Med Surg III Exam 2 Study Guide PDF

1 Med Surg III Exam 2 Cardiovascular – ch. 29, 32, 34 Prioritization -​ When is a rapid response called? o​ A client who is rapidly deteriorating o​ Respiratory, cardiac, BP changes o​ Hypoxemia o​ Change in mental status -​ When is a code...

1 Med Surg III Exam 2 Cardiovascular – ch. 29, 32, 34 Prioritization -​ When is a rapid response called? o​ A client who is rapidly deteriorating o​ Respiratory, cardiac, BP changes o​ Hypoxemia o​ Change in mental status -​ When is a code blue called? o​ Client in full cardiac arrest -​ What are early and subtle signs of deterioration in a client before cardiac or respiratory arrest? o​ Mild confusion o​ Tachypnea o​ VS changes Ethical considerations -​ Can children override a DNR order for an 80-yr old in v-fib? o​ Yes -​ As nurses, what can you explain to the children of this patient? o​ Explain to the children softly that he will not live. -​ What are the nursing ethical standards? o​ Beneficence (do good) o​ Justice (fairness) o​ Fidelity (truth telling) o​ Autonomy (self-determination) o​ Nonmaleficence (do no harm)  2 -​ What can you do with pts who have no prognosis for improvement and family wants all measures taken for resuscitation? o​ Make sure to talk to family and discuss the quality of life the patient may have afterwards. Medications -​ What is contraindicated with nitroglycerin? o​ Erectile dysfunction meds (sildenafil) -​ What medications are given for pain in the critical care unit? o​ Opioids, morphine, fentanyl. -​ What s/s do opioids cause?​ o​ Decreased RR and O2 o​ Change in LOC o​ Increased CO2 -​ What medications are vasopressors? o​ Norepinephrine o​ Vasopressin -​ What is vasopressin used for? o​ Hypotension and vasodilation. -​ What can these vasopressors help treat? o​ Cardiogenic shock. o​ Improves CO, HR o​ CHF o​ Hypovolemia o​ Cardiac arrest -​ What are the two classes of inotropic meds? o​ Catecholic  3 ▪​ Increase HR, cardiac contractility, BP, air in/out of lungs, blood flow. o​ Phosphodiesterase inhibitors -​ What medications are catecholic medications? o​ Epinephrine o​ Dopamine o​ Dobutamine Hemodynamics -​ CO = HR x SV -​ What is cardiac output? o​ The volume of blood pumped by the heart each minute. -​ What is stroke volume? o​ The volume of blood ejected by the left ventricle with each heartbeat. -​ -​ What are indications for hemodynamic monitoring? o​ All shock states o​ Loss of cardiac function o​ Decreased CO -​ What are different invasive hemodynamic monitoring systems? o​ Arterial cath o​ Central venous cath  4 o​ Pulmonary artery cath -​ What are principles of invasive pressure monitoring? o​ The transducer should be secured at the phlebostatic axis, 4th intercostal space. o​ Zeroing on the monitor Arterial line (A-line) -​ What is an arterial line? o​ A small catheter is inserted into an artery to display continuous pressure, MAP or ABG sample. -​ What needs to be done before placing an arterial line? o​ An Allen test o​ only on ulnar artery -​ What are nursing considerations for an arterial line? o​ Keep arterial site in view o​ Assess distal area of insertion site o​ NO meds given via arterial line o​ When removing, put pressure above insertion site for 3-5 min. -​ What are normal assessments with an arterial line? o​ No overdamped or underdamped waveforms (oscillations) o​ Proximity extremity warm to touch  5 o​ Pressure bag inflated to 300 o​ Slight discomfort at insertion site o​ Normal saline to maintain patency Pulmonary artery catheter (PA or Swan-Ganz) -​ What is a PA line? o​ Flexible, balloon-tipped catheter guided through the right side of heart into pulmonary artery via central line called an introducer. Assess central venous pressure. (CVP) o​ -​ Where are the 4 sites you can place this? o​ Subclavian, jugular, radial, or femoral. -​ What is central venous pressure (CVP) o​ Reflection of right heart preload or right ventricular end diastolic volume (pressure in the right atrium) (norm is 2-6) -​ What is the cause and treatment for low CVP? o​ Cause: hypovolemia or peripheral vasodilation, low volume o​ Tx: fluid bolus or vasopressors -​ What is the cause and treatment for high CVP? o​ Cause: right HF, tension pneumothorax, tamponade, increased volume o​ Tx: determined by cause -​ What is SvO2? o​ Mixed venous oxygen saturation, normal is 60-80%. Decreased SvO2 = decreased CO.  6 -​ What is pulmonary artery occlusion pressure or pulmonary artery wedge pressure (PAOP/PAWP)? o​ Reflects left heart preload or left ventricular end-diastolic pressure, normal is 4 – 12. Central Venous Catheter -​ What are a central venous catheter used for? o​ Fluid maintenance meds o​ blood draws o​ parenteral administration o​ transvenous pacemaker insertion Cardiomyopathy -​ What is cardiomyopathy? o​ Decreased function of the heart muscles due to it being weak, enlarged, thick, or rigid. -​ How many types of cardiomyopathy are there? o​ 3 types of nonischemic: ▪​ Dilated ▪​ Hypertrophic ▪​ Restrictive -​ What is dilated cardiomyopathy? o​ Left ventricular muscle enlargement -​ What is hypertrophic cardiomyopathy? o​ Left ventricular becomes stiff, obstructing blood flow. -​ Who is hypertrophic cardiomyopathy common in? o​ Young athletes, sudden cardiac death. -​ What is restrictive cardiomyopathy?  7 o​ Heart ventricles stiffen due to heart muscle being replaced by scaring and fibrosis -​ What are s/s of cardiomyopathy? o​ Chest pain o​ Irregular heart rate o​ Indigestion o​ Dizziness o​ SOB o​ N/V o​ JVD o​ Orthopnea -​ What medical interventions can help? o​ Med management: ACE, ARBs, beta blockers, diuretics o​ Pacemaker o​ Surgery ▪​ Pacemaker, LVAD -​ What are nursing interventions? o​ Place in semi or high fowlers. o​ Fluid restriction, Na restriction o​ Medication compliance o​ Moderate exercise, low stress environment Flash pulmonary edema -​ What is pulmonary edema? o​ Accumulation of fluid in the interstitial and alveolar spaces of the lung due to elevated filling pressures in the heart. -​ What are s/s of pulmonary edema?  8 o​ SOB, low O2, orthopnea o​ Pink and frothy sputum o​ Tachycardia, chest pain o​ Anxiety/fear, dysrhythmias -​ What is the tx for pulmonary edema? o​ Diuretics o​ CPAP/BIPAP o​ Intubation with mechanical ventilation End stage heart failure -​ With someone in end stage HF who has not improved with inotropic meds or intraaortic balloon pump, what is the intervention? o​ Referral for placement of mechanical circulatory support or heart transplant. -​ What are mechanical circulatory devices to help with end stage HF? o​ LVAD or RVAD o​ Intra-aortic balloon pump ▪​ Do not leave dormant for too long to reduce risk of clot formation. ▪​ Signs of balloon rupture: brown fleck of blood or gas leak alarms o​ ECMO o​ Total artificial heart -​ Note: these devices bridge the gap and help the pts who do not respond to other options. (advanced HF) -​ What are signs of right sided HF (cor pulmonale)? o​ JVD o​ Dependent edema o​ Ascites  9 o​ Hepatomegaly -​ What are signs of left sided heart failure? o​ SOB, dyspnea o​ Crackles o​ Pale, weak pulses -​ What is important teaching with HF patients? o​ Low sodium diet o​ Daily weight o​ Activity as tolerated o​ Monitor for s/s of worsening HF (edema, SOB, fatigue, orthopnea) Myocardial infarction -​ What is the patho of an MI? o​ Destruction of heart muscle from the lack of oxygenated blood supply -​ What is the most common cause of an MI? o​ Atherosclerosis -​ What are complications of an MI? o​ Cardiomyopathy o​ Cardiogenic shock o​ Heart failure o​ Arrythmias -​ What are the risk factors for an MI? o​ Smoking, high LDL, type 2 diabetes, obesity, inactivity, HTN -​ What are s/s of an MI? (man and women) o​ Jaw and tooth pain o​ Shoulder blade pain  10 o​ Upper back pain o​ SOB, N/V o​ Sweating o​ Chest pain/angina (stable or unstable) -​ What other symptoms can a women present with? o​ Fainting o​ Indigestion o​ “feeling fine” o​ Extreme fatigue o​ Pain in lower chest or upper abdomen -​ What are important diagnostic tests for an MI? o​ EKG -​ Gold standard for diagnosis of the flow being limited o​ Angiography o​ MRI o​ Echocardiogram o​ Stress test -​ What lab tests are completed to assess for an MI? o​ Troponin, CK, CK-MB o​ CMP, CBC, coagulation studies, ABG -​ What is the treatment for MI? o​ Oxygenation o​ Control pain o​ Dilate coronary arteries o​ Prevent clots  11 o​ MONA!! (morphine, oxygen, nitroglycerin, aspirin) (oxygen 1st) o​ Beta blocker if HR is 110 -​ What is important to know about morphine with an MI? o​ Morphine can mask pain symptoms, not necessarily improving blood flow causing a worsening MI. -​ What is another treatment intervention for an MI? o​ Percutaneous coronary intervention (PCI) ▪​ Gold standard for emergency o​ Fibrinolytics (when PCI is not available) o​ Surgery: CABG o​ Note: 90 min from door to balloon. -​ What are post procedure management interventions after a PCI? o​ If radial, apply compression device o​ If femoral, lay patient flat for 2-6 hrs., no bending leg, and monitor for hematoma. Apply firm pressure for 20 – 30min. -​ What is STEMI? o​ Complete occlusion of the coronary artery o​ ST elevation, area of tissue is dead -​ What is a NON-STEMI? o​ Partial occlusion of the coronary artery, thrombus o​ No ST elevation but ST depression, ischemia -​ What is unstable angina? o​ Exercising and having chest pain o​ No elevated cardiac markers o​ May or may not have ST depression or elevation -​ What is the treatment for unstable angina?  12 o​ Nitroglycerin, but if BP is low hold. Cardiogenic shock -​ What is cardiogenic shock? o​ When the heart muscle is unable to effectively pump causing low CO to maintain tissue perfusion. Caused by an MI. -​ What are s/s of cardiogenic shock? o​ Decreased CO o​ Hypotension, tachycardia o​ Venous congestion o​ Decreased UO o​ End-organ dysfunction o​ Metabolic acidosis -​ What are treatment options? o​ Vasopressors o​ Dobutamine o​ Nitroglycerin o​ Diuretics o​ Stabilizing oxygen is a priority. o​ Possible surgery ▪​ IABP ▪​ LVAD ▪​ ECMO -​ What happens with the intra-aortic balloon pump? o​ Balloon inflates during diastole to push blood into coronaries and deflates during systole to decrease systemic vascular resistance. -​ What are important teaching tips?  13 o​ Importance of rest periods o​ Fluid and sodium restriction o​ Know symptoms of HF to prevent progression into shock. Coronary artery bypass grafting (CABG) -​ What is a CABG? o​ Revascularization method that bypasses blockages in the coronary arteries. -​ When is a CABG done? o​ Failed PCI o​ 3 occluded vessels o​ Critical left main vessel occluded -​ What are complication with a CABG? o​ Arrythmias o​ Bleeding o​ Sternal infection o​ Heart failure -​ What are important nursing assessments with a CABG? o​ Monitor -​ VS and pulse ox (hypoTN and tachy = inadequate CO and O2) -​ ECG (ST depression = ischemia, ST elevation = injury) -​ Monitor UO (decreased renal perfusion) -​ restlessness -​ Hemodynamic monitoring -​ Chest tube output, color, volume o​ Assess -​ pain (continued or changing pain is bad)  14 -​ skin color, temp, pulses, and diaphoresis (Rewarm pt slowly) -​ Heart tones (muffled = tamponade, crackles = HF) -​ What are important teaching post CABG? o​ Signs of infection o​ Sternal precautions o​ Cardiac rehab -​ What are ways to reduce infection? o​ Oral hygiene o​ Cough and deep breathe o​ Monitor incision -​ What are sternal precautions? o​ No lifting weight over 10 lbs. o​ Raise arms overhead, do not use arms o​ Bend at waist o​ Use pillow to get up or cough o​ No vigorous physical activity -​ When should a patient go back to the hospital? o​ If they have consistent pain that is unresolved. Common rhythms and treatments -​ What rhythms are considered supers? o​ SVT, atrial tachycardia, atrial flutter, atrial fibrillation with RVR, junctional tachycardia -​ What is the cause of heart blocks? o​ Delay or blockage in AV node o​ New pathways develop causing delay or atria/ventricle association. -​ What is any rhythm that is not normal sinus?  15 o​ Dysrhythmia -​ What are s/s of reduced CO? o​ Palpitations, hypotension o​ Diaphoresis, SOB o​ Syncope o​ Anxiety -​ What does a normal heartbeat pattern mean? o​ P wave = atrial contraction o​ QRS = contraction of ventricles o​ T wave = relaxation of the ventricles -​ How can you identify an ECG strip? o​ -​ Note: small box on ECG = 0.04, large box = 0.20 -​ P wave: atrial contraction (depol) -​ QRS greater than 0.10 sec (two and a half small boxes) means problem with ventricles. = ventricular contraction (depolarization) -​ T wave, ventricular rest/filling (repolarization) -​ PR interval = 0.12 - 0.20 sec -​ QRS interval = below 0.10 sec -​ Ventricular rhythms = no P waves -​ When is transcutaneous pacing (TCP) used? o​ Bradycardia  16 o​ Pads are placed on front and back -​ Who is electrical cardioversion for? o​ Symptomatic tachycardic pts with a pulse -​ Who is chemical cardioversion for? o​ Stable patients, gets rhythm back to normal -​ Who is defibrillation for? o​ VT or VF without a pulse Sinus Bradycardia -​ -​ What are causes? o​ Med toxicity: beta blockers o​ Hypoxia o​ Hypothermia o​ Well trained athletes o​ Valsalva maneuver -​ When is treatment initiated? o​ When pt is asymptomatic, observation is required o​ When a pt is symptomatic, tx is required. -​ What are the treatment options? o​ Atropine (blocks AV current to make it increase) o​ Pacemaker if atropine does not work Sinus Tachycardia  17 -​ -​ What are the causes? o​ Fever o​ Anemia o​ PE or MI o​ Hypovolemia o​ Stimulants o​ Infection o​ Medications: atropine, dopamine, dobutamine, epi, amphetamines. -​ What is the treatment? o​ Check LOC o​ Monito EKG (make sure P waves and rhythms are regular) o​ Beta blocker o​ Calcium channel blockers Atrial Fibrillation -​ -​ No P wave -​ Narrow QRS with irregular R-R intervales -​ AF w/ HR >100 it is uncontrolled  18 -​ AF w/ HR