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Questions and Answers
What is the appropriate treatment for atrial flutter with a visible QRS complex?
What is the appropriate treatment for atrial flutter with a visible QRS complex?
Which arrhythmia is characterized by a rapid heart rate where P waves are not visible?
Which arrhythmia is characterized by a rapid heart rate where P waves are not visible?
What should be avoided to decrease ICP in neurocritical care?
What should be avoided to decrease ICP in neurocritical care?
In which cervical spinal injury region is monitoring for respiratory function particularly important?
In which cervical spinal injury region is monitoring for respiratory function particularly important?
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What is a defining characteristic of secondary wound intention?
What is a defining characteristic of secondary wound intention?
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Which phase of wound healing involves inflammation and lasts for 3-4 days?
Which phase of wound healing involves inflammation and lasts for 3-4 days?
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What should be done before suctioning a patient to help prevent increase in ICP?
What should be done before suctioning a patient to help prevent increase in ICP?
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What is the priority intervention for a patient experiencing ventricular fibrillation?
What is the priority intervention for a patient experiencing ventricular fibrillation?
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What is the appropriate nursing intervention for an O+ patient receiving A+ blood?
What is the appropriate nursing intervention for an O+ patient receiving A+ blood?
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Which suction pressure range is recommended for suctioning a patient?
Which suction pressure range is recommended for suctioning a patient?
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What is the maximum duration of suctioning allowed while withdrawing the catheter?
What is the maximum duration of suctioning allowed while withdrawing the catheter?
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Which steps should be followed when changing a tracheostomy tube?
Which steps should be followed when changing a tracheostomy tube?
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What is the primary focus when assessing a patient experiencing cardiac arrhythmias?
What is the primary focus when assessing a patient experiencing cardiac arrhythmias?
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How should the technique be modified during suctioning to ensure patient safety?
How should the technique be modified during suctioning to ensure patient safety?
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When should fresh frozen plasma (FFP) be administered?
When should fresh frozen plasma (FFP) be administered?
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In the context of endocrine glands, which statement about calcium regulation is correct?
In the context of endocrine glands, which statement about calcium regulation is correct?
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What does a Braden score of 20 indicate regarding pressure ulcer risk?
What does a Braden score of 20 indicate regarding pressure ulcer risk?
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Which stage of a pressure ulcer is characterized by full thickness and potentially exposing bone?
Which stage of a pressure ulcer is characterized by full thickness and potentially exposing bone?
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What type of dressing is recommended for a wound exhibiting adipose tissue?
What type of dressing is recommended for a wound exhibiting adipose tissue?
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What is the maximum recommended duration for heat or cold therapy application?
What is the maximum recommended duration for heat or cold therapy application?
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What is the best initial action when dealing with evisceration of a wound?
What is the best initial action when dealing with evisceration of a wound?
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In terms of wound healing, which nutrient is crucial for tissue repair?
In terms of wound healing, which nutrient is crucial for tissue repair?
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Which term describes the act of deliberately producing or feigning illness for personal gain?
Which term describes the act of deliberately producing or feigning illness for personal gain?
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What is the key distinguishing factor between malingering and factitious disorder?
What is the key distinguishing factor between malingering and factitious disorder?
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Study Notes
Pressure Ulcers
- Braden scale ranges from 6 to 23; 20 is normal, lower scores indicate higher risk.
- Pressure ulcer stages:
- Stage 1: Non-blanchable erythema (e.g., sunburn)
- Stage 2: Partial thickness skin loss with fluid-filled blister (e.g., bad sunburn)
- Stage 3: Full thickness skin loss with adipose tissue visible, may show slough/eschar.
- Stage 4: Full thickness, extends down to bone, risk of osteomyelitis.
Wound Management
- Dehiscence: Wound opens; Evisceration: organs protrude, often seen in obesity or post-abdominal surgery.
- Interventions for dehiscence/evisceration: Saline-soaked dressings, call for help, use abdominal binders.
- Heat therapy promotes circulation; cold therapy reduces swelling; apply for no longer than 20 minutes.
- Dressing types depend on wound stage:
- Stage 1-2: Clear tegaderm.
- Adipose tissue visible: Wet-to-dry or damp-to-dry dressings.
- Surgical wounds: Non-adherent dressing (e.g., Tefla pad).
- Honey/hydrogels used only in wounds with slough/eschar for rehydration and autolytic debridement.
Debridement Techniques
- Mechanical: High force irrigation, wet/dry, jet bath.
- Sharps: Scraping tissue.
- Chemical: Enzymatic products used to assist in wound healing.
Wound Characteristics
- Tunneling: Depth in wound; document using clock method.
- Undermining: Q-tip used under skin layers; document using clock method.
Drain Care
- Hemovac & JP drains: Monitor output; alert for none during shift or if output exceeds 100ml in a short time.
- Pin drains to patient gown, avoid dislodgement, and monitor for infection.
Nutrition for Wound Healing
- Important nutrients: Vitamin C and protein-rich foods (lean meats, organ meats, nuts).
- Hydration with fluids like orange juice enhances nutrient absorption.
Psychological Conditions
- Factitious disorder: Intentionally faking illness for personal gain (e.g., Gypsy Rose).
- Malingering: Falsifying injury or illness for personal benefits.
Cardiac Rhythms
- Atrial rhythms: QRS present, looks like wings (Atrial flutter); manage with synchronized cardioversion.
- Atrial fibrillation: QRS present, appears vibrating; also treated with synchronized cardioversion.
- Supraventricular tachycardia (SVT): Rapid rate, P waves not visible; treat with adenosine push.
- Ventricular tachycardia (V-tach): QRS absent, treat with Amiodarone.
- Ventricular fibrillation (V-fib): No discernible QRS; requires defibrillation.
Cardiac Devices
- Biological valves: Shorter lifespan, prone to infections; often on antibiotics.
- Mechanical valves: Long-lasting; require anticoagulation and close monitoring of PT/INR.
Neuro Care
- Strategies to manage increased intracranial pressure (ICP):
- Minimize stimuli to create a quiet environment.
- Pre-oxygenate prior to suction.
- Avoid hip flexion; logroll carefully.
Trauma Awareness
- Halo sign indicates cerebrospinal fluid leakage; a medical emergency.
- Spinal shock lasts 2-4 days post-injury; C1-C2 injuries may lead to death, C2-C5 impacts respiration, T6 and above risk autonomic dysreflexia.
Wound Healing Processes
- Healing phases:
- Phase 1: Inflammation (3-4 days).
- Phase 2: Proliferation/new cell growth (1-2 weeks).
- Phase 3: Scar formation.
Blood Transfusion Protocol
- Discontinue transfusion for O+ patients receiving A+ blood.
- Fresh frozen plasma administered rapidly for clotting abnormalities.
- Monitor for infusion reactions: chills, shortness of breath, hives, warmth, itching.
Suctioning Protocol
- Utilize sterile technique for suctioning; limit to 10-12 seconds.
- Hyperoxygenate 100% O2 before suctioning.
- Regularly check for cardiac arrhythmias during procedure.
Tracheostomy Care Steps
- Replace inner cannula, clean stoma, secure new ties, and ensure sterile technique throughout.
Endocrine System
- Thyroid activity inversely affects calcium levels; parathyroid closely regulates calcium levels.
- Adrenal glands manage salt, sugar, and sex hormones; Cushing’s increases salt, Addison’s decreases salt.
- Prioritize patient assessment over rhythm review; patient symptoms are key.
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