Exam 4
Tx of flail chest
- Maintain ventilatory support potential chest tube - Supplemental O2 - Pain control
Abnormal Q Wave
- sign of ongoing or previous myocardial infarction • The result of absence of electrical activity (decrease perfusion)
metabolic syndrome symptoms
-Central obesity = -HTN (>140/90) -High triglycerides (>150) -Low HDL (<35) -Hyperglycemia Also: -Hyperuricemia -High LDL -Increased prothrombotic states
cardiac tamponade treatment
-removal of the fluid pericardialcentisis Sternomoty w drain
Expected findings for flail chest
-unequal chest expansion -paradoxical chest movement -tachycardia -hypotension -dyspnea -cyanosis -angina -anxiety
Normal lactic acid levels
0.5-2.2 mEq/L
lactic acid range
0.5-2.2 mEq/L
Body temp of heat stroke
104+
Compression to breathe ratio
30:2
• Normal MAP value: 60-90 mmHg
60-90 mmHg below 50: perfusion slightly impaired above 90: HTN
Hypothermia: Mild Signs
90-95º F (32-35º C): Shivering, confused, slurred speech
A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first? A 22 year old with a painful and swollen right wrist A 45 year old reporting chest pain and diaphoresis A 60 year old reporting difficulty swallowing and nausea An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8° C)
A 45 year old reporting chest pain and diaphoresi
hypovolemic shock
A condition in which low blood volume, due to massive internal or external bleeding or extensive loss of body water, results in inadequate perfusion.
Time cycled ventilator
A type of positive-pressure ventilator in which the ventilator ends inspiration after a selected inspiratory time has been achieved.
EXAM Which statements about shock are true? Select all that apply. A. Affects all body organs B. Occurs only in the acute care setting C. Is a whole-body response to tissue hypoxia D.. Results in widespread abnormal cellular metabolism E. Is classified as a disease rather than a discreet disorder F. May occur in older clients in response to urinary tract infections
A. Affects all body organs( starts non vital and progression all organs) C. Is a whole-body response to tissue hypoxia D.. Results in widespread abnormal cellular metabolism F. May occur in older clients in response to urinary tract infections
• Which clients would the triage nurse classify as emergent, needing to be seen immediately? Select all that apply. A. Client with crushing substernal chest pain and shortness of breath B. Client with a generalized skin rash who had shellfish for dinner yesterday C. Client with active hemorrhage after a motor vehicle crash D. Client with back pain and hematuria with a history of kidney stones E. Client with a dislocated shoulder F. Client with dysuria from a long-term care facility
A. Client with crushing substernal chest pain and shortness of breath C. Client with active hemorrhage after a motor vehicle crash
• Which factors will help an older adult client to avoid a heat-related injury? Select all that apply. A. Use a sunscreen with an SPF of at least 30 B. Limit activity at the hottest time of the day C. Wear lightweight, light-colored and loose-fitting clothing D. Take hot baths or showers to help cool the body's temperature E. Pay attention to personal physical limitations F. Take breaks from being in a hot environment
A. Use a sunscreen with an SPF of at least 30 B. Limit activity at the hottest time of the day C. Wear lightweight, light-colored and loose-fitting clothing E. Pay attention to personal physical limitations F. Take breaks from being in a hot environment
For which signs and symptoms does the nurse monitor when a client comes in to the emergency department with an anaphylactic reaction to a bee sting? Select all that apply. A. Bronchospasm B. Hypertension C. Laryngeal edema D. Respiratory distress E. Hypoglycemia F. Cardiac dysrhythmias
A.Bronchospasm C. Laryngeal edema D. Respiratory distress F. Cardiac dysrhythmias
ACRONYM FOR ASSESSSMENT PRIORITY: ABCDE
A:airway/c-spine B: Breathing: labored, oxygen needed, intubation C: Circulation: HR, BP, Pulse D: Disability-- lOC A: alert, V: responses to voice, P: pain U: unresponsive E: Exposure
What test determines FiO2
ABG
• Which first action would the triage nurse take for a client who comes to the ED with blurred vision, difficulty speaking, left extremity weakness, and difficulty talking? A. Send the client immediately for a head CT scan B. Notify the ED health care provider C. Delegate the assistive personnel (AP) to stay with the client D. Categorize the client as emergent
D. Categorize the client as emergent
While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. What action would the nurse take first? Deliver rescue breaths. Wrap the client in dry blankets Assess for signs of bleeding. Check for a carotid pulse.
Deliver rescue breaths.
Who at the biggest risk for ARDS?
Infection/ Sepsis patients
pulmonary contusion
Injury or bruising of lung tissue that results in hemorrhage.
• Myocardial Injury:
Prolonged lack of oxygen/ damage to cell- reversible but need tx quickly
Resolution phase of ARDS
After 14 days may have neuropsychological defects and poor quality of life
Volume cycled ventilator
Air pushed into lungs until a preset volume is delivered
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes that the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? Allow the client to rest quietly. Assess the client for bleeding. Document the findings in the chart. Medicate the client for pain.
Assess the client for bleeding.
Lung potential affects from ventilation
Barotrauma
Exudative Phase of ARDS
Beginning damage to alveoli Dyspnea
Important medication to give for heat stroke
Benzo: Shivering increases body temp
D-Dimer
Blood Test: measures break down products of blood clots: negative less likely of clot; positive confirms and further investigation Normal: below 0.4
• What is the priority action for the nurse to take at a picnic when an adult who is alert, has no difficulty breathing, and is not allergic to wasps is stung by a wasp. A. Apply a warm pack to the area and elevate B. Place a tourniquet proximal to the sting C. Gently scrape the stinger off with the edge of a credit card D. Observe for signs of inflammation before taking any action.
C. Gently scrape the stinger off with the edge of a credit card
Heat stroke assessment findings
Cause • Prolonged exposure to high temperatures Signs and Symptoms • Vital signs - Temp 104+, LOW BP, TACHY, Rapid Resp, • Skin: extremely flushed, may got to the point and stopped sweating • GI: N/V • Neuro: confusion, headache- AMS MODS
best way to verify placement of ET tube?
Chest x ray
The nurse gets the hand-off report on four clients. Which client would the nurse assess first? Client with a blood pressure change of 128/74 to 110/88 mm Hg Client with oxygen saturation unchanged at 94% Client with a pulse change of 100 to 88 beats/min Client with urine output of 40 mL/hr for the last 2 hours
Client with a blood pressure change of 128/74 to 110/88 mm Hg
paradoxical chest movement
Describes an abnormal chest movement, with your chest moving inward during inhalation rather than outward
Stage of shock #1- Initial
Early Stage) • MAP decreased 5-10 mm Hg from baseline • Compensatory Mechanisms are effective: Tachycardia and blood vessels constrict • Cardiac output and MAP are maintained within normal range • Production of lactic acid • Hard to detect at this point
Embolus vs. Thrombus
Embolus is a moving/traveling clot Thrombus is a stationary clot in an unbroken vessel
Three-Tiered Triage
Emergent: life or limb, ABC, stroke, hemorrhage, chest pain Urgent: tx quickly abdominal pain, fc laceration, high temp, pneumonia Non urgent: rash, finger fx, sprains
A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? Apply direct pressure to the bleeding. Ensure the client has a patent airway. Obtain a pulse oximetry reading Start two large-bore IV catheters
Ensure the client has a patent airway.
Nursing interventions for ARDS
Fluild, feeding tube/nutrition, positioning (prone)
Assessment early findings of sepsis:
HYPOtension Decrease/low urine output Tachycardia: secondary response to dehydration
MAP is influenced by:
Increase blood volume, increase MAP, Increased cardiac output, increased MAP • Total blood volume • Cardiac Output • Size of the vascular bed: vessels dilate; decrease MAP, contrict, blood flows faster increase MAP MAP is low inability to perfuse tissues and oxygenate
A nurse is caring for a client who suffered massive blood loss after trauma. How does the nurse correlate the blood loss with the client's mean arterial pressure (MAP)? It causes vasoconstriction and increased MAP. Lower blood volume lowers MAP. There is no direct correlation to MAP. It raises cardiac output and MAP.
Lower blood volume lowers MAP.
Fibroproliferative phase of ARDS
Lung damage leads Pulmonary Hypertension & Fibrosis Multiple Organ Dysfunction Syndrome (MODS)
Medication for Anaphylactic Shock
May need emergent intubation EPI- Antihistamines: Benadryl Steroids: decrease inflammation *Vasoconstrictors: Dopamine/ Levophed (Norepinephrine) is BP too low;
Distributive- Capillary Leak Syndrome
Mechanism: Fluids and proteins leak out of the tiny blood vessels; fluid in 3rd spacing • Common Causes: • Severe burns - • Liver disorders - ascites • Severe malnutrition - large "beer" bellies and tiny skeleton • Trauma:
EXAM Who is most at risk for coronary artery disease?
Metabolic Syndrome
First indicators of sepsis
Mild HYPOtension decreased urine output notify provider immediately of findings
Hypothermia: Moderate Signs
Moderate: 82.4-90º F (28-32º C): extreme confusion, stupor -ABCS
Obstructive Shock
NONCARDIAC problem inability for heart to pump from outside forces Preventing ventricles from filling HEART MUSCLE NOT DAMAGED
Medications for ARDS
Oxygen: most likely will require intubation Sedation/ Paralysis: highly oxygenated through ET tube; sedating pt reduces tissue oxygen needs Medications Corticosteroids: autoinflammatory **Antibiotics Fluid: maintain healthy fluid balance; diuretics Nutrition: enteral tube feeds, TPN
• Treatment septic shock
Oxygenation, intubation, *antibiotics, replenish fluid loss as severe dehydration Vasopressors: adequate tissue perfusion and increase BP
ARDS Treatment
Remove causative factors Administration of 100% oxygen Mechanical ventilation with positive end-expiratory pressure (PEEP).
Hyperventilation respiratory acidosis or alkalosis
Respiratory alkalosis
EKG marker to assess with angina
ST inverted or depressed-adequate supply of oxygen but reduced
ST segment elevation
STEMI: ST elevated myocardial infarction Cath Lab ASAP
Hypothermia: Severe Signs
Severe: Below 82.4º F (<28º C): MODS, LOW vitals
cardiogenic shock
Shock caused by inadequate function of the heart, or pump failure. MI
Assessment comparison MI vs Angina
Stable angina: -precipitated by exertion or stress -relief from nitro or rest - less than 15 mins - Not associated with N/V/ dyspnea, anxiety MI: occur with or without cause -relief only with opioids -lasts over 30 minutes -associated with N/V, epigastric distress, dyspnea, diaphoresis, and anxiety
Stage of Shock#2 : Compensatory (Nonprogressive)
Stages of Shock #2: • When MAP decreases 10-15 mm Hg from baseline • Tissue hypoxia in nonvital organs - Skin, kidneys, GI tract • Signs/Symptoms • *Vitals - Tachycardia, hypotension, increased respiratory rate; 2-5% decrease in pulse ox • Kidneys - decrease in urine output • Skin - cold • Neuro - confusion and restlessness • If recognized and treated - still reversable
Stage of shock #3- Progressive Stage of Shock (Intermediate Stage)
Stages of Shock #3: • Sustained decrease in MAP > 20 - from baseline • Vital organs - Heart, brain, lungs -hypoxic • Less vital organs - hypoxic • Signs and Symptoms become worse • Neuro - confusion • Mucous membranes - • Skin - pallor, cyanosis, cool • Kidneys - no urine output • 5-20% decrease in 02 saturation • To preserve life causes of shock needed to be resolved - why? need improvement/changes within an hour else death occurs; body cannot function without oxygenation to vital organs
Stage of shock# 4 - Refractory Stage of shock (Irreversible Stage)
Stages of Shock #4: Refractory Stage of shock (Irreversible Stage) • Widespread Tissue Damage Release of toxic metabolites and destructive enzymes Cell damage will continue even with aggressive intervention As cells die more harmful metabolites are released Results in MODS -Multiple • Neuro - Rapid loss of consciousness • Vitals - No palpable pulse • Skin - waxy pre death look • 02 Sat - unmeasurable
On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take? Encourage the client to drink cool water or sports drinks. Start an intravenous line and infuse 0.9% saline solution. Administer acetaminophen (Tylenol) 650 mg orally. Encourage rest and reassess in 15 minutes.
Start an intravenous line and infuse 0.9% saline solution.
Pulmonary artery catheter
Swan-Ganz catheter measures perfusion monitor cardiac and pulmonary function
Priority for sepsis
TREAT INFECTION Within 1 hour administer broad spectrum antibiotics Vancomycin
Key Assessment of Shock
Tachycardia HYPOtension Rapid Respirations Bump Lactic Acid
Potential risk with mechanical ventilation
Ventilator associated pneumonia (VAP)
Medications for ARDS
corticosteroids and antibiotics
acute respiratory distress syndrome (ARDS)
acute respiratory failure that has: -hypoxemia even with max O2 delivery -severe dyspnea - Bilateral pulmonary edema - dense infiltrates
Cause of MI
atherosclerosis
Leading cause of coronary artery disease
atherosclerosis
How is lactic acid produced?
bacteria in blood stream) destroyed in blood stream releases as endotoxins; cell death=lactic acidosis oxygen levels low carbohydrates breakdown for energy and results in lactic acid
Paralytic ileus
complete absence of peristaltic movement can occur from ventilation change in abdominal pressure
Barotrauma lung
damage to lungs from ventilator positive pressure & PEEP too high
Distrubutive shock
excessive dilation in blood vessels blood improperly stored
Flail Chest
fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment
Hemothroax Massive
greater than >1000ml
respiratory alkalosis
high pH, low CO2 hyperventilation
Lab to monitor with sepsis
lactic acid
Hemothroax Simple
less than < 1000ml
What causes hypovolemic shock
loss of blood volume
respiratory acidosis
low pH, high CO2 hypoventilation
positive end-expiratory pressure (PEEP)
positive pressure maintained by the ventilator at the end of exhalation (instead of a normal zero pressure) to increase functional residual capacity and open collapsed alveoli; improves oxygenation with lower fraction of inspired oxygen
Cardiac Tamponade
pressure on the heart caused by fluid in the pericardial space
ST segment
represents time from depolarization to repolarization of Myocardial muscle
Most common cause of ARDS
sepsis
• Myocardial Infarction:
tisssue death; absence of blood supply: irreversible • EKG Changes: ST elevation and abnormal Q wave
What makes lactic acid?
when O2 levels are down, carbs breakdown for energy and makes lactic acid
Heat Stroke Treatment
• ABCs • IV fluids (NO ORAL FLUIDS- if N/V or AMS risk of aspiration) • Cooling Blankets/ ice packs • Medications to prevent shivering- Benzo: shivering as physical activity increase temp Goal: tx aggressively until temp below 100
Pressure cycled ventilators
• Air pushed into lungs until a preset airway pressure is reached: positive pressure most common
• Microprocessor Ventilator
• Computer managed - components of pressure, time, AND volume
Multiorgan Dysfunction Syndrome (MODS)
• Defined: Two or more organs failing at the same time • caused by the immune system's uncontrolled response to severe illness or injury • Common cause of death of patients in the ICU • Identifying and acting quickly can help survival-- • Mortality rate: 50% • Can develop quickly following surgery, trauma, or severe burns or slowly in the case of an infection
phases of ARDS: exudative
• Early changes and dyspnea • Oxygen may be necessary • Alveoli are beginning to become fluid overloaded
Cardiovascular potential affects from ventilation
• Hypotension: increased chest pressure and inhibits natural blood flow back to heart • Fluid Retention: inhibit natural blood return to heart; kidneys receive less blood flow which stimulates RAAS system to retain fluid
Physiology of HYPOperfusion = Shock
• Inadequate Tissue Perfusion • Inadequate delivery of Oxygen and nutrients Inadequate elimination ofMetabolic wastes
Myocardial ischemia
• Lack of oxygenation; complete or decrease blood supply to any myocardial tissue; reversible:Treatment: NITRO (constricts blood vessels; bring oxygenated blood back around to heart)
phases of ARDS: • Fibroproliferative Phase
• Lung damage leads to Pulmonary Hypertension and Fibrosis P HTN: increased pressure in lungs; Fibrosis: stiffness/ inability to contract Multiple Organ Dysfunction Syndrome (MODS):
Distributive Anaphylactic Shock
• Mechanism: severe allergic reaction • Skin: Hives (urticaria), cyanotic, pallor • Blood pressure: HYPO; abrupt fall in cardiac output • Respirations: rapid, shallow, dyspnea leading to respiratory arrest • Other: swelling of mucus membranes/ pulmonary edema Treatment: May need emergent intubation EPI- Antihistamines: Benadryl Steroids: decrease inflammation *Vasoconstrictors: Dopamine/ Levophed (Norepinephrine) is BP too low;
Phase of ARDS: Resolution Phase
• Occurs after 14 days • Many patients who survive ARDS have neuropsychological deficits and poor quality of life: depending on how long patients suffered lack of oxygenated blood. • Monitor when enter resolution phases: LOC, Hypoxic brain injury, memory loss
assessment of hypothermia
• Occurs at core body temp <95º F (35º C) • Signs and Symptoms - based on severity... • Categories by severity • Mild: 90-95º F (32-35º C): Shivering, confused, slurred speech • Moderate: 82.4-90º F (28-32º C): extreme confusion, stupor -ABCS • Severe: Below 82.4º F (<28º C): MODS, LOW vitals Goal: warm core temp, warm IV fluilds
heat exhaustion assessment findings
• Onset - Sudden • Cause • Too much perspiration and not enough rehydration • Dehydration • Losing too much body fluilds cannot replace • Signs and Symptoms • Vital Signs: HYPO, low grade fever • Skin: diaphoretic • GI: N/V, cramping • Other: dehydration extreme, headache, fatigue, dark urine
Assess Respiratory Status of patient on vent
• Q 4 hours, color, bilateral chest expansion, spO2, ABGs • Auscultate lungs
GI/Nutritional Potentially affects of ventilation
• Stress on the body can cause ulcers • Antacids, H2s or PPIs will be ordered as soon as pt is intubated Changes in chest/abdominal pressure:paralytic ileus
Treatment of Shock
• Treat underlying cause • Increase oxygenation • Improve tissue perfusion: biggest problem Fluid replacement • Blood - replace blood products help to replenish fluid volume and • Crystalloids - LR or normal saline • Albumin (colloid) expands plasma volume Interventions: #1 manage BP—able to support BP and maintain good cardiac output • Vasoconstrictors • Norepinphrine (Levophed): emergency shock situation bolus • Dopamine • Inotropes • Dobutamine (Dobutrex): support BP; early on intervention • Oxygen therapy • Maintain PaO2 > _80-100 mmHg
Heat Exhaustion Treatment
• Treatment • Bring core temp down to prevent progression of heat stroke • Fluids - oral water or sports drinks • Monitor closely
Distrubutive- Septic Shock
• starts with infection and worse if not managed • SIRS: Systemic Inflammatory Response System: bodies response to infectious or noninfectious • Signs and Symptoms • Skin: Flushed and fever, potential pale cyanotic • Blood pressure: early increase cardiac output but later progression HYPO • Respiratory: dyspnea with altered lung sounds • Kidneys - no/low urine outpiut • Other: high fever: except in elderly not key dx for infection • Lead to Multi organ failure or bleeding
