidine
lorazepam
propofol
midazolam
barbiturates
Roles of RN with sedation (5)
Daily sedation holiday unless contrainidcated
educate family
skin management
DVT prophylaxis
pain control
management of delirium (6)
treat the cause
mobilize patient if possible
provide sleep enhancement
antipsychotic meds
manage withdrawal symptoms
family involvement
goals of neuromuscular blockade
decrease oxygen consumption
decrease total body work
decreasing pain and anxiety
decreasing temperature
golden rule of sedation
never start without sedation
types of neuromuscular blockades
vecuronium
pancuronium
rocuronium
