Chapter 1

Describe the profile of the High-Acuity Nurse.

 Able to analyze clinical situations, make decisions based on this analysis, and rapidly intervene
to ensure optimal patient outcomes.
 Must be comfortable with uncertainty and patient instability.
 Instrumental in treating patients’ health problems as well as their reactions to the healthcare
environment.
 Often the first member of the team to detect early signs of impending complication.
Explain the use of technology (and its limits) in high-acuity environments.
 Technology has provided the nurse with many advantages and improved patient outcomes,
BUT…….
 Patient Depersonalization
 Overload and Over-reliance
 “The skilled nurse who practices in a high-acuity setting must be able to bridge the gap between
complex technology and the art of caring.”
Describe a healthy work environment.
 AACN (2001): “Commitment to promote healthy work environments that support quality patient
care and high levels of nurse satisfaction.”
 Skilled communication
 True collaboration
 Effective decision-making
 Appropriate staffing
 Meaningful recognition
 Authentic Leadership
Ensure patient safety in high-acuity environments.
 Patient safety and healthy work environments are closely linked.
 Working conditions, teamwork, and patient outcomes closely linked
 Systems improvement is goal in reducing healthcare errors.
Palliative Care
 Palliative care means patient and family‐centered care that optimizes quality of life by
anticipating, preventing, and treating suffering. Palliative care throughout the continuum of
illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to
facilitate patient autonomy, access to information, and choice.

Chapter 5
Drug classes (MOA, side effects)
 Opioids—respiratory depression, CNS depression, constipation, urinary retention
 NSAIDs—(Ibuprofen, naproxen, Tordol)
 Aspirin (ASA)
 Acetaminophen
 Tricyclic antidepressants (adjuvant)
 Non-pharmacological treatments
Why does pain go untreated?
Table 5-7: effects from different drugs/intoxication
Chapter 6: Nutritional Support
Definitions
 Malnutrition: change in body composition and diminished function.
 Undernutrition: arises when body’s minimum nutritional requirements of CHS, PRO, lipids and
other essential nutrients are not met.
 Starvation: Severe malnutrition condition characterized by failure to meet the minimum body
requirements. During times of metabolic stress, increased energy expenditure and
gluconeogenesis. Stored glycogen gone within 24 hours….moves on to fatty acids mobilized.
 Marasmus: Often associated with altered GI functioning, severe cachectic process. Wasting.
 Kwashiorkor: caused by prolonged protein malnutrition.
 Protein-calorie malnutrition commonly seen in acute/chronic illness due to depletion of fat,
muscle wasting, and micronutrient deficiencies.Discuss enteral nutrition, including benefits,
potential complications, barriers
Explain nutritional alterations associated with selected disease states.
 Liver: High CHO, normal to moderate protein, low-fat diets
 Lung: Lower CHO with adequate protein to maintain nutritional needs
 Kidney: Protein restriction until on dialysis (nitrogenous waste products = raised BUN and
creatinine). Extra CHO for calories. Low calcium/high phosphorus = supplement calcium
 Heart: Can become cachectic. Fluid restriction.
 GI: SNS slows down the gut.
 Burns: CALORIES CALORIES CALORIES + fluids
 Traumatic Brain Injury: VERY HIGH ENERGY NEEDS – risk of catabolic state
Discuss enteral nutrition, including benefits, potential complications, barriers
 Using the gut via G-tube, PEG, NG, etc.
 Start within 24-48 hours
 Contraindications—bowel obstruction
 Benefits include reduced risk of sepsis/infection, lower inflammation, more effective absorption,
much cheaper than TPN
 Complications—aspiration, diarrhea
 Can be placed post-pyloric if vomiting/delayed gastric emptying is an issue
o Only continuous feeds with jejunum
Discuss parenteral nutrition, including potential complications.
 Generally given via central line
o Infection risk d/t high sugar content of solution
o Watch for fever, chills, hypotension, tachycardia
o Risk of air embolism if port is left open when inserting (treat with left side
trendelenburg)
Describe refeeding syndrome and management strategies.
 In Starvation, body uses stored fats.
 Huge release of insulin.
 Leads to major electrolyte abnormalities.
 Patients at risk: cancer, cachexia, HIV/AIDS, chronic alcoholism, anorexia
 REFEED SLOWLY!! Initially only 20 cals/kg
Chapter 11: Determinants and Assessment of Pulmonary Function
 Explain the conducting airway and the concept of ventilation.
o Conducting (trachea, nose: moving air, no gas exchange)—humidifying, filter, warming
the air, mucociliary blanket to trap debris and microbes
o Ventilation—air in and out
o Compliance—how easy it is to inflate and deflate lungs
(change in volume / change in pressure)
 Discuss external vs. internal respiration and pulmonary gas diffusion.
o Respiration—gas exchange
o External = between blood and alveoli (external air)
o Internal = between blood and tissues
 Describe pulmonary perfusion and its components.
o Affected by cardiac output, gravity, V:Q, Pulmonary Vascular
Resistance (PVR)
o Alveoli ventilation = 4L/min
o Perfusion = 5L/min
o V:Q ratio = 0.8
o Ventilation (V) problem = low V:Q ratio = shunting
o Perfusion problem (Q) = high V:Q ratio
 Interpret ABGs, including compensation.
o Resp = CO2 vs. metabolic = bicarbonate
 Conduct a focused respiratory nursing history and assessment.
o Sputum—yellow/green vs white vs frothy
o Breath sounds—abnormal (wheezing, crackles, rhonchi (bigger
airways, probably secretions)
o Vesicular breath sounds in peripheral lung fields = normal
o Dyspnea (shortness)/PND (sudden shortness of breath at
night)/Orthopnea (can’t lay flat)
o Chest pain—respiratory or cardiac? Resp. might change with
inhale/exhale
 Describe tests used to evaluate pulmonary function.
o FEV1 (Forced expiratory volume over 1 second)
 Discuss noninvasive and invasive methods of monitoring gas exchange.
o Pulse ox relies on hemoglobin binding—lower hemoglobin doesn’t show change in
saturation.
o CO poisoning—binds to hemoglobin, will show normal saturation
o Capnography—monitoring exhaled CO2

Chapter 7: Mechanical Ventilation

 Two types of ventilation—negative pressure (normal breathing) vs. positive pressure ventilation
(ventilator)
o Can regulate amount of tidal volume by controlling volume or pressure
 Volume control
o SIMV = weaning, more work for pt. Assist Control = control (every breath is ventilator
breath) and rest for patient
 Pressure control
 o Reduce risk for barotrauma when compliance is poor
o PIP = peak inspiratory pressure
 PEEP = positive end expiratory pressure—keep alveoli inflated
 Pressure support—designed to eliminate the resistance of the tubing for spontaneous breaths
 CPAP = continuous positive airway pressure
o Like PEEP and pressure support combined
 X Pressure-Regulated Volume-Controlled Mode
o Like AC, tidal volume and rate are present
o Patient can initiate breaths too
o Pressure readjusts on a breath-to-breath basis to achieve set tidal volume
 X High frequency oscillating ventilation (HFV)—high respiratory rates with tidal volumes that are
tiny; oscillatory pump delivers high rate of gas
 Identify criteria used to determine the need for mechanical ventilation.
o pH < 7.30
o PCO2 > 50
o PO2 < 60
o RR > 35
 Select equipment needed for mechanical ventilation.
o Softcuffed ET tubes (in a variety of sizes)
o Stylet – to guide the tube in place by keeping it stiff (orotracheal route only)
o Topical anesthetic – to promote comfort and local anesthesia
o Laryngoscope handle with blade attached and functional
o light source – to open and visualize the airway
o Magill forceps – to assist with guiding the tube past the pharyngeal area
o Suction machine or set up to wallmounted suction head
o Suction catheter kit with sterile gloves
o Yankauer (oral) suction catheter – to clear the airway of secretions
o Syringe for cuff inflation
o Watersoluble lubricant – to apply to the ET tube to facilitate
o insertion
o Endotracheal tubeholding device (or adhesive tape if device not available) – to secure
the ET tube following insertion
o Personal protective equipment
o Sedative medication (under guidance of credentialed provider) and intravenous access –
for patient comfort and safety and facilitating insertion process
o Stethoscope – to auscultate bilateral lung sounds post insertion • CO2 detector – to aid
in identification of tube location
 Describe common modes/monitored ventilator settings.
 Explain noninvasive ventilatory support.
o CPAP
o BiPAP—higher pressure on inspiration, lower pressure on expiration
 Discuss major complications of mechanical ventilation.
o Decreased cardiac output
o Barotrauma
o Increased ICP and decreased CPP
o Decreased renal blood flow
 o Decreased GI blood flow
o Cuff trauma
 Describe nursing care of patient requiring ventilatory support.
 Apply the golden rule of ventilator alarms
o If system is alarming and you can’t figure out why immediately, remove from ventilator
and bag manually!

Chapter 12: Alterations in Pulmonary Function

 Explain the basic differences between restrictive and obstructive pulmonary diseases.
o Obstructive = can’t get air out (exhale); CO2 retention, O2 decrease; FEV1 decreases;
total lung capacity is increased d/t air trapping; wheezing, rhonchi; cor pulmonale
o Restrictive = can’t get air in (inhale); pneumonia, neuromuscular issues, obesity;
generally normal CO2 (depends on disease state); normal FEV1; tidal volume decreases;
increased RR; crackles
o Status asthmaticus
 Heavy wheezing or none at all due to complete obstruction of airway
 Pulsus paradoxus—trapped air putting pressure on heart, decreased pulse with
inspiration
 Describe the pathophysiologic basis of respiratory failure.
o Unable to maintain adequate gas exchange, low O2; muscles work harder and need
more O2 which then produce more CO2
 Describe acute respiratory distress syndrome (ARDS).
o Etiology is inflammatory response gone wrong (uncontrolled systemic inflammation)
o Hypoxemia that is refractory to oxygen therapy
o ALI/ARDS continuum
 P/F >300 (normal)
 P/F = 200-299 (Acute lung injury)
 P/F < 200 (ARDS)
 P/F < 100 (severe)
o #1 direct = pneumonia, #1 indirect = sepsis
 Explain the types, pathophysiology, and management of acute pulmonary embolism.
o Types:
 Thromboembolism—DVT
 Fat embolism—broken long bone(s)
 X Amniotic embolism—baby junk gets into mother’s blood
 Septic embolism—septic emboli
 Venous air embolism—air in the blood, usually d/t central line placement
o PE puts stress on right side of heart
o S/S of PE
 Tachypnea
 Dyspnea
 Pleuritic pain
 Discuss the types, pathophysiology, and management of acute bacterial and viral pneumonia.
o Aspiration risk
 Describe the principles and management of patients undergoing thoracic surgery and chest
drainage.
o Water seal to prevent air from backing up into tube
 o Suction can be added to speed up process of air removal
o Occlusive dressing to prevent air from going into chest, tape it very well; chest tube
positioned without dependent loops
o If tube comes disconnected from pleurovac, stick the end of tube in sterile water
o Intermittent bubbling is good (air removal occurring), continuous bubbling means a leak
in the system
 Implement a general plan of care for a patient with an acute alteration in respiratory function.

Chapter 13: Determinants and Assessments of Cardiac Function

 Describe the normal anatomy of the cardiovascular system.
o Pulmonary and Systemic Circuits — right ventricle -> lungs; left ventricle -> systemic
o Blood Vessels: Layers—(outer to inner) tunica externa, tunica media, tunica intima
o Arteries, Veins, Capillaries—arteries actively
constrict/dilate, veins do not but they have valves
to help pass blood back to heart
o All Providers Earn Their Money
 Cardiac Cycle
o 1. Closure of AV valves, “lub” sound
o 2. Isovolumetric contraction
o 3. Semilunar valves open
o 4. Blood rushes to lungs (right) or body (left)
o 5. Semilunar valves close, “dub” sound
o 6. Isovolumetric relaxation
o 7. AV valves open
o 8. Ventricles fill with blood
 Discuss cardiac output and its determinants, including preload, contractility, and afterload and
how they relate to stroke volume.
o Cardiac output = amount of blood per minute
o CO = HR x SV — usually 4-8L/min
o SV consists of preload, afterload and contractility
 Preload is venous return (volume)
 Afterload is systemic resistance (d/t arterial constriction/dilation)
 Contractility is force of contraction
o Pressure = Flow x Resistance
 Vasoconstriction generally reduces output, increases pressure
 Vasodilation increases output but lowers pressure
 Describe the basis of arterial and venous blood pressure and the regulation of arterial blood
pressure.
o Constricted venous return will drop preload and cardiac output
o RAAS = Decreased renal perfusion -> releases renin -> angiotensinogen converts to
angiotensin I -> angiotensin I to angiotensin II -> secretion of aldosterone -> increase
absorption of sodium, water follows
 Apply knowledge of the assessment of cardiac function to provide safe, quality patient care.
o What are the parts to a cardiac physical assessment?
 Inspection—skin color, edema, change in mental status, JVD
 Palpation—pulses, capillary refill, temperature of skin, edema, point of maximal
impulse, thrills
  Auscultation—S1 and S2, murmurs (valve problems, infective endocarditis), S3
(between S1 and S2; early sign of heart failure, may hear crackles in lungs), S4
(right before S1; MI or restriction of blood flow out of left ventricle)
o How do you assess cardiac output?
 Urine output—if it drops, CO is likely dropped
o What labs are relevant?
 Troponin = cells have died
 BNP = marker of heart failure
 CK-MB (creatine kinases)
 Creatinine and BUN
 Electrolytes
o “The key to accurately evaluating cardiac function lies in the
assessment skills of the nurse.”
 Describe common cardiovascular diagnostic procedures used to
evaluate cardiac function.
o Noninvasive:
 CXR—enlarged heart, fluid
 CT—more accurate look
 Exercise ECG, aka “Stress Test”/radioactive isotopes
 Echo—2D; valves, cardiac ejection (55%-65%)
o Invasive
 TEE—look at backside of heart through esophagus wall
 Cardiac Catheterization—diagnosis (blockage) and treatment (stent placement)
 Pre: vitals, IV, blood coagulation, allergies
 Intra: vitals, sedation, LOC, bleeding, monitor for chest pain (MI)
 Post: bleeding at site, keep flat for 4-6 hours if had femoral access,
retroperitoneal bleeding, allergies, chest pain
 EPS—electrophysiologic studies; identify abnormal electrical pathways
o Labs: Troponin, BNP, CRP, CK-MB

Chapter 8: Hemodynamic Monitoring

 Describe the major parameters of interest when monitoring a patient's hemodynamic status.
 Identify the normal values for CI, CO, MAP, CVP, PAWP and define PVR, and SVR.
o CI = CO/BSA (2.4-4)
o MAP: (Systolic x 2 diastolic)/3 (70-90)
o SVR = systemic vascular resistance (left side afterload)
o PVR = pulmonary vascular resistance (right side afterload)
o CVP = Central venous pressure; preload for right side (2-6)
o PAWP = Pulmonary artery wedge pressure; catheter placed in pulmonary artery,
wedging balloon for split second to get pressure; left side preload (4-12)
 Discuss noninvasive and minimally invasive hemodynamic monitoring technologies, including
impedance cardiography, Doppler ultrasound, central venous pressure, direct arterial blood
pressure measurement, and arterial pulse contour analysis technology.
 Explain pulmonary artery (PA) catheters, including their purpose, required competencies,
interpretation of data, functional components, and care of the catheter.
1. Hypovolemia: CVP decreased, SVR increased, CO decreased, BP low normal; eventually drop
2. Decompensated heart failure: CVP increased, SVR increased, CO decreased, PAWP increased
Chapter 14: Alteration in Cardiac Function
 Describe the pathophysiology and treatment of patients with valvular heart diseases.
 Stenosis (sticky valve) or regurgitation (leaky valve)
 In systole
o Valves open = aortic and pulmonic
o Valves closed = mitral and tricuspid
 In diastole
o Valves open = mitral and tricuspid
o Valves closed = aortic and pulmonic

Should be Open (stenosis) Should be Closed (regurgitation)

Systolic (murmur) Aortic or pulmonic Mitral or tricuspid
Diastolic (murmur) Mitral or tricuspid Aortic or pulmonic

 How to diagnose?
o Physical Exam—listen to heart tones
o Echo – 2D or TEE: usually 2D is enough but TEE gives better view of posterior of heart
o Risk factors—endocarditis/sepsis, cardiac surgery, IV drug users, rheumatic fever,
congenital heart disease, elderly patients (especially those with HTN)
o How to treat? Depends on severity—monitoring; treat it medically (treat heart failure or
replace valve)
 Medically: abx, furosemide, HTN meds, weight monitoring
 Low Na+ diet, frequent breaks/space out activities, maybe on
anticoagulants
 Replacement: biological or mechanical
 Apply knowledge of heart failure to the assessment and management of the high-acuity patient.
o Risk factors—valvular disorders (aortic, mitral = left sided failure), (tricuspid, pulmonic =
right sided failure); genetics; chronic HTN (left sided HF); diet (coronary heart disease);
chronic lung disease (right sided HF/cor pulmonale); persistent left sided failure can lead
to right sided failure
o Clinical Manifestations
 Left side—crackles, shortness of breath, fatigue, hypoxia; S3 heart tone
 Right side—edema, JVD, weight gain
o Classification—Class I (mild) to IV (severe)
o Pathophysiology—problem with a pump(s)
 Decreased CO; RAAS activation = vasoconstriction and fluid retention (increasing
afterload and preload respectively; SNS activation = vasoconstriction; ventricle is
getting overstretched
 BNP think HF
o Assessment and Diagnosis—echo to find ejection fraction (55%-70%); chest x-ray; ECG
o Treatment: Control risk factors, Pharmacology, Invasive
 CO = HR x SV
 Reduce preload (furosemide, spironolactone, ACE inhibitor/ARBs, beta
blockers), afterload (ACE inhibitors/ARBs, calcium channel blockers,
vasodilators) and improve contractility (inotropes, digoxin, dobutamine)
 Control risk factors via lifestyle, statins, HTN meds, DM2 meds
o Weight gain limits for HF: 1-2lb/day or >3lb in a week
 o Urine output: 30mL/hr is okay for 2-3 hours
o Normal is at least 60mL/hr

 Demonstrate the ability to assess and manage care of patients with hypertension.
o Normal: <120 / <80
o Elevated: 120–129 / <80
o Stage 1: 130-139 / 80-89
o Stage 2: >140 / > 90
 Apply knowledge of hypertensive crises to the assessment and management of the high-acuity
patient.
o Any target organ damage + >180 / 110 = inpatient treatment
o Only drop 20% in first hour to reduce risk of organ ischemia; 160 / 100 in 2-6 hours
 Demonstrate the ability to assess and manage the patient with aortic aneurysm.
o Classification—saccular, dissecting, ruptured fusiform, false aneurysm
o Risk Factors—hyperlipidemia, HTN, stress on vessel walls, plaques
o Pathophysiology
 Dissecting—blood in tunica media
 Rupture—drop in BP, ripping/tearing sensation
o Clinical Manifestations
o Diagnosis: CT, TEE
o Management
 Medical management—if it’s small and not a rupture risk
= watch BP, treat hyperlipidemia, manage DM2, quit
smoking
 Surgical management—repair via open chest arterial
graft; endovascular repair

Chapter 15: Alterations in Myocardial Tissue Perfusion

 Describe the pathophysiology of atherosclerosis and coronary artery
disease.
 Identify risk factors for coronary artery disease and discuss collaborative
interventions to reduce or manage the risk factors.
o Older, men, genetic predisposition
o Hyperlipidemia, hypertriglyceridemia, DM2, metabolic syndrome,
hypertension, obesity, physical inactivity, smoking, diet
 Differentiate types of angina and their assessment including stable angina,
unstable angina, and variant angina.
o Stable — “capped” = stable angina (goes away with rest)
 ST depression and/or T wave inversion, no increase of
enzymes
o Unstable — either unstable angina or acute coronary syndromes
o P (palliative/provoked); Q (quality); R (region of pain/radiation); S
(severity/ symptoms); T (time factors)
o STEMI = ST elevation myocardial infarction, increased cardiac
enzymes
 Non-STEMI = ST depression and/or T wave inversion,
increase in cardiac enzymes
  Describe the diagnostic work-up for alterations in myocardial tissue perfusion.
 Describe the initial collaborative management of acute coronary syndromes, unstable angina,
and myocardial infarction.
o Diagnosis of ACS
o Rapid triage — prefer EKG within 10 minutes of arrival, decide plan of action within 30
minutes
o What else? Vitals, oxygen, chew aspirin (inhibits platelet adhesion), nitroglycerin,
morphine (MONA—morphine, oxygen, nitro and aspirin)
 Explain the collaborative interventions commonly used to restore myocardial tissue perfusion.
o Reperfusion reduces injury and preserves ventricular function! Within 30 minutes
o Thrombolytics (TPA): high risk for bleeding
o Percutaneous Coronary Intervention
o CABG (coronary artery bypass graft)

Conditions for templates

 COPD
 Status Asthmaticus
 Acute Respiratory failure
 Acute Respiratory Distress Syndrome
 Pulmonary Embolism
 Pneumonia
 Chest Tubes
 Valvular Disease/Valve Replacement
 Heart Failure
 Hypertensive Urgency/Emergency
 Aortic Aneurysm
 Stable angina
 Unstable angina
 Acute myocardial infarction (STEMI, Non-STEMI)