Critical Care Flashcards
Reflects left ventricular end-diastolic pressure
Pulmonary artery Wedge Pressure (PAWP)
What is the volume of blood within the ventricle at the end of diastole called?
Preload
Reflects right ventricular end-diastolic pressure and volume depletion or overload
Central Venous Pressure
Forces opposing ventricular ejection
Afterload
Systemic venous resistance and arterial pressure indicate?
Left ventricular afterload
Peripheral vascular resistance and pulmonary arterial pressure indicate
Right ventricular afterload
Increased preload does what to Cardiac Output?
increases it
Increased afterload does what to cardiac output?
decreases it
How often should arterial lines be changed?
q96h
What two invasive pressure monitors assess cardiac function and fluid volume status?
Pulmonary artery diastolic pressure and PAWP
What is used to monitor Pulmonary Artery Pressure?
PA flow-directed catheter (e.g. Swan-Ganz)
What are the two proximal lumens in a Swan-Ganz used for?
Central venous pressure monitoring, injecting fluid for cardiac output, drawing blood, and administering fluids or drugs
What is the distal port used for in a Swan-Ganz?
Thermistor port
Increased systemic vascular resistance indicates what?
vasoconstriction
Decreased systemic vascular resistance indicates what?
vasodilation
Central venous pressure measures what?
Central venous oxygen saturation and indicates volume status
Pulmonary artery catheters measure what?
Mixed venous oxygen saturation (SvO2) to see if gas exchange is occurring
SvO2 and ScvO2 reflect what?
the balance between oxygenation of arterial blood, tissue perfusion, and tissue oxygen consumption
Normal venous O2 concentration is what?
60-80%
What is the tidal volume normal set at on a mechanical ventilator?
6-7 mL/kg
What is the FiO2?
Fraction of inspired oxygen, usually >21% (room air) if ventilated
Positive end-expiratory pressure is used for what and what pressure is typical?
PEEP maintains alveolar inflation and functional reserve. It is normally between 5-10 cm H2O.
In which mechanical ventilatory mode does the ventilator do all of the WOB?
Controlled Ventilatory support
In which mechanical ventilatory mode does the ventilator and patient share the WOB?
Assisted Ventilatory support
Which ventilation mode delivers a present Vt at a preset frequency and when the patient initiates a breath, the preset Vt is delivered?
Assist-Control (A/C) ventilation
Which ventilator mode delivers a preset Vt at a preset frequency in synchrony with the pt’s spontaneous breathing. In between delivered breaths, the patient is able to breath spontaneously. The pt receives a preset FiO2, but self regulates the rate and volume of spontaneous breaths.
Synchronized intermittent mandatory ventilation
Which ventilator mode gives positive pressure to the airway only during inspiration in conjunction with spontaneous respirations. The machine senses spontaneous effort and supplies rapid flow of gas at initiation of breath. The patient determines the inspiratory length, Vt, and respiratory rate.
Pressure support ventilation
Positive pressure is applied to airway during exhalation, preventing alveolar collapse.
Positive end-expiratory pressurje
Pressure is delivered continuously during spontaneous breathing. There is increased WOB.
Continuous positive airway pressure (CPAP)
Delivers oxygen and two levels of positive pressure support. Higher inspiratory positive airway pressure and lower expiratory positive airway pressure. The patient must be able to breathe spontaneously.
Bilevel positive airway pressure (BiPAP)
Delivery of a small Vt at a rapid respiratory rate
High-frequency oscillatory ventillation
Nitric Oxide causes what and is used to treat what?
Pulmonary vasodilation, ARDS
What special considerations are there for the prone patient?
No NAPs!
Dobutamine is used in what type of shock? What effects does it have?
Cardiogenic shock and septic shock
Increased myocardial contractility
Decreases SVR/PAWP
Increases CO/SV/CVP
What are the nursing considerations for dobutamine?
Administer via central line (avoids tissue sloughing)
Monitor HR/BP (hypotension may occur, requiring vasopressor)
Do not administer in same line as NaHCO3 (sodium bicarb)
Dopamine is used in what type of shock? What effects does it have?
Cardiogenic shock
Increases myocardial contractility
Increases HR/CO/BP/MAP, blood flow to renal/mesenteric/cerebral circulation
Anticoagulant/antiinflammatory/vasoconstrictive effects
What are the nursing considerations for dopamine?
Administer via central line to avoid tissue sloughing
Do not administer in same line as NaHCO3
Monitor for tachydysrhythmias, peripheral vasoconstriction
Xigris is used in what type of shock? What effects does it have?
Septic shock
anticoagulant/antiinflammatory
What are the nursing considerations for Xigris?
Monitor for signs of BLEEDING, Hb, platelets, PT, PTT
Epinephrine is used in what type of shock? What effects does it have?
Cardiogenic, anaphylactic shock
Cardiac stimulation, bronchodilation, peripheral vasodilation (low doses), vasoconstriction (high doses)
increased HR/contractility/CO/SV/CVP/PAWP
What are the nursing considerations for epinephrine?
Monitor for HR >110 bpm, dyspnea, pulmonary edema, chest pain, dysrhythmias, renal failure (secondary to ischemia)
Hydrocortisone (solu-cortef) is used in what type of shock? What effects does it have?
Septic and Anaphylactic shock
Decreases inflammation, reverses increased capillary permeability
Increases BP/HR
What are the nursing considerations of hydrocortisone (Solu-cortef)?
Monitor for hypokalemia and hyperglycemia
Norepinephrine (Levophed) is used in what type of shock? What effects does it have?
Cardiogenic (after MI), Septic, and hypovolemic shock unresponsive to fluid resuscitation
Peripheral/renal/splanchnic vasoconstriction
Increased BP/MAP/CVP/PAWP/SVR
What are the nursing considerations for levophed?
Administer via central line to avoid tissue sloughing
Monitor for dysrhythmisas
Neo-Synephrine is used in what type of shock? What effects does it have?
Neurogenic shock
peripheral vasoconstriction
Increased HR/BP/SVR
What are the nursing considerations for Neo-Synephrine?
Monitor for: reflex bradycardia, headache, restlessness, renal failure secondary to decreased renal blood flow
Administer via central line to avoid tissue sloughing
Nitroglycerin is used in what type of shock? What effects does it have?
Cardiogenic shock
Venodilation, dilates coronary arteries
decreases preload, MVO2, SVR, BP
What are the nursing considerations for nitroglycerin?
Continuously monitor BP and HR as reflex tachycardia may occur
Glass bottle recommended for infusion
Nipride is used in what type of shock? What effects does it have?
Cardiogenic shock with increased SVR
Vasodilation, decreased preload/afterload, decreased CVP/PAWP/BP
What are the nursing considerations for Nipride?
Continuously monitor BP
Administer with D5W
Monitor for almond smell on breath (cyanide toxicity)
Protect solution from light
Vasopressin is used in what type of shock? What effects does it have?
Shock states (most commonly septic shock) refractory to other vasopressors ADH, vasoconstrictor, increased MAP/UOP INFUSE AT LOW DOSES, DO NOT TITRATE. USE CAUTIOUSLY IN PATIENTS WITH CAD
(PRELOAD) Right atrial pressure or CVP normal range:
2-8 mm Hg
PRELOAD
PAWP or left atrial pressure normal range
6-12 mm Hg
Preload
Pulmonary artery diastolic pressure (PADP)
4-12 mm Hg
Afterload
Pulmonary vascular resistance normal range
<250 dynes/sec/cm-5
Pulmonary vascular resistance index normal range
160-380 dynes/sec/cm-5/m2
Systemic Vascular Resistance normal range
800-1200 dynes/sec/cm-5
Systemic Vascular resistance index range
1970-2390 dynes/sec/cm-5/m2
Mean arterial pressure normal range
70-105 mm Hg
Pulmonary artery mean pressure normal range
10-20 mm Hg
Stroke volume normal range
60-150 mL/beat
Stroke volume index
30-65 mL/beat/m2
Heart rate normal range
60-100 bpm
Cardiac output normal range
4-8 L/min
Cardiac index normal range
2.2-4 L/min/m2
Arterial hemoglobin saturation
95-100%
Mixed venous hemoglobin oxygen saturation
60-80%
Venous hemoglobin oxygen saturation
70%
What are the 4 parameters for ventilator weaning readiness?
- Reversal of underlying cause of respiratory failure
- PaO2/FiO2 >150-200; PEEP 7.25
- Hemodynamic stability (absence of myocardial ischemia or clinically significant hypotension (no vasopressor therapy or low dose))
- Patient ability to initiate inspiratory effort
The volume of air that the client receives with each breath
Tidal Volume
The number of ventilator breaths delivered per minute
Rate
The volumes of air that are 1.5 to 2 times the set tidal volume, delivered 6-10 times per hour; may be used to prevent atelectasis
Sighs
The oxygen concentration delivered to the client; determined by the patient’s condition and ABG levels
Fraction of inspired oxygen (FiO2)
The pressure needed by the ventilator to deliver a set tidal volume at a given compliance. Monitoring this reflects changes in compliance of the lungs and resistance in the ventilator or client.
Peak airway inspiratory pressure
The application of positive airway pressure throughout the entire respiratory cycle for spontaneously breathing client. No ventilator breaths are delivered, but the ventilator delivers oxygen and provides monitoring and an alarm system; the respiratory pattern is determined by the client’s efforts
Continuous positive airway pressure
Positive pressure is exerted during the expiratory phase of ventilation, which improves oxygenation by enhancing gas exchange and preventing atelectasis. Indicates a severe gas exchange disturbance. Higher levels increase chance of complications such as barotrauma tension pneumothorax
Positive end-expiratory pressure
The application of positive pressure on inspiration that eases the workload of breathing. May be used in combination with PEEP as a weaning method. As the weaning process continuous, the amount of pressure applied to inspiration is gradually decreased
Pressure support
What fluids would be used for initial volume replacement in most types of shock? Why? What nursing implication(s) is/are there?
0.9% NaCl, LR
These fluids primarily remain in the intravascular space, increasing volume
Monitor for fluid overload
What fluid would be used for initial volume expansion in hypovolemic shock? Why? What nursing implications are there?
Hypertonic saline solutions: 1.8%,3%,5%
Fluid remains in the intravascular space, rapid volume expansion
Monitor patient closely for signs of hypernatremia (disorientation, convulsions) Central line preferred
In which type of shock would blood products be administered?
all types of shock, potentially
What type of colloids would be administered in all types of shock except cardiogenic and neurogenic? Why? What nursing considerations are there?
Hespan, Human serum albumin
Volume expanders, rapid
Monitor for circulatory overload
Hespan may increase risk of bleeding and is costly.
Human serum albumin side effects of chills, fever, and urticaria
The respiratory rate (f) on the ventilator is usually set to what?
6-20 breaths/min
The tidal volume is what and what is the usual setting?
Volume of gas delivered to the patient during each ventilator breath; usual volume is 6-10 mL/kg
Pressure support is what and what is the usual setting?
Positive pressure is used to augment patient’s inspiratory pressure; usual setting is 6-18 cm H2O.
What is the I:E ratio and what is the normal range?
Duration of inspiration (I) to duration of expiration (E); usual setting is 1:2 to 1:1.5 unless IRV is desired.
What is the inspiratory flow rate and time and what is the normal range?
Speed with which the Vt is delivered; usual setting is 40-80 L/min and time is 0.8-1.2 sec
What is sensitivity and what is the normal range?
Determines the amount of effor the patient must generate to initiate a ventilator breath; it may be set for pressure triggering or flow triggering; usual setting for a pressure trigger is 0.5-1.5 cm H2O below baseline pressure and for a flow trigger is 1-3 L/min below baseline flow.
What is the high pressure limit and what is the normal range?
Regulates the maximal pressure the ventilator can generate to deliver the Vt; when the pressure limit is reached, the ventilator terminates the breath and spills the undelivered volume into the atmosphere; usual setting is 10-20 cm H2O above peak inspiratory pressure.
These labs have the potential to be elevated in shock states?
RBCs, DIC screen (Fibrin split products, PTT and PT, thrombin time, D-dimer), Creatine kinase, troponin, BUN, Creatinine, Glucose, Serum electrolytes, ABGs, base deficit, blood cultures and lactic acid
What lab tests have the potential to be decreased in shock states?
Fibrinogen level
RBCs (hemorrhagic shock after fluid resuscitation)
Platelet count
Glucose (late)
Sodium (if hypotonic fluid is used)
Potassium (early, increased renal excretion)
Metabolic acidosis (late, from lactic acid buildup)
