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