NUR353 Exam Prep Flashcards
1
Q
What makes us breathless? (List 5)
A
- Pain
- Exercise
- Obesity
- Genetics
- Smoking
- Allergy: Dust, Pollen, Fur, Grass, etc.
2
Q
List some common respiratory conditions: (List 5)
A
Chest Infection Pneumonia Emphysema Dyspnoea Respiratory failure Asthma COPD PE TB Bronchiectasis Bhronchitis CF
3
Q
What is pneumonia?
A
Infection that inflames air sacs in one or both lungs, which may fill with fluid.
4
Q
What are some of the symptoms of pneumonia?
A
cough with phlegm or purulent,
fever,
chills,
difficulty breathing.
5
Q
What is emphysema?
A
Emphysema is a long-term, progressive disease of the lungs that primarily causes shortness of breath due to over-inflation of the alveoli (air sacs in the lung). In people with emphysema, the lung tissue involved in exchange of gases (oxygen and carbon dioxide) is impaired or destroyed.
6
Q
Define dyspnoea:
A
Difficult or laboured breathing.
7
Q
What is COPD?
A
Chronic obstructive pulmonary disease (COPD) is an umbrella term for chronic lung conditions characterised by airflow obstruction that cannot be fully reversed, such as emphysema and chronic bronchitis.
8
Q
What are some symptoms of COPD?
A
shortness of breath, wheezing chronic cough (can be dry or with phlegm) frequent respiratory infections fatigue or inability to exercise chest pressure
9
Q
Indications for an adjunct airway:
A
- GCS < 8,
- Compromised airway,
- Patient unconscious, not breathing,
- Patient being anaesthetised.
- Decreased respiratory centre due to drug/opioid overdose
- Possible aspiration
10
Q
What causes respiratory acidosis?
A
Alveolar hypoventilation
Inadequate perfusion
Mechanical ventilation
Diseases:
Asthma
COPD
Pneumonia
11
Q
Describe the differences between Type I Respiratory Failure and Type II Respiratory Failure:
A
Type I respiratory failure involves low oxygen, and normal or low carbon dioxide levels.
Type I respiratory failure occurs because of damage to lung tissue. This lung damage prevents adequate oxygenation of the blood (hypoxaemia); however, the remaining normal lung is still sufficient to excrete the carbon dioxide being produced by tissue metabolism. This is possible because less functioning lung tissue is required for carbon dioxide excretion than is needed for oxygenation of the blood.
Type II respiratory failure involves low oxygen, with high carbon dioxide.
Type II respiratory failure is also known as ‘ventilatory failure’. It occurs when alveolar ventilation is insufficient to excrete the carbon dioxide being produced. Inadequate ventilation is due to reduced ventilatory effort, or inability to overcome increased resistance to ventilation – it affects the lung as a whole, and thus carbon dioxide accumulates. Complications include: damage to vital organs due to hypoxaemia, CNS depression due to increased carbon dioxide levels, respiratory acidosis (carbon dioxide retention). This is ultimately fatal unless treated. Complications due to treatment may also occur.
12
Q
ABG normal results: PaO2 PaCO2 HCO3 pH BE
A
PaO2: 70-100 mmHg PaCO2: 35-45 mmol/l HCO3: 22-26 mmol/l pH: 7.35 – 7.45 BE: +/- 2mmol/l
13
Q
Differentiate between objective and subjective data:
A
Subjective data: data collected from the patients information
Objective data: data collected using the 5 human senses.
14
Q
Give examples of subjective date in regards to respiratory history:
A
- Important health information: Past health history, medications, surgery or other treatments
- Any risk factors for respiratory disease
- Smoking: Pack years (PPD x years), exposure to smoke, history of attempts to quit, methods, results
15
Q
Give examples of objective date in regards to respiratory history:
A
Objective data: data collected using the 5 human senses.
- Respiratory rate, depth and rhythm, breath sounds, equal chest movement - use of accessory muscles.
- Mouth and pharynx: use light source/tongue blade
- Tracheal central. Neck symmetry, palpate glands
- O2 saturations.
- Auscultation
16
Q
Define stridor:
A
High pitched noise on using on inspiration but can be on expiration, indicates a disturbance to the airflow in the upper respiratory tract.
17
Q
Define stertor:
A
Snoring during sleep or altered consciousness
18
Q
What is Non Invasive Positive Pressure Ventilation and how is it delivered?
A
Non Invasive Positive Pressure Ventilation:
- Delivers positive pressure breaths to a spontaneously breathing patient
- Reduces the occurrence of patients being intubated
- Delivered by a mask with an airtight seal
19
Q
Discuss what CPAP is, how it works and who it is used for.
A
Continuous positive airway pressure:
- Provides support for spontaneously breathing patients and ventilated patients
- Is delivered non invasively via a mask
- Addition to mechanical ventilation
(The raised positive pressure assists in reducing the work of breathing on inspiration, increases gas exchange and reduces hypoxia)
20
Q
What conditions is CPAP commonly used for? (List 3)
A
Pulmonary oedema
COPD
Asthma
21
Q
What is BiPAP and what does it involve?
A
Bilevel Positive Airway Pressure
Involves
IPAP (Inspiratory positive airway pressure)
-Higher pressure delivered on inspiration
EPAP (Expiratory Positive Airway Pressure)
-Lower pressure (still +ve) on expiration
22
Q
Define wheeze:
A
High pitched whistling sound heard on expiration, indicates resistance to airflow in lower respiratory tract.
23
Q
Define rattle:
A
Heard on inspiration and expiration, associated with secretions in the lower respiratory tract (death rattle!)
24
Q
What are some indications for invasive positive pressure ventilation? (Mechanical) (List 4)
A
◦ Inability to protect own airway (gag response diminshed, GCS reduced)
◦ inadequate breathing pattern rate and/or depth (vital capicity <15mL/kg; resp rate < 10 or > 30/min)
◦ inability to sustain O2 demands of the body PaO2 <55 mmHg, with supplemental O2,
◦ hypercapnia PCO2 > 50mmHg with acidosis pH< 7.30
25
Define asthma:
A chronic inflammatory disease of the airways that causes hyper-responsiveness, mucosal oedema and mucous production.
26
List the diagnostic testing you would do for a respiratory patient in the community. (List 3)
Chest x-ray
Pulse oximetry
Microscopy, culture and sensitivity (MC&S)
27
What are some treatments for a respiratory patient in the hospital? (List 6)
```
Oral/IV antibiotics
Oxygen therapy
Nebulisers
Chest physio
Non-invasive ventilation
Surgery
```
28
List the assessments you would perform on a respiratory patient. (List 4)
- Inspection: respiratory rate, rhythm and depth. Symmetry of chest rise and fall. Use of accessory muscles, nasal flaring or head bobbing in children. Tracheal central or deviated. Breath sounds. Tidal volume, cyanosis or diaphoresis.
- Auscultation
- O2 sats
- GCS
29
What is the treatment aim for asthma and how is it treated?
Treatment aim is for symptom control/optimised lung function/lowest effective dose of medication/fewest possible side effects.
• Quick-relief medications (relievers)
• Long-acting medications (preventers)
30
What is BiPAP commonly used in? (List 6)
* High dependency patients
* Neurological disorders (Guillain Barre syndrome)
* Obstructive sleep apnoea
* COPD
* Asthma
* Post extubation weaning issues
31
What are some indications of invasive positive pressure ventilation? (Mechanical) (List 4)
◦ Inability to protect own airway (gag response diminshed, GCS reduced)
◦ inadequate breathing pattern rate and/or depth (vital capicity <15mL/kg; resp rate < 10 or > 30/min)
◦ inability to sustain O2 demands of the body PaO2 <55 mmHg, with supplemental O2,
◦ hypercapnia PCO2 > 50mmHg with acidosis pH< 7.30
32
What are some common conditions mechanical ventilation is used in? (List 6)
- Acute lung injury
- Asthma
- Pulmonary embolism
- Pneumonia (Community, hospital, ventilator associated)
- Aspiration
- Severe acute respiratory syndrome
33
What are the bodies compensatory mechanisms for respiratory acidosis? (List 4)
```
Compensations:
• Initial response increased respiratory rate and depth of breathing
• Increase in minute ventilation
• Increased heart rate
• Possible vasoconstriction
```
34
What effect does mechanical ventilation have on the full body in A-E format?
A – protection and patency
B – respiratory failure (hypercapnic or hypoxic), increase FRC, decrease WOB, secretion management/ pulmonary toilet, to facilitate bronchoscopy
C – minimise oxygen consumption and optimize oxygen delivery (e.g. sepsis)
D – unresponsive to pain, terminate seizure, prevent secondary brain injury
E — temperature control (e.g. serotonin syndrome)
Other — safety for transport (e.g. psychosis), humanitarian reasons
35
Define croup:
Croup is a condition caused by a viral infection. The virus leads to swelling of the voice box (larynx) and windpipe (trachea). This swelling makes the airway narrower, so it is harder to breathe. Children with croup develop a harsh, barking cough and may make a noisy, high-pitched sound when they breathe in (stridor).
36
Define PE:
Pulmonary embolism (PE) is a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism). Symptoms of a PE may include shortness of breath, chest pain particularly upon breathing in, and coughing up blood.
37
Define bronchitis:
Inflammation of the lining of bronchial tubes, which carry air to and from the lungs.
38
Define pneumothorax:
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall.
39
Outline the indications for oxygen therapy: (List 3)
Indications:
• The treatment of documented hypoxia/hypoxaemia as determined by SpO2 or inadequate blood oxygen tensions (PaO2).
• Achieving targeted percentage of oxygen saturation (as per normal values unless a different target range is specified on the observation chart.)
• The treatment of an acute or emergency situation where hypoxaemia or hypoxia is suspected, and if the child is in respiratory distress manifested by:
o Dyspnoea, tachypnoea, bradypnoea, apnoea
o Pallor, cyanosis
o Lethargy or restlessness
o Use of accessory muscles: nasal flaring, intercostal or sternal recession, tracheal tug
40
Outline the complications of oxygen therapy: (List 5)
Complications:
• CO2 Narcosis - This occurs in patients who have chronic respiratory obstruction or respiratory insufficiency which results in hypercapnea (i.e. raised PaCO2). In these patients the respiratory centre relies on hypoxaemia to maintain adequate ventilation. If these patients are given oxygen this can reduce their respiratory drive, causing respiratory depression and a further rise in PaCO2.
• Pulmonary Atelectasis
• Pulmonary oxygen toxicity - High concentrations of oxygen (>60%) may damage the alveolar membrane when inhaled for more than 48 hours resulting in pathological lung changes.
• Retinopathy of Prematurity (ROP) - An alteration of the normal retinal vascular development, mainly affecting premature neonates (<32 weeks gestation or 1250g birthweight), which can lead to visual impairment and blindness.
• Substernal pain-due: characterised by difficulty in breathing and pain within the chest, occurring when breathing elevated pressures of oxygen for extended periods.
41
What PPE should be used for a patient with pneumonia (droplet precautions)?
- Mask
| - Gloves
42
What is Kussmaul breathing?
Kussmaul's breathing is a deep and laboured breathing pattern often associated with severe metabolic aci-dosis, particularly (DKA) but also kidney failure.
43
What is Cheyne–Stokes breathing?
Cheyne–Stokes is an abnormal pattern of breathing characterised by progressively deeper, and some-times faster, breathing followed by a gradual decrease that results in apnoea.
44
What is TB?
Tuberculosis (TB) is an infectious disease usually caused by the bacterium Mycobacterium tuberculosis (MTB). It usually affects the lungs, but can involve the kidneys, bones, spine, brain and other parts of the body.
45
What are some symptoms of TB? (List 5)
- Can be asymptomatic
- Cough (sometimes blood-tinged),
- Weight loss,
- Night sweats
- Fever.
People may experience:
Pain areas: in the chest
Pain circumstances: can occur while breathing
Cough: can be chronic or with blood
Whole body: chills, fatigue, fever, loss of appetite, malaise, night sweats, or sweating
Also common: loss of muscle, phlegm, severe unintentional weight loss, shortness of breath, or swollen lymph nodes
46
What is bronchiectasis?
Bronchiectasis is a common lung disease characterised by chronic infection in small airways that results in some parts of the lung becoming damaged, scarred and dilated, allowing infected mucus to build up in pockets.
47
What are some symptoms of bronchiectasis? (List 3)
- chronic cough,
- producing mucus (sputum)
- sinusitis/nasal inflammation and fatigue.
Less common symptoms include
- chest pain,
- shortness of breath and
- coughing up blood.
48
What is CF?
People with CF develop an abnormal amount of excessively thick and sticky mucus within the lungs, airways and the digestive system. This causes impairment of the digestive functions of the pancreas and traps bacteria in the lungs resulting in recurrent infections, leading to irreversible damage. Lung failure is the major cause of death for someone with CF.
49
What are some causes of respiratory alkalosis? (List 4)
Hyperventilation - anxiety induced
Asthma
Pneumonia
PE
50
What are the 2 common types of adverse blood transfusion reactions and 3 of their symptoms?
Febrile non-haemolytic reaction
- Tachycardia
- Febrile
- Hypotensive
Acute haemolytic reaction
- Febrile
- Flank pain
- Hemoglobinuria (excretion of free haemoglobin in the urine)
51
What are you observing when assessing a patients breathing pattern?
Respiratory rate, rhythm, and depth. Regularity of breathing, chest wall movement and difficulty in breathing. (Accessory muscle use - intercostal recession, nasal flaring, head bobbing in children.)
52
How can you determine a patients difficulty in breathing?
Orthopnoea – DIB Lying down
Use of accessory muscles
Nasal Flaring
Head bobbing (Children)
53
What does chest recession indicate and what is it caused by?
Chest recession / Intercostal retractions indicate that something is blocking or narrowing your airway.
Asthma, pneumonia, and other respiratory diseases can all cause a blockage.
54
List some symptoms of asthma? (List 4)
Cough
Chest tightness
Wheezing
Dyspnoea
55
Describe the pathophysiology of asthma?
- muscles of bronchial tubes tighten and thicken
| - air passages become inflamed and mucous filled
56
Triggers of asthma: (List 6)
```
exercise
allergies
emotions
irritants
infections
cold air
```
57
What patient teaching would you implement for a asthmatic patient? (Hint - there is 7 points.)
The nature of asthma as a chronic inflammatory disease
Identification of triggers and how to avoid them
Purpose and action for each medication
Proper inhalation techniques
How to perform peak flow monitoring
How to implement an action plan
When and how to seek assistance
58
What are you assessing when looking at the C aspect of the A-E assessment?
Blood pressure, pulse, cap refill, urine output, pallor
59
What are the different types of haemodynamic monitoring and why is each used?
Non-invasive - clinical assessments (HR, BP, Temp, urine output, SpO2)
Direct measurement of arterial pressure - frequent titration of vasoactive drips, unstable BP, frequent ABGs, if unable to obtain non-invasive NP
Invasive haemodynamic monitoring - invasive monitoring is more accurate, should be higher than BP cuff
60
What are the common medications used in the treatment of ACS:
Anticoagulants, beta-blockers, antiplatelets, nitroglycerin
61
What is the recommended position for a patient with breathing difficulties and why?
Nurse in Upright position in chair or bed
Increases lung expansion
Assists gaseous exchange in alveoli
May help relieve anxiety
AVOID laying flat
Allow patient to lean e.g. over bedside table
62
How do you perform peak flow monitoring? (If you were to explain to a patient.)
Move the marker to the bottom of the numbered scale.
Stand up straight.
Take a deep breath. Fill your lungs all the way.
Hold your breath while you place the mouthpiece in your mouth, between your teeth. Close your lips around it. DO NOT put your tongue against or inside the hole.
Blow out as hard and fast as you can in a single blow. Your first burst of air is the most important. So blowing for a longer time will not affect your result.
Write down the number you get. But, if you coughed or did not do the steps right, do not write down the number. Instead, do the steps over again.
Move the marker back to the bottom and repeat all these steps 2 more times. The highest of the 3 numbers is your peak flow number. Write it down in your log chart.
63
What does a peak flow monitor do?
A peak flow meter is a small device that helps check how well asthma is controlled. Measuring peak flow can tell how well air is being blown out of a patients lungs. If the airways are narrowed and blocked due to asthma, the peak flow values drop.
64
What are two assessments to assess a patients conscious state?
AVPU and GCS
65
How do you calculate the HR on an ECG?
Regular: Count the number of large boxes between 2 R waves
Divide the number of large squares by 300
-Eg. 300/4 = 75
HR=75
Irregular: On a 10 second rhythm strip - Count the number of QRS complexes and multiply by 6
-Eg. if there are 9 QRS complexes on the strip 9x6=54
HR=54
66
What is the normal width of a QRS interval on a ECG?
2.5 small squares
67
What is the normal length of the p-r interval on a ECG?
Less than 5 small squares
68
What is Intravascular disseminated coagulation disorder?
A condition affecting the blood's ability to clot and stop bleeding. In disseminated intravascular coagulation, abnormal clumps of thickened blood (clots) form inside blood vessels. These abnormal clots use up the blood's clotting factors, which can lead to massive bleeding in other places.
69
What are shockable and non-shockable rhythms?
Shockable:
Atrial fibrillation (AF) if newly diagnosed.
Ventricular tachycardia (VT)
Ventricular fibrillation (VF)
Pulseless ventricular tachycardia (PVT)
Non-shockable:
Asystole
Pulseless electrical activity (PEA)
70
When and what drugs should be given during an MI?
For non-shockable rhythms:
Adrenaline 1mg immediately (then every second loop)
For shockable rhythms:
Adrenaline 1mg after second shock (then every second loop)
Amiodarone 300mg after three shocks
71
What should be done to provide post resuscitation care?
```
Re-evaulate ABCDE
12 lead ECG
Treat precipitating causes
Aim for SpO2 94-98%, normocapnia and normoglycaemia
Targeted temperature management
```
72
What is the equation for calculating IV fluid requirements for a burns patient?
(4 mL of intravenous solution [Ringer’s lactate solution] x patients weight prior to burns x percentage of total body surface area burned) and modified according to clinical variables such as urine output.
73
What are you assessing when looking at the C aspect of an A-E assessment?
Blood pressure, pulse, cap refill, urine output, pallor
74
What are you assessing when looking at the 'D' aspect of an A-E assessment?
Pt's concious state - AVPU and GCS.
Pt's pupil response.
Neurological observations.
Pain?
75
What are you assessing when looking at the 'A' aspect of an A-E assessment?
If the patients airway is patent, are they talking? Any breath sounds? (e.g. wheeze, stridor etc.)
76
What are you assessing when looking at the 'B' aspect of an A-E assessment?
RR, depth, rhythm, chest symmetry, any accessory muscle use. O2 sats.
77
What is the max and min score for total GCS and max for each aspect?
```
15 max.
3 min.
Eye response: 4
Verbal response: 5
Motor response: 6
```
78
What are the aspects of eye response in GCS and the equivalent scores:
4: Eyes open spontaneously.
3: Eyes open to voice.
2: Eyes open to pain.
1: No response
79
What are the aspects of verbal response in GCS and the equivalent scores:
5: Patient is orientated to time, person and place.
4: Patient is confused.
3: Patient is using inappropriate words.
2: Patient is using incomprehensible sounds.
1: No response.
80
What are the aspects of motor response in GCS and the equivalent scores:
6: Patient obeys complex commands.
5: Patient localises to pain.
4: Patient withdraws from pain.
3: Abnormal flexion. (Decorticate)
2: Abnormal extension. (Decerebrate)
1: No response.
82
Indications for Enoxaparin
Type: low molecular heparin
Indicated: for prophylaxis of DVT during surgery of the heart or blood vessels, during blood transfusion, in individuals with disseminated intravascular coagulation (DIC) and during haemodialysis.
82
Indication of Mannitol
Type: Osmatic diuretic
Indication: Promotion of diuresis in the prevention or treatment of the oliguric phase of acute renal failure before irreversible renal failure becomes established. Reduction of high intraocular pressure when the pressure cannot be lowered by other means.
83
What does decorticate posturing indicate?
- there may be damage to areas including the cerebral hemispheres, the internal capsule, and the thalamus.
- an ominous sign of severe brain damage, and may also indicate lesion(s) in the lower brainstem.
84
Indications for Maxolon (metoclopromide)
Type: antiemetic
Indicated: diabetic gastroparesis, GORD, and prevention of nausea and vomiting.
85
What does decerebrate posturing indicate?
It is exhibited by people with lesions or compression in the midbrain lesions in the cerebellum.
86
Prior to collection of a red cell pack from a blood fridge or transfusion service provider, ensure that:
- The prescription/order is complete
- Informed consent is documented/charted
- Full explanation to patient including potential reactions
- Intravenous access (18-20G) is inserted and patent
- Check if other IV medications are due
(Majority cannot be given with blood)
- Baseline observations (TPR, BP, SpO2) & assessment
- Be aware of reason for transfusion
- Resuscitation equipment, including oxygen and adrenaline, are available and in working order
- Know patient history/co-morbidities/previous transfusion history
87
What are the expected systemic effects from the nebulizer?
| ie effects upon cardiovascular, respiratory system and observations
Bronchodilation, tachycardia
88
What are the indications for a nasophargeal airway? (List 4)
trauma to oral area,
unable to tolerate,
obstructions,
broken teeth.
89
What are the contraindications for a nasophargeal airway?(ie when would you NEVER use an nasophageal airway) (List 2)
confirmed or suspected base skull fracture,
| head trauma.
90
Document what L/min O2 is to be administered by each oxygen device. (NP, HM, NRB, BMV)
NP: 2-4 L/min (book says 1L/min)
HM: 5-8 L/min
NRB: 10-12 L/min
BMV: 12-15 L/min
91
Document what L/min O2 is to be administered by Venturi:
```
Venturi:
4L – 24%
4L – 28%
6L – 31%
8L – 35%
10L – 40%
10L – 50%
12L – 60%
```
92
When would you apply Nasal prongs for a patient?
When a patient is in mild respiratory distress and requires low to medium dose oxygen concentrations.
93
Why would you use nasal prongs in preference to a Hudson mask?
- Can be used to deliver low and medium dose oxygen concentrations (22- 40%)
- Advantages of improved comfort, less claustrophobia, ability to eat and speak freely, less easily dislodged, less inspiratory resistance and no risk of CO2 rebreathing.
94
When would you apply a Hudson mask for a patient?
- Deliver oxygen concentrations up to 60%. The flow should be at least 5 L/min because lower flows can cause resistance to inspiration and rebreathing of exhaled CO2.
- Suitable for patients with hypoxaemic (Type I) respiratory failure but not for patients with hypercapnoeic (Type II) respiratory failure.
95
When would you apply a Hudson mask with Non rebreather mask for a patient?
- Used to provide a higher FiO2 than simple masks.
| - Most suitable in an emergency (e.g. shock, trauma) where CO2 retention is less relevant.
96
When would you apply a Venturi mask for a patient?
| What mask delivers the highest fraction of oxygen to a patient?
- Suitable for all patients needing a known concentration of oxygen
- Particularly suited to those at risk of CO2 retention.
97
What are your options for oxygen delivery if you cannot maintain saturations on 15 litres of oxygen?
CPAP and BiPAP
98
Symptoms of a haemolytic transfusion? (List 5)
Fever
Chills
Hypotension/Hypertension
Pain (along IV infusion line, chest or back)
Acute Respiratory Distress/stridor/wheeze
99
What are the four quadrants of the abdominal wall/area?
Right upper quadrant (RUQ),
Right lower quadrant (RLQ),
Left upper quadrant (LUQ),
Left lower quadrant (LLQ).
Epigastric,
Umbilical,
Hypogastric or suprapubic.
100
Define Blumberg’s sign.
| What it is indicative of?
- It refers to pain upon removal of pressure rather than application of pressure to the abdomen.
- Clinical sign that is elicited during physical exam by a doctor or there healthcare provider
- Also referred to as rebound tenderness
- Indicative of peritonitis
101
Define Murphy’sign:
Test for gallbladder disease in which the patient is asked to inhale while the examiner's fin-gers are hooked under the liver border at the bottom of the rib cage. The inspiration causes the gallbladder to descend onto the fingers, producing pain if the gallbladder is inflamed.
102
How is the Iliopsoas muscle test conducted:
Individual Position: The individual is lying supine with their knee flexed at 90 degrees.
Practitioner Position: The practitioner is standing with their hand placed on the individual’s flexed knee.
Description of Muscle Test: The individual is requested to further flex their knee against the practitioner’s resistance.
103
What muscles do the obturator test assess:
Obturator test:
Either of two muscles covering the outer front part of the pelvis on each side and involved in movements of the thigh and hip.
104
State some signs and symptoms of a small bowel obstruction: (There are 9 listed.)
* Anorexia, early satiation, fullness
* Bloating, tender abdomen
* Tinkling bowel sounds +/- visible peristaltic waves (Borborgymus)
* Cramping Pain/Colic which is intermittent
* Initial diarrhoea followed by constipation
* Signs of fluid and electrolyte imbalance, hypovolaemia –tachycardia and tacypnoe-ic, hypotension
* Nausea and vomiting
* Later stages silent bowel
* Abdominal distension is minimal with proximal obstructions
105
State the complications of small bowel obstructions: (List 4)
* Hypovolaemia
* Renal insufficiency
* Pulmonary ventilation is impaired
* Strangulation of incarcerated hernias, leading to peritonitis and septicaemia
106
What is the rationale for fluid resuscitation in the first 24 hours?
Burns patients have a massive loss of fluid, which if left untreated can lead to hypovolaemia or hypovolemic shock.
107
What is the essential pre-hospital information needed for a trauma accident. (There are 7 listed.)
* Mechanism
* Number of, age, sex of casualties
* ABC status of patient
* Conscious level (D)
* Recognised injuries
* Emergency management at scene
* Estimated time of Arrival
108
What history do you need to know for a trauma patient?
Medical History
•Associated pre-existing medical problems •AMPLE history
Social History
•Increased stress/emotional problems contributory factors to accidents
• Are there any relatives/friends involved in accident? • Patients’ social network can influence ability to cope
109
How is the Iliopsoas muscle test conducted:
Individual Position: The individual is lying supine with their knee flexed at 90 degrees.
Practitioner Position: The practitioner is standing with their hand placed on the individual’s flexed knee.
Description of Muscle Test: The individual is requested to further flex their knee against the practitioner’s resistance.
110
Diagnosis of small bowel obstructions: (List 3)
X ray, Barium series and Colonoscopy
111
List 6 common causes of small bowel obstructions.
* Adhesions or scar tissue
* Single blockage
* Tumours
* Foreign bodies
* Stricture
* Inflammatory bowel disease
112
List some signs and symptoms of large bowel obstructions. (There are 7 listed)
* Constipation
* Colicky/Cramping abdo pain
* Severe continuous pain can indicate bowel ischemia
* Vomiting –Late sign
* Distention
* High pitched tinkling bowel sounds and ‘Rushes, Gurgling’
* Localised tenderness on palpation
113
List some causes of large bowel obstructions. (List 5)
Occlusion to bowel lumen
Lack of normal propulsion
Cancer of the bowel is the most common cause
Other causes are volvulus, diverticular disease, inflammatory disorders
114
List 3 causes of mechanical obstructions:
(i) outside the intestine
(ii) inside the intestine
(iii) obstruction of bowel lumen
115
List some causes of abdominal complications. (List 7)
```
Infections
Trauma (blunt and Penetrating)
Inflammation
Pre-existing conditions
Cancers
Organ failure
Bowel Obstruction
```
116
List 7 functional obstructions:
```
Tumor mass
Constipation/impaction
Adhesions
Volvulus
Ileus
Peritonitis
Massive ascites
```
117
List some treatment methods of bowel obstructions: (There are 9 listed)
```
Surgical approaches
• Depends on etiology, symptoms, patient’s wishes
Medical approaches
• Rest and Rehydration usually IV
• Nasogastric tube
• Steroids for small bowel obstruction
• Laxatives, enemas
• Occasionally radiation in the case of cancerous tumors
Recommence oral fluids slowly
Treat nausea and vomiting
• Analgesia
• Anticholinergics, antispasmodics for colic
• Laxatives
```
118
What are the nursing interventions for a patient with an obstructed bowel? (There are 5 listed)
Monitoring for signs and symptoms of deterioration
Fluid balance monitoring
Administration of IV fluids and electrolytes
Pain and symptom management
Naso gastric tube
119
What are the 4 H's? (Relating to causes of cardiac arrest.)
Hypoxaemia
Hypovolaemia
Hyper/hypokalaemia (&metabolic disorders)
Hypo/hyperthermia
120
What are the 4 T's? (Relating to causes of cardiac arrest.)
Tension pneumothorax
Tamponade
Toxins (poisns/drugs)
Thomboembolic (pulmonary/coronary)
121
What is the normal range for BSL?
4.0–7.8mmol/L.
122
What is the chain of survival and what are the 4 steps? (trauma)
In an emergency situation, immediate action needs to be taken to maximise a casualtys chances of survival.
Early first aid (to prevent immediate deterioration)
Early BLS/ALS (to secure vital functions)
Early advanced therapy (to limit or repair injury)
Early rehabilitation (to restore quality of life)
123
What should be done to provide post resuscitation care? (There are 5 listed)
* Re-evaulate ABCDE
* 12 lead ECG
* Treat precipitating causes
* Aim for SpO2 94-98%, normocapnia and normoglycaemia
* Targeted temperature management
124
When and what drugs should be given for non-shockable rhythms:
• Adrenaline 1mg immediately (then every second loop)
125
When and what drugs should be given for non-shockable rhythms for shockable rhythms:
* Adrenaline 1mg after second shock (then every second loop)
| * Amiodarone 300mg after three shocks
126
List 2 non on-shockable rhythms:
* Asystole
| * Pulseless electrical activity (PEA)
127
List 4 shockable rhythms:
* Atrial fibrillation (AF) if newly diagnosed.
* Ventricular tachycardia (VT)
* Ventricular fibrillation (VF)
* Pulseless ventricular tachycardia (PVT)
128
What are the care goals for a patient with neurological compromise? (List 6)
```
Monitor airway and breathing,
pressure area care,
oral care,
monitor ABGs,
NBM,
monitor for aspiration
```
129
What determines cardiac output and how is it assessed/calculated?
Cardiac output is the amount of blood the heart pumps in 1 minute, dependant on the heart rate, contractility, preload and afterload.
Cardiac output = heart rate x stroke volume
130
What are the signs and symptoms of raised intracranial pressure? (There are 15 listed.)
* Headache
* Vomiting
* Restlessness and irritability
* Increased blood pressure
* Decreased mental abilities
* Confusion about time, location and people as the pressure worsens
* Double vision
* Pupils that don’t respond to changes in light
* Shallow breathing
* Seizures
* Decreased level of consciousness
* Coma
* Ipsilateral motor weakness
* Deceased GCS
* Decreased BP
131
Identify the criteria for fluid resuscitation in a burns patient and the formula used to calculate fluid requirements.
Fluid and electrolyte shifts in burn injury in the movement of large amounts of fluid from the intracellular and intravascular compartments into the interstitial spaces. This results in hypovolaemia and shock.
Calculation: 4 mL of intravenous solution [Ringer’s lactate solution] x patient body weight in kg prior to burns x percentage of total body surface area burned) and modified according to clinical variables such as urine output.
132
Who is more likely to suffer from burns and what are the 3 most common types?
Young children aged 0-4.
Most common types:
- Contact
- Scalds
- Thermal
133
Discuss the classification system used for burn injuries (explain rule of 9ths and depth):
- total body surface area involved
- the degree or depth of the burn.
Burns can be described by:
- degree (first-, second-, third- or fourth-degree burns)
- thickness (superficial, partial or full)
- or by which layer of the skin is in-volved (epidermal, superficial dermal, mid-dermal, deep dermal, full thickness).
134
Describe the local effects of a major burn injury:
Zone of coagulative necrosis:
- Necrotic area with cellular disruption, irreversible tissue damage.
Zone of stasis:
- Moderate insult with decreased tissue perfusion, can survive or go on to coagulative ne-crosis depending on environment
Zone of hyperaemia:
- Viable tissue, not at risk for further necrosis
135
Describe the systemic effects of a major burn injury:
- increased capillary permeability, leading to widespread tissue oedema, increased blood viscosity due to fluid shifts, and decreased cardiac output hypovolaemic shock. This leads to organ hypoperfusion and decreased gastrointestinal function and urine output.
- Widespread tissue damage releases intracellular potassium causing hyperkalaemia.
- Elevated levels of cortisol and catecholamines occur due to the stress response, leading to a hypermetabolic state with increased oxygen and nutritional requirements, and a higher hypothalamic set point for body temperature.
- Immune function is impaired.
136
Discuss the phases of Burn Care and the nursing interventions for each.
1. Resuscitative phase:
- first aid, primary survey, secondary survey.
- Fluid resuscitation,
- remove as much burnt clothing as possible,
- cover with blanket to keep warm,
- analgesia
2. Acute-wound healing phase:
- starts with diuresis, end point defined by persons goals.
- wound care management,
- nutritional therapies,
- measure to control infectious processes.
3. Rehabilitative phase:
- starts on day of injury, ends when person returns to highest level of health.
- Range of motion exercises,
- prevention of contractors and scars.
137
Discuss emergency medical procedures to prevent damage immediately at the burn scene.
At the scene of the burn priority is the patient is removed from any danger, life threatening conditions are managed and cooling of the burn.
Electrical burn - Switch off power, remove patient from source of electricity. Put out flames if the person has sustained a flame injury as well. Begin primary survey. Protect cervical spine.
Chemical burn - Brush residual dry chemical from person. Copious irrigation of area ‘to the floor’ with wa-ter.
Observe for signs of hypothermia, begin primary survey.
Flame burn - Stop, drop and roll. Extinguish flames, remove clothing if possible and restrictive jewellery. Irrigate under cool, clean water for at least 20 minutes. If unavailable use wet cool towels and replace once warm. Observe for hypothermia, begin primary survey.
Scald - Remove clothing where possible. Irrigate with copious cool, clean water for at least 20 minutes. If unavailable use wet cool towels and replace once warm. Observe for hypothermia, begin primary survey.
138
Discuss strategies of burn prevention.
```
Education,
smoke alarms,
regulation of hot temperature,
nonflammable fabrics,
electrical safety,
sprinklers,
child-resistant lighters,
fire-safe cigarettes,
making fireworks safer
```
139
Explain decorticate positioning and the score they are given as part of the GCS:
Decorticate: flexing to the core of your body. Thalamus / cerebral hemisphere damage. At risk of cardiac arrest and respiratory failure. Can be in a coma. Score of: 3:
• Indicates that there may be damage to areas including the cerebral hemispheres, the internal capsule, and the thalamus.
• an ominous sign of severe brain damage, and may also indicate lesion(s) in the low-er brainstem.
• Normally people displaying decorticate or decerebrate posturing are in a coma and have poor prognoses, with risks for cardiac arrythmia or arrest and respiratory failure.
140
Explain decerebrate positioning and the score they are given as part of the GCS:
Decerebrate: Damage to midbrain where brain stem is / cerebellum is. Score of: 2.
• It is exhibited by people with lesions or compression in the midbrain lesions in the cerebellum.
• Progression from decorticate posturing to decerebrate posturing is often indicative of tonsilar brain herniation.
141
Define eschar:
a dry, dark scab or falling away of dead skin, typically caused by a burn, an insect bite, or infection with anthrax.
142
What is a normal renal output?
>30ml/kg/hr or 0.5ml/kg/hr
143
What types of routes can you administer fluid resuscitation and provide rational.
Peripheral Intravenous Catheter - the 'go to' IV access if able to obtain, changed 72 hours
Intra-Osseous - used for when unable to insert a PIVC cannula, more short term
Central Venous Catheter - for more long term
144
Why is mechanism of injury important information in diagnosing injuries?
It would guide investigations and treatments as it would determine the potential anatomical location and severity of injuries, which would then explain the manifestations and immediate priorities
It's important to know the mechanism of injury in order to know of any underlying damage.
145
What are the indications for activating a massive blood transfusion guideline?
loss of 3ltr of blood
abdominal trauma, pelvic trauma
low Hb
146
What steps need to be taken to deem patients cervical spine injury free?
spinal xray, interpreted by radiologist, clearance by senior medical team
147
What constitutes major trauma?
Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds
148
Describe the aetiology (cause) and clinical manifestations of sepsis:
```
Sepsis is caused by the presence of microorganisms in the blood and is caused by a failure of the body’s inflammation and immune defines mechanism.
Fever
Hypothermia
Heart rate >90 bpm
Fast respiratory rate
Altered mental status (confusion/coma)
Oedema
High BGL without diabetes
```
149
Sepsis is...
Sepsis is a potentially life-threatening complication of an infection. Sepsis occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body.
150
Septic shock is...
A widespread infection causing organ failure and dangerously low blood pressure.
151
What is SOFA
SOFA
Sequential Organ Failure Assessment (SOFA) Score is a scoring system that assesses the performance of several organ systems in the body (neurologic, blood, liver, kidney, and blood pressure/hemodynamics) and assigns a score based on the data obtained in each category. The higher the SOFA score, the higher the likely mortality.
152
Define bairhugger:
The Bair Hugger system is a convective temperature management system utilized within a hospital or surgery center to maintain a patient's core body temperature. The Bair Hugger system consists of a reusable warming unit and a single-use disposable warming blankets for use before, during and after surgery.
153
Define inflammation:
A localized physical condition in which part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection.
154
What is Hartmann's solution
The active ingredients in Hartmann’s solution comprise sodium chloride (6g/L), sodium lactate (3.22g/L), potassium chloride (0.4g/L), and calcium chloride dihydrate (0.27g/L), whilst the modified Hartmann’s solution contains the same compositions except potassium chloride is fortified (2.2g/L). Hartmanns IV Infusion Solution 1000ml is ideally designed crystalloid solution. It is intended to be used for effective intravenous management. It replaces mineral salts and body fluids that are lost for different medical reasons.
155
Define eschar:
a dry, dark scab or falling away of dead skin, typically caused by a burn, an insect bite, or infection with anthrax.
156
Define escharotomy
Escharotomy is a surgical procedure done by making an incision through the eschar to relieve the underlying pressure, measuring the pressure in the compartment (closed space of nerves, muscle tissue and blood vessels) distal (furthest) to the affected area is one of the parameters used to determine the timing of escharatomy.
157
What is the ‘golden hour’?
The goal time frame in which it is important to get the patient to a facility within 60 minutes where definitive care can be provided after the injury.
158
What are the care goals for a patient with neurological compromise?
Monitor airway and breathing, pressure area care, monitor ABGs, NBM, monitor for aspiration
159
Discuss the different roles needed in trauma management and specifically nursing roles.
```
Multidisciplinary
Team leader
Airway doctor
Doctor 1 (IV, breathing, procedures)
Doctor 2 (IV, Bloods, circulation)
Nursing resuscitation Coordinator (Scribe)
Airway nurse
Circulation nurse
Runner/procedure nurse
```
160
Identify the signs and symptoms of septic shock:
Hypotension, chills, fatigue, febrile, hypothermia, SOB, tachycardia, oliguria, or mental confusion
```
Manifestations:
Infectious agents in blood cause haemodynamic compromise
Ineffective tissue oxygen delivery
Inappropriate vasodilation
Normal or increased CO
Hypovolaemic due to >vasodilation
Pt presentation
Warm, pink well perfused
```
161
What is normal lactate levels?
The normal blood lactate concentration in unstressed patients is 0.5-1 mmol/L.
162
Discuss the common signs of a significant head injury:
Persistent headache or worsening, repeated nausea or vomiting, convulsions/seizures, CSF leakage from nose or ears, fatigue/drowsiness, dilation of one or both pupils, confusion, slurred speech
163
What are cytokines?
Cytokines are a large group of proteins, peptides or glycoproteins that are secreted by specific cells of immune system. Cytokines are a category of signaling molecules that mediate and regulate immunity, inflammation and hematopoiesis.
164
What are the 2 sepsis care bundles and what do they suggest?
Within 3 hours:
• Measure lactate level. Remeasure if initial lactate level > 2 mmol/L.
• Obtain blood cultures before administering antibiotics.
• Administer broad-spectrum antibiotics.
• Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L.
Within 6 hours:
• Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg
• In the event of persistent hypotension or if initial lactate was ≥ 4mmol, re-assess volume status and tissue perfusion
• Re-measure lactate
165
What is the trauma triad?
The trauma triad of death is a medical term describing the combination of hypothermia, acidosis and coagulopathy. This combination is commonly seen in patients who have sustained severe traumatic injuries and results in a significant rise in the mortality rate.
166
Penetrating trauma is caused by:
Injury is produced by either a stab wound or firearm.
Severity depends on:
• Length of instrument (stab)
• Velocity
• Angle of entry
• Bullets
o Projectile mass, fragmentation, type of tissue struck and striking velocity.
167
Describe the lead placement of a 12 lead ECG:
RA Right clavicle
LA Left clavicle
RL Right hip
LL Left hip
V1 Fourth intercostal space at right sternal border
V2 Fourth intercostal space at left sternal border
V3- Midway between V2 and V4.
V4 Fifth intercostal space left of midclavicular line.
V5 Anterior axillary line at same level as V4
V6 Midaxillary line at same level as V4
168
What does holistic care mean to you?
Holistic health care is an integrated approach to health care that treats the "whole" person, not simply symptoms and disease. Mind and body are integrated and inseparable
169
What are your considerations regarding your patients language and cultural needs?
If the patient can understand you, possibly need a translator? Assess if appropriate for female nurse/male nurse
170
How can you deliver culturally competent care?
By just being aware of their beliefs, being mindful of how you approach the patient + touch
171
Define apoptosis:
The death of cells which occurs as a normal and controlled part of an organism's growth or development.
172
Action of the antineoplastic agent: Mitotic Inhibitors:
- Blocks cell division in metaphase.
173
Define ICC:
Insertion of an intercostal catheter (ICC) enables drainage of air or fluid from the pleural
174
Action of the antineoplastic agent: Antitumour Antibiotics :
- Interferes with DNA functioning by blocking transcription of DNA to RNA; they may also delay or inhibit mitosis.
175
What is the action of Antimetabolites
Have structures similar to those necessary cofactors or building blocks for the formation of DNA. This ‘false building block’ is accepted by the enzyme or cell but, because it is an imposter, it interferes with the normal production of DNA.
176
What is the action of Alkylating Agents
Substitute an alkyl chemical group for a hydrogen atom in DNA, resulting in cross-linking between strands of DNA, preventing cell division.
177
MET Criteria:
Airway threatened.
RR < 4, > 36, O2 of < 84.
HR < 30, >140.
Systolic BP <90, less than <70 for maternity.
Sudden fall in level of consciousness. ( Fall in GSC of >2)
Repeated of prolonged seizures.
Any patient that you feel seriously concerned about that doesn't meet the above criteria.
178
What is the secondary survey?
Top Down
All systems approach
Detailed assessments
Anything and everything else!!!
179
MET Criteria:
Airway threatened.
RR < 4, > 36, O2 of < 84.
HR < 30, >140.
Systolic BP <90, less than <70 for maternity.
Sudden fall in level of consciousness. ( Fall in GSC of >2)
Repeated of prolonged seizures.
180
What potential x-rays would you do for a trauma patient?
C-spine
Chest
Pelvis
181
What is blunt trauma?
What are the various forces included under blunt trauma?
What part of the body does blunt trauma commonly affect?
What is blunt trauma commonly caused by?
Blunt trauma occurs when there is no communication between the damaged tissues and the outside environment. It is caused by various forces including:
- Deceleration
- Acceleration
- Shearing
- Compression and
- Crushing
Blunt forces often cause multiple injuries that can affect the head, spinal cord, bones, thorax and abdomen.
Blunt trauma is frequently caused by motor vehicle crashes, falls, assaults and sports activities.
182
What ECG leads correlate with the different parts of the heart (lateral, septal, anterior, inferi-or)?
Inferior leads i.e. look up at the inferior surface of the heart (II, III, VF)
*This answer needs to be finished.*
183
Describe primary survey:
Primary is the initial assessment and management of a patient. It is conducted to detect and treat actual or imminent life threats and prevent complications from these injuries. A systematic approach using ABCDE is used.
Airway - Airway always takes priority
c-spine - Collar, blocks, straps/take, spinal board
Breathing - RR, IPPA, Objective data: depth, bruising, abrasions, paradoxical movements, flail segments, link with subjective data/Hx
Circulation and haemorrhage control - Skin, pulse, conscious level, BP, Urine output, heart sounds, cardiac monitor, observe for S and S hypovolaemia
Disability - AVPU, blood gases, neuro observations (how often?)
Exposure - Cut all clothing, log roll
Fahrenheit - hypothermia often ‘latrogenic’, bairhugger, warm fluids, warm humidified oxygen, other methods
184
Discuss the options for cancer treatment including antineoplastic agents:
• Surgery removal of malignant mass.
• Radiation therapy uses X-rays targeted to minimize damage to non-cancer cells, or radiopharmaceuticals, drugs or chemicals containing radioactive isotopes emitting ionizing rays that damage cells. Radiation therapy is important in reducing the risk of metastases. It can be given externally or internally.
• Chemotherapy refers to relatively non-selective cytotoxic drugs that target vital cel-lular or metabolic processes critical to both malignant and normal cell growth and replication.
Chemotherapy is used exclusively with curative intent but can be used to manage cancer growth, as palliative intent.
• Combination chemotherapy is the use of two or more anti cancer drugs at the same time. It may prolong survival times, due to a higher cancer cell-kill fraction than treatment with a single drug, and specific drug toxicities may be reduced.
185
List the different routes for fluid resuscitation.
PIVC
Intra-Osseous
CVC
186
Describe non-invasive ventilation techniques and when they are appropriate:
Non-Invasive:
• Non Invasive Positive Pressure Ventilation delivers positive pressure breaths to a spontaneously breathing patient.
• Delivered by a mask with an airtight seal
• Reduces the occurrence of patients being intubated
