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Critical care HESI
Get Quizlet's official HESI A2 - 1 term, 1 practice question, 1 full practice test
Terms in this set (44)
spinal cord injury at the scene
Nursing interventions are focused on stabilization of the spine, preserving the airway and respiratory status and preventing complications associate with SCI. Assessment of respiratory and neurological status is first priority, might need to be tubed. If in neurogenic shock, they cannot regulate body temperature
teaching for ICD
site care and symptoms of complications, hematoma at the site is common, wear a medic alert bracelet, when device fires the patient will feel either tingling or discomfort or wont even know it went off. avoid strong magnetic fields (MRI), keep cell phones 6 inches from ICD, may fire when tachycardic, avoid driving for 6 months if hx of cardiac arrest, teach family CPR
can be caused by biting tube, kinks, need suctioned or trying to talk
ARDS and lung trauma
Refractory hypoxemia: hallmark sign of ARDS. FiO2 could be 100% but Pao2 is <60%. only intervention is ECMO which is difficult because adults need anticoagulation therapy.
Bilateral patchy infiltrates: patches of white on a lung x ray
Noncompliance of the lung: it will not expand, need to be sedated
-initial ABGs show low CO2 because of hypervention then it flips to metabolic acidosis
- lungs clamp down so it is difficult to breath, capillary membrane damage)
Treatment: ventilator, lung protective strategies (low TV, FiO2 at nontoxic levels ~60%, unconventional vent settings i.e. RR 300-420 BPM)
main cause is aspiration, poor oral hygiene, contaminated equipment.
strategies to reduce VAP: - elevated HOB 30-45 degrees, hand hygiene and gloves when suctioning, suction above cuff before deflation, oral hygiene Q2!!!!
documentation of pneumothorax breath sounds
they are absent
tension pneumothorax and trauma
tension pneumo can be caused by mechanical ventilation. pressurized air enters the pleural space and continues to accumulate which causes an increase in pressure, increasing amount of alveoli collapse and pressure on the heart and great veins. immediate insertion of a chest tube is needed and removed from vent
chest tube assessment
splint insertion site to facilitate coughing and deep breathing. do not milk the tube, do not clamp the tube
mechanical ventilator and respiratory acidosis
If the ventilator is set at a low RR (e.g., 2 to 6 breaths per minute) and the patient does not have an adequate drive to initiate additional breaths, respiratory acidosis may occur. Ideally the VT and RR are set to achieve a VE that ensure a normal PaCO2 level
first action with a PE
anticoagulation with heparin. venous preventions-- is NOT oxygen first, anticoag first
patient safety and ICU confusion
Acute delirium is common in critically ill patients; more than 70% to 80% of patients develop some form of delirium, resulting in longer duration of mechanical ventilation and longer ICU stay than those without delirium.
Non restraints and pharmacologic measures are taken first. If pulling at drains then they may be restrained. Haloperidol is the drug of choice to calm patients
must be repositioned, and the areas where the restraints are applied are assessed for perfusion and sensation at least every hour
aortic aneurysm repair
Post op: VS Q1 hour (watch for tachycardia and hypotension). Peripheral pulses. Monitor for hemorrhage.
CHF and hemodynamic readings
Mixed venous oxygen saturation, stroke index, cardiac index, and pulmonary artery pressures
***PCWP/ pulmonary diastolic will be elevated
medications for CHF/shock/renal failure. it helps tissue perfusion
side effects of Primacore
if it infiltrates it causes necrosis (be sure to use large vein to infuse)
PTCA post op management
watch groin for bleeding and check distal pulses
Cardiac perfusions occur frequently after an MI so TPA must be given with caution
air embolism nursing interventions
position patient in trendelenberg on left side (left lateral)
give high FiO2 (100%) to decrease ischemia
Amiodarone: 1st drug for pulseless Vtach
-Lidocaine: if cannot give amiodarone (VF, VT, PVC)
Epinepherine: given if unresponsive to CPR (can go down ETT)
Atropine: increases HR, SVR, BP
Dopamine: given if hypotensive not caused by hypovolemia
Sodium bicarb: last ditch effort if everything fails
calcium choride: hyperkalemia, hypocalcemia
***drugs down ETT: LEAN (Lidocaine, Epinepherine, Atropine, Narcan)
***Phentolamine given for infiltrated area
Hemodynamic normal values
CI: 1.5-2.0 for cardiogenic shock (<1.5 irreversible)
Pulmonary artery BP: 15-30/4-12
PCWP: 6-12 (12-18 for optimal contraction)
given if patient is hypotensive but not hypovolemic.
started at 2-5 mg/kg/hr then titrated up based on response
can cause MI, dysrhythmias like tachycardia and PVC
Can cause severe infiltration. Give Phentolamine to help area
VAP is common infection that causes sepsis
Before antibiotics are started, the source of infection must be identified, C&S.
S/S include: chills or fever, low BP, tachycardic, shakiness, hyperglycemia and/or insulin resistance ****decreased SVR, flushing, oliguria!!!!
Common cause of SIRS and MODS
septic shock and dopamine
do not give dopamine until fluids are replaced
could be used for someone who cannot go to cath lab they use thrombolytics instead.
- reperfusion (drug was successful) for LAD lesion patient when they are bradycardic and chest pain is no more
nitroglycerin and nipride
vasodilators. Do not give if BP is low. watch for toxicity
dissecting AAA physical assessment
sudden severe chest pain is most common sign or pain between the scapulae. systolic BP might be different if taken in each arm. Paresthesias
trauma and emergency
Evaluation of airway patency, ventilation, and venous access with circulatory support are of prime importance and take precedence over other diagnostic or definitive interventions.
ABCDE (airway, breathing, circulation, disability (glascow coma score), expose patient)
shock (hypovolemia) first aide
give fluids first
For every 1 cc of blood loss, need 3 cc of crystalloids or blood
allergy assessment before angioplasty
IV dye or shellfish
DEHYDRATED. dry mucous membranes, tachycardic, hypotensive, acetone breath, anorexia, polydipsia, usually hyperkalemic. Before insulin drip, fluids must be replaced and potassium must be >3.3
DKA and IV potassium
patient's serum potassium will go down. 3.3 is ideal
chronic adrenal insufficiency
-low cortisol levels
1 L bolus of NSS then 10-15 ml/kg/hr
-- if in shock or hypotensive then 20ml/kg/hr **if sodium is normal or elevated then give 1/2 NSS at a slower rate (7.5 ml/kg/hr)
facial burns, soot in mouth, singed nose hairs/eyebrows, carbon in sputum, lip edema
**dangerous because epiglottis swells and occludes the airway
rule of 9's
Glasgow coma score of 14 and GCS level
"less than 8, intubate"
vein is torn around cerebral cortex. people at risk are on warfarin or Plavix like drugs
traumatic brain injury and ICP
normal ICP-- 0-15 (if above 20 then interventions are done) i.e. mannitol. need a MAP greater than 50
psych/mental health (asystole and the family)
turn the whole monitor off to not confuse the patients
endotracheal tube placement
auscultation of the epigastrium and lung fields, and observing for bilateral chest expansion (if unilateral expansion then suspect the ETT tube went too far and is in right bronchus). Also use a ETCO2 monitor on the end of the tube that measures CO2
MODS and hyperglycemia
interventions to decrease MODS:
(1) prevention and treatment of infection, (2) maintenance of tissue oxygenation, (3) nutritional and metabolic support, and (4) appropriate support of individual failing organs.
(1) red indicates emergent, life-threatening injuries; (2) yellow means urgent major illness requiring care within an hour; (3) green indicates nonurgent injuries that the patient can self-treat; and (4) black signifies the patient is dead or near death.
behavior pain scale: used for patients on ventilator. Assesses facial expressions, upper limbs (holding close to the body/guarding) and compliance with the ventilator
Critical care pain observation tool: for vent patients or non-ven patients. Assesse facial expressions and body movements, muscle tension, ventilator compliance or sighs/body language in the non vented patients.
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