MedSurg2.docx

Introduction to Critical Care - Healthy work environment - Box 3-1 pg.24 critical care book - Rapid assessments - ***Primary survey ( ABCDE)*** - Airway/cervical spine, Breathing, Circulation, Disability, Exposure - Exception - In presence of excessive bl...

Introduction to Critical Care - Healthy work environment - Box 3-1 pg.24 critical care book - Rapid assessments - ***Primary survey ( ABCDE)*** - Airway/cervical spine, Breathing, Circulation, Disability, Exposure - Exception - In presence of excessive bleeding utilize circulation, airway, breathing (CAB) - Goal is to stop active bleeding - In trauma you get 2 large bore needles (AC or above) - ***Secondary survey and resuscitation interventions*** - Comprehensive head to toe assessment - Identifies other injuries/issues (after immediate life threats addressed) - ***Airway*** - ***Spontaneous breathing*** - Non-rebreather mask - ***Ventilatory support*** - Bag valve mask w/ appropriate airway and 100% oxygen source - ***Significant impairment*** - Need endotracheal tube & mechanical ventilation - ***Triage*** - ***Emergent*** - Immediate threat to life or limb, - ***Example***: chest pain - ***Urgent*** - Req. Quick treatment but immediate threat to life doesnt exist - ***Ex:*** abdominal pain - ***Nonurgent*** - Wait 7 hrs for care without significant risks - ***Examples:*** strains and sprains - ***Glasgow Coma Scale*** - ***Eye opening response*** - Spontaneous: 4 - Speech: 3 - Pain: 2 - No response: 1 - ***Best verbal response*** - AOx 3 = 5 - Confused= 4 - Inappropriate words= 3 - Incomprehensible sounds= 2 - No response =1 - ***Best motor response*** - Obeys= 6 - Moves to localized pain= 5 - Flexion from pain = 4 - Abnormal flexion (decorticate) = 3 - Abnormal extension ( decerebrate) =2 - No response= 1 - ***Total score*** - ***Best response : 15*** - ***Comatose: 8 or less*** - ***Totally unresponsive: 3*** - ***Heat Exhaustion*** - Results from ***dehydration*** caused by heavy perspiration, and inadequate fluid and electrolyte intake. - If untreated = heat stroke - ***Symptoms "flu-like"*** - Weakness, nausea, vomiting, headache, body temp not elevated - hyponatremia - ***Heat Stroke*** - Medical emergency - Has to be treated to prevent death - Body temperature can exceed 104 degrees - ***Types*** - ***Exertional vs. Classical(nonexertional)*** - ***Exertional*** - Sudden onset from strenuous physical activity - Wearing too heavy clothing, in hot humid conditions. - ***classical*** - Over period of time from exposure to hot, humid environments - ***Assessment -- heat stroke*** - Hx of heat exposure - Profound elevated temp above 104 - Mental status changes(confusion, agitation, bizarre behavior, seizures, coma) - Hypotension, tachycardia, tachypnea - Hypovolemia - Pulmonary edema - Hot and dry skin - Oliguria - Elevated cardiac troponin - Electrolyte imbalance ( K+ and Na+) - ***Planning/ Implementation*** - Seek emergency care ( restore thermoregulation for complete list) - ABCDE ( Treatment in clinical setting) - Arthropods and Bees : Anaphylaxis - ***Bee sting cues*** - ***Assess for*** - Skin reactions, swelling at site and beyond; urticaria; pruritis; lip/tongue edema; - Anaphylaxis: bronchospasm, laryngeal edema; hypotension and cardiac arrythmias - Systemic effects: nausea, vomiting, or renal failure - Monitor VS, BP and cardiac function - Administer antihistamines, epinephrine, albuterol, and corticosteroids - Observe for 7hrs or admit - ***Snakebites*** - Most significant risk is airway compromise and respiratory failure - Ensure patent IV lines - Have resuscitation equipment immediately available - Contact Poison Control for antivenin guidance - ***Lightening Injuries*** - Highly preventable - ***Mild*** - Stunned or confused - ***Moderate*** - Confusion or comatose - Temp. paralysis - ***Severe*** - Cardiac/ CNS profoundly affected - Cardiac arrest (monitor ABCs) - ***Assessment*** - Cataracts, tympanic membrane rupture, cerebral hemorrhage, depression, PTSD, Lichtenberg figures - Assess for hypovolemia and shock - May req. Ventilation - Assess for obvious and hidden injuries - Creatinine kinase (CK) to detect skeletal muscle damage - Monitor kidney function (rhabdomyolysis) - ***Tetanus prophylaxis*** - May need burn center follow up - ***Frost Bite*** - Body tissue freezes and causes tissue integrity - Frostnip = superficial cold injury - Main risk factor - Inadequate insulation against cold weather - **Types** - **Grade 1** - hyperemia and edema - ***Grade 2*** - large, clear-to-milky, fluid-filled blisters with partial-thickness skin necrosis - ***Grade 3*** - small blisters containing dark fluid; body part is cool, numb, blue or red, and doesn't blanch - ***Grade 4*** - blister over the carpal or tarsal (not just the digit); numb, cold, bloodless; necrosis extends to muscle and bone - ***Treatment*** - Rapid rewarming(99-102 F) ; analgesics, IV opiates / rehydration - Elevate part above heart level if possible - Assess for compartment syndrome - Tetanus immunization - Loose, nonadherent sterile dressings - Avoid compression of injured tissues - Topical and systemic abx. - Debridement of necrotic tissue or amputation may be needed - ***Altitude Related illness "Altitude Sickness"*** - Acclimation is key - Low partial exposure of oxygen at higher altitudes - Altitude inc= dec. Oxygen (hypoxemia) - ***High risk groups*** - Living @ low altitudes - Chronic illness - Sickle cell disease (HOPIA) - CVD - Dehydration - ***Acute Mountain Sickness (AMS)*** - Symptoms generally noticed upon waking - Throbbing headache - Anorexia, nausea, and vomiting - Chills - Irritability - Apathy - May feel like "alcohol-inducted hangover - ***High Altitude Cerebral Edema (HACE)*** - Cannot perform ADLs - Extreme apathy - Ataxia - Mental status changes - Cranial nerve dysfunction and seizures may occur - ***Interventions*** - Dexamethasone / Acetazolamide - Go to lower altitude - Hydrate and eat (carbs) - ***High Altitude Pulmonary Edema (HAPE)*** - Fatigue, weakness - Persistent dry cough - Lip and nail bed cyanosis - tachycardia and tachypnea at rest - Crackles in one or both lungs - Pink, frothy sputum - Chest x-ray shows pulmonary infiltrates - ABG shows respiratory alkalosis and hypoxemia - ***Interventions*** - Phosphodiesterase Inhibitors (Sildenafil) and Nifedipine - Acetazolamide - Go to lower altitude - Hydrate and eat (carbs) - ***Drowning*** - Survival after immersion after 24hrs - Prevention is key - Aspiration of fresh or saltwater causes damage - Washes surfactant - Water quality- bacteria - ***Interventions*** - Spine stabilization - Airway clearance and ventilatory support - Handle gently to prevent v.fib - Secondary drowning -- delayed by 24hrs (chest pain, fever, cough, vomiting, SOB) - Table 68-1 - Table 4-9 pg.44 - Figure 5-1 pg.50 - ***Sedation holiday*** - Turn off sedative infusions once daily - Stop analgesics per protocol - Assess patient using RASS/SAS - Assess LOC & neuro function - ***RASS ( Richmond Agitation and Sedation Scale)*** - ( +4) = combative -- violent immediate danger to staff - ( +3) = very agitated -- pulls/removes tubes or catheters; aggressive - (+ 2)= agitated; freq. Non purposeful movement; fight ventilator - (+1) = - restless ; anxious, apprehensive but movements not aggressive/vigorous - 0 : Alert & Calm - ( -1): drowsy ; not fully alert; sustain awakening to voice - ( -2): light sedation; briefly awakes to voice - ( -3): - moderate sedation ; movement or eye opening to voice (no eye contact) - ( -4): no response to voice, eye opening /movement to physical stimulation - ( -5): no response to voice or physical stimulation - ***Pharm management of sedation*** - ***Benzodiazepines*** - Amnesic - Not analgesic - Not recommended for routine sedation - ***Reversal agent:*** flumazenil - Unwanted side effects: - Hypotension, resp. Depression, agitation/confusion - Oversedation ; delayed awakening/ extubation - ***Sedative hypnotic-agents (propofol)*** - OR/ ICU uses - Lipid soluble - Rapid onset/short half life - Not amnesiac or analgesic - Complications - Unwanted side effects: - Hypertriglyceridemia; CVS depression; hypotension - Oversedation ; delayed awakening/ extubation - ***Central alpha agonist*** - Clonidine - Unwanted side effects: - Hypotension ; bradycardia - Oversedation ; delayed awakening/ extubation - ***Ketamine*** - Unwanted side effects: - Hypertension; secretions; dysphoria - Oversedation ; delayed awakening/ extubation - - ***Triage systems*** - ***Red*** - High priority - Ex: massive hemorrhage - ***Yellow*** - Medium priority - Ex: fracture - ***Green*** - Ambulatory patients - Ex: isolated abrasions, contusion, sprains - ***Black*** - Dead or those with minimal chance of survival - Ex: massive head injuries, 95% coverage 3^rd^ degree burns - ***[Perfusion : Shock, Sepsis, DIC and MODS]*** - ***Shock*** - Life-threatening condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function - Affects all body systems - May develop rapidly or slowly - Any patient with any disease state may be at risk for developing shock - Regardless of the initial cause of shock, certain physiologic responses are common to all types of shock: hypoperfusion of tissues, hypermetabolism, and activation of the inflammatory response - ***Compensatory Stage of Shock*** - BP within normal limits - Adequate cardiac output - "Fight-or-flight" response - ***Clinical manifestations*** - Inadequate perfusion - Increased respirations - Anxiety - Confusion - Table 11-1 - ***Nursing Management*** - Fluid replacement, supplemental oxygen, dec. Patient anxiety - Maintain BP & tissue perfusion - Freq. Assessment (subtle changes) - LOC & I/O ; resp. And hr; BP(MAP of 65mm hg or less; narrowing or dec. Pulse pressure) - Promote safety (advanced directives) - Gerontologic considerations - ***Progressive Stage of Shock*** - BP no longer compensated (patient hypotensive) - MAP below normal limits - Decreased mental status - ***Pathophysiology*** - Heart failure - Decreased cellular perfusion - Interstitial edema - Anaerobic metabolism - Hyperactive clotting cascade - ***Clinical manifestations*** - Rapid and shallow respirations - Chest pain (increased cardia biomarkers) - Changes in mental status - Acute kidney injury (decreased GFR) - Liver failure - GI bleeding - Abnormal bruising and petechiae with prolonged clotting times - ***Treatment*** - Restore tissue perfusion - Respiratory support - Rest and comfort to reduce stress ; dec. Chance of postintensive care syndrome - ***Assessment*** - ABGs, hemodynamic/ECG monitoring, Mental status changes, and serum electrolytes - ***Irreversible stage of shock*** - ***Signs and symptoms*** - Unable to respond to treatment - Ventilator dependent - Severe hypotension - Complete decline in mental status - oliguria - ***Treatment*** - Respiratory/circulatory/nutritional support - Palliative care - Support and edu. For friends and family - ***Hypovolemic Shock*** - Most common type - External fluid loss - From trauma, surgery, diarrhea - Internal blood loss - 15-30% reduction in intravascular volume - Hemorrhage, burns - ***Signs and symptoms*** - Dec. Blood volume; cardiac output; tissue perfusion - ***Treatment*** - Vasoactive meds, focus on prevention, oxygen - Restore & redistribute intravascular volume with fluid, blood replacement - ***Cardiogenic shock*** - Caused by failure of heart to pump effectively - Heart unable to contract and pump blood impaired leading to inadequate supply of oxygen to heart and tissues - Coronary or noncoronary issues - Doesnt cause hypovolemia - ***Signs and symptoms*** - Angina, arrhythmias, fatigue, feelings of doom, ECG changes, inc. Cardiac enzyme levels and cardiac biomarkers - ***Treatment*** - Inc, myocardial oxygen delivery, maximize cardiac output, dec. Left ventricular workload - Fluids, diuresis, or nitrates - Electrolyte repletion - Analgesia, sedatives - Monitor for dysrhythmias and hemodynamic status - Monitor resp. Status - ***Distributive Shock*** - Pooling of intravascular volume in peripheral blood vessels - ***Three types:*** - Septic shock - neurogenic shock - Anaphylactic shock - ***Septic Shock*** - Most common type of distributive shock - high mortality - Incidence is increasing - Older adults at higher risk - Chart 11-5 - ***Signs and symptoms*** - ***Initial sepsis*** - Hyperthermia, bounding pulses, hypotension with dec. Urine output - N/v/ dec. GI motility - Subtle changes in mental status - ***Later sepsis*** - BP continue to drop; cool mottled skin; MODS with no response to treatment - Treatment -- fluid replacement, pharmacologic treatment & nutrition therapy - ***Neurogenic Shock*** - Imbalance between parasympathetic and sympathetic stimulation - Can be caused by spinal cord injury, spinal anesthesia or nervous system damage - ***Pathophysiology*** - Sympathetic stimulation - Vascular smooth muscle contractions - Predominant parasympathetic stimulation - Vascular smooth muscle dilation - Leads to blood volume displacement - Inadequate tissue perfusion - ***Signs/ symptoms*** - Hypotension, bradycardia, syncope/ fainting, dry warm skin - Prevent through proper patient positioning and immobilization if injury - Support cardiovascular and neurological function ***Anaphylactic Shock*** - Severe allergic reaction - ***Triggers*** - Foods, meds, insect stings and bites - ***Defining characteristics*** - Acute onset - Presence of 2+ symptoms - Resp. Distress, hypotension, GI distress, skin or mucosal irritation - Cardiovascular compromise - Signs occur within 2 to 30 minutes after exposure to the antigen - ***Mild anaphylaxis:*** - headache, lightheadedness, nausea, vomiting, pruritus, generalized flushing, dyspnea, bronchospasm, cardiac arrhythmias, hypotension - ***Severe anaphylaxis***: - rapid hypotension, decreased LOC, respiratory distress, cardiac arrest - ***Nursing management*** - Remove antigen, fluid management, epinephrine, CPR, assess for allergies prior and during treatment; medical hx to determine past reactions - ***Systemic Inflammatory Response Syndrome (SIRS)*** - Caused by any type of shock / other insults (massive blood transfusion, traumatic injury, brain injury, surgery, burns, and pancreatitis) - Precedes septic shock - ***Multiple Organ Dysfunction Syndrome (MODS)*** - Loss of integrity of mucosal barrier function may liberate bacterial toxins from gut causing damage to multiple organs. - Tissue hypoxia caused by microvascular thromboses - Hypotension, tachycardia, tachypnea, hypothermia. And hyperthermia - ***Disseminated Intravascular Coagulation (DIC)*** - Clotting and bleeding and same time - Imbalance between natural procoagulant and anticoagulant systems - Secondary complication - ***Triggers*** - Sepsis, trauma, shock, cancer, abruptio placentae, toxins, and allergic reactions - Assess for s/s and progression of thrombi and bleeding - ***Potential complications*** - Kidney Injury, Gangrene, Pulmonary Embolism or hemorrhage; acute respiratory distress syndrome; stroke - ***Treatment*** - Correct tissue ischemia, replace fluids/ electrolytes, maintain BP; replace coagulation factors; use heparin or LMWH - Abx. Or antifungal therapy for sepsis - Fluid replacement - FFP, cryoprecipitate, RBC - Avoid trauma and procedures that inc. The risk of bleeding, including activities that would inc. Intracranial pressure - ***Clinical presentations*** - Systemic ischemia from thrombi formation; minor or major hemorrhage - Low grade bleeding - s/s of inappropriate clotting - Bleeding from nose, gums, lungs, GI tract, IV access sites; hematuria; petechial rashes and purpura fulminans - ***Care of Patient*** - Sudden/ acute onset - Constant reassessment - Dyspnea, hypotension, ischemic bowels - s/s of onset of shock - ***[Labs]*** - Platelets, Fibrinogen, PT, PTT, INR, D-Dimer; CRP; Procalcitonin - MAP = ( SBP / DBP x 2) /3 - MAP = CO x SVR - SVR= ( 80 (MAP -- MVP)/ CO - Table 11-1 ***Management of Patients with Coronary Vascular Disorders*** - ***Coronary Atherosclerosis*** - Blockage and narrowing of coronary vessels reduces blood flow to myocardium - CAD is most prevalent cardiovascular disease in adults - ***Signs/ Symptoms*** - Symptoms caused by myocardial ischemia - Related to location and degree of vessel obstruction - Most common manifestation (angina pectoris) - Epigastric distress, pain radiating from jaw or left arm; SOB; atypical signs in women - MI , HF , sudden cardiac death - ***Risk Factors*** - Cigarette smoking, high blood cholesterol, HTN, physical inactivity; obesity and overweight' diabetes; stress and excessive alcohol intake - Age ( 65+) ; hereditary ( race- AA, Mexicans, Native Americans/Hawaiians and some Asians) - Gender(men, after menopause ,death rate rises in women) - ***Cholesterol Meds*** - ***Statins*** - Atorvastatin (Lipitor) - Monitor liver enzymes - hepatoxic - Nicotinic Acids - Bile Acid Sequestrants (resins) - Cholesterol absorption inhibitors - Omega 3 acid-ethyl esters - ***Angina Pectoris*** - Characterized by episodes or paroxysmal pain or pressure in anterior chest caused by insufficient coronary blood flow - ***Assessment and Finding\'s*** - Described as tightness, choking, or a heavy sensation - Freq. Retrosternal, may radiate to neck, jaw, shoulder, back or arms (usually left side) - Anxiety accompanies pain - Dyspnea or SOB, dizziness, n/v - Pain of typical angina subsides with rest or NTG - ***Types of angina*** - ***Stable angina/ angina pectoris*** - Physical exertion or emotional stress - Relieved by rest or nitroglycerin - ***Variant (Prinzmetal) angina*** - Form of unstable angina - At rest; between midnight and 8am - Result of coronary artery spasm - Has severe atherosclerosis of at least 1 major coronary artery - ***Microvascular angina*** - Chest pain with normal epicardial coronary arteries - ***Unstable angina*** - Characterized by inc. Freq. And severity - Not relieved by rest and NTG - Req/ medical intervention - ***Treatment of Angina Pectoris*** - Dec. Myocardial oxygen and inc. Oxygen supply - Meds; oxygen; reduce and control risk factors - Reperfusion therapy may also be done - ***Meds used*** - Nitroglycerin(Nitrate); Beta Blockers(LOL); Calcium Channel Blockers; Antiplatelets(Aspirin) and Anticoagulation meds(heparin/enoxaparin); Aspirin; Clopidogrel and Ticlopidine; Heparin ; Glycoprotein IIb/iiia agents - ***Acute Coronary Syndrome (ACS) & Myocardial Infarction (MI)*** - Emergent situation - Characterized by an acute onset of myocardial ischemia that results in myocardial death (i.e., MI) if definitive interventions do not occur promptly - ***Location* of the *Infarction*** - ***Anterior left ventricle*** - Occlusion of left anterior descending (LAD) - ***Lateral and posterior left ventricle*** - Left circumflex artery - ***Inferior left ventricle*** - Occlusion of right coronary artery - ***Right ventricle*** - Occlusion of right coronary artery - ***Diagnostic Testing*** - ***Troponin*** - Preferred biomarker - ***Troponin 1*** rises in 3-12 hrs.; peaks at 24hrs and remains elevated for 5-10days - ***Troponin 2*** rises in 3-12 hrs.; peaks in 12hrs - 2days and remains elevated for 5-14 days - ***Other blood tests*** - Chemistry, CBC, coagulation studies, full lipid profile - Exercise stress testing - CXR; PET Scan; echocardiogram; MRI; Coronary angiography - ***Early management*** - Evaluate within 10min arrival. - Pt hx & ekg elevation greater than 1mm in two or more continuous leads = MI - ASA, Oxygen, nitroglycerin, morphine, betablocker, VS, IV access, continuous cardiac monitoring - CXR, echocardiography - ***Percutaneous coronary intervention*** - Reestablishes blood flow - Artery is opened by balloon and stent is placed. - Used for patients who present within 12 hours - ***Fibrinolytic therapy*** - In STEMI, door to drug within 30 minutes - Given within 3 hours of onset of symptoms - ***Surgical intervention*** - CABG - ***Mechanical Complications of MI*** - ***Ventricular septal wall rupture*** - Greatest risk is within the first 24 hours and up to 5days. - New, loud systolic murmur with thrill - Progressive dyspnea, tachycardia, and pulmonary congestion - Urgent cardiac catheterization and surgical correction - Support with fluids, inotropes, IABP, afterload reduction - ***left ventricular free wall rupture*** - Occurs within the first 24 hours or days 3 to 5 - Greater in age \> 70, women, hypertension, first MI - Prolonged chest pain, dyspnea, sudden hypotension, jugular venous distention, tamponade, and ECG evidence of electrical-- mechanical dissociation - Often results in death - ***Mitral regurgitation*** - Papillary muscle rupture or postinfarction ventricular remodeling - Systolic murmur, pulmonary edema, and/or shock - Diuretics and afterload- reducing agent until emergent surgery - ***Pericardial Complication*** - 3days- 7weeks after MI - Chest pain worse with deep breathing, cough, swallowing or lying flat, fever, friction rub. - Treat with anti-inflammatory for 7-14days - ***Other complications*** - ***Thromboembolic and bleeding complications*** - Fewer complications because of routine use of anticoagulants - Watch for thrombocytopenia in patients on heparin - ***Dysrhythmia complications*** - Causes include MI, myocardial necrosis, autonomic tone, electrolyte imbalances, acid-base disturbances, and adverse drug effects - Acute kidney injury - Hyperglycemia - ***Cardiac rehabilitation*** - Combines exercise, education, and counseling - Limit adverse physiological and psychological effects of heart disease - Modify risk factors - Reduce sudden death or reinfarction - Control cardiac symptoms - Stabilize/reverse atherosclerosis process - Enhance psychosocial and vocational status - ***ACS nursing interventions*** - Stop all activities and sit/rest in bed (semi-fowlers position) - Assessment (VS, observe for resp, distress and pain. ECG obtained/assess - Meds NTG, reassess pain and admin. NTG up to 3dose - Administer oxygen 2L/min by nasal cannula - Nursing management - Oxygen / meds therapy - Freq. VS assessment - Physical rest in bed with HOB elevated - Monitor I&O and tissue perfusion - Report changes in patient conditions - ***Patient Teaching*** - Diet in low fat and high fiber - Carry NTG at all times - Follow up with HCP - Report inc. In s/s to provider - Maintain normal BP & BG levels - ***Invasive Coronary Artery Procedures*** - ***Percutaneous transluminal coronary angioplasty (PTCA)*** - ***Coronary artery stent*** - ***Coronary artery bypass graft (CABG)*** - Native vessels or conduits are "harvested" and used to bypass blood flow past diseased areas of coronary artery - ***Patient teaching & Discharge Information*** - Hospitalization after CABG usually 4-7days - Discharge meds typically include - Aspirin, Betablocker, ACE Inhibitor, Statin - Smoking cessation interventions - ***Off Pump CABG Surgery*** - Dec. Length of stay - Incidence of stroke 48-72 hrs - ***Minimally invasive direct coronary artery bypass grafting (MIDCABG)*** - \# of grafts restricted - Not as successful as anticipated - ***Cardiac surgery*** - ***Saphenous Vein Graft*** - Anastomoses one end of vein to aorta (proximal) and other end to coronary artery past obstruction (distal) - May be simple or sequential (also called skip) - May be taken from above or below the knee - About 50% occluded after 10 years - ***Vein failure:*** - Thrombosis - Fibrointimal hyperplasia - Atherosclerosis - ***Internal Mammary Artery Grafts*** - Preferred alternative to saphenous - Used as a pedicle graft to bypass diseased artery - Both left and ri - ght can be used. - Left internal mammary artery longer and larger - Used to bypass LAD - Right internal mammary artery is used for right coronary artery or LCX. - 90% patency at 10 years ***Management of Patients with Dysrhythmias and Conduction Problems*** - ***Types of rhythms*** - ***Normal Sinus rate*** 60-100 bpm - ***Sinus bradycardia*** less than 60 bpm - ***Sinus tachycardia*** more than 100 bpm - ***Causes:*** caffiene, meication, anxietym dehydration - Ventricles fill inadequately - ***Supraventricular Tachycardia:*** 150-250 bpm ; medical emergency - ***Purkinje systole:*** emergency 20-40 bpm - ***Each small cube = 0.04secs.*** - ***Each big cube = 0.20 secs*** - ***5boxes = 1sec*** - ***How to count rhythm*** - Count each "R" wave (10) - Example (4 x10= 40 bpm) sinus bradycardia(less than 60) - -  - ***Dysrhythmias*** - Disorders of formation or conduction (or both) of electrical impulses within heart - Can cause disturbances of rate and rhythms - ***Types*** - ***Atrial*** - Premature atrial complex (PAC) - - Atrial flutter - Atrial fibrillation - ***Ventricular*** - Premature ventricular complex (PVC) - Ventricular tachycardia - Ventricular fibrillation - Ventricular asystole - ***Torsade De Pointes*** - Type of ventricular tachycardia - - ***Conduction abnormalities*** - *1^st^ degree AV Block* - *2^nd^ degree AV Block (type 1- Wenckebach)* - *2^nd^ degree AV Block, type 2* - *3^rd^ degree AV Block* - ***Electrolyte abnormalities on ECG*** - ***Hyperkalemia*** - Tall, narrow, peaked T Waves - ***Hypokalemia*** - U Waves - ***Hypercalcemia*** - Shortened QT interval - ***Hypocalcemia*** - Prolonged QT Interval - ***Assessment of patient with dysrhythmia*** - ***Physical assessment includes*** - Skin(pale and cool) - Signs of fluid retention (JVD, lung auscultation) - Rate, rhythm of apical, peripheral pulses - Heart sounds - BP , Pulse pressure - ***Problems and potential complications*** - Cardiac arrest, HF, Thromboembolic events (especially with = A.Fib) - ***Nursing interventions for dysrhythmias*** - Monitor/manage dysrhythmia - Reduce anxiety - Promote home-and community based care - Educate patient about self care - Continuing care - Assess VS ongoing basis - Assess for lightheadedness, dizziness, fainting, - If hospitalized - 12 lead ECG, Cont. Monitoring - ***Antidysrhythmic meds*** - "6min walk test" - ***Class 1 antiarrhythmic drugs*** - Block influx of sodium into cells - ***Class 2 antiarrhythmic drugs*** - Interfere with sympathetic nervous system stimulation - ***Class 3 antiarrhythmic drugs*** - Individual agents contains unique properties - ***Class 4 antiarrhythmic drugs*** - Calcium channel blocker antiarrhythmics - ***Eval. Of dysrhythmia of patient*** - ***Maintain cardiac output*** - Stable VS, no signs of arrhythmia - ***Experience reduced anxiety*** - Positive attitude, confidence in ability to act if an emergency occurs - ***Express understanding of dysrhytmias and treatment*** - ***Safety Measures for Defibrillation*** - Ensure good contact between skin, pads, and paddles - Use conductive medium, 20 to 25 pounds of pressure - Place paddles so they do not touch bedding or clothing and are\ not near medication patches or oxygen flow - If cardioverting, turn synchronizer on - If defibrillating, turn synchronizer off - Do not charge device until ready to shock - Call "clear" three times; follow checks required for clear - Ensure no one is in contact with patient, bed, or equipment - ***Pacemakers*** - Electronic device that provides electrical stimuli to heart muscle - ***Types*** - Permanent - Temporary - Pacemaker generator functions - NASPE-BPEG code for pacemaker function - ***Cardiac pacemakers*** - ***Indications for cardiac pacing*** - Conditions that result in failure of heart to initiate or conduct an intrinsic electrical impulse at a rate adequate to maintain perfusion system - Dysrhythmias or conduction defects compromise the electrical system and the hemodynamic response of the heart - ***Pulse generator*** - Lithium iodide battery source and electronic circuits enclosed in a hermetically sealed metal container - Permanent pulse generators are inserted in a subcutaneous pocket in the pectoral region below the clavicle. - ***Lead system*** - Communication network between the pulse generator and the heart muscle. One or more electrodes are at the distal end of the lead and provide sensing and pacing of the heart muscle - ***Pacemaker Functioning*** - Senses and treats heart rhythm dysfunction - When intrinsic heart rate drops to the programmed minimum rate, the pacemaker delivers a stimulus through the lead. - As a result of this stimulus, the cardiac chamber containing the pacemaker lead is depolarized. - Capture is the term used to indicate depolarization of the atria or ventricle in response to a pacing stimulus - ***Complications of Pacemakers use*** - Infection - bleeding or hematoma formation - discoloration of lead - Skeletal muscle or phrenic nerve stimulation - Cardiac tamponade - Pacemaker malfunction - ***Catheter Ablation*** - ***Indications for ablation*** - Atrioventricular nodal reentrant tachycardia - Atrioventricular reentrant tachycardia - Atrial fibrillation or flutter - Ventricular dysrhythmias - ***Procedure*** - Ablating catheter is positioned in the targeted area of the heart - Radiofrequency current is applied for 7 seconds until the target tip temperature is achieved - ***Implantable Cardioverter Defibrillator*** - Device that detects and terminates life-threatening episodes of tachycardia and fibrillation - ASPE-BPEG code - antitachycardia pacing - ***Hemodynamic monitoring*** - Evaluates intracardiac and intravascular volume, pressures, and cardiac function - Aids in diagnosis of CV disorders - guides therapy - Evaluates patients' response - Patients in cardiogenic shock, severe HF, septic shock, MSOD, ARDS - ***Central Venous Pressure Monitoring*** - Measures pressures in the right atrium - Reflects intravascular blood volume, right ventricular end-diastolic pressure, and right ventricular function - Normal less than 8 mm Hg - Catheter insertion - ***Complications*** - Infection - Thrombosis - Air embolism - ***Pulmonary Artery Pressure Monitoring*** - Assessment of right ventricular function, pulmonary vascular status, and LV function - Measures RA, RV, and PA, and PAOP pressures - ***Complications*** - Pneumothorax - Infection - Ventricular dysrhythmias - Pulmonary artery rupture or perforation - Accidental blood loss - Impaired circulation to extremity - When obtaining a cardiac output, 1min should be in between injections - Oxygen content and cardiac output determines oxygen delivery - ***Determinants of Oxygen Delivery*** - ***Oxygen content*** - Hemoglobin and oxygen saturation - ***Cardiac output*** - Delivers oxygen to the cells - DaO2 is CO and arterial oxygen content. - Normal is 1,000 mL O2/minute. - Increase in demand results in compensatory increase in CO - ***Determinants of Oxygen Consumption*** - ***Oxygen demand*** - Stress increases demand. - Need adequate delivery of oxygen and cellular extraction of oxygen - ***Oxygen delivery*** - Delivery increases \> consumption increases \> oxygen demand is met. - ***Oxygen extraction*** - Amount of oxygen removed from blood for use by cells - ***SvO2---mixed venous saturation*** - Level of oxyhemoglobin in desaturated blood returning to the right ventricle - Can be monitored at the bedside with specialized central venous catheters - Evaluates the balance of oxygen supply, utilization, and demand - Normal ranges from 60% to 80% Moron 354-355 ekg 188 , 189 p\. 364 box 1810 -- horton 742-744 inkle Check magnesium for torsade de pointes v-fib no pulse present \- not tested Hemodynamic/ heart blocks Pacemakers with letters