COMPLEX CR 341 Complex Adult Health Study Guides
Normal Lab Ranges
Albumin: 3.5-5.0
Pre- albumin: 19-35
ABG’s
o pH 7.35-7.45
o paCo2 35-45
o HCo3 22-26
o paO2 80-100
▪ Below 60 is severe hypoxemia
• When given a list of patients and deciding who to see first, always look at PaO2.
• Need to know compensation, level of hypoxemia
• ABG example - Work on ABG problems
o pH 7.35 - normal (leans toward acidic side)
o Pco2 68 - high
o Hco3 30 - high bc its trying to fix the acid
o Pao2 55
▪ Fully compensated respiratory acidosis with mild hypoxemia
• Metabolic acidosis
o Causes
▪ DKA - most common
▪ CKD
▪ Shock
▪ Diarrhea
o Compensation
▪ Increased respiratory rate (hyperventilation)
• Metabolic alkalosis
o Causes
▪ NG suctioning
▪ Diuretics (increase K and decrease HCo3)
▪ Vomiting
o Compensation
▪ Decreased respiratory rate
• Respiratory acidosis
o Causes
▪ Hypoventilation
▪ Narcotics
▪ Hypercapnic respiratory failure
▪ Low pH and high Pco2
▪ COPD- Compensated
▪ CNS Depression
o Compensation
▪ Excrete H+ ions through urine
• Respiratory alkalosis
o Causes
▪ Hyperventilation
▪ Anxiety
,COMPLEX CR 341 Complex Adult Health Study Guides
• Early signs of respiratory distress
o Restlessness
o Agitation
o Tachypnea- respiratory alkalosis 1st then will go into acidosis
o Tachycardia
Critical Care
• CPOT: Critical Care Pain Observation Tool
o 1st thing- 1 minute observation!!!!
▪ You can get anywhere between 0-8 points. There are 4 categories worth
2 points each. Know how your patient presents in each category.
▪ Facial expression
▪ Patient is frowning or lowering brow- he is tense. He will
get 1 point
▪ Eyes shut and orbital tension (Grimacing)- 2 points
▪ Body movements
▪ Slow cautious movements- protection - 1 point
▪ Pull on tubes, trying to get out of bed- 2 points
▪ Muscle tension
▪ No resistance with passive movement - 0 pts
▪ Resistance to passive movement - 1 pt
▪ Very tense & rigid- 2 pts
▪ Compliance with vent or vocalization
▪ Tolerates the vent- 0 pts
▪ Alarms going off but they are spontaneous - 1 pts
▪ Asynchrony (fighting the vent)- 2 pts
▪ Vocalization
▪ Sobbing and crying- 2 points
• Delirium
o Risk Factors
▪ Age
▪ Being on a ventilator
▪ Polypharmacy
▪ Visual and hearing deficits
▪ Make sure pt has glasses and hearing aid
▪ Sleep deprivation
▪ Ensure they get adequate rest. Cluster care to give periods of
rest.
▪ History of dementia
▪ Tubes and restraints
▪ Never put restraints on patients with delirium- it will make it
worse.
▪ There is a sequence of how you deal with agitation
▪ 1st: therapeutic communication
▪ Sitter
▪ Medicate
▪ Restraints
▪ Avoid benzos and narcotics
,COMPLEX CR 341 Complex Adult Health Study Guides
o Medication
▪ Haldol - Good drug to give
• Propofol
o Used as a sedative & antiasthenic - patient must be on
Vent
o Given as an infusion that will need to be titrated
o CANNOT IV PUSH without doctor in room giving directions
o Short half life- good thing!
o Turns urine green
o Monitor BP every 5 minutes - causes hypotension
o Cannot be used in pt’s with allergies to eggs or soy
o Will increase fats - triglycerides and cholesterols.
o Change tubing using aseptic technique every 12 hours
• Richmond Agitation and Sedation Scale (RASS)
o Use for patients with delirium
o 0, +4, or -5
o 0 is alert and calm
o +4 is combative and agitated
o -5 unresponsive
▪ Nursing interventions
▪ Use propofol as a sedative
▪ May need to titrate infusion based on provider order
▪ Physician order will say “keep below -2 (slightly sedated)
on RASS scale”
• CAM ICU- Confusion Assessment method
o In order to do this, you must have completed a RASS scale.
o 1st thing to remember- it has to be acute onset and a fluctuating course (changes
in how pt presents)
▪ This means if a patient has a history of dementia and is acting like he did
when he first came in it is not delirium.
o 4 parts
▪ Acute onset / fluctuating course- have to have these 2
▪ Inattention
▪ Squeeze my hand every time you hear an A in the phrase “Save A
Heart”
▪ Disorganized thinking
▪ Ask questions… 1 right & 1 wrong
▪ Will a stone float on water?
▪ Are there fish in the sea?
▪ Altered level of consciousness (positive RAAS)
• ABCDEF Bundle - for delirium
, COMPLEX CR 341 Complex Adult Health Study Guides
o A- assess and manage pain
▪ CPOT
o B- both SAT (spontaneous awakening trial)
▪ Take the pt off the ventilator and see if he wakes up & if he can
comprehend instructions
▪ and SBT (spontaneous breathing trial )
▪ Everyday hes on the ventilator, we take off ventilator and propofol
to see if he can breathe on his own
o C-choice of sedation
▪ No benzos- will use haldol
o D- delirium arbitrary (CAM ICU)
▪ Acute change or fluctuating course of mental status
o E- early mobility
o F- family
▪ Family is NOT TO BE USED AS SITTERS. It is important to have family
around as it helps to reorient the patient.
▪ What do you do the first time the family comes in to see the patient?
▪ Walk with them to the room
▪ Explain the equipment in the room
▪ Tell them what the patient will look like
▪ It is ok to touch the patient
▪ Go into the room with the family & stay for awhile to
answer questions
▪ Should not have restricted visiting hours.
• Medications for Delirium
** NO Benzo’s or Opiods for delirium - ever!
o If pt has a +3 on RAAS & has delirium they will be on haldol
o Haldol or haloperidol ******* antipsychotic
▪ Can cause tardive dyskinesia
▪ Can cause hypotension
▪ Fall Risk
▪ Has anticholinergic effects
• Can cause dry mouth
• Urinary retention
• Constipation
▪ QT prolongation
o Omeprazole
▪ PPI
▪ MOA:
▪ Can cause C diff
o Famotidine
▪ H2 blocker
▪ MOA
▪ Can cause altered LOC
o Heparin
Normal Lab Ranges
Albumin: 3.5-5.0
Pre- albumin: 19-35
ABG’s
o pH 7.35-7.45
o paCo2 35-45
o HCo3 22-26
o paO2 80-100
▪ Below 60 is severe hypoxemia
• When given a list of patients and deciding who to see first, always look at PaO2.
• Need to know compensation, level of hypoxemia
• ABG example - Work on ABG problems
o pH 7.35 - normal (leans toward acidic side)
o Pco2 68 - high
o Hco3 30 - high bc its trying to fix the acid
o Pao2 55
▪ Fully compensated respiratory acidosis with mild hypoxemia
• Metabolic acidosis
o Causes
▪ DKA - most common
▪ CKD
▪ Shock
▪ Diarrhea
o Compensation
▪ Increased respiratory rate (hyperventilation)
• Metabolic alkalosis
o Causes
▪ NG suctioning
▪ Diuretics (increase K and decrease HCo3)
▪ Vomiting
o Compensation
▪ Decreased respiratory rate
• Respiratory acidosis
o Causes
▪ Hypoventilation
▪ Narcotics
▪ Hypercapnic respiratory failure
▪ Low pH and high Pco2
▪ COPD- Compensated
▪ CNS Depression
o Compensation
▪ Excrete H+ ions through urine
• Respiratory alkalosis
o Causes
▪ Hyperventilation
▪ Anxiety
,COMPLEX CR 341 Complex Adult Health Study Guides
• Early signs of respiratory distress
o Restlessness
o Agitation
o Tachypnea- respiratory alkalosis 1st then will go into acidosis
o Tachycardia
Critical Care
• CPOT: Critical Care Pain Observation Tool
o 1st thing- 1 minute observation!!!!
▪ You can get anywhere between 0-8 points. There are 4 categories worth
2 points each. Know how your patient presents in each category.
▪ Facial expression
▪ Patient is frowning or lowering brow- he is tense. He will
get 1 point
▪ Eyes shut and orbital tension (Grimacing)- 2 points
▪ Body movements
▪ Slow cautious movements- protection - 1 point
▪ Pull on tubes, trying to get out of bed- 2 points
▪ Muscle tension
▪ No resistance with passive movement - 0 pts
▪ Resistance to passive movement - 1 pt
▪ Very tense & rigid- 2 pts
▪ Compliance with vent or vocalization
▪ Tolerates the vent- 0 pts
▪ Alarms going off but they are spontaneous - 1 pts
▪ Asynchrony (fighting the vent)- 2 pts
▪ Vocalization
▪ Sobbing and crying- 2 points
• Delirium
o Risk Factors
▪ Age
▪ Being on a ventilator
▪ Polypharmacy
▪ Visual and hearing deficits
▪ Make sure pt has glasses and hearing aid
▪ Sleep deprivation
▪ Ensure they get adequate rest. Cluster care to give periods of
rest.
▪ History of dementia
▪ Tubes and restraints
▪ Never put restraints on patients with delirium- it will make it
worse.
▪ There is a sequence of how you deal with agitation
▪ 1st: therapeutic communication
▪ Sitter
▪ Medicate
▪ Restraints
▪ Avoid benzos and narcotics
,COMPLEX CR 341 Complex Adult Health Study Guides
o Medication
▪ Haldol - Good drug to give
• Propofol
o Used as a sedative & antiasthenic - patient must be on
Vent
o Given as an infusion that will need to be titrated
o CANNOT IV PUSH without doctor in room giving directions
o Short half life- good thing!
o Turns urine green
o Monitor BP every 5 minutes - causes hypotension
o Cannot be used in pt’s with allergies to eggs or soy
o Will increase fats - triglycerides and cholesterols.
o Change tubing using aseptic technique every 12 hours
• Richmond Agitation and Sedation Scale (RASS)
o Use for patients with delirium
o 0, +4, or -5
o 0 is alert and calm
o +4 is combative and agitated
o -5 unresponsive
▪ Nursing interventions
▪ Use propofol as a sedative
▪ May need to titrate infusion based on provider order
▪ Physician order will say “keep below -2 (slightly sedated)
on RASS scale”
• CAM ICU- Confusion Assessment method
o In order to do this, you must have completed a RASS scale.
o 1st thing to remember- it has to be acute onset and a fluctuating course (changes
in how pt presents)
▪ This means if a patient has a history of dementia and is acting like he did
when he first came in it is not delirium.
o 4 parts
▪ Acute onset / fluctuating course- have to have these 2
▪ Inattention
▪ Squeeze my hand every time you hear an A in the phrase “Save A
Heart”
▪ Disorganized thinking
▪ Ask questions… 1 right & 1 wrong
▪ Will a stone float on water?
▪ Are there fish in the sea?
▪ Altered level of consciousness (positive RAAS)
• ABCDEF Bundle - for delirium
, COMPLEX CR 341 Complex Adult Health Study Guides
o A- assess and manage pain
▪ CPOT
o B- both SAT (spontaneous awakening trial)
▪ Take the pt off the ventilator and see if he wakes up & if he can
comprehend instructions
▪ and SBT (spontaneous breathing trial )
▪ Everyday hes on the ventilator, we take off ventilator and propofol
to see if he can breathe on his own
o C-choice of sedation
▪ No benzos- will use haldol
o D- delirium arbitrary (CAM ICU)
▪ Acute change or fluctuating course of mental status
o E- early mobility
o F- family
▪ Family is NOT TO BE USED AS SITTERS. It is important to have family
around as it helps to reorient the patient.
▪ What do you do the first time the family comes in to see the patient?
▪ Walk with them to the room
▪ Explain the equipment in the room
▪ Tell them what the patient will look like
▪ It is ok to touch the patient
▪ Go into the room with the family & stay for awhile to
answer questions
▪ Should not have restricted visiting hours.
• Medications for Delirium
** NO Benzo’s or Opiods for delirium - ever!
o If pt has a +3 on RAAS & has delirium they will be on haldol
o Haldol or haloperidol ******* antipsychotic
▪ Can cause tardive dyskinesia
▪ Can cause hypotension
▪ Fall Risk
▪ Has anticholinergic effects
• Can cause dry mouth
• Urinary retention
• Constipation
▪ QT prolongation
o Omeprazole
▪ PPI
▪ MOA:
▪ Can cause C diff
o Famotidine
▪ H2 blocker
▪ MOA
▪ Can cause altered LOC
o Heparin
