NUR 425: Exam #1

What does CPOT assess?

Pain in critically ill patients who may be unable to communicate their pain.

What are the 4 CPOT categories?

Facial expression, body movement, muscle tension, and compliance/vocalization.

What is the CPOT score range?

0–8.

According to the study guide, what CPOT score indicates unacceptable pain?

2.

What should the nurse do when CPOT is >2?

Give pain medication according to the study guide.

What does BPS assess?

Pain in critically ill patients, including facial expression, upper limb movements, and compliance with mechanical ventilation.

What are the 3 BPS categories?

Facial expression, upper limb movements, and compliance with mechanical ventilation.

What is the BPS score range?

3–12.

According to the study guide, what BPS score indicates no pain?

3.

According to the study guide, what BPS score indicates pain/pain medication may be needed?

4 or 5+.

According to the study guide, what BPS score indicates medication should be given now?

12.

What are nonpharmacologic pain interventions?

Music, massage, aromatherapy, positioning/mobility, and meditation.

What is an important principle when managing pain and sedation?

Treat pain before sedating.

What type of medication is ideally used for pain/sedation according to the study guide?

An opioid.

What is the purpose of sedation?

Decrease level of consciousness and establish calm.

What are indications for sedation?

Facilitate ventilation, promote patient safety, minimize discomfort during procedures, minimize psychological disturbance, control behavior, and maximize amnesia when appropriate.

What should be tried before pharmacologic treatment of anxiety?

Nonpharmacologic anxiety measures.

What level of sedation is preferred?

Light sedation rather than deep sedation.

What RASS range is the goal for light sedation?

-1 to +1.

According to the study guide, which medication is preferred over propofol when light sedation and decreased delirium risk are desired?

Dexmedetomidine.

How often should spontaneous awakening trials/sedation interruptions occur?

At least once daily.

What should the nurse document with continuous sedation?

Pain, infusion rate, sedation goal, and relevant monitoring.

What is RASS used to assess?

Level of agitation and sedation.

What is the RASS score for a combative patient?

+4.

What is the RASS score for a very agitated patient?

+3.

What is the RASS score for an agitated patient?

+2.

What is the RASS score for a restless patient?

+1.

What is the RASS score for an alert and calm patient?

0.

What is the RASS score for a drowsy patient who sustains awakening to voice/eye contact for more than 10 seconds?

-1.

What is the RASS score for light sedation with brief awakening to voice and eye contact less than 10 seconds?

-2.

What is the RASS score for moderate sedation with movement or eye opening to voice but no eye contact?

-3.

What is the RASS score for deep sedation with no response to voice but movement or eye opening to physical stimulation?

-4.

What is the RASS score for an unarousable patient?

-5.

What is the Ramsey Sedation Scale score for an anxious/agitated patient?

1.

What is the Ramsey Sedation Scale score for a cooperative, oriented, tranquil patient?

2.

What is the Ramsey Sedation Scale score for a patient who responds only to verbal commands?

3.

What is the Ramsey Sedation Scale score for a patient asleep with brisk response to light stimulation?

4.

What is the Ramsey Sedation Scale score for a patient asleep without response to light stimulation?

5.

What is the Ramsey Sedation Scale score for a nonresponsive patient?

6.

Which sedation scale does the study guide prefer?

RASS.

What is delirium?

A serious sudden change in brain function involving severe confusion, changes in alertness, and disorganized thinking.

What is delirium NOT?

Dementia or psychosis.

What medications can contribute to delirium?

Sedatives, benzodiazepines, opioids/analgesics, and aminoglycosides.

What nonmedication factors can contribute to delirium?

Sleep deprivation, sensory overload, anxiety, and disease processes such as hypoxia.

What are signs of delirium?

Altered mentation, psychomotor changes, and altered sleep-wake cycle/night agitation.

What altered-mentation findings can occur with delirium?

Delusions, short-term memory loss, distractibility, and short attention span.

What psychomotor changes can occur with delirium?

Restlessness or lethargy.

What sleep-related finding is common with delirium?

Altered sleep-wake cycle and nighttime agitation.

What does CAM-ICU assess?

Acute mental status changes, inattention, level of consciousness, and disorganized thinking.

What are risk factors for delirium?

Older age, dementia, prior coma, trauma/surgery, benzodiazepines, and blood transfusions.

What is the relationship between immobility and delirium?

Immobility increases delirium risk.

What is the biggest risk factor for complications related to bed rest according to the study guide?

Bed rest/immobility.

What should nurses encourage to reduce complications of immobility?

Early mobilization, rehabilitation, and patient participation.

What factors can disrupt sleep in critically ill patients?

Pain, environmental stimuli, healthcare interruptions, psychological factors, respiratory factors, and medications.

What are consequences of sleep disruption?

Delirium and cognitive dysfunction.

How can nurses promote sleep?

Reduce noise and light and cluster care.

According to the study guide, what medication reduces sleep quality?

Propofol.

According to the study guide, what is recommended over no melatonin for sleep?

Melatonin.

What does the ABCDEF bundle include?

Awakening and Breathing Coordination, Delirium prevention and Management, Early Physical Mobility, and Family Involvement.

What should be done to prevent and manage delirium?

Monitor early/per protocol, assess and treat causes, promote sleep, cluster care, reduce noise, and provide orientation cues such as signs and clocks.

What information should a continuous titratable infusion order include?

Medication, route, starting rate, titration frequency, maximum rate, and objective endpoint.

What are examples of objective endpoints for titratable infusions?

Pain goal, sedation goal, or MAP.

What should nurses monitor with continuous titratable infusions?

Medication concentration, infusion rate, calculations, multiple drips, tapering/off-drip instructions, maximum rate, and medication changes.

What is angina?

Chest pain caused by an imbalance between myocardial oxygen supply and demand due to ischemia.

How is typical angina pain described?

Squeezing, burning, heavy, tight, smothering, choking, or pressure.

Where can angina pain occur?

Substernal, left pectoral, or epigastric areas.

Where can angina pain radiate?

Jaw, left shoulder, or left arm.

What symptoms can accompany angina?

Dyspnea, lightheadedness, and diaphoresis.

What is stable angina?

Chronic exertional angina that occurs with exertion and is relieved by rest or nitrates.

What ECG changes may occur with stable angina?

ST depression or T-wave inversion.

What happens to the ECG after stable-angina symptoms resolve?

It returns to normal.

What is unstable angina?

Severe or crescendo angina that can occur at rest and requires more frequent nitrate therapy.

What ECG findings may occur with unstable angina?

ST depression, T-wave inversion, or no change.

Why is unstable angina concerning?

It increases the risk of myocardial infarction.

What does ACS stand for?

Acute coronary syndrome.

What conditions are included in ACS?

Unstable angina, NSTEMI, and STEMI.

What commonly causes ACS?

Rupture of an unstable atherosclerotic plaque followed by thrombus formation.

What is NSTEMI?

Myocardial infarction caused by a partially or nonoccluded coronary artery without ST elevation.

What ECG findings can occur with NSTEMI?

ST depression, T-wave inversion, or no changes.

Is emergent catheterization the treatment for NSTEMI according to the study guide?

No; catheterization is usually performed within 12–72 hours.

Are thrombolytics used to treat NSTEMI according to the study guide?

No.

What is STEMI?

Myocardial infarction caused by a completely occluded coronary artery with ST elevation.

What ECG finding is associated with STEMI?

ST elevation and potentially a pathologic Q wave.

How quickly should the artery be opened in STEMI?

Within 90 minutes.

What are the methods for opening the artery in STEMI?

PCI or thrombolytics if PCI is unavailable.

How long does AMI chest pain typically last?

20 minutes or longer.

How can AMI pain present?

Heavy, pressure-like, tight, burning, or crushing pain.

Where can AMI pain occur or radiate?

Substernal/epigastric and radiating to the neck, jaw, arms, or back.

Which patients may have atypical AMI symptoms?

Women, people with diabetes, and older adults.

What sympathetic signs can occur with AMI?

Diaphoresis, increased heart rate and blood pressure, vasoconstriction, and cool/clammy/ashen skin.

What can happen to blood pressure during an AMI if cardiac output decreases?

Blood pressure may fall.

What findings can indicate heart failure during AMI?

Crackles, JVD, hepatic engorgement, and peripheral edema.

What do S3 and S4 heart sounds suggest in AMI?

Left ventricular dysfunction.

What type of murmur may occur with AMI?

A holosystolic murmur.

What GI symptoms can occur with AMI?

Nausea and vomiting.

What temperature change can occur within 24–48 hours after AMI?

Fever around 100.4°F/38°C that may last 4–5 days.

How common are dysrhythmias during MI according to the study guide?

80–90%.

What ECG monitoring is needed for AMI?

A 12-lead ECG and continuous ECG monitoring.

What medication should the patient chew during suspected AMI?

Aspirin 162–325 mg.