Acute Care 3 Flashcards
(235 cards)
1
Q
WBC
A
Normal 5-10 x 10^9 /L
Trending upward:
Leukocytosis > 11 x 10^9/L
Bacteria infection, stress/trauma, allergy, smoking, pneumonia, neoplasm
Trending downward:
Leukopenia < 4 x 10^9/L
Bone marrow failure (aplastic anemia), radiation/chemo, HIV, viral disease
< 5 with fever : HOLD PT
> 5 light exercise, progress as tolerated
2
Q
CPAP
A
Constant airway pressure
Spontaneous ventilation
Indications:
Mild/moderate sleep apnea
Cardiogenic APE
PO abdominal surgery
3
Q
Droplet precautions
A
Transmission involves contact of conjunctiva or mucous membranes in nose or mouth w/ large-particle droplets
Influenza, meningitis, mumps, rubella, certain types of pneumonia
STD precautions + mask w/ or w/o face shield
4
Q
Hospital- code silver
A
Active shooter
5
Q
ICU PT indications
Goals to determine…
A
Goal to determine stability for ambulation, transfers, stairs, ADLs, assistive device needs, tolerance to activity, PLOF
D/C planning - asking Q (live alone, stairs, etc) - May ask family if pt on vent
6
Q
ICU - PT indications
Getting pt movement prevents:
A
Prevents deconditioning
Reduces risk of atelectasis-> consolidation-> pneumonia
Reduces risk of bed sores and DVT
7
Q
FiO2 of room/ambient air is __%
Each liter increase with supplemental O2 increases FiO2 by appx __%
Low flow FiO2 …
High flow FiO2….
Maximum of __% used for vents to avoid O2 toxicity
A
20.9% (78% nitrogen; 1% CO2)
Each liter of supplemental O2 increases FiO2 by ~ 4%
Low flow is approximation- varies with RR and TV
High flow is precise delivery, does NOT vary with RR and TV
Max 60%
8
Q
Type III
Respiratory failure
A
Perioperative
Atelectasis
Often results in Type I or II
9
Q
If MI diagnosed must wait for 2 consecutive downtrending values before initiating PT
A
Cardiac troponin (cTn) Cardiac creatine kinase (CK-MB or CPK-MB)
10
Q
PaO2
A
75-100 mmHg
Normal value changes with age
70-70 rule
After 70- each decade value decreases by 10
11
Q
Neurological considerations
Red/Yellow/Green
Delirium
A
Delirium tool (CAM-ICU)….
(-) = green
(+) and able to follow simple commands-
Green: in-bed
Yellow: out-bed
(+) and unable to follow commands = yellow
12
Q
Respiratory acidosis
A
Reduction in alveolar ventilation
Results in more CO2 in blood
Body compensates by producing more HCO3 (bicarbonate)
pH =< 7.35
PaCO2 => 45 mmHg
13
Q
Alkalemia
A
pH > 7.45
14
Q
Anesthesia- Effects by system
Respiratory
A
Hypoventilation
Decreased ventilation drive
Aspiration
PE
15
Q
Hospital codes that can be initiated by therapy team
A
Code blue
Rapid response
Stroke alert
16
Q
Na+
A
Regulates fluid volume and impt in nerve conduction
Normal 134-142 mEq/L
Hyponatremia: low Na+
< 130
Monitor vitals 2ndary to risk for orthostatic hypotension
Hypernatremia: common in elderly who don’t drink enough water
> 145
Seizure precautions for pt w/ past hy
17
Q
Acute care exam - initiation
A
Always check w/ nurse about any new developments or info on the pt that may not have been in your chart review
Survey the room during introduction
Subjective info:
PLOF and work/school/activity- fall history
Caregiver support and availability
Home situation and barriers- stairs, where bedroom and full bathroom
Availability of AD
Pt/caregiver d/c plans (may not match w/ each other or yours)
18
Q
Hypoglycemia s/s
A
Clammy skin/Sweating Shaking Delirium Vision changes HA Tachycardia Weakness Lightheaded LOC Seizures
19
Q
Neurological considerations
Red/Yellow/Green
Spinal precautions (pre-clearance or fixation)
A
Red
20
Q
A disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time
A
Delirium
21
Q
IABP- considerations and safety measures
A
Limit shoulder flexion on side of IABP placement to 90* or level of comfort (<90*)
Leveling the arterial line connected to IABP when ambulating
Ensure that the PT has training to leave ICU with patient
Never take patient to area where there are no outlets if battery starts to die (check battery frequently)
22
Q
If you pull out a line…
A
Apply pressure
Have patient sit
Call nurse
23
Q
Home with referral to outpatient therapy
A
Can the pt drive?
What kind of assistance still needed?
Often, a significant gap exists between hospital d/c and start of care in OP- HEP/education critical!
24
Q
Rapid response
A
Goal: intervene before onset of injury, respiratory arrest or cardiac arrest
HR > 140 or HR < 40 RR > 28 or RR < 8 Systolic BP > 180 or < 90 Urine output < 50 cc over 4 hours Staff, family or visitor has significant concern about pt condition
25
Respiratory parameters-
Red/Yellow/Green
Percutaneous Oxygen Saturation
=> 90% green
< 90% yellow: in-bed /red: out-bed
26
Hct
Hematocrit- % by volume RBC
Trending downward (anemia)
Low critical value (<15-20%) Cardiac failure or death
< 25% symptom based approach
< 25% HOLD PT- essential daily activity only
< 25-35 PT permitted- ambulation and stairs, light aerobics, light weights (1-2 lbs)
> 35% resistance and moderate aerobic exercise
```
Trending upward (polycythemia)
High critical value (>60%) spontaneous blood clotting
heart defects, severe dehydration, hypoxia, smoking
```
27
CPAP
Continuous positive airway pressure
Weaning mode
Completely spontaneous
Positive pressure maintained to prevent alveolar collapse
Usually 5-7 cmH2O
28
Cardiovascular considerations
Red/Yellow/Green
Stable tachyarrhythmia
Ventricular rate > 150 bpm
Yellow: in-bed
Red : out-bed
Ventricular Rate 120-150 bpm
Yellow
29
Chest tube- air bubbles in tank
Stop treatment and notify nurse
| Bubbles = air leak
30
Inspiratory muscle training is contraindicated during ___.
| At this juncture resting the respiratory muscles indicated.
Acute respiratory failure
31
B of SBAR
Background
Pt reason for and date of admit
Significant medical hy
Impt meds
(Admit 5/20/19 w/ chest pain and decreased mobility)
32
Respiratory acidosis
pH?
PaCO2?
HCO3-?
pH decrease < 7.35
PaCO2 increase > 45
HCO3- normal
Increased H+ due to excessive CO2 and decreased alveolar ventilation
33
Anesthesia- Regional
Pt is awake, usually given additional drugs to decrease awareness
Ex: spinals or epidurals
Epidurals fall into “local” category- lidocaine
Often delivered in combo with opioids/narcotics (such as fental) to decrease required dose of local anesthetic
34
Effects of general anesthesia
```
Side effects:
Nausea
Vomiting
Sore throat
Confusion
Muscle aches
Itching
Hypothermia
```
Serious complications:
Delirium, Cognitive dysfunction, Malignant hyperthermia
35
Orthostatic intolerance
Hypotension associated with a change in position, typically when moving supine to stand
Symptoms may include: dizziness, change in mentation, postural instability, and possibly loss of consciousness
Causes: depletion of blood volume; impairment of baroreflex-mediated vasoconstriction
Early mobility will reduce the risk of it
PT may be 1st to identify it- alert med team
36
Ca2+ levels tending down
| What expect?
Confusion
Seizure
Fatigue
37
Considerations and safety measures when mobilizing on ECMO
Ambulatory/mobility team (PT, RT, RN, ECMO clinician, cardiologist m, surgeon, and any extra hands)
Cannulation sites
Equipment
Unexpected outcomes
Center specific protocols
38
Other considerations
Red/Yellow/Green
Patient febrile with temp exceeding acceptable max despite active physical or pharmacological cooling mgmt
Yellow
39
Hyperchloremia
Causes: dehydration, kidney disease
S/S: can cause metabolic acidosis
40
CMV : Controlled mandatory ventilation
Ventilator has total control of FiO2, tidal volume, flow rate
Patients likely sedated/pharmacologically paralyzed
No respiratory effort by pt
41
Doppler MAP
Due to pump being continuous not pulsatile
Difficult to get accurate pulse or cuff BP
MAPs should be between 60-80 mmHg
When taking MAP with Doppler you hear 1 sound that is the MAP (mean arterial pressure)
(LVAD)
42
Hypermagnesemia
Typically renal insufficiency
Normally kidneys excrete large amounts
> 2 mmol/L vasodilation and NM blockade
> 4 mmol/L nausea, lethargy, weakness, respiratory failure, paralysis, coma, hypoactive tendon reflex
43
DIC
Disseminated intravascular coagulopathy
Overactive proteins/clotting factors
Causes: severe trauma, liver failure, transfusion failure, sepsis, venom poisoning, cancer
Small clots form - can block vessels supplying organs, leading to failure
Also clotting factors get “used up” and can have serious uncontrolled bleed
44
MIP
Maximum inspiratory pressure
45
Hyperglycemia s/s
Frequent urination
Increased thirst
Severe fatigue
46
Respiratory alkalosis
pH?
PaCO2?
HCO3-?
pH increases > 7.45
PaCO2 decreases < 35 mmHg
HCO3- normal
Decreased H+ due to decrease CO2 when too much blown off
47
Step down units that bridge between ICU and general
Patient to nurse ratio between ICU and general care
Transitional units
48
SIMV : Synchronous intermittent mandatory ventilation
Rate and tidal volume set by RRT
Ventilator assists pt w/ breath of needed
Pt can breathe spontaneously on own between ventilator breaths
Used as a weaning mode
SIMV 2 = pt almost breathing independently
SIMV 15 = mostly relying on ventilator
49
Low flow O2 delivery-
| Simple face mask
35-55% FiO2 at 5-10 min/flow
Easily portable w/ portable O2
Makes talking/eating difficult
50
Respiratory alkalosis
Elevation in alveolar ventilation
Results in less CO2 in blood
Body compensates by producing less HCO3 (bicarbonate)
pH => 7.45
PaCO2 =< 35 mmHg
51
Cardiovascular considerations
Red/Yellow/Green
Bradycardia
Red : if requires pharmacological treatment OR awaiting emergency pacemaker insertion
Yellow : not requiring pharmacological treatment and Not awaiting emergency pacemaker insertion
52
ICU delirium and mortality
Independent predictor of higher 6-month mortality and longer hospital stay
53
Hypokalemia
Trending downward < 3.5 mEq/Lm
Causes: NG suctioning, diuretics, diarrhea, Cushing’s
S/S: flattened T-wave, arrhythmias, clammy skin, muscle tetany, weakness, abdominal distention, respiratory failure
<2.5 collaborate with inter professional team on proceeding
54
Possible discharge dispositions
Home with no further therapy needed
Home with home health PT
Home with referral to outpatient therapy
Post-acute facility placement
(IRF, SNF, LTAC, nursing home/LTCF)
55
Wells DVT score
> 2.0 : High probability
1.0-2.0 : moderate probability
< 2.0 : low probability
1 point each:
1. Active cancer
2. Calf swelling >=3 cm (10 cm below tibial tuberosity)
3. Swollen unilateral superficial veins
4. Unilateral pitting edema
5. Previous DVT
6. Swollen leg
7. Tenderness along deep venous system
8. Paralysis, paresis, or immobilization of LE
9. Bedridden >=3 days; major surgery 12 weeks
- 2 points for : alternative diagnosis at least as likely
56
DNR
Usually only applicable to hospital
Usually has s colored bracelet to identify
No CPR etc - don’t initiate code blue
Some new terminology proposed to avoid confusion:
AND- allow natural death
AND-I allows specified interventions that can be performed
57
Chest tube
Reservoir must be kept lower than insertion site
58
Respiratory parameters-
Red/Yellow/Green
Respiratory Rate
=< 30 bpm: green
> 30 bpm: yellow
59
PPN- partial parenteral nutrition
Peripheral veins
60
Neurological considerations
Red/Yellow/Green
Vasospasm post-aneurysmal clipping
Green- in-bed
| Yellow: out-bed
61
4 lab values indicating pt not ready for PT
1. Hematocrit <25%
2. Hemoglobin <8 g/dL
3. Platelets <20,000/mm^3
4. Anticoagulation INR >=2.5-3.0
62
Anesthesia- Effects by system
| Psychomotor function
Time to regain consciousness
Delirium
Personality changes
Memory loss
63
HbA1C
Glycated hemoglobin
Based on attachment of glucose to HgB within RBC
RBC lives ~3 months- so A1C reflects average blood glucose levels over past 3 months
Normal <5.7%
Pre-diabetic 5.6-6.4%
Diabetic > 6.5%
Well controlled DM is at least 7%
64
Increased H+ due to excessive CO2 and decreased alveolar ventilation
Respiratory acidosis
65
Anesthesia- general
Propofol is one of most commonly used
Pt unconscious with no awareness and no sensation
Majority of effects gone within 24 hours, however complete resolution can take week(s)
66
Other considerations
Red/Yellow/Green
Femoral sheaths
Yellow: in-bed
Red: out-bed
67
Hospital- code pink
Abducted child/baby
68
Mechanical ventilation
Terms
PEEP
Positive end-expiratory pressure
69
Metabolic acidosis
pH?
PaCO2?
HCO3-?
pH decreases < 7.35
PaCO2 normal
HCO3- decreases < 22
Increased H+ due to a drop in HCO3-
70
Cardiovascular considerations
Red/Yellow/Green
IV antihypertensive therapy for hypertensive emergency
Red
71
Neurological considerations
Red/Yellow/Green
Level of consciousness
Drowsy, calm or restless (RASS -1 to +1) = green
Lightly sedated or agitated (RASS -/+ 2) = yellow
Unrousable or deeply sedated (RASS < -2)
Yellow: in-bed
Red: out-bed
Very agitated or combative (RASS >+2) = red
72
Hospital- code gray
Severe weather
73
Mg2+
Magnesium
Crucial for normal NM activity
Normal 0.7-1.0 mmol/L
74
ICUAW: ICU-acquired weakness
Muscle weakness that develops during ICU stay
Other items include critical illness myopathy/polyneuropathy
33% of all pt on ventilators
50% of all pt admitted w/ severe infection (sepsis)
Up to 50% of pt who stay in ICU for at least 1 week
May take more than a year to fully recover, making ADLs difficult and increasing burden of care
75
Anesthesia- Effects by system
| Cardiovascular
```
Hypotension
Hypertension
Dysarrhyrhmia
Increased risk for MI
DVT
```
76
pH
7. 4
| 7. 35-7.45
77
Main components of EMCO circuit
Tubing
Blood pump
Gas exchange
Heat exchange
78
Oxygen toxicity
Occurs when partial pressure of alveolar O2 remains elevated above normal levels prolonged periods of time (> 24 hours)
Supraphysiologic concentration of O2 can cause a state of hyperoxia
Development of reactive O2 species (ROS) - damaging cells/tissues; inflammation w/ diffuse alveolar damage
Absorption atelectasis
79
Highest patient to nurse ratio
General care (Acute)
80
PT- prothrombin time
Time it take plasma to clot
Normal range 11-12.15 sec
1-2x normal = therapeutic
2-3x normal = “risk of bleeding”
81
Nasogastric rube
Drain
Feeding tube
Head at 45* or greater to prevent aspiration
(Ask nurse if can be turned off during intervention)
82
Hyperkalemia
Trending upward > 5.5 mEq/L
> 5 pt at risk for cardiac issues
Might exhibit muscle weakness
Causes: severe cell destruction, redistributes K+ from ICF->ECF
S/S: flaccid paralysis m, peaked T-waves, shortened Q-T wave intervals
83
Arterial blood gases
Measure acidity and levels of oxygen, CO2, and bicarbonate within blood
Qualifies magnitude of gas exchange abnormalities
Identify type of respiratory failure
pH 7.35-7.45
PaO2 75-100
PaCO2 35-45
HCO3- 22-26
84
Glucose
Normal 70-100 mg/dL for non-diabetics
Glucose target 140-180 for most pt in non critical care while hospitalized
Hypoglycemia <70 mg/dL
Hyperglycemia > 200 mg/dL
Failure to correct hyperglycemia (> 240) can result in life threatening ketoacidosis
85
Low flow O2 delivery-
| Non-rebreather
80-90% FiO2 10-15L/min
Works similar to partial rebreather- but one-way valve that exhalation onto bag- resulting in higher concentration in bag
Only used in seriously ill pts, and possibly during exercise in pt with ESLD
86
Hospital- code red
Fire
87
Safety in acute care - establish appropriateness of care
- verify order and precautions
- chart review to determine preliminary precaution list and plan
- VITALS
- key discussion w/ other providers - esp nursing and MD
- anticipate difficulties/challenges in patient mobility/status, and plan accordingly
Assemble require assistance and items
Two patient identifiers (name and DOB)
88
Other considerations
Red/Yellow/Green
Suspicion of active bleeding or increased bleeding risk
Green: in-bed
Yellow: out-bed
89
Hospital- code black
External emergency
90
Low flow O2 delivery-
| Partial-rebreather
40-60%FiO2 10-15L/min flow
Reservoir attached to mask
Air entering bag from trachea and primary bronchi, where no gas exchange occurs
Pt rebreathes O2 “just expired”
Easily mobile
91
Other considerations
Red/Yellow/Green
Active hypothermia management
Yellow
92
RASS
Richmond agitation-sedation scale
Response to verbal and physical stimuli
93
Post-op activities/exercise should...
Promote confidence in you
Don’t hurt
Give pt some control
Promote upright posture
Consider the incision
Avoid stretching/stressing incision
Avoid unilateral stress especially with abdominal and thoracic incisions
Offer incentives- ice chips, warm blanket, etc
94
Creatinine
Waste product of muscle metabolism of creatine
Usually relatively constant and related to muscle mass
Filtered but not reabsorbed by kidneys
Elevation can indicate kidney issues, dehydration or rhabdo
95
Code blue vs Rapid response
Code blue = resuscitation goal
Rapid response = goal is prevention of decline
96
ABCDEF Bundle
A- assess, prevent and manage pain
B- both SAT and SBT (breathing)
C- choice of analgesia and sedation
D- delirium: assess, present and manage
E- early mobility and exercise
F- family engagement and empowerment
97
Acidemia
pH < 7.35
98
Mechanical ventilation
Settings
Ventilator rate
Breaths/minute
| Set at lowest rate to keep PaCO2 between 35-45 mmHg
99
Acute care exam - tests and measures
VITALS - before, multiple times during if need, after activity
Pain is part of vital assessment
As Applicable:
Cognition, speech/language ability, general appearance, CVP, MSK (functional mobility if unable to assess via traditional), Neuro (screen vs full exam), integumentary, pain, functional mobility, std measures
100
Delirium in the ICU
Up to 80% of mechanically ventilated ICU patients
3 types:
1. Hyperactive (ICU psychosis)
2. Hypoactive
3. Mixed
101
Home with no further therapy needed
Pt may not even need therapy in the hospital or have no other needs after initial treatments
102
BUN
Blood urea nitrate
Increases: kidney disease/dysfunction, excessive protein intake, excessive tissue destruction, HF, dehydration, shock, GI bleeds
Decreases: low-protein diet, muscle wasting, starvation, liver failure, cirrhosis, high urine flow
103
Mechanical ventilation
Settings
FiO2
Fraction of inspired oxygen
Lowest value to meet satisfactory O2
(75-100)
104
VIDD: ventilator-induced diaphragmatic dysfunction
Prolonged controlled mechanical ventilation (CMV) results in a rapid diaphragmatic atrophy
In as few as 12-18 hrs of CMV, significant fiber atrophy in both slow and fast muscle fibers of diaphragm
Occurs before skeletal muscle atrophy
CMV-induced atrophy exceeds rate reported for diaphragm after denervation
Diaphragm recovery- returns to near normal levels w/in 24 hrs after return to spontaneous breathing
105
Balance and falls
Functional measures
Acute care
TUG
Berg
Forward reach
Single limb support
106
Mechanical ventilation
Settings
Tidal volume
Usually set 400-1200 cc
| Dependent on body mass
107
Long-term Acute Carr hospital
Pts with multiple co-morbidities who need a long stay of hospital care
Still need daily medical management by a physician
Average LOS > 25 days
Provide: ventilator weaning, IV antibotics, dialysis, rehab services, wound care services
108
Cardiovascular considerations
Red/Yellow/Green
Transvenous or epicardial pacemaker
Dependent rhythm:
Yellow: in-bed
Red: out-bed
Stable underlying rhythm = green (both: in and out bed)
109
Anesthesia- conscious sedation
Midazolam and propofol are most commonly used sedatives
Fentanyl most frequent analgesic
Help relax and block pain while pt remains awake but unable to speak and won’t remember much about procedure
Colonoscopy, breast biopsy, Minor surgical procedures
110
Standard precautions- infection control
Treat all pt as if they are infectious
Wash hands before and after, new gloves- every pt
PPE if contact w/ bodily fluids possible
Respiratory hygiene and cough etiquette
Aseptic technique
111
HCO3-
Bicarbonate
Critical in maintaining acid-base balance
Mediated by kidneys
112
Inpatient rehab facility criteria
Pt who needs intensive rehab services
Must be able to tolerate 3 hours therapy 5-7 days/week (includes PT, OT, ST- must have AT LEAST 2 disciplines on board)
Length of stay determined by diag - typically 10-12 days
Rehab is main focus, medically stable
No qualifying length of stay required in acute care hospital- patients can be referred from home or ED
“60% rule” for Medicare pts
113
HgB
Hemoglobin - Indicator of severity of anemia or polycythemia
Trending downward (anemia):
Low critical (<5-7) can lead to HF or death
< 8 = essential daily activity only- HOLD PT
> 8 : ambulation permitted
8-10 :stairs,light aerobics,light weights(1-2 lbs)
> 10 : resistive exercise permitted
```
Trending upward (polycythemia):
COPD, altitude
High critical (>20) can lead to clogged capillaries
```
114
5 cardiovascular measures indicating lack of readiness for PT
1. MAP <65 or >120 mmHg
OR >=10 mmHg lower than normal SBP or DBP for pt receiving renal dialysis
2. RHR <50 or >140 bpm
3. SBP <90 or >200 mmHg
4. New arrhythmia
5. New onset angina-Type chest pain
115
PVC limit of ___ to stop exercise and have patient sit, if worsens ____. If patient rhythm deteriorated into arrhythmia _____.
PVC limit of 6
If worsens return to bed
If arrhythmia return to room
116
Other considerations
Red/Yellow/Green
Uncontrolled active bleeding
Red
117
Type II
| Respiratory failure
Failure to exchange or remove CO2
Hypoxia with hypercapnea
```
Low PaO2 (< 55 mmHg)
High PCO2 (>45 mmHg)
Low pH (< 7.3)
```
118
Central line - possible locations
Central central line:
Subclavian
Internal jugular
External jugular
Peripheral central line:
Basilic
Cephalic
Femoral
119
Cardiovascular considerations
Red/Yellow/Green
Known/Suspected pulmonary hypertension
Yellow
120
Weaning criteria
Mode: spontaneously breathing w/ natural RR (<25 breaths/min)
PaCO2: 35-44 mmHg
FiO2: less than 40-50% w/ a PaO2 > 60 mmHg
PEEP: < 5-7 cmH2O
MIP at least -20 cmH2O
121
Neurological considerations
Red/Yellow/Green
Uncontrolled seizures
Red
122
SaO2
88% or greater when measured with ABG
| Is SpO2 when measured by pulse oximeter
123
Anesthesia- local/peripheral
Injected into tissue to temporarily numb
124
PICS: post-intensive care syndrome
| Cognitive dysfunction
Problems connecting w/ remembering, paying attention, solving problems, and organizing and working on complex tasks
30-80% ICU pts
In some cases this may be permanent
May affect when pt can return to work, balance a checkbook, or perform other tasks that involve organization and concentration
125
Decreased H+ due to decreased CO2 when too much blown off
Respiratory alkalosis
126
aPTT
Time for blood to clot
Normal range 30-40 sec
Values 1-2x normal- May need to hold exercise due to risk of bleeding
127
Neurological considerations
Red/Yellow/Green
Acute spinal cord injury
Green: in-bed
Yellow: out-bed
128
Pulmonary artery pressure monitors
AKA Swan-Ganz catheter
Inserts directly into pulmonary artery at R side of heart
Measures arterial pressure, normal = 8-20 mmHg at rest
If > 25 mmHg at rest or >30 with physical activity...pulmonary HTN
Check with nursing prior to mobilization
129
4 possible effects of anesthesia
General
Regional
Local/Peripheral
Conscious sedation
130
Lowest patient to nurse ratio
Intensive care
May be general ICU or specialty (trauma, cardio, neuro, pediatric etc)
131
Ca2+
Normal 8.5-10.5 mg/dL
Hypocalcemia: most often impaired PTH (parathyroid hormone)
Hypercalcemia: excessive PTH production, hyperthyroidism and malignancy
Severe > 12-13: lethargy, stupor, coma, bradycardia, AV block, shorter QT interval
132
4 pulmonary measures indicating lack of readiness for PT
1. SaO2 < 88%
OR pt experiences a 10% oxygen desaturation below resting SaO2
2. RR > 35 breaths per minute
3. PEEP > 10 cmH2O
4. FiO2 >= 0.6
133
PICS: post-intensive care syndrome
Collection of Heath problems that remain after critical illness- can involve body, thoughts, feelings, or mind and may affect the family
ICU-acquired weakness
Cognitive or brain dysfunction
Other mental health problems
134
Cardiovascular considerations
Red/Yellow/Green
Known/Suspected severe aortic stenosis
Green: in-bed
Yellow: out-bed
135
Cardiovascular considerations
Red/Yellow/Green
MAP
Below target range- causing symptoms or despite support
Yellow: in-bed
Red : out-bed
Below target range - no/low support
Green (both)
Greater than lower limit w/ moderate support-
Yellow (both)
Greater than lower limit w/ high support-
Yellow: in-bed
Red: out-bed
136
Ketoacidosis
Hyperglycemia >240 mg/dL uncorrected
Can be life threatening
S/S: SOB, nausea, vomiting, dry mouth, fruity breath
137
Exercise considerations and glucose
Can be too low or too high
<70 give pt carb snack before exercise
> 250 EXERCISE typically CONTRAINDICATED
Exercise can make hyperglycemia worse
138
IABP
Placed?
Indications?
Intra-Aortic balloon pump
Typically placed in femoral artery- requires bed rest and significant risk for lower extremity ischemia
Indications:
Refractory angina pectoris
Post-cardiopulmonary bypass shock
Temporizing complications of Percutaneous coronary intervention
Complications of MI refractory to pharmacologic therapy
139
ACV : Assist control ventilation
Rate and tidal volume set by RRT
Pt controls respiratory rate but ventilator assists every breath
Once pt initiated breath, preset volume or pressure flow rate is delivered by ventilator
Can be set so machine will initiate breath if pt initiated respiratory rate is too low to meet rate set by therapist
Machine does 90-100% of work
Risk of hyperventilation and barotrauma
140
High flow O2 delivery-
| Transtrachael catheters “Trach mask”
May reduce work of breathing and augment CO2 removal
Pts who have been extubated and taken off ventilators May benefit from an interim of this to ensure weaning success
141
CAM-ICU
Confusion assessment method for the ICU
Good for screening/detecting delirium in critically ill pts
142
Respiratory parameters-
Red/Yellow/Green
Rescue therapies- prostacyclin
Yellow
143
TPN- total patenteral nutrition
Central line- vena cava
| Bypasses GI tract
144
Femoral IABP need to avoid...
Avoid flexion >30* at hip
They can walk - the challenge is getting them up with this restriction
Can get up with catalyst bed or tilt table
145
Cardiovascular considerations
Red/Yellow/Green
ECMO
Femoral or Subclavian:
Green: in-bed
Red: out-bed
Single bicaval dual lumen inserted into central vein:
Green: in-bed
Yellow: out-bed
146
Respiratory parameters-
Red/Yellow/Green
PEEP
=< 10 cmH2O: green
> 10 : yellow
Ventilator dysynchrony : yellow
147
PPC
Post-op Pulmonary complications
```
Age > 60
Decreased mobility
Malnourished
Past respiratory ds
Prolonged procedure
Expected intubation
```
148
Metabolic alkalosis
pH?
PaCO2?
HCO3-?
pH increases > 7.45
PaCO2 normal
HCO3- increases > 26
Decreased H+ due to increased renal absorption of HCO3-
149
Low flow O2 delivery -
| Nasal canula
```
Nasal canula:
Easily portable
Only 22-44% FiO2
Don’t use > 6 L
Can dry nasal passages; often humidified when > 3 L
```
150
Neurological considerations
Red/Yellow/Green
Craniectomy
Green: in-bed
Yellow: out-bed
151
Risk factors for HAI (healthcare associated infections)
```
Age
Immunodeficiency
Immunosuppression
Misuse of antibiotics
Use of invasive diagnostic or therapeutic procedures
Agitation
Surgery
Burns
Length of hospitalization
```
152
BiPAP
Two pressure levels:
IPAP
EPAP
Indications:
Acute hypercapnea- respiratory muscle rest;
Cardiogenic APE;
Immunosuppressed pt w/infection
153
Ventricular assistive devices
Mechanical device that augments pumping capability of heart providing circulatory support necessary to sustain life
Most commonly used = LVAD
But can be for R, L or both
154
Indications for VA ECMO
Cardiogenic shock with inability to oxygenate, due to...
Acute MI, Cardiac arrest, decompensated HF, post-partum cardiomyopathy
Post-cardiotomy shock
Bridge to durable VAD/TAH support or transplant
Absence of non-reversible organ failure
155
Types of ECMO support
Veno-arterial (VA) ECMO-
Blood removed from vein, circulated through pump and artificial lung, and returned to artery
Supports heart and lungs
Veno-venous (VV) ECMO-
Blood removed from vein, circulated through pump and artificial lung, and returned to vein
Supports lungs only
156
Respiratory parameters-
Red/Yellow/Green
Rescue therapies: Nitric Oxide
Yellow
157
Hand hygiene
Wet hands -> soap -> front/back/under nails ***scrub at least 20 sec (“Happy birthday song” twice) -> rinse -> dry and turn off water with towel
Alcohol based sanitizer at least 60% alcohol
If soap/water unavailable
Isn’t as effective
“Foam in, Foam out” - be visible using it.
158
How to choose functional measures in acute care
Applicable to pt
Practical for use in acute care (time, cost, feasibility)
Assistance w/ d/c planning and pt safety
Acceptability of test to the individual (tolerance for test, positioning)
Appropriateness of test for application to the pathology or health condition, body function or status, activity or participation
159
BUN:Creatinine ratio
Used to determine cause of acute kidney injury or dehydration
Normal ratio 10:1
10-20:1 = likely kidney dysfunction
> 20:1 = likely due to dehydration
160
ICU delirium and cost
Higher severity and duration were associated with incrementally greater costs
29% higher ICU costs
31% higher hospital costs
Efforts to prevent or treat ICU delirium have potential to improve pt outcomes and reduce cost of care
161
DNI
Do not intubate
Resulted from separating wishes of no CPR from no mechanical ventilation (MV)
162
PICS: post-intensive care syndrome
| Other mental health problems
```
Critically ill pt may develop:
Problems falling asleep/staying asleep
Nightmares or unwanted memories
Anxiety/Depression
Can be similar to PTSD
```
May benefit from psychotherapy and/or psychiatry following ICU discharge
Speech therapy can also assist with strategies to deal with impaired memory and attention
163
Assisted living facility -
| Discharge disposition requirements
Pt who need housing, support services, and health care
Services/Amenities (facility dependent):
3 meals/day in common dining area
Housekeeping, laundry, transportation, assistance with ADLs, medication assistance, rehab services (HH vs OP)
NOT to be confused with senior independent living apartment communities
Often hour ALFs
Some offer continuum of care
164
Indications for VV EMCO
Potential reversible lung insult
Condition consistent with ARDS
Mechanical ventilation <7 days
Profound hypoxemia or hypercapnea
Bridge to lung transplant
Absence of non-reversible organ failure
165
Metabolic measure indicating patient not ready for PT
Glucose <70 or >=200 mg/dL
166
Cardiovascular considerations
Red/Yellow/Green
Cardiac ischemia
Yellow: in-bed
Red: out-bed
167
Skilled nursing facility criteria
Pt who needs daily skilled care under direction of skilled nursing or rehab staff for a hospital related medical condition
Rehab services, nursing services (IV injections etc), Activities
Billed under Part A Medicare for those 65+
Otherwise private insurance
Requires 3 midnight stay I acute care hospital (Medicare)
Length of stay: up to 100 days
Can be within a longterm facility or a free standing facility (often combo with inpatient rehab services)
168
PaCO2
35-45 mmHg
169
BMP
Basic metabolic panel
Na+, Cl-, K+, HCO3-, BUN, creatinine, glucose
170
Cardiovascular considerations
Red/Yellow/Green
Known/Suspected DVT/PE
Yellow
171
Ambulation with femoral IABP
Using catalyst bed or tilt table to get them up because can’t hip flex >30*
172
PT and the post-op patient
| These items should be addressed with every visit.
Assess cough- teach splinted breathing; teach airway clearance
Teach diaphragmatic breathing
Teach incentive spirometry
Teach frequent position changes
And education on all the above
173
Cl-
Works w/ Na+, K+ and bicarbonate to regulate acid-base balance
Hyperchloremia - can cause metabolic acidosis
Hypochloremia- rarely occurs in isolation; can cause metabolic alkalosis
Monitor level of consciousness and motor function
174
Code blue
Goal: perform resuscitation efforts after a person has stopped breathing or after heart stopped beating
Initiated by anyone with CPR certification or can verify person stopped breathing or has no pulse - or unresponsive and unable to determine if pulse/breathing
Can also initiate if unsure what to do and have dire concern for life of person
175
Neurological considerations
Red/Yellow/Green
Subarachnoid hemorrhage with unclipped aneurysm
Green: in-bed
Yellow: out-bed
176
Cardiovascular considerations
Red/Yellow/Green
Femoral IABP
Green : in-bed
| Red: out-bed
177
Cardiovascular considerations
Red/Yellow/Green
Pulmonary artery catheter or other continuous cardiac output monitoring device
Green: in-bed
Yellow: out-bed
178
High flow O2 delivery -
| Venturi mask
Mixes O2 with room air
Accurate constant FiO2
Typically: 24, 28, 31, 35 and 40% oxygen
Often used when concern about CO2 retention
179
Ventricular assist device
Can support either R, L, or both
180
Contact precautions
MRSA
Shingles
VRE
C-diff
STD precautions +
Gown and gloves req’d
In the case of c-diff, MUST use soap and water bc alcohol does NOT kill the bacteria
181
PCA pump
Pt controlled analgesic
182
Hypernatremia s/s
Swelling, increased thirst, lack of urination, cramps/spasms, weakness
Seizure precautions for patient with past hy
183
A of SBAR
Assessment
Medical assessment findings/concerns
Ex: MI
PT: slow progress, only to toilet and back
184
Home health homebound criteria
1: the patient MUST EITHER:
- bc of illness/injury, need aid of supportive devices (AD); special transportation; or assistance of another person in order to leave their place of residence
OR
- have a condition such that leaving his/her home is medically contraindicated
AND
2: A normal inability to leave home AND leaving home must require a considerable and taxing effort
185
BNP
| Levels indicate...
< 100 pg/mL NO HF
100-300 HF present
> 300-600 mild HF
> 600 moderate to severe HF
186
Other considerations
Red/Yellow/Green
Large open surgical wound (chest/sternum, abdomen)
Green: in-bed
Red: out/bed
187
Type I
| Respiratory failure
Hypoxemic
Failure of oxygen exchange
Hypoxia without hypercapnea
```
Low PaO2 (< 55 mmHg)
Normal PCO2 (35-45 mmHg)
```
188
What does an IABP do?
Increases myocardial oxygen perfusion while increasing CO
Increasing CO therefore increases coronary blood flow which increases myocardial oxygen delivery
Balloon sits in aorta:
Deflates during systole- increases forward blood flow by decreasing afterload
Inflates during diastole- increases blood flow to coronary arteries via retrograde flow
189
Coagulability tests
PT- prothrombin time
aPTT- activates partial thromboplastin time (heparin)”/lovenox)
INR - international normalized ratio (warfarin/Coumadin)
190
Home with home health PT
“Home bound” status
Does pt need supervision or assistance?
Pt’s own home, family/caregiver home, assisted-living facility?
191
SBAR
Situation
Background
Assessment
Recommendations
Situational briefing guide for staff and provider communication
Re: pt status or needs for non-emergent events, related issues, events in unit, lab or within health team
Does NOT become part of medical record- is to communicate to other providers with same pt
192
External ventricular drain (EVD)
Monitors and alleviates swelling and increased pressures in the ventricles of the brain
Must keep head at 30* when drain is open
Always check with nursing before working with these pt
Common dx: CVA, TBI, Hydrocephalus
193
R of SBAR
Recommendation
Suggestion for treatment
Referral to social work for revision of care; est d/c date
Ex:
OT referral
Contact SW for d/c dispo, social concerns
EDD 5/25/19
194
PLT
Platelets
Normal 140-400 k/uL
Trending upward:
Thrombocytosis: >450 ;iron deficiency, cancer, infection and inflammation
Elevated levels can lead to venous thromboembolism
Trending downward:
Thrombocytopenia <150 ; liver disease, aplastic anemia, viral infection, radiation/chemo
Fall risk awareness (risk of spontaneous hemorrhage)
< 100 and/or temp >100.5 = HOLD PT
100-200 : PT permitted, exercise/bike w/o resistance
> 200 : Therapeutic exercise/bike with or without resistance
195
1-to-1 supervision
Medical, mental health or behavioral conditions necessitate 1-on-1 care
Can be situational- like during meals bc aspiration precaution
Danger to self or others
Extreme fall risk
Delirium, extreme confusion
NEVER leave pt alone
196
INR
International normalized ratio
INR > 3 : risk for bleeding
INR < 4 : PT indicated; light exercise, hold progressions until INR at therapeutic levels
INR > 5 : HOLD exercise- can perform PT eval in room
INR > 6: PT CONTRAINDICATED, 2 days bed rest likely, possible transfers OOB to chair only
197
Stroke alert
Timely CT scan
Neuro eval
Determining need to admin tPA and/or surgical interventions
```
Call if pt exhibits signs of acute stroke (FAST)
F- face : look for uneven smile
A- arm: check if 1 arm weak
S- speech: slurred?
T- time: 911/call code right away
```
198
Advanced directives
Specify decisions about end-of-life care
Living will- outlines what treatment wants in event I life threatening conditions and/or inability to express those desires themself- May also contain info regarding organ/tissue donation
Durable power of attorney for health care- names a trusted health care proxy to make decisions when pt unable
199
Cardiovascular considerations
Red/Yellow/Green
Tachyarrythmia with ventricular rate < 120 bpm
Green
200
LVAD
Implanted in patients with end stage heart failure
Bridge to recovery, transplantation, or for patients not eligible for transplant
Can aid to restore adequate CO and help recovery from 2ndary organ dysfunction
201
Cardiovascular considerations
Red/Yellow/Green
Shock of any cause with lactate >4 mmol/L
Yellow
202
Decreased H+ due to increased renal absorption of HCO3-
Metabolic alkalosis
203
Hypochloremia
Causes: NG suction, diarrhea, cystic fibrosis vomiting
Usually occurs with metabolic alkalosis
Rarely occurs in isolation
204
Contraindications for mobilization
| ICU/Acute
1. Significant doses of vasoactives for hemodynamic stability (maintain MAP > 60)
2. Mechanically ventilated and require FiO2 80% and/or PEEP > 12, OR have acutely worsening respiratory failure
3. Maintained on NM paralytics
4. Neurologic instability or acute event (< 24 hrs)
5. Unresponsive/Unable to reduce sedation
6. Unstable spine or extremity fractures
7. Transitioning to comfort care
8. Rigid femoral catheters
9. Open abdomen, at risk for dehiscence
10. Recent autograft or flap placement (plastic surgery)
205
S of SBAR
Situation
Current situation
Ongoing investigation, family situation, how much pt knows about condition
Can be as simple as “take patient to therapy”
206
Nosocomial infection
AKA HAI
| Healthcare associated infection
207
Wells score PE
> 4 PE likely
3 points each:
Suspected DVT
Alternative diag less likely than PE
1.5 points each:
Immobilization >=3 days; surgery in prev 4 weeks
History of PE or DVT
HR >100
1.0 points each:
Hemoptysis
Malignancy within past 6 months
208
Catheter
Keep collection bag lower than bladder
209
Other considerations
Red/Yellow/Green
Unstable major fracture (pelvic, spinal, lower limb long bone)
Yellow: in/bed
Red: out-bed
210
CBC
Complete blood cell count
WBC
HCT - hematocrit
Hbg- hemoglobin
Platelets
211
Orthostatic intolerance vs Normal
| HR and Systolic
Normal:
HR: increase of 5 bpm
Systolic BP: decrease of 10 mmHg
Abnormal:
HR : increase of 20 or more bpm
Systolic BP: decrease of 20 or more mmHg
212
Hypomagnesemia
Malabsorption; protracted vomiting, diarrhea, or intestinal drainage; defective renal tubular reabsorption; Cyclosporine
S/S: generalized alterations in NM function, depression, irritability, delirium, tachycardia
213
Post-acute facility placements
IRF (inpatient rehab)
SNF (skilled nursing)
LTAC (longterm acute care
LTCF (longterm care facility/nursing home)
214
____ can reduce atelectasis and should be instructed on every post-op with abdominal or thoracic incision
Diaphragmatic breathing
215
Hyponatremia s/s
Confusion, weakness, cramps/spasms, HA, convulsions, irritability
< 130 mEg/L
Water moves into cells to balance, brain cells especially sensitive to swelling- Can be fatal
Dehydration or over-hydration
Can be fatal
Monitor vitals 2ndary to risk for orthostatic hypotension
216
RBC
Normal
4. 7-6.1 x10^6/uL male
4. 2-5.4 x10^6/uL female
Decrease: anemia, cancer, blood loss, malnutrition
Increase (polycythemia): dehydration, R HF, COPD, smoking
217
NPO
Nothing by mouth - NO food or drink
Safety -
Minimize aspiration
Protect pt from dangerous swallowing condition
Enforce bowel rest (GI system)
218
Impella and IABP
Impella: Inserts into L side of heart to pump
IABP: Intra-aortic balloon pumps
219
Type IV
| Respiratory failure
Shock
220
Respiratory parameters-
Red/Yellow/Green
Fraction of inspired oxygen (FiO2)
=< 0.6 green
| > 0.6 yellow
221
Airborne precautions
Contagious pathogens transmitted by airborne droplet nuclei that have ability to remain suspended in air for extended time
Measles, varicella (until dry/crusted), TB
STD precautions + N95 respirator mask or positive air purifying respirator (PAPR); eye protection; airborne isolation room required
222
Neurological considerations
Red/Yellow/Green
Subgaleal drain
Green: in-bed
Yellow: out-bed
223
D-dimer test
Ordered when DVT or PE suspected, and to confirm DIC
Measures degradation levels of fibrin
Positive > 500 ug/L
224
K+
Affects excitability of heart, muscles and nerves
Normally excreted in urine
Normal 3.7-5.1 mEg/L
Hypokalemia
Hyperkalemia
225
Increased H+ due to a drop in HCO3-
Metabolic acidosis
226
ECMO/ECLS
Extracorporal membrane oxygenatio/life support
Mechanical devices to temporarily support heart and/or lung function during cardiopulmonary failure, allowing organ recovery or replacement
227
Neurological considerations
Red/Yellow/Green
ICP
Active mgmt of intracranial hypertension w/ ICP not in desired range = red
Intracranial monitoring w/o active mgmt of intracranial hypertension-
Green: in-bed
Yellow: out-bed
228
PSV : Pressure support ventilation
PF initiated breaths are augmented by ventilator to maintain a certain inspiratory pressure and tidal volume
The greater the PSV the less effort by pt
Usual range 5-25 cmH2O
Used as a weaning mode
Can reduced pressure support volume
Can increase time spent with this reduced assistance to address impaired endurance
229
Neurological considerations
Red/Yellow/Green
Open lumbar drain (not clamped)
Green: in-bed
Red: out-bed
230
Patient selection for ambulatory IABP
Used in patients who benefit from IABP but need ambulatory and long-term support
Requires ICU setting
Used as bridge to: transplant, MCS, determination, recovery (post MI or post ECMO; after high-risk surgery)
231
Respiratory parameters-
Red/Yellow/Green
Rescue therapies- Prone Positioning
Red
232
Functional strength
Functional measures
Acute care
Chair rise test (quad strength)
30 sec, timed 5 reps
Arm curl
Supine hip extension
Heel rise
Toe tap
233
PT and the post-op patient
| Observation/Assessment with every visit.
Edema
Assess for DVT
Look at incision if possible- at least look for drainage
Assess orientation and ability to follow commands
Involve family if possible (but if they are getting in the way- suggest they take a break and go get a cup of coffee or something)
234
General functional mobility and endurance
Functional measures
Acute care
Functional test (AMPAC 6-clicks)
Cardiovascular endurance (6MWT, 2MWT, 400m walk test, 2 min step test)
Walking speed
RPE during functional activities
235
Respiratory parameters-
Red/Yellow/Green
Ventilation- HFOV
Yellow- in-bed
| Red- out-bed
