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Cardiopulmonary > Intensive Care Unit and Early Mobility > Flashcards

Intensive Care Unit and Early Mobility Flashcards

1
Q

What is the care improvement ABCDEF bundle

A
  • Assess, prevent, and manage pain
  • Both spontaneous awakening trials and spontaneous breathing trials
  • Choice of sedation
  • Delirium
  • Early mobility and Exercise
  • Family engagement and empowerment
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2
Q

What are the PAD symptoms (AKA ICU triad)

A
  • Pain
  • Agitation
  • Delirium
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3
Q

Triad of anesthesiia

A
  • Hypnotics
  • Analgesics
  • Muscle relaxants
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4
Q

Sedatives should be used only when ______ and __________ have been addressed with the use of specific pharmacologic and nonpharmacologic strategies.

A
  • Pain and delirium
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5
Q

Describe the activity and mobility promotion (AMP) scale

A
  • 1 = lying in bed
  • 2 = bed activities/dependent transfer
  • 3 = sit at edge of bed
  • 4 = move to chair/commode
  • 5 = standing (1 or more minutes)
  • 6 = walk 10 steps or more
  • 7 = walk 25ft or more
  • 8 = walk 250ft or more
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6
Q

Mobility and rehab guidelines for PT in ICU; physician should be contacted before starting PT if any of the following conditions exist

A
  • RASS score = -4, -5, or ≥+3
  • Pulse Oxi <88% OR FiO2 >0.6 and PEEP >10 OR HFO ventilation
  • RR >45
  • Most recent arterial pH <7.25
  • MAP <55 or >140
  • Duration of anti-coagulation <36hrs
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7
Q

Safety screen assessment MOVES stands for

A
  • Myocardial
  • Oxygenation
  • Vasoactive
  • Engaged
  • Special considerations
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8
Q

What does the CPOT (Critical Care Pain Observation Tool) include

A
  • Facial expression
  • Body movements
  • Muscle tension (eval by passive flexion/extension of UEs)
  • Compliance with the ventilator (intubated pts) OR vocalization (extubated pts)
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9
Q

Behavioral Pain Scale (BPS) in intubated pts scoring

A
  • Facial expression: (1) relaxed, (2) partially tightened (brow lowering), (3) fully tightened (eyelid closer), (4) grimacing (folded cheek)
  • Movements of UEs: (1) no movement, (2) partially bent, (3) very bent w/finger flexion, (4) retracted/opposition to care
  • Compliance w/ventilation: (1) tolerating ventilation, (2) coughing but tolerating ventilation most of the time, (3) fighting ventilator but ventilation possible sometimes, (4) unable to control ventilation
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10
Q

Richmond Agitation Sedation Scale (RASS) grading

A
  • +4 combative: immediate danger to staff
  • +3: very agitated: pulls on/removes tubes
  • +2 agitated: frequent non-purposeful movement
  • +1 restless: anxious/apprehensive
  • 0 alert and calm
  • -1 drowsy: >10 secs awake with eye contact to voice
  • -2 light sedation: <10 secs awake with eye contact to voice
  • -3 moderate sedation: no eye contact but any movement to voice
  • -2 deep sedation: no response to voice but any movement to physical stimuli
  • -1 unarousable: no response to voice or physical stimulation
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11
Q

Describe critical illness myopathy

A
  • Evolving myopathy in an ICU setting where pts are typically exposed to high dose steroids with or w/o prolonged neuromuscular blockade
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12
Q

Who is prone to develop critical illness myopathy (CIM)

A
  • pts with systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction w/respiratory insufficiency
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13
Q

Risk factors for critical illness myopathy

A
  • Severity of illness and prolonged ICU length of stay
  • Sepsis, SIRS
  • Multi-organ failure
  • Female sex
  • Malnutrition, ionic abnormalities
  • Low serum albumin, parental nutrition, vasopressor catecholamine support
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14
Q

Findings of a physical exam for critical illness myopathy

A
  • Diffuse symmetric proximal muscle weakness (neck flexors and respiratory muscles)
  • Flaccid tone
  • NO sensory involvement
  • Facial weakness should raise concern for other neurologic disorders as it is rare for CIM
  • Normal/reduced DTRs
  • Normal/mildly elevated creatinine kinase (CK)
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15
Q

What are the 4 levels in the American Academy of Critical Care Nursing (AACN) mobility protocol

A
  • (1) Elevated supine
  • (2) Sitting EOB
  • (3) Sitting in chair
  • (4) Ambulation
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16
Q

Signs and symptoms of respiratory disturbance in acidosis and alkalosis

A
  • Acidosis: hypercapnia, visual disturbances, drowsiness, V-fib, depressed tendon reflexes
  • Alkalosis: hypocapnia, lightheadedness, tetany, convulsions, numbness/tingling of digits
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17
Q

Signs and symptoms of metabolic disturbance in acidosis and alkalosis

A
  • Acidosis: hyperventilation, coma, stupor (near unconsciousness), deep respirations, mental dullness
  • Alkalosis: depressed respirations, dizziness, tetany, convulsions, hypokalemia, mental confusion, numbness/tingling of digits
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18
Q

Patients who are on ________________ typically require continuous blood pressure management

A
  • vasoactive drips
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19
Q

An arterial line is most commonly inserted through the _________ artery, but can also be inserted through the _________ artery

A
  • Radial
  • Femoral
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20
Q

Mean arterial pressure (MAP) can be an important indicator of hemodynamic tolerance and should be at least

A
  • 60 mmHg
  • Typically 70-110 mmHg
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21
Q

The transducer for an arterial line should be positioned at the level of the ______________ to assure accurate pressure values

A
  • Right atrium
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22
Q

Implications if an arterial line transducer in placed too high versus too low

A
  • If transducer is too low: blood pressure will read higher
  • If transducer is too high: blood pressure will read lower
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23
Q

What should you do if an arterial line is dislodged accidentally

A
  • Apply pressure immediately & notify nursing staff
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24
Q

Inaccuracies in the pulse oximetry readings may be seen in

A
  • Low perfusion states (low cardiac output, vasoconstriction, & hypothermia)
  • Anemia
  • Abnormal Hb
  • Jaundice
  • Arrhythmias, including atrial fibrillation
  • Intravascular dyes such as methylene blue
  • Dark nail polish
  • Fluorescent light
  • Motion artifact
  • Dark skin pigmentation
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25
Q

ECG indications of declining cardiac status

A
  • ST changes: elevation or depression
  • Onset/increase/change of foci of premature ventricular contractions (PVCs)
  • Onset of ventricular tachycardia or fibrillation
  • Onset of arterial flutter or fibrillation
  • Progression of heart block
  • Loss of pacer spike
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26
Q

Slide 53

A
27
Q

Describe a temporary pacemaker

A
  • Epicardial: inserted during surgery
  • External transcutaneous: big patch over chest/back attached to defibrillator
  • Transvenous: electrodes to RA, RV for bradycardia
  • If dislodged call for help immediately & start CPR if systole occurs
28
Q

The central line is a central venous catheter inserted most commonly through the __________ or __________ vein; however, the femoral access may also be used if the need arises.

A
  • Subclavian or Jugular vein
29
Q

The catheter is placed by a physician and is advanced to rest in the proximal __________ vena cava. The central venous catheter allows for direct and continuous monitoring of ___________ venous pressure (CVP) or _______ atrial pressure (RAP) to assess cardiac function and intravascular fluid status.

A
  • Superior
  • Central
  • Right
30
Q

What can a central line be used for

A
  • Medication or fluid administration
  • Blood sampling
  • Emergency placement of a temporary pacemaker
31
Q

What is used for interventions requiring a prolonged placement of a central line

A
  • Peripherally inserted central catheter (PICC or PIC line) or a tunneled catheter
32
Q

What peripheral veins is a PIC line inserted into and advanced through increasingly larger veins toward the heart until the tip rests in the ________________________

A
  • Cephalic, basilic, or brachial vein insertion
  • Advanced to the distal superior vena cava
33
Q

Define a tunneled catheters

A
  • Long term catheter that aer tunneled under the skin before entering a central vein
34
Q

Tunneled catheters rarer associated with a ________ rate of infections

A
  • Lesser
35
Q

In addition, the cuff around the tunneled catheter causes fibrin and collagen deposition under the skin that provides stability and provides a second internal ________________________

A
  • Barrier against infection
36
Q

Risks associated during insertion of central venous access

A
  • Pneumothorax
  • Bleeding
  • Arrhythmias
  • Arterial entry
37
Q

Delayed risks associated with central venous access

A
  • Infection
  • Catheter fracture
  • Catheter dislodgment
  • Catheter occlusion
  • Air in the catheter
38
Q

A pulmonary artery catheter (Swan-Ganz) allows monitoring of

A
  • Direct measurement of Right Atrial Pressure (RAP)
  • Direct measurement of pulmonary arterial pressure (PAP) and pulmonary capillary wedge pressure (PCWP)
  • Indirect measurement of left atrial pressure (LAP)
  • Determination of mixed venous oxygen saturation (SvO2) and cardiac output (CO)
  • Calculation of systemic and pulmonary vascular resistance (PVR)
  • Pacing of the atrium and ventricles
39
Q

What structures does a pulmonary artery catheter (Swan-Ganz) pass through

A
  • Central venous access point
  • Vena cava
  • Right atrium
  • Right atrioventricular (tricuspid) valve
  • Right ventricle
  • Pulmonary valve
  • Pulmonary artery
40
Q

What are pulmonary capillary wedge pressures monitored

A
  • Assess severity of left ventricular failure
  • Assess mitral and aortic valve dysfunction
  • Assess and treat pulmonary edema (PCWP >20 mm Hg)
  • Assess pulmonary hypertension
  • Assess and treat hypovolemic state
41
Q

Presence of a pulmonary artery catheter (Swan-Ganz) is not a contraindication to mobilization (True/False)

A
  • True
42
Q

Complications of insertion and dislodgement of the Swan-Ganz catheter include

A
  • Malignant arrhythmias
  • Pulmonary artery rupture
  • Pulmonary valve tear
  • Infection
43
Q

Activities that may increase ICP (intracranial pressure)

A
  • Isometric exercise
  • Valsalva maneuver
  • Extreme hip flexion
  • Lateral neck flexion
  • Coughing
  • Prone position
  • Head position below 15 degrees horizontal (ideal position for venous drainage: HOB >30 degrees)
  • Occlusion of the tube
  • Pain
44
Q

Describe ventriculostomy/EVD

A
  • Measures ICP & drains cerebrospinal fluid
  • Indicator line/light must line up with the external auditory meatus
  • Mobility is safe
  • Ensure secure connection prior to mobility
  • Goal is ICP <20 mmHg
  • Must be clamped by RN prior to mobility
  • Elevate head of bed to 30º after placement and attach EVD CSF collection system to a pole near the head end of the bed
  • LIFE THREATENING if dislodged
45
Q

Contraindications to mobilizing with EVD

A
  • hemodynamic instability
  • active bleeding or angioedema
  • heart rate greater than 120bpm
  • ICP higher than 25mm Hg or as deemed unstable by the treating NSICU/neurosurgery team
  • a cerebral perfusion pressure lower than 50mm Hg
  • resting heart rate of 50% age-predicted maximum or less
  • systolic blood pressure lower than 90 or higher than 180, diastolic blood pressure higher than 105
  • peripheral oxygen saturation of 90% or less
  • marked diaphoresis, facial pallor, intense anxious or painful facial expression (especially in patients who were aphasic)
  • active bleeding from lines, catheters, or wounds
46
Q

Describe a lumbar drain

A
  • Small flexible tube that is placed in the lumbar spine
  • Drains some of the CSF that fills the ventricles of the brain & surrounds the brain and spinal cord
  • Draining CSF for a few days is helpful in determining if the pt will benefit from a shunt
  • Drain must be CLAMPED prior to mobilizing
47
Q

Describe a urinary catheter

A
  • Collects urine
  • Keep collection bag below bladder
  • Ensure catheter is secure
48
Q

Types of urinary catheters

A
  • Condom: frequently fall off, ask nursing staff to reapply
  • External: connected to suction, remove prior to mobility
  • Foley and suprapubic if dislodged call RN immediately as they are secured with balloon in bladder
49
Q

Describe fecal management systems

A
  • Typically used in pts with excessive loose stools in order to protect skin
  • Avoid shearing with transfers
  • Held in place with balloon in rectum
  • If dislodged notify RN
50
Q

Descrive Gastrointestinal (GI) tubes

A
  • Drain GI contents or administer internal feedings & medication
  • Inserted in nose, mouth, or abdomen
  • Shot or long term use
  • Turn OFF feeding if HOB is <30º
  • If dislodged immediately alert RN
51
Q

What are the different types of GI tubes

A
  • NG: nose to stomach
  • ND: nose to duodenum
  • NJ: nose to jejunum
  • Gastric tube (G-tube): directly inserted into stomach
  • GJ: gastric to jejunum
  • PEG: percutaneous endoscopic gastrostomy (flexible feeding tube is placed through the abdominal wall & into the stomach)
  • Jejunal (J-tube): inserted directly into jejunum
52
Q

Describe surgical drains

A
  • Placed during surgery to drain pus, blood, or other fluids
  • Active vs passive drain, closed system: vacuum vs nonvacuum
  • Open system
  • Ensure drains are secure prior to mobility
  • If dislodged cover area with hand, apply pressure, and call RN immediately
53
Q

Describe a wound VAC

A
  • Type of closed active drainage system used foe wounds
  • Vacuum assisted closure (VAC) of a wound
  • Negative pressure wound therapy to promote healing in acute/chronic wounds
  • Commonly used on skin flaps/grafts, ulcers after debridement, and surgical closings
54
Q

Reasons for insertion of a chest tube

A
  • Thoracotomy
  • Pleural effusion
  • Pneumothorax, hemothorax, or chylothorax
  • empyema
  • Chemical pleurodesis
55
Q

Describe the purpose of a chest tube

A
  • Used to remove and prevent the reentry of air or fluid from the pleural or mediastinal space & provide negative intrapleural pressure
56
Q

Presence of a chest tube is NOT a contraindication to mobilization (True/False)

A
  • True
57
Q

For effective mobilization with pts with chest tubes you need to

A
  • Ensure that the pt is premeditated for pain
  • Always keep chest tube drainage system below the chest level
  • Check for air leaks
  • Always discuss with doctor or nurse before disconnecting suction
  • A portable suction device may be used when indicated
  • Changes in the quantity & quality of exudates should be noted by the PT before, during, & after changes in position & therapeutic interventions
  • After chest tube removed hold therapy until X-ray rules out pneumothorax
58
Q

Individual with at least 2 of the following indicates strong consideration for ICU admission due to organ dysfunction (sepsis)

A
  • RR >22 breaths/minute
  • Change in mental status
  • SBP <100 mmHg
59
Q

Reasons to stop PT intervention with acute coronary syndrome/MI patients

A
  • Unable to comfortably speak
  • RR >40 breaths/minute
  • Onset of S3 heart sound
  • HR decreased >10 bpm
  • SBP decreased >10 mmHg
  • MAP increased >10 mmHg
  • CVP decrease/increase >6 mmHg
  • SpO2 <90% or a decrease ≥4%
  • New onset or worsening of cardiac dysrhythmia
  • Return of pre-MI angina like pain
60
Q

Common indications for vasopressors

A
  • Shock (septic, cariogenic, anaphylactic)
  • Heart failure
61
Q

Positive inotropes

A
  • Beta Agonists
  • Cardiac Glycosides
  • Dobutamine
62
Q

Neuromuscular blocking agents

A
  • Nimbex
  • Rocuronium
63
Q

General anesthetics

A
  • Propofol
  • Ketamine

Cardiopulmonary (18 decks)

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