I'm Blue
Name 2 methods to mobilize secretions
Encourage coughing and deep breathing
Encourage ambulation
Encourage incentive spirometer use
What is the least invasive method to thin secretions
If you suspect DIC, what is your priority
Inform the provider
Stand up and demonstrate the placement of defibrillator pads
To the right of the sternum just below the clavicle and to the left side, just below and to the left of the pectoral muscle
acronym for tasks that cannot be delegated
TAPE- Teach, Assess, Plan, and Evaluate
In which stage of ARDS does mechanical ventilation usually need to be implemented?
What is the 1st stage, the Injury or Exudative stage?
Name 2 of signs of pain for a sedated patient
Increased agitation
Increased restlessness
Facial grimacing
Stiff body
Rigid body
Name 2 priority interventions for DIC
Diagnose quickly
Stabilize the patient (e.g., O2, volume replacement
Treat the underlying causative disease/problem, control thrombosis & bleeding.
True or false: a 1st degree AV block always requires treatment
False, especially if the patient is asymptomatic
Normal width of QRS complex
<0.12seconds
Name 1 early sign of hypoxemia
Tachypnea
Confusion
Tachycardia
Name the 3 phases Pathophysiologic Changes in ARDS
Injury or exudative phase
Reparative or proliferative phase
Fibrotic Phase
Normal platelet level
150,000 to 450,000
These 3 electrolyte levels can cause dysrhythmias
How to identify PEA
What is check patient's pulse?
Name 2 late signs of hypoxemia
Bradypnea
Cyanosis
Coma
Dysrhythmias
Hypotension
Seizures
What is the primary cause of atelectasis in the 1st stage of ARDS?
Damage to cells that produce surfactant (alveolar cells types 1 & 11)
This common blood thinner can reduce platelet count
Priority intervention when there is a change in the patient's rhythm?
Check responsiveness
What is the priority nursing diagnosis for COPD:
Ineffective airway clearance
Altered breathing
Impaired gas exchange
Low cardiac output
Ineffective airway clearance
Name 2 components of the ventilator bundle
Elevation of HOB 30-45 degrees
Daily sedation holidays & assessment of readiness for extubation
Peptic ulcer disease prophylaxis (Protonix)
DVT prophylaxis (Subcut Lovenox or Heparin)
Daily oral care with chlorhexidine (0.12%) solution.
Reposition pt q2hr
Name two of the three positioning strategies for respiratory failure
Prone
Lateral rotation
Kinetic
At what level (mg/dL) do we give fibrinogen?
80-100
What intervention is done for stable a fib unresponsive to drug conversion?
If only one lung is affected with PNA, what is the best way to position the patient for maximal oxygenation
"Bad" lung up to promote drainage
What is a consequence of fibrosis in the lungs?
What is pulmonary hypertension?
Name 2 benefits of proning
Reduced risk of ventilator injury
Reduced lung compression
More efficient gas exchange in the lungs
Improved cardiac function and oxygen delivery
Improved drainage of secretions
Name 3 clinical manifestations of bleeding in DIC?
Integumentary → pallor, petechiae, purpura oozing blood,venipuncture site bleeding, hematomas, and occulthemorrhage
Respiratory → tachypnea, hemoptysis, and orthopnea
Cardiovascular → tachycardia and hypotension
GI → upper and lower GI bleeding, abdominal distention,and bloody stools
Urinary → hematuria
Neurologic → vision changes, dizziness, headache, changes in mental status, and irritability
Musculoskeletal complaints → bone and joint pain.
3 interventions for new onset a flutter
Amiodarone, anticoagulants, synchronized cardioverson
True or false: the patient will need to be intubated when their oxygen saturation is low and they're tachypneic
False- only if they're bradypneic
True
What is your priority intervention for the nurse if the ventilator is malfunctioning?
Manually ventilate the patient
Name 2 clinical manifestations of thrombotic manifestations of DIC
Integumentary → cyanosis, ischemic tissue necrosis (e.g.,gangrene), & hemorrhagic necrosis
Respiratory → tachypnea, dyspnea, pulmonary emboli, &ARDS
Cardiovascular → ECG changes & venous distention
GI → abdominal pain and paralytic ileus
Kidney damage & oliguria, leading to failure.
Priority interventions for v fib
What is immediate CPR and defibrillation?
What is immediate CPR?
Name 2 causes of hypercapnic respiratory failure
Asthma, COPD, Cystic fibrosis
Brainstem injury, Sedative/ opioid abuse, TBI, SCI
Thoracic trauma, kyphoscoliosis, pain, obesity
MG, polyneuophaty, acute myopathy, toxin ingestion, ALS, polio, MD, MS
Name 2 causes of hypoxemic respiratory failure
ARDS, PNA, toxic inhalation, hepatopulmonary syndrome, PE, PA lac/ hemorrhage, inflammation& alveolar injury
Anatomic shunt, cardiogenic pulmonary edema, shock, high CO states
Name 2 risk factors for acute DIC
Shock
Sepsis
Hemolytic processes
OB conditions
Malignancies
Tissue damage
V tach without a pulse- list 3 interventions in order
CPR
Defibrillation
Amiodarone (antidysrhythmics)
Epinephrine (vasopressors)