Study sets, textbooks, questions
Upgrade to remove ads
CBN IV Final Study Guide Part 1
Terms in this set (84)
What are some examples of primary care settings?
Primary care offices, health clinics, and health fairs (teaching)
What are some examples of secondary care settings?
Acute and long term hospitals
What are some examples of nurse-sensitive indicators?
Anything the nurse has a direct impact on. Ex: how many falls occur? Pressure ulcers? Length of stay?
What are magnet model components?
"Magnet" recognizes health care organizations for quality in patient care, nursing excellence, and innovations in nursing practice.
What do you have to monitor for with an intubated patient?
Correct tube placement, proper cuff inflation (20-25 cm H2O), tube patency, and oxygen and ventilation of the patient
What are signs of hypoxia in an intubated patient?
mental status changes, anxiety, restlessness, dusty skin, and dysrhythmias
What are oral care guidelines for a intubated patient?
Provide oral care every 2 hours and do NOT routinely suction
What are indications for suctioning an intubated patient?
visible secretions, sudden onset respiratory distress, suspected aspiration of secretions, increased Respiratory rate, sudden decrease in SpO2, and an increase in peak airway pressure
What are signs of an unplanned extubation?
patient talking, low pressure alarm, diminished breath sounds, respiratory distress, and gastric distention
How do you verify the correct placement of an endotracheal tube?
listen to lung sounds bilaterally, observe for bilateral chest rise and fall, EtCO2 valve, and chest x-ray
What is the "assist control mode on a ventilator?
it delivers preset tidal volume when the patient triggers a breath
Can the patient breath faster then the ventilator on "assist control? Can the patient breath slower?
What is the patient at risk for on "assist control" mode on the ventilator?
What is BiPAP used for?
Two way pressure, inspiratory and expiratory; used for airway splinting, oxygenation, and ventilation
What are contraindications of BIPAP/CPAP?
Facial fractures, thick secretions, vomiting, and status asthmatics; cannot be restrained on BIPAP
What is CPAP used for?
Continuous one way pressure (inspiratory), used for airway splinting and oxygenation
What is the normal range for pH?
What is the normal range for PaO2?
What is the normal range for PaCO2?
What is the normal range of HCO3?
What is Community acquired pneumonia?
Pneumonia that developed in someone who has not been in the hospital or long term care facility within 14 days of onset of symptoms?
What is hospital-associated/ healthcare associated pneumonia?
Occurs 48 hours or longer after admission to a hospital or long term care facility
What is ventilator associated pneumonia?
Pneumonia that develops more than 48 hours after endotracheal intubation
How does aspiration pneumonia occur?
abnormal entry of secretions or fluid into the lower airway
What is the CURB-65 assessment tool (extended version)?
C-Confusion compared to baseline
BUN > 20
respiratory rate greater than or equal to 30
systolic BP less than 90 or diastolic less than or equal to 60
65 years old or greater
LDH above 230
albumin less than 3.5
platelet less than 100
What is a chest tube used for?
to remove air or fluid from the pleural and/or mediastinal space
Is tidaling normal in a chest tube?
What if there is no tidaling in the chest tube?
there is a block in the drainage system, the lungs are re-expanded, or the system is attached to suction
What should the nurse do if there is vigarious bubbling in the water-seal chamber on a chest tube?
Check the system for an air-leak
What is proper management of a chest tube?
keep the tubing below the level of the patient, keep the tubing free of loops, and chart the drainage output
What are the types of angina?
Chronic stable, silent ischemia, Prinzmetal (variant), and unstable
What is Chronic stable angina?
Intermittent chest pain that occurs over a long period with the same onset, duration, and intensity
How long does chronic stable angina last?
few minutes and is relieved by rest/relaxation
What can cause a chronic stable angina flare up?
Physical exertion, stress, or emotional upset
What is silent ischemia?
angina that occurs free of any subjective symptoms with diabetic neuropathy; only evident on an EKG
What is Prinzmetal's (variant) angina?
Spams of the major coronary artery; its a rare condition that only occurs at rest
What is unstable angina?
A new in onset angina that occurs at rest
How long does unstable angina last?
less than or equal to 10 minutes; unrelieved by nitro; needs immediate treatment
What are nursing indications for a patient receiving IV nitroglycerin?
Acute coronary syndrome or cardiogenic shock; goal is to reduce chest pain by restoring/improving coronary blood flow
What is important to assess on a patient receiving nitroglycerin
How do you treat DIC is the patient is not actively bleeding?
Administer anti-thrombotic therapy(heparin, lovenox) to treat micro clots and monitor for bleeding
How do you treat DIC in a patient who is bleeding?
Apply pressure to stop the bleed and administer blood products/clotting factor (platelets, cryoprecipitate, and FFP)
What type of organism causes septic shock?
gram positive/gram negative bacteria
What will the nurse assess in a patient who is experiencing septic shock?
tachycardia, high/low temp, decreased urine, hyperventilation, hypoxia, change in mental status, and hypotension (unrelieved by fluids)
What labs will be altered with septic shock?
WBC's (high or low) and high lactate (over 2)
How do you treat septic shock?
Give fluids, vasopressors can be given AFTER fluids (norepi, epi, vasopressin, dopamine), broad spectrum antibiotics, and albumin may be given
What is the goal of a patient in septic shock?
Keep the MAP 65 or greater
What symptom of shock is asymptomatic- minor symptoms with an increased lactate?
What stage of shock consists of hypotension, increased K, decreased bowel sounds, and increased respirations?
What stage consists of severe hypotension, mental status changes, crackles in lungs, increased respirations, third spacing, and weak pulses?
What stage of shock consists of increasing lactate and CO2, decreased cardiac output, vasoconstriction, decreased BP and increased HR, hypoxia, and organ failure?
What are assessments in a patient with cardiogenic shock?
tachycardia, hypotension, decreased capillary refill, cyanosis, tachypnea, decreased urine output, cool/clammy skin, and anxiety
How is cardiogenic shock diagnosed?
Chest x-ray, high cardiac biomarker, high BUN, and dysrhythmias
What is cardiogenic shock?
when systolic or diastolic dysfunction of the heart's pumping action occurs
What is hypovolemic shock?
when there is insufficient fluid volume in the intracellular fluid
What are symptoms of hypovolemic shock?
tachycardia, decreased capillary refill, hypotension, tachypnea/bradypnea (late), decreased urine, cool/clammy skin, and absent bowel sounds
What is neurogenic shock?
hemodynamic phenomenon that occurs within 30 min-6 weeks of a spinal cord injury
What are symptoms of neurogenic shock?
bradycardia, hypotension, high/low temp, cool/warm and dry skin, flaccid paralysis and loss of reflex activity
What is anaphylactic shock?
An acute and life threatening hypersensitivity (allergic) reaction to the sensitizing substance (e.g., drugs, chemical, vaccine, food, insect.)
What symptoms of anaphylactic shock?
tachycardia, chest pain, wheezes, SOB, stridor, flushed skin, and anxiety
What is septic shock?
Life threatening immune response to an infection; hypotension that is NOT relived by IV fluids
What is obstructive shock?
when a physical obstruction occurs and obstructs the blood flow
What are symptoms of obstructive shock?
tachycardia, hypotension, tachypnea/bradypnea (late), cool/clammy skin, anxiety, confusion, and agitation
What is central venous pressure (CVP)?
the measurement of the right ventricle preload; reflects fluid volume volume status
Where is the CVP transducer located?
jugular or subclavian vein
What is a normal range of CVP?
What does a CVP of 10-12 mmHg indicate?
What medications are used to treat spetic shock?
Fluids (NS and LR), vasopressors (norepi, epi, vasopressin, and dopamine), broad spectrum antibiotics, and PPIs (protonix)
How can SIRS be prevented?
Aseptic techniques: CHG baths, catheter care, scrubbing central lines/ IV's, covering the ports with green caps, and cleaning dirty patients
What are adverse effects of ibuprofen?
Increased risk of GI issues (bleeding, ulceration, perforations), fluid retention, and tinnitus
What are adverse effects of aspirin?
bleeding, risk for GI issues (bleeding, perforation, ulceration)
What are adverse effects of prednisone?
retention of sodium and water, weight gain, loss of K, hypertension, increased blood sugar
What is nitroprusside (nitrate) given for?
hypertension; reduces afterload
How does nitroprusside work?
dilates the arterioles of the kidneys leading to increased renal perfusion
What fluid(s) is nitroprusside given with?
What is the nursing care of a patient with a gunshot wound?
locate entry/exit wound, monitor vitals, leave bullet in place, apply pressure to bleeding
What is melena?
abnormal tarry, black stool usually caused by the presence of digested blood
What are some possible causes of melena?
Cancer, upper GI bleeding (ulcers and varices)
What labs should the nurse monitor with melena?
Hemoglobin and hematocrit
What are the symptoms of a bone fracture?
local swelling, tenderness, unusual pelvic movement (pelvic fracture), decreased function, inability to bear weight on extremity
What are the 6 P's for compartment syndrome?
Pain, Pallor, Pulselessness, Paresthesia, Pressure, and Paralysis
What assessments should the nurse perform with a bone fracture?
Check pulses distal to fracture and monitor for compartment syndrome
What could severe abdomen pain and rebound tenderness indicate?
appendicitis or peritoneal pain
What tests can be done to examine the abdomen if severe pain and rebound tenderness is being experienced?
Blumberg sign (test for rebound tenderness), CT exam, and FAST test
Other sets by this creator
CBN IV Final Exam Study Guide part 2
CBN IV Final
Other Quizlet sets
Kettering: Image Production
COM 288 Final
Rad Test 2 Overview