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.
