NUR 203 Final Review - WordPress.com 203 Final Review Page 2 of 65 Module C Improving Cerebral...

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NUR 203

Final Review

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Module C

Improving Cerebral Perfusion

Monitoring for Increased ICP

Cushing’s Triad – widening pulse pressure, bradycardia, irregular respirations (possible

Cheynne Stokes),

Other Signs - blown pupils or constricted and nonreactive, abnormal posturing, severe

HTN, behavior changes, ALOC, aphasia, slurred speech, ataxia

Meds & Pt. Education

o Mannitol = Osmotic Diuretic – monitor for severe dehydration = I/O, BP,

sunken eyes, skin turgor

o Barbiturates (end in barbital) = Medically Induced Coma = trach vent,

monitor Hemo, monitor swan cath.

Decadron = ↓ edema = ↑ BS, H2O retention, immune compromise

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TBI & ICP

Early Signs Late Signs

Pinpoint Pupils

↑ BP, ↓ HR

Ataxia, Uneven Gait

GCS > 8 +

Rapid, Deep Breathing

Big Blown Pupils

↓ HR, BP 180/40 = Widening Pulse

Pressure – Cushing’s Triad

Decerebrate/Decorticate

GCS < 8

Slow Breathing

Normal ICP = 10 – 15

Herniation: shifting of brain tissue d/t ↑ ICP (Central = down pressure

centrally w/pinpoint pupils; UNCAL = Bilateral w/dilated pupils & fixed)

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Posturing

“Hold the Cat” (CAT in DecortiCATe ~ Flexion)

“Drop the Rat” (RAT in DecerebRATe ~ Extension)

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Glasgow Coma Scale

in GCS – Tell M.D. in 1st 48° if ↑ or

↓; After 1st 48° = call if ↓

GCS ↓ 8 = E Tube

Positioning = Neutral, Log Roll, No

Flex

↑ CO2 = ICP ↑ 40 (4.5) – Keep

Alkaline

Cluster Care w/ADL’s, etc.; Do not

cluster Neuro Checks

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Cranial Nerves

On Old Olympus Towering Tops A Fin And German Viewed Some Hops

1 Nose = Olfactory

2 Eyes = Optic

3, 4, 6 = Make my eyes do tricks: Oculomotor, Trochlear,

Abducens

5 Tri = Trigeminal

7 Fits on Face = Facial

8 Fits in Ear = Acoustic

9, 10 Under My Chin = Glossopharyngeal, Vagus

11 Fits on Shoulders = Spinal Accessory

12 Tongue Movement = Hypoglossal

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ICP & SI ADH and DI

SI ADH (Kidneys Locked) DI (No Lock on Kidneys)

↑ADH, ↑ H2O, ↑ ICP = ↑ Dilution,

↓ Na+; Kidneys keep H2O in and

do not let H2O out.

3% Na+ IV, ALOC, ↓ Deep Tendon

Reflexes, ↑ HR, N/V, H/A, Give

Declomycin, Diuretics

↓ ADH, ↑ Output, Renal Failure =

Dehydration, Excessive Thirst,

Weakness, Give Pitressin

ICP & Shock Have Opposite V/S

ICP = ↑ BP, ↓ Pulse, ↓ Resp

Shock = ↓ BP, ↑ Pulse, ↑ Resp

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P.P. ↓ SI ADH P.P. ↓ P.P. ↑ DI ADH P.P. ↑

↑ ADH → PP ↓ (PP to body, not in

potty)

Hemodilution d/t ↑ H20 in body

Causes: Head Trauma, CV Disease,

TB, Cancer

S/S: **Fluid Overload**, ↓ urine, ↑

H2O, Bounding Pulse, ↑ BP, ↓ HR,

JVD, H/A, N/V, ↑ Wt., ↓ appetite, in

LOC, Fatigue, Hypothermia, Dark

Urine

Labs: ↓ Na+ (Hyponatremia), ↑ Urine

Osmo, ↑ Urine SG = ≥ 1.03

Interventions: ↓ Fluids, Replace Na+,

3% NaCl, ↓ Noise & Light; Drugs:

Declomycin, Vasopressin Antagonist

→ Samsca, Vaprisol

Monitor for: Pulmonary Edema,

Neuro

↓ ADH → PP ↑ (PP to potty, not in body)

Hemoconcentration d/t ↓ H2O in body

Classifications: --Nephrogenic: inherited,

↓ kidney response, Primary:

hypothalamus & Pituitary Deficiency,

Secondary: other disease, Tumor, Drug

Related→Lithium & Declomycin

S/S: ↑ HR, ↓ BP, ↓ pulse pressure, ↑ Urine

(Polyuria) ≥ 4 L & ≥ than intake, ↑ thirst

(Polydipsia), ↑ hunger (Polyphagia), weak

& thready pulse, poor skin turgor d/t

dehydration, syncope (dizziness), Hypovolemia

Labs: ↓ Urine SG = ≤ 1.005, ↓ Urine

Osmo, ↑ Na+

Interventions: Strict I/O, Restrict Fluids,

SG, Wt. q d, Med. Alert bracelet; Drugs:

Diabinese, DDAVP (Desmopressin) → ↓

fluids, sit ↑, Test: Hypertonic Saline test

(24 hr.) Urine Collection → Circadian

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Strokes

Left Hemisphere Stroke Right Hemisphere Stroke

Previously learned motor skills

(Apraxia), problems following

directions

Sensation, vision proprioception

Hemiparesis – weakness on one side of the body; Hemiplegia – paralysis

on one side of body; Aphasia: Expressive (motor/Broca) – difficulty

making thoughts known to others, speaking and writing most affected;

Receptive (sensory or Wernicke) – difficulty understanding what others

are trying to communicate; interpretation of speech and reading is most

affected; Global – affects both expression and reception

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Types of Strokes

Thrombotic Embolic Hemorrhagic

Cause: CLOT

Cause: Emboli from another area in

body; Atrial Fibrillation, Ischemic Heart Disease, Rheumatic Fever,

MI, Prosthetic valve, MCA is most

common site

Bleeding into brain tissue

or spaces around brain

Cause: ruptured aneurysm

Ischemic Stroke – caused by occlusion (blockage) of a cerebral artery by

either a thrombus or an embolus

Ischemic Hemorrhagic

Thrombotic

Embolic

Aneurysm

HTN

Arteriovenous Malformation

.

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Unilateral Body Neglect

Most common in clients w/right cerebral stroke

Inability to recognize physical impairment or lack of

proprioception

Teach to touch and use both sides of body

Dress affected side first

With hemianopsia, turn head from side to side

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Parts of the Brain

Frontal Lobe – controls contraction of skeletal muscles and

synchronization of muscular movements; influences abstract thinking,

sense of humor, & uniqueness of personality, inhibitions

Parietal Lobe (Proprioception problems)– translates nerve impulses

into sensations (touch, temperature); interpret sensations; provides

appreciation of size, shape, texture, and weight; interprets sense of taste

Temporal Lobe – translate nerve impulses into sensations of sound and

interpret sounds (Wernicke’s area); interpret sense of smell; control

behavior patterns.

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Spinal Shock Symptoms

Flaccid paralysis, loss of reflex below area of injury, bradycardia, paralytic ileus,

urinary retention, hypotension, may last few days to several mos.

Spinal Cord Injury

Patho

C-4: controls Respiratory

T-1: controls Paralization

↓ L1 – L2 = Flaccid “Dilated” Bladder

↑ L1 – L2 = Spastic “Constricted” Bladder

Assessment – Motor Senses

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Module B

Primary Prevention of Lung Cancer – stop smoking, wear

special masks and protective clothing to reduce exposure, reduce

exposure to 2nd

hand smoke and chemicals.

Secondary Prevention of Lung Cancer – early detection, screen

people at risk for lung cancer using annual CT scans can detect

cancers at stage I.

Pleurodesis - A procedure that causes the membranes around the

lungs to stick together and prevents the buildup of fluid in the

space between the membranes (pleural space). Pleurodesis is done

in cases of severe recurrent pleural effusions (outpourings of fluid

around the lungs) to prevent the reaccumulation of the fluid.

During pleurodesis, an irritant is instilled inside the pleural space

in order to create inflammation that tacks the two pleura together.

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This procedure thereby permanently obliterates the space between

the pleura and prevents the reaccumulation of fluid.

Thoracentesis – fluid removeal by suction after the placement of a

large needle or catheter into the intrapleural space.

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Miscellaneous Pressures

RAP = 1-8

PAP = 15-26/5-15

PAWP = 4-12

CVP = 5-10

CO = 4-6

CI = 2.7-3.2

SvO2 = 60%-80%

PEEP – keeps alveoli open, ↓ C.O., PIP – ARDS, ↑ PIP, FiO2 – 21% - 100%

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Mechanical Ventilation

Types Modes Settings Interventions Weaning Pressure-cycled –

Push air into the

lungs until a preset airway pressure is

reached.

Time-cycled – Push air into the

lungs until a preset

time has elapsed. Volume-cycled –

push air into the

lungs until a preset volume is

delivered.

Microprocessors – are computer-

managed positive-

pressure ventilators

AC (Assist

control) – used

often as a resting mode. Vent takes

over work of

breathing for the patient. Does not

allow spontaneous

breathing.

SIMV

(Synchronized

intermittent

mandatory

ventilation) – If

patient does not breathe, a vent

pattern is

established by ventilator. Does

allow spontaneous breathing.

Weaning.

Tidal Volume

(VT) – volume of

air received w/each breath.

Average setting =

7 – 10 mL/kg of body wt. Adding 0

to wt. in kg is

estimate. Rate - # of breaths

per minute usually

10 – 14. FiO2 – O2

(humidify &

warm) delivered to pt. based on

ABG’s: 21% -

100%. PIP – pressure

used by ventilator to deliver a set

tidal volume at a

Mouth care q 8

hrs.; Strict oral

care q 2 hours; Monitor VS q 30

min to 1 hr at 1st.

Synchronous

Intermittent

Mandatory Ventilation; T-

Piece Technique;

Pressure Support Ventilation

Monitor VS after

extubation q 5 min. at 1st, and and

assess the

ventilator pattern for manifestations

of respiratory

distress. Sit in semi-fowler’s

position, take deep

breaths q half-hour, incentive

spirometer q 2 hrs., limit speaking.

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BiPAP –

noninvasive pressure support

ventilation by

nasal mask or face mask.

given lung

compliance. CPAP – applies

positive airway

pressure during the entire respiratory

cycle for

spontaneously

breathing pts. 0

vent breaths given

PEEP – Positive pressure exerted

during expiration.

Flow Rate – How fast each breath is

delivered and is

usually set to 40 L/min.

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High-Pressure Alarm

Sounds when peak inspiratory pressure (PIP) reaches the set alarm limit (usually set 10-

20 mm Hg above the patient’s baseline PIP)

An ↑ amount of secretions or a mucus plug is in

the airways Suction as needed.

The patient coughs, gags, or bites on the oral

ET tube Insert oral airway to prevent biting the ET tube

The patient is anxious or fights the ventilator

Provide emotional support to ↓ anxiety; ↑ the

flow rate; Explain all procedures; sedation or

paralyzing agent per the physician’s

prescription.

Airway size ↓ related to wheezing or

bronchospasm Auscultate breath sounds

Pneumothorax occurs

Alert the physician or rapid response team for

management of bronchospasm; Auscultate

breath sounds; Alert the physician or Rapid

Response Team about a new onset of ↓ breath

sounds or unequal chest excursion, which may

be d/t pneumo

Artificial airway is displaced; the ET tube may

have slipped into the right mainstem bronchus

Assess the chest for unequal breath sounds and

chest excursion; Obtain a CXR as ordered to

evaluate the position of the ET tube; After the

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proper postion is verified, tape the tube securely

in place

Obstruction in tubing occurs because the patient

is lying on the tubing or there is water or a kink

in the tubing

Assess the system, moving from the artificial

airway toward the ventilator

There is ↑ PIP associated w/deliverance of a

sight

Empty water from the ventilator tubing, and

remove any kinks; Coordinate w/respiratory

therapist or physician to adjust the pressure

alarm.

↓ compliance of the lung is noted; a trend of

gradually ↑’ing PIP is noted over several hours

or a day

Evaluate the reasons for the ↓ compliance of the

lungs; ↑ PIP occurs in ARDS, pneumonia, or

any worsening of pulmonary disease

Remember – HOLD: High Alarm = Obstruction d/t ↑ secretions, kink, pt. coughs, gag or bites;

Low Alarm = Disconnection or leak in vent. Or in pt. airway cuff, pt. stops spontaneous breathing.

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Low-Pressure Alarm

Low exhaled volume (Low-Pressure Alarm) sounds when there is a

disconnection or leak in the ventilator circuit or a leak in the patient’s artificial

airway cuff

A leak in the ventilator circuit prevents

breath from being delivered

Assess all connections and all ventilator

tubings for disconnection

The patient stops spontaneous breathing in

the SIMV or CPAP mode or on pressure

support ventilation

Evaluate the patient’s tolerance of the

mode

A cuff leak occurs in the ET or

tracheostomy tube

Evaluate the patient for a cuff leak. A cuff

leak is suspected when the patient can talk

(air escapes from the mouth) or when the

pilot balloon on the artificial airway is flat

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ABG Disorders

Respiratory Acidosis Respiratory Alkalosis

pH less than 7.35 and a PaCO2

greater than 45 mm Hg; caused by

any condition that results in

hypoventilation – sleeping, COPD

pH greater than 7.45 and a PaCO2

less than 35 mm Hg; caused by an

condition that causes

hyperventilation – Anxiety, Renal

Failure; Early PE

Metabolic Acidosis (ass/diarrhea) Metabolic Alkalosis (↑ pee/vomit)

pH of less than 7.35 and a

bicarbonate level of less than 22

mEq/L; caused by either a deficit of

base in the blood stream or an

excess of acids, other than CO2,

Diarrhea, Shock, Sepsis

pH greater than 7.45 and

bicarbonate greater than 26 mEq/L;

caused by an excess of base or a

loss of acid within the body; Tums,

Vomit, ↑ Pee

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ABG’s

ROME

Respiratory Opposite

Metabolic Equal

PH Normal = Fully

Compensated

All Values Abnormal =

Partially Compensated

Marching Band Suit

*Match PH w/Resp. or Metab.*

A B

PH 7.35 ———————— 7.45

B A

PcO2 35————————— 45 Resp

A B

HcO3 22————————— 26 Metab.

Remember: ROME; Full Comp. = 1 NL; Partial Comp. = All Abnormal; Do Allen’s Test 1st

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Common Conversions

1 tsp = 5 mL

1 Tbsp = 3 tsp or 15 mL

1 oz = 30 mL

8 oz = 1 cup or 240 mL

1 pint = 1 lb or 16 oz

1 kg = 1000 g

1 g = 1000 mg

1 mg = 1000 mcg

1 L = 1000 mL

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Labs Normal Labs Normal

Na+ (Sodium) 135-145 K+ 3.5-5.0

Cl+ 98-106 Ca+ 9.0-10.5

Albumin (Liver) 3.5-5.0 Crea (Kidney) 0.7-1.3

BUN (Kidney) 8-25 Glucose 70-110

WBC 5,000-10,000 RBC (M)4.7-6.1 (F)4.2-5.4

Hgb (M)14-18(F)12-16 Hct (M)42-52(F)37-47

PLTS (ASA)

150,000-400,000

(↑Clot; ↓Bleed) Mag 1.6-2.6

PT (Heparin) 11-15 PTT (Heparin) 30-60

INR (Coumadin) 0.9-1.2 ALT (Liver) (M)10-40(F)7-35

ALT (Liver) (M)10-40(F)7-35 AST (Liver) 12-31

SG (Kidney)

1.005-1.03

(SIADH↑;DI↓) Amylase 25-151

Ammonia 10-80 T3 70-205

T4 4-12 TSH 0.3-5 (Hypo↑;Hyper↓)

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Platelets

Platelets = 150,000 – 400,000

Platelets ↑ = Clot

Platelets ↓ = Bleed

PT used for Heparin

H/H = 1/3 ratio = HgB: 15

HCT: 45

.

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Module E

Bioterrorism Module – Look at Certificate questions we had to do.

Hypothermia

Patho: Core body temperature ↓ 95° F, or 35° C. An environmental

temperature below 82° F or 28° C can produce hypothermia in any

susceptible person.

S/S:

Three Categories Include (IMPORTANT):

o Mild – shivering, dysarthria (slurred speech), muscular

incoordination, impaired cognitive abilities (mental

slowness), and cold diuresis.

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o Moderate – Coagulopathy (abnormal clotting) or cardiac

failure can occur. Muscle weakness, acute confusion,

apathy, incoherence, possible stupor, decreased clotting

o Severe – bradycardia, severe hypotension, decreased

respiratory rate, cardiac dysrhythmias, including possible

ventricular fibrillation, or asystole, decreased neurologic

reflexes, decreased pain responsiveness, acid-base

imbalance.

Treatment: Priority is warming; avoid alcohol. Core (trunk 1st) rewarming

methods for moderate hypothermia include administration of warm IV heated

fluids, heated O2, or inspired gas, heated peritoneal, pleural, gastric, or bladder

lavage. The patient who is severely hypothermic is at high risk of cardiac arrest.

TOC is extracorporeal rewarming methods such as cardiopulmonary bypass,

hemodialysis, or continuous arteriovenous rewarming. General Management for

moderate and severe: protect patients from further heat loss and handle them

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gently to prevent ventricular fibrillation; position in supine position to prevent

orthostatic changes in blood pressure from cardiovascular instability; follow

standard resuscitation efforts

Mass-Casualty Triage

Process: Rapidly sort ill or injured patients into priority categories based on their acuity

and survival potential.

Triage Method:

Class

Tag

Color Type of Injury

Class I – Emergent Red

Immediate threat to life, occluded

airway, active bleeding,

hemothorax, tension pneumothorax,

unstable chest and abdominal

wounds, incomplete amputations,

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OPEN Fx’s of long bones, and

2nd

/3rd

degree burn with 15%-40%

of total body surface

Class II – Urgent, but

can wait short time Yellow

Major injuries that need treatment

within 30 min to 2 hours, Stable

abd. wounds without evidence of

hemorrhage, Fx requiring open

reduction, debridement, external

fixation, most eye and CNS injuries

Class III – Non-urgent

or “walking wounded” Green

Minor injuries that can be managed

in a delayed fashion, generally more

than 2 hours, upper extremity FX,

minor burns, sprains, sm.

lacerations, behavior disorders

Class IV – Expectant Black

Patients who are expected to die or

are dead, unresponsive, spinal cord

injuries, wounds w/anatomical

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organs, 2nd

/3rd

degree burn w/60%

of BSA, Seizures, profound shock

w/multiple injuries, no pulse, BP,

pupils fixed or dilated

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Hospital Emergency Preparedness Personnel Roles and

Responsibilities

Hospital Incident Command System – roles are formally structured

under the hospital or long-term care facility incident commander with

clear lines of authority and accountability for specific resources.

Personnel Role Personnel Function

Hospital Incident Commander

Physician or administrator who assumes overall

leadership for implementing the emergency plan

Medical Command Physician

Physician who decides the #, acuity, and

resource needs of patients

Triage Officer

Physician or nurse who rapidly evaluates each

patient to determine priorities for treatment

Community Relations or Public

Information Officer

Person who serves as a liaison between the

health care facility and the media

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Event Resolution and Debriefing

When the last major casualties have been treated and no more are expected to arrive, the

incident commander considers “standing down” or deactivating the emergency response

plan.

A vital consideration in event resolution is staff and supply availability to meet ongoing

operational needs.

Severe shortages of supplies and the need to clean and restock the ED may pose a threat

to normal operations at the conclusion of an incident.

Two Types of Debriefing Occur following a Mass Casualty event or period:

o CISD or CISM – addresses pre-crisis through post-crisis interventions for

small to large groups, including communities. The team leader typically has

background in a mental health/behavioral health field. Prevent PTSD

o Administrative Review – directed at analyzing the hospital or agency response

to an event soon afterwards. The goal is to evaluate the implementation of the

emergency preparedness plan so that changes can be made. Representatives

come together for discussion.

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Module F

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Resuscitation fluid formulas are a guide, fluid rate should be

adjusted to patient response determined by hourly urine output.

Goal is 0.5ml/kg urine output.

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Type of Burn Minor Moderate Major

Criteria

Deep partial-thickness

↓ 15% TBSA; Full-

thickness burns ↓ 2%

TBSA; No burns of

eyes, ears, face, hands,

feet, or perineum; No

electrical burns; No

inhalation injury;

Younger than 60 w/no

chronic cardiac,

pulmonary, or

endocrine disorder

Deep partial-thickness

15%-25% TBSA;

Full-thickness burns

2%-10% TBSA; No

burns to eyes, ears,

face, hands, feet, or

perineum; No

electrical burns; No

inhalation injury; ↓ 60

w/no chronic cardiac,

pulmonary, or

endocrine disorder

Partial-thickness burns

↑ 25% TBSA; Full-

thickness burns ↑

10%; Any burn

involving the eyes,

ears, face, hands, feet,

perineum; Electrical

or Inhalation injury; ↑

60; Burn complicated

w/other injuries; Has

cardiac, pulmonary, or

other chronic issue

Disposition Outpatient

Special Hospital

Admissions or Burn

Center

Burn Center Referral

ASAP

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Degree of Burn Depth/Color of Burn Characteristics

Superficial (1st Degree) Epidermis; Pink/Red

NO Blisters or raw areas; Can be painful;

Desquamation (peeling)

of dead skin in 2-3 days; EX: Sunburn

Partial (2nd Degree) Superficial Deep Superficial Deep

Superficial Deep

Epidermis/Partial

dermis; Pink/Red

Epidermis/Deep

Dermis; Red/White

Min.

edema;

YES Blister;

PAIN;

heals 10-21 days;

Blanch;

NO Scar; EX: Brief

Hot

Mod.

Edema;

NO blister; ↓ PAIN;

heals 3-6

wks.; Slow/NO

Blanch;

YES Scar; EX: Long

Hot

Full (3rd Degree)

Epidermis, Dermis, SC Tissue, Nerves; White, Brown, Deep Red, Yellow, Leathery, Black,

Charred, Eschar

Skin does NOT regrow;

NO edema; May/May not have PAIN; EX: Fire, Tar,

Grease, Electric, Chemica

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Dressing the Burn Wound

Standard wound dressings

Biologic dressings – temp. wound cover and closure. Expensive.

o Homograft – Human skin

o Heterograft – Skin from other species (PIG)

o Cultured skin

o Artificial skin

Biosynthetic dressings

Synthetic dressings

Topical medications and medicated dressings

o Chart 28-5

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Module D

Types of Shock

Hypovolemic shock – when too little circulating blood vol. (hemorrhage)causes a MAP

↓ → ↓ O2

Cardiogenic shock –when the actual heart muscle is unhealthy & pumping is impaired,

usually after MI

Distributive shock – blood vol. not lost; distribute to interstitial tissues/cannot deliver

O2

o Neural induced

o Chemical induced

Anaphylaxis

Sepsis

Capillary leak syndrome

Obstructive shock – caused by problems that impair ability heart muscle to pump effectively

Anaphylactic shock – allergic reaction

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Stages of Shock

Initial

(Early)

Nonprogressive

(Compensatory)

Progressive

(Intermediate)

Refractory

(Irreversible) MODS

Early shock;

baseline MAP is ↓

by less than 10 mm

Hg;

Lactic acid will

cause compensation of

sympathetic

system; vasoconstriction

and increased heart

rate;

Symptoms are so

mild it is hard to detect shock

MAP ↓ 10 to 15

mm Hg from

baseline

Kidney and

baroreceptors

trigger release of renin, ADH,

aldosterone, epi

and norepi Tissue hypoxia in

nonvital organs and

in kidney, it is not

↑ enough to cause

permanent damage Mild acidosis and

hyperkalemia; ↑

HR/R/T

Sustained decrease

in MAP of more

than 20 mm Hg

from baseline

Compensatory

mechanisms are functioning but no

longer deliver

sufficient oxygen, even to vital organs

Overall metabolism

is anaerobic:

moderate acidosis

and hyperkalemia; tissue ischemia

Life threatening

emergency; Cold

Severe tissue

hypoxia with

ischemia and

necrosis

Release of

myocardial depressant factor

from the pancreas

Buildup of toxic metabolites

MODS

Death

SIRS

Sequence of cell

damage caused by

the massive release

of toxic

metabolites and

enzymes Metabolites trigger

small clots to form

Occurs first in the liver, heart, brain,

and kidney

Damage to the

heart muscle is

severe (one cause is the release of

MDF from

ischemic pancreas)

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Other Shock Stuff

↑ Creat, ↑ BUN = Renal Failure

↓ Urine Output

↓ O2

↑ CRP, ↑ BNP

Tests: Blood Cultures, Lactase, ABG

Key Features: Teach pt. to watch after d/c, could occur after d/c

Respiratory Neuro Integumentary Kidney ↑ respiratory rate

Shallow depth of

respirations

↑ Paco2; ↓ PaO2

Cyanosis, especially

around lips & nail beds

Anxiety

Restlessness

↑ Thirst

Feeling of

impending doom

Cool to cold

Pale to mottled to

cyanotic

Moist, Clammy

Mouth dry; pastelike

coating present

↓ urine output

↑ specific gravity

Sugar & acetone

present in urine

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Shock Key Features Continued

Cardio GI Late ↓ CO

↑ Pulse Rate

Thready pulse

↓ BP

Narrowed Pulse Pressure

Postural Hypotension

Low CVP

Flat neck & hand veins

in dependent positions

Slow Cap Refill in nail

beds

Diminished peripheral

pulses

↓ Motility

Diminished or absent

bowel sounds

N & V

Constipation

↓ central nervous

system activity

(lethargy to coma)

Generalized muscle

weakness

Diminished or absent

deep tendon reflexes

Sluggish pupillary

response to light

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Module A

Pressures

Right Atrial

Pressure

Pulmonary

Artery Pressure

Pulmonary Artery Wedge

Pressure (PAWP) or Pulmonary

Artery Occlusive Pressure

(PAOP)

Central Venous

Pressure

Normal: 1 to

8 mm Hg

Increased:

right

ventricular

failure

Decreased:

hypovolemia

15 to 26 mm of Hg

systolic/5 to 15 mm Hg diastolic (mean of

15)

Constantly seen on

the monitor

Increased:

hypertension, pulmonary edema

Decreased:

dehydration, diuretics

Balloon inflated, becomes wedged in

branch of pulm. artery Tip of wedged cath. senses pressures

from L atrium which reflect L vent.

end-diastolic pressure

Normal: 4-12 mm Hg

Increased: L vent. failure,

hypervolemia, mitral regurgitation, cardiac shunt

Decreased: hypovolemia, afterload

reduction

Pressure within the

superior vena cava

Reflects the pressure

under which blood is

returned to the heart

Normal: 5-10cm H20

Increased: overload

(heart failure)

Decreased: reduce

blood volume

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Tetrology of Fallot

(+Lesions w/Decreased Pulmonary Blood Flow)

Patho

Altered

Hemodynamics Manifestations

Therapeutic

Management

5% - 10% of

congenital

cardiac defects;

most frequently

seen cyanotic

lesion;

constellation of

lesions results

from

malalignment of

ventricular

septum during

Equal right and

left sided

ventricular

pressures r/t

pulmonary

artery

obstruction and

size of VSD,

desaturated

blood enters the

systemic system

by shunting

Onset and

severity of s/s

are r/t extent of

obstructed

pulmonary

blood flow,

which causes the

right to left

shunting; if

lesions are mild,

shunting is ↓ and

saturations are

PGE

(Prostaglandin),

infusion to

maintain

patency of

ductus arteriosus

and blood flow

to lungs,

management of

hypercyanotic

episodes, TX of

iron deficiency

of 65

fetal

development –

VSD, right

ventricular

outflow tract

obstruction

pulmonary

stenosis,

overriding of the

aorta, right

ventricular

hypertrophy

right to left

across the VSD,

or into the

overriding aorta

mildly ↓;

cyanosis,

extreme fatigue,

hypercyanotic

episodes,

chronic

hypoxemia;

Harsh systolic

murmur

w/palpable

thrill, boot-

shaped heart on

radiography

anemia

of 65

Coarctation of the Aorta

Patho

Altered


Therapeutic

Management

8% to 10% of cardiac

defects; aorta is

constricted near the ductus arteriosus

insertion location;

associated w/bicuspid aortic valve that can later

become stenotic

Narrowing of the aortic

structure obstructs the

left ventricular output, ↑

afterload to left ventricle,

blood supply is ↓ in the

abdominal organs and the ↓ periphery, left

ventricular pressure ↑

aortic pressure is high proximal to constriction

and low distral;

pulmonary edema can occur. If coarctation is

miled, collateral blood

supply can develop to channel blood past the

constriction.

Left-sided HF w/low

cardiac output, poor

lower extremity peripheral perfusion,

metabolic acidosis,

shock; If PDA present – right-to-left shunting

w/differential cyanosis

(color and oxygenation differential between

upper and lower

extremities); Systolic murmur accompanied by

ejection click or thrill

Diuretics and Digoxin

Must have Patent Ductus – Give Prostaglandin to

keep open

of 65

Patent Ductus Arteriosus (Left-to-Right Shunting)

Patho

Altered


Therapeutic

Management

5% to 10% of all

congenital heart

lesions

Caused by failure of

fetal ductus arteriosus

to close completely

after birth – normal

closure within 24 to

72 hours after birth d/t

↓ prostaglandin levels

and ↓ BP in ductus

lumen

D/T ↓ in pulmonary

vascular resistance

and failure of the

ductus arteriosus to

close, ↑ systemic

pressure moves

satuated blood from

aorta into pulmonary

arteries (left-to-right

shunt), the lungs, and

left side of heart

causing both ↑ left

sided cardiac

workload and ↑

pulmonary blood flow

Continuous murmur –

machinery like sound;

Widened pulse

pressure; bounding

pulses; cardiac

enlargement

Administration of

Indocin to close PDA,

a PG inhibitor that

constricts the ductus;

Monitor respiratory

status, renal function,

and growth;

Interventional Cardiac

Catheterization – a

coil is placed to

occlude the ductus;

Ligation of ductus via

left thoracotomy,

usually within the 1st

year of life

of 65

ACLS Algorithyms

Bradycardia – Give Atropine 0.5 mg to 1 mg, up to 3 mg, Can give every 3 to 5

minutes.

SVT or Tachy – Give Adenosine 6 mg 1st dose and 12 mg 2nd dose. Follow both

with NS flush rapid IV push.

Cardiac Arrest – Important to defibrillate early; then epinephrine 1 mg every 3

to 5 minutes

of 65

CABG

Patho Candidates Preop PostOp

Most common type

of cardiac surgery

Occluded coronary

arteries are

bypassed with the

client’s own

venous or arterial

blood vessels or

synthetic grafts

IMA is the graft of

choice due to

patency rate

Angina greater than 50%

occlusion of the left main

coronary artery

Unstable angina with

severe two-vessel or

moderate three-vessel

disease

Ischemia with heart

failure

Acute MI

Signs of ischemia or

impending MI after

angiography or PTCA

Valvular disease

Coronary vessels

unsuitable for PTCA

May be elective or

emergent procedure

May be traditional

technique or MIS

technique

Pre-op teaching is

very important:

Report pain to the

staff

T, C, & DB exercises

will be expected

Early ambulation

Monitor for

dysrhythmias and

complications

Fluid and electrolyte

balance

Hypotension

Hypothermia

Hypertension

Bleeding, no more

than 15 mL/hr

Cardiac tamponade

Altered LOC

Anginal pain

Transfer from the

SCU

of 65

ECG Lead Groups

Septal

Anterior

Lateral

Inferior

You may see changes in more than 1 lead group!

Septal Leads

V1, V2

Look at the septum between the ventricles

Perfused by the RCA and LAD

Anterior Leads

of 65

V3 and V4

Look at the anterior portion of the left ventricle

Perfused by the LAD

Lateral Leads

I, aVL, V5, and V6

Reflect the lateral part of the left ventricle

Perfused by the circumflex (LCX)

Inferior Leads

II, III, and aVF

Look at the right side of the heart

Perfused by the RCA

of 65

This area is innervated by the same group of nerves that innervate the

stomach

Nausea, vomiting, and hiccups

of 65

Module G

Causes of Intellectual Disability – PKU, Tay Sachs, Alcohol, Drugs, Prematurity,

Toxemia, Exposure to Toxins, Lack of Nurturing, Trauma, Head Injury, Asphyxia,

High Temps (Hyperpyrexia). Moderate - Requires supervision with activities;

academic skills to 2nd grade; sheltered workshop environment; difficulty with

speech

Personality Disorders –

Cluster A (Odd Eccentric Behavior):

o Paranoid – Suspicious of others, as a child had parental

harrassment

o Schizoid – Shy, introverted, detached, Indifferent, Lacked

nurturing in childhood, Socially withdrawn; prefer to work

alone, computer programmer only relationship is w/computer

of 65

o Schizotypal – magical thinking, 6th sense, bizarre speech;

rejected, humiliated, overlooked as a child, socially isolated

Cluster B (Dramatic, Emotional Behaviors):

o Antisocial – Sociopaths; Socially irresponsible; disregard for the

rights of others; cold and callous, manipulative, con-artist

o Borderline – always in a state of crisis; Always in a state of crisis;

chaotic relationships; impulsive and self-destructive

o Histrionic – always have to be center of attention, flighty,

Attention-seeking behavior; center of attention, overly dramatic

o Narcissistic – very self-centered, superior to everyone else,

needs special attention.

Cluster C

o Avoidant – fearful, uncomfortable in social situations; lonely;

depressed

o Dependent – very submissive, clingy, Cannot make decisions;

lack self-confidence

of 65

o OCD – preoccupied with rules and tasks; Preoccupied with rules,

lists and organization

o Passive-Aggressive – feel cheated, underappreciated, world out

to get them; Believe that life is unkind and everyone has it

"easier"

Eating Disorders

o Anorexia Nervosa – underweight, refuses to eat, Intense fear of

gaining weight; refusal to maintain body weight, electrolyte

imbalances, want to control everything. Gain pleasure from

providing others w/food and watching them eat. Do not allow

them to plan or prepare food for unit based activities.

o Bulemia Nervosa – normal weight, binge and purge, loose

enamel on teeth, at risk for dehydration, inappropriate behavior

to prevent weight gain (vomiting, laxatives, enemas)

of 65

Theories of Aging

Biological Theories:

o Genetic Theory – aging is an involuntarily inherited process that

operates over time to alter cellular or tissue structures.

o Wear-and-Tear Theory – body wears out on a scheduled basis, free

radicals cause issues

o Environmental Theory – factors in the environment (carcinogens,

sunlight, trauma, and infection) bring about changes in aging process.

o Immunity Theory – age-related decline in immune system

o Neuroendocrine Theory – slowing of secretion of certain hormones

that have an impact on reactions regulated by nervous system.

Psychological Theories:

o Personality Theory – address aspects of psychological growth w/o

delineating specific tasks or expectations of older adults (Mature men,

Rocking Chair personality, Armored men, Angry men, Self-haters)

of 65

o Developmental Task Theory – activities and challenges that one must

accomplish at specific stages in life to achieve successful aging.

o Disengagement Theory – describes the process of withdrawal by older

adults from societal roles and responsibilities.

o Activity Theory – opposite of disengagement theory; the way to age

successfully is to stay active.

o Continuity Theory – also known as developmental theory; a follow-up

to the disengagement and activity theories. Emphasizes the

individual’s previously established coping abilities and personal

character traits as a basis for predicting how the person will adjust to

the changes of aging.

How Old Is Old

Older – 55 to 64

Elderly – 65 to 74

Aged – 75 to 84

Very Old – 85 years and older

of 65

Intimate Partner Abuse

Cycle of Battering

o Phase 1 (Tension Building Phase)– Less and Less tolerant, can last

weeks to years; woman makes excuses for the batterer

o Phase 2 (Acute Battering) – battering phase, most violent, shortest, up

to 24 hrs.

o Phase 3 – Honeymoon phase, never going to happen again, apologies,

excuses; woman wants to believe he can change

Child Abuse (Pg. 782 – 784)

Physical and Emotional Abuse

o Physical – includes any nonaccidental physical injury as a result of

punching, beating, kicking, biting, shaking, throwing, etc.

Unexplained burns, bites, bruises, broken bones, or black

eyes

of 65

Fading bruises or other marks noticeable after an absence

from school

Frightened of parents and protests or cries when it is time to

go home

Shrinks at the approach of adults

Reports injury by a parent or another adult caregiver

Abuses animals or pets

When parent or other caregiver:

Offers conflicting, unconvincing, or no explanation

for child’s injury

Describes the child as “evil” or in some other very

negative way

Uses harsh physical discipline w/child

Has HX of abuse as child

Has HX of abusing animals or pets

of 65

o Emotional – involves a pattern of behavior on the part of the parent

or caretaker that results in serious impairment of the child’s social,

emotional, or intellectual functioning.

Extremes in behavior such as overly compliant or demanding

behavior, extreme passivity, or aggression

Either inappropriately adult (parenting other children) or

inappropriately infantile (rocking or head-banging)

Delayed in physical or emotional development

Has attempted suicide

Reports a lack of attachment to the parent

Emotional Abuse may be suspected when the parent or

caregiver:

Constantly blames, belittles, or berates the child

Is unconcerned about the child and refuses to

consider offers of help for the child’s problems

Overly rejects the child

of 65

Physical and Emotional Neglect

o Physical Neglect – includes refusal of or delay in seeking health care,

abandonment, expulsion from the home or refusal to allow a runaway

to return home, and inadequate supervision

o Emotional Neglect – Refers to a chronic failure by the parent or

caretaker to provide the child with the hope, love, and support

necessary for the development of a sound, healthy personality.

o Indicators of Neglect

Frequently absent from school

Begs or steals food or money

Lacks needed medical or dental care, immunizations, or

glasses

Consistently dirty and has severe body odor

Lacks sufficient clothing for the weather

Abuses alcohol or other drugs

States that there is no one at home to provide care

o Possibility of neglect may be considered when parent or caregiver

of 65

Appears to be indifferent to child

Seems apathetic or depressed

Behaves irrationally or in a bizarre manner

Is abusing alcohol or other drugs

PPE Sequence Putting On (Donning)

Gown

Mask

Goggles

Gloves

PPE Sequence Taking Off (Doffing)

Gloves

Goggles

Gown

Mask

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