Exam 1: Case Studies & Pulmonary Embolism

• Exam one contains 50 multiple choice questions including "select all that apply," fill in the blank, plus two case studies (6 points each), totaling 60 points.
• Knowing nursing diagnoses for each condition is important

PE (Pulmonary Embolism)

• Risk factors include the presence of DVT (Deep Vein Thrombosis)
• Risk factors for DVT include obesity, smoking, chronic heart disease, A-fib, fracture, hip or knee replacement, major surgery/trauma, spinal cord injury, history of previous VTE, malignancy, estrogen use, age > 50, pregnancy
• Virchow's triad is a major DVT risk factor including venous stasis (PVD, immobility), vessel wall damage (diabetes, HTN, high cholesterol), hypercoagulability or blood disorder
• Causes/Patho involves blood clot lodge in pulmonary artery (PE) or air, tumor, amniotic fluid, fat
• V/Q mismatch results in ventilation that is good, but gas exchange isn't occurring leading to no perfusion
• This causes the heart to work extra hard leading to R sided HF
• As R side expands, it pushes on L side, which can't fill, leading to L sided HF
• Clinical Manifestations include dyspnea, pleuritic chest pain, and tachypnea

PE Continued

• Other Clinical Manifestations include tachycardia, hemoptysis, cough, accessory muscle use, anxiety/restlessness, feelings of doom due to not enough perfusion to the brain
• Diagnostics involve imaging studies and laboratory studies
• Imaging studies include ECG (to r/o MI), CXR (to r/o other causes of resp distress), CT scan with contrast (to identify PE) and holding metformin with contrast, a VQ scan to visualize PE if CT isn't available (> 0.8), pulmonary angiography most definitive test (Cath lab), LE doppler to id DVTs
• Laboratory studies include the D-dimer indicating if fibrin is elevated in blood d/t body trying to break down a clot, ABGS which starts as respiratory alkalosis, and eventually progresses to metabolic acidosis
• Pharmacological treatments include anticoagulants, which don't dissolve clot, but rather prevents growth of clot and new ones from forming. These include heparin drip, and warfarin.
• Heparin drip uses aPTT, and must be between 40-90 seconds or 1.5-2.5 x normal range
• Warfarin uses INR, and must be between 2.0-3.0 with heart valve = 2.5-3.5
• Two meds are used at the start because Warfarin takes a few days to reach therapeutic dose so give heparin in the meantime
• Thrombolytics include tPA, Alteplase, Streptokinase
• A Catheter directed thrombolysis (CDT) used for large PE or submassive.
• Surgical management includes embolectomy with a catheter, surgical most common if thrombolytics are contraindicated
• An inferior vena cava filter catches clots from lower extremities while still allowing blood flow to prevent clot from traveling up

Nursing Management and How to Prevent Complication

• Nursing Management includes assessment involving airway, oxygenation, frequent vital signs where BP might be elevated, chest pain, lab values (ABGS, lactic acid, aPTT, PT/INR), urine output, < 0.5 ml/kg/hr sign of shock and < 30 ml/hr is never a good sign (Kidneys not being perfused)
• Actions include:
  • Elevate head of bed
  • Administer IV fluids to thin blood a little (monitor for HF)
  • Administer Thrombolytics, and Anticoagulants (maybe also digoxin or pressors)
  • Institute bleeding precautions
  • Prepare for intubation and resuscitation with intubation tray and crash cart ready
• Prevention of complications involves:
  • Disease process/lifestyle modifications and medications
  • Avoiding vitamin K and bleeding precautions
  • Diet must be cardiac and avoid vitamin K
• Remember the therapeutic range of PTT if on heparin drip and goal INR for Warfarin (aPTT).

Chest Trauma

• The purpose of a chest tube is to remove fluid from the pleural space
• If a chest tube comes out: Petroleum gauze → then sterile gauze → then tegaderm (leave one side open)
• Tension pneumothorax is when air or blood collection in pleural space, with a tracheal deviation (cardinal sign), leading to a medical emergency because organs pushing on heart can lead to pressure on heart and PEA arrest. Treat with a chest tube.
• Cardiac tamponade means the heart cannot adequately fill or contract because of the compression of the ventricles, with hypotension, muffled heart sounds, and distended neck veins (Beck's triad), causing PEA arrest, and is treated by a Pericardiocentesis
• Signs and symptoms of chest wall contusion are tachypnea, tachycardia, shortness of breath, decreased oxygenation, decreased level of consciousness, decreased/absent lung sounds, Asymmetrical chest excursion

Respiratory Failure/ARDS

• Signs and Symptoms of respiratory failure include hypercapnia (headache, confusion, decreased LOC, can appear to be pink), and hypoxemia (changes in respiratory rate, heart rate, blood pressure, appear blue, and symptoms that tend to worsen as there is less cerebral perfusion, anxiety, restlessness, confusion).
• Signs/symptoms of ARDS include tachypnea, tachycardia, refractory hypoxemia (Low O2 despite oxygen delivery), sudden SOB (within 12-48 hours of lung injury), labored and fast breathing, coughing, tiredness, dizziness, headaches, cyanosis
• Management/Treatment/Complications of ARDS:
  • Mechanical ventilation (Low tidal volume d/t scarring of lungs, High PEEP- positive end expiratory pressure)
  • High-flow nasal cannula, ECMO (takes blood out, oxygenates blood, puts it back in), Prone positioning (16 hours prone, 8 hours supine, Recruit alveoli), and Medications are Antibiotics (after culture is done), Neuromuscular blockade (Train of 4, paralyzing medications, analgesia, anesthesia, Promote vent synchrony), Hydration (Thin secretions), Nutrition (Tube feedings)
• Ventilator Therapy: understand FiO2 (Fraction of inspired O2, Normally 21% FiO2 on room air), Peep being Positive pressure applied at the end of expiration of ventilator breaths (Usual setting 5 cm H2O where the higher, the sicker), Tidal Volume (Volume of delivered with each ventilator breath; 6-8ml/kg or 500 ml), Pressure Support (Positive pressure used to augment patient's inspiratory pressure; usual setting 5-10 cm H2O)
• The goal of medications for patient on ventilator therapy is Sedation (Drips: propofol, precedex, versed; IVP: fentanyl, versed, dilaudid with orders needed to titrate based on RASS Score) and VAP prevention (Famotidine, CHG PO; Famotidine to prevent stress induced stomach ulcers)

Sepsis/MODS

• Pathophysiology: Deregulated host response to infection with Excessive release of proinflammatory cytokines (Vasodilation, Decreased vasomotor tone, Increased capillary permeability lack of return of blood flow to the heart)
• Manifestations: Early stage/"warm" phase has tachycardia, bounding pulses, fever, whereas the Late stage/cold phase has cool, pale skin, weak, thready pulses, tachycardia, and hypotension
• Labs to monitor: ABGS, and Venous oxygen saturation
  • ABGS will show Respiratory alkalosis with progression to metabolic acidosis as sepsis gets worse
• Treatment Review of Bundle of Care involving a 1 hour period upon arrival to complete.
• Treatment may not be completed in 1 hour, but should begin immediately with Antibiotics (Administered within 1 hour that Cultures should be done before are administered)
• Labs to monitor: CBC, coagulation factors, CMP, ABGS with Fluid resuscitation as a priority, Vasopressors, Corticosteroid therapy for conflicting evidence because it is an immunosuppressant (varies by hospitals), then ongoing monitoring
• Complications of septic shock:
  • DIC: Disseminated intravascular coagulation; treated by Correcting the cause and blood transfusions; includes; Accelerated clotting within blood vessels → elevated consumption of platelets, which leads to Uncontrollable bleeding.
  • MODS: Multiple Organ Dysfunction Syndrome and Stress ulcers
• Nursing management/interventions:
  • Assess for Neurological status, skin color and temperature, bleeding (Stool, urine, gums → signs of DIC)
  • Vital signs with a Fevers → then progression to hypothermia and Tachycardia
  • Lab test includes: ABGs, venous 02 sat, Metabolic profile with ABGs and Usually respiratory alkalosis with progression to metabolic acidosis
• Actions include meticulous hand washing, aseptic technique, oxygenation, preparing for intubation, administering antibiotics, starting with broad spectrum and then switching to more specific when cultures come back, Fluid replacement, Vasoactive support , and Mouth care
• Teachings include cause of sepsis, and Teach women how to wipe properly, Handwashing, and Allow family visitation. In evaluating care outcome of Satisfactory BP, Satisfactory cardiac output and, and Tissue perfusion patients.

Shock

• MODS occurs in Respiratory failure / distress then Renal failure, then Liver dysfunction, then GI dysfunction
• Having 3 or more dysfunctions occurs in 80%-90% mortality rate. With cardio and neuro it is 100% mortality.
• Initial Shock:
  • is Hypoxia due to decreased oxygen delivery (DO2) to cells, the clinical manifestions shows subtle heart rate changes and Decreased cardiac output
• Compensatory
  • Neural compensation: increased and decreased heart rate
  • Endocrine compensation: vasoconstriction
  • Chemical compensation
• Manifestations:
  • Tachycardia and Tachypnea
  • Low but normal BP with narrow pulse pressure (normal is 40)
• Progressive
  • Has decreased urine output
  • Failure of compensatory mechanisms to maintain adequate blood pressure and volume
• Nursing management/interventions include assessment: Neurological status, Vital signs, Hemodynamic readings with actions of LR fluids
• Labs will monitor O2, saturation, H& H (Hemoglobin and hematocrit), and Lactate

Types of Shock

• Hypovolemic Shock: Caused from decreased vascular system and Acute loss of volume (blood of fluid)
  • Decreased venous return, decreased tissue perfusion causes kidney to RAAS
  • Caused from Restlessness or confusion dt. lowered O2, Weak pulses, and Delayed cap refill
  • Manifestations are from traumas (bleeds) burns, and diarrhea -Treatment option is NS or LR
• Cardiogenic Shock:
  • Increased compensatory mechanisms (increases workload and myocardial oxygen demand)
    • Manifestations: nausea/vomiting, Decreased cardiac output, and output and LOC. -Kidneys go first ( creatinine indicates dysfunction)
  • Impaired oxygenation perfusion and not pink and warm
  • Pulmonary pressure and VO2 stat will be down
• Obstructive Shock
  • Has a mechanical barrier or ventricular filling
  • Includes Acute PE
  • Nursing management/interventions Decrease in output/perfusion
  • Vital signs show hypotension
  • Diminished the lung and heart sounds
  • Labs to monitor for O2 in Venous
  • Includes Neurogenic and anaphylactic shock
  • Patho-Decreased vascular tone. Causes cervical spinal injury Distributive Shock - Anaphylaxis
• Causes of upper T5 (Spinal shock)
  • Manifestations included, warm and hyperthermia -Sympathetic nervous system and Decreased vascular tone
  • Nursing management/interventions, and oxygenation
  • Monitor for a low CVP and output with vital signs

Hemodynamics

• Pulmonary Catheter. -Pressures are pulmonary artery
  • Obtraining inflation with the balloon with the syringe to measure Cardiac output during Thermodilution
• Catheter is placed with Central Line to for Measure RA pressure from system from circulation
• Arterial Line can use for infusions, blood draws, trans pacemaker.
• Zero infusion, check if central, PaOp if high and abnormal to perfusion
• Placed IJ, check the placement for an Air embolism when removing. Then apply a hold pressure.
• Myocardial Infarction -Atherosclerosis causing decreased perfusion. -Progresses along the coronary system and Angina . -Diagnostics:
  • Lab work with troponin (best diagnosis) to muscle but could anywhere to Elevate in hours and days
  • EKG = GOLD standard
  • 12 lead indicates where the issues the are
• Treatment/Intervention for chest pain =remove clots with Medications, Increase blood and lower workload by monitoring.
• Antiplatelets/ Antithrombitics used for ASA or heparin and Percutaneous Coronary bybass (CABG/icu ) for assessment (heart tones) and with medications (monitor function) and interventions
• Cardiomyopathy
• Review signs, Weak, Weak, altered or decreased function. - Decreased lung function
• Medications like Beta and calcium

EKGs

• One small box is 0.04 seconds
• Intervals and normal ranges (QT intervals: 0.36 to .44 with Small box number.

Exam 1 contains 50 multiple-choice questions, fill-in-the-blank, and two case studies. It covers pulmonary embolism including risk factors, diagnosis, and nursing diagnosis. The exam is worth 60 points.