CCRN/PCCN Certification Review Multisystem

CCRN/PCCN Certification Review Multisystem

What’s on the Exam CCRN and PCCN CCRN only Sepsis continuum
Wounds and pressure ulcers Healthcare acquired infections Palliative care End of life care Infectious diseases Pain Shock states CCRN only Bariatric complications Comorbidity in patients with transplant history Multi-organ dysfunction syndrome Multisystem trauma Rhabdomyolysis Sleep disruption Thermoregulation Toxin/drug exposure Toxin ingestions/inhalations Review what’s on each exam. Point out that, as infections diseases were discussed throughout the program, under each system, it won’t be discussed here.. Healthcare acquired infections, palliative care, end of life care, and pain management may only have one to no questions on the exam. Their hospitals’ policies most likely follow national guidelines and they should already be familiar with it. This discussion will focus on sepsis, SIRS and MODS, which will be the great majority of the questions. Trauma procedure only will be discussed, as organ system trauma was discussed in each section. Bariatric complications was covered in GI Sleep disruptions is covered in behavioral under delirium

What’s on the Exam Approximately 14% of the CCRN exam will focus on Multisystem Multisystem is combined with Neurology and behavioral to make up 15% of the PCCN exam

SHOCK Inability of the circulatory system to supply oxygen and nutrients to the cells of the body Types of shock: Hypovolemic Neurogenic Anaphylactic Cardiogenic Septic Septic shock definitely has a lot of questions on the exam PCCN does not include neurogenic shock, but all other shocks are on the PCCN blueprint

Hypovolemic Shock Caused by loss of circulating blood volume
Commonly associated with bleeding Associated with early sepsis (capillary leakage) Compensatory mechanism: Renin- Angiotensin Syndrome and the Sympathetic Nervous System Renin Angiotensin Syndrome: When hypoperfused, kidneys release renin which converts angiotensin I to angiotensin II. Angiotensin II is a patent vasoconstrictor, shunting blood away from non vital organs. Antioensin II alsto stimulates the release of aldosterone, which results in reabsorption of sodium and water. This decreases urine output Sympathetic nervous system results in tachycardia, increased myocardial contractility and vasoconstriction

Signs and Symptoms of Hypovolemic Shock
Svo2 or ScVo2 is low (<60 or 70%) Cardiac output is low Cardiac index is low (<2.5 mL/m2) Stoke volume is low (<50 mL) CVP is low (<6) PAOP is low (<8) Mean arterial pressure is low (<60 mm Hg) Tachycardia Changes in levels of consciousness Reduced urine output Lactate is elevated (>4 mmol) Signs on left hand side are just for CCRN

Treatment of Hypovolemic Shock
Replace the vascular volume Crystalloid Solution: Ringer’s or normal Saline Colloids: Whole Blood/Red blood cells for decreased hemoglobin Colloids: Albumin Remember when giving a lot of blood, need to also give FFP and platelets as packed red blood cells are void of clotting factors and platelets. Some practitioners give one unit of FFP for every unit of blood Watch for TRALI (transfusion related acute lung injury – covered in Pulmonary lecture) whenever giving blood Also watch for electrolyte disorders (hypocalcemia, hypo-or hyperkalemia, hypo magnesia) when giving transfusions due to shelf life of blood, and citrate binding of electrolytes. Citrate binds calcium and magnesium; shelf life alters potassium

Some “Pearls” Large amounts of Normal saline can cause hyperchloremic metabolic acidosis Only give blood for active bleeding (Hemoglobin < 7 g/dL) Base deficit/or lactate can be used to see if more fluids are needed. A base deficit of more than -15 may indicate an ongoing blood loss Watch for abdominal compartment syndrome with aggressive fluid resuscitation

QUESTION 1. Which of the following is the earliest clinical sign of impending hypovolemic shock? A. Systolic BP of less than 90 mm Hg B. Capillary refill time greater than 4 seconds C. Decreased urine output D. Tachycardia greater than 120 beats/minute

ANSWER 1. Which of the following is the earliest clinical sign of impending hypovolemic shock? A. Systolic BP of less than 90 mm Hg B. Capillary refill time greater than 4 seconds C. Decreased urine output D. Tachycardia greater than 120 beats/minute Activation of sympathetic nervous system causes vasoconstriction which decreases renal blood flow. Hypotension and tachycardia are seen later on.

Neurogenic Shock Results from loss of normal sympathetic nervous system response Commonly occurs following cervical and upper thoracic (above T6) cord injury Hypotension and Bradycardia Treatment: Fluids, vasopressors, Atropine Only covered on CCRN Loss of cardiac acceleration reflex prevents vasoconstriction and tachycardia

Anaphylactic Shock Anaphylaxis is an acute, generalized, and violent antigen-antibody reaction that can be fatal “Allergens” include food, drugs, insect-sting venom, latex, exercise, animal dander, dust, pollen. Reaction is a histamine reaction, which causes vasodilation of capillaries and increased cellular permeability Fluid moves from vascular system into the interstitial spaces Histamine also causes the release of other “amines” into the bloodstream which cause bronchiolar constriction The other “amines” include bradykinin, serotonin, slow-reacting substances, chemotactic vactor attracting eosinophils, prostaglandins, acetycholine

Signs and Symptoms of Anaphylaxis
Pruritus Respiratory Distress Syncopy Apprehension Angioedema Edema of uvula and larynx Barking/high pitched cough Hypotension Tachycardia Stridor Bronchospasm Laryngeal edema Angioedema is seen in eyes and mouth. Can also occur in tongue, hands, feet and genitalia. A diffuse erythema can occur in the upper body parts. Occasionally, abdominal cramps, vomiting, and diarrhea may occur

TREATMENT ABC’s Manage hypotension with intravenous fluids
Realize that decreased blood pressure leads to increased tissue hypoxia. Other management was discussed in Pulmonary lecture (epinephrine, antihistamines, intubation, hydrocortisone)

QUESTION Which assessment data would help to differentiate neurogenic from anaphylactic shock? A. Hypotension B. Bradycardia C. Low urine output D. Low CVP

ANSWER Which assessment data would help to differentiate neurogenic from anaphylactic shock? A. Hypotension B. Bradycardia C. Low urine output D. Low CVP

Cardiogenic Shock Produces the same cellular disruption of oxygen as does hypovolemic shock Both cardiogenic and hypovolemic shock have the following: Low blood pressure Tachycardia Altered level of consciousness Skin: cold and clammy Urine output: Low (<0.5 mL/Kg) Causes for cardiogenic shock include: myocardial infarction, valvular disease, cardiomyopathy, massive pulmonary embolism. Hypertension, aortic dissection May give the risk factors in the question as a hint to assist with managing cardiogenic shock

Differences Between Cardiogenic and Hypovolemic Shock
Cardiogenic shock Hypovolemic shock PaO2/ SaO2: Low Cyanosis: May be present PAOP: High (>18) CVP: High Orthopnea: Present Crackles: Present Dependent edema: Present PaO2/SaO2: Normal Cyanosis: Absent PAOP: Low (<10) CVP: Low Orthopnea: Absent Crackles: Absent Dependent edema: Absent

Treatment of Cardiogenic Shock
Inotropic agents Vasodilator therapy Fluid challenges with inotropic agents Mechanical assistance (Intra-aortic Balloon Pump) Left ventricular assist device Vasoconstrictors used with caution – Prefer norepinephrine instead of Dopamine Treatments are what were discussed in heart failure lecture under cardiac

Question You suspect your patient is in cardiogenic shock. Choose the hemodynamic parameter that best shows your suspicion: A. Cardiac output of 8.6 L/minute B. Cardiac index of 1.5 L/minute C. Right atrial pressure of 4 mm Hg D. Pulmonary artery occlusive pressure of 5 mm Hg

Answer You suspect your patient is in cardiogenic shock. Choose the hemodynamic parameter that best shows your suspicion: A. Cardiac output of 8.6 L/minute B. Cardiac index of 1.5 L/minute C. Right atrial pressure of 4 mm Hg D. Pulmonary artery occlusive pressure of 5 mm Hg Correct answer is B The low cardiac index value indicates left pump failure . Normal cardiac index is 2.5 – 4 L/minute Right atrial pressure is low as is PAOP. These would be high in heart failure RAP = 4 – 6 mm Hg; PAOP= 6 – 12 mm Hg

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME
Response to a variety of severe clinical insults Manifested by two or more of the following Temperature > 38 C or < 36 C Heart rate > 90 Respiratory rate >20 or PaCO2< 32 mm WBC > 12,000 or >10% bands Go over the bottom of the slide What is sepsis, severe sepsis, and septic shock

Definitions Sepsis: Two or more of the SIRS criteria, plus a known or suspected infection Severe sepsis: Sepsis with hypotension or hypoperfusion Blood pressure <90, MAP <70 mm Hg Decrease in BP more than 40 mm Hg from baseline Oliguria/ Creatinine increase Increased lactate level >4 mmol Alteration in mental status Oliguria < 0.5 ml/kg/ hour Coagulation abnormalities Hyperbilirubinemia (total bilirubin > 2 mg/dL) Simply ready the definitions 25

More Definitions Septic Shock:
Severe Sepsis with hypotension and signs of hypoperfusion despite adequate fluid resuscitation Multiple Organ Dysfunction Syndrome (MODS): Presence of altered organ function involving two or more organs Mortality is greater with more organs involved

MODS PaO2/FiO2 ratio <300
Increased serum creatinine >2.0 or creatinine increase>0.5 mg/dL Increased bilirubin levels > 4 mg/dL Decreased platelet counts < 100,000 uL INR> 1.5 aPTT> 60 seconds Altered Glasgow Coma Scale The symptoms show signs of pulmonary failure, renal failure, liver failure, hematologic failure, neuro failure 27

Who is at risk for Severe Sepsis and MODS?
Chronic disease Immunosuppressed Age – young and elderly Malnutrition – obese also Alcohol abuse Cancer Burn/Trauma Sepsis Surgical or invasive procedures Indwelling catheters Mechanical ventilation Give examples of immunosuppressed, so they are aware of how many people actually are: COPD and arthritis patients using steroids, cancer patients on chemo, HIV/AIDs, transplant patients, etc 28

Typical MODS Progression
Day 1 – SIRS event Day 2 or 3 – lungs Day 6 or 7 – liver Day 10 – GI bleed Day 12 up to 14 – renal failure Mortality increases with the number of organs involved Mortality with one organ = 20% Mortality with four organs = 100% May not be in this order, or in this time frame Give examples of how quickly four organ failure can occur: respiratory failure or ARDS, renal failure, DIC, and GI bleed or ileus.

Definitions for Normal Physiology of Infection
When macrophages recognize invading microbes, they react by producing pro-inflammatory molecules called cytokines These cytokines act locally Near the infection, neighboring endothelial cells respond to the cytokines by producing adherence molecules The complement system is activated. These proteins can help immobilize and breakdown the pathogen or put more cytokines into play Local activation of the blood coagulation system occurs Point out that this part of the discussion is to help them understand why we do what we do. It won’t be tested as such on the exam, but knowledge of it may help to determine what answer they are looking for. Cytokines include interleukins, interferons, tumor necrosis factor, transforming growth factor, chemokines.

Normal Pathophysiology
Fibrinogen converts to fibrin for clot formation to isolate antigen/bacteria Plasminogen activating factor – 1 and thrombin are released to maintain clot by suppressing fibrinolysis so antigen/bacteria is not destroyed before body lyses clot Pro-inflammatory mediators attract activated neutrophils to engulf the isolated antigen. They attach to the endothelium via the adherence molecules Again, normally what happens during a local infection

Normal Physiology Anti-inflammatory mediators also released
IL-4, TGF-B Prevents pro-inflammatory response from damaging normal tissue Balance between pro and anti- inflammatory mediators keeps the inflammatory response non-systemic, local to site of infection only NO SIRS Remind them again that they don’t have to memorize this; it’s just to help them understand SIRS. They will be tested on scenarios in which a patient presents with SIRS IL-4: Interleukin-4; TGF-B: Transforming Growth Factor. In handout.

Etiology of Sepsis Gram Positive Bacteria (most common organism)
Methicillin-resistant Staphylococcus Aureus (MRSA) Streptococcus Gram Negative Bacteria E. coli, Klebsiella, Citrobacter, Pseudomonas aeruginosa, Enterobacter, Proteus certain gram negative bacteria release endotoxins which further complicate the immune response Fungus (seen more with immunosuppressed populations) Self explanatory

Pathophysiology of Sepsis
Imbalance between pro-inflammatory and anti- inflammatory mediators = SIRS, not local infection anymore Excessive Coagulation Exaggerated Inflammation Impaired Fibrinolysis This is the beginning of the discussion of sepsis, or massive infection. Because the infection is so overwhelming, the body doesn’t know where to send its anti-infection mediators. So it sends them everywhere. They should know that sepsis/SIRS is the result of the last three things occurring at once.

Sepsis and Coagulation
SIRS/Sepsis imbalance favors coagulation Increased thrombin formation Pro-coagulation damages endothelium and vasculature Increased fibrin clot deposits in the organs Net result: Causes microvascular hypo perfusion, decreased O2 delivery, tissue necrosis, leakage of fluid outside vascular space Point out the end result of microvascular hypoperfusion. Oxygen uptake to the organs occurs at the microvascular level, and so does not occur to the degree necessary for adequate oxygenation of the tissues. Emphasize also that the endothelium is damaged; since all tissues receive their oxygen and nutrients from the vascular system, this profound endothelial damage significantly reduces delivery.

SEPSIS PRESENTATION Decreased urine output Chills, Fever Skin mottling
Tachypnea Unexplained alterations in mental status Tachycardia Altered white blood cell count Elevated numbers of immature neutrophils Decreased skin perfusion Hypotension Decreased urine output Skin mottling Poor capillary refill Hyperglycemia Petechiae Serum Lactate elevated Arterial hypotension SvO2>70% (late) CI>3.5 L/minute (early) Organ Dysfunction Decreased systemic vascular resistance (early) We will talk about SvO2 in next slide

SVO2/ScVO2 Mixed venous oxygen: 40 mm Hg (“snapshot”)
SvO2 is monitored in pulmonary artery: 60 – 80% ScvO2 is monitored in the right atrium: 70% Assesses global oxygenation (balance between oxygen delivery and utilization)

Assessing High versus Low ScVO2/SVO2
Low SVO2/ScVO2 is < 70% Oxygen deficit increases O2 extraction by tissues in early sepsis High SVO2/ScVO2 is > 70-75% Hyperdynamic state In late sepsis, cells become dysfunctional, can no longer extract oxygen Unused oxygen passes from arterial system to venous system without being taken up by tissues WOB = work of breathing

Diagnostics of Sepsis Cultures ABGs – respiratory alkalosis
Lactate levels – lactic acidosis > 4mmol/dl; 30 mg/dl Base Deficit/Excess +/- 4 CBC – WBC, platelets Coagulation panel Hyper or hypoglycemia Initially will have respiratory alkalosis because of hypoxia – causes hyperventilation in an effort to obtain more oxygen. CO2 is exhaled, causing the alkalosis. Point out that lactate levels indicate anaerobic metabolism, but doesn’t indicate which tissues or organs are affected.

TREATMENT FIRST THREE HOURS
Severe Sepsis 3-Hour Resuscitation Bundle: Evidence-based goals that must be completed within 3 hours for patients with severe sepsis. To be completed within 3 hours of the time of presentation: Measure Lactate Level Obtain Blood Cultures Prior to Administration of Antibiotics Administer Broad Spectrum Antibiotics Administer 30 mL/kg Crystalloid for Hypotension or Lactate ≥4 mmol/L Algorithm for interventions for first six hours after sepsis is suspected Surviving Sepsis guidelines Once sepsis is suspected or identified, the nurse will be the one who can administer EGDT interventions in a timely manner and are the first to assess their effectiveness. These are the nursing actions that may be found on the exam. 40

TREATMENT WITHIN SIX HOURS
6-Hour Septic Shock Bundle: Evidence-based goals that must be completed within 6 hours for patients with severe sepsis. To be completed within 6 hours of the time of presentation: Apply Vasopressors For Hypotension That Does Not Respond to Initial Fluid Resuscitation to Maintain a Mean Arterial Pressure (MAP) ≥65 mm Hg) In the Event of Persistent Arterial Hypotension Despite Volume Resuscitation (Septic Shock) or Initial Lactate ≥4 mmol/L (36 mg/dL) Measure Central Venous Pressure (CVP) Measure Central Venous Oxygen Saturation (ScvO2) Remeasure Lactate If Initial Lactate Was Elevated

DIAGNOSIS OF INFECTIOUS CAUSE
Two blood cultures prior to antibiotic administration One drawn percutaneously One drawn through each vascular access device Other sites as indicated This and following slides describes EGDT. Other sites examples: pressure ulcer, wound, urine, sputum TREAT SOURCE IF IDENTIFIED Drain abscess Debride infected necrotic tissue Remove infected device 42

ANTIBIOTIC THERAPY Begun within first hour of recognition of severe sepsis EMERGENCY DRUG in SEPSIS Selection of agent guided by community and hospital ongoing microbial and fungal activity Reassess after hours Change to appropriate monotherapy Administer for 7-10 days Assess clinical response Elapsed times from triage and qualification for early goal-directed therapy to administration of appropriate antimicrobials are primary determinants of mortality in patients with severe sepsis and septic shock treated with EGDT 43

FLUID THERAPY Crystalloids: 30 mL/kg over 30 minutes
Colloids: ml over 30 minutes Repeat based on CVP, urine output, BP Assess for fluid overload If CVP 8-12 mmHg after fluid resuscitation, but mixed venous is < 70%, transfuse packed red blood cells to a Hgb > 7; hct of ≥ 30% These describe interventions and their goals; reaching or not reaching goals determines next steps 44

VASOPRESSORS and POSITIVE INOTROPES
If fluid challenges do not result in adequate CVP, SVO2, BP begin vasopressor therapy with norepinephrine (Levophed) Vasopressin and Epinephrine infusions may be used in conjunction with Levophed Begin Dobutamine if patient has a low cardiac output after adequate fluid/blood transfusion resuscitation – goal SVO2 Fluid, pressors and inotropy is not uncommon Neosynephrine not studied. If patient is tachycardic, Levophed would most likely be a better choice, as it doesn’t cause tachycardia as dopamine does. Dobutamine not used in this instance for heart failure; it it used to increase cardiac output to improve delivery of oxygen to tissues. Don’t necessarily have to obtain a CO reading; if SVO2 goals not met, assume that inadequate oxygen is reaching tissues; use Dobutamine to improve. 45

ADJUNCT TREATMENTS BLOOD PRODUCT ADMINISTRATION STEROIDS
Give packed RBCs for hgb < 7 gm/dl when hypoperfusion has resolved Administer platelets for platelet count ≤ 5,000/mm3 Consider platelet transfusion for platelet count 5,000-30,000/mm3 if significant risk for bleeding STEROIDS Hydrocortisone IV 300 mg/day divided100 mg Q 8 hours for 7 days if BP still low with FR and vasopressor on board ACTH stimulation test prior to initiation no longer recommended If goals are not being met, assume adrenal insufficiency Self explanatory 46

MECHANICAL VENTILATION
ARDSnet protocol Tidal volume of 6 ml/kg Plateau pressure <30 cm H2O Allow permissive hypercapnia to maintain tidal volume and plateau pressure goals Set PEEP to maintain adequate oxygenation Consider prone positioning VAP Bundle – HOB > 30% Weaning protocol This is the ARDSnet protocol discussed in Pulmonary presentation. Prone positioning should be considered sooner rather than later for best effects. A weaning protocol should be used when patient is determined to be ready for weaning 47

SEDATION, ANALGESIA, AND NMB
Use protocols that include use of a sedation goal, measured by a standardized subjective sedation scale Intermittent or continuous infusion for sedation to predetermined end points Daily wake up NMB should be avoided if possible NMB: neuromuscular blockade. Daily wake up needs to consider status of patient. If still unstable, most likely not practical. There are new articles and studies underway to determine the need for deep sedation and daily wake up. This will not be on the exam, as it is too new, and the CCRN exam is currently over three years old. 48

GLUCOSE CONTROL and STRESS ULCER PROPHYLAXIS
Maintain blood glucose < 180 mg/dl Administer continuous infusion of insulin Monitor BS every minutes Nutrition protocol with preferred enteral route STRESS ULCER PROPHYLAXIS H2 receptor inhibitor Proton pump inhibitors not assessed Self explanatory. Enteral route can help prevent GI bleed and ileus 49

RENAL REPLACEMENT BICARB and DVT
Renal replacement in acute renal failure Hemodialysis or CRRT Bicarbonate therapy Use only if pH ≤ 7.15 DVT prophylaxis Low-dose unfractionated heparin Low molecular weight heparin Sequential compression device if anticoagulation contraindicated 50

REDUCE RISK OF SEPSIS Enforce infection control measures
Sterile technique during procedures Handwashing – wash in/wash out Universal and Contact precautions Skin care – Mobility Bundles Catheter care – UTI Bundles Oral care – VAP Bundles Dedicated suction lines; keep closed suction closed Wipe ports with alcohol prep before accessing IV ports - CR-BSI Bundles Nurses are the last line of defense for patient safety and should ensure strict adherence to accepted infection control measures. 51

PATIENT AND FAMILY COMFORT
Administer analgesia Administer sedation Assess effectiveness Caring Communication Bundles Palliative Bundles Family Family teaching Address needs of families Self explanatory. Point out that the patient in the bed is not the nurse’s only patient – the family is as well. This is what AACN means by synergy 52

QUESTION The patient in septic shock may present with a variety of clinical manifestations that may change dramatically as the condition progresses. Which physiologic symptoms best describe the clinical manifestations associated with septic shock? A. Increased temperature and increased urine output B. Decreased systemic vascular resistance and decreased cardiac output C. Increased mixed venous oxygen saturation and increased heart rate D. Increased right atrial pressure and increased respiratory rate

ANSWER The patient in septic shock may present with a variety of clinical manifestations that may change dramatically as the condition progresses. Which physiologic symptoms best describe the clinical manifestations associated with septic shock? A. Increased temperature and increased urine output B. Decreased systemic vascular resistance and decreased cardiac output C. Increased mixed venous oxygen saturation and increased heart rate D. Increased right atrial pressure and increased respiratory rate Several factors can increase svo2: increase in oxygen saturation and increase in cardiac output. The increased heart rate caused by sympathetic stimulation causes increased cardiac output; the tissues aren’t using all of this oxygen so the SVO2 is elevated.

QUESTION A 60 year old patient is admitted to the PCU with a three day history of nausea, vomiting, and diarrhea. Admitting vital signs reveal the following: Temperature 102 degrees F; HR 110/minute, BP: 90/40 mm Hg; RR 30/minute. Laboratory values from ER are as follows: WBC 20,000/mm3 , hemoglobin: 10 g/dL; BUN 80 mg/dL; creatinine : 2.5 mg/dL; serum lactate: 6 mmol/L. Cultures have been sent and antibiotic therapy has been started. The critical care nurse should expect the patient’s immediate treatment to include the following: A. Inotropic support B. IV fluid bolus C. Blood transfusion D. Beta blocker therapy

ANSWER A 60 year old patient is admitted to the PCU with a three day history of nausea, vomiting, and diarrhea. Admitting vital signs reveal the following: Temperature 102 degrees F; HR 110/minute, BP: 90/40 mm Hg; RR 30/minute. Laboratory values from ER are as follows: WBC 20,000/mm3 , hemoglobin: 10 g/dL; BUN 80 mg/dL; creatinine : 2.5 mg/dL; serum lactate: 6 mmol/L. Cultures have been sent and antibiotic therapy has been started. The critical care nurse should expect the patient’s immediate treatment to include the following: A. Inotropic support B. IV fluid bolus C. Blood transfusion D. Beta blocker therapy RBC not immediate treatment; takes too long with the low blood pressure Fluids are always first . Hemoglobin is not below 7;

Question A patient is admitted with pneumonia, a body temperature of 95.7 F (35.4 C), blood pressure 82/43 mm Hg., mean arterial blood pressure of 56 mm Hg, RR 28/min, HR 112/minute, lactate 4.2 mmol/L. A fluid bolus of 30 mL/kg has been provided and a Levophed (norepinephrine) infusion started. The nurse anticipates the initial hemodynamic goals in the care of this patient to include: A. MAP greater than 75 mm Hg, CVP of 2 mm Hg, and ScVO2 of 50% B. MAP greater than 60 mm Hg, CVP or 3 mm Hg, and ScVO2 of 60% C. MAP greater than 70 mm Hg, CVP of 5 mm Hg, and ScVO2 of 65% D. MAP greater than 65 mm Hg, CVP of 8 mm Hg, and ScVO2 of 70%

Question A patient is admitted with pneumonia, a body temperature of 95.7 F (35.4 C), blood pressure 82/43 mm Hg., mean arterial blood pressure of 56 mm Hg, RR 28/min, HR 112/minute, lactate 4.2 mmol/L. A fluid bolus of 30 mL/kg has been provided and a Levophed (norepinephrine) infusion started. The nurse anticipates the initial hemodynamic goals in the care of this patient to include: A. MAP greater than 75 mm Hg, CVP of 2 mm Hg, and ScVO2 of 50% B. MAP greater than 60 mm Hg, CVP or 3 mm Hg, and ScVO2 of 60% C. MAP greater than 70 mm Hg, CVP of 5 mm Hg, and ScVO2 of 65% D. MAP greater than 65 mm Hg, CVP of 8 mm Hg, and ScVO2 of 70% Correct Answer is D The six hour bundle includes : Perfuse peripheral tissues by having a BP of greater than or equal to 65mm Hg Ensure adequate preload with a CVP of 8 – 12 mm Hg Ensure adequate global tissue perfusion with a SCVO2 of 70%

Trauma Epidemiology Leading cause of death-1 to 37 yrs
4th leading cause for all ages Males higher risk – 2.5 greater 55, 000 intentional deaths/yr

Multisystem Trauma Definitions
Injury Physical harm/damage to the body from an acute mechanical, chemical, thermal, environmental injury Unintentional Injury Accidental harm from sudden unplanned traumatic event Intentional Injury Planned, premeditated Definitions

Mechanism of Injury Blunt Injury - Vehicle crash or fall Acceleration
Speed = increased tissue damage Deceleration Usually with acceleration Shearing Structures slip across each other on plane Crushing/Compression Neurovascular compromise, rhabdomyolysis More definitions. Important to know to understand what is being asked in a trauma question. Knowledge of the mechanisms of injury assists the trauma team in early identification and management of injuries that may not be readily apparent Blunt trauma is most common cause of injury. Happens most often in motor vehicle accidents. Can also happen when being assaulted with a blunt object, falls from heights, sports related activity. Organ trauma from blunt injury may not be readily visible.

Mechanism of Injury Penetrating Injury
Motion of foreign object entering tissue causing direct damage Indirect damage of surrounding tissues GSW – high velocity Stab – low velocity Impalement – collision of object into patient Avulsion/Degloving – stretching/tearing away soft tissue More definitions. These are easier injuries to diagnose because of obvious signs of injury Guns do more damage than stabbing. Injury from stabbing is length of weapon. Bullet goes further. Example of impalement: Falling on top of a picket fence. Example of avulsion/degloving would be the old Indian scalping. Removes skin from head. As it’s very vascular pioneers would die from blood loss. Also happends in machinery accidents. High velocity injuries result in greater dissipation of kinetic energy and more damage. With penetrating injuries, monitor for organ damage, hemorrhage and infection

Assessment of Multiple Trauma
What is the mechanism of injury ETOH/Drugs involved PMH: AMPLE Allergies Medications – Rx, OTC, last tetanus Past Illnesses Last Meal – in case needs to go to OR Events preceding injury (MI) AMPLE is an acronym used by trauma centers to be sure these are determined in the initial assessment

Primary Survey-Rapid 30 sec -2 min ABCD’s – Is this a code situation? A: Airway; must stabilize C-spine B: Breathing adequate C: Circulation – control Hemorrhage, tamponade, tension PTX D: Disability/defibrillation - AVPU A(alert) V(verbal) P(pain) U (unresponsive) There is a primary, secondary and tertiary survey to be sure that a complete assessment has been done. Trauma uses a lot of acronyms, and these should be studied for the exam. Circulation includes pulses, but also is there presence of hemorrhage? Disability is gross neurological status (such as the Glasgow coma scale) or AVPU

Secondary Survey – E thru H resuscitation does not stop E: Exposure – fully undress F: Full VS; 5 interventions; family + SpO2, O2, foley, NGT, Labs G: Give comfort – meds, assurance H: History and head-to-assessment Tertiary Survey - no misses Secondary continues the alphabet reminders of what needs to be done. In a tertiary survey, A through H is done again.

Trauma Diagnostics Radiologic
Fx, air/fluid collection, foreign objects FAST (Bedside ultrasound) Focused Abdominal Sonography for Trauma Assesses for free fluid, usually blood in a trauma, in the liver, spleen, pericardium and pelvis Done immediately after the primary survey Still need CT for confirmation Computed tomography = CT Soft tissue injury, hematomas, fx Labs – CBC, T&C, Chemistries, Lactic Acid Chemistries include a metabolic panel, other electorlytes, drug screen, etc. Lactic acid levels will indicate severity of shock, or act as a baseline

Trauma Physiology Stress Response r/t tissue injury
First hrs of injury Tissue Hypoxia r/t blood loss Hypovolemic vs. Vasogenic Shock Acidosis, Hypothermia, Coagulopathy High risk for Triad/Triangle of Death Part of what can lead trauma to MODS Vasogenic shock is “third spacing” where vasodilation without loss of fluid occurs Hypovolemia can cause metabolic acidosis which produces lactic acid Tissue hypoxia can be determined by Sto2 monitoring or sublingual capnometry where a probe is placed under the patient’s tongue and measures carbon dioxide. An elevated sublingual carbon dioxide indicates poor tissue perfusion. Normal Sto2 = 75% to 91%

Trauma Physiology SNS Response Pain, fear, anxiety
Increase: HR, BP, contractility, vasoconstriction, tachypnea Redistribution of blood volume from venous/vessels to central organs Increased capillary permeability Causes intravascular hypovolemia, hypoperfusion, edema formation Response to hypotension Baroreceptors from carotid arteries and aorta released activates the SNS Sympathetic nervous system response to trauma

Trauma Physiology Release of norepinephrine and epinephrine
Causes vasoconstriction; shunts blood away from non- vital organs Maintains blood flow to heart/brain Decreased renal blood flow activates the renin- angiotensin-aldosterone system Renin helps produce angiotensin II (vasoconstrictor) Angiotensin stimulates aldosterone release from adrenal cortex – result NA+/H20 retention for initial increase in CO and BP Note that this is why reverse Trendelenburg should never be used in hypotension. It increases blood flow to the baroreceptors, falsely indicating that the problem has been corrected. The baroreceptors will not activate the SNS, and tissues will not receive adequate perfusion. In hypotension, the patient should be laid flat, or, preferred, with legs only elevated

Trauma Physiology Metabolic, hyperdynamic state Edema
Increased CO/stress response Impaired tissue perfusion Increased O2 demand Increased glucose Increased WBC without infection

Management of Trauma Oxygen and Ventilation Fluid Resuscitation
Crystalloids and colloids Surgical Intervention Normal Thermoregulation** Prolonged hypothermia associated with myocardial dysfunction coagulopathies, reduced perfusion, dysrhythmias, and decreased metabolic rate Prevent Infection and SIRS NUTRITION **Hypothermia may be initiated in instances of head trauma or cardiac arrest. Patient is susceptible to hypothermia due to excessive blood loss, alcohol use, massive fluid resuscitation, clothing removal, contact with wet linens, surgical exposure of body cavities during intiail assessment. May need to warm IV fuids, warm room, cover patient’s head, use convection air blankets, radiant lights Patient is in a hyperdynamic state – needs a much greater amount of calories. Nutrition should be started immediately. A critical care dietician should be consulted. The decision to administer blood is based on patient’s response to initial crystalloid therapy and the amount of blood loss. If patient not responsive to initial crystalloid, type specific blood may be administered. Type O is universal donor type Massive blood transfusion is defined as 10 or more units of packed cells in 24 hours; in this case, fresh frozen plasma should be given. 1 unit of blood = 1 unit of platelets, and 1 unit of FFP. SIRS occurs when the body is hypoperfused and acidotic

QUESTION #1 For a patient admitted to the hospital after a motor vehicle crash, which of the following assessment components would the critical care nurse expect to perform at the bedside immediately upon arrival? A. Breathing, circulation, and vital signs B. Airway, breathing and circulation C. Disability, head to toe examination and exposure D. Vital signs, circulation and inspection

ANSWER #1 For a patient admitted to the hospital after a motor vehicle crash, which of the following assessment components would the critical care nurse expect to perform at the bedside immediately upon arrival? A. Breathing, circulation, and vital signs B. Airway, breathing and circulation C. Disability, head to toe examination and exposure D. Vital signs, circulation and inspection

Question Your patient’s lactic acid level has risen from 2 mmol/L to 6 mmol/L eight hours after his motor vehicle crash. You, the critical care nurse, know that this likely indicates which of the following? A. Appropriate fluid resuscitation B. Inadequate tissue perfusion C. The need to start TPN immediately D. The need to transfuse 20 units of cryoprecipitate

Question Your patient’s lactic acid level has risen from 2 mmol/L to 6 mmol/L eight hours after his motor vehicle crash. You, the critical care nurse, know that this likely indicates which of the following? A. Appropriate fluid resuscitation B. Inadequate tissue perfusion C. The need to start TPN immediately D. The need to transfuse 20 units of cryoprecipitate The correct answer is B Increased lactic acid is a by product of anaerobic matabolish secondary to inadequate tissue oxygenation and perfusion. Increased lactic acid is seen in patients with metabloc disorders such as DKA, severe septic shock, trauma, burns, and rhabdo.

Toxicology Majority of multisystem questions will be on sepsis, SIRS and MODS. In the PCCN, it will also focus on hypovolemic shock. At most, there will be one or two quesitons on toxicology. Know the basics.

Toxicology Definitions
Study of adverse effects of chemicals Toxicant Poison Median Lethal Dose Amount that will kill 50% of the population Absorption Extent and rate Distribution Dissemination throughout the body Clearance Ability to eliminate substance from blood over time Just for their info Don’t need to go over this

“Pearls” for Toxic Ingestions
Opioids, sedatives and alcohol ae the most common overdose seen in emergency rooms. Hallmark symptom is depressed level of consciousness Acetaminophen is the most common single drug overdose Most overdoses involve more than one class of drugs Vital signs and neurological assessments are most important in the initial evaluation of determining the cause of overdose Sympathomimetic drugs (cocaine, amphetamines) cause hypertension Decreased LOC and respirations are usually caused by sedatives or hypnotics Respiratory depression = will need to intubate Neuro assessment includes level of consciousness, ocular movement and motor skills

Toxicology Ingestion Assessment A – Airway B – Breathing
C – Circulation D – Disability/LOC and Dysrhythmia E – Exposure – what chemical? CONTACT POISON CONTROL

Management All comatose adolescents/adults D50W – 2 amps
r/o hypoglycemia Thiamine 100mg IV Prevent Wernicke-Korsakoff’s Syndrome with ETOH/malnutrition Naloxone/Narcan 2mg IV, IM, ETT Narcotic antagonist – not benign Arrhythmias, pain, seizures If patient hyperglycemic, this can be corrected. If hypoglycemic, time is of the essence. Will automatically be given

Toxic Ingestion Managment
Determine Toxidrome/toxicant Labs Gastric Emptying to prevent absorption if indicated Enhanced elimination – dialysis Antidote Determine disposition based on management Determine what was ingested. NGT with gastric emptying if required due to nature of the poison. Dialysis if the drug can be removed in this manner (ie, Digoxin). Administer antidote if there is one. All overdoses are reviewed for proper management, improvement Goals of treatment: Remove the agent, detoxify the patient, and prevent absorption of the suspected agent

Acetaminophen Overdose
#1 Drug reason for Acute Liver Failure and transplant in the US It is hepatotoxic Included in 600 commercial preps Almost 1/3 of Tylenol ODs are unintentional Self explanatory

Three Clinical Stages of Tylenol Overdose
Initial stage First 24 hours – no signs or symptoms; no abnormal labs Second stage 24-72 hrs post ingestion Signs and symptoms are minimal but will have an increased AST that will peak in hrs Third stage In severe cases hours Encephalopathy, coagulopathy Due to liver failure Death occurs within 3-5 days Although there are no symptoms for the first 24 hours, it is imperative that it be treated immediately to prevent advancement to liver failure.

Prognostic Markers of Tylenol OD
Hepatotoxic Dose varies 8 gms or higher = hepatotoxic Chronic ETOH increases susceptibility Plasma Drug Levels Plasma acetaminophen level Toxic dose has not been determines

Treatment Activated Charcoal Only recommended in first 4 hours
Mucomyst/N-acetylcysteine = NAC Antidote – inactivates the toxic metabolite Use in first 24 hours; best effect in first 8 hours Activated charcoal is a dry, black powder which is tasteless, odorless and gritty Also can come in an aqueous slurry or in a suspension of charcoal in sorbitol. Sorbitol acts as a cathartic, thus decreasing the time the Tylenol stays in the bowel to be absorbed. Can be given orally or down NG tube Activated charcoal also absorbs therapeutic medications. If you need to give more than one dose of charcoal, don’t use sorbitol with the other doses NAC can be given orally or intravenously

Adverse Effects of NAC Oral = smells like rotten eggs because of the sulfur content Bad taste and smell = noncompliance Vomiting May require NGT placement Oral produces diarrhea 50% time Resolves 90% time IV can trigger anaphylaxis - rare

Benzodiazepines 2nd most OD Rx drug in US
2nd only to Tylenol as cause of OD death Antidote = flumazenil Pure antagonist to benzo receptor in CNS Rapid response with peak in 6 min Effect lasts 1 hour Will need to repeat Sedation recurrence is common Adverse reactions: benzodiazepine withdrawal syndrome Self explanatory Examples of benzodiazepines: Valium, Versed, Xanax

Opioid Analgesic OD Antidote: Naloxone (Narcan)
May be administered IV bolus, gtt, IM, ETT Most common: Opioid Withdrawal Syndrome Anxiety Abdominal cramping Vomiting Rare Pulmonary Edema, Generalized Seizures Most likely exam will want to know if candidate knows antidote. May have a question on complications related to giving too fast. Must be given very slowly. Also, most opiods last longer than Narcan, so nurse should anticipate repeating dose. Given as 0.01 mg/kg/IV Opoids include morphine, codeine, heroin, demerol

Beta Blocker OD CV Toxicity Bradycardia and Hypotension Neuro Toxicity
Because drug is lipid soluble, it accumulates in lipid-rich organs such as the BRAIN Depressed consciousness, seizures Antidote: Glucagon Point out that Beta Blockers are given to decrease blood pressure or lower heart rate. So, an overdose would do this to the extreme, including death Examples of beta blockers: Atenolol, metoprolol, labetalol. Give glucagon 1 – 5 mg IV

Beta Blocker OD Mechanism of Action of Glucagon 90% effective
Activates the receptors on surface of heart independent of beta blockade Indications Acutely treats symptomatic bradycardia and hypotension Not indicated for reversing prolonged effects affecting AV conduction Adverse Effects of Glucagon Nausea, Vomiting, Hyperglycemia Contraindication Pheochromocytoma – hypertensive crisis Self explanatory

QUESTION All of the following are anticipated treatments for Acetaminophen overdose except: A. Charcoal administration B. Mucomyst (NAC) C. Acute dialysis D. Gastric Lavage

ANSWER All of the following are anticipated treatments for Acetaminophen overdose except: A. Charcoal administration B. Mucomyst (NAC) C. Acute dialysis D. Gastric Lavage Tylenol is not dialyzeable

QUESTION A. Chest pain, hypothermia, hypoxia
When assessing a patient with suspected cocaine intoxication, a nurse would expect to see: A. Chest pain, hypothermia, hypoxia B. Tachycardia, chest pain, hyperthermia C. Hyperthermia, hypotension, drowsiness D. Anxiety, hypertension, hematuria

ANSWER When assessing a patient with suspected cocaine intoxication, a nurse would expect to see: A. Chest pain, hypothermia, hypoxia B. Tachycardia, chest pain, hyperthermia C. Hyperthermia, hypotension, drowsiness D. Anxiety, hypertension, hematuria

Pain Pain is what the patient says it is Measurement tools
Visual analog scale Likert scale Critical Care Pain Observation Tool (CPOT) Behavioral Pain Scale Facial expressions Pain assessments should be done routinely “5th vital sign” Pain contributes to posttraumatic stress disorder (PTSD) Consider alternative therapies as well as pharmacologic Behavioral pain scale and CPOT are use for patients who cannot self-report pain (e.g. ventilated patient) Alternative therapies include massage, heat/cold, biofeedback, TENS, prayer, mental imaging

Palliative Care/End of Life Care
Hospice care is care provided at the end of life Palliative Care is indicated whenever there are significant burdens from illness or trauma Palliative Care can be delivered concurrently with life prolonging treatment or as the main focus of care Palliative Care does not require the patient to be a “Do not Resuscitate” Palliative Care honors the preferences of the patient and family through careful attention to their goals, values, and priorities

Pressure Ulcers Stage I: Skin intact with non-blanchable erythema
Stage II: Partial thickness epidermis open, superficial – not depth Stage III: Full thickness through dermis Stage IV: Full thickness through dermis with exposure of underlying structures (muscle, bone) Unstageable: Unable to assess thickness (eschar or covered) Deep Tissue Injury: Maroon or purple in color; unable to determine depth

Pressure Ulcers Assess for patients at risk Prevent and Treat
Remember vasopressors, malnutrition, immobility seen more in acute care settings Picture of stage III, deep tissue injury, and unstageable Vasopressors, malnutrition and immobility are all causes of pressures ulcers. Need to think about repositioning patients on vasopressors with low blood pressures

EXAM QUESTION # 1 Which of the following are signs and symptoms of the late stage of septic shock? A. Warm skin, decreased level of consciousness, and tachycardia B. Cold and clammy skin, decreased cardiac output, decrease urine output, and tachycardia C. Chills, metabolic acidosis, and normal urine output D. Decreased central venous pressure, and normal urine output Answers are on slide after questions and answer selections. Be sure to review not only why the correct answer is right, but also why the incorrect answers are wrong. 99

EXAM QUESTION # 1 Answer: B
Which of the following are signs and symptoms of the late stage of septic shock? A. Warm skin, decreased level of consciousness, and tachycardia B. Cold and clammy skin, decreased cardiac output, decrease urine output, and tachycardia C. Chills, metabolic acidosis, and normal urine output D. Decreased central venous pressure, and normal urine output Answer: B Cold and clammy skin, decreased cardiac output, decrease urine output, and tachycardia Remember to look at all components of the question. Answer A is wrong because skin is not warm in the late stages. Answers C and D are wrong because urine output would not be normal 100

EXAM QUESTION # 2 A 25 YO man admitted with multiple trauma has had significant changes in the last 12 hours. His temperature is 39oC, his skin is warm and dry, and he is restless and agitated. The following are his hemodynamic parameters: BP 88/ CVP 2 mm HG HR 124/min PAOP 3 mm HG CO 10.5 L/min SVR 452 CI 5.25 L/min/m SvO2 55% 101

EXAM QUESTION # 2 cont. What do you think is happening?
A. Cardiac Tamponade B. Hypovolemic Shock C. Septic/Vasogenic Shock D. Cardiogenic Shock 102

EXAM QUESTION # 2 cont. What do you think is happening?
A. Cardiac Tamponade B. Hypovolemic Shock C. Septic/Vasogenic Shock D. Cardiogenic Shock Answer: C The hemodynamic values do not fit any of the other shock states. In cardiac tamponade, hypovolemic shock, and cardiogenic shock, the CO would be low, not high. In cardiac tamponade and cardiogenic shock, the CVP and PAOP would be high, not low 103

EXAM QUESTION # 3 Which of the following does an SvO2 of 90% demonstrate? A. A hypoxemic state B. An increase in oxygen delivery C. A decrease in oxygen extraction D. Intra-cardiac shunt 104

EXAM QUESTION # 3 Answer: C.
Which of the following does an SvO2 of 90% demonstrate? A. A hypoxemic state B. An increase in oxygen delivery C. A decrease in oxygen extraction D. Intra-cardiac shunt Answer: C. SvO2 is high when the tissues cannot extract oxygen from hemoglobin because of acidosis. In a hypoxemic state, the SvO2 would be low (A). Increased oxygen delivery beyond what the tissues require would cause an elevated SvO2, but there is nothing in the scenario to indicate this is occurring (B). Intra-cardiac shunt (D) would cause a decrease in SvO2. 105

EXAM QUESTION #4 Three days ago, an older patient was admitted to the ICU following abdominal surgery for a perforated bowel. During the past 4 hours, the patient has developed progressive hypotension unresponsive to fluid boluses, has become oliguric and demonstrates signs of MODS. The nurse’s priority for care now centers on which of the following as the most important intervention in reducing mortality of patients with SIRS and MODS? A. Pain management B. Maintenance of tissue oxygenation C. Nutritional and metabolic support D. Identification and treatment of underlying source 106

EXAM QUESTION #4 Three days ago, an older patient was admitted to the ICU following abdominal surgery for a perforated bowel. During the past 4 hours, the patient has developed progressive hypotension unresponsive to fluid boluses, has become oliguric and demonstrates signs of MODS. The nurse’s priority for care now centers on which of the following as the most important intervention in reducing mortality of patients with SIRS and MODS? A. Pain management B. Maintenance of tissue oxygenation C. Nutritional and metabolic support D. Identification and treatment of underlying source 107

EXAM QUESTION #5 Your patient is in anaphylactic shock after receiving contrast dye for a CAT scan. Identify the drug you expect the doctor to order, which promotes bronchodilation and vasoconstriction: A. Atropine B. Epinephrine C. Gentamycin D. Methylprednisolone 108

Exam Question #5 Your patient is in anaphylactic shock after receiving contrast dye for a CAT scan. Identify the drug you expect the doctor to order, which promotes bronchodilation and vasoconstriction: A. Atropine B. Epinephrine C. Gentamycin D. Methylprednisolone Correct Answer is B Epinephrine relaxes bronchial smooth muscle by stimulating beta 2 adrenergic receptors and constricts blood vessels Atropine counteracts bradyarrhythmias Gentamycin counteracts septic shock Methylprednisolone may be given is analphylactic shock as a second line drug to prevent histamine release 109

Exam question #6 An 82 yr old man is admitted post MVC with a humeral fracture, hemopneumothorax from left rib fx #4-7. On tertiary survey the pt. becomes confused, dyspneic, tachypneic with RR >32min, HR > 122 bpm. What is the most likely cause of this change in assessment? A. Pulmonary embolus B. Cardiac Tamponade C. Respiratory failure r/t splinting from the rib fracture D. Heart Failure

Exam question #6 Answer: A.
An 82 yr old man is admitted post MVC with a humeral fracture, hemopneumothorax from left rib fx #4-7. On tertiary survey the pt. becomes confused, dyspneic, tachypneic with RR >32min, HR > 122 bpm. What is the most likely cause of this change in assessment? A. Pulmonary embolus B. Cardiac Tamponade C. Respiratory failure r/t splinting from the rib fracture D. Heart Failure Answer: A. PE. The patient’s humeral fracture has caused a fat emboli. There is no description in the scenario to point towards cardiac tamponade (B), such as bulging next veins, distant heart sounds, etc. Although the hemopneumthorax (C) could cause respiratory failure, it would not be from splinting. There is also nothing in the scenario to suggest heart failure (D).

Exam question # 7 An unconscious patient is admitted with toxic ingestion of an unknown substance. Which one of the following is the most appropriate assessment and intervention? A. ABCs, activated charcoal, narcan B. ABCDEs, VS, D50W 100 ml IVP, thiamine 100mg IV, Narcan IV, consider gastric emptying, consider dialysis, call Poison Control C. Ipecac via NGT D. ABCs, D50W IVP, Narcan

Exam question # 7 An unconscious patient is admitted with toxic ingestion of an unknown substance. Which one of the following is the most appropriate assessment and intervention? A. ABCs, activated charcoal, narcan B. ABCDEs, VS, D50W 100 ml IVP, thiamine 100mg IV, Narcan IV, consider gastric emptying, consider dialysis, call Poison Control C. Ipecac via NGT D. ABCs, D50W IVP, Narcan Answer B. This is the only answer that includes calling poison control, which is essential. Note that this isn’t the correct answer because it’s the longest. Choosing the longest answer when you don’t know the correct answer is a fallacy

Exam question # 8 A patient is admitted after exhibiting several neuropsychiatric symptoms including motor coordination difficulties, delayed reaction times, headache, and impaired cognitive skills. During the nurse’s conversation with the family to secure a patient history, the patient’s spouse mentioned that they are in the process of renovating a home that has been in the family for over 50 years

Exam question # 8 This information suggests that the most likely etiology for this patient’s symptoms is: A. Cyanide poisoning B. Carbon monoxide exposure C. Exposure to pesticides D. Lead poisoning

Exam question # 8 This information suggests that the most likely etiology for this patient’s symptoms is: A. Cyanide poisoning B. Carbon monoxide exposure C. Exposure to pesticides D. Lead poisoning Answer: D – Lead poisoning. The family’s information that they have been renovating an old house is a key clue to possible cause. There is nothing in the scenario to suggest the other answers

QUESTION #9 Assessment data that increases suspicion that a patient is developing SIRS would include: A. Temperature 38 degrees C, platelets 72,000, positive D- dimer B. WBC = 13.7, HR- 127, Respiratory rate = 37 C. Hospital acquired pneumonia, WBC= 11.5, pH= 7.24 D. Temperature 37.4 degrees C, heart rate 54, Glucose = 200

Exam Question #9 Assessment data that increases suspicion that a patient is developing SIRS would include: A. Temperature 38 degrees C, platelets 72,000, positive D- dimer B. WBC = 13.7, HR- 127, Respiratory rate = 37 C. Hospital acquired pneumonia, WBC= 11.5, pH= 7.24 D. Temperature 37.4 degrees C, heart rate 54, Glucose = 200 Correct Answer is B: These are the SIRS criteria Platelets and D-dimer (answer A), Hospital acquired pneumonia, low heart rate and high glucose may be part of the septic picture, but are not SIRS criteria

Exam Question #10 Mr. M is in the PCU for the management of exacerbation of his heart failure. He develops a fever and his WBC count has elevated to 14,000. What is the recommended time frame to initiate antibiotics? A. Within one hour B. 2 to 3 hours C. Within 6 hours D. Antibiotics are not indicated

Exam Question #10 Mr. M is in the PCU for the management of exacerbation of his heart failure. He develops a fever and his WBC count has elevated to 14,000. What is the recommended time frame to initiate antibiotics? A. Within one hour B. 2 to 3 hours C. Within 6 hours D. Antibiotics are not indicated Correct answer is A Patient meets criteria for sepsis: Fever, WBC elevated

CCRN/PCCN Certification Review Multisystem

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