Term
|
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. |
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|
Term
| Institutional Ethics Committees |
|
Definition
Education
Consultation
Recommendation |
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Term
|
Definition
| interventions that are unlikely to produce any significant benefit for the patient. |
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|
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 |
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Term
| Nursing Process and Legal Issues - Planning |
|
Definition
| Failure to appropriately diagnose |
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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 |
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Term
| Nursing Process and Legal Issues - Evaluation |
|
Definition
| Failure to act as a patient advocate, Failure to act consistently with applicable standards of care |
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Term
| Acute Renal Failure - Def. |
|
Definition
rapid decline or cessation of kidney function
azotemia, elevated creatinine and decreased urine output |
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|
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 |
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|
Term
| Acute Renal Failure - Intrarenal |
|
Definition
direct damage to kidneys
ischemia
nephrotoxic drugs
myoglobin, rhabdomyolysis
glomerulonephritis |
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|
Term
| Acute Renal Failure - Postrenal |
|
Definition
obstruction of urine flow
mechanical obstruction
functional obstruction |
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|
Term
| Acute Renal Failure - Pathology |
|
Definition
| renal blood flow - ischemia - RAA mechanism - vasoconstriction |
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|
Term
| Acute Renal Failure - Phases |
|
Definition
oliguric phase
diuretic phase
convalescent phase |
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Term
| Acute Renal Failure - Assessment |
|
Definition
| decreased urine output, dysuria, cloudy urine, edema, hypertension, lethargy, dehydration etc |
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Term
| Acute Renal Failure - Laboratory Tests |
|
Definition
urine lytes
urine osmolality urinalysis
serum lytes
xrays, ultrasound
angiography |
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|
Term
| Acute Renal Failure - Planning |
|
Definition
correct hemodynamics
diet
dialysis |
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|
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 |
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|
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
|
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 |
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|
Term
|
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 |
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|
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 |
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|
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 |
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|
Term
| AKI Prevention - Nephrotoxins - Aminoglycosides |
|
Definition
Added risks elderly, dehydration
Manage by decreasing the dosage as prevention and intervention when AKI identified |
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|
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 |
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|
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 |
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|
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 |
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|
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 |
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|
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 |
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|
Term
|
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 |
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|
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
|
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
|
|
Term
| Status Asthmaticus - Medical interventions |
|
Definition
sympathomimetics - epinephrine
bronchodilators
steroids
mechanical ventilation |
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|
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
|
Definition
| associated with shock, trauma, hypotension, burns, sepsis, pancreatitis etc. |
|
|
Term
|
Definition
injury with release of vasoactive substances such as kinins and serotonin
autolysis of vascular endothelium
bronchoconstriction
damage to type II pneumocytes |
|
|
Term
|
Definition
mechanical ventilation with PEEP
steroids
oxygen free radical scavengers |
|
|
Term
|
Definition
impaired gas exchange
ineffective airway clearance
anxiety
potential for injury |
|
|
Term
|
Definition
| assess, ABG, hemodynamics, fluid balance, respiratory interventions |
|
|
Term
|
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
|
Definition
| o patient responses to anesthesia are individualized, influenced by medications and patient’s unique metabolic situation. |
|
|
Term
|
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
|
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
|
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
|
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
|
Definition
| frequently relaxation of airway muscles – use jaw thrust |
|
|
Term
|
Definition
| from positive pressure breathing at a set tidal volume and pressure with deep breathing |
|
|
Term
|
Definition
| results in airway obstruction – elevate HOB, administer cool oxygen, aerosolized epinephrine, brochodilators and antihistamines – reintubation may be needed |
|
|
Term
|
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
|
Definition
| obstruction in the lower airways frequently from inflammation - remove the irritant and administer bronchodilators – steroids and epinephrine may be needed |
|
|
Term
|
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
|
|
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
|
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 |
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|
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
|
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 |
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Term
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Definition
| is a slow progressive degeneration of liver cells resulting in decreased liver function and liver failure |
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Term
| Etiology/Pathophysiology of Fulminant Liver Failure |
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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 |
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Term
| Etiology of Chronic Hepatic Failure |
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Definition
| •Cirrhosis •Chronic active hepatitis •Hepatic vein thrombosis |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure Neuro: Hepatic encephalopathy Liver tube Feeding / Lover TPN |
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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 |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Hematologic: Coagulopathy |
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Definition
| decreased production of clotting factors II, V. VII, IX, X (at risk for bleeding) activation of Hageman factor abnormal platelet production and function |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Hematologic: Increased risk of infection |
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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 |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Metabolic: Jaundice |
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Definition
| inability to metabolize bilirubin decreased survival of erythrocytes |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Metabolic: Fetor Hepaticus - (Breath odor) |
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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 |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Metabolic: Cardiovascular |
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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 |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Metabolic: Pulmonary |
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Definition
| intrapulmonary shunting ventilation perfusion mismatch decreased diffusing capacity hypoxemia, clubbing, and cyanosis |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Metabolic: Amino Acid formation |
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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 |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Metabolic: Endocrine |
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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) |
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Term
| Fulminant Hepatic Failure |
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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 |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Assessment - Fulminant (Acute) |
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Definition
headaches, dizziness, jaundice, vomiting, altered mentation
asterixis, fetor hepaticus, small liver, decerebrate posture
hypotension, tachycardia, dysrhythmias, cardiac failure
tachypnea, fever |
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Term
| Chronic Hepatic Failure - Portal Hypertension |
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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 |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Assessment - Chronic |
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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 |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Blood Glucose |
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Definition
fulminant (acute) - hypoglycemia (Doesn't breat down sugars)
chronic - hyperglycemia |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Lytes |
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Definition
| Decreased K (Hi aldosterone - not broken down retain Na+ and H2O), Na, PO4 |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - BUN |
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Definition
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Coagulation |
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Definition
| Increased PTT, PT, Decreased Platelets |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - LFT |
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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 |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Albumin |
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Definition
| Decrease - Protein metabolism altered |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Globulin |
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Definition
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Alpha Fetoproteins |
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Definition
| decreased but increases with liver regeneration in fulminant hepatic failure |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - WBC, Hgb, Hct |
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Definition
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Serum Ammonia |
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Definition
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - ABG |
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Definition
| Decreased PaO2, metabolic acidosis |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Lab Tests - Amylase |
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Definition
| Increased if associated pancreatitis |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Planning |
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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 |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Medications |
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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 |
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Term
| System Changes Related to Fulminant and Chronic Liver Failure - Nursing Diagnoses |
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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 |
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Term
| Patients with Pancreatitis - Definition |
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Definition
acute pancreatic inflammation
isolated event or repeated attacks |
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Term
| Patients with Pancreatitis - Etiology |
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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 |
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Term
| Patients with Pancreatitis - Pathophysiology |
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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 |
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Term
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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 |
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Term
| Risks for Complications - Pancreatitis |
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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 |
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Term
| Assessment - Pancreatitis |
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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 |
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Term
| Laboratory - Pancreatitis |
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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 |
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Term
| Diagnostics - Pancreatitis |
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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 |
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Term
Planning: Supportive care – Pain Management, Fluid Balance, Nutrition
- Pancreatitis |
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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 |
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Term
| Pancreatitis - Planning: Monitor for complication: GI |
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Definition
pseudocysts, abscess, fistula, ascites
intraabdominal hemorrhage
bowel fistula, necrosis, perforation
spleen abscess, infarction, GI varices |
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Term
| Pancreatitis - Planning: Monitor for complication: Respiratory |
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Definition
| Pleural effusion, pneumonitis, ARDS, erodes diaphram |
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Term
| Pancreatitis - Planning: Monitor for complication: CV |
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Definition
| Hypotension, shock, pericardial effusion |
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Term
| Pancreatitis - Planning: Monitor for complication: Metabolic |
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Definition
| Hyperglycemia, hypocalcemia, fat necrosis |
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Term
| Pancreatitis - Medication: |
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Definition
analgesics - demerol
colloids and crystalloids
histamine receptor antagonists
antibiotics
antacids |
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Term
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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 |
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Term
| Pancreatitis - Life Threatening Complications: |
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Definition
hemorrhagic shock
ARDS
DIC
ARF
Septic shock
MODS |
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Term
| Patients with Disseminated Intravascular Coagulation - Definition |
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Definition
| Inappropriate, accelerated, and systemic activation of the coagulation cascade with thromboses and hemorrhage occurring simultaneously |
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Term
| Patients with Disseminated Intravascular Coagulation - Etiology |
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Definition
1. Tissue injury
2. Antigen antibody reactions
3. Neoplasms
4. Infections
5. OB emergencies
6. Profound hypotension |
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Term
| Patients with Disseminated Intravascular Coagulation - Pathophysiology |
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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 |
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Term
| Patients with Disseminated Intravascular Coagulation - Manifestations |
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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. |
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Term
| Patients with Disseminated Intravascular Coagulation - Laboratory Value Changes |
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Definition
PT, PTT prolonged
Platelets decreased
Fibrinogen decreased
FSP/FDP increased
D-dimer increased |
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Term
| Patients with Disseminated Intravascular Coagulation - Treatment |
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Definition
Correct primary disorder
Heparin
Blood component replacement
Recombinant human protein C (anticoagulant) |
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Term
| Patients with Disseminated Intravascular Coagulation - Goals |
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Definition
Replace blood loss
Prevent shock
Replace depleted coagulation factors |
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Term
| Patients with Disseminated Intravascular Coagulation - Nursing Diagnoses |
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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 |
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Term
| Patients with Multiple Organ Dysfunction Syndrome - Definition |
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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 |
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Term
| Patients with Multiple Organ Dysfunction Syndrome - Risk Factors |
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Definition
| sepsis, critically ill, very young or old, impaired immunity, dysfunction of one organ, multiple trauma etc. |
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Term
| Patients with Multiple Organ Dysfunction Syndrome - Metabolic Responses |
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Definition
generalized intracellular and extracellular edema
increased energy expenditure resulting in glycolysis
autocannibalism unresponsive to amino acid administration |
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Term
| Patients with Multiple Organ Dysfunction Syndrome - Pathophysiology |
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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 |
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Term
| Patients with Multiple Organ Dysfunction Syndrome - Assessment |
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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 |
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Term
| Patients with Multiple Organ Dysfunction Syndrome - Laboratory |
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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 |
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Term
| Patients with Multiple Organ Dysfunction Syndrome - Medications |
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Definition
Volume expanders
Inotropic agents
Vasodilators
Antibiotics
Diuretics
Steroids
Antioxidants
Arachidonic acid metabolite modulators
Protease inhibitors
Recombinant activated protein C (Xigris) |
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Term
| Patients with Multiple Organ Dysfunction Syndrome - Nursing Diagnoses |
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Definition
Altered tissue perfusion
High risk for infection
Altered nutrition
Tissue integrity impaired
Fluid volume deficit |
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Term
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Definition
Cadaver organ transplants – 1960’s
Need for organs exceeds the available organs
Immune manipulation has advanced significantly resulting in improved success |
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Term
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Definition
Firbrous Split Products - Breakdown Clots
FDP - Fibrous degredation Products - Risk for DIC: Burns, Transfusion, Shock |
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Term
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Definition
Decisions to Donate
Brain Death - Criteria |
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Term
| Regulations Relating to Organ Donation |
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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 |
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Term
| Organ and Tissue Donation |
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Definition
Conditions of Participation – 1998 and 2003
Consent to Donate
Death Investigation Systems
Donor Families
Donor Designation
Cardiac Death Donors
Communicating with Donor Families |
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Term
| Organ and Tissue Donation Process - Determination of Brain Death |
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Definition
Cerebral Motor Responses
Pain Responses
Apnea Test – Motor Responses |
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Term
| Organ and Tissue Donation Process - Brainstem Reflexes |
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Definition
Pupillary Activity
Ocular Movement
Corneal and Jaw Reflexes
Gag Reflex |
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Term
| Organ and Tissue Donation Process - Apnea Tests |
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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. |
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Term
| Organ and Tissue Donation Process - Cerebral Perfusion Studies |
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Definition
Cerebral angiography
Electroencephalography
Transcrainal Doppler sonography
Somatosensory and brainsteam auditory envoked potential testing.
Technetium Tc 99m brain scan.
MRI |
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Term
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Definition
Blood Pressure
Glucose
Temperature
RBC and Coagulation
F & E – Polyuria
Acid Base
Mechanical Ventilation |
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Term
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Definition
Surgical Preparation
Care in the Critical Care Unit
Transport to Surgery |
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Term
| Transplant Success and Rejection |
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Definition
Graft Rejection
Immunosuppressive Therapy: Corticosteroids, Cyclosporine, Tacrolimus (Prograft), Azathioprine (Imuran), Mycophenolatemofetil (Cell-Cept), Sirolimus (Rapamycin) |
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Term
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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 |
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Term
| Heart Lung Tansplantation |
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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 |
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Term
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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 |
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Term
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Definition
ESRD and Transplantation
Living and Cadaver Donors
Postoperative Care - Fluid management
Rejection Surveillance |
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Term
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Definition
Diabetes Mellitus – ESRD
Surgical blood flow and exocrine flow
Rejection Surveillance |
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Term
| Midwest Transplant Network |
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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 |
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Term
| Coronary Artery Disease – Acute Coronary Syndrome |
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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 |
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Term
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Definition
| Ischemia of cardiac Muscle |
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Term
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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 |
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Term
| Myocardial Infarction - MI |
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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 |
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Term
| Assessment of Myocardial Pain – Male vs Female |
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Definition
| PQRST – palliatives or provocation, quality, radiation and region, severity, time (length of) and treatment |
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Term
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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 |
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Term
| Diagnostic Testing - Cardiac |
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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 |
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Term
| EKG Changes of Myocardial Ischemia/Injury/Infarction |
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Definition
Areas (zones) involved:
Ischemia - Decreased tissue perfusion
Injury – recoverable cells
Infarction – death of cells |
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Term
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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 |
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Term
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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 |
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Term
| Systems Assessment (selected) |
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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 |
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Term
|
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) |
|
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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 |
|
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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 |
|
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Term
| Medical Interventions- Monitor |
|
Definition
(post procedure): EKG normalization; Reperfusion dysrhythmias – VT and AV block; Allergies; Bleeding; Hypotension;
Reocclusion - Chest Pain - management |
|
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Term
| Medical Interventions - Complications |
|
Definition
|
|
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 |
|
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Term
| Medical Interventions - Medications |
|
Definition
Oxygen: O2
Lipid Reducing Medications: (normally –statin, there are others) |
|
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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) |
|
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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
|
|
Term
| Medical Interventions – Medications: Antithrombotics |
|
Definition
|
|
Term
| Medical Interventions – Medications: Glycoprotein IIb/IIIa Inhibitors |
|
Definition
Abciximab (RePro)
Tirofiban (Aggrastat)
Eptifibatide (Integrillin) |
|
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Term
| Medical Interventions – Medications: Beta blockers |
|
Definition
Tenormin (Atenolol)
Lopressor (Metoprolol)
Propanolol (Inderol)
(Reduce mycocardial O2 demand, makes muscles sluggish) |
|
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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
|
Definition
Acute chest pain
Risk for decreased CO
Fear
Risk for activity intolerance
Knowledge deficit |
|
|
Term
|
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
|
Definition
Cardiac assessments
BNP – B natriuretic peptide
LFT - Liver Function Test - Dilated liver - hepatomegly - O2
EKG |
|
|
Term
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
Definition
Teaching
ICU environment
Postoperative care |
|
|
Term
|
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
|
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
|
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
|
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
|
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
|
Definition
Valve surgery and antibiotics
Anticoagulation for mechanical valve patients |
|
|
Term
|
Definition
|
|
Term
|
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
|
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
|
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
|
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
|
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 |
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Term
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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 |
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Term
| Advanced Trauma Life Support- Primary Survey |
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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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