Critical Care NURS 440 Exam 1: Respiratory – Questions
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Terms in this set (97)
What does the A, in the ABCDEF bundle for Awakening Daily- Turning the sedation off to assess the
delirium in ventilated patients stand for? patient if they are ready to wean from the ventilator. Check
What would the nurse assess? Sedation levels and neurological status
What does the B, in the ABCDEF bundle for Breathing Trials- Ventilator weaning
delirium in ventilated patients stand for?
What does the C, in the ABCDEF bundle for Careful Choice of Sedation- Lowest amount for the safest
delirium in ventilated patients stand for? effect
What does the D, in the ABCDEF bundle for Delirium Assessment- Use of confusion assessment method
delirium in the ventilated patients stand for? (CAM-ICU)
What does the E, in the ABCDEF bundle for Early mobility and Exercise- ROM and ambulation ASAP
delirium in the ventilated patients stand for?
What does the F, in the ABCDEF bundle for Family integration- They may be the first to note behavior
delirium in the ventilated patient stand for ? changes.
What does the THINK method for T- Toxic situations (Heart failure, shock, dehydration, organ
underlying conditions that cause delirium failure)
stand for? H- Hypoxemia
I- Infection and Immobilization
N- Neglect (Not giving patient their glasses/ hearing aids)
K- K+ LYTE imbalances (electrolyte imbalances)
What is a pulmonary embolism? Blockage of the pulmonary artery by a clot that has traveled
from circulation to the lungs.
What are conditions that can contribute to a -Heart failure
pulmonary embolism ? -Cardiomyopathy
- Atrial Fibrillation
-Smoking
-Birth control
-Pregnancy/ post- partum
-Surgeries
-Trauma
-Cancer (Commonly ovarian and pancreatic)
, What are the three parts of Virchow's Triad Hypercoagulability- Polycythemia (Too many RBC's, cause
in blood coagulability? blood to become viscous --> Easy to clot)
Venous Stasis- DVT, atrial fibrillation
Endothelial injury- Vessel injury, infection, atherosclerosis, and
cellulitis
What symptoms would a patient with a -Pleuritic chest pain
pulmonary embolism experience? - Shortness of breath
-Dyspnea
- Apprehension (early sign --> cant breath = stresses patient
out)
- Increased respirations
-Increased CO2 (becomes lethargic after hyperventilation)
-Decreased oxygen levels
- Decreased blood pressure
- Cool clammy skin (typically massive PE)
What diagnostics can be done to detect a - D- Dimer (detects clot present, no specifics on location)
pulmonary embolism? -ABG's
-Chest x-ray
- ECHO
- Ultrasound for DVT
- Spiral CT
-V/Q scan (Ventilation/ perfusion scan, patient inhales
radioactive gas + IV radioisotope injected)
- Trans-esophageal echocardiogram
- Pulmonary angiogram (invasive, dye given and x-ray shows
vessels in lung for blockage)
What pharmacologic nursing considerations -Heparin drip/ Subcutaneous heparin
are there for a pulmonary embolism? -Lovenox subcutaneous
- TPA for clot dissolution
Prevention measures for patients at risk for a - Cough and deep breathe
pulmonary embolism - NO crossing legs, NO prolonged sitting
-Ted hose leg stockings
-SCDs
- Greenfield (IVC) Filter (filter placed in groin to filter clots
coming from lower extremities)
-Decrease anxiety (decreases respirations)
What is Acute Respiratory Distress Rapid progressing acute lung injury which results in
Syndrome (ARDS)? hypoxemic respiratory failure
The alveoli membranes are disrupted, causing infiltrates to
move into alveoli
What is a direct pulmonary traumas that - Aspiration
cause ARDS? -Pneumonia
-COVID19
-Near drowning
-Toxic inhalation
-Pulmonary contusion/ trauma
-Oxygen toxicity
-Transthoracic radiation
-Severe Acute Respiration Syndrome (SARS)
With Valid Solutions
Save
Students also studied
Sherpath: Diabetes Mellitus Chapter 21 Test Case Study 4 (Short
30 terms 24 terms 22 terms
jesssbee Preview kenanderson2017 Preview Brittany182
Terms in this set (97)
What does the A, in the ABCDEF bundle for Awakening Daily- Turning the sedation off to assess the
delirium in ventilated patients stand for? patient if they are ready to wean from the ventilator. Check
What would the nurse assess? Sedation levels and neurological status
What does the B, in the ABCDEF bundle for Breathing Trials- Ventilator weaning
delirium in ventilated patients stand for?
What does the C, in the ABCDEF bundle for Careful Choice of Sedation- Lowest amount for the safest
delirium in ventilated patients stand for? effect
What does the D, in the ABCDEF bundle for Delirium Assessment- Use of confusion assessment method
delirium in the ventilated patients stand for? (CAM-ICU)
What does the E, in the ABCDEF bundle for Early mobility and Exercise- ROM and ambulation ASAP
delirium in the ventilated patients stand for?
What does the F, in the ABCDEF bundle for Family integration- They may be the first to note behavior
delirium in the ventilated patient stand for ? changes.
What does the THINK method for T- Toxic situations (Heart failure, shock, dehydration, organ
underlying conditions that cause delirium failure)
stand for? H- Hypoxemia
I- Infection and Immobilization
N- Neglect (Not giving patient their glasses/ hearing aids)
K- K+ LYTE imbalances (electrolyte imbalances)
What is a pulmonary embolism? Blockage of the pulmonary artery by a clot that has traveled
from circulation to the lungs.
What are conditions that can contribute to a -Heart failure
pulmonary embolism ? -Cardiomyopathy
- Atrial Fibrillation
-Smoking
-Birth control
-Pregnancy/ post- partum
-Surgeries
-Trauma
-Cancer (Commonly ovarian and pancreatic)
, What are the three parts of Virchow's Triad Hypercoagulability- Polycythemia (Too many RBC's, cause
in blood coagulability? blood to become viscous --> Easy to clot)
Venous Stasis- DVT, atrial fibrillation
Endothelial injury- Vessel injury, infection, atherosclerosis, and
cellulitis
What symptoms would a patient with a -Pleuritic chest pain
pulmonary embolism experience? - Shortness of breath
-Dyspnea
- Apprehension (early sign --> cant breath = stresses patient
out)
- Increased respirations
-Increased CO2 (becomes lethargic after hyperventilation)
-Decreased oxygen levels
- Decreased blood pressure
- Cool clammy skin (typically massive PE)
What diagnostics can be done to detect a - D- Dimer (detects clot present, no specifics on location)
pulmonary embolism? -ABG's
-Chest x-ray
- ECHO
- Ultrasound for DVT
- Spiral CT
-V/Q scan (Ventilation/ perfusion scan, patient inhales
radioactive gas + IV radioisotope injected)
- Trans-esophageal echocardiogram
- Pulmonary angiogram (invasive, dye given and x-ray shows
vessels in lung for blockage)
What pharmacologic nursing considerations -Heparin drip/ Subcutaneous heparin
are there for a pulmonary embolism? -Lovenox subcutaneous
- TPA for clot dissolution
Prevention measures for patients at risk for a - Cough and deep breathe
pulmonary embolism - NO crossing legs, NO prolonged sitting
-Ted hose leg stockings
-SCDs
- Greenfield (IVC) Filter (filter placed in groin to filter clots
coming from lower extremities)
-Decrease anxiety (decreases respirations)
What is Acute Respiratory Distress Rapid progressing acute lung injury which results in
Syndrome (ARDS)? hypoxemic respiratory failure
The alveoli membranes are disrupted, causing infiltrates to
move into alveoli
What is a direct pulmonary traumas that - Aspiration
cause ARDS? -Pneumonia
-COVID19
-Near drowning
-Toxic inhalation
-Pulmonary contusion/ trauma
-Oxygen toxicity
-Transthoracic radiation
-Severe Acute Respiration Syndrome (SARS)
