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nurs 471: quiz
questions with
accurate answers
"Critical care nursing is that specialty that deals specifically with human responses to life threatening problems. correct answer A critical care nurse is a licensed professional nurse who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care." = could be stable or unstable, assess BP = bolus, pacing, atropine = increase HR PVC: perfusing, labs = K, electrolytes correct answer A-flutter: regular A-fib: irregular = beta blockers, anticoagulants STEMI: "tombstones", MI SVT: HR so fast, can't see P waves = CO decreases 0-8 hours: induction = 32-36 C 24 hours: maintenance = maintain at target temperature 48 hours: rewarming = 0.25 C/hr until temperature reaches 36 C correct answer ICU Management TTM Systemic effects Cardiovascular: HR does down Gastrointestinal: hypoactive Hematological: clotting Renal: slowed down Metabolic Accuracy dependent on:
Leveling transducer: level it with leveler with phlebostatic axis Zeroing system Square wave testing correct answer Normal Values HR 60-100 bpm SV 60-100 ml/beat CO 4.0-8.0 Liters/min CI 2.5-4.0 Liters/min/m Anoxic brain tissue = cerebral edema TTM: therapeutic hypothermia Cold = preserves brain Active treatment to achieve and maintain a specific temperature = between 32-36 C correct answer Goal is to preserve neurological function Ice packs under armpits, groin, neck or cooling blanket = arctic sun: machine with water put on patient to control temperature Slows cerebral metabolism, decreases oxygen consumption, lessens cerebral edema Are in renal failure and require adjustment of their diet Are intubated and require enteral or parenteral nutrition Have had surgery and require specialized nutrition correct answer Require nutritional therapy to modulate metabolic response to stress Have increased caloric and other nutritional needs following trauma or burns Arterial Line Complications Bleeding Impaired circulation Infection Thrombus Hematoma Nerve injury correct answer Central Venous Catheters
Output of the left heart Blood pressure Blood flow Arterial Pressure Systolic 90-140 mmHg Diastolic 60-90 mmHg MAP 65-100 mmHg CVP/RAP 2-6mmHg preload = 12 = overload ScvO2 & SvO2: 60-80% 02 supply demand correct answer PAP Systolic 15-25 mmHg Diastolic 5-15 mmHg PAP mean 8-16 mmHg PAWP 4-12 mmHG wedge preload LVED PVR <250 dynes · sec/cm5 = afterload SVR 800 - 1200 dynes · sec/cm5 = afterload Atrial Dual Ventricular Dead: all spikes = failure to capture correct answer Acute Coronary Syndrome Case Study Situation: Mrs. Dunham 56 year old female Background: HTN, hypothyroidism, anxiety, depression, and cigarette smoking Being restricted by tubes/lines Being unable to sleep Being unable to be in control Nurses response:
Communication = boards with pictures correct answer Comfort Pain assessment and management Sedation Delirium assessment and prevention Sleep Nutrition BLS/CPR should be initiated ASAP and should only be interrupted when absolutely necessary < seconds Sudden cardiac death: life vest Synchronized Cardioversion Electrical charge is synchronized with the QRS of the patient's heart rhythm R waves marked correct answer Patient placed on monitor with physician and emergency equipment at bedside Once pads are on, set defibrillator to synch, select proper electrical setting, MD determines amount of energy, often start at 100 joules Premedicate patient if able C. Administer epi 1 mg IV A. Pulseless V-tach A. Amiodarone B. 300 mg A. Epi can be given every 2-5 minutes correct answer A. Push hard (> 2 inch) and fast (100-200/min) Treat polymorphic V-tach? B. Mg replacement B. 2nd degree heart block B. V-fib C. Defibrillate at the same dose or higher than previous shocks Achieves ROSC A. Optimize oxygenation and ventilation
5-lead ECG placement: want accurate placement, might need to replace / 12-lead ECG placement / 15 or right sided ECG: RV infarcts Cardiac Output Measurement Thermodilution Performed every 4 hours Closed system 10 ml of injectate flushed Computer/Monitor will calculate Use average of 3 values correct answer Normal value? CCO: 2.5 = bad 4-8 liters 49, 60- Non invasive CO Monitoring Edwards LifeScience: EV1000 = put on finger = measures BP, CO, SV, SVV, SVR Dynamic measurement Cardiodynamnics Stroke volume x HR CO = HR x SV Normal: 4-8 L/min Cardiac index: CO adjusted to body size, 2.5-4L/min Ejection fraction: should be around 65 correct answer Heart rate: tachycardia, bradycardia Dec cardiac output for both Stroke volume 60-80 mL/beat Preload: filling pressure, vasodilators Afterload: compliance of aorta, SVR, surgery Contractility: "squeeze" or force of contraction Case Study
Mrs. Smith is a 67 y/o female, presents to ED with chest pain that is unrelieved by rest. She has had the pain for one day and it has significantly worsened over time. She also complains of weakness, shortness of breath and nausea. correct answer She rates her pain as a 10 on a 0-10 scale. PMHX: None Vitals: 36.6, 116, 26, 110/ SpO2 96% RA 12-lead ECG Labs: Troponin 0. Echo ordered Central Line Indications, does it look like it's supposed to or not? Rapid fluid administration Administration of vasoactive medication Frequent blood sampling, ScvO Assess volume status Assess need / infection daily correct answer Central Venous Pressure Monitoring What does this measure? Preload, RA, filling pressure Measurement of ScvO What does this show? O2 supply and demand... Chest pain ECG changes SOB N/V Weakness and fatigue Irregular heartbeat In severe cases, a pt. can have symptoms of heart failure with fluid overload, pulmonary edema and shock correct answer Exact cause unknown Stress response releases catecholamines "Stunned" heart
Titration: 25 mcg/hr q 15mins to achieve CPOT < 3 Max: 300 mcg/hr Side effects: apnea, bradycardia, hypotension, and respiratory muscle rigidity! Precedex CPOT Common reversible physiologic causes of anxiety and agitation include: Hypoxia Hypoglycemia Withdrawal Sleep deprivation Immobility Fear Pain? correct answer Common medications for sedation Propofol, diprivan Indications: Sedative-hypnotic agent administered to intubated mechanically ventilated patients Onset: seconds Duration: 3-5 minutes Complex patient: comorbidity, multimorbidity, substance abuse, etc. Complex / Critical Care "Direct delivery of medical care for a critically ill or injured patient. correct answer To be considered critical an illness or injury must acutely impair one or more vital organ systems so that a patient's survival is jeopardized." Components of Burnout Syndrome Exhaustion Emotional & Physical
Depersonalization Reduced Accomplishment Incivility Frustration Compassion fatigue correct answer Prolonged exposure can lead to moral distress compassion fatigue = burnout = PTSD, increased rates of job turnover, decreased patient satisfaction and quality of care Considerations What kind of pacemaker is it? Manufacturer? Is it functioning as it should? Does it need interrogation? Company has to come and check on it Potentially no MRIs correct answer National generic pacemaker code Examples: DDD = dual, dual, dual, VVI = ventricle, ventricle, inhibited Terminology Capture: ability of the heart to depolarize after the pacemaker fires an impulse Contractility: "Squeeze" or force of contraction Inc contractility inc stroke volume and after load dec contractility dec stroke volume and afterload: MI SV: 60-80 mL beats correct answer Elevated Preload RV: Volume overload, Stenotic or Insufficient valve, Pulmonary HTN, RV infarct LV: Volume overload, Stenotic or Insufficient valve, Cardiomyopathy, HF Decreased Preload Right Ventricle / Left Ventricle: Hypovolemia Defibrillation vs cardioversion Pad placement: on pace Defibrillation/AED
Side effects: hypotension, bradycardia, may turn urine green correct answer Precedex, dexmedetomidine Indications: both sedative & moderate analgesic activity. Sedation of intubated as well as non intubated patients. Onset: seconds Duration: 15 minutes EKG Analysis Analyze P wave Present? How many? P waves regular? Analyze QRS, R waves Present? How many? R waves regular? correct answer Determine heart rate Measure PR interval Measure QRS duration Measure QT interval Interpret rhythm Elements of Critical Illness or Injury Patient survival is jeopardized Unalterable, unstable, complex Impairment of one or more vital organs Care provided often within specialty unit Often special personnel and equipment correct answer Levels of Care I: most comprehensive ICU, teaching hospitals, special equipment, specialized doctors, nurses, pharmacist, nutritionist, etc., example: Stanford, UCSF Epicardial
Set rate & MA, ensure capture, ensure connections secure, keep pacer box within reach, inspect site, DC asap usually day 3-5 correct answer Permanent Immobilize arm first 24-48 hrs Monitor site for infection Monitor HR and BP, teach patient Failure to capture Signs & symptoms: bradycardia, hypotension, unstable Potential cause: hardware problem = lead contact, battery, electrolytes, drugs: beta blockers, MI Intervention: cardiology consult = may temporary need pacer pads placed correct answer Failure to sense: "undersensing", spikes are not where they are supposed to be Signs & symptoms: bradycardia, hypotension Potential causes: hardware problem, low native voltage Intervention: cardiology consult = may temporary need pacer pads placed go in groin or wrist, assessing for chest pain or groin site = bleeding, squirting from artery = pressure = femostop, 10-20 mmHg above systolic BP and checking to see if pulse in foot correct answer collagen plug: dissolves on its own, bruising, radial assess: TR band = pressure, check for circulation, can't bend for 6 hours, stay in bed Healthcare Environment is a Stressful Environment Sources of Moral Distress Balancing budgets, staff Workforce shortage Need to constantly do more with less correct answer High morbidity and mortality Confrontations with ethical dilemmas Tension-charged atmosphere = consequences Heart blocks
Potential complications II: comprehensive care for specific population, example: would be open heart surgery but not heart transplant = transfer III: able to stabilize critical patient but limited = transfer correct answer Open & Closed Units ICU Open: nursing, resp therapist, etc. but provider has patients throughout hospital, they rotate every month, have patients in ICU and elsewhere Inferior wall infarct: button of heart, right side = II, III, aVF Anteroseptal wall infarct: anterior = V1, V2, V3, V Lateral wall infarct: lateral = I, aVL, V5, V6 correct answer Normal sinus rhythm Sinus tachycardia: faster than 100, running, dehydration, stress, hypovolemia Sinus bradycardia: lower than 60, lightheaded, dizzy, about to pass out Inflate balloon = pain = block artery Angiogram DES LAD: look at coronary vesicles with dye to see what is blocked = do nothing or put in stent correct answer or bypass surgery = drug-eluting stents: to prevent clots or reocclusion = same symptoms but with discomfort = 12-lead ECG Malfunctions Failure to Pace Failure to Capture Failure to Sense Failure to pace: ventricular, no spike correct answer Signs & symptoms: bradycardia, hypotension Potential cause: hardware problem = lead contact, insulation, pulse generator, oversensing T waves Intervention: cardiology consult = may temporary need pacer pads placed Management 1:1 nurse Temperature probe
Mild sedation Prevent shivering Maintain hypothermia treat hyperthermia correct answer Pain medications Rationale for cooling patients post cardiac arrest = preserve neurological function Management of Delirium Treatment of delirium includes use of medication and environmental and supportive strategies correct answer Quetiapine: Seroquel 25-50 mg daily Haloperidol: 0.5-1 mg q 2-4 hours Dexmedetomidine: 0.2 mcg/kg/hr. max 1.4mcg/kg/hr, titrate RASS 0 to - meds: adenosine = stops HR/shock Torsade de pointes: Mg V-tach: stable V-fib: shock correct answer More about Afib In the Framingham Study, the annual risk of stroke attributable to a-fib was 1.5% among patients ages 50 through 59 years; this increased to 23.5% in patients age 80 years and older Megacode You're walking along the street when an elderly person ahead of you suddenly collapses. You rush to them and find them unresponsive.
- What would be your next step? correct answer B. Call for help
- What is the rhythm? D. V-fib C. Defibrillate 120-200 J C. Resume CPR for 2 minutes A. Analyze rhythm and repeat shock if needed Micra Pacemaker Micra is about one inch long and one-quarter of an inch wide
Not a preload problem because CVP is ok, have enough volume Give them vasopressor to get pressure up, echo, increase contractility correct answer Potential Complications CVP, nurses can take out line Carotid artery puncture Pneumothorax Hemothorax Hemorrhage Air embolism: cannot take out if in chair, lay down Thrombosis Dysrhythmia Catheter migration Cardiac perforation Infection Numeric scale, face's scale, etc. Pain assessment tool: critical care plan observation tool = CPOT facial expression body movements correct answer muscle tension evaluation by passive flexion and extension of upper extremities compliance with ventilator or vocalization Nursing care Transcutaneous Set monitor to pace, set rate & MA, ensure capture, inspect skin, medicate prn correct answer Transvenous Set rate & MA, ensure capture, ensure connections, keep pacer box within reach, inspect site Optimal patient outcomes = healthy work environment = true collaboration, appropriate staffing, etc. = clinical excellence I would define a healthy environment as one in which respect each other, collaborate, work as a team
Resilience correct answer Strategies for self care Recovery time (take a break) Establishing boundaries Time away Intentional Interruptions Organizational culture of safety: everyone on the same page for safety Simplify & standardize key processes: checklists Develop multidisciplinary approach: all a team, working together Adequate appropriate competent staffing Limit work hours correct answer Safety training: "Keep Me Safe: Universal Skills" pay attention to detail, avoid errors = STAR practice and accept a questioning attitude communicate clearly be accountable team member PA Catheter Management Management Assist provider with placement Observe/record various waveforms Exercise caution when "wedging" Titrate medications/Assess effectiveness correct answer Troubleshooting Ensure waveform is continuous Respond immediately to any alarms Patient/family needs + Nurse competencies = Optimal patient outcomes Patient characteristics, nurse competencies, patient and family outcomes, unit outcomes, system outcomes correct answer Patient Needs: laughter Stress & Worry from Patients
