Critical care HESI
spinal cord injury at the scene - ANS-Nursing interventions are focused on stabilization
of the spine, preserving the airway and
... [Show More] respiratory status and preventing complications
associate with SCI. Assessment of respiratory and neurological status is first priority,
might need to be tubed. If in neurogenic shock, they cannot regulate body temperature
teaching for ICD - ANS-site care and symptoms of complications, hematoma at the site
is common, wear a medic alert bracelet, when device fires the patient will feel either
tingling or discomfort or wont even know it went off. avoid strong magnetic fields (MRI),
keep cell phones 6 inches from ICD, may fire when tachycardic, avoid driving for 6
months if hx of cardiac arrest, teach family CPR
ventilator alarms - ANS-can be caused by biting tube, kinks, need suctioned or trying to
talk
ARDS and lung trauma - ANS-Refractory hypoxemia: hallmark sign of ARDS. FiO2
could be 100% but Pao2 is <60%. only intervention is ECMO which is difficult because
adults need anticoagulation therapy.
Bilateral patchy infiltrates: patches of white on a lung x ray
Noncompliance of the lung: it will not expand, need to be sedated
-initial ABGs show low CO2 because of hypervention then it flips to metabolic acidosis
- lungs clamp down so it is difficult to breath, capillary membrane damage)
Treatment: ventilator, lung protective strategies (low TV, FiO2 at nontoxic levels ~60%,
unconventional vent settings i.e. RR 300-420 BPM)
VAP - ANS-main cause is aspiration, poor oral hygiene, contaminated equipment.
strategies to reduce VAP: - elevated HOB 30-45 degrees, hand hygiene and gloves
when suctioning, suction above cuff before deflation, oral hygiene Q2!!!!
documentation of pneumothorax breath sounds - ANS-they are absent
tension pneumothorax and trauma - ANS-tension pneumo can be caused by
mechanical ventilation. pressurized air enters the pleural space and continues to
accumulate which causes an increase in pressure, increasing amount of alveoli collapse
and pressure on the heart and great veins. immediate insertion of a chest tube is
needed and removed from vent
chest tube assessment - ANS-splint insertion site to facilitate coughing and deep
breathing. do not milk the tube, do not clamp the tube
mechanical ventilator and respiratory acidosis - ANS-If the ventilator is set at a low RR
(e.g., 2 to 6 breaths per minute) and the patient does not have an adequate drive to
initiate additional breaths, respiratory acidosis may occur. Ideally the VT and RR are set
to achieve a VE that ensure a normal PaCO2 level
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