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NURS 4350 Midterm Exam 2025 – Latest
Question And Answer Graded A With Answers
Trends affecting patient management in the ICU Increasing complexity of illness Aging population More ethical issues Control of costs and quality Rapidly changing technology Early transfer from ICU Staff Intensivists E- ICUs Inclusion of family in all aspects of care ICU patient criteria Critically ill patient Close Monitoring, intensive therapies Unstable airways Hemodynamically unstable LVADs Anyone that needs high vigilant nursing care Continuous monitoring (balloon pumps, vents, brain surgery) stress response glucose levels Increases blood glucose levels as a form of energy for the body when the body is under increased stress (running from a bear is stressful, and you need more energy to run) 2 abnormal responses to critical illness that require medical workup delirium, depression Order Sets Provides minimum requirements for patient care based on patient's condition (like oral care for intubated patient or DVT prophylaxis) However, care is still individualized Algorithms Decisional flow charts based on symptoms and occurrences Example: for chest pain get blood, ECG, CXR, oxygen, assessment, etc. However, care is still individualized for patients ICU bundles Short list of interventions that promote guideline recommendations Goal to make them easier to use ABCDE bundle Awakening and Breathing Trials Choice of sedative Delirium identification and management Early mobility drug of choice for sedation propofol
Basic steps to analyze heart rhythms determine the HR evaluate heart rhythm identify P wave measure PR interval (0.12-.20) Evaluate the QRS complex (<.12 sec) symptomatic bradycardia intervention Atropine^ and^ pacing^ with^ pacemaker Sinus tachycardia/SVT treatment Valsalva^ maneuver,^ carotid^ massage,^ adenosine,^ amiodarone A-fib treatment control rate - calcium channel blockers, beta blockers, anticoagulants convert to sinus rhythm - drugs, cardio version, ablation, doltiazam, amiodarone PVC treatment look^ for^ cause^ and^ treat^ it,^ draw^ labs:^ SvO2^ level^ is^ super^ important V tach treatment if responsive (stable): amiodarone if unresponsive (unstable/pulseless: immediate defibrillation V fib treatment Immediate^ defibrillation,^ per^ ACLS^ guidelines Arterial Pressure Most accurate measurement of BP and indicator of organ perfusion cannulation sites: radial, femoral, brachial normal waveform= rapid upstroke with clear diacritic notch (aortic valve closure) MAP range 70 -^100 mmHg^ (measures^ perfusion^ in^ body) How does the arterial curve change with a PVC? Poorly perfused arterial pressure after PVC, well perfused when patient is in normal sinus rhythm smaller wave form, less force of pressure (lower systolic) How does the curve change with a. fib? Line^ dampens,^ gets^ smaller,^ decrease^ curve transducer placement In line with the phlebostatic axis level of RA in chest, mid-axillary line, 4th intercostal CVP information gathered Fluid status Direct measure of preload Right atrial pressure Venous return to the heart Low CVP interventions Fluids Pressor s High CVP interventions Diuretic Vasodilators Pulmonary artery catheter information Left atrial filling Left sided pressures overall High PA pressure indicates Not functioning how it should Example: cardiogenic shock how to measure PCWP Balloon on a pulmonary artery catheter wedges into pulmonary vascular system Indirectly gives measurement of preload on the left side of the heart (Like a CVP for the heart) Cardiac output reading HR x SV Some PA caths allow continuous CO monitoring CO versus CI CO is how much blood is expelled from the heart Cardiac index is CO that takes into account body surface area
Progressive stage cardiac and pulmonary changes Decreased CO, BP, coronary perfusion Pulmonary vasoconstriction Less surfactant Interstitial edema Lungs very vulnerable to injury - ALI, ARDS Progressive stage neuro and renal changes Decreased cerebral perfusion Kidneys vulnerable to mediator-induced injury AKI, ATN Progressive stage GI and heme changes Ischemia and ulceration of the GI tract Hypoperfusion of liver, "shock liver" Thrombocytopenia and DIC Progressive stage lab changes Increased BUN, increased Creatinine, increased LFTs, increased pCO2, decreased pO2, decreased pH, decreased HCO3, increased SvO2, increased BG Refractory stage
MODS
Hypotension unresponsive to vasopressors Refractory hypoxemia Hypovolemic shock interventions Fluid resuscitation: IV fluids at first while you wait for blood to come (if they're bleeding) Correct precipitating condition Monitor CVP for fluid status (will be low for hypovolemic shock) Septic Shock interventions Both crystal and colloid fluids Oxygen Pressors Identification of organism Start ABX Remove source of infection Sepsis protocols Shock treatment goals Mean arterial pressure * 65 CVP 8-12 mmHg PCWP 12 - 15 mmHg Urine output * 0.5 ml/kg/hr SVO2 * 70% Blood lactate < 2 mmol/L ACS sis Nausea, vomiting, SOB, pain, angina Does not feel better with rest Nitro does not relieve pain Women: pain in left shoulder, jaw pain, anxiety Why an MI is an emergency No blood flow to heart Heart dying Ischemia Scar tissue Decreased EF heart cells do not regenerate ACS diagnostic tests Troponin/CKMB 12 lead ECG
MONA
M- morphine (pain relief) O- oxygen (maintaining 02 saturation above 90%) N- nitroglycerin (vasodilation of vessels) A- aspirin (prevents further platelet aggregation) echocardiogram Shows^ the^ movement^ of^ blood^ through^ the^ heart^ and^ contraction^ (ultrasound) ectrocardiogram Shows^ ischemia^ in the^ heart^ (electrical) medication to help with contractility Inotropes (dobutamine) Helps when CO problem is the contractility CO= HRxSV SV= preload/contractiIity/afterload best intervention for V tach or V fib Defibrillate^ (CPR^ important,^ but^ not^ most^ important) ET tub more likely to end up in which lung right^ lung PCWP Indirect^ measure^ of^ pressure^ on^ the^ left^ side^ of^ the^ heart Cardiac index Cardiac^ output^ that^ takes^ into^ account^ body^ surface^ area HF sis crackles in lungs, fluid backing into lower extremities, can have pink frothy sputum Right HF problem w right ventricle: will start backing up into extremities Peripheral edema, hepatomegaly Left HF problem w left ventricle: things will start backing up into lungs, lots of pulmonary congestion Can back up from lungs into right side into system Systolic HF Failure of ventricular contraction Most common Reduced EF dilated cardiomyopathy Diastolic HF ventricles can't relax and fill Hypertrophic cardiomyopathy and restrictive cardiomyopathy acute decompensated heart failure Congestion (Dyspnea, Orthopnea, JVD, Peripheral edema) Decreased cardiac output (Cool extremities, Hypotension, Altered mental status, Decreased urine output) Role of diuretics in HF Decrease^ afterload^ and^ increase^ CO^ (decrease^ fluids^ in^ body that^ are^ built^ up) Role of beta blockers in HF Keeps heart rate low and controlled so the heart can tolerate it Allows for filling Role of ACE inhibitors in HF Preventing RAA system from developing and getting more fluid and eliciting remodeling system How do milrinone and dobutamine infusions help patients with acute decompensated HF? Contractility Reduce symptoms and hospitalizations
What are some serious reactions to massive transfusion? TRALI: transfusion reaction acute lung injury TACO: transfusion associated circulatory overload Overwhelming immune reaction Hypothermia Hyperkalemia and acidosis Citrate toxicity and hypocalcemia Factor depletion Active bleed transfusion indications PRBCs- Hgb < FFP- INR >1. cryo- fibrinogen < platelets- count <50, How does the team decide if a patient with anemia needs a blood transfusion? what is an independent predictor of mortality in critically ill (ICU) patients? thrombocytopenia
