Shared Flashcard Set

Details

Intro to Critcal Care
Week 1 Monday 478
38
Nursing
Undergraduate 4
02/01/2016

Additional Nursing Flashcards

 


 

Cards

Term
What is the most important thing to do as a nurse?
Definition
Assess your patient
Term
What 4 things should be included in the assessment
Definition

1.subjective data-ask patient, listen, ask for help understanding pain, info from patient's family/so's

2.objective data-head to toe, Vitals, EMR trends, lab results and diagnostic tests

3.machinery-assessment the patient first, don't rely fully on machinery,

4.bedside rounding-include patient, family, and friends

Term
neurological assessment
Definition

LOC

orientation to Person, place, time

pupilary reac-pen light

response to painful and verbal stimuli

purposeful movement/reflexive movement

glascow coma scale, delirum scale (CAM), MMSE (dementia)

Intracranial pressure

Term

intracranial pressure monitoring

 

Definition

invasive

SjvO2-O2 concentration in jugular vein

Normal-60-80%

Less than 50%-hypoxia

Term
General criteria for brain death
Definition

varies from states to state

absence of purposful movement

flaccid tone/absence of spontaneous movements

persistent deep coma

no response to pain

absence of brain stem reflexes-pupils fixed and dilated, no corneal, gag or cough reflexes, doll eyes (absence of spontaneous oculo cephalic reflexes)

Isoelectric or flat ECG

Term
Nursing role in organ donation
Definition

identify possible donations early

provide accurate information

work closely with organ procurement agency

respect cultural/religous beliefs

provide emotional support

Term
cardiac assesment
Definition

vital signs-trends

assesment of chest pain (PQRST)

Heart sounds-s3 s4 can be indicative of cardiac overload

peripheral pulses

invasive monitoring-artial line to measure BP, PAP catheter to measure PAP, central venous pressure monitoring

cardiac monitoring-arrythmias

ventricular assistive devices-end stage disease/transplant candidates

 

Term
VTE/DVT prophylaxis
Definition

early ambulation best prevention

difference in treating medical and post op

eval risk for hemorrhagic stroke

med managment options include heparin, lovenox, or fragmin

non pharm options includes teds, weight bearing and amb, no crossing legs when in bed or sitting

Term
respiratory assessment
Definition

assess breath sounds

monitor abgs and pulse oximetry

observe res assessment-breathing effort, skin color, rate, accessory muscles

O2 by cannula, mask, mech ventilation

 narcotics depress RR, monitor closely with PCA pump, have narcan available

Term
pnemonia prevention
Definition

oral care

coughing and deep breathing

T and P 2qh for bed bound

OOB to chair ASAP-even for short interval

suctioning

incentive spirometer

Term
EBP to prevent VAP
Definition

 

uElevate HOB 45 degrees at all times

 

uContinuous Lateral Rotation Therapy or mechanical rotation beds with 40 degree turns

 

uOral Care q 12h & prn: brush teeth & tongue/lip balm/moisture mouth swabs/

 

uPrevent Stress Ulcers: GI Prophyaxis:H2 Blockers

 

uInfection Control: Hand –washing & Gloves & Isolation prn

 

uDrain condensation in vent tubing AWAY from patient

 

uSuction prn (vs scheduled suction??)

 

uProvide “sedation vacations” at least once q 24 hrs.

 

uSlowly decrease sedation dose & frequency

 

uAssess readiness to extubate & extubate ASAP

 

uConsider non-invasive ventilation support: BiPAP & CPAP

 

Term
ABCE-F Bundle
Definition

ABC=awakening and breathing and trial cordination

awakening trials daily, breathing/spontaneous trials, coordination of extubation with respiratory trials

D=delirium, assess and treat early

E=early exercise and ambulation, passive to active ROM, ambulate while intubated

F=family, include and listion

Term
Ventilator/sedation weaning
Definition

medications include sedatives, anxiolytics, analgesics

sedation weaning includes short term sedatives, sedation vacations daily, assess and manage pain, assesment of delirum,

Term
Gi assessment
Definition

IV fluids and correct rate,

abdominal assessment

stool assessment

stress ulcer prophylaxis

feedings can be enteral or parental

if tube feed is late can hang IV dextrose 10% until feed back comes up for day

Term
TPN
Definition

solutions with more than 10% IV dextrose require central line for infusion

TPN is an IV soltions containing 10-50% IV dextrose, amino acids, fatty acids, calories, electrolytes, added trace elements, vitamins, minerals, insulin etc

 

Term
indications for TPN
Definition

NPO for more than 5 days (Crit care, post op major surg)

severe malnutrition

burns

bowel disorders

severe acute pancreatis

acute renal failure

hepatic failure

metastic cancer-very malnourished

Term
nursing management of TPN
Definition

each bag and tubing must be changed q24 hours

Strict I and O required

monitor Blood sugar

monitor serum electrolytes

sterile dressing change to central line site q48-72 hour per facility protocol

hang only 10% dextrose only when solution is unavail (at same rate)

Infuse TPN via pump only!-no catch up in rate, monitor rate hourly

gaps in nutritional guidelines-work with registered dietician

 

Term
GU assessement
Definition

foley catheters common-I & O, need to remove ASAP, prevent UTI's, clinical practice guidelines

Intake-PO, tube feeds, IV lines, tube feeds

Output-urine output, NG secretions, JP or hemovac

monitor fluid and electrolyte balance-skin turgor, electrolytes (K+ critical)

Term
Bun and creatinine
Definition

 

creatinine-A normal result is 0.7 to 1.3 mg/dL for men and 0.6 to 1.1 mg/dL for women. Women usually have a lower creatinine level than men.

 

This is because women usually have less muscle mass than men.

Normal BUN-8-25

 

BUN going up and Creatine staying normal-hypovolemia-dehydrated, not enough volume

 


 

Term
regardless of onset or cause of uncontrolled blood sugar...
Definition
increase hospital stay, increase risk of infection, increase mortality
Term
endocrine assessment/insulin
Definition

know px's most recent blood glucose level

insulin is a high alert drug

Term

nursing care of critical care patients and insulin protocols

 

Definition

freq glucose monitoring

adjust insulin dosages per protocol

hypoglycemia guidelines <70mg/dL

Term
skin assesssment
Definition

critically ill patients are at major risk of skin breakdown

daily head to toe assessment

TP, mattress rotation

skin care

attention to pressure points

wound assessment: wound RN consult

 

uEdema or anasarca (generalized edema with weeping skin)

 

uMany patients sedated, delirious, comatose, unconscious

 

Term
mobility and immobility issues
Definition

all px should be OOB unless contraindicated

t and p imporatant

ROM

ambulate px as ordered, esp post op patients

hazards of immobility-pnemonia, skin breakdown, PE

Term
Pain issues
Definition

verbal and non verbal responses to pain

non verbal responses need to be used for unconscious or intellecutllay disabled

some patients may require referral to pain management specialists

Term
IV Opiod Management for acute pain management
Definition

 

uEBP to keep pain at a level of 3 or below.

 

uAge 12 protocol example

 

uMorphine 1 to 4 mg IV every hour prn pain; comfort-function goal: 1/10 to walk to the playroom and rest adequately

 

uAge 48 protocol example

 

uFentanyl 10 to 40 mcg IV every hour prn pain; comfort-function goal: 3/10 to ambulate and rest adequately

 

uAge 86 protocol example

 

uHydromorphone 0.3 to 0.8 mg IV every 2 hours prn for pain; comfort-function goal: 2/10 to C&DB & ambulate

 

Term
ICU psychosis
Definition

 

uNoisy

 

uFrequent interruptions

 

 

uLights on constantly

 

 

uSleep disturbances : Provide periods of uninterrupted sleep.

 

 

uSleep apnea à continuous pulmonary airway pressure (CPAP) machines

 

uPatients may need to be restrained.

 

Term
Delirium
Definition

acute delusional state

 

uAffects 80% of ICU patients

 

uUndiagnosed & Untreated ( “They’ll clear up when out of ICU”)

 

uEstimated Costs: $ 4 -16 BILLION $$$$$$ annually in US ( 2006) 

 

uIncreased  LOS

 

uIncreased time on ventilators

 

uIncrease Mortality

 

uLong Term Neuro-Psychological  deficits

 

uDelirium is under diagnosed and untreated

 

uDelirium is unreported and understudied

 

uPatients are not satisfied with  their intra/ post-ICU outcomes

 

Term
Think mnemonic for delirium
Definition

 

uT= Toxic Substances/Situations

 

uMedications (Sedatives/Benzos)

 

uDehydration

 

uNew onset Organ Failure ( liver/kidney)

 

uH=Hypoxemia

 

uI= Infection/Sepsis

 

uImmobility

 

uNon=Pharmacologic

 

uSensory deficits ( hearing aid/glasses/noise/sleep deprivation

 

uK+= Electrolyte Imbalances

 

Term
Goal of ABCEF bundle
Definition

improve patient outcomes in post ICU experiences

improve team collab

standardize care process

break the cycle of over sedation and prolonged ventilation

Term

ABCDE bundle includes

 

Definition

spontaneous awakening

spon breathing trial

careful sedation choice

assessment of delirium

early progressive mobility (passive ROM), active ROM, standing to ambulation

Term
Infections
Definition

include MRSA and Cdiff

prevention is key

come from invasive procedures, poor immune system, mult IV lines, and lots of antibiotics

respiratory-require a sputum culture

blood-blood culture

urine-urine culture

monitor WBC and erythrocyte sedimentation rate (ESR)

check patients temp early in shift and prn throughout day

Term
prevention of infections
Definition

handwashing!

universal precautions

sterile tech when indicated

Term
communication
Definition

ther comm

px and family education

writing board

alphabet board

protocol for translators in facility

Term

psychosocial

 

Definition

disturbed body image

patients frequenelty fearful and anxious

disturbed Self esteem

powerlessness

ICU psychosis

spirital distress

coping mechanisms

affects of family

spiritual and cultural concerns

Term
gerontological considerations
Definition

50% of hospitalized patients are greater than 65

alert and oriented?

hearing and eyesight issues

skin, nutrition, and hydration issues

little or no reserves to heal

exacerbation of cognitive impairment in an acute setting

 

Term
moral, ethical and legal issues of person centered care
Definition

DNR, DNI

MOLST/ advanced directives

benefit vs burden

QOL: personal definition

HCP: only when person can't make wishes known

patient advocacy

moral distress

Term
good rules to follow
Definition

 

uCirculation – Airway – Breathing

Cardiac arrest victims are more likely to survive if rescuers take a pause of < 10 sec. in CPR before or after defibrillating the patient(2011

General good rules with a focus on safety (prevention of needle sticks etc..)

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