NUR 425-Complex Care Exam 1 Blueprint 2023/2024 (Updated)

NUR 425-Complex Care Exam 1 Blueprint 2023/2024 (Updated). You should know the normal values for: • Serum Potassium: o 3.5-5.0 mEq • PR interval: o 0.12-0.20 sec • QRS interval: o 0.12 sec • Central Venous Pressure (CVP) in adults o 2-8mmHg • Cardiac Output (CO) in adults o 4-8L/min • Cardiac Index (CI) in adults o 2.2-4L/min/m^2 • MAP in adults o 70-105mmHg • Normal vital signs parameters for adults o BP: 120/80 o HR: 60-100 o RR: 12-20 o Temp: 97.8-99.1F, o Pulse Ox: 95-100% • Normal INR o 0.8-1.2 sec Understand the significance of the following Not required to memorize actual normal ranges • Systemic Vascular Resistance (SVR) o Resistance to left ventricle • Pulmonary Vascular Resistance (PVR) o Resistance to right ventricle • Wedge Pressure (PAOP/PAWP) o Estimates the left atrial pressure by “looking through” the lungs • Stroke Volume o Amount of blood ejected from left ventricle o Measure of CONTRACTILITY o Volume measured in mL • Ejection fraction o Fraction (percentage) of blood ejected from the left ventricle with each beat o Measure of CONTRACTILITY o Left ventricle must squeeze hard enough to get blood out • Serum Lactate o When pt is unable to perfuse oxygen, aerobic metabolism converts to anaerobic metabolism and lactate is released. o Elevated serum lactate indicates significant hypoperfusion • PTT/aPTT o Partial Thromboplastin Time o May be prolonged with DIC o Measures integrity of the intrinsic system • D-Dimer o Detects protein that results from clot breakdown o Indicated that fibrin has been formed and degraded (fibrinolysis) o Often markedly elevated with DIC o Unlikely DIC if this test is normal • Fibrinogen o Clotting factor that typically is low with DIC • The concept of a therapeutic PTT and INR o PTT: o INR: While taking Warfarin, it is typically expected that INR (standardized measurement of PT) is prolonged. ▪ 2-3 seconds You DO NOT need to memorize the coagulation cascade (eg. which factors activate which factors), just a general understanding of its purpose and what happens if there are more or less clotting factors, if it is slowed down/sped up, and what triggers the coagulation cascade. The following medications could be tested on this exam. You should know the medication’s indications, side effects, and nursing considerations when administering these: • Warfarin (Coumadin) - Anticoagulant o Interferes with synthesis of clotting factors that use Vitamin K to be synthesized o Will not affect factors already floating around, will prevent future factors from being made o Indications: ▪ Venous Thrombosis ▪ Pulmonary Embolism ▪ A-fib ▪ Myocardial Infarction o Nursing Considerations: ▪ Can cause bleeding ▪ Aspirin and NSAIDs increase risk of bleeding ▪ Therapeutic levels: PT 15.5-35 seconds, INR 2-3 ▪ Avoid alcohol ▪ Avoid foods that have a lot of Vitamin K: green vegetables, grains, mayo, canola and soybean oil ▪ Vitamin K is antidote o Contraindications: ▪ Vitamin K deficiency ▪ Liver disease ▪ Alcoholism ▪ Pregnancy • Aspirin – Non opioid analgesic, antiplatelet o Platelet aggregation leading to a decrease in ischemic diseases o COX inhibitor o Irreversible 7-10 days o Indications: ▪ Ischemic strokes and MI prophylaxis ▪ Angina o Nursing Considerations: ▪ Increases risk for bleeding with warfarin, heparin, clopidogrel ▪ Monitor LFTs ▪ Increased risk for GI bleeding very high with NSAID, alcohol use o Contraindications: ▪ Hemorrhagic stroke ▪ PUD o Caution: ▪ Renal dysfunction ▪ Pregnant women ▪ Smokers ▪ Nasal polyps • Clopidogrel (Plavix) – Antiplatelet o Inhibits platelet aggregation o Blocks ADP receptors o Irreversible 7-10 days o Indications: ▪ Artherosclerotic events ▪ MI, ACS ▪ CVA, PVD o Nursing Considerations: ▪ Monitor for signs of bleeding ▪ Monitor CBC and platelet count ▪ Discontinue 5-7 days before surgery ▪ Watch for TTP in first two weeks • Dabigatran (Pradaxa) - Anticoagulant o Directly inhibits thrombin o Indications: ▪ CVA prophylaxis ▪ Non-valvular A-fib o Nursing Considerations: ▪ Do not need INR checks ▪ GI distress ▪ Strict schedule-BID ▪ Antidote: Praxbind ▪ Pt do not need to focus on diet compared to warfarin • Heparin - Anticoagulant o Prevents clotting by activating antithrombin, thus indirectly inactivating both thrombin and factor Xa.-- “revs up” antithrombin o Indications: ▪ Venous thrombi ▪ DVT prophylaxis, current DVT, AMI, DIC o Nursing Considerations: ▪ Cannot dissolve existing clots, prevents further clot formation ▪ PTT: 1.5-2x control value ▪ Treatment for hemorrhage: Protamine Sulfate ▪ SubQ injections 2 inches from umbilicus o Adverse Effects: ▪ Bleeding ▪ Heparin Induced Thrombocytopenia ▪ Hypersensitivity o Contraindications: ▪ Thrombocytopenia ▪ Uncontrollable bleeding ▪ Surgery ▪ Lumbar puncture o Caution: ▪ Hemophilia ▪ Aneurysm ▪ Severe HTN ▪ Severe liver or kidney disease • Enoxaparin (Lovenox) - Anticoagulant o Inactive factor Xa, o Inidications: ▪ At home use o Nursing Considerations: ▪ Lower risk for thrombocytopenia ▪ Do not need to monitor PTT ▪ Longer half life ▪ Antidote: Protamine Sulfate • Midazolam (Versed) – Benzodiazepine o Acts to produce CNS depression o Indications: ▪ Sedation/ conscious sedation ▪ Anesthesia o Nursing Considerations: ▪ Assess level of sedation ▪ Monitor BP, pulse, resp during IV admin ▪ May lead to apnea, cardiac arrest, resp depression ▪ Antidote: Romazicon (flumazenil) • Propofol – Sedative, General Anesthetic o Produces amnesia with no analgesic properties o Indications: ▪ Anesthesia ▪ Sedation o Nursing Considerations: ▪ Can cause apnea, bradycardia, hypotension ▪ Can turn urine green ▪ Burning and pain at insertion site ▪ Assess respiratory status and hemodynamics, and level of sedation ▪ Maintain patent airway • Fentanyl • Epinephrine • Diphenhydramine • Amiodarone - Antiarrhythmias • Atropine • Adenosine • Magnesium • Furosemide - Diuretic • Norepinephrine • Metoprolol – Beta-Blocker • Dopamine • Dobutamine • Nitroglycerine - Vasodilator • General understanding of indications for specific blood products (RBCs, FFP, Cryoprecipitate, Platelets) and nursing considerations for blood transfusion reactions Distribution of Questions by Learning Outcome (LO) Week 1: Monday (ICU Pain, Sedation, Delirium): 5 questions • LO 1 and LO 2 (1 question), LO 3 (1 question), LO 4&6 (1 question), LO 5 (1 question) ; LO 7 (1 question) Week 1: Wednesday (Dysrhythmias & Pacemakers): 13 questions • LO 1 (5 questions), LO 2(1 question), LO 1&2 (1 question) LO 1,2,3 (3 questions), LO 4 & 5 (1 question), LO 6&7 (2 questions) Week 2: Monday (Hemodynamics): 10 questions LO 1 & 2 (3 questions), LO 3&4 (1 question), LO 1,3,&4 (1 question), LO 3,4,&5 (1 question), LO 1,2,& 7 (1 question), LO 6&7 (2 question), LO 5,6,&7 (1 question) *Some questions for LO 2 may overlap with related content from LO 4 in the shock module Week 2: Wednesday (Shock, AMI): 12 questions LO 1,2,&3 (1 question), LO 4,5,&6 (1 question), LO 2,3,&4 (1 question), LO 3&4 (1 question), LO 6 (2 questions) LO 7 (2 questions), LO 7a (1 question), LO 8&9 (1 question), LO 9 & 10 (2 questions) Week 8: Wednesday (DIC, Antiplatelet and Anticoagulant Review): 10 questions LO 1 (1 question), LO 2&4 (1 question), LO 3 (1 question), LO 4 (1 question), LO 5 (1 question), LO 6 (2 question) LO 6& 7 (1 question), LO 8&9 (1 question), LO 9 (1 question) Associated Learning Outcomes for Each Module Week 1 Monday (Sensory Perception/Pain/Sedation): (5) 1. Describe pain assessment strategies appropriate for the ICU setting 1. Verbal: 1. 1-10 scale 2. Pt self-report 2. Non-Verbal: 1. Critical Care Pain Observation Tool 1. Facial expression: relaxed-tense-grimacing 2. Body movements: absence of movement-protection-restlessness 3. Muscle tension: relaxed-tense, rigid-very tense, rigid 4. Compliance w/ ventilator: tolerating-coughing but tolerating-fighting ventilator 2. Behavior Pain Scale 1. Facial expression: relaxed-partially tightened-fully tightened-grimacing 2. Upper limb movements: no movement-partially bent-fully bent/finger flexion-permanently retracted 3. Compliance w/ ventilator: tolerating-coughing-fighting-unable to control 2. Analyze appropriate methods for addressing pain issues in the critically ill patient 1. Drug: 1. Per protocol 2. Non-Drug: 1. Positioning 2. Cutaneous Stimulation: heat, cold, vibration 3. Massage, meditation 4. Distraction: Music, aromatherapy, conversation (pt can still hear you) 5. Presence of family member promotes healing, decreases anxiety 3. Define the purpose of sedation and reasons patients are sedated 1. Decrease LOC, establish state of calm. (does not always decrease pain!) 2. Used to minimize discomfort during procedures 3. Minimize psychological disturbance 1. Stress leads to fight or flight responses: tachycardia, hypertension, tachypnea, hyperglycemia 4. Control behavior 5. Goal: calm but easily arousable 4. Identify nursing roles in relation to the sedated patient (also considering specific sedative medications) 1. Medications (administration, monitoring): 1. Fentanyl: analgesic, rapid onset and offset 2. Midazolam (Versed): sedating properties, can lead to tolerance and withdrawal 3. Propofol: lipid-based, rapid onset and offset. 2. Risks (identify, assess) 1. Can lead to tolerance over time 2. Reduced REM sleep while under sedation, can impact learning and memories 3. Oversedation: leads to increased time on ventilator and length of stay 1. Goal is to get them off of sedation and out of hospital! 4. Undersedation: leads to hyper-catabolism, immunosuppression, hypercoagulability, SNS response 1. Pt can become stressed and body will have difficulty healing 2. Pt won’t be able to cooperate with interventions 3. Monitor 1. RASS scale 1. Goal is 0-2+ 4. Best practice to minimize use of sedation 1. Treat pain FIRST 1. Controlled pain may decrease anxiety leading to need for sedation 2. Sedate SECOND 3. Paralyze LAST