C488 Critical Care

Glasgow Coma Scale

eyes, verbal, motor Max- 15 pts, below 8= coma

Yellow or tenacious sputum

indicative of a respiratory infection

Blunt trauma to the abdomen, with lacerated liver and abdominal hemorrhage. During the recovery period, the nurse would monitor the client for which indications of peritonitis/

-Boardlike abdomen -Abdominal tenderness -Decreased bowel sounds

After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. To ensure adequate cerebral blood flow the nurse should: 1. Clear the ear of draining fluid 2. Discontinue anticonvulsant therapy 3. Elevate the head of the bed 30 degrees 4. Monitor serum carbon dioxide levels routinely

Monitor serum carbon dioxide levels CO2 levels must be maintained bc CO2 can cause vasodilation, increasing ICP and decreasing blood flow.

Which area of assessment is included in the Glasgow Coma Scale?

Motor response to verbal commands, eye-opening in response to speech and verbal response to speech

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock?

Bradycardia, hypotension, urinary retention

A client had a wedge resection of a lobe of the lung and now has a chest tube with a three chamber underwater drainage system in place. The nurse recalls that the third chamber has which main purpose?

Controls the amount of suction -The first chamber collects drainage; the second chamber provides for the underwater seal.

Postoperatively, a client who had a thyroidectomy complains of tingling and numbness of fingers and toes, and the nurse observes muscle twitching. Which complication would the nurse suspect?

Hypocalcemia -injury to the parathyroid glands during a thyroidectomy commonly results in decreased serum calcium levels.

Which action would the nurse anticipate taking when a client develops third degree atrioventricular black with a HR of 30/bpm?

Obtain the transcutaneous pacemaker Transcutaneous pacing is used for emergency treatment of bradycardia, because it is noninvasive and can be rapidly initiated.

Which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain?

Stop the blood transfusion and infuse saline. These symptoms indicate hemolytic rxn, which is potentially life threatening; infusing saline limits kidney damage.

azotemia

(excessive) urea and nitrogenous substances in the blood

When providing care for a client experiencing cardiogenic shock, which clinical manifestation would the nurse anticipate?

-Rapid pulse -Decreased urinary output -decreased BP -cool, clammy skin HR increases to meet the body's oxygen demands and circulate blood to vital organs; the pulse is weak and thready bc of peripheral vasoconstriction. The UOP decreases bc of increased fluid absorption in the kidneys. Respirations are rapid and shallow. Skin is cold and clammy caused by the shunting of blood to vital organs. BP is decreased bc of continued hypoperfusion and multiorgan failure. BP decreases due to poor cardiac output Skin is cool and clammy due to vasoconstriction

Which Glasgow Coma Score indicates the client is in a coma?

6 -A score of 8 or below indicates coma.

Which rewarming method is appropriate specifically for a client suffering from severe hypothermia?

Applying heated humidified oxygen

When caring for a client who has a hemopneumothorax and a chest tube, which prescribed action by the healthcare provider would the nurse question?

Autotransfuse the blood in the blood in the collection chamber after 6 hours -Autotransfusion of blood from the collection system helps decrease the need for transfusion, but is not recommended for blood that has been in the system for more than 4 hours. ***the suction control chamber can be disconnected from wall suction to ambulate the patient; fluid in the suction control chamber frequently evaporates and needs to be replinished; 20 cm of suction is commonly prescribed. Dressings impregnated with petroleum jelly are frequently use around chest tube insertion sites to prevent air from entering the pleural space.

Cerebral Perfusion Pressure (CPP)

CPP = MAP - ICP -MAP: mean arterial pressure ICP: Intracranial pressure

Cardiogenic shock

Crackles are associated with pulmonary edema caused by cardiogenic shock

angiogram

The radiographic visualization of blood vessels after the injection of radiopaque substance.

antidote for warfarin

Vitamin K

Escharotomy

an emergency surgical procedure involving incising through areas of burnt skin to release the eschar and its constrictive effects, restore distal circulation, and allow adequate ventilation

Hypervolemia

bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's

DKA-blood glucose reading too high to register on glucometer

give immediate bolus of 1 liter of normal saline infusion until blood glucose, potassium, and phosphorus levels are known

symptoms of hypokalemia

weak pulse, generalized weakness, diminished reflexes, shallow respirations, nausea, vomiting, decrease specific gravity of urine. and cardiac dysrhythmias Depressed s-t , inverted T waves

side effect of nitroglycerin

orthostatic hypotension and headache (due to venous and arterial dilation)

Melana

passage of dark-colored, tarry stools due to the presence of blood in the stool

ARDS positioning for intubated client

prone for 16 hours a day to remove the weight of the heart and abdomen away from the lungs and improves oxygenation

Which assessment has the highest priority when providing care for a client with a burn in the emergent stage?

Extent of burn First assess the burn, then the cause of the burn, then where it occurred, and the determines first aid measures that were used. For immediate treatment of the burn, the nurse would be concerned with the body location and extent of the burn.

Client develops flank pain, chills, and fever while receiving a blood transfusion. Which type of transfusion rxn would the nurse conclude that the client is probably experiencing?

Hemolytic **Results from incompatibility between recipient's antibodies and transfused red blood cells (type 2 hypersensitivity) Clinical findings are a result of red blood cell hemolysis, agglutination, and capillary plugging.

The health care provider prescribes lidocaine to treat ventricular dysrhythmia in a client with cirrhosis of the liver. Which alterations in the usual lidocaine dosage would the nurse anticipate for the client?

Lower than usual dosage because the medication is metabolized at a diminished rate -the liver will not be able to break down lidocaine as effectively as necessary. (higher doses could increase concentration in the blood and lead to toxicity)

Which complication will the nurse anticipate when caring for a client in late hypovolemic shock?

Metabolic acidosis -decreased cellular oxygen caused by poor perfusion increases the conversion of pyruvic acid to lactic acid resulting in metabolic acidosis. Hyperkalemia will occur in early shock and CO2 levels will increase in profound shock

A client with severe hyperkalemia develops acidosis. Immediate administration of which medication can help prevent a life-threatening crisis?

Sodium bicarbonate -it decreases the potassium level if acidosis is present.

Antidote for Acetaminophen

acetylcysteine

Sign of splenic rupture

referred pain to the left shoulder, known as Kehr's sign

Which specific emergency burn management would be appropriate for a client received in the emergency department with burns caused by flames?

Removing all metal objects **primary care provider should remove all smoldering clothing and metal objects

Which clinical indicators would the nurse consider evidence of increasing intracranial pressure?

Vomiting, irritability, and decreased level of consciousness. -anorexia, n/v occur because of pressure on the brain. Increasing pressure on the vital centers in the brain and irritation of cerebral tissue result in irritability and seizure. Blood pressure will be increased and pulse pressure also increases. Respiratory rate also decreases.

Which assessment finding alerts the nurse to increasing intracranial pressure?

Widening pulse pressure -pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between systolic and diastolic pressure. the client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated, not constricted. Pressure on the vital centers in the brain results in a decreased heart rate

The nurse would monitor postoperative clients for which clinical manifestations of a pulmonary embolus?

-Dyspnea (bc of increased alveolar dead space, which impedes ventilation) -Hemoptysis (coughing up blood) -Feeling of impending doom

Extubation

Removal of endotracheal tube

frothy sputum

pulmonary edema (contains bubbles and is foamy) also seen with left sided HF

electromyogrpahy (EMG)

recording the strength of muscle contraction as a result of electrical stimulation -can reveal nerve/muscle dysfunction or problems with nerve-to muscle transmission

A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority?

Institute fall prevention and safety measures -high ammonia levels contribute to deterioration of mental function and then to hepatic encephalopathy and hepatic coma; safety is a priority

the nurse is collecting a sample of ABGs for a client with hypoxia due to cardiomyopathy, Which should the nurse assess prior to obtaining the arterial blood sample?

Ulnar blood flow

CT scan

a series of x-ray photographs taken from different angles and combined by computer into a composite representation of a slice through the body

For a client 2 days after admission with a burn injury, which type of sputum would the nurse anticipate when performing the respiratory assessment?

Sooty The mucous membranes of the respiratory tract may be charred after inhalation burns.

Most common adverse effect of a tissue plasminogen activator (t-PA)

increased bleeding at IV insertion site bc of thrombolytic action of the medication

Upon admission to the emergency unit, which intervention would be beneficial for the client who survived a lightning strike?

-Applying spinal immobilization technique -Stabilization of ABCs---airway-breathing-circulation Applying spinal immobilization would reduce spinal cord injury pain. Stabilization of ABCs may be beneficial to prevent respiratory and cardiac arrest

Which medications are used to treat cerebral edema or decrease free water in clients with submersion injuries in the ED?

Furosemide and Mannitol

Signs of Beck's Triad

-low arterial blood pressure -distended neck veins -distant, muffled heart sounds indicative of cardiac tamponade

Which finding would the nurse expect when assessing a client diagnosed with hypovolemic shock?

Oliguria UOP decreases to less than 20-30 mL/hr bc of decreased renal perfusion secondary to s decreased circulation blood volume

Hepatic failure

Definition: The inability of the liver to function because of a disease process within the liver or because of demands beyond its capability. -increased risk of coagulation abnormalities causing an increased risk of bleeding; interventions to minimize the risk of bleeding: -stool softeners -limited puncture sites into skin -limit protein intake -perform abdominal girths to assess for develpment of ascites -monitor labs for coagulation discrepancies such as PT/PTT and liver function tests such as the BUN

The nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response would the nurse expect?

Metabolic acidosis -Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. **Hyperkalemia will occur with shock bc of renal shutdown, but is not measured with ABGs. **Respiratory alkalosis may occur in early shock bc of rapid shallow breathing, but in late shock, metabolic and respiratory acidosis occurs and CO2 level increases in profound shock

anastomotic leak

Occurs when there is a breakdown of the suture line in a surgical anastomosis and results in leakage of gastric or intestinal contents into the abdomen Can lead to sepsis and multiorgan failure if uncontrolled - Signs and Symptoms include: - Tachycardia - Hypotension - Fever - Abdominal pain - Left shoulder pain - Oliguria - "Sense of doom" - Hiccups • NOTIFY THE SURGEON ***small leak treated by NPO status, antibiotics and draining the fluid percutaneously; big leak an urgent laparotomy

When the nurse is administering intravenous potassium to a client with hypokalemia, which finding is most important to communicate to the health care provider?

QRS duration of 0.28 seconds When administering IV K+ supplements, it is important to evaluate for clinical manifestations of hyperkalemia. Widening of the Q waves is a potentially fatal manifestation of hyperkalemia (bc it may lead to cardiac arrest) and would be communicated rapidly to the HCP so the infusion can be stopped and K+ levels rechecked. **U waves are an expected manifestation of hypokalemia and are not an indication for a change in treatment

Which diagnostic test result will the nurse review after noticing large U waves on the ECG for a client who was just admitted to the cardiac unit?

Serum potassium -Large U waves suggest possible hypokalemia, which should be corrected to decrease dysrhythmia risk.

acute respiratory distress syndrome (ARDS)

a form of the sudden onset of severe lung dysfunction affecting both lungs, making breathing extremely difficult -a "white-out" appearance on the chest x-ray indicates opacity of pulmonary edema and density of lung consolidation

Which medication is most beneficial to the client with sickle cell anemia on a blood transfusion regimen who has cardiac dysrhythmias due to iron overdose toxicity?

Deferoxamine -A client with sickle cell anemia requires frequent blood transfusions and is at an increased risk for iron toxicity. Deferoxamine is an IV med that chelates with the iron and reduces iron overload.

When a client's cardiac monitor shows ventricular tachycardia, which action would the nurse take first?

Check for a pulse The treatment of ventricular tachycardia depends on whether the client has a pulse and is symptomatic with dysrhythmia. **The client with pulseless ventricular tachycardia may be defibrillated, but the nurse first needs to check for a pulse.

antidote for heparin (administered if their is evidence of excessive bleeding)

Protamine Sulfate - must push SLOW! -binds with heparin to form a physiologically inert complex; it corrects clotting deficits

Allergic transfusion reaction

Pts w/ hx of allergies; SS: urticaria (hives), itching, bronchospasm, anaphylaxis; Onset during or up to 24 hrs after; Prevent w/ leukocyte-reduced or washed RBCs (WBCs and plasma removed)

Which is the correct order of events that take place in a client with saltwater submersion injury?

1. Fluid is drawn from the vascular space into the alveoli 2. Alveolar ventilation is impaired 3. Hypoxia occurs 4. Blood is shunted to the lungs 5. Pulmonary pressure keeps increasing **More and more blood is shunted through the alveoli and since the blood is not adequately oxygenated, hypoxemia worsens which can result in cerebral injury, edema, and brain death

order of airway management

1. Intubate the client within 1 to 2 hours after injury 2. place the client on ventilatory support 3. Escharotomies of the chest wall, if necessary 4. Extubation is indicated when edema reolves **extubation usually occurs 3-6 days after initial injury, unless severe inhalation injury is involved

Order of jaw thrust maneuver on an unconscious client admitted in the emergency unit with traumatic injuries and a suspected spinal injury

1. Lay the client in supine position 2. Kneel at the top of the client's head to initiate the procedure 3. Rest elbows on the surface 4. Place one hand on each side of the client's head 5. Grasp the clients lower jaw and lift forward with both hands without tilting the head

When a norepinephrine intravenous infusion is prescribed for a patient in septic shock, which IV line would the nurse choose for the infusion?

Peripherally inserted central catheter (PICC) line Norepinephrine is a vesicant and can cause tissue necrosis if it infiltrates into the intradermal or subcutaneous tissues. It is best infused through a central line, such as a PICC line. ***Infiltration of fluids occurs more frequently when fluids are infused through the smaller and more fragile peripheral veins