MED SURG FINAL: exams 1, 4, 5, 6, + unit 14
isotonic solutions are the closest to Osmo of
ECF
if chest pain occurs check the
ECG
complication of sexuality with men with SCI
ED
ejection fraction formula
EF = SV/EDV (around 55-70%)
ECG
Electrocardiogram, performed within 10 minutes of arrival
MAP calc
(SBP + 2DBP)/3
closed brain injury
(blunt trauma): acceleration/deceleration injury brain tissue is damaged but there is no opening through the skull/dura
station is crowning and beginning to emerge from the birth canal
+3
station is crowning
+4
preeclampsia risk factors
- 1st time pregs - preg teens, women >40yrs - hx of HTN - hx of preeclampsia - immed family had it - obesity hx - carrying more than 1 baby hx of DM, kidney dx, lupus, or RA
initial management of pt with TBI
- ABCDE - AVPU
2nd stage progressive shock
- BP can't compensate and drops, HYPOTENSION - systolic <100 or decreased from 40 - Map <65 HR increases >150 declining mental status restlessness crackles, PE, RR increase increased CO2 --> leads to ARDS starts affecting organs edema kidney damage
treatment of hypovol shock
- NS (fluids 1st) - vasoactive drugs - check BP, get MAP over 65 - blood prods - O2 (for hemorrhage) - insulin if related to hyperglycemia - desmopressin for DI - antidiarrheals/antiemetics
management for all shock pts
- O2, pulse ox -ecg - IV access - BLS - glucose testing - nutritional support (NG/NJ or IV) - keep safe temp - tx hypotension - tx acidosis
hyperkalemia treatment
- assess ECG - insulin 100-500 mL over 10-15 mins
assessment for DIC
- assess for s/s - know conditions at risk - check for s/s of bleeding - assess IV sites Q15 mins for bleeding
spinal precautions
- assume anyone in an accident MVA, sports, diving, or fall-related is an SCI - prevent head and neck from moving - spinal backboard used - extended position - cervical collar - special rotating mattress or firm one
internal arteriovenous fistula and graft
- auscultate for bruit - palpate for thrill to check for obstructions - no BP cuff
things to monitor with epidural
- can lower moms BP - can cause late decels for FHR - tx by giving O2 2-8L , lateral left side
cardiogenic shock in peds
- caused by congenital heart defect - be careful with fluids replacement 5-10ml/kg
assessing neuro function means checking
- cerebral function - cranial nerves - motor system - sensory system - reflexes
things to maintain with a head injury
- cerebral perfusion - oxygenation - F/E balance
pre signs of labor
- cervical changes - lightening - nesting; increased energy - bloody show - braxton hicks - ROM
teach patient to monitor their skin status
- change positions every 2 hrs - skin cleaning - check bony prominences - use mirrors to check these areas - relieve pressure in wheelchair
nursing management after a PTCA
- check for bruising/bleeding - palpate site - mark area of bleeding to check for growth - hold pressure for active bleeding - atropine if pt bears down
Musckuloskeletal system assessment includes
- check for fractures - atrophy - loss of motor and sensation functions - resp distress d/t paralysis of the diaphragm, abdominal, or intercostal muscles
monitoring and managing potential complications
- check for pneumonia, aspiration, resp failure - check for depressed LOC - longer they are unconscious the greater risk of pulmonary complications - check VS, resp function closely - check skin impairment - check for VTE, DVT, PE and admin heparin - prevent contractures
temperature assessment
- check for rapid onset of fever b/c they can't sweat where they are paralyzed (hyperthemia)
communication techniques with the pt
- check for understanding of their diagnosis - ask for clarifications and allow the pt to explain - ask about values, preferences, and concerns - assess pt coping and support system - ask important questions to fam members when the pt is unable to participate in conversation
other nursing interventions for AD
- check rectum; remove mass - check skin for pressure, irritation, ulcer, loose clothing, shoes, toenails - examine for objects next to skin - check for draft a cool air
preserving corneal integrity
- clean with a cotton ball with NS - cold compress after cranial surgery - eye patches to prevent scratches - artificial teaches touch cornea with a wisp of clean cotton; if they blink the response is normal (would be absent in deep coma) - this tests cranial nerves V and VII to help determine location of the brain lesion
what are s/s of a pt at end of life
- clusters of s/s - pain (MOST FEARED) - delirium/agitation - dyspnea - weakness, fatigue - constipation - N/V - poor secretion control - nutritional probs - mottling - resp changes - decreasing LOC
C1 injury devices
- continuous ventilation - voice or sip-n puff controlled wheelchair
other reasons to go to the hospital
- decreased fetal movement - nullipara with contractions 5 mins apart over 1 hr -multipara with contractions 6-8 mins apart over 1 hr - Rupture of membranes - any vaginal bleeding, abruption, miscarriage
signs of bleeding progression
- decreased platelets - thrombosis or clotting-involved organs - clotting factors and platelets are consumed to form thrombi, then bleeding occurs
meeting family needs
- depending on prognosis fam may be unprepared for changes - help them with resources, coping skills, clarify infor - encourage them to share their feelings, be involved in their care - explain to them about brain death as it can be confusing
other nursing interventions for fetal distress
- discontinue oxytocin - high O2 mask - IV hydration - amnioinfusion - possible C section
what to assess with halo pins
- drainage: clear= ok, purulent= infection - lots of redness/swelling - warmth - excessive pain - check for loosening--> notify PCP
premature beat
- early - can be complete or incomplete - can throw off next beat - too many= arrhythmias
nursing care for all cath lab procedures
- fast 8-12 hrs - someone else must take them home - may be asked to cough and deep breath - the pt may feel palpitations as the cath tip touches the endocardium - injection of contrast dye is used - will feel flushed and may feel need to void
how to manage parent's fears
- fear of pain they may experience - extra support can be used - feelings conflicted on what's the right choice for treatment
1st stage compensatory shock
- flight of flight - normal BP - increased HR - cool/pale extremities - RR can increase - can lead to metabolic acidosis
wedge pressure how to
- get 1.5 mL syringe type to use to inflate balloon - stop cock is opened sterilly - when PA is occluded we will get a measurement of wedge pressure or preload of L ventricle of the heart - monitor for PA pressure waveform on ECG (it will change once wedged, and will change back to PA waveform after it's deflated) - stop cock stopped again
sensation assessment includes
- getting a neuro baseline - checking motor response - sensation response
nursing interventions for the stages of grief
- grieving is not a linear process - each person copes in their own way, there's no right way to cope
neurogenic shock treatment
- immobilization - fluids - vasopressors - thermoregulation
as preeclampsia worsens these are the s/s
- increasing edema on hands and face - worsening HA - epigastric pain - visual disturbances - decreased urine output - N/V - bleeding gums (low platelets)
how does a head injury result in blood flow to the brain stopping
- injury causes swelling - increases ICP - cranium is rigid, doesn't expand - causing ICP to continue - pressure on blood vessels to the brain slow d/t pressure - hypoxia and ischemia occur - brain herniates - blood flow stops
promote bowel function
- listen to bowel sounds - measure abd girth - check for fecal impaction (lots of loose stools) - admin stool softeners - glycerin suppository - routine enema
skull fracture s/s
- localized, persistent pain base of skull: - bleeding from nose, pharynx or ears - battles sign - CSF leak - also portal of infection
with spinal shock it can cause what to the bladder and GI?
- loss of bladder/bowel function - bladder distention - paralytic ileus
supportive measures for brain herniation
- maintain airway, mech vent - seizure precautions - NG to manage GI motility and prevent aspiration - F/E balance - pain/anxiety management - nutrition: SBFT
nursing care for increased ICP priority
- maintain and protect the airway - prevent secondary injury - hyperoxygenate - positioning: raise HOB - suctioning (no more than 2 passes) - oral hygiene
other nursing interventions for increased ICP
- maintain body temp - hypothermia blanket - avoid shivering (low O2 to brain) - prevent hyperthermia - admin antipyretics - maintain hydration - cool the room 65 F - minimal bedding
palliative care also includes what methods of pain control?
- moderate sedation if pt is in the ICU - holistic care (same as hospice) - may use with other treatments that are cure oriented
oliguria period (ischemic ATN)
- need 400mL of urine to be rid of waste products d/t less than 400mL or urine made in 24 hrs - non oliguric form tx by administering 100-500mL of NS
treatment for eclampsia seizures
- notify PCP - maintain ABC, IV - seizure precautions - MG sulfate - quiet environment - monitor for HELLP
nurse management for post cath lab
- observe cath site for bleeding or hematoma - eval temp, color, cap refill of affected extremity - check for arrhythmias - maintain activity restrictions for 2-6 hrs after procedure - HOB elevated more more than 30 - teach to report CP, bleeding, discomfort - monitor pt for elevated creatinine levels - monitor for ortho hypo
prevent urinary retention
- palpate and scan bladder - intermittent cath for pt not voiding - monitor Is/Os - observe caths for UTI s/s scan bladder after cath removal - condom cath for males - bladder training once conscious
maintain skin and joint integrity
- pay special attention to unconscious pts - regular position changes (turning) - don't drag or pull pt up in bed - maintain correct body position - PROM of extremities - splints and foam boots to prevent foot drop - trochanter rolls for hips - check heels of feet for pressure areas - specialty beds to decreased pressure on bony areas
restoring health maintenance
- restore the health of unconscious pt - do auditory, visual, olfactory, gustatory, tactile, and kinesthetic activities to stimulation pt - maintain night and day patterns for activity and sleep - touch and talk to pt and have fam do the same - avoid neg comments on the pts prognosis - orient pt to time and place every 8 hrs - minimize stimulation once they begin waking up - have one person speak at a time
resp assessment, check for
- secretions - if they can cough and get rid of secretions - lung sounds for pneumonia - deep breaths
s/s of abruption placentae
- severe abd pain - uterus is hard/rigid - abnormal FHR - shock symptoms
pain assessment scales
- simple descriptive pain intensity scale - 0-10 numeric scale - visual analogs scale VAS
recovery period
- takes 3-12 mons - permanent 3% reduction in GFR is normal - monitor renal function
end of life assesssment
- talk about death, how they feel - spirituality of the pt and fam - cultural beliefs, rituals
treatment of abruption placentae
- treat hemorrhagic shock if needed - VS - high flow O2 - IV NS/LR STAT delivery by C SECTION
for MG toxicity
- turn off infusion - side lying position - fetal monitoring -Ca gluconate @ bedside
cardiovascular assessment for suspected SCI involves
- using continuous ECG monitoring - b/c bradycardia and asystole commonly occurs
9 things not to say to someone with a brain injury
- you seem fine - you're lazy - you're grumpy - how many times do I have to tell you - your prob is the meds you take - let me do that for you - try to think positively -you're lucky to be alive
dysrhythmias can come from
--anywhere in the electrical conduction pathway --irritable sites in heart tissue outside the pathway --irregular/abnormal conduction pathways
station when the head is above the pelvis
-2
station when the fetal head is floating
-4
what is true about orth hypotension
-BP tends to be unstable and low the first 2 wks -BP can gradually return to normal -vasopressor meds can be used to tx vasodilation
TAH (total artificial heart)
-Completely replaces both ventricles -End-stage heart failure (no other options remain) -Temporary replacement while awaiting a heart transplant
teach prevention
-don't drink and drive - have a designated driver - avoid high-risk activities - wear a seatbelt - wear a helmet - wear protective gear with sports - test the water prior to diving
initiation period
-most significant sign of ARI is decreased urine output (<400 in 24 hrs) -includes initial injury to when oliguria develops
tx of late decels
-position pt into left lateral position - IV fluids - discontinue oxytocin - admin O2 - notify PCP - prepare for birth
when a baby has died
-put sign on door for staff - private room - offer to see the baby - encourage grieving
ways to decrease anxiety during ventilation use
-sedation - neuromuscular relaxing agent
monitor with MG sulfate
-serum levels - RR - BP - DTRs - I/Os
what do both hospice and palliative care have in common
-they use the world health organization ladder to determine pain control options - holistic care
station when the head is at the bottom of the pelvis and is fully engaged
0
normal ICP
0-10
normal ICP
0-10mmhg
latent phase
0-6 dilation contractions last 30-40 secs
one box on an ECG heart reading is equil to
0.04 seconds
small box=
0.04 secs
adult PR is
0.12-0.20
PR interval normal
0.12-0.20 secs PR= atria
large box=
0.20 secs
ST seg in an adult is < or = to
0.40
phases of an acute renal injury
1. initiation 2. oliguria 3. diuresis 4. recovery
3 grades of a concussion
1. mild/grade 1 2. moderate/grade 2 3. severe/grade 3
10 step of ECG interpretation
1. wide or narrow QRS 2. rhythm 3. rate 4. p waves 5. PR interval 6. QRS 7. QT interval 8. ST seg 9. T waves 10. U waves then check ectopic beats and irregularities
zeroing the cath should occur
1/day
an ECG should be done in what time frame upon coming into the hospital?
10 minutes
tachycardia HR
100-160
second stage of labor- complete dilation and effacement
10cm-birth of fetus contractions occurs every 2-3 mins for 60-90secs
normal FHR
110-160 bpm
diagnostic tools for MI
12 lead ECG Labs Echocardiogram exercise stress test EST
normal end diastolic vol
120-130 mL
Na
135-145
the first stage can last
14 hrs
second trimester is
14-27 wks
normal GCS score
15
platelets
150,000-400,000
first trimester starts on the
1st day of last menstrual period- 13 wks
nonmodifiable risk factors of CAD
1st degree relative with CAD increasing age male race- higher in african americans
world health organization ladder
1st- mild pain (1-3) 2nd- mod pain (4-6) 3rd- severe pain (7-10)
engagement usually begins
2 weeks before labor onset
inferior wall ECG
2, 3, AVF
normal DTRs
2-3+
CVP normal
2-6
central venous pressure (CVP) normal range
2-8
cardiac index (normal value)
2.5-4 L/min/m2; is a more specifiy CO d/t pt size being included
anterior cord syndrome damage
2/3rd of anterior and spinal artery injury
pulmonary artery systolic pressure PAS
20-30
inherent rate in adults of purkinje fibers
20-40bpm; isn't viable on it's own
MG sulfate is infused up to how long
24 hrs for preg induced hypertension
leads are changed every
24-36 hrs; typically with a bath, clean skin with soap+water
third trimester is
28-40wks (or till birth)
early stabilization is used to prevent
2ndary injury
troponin I elevation is detectable within
3 hrs of the MI
ventricular tachycardia=
3 or more PVCs in a row at a rate >100bpm
normal ICP for children and infants
3-7 1.5-6
potassium
3.5-5.2
how many large boxes in a strip
30
normal pulse pressure
30-40
pressure bag on art line is set to
300; keeps blood pressurized to prevent backflow of blood into tubing
target temp when managing hyopthermia
32-36 C within 2-4 hrs for at least 24 hrs
Tocolytics can be administered before
34 wks
premature delivery is before
37 wks
full term delivery is
38+ wks
normal WBC
4,500-11,000
pulmonary artery wedge pressure (PAWP) normal range
4-12
wedge pressure/PAWP normal
4-12
secondary SCI is preventable and reversible within what time after the injury
4-6 hrs
normal CO for the heart
4-8 L/min
a normal preg is
40 wks long
inherent rate of adults of the bundle of HIS
40-45bpm; slower than HR needs to be, symptoms will occur
rate of the AV node in adults
40-60bpm
normal pulse pressure=
40mmhg
transducer location
4th intercoastal space btw posterior and anterior chest, taped to arm on the right side
males are how many time more likely to get an SCI than females?
4x
TAH are designed to last
5 yrs
ICP normal is
5-15
pulmonary artery diastolic pressure PAD
5-15 mmHg
Positive end expiratory pressure normal
5-20 (5 in the lung)
MAP of TAH and VAD pts
50-90
length of spinal shock
6 mons
ECG strips are how long
6 seconds
active phase
6-10 dilation contractions last 45-60 secs
small aneurysms are watched every
6-12 mons for enlargement (US or CT)
normal ejection fraction=
60%
normal sinus rhythm of the heart
60-100
SA node inherent rate in adults
60-100 bpm
an occluded vessel needs treatment within
60-90 mins
normal MAP
70-110
normal CPP
70-80 or above
CPP is ideally
70-80mmhg+
damage to muscle in an MI affects the heart conductivity and can cause dysrhythmias for up to
72 hrs post MI
glascow coma score above what is good
8
what MAP needs to be retained to what level for spinal shock to prevent further spinal cord damage?
85mmhg or higher
PT normal
9.5-12 secs; correlates with INR, used to measure warfarin therapy
the cath lab can tx an occluded vessel in
90 mins
normal QRS
<0.12
normal Troponin T
<0.2 if elevated= cardiac damage
normal Troponin I
<0.35
INR normal
<1 (2-3 with warfarin)
creatinine normal
<1.0
normal fasting glucose
<110
spontaneous abortion occurs
<20 wks
abd aorta aneurysms are
<4cm men >50 are at highest risk of death incidence increases with age
irreversible damage is when CPP is
<50
troponin I indicates
>2= heart damage
mortality rate of DIC pts
>80%
AV node reentry tachycardia
A is unmeasurable A rate is unmeasurable, V >150 No visible P wave No PRI
Glasgow coma score GCS
A neurological scale 3-15 used to determine the level of consciousness of a patient. by checking eye opening, verbal response, and motor
FLACC pain scale
F: Faces. L: Legs. A: Activity. C: Cry C: Consolability used when pt can communicate their pain
emergency care priority for SCI involves
ABC's airway breathing circulation
treatment of posturing
ABCs VS and heart monitoring treat temp >99.6 (hypothermia= poorer outcome) stroke team eval thrombolytic therapy control HTN- TPA
SCI places women at greater risk of
AD constipation bladder spasms UTIs pressure sores resp complications muscle spasms swelling in legs/feet
acute coronary syndrome nursing interventions
ASA O2 ECG cath lab on standby prior to admin to the hospital - tx occluded vessel - thrombolytic therapy - antiplatelet therapy - pain control - establish 2 large bore IVs - CXR - CP -B blocker - Ace inhibitor - heparin - check electrolyte imbalances
PR interval is when there is a delay at the
AV node
QRS Complex is when the electrical impulse is at the
AV node and purkinje fibers
S3
Abnormal heart sound heard after S2 indicative of fluid volume overload in HF
S4
Abnormal heart sound heard before S1, associated with ventricle enlargement or hypertrophy
During unplanned, spontaneous moments, dying clients usually discuss fears or concerns that nurses should not ignore or rush. What is the nurse's best response in such situations?
Communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact.
Acute Coronary Syndrome (ACS)
Condition characterized by sudden myocardial ischemia/chest pain
Unstable Angina
Condition characterized by sudden myocardial ischemia/chest pain, normal coronary artery
pts with leukemia are at a greater risk for
DIC
with an IUFD the mother may have a
DIC
determine if their child is going to be
DNR or full code; one of the most difficult decisions for a family to make.
with post partum depression
DON'T ignore s/s get help
if MG sulfate is too high
DTRs will be diminished or absent oliguria confusion LOC changes Resp depress circulatory collapse respiratory paralysis
anticoags are given for SCI pt to prevent
DVT and PE
Myocardial Infarction (MI)
Death of myocardial tissue due to insufficient oxygen supply
Lasix
Diuretic used to decrease fluid retention
Contractility
Force with which the heart pumps blood Ex in HF this decreases
A client has been using NSAIDs daily over an extended period. Which of the following effects should the nurse carefully monitor for in this client?
GI bleeding
Which of the following nursing interventions is appropriate with regard to pain control in the dying client?
Give pain medications on a routine schedule.
GTPAL
Gravida, Term, Preterm, Abortions, Living
pulmonary HTN is diagnosed with
H&P, CXR, pulmonary function studies, electrocardiogram and echocardiogram and is confirmed with a PA cath
beta blockers shouldn't be used with
HF because it decreases the contractility of the heart, check for worsening HF
causes of cardiogenitc shock
HF, MI, (first 2 are most common) congenital heart defects, valve replacement, electrolyte imbalances, acidosis
cardiogenic shock can have increased or decreased
HR
septic shock can have increased
HR and RR
after rupture of membranes whether natural or manually the nurse should check the baby's
HR and for prolapsed cord DANGEROUS
sinus bradycardia
HR less than 60, everything else is regular/equal
anaphylactic shock can have increased
HR, RR
sinus tachycardia
HR>100
preeclampsia s/s
HTN proteinuria HA N/V blurred vision/blind spots hyperreflexia hyperactive DTRs right upper quadrant pain impaired liver function edema decreased urine HELLP low platelet count PE
brain injury assessment
Health history with focus on the immediate injury, time, cause, and the direction and force of the blow Baseline assessment LOC—Glasgow Coma Scale Frequent and ongoing neurologic assessment Multisystem assessment: cushings triad
becks triad
Hypotension with narrowing pulse pressure, JVD, muffled heart sounds; cardiac tamponade
discourage coughing with increased
ICP
vasopressor is used to increase BP if
ICP is low
PCA pump is more effective at pain management vs IM due to
IM taking longer to be effective and it has a greater risk of toxicity. A PCA is more consistent, minimizes toxicity, and consistently helps pain management
treatment for cardiogenic shock
IV fluids-- don't overload check CVC placement antiarrhythmic norepinephrine or vasopressin in SBP <80 intra aortic balloon pump
hydralazine/nipride is given
IV slowly decreases BP
Babinski reflex
Infant reflex where if its foot is stroked, the baby's toes fan out
Dobutamine
Inotropic drug used to increase cardiac output
Dopamine
Inotropic drug used to increase cardiac output
Which is a sign of approaching death?
Irregular breathing patterns
U wave and P waves can be hard to distinguish btw
It will be a Pwave if it looks identical to other pwaves, and will be a Uwave if it looks different
manage F/E balance and pay special attention to what electrolyte
K+ (hypokalemia), also check for hypoglycemia
pulmonary artery systolic pressure high value means
L HF, pulmonary shunting, pulmonary HTN, fluid overload, hypoxia
lumbar spine
L1-L5
assessment of altered mental status includes
LOC GCS pupils motor sensation vol vs invol reflexes speech
NS plus what other solution would be used to treat hypovolemic shock
LR
norepinephrine can to used to increase what
MAP
CPP (cerebral perfusion pressure) formula
MAP-ICP
ativan can be used for recurrent convulsions if
MG sulfate isn't working
R sided HF can be caused as a result of what
MI
Transmural MI (Q wave)
MI that affects all layers of the heart muscle
Subendocardial MI (NON Q wave)
MI that involves the layer below the endocardium
the ejection fraction can be measured by
MOSt common: ultrasound of the heart (echocardiography) or cardiac catheterization
Major cause of SCIs
MVA's 36.5%
central venous pressure monitoring
Measurement of right ventricular preload → reflects fluid volume Obtained from: Central venous catheter PA catheter Similar to PAWP waveforms
QRS is narrow
NOT ventricular can be atrial, junction, re-entry, or other types of blocks (1st, 2nd)
fluid replacement for hypovol shock in a ped pt
NS or LR 20mL/kg bolus
Coronary Artery Disease (CAD)
Narrowing of the coronary arteries
NSTEMI
Non-ST Elevated Myocardial Infarction, partially or intermittently occluded coronary artery
immobility complications
PE DVT skin breakdown bowel retention incontinence infection unstable BP contractures
major causes of death for person with SCI
PE, pneumonia, sepsis
ABGs
PH= 7.35-7.45 PaCO2= 45-35 HCO3= 22-25
tests to confirm HELLP/severe preeclampsia
PT PTT liver profiles CBC UA
A medical nurse is providing end-of-life care for a client with metastatic bone cancer. The nurse notes that the client has been receiving oral analgesics for pain with adequate effect, but is now having difficulty swallowing the medication. What should the nurse do?
Request the analgesics be prescribed by an alternative route.
diuretics are used for fluid overload associated with what heart sound?
S3
men can still have an erection with
SCI
a cervical collar is removed only if
SCI has been ruled out; the extent of the injury has been determined
tell stroke what acronym
SCRAM stroke warning s/s call 922 risk factors after care meds
septic shock results from
SIRS systemic inflammatory response syndrome
if a pt is unable to swallow what is a similar route that works well
SL
what to check for with NSTEMI on an ECG
ST depression, T inversion
STEMI causes elevation of what segment on an ECG
ST-segment
cushings triad
Signs of increased intracranial pressure: 1. hypertension 2. bradycardia 3. decreased respirations
epidural hematoma patho
Skull fracture can cause rupture or laceration of an ARTERY (EMERGENCY) WORSE THAN SUBDURAL
The nurse is admitting a 52-year-old father of four into hospice care. The client has a diagnosis of Parkinson disease, which is progressing rapidly. The client has made clear his preference to receive care at home. What intervention should the nurse prioritize in the plan of care?
Supporting the client's and family's values and choices
secondary injury
damage after initial injury; goal is to minimize effects
contrecoup injury
damage to the brain made by when the skull stops moving but the brain continues to.
decerebrate posturing
damage to the brain stem external rotation of the hands/arms/feet - WORST prognosis
pulmonary hypertension
damaged, thickened arteries cause narrowing, thickened, stiff arteries
DIC leads to organ damage, failure and then
death
PE is the most common cause of
death with SCI; generally comes from a DVT
in most shocks VS look like
decrease BP increased HR increased RR Normal temp
what decreases systemic afterload
decreased BP ex vasodilator nitrogllycerin
L sided HF s/s
decreased CO, activity intolerance, pulmonary congestion, cyanosis, hypoxia, cough with frothy sputum, crackles, paroxysmal nocturnal dyspnea, increased venous pressures, impaired O2 exchange
s/s of hypovolemic shock
decreased O2 decreased BP increased HR narrowing pulse pressure edema/ascites, hypernatremia, decreased urine, cool/moist skin
PAS low value means
decreased circulation volume, R HF
nonoliguric form
decreased renal function increased nitrogen NORMAL urine output 2L/day or more
not enough fluid=
decreased right and left heart preloads
signs of microvascular thrombi
decreased temp, cyanosis of extremities, >3sec cap refill, hypoxia, CP, heartburn, GI pain, decreased urine outpt, increased BUN creatinine, decreased CNS
ace inhibitor
decreases fluid retention
increased pressure from HTN increases the resistance/afterload and over time
decreases the hearts ability to compensate and push out the blood (SV)
A patient is at risk of a pulmonary infection if they aren't
deep breathing; check for diminished lung sounds in the bases
decerebrate posturing indicates a
deeper and more severe dysfunction than decorticate posturing
comfort
defined by the individual and requires that they are satisfied in the physical, psycho, social, spiritual, and environmental domains
opioids are given 4 or more hours before
delivery because they can cause resp depression, decreased FHR
neurons consist of
dendrites, cell body, and axon
stages of grief
denial, anger, bargaining, depression, acceptance
P wave causes what is the atria
depolarization
QRS Complex is when the ventricles
depolarize
T waves causes the ventricles to
depolarize
watch for s/s of this with a pt with SCI
depression
teach pts to report s/s of
depression/suicide
s/s of brain herniation
deteriorating LOC, neuro deficits, dilated and fixated pupil, paralysis of an extremity
narrowing pulse pressure is an early sign of
deterioration
ASIA Scale
determines the severity of the injury and helps determine treatment plan for providers for SCI
bronchiolitis scoring
developed by the health care ped specialties to determine medical tx for doctors to refer to
don't every remove any
devices (C collar)
atypical s/s of MI will occur with
diabetics, elderly, females
C3-C4 controls what
diaphragm care considerations: will need ventilator support as they will have breathing probs
how to treat diaphragm that isn't working after SCI
diaphragmatic pacing
tricuspid and mitral valves are open during
diastole
P wave causes the ventricles to
diastole (relax)
QRS Complex affects the atrias with
diastole (relax)
T wave causes atrial
diastole (relax)
T wave causes ventricular
diastole (relax)
isoelectric line the atria and ventricles are in
diastole (relax)
the PR interval causes ventricular
diastole (relax)
HF can be a problem with the filling of the heart
diastolic failure
pulse pressure
difference btwn systolic and diastolic pressure
spinal shock affects everyone
differently; some reflexes can come back
this is one of the most common and devastating types of TBI
diffuse axonal injury
DIC
disseminated intravascular coagulation- altered hemostasis mech causes massive clotting. As clotting factors are consumed, bleeding occurs
most common cause of autonomic dysreflexia
distended bladder
MM for pulmonary HTN
diuretics O2 anticoag digoxin exercise training
CT
doesn't take long pt has to stay still not as clear of an image
xrays
doesn't take long shows bone injury doesn't show the big pic used to check cervical spine injuries
nursing management when warming a pt
don't add additional heat to do so
peritoneal dialysis
done during the day or overnight - peritoneal is a semi-permeable membrane - get baseline VS and electrolytes first
CBC
done to determine the amount of platelets and blood loss a pt can have
Extraventricular Drain (EVD)
drains CSF out of the ventricles
burr holes
drill into the skull to relieve pressure or to remove hematomas
RSV is
droplet precautions
S2 sound
dub
types of obstructive shock
ductal dependent tension pneumothorax cardiac tamponade PE
prerenal (most common)
due to hypovol, HTN, decreased CO, HF also burns, hemorrhage or GI losses -get labs
teach parents that CPR may be
inappropriate and lead to more suffering than if death were allowed to occur naturally. When palliative care is chosen, the focus on the child's care is changing but the child and family are not being abandoned.
craniotomy
incision is made into the skull to relieve pressure
false s/s of labor
inconsistent contractions pain relieves with activity pain in front of abdomen
pressure injury causes other than C collars
incontinence trauma bumps unnoticed abrasions and wounds perspiration anemia diabetes
CO2 plays a role in increased ICP
increased CO2 from resp acidosis can result in vasodilation leading to increased ICP
too much fluid
increased right and left heart preload
SIADH results from
increased secretion of ADH causing fluid overload, sodium dilutes
ICP with cushings
increased systolic decreased pulse and RR
pain and anxiety effects ICP how
increases it; manage it to prevent increasing ICP
acids are H+ donor that lower the PH by
increasing the amount of free hydrogen ions
C6 injury devices
independent in transfers and wheelchair
most common complication with prolonged ROM is
infection
main complications to watch for with IABP
infection bleeding
complications of TAH and VAD
infection pump thrombus hemorrhage HTN suction event arrhythmias psychosocial support
main concern with continuous ICP recordings
infection, meningitis, ventricular collapse, occlusion of the catheter by brain tissue or blood
The presence of many band cells in WBC indicates
infection; normal= 3-6%
40-50% of all MI are on what wall of the heart
inferior wall
triggers to DIC all have what in common? they cause an
inflammatory response
primary injury
initial damage; no control over what happens
primary SCI
initial injury permanent
fourth stage=
initial recovery lasts 1-4 hrs after birth
spinal cord injury
injury to the spinal cord, vertebral column, soft tissue, or discs caused by trauma. It is a major health disorder
to increase contractility in HF pt admin
inotropic drug such as dobutamine
tx of decreased contractility
inotropic meds: digoxin, epinephrine, dopamine
repolarization
inside of cell is negative relaxation, filling of ventricles RRR: repolarization rest, relax refill
depolarization
inside of cell is positive contraction SS: systole, squeeze
complicated or prolonged grief
intense response after loss where profound emotions persist >1yr Ex widow who stops caring for herself after the death of her husband and sobs at the mention of his name a yr later
what system can be impaired in pts who are experiencing a sustained increase in ICP
intracranial autoregulation
IUFD
intrauterine fetal death
distributive shock
intravascular vol pooling into peripheral vessels, decreased blood return 3 types
minimize parents anxiety bu
involving parents and other family members in ALL aspects of the child's care. this will decreased anxiety
DI
is a complication of increased ICP with s/s of hypernatremia, high serum osmo, decreased urine concentration polyuria, polydipsia, polyphasia
combined spinal/epidural CSE
is most common and contains an anesthetic and opioid for immed pain relief.
active phase of labor mom
is uncomfortable and limits interactions, could be irritable, she is focused and will begin to use relaxation and breathing techniques
increase ICP decreases CPP and causes
ischemia, cell death, edema
secondary SCI results in what damage to the spinal cord?
ischemia, hypoxia, or hemorrhage
causes of intracranial reg dysfunction
ischemic stroke hemorrhagic stroke TIA tumors head injuries surgery infection encephalopathy vascular malformation hydrocephalus
the PR interval pattern
isoelectric after P wave
there is no electrical stimulation during the
isoelectric line
CK-MB
isoenzyme of the heart that measure the damage to the muscle tissue
how does spinal shock affect the resp system
it can cause accessory muscle, diaphragm, and intercostal muscle use loss causing decreased lung capacity, increased secretions, increased CO2, resp failure, and a PE
CO is affected how by spinal shock
it decreases; bradycardia occurs (also due to imbalance btw NS)
during shock what is happening to perfusion
it's inadequate and blood is shunted to vital organs. weaker pulses in periphery vs centrally
elderly MI s/s
jaw pain, fainting, no pain
CI cardiac index normal
keeping it 2+ is usually good
ventilator issues to check fo
kinks check secretions for suctioning assess pneumothorax NEVER turn alarms off
prolapsed cord interventions- mother positions to
knee-chest position
in someone having their first baby they go through effacement before the onset of
labor begins and it is followed by dilation
if the cerebellum is damaged what would you monitor for?
lack of balance and coordination
the purkinje fibers are the
last backup of the heart
escape beats are generally
late and look junctional or ventricular
ICP is measured where
lateral ventricles
in septic and anaphylactic shock increased cap permeability leads to
leaky vessels causing vol loss in the intravascular space
L1-L5 controls what
leg muscles
brown sequard syndrome cause
lesion, tumor, ischemia, infection, MS
SCI effects on women
level of injury doesn't matter to engage in sexual activity
isoelectric line
line on the graph that remains flat when no electrical activity is detected
hyperkalemia
long PR, wide QRS, asystole, tall peaked T waves, used on death row
hypermg
long PR, wide QRS, bradycardia, tall peaked T waves
a pt with a concussion can be admitted or sent home. If sent home teach the family
long term s/s to look for: - LOC changes - difficulty waking up - dizziness - confusion - irritability - anxiety worsening HA seizures abnormal pupil response V slurred speech numbness/weakness in extremities difficulty moving or speaking
s/s of contusion
longer period of lost consciousness more neuro deficits VS changes stupor/confusion usually occurs in frontal/temporal lobes
1st stage of labor- onset of dilation to complete cervical dilation
longest; two stages starts - latent - active
anterior-lateral MI
look for ST seg elevation in the leads
tx for anxiety with EOL
lorazepam, valium
s/s of anterior cord syndrome
loss of pain, temp, motor function below lesion. Light touch, position, and vibration + proprioception ARE STILL intact
s/s of central cord syndrome
loss of proprioception, vibratory sense below injury, urinary incont, bowel dysfunction, arms and hands are more impacted than legs
hemonymous hemianopsia
loss of right/left half of vision view in each eye (the right half of the brain has visual pathways for the left)
scalp wounds s/s
lots of bleeding; this injury is a portal for infection
bone marrow suppression occurs with a WBC that is
low
s/s of neurogenic shock
low BP, HR warm, dry skin (sympathetic NS can't respond and compensate)
diet for child with kidney dx
low Na, K, P, and sugar for DM, low fluids
hypovolemic shock
low intravascular vol 15-30% most COMMON shock caused by blood loss, fluid shifts, dehydration, edema/acites, burns, surgery, DI, severe dehydration, hemorrhage, DKA, diuresis
s/s of depression
low mood, changes in appetite, sleep disturbance, agitation, fatigue, difficulty concentrating
s/s of septic shock
low temp initially then goes to phase 2 and fever occurs increased HR and RR warm/flushed skin hypotension metabolic acidosis resp alkalosis too high/low WBC petechiae or purpuric rash
with an renal injury the GFR will
lower
ectopic preg s/s
lower abd pain, bleeding may or may not be visible
bases absorb H+ ions and the higher the PH is the
lower level of free hydrogens
S1 sound
lub
if wedge pressure is normal with a PE then it could be a
lung problem (ARDS) if BNP is normal
surgical management for pulmonary HTN
lung transplants heart transplant atrial septostomy
resp therapy for SCI includes
maintaining high PaO2 oxygenating - done to prevent secondary injury
risk factors of SCIs
male 16-30 yrs alcohol/drug use
who are at highest risk for head injuries
males 15-19 children 0-4 yrs adults 65+yrs
caring for dying children includes
managing parent's fears of death and dying question of precedence the grieving period support role for the nurse
treatment of cushings
mannitol hyperventilate elevate HOB
if a pin falls out what do you do
manual traction and have another nurse call PCP
C7-C8 injury devices
manual wheelchair
this inflammatory response leads to DI as it causes
mass coagulation within the vasculature causing tons of clots to form
Troponin T
may be present 21 days after an MI, sensitive to skeletal muscle damage and kidney dx
diabetics MI s/s
may not experience any pain or discomfort
behavioral pain scale BPS
measures facial expression, upper limb movements, compliance with mech ventilation - ranges from 3 (no pain)- 12 (max pain)
perfusion
mechanisms that facilitate or impair circulation of blood through tissue
fever could indicate a sign of what infection
meningitis or neurogenic fever (may need to ice pack them)
nuchal rigidity and photophobia are a sign of
meningitits
cerebral function assessment
mental status, intellectual function thought content, emotional status, perception, motor ability, and language ability, LOC, perception, motor, speech
A pt with a concussion should be aroused and assessed freq unless it is
mild
ways to help a pt compensate for sensory and perceptual alterations with SCI
mirror glasses music always announce yourself when coming into room
traumatic causes of intra cerebral hemorrhage
missiles, bullets, stabbing
treat variable decels by turning
mom side to side for amnioinfusion
how to care for PA cath/swan ganz
monitor for pneumothorax, infection, air emboli
med tx of dissecting AA
monitor to see if it gets bigger stop smoking gentle, reg exercise avoid heavy lifting heart diet control HTN with meds bypass graft through femoral artery (if >5.5cm)
VAD pt education
monitoring for infection self-checking med management device management psychosocial support
prevent an AKI by
monitoring urine output hrly check BUN/Creatinine remove catheters fluid/blood replacement hydrate renal dosing of particular meds
fetal scalp electrol
monitors baby PCP places
transducer
monitors baby by sending ultrasounds waves
Assisted coughing can be
more effective than suctioning as it is more effective at clearing secretions from both left and right bronchus whereas suctioning only clears the right bronchus
Left sided HR occurs
more freq
during the second stage of labor mom may feel
more in control and less irritable and agitated, she is focused on the pushing, urge to PUSH
more fluid vol=
more pressure inside the ventricles
Troponin I
most accurate lab; increases 3 hrs after an MI, if rising it may be drawn again until fall is seen
risk factors for abruption placentae
mother HTN, trauma smoking cocaine use adv maternal age scarred uterus PROM>24 hrs amniocentesis
multipara means
multiple births
MODS
multiple organ dysfunction syndrome
clonus
muscle spasm or twitching; test by sharply dorsiflexing the foot
baclofen is given for
muscle spasms related to SCI
for a pt with severe preeclampsia will have 3+ proteinuria on a dipstick; so pt would
need protein in their diet
for tractions of all kinds check
neuro status, sensory/motor changes at least every shift
basic functional unit of the NS
neuron
NTs are used to communicated btw
neurons
prevent DVT by
never rubbing calves/thighs, not wearing compression boots
preeclampsia
new HTN with proteinuria and or maternal organ dysfunction
desired outcome of treatment of ACS
no CP, normal ECG, LOC improves
nullipara means
no births greater than 20 weeks
persistent vegetative state (irreversible coma)
no cog function but has sleep-wake cycles, swallow, cough, eye movement
s/s of aneurysm
no early back/flank pain= classic sign (presses against nerves invertebrae) abd pain feeling full nausea pulsating abd mass rupture
dampened waveform with art line=
no notch on top, is more flat and indicates BP could be low or inaccurate-- need to zero it out, compare to manual BP
spinal shock and temperature s/s
no sweating d/t sympathetic response being blocked below injury. Fever occurs quickly, lack of O2 can increase temp
an incomplete premature beat is
nonconducted and have a P wave only with no QRS
sympathetic NS main NT is
norepinephrine
typical VS for pt in shock
normal BP (initially) HR increases RR increases
basilar fractures are the fractures that cause the leaking from the
nose and ears
LDH
not as reliable as other labs, takes longer to peak and stays elevated longer. Used to diagnose a past MI
incomplete injury
not completely severed; some sensory and motor movement is still there, leads to BETTER outcomes
myelography is
not done a lot because of the CT and MRI
rate=
number of complete R waves x 10
preterm=
number of pregnancies carried 20-37 wks
Term=
number of pregnancies carried for 37+ wks
Abortions=
number of pregnancies ending <20wks
Gravidity=
number of pregnancies including CURRENT
s/s of ischemic stroke
numbness or weakness of the face, arm, or leg esp on one side. Confusion, change in mental status, speech, balance, coordination, sudden vision changes
sensation assessment to check for
numbness, tingling, painful stimuli
Which intervention is appropriate for a nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?
obtaining baseline VS before administering the 1st dose
cause of hemonymous hemianopsia
occipital lobe tumor
T wave pattern
occurs after the QRS complex
nerves that are motor
oculomotor trochlear abducens spinal accessory hypoglossal
nerves that control sensory
olfactory optic acoustic
don't sit a pt up that has a halo device without it
on
when there's fetal distress what position can you put mom in
on her LEFT side to increase uterine blood flow
how often should traction weights be checked?
once a shift; never change them without orders
brown- sequard syndrome damage
one lateral side is damaged on spinal cord
uncompensated PH
only one buffer is out of range, PH is out of range, and the other is normal
admin a stool softener or laxative when taking an
opioid; hydrocodone or oxycodone
STEP THREE: severe pain 7-10 tx
opioids: morphine, hydromorphone extended release (long lasting) PCA pump continue adjuvant meds, nonpharm methods may need to increase dose due to tolerance
ventricular rhythm characteristics
originat in the ventricles wide qrs pwaves absent
ventricular dysrhythmias
originate from purkinje fibers or lowe conduction systme
reentry dysrhythmias
originate from reentry pathways that go in and out of the conduction system
juntional dysrhythmias
originate from the AV junction of ectopic areas near it
atrial dysrhythmias
originate from the SA node or ectopic areas in the atria
junctional dysrhythmias
originate in the AV junction narrow WRS P wave upside down or absent or after QRS
Normal SCI s.s for a pt within the first 2 wks
ortho hypo unstable BP BP gradually returns to normal
T7 or above can have
ortho hypotension; use embolism stocking, abdominal binders to help aid blood return and diaphragm support
the time stroke s/s start is a major indicator of the
outcome
most important thing for a nurse to do with secondary SCI is
oxygenate
oxygen is used to
oxygenate cardiac tissues
SCI requires what treatment to prevent secondary injury
oxygenation
purkinje's fibers have
pacemaker cells
AV node doesn't have
pacemaker cells like the SA node does but it has tissue around it which does
SA node
pacemaker of the heart
sinoatrial (SA) node
pacemaker of the heart
what s/s of EOL is most feared
pain
morphine is the global standard for cancer
pain; used in hospice as there is no ceiling affect with morphine (can continue to increase the dose)
hospice is a type of what
palliative care
differences in palliative and hospice care
palliative= broader; preventative care aimed to cure including surgeries hospice= relieving pain and suffering, provided with disease remitting treatment (life ending illness)
a cervix that is ready to deliver will be
paper thin or not easy to feel anymore
tetraplegia/quadraplegia
paralysis of all 4 extremities
paraplegia
paralysis of the lower body
s/s of brown sequard syndrome
paralysis with loss of motor control on the SAME side of the injury on the spine. Loss of sensation on the OPP side (pain, temp, sensation)
exs of complete SCI
paraplegia tetraplegia/quadriplegia
above the injury is what NS response?
parasympathetic rest and digest
causes of decreased contractility
parasympathetic stimulation of the heart, ischemia, drugs, disease
complications for labor
passageway- abnormal pelvis shape passenger- malpresentation, multi gestation, prolapsed cord
PROM
passive range of motion, 4x/day
altered LOC is NOT the disorder but the result of
pathology
open brain injury
penetrating head injury or blunt trauma so severe that the brain is damaged and the scalp, skull, and dura are opened to expose the brain
treatment for ED
penile injection medicated urethral system erection vacuum pump viagra
med tx of cardiac tamponade
pericardiocentesis, pericardial window
AKI compications
pericarditis pericardial effusion pericardial tamponade HTN anemia bone dx
bereavement
period of time where mourning for the loss takes place
pauses
period of time without a beat, sometimes followed by a different type of beat
initial bleeding is normal for
peritoneal dialysis unless it has been in place for a good amount of time
inverse of Ca is
phosphorus
What nerve innervates the diaphragm?
phrenic nerve
Subarachnoid screw or bolt
placed just through skull and dura mater to monitor ICP but does not allow for CSF drainage. It doesn't require a ventricular puncture
abrade the skin prior to
placing leads
with DIC the number of _________ and ___________ decreases
platelets, fibrinogen
lab values in DIC
platelets, fibrinogen= low D-dimer= high PT= high aPTT= high INR= high FDP's= high Hgb= low Hct= low
infections a pt with immobility is at risk for
pneumonia UTI DQ
other causes of septic shock
pneumonia wound infection catheter use invasive procedures immunosuppression
always monitor BP during
position changes
modified trendelenburg
position ideal for hypotensive pts to restore blood flow to the brain and heart
cardiac tamponade causes
post cabg, MI
use assessment scales to determine what pts are at risk of
post partum depression EX: EPDS
posterior cord syndrome damage
posterior columns damaged
motor system assessment
posture gait muscle tone/strength coordination/balance
electrolytes used for conduction
potassium, calcium
s/s of autonomic dysreflexia
pounding HA rapid increased BP diaphoresis on forehead blotching flushed/red face cold/clammy skin goosebumps restlessness Nausea nasal congestion bradycardia
you don't need protein in the urine to have
preeclampsia
women can still get
preg with SCI
anything that increases venous return to the heart increases the
preload Ex: vasopressors
anything that decreases venous return to the heart decreases the
preload ex: hemorrhage, vasodilators
wedge pressure measures the
preload of the left heart, CO, or cardiac index
categories of causes of ARI
prerenal intrarenal postrenal
therapy for head injury goal
preserve brain homeostasis and prevent secondary damage
goal of surgery is to
preserve neuro function and stabilize the spinal cord by removing pressure
C collars can cause these when worn for long periods of time
pressure injuries
tocodynamometer
pressure sensitive device placed on the fundus to measure contractions
corticosteroid (betamethasone) is administered for
preterm birth
PPROM
preterm premature rupture of membranes <38 wks
pt teaching with AD
prevention and management of stimulus
if PH is leaning toward acidic or basic then that is the
primary problem
Right sided HF causes
prior MI, Left HF
what happens when a healthcare professional and parents don't share the same view about which is in the best interests for the child or young person?
prioritize parent decisions in care
amylase is an enzyme
produced by the pancreas and if elevated it means pancreatitis
s/s of pulmonary HTN
progressive dyspnea with exertion then with rest increased RR weakness fatigue syncope occasional hemoptysis R sided HF s/s
chronic renal failure
progressive, irreversible damage to renal function that results in azotemia
HF is usually
progressive, lifelong disorder managed with lifestyle changes and medications
lab tests for DIC
prolonged PT, aPTT, and INR
when moving a pt slowly to standing position maintain
proper alignment check BP turn only if spine is stable use C collar if prescribed during mobilization
heparin antidote
protamine sulfate
Troponin
protein found in myocardial cells, released when cells are damaged, detects recent heart damage
sepsis bundles
protocol given for PCP to treat sepsis
hospice uses
pt MUST have terminal diagnosis end of life care, home care, bereavement care to family
tx of hemorrhagic stroke
pt monitoring possible placement of external ventricular drain, craniotomy maintain airway and vent vasospasm (nimodipine), HTN, seizure potential, prevent bleeding
check suicide risk for a
pt with SCI
3rd stage irreversible stage (refractory)
pt won't survive and aren't responding to treatment organ damage is severe BP remains low acidosis worsens BP low HR erratic RR is high
LOC is the most important indicator of the
pts condition
R ventricle pushes against what pressure
pulmonary
if pt has severe onset of CP on PA cath then they could have a
pulmonary artery rupture
with L sided HF the blood backs up into the
pulmonary system
potassium is given on
pump
myocardium is the layer of the heart responsible for the
pumping action of contractility
s/s of cardiac tamponade
quiet/muffled heart sounds, becks triad, syncope, decreased CO, cough, dyspnea, pain anxiety, paradoxical pulse
An assessment for autonomic dysreflexia should be done
rapidly to determine the cause and stop it
junctional rhythm
rate 40-60 bpm, p wave upside done, absent, or right after QRS PRI unmeasurable
U wave represents
recovery of purkinje fibers; is rarely seen and not well understood
power trialysis catheter
red and blue ports= for dialysis purple= for blood draws, meds
IABP (intra-aortic balloon pump)
reduces afterload by deflating when it contracts (systole) reduces afterload by inflating during filling (diastole)
preterm labor
regular contractions cervical dilation and effacement <38 wks
measure R-R to determine
regularity
PAC premature atrial complex
regularity interupted flattened pwave, notched, hidden PRI can be prolonged QRS <.1 secs
fetal station
relation of the fetus to the pelvic ischial spines. Measured in plus or minus -4 to +4
morphine is used to
relax blood vessels, increase the blood flow, decrease pain/anxiety
potential complications with DIC
renal failure, gangrene, pulmonary embolism or hemorrhage, ARDS, stroke (headache!)
any change in neuro status needs to be
reported
prevent skin breakdown by
repositioning using gel cushion in wheelchair
afterload=
resistance
hypoventilation
resp acidosis
opioid risks
resp depression addiction tolerance of dose- may need to increase change in LOC slows GI tract
NC during epidural hematoma
resp support (RA occurs within mins) reduce ICP procedures above rare in children
hyperventilation
respiratory alkalosis
spinal cord injury assessment check
respiratory, cardio, musculoskeletal, sensation, temperature, and for spinal shock
parasympathetic NS
rest and digest -bradycardia -hypotension -vasodilation -flushed, red face -nasal congestion
reduction of an injury means to
restore it to it's normal position
Always assess the patient, not just the
rhythm strip
bundle of HIS
right and left bundles extending to each ventricle
diagnosis's of DIC
risk for fluid vol deficit risk for impaired skin integrity risk for imbalanced fluid vol ineffective tissue perfusion death anxiety
pupils should be
round and reactive to light
always assume a pt with a head injury has a cervical spine injury as well until it is
ruled out
PROM (prolonged)
rupture before true labor onset
rupture of membranes
rupture of membranes can be naturally caused or artificial
acute subdural hematoma
s/s develop 24-48 hrs
subacute subdural hematoma
s/s develop >48 hrs to two weeks
report these s/s immediately
s/s of UTI resp complications
HELLP=
s/s of severe pre/eclampsia and eclampsia. It occurs due to maternal immune system being down. hemolysis elevated liver enzymes low platelet levels
grade 1: mild concussion
s/s<15 mins no loss of consciousness
grade 2: moderate concussion
s/s>15 mins no loss of consciousness
C2-C3 injury devices
same as C1 but can be independent of mech ventilation for short periods
recognizing the s/s of a chronic subdural hematoma can
save lives
A pt with autonomic dysreflexia should be in what position
seated at 45 degrees if not contraindicated (to lower BP and decrease ICP)
death rattle is caused by
secretions
raise the HOB 1st for autonomic dysreflexia to
semi fowlers (30-40degrees)
mom feels what way during 4th stage of labor
sense of peace and excitement, is wide awake, talkative
cranial nerve assessment
sensory, motor, or mixed nerves
DIC can be life-threatening and has several triggers/causes
sepsis, trauma, shock, cancer, abruptio placenta, toxins, allergic reactions
3 types of distributive shock
septic neurogenic anaphylactic
neurogenic shock cause
severe CNS damage (brain/spinal cord injury) that results in loss of balance btw the sympathetic and parasymp communication.
aneurysm impending rupture
severe sudden back/flank or abd pain and pulsating mass
vasopressors are used for treatment of what
shock; epinephrine, norepinephrine
cushings triad can lead to
shock; s/s decreased BP increased pulse increased RR
Both TAH and VAD have
similar risks and both may not have a pulse
hypovolemic shock in ped pts s/s
similar to adults pluse sunken fontanelles
s/s of hemorrhagic stroke
similar to ischemic stroke SEVERE HA early, sudden changes in LOC vomiting
sinus tachy vs SVT
sinus tachy= slower onset cool down termination rate >100 P wave= normal HR varies with fever, anxiety, infection SVT= sudden onset abrupt termination rate >150 (>180, >220) p waves buried doesn't vary more than 1-2 bpm even with fever, anxiety, infection
s/s of contusion depend on
size location and extend of bruising
BP can be unstable so for ortho hypo
slowly change positions, dangle extremities raise HOB tilt table
SBFT
small bowel follow-through (x-ray study of the small intestine with contrast)
women's hearts are
smaller than men
risk factors of dissecting aortic aneurysm
smoking men >50
causes of CAD
smoking, HTN, hyperlipidemia, diabetes, obesity, sedentary lifestyle, stress, ETOH (more than 3 drinks)
prognosis of central cord syndrome
some return of normal function can occur, most have incomplete to moderate recovery
monroe kellie hypothesis
space is limited inside the skull, increased in one (brain, CSF, intracranial blood) requires a decrease in another; increases ICP with coughing, sneezing, straining
epidural types
spinal block epidural CSE
emergency care includes ABCs then
spinal precautions immobilization jaw thrust don't move pt
An NG tube would be used potentially for a pt with
spinal shock
A catheter would need to be put in place for what kind of pt
spinal shock pt
<50,000 platelets=
spontaneous bleeding
systemic vascular resistance determines the
squeeze of the heart related to afterload
early decompression
stabilizes the spine
traction is an example of
stabilizing an injury
you can turn a pt only if they are
stable and if indicated by PCP
A tilt table can help a pt transition to
standing; it determines whether the pts BP is normalized enough to stand without a drop in BP
MRIs could be difficult for pt with a head injury because they would have to
stay still
what increases the systemic afterload
stenotic valve, stress/anxiety
you may need to prep the skin with leads to get them to
stick
HF is reversible if caused by
stimulant use
intensity
strength of the contraction determined by palpitation of intrauterine pressure cath
IABP can be used for
strengthening the heart prior to heart transplant
severe headache could be a sign of what
stroke
non traumatic causes of intra cerebral hemorrhage
stroke high BP aneurysm tumor bleeding disorders anticoag complications
a concussion involves NO
structural damage and the loss of neuro function is TEMPORARY
areflexia
sudden loss of reflexes below SCI
acute renal injury
sudden onset capable of being reversed. Results from decreased GFR and oliguria. Creatinine is greater than 50% of normal value
art line position
supine up to 45 degrees with the transducer level with the right atrium
treatment of intra cerebral hemorrhage
supportive care control ICP admin: F/E, antihypertensives craniotomy or craniectomy to remove clot and control bleeding
treatment of ectopic preg
surgery methotrexate if embryo is unruptured
motor assessment involves checking for
symmetry vs asymmetry
below the injury is what NS response?
sympathetic fight or flight
in neurogenic shock there is a loss of
sympathetic tone leading to vasodilation and lack of compensatory mechs
autonomic NS divisions
sympathetic- flight/fight parasympathetic- rest/digest
70% occluded coronary vessel=
symptomatic, can become an MI
with R sided HF the blood backs up into the
systemic circulation
aortic and pulmonary valves are open during
systole
P wave causes the atria to
systole (contract)
QRS Complex affects the ventricles by causing
systole (contract)
during the PR interval the atria are in
systole (contract)
a late sign of shock is a drop in
systolic BP <90
HF can be a problem with contraction of the heart
systolic failure
Pulse pressure equation
systolic pressure - diastolic pressure
MAP equation
systolic+2diastolic/3
tx of ischemic stroke
tPA for bleeding risk pt monitoring lower HOB unless C maintain airway and vent continuous hemodynamic monitoring and neuro assessments meds
hypocalcemia
tachydysrhtymias, CA
sensory system assessment
tactile sensation, superficial pain, vibration and position sense
MRIs
take longer very loud pt can't have metal provides better image claustrophobia pt has to stay still
recovery from a TBI
takes yrs - many therapies - vocational rehab - neuropsychological testing
how to treat pt in irreversible shock
tell them brief explanations of what is occurring, provide reassuring touches even when unresponsive
TIA
temp neuro deficit from impaired blood flow to the brain - stroke s/s - is a warning of impending stroke - s/s resolve in 24 hrs, no long term deficits
IABP intra-aortic balloon pump
temporary Catheter balloon threaded up through descending aorta, synchronized with person's heart rhythm Inflates during diastole Displaces blood to the coronaries arteries and organs Improves coronary perfusion and perfusion of organs Balloon deflates when systole begins-creates a suction to pull blood out of left ventricle and improve cardiac output Decreased workload for LV and Afterload
L ventricle pushes against what pressure
the aortic and blood pressures
how autonomic dysreflexia causes an imbalance of the autonomic NS
the body's first response to an SCI is pain/discomfort below the injury which makes it go into the sympathetic fight of flight mode. To counteract this response the brain tries to send the parasympathetic rest and digest response but the injury blocks this signal. It causes the fight or flight response to remain below the injury while rest and digest response occurs above it.
increased temp or hyperthermia can be due to what damage to the brain?
the brainstem; treat by administering antipyretics regularly
tetraplegia is caused by a injury to
the cervical spine
fetal engagement
the entrance of the largest diameter of the fetal presenting part (usually the head) through the smallest diameter of the maternal pelvis
Frank Starling's law of the heart states
the greater the stretch of the muscle, the greater the force of contraction and more blood will be pumped out 1. increased preload increases contraction 2. decreased preload decreases contraction
disenfranchised grief
the grieving person feels that society doesn't acknowledge or support a person's right to grieve ex: mistress, homosexual partner, colleagues
heart failure
the inability of the heart to pump enough blood to meet tissue needs of O2 and nutrients
steroids are not used often for SCI treatment d/t
the lack of benefit suppresses the immune system increases infection risk ex methylprednisone sodium succinate
the left bundle of HIS splits b/c
the left side of the heart is larger and pumps throughout the body (has more resistance to overcome)
the left bundle of HIS extends to
the left ventricle and splits into two
dysrhythmias are named after
the part of the conduction system they originate from
fetal presentation
the part of the fetus that presents first through the pelvic inlet (it is the part that comes out first in birth)
Bachmann's bundle controls the contraction of
the right and left atrium
grade 3: severe concussion
there is a loss of consciousness
A feeding tube doesn't need to be placed for EOL as
they aren't utilizing these calories; teach family this
children and SCI
they have a greater ability to create nerve cells, and have more elasticity than adults; they overall have better outcomes
effacement
thinning of the cervix
paraplegia is caused by injuries to the
thoracic or lumbar spine
septic shock can lead to
thrombi that can cause organ failure or DIC
junctional tissue
tissue around the AV node with pacemaker cells
goal of hospice
to allow pt to be able to die at home, if the pt chooses, in comfort with their family
tilt table is used
to check pts BP with position changes. If it drops they aren't ready to stand up
why do we use cooling for MI
to decrease metabolic demands to allow for more healing for the brain and other organs post MI for better outcome
joints that need exercises implemented asap after injury to prevent contractures
toes, metatarsals, ankles, knees, and hips need full PROM at least 4x/day
When a client who has been taking opioids becomes less sensitive to the drug's analgesic properties, that client is said to have developed a(n)
tolerance
hypomg
torsades- form of V tac tx with mg
MG crosses the placenta and can cause the newborn to have
toxicity s/s; so ensure to monitor baby
external monitors (noninvasive)
transducer tocodynamometer
the most common cause of death with a head injury is from
trauma
cause of intra cerebral hemorrhage
trauma or non traumatic causes
unresolved grief
traumatic or unexpected losses Ex: death of a child, suicide, disaster-related death
tx of DIC
treat cause, replace fluids, maintain BP, replace coag factors, heparin
mannitol use
treats cerebral edema with a head injury by increasing serum osmolality
nimodipine use
treats cerebral vasospasm with a head injury
mixed nerves
trigeminal vagus
central cord syndrome cause
tumor, MS, infectious disorder- syphilis, B12 deficiency, MOST common cause is trauma
tx for pain at EOL
tylenol, lortab/percocet, morphine, fentanyl, dilaudid routes: PO, SL, rectal, transdermal patches, PCA
coma
unconsciousness, unarousable, unresponsive
causes of aneurysms are
unknown but there are contributing factors: atherosclerosis, HTN, smoking, trauma, heredity, congenital abnormalities
akinetic mutism
unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes
ACS is caused by
unstable angina or MI
CVP also helps when managing
unstable fluid vol status
spinal shock lasts how long?
up to 6 mons
p wave pattern
upside down U
with chronic renal failure it can cuase
uremic frost: skin and oral care
CMP
used to check O2 levels, liver and kid functions. Uses contrast dye, highly renal toxic
thallium test
uses a radioactive tracer to assess how much blood is reaching different parts of the heart
prevent O2 toxicity by
using the lowest effective dose of O2 - monitor need for O2 and when it can be lowered
nerve conduction studies is
usually done with EMG
Torsades de pointes
usually reg or slightly irreg A rate can't be determined, V rate 150-250 PRI rhythm is in ventricles, no PRI QRS: wide bizarre QRS and I wave varies in height looks like a party streamer or DNA helix
V tach
usually reg or slightly irreg rate: A can't be determined, V 150-250 <150= slow VT, >250= V flutter no pwave, disassociated PRI originates in ventricles, none QRS: wide and bizarre, hard to distinguish qrx and t wave
visual analogs scale for pain (FACES)
usually used for children
v fib vs ventricular tachy
v fib is irregular with undulating waves and no QRS complex, vent tachy is usually regular and fast with wide QRS complexes
SVT managment
vagal maneuvers 1st adenosine 2-3 times cardioversion if uneffective, and decompensation
sinus brady cause
vagal stimulation, hypothyroidism, digoxin
mitral valve
valve between the left atrium and the left ventricle; bicuspid valve
what occurs to the blood vessels during shock
vasoconstriction
afterload increases when there is arterial
vasoconstriction or CAD/plaque
nitroglycerin is used to
vasodilate and decrease chest pain
so increased CO2 does wat to the brain
vasodilates
DI treatment
vasopressin/decompression, replace fluids, replace electrolytes
treatment of ICP
vasopressor: increases BP if ICP is low Mannitol or hypertonic NS: to decrease ICP
nimodipine is used to prevent
vasospasms
during the T wave the electrical impulse leaves the
ventricles
wide QRS=
ventricular beat or 3rd degree block
atrial flutter characteristics
ventricular can be reg or irreg rate: A 250-350, V varies PWave- SAWTOOTh PRI: unmeasurable QRS difficult to measure
repolarization affects the ventricles by
ventricular diastole
PVC
ventricular dysrhythmias can be reg or irreg rate: not usually including in the rate determination because they typically don't produce a pulse Pwave- ectopic is not preceded by a pwave PRI: ectopic comes from a lower foucs, no PRI QRS: wide and bizarre, T wave can in in opp direction
T wave represents
ventricular repolarization
depolarization affects the ventricles by
ventricular systole, contraction
methods used to monitor ICP/CPP
ventriculostomy subarachnoid screw/bolt transducer-tipped cath ALL ARE BIG INFECTION RISKS
other causes of SCIs
violence, falls, sport injuries
the greater the preload, the greater the
vol of blood in the heart at the end of diastole
if CVP is low then it's a
volume problem; hypovolemic shock
s/s of decreased contractility
weak, thready pulse
childrens meds for shock treatment are based on
weight
spinal fusion
Surgical immobilization of adjacent vertebrae. This may be done for several reasons, including correction for a herniated disk.
the isoelectric line occurs after the
T wave
thoracic spine
T1-T12
Cardiac Bypass
Use of heart-lung bypass machine during cardiac surgery
Thrombolytic Therapy
Use of thrombolytics to dissolve blood clots
hypokalemia causes what heart rate
V fib
increase dietary protein for a pt with
VAD or TAH
nurse management of VAD and TAH
VS- BP, MAP, may not have a pulse battery- charge and change line dressing changes daily self test MM fluid and electrolytes- 2L/day watch for fluid overload (RV failure)
VEAL CHOP
Variable decels--Cord compression Early decels----Head compression Acceleration---OK Late decels---- Placental insuff
Nitro
Vasodilator used to decrease chest pain
prognosis of anterior cord syndrome
WORST prognosis, 10-20% regain motor, long rehab process
Which of the following assessment tools will be most effective when assessing for pain in a four-year-old client?
a FACES scale
ischemic stroke is due to what
a blood clot
hemorrhagic stroke is due to what
a brain bleed
ventriculostomy
a catheter placed in one of the lateral ventricles of the brain to measure intracranial pressure and allow for drainage of fluid
a concussion is also known as
a closed head injury or mild TBI
Pulseless Electrical Activity (PEA)
a condition in which the heart's electrical rhythm remains relatively normal, yet the mechanical pumping activity fails to follow the electrical activity, causing cardiac arrest
hospice
a coordinated program of interdisciplinary care and services for terminally ill pts and their families
dysrhythmia/arrhythmia def
a disorder of the formation and/or conduction of the heart that changes the HR, rhythm, or both. Causing altered blood flow
Autonomic Dysreflexia
a life-threatening emergency that occurs d/t exaggerated autonomic response that would normally be harmless to someone without a SCI. It occurs to patients with spinal cord injuries are at risk for developing this if SCI is (T-6 or above) and only after spinal shock as resolved
medicare hospice benefit
a medicare entitlement that provides comprehensive, interdisciplinary palliative care and services for eligible beneficiaries who have a terminal illness and life expectancy of less than 6 mons
prenatal care is necessary with
a mom with SCI
contusion
a more severe TBI with structural damage. the brain is bruised and damaged because of acceleration-deceleration force (coup/contrecoup injuries) or blunt trauma
palliative care
a pt and family centered approach that attends to the physical, functional, psychological, spiritual, and existential aspects of a serious illness
Pulmonary artery cath (PAP/swan-ganz)
a right heart cath with a transducer device used in critical care to assess the left ventricular function (CO) - helps eval pts response to fluids and meds - contains a wedge pressure
spinal shock=
a type of neurogenic shock that includes areflexia, loss of spinal reflexes below injury to the spine
S3 sounds like what
a ventricular gallop
traction
weights are placed to align bones. They are hung freely in neutral position and work by slowly adding more weight to allow vertebrae out of place to slip back into position
hemodialysis is used
when 80% of the nephrons are no longer working - 3x/wk -3-4 hrs - NO antihypertensives, blood draws
negative deflection
when ECG waveform moves toward the bottom of the paper
positive deflection
when an ECG waveform moves towards the top of the paper
paradoxical pulse
when breathing in BP drops and when inhaling BP increases due to pressure in thoracic cavity
floating
when engagement has not occurred because the presenting part is freely moveable above the pelvic inlet
breech presentation
when the butt or feet present first
abruption placentae
when the placenta breaks away from the wall before the birth
unifocal
when wide QRS complexes resemble eachother
3 lead placement
white on right, smoke over fire
5 lead placement
white on the right, grass under clouds, smoke over fire, and chocolate is close to my heart
diffuse axonal injury
wide axon damage in the brain d/t head trauma. Pt immediately goes into coma
diffuse axonal injury is known for it's damage being
widespread and is one of the major causes of unconsciousness, vegetable state after head trauma
the nurse can check dilation using the
width of their fingertips and gloves
to minimize fear that the child will die alone by remaining
with the child when a family member is not in the room
chronic subdural hematoma develops over
wks-mons cause of injury may be forgotten s/s fluctuate
both hospice and palliative care use what to determine the steps of pain treatment
world health organization ladder of pain control
STEM is
worse as it results from a fully occluded coronary artery; NO blood flow occurs
typically what diagnostics are taken first
xrays- checks cervical injuries CT scan
whos are the greatest risk of an SCI
young male that dirt bikes
when using a art line correct the body placement to
zero the cath and set atmospheric pressure to zero
to zero a catheter-steps
zero the stop cock by turning it off to the pt take cap off sterilly open to air press 0 on monitor place cap back on turn to neutral position reassess wave form
diagnostic tests for aneurysms
abd US abd CT MRI
mom may feel what during the 1st stage
abd cramping stretching
what aneurysm is the most common
abdominal aorta
T6-T12 controls what
abdominal muscles care considerations: may need assistance sitting in wheelchair
conductivity
able to conduct the impulse and send it
contractility
able to contract heart when stimulated
rhythmicity
able to have regularity
automaticity
able to initiate an impulse
excitability
able to respond to stimuli
S3 and S4 are
abnormal heart sounds
placenta previa
abnormally low implantation of the placenta on the uterine wall completely or partially covering the cervix
if PROM occurs give and
abx for infection
culture and sensitivity FIRST before
abx treatment
treatment of septic shock
abx- broad first then narrow fluids sepsis bundles
cause of concussion
acceleration/deceleration force direct blow blast injury
STEP ONE: mild pain 1-3 tx
acetaminophen NSAIDS adjuvant meds: tricyclic antidepressants, muscle relaxants nonpharm methods
main NT for parasympathetic NS
acetylcholine
PCO2 is
acidic; controlled by the lungs
ARI
acute renal injury
subdural hematomas can be
acute, subacute, chronic
med tx for CAD
admin ASA to prevent thrombus formation with plaque rupture
get a reassignment if you aren't comfortable doing what as a nurse
administering meds that help them pass away
treat peds septic shock similarly to
adult treatment; children my show hypotension early in septic shock
factors that affect SV
afterload- impedance to eject blood from the ventricle
locked in syndrome
alert and aware but inable to more or respond except for eye movement d/t a lesion affecting the pons, communicated by blinking
some facilities refer to DNR as
allowing a natural death-- is a more acceptable option for families facing the decision to withhold resuscitation
Families may want to specify a certain extent of resuscitation that they feel more comfortable with for example
allowing supplemental O2 but not providing chest compressions
s/s of brain injury
altered LCO abnormal pupils neuro changes VS changes HA seizures
T11-L5 injury devices
ambulates with assistence
S1-S5 injury devices
ambulates with or without assistance normal to impaired bowel and bladder function
artificially caused rupture of membranes
amniotomy; use of a hook
S4 sounds like
an atrial gallop
cardiac bypass (CABG)
an operation to restore the flow of blood through the arteries that supply blood to the heart, when a blockage or partial blockage occurs in these arteries
s/s of cardiogenic shock
angina mental status changes dysrhythmias increased BNP angina decreased HR and BP clammy skin FEELINGs of doom
an interior wall MI is a more favorable prognosis than a
anterior wall MI
pharm therapy used for SCI
anticoags pain management muscle relaxants fluids
admin what for N/V
antiemetics
s/s of DIC
anxiety restlessness increased HR decreasing urine outpt bleeding severe HA= STROKE
signs of frank bleeding
anxiety, restlessness, decreased LOC, tarry stools, distended abd, high pitched bronchial sounds, tachypnea, hematuria, tachycardia, petechiae, gum bleeding, injection site bleeding, bruising, jt pain
causes of increased contractility=
anything that stimulates the sympathetic NS (flight/fight), MI, drugs: digoxin, epinephrine, dopamine
speech assessment
aphasia: receptive, expressive, gloval slurred speech
latent phase of labor mom will be
apprehensive but excited
FHRl accelerations
are ok, means good O2 reserve
escape beats are generated by
areas inside the conduction system, from a pacemaker lower down
arterial line components
art line transducer arterial pressure waveform on ECG connects tubing to pressure bag with NS
invasive catheters
arterial cath (BP) pulmonary artery (PA) pulmonary artery cath (PAP/swan ganz)
brain injuries may exhibit fast or slow bleeding, what bleeds faster veins or arteries
arteries
peritoneal dialysis can be taught to do at home
aseptically
straight cath can be done
aseptically
traction pins care involves what cleaning technique
aspetic
A transmucosal pain management is used
at the beginning of the administration of a transdermal patch d/t it taking time to be effective; and can be used at the tail end of the transdermal patch for the pain that begins there
dyrhythmia categories
atrial junctional reentry ventricular heart block
atrial flutter
atrial rate of 250-400 with saw-toothed p waves
Atrial Fibrillation
atrial rhythm= unmeasurable, ventricular=irregular rate: A >350, V <100 or >100 no P wave no PRI
braces are BEST for mobilization/contraction prevention because they allow for less
atrophy, muscles are used sooner, allows for ambulation for short distances
tx for excessive secretions with EOL
atropine drops, hyoscyamine, scopolamine
properties of cardiac cells
automaticity, excitability, conductivity, contractility
what is life threatening and leads to death and stroke
autonomic dysreflexia
what risk needs to be labeled on a pts chart?
autonomic dysreflexia
treatment of anaphylactic shock
avoid cause, epinephrine fluids albuterol O2 antihistamines IV benadryl CPR and intubation
HCO3 is
basic; controlled by the kidneys
to support as a nurse
be present, hearing, listening to the parents
PTCA when just a balloon is used can
be reoccluded by platelets that can clot again. Stents are used to prevent this but they too can still clot
anaphylactic shock cause
bee sting, PB, meds that cause a systemic antigen-antibody response that leads to systemic vasodilation and leaking capillaries
aortic valve
between left ventricle and aorta
tricuspid valve
between right atrium and right ventricle
pulmonary valve
between right ventricle and pulmonary artery
third stage of labor- placenta
birth of fetus-birth of placenta watch for HEMORRHAGE skin to skin
chronic HF is frequently what kind?
biventricular
without platelets and fibrinogen the body runs out of ways to clot blood and begins excessively
bleeding
intracerebral hemorrhage and hematoma
bleeding in the brain tissue
hemorrhagic stroke cause
bleeding into brain, ventricles, or subarachnoid space
obstructive shock
block in blood flow
subdural hematoma
blood btw the dura and brain
epidural hematoma
blood btw the skull and dura
anterior cord syndrome cause
blood flow issue, ischemia, aortic dissection, blood clot
VAD reroutes
blood from one of the ventricles back into the aorta to pump throughout the body used for recovery heart transplant or permanent solution
herniation=
blood supply is cut off from brain
ischemic stroke
blood supply stops to brain due to obstruction, usually a clot, causes infarction of the tissue
nitrazine paper will turn
blue if amniotic fluid is present
compensated PH
both buffers are out of range and PH is normal
s/s of increased contractily
bounding pulse
S1-S5 controls what
bowel, bladder, sexual function care considerations: bowel paralysis, bladder probs
risks of cooling
bradycardia (NO BBlockers, CCB, amiodarone) hypotension low CO fluid and electrolyte shifts (hypokalemia- dysrhythmias while cooling, hyperkalemia while warming) infection: WBC hyperglycemia: doesn't respond to insulin as well when hyperthermic, can drop when warming
hypercalcemia
bradydysrhythmias, blocks, CA
hypokalemia causes
bradydysrhythmias, conduction blocks
CNS
brain and spinal cord
what risk occurs with elevated ICP
brain herniation;
coup injury
brain injury from direct blow
epidural hematoma s/s
brief loss of consciousness with return to lucid state, then as it expands increased ICP reduces LOC suddenly
for incontinence wear
briefs keep dry and clean Is/Os straight cath teach family how to straight cath
head injury
broad term that includes injuries to the scalp, skull, or brain
tx for dyspnea EOL
bronchodilators, diuretics O2 , lorazepam and morphine in combo
exs of incomplete injury
brown Sequard syndrome anterior cord syndrome posterior cord syndrome central cord syndrome
bradycardia occurs as a result of spinal shock because of what imbalance?
btw the parasympathetic and sympathetic NS
PCO2 and HCO3 are
buffers that body uses to maintain balance. They are compensating for a PH imbalance
aneurysm
bulging, ballooning, or dilation at a weak pt of an artery
antidote for too much Mg sulfate
calcium gluconate
transducer-tipped catheter
can be placed in a ventricle, subdural, subarachnoid space, brain parenchyma or under a bone flap
peritonitis
can occur with peritoneal dialysis check for cloudy, puss, increased WBC, rigid abd)
why shouldn't you move a pt with a suspected sci
can worsen prognosis from incomplete SCI to complete SCI
primary injury you can't prevent but secondary you
can; timeline for prevention is 4-6 hrs after injury
illness that progress over time and are terminal (hospice care)
cancer, COPD, HF
TAH are used for pts who are not
candidates for heart transplant or are on the waiting list
PAWP will increase related to
cardiac tamponade, fluid over load, LV failure, pulmonary HTN, cardiogenic shock
IABP is used for
cardiogenic shock; controls blood flow to the heart
types of shock
cardiogenic, obstructive, hypovolemic, distributive (septic, neurogenic, anaphylactic)
maintain oxygenation by checking
cardiovascular and resp functions
involve children in their own
care; according to the extent that they are able to
pt with tetraplegia will need to relieve pressure on their skin with assistance from
caregiver
variable decelerations
caused by cord compression abrupt decrease of FHR BAD if persistent
intrarenal
caused by infection, nephrotoxicity, crush injuries actual damage to kidney tissue acute tubular necrosis occurs ATN Tx with abx
late decelerations
caused by placental insuff BAD
postrenal (least common)
caused by urinary tract obstruction due to obstruction distal to the kidney including arteries or veins (kidney stone can cause but are rare) tx: remove stone/obstruction
spinal shock affects peripheral circulation by
causing vasodilation in the lower extremities venous pooling occurs increased clotting risk hypotension leads to--> shock
central cord syndrome damage
center of spinal cord damaged
normally delivers involves what presentation
cephalic
ICP is equal to MAP when
cerebral circulation stops
causes of secondary injury (head)
cerebral edema, ischemia, chemical changes, inadequate O2
CPP
cerebral perfusion pressure; pressure it takes for the heart to provide brain with blood
tetraplegic SCI injury occurs where
cervical
resp system should be assessed especially if injury is located in the
cervical area (C4) or T12 and above
true labor s/s
cervical changes consistent contractions that continue no matter the position made dilation pain that starts in the back and radiates to the front
central cord syndrome most common cause is trauma caused by what
cervical injury, whiplast
brain death
cessation and irreversibility of all brain functions, including brainstem
increases ICP early s/s
changes in LOC, restlessness, disorientation
neuro changes to look for
changes in sensation, movement, reflexes
nursing management for CAD
check pts risk factors modify risks that can be
if the monitor alarms the first thing to do is
check the pt and the leads to ensure they are still on and reading
if the patient looks fine when an alarm sounds
check to see if the leads are in the right place and stuck well
PT/INR/PTT
checks for blood clots, can indicate a PE. These labs are checked to determine bleeding risk prior to a cath lab procedure
female MI s/s
chest discomfort in neck, back, arm, shoulder, jaw, or throat, SOB, N/V, indigestion UNRELIEVED with antacids, upper abd pain, dyspnea, fatigue, diaphoresis, fainting, dizziness
T1-T6 controls what
chest muscles care considerations: resp complications
PE s/s
chest pain, anxiety, SOB, increased CO2, decreased O2
children and shock s/s
children don't tend to show the early s/s of hypotension and decompensate quickly
Living children=
children living; NOT including current preg
involve parents in all aspects of their
children's care
syndrome that is caused by repeated concussions
chronic traumatic encephalopathy
anaphylactic shock
circulatory shock caused by a severe allergic reaction - vasodilation - hypovolemia
septic shock (most common type of distributive shock)
circulatory shock from infection, hypovolemia
during DIC the body experiences mass _____ and ________
clotting, bleeding
synergism
clusters of s/s of EOL have this effect
with septic shock the temperature can be warm at first and then go
cold (phase 2)
subdural hematoma patho
collection of venous blood btw the dura and brain
STEP TWO: moderate pain 4-6 tx
combo opioids: hydrocodone and acetaminophen, oxycodone and acetaminophen, continued adjuvant meds
epidural hematoma is an emergency because
compensation mechs fail. increased ICP leads to herniation. Pt condition will deteriorate rapidly
3 stages of shock
compensatory progressive irreversible (refractory)
intracranial autoregulation
compensatory mech that allows the brain to change the diameter of the blood vessels to maintain constant blood flow to the brain during changes in systemic BP
primary injury could include
complete transection, severing of the spinal cord
complete injury
completely severed; loss of sensory and motor movement below the injury
PTCA through the femoral artery has more
complications
prevent PE with
compression socks, devices, PROM, hydration, greenfield filter/inferior VC device
intra aortic balloon pump (for cardiogenic shock) can
compromise the leg on the side of the cath balloon, check neuro status and lower extremities freq
osmolality=
concentration
types of brain injury
concussion, contusion, closed brain injury, open brain injury
SCI is the result of a
concussion, contusion, laceration, or compression of the spinal cord
heart block dysrhythmias
conduction block btw ventricles
other causes of autonomic dysreflexia
constipation, impaction skin stimulation thermal stimulus pressure ulcer sexual activity/overstimulation cramps labor/delivery men sitting on scrotum skeletal fractures
Chronic Traumatic Encephalopathy (CTE) is common in what sports
contact sports; s/s are similar to Alzheimers dx with personality changes, memory impairment, speech/gait disturbances, atrophy of the cerebral and temporal lobes
colloids
contain large insoluble particles which exert pressure albumin, FFP
art line is used for
continuous BP monitoring, blood testing, ABGs
LOC is the
continuum form normal alertness and full cognition to coma
women with SCI need what to prevent preg
contraceptives
frequency
contraction measurement from beginning of one contraction to the beginning of the next
risk factors with AKI
contrast dye use older adults diabetics infections sepsis nephrotoxic drugs dehydration chronic use of NSAIDS
causes of primary injury (head)
contusions lacerations damage to blood vessels acceleration/deceleration injury (MVA), object penetration, diffuse axonal
preeclampsia becomes eclampsia when
convulsions or coma occur
surgery is indicated for
cord compression, fragmented vertebrae, penetrating cord wound, or if pts neuro status is deteriorating
abdominal thrusts are used to help a pt
cough, clear secretions
PNS
cranial and spinal nerves autonomic and somatic systems
surgical interventions for increased ICP
craniotomy burr holes
what may not be possible for treatment of a intra cerebral hemorrhage b/c of the inaccessible location or lack of clear circumscribed area of hemorrhage
craniotomy or craniectomy; esp in the case of a bullet wound
a platelet count of 20,000 or lower is
critical
hospice is care minded NOT
cure minded; care team helps fam and pt accept dying as a normal part of life
other s/s of death
cyanosis/mottled skin loss of bowel and bladder control change in muscle control restless decreased urine outpt decreased temp
tx of increased contractility
B blockers, CCB
stroke kills acronym
BE FAST balance loss eye changes face weakness arm weakness speech difficulty time of when s/s started
prognosis of brown sequard syndrome
BEST 75-90% recover
late s/s of increased ICP
BLOWN PUPIL resp and vasomotor changes further LOC changes cushings triad posturing
what lab is helpful when diagnosing HF
BNP
if wedge pressure is high then it's a heart prob
BNP would we high= cardiogenic shock tx: diuretic
nonsevere preeclampsia
BP >140/90 after 20wks gestation - no seizures, hyperreflexia
eclampsia
BP >160/110 - seizures/coma -hyperreflexia - severe HA - cerebral hemorrhage - Renal failure - HELP
severe preeclampsia
BP greater or equal to 160/110 on two occasions 6 hrs apart on bedrest hyperreflexia is present
for afterload; when the ventricle contraction is must generate enough pressure to exceed
BP to open the semilunar valves
VS during the 4th stage of labor should be
BP= increased (can decrease with epidural) HR= increases Uterus= firm, located at the midline
Propranolol
Beta blocker used to decrease heart rate
battles signs
Bruising behind the ears (over the mastoid process)
first thing ordered with a SCI
C coller, stabilize, O2
placenta previa will result in an
C section delivery
cervical spine
C1-C7
S4 heart sound indicates what conditions
CAD, HTC, stenosis of the aortic valve
L sided HF causes
CAD, high BP, heart attack
pharm management of pulmonary HTN
CCB, prostanoids, endothelin antagonists, phosphodiesterase 5 inhibitors
early s/s of increased ICP
CHANGES IN LOC slowing of speech/delay in response - impaired extraocular movements - weakness - HA
cardia outpt equation
CO= HR x SV
Venturi mask is the most accurate way to deliver O2 and is used most oftenly for
COPD pts
critical care pain observation tool
CPOT; used in critical care units who cannot self report their pain whether they are intubated or not.
with dx or injury ICP may increase which decreases what
CPP
parents may feel they are giving up on their child to allow withholding
CPR
diag test for TIA
CT MRI PET cerebral angiography myelography noninvasive carotid flow studies transcranial doppler EEG EMG nerve conduction studies LP labs
diagnostics for brain herniation
CT scan skull and spinal xrays MRI physical and neuro exam PET
diagnostic tests for SCI
CT, xray, MRI
where would we detect increased pressure with a PA cath with pulmonary HTN?
CVP, PAS, PAD, PAWP
Verapamil
Calcium channel blocker used to decrease heart rate
early decelerations
Caused by head compression OK
typical MI s/s
Chest pain, Dyspnea/SOB, N/V, Diaphoresis.
S2
Closure of the aortic and pulmonic valves
S1
Closure of the tricuspid and mitral valves
Hb
females: 12-16 males: 14-17 children: 9-15
HCT
females: 36-48% males: 42-52% children: 30-42%
PTCAs are done in the cath lab through the
femoral artery or radial artery
S/S of meningitis
fever, chills, neck rigidity, increasing persistent HA
sympathetic NS
fight of flight response - vasoconstriction - hypertension 200/100 - increased muscle tone - blotching - goosebumps - cold, clammy skin - restlessness
careful with fluid admin with intra cerebral hemorrhage treatment b/c there is a
fine amount of fluid amount used to prevent fluid overload
halo device
fixated to the skull by pins it supports the head and immobilizes the spine with skeletal traction to allow for early ambulation
s/s of spinal shocks
flaccid muscles, loss of spinal reflexes, loss of DTRs and motor/sensory function, bladder paralysis and distention, paralytic ileus and distended abd, hypotension, bradycardia
the most severe neuro impairment results in
flaccidity; the motor response can't be seen or assessed when the pt has been given pharm paralyzing agents (neuro blocking agents)
endotracheal intubation may be indicated but don't
flex or extend the neck
pressure=
flow x resistance
the pressure in the ventricle at the end of diastole is determined by how much
fluid is in the ventricle right before the next contraction
HF is characterized by
fluid overload or inadequate tissue perfusion
treatment of SIADH
fluid restriction (<800mL/day) hypertonic saline 3%
monitor the pts core temp with a
foley, probe in esophagus, or schwann
neurogenic shock
from loss of sympathetic tone, hypovolemia
Purkinje fibers extend
from the bundle branches into the endocardium deep into the heart tissue
abnormal activation of fibrinolysis leads to
further bleeding
reflexes assessment
gag corneal plantar (babinski) DTRs
AV node is the
gatekeeper, delays impulses to allow ventricles to fill
p wave is when the SA node
generates the impulse
check sensation by
gently pinching skin, touching skin lightly with a tongue blade working from the shoulder down both sides of the body with pts eyes closed. Pt is asked where the sensation is felt
cardiac leads are used to
get an EKG/ECG reading of the heart
reentry rhythm
get stuck in conduction loops, narrow QRS
suction PPE- droplet precautions
gown mask goggles gloves
the duration of the mental status changes is an indicator of the
grade of a concussion
diuresis period
gradual increase in urine output, labs stabilize
anticipatory grief
grief experienced prior to a loss Ex: grief at diagnosis at loss of "normal" life; preparing for the loss of a limb for amputation
IABP is inserted in the
groin; above the renal bartering and below the aortic arch
CSF leak s/s
halo sign; ring of fluid around the blood stain from drainage
tx for delirium EOL
haloperidol
ASA
has an antiplatelet effect, prevents blockages
characteristics of atrial dysrhythmias
have p wave- can have some abnormal, have a narrow QRS complex
check motor response by
having them spread their fingers, squeezing your hand, move toes or feet
key components of assessment
health hx physical assessment monitor labs, diagnostic tests
MI=
heart attack
cardiogenic shock
heart can't pump well enough to supply blood and O2 to tissues
Age effects cardiac structure and function of conduction pathways
heart increases in size (hypertrophy) slower HR valves stiffen, don't close properly
angina=
heart ischemia
CVP will increase related to
heart prob, R HF
if CVP is high then it's a
heart problem, Right sided HF
goals for rehab with hemonymous hemianopsia
help them learn to read and navigate their environment
ammonia
helps maintain acid/base balance, elevation is a sign of liver dx normal= 15-45
a deep contusion involves
hemorrhage and destruction of reticular activating fibers, altering arousal
intra cerebral hemorrhage patho
hemorrhage in the substance of the brain
with increased ICP brain tissues may shift through dura and result in
herniation
cushings triad is a sign of
herniation of the brain stem and occlusion of the cerebral blood flow
leukocytosis occurs if the WBC is
high
mannitol is used to treat
high ICP
proper nutrition for SCI pt
high cal high protein high fiber
pregnancy with SCI becomes
high risk
SCI effects on delivery
higher risk for autonomic dysreflexia during labor may not be able to push during contractions vaginal delivery preferred
older adults have poorer outcomes with a head injury d/t
higher risk of hematoma comorbidities take anticoags (bleeding)
acme
highest pt of a contraction
hospice also includes what methods of pain control?
holistic care: - spiritual care - singing with pt - music - holding hands
subarachnoid screw/bolt
hollow device inserted through a hole in the skull that measures ICP. Not as invasive but CANNOT drain CSF excess
NO treatments or attempt for curing a pts dx is made with what kind of care
hospice
secondary injury can last
hours to days
duration
how long a contraction lasts; measured from beginning to end of the same contraction
fetal lie
how the fetus corresponds with the mothers spine
SIADH cause
hx of head injury, pituitary tumor or craniotomy, is also a complication of increased ICP
DI causes
hx of head injury, pituitary tumor, or craniotomy decreased secretion of ADH
eclampsia treatment
hydralazine mg sulfate steroids for fetal lung maturation
med management for AD
hydralazine, nipride baclofen
those with oliguria or anuria are at an increased risk of what complications related to renal injury
hyperkalemia; admin IV NS for oliguria
most common cause of death with acute kidney injury is
hyperkalemia; so a priority assessment is to monitor ECG for dysrhythmias
treat hypokalemia with
hypertonic NS 3% or 5%
causes of alkalosis
hyperventilation excessive vomiting overuse of antacids hypokalemia
ARI can cause other electrolyte imbalances
hypocalcemia: osteoporosis hypomag
cause of PVCS
hypokalemia
SIADH progs
hyponatremia, decreases osm, increased urine concentration
AR of hemodialysis
hypotension N/V anemia
to maintain cerebral perfusion treat
hypotension hypovolemia bleeding manage ICP
aneurysm rupture can cause
hypotension and shock
causes of acidosis
hypoventilation DKA severe diarrhea
sinus tachycardia cause
hypovolemia, or psychologic stress
PAWP will decrease related to
hypovolemia, vasodilation
CVP will decrease related to
hypovolemia; hypovolemic shock
supplemental O2 is given to an SCI pt as
hypoxemia can worsen neuro deficits
hypotension for children 1-10yrs
if SBP <70 + (childrens age x2)
when do pts need to go to the hospital for an eval or delivery
if contractions are 5 mins apart lasting 45-60 secs and are strong enough to not have a conversation during one
multifocal
if the qrs complex have two different appearance
acute/subacute subdural hematoma management
immediate craniotomy (to remove clot)
ICP >20 in adults warrants
immediate treatment interventions
spinal shock occurs
immediately after injury within the first hr
decorticate posturing
impairment of the cerebral cortex internal rotation of the hands/arms/feet
VAD (ventricular assist device)
implanted mechanical device that partially or completely replaces the pumping action of a failing heart
goal of palliative care
improve the quality of life to both patient andfamily in comfort-focused approaches to care inconjunction with cure-focused treatment.
ectopic beats
impulses caused by irritable tissue outside the conduction system
ED
inability to ejaculate or retrograde ejaculation
Oxygen
Administered to increase oxygenation
ABCDE
Airway Breathing Circulation Disability Exposure
AVPU
Alert, Ventilation, Pain stimuli, Unresponsive
Stroke Volume
Amount of blood ejected by the ventricle with each heart beat
Cardiac Output
Amount of blood pumped by the heart per minute
Dissecting Aortic Aneurysm
Aortic aneurysm caused by a tear in the aortic wall
Antiplatelet therapy
Aspirin; continued for life or Clavix; continued for 1 yr post MI
5 Ps of labor
Passenger, passageway, powers, position, and psychological response
Ejection Fraction
Percentage of ventricular end-diastolic volume pumped out from the ventricles in one beat
PTCA
Percutaneous Transluminal Coronary Angioplasty, procedure to open blocked coronary arteries by placing a deflated balloon to inflate and press plaque against the arterial wall, then balloon is removed
Preload (filling pressure)
Pressure inside the ventricle at the end of diastole; determined by how much fluid is in the ventricle right before it contracts
Cardiac Tamponade
Pressure on the heart due to excess pericardial fluid created to decrease friction when inflammation occurs post MI
Afterload
Pressure that the ventricle has to pump against to get blood to the heart
intracranial regulation
Processes that impact intracranial compensation and adaptive neurological function. (head injury)
normal sinus rhythm
R-R constant, equal rate, HR 60-100, QRS and PRI within range
contracture prevention
ROM 4x/day braces (best) trochanter rolls for hips
internal monitors
ROM required dilated at a 2 used for high risk pregs EX: fetal scalp electrode, intrauterine pressure catheter
neurogenic shock can have decreased HR and increased
RR
uncomplicated grief
Range of emotions experienced after a loss moving toward adjustment; brief periods of relapse common Examples: Missing a deceased grandparent during holidays
Targeted Temperature Management
Therapeutic hypothermia to decrease metabolic demands and promote healing
using a straight cath prevents
UTIs
PTCA uses
dye to find a clot
ectopic beats are usually
early and look different than the other beats in the ECG
ST seg represents
early phase of ventricular repolarization
give the pt what they want to
eat
C4 injury devices
eat with adaptive sling electric wheelchair
s/s of R HF
edema, wt gain, JVD, ascites around abd, hepatomegaly, GI upset, anorexia, weakness
the family may misinterpret actions of the care team with irreversible shock
educate them on the prognosis - that this stage is irreversible - they may be angry - don't indicate pt will recovery
in a multipara birth they don't experience
effacement or dilation until labor starts; it occurs simultaneously
ejection fraction measures what of the ventricles
efficiency
C5 injury devices
electric or modified manual wheelchair
ECG is only a reading of the
electrical activity of the heart. It doesn't include the physical activity
PR interval causes a delay in the
electrical stimulation
BMP
electrolyte lab to prevent imbalances that cause arrhythmias
DIC lab values
elevated PT and INR
emergency tx for epidural hematoma
emergency craniotomy burr holes
A hospice nurse is well aware of how difficult it is to deal with others' pain on a daily basis. This nurse should put healthy practices into place to guard against what outcome?
emotional exhaustion
what's a nursing intervention that can be done for AD caused by bladder distention
empty the bladder check catheter for kinks irrigate catheter replace catheter
tx for constipation EOL
enema, suppository
cardinal movements
engagement flexion internal rotation extension external rotation expulsion
intracranial bleeding types
epidural hematoma subdural hematoma
chronic subdural hematoma treatment is
evacuation of the clot; burr holes or craniotomy
2.5 million people
every year get head injuries in the US
partially compensated
everything is out of range
azotemia
excess urea and nitrate wastes in the blood
laminectomy
excision of the posterior arch of a vertebra
EDC means
expected date of confinement; due date
trochanter rolls prevent
external rotation of hip joints
ventriculostomy EVD
external ventricular drain; a small cath is placed in a lateral ventricle connected to a fluid-filled system and transducer. It records ICP and allows excess CSF to drain
for increased ICP avoid
extreme hip flexion or neck (increases ICP)
glascow coma measures
eye opening, verbal, motor
homonymous hemianopsia is not an
eye problem; a brain prob
most common cause of brain trauma is
falls
causes of epidural hematoma in children
falls, assaults, baseball to the temporal area
Braxton Hicks contractions
false labor - tightening sensation - relieves with activity - last 30 secs-2mins - experienced throughout pregnancy
T/F a contusion is a temporary loss of neuro function with NO structural damage to the brain
false; this is the definition of a concussion
s/s of postpartum depression
fatigue withdrawn wt loss hopelessness
careful with repositioning pts as they can't
feel