Exam 2: week 5 & 6 Flashcards
1
Q
A patient has chest pain when they lie down. This can be indicative of what
A
esophagitis
2
Q
A patient has chest pain due to trauma. This can be indicative of what
A
- chest contusion
- rib fractures
- pneumothorax
3
Q
A patient has chest pain with activity. This can be indicative of what
A
angina
4
Q
What are the unmodifiable risk factors of coronary artery disease
A
- age
- genetics
- race
- sex
5
Q
What are the modifiable risk factors of coronary artery disease
A
- smoking
- high cholesterol
- hypertension
- sedentary lifestyle
- obesity
- diabetes
6
Q
When a patient comes in with chest pain, which symptoms would lead you to believe they are having an MI
A
- N/V
- diaphoresis
- SOB
- syncope
7
Q
When a patient comes in with chest pain, which symptoms would lead you to believe they have a PE
A
- SOB
- apprehension
- hemoptysis (coughing up blood)
8
Q
When a patient comes in with chest pain, which symptoms would lead you to believe they have pneumonia
A
- fever
- cough
- sputum change
9
Q
When a patient comes in with chest pain, which symptoms would lead you to believe they have pericarditis
A
If they also have an autoimmune disease
10
Q
When a patient comes in with chest pain, which symptoms would lead you to believe they have cholecystitis
A
Right sided chest pain that radiates to the right shoulder and upper back
11
Q
When a patient comes in with chest pain, which symptoms would lead you to believe they have a peptic ulcer
A
blood in emesis
12
Q
When a patient comes in with chest pain, which symptoms would lead you to believe they have pancreatitis
A
excruciating, constant left upper quadrant pain radiating to chest, shoulder, and arm. Also associated with hypertension
13
Q
When a patient comes in with chest pain, which symptoms would lead you to believe they have herpes zoster (Shingles)
A
unilateral burning, pruritic (itching), or stabbing pain in one dermatome (area of skin innervated by one specific nerve section)
This can be without the presence of a rash because the rash appears several days after the pain begins
14
Q
When a patient comes in with chest pain, which symptoms would lead you to believe they have arthritis of the spine
A
pain with ROM
15
Q
What is ischemia
A
lack of blood flow to the tissue
16
Q
What is infarction
A
Death of tissue due to complete loss of blood flow
17
Q
What does this show
A
Myocardial ischemia
(due to inverted T wave when everything else looks normal)
18
Q
What does this show
A
Myocardial injury
More than ischemia but not quite infarction
(due to the elevation of the S wave but still normal Q wave)
19
Q
What does this show
A
Myocardial infarction
(due to the dip in the Q wave, elevation of the S wave, and inversion of the T wave)
20
Q
What are some atypical symptoms that women have that can mean they are having an MI
A
- nausea
- vomiting
- dyspnea
- fatigue
- neck pain
- abnormal pain location
(will still have chest pain)
21
Q
What is the acronym used for chest pain evaluation
A
OPQRST
O - onset
P - precipitating factors
Q - quality
R - region/radiation
S - severity
T - time
also ask about relieving factors, aggravating factors, and associated symptoms like you do in all pain assessments
22
Q
What are the different types of angina
A
- stable
- unstable
- variant
- silent ischemia
23
Q
What is stable angina
A
typical chest pain caused by exercise
pain relieved with rest and nitro
24
Q
What is unstable angina
A
Change in pattern and more severe
pain wakes you up
need more nitro than usual
25
What is variant angina
Pain at rest at the same time every day
exacerbated by smoking, drinking, or doing cocaine
ST segment elevation
26
What is silent ischemia
No chest pain
EKG evidence of ischemia
Type II diabetics are vulnerable to this
- may take nausea and diaphoresis as sugar imbalance
- neuropathy causes them to not feel the chest pain
27
As a nurse, what do you do for someone experiencing stable angina
- educate about nitro use
- identify aggravating and relieving factors
- educate them on when to call 911
28
As a nurse, what do you do for someone experiencing unstable angina
- may need more nitro
- educate one when to call 911 (pain lasting more than 5 minutes)
- instruct patient to take one regular aspirin (if not taken already that day)
29
What is used to diagnose an acute MI
- EKG
- patient symptoms
- Biomarkers (myoglobin, creatine kinase, and troponin)
- if they come to the ED immediately, the biomarkers may not be elevated yet, so EKG and symptoms are used to diagnose
30
How long after an acute MI does myoglobin elevate and return to normal
elevates - 1 hour post MI
peaks - 4-12 hours
returns - immediately (after peak)
31
How long after an acute MI does creatine kinase (CK-MB) elevate and return to normal
elevates - 4-8 hours
peaks - 24 hours
returns - 2-3 days
32
How long after an acute MI does Troponin elevate and return to normal
Troponin has two types- Tn1 and TnT
elevates - 3 hours (both)
peaks - 24 hours (Tn1) 12-48 hours (TnT)
returns - 5-10 days (Tn1) 5-14 days (TnT)
33
What are the branches of the right coronary artery and where do they supply blood to the heart
marginal branch - R atrium and R ventricle
posterior descending branch - walls of both ventricles
RCA feeds - SA node and AV node (not in everyone but dont need to know percentages)
34
What are the branches of the left coronary artery and where do they supply blood to the heart
Left anterior descending (LAD) - anterior/lateral wall of left ventricle
Circumflex - posterior/lateral wall of left ventricle
35
What is the most dangerous type of heart attack
Anterior wall MI
- blockage of the LAD
- affects left ventricle
- affects anterior portion of heart
- leads V2-V4
36
What is a lateral MI
Circumflex artery infarct
- left lateral leads (I, aVL, V5, V6)
- usually accompanies anterior or inferior MI
37
What is an inferior wall MI
Right coronary artery (RCA) infarct
- leads II, III, AvF
- can lead to R ventricle failure or bundle branch block
38
A patient comes in with chest pain. What are going to do immediately
- take vitals
- 12-lead ECG
- Cardiac monitor set up
- start 1-2 IVs
- draw blood
- chest X-ray
39
ECG, blood, and chest X ray show that the patient is having an MI. What are you going to do immediately
Give in this order
- Aspirin (160-325 mg chew and swallow)
- Oxygen (4L)
- Nitro (sublingual or IV)
- Morphine (2-4 mg every 5-10 min PRN)
40
What are the two types of therapies for STEMI or bundle branch blocks
Adjunctive
Reperfusion
41
What is adjunctive therapy
- beta blockers
- ACE inhibitors
- Glycoprotein inhibitors
- heparin
42
What is reperfusion therapy
- fibrinolytic therapy
- percutaneous coronary intervention (PCI)
43
What is PCI
percutaneous coronary intervention
- angioplasty with or without a stent
- first choice if cardiogenic shock is present
44
What is fibrinolytic therapy and when would you use this over PCI
Drugs that dissolve fibrin bonds by converting plasminogen to plasmin
Use these over PCI if:
- onset of symptoms <12 hours ago
- ST elevation > or = to 1 mm in two consecutive leads
- no contraindications
- patient is < 75 years old
45
What are some drug classes for treating an MI
- fibrinolytics (door to drug in <30 minutes)
- anticoagulants
- antiplatelets
46
How do you assess for reperfusion in a patient receiving drug therapy for MI
- reperfusion dysrhythmias
- ST segment normalization
47
What are some major complications that can occur with PCI
- Acute closure/reocclusion of stent
- groin hematoma
- retroperitoneal hematoma (low back pain)
48
What is therapeutic hypothermia
A technique applied to patients who are going through cardiac arrest
- reduces the body's need for oxygen
- lower temp to 32-34 degrees
- improves mortality and neurological function
49
What is wolff-parkinson white syndrome
When the electrical signals in the heart bypass the SA node.
50
What is a bundle branch block
A conduction delay within the ventricles
- QRS is > 0.12
51
What are the different levels of sedation
- minimal sedation (anxiolysis)
- moderate sedation/analgesia
- deep sedation/analgesia
- general anesthesia
52
What are the characteristics of minimal sedation
(LOC, Airway, spontaneous ventilation/CV function)
LOC: Normal (conscious)
Airway: unaffected
ventilation/CV: unaffected
53
What are the characteristics of moderate sedation
(LOC, Airway, spontaneous ventilation/CV function)
LOC: respond to verbal or tactile stimuli
Airway: no intervention required
ventilation/CV: adequate/maintained
54
What are the characteristics of deep sedation
(LOC, Airway, spontaneous ventilation/CV function)
LOC: respond to painful stimuli
Airway: intervention may be required
ventilation/CV: may be inadequate/usually maintained
55
What are the characteristics of general sedation
(LOC, Airway, spontaneous ventilation/CV function)
LOC: unarousable
Airway: intervention often required
ventilation/CV: inadequate/may be impaired
56
During your assessment, what part of the history could affect sedation
patients taking benzos or opiates can affect dosing
57
What are the ASA classifications
American society of anesthesiologists
classes I-V
- how anesthesiologists classify patients and how they react to sedation
58
Who would be placed in ASA Class I
Normal healthy patient with no problems
59
Who would be placed in ASA class II
Patient with slight health problems
- well controlled HTN
- anemia
- smoker w/o respiratory disease
- well controlled diabetes
- chronic bronchitis
- age <1 or >70
- pregnancy
60
Who would be placed in ASA Class III
Patient with severe health problems
- angina
- poorly maintained HTN
- Past MI with mild/moderate symptoms
- symptomatic respiratory disease (COPD, asthma)
61
Who would be placed in ASA Class IV
patient with severe/life-threatening disease
- unstable angina
- CHF
- debilitating respiratory disease
- hepatorenal failure (needs dialysis)
62
Who would be placed in ASA Class V
A person on the brink of death who will die without the procedure
- ruptured aneurysm
- major cerebral trauma with rapidly increasing ICP
- massive PE
63
What type of sedation occurs with the use of propofol and/or ketamine
ALWAYS moderate/deep sedation
- doctors must push this
64
What are some sedatives used in sedation
- propofol (non-barb)
- versed (benzo)
- valium (benzo)
- ativan (benzo)
65
What must you give with a sedative when sedating a patient for a procedure
Pain medication (opioids)
- dilaudid
- morphine
- fentanyl
66
What kind of care is required during a procedure when the patient is sedated
Monitoring
- vitals Q 5 minutes
- continuous pulse Ox
- one nurse to monitor and one nurse to assist w/procedure
Rescue capacity
- IV access and IV fluids running
- crash cart/bag valve mask
- suction
- intubation equipment
- reversal agents
67
Which reversal agents need to be readily available for a patient under sedation
Narcan (opiate antidote)
Romazicon (benzo antidote)
68
When monitoring a patient under sedation, what are you looking for
- relaxation of facial expressions
- slurred speech
- unconsciousness
- respiratory/airway changes
- deteriorating O2 levels/ hypoxemia
- hypoventilation
- CO2 retention
- hypotension
69
What do you do if you notice a negative change in your patient under anesthesia
- stop sedation
- check level of consciousness
- maintain airway (chin lift)
- ventilate with bag mask
- reversal agents
- call anesthesia STAT
70
When can you discharge a patient after being under anesthesia
- vital signs within pre-procedure limits
- CV and airway stable
- patient is alert
- return to pre-sedation mental status
- patient returns to baseline muscle control
- observe for min of 2 hours if reversal was given
- Aldrete score >9
71
What is the Aldrete scoring system
Gives a score for the following functions:
- activity
- breathing
- consciousness
- circulation
- SpO2
score of >9 needed for discharge
72
How do you perform the sedation awakening trial
- turn off sedation once daily
- stop analgesics
- assess patient using RASS or SAS scale (agitation/sedation scales)
- assess LOC
73
What are some things we can do for a patient experiencing delirium
Drugs
- Haldol
Non-pharm (prevention)
- spontaneous awakening trials
- early mobility
- daily delirium monitoring
- sleep protocols
74
What scale do we use to screen patients who we suspect are withdrawing from alcohol
CIWA scale
- N/V
- tremor
- sweats
- anxiety
- agitation
- tactile disturbances
- auditory disturbances
- visual disturbances
- headache
- orientation/brain fog
Max score is 67
assess how much ativan to give
75
What do we give a patient to manage alcohol withdrawal symptoms
- multivitamins
- long-acting benzos (valium/ativan)
76
What are the symptoms of alcohol withdrawal
day 1: hangover symptoms
day 2: night sweats
day 3: tremors
day 4: paranoia
day 5: relief
day 6: brain fog
day 7: cravings
day 8: better sleep
77
What is something to avoid giving to patients experiencing delirium
Benzos
78
What are some abnormal breath sounds that can be heard during a respiratory exam
Fine crackles
Coarse crackles
wheeze
rhonchi (snoring/moaning sound)
pleural friction rub (surface rubbing sound)
79
What are the characteristics of a nasal cannula
- delivers 1-6 L of O2 (28-44%)
- use humidification for >2L
- can use at home
80
What are the characteristics of high flow nasal cannula
- delivers up to 100% heated and humidified O2
- up to 60 L per min
- modified nasal cannula
- uses PEEP (positive end-expiratory pressure) to open alveoli
81
What are the characteristics of a venturi mask
- delivers 40-60% O2
- most accurate
- valves based on how much O2
- used in COPD or where accurate amount of O2 is needed
- no humidification needed
82
What are the characteristics of a non-rebreather mask
- highest O2 delivery with low flow
- meter should be set to 10-15 L
- Close to 100% O2
- Fill bag with O2 before placing on patient
- bag ensures pt doesn't inhale exhaled CO2
83
When looking at blood labs, what are "segs"
Mature white blood cells in circulation
84
When looking at blood labs, what are bands
Immature white blood cells in circulation
these are ineffective at fighting infection
85
What does "shift to the left" mean when looking at blood labs
a high level of bands that form in response to an infection
86
What are the normal levels for pH, PCO2, and HCO3
pH = 7.4 (7.35-7.45)
PCO2 = 35-45
HCO3 = 22-26
87
How can we determine if the acidosis/alkalosis is metabolic or respiratory
ROME
Respiratory Opposite (pH and CO2 arrows opposite)
Metabolic Equal (pH and CO2 arrows same direction)
88
How do you determine compensation for ABGs
If HCO3 changes in order to even out the abnormal PCO2
(Met Acid = low pH, low PCO2 = low HCO3 to compensate)
89
What is a non-invasive technique to help someone who is having trouble breathing but is still conscious
BiPaP
- positive airway pressure
- keeps alveoli open
- provides different levels of pressure
90
A patient is on a BiPap and is still struggling to breathe. What do you do
Intubate and place on a mechanical ventilator
- insert an endotracheal tube
- insert orally unless unavailable
- inserting nasally has a high chance of sinus infections
- ET tubes are good for several weeks
91
What are the different types of ventilators
volume cycled
pressure cycled
92
What are the characteristics of a volume cycled ventilator
- delivers a constant volume of air every time
- most common in ICU
- all breaths positive pressure
- constant rate (respiratory rate) (12-20 breaths/min)
- constant volume (tidal volume) (based on wt)
- full assist
93
What are the characteristics of a pressure cycled ventilator
- applies small amount of pressure to encourage active breathing
- patient regulates respiratory rate
- step between volume cycled and extubation
94
What are the different settings on a ventilator
Respiratory rate
tidal volume
FiO2 (want to keep below 50%)
PEEP (between 5-10)
95
What is FiO2
It's the fraction of oxygen in the inspired air
room air = 21%
96
What do you do if the ventilator is alarming
Check the patient first
high pressure alarm = increased resistance from pt coughing, needing to be suctioned, tubing popped off
Low pressure alarm = disconnect of tubing somewhere
97
What is the weaning criteria for someone on a vent
- acceptable ABGs
- patient breathing on their own
- intact gag
- ability to cough
- ability to take a deep breath
- FiO2 < 50%
98
What is Homan's sign
Test for DVT
pain in calf on dorsiflexion is a positive sign of DVT
99
What is this
Right mid lung pneumonia
100
What is this
Left lung atelectasis
101
What is this
COVID - acute respiratory distress syndrome (ARDS)
102
Which of the pulmonary function tests are used to determine readiness to be weaned from a vent
Even more helpful if you have baseline PFT data
- tidal volume
- vital capacity
- negative inspiratory force
103
What are some symptoms of acute respiratory distress in a patient who is on a vent
- agitation
- extreme anxiety
- chest pain
- mental status change
- CV decompensation
- sweating
- change in respiratory pattern
- arrhythmias
104
What are some specific causes of acute respiratory distress in a vented patient
- right main stem intubation (hear less or no breath sounds on left)
- esophageal intubation (see abdominal distention)
- self extubation
- mucus plug
- barotrauma (pneumothorax)
- GI-bleeding (stress ulcer)
- patient-ventilator asynchrony
- failure to wean
105
What is ventilator associated pneumonia
Pneumonia caused by an infection related to poor vent care
- Considered a never event
- increases length of stay
- insurance wont cover it; hospital pays
106
What are some (non-preventable) risk factors of VAP
- being on a ventilator
- advanced age
- pre-existing lung disease
- immune suppression
- malnutrition
- NG tubes
107
How do we prevent VAP
- hand washing
- maintain HOB > 30 degrees
- oral hygiene w/chlorohexidine
- secretion management
108
What is SBAR
Communication for handoff of patients to next shift nurse
S - situation
B - background
A - Assessment
R - recommendation
