Final: lectures Flashcards
1
Q
rule of nines
A
body is divided into areas that are multiples of 9% to calculate burn injury in adults
2
Q
rule of nine: major sections
A
head
each arm
chest and back
each leg
3
Q
rules of nine: head
A
-whole head: 9%
front: 4.5%
back: 4.5%
4
Q
rules of nine: each arm
A
whole: 9%
front: 4.5%
back: 4.5%
5
Q
rule of nine: chest and back
A
chest: 18%
back: 18%
6
Q
rule of nine: each leg
A
whole: 18%
front: 9%
back:9%
7
Q
Parkland/Consensus formula starts calculating at time of:
A
injury
8
Q
Consensus formula:
1st half given:
2nd half given:
A
(2-4 mL)(kg)(TBSA%)
1st half: first 8 hrs
2nd: 16 hours
9
Q
primary assessment of burn patients focuses on (5)
A
airway
breathing
circulation
disability
environment
10
Q
secondary assessment of burn patients focuses on: (6)
A
total body scan to determine extent of burns
fluid resuscitation
labs (BMP, CBC, ABG)
Foley placement
Pain management
Administering tetanus/other necessary vaccines
11
Q
pain management consideration w/ burn patients
A
higher dose/more frequent administration because metabolic rate will be higher
12
Q
burn complications (circulatory) (5)
A
Massive edema
-electrolyte imbalances
-decreased cardiac output
-hypotension
-hypovolemic shock
13
Q
burn complications (non circulatory) (5)
A
carbon monoxide impacts
impaired immunity/infection
impaired temperature regulation
decreased GI motility
stress/injury ulcers (GI)
14
Q
burn is painful with mild edema
A
superficial
15
Q
burn is painful with blisters and mild-moderate edema
A
partial-thickness burn
16
Q
burn causes little to no pain and severe edema
A
full-thickness burn
17
Q
burn is painless with little to no edema
A
deep-full thickness
18
Q
burn effects only epidermis layer
A
superficial
19
Q
burn effects epidermis and 1/3 of dermis
A
superficial partial thickness
20
Q
burn effects epidermis and more than 1/3 (but not whole) dermis
A
deep partial thickness
21
Q
burn effects epidermis and all of dermis
A
full-thickness
22
Q
burn effects all skin layers
A
deep full-thickness
23
Q
TBI priority action
A
apply C-collar and don’t remove until provider has assess and cleared patient
24
Q
Glasgow coma scale:
less than 8:
9-12
more than 13:
A
<8: severe head injury/coma
9-12: moderate head injury
>13: minor head trauma
25
____________ pupils indicate severe brainstem injury and possible brain death
bilateral, fixed pupils
26
assessment for TBI (4)
Glasgow coma scale
cranial nerves
pupillary assessment
reflex assessment
27
_______ and _______ are both posturing indicating life-threatening brain damage with _________ being most severe
decorticate and decerebrate
decerebrate more severe
28
TBI monitoring: (5)
ICP
CPP
airway
circulation
neuro
29
Cerebral perfusion pressure formula
MAP - ICP
30
CPP should always be greater than _______, if less than, indicates _____________
60 mmHg
brain ischemia
31
normal CPP
60-100 mmHg
32
Normal ICP
10-15
33
________ and _______ indicates increased ICP and is a potential sign of brain __________
projectile vomiting and severe headache
brain herniation
34
TBI airway management: if GCS is 8 or less _______
intubate
35
With TBIs NEVER insert ____________
nasogastric tube
36
PaO2 should be over:
100 mmHg
37
_________ is one of the first signs of impending herniation
unilateral pupil dilation
38
Contraindication of HOB being elevated 30 degrees
spinal cord injury
39
_____________ is used if herniation is indicated as its a potent vasodilator and lowers CPP/ICP
hyperventilation
40
medications to reduce ICP (2)
Mannitol: osmotic diuretic
Vecuronium: neuromuscular blocking agent
41
_____ is the most common type of stroke (80-85%)
ischemic
42
ischemic strokes are caused by ________ generally coming from __________ following ___(3)_____
local thrombus/emboli
heart or large arteries
a-fib, acute MI, or surgery
43
Time goal for stroke management ED door - needle
60 minutes
44
NIHSS Score interpretation
0
1-4
5-15
16-20
21-42
no stroke
minor stroke
moderate to severe stroke
sever stroke
45
when to use NIHSS (4)
when patient arrives
following any intervention
when significant changes in pt status occurs
prior to discharge from ED
46
when to treat BP and BG before giving TPA:
-BG: <50mg/dL
-BP: S > 185; D>110 mmHg
47
Once TPA is initiated ________ can not be done
insertion of any tubes (foley, NG, IV, etc)
48
complications of thrombolytic therapy (4)
bleeding
angioedema
anaphylactic reaction
further deterioration in neurological status
49
assessment before/during/after TPA (6)
-Neuro assessment & vitals every 15 minutes for 2 hours than every 30 minutes for 4-6hrs
-Record I&Os
-Don't administer any thrombotic for first 24 hours
-fall precautions
-telemetry
-monitor hemoglobin and platelets
50
TIA->stroke risk ABCD assessment
Age < or equal to 60
Blood pressure < or equal to 140/90
Clinical TIA features
Duration of symptoms (longer the symptoms, greater the risk of stroke
51
most common cause of hemorrhagic stroke
hypertension
52
s/s of autonomic dysreflexia (6)
sudden increase in BP
goodebumps
bradycardia
sense of anxiety
blurred vision
pain
53
hypovolemic shock results from
inadequate circulating volume
54
carcinogenic shock results from
pump failure
55
distributive shock results from
abnormal distribution of blood
56
obstructive shock results from
obstruction of blood flow
57
major intervention for cariogenic shock
position in semi-flowers or high fowlers
58
if cariogenic shock is caused by right sided pump failure, there is an increase in _______ and should be treated with _______
increased preload
isotonic fluids
59
Indicators of SIRS (7)
-fever + leukocytosis
-hyper/hypothermia
-HR > 90
-RR>20
-pCO2 < 32
WBC > 12000 or < 4000
10% immature neutrophils
60
client diagnosed with sepsis has a higher risk of developing _____ or ______
DIC or MODS
61
Risk factors of SEPSIS (6)
suppressed immune system
extreme age
people who have received an organ transplant
surgical procedure
indwelling device
sickness
62
Initial stage of septic shock (2)
Baseline MAP decreased by <10 mmHg
Vascular constriction and increased HR
63
in the initial stage of septic shock caused by bacterial sepsis, you will most likely see an elevated ____________ normal:
prolactin (normal: 0.01 ng/dL)
64
Compensatory phase of septic shock (6)
Map decreased by 10-15 mmHg
Urine output decreases
Blood vessel constriction increases
Tissue hypoxia occurs
Thirst and anxiety are subject to changes
65
in septic shock: a MAP <65 after fluid administration indicates:
condition is worsening
66
in septic shock, nurse should talk to provider about holding vasopressors if MAP is:
55 or less
67
Progressive stage of septic shock (7)
-sustained decreased MAP of more than 20 mmHg from baseline
-vital organs develop hypoxia; some tissues die
-rapid, low pulse
-low BP
-pallor; cool, moist skin
-anuria
-decrease in SpO2
68
Condition causing shock must be corrected within _______ of progressive stage onset
1 hour or less
69
refractory stage of septic shock (6)
-too little oxygen reaches tissues; cell death and tissue damage results
-MODS develops
-Rapid loss of consciousness
-nonpalpable pulse
-cold, dusky extremities
-slow, shallow respirations; unmeasurable SpO2
70
early s/s of septic shock (7)
warm flushed skin
hypotension
tachycardia
tachypnea
fever
high cardiac output
restless/anxiety
71
late s/s of septic shock (6)
cold and clammy skin
cardiac output decreases
oliguric
hypotension
decreased LOC
hypothermia
72
Treatment for septic shock (7)
start antibiotics within one hour
oxygenate
vasopressors
fluids
nutrition
corticosteroids
monitor BG for hyperglycemia
73
for a patient with septic shock, its important to review medications for:
diuretics- contraindicated
74
physiologic responses to all types of shocks include (3)
activation of inflammatory system
activation of coagulation system
hypoperfusion of tissues
75
patients receiving fluid replacement therapy for shock should be frequently monitored for (3)
adequate urinary output
changes in mental status
vital sign stability
76
the main goal of treating septic shock is
identification and elimination of infection
77
AKI is a rapid reduction in kidney function resulting in a failure to: (3)
maintain waste and elimination
fluid and electrolyte balance
acid-base balance
78
Labs indicating AKI (3)
-increase in serum creatinine by 0.3 mg/dL or more within 48 hrs
-increase in serum creatinine to 1.5x baseline in last 7 days
-urine volume less than 0.5mL/kg/hr for 6 hours
79
phase of AKI where patient is sickest
oliguric phase
80
phase of AKI that is most dangerous/life threatening
diuretic phase
81
phase of AKI where there's a return to normal function while healing takes place
recovery phase
82
indications of CRRT (3)
-sepsis
-MODS
-clients aren't able to tolerate intermittent dialysis
83
DKA is characterized by (4)
profound dehydration
electrolyte losses
ketonuria
acidosis
84
priority treatment of DKA (3)
potassium changes
fluid replacement (NS->D5W)
regular insulin drip
85
DKA is more common in type ____ and HHS is more common is type ____
DKA: type 1
HHS: type 2
86
treatment of HHS
Potassium changes
fluid replacement (NS-> D5W)
regular insulin drip
87
Type of insulin: lispro, aspart, glulisine
rapid-acting
88
peak of rapid-acting insulin
one hour
89
regular insulin peak
2-4 hours
90
what type of insulin: NPH, detemir
intermediate-acting
91
intermediate acting insulin peak
4-12 hours
92
what type of insulin: glargine, degludec
long-acting
93
long acting insulin starts working within ______ and lasts ______
2 hours, 24 hours
94
most common s/s of pulmonary embolism
coughing up blood
95
complications of PE (5)
cardiac arrest
arrhythmia
pulmonary effusion
pulmonary hypertension
pulmonary infarction
96
treatment of PE (5)
thrombolytics
anticoagulants
clot removal
inferior vena cava filter placement
balloon angioplasty
97
treatment of pulmonary hypertension (4)
anticoagulants
diuretics
oxygen
digoxin
98
procedure performed to remove fluid from the thoracic cavity; for both diagnostic and therapeutic purposes
thoracentesis
99
minimally invasive procedure that lets doctors look inside airways and lungs
bronchoscopy
100
common causes of type 1 respiratory failure (7)
trauma
pneumonia
lung disease
smoke, chemical, or water inhalation
blood clot
sepsis
heart attack
101
common causes of type II respiratory failure (5)
stroke
spinal cord injury
drug/alcohol overdose
sepsis
cardiac arrest
102
treatment of acute respiratory failure (4)
oxygen therapy
breathing treatments
fluid
ECLS
103
takes over the function of the heart and lungs, supplying oxygen and removing carbon dioxide
gives lungs a break, allows for time to recover
Extracorporeal life support (ECLS)
104
ventilator bundle (6)
oral care q2hrs
HOB 30 degrees
sedation holiday
GI prophylaxis
DVT prevention
daily assessment for extubation/weaing
105
complications of mechanical ventilation (6)
barotrauma
hemodynamic instability
Ventilator associated pneumonia (VAP)
aspiration
immobilization
anxiety/pain/delirium
106
degree of STRETCH of cardiac muscle fibers at end of diastole
preload
107
RESISTANCE to ejection of bleed from ventricle
afterload
108
STRENGTH/ABILITY of cardiac muscle to shorten in response to electrical impulse
contractility
109
percent of end diastolic volume ejected with each heart beat
ejection fraction
110
amount of blood pumped by ventricles in L/min
cardiac output
111
cardiac output formula
stroke volume x hr
112
normal cardiac output
4-8 L/min
113
normal cardiac index
2.5-4 L/min
114
normal central venous pressure
2-6 mmHg
115
central venous catheter contraindications (2)
recurrent sepsis
hypercoagulable state
116
MAP formula
(SBP + (DBPx2)) / 3
117
non-pharmacologic pain intervention (7)
ET suctioning
Repositioning
Oral Care
Reassurance/ family presence
Heat/Cold therapy
massage, acupuncture, relaxation
Music, low lights, adequate room temp
118
common sedatives (5)
dexmedetomidine
lorazepam
propofol
midazolam
barbiturates
119
Roles of RN with sedation (5)
Daily sedation holiday unless contrainidcated
educate family
skin management
DVT prophylaxis
pain control
120
management of delirium (6)
treat the cause
mobilize patient if possible
provide sleep enhancement
antipsychotic meds
manage withdrawal symptoms
family involvement
121
goals of neuromuscular blockade
decrease oxygen consumption
decrease total body work
decreasing pain and anxiety
decreasing temperature
122
golden rule of sedation
never start without sedation
123
types of neuromuscular blockades
vecuronium
pancuronium
rocuronium
