Exam 1 Flashcards
Ischemic chest pain becomes unpredictable, more intense, and more difficult to review; can awaken patient from sleep
Acute Coronary Syndrome: Unstable Angina
EKG & Lab results: Unstable Angina
All negative/no notable findings
Ischemic chest pain that
EKG: ST depression or T wave changes
Labs: positive cardiac biomarkers
Acute Coronary Syndrome: Non-stemi
Associated with complete occlusion of a coronary artery by a thrombus superimposed on ruptured plaque
Acute Coronary Syndrome: Stemi
EKG & Lab results: Stemi
EKG: 1mm or more ST elevation two or more contiguous leads
Labs: positive cardiac biomarkers
2 important Cardiac Biomarkers with MI
Troponin
CKMB
RV Triad
Systemic hypotension
Absence of pulmonary congestion
Increased CVP and jugular venous distention
S/S Acute Coronary Syndrome (4)
Chest pain/discomfort unrelieved by rest
Sense of impending doom
-Bradycardia: inferior MI
-Tachycardia: sympathetic stimulation
Tx: acute coronary syndrome (6)
-oxygen
-325 aspirin (have them chew; so no enteric coating)
-nitroglycerin (every 5min up to 3x)
-Morphine
-Beta Blocker
-ACE inhibitor
treatment of stemi
heart cath within 90-120 minutes
Parameters for administering nitroglycerin
SBP > 90 mmHg
Pulse > 50
_________ decrease myocardial oxygen demand by decreasing heart rate, contractibility, and BP
Beta-blockers
___________ are generally given after repercussion therapy because they reduce infarct size and improve ventricular remodeling
ACE inhibitors
Normal Sinus
Sinus Brady
Sinus Tachycardia
Sinus Dysrhythmia (arrhythmia)
Premature Atrial Contraction (PAC)
Premature ventricular contraction (PVC)
Atrial Fibrillation
Atrial Flutter
Ventricular Fibrilation
Ventricular Tachycardia
Supraventricular Tachycardia (SVT)
1st degree heart block
3rd degree heart block
therapeutic interventions for SVT (4)
-vagal maneuver
-adenosine (drug of choice)
-diltiazem or beta blocker
-cardioversion
what should be ready when administering adenosine and why?
crash cart, asystole occurs after administration
collection of air in the pleural space
pneumothorax
occurs when air accumulates in the pleural space to the point of causing a mediastinal shift pushing the heart, great vessels, trachea, and lungs toward the unaffected side of the thoracic cavity
tention pneumothorax
collection of blood in the pleural cavity
hemothorax
excessive fluid in the pleura cavity
pleural effusion
collection of purulent material from an infection like pneumonia
empyema
4 common causes of air/fluid in the pleural space (need for a chest tube)
trauma
medical/surgical complications
infectious disease
cardiovascular problems
risk associated w/ chest tubes (5)
risk for infection
subcutaneous emphysema
lung trauma/perforation of diaphragm
bronchopleural fistula
malposition
what do you do when the chest tube becomes disconnected from the patient
Cover the whole with jellied gauze, taping 3 sides
If in the field, cover with cleanest thing nearby
what do you do when the chest tube becomes disconnected from the drainage system?
place tube end in sterile water until new system can be obtained
Which information would the nurse educator include in a presentation on how to care for clients with a chest tube drainage system? Select all that apply. One, some, or all responses may be correct.
* Ensure that chest tube dressing is tight and intact.
* Palpate the skin to detect subcutaneous emphysema.
* Place the chest tube drainage system below the chest.
* Quickly attempt to reinsert the chest tube if it falls out.
* stripped the chest tube with long strokes to promote drainage
Ensure that chest tube dressing is tight and intact.
Palpate the skin to detect subcutaneous emphysema.
Place the chest tube drainage system below the chest
Which actions will the nurse take when caring for a client with a chest tube in place after thoracotomy, select all that apply. One, some, or all responses may be correct.
* Administer prescribed analgesic medications.
* Check around chest tube insertion site for crepitus.
* Clamp the chest tube before the client ambulates.
* Add fluid to the suction control chamber as needed.
* Milk the tubing toward the collection chamber.
* Check for air bubbling in the water seal chamber.
Administer prescribed analgesic medications.
Check around chest tube insertion site for crepitus.
Add fluid to the suction control chamber as needed.
Check for air bubbling in the water seal chamber
Which finding in a client who has had a chest tube removed would be of most concern to the nurse ?
* poor cough effort.
* Pain at the chest tube site.
* Crepitus at the chest tube site.
* 2 centimeters of pink drainage on dressing
Crepitus at the chest tube site
A client with a chest tube is to be transported via a stretcher.When transporting the client, what would the nurse do?
* Keep collection device attached to mechanical suction.
* Keep chest tube clamped distal to the water seal chamber.
* Keep collection device below the level of the client’s chest.
* Keep the chest tube and covered with sterile gauze pads taped to theclient
Keep collection device below the level of the client’s chest
When a client has a chest tube placed in the second intercostal space, how will the nurse evaluate for the effectiveness of the chest tube?
* Check for bubbling in the suction control chamber.
* Measure the amount of drainage in the collection chamber.
* Inspect the amount of bubbling in the water seal chamber.
* Observe for the presence of clots in the tubing
Inspect the amount of bubbling in the water seal chamber
When caring for a client after a thoracotomy, which action would the nurse take to keep the chest tube and closed chest drainage system patent?
* Position the drainage system below the level of the client’s heart.
* Empty the collection chamber and measure contents every 12 hours.
* Assure that a daily chest X-ray is done to check chest tube position.
* Keep the client on bed rest until the chest tube is disconnected.
Position the drainage system below the level of the client’sheart.
A client anticipates removal of his or her chest tube with angst. Which diagnostic procedure does the nurse discuss when determining when to remove a client’s chest tube?
* The client tolerates disconnection from the chest tubes drainage system for 24 hours.
* A chest X-ray examination occurs before removal to determine lung re-expansion.
* A required arterial blood gas occurs to determine sustained oxygen status.
* The nurse will sedate the client 30 minutes before the scheduled procedure.
A chest X-ray examination occurs before removal to determine lung re-expansion
The client has a closed chest tube drainage systemconnected to section. Which assessment findingrequires additional evaluation by the nurse?
* A column of water 20cm high in the suction control chamber.
* 75 mL a bright red blood in the drainage collection chamber.
* An intact occlusive dressing at the insertion site.
* Constant bubbling in the water-seal chamber
Constant bubbling in the water-seal chamber
Which action would the nurse take to determine patency of the chest tube and closed chest drainage system in a client after left lower lobectomy?
* milk the chest tube toward the drainage unit.
* Check the amount of bubbling in the section control chamber.
* Observe for fluctuations of the fluid in the water seal chamber.
* Assess for extent of chest expansion in relation to breast sounds.
Observe for fluctuation of the fluid in the water seal chamber
After being notified that a client with a sucking chest wound Is being transported to the emergency department, the nurse will anticipate which initial collaborative intervention?
* Obtaining a chest X-ray.
* Notifying the on call surgeon.
* Preparing for chest tube insertion.
* Drawing blood for laboratory studies
Prepare for chest tube inertion
Which nursing action is of the highest priority when aclient’s chest tube has accidentally dislodged?
* place the client in a left side lying position.
* Apply oxygen via non rebreather mask.
* Apply a petroleum gauze dressing over the site.
* Prepare to insert a new chest tube.
Apply a petroleum gauze dressing over the site
When caring for a client who has a hemopneumothorax and a chest tube, which prescribed action by the health care provider would the nurse question?
* Auto transfuse the blood in the collection chamber after six hours
* Disconnect the drainage system from the suction to ambulate the client.
* Add sterile water to the suction control chamber to maintain the 20cm Of suction.
* Use a dressing impregnated with a petroleum Jelly around the chest tube insertion site.
Auto transfuse the blood in the collection chamber after six hours
A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and the closed chest drainage system are affective, which type of pressure will be reestablished?
* Neutral pressure in the pleural space.
* Negative pressure in the pleural space.
* Atmospheric pressure in the thoracic cavity.
* Intrapulmonary pressure in the thoracic cavity.
Negative pressure in the pleural space
While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. Which action would the nurse take?
* Place the client in the supine position.
* Spread a clamp in the insertion site to hold the site open.
* Obtain a sterile Vaseline gauze to cover the opening.
* Cover the opening with the cleanest material available.
Cover the opening with the cleanest material available.
After a change of shift report, which client would the nurse assess first?
* Client with possible lung cancer who has just returned from the nursing unit after mediastinoscopy
* Client with cough whose chest X-ray shows possible active tuberculosis and needs sputum testing.
* Client who has pneumococcal pneumonia and very decreased breath sounds in the right lung base.
* Client who has a chest tube with rapid bubbling in the suction controlChamber of the drainage system.
Client with possible lung cancer who has just returnedfrom the nursing unit after mediastinoscopy
Ventilator mode that allows for a minimum # of preset mandatory breaths delivered by the vent but does NOT allow for spontaneous breaths
Assist/Control mode
Complication from A/C mode
hyperventilation -> respiratory alkalosis
Ventilator mode that allows for preset minimum # of breaths and ALLOWS patient to initiate spontaneous breaths in-between mandatory ones
Synchronous Intermittent Mandatory Ventilation (SIMV) mode
When should A/C vs SIMV mode be used
-A/C should be used for pts who need full ventilatory support
-SIMV should be used for pts who need partial ventilatory support or are weaning off vent
advantages of SIMV mode (3)
-helps maintain respiratory muscle strength avoiding atrophy of respiratory muscles
-distributes tidal volume throughout the lung fields evenly
-helps to decrease mean airway pressure
vent mode that allows pressure above atmospheric pressure to be maintained throughout the breath cycle
CPAP
vent mode that allows spontaneous breaths supported by the vent during inspiratory breathing phase
Pressure Support Ventilation (PSV)
vent mode that delivers a supported breath to reach a set tidal volume
volume support
FiO2 > __________ for a prolonged time increase risk of oxygen toxicity
60%
Flow rate too low can cause: (2)
-patient-ventilator dyssnchrony
-increase work of breathing
Side effects of PEEP (5)
decreased systolic blood pressure
decreased cardiac output
decreased venous return to heart
barotrauma
increased ICP
Nursing care during intubation (5)
-assist with set-up
-administer medications
-monitor vs
-documentation
-family/patient education
what is needed in intubation set-up (3)
intubation box/cart
suction
Ambu-bag
intervention measures to clear airway (4)
suctioning
CPT
position changes
promote mobility
how to prevent ventilation association pneumonia (VAP) (5)
-HOB up 30-45 degrees
-oral care every 2 hours
-Closed suction device
-humidified oxygen
-in-line metered dose inhaler administration
Ventilator bundle (6)
-oral care every 2 hours
-HOB elevated at least 30 degrees
-daily sedation holiday/interruption
-daily assessment for extubation/weaning
-GI prophylaxis
-DVT prophylaxis
Vent bundle GI prophylaxis includes (2)
H2 blocker (Pepcid)
PPI (Protonix, Prilosec, or Nexium)
Vent bundle DVT prophylaxis inlcludes (2)
-anticoagulation (heparin, lovenox)
-SCDs
Complications of mechanical ventilation (6)
-barotrauma/volutrauma
-hemodynamic instability
-Ventilator associated pneumonia (VAP)
-aspiration
-immobilization
-anxiety/pain/delirium
Post extubation nursing bedside swallow screening procedures (4)
-patient must be alert and able to sit upright
-position patient at 90 deg with head in neutral position
-instruct patient to drink 3ox water w/o interruption
-watch for s/s of aspiration up to 1 min after water drank
if patient fails swallow screen: (2)
NPO
Speech consult
consequences of pain (8)
-inadequate sleep
-anxiety
-increases stress response
-prevents and slows rest/healing
-tachycardia
-hypertension
-hypoxia
-linked to patient death
Scales to assess pain (3)
-self report
-behavioral pain scale (BPS)
-Critical Care Pain Observation Tool (CPOT)
non-pharmacological interventions for pain (7)
-ET section/repositioning
-Reposition patient in bed
-Oral care
-Reassurance/family presence
-heat/cold therapy
-massage, acupuncture, relaxation
-muscle, low lights, room temp
Pharmacological pain management (2)
-continuous pain management
-breakthrough pain management
Most common medications for pain management (6)
-hydromorphone
-morphine
-fentanyl
-methadone
-oxycodone
-hydrocodone
scales to assess agitation
RASS
Ramsay SAS
Riker SAS
goal is to reach a quality of sedation where patients are:
cooperative
comfortable
accepting of care
Sedative medications (5)
Dexmedetomidine (presidex)
Lorazepam
Propofol
Midazolam
Barbituates
Role of RN with sedation management (6)
Daily sedation holiday
educate family
skin management
DVT prophylaxis
pain control
assessment
Equipment needed for conscious sedation (7)
intravenous access
monitoring equipment (pulse, BP, rhythm)
Emergency cart w/ defibrillator & medications
Suction equipment
Ambu bag
Supplemental oxygen
appropriate artificial airways
monitor that measures and displays end tidal carbon dioxide
capnograph monitor
daily planned discontinuation of paralytics and/or sedation in order to do neurological assessment of paient
Sedation holiday
syndrome characterized by the acute onset of cerebral dysfunction with a change or fluctuation in baseline mental status, inattention, and either disorganized thinking or an altered level of consciousness
delirium
impact of delirium (4)
-increased mortality
-increased length of stay
-increased cost of care
-long-term cognition impairment
assessment tools for delirium (2)
Confusion assessment method of the ICU (CAM-ICU)
Intensive Care Delirium Screening Checklist (ICDSC)
3 subtypes of delirium
-Hyperactive
-Hypoactive
-Mixed
characteristics of hyperactive delirium (3)
Combative
Agitated
Restless
characteristics of hypoactive delirium (3)
-lethargic
-Sedated
-Stupor
Management of delirium (6)
-treat the cause of the delirium
-mobilize the patient if possible
-provide sleep enhancement
-antipsychotic such as haloperidol
-manage withdrawal symptoms
-family involvement
Goal of neuromuscular blockage (4)
decrease:
-oxygen consumption
-total body work
-pain and anxiety
-temeprature
golden rule of sedation/paralytic
never start a neuromuscular blockade without sedation
Common paralytics (3)
Norcuron (vecuronium)
Pavulon (pancuronium)
Rocuronium
classification of post complications (3)
immediate: within 24 hrs of procedure
early: occurs as inpatient or within 30 days of procedure
late: occurs following discharge of >30 days of procedure
amount of blood pumped by ventricle in liters per minute
cardiac output
percent of end diastolic volume ejected with each heart beat (left ventricle)
ejection fraction
amount of blood ejected with each heartbeat
stroke volume
3 components of stroke volume
preload
afterload
contractility
degree of stretch of cardiac muscle fibers at end of diastole
preload
resistance to ejection of blood from ventricles
afterload
ability of cardiac muscle to shorten in response to electrical impulse
contractility
cardiac output formula
heart rate x stroke volume = cardiac output
normal cardiac output:
4-8 L/min
cardiac output correction method accounting for body surface area (CO/BSA)
cardiac index
normal cardiac index
2.5-4 L/min/m2
direct measurement of blood pressure in the right atrium and vena cava
central venous pressure
normal central venous pressure
2-6 mmHg
indications for central venous access (7)
-need to rapid fluid infusion
-IV fluid requiring CVC
-Frequent blood draws
-Chronically ill/unable to obtain peripheral access
-CVP monitoring
-SvO2 monitoring
-Administration of several IV medications/vasoactive/incompatible meds
contraindications for central line (2)
recurrent sepsis
hypercoagulable state
normal MAP ranges from
70-90 mm
MAP formula
(Systolic + (2x diastolic)) / 3
isotonic fluids given to
increase intravascular volume
isotonic fluids (3)
0.9% sodium chloride (normal saline)
Lactated ringers (LR)
Dextrose 5% in water (DSW)
Hypotonic Fluids (3)
Quarter (0.225%) normal saline
Half (0.45%) normal saline
Dextrose 5% in water (D5W)
hypotonic fluid indications
hyper- states (hypernatremia, DKA)
hypertonic fluid indications
Hypo-states (hypovolemia, hyponatremia)
Dexmedetomidine (presidex) side effects (4)
hypotension
bradycardia
sinus arest
AFib
Dexmedetomidine (presidex) nursing implications (2)
continuous vital sign, telemetry, & fluid balance monitoring
assess sedation w/ sedation scale
Dexmedetomidine (presidex) expected outcomes
sedation & decreased need for additional analgesia medication
Dexmedetomidine (presidex) teaching (5)
report agitation, confusion, weakness, abdominal pain, & changes in bowel movements
Digoxin expected outcomes (2)
slow heart rate
increase cardiac output
Digoxin side effects (5)
dizziness
fatigue
headache
weakness
blurred vision
Digoxin nursing implications (4)
monitor apical pulse and hold if <60 bpm
Monitor BP and heart rhythm
Monitor I&O, edema, lung sounds for fluid overload
Monitor potassium, calcium, and magnesium
Digoxin teaching (3)
How to take pulse and hold if <60bpm
Don’t double dose
Report s/s of toxicity
Digoxin toxicity s/s (3)
-GI distress
-visual disturbances
-arrhythmais
Fentynal expected outcome
decrease moderate-severe pain
Fentynal s/s (5)
confusion/sedation
weakness
constipation
apnea
respiratory depression
Fentanyl nursing implications (3)
-baseline assessment of vitals, pain, and respiratory status before and after giving
-remove old patches before placing new ones
-if overdose occurs, removing patch will not immediately reverse effects
Fentanyl education (3)
-avoid alcohol consumption
-constipation, over sedation, and dependency risks
-change positions carefully & avoid driving
Heparin action/expected outcome
prevention/treatment of thrombi emboli and DIC
Heparin side effects (4)
hematuria
hemorrhage
prolonged coagulation time
tarry stools
heparin nursing indications (3)
-obtain PTT and anti-Xa labs prior to & designated interbals
-assess for s/s of bleeding
-rotate subq sites
heparin antidote
protamine sulfate
heparin teaching (4)
-report s/s of bleeding
-n/v of blood
-dark tary stools
-report bruising or bleeding from gums
Ipratropium action
maintenance therapy of reversible airway obstruction through bronchodilator or reduction in rhinorrhea
ipratropium side effects (6)
dizziness
nervousness
blurred vision
bronchospasm
cough
hypotension
Ipratropium nursing indications (4)
assess respiratory status before & at peak
have patient rinse mouth after use
assess oral cavity for stomatitis
intranasal: avoid inhalation during administration
Ipratropium education (2)
rinse mouth after use (inhalation)
don’t inhale medication (intranasal)
Lorazepam action (3)
CNS depressant decreases anxiety, improves sleep, and decreases seizure activity
Lorazepam side effects (5)
dizziness
drowsiness/lethargy
confusion
hepatic dysfunction
respiratory depression
Lorazepam nursing interventions (5)
-Assess geriatric patients carefully for CNS reaction
-Assess fall risk
-Monitor renal, hepatic, and hematologic function
-Monitor VS for hypotension
-Verify patient is not pregnant
Lorazepam education (3)
-Used for short-term therapy
-Avoid driving until response to medication is known
-Taper off when stopping
Morphine/Dilaudid action
relief of moderate to sever pain
Morphine is the analgesic of choice for (2)
MI pain
Acute pulmonary edema associated w/ left ventricle failure
Morphine/Dilaudid side effects (5)
respiratory depression
anxiety
bradycardia
constipation
urinary retention
Morphine/Dilaudid nursing implications (2)
Frequent VS & pain assessment before and after
Have oxygen, respiratory equipment, and antidote available
dilaudid/morphine teaching (3)
avoid alcohol
educate about constipation, over sedation, and dependency risks
change positions carefully and avoid driving
Nitroglycerin action
increases coronary blood flow to relieve or prevent angina pain and reduce BP
Nitroglycerin side effects (5)
Dizziness
headache
hypotention
tachycardia
nausea
Nitrolgycerin nursing interventions (3)
-Monitor BP, HR, & telemetry
-have patient sit or lie down before giving med
-notify PCP if patient is taking erectile
dysfunction medication
Nitroglycerin education (3)
sit down before taking
avoid alcohol
change positions slowly
propanolol action
decreases heart rate & BP
arrhythmia suppression
MI prevention
propranolol side effects (6)
fatigue/weakness
bradycardia
pulmonary edema
hyper/hypoglycemia
bronchospasm
orthostatic hypotension
propranolol nursing implications (4)
hold if SBP <100
Monitor telemetry, I/O, edema, & lung sounds
monitor renal function and potassium levels
monitor blood glucose
propranolol education (3)
check pulse daily & BP bi-weekly
take at same time each day
taper off medication when stopping
Vecuronium Bromide action
paralysis
Vecuronium Bromide side effects (6)
muscle weakness
respiratory insufficiency
apnea
bronchospams
hypotension
tachycardia
Vecuronium Bromide nursing implications (3)
assess patient response using nerve stimulator
monitor vital signs
promote frequent ROM & repositioning
Vecuronium Bromide education
use of paralytic during ET intubation and mechanical ventilation
normal pH
7.35
normal PaCo2
35-45
normal HCO2
22-26
pH high; PCO2 is low
respiratory alkalosis
pH low; PCO2 is high
Respiratory acidosis
pH high; HCO3 high
metabolic alkalosis
pH low; HCO3 low
metabolic acidosis
ABG: uncompensated
if respiratory: HCO3 is normal
if metabolic: PCO2 is normal
ABG: partially compensated
nothing is normal
ABG: compensated
pH is normal
