Final Exam Flashcards
(104 cards)
1
Q
How should all hemodynamic measurements be taken?
A
At phlebostatic axis with the HOB 45 degrees
2
Q
PVR (Pulmonary Vascular Resistance): Value
A
37 - 250 dynes
Right Afterload
3
Q
SVR (Systemic Vascular Resistance): Value
A
800 - 1,400 dynes
Left Afterload
4
Q
Cardiac Output (CO)
A
4 - 8 L/min
5
Q
Stroke Volume (SV)
A
50 - 100 ml/beat
6
Q
RA/CVP
A
2 - 6 mmHg
Right Preload
7
Q
Wedge Pressure
A
8 - 12 mmHg
Left Preload
*If unavailable, check PA diastolic
8
Q
Ejection Fraction
A
60 - 70%
9
Q
Monro-Kellie Hypothesis
A
3 components in the skull: CSF, brain, blood
Increases in any one, increases ICP
10
Q
ICP: Normal Value
A
5 - 15
11
Q
Intracranial HTN: Value
A
> 20
12
Q
High ICP: S/S
A
- LOC change**
- Pupillary changes
- Papilledema
- Motor changes (decorticate, decerebrate, flaccid)
- Headache
- Projectile Vomiting
13
Q
High ICP: Treatment
A
-Hypertonic Saline (3% NaCl)*
-Osmitrol (Mannitol)*
Use a filter d/t crystallization possibility
Bolus is best method
-Dexamethasone, Solumedrol (steroids)
No hypotonic fluids (D5W or 1/2 NS) -> causes swelling
HOB >30 degrees
14
Q
Spinal Shock: Definition
A
Temporary loss of all motor and sensory function BELOW LOI - immediately after injury
Gradual return of function: 4-6 weeks
15
Q
Spinal Shock: S/S
A
- Complete loss of motor reflexes
- Flaccid paralysis
- Loss of Bowel and Bladder control (retention)
Assess for (+) anal wink at onset = incomplete injury (good sign)
16
Q
Neurogenic Shock: Definition
A
Temporary loss of SNS innervation (often SCI above T6) - immediately after injury
Without SNS, PNS takes over (vagal nerve)
17
Q
Neurogenic Shock: S/S
A
- Vasodilation
- Hypotension (treat with vasopressors and volume)
- Bradycardia (treat with Atropine if bpm 40s-50s)
- Skin, warm and dry
18
Q
Neurogenic Shock: Care
A
- Ace wraps, compression boots (to circulate perfusion centrally)
- Vasopressors and volume
- Atropine
19
Q
Autonomic Dysreflexia: Definition
A
Overstimulation of SNS below LOI - a few weeks after the injury
Common cause: Bowel and Bladder
20
Q
Autonomic Dysreflexia: S/S
A
- HA
- Facial flushing and warmth
- Nasal congestion
- # 1 HTN
- Bradycardia
- Anxiety/impending doom
Below Injury: cold skin with goosebumps
21
Q
Autonomic Dysreflexia: Interventions
A
- Sit patient up, elevate HOB to lower BP
- Identify and remove stimulus
- Treat BP if remaining high
22
Q
Stroke: Presentation
A
GFAST
Gaze Facial Droop Arm Weakness Speech Difficulty Time of Onset
23
Q
Basilar Artery Syndrome: S/S
A
Basilar Artery supplies 95% of blood to brain stem
- Dizziness
- Ataxia (loss of body control)
- Tinnitus
- N/V
- One sided weakness
24
Q
Right MCA Stroke: S/S
A
Most common
- Left weakness
- Head/eyes turn to stroke side (right)
- “Let side neglect”
- Disoriented
- Impulsive
- Poor judgement
- Lack of proprioception
25
Left MCA Stroke: S/S
- Right sided weakness
- Altered intellectual ability
- Slow
- Cautious
- Anxious
- Depressed
- Dyslexia
- Aphasia
26
Expressive Aphasia
Affects Broca's Area (frontal lobe)
Understand language, but can't communicate/talk/write
Use a picture board
27
Receptive Aphasia
Affects Wernicke's Area (temporal lobe)
Unable to understand language
Make up new words
28
Ischemic Stroke: Meds
Fibrinolytic/Thrombolytic Therapy
TPA (must meet criteria)
- No acute hemorrhage
- Tx sooner than 4.5 hours after onset
- BP <185/110 (use Labetalol and Nicardipine)
- Neuro assessment after admin
NO TPA IF RECENT BLEED OR RISK FOR BLEEDS
29
Stroke: Nursing Care
-Determine time of onset
-Urgent non-contrast CT (determines stroke type)
-Prioritize ABC
-Impaired swallowing
-Impaired communication
-Clothe weak side first
-If Blind on one side:
Rotate Tray
Neglect Syndrome (use mirror for self care)
30
Meningitis: Definition
Infection of the meninges surrounding the brain and spinal cord
31
Meningitis (Bacterial): Presentation
MOST LETHAL
- Brain damage
- Hearing loss
- Epilepsy
- Death
- Meningococcal may cause death in 24 hr
32
Meningitis (Viral): Presentation
Self-limiting
Sometimes herpes can cause rapid brain tissue necrosis
33
Meningitis: General S/S
- Photophobia
- Nuchal Rigidity
- Brudzinski's Sign & Kernig's Sign
- HA
- Weakened immune system
- N/V, fever, chills, generalized muscle aches and pain
- Red macular skin rash (meningococcal)
34
Meningitis: Diagnosis
Lumbar puncture and analyze CSF
Cloudy, low glucose: Bacterial
Clear, normal glucose: Viral
35
Meningitis: Nursing Care
-Droplet and Standard Precautions (until abx 24-48 hr)
Regular room
Don't have to close door
Surgical mask within 3 ft.
Mask on patient when out of room
-Abx, anti-seizure, analgesic, anti-pyretic, corticosteroids
36
Pulmonary Embolism
Obstruction of pulmonary artery (most commonly a clot)
Large emboli can impair circulation and gas exchange
PE common in hospitalization (can cause death with 1 hr)
37
Pulmonary Embolism: Risk Factors
- Prolonged immobility (venous stasis)
- CVC
- Surgery (vessel damage and clot formation)
- Obesity
- Advancing age
- Conditions that increase clotting (pregnancy, sickle cell, estrogen tx)
- History of thromboembolism
38
Pulmonary Embolism: Classic S/S
- **Sudden dyspnea**
- Pleuritic chest pain
- Tachypnea
- Anxiety
- Cough
- Hemoptysis
- Feeling of impending doom/anxiety
39
Massive Pulmonary Embolism: S/S
- Tachycardia
- JVD
- Hypotension
40
Pulmonary Embolism: Prevention
- DVT prophylaxis
- Passive and Active ROM
- SCDs. TEDs
- Anticoagulants/Antiplatelets
- Avoid smoking
41
Pulmonary Embolism: Diagnosis
- CT scan (check kidney function: BUN/Cr, UOP)
- Multidetector or CT angiography
- D Dimer assay
- Ventilation perfusion scan (VQ scan)
42
Pulmonary Embolism: Drug Therapy
-Draw coagulation studies first**
-Anticoagulants
Heparin (PTT: 40-90)
Warfarin/Coumadin (INR: 2-3)
Lovenox (Enoxaparin)
Xarelto (Rivaroxaban)
-Thrombolytic if ordered ("-ase"
43
Acute Respiratory Distress Syndrome (ARDS): Criteria
-Onset <7 days
-Refractory hypoxemia (doesn't respond to non-invasive O2 tx)
-Bilateral chest infiltrates ("white out" on X-Ray)
-No Left HF evidence
Normal Wedge: 8-12
44
ARDS: Precipitating Factors
- Shock
- Trauma
- Pancreatitis
- Sepsis
- Pulmonary Aspiration
- Toxin Inhalation
- Multiple Blood Transfusions
45
ARDS: Manifestations
- Rapid onset dyspnea**
- Increased alveolar dead space**
- Refractory hypoxemia (needs intubation)**
- Abnormal lung sounds
- Cyanosis
- Intercostal/substernal retractions
- Tachycardia
- Hypotension
46
ARDS: Nursing Implications
-Intubation and Mechanical Vent
-Corticosteroids (anti-inflammatory)
-Nutritional support
-Fluids per protocol
-Inhaled nitric oxide (vasodilator)
-Surfactant Replacement
-ECMO
Re-oxygenates blood
Allows lungs to rest and heal
47
Laryngeal Trauma
Ensure patent airway
May have to prep for total laryngectomy (teach patient they won't be able to speak after)
48
Laryngeal Trauma: Presentation
- Hoarse
- Swelling
- Dyspnea
- Hemoptysis
- Hematoma/Edema of neck
49
Laryngeal Trauma: Interventions
- Monitor Airway
- Trach kit and emergency equipment at bedside
- Provide humidified air
- HOB >45 degrees
- Aspiration precautions
- Voice Rest
50
Chest Trauma: Primary Survey
ABCDE
-Airway - C Spine (C4 and C5 innervate the diaphragm)
-Breathing - equality/quality of breath sounds
-Circulation - Pulse, HR, skin, BP, bleeding signs, IVF
-Disability - GCS or AVPU (alert, voice, pain, unresponsive)
-Expose (remove clothing for complete emergency assessment)
Cover with warm blanket
51
Chest Trauma: Nursing Interventions (order)
- Open airway under C-Spine precautions
- Provide oxygen
- Prepare for ETT
- Establish IV access
- Fluids as ordered (warmed)
- Monitor temp
52
Chest Trauma: Secondary Survey
AMPLE
```
Allergies
Medication use
Past medical hx
Last meal
Events leading to injury
```
53
Assessment Findings for clues of injury
Pneumothorax - diminished breath sounds
Ruptured Diaphragm - Breath sounds in lower mid chest
Vascular Injury - bruit
Cardiac Tamponade or Pericardial Bleed - muffled heart sounds
Tension Pneumothorax or Cardiac Tamponade - Distended neck veins
Hypovolemia - flat jugulars
Tension Pneumothorax or Massive Hemothorax - tracheal shift
54
Trauma Triad of Death
Coagulopathy
Hypothermia
Metabolic Acidosis
55
Pneumothorax
Air in the pleural space
56
Pneumothorax: Types
Closed - spontaneous after respiratory disorders (Thomas)
Open - wound opens pleural cavity to the outside
57
Pneumothorax: S/S
- Dyspnea
- Tachycardia
- Hyper resonance on affected side
- Decreased breath sounds on affected side
- Pleuritic chest pain
- SubQ Emphysema/Crepitus
58
Pneumothorax: Implications
- Prep for Chest Tube
| - For open pneumo, non-porous dressing taped on 3 sides
59
Tension Pneumothorax
Air enters on inspiration, can't leave on expiration
Decreased CO
60
Tension Pneumothorax: S/S
- Increased HR
- Severe respiratory distress
- JVD
- Angina
- Tracheal shift
- Cyanosis
61
Tension Pneumothorax: Implications
Needle decompression
2nd intercostal at midclavicular
Prep for chest tube
62
Hemothorax
Blood in the pleural space
63
Hemothorax: S/S
- Dyspnea, Tachycardia, chest pain, tracheal shift
- Dullness on percussion of affected side
Hypovolemic Shock
- Tachycardia
- Hypotension
- Tachypnea
- Decreased LOC
- Decreased UOP
- Cold, clammy skin
64
Hemothorax: Implications
-Chest tube
-Replace volume lost
-Open thoracotomy (if severe)
Immediate drainage of 20 mL/kg
Accumulation of >3mL/kg/hr
65
ABGs
pH: 7.35 - 7.45
CO2: 35 - 45
HCO3: 22 - 26
66
Chest Tube Placement
Pneumothorax: 2nd/3rd intercostal at midclavicular
Hemothorax: 4th-8th intercostal at midaxillary
67
Ventilator: Monitor
For changes in:
- VS
- S/S of hypoxia or hypoxemia
- Dysrhythmias
- Aspiration
68
Ventilator: Clinical Assessment
-Watch for chest rise
-Listen for breath sounds
-Check placement for gurgling in stomach (indicates esophagus instead of trachea)
Capnography can assess too
-Stabilize and mark tube at incisor or naris
69
Proper CO2 Capnography: Value
35 - 45 mmHg
70
Ventilator: Low Pressure Alarm
- Leakage
| - Patient stopped breathing if on CPAP or SIMV
71
Ventilator: High Pressure Alarm
- Blockage
- Biting, coughing, mucus plug, kink, water collection
Suction to resolve
72
Ventilator: Complications
-Hypotension (Increased intrathoracic pressure = decreased CO)
-Aspiration (epiglottis issues)
-Infection
-Ventilator Associated Pneumonia (VAP)
48+ after intubation
Prevent with daily "Chlorhexidine"
-Barotrauma (alveolar rupture)
Increased positive pressure
Overdistention of alveoli
Friable lung tissue
73
ETT Patient Care
-HOB 30-45 degrees
-Monitor respiratory status
-Check ETT placement and vent settings
-Mouth care ("Chlorhexidine")
Reduces VAP
-Monitor for S/S infection
VAP, aspiration pneumonia
-NPO, TPN/tube feeds
-Chemical sedation or restraints
-DVT prophylaxis
-Peptic ulcer prophylaxis
74
Weaning Off a Ventilator: Criteria
- Ability to breathe spontaneously
- Ability to support adequate O2
- Ability to maintain adequate hemodynamic stability
75
Weaning Off a Ventilator: Nurse Responsibilities
- DC Sedation
- Assess for respiratory distress
- Evaluate LOC
- ABGs
76
Tidal Volume: Value
500
77
FiO2: Value
~30%
78
SaO2: Value
>90%
79
PaO2: Value
80 - 100 mmHg (>60 mmHg if acute care)
80
PEEP: Value
5 - 15 cmH2O
81
PEEP: S/E
- Additional thoracic pressure
| - Risk for pneumo, barotrauma, and low CO
82
5 P's for Monitoring Distal to ABG site
- Pain
- Paresthesia
- Pulse
- Paralysis
- Pallor
83
GCS
15: normal
<8: need to be intubated
3: comatose
84
What drugs slow healing?
Corticosteroids
85
Acute Pancreatitis: Etiology
-ETOH
-Bile duct obstruction
-Other
Abd surgery
Trauma
Infection
Drug use
Idiopathic
86
Acute Pancreatitis: S/S
- LUQ severe pain**
- N/V
- Abd Distention
- Jaundice
- Low grade fever
- Hypovolemic Shock: tachycardia and hypotension
- Grey Turner's Sign: flank
- Cullen's Sign: belly button
87
Acute Pancreatitis: Complications
-Jaundice
-Hyperglycemia (can't make insulin)
-Hypocalcemia (r/t fat/pancreatic necrosis)
Tetany and seizures
-Pulmonary (ARDS, atelectasis)
-Paralytic Ileus
-Hypovolemic shock d/t fluid shift and hemorrhage
-DIC
-Renal failure r/t hypovolemia
88
Acute Pancreatitis: Diagnostic Tests
```
WBC: >10,000
H&H: <12; 36%
ALT: >20 = gallstones
Glucose: increased d/t insulin production stopped
E-lytes:
Potassium (3.5 - 5.0)
Calcium (8.5 - 10.5)
```
89
Acute Pancreatitis: Interventions
- PRIORITY: replace fluids**
- ABC
- Pain control (morphine, Dilaudid, Demerol)
- Input and Output
- Monitor labs
- Nutrition
- H2 blockers, PPI
90
Gallstone Removal Procedure
ERCP
91
Hep A: Transmission
Fecal --> Oral
92
Hep A: Labs
IgM: current infection
IgG: immunity/recovery
93
Hep A: Nursing Care
Post-Exposure:
Healthy- vaccine only
Unhealthy- vaccine + immunoglobulin
94
Hep B: Transmission
Blood and Body Fluids
| Mother -> child at birth
95
Hep B: Labs
HBcAB/Core Antibody: exposure (presumptive infections)
HBsAG/Surface Antigen: currently infected
HBsAB: Immunity
96
Hep B: Nursing Care
Most develop immunity after exposure
If becomes chronic (>6 mo) = liver cirrhosis and cancer risk
Post-Exposure: Vaccine + immunoglobulin
97
Hep C: Transmission
Blood
| Mainly IV drug abuse
98
Hep C: Labs
HCV antibody: exposure/past infection
| HCV RNA: current active infection
99
Hep C: Nursing Care
Breastfeeding is ok if nipples not cracked/bleeding
| No vaccine, but there is a cure
100
Liver Cirrhosis: Types
- Laennec's: ETOH
- Post Necrotic: r/t infection (MOST COMMON)***
- Biliary Cirrhosis: biliary obstruction or destruction
- Cardiac Cirrhosis: secondary to CHF
101
Liver Cirrhosis: Presentation
- Jaundice
- Ascites
- Edema
- Vitamin Deficiency
- Petechiae
- Ecchymosis
102
Liver Cirrhosis: Complications
-Portal hypotension
-Bleeding Esophageal varices
Rupture Causes: cough, strenuous exercise, trauma
-Coagulation defect
-Jaundice
-Ascites
-Gynecomastia
103
Hepatic Encephalopathy: Precipitating Factors
- Excessive protein intake
- GI bleed*
- Constipation
- Drugs (opioids, sedatives, analgesics)
- Infection
- Hypokalemia
104
Variceal Hemorrhage: Emergency Care
- Maintain airway
- Replace volume (not LR = increased ammonia = decreased LOC)
- Prep for emergency endoscopy
- Insert NGT
- Reduce hepatic blood flow (vasopressin)
- Watch for Projectile Vomiting
