Neuro
This anatomical landmark is used when leveling an EVD system to the patient.
EAC (External Auditory Canal)
When transfusing blood products, vital signs are to be checked at three different intervals. Name all three intervals.
prior to initiating transfusion, 15 minutes after starting transfusion, at completion of transfusion
Name three signs of septic shock.
delayed cap refill, altered mental status, cool extremities, weak pulses, mottling, hypotension (late finding), flushed, warm extremities, bounding pulses, flash cap refill
To prevent VAPs, we do mouth care at these times during a shift.
8, 12, and 4
If your patient is hypercarbic, this vent setting would be increased to blow off CO2.
respiratory rate
This equation is used to calculate a patient's CPP (Cerebral Perfusion Pressure).
MAP-ICP=CPP
Blood products must be started within this time frame of arriving on the unit.
30 minutes
You have this much time to administer IV antibiotics from the time septic shock is recognized.
60 minutes
To prevent CAUTIs, we do foley care at these times during a shift.
8 and 8
These are the three buttons on a ventilator, nurses can touch.
silence button, FiO2, 100% boost
Name three nursing interventions you could do to help lower your patient's ICP.
HOB 30 degrees, pt supine with head midline, sedation, decreased stimuli, thermoregulation
Blood filters and tubing need to be changed every ___________ hours.
Four
In initial septic shock management, you could expect to give an initial fluid bolus of this volume (ml/kg).
20mL/kg
These monitors are utilized to assess a PIV for infiltration but do not take the place of your hourly IV checks.
IV watch
Tidal volumes are determined by patient size. Name the appropriate range per kilograms for TVs.
6-8ml/kg
These three symptoms are the classic sign for Cushing's Triad indicating impending herniation.
hypertension, bradycardia, irregular respirations
True or False: Blood products can be run with a Normal Saline KVO.
False
At what body temperatures would you expect to draw cultures on your patient?
38.0 for immunocompromised patients, 38.5 for non-immunocompromised patients
Breastmilk feed bags are changed every _____ hours.
4
If your patient is hypoxic, these two settings are increased to deliver more oxygen.
FiO2 and PEEP
This medication helps to lower the ICP by increasing the serum osmolality allowing fluid to shift from the cerebral tissue into the intravascular space.
Hypertonic Saline (3%)
This is the appropriate volume per kilogram for packed red blood cell administration.
15 ml/kg
In septic shock, this lab value is increased and used to assess tissue hypoxia as well as morbidity.
Lactate
Accessed ports that are hep locked need to be flushed every _____ hours.
24
In PCPS, you have a constant set, and this becomes your variable. Name your constant and your variable.
PIP (Constant)= PC + PEEP
Tidal Volumes (Variable)