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CC Final Exam
Information for CC Final exam.
306
Nursing
Undergraduate 4
02/25/2011

Additional Nursing Flashcards

 


 

Cards

Term
Ethical Decision Making
Definition
Identify the health problem.
Define the ethical issue.
Gather additional information.
Delineate the decision maker.
Examine ethical and moral principles.
Explore alternative options.
Implement decisions.
Evaluate and modify actions.
Term
Institutional Ethics Committees
Definition
Education
Consultation
Recommendation
Term
Medical Futility
Definition
interventions that are unlikely to produce any significant benefit for the patient.
Term
Nursing Process and Legal Issues - Assessment
Definition
Failure to assess and analyze the level of care needed by the patient, Failure to ascertain a patient’s wishes with regard to self-determination
Term
Nursing Process and Legal Issues - Planning
Definition
Failure to appropriately diagnose
Term
Nursing Process and Legal Issues - Implementation
Definition
Failure to timely communicate patient findings, Failure to take appropriate action, Failure to document, Failure to preserve patient privacy
Term
Nursing Process and Legal Issues - Evaluation
Definition
Failure to act as a patient advocate, Failure to act consistently with applicable standards of care
Term
Acute Renal Failure - Def.
Definition
rapid decline or cessation of kidney function
azotemia, elevated creatinine and decreased urine output
Term
Acute Renal Failure: Etiology and Pathophysiology - Risks
Definition
trauma, surgery, DM, hypertension, CV disease, hypotensive episode, MODS,
crush injuries, allergic reactions etc.
Term
Acute Renal Failure - Prerenal
Definition
decreased blood flow to the kidneys
decreased intravascular volume
redistributed volume
decreased cardiac output
renal artery stenosis or thrombosis
Term
Acute Renal Failure - Intrarenal
Definition
direct damage to kidneys
ischemia
nephrotoxic drugs
myoglobin, rhabdomyolysis
glomerulonephritis
Term
Acute Renal Failure - Postrenal
Definition
obstruction of urine flow
mechanical obstruction
functional obstruction
Term
Acute Renal Failure - Pathology
Definition
renal blood flow - ischemia - RAA mechanism - vasoconstriction
Term
Acute Renal Failure - Phases
Definition
oliguric phase

diuretic phase

convalescent phase
Term
Acute Renal Failure - Assessment
Definition
decreased urine output, dysuria, cloudy urine, edema, hypertension, lethargy, dehydration etc
Term
Acute Renal Failure - Laboratory Tests
Definition
urine lytes
urine osmolality urinalysis
serum lytes
xrays, ultrasound
angiography
Term
Acute Renal Failure - Planning
Definition
correct hemodynamics
diet
dialysis
Term
Acute Renal Failure - Medications
Definition
diuretics
ion exchange resins - kayexalate
phosphate binders - amphojel
low dose dopamine – questionable use
hypertonic glucose with insulin
epogen
others
Term
Acute Renal Failure - Nursing Diagnoses
Definition
fluid volume excess
risk for injury
altered tissue perfusion: renal
infection, high risk for
nutrition, altered
others
Term
Acute Renal Failure (ARF)
Definition
Major concern with critical care patients
Related to high mortality rates in critical care patients
Aging population
Comorbidities – DM, CV path,
Respiratory path
Dialysis dependence
Decreased quality of life
Term
Acute Kidney Injury (AKI)
Definition
Sudden decline in kidney function – minor to major Altered F&E, acid base, GFR
Term
AKI Classification
Definition
Grades of severity:
risk for acute renal failure R GFR decreased 25% Creatinine increased 1.5 times

injury to kidney I GFR decreased 50% Creatinine increased 2 times

Failure of renal function F GFR decreased 75% Creatinine increased 3 times
Outcomes:
loss of renal function L loss of renal function for 4 wks

end stage renal disease E renal replacement tx for 3 mon
Term
Historical Diagnosis/Markers AKI
Accumulation of end products of metabolism - Creatinine
Definition
Released at a constant rate and filtered by glomerulus but not reabsorbed
Not produced at a constant rate

Altered by muscle mass, gender, age, diet, drugs, diseases
Term
Historical Diagnosis/Markers AKI
Accumulation of end products of metabolism - Urea
Definition
By product of protein metabolism – used to estimate uremic solute retention and elimination

Not produced at a constant rate – rate altered by critical illness, burns, trauma, sepsis, medications, diet

Steroids increase urea as well as
Urea increased by protein catabolism – hypercatabolism of critical injury or illness

Liver failure patients may show WDL urea from decreased liver production or protein restriction with liver failure tx
Term
Fractional Excretion of Sodium
Definition
Not an accurate indicator of AKI
Term
Biomarkers of AKI
Neutrophil Gelatinin-Associated Lipocalin (NGAL)
Definition
Present in kidneys, lungs, stomach, colon
Elevated with epithelial injury of pulmonary disease, asthma, acute bacterial infections

More accurate marker of kidney function in post ischemic or nephrotoxic kidneys

Elevated blood levels occur 2 to 6 hours after injury rather than 24 to 48 for serum creatinine levels – measured serum and urine

Reliable biomarker for post transplant kidney function
Term
Biomarkers of AKI - Kidney Injury Molecule-1 (KIM-1)
Definition
Significantly elevated after ischemic or nephrotoxic AKI

Used to differentiate ischemic and nephrotoxic injury from chronic renal disease and UTI
Term
AKI Prevention
Definition
RIFLE assists with identifying early stages and mild forms of AKI

Preserve renal function and prevent complications rather than only manage renal failure
Term
AKI Prevention - Hydration
Definition
Oliguria = less than 200 to 500 cc in 24 hours
Fluid replacement may not be indicated intervention
ARDS patient mortality increases with positive fluid balance

Low intravascular volume – risk for AKI – manage with crystalloids and colloids

Rhabdomyolysis – massive fluid intervention
Term
AKI Prevention - Renal Perfusion Pressure
Definition
Administer fluid based on mean arterial pressure, CI, CVP, UOP

Sepsis

Hypotension with capillary leak– rapid fluid replacement may lead to pulmonary complications and abdominal fluid leaks – increased abdominal pressure (IAP)& organ ischemia, ascites (protein and F&E leaks), compression of intraabdominal vessels and decreased cardiac output decreasing renal perfusion
Term
AKI Prevention - Abdominal Compartment Syndrome
Definition
Normal intraabdominal pressure – below 5-7 mm Hg to 12 mm Hg

Similar to above hypotension with capillary leak

Monitor IAP

Treat by laparotomy to decrease pressure and preserve renal function
Term
AKI Prevention - Nephrotoxins
Definition
Alone or together nephrotoxins increase risk for AKI

Kidneys excrete many drugs that cause injury to renal tubules, inflammation, and death of renal tubules
Term
AKI Prevention - Nephrotoxins - Radiologic Contrast Media
Definition
Contrast media induced nephropathy (CIN) – increase in creatinine within 24 hours of contrast exposure

Added risk with DM, dehydration, nephrotoxic drugs, cardiac failure, hemodynamic instability

Treat with volume expansion (crystalloids), dialysis, and N-acetylcysteine
Term
AKI Prevention - Nephrotoxins - Aminoglycosides
Definition
Added risks elderly, dehydration

Manage by decreasing the dosage as prevention and intervention when AKI identified
Term
AKI Prevention - Nephrotoxins - Amphotericin B (treat fungal infections)
Definition
Highly nephrotoxic

Risk accumulates with cumulative doses

Binds to tubular epithelial cells altering permeability resulting in Na, K, Mg wasting

Manage by infusing over 24 hours, Na loading
Term
AKI Prevention - Nephrotoxins - Vancomycin (treat MRSA – gram positive bacterial infections)
Definition
Used with other aminoglycosides
Toxicity mechanism not currently defined

Risk increases with patient age, duration of administration, medication levels, and other nephrotoxic agent administration

Manage with assessment and monitoring of peak and trough levels of the medication
Term
Prevention of AKI - Loop Diuretics
Definition
Oliguria management – rule out obstruction, maintain hydration, urine flow

Furosemide (Lasix) – use on patient by patient basis
Term
Prevention of AKI - Dopamine
Definition
Vasodilate renal vessels

Studies demonstrate no use for dopamine in prevention of AKI
Term
Prevention of AKI - Natriuretic Peptides
Definition
Human recombinant natriuretic peptides in low doses

Some association of decrease need for dialysis with use
Term
Prevention of AKI - N-Acetylcysteine
Definition
Antioxidant

Few small studies demonstrated decreased CIN with administration

Inexpensive

Use with fenoldopam – selective stimulator of D1 dopamine receptor resulting in increased renal blood flow

Some studies show some renal protection with use of N-Acetylcysteine and fenoldopam together
Term
Renal Replacement Therapy for AKI - Intermittent Hemodialysis (IHD)
Definition
Use dialysis with fluid volume excess, hyperkalemia, uremia, metabolic acidosis, overdoses

Rapid changes in fluid and plasma osmolality with dialysis may result in renal ischemia
Term
Renal Replacement Therapy for AKI - Continuous Renal Replacement Therapy (CRRT)
Definition
For critical patients with catabolic states – systemic inflammatory response (SIRS), sepsis, organ failure

More stable fluid and plasma osmolality than with dialysis, clears solutes, hemodynamic tolerance

24 hr/day for several days

Less long term dialysis required with use of CRRT than with IHD even though survival similar for both
Term
Status Asthmaticus
Definition
Asthma - chronic disease characterized by recurrent attacks of reversible airway obstruction

Status asthmaticus - severe asthma attacks that are intense, unrelenting and not responsive to the usual modes of therapy - clinical emergency
Term
Status Asthmaticus - Three pathological problems:
Definition
bronchial smooth muscle spasm related to hyperactivity of bronchial smooth muscle

mucosal edema resulting in air trapping

hypersecretion of mucus resulting in increased shunting and hypoxemia
Term
Status Asthmaticus - Precipitating factors
Definition
respiratory infections, inappropriate use of medications, allergans, stress, environmental factors
Term
Status asthmaticus - S&S
Definition
dyspnea, exhaustion, fear, tachypnea, retractions, ukse of accessory muscles, decreased
breath sounds, wheezes, tachycardia, diaphoresis, dehydration, increased work of
breathing etc.
Term
Status Asthmaticus - Diagnostics
Definition
ABG
PFT
xrays
Term
Status Asthmaticus - Medical interventions
Definition
sympathomimetics - epinephrine
bronchodilators
steroids
mechanical ventilation
Term
Status Asthmaticus - Nursing diagnoses
Definition
impaired gas exchange
ineffective airway clearance
activity intolerance
FVD
anxiety, fear
Term
Adult Respiratory Distress Syndrome - (ARDS)
Definition
noncardiogenic pulmonary edema, stiff lungs, hyaline membrane disease of adults etc.

injury to alveolar capillary membrane resulting in stiff, wet lungs and refractory
hypoxemia
Term
ARDS - Etiology
Definition
associated with shock, trauma, hypotension, burns, sepsis, pancreatitis etc.
Term
ARDS - Pathophysiology
Definition
injury with release of vasoactive substances such as kinins and serotonin

autolysis of vascular endothelium
bronchoconstriction

damage to type II pneumocytes
Term
ARDS - Medical Treatment
Definition
mechanical ventilation with PEEP

steroids

oxygen free radical scavengers
Term
ARDS - Nursing diagnosis
Definition
impaired gas exchange
ineffective airway clearance
anxiety
potential for injury
Term
ARDS - Interventions
Definition
assess, ABG, hemodynamics, fluid balance, respiratory interventions
Term
Perianesthesia - Def.
Definition
care immediately prior to surgery in the critical care or medical surgical care units
care in the preoperative and operative areas
care in the post anesthesia recovery units or critical care units

many patients recovered from anesthesia in the surgical critical care areas following major surgical interventions
Term
Anestheia - Patient
Definition
o patient responses to anesthesia are individualized, influenced by medications and patient’s unique metabolic situation.
Term
Anesthesia - types
Definition
general, regional, or local
patient may be conscious or unconscious
choice of anesthesia individualized to patient, pathology, anticipated surgical procedure.

levels of general anesthesia: analgesia, delirium, and surgical anesthesia
drugs selected to rapidly move patient through the level or stage of delirium
Term
Inhalation anesthetic agents
Definition
Inhalation anesthetic agents utilized, metabolized, and eliminated at varying individual patient rates but tend to allow for rapid recovery from anesthesia
Term
Intravenous anesthetic agents
Definition
Intravenous anesthetic agents include narcotics which may be reversed with naloxone (Narcan) and benzodiazepines which may be reversed with flumazenil (Romazicon)
Term
Reversal agents
Definition
Reversal agents provide rapid recovery from the anesthetic properties of the medications but also reverse the pain relieving effects of the medications resulting in the acute awareness of pain
Term
Neuromuscular blocking agents
Definition
Neuromuscular blocking agents relax muscles during a surgical procedure to facilitate insertion of endotracheal tubes, opening of the abdomen etc. to better visualize within the surgical site
neuromuscular blocking agents may be medically reversed.
Term
Epidural anesthetic agents
Definition
Epidural anesthetic agents commonly used for surgical procedures of the perineal area and lower extremities
patient retains alert and oriented level of consciousness during surgery
easier to ambulate during the immediate post operative period when the epidural infusion remains in place to relieve pain
complications such as infection and temporary loss of mobility from pressure of the epidural catheter on nerves may necessitate discontinuing postoperative epidural pain management
Term
Mid Level or Conscious Sedation (1)
Definition
used for many short, outpatient, minor surgical procedures
diagnostic testing; or interventions such as insertion of PEG tubes
used to depress the central nervous system enough to decrease patient anxiety, elevate pain threshold, and provide amnesia while maintaining the patient’s awake and cooperative state and protective reflexes
Term
Mid Level or Conscious Sedation (2)
Definition
during the time of light sedation the patient may appear to be sleeping, but can be aroused, can speak, and maintains gag and cough reflexes
light sedation is ideal for most conscious sedation procedures
medications used for conscious sedation include midazolam (Versed), propofol (Diprivan) and lorazepam (Ativan)
nursing guidelines for nurse administration of conscious sedation are Minimum Standards from Association of Operating Room Nurses (AORN)
guidelines include nurse skills and credentials as well as equipment and support personnel available for administration of conscious sedation agents
specific for adults and for pediatric patients
Term
Anesthesia Related Nursing Assessments and Interventions
Definition
pre and post anesthesia nursing assessments include complete physical assessment with focus on respiratory, cardiovascular, and central nervous systems
focus also directed toward patient’s fluid and electrolyte situation, thermal regulation, psychosocial situation
Term
Post anesthesia care
Definition
addresses respiratory nursing diagnoses of potential for ineffective breathing, potential for ineffective airway clearance, ineffective gas exchange
Term
Respiratory - Interventions
Definition
continuous respiratory assessment, oxygen saturation or ABG monitoring, airway maintenance following tongue and airway relaxation from anesthetic and neuromuscular blocking agents, pain management, and oxygen administration by the appropriate method for the patient situation frequently awakening the patient and reminding the patient to breathe will resolve short term oxygenation issues
Term
Pain - Anesthesia
Definition
a priority nursing diagnosis in the perianesthesia time usually managed with medications specific to the patient and the excretion of the anesthetic agents used in surgery PACU pain medications are usually administered IV in small increments
Term
Alterations in fluid and electrolyes and cardiac output
Definition
critical in the perianesthesia period
preoperative dehydration, blood and fluid loss, hypothermic vasoconstriction and dilation, effects of drugs on the myocardium and vasculature influence the body’s ability to maintain fluid and electrolyte balance and cardiac output
patients may arrive in the PACU hyper or normotensive during the time of hypothermic vasoconstriction and change to hypotensive when the body temperature returns to normothermic
pain and pain medication also major variables in the maintenance of blood pressure and CO
Term
Airway obstruction
Definition
frequently relaxation of airway muscles – use jaw thrust
Term
Atelectasis
Definition
from positive pressure breathing at a set tidal volume and pressure with deep breathing
Term
Laryngeal edema
Definition
results in airway obstruction – elevate HOB, administer cool oxygen, aerosolized epinephrine, brochodilators and antihistamines – reintubation may be needed
Term
Laryngeal spasm
Definition
result in airway obstruction – crowing respiration or S/S of hypoxia – attempt to open the airway and administer oxygen by bag/mask and seek assistance to intubate
Term
Bronchospasm
Definition
obstruction in the lower airways frequently from inflammation - remove the irritant and administer bronchodilators – steroids and epinephrine may be needed
Term
Aspiration
Definition
risk related to relaxation of muscles and suppression of gag and cough reflexes
Term
Aeration concerns - Hypoventilation
Definition
CNS depression from anesthetic agents
Term
Aeration concerns - Hypercarbia
Definition
from hypoventilation - manage medications that result in respiratory
suppression – elevation of HOB and awakening or stimulating the patient –encouraging deep breathing
Term
Aeration concerns - Pulmonary Edema
Definition
may result from inflammatory/allergic reactions, aspiration, obstruction – maintain airway, administer oxygen, PEEP if needed, steroids
Term
Altered Tissue Perfusion – Decreased cardiac output: Myocardial depression
Definition
from anesthetic agents and ischemia of myocardium – may be experienced as hypotension, arrythmias and/or congestive heart failure -administer fluid volume and/or elevate legs if BP low – administer diuretics and inotropes if CHF
Term
Altered Tissue Perfusion – Decreased cardiac output: Dysrhythmias
Definition
reaction to meds, ischemia, hypothermia, positioning, pain, stress
Term
Altered Tissue Perfusion – Decreased cardiac output: HTN
Definition
preexisting hypertension, fluids, pain (sympathetic stimulation), distended bladder – may treat with rapidly metabolized vasodilator (nitroprusside) if removal of the initiating factor does not decrease the BP
Term
Altered Tissue Perfusion – Decreased cardiac output: Hypotension
Definition
results from low volume, decreased CO, vasodilation, sepsis – treat the cause, administer volume, elevate legs, vasodilators, positive inotropes
Term
Altered temperature regulation - Hypothermia
Definition
results from central acting anesthetic agents and heat loss with cool environment and exposure of body surfaces and organs
Term
Altered temperature regulation - Shivering
Definition
(muscle relaxants/neuromuscular blockade prevent shivering during OR) - may be seen as a result of anesthetic medications or hypothermia – shivering elevates metabolic rate and increases oxygen need – rewarm – cover head – pain medication
Term
Altered temperature regulation - Changes in drug clearance
Definition
related to hypothermia
Term
Altered temperature regulation - Treat Hypothermia
Definition
gradual rewarming ie Baer hugger air flow mattress, administration of oxygen – warm fluids/blood replacement
Term
Altered temperature regulation - Hyperthermia
Definition
– from infection, sepsis, blood reactions, rewarming, increased metabolic rate – Respond by cooling air flow mattress, ice packs, cool water lavage of stomach or bladder – Tylenol
Term
Altered temperature regulation - Malignant Hyperthermia
Definition
emergency situation - massive hyperthermia in persons with genetic predisposition – occurs at anesthesia induction most frequently
 complete thorough history especially of biological family anesthesia and surgery related complications – often seen in patients with ptosis, strabismus and kyphoscoliosis

 calcium stays in the intracellular space and maintains a state of constant muscle contraction resulting in metabolic acidosis – absence of adequate breathing results in respiratory acidosis – untreated results rapidly in death

 be prepared – treat with dantrolene sodium (like the narcotic reversal agents, the dantrolene sodium may have a shorter half life than the life of the malignant hyperthermia episode and require administering an additional dose) – cooling blanket, iced saline stomach and urinary lavage – monitor in intensive care post resuscitation even if a minor surgical procedure
Term
Alteration in Neurological Status
Emergence Delirium
Definition
random movement and agitation - seen in the recovery from anesthesia process
 maintain patient safety
 treat pain – may need to administer more anesthetic agent and recovery from anesthesia more slowly the second attempt
Term
PACU Scoring System
Definition
Aldrete Scoring System or adaptations of the system are used in many PACUs as a guide to anesthesia recovery - scoring system does not need to be memorized but used as a guide for assessment of the PACU patient using the parameters of activity, respiration, circulation, consciousness, and color
Term
Alterations in Intracrainal Pressure - Nursing Diagnosis
Definition
Altered cerebral tissue perfusion – minimize secondary injury
a. Primary injury
b. Secondary injury
Term
Alterations in Intracranial Pressure - Terminology
Definition

ICP - Intracrainal pressure

CPP - Cerebral perfusion pressure 

CMRO2 - Cerebral Metabolic Rate of O2

Term
Alterations in Intracranial Pressure - Regulation of ICP
Definition
a. autoregulation
b. accommodation
Term
Risks for Increases in ICP
Definition
Increase in brain volume
Increase in blood volume
Term
Central downward herniation
Definition
early diencephalion stage
late diencephalion stage
midbrain-upper pons stage
lower pons-upper medulla stage
Term
Uncal herniation
Definition
early third nerve stage
late third nerve stage
Term
Effect of ICP on Body Systems
Definition
brain metabolism
respiratory system
circulatory system
GI system
thermoregulation
Term
Assessment and Diagnosis of ICP Alterations - Assessment
Definition
Glasgow Coma Scale
eye opening
best verbal response
best motor response
Term
Assessment and Diagnosis of ICP Alterations - Assessment (2)
Definition
cranial nerves
language/verbal
Memory
motor/muscle strength/muscle tone/coordination
Term
Assessment and Diagnosis of ICP Alterations - Assessment (Reflexes)
Definition
DTR
babinski
posturing
pupils
brain stem reflexes
Term
Assessment and Diagnosis of ICP Alterations - Assessment (3)
Definition
sensory
respiratory pattern
Cushing Triad - (increased systolic blood pressure, a widened pulse pressure, bradycardia, and an abnormal respiratory pattern)
Term
Assessment and Diagnosis of ICP Alterations - Focused Assessment
Definition
mental status
focal motor
pupils
brainstem/cranial nerves
Term
Assessment and Diagnosis of ICP Alterations (2)
Definition
Radiology (skull, spine films) Scans(CT)
MRI
EEG
Multi-nodal evoked potential
Positron emitted transaxial tomography
Term
Cerebral circulation studies
Definition
doppler
CT angiography- digital subtraction angiography
cerebral perfusion studies
Term
Intracranial pressure monitoring
Definition
fiber-optic intraventricular device
subarachnoid bolt
intracerebral (parenchymal) catheter
epidural transducer
monitoring and wave forms
CMRO2
Term
Selected Nursing Interventions -resuscitation
Definition
coma scales
airway – intubate – OET
breathing – high flow O2 – O2 sats >95 – CO2 35-38 – neuromuscular blockade if needed
circulation – MAP 70-90 – HCT >30, Hgb > 10 – volume restoration – a line – hydration – labs – electrolytes – coagulation studies
disability – serial neuro exams – concurrent injuries – safety – temperature – positioning – sedation – increased HOB
Term
Selected Nursing Interventions - related to pharmacological interventions
Definition
diuretics – mannitol bolus preferred to continuous infusion – blood brain barrier altered at site of injury - if herniation or progressive deterioration occurs – may cause renal failure – maintain euvolemia
fluid balance
BP regulation
decreasing metabolic demands - barbiturates – for severe situations when hemodynamically stable and potential for recovery exists – use after other methods have been tried – use BIS monitoring
steroids – not recommended for cerebral trauma – helpful for patients with cerebral tumors
neuromuscular blocking agents
seizure precautions - antiseizure medications – prophylaxis after 7 days is not standard at this time
thorazine – for shivering
nimodipine - SAH
others – midazolam (versed),) propofol (diprivan
Term
Selected Nursing Interventions - related to nonpharmacological
Definition
hyperventilation – CO2 management - brief periods only - avoid in absence of increased ICP – only when medical and surgical interventions have been used
hypothermia - euthermia
surgery – decompression
CSF monitor and drainage
Term
Selected Nursing Interventions - Others
Definition
intracranial Doppler
microdialysis – brain tissue catheter – NS, dwell, drain
hypothermia – decrease cerebral oxygen/nutrition need
cerebral blood flow analysis
Term
Selected Nursing Interventions -independent nursing interventions
Definition
assessment
environmental management – quiet, sedation, HOB (30º vs flat)
nutrition – 140% of nutritional needs – 100% of nutritional needs if neuromuscular blockade used – use jejunal feedings with GJ tube (not for meds) to avoid gastric distention
safety – ie. suctioning (hyperoxygenate, lidocaine)
communication
body alignment –avoid hip flexion
neutral head position – restrictions on neck
I&O (DI, SIADH)
fever management – normo or hypothermic
communication and family needs
Term
Selected Nursing Interventions - Nursing Diagnoses
Definition
Decreased intracranial adaptive capacity
Ineffective tissue perfusion
Impaired gas exchange
Risk for imbalanced fluid volume
Disturbed thought processes
Impaired family processes
Term
Patients with Continuous Seizure Activity – Status Epilepticus - Patho: increased cerebral metabolism
Definition
increased cerebral blood flow (catecholamine release)
hyperglycemia (epinephrine)
hyperthermia
lactic acdosis
cardiac dysfunction (epinephrine)
autonomic (sweat, vomit)
Term
Patients with Continuous Seizure Activity – Status Epilepticus - Patho: Decompression
Definition
decreased CBF
decreased BP
increased ICP
autoregulation lost
Term
Patients with Continuous Seizure Activity – Status Epilepticus - Diagnostics
Definition
precipitating factors
movement
pupils
stimulus response
LOC
bowel/bladder
dialysis
injury
oxygen
labs
lytes, LFT, medication levels, toxicology, cardiac enzymes, ABG
EEG, MRI
VS
Term
Patients with Continuous Seizure Activity – Status Epilepticus - Nursing Diagnoses
Definition
Altered cerebral tissue perfusion
Ineffective airway clearance
Ineffective breathing pattern
Potential for injury
Sensory perceptual alterations
Term
Patients with Continuous Seizure Activity – Status Epilepticus - Other
Definition
Terminology

Risk for continuous seizure activity

Nursing interventions
1. ABCs
2. IV
3. safety

Pharmacological interventions
4. propofol
5. neurovascular
6. sedation
Term
Spinal Cord Injury - Assessment
Definition
neurological
hemodynamics - spinal shock
bowel and bladder
skin
psychosocial
Term
Spinal Cord Injury - Nursing Diagnosis
Definition
Risk for injury
Impaired gas exchange
Ineffective airway clearance
Ineffective thermoregulation
imbalanced nutrition
Ineffective tissue perfusion (DVT)
Risk for infection
Constipation
Fear/Anxiety
Powerlessness
Term
Patients with Liver Failure Definition
Definition
Fulminant liver failure is acute liver failure with hepatic encephalopathy Results from massive necrosis of liver cells or sudden reduction of liver function
Term
Chronic liver failure
Definition
is a slow progressive degeneration of liver cells resulting in decreased liver function and liver failure
Term
Etiology/Pathophysiology of Fulminant Liver Failure
Definition
Infection - hepatitis A, B, C, D - herpes simplex - CMV - adenovirus Toxins - mushroom poisoning - hydrocarbons Drugs - tylenol OD - antidepressants - NSAIDS - phenytoin - isoniazid - sulfonamides Ischemia- cardiac failure - hepatic vascular occlusion - shock -hypertension - hypoxemia Metabolic disorders -Reye’s - fatty liver of pregnancy
Term
Etiology of Chronic Hepatic Failure
Definition
•Cirrhosis •Chronic active hepatitis •Hepatic vein thrombosis
Term
System Changes Related to Fulminant and Chronic Liver Failure Neuro: Hepatic encephalopathy Liver tube Feeding / Lover TPN
Definition
decreased hepatocyte function shunting of blood from portal system via the collateral circulation or shunting of blood through the damaged liver liver blocks the degradation of ammonia into urea resulting in neurotoxic ammonia (through the brain into CSF to tissue cerebral edema) confusion treat with lactulose(converts ammonia to non-absorbable form), antibiotic, decreased protein diet
Term
System Changes Related to Fulminant and Chronic Liver Failure - Hematologic: Coagulopathy
Definition
decreased production of clotting factors II, V. VII, IX, X (at risk for bleeding) activation of Hageman factor abnormal platelet production and function
Term
System Changes Related to Fulminant and Chronic Liver Failure - Hematologic: Increased risk of infection
Definition
impaired function of Kupffer cells and polymorphonuclear leukocytes - (Bacteria in the bloodstream) impaired cell mediated and humoral immunity bacteria enter via collateral shunting and poor liver filtration
Term
System Changes Related to Fulminant and Chronic Liver Failure - Metabolic: Jaundice
Definition
inability to metabolize bilirubin decreased survival of erythrocytes
Term
System Changes Related to Fulminant and Chronic Liver Failure - Metabolic: Fetor Hepaticus - (Breath odor)
Definition
increased level of mercaptans from bacterial action of GI tract injured liver does not process mercaptans decreased lipoproteins, cholesterol and phospholipid metabolism decreased bile salt synthesis resulting in decreased absorption of A, D, E, K (Needed for clotting) decreased fat breakdown decreased protein metabolism resulting in decreased albumin, fibrinogen
Term
System Changes Related to Fulminant and Chronic Liver Failure - Metabolic: Cardiovascular
Definition
vasodilation with decreased systemic vascular resistance and hypotension (Increase Epi level, Increase HR, Increase BP, vasoconstriction) hypovolemia (decrease BP & vasodilation) increased CO, CI and interstitial edema stimulation of sympathetic nervous system
Term
System Changes Related to Fulminant and Chronic Liver Failure - Metabolic: Pulmonary
Definition
intrapulmonary shunting ventilation perfusion mismatch decreased diffusing capacity hypoxemia, clubbing, and cyanosis
Term
System Changes Related to Fulminant and Chronic Liver Failure - Metabolic: Amino Acid formation
Definition
increased tissue protein breakdown and decreased hepatic oxidation resulting in elevated tyrosine increased plasma levels of aromatic amino acid - tyrosine, methionine decreased levels of branched chain amino acids - leads to encephalopathy
Term
System Changes Related to Fulminant and Chronic Liver Failure - Metabolic: Endocrine
Definition
estrogen, testosterone, aldosterone, cortisol not broken down
results in gynecomastia, palmar erythema, signs of cushings
(aldosterone results in increased sodium retention and edema - anasarca - also the decreased proteins)
Term
Fulminant Hepatic Failure
Definition
cerebral edema - hypoglycemia - glycogen depletion - elevated insulin from inadequate uptake - lactic acidosis from inability of liver to metabolize lactate - hypokalemia, hyponatremia - hypophosphatemia from K urine losses, poor intake and metabolic acidosis
Term
System Changes Related to Fulminant and Chronic Liver Failure - Assessment - Fulminant (Acute)
Definition
headaches, dizziness, jaundice, vomiting, altered mentation
asterixis, fetor hepaticus, small liver, decerebrate posture
hypotension, tachycardia, dysrhythmias, cardiac failure
tachypnea, fever
Term
Chronic Hepatic Failure - Portal Hypertension
Definition
obstructs blood flow and results in high pressure in the portal system
collateral vessels form between portal vein, spleen stomach, esophagus and bowel vascular spiders, palmar erythema, gynecomastia, testicular atrophy
estrogen decreased with free testosterone
decreased rate of hormone metabolism hypoalbuminemia
not synthesized
anorexia
Term
System Changes Related to Fulminant and Chronic Liver Failure - Assessment - Chronic
Definition
malaise, weakness, fatigue, anorexia, wt loss, bruising, jaundice
emaciated, vascular spiders, palmar erythema
enlarged abdomen from ascites, peripheral edema
flushed extremities
altered mental status, asterixis, fever, gynecomastia
tachypnea, hypotension, tachycardia
fetor hepaticus, GI bleeding
Term
System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Blood Glucose
Definition
fulminant (acute) - hypoglycemia (Doesn't breat down sugars)
chronic - hyperglycemia
Term
System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Lytes
Definition
Decreased K (Hi aldosterone - not broken down retain Na+ and H2O), Na, PO4
Term
System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - BUN
Definition
Decreased
Term
System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Coagulation
Definition
Increased PTT, PT, Decreased Platelets
Term
System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - LFT
Definition
increased CPK, AST (SGOT), ALP (SGPT), LDH
increased bilirubin-
indirect (unconjugated) – hemolysis
direct (conjugated)– hepatocellular injury
total – biliary obstruction
decreased urine bilirubin – biliary obstruction
increased urobilinogen - hemolysis
Term
System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Albumin
Definition
Decrease - Protein metabolism altered
Term
System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Globulin
Definition
Increased - hepatitis
Term
System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Alpha Fetoproteins
Definition
decreased but increases with liver regeneration in fulminant hepatic failure
Term
System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - WBC, Hgb, Hct
Definition
Increased or decreased
Term
System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Serum Ammonia
Definition
Increased
Term
System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - ABG
Definition
Decreased PaO2, metabolic acidosis
Term
System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Amylase
Definition
Increased if associated pancreatitis
Term
System Changes Related to Fulminant and Chronic Liver Failure - Planning
Definition
Monitor for and reduce cerebral edema
Monitor for hepatic encephalopathy - restrict protein, ng, no sedation, VS, ammonia levels, lactulose and neomycin
Control hypoglycemia and improve nutrition
Monitor coagulopathy and bleeding -vitamin K, FFP, platelet packs
Monitor and prevent infection
Maintain CO
Monitor for hepato renal failure-I&O, decrease Na intake, LeVeen shunt, hemodialysis, no nephrotoxic drugs
Monitor liver function - drug use, mucomyst for tylenol overdose
Term
System Changes Related to Fulminant and Chronic Liver Failure - Medications
Definition
Mannitol - prevent cerebral edema
Lactulose - cephulac - increases osmotic pressure in the gut - reduces production and increases utilization of ammonia
Neomycin - sterilizes gut and decreases ammonia production
Vitamins
Blood - clotting issues, protein volume issue, lasix
Histamine receptor antagonists - to save GI tract bleeding
Dopamine - liver perfusion dose
K sparing diuretics - aldactone - antagonizes action of aldosterone that is not being broken down
loop diuretics - caution
volume expanders - albumin (watch for pulmonary edema)
mucomyst - prevent hepatoxic effects of tylenol overdose
Term
System Changes Related to Fulminant and Chronic Liver Failure - Nursing Diagnoses
Definition
Altered thought processes - assess, avoid sedation, decrease protein intake, avoid alcohol
High risk for injury - bleeding, vitamin K
High risk for infection - assess, prevent
Altered tissue perfusion: hepato renal
assess - UOP - urinalysis, proteinuria
Na restriction - low dose dopamine - no hepatotoxic drugs
Fluid volume excess or deficit- labs - weigh - abdominal girth (acites - cause respiratory problem) - orthostatic changes - flank bulging - umbilical displacement
fluid waves - fatigue - anorexia
Nutrition - dextrose IV - branched chain amino acids IV, po
thiamine, folic acid, vit K, trace elements, lipids, protein 20-100 grams
Skin integrity - control pruritis with cholestyramine (Questran - controls itching)
Breathing pattern ineffective
Term
Patients with Pancreatitis - Definition
Definition
acute pancreatic inflammation
isolated event or repeated attacks
Term
Patients with Pancreatitis - Etiology
Definition
ethanol abuse, cholelithiasis, idiopathic
trauma, abd surgery, cholangiopancreatography
hyperlipidemia, organ transplant, peptic ulcer
outflow obstruction, pregnancy, heredity, renal failure, virus infection
hypoperfusion, biliary stones
drugs - thiazides, lasix, estrogen, sulfonamide, steroids
Term
Patients with Pancreatitis - Pathophysiology
Definition
digestive enzymes become activated within the pancreas resulting in autodigestion of the pancreas
activation of trypsin stimulates the secretion of proteolytic enzymes kallikrein, chymotrypsin, elastase, phospholipase A, and lipase
capillary permeability is increased resulting in leakage of fluid into the interstitium, edema, and relative hypovolemia
hemorrhage results from dissolution of the elastic fibers of the blood vessels and ducts
cell membranes are damaged resulting in necrosis of pancreatic and adipose tissue
lipase results in fat necrosis of the pancreas and surrounding tissues
autodigestion, hypocalcemia, cysts, ascites, pulmonary effusions, pneumonitis, fat necrosis,
abscesses, vasodilation, pain, third spacing, shock, DIC
Term
Stages of Pancreatitis
Definition
1. Acute edematous pancreatitis- interstitial edema, leukocyte infiltration, dilated capillaries and lymphatics
2. Necrotizing pancreatitis -acinar cell death, necrosis of surrounding fatty tissues
3. Hemorrhagic pancreatitis (Most life threatening) - blood around and within the pancreas
Term
Risks for Complications - Pancreatitis
Definition
increased age
leukocytosis
hyperglycemia
increased LDH, AST, SGOT
low H & H
increased BUN
PaO2 < 60
hypotension
increased calcium
serum albumin below 3.5 g/100 ml
need for transfusion
hemorrhagic peritoneal fluid
first episode of pancreatitis
Term
Assessment - Pancreatitis
Definition
epigastric pain
dull, steady, radiates to back, chest, flank; worse in supine position; relieved in knee chest; referred to shoulders (Hiccups -irritated diaphragm)
N/V, hiccoughs
acute distress
abdominal distention
tachypnea, febrile
Grey Turner’s sign – flank discoloration - (Bleeding into tissue on back)
Cullen’s sign – periumbilical discoloration - (bleeding around Umbilicus)
erythematous skin nodules on extremities
rarely jaundice
cool, clammy skin
oliguria
coma or confusion
decreased bowel sounds
crackles, atelectasis, pleural effusion
hypotension
abdominal rigidity (board-like abdomen) or rebound tenderness
fever
Term
Laboratory - Pancreatitis
Definition
Amylase - increased
Lipase - increased
ascites fluid or pleural fluid amylase - elevated
liver enzymes - increased
blood sugar - increased
calcium - decreased
albumin - decreased
H & H - increased with dehydration
WBC - Increased
Triglycerides - increased
BUN - increased
Term
Diagnostics - Pancreatitis
Definition
Abdominal films - free intraperitoneal air from perforation; intestinal edema or thumb printing of intestinal infarction
Abdominal ultrasound
Chest x ray - pleural effusion
UGI - increased pancreas size
CT abdomen – Diagnostic: increased pancreas size
ERCP - endoscopic retrograde cholangiopancreatography
Term
Planning: Supportive care – Pain Management, Fluid Balance, Nutrition
- Pancreatitis
Definition
fluid and electrolytes
hemodynamic support
peritoneal lavage
pancreas abscess draining
labs
NG & NPO to decrease stimulation for release of pancreatic enzymes
antiacids
analgesics and rest
nutritional support – TPN
Term
Pancreatitis - Planning: Monitor for complication: GI
Definition
pseudocysts, abscess, fistula, ascites
intraabdominal hemorrhage
bowel fistula, necrosis, perforation
spleen abscess, infarction, GI varices
Term
Pancreatitis - Planning: Monitor for complication: Respiratory
Definition
Pleural effusion, pneumonitis, ARDS, erodes diaphram
Term
Pancreatitis - Planning: Monitor for complication: CV
Definition
Hypotension, shock, pericardial effusion
Term
Pancreatitis - Planning: Monitor for complication: Metabolic
Definition
Hyperglycemia, hypocalcemia, fat necrosis
Term
Pancreatitis - Medication:
Definition
analgesics - demerol
colloids and crystalloids
histamine receptor antagonists
antibiotics
antacids
Term
Pancreatitis - Nursing:
Definition
Pain- knee chest position, medications
FVD -replacement of fluids and electrolytes, weights, girths, check LOC, hemodynamics
diarrhea or constipation- GI healing with ng, antacids, histamine receptor antagonists
nutrition: less, labs, TPN
tissue perfusion- heparin contraindicated
skin integrity
impaired gas exchange
ineffective breathing pattern
airway clearance
risk for injury
Term
Pancreatitis - Life Threatening Complications:
Definition
hemorrhagic shock
ARDS
DIC
ARF
Septic shock
MODS
Term
Patients with Disseminated Intravascular Coagulation - Definition
Definition
Inappropriate, accelerated, and systemic activation of the coagulation cascade with thromboses and hemorrhage occurring simultaneously
Term
Patients with Disseminated Intravascular Coagulation - Etiology
Definition
1. Tissue injury
2. Antigen antibody reactions
3. Neoplasms
4. Infections
5. OB emergencies
6. Profound hypotension
Term
Patients with Disseminated Intravascular Coagulation - Pathophysiology
Definition
1. Widespread formation of clots
Clots in the microcirculation result in decrease in blood flow to cells – organ ischemia
2. Depletion of clotting factors
Resulting from consumption of clotting factors from diffuse clotting in the microcirculation
3. Secondary activation of the fibrinolytic system
Massive clotting increases fibrinolytic activity
Breakdown of clots releases fibrin split products (FSP or FDP)
FSP/FDP are anticoagulants – inhibit thrombin formation and decrease platelet aggregation
Results in increased bleeding
Term
Patients with Disseminated Intravascular Coagulation - Manifestations
Definition
1. Bleeding
Oozing from IV sites, surgical or trauma wounds, mucous membranes, etc.
Multiple sites
Petechiae, bruising, hematuria
2. S/S of impaired organ function
Restlessness, confusion, decreased urine output, ST changes, dyspnea, angina, etc.
Term
Patients with Disseminated Intravascular Coagulation - Laboratory Value Changes
Definition
PT, PTT prolonged
Platelets decreased
Fibrinogen decreased
FSP/FDP increased
D-dimer increased
Term
Patients with Disseminated Intravascular Coagulation - Treatment
Definition
Correct primary disorder
Heparin
Blood component replacement
Recombinant human protein C (anticoagulant)
Term
Patients with Disseminated Intravascular Coagulation - Goals
Definition
Replace blood loss
Prevent shock
Replace depleted coagulation factors
Term
Patients with Disseminated Intravascular Coagulation - Nursing Diagnoses
Definition
Deficient Fluid Volume RT blood loss
Decreased CO RT decreased preload
Risk for Infection
Anxiety
Compromised Family Coping
Altered Tissue Perfusion
Impaired Gas Exchange
Pain
Altered LOC
Potential for Injury
Term
Patients with Multiple Organ Dysfunction Syndrome - Definition
Definition
Systemic Inflammatory Response Syndrome (SIRS) is an overall inflammatory response to severe injuries or illness
Multiple Organ Dysfunction Syndrome (MODS) is a progression of SIRS: imbalance of oxygen supply and demand; failure of the capillaries to extract the delivered oxygen; organ dysfunction requiring intervention
Term
Patients with Multiple Organ Dysfunction Syndrome - Risk Factors
Definition
sepsis, critically ill, very young or old, impaired immunity, dysfunction of one organ, multiple trauma etc.
Term
Patients with Multiple Organ Dysfunction Syndrome - Metabolic Responses
Definition
generalized intracellular and extracellular edema
increased energy expenditure resulting in glycolysis
autocannibalism unresponsive to amino acid administration
Term
Patients with Multiple Organ Dysfunction Syndrome - Pathophysiology
Definition
humoral immune mediator release resulting in: cardiac dysfunction from MDF from ischemic pancreas
loss of capillary endothelial function and integrity
pulmonary dysfunction from leaky pulmonary capillary membranes
microemboli and vasoconstriction leading to ventilatory failure and ARDS
CNS dysfunction from cerebral hypoperfusion
renal dysfunction from renal vasoconstriction and hypoperfusion leading to ATN
hematologic dysfunction from overstimulation of the coagulation cascade leading to DIC
GI dysfunction from vasoconstriction and hypoperfusion leading to GI failure and release of gram negative bacteria into the system with gram negative sepsis
Term
Patients with Multiple Organ Dysfunction Syndrome - Assessment
Definition
History - history of injury or illness
Neuro - confusion, agitation, lethargy, GSC < 6, temperature fluctuation
Resp - low or high RR, hypoxemia with restlessness, confusion, dyspnea, crackles, ARDS
CV - tachycardia, bradycardia, hypotension, anasarca, shock
GI - board like abdomen with pain, diarrhea, jaundice, GI bleeding, paralytic ileus, hepatic failure, acalculos cholecystitis, hypermetabolism
Hematological - bruising, bleeding, tarry stools, coffee ground emesis, DIC
Renal - oliguria and sediment in urine
Term
Patients with Multiple Organ Dysfunction Syndrome - Laboratory
Definition
ABG - respiratory and metabolic acidosis with hypoxemia; mixed venous oxygen saturation increased
WBC - increased and eventually decreased
Coagulation - increased PT, PTT, and FSP
Glucose - increased then decreased
Lactate - increased
Renal - increased BUN and creatinine
LFT - increased enzymes
Cardiac enzymes - increased
Chest xray - infiltrates
Hemodynamics - decreased CO, increased SVR, PCWP, CVP
Term
Patients with Multiple Organ Dysfunction Syndrome - Medications
Definition
Volume expanders
Inotropic agents
Vasodilators
Antibiotics
Diuretics
Steroids
Antioxidants
Arachidonic acid metabolite modulators
Protease inhibitors
Recombinant activated protein C (Xigris)
Term
Patients with Multiple Organ Dysfunction Syndrome - Nursing Diagnoses
Definition
Altered tissue perfusion
High risk for infection
Altered nutrition
Tissue integrity impaired
Fluid volume deficit
Term
Transplants
Definition
Cadaver organ transplants – 1960’s
Need for organs exceeds the available organs
Immune manipulation has advanced significantly resulting in improved success
Term
FSP

FDP
Definition
Firbrous Split Products - Breakdown Clots
FDP - Fibrous degredation Products - Risk for DIC: Burns, Transfusion, Shock
Term
Organ and Tissue Donors
Definition
Decisions to Donate
Brain Death - Criteria
Term
Regulations Relating to Organ Donation
Definition
National Organ Transplant Act – 1984
Organ Donation and Recovery Improvement Act – 2004
United Network for Organ Sharing
Registries
Required Request
Brain Death – Non Heart Beating Organ Donation
Term
Organ and Tissue Donation
Definition
Conditions of Participation – 1998 and 2003
Consent to Donate
Death Investigation Systems
Donor Families
Donor Designation
Cardiac Death Donors
Communicating with Donor Families
Term
Organ and Tissue Donation Process - Determination of Brain Death
Definition
Cerebral Motor Responses
Pain Responses
Apnea Test – Motor Responses
Term
Organ and Tissue Donation Process - Brainstem Reflexes
Definition
Pupillary Activity
Ocular Movement
Corneal and Jaw Reflexes
Gag Reflex
Term
Organ and Tissue Donation Process - Apnea Tests
Definition
1. Disconnect the vent.
2. Deliever 100% O2 at rate of 6L/min thought the ET. The O2 cannula can be placed at the level of the carina.
3. Observe the patien closely for respiratory movements (abdominal or chest excursions that produce adequate tidal volume.)
4. mease paO2, PaCO2, and pH after approximately 8 mins and reconnect vent.
Term
Organ and Tissue Donation Process - Cerebral Perfusion Studies
Definition
Cerebral angiography
Electroencephalography
Transcrainal Doppler sonography
Somatosensory and brainsteam auditory envoked potential testing.
Technetium Tc 99m brain scan.
MRI
Term
Care of the Organ Donor
Definition
Blood Pressure
Glucose
Temperature
RBC and Coagulation
F & E – Polyuria
Acid Base
Mechanical Ventilation
Term
Organ Recovery Process
Definition
Surgical Preparation
Care in the Critical Care Unit
Transport to Surgery
Term
Transplant Success and Rejection
Definition
Graft Rejection

Immunosuppressive Therapy: Corticosteroids, Cyclosporine, Tacrolimus (Prograft), Azathioprine (Imuran), Mycophenolatemofetil (Cell-Cept), Sirolimus (Rapamycin)
Term
Heart Transplantation
Definition
Potential Recipients and Contraindications
Postoperative Care - Variations related to anatomical changes from transplantation: EKG changes, Medications, Tamponade
Rejection and Infection Surveillance & Intervention: Endomyocardial biopsy, Treatment with solumedrol IV
Recipient Post Operative Self Surveillance: Immunosuppression, Silent MI, Quality of Life
Term
Heart Lung Tansplantation
Definition
Potential Recipients and Contraindications
Intra operative Medications - Alprostadil (prostaglandin E1)
Postoperative Care- Variations related to anatomical changes from transplantation: Similar to heart transplantation; Initial immunosuppression usually does not include methylprednisolone
Rejection and Infection Surveillance & Intervention: Transbronchial biopsy, Treatment with solumedrol IV
Recipient Post Operative Self Surveillance: CMV Prophylaxis and Treatment, Quality of Life
Term
Liver Transplantation
Definition
Increased with availability of cyclosporine

Potential Recipients: Living and cadaver donors, Preparation of Recipient for Transplantation
Post operative Care: Hemodynamic Management & Coagulation Risks
Liver function assessment and management, Neurological Changes
Rejection Surveillance
Term
Kidney Transplantation
Definition
ESRD and Transplantation
Living and Cadaver Donors
Postoperative Care - Fluid management
Rejection Surveillance
Term
Pancreas Transplantation
Definition
Diabetes Mellitus – ESRD
Surgical blood flow and exocrine flow
Rejection Surveillance
Term
Midwest Transplant Network
Definition
Withdrawing Care Decision and Decision to Donate - Separate decisions
Role in Managing the Donation and Transplant Processes
Donor Family Adaptation
Recipient Adaptation
Who Pays
Term
Coronary Artery Disease – Acute Coronary Syndrome
Definition
Narrowing of coronary arteries by atherosclerosis
History
Risk Factors - Heredity, gender, age, DM, obesity/overweight, smoking, inactivity, elevated lipids, HTN
A – antianginal drugs, aspirin; B – beta blockers, BP - Decrease HR, Decrease O2 Demand, decrease Afterload; C- cholesterol, cigarettes; D- diet, DM; E-education, exercise
Term
Angina
Definition
Ischemia of cardiac Muscle
Term
Types of Angina
Definition
Stable Angina - Paroxysmal substernal pressure or pain - decrease O2 Demand; Relieved by NTG - Headache

Unstable or Preinfarction Angina/Acute Coronary Syndrome and MI (check for Meds): Pain unpredictable; Not relieved by NTG or rest:
Class I Pain with strenuous activity
Class II Pain with ADL some limitations
Class III Pain with ADL marked limitations
Class IV Pain with any activity and/or at rest
Variant/Prinzmetal’s Angina - artery spasms: Shunt - ischemia not a lot of intervention, Ca++ Channel blockers - relaxes smooth muscle, Pneumonia, pleural effusion, Aortic Aneuerysm, CK-MB,Troponin
Term
Myocardial Infarction - MI
Definition
Ischemia and death of myocardium from occlusion of coronary arteries
Complications of MI: dysrhythmias, HF, ventricular, septal, papillary muscle rupture, thromboemboli, pericarditis, shock
MONA M-morphine; O-oxygen; N-nitrates; A-aspirin, analgesics
Changes in HR, Changes in BP, Heart Attack - diaphoresis, Epi Release
Term
Assessment of Myocardial Pain – Male vs Female
Definition
PQRST – palliatives or provocation, quality, radiation and region, severity, time (length of) and treatment
Term
Diagnostic Test - EKG
Definition
EKG – 12 lead:
Angina- ST segment depression ischemia & T-wave inversion
Possible Ischemia-T wave inversion, positive inflection - inverted to QRS; check troponin levels; Injury-ST segment elevation; Infarction-pathological Q wave
Changes in the leads that reflect the ischemic/injured/infarcted area of the heart; Compare to baseline EKG:
Limb leads, Augmented leads, Precordial leads, Posterior leads
Term
Diagnostic Testing - Cardiac
Definition
Stress testing/Exercise Tolerance Testing
Treadmill (exercise), persantine, thallium
Holter Monitor
Chest x-ray
ECHO
Transesophageal Echocardiogram
Scans – Thallium 201
MUGA
MRI
Electrophysiology Study
Angiography – cardiac catheterization
Risks Identification– Homocysteine Levels, Lipids
Term
EKG Changes of Myocardial Ischemia/Injury/Infarction
Definition
Areas (zones) involved:
Ischemia - Decreased tissue perfusion
Injury – recoverable cells
Infarction – death of cells
Term
12 Lead EKG - Changes:
Definition
views electrical activity from different planes and/or directions; vectors; changes with MI progress over time and with myocardial damage

Ischemia- T wave elevation – lasts for minutes or hours; Followed by T wave inversion
Injury: ST segment elevation – lasts for days.
Infarction: Q waves present in leads of infarction – lasts forever – (also non q wave MI); Small q waves are normal in I, AVL, V5 and V6; Pathological Q waves are more than one box; Size of the infarct is determined by duration of ischemia, collateral, metabolic needs of the myocardium
Term
Enzyme Changes:
Definition
CK - rises in 2-6 hours, peaks in 18-36 hours, elevated for 3-6 days
CK-MB - specific for MI rises in 4-8 hours, peaks in 15-24 hours, elevated for 2-3 days
LDH isoenzymes – LDH1, LDH2 are specific for myocardium if LDH1 is greater than LDH2
Troponin 1 and Troponin T elevated: Highly specific for myocardium
Rises in 1 hour
Peaks in 10-24 hours and remains for weeks
Myoglobin elevated in 30 minutes - 1 hour: Released from ischemic muscle – nonspecific but elevates early; Elevates before CK – CK is not specific for cardiac muscle
Term
Systems Assessment (selected)
Definition
Neuro – pain
Skin – s/s of decreased CO
CV – pulses, pulse deficit, rhythm, sounds, JVD, edema, varicosities, hemodynamics, pacer, paracarditis, Pleural Rub
Resp – cough, sputum, BS, ABG, oxygenation
GI – abdomen size, BS, nutrition, ascites (HF)
GU – UOP
IV – size, solution, medications
Term
Medical Interventions
Definition
Goal is to limit the area of injury by restoring blood flow to ischemic tissue - STEMI; Infarction is death of tissue that results from prolonged ischemia
PTCA – Balloon Angioplasty (cardiac catheterization)
Stents
Term
Medical Interventions - Fibrinolytics – Thrombolytics
Definition
Lyse thrombi by converting plasminogen to plasmin causing fibrin to fibrinogen
Streptokinase, tissue plasminogen activator; TPA works more rapidly than streptokinase
Occlusion time directly correlated with infarct size
First 2-3 hours see maximum myocardial survival, moderate in 6 hours and marginal after 12 hours;
(Use when contraindicated for Stenting)
Term
Medical Interventions - Reperfusion Injury
Definition
Reperfusion releases oxygen free radicals and cellular swelling occurs - Restrictive heart Failure; Tissue swelling related to ischemia may prevent reperfusion - Diastolic Heart Failure; Reperfusion arrhythmias - PVC; Check for: Allergy to streptokinease, Iodine
Term
Medical Interventions - Contraindications of fibrinolytics
Definition
12 hours out from MI; Active bleeding;
Recent surgery, head trauma; Known neoplasm; BP greater than 200/120; Allergy to med; Pregnancy & post partum; Post CPR; Trauma or surgery within 2 weeks; Hemorrhagic stroke within 3 months
Term
Medical Interventions- Monitor
Definition
(post procedure): EKG normalization; Reperfusion dysrhythmias – VT and AV block; Allergies; Bleeding; Hypotension;
Reocclusion - Chest Pain - management
Term
Medical Interventions - Complications
Definition
Bleeding
Term
Medical Interventions- Nursing Care
Definition
Monitor distal pulses
Pain management (*)
Hemorrhage - Check site; Retroperitoneal – back pain; Arrhythmias; Chest pain with reocclusion; PTT, heparin; Mentation UOP, fluids, decrease Cardiac Output
Term
Medical Interventions - Medications
Definition
Oxygen: O2
Lipid Reducing Medications: (normally –statin, there are others)
Term
Medical Interventions - Medications: Dilators
Definition
Nitroglycerin/tridil-
Transdermal patch 2.5
Sublingual 0.5 mg every 5 min times 3 doses
IV 5-10 mg/min and titrate to pain
Isosorbide (Isordil) vasodilate
Nipride (Nitroprusside)
Term
Medical Interventions – Medications: Analgesics
Definition
Morphine - IV 2to 5 mg repeat every 5-30 min to relieve pain
Term
Medical Interventions – Medications; Anticoagulants
Definition
ASA
Clopidogrel (Plavix)
Term
Medical Interventions – Medications: Antithrombotics
Definition
Heparin
Lovenox
Term
Medical Interventions – Medications: Glycoprotein IIb/IIIa Inhibitors
Definition
Abciximab (RePro)
Tirofiban (Aggrastat)
Eptifibatide (Integrillin)
Term
Medical Interventions – Medications: Beta blockers
Definition
Tenormin (Atenolol)
Lopressor (Metoprolol)
Propanolol (Inderol)
(Reduce mycocardial O2 demand, makes muscles sluggish)
Term
Medical Interventions – Medications:Calcium channel blockers
Definition
Dilate coronary and other arteries to decrease afterload
Diltiazem (Cardizem) - Slows down the heart w/o making muscle sluggish
Term
Medical Interventions – Medications: HF Medications
Definition
Nesiritide (Natrecor) – B type natriuretc peptide - vasodilates
Term
Medical Interventions - Other Treatments
Definition
IABP
Balloon angioplasty
CABG - titrate vasopressors, MgSO4
Term
Nursing Diagnoses
Definition
Acute chest pain
Risk for decreased CO
Fear
Risk for activity intolerance
Knowledge deficit
Term
Heart Failure
Definition
- Heart unable to meet metabolic demands
Left heart systolic failure (pump) - decrease HR to pump out;
Left heart diastolic failure - unable to fill restrictive caridomyopathy;
Right heart systolic failure (volume) - hypovolemia;
Right heart diastolic failure
(acute diastolic failure, cardiac tamponade)
Term
HF - Diagnosis
Definition
Cardiac assessments
BNP – B natriuretic peptide
LFT - Liver Function Test - Dilated liver - hepatomegly - O2
EKG
Term
HF - Interventions
Definition
Manage S/S – SOA, DOE, Orthopnea, PND, Wheezes (Check Respirations, O2, get wheelchair);Prevent complications; Treat cause (*); Pump – ACE inhibitors (inhibits vasoconstriction, inhibits RAA), inotropes, nesiritide; Decreased cardiac workload – IABP, VAD, biventricular pacing, rest;
Oxygen
DVT prevention
Diuretics - Na/fluid management – weight monitoring
Term
HF - Nursing Diagnoses
Definition
Decreased CO
Fluid volume excess
Fluid and electrolyte imbalances
Sleep deprivation
Knowledge deficit
Term
Cardiac Alterations - Other
Definition
Pulmonary Edema
Pericarditis
Aneurysm Dissection
Transplantation
Term
Shock
Definition
Body’s response to inadequate tissue perfusion;
Pathophysiological process that frequently results in multiple system organ syndrome (MODS);
Syndrome of cellular metabolic disturbances and hemodynamic disturbances;
Mortality rate is high
Term
Initial/Initiation Stage - Shock
Definition
Cardiac output and tissue perfusion decrease
Anaerobic metabolism begins
Lactic acidosis leads to cellular damage
Term
Compensatory Stage - Shock
Definition
Body attempting to restore CO, BP, and improve tissue perfusion:
Neuro compensation (SNS) – catecholamine response - ↑HR and contractility, arterial and venous vasoconstriction, shunting of blood to vital organs;
Hormonal - endocrine compensation – Anterior Pituitary and Adrenal Medulla
RAA - ↑aldosterone and ADH →sodium and water retention;
ACTH from Anterior Pituitary increases glucocorticoid production →elevated BG
Adrenal Medulla →release of epinephrine and norepinephrine
Chemical – chemoreceptors
Term
Compensatory Stage - Shock: Clinical manifestations
Definition
BP low normal;HR increased – peripheral pulses weak; Pale, cool, moist skin; UOP below 30cc/hr; Rapid, deep respirations; Hypoactive bowel sounds – distention; Dilated pupils, restless; Glucose, Na increased; PaO2, PaCO2 deceased – alkalosis; Lactate levels high normal
Term
Progressive Stage - Shock: Cellular
Definition
Anaerobic metabolism
Swelling of organelle
Release of enzymes from mitochondria
Term
Progressive Stage - Shock: CV
Definition
Decreased coronary artery perfusion, ischemia, lactic acidosis; Capillary sludging – resulting DIC, SIRS/MODS;
Release of MDF from pancreas; Weak or absent pulses; Myocardial Ischemia
Term
Progressive Stage - Shock: CNS
Definition
Dysfunction resulting in cardiac, respiratory, and thermoregulatory failure
Decreased LOC from cerebral ischemia
Term
Progressive Stage - Shock: Pulmonary
Definition
ARDS – ischemia of alveolar cells – decreased surfactant – airway & alveolar collapse –acidosis
Atelectasis
ARDS 18 < wedge pressure > 18 cardiogenic shock
Term
Progressive Stage - Shock: Renal
Definition
Decreased perfusion – renal vasoconstriction – ATN - RAA; Oliguria
Term
Progressive Stage - Shock: GI
Definition
Hypoperfusion – release of gram negative bacteria – sepsis and shock
Term
Progressive Stage - Shock: Hematological
Definition
Hypoperfusion – acidosis results in stasis of blood – DIC
Term
Signs and Symptoms - Shock
Definition
Hypotension – tachycardia – cool skin – cyanosis – mottling- weak pulses – oliguria – decreased LOC; Respiratory crackles – absent bowel sounds; Elevated amylase, lipase, SGOT, SGPT; Elevated BUN, creatinine, K; Decreased PaO2 and pH; Increased Pa CO2, Decreased H2CO3 – resp and metab acidosis; Elevated lactate
Term
Refractory and Irreversible Stage - Shock
Definition
MODS
May survive but with organ damage
Term
Hypovolemic Shock
Definition
Decrease volume: Internal fluid shifts; External fluid loss; Loss of body fluids
Stages & Classes-
Initial (Class I) 15% BV (750 mL)Compensatory (Class II) 15-30% BV – (750-1500 mL) - symptomatic
Progressive (Class III) 30-40% BV – (1500-2000 mL) - multiple symptoms
Refractory (Class IV) greater than 40% BV (2000 mL)

Treatment - Replace blood loss with blood, crystalloids, colloids
Hemodynamics:
CO/CI ↓; SVRI ↑; PCWP ↓; CVP ↓
Management: Prevention – I & O, wts, ID
Monitor tissue perfusion, vascular volume, response to interventions; Fluids, volume replacement; Elevate legs, trunk flat, head and shoulders above chest
(unavailable fluids - hemorrhagic, nonhemorrhagic (vomiting, severe diarrhea, severe dehydration, burns, 3rd spacing loss in bowel obstruction))
Term
Cardiogenic Shock
Definition
- Impaired Cardiac Function
Causes: myocardial ischemia, structural problems, dysrhythmias
Patho: Impaired ventricles → SV↓ → CO↓ → ↓tissue perfusion; Inflammatory process; ↑ end diastolic volume and heart failure (pulmonary edema)
Assessment: signs and symptoms of ↓CO
Hemodynamics:
CO/CI↓; SVRI↑; PCWP: ↑; CVP↑
Management; ↑ pump efficiency – preserve myocardium; Rest and analgesics; Oxygen (ventilator assistance); Thrombolytics
Term
Cardiogenic Shock - Management Meds: Dopamine
Definition
Intropin – usage varies
Low – 0.5-3 mcg/kg/min – renal perfusion
Moderate – 4 to 8 mcg/kg/min –beta one - positive inotrope
High – over 10 mcg/kg/min – alpha – vasoconstriction – potential tissue necrosis
(antidote) Regitine – alpha blocker used to infiltrate tissue if; dopamine infiltrates (to prevent tissue necrosis); Do NOT give IV, rapid onset short duration
Term
Cardiogenic Shock - Management Meds: Dobutamine - dobutrex
Definition
Beta one and weak beta two receptor response
Positive inotrope – mild vasodilation (Increase contractility)
Term
Cardiogenic Shock - Management Meds: Epinephrine
Definition
Alpha and beta effects
Beta receptor effects until high dose then alpha effects;
HR and contractility
Term
Cardiogenic Shock - Management Meds: Norepinephrine - Levophed
Definition
Beta one effects – lower doses
increases HR and contractility resulting in increased CO
As dose increases loses positive inotrope effects and get alpha effects –potential tissue necrosis
Term
Neo-Synephrine – phenylephrine
Definition
Alpha agonist – vasoconstriction

Infiltrate tissue with regitine if medication infiltrates into tissues
Term
Cardiogenic Shock - Management Meds: Vasopressin (pituitary hormone)
Definition
Smooth muscle contraction of arteries and veins - vasoconstriction
Term
Cardiogenic Shock - Management Meds: Vasodilators
Definition
↓ SVR and afterload
Nitroglyerine – Tridil: Dilates veins primarily and arteries (coronary arteries) (when IV infusion) - titrate; May result in tachycardia, hypotension; Headache
Nipride – nitroprusside: Dilates arteries primarily and veins; increases pre and afterload (careful with flushing); Thiocyanide toxicity – nausea, confusion, tinnitus
Calcium channel blockers; ACE inhibitors; Morphine: Dilates – ↓ pre and after load
Term
Cardiogenic Shock - Management: Nonphramacological management
Definition
Intraortic balloon pump – IABP -(Invasive when shock patient is already at risk for sepsis) blocks off major artery; Femoral artery to descending thoracic aorta; Inflates during diastole; Shunts blood to perfuse coronary arteries during diastole; Deflates prior to systole: ↓ in afterload – therefore ↑CO; complications- Limb ischemia; Sepsis; Dislodgement of catheter; External counter pulsation (inflates like BP cuff); ECHMO (extracorporeal membrane oxygenation); Ventricular Assist Devices - LVAD
Term
Obstructive Shock - Impaired diastolic filling
Definition
tamponade
tension pneumothorax
constrictive pericarditis
compression of great vessels
(anything that obstructs blood flow)
Term
Obstructive Shock - ↑ right ventricular afterload
Definition
pulmonary embolism
pulmonary hypertension
↑ intrathoracic pressure
Term
Obstructive Shock - ↑ left ventricular afterload
Definition
aortic dissection
systemic embolization
aortic stenosis
abdominal hypertension
Term
Obstructive Shock - Signs and Symptoms
Definition
↑HR; ↓BP; cool pale skin; ↓urine output;
signs and symptoms specific to each diagnosis
Hemodynamics: CO/CI↓; SVRI↓; PCWP↑; CVP varies with primary pathology;
Management- treat the cause, underlying pathology
Term
Distributive Shock - Neurogenic Shock
Definition
Loss of sympathetic tone resulting in vasodilation – spinal shock; Baro receptor response impaired
Bradycardia – hypotension – hypothermia
Hemodynamics: CO/CI ↓; SVRI↓; PCWP↓; CVP↓;
Management: Treat the cause and the relative hypovolemia with fluids and vasopressors
Term
Distributive Shock - Anaphylactic Shock
Definition
Antigen antibody reaction – ↑capillary permeability – massive vasodilation
Assessment – stridor, wheezes; Hypotension, tachycardia; Rash; Restless and anxious; NVD (nausea, vomiting, diarrhea)
Hemodynamics: CO/CI↓; SVRI↓; PCWP↓; CVP↓
Term
Distributive Shock - Anaphylactic Shock: Management
Definition
Remove the offender; Reverse mediators – epinephrine; ↑tissue perfusion; Intubate, mechanical ventilation
Epinephrine- 0.3 -0.5 mg (0.3-0.5 mL of 1:1000 dilution) IM (not subcutaneous) - repeat every 5-15 minutes
Epinephrine – 0.1 (l mL of 1:1000 dilution) IV over 5 minutes then infuse 1-4 mcg/min titration up to 10 mcg/min
Glucagon – IV 20-30 mcg/kg bolus over 5 minutes then infuse 5-15 mcg/min
Diphenhydramine - Benadryl – 25-50 mg slow IV every 4-8 hours
Positive inotropes and vasoconstrictors
Fluids
Steroids
Term
Septic Shock
Definition
Severe infection; High mortality; Etiology – frequently gram negative; Risks
Phases of Septic Shock (rampant): Hyperdynamic – warm - CO/CI normal or high; SVRI↓; PCWP↓; CVP↓; Respiratory alkalosis and metabolic acidosis
Hypodynamic(inadequate tissue perfusion) – Compensatory: CO/CI↓; SVRI↑; PCWP↑; CVP↑
Term
Septic Shock - Treatment
Definition
Monitor lactate levels; Appropriate cultures; Control infection– antibiotics; Insulin and glucose infusion; Metabolic support – TPN – Insulin; Vasopressors; fluids; Positive inotrope; Mechanical ventilation
Recombinant human activated protein C – drotrecogin alfa (Xigris) – anti-inflammatory, antithrombotic, and profibrinolytic (bleeding risk); Steroids
Term
Shock: Summary – Management of Care
Definition
Functional Blood Volume - Fluids, Fluid Challenge; Respiratory Management - Mechanical Ventilation Modes; Medications; Nutritional Support; Thermoregulation; Psychosocial Support
Term
Patient Undergoing Cardiac Surgery
Definition
Coronary Artery Bypass (CABG)
Minimally Invasive CABG
Transmyocardial Revascularization
Valvular Repairs
Septal Defect Repairs
Ventricular Aneurysm Repairs
Radiofrequency Ablation
Term
Management of the Patient Undergoing Cardiac Surgery
Definition
Purpose - Revascularize the myocardium, repair or replacement of anatomical pathologies
Revascularization - Saphenous vein grafts, internal mammary artery, radial artery, gastric artery
Valve Replacements - Mechanical and tissue valves (porcine)
Minimally Invasive Cardiac Surgeries - Visualization and repair through a scope
Sternotomy Incisions
Term
Cardiopulmonary Bypass (CPB)
Definition
- Mechanical means of oxygenating and circulating blood during surgery.
Cannula in SVC or RA to remove blood from the body to the CPB machine for oxygenation.
Blood is returned through a cannula in the aorta. Cardioplegia (cold, K rich fluid) used
Term
Cardiopulmonary Bypass (CPB) - Effects (1)
Definition
FVD (hypotension)- Third spacing; Diuresis; Vasodilators
Third spacing - Decreased plasma proteins; Increase capillary permeability
Decreased CO(myocardial depression) - Hypothermia; Preexisting cardiac pathology; Increased SVRI
Hemolysis- Pump damage
Hyperglycemia- Decrease insulin release; Glycogenolysis
Term
Cardiopulmonary Bypass (CPB) - Effects (2)
Definition
Bleeding (coagulopathy)- Heparin; Platelet trauma; Hypothermic liver
Hypokalemia/Hyperkalemia - Intracellular shifts/cell damage
Decreased LOC, sensory deficit -Microemboli to brain; Decreased cerebral tissue perfusion
Hypertension- Hypothermia; Catecholamine release
Stroke – Lacunar- Anticoagulated but small clot formations
Term
CPB -Preoperative Care
Definition
Teaching
ICU environment
Postoperative care
Term
CPB -Postoperative Care
Definition
15 minutes = Assessment, VS, CVP, PA pressure, Rhythm, Incision, Dressing, CT drainage, Peripheral pulses, UOP, Heart sounds, Respiratory ( lung sounds, SVO2, airway pressure, VT, RR), Neuro (LOC, movement, strength, follow commands)

Admission and every 8 hours = Complete cardiac profile – CO, CI, SVRI, LVSWI

Report: Drop in CO or down ward trend in CO; Hypo or hypertension; Cessation of CT drainage; Excess CT drainage;
Onset of ST segment and T wave changes;
Muffling of heart tones; Decrease in UOP
Term
CPB -Maintaining CO -- HR
Definition
temporary pacing- epicardial pacing wires; Beta blockers or calcium channel blockers to slow heart rate (110); Monitor serum K – keep in high normal range; Monitor serum Mg

Atrial fibrillation – frequently in day 2-3; Beta blockers decrease the risk of AFib
Term
CPB -Maintaining CO -- Preload
Definition
for many decreased preload is cause of decreased CO; PCWP monitored – tells of left ventricular preload; Administer volume – crystalloid, colloid, and RBC – autotransfuse; Maintain PCWP slightly higher to assure adequate filling pressure
Term
CPB -Maintaining CO -- Afterload
Definition
hypothermia is vasoconstriction – results in higher SVRI; Transient hypertension may result in bleeding from the mediastinal chest tubes; High SVRI can increase myocardial workload;
Treat with vasodilator –to decrease; afterload, control hypertension and improve CO – keep SBP 100-130 - nitroprusside (Nipride) – fenoldopan (Corlopam)
Term
CPB -Maintaining CO -- Contractility
Definition
If CO stays low, may need to enhance contractility: Positive inotropic meds;
IABP
Term
CPB - Bleeding Control
Definition
Inadequate hemostasis, loss of suture integrity, coagulopathy (CPB or hypothermia); Mediastinal chest tube output greater than 150 cc per hour; Administer FFP, fibrinogen, platelets, protamine, blood replacement - Autotransfusion
Term
CPB -Bleeding Control - Cardiac Tamponade
Definition
Blood in the mediastinal space- impairs cardiac filling; Elevated and equalized filling pressures (CVP, PCWP), decreased CO, decreased BP,
JVD, pulsus paradoxus, muffled heart sounds, sudden cessation of chest tube drainage, wide cardiac silhouette on xray
Sternotomy - Return to OR for clot evacuation
Term
CPB -Bleeding Control - Temperature Regulation
Definition
Hypothermia decreases myocardial contractility and increases bleeding risk; Rewarm using warming blanket, Bear Hugger
Term
CPB -Airway Management
Definition
Early extubation – first 4-8 hours post op: May use PEEP to increase intrathoracic pressure to tamponade bleeding in chest (PEEP
may decrease CO)
Anesthesia must start the early extubation plan; Short acting anesthetic agents – propofol (Diprivan) at termination of surgery rather than Narcotics
Use neostigmine at end of surgery to reverse the neuromuscular blockade
Oxygen
Meds for pain
Term
CPB -Neurological Stability
Definition
CPB pump may result in neurological deficits; CVA a potential; Postcardiotomy delirium – mild to agitation, hallucinations, paranoia;
Modify environment – noise-day/night-familiar objects-calm-reorient; Treat with benzodiazepines; Neuro with fast tracking
Term
CPB -Prevent Infection
Definition
Hypothermia immediately post op; Hyperthermia common; Temperature more than 38.3/101 should be investigated; Sternal wound infections – increased risk with IMA; Infective endocarditis; Pneumonia; Leg wound infections; UTI
Term
CPB -Renal Function
Definition
Hemolysis from CPB trauma to RBC may be seen as hemoglobinuria – renal tubule
damage; Small doses of lasix given to keep urine flow if UOP less than 30 cc/hour or pink tinged
Term
CPB -Education
Definition
Valve surgery and antibiotics
Anticoagulation for mechanical valve patients
Term
CPB -Pain Management
Definition
IV Morphine
Term
CPB -Heart Transplant
Definition
Denervated heart and stress and medication response – atropine, epinephrine
Term
History of Emergency Care
Definition
Military statistics show a decrease in trauma deaths beginning in WW1 through Vietnam.
Decrease has been attributed to the emergency response system.
Response system includes assessment, on the scene management, efficient evacuations, transportation, coordination between field and definitive hospital based services.

Department of Health, Education and Welfare, American Heart Association and National Highway Traffic Safety Department set standards for pre hospital care.
Term
Pre hospital triage
Definition
French word for sort into three groups;
Process of deciding the priorities for therapeutic intervention of a given individual or individuals and the place where these interventions should occur

Pre hospital triage: Triage of matching patient illness or injury to appropriate facility for treatment;
Triage at the scene - first responders
Hospital triage for urgency of care need - triage nurse role; Triage for hospital bed assignments
Term
Management of Patients at the Scene
Definition
Delivery of emergency care to the ill or injured at the scene of an emergency and during transport to a receiving facility.
Responsibilities: Assess patient; Relay information to the hospital: Type of injury, Age, General description of injuries; VS; Assess patient further and continuously- Trauma scores; Provide therapeutic interventions- Suctioning, O2, IV, intubation, drugs, etc.; Transport: Ground transport; Life flight; Snowmobile, etc.
Term
Mechanism of Injury
Definition
Blunt trauma, Penetrating trauma (What type and Depth), Blast injury
Term
Emergency Department Care - Primary Survey:
Definition
Airway - Check for obstructions - wheezing, stridor, choking – facial trauma; Patient may sit to open airway; Finger sweep - C spine; Airways
Breathing & Ventilation - Look, listen, feel
Circulation - Carotids - Femoral if neck injury; Chest massage; Control hemorrhage; Shock management
Disability- Glasgow – neurological check; C-spine
Exposure or Environmental Control- Soft tissue injuries, deformities, chemicals (Was the vehicle still driveable);
History of Injury of Illness
Term
Secondary Survey - Two Minute Exam
Definition
General Appearance- LOC; Odors: gas, feces, diabetes
Cardio respiratory- Airway patent; Breathing present (Vent); Circulation present (2 lg bore IVs); Obvious hemorrhage (vasopressins); Thorax and pleural space status(chest x-ray): flail chest, open pneumothorax, tension pneumothorax, massive hemothorax, cardiac tamponade, check for symmetry, fractures, breath sounds (Beck's Triad --> Narrowing pulse pressure, JVD, Muffled heart sounds)
Term
Secondary Survey - Two Minute Exam: Anatomical Assessment(1)
Definition
Head and Neck: if head injuries, also C spine
Scalp- wet or matted hair, lacerations, feel fractures
Ears- blood, CSF, battles sign - Bleeding-basilar fracture,
Nose- blood, CSF, nasal drainage, disrupts, blood brain barrier
Mouth- teeth that obstruct airway
malocclusion that obstructs airway (Keep track of teeth)
lacerations
eyes- PERL
face- lacerations, LaForte fractures
neck- tracheal shift, vein distention, ecchymosis, airway threats
Term
Secondary Survey - Two Minute Exam: Anatomical Assessment(2)
Definition
Chest- symmetry, palpate, crepitation, stability, work opposite side toward self, subcutaneous emphysema, sternal pressure may result in loss of lung integrity, bilateral BS
Abdomen- abdominal wall intactness, obvious bruises, abrasions, distention, guarding, rebound, localized pain
Pelvis- pressure on pubic bone, stress to note stability
Extremities- obvious deformity, wounds, symmetry movement and sensation pulses, color, temperature posturing impounded femur/pelvis fracture
Perineum- blood, ecchymosis, rectal tone (spinal cord injury, bladder stop, rectum release)
Vertebrae- pain, dislocation, movement, sensation; C collar and log roll
Term
Secondary Survey - Two Minute Exam: Concurrent Assessments
Definition
LOC - alert, purposeful/nonpurposeful movement - responsiveness
Complexion - flushed, pale, cyanotic, cherry red (carbon monoxide), jaundice
Posturing
Touch – palpate- warmth, diaphoresis, crepitation
Smell - acetone, alcohol, urine, feces, emesis
Term
Resuscitation Phase
Definition
Initiated at scene and continued in ED;
Airway, Breathing, Circulation
Neurological-AVPU: A- alert; V- responds to verbal stimulation; P- responds to pain; U- unresponsive
Past History AMPLE: Allergies; Medications; Past medical illness/pregnancy; Last meal; Events/environment
Diagnostics: Radiology; Focused assessment with sonography for trauma - Peritoneal lavage; Pneumatic antishock garment; Pericardiocentesis; Fluid Resuscitation; Neurological Resuscitation; Exposure
Term
Critical Care Phase- Thoracic Injuries
Definition
Cardiac Injuries – tamponade (tomorrow/day after), cardiac contusion
Pulmonary Injuries – pneumothorax, hemothorax, rib fractures, flail chest
Abdominal Injuries – liver, spleen, bowel fractures
Musculoskeletal Injuries –fractures, soft tissue injury, crush injuries,
Compartment syndrome, Rhabdomyolysis, Fat emboli, DVT
Acute - Present, Subacute:2-3 days, Chronic: 1-3 months
Term
Critical Care Phase- Thoracic Injuries
Definition
Thermal
Chemical
Electrical
Radiation
Inhalation
Term
Critical Care Phase- Burn Depth
Definition
Superficial – First Degree: Red, painful, rare blisters
Partial Thickness – Second Degree: Moist, mottled red, painful, blisters, blanches
Deep Partial Thickness – Second Degree: Moist, pearly red/white, less painful, blanching diminished
Full Thickness – Third Degree: Dry, leathery, white, red, or black, painless, absent blanching
Term
Critical Care Phase- Body Response
Definition
CV – Decrease intravascular volume – sympathetic response
Skin – Defense mechanism altered or lost: Protection from infection - check orders prior to dressing change
Pulmonary – Vasoconstriction with pulmonary hypertension
Renal – Hypoperfusion – RAA
GI – Vasoconstriction/shunting – Curling’s/stress Ulcer – Ileus(Increase level of cortical steroids, Meds: Protonix)
Metabolic Response – Decrease in organ function followed by hypermetabolic state
Term
Burns (2)
Definition
Ineffective Airway Clearance – Impaired Gas Exchange
Deficient Fluid Volume – Fluid shifting – Fluid Replacement Formulas
Hypothermia –
Ineffective Tissue Perfusion –Escharotomy
Pain
Infection – Open versus closed management – Grafting – Antimicrobials
Risk for Injury: Gastrointestinal Bleeding & Altered Nutrition (hypermetabolic)
Effective/Ineffective Coping
Term
Legal Considerations
Definition
Good Samaritan laws - protect physicians, nurses and other health care providers from liability in ordinary negligence - provided that care was rendered in good faith, based on judgment that the situation constituted an emergency

Duty to treat/right to treatment - laws not universally consistent: “antidumping laws”; consent implied by patient actions; minors/emancipated minors
Reporting and releasing information- confidentiality: mandatory reporting: Department of Health - contagious, public health issues; Police - chain of evidence; Welfare Department – abuse; Coroner
Establishing priorities of care- Triage tag system
Term
Advanced Trauma Life Support- Primary Survey
Definition
Airway - c spine precautions; Breathing; Circulation - hemorrhage control; Disability - neuro ;
A- alert; V- responds to verbal stim; P- responds to pain; U- unresponsive
Glasgow Coma Scale
Exposure/environmental control

Resuscitation Phase- Therapeutic measures; Infection control
Secondary Survey- Allergies; Medications; Past medical illness/pregnancy; Last meal; Events/environment; PR, Education
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