Prelab-Midterm Flashcards
What causes the dicrotic notch
Closure of the aortic valve
Central Venous Pressure is
Increase with positive pressure ventilation but decreased with spontaneous breathing
What leads are associated with the inferior portion of the heart?
II, III, and aVF
What leads are associated with the septal portion of the heart?
Lead V1 and V2
What leads are associated with the anterior portion of the heart?
Lead V3 and V4
What leads are associated with the lateral portion of the heart?
Lead V5, V6, I, and aVL
Rhythm: Regular
Rate: 37
P Wave: Round, Upright, and more p waves than QRS
PRI: 0.28 (LONG)
QRS: 0.14 sec
Intrepretation: 2nd Degree Heart Block Type II (Mobitz)
Oral and tracheal suction assesses which of the cranial nerves? What type of reflex is assessed when doing this?
IX-glossopharyngeal (sensory for the gag) *also innervates the carotid sinus
X-vagus (motor for gag, sensory for cough—laryngeal nerve; a branch of the vagus…and glottis closure is due to vagal innervation (Note phrenic nerve/spinal nerve for the diaphragm contraction part of the cough))
A decreased PaCO2 level has what impact on cerebral blood flow?
Decreased CO2 levels in the brain causes vasoconstriction; this decreases cerebral blood flow
Major Steps in Assessing the Critically Ill
- Pt. Information
- Body System Assessment
- Intrepreting/Integrating
- Planing/Reporting/Communicating
- Documentation
Resuscitative Care
Resucitative Care-Medical care and intreventions including resuscitation followed by intensive care unit
R1-Everything
R2-Everything but chest compression
R3-Everything but Chest Compression and Intubation
Medical Care
Medical-Medical Care and Intervention excluding resuscitation
M1-No ICU
M2-Only medications
Comfort Care
Comfort-Focused on pain relief
C1-Symptom relief
C2-Pallative
Describe the difference between a monitor and a diagnostic test?
monitor: real time measurements; connects patient to technology
Diagnostic: intermittent procedures to obtain information
Differentiate between accuracy and precision of a monitoring device.
Accuracy: how well it measures a known reference value.
Precision: synonymous with reliability of measurements, and the opposite of variability; precision is the index of dispersion of repeated measurements
Define “therapist -driven protocol”
n the presence of certain conditions the RT can initiate therapy, discontinue therapy, adjust or restart different care, all without having to first consult the physician.
Differentiate between the CNS and PNS.
CNS-brain and spinal cord (*brain = cerebrum + cerebellum + brainstem)
PNS-12 pairs of cranial nerves (most originate in brainstem), 31 pairs spinal nerves
Where in the brain does the control of respiration reside?
In the brainstem:
Medulla (dorsal and ventral groups, primary control)
Pons (apneustic and pneumotaxic center that fine tunes the main controls)
NOTE: there is also the chemical control of respiration (Central and peripheral chemoreceptors)
Where does the phrenic nerve arise from?
C3 to C5 (branches at each level)
Describe how CO2 impacts cerebral blood flow.
Increased CO2 levels in the brain causes vasodilation; this increases cerebral blood flow
What three categories does the GCS assess?
Motor
Eye Response
Verbal
What are the different features that are assessed to define delirium?
Feature 1: Acute change or fluctuating mental status
Feature 2: Inattention
And Feature 3: Altered LOC or Feature 4: Disorganized thinking
List five specific causes of delirium.
TOXIC and DELERIOUS are the pneumonics
CHF, shock, dehydration, meds (tight titration), new organ failure (kidney, liver), hypoxemia, infection/sepsis, immobiliziation, lack of other non-pharm (glasses, hearing aids, sleep protocols, noise), electrolyte problems (K+ especially)
Drugs, labs (BUN/Cr), environmental factors, labs, infection, respiratory status, immobility, organ failure, unrecognized dementia, shock (sepsis, cardiogenic, steroid use
ABCDE PRotocol
ABC-Awakening and Breathing Coordination…structured approach to SATs and SBTs
D-Delirium management/Nonpharm interventions
E-Early exercise and mobility
Timing of SATs and SBTs needs to be coordinated amongst RN and RT. RTs can help with non-pharm (orientating the patient, introduce, honour day/night, oral care etc). And RTs may manage airway in the early exercise—coordination required.
CPP Calculation
CPP = MAP – ICP
Jugular venous saturation
Measure sjvO2 although a blood smaple can be taken to give a PaO2 measurement
Give a global approximation
Can be a continuous monitor or a spot check
Cerebral Oximetry
Measure SO2 of the underlying tissue (general not global)
Can be continuous or a spot check
Licox
Measure PO2 of the underlying tissue (general not global)
Continuous monitor
What type of ICP monitor allows for concurrent EVD?
Fluid-filled system where catheter is inserted into the brain ventricle.
What is the relationship between SjvO2, cerebral metabolic rate and cerebral oxygen delivery? (i.e. how can you mathematically represent it?).
SjvO2 =cerebral oxygen delivery/ Cerebral metabolic rate
List the complications/disadvantages of over-sedating patients in the ICU.
Prolonged mech. ventilation and length of ICU stay
Tracheostomy
DVT, VAP
Additional testing
Added cost
Inability to communicate
Cannot evaluate for delirium
Define delirium.
An acute brain dysfunction (not chronic, like dementia) that involves altered LOC and inattention or disorganized thinking.
Tends to fluctuate through the day.
Why is evaluating for delirium important in our critically ill patients?
B/C it points to an underlying medical problem (infection/sepsis, organ failure, electrolyte problems, acid-base imbalance, need for non-pharmacological interventions).
Helps us optimize sedation and improve the patient care
Describe why lead II is the most commonly monitored lead.
How is a critically ill patient’s level of consciousness best evaluated?
he level of stimulus required is the guide
a) full consciousness - pt alert, attentive, follows command etc
b) lethargy - pt drowsy but awakens to stimulus
c) obtundation - pt difficult to rouse, needs constant stimulus
d) stupor - pt rouses to vigorous and constant stimulation
e) coma - pt does not respond to continuous or painful stimulus .
How is the Glasgow Coma Scale level modified when the patient is intubated
Basically the verbal is eliminated and a “T” is charted to indicate the patient
has a tube in place. The scale then essentially becomes out of 11 because a
max score of 1 can be given for verbal.
Your patient has a cervical spine fracture at C4 with spinal cord involvement. How will this impact their respiratory system?
Patients with high cervical cord lesions seldom survive without immediate ventilatory support. The phrenic nerve for each hemidiaphragm emerges from the spinal cord at level C3 through C5. Depending on the degree of involvement, injury to this region of the neck can damage the phrenic nerve and cause an incomplete or complete diaphragmatic paralysis.
How can motor strength be assessed in an unconscious patient?
Sternal rub, trap squeeze, nail bed pressure, supraorbital pressure. All these tests should elicit a withdrawal from pain. Also observe patient for signs of posturing.
What brainstem reflexes do RTs typically assess? Which cranial nerves are responsible for these
Gag reflex (IX), Cough (X), Pupils (II, III)
patient does not respond to your voice but withdraws to physical stimulation. What level of sedation is this according to the Richmond Agitation Sedation Scale (RASS)?
-4
Your patient is moving about spontaneously with non-purposeful movements. The ventilator is frequently alarming because of patient-ventilator dysynchony. What level of sedation is this according to the Richmond Agitation Sedation Scale (RASS)
+2
Define delirium.
acutely disturbed state of mind typically resulting in confusion, illusions,
hallucinations and incoherence of thought.
non-pharmacologic interventions that can be used to manage delirium
freq reorientation of pt
cognitively stimulating activities
sleep protocol (day/night) routines
early mobility and ROM exercises
timely removal of catheters, restraints etc
use of eye-glasses, hearing aid etc
early correction of dehydration
minimize unnecessary noise
Describe the purpose of jugular venous oxygen saturation monitoring.
Approximates global cerebral oxygenation
may be done for monitoring in a traumatic brain injury
can provide early detection of cerebral ischemia
normal (50-75%)
Describe the purpose of Licox monitoring. Compare this to SjvO2 monitoring.
Monitor is connected to a catheter that is inserted in the brain tissue
measures brain tissue oxygenation
measures oxygen and temperature
normal 25-35mmHg
SjvO2 reflects overall brain oxygenation as a whole whereas PBTO2 reflects oxygenation in the area localized around where the catheter is inserted.
When is Train of Four monitoring used and why
Peripheral nerve stimulator
monitors the effects of neuromuscular blockade agents (paralytics)
electrodes are placed over ulnar nerve at wrist or elbow
response to stimulus is monitored by counting the muscle twitches
Describe purpose of therapeutic hyperventilation. Is this a routine therapy?
Increasing minute volume with the goal of decreasing the PaCO2
Indications: only done acutely and short term
Effects: The low PaCO2 results in vasoconstriction of the cerebral arteries reducing blood in the brain, thus reducing the intercranial pressure
Routine? No..effects are disputed
It is not true hyperventilation in that the suggested goal range for PaCO2 is 35-40 (as per AHS TBI protocol
Your patient is being sedated with midazolam and morphine and is receiving tubocarine. The TOF is at ¼ twitches. What do you expect when assessing their gag and cough response? Explain why
Their gag and cough responses would be minimal to none due to the sedation caused by the midazolam, the pain relief from the morphine, and at ¼ twitches, 90% of their neuromuscular receptors are blocked from the tubocurarine
Describe purpose of therapeutic hypothermia. Is this a routine therapy?
Also known as “protective hypothermia”, therapeutic hypothermia is the lowering of the patient’s body temperature to help reduce the risk of ischemic injury after a period of insufficient blood flow.
Yes this is a routine therapy with post-cardiac arrest, stroke and traumatic brain injury or spinal cord injury patients.
Sedation level in the ICU is a delicate balance. Discuss the negative impact of too little and too much sedation.
Too little sedation would cause increased pain, anxiety, oxygen consumption, stress, depression and PTSD.
Too much sedation can cause failure to initiate SBTs, longer duration of time on mechanical ventilation and a longer stay in the ICU.
