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CRITICAL CARE EXAM 1
REVIEW
- End of life care – Critically ill and ethical issues- Respect DNR a. Living wills b. Health care surrogate c. Communication
- Advanced directives
- Communication
- Environmental factors a. Noise reduction - reduce the alarms.
- Therapeutic response to family - keep informed, know who is in charged w/family
- Communication in critically ill - inform them on what is going on
- What to watch for in critical pt with opiates - antidote is narcan - watch respirations, hypotension, apnea, bradycardia, restlessness and nausea
- Ventilator weaning process - spontaneous breathing trial (pg215 table 9.5) before extubating Assess pt discomfort - signs and symptoms pg 214 a. What would be the appropriate method to wean someone? i. Not going to have someone on PEEP or high oxygen ii. spontaneous breathing trial (pg215 table 9.5) before extubating
- Handoff report to other nurses - SBAR - situations, background, assessment and recommendations
- Which pt would you select for priority intervention - ABC's and Maslow’s
- Paradoxical means not equal or opposite of chest rise – can see this in COPD pts.
- Cagnography & hypercapnia both relates to CO2 - end of ETT to check for placement, not the best option, checks for high or low co2 after exhaling
- Angiogram and pt is agitated you need to sedate, if invasive you need a consent
- Any kind of scan (CT Scan, angiogram) and patient is anxious: patient needs to remain sedated
- Risk factors for ARDS - trauma, sepsis, gastric aspiration content, pneumonia,
- ARDS and chest x-rays - bilateral infiltrates (white-out) , it is positive for ARDS, "ground glass appearance" a. Bilateral infiltration b. White out on xray c. “Ground glass”
- Ards - they will be on antibiotics and steroids (increases sugar and oral thrush), look for hyperglycemia or infections.
- Someone with ARDS will be on (hypovolemia=fluids/sepsis=antibiotics) a. Antibiotics b. Steroids (hyperglycemia) c. Thrush (candidiasis) They will be on antibiotics and steroids (increases sugar and oral thrush), look for hyperglycemia or infections.
- Trying to decrease Vap (pg422,box 14-4 & 14-5)- elevated head greater then 45, hand hygiene, …….
- Oral care for decreased chances of VAP (Ventilatory acquired pneumonia) Trying to decrease Vap (pg422,box 14-4 & 14-5)- elevated head greater then 45, hand hygiene
- Lab values - understand factors of O2 stats - know what it is and what it means pg 404 - depends on pt and condition. O2 stats is the measurement of oxygen on the hemoglobin.
- Understand the factors of O2 Saturation; 92% is normal for a COPD patient, but not normal for a healthy adult
- Rank in order of priority - optimizing oxygen delivery to patient - pain is low, then is not priority. if pain in high then it is a priority
- Copd -(barrel chest, purse lip breathing, large ap diameter, tripod position) greatest risk for developing respiratory failure, why? Increase ap diameter is bigger risk,
- COPD patients have Barrel chest, AP diameter
a. know lab levels (CBC, PT/PTT, WBC, INR, D-Dimer) b. birth control c. smoking d. obesity e. age a. immobility b. post op patients c. HF d. AFib and arrhythmias
- Ending in ACE is a thrombolytic Ending in Onimuin is a NMB
- Know labs - pt - 10-14sec aptt - less than 35sec cbc = Wbc - 4,500 - 11, Hematocrit - Hemo - Rbc - Platelet - 150- Inr - 0.9-1.1 therapeutic value Pt comes in with suspected pneumonia - check lung sounds, crackles at the bottom of lungs
- Patient comes to the ER with cough and suspected pneumonia and SOB what is the priority vital sign assessment? Lung sounds, check the base of the of the lungs Surgery to remove a clot a. Embolectomy b. V/Q scan high probability is followed by angiogram c. V/Q scan is low probability patient is sent home on aspirin
v/q scan then angiogram - to check for PE. If high then you get angio, if low you aspirin or antiplatelet (Plavix) Ards, not a lot on vent, know pip and plateu pressure, fio2, copd, ethical dilemmas, Best method of communication with a patient with a foreign language is a translator Simv - it synchronizes with your breathing ARDS/COPD/PIP/PEEP/SIM-V/ethical/environmental/Pressure support (similar to plateau pressure support--page 195—monitored to avoid excessive pressure) Prevention of clot AnticoagulantIf patient has history of clots See if patient is candidate for thrombolytic(-ase) CRITICAL CARE CONCEPT REVIEW EXAM 2 60 questions 9 select all 6 math contributing factors for cad and acute mi Gender Age Hereditary Smoking High bp Cholesterol Inactivity Smoking Diabetes and obesity Not SATA***Pt with chest pain what lab results Pt status post op cath - what care should be included
Not Disequilibrium syndrome (only happens two first times) Infection Pt has an arterial line what action should you take to prevent complications Pt has diabetes and is many meds, what would you want to know about pt to avoid AKI when they are having surgery? Kidney function, aminoglycosides or nsaids , know bp Order Prioritizing - what would be the priority for pt with cardiac surgery?
- Vital signs
- Pain
- H & H
- Infection
- Assess drainage in chest tube How do you assess jugular venous pressure.
- Position 30 to 45
- Head turn to left
- Id jugular vein
- Assess highest point at end of exhalation
- Observe pulsation
- Add 5 cm 7 -9 in normal Pt being discharged with pacer - priority teaching
- Teach why they have it
- Assess knowledge
- Explain back to you the treatment
- Identify misconception about care Hypovolemic Trauma Burns Hemorrhage Increased hr Decreased bp Increased respirations Oliguria They get isotonic lr/ns Prbc - coiloids Albumin Platelete Ffp They need a-line to monitor bp / cvp less than 2
Neurogenic Spinal cord Post anesthesia Post epidural cath Decreased hr - atropine Decreased bp Decreased temp Imobilize with brace or traction Vasopressors - to keep normal cpp Vasopressin Epi Dopamine Slow rewarming - bear hugger blanket, fluid warmer Septic Leads to mods Increased hr Decreased bp Iv antibotics - require peak (if high lower dose) and trough (if high lower frequency) Vancomycin Aminoglycosides Anaphylaxis Different causes Deceased bp Relative hypovolemia Give epi 1-10,000 - subQ Corticosteroids Antihistamine If you were pt and a loved one were in major accident- you wanna go to trauma one center Head traumas that you may see- lacerations, coup contra coup, Signs with head trama - battle signs, raccon eyes What labs we check with fluid resuscitation - abgs, h&H, lactate levels Someone hits sterring wheel - cardiac contusion (vasopressors), cardiac tamponade (pericardiocenthesis), rib fracture (pain meds), pnuemo &hemo (chest tube) Long bone fracture - risk for dtv - fat emboli, heprin & scd What is primary survey in trauma unit - abc, glascow coma Transfusion try to be avoided? Yes we rather use fluids first Cross and match for transfusion Most critical thing to monitor in a patient???? Glascow coma Icp - 5 -15 normal
b. Peak levels within 18-36 hrs c. Levels return to baseline in 3-6 days d. Nonspecific because can also mean muscle injury or acute renal failure
- CK2-MB (heart) a. Fraction of total CK, specific for cardiac muscle b. Normal 0%-6% or 0.3-4.9 ng/ml c. Elevated after MI, cardiac surgery & blunt cardiac truama d. Initial rise between 4-8 hrs after damage e. Peak levels 18-24 hrs f. Return to baseline 3 days g. Ordered initially with total & then again at 8 , 16 & 24 hrs
- troponins I & T a. Useful in early AMI b. Normally undetectable c. Elevate at early as 1 hr after injury d. Normal levels troponin I <0.5 mcg/L & troponin T < mcg/L
- myoglobin a. Released with 30-60 min after AMI, useful in diagnosis b. Normal value <72 ng/mL in men, <58 ng/mL in women c. Rise before Ck and CK2-MB d. Not specific for it but when used with other test, it can help the diagnosis e. Doubling in levels for one sample to the next means AMI, some places draw every 2 hours.
- Chest tube monitoring in post CABG surgery - pg. 321 box12-
- Make sure all connections are tight
- Assess dressing over site to be dry & intact
- Palpate to feel for subcutaneous crepitus
- Listen to breath sounds bilaterally
- Look and color and consistency of fluid in collection tube
- Mark fluid level on the drainage system
- Assess for proper functioning
- Check water in water seal chamber (should be fluctuating with respirations)
- Check suction control
- If water bubbles in the water seal chamber then there is a leak in pleural tube
- Keep tube coiled on bed
- Record drainage; tell doc if excessive
- Change dressing as protocol
- Splint insertion site to help with coughing & deep breathing
- Make sure flow is draining with gravity; do not milk or strip tube or will have negative pressure
- If moving pt then keep drainage system upright and below the level of the chest; do not clamp tube
- Chest x-ray right after insertion & daily after.
- Priority nursing functions for the possible MI patient - pg. 315
- MONA
- Rank nursing actions after CABG surgery pg 321 box 12-
- Monitor for hypotension (give fluids or vasopressors as needed)
- Assess for hypovolemia (monitor output of chest tubes & urine output)
- Monitor hemo pressures (SvO2, stroke index, cardiac index, PAOP & RAP)
- Rewarm gradually
- Monitor& treat fluids & electrolytes, h&h, renal functions & coagulation studies
- Pain relief
- Monitor for complications a. intraoperative AMI, b. dysrhythmias, c. heart failure, d. cardiac tamponade, e. thromboembolism, f. impaired renal functions, g. pneumonia, h. pneumothorax, i. pleural effusion, j. cerebral ischemia, k. stroke
- Wean from ventilator; extubate; pulmonary hygiene every 1 to 2 hrs while awake
- Assess wounds & provide care
- Gradually increase pt's activity
- Emotional support to pt & family
- Nursing concerns for a patient with CAD/chest pain pg 298 /299 table 12-
- Need to know prior hospitalizations
- Family Medical history
- Allergies
- Any other cardiac events or cardio test
- Current meds like sildenafil (Viagra)
- Exercise routine?
- Daily food pattern?
- Sleep pattern?
- Social stuff like tobacco, alcohol, drugs, coffee, tea?
a. fatigue; diaphoresis; b. indigestion, c. arm or shoulder pain; d. nausea and vomiting.
- Spirolactone for heart failure - pg.
- also called Aldactone (a aldosterone receptor antagonist);
- it is a potassium spearing diuretic;
- there will be more potassium in the blood serum;
- it helps reduce sodium and H2O that causes edema in HF;
- monitor kidney function as well. Hemodynamics/Shock
- Zero arterial line:
- Measuring Jugular Venous pressure: steps of procedure pg. 148 figure 8-
- Supine w/ head elevated 30-45 degrees
- Get on pt's right side
- Tell pt to turn head to the left
- If you can't see jugular, press SCM so it can fill and you can see it. Shine a pen light to see it better? (that stupid)
- Assess distention at exhalation
3 cm elevated from sternal angle (angle of Louis) considered elevated jugular pressure 7. Observe highest point of pulse at end exhalation 8. Measure vertical distance between pulse & sternal angle in cm 9. Add 5cm to estimate CVP
- Normal 7-9 cm
- Procedure for PA catheter insertion: positioning. Pg. 158-
- Trendelenburg position to help venous filling, cath go in smoothly and prevent air embolism
- If ICP or respiratory distress then place blanket roll between shoulder blades.
- CVP pressures and interpretation: know values pg147 table 8-
- Cardiac output (CO) - 4-8 L/min
- Cardiac index (CI) - 2.5-4.2 L/min/ m
- Central venous pressure (CVP) - 2-6 mm Hg
- Right atrial pressure (RAP) - 2-6 mm Hg
- Stroke volume (SV) - 60-130 mL/beat
- Stroke volume index (SI) - 30-65 mL/beat/m
- Systemic Vascular Resistance (SVR) - 770-1500 dynes/sec/cm-
- Pulmonary vascular resistance (PVR) - 20-120 dynes/sec/cm-
- Arterial lines: assessment, nursing care/monitoring pg154-
- Invasive is more accurate than noninvasive
- A difference of 10 -20 mmHg or more between invasive & noninvasive is expected; invasive should be higher
- If non-invasive is higher then suspect technical error.
- In hypotensive, serious discrepancy between the two
- Assess every 2 hours (color, perfusion, sensation, pulse, capillary refill)
- Keep pt wrist in neutral position or on arm board
- If removed keep a lot of pressure on it for a minimum of 5 mins.
- Never administered meds via a-line; can cause complications
- Types of shock: : Vital signs pg 270 table 11-
- Neurogenic a. causes i. Spinal cord ii. Post anesthesia iii. Post epidural cath b. Symptoms i. Decreased hr - atropine ii. Decreased bp iii. Decreased temp c. Intervention i. Immobilize with brace or traction ii. Vasopressors - to keep normal cpp
- Vasopressin
- Epi
- Dopamine iii. Slow rewarming - bear hugger blanket, fluid warmer
- Septic a. Leads to sirs & mods b. Causes i. Immunosuppression ii. Bacteria in blood c. Symptoms i. Increased hr ii. Decreased bp iii. Confusion iv. Oliguria v. Warm early signs then cold late signs d. Interventions i. Iv - require peak (if high lower dose) and trough (if high lower frequency)
i. Increased hr ii. Deceased bp iii. Chest pain iv. Tachypnea v. Oliguria vi. Relative hypovolemia c. Interventions i. Give epi 1-10,000 - subQ or iv in 3-5 ml - best choice to give when they have hypotension and anaphylactic shock ii. Corticosteroids iii. Antihistamine
- Therapeutic effects after shock interventions ….. (I don’t know what the fuck they mean) Treat underlining cause to create optimal tissue profusion Normal tensive
- Multiorgan dysfunction syndrome( MODS): clinical manifestations pg
- Pulmonary dysfunction happens first a. Tachypnea b. Hypoxemia c. Chest x-ray changes
- Hematological a. Petechiae b. Bleeding c. Thrombocytopenia d. Prolonged PT & aPTT e. Increased fibrin split f. Positive d-dimer
- Hepatic dysfunction a. Hypoglycemia b. Jaundice c. Increased liver enzymes & bili d. Prolonged PT e. Decreased albumin
- Intestinal a. Frequent intolerance to enteral feedings b. Abdominal distension c. Increased retention volumes
- Renal a. Oliguria to anuria b. Increased BUN & creatinine c. Fluid & electrolyte imbalance
- Cardio
a. Tachypnea (w/ dysrhythmia) b. Hypotension c. Hemo alterations indicating cardio dysfunction
- Cerebral a. Change in LOC b. Confusion c. Focal neuro signs of hemiparesis
- Systemic Inflammatory Response Syndrome pg256-
- Widespread inflammation
- Caused by either a. Infection b. Trauma c. Shock d. Pancreatitis e. Ischemia
- Can be from or lead to MODS
- Associated w/ sepsis (infection associated with SIRS)
- Mediators that are released cause increase in permeability of endothelial walls so fluid moves from inside vessels to outside space
- Volume in vessels reduces because of it causing relative hypovolemia
- Other mediators cause a. microvascular clotting b. Impaired fibrinolysis c. Widespread vasodilation
- Family centered care with dialysis, education
- Bacterial meningitis: cause s pg. 387 box13-
- Bacterial - worse a. Streptococcus pneumoniae (pneumococcus) b. Neisseria meningitidis (meninggococcus) c. Haemophilus influenzea type b (Hib) d. Staphylococci (staphylococcus aureus) e. Gram-neg bacilli (E.coli, Enterobacter, Serratia)
- Virus a. Echovirus b. Coxsackievirus c. Mumps d. Herpes type 1 & 2 e. St. louis encephalitis f. Colorado tick fever g. Epstein-barr h. West nile i. Influenza type A & B
- Evaluate every 8 hours
- Notify physician if no bruit auscultated, no thrill is palpated, or distal pule is absent
- Percutaneous catheters for dialysis Commonly used with patients with AKI because they can be used immediately Can be inserted into the subclavian, jugular, and femoral xxviii. Femoral site is discouraged because it carries an increased risk for infection xxix. Subclavian should be avoided in patients with advanced kidney disease— risk of subclavian vein stenosis xxx. Routine replacement not recommended due to increased risk of infection xxxi. Nursing care for percutaneous catheters
- Strict aseptic technique
- Replace transparent dressing at least every 7 days and no more than 1x per week, unless dressing is soiled or loose
- Tenderness at insertion site, erythema, swelling or drainage should be reported to physician
- Minimize manipulation of catheter
- Not used to administer fluids or sample blood, unless a specific order is obtained to do so. Drugs to lower cholesterol Antilipemic agents - used to lower total & LDL cholesterol. Help reduced risk of AMI & stroke o All end in "statins" Antilipemic agents (bile acid sequestrants) - used to manage hypercholesterolemia o Cholestyramine o Colesevelam o Colestipol o Ezetimibe Antilipemic agent (niacin) - adjunctive treatment of hyperlipidemia o Nicotinic acid Antilipemic agent (fibric acid) - treatment of hypertriglyceridemia in patients who have not responded to dietary interventions. o Gemfibrozil o Fenofibrate Drugs for Acute coronary syndrome Nitrates - for anginas Nitroglycerin Isosorbide dinitrate Isosorbide mononitrate Beta-blockers - treats anginas, AMI, dysrhythmias & heart failure
End in "lol" Calcium channel blocker - treats hypertension. Tachydysrhythmias, vasospasms & angina Verapamil Nifedipine Diltiazem Antiplatelet agents - unstable angina, AMI, coronary interventions Aspirin Clopidogrel (plavix) Prasugrel Ticagrelor Glycoprotein inhibitors - acute coronary syndromes, coronary interventions Abciximab Tirofiban Eptifibatide Antithrombin agents - prevent of or delay in thrombus formation Heprin Enoxaparin (lovenox) Analgesic - pain relief & anxiety reduction during AMI Morphine Angiotension-converting enzyme inhibitors (ACE) - hypertension, heart failure & pts after MI All end in "pril" Dysrhythmias Flecainide - ventricular dysrhythmias Sotalol - verntricular dysrhythmias Propafenon - ventricular dysrhythmias Amiodarone - ventricular dysrhythimas, svt, a-fib/flutter Diliazem - svt, a-fib/flutter Ibutilide - a-fib/flutter Heart failure ACE inhibitors - hypertension, heart failure, after MI o All end in "pril" Diuretics - management of edema or fluid volume overload associated w/ heart failure & hepatic or renal disease (loop) o Furosemide (lasix) o Bumetanide (bumex) o Torsemide o Metolazone o Ethacrynic acid Beta blockers - angina, AMI, and heart failure (decreases hr, bp and heart contractility) o All end in "lol" Aldosterone receptor antagonist - edema associated w/ excessive aldosterone secretion (potassium spearing) o Spironolactone (aldactone)
