Cardiovascular Nursing Notes PDF

\*\*!!A-fib/A-Flutter - Control rate: Lopressor's, BB Control rhythm: Digoxin and Amiodarone (doesn't affect BP), Diltiazem (CaCB) Anticoagulants- Heparin & Warfarin Cardioversion \*but first I need to get a TEE A-Fib- no P wave for every QRS and NOT REGULAR A-Fib w/ RVR- feel their heart beating ou...

\*\*!!A-fib/A-Flutter - Control rate: Lopressor's, BB Control rhythm: Digoxin and Amiodarone (doesn't affect BP), Diltiazem (CaCB) Anticoagulants- Heparin & Warfarin Cardioversion \*but first I need to get a TEE A-Fib- no P wave for every QRS and NOT REGULAR A-Fib w/ RVR- feel their heart beating out of their chest, SOB- SHOCK \*\*!!Bradycardia- give Atropine, if not working- pacemaker Supraventricular tachycardia- Vagal maneuvers, Adenosine V-fib = DE-FIB, CPR, Epi, Amiodarone 3rd Degree Heart Block= Pacemaker  Low HR PEA and Systole- NO SHOCK- give Epi and CPR Shockable= VFIB, SVT uncontrolled V TACH w/ a rate of 180- if not relatively symptomatic, and still have a BP= have them do a vagal maneuver(1st)- bear down  If pale and diaphoretic and decreased LOC & BPCardiovert!! (3rd)  If that doesn't work- give Adenosine (2nd) Frequent PVCs= Hypokalemia Signs and symptoms of a Myocardial Infarction- mid-sternal chest pain that radiates, syncope, N/V, feeling of impending doom, pale and diaphoretic, dysrhythmias, dyspnea, hypotension Nitroglycerin once every 5 minutes for three doses- if not relieved call 911 Side effects of continuous Nitro drip- low blood pressure Cardiac Meds and VS · ACE- Blood pressure · ARB- blood pressure and HR · Beta blockers- blood pressure and HR · CCB- blood pressure and HR · Digoxin- Heart rate Post-Op CABG= monitor for decreased CO= \#1 NURSING ASSESSMENT  CMS checks- pulses, cap refill  Worry About: bleeding, muffled heart sounds (d/t tamponade)  If bleeding- lower pressure, less CO, low BP  Low CO sx's= low BP, signs of bleeding, increased output in drains, decreased urine output Purpose of intra-aortic balloon pump- pushes blood through left ventricle and then aorta, which increases cardiac output Cath Lab  MONA- Morphine, O2, Nitro, Aspirin- immediate tx for someone suspected of having MI!!!!  Worry about ST Elevations (Tombstone)= STEMI  Angiogram/Arteriogram done 1st!! w/ contrast dye- affects KIDNEYS  Revascularize with stent placement  Post-op: monitor distal pulses, bleeding, CMS checks, neuro status (stroke)  \#1 sign of re-occlusion= CHEST PAIN  Angiogram- contrast →kidney complications- AKI  Stent- post op COMPLICATION chest pain\*,  Teaching points of stent- going to be on an Antiplatelet so increases risk of bleeding. Medicare/Medicaid for MI - Lipid Lowering Agents - Aspirin - ACEI or ARBs - BB NIHSS Scale- for potential stroke Know PAWP and what to do, tx for elevated wedge pressure & decreased cardiac index = diuretic and positive inotrope (Digoxin, Dobutamine, Epi) Positive Inotropes: strengthen the force of the heartbeat. Improves contractility and CO Negative Inotropes: weaken the heart's contractions and slows the HR. (BB, Atenolol, CaCB) Hemodynamics  Increased PAWP= give diuretics  Decreased PAWP= give fluids  CVP can be taken from PAC or Central line- sits in R. Atrium- measures return of blood to the heart from the vena cavas- gives you FLUID STATUS  A LINE- continuous BP monitoring, don't need to know much about PAWP: 6-12 mmHg CVP: 2-6 mmHg CO - 4-8 L/min CO: HR x Stroke Volume CI - CO divided by body surface area Stroke Volume: Preload, Afterload, Contractility To increase SV: decrease afterload, increase preload and contractility To decrease SV: increase afterload, decrease preload and contractility Afterload: Stroke volume, MAP, PVR Cardiac index vs cardiac output and what goes into stroke volume Liver Damage= D/t: Acetaminophen or Hep C Give: Albumin to help the liver: Albumin- used to check nutritional status SHOCK An acute, widespread process of impaired tissue perfusion that occurs when an imbalance develops between cellular oxygen supply and cellular oxygen demand Patient with a MAP less than 60 mmHg or with evidence of global tissue hypoperfusion is considered to be in a shock state Hypovolemic shock- d/t fluid loss; caused by diarrhea, vomiting, fluid shifts(burn pts), trauma, surgery, GI bleeds ○ Sx include hypotension, tachycardia, low CVP, low U/O; ○ TX by lowering HOB to increase BP, IV NS then vasopressors (norepi/dop) Cardiogenic shock- heart fails to act as effective pump; try to limit myocardial oxygen demand, enhance oxygen supply, MEDs: Digoxin or Dopamine for more forceful beats (positive inotropic) Tx= Intra-aortic balloon pump Distributive Shock- widespread vasodilation and decreased vascular tone resulting in a relative hypovolemia: Neurogenic, Anaphylactic, Septic Septic Shock- widespread bloodborne infection, resulting from initiation of systemic inflammatory response; goal is to control the infection with early identification. ○ sx include decreased BP, cool and clammy/delayed cap refill, mental status change ○ Tx- Vasoconstrictors, fluids and antibiotics Anaphylactic Shock- severe allergic reaction. ○ sx include hives, itching, wheezing, SOB, low BP, pale skin, dyspnea. ○ tx with Epi immediately and repeat q5-15 min if sx continue, after epi admin Benadryl/Diphenhydramine Neurogenic shock- Parasympathetic dominance d/t loss of sympathetic tone d/t spinal cord injury ○ Sx include bradycardia, low BP, skin is flushed/warm/pink/dry from the vasodilation ○ Tx the hypovolemia with IV NS 0.9%, Vasopressors o complications include autonomic dysreflexia How is neurogenic shock different? - bradycardia and vasodilation Vasopressors: Epi/Norepi, Dopamine, Vasopressin Vasodilators: ACEI, ARBs, CaCB, Nitro Management of patient with ARDS- prone positioning, bronchodilators, steroids, mucolytics, anti -anxiety meds prn, promote secretion clearance (Incentive spirometer, Deep breathing, and cough)  NEED to sedate the pt before prone positioning  Give paralytic if prone and sedation is NOT working  Intubation Sedation Meds: Propofol, Fentanyl  Intubation Paralytic Meds: Succinylcholine Chloride, Pancuronium Bromide, Atracurium On ABG- Respiratory Acidosis- if pt is going into ARDS- Low O2 What happens if you increase PEEP on ventilator, correlations between PEEP and effects on vitals- Increased PEEP causes HYPOTENSION & Decreased CO Normal PEEP we have= 3 Starting PEEP on ventilator= 5 How to take care of a patient who is sedated and paralyzed- q2hr turn, suction, eye-drops, oral care ABGs - Ph 7.35-7.45, PCO2 45-35 (respiratory), HCO3 22-26 (metabolic), Know code drugs and which one to give first- Epinephrine (1st), Amiodarone, Adenosine Cardiac Tamponade: bleeding into pericardial space leading to impaired pumping ability, suspecting decreased CO. Pulsus paradoxus- abnormal drop in systolic BP during inhalation, narrowed pressure Becks Triad- hypotension, muffled heart sounds, increased venous pressure (JVD) Causes: blunt/penetrating trauma, cardiac surgery, heart attack Tx with pericardiocentesis to increase CO and tissue perfusion ○ Keep pt attached to cardiac monitor ○ Keep catheter attached to closed drainage system ○ Assess drainage device for kinks and slow drainage Tension Pneumothorax: deviation of trachea d/t pressure built up and pushing organs out of the way, can cause vascular collapse by the heart sx: sharp chest pain, increased RR, SOB, tachycardia, low BP, JVD, cyanosis(late) emergency TX with needle: thoracostomy and chest tube after needle decompression IMPAIRED GAS EXCHANGE Flail Chest- paradoxical movements on inspiration, impaired gas exchange What is the best thing to do with the chest tubes when moving patient when going down to CT? -Hold below level of the pt (NEVER above the pt) -Don't pull out the tube -NEVER clamp the chest tube -Secure chest tube on the bed Assessing for Abnormal Chest Tubes - Chest tube is @ the level of the pt - No tilting/movement of water in chest tube (most likely a kink) - Continuous bubbling in water sealed chamber NEED TO KNOW WHAT CHEST TUBE SYSTEM LOOKS LIKE!! Titling- goes up and down and synchs up with the pt's breathing Who Gets a Chest Tube?  Tension pneumothorax after needle decompression ( if no breath sounds heard on one side of the lungs)  Flail chest TCA overdose- Causes Dysrhythmias, monitor EKG q4hrs Phenobarbital OD= Bradycardia, Hypotension, Altered mental status. NO TX- supportive care and maintain BP Tylenol overdose- give Acetylcysteine, monitor LFTs. - know it's working when LFTs decrease Signs and symptoms of alcohol withdrawal - tremors, seizures, agitation, increased HR IV Ativan/Lorazepam = to stop an acute seizure After TBI- MOST LIKELY TO DEVELOP SEIZURE Carbon monoxide poisoning- monitor Lab/CONFIRMS they have it= Carboxyhemoglobin Interventions for elevated ICP: Mannitol and Hypertonic Saline  Know it is working when increased urine output and decreased ICP Diabetes Insipidus: High Urine Output, Hypernatremia, Dehydration, low levels of ADH, Low Urine Osmolarity/Specific Gravity, High Serum Osmolarity Treatment: DDAVP = decreases urine output Head injury more at risk for DI SIADH: Low Urine Output(Oliguria), Hyponatremia, Wt. gain, Edema, high levels of ADH, Low Serum Osmolarity, High Urine Osmolarity/Specific Gravity Treatment: Fluid restrict Head Injuries pt- MOST LIKELY TO GET DI OR SIADH Nonmaleficence- do no harm EX. Doing multiple checks before administering meds to a pt Autonomy- nurse's ability to think critically and take actions in pt care EX. a nurse is concerned about a patient, so they take the pt's vitals without being told to Beneficence- kindness to others, how a nurses actions can benefit others EX. A pt wants to stop their cancer tx, the nurse advocates to the treatment team for their pt Justice- being fair to all patients, equality Veracity- tell the truth Fidelity- keep your promises What drug can cause thrombocytopenia- HEPARIN Which patient has contact precautions- C. diff, draining wounds, pressure ulcers Droplet precautions- meningitis Difference between intermittent hemodialysis and CRRT- CRRT is used for pt's too unstable for Hemodialysis, a slower removal that puts less strain on the heart. Hemodialysis is faster removal  When a pt is getting dialysis= STAY WITHIN close proximity to pt, need to do VS q15 min  Dialysis- feel a thrill and hear a bruit What rules someone out from TPA- increased age 80, recent major surgery within 21 days, having a seizure with a stroke, past 4hrs, hemorrhagic stroke TPN (INCREASED GLUCOSE LEVELS) i. IV nutrition support using a formulation of amino acids, carbohydrates, lipids, electrolytes, MVI, minerals, and supplemental medication (insulin or iii. Q6 BG (albumin and glucose) iv. Change tubing AND bag q24 hr v. Check bag against MAR to make sure it is correct Non-modifiable risk factors- Age, sex, family history Modifiable Risk Factors- HTN, diabetes, hyperlipidemia, inactivity, smoking Delirium- what can a nurse do to decrease this, regulate day/night schedule, limit midazolam/versed, keep lights on during day, and off and dark at night Benzos increase the chance of delirium!! Unlicensed personnel- can't give meds or do education, can't give or take blood Triple A/Abdominal Aortic Aneurysm -low back pain and pulsating/throbbing abdomen Pulmonary embolism- when a clot or other matter lodges into pulmonary arterial system; disrupting blood flow to a region of the lungs Sx: chest pain, sudden SOB, "impending doom" Goal is to optimize oxygen exchange and ventilation- high fowler\'s position During clot: thrombectomy, fibrinolytics x clot buster (TPA- huge bleeding risk) After clot: heparin, warfarin, aspirin, antiplatelet Tests: venous ultrasound Labs: elevated D-Dimer Superficial (1st degree burns)- erythema, mild pain and swelling, NO blisters, blanching on pressure (sunburn) Partial Thickness (2nd)- skin is red, shiny, and wet. SEVERE PAIN, fluid filled blisters Full Thickness Burns- skin is dry, waxy, and white. Can also be black and charred. NO PAIN d/t nerve destruction. Dry d/t burning all moisture filled skin layers Full thickness Circumstantial Burns- worry about compartment syndrome- fasciotomy IV Dilaudid or Fentanyl for burn pt's Electrocution- worry about DYSRHYTHMIAS Frostbite- swelling, edema where frostbite is (d/t increased vascular permeability), ice crystals Sedating drugs- propofol (check triglycerides), fentanyl Complications for Arteriogram- kidney complications/ AKI d/t the dye contrast; flush out the kidney with fluids after procedure How to assess for a ruptured spleen- Kehr\'s sign- pain to the left shoulder on gentle palpation of the abdomen when the patient is lying down with legs elevated PARKLAND FORMULA - 4mL x Body Surface Area x Weight in kg = amount of fluid to give over 24hr, first ½ over 8 hours second ½ over the last 16 hours. MAP= SP + 2(DP)/3 CPP= MAP - ICP Basilar skull fracture- raccoon eyes Least Likely to get TPN- Young pt (30-40 yo) that got a Cholecystectomy SOFA SCALE- tells you how likely you are to die from sepsis (higher= worse) - Hypotensive - Tachypnea/Hypoxic - Altered mental status 1-hour sepsis bundle 1) Measure Lactate level, remeasure lactate if initial lactate elevated (greater than 2 mmol/L) 2) Obtain Blood cultures before administering antibiotics 3) Administer Broad-spectrum Antibiotics 4) Begin rapid administration of 30 mL/kg Crystalloid for hypotension or lactate greater than or equal to 4 mmol/L 5) Apply Vasopressors if hypotensive during or after fluid resuscitation to maintain a MAP greater than or equal to 65 mmHg o Norepinephrine/Levophed= best vasopressor for SEPSIS Acute Pancreatitis- NPO and Fluids  Labs- Amylase and Lipase- DON'T need to know the values  Can start feeding them- has to be enteral feedings and BELOW the duodenum  Sx's: N,V, extreme abd. PAIN, can't hold fluids down KNOW: Types of aphasia BP Parameters: BP 20= BAD Pt's husband just died= stay with them, be kind, don't kick them out Organ Donation  Triggers for calling organ donation- family is talking about withdrawing care, ANY pt that is intubated, pt is brain dead, GCS