Exam 1 Flashcards
Delirium Mnemonic
D: Dementia, dehydration
E: electrolyte imbalances, emotional stress
L: lung, liver, heart, kidney, brain
I: infection, ICU
R: Rx drugs
I: Injury, immobility
U: untreated pain, unfamiliar environment
Delirium
Acute changes in mental status
-some elderly delirium will never clear
*Not severe depression (psychosis), or dementia
Delirium Interventions
-Environment so pt can sleep
-pt safety (pulling tubes, near nursing station)
-avoid antipsychotics
-reorient as much as possible
*Avoid restraints
Delirium Assessments
-CAM-ICU
Pain Assessment Tools
FLAAC
C-CPOT
C-CPOT
Critical Care Observation Tool
FLACC
Behavioral Scale
*any-age that cannot communicate pain
Morphine Assessment
reassess pain after 15-30 min
Percocet Assessment
reassess pain after 60 minutes
Fentanyl
Fastest onset
Morphine
Longest duration
*Assess pain after IV 15-30 min
Hydromorphone (Dilaudid)
*1mL Dilaudid = 7mL Morphine
Opiod Concerns
-Respiratory Depression (most severe)
-Constipation (Most common): Increase ROM, stool softeners, fluids
-hypotension
-CNS Depression
-hallucinations
-geriatrics
PCA pt’s
-Elective surgery
-large surgical or traumatic wounds
-normal cognitive function
-normal motor skills
Sedation Assessment Tools
RASS
RIKER
*Both measure agitation and sedation
Four types of sedation
- Anxiolysis
- Moderate sedation
- Deep sedation
- Anesthesia
*DO NOT REDUCE PAIN
Anxiolysis
-Pt awake and responsive
-Minimal sedation
-anxiety relieved
Moderate Sedation
-Pt responds with verbal commands only or light touch
-Maintains own airway
Deep Sedation
-Pt asleep
-MAY need assistance with airway and ventilatory effort
Anesthesia
-loss of sensation
-cannot maintain airway
Sedation Purpose
Reduce agitation and anxiety
Diazepam (Valium) Indications
-anxiety
-acute alcohol withdrawal
-pre-op skeletal muscle relaxent
Diazepam (Valium) Risk
-CNS Depression
-Confusion
-Drowsiness
-Resp depression
-orthostatic hypotension
Diazepam (Valium) Nursing implications
-do not dilute
-give into large vein over 3 minutes
-assess vitals before, during, and after
-assess CNS and LOC
Succinylcholine (Anectine) Indication
-Paralysis
*Does not decrease pain
Succinylcholine (Anectine) Risk
-Hyperkalemia
-muscle pain
-malignant hypothermia
Succinylcholine (Anectine) Intervention
-peaks 1 min, fades in 4-10 minutes
*Give with intubating
Succinylcholine (Anectine) Nursing Management
*Pt can’t move, talk, blink, pee
-Foley
-Eye lubrication
-Reposition & ROM exercises(DVT prevention)
-Oral care
-Vitals and assessment Q1hr
-Daily Labs (BUN, CREAT, GFR)
Acute Coronary Syndrome Types
-Stable angina
-Unstable angina
-Acute MI
Acute Coronary Syndrome Causes
Stable angina Causes
Most common
-chest pain with exertion
Stable angina Treatment
rest and nitroglycerin
Unstable Angina Causes
-chest pain with exertion
-DOES NOT resolve w/ rest or meds
Non-ST (NSTEMI) Acute MI
-MI w/out changes to EKG
-partial occlusion of artery
-Less permanent damage than STEMI
ST (STEMI) Acute MI
-complete occlusion
-EKG changes
Acute Coronary Syndrome Causes
-Artherosclerosis (build up of fats and cholesterol)
-Emboli
-Blunt trauma
-Spasms
Acute MI Assessment
-Midsternal chest pain -> radiates to left arm in men
-pale, diaphoretic
-dyspnea
-hypotension
-syncope (loss of consciousness)
-Sweating and vomiting out of nowhere
Women:
-jaw pain
-back/shoulder pain
-severe indigestion
Elder:
-epigastric pain
Acute MI Labs
- Troponin: cardiac protein released after damage to the myocardium
-Rises within 4-6 hrs
-Peaks 10-24 hrs
-detected up to 10-14 days - Cardiac Biomarkers: TKMB
-not common
-confirms troponin - Myoglobin
-not common
Acute MI 12-lead Diagnosis
-ST elevation followed by Q wave (Tombstones)
-ST depression
N-STEMI does not have EKG changes
Acute MI Management
-Pain relief: morphine, nitroglycerin
-Oxygen
-Antiplatelets: aspirin/plavix
-PCI ( coronary cath, fibrinolytic therapy)
-Beta blockers
-ACE inhibitor
Nitroglycerin
Nonselective vasodilator
Nitroglycerin side effects & when to NOT give
-headache
-hypotension (synscope)
DO NOT GIVE WITH:
-right sided MI
-Viagra
-increased ICP
-pericardial tamponade
Nitroglycerin Interventions
-Obtain baseline ECG (before/after)
-Check current meds (no viagra)
-monitor HR, BP, Chest pain
Aspirin
-NSAID
-Irreversible platelet aggregation inhibition
Aspirin Risk
-Severe bleeding risk
-GI bleed
Aspirin Nursing Interventions
-monitor for bleeding
-infusions
-activated charcoal
*no antidote
Lethal Rhythms
-V tach
-PEA
-Asystole
V tach
-impulse coming from ventricles
-Wide QRS complex (>.12)
-Looks like mountains
-3 pvs in a row
-no P wave
-rate >100 (usually 110-250 bpm)
-MUST defibrillate before anything else
V tach identification/causes
-myocardial ischemia, infarction
-Decreased K, Mg
-hypoxia
-acid-base imbalance
Asystole
-Flat line
-NO P, QRS, or T
Pulseless Electrical Activity (PEA)
-Causes: H&Ts
-Electrical activity but no pulse
present muscles doesn’t work
Code Equipment
-Defibrillator
-Code Cart
-BVM
Defibrillator
-Delivers external electrical current
-depolarizes
-disrupts impulse causing dysrhythmia
Defibrillator Indications
-V fib
-Pulseless V tach
Defibrillator Considerations
-Clear before delivery (Hands off and Oxygen)
-Remove everything from pt
-Dry skin
-wax hair off
Code cart
-ACLS drugs
-AED
Non-shockable Rhythms
-Asystole
-PEA
Epinephrine Indications
Cardiac arrest
all rhythms: V fib, V tach, asystole, and PEA
Administer at 15 compressions
Epinephrine Dosing
-1mg rapid IV push
-repeat ever 3 minutes
Epinephrine Cautions
-Potent vasoconstrictor
-do not give w/ sodium bicarb in same line bc alkaline solution can inactivate
Atropine Indications
Symptomatic bradycardia
Atropine Dosing
1mg rapid IV push
-repeat every 3-5 minutes
-Max dose of 3mg
Atropine Cautions
-decreases vagal tone, do not push slowly
-using during MI can worsen ischemia
Adenosine Indications
-Stable tachycardia
-SVT
Adenosine Dosing
-6mg rapid IV push followed by rapid flush of 20 mL NS
-A repeat of 12mg may be given 1-2 minutes later
Adenosine Cautions
-Do not give with 2nd or 3rd degree block- Slows conduction through AV node
-Do not give to pt w/ asthma or emphysema -can cause rep. destress
-Expect slowing or loss of rhythm(moment of asystole), pt may feel flush, or short of breath
PR Interval times
0.12-0.20 seconds
QRS complex times:
0.06-0.11 seconds
QT Interval:
0.32-0.50 seconds
P wave
represents atrial depolarization
QRS complex
ventricular depolarization
ST Segment
Time between ventricular depolarization and repolarization
-flat, isoelectric
T wave
Ventricular repolarization
Sinus Rhythm
60-100bpm, upright
Sinus Tachycardia
> 100-150bpm
Sinus Tachycardia Causes
-Hyperthyroidism
-hypovolemia
-heart failure
-anemia
-exercise
-stimulants
-fever
-fear
-pain
-anxiety
Sinus Brady
<60bpm
Sinus Brady Causes
-vagal, drugs, ischemia, disease of nodes, Increased ICP, hypoxemia, athletes
Sinus Brady Treatment
Atropine
A Fib
-Erratic impulse formation in the atria
-No P wave
-Irregular rate
A Fib Characteristics
-no P wave
-narrow QRS
-loss of atrial kick (less blood pushed from Left Atrium to Left Ventricle)
-irregular ventricular rate ( can be fast, slow, or normal rate)
-high risk for pulmonary or systemic emboli
-increased risk of blood pooling in L atrial appendix
A fib Treatment
1. Cardioversion (150J)
#2. Meds: diltiazen, amiodarone
#3. Cardiac ablation
All need anticoagulant and heparin/coumadin
Supraventricular Tachycardia (SVT)
General term
-regular rhythm
-Narrow QRS (<.12)
-No P wave, too fast to see
-HR >160bmp
SVT Treatment
1. Vagal maneuver
#2. adenosine
#3. cardioversion
PVC
-Single or double beat -not rhythm
-No P wave
-Wide QRS (>.12)
-T wave opposite of QRS complex (on lead 2 its inverted)
2 PVCs = Couplet
3 PVCs = V tach
V Fib
Pt is clinically dead
-chaotic pattern
-no discernible P, Q, R, S, or T waves
-no cardiac output
-no pulse
-no BP
3rd Degree AV Block
-P-P regular
-R-R is regular
-More waves than QRS complexes
-No relation between the P and QRS
-Wide QRS
-Av node blocked so perkinje fibers take over (20-40bpm)
Cardizem (Diltiazem)
Calcium channel blocker
*use for A fib
Cardizem (Diltiazem) Dose
-0.25mg/kg given slowly over 5min
-Than begin infusion 10-20mg/hr
Cardizem (Diltiazem) Risk
hypotension
heart block
renal failure
Cardizem (Diltiazem) Interventions
Labs
monitor rhythm
BP, VS, output
Amiodarone
Use for unstable V tach or A fib
Amiodarone Dose
1st dose 300mg IV push followed by 150mg IV push
*DO NOT GIVE IV PUSH TO ALIVE PERSON
MONA
Morphine: low dose, mild vasodialator, pain control
Oxygen: oxygen rich blood
Nitro: vasodialator, *chest pain lowered
Aspirin: chew it or rectal if they can’t swallow
*not in this order
V tach pt’s
-Stable, no symptoms
-Stable, symptomatic
-Unstable, symptomatic
-Dead
What are the s/s of low CO?
-Change in level of consciousness
-Chest discomfort
-Hypotension
-Shortness of breath; respiratory distress
-Pulmonary congestion; crackles
-Rapid, slow, or weak pulse
-Dizziness, Syncope
-Fatigue, Restlessness
V tach Unresponsive Treatment
Call for help! Start CPR!
Place pads asap
V tach unstable treatment
Amiodarone
MAP minimum
60
Noninvasive BP and ABP difference
No more than 10
