CC Exam 3
flail chest
2 or more ribs broken in 3 or more places, can cause a pneumothorax
B (establish airway), D (provide adequate ventilation), E (assess neuro function)
A nurse is performing a primary survey of a client brought to the emergency department. Which of the following would the nurse include? Select all that apply. •A. Obtaining a complete health history •B. Establishing airway patency •C. Applying monitoring devices •D. Providing adequate ventilation •E. Assessing neurological function
A. Elevated HOB C. Oral care D. Subglottic suctioning every 2 hours
A ventilated client in the intensive care unit (ICU) has the "ventilator bundle" ordered. The nurse recognizes that the ventilator bundle includes (select all that apply)? a. Head of bed 30 to 45 degrees to prevent aspiration b. Legs elevated 35 degrees to promote venous return c. Oral care every 2 hours to reduce bacterial colonization d. Subglottic suctioning every 2 hours to remove secretions e. Eyecare every 2 hours to prevent sclera edema
primary assessment
A-alertness and airway B- breathing C- circulation D- disability/ neuro status
secondary assessment
E-exposure and environmental control F-full set of VS G- get monitoring devices and give comfort measures (LMNOP)
volume controlled ventilation
amount of air delivered with each breath is constant for every breath delivered by the ventilator -AC or SIMV
AVPU
assessing if patient is Alert, Responds to Verbal, Responds to Pain, or is Unresponsive
lactated ringers
preferred fluid for fluid resuscitation
subdural hematoma
slow venous bleed CT is wonky without clean lines
100% oxygen
treatment for carbon monoxide poisoning
120 degrees
water heater temperature to prevent scalding injuries
chest tube clamps at head of bed
what do you always have for a patient with a chest tube?
clamp chest tube, milk chest tube
what do you never do with chest tubes?
3 mm above carina
what is good ETT placement for intubation?
ARDs, DIC, or MODS
what is more likely in Pts with 20% BSAB burns?
metabolic alkalosis
pH greater than 7.45, HCO3 high -excessive use of bicarb and antiacids, vomiting, NG suctioning, hypokalemia -lethargy, muscle twitching, N/V
total respiratory rate
# of breaths initiated by ventilator plus the # of breaths initiated by the patient
Fluid resuscitation in burns
*Parkland Formula:* 2-4 mL/kg for initial 24 hr *HOW MUCH FLUID A BURN VICTIM NEEDS FOR INITIAL 24 HR* - Half of fluid given in *first 8 hours* - Second half of fluid given over remaining 16 hours - *Starts from time of injury* - 2 large bore IVs, warm LR - Pain control w/ IV, or PO, narcotic (*IM meds not absorbed well)* - Maintain Temperature
water seal chamber
-B on Atrium -fill to 2 cm mark
air-leak monitor
-C on atrium -look for new onset bubbling or tidaling
diagnosis of ARDS
-PaO2/FiO2 ratio less than 200 -bilateral infiltrates on X-ray -no cardiac reason for pulmonary edema -ventilatory pressure changes -refractory hypoxemia -ventilation perfusion mismatch -acute onset
PEEP
-adjunct therapy -pressure that is maintained in the lungs at the end of EXPIRATION -keeps the alveoli from closing completely and helps recruit alveoli -used with stiff lungs (ARDs, COPD), or with severe hypoxia -5-20 cm H2O
tidal volume
-amount of air delivered with each breath -8-10 ml/kg of body weight
CPAP
-delivers constant small amounts of pressure throughout the respiratory cycle -may be delivered via facemask (obstructive sleep apnea) or as a ventilator mode - indicated for weaning or OSA
BiPAP
-delivers two levels of pressure, inspiratory and expiratory -non-invasive positive pressure ventilation -to prevent intubation -often used for patients with COPD exacerbation
pressure support ventilation
-extra help on inspiration -used to assist spontaneous breathing and decreased WOB -indicated for weaning, often used as an adjunct therapy when weaning with SIMV or CPAP modes
beck's triad
-for cardiac tomponade -Hypotension, Muffled heart tones, and JVD
SIRS Criteria
-high or low temperature -HR higher than 90 -RR greater than 20 -low or high WBC
B. Assist Control
A client has undergone abdominal surgery and is still under the effects of anesthesia. What ventilator mode would you anticipate the client to return on to the unit? a. Synchronized Intermittent Mandatory Ventilation (SIMV) b. Assist Control (AC) c. Pressure Control Ventilation (PCV) d. Pressure Regulated Volume Control (PRVC)
14,400 ml total 7200 ml in first 8 hours (900 ml/hour) 7200 ml in next 16 hours (425 ml/hour)
Complete the following fluid resuscitation for a patient. Order: 4mL/kg/BSA% Patient weighs 198 lbs. % of body burned 40% ________ during first 8 hours ----------- during the next 16 hours
respiratory acidosis
pH less than 7.35, CO2 high -trauma, hypoventilation, over sedation, severe pulmonary infection -SOB, restlessness, confusion, lethargy, HA, tachycardia, drowsiness
Fast-track
In which triage category would the nurse include a client who requires simple first aid or basic primary care? a. Urgent b. Fast track c. Nonurgent d. Emergent
acute lung injury (ALI)
P/F ratio less than 300
central circulation
Palpate radial: SBP at least 80 Femoral: at least 70 Carotid: at least 60
metabolic acidosis
pH less than 7.35, HCO3 low aspirin OD, ketoacidosis, starvation, diarrhea, intestinal fistula -HA, confusion, restlessness, weakness, kussmaul respirations -treat diarrhea and give bicarb
Wears hats and wigs Participates in ADLs Reports absence of sleep disturbance
The nurse cares for a 30-year-old client who suffered severe head and facial burn injuries. Which action, if completed by the client, indicates the client is adapting to altered body image? Select all that apply. •Wears hats and wigs •Covers face with a scarf •Participates actively in daily activities •Reports absence of sleep disturbance
Heart rate, UOP, Blood Pressure
The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply. •Heart rate •Urine output •Oxygen saturation •Respiratory Rate •Blood pressure
Tissue edema may interfere with drug absorption via other routes
The nurse cares for a client with superficial partial-thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because •the client can experience nausea and emesis when given oral medications. •pain resulting from a burn injury requires relief by the fastest route available. •bleeding may occur at injection sites when the intramuscular route is used. •tissue edema may interfere with drug absorption via other routes.
C. BP 200/100 and has chest pain that is 10/10
The nurse in the ER is assigned to the following 4 patients. Which patient will they see first? a.A 24 yo with a BP of 146/82 who reports feeling very anxious and is breathing rapidly. b.A 68 yo hemodialysis patient who skipped dialysis yesterday and has a potassium of 5.4. c.A 59 yo with a BP of 200/100 who is complaining of chest pain that is a 10/10 d.A 82 yo who fell in their home and states that their hip is "very sore."
Establish airway Apply pressure Start IV insertion and fluid infusion Assess for head and neck injuries Examine client for additional injuries to the body
The nurse is assigned to a client admitted to the ICU from the emergency department. The client sustained multiple injuries from a motor vehicle accident. When reviewing the client chart, the notes indicate the client's emergency care was managed in what sequence of steps? a. Assess for head and neck injuries b. Application of pressure to control abdominal bleeding c. Start peripheral intravenous insertion and infusion of fluids d. Examine client for additional injuries to the body e. Establish airway and start ventilation
Stop the transfusion Assess the airway Check full VS Ensure the NS IV line is open Notify the physician
The nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs) in the ER for a hemorrhage post MVR. After 15 minutes of the transfusion, the nurse notes the client has a fever and shortness of breath. Place in order the steps the nurse should take in response to these findings. Use all options. Stop the transfusion Ensure the normal saline IV line is open. Notify the physician Check full vital signs Assess the airway
B. Pneumo=absent breath sounds on affected side
Which sign should alert the nurse to a possible pneumothorax in a ventilated client with a high peep of 20? a. Rhonchi and rales throughout all lung fields b. Decreased or absent breath sounds of affected side c. Increased or hyperresonance breath sounds of affected side d. Adventitious breath sounds on affected side
B. Possible chest tube dislodgment
Your client had a chest tube placed during the previous shift. During your initial assessment you palpate subcutaneous air above the chest tube. You recognize that this finding could indicate: a. Insignificant minimal air escape b. Possible chest tube dislodgement c. An expected finding on a newly inserted chest tube d. Blood within the subcutaneous tissue
ARDS
Your client was admitted with acute lung injury and their respiratory status has started to decline. The HCP orders a PCXR (portable chest xray or portable radiograph) and arterial blood gases (ABGs), the PCXR report reads bilateral opacities with ground glass appearance and abg results are pH 7.29, paCO2 55, pO2 90, HCO3 20, SaO2 89% on FiO2 75%. The nurse recognizes that these results indicate the development of: a. Severe pneumococcal pneumonia (SPP) b. Acute Respiratory Syncytial Virus (ARSV) c. Acute Respiratory Distress Syndrome (ARDS) d. Recovery within the alveolar structures of the lungs
pressure control ventilation
does allow for patient initiated breaths patient needs to be sedated indicated for lungs with decreased compliance and increased resistance (stiff or fibrotic lungs as seen in ARDS)
ventilator bundle
elevated HOB 30-45 interrupt sedation each day to assess readiness to wean provide DVT prophylaxis and PUD prophylaxis
assist control ventilation
every breath is supported to fully support a patient breathing such as when first intubated or when patient is too weak to perform the work of spontaneous breathing (overdose, post op anesthesia)
epidural hematoma
fast, arterial bleed CT has a clean line Pt nonresponsive -> lucid -> back to nonresponsive
FIO2
fraction of inspired oxygen; the concentration of oxygen in the air we breathe
respiratory alkalosis
pH greater than 7.45, CO2 low -anxiety, hyperventilation, palpitations -lightheadedness, confusion, HA, blurred vision
Synchronized Intermittent Mandatory Ventilation (SIMV)
guarantees a set rate of breaths, but the patient can breathe above the set rate (not supported) often used as a weaning move
E-equipment
high or low pressure alarm disconnect the ventilator and attach BVM
P-pneumothorax
high pressure alarm US or CXray to rule out pneumo
O-obstruction
high pressure alarm check all tubing, suction deep into ETT
2 liters
how many liters of blood may be lost from a pelvic fracture
LMNOP assessment
labs, monitor patient, nasogastric/orogastric tube, oxygen titration, pain assessment
pulmonary injury
leading cause of death in first 24 hours post burn
GCS
looks at eye opening, verbal, and motor response 3:completely unresponsive less than 8, intubate
D-dislodged or displaced ETT
low pressure alarm check connections, confirm tube placement
Peak Inspiratory Pressure (PIP)
maximum pressure that occurs during inspiration -amount of pressure necessary to ventilate patient
infection
most common cause of death after first 7 days post burn