Untitled Quiz

Acute Myocardial Infarction

• Symptoms (S/S):

  • Constant, unstable chest pain
  • Diaphoresis
  • Shortness of breath (SOB)
  • Pain radiating to jawline/shoulder
  • Nausea/vomiting (N/V)
  • Syncope (fainting)

• Nursing Interventions (NI):

  • Vital signs monitoring
  • Continuous ECG monitoring
  • Pain assessment
  • Skin assessment (color, temperature, pulses)
  • Intake and output (I&O)
  • Lab work

• Treatment (TX):

  • Aspirin
  • Nitroglycerin
  • Morphine
  • Supplemental oxygen (O2)
  • P2Y12 inhibitor (e.g., Plavix)
  • Two intravenous (IV) lines
  • Bed rest

Shock

• Stages of Shock:
  • Compensatory: Normal blood pressure, increased heart rate, confusion, agitation, cold clammy skin, respiratory alkalosis, Paco2 >20 <35
  • Progressive: Systolic blood pressure (SBP) <90, mean arterial pressure (MAP) <65, rapid shallow breathing, lethargy, possible coma, dysrhythmias, Paco2 >45, acidosis
  • Irreversible: Severe hypotension, erratic heart rate, asystole, anuric, jaundice, necrosis, coma, mechanical ventilation, and acidosis

Burns

• Parkland Formula:

  • 2 mL x patient weight (kg) x % total body surface area (TBSA) burned
  • 4 mL for electrical burns
  • 50% given over 8 hours, 50% over 16 hours

• Emergent Phase Priorities:

  • Fluid resuscitation
  • Pain management
  • Prevention of hypothermia
  • Airway management
  • Initiation of wound care
  • Diagnostic testing

Different Types of Shock (excluding septic)

• Hypovolemic Shock:

  • S/S: Hypotension, tachycardia, thirst, pallor, cool/clammy skin, altered mental status
  • TX: Isotonic solution or blood replacement; treat underlying cause

• Cardiogenic Shock:

  • S/S: Hypotension, tachycardia, tachypnea, weak pulses, pallor, cool clammy skin, altered mental status, chest pain, dysrhythmias,
  • TX: Oxygen, medications to support the heart, pain management, fluid management

TBI & Increased ICP

• Symptoms (S/S):

  • Early: Nausea/vomiting (N/V), headache (HA), lethargy, irritability, slow decision making
  • Late: Pupil changes, seizures, coma, bleeding from nose/ears, Battle's sign, halo sign, scalp wounds

• Nursing Interventions (NI):

  • HOB elevated 30-45 degrees
  • Head in neutral position
  • Limit stimuli
  • Maintain blood pressure
  • Nutritional support
  • Monitor vital signs (vitals)
  • Use padded side rails

• Treatment (TX):

  • Neuro assessment
  • Suction as needed
  • Hypertonic solution to pull fluid off brain
  • Ventriculostomy
  • Craniectomy
  • Craniotomy

Aneurysms

• Symptoms (S/S):

  • Atherosclerosis, hypertension (HTN), high cholesterol
  • Asymptomatic until rupture or dissection
  • Rupture: Chest pain
  • Dissection: Flank pain

• Nursing Interventions (NI):

  • Neuro checks
  • CT scan with contrast
  • Control HTN and atherosclerosis
  • Maintain calm environment

• Treatment (TX):

  • Stop smoking
  • Surgery
  • Antihypertensives
  • Statins

Cardiac Tamponade

• Symptoms (S/S):

  • Beck's triad: Hypotension, jugular venous distention (JVD), muffled heart sounds
  • Narrowed pulse pressure

• Nursing Interventions (NI):

  • Continuous cardiac monitoring
  • Two intravenous (IV) lines

• Treatment (TX): Pericardiocentesis

Tension Pneumothorax

• Symptoms (S/S):

  • Chest pain
  • Tracheal deviation to the unaffected side
  • Shortness of breath (SOB)
  • Anxiety
  • Cyanosis
  • Decreased breath sounds on affected side

• Nursing Interventions (NI):

  • Monitor vital signs (respiration, O2 saturations)
  • Assist respirations/treatment
  • CXR (chest x-ray)
  • Supplemental oxygen (O2)
  • Advanced airway management/ventilation

• Treatment (TX):

  • Chest tube placement
  • Needle decompression.

Primary Survey (ABCDE)

• Airway (A):

  • Open airway
  • Patency (obstruction assessment)
  • Jaw thrust, suction if needed

• Breathing (B):

  • Chest rise and fall
  • Effort required to breathe
  • Assess for deviations or abnormal sounds.
  • Rate / quality. Sounds of breathing.

• Circulation (C):

  • Palpate pulses
  • Assess skin color, temperature, capillary refill time
  • IV access
  • Control external bleeding

• Disability (D):

  • Glasgow Coma Scale (GCS) (eyes, verbal, motor)
  • Pupil assessment (PERRLA)

• Exposure (E):

  • Remove clothing, keep patient warm
  • Identify injuries
  • Maintain Body Temperature

Adult Respiratory Distress Syndrome (ARDS)

• Symptoms (S/S): Tachypnea, tachycardia, progressive refractory hypoxemia, bilateral pulmonary infiltrates on CXR, worsening PaO2/FiO2 ratio

• Nursing Interventions (NI):

  • Suction airway
  • Medications (e.g., infection prevention)
  • Prone positioning (where appropriate)
  • UO 0.5mg/kg/hr
  • Continuous monitoring of mechanical ventilation parameters.

• Treatment (TX):

  • High-flow nasal cannula (NC)
  • Mechanical ventilation
  • High positive end-expiratory pressure (PEEP)
  • Extracorporeal Membrane Oxygenation (ECMO) if necessary
  • Early prone positioning

Flail Chest

• Symptoms (S/S):

  • Paradoxical chest wall movement
  • Tracheal deviation to affected side

• Nursing Interventions (NI):

  • Assess respiratory/O2 status
  • Monitor vitals
  • Assess for respiratory depression
  • Assess for V/Q mismatch
  • Manage pain
  • Encourage coughing, deep breathing, and movement.

• Treatment (TX):

  • Ventilation
  • Pain management
  • Spinal nerve block

Hemothorax

• Symptoms (S/S):

  • Hypovolemia/shock
  • Respiratory acidosis
  • Absent breath sounds on affected side, hypotension, reduced O2 saturation, reduced blood pressure.

• Nursing Interventions (NI):

  • Assess breathing status (rate, sounds, O2 saturations)
  • Assess for Shock
  • Obtain chest X-ray(CXR)

• Treatment (TX):

  • Chest tube insertion
  • Thoracotomy (rare)

Angina

• Stable Angina:

  • Occurs with activity
  • Predictable
  • Resolves with rest/medications
  • Fixed Plaque

• Unstable Angina:

  • Occurs with or without activity.
  • Unpredictable
  • Emergency

• Prinzmetal's Angina:

  • Variation of unstable angina
  • Occurs during the night/early morning (midnight to early AM)
  • Coronary artery spasm

Chest Tubes

• Indications for Placement:

  • Pneumothorax
  • Hemothorax

• Normal Findings:

  • Tidaling in the water seal chamber
  • Occasional bubbling in the water seal chamber

• Abnormal Findings:

  • No tidaling
  • Continuous bubbling
  • Drainage exceeding 500 mL
  • Bright red blood gush
  • Crepitus

Nursing Care Considerations for Hemodynamic Monitoring

• Normal Parameters:
  • Central Venous Pressure (CVP): 2-6 mm Hg
  • Pulmonary Artery Wedge Pressure (PAWP) / Pulmonary Artery Occlusion Pressure (PAOP): 8-12 mmHg
  • Pulmonary Artery (PA) Pressure: 25/10 mmHg.

Synchronized Cardioversion vs. Defibrillation

• Cardioversion:

  • Controlled electric shocks delivered at the peak of the R wave during a cardiac cycle
  • Treats specific dysrhythmias (e.g., SVT, atrial fibrillation with a pulse, flutter).

• Defibrillation:

  • Uncontrolled electric shock delivered at any point during the cardiac cycle
  • Treats life-threatening cardiac rhythms (e.g., ventricular fibrillation, ventricular tachycardia without a pulse)

Dysrhythmias - Treatments

• Atrial Fibrillation (A-Fib):

  • Antiarrhythmics, cardiac ablation, rate control.

• Bradycardia:

  • Atropine IV bolus (up to 3mg). Transvenous pacing.

• Supraventricular Tachycardia (SVT):

  • Adenosine (6-12 mg) IV push. Vagal maneuvers

• Ventricular Tachycardia (V-Tach) - with a pulse:

  • Cardioversion.

• Ventricular tachycardia (V-Tach) - without a pulse:

  • Defibrillation.

• Polymorphic Ventricular Tachycardia (Torsades de Pointes):

  • Magnesium IV.

Infective Endocarditis

• Symptoms (S/S):

  • Osler nodes
  • Janeway lesions
  • Splinter hemorrhages
  • Fever
  • Fatigue
  • Confusion
  • Murmur

• Nursing Interventions (NI):

  • Long-term antibiotic therapy (minimum 4-6 weeks)
  • PICC line for long-term antibiotics
  • Oral hygiene
  • Notify healthcare providers of any procedures

Myocarditis

• Symptoms (S/S):

  • Viral infection-related symptoms
  • Shortness of breath (SOB)
  • Chest pain
  • Myalgia (muscle pain)
  • Fatigue
  • Dysrhythmias
  • Heart failure (HF)
  • Dyspnea
  • Palpitations
  • Syncope

• Nursing Interventions (NI):

  • Monitor vital signs.
  • Assess for cardiac rhythm disturbances.
  • Assess for heart failure (HF) symptoms.
  • Avoid strenuous activity.
  • No return to sports activities for at least 3-6 months following diagnosis.

Pericarditis

• Symptoms (S/S):

  • Pleuritic chest pain, relieved by sitting up or leaning forward
  • Friction rubs
  • Abnormal ECG
  • New or worsening pericardial effusion
  • Fever
  • Pain
  • ECG abnormalities

• Nursing Interventions (NI):

  • Monitor vital signs
  • Administer medications as ordered
  • Elevate head of bed
  • Emotional support
  • Avoid strenuous activities

Heart Valve Disorders - Aortic Stenosis

• Pathophysiology:
  • Narrowed aortic valve opening reduces blood flow.
  • Ventricular hypertrophy develops (overgrowth).
  • Left Ventricular hypertrophy leads to heart failure (HF)

Blood Transfusion Reactions

• Hemolytic: low back pain, blood in urine, tight chest, impending doom
• Febrile: temperature increased by at least 1 degree F
• Anaphylactic: Hching(hives), urticaria(skin rash), Antihistamine
• Bacterial: wheezing, dyspnea, send culture

Cardiac Catheterization

• Indications: Blockages in coronary arteries

• Post-procedure Nursing Interventions and Assessments:

  • Monitor respiratory status
  • Monitor cardiac rhythm
  • Monitor vital signs (BP, HR, temperature)
  • Monitor surgical site for infection/hematoma
  • Tight blood pressure control
  • Pulmonary hygiene
  • Avoid lifting >10 pounds

Hemodynamics - Devices

• Pulmonary Artery (PA) Catheter:
  • Measures pressure in pulmonary arteries.
  • Evaluates left ventricle function
  • Measures mixed venous oxygen saturation (SvO2)

Arterial Line

• Indications: Continuous BP monitoring, ABG/O2
• Considerations: ARDS

Central Line

• Indications: Monitoring right heart function (SvO2)
• Considerations: Medications can be administered through line

Spinal Cord Injury – Complete vs. Incomplete

• Complete: No motor or sensory function below the level of injury.
• Incomplete: Some motor or sensory function remains below the level of injury.

Incomplete SCI types and symptoms

• Central Cord Syndrome: Hyperextension injury, more motor and sensory loss in the upper extremities than the lower extremities.
• Anterior Cord Syndrome: Compression of the anterior spinal cord, resulting in motor loss, loss of pain and temperature sensation, with preserved proprioception.
• Posterior Cord Syndrome: Compression of the posterior spinal cord, resulting in loss of proprioception and vibration sense, with preserved pain, and temperature sensation.
• Brown-Sequard Syndrome: Hemisection of the spinal cord; ipsilateral (same side) motor paralysis and loss of proprioception and vibration; contralateral (opposite side) loss of pain and temperature sensation.

Burn Assessment Methods

• Rule of Nines: Divides the body into percentages to quickly estimate the total body surface area (TBSA) burned.
• Rule of Palms: Palm of the patient's hand covers approximately 1% of TBSA
• Lund-Browder Chart: More precise method for estimating TBSA burned compared to the Rule of Nines. Takes into account the patient's body proportions.

Mass Casualty Incidents (MCI)

• Triaging Goals: To maximize the overall survival rate by prioritizing the "Greatest Good for the Greatest Number" (e.g. greatest number of lives saved).

START Triage

• Time Objective: Complete in 60 seconds
• Components:
  • Respirations (R: 30 seconds)
  • Perfusion (P: 20 seconds)
  • Motor (M: can do )
  • Assess airway, control breathing, apply pressure to bleeding areas, immobilize the injury area.

Disaster Cycle

• Mitigation: Prevention measures (e.g., disaster preparedness planning )
• Preparation: Gathering supplies, training.
• Response: First responders and agencies respond to the incident.
• Recovery: Restoring function/community to a pre-disaster state.

Burn Types

• First-degree: Superficial burning of the epidermis only, mild redness, pain, and blanching on touch.
• Second-degree (superficial): Epidermis and some dermis burned, blisters, pink/red, easily blanches, heals in weeks.
• Second-degree (deep): All epidermis and dermis are damaged, waxy appearance, cherry-red scarring, slow healing, considerable edema.
• Third-degree: Severe burn. All layers of skin are destroyed - including underlying tissues, subcutaneous fat, muscle, and bone. Appearance: dry/leather-like, no pain, pale, white, or black color, and no blanching.

Basilar Skull Fractures

• Symptoms (S/S): Battle's sign, raccoon eyes, halo sign, bleeding from ears, nose

• Nursing Interventions (NI):

  • No NG tubes
  • Monitor for CSF leak/Increased intracranial pressure (ICP)
  • Neuro checks
  • Monitor vital signs
  • Don't allow blowing nose

• Treatment (TX): Airway management and head elevation.