Exam III - Sepsis and Neuro Flashcards
(107 cards)
1
Q
LOC is composed of _______ and _________
A
Alertness and Orientation
2
Q
Lowest LOC
A
arousal/alertness
3
Q
GCS stands for ______________
A
Glascow-Coma Scale
4
Q
Lowest score on the GCS (even if dead)
A
3
5
Q
GCS does not account for __________ or inability to ___________
A
Lateralization (one sided responses) or inability to speak
6
Q
If you are assessing verbal commands, do NOT ________
A
Touch the patient (or model the command)
7
Q
Two types of posturing are __________ and _________
A
Decerebrate and decorticate
8
Q
Pupil function assesses both __________ and ________ pathways
A
Sympathetic and parasympathetic
9
Q
“If you code me, ____ me”
A
cool
10
Q
Cluster breathing
A
irregular, gasping
11
Q
Cheyne-Stokes breathing
A
very fast then very slow (torsades of breathing)
12
Q
Apneustic breathing
A
prolonged inhale/exhale with long pauses
13
Q
Ataxic breathing
A
irregular deep then shallow with apneic periods
14
Q
Cushing Triad
A
Increased pressure on the brainstem cause bradycardia, hypertension, and wide pulse pressure
15
Q
CVA stands for ____________________ and is also known as _______
A
Cerebrovascular attack AKA stroke
16
Q
TIA stands for __________________
A
Transient ischemic attack AKA “mini stroke”
17
Q
Modifiable risk factors for stroke
A
- Uncontrolled hypertension
- (HTN)-single most modifiable factor
- Obesity
- Atrial fibrillation (25% of all strokes)
- Hyperlipidemia
- Smoking
- Diabetes mellitus
- Drug/alcohol abuse
- Poor diet/exercise
- Use of oral contraceptives
18
Q
Non-modifiable risk factors for stroke
A
- Age
- Gender
- Ethnicity/race
- Heredity/family history
19
Q
Types of stroke
A
Ischemic ----Thrombotic ----Embolic Hemorrhagic ----Intracerebral ----Subarachnoid
20
Q
Ischemic stroke
A
Inadequate blood flow to brain
Subtypes: Thrombotic and Embolic
See slide 17
21
Q
Hemorrhagic stroke
A
Bleeding into brain tissue
Subtypes intracerebral or subarachnoid
See slide 17
22
Q
Right sided stroke patients are a ________ concern
A
SAFETY - typically unaware that they have a deficit
23
Q
Left sided stroke patients are at greater risk for _______
A
Depression - typically aware of deficit
24
Q
FAST - what if unknown time?
A
Ruled out for tPA
25
FAST
****Emphasized as test question
| Face, arms (have them close their eyes), speech, time
26
Blood pressure and stroke
Allow BP to be high for perfusion to the brain
27
Stroke nursing care
Based on deficit:
- maintain airway
- aspiration prevention
- elimination assistance
- seizure precaution
- promote communication
- assist with mobility & ADLs
- maintain skin integrity
- referral to OT/PT/ST/rehabilitation
- health promotion/education
- emotional support (depression screening***)
- monitor for impulsivity***
*** emphasized
28
Ischemic Stroke Tx
Stent
TPA – strict time rules & contraindications***
Long term anticoagulants***
***emphasized
29
Hemorrhagic Stroke Tx
Resection
Aneurysm clip
Evacuation of hematoma
30
Assessment of a stroke patient (head to toe)
Neuro:
- Stroke Scale
- LOC – Q1hr focused neuro assessment
Cardio:
- Co-morbidities may increase incidence of cardiac dysfunction
- Hypertension is common (and often preferred) to increase blood flow to the brain
Respiratory:
- Muscle weakness predisposes stroke patients to obstruction risk & aspiration pneumonia
GI / Nutrition:
- Constipation is common – if stool is liquid assess for impaction
- Additional tools for eating (other than a traditional fork)
- Assessment by a ST if available & Nursing bedside swallow assessment
- PEG tube if needed
Urinary:
- Loss of bladder control – inability to void or incontinence
Musculoskeletal System:
- ROM & positioning to prevent joint contractures and muscle atrophy
Integumentary:
- Increased risk of skin breakdown
31
What else can you do to help a stroke patient?
EMPATHY
- Assess for coping
- Ask what helps *them*
- Try to stand where they can see you
- Be patient and allow time for communication
32
Post-acute care
Begin planning transition early – as soon as patient is stable
Placements include:
Home (respite care may be available)
Rehab - intermediate or ambulatory ($$$)
LTC – may be permanent ($$$)
33
Monro-Kellie Doctrine/Hypothesis
Brain
Blood
CSF
If the VOLUME of 1 of one increases, then a reciprocal decrease in one or both of the others must occur (increase in ICP)
34
Using Monro-Kellie Hypothesis, what would happen in a hemorrhage?
Brain and CSF become compressed
35
Using Monro-Kellie Hypothesis, what happens if the brain swells?
Blood and CSF become compressed
36
What two things does the brain need?
Sugar and Oxygen
37
If no medical interventions are provided, the brain will __________
Herniate
38
Normal Intracranial Pressure
0-15 mm Hg
39
Diagnostic Criteria for ICP
20 mm Hg or > persisting for 5 minutes or longer
40
Cerebral Perfusion Pressure (CPP)
MAP - ICP = CPP
41
Normal CPP
60-100 mm Hg, keep at 70 or higher in those with abnormal brain pathology
42
If the brain herniates, this is an indicator of _____________
brain death
43
What is the single most important factor in maintaining brain health?
CPP
44
An increase in ICP or decrease in CPP will result in decreased ________
Cerebral blood flow (cutting off sugar and oxygen)
45
The EVD should be leveled (zeroed) to the _______
Tragus of the ear
*** Emphasized
46
EVD uses Saline without _______
Preservatives
Must use sterile NS flush
*** Emphasized as test question
47
Fluid filled EVD system
- Absolute sterile setup
- Most common
- Similar to hemodynamic monitoring systems
48
Increased ICP nursing care positioning
Positioning
- HOB elevation supine and no more than 30 degrees
- Neutral head position
- Turn side to side
- ------Watch for return to baseline CPP
49
Mannitol
- For edema
- Bolus or push
- Should see decrease in ICP within 15 minutes
——Side effects: MASSIVE diuresis (dehydration), tachycardia, hypotension
50
Normal HR
60-100
51
Normal BP
S: 100-130
D: 60-90
52
Normal CO (cardiac output)
4-8 L/min
53
Normal SVR
800-1200
54
Normal PVR
<250
55
Normal CVP
2-8 mmHg
56
Normal SvO2
60-80%
57
Define Sepsis
Systemic response to infection
58
Define Severe Sepsis
Sepsis with organ dysfunction
59
Define Septic Shock
Sepsis with marked hypotension despite adequate fluid resuscitation
60
Sepsis from non-infection (SIRS)
```
Pancreatitis
Tissue Ischemia
Trauma
Burn
Drug Reaction
Auto-immune
```
61
SIRS
Systemic Inflammatory Response Syndrome
62
Positive signs of SIRS
```
Two of these:
Temp (fever or hypothermia)
HR above 90
RR above 20
WBC <4k or >12k
Glucose above 140 in non-diabetic
```
AND
A known source of infection or one of the non-infection criteria (pancreatitis, burn, auto-immune, etc)
***emphasized
63
Blood cultures are drawn as ___ bottles, ___ sets and must be drawn from ___ site(s)
4 bottles, 2 sets (anaerobic and aerobic each set)
Must be from two sites
**** Only one set can be taken from a central line
***emphasized as exam question
64
How many mL of fluid do you give as resuscitation for someone with sepsis?
30mL/kg within 1 hour
65
One hour bundle for sepsis
- Measure Lactate (greater than 4 is critical)
- Obtain Blood Cultures x2
- Initial fluid resuscitation 30ml/kg
- Begin brought spectrum antibiotics (Zosyn & Levaquin)
- Closely monitor hemodynamics
- Repeat Lactate at 2 hour mark
*** Emphasized
66
Six hour bundle for sepsis
- Vasopressors for hypotension persisting after fluids (titrate to maintain MAP above 65)
- Place CVC with monitoring (keep CVP between 8 and 12 or 12 to 15 if vented, keep SCVO2 above 70%)
- Keep urine output greater than 0.5ml/kg/hr
- Redraw Lactate Q4 hrs
- If vented, ensure Vt at 6ml/kg IBW, monitor FiO2/PaO2 ratio, assess for ARDS/abdominal compartment syndrome (3rd spacing)
67
Define Shock
- Life-threatening response to alterations in circulation
- Inadequate tissue perfusion
- Imbalance between cellular oxygen supply and demand
68
Stages of shock
Shock is categorized into four overlapping stages:
- Initial
- Compensatory
- Progressive
- Refractory
69
Stage I of Shock
Initial
- Hypo-perfusion: inadequate delivery or extraction of oxygen
- Metabolism changes at cellular level from aerobic to anaerobic
- Lactic acid builds up and must be removed by liver
- Process requires O2, unavailable due to decreased tissue perfusion
70
Stage II of Shock
Compensatory
- Sustained reduction in tissue perfusion
- Initiation of compensatory mechanisms
- If cause corrected, patient recovers, if not patient enters progressive stage
71
Stage III of Shock
Progressive
- Failure of compensatory mechanisms (leakage of protein into interstitial space, increase of systemic interstitial edema)
- Distinguishing features of decreased cellular perfusion and altered capillary permeability
- Profound cardiovascular effects (hypo-perfusion, vasoconstriction)
72
Stage IV of Shock
Refractory
- Prolonged inadequate tissue perfusion
- Exacerbation of anaerobic metabolism
- Accumulation of lactic acid and waste products
- ----Unresponsive to therapy
- ----MODS
73
Accumulation of lactic acid and waste products results in:
- Dysrhythmias
- Pulmonary edema
- Respiratory Distress Syndrome (RDS)
- Cerebral changes
- Renal decreased GFR
- Contributes to multiple organ dysfunction and death
74
Shock assessment initial stage v late stage
Initial stage: anxiety, restlessness, elevated BP, rapid and deep breaths (Kussmaul), decreased renal function, nausea, Decreased bowel sounds, distension, constipation
Late stage: Coma, loss of peripheral pulses, low BP, Shallow respirations, Poor gas exchange
75
Absolute hypovolemic shock
Blood loss
76
Relative hypovolemic shock
Dehydration
77
Distributive Neurogenic Shock HR
Severe bradycardia and hypotension
78
Risk factors for death by trauma
- Co-morbities
- Hemorrhage
- Low initial GCS
- Over age 60
- Blood thinners
79
Define Trauma
Injury to living tissue caused by extrinsic agent. Regardless of mechanism of injury (MOI).
80
Blast trauma
Unique combination of blunt and penetrating trauma
81
Primary Survey of trauma patient
```
A—Airway (and alertness w/simultaneous cervical spinal stabilization
B—Breathing (and ventilation)
C—Circulation (and control hemorrhage
D—Disability (neurologic status)
E—Exposure (and environmental control)
F—Full set of VS (family presence)
G—Get adjuncts
----L—Lab studies (ABGs, Blood Type)
----M—Monitor (cardiac)
----N—Naso/Orogastric tube
----O—Oxygenation and Ventilation
----P—Pain assessment and management
```
82
Secondary survey of trauma patient
H—History (and Head-to-toe)
| I—Inspect posterior surfaces
83
Triage for mass casualty (AVPU)
Awake - Green
Verbally responsive - Yellow
Painful responses - Orange
Unresponsive - Red
84
Trauma Phases of Care
- Resuscitation
- Secondary Survey
- OR (surgical)
- ICU (CCU)
- Ortho
85
Trauma Triad of Death
Hypothermia
Metabolic Acidosis
Coagulopathy
86
Criteria for brain death
- No movement or posturing. Seizures, shivering or response of any sort
- No pupillary reflex
- No corneal, oculocephalic, cough or gag reflex
- No oculovestibular reflex
- No HR increase with atropine
- No respiratory effort
Must be confirmed by two separate assessors 6 hours apart
87
Types of trauma
Penetrating, blunt, and blast
***Emphasized as test question
88
What percentage of strokes are caused by Afib?
25%
89
Which statement by the nurse is INCORRECT about TIA - Transient Ischemic Attack?
1 - A TIA is a transient episode of neurologic dysfunction without acute infarction of the brain
2 - Symptoms usually last less than an hour
3 - S/S of TIA depend on location of dysfunction but mimic CVA
4 - 50 percent of patients who have a TIA will have a stroke
50 percent of patients who have a TIA will have a stroke
90
```
Which risk factor for stroke is not modifiable?
1 - Hypertension
2 - Alcohol Intake
3 - Family History
4 - High Fat Diet
```
3 - Family History
91
The nurse explains to a TIA patient that he is scheduled for a CTA this afternoon, which statement best describes the rationale for the exam?
1 - The CTA will help predict Mr. Lewis's risk for stroke
2 - The CTA will guide treatment with medications
3 - The CTA will determine if the cause of the TIA was a blockage in the cerebral arteries
4 - The CTA is the standard treatment for TIA
3 - The CTA will determine if the cause of the TIA was a blockage in the cerebral arteries
92
What is the time limit for the administration of TPA?
4.5 hours
93
Contraindications for the use of tPA does not include: *
1 - Suspected internal bleeding within 3 months
2 - Unknown symptom onset
3 - Surgery within 14 days
4 - Current or suspected infection
4 - Current or suspected infection
94
At arrival to the unit, Mr. Lewis has a blood pressure of 178/100, the nurse understands which of the following is INCORRECT about BP in the acute phase of a CVA?
1 - Hypertension is not treated in the acute phase unless BP is above 220/120
2 - Patients must have BPs below 185/110 to receive fibrinolytics
3 - Hypotension in the acute phase of a CVA is more common than hypertension
4 - If warranted, IV antihypertensives are preferred treatments
3 - Hypotension in the acute phase of a CVA is more common than hypertension
95
Which of the following medication orders would the nurse question for the patient in the acute phase of a CVA? *
1 - Heparin 18units/kg/hr IV infusion
2 - Labetalol 1mg/min for SBP above 220
3 - Normal Saline 0.9% IV infusion 50mL/hr
4 - Dextrose 50% IV Push for BG less than 50mg/dL
1 - Heparin 18units/kg/hr IV infusion
96
Which of the following would NOT be included in the nurses plan of care for the patient having a CVA?
1 - Assessment and documentation of neurological status
2 - Assess patient's ability to swallow
3 - Ensure positioning to reduce risk of aspiration
4 - Delegate regulation of IV fluids to the UAP based on output
4 - Delegate regulation of IV fluids to the UAP based on output
97
```
Mr. Lewis had a right sided stroke, in addition to left sided weakness, the nurse can expect all of the following except?
1 - Perceptual deficits
2 - Cautious and slow movements
3 - Impaired time judgement
4 - Minimization of problems
```
2 - Cautious and slow movements
98
Increased ICP suctioning and oxygenation goals
Suctioning
- Only when necessary
- Preoxygenate
- Limit suction to 10 seconds
Adequate Oxygenation
- Goal: PaO2 > 80 mmHg
- Airway vigilance
- Mechanical ventilation
- ------Positive end-expiratory pressure (PEEP) – use with caution
99
Increased ICP CO2 management
Carbon Dioxide Management
- PaCO2 35-45 mm Hg (changes in CO2 increase ICP)
- Avoid hyperventilation
100
Increased ICP Diuretics and Fluid management
Diuretics
- Osmotic diuretics
- ------Reduce brain tissue volume (Mannitol, Hypertonic saline)
- Loop diuretics
- ------Reduce brain tissue volume
- ------Decrease CSF formation
Fluid Administration
- Optimized fluid administration with isotonic solutions
- Strict intake/output
- Goal: serum osmolality less than 320 mOsm/L.
- Colloids or blood products to restore volume
101
Increased ICP blood pressure
Blood Pressure
- Goal: MAP 70-90 mm Hg
- CPP: at least 70 mm Hg
- Avoid hypertension
- -----Increases cerebral blood volume
- -----Nicardipine
- Avoid hypotension
- -----Ischemia
- -----Vasopressors
102
Increased ICP metabolic demands
Metabolic Demands
- Temperature control
- ------Induced hypothermia (Goal: 34o – 35o C)
103
Increased ICP sedation
Sedation
- Benzodiazepines
- Propofol
- Analgesia
104
Increased ICP seizure prophylaxis
Seizure prophylaxis
| - Neuromuscular blockade
105
Septic shock vitals
```
HR - High
BP - Low
CO - initially high then very low
SVR - Very low
CVP - Low
O2 - Low
```
106
Hypovolemic shock vitals
```
HR - High
BP - Severely Low
CO - Low
SVR - Low
CVP - Low
O2 - Low
```
107
Cardiogenic shock vitals
```
HR - High
BP - Low
CO - Very Low (LV not pumping)
SVR - High
CVP - High
O2 - Low
```
