NUR 305 exam prep Sam Fox Flashcards

Question

BiPAP (Bilevel positive airway pressure)

Answer 1

Involves: IPAP (Inspiratory positive airway pressure • A higher pressure is delivered on inspiration EPAP (Expiratory positive airway pressure) • Lower pressure but still positive on expiration BiPAP is sometimes used in patients who have pulmonary lung issues, like COPD. The difference in pressures helps to eliminate extra CO2 carbon dioxide gas from the body.

Answer 2

* High dependency patients * Neurological disorders ( Guillain Barre syndrome) * Obstructive sleep apnoea * COPD * Asthma * Post intubation weening issues

Answer 3

* Respiratory failure (type 1, post anaesthetic) * Acute lung injury * Asthma * Pulmonary embolism * Pneumonia * Severe acute respiratory syndrome

Answer 4

* Fraction of inspired 02 (Fi02) os 0.6 = 60% * Inspiratory : expiratory ratio * Tidal volume / minute volume * Ventilator breath rate * Pressure support

Answer 5

``` Type 1: Post anesthetic Lung injury Asthma Pneumothorax (collection of air in the cavity causing the lung to collapse) Pneumonia ``` ``` Type 2: Asthma COPD Upper airway Obstruction ```

Answer 6

* Lactate & acid base disturbances * Need to assess – ABG, pH, base excess * Increased lactate is a warning sign of organ failure

Answer 7

Nasal canula 2 - 4L/min 25 - 45% Venturi 4 - 8 L/min 24 - 50% (COPD) Hudson 6 - 10/Lmin 40 - 60% Non-rebreather 10 - 15 L/min 60 - 100%

Answer 8

* Lactate & acid base disturbances * Need to assess – ABG, pH, base excess * Increased lactate is a warning sign of organ failure

Answer 9

Is the inability of the body to meet the metabolic demands of the tissues = hypoperfusion (the amount of 02 reaching the cells) Homeostatic imbalance occurs between nutrient supply and demand = Adaptive responses can no longer accommodate circulatory changes

Answer 10

* Lactate & acid base disturbances * Need to assess – ABG, pH, base excess * Increased lactate is a warning sign of organ failure

Answer 11

1. Tachycardia 2. Altered GCS 3. Cold skin 4. Tachypnoea 5. Shallow resps 6.

Answer 12

a.) external haemorrhage. b.) in the chest i.e. haemothorax. c.) in the abdomen. Spleen and liver are common. d.) pelvic fractures. e.) long bone fractures. Feel: Skin temp., capillary refill. Pulse rate and volume. (Use a central pulse – femoral or carotid) You should have already examined the chest. Inspect the abdomen. Palpate the pelvis. Look for signs of long bone fractures. Useful adjuncts at this stage include a urinary catheter and a nasogastric tube.

Answer 13

a. ) external haemorrhage. b. ) in the chest i.e. haemothorax. c. ) in the abdomen. Spleen and liver are common. d. ) pelvic fractures. e. ) long bone fractures. Feel: Skin temp., capillary refill. Pulse rate and volume. (Use a central pulse – femoral or carotid) You should have already examined the chest. Inspect the abdomen. Palpate the pelvis. Look for signs of long bone fractures. Useful adjuncts at this stage include a urinary catheter and a nasogastric tube.

Answer 14

a.) external haemorrhage If blood is not on the floor it could be.... b. ) in the chest i.e. haemothorax c. ) in the abdomen. Spleen and liver are common d. ) pelvic fractures e. ) long bone fractures Feel: Skin temp., capillary refill. Pulse rate and volume. (Use a central pulse – femoral or carotid) You should have already examined the chest. Inspect the abdomen. Palpate the pelvis. Look for signs of long bone fractures. Useful adjuncts at this stage include a urinary catheter and a nasogastric tube.

Answer 15

1. Hypovolemic 2. Cardiogenic 3. Distributive shock: • Sepsis • Anaphylaxis • Neurogenic

Answer 16

Primary Survey: A – E assessment | Secondary Survey – top to toe

Answer 17

Primary Survey: A – E assessment Secondary Survey – top to toe

Answer 18

* Low volume of blood or fluid – bleeding (internal/external), vomiting, diarrhoea, burns, dehydration * Most common cause is bleeding * Easy to diagnose & treat

Answer 19

- Rapid A - E - Secure airway/breathing - Fluid resuscitation - Increase preload - cardiac output - minimize further fluid loss - Fluid infused to reflect loss (burns = plasma, hemorrhage = blood/colloid/crystalloid) to maintain agreed MAP and SBP - NOTE: can cause overload- need to monitor ABGs, Vitals, cap refill - Keep patient warm - Bolus dose = Vol/Kg - Prepare for theatre

Answer 20

• Is the inability to maintain adequate perfusion despite adequate circulatory volume 02 is not clinging to the molecules and therefore, not reaching the tissue Shift to right of dis curve = high affinity Base excess is out of normal range (+- 3) = compensating (body has used up all compensatory mechanisms) = deterioration - Increase lactate = warning sign of organ failure • Difficult to diagnose • Usually occurs within 48 hrs after a MI • Main cause if left ventricular failure - Mortality 50 - 80%

Answer 21

- Low cardiac output - Sever pulmonary congestion (feel like drowning) - Hypotension 10 sec - Anxiety - Dyspnea (

Answer 22

* Multi system approach * Frequent assessments * Increase oxygen supply – CPAP / BiPAP as required * Decrease physical activity * Holistic care & support * ?fluids * Inotropes

Answer 23

Inotropes are a group of drugs that alter the contractility of the heart. Positive inotropes increase the force of contraction of the heart, whereas negative inotropes weaken it. Inotropes are indicated in acute conditions where there is low cardiac output (CO), such as cardiogenic shock following myocardial infarction, acute decompensated heart failure and low CO states after cardiac surgery. Reduced CO leads to tissue hypo-perfusion and subsequent hypoxia. Metabolism switches from aerobic to anaerobic, resulting in the formation of lactic acid. If left untreated, this can result in multi-organ failure and death

Answer 24

``` • Tissue has impaired oxygen & nutrient delivery • Failure of the vascular system • Leading to widespread vasodilation  Septic shock  Anaphylaxis  Neurogenic ```

Answer 25

• Is systematic inflammation – Caused by – sepsis, burns, pancreatitis, trauma • restricts blood flow • oxygen delivery to tissue is compromised • cardiac output increases • hypovolemia occurs – the blood dilates & distributes • the patient will need >fluid to accommodate tissue = which is bad, the blood will continue to expand & the patient will become over loaded • patient will present – warm, pink & well perfused • decompensation will lead to cell death & multiple organ failure

Answer 26

similar to hypovolemia, assess, fluid management, treat underlying infection, administer inotrope vasopressin

Answer 27

• severe allergic reaction • 1st expose to the allergen – no anaphylaxis (poss reaction) • 2nd exposure to allergen = anaphylaxis Patient may present - anxiety, dizzy, faint, stridor (high pitch sound), wheeze, tachypnoea, dyspnoea (SOB), pharyl/laryngeal oedema, bronchospasm, cyanosis, tachycardia, hypotension, arrhythmias, N & V, diarrhoea, rash, itchy, erythema

Answer 28

Rapid A - E - Adrenaline - Antihistamine - Corticosteriods

Answer 29

- spinal shock • Spinal cord injury above T6 • Commonly caused by trauma • Loss of vasomotor tone – disruption to neural output

Answer 30

Hypotension ( HR does NOT occur

Answer 31

* ABC * Stabilise neck & torso * Fluids if needed * Resp assessment (risk of pneumonia & atelectasis * Maintain core temp * Initiate NBM * Pressure area care

Answer 32

1. Rapid A – E 2. Holistic care – involve family 3. Communication – patient, staff, family 4. Interventions – fluids, obs, scribe, meds, transfer

Answer 33

Ventilation - airway, added and ventilation Infusion - of appropriate volume expanders Pumping - improve heart pumping with drugs - antiarrythmics, inotropes, diurectics, vasodilators

Answer 34

1. Cardiovascular 2. Neurological 3. Renal function - insert catheter to measure urine output

Answer 35

``` Resps, Temp, HR, BP, Sa02, U/o, GCS, ABGs, - bloods to measure lactate = > lactate warning sign of organ failure cardiac output – central line ```

Answer 36

class of drugs that evlevate mean arterial pressure by inducing vasoconstriction

Answer 37

Heart failure: - Dobutamine - Dopamine Septic shock, Cariogenic shock, anaphlatic shock, neurogenic shock and hypotension (following anesthethic): - Adrenaline - Epinephrine - Phenlepfine - Noradrenaline second line agent for septic and anaphlatic: - Vasopressin

Answer 38

``` fluid resus medication management theartre rehab transfer - ICU, spinal unit ```

Answer 39

1. Sinoatrial - SA node (pacemaker) fires 2. excitation spreads through atrial myocardium 3. Atrioventricular - AV node fires 4. Excitation spreads down AV bundle 5. Perkinje fibres distribute excitation through ventricular myocardium

Answer 40

* large arteries = > damage | * artery branches =

Answer 41

* the amount of blood pumped by the heart each minute * regulated by homeostatic mechanisms * regulated in response to stress & disease * is affected by preload, afterload & contractility * critically ill patients do not compensate as well as healthy people * maybe unable to >HR to compensate BP & hypertension

Answer 42

HR x Stroke volume

Answer 43

• the volume of blood pumped with heart beat (50-100ml/beat)

Answer 44

Pressure of stretch exerted on the walls of the ventricle by the volume of blood filling the ventricles at the end of diastole; used as an indication of volume status

Answer 45

* volume loss – haemorrhage * venous dilation – hyperthermia / medication * tachycardia’s AF / super ventricular tachycardia (SVT) * raised intrathoracic pressure – need to use NIV, BiPAP, CPAP * raised intracardiac pressure – tamponade - Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium). * Body position can affect preload due to the effect on venous return

Answer 46

• Preload of the right ventricle measured by the CVP

Answer 47

The ability of a muscle to shorten when stimulated; in particular the force of the myocardial contraction • Is difficult to measure clinically • Decreased by: 1. Hypoxia Both cause MI’s 2. Ischemia 3. Drugs: thiopentone, calcium channel blockers • Increasing contractility will increase myocardial oxygen demand

Answer 48

• Average pressure within the arterial system throughout the cardiac cycle 70 – 90 mmHg

Answer 49

* Establish Dx * Determine therapy & monitor response to it * Heart rate & rhythm - 4 or 5 lead or 12 lead ECG * Non- invasive monitoring – obs, check all pulses (don’t just relay on monitors) * Invasive – catheter – arterial pressure monitoring, central venous pressure, pulmonary artery pressure, pulmonary capillary wedge pressure

Answer 50

* Count the number of large boxes between R to the next R | * Divide 300 by the number of large squares

Answer 51

``` Atrial Depolarization = P wave Delay at AV node = PR segmant Ventricular Depolarization = QRS complex Ventricular Repolarisation = T wave No electrical activity = Isoelectric line (the flat line at the end before it starts again) ```

Answer 52

``` Myocardial ischaemia Coronary artery spasm (angina) Myocardial infarction Pericarditis Pulmonary embolism Mitral valve proplapse Ca - usually secondary cancer ```

Answer 53

``` Dissecting thoracic aneurysm Herpes zoster Oesophageal reflus and spasm Hiatus hernia Pneumonia Pneumonthorax Pleurisy Peptic unlceration Gallbladder disease Musculoskeletal pain Costochondritis ```

Answer 54

* Inflammation of the intercostal muscles * Musculoskeletal pain 10/10 * Non-specific, non-localised (everywhere) * Resembles MI but clear ECG * Non-reactive to morphine * Need I'm ibroprofen * Skin is pale & sweaty

Answer 55

• Often relieved by rest alone Symptoms – chest discomfort

Answer 56

• May come on at rest Symptoms – Acute MI (occlusion) Sudden death

Answer 57

* A – E assessment * 02 at 6L / min via Hudson mask * Medication as prescribed Administer 02 b/c of the active chest pain even if sats are normal, however, studies show with holding 02 > survival rates as the body is forced to use the 02 it has in a much better way

Answer 58

``` Age Gender Ethnicity Genetic predisposition Low birth weight Diabetes Hormonal/biochemical factors ```

Answer 59

``` Blood cholesterol Tobacco smoking High BP Overweight/obesity Diet Alcohol consumption Social class Geographical distribution ```

Answer 60

Includes all cases of unstable angina and acute MIs Underlying pathology is the abrupt, complete or partial obstruction (occlusion) of a coronary artery Most often triggered by the rupture of an atheromatous plaque Nearly all deaths from CHD are the result of MI

Answer 61

Arises when a region of the myocardium becomes irreversibly necrosed. It is usually due to thromboembolic occusion of the coronary artery supplying that are of the heart muscle

Answer 62

All of the myocardium is being damaged

Answer 63

P – What happened, sitting down? Running? Q – Where is it, how does it feel, stabbing, crushing? R – Do they have pain anywhere else? Shoulder, jaw? S – Rating out of 10 T – When did it start?

Answer 64

Each year, around 54,000 Australians suffer a heart attack. More than 100,000 patients

Answer 65

``` Pain: Chest Left arm Right arm Both arms Neck Jaw back ``` ``` Skin: Pale Sweaty Clammy cyanosed ``` Respiratory: Tachypnoea Dyspnoeic Pulmonary oedema Physical signs: Nausea Vomiting Psychological: Anxiety confusion

Answer 66

Patient History Symptoms ECG Bloods

Answer 67

``` Reassure patient – rest Baseline observations ? Need for cardiac monitoring 12 lead ECG IV access Troponin (T & I) levels and cardiac enzymes (CK – creatine kinase) Contact Dr ```

Answer 68

Thrombolysis PCI (Percutaneous coronary intervention) Previously called Angioplasty

Answer 69

The development of thrombolysis is the single most important advance in the care of coronary patients since defibrillation Mortality is approximately 30% less than if patients are left untreated, and the NSF for CHD recommended: Thrombolysis be given within 60 minutes of a call for help Within 20 minutes of admission to hospital However, Thrombolysis is now secondary treatment pathway

Answer 70

Streptokinase. Most widely used, and cheapest. A bacterial protein. Patients develop antibodies, and can only be given once. Recombinant tissue-type plasminogen activator (tPA). A naturally occurring human protease that is fibrin specific and this works predominantly on the clot, with less risk of systemic bleeding Retaplase. A new generation, appears to be as effective as streptokinase. However can be given as a bolus and is non-antigenic

Answer 71

Invasive procedure Access through femoral artery Catheter inserted into coronary artery Balloon inflated in CA to open stenosed area Stenting carried out at same time if required Risk of cardiac arrhythmias/cardiac arrest

Answer 72

Hx, vitals, ECG – repeated every 5 mins, ABGs, 02, IV access, chest x-ray, troponin, and reassurance

Answer 73

``` Maintain safe environment Communication Breathing Eating and drinking Elimination Personal cleasing and dressing Control body temp Mobilizing Working ang playing Expressing sexulaity Sleeping Dying ``` Patient may worry if the do anything the pain will return or even die – need to help relieve anxiety

Answer 74

requires that nurses act in a way that promote the wellbeing of another person. Incorporates 2 actions of doing no harm & maximising possible benefits whilst minimising possible harm (non-maleficence).

Answer 75

There may be times where to ‘maximise benefits’ for positive health outcomes it is considered ethically justifiable that the patient be exposed to a ‘higher risk of harm’ (minimised by the caregiver as much as possible).

Answer 76

All treating staff are required to facilitate discussions about diagnosis, treatment options and care with the patient to enable the patient to provide informed consent

Answer 77

All treating staff are required to facilitate discussions about diagnosis, treatment options and care with the patient to enable the patient to provide informed consent Patients have the right as autonomous individuals to discuss any concerns or raise questions at any time with staff. Because of the vulnerable nature of the critically ill individual, direct informed consent is often difficult, and surrogate consent may be the only option, particularly in an emergency.

Answer 78

For individuals who want to document their preferences regarding future healthcare decisions. Advanced directives can only be signed by a competent person (before the onset of incompetence). Advanced directives can therefore inform healthcare professionals how decisions are to be made, in addition to who is to make them. Instructions given by the individual specifying what actions should be taken for their health in the event that they are no longer able to make decisions due to illness or incapacity, and appoints a person to make such decisions on their behalf.

Answer 79

People with acute, reversible illness conditions should have the prerogative of resuscitation. Reflects a decision against any further proactive treatment such as ‘CPR’.

Answer 80

Good trauma care starts at the road side. Results in improved survival of trauma patients. Reduces clinical errors in the management of trauma patients.

Answer 81

Multidisciplinary team, Team leader who is a doctor or nurse depending on the skill set, team leader doesn’t touch the patient. Nurses will manage ABC, nurse 1 = pt’s L side nurse 2 = pt’s R side nurse 3 is a runner for fluids, packs & will be talking to the scribe nurse, specialities will be surgeon and anaesthetist.

Answer 82

PRIMARY SURVEY – ABCDEF (F=Farenheit). Airway breathing & circulation take precedence. The components of the survey will occur simultaneously.

Answer 83

1. Maintaining life with priority given to airway, breathing & circulation 2. Treating immediate problems such as bleeding 3. Preventing complications or further compromise

Answer 84

 Airway = risk of aspiration (blood, vomit, teeth). C Spine control in trauma cases  Breathing = RIPPA assessment – RR, inspection, Palpation, percussion, auscultation  Circulation = Direct pressure to control haemorrhage. Fluid resus. Haemo-dilution. – hypovolemic until proven otherwise  Disability = AVPU (alert, voice, pain, unresponsive). Blood gases. Continuous neuro obs.  Exposure = Remove all clothing. Log roll to check for injuries on the back of the body ( you never know what lies behind!)  Farenheit = Hypothermia (often caused by medical staff exposing pt). Bair hugger (keeps patient warm at night), Warm fluids, Warm humidified oxygen.

Answer 85

This follows the primary survey & the patient is stabilised. This is a systematic examination of the body regions to identify injuries that have not yet been recognised. Essential that the front and back of the patient as well as areas covered by clothing, are examined during this process. Looking for fractures, bleeding etc.

Answer 86

 In order to improve outcomes, definitive care should be provided to patients as soon as possible and preferably within 1 hour of the injury being sustained.  In countries with large distances & sparse populations this aim presents particular challenge and cannot be met in many regions.  Recognition of life-threatening conditions, application of appropriate emergency interventions & prompt transport to the nearest appropriate hospital remain the principles of pre-hospital care.

Answer 87

from the place of injury to the first healthcare facility to provide care to the patient. This is sometimes referred to as pre hospital transport

Answer 88

between healthcare facilities. Sometimes referred to as inter hospital transport and can occur via ground or air.

Answer 89

between healthcare facilities. Sometimes referred to as inter hospital transport and can occur via ground or air.  Most common cause of traumatic injury include RTA’s (road traffic accident?), falls & collisions

Answer 90

hypothermia, acidosis, coagulopathy. (HAC)  Can occur individually but often occur simultaneously  Hypothermia inhibits blood coagulation which causes a build-up lactate in blood causing metabolic acidosis  The recognition of the importance of this triad has led to the development of damage control surgery. Surgery is initiated rapidly, only the most rapid & simplest interventions that are required to stop bleeding & contamination are undertaken.

Answer 91

mechanism of injury is the energy kinetic eg: blunt or penetrating injury. Blunt injury can be a fall or impact. Combination of forces, acceleration (how fast was the impact), deceleration (what did they hot), shearing (brain shifts from one side of the skull to the other), compression. Penetrating injury can be a stab wound. Consider positioning & mobilisation of the patient, history (how has this happened), x rays, CT or MRI scan, hard collar (major trauma).

Answer 92

 Thermal (electrical)  Chemical (bleach) – cement = lime – alkaline = worst type of burn  Radiation,  Fire – smoke inhalation

Answer 93

```  46,000 hospitalised 1999-2004  0-4 years scalding is most prevalent  Males 1 in 5 are at work aged 15-39  69% admitted between 1-3 days  57% admitted require ```

Answer 94

* Involves the epidermis * Skin is pink, red and painful * Heals in 7 days

Answer 95

epidermis & superficial dermis – top/middle skin layer – blisters, painful, exudate – heals in 14 days

Answer 96

* Epidermis and dermis * Large zone of non -viable tissue * Less painful – diminished nerve endings * Pale to dark pink

Answer 97

``` Waxy appearance • > risk infection • Liminted movement • Deep into the dermis • Pink to pale ivory colour • Skin does not blanch • Hair falls out • Surgically excised ```

Answer 98

* Epidermis and dermis destroyed, may penetrate into underlying structures * Dense white, waxy, charred * Skin often feels leathery (eschar)

Answer 99

Includes whole surface area, skin becomes tourniquet (cannot expand because the skin is so tight. Treatment is escharotomy

Answer 100

LOCAL EFFECTS = zone of the burn injury. Each burn area has 3 zones of injury.  Inner zone – area of coagulation – cellular death occurs – most damage sustained  Middle zone – zone of stasis – compromised blood supply, inflammation & tissue injury  Outer zone – zone of hyperaemia – sustains least damage

Answer 101

TBSA 20% produce both a local & systemic response & considered major burn injuries Burns

Answer 102

Initial systemic effect is haemodynamic instability from loss of capillary integrity and shift of fluid, protein and sodium from the intravascular space into the interstitial spaces. Haemodynamic instability involves:  Cardiovascular – Hypovolaemia,oxygen delivery = CO, BP. SNS releases catechlamines (adrenaline & noradrenaline) for vasoconstriction & ^HR. Fluid resus required, if not, distributive shock will occur

Answer 103

Inhalation injury – inhalation of noxious gas and superheated air (explosion or burning structure & trapped inside). Increases risk of pneumonia. Respiratory depression occurs in burns patients without evidence of smoke inhalation injury. Bronchoconstriction (due to release of histamine) and chest wall constriction secondary to circumferential full thickness chest burns causes respiratory depression. Hypoxia may occur (catecholamines released – vasoconstrictors) which hen requires supplemental oxygen. Intubation is required as soon as increasing airway obstruction is determined.

Answer 104

Fluid & electrolyte alterations. During burn shock, serum sodium levels vary in response to fluid resuscitation. Usually hyponatraemia (sodium depletion) is present. Hyponatraemia is common during the first week of the acute phase as fluid shifts from the interstitial to vascular space. Immediately after burn injury, hyperkalaemia (excessive potassium) results from massive cell destruction. Hypokalaemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. Red blood cells destroyed results in anaemia. Blood transfusions required maintain adequate haemoglobin levels for oxygen delivery. Oedema occurs at the time of burn injury and is seen within 1 hour of injury when there is a fluid shift into the burn tissue. Patients with severe (>20%) burns develop massive systemic oedema. Reabsorption is dependent on the depth of injury to the tissue. As oedema increases this puts pressure on small blood vessels & nerves in distal extremities causing blood flow to be obstructed and consequent ischaemia. This is compartment syndrome. Escharotomy, surgical incision to the eschar (devitalised tissue from burn) to relieve the constricting effect of the burned tissue.

Answer 105

Immunological defences greatly altered by burn injury. Serious burns diminish resistance to infection. Sepsis remains one of the leading causes of death in burn patients. Loss of skin integrity is compounded by the release of abnormal inflammatory factors. These alterations result in immunosuppression and increase risk for sepsis. As a result, the major cause of death in the burn patient who survives after 24 hours is multiple organ dysfunction syndrome MODS. Infection controlled environment is important. Immunosuppression places burn patients at high risk of sepsis.

Answer 106

Remove patient from danger – Stop the burning – Airway, look in mouth, look at tongue, up nose for signs of singed nose hair, cold running water or wet towels applied to burn area for 20 mins, remove clothing as they can continue to burn skin. Sedate & intubate if any signs of burns in nose or mouth as swelling will increase.

Answer 107

consider intubation & high flow oxygen (non-rebreather) as burns to the airway can cause swelling that blocks the flow of air into the lungs. Circulation, oxygen therapy, NIL by mouth to prevent aspiration of vomitus as nausea & vomiting occur due to paralytic ileus from stress of injury.

Answer 108

T, P, RR, BP, cardiac monitoring if history of cardiac disease, electrical injury or respiratory problems.  Elevation of burned extremities to decrease oedema, elevation of lower & upper extremities on pillows or suspension using IV poles.  Indwelling urinary catheter inserted for major burns to accurately monitor urine output and renal function.  Tetanus prophylaxis administered if patients’ immunisation status is unknown because burns are contaminated wounds.  Fluid resuscitation – management of fluid loss & shock – see below for calculation

Answer 109

Formula - | 2mls/kgx %TBSA x Pre-body weight (In kg) = Volume in mls

Answer 110

Patient that was 60Kg pre-burn with 60% TBSA = (2mls/kg x %TBSA x pre-burn body weight (in kg) = volume in mls) = 2ml x 60 %TBSA = 120 120 x 60 kg = 7200mls

Answer 111

50% of 7200 is required in the 1st 8 hrs post burn = 3600ml 25% of 7200mls is required in the 2nd 8 hrs post burn = 1800 25% of 7200mls is required in the 3rd 8 hrs post burn = 1800 NOTE: on top of this fluid quantity, the pt will also require the 'normal' daily intake of hydration over 24/24 Average intake = 200mls over 24/24 = 83mls (2000 / 24) * In the 1st hour 533mls/hr of CSL

Answer 112

monitor IV & oral fluid intake – Input, output & daily weights obtained to monitor fluid status changes.

Answer 113

Clean technique used for wound care procedures – provide a safe & clean environment & check burn wound to detect early signs of infection

Answer 114

when bowel sounds resume oral fluids should be initiated slowly – patient’s tolerance noted & fluids increased gradually and normal diet resumed if vomiting & distension do not occur. Nurse to liase with dietician to plan a diet acceptable to the patient

Answer 115

Support patient during emotionally, distressing & painful experience of wound care. Nurse to make assessments of the wound status & record changes or progress in wound healing and keep all members of the healthcare team informed of changes in the wound or treatment.

Answer 116

50% of 7200 is required in the 1st 8 hrs post burn = 3600ml 25% of 7200mls is required in the 2nd 8 hrs post burn = 1800 25% of 7200mls is required in the 3rd 8 hrs post burn = 1800 NOTE: on top of this fluid quantity, the pt will also require the 'normal' daily intake of hydration over 24/24 Average intake = 200mls over 24/24 = 83mls (2000 / 24) * In the 1st hour 533mls/hr of CSL Need to prevent over loading, hence the 24 hour period Normal daily intake 2000ml over 24 hour = 83ml 50% 25% = 83ml each 25%

Answer 117

Priority to prevent complications from immobility. Deep breathing, turning, proper repositioning are essential to prevent atelectasis, pneumonia, & prevent ulcers & contractures. Early sitting & ambulation are encouraged. Prevention of DVT, compression bandages in lower limb burns promote venous return & minimise oedema formation.

Answer 118

Depression, regression & manipulative behaviours are common responses of patients who have burn injuries. Psychological distress & depression are common in people who have experienced burns. Nurses can assist patients to develop effective coping strategies by setting specific expectations for behaviour, build trust, give positive reinforcement when appropriate.

Answer 119

Family functioning is disrupted with burn injury. Nurses responsibility is to support the patient & family & to address their spoken & unspoken concerns. Family members need to be instructed about ways that they can support the patient as adaptation to burn trauma occurs. Burn injuries impacts patient & family psychologically, economically & practically. Social support & counselling should be made available. Patient & family education. Assess learning styles of patient & family & tailor teaching activities to these.

Answer 120

Heart failure & pulmonary oedema – acute respiratory failure & acute respiratory distress syndrome – visceral damage

Answer 121

 Psychological support |  Abnormal wound healing

Answer 122

 Extinguish the flames – smother flames – stop, drop, roll – disconnect electrical source if burn source is electrical  Cool the burn – tepid running tap water for 20 mins or cool wet towels – NO ICE  Remove restrictive objects/clothing  Cover the wound – use cling film as it is sterile – minimises bacterial contamination – decreases pain by preventing air coming into contact with the burn – no creams or ointments at they compromise the assessment of the burn  Irrigate chemical burns – if at home brush off the chemical agent, remove clothing immediately, rinse all areas of the body that have come into contact with the chemical with running water/shower.  Local effects of a burn are most evident but the systemic effects pose greater threat to life. Primary survey ABC, C spine, cardiac monitoring for patients with high voltage electrical injuries.

Answer 123

A 80kg pt has 25% TBSA burn. The pt is NBM so include the 2L maintenance fluid requirements. Formula: 2ml x kg x %TBSA + 2oooml = 2ml x 80kg x 25% TBSA + 2000ml = 6000ml

Answer 124

Answer = C

Answer 125

Calculate how much is burnt & how much we need to fluid resus

Answer 126

1. Inner zone: - area of coagulation - cellular death occurs - most damage sustained 2. Middle zone: - Compromised blood supply - inflammation - tissue damage 3. Outer zone: - Zone of hyperaemia (excess of blood in the vessels) - Sustains least injury

Answer 127

1. Cardiovascular: - hypovolemia 2. Respiratory: - Bronchconstriction 3. Metabolic: - hyponatraemia (

Answer 128

– elderly & infants

Answer 129

* Are more at risk of heat loss and fluid loss due to increased surface area to volume ratio * > risk of dehydration & hypothermia * > risk of hypoglycaemia due to metabolic rate (b/c they’re continually developing * Any fluid requirement needs to be calculated by weight * Adjust 02 delivery * ABGs & electrolyte values are the same as adults

Answer 130

* Different from adult * Large tongue, short trachea * Newborn larynx is 1 3rd of adults * Do NOT do head tilt, neck it too short = occlude airway * Keep in neutral nose up position * Risk for aspiration is high

Answer 131

* RR = 40 bpm * Underdeveloped intercostal / accessory muscles * Tachypnoea is a normal response * Slowing RR (is not an improvement) could mean impending collapse (decompensating) * RNs do NOT do nasopharyngeal on infants (nasal breathers) need advanced nurse

Answer 132

* Nasal prongs, CPAP, BiPAP, head box, adults masks if emergency * Head box is better – the infant can still see shadows etc.… & parents can see child

Answer 133

* Ensure patency * Good to hear the infant cry = clear airway * Assess for adventitious sounds – stridor, wheeze, grunting * Resp distress = head bobbing, nasal flaring, intercostal or sternal recession * Fatigued / flat child – NOT good

Answer 134

- Acute swelling causing upper airway obstruction - Treat with steroids and nebulised adrenaline

Answer 135

- Inflammation of the epiglottis | - urgent intubation, nurse upright/supoorted until EET

Answer 136

- anything small enough to fit in the mouth | - coughing, back blows, removal of FB with magill forceps

Answer 137

- viral - obstruction of small airways resulting in air trapping - Continuous monitoring, SP02 - supportive management

Answer 138

- mucosal and immune system dysfunction - lower resp inflammation of the airways - asthma severity assessment, oxygenation, bronchdilation, steroids, magnesium

Answer 139

``` ETT uncuffed up to puberty, the tube is monitored very closely, Suctioning, 2-6hlry , suction catheter less than 2/3 the internal diameter of the ETT Humidification necessary Gastric Decompression Restraints required Analgesia and sedation Ventilator Non invasive vent Bi PAP, CPAP High frequency oscillatory ventilation ```

Answer 140

``` Pulses Brachial BP – Age related (p888) Fluid and drugs calculated on weight Urine output 0.5-2mls per hour Calculating child's weight (Age + 4) x 2 Broselow Tape ```

Answer 141

Children compensate for hypovolaemia by vasoconstriction and tachycardia, and may lose up to 30% of blood volume before becoming hypotensive The pulse pressure will narrow before hypotension occurs. Capillary refill is a non-specific sign of circulatory compromise in a hypothermic child. Tachycardia is also non-specific, and occurs in children who are hypovolaemic, in pain, frightened, hypoxic, hypercapneic, having seizures etc. Look for the cause and treat it.

Answer 142

``` Patients weight: 3kg - 10kg Mls/day: 100mls x weight mls/hour: 4 x weight ``` ``` Patients weight: 10kg - 20kg mls/day: 1000 plus 50 x (wt - 10) mls/hour: 40 plus 2 x (wt - 10) ``` ``` Patients weight: > 20kg mls/day: 1500 plus 20 x (wt - 20) mls/hour 60 plus 1 x (wt - 20) ``` IV fluids are different and commonly used fluids are 0.45% Normal Saline and 2.5%

Answer 143

Commonest form of shock in children, HR not BP Haemorrhage, trauma, GIT bleeding, burns, peritonitis & diarrhoea. Responds well to fluid resuscitation Fluids titrated to maintain adequate cardiovascular function

Answer 144

Manifests as hypoxemia, hyperthermia or hypothermic, HR, cap refill, peripheral pulses, cool, mottled, urine output.

Answer 145

Assessment ABCDE (rash) Cardio respiratory monitoring, temperature, urine output, ABG, U&E Fluid resuscitation, early and aggressive, within first hour, before hypotension develops, O2 therapy Improve cardiac performance, optimise O2 delivery to tissues Inotrope/vasopressors (dopamine, dobutamine/adrenaline and noradrenaline)

Answer 146

``` Gastrointestinal system Central nervous system Cardiovascular system Respiratory system Integumentary system Musculoskeletal system ```

Answer 147

``` Neurological Dysfunction Meningitis Encephalitis Seizures Encephalopathy ```

Answer 148

MVA’s trauma near drowning assault & falls Similar to adults, trauma team

Answer 149

Adults older than 65 use 46% acute care beds although only 12.5% of the population Most common admissions include Arrhythmias, heart failure, stroke, fluid and electrolyte imbalances, pneumonia, hip fractures

Answer 150

Multi-system conditions and co-morbidities Arrhythmias, heart failure, stroke, fluid and electrolyte imbalances, pneumonia, hip fractures Identify falls risk, early d/c and assistance required, interdisciplinary teams, community based referrals, standard protocols

Answer 151

Surgical risk- higher so ICU or HDU admissions Delirium, sensitive to changes in fluids, metabolic and nutritional imbalances, medications and infections Nosocomial infections, decreased immuno- competence, underlying disease, increased drug adverse reactions Pain management Medication use poly-pharmacology, Depression Nutrition, physical and social considerations

Answer 152

Cardiovascular, cardiac output, rate and rhythm, structural changes, arterial circulation, venous circulation, peripheral pulses Respiratory, structures, ventilation and perfusion, ventilation control, lung compliance decreased Urinary- bladder- functioning nephrons decreased, excretion of toxins decreased

Answer 153

``` Patients may require Intensive care for any of the following: Instability (hypotension/hypertension) Respiratory compromise Cardiac arrhythmias Acute renal failure Multiple organ failure Intensive invasive monitoring Post surgery ```

Answer 154

``` Surface landmarks Borders of abdominal cavity Abdominal muscles Internal anatomy (viscera) Solid viscera Liver Pancreas Spleen Adrenal glands Kidneys Ovaries Uterus ```

Answer 155

* Liver - bleed a lot in trauma – total body fluid requirements * Pancreas * spleen - bleed a lot in trauma – total body fluid requirements * adrenal glands * kidneys * ovaries * uterus

Answer 156

* stomach * gallbladder * small intestines * colon * bladder

Answer 157

cardiac, gallbladder, kidneys etc.

Answer 158

Refers to discomfort in your upper abdomen or back and sides It develops in the area below the ribs and above the pelvis. Usually, the pain is worse on one side of your body. Most people experience flank pain at least once in their life, and the discomfort is usually temporary.

Answer 159

laparoscopy, ectopic pregnancy

Answer 160

1. Prostate 2. Bowel 3. Breast 4. Melanoma 5. Lung

Answer 161

* 20 – 25% of all ICU patients | * > mortality rate

Answer 162

* More common I women | * Diabetic patients – 35% over 20 years has it

Answer 163

Each kidney has approx. 1 million nephrons

Answer 164

``` Right upper (RUQ) Left upper (LUQ) Right lower (RLQ) Left lower (LLQ ```

Answer 165

Rebound tenderness (Blumberg’s sign), choose a site away from tender area, pain on release of pressure Inspiratory arrest (Murphy’s sign), inflamed gall bladder, pain on deep breath when palpating liver Iliopsoas muscle test, ? Appendix/leg lift Obturator test, questionable

Answer 166

``` Infections Trauma (blunt and Penetrating) Inflammation Pre-existing conditions Cancers Organ failure ```

Answer 167

``` Acute Renal Failure (ACR) 20-25% of Intensive Care patients High mortality rates Poor outcome if RRT required Chronic Kidney Disease CKD is more common among women than men. More than 35% of people aged 20 years or older with diabetes have CKD. More than 20% of people aged 20 years or older with hypertension have CKD ```

Answer 168

``` Each Kidney has approx 1 million nephrons Filters blood to produce urine Each nephron contains Glomerulus Glomerulus (Bowmans) capsule Loop of Henle ```

Answer 169

``` Pre-renal Blood supply to the kidneys hypovolemia decreased cardiac function decreased peripheral vascular disease decreased renovascular blood flow ```

Answer 170

Acute Tubular Neurosis (ATN) Glomerulonephritis Nephrotoxicity Vascular insufficiency

Answer 171

Damage to the tubular portion of the nephron may be caused by more than one mechanism. Most commonly associated with administration of nephrotoxic agents in association with prolonged hypoperfusion or ischemia. Provoked by Infection , blood transfusion, drugs, ingested toxins and poisons complication of heart failure or cardiovascular surgery. Term often used in ICU to describe ARF. Accounts for 30% ARF in ICU.

Answer 172

Infective/inflammatory process damaging glomerular membrane or a systematic autoimmune illness attacking the membrane. This allows larger blood components eg plasma proteins and WBC cross the membrane. This causes tubular congestion and nephron failure.

Answer 173

``` Damage to nephron from causative agent Drugs Antibiotics anti-inflammatory cancer drugs radio opaque dies. ```

Answer 174

1/3 of pts in ICU have chronic renal dysfunction. May be undiagnosed related to diabetes, ageing process , hypertension. These factors create reduction in vasculature of the kidney therefore reduce glomerular filtration.

Answer 175

``` Benign prostatic hyperplasia Bladder cancer Calculi formation Neuromuscular disorders Spinal cord disease Strictures Trauma (back, pelvis, perineum) ```

Answer 176

Clinical history essential in differentiating between pre-existing renal disease and potential for ARF Clinical History along with key assessments allow for accurate diagnosis

Answer 177

``` Assessment renal output, serum creatinine levels, HR, CVP, BP, PCWP ```

Answer 178

``` Reducing further Damage IV fluid resuscitation Assessment for renal outflow obstruction Cease or modify any nephrotoxic drugs or agents Treat infection with alternate less toxic antibiotics Nutrition Enteral or Parenternal 30-35kcal/kg/day Protein intake 1-2g/kg/day Renal replacement Therapy (RRT) ```

Answer 179

If conservative measurements fail, renal replacement therapy is required to: Control blood biochemistry Prevent toxin accumulation Allow removal of fluids to allow adequate nutrition One criteria is sufficient to initiate RRT Two or more signify urgent and mandatory RRT ``` Renal replacement therapy Initiation criteria (Box 18.1, Elliott et al 2015 p 595) Oliguria (UO 6.5mmol/L) Severe acideamia (pH 30mmol/L) Clinically significant organ (esp Lung) oedema Uraemic encephalopathy Uraemic pericarditis Uraemic neuropathy/myopathy Severe dysnatreamia (Na > 160 or ```

Answer 180

``` Peritoneal dialysis Haemodialysis Continuous renal replacement therapy (Acute) Haemodialysis Community based (Chronic) Access - Catheter AV access AV fistula – (no catheter) Renal transplant ```

Answer 181

Liver failure is the inability of the liver to perform its normal synthetic and metabolic function as part of normal physiology. There are two types of liver failure Acute Chronic

Answer 182

Acute Liver Failure is the rapid development of hepatocellular dysfunction, specifically coagulopathy and mental status changes (encephalopathy) in a patient without known prior liver disease Diagnosis Based on: physical exam laboratory findings patient history past medical history to establish mental status changes, coagulopathy, rapidity of onset, and absence of known prior liver disease respectively

Answer 183

Usually associated with Cirrhosis & can develop from viral Hep B & C, alcohol, metabolic (Wilson’s disease) or autoimmune.

Answer 184

``` Hepatic Encephalopathy Hepatorenal Syndrome Varices & Variceal Bleeding Ascites Respiratory Compromise ```

Answer 185

Orthotopic Liver Transplantation Split-liver Transplantation Adult-Living Donor Transplantation

Answer 186

Failure to Rescue Specified MET criteria for health care facilities Parameters set for notification for specific patients National consensus statement: essential elements for recognising and responding to clinical deterioration (Australian Commission on Safety and Quality in HealthCare)

Answer 187

Filtration Reabsorption Secretion

Answer 188

 Closely related to outcome of Sepsis  Abnormal cellular responses involving multiple organ systems  Sequential process – flows – domino effect – teying to treat & prevent at the same time  Complex Process  Simultaneously involving every cell type

Answer 189

 Hypoxic - Hypoxia is caused by altered metabolic regulation of tissue oxygenation starving tissue  Microcirculatory injury occurs – damage & injury to micro vessels – kidneys, lungs, brain etc.  During Sepsis or ischemia mitochondria cause cell death rather than restore homeostasis  Can happen over several days 4,5,6,7 days eg. Burns patients

Answer 190

 SIRS ◦ Inflammatory state affecting the whole body ◦ Serious condition related to systemic inflammation, organ dysfunction & organ failure ◦ Abnormal regulation of cytokines ◦ Signs and symptoms  SIRS > Sepsis > Shock > MODS  Wide spread inflammation: heart, kidneys etc… kidney fails = domino effect = MODS

Answer 191

 Systemic inflammatory response syndrome must be diagnosed by finding at least any two of the following:  Temperature 38.5 degrees – hypo or hyperthermia  Heart Rate >90 - tachycardia  Tachypnoea RR >20  WCC – significantly low or elevated – white cell count  Second, SEPSIS = other comorbidities  Third, signs of end-organ dysfunction  * must be diagnosed with at LEAST two symptoms

Answer 192

 Treatment primarily consists of the following: ◦ Volume resuscitation ◦ Early antibiotic administration ◦ Early goal directed therapy - is individual to patients needs ◦ Rapid source identification and control – what caused it? Where did it start? Eg. Did they get pancreatitis pre or post-surgery ◦ Support of major organ dysfunction

Answer 193

 Early identification of organ dysfunction critical  Early intervention reduces damage > recovery – Car analogy- flat tyre – get it changed & fixed = short recovery time If you keep driving on it – will damage the rim, road, driveway = will need to fix all of them = long recovery time  Risk of death 11-23% as each organ fails  Up to 75% of patients in sepsis have at least 2 failing organs  Organ failure cascade:  Pulmonary system  Cardiovascular  Renal  Haematological system

Answer 194

 Formation of microvascular platelet aggregates (and possible fibrin formation)  Meaning – clots develop in the macrovascular area  Usually caused by injury to microvascular endothelium: ◦ Haemolytic anaemia, > liver enzymes,

Answer 195

 Widespread activation of tissue factor –dependent coagulation (

Answer 196

 MODS can result from: ◦ Traumatic brain injury - CVA ◦ Subarachnoid haemorrhage – SPONTANEOUS BLEED  Causes respiratory and cardiovascular organ dysfunction  Due to dysfunction of the sympathetic nervous system  Survivors of sepsis induced MODS may suffer cognitive impairment

Answer 197

 Many scoring systems for predicting mortality  Some adapted for assessing organ dysfunction ◦ APACHE (acute physiology and chronic health evaluation) ◦ SAPS (simplified acute physiology score) ◦ MPM (mortality probability models)  Specific organ dysfunction assessments ◦ SOFA (Sepsis-related/sequential organ failure assessment

Answer 198

```  Uses the worst values for 6 clinical parameters within 24hr period: ◦ Pa02/Fi02 ◦ Platelet count ◦ Bilirubin ◦ BP ◦ GCS ◦ Urine output/creatinine concentration  As number of dysfunctional organs increase – SOFA score increases – mortality increases ```

Answer 199

```  Shock Management  Awareness of Secondary Insults – what could go wrong  High level critical care management  Prevention and management ◦ Effective shock resuscitation ◦ Timely treatment of infection ◦ Exclusion of secondary inflammatory insults ◦ Organ support ```

Answer 200

 Interventions to reduce MODS from Sepsis ◦ Surviving sepsis guidelines (SSG)  Based on clinical evidence  Graded according to the quality of evidence ◦ Early Goal Direct Therapy (EGTP)  Provides clinicians with target outcomes for treatment in early sepsis management  Encourages early intervention

Answer 201

 Essential in Prevention and Management of MODS  Antimicrobial therapy in septic shock essential  Inappropriate initial antimicrobial therapy = five fold decrease in survival  Increase in incidence of acute kidney injury if antimicrobial therapy delayed  Treat early!

Answer 202

 MODS is complex and requires highly skilled nurses  Understanding of pathophysiology, inflammatory response and sepsis essential if early intervention is to be implemented  Nurses require: ◦ High knowledge base ◦ Vigilant assessment skills ◦ Identification of interventions required ◦ Prioritisation skills ◦ Time management skills

Answer 203

 117,000 ICU attendances per year in Australia  Survival rate of 89% that reach discharge  >6 months for functional recovery at home -  Physical deconditioning  Neuromuscular dysfunction  Psychological issues

Answer 204

When the patient leaves the ward, their journey is just beginning…. The longest part of recovery We need to supply them with all the resources & referrals

Answer 205

 Critical care one component in the continuum of care  Critical illness begins with onset of acute illness, includes ICU and incorporates the risk of related problems  Nurses now consider patients recovery in terms of:  Health Related Quality Of Life (HRQOL)  Need to continue the concept of holistic care beyond the ICU

Answer 206

``` Primary Survey  A - Airway  B - Breathing  C - Circulation  D - Disability  E – Exposure ```

Answer 207

 A – Awaken the Patient Daily  B – Breathing trials (to minimise mechanical ventilation duration)  C – Coordination (to daily awaken and spontaneous breathing trials)  D – Delirium Monitoring  E – Exercise/Early Mobility (requires a patient to be

Answer 208

 46% of Patients acquire ICU Acquired Weakness (ICU-AW)  Critical illness Myopathy  Polyneuropothy – nerves weakness to multiple nerves  Neuromyopathy – muscle  Acquisition of ICU-AW is associated with:  Co-existing conditions (COPD, CCF, DM)  Critical Illness (Sepsis, SIRS) Treatments (mechanical ventilation, hyperglycaemia, sedatives, immobility

Answer 209

 Measurements need to be taken to ensure the patient meets HRQOL indicators  Patients must be considered holistically  Measurements taken to ensure appropriate development in:  Physical Function  Psychological function (See pg 60 Elliott 2012 for measurement tools)

Answer 210

```  Physical recovery can be short  Psychological recovery can be long  Effected by memories and experiences  Patients suffer  Powerlessness  Reality-unreality  Reactions and acceptance  Comfort-discomfort  Anxiety  Depression  PTSD ``` Comes out over time, the patient may have been a very fit & active person – accident occurs – wake up in ICU 3 weeks later….

Answer 211

 Psychological care of post ICU patients can be difficult  Long term  Specific interventions  Patient diaries – provides missing pieces of information  Not all patients want to be reminded of their experience  Regular psychological assessment recommended by NICE  Including 2-3 months after being at home/rehab

Answer 212

```  5% of patients who survive will die within 12 months  Follow up essential  ICU FU Clinics - - follow up clinics  Review progress  Identify problems early  Coordinate care  Support rehab  Discuss ICU experience  Offer visits to ICU  Allow relatives to ask questions ```

Answer 213

 Remember – discharge begins at admission  Planning of care needs to be long term  Considerations at home  Care needs to be Holistic A –E assessment Realistic goals Do they need any help / other services to help at home?

Answer 214

Good luck, work your socks off & you’ll get where you want to be X

NUR 305 exam prep Sam Fox Flashcards

(239 cards)