NUR 203 Final Review - WordPress.com 203 Final Review Page 2 of 65 Module C Improving Cerebral...
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Page 2 of 65
Module C
Improving Cerebral Perfusion
Monitoring for Increased ICP
Cushing’s Triad – widening pulse pressure, bradycardia, irregular respirations (possible
Cheynne Stokes),
Other Signs - blown pupils or constricted and nonreactive, abnormal posturing, severe
HTN, behavior changes, ALOC, aphasia, slurred speech, ataxia
Meds & Pt. Education
o Mannitol = Osmotic Diuretic – monitor for severe dehydration = I/O, BP,
sunken eyes, skin turgor
o Barbiturates (end in barbital) = Medically Induced Coma = trach vent,
monitor Hemo, monitor swan cath.
Decadron = ↓ edema = ↑ BS, H2O retention, immune compromise
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TBI & ICP
Early Signs Late Signs
Pinpoint Pupils
↑ BP, ↓ HR
Ataxia, Uneven Gait
GCS > 8 +
Rapid, Deep Breathing
Big Blown Pupils
↓ HR, BP 180/40 = Widening Pulse
Pressure – Cushing’s Triad
Decerebrate/Decorticate
GCS < 8
Slow Breathing
Normal ICP = 10 – 15
Herniation: shifting of brain tissue d/t ↑ ICP (Central = down pressure
centrally w/pinpoint pupils; UNCAL = Bilateral w/dilated pupils & fixed)
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Posturing
“Hold the Cat” (CAT in DecortiCATe ~ Flexion)
“Drop the Rat” (RAT in DecerebRATe ~ Extension)
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Glasgow Coma Scale
in GCS – Tell M.D. in 1st 48° if ↑ or
↓; After 1st 48° = call if ↓
GCS ↓ 8 = E Tube
Positioning = Neutral, Log Roll, No
Flex
↑ CO2 = ICP ↑ 40 (4.5) – Keep
Alkaline
Cluster Care w/ADL’s, etc.; Do not
cluster Neuro Checks
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Cranial Nerves
On Old Olympus Towering Tops A Fin And German Viewed Some Hops
1 Nose = Olfactory
2 Eyes = Optic
3, 4, 6 = Make my eyes do tricks: Oculomotor, Trochlear,
Abducens
5 Tri = Trigeminal
7 Fits on Face = Facial
8 Fits in Ear = Acoustic
9, 10 Under My Chin = Glossopharyngeal, Vagus
11 Fits on Shoulders = Spinal Accessory
12 Tongue Movement = Hypoglossal
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ICP & SI ADH and DI
SI ADH (Kidneys Locked) DI (No Lock on Kidneys)
↑ADH, ↑ H2O, ↑ ICP = ↑ Dilution,
↓ Na+; Kidneys keep H2O in and
do not let H2O out.
3% Na+ IV, ALOC, ↓ Deep Tendon
Reflexes, ↑ HR, N/V, H/A, Give
Declomycin, Diuretics
↓ ADH, ↑ Output, Renal Failure =
Dehydration, Excessive Thirst,
Weakness, Give Pitressin
ICP & Shock Have Opposite V/S
ICP = ↑ BP, ↓ Pulse, ↓ Resp
Shock = ↓ BP, ↑ Pulse, ↑ Resp
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P.P. ↓ SI ADH P.P. ↓ P.P. ↑ DI ADH P.P. ↑
↑ ADH → PP ↓ (PP to body, not in
potty)
Hemodilution d/t ↑ H20 in body
Causes: Head Trauma, CV Disease,
TB, Cancer
S/S: **Fluid Overload**, ↓ urine, ↑
H2O, Bounding Pulse, ↑ BP, ↓ HR,
JVD, H/A, N/V, ↑ Wt., ↓ appetite, in
LOC, Fatigue, Hypothermia, Dark
Urine
Labs: ↓ Na+ (Hyponatremia), ↑ Urine
Osmo, ↑ Urine SG = ≥ 1.03
Interventions: ↓ Fluids, Replace Na+,
3% NaCl, ↓ Noise & Light; Drugs:
Declomycin, Vasopressin Antagonist
→ Samsca, Vaprisol
Monitor for: Pulmonary Edema,
Neuro
↓ ADH → PP ↑ (PP to potty, not in body)
Hemoconcentration d/t ↓ H2O in body
Classifications: --Nephrogenic: inherited,
↓ kidney response, Primary:
hypothalamus & Pituitary Deficiency,
Secondary: other disease, Tumor, Drug
Related→Lithium & Declomycin
S/S: ↑ HR, ↓ BP, ↓ pulse pressure, ↑ Urine
(Polyuria) ≥ 4 L & ≥ than intake, ↑ thirst
(Polydipsia), ↑ hunger (Polyphagia), weak
& thready pulse, poor skin turgor d/t
dehydration, syncope (dizziness), Hypovolemia
Labs: ↓ Urine SG = ≤ 1.005, ↓ Urine
Osmo, ↑ Na+
Interventions: Strict I/O, Restrict Fluids,
SG, Wt. q d, Med. Alert bracelet; Drugs:
Diabinese, DDAVP (Desmopressin) → ↓
fluids, sit ↑, Test: Hypertonic Saline test
(24 hr.) Urine Collection → Circadian
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Strokes
Left Hemisphere Stroke Right Hemisphere Stroke
Previously learned motor skills
(Apraxia), problems following
directions
Sensation, vision proprioception
Hemiparesis – weakness on one side of the body; Hemiplegia – paralysis
on one side of body; Aphasia: Expressive (motor/Broca) – difficulty
making thoughts known to others, speaking and writing most affected;
Receptive (sensory or Wernicke) – difficulty understanding what others
are trying to communicate; interpretation of speech and reading is most
affected; Global – affects both expression and reception
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Types of Strokes
Thrombotic Embolic Hemorrhagic
Cause: CLOT
Cause: Emboli from another area in
body; Atrial Fibrillation, Ischemic Heart Disease, Rheumatic Fever,
MI, Prosthetic valve, MCA is most
common site
Bleeding into brain tissue
or spaces around brain
Cause: ruptured aneurysm
Ischemic Stroke – caused by occlusion (blockage) of a cerebral artery by
either a thrombus or an embolus
Ischemic Hemorrhagic
Thrombotic
Embolic
Aneurysm
HTN
Arteriovenous Malformation
.
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Unilateral Body Neglect
Most common in clients w/right cerebral stroke
Inability to recognize physical impairment or lack of
proprioception
Teach to touch and use both sides of body
Dress affected side first
With hemianopsia, turn head from side to side
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Parts of the Brain
Frontal Lobe – controls contraction of skeletal muscles and
synchronization of muscular movements; influences abstract thinking,
sense of humor, & uniqueness of personality, inhibitions
Parietal Lobe (Proprioception problems)– translates nerve impulses
into sensations (touch, temperature); interpret sensations; provides
appreciation of size, shape, texture, and weight; interprets sense of taste
Temporal Lobe – translate nerve impulses into sensations of sound and
interpret sounds (Wernicke’s area); interpret sense of smell; control
behavior patterns.
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Spinal Shock Symptoms
Flaccid paralysis, loss of reflex below area of injury, bradycardia, paralytic ileus,
urinary retention, hypotension, may last few days to several mos.
Spinal Cord Injury
Patho
C-4: controls Respiratory
T-1: controls Paralization
↓ L1 – L2 = Flaccid “Dilated” Bladder
↑ L1 – L2 = Spastic “Constricted” Bladder
Assessment – Motor Senses
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Module B
Primary Prevention of Lung Cancer – stop smoking, wear
special masks and protective clothing to reduce exposure, reduce
exposure to 2nd
hand smoke and chemicals.
Secondary Prevention of Lung Cancer – early detection, screen
people at risk for lung cancer using annual CT scans can detect
cancers at stage I.
Pleurodesis - A procedure that causes the membranes around the
lungs to stick together and prevents the buildup of fluid in the
space between the membranes (pleural space). Pleurodesis is done
in cases of severe recurrent pleural effusions (outpourings of fluid
around the lungs) to prevent the reaccumulation of the fluid.
During pleurodesis, an irritant is instilled inside the pleural space
in order to create inflammation that tacks the two pleura together.
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This procedure thereby permanently obliterates the space between
the pleura and prevents the reaccumulation of fluid.
Thoracentesis – fluid removeal by suction after the placement of a
large needle or catheter into the intrapleural space.
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Miscellaneous Pressures
RAP = 1-8
PAP = 15-26/5-15
PAWP = 4-12
CVP = 5-10
CO = 4-6
CI = 2.7-3.2
SvO2 = 60%-80%
PEEP – keeps alveoli open, ↓ C.O., PIP – ARDS, ↑ PIP, FiO2 – 21% - 100%
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Mechanical Ventilation
Types Modes Settings Interventions Weaning Pressure-cycled –
Push air into the
lungs until a preset airway pressure is
reached.
Time-cycled – Push air into the
lungs until a preset
time has elapsed. Volume-cycled –
push air into the
lungs until a preset volume is
delivered.
Microprocessors – are computer-
managed positive-
pressure ventilators
AC (Assist
control) – used
often as a resting mode. Vent takes
over work of
breathing for the patient. Does not
allow spontaneous
breathing.
SIMV
(Synchronized
intermittent
mandatory
ventilation) – If
patient does not breathe, a vent
pattern is
established by ventilator. Does
allow spontaneous breathing.
Weaning.
Tidal Volume
(VT) – volume of
air received w/each breath.
Average setting =
7 – 10 mL/kg of body wt. Adding 0
to wt. in kg is
estimate. Rate - # of breaths
per minute usually
10 – 14. FiO2 – O2
(humidify &
warm) delivered to pt. based on
ABG’s: 21% -
100%. PIP – pressure
used by ventilator to deliver a set
tidal volume at a
Mouth care q 8
hrs.; Strict oral
care q 2 hours; Monitor VS q 30
min to 1 hr at 1st.
Synchronous
Intermittent
Mandatory Ventilation; T-
Piece Technique;
Pressure Support Ventilation
Monitor VS after
extubation q 5 min. at 1st, and and
assess the
ventilator pattern for manifestations
of respiratory
distress. Sit in semi-fowler’s
position, take deep
breaths q half-hour, incentive
spirometer q 2 hrs., limit speaking.
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BiPAP –
noninvasive pressure support
ventilation by
nasal mask or face mask.
given lung
compliance. CPAP – applies
positive airway
pressure during the entire respiratory
cycle for
spontaneously
breathing pts. 0
vent breaths given
PEEP – Positive pressure exerted
during expiration.
Flow Rate – How fast each breath is
delivered and is
usually set to 40 L/min.
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High-Pressure Alarm
Sounds when peak inspiratory pressure (PIP) reaches the set alarm limit (usually set 10-
20 mm Hg above the patient’s baseline PIP)
An ↑ amount of secretions or a mucus plug is in
the airways Suction as needed.
The patient coughs, gags, or bites on the oral
ET tube Insert oral airway to prevent biting the ET tube
The patient is anxious or fights the ventilator
Provide emotional support to ↓ anxiety; ↑ the
flow rate; Explain all procedures; sedation or
paralyzing agent per the physician’s
prescription.
Airway size ↓ related to wheezing or
bronchospasm Auscultate breath sounds
Pneumothorax occurs
Alert the physician or rapid response team for
management of bronchospasm; Auscultate
breath sounds; Alert the physician or Rapid
Response Team about a new onset of ↓ breath
sounds or unequal chest excursion, which may
be d/t pneumo
Artificial airway is displaced; the ET tube may
have slipped into the right mainstem bronchus
Assess the chest for unequal breath sounds and
chest excursion; Obtain a CXR as ordered to
evaluate the position of the ET tube; After the
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proper postion is verified, tape the tube securely
in place
Obstruction in tubing occurs because the patient
is lying on the tubing or there is water or a kink
in the tubing
Assess the system, moving from the artificial
airway toward the ventilator
There is ↑ PIP associated w/deliverance of a
sight
Empty water from the ventilator tubing, and
remove any kinks; Coordinate w/respiratory
therapist or physician to adjust the pressure
alarm.
↓ compliance of the lung is noted; a trend of
gradually ↑’ing PIP is noted over several hours
or a day
Evaluate the reasons for the ↓ compliance of the
lungs; ↑ PIP occurs in ARDS, pneumonia, or
any worsening of pulmonary disease
Remember – HOLD: High Alarm = Obstruction d/t ↑ secretions, kink, pt. coughs, gag or bites;
Low Alarm = Disconnection or leak in vent. Or in pt. airway cuff, pt. stops spontaneous breathing.
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Low-Pressure Alarm
Low exhaled volume (Low-Pressure Alarm) sounds when there is a
disconnection or leak in the ventilator circuit or a leak in the patient’s artificial
airway cuff
A leak in the ventilator circuit prevents
breath from being delivered
Assess all connections and all ventilator
tubings for disconnection
The patient stops spontaneous breathing in
the SIMV or CPAP mode or on pressure
support ventilation
Evaluate the patient’s tolerance of the
mode
A cuff leak occurs in the ET or
tracheostomy tube
Evaluate the patient for a cuff leak. A cuff
leak is suspected when the patient can talk
(air escapes from the mouth) or when the
pilot balloon on the artificial airway is flat
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ABG Disorders
Respiratory Acidosis Respiratory Alkalosis
pH less than 7.35 and a PaCO2
greater than 45 mm Hg; caused by
any condition that results in
hypoventilation – sleeping, COPD
pH greater than 7.45 and a PaCO2
less than 35 mm Hg; caused by an
condition that causes
hyperventilation – Anxiety, Renal
Failure; Early PE
Metabolic Acidosis (ass/diarrhea) Metabolic Alkalosis (↑ pee/vomit)
pH of less than 7.35 and a
bicarbonate level of less than 22
mEq/L; caused by either a deficit of
base in the blood stream or an
excess of acids, other than CO2,
Diarrhea, Shock, Sepsis
pH greater than 7.45 and
bicarbonate greater than 26 mEq/L;
caused by an excess of base or a
loss of acid within the body; Tums,
Vomit, ↑ Pee
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ABG’s
ROME
Respiratory Opposite
Metabolic Equal
PH Normal = Fully
Compensated
All Values Abnormal =
Partially Compensated
Marching Band Suit
*Match PH w/Resp. or Metab.*
A B
PH 7.35 ———————— 7.45
B A
PcO2 35————————— 45 Resp
A B
HcO3 22————————— 26 Metab.
Remember: ROME; Full Comp. = 1 NL; Partial Comp. = All Abnormal; Do Allen’s Test 1st
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Common Conversions
1 tsp = 5 mL
1 Tbsp = 3 tsp or 15 mL
1 oz = 30 mL
8 oz = 1 cup or 240 mL
1 pint = 1 lb or 16 oz
1 kg = 1000 g
1 g = 1000 mg
1 mg = 1000 mcg
1 L = 1000 mL
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Labs Normal Labs Normal
Na+ (Sodium) 135-145 K+ 3.5-5.0
Cl+ 98-106 Ca+ 9.0-10.5
Albumin (Liver) 3.5-5.0 Crea (Kidney) 0.7-1.3
BUN (Kidney) 8-25 Glucose 70-110
WBC 5,000-10,000 RBC (M)4.7-6.1 (F)4.2-5.4
Hgb (M)14-18(F)12-16 Hct (M)42-52(F)37-47
PLTS (ASA)
150,000-400,000
(↑Clot; ↓Bleed) Mag 1.6-2.6
PT (Heparin) 11-15 PTT (Heparin) 30-60
INR (Coumadin) 0.9-1.2 ALT (Liver) (M)10-40(F)7-35
ALT (Liver) (M)10-40(F)7-35 AST (Liver) 12-31
SG (Kidney)
1.005-1.03
(SIADH↑;DI↓) Amylase 25-151
Ammonia 10-80 T3 70-205
T4 4-12 TSH 0.3-5 (Hypo↑;Hyper↓)
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Platelets
Platelets = 150,000 – 400,000
Platelets ↑ = Clot
Platelets ↓ = Bleed
PT used for Heparin
H/H = 1/3 ratio = HgB: 15
HCT: 45
.
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Module E
Bioterrorism Module – Look at Certificate questions we had to do.
Hypothermia
Patho: Core body temperature ↓ 95° F, or 35° C. An environmental
temperature below 82° F or 28° C can produce hypothermia in any
susceptible person.
S/S:
Three Categories Include (IMPORTANT):
o Mild – shivering, dysarthria (slurred speech), muscular
incoordination, impaired cognitive abilities (mental
slowness), and cold diuresis.
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o Moderate – Coagulopathy (abnormal clotting) or cardiac
failure can occur. Muscle weakness, acute confusion,
apathy, incoherence, possible stupor, decreased clotting
o Severe – bradycardia, severe hypotension, decreased
respiratory rate, cardiac dysrhythmias, including possible
ventricular fibrillation, or asystole, decreased neurologic
reflexes, decreased pain responsiveness, acid-base
imbalance.
Treatment: Priority is warming; avoid alcohol. Core (trunk 1st) rewarming
methods for moderate hypothermia include administration of warm IV heated
fluids, heated O2, or inspired gas, heated peritoneal, pleural, gastric, or bladder
lavage. The patient who is severely hypothermic is at high risk of cardiac arrest.
TOC is extracorporeal rewarming methods such as cardiopulmonary bypass,
hemodialysis, or continuous arteriovenous rewarming. General Management for
moderate and severe: protect patients from further heat loss and handle them
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gently to prevent ventricular fibrillation; position in supine position to prevent
orthostatic changes in blood pressure from cardiovascular instability; follow
standard resuscitation efforts
Mass-Casualty Triage
Process: Rapidly sort ill or injured patients into priority categories based on their acuity
and survival potential.
Triage Method:
Class
Tag
Color Type of Injury
Class I – Emergent Red
Immediate threat to life, occluded
airway, active bleeding,
hemothorax, tension pneumothorax,
unstable chest and abdominal
wounds, incomplete amputations,
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OPEN Fx’s of long bones, and
2nd
/3rd
degree burn with 15%-40%
of total body surface
Class II – Urgent, but
can wait short time Yellow
Major injuries that need treatment
within 30 min to 2 hours, Stable
abd. wounds without evidence of
hemorrhage, Fx requiring open
reduction, debridement, external
fixation, most eye and CNS injuries
Class III – Non-urgent
or “walking wounded” Green
Minor injuries that can be managed
in a delayed fashion, generally more
than 2 hours, upper extremity FX,
minor burns, sprains, sm.
lacerations, behavior disorders
Class IV – Expectant Black
Patients who are expected to die or
are dead, unresponsive, spinal cord
injuries, wounds w/anatomical
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organs, 2nd
/3rd
degree burn w/60%
of BSA, Seizures, profound shock
w/multiple injuries, no pulse, BP,
pupils fixed or dilated
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Hospital Emergency Preparedness Personnel Roles and
Responsibilities
Hospital Incident Command System – roles are formally structured
under the hospital or long-term care facility incident commander with
clear lines of authority and accountability for specific resources.
Personnel Role Personnel Function
Hospital Incident Commander
Physician or administrator who assumes overall
leadership for implementing the emergency plan
Medical Command Physician
Physician who decides the #, acuity, and
resource needs of patients
Triage Officer
Physician or nurse who rapidly evaluates each
patient to determine priorities for treatment
Community Relations or Public
Information Officer
Person who serves as a liaison between the
health care facility and the media
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Event Resolution and Debriefing
When the last major casualties have been treated and no more are expected to arrive, the
incident commander considers “standing down” or deactivating the emergency response
plan.
A vital consideration in event resolution is staff and supply availability to meet ongoing
operational needs.
Severe shortages of supplies and the need to clean and restock the ED may pose a threat
to normal operations at the conclusion of an incident.
Two Types of Debriefing Occur following a Mass Casualty event or period:
o CISD or CISM – addresses pre-crisis through post-crisis interventions for
small to large groups, including communities. The team leader typically has
background in a mental health/behavioral health field. Prevent PTSD
o Administrative Review – directed at analyzing the hospital or agency response
to an event soon afterwards. The goal is to evaluate the implementation of the
emergency preparedness plan so that changes can be made. Representatives
come together for discussion.
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Resuscitation fluid formulas are a guide, fluid rate should be
adjusted to patient response determined by hourly urine output.
Goal is 0.5ml/kg urine output.
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Type of Burn Minor Moderate Major
Criteria
Deep partial-thickness
↓ 15% TBSA; Full-
thickness burns ↓ 2%
TBSA; No burns of
eyes, ears, face, hands,
feet, or perineum; No
electrical burns; No
inhalation injury;
Younger than 60 w/no
chronic cardiac,
pulmonary, or
endocrine disorder
Deep partial-thickness
15%-25% TBSA;
Full-thickness burns
2%-10% TBSA; No
burns to eyes, ears,
face, hands, feet, or
perineum; No
electrical burns; No
inhalation injury; ↓ 60
w/no chronic cardiac,
pulmonary, or
endocrine disorder
Partial-thickness burns
↑ 25% TBSA; Full-
thickness burns ↑
10%; Any burn
involving the eyes,
ears, face, hands, feet,
perineum; Electrical
or Inhalation injury; ↑
60; Burn complicated
w/other injuries; Has
cardiac, pulmonary, or
other chronic issue
Disposition Outpatient
Special Hospital
Admissions or Burn
Center
Burn Center Referral
ASAP
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Degree of Burn Depth/Color of Burn Characteristics
Superficial (1st Degree) Epidermis; Pink/Red
NO Blisters or raw areas; Can be painful;
Desquamation (peeling)
of dead skin in 2-3 days; EX: Sunburn
Partial (2nd Degree) Superficial Deep Superficial Deep
Superficial Deep
Epidermis/Partial
dermis; Pink/Red
Epidermis/Deep
Dermis; Red/White
Min.
edema;
YES Blister;
PAIN;
heals 10-21 days;
Blanch;
NO Scar; EX: Brief
Hot
Mod.
Edema;
NO blister; ↓ PAIN;
heals 3-6
wks.; Slow/NO
Blanch;
YES Scar; EX: Long
Hot
Full (3rd Degree)
Epidermis, Dermis, SC Tissue, Nerves; White, Brown, Deep Red, Yellow, Leathery, Black,
Charred, Eschar
Skin does NOT regrow;
NO edema; May/May not have PAIN; EX: Fire, Tar,
Grease, Electric, Chemica
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Dressing the Burn Wound
Standard wound dressings
Biologic dressings – temp. wound cover and closure. Expensive.
o Homograft – Human skin
o Heterograft – Skin from other species (PIG)
o Cultured skin
o Artificial skin
Biosynthetic dressings
Synthetic dressings
Topical medications and medicated dressings
o Chart 28-5
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Module D
Types of Shock
Hypovolemic shock – when too little circulating blood vol. (hemorrhage)causes a MAP
↓ → ↓ O2
Cardiogenic shock –when the actual heart muscle is unhealthy & pumping is impaired,
usually after MI
Distributive shock – blood vol. not lost; distribute to interstitial tissues/cannot deliver
O2
o Neural induced
o Chemical induced
Anaphylaxis
Sepsis
Capillary leak syndrome
Obstructive shock – caused by problems that impair ability heart muscle to pump effectively
Anaphylactic shock – allergic reaction
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Stages of Shock
Initial
(Early)
Nonprogressive
(Compensatory)
Progressive
(Intermediate)
Refractory
(Irreversible) MODS
Early shock;
baseline MAP is ↓
by less than 10 mm
Hg;
Lactic acid will
cause compensation of
sympathetic
system; vasoconstriction
and increased heart
rate;
Symptoms are so
mild it is hard to detect shock
MAP ↓ 10 to 15
mm Hg from
baseline
Kidney and
baroreceptors
trigger release of renin, ADH,
aldosterone, epi
and norepi Tissue hypoxia in
nonvital organs and
in kidney, it is not
↑ enough to cause
permanent damage Mild acidosis and
hyperkalemia; ↑
HR/R/T
Sustained decrease
in MAP of more
than 20 mm Hg
from baseline
Compensatory
mechanisms are functioning but no
longer deliver
sufficient oxygen, even to vital organs
Overall metabolism
is anaerobic:
moderate acidosis
and hyperkalemia; tissue ischemia
Life threatening
emergency; Cold
Severe tissue
hypoxia with
ischemia and
necrosis
Release of
myocardial depressant factor
from the pancreas
Buildup of toxic metabolites
MODS
Death
SIRS
Sequence of cell
damage caused by
the massive release
of toxic
metabolites and
enzymes Metabolites trigger
small clots to form
Occurs first in the liver, heart, brain,
and kidney
Damage to the
heart muscle is
severe (one cause is the release of
MDF from
ischemic pancreas)
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Other Shock Stuff
↑ Creat, ↑ BUN = Renal Failure
↓ Urine Output
↓ O2
↑ CRP, ↑ BNP
Tests: Blood Cultures, Lactase, ABG
Key Features: Teach pt. to watch after d/c, could occur after d/c
Respiratory Neuro Integumentary Kidney ↑ respiratory rate
Shallow depth of
respirations
↑ Paco2; ↓ PaO2
Cyanosis, especially
around lips & nail beds
Anxiety
Restlessness
↑ Thirst
Feeling of
impending doom
Cool to cold
Pale to mottled to
cyanotic
Moist, Clammy
Mouth dry; pastelike
coating present
↓ urine output
↑ specific gravity
Sugar & acetone
present in urine
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Shock Key Features Continued
Cardio GI Late ↓ CO
↑ Pulse Rate
Thready pulse
↓ BP
Narrowed Pulse Pressure
Postural Hypotension
Low CVP
Flat neck & hand veins
in dependent positions
Slow Cap Refill in nail
beds
Diminished peripheral
pulses
↓ Motility
Diminished or absent
bowel sounds
N & V
Constipation
↓ central nervous
system activity
(lethargy to coma)
Generalized muscle
weakness
Diminished or absent
deep tendon reflexes
Sluggish pupillary
response to light
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Module A
Pressures
Right Atrial
Pressure
Pulmonary
Artery Pressure
Pulmonary Artery Wedge
Pressure (PAWP) or Pulmonary
Artery Occlusive Pressure
(PAOP)
Central Venous
Pressure
Normal: 1 to
8 mm Hg
Increased:
right
ventricular
failure
Decreased:
hypovolemia
15 to 26 mm of Hg
systolic/5 to 15 mm Hg diastolic (mean of
15)
Constantly seen on
the monitor
Increased:
hypertension, pulmonary edema
Decreased:
dehydration, diuretics
Balloon inflated, becomes wedged in
branch of pulm. artery Tip of wedged cath. senses pressures
from L atrium which reflect L vent.
end-diastolic pressure
Normal: 4-12 mm Hg
Increased: L vent. failure,
hypervolemia, mitral regurgitation, cardiac shunt
Decreased: hypovolemia, afterload
reduction
Pressure within the
superior vena cava
Reflects the pressure
under which blood is
returned to the heart
Normal: 5-10cm H20
Increased: overload
(heart failure)
Decreased: reduce
blood volume
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Tetrology of Fallot
(+Lesions w/Decreased Pulmonary Blood Flow)
Patho
Altered
Hemodynamics Manifestations
Therapeutic
Management
5% - 10% of
congenital
cardiac defects;
most frequently
seen cyanotic
lesion;
constellation of
lesions results
from
malalignment of
ventricular
septum during
Equal right and
left sided
ventricular
pressures r/t
pulmonary
artery
obstruction and
size of VSD,
desaturated
blood enters the
systemic system
by shunting
Onset and
severity of s/s
are r/t extent of
obstructed
pulmonary
blood flow,
which causes the
right to left
shunting; if
lesions are mild,
shunting is ↓ and
saturations are
PGE
(Prostaglandin),
infusion to
maintain
patency of
ductus arteriosus
and blood flow
to lungs,
management of
hypercyanotic
episodes, TX of
iron deficiency
Page 48 of 65
fetal
development –
VSD, right
ventricular
outflow tract
obstruction
pulmonary
stenosis,
overriding of the
aorta, right
ventricular
hypertrophy
right to left
across the VSD,
or into the
overriding aorta
mildly ↓;
cyanosis,
extreme fatigue,
hypercyanotic
episodes,
chronic
hypoxemia;
Harsh systolic
murmur
w/palpable
thrill, boot-
shaped heart on
radiography
anemia
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Coarctation of the Aorta
Patho
Altered
Hemodynamics Manifestations
Therapeutic
Management
8% to 10% of cardiac
defects; aorta is
constricted near the ductus arteriosus
insertion location;
associated w/bicuspid aortic valve that can later
become stenotic
Narrowing of the aortic
structure obstructs the
left ventricular output, ↑
afterload to left ventricle,
blood supply is ↓ in the
abdominal organs and the ↓ periphery, left
ventricular pressure ↑
aortic pressure is high proximal to constriction
and low distral;
pulmonary edema can occur. If coarctation is
miled, collateral blood
supply can develop to channel blood past the
constriction.
Left-sided HF w/low
cardiac output, poor
lower extremity peripheral perfusion,
metabolic acidosis,
shock; If PDA present – right-to-left shunting
w/differential cyanosis
(color and oxygenation differential between
upper and lower
extremities); Systolic murmur accompanied by
ejection click or thrill
Diuretics and Digoxin
Must have Patent Ductus – Give Prostaglandin to
keep open
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Patent Ductus Arteriosus (Left-to-Right Shunting)
Patho
Altered
Hemodynamics Manifestations
Therapeutic
Management
5% to 10% of all
congenital heart
lesions
Caused by failure of
fetal ductus arteriosus
to close completely
after birth – normal
closure within 24 to
72 hours after birth d/t
↓ prostaglandin levels
and ↓ BP in ductus
lumen
D/T ↓ in pulmonary
vascular resistance
and failure of the
ductus arteriosus to
close, ↑ systemic
pressure moves
satuated blood from
aorta into pulmonary
arteries (left-to-right
shunt), the lungs, and
left side of heart
causing both ↑ left
sided cardiac
workload and ↑
pulmonary blood flow
Continuous murmur –
machinery like sound;
Widened pulse
pressure; bounding
pulses; cardiac
enlargement
Administration of
Indocin to close PDA,
a PG inhibitor that
constricts the ductus;
Monitor respiratory
status, renal function,
and growth;
Interventional Cardiac
Catheterization – a
coil is placed to
occlude the ductus;
Ligation of ductus via
left thoracotomy,
usually within the 1st
year of life
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ACLS Algorithyms
Bradycardia – Give Atropine 0.5 mg to 1 mg, up to 3 mg, Can give every 3 to 5
minutes.
SVT or Tachy – Give Adenosine 6 mg 1st dose and 12 mg 2nd dose. Follow both
with NS flush rapid IV push.
Cardiac Arrest – Important to defibrillate early; then epinephrine 1 mg every 3
to 5 minutes
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CABG
Patho Candidates Preop PostOp
Most common type
of cardiac surgery
Occluded coronary
arteries are
bypassed with the
client’s own
venous or arterial
blood vessels or
synthetic grafts
IMA is the graft of
choice due to
patency rate
Angina greater than 50%
occlusion of the left main
coronary artery
Unstable angina with
severe two-vessel or
moderate three-vessel
disease
Ischemia with heart
failure
Acute MI
Signs of ischemia or
impending MI after
angiography or PTCA
Valvular disease
Coronary vessels
unsuitable for PTCA
May be elective or
emergent procedure
May be traditional
technique or MIS
technique
Pre-op teaching is
very important:
Report pain to the
staff
T, C, & DB exercises
will be expected
Early ambulation
Monitor for
dysrhythmias and
complications
Fluid and electrolyte
balance
Hypotension
Hypothermia
Hypertension
Bleeding, no more
than 15 mL/hr
Cardiac tamponade
Altered LOC
Anginal pain
Transfer from the
SCU
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ECG Lead Groups
Septal
Anterior
Lateral
Inferior
You may see changes in more than 1 lead group!
Septal Leads
V1, V2
Look at the septum between the ventricles
Perfused by the RCA and LAD
Anterior Leads
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V3 and V4
Look at the anterior portion of the left ventricle
Perfused by the LAD
Lateral Leads
I, aVL, V5, and V6
Reflect the lateral part of the left ventricle
Perfused by the circumflex (LCX)
Inferior Leads
II, III, and aVF
Look at the right side of the heart
Perfused by the RCA
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This area is innervated by the same group of nerves that innervate the
stomach
Nausea, vomiting, and hiccups
Page 56 of 65
Module G
Causes of Intellectual Disability – PKU, Tay Sachs, Alcohol, Drugs, Prematurity,
Toxemia, Exposure to Toxins, Lack of Nurturing, Trauma, Head Injury, Asphyxia,
High Temps (Hyperpyrexia). Moderate - Requires supervision with activities;
academic skills to 2nd grade; sheltered workshop environment; difficulty with
speech
Personality Disorders –
Cluster A (Odd Eccentric Behavior):
o Paranoid – Suspicious of others, as a child had parental
harrassment
o Schizoid – Shy, introverted, detached, Indifferent, Lacked
nurturing in childhood, Socially withdrawn; prefer to work
alone, computer programmer only relationship is w/computer
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o Schizotypal – magical thinking, 6th sense, bizarre speech;
rejected, humiliated, overlooked as a child, socially isolated
Cluster B (Dramatic, Emotional Behaviors):
o Antisocial – Sociopaths; Socially irresponsible; disregard for the
rights of others; cold and callous, manipulative, con-artist
o Borderline – always in a state of crisis; Always in a state of crisis;
chaotic relationships; impulsive and self-destructive
o Histrionic – always have to be center of attention, flighty,
Attention-seeking behavior; center of attention, overly dramatic
o Narcissistic – very self-centered, superior to everyone else,
needs special attention.
Cluster C
o Avoidant – fearful, uncomfortable in social situations; lonely;
depressed
o Dependent – very submissive, clingy, Cannot make decisions;
lack self-confidence
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o OCD – preoccupied with rules and tasks; Preoccupied with rules,
lists and organization
o Passive-Aggressive – feel cheated, underappreciated, world out
to get them; Believe that life is unkind and everyone has it
"easier"
Eating Disorders
o Anorexia Nervosa – underweight, refuses to eat, Intense fear of
gaining weight; refusal to maintain body weight, electrolyte
imbalances, want to control everything. Gain pleasure from
providing others w/food and watching them eat. Do not allow
them to plan or prepare food for unit based activities.
o Bulemia Nervosa – normal weight, binge and purge, loose
enamel on teeth, at risk for dehydration, inappropriate behavior
to prevent weight gain (vomiting, laxatives, enemas)
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Theories of Aging
Biological Theories:
o Genetic Theory – aging is an involuntarily inherited process that
operates over time to alter cellular or tissue structures.
o Wear-and-Tear Theory – body wears out on a scheduled basis, free
radicals cause issues
o Environmental Theory – factors in the environment (carcinogens,
sunlight, trauma, and infection) bring about changes in aging process.
o Immunity Theory – age-related decline in immune system
o Neuroendocrine Theory – slowing of secretion of certain hormones
that have an impact on reactions regulated by nervous system.
Psychological Theories:
o Personality Theory – address aspects of psychological growth w/o
delineating specific tasks or expectations of older adults (Mature men,
Rocking Chair personality, Armored men, Angry men, Self-haters)
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o Developmental Task Theory – activities and challenges that one must
accomplish at specific stages in life to achieve successful aging.
o Disengagement Theory – describes the process of withdrawal by older
adults from societal roles and responsibilities.
o Activity Theory – opposite of disengagement theory; the way to age
successfully is to stay active.
o Continuity Theory – also known as developmental theory; a follow-up
to the disengagement and activity theories. Emphasizes the
individual’s previously established coping abilities and personal
character traits as a basis for predicting how the person will adjust to
the changes of aging.
How Old Is Old
Older – 55 to 64
Elderly – 65 to 74
Aged – 75 to 84
Very Old – 85 years and older
Page 61 of 65
Intimate Partner Abuse
Cycle of Battering
o Phase 1 (Tension Building Phase)– Less and Less tolerant, can last
weeks to years; woman makes excuses for the batterer
o Phase 2 (Acute Battering) – battering phase, most violent, shortest, up
to 24 hrs.
o Phase 3 – Honeymoon phase, never going to happen again, apologies,
excuses; woman wants to believe he can change
Child Abuse (Pg. 782 – 784)
Physical and Emotional Abuse
o Physical – includes any nonaccidental physical injury as a result of
punching, beating, kicking, biting, shaking, throwing, etc.
Unexplained burns, bites, bruises, broken bones, or black
eyes
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Fading bruises or other marks noticeable after an absence
from school
Frightened of parents and protests or cries when it is time to
go home
Shrinks at the approach of adults
Reports injury by a parent or another adult caregiver
Abuses animals or pets
When parent or other caregiver:
Offers conflicting, unconvincing, or no explanation
for child’s injury
Describes the child as “evil” or in some other very
negative way
Uses harsh physical discipline w/child
Has HX of abuse as child
Has HX of abusing animals or pets
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o Emotional – involves a pattern of behavior on the part of the parent
or caretaker that results in serious impairment of the child’s social,
emotional, or intellectual functioning.
Extremes in behavior such as overly compliant or demanding
behavior, extreme passivity, or aggression
Either inappropriately adult (parenting other children) or
inappropriately infantile (rocking or head-banging)
Delayed in physical or emotional development
Has attempted suicide
Reports a lack of attachment to the parent
Emotional Abuse may be suspected when the parent or
caregiver:
Constantly blames, belittles, or berates the child
Is unconcerned about the child and refuses to
consider offers of help for the child’s problems
Overly rejects the child
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Physical and Emotional Neglect
o Physical Neglect – includes refusal of or delay in seeking health care,
abandonment, expulsion from the home or refusal to allow a runaway
to return home, and inadequate supervision
o Emotional Neglect – Refers to a chronic failure by the parent or
caretaker to provide the child with the hope, love, and support
necessary for the development of a sound, healthy personality.
o Indicators of Neglect
Frequently absent from school
Begs or steals food or money
Lacks needed medical or dental care, immunizations, or
glasses
Consistently dirty and has severe body odor
Lacks sufficient clothing for the weather
Abuses alcohol or other drugs
States that there is no one at home to provide care
o Possibility of neglect may be considered when parent or caregiver