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UTA NURS 4581 Final

UTA NURS 4581 Critical Care Final Review

bariatric surgery criteria guidelines BMI ≥40 or a BMI ≥35 with one or more severe obesity-related medical complications (e.g., hypertension, type 2 diabetes mellitus, heart failure, or sleep apnea) AND documentation of three unsuccessful attempts at medically supervised weight loss programs
Benefits of restrictive bariatric surgery vs. malabsorptive Since digestion is not altered, the risk of anemia or cobalamin deficiency is low. Procedures can be performed using a laparoscopic approach, decreasing postoperative pain, hospital stays, and the rate of wound infection and hernia formation
Dumping syndrome gastric contents empty too rapidly into the small intestine, overwhelming its ability to digest nutrients
Nutritional therapy postgastrectomy dumping syndrome divide meals into 6 small feedings; fluids not taken with meals (at least 30-45 min before or after); avoid concentrated sweets; increase protein and fats (meat, cheese, and eggs); cobalamin injection monthly
General Adaptation Syndrome (GAS) stages alarm reaction, stage of resistance, and stage of exhaustion
Respiratory acidosis causes Chronic obstructive pulmonary disease, Barbiturate or sedative overdose, Chest wall abnormality (e.g., obesity), Severe pneumonia, Atelectasis, Respiratory muscle weakness (e.g., Guillain-Barré syndrome), Mechanical hypoventilation
Respiratory acidosis manifestations Drowsiness, Dizziness, Headache, Disorientation→ Stupor & coma; ↓ Blood pressure, Ventricular fibrillation (related to hyperkalemia from compensation), Warm, flushed skin (related to peripheral vasodilation); Seizures; Hypoventilation and hypoxia
Respiratory acidosis management identify/treat cause (do not give bicarbonate) by increasing ventilation and decreasing dead space (increase rate and volume of respiration); for COPD it is normal for them to be in fully compensated acidosis and no treatment is necessary
Respiratory alkalosis causes Hyperventilation (caused by hypoxia, pulmonary emboli, anxiety, fear, pain, exercise, fever); Stimulated respiratory center caused by septicemia, encephalitis, brain injury, salicylate poisoning; Mechanical hyperventilation
Respiratory alkalosis manifestations Lethargy, Light-headedness, Confusion; Tachycardia, Dysrhythmias (r/t hypokalemia compensation); Nausea, Vomiting, Epigastric pain; hypocalcaemia manifestations (Tetany→ convulsions & unconsciousness); hyperventilation
Respiratory alkalosis management slow ventilation, rebreather mask, increase dead space
Metabolic acidosis causes Diabetic ketoacidosis, Lactic acidosis, Starvation, Severe diarrhea, Renal tubular acidosis, Renal failure, Gastrointestinal fistulas, Shock, Poisoning
Metabolic acidosis manifestations Drowsiness, Headache, Disorientation→coma; ↓ BP, Dysrhythmias (r/t hyperkalemia from compensation), Warm, flushed skin (related to peripheral vasodilation); Nausea, vomiting, diarrhea, abdominal pain; Kussmaul respirations (Deep, rapid)
Metabolic acidosis management indentify/treat underlying cause; sodium bicarbonate (NaHCO3) if severe
Metabolic alkalosis causes Severe vomiting, Excess gastric suctioning, Diuretic therapy (increased excretion of H+), Potassium deficit, Excess NaHCO3 intake, Excessive mineralocorticoids
Metabolic alkalosis manifestations Dizziness, Irritability, Nervousness, confusion; n/v, Anorexia; hypokalemia (Tetany, Tremors, Tingling of fingers and toes, Muscle cramps, hypertonic muscles, Seizures); hypocalcemia (r/t increased calcium binding to proteins); Hypoventilation
Metabolic alkalosis management treat underlying cause, Diamox (acetazolamide)
volume ventilation a predetermined tidal volume (VT) is delivered with each inspiration, and the amount of pressure needed to deliver the breath varies based on the compliance and resistance factors of the patient-ventilator system.
pressure ventilation the peak inspiratory pressure is predetermined and the VT delivered to the patient varies based on the selected pressure and the compliance and resistance factors of the patient-ventilator system.
Usual Tidal Volume Setting on Mechanical Ventilator 6-10 mL/kg
Usual FIO2 setting on Mechanical Ventilator may be set between 21% (essentially room air) and 100%; usually adjusted to maintain PaO2 level >60 mm Hg or SpO2 level >90%
Assist-Control (AC) or Assisted Mandatory Ventilation (AMV) The ventilator sensitivity is set so when the patient initiates a spontaneous breath, a full-volume breath is delivered.
Intermittent Mandatory Ventilation (IMV) and Synchronized Intermittent Mandatory Ventilation (SIMV) In between “mandatory breaths,” patients can spontaneously breathe at their own rates and VT. With SIMV, the ventilator synchronizes the mandatory breaths with the patient's own inspirations.
Pressure Support Ventilation (PSV) Provides an augmented inspiration to a spontaneously breathing patient. When the patient initiates a breath, a high flow of gas is delivered to the preselected pressure level and pressure is maintained throughout inspiration.
VAP prevention elevate HOB 45 degrees, maintain ET cuff pressure at 20 cm H2O, good handwashing, and meticulous oral care
Train-of-four assessment used for administration of paralytics; use of a peripheral nerve stimulator to deliver four successive stimulating currents to elicit muscle twitches. The usual goal is 1-2 twitches out of 4.
Indicators for Weaning from mechanical ventilator reversal of underlying cause; adequate oxygenation; hemodynamic stability (absence of myocardial ischemia or clinically significant hypotension); and ability to initiate an inspiratory effort
Mechanical ventilator weaning parameters maximum inspiratory pressure -20 to -30; minute ventilation <10 L/min; PaCO2 normal for patient (e.g., elevated for COPD); PaO2 ≥ 60; FIO2 ≤ 50%; PEEP ≤ 5 cm; and PSV ≤ 10
factor commonly responsible for sodium and fluid retention in the patient on mechanical ventilation decreased renal perfusion with increased release of renin
Hypoxemic vs. hypercapnic respiratory failure in hypoxemia, the PaO2 is 60 mm Hg or less when the patient is receiving an inspired oxygen concentration of 60% or greater; in hypercapnic, the PaCO2 is above normal (> 45) in combination with acidemia (arterial pH < 7.35)
acute respiratory failure management identify/treat cause; O2 therapy, mobilization of secretions (hydration/humidification, CPT, airway suctioning), positive pressure ventilation; goal: PaO2 55-60 with least amount of O2 admin
PaO2/FIO2 ratio is 200-300 etiology acute lung injury (ALI)
PaO2/FIO2 ratio is less than 200 etiology acute respiratory distress syndrome (ARDS)
ARDS management Respiratory therapy (O2 administration, Lateral rotation, PEEP, prone positioning, mechanical ventilation); supportive therapy
Angina decubitus chest pain that occurs only while the person is lying down and is usually relieved by standing or sitting
Prinzmetal's angina variant angina; occurs at rest, usually in response to reversible, severe spasm of a major coronary artery
Chronic stable angina management decrease oxygen demand and/or increase oxygen supply (e.g., preventing an increased HR decreases demand)
First action taken when transesophageal echocardiography (TEE) is ordered Make the patient NPO.
percutaneous coronary intervention (PCI) complications dissection of the newly dilated coronary artery. If the damage is extensive, the coronary artery could rupture, causing cardiac tamponade, ischemia and infarction, decreased CO, and possible death.
Post-cardiac catheterization insertion monitoring Check peripheral pulses every 15 minutes during the first hour post-procedure; monitor the patient's apical pulse and blood pressure frequently
Goal for emergent PCI (percutaneous coronary intervention) to open the affected artery within 90 minutes of arrival to a facility with an interventional cardiac catheterization lab.
Sign that chest pain is caused by an acute myocardial infarction (MI) Pain has lasted longer than 30 minutes.
common MI complication dysrhythmias
myocardial infarction (MI) management ONAM: initiate oxygen, sublingual NTG, and aspirin then, if pain unrelieved, morphine
Cardiac marker that remains elevated 10-14 days after MI Troponin; begins to rise at 4-6 hrs
Cardiac marker that begins to elevate within 2 hrs of an MI Myoglobin; returns to baseline within 24 hrs
ECG changes during MI ST-segment elevation( ≥1 mm above the isoelectric line), Pathologic Q wave (≥25% of the height of the R wave), and T wave inversion
MI Healing process Within 24 hours, leukocytes infiltrate and the inflammatory process begins. At 10-14 days, new scar tissue is still weak and vulnerable to increased stress. By 6 weeks, scar tissue has replaced necrotic tissue and injured area is considered healed.
Left-sided HF manifestations pulmonary congestion and edema; shortness of breath
Right-sided HF manifestations jugular venous distention, hepatomegaly, splenomegaly, vascular congestion of the gastrointestinal (GI) tract, and peripheral edema.
Beck’s Triad classic signs of cardiac tamponade; increased CVP and jugular vein distention; muffled heart sounds; and narrowed pulse pressure.
hemodynamic changes expected after successful initiation of an intraaortic balloon pump in a patient in left ventricular failure decreased PAWP (pulmonary artery wedge pressure) and increased CO (cardiac output).
An IABP (intra-aortic balloon pump) complication Vascular injuries such as dislodging of plaque, aortic dissection, and COMPROMISED DISTAL CIRCULATION
common complication of coronary artery bypass graft surgery supraventricular dysrhythmias, especially atrial fibrillation
commissurotomy (valvulotomy) surgical procedure of choice for patients with pure mitral stenosis; removes thrombi from the atrium, makes a commissure incision, and, as indicated, separates fused chordae by splitting the underlying papillary muscle and debriding the calcified valve.
valvuloplasty repair of the valve by suturing the torn leaflets, chordae tendineae, or papillary muscles. It is primarily used to treat mitral or tricuspid regurgitation.
Annuloplasty Further valve repair for patients with mitral or tricuspid regurgitation. Reconstruction of the annulus, with or without the aid of prosthetic rings (e.g., a Carpentier ring).
Valve replacement surgical treatment of choice for combined aortic stenosis and aortic regurgitation
Resumption of Sexual activity Resumption of sexual activity can begin 7-10 days after uncomplicated MI when able to climb 2 flights of stairs without SOB. Avoid after a heavy alcohol intake, a big meal, or with an unfamiliar partner in the immediate post-MI period.
Post Valve replacement teaching antibiotics for invasive or dental procedures
Peritonitis manifestations cloudy peritoneal effluent with a WBC count greater than 100 cells/μL (more than 50% neutrophils) or demonstration of bacteria in the peritoneal effluent by Gram stain or culture.
Kidney Failure Nutritional Therapy 30 to 35 kcal/kg with 0.8 to 1.0 g of protein/kg of desired body weight and increased fat (at least 30% to 40% of total calories); Potassium and Sodium restrictions.
Metabolic changes in kidney failure hyperkalemia (treated with calcium gluconate) and hypernatremia; potassium and sodium restricted diets are required
most common complication during a hemodialysis treatment hypotension.
Peritoneal Dialysis (PD) Complications exit site infection, peritonitis (look for cloudy effluent), hernias, lower back problems, bleeding, pulmonary complications (atelectasis, pneumonia, and bronchitis), protein loss
maximum amount of weight gain between dialysis treatments 1.5 kg
oliguric phase of acute renal failure (acute kidney injury) management To prevent life-threatening pulmonary edema, fluids should be limited and I and O strictly monitored.
Intervention to reduce chances that the dye used during a renal arteriogram will damage the kidneys NS IV
serum electrolyte imbalances seen in the diuretic phase of acute renal failure (acute kidney injury) Hypokalemia and hyponatremia.
Intrarenal damage prevention for patient with AKI due to myoglobin release maintaining a positive fluid balance.
primary goal of treatment for acute kidney injury (AKI) eliminate the cause and provide supportive care while the kidneys recover.
hypotention management during hemodialysis treatment Decrease the volume of fluids being removed and infuse NS
Absolute hypovolemia fluid is lost through hemorrhage, gastrointestinal (GI) loss (e.g., vomiting, diarrhea), fistula drainage, diabetes insipidus, or diuresis.
relative hypovolemia fluid volume moves out of the vascular space into the extravascular space (e.g., interstitial or intracavitary space). This type of fluid shift is called third spacing. Seen in sepsis, burns, and FRACTURED FEMUR.
Cause of large weight gain in shock patients third spacing
elevated serum lactate (lactic acid) level in patient with hypovolemic shock indication significant hypoperfusion.
Fluid used for initial volume replacement in most types of shock Isotonic (0.9% NaCl, LR)—caution with LR d/t increased lactic acid
Indications of successful fluid resuscitation Assessment of end organ perfusion, such as an adequate urine output (at LEAST 0.5 mL/kg/hr), is the best indicator that fluid resuscitation has been successful.
Pulse oximetry placement on patient in shock state ear, nose, or forehead (not finger because of poor peripheral circulation
Reason elevated temperature and shivering must be controlled in shock patient they increase metabolic need for oxygen
septic shock management O2, intubation/mechanical ventilation; AGGRESSIVE FLUID RESUSCITATION; antibiotics (after culture)
Only shock with Bradycardia neurogenic shock
Indication that septic shock is progressing change from warm and dry skin to cool and clammy skin
systemic inflammatory response syndrome (SIRS) manifestations Fever, decreased SVR/BP, elevated HR/Stroke Volume
First system to show signs of dysfunction in SIRS and MODS respiratory (assess for lung sounds and oxygenation status to monitor for early organ damage)
Sign that cardiogenic shock is developing into multiple organ dysfunction syndrome (MODS) elevated serum creatinine (indicates renal failure) or other sign of involvement of an organ other than the heart
multiple organ dysfunction syndrome (MODS) risk factors older adults, patients with chronic diseases (e.g., diabetes mellitus, chronic kidney disease, heart failure), patients receiving immunosuppressive therapy or who are malnourished or debilitated
develop disseminated intravascular coagulation (DIC) cause abnormal activation of the clotting mechanism causing accelerated clotting
hepatic encephalopathy changes in neurologic and mental function resulting from high levels of ammonia in the blood that a damaged liver cannot detoxify
Asterixis flapping tremor (liver flap) commonly affecting the arms and hands that is a manifestation of hepatic encephalopathy
Fetor hepaticus musty, sweet odor of the patient's breath which occurs in some patients with encephalopathy from the accumulation of digestive by-products that the liver is unable to degrade.
cirrhosis metabolic manifestations hypokalemia; hyponatremia; hypoalbuminemia
Cirrhosis management I&Os, daily weights, abdominal girth and extremity measurements to assess extent of edema; paracentesis (to remove excess fluid from abdominal cavity); monitor for hemorrhage and low blood count; avoid heavy lifting or stress; assess for LOC; drug therapy
Cirrhosis diet high calorie (3000 cal/day) with high carbohydrate and moderate to low levels of fat. Low sodium (with ascites and edema); monitor potassium; fluid restriction (< 1 L/day)
Sengstaken-Blakemore Tube Type of tube used for balloon tamponade in patients with esophageal and/or gastric varices; the gastric and esophageal balloons put mechanical compression on the varices.
Pancreatic autodigestive enzymes Trypsin, Elastase, Phospholipase, Lipase, Kallikrein
Most common causes of pancreatitis alcoholism (men), biliary tract disease (women); trauma, infection, drugs
Pain associated with pancreatitis sudden onset, deep, piercing, continuous/steady LUQ or midepigastric pain that commonly radiates to the back
Pain associated with cirrhosis RUQ or epigastric pain
First priority in managing acute pancreatitis administration of IV fluids and electrolyte repletion
Most effective means of relieving pain from pancreatitis NPO status
Stroke nonmodifiable risk factors age (doubles each decade after 55 years of age, 2/3 occur >65 yrs of age), gender (more common in men, more deaths in women), ethnicity/race (African Americans have higher incidence), family history/heredity
transient ischemic attack (TIA) transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of the brain; clinical symptoms typically last less than 1 hour
right-brain damage manifestations paralyzed left side (hemiplegia); left-sided neglect; spatial-perceptual deficits; tends to deny or minimize problems; rapid performance, short attention span; impulsive, safety problems; impaired judgment
left-brain damage manifestations paralyzed right side (hemiplegia); impaired speech/language aphasias; impaired right/left discrimination; slow performance, cautious; aware of deficits (depression, anxiety); impaired comprehension r/t language and math
treatment of choice for individuals with atrial fibrillation who have had a TIA Oral anticoagulation using warfarin
Stroke acute care management airway, Fluid therapy (NS), maintain adequate O2 and BP, remove clothing, obtain CT immediately (w/o contrast), position head midline and elevate 30 degrees, administer thrombolytics (for ischemic stroke), NPO until swallow reflex evaluated
Ischemic Stroke management Tissue plasminogen activator (tPA) IV or intraarterial and MERCI retriever
Hemorrhagic Stroke management Surgical decompression if indicated; Clipping or coiling of aneurysm; nimodipine (Nimotop) administration to decrease vasospasm; Antiseizure drugs, such as phenytoin (Dilantin) or levetiracetam (Keppra), are given if a seizure occurs.
The LICOX brain tissue oxygen system a catheter inserted through an intracranial bolt. The system measures oxygen in the brain (PbtO2), brain tissue temperature, and intracranial pressure (ICP)
“ATES” of ICP management ElevATE, StrAIGHT, RegulATE, SeparATE, IntubATE, CoagulATE, MedicATE, HyperventilATE, EvacuATE, OperATE
Kidney cold ischemic time can be preserved for up to 72 hours, but most transplant surgeons prefer to transplant kidneys before the cold ischemic time reaches 24 hours.
Organ cold ischemic times Kidney longest (up to 72 hrs), Liver (20 hrs), Pancreas (12 hrs), and heart shortest (4-6 hrs)
Organ recipient criteria <70 years, absence of infection, absence of general malignancy
Test used to detect rejection of transplanted heart and timing of tests an endomyocardial biopsy (EMB) is obtained on a weekly basis for the first month, monthly for the following 6 months, and yearly thereafter.
Heart’s Breath Test measures methylate alkalies in patient’s breath and compares with results of endo to separate less severe (low levels) to more severe (higher levels)
Leading cause of death after renal transplant cardiovascular disease
Leading cause of death in the early period after lung transplantation bacterial, viral, fungal, or protozoal infections
allogeneic transplantation stem cells are acquired from a donor who, through human leukocyte antigen (HLA) tissue typing, has been determined to be HLA matched to the recipient.
syngeneic transplantation a type of allogeneic transplant that involves obtaining stem cells from one identical twin and infusing them into the other.
autologous transplantation patients receive their own stem cells back following myeloablative (destroying bone marrow) chemotherapy
crossmatch uses serum from the recipient mixed with donor lymphocytes to test for any preformed anti-HLA antibodies to the potential donor organ; POSITIVE CROSSMATCH IS A CONTRAINDICATION TO TRANSPLANTATION
Effects of aging on drug-receptor interaction brain receptors become more sensitive, making psychoactive drugs very potent.
Effects of aging on drug metabolism liver mass shrinks, hepatic blood flow and enzyme activity decline, metabolism drops, and enzymes lose ability to process some drugs, prolonging drug half-life.
Effects of aging on drug absorption gastric emptying and motility slow, absorption capacity of cells and active transport decline.
Effects of aging on drug circulation vascular nerve control less stable, may cause increased effect (anti-HTN drops BP too low, Digoxin slows HR too much)
Effects of aging on drug excretion kidney function declines, blood flow and waste removal slow, lengthening half-life for renally excreted drugs (oral antidiabetic stay in body longer)
Effects of aging on drug distribution lean body mass decreases and adipose stores increase, total body water declines, raising concentration of water-soluble drugs (increased digoxin can cause heart dysfunction), plasma protein diminishes, raising blood levels of free protein-bound drugs.
Risks of electrical injuries dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria, which can lead to acute tubular necrosis (ATN).
partial-thickness burn varying degrees of epidermal and dermal skin injury in which some skin elements remain viable for regeneration
full-thickness burn destruction of all skin elements and subcutaneous tissues with possible involvement of muscles, tendons, and bones
Rule of nines Guide for determining total body surface area affected or the extent of a burn; 9% for each side of each leg; 9% for both arms for each side; 18% for trunk for each side; 4.5% for head for each side; and 1% for groin
greatest initial threat to a patient with a major burn hypovolemic shock
Adequate fluid resuscitation urine output 0.5 to 1 mL/kg/hr; 75 to 100 mL/hr for electrical burn patient with evidence of hemoglobinuria/myoglobinuria
Trauma center designation from Level I, capable of providing total care, to Level IV, ability to provide trauma life support prior to transfer to higher level
Trauma ABC A: Airway (and c-spine); B: Breathing; C: Circulation; D: Disability (neuro); E: Exposure control; F: full VS, focused adjuncts, family; G: give comfort measures (pain control); H: History/Head-to-toe assessment; I: inspect posterior surfaces
Fractured rib management DON’T strap or bind chest; NSAIDs, opioids, and nerve blocks are used to reduce pain and aid with deep breathing and coughing. Patient teaching should emphasize deep breathing, coughing, use of incentive spirometry, and use of pain medications
management of chest wound with object that caused it still in place do not remove it until a physician is present. Stabilize the impaled object with a bulky dressing.
Kehr’s sign pain over the scapula caused by irritation of the phrenic nerve by free blood in the abdomen or ruptured spleen
Abdominal girth increase with abdominal bleed 1 inch/500 mL - 1 L of blood
Peritoneal lavage most sensitive technique for detecting injuries to hollow organs and mesenteric structures; large catheter inserted into abdomen, attempt to aspirate, if < 10 mL aspirated inject saline and drain, observe fluid, especially for blood, send to laboratory
Bowel sounds in the chest indicates may indicate a diaphragmatic rupture
spinal shock resolution signs return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.
Level of lesion that causes tetraplegia cervical (C8 and above)
Level of lesion that causes paraplegia thoracic and lumbar (T1 and below)
Level of lesion that corresponds with total loss of respiratory muscle function above the level of C4
Brown-Séquard syndrome damage to one half of the spinal cord characterized by spastic paralysis on the body's injured side, loss of postural sense (proprioception), and loss of the senses of pain and heat on the other side of the body
Autonomic dysreflexia most common precipitating cause a distended bladder or rectum
Marked perspiration above the level of injury concern Autonomic dysreflexia
Autonomic dysreflexia management elevation HOB 45 degrees or sitting the patient upright, notification of the physician, and assessment to determine the cause. Possible immediate catheterization or checking of existing catheter for kinks, or digital rectal exam (after anesthetic).
Factors that predict a poor outcome after head injury the presence of an intracranial hematoma, older age of the patient, abnormal motor responses, impaired or absent eye movements or pupillary light reflexes, early sustained hypotension, hypoxemia or hypercapnia, and ICP levels greater than 20 mm Hg.
Tests to determine if fluid leaking from nose or ear is CSF if no blood, glucose test (Dextrostix, Tes-Tape strip)—positive if CSF; if blood is present, look for halo/ring sign (when dripped on white pad/towel, yellowish ring encircles blood if CSF is present)
initial period of unconsciousness at the scene, with a brief lucid interval (up to 12 hours) followed by a decrease in LOC indication epidural hematoma
posturing (decorticate vs. decerebrate) that may indicate more serious damage decerebrate
Oropharyngeal airway purpose Maintain airway in unconscious patients and used as a bite block for patients with endotracheal tubes
Oropharyngeal airway sizing place the airway on the patient’s cheek with the flat plate at the lips. The end of the airway should hit the jaw.
Nasopharyngeal airway purpose Facilitates suctioning in semi-conscious/conscious patient
Nasopharyngeal airway sizing place the airway on the patient’s cheek with the flange at the nares. The end of the airway should hit below the mandible.
Endotracheal Tube airway purpose Provide stabilization of airway; Ensure proper ventilation via mechanical ventilator; Facilitate removal of secretions
Endotracheal Tube placement confirmation listen for breath sounds bilaterally (if on one side, too far); use CO2 detector (if not detecting CO2, not far enough); chest x-ray
Tracheostomy purpose Bypass an upper airway obstruction; Facilitate removal of secretions; Permit long-term mechanical ventilation; Permit oral intake and speech in the patient who requires long-term mechanical ventilation
Cuffed tracheostomy tube When properly inflated, low-pressure, high-volume cuff distributes cuff pressure over large area, minimizing pressure on tracheal wall.
Cuffed tracheostomy tube indication used with patients at risk of aspiration or in need of mechanical ventilation
Fenestrated tracheostomy tube When inner cannula is removed, cuff deflated, and decannulation plug inserted, air flows around tube, through fenestration in outer cannula, and up over vocal cords. Patient can then speak.
Tracheostomy dislodgement management immediately attempt to replace it; if cannot be replaced, raise to semi-fowlers to alleviate dyspnea; if severe dyspnea causes a respiratory arrest, cover stoma with a sterile dressing and ventilate patient with bag-mask ventilation until help arrives
Blood infusion time constraints Do not keep blood out of monitored refrigerator >30 min. before starting transfusion; Do not use same blood filter for > 4 hours or 2 units; Do not allow unit of blood to “hang” for > 4 hours.
Acute hemolytic blood transfusion reaction manifestations chills, fever, low back pain, increased heart rate, increased respiratory rate, decreased blood pressure then shock, possible arrest.
Blood transfusion reaction management Stop the transfusion. Keep IV open with NS. Report to MD and blood bank immediately. Re-check ID tags and numbers. Treat sx and monitor V/S. Send to blood bank. Collect blood and urine samples and send to lab. Document thoroughly. Pt/family teaching
most common complication encountered during the insertion of a pulmonary artery catheter Dysrhythmias
Arterial line complication prevention Luer-Lok connections, check arterial waveform, activate alarms, inspect for s/s of inflammation and systemic infection, Allen test before inserting, assess continuous flush every 1-4 hrs, and hourly neurovascular checks
Pulmonary artery catheter complications prevention aseptic technique, check catheter for balloon integrity before insertion, aspirate (should not see blood), never inflate balloon beyond capacity or leave inflated more than 4 breaths (8-15 seconds), monitor PA pressure waveforms, continuously flush cathet
Pulseless rhythms VF (ventricular fibrillation)/VT (ventricular tachycardia without a pulse), PEA (pulseless electrical activity), and Asystole
Chylothorax the presence of lymphatic fluid in the pleural space due to a leak in the throacic duct (trauma, surgical procedures, malignancies)
Empyema an accumulation of purulent exudates in a body cavity, especially the pleural space, as a result of bacterial infection, such as pleurisy or tuberculosis
Chest Tube removal removed at end of expiration and close with dressing (Vaseline gause) ASAP; chest x-ray
Positioning of pt with Chest Tube position patient on operative side to facilitate expansion of remaining lung
ideal training age-related heart rate 220 – age * 80% (e.g., 220-65 * 80% is 124)
Calculation of Cerebral Perfusion Pressure (CPP) MAP-ICP
Calculation of MAP [SBP + 2(DBP)] / 3
Parkland Formula of Fluid Resuscitation (>20% TBSAB) 4 mL LR x kg x %TBSAB; give ½ in first 8 hours, remaining over next 16 hours
BP normal SBP <120 mm Hg and DBP <80 mm Hg4
RR normal 12-20 breaths/min
HR normal 60-100 beats/min
Glucose (fasting) normal 70-99 mg/dL
PaCO2 Normal 35-45
HCO3- Normal 22-26
pH Normal 7.35-7.45
Base excess (B.E.) Normal +/-2.0
PaO2 Normal 80-100
O2 Sat Normal 96-100%
CVP normal 2-8 mm Hg
Steady CVP WNL indicates right heart is still adequately handling venous return
Decreased CVP etiology hypovolemia
Elevated CVP etiology right ventricular failure or volume overload
PAWP normal 6-12 mm Hg
Elevated PAWP etiology left ventricular heart failure and fluid volume overload (should not infuse IVF as this will exacerbate problem)
CO normal 2-8 L/min
CI normal 2.2-4 L/min
Decreased CO and CI etiology shock states (e.g., cardiogenic, hypovolemic) and heart failure
SVR normal 800-1200 dynes/sec/cm-5/m2
Decreased SVR etiology vasodilation, which may occur in shock states (e.g., septic, neurogenic) or with drugs that reduce afterload
Elevated SVR etiology vasoconstriction from shock, hypertension, increased release or administration of epinephrine and other vasoactive agents, or left ventricular failure
ICP normal 5 to 15 mm Hg
CPP normal 60-100 mm Hg
Decreased CPP etiology ischemia and neuronal death
MAP normal 70-105 mm Hg
MAP where autoregulation is effective 50 to 150 mm Hg
Decreased MAP etiology <60 will not adequately perfuse and sustain the vital organs; if remains low for long, vital organs with be underperfused and will become ischemic
GFR normal about 125 mL/min
Decreased GFR etiolgoy Chronic Kidney Disease
Elevated serum lactate (lactic acid) level in a hypovolemic shock patient indicates significant tissue hypoperfusion
elevated ALT etiology liver damage
Lab value most useful in evaluating improvement in kidney function for a patient with chronic kidney disease (CKD) Calculated glomerular filtration rate (GFR)
Creatinine normal 0.6-1.3 mg/dL
BUN normal 6-20 mg/dL
elevated blood urea nitrogen (BUN) and creatinine levels etiology impaired kidney function, due to hypoperfusion as a result of severe vasoconstriction or occurs secondary to catabolism of cells (e.g., trauma, infection)
elevated serum creatinine level etiology impaired kidney function due to hypoperfusion as a result of severe vasoconstriction; is more sensitive indicator of renal function than BUN
Chest tube drainage normal < 100 mL/hr drainage
EKG grid paper small squares width 0.04 seconds
EKG grid paper large squares width 0.2 seconds
PR interval normal duration 0.12-0.2 seconds (or three to five tiny boxes)
QRS interval normal duration 0.06-0.1 seconds (or 1.5 to 2.5 tiny boxes)
Elevated amylase etiology Injuries to pancreas
Cholesterol normal level <200 mg/dL
HDL normal level Male: >40 mg/dL; Female: >50 mg/dL
LDL recommended level <100 mg/dL (Near optimal: 100-129 mg/dL)
LDL level with Moderate to High risk for CAD Moderate risk: 130-159 mg/dL; High risk: >160 mg/dL
Triglyceride level with risk for CAD ≥150 mg/dL
Hypertension >140/90 (or >130/80 in patients with diabetes or CKD)
BP with risk for CAD elevated systolic BP >160 mm Hg
Obesity BMI > 30 and Waist circumference ≥40” in men and ≥35” in women
BNP (B-type Natriuretic Peptide) levels suggestive of HF 100-500 pg/mL (HF probable); >500 pg/mL (HF highly probable)
Drug that Prinzmetal's angina would respond best to Calcium channel blocker.
ACE inhibitor actions Decreased preload and afterload.
Primary drug administered in anaphylactic shock epinephrine (Adrenalin)
Drug used to treat cardiogenic shock dobutamine (Dobutrex) to increase myocardial contractility
Dobutamine (Dobutrex) classification and use Adrenergic direct-acting β1-agonist, cardiac stimulant; Causes increased contractility, increased CO without marked increase in HR; used for cardiac decompensation due to organic heart disease or cardiac surgery
Sodium nitroprusside (Nipride) classification and use a potent IV vasodilator that reduces both preload (CVP) and afterload (SVR), thus improving myocardial contraction, increasing CO, and reducing pulmonary congestion.
Drug used for rapid reduction of hypertensive crisis Sodium nitroprusside (Nipride)
amlodipine (Norvasc) classification and use Calcium channel blocker; Decreases spasms of the coronary artery by blocking movement of extracellular calcium into cells, causing vasodilation and decreased heart rate, contractility, and SVR (afterload).
nitroglycerin (Nitro-Bid IV, Tridil) classification and use Vasodilator; used to relieve chest discomfort associated with chronic stable angina and acute coronary syndrome; Relaxes arterial and venous smooth muscle, reducing preload and SVR
Vasopressin (Pitressin) adverse effect Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion, causing chest pain.
Norepinephrine (Levophed) classification and action Potent peripheral venous/arterial vasoconstriction
Drug given to treat severe hypotension norepinephrine (Levophed)
Norepinephrine bitartrate (Levophed) classification and use positive inotropes/β-adrenergic agonists; used to treat hypovolemia when patient has persistent hypotension AFTER fluid resuscitation and normalized CVP; increase or improve contractility
Norepinephrine (Levophed) contraindication Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. If CVP is low (normal 2-8 mm Hg), provide more volume replacement before administering.
drug that will help relieve a patient's anxiety in addition to improving cardiac output Morphine sulfate (MS)
Nitroglycerin teaching make certain the medication is stored in a dark container.
statin drugs critical side effect can cause liver damage (check for elevated ALT levels)
Enalapril (Vasotec) classification and use an ACE-inhibitor; It reduces blood pressure by inhibiting angiotensin converting enzyme, reducing the conversion of angiotensin 1 to angiotensin 2, thus reducing vasoconstriction.
Enalapril (Vasotec) consideration Because it blunts the renin-angiotensin-aldosterone system to some degree, it can result in hyperkalemia (especially in those with conditions such as CKD which can also cause hyperkalemia)
fibrinolytic therapy use Treatment of MI to stop the infarction process by dissolving the thrombus in the coronary artery and reperfusing the myocardium (chest pain should decrease after administration)
Thrombolytic (fibrinolytic) agent major complication acute intracranial bleeding, which presents as a decrease in the level of consciousness, from break down of protective clots.
Sodium polystyrene sulfonate (Kayexalate) contraindication should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur.
nitroprusside (Nipride) indication of effectiveness in treating cardiogenic shock Warm, pink, and dry skin indicates that perfusion to tissues is improved.
Diamox (acetazolamide) classification and use Diuretic, carbonic anhydrase inhibitor, antiglaucoma agent, antiepileptic; used to treat acute altitude sickness; glaucoma; seizures; and edema
ARDS medication management inotropic/vasopressor meds [dopamine (Intropin), dobutamine (Dobutrex), norepinephrine (Levophed)], diuretics, sedation/analgesia, neuromuscular blockade)
Propofol (Diprivan) classification and use anesthetic; used as short-term sedation of patients receiving mechanical ventilation
Propofol (Diprivan) side effects hypotension, bradycardia, and increased triglyceride levels
Neuromuscular blocking agents suffix “URIUM” or “ONIUM” (e.g., Atracurium besylate, Cisatracurium besylate, Doxacurium chloride, Pancuronium bromide, Vecuronium bromide)
First drug given for SVT Adenosine (Adenocard)
Adenosine dosage 6-12-12: Initial dose 6 mg over 1-3 seconds followed with 20 ml 9% NACL and Subsequent doses (after 1-2 minutes)of 12 mg over 1-3 seconds. May repeat once.
First drug given for pulseless rhythms Epinephrine
Epinephrine dosage 1 mg IV/IO q 3-5 min
First drug given for Vtach with a pulse Amiodarone (Cordarone)
Amiodarone (Cordarone) contraindications Cannot use in patients with iodine allergy
Drug given for bradycardia Atropine
Drug given for unstable junctional rhythms Atropine
Drug given for Second Degree AV Block, Type 2 Atropine
Drugs used to treat tachycardia Beta blockers
Beta blockers suffix "OLOL"
ACE inhibitor suffix "PRIL"
Drugs given for atrial flutter or atrial fibrillation calcium channel blockers (e.g., Cardizem), amiodarone, beta blockers, digoxin, and anti-coagulation
Drug given for ischemic stroke Tissue plasminogen activator (tPA)
Tissue plasminogen activator (tPA) precautions noncontrast CT or MRI scan to rule out hemorrhagic stroke, blood tests for coagulation disorders, and screening for recent history of gastrointestinal bleeding, stroke, or head trauma within the past 3 months, or major surgery within 14 days.
Drug given to treat cerebral vasospasm either before or following aneurysm clipping or coiling nimodipine (Nimotop)
Drug used to treat delayed gastric emptying Metoclopramide (Reglan)
Medication given within 8 hours of spinal cord injury that significantly improves motor function and sensation methylprednisolone (MP)
methylprednisolone (MP) contraindications penetrating trauma to the spinal cord and should be used with caution in the elderly population
Drugs that prevent a cell-mediated (Helper T cell) attack against the transplanted organ Calcineurin inhibitors (e.g., tacrolimus and cyclosporine)
Drugs used pre-treatment for transplantation Monoclonal antibodies (e.g., Muromonab-CD3 [Orthoclone OKT3], daclizumab [Zenapax] and basiliximab [Simulect])
Drugs used as induction therapy to severely immunosuppress an individual immediately after transplantation Polyclonal antibodies (e.g., Lymphocyte immune globulin [Atgam])
Drug therapy for Hemostasis and control of bleeding in esophageal varices, constriction of splanchnic arterial bed vasopressin (Pitressin); octreotide (Sandostatin)
Statin drug complications liver damage and myopathy that can progress to rhabdomyolysis (breakdown of skeletal muscle); Symptoms of myopathy (e.g., muscle aches, weakness) should be reported to the healthcare provider
information obtained to evaluate the effectiveness of calcium gluconate Cardiac rhythm
Drug therapy for hyperkalemia calcium gluconate or IV glucose and insulin
Created by: camellia