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CCRN

Terms in this set (372)

Normal Osmolarity
275-295
How do you calculate osmolarity?
2x Sodium Level
Signs of Syndrome of Inappropriate ADH (SIADH)
1. Decrease Na
2. Decreased Serum Osmolarity
3. Decreased Urinary Output
4. Increased Urine Osmolarity
Causes of SIADH
1. Oat Cell Carcinoma
2. Viral Pneumonia
3. Head Problem (Structural)
4. Dehydration
5. Anesthesia
What is Oat Cell Carcinoma?
(Bronchogenic Cancer)
Tumor in apical portion of lung that makes own ADH. Located in Right Upper Lung
What is the biggest complication of SIADH?
Seizure Activity
How do you treat SIADH?
1. Get rid of problem
2. Fluid Restriction
3. Hypertonic Solutions (3% NaCl) at 25cc/hr for 3-4 hours and then reassess
What are the Hypertonic Solutions?
1. 3% NaCl
2. D5NS
3. D5/.45NS
What are the Hypotonic Solutions?
1. .45NS
2. .33NS
3. 2.5 Dextrose
4. D5W
Signs of Diabetes Insipidus (DI)
1. Increased Na Levels
2. Increased Serum Osmolarity
3. Low URINE Osmolarity
3. Increased UOP (6L-24L/Day)
Specific Gravity: 1.001-1.005
Causes of Diabetes Insipidus (DI)
1. Head Problems
2. Dilantin
The body holds how many Liters of fluid?
40 L
Main complication of Diabetes Insipidus
Hypovolemia
Treatments for Diabetes Insipidus?
1. Give ADH (Pitressin)* Monitor EKG for Ischemia because it is a potent vasopressor
2. Give fluids to increase intravascular volume
3. Monitor urine specific gravity
Hypoglycemia signs 1st to 2nd
1st: CVS
-Tachycardia
-Palpitations
-Diaphoresis
-Irritable
-Restlessness

2nd: CNS
-Confusion
-Lethargy
-Slurred Speech
-Seizure
-Coma
What medication can hide the signs of hypoglycemia?
Beta-Adrenergic Blockers
What is DKA?
Diabetic Ketoacidosis
What is HHNK?
Hyperglycemic Hyperosmolar Non-Ketotic Coma
Who gets HHNK?
Hyperglycemic Hyperosmolar Non-Ketotic Coma

-Old Age
-Diet Controlled Diabetics
-TPN
-Pancreatitis (Autodigestion of Pancreas)
-Thiazide or Steriod Therapy (Thiazide-hold on to glucose and steroids make body resistant to insulin)
DKA signs?
-BS: 400-900
-Dehydration (4-6L)
-No Insulin in Circulation
-Acidosis (Breaks down fats because no insulin)
-Kussmaul Breathing
HHNK Signs?
Hyperglycemic Hyperosmolar Non-Ketotic Coma
-BS: 1000-2000
-Severe Dehydration (6-8L) (Serum Osmolarity increased)
-Insulin in Circulation (Prevents break down of fats--No Acidosis)
-LTBB (Little Tiny Baby Breaths)
How do you treat DKA?
-Lots of Insulin (Drip)
-Fluid
--NS
--.45NS
--D5/.45NS
How do you treat HHNK?
-Lots of Fluid
-Little Insulin
What are the fluids to treat DKA and HHNK?
Normal Saline
.45% Saline
D5 1/2 Saline
In acidosis what happens to potassium?
In a state of acidosis, potassium will come out of the cell and hydrogen will go into the cells.
Measuring Acidosis and Potassium Levels
pH decrease of .1 will increase potassium by .6

7.45 = 4.5
7.35 = 5.1
7.25 = 5.7
7.15 = 6.3
7.05 = 6.9
The releasing stimulus for ADH is normally?
increased serum osmolarity
SIADH manifests clinically as?
Water Intoxication State
In addition to its affect on body, ADH is also a?
Vasopressor (Watch cardiac monitor)
What is the cardinal sign of ADH?
Dilutional hyponatremia
Described Kausmaul breathing associated with DKA
Increased rate and depth of breathing
The altered mental status in a patient in HHNK results from?
Intracerebral Dehydration
The nurse understands that resistance to Vasopressin (Pitressin) therapy may be caused by?
Inadequate warming or agitation of the medication vial.
Its must be warmed in hot water and shaken vigorously, brown specks are normal for IM
A thyroidectomy, pituitary tumor and hypophysectomy can cause what?
Myxedema Coma
Decreased levels of thyroxine (T4) result in?
hypothyroidism
The two main signs for someone in a Myxedema coma?
Seizure Activity and Hypothermia
An audible bruit over the thyroid gland is found in what?
Hyperthyroidism
Myxedema coma define
results in interstitial accumulation of a substance called mucopolysaccharides, which attract water causing a dilution hyponatremia, non pitting edema, and fluid accumulation around organs--thus leading to pericardial and pleural effusions.
Breathing for a Myxedema coma would cause?
Decreased O2 levels and Increased CO2 levels from hypoventilation
Nursing intervention in Myxedema coma
Administering thyroxin IV
3% NACL should not be given faster than?
50mL/hr
For patient in hypothermia, why is a hyperthermia blanket contraindicated?
because rapid rewarming can precipitate vasodilation which cause cardiac dysrthymias and cardiovascular collapse.
Precipitating factors of hypoparathyroidism include?
Surgery of thyroid
Radiation injury secondary to thyroid therapy
Acute Pancreatitis
PTH does what?
PTH increases bone resorption of calcium, increases renal and GI absorption of calcium, and decreases phosphate reabsorption in the renal tubules.
Hypoparathyroidism signs and symptoms
Numbness, tingling, laryngeal stridor, dyspnea, cyanosis, confusion, lethargy, and emotional lability
A carpopedal spasm (hand folding in) occurs in a patient with hypocalcemia when the circulation is interrupted with a blood pressure cuff.
Positive Trousseau's sign
Twitching of muscles along facial nerve when the side of the face is tapped.
Positive Chvostek's sign
Ecchymosis around the umbilicus during acute hemorrhagic pancreatitis
Cullen's sign
What may an EKG look like with a patient who has hypocalcemia?
Prolonged QT interval
IV calcium should not be mixed with saline for infusion because?
It will precipitate with micro-crystals
The Thyroid secretes what hormone?
The Parathyroid secretes what hormone?
Calcitonin- puts calcium in the bone decreasing serum calcium

PTH- pulls calcium out of the bone increasing serum calcium
What does calcium do to phosphorus?
Increase calcium, decrease phosphorus
Increase phosphorus, decrease calcium
Stress-ralated hyperventilation can cause Alkalosis from a decrease in CO2; Alkalosis does what to serum calcium levels?
Decreases serum calcium levels
The thyroid gland produces what?
Thyroxine
Tri-iodothyronine
Calcitonin
Secretion of thyroid hormone is regulated by hormones of where?
The anterior pituitary and the hypothalamus
Why must must aspirin be avoided in a patient with a thyroid storm?
Salicylates interfere with binding of T3 and T4.
The adrenal cortex produces?
Glucocorticoids and androgens
Precipitating factors of adrenal insufficiency include?
Abrupt cessation of steroid therapy
Stress after trauma
Infection
Surgery
Water-Friderichsen syndrome (Adrenal hemorrhage from meningococcal meningitis)
Adrenalectomy
Signs and symptoms of an Adrenal Crisis
Confusion
Restlessness
Decreased LOC
Hypotensive
Rapid Thready Pulse
Oliguria
Hyperkalemia can cause what EKG changes
Tall, tented T waves, wide QRS complexes, and prolonged PR intervals
Which has a greater effect on cardiac and metabolic activities? Epinephrine or Norepinephrine
Norepinephrine
Adrenal Crisis fluid requirements?
Dextrose 5% with normal saline solution at 1L in 2 Hours
The risk of intensive glucose control in the critical care unit is an increased risk of:

A.
pneumonia.

B.
infection.

C.
dysrhythmia.

D.
hypoglycemia.
D.

Previously advocated intensive insulin protocols increase the risk of hypoglycemia. It is now recommended that keeping serum glucose less than 150 mg/dL is preferable to trying to keep serum glucose less than 110 mg/dL because of this risk of hypoglycemia.
Which of the following would not be prescribed in SIADH?


A.
Fluid restriction

B.
Diuretics

C.
Hypertonic (3%) saline

D.
D5W
D.

This patient is already hypoosmolar. While D5W is isotonic in the bottle, the dextrose is rapidly metabolized, leaving free water. A hypoosmolar solution, such as water, would make things worse by further reducing the serum osmolality.
A 30-year-old woman with type 1 diabetes mellitus is admitted with complaints of nausea, vomiting, and diarrhea. She has not been eating and she has not taken her insulin for 2 days. She has been taking glargine (Lantus) 45 units daily and aspart (NovoLog) with meals (5 units with breakfast, 8 units with lunch, and 10 units with dinner). Her blood pressure is 92/54 mm Hg, heart rate is 112/min, respiratory rate is 40/min and deep, temperature is 99.2° F. Laboratory results include serum glucose 420 mg/dL, pH 7.1, potassium 4.5 mEq/L, and serum osmolality 320 mOsm/kg. She is not responding to voice but she does respond to pain. Her mucous membranes are dry and urine output is scant and concentrated. What is the priority of care for this patient at this time?

A.
Reduction of serum glucose

B.
Replacement of fluid and electrolytes

C.
Ventilatory support

D.
Prevention of seizures
The hypotension, tachycardia, dry mucous membranes, and oliguria are all indications that she is severely dehydrated. Also, considering her degree of acidosis, her potassium will fall to approximately 3 mg/dL. The other electrolyte likely to need replacement is phosphorus. This is why KCl and KPO4 are frequently used for potassium replacement.

Remember that people do not die from hyperglycemia, but they do die from hypovolemia, and this patient is presenting with indications of significant dehydration.
The goal is to reduce the serum glucose by ____________ mg/dL/hr to prevent cerebral edema. When the serum glucose is rapidly reduced, it reduces the intravascular osmolality so that fluid moves into the more hypertonic brain cells.
50-100
Patients with hyperglycemic hyperosmolar state (HHS) are susceptible to thrombosis and pulmonary embolism because:

A.
they are dehydrated.

B.
they are hyperglycemic.

C.
they have vascular changes.

D.
they are immobile.
Patients with HHS are extremely dehydrated, which makes them hypercoagulable.

Imagine the diuresis that would be caused by a serum glucose of 1100 mg/dL (and this is average in HHS; some patients have even higher serum glucose levels). This causes a tremendous osmotic diuresis and dehydration. Dehydration causes hypercoagulability and predisposes the patient to thrombosis and pulmonary embolism. Remember that hypercoagulability is one component of Virchow's triad. Choose option a.
A patient is receiving morning and evening doses of NPH Humulin. He refused his nighttime snack last night and is hyperglycemic this morning. The physician has requested a 3 am serum glucose to confirm Somogyi phenomenon. The physiologic reason for the Somogyi phenomenon is:

A.
counterregulatory hormones.

B.
insulin resistance.

C.
dehydration after hyperglycemia.

D.
hypoglycemia after dehydration.
Insulin resistance does not occur with Humulin as it did with pork or beef insulin. Dehydration is not a component of Somogyi phenomenon. Remember that Somogyi phenomenon is suspected when the morning serum glucose is unexpectedly elevated. This hyperglycemia is due to the release of counterregulatory hormones (epinephrine, glucagon, glucocorticoids, and growth hormone) after hypoglycemia.
A patient with small cell (i.e., oat cell) carcinoma develops SIADH. The physician prescribes demeclocycline. What does this drug do in SIADH?

A.
Blocks the action of ADH or ADH-like hormone on the renal tubule

B.
Decreases the release of ADH from the posterior pituitary

C.
Decreases the release of an ADH-like hormone associated with the malignancy

D.
Increases the retention of sodium by the renal tubule
SIADH frequently occurs in oat cell carcinoma of the lung as well as other malignancies. This is an example of ectopic ADH because the tumor secretes a substance that acts like ADH. Demeclocycline blocks the action of ADH or this ADH-like substance on the renal tubes, allowing diuresis to occur.
Which of the following is true regarding the difference between diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS)?

A.
There is less dehydration in HHS than there is in DKA.

B.
DKA occurs in type 1 diabetes mellitus (DM), and HHS occurs in type 2 DM.

C.
Less insulin usually is needed in HHS than is needed in DKA.

D.
Potassium is low in DKA and normal or high in HHS.
Patients with HHS have more dehydration and azotemia than patients with DKA. Although patients with HHS have higher serum glucose levels, it takes less insulin to normalize their glucose metabolism. Patients with DKA have elevated potassium levels because they are acidotic. Patients with HHS are not acidotic, and their potassium levels are not skewed by acidosis. Therefore they have a normal or low (because of loss in diuresis) potassium. Patients with type 1 DM develop DKA, but patients with type 2 DM develop HHS.

Always be logical. Remember that insulin need is absolute in type 1 DM and that the hyperglycemia that occurs in DKA is accompanied by acidosis because gluconeogenesis occurs with liberation and incomplete breakdown of free fatty acids. The insulin deficiency in type 2 DM is relative. In the hyperglycemia that occurs in HHS, there is enough insulin to prevent gluconeogenesis and therefore acidosis. Choose option b as the correct answer.
A 55-year-old man has been prescribed acarbose (Precose) to control his type 2 diabetes mellitus. When you teach him about the drug, which of the following would you tell him to use for hypoglycemia?

A.
Orange juice

B.
Fresh fruit

C.
Cheese and crackers

D.
Glucose tablets
Acarbose (Precose) is an alpha-glucosidase inhibitor. It delays digestion of ingested carbohydrates, resulting in a smaller rise in serum glucose after meals. Simple sugar must be given for hypoglycemia. The patient should be instructed to carry glucose tablets and to use them for indications of hypoglycemia.
Weakness, fatigue, muscle pain, and abdominal discomfort in a patient receiving metformin would likely be associated with which of the following?


A.
Hypoglycemia

B.
Hyperglycemia

C.
Heart failure

D.
Lactic acidosis
These are symptoms that may indicate the serious adverse effect of metformin of lactic acidosis and rhabdomyolysis.

Hypoglycemia can cause weakness. Abdominal pain is associated with metabolic acidosis which can occur with hyperglycemia (DKA) and severe heart failure. Weakness and fatigue do occur with heart failure. The symptom that is inconsistent with both hyperglycemia and heart failure is muscle pain. This would lead you to rhabdomyolysis and the resultant lactic acidosis.
Which of the following would be inappropriate for a patient with diabetic ketoacidosis?

A.
Rapid infusion of normal saline (NS)

B.
Regular insulin intravenous injection followed by infusion

C.
Potassium replacement

D.
50 mL of 50% dextrose in water (D50W) if blood glucose falls to less than 250 mg/dL
Dextrose should be added to the NS or ½NS (depending on serum osmolality) when the blood glucose decreases to less than 250 mg/dL, but only in a concentration of 5% (D5W). D50W would be too much and would cause more hyperglycemia.
A friend brings a 22-year-old woman to the emergency department. She says that the patient is a diabetic and takes insulin. She reports that they were out exercising and the patient became agitated and argumentative and then lost consciousness. The friend called an ambulance. When you measure the serum glucose, it is 25 mg/dL. What should you do?

A.
Administer 25 g of glucose intravenously.

B.
Administer 12.5 g of glucose intravenously.

C.
Administer 10 g of glucose by mouth.

D.
Administer glucagon intramuscularly.
She is unconscious, so 25 g should be given. Because she cannot take anything by mouth, it should be given intravenously. D50W is 50% dextrose, which has 50 g/100 mL. An ampule is 50 mL, so it supplies 25 g of dextrose. Glucagon is a hormone that causes the body to mobilize glucose. Glucagon is an indirect way to increase the serum glucose and will take longer than giving the glucose directly.
TIA is what? How long before improvement?
Transient Ischemic Attack

Improvement in 24 hours
RIND is what? How long before improvement?
Reversible Neurological Deficit

Improvement in 3 Months
What is a CI?
What are the types? and what is important to know about each of them?
Basilar Vertebral Artery- normally occurs in back of head (brain stem)

Carotid Artery- Left/Right weakness
For Cerebral Infarcts what is important goals for patients?
To decrease cerebral edema
--If NPO, protein decreases
--Decreasing proteins-->H20 in cells
If cerebral edema increases what is a common sign?
Confusion
Strokes that occur in the cortex of the brain typically have what sign?
Decortication (better than decelerate)
Describe deCORtivation.
Arms up & in
Strokes that occur in the brain stem of the brain typically have what sign?
Decelerbrate (Down & Out)
Describe the parts of the brainstem
Midbrain
Pons
Medulla
What purpose do the pyramidal tracts have?
Help with movement
The right pyramidal tracts control?
The left pyramidal tracts control?
Control the left side
Control the right side
(Opposite)

A bilateral babinski would indicate both pyramidal tracts
The cranial nerve III effects?
Eyes

Sympathetic= Dilates
Parasympathetic= Pinpoint
What part of the brain is the weakest?
Paritials
What is uncal herniation?
--Nursing Interventions?
-Bleeding on one side of brain- causes lateral shift
-No Change in LOC
-Do not give Manitol (only works on GOOD tissue); it decreases swelling and decreasing swelling with decrease opposite swelling giving more room for bleeding
FOR EXAMPLE: LEFT SIDED UNCAL HERNIATION what are S/S
Left Eye: Ipsilateral Dilated Pupil
Right Foot: Babinski +
Supratentorial Herniation
Downward shift of the brain
Supratentorial Herniation S/S
-Change in LOC****
-Dilated Pupils
-Change in Breathing
Glascow Coma Scale
Eyes:
4- Spontaneously
3- To Commands
2- To Pain
1- No Response

Motor:
6- Obeys Commands
5- Localizes Pain
4- Flexion-Withdral
3- Flexion
2- Extension
1- No Response

Verbal:
5- Oriented
4- Confused
3- Inappropiate Words
2- Incomprehensible Words
1- No Response
CUSHINGS as related to Supratenorial Herniation is?
Brain coming down through the foreman magnum

-Manitol will only work on good cells, does not work on edematous cells
Increased intracranial pressure S/s
-Acidosis (Keep Alkalotic)
-Hypotonic Solutions- Dexrose
-Hyperextension, Flexion
-Decrease Protein Intake
-Wrist Restraints
Cerebral Perfusion Pressure (CPP) Formula and Normal Range
MAP-ICP=CPP

70-95 mmHg
Seizure Assessment Data
-Precipitating Event
-Site of Origin
-Duration and Frequency
-Loss of Consciousness
-Seizure H(X)
-Pharm H(X)
-Recent Trauma
-Eye Deviation (Points to Problem)
Seizure Interventions
-Seizure Precautions
-Padded Side Rails
-Stretcher Straps
-No Oral Temperature
-Suction
-Airway at Bedside
Myasthemia Gravis Define
decreased number of acetylcholine receptor sites at the neuromuscular junction

Increased Weakness, Decreased Movement that improves with rest.

Frequent rest periods
Myasthemia Gravis S/S
Occular Weakness/Double Vision
Dysphagia
Hoarseness
Limb Weakness
Respiratory Difficulty/Failure
Myasthemia Gravis Precipitating Factors
Inadequate Medication
Stress
Surgery
Drugs
Pregnancy
Myasthemia Gravis Treatment
-Manage Vent for Resp Failure
Steroids
-Meticulous Nursing Care
Myasthemia Gravis Diagnostics
Teslon 2mg IV--Increase Movement
Neostigmine if Teslon is not conclusive
Myasthemia Gravis What drugs do you want to stay away from?
Aminoglycosides
Procainmide
Quinidine
Barbituates
Narcotics
Basilar Skull Fracture S/S
Raccoon Eyes
Battle Sign: Black/Blue Mastoid Bones
Otorrhea: Bloody ear. Put on gauze if clot with yellow ring around it is spinal fluid
Rhinorrhea-nose
Lose of Cranial Nerve I: No smell
Bacterial Meningitis
Staphylococcus Aureus
Very Elevated Protein
Low Glucose Level (Sweet tooth of bacteria eat it)
Purulent
Leukocytes
Viral Meningitis
Enterovirus Herpesvirus
Elevated Protein
Normal Glucose
Clear
Lymphocytes
Meningitis S/S (4)
Headache
Nuchal Rigidity
Brudzinski's Sign (Chest to Chin, Legs Fly Up)
Kernig's Sign (Leg extend up and out, pain in neck)
Guillain-Barre Define
Acute Onset: myelin sheath that covers nerves are destroyed= loss of conduction, regenerates in 3 weeks to 3 months

Ascending Paralysis, then Descending Improvement
Guillain-Barre Causes
Upper Respiratory Infection
Epistein-Barr Virus
Campylobactor Jenjuni Infection (Bowels)
Vaccinations
Hepatitis A B C
Immunodef.
Guillain-Barre Diagnostics
CSF High Protein Levels
Manage Vent. F(X)
Quick Rotation of the head back and forth while holding the eyes open causing the eyes of the comatose patient to rotate opposite the side toward which the head is turned is a positive response known as:
Oculocephalic Reflex
"Dolls Eyes"
"Dolls Eyes" affect what cranial nerves
3, 6, 8...Dolls eyes great! (Sarcasm)
The response elicited when the neck is flexed, producing flexion of both thighs at the hips, as well as flexion movements of the antes and knees is called
Brudzinski's sign
The respiratory pattern seen in upper brainstem lesions (midbrain) is:
Hyperventilation
aPneustic breathing is?
Long pauses blow in and out
Pons damaged/Pinpoint Eyes--aPneustic
The classic cardiovascular signs of increasing intracranial pressure known as Cushing's triad include?
1. Decreasing Pulse
2. Increasing Systolic BP
3. Widening Pulse Pressure
What is the most sensitive indicator of increased intracranial pressure?

Normal Range?
Ventricular Fluid Pressure

0-10 mmHg
Normal ICP
5-15 mmHg
A patient has a subarachnoid screw inserted
to monitor his intracranial pressure (ICP) and cerebral perfusion pressure (CCP). The ICP and CPP are both 35 mm Hg. This means that this patient's:
A. Intracranial venous pressure is decreased
B. Condition is stable
C. Systemic arterial pressure is elevated
D. Cerebral blood flow has markedly decreased to
D. Cerebral blood flow has markedly decreased to the
the brain
D. Cerebral blood flow has markedly decreased to the
the brain
Which of the following parameters are graded when using the Glasgow Coma scale in the assessment of the patient with an altered state of consciousness?
A. Eye opening sensory level and verbal response
B. Motor response, pupillary signs and orientation
C. Pupillary signs, orientation and BP
D. Eye opening, motor response, and verbal response
D. Eye opening, motor response, and verbal response
Blindness in one half of both visual fields following a CVA is referred to as:

A. Homonymous Hemianopia
B. Astereognosis
C. Homonymous hemignosia
D. Optic hemianopia
A. Homonymous Hemianopia
Patients with injury to the left cerebral hemisphere may exhibit:
A. Left hemiparesis or hemiplegia
B. Deviation of the eye to the left
C. Left homonymous hemianopia
D. All of the above
B. Deviation of the eye to the left
Homonymous hemignosia is?
Can identify what is in hand
Pinpoint pupils that react to light if viewed with a magnifying glass are indicative of:

A. A lesion in the pons
B. A lesion in the basal ganglia
C. Oculomotor dysfunction
D. Sympathetic nervous stimulation
A. A lesion in the pons && aPneustic breathing
The nurse caring for a patient with a supratentorial herniation understands that the earliest sign would be:
A. Decerebrate posturing
B. Wide and fixed pupils
C. Lethargy and Stupor
D. Ipsilateral dilated pupil
C. Lethargy and Stupor // Change in LOC
Which is better Obtunded or Stupor?
Obtunded

O before S

O= Speak
S= Garbled
Which of the following treatment modalities would the nurse consider to be inappropriate for the ventilator dependent patient with Increased intracranial pressure?
A. Maintaining the CO2 level between 29-33
B. Feeding the patient via an NGT
C. Administering D5%W at 75 cc/h
D. Log roll when turning the patient
C. Administering D5%W at 75 cc/h
While assessing the laboratory data of a patient with head trauma, which finding necessitates notification of the physician?
A. A serum osmolarity of 275
B. A serum sodium level of 138
C. A urine specific gravity of 1.005
D. A urine osmolarity of 400
C. A urine specific gravity of 1.005
A basal skull fracture affecting the middle fossa may cause which of the following?
A. Cranial nerve injuries
B. Battle's sign
C. C.S.F. otorrhea or rhinorrhea
D. All of the Above
D. All of the Above

(Nerve #1)
Normal Urine Osmolarity
400-1200
What should the nurse do when his/her patient with a basilar skull fracture begins to have clear fluid draining from one ear?
A. Pack the external auditory canal with sterile cotton and notify the doctor
B. Apply a loose sterile dressing over
call the doctor
C. Apply an occlusive sterile dressing over the ear and change it frequently
D. Suction the ear with a sterile catheter
B. Apply a loose sterile dressing over
call the doctor
To determine if bloody head drainage contained C.S.F., a nurse would put some on a gauze and observe:
A. Absence of a clear line of demarcation between the serum and blood
B. A blood clot in the middle with a around it yellow ring around it
C. A yellow ring with two bloody rings around it
D. Absence of the clot but one bloody ring at the center of the gauze
B. A blood clot in the middle with a around it yellow ring around it
Examination of the CSF in bacterial meningitis will reveal all but which of the following?
A. Cloudiness
B. Increased white blood cells
C. Decreased protein
D. Increased pressure and decreased glucose
C. Decreased protein
Which statement is accurate regarding the differentiation of CSF in bacterial and viral meningitis?
A. Higher level of protein in bacterial meningitis than viral
B. Low sugar content seen in bacterial meningitis, usually normal in viral
C. CSF is purulent and turbid in bacterial, may be clear with viral
D. All of the above
D. All of the above
Care of the patient with Myasthenia Gravis would include:
A. Administeration of anticholinesterase medications on time
B. Scheduling activities in the morning to avoid fatigability of muscles
C. Administration of steroids
D. All of the Above
D. All of the Above
Guillain-Barre syndrome is:

A. An upper motor neuron disease
B. The result of a decrease in cholinesterases
C. Usually occurs after a viral infection
D. Found predominately in young women and older men
C. Usually occurs after a viral infection
Pancreatitis Causes
-Obstruction of Pancreatic ducts, Gallstones, Infection
-Alcoholism

-Drug Toxicity:

Cyclosporine, Steroids
Thiazides, Tetracyclines

-Trauma
Cause of Pancreatitis
Auto digestion of the organ; it is a fatty organ and needs calcium to autodigestion
Side effects of Pancreatitis
-Hypocalcemia: auto digestion

-HHNK: doesn't have time to make insulin because of auto digestion

-Left side atelectasis: Cause diaphragm to move up

-Bilateral Rales

-ARDS: die of because auto digestion occurs it releases phospholipase A goes to lung to kill Type II alveoli cells- no surfactant
Pancreatitis
What is cullers sign?
Black/Blue Belly Button: Auto digestion eats blood vessels
Pancreatitis:
Grey-Turner's sign
Flank/Groin
What medicine do you not give Pancreatitis patients?
Morphine
Difference between large bowel obstruction and small bowel obstruction
Large: Large Distention

Small: Small distention, diarrhea, vomiting
Liver Functions
Kupper Cells- Detoxifies the Blood Bile

Synthesis Amino Acids

Albumin, Prothrombin, Fibrinogen

Converts Glucose into Glycogen

Converts Ammonia into Urea
How much blood goes through Liver in a minute?
1,500 mL
Decrease albumin leads to?
Third Spacing
Liver Disease Problems

(Do not want to happen)
-Decrease in Potassium: Kidney will hold on to potassium/hold on to ammonia ion

-Increase in BUN: breakdown of blood urea nitrogen--releases ammonia--leads to dehydration

-Increase in protein

-Increase in Acids- Metabolic Acidosis because of decrease in BP

All these increase Ammonia levels-which lead to Hepatic Encephalopathy
What is contraindicated in patients with Liver Failure?
Glucagon
In liver disease or when BP is decreased can lead to Metabolic Acidosis what type of fluid is recommended and why?
Ringer's Lactate- Lactate is converted to bicarb by Liver
Complication of Neomycin Therapy?
Not absorbed systemically; therefore, no ottotoxicity
What part of the body is vital in making vitamins?
Bowels
Liver:
Unconjugated or Indirect Bilirubin go to ________________ (1)

The ______________(1) converts to __________________ (2)

The _________(2) goes to _________(3) to live happily ever after
(1) Liver

(2) Conjugated or Direct Bilirubin

(3) gallbladder
Increases in Indirect or Unconjugated Bilirubin would indicate
Hepatic Failure
Liver Disease
Increases in Direct or Conjucated Bilirubin would indicated
Gallblader
Billary Tract Disease
Ruptured Spleen
-Typical Cause?
-Sign?
Abdominal Trauma
Kehr's Sign
Kehr's sign?
Left Shoulder Pain--typical in Ruptured Spleen
In order to most accurately establish that your patient has no bowel sounds, you must listen in each quadrant for at least:

A. 30 seconds
B. 1 full minutes
C. 1-1/2 minutes
D. 2-5 minutes
D. 2-5 minutes
The usual order for carrying out physical assessment of the abdomen is:

A. Palpation, inspection, auscultation, percussion

B. Auscultation, percussion, palpation, inspection

C. Inspection, auscultation, percussion, palpation

D. Percussion, auscultation, inspection, palpation
C. Inspection, auscultation, percussion, palpation
The function of the liver includes all of the following except:

A. Formation of ammonia to remove urea from the
from the blood

B. Hepatocytes secrete bile

C. Synthesizes amino acids and albumin

D. Synthesizes prothrombin, fibinogen and albumin
A. Formation of ammonia to remove urea from the
from the blood
Nursing interventions for the patient with hepatic failure include:

A. Restrict protein in the diet

B. Avoid use of narcotics, sedatives and tranquilizers

C. Administer lactulose and neomycin as prescribed

D. All of the Above
D. All of the Above
The underlying cause of most bleeding esophageal varices is:

A. Acid pepsin erosion secondary to gastroesophageal reflux

B. Portal hypertension due to liver disease

C. High venous pressures at the esophagogastric junction due to systemic hypertension

D. Traumatic esophageal damage
B. Portal hypertension due to liver disease
The rationale for the use of neomycin in the setting of liver failure is to:

A. Prevent the likelihood of sepsis in the event of severe gastrointestinal bleed

B. Promote the manufacture of prothrombin by activating vitamin K

C. Inhibit the production of ammonia by intestinal bacteria

D. Establish a blood level of antibiotic in anticipation of surgery
C. Inhibit the production of ammonia by intestinal bacteria
The administration of vasopressin should be most carefully monitored in patients who have:

A. Diabetes Insipidus

B. Coronary artery disease

C. Hypotension secondary to G.I. Bleeding

D. Diabetes Mellitus
B. Coronary artery disease
Urea is formed by the liver to rid the body of:

A. Creatinine

B. Bicarbonate

C. Bilirubin

D. Ammonia
D. Ammonia
The inability of the liver to conjugate what substance is a primary contributor to hepatic coma?

A. Ammonia

B. Urea

C. Fatty acids

D. Bilirubin
A. Ammonia
Which of the following may precipitate the onset of hepatic encephalopathy in patients with severe liver dysfunction?

A. Diuretics

B. Acute infection

C. G.I. Bleeding

D. All of the Above
D. All of the Above

Diuretics: Decrease potassium levels

Acute Infections: Increase BUN

Gi Bleed: Blood is protein; blood releases ammonia
Ecchymoses around the umbilicus indicative of peritoneal bleeding is called:

A. Chvostek's sign

B. Grey Turner's sign

C. Cullen's Sign

D. Trousseau's sign
C. Cullen's Sign


Chvostek's sign: low calcium--touch cheek
Pulmonary complications of acute pancreatitis may include:

A. Adult respiratory distress syndrome

B. Elevation of the diaphragm and bilateral basilar rales

C. Atelectasis, especially of left base

D. All of the Above
D. All of the Above
A bluish-green, brown discoloration in the flank and groin due to retroperitoneal bleeding is called:

A. Grey-Turners Sign

B. Cullen's sign

C. Kernig's sign

D. Welch's sign
A. Grey-Turners Sign
Which of the following may contribute to the precipitation of encephalopathy in the patient with liver failure?

A. G.I. Bleeding

B. Hypokalemia

C. Hypotension

D. All of the Above
D. All of the Above

*Hypotension due to Acidosis
Patient assessment findings indicative of a bowel infarction would include:

A. Hypoactive bowel sounds and leukocytosis

B. Hyperresonance and abdominal tenderness

C. Absence of dullness in the liver area

D. All of the Above
D. All of the Above
Disseminated Intravascular Coagulation

-The Clotting Cascade-

Differentiate between intrinsic and extrinsic pathway, conversions
Uses up all clotting factors until all gone
Disseminated Intravascular Coagulation

Laboratory Findings
Decreased Fibrinogen Levels- TEST

Increased PT and PTT Values

Increased Fibrin Split Products

Increased D-Dimers Values
Disseminated Intravascular Coagulation

Treatment Modalities
-Heparin

-FRESH FROZEN PLASMA

-CRYOPRECIPITATE (8, 13, Fibrinogen)

-GET RID OF THE TRIGGERING EVENT/CAUSE
Heparin Functions
-Heparin inhibits the conversion of prothrombin into thrombin

-Heparin inactivates circulating thrombin

-Heparin inhibits the conversion of fibrinogen into fibrin-
Heparin Induced Thrombocytopenia HITTS

In patients who do not have anti-thrombin III, Heparin may ________________?

What medication is given instead?
have opposite effect, thus causing blood to clot.

Argatrobon (ACOVA), a thrombin inhibitor which does not require anti-thrombin III is given instead of Heparin.
Idiopathic (Immune) Thrombocytopenic Purpura (ITP) define
In ITP antibodies form and destroy the body's platelets resulting in thrombocytopenia.
Etiologies of Idiopathic (Immune) Thrombocytopenic Purpura (ITP)
Etiologies Include:

-BONE MARROW DOES NOT PRODUCE ENOUGH PLATELETS
Leukemias, Lymphoma, Anemias, Bone Marrow Disorders Chemotherapy, Radiation therapy

-PLATELETS BECOME ENTRAPPED IN ENLARGED SPLEEN
Cirrhosis with congestive splenomegaly

-USE OR DESTRUCTION OF PLATELETS INCREASES
HIV infection, Medications (Heparin, Quinidine, Oral Diabetic Drugs) DIC, Septicemia from gram negative bacteria
Etiologies of Idiopathic (Immune) Thrombocytopenic Purpura (ITP)

-S/S
-Labs
-Platelets are less than 50,000

-Both Hb and HCT are decreased

-Pallor, petechiae, purpura, ecchymoses, and oozing of blood from venipuncture sites, etc.
Why is a platelet transfusion not indicated for Idiopathic (Immune) Thrombocytopenic Purpura (ITP)
PLATELET TRANSFUSIONS ARE NOT INDICATED AS THE UNDERLYING PROBLEM IS PLATELET CONSUMPTION, NOT PLATELET PRODUCTION.
Differentiation between DIC and ITP
DIC: Increases fibrinogen split production

ITP: does not

Both ooze blood
Which of the following blood products contains only factors VIII, fibrinogen and XIII and is utilized in hemophilia A and D.I.C.?

A. Platelet concentrate

B. Plasmanate

C. Fresh frozen plasma

D. Cyroprecipitate
D. Cyroprecipitate
Disseminated intravascular coagulopathy is:

A. Usually a primary disorder

B. A hemorrhagic episode from an initial lack of clotting mechanisms

C. Widespread inappropriate clotting that triggers bleeding

D. Diagnosed by an increase level of clotting factors
C. Widespread inappropriate clotting that triggers bleeding
The pathophysiology of disseminated intravascular coagulation includes:

A. Inhibition of thrombinolysins

B. Enhanced production of intravascular
thrombin resulting in increased fibrin
and platelet aggregation

C. Diminished platelet adhesiveness and aggregation

D. Enhancement of intravascular clots due to an overproduction of clotting factors
B. Enhanced production of intravascular
thrombin resulting in increased fibrin
and platelet aggregation
Which of the following laboratory diagnostic findings is NOT likely to be seen in D.I.C.?

A. PT and PTT prolonged

B. Platelet count decreased

C. Fibrinogen Increased

D. Fibrin split products elevated
C. Fibrinogen Increased
The beneficial effects of heparin in D.I.C. are thought to be due to its:

A. Stimulating effect on platelet manufacture

B. Neutralizing of free-circulating thrombin

C. Antifibrinolysin activity

D. Inhibition of platelet factor XII release
B. Neutralizing of free-circulating thrombin
Which statement is correct regarding ITP?

A. Steroids may be given as it blocks the antibodies that destroy the platelets

B. Cirrhosis, HIV infection, leukemias and some medications such as Quinidine may cause ITP

C. Bleeding can occur when the platelet count falls below 50,000

D. All of the above statements are correct
D. All of the above statements are correct
Acute Renal Failure

Pre-Renal
Decrease in urinary output due to a decreased blood supply to the kidney

CHF or Low BP
Acute Renal Failure

Renal
Decrease in urinary output due to kidney damage to tissues or nephrons

ATN:
-Ischemia
-Nephrotoxicity
Acute Renal Failure

urine output
Decrease in urinary output, less than 400cc in 24 hours
Acute Tubular Necrosis

1. Ischemia (Causes)

2. Nephrotoxicity (Causes)
1. Ischemia (Causes)

-Hemorrhage
-Burns
-Sepsis
-Heart Failure
-Transfusion Reactions

2. Nephrotoxicity (Causes)

-Heavy Metals
-Medications
-Street Drugs
-Rhabdomyolysis
-Radiocontrast
Acute Tubular Necrosis Stages
Oliguric Stage

Polyuric Stage

Recovery Stage
Acute Tubular Necrosis

Oliguric Stage
-Lasts 10 - 17 days

-Increased BUN,Creatinine,Potassium

-Fluid overload, CHF

-Peritoneal Dialysis
Acute Tubular Necrosis

Polyuric Stage
-Lasts 2 weeks - 3 months

-Increased BUN, Creatinine

-Low Potassium

-Fluid Depleted
Acute Tubular Necrosis

Recovery Stage
Lasts 3 months - 1 year

PRAY THE KIDNEYS REGENERATES!
Acute Renal Failure

Pre-Renal
Urinary Sodium: <20 (holding on to sodium to hold on to water)

BUN:Creatinine: 20:1

Lasix/Fluid Challenge: +Urine
Acute Renal Failure

Renal (ATN)
Urinary Sodium: 40-100

BUN:Creatinine: 10:1

Lasix/Fluid Challenge: No Urine
Normal Urinary Sodium Level?
20-200
Normal Urinary Potassium Level?
20-200
Continuous Renal Replacement Therapy (CRRT)

Define
CRRT is a 24 hour continuous dialysis therapy provided to patients who are medically unstable. CRRT is not as aggressive as hemodialysis treatments. CRRT is
delivered via the Prisma Dialysis Machine.
Continuous Renal Replacement Therapy (CRRT)

Works by
CRRT: Removes volume and solutes slowly

• Correct electrolyte and metabolic abnormalities associated with renal dysfunction

• Maintain optimal fluid balance
Continuous Renal Replacement Therapy (CRRT)

Unstable Patients who may be candidates for CRRT
• Fluid Overload
• Acute Renal Failure
• Chronic Renal Failure
• Electrolyte Imbalances • Drug Overdose
Continuous Renal Replacement Therapy (CRRT)

CRRT can be done two ways: Arteriovenous or Venovenous
Arteriovenous CRRT-

The force of the patients BP is used to pump blood from an artery into the circuit and hemofilter.

Venovenous CRRT-

A blood pump is used to force blood from the patient to the filter. This ensures a consistent pressure in the circuit and hemofilter.

It can be performed FOUR ways:

SCUF CVVH CVVHD CVVHDF
Four Modes of Venovenous CRRT
SCUF - Slow Continuous Ultrafiltration

CVVH - Continuous VenoVenous Hemofiltration

CVVHD - Continuous VenoVenous Hemodialysis

CVVHDF - Continuous VenoVenus Hemodiafiltration
Venovenous CRRT

SCUF
Slow Continuous Ultrafiltration

*Primary Goal is fluid removal
Venovenous CRRT

CVVH
Continuous VenoVenous Hemofiltration

*Primary Goal is fluid volume management with
moderate solute removal
Venovenous CRRT

CVVHD
CVVHD - Continuous VenoVenous Hemodialysis

*Primary Goal is fluid volume management with a greater level of solute removal
Venovenous CRRT

CVVHDF
CVVHDF - Continuous VenoVenus Hemodiafiltration

*Primary Goal is maximal fluid and solute removal
Chronic Renal Failure

-Define

-Stages
The decline in kidney function correlates with the degree of nephron loss, which can be linked with the serum creatinine levels

-Diminished Renal Reserve

-Renal Insufficiency

-End Stage Renal Disease (ESRD)

-Uremic Syndrome
Define each stage of chronic renal failure
Diminished Renal Reserve: 50% Nephron Loss

Renal Insufficiency: 75% Nephron Loss

End Stage Renal Disease (ESRD): 90% Nephron Loss

Uremic Syndrome: Complete Nephron Los
An inverse relationship exist between serum creatinine levels and GFR and ______________
the stage of Chronic Renal Failure.
Hyperkalemia causes what to EKG

-Hyperkalemia greater that 8 mEq causes?
Peaked T Waves

-Sine
S/S of Hyperkalemia
Muscle Weakness
EKG Changes
Hyperkalemia Treatments
Calcium Chloride: Works within minutes (If EKG Involvement)

Insulin + Glucose: Pushes into cell

Sodium BiCarb: Pushes into cell

K-Excelate: Pushes into bowel
Calcium & Phosphate have what kind of relationship?
Reciprocal Relationship
Decreased Calcium
Increased Phosphate S/S
Chvostek's

Trousseau's

Twitch, Twitch

Seizures
Increased Calcium
Decreased Phosphate S/S
Muscle Weakness
Apathy
Kidney Damage can cause low calcium why?
It cannot absorb vitamin D
Decreased Phosphate to improve you should?
Only give green leafy vegetables, TPN infusions
Which of the following drugs actually removes potassium from the body in hyperkalemic patients in acute renal failure?

A. Sodium bicarbonate

B. Calcium chloride

C. Glucose and insulin infusion

D. Kayexalate and sorbital
D. Kayexalate and sorbital
The electrolyte abnormality that produces a U wave, a depressed ST segment, and ventricular irritability is

A. Hypernatremia

B. Hyperkalemia

C. Hypokalemia

D. Hypocalcemia
C. Hypokalemia
Which EKG finding would not be observed in the presence of hyperkalemia?

A. Prolonged PR interval

B. Absence of P waves

C. Ventricular Irritability

D. Widened QRS complexes
C. Ventricular Irritability
A weight gain of one kilogram in 24 hours may indicate fluid retention of at least: _______
1000 mL
Signs of rapidly-developing Alkalosis include?
1. Nervous Irritability
2. Muscle Tremors
3. Seizures
A patient has a urinary output of 1000 cc in 24 hours with a urine sodium level of 25 mEq/liter These findings probably indicate:

A. The patient is on a salt-free diet

B. The patient's kidneys have a decreased blood perfusion

C. The patient is in the beginning of renal failure

D. The patient is progressing to the prerenal phase
A. The patient is on a salt-free diet
Ischemia injury to the kidney will usually commence when the mean arterial blood pressure falls below:


A. 100 mmHg for 30 minutes

B. 90 mmHg for 2 hours

C. 60 mmHg for 40 minutes

D. 50 mmHg for 2 hours
C. 60 mmHg for 40 minutes
The two most common causes of acute renal failure or (ATN) are:

A. Nephrotoxic Substances and Ischemia

B. Ischemia and urologic obstructions

C. Nephrotoxic drugs and heavy metals

D. Impaired renal perfusion and hepatorenal causes
A. Nephrotoxic Substances and Ischemia
The patient with acute tubular necrosis
is differentiated from a patient with decreased renal perfusion because ONLY in decreased renal perfusion:


A. The urine volume is low and the kidneys fail to respond to Lasix

B. The urine osmolality is greatly reduced

C. The urinary sodium is 40 to 100 mEq/L

D. The BUN to creatinine ratio is 20:1
D. The BUN to creatinine ratio is 20:1
The oliguric stage of acute renal failure WOULD NOT include which of the following:

A. BUN 20 mg%

B. Creatinine 9 mg%

C. Signs of congestive heart failure

D. Potassium 7 mEq/L
A. BUN 20 mg%
In ATN caused by nephrotoxic drugs, Lasix will:

A. Increase Toxicity

B. Cause diuresis, thus correcting oliguria

C. Increase blood flow to the kidneys

D. Improve the patient's renal status
A. Increase Toxicity
Which of the following modes of CRRT would have the primary goal of just fluid removal?

A. SCUF

B. CVVH

C. CVVHD

D. CVVHDF
A. SCUF
USE OF RESTRAINTS

-EXTREMELY OR USUALLY APPROPRIATE

-SOMETIMES APPROPRIATE

-RARELY OR NEVER APPROPRIATE
EXTREMELY OR USUALLY APPROPRIATE

-Acute danger to other patients, staff or self

SOMETIMES APPROPRIATE
-To prevent an involuntary patient from leaving

RARELY OR NEVER APPROPRIATE
•A history of previous self-injury or aggression • Lack of resources to supervise patient
• To prevent a voluntary patient from leaving
Multisystem Trauma Steps (3)

1.
1. Stress Response

Occurs after injury initiated by tissue injury, acute blood lose, shock, hypoxia, acidosis, pain, anxiety and fear

-SNS: epinephrine, norepinephrine and cortisol ...increase HR, BP, ventilation

-Prolonged vasoconstriction leaved to impaired delivery of oxygen and nutrients to tissues

-Renin-Angiotension: release of aldosterone
Multisystem Trauma Steps (3)

2.

3.
2. Psychological Response

-Pt. fear, withdrawal, anger, hostility, anxiety, depression, hyperarousal

3. Metabolic Derangement

-Edema
-Increased CO2
-Increased Oxygen Transport
-Altered Glucose Metabolism
-Altered Fat Metabolism
MSOF: Multi-System Organ Failure

MODS: Multi-Organ Dysfunction Syndrome
#1 cause of death in surgical/trauma patients

Failure of vital organs:

* Lungs (ARDS)
* Kidneys (ATN)
* Liver (Liver Failure)
* Blood (DIC)
* Brain ( CPP)
* Heart (Ischemia/Injury)
Multisystem Trauma Assessment System
AMPLE
A - ALLERGIES
M - MEDICATIONS
P - PAST ILLNESSES
L - LAST MEAL
E - EVENTS PRECEDING INJURY
For poisoned patients who are comatose be prepared to give:
Dextrose 50% 100 ml

Thiamine 100 mg IV

Naloxone 2 mg IV

Activated Charcoal 1 gram/kg of weight

Provide Antidote
Poisonings

Acetaminophen Overdose

Antidote?

Grades (3)?
ANTIDOTE:

NAC (Mucomyst)

140 mg/kg loading dose

70 mg/kg every 4 hours for 17 doses

Give activated charcoal if less
than 4 hours since ingestion (Wait 1 hr before giving NAC if charcoal is given)

GRADES:

I - Nausea, vomiting II - RUQ Pain
III - Liver function
abnormalities
Poisonings

Salicylate Overdose

Antidote?

Observe for?
ANTIDOTE:

Lavage or induce emesis

Activated Charcoal

Urinary Alkalinization (with sodium bicarbonate)
* (Observe for Hypokalemia)

Hemodialysis

Observe For:

-Renal Tubular Acidosis
Massive Blood Transfusions can cause?
Low Calcium Levels
TPN Causes
Hypophosphatemia
Amphogel reduces?

Why would it be given?
Hyperphosphatemia

Kidney disease because it causes calcium to decrease thus it increase phosphorus levels
For ARDS it is important to what?
Keep the patient dry
(decrease fluid)
Acidosis causes a rise in what level?
Potassium
MCL1 helps differentiate?
ventricular arrhythmia (Ectopy) from supraventicular arrhythmias (Aberrancy)
What is a V V I Pacemaker?
1st initial- chamber paced

2nd initial- chamber sense

3rd initial mode
How to drain left lower lobe?
Trandelenburg
How do you drain upper lobes?
Sit in chair, lean back, cup and clap
What is a left ventricular assist device?
Blood is diverted from the left atrium and returned to the patient via ascending aorta
IABP augments the cardiac output by?
15%
Toursades de Pointe treatment?
Magnesium
MVA patient is most at risk for?
Fat emboli
Malignant Hypertension
Diastolic BP of >140 mm Hg and is associated with retinal hemorrhages and papilledema
Hypertrophic Cardiomyopathy (HCM)

Hypertrophic Obstructive Cardiomyopathy

Idiopathic Hypertrophic Subaortic Stenosis (IHSS)

Define
Septum that hangs over into Left Ventricle

Ventricles become rigid and stiff, restricting filling and stroke volume decreases, cardiac output decreases.

Instead of filling up with 70% it fills up with 30%
Hypertrophic Cardiomyopathy (HCM)

Hypertrophic Obstructive Cardiomyopathy

Idiopathic Hypertrophic Subaortic Stenosis (IHSS)

Pharmacological Modalities

Give?

Contraindicated
Give:

Beta Blocker
Calcium Channel Blocker

Inderal & Verapamil

Digoxin, Nitrates, Dopamine, Isuprel, Morphine CONTRAINDICATED
Swan-Ganz Catheter
Advanced to Right Artia, Advanced to Right Venticle, Advanced to Pulmonary Artery
Swan-Ganz Catheter

PULMONARY ARTERY PRESSURE (PAP)

Systolic elevated in:
Pulmonary Hypertension Pulmonary Hypoxia COPD
ARDS
Pulmonary Embolism
Swan-Ganz Catheter

PULMONARY ARTERY PRESSURE (PAP)

Diastolic elevated in:
Cardiac Tamponade

Left Ventricular Failure

Mitral Valve Disease

PAD=LVEDP
PULMONARY ARTERY PRESSURE (PAP)

Normal PA Systolic
PA Systolic 20-30 mm Hg
PULMONARY ARTERY PRESSURE (PAP)

Normal PA Diastolic
PA Diastolic 6-12 mm Hg
Know that PAD is not always?
accurate of left side of heart or LVEDP
PULMONARY ARTERY WEDGE PRESSURE

Define

Normal Values
Putting air into the balloon. Changes the waveform

PAWP reflects left atrial pressure/LVedp

A-Wave
C-Wave
V-Wave

4 - 12 mm Hg
PULMONARY ARTERY WEDGE PRESSURE

Waves
A = atrial contraction (after QRS)

C = mitral valve closing

V = atrial filling (after T wave)
PULMONARY ARTERY WEDGE
PRESSURE

Elevated in:
Left -Sided Heart Dysfunction

Mitral Stenosis/Insufficieny

Cardiac Tamponade

Constrictive Pericarditis

Left Ventricular Failure

Volume Overload
The PAWP is
1 - 4 mmHg LOWER
than the PAD
The PAWP is
1 - 4 mmHg LOWER
than the PAD
The PAWP SHOULD NOT be greater
than the ________
PAD.

This discrepancy is caused either by overwedging the catheter or physiological Conditions (Zone I, II or PEEP).
How do you know catheter is in Zone I or II?
Damped wedge tracing (Cant find A V waves)

PAWP higher than PAD

Absence of "A" and "V" waves

Marked respiratory variations
Anyone on a PEEP greater than 10, the PAWP....
is not going to be accurate
Calculating the PAWP on PEEP
1. Change PEEP cm H2O into mm Hg

2. Divide PEEP by 1.36 (1 mm Hg = 1.36 cm H2O)

3. Then divide the mm Hg of PEEP by 2

Divide by 1.36 then Divide by 2
Calculating the PAWP on PEEP
PEEP applied = 15 cm H2O

Measured PAWP = 18 mm Hg

1.36 of 15 = 11 mm Hg

Divide by 2 = 5.5 mm Hg of PEEP

18 mm Hg measured PAWP - 5.5mmHg PEEP=
12.5 mm Hg true PAWP reading
Two Causes of Murmurs
•FORWARD flow of blood through stiff stenotic OPEN valves

Stenosis=Open

•BACKWARD flow of blood through incompetently CLOSED valves

Insufficiency=Closed
Where do you listen for murmurs?
AORTIC AREA: RIGHT 2nd ICS

PULMONIC AREA: LEFT 2ND ICS

MITRAL AREA: 5TH ICS MCL

TRICUSPID AREA: 4-5TH ICS LEFT
STERNAL BORDER
Diastolic Murmur
S1 (Lub) S2 (Dub) MURMURRRRRRR
Systolic Murmur
S1 (Lub)

MURMURRRRRRR

S2 (Dub)
Diastolic Murmur

MITRAL STENOSIS
Low pitched rumbling noise heard at apex that will increase in left lateral position.


Causes include calcification of leaflets.
Diastolic Murmur
AORTIC INSUFFICIENCY
High pitched, blowing noise that increases with exhalation

Causes include systemic hypertension and rheumatic
heart disease.
Systolic Murmur
AORTIC STENOSIS
Medium pitched, radiating to the neck and right carotid
which increases with sitting and holding one's breath.

HARSH, ROUGH SOUND

Causes include calcification of valves and rheumatic
fever. (Little old women)
Systolic Murmur
MITRAL INSUFFICIENCY
High pitched, BLOWING SOUND. Increases with squatting

Causes include myocardial infarction, rheumatic heart
disease.
Cardiac Catheterization

Define
Cardiac catheterization is done to confirm and define the extent of coronary artery disease; to evaluate cardiac function in heart disease and to perform catheter-based interventional procedures to treat coronary artery disease.
Cardiac Catheterization

prevent contrast induced nephropathy?
Measures to prevent contrast induced nephropathy include using a low dose of contrast as possible; hydration with IV Normal Saline and the administration of acetylcysteine (Mucomist) which has antioxidant and vasodilatory effects on the day before and the day of the procedure.

Nephrotoxic drugs such as some antibiotics, cyclosporine, non-steroidal anti-inflammatory drugs & metformin must be withheld 24 hrs prior to procedure
PCI (Percutaneous Coronary Intervention) is the treatment of coronary artery disease via catheter-based procedures. PCI is performed via left heart catheterization and includes:
Nurses should be aware of the importance of continued ASA and Plavix therapy in patients with DES implants and stress the importance of taking these drugs when doing patient teaching. Patients must consult with cardiologist before discontinuing ASA and Plavix even for diagnostic or surgical procedures.
Cardiac Catheterization

NURSING CARE POST PROCEDURE
NURSING CARE POST PROCEDURE

-Manual pressure for 20 - 30 minutes until bleeding is controlled

-Mechanical compress, C-clamp; Arterial puncture closure devices; sutured mediated devices can be used

• Vital Signs and Distal Pulse Checks

• Observation of access site for bleeding or hematoma formation

• Observation of extremity below the access site for color, temp. & movement

• Q 15 minutes the first hour and every 30 minutes the second hour then hourly • Bedrest with the affected leg straight for 2-4 hours
Cardiac Catheterization

Complications
Most common complications are local vascular problems at insertion site.

Hematoma
Formation

Retroperitoneal

Bleeding Thrombosis

Distal Embolization
Acute Coronary Syndrome

Define?

Includes?
With ACS there is an urgency for treatment to preserve myocardial function. After 20 minutes of oxygen deprivation, irreversible cellular injury begins.

Acute Coronary Syndrome includes:

Unstable Angina
Non-STEMI
STEMI

Patients presenting with STEMI are candidates for reperfusion therapy
12 Lead EKG Interpretation
Look at notes
Right Coronary (Inferior Wall) Supplies?

Complications?
SINUS NODE: BRADYCARDIA from Ischemic

Pt can be asymptomatic. If symptomatic and BP ok, lie pt flat and put legs up in air. Put more blood in Right atrium that will release chemical to increase
HR

AV NODE: CHB, 3RD HB, AV
DISSOCIATION have any these and inferior wall MI must have a pacemaker



RA & RV: RV INFARCTION

MITRAL VALVE: MITRAL INSUFFICIENCY
LEFT ANTERIOR DECENDING (ANTERIOR-SEPTAL WALL) SUPPLIES:
BUNDLE OF HIS: MOBITZ II

BUNDLE BRANCHES: RBBB

94% mortality without pacemaker

14% mortality with pacemaker

VENTRICULAR SEPTUM: VSD
Myocardial contusion
ST elevation in leads looking at the injury
Pericarditis
ST elevation in all the leads
Stock States
Compensatory Stage

Progressive Stage

Refactory
SHOCK

Compensatory Stage
Decrease in CO stimulates the Sympathetic Nervous System to release ADRENALIN


Adrenalin Increases CO, BP, ADH Vasoconstriction
SHOCK

Progressive Stage
Vasodilatation due to lactic acidosis

Decrease in CO & BP
HYPOTENSION
Hypovolemic Shock

Compensatory S/S
Anxious & Irritable

Tachycardia

Cool and Pale

Decreased Urinary Output
Hypovolemic Shock

Progressive S/S
Obtunded and Stuporous

Hypotension

Decreased CVP, PCWP, CO

Increased SVR
Hypovolemic Shock

Treatment
Replacement volume, crystalloid (NS, LR), colloids (Albumin), FFP, RBC's
Cardiogenic Shock

Etiology?
Etiology:
Myocardial Infarction Cardiomyopathy/ CHF Arrhythmias Cardiac Tamponade Papillary Muscle Rupture
Cardiogenic Shock

Patient Assessment?
Patient Assessment:
Confused - Restless Rapid Respirations - Rales Rapid Thready Pulse Neck Vein Distention Narrow Pulse Pressure
S3 S4 Hypotension
Oliguria Decreased CO Elevated CVP, SVR, PCWP
Cardiogenic Shock

Treatment?
Treatment:
Early Reperfusion PTCA, Thrombolytics,
CABG IABP Inotropic Drugs
intra-aortic balloon pump (IABP)

define
An intra-aortic balloon pump (IABP) is a mechanical device that helps the heart pump blood. This device is inserted into the aorta, the body's largest artery. It is a long, thin tube called a catheter with a balloon on the end of it.

It inflates and deflates continuously
intra-aortic balloon pump (IABP)

Purpose?

Uses?
PURPOSE:
Decrease Afterload Decrease Myocardial O2 Demand Increase Coronary Perfusion Improve Cardiac Output

USES OF IABP:
Support Acute MI with Shock with Mitral Regurgitation Circulatory Support CABG pts Support high risk Cardiac Caths
intra-aortic balloon pump (IABP)

CONTRAINDICATIONS?

Complications?
CONTRAINDICATIONS:
Aortic Insufficiency Peripheral Vascular Disease

COMPLICATIONS:
Ischemia of Limb Dissection of aorta Infection
intra-aortic balloon pump (IABP)

interventions
INTERVENTIONS:
IABP
Do not elevate bed >15 Assess Pulses Monitor Bleeding
IABP

Balloon inflates during ______________ and deflates during ____________
Diastole

Systole
Septic Shock

Sepsis usually caused by gram-negative bacteria:
E. Coli
Klebsiella
Enterobacter
Pseudomonas
Serratia Marcescens

may release endotoxins that cause septic shock
Septic Shock Predisposing Factors
Old Age

Granulocytopenia

Severe Burn Injury

Alcohol & Drug Abuse

Recent Surgical Procedures

Immunosuppression (HIV, Chemo)

Prolonged Intensive Care Unit Stay
Septic Shock Cascade
GRAM NEGATIVE BACTERIA ->

ENDOTOXIN ->

VASOACTIVE SUSTANCES ->

VASODILATION
Septic Shock

Warm Stage
Confusion

Increased CO

Increased RR

Best ABG

Good BP

Increased UO
Septic Shock

Warm Stage
Stuporous & Obtunded

Decreased CO

Decreased UO

Poor ABG

Metabolic Acidosis

HYPOTENSION->

ARDS, ATN, MSOF, DIC
Septic Shock

Interventions
FLUIDS * ANTIBIOTICS
VASOPRESSORS

( Levophed, epinephrine, vasopressin)

(Dopamine is used only if heart rate is low)

Norepinephrine (Levophed) is favored as the first line vasopressor for septic shock. It increases the mean arterial pressure through vasoconstriction, with little effect on heart rate, stroke volume and cardiac output.

Target is a MAP of 65

MAP = 2D + S / 3
Which of the following pressures are within normal limits?

A. PAP 34/24 PCWP 12

B. PAP 30/20 PCWP 10

C. PAP 28/18 PCWP 20

D. PAP 24/14 PCWP 12
D. PAP 24/14 PCWP 12
Which of the following would cause an elevated pulmonary artery pressure and a normal wedge pressure?

A. Pulmonary Hypertension

B. Pulmonary edema

C. Left ventricular failure

D. Constrictive pericarditis
A. Pulmonary Hypertension
A large V wave appears on the PCWP tracing of a patient with an inferior wall myocardial infarction.
This finding is consistent with:

A. Cardiogenic shock
B. Congestive heart failure
C. Mitral Regurgitation
D. Pericarditis
C. Mitral Regurgitation
ST elevations and absence of an "R" wave in V1-V4 would be indicative of:

A. Anterior-Septal Wall Infarction

B. Inferior wall ischemia

C. Anterior - septal wall ischemia

D. Anterior - lateral wall infarction
A. Anterior-Septal Wall Infarction
Which of the following hemodynamic parameters would indicate left ventricular failure in a patient with COPD?

A. PAP 54/22 PCWP 14 CVP 8
B. PAP 48/26 PCWP 16 CVP 6
C. PAP 22/12 PCWP 26 CVP 16
D. PAP 48/26 PCWP 20 CVP 16
D. PAP 48/26 PCWP 20 CVP 16
The reciprocal changes that occur with an inferior wall MI are seen as ST depressions in Leads:

A. II, III, aVF

B. V1 - V4

C. II, aVL

D. I, aVL
D. I, aVL
Which of the following complications is most likely to occur in acute inferior myocardial infarction?

A. Mobitz Type I Heart Block (Wenckebach)

B. Paroxysmal atrial tachycardia (PAT)

C. Right bundle branch block (RBBB)

D. Cardiogenic shock
A. Mobitz Type I Heart Block (Wenckebach)
Your patient with an inferior wall MI also has a right ventricular infarction & develops right ventricular failure.

Which data obtained would correlate with this patient's condition?

A. PAP 28/10 PCWP 10 CVP 18
B. PAP 38/22 PCWP 20 CVP 6 C. PAP 54/28 PCWP 14 CVP 14 D. PAP 23/8 PCWP 19 CVP 20
A. PAP 28/10 PCWP 10 CVP 18
The treatment modality for a patient with RVF from an inferior wall MI would include:

A. Nipride and Low dose dopamine
B. Normal Salin Fluid Challenges
C. Lasix and preload reducers
D. Lidocaine and afterload reducers
B. Normal Salin Fluid Challenges
Which of the following groups of hemodynamic data reflects cardiogenic shock as opposed to hypovolemic shock?

A. BP 88/60 PA 18/8 PCWP 12

B. BP 70/40 PA 30/20 PCWP 22

C. BP 90/60 PA 24/18 PCWP 25

D. BP 94/56 PA 40/22 PCWP 20
D. BP 94/56 PA 40/22 PCWP 20
Clinical manifestations of cardiogenic shock following an Anterior wall MI include all of the following except:

A. Distended neck veins

B. Pulmonary congestion, rales

C. Presence of an S3

D. Low CVP reading
D. Low CVP reading
"Unloading" therapy by nitroprusside is beneficial because it:

A. Enhances ventricular emptying

B. Diminishes peripheral vascular resistance or "afterload"

C. Relieves pulmonary congestion by promoting venous pooling of blood

D. All of the Above
D. All of the Above
Which of the following is an expected outcome from Intra-Aortic Balloon Pump?

A. Decreased mean systemic B. Increased Cardiac Output
C. Increased P.C.W.P.
D. All of the above
B. Increased Cardiac Output
To be operating correctly, the intra- aortic balloon pump is timed to work in which manner?

A. Inflate during systole, deflate during diastole

B. Inflate when the mean aortic pressure falls below a preset limit

C. Inflate when the heart rate falls below a preset limit

D. Inflate during diastole, deflate during systole
D. Inflate during diastole, deflate during systole
Absolute contraindications to intra- aortic balloon counterpulsation include:

A. Mitral insufficiency

B. Aortic Insufficiency

C. Sepsis

D. Femoral artery aneurysm
B. Aortic Insufficiency
All postoperative cardiac surgery patients develop:

A. Pericarditis

B. Electrolyte imbalances

C. Hypoxia

D. Atelectasis
A. Pericarditis
Which of the following kinds of shock is characterized by increased venous capacitance and pooling?


A. Hypovolemic shock

B. Cardiogenic shock

C. Distributive Shock (Septic)

D. Obstructive shock
C. Distributive Shock (Septic)
The early stages of septic shock are characterized by:

A. Vasoconstriction with the release of histamine

B. Increased cardiac output with peripheral vasoconstriction

C. Vasodilatation with fluid loss and the release of leukocytes

D. Increased Cardiac Output with decreased vascular vascular reistance
D. Increased Cardiac Output with decreased vascular vascular reistance
The signs of hyperventilation, diminished sensorium, and increased cardiac output are often found in which form of shock?

A. Neurogenic
B. Septic
C. Hypovolemic
D. Cardiogenic
B. Septic
A patient admitted to the ICU in the early stages of septic shock presents with:

A. Weak thready pulses and a low BP

B. Decreased urinary output

C. Warm flushed skin

D. Hyperpnea with pulmonary congestion
C. Warm flushed skin
Which of the following signs is NOT characteristic of cardiac tamponade?

A. Widening Pulse Pressure
B. Rising C.V.P.
C. Wide mediastinum on x-ray
D. A fall in systolic B.P. of more than 10 mmHg during inspiration
A. Widening Pulse Pressure
The placement of MCL, electrodes is:

A. Postive electrode, 4th ICS, right sternal border; negative electrode, below outer third of left clavicle

B. Positive electrode, 5th ICS, right sternal border; negative electrode left lower abdomen

C. Positive electrode, left shoulder; negative electrode, right shoulder

D. Positive electrode, left midaxillary line, 5th ICS negative electrode, below outer third of left clavicle
A. Postive electrode, 4th ICS, right sternal border; negative electrode, below outer third of left clavicle
The most serious EKG finding associated with Anterior wall MI is:

A. Fascicular blocks and tachycardia

B. RBBB and second degree blocks

C. Few ventricular ectopic beats

D. Rapid supraventricular rhythms
B. RBBB and second degree blocks
The hemodynamic parameter that clinically measures afterload is:

A. Central venous pressure (CVP)

B. Mean arterial pressure (MAP)

C. Systemic Vascular Resistance (SVR)

D. Left ventricular end-diastolic pressure (LVedp)
C. Systemic Vascular Resistance (SVR)
All of the following support the diagnosis of cardiac tamponade EXCEPT:

A. Widening Pulse Pressure

B. Equalization of right and left heart pressures

C. Pulsus paradoxus

D. Enlarged heart on X-ray
A. Widening Pulse Pressure
A patient with a blood pressure of 200/142 mm Hg would have which of the following forms of hypertension?

A. Essential hypertension
B. Accelerated hypertension
C. Malignant Hypertension
D. Hypertensive encephalopathy
C. Malignant Hypertension
ABG Interpretation
See Notes
What causes Respiratory Acidosis
-Drugs, Cardiac Arrest

-Muscle Weakness (MG, ALS, GB)

-Pulmonary Disease (COPD)
What causes Respiratory Alkalosis?
-Hypoxemia

-CNS Disorders

-Salicylate Intoxication

-Cirrhosis, Sepsis
Metabolic Acidosis Causes?
-Ketoacidosis

-Lactic Acidosis

-GI Loss (Diarrhea)

-Renal Failure
Metabolic Alkalosis causes?
-Blood Transfusions

-Hypokalemia

-GI loss (gastric acids)

-Contraction Alkalosis
Bronchial Breath Sounds
Heard over Trachea

Very Harsh, Continuous and Exhalation
Bronochovesicular
Right/Left Main Stem Bronchi

Inspiration/Exhalation
Vesicular
Inspiration only
Bronchial Breath sounds over lung lobes would be?
Pneumonia
Scattered Rhonchi?
Intermittent rumbling on inspiration and exhalation
Acute Respiratory Failure

TYPE I HYPOCAPNIC FAILURE Define
Decreased oxygen level with a normal or low CO2

Ventilation-Perfusion Imbalance
Acute Respiratory Failure

TYPE I HYPOCAPNIC FAILURE

Examples
Pulmonary Edema Pulmonary Embolism Aspiration Pneumonia Asthma
ARDS
Acute Respiratory Failure

TYPE II HYPERCAPNIC FAILURE Define
Decreased oxygen level with a high CO2 level

Respiratory Mechanical Performance
Acute Respiratory Failure

TYPE II HYPERCAPNIC FAILURE Examples
Drug Overdose
COPD CVA
Spinal Cord: ALS, GB, MG Pneumothorax
Decreased Phosphates
Shunt is no contact between Blood and Alveoli what is an example of this?
ARDS

NON CARDIOGENIC PULMONARY EDEMA

Damage to the alveolar capillary membrane

Hemorrhage

Inhalation

Vasoactive Substances

Chemotherapy

Calcium Channel Blockers


Applied oxygen will no improve 02 sat only PEEP

PEEP PEEP PEEP PEEP PEEP PEEP
Which of the following statements regarding vesicular breath sounds is TRUE?

A. These are medium intensity sounds heard over the large main-stem bronchi

B. They are heard longer on exhalation

C. They are decreased or absent when airflow to that area of lung is diminished

D. They are auscultated over the trach
C. They are decreased or absent when airflow to that area of lung is diminished
Which of the following chest auscultation findings is ABNORMAL?

A. Vesicular breath sounds over lung periphery

B. Bronchial breath sounds heard over large airway

C. Vesicular breath sounds heard during inspiration and expiration

D. Bronchovesicular sounds adjacent to the sternum
C. Vesicular breath sounds heard during inspiration and expiration
Patient in C.C.U. post cardiac arrest: Fi02 0.8, pH 7.31, pCO2 42, pO2 60, O2 sat 85% and a HCO3 18:

A. Compensated metabolic acidosis

B. Uncompensated respiratory acidosis

C. Uncompensated metabolic alkalosis

D. Uncompensated metabolic acidosis
D. Uncompensated metabolic acidosis
Patient in the R.R. who presents with agitation and tingling of the fingers: Fi02 roomair,pH7.49,pCO225,pO2 90,
O2 sat 98%, HCO3 22


A. Normal acid-base balance

B. Uncompensated respiratory alkalosis

C. Uncompensated respiratory acidosis

D. Uncompensated metabolic alkalosis
B. Uncompensated respiratory alkalosis
Newly admitted M.I. patient on thiazide diuretics at home for hypertension has an ABG:FiO2 0.6, of: pH 7.58, pCO2 36, pO2 70, 02 sat 90%, HCO3 34

A. Uncompensated metabolic alkalosis

B. Uncompensated respiratory alkalosis

C. Uncompensated metabolic acidosis

D. Compensated metabolic alkalosis
A. Uncompensated metabolic alkalosis
Pulmonary consolidation (lobar pneumonia) will cause which of the following physical findings over the diseased area?

A. Dull percussion note

B. Decreased tactile fremitus

C. Bronchial breath sounds

D. Both A and C
D. Both A and C
A notable characteristic of mucus will often be present in patients with status asthmatic attack in its:

A. Color

B. Tenaciousness

C. Copious nature

D. Absence
B. Tenaciousness

The are extremely dehydrated after status asthmatic
An ominous finding in the patient with status asthmaticus would be:

A. A respiratory rate of 34

B. Loud expiratory wheezing

C. A CO2 of 55

D. Use of accessory muscles
C. A CO2 of 55
A patient with status asthmaticus is admitted. His breath sounds are diminished throughout his lung fields. RR=40. After giving your patient an aerosol bronchodilator, your patient sounds worse as they are now louder. This indicates:

A. The patient has gotten worse

B. The need for anesthesia to be present STAT

C. The patient is getting better

D. The patient does not have asthma
C. The patient is getting better
When adjusting the initial settings on a volume ventilator for an adult in respiratory failure, the tidal volume is usually set at:

A. At least 10 ml per Kg or twice normal tidal volume

B. 15-20 ml per Kg or twice normal

C. 500 ml for all patients

D. 300-500 ml
A. At least 10 ml per Kg or twice normal TV
A 70 kg patient ventilated with FiO2 of 45%, VT of 800, IMV of 8. Patients respirations are 10/min. ABG results:
O2 85, CO2 55. What ventilator parameter should be changed?

A. FiO2

B. IMV

C. VT

D. All of the above
B. IMV
Administration of 100% oxygen will NOT improve the PaO2 in hypoxia caused by:

A. V/Q imbalance

B. Right to Left Shunting

C. Alveolar hypoventilation

D. Impaired diffusion

E. None of the above. It will improve them all
B. Right to Left Shunting
Which of the following disease states does NOT cause hypoxia due to a primary mechanism of V/Q mismatching?

A. Bronchospastic disease

B. Pulmonary emphysema

C. Adult Respiratory Distress Syndrome

D. Pulmonary embolization
C. Adult Respiratory Distress Syndrome
The administration of oxygen alone will NOT improve hypoxia due to:

A. V/Q mismatch

B. Shunting

C. Hypoventilation

D. Decreased F102
B. Shunting
Which of the following statement regarding ARDS is true?:

A. There is a decrease capillary permeability

B. There is damage to type II pneumocystis with a decrease of surfactant

C. There is an increase in lung compliance

D. There is an increase in functional residual capacity
B. There is damage to type II pneumocystis with a decrease of surfactant
Assessment findings indicative of ARDS in the early stage, would include all of the following except:

A. Tachypnea

B. Normal PCWP

C. Respiratory alkalosis

D. Hypercapnia
D. Hypercapnia
The hallmark of Adult Respiratory Distress Syndrome (ARDS) is:

A. Refractory hypercapnia

B. Refactory Hypoxemia

C. Low F.R.C. (functional residual capacity)

D. Increased compliance secondary
B. Refactory Hypoxemia
The nurse considers which intervention to be inappropriate while caring for the patient with ARDS?

A. Administer small doses Lasix as ordered by MD

B. Infusion of normal saline rapidly in order to maintain hydration

C. Pulmonary toileting

D. Frequent position changes
B. Infusion of normal saline rapidly in order to maintain hydration
The plan of therapeutic attack in the care of ARDS patients may include:

A. Use of a ventilator with high pressure and high flow characteristics

B. Diuretics and fluid restriction

C. Use of P.E.E.P. (positive and expiratory pressure)

D. All of the above
D. All of the above
Palpation of a tracheal shift to the left may indicate:

A. A tension pneumothorax on the right

B. Massive atelectasis on the right

C. A tension pneumothorax on the left

D. Diffuse airways obstruction
A. A tension pneumothorax on the right
Initial nursing assessment findings in the patient with an acute pulmonary embolism includes:

A. Chest pain, ST changes, pulmonary edema

B. Rales, rhonchi, tachycardia

C. Chest pain, dyspnea, cough

D. Tachypnea, bradycardia, rales
C. Chest pain, dyspnea, cough
Which assessment finding would not be present in the patient with a massive pulmonary embolism?

A. Increased CVP reading

B. Pulmonary Rales

C. Distended neck veins

D. Liver engorgement
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