Chapt 66 Flashcards
What are RRT’s
Critical care nurse, RT, MD or APN. RRT do not guarantee a doctor.
What is the difference between calling RRT and a code blue?
The presence of a doctor
What are PCUs?
Transition between ICU and general care. Stable enough to leave ICU but not enough for general because they are still connected to all the monitors
What are common problems with ICU patients?
Venous thromboembolism d/t immobility Skin problems d/t immobility HAI= Trachs and Foleys Sepsis= Inflammatory response Multiple Organ dysfunctions Syndrome= Inflammatory response linked to sepsis Nutrition deficiencies d/t hpermetabolic and catabloic states.= Healing burns calories, we need nutrients; PEG TUBE G TUBE TPN Anxiety Impaired Communication
What medications is typically used ICU Sedation?
Propofal, Diprivan (sedative wjth a short half life) and Fentanyl, Sublimaz (analgesic.
What is the purpose of a sedation vacation?
When doing a neuro assessment we need to pull the patient out of sedation. that is why Propofal, Dirprivan is used because of the short half life.
What common problem do 80% of ICU patients have?
Sensory-Perceptual Problems r/t delirium
How do you treat delirium in the ICU?
Address physiological factors first (oxygen)
Use clocks and calendars to orient the patient
Encourage caregiver presence
Haloperidol,Haldol (last intervention)
How do you treat sleep problems in the ICU?
Structure the environment for sleep and wake cycles.
Cluster activities
Scheduled rest periods
Limit noise
Provide comfort measures (back rub)
Use benzodiazepines cautiously
Tamazepam,Restoril
Zolpidem, AmbienShould caregivers be in the room when a pts codes?
Yes, because they can see that we are doing everything we can for our patient.
CVP
Central Venous Pressure. We use a Swan Ganz Cathater
Systemic and Pulmonary atrial pressures
Blood pressure cuff on either the brachial, radial, or femoral arteries.
PAWP
Pulmonary artery wedge pressure. Determines preload on the left side of the heart.
SaO2
SvO2
SpO2
Arterial O2
Mixed venous oxygen saturadation.
Oxygen Saturation
CHF
Too much fluid in the heart
What are the two goals of Hemodynamic Monitoring?
Maintain adequate tissue perfusion
Early detection of changes
Titration of therapy in unstable patients
Determine what organ is a causing a problem
When do we use hemodynamic monitoring?
Shock Spesis Any loss of cardia function burns surgeries hemorrhage dehydration
Cardiac Output
Icreases with high volume
decreases with low volume
Stroke volume
Volume of blood ejected with each heartbeat. Determined by preload, afterload, and contractility.
Ejection Fraction
Measurement of the percentage of blook leaving you heart each time it contracts.
Normal=60-75%
Determined on a echocardiogram
Left sided CHF issues
Left side means systemic.
Pumping issues/systolic
Right sided CHF issues
Diastolic functioning effected
Filling issue
Contractility
Increase effects
decreased effects
Strength of Contraction
Increased: Positive inotropes, B1 receptors (epi,Norepi,dopamine)
Decreased: Heart Failure, alcohol, negative inotropes
(Calcium channel blockers, beta blockers)
What are the different receptors and effects?
B1- Contraction=Postiive Inotropes
B2- Lungs Open
A1- Vasoconstriction
Dopaminergic- Vasodilate organ vasculature/ constrict peripheral arteries.
Preload
Volume in the ventricle at the end of diastole
Diastole
the phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood
Frank Sterlings Law
PAWP will show us left ventricular preload
CVP (Central Venous Pressure) shows >
Right Ventricular Preload
What does vasoconstriction do to afterload?
Decreases
Afterload
Resistance the ventricle has to over come to send blood to the body (SVR) or to the lungs (PVR).
What happens to CO when afterload is increased?
CO is decreased
What medication would you give a pt to decrease PVR?
- O2
- Calcium Channel Blockers
- Aminophylline,
- Isoproteronol
What medications would we give to decrease SVR
We want to vasodilate
- Morphine
- Nitrates
What increases PVR
Pulmonary HTN (Right heart Failure)
Hypoxia
PE
What increases SVR
HTN hardened arteries CAD low volume catecholamines
How do you set up Hemodynamic monitoring?
- Arterial cathater is placed
- Get pressure bag (NS)
- Place a pressure cuff over the bag
- Spike the bag and prime tubing
- Inflate the bag to 300mmHg/Insures 3-6 mL are going into the heart lines at one time.
- Transducers reads the presssure and sends it to the montior
- 3 way stop cock needs to be zero out
- Fast Flush device allow a bolus of fluid to to the patient. This prevents clots
When reading hemodynamic montioring, what angle does the pt needs to be at
45 degrees
When do you obtain hemodynamic results?
At the end of expiration
What is the phlebostatic Axis?
4th intercoastal, mid axillary line. The tranducer is at this level to prevent flase high and or lows
How often is pressure tubing, flush bag, and transducer changed in hemodynamic monitoring?
Every 3 days to decrease risk for infection.
When do you fast flush?
Every shift to insure accurate wave forms.
What is the dicrotic Notch?
Represents the atrial valve closing.
Before an aterial line is placed, what test should you peform?
Allan Test
What is the normal MAP
70-105
What is the formula for MAP
(Diastolic x 2 ) + Systolic/ 3
Normal range for pH
7.35-7.45
Normal PaCO2
35-45
Normal range for Bicarb
22-26
Aterial Oxygen Saturation (bound to hemoglobin) (SaO2)
95-100%
Partial Pressure of Aterial Oxygent (PaO2)
-Total amount of O2 in the blood (bound = unbound)
80-100
What position is the patient in when CVP monitoring is placed?
Trendelberg position
What is the purpose of CVP monitoring?
To measure the filling pressure of the right side of the heart
What happens to SvO2 (how much o2 is returing to the heart) in alkalosis?
Increase affinity for O2 so blood dosent let it go. Pt organs begin to shut down from starvation
Why is tension pnuemothorax a complication of CVP monitoring?
Because we punctured the lung during placement.
What pressure does CVP (Central Venous Pressure )represent?
Right Aterial Filling Pressure/ Preload of Right side of the heart
2-8mmHg
What is another name for the Pulmonary Aterial Cathater?
Swan Ganz/Venous Circulation
What is beneficial about the Swan Ganz catheter?
Mult ports.
- CVP/RAP Monitoring 2-8mmHg
- Blood sampling
- SvO2 (60-80%
- Temp
- CO thermo monitoring (Stroke Volume)
- Pulmonary Wedge pressure (6-12 mmHg)
What does the pumonary wedge pressure tell us?
The preload of the L side of the heart
6-12 mmHg
When are ciculatory Assist Devices used?
Used temporarily or permanently to decrease ventricular work and improve end-organ perfusion.
What are two examples of Circulatory Assist Devices?
- Intraaortic Balloon Pump= IABP (most common)
2. Ventricular Assist Device=VAD
What percentage of blood does the myocardium need?
80%
Describe IABP
The baloon is placed in the descendig thoracic aorta above the renal arteries. The balloon fills with helium at the start of diastole and deflates before systole. Inflates opposite to ventricular contraction. The balloon inflates at every heart beat.
How can you check the therapuetic effect of IABP?
Perfusion
What are the two main befits from IABP
- Feeds the mycardium during diastole
2. Decrease afterload
What is the nursing care for IABP
Heparin- to prevent clotting
HOB>30 degrees b/c of leg cannulation (femoral a)
Hourly Urine Output (Renal a.)
Limit movement to prevent balloon displacement
Hourly assessments of CV, Neurovascular,and hemodynamic status
Is IABP temporary or permanent?
Temoporary
What is a Vascular Assist Device (VAD)
Takes blood from the Left atrium to the device, and then to the aorta. Bypassing the Left ventricle. Can be used on the left and the right side of the heart.
What is the nursing care for VAD?
Odd heart sounds
May no have a pulse
CPR is not safe for them but ahs to be done.
Need to be disconnected for difibrillaton
When a pt has a VAD how do you obtain their BP?
MAP
Doppler device
