Normal blood gases; pH
7.35-7.45
Normal blood gases: CO2
35-45
Normal blood gases: HcO3
22-26
Normal blood gases: PO2
80 or
... [Show More] above
Normal vacuum pressures for suction?
120-140 mmHg
What may a high pressure vent alarm indicate?
Pt is biting on the tubing, excessive secretions in the tubing, kinked tubing
What may a low pressure vent alarm indicate?
cuff leak or the tubing is disconnected somewhere
How do you verify positioning of an endotracheal tube?
-auscultate lung bases and apices for bilateral breath sounds
-observe chest for symmetric chest wall movement
-confirm with end tidal CO2 measure
GOLD STANDARD: chest x-ray
t/f: people with ET tubes should be suctioned routinely
FALSE-- they should be suctioned on an as needed basis
what should ET tube cuff pressure be kept at?
20-25 mmHg
What measures should nurses take to avoid ET tube problems?
-confirm that exit mark on ET tube remains constant when providing patient care, repositioning, and transporting patient
-maintain proper cuff inflation (listen for an air leak-- if pt can talk, you must inflate more)
-continually monitor SpO2, RR, HR and rhythm, mental status, and ABGs
-pre-oxygenate before suctioning
What should be done if a patient is not tolerating ET tube suctioning?
STOP and manually hyperventilate with 100% oxygen
Measures to prevent aspiration?
-avoid bolus tube feedings
-monitor tube feeding residuals
-maintain HOB at LEAST 30 degrees or greater
-maintain proper ET tube cuff inflation
-perform frequent oral pharyngeal suctioning
-maintain an NG tube connected to low, intermittent suction if feeding tube is placed below the pylorus
what are recommendations for preventing ventilator associated pneumonia?
-manage ventilated patients without sedatives whenever possible
-interrupt sedation once a day (spontaneous breathing trials)
-provide early exercise and mobility
-provide regular oral care
-minimize pooling of secretions above the ET tube cuff
-use ET tubes with subglottic secretion drainage for patients likely to require greater than 72 hours of intubation
-keep HOB elevated 30-45 degress
-change ventilator circuit only if visibly soiled or malfunctioning
What is the biggest complication associated with high cervical spinal cord injuries?
BREATHING-- the diaphragm is innervated by C3-C5 levels
C4-diaphragm
will likely need mechanical ventilation mgmt
signs and symptoms of increased intracranial pressure?
-altered LOC
-headache
-bradycardia
-decreased respirations
-acute HTN with widening pulse pressure
-N/V
-worsening neuro deficits
-pupils that are nonreactive
What are the components of a neuro exam? (7)
1. LOC
2. mental status and cognitive function
3. cranial nerves
4. motor
5. sensory
6. coordination
7. reflexes
What are the three components of the glasgow coma scale?
1. eye opening
2. motor
3. verbal
What is a negative and positive babinski reflex? what do each indicate?
negative (normal) response: toes curl downward
positive (pathologic) response= toes curl upward
a positive babinski in adults indicates dysfunction in the motor pathways of the brain or spinal cord
what is the initial dosing of tpa?
-0.9 mg/kg
-10% as a bolus over 1 minute and 90% as continuous infusion over 60 minutes
What are the requirements for receiving tpa?
-onset of stroke was within 3-4.5 hours
-CT negative for bleed or lesion
-glucose >50
During the thrombolytic infusion of tpa, neuros need to be assessed every ___ minutes
15
What are the frequency of neuro checks after receiving thrombolytic tpa infusion?
-VS and neuro checks every 15 min for 1 hour
-every 30 min for 6 hours
-then every hour for 16 hours
what are possible complications of rTPA?
-signs of ICH or ICP
-systemic bleeding (wait 6 hours before inserting devices like foleys, etc)
-angioedema of airway
for patients receiving rTPA or IA therapy, treat prn for SBP > ____ mmHg or DBP > ____ mmHG
treat for SBP >180 or DBP >105 mmHG
we want to manage hypertension!!!
Acute mgmt measures for ischemic stroke patients?
1. aspirin within 24 hours
2. NS (Avoid hypotonic IV solutions)
3. blood glucose maintain less than or equal to 150 mg/dL
4. surgical consult
5. no indication for steroids or anticonvulsants
6. rehab (PT/OT/SLP consults)
in HEMORRHAGIC stroke patients, what do we want to keep their blood pressure at?
SBP >150 mmHG and DBP >105
what do we want to keep ischemic stroke pt's BPs who have not received tpa?
Treat PRN if SBP >220 mmHg, DBP >120 mmHG or MAP >130
what is the main complication with IV dilantin?
must ONLY be combined with NS
what occurs in SIADH?
too much ADH!!!
what are some neuro causes of SIADH?
TBI
SAH
stroke
CNS infection
brain tumors
Guillian-Barre (GBS)
MS
pituitary adenoma
What is the recommended treatment for SIADH? (3)
1. fluid restriction
2. diuresis (Lasix)
3. administer sodium -- 3% saline (Frequent Na labs)
Do not increase Na more than ___ mEq/L in 24 hours period d/t risk for central pontine myelinolysis
10
what is occurring in diabetes insipidus?
not enough production of ADH!!!
What are s/sx of DI?
-increased urine output (>250 cc/hr)
-increased thirst
-dehydration symptoms
-dilute urine (low specific gravity 1.001-1.005)
-decreased urine osmolality (<400 mOsm/kg H20)
-low urine Na
-concentrated blood (serum osmolality >295 mOsm/L)
-hypernatremia (>145)
Treatment for Diabetes Insipidus (DI)?
1. replace volume (oral fluids/IV fluids)
2. replace ADH by giving DDAVP or Vasopressin
drugs given for increased ICP?
3%
mannitol
23%
what are s/sx of DKA?
patient history
-polyuria
-polydipsia
-weight loss
-vomiting
-blurry vision
-weakness
-abdominal pain
Physical findings
-poor skin turgor
-kussmaul respirations
-fruity breath
-tachycardia
-hypotension
-mental status changes
what are the three main components of treatment for DKA?
1. REHYDRATE
2. RESTORE GLUCOSE METABOLISM
3. CORRECT ELECTROLYTES AND ACIDOSIS
what is the progression of IVF administration during DKA?
-start with 1 L bolus NS over 1 hour
-500 mL/hr for 2 hours
-150 mL/hr for 1 hour
-once glucose 250 mg/dL, change to D5 NS 0.45% 125 mL/hr
why do we add D5 to solutions for DKA treatment later on?
because hyperglycemia is corrected much faster than acidosis!!
-the addition of dextrose to the fluids allows continued insulin administration until the ketonemia is cleared, while preventing hypoglycemia
Do not start an insulin infusion for treatment of DKA until it is confirmed that the L level is greater than ____
3.3 mEq/L
what do we give to correct electrolytes and acidosis in DKA?
potassium and bicarbonate!
Why can hypokalemia occur in dka treatmnet/
because potassium shifts with insulin
what are s/sx of hyperglycemia?
polydipsia
polyphagia
polyuria
fruity breath
nausea/vomiting
What are s/sx of hypoglycemia?
increased HR, sweating, shaking, HA, vision changes (blurred)
What is treatment for hypoglycemia?
1. if eating, give 15 g of fast acting carbohydrate like juice, oral gel, or glucose tablets
-NOTE: repeat up to three times
2. if pt is NPO, administer 15-20 grams 50% dextrose
3. give glucaagon 1 mg IM if IV access not prompty available
Treatment for hyperglycemia?
usually insulin
-follow endotool
what is the impact of critical illness on blood sugars?
critical illness causes hyperglycemia-- the patient will require increased dosages of insulin
what meds should be tapered to prevent adrenal problems?
corticosteroids
Onset/Peak/Duration of Rapid-acting insulin? (Novolog)
Onset: 15-30 minutes
Peak: 0.5-3 hours
Duration: 3-6 hours
Onset/Peak/Duration of REGULAR insulin (humulin r)?
Onset: 30-60 minutes
Peak: 1-5 hours
Duration: 6-10 hours
Onset/Peak/Duration of intermediate acting insulin (NPH)?
Onset: 1-2 hours
Peak: 6-14 hours
Duration: 16-24 hours
Onset/Peak/Duration of Long-acting insulin (Lantus)?
Onset: 1-2 hours
Peak: relatively peakless
Duration: 18-24 hours
Lab indicators of renal failure
INCREASED CREATININE (>1.2)
INCREASED BUN (>20)
INCREASED POTASSIUM
FlUID OVERLOAD
what adjustments are made with meds in renal failure?
med dosages are decreased or the time between subsequent dosages is increased
diet restrictions in acute renal failure (What would a tube feed consist of)?
low potassium
low sodium
low phos
low protein
what are some complications of acute renal failure?
-fluid overload
-hyperkalemia (cardiac dysrhythmias)
-HTN
-metabolic acidosis
What is normal urine output?
30 mL/hr
CAUTI prevention measures
-frequently assess need for catheter
-prevent dependent loops
-always assure that bag is less than half full
-perform peri care every shift
-maintain tubing free of kinks
-if breaks in system are noted, replace catheter and collecting system
NG tube placement verification
Gold standard for confirmation is x-ray
Assessing for GI bleed
coffee ground drainage in suction container
Aspiration precautions for gI patient
-elevate hob 30-45 degrees
-consider post-pyloric placement of feeding tube if residuals continue to be above 500 mL
-Consider prokinetics to promote gastric emptying (such as erythromycin, metoclopramide, or naloxone) after three consecutive residuals > 500 mL
what are some indications for GI suction?
to decompress the stomach (aspiration of gastric fluid content)
if theres an obstruction
what should be your first action when a transfusion reaction occurs?
stop the infusion!
what are some types of transfusion reactions?
hemolytic
febrile rxn
allergic
TRALI
transfusion related immunmodulation (TRIM)
treatment for hemolytic transfusion reaction
Hemolytic transfusion reactions are treated as follows:
Stop transfusion as soon as a reaction is suspected
Replace the donor blood with normal saline
Examine the blood to determine if the patient was the intended recipient and then send the unit back to the blood bank
Furosemide may be administered to increase renal blood flow
Low-dose dopamine may be considered to improve renal blood flow
Make efforts to maintain urine output at 30-100 mL/h
treatment for anaphylactic blood reaction
Anaphylactic reactions are treated as follows:
Stop the transfusion immediately
Support the airway and circulation as necessary
Administer epinephrine, diphenhydramine, and corticosteroids
Maintain intravascular volume
treatment for febrile infusion reaction
Aggressive treatment of simple febrile reactions is not necessary; however, because the nonspecific symptoms are similar to those of a hemolytic transfusion reaction, differentiating this entity from a hemolytic reaction is necessary
The transfusion should be terminated
Evaluate the patient for evidence of hemolysis
The patient's fever can be treated with acetaminophen
what are the compensatory mechanisms for patients in shock?
epi and norepi are released >> increase HR, SBP, RR, dilate coronaries
ACTH, cortisol released and blood sugar increases
RAAS system activated >> na+ and water retention occur with decrease in urine output
Treatment for hypovolemic shock
1. fluids fluids fluids! (crystalloid/colloid replacement, RBC for hemorrhage)
2. support oxygenation
3. vasopressors started after fluid replacement
WHAT ARE s/sx of cardiogenic shock?
decreased BP, increased HR
increased filling pressures (CVP, wedge)
increased SVR
decreased CO, CI
what is the indicated treatment for cardiogenic shock?
1. support myocardial perfusion by decrease filing pressures and SVR (vasodilators like nitoglycerin)
2. use inotropes to support increase in CO (dobutamine, milrinone)
3. control rhythm disturbances
4. reduce myocardial workload and improve coronary flow (stent, bypass surgery)
5. remove obstruction (cardiac tamponade-- drain, aspirate or PE- give antithrombotic)
what are the hemodynamic changes during anaphylactic shock?
decreased BP
increased HR
CO/CI decreased
CVP/PAWP decreased
SVR decreased
Treatment for anaphylactic shock?
1. REMOVE the causative factor
2. maintain patent airway
3. give epinephrine
4. meds! vasopressors, bronchodilators, benadryl, steroids, histamine blockers
5. educate to prevent in future
Treatment for sepsis
1. draw lactate within 3 hours
2. blood cultures and abx within 1 hour
3. FLUIDS!!! 30 mL/kg of crystalloid fluids
4. start pressors to keep MAP > 65 (LEvophed is first choice)
5. inotrope like dobutamine added if they have evidence of myocardial dysfunction [Show Less]