Critical Care Final

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Anion gap equation

(Na+K) - (Cl+HCO3)

Base excess

-2 to +2

BNP

normal BNP

lipase

0-160

10. For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a. prevent respiratory alkalosis. b. lower arterial pH. c. promote carbon dioxide elimination. d. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

0. Answer C. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.

Normal QRS complex

0.06-0.10

QRS interval

0.06-0.10

creatinine

0.07-0.14

Normal PR interval

0.12-0.20

PR interval

0.12-0.20 if >0.20 then heart block

Normal QT interval

0.36-0.44

QT interval

0.36-0.44

TSH

0.47-6.9

INR

0.75-1.25

RAP

1-7

magnesium

1.8-2.4

magnesium normal range

1.8-2.4 mg/dL

what is the only diagnostic test that can diagnose an MI

12 lead EKG

Hgb

12-16

12-20

cholesterol

120-200

120/80

AST

13-39

normal sodium range

135-145

sodium

135-145

Class II bleed

15-30% loss, increased HR, RR; decreased BP, diaphoretic

ammonia

15-45

15. The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. Head mildline b. Head turned to the side c. Neck in neutral position d. Head of bed elevated 30 to 45 degrees

15. Answer B. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

platelets

150-400

Nonrebreather

15L on the flow meter - 100% O2 If perfusion does not improve, 100% O2 is not working, needs intubation!

16. A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: a. Is clear and tests negative for glucose b. Is grossly bloody in appearance and has a pH of 6 c. Clumps together on the dressing and has a pH of 7 d. Separates into concentric rings and test positive of glucose

16. Answer D. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

17. A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? a. Strict adherence to a bowel retraining program b. Keeping the linen wrinkle-free under the client c. Preventing unnecessary pressure on the lower limbs d. Limiting bladder catheterization to once every 12 hours

17. Answer D. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

Chest Tube

2 hemostats, vaseline, gauze, and a dressing should be at the bedside If it comes out, tape 3 sides to allow air to come out Occlusive dressing over it - 4 sides covered

how many IVs for burn fluid resuscitation

2 large bore IVs

MAP equation

2(DBP) + SBP/3

how long until the pt is extubated post CABG

2-4 hours

CVP

2-6

phosphate

2.5-5

PTT

20-35

what percentage of people die within the first year of being diagnosed with cardiomyopathy

20-50

Normal room air

21% 1-2L = 24-28% 3-4L = 30-36% 5-6L = 38-44% Greater than 6L = needs humidified

HCO3

22-26

how long until a patient is transferred to a step down unit post CABG

24 hours

Venturi mask

24%-60%, color coded

amylase

24-130

time frame for an acute rejection

3 months

normal phosphate range

3-4.5

how long until a patient is discharged home post CABG

3-5 days

Class I bleed

3-5% loss, asymptomatic

normal potassium range

3.5-5

potassium

3.5-5

RBC

3.5-5.5

How long must a patient stay at home before being readmitted for reimbursement to occur?

30 Days

half life of heparin

30 min

at what pressure must an artery be kept open in order to stay patent and avoid bleeding out

30 mmHg

alkaline phosphatase

30-108

Class III bleed

30-40% loss, reversible but can be fatal

aPTT

30-45

CO2

35-45

Hct

36-48

how long until the patient is up out of bed post CABG

4-8 hours

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of recurrence? 1. strict adherence to a bowel retraining program 2. keeping the linen wrinkle free under the client 3. avoiding unnecessary pressure on the lower limbs 4. limiting bladder catheterization to once every 12 hours

4. limiting bladder cath to once q12h (the most frequent cause of autonomic dysreflexia is a distended bladder . Straight cath should be performed q4-6 hrs and foley cath should be checked frequently for kinks in tubing . Constipation and fecal impaction are other causes, so maintaining bowel irregularity is important .

4..5-11.5

WBC

4.5-10

ejection fraction

40-60%

what is a normal ejection fraction

40-60%

parkland formula

4ml x %burns x pt weight in kg= total amount of fluid half the fluid given in the first 8 hours, second half given over 16 hours

5. The nurse is working on a surgical floor. The nurse must logroll a male client following a: a. laminectomy. b. thoracotomy. c. hemorrhoidectomy. d. cystectomy.

5. Answer A. The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.

how many joules are received in cardioversion

50-200

Normal tidal volume

500 mL MAX 1000mL

urine osmolarity

500-850

PAWP

6-12

BUN

6-20

how long should a patient be on bedrest post heart cath or PTCA

6-8 hours with minimum elevation

60-100

how much gas exchange does the alveoli do

65%

Alveoli

65% of gas exchange

ALT

7-55

blood pH

7.35-7.45

glucose

70-100

MAP

70-110

normal MAP

70-110

SvO2

70-80%, Swan-Ganz catheter (venous), concerning is less than 60%, loss of 02 from a delivery system/decreased CO

how long post-op should bowel sounds occur

72 hours, do not eat until bowel sounds return

anion gap

8-16

calcium

8.5-10.5

calcium normal range

8.5-10.5 mg/dL

PO2

80-100

9-11

Normal SaO2

92-100%, measured by pulse oximetry, concerning if less than 92%, look for CO drop/loss in blood volume

chloride

98-106

normal D-Dimer level

<250

normal diameter of the aorta

<4mm

what percentage of blockage requires treatment

> 75% of the vessel is blocked

Class IV bleed

>40% MODS, irreversible

GFR

>70, 90-125

O2 sat

>90%

a patient has impairments from a SCI at C4 classified as incomplete C on the American Spinal Injury Association, (ASIA) Impairment Sclae. Which patient assessment is the nurse likely to observe in this patient? A. poor propricopetor in the legs B. poor peristalsis in the intestines C. Absent gag and blinking reflexes D. Absent bladder fulness sensation

A patient who has a SCI has neurologic impairment to all extremities and the diaphragm. However, because the injury is C on the ASIA impairment Scale, sensory function can be intact but motor function will be impaired significantly or absent.the patient can lose moderate to complete peristatlic action in the intestines but should reatine the ability to sense bladder fulnessand the position of the legs. Answer is B

Which is most important to respond to in a patient presenting with a T3 spinal injury? A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute B. Deep tendon reflexes of 1+, muscle strength of 1+ C. Pain rated at 9 D. Warm, dry skin

A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute Neurogenic shock is a loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. The loss of sympathetic nervous system innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The other options can be expected findings and are not as significant. Patients in neurogenic shock have pink and dry skin, instead of cold and clammy, but this sign is not as important as the vital signs.

Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses

A. Bradycardia Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.

Urinary function during the acute phase of spinal cord injury is maintained with a. an indwelling catheter b. intermittent catheterization c. insertion of a suprapubic catheter d. use of incontinent pads to protect the skin

A. an indwelling catheterization

During the patient's process of grieving for the losses resulting from spinal cord injury, the nurse a. helps the patient understand that working through the grief will be a lifelong process b. should assist the patient to move through all stages of the mourning process to acceptance c. lets the patient know that anger directed at the staff or the family is not a positive coping mechanism d. facilitates the grieving process so that it is completed by the time the patient is discharged from rehabilitation

A. helps the patient understand that working through the grief will be a lifelong process

A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. which of the following should be the nurses' greatest priority? a. prevention of further damage to the spinal cord b. prevention of contractures of the lower extremities c. prevention of skin breakdown of areas that lack sensation d. prevention of postural hypotension when placing the client in a wheelchair

A. prevention of further damage to the spinal cord Rationale: The greatest risk to the client during the acute phase of a SCI is further damage to the spinal cord. Therefore, when planning care, the priority should be the prevention of further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.

what kind of drug is aspirin

ANTIPLATELET

what class of medication will a patient whose had a PTCA need to be on, probably long term

ANTIPLATELET medication

Diagnosis

ASIA Impairment scale: gauge motor & sensory function CT Scan- gold standard: detects injury, location, level Xrays MRI Myelogram, PFT's Neuro exam - usually other injuries

The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? A) Central cord syndrome B) Spinal shock syndrome C) Anterior cord syndrome D) Brown-Séquard

About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function. Points Earned: 1.0/1.0 Correct Answer(s): B

Initial care

Airway & Immobilization Team goals: sustain life; ABC's, prevent further damage NonSx: stabilization of injured segment, decompression of cord, bed rest & immobile, backboard & cervical color, brace/corset for lumbar, Stryker frame, skeletal traction (tongs or halo), cervical traction- pin care, traction, alignment, log rolling, meticulous skin care Sx: cord compression, dec of neuro disorder, fractures, removal of fragments, decompression laminectomy (remove part of vertebral column; spinal fusion; rod insertion (can be anterior, thoracic, posterior approach) Stimulate patient above level of injury

what is the test called that is used to determine if an artery can be used to insert an arterial line

Allen's test postitive test = adequate perfusion

Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? A) Headache and rising blood pressure B) Irregular respirations and shortness of breath C) Decreased level of consciousness or hallucinations D) Abdominal distention and absence of bowel sounds

Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic. Points Earned: 1.0/1.0 Correct Answer(s): A

what kind of drug is aspirin

Antiplatelet

Meds

Atropine-bradycardia Vasopressor- dopamine (intropin) to improve pumping action of heart Heparin/Fragmin - prophylactic anti-platelet aggregation Ditropan -smooth muscle relaxant - bladder Detrol -smooth muscle relaxant - skeletal Cardur & Hytrin - alpha adrenergic blockers - for HTN & smooth muscle relaxant Liosresal - antispasmotics - muscle relaxant Reglan - promote GI motility Proton pump inhibitors - dec. acid avoid stress ulcers H2 receptor blocker - dec. acid avoid stress ulcers Solumedrol - steroid to reduce inflammation—Not with penetrating spinal injury, give within 8 hrs of event, dec edema/inflammation, inc blood flow. S/E dec. immune, GI bleed, infection Procardia - vasodilator

The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? A) Tachycardia B) Hypotension C) Hot, dry skin D) Throbbing headache

Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis. Points Earned: 0.0/1.0 Correct Answer(s): D

Goals of rehabilitation for the patient with an injury at the C6 level include (select all that apply) a. stand erect with leg brace b. feed self with hand devices c. drive an electric wheelchair d. assist with transfer activities e. drive adapted van from wheelchair

B, C, D, E

One month after a spinal cord injury, which finding is most important for you to monitor? A. Bladder scan indicates 100 mL. B. The left calf is 5 cm larger than the right calf. C. The heel has a reddened, nonblanchable area. D. Reflux bowel emptying.

B. The left calf is 5 cm larger than the right calf. Deep vein thrombosis is a common problem accompanying spinal cord injury during the first 3 months. Pulmonary embolism is one of the leading causes of death. Common signs and symptoms are absent. Assessment includes Doppler examination and measurement of leg girth. The other options are not as urgent to deal with as potential deep vein thrombosis.

A patient with paraplegia has developed an irritable bladder with reflex emptying. The nurse teaches the patient a. hygiene care for an indwelling urinary catheter b. how to perform intermittent self-catheterization c. to empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns d. that a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination

B. b. how to perform intermittent self-catheterization Rationale: Intermittent self cath five to six times a day is the recommended method of bladder management for the patient with a spinal cord injury because it more closely mimics normal emptying and has less potential for infectinon. The patient and family should be taught the procedure using clean technique, and if the patient has use of the arms, self-cath is use during the acute phase to prevent overdistention of the bladder and surgical urinary diversions are used if urinary complications occur.

A nurse is positioning a client with increased ICP. Which position would the nurse avoid? A. head midline B. head turned to the side C. neck in neutral position D. head of bed elevated 30-45 degrees

B. head turned to the side (The head of a client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side . The head of the bed should be raised 30-45 degrees . Use of proper position promotes venous drainage from the cranium to keep ICP down)

A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. vital signs include BP 220/110, apical heart rate of 54/min. Which of the following acctions should the nurse take first? a. notify the provider b. sit the client upright in bed c. check the client's urinary catheter for blockage d. administer antihypertensive medication

B. sit the client upright in bed Rationale: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated BP. The first action by the nurse is elevate the head of the bed until the client is in an upright position. this will lower the BP secondary to postural hypotension.

A patient is admitted with a spinal cord injury at the C7 level. During assessment the nurse identifies the presence of spinal shock on finding a. paraplegia with flaccid paralysis b. tetraplegia with total sensory loss c. total hemiplegia with sensory and motor loss d. spastic tetraplegia with loss of pressure sensation

B. tetraplegia with total sensory loss Rationale: At the C7 level, spinal shock is manifested by tetraplegia and sensory loss. The neurologic loss may be temporary or permanent. Paraplegia with sensory loss would occur at the level of T1. A hemiplegia occurs with central (brain) lesions affecting motor neurons and spastic tetraplegia occurs when spinal shock resolves.

A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse he is recovering some function. The nurses' best response to the patient is, a. it is really still too soon to know if you will have a return of function b. the could be a really positive finding. can you show me the movement c. that's wonderful. we will start exercising your legs more frequently now d. im sorry, but the movement is only a reflex and does not indicate normal function

B. the could be a really positive finding. can you show me the movement Rationale: in 1 week following a spinal cord injury, there may be a resolution of the edema of the injury and an end to spinal shock. When spinal shock ends, reflex movement and spasms will occur, which may be mistaken for return of function, but with the resolution of edema, some normal function may also occur. it is important when movement occurs to determine whether the movement is voluntary and can be consciously controlled, which would indicate some return of function.

Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. The best response by the nurse is, a. you will have more normal function when spinal shock resolves and the reflex arc returns b. the extent of your injury cannot be determined until the secondary injury to the cord is resolved c. when your condition is more stable, an MRI will be done that can reveal the extent of the cord damage d. because long-term rehabilitation can affect the return of tunction, it will be years before we can tell when the complete effect will be

B. the extent of your injury cannot be determined until the secondary injury to the cord is resolved Rationale: Until the edema and necrosis at the site of the injury are resolved in 72 hours to 1 week after the injury, it is not possible to determine how much cord damage is present from the initial injury, how much secondary injury occurred, or how much the cord was damaged by edema that extended above the level of the original injury. The return of reflexes signals only the end of spinal shock, and the reflexes may be inappropriate and excessive, causing spasms that complicate rehab.

lab for CHF

BNP

lab for heart failure

BNP

dilate

7. Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia? A) Urinary catheterization B) Administration of benzodiazepines C) Suctioning of the patient's upper airway D) Placement of the patient in the Trendelenburg position

Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated and suctioning is likely unnecessary. Points Earned: 0.0/1.0 Correct Answer(s): A

term synonymous with 3 criteria for cardiac tamponade

Becks triangle

mode of ventilation used to wean a patient

C-PAP

The healthcare provider has ordered IV dopamine (Intropin) for a patient in the emergency deparement with a spinal cord injury. The nurse determines that the drug is having the desired effect when assessment findings include a. pulse rate of 68 b. respiratory rate of 24 c. BP of 106/82 d. temperature of 96.8

C. BP of 106/82 Rationale: Dopamine is a vasopressor that is used to maintain BP during states of hypotension that occur during neurogenic shock associated with spinal cord injury. Atropine would be used to treat bradycardia. The T reflects some degree of poikilothermism, but this is not treated with medications.

During assessment of a patient with a spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, the nurses' first action should be to a. initiate frequent turning and repositioning b. use tracheal suctioning to remove secretions c. assess lung sounds and respiratory rate and depth d. prepare the patient for endotracheal intubation and mechanical ventilation

C. assess lungs sounds and respiratory rate and depth Rationale: Because pneumonia and atelectasis are potential problems RT ineffective coughing function, the nurse should assess the patient's breath sound and resp function to determine whether secretions are being retained or whether there is progression of resp impairment. Suctioning is not indicated unless lung sounds indicate retained secretions: position changes will help mobilize secretions. Intubation and mechanical ventilation are used if the patient becomes exhausted from labored breathing or if ABGs deteriorate.

An initial incomplete spinal cord injury often results in complete cord damage because of a. edematous compression of the cord above the level of the injury b. continued trauma to the cord resulting from damage to stabilizing ligaments c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites d. mecheanical transection of the cord by sharp vertebral bone fragments after the initial injury

C. c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites Rationale: The primary injury of the spinal cord rarely affects the entire cord, but the patho of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through autodestruction of the cord by hemorrhage, edema, and the presence of metabolites and norepinephrine. resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory response may increase the damage as it extends above and below the injury site.

A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that a. rehabilitation measures cannot be initiated until spinal shock has resolved b. the patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder d. the patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected

C. c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder Rationale: Spinal shock occurs in about half of all people with acute spinal cord injury. In spinal shock, the entire cord below the level of the lesion fails to function, resulting in a flaccid paralysis and hypomotility of most processes without any reflex activity. Return of reflex activity signals the end of spinal shock. Sympathetic function is impaired belwo the level of the injury because sympathetic nerves leave the spinal cord at the thoracic and lumbar areas, and cranial parasympathetic nerves predominate in control over respirations, heart, and all vessels and organ below the injury. Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased CO. Rehab activities are not contraindicated during spainl shock and should be instituted if the patient's cardiopulmonary status is stable.

Without surgical stabilization, immobilization and traction of the patient with a cervical spinal cord injury most frequently requires the use of a. kinetic beds b. hard cervical collars c. skeletal traction with skull tongs d. sternal-occipital-mandibular immobilizer (SOMI) brace

C. skeletal traction with skull tongs Rationale: Cervical injuries usually require skeletal traction with the use of Crutchfield, Vinke, or other types of skull tongs to immobilize the cervical vertebrae, even if fracture has not occurred. Hard cervical collars are used for minor injuries or for stabilization during emergency transport of the patient. Sandbags are also used temporarily to stabilize the neck during insertion of tongs or during diagnostic testing immediately following the injury. Special turning or kinetic beds may be used to turn and mobilize patients who are in cervical traction.

where does the phrenic nerve innervate respiratory muscles

C3 & C4

treatment and education for cardiomyopathy

CPR ICD- implantable cardioverter defibrillator **can be paced or not paced

what to do if a patient has a Sengstaken/Blakemore tube and begin to experience respiratory distress

CUT THE BALLOON

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? 1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. autonomic failure

Correct Answer: 1 Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.

Which patient is at highest risk for a spinal cord injury? 1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) 2. 20-year-old female with a history of substance abuse 3. 50-year-old female with osteoporosis 4. 35-year-old male who coaches a soccer team

Correct Answer: 1 Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. Females tend to engage in less risk-taking behavior than young men.

An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed? Select all that apply. 1. Immobilize the neck using rolled towels or a cervical collar. 2. The patient will be placed in a supine position 3. The patient will be placed on a ventilator. 4. The head of the bed will be elevated. 5. The patient's head will be secured with a belt or tape secured to the stretcher.

Correct Answer: 1,2,5 Rationale: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be considered after admittance to the hospital.

The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs? 1. "I will have less pain if I use the halo device." 2. "The halo device will allow me to get out of bed." 3. "I am less likely to get an infection with the halo device." 4. "The halo device does not have to stay in place as long."

Correct Answer: 2 Rationale: A halo device will allow the patient to be mobile since it does not require weights like the Gardner-Wells tongs. The patient's pain level is not dependant on the type of stabilization device used. The patient does not have a great risk of infection with the Garnder-Wells tongs; both devices require pins to be inserted into the skull. The time required for stabilization is not dependant on the type of stabilization device used.

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.

Correct Answer: 2 Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.

The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? 1. paralysis 2. spinal shock 3. high cervical injury 4. temporary hypovolemia

Correct Answer: 2 Rationale: Spinal shock is common in acute spinal cord injuries. In addition to the signs and symptoms mentioned, the additional sign of absence of the cremasteric reflex is associated with spinal shock. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in an spinal injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.

The nurse understands that when the spinal cord is injured, ischemia results and edema occurs. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week? 1. "Tissue repair does not begin for 72 hours." 2. "The edema extends the level of injury for two cord segments above and below the affected level." 3. "Neurons need time to regenerate so stating the injury early is not predictive of how the patient progresses." 4. "Necrosis of gray and white matter does not occur until days after the injury."

Correct Answer: 2 Rationale: Within 24 hours necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost. Because the edema extends above and below the area affected, the extent of injury cannot be determined until after the edema is controlled. Neurons do not regenerate, and the edema is the factor that limits the ability to predict extent of injury.

A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient? Select all that apply. 1. modifying the traction weights as needed 2. assessing the patient's skin integrity 3. applying the traction upon admission 4. administering pain medication 5. providing passive range of motion

Correct Answer: 2,4,5 Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device must not be changed without the order of a healthcare provider. When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or a nurse.

A patient has manifestations of autonomic dysreflexia. Which of these assessments would indicate a possible cause for this condition? Select all that apply. 1. hypertension 2. kinked catheter tubing 3. respiratory wheezes and stridor 4. diarrhea 5. fecal impaction

Correct Answer: 2,5 Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing allowing the bladder to become full, triggering massive vasoconstriction below the injury site, producing the manifestations of this process. Acute symptoms of autonomic dysreflexia, including a sustained elevated blood pressure, may indicate fecal impaction. The other answers will not cause autonomic dysreflexia.

While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every two to three minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following? 1. hypoxia 2. bradycardia 3. elevated blood pressure 4. tachycardia

Correct Answer: 3 Rationale: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Additional nursing assistance will be needed and a colleague needs to reach the physician stat.

The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided? 1. Reposition the patient every two hours. 2. Position the patient with the head elevated 30 degrees. 3. Suction the airway every two hours per standing orders. 4. Provide continuous oxygen as ordered.

Correct Answer: 3 Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to maintain a patent airway but not as a matter of routine. Maintaining patient comfort by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) IICP. Keeping the patient properly oxygenated may also help to control ICP.

Which of the following nursing actions is appropriate for preventing skin breakdown in a patient who has recently undergone a laminectomy? 1. Provide the patient with an air mattress. 2. Place pillows under patient to help patient turn. 3. Teach the patient to grasp the side rail to turn. 4. Use the log roll to turn the patient to the side.

Correct Answer: 4 Rationale: A patient who has undergone a laminectomy needs to be turned by log rolling to prevent pressure on the area of surgery. An air mattress will help prevent skin breakdown but the patient still needs to be turned frequently. Placing pillows under the patient can help take pressure off of one side but the patient still needs to change positions often. Teaching the patient to grasp the side rail will cause the spine to twist, which needs to be avoided.

A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation? 1. hemiplegia 2. paresthesia 3. paraplegia 4. quadriplegia

Correct Answer: 4 Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.

A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse? 1. Remind the patient of her injury and try to comfort her. 2. Call the healthcare provider and get an order for radiologic evaluation. 3. Prepare the patient for surgery, as her condition is worsening. 4. Explain to the patient that this could be a common, temporary problem.

Correct Answer: 4 Rationale: Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury, and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level. In this case, the nurse should explain to the patient what is happening.

18. A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet q2-3hr c. Use of the Credé method to empty the bladder d. Catheterization for residual urine after voiding

Correct Answer: A Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

21. A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where "they know what they are doing." The best response by the nurse to the patient's behavior is to a. ask for the patient's input into the plan for care. b. clarify that abusive behavior will not be tolerated. c. reassure the patient that the anger will pass and rehabilitation will then progress. d. ignore the patient's anger and continue to perform needed assessments and care.

Correct Answer: A Rationale: The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Refusal to acknowledge the patient's anger by telling the patient that the anger is just a phase is inappropriate. Continuing to perform needed assessments and care is appropriate, but the nurse should seek the patient's input into what care is needed.

19. A patient with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Notify the patient's health care provider. b. Check the blood pressure (BP). c. Give the ordered antiemetic. d. Assess for a fecal impaction.

Correct Answer: B Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is causing the symptoms, including hypertension. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.

14. When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to a. administer oxygen at 7 to 9 L/min with a face mask. b. place the hands on the epigastric area and push upward when the patient coughs. c. encourage the patient to use an incentive spirometer every 2 hours during the day. d. suction the patient's oral and pharyngeal airway.

Correct Answer: B Rationale: The nurse has identified that the cough effort is poor, so the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia, and oxygen will not help expel respiratory secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.

16. A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.

Correct Answer: B Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.

MULTIPLE RESPONSE 1. When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care? (Select all that apply.) a. Endotracheal suctioning b. Continuous cardiac monitoring c. Avoidance of cool room temperature d. Nasogastric tube feeding e. Retention catheter care f. Administration of H2 receptor blockers

Correct Answer: B, C, E, F Rationale: The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distension, a retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine. Cognitive Level: Application Text Reference: pp. 1594-1595, 1597, 1603 Nursing Process: Planning NCLEX: Physiological Integrity

27. When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Continuous cardiac monitoring for bradycardia b. Administration of methylprednisolone (Solu-Medrol) infusion c. Assessment of respiratory rate and depth d. Application of pneumatic compression devices to both legs

Correct Answer: C Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions are also appropriate but are not as important as assessment of respiratory effort.

17. The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess a. blood pressure and heart rate. b. respiratory effort and O2 saturation. c. motor and sensory function of the legs. d. bowel sounds and abdominal distension.

Correct Answer: C Rationale: The purpose of methylprednisolone administration is to help preserve neurologic function; therefore, the nurse will assess this patient for lower-extremity function. Sympathetic nervous system dysfunction occurs with injuries at or above T6, so monitoring of BP and heart rate will not be useful in determining the effectiveness of the medication. Respiratory and GI function will not be impaired by a T10 injury, so assessments of these systems will not provide information about whether the medication is effective.

1. In which order will the nurse perform the following actions when caring for a patient with possible cervical spinal cord trauma who is admitted to the emergency department? a. Administer O2 using a non-rebreathing mask. b. Monitor cardiac rhythm and blood pressure. c. Immobilize the patient's head, neck, and spine. d. Transfer the patient to radiology for spinal CT.

Correct Answer: C, A, B, D Rationale: The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, continuous monitoring of heart rhythm and BP is indicated. CT scan to determine the extent and level of injury is needed once initial assessment and stabilization is accomplished.

13. A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. the presence of hyperactive reflex activity below the level of the injury. d. flaccid paralysis and lack of sensation below the level of the injury.

Correct Answer: D Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury.

22. A 26-year-old patient with a C8 spinal cord injury tells the nurse, "My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually." The most appropriate response by the nurse to the patient's comment is to a. advise the patient to talk to his wife to determine how she feels about his sexual function. b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury. c. inform the patient that most patients with upper motor neuron injuries have reflex erections. d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling.

Correct Answer: D Rationale: Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be handled by someone with expertise in sexual counseling. Although the patient should discuss these issues with his wife, open communication about this issue may be difficult without the assistance of a counselor. Sildenafil does assist with erectile dysfunction after spinal cord injury, but the patient's sexuality is not determined solely by the ability to have an erection. Reflex erections are common after upper motor neuron injury, but these erections are uncontrolled and cannot be maintained during coitus.

23. A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient's spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the family members that the patient can perform ADLs independently. b. remind the patient about the importance of independence in daily activities. c. recognize that it is important for the patient's family to be involved in the patient's care and support their activities. d. develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and parents.

Correct Answer: D Rationale: The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the family that the patient can perform ADLs independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the family members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient.

20. The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is a. transfers independently to a wheelchair. b. drives a car with powered hand controls. c. turns and repositions self independently when in bed. d. pushes a manual wheelchair on flat, smooth surfaces.

Correct Answer: D Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

The patient arrives in the emergency department from a motor vehicle accident, during which the car ran into a tree. The patient was not wearing a seat belt, and the windshield is shattered. What action is most important for you to do? A. Determine if the patient lost consciousness. B. Assess the Glasgow Coma Scale (GCS) score. C. Obtain a set of vital signs. D. Use a logroll technique when moving the patient.

D. Use a logroll technique when moving the patient. When the head hits the windshield with enough force to shatter it, you must assume neck or cervical spine trauma occurred and you need to maintain spinal precautions. This includes moving the patient in alignment as a unit or using a logroll technique during transfers. The other options are important and are done after spinal precautions are applied.

In planning community education for prevention of spinal cord injuries, the nurse targets a. elderly men b. teenage girls c. elementary school-age children d. adolescent and young adult men

D. adolescent and young adult men Rationale: Spinnal cord injuries are highest in young adult men between the ages of 15 and 30 and those who are impulsive or risk takers in daily living. Other risk factors include alcohol and drug abuse as well as participation in sports and occupational exposure to trauma or violence.

One indication for surgical therapy of the patient with a spinal cord injury is when a. there is incomplete cord lesion involvement b. the ligaments that support the spine are torn c. a high cervical injury causes loss of respiratory function d. evidence of continued compression of the cord is apparent

D. evidence of continued compression of the cord is apparent Rationale: Although surgical treatment of spinal cord injuries often depends on the preference of the health care provider, surgery is usually indicated when there is continued compression of the cord by extrinsic forces or when there is evidence of cord compression. Other indications may include progressive neurologic deficit, compound fracture of the vertebra, bony fragments, and penetrating wounds of the cord.

A client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which of the following activities? A. blowing the nose B. isometric exercises C. coughing vigorously D. exhaling during repositioning

D. exhaling during repositioning (activities that increase intra-throacic and intra-abdominal pressures cause indirect elevation of the ICP. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intra-thoracic pressure from rising).

A patient is admitted to the hospital with a CD4 spinal cord injury after a motorcycle collision. The patient's BP is 83/49, and his pulse is 39 beats/min, and he remains orally intubated. The nurse identifies this pathophysiologic response as caused by a. increased vasomotor tone after injury b. a temporary loss of sensation and flaccid paralysis below the level of injury c. loss of parasympathetic nervous system innervation resulting in vasoconstriction d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

D. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

A nurse is caring for a client who experienced a cervical spine injury 24 hours ago. which of the following types of prescribed medications should the nurse clarify with the provider? a. glucocorticoids b. plasma expanders c. H2 antagonists d. muscle relaxants

D. muscle relaxants Rationale: The client will still be in spinal shock 24 hours following the injury. the client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.

Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, the nurse anticipates that the patient will need a. IV fluids b. tube feedings c. parenteral nutrition d. nasogastric suctioning

D. nasogastric suctioning Rationale: During the first 2 to 3 days after a spinal cord injury, paralytic ileus may occur, and NG suction must be used to remove secretions and gas from the GI tract until peristalsis resumes. IV fluids are used to maintain fluid balance but do not specifically relate to paralytic ileus. Tube feedings would be used only for patients who had difficulty swallowing and not until peristalsis is returned; PN would be used only if the paralytic ileus was unusally prolonged.

A nurse is caring for a client who has a C4 spinal cord injury. which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise

D. respiratory compromise Rationale: Using the airway, breathing and circulation priority framework, the greatest risk to the client with a SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintainance of an airway and provision of ventilator support as needed is the priority intervention.

In counseling patient with spinal cord lesions regarding sexual function, the nurse advises a male patient with a complete lower motor neuron lesion that he a. is most likely to have reflexogenic erections and may experience orgasm if ejaculation occurs b. may have uncontrolled reflex erections, but that orgasm and ejaculation are usually not possible c. has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm d. will probably be unable to have either psychogenic or reflexogenic erections with no ejaculation or orgasm

D. will probably be unable to have either psychogenic or reflexogenic erections with no ejaculation or orgasm Rationale: Most patients with a complete lower motor neuron lesion are unable to have either psychogenic or reflexogenic erections, and alterative methods of obtaining sexual satisfaction may be suggested. Patients with incomplete lower motor neuron lesions have the highest possibility of successful psychogenic erections with ejaculation, whereas patients with incomplete upper motor neuron lesions are more likey to experience reflexogeic erections with ejaculation. Patients with complete upper motor neuron lesions usually only have reflex sexual function with rare ejaculation.

what solution should you run if TPN runs out

D10

FIRST step for a patient experiencing v-fib

DEFIBRILLATE

if your patient is intubated and in a ventilator, what is the preferred feeding method

Enteral feeding is preferred IF THE GUT WORKS, USE IT

when should a trauma patient be intubated

GCS <8

Ending -lol

HR and BP beta-blocker

what to look for in a patient who is being rapidly digitalized (digoxin)

HYPOKALEMIA

leads associated with inferior wall MI

II, III, aVF

what population of people are known to develop endo or myocarditis

IV drug users

Patho

Initial Injury: compression (concussion, contusion); penetrating trauma (laceration, transection); Neuro damage r/t primary injury or secondary damage (ischemia; inflammation; hemorrhage l/t progression of injury 72 hrs to know extent Skeletal level: Cervical = tetraplegia; Thoracic/Lumbar= paraplegia C1-C3 = total loss of respiratory muscle function Below C4 = diaphragmatic breathing, hypoventilation-ventilator at night Above T6 = dec influence of SNS=bradycardia, asystole (dec B/P, dec Pulse); Neurogenic shock= blood not forced to heart l/t dec cardiac output: Peripheral vascular - DVT, pulmonary embolus; orthostatic HTN Degree: Complete cord involvement: total loss of sensory & motor below level of lesion (also loss visceral: GI, Bowel/Bladder, sweat gland control) Incomplete (partial) cord involvement: Mixed loss of voluntary motor activity & sensation; potential to improve; 6 syndromes

What is it?

Injury to spinal cord interrupting nerve impulses btwn PNS & CNS impairing sensory & motor function Spinal Nerves: Cervical 8; Thoracic 12; Lumbar 5

What does PEEP do?

Keeps alveoli open at end of expiration; prevents collapse

Where is lovenox injected?

Love handles

immediate postinjury problems include

MAINTAIN: a patent airway***** adequate ventilation and adequate circulating blood volume, and preventing extension of cord damage

CPP equation

MAP-ICP

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A) Risk for impairment of tissue integrity caused by paralysis B) Altered patterns of urinary elimination caused by quadriplegia C) Altered family and individual coping caused by the extent of trauma D) Ineffective airway clearance caused by high cervical spinal cord injury

Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs. Points Earned: 1.0/1.0 Correct Answer(s): D

can you be cold and dead

should you reach out to the family AS A NURSE for organ transplant

should you stop taking beta blockers suddenly

treatment for Dresslers

NSAID aspirin STOP ANTICOAGULANTS

Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? A) Bradycardia B) Hypertension C) Neurogenic spasticity D) Bounding pedal pulses

Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output. Points Earned: 0.0/1.0 Correct Answer(s): A

what fluids may be ran through an arterial line

ONLY NORMAL SALINE 10mL/hr

what does an EKG look like for a second degree heart block TYPE 1

PR interval continues to get longer until you lose the QRS

lab for warfarin

PT/INR

what complications arise if the an MI occurs on the left side of the heart

PVCs Vtach Vfib

what wave is cardioversion synced with

R wave

how to determine heart rate

R-R Interval, 1500/# of small boxes

Cor Pulmonale

RIGHT sided heart problem, pulmonary HTN induced -> will cause further pulmonary HTN, unable to perfuse to the left size, preload increases

Nursg actions

Respiratory: Monitor resp status-accumulation of secretions: atelectasis, pneumonia, pulmonary embolus: Ventilation, suction, chest physiotherapy, assist cough, IS, eval O2, breath sounds, ABG's, sputum, resp. rate, effort: pain mgmnt; turning, sitting, exercising breathing muscles, ROM Cardio: CVP line; ECG, freq VS, Bradycardia (atropine, pacer), dec cardiac output, HTN Neurogenic Bladder - loss of muscle & neuro control; retention initially (r/t spinal shock l/t reflux of urine to kidney l/t UTI & kidney damage) followed by incontinence & spasticity r/t hyperactive bladder & sphincter: Foley, I & O, alert to UTI's-bladder control intermittent catheters q3-4 hrs preferred method, Older: prostate & renal calculi (r/t dec fluid) Remove Foley after initial period & go to intermittent cath. GI: Upper GI-swallowing, hypomotility (above T5) , gastric distention, stress ulcers: NG, NPO GI: Lower GI - neurogenic bowel (sphincters not working)-constipation, impaction: Bowel program (gastric callic reflex - 30-60 min after meal peristalsis increased and want to have a BM), rectal stimulant (suppository or enema) q day, inc fiber & fluids Nutrition: Wt. loss, anorexia, refusal to eat; inc protein & nutrious meals, inc protein, calories, fiber; TPN, tube feed, monitor e-lytes r/t NG l/t imbalance. Check albumin & e-lytes Integumentary: pressure ulcers (Life Threatening; can lead to sepsis)- position; turn; skin care; nutrition. Thermo regulation-paklothermia; hypo & hyper-thermia Always assume trauma patient has a spinal cord injury Pin care: saline & antiseptic & antibiotic ointment. Monitor for s/s of infection. Traction weights hand freely/ never take traction off

what is the CPK lab used to indicate

Rhabdo

fluid overload

LVD

how to calculate pulse pressure

SBP-DBP

Prevention

SCD's, TED, ROM (may not feel DVT development)

priority SERUM test for kidney function

SERUM CREATININE

what is DRESSLERS

ST elevation on EVERY LEAD

what are janeway lesions

Small, painless, erythematous lesions on palm or sole

Progression of SCI

Spinal shock: 50% = dec reflexes; flaccid paralysis below level of injury; lasts 24-72 hours to months; not usual in lumbar injury; difficult to make predictions. Return of spinal reflex signals end of spinal shock= paralysis replaced by reflex of spasticity & Autonomic dysreflexia (LIFE THREATENING) Autonomic dysreflexia - severe HTN, bradycardia, severe headache, diaphoresis above injury, nasal congestion, piloerection, nausea, blurred vision, anxiety, impending doom. Caused by distended bladder/rectum or any sensory stimulation. Nsg. Elevate HOB 45 degrees or sit pt up & Call Dr; assess B/P, cause-bladder, catheter, give antiHTNM, procarida, Nitro paste. Teach how to prevent, S/S, what to do Rehab-focus on pt goals/needs, pt expected to participate/learn self-care, Planning: Maintain opt. neuro function; minimal/no complications; learn skills, self-care, return home and function optimally

example of a potassium sparing diuretic

Spironolactone

side effect of antibiotic use in burn patients

Steven Johnsons Syndrome

what does and EKG look like for a second degree heart block TYPE 2

TWO P's per QRS

what are osler nodes

Tender lesions on fingers or toes.

A 25-yr old male pt who is a professional motorcross racer has anterior spinal cord syndrome at T10. His history includes tobacco use, alcohol abuse, marijuana abuse. What is the nurse's priority during rehabilation? A. Monitor the patient 4 times an hour B. Encourage him to verbalize feeling. C. Prevent urniary tract infection D. Teach about using gastrocolic reflex

The pt is at high risk for depression and self-injury because he is likely to lose function below the umblicus . resulting in loss motor function. In addition he will need to be in a wheelchair, impaired sexual function, and can not use tobacco, alcohol, marijuana abuse for coping. The answer is B

What does it cause?

Trauma

leads associated with a septal wall MI

V1 and V2

leads associated with an anterior wall MI

V2, V3, V4

leads associated with a lateral wall MI

V5, V6, aVL

Pulmonary function test

VQ (ventilation perfusion) Scan - how much you take in vs how much is exchanged and perfused, PE - high, atelectasis - low

antidote for warfarin

Vitamin K

A 70 yr old patient who has a spinal cord injury at C8 resulting in central cord syndrome. Which effect of the patient's most likely to be life threatening after completeing rehabiliation? A. increased bone density loss B. higher tisk for tissue hpoxia C. vasomotor compensation lost D. Weakness of thoracic muscles

Weakness of thoracic muscle is most likely to cause life-threatening complications because affects patients oxygentation and ventilation. Answer is D

because of loss of voluntary neurologic control over the bowel, ...

a bowel program should be started during the acute phase.

which arrhythmia is associated with mitral valve regurgitation

a fib

changes in elderly cardiovascular system

a fib decreased cardiac compliance valve calcification wall thickening

spinal shock.

a temporary neurologic syndrome that s/s decreased reflexes loss of sensation, and flaccid paralysis bewlos the level of the injury

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following types of bladder management methods should the nurse use for this client? a. condom catheter b. intermittent urinary catheterization c. crede's method d. indwelling urinary catheter

a. condom catheter Rationale: a client who has a cervical spinal cord injury will also have a upper motor neuron injury, which is manifested by a spastic bladder. because the bladder will empty on its own, a condom catheter is an appropriate method and is noninvasive. B & C are for flaccid bladder.

A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During the admission of the patient, the nurse places the highest priority on a. maintaining a patent airway b. assessing the patient for head and other injuries c. maintaining immobilization of the cervical spine d. assessing the patient's motor and sensory function

a. maintaining a patent airway Rationale: The need for a patent airway is the first priority for any injured patient, and a high cervical injury may decrease the gag reflex and ability to maintain an airway, as well as the ability to breathe. Maintaining cervical stability is then a consideration, along with assessing for other injuries and the patients neuro status.

lab for heparin

aPtt

is elevated ST chronic or acute

acute within the last two weeks

RASS Score

agitation and sedation scale, used in ICU patients

Pneumothorax

air in the lungs, air rises, chest tube is threaded at the 2nd/3rd intercostal space

what is the effect of alcohol use on the GI system

alcohol increases gastric acid production

CAM ICU

alert and calm scale, vented patients

what does an EKG look like for a first degree heart block

all PR intervals are prolonged and regular

Total lung capacity

amount lung can hold entirely

Residual volume

amount of air left in the lung after being forced out, good for vents and COPD

labs/enzymes for pancreatitis

amylase lipase

early signs of cirrhosis

anorexia, nausea, vomiting, RUQ pain

if BP is not equal bilaterally, what does that indicate?

aortic aneurysm thoracic aneurysm

Tidal volume

approximately 500mL, kg x 6-8, max of 1000mL

left sided heart caths go in which type of vessel

arteries **usually femoral artery

A in tx for MI

aspririn

what to assess in a patient who is experiencing autonomic dysreflexia

assess bladder and rectum

O2 sat drops while on oxygen

assess pulse ox, check to see if the tubing is hooked up to the wall, assess symmetry of chest expansion

what is a peritoneal lavage

assessing the patient for abdominal bleeding

when to give vasopressin

asystole

what to look for if giving epinephrine

asystole v-fib/v-tach without a pulse

patient has a C7 fracture w/ headache, flushed and warm skin; what is the patient experiencing

autonomic dysreflexia

after return of reflexes after resolution of spinal shock means that patient with an injury level at t6 or higher may develope life threating condition known as

autonomic dysreflexia common precipitaing cause is distended bladder or rectum, although any sensoty stimulation amy cause autonomic dysreflexia. Immediate care : elevate hob to 45 degrees, sitting the patient upright perform an assessment to determine the cause and notify the physician.

A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of the following findings is of most concern to the nurse? a. SpO2 of 92% b. HR of 42 beats/min c. BP of 88/60 d. loss of motor and sensory function in arms and legs

b. HR of 42 beats/min Rationale: Neurogenic shock associated with cord injuries above the level of T6 greatly decrease the effect of the sympathetic nervous system, and bradycardia and hypotension occur. A heart rate of 42 is not adequate to meet oxygen needs of the body, and while low, the BP is not at a critical point. The O2 sat is ok, and the motor and sensory loss are expected.

signs and symptoms of cardiogenic shock

becks triad

causes of anaphylactic shock

bee sting, allergies, blood transfusion

What does kayexalate do?

binds K+ and helps excrete it through feces (slow acting)

how to ID DIC

bleeding from injection sites

if your patient is experiencing back pain post PTCA/cath what does this indicate

bleeding into the retroperitoneal cavity

example of a 2nd degree burn

blisters, sun poisoning

what is a bruit

blood flow through a tortuous vessel

Hemothorax

blood in the lungs, 5th/6th intercostal space, insertion site is the same for both

Ventilator Screen

bottom screen - physicians orders, top screen - what the patient is actually doing

what to assess -pril

what to assess with beta blocker

hemolytic jaundice

breakdown of RBCs, increas in cinjugated billi, NO BILIRUBIN IN URINE

signs and symptoms of anaphylactic shock

bronchial constriction, hives, flushed skin, increased temp

Grey-turners signs

bruising of flank retroperitonel bleeding, pancreatic hemorrhage

What does a wide QRS indicate?

bundle branch block complete heart block

A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The initial action of the nurse is to a. call the physician b. check the patient's temperature c. take the patient's BP d. elevate the HOB to 90 degrees

c. Take the patient's BP

what medications prolong a QT interval

calcium channel blockers digoxin

what to do if experiencing chest pain

call 911

vasomotor

causing dilation or constriction of the blood vessels

procedure if a patient is presenting with asystole

check leads call code start CPR give epinephrine apply pacer intubate

if your patient has circumferential burns, what is the priority nursing intervention

check pulses first

your patient with ARDS is desating, what should you do first

check the pulse ox

symptoms of carbon monoxide poisoning

cherry lips, carboxyhemoglobin

what can cause cardiac tamponade

chest wall injury trauma

sound heard in a stenotic valve

clicking heart sounds

what do sodium and potassium do for the heart

conductivity

what do calcium and magnesium do for the heart

contractility

what are plummers nails

cracked nails

priority lab test for renal function

creatinine clearance test

what solution is given for hypovolemic shock

crystalloid solution

your patient has a class III hemorrhage, what are the two products to be infused

crystalloid solution and PRBC

causes of cardiogenic shock

decreased contractility of the left ventricle, decreased CO, decreased preload, increased afterload

what physiological process prompts adrenal aldosterone secretion

decreased plasma volume secondary to hemorrhage

what does a beta blocker do

decreased workload decrease size of infarction

what does nitroglycerin do for a patient having an MI

dilates vessels increase oxygen supply

treatment for a fib

diltiazem anticoag/antiplatelet

which type of shock vasodilates initially

distributive shock (anaphylactic, septic)

what NOT to do with a patient with cerebral edema

do not flex the neck do not do cluster care- too much stimulation

lethargic

drowsy but easily arousable, slow response

obtunded

drowsy when not stimulated, follows simple commands

what is usually the cause if a QT interval is >.44

drugs

A male patient has a pinal cord injury at L 1-2 . Which clinical manifestation of the patient's injury is the nurse likely to observe before spinal shock resolves? A. opoiod analgesic Iv for foot pain B. able to blance in sitting position C. unresponsive quadriceps muscle D. requites asssist control ventilation

during spinal shock neuromuscular function is lost below the level of the injury along with hyporeflexia and loss of sensation. So the pt will not be able to sit until the pinal shock resolves. Answer : C

signs of right side HF

edema weight gain JVD hepatomegaly tachy

Cullen's sign

edema and bruising around umbilicus

what complications arise if the MI occurs on the right side or inferior portions of the heart

effects SA node heart block slows down conduction

what population has a matured collateral circulation

elderly

how to assess for JVD/HJR

elevate 45 degrees, palpate liver and look for jugular distention

VAP (ventilator acquired pneumonia)

elevate HOB 30-45 degrees, brush teeth once a shift Q8H, suction PRN (subglottic), turn Q2H, oral care Q2H

labs for DIC

elevated D-dimer, decreased fibrinogen, elevated FSP

Components of Cushing's Triad

elevated SBP widened pulse pressure bradycardia

signs of septic shock

elevated temp, HR and RR, decrease in BP, decreased CO2 with high pH, bands >10%

Bag-valve systems

emergency, pulseless vtach, vfib, asystole, 100% O2 if you hook the oxygen up, if not then they're only getting 21%

what should we do if left main artery becomes clotted

emergent open heart surgery decreased life expectancy

Intubation

endotracheal tube (ET tube), cuff on the end that gets blown up with a 10cc balloon, occludes the airflow from the atmospheric air to the lungs, instantly makes the patient unable to talk

what is cardiomyopathy

enlargement of the heart

medications to know for dysrhythmias

epinephrine vasopressin amiodarone atropine

if your patient is intubated, on a ventilator, and anxious what is the priority nursing intervention

establish effective communication

what is phase two of rehab consist of

exercise 4-6 weeks

What is decerebrate posturing?

extension and pronation of upper extremities

criteria for brain death

flaccid, no brain wave activity, fixed and dilated pupils, no gag reflex, no pupillary restriction, no dolls eyes

priority intervention for burn victims

fluid resuscitation

fluid volume overload

how many classes of HF

four

why would we use an arterial line

frequent lab draws frequent ABGs

example of 3rd degree burn

full thickness burn, nerve fibers destroyed, no pain around edges, charred skin

example of loop diuretic

furosemide

Rule of 9's for burns

head = 9% (4.5 each side) trunk = 36% (18 each side) legs = 18% each (9 each side) arms = 9% each (4.5 each side) genitals = 1%

signs and symptoms of infective endocarditis

headache, malaise, anorexia, hemorrhaging under fingernails

which organs are protected in the body's compensation of shock

heart and lungs

what if your PR interval is greater than .2

heart block

procedures for pre-op CABG

heart cath coagulation labs 8 hours NPO skin prep cough and deep breathing consult OT/PT if using the saphenous vein

beta-blocker

heart rate

types of jaundice

hemolytic hepatocellular obstructive

treatment for DIC

heparin, redirect to normal clotting, give platelets, FFP, cryoprecipitates and PRBC

diet for SCI after bowel sounds are present

high protein, high calorie, becuase of catatbolism and is necessary for energy and tissue repair

diet for hepatic patient

high protein, low fat, low sodium

time frame for a hyperacute rejection

hours

Diffusion

how rapidly it crosses over and can be exchanged, depends on surfactant level, ARDS

what to assess with calcium channel blocker

hr and bp

Example of thiazide diuretic

hydrochlorothiazide

complications of a transplant

hyperacute rejection, acute rejection, chronic rejection, and pulmonary edema

trauma triad of death

hypothermia, acidosis, coagulopathy

when is it okay to see PVCs

if a patient is having an MI PVCs is a sign of improvement

key sign an epidural hematoma is present

if a patient is unconscious, regains consciousness, and goes out again

when does bleeding during/post CABG become a medical emergency

if the patient begins to bleed >500mL/hr

what is the next step if 75% blockage is seen in 4 different vessels

immediate open heart surgery

primary nursing diagnoses for CHF

impaired gas exchange decreased CO fluid overload

hepatocellular jaundice

impairment of a phase of bilirubin conjugation, increases conjugated bilirubin

if you ask the patient to hold their breath and you STILL HEAR a friction rub, where is this occurring

in the heart

if you ask the patient to hold their breath and you NO LONGER HEAR a friction rub, where is this occurring

in the lungs

where is endocarditis and myocarditis located

in the valves murmur

priority intervention for a patient with hypercalcemia

increase fluid intake

what to look for if giving atropine

increased HR from bradycardia

change in labs for trauma/shock

increased d-dimer

what does phase one of rehab consist of

increased range of motion ADLs

A nurse is caring for a client with increased intracranial pressure (ICP). the nurse should monitor for what vital signs that would occur if ICP is rising

increased temp, decreased pulse, decreasing respirations, and increasing bp (a change in vital signs may be a late sign of increased ICP)

what does spironolactone do to potassium levels

increases potassium

what kind of MI is occurring in a patient experiencing ST elevation in II, III and avF leads

inferior wall MI

what kind of response is a heart attack

inflammatory

what does it mean if there is a left shift in septic shock

inflammatory process

What is decorticate posturing?

internal rotation of upper extremities, "O"

Difficulty with lung expansion with ARDS

intubation, paralytic agent (neuromuscular blocker - NIMBEX), last sense to leave is hearing - they can hear you always, propofol - anesthetizing agent, sedative - versed/ativan/fentanyl so they can't hear what we're saying

if a patient has a depressed ST for 1x1 box, what does this indicate

ischemia and unstable angina, not permanent

what is the most common CVA

ischemic/thrombotic

how do you "fill the tank" with septic shock patients

isotonic solutions and vasopressors

late signs of liver failure

jaundice, ascites, palmar erythema, spider angiomas

what if you PR interval is less than .12

junctional rhythm

post op CABG procedures

keep MAP >65 assess LOC check insertion sites assess for cardiac tamponade

what organ loses perfusion first

kidney

High Pressure Alarm

kinked due to biting, turned head to kink, lots of secretions and need suctions, anxious and flopping around, not getting oxygenated Unkink, tell them to stop biting, suction (coming out/intermittent/always HYPEROXYGENATE first), sedate if necessary - last resort

cause for high pressure vent alarm

kinked tubing, patient biting down, obstruction

how to treat high ammonia levels

lactulose

Wernicke's area

language comprehension

CPAP

last mode you use as you're trying to ween them off the vent, need to be conscious/alert/must be able to breathe on their own No BIPAP on a vent Very hard to ween a COPD patient off a ventilator if put on assist control, put them on SIMV

artery associated with anterior wall MI

left anterior descending

artery associated with septal wall MI

left anterior descending

where does lead III look

left arm to left leg

artery associated with lateral wall MI

left circumflex artery

Where does aVF look

left foot

aortic stenosis is linked to what kind of HF

left sided heart failure

left ventricular function

Face mask

less than or equal to 65%

if your patient has experienced a TBI following an MVA, what is the priority for this patient

limit IV fluid intake in order to prevent cerebral edema

what to look for if giving amiodarone

look for v-tach or a-fib

High flow O2

looks like a NC, heated circuit that allows more exchange to occur, softens the lungs, helps with chest expansion

L in tx for MI

lopressor

neurogenic shock

loss of vasomotor caused by injury characerized by hypotension, bradycardia

diet for a pancreatic patient

low fat, high protein, high carb

bright blood in stool indicates

lower GI bleed

what does it mean if a CXR is whited out

lungs are full of fluid

what is vital capacity

max air inspired and expired in one breath

what do we need to assess in chain stokes

measure the periods of apnea **the longer they get, means the person is passing away

Tension Pneumothorax

mediastinum/trachea shifts to the UNAFFECTED side Biggest cause: inserting a central line

where is vital capacity regulated

medulla and pons

stuporous

minimal spontaneous movement, only arousbale by vigorous stimuli

Assist control (AC)

mode on a ventilator

SIMV (spontaneous intermittent mechanical ventilation)

mode on a ventilator, patient must be breathing somewhat on their own, good for not being dependent on the vent

patient with DMII, glucose of 800, and decreased UO.. what should you do

monitor for dehydration (HHNK)

Flail Chest

more than 3 ribs broken Broken rib can puncture a lung

M in tx for MI

morphine

ARDS

most commonly caused by pneumonia/trauma to the lungs or sepsis, multisystem failure disorder, lack of perfusion, mortality rate is 60% or higher, lose surfactant, capillary leak syndrome, non-cardiogenic CHF, can lead to LEFT AND RIGHT SIDED HF, lung becomes extremely stiff, put them on reverse ventilation - can't take the breath in, 2x inspire per 1x expire (opposite of normal), nitrous oxide through the vent - bronchodilator that helps with perfusion, antibacterial if that's the cause, steroids - solumedrol, use a rotoprone bed which faces them to the floor and allows their lungs to fully expand - look for increased SaO2 when you turn them over/decreased HR, and increased BP, turn Q2H, all vented patients will have an OG/NG tube

components of Beck's Triad

muffled heart sounds hypotension/narrow pulse pressure NVD

MEDICATION TRIFECTA for liver

multivitamin, thiamine, folic acid

valve

murmur

Intubation SvO2 Capnography Device

needs it to turn purple so it indicates it's in the lungs and not the stomach

N in tx for MI

nitroglycerin

what medication do we give to a patient who becomes hypertensive post CABG

nitroglycerin IV or SL

can you suction out crackles

is there a treatment for a flutter

should the patient be able to talk if they are ventilated

what does hydrochlorothiazide do to potassium levels

no change in potassium

Partial rebreather

no inspiration, max 15L on the flow meter - 60% O2

signs of left side HF

nocturnal dyspnea s3 fatigues crackles SOB

what is an NSTEMI

non ST elevated MI EKG is normal

Low Pressure Alarm

not connected, no O2 going through, machine shut off Connect it

late signs of meningitis

nuchal rigidity, photophobia, seizures

obstructive jaundice

obstruction to bile flow, increased conjugated bilirubin

O in tx for MI

oxygen

treatment regimen for complete heart block

pacemaker atropine

what is the SA node

pacemaker of the heart

what does a MAP determine

perfusion

sign of pulmonary edema

pink frothy sputum

a patient involved in an MVA has spontaneous breathing, what is the priority

place patient on a non-rebreather mask, airway oxygenation is key

What is the phlebostatic axis?

point of maximal blood flow to the heart **It is the reference point on the chest that is used as a baseline for consistent tranducer height placement. It is the 4th intercostal point and midaxillary line.

complications of liver failure/cirrhosis

portal vein hypertension and esophageal varices

PEEP

positive end expiratory pressure

what does PEEP stand for

positive end expiratory pressure

what class of medication is given to those with a fib

positive inotrope

what do we give to a patient who become hypotensive post CABG

positive inotrope IV dobutamine

treatment for cardiogenic shock

positive inotrope (dobutamine), vasopressors (dopamine and norepinephrine), balloon pump

what electrolyte needs replaced in a patient with DKA

potassium

what does Cyclosporin A do?

prevents, delays, and/or reverses graft rejection

Q wave greater than 1 box down and wide

prior MI long term

cure for heparin

protamine sulfate

Dilate

pulse, airway, BP

signs of an intact CNIII

pupillary restriction and accomodation

what do we do if a patients MAP is too high

put them on a short term dilator nitroglycerin

what does furosemide due to potassium levels

reduces potassium

what do you do if the patient is vented and talking

reinflate the balloon

what does morphine do for a person who is having an MI

relieve anxiety

treatment for anaphylactic shock

remove the cause, give epi and/or benadryl

what are chain stokes respirations

respirations often found in a dying individual

alert

responds to minimal external stimuli, follows commands

incomplete cord involvement

results in miced loss of voluntary motor activiey and senstion and leaves some tracts intact.

complete cord involvement

results in total loss of sensory and motor function below the level of the lesion(injury),

what are roth spots

retinal hemorrhages

where does lead II look

right arm to left leg

artery associated with inferior wall MI

right coronary artery

what does NVD/JVD/HJR indicate

right sided heart failure

pulmonary valve disorders are related to what kind of HF

right sided heart failure blood backs up behind valve

the three s/sx of cardiac tamponade

rt side NVD narrow pulse pressure muffled heart sounds

fluid overload

lvd

what vessels are usually used as a graft in a CABG

saphenous vein mammary arteries

causes of DIC

sepsis burns liver/GI bleeding

characteristics of pancreatitis

severe LUQ pain, radiates to back, pain worsens with eating, not relieved by vomiting

topical medication used for burns

siilver sulfadiazine (Silvadene)

symptoms of smoke inhalation

singed/black nose hairs, soot, course stridor/wheezing, respiratory injury

what condition is not contraindicated in organ transplant

skin cancer

Broca's area

speech production

what is important for trauma patients

stabilize the c spine

if your patient is experiencing V TACH, the QRS is >.10 and YOU FEEL A PULSE.. what do you do

stable V Tach give amiodarone begin cardioversion

precautions to be followed for trauma/shock

standard precautions

treatment for stenotic valve

stent placement long term anticoagulants valvuloplasty short term abx

what kind of culture is needed to test for steatorrhea

stool sample

if the patient is experiencing an anaphylactic reaction, what is the priority nursing intervention

stop the antibiotic infusion then administer epinephrine, sometimes diphenhydramine is given

exclusions for thrombolytics during MI

stroke/brain bleed aneurysm/dissection inc. use of CPR internal bleed BP 200/120

example of 1st degree burn

sunburn, reddend skin, blanching

PAP

sys 15-25 dia 8-15

what does SIRS stand for

systemic inflammatory response syndrome

poiklotherminism

the adjustment of the body temp to the room temperature occurs because of the interruption of the sns prevenets peripheal temp sensationf from reaching the hypothalamus

You're patient has just returned from a PTCA and is experiencing chest pain. Also, you see elevated ST segments on the EKG, what does this mean?

the arteries have closed off

Nurse is assessing a patient who has a spinal cord injury?Which should the nurse include in the nervous system assessment to determine the extent of the patient's injury? a. vital sign b. romberg test c. plantar reflexes d. bilatereal hand grasps e. description of trauma

the assessment to determine the level of spinal cord injury includes analyzing the -vital sign, plantar reflexes, bilatereal hand grasp, description of trauma. Romberg test must be performed while standing therefore not suitable for unstable patient Answer: a, c, d, e

what occurs during a third degree/complete heart block

the atria and ventricles are not communicating at all

A female nurse is injured in an automobile accident and suffers acute compresssion of the anterior apinal cord at T8-10 Which nursing rols is a potential source of employment for the patients after completing rehabilitation ? A. Certified nurse practioner B. Community health nursing C. Hospital case mangement D. Inpatient behavioral health

the nurse in most likely to have an anterior cord syndrome resulting in the loss of neuromuscular and pain and temp sensation below t8. Pt will have full use of upper extremities , upper back, and resp muscles.thus she will be in a wheel chair. Best position for her would be C. Hospital case management

The nurse admnisters methylprenisone(Solu-Medrol) as a continous IV fusion to a male patient who has fractures of the cervical vertebrae. Which intervention would prevent or detect adverse effects of the medication? A. record pt baseline weight B. adminster PPI( proton pump inhibitor) C. Check the hear rate for bradycardia D. suction the patient's oropharyn

the nurse should adminster PPI because they are at high risk for Gi erosion and bleeding. from the steriod. Answer: B

what is an angioplasty

the opening of blood vessels with a balloon **compresses plaque in arteries **Often called PTCA

why should we not leave a person with COPD on a ventilator for long periods of time

they become vent dependent because they don't have to work as hard to breath

Report vent settings

tidal volume (TV), FiO2 (% of oxygen being given, 24%-100% on vent), respiratory rate, mode (AC/SIMV), PEEP (can be 2.5-20), PS (pressure support, unable to expand to take a big inspiratory breath)

why should a person who has had an MI be put on an ACE inhibitor

to prevent CHF which could lead to death

MONA+L

treatment for MI

LAB SPECIFIC TO MI

troponin I & T

cause for low pressure vent alarm

tubing is disconnected

what can chest pain at rest indicate

unstable angina brewing MI

if your patient is experiencing V TACH, the QRS is >.10 and you DO NOT FEEL A PULSE... what do you do

unstable v tach not perfusing defibrillate (200-360 joules)

dark blood in stool indicates

upper GI bleed

Acute respiratory failure (ARF)

usually from hypoxemia from poor circulatory flow, high lactic acid level, metabolic acidosis -> respiratory acidosis, pH < 7.35 - if less than 7.25 = intubate Give bronchodilator (theophylline or aminophylline 10-20 is therapeutic) - IV is the fastest, inhalation is the second Corticosteroid - anti-inflammatory Hypoxic/anoxic encephalopathy

what type of medication will an organ donor be on to preserve organs as not as they meet brain death criteria

vasopressing agents

right sided heart caths go in which type of vessel

veins

Dead space

ventilation without any gas exchange occurring, atelectasis of the bases and pneumonia

Pulse Ox

waveform on monitor = pleph, monitors pulse so it needs to be on a pulse point (finger, earlobe, toe, forehead)

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