1
Critical Care FINAL Study Guide:
50-55 Questions
Mechanical Ventilation (Q?)
Device
LOW FLOW SYSTEM → Nasal
Cannula: A length of tubing with
two small prongs for insertion into
nares
Uses/Considerations
● Delivers 1-6 L O 2
Liters of O2
FIO2 (%)
1
24%
2
28%
3
32%
4
36%
5
40%
6
44%
● Safe, easy to apply, well tolerated
● Assessments
○ Skin Breakdown
○ Patency of nares
○ Mucous membranes → often become dry
■ Humidification if >4L O 2
○ Let the provider know if there is an increased O2 requirement to maintain sufficient O2 sat.
RESERVOIR SYSTEMS
Simple Face mask
● Requires at least 5LO2 to avoid rebreathing CO2
● Use if a patient requires >6LO2
● Short term
● Contraindicated for those with CO2 retention
● 6-10 L O 2 = 35-60% FIO2
● Caution with patients who have r/f aspiration or airway obstruction
● Careful with COPD patients!
● Patients cannot eat or drink → wear NC during meals/drinking
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Partial Rebreather
● Reservoir bag attached with no valve → allows client to re-breathe some exhaled air together with room
air.
● 6-15 L/min = 60%-80% FIO2
● Make sure bag stays inflated
● Assess for skin breakdown
● Wear NC if eating or drinking
Non-rebreather (NRB)
● Reservoir bag with valve → does not allow for client to rebreathe their own air
● Allows for highest concentration of O2 if clients can still breathe on their own (not breathing any
atmospheric air, only oxygenated volume)
● 6-15 L/min = 60%-80% FIO2
Air entrainment Mask
● Provide humidification and oxygen
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● Provide FIO2 24-100%
● O2 at 10L/min
● Replacing humidification canister
● Emptying condensation from tubing
● Keeps mouth and nares moist and lubricated
Optiflow → high flow nasal
cannula
● For people who have trouble oxygenating but need > 6LO2
● Allows us to give high volumes of oxygen through nasal cannula
● Patients can be on high amounts of O2 without causing breakdown/dryness
● 5-60 L/min O2 = 21-80% O2
Manual Resuscitation
Ambu bag (Bag-valve mask
device)
● Four basic parts:
○ Nonrebreathing valve → directs oxygen to patient when bag is compressed, and away from patient into
atmosphere on exhalation
○ Bag → compress to deliver O2; should re-inflate after each squeeze; 1 squeeze every 3 seconds
○ Adapter
○ Reservoir
○ Connect to O2 and turn up as high as possible
● If unsure if the machine/equipment is not working properly, throw them on a bag mask!
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Artificial Airways
Nasal Trumpets
● Helps to keep airway patent
● Can be placed by RN
● Stops in back of throat and bypasses gag reflex
● Can connect to suction to remove secretions
● Lubricate when inserting
Nasopharyngeal Airways
● A tube inserted through a nostril, across the floor of the nose, and through the nasopharynx so that the
tongue does not block air flow in an unconscious person
● Ask patient to swallow when inserting
Endotracheal Tube
● Curved tube placed through the patient's nose or mouth into his trachea; tape or a soft strap holds the
tube in place.
● Note depth marking at beginning of shift
● Can cause skin breakdown → rotate sites once a shift
● Helps with ventilation AND oxygenation
● Patients will ALWAYS be connected to a ventilator
● Can be cuffed or uncuffed
○ Cuffed → prevents air leaks, deflate balloon when extubating
○ Uncuffed → typically seen in peds because trachea is smaller
● Can be in for two weeks maximum (if needed for longer, they will need a tracheostomy)
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● Complications
○ Nasal and oral inflammation and ulceration
○ Laryngeal and tracheal injuries
○ Vocal cord injuries → voice may sound different
○ Tube obstruction/displacement
○ Cricoid abscess, bacteria buildup
● Intubation process
○ Make sure to have working suction, ambu bag with mask at 100% O2, laryngoscope, ETTs, stylet
○ Monitor POX
○ Sedated if they have a pulse
○ End Tidal CO2 detector → pedi-cap
○ Listen for breath sounds once tube is placed
○ Secure tube
○ Note level of insertion
○ Confirm placement with CXR
Tracheostomy
● Preferred if patient requires longer term intubation
● Helps avoid nasal, oral, pharyngeal and laryngeal complications
● Maintaining patency and position is important → trach. collars
● Change trach ties, and inner cannula care q shift
○ Changing cannula, you will need to disconnect them from ventilator (machine will time you!)
○ Note for any skin breakdown
● HOB min at 30 degrees
● Sterile suctioning
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○ HYPEROXYGENATE PRIOR! → 100% oxygen 30 seconds before!
○ Thread catheter down
○ Only suction for 5-10 seconds, ONLY ON THE WAY OUT
● Pre Perforated gauze strips for area around trach ONLY! (DO NOT cut your own gauze because fibers
can get lodged into trach. and lead to bacterial growth)
● In line suctioning can only be done if they are connected to ventilator
Ventilators:
● Negative Pressure → external, not used in ICU
● Positive pressure (more commonly seen in ICU) → helps assist volume or breath to get into patient
● Important terminology
○ Tidal Volume (VT) → amount of volume (mL), to cause an inhalation (volume given to assist in an inhalation)
○ Rate → respiratory rate per minute
○ FiO2 → fraction of inspired oxygen that we breathe in, expressed as a percentage (oxygen concentration)
○ PEEP → positive end expiratory pressure; helps alveoli remain open for a little bit longer at the end of respiration (normal is +5)
■ CONTRAINDICATIONS: COPD (higly compliant lungs), hypovolemia/Low CO (PEEP increases pressure on chest, this will interfere with
venous return if CO is low)
■ Side effects: Low BP, Decreased CO, Barotrauma (too much pressure), pneumothorax
○ PS → push of air to help with spontaneous breathing
● Types of ventilation
○ Volume Control → preset tidal volume that is constant for each breath; for spontaneously breathing patients with weak respiratory muscles
■ Assist Control (AC) → full machine breathing
● Preset amount of Tidal Volume for each breath
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● If a patient fails to take a breath in a preset amount of time, one will get delivered to them
● Once the ventilator senses a breath, it will resort to its preset
■ SIMV → weaning mode
● Allows patient to take control of their own respirations
● Preset TV and RR on ventilator
● Patient may take own breaths at their own rate & volume
● Ventilator breaths are synchronized to the patient's respiratory effort
● When a respiration is sensed, it allows the patient to take the respiration! (DOES NOT DEFAULT BACK TO VENT SETTINGS!)
○ Pressure control → preset inspiratory and expiratory pressures, inspiratory pressures constant for each breath; for those with decreased lung
compliance or airway resistance
■ Patient takes their own breath and tidal volume
■ A weaning mode typically
■ PS → helps overcome resistance
■ Helpful for ARDS
● Alarms
○ Low pressure: Loss of connection or Leak
■ Causes: cuff leak, ET tube displacement, disconnection
○ High pressure: High blockage
■ Causes: Biting on tube, kinks in tube, excessive airway secretion, coughing, mucus plugs, pulmonary edema, pneumothorax
● Things to note:
○ Dyssynchrony → is their RR lower than the preset settings?
○ Tolerating vent. Settings?
● Usually begin weaning process during the day → patients are typically the most alert and arousable
● Barotrauma → too much pressure; caused by too much PEEP, can cause alveoli to pop, and a collapsed lung (pneumothorax)
● Volutrauma → hyperventilating; volume in does not equal the amount of volume out; caused by a high tidal volume
● Reassessing sedation to suppress gag reflex
● Tube feeds
○ Check residuals → if >150, they are not tolerating the feeds
● Q2H mouth care to prevent VAP
Respiratory (3-5 Questions)
●
●
Overall Assessment
○ Color (pink, pale, or cyanotic)
○ Cough
○ Effort (easy, WOB)
○ Rate (fast, slow)
○ Lung Sounds (clear, adventitious)
○ Airway (maintainable, un-maintainable)
Diagnostics
○ Pulse Oximetry → non-invasive infrared sensor; measures degree of oxygen saturation in capillary bed
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Disease
Causes
Manifestations
Diagnostics
Intervention
Acute
Respiratory
Failure (ARF)
● Failure to adequately
ventilate/oxygenate
● Diseased lung
● Neuro → mental status
changes, anxiety,
restless, confusion
● Respiratory → starts as
tachypnea and
increased tidal volume,
progresses into
shallow, dec. RR,
accessory muscles,
SOB
● Cardiac → decreased
pulses, skin color
● ABGs
● CXR
● POX
● Maintain airway
● O2 Delivery → supplemental O2, positioning
● Minimize O2 demand → decreasing activity,
agitation, stress, fever, restlessness
● Treat the cause
● Pharm:
○ Bronchodilators
○ Steroids
○ Sedatives, Analgesics
○ NM Blockade → make sure they are on a
ventilator!
○ Nebulizer Tx.
● Exudative/Acute phase:
increased capillary
permeability,
developing
microthrombi,
pulmonary HTN, V/Q
mismatching
● CXR
● EKG →
rule out
cardiac
involvemen
t
● Hemodyna
mic
monitoring
● Recovery takes several weeks
● Management is really difficult
○ Mechanical Ventilation: Keep VT the
same and lower PEEP
● Pharm: bronchodilators, sedatives,
analgesics, NM blockade (to help
ventilation)
● Prone positioning!
● Rotating beds
● Suction PRN
● Nutrition support
Ventilation Issues → mechanical
issues, impaired muscle fx., malfx. of
respiratory control center in the brain
Oxygenation Issues → lack of
perfusion to pulmonary capillary bed,
altered gas exchange (d/t pulmonary
edema or pneumonia)
Acute
Respiratory
Distress
Syndrome
(ARDS)/
Acute Lung
Injury(ALI) →
pulmonary
manifestation
s of MODS
and Sepsis
● Systemic Inflammatory response
injures alveoli-capillary membrane
● Reduction in surfactant weakens
alveoli
Direct causes: Aspiration, Near
drowning, Toxic inhalation,
Pneumonia, Thoracic radiation
Indirect causes: Sepsis,
Cardiopulmonary bypass, Severe
pancreatitis, Embolism, DIC, Shock
states
● Fibroproliferative
phase: alveoli enlarge,
scarring, stiffness of
alveoli, further
hypoxemia
Early S/S:
Tachypnea
Restlessness
Normal PaO2 and CXR
Late S/S:
Accessory muscle usage
crackles/rales
Infiltration on CXR
Lactic acidosis
Organ dysfunction
Complications: encephalopathy,
dysrhythmias, VTE, GIB, barotrauma,
volutrauma, O2 toxicity
Reduce O2 demand with ADLs!!!
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Pneumonia:
inflammatory
process of the
lungs that
produces
excess fluids,
may be
triggered by
infectious
organisms or
aspiration
(can be a
primary
disease or a
complication
of another
process)
● Leading
cause of
death in US
● Community-acquired (CAP)
● Hospital-acquired (HAP)
● Ventilator-acquired (VAP)
● Aspiration pneumonia
● Bacteria accumulates in lower
respiratory tract and overwhelms
body’s normal mechanisms
● Risk Fx: COPD, ETOH Abuse,
impaired swallowing (stroke
patients), Tube Feedings,
Smokers, DM,
immunocompromised, increased
age, ventilator support
● Pinpoint crackles (in
the area of the lung that
the bacteria is
affecting)
● Cough
● Fever
● Dyspnea
● Tachypnea
● Chest pain
● CXR
● Bronchosc
opy
● CBC
● Blood Cx.
● Chem
Panel
● ABGs
● O2 Therapy
● Abx → draw cultures, then start on broad
spectrum
● Bronchodilators
● Positioning
● Suction PRN
● Checking residuals = prevent aspiration
● CPT
● Pulmonary toileting → cough and deep
breathing exercises
● Pneumococcal vaccine for older population
● Comfort and support
Complications: ARF
Pulmonary
Embolism:
Occurs when
a
substance
(solid,
gaseous, or
liquid) enters
venous
circulation
and forms a
blockage in
the
pulmonary
vasculature.
● DVTs/venous stasis/immobility
● Atrial Fibrillation
● Injury to endothelium →
infection/atherosclerosis
● Hypercoagulability
● Surgery
● Cancers
● Trauma
● Pregnancy
● Tachycardia
● Tachypnea
● Dyspnea, SOB
● Fever
● Crackles, Rales
● Chest pain
● Cough
● DVT
● Hemoptysis
● ABGs
● D-dimer →
elevated
with blood
clots
● ECG
● CXR
● Echo
● CT Scan
● V/Q Scan
→
VentilationPerfusion
mismatch
(will have
altered
perfusion
→ V/Q ratio
< 1)
● DO NOT massage extremities, take off heel
boots
● Prevention → low dose heparin, low
molecular weight heparin, lovenox,
coumadin, compression stockings,
compression boots
● O2
● Anticoagulants
● Bronchodilators
● Sedatives, Analgesics
● Fluids
● Positioning
● Thrombolytics → clot busters
● Greenfield filter → invasive, can catch the
clot
● Surgery → embolectomy
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● Pulmonary
angiogram
● DVT
studies
Neuro (10-15 Questions)
● Monro-Kellie Hypothesis: Skull only has room for brain (80%), blood volume (10%), CSF
(10%), if volume increases in one compartment, the others must compensate by decreasing
○ Body can accommodate, but only to certain circumstances
○ If one of the three components is elevated too much, it increases ICP
■ Normal ICP: 0-15 mmHg
■ Increased → >20 mmHg for 5 MINS OR LONGER
● S/S: Headache, N/V, Altered LOC, pupillary changes
● Difficult to assess in patients who are not AAOx4
○ Cerebral Blood Flow (CBF): Blood's ability to perfuse brain adequately
■ Hypoxia > 5 mins (at normal body temperature) → neurons destroyed
○ Cerebral Perfusion Pressure (CPP): pressure required to perfuse brain; CPP = MAP - ICP
■ Normal Range → 60-100 mmHg
■ CPP determines CBF (perfusion in brain); ischemia can occur if inadequate
● Brain Herniation → increased pressure in the skull forces cerebellum out of the foramen
magnum in order to relieve pressure, if this occurs, the patient will be in a vegetative state
● Neurological Assessment
○ ICU → Q 1 Hour
○ GCS = Eyes, Best motor, Best verbal; ranges from 3-15
○ Pupillary Response
■ Unequal pupils are a late sign of increased ICP → optic nerve sits at center of brain and
when pupils are affected, swelling has reached center of brain
○ Abnormal Motor Responses
■ Decortication → Abnormal Flexion (may be spontaneous) in response to noxious stimuli
■ Decerebration → Abnormal extension (may be spontaneous) in response to noxious
stimuli
■ Flaccid → no response to noxious stimuli = brain dead
○ Brain Death protocol → two separate doctors at two separate times
■ In a comatose state, unresponsive to noxious stimuli (without pressors sedation, pain
meds)
■ Absence of brainstem activity and reflexes
● Pupils fixed or dilated
● No ocular movement
● No corneal reflexes
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● No facial grimacing/movement with pressure in TMJ
● Absent gag reflex
■ Apnea → no automatic respirations (no brainstem activity = cannot regulate breathing)
○ Protective reflexes → shows us if they are neurologically intact
Reflex
Expected finding
Abnormal finding
Corneal/blink reflex → cotton ball to
the eyes
Blinking
Not blinking
Gag reflex → touching palatal arches
with tongue depressor
Gagging
Absence of gag
Swallowing reflex → have patient
swallow water
Swallows water
Cannot swallow/aspirates
Cough reflex → use tussive agent
(such as capsaicin) to stimulate cough
Cough
No cough
Oculocephalic reflex (Doll’s eye) →
turning head side to side, observing
movements of eyes
-
NOT present if AAOx3
Comatose patients → eyes move to the
opposite direction that you move the head
Oculovestibular reflex (Cold
Caloric/Iced Caloric Test): injecting
cold water into ears
-
Normal → patient looks at the ear that the
water is being shot into
Absent in comatose patient → indicates
brainstem dysfunction
-
Patient looks in the opposite direction
Absence of reaction = problem with
pons/medulla
○ ALL protective reflexes must be absent in order to classify as brain dead
○ Decompensation → Cushing’s Triad: last s/s before herniation
■ Widening pulse pressure
■ Bradycardia
■ Respiratory changes
● Monitoring ICP → Ventriculostomy
○ Indications: Trauma, TBI, stroke, brain tumor, craniotomy, coma, subarachnoid hemorrhage, hydrocephalus
○ Contraindications: coagulopathy, infection
○ Types (based on where they are placed): intraventricular, subarachnoid, intraparenchymal, epidural
○ Uses: monitor ICP and remove CSF if needed
○ Line connected to a bag that is a gravity drainage system, orders will tell you how much pressure to set it at
○ Nursing considerations
■ Monitor calipers q shift
■ Transducing to tragus of ear and zeroing each shift
■ Assess waveform integrity
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■
■
Disease
Remove CSF if ordered
Monitoring drainage
Causes
Traumatic Brain
● Missile injuries
Injury (TBI): happens ● Cerebral
when a sudden,
hematomas →
external, physical
subdural, epidural
assault damages the ● Coup-counter coup:
brain. It is one of the
common in car
most common causes
injuries, caused by
of disability and death
acceleration/deceler
in adults.
ation
● Diffuse Axonal →
trauma to actual
nerves; messages
fire but cannot be
delivered
● Skull fractures →
in-bending of skull at
point of impact
Manifestations
Diagnostics
Intervention
● Diffuse Axonal →
patients age will not be
chronological (will act
younger than they are),
and have trouble
toileting and bathing
● Skull fractures →
Battle sign
(postauricular
bruising), and raccoon
eyes (b/l periorbital
edema and bruising)
○ CSF leakage
possible (halo sign
on pillowcase)
● Dexastrip → helps test if
secretions are CSF
● Ventriculostomy →
measure ICP
● CT → for emergent
situations
● MRI → when patients are
stable enough
● EEG → seizure activity
● NO NGT by RN (can perforate brain)
● Prevent front extraneously
increasing ICP!
○ DO NOT BLOW NOSE
○ Physical activity
○ Pain
○ Straws
○ Vomiting → Zofran
○ Noise
○ Positioning → HOB elevated with
head neutral and body midline
(DO NOT lay flat)
○ Low stimuli
● Meds
○ Diuretics → Lasix, Mannitol
● Maintain PEEP < 20 cm
● Maintain pCO2 (30-49) + SpO2 >
95%
○ CO2 < 30 → vasoconstriction =
cerebral ischemia
○ CO2> 49 → vasodilation =
increased ICP
● BP control → MAP between 70-90
● Seizure prophylaxis → keppra,
dilantin, ativan
● Hypertonic saline
● Suction PRN
● Surgery: Craniotomy→ Helps gain
access to portions of the CNS
○ Indications: tumor
resection/removal, cerebral
decompression (to decrease
ICP), evacuation of
hematoma/abscess,
Clipping/removing aneurysms
○ Preop → baseline neuro
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assessment, diagnostics (blood
tests, type and screen), CXR, 12
Lead-EKGs, FFP prior to surgery
○ Post Op → manage/prevent
complications (hemorrhage, fluid
imbalances, CSF leakages, DVT
prophylaxis, safety, infection)
Complications:
● Diabetes Insipidus (DI): trauma to
posterior pituitary or hypothalamus
leads to deficiency of ADH
○ S/S: Polyuria, thirst, Na>145
○ Treating TBI usually resolves DI
● SIADH: trauma to posterior pituitary
or hypothalamus leads to excess of
ADH
○ “Water intoxication”
○ S/S: Na<135, concentrated
urine, retaining fluid
Cerebral Vascular
Accident (Stroke):
disruption of blood
flow to the brain
secondary to
ischemia,
hemorrhage, brain
attack, or embolism
● Ischemia → lack of
volume and blood
flow
● Subarachnoid
Hemorrhage
(SAH)→ ruptured
artery or aneurysm
● Brain attack
● Embolism
SAH: “worst headache of
my life”, decreased LOC,
N/V, stiff neck
Transient manifestations
(indicate TIA which is a
warning of a stroke)→
visual, dizziness, slurred
speech, weak extremity
Manifestations depend
on area of brain deprived
of O2 or blood
F.A.S.T.
● Facial drooping
● Arm weakness
● Slurred speech
● Time to call 911
● CT → faster for more
emergent cases
● MRI
● EKG
● CBC
● Coag. studies
● MRI
● Carotid doppler u/s
● LP
● Cerebral Angiography
SAH:
● Priority → ABCs
● Surgery → clipping aneurysm,
excision of blood, Coil
● DO NOT give
anticoagulants/thrombolytics
Ischemic: thrombolytic therapy w/i 4.5
hours
*thrombolytics contraindicated if you
had recent head trauma, uncontrolled
HTN, seizure, recent MI, active
internal bleeding
● Airway mgmt.
● BP control
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Chest Tubes/Trauma (6-10 questions):
Disease
Cause
Manifestations
Diagnosis
Intervention
Rib Fracture
● CPR?
● Pain
● Pneumonia
● ABGs
● CXR
● Thoracentesis
● Pain mgmt.
● Splint with pillow
● Incentive spirometry
● Cough and deep breathing
Flail Chest
● Two or more adjacent rib
fractures creating an
instability of lung and
chest wall
● Abnormal chest wall
expansion
● Respiratory distress
● Subcutaneous
emphysema
● Paradoxical chest
movement
○ Inspiration → flail in
○ Expiration → flail out
● Potential Chest tube placement
● Pain mgmt.
● Support respiratory → may need
ventilator to allow healing
Ruptured Diaphragm
● Trauma
● Iatrogenic (as a result of
a medical intervention)
● Abdominal contents can
enter thoracic cavity
● Difficulty ventilating
● Can hear bowel sounds
when you auscultate for
lung sounds
● Life threatening!
● Surgery
Pneumothorax: air in the
pleural space, that causes
collapse of the lung
● Trauma
● Chest tube occlusion
● Older clients →
decreased pulmonary
reserve, decreased
elasticity, thickening of
alveoli
● COPD
● Spontaneous: happens
randomly; unknown
cause; may be
exacerbated by smoking,
more prevalent in tall,
thin males
● Anxiety
● Pleuritic pain
● Unilateral/asymmetrical
chest expansion
● Respiratory distress →
tachypnea, tachycardia,
hypoxia, cyanosis,
accessory muscle usage
● SOB
● Low POX
● SC emphysema
● Reduced/absent lung
sounds on affected side
● Tension Pneumo:
Chest Tube {“Pleural drainage
system”) → helps to remove air
and/or fluid from pleural space
● Initial placement can be done at
bedside
● During insertion…
○ Benzos → anxiety
○ Opioids → pain mgmt.
● Confirm with CXR once chest tube is
placed, should sit at the base of the
lungs
● 360 finger sweep!
● Wet → collection chamber, water
SEAL chamber, water SUCTION
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● Tension Pneumo: airflow
into pleural space with
inspiration and becomes
trapped, lung on injured
side collapses and
causes mediastinum to
shift to the other side
Hemothorax: blood
collecting in pleural space
that causes lung to
collapse
● Blunt force trauma
tracheal deviation
towards unaffected side
● All general symptoms of
pneumo
● Hemoptysis
● Crackles, bubbling →
fluid sitting in lungs
chamber
● Dry → collection chamber, water
seal chamber, dry suction chamber
● CHAMBERS
○ Collection chamber: collects air
OR fluid from pleural space
■ Normal Output <100 mL/hr
(but more is okay in acute
period)
■ Tally + initial at start and end of
shift
○ Water SEAL chamber: ensures
proper location of tube and helps
assess removal of air from pleural
space
■ Maintain 2 cm water at all
times!
■ Tidaling → represents change
in pressure in the pleural
space, rises and falls; this is a
good indication that air is being
removed
● Tidaling may be absent if…
○ Lung is re-expanded and
there is no more air to
remove → assess patient
to see how they are feeling
○ Catheter is not sitting in
correct spot
■ Bubbling = BAD!
● Chest tube is not in the
correct spot OR…
● Puncture to the physical tube
(can kink at different spots to
find the leak)
○ Water SUCTION chamber (only
wet) → filling this chamber with
20 cm water will create suction,
generally more aggressive
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suction, refill chamber as needed!
○ Dry suction chamber (dry only)
→ turn dial to create suction
● Chest tube Complications:
○ Dislodgement → take 4 by 4, or
sponge, tape three of the four
sides, leave a free edge to help
air escape
○ Disconnected from pleural
drainage system → submerge
end into sterile water, notify
doctor, and get new chest tube
● DO NOT milk tubing
● Wrap vaseline based dressing
around insertion site q shift
Trauma (3-6 Questions)
●
Trauma: force of energy impacts the body and causes structural and physiological alterations or injuries; can be intentional or unintentional
○ Blunt → MVCs, falls, contact sports, assaults
○ Penetrating → gunshot wounds, stabbings, impalements
○ Phases:
■ Prehospital → stabilize and transport, airway, control bleeding, establish IV access, give IVF (NS/LR)
■ Emergency Department
● Primary survey
○ A: airway
○ D: disability and neuro decline
○ B: breathing
○ E: exposure/environmental
○ C: circulation
control
● IV/IO access if not already established
● Foley
● NGT/OGT → decompress stomach and prevent aspiration
● Treat hypovolemia if indicated → o neg blood, fluids
● Secondary survey → AMPLE
○ Allergies
○ Meds (that patient is currently taking)
○ PMH
○ Last meal
○ Events/environment related to injury
● Labs → ABG, CBC, CMP, coag, amylase, lipase, tox. Screen, pregnancy test, urinalysis
■ Operative → transfer to OR to fix what is fixable, if unstable, operate in trauma bay
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Disease
Causes
Manifestations
Spinal Cord Injury (SCI):
involve the loss of
motor function, sensory
function, reflexes, and
control of elimination due
to trauma to spinal cord
● Complete → break
across the whole spinal
cord, recovery is
impossible
● Incomplete → partial
break of the spinal cord,
potential for recovery
● Stable → low probability
of getting worse
● Unstable → high
probability of getting
worse
● Hyperflexion → head on
collisions, diving
● Hyperextension →
MVCs/chin struck
● Axial loading →
diving/falling on feet
● Penetrating injuries
● Primary → damage
occurring at the moment
of impact
● Secondary → complex
biochemical mechanisms
affecting cellular
processes, can last mins
to weeks after impact
(ex: inflammation
causing interference)
● Manifestation depends
on location of injury
● Take note if symptoms
are ascending, and tell
the provider!
● Breaks above C4 =
ventilator dependent
Diagnostics
Treatment
● Devine’s Rule of 3 → you
have anterior column,
SC, and posterior
column. If either AC or
PC break, you still have
some support, but if you
break BOTH AC and PC,
spinal cord will sever
● Maintain airway and
breathing
● Manage neurogenic
shock if applicable
● CTM for ascending sx.
● Surgery
● Medications
○ Solumedrol →
swelling
● Cervical SCI → Halo
traction
○ Prevents patient from
moving neck to allow
bones to properly
calcify
● Skin breakdown →
relieve sacral pressure
Q30 mins, heel boots
● DVT prophylaxis
(because most will be
bed bound)
● Bowel and bladder
considerations → trouble
with retention so teach
patients to schedule to
self-catheterize and
defecate
Complications: Neurogenic
Shock, Spinal Shock
18
● Autonomic Dysreflexia →
paroxysmal HTN,
pounding headache,
bradycardia, sweating,
goosebumps,
dysrhythmias, due to
noxious stimuli, will
constrict everything
below SCI but will not
relax due to lack of
communication
○ Should self resolve
when you remove the
stimuli
○ Try to remove any
noxious stimuli to
prevent this!
Cardiac complications → Beck’s triad
Abdominal Injuries
?
● Cullen’s Sign →
bruising around
umbilicus, indicates
internal hemorrhaging
● Gray-Turner’s Sign →
retroperitoneal bruising
● Distended abdomen
● Rebound tenderness
● Kehr’s Sign → palpating
abdomen causes
scapular/clavicular pain
(may indicate splenic
ruptures)
● Subcutaneous
Emphysema: air
bubbles under the skin,
may indicate bowel
rupture
● Seatbelt sign: trauma
around seatbelt area
● Focused assessment
with sonography for
trauma (FAST) →
Bedside U/S
● Diagnostic peritoneal
lavage → aspirate
peritoneal/abdominal
contents, if nothing is
obtained, insert a
catheter and infuse 1 L
NSS and drain bag into
back, send off to lab to
confirm results
● CT scan
19
Pelvic Fractures → cast or splint (cannot operate), high r/f fat embolism and will get placed on prophylactic anticoagulants
Compartment Syndrome → increased pressure within a certain space compromises circulation resulting in ischemia and necrosis of tissue
within that space
BURNS (4-6 Questions)
● Burn = ↑capillary permeability → loss of plasma and electrolytes → ↑ interstitial fluid + ↓ intravascular volume → edema + hypovolemia → ↓BP →
SHOCK
● Children vs adult Differences
○ Burns are more severe in children than adults because adults → adults have a greater BSA
○ Children skin thinner so burns go deeper
○ Elderly less resilient to trauma
● Thermal
○ Flame: ignition of combustible material & contact with fire
○ Flash: caused by explosions, especially with combustible fuels
like gasoline, kerosene, & charcoal lighter
○ Contact: exposure to a hot object such as an oven, hot iron,
radiator
○ Scalds: occur when hot liquid is spilled on a child or from hot
tap H2O
■ Damaged cells release substances that increase vascular
permeability – fluid/electrolyte shifts
■ High risk for hypovolemic shock / burn shock
● Electrical
○ High voltage or Low voltage
○ Greatest heat is at point of entry
○ Injury usually greater than initially appears – deep tissue
necrosis
● Chemical
○ Tissue damage continues until agent completely removed or
neutralized
○ Pulmonary Inhalation → look out for pulmonary injuries
■ Singed nose hairs
■ Erythema
■ Swelling
■ Brassy cough
■ Blackened nares
■ Humidified O2 100% = NRB
○ Chemo
○ Cleaning supplies
20
○ Take clothes off, flush skin
○ CO Poisoning
■ CO binds to HGB, preventing O2 from attaching
■ POX unreliable because it reads HGB
● Circumferential Burns
○ Clean delineation = abuse
○ Splash pattern → not abuse
● Extent → size to overall body
○ Lund and Brower
○ Rule of 9s
○ Body part burned
● Fluid resuscitation → Parkland Formula
○ First 24 Hrs: 2-4 mL LR solution x kg x %TBSA
■ ½ of this volume is given in the first 8 hours
■ The second ½ of this volume is given over the next 16 hours
■ Titrate based on UOP
■ Watch for pulmonary edema
● Pain mgmt
● Wound cleansing, hydrotherapy/irrigation bed
● Nutritional support
● Do not give patient mirror until they are ready
Organ Donation
●
●
●
●
●
●
●
Prerequisites for brain death criteria → irreversible coma, normal core temperature, SBP > 100, neuro exam
Brain death → irreversible loss of all brain function; 3 cardinal findings:
○ Coma
○ NO brainstem reflexes
○ Apnea
Patients meeting brain death criteria are seen by the OPO (organ procurement organization)
○ Comes and makes initial contact with family (NURSES CANNOT INITIATE THIS CONVERSATION!)
○ Determine if it is a suitable donor (hemodynamic status, consent, contraindications (ex: HIV, AIDS, STDs, etc.)
Donor is tested for transmittable diseases, blood type, and HLA
Preserving donor and recipient is difficult! Time is NOT on your side!
Organ rejection is the most common complication
Meds → lifetime immunosuppressants, methylprednisolone (solumedrol), cyclosporine
21
OLD MATERIALS (6-10 Questions)
Heart Failure
● Heart Failure = pump failure → inability of heart to pump properly to meet tissue O2 needs and nutrients
● Structural or functional issue that impedes left side of the heart to fill and eject
● Causes: CAD, HTN (uncontrolled) → causes loss of elasticity, ETOH abuse, cardiomyopathy, MI (especially w/ necrotic damage to LV)
● Compensatory mechanisms → RAAS
● Importance of diet and exercise
● Reducing salt and fat intake
Classification of HF
Systolic Heart Failure
(HFrEF)
Diastolic Heart Failure
(HFpEF)
Causes/Risks
● Decreased blood supply
to heart (CAD)
● Dilated cardiomyopathy
● Valve disease (MV/TV
regurgitation,
aortic/pulmonic
stenosis)
● Arrhythmias
● HTN (chronic,
uncontrolled)
● Stenosis
● Restrictive
cardiomyopathy (causes
decreased stretch)
● Hypertrophic
cardiomyopathy
● CAD
● MI
● Age
Manifestations
Diagnostics
Treatment/Nursing consid.
● Thin heart walls
● Enlarged ventricles
● Decreased force of
contraction =
↓contractility =↓ inotropy
● Decreased force of
contraction will cause
decreased stroke volume
= dec. CO
● Causes decreased LVEF
(<40%)
● EKG
● CXR → can show
cardiomegaly and
pulmonary edema
● Echo
● Hemodynamics
● BNP → release of this
indicates stretch of
ventricles
○ > 100 → dyspnea is
r/t cardiac vs
pulmonary failure
○ >400 → definite
cardiac failure
○ <100 → pulmonary
cause
○ Degree of HF
increases with
increasing BNP
● Dysrhythmia
monitoring
Labs → electrolytes,
renal fx.
● ACE Inhibitors, ARBs,
calcium channel
blockers, PDE-3
inhibitors → reduce
afterload
● Diuretics (loop, thiazide,
potassium sparing) →
helps reduce preload and
manage fluid overload
● Digoxin → inotropic agent,
improves contractility
○ Toxicity → N/V,
hyperkalemia, halos,
arrhythmias
○ CONTRAINDICATED w/
Diastolic HF
● Vasodilators
(Nitroglycerin)
● Beta blockers → lowers
heart rate, decreasing
contractility
● Salt and fluid restrictions
(IV + PO fluids)
● Inability of heart to relax
● Filling problem →
reduced preload
● Thick heart walls →
myocardial hypertrophy
● Can still have a normal
EF
● Pulmonary congestion
● HTN
● Edema
Nursing Considerations: DW,
I/O, O2 as prescribed,
22
Left Sided Heart Failure
Right sided heart failure
● Stenosis
● Valvular Diseases →
aortic stenosis, mitral
regurgitation
● Cardiomyopathy
● CAD
● Backup into systemic
circulation
● Left sided HF
● Isolated causes →
shunts (ASD, VSD)
● Chronic lung disease →
Cor Pulmonale
● Backup of blood into
pulmonary circulation
● Increased PAP
● Pulmonary edema →
fluid shifting into alveoli,
tx. with IV lasix and chest
PT, reverse
trendelenburg position to
help expectorate!!
● Crackles/rales on
inspiration/expiration
● Dyspnea, orthopnea
● Hemoptysis: Pink,
frothy sputum
● Fatigue, weakness,
lethargy
● Decrease UOP
● Gallop rhythm
● Cough
● Tachypnea
● Tachycardia
● Cyanosis
elevated HOB, CTM UOP!!!
Later stages:
● Cath lab,
revascularization/CABG,
valve repair
● Ventricular assistive
devices (VAD)
● ICD, pacemaker
● Biventricular pacing
● IABP → reduces workload
● Heart transplantation
Complications: Pulmonary
edema (elevate HOB>60, IV
lasix, morphine, administer
O2, mechanical ventilation if
necessary, ABGs),
cardiogenic shock,
pericardial tamponade
● Increased CVP
● Peripheral edema
● JVD
● Hepatosplenomegaly
● Weight gain
● Indigestion, Feeling full
● Ascites
Pacemakers
● Pacemaker: An electric device used to pace the heart when the normal conduction pathway is damaged/disrupted; Consists of a power source
(battery-operated pulse generator), conducting lead, to the myocardium
● Indicated for people who have multiple instances of dysrhythmias (needing AED/atropine many times) or heart blocks, an aging heart (trouble with
SA node)
● Temporary pacemakers → energy is from an external battery source
○ Transcutaneous pacing → shocked through the skin, through thoracic musculature
○ Transvenous pacing → external wire connected to battery, then thread through the vein
○ Epicardial pacing → pacemaker connected to myocardium, typical during OR/surgery
23
● Permanent pacemaker:
○ Battery sewn into chest wall, catheter comes off of battery and sits in the wall of the heart
○ Shocks the patient when necessary
○ Complications: infection, pneumothorax (puncturing the lung), dislocation of the lead (catheter does not sit in the proper part of the heart),
cardiac perforation (catheter will scrape through heart)
○ Single chamber → catheter ends in either atria or ventricle of the heart
■ Where the catheter sits is important
■ Ventricular pacing → heart blocks
■ Atrial pacing → sinus bradycardia
○ Dual chamber → paces atria and ventricles
■ Pacers have the ability to sense if the SA/AV will fire by itself, it will not always fire (indicated by circles)
● Malfunctions
○ Failure to pace → no pacemaker spike where it should be firing, HR will start to fall below 60
24
○ Failure to capture → pacer fires but fails to initiate contraction
○ Failure to sense → fires when it should not (randomly firing); typically higher heart rate, an over stimulus
○ Nursing considerations/teaching
■ Airport security → let them know you have an internal pacemaker, will set off metal detector, request medical ID band/doctor note
■ Lifting precautions →
■ Take pulse daily → pulse log
■ Infection
■ CAN NEVER GET MRI!!!
■ Lifting precautions → for 6-8 weeks after surgery
● Battery placed on non-dominant hand to limit mobility
● Cannot lift above your shoulders, risk for displacing battery/catheter
● Cannot lift more than 5-10 lbs
● Can get a sling to prevent movement
● Can still use the non-affected side!
■ CXR → confirm placement
■ Incision care → no shower for first couple days, make sure to dry axillary area
● Automatic implantable cardioverter defibrillator (AICD) → internalized AED
○ Indicated for someone who randomly has gone into a pulseless rhythm
○ Prevents episodes of sudden deaths
○ Should not be firing normally, shocks if there is a lethal dysrhythmia
○ If you notice that it fired, go to doctor or ER immediately
○ No swimming, baths, or hot tubs alone!
25
EKG STRIPS
Rhythm
Characteristics
Normal Sinus Rhythm
● HR within 60-100
● 1:1 Ratio
● Normal PR int.
(0.12-0.20 seconds)
Sinus Tachycardia
● HR > 100 (tachy)
● 1:1 Ratio (sinus)
● PR interval still WDL
● Isoelectric line
shorter
Causes
● Pain
● Hypovolemia
● Anxiety
● Stress
● Difficulty breathing
Manifestations
Interventions
● N/A
● None
● Anxiety
● Eliminate cause (caffeine
etc.)
● Vagal Maneuvers →
bearing down
● Medications → Beta
blockers, calcium channel
blockers
26
Sinus Bradycardia
● HR < 60 (brady)
● 1:1 Ratio (sinus)
● PR still WDL
● Isoelectric line longer
● Sleeping
● Hypothyroidism
● Drug abuse
● Anorexia
● SOB
● Cool extremities
● Anxious
● Dizziness
● Confusion
● Irritability
● Eliminate/reverse causes
● Increase HR
○ Atropine → 0.5 mg
every 3-5 mins; total of
3 mg can be given
○ Epi/Dopamine drip
○ Emergency
transcutaneous
pacemaker
● Palpitations
● Weakness
● Fatigue
● SOB
● Anxiety
● Hypotension
● Syncope
● Angina
● Decreased LOC,
change in mental
status
● Vagal Maneuvers
● Adenosine → 6 mg, 12 mg
○ Rapid IV dose
○ Immediately flush with
saline
○ Monitor EKG
continuously when
administering
○ Tell patient it will feel
really bad
● Amiodarone →
antiarrhythmic
● Calcium channel blocker,
Beta blocker to lower HR
● Cardioversion IF resistant
to meds
● Anxiety
● Uncontrolled (Vent. rate >
100): Rate control drug
(beta blocker, calcium
channel blocker) + ibutilide
and/or amiodarone
● Controlled (Vent. rate <
100): ONLY ibutilide and/or
amiodarone
● DO NOT give rate
controlled drugs for
controlled Afib b/c it will
ATRIAL DYSRHYTHMIAS
Supraventricular Tachycardia (SVT) →
think “Supraventricular” = above the
ventricle = atria = atrial issue
Atrial Fibrillation (Afib)
● Rate → tachy
● Rhythm - regular
(one ectopic beat)
○ NOT 1:1 ratio → T
+ P waves
combine together
○ QRS complex <
0.10 seconds
● NO isoelectric line →
heart lacking O2
● Unrelieved sinus
tachycardia
● SA Node problem
● Paroxysmal → self
resolving SVT
● Multiple ectopic foci
● Rate
○ Controlled:
Ventricular rate
<100
○ Uncontrolled:
Ventricular rate
>100
● QRS are NOT
equidistant
● Ventricles not getting
● Atria quivering
● Advanced age
(80+)
● Heart failure
● Valvular disease
● Congenital heart
disease
● CAD
● MI
● Hypertension
● Cardiomyopathy
Risk fx: Female,
Women < 40,
Caffeine, Nicotine,
Hypoxia, Stress,
CAD,
cardiomyopathy
27
filled because atrial
contractions are not
strong = stagnant
blood in atria = inc.
r/f clots and emboli
Atrial Flutter
● Saw toothed P
waves
● Single ectopic focus
→ regular rhythm
● Hyperthyroidism
● Pulmonary disease
● Obstructive sleep
apnea
● Acute moderate to
heavy ingestion of
alcohol
● Post-open heart
surgery
lead to brady.
● r/f thrombus formation and
myocardial ischemia
● Decreased SV
● Anticoagulant → Heparin
● TEE
● CAD
● HTN
● Mitral valve
disorders
● PE
● Lung disease
● Digoxin
● Epi
● Antidysrhythmics
(Amiodarone)
● Cardioversion if necessary
VENTRICULAR DYSRHYTHMIAS
PVCs
● Wide Bizarre QRS
complexes
● PVCs = no QRS, P
or T wave = no refill
● AV node firing
● SOB
before SA node
● Anxiety
● Caffeine
● Irritability
● Nicotine
● Alcohol
● Cardiac ischemia or
infarction
● Exercise
● Tachycardia
● Fever
● Hypervolemia
● Heart failure
● Digitalis toxicity
● Hypoxia
● Acid/base
imbalance
● Electrolyte
● Note frequency → one
PVC can self resolve (no
intervention needed), BUT
if bigeminy or trigeminy or
RUN of PVCs (>3 in a row)
call physician
● Continue to monitor
patients (many PVCs can
turn into VTach!)
● O2
● Correct underlying cause
(correct electrolyte
imbalance, decrease
caffeine etc.)
● Beta blockers
○ Parameters: HR > 60;
BP > 100/60
28
imbalances →
Hypokalemia
● Antidysrhythmics →
amiodarone, lidocaine
Ventricular Tachycardia
● Back to Back PVCs
● NO CO = MEDICAL
EMERGENCY!
● Unifocal (only ONE
ectopic beat)
●
● Acute Coronary
Syndrome
● Cardiomyopathy
● Tricyclic overdose
● Digoxin toxicity
● Cocaine abuse
● Mitral Valve
Prolapse
● Acid-base
imbalances
● Trauma
● Pulseless →
unresponsive
● Nursing Interventions
○ Check to see if patient
responsive
○ Check for carotid pulse
○ Pulseless V tach. →
CPR + defib.
○ Pulse → O2 , IV access,
Ventricular
antiarrhythmic
(amiodarone), electrical
therapy
● Lidocaine
Torsades De Pointes
● Polymorphic V-Tach
● Multifocal (many
ectopic beats)
●
● Magnesium
Deficiency
(common in burn
patients)
● Pulseless (most
often patient will be
unresponsive)
● Check for pulse, start CPR
if pulse less
● Replete magnesium
29
Ventricular Fibrillation (V-Fib)
● Multiple ectopic
beats
● Ventricles quivering
→ no CO =
MEDICAL
EMERGENCY!
●
Asystole
● TOTAL absence of
ventricular electrical
activity
Pulseless Electrical Activity (PEA)
● Electrical activity
observed BUT no
pulse on patient
● V-Tach. can
progress into V-Fib
● ↑ sympathetic
nervous system
activity
● Vagal stimulation
● Electrolyte
imbalance
● Antiarrhythmics and
other meds
● Electrocution
● Acute Coronary
Syndrome
● Heart failure
● Nursing: Assess ABCs,
then treat
● Check for pulse
● If pulseless/unresponsive,
CPR and Defib., AED if
available
● Lidocaine
● Assess MORE THAN ONE
lead
● CANNOT SHOCK
● Start immediate CPR
● Push EPI
● Call Code
● O2, IV access, consider
pacing, meds, termination
● EKG leads
sometimes confuse
ATP for electrical
● If no pulse, start CPR,
code, EPI
30
●
activity
HEART BLOCKS
First Degree AV Block
● Looks exactly like
NSR, but PR interval
is > 0.20 seconds
Second Degree Type I (Mobitz Type I)
Second Degree Type II (Mobitz Type II)
● Interruption in
conduction (total
OR partial)
between atria and
ventricles
● AV node problem
→ PR interval
shortened
● Temporary: MI, Dig.
toxicity,
myocarditis,
calcium channel
blockers, beta
blockers, cardiac
surgery
● Permanent: aging,
congenital, MI,
cardiomyopathy,
surgery
● Many are
asymptomatic
● Treat symptoms
● Continue to monitor
● Starts with a normal
conduction cycle
● PR interval increases
with each beat until
QRS is missed, and
then cycle starts all
over again
● Potential CO issues
● May or may not be
symptomatic
● Hypotension
● Light-headedness
● Asymptomatic → no
treatment necessary
● Symptomatic → Atropine,
temporary pacemaker
● Multiple QRS
● MOST patients are
● Atropine
31
Third Degree (Complete) Heart Block
dropped
● When conduction is
occurring, it looks
normal BUT when
SA node fails to
conduct, QRS’s are
dropped
symptomatic
● Hypotensive
● Light-headedness
● Chest pain
● Palpitations
● Dopamine
● Epinephrine
● Permanent Pacemaker
● QRS and p waves on
top of each other?
● We do not need to
know what this one
looks like
● No communication
between AV and SA
node
● VERY symptomatic
● Fatigue
● Dyspnea
● Severe fatigue
● Chest pain
● Change in mental
status
● Hypotension
● Pallor
● Bradycardia
●
● Atropine
● Dopamine
● Epinephrine
● Pacemaker
DEFIB VS. CARDIOVERT
Electrical Therapy
Defibrillation
(non-synchronized)
● Pulseless V TACH
● V FIB
● Completely depolarizes heart by
disrupting impulses causing the
dysrhythmia
● Monophasic: current delivered in
one direction
● Biphasic: current delivered in
two directions at the same time
(less voltage needed)
Cardioversion (synchronized)
● Counter shock synchronized
with “R” waves (calculated as
spikes on the monitor)
● Need to hit “sync” button
● Give Versed/Ativan prior
● A FIB
● A FLUTTER
● SVT
● V TACH w/ pulse
● Counter shock synchronized
with “R” waves
● Helps disrupt ectopic pacemaker
and allows SA node to take
control of the heart
● Starts with 50-100 joules
32
Pacemaker: Electric device used
to pace heart when normal
conduction pathway is damaged
or disrupted
● Prophylaxis after Heart sx.
● Acute MI
● Bradycardia
● 2nd/3rd degree heart blocks
● AFIB with slow ventricular
response
● Cardiomyopathy
● Tachydysrhythmias
● Power source connected to
myocardium
● Delivers electricity when HR is
under a certain threshold
● Conscious sedation may also be
needed
OVERALL CARE → ICU delirium, cluster care, etc
HEMODYNAMIC LINES
Invasive Line
Purpose/Fx.
Nursing Considerations
Normal Values
Arterial Line
(A-Line)
● Constant, accurate
monitoring of BP/MAP
● Labs
● Arterial Blood Gases (ABGs)
● CANNOT GIVE MEDS **only
for emergencies**
● Most common in radial or femoral
arteries
● Confirm A-line pressure with cuff
pressures
● CANNOT be placed by RN
● RN CAN REMOVE A-line!
○ Place pressure for 5 mins
○ Check for bleeding, if still
● Absence of dicrotic notch → not
bleeding continue to apply
placed in artery
pressure
● Causes of overdamped waves→
○ Pressure dressing
○ Air bubbles
● ALWAYS connected to fluid to
○ Overly compliant, distensible
maintain patency
tubing
● Flush Q shift
○
Catheter kinks
● Allen’s Test: helps us verify radial
○ Clots
and ulnar circulation and if an
○ Low pressure flush bag or
A-line could be placed
syringe pressure
○ Instruct client to make a fist
○ No fluid in pressure bag or
and compress the radial and
syringe
ulnar arteries
○
Vessel spasm
○ Tell client to relax hand and
● Causes of underdamped waves →
observe for blanching
○ Increased vascular resistance
○ Release ulnar artery and
○ stiff/non-compliant tubing
observe hand for flushing →
hand should turn pink in 15
Complications
● Limb
impairment
● Infection
● Thrombosis/
occlusion
33
seconds
● Integrity of waveform → dicrotic
notch
● Limb circ. → NV assessments
○ Numbness
○ Tingling
○ Capillary refill
○ DO NOT palpate radial artery,
cannot palpate ulnar artery
● Can be kept in indefinitely
Central Line
(CVC):
pressure in
right atrium
● Blood
● CVP measurements →
pressure in vena cava/right
atrium (filling pressure of RV)
● Long term chemo
● Can give meds
● Abx.
● TPN
● Labs
● CANNOT get a continuous
BP
● Tunneled → long term
● Non-tunneled → shorter periods
● Measure calipers at beginning of
shift
● Confirm placement with CXR
before admin. meds
● Assess site for redness, draining,
tenderness
● Transparent dressings → allows
visualization
● Dressing changes → typically
once a week
● Cover dressing site when
showering
● BP on arm without PICC line
● RN CANNOT REMOVE!
● CVP → normal: 2-6
○ Low CVP causes…
■ Dehydration (lack of volume)
→ give fluids
■ Vasoconstrictor → helps
constrict the vessels to
improve venous return
○ High CVP causes…
■ heart failure (normally a Left
ventricle problem)
■ Crackles/adventitious lung
sounds
■ overaggressive fluid mgmt
● Phlebitis
● Occlusion
● Mechanical
issues
● Pneumothorax
Pulmonary
Artery
Catheter →
(SWAN):
measures
pressure of left
atrium (LV
preload)
● Reflect pressure of left
atrium (when balloon is
inflated), left ventricular
preload → PAWP
● Will always give you a
● CVP measurements
● Labs, venous
● IVF
● Cardiac Index
● Temperature
● Doctor will inflate a balloon and
advance it through right side,
then left side; will reaching
pulmonary artery and it will
wedge itself
● Confirm placement with CXR
before admin. meds
● Sterile dressing changes q 1
week
● Measuring calipers at beginning
of shift
● CVPs (see above)
● PAP/PAWP
○ Low PAWP causes
■ MI
■ HF
■ Hypovolemia
■ Cardiogenic shock
■ Cardiac tamponade
■ Late sepsis
○ High PAWP causes
■ Early sepsis
■ Hyperthyroidism
● Infection/Sepsis
● Embolism
34
■ Fever
■ Exercise
ORGAN DONATION
DO NOT TALK ABOUT ORGAN DONATION, DONE BY UNOS
BRAIN DEATH CRITERIA → generalized
Care of donor and recipient
OLD MATERIAL
- Icu delirium → sleep patterns, time of day, cluster care, minimize alarms (CANNOT TURN OFF)
- EKG
- DEFIB VS CARDIOVERT (CLOSER TO SIX QUESTIONS
- Pacer, single vs dual
SCIs, complete vs incomplete, para, quad
Chest tubes → chambers and their fx (Do not confuse water seal vs water suction control)
Pneumo → absent or diminished breath sounds, asymmetric chest expansion, low pox, pain, high RR, tension
pneumo (Tracheal deviation),
NEURO
Cerebral hemmohage = increased ICP
GCS QUESTION!
If they have a low GCS and they arent responding to stimuli they arent the most urgent!!!! (will have chart)
Basics of ventric → measure ICP and remove CSF, keep level with tragus
Ischemic vs hemorahic stroke!!!
ASSESSMENT IS BULK OF NEURO
RESP → ARDS PE, PNEUMONIA