Pookie
The ECG monitor is showing Atrial Fibrillation. What interventions should the nurse do next?
1) Check if leads are on correctly
2a) Correct rhythm with amiodarone
2b) Prepare for cardioversion (administer benzo before) (check TEE/TTE FIRST!!!)
3) Administer anticoagulants - bleeding precautions
4) Administer thromoblytics if clot is present
What are the parts of:
Virchows Triad:
Triad of Death:
Cushings Triad:
Beck's Triad
Virchows Triad (risk for blood clots): venous stasis, hypercoagability, & venous injury
Triad of Death: (trauma): Hypothermia, metabolic acidosis, & coagulopathy
Cushings Triad (increased ICP): Widened push pressure, bradycardia, & irregular respiration pattern
Beck's Triad (Cardiac tamponade): Muffled heart sounds, JVD, & hypotension
The patient's ABG results are:
PH: 7.47
PaCO2: 37
HCO3: 30
What Acid-Base Imbalance is the patient in? What interventions are anticipated?
This patient is in metabolic alkalosis
1) STOP NG SUCTIONING
2) Monitor for hypokalemia - Use potassium sparing diuretics
3) Administer Acetazolamide
4) Administer antiemetics - Stop vomiting
Risk factors for depression?
Depression increases risk for?
Risk factors include: women, not married, above 45 years old, lower economic status, and recently changed health state.
Depression increases risk for suicide - Suicide screenings, depression screenings, NEVER LEAVE PATIENT ALONE!
This patient was recently admitted to the ER following a chemical burn. What is the nurses priority?
STOPPING THE BURN!
1) Wear PPE
2a) Remove saturated clothing of patient
2b) Brush off chemical powder if any
3) Irrigate with water until no pain is noted or temperature is too much!
NEVER NEUTRALIZE
4) Follow with ABCs
ICP QUESTIONS !
1) What is the Monro-Kellie doctrine theory?
2) Normal ICP range?
3) How do you calculate CPP?
1) Monro-Kellie doctrine is the theory that if one goes up, the other 2 goes down (Brain tissue is 80%, CSF is 10%, & Blood is 10%)
2) Normal ICP is 0-15
3) CPP = MAP - ICP
Clinical manifestations of increasing intracranial pressure?
Priority nursing action?
Clinical manifestations of increasing ICP: Pupillary changes, sudden chance in LOC, Increased BP, widened pulse pressure, & VOMITING WITHOUT NAUSEA!
If any of these occur... NOTIFY PROVIDER BABY
1) Difference between ischemic vs hemorrhagic stroke?
2) What can you use to tell diagnose?
3) Can you use TPA for hemorrhagic stroke?
1) Ischemic strokes involve a clot blocking blood flow to a part of the brain causing an infarction (left middle artery is most common). Hemorrhagic involves a blood pool putting pressure on the brain.
2) You can diagnose and differentiate using a CT
3) TPA is ONLY used for ischemic stroke NOT hemorrhagic
Your patient has started experiencing deja-vu, butterflies in the tummy, seeing green, and has stated the room smells weird. What should you do?
What precautions should you start? And what if it lasts longer than 5 minutes?
1) Seizure precautions - time seizure, suction is nearby, IV access, padding, remove restrictive clothing, move on left side.
2) If seizure last longer than 5 minutes, this is a MEDICAL EMERGENCY STATUS EPILEPTICUS. Notify provider and prepare for intubation
How do you patient these patients?
1) Patient experiencing a seizure
2) Patient with hypertension
3) Patient with hypotension
4) Patient with severe electrical burns
5) Patient admitted for trauma
6) ARDS
7) ARF
1) Seizures - Gently guide to left side
2) Hypotension - Trendelenburg
3) Hypertension - Legs elevated
4) Burns - Neutral head position (no pillow) with cervical spine collar, elevate HOB 30 degrees
5) Trauma - Neutral head position (no pillow) with cervical spine collar, elevate HOB 30 degrees
6) ARDS - PRONE
7) ARF - Good lung down
Explain when you would use these...
Transcutaneous pacing?
Cardioversion?
Defibrillation?
Transcutaneous pacing is used for sinus bradycardia (midazolam (benzo) before)
Cardioversion is used for arrhythmia with a pulse like AFIB or Aflutter (benzo, anti anxiety meds, pain meds)
Defibrillation is used for arrhythmia without a pulse like symptomatic VTACH or VFIB (Always compressions first, then shock, then medications)
This patient is curious about the side effects of first gen antipsychotics (haloperidol) How would you respond?
First gen antipsychotics puts the patient at risk for developing Extra Pyramidal symptoms, like tardive dyskinesia or akinesia.
First gen antipsychotics also puts the patient at risk for developing Neuroleptic Malignant syndrome (NMS): muscle rigidity and fever.
This patient is experiencing respiratory alkalosis.
What should the nurse teach this patient?
- Relaxation techniques
- Breath into paper bag or cupped hands
- Pain medication or antibiotic administration
This patient was admitted to the ER for septic shock. What is the priority nursing action?
1) Obtain lactate acid levels (high levels shows sepsis)
2a) Obtain TWO blood cultures
2b) Administer antibiotics
3) Administer fluids
A patient was admitted to the ER for severe burns. This patient has soot in nares, is coughing, and had singed facial hair. What is the nurse's priority action?
2) Compromised airways need intubation
3) 100% by face mask/humidified air to lower carboxyhemoglobin levels. Assess respiration rate and O2 levels.
4) Move on with ABC - Circulation for Blood pressure and heart rate.
NOTE! NEVER use adhesives for patients intubated with facial burns!
Quick Questions:
1) Leading cause of death to patients with severe burns after their first 24 hours?
2) Medication used to lower ICP?
3) What should always be on STANDBY during a dressing change for severe burns?
4) Bruising around the ears indicates a?
5) Is wound care done in the Emergent phase?
1) Sepsis is the leading cause of death in patients w/ severe burns after their first 24 hours.
2) Mannitol lowers ICP - Monitor BUN & creatinine
3) An AMBU bag should ALWAYS be there during dressing changes for burns!
4) Bruising behinds the ears (battle sign) indicates a basilar bone fracture, same with raccoon eyes
5) Wound care is down during the intermediate phase
Difference between rapid response & cold blue?
Give examples of both.
- Patient throws up blood
- Stroke alert
Code Blue is called for patients with no pulse, no breathing, and needs CPR!
- VFIB
- Cardiac/Respiratory arrest
The monitor for the patient is showing Ventricular Fibrillation. What is the priority nursing action?
1) ASSESS FIRST - check lines and patient for pulse
2) CALL FOR HELP - CODE BLUE
3) Start chest compressions (30 compressions: 2 breaths)
4) Defibrillation
5) Medication: Epinephrine
I know you hate this question! Explain the 3 zones of a burn wound and the 4 types of burn depths
Zone of Coagulation - deepest part, does not heal
Zone of Stasis - Impaired circulation, does heal
Zone of Hyperemia - Does heal, most nutrients and circulation
Superficial - pink/red/dry, heals in one week
Superficial/Partial - pink, BLISTERS, heals in 2 weeks
Partial/Thickness - cherry red, blisters, heals in 3-6 weeks
Full Thickness - black, brown, white, tan, leathery, fatty tissue/bone, does not heal without graft.
Question time!
1) Leading cause of cirrhosis:
2) Clinical Manifestations of cirrhosis:
3) Is it reversible?
4) Interventions?
1) Hepatitis C is leading cause of cirrhosis
2) SOB, Ascites, Jaundice, Hepatic encephalopathy, dark urine, bleeding, spider angiomas
3) Not reversible
4) Avoid high protein, diuretics for fluid retention, monitor for bleeding, lactulose for ammonia
Question time!
1) Pain location for acute pancreatitis:
2) Clinical manifestations of accurate pancreatitis:
3) What kind of diet should they be on? They should avoid what foods?
4) Monitor what lab values?
1) Upper left quadrant, radiates to shoulder, and upper back.
2) Steatorrhea, hypocalcemia, hyperglycemia, N/V, pain at rest or with food, hiccups, indigestion.
3) NPO, if they're eating avoid foods with fat
4) Monitor amylase, lipase, calcium, and glucose
1) How many nurses do you need for a blood transfusion?
2) How long do you wait to assess the patient after starting the infusion? How long do you have to give the blood once you have it?
3) What is the priority nursing action if a reaction occurs?
1) You need 2 nurses! You to need to verify the blood with 2 people!
2) You need to wait 15 minutes to assess. You have 4 hours to administer the blood.
3) If a reaction occur, STOP infusion, notify provider and get vitals. Might need to restart.
Explain what happens in the Emergent Phase of a patient with burns.
Explain what happens in the Intermediate Phase of a patient with burns.
Emergent (primary) - ABCDEF: Airway/c-spine, 100% oxygen humidified/O2/RR, remove restriction clothing/BP/HR, assess neurological, assess severity of wounds/dry sheet, 2 large bore its/ALWAYS LR.
Emergent (secondary) - Background/medical history on patient, labs, TBSA, and vaccines.
Intermediate - Wound care, pain management, infection prevention, and proper nutrients
Mechanical Ventilation Questions:
1) How can a nurse help with the intubation process?
2a) High pressure alarms?
2b) Low pressure alarms?
3) What settings can cause barotrauma?
4) Nursing interventions for self-extubation?
1) Keep intubation trey at bedside, administer analgesics/sedatives/muscle paralyzers, assess respirations/vitals, lungs bilaterally expand not belly, if longer than 30 seconds STOP
2a) High pressure alarms are blockage in the tubes: kink, secretions, or patient biting down.
2b) Low pressure alarms are cuff leaks or tube comes off.
3) PEEP and VT cause barotrauma
4) Notify provider, ambu bag them, soft restraints, sedate them
Final Random Questions:
1) What is a dangerous GCS score?
2) What do you do if clear liquid comes out of nose after a traumatic accident?
3) Why is hypotension a worry for patients with severe burns?
4) First and second line medication for a seizure?
5) AFIB puts patient at risk for?
6) Priority nursing action for a patient with a stroke?
7) A Spinal cord injury puts the patient at risk for?
8) Burn shock is a mix between?
9) Should you do insulin first for DKA?
10) What is Brocas & Wernickes area?
1) Severe is anything below 8
2) Use gauze to collect the liquid
3) Hypotension indicates burn shock which is an emergency
4) First benzo (Lorazepam), then phenytoin
5) Clots - Stroke
6) Perform a CT ASAP!
7) Aspiration, losing function, death, and neurologic shock8) Hypovolemic shock and distributive shock
9) NO, fluids before insulin for DKA
10) Affected by a left sided stroke, brocas is the the inability to speak, Wernickes is the inability to understand what is being said