Critical Care Nursing: Med Surge 3.
Exam 2 (Answered) 2022
· Post-op nursing interventions for AAA with a graft
o Must lie supine for 6 hours
o Assess femoral artery site
o Monitor circulation and peripheral pulses
o Maintain appropriate fluid volume
o No activities that can increase intrathoracic/ intra-abdominal pressures
o Monitor for fever - infection or implant rejection
CNA Post-Op AAA Graft Concern
o CNA tries to take aneurysm post op out of bed to bathroom, tell them no
AAA Rupture Symptoms
o Severe lower back and abdominal pain
AAA Classic Sign
**Classic sign: pulsatile mass in middle to upper abdomen with systolic bruit
Many patients are asymptomatic until rupture
Medical Intervention for Cardiac Tamponade
Pericardiocentesis
Aspiration of pericardial fluid
Fluid tested
Pericardiotomy (pericardial window)
For chronic pericardial effusions
Surgical procedure to create drain from pericardium to lymphatic system
Cardiac Tamponade Assessment Findings
Beck's Triad
Decreased BP
Increased JVD
Muffled Heart Sounds
Pulsus Paradoxus - systolic BP lower during inspiration than expiration
Chest pain, dyspnea, tachypnea, tachycardia***
What type of shock is pericardial effusion, cardiac tamponade?
Obstructive Shock
Expected Orders for Patient in DIC
Treat underlying cause
Support organs (oxygenation, fluids, electrolytes, vasopressors)
Heparin administration
Inhibits conversion of prothrombin to thrombin (blocks fibrin formation)
, Used to prevent DIC and to keep DIC from getting worse
Volume and blood replacement
Isotonic Fluids (NS, LR)
PRBC
FFP
Cryoprecipitate
Platelets
What is the biggest risk factor for DIC?
Sepsis
DIC Labs
Platelets Decrease
Fibrinogen Decreased
PT/aPTT Prolonged
D-Dimer Increase
Microvascular and Frank Bleeding
Petechiae
Bleeding gums, oozing from wounds, previous wounds
Tachycardia
Tachypnea
Retroperitoneal (flank bleeding)
Hematuria
Anxiety, restlessness, decreased mentation, altered LOC
Microvascular Thrombosis
Decreased temp and sensation
Increased pain and cyanosis in extremities
Decreased Pulse
Long Cap Refill
Hypoxia, Dyspnea, Chest Pain
Heartburn
Decreased urine output, increased BUN, increase creatinine
Decreased Alertness and orientation and pupil reaction and strength
Clinical Manifestations of DIC
The clinical manifestations of DIC are primarily reflected in compromised organ function
or failure. Decline in organ function is usually a result of excessive clot formation (with
resultant ischemia to all or part of the organ) or, less often, of bleeding.
Patients with frank DIC may bleed from mucous membranes, venipuncture sites, and
the GI and urinary tracts. The bleeding can range from minimal occult internal bleeding
to profuse hemorrhage from all orifices. Patients typically develop MODS, and they may
exhibit acute kidney injury as well as pulmonary and multifocal central nervous system
infarctions as a result of microthromboses, macrothromboses, or hemorrhages.
During the initial process of DIC, the patient may have no new symptoms—the only
manifestation being a progressive decrease in the platelet count. As the thrombosis
becomes more extensive, the patient exhibits signs and symptoms of thrombosis in the
organs involved. Then, as the clotting factors and platelets are consumed to form these
thrombi, bleeding occurs. Initially, the bleeding is subtle, but it can develop into frank
Exam 2 (Answered) 2022
· Post-op nursing interventions for AAA with a graft
o Must lie supine for 6 hours
o Assess femoral artery site
o Monitor circulation and peripheral pulses
o Maintain appropriate fluid volume
o No activities that can increase intrathoracic/ intra-abdominal pressures
o Monitor for fever - infection or implant rejection
CNA Post-Op AAA Graft Concern
o CNA tries to take aneurysm post op out of bed to bathroom, tell them no
AAA Rupture Symptoms
o Severe lower back and abdominal pain
AAA Classic Sign
**Classic sign: pulsatile mass in middle to upper abdomen with systolic bruit
Many patients are asymptomatic until rupture
Medical Intervention for Cardiac Tamponade
Pericardiocentesis
Aspiration of pericardial fluid
Fluid tested
Pericardiotomy (pericardial window)
For chronic pericardial effusions
Surgical procedure to create drain from pericardium to lymphatic system
Cardiac Tamponade Assessment Findings
Beck's Triad
Decreased BP
Increased JVD
Muffled Heart Sounds
Pulsus Paradoxus - systolic BP lower during inspiration than expiration
Chest pain, dyspnea, tachypnea, tachycardia***
What type of shock is pericardial effusion, cardiac tamponade?
Obstructive Shock
Expected Orders for Patient in DIC
Treat underlying cause
Support organs (oxygenation, fluids, electrolytes, vasopressors)
Heparin administration
Inhibits conversion of prothrombin to thrombin (blocks fibrin formation)
, Used to prevent DIC and to keep DIC from getting worse
Volume and blood replacement
Isotonic Fluids (NS, LR)
PRBC
FFP
Cryoprecipitate
Platelets
What is the biggest risk factor for DIC?
Sepsis
DIC Labs
Platelets Decrease
Fibrinogen Decreased
PT/aPTT Prolonged
D-Dimer Increase
Microvascular and Frank Bleeding
Petechiae
Bleeding gums, oozing from wounds, previous wounds
Tachycardia
Tachypnea
Retroperitoneal (flank bleeding)
Hematuria
Anxiety, restlessness, decreased mentation, altered LOC
Microvascular Thrombosis
Decreased temp and sensation
Increased pain and cyanosis in extremities
Decreased Pulse
Long Cap Refill
Hypoxia, Dyspnea, Chest Pain
Heartburn
Decreased urine output, increased BUN, increase creatinine
Decreased Alertness and orientation and pupil reaction and strength
Clinical Manifestations of DIC
The clinical manifestations of DIC are primarily reflected in compromised organ function
or failure. Decline in organ function is usually a result of excessive clot formation (with
resultant ischemia to all or part of the organ) or, less often, of bleeding.
Patients with frank DIC may bleed from mucous membranes, venipuncture sites, and
the GI and urinary tracts. The bleeding can range from minimal occult internal bleeding
to profuse hemorrhage from all orifices. Patients typically develop MODS, and they may
exhibit acute kidney injury as well as pulmonary and multifocal central nervous system
infarctions as a result of microthromboses, macrothromboses, or hemorrhages.
During the initial process of DIC, the patient may have no new symptoms—the only
manifestation being a progressive decrease in the platelet count. As the thrombosis
becomes more extensive, the patient exhibits signs and symptoms of thrombosis in the
organs involved. Then, as the clotting factors and platelets are consumed to form these
thrombi, bleeding occurs. Initially, the bleeding is subtle, but it can develop into frank
