Unit 3 NUR213
Tetraplegia Oddly twisted neck Weakness, loss of respiratory muscle control Hypotension Bradycardia, arrhythmias Autonomic dysreflexia Decreased peristalsis these manifestations can be caused by a SCI to what area
cervical
S/S: crackles in lungs, FVO, JVD, bounding pulses, HTN, anemia
ckd
injury in which there is complete loss of sensation and muscle control below the level of the injury
complete SCI
diagnostics for CKD
creatinine over 1.3 creatinine clearance test 24hr urine collection (discard the first specimen, put on ice)
most critical lab value for kidney function
creatinine shows clogging (over 1.3 is bad!)
bluish discoloration around umbilicus, indicating peritoneal bleeding often pancreatic hemorrhage
cullen sign
three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation
cushings triad
high phosphorus s/s (over 4.5)
decreased calcium (osteoporosis)
interventions for oliguric phase of AKI
diuretics, fluid bolus
- focused abdominal sonography for trauma - portable - detects as little as 100mL of blood in the abdomen - views liver, spleen, pelvis - decreased accuracy in obese patients
fast US
bluish discoloration of lower flanks/back - sign of retroperitoneal hemorrhage of kidneys/pancreas or pelvic fracture. takes 24-48hrs to develop
grey turners sign
priority signs of hypertensive crisis to report
headache, n/v, ALOC
injury upper motor neurons- occurring above L1 or L2 will result in
hypertonia
what maneuver is done when doing cpr on a client with suspected sci
jaw thrust
the lower pressure alarm on a ventilator may indicate
loss of connection, leak
Paraplegia Cauda equina syndrome these manifestations can be caused by a SCI to what area
lumbar/sacral
what f/e imbalance are pts in the oliguric stage of aki at risk for
metabolic acidosis
meds to avoid CKD
nsaids, milk of magnesia (antacid), antibiotics (vancomycin/gentamicin), ct contrast dye
The ICU nurse is caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Check the ventilator to resolve the problem. 4. Auscultate the client's lung sounds.
3
The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client's arterial blood gas results.
3
Caused by too rapid a decrease of BUN and circulating fluid volume. It may result in cerebral edema and increased intracranial pressure. Early recognition of disequilibrium syndrome is essential. Pulling off fluid too fast, significant neurological change, slow down the fluids. Signs include: Nausea Vomiting Cerebral edema (↑ ICP- pulling off fluid too fast) Neuro checks Mannitol (cannot give if active bleeding) Change in LOC Seizure Agitation Advanced age is a risk factor
Disequilibrium Syndrome
this medicine binds to phosphorous to help ↓ hyperphosphatemia
Aluminum hydroxide (Amphojel), an antacid
the following are risk factors: older age, uncontrolled diabetes and/or HTN, autoimmune disorders, worsening AKI
CKD
what medicine can be given to pts with AKI to promote absorption of calcium
Calcitriol, Vit D analog
causes of CKD
DM, HTN, ischemia, infection, obstruction, toxins, autoimmune diseases
Pneumonia, aspiration of gastric content inhalation injuries and near drowning; these are example of
Direct lung injuries
AKI expected findings:
Elevated BUN & Potassium Decreased Calcium & hct
stages of aki
Onset Oliguric Diuresis Recovery
Pt scheduled for hemodialysis is at risk for seizures due to:
Rapid decrease in fluid: (can result in cerebral edema and ↑ ICP)
the nurse would question given mannitol when?
TBI or bleed
tx for neurogenic shock
administration of iv fluids, vasopressors, atropine
increased fluid in the abdomen, often a result of cirrhosis
ascites
acute episodic HTN resulting from sympathetic hyperactivity. - occurs in pt with a SCI at T6 or above
autonomic dysreflexia
Electrolytes increase when in this phase; increase BUN & Cret can throw off other electrolytes <400 mL/day/2-3 wks. temp. dialysis (permcath) very little output) or Anuric (no urine output) pale colored urine is almost clear. Daily weight is the best way to keep up with it. Trying to restore volume (Hyperkalemia will cause dysrhythmias PVC's that can lead to V-tach/need to be on cardiac monitor) Neuro checks Kussmaul's breathing
oliguric aki
Common triggering events; **find the cause** (significant blood loss, bruns, fluid loss, diabetes, renal blood flow 25%, tissue oxygenation 25% of normal, urine output 0.5 mL/kg/hr (< 500 mL/lasts hours to days) S3=fluid volume overload, JVD, ascites, pitting edema, decreased albumin
onset AKI
1. calcium gluconate (prevent dysrhythmias) 2. iv 50% dextrose + regular insulin 3. kayexalate 4. dialysis
order for hyperkalemia meds
what ecg changes are expected with potassium 6-7 meq/l
peaked t waves
renal blockage after the kidneys ex: kidney stones, BPH, tumor
postrenal AKI
decreased blood flow to kidneys due to obstruction or vessel occlusion ex: emboli, blood clots, tumor, hypotension, low cardiac output
prerenal AKI
why is calcium gluconate given for hyperkalemia
prevents dysrhythmias
decreasing what would decrease ammonia levels
protein
What lung sounds may be heard upon auscultation on a pt w/ards
rales, crackles, rhonchi
a client with injury to c4 or above will be at a high risk for
respiratory dysfunction
what can trigger autonomic dysreflexia
restrictive clothing, pressure areas, full bladder, fecal impaction
Mechanism of injury, Injuries sustained, S/s in field, Tx in field
secondary trauma assessment
#1 priority for autonomic dysreflexia
sit the pt up, notify provider, fix the cause, administer antihypertensives
this medicine decreases potassium levels through the stool
sodium polystyrene (kayexalate)
what ecg changes are expected with potassium 7-8 meq/l
st elevation
Paraplegia Impaired breathing Autonomic dysreflexia these manifestations can be caused by a SCI to what area
thoracic
what ecg changes are expected with potassium over 8 meq/l
wide qrs complex
In assessing a client with a T12 SCI, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock? 1. No reflex activity below the waist. 2. Inability to move upper extremities. 3. Complaints of a pounding headache. 4. Hypotension and bradycardia.
1
A client has end stage renal disease with potassium 7.2, BUN 35, creatinine of 3.8, and urine output of 300 ml in 24 hours. Which order is PRIORITY? 1. IV Regular insulin & 50% Dextrose 2. IV loop diuretic 3. Dialysis
1
Which of the following medications can be used to treat clients with anxiety disorders? SATA 1. Clonidine hydrochloride (Catapres). 2. Fluvoxamine maleate (Luvox). 3. Buspirone (BuSpar). 4. Alprazolam (Xanax). 5. Haloperidol (Haldol).
1, 2, 3, 4
The nurse is planning care for a child with a T12 spinal cord injury. Which lifelong complication should the child and family know about? SATA 1. Skin integrity. 2. Incontinence. 3. Loss of large and small motor activity. 4. Loss of voice.5. Spasticity.
1, 2, 3, 5
The nurse in the neurointensive care unit is caring for a client with a new C6 SCI who is breathing independently. Which nursing interventions should be implemented? SATA 1. Monitor the pulse oximetry reading. 2. Provide pureed foods six (6) times a day. 3. Encourage coughing and deep breathing. 4. Assess for autonomic dysreflexia. 5. Administer intravenous corticosteroids.
1, 4, 5
How often does it take for ARDS to develop post injury
1-2 days
The nurse is caring for a client diagnosed with flail chest who has had a chest tube for 3 days. The nurse notes there is no fluctuation or tidaling in the water seal compartment. Which intervention should the nurse implement first? 1. Check the tubing for any dependent loops. 2. Auscultate the client's posterior breath sounds. 3. Prepare to remove the client's chest tubes. 4. Notify the HCP that the lungs have re-expanded.
2
The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? SATA 1. Place the client in the low Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bedrest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.
2, 4, 5
what does the diuresis phase of AKI cause
3-6L of urine/day (low SG)
what degree should the HOB be when pt comes in for trauma
30-45 degrees (prevent aspiration)
A pt with CKD missed 3 dialysis sessions and has a potassium level of 8.1 with wide QRS complexes, heart rate of 58 & lethargy. Which order should the nurse implement first? 1. IV 50% dextrose & regular insulin 2. sodium polystyrene sulfate 3. hemodialysis 4. iv calcium gluconate
4
A disorder characterized by rapid onset of noncardiac Pulmonary edema and progressive refractory hypoxemia. Common in pts w/pneumonia, sepsis, aspiration and severe trauma. Can be direct/indirect trauma
ARDS
the high pressure alarm on a ventilator may indicate
blockage, kinks
what is the cardinal sign of spinal shock
bradycardia
sepsis, major burns, overdose and pancreatitis are examples of
indirect lung injuries
CT contrast dye, antibiotics (-myocins), untreated infections and prolonged use of NSAIDs
intrarenal AKI
shoulder pain while supine caused by diaphragmatic irritation ex: spleen injury, free air, intra-abdominal bleeding
kehr sign
this medicine decreases ammonia levels through the stool
lactulose
what does the oliguric phase of AKI cause
less than 400ml output in 24 hrs (high SG)
autonomic nervous system dysregulation following SCI usually when injury is above T6 -loss of parasympathetic nervous system s/s: hypotension, bradycardia, flushed/warm skin
neurogenic shock
complications for SCI
neurogenic shock, hemorrhage, autonomic dysreflexia
A teen who was hospitalized for CKD develops symptoms of polyuria, polydipsia, and bone pain. Which body mineral might be causing these symptoms? 1. Elevated calcium. 2. Low phosphorus. 3. Low magnesium. 4. High aluminum hydroxide.
1
The client diagnosed with CKD on hemodialysis is prescribed lanthanum carbonate. Which interventions should the nurse discuss with the client? SATA 1. "Chew the tablets completely before swallowing." 2. "Monitor the dialysis graft for bleeding." 3. "Take an over-the-counter proton-pump inhibitor." 4. "Check the radial pulse prior to taking the medication." 5. "Take the medication with or right after meals."
1, 5
what happens to a client when put in prone position
increases gas exchange against gravity
life threatening HTN following spinal cord injury. Stimuli below the spinal cord injury initiating a sympathetic response (distended bladder, restrictive clothing, fecal impaction), causing vasoconstriction. s/s: extreme htn, severe headache, blurred vision, diaphoresis
autonomic dysreflexia
injury lower motor neurons- occurring below L1 or L2 will result in
hypotonia (flaccid muscle tone and bladder)
partial preservation of sensory or motor function below the level of the injury
incomplete SCI
