Trauma ACU/ICU Flashcards
Vital Sign Contraindications?
Mean Arterial Pressure (MAP)
Norm: 70–110mm HG (Millimeters of Mercury)
Abnormalities:
<65 mm Hg
BP
120/60 mm Hg
Abnormalities:
Hypotension vs Hypertension
Heart Rate (HR)
60–100bpm
* Bradycardia: <60bpm (if <40, call nurse)
* Tachycardia >100bpm (if >160, call nurse)
Respiratory Rate (RR)
12–20 bpm
Oxygen saturation (SPo2)
95% If below = Hypoxemia.
General Contraindications in ICU?
Increased Intracranial pressure
Active Gastrointestinal bleed
Active Myocardial Infarction
Unsecure airway
Compromised airway
Pulse oximetry (SpO2) norm
≥95% If below = Hypoxemia.
Oxygen saturation/SpO2 factors to monitor
Check for elevated respiratory rate, HR, & anxiety.
Things to check with nursing
Can any lines, drains, or equipment be temporarily disconnected for therapy?
Define hemodynamic instability
Abnormal or unstable bp
Sepsis: What is it & symptoms?
Systemic inflammatory response to infection, a life-threatening condition compromising cardiopulmonary status.
Results in confusion, weakness, & loss of endurance.
Assessments for Cognition & Delirium
Glasgow Coma Score
Coma Recovery Scale–Revised (CRS–R): Helpful in identifying differential diagnosis & emergence from minimally conscious state. Provides prognostic assessment & Tx.
Richmond Agitation–Sedation Scale (RASS): Differentiates appropriateness of PROM & sitting at EOB from progressing to walking & other ADLs.
Confusion Assessment Method for the ICU (CAM–ICU): : Assesses altered mental status, inattention, altered consciousness, & disorganized thinking.
Intensive Care Delirium Screening Checklist
Upon evaluation, assess…
Cognition, Vision, ROM, Strength/MMT, & Vitals
Goals…
Can or may need to include maintaining vital/goal signs while performing Self-Care ADLs (e.g., within 1-week pt will remain asymptomatic with MAP ≥65 when the head of bed is at 45 degrees while the pt performs grooming task for 5min with max A. Progress to sitting EOB then to sink level).
In the case of Profound Cognitive impairment such as emerging from a Coma or minimally conscious state, goals will focus on basic vision, hearing, cognitive, & motor skills like maintaining eye-opening, fixing gaze on objects or faces, attending to voice or touch, or following basic motor commands (e.g., within 1 week the pt will be able to maintain eye-opening for >30sec x 3 sets with <3 cues).
After a total knee replacement, in what position is it important to keep the affected extremity at rest?
a. Knee flexion
b. Knee extension
c. Hip flexion
d. Hip extension
b. Knee extension
Following a THR, what device is often used for proper positioning?
a. An adduction pillow to prevent excessive hip adduction.
b. A continuous passive motion machine.
c. Lateral towel rolls to maintain hip adduction.
d. A full-length leg cast.
a. An adduction pillow to prevent excessive hip adduction.
How to recognize Exercise-Induced Hypotension?
Symptoms?
Appropriate reaction?
BP drop of 10-20mmhg (norm = 120/80)
Symptoms:
- Light-headedness
- Weakness
- Syncope
- Blurred vision
- Confusion
- Sleepiness
Reaction:
Have pt sit, monitoring BP. If returns to normal, proceed carefully with activity, continuously monitoring BP.
If BP drops more than 20, have pt lie down & elevate lower extremities.
How to recognize Hypertension?
Symptoms?
Appropriate reaction?
BP exceeds 140/90mmhg (norm = 120/80)
Hypertensive Crisis: 180/120
- Reaction to HC = Activity is contraindicated. Back out…Back out!
Symptoms:
- Fatigue
- Confusion
- Chest pain
- Visual changes
Reaction to Hypertension:
- Slow down
HR: Normal resting range for an adult
60-100BPM (active people may have lower resting HRs)
HR: Abnormal resting range
Bradycardia = <60BPM
Tachycardia = >100BPM
Max HR = 220–age.
E.g., pt is 40 y/o. 220-40= 180BPM.
Abnormal HR symptoms
Fatigue, SOB, dizziness, fainting, chest pain, & cardiac arrest.
Abnormal HR clinical implications
Tachy = rest break; monitor; continue/discontinue.
Brady/Tachy = notify RN. May be advised to discontinue.
Oxygen Saturation (02 levels)
Normal range: 97-99%
Abnormal range: <90%
O2-level clinical implications
Deep breathing, exhale being 2x longer than inhale.
Upright positioning with oxygenation.
Glucose normal/abnormal range
Normal range: 70-110mg/dl (fasted)
Hypoglycemia: <60mg/dl
Hyperglycemia: >250mg/dl
Hypoglycemia causes, symptoms, & clinical implications
<60mg/dl
Causes: overexertion in exercise, insulin overdose, or skipped meals.
Symptoms:
- Headache
- Weakness
- Shakiness
- Claminess
- Impaired muscle control
- Blurred vision
- Difficulty responding to commands
Clinical Implications:
- Defer therapy
- Avoid exercise before mealtime & after insulin because both can result in reduced blood sugar levels.
Central Cord Syndrom?
Greater impairment in BUE than the BLE.
Anterior Cord Syndrom?
Posterior preserved: proprioception and light-touch sensation. Anterior function is lost: Motor, pain, and temperature.
Posterior Cord Syndrom?
Anterior cord function is preserved: motor, pain, and temperature.
Posterior cord function is lost: proprioception and light-touch sensation.
P-p, and “he touched the butt.”
Encephalopathy
A general term for any disorder, disease, or damage that affects the structure or function of the brain.
Symptoms:
* AMS
* Confusion
* Memory loss
* Seizures
Pulmonary Embolism
When a blood clot blocks an artery in the lungs, typically when a clot in the legs breaks off from a deep vein in the legs.
Symptoms:
* SOB
* Light headedness
* Chest pain
Elevated Tryptophan symptoms
Symptoms:
* Drowsiness
* Stomach pain
* Vomiting
* Diarrhea
* Headache
* Blurred vision
Hashimoto’s Thyroiditis symptoms
A.K.A. chronic thyroiditis.
Symptoms:
- Fatigue
- Muscle weakness
- Stiff joints (elbows & hands, knees & feet)
- Cog changes
- Depression
- Weight gain
- Constipation
ASIA A?
Complete - No motor or sensory function preserved in sacral segments
ASIA B?
Incomplete: Sensory but no motor function below neurological level.
ASIA C?
Incomplete: Motor function is preserved below the neurological level, and MORE than half of muscles have a muscle grade of < 3
ASIA D?
Incomplete: Motor function is preserved below, and >50% of muscles = ≥ 3
ASIA E?
NormiE
Central Cord Syndrome
Injury to the Central area of the SC that leads to UE > LE weakness. Sacral sensory spared.
Anterior Cord Syndrom
Incomplete: Posterior functions preserved: proprioception & light-touch sensation. Anterior function: motor, sensory, pain, temperature is lost.
Brown Sequard syndrome
Incomplete, half of the cord has been damaged:
Ipsilateral: Motor and proprioceptive loss
Contralateral: Pain and temperature loss.
C4?
Weened off ventilator, no longer dependent.
C5?
“We fly”
Shoulder flexion/extension and abduction **
Scapular ab and adduction
And Elbow flexion. **
Independent eating w/ adapted utensils!
C6?
“Date is late”
Forearm supination
Wrist extension ***
!! Tenodesis Grasp !!
A lot of ADLs w/ UE, including bed mobility!
C7
“Awkard hug”
Elbow extension ***
Forearm pronation
Wrist flexion
Transfers!
C8
“Claw hands”
Hand extrinsic muscles
T1
Full hand / finger function
Hand intrinsic muscles
