Exam 2 review sheet Flashcards

Question

neurologically big pupils

Answer 1

damage to brain stem

Answer 2

impending herniation

Answer 3

1. Slight LOC changes \*\*\*MOST IMPORTANT\*\*\*\* 2. Pupils sluggish / Impaired eye movement 3. Limb strength changes 4. Headache

Answer 4

48 – 72 hours after injury

Answer 5

Blood Pressure - Systolic BP Increases - Diastolic BP Decreases - Pulse Decreases Widening Puse Presure Bradycardia Might also see cheyne-stokes breathing and elevated temperature

Answer 6

a part of the brain pushes downward inside the skull through the opening that leads into the neck | (Foramen Magnum)

Answer 7

Maintain Cerebral perfusion pressure CPP of 50 – 70 mm Hg Prevents Hypoxia (Hypercarbia)

Answer 8

* potentially reversible * level of conciousness may not be impaired initially * alert to stuperous, pupils sluggish, cheyne-stokes respiration, slight increase in pulse pressure

Answer 9

Deep Coma, Dolls eyes, pupils fixed, posturing, hyperventilation, wide pulse pressure

Answer 10

* late phase of UNCAL herniation * irreversible (terminal) * Deep Coma * no pupillary response * cluster or apneic * pulse pressure starts to narrow again

Answer 11

Used to: * Electrical Activity * Identify seizure activity * Determine Brain Death

Answer 12

Used to * Identify shifts from midline * May show ventricular dilation

Answer 13

CT: Show Horizontal and Vertical Cross Sections MRI: Show tissue discrimination

Answer 14

* Severe Head Injury * GCS 3-8 (less than 9) * Abnormal Imaging * SBP less than 90 mm/hg * Subarachnoid hemorrhage * Hydrocephalus * Brain tumors * Stroke * meningitis

Answer 15

* Central nervous system infection * Coagulation defects * Anticoagulant therapy * Scalp infection * Severe midline shift resulting in ventricular displacement * Cerebral edema resulting in ventricular collapse

Answer 16

* Q 1hour Neuro Checks * Monitor MAP, ICP, CPP (MAP-ICP) * Monitor ICP wave Forms * Strict Asepsis * Assess ICP site * Watch for CSF leaks (ear, see halo with the fluid) * Watch for Blood in the ICP monitoring system (should never see blood in there)

Answer 17

* never use a flush device. Use only sterile 0.9% NaCl to fill the pressure tubing. * Never use a heparinized solution.

Answer 18

30-45 degree

Answer 19

flexion and hyperextension of the neck

Answer 20

Simultaneous drainage and pressure monitoring is not recommended. To ensure precise pressure measurements, perform only pressure monitoring while keeping the stopcock closed to the drainage system.

Answer 21

\*gold standard\* Advantages * Allows for CSF drainage * Provides direct measurement of CSF pressure Disadvantages * Most Invasive * High risk for infection/ hemorrhage/ infection * Contraindicated with coagulopathies

Answer 22

Advantages * Less invasive * Easy to place * Low risk of infection * Able to sample CSF * Can be used if ventricles are not able to be cannulated Disadvantages * Unable to drain CSF * Decreased accuracy with time * Needs frequent recalibration * Easy to be obstructed with bone/tissue

Answer 23

advantages * Easy placement * Low risk of infection * Highly accurate disadvantages * Unable to drain CSF * Needs a separate monitoring system * Catheters kink easy * Risk of hemorrhage/ infection * Can not be re-zeroed

Answer 24

advantages * Easy placement * Low risk of infectin disadvantages * Unable to drain CSF * Can not be re-zeroed * Accuracy questionable

Answer 25

* head 30 degrees * ear in line with transducer * leveler is at 90 degrees (upright)

Answer 26

Mannitol * Pulls fluid into the cerebral vascular space * Reduces cerebral blood viscosity * Increases cerebral blood flow * Increased cerebral oxygen delivery * Dosage: 1.0 gm/kg * Nurse considerations: Watch serum osmolality

Answer 27

* Reduces ICP * Decrease levels of excitatory neurotransmitters * Cerebral edema * Free radicals * Cerebral metabolic rate * 33 degrees celcius

Answer 28

Monitor for S/S of: * Shivering * Arrhythmias * Coagulopathies * Hypothermia-induced diuresis * Electrolyte imbalance * Hiccoughs * Rewarming slowly

Answer 29

* Seizures are very common with increased ICP Phenytoin may be initiated with * GCS less than 10 * Cortical Contusions * Depressed skull fractures * Subdural, epidural and intracerebral hematomas * Penetrating head injuries * A seizure within the first 24 hours post injury Nursing considerations: Safety * Oral airway * Side rails padded * Suction and oxygen set-up * Patient/ family teaching * Administration and monitoring of pharmacological interventions

Answer 30

ATLS (asvance trauma life support)evaluation & intervention (ABCs / Foley / NG / oxygen / Maintain traction) Constant Monitoring \*Diagnosis: - CT scan (FAST!) - MRI - PET Scan (brain function assessment) \*Medical interventions depend on severity: - Endotracheal intubation / hyperventilation - Sedation - Diuresis - Rapid surgical evacuation

Answer 31

* Continuous monitoring of Vitals, PERRL and Glasgow Coma Score * Report client condition changes ASAP * Maintain airway patency- positioning, suctioning (if necessary) * Minimize cerebral edema * Maximize cerebral perfusion * Implement seizure precautions / Siderails * Provide emotional support * Address all self-care deficits

Answer 32

Anticonvulsants - Phenytoin (Dilantin) - 10-20 mg/kg loading dose - Mix with NS not dextrose - 25-50 mg/min IVP - Monitor MP and Heart Rate x 30 min: May use Fosphenytoin children (SIVP or IM)\* -Benzodiazepine: Given emergent with Dilantin Keatogenic Diet: High fat, low carb, low protein Vagus Nerve Stimullator: implanatble device that stimulates the vagus nerve. Done after trying 3 or more meds

Answer 33

* Make certain that the patient has the following equipment: Nasal cannula and tubing, Oxygen flow meter; , Suction gauge, Suction canister, Suction tubing to connect to canister * Assign patient to room in close proximity to the nurses station * Maintain continuous observation via video monitor or sitter * Pad side rails of bed * Keep bed in low position with all side rails up at all times * Keep unnecessary equipment out of patients room * Instruct patient not to get out of bed without assistance * Assure that call bell is always within patients reach. Make sure that the family knows where it is and how to use it * Avoid use of restraints * Check vital signs every fifteen minutes and maintain airway patency during the post ichtal phase (period of time immediately following the seizure, during which the patient remains comatose or stuperous).

Answer 34

* Linear (very small line) or depressed skull fracture * Simple, compound, or comminuted * Closed or open * Direct and Indirect * Coup (head goes forward quickly and the injury goes to the back of the brain) and Countercoup (head goes back quickly and injures the front of the brain)

Answer 35

* CSF leakage through nose or ear * high risk for infection * battle signs (bruising behind ear) * raccoon sign (bruising around the eyes) * possible injury to internal carotid artery * permanent CSF leakage

Answer 36

Minor * May loose conciousness * transient period of confusion * somnolence * listlessness * irritability * pallor vomiting Severe * Increased ICP * Bulging fontanel (infants) * reinal hemorrhages * extraocular palsises (CN111) * hemiparesis * quadraplegia * increase temperature * change in gait * papilledema

Answer 37

Mild Head Injury

Answer 38

moderate head injury

Answer 39

severe head injury

Answer 40

* Transient confusion * no loss of consciousness * symptoms resolve in less than 15 minutes

Answer 41

* transient confusion * no loss of consciousness * symptoms last more than 15 minutes

Answer 42

Any loss of consciousness, brief or prolonged

Answer 43

contusion: bruising of brain tissue withing a focal area that maintains the integrity of the pia mater and arachnoid layers Laceration: involve actual tearing of the brain tissue. Intracerebral hemorrhage is generally associated with cerbral laceration

Answer 44

results from bleeding between the dura and the inner surgace of the skull. It is a neurologic emergency and of venous or arterial origin

Answer 45

Occurs from bleeding between the dura matter and arachnoid layer of the menigeal covering of th ebrain

Answer 46

widespread axonal injury occuring after a mild, moderate, or severe tbi

Answer 47

* Infants born before 30 weeks of pregnancy are at highest risk for such bleeding (smaller and younger, higher the risk bc blood vessels are premature and fragile) * IVH is more common in premature babies who have had: respiratory distress syndrome, high BP, can occur in healthy premature babies born without injury * Rarely present at birth * Develops in first several days of life, and rare after one month of age * Falls into 4 grades, the higher the grade the more severe the bleeding * Presses on or leaks into the brainm, blood clots form around that, leads to increased fluid volume creating hydrocephalus

Answer 48

* Grade 1 &2 involve small amounts of bleeding and do not usually cause long term problems * Grade 3 & 4 involve more severe bleeding

Answer 49

* There may be no symptoms * Breathing pauses * Changes in BP and heart rate * Decreased muscle tone * Decreased reflexes * Excessive sleep * Lethargy * Weak Suck

Answer 50

Catastrphic Acute IVH with bulgin fontanel, spil sutures, change in level of consciousness, pupillary and cranial nerve abnormalities, decerebrate posturing, and often with rapid decrease in blood pressure andor hematocrit. Saltatory Gradual deterioration in neurological status, may be subtle abnormalities in level of consciousness, movement, tone, respiration and eye/position movement Asymptomatic 25-50%, discovered on ultrasound. Fall in hematocrit or failure of hematocrit to rise wiht tranfusion should cause concern

Answer 51

bleeding condined to periventricular area (germinal matrix)

Answer 52

Intraventricular bleeding less than 50%

Answer 53

intraventricular bleeding greater than 50%

Answer 54

Intra-Parenchymal echodensity (IPE) reperesents periventricular hemorrhagic infarction

Answer 55

* bacterial culture and gram staining of csf and blood are key diagnostic tests * the presence of polysaccharide antigen in csf futher supports the diagnosis of bacterial meningitis

Answer 56

adult: vomiting, headachem drowsiness, seizures, high temp, stiff neck, joint pain, dislike of light child: high pitched cry, dislike of being held, fearful, arching back, blank staring expression, pale blotchy skin color, refusing feeds or vomiting, fever, may have cold hands and feet, difficult to wake up, very lethargic

Answer 57

* frequent/continual assessment including vs and LOC * protect patient form injury related to seizure activity or altered LOC * monitor daily weight, serum electrolutes, urine volume, specific gracity, and osmolality * prevent complications associated with immobility * infection control precautions * supportive care * measures to facilitate coping of patient and family s/s meningitis * Look for kurnig sign: hip and knee flexed 90 degrees, and when you try to extend it it's painful * brudzinski sign: pt is laying extended, bring up their neck, and their knees will flex up * petichiae that if you blanch it they won't go away

Answer 58

* irreversible cessation of circulatory and respiratory function * irreversible cessation of all functions of the entire brain, including the brain stem, is dead. * A determination of death must be made in accordance with accepted medical standards.

Answer 59

* apneaic testing * testing with cranial nervees * diagnostics with brain imaging and brain blood flow: If the first 2 are inconclusive, then this one is done or under the age of 1 * Brain death is a clinical diagnosis. It can be made without confirmatory testing if you are able to establish the etiology, eliminate reversible causes of coma, complete fully the neurologic examination and apnea testing. * The diagnosis requires demonstration of the absence of both cortical and brain stem activity, and demonstration of the irreversibility of this state.

Answer 60

* No pupillary response to light. Pupils midline and dilated 4-6mm. * No oculocephalic reflex (Doll’s eyes) – contraindicated in C- spine injury. * No oculovestibular reflex (tonic deviation of eyes toward cold stimulus) – contraindicated in ear trauma. * Absence of corneal reflexes * Absence of gag reflex and cough to tracheal suction.

Answer 61

* Once coma and absence of brain stem reflexes have been confirmed --\>Apnea testing. * Verifies loss of most rostral brain stem function * Confirmed by: PaCO2 \> 60mmHg, or PaCO2 \> 20mmHg over baseline value. * Testing can cause hypotension, severe cardiac arrhythmias and elevated ICP. * Therefore, apnea testing is performed last in the clinical assessment of brain death.

Answer 62

* Core temp \> 35.0 C * Systolic blood pressure \> 90mmHg. * Euvolemia * Corrected diabetes insipitus * Normal PaCO2 ( PaCO2 35 - 45 mmHg). * Preoxygenation (PaO2 \> 200mmHg).

Answer 63

* Neonate less than 7 days ---\> Brain death testing is not valid. * 7 days – 2 months: Two clinical exams and two EEG 48 hrs apart. * 2 months – 1 year: Two clinical exams and two EEG 24 hrs apart, or two clinical exams, EEG and blood flow study. * Age \> 1 year to 18 years: Two clinical exams 12 hrs apart, confirmatory study (Optional) *

Answer 64

* Loss of vasomotor control leads to a hyperdynamic state. * Cardiac arrhythmias * Loss of respiratory function * Loss of temperature regulation --\> Hypothermia * Hormonal imbalance --\> DI, hypothyroidism

Answer 65

* Maintain SBP and PaO2\> 100mmHG * maintain HR and Urine output \< 100 BPM

Answer 66

Massive release of catecholamines, aka “autonomic storm”

Answer 67

* Fluid Bolus – NS or LR ((Followed by MIVF (maitenance IV fluids) NS or .45 NS)) * Consider colloids * Dopamine: increase contractility of the heart and promote vasoconstriction * Neosynephrine: increase contractility of the heart and promote vasoconstriction * Vasopressin: helps with urine output * Thyroxine (T4 protocol)

Answer 68

* Low dose shown to reduce inotrope use * -Plays a critical role in restoring vasomotor tone * Vasopressin Protocol - 4 unit bolus IVP - 1- 4 u/hour – titrate to keep SBP \>100 or MAP \>60

Answer 69

* Treatment is aimed at correcting hypovolemia * Desmopressin (DDAVP) 1 mcg IV, may repeat x 1 after 1 hour. * Replace hourly U.O. on a volume per volume basis with MIVF to avoid volume depletion * Leads to electrolyte depletion/instability monitor closely to avoid hypernatremia and hypokalemia * Goal is UOP 1-3 ml/kg/hr * Rule of thumb – 500 ml UOP per hour x 2 hours is DI * Severe cases – Notify OPC. Assess clinical situation.

Answer 70

Hypokalemia -If K+ \< 3.4 – Add KCL to MIVF (anticipate low K+ with DI & T4 administration) Hypernatremia -If NA+ \>155 – Change MIVF to include more free H20, ----Free H20 boluses down NG tube (this is often the result of dehydration, NA+ administration, and free H20 loss 2o to diuretics or DI) Calcium, Magnesium, and Phosphorus -Deficiencies here common…often related to polyuria associated with osmotic diuresis, diuretics & DI.

Answer 71

Monitor temperature continuously - NO tympanic, axillary or oral temperatures. Central only. - Place patient on hypothermia blanket to maintain normal body temperature - In severe cases (\<95 degrees F) consider: - warming lights - covering patient’s head with blankets - hot packs in the axilla - warmed IV fluids - warm inspired gas

Answer 72

* SBP 90-110 mmHg * U/O 1-3 cc/kg * HR 60-140 * PAWP (pulmonary artery wedge pressure) 7-12 mmHg * Serum electrolytes WNL * CBC and coags WNL * SPO2 \>95% * PaO2 90-110 * pH 7.35-7.5 * PCO2 25-45 * PF ratio \>300

Answer 73

* originate in cerebral cortex * -project downward * -result in skeletal muscle movement * -injury: spastic paralysis

Answer 74

* originates at each vertebral level * -project to specific parts of the body * -results in movement/sensation * -injury=flaccid paralysis

Answer 75

involuntary response to a stimulus without direct input from the brain

Answer 76

_-primary_: right when the injury happens, immediate injury to spinal cord -_secondary_: physiological response to the trauma: ischemia, hypoxia, hemorrhaging, edema

Answer 77

* due to loss of vasomotor tone * -SNS loss results in arasympathetic dominance with vasomotor failure * -loss of SNS innervation causes peripheral pooling and decreased cardiac output * -hypotention and bradycardia * -orthostatic hypotension and poor temperature control (poikilothermic)

Answer 78

* one of the first signs that spinal shock is resolving * -hyperflexia of foot * -test by flexing leg at knee and quickly dorsiflex the foot * -rhythmic oscillations of foot agains hand

Answer 79

* after spinal shock: * -motor deficits:spastic paralysis below level of injury * -sensory: loss of all sensation perception * -autonomic deficits: vasomotor failure and spastic bladder

Answer 80

* injury to the center of the cordd by edema and hemorrhage * -motor weakness and sensory loss in all extremities * -upper extremities affected more

Answer 81

hemisection of cord - ipsilateral paralysis - ipsilateral superficial sensation, vibration and proprioception loss - contralateral loss of pain and temp perception

Answer 82

* injury to anterior cord * -loss of voluntary motor, pain, and temp perception below injury * -retains posterior column funtion (sensations of touch, position, vibration)

Answer 83

* least frequent syndrome * -injury to the posterior (dorsal) columns * -loss of proprioception * -pain, temp, sensation, and motor function below the level of the lesion remain intact

Answer 84

* clonus medullaris: injury to the sacral cord (conus) and lumbar nerve roots * -cauda equina: injury to the lumbosacral nerve roots * -result: are flexic (flaccid) bladder and bowel, flaccid lower limbs

Answer 85

spastic paralysis

Answer 86

flaccid paralysis and muscle atrophy

Answer 87

c1-c3 injury

Answer 88

dependent on ventilator

Answer 89

* transport with c-collar * -assess abc's * iv for life line * ng to suction * foley

Answer 90

* pt started within 4, treated for 24 hours of solumedrol * -within 8 hours, treated for 48 hours * -to decrease edema around spinal cord

Answer 91

* vasopressors to maintain perfusion * -histamine H2 blockers to prevent stress ulcers * -anticoagulants * -stool softeners * -antispasmodics

Answer 92

LOC and pupils, may have indirect SCI from head injury - respiratory status-phrenic nerve (diaphragm) and intercostals, lung sounds - vital signs - motor - sensory - bowel and bladder function

Answer 93

c6: thumb t4: nipple t10: naval

Answer 94

* SCI above T6 * -Results in loss of normal compensatory mechanisms when sympathetic nervous system is stimulated * -Life threatening-if goes unchecked BP an result in cerebral hemorrhage * -Vasodilation symptoms above SCI * -Vasoconstriction symptoms below SCI * -the cause of SNS stimulation

Answer 95

* elevate HOB-causes orthostatic hypotention * -indentify cause/alleviate if full bladder/cath, if skin/ remove pressure, if full bowel/ empty, etc * -remove support hose/abdominal binder * -monitor BP- can get \>300 S * -Give PRN medication to lower BP * -If above not effective-call physician

Answer 96

* sensory root or nerve usually affected: pain, parenthesis, or loss of sensation * -motor root or nerve may be affected: paresis or paralysis * -Manifestations: depend on what nerve root, spinal nerve is being compressed-which dermatomes * -radiculopathy: pathology of the nerve root

Answer 97

* postural changes * -urinary.male sexual function changes * -paresis or paralysis * -paresthesisa * -numbness * -muscle spasms * -absent cord relexes

Answer 98

* -pain-neck, shoulder, anterior upper arm to thumb * -absent/diminished reflexes to the arm * -motor changes-paresis or paralysis * -sensory- paresthesias or pain * -muscle spasms

Answer 99

* Bed rest with firm mattress: log roll, side lying position with knees bent and pillow between legs to support legs * -avoid flexion of the spine: brace/corset, cervical collar to provide support * -medication: non-narcotic analgesiscs, anti-inflammatory, muscle relaxants, antispasmodics, tranquilizers * -heat and cold, massage therapy * -weight loss * -TENS units

Answer 100

remove portion of the lamina to relieve pressure to get the herniated nucleus puplosus that is protruding

Answer 101

enlargement of the bony overgrowth at the opening which is compressing the nerve

Answer 102

use of electron microscope through a small incision to remove a portion of the HNP that is displaced

Answer 103

* sensory/motor assessment -care not to injure op site * -assess for csf drainage or bleeding from op site * -encourage turn (log roll, cough, deep breathe) * -assess for postural hypotension: especially if client was on bed rest for several days/weeks prior to surgery * Anterior cervical: assess injury to carotid, esophagus, trachea, laryngeal nerve, respiration, neck size, swallowing and speech * Lumbar: asses bowel sounds, voiding, minimize stress of post op site: glat with pillow between knees, log rolling, etc.

Answer 104

* post surgery the individual may have similar pain as pre-op due to lack of resiliency of the spinal nerves to 'bounce' back quickly * -donor site (iliac crest) may cause more pain than laminectomy * -individual may be in pain-spasm-pain cycle, therefore may need both antispasmodic as well as analgesic

Answer 105

arise from neural tissues of the spinal cord

Answer 106

arise from tissues outside the spinal cord may be benign or malignant

Answer 107

from the nerve roots or meninges in subarachnoid space

Answer 108

from the epidural tissue or vertebra

Answer 109

originating in the spinal cord or meninges

Answer 110

metasteses from other parts of the body

Answer 111

in the thoracic region

Answer 112

* paresis and spasticity of one leg then the other * -pain back and chest, not relieved by bedrest * -sensory changes * -babinski reflex * -bowel, bladder dysfunction

Answer 113

* symptoms depend on the anatomical level of the spinal column, the anatomical location, the type of tumor and spinal nerves affected * \*PAIN that is NOT relieved by bed rest is the most common presenting symptom * -sensory and motor

Answer 114

* The cardiac output pushes the blood through the vascular system. * Cardiac output (CO) is calculated by multiplying the heart rate (HR) by the stroke volume (SV). * Stroke volume is the volume of blood pumped out of the heart with each heartbeat. * If the stroke volume drops, the body will compensate by increasing the heart rate to maintain cardiac output. * This is known as compensatory tachycardia. * heart rates greater than 150 bpm actually drop stroke volume

Answer 115

* he amount of stretch on the cardiac myofibril at the end of diastole. * When the ventricle is at its fullest

Answer 116

Fluid volume

Answer 117

* describes the relationship of preload to cardiac output * As preload (fluid volume) increases, cardiac output will also increase until the cardiac output levels off. * If additional fluid is added after this point, cardiac output begins to fall.

Answer 118

Not measured directly...instead measured by physical assessment of fluid volume

Answer 119

* Poor skin turgor * Dry mucous membranes * Low urine output * Tachycardia * Thirst * Weak pulses * Flat neck

Answer 120

* distended neck veins * crackles in the lungs * Bounding pulses

Answer 121

the resistance that the ventricle must overcome to eject its volume of blood.

Answer 122

to assess the patient for signs of insufficient preload (e g volume or blood loss)

Answer 123

vascular resistance

Answer 124

* blood viscosity * aortic compliance * valvular disease.

Answer 125

the afterload increases

Answer 126

the afterload decreases

Answer 127

volume, until you know if its a stretch issue

Answer 128

ncreases myocardial work and decreases stroke volume.

Answer 129

* cool clammy skin * capillary refill greater than 5 seconds * narrow pulse pressure.

Answer 130

myocardial work and results in increased stroke volume.

Answer 131

* warm flushed skin * Bounding pulses * wide pulse pressure

Answer 132

hypotension

Answer 133

the inherent ability of the cardiac muscle to contract regardless of preload or afterload status.

Answer 134

exercise, catecholamines, and positive inotropic drugs

Answer 135

by hypothermia, hypoxemia, acidosis, and negative inotropic drugs.

Answer 136

valuation of effectivess is whether or not the intervention was successful in improving tissue perfusion.

Answer 137

* Assessment of cardiovascular function (complicated MI, Cardiogenic shock, papillary muscle rupture) * Peri-operative monitoring of surgical patients with major systems dysfunction * Shock of all type (septic, hypovolemic, any shock that is prolonged or origin is unknown) * Assessment of pulmonary status * Assessment of fluid status (dehydration, hemorrhage, GI bleed, burns) * Therapeutic indications (cardiac pacing ) * Diagnostic indications (pulmonary hypertension)

Answer 138

25-45mL/M2

Answer 139

60-100mm Hg

Answer 140

20-30mm Hg

Answer 141

5-15 mm Hg

Answer 142

8-12 mm Hg

Answer 143

900-1300 dynes.sec.com

Answer 144

* Using proper technique when obtaining blood from an intra-arterial catheter: * Maintain aseptic technique for any line access and use standard precautions * Withdraw blood gently and slowly from the line * Waste the first 5mL * Flush the collection port to prevent clot formation and bacterial colonization * Maintain sterility of the system; place a new sterile cap over the sample port * Fast-flush the system to the patient for no more than 3 seconds at a time * Do not use a syringe to manually flush arterial catheters * Manual flushing with a syringe generates enough pressure that the injected fluid can invade the cerebral circulation

Answer 145

* Measure right atrial pressure (RAP) * Same as Central Venous Pressure (CVP) * 1-7 mm Hg * Assess blood volume; reflects preload to the right side of the heart * Assess right ventricular function * Infusion site for large fluid volume * Infusion site for hypertonic solutions

Answer 146

Widespread use in critically ill patients Remains controversial

Answer 147

* CVP * PAP * PAOP * Cardiac Index * SVO2

Answer 148

* The proximal port which is used for central venous pressure monitoring * The distal port which measures pulmonary artery and pulmonary artery wedge pressure * The balloon port with 1.5ml special syringe for measurement of pulmonary artery wedge pressure * The thermistor connector to assist with cardiac output measurement

Answer 149

* ny Factor that increases PVR * Pulmonary Embolism * Hypoxemia * COPD * ARDS * Sepsis * Shock * Primary Pulmonary Hypertension * Restrictive Cardiomyopathy * Significant left-to-right shunting

Answer 150

* Any Factor that increases pulmonary artery systolic pressure * Intravascular volume overload * Left Heart Dysfunction * Mitral Stenosis/Regurgitation * Aortic Stenosis/Regurgitation * Decreased LV Compliance * Cardiac Tamponade/Effusion

Answer 151

* Hypovolemia * Severe Tricuspid or Pulmonic Stenosis

Answer 152

* Left Heart Dysfunction * Mitral Stenosis/Regurgitation * Aortic Stenosis/Regurgitation * Decreased Left Ventricular Compliance * Intravascular Volume Overload * Tamponade/Effusion * Obstructive Left Atrial Myxoma * Restrictive Cardiomyopathy

Answer 153

Hypovolemia Pulmonary Embolism

Answer 154

Measuring Cardiac Output Inject fluid in to r atrium, fluid migrates through, change in temp over time and tells you how well the heart is contracting

Answer 155

* Air in line or stopcocks * Precipitates * Leaking at site * Increasing resistance * Condition of entrance sites

Answer 156

* Cardiac Index (CI) * Stroke Volume (SV) – CO/HR * Stroke Volume Index (SVI) – CI/HR * MAP- SBP + 2(DBP)/3 * Systemic Vascular Resistance (SVR)- (MAP-RAP) x 80/CO * Systemic Vascular Resistance Index (SVRI) - (MAP-RAP) X80/CI

Answer 157

* Dopamine * Dobutamine * Epinephrine * Phenylephrine * Norepinephrine * Vasopressin

Answer 158

* Dose dependent receptor activation * Low dose (1-5mics) - increases blood flow via dopamine receptors in renal, mesenteric, cerebral circulation * Intermediate dose (5-10mics) - increases cardiac output via - receptors * High dose(\>10mics) - progressive vasoconstriction via -receptors in systemic and pulmonary circulation * In vivo, receptor effects are often mixed * Tachyarrhythmias are most common complication * Low dose dopamine has no proven renal benefit * Significant immunosuppressive effects through suppression of prolactin from hypothalamus

Answer 159

* Synthetic catecholamine generally considered the drug of choice for severe systolic heart failure * Increases cardiac output via Beta 1 -receptor and causes vasodilation via Beta 2 -receptor * Inotropic and chronotropic effects are highly variable in critically ill patients * Data supports use in septic shock when cardiac output remains low despite volume resuscitation and vasopressor support

Answer 160

* The most potent adrenergic agent available * Potency and high risk of adverse effects limit use to cardiac arrest (and specific situations after cardiac surgery) * Primarily Beta receptor effects at low doses and alpha receptor effects at high doses * Arrhythmogenic

Answer 161

* Relatively pure beta adrenergic agonist * Minimal inotropic effects; often causes reflex bradycardia * Consistently decreases cardiac output * Increased propensity to cause ischemic complications * Be wary in the OR

Answer 162

* More potent vasoconstrictor than dopamine; some inotropic effect * Potent alpha 1 stimulation * Moderate beta 1 activity * Minimal beta 2 activity

Answer 163

* Acts on vascular smooth muscle via V1 receptors, independent of adrenergic receptors * Considered replacement therapy * Traditionally not titrated * Significant splanchnic vasoconstriction

Answer 164

* A flexibile catheter is inserted into the femoral artery and passed into the descending aorta. * Correct positioning is critical in order to avoid blocking off the subclavian, carotid, or renal arteries. * When inflated, the balloon blocks 85-90% of the aorta. Complete occlusion would damage the walls of the aorta, red blood cells, and platelets.

Answer 165

* Explain procedure to patient * Assemble all equipment * Set up all monitoring lines aseptically * Prime all IV tubing and transducer flush lines (Pressure Bag @ 300 mmHg) * Connect PAC cable to monitor and attach to transducer * Connect CVP cable to monitor and attach to transducer * Check PAC packaging for to ensure sterility/expiration date * Zero transducers (mid axillary) * Place monitor in wedge/insertion mode (scale should be 30-60) * Turn on and set continuous cardiac monitor/Svo2 monitor for insertion (make sure previous patient data is erased)

Answer 166

* Position patient for insertion (flat for femoral, Trendelenburg for subclavian or jugular) * Assist with creating a sterile field * With the assistance of the physician, open PAC and connect transducers to the distal and proximal lumens * Connect the IV line to the medication port * Connect the cardiac output cable and Svo2 cables * Remove the 1.5 ml syringe and connect it to the syringe port * Zero catheter while still in package * Inflate air into the balloon to assure balloon integrity prior to insertion * After physician places sterile sheath over catheter, waveform presents should be assessed on the monitor (usually a small shake of the catheter itself will confirm) * Once physician inserts and advances the catheter to right atrium, he will request that the RN inflate the balloon * If for any reason during floatation of a PAC the physician wishes to withdraw the catheter, the balloon must be deflated * During floatation of a PAC the right atrial (CVP), right ventricle, pulmonary artery and pulmonary artery wedge pressure (PAWP) waveforms/pressure tracings should be noted and printed

Answer 167

* Make sure that PAC cap is in the lock position so catheter will not migrate * Secure catheter to patient with tape * Apply occlusive dressing * Set high and low alarms on monitor as appropriate for patient * Double check to assure that physician has disposed of all sharps * Double check to see that Chest X-ray was ordered

Answer 168

* Make sure the balloon is COMPLETELY deflated. Pull back extra, then lock. * When removing, if piece of catheter is left in patient, IMMEDIATELY put patient in trendelenburg and place pt on left side

Answer 169

Electrolyte Normal Range Sodium (Na+) 135-145 mEq/L Potassium (K+) 3.5-5 mEq/L Chloride (Cl-) 100-110 mEq/L Calcium (Ca2+) 8.5-10.0 (total) mg/dL Phosphorus (Po4-) 2.5-4.5 mg/dL Magnesium (Mg2+) 1.8-2.5 mEq/L

Answer 170

* Increases the permeability of collecting tubule cells to water. * Increases water, but not electrolyte reabsorption

Answer 171

* Converts angiotensin into angiotensin I which is then converted to angiotensin II * Angiotensin II causes vasoconstriction and the release of aldosterone (important for na+ reabsorption in the distal tubules)

Answer 172

* Promotes sodium reabsorption in the distal tubules * Leads to increase water absorption

Answer 173

* Creatinine/ Creatinine Clearance * Estimated Creatinine Clearance formula * (140-age) X weight in kg/ (Plasma Creatinine mg/dL) X 72 * Blood Urea Nitrogen: increases in renal failure, GI bleed, dehydration, trauma. * 8-20 mg/dL (normal) * BUN/Creatinine ratio: * Based on serum creatinine * BUN:Creatinine – 10:1 (normal) * -when ratio goes down: liver failure, fluid volume overload, * -ratio up: dehydration, catabolic states or high protein diets * Osmolality: Up= kidneys not filtering properly * Normally 280-290 * Uric Acid: elevated=kidneys not filtering uric acid properly * 2-8.5 mg/dL * Hemoglobin & Hematocrit: decrease shows renal problems * Men 13.5-17.5 g/dL & 40-52% * Women 12-16 g/dL & 37-48%

Answer 174

* Hypotention * Hypovolemia * Decrease CO * Dehydration * Vascular Disease * Renal Vein Thrombosis * DM

Answer 175

* Nephrotoxic episodes * Infection * Systemic inflammation * Injured red blood cells * Hemolytic blood transfusion reactions * Glomerular diseases (systemic lupus, glomerulonephritits) * Rhabdomylolysis

Answer 176

* Medication that interferes with normal bladder emptying. * Benign prostatic hypertrophy (BPH) * Prostate cancer * Ovarian cancer * Obstruction of a urinary catheter * Renal calculi * Bladder/pelvic neoplasms * Urethral strictures

Answer 177

* Pre-Renal: occurs before you get to the kidneys. Hypovolemia, blockages. Can lead to Intra-Renal. * Intra-Renal: Occurs inside the kidney. Metabolites collecting and causing damage, trauma, toxicity, etc. * Post-Renal: Involves ureters, prostate, and bladder.

Answer 178

Causes: * Contrast media * Diuretics (Furosemide) * Heavy metals (mercury, gold lead) * Ibuprofen * Organic chemicals or solvents * Nephrotoxic antibiotics (Gentamycin/Piperacillin) * ACE Inhibitors Aggravators: * Amiloride * Any medication containing magnesium tetracycline * Cisplatin * Aspirin * Lithium * Nonsteriodal anti-inflammatory agents * Spironolactone

Answer 179

* Decreased urine output (urine may be pink or reddish in color) * Edema (face, arms, legs, feet eyes) * Flank pain/Pelvic pain * Poor appetite (nausea, vomiting) * Bitter or metallic taste in mouth * Dry itchy skin * Easy bruising * Fatigue * Seizures/LOC * Shortness of breath * Arrhythmias * Sudden weight gain

Answer 180

_Onset Phase_: from hours to a day * -Renal flow at 25% of normal * -Oxygenation to the tissue at 25% of normal * -Urine output at 30 ml (or less) per hour * -Urine sodium excretion greater than 40 mEq/L. _Oliguric Phase_: lasts 8-14 days. Tubular wall damage * -Significant decrease in GFR * -Increase BUN/Creatinine * -Electrolyte Imbalance * -Metabolic Acidosis _Diuretic Phase_: Occurs if problem corrected. Lasts 7-14 days. * -Increase in GFR * -Urine output as high as 2-4 L/day * -Renal cells that cannot concentrate urine _Recovery Phase_: lasts months to a year. Cells start having some recovery and generation * -GFR returns to70-80% Baseline * -Renal Tubules begin to function * -Fluid/ electrolyte balance returns

Answer 181

* Address underlying cause * Maintain intravascular volume: monitoring how much output and dialyzing them or giving diuretics to get the volume out * Maintain MAP: want it above 70. For elderly person, 90-100. * Discontinue nephrotoxic agents * Correct Acidosis * Correct hemolytic issues * Correct electrolyte imbalances * Strict I & O’s and daily weights * Fluid and diet restrictions

Answer 182

Furosemide (Lasix)

Answer 183

N-acetylcysteine (Mucomyst)

Answer 184

Hemodialysis * Peritoneal dialysis: Not used in ARF * Hemodialysis. Good for quick removal of water and toxins CRRT * Less likely to cause hypotension: Hemodynamic stability * Correction of metabolic acidosis. Quicker kidney recovery time. Correction of malnutrition. Solute removal

Answer 185

* Cleanse with Soap and water daily * Limit contact with site * Assess for signs of infection * No BP or needle sticks to arm * Assess site for Thrill/bruit * Patient teaching to avoid pressure to site \*wait 1-3 months to use

Answer 186

* Slow Continuous Ultrafiltration (SCUF): 100-300 ml taken off every hour. Good for removing fluid, but not good for uremia. * Continuous Venovenous Hemofiltration (CVVH): 7-30 liters removed every 24 hours. Can be used for convection. * Continuous Venovenous Hemodialysis (CVVHD): Used a lot. Good at getting fluid off, but not the moderate sized molecules * Continuous Venovenous Hemodiafiltration (CVVHDF): Good for small and moderate sized molecules. Run continuously, low rate, over 24 hours. Best type for acute renal failure pt.

Answer 187

Severe Metabolic Acidosis common in AKI ph?

Answer 188

* Treatment * Alkaline Medications * Sodium bicarbonate tablets) * Sodium bicarbonate??? * Used in severe acidosis. Many complications. Now try to not give this bc increases sodium levels and osmolarity. * Hemodialysis

Answer 189

* Alteration in urinary elimination * Fluid volume deficit * Fluid volume overload * Altered nutrition (less than bodily requirement) * Potential for impaired skin integrity * Decreased cardiac output * Activity intolerance

Answer 190

* Maintenance fluids * Crytalloids * D5W * Normal Saline * .45Normal Saline * LR * Colloids * Albumin * Hetastarch * Dextran * Fluid Volume Excess * Loop Diuretics (Lasix & Bumex) * Osmotic Diuretics (Mannitol)

Answer 191

* Recognize that patients with pre‐existing renal impairment are at higher risk of developing further renal insufficiency—treat and monitor accordingly * Temporarily withhold nephrotoxic (especially ACE‐I, ARBs, NSAIDs) and diuretics (to prevent dehydration) when patients become unwell—either in the community or in hospital * Ensure that patients remain adequately hydrated, to maintain renal perfusion * Remember to monitor renal function after starting, or increasing the dose, of ACE‐I or ARBs (check one to two weeks later) * Where necessary, adjust drug doses in patients with renal impairment * Monitor drug levels when using aminoglycoside (gentamicin) and/or glycopeptide (vancomycin) antibiotics—and adjust dose accordingly * Hydrate the patient and consider using N‐acetyl cysteine before procedures entailing radiological contrast media

Exam 2 review sheet Flashcards

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