NSG 220 Guide to Final Exam -Critical Care

Guide to Final Exam N220 Sp 2018

Critical Care: 45 Critical Care (GF)

Introduction to critical care 2

Addressing needs of families who experienced loss.
- Studies have shown that families have predictable sets of needs:
  - Receiving assurance
  - Remaining near the patient
  - Receiving information
  - Being comfortable
  - Having support available
- Families have consistently rated cognitive needs as being more important than emotional or physical needs. “To have questions answered honestly and to know specific facts regarding what is wrong with the patient and patient’s progress” were identified as the most important.
- Mechanism through which information could be received such as a consistent nurse who could be contacted or who would contact the family.
Treatment that may be continued or withdrawn for a patient scheduled for terminal extubation

Dysrhythmias& management/pacemaker 5

Pacemaker malfunction
- Failure to discharge: if PM is set at a certain #, but there’s no spikes…there’s a failure to d/c
- Failure to Capture: there’s a spike, but not followed by QRS. Firing, but not capturing a complex. Could be due to displacement, battery dying, etc.
- Failure to sense: ex. Pt’s HR is 80, pm set at 70. Should you be seeing any spike? No. PM should only fire if the HR falls below set #. If it fires in this scenario, then it’s a failure to sense.

Defibrillation; ICD
- Defibrillation
  - emergency delivery of direct current without regard to cardiac cycle to treat fib and pulseless VT(most common cause of sudden cardiac death).
  - if used within 1 min of cardiac arrest, survival rate is 90%.
  - 200 joules for biphasic defibrillators and 360 for monophasic.
  - performed externally or internally (surgery, open chest);
  - also automatic external defibrillators(AED)
- Roles in code blue
  - Phase 1 Putting the code in motion :
    - Consist of:
      - Finding & assessing the victim , Call for help
      - Initiating CPR
      - This phase lasts until the code team arrives.
    - PHASE 2 Drugs & Defibrillation : Begins with the arrival of the code team.
      - Initiation of ACLS protocols
      - Evaluation of patient’s response to therapy

MEMBERS OF THE CODE TEAM
- Team Leader – directs & coordinates resuscitation efforts; ensures that procedures & patient assessments are performed rapidly & correctly.
- Defibrillator operator
- Recorder – notes the start of the code & events & interventions (intubation, meds); also announces when meds are due. Completes the resuscitation record & notes when the patient is pronounced dead.
- Medication Nurse – establish & maintain IV lines, calculates drugs & fluids; dispose of sharps.
Possible causes of cardiac arrest (ACLS algorithm)
- Sudden cardiac arrest is the sudden, unexpected loss of heart function, breathing and consciousness. Sudden cardiac arrest usually results from an electrical disturbance in your heart that disrupts its pumping action, stopping blood flow to the rest of your body.
- ***Use the ACLS Algorithm PDF Frane posted on Canvas***

NSG 220 Guide to Final Exam -Critical Care

Ventilators/ Resp failure/ARDS 8

ABGs;
- Great website for practicing ABG’s à https://abg.ninja/abg
- Use Frane’s ABG practice worksheet
ARDS assessment;
- Type of respiratory failure caused by diffuse injury to the alveolar- capillary membrane, resulting in non cardiogenic pulmonary edema.
- Pathophysiology: damage to the alveolar-capillary membrane lead to:
  - increased permeability leading to accumulation of protein-rich fluid in the interstitial and intra- alveolar spaces.
  - there is often a period of 24-48 hours between the initial event and the development of ARDS.
- Etiologic Factors: Can be triggered by direct (chest trauma, pneumonia, aspiration, pulm. Contusion, near drowning, inhalation injury, pulmonary embolus, radiation, eclampsia of pregnancy) or indirect pulmonary injury (sepsis, burns, severe trauma w/ multiple blood transfusions, drug overdose, cardiopulmonary bypass, acute pancreatitis, intracranial hypertension)
- Clinical Manifestations:
  - Increasing pattern of dyspnea and tachypnea
  - As ARDS progresses, cyanosis and accessory muscle use may be noted.
  - Cough, with blood-tinged, frothy sputum
  - PO2 of < 50 mm Hg, at O2 conc. of > 50 % ( Refractory Hypoxemia)
  - CXR at later stages: diffuse, fluffy infiltrates
  - PFTs : consistent with decreased lung compliance and decreased functional residual capacity (FRC). Mortality is about 50 %
- Assessment of pt. with ET tube;
- Ventilator bundle/purpose;
  - Ventilator bundle used to prevent ventilator associated pneumonia.
  - Key Components of IHI ventilator bundle:
    - Elevation of the head of the bed (30-45 degrees)
    - Daily “sedation vacations” & assessment of readiness to extubate
    - Peptic ulcer disease prophylaxis
    - DVT prophylaxis
    - Daily oral care with Chlorhexidine (0.12% oral rinses)
  - Vent modes
    - Control ventilation (CV)-volume or pressure : delivers gas at a prest volume or pressure regardless of the patient’s inspiratory effort
      - Clinical application: CV: used as primary mode in patients who are apneic
      - Nursing Implications: Used in patients unable to initiate a breath. Spontaneously breathing patients must be sedated &/or paralyzed
    - Assist-control ventilation (A/C) or continuous mandatory ventilation (CMV): delivers gas at a preset tidal volume or pressure in response to the patient’s respiratory efforts & will initiate breath if patient fails to do so within preset time
      - Clinical Application: A/C or CMV is used as primary mode in sponta-neuosly breathing patients with weak respiratory muscles
      - Nursing Implications: Hyperventilation can occur in patients with increased respiratory rates. Sedation may be necessary to limit the number of assisted breaths.
    - Synchronous intermittent mandatory ventilation (SIMV): delivers gas at a preset tidal volume or pressure and rate while allowing the patient to breathe spontaneously; ventilator breaths are synchronized to the patient’s respiratory effort.
      - Clinical Application: SIMV is used both as a primary mode of ventilation & as a weaning mode.
      - Nursing Implications: May increase work of breathing & promote respiratory fatigue.
    - Positive-end-expiratory pressure (PEEP): applied at the end of expiration of ventilator breaths. Used with A/C& SIMV. & Constant positive airway pressure (CPAP): positive pressure applied during spontaneous breaths
      - Clinical Application: PEEP & CPAP are used in patients with hypoxemia refractory to O2 therapy; Increase FRC & improve oxygenation by opening alveoli at end expiration

NSG 220 Guide to Final Exam -Critical Care

Nursing Implications: S/E: decreased CO,volutrauma & increased ICP. No ventilator breaths are delivered in PEEP & CPAP mode unless used with A/C, CV or SIMV.

Pressure support ventilation (PSV); preset positive pressure is used to augment patient’s inspiratory efforts. Patient controls rate, inspiratory flow and tidal volume.
- Clinical Application: Primary mode of ventilation in patients with stable respiratory drive. Used with SIMV to support spontaneous breaths & is used as a weaning mode in patients who are difficult to wean.
- Nursing Implications: Advantages include increase patient comfort, decreased work of breathing and decreased respiratory muscle fatigue& promotion of respiratory muscle conditioning.

Hemodynamics 1

Shock 6

Assessment on pt. with hypovolemic shock,
- Clinical Manifestations
  - Hemodynamic Indices
  - Decreased CO (Tachycardia & Hypotension)
  - Decreased Preload Parameters: CVP& PCWP
  - Increased SVR (Afterload): decreased pulse pressure
  - Tachypnea
  - Flat Neck Veins
  - Pallor, cool clammy skin
    - When caused by actual fluid loss: Poor skin turgor, tenting may be evident
    - When caused by fluid shift: Edema is present, skin is stretched and shiny in appearance
  - Assessment/management of cardiogenic shock;
    - Clinical Manifestations
      - Hemodynamic Indices
        
        Decreased CO/CI; EF < 30%
        
        Increased CVP
        
        Increased PCWP
        
        Increased SVR
        
        BP less than 90 systolic
        
        Increased HR
      - Neck Veins Distended
      - Pulmonary Edema: crackles, wheezes, labored respirations.
      - Confusion secondary to decreased perfusion to the brain
      - Oliguria secondary to decreased renal perfusion
    - Management
      - High Flow Oxygen
      - Administration of (+) Inotropic agents
      - Careful fluid administration if hypovolemic
      - Decrease afterload with vasodilators
      - Decrease preload with diuretics
      - Intraaortic Balloon Pumping
      - Emergency cardiac surgery
      - Pericardiocentesis for tamponade
      - Chest tube for tension pneumothorax
      - Treat dysrhythmias
    - Evaluation of positive response to management of septic shock/prevention;
      - Etiology
        
        Septicemia with Gm (-) bacteria (pseudomonas & E. Coli)
        
        Staph, Strep, Yeast & Viruses.
        
        Gm(-) infections are most commonly associated with conditions that involve fecal contamination of blood (perforated bowel & bowel surgery)
      - Warm Shock: Vasodilation, Tachycardia, Decreased SVR, Cardiac output- normal or increased, Skin – warm, pink, & dry (hyperpyrexia), Good urinary output
      - Cold Shock: Vasoconstriction, Metabolic acidosis, Increased SVR, Decreased Cardiac Output & BP, Skin cold & clammy, Decreased urine output
      - Management
        
        Identify etiology through C&S
        
        High Flow O2
        
        IV Fluids
        
        Antibiotics
        
        Vasopressors
        
        Inotropic agents
        
        Steroids
      - Prevention (from online source)
        
        There are a few things that people can do to help reduce their chances of developing sepsis which can lead to septic shock.
        
        Get vaccinated against the flu, pneumonia, and other infections that could potentially lead to sepsis
        
        Practice good hygiene such as bathing regularly, and thoroughly clean any scrapes and wounds to help prevent infection
        
        Look for signs of infection such as fever, chills, rapid breathing, rash, or confusion
        
        Control diabetes
        
        Clean wounds properly
        
        Treat UTI’s promptly, appropriate use of foley’s

MI 4

ECG findings
- Electrocardiography
  - Inversion of the T wave
  - Elevation of the ST segment
  - Formation of a Q wave
- Significance of PVCs
  - PVC= SIGN OF REPERFUSION! Reperfusion dysrhythmias: PVCs, accelerated Idioventricular Rhythm (IVR), Ventricular Tachycardia, AV blocks
- MI complications (signs and symptoms)
  - Structural defects:
    - papillary muscle rupture– mitral regurgitation -findings: pulmonary edema, sudden holosystolic murmur; shock; Tx: IABP, inotropic support with dobutamine prior to MV replacement
    - ventricular septal rupture: shunting of blood from LV to RV. Findings: chest pain, loud S2; new holosystolic murmur; dx: bedside echo; Tx. IABP; afterload reduction with Sodium Nitroprusside (Nipride) IV drip.
  - Ventricular Aneurysm– thin-walled , non-contractile outpouchings of the ventricle, usually at the apex of the left ventricle.
    - Suspected when patients have persistent ST elevation, distortion of cardiac image on CXR, and presence of holosystolic apical thrust. Echo.
  - Aneurysm: Clinical manifestations: CHF, LV thromboembolism, VT and chest pain.
    - Pharmacologic– Digoxin, Diuretics, Anticoagulation with Heparin followed by Coumadin. Nitrates for chest pain; ICD for refractory ventricular dysrhythmias; Surgery for patients with refractory angina; aneurysmectomy with revascularization procedure.
  - Hemodynamic alterations: Cardiogenic shock; CHF
  - Inflammatory responses:
    - Pericarditis– can occur 2-4 days after an MI. S/S: precordial pain increases with deep inspiration, pericardial friction rub, ST segment elevation. Tx. NSAIDs (Indomethacin)for 3-5 days.
  - Dressler’s Syndrome (late pericarditis) : occurs from 1 week to several months after an MI.S/S: similar to pericarditis; diffuse ST segment changes; fever, arthralgias; pericardial effusion. NSAIDs, corticosteroids(prednisone).

NSG 220 Guide to Final Exam -Critical Care

MI discharge instructions
- Emphasis is on realistic application of the information (life-style modifications).
  - Quitting smoking;
  - Eating to reduce high blood cholesterol;
  - Maintaining a healthy weight; and
  - Being physically active each day
- Emphasize importance of complying with medical regimen, cardiac rehabilitation program & follow-up care.
- Provide info about community resources.

Cardiac Surgery/Aortic Aneurysms 3

RN responsibility re prep for patient scheduled for cardiac surgery
- Focuses on stabilizing any other disease condition and optimizing cardiac function.
- Sources of infection are investigated and treated
- Therapies are adjusted to control heart failure, dysrhythmias & fluid or electrolyte imbalances.
- Patient is encouraged to stop smoking
Consequence of a fever after cardiac surgery; significant assessment
- By cooling the patient to 82.4 to 89.6 F, oxygen requirements is decreased by 50% & protects the major organs from ischemic injury.
Finding after repair of AAA that requires intervention?? (Unsure about this one)

Monitor for and report manifestations of leakage at the graft site:

Ecchymoses of the scrotum, perineum, or penis.
New expanding hematoma at the incision site.
Increased abdominal girth
Increasing pain in the abdomen, pelvic, or lumbar regions.
Decreasing urinary output (less than 30 ml/hour)
Decreasing CVP, Pulmonary artery pressure or pulmonary artery wedge pressure.
Implement interventions to prevent hypovolemic shock
Monitor for & report manifestations of lower extremity embolism.
Monitor for & report manifestations of bowel ischemia or gangrene (occult or fresh blood in the stools, diarrhea & abdominal distention).
Monitor for & report manifestations of impaired renal function.
Monitor for & report manifestations of spinal cord ischemia: weakness in the lower extremities & paraplegia.

Transplants 4

Liver, Kidney transplants in older adults & cadaveric type;
- Cadaveric kidneys usually have some degree of Acute Tubular Necrosis. Dialysis may be needed
Antirejection meds-side effects;

Cyclosporine (Cy A) (Neoral)

Use : helps prevent rejection but does not treat rejection
Action: suppresses cell-mediated immune response with minimal effect on phagocytosis & humoral-mediated immunity. No bone marrow suppression capability.
Side effects: nephrotoxicity, hepatotoxicity, HTN, tremors, Hirsutism, increased risk for infection & malignancy.

Macrolide antibiotics

Tacrolimus (Prograft)
Sirolimus (Rapamune)- Inhibit T-cell and B-cell proliferation.
Similar to cyclosporine & about 100 times more potent.
Sirolimus should not be administered within four hours of cyclosporine to reduce nephrotoxicity. S/E hyperlipidemia, hepatotoxicity, hyperglycemia
Tacrolimus S/E: Diabetes Mellitus

Corticosteroids

Use: prevention & treatment of established rejection
Action: affects both humoral & cell-mediated immune response.
Side effects: cushingoid appearance, glucose intolerance, sodium & water retention, increased appetite, osteoporosis, muscle wasting, gastric ulcers, exacerbation of infection, steroid-induced psychosis.

Antimetabolites

Azathioprine (Imuran)- cause suppression of cell-mediated immunity and some B-cell.
Mycophenolate mofetil (Cellcept)- inhibits DNA & RNA synthesis.B & T cell lymphocytes are targeted. More effective than Azathioprine.
- Side effects: bone marrow suppression, neutropenia, increased risk for infection, GI upset, hepatoxicity.

Antibodies

Orthoclone T-3 (OKT 3)
- Use: to prevent & treat rejection
- Action: binds with T-cell specific antigen receptor, blocking the generation & function of cytotoxic T cells.
- Side effects: hypersensitivity, severe N/V, bronchospasm, lymphoma & development of antibodies against the drug.

Oncologic Emergencies 1

Tumor lysis syndrome

**MY OWN NOTES:**

So, what’s happening here?

You have a type of cancer (w/ usually big tumor cells) like leukemias & lymphomas. Then, you are being treated for this type of cx w/ chemo/radiation à Destruction of these cancerous cells occur (good/bad) à The destruction of them causes a spillage of K+ & Uric Acid (which get filtered out by the kidneys, until they become too much) à when this uric acid & k+ builds up, it eventually blocks the kidneys & leads to AKI à Now, you have all of this uric acid & K+ in the blood cuz it can’t be filtered out à So, you have to make sure that you monitor & tx this.
Tumor Lysis Syndrome:
- Hydrate via IV to have 3L/day for 48 hrs of
- Allopurinol, Sodium BiCarb (prevent crystallization)
- Hyperkalemia: monitor àwhen cells are destroyed = increase in K+**

Trauma 4

Assessment of pt. who sustained an injury;
- Primary Survey
  - designed for use in the rapid assessment and intervention of the multiple trauma patient
  - patient is assessed for life threatening injuries
  - as problems are identified, interventions should be initiated.
  - Five steps in primary survey include ABCs plus D& E
  - Disability (Mini neurologic examination)
  - Exposure ( Undress with temperature control).

S/S associated with blood loss
- Mild symptoms can include: (from online)
headache
fatigue
nausea
profuse sweating
dizziness
- Severe symptoms: (from online)
  - cold or clammy skin
  - pale skin
  - rapid, shallow breathing
  - rapid heart rate
  - little or no urine output
  - confusion
  - weakness
  - weak pulse
  - blue lipsand fingernails
  - lightheadedness
  - loss of consciousness
- Before discharge from the hospital, all patients who have experienced abdominal trauma are taught the signs & symptoms of abdominal bleeding
  - Abdominal pain
  - Nausea/Vomiting
  - Bloody or black stools
  - Fever
  - Weakness
  - Dizziness
- Legal implications/consents;

Disaster nursing 1

NSG 220 Guide to Final Exam -Critical Care

Antibiotics 1

Fluoroquinolones
- Action: broad spectrum, bactericidal;
- Used against gm(-) & selected gm(+) organisms; lower resp. tract infections, sinusitis, bone & joint, infectious diarrhea, intra-abdominal infections, & STIs.
- Common meds: ends in “oxacin”; Ciprofloxacin, Levofloxacin, Moxifloxacin (Avelox).
- Monitor PT/INR, renal function, protect from sunlight, do baseline ECG; maintain hydration.

KINDLY ORDER NOW FOR A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER

Renal Failure 4

Common problem with ESRD; *(Unsure of this one)*
Meds that can be given to pt scheduled for hemodialysis;
- Weigh the client before and after procedure
- Monitor client continuously during procedure; blood pressure may “bottom out” (hypotensive) Give NS.
- Provide care to access site to prevent clotting and infection.
- Assess bruit and thrill to determine patency of fistula
- Withhold antihypertensive medications and water soluble medications.
- Observe for psychological and physiological complications.
Renal diet
- Implement renal diet: low protein, low potassium, high carbohydrate, vitamin and calcium supplements, low sodium, low phosphate
  - **Everything low, except calcium**

Calculation 1

NSG 220 Guide to Final Exam -Critical Care

NSG 220 Guide to Final Exam -Critical Care

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