Critical Care Exam 3

When do pts transission to subq insulin therapy from IV?

- Blood glucose <200 - two criteria met of: - ph >7.30 - HCO3 - >15 - anion gap < or = 12

DKA vs. HHS -

- Blood sugar of HHS is higher than DKA (HHS BS can be over 1000) - normal arterial blood gases in HHS - more electrolyte imbalances in HHS - higher serum osmolarity than DKA - ketosis is abesent

Diagnosis of Thyroid storm -

- Elevated T3 and T4 Elevated T3 resin intake Lowered thyroid-stimulating hormone Electrolyte imbalances

Causes of Myzedema coma -

- Hashimotos - treatment of graves disease with inadequate follow up treatment - hypothalamus or pituitary disease - exacerbation of hypothyroid state

DI causes -

- genetics, -head trauma, -neurological abnormalities, - increased ICP, -pituitary surgery, - chronic renal disease, -multisystem disorders affecting the kidney (multiple myeloma, sickle cell, and CF

counterregulatory hormones -

- glucagon - corisol - catecholamines - growth hormone

what type of hormonal replacement meds?

- hydrocortisone (glucocorticoid) - Fludrocortisone (mineralocorticoid)

primary mechanisms that result in adrenal insufficiency-

- inadequate cortisol and aldosterone - autoimmune (addisons) - hemorrhagic destruction - infiltration - infection/sepsis - meds - TB - HIV

DKA: Patho -

- insulin deficiency - increase in counterregulatory hormones

Secondary prevention -

- seatbelt - airbags - car seats - helmets

secondary mechanisms that cause adrenal insufficiency

- withdrawal from long-term steroid use - pituitary and hypothalamus disorders - systemic inflammatory response - inadequate steroids in highly stressed pt who has received chronic steroid therapy

Keep potassium between -

-4-5

Meds for thyroid storm -

-o Inhibit thyroid hormone production and CV effects o Propylthiouracil (PTU) and methimazole (Tapazole) inhibit thyroid synthesis o Iodide agents retard release of hormones o Medication to block effects: beta-blockers, steroids

An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? (Points : 1) Level I Level II Level III Level IV

A

An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.)(Points : 1) involves a joint. involves the face, hands, or feet. is infected. requires more than 2 weeks for healing

ABD

Question 9 of 10What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.) (Points : 1) Altered sleep/rest patterns Eating disorder Exposure to influenza High levels of stress Lack of financial resources

ABDE

Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.) (Points : 1) Heredity Medications, including phenytoin (Dilantin) and lithium carbonate Meningitis Pituitary tumors Sickle cell disease

ABE

The patient is diagnosed with hepatitis. In caring for this patient, the nurse should: (Points : 1) administer antiinflammatory medications. provide rest, nutrition, and antiemetics if needed. provide antianxiety medications freely to decrease agitation. instruct the patient to take over-the-counter antiinflammatory medications at home.

B

o Blast Trauma

Blunt and penetrating trauma Tissue and organ injury • Gas containing organ injury(eardrums, lungs, intestine)

What is the most efficient way to test blood sugar hourly

Finger prick

Which kind of insulin can be put into an IV?

Regular only

o Mechanisms of Injury

how a traumatic event occurred, the injuring agent, and information about the type and amount of energy exchanged during the event

leading cause of death in teens -

- MVA

The nurse is caring for a patient with severe pancreatitis and who is orally intubated and on mechanical ventilation. The patient's calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and: (Points : 1) places the patient on seizure precautions expects that the provider will come and remove the endotracheal tube. withhold any further calcium treatments. place an oral airway at the bedside.

A 9-10 calcium

Which of the following pts would require greater amounts of fluid resucitation to prevent acute kidney injury associated with rhabodomyolosis? A. Crush injury to right arm B. Gunshot wound to the abdomen C. Lightining strike of the left arm and chest D. pulmonary contusion and rib fracture

AC

Which of the following infection control strategies should the nurse implement ro descrease the risk of infection in the burn patient? A. Apply topical antibacterial wound ointments/dressings B. change indewelling catheter every 7 days C. Daily assess the need for Central IV catherters D. restrict family visitation E. Maintain strict aseptic technique during burn wound management -

ACD

Question 2 of 10Fluid resuscitation is an important component of managing the trauma patient. Which of the following statements are true regarding the care of a trauma patient? (Select all that apply.) (Points : 1) 5% Dextrose is recommended for rapid crystalloid infusion. IV fluids may need to be warmed to prevent hypothermia. Massive transfusions should be avoided to improve patient outcomes. Only fully cross-matched blood products are administered.

BC

It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) (Points : 1) ARDS Coagulopathies Dysrhythmias Myocardial dysfunction

BCD

An 72-year-old patient is admitted after being found unresponsive by a caregiver. The following laboratory findings are reported: glucose 628 mg/dL; BUN 62 mg/dL; creatinine 3.8 mg/dL; sodium 130 mEq/L; potassium 3.1 mEq/L; pH 7.2; CO2 28 mm Hg; HCO3 8 mEq/L; anion gap 18 mEq/L. These findings are consistent with which of the following? • Adrenal crisis • Diabetes insipidus • Diabetic ketoacidosis • Hyperosmolar hyperglycemic state

C

Question 1 of 10The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, "What causes this? Why does it hurt so much?" The nurse should answer: (Points : 1) "Pancreatitis is extremely rare and no one knows why it causes pain." "Pancreatitis is caused by diabetes; you should be checked." "Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain." "The pain is localized to the pancreas. Fortunately, it will not affect anything else."

C

• Why is dexamethasone given as emergency treatment during a cosyntropin test? o To reduce cerebral edema o To treat an allergic reaction o Its administration will not alter the test results o It enhances effect of cosyntropin.

C

o Primary Survey

Done in 1 to 2 minutes • Airway patency (with C-spine immobile) • Breathing effectiveness • Circulation, including hemorrhage and pulses • Disability (overview of neurological status) • Expose the patient, remove clothing, warm patient and trauma room Identify life-threatening injuries accurately to establish priorities

Trauma team -

Emergency medical services (EMS) response team • • Trauma surgeon (team leader) • • Emergency physician • • Anesthesiologist • • Trauma nurse team leader • • Trauma resuscitation nurse • • Trauma scribe • • Laboratory phlebotomist • • Radiologic technologist • • Respiratory therapist • • Social worker/pastoral services • • Hospital security officer • • Physician specialists

o Prehospital Care/Transport

Emergency stabilization and quick transport ABCs (with cervical stabilization) IV access and fluid administration Hemorrhage control Fracture stabilization

What factors predispose the patient to hypothermia

Environemental factors (weather, wet), age (young and old increase inability to maintain body heat

Trauma triage -

Essential for determining if patient needs to be transferred to a Level I trauma center

Level III -

Ex. community hospital where no level I or level II exists •Provides prompt immediate emergency care and stabilization of patient with transfer to a higher level of care •Serves a community that does not have immediate access to a Level I or II center

Level IV -

Ex.provides advanced trauma life support (ATLS) and transfer •Provides advanced trauma life support prior to transfer •Primary goal is to resuscitate and stabilize the patient and arrange for immediate transfer to a higher level of care

o Penetrating Trauma

Impalement of foreign objects into the body Stab wounds are low-velocity injuries • Medium velocity: handguns, some rifles • High velocity: assault and hunting rifles • Velocity and missile (bullet) determine tissue damage • Cavitation

o Resuscitation phase

Time from injury to stabilization Focus: establishing effective circulatory volume ABCDE's

Why is the insulin drip decreased when the blood sugar reaches 250 mg/dL?

To prevent development of cerebral edema, which can be promoted by rapid declines in glucose.

SIADH -

excess ADH and plasma hypotonicity

Which of the following factors increase the burn pts risk for venous thromboembolism? A. Burn injury less than 10% B. Bedrest C. burns to lower extremities D. electrical burn injury E. delayed fluid resuscitation

- BCE

Myxedema coma: patho

- Hypofunction of thyroid Hypometabolism and hypodynamic state

Interventions for adrenal insufficiency -

- correct fluid and electrolyte imbalance with D50 and NS - hormonal replacement - patient or family education

Primary prevention for trauma -

- driving safety classes - speed limits - compaigns to not drink and drive

tertiery -

- maximize patient outcomes after a traumatic event through emergency response systems, medical care, and rehabilitation

A 20-year-old female with a history of type 1diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose648 mg/dL pH6.88 PaCO220 mm Hg PaO295 mm Hg HCO3- undetectable Anion gap>31 Na+127 mEq/L K+ 3.5 mEq/L Creatinine1.8 mg/dLAfter the patient's airway and ventilation have been established, the next priority for this patient is: (Points : 1) administration of a 1-L normal saline fluid bolus. administration of 0.1 unit of regular insulin IV push followed by an insulin infusion. administration of 20 mEq KCl in 100 mL. IV push administration of 1 amp of sodium bicarbonate.

A

DI -

deficiency in synthesis or release of antidiuretic hormone (ADH) which is produced from the posterior pituitary gland that results in EXCESSIVE WATER LOSS

Blood sugar is 40, what do you do?

give d50 and check labs.

normal ICP - normal CPP -

- 0-15 - >70

If lavage is ordered...

- 1000-2000 ml of room temperature normal saline is instilled cia NG tube and is gently removed by intermittent suction or gravity

normal portal venous pressure -

- 2-6

residual greater than what is a concern?

- 200-250 ml - order a promotility agent

Feeding tubes are flushed with - when?

- 30 ml of water every 4 hours during continuous feedings - before and after feedings -before and after meds

Parkland formula for volume of IV fluid to be infused -

- 4mlxkgx%TBSA

If GRV is greater than

- 500, feedings should be held and pt assessed for other signs of intolerance

cardiovascular stability: MAP -

- 85-90 - maintain spinal cord perfusion

percentage for adult: head - arms (each) - genitalia - hands - legs (each) - back -

- 9% - 9% - 1% - 1% - 18% - 18%

High voltage - low - AC has a higher probability to do what?

- >1000 <1000 - to produce cardiac arrest

prevention part of ICU bundle of care -

- Antacids or H2 receptor blocker meds

chapter 17: GI GI bleeding assessment -

- BLOOD LOSS: - Vital signs - LOC - urine output - then to: hyperactive bowel sounds - distended abdomen

Indications of abnormal ICP and CPP -

- GCS 3-8 -

Treatment for Upper GI bleeds -

- Gastric lavage: - or it can be done prior to endoscopy to provide better visualization of gastric fundus.

medications -

- Glucocorticoids - high dose - vasopressors/fluids - proton pump inhibitors - IV fluids

types of spinal cord stabilization -

- Halo vest - surgical intervention with plates, rods, etc.

causes of HHS -

- Inadequate insulin secretion, usually type 2 DM - geriatric pt with decreased compensatory mechanisms - stress response

Thyroid storm assessment -

- Increased cardiac workload Increased oxygen demands and alterations in respirations Severe fever Fear, delirium, overt psychosis, convulsions, stupor, or coma Fatigue Nausea, vomiting, diarrhea, and cramps

• Electrolyte replacement (DKA and HHS

- K - phopherous - Mg - Monitor ECG

indications for lung transplants -

- LAS score is used to detmine recipient priority

Neuro - renal -

- LOC - urine output

Neuro - Renal - GI -

- LOC - urine output - occult bleeding

equation for CPP -

- MAP-ICP

Pharmacological therapy for surgical therapies -

- PPI - Antacids - H2 receptor blockers - mucosal barrier enhancers - Antibiotics

nursing interventions in resuscitative phase -

- Stop the burning process Identify life-threatening injuries ABCs and cervical spine Oxygen at 100%; intubation if needed Assess circulation Assess for additional trauma Minimize time on the scene

Causes of acute adrenal insufficiency -

- abrupt withdrawal of corticostroid therapy (most common) - pituitary and hypothalamic disprders - sepsis

Hands and feet or major joints - genitalia -

- adequate circulation, maintain function - meticulous would care to prevent infection

risk factors for chronic rejection -

- advanced donor age - young recipient age - black race - presensitization - hypertension - hyperlipidemia

psychosocial effects -

- affects whole family - long term effects - consider: - preinjury personality - extent of injury - social support system - home environment

4. Nursing management of patients with a spinal cord injury.

- airway management - cardiovascular stability - DVT prophylaxis - Gastric decompression - skin care - elimination - spinal cord stabilization - medications

three categories of chemical agents -

- alkalies -acids - organic compound

Challenges of pain control in burn patients -

- always give pain meds before procedures - adequate pain scale - opiates - PCA pumps may help -

5. Root cause of increase ICP

- any patient who has sustained an injury to the central nervous system - when there is an increase in brain volume, blood or CSF fluid = ICP increase

o Mallory-Weiss Tear What is it? what happens? caused from?

- arterial hemorrhage - forceful retching - long-term NSAIDS - excessive alcohol

Psychosocial -

- assess response to injury - pain assessment

Interventions during transition?

- basal/bolus insulin preferred - administer subq priopr to d/cing IV - monitor q 6-8 hours - unless NPO, then every 6

Chapter 13: Neuro clinical manifestations with basilar skull fractures -

- battle sign (ear) - raccoon eyes - dural tears (CSF drainage from nose, ear,) - Halo sign on CSF - red in middle

liver secretory function -

- bile production - bilirubin metabolism - coagulation of bile - secretion of bile

storage function -

- blood glucose - vitamine DAKE B12 - fat

Liver vascular functions -

- blood storage - filtration

Chapter 18: endocrine: Target glucose -

- book - 140-180; powers likes 120.

types of inhalation injury: exposure to toxic gases -

- carbon monoxide - tissue hypoxia by binding to hemoglobin - cyanide poisoning - inhibits cell metabolism and utilization of o2

Acids -

- cause coagulation necrosis of tissue and percipitation of protein. - hydrofluoric acid is lethal by binding to calcium in blood

Subglottic: inhalation injury below the glottis -

- chemical injury - erythema, hypersecretion, edema, ulceration of mucosa, increased blood flow and spams of bronchi

Types of pain during recovery for burn pts

- constant background or resting pain - excruciating pain with activity or therapeutic procedures

acute pancreatitis: nursing care priorities -

- control pain, promote comfort - prevent and treat shock - maintain nutrition - prevent or minimize complications

maintenance therapy =

- corticosteroids - calcinerurin inhibitors - antimetabolites

patho of peptic ulcer -

- crater surrounded by acutely or chornically inflammed cells - over time its replaced by necrotic tissue, then granulation then scar tissue

thermal injury -

- damaged by flame, scalding liquids and heat source.

stress ulcer: Ischemic: what is it? caused by -

- decreased blood flow -hemorrhage - trauma - burns (curlings ulcers)

Cushings: what is it - caused by -

- decreased blood flow and hypersecretion of acid - head trauma

early enteral feeding withinthe first 24 hours -

- decreases production of catabolic hormones - improves nitrogen balance - reduces wound infection rate - maintains gut integrity - lowers the incidence of diarrhea - decreases duration of hospital stay

signs of DKA -

- dehydration signs - orthostasis - three p's - hyperventilation - fruity breath - flushed/dry skin - lethargy/LOC change - abdominal pain - nausea - vomiting - blood glucose greater than 250 - ketonuria/glucosuria - weight loss - metabolic acidosis

third degree (full thickness) -

- destruction of all layers down to or past fat, fascia, muscle or bone - thick dry leathery appearnce - insensate (no pain)

candidate criteria for kidney -

- dialysis dependent - GFR <20 ml/min not on dialysis

Skin -

- document extent of injury - measure severity of burn

cause of peptic ulcer -

- duodenal and gastric ulcers. - these are also the most common cause of upper GI bleeds

why is there an increased risk for malignancies among transplant recipients -

- effects of medications at the cellular level

complications we can prevent

- enteral tube obstruction - aspiration and improper tube placement - diarrhea - dumping syndrome - hyperglycemia - electrolye imbalance

superficial partial thickness -

- epidermis and limited portion of the dermis - heals in 7-10 days

Second degree (partial thickness)

- epidermis and most of dermis

First degree burn (superficial) -

- epidermis only - heals in 3-5 days without treatment - erythema - not calculated for fluid resuscitation

LAS score for lung

- estimates chance of first-year survival

candidate criteria for lung-

- failed medical/surgical therapies - expected survivial less than 24 months

Phases of burns: Resuscitative (emergent)-

- first 48 hours - ABC;s - includes prehospital time - fluid management to prevent shock

what to do with these complications: enteral tube obstruction - improper tuve placement - aspiration - diarrhea - dumping syndrome -

- flush - verify w/ xray, gag reflex, cough reflex, sedation if intubated. - mark tube at nose, GRV, HOB 30-45, abdominal girth, bowel sounds - C. diff, meds - slow rate and frequency of bolus feedings if abominal distention or cramping

Priority treatment -

- hemodynamic stabilization: - O2 administration - arterial pressure monitoring - administration of fluids or blood - hematocrit may not reflect actual blood loss

electrical injuries -

- high vs low voltage - energy is converted into heat - AC vs DC

Meds that ots are on after transplant -

- immunosuppressents to decrease risk for rejection

Thyroid storm (medical emergency) -

- inadequatelly controlled hyperthyroidism - produced hyperdynamic and hypermetabolic state

Causes of DKA -

- initial presentation of type 1 DM - infections - insufficient insulin relative to need - severe stress - trauma, sugery, MI - Pregnancy with type 1 - Missed or reduced insulin - nonadherance to insulin - intentional - due to eating disorders and behavioral health issues. - medications like glucocorticoids

the feedings can also be adminstered..... in which the amount prescribed in infused via...

- intermittently - gravity administration ordered at intervals per patients needs

Drugs and enteral feedings: what has preference?

- liquid formulation

Donor criteria -

- living or deceased - paired exchange

Target cells for immunosuppression -

- lymphocytes - marcophages - dendritic cells - monocytes

Fluid guidelines - inhalation - electrical -

- maintain urine output to 30-50 ml/hour - place IV in nonburned areas - hold colloids for 8-12 hours after injury - inhalation typically need more resuscitation fluids - electrical urine output - 75-100 - because you need more fluids because risk for rhabdomylosis and myoglobinuria

Interventions for DKA and HHS -

- manage airway - fluid replacement first using 0.9 NS, then 0.45. - dextrose added when glucose approaches 200 - monitor for fluid overload

metabolic functions -

- metabolism of carbs, proteins and fats - synthesis of prothrombin

Chronic rejection -

- months to years after transplantation - progressive form on immunological injury to the allograft vasculature -

signs of feeding intolerance -

- nausea - vomiting - absent bowel sounds - abdominal distention - crampong

Hepatitis management -

- no definitive treatment - rest - nutritional support - prevention of spread of virus - antiemetics - avoidance of alcohol

cardiovascular -

- o Maintain fluid requirement o Monitor intake and output o Monitor weight

Examples of PPI -

- omeprozole - lansoprazole - esomeprazole - raveprazole

Acute phase -

- onset of diuresis to would closure - 48-72 hours post injury until wounds close - can last for weeks or months

o Esophageal Varices: caused by - common sites -

- portal hypertension - esophagus and upper portion of stomach

Ears - eyes -

- prevent infection and breakdown - keep moist, consult

goals for zones of injury -

- prevent secondary insults

Acute phase: focus of interventions -

- promote wound healing - prevent complications - improve functions of body systems

levels of trauma care: Level I -

- provides comprehensive trauma care - Regional resource center that provides leadership in education, research and systems planning - Providers immediately available, including trauma surgeon, anesthesiologist, physician specialists, and nurses Ex. OSU

organ recovery -

- pt identification - operating room - ongoing monitoring of vitals and mechanical support to ensure hemodynamic stability - OPO coordinator communicates with donor family, nurses, and physcians once organs are recovered

DCD cases -

- pt. transferred to OR where life-sustaining measures withdrawn, pronounced dead, organ recovery

Point system for kidenys -

- ranks candidates - ABO typing, time on wait list, HLA - high level of PLA antibodies

Meds in enteral: biovailability is -

- reduced for some like phenytoin when administer in the tube. - may require temporary discontinuation before and after med administration

transphenoidal hypophysectomy

- removal of pituitary gland - this produced TSH so this is why above answer is true

Postop care/monitoring -

- respiratory status - hemodynamic status - fluid balance - electrolyte balance - weigjt

Two situations where you always intubate at the scene?

- respiratory stridor - patients with severe facial burns

CSW interventions -

- restore sodium and fluid volume with isotonic or hypertonic 3% saline - Fludrocortisone

Rehabilitative phase -

- restore to functional status - minimize scarring and contractures - psychosocial

Complications of tube feeding -

- risk of refeeding syndrome - risk for diabetes or glucose intolerance - monitor liver function for parenteral support

treatments for specific burn areas: facial burns -

- risk of respiratory inkiry - oral hygiene - promote healing

acute phase assessment: respiratory -

- signs of pneumonia and ARDS - chest x-rays - fever - secretions - WBC counts

HHS assessment -

- similar to DKA - three p's - nausea - vomiting - dehydartion and hypovolemia - decreased LOC

Peptic ulcer disease: risk factors -

- smoking - H. pylori bacteria - NSAIDS - aminosalicyclic acid - steroids - alcohol

what electrolytes do you monitor?

- sodium - potassium - blood urea nitrogen - glucose - lactate

Treatment of Hypovolemia

- stop the bleeding - two large bore IV - intraosseous IV - central line - lactacted ringers - blood adminstration

What meds are not crushed and given via ET tube?

- sustained- release. may cause overdose

Trimodel distribution of death - occurs in one of the three periods -

- the first peak of death occurs within seconds to minutes from time of injury (only prevention stops this peak) - the second occurs within minutes to several hours of injury (golden hour can help) - the third peak occurs several days to weeks after the initial injury.

Methamphetamine-related chemical burn injury: type of burn? assess for -

- thermal and chemical - a vague or incosistent injury history - burns to face and hands - signs of substance withdrawel or agitation.

Supraglottic: inhalation above the glottis -

- thermal injury - occurs in pharnyx and larynx - airway obstruction

medications that affect blood glucose levels

- thiazides (dilantin) - phenytoin - glucocorticoids - beta-blockers - calcium channel blockers - enteral and parenteral nutrition

causes of SIADH -

- trauma - tumor - small cell lung carcinoma - Hodkins lymphoma - pancreatic and duodenal carcinoma - TB - lung abcess - pneumonia - COPD - meds

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- triple therapy of: - calcineurin inhibitor - corticosteroid - antimetabolite

Factors of extent of electrical injuries -

- type and path of current - duration of contact - environmental (lightning strikes that cause cardiac arrest) - tissue resistance

Thermal methods of endoscopic

- use of the heater probe, - laser photocoagulation - electrocoagulation to tamponade the vessel

Hyperacute rejection

- usually occurs within hours or days of implantation - symptoms related to the organ transplanted

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- vital signs - pulses - urine output - pulse ox - hemodynamic monitoring with central venous line and PAC - Gastric pH - prevent hypothermia - VTE prophlaxis - maintain joint function and mobility

Material safety data sheets -

- website to help know what to do with each chemica

alkalies -

- worse than acids - bind to tissue proteins and make it more difficult to stop burning process

Donor criteria for lung -

- younger than 55 - fewer than 2 pacls/year smoking history

things that produce pain in patients with burns -

- • Burn wound care • Ambulation • Physical/occupational therapy • Suctioning • Turning

HHS patho -

- • Hyperglycemia, Hyperosmolar and severe dehydration secondary to osmotic diuresis • Decreased use of glucose and/or increased production • Hyperglycemia; increased extracellular osmolality • Osmotic diuresis • Profound dehydration • No ketoacidosis

Other interventions for thyroid storm -

- • Monitor cardiovascular status • Monitor and treat hyperthermia • Promote oxygenation • Fluid replacement • Adequate nutrition • Prevent injury • Patient and family education

Level II -

-Provides comprehensive trauma care as a supplement to a Level I center •Meets the same provider expectations for care as a Level I center •Is not required to participate in education and research Ex. provides care for trauma pts and transfer to level I if needed

signs of pneumonia -

-Tachypnea, - abnormal breath sounds, - fever, - increased white blood cell count, - purulent secretions, -infiltrations on chest x-ray films

Complications to TPN -

-a. Infection (sepsis) b. Electrolyte imbalances c. Fluid imbalances d. Hyperglycemia

Chapter 6: Nutrition EN in critical care is typically administer -

-continuously via a feeding pump

Deep partial thickness -

-epidermis and most of dermis - heals within 2-4 weels

Organic compounds -

-phenols and petroleum - cause coagulation necorisis of dermal proteins and produce a layer of thick, nonviable tissue - causes CNS depression.

Tolerance of feedings includes -

-presence of bowel sounds in four quadrants - the presence of bowel motility - bowel movements - palpation of a soft abdomen - percussion of the abdomen being tympany

b. Increased Intracranial Pressure Diagnostic Tests: Blood/urine -

1. ABGs 2. CBC 3. Coagulation profile 4. Electrolytes 5. Serum osmolality 6. Urinalysis and osmolality

ii. Radiographic/Other

1. Computed tomography (CT) of the head 2. Magnetic resonance imaging (MRI) 3. Cerebral blood flow with transcranial doppler 4. Evoked potentials 5. EEG 6. Angiography

how much do you flush if on a fluid restriction?

15 ml

The liver recieves ___ of cardiac output

25%

Trauma patients are at high risk for multiple complications not only due to the mechanism of injury but also due to the patients' long-term management. Which of the following statements apply to trauma patients? (Select all that apply.)(Points : 1) Indwelling urinary catheters are a source of infection. Patients often develop infection and sepsis secondary to central line catheters. Pneumonia is often an adverse outcome of mechanical ventilation. Wounds require sterile dressings to prevent infection

ABC

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) (Points : 1) Additional pain medication may be needed because of rapid body metabolism Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. Patients with a history of drug and alcohol abuse will require higher doses of pain medication. The intramuscular route is preferred for pain medication administration

ABC

When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? (Select all that apply.) (Points : 1) Severity of blood loss Hemodynamic stability Vital signs every 30 minutes Signs of hypervolemic shock Necessity for fluid resuscitation

ABE

The family of a critically ill patient has asked to discuss organ donation with the patient's nurse. When preparing to answer the family's questions, the nurse understands which concern(s) most often influence a family's decision to donate? (Select all that apply.) (Points : 1) Donor disfigurement influences on funeral care Fear of inferior medical care provided to donor Age and location of all possible organ recipients Concern that donated organs will not be used Fear that the potential donor may not be deceased Concern over financial costs associated with donation

ABEF

Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.) (Points : 1) Administer levothyroxine (Synthroid) as ordered. Encourage the intake of foods high in sodium. Initiate passive rewarming interventions Monitor airway and respiratory effort. Monitor urine osmolality

ADE

o Massive Fluid Resuscitation

Administration greater than 10 units of packed red blood cells (RBCs) in 24 hours Or replacement of patient's total blood volume in 24 hours

Immunosuppressant medication side effects

Anemia - Impaired wound healing Hyperlipidema - Hyperuricemia Hypertension - Hyperkalemia Bone disease - Hypomagnesemia Nephrotoxicity - Infection Nuerotoxicity - Malignancy Glucose intolerance Nausea

• How to connect the patient to monitor

Assess the pt first, make sure they are alive, breathing, connect the pt from their portable monitor to your monitor, then do a more thorough assessment, like VS. correct IV.

o A 54-year-old male was working on his car and the carburetor exploded. He presents with singed nose hairs and red, painful blisters on his face and bilateral forearms and hands. What type and depth of burn injury do you suspect? Inhalation injury below the glottis with superficial burns Inhalation injury above the glottis with superficial partial-thickness burns Deep partial-thickness burns and carbon monoxide poisoning o Full-thickness burns and inhalation injury above the glottis

B

o The post anesthesia care nurse is caring for a renal transplant recipient who received anti thymocyte globulin intraoperatively. The nurse assesses the patient to be experiencing chills, a headache, and a temperature of 100.5° F. What is the best interpretation of these findings by the nurse? o Anaphylactic reaction o Expected side effects o Early graft rejection o Postoperative infection

B

The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient's care to prevent stress ulcers, the nurse would provide: (Select all that apply.) (Points : 1) vagal stimulation proton pump inhibitors. anticholinergic drugs antacids. cholinergic drugs.

BCD

Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following? (Select all that apply.) (Points : 1) Obstructed portal circulation Dilated vessels Tortuous vessels Constricted vessels Presence of an abscess

BCD

o What is an appropriate intervention in the prehospital setting in the management of an unconscious patient who was pulled from a house fire. His vital signs are BP 100/82 mm Hg, HR 122 beats/min, RR 26 breaths/min, SpO2 100%. Monitor vital signs every 15 minutes. Cover the patient with warm blankets. Apply 100% humidified oxygen. Place the patient in a side lying position.

C

• Pt fell out of tree, what do you do first?

C-spine precaution

o Myxedema Coma: Assessment

Cognitive changes Activity intolerance, decreased reflexes, and slow movements o Bradycardia, hypotension o Cardiomegaly o Decreased cardiac output o Electrocardiogram (ECG) changes o Edema - hypoventilation - Co2 retention - pleural effusion - upper airway and tongue edema - hypothermia

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Coma: patient unresponsive to noxious stimuli in absence of CNS depressants and neuromus. blockades Absence of brainstem reflexes (pupils fixed and dilated & absence of ocular movements / corneal reflex / facial grimacing w pressure on temporomandibular joint or supraorbital ridge) Apnea: absence of autonomic respirations tested w CO2 challenge (document h in PaCO2 levels)

What would happen to a burn patient, psychologically

Depression, PTSD, suicidal

Why is it important to start IV lines immediately

Effective fluid resuscitation is essential to burn patient survival and thus is started immediately.

o Prerequisites for the clinical evaluation

Establish irreversible coma and cause of coma (excludes effects of CNS depression medications) Achieve normal core temperature (warming blanket) Achieve normal systolic blood pressure (vasopressors) Perform neurological exam

Clues that it is a thermal injury to the airway?

Facial swelling, soot singed nose hairs

criteria for brain death -

Flat EEG, no reflexes, no breathing

Effects of aging on skin -

Flattened dermal-epidermal junction Dermal and subcutaneous atrophy Reduced microcirculation Consequence is thinned skin, predisposition to deeper burns, and delayed or poor healing Complicated by decreased ability to tolerate burn stress

o Burns of the Eyes

Immediate examination of the eyes is necessary because eyelid edema forms rapidly; eyelid edema can cause the cornea to become exposed as the eyelid retracts. - eye drops - watch eyelashes

If a pt is so dehydrated and you are having trouble getting Iv in ?

Intraosseous

Goals for donor management process?

Make sure their hemodynamic is stable, maintain HR, BP, perfusion, make sure labs are normal.

o Why are nasal tubes avoided in pts with maxillofacial trauma or basilar skull fractures?

May cause further tissue/bone structure injury. The tube may also penetrate the brain.

• How do you put in an NG tube?

Measure, lean head forward, insert in, chest x-ray, residual

Severe burn patient, can smell the burn on his breath, facial burn with hand and patient telling me he was trying to burn things and he started going crazy

Meth, on drugs

o Focused Assessment with Sonography for Trauma (FAST) -

Noninvasive Determines potential sources of bleeding • Peritoneal cavity • Pericardial sac

o Secondary Survey

Performed after life-threatening injuries are identified and treated Examination of all body systems: • Full set of vital signs; focused interventions, family presence • Give comfort measures • History and more thorough head-to-toe assessment • Inspect posterior surfaces Maintain C-spine immobilization until cleared by x-ray X-ray studies (as determined by injury) Laboratory studies Tetanus toxoid administration - give this every ten years. Specialty physician consults

Function of skin -

Protection from infection Prevention of loss of body fluids Thermoregulation Production of vitamin D Excretion Determination of identity Sensation reception

Which heart transplant patient being cared for in the ICU is exhibiting signs of acute rejection?

Pt with PAOP of 36 mmHg

• Which traumatic chest injury is most likely to result in patient death?

Pulmonary contusion

o Response to Treatment

Rapid responders Transient responders Minimal or no responders

Color coded hospital things: Red - yellow - green - black -

Red indicates emergent, life-threatening injuries o •Yellow is urgent major illness requiring care within an hour o •Green indicates non-urgent patient who can self-treat within 3 hours o •Black signifies the patient is dead or near death.

priority of care is resuscitation phase

Remove the patient from thermal source Cover and prevent hypothermia Remove jewelry, belts, clothing that may retain heat Scalds, tar, asphalt burns: cool with water Large-bore IV catheters and fluids Pain management with narcotics Vital signs and baseline assessment

o Endoscopic Treatment

Sclerotherapy Thermal methods Band ligation (varices)

Prioritize the burn process prehospital wise

Stop the burn, assist ABC's, give them o2 if needed, head to toe assessment.

CSW assessment -

Tachycardia Weight loss Hypotension Dry mucous membranes; poor skin turgor Lethargy and weakness Mental status changes Seizures and coma Sodium (serum) - <135 Osmolality (serum) - >295 Osmolality (urine) - <100 Sodium (urine) - >200

o Ongoing Signs and Symptoms of Shock

Tachycardia, tachypnea Narrowing pulse pressure Falling PaO2 Decreasing urine output Increased serum lactate levels Falling hematocrit

o Newer Technologies

Technologies that can be used to assess tissue perfusion Sublingual capnometry Near-infrared spectroscopy (NIRS) • StO2 ≤ 80% indicates shock

response of the immune system to a newly transplanted organ

The donor graft antigens alert the antigen-presenting cells (APC) that nonself tissue is present. The APC sends a message to the CD4+ helper cell to activate an immune response with cytotoxic T cells attacking the newly transplanted organ.

o Myxedema: Interventions

Treat with replacement thyroid hormone Fluid and electrolyte replacement; thyroid replacement usually corrects sodium Monitor gas exchange and respiratory status Monitor cardiovascular status Manage hypothermia Protect from injury and infection Educate patient and family

o Burn Classification and Severity

Type of burn injury Burn wound characteristics burned Concomitant injuries Patient age Pre-existing health status

o Zones of Injury

Zone of hyperemia • Minimal injury Zone of stasis • Potentially reversible damage Zone of coagulation • Greatest injury

The following findings are reported on a patient who suffered a traumatic brain injury: serum Na+ 120 mEq/L; BUN 34 mg/dL; creatinine 1.1 mg/dL; urine sodium 60 mmol/L; urine output 175 mL/hr; pulse 112 beats/min; BP 96/58 mm Hg; dry mucous membranes. These findings are consistent with: A) Cerebral salt wasting B) Diabetes insipidus C) Diabetic ketoacidosis D) SIADH

a

• A patient who has previously undergone a transphenoidal hypophysectomy has been nonadherent with hormone replacement therapies. Which of the following lab findings would be consistent with this patient's history? o A) Decreased T3, T4; decreased TSH o B) Decreased T3, T4; increased TSH o C) Decreased cortisol; increased ACTH o D) Increased cortisol; decreased ACTH

a

Near-infrared spectroscopy (NIRS)

a continuous noninvasive technology that uses principles of light transmission to measure skeletal muscle oxygenation as an indicator of shock.

o What strategy is helpful for promoting nutrition in the patient with thyroid storm? Provide high-calorie, high-protein oral diet ) Insert feeding tube for enteral nutrition Start TPN via central catheter. Provide Ensure or Boost supplements if the patient will not eat.

a(because the storm makes excessive caloric expenditures and muscle wasting

3. Nursing management for CSF drainage

a. ATB b. Corticosteroids c. Droplet precautions (private room, dim light) d. Monitor for h ICP e. Seizure precautions f. Steroids administration / protocols

how to insert tube feed

a. Get prealbumin b. Insert tube c. Chest x-ray for placement d. Flush tube to verify patency e. Initiate tube feeds f. Check residuals 2 hours after feeding initiation

2. Management

a. Reduce ICP, neuro assessment, Glasgow coma scale b. Maintain airway and provide oxygenation c. Maintaining cerebral perfusion d. Preventing secondary TBI e. Therapeutic hypothermia

Calculate the volume of IV fluid needed for the first 8 hours after burn injury: 60 years old, 82 kg, 42% TBSA. • 3,444 mL • 6,888 mL • 13,776 mL • 19,456 mL

b

o Approximately how many burn injuries require acute hospitalization annually in the United States? o o 28,000 o 45,000 o 63,000 o 92,000

b

• Rib fracture, pts pressure drops and sats drop, and you can't hear lung sounds. What do you think the physician is going to do

chest tube

Lungs harvested from children/adolescents are offered to

children first

brain death -

complete irreversible cessation of function of brain and brainstem

First thing you have to do with a chemical burn is...

completely remove it or neutralize it, if you don't the damage will continue

Chemical injury: methods of injury -

contact inhalation ingestion

2. Psychosocial issues that may precipitate or accompany hyperglycemic emergencies

coping issues such as diabetes-related distress and depression. The importance of a regular eating schedule, exercise, rest, sleep, and relaxation must be emphasized.

vagotomy -

decreases acid secretion in the stomach by dividing the vagus nerve along the esophagus.

The dermatalogical structures in the skin do what

detection of pain, pressure, touch and temperature

How often is residual checked in gastric feeding tubes?

every 4 hours which is easier in large bore because small can collapse but still assessed

extent of injury -

expressed as a precentage of total body surface area (%TBSA)

Minimal or no responders

fail to respond to crystalloid and blood administration in the emergency department, and surgical intervention is needed immediately to control hemorrhage.

when is fluid resuscitation instituted?

for pts with greather than 20% TBSA

NG tubes left in place may increased -

hydrochloric acid secretion in stomach and cause increased bleeding

Patients who present to the emergency department after traumatic injury are at high risk for

hypothermia.

d. Nursing Interventions w/ Basilar skull fractures:

i. Allow CSF to flow freely - place nothing in nose or ears unless to collect drainage ii. Instruct patient not to blow their nose iii. No tubes through nose, put in mouth instead

what steroids?

i. Dexamethasone 10 mg initiated before or w first dose of ATB and then every 6 hours for 4 days

Transient responders

improve in response to the initial fluid bolus. However, these patients begin to show deterioration in perfusion when fluids are slowed to maintenance rates. This finding indicates ongoing blood loss or inadequate resuscitation. Continued fluid administration and blood transfusion are indicated. If the patient continues to respond in a transient manner, the patient is probably bleeding and requires rapid surgical intervention.

Why is pain treated with IV narcotics?

inconsistent perfusion to muscles and skin that prevents effective analgesia from meds administered IM or subq

If tracheal edema is suspeted, what is the best way to manage the airway?

intubate

Sclerotherapy

involves injecting the bleeding ulcer with a necrotizing agent

The effect of chemical injuries is both -

local and systemic

pyloroplasty -

may be performed in conjunction with a vagotomy to prevent stomach atony, a common complication of the vagotomy procedure.

Sublingual capnometry

noninvasive technology that provides information about the degree of hypovolemia and adequacy of fluid resuscitation based on the sublingual partial pressure of carbon dioxide (PCO2

• What are the component associated with high ICP?

o Brain injury and stroke o Venous stasis and abdominal injury

• Nursing intervention for a lethargic patient who respond to voice but falls asleep when not stimulated?

o Frequent neuro assessment o Position patient side to o ROM q1 hr

19. Review the necessity of enteral feeding if the patient cannot tolerate or meet caloric needs through oral intake

o Hypermetabolic-catabolic state o Consult to determine caloric needs o Early enteral nutrition warranted o Beta-blockage and anabolic hormones - small bowel is preferred over stomach because feedings can be continued during wound care, sedation and procedures

what the nurse does in the organ procurement part -

o Nurse provides info., support, clarity, and ensures families have easy access to their loved one to say good-bye

Review when donation after circulatory death is considered.

o Once family makes a decision to withdraw life support, OPO is notified o If pt. meets age and medical criteria for donation, the option to donate organs is presented by OPO to the family o Decision to withdraw life support is made first and is independent of the decision to donate o Care of the grieving family is an integral part of the donation process

Risk factors for stress-induced hyperglycemia -

o Preexisting DM (diagnosed or undiagnosed) o Comorbidities such as obesity, pancreatitis, cirrhosis, hypokalemia o Stress response release of cortisol, GH, catecholamines, glucagon, glucocorticoids, cytokines o Aging o Lack of muscular activity o Relative insulin deficiency/insulin resistance o Administration of exogenous catecholamines, glucocorticoids o Administration of dextrose solutions, nutritional support / enteral or parenteral nutrition o Medications

• Trauma care systems includes what?

o Prevention, rapid access o acute hospital care and rehab/research

• The golden hour in trauma refers to what?

o Rapid assessment, resuscitation, o treatment of life-threatening injuries

• Electrical burn injury patients are high risk for acute kidney secondary to what?

o Release of myoglobin from injured tissues

• Nursing interventions for patient's with post op lung transplantation?

o Respiratory status o Infection prevention o Hemodynamic status o Fluid and electrolytes o Pain control o Early ambulation

• Name the priority order of actions in prehospital primary survey.

o Stop the burning process, o Assess ABC's o Inhalation therapy if smoke inhalation is a culprit o Rapid head to toe assessment

why do these changes happen?

o These changes are due to a combination of both i insulin production and h insulin resistance, independent of any other coexisting disease states

Severity of injuries depends on -

o Type of agent o Volume of agent o Duration of contact o Concentration of agent

3. Know the effects of aging on pancreatic function.

pancreatic endocrine function declines o Fasting glucose levels incresase - glucose tolerance decreases

antrectomy -

performed for duodenal ulcers to decrease the acidity of the duodenum by removing the antrum, which secretes gastric acid.

No IM meds given during this phase because -

perfusion of edematous tissues is poor and produces sporadic narcotic absorption

3. Blood test as the most sensitive indicator of protein synthesis and catabolism

prealbumin

Billroth I -

procedure involves vagotomy, antrectomy, and anastomosis of the stomach to the duodenum

Billroth II -

procedure involves vagotomy, resection of the antrum, and anastomosis of the stomach to the jejunum.

Rapid responders

react quickly to the initial bolus and remain hemodynamically stable after administration of the initial fluid bolus. Fluids are then slowed to maintenance rates.

o Organ Procurement Organization

responsible for approaching family for consent o Fears and concerns about donation affect outcome for consent

what does massive fluid resuscitation do?

restore oxygen tranport to tissue stop progress of shock - prevent complications - electrolyte imbalances

Why is it important to remove all clothing and jewelry early?

retain heat

Cerebral salt wasting: result of - disorder of -

serious brain injury - sodium or fluid balance

Pt taking care of a probable organ donor - must maintain hemodynamic stability. What would happen if the ph was 7.30 and bicarb is 18, and co2 is 20, what are you going to do

start a bicarb drip after getting an order. Notify the physician.

when you use that formula,

that is how much fluid is needed in 24 hours, but you need half of the 24 hour fluid within the first 8 hours.

leading cause of death 16-54 years -

trauma

induction therapy -

upon transplantation in the OR - monoclonial antibody

Totally intravascularly resuscitated for burns

urine output

Acute rejection -

weeks to months posttransplantation - managed with increasing oral immunosuppressive meds or steroids

Causes of Mallory-Weiss tear?

• Arterial hemorrhage, forceful retching, use of asa, alcohol consumption • Excessive smoking • Venous bleeding • stroke

cardiovascualr -

• Assess for fluid volume status • Vital signs • Prevent heat loss

assessment for resuscitative phase: respiratory -

• Assess for hypoxemia • Carbon monoxide poisoning • Assess for direct injury • Maintain cervical spine precautions

Treatment of acidosis (DKA)

• Assess respiratory compensation and LOC • Usually corrected by fluids and insulin • Bicarbonate only if pH is less than 6.9 • Administered by infusion until pH is 7.0

complications of stress-induced hyperglycemia -

• Cerebral ischemia/stroke • Dehydration/osmotic diuresis • Impaired wound healing • Endothelial dysfunction/thrombosis • Decreased erythropoiesis • Impaired gastric motility

Burn wound characteristics

• Depth • Extent • Body part burned

Insulin therapy (DKA and HHS)

• Fluid replacement initiate first; monitor K+ • Loading dose (not in children) • Continuous infusion • Hourly glucose monitoring o When glucose is less than 200 mg/dL, adjust infusion to maintain values of 150 to 200mg/dL

Complications of Massive Fluid Resuscitation

• Fluid-electrolyte imbalances • Hypothermia • Coagulopathies and dysrhythmias. o Abdominal compartment syndrome o ARDS o Acute kidney injury o MODS

o Surgical Treatment for peptic ulcer disease: types -

• Gastric resection • Billroth I or II • Vagotomy • Pyloroplasty

• Medications use to treat peptic ulcer?

• H2-histamine receptor and proton pump inhibitor • Vagal stimulation and gastrinicide • Vitamin c and vit d

lab findings for adrenal insufficiency -

• Hyponatremia, hyperkalemia, and hypercalcemia o Eosinophilia o Metabolic acidosis o Hypoglycemia o Hyperuricemia • Cortisol levels - to diagnose • ACTH levels - to diagnose • Cosyntropin stimulation test - to diagnose

o Thyroid Storm: Interventions

• Inhibit thyroid hormone biosynthesis • Block thyroid hormone release • Antagonize peripheral effects of thyroid hormone • Provide supportive care • Treat precipitating cause • Educate

Labs of DKA -

• Osmotic diuresis and dehydration • Hyperlipidemia • Metabolic acidosis/ketosis • Altered potassium balance • Excess acids result in increased anion gap • Altered consciousness related to acidosis and dehydration

What nursing interventions can be done to prevent and/or treat hypothermia

• Warm trauma room • External heating device (force air warmer) • Warm fluids, especially blood products (rapid infuser)

o Blunt Trauma

Severity depends on kinetic energy dissipated to the body Common vehicular trauma, assault with blunt objects, falls, and sports Acceleration Deceleration Shearing Crushing Compression