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NUR 340 > Exam 3: weeks 8, 9, & 10 > Flashcards

Exam 3: weeks 8, 9, & 10 Flashcards

1
Q

What is preload

A

The amount of blood left in the ventricles after diastole (end diastolic pressure)

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2
Q

In what conditions would we see an increase in preload

A
  • hypervolemia
  • valve regurgitation
  • heart failure
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3
Q

What is afterload

A

The resistance that the left ventricle must overcome in order to pump blood to the body

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4
Q

In what conditions would we see an increase in afterload (broad)

A
  • hypertension
  • vasoconstriction
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5
Q

What is the Frank Starling Pricipal

A

The amount of blood entering the heart during diastole is the amount of blood that will be pumped during systole

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6
Q

What is this

A

Ventricular paced rhythm

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7
Q

What is Intrinsic rate

A

The patient’s own heartbeat

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8
Q

What is extrinsic rate

A

A rate that is set by an artificial source

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9
Q

What is capture

A

When the heart responds to the pacer stimulation

There will be a P (a-paced) or QRS (v-paced) after the pacer spike

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10
Q

What is sense

A

The ability of the pacer to “see” the intrinsic activity of the heart

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11
Q

What is a trigger

A

An intrinsic event causes a stimulus to be delivered (ex. long AV delay)

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12
Q

What does is mean when the pacer is inhibited

A

An intrinsic event causes the pacer to “turn off” because some activity is seen
(ex. QRS comes faster than the pacer rate set)

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13
Q

What is asynchronous pacing

A

Fixed pacing – Set at a fixed rate, a non sensing mode. Pacer paces regardless of the intrinsic activity.

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14
Q

What is synchronous pacing

A

Pacer delivers a stimulus in response to what it senses
(fires when it needs to based on what it senses intrinsically)

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15
Q

What are the three different modes when it comes to pacemakers

A
  • Atrial pacing
  • ventricular pacing
  • Atrial/Ventricular pacing
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16
Q

What is atrial pacing

A

stimulates atria to contract

must have an intact AV node conduction system for the signal to pass to the ventricles

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17
Q

What is ventricular pacing

A

Stimulates the ventricles to contract when there is a loss of “atrial kick”

this sustains cardiac output

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18
Q

What is meant by “atrial kick”

A

When the atria contract, the electrical current is then passed to the ventricles to tell them to contract. Loss of this is usually due to a disruption in the AV node conduction system

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19
Q

What is atrial/ventricular pacing

A

Stimulates both the atria and ventricles to contract
- more like intrinsic pacing
- synchronizes atria and ventricles

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20
Q

what is this

A

atrioventricular pacing

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21
Q

what is this

A

3rd degree heart block

Assess patient
initiate transcutaneous pacing
- atropine (anticholinergic), epinephrine (alpha/beta-adrenergic agonist), or dopamine (+inotrope)
- oxygen

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22
Q

What are the three types of temporary pacing routes

A
  • transcutaneous
  • epicardial
  • transvenous
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23
Q

What is transcutaneous pacing

A

Apply the electrodes to the anterior and posterior chest (skin)
Like and AED
Very painful - give pain meds

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24
Q

What is epicardial pacing

A

Routinely done after many heart surgeries
electrodes attached to epicardium
may have both atrial and ventricular leads or just ventricular leads

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25
Q

What is transvenous pacing

A

An external pacemaker attached to the heart through the femoral artery
emergency; used as a bridge

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26
Q

What do the three letters indicate in pacemaker codes

A

1st letter - the chamber that is being paced (A,V,D)
2nd letter - which chamber is sensed (A,V,D, O)
3rd letter - the pacers response to the sensed event (I,T,D,O)

A - atrial
V - ventricular
D - dual (both)
O - none
I - inhibit
T - triggered

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27
Q

What are some common pacemaker codes

A

DDD - synchronous AV pacing (most physiologic)
VVI - synchronous V pacing (best for a-fib)
DOO - asynchronous AV pacing (emergency asystole or OR)
VOO - asynchronous V pacing (emergency asystole or OR)

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28
Q

What is failure to pace

A

The voltage isn’t high enough on the pacemaker to incite a response by the myocardium

no pacer spikes seen on EKG

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29
Q

What is failure to sense

A

The pacer isn’t sensing intrinsic beats from the heart which leads to overpacing

only relevant in synchronous pacing

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30
Q

what is failure to capture

A

When the pacer fires but doesn’t elicit a response from the myocardium

pacer spikes are seen on the EKG

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31
Q

What needs to be avoided by patients with a pacemaker

A

High voltage electrical equipment/generators

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32
Q

what is this

A

failure to pace

increase mV

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33
Q

what is this

A

failure to capture

increase mV

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34
Q

what is this

A

failure to sense

decrease mV

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35
Q

what is this

A

Normal atrial pacing; failure to sense for v pacing

decrease mV

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36
Q

what is this

A

failure to capture

increase mV

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37
Q

what is this

A

V paced; oversensing (tachycardia)

increase mV

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38
Q

What is an ICD

A

Implantable cardioverter defibrillator

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39
Q

How does an ICD work

A
  • paces the heart when in V tach (synchronous)
  • if V tach continues, gives multiple low energy shocks (cardioversion)
  • when in V fib, sends high energy shock that feels like a “kick in the chest” (defibrillator)
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40
Q

What are the two types of valvular disease

A
  • stenosis
  • insufficiency
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41
Q

What is valvular stenosis

A

When the aortic or mitral valve become stiff and hard to open or close

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42
Q

What is valvular insufficiency

A

When the aortic or mitral valve don’t close all the way which leads to regurgitation

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43
Q

What causes valvular stenosis

A
  • rheumatic heart disease/fever (aortic and mitral)
  • calcification with age (aortic)
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44
Q

What causes valvular insufficiency

A
  • rheumatic heart disease/fever (both)
  • left ventricle dilation (mitral)
  • aneurysm of ascending aorta (aortic)
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45
Q

What is cardiopulmonary bypass

A

Used for open heart surgery

sends blood to a machine to be oxygenated instead of the lungs and then pumps it to the heart and the rest of the body

core body temperature is lowered in order to decrease the body’s need for oxygen

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46
Q

What is a carotid endarterectomy

A

Done when the carotid artery is stenosed and occluded by 70-90%

The carotid is cut open and the occlusion is scraped off the walls and removed. Then the artery is sewn back up

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47
Q

What are some post operative measures we take as nurses for a patient who underwent a carotid endarterectomy

A

Control blood pressure - don’t want the stitches to burst

Assess cranial nerves VII, X, XI, XII - facial, gag, shoulder muscles, swallowing

Assess for bleeding - neck size (burst stitches), swelling (possible hematoma)

Difficulty swallowing/breathing - airway (could be due to cranial nerves or bleeding)

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48
Q

What is an intraaortic balloon pump

A

Used in heart failure when other methods don’t work or as a bridge from surgery to recovery

balloon pump inserted into aorta from the groin to decrease myocardial workload and ensure perfusion to vital organs

balloon deflates during systole to decrease afterload and inflates during diastole to increase blood flow to carotid arteries

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49
Q

What is stroke volume

A

The volume of blood the heart is pumping with each beat

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50
Q

How do you calculate stroke volume

A

end diastolic volume - end systolic volume

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51
Q

What are some ways to increase preload

A
  • give fluids
  • increase bp (vasoconstrictors)
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52
Q

what are some ways to decrease preload

A
  • diuretics
  • vasodilators
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53
Q

What are the levels of bedside hemodynamic monitoring from least invasive to most invasive

A

non-invasive monitoring - leads hooked to patient sent to bedside monitor

CVP/arterial monitoring - inserted through wrist/groin to heart

pulmonary artery monitoring - Swan Ganz catheter in neck to heart

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54
Q

What is intraarterial BP monitoring

A

catheter is inserted in the radial artery (or femoral artery) and is used to monitor blood pressure

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55
Q

How do you set up an arterial line for BP monitoring

A
  • Remove the air from the IV saline bag
  • Place IV bag in a pressure bag
  • connect to transducer
  • insert in radial artery
  • zero the line at the phlebostatic axis
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56
Q

What is the phlebostatic axis

A

level with the atria; when lying flat, midaxillary
4th intercostal space

the point where you zero both an arterial line and a central venous pressure line

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57
Q

What test must be done before inserting an arterial line

A

Modified Allen’s test
- have patient make a fist
- occlude both radial and ulnar artery
- release ulnar artery and see if hand reperfuses

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57
Q

What is the phlebostatic axis

A

level with the atria; when lying flat, midaxillary
4th intercostal space

the point where you zero both an arterial line and a central venous pressure line

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57
Q

What is central venous pressure monitoring

A

A central line inserted, using sterile technique, through the internal jugular vein and into the superior vena cava that measures a patient’s fluid status

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58
Q

How do you set up CVP monitoring

A

Make sure dressing is clean and intact and zero is at the phlebostatic axis

be sure you have a good waveform

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59
Q

What is the range for a normal CVP reading

A

2-5 mmHg
<2 = hypovolemia
>5 = hypervolemia

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60
Q

What are some complications that can arise with CVP monitoring

A
  • infection
  • air embolism
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61
Q

What is pulmonary artery pressure monitoring

A

Using a Swan Ganz catheter, insert into the pulmonary artery from the right ventricle to measure pulmonary capillary wedge pressure (PAWP/PAOP)

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62
Q

When would you use pulmonary artery pressure monitoring

A

for patients with:
- cardiac output issues
- shock (hypovolemic, cardiogenic, or septic)
- multisystem failure
- Acute respiratory distress syndrome

63
Q

How do you know when the Swan Ganz catheter is in the pulmonary artery

A

When the waveform measures tall, even peaks between 10-25 mmHg

64
Q

What are some non-invasive ways to monitor cardiac output

A
  • Echocardiogram
  • Transesophageal echocardiogram (TEE)
  • Passive leg raises
65
Q

What are the signs and symptoms of increased afterload

A
  • crackles
  • pulmonary congestion
  • dyspnea
  • Low O2 saturation
  • mental status changes
66
Q

What is an LVAD

A

Left ventricular assistive device

implanted device with an external box that helps the left ventricle pump blood to the body

bridge between heart failure and transplant

67
Q

What is ejection fraction

A

How much blood is being pumped from the left ventricle to the body

68
Q

How do you calculate EF

A

stroke volume / end diastolic volume

69
Q

What does EF<40% mean

A

Heart failure or cardiomyopathy

70
Q

What is systolic heart failure

A

heart failure with a reduced EF
HFrEF (<50%)

71
Q

What is diastolic heart failure

A

heart failure with a preserved EF
HFpEF (50-70%)

72
Q

What does it mean if someone has an EF > 70%

A

Left ventricle stenosis

73
Q

What are some things that can cause heart failure

A
  • faulty valves
  • arrhythmias
  • MI/CAD
  • genetics
  • uncontrolled HTN
  • recreational drugs
  • infections
74
Q

What are the symptoms of left sided heart failure

A

D - dyspnea
R - rales
O - orthopnea
W - weakness
N - nocturnal paroxysmal dyspnea (SOB that wakes
you up at night)
I - increased HR and volume
N - Nagging cough
G - gaining weight

75
Q

What are some common causes of right sided heart failure

A
  • left sided heart failure
  • COPD
  • Pulmonary HTN
76
Q

What are the symptoms of Right sided heart failure

A

S - swelling in legs
W - weight gain (2 lbs a day or 5 lbs a week)
E - edema
L - large neck veins (JVD)
L - lethargy
I - irregular HR (a-fib)
N - nocturia
G - girth (ascites)

77
Q

What is the major sign of pulmonary edema

A

pink, frothy sputum

78
Q

What is pulmonary edema

A

Capillary fluid moves into alveoli caused by damage to the left ventricle (L sided HF)

79
Q

How do we treat pulmonary edema

A

Reduce preload and afterload
- diuretics
- digitalis
- morphine (not only for pain but also reduces RR)
- non-invasive mechanical ventilation (CPaP or BiPaP)
- invasive mechanical ventilation if it progresses

80
Q

What is cardiogenic shock

A

When the heart fails to pump enough blood to the body

81
Q

what are the most common causes of cardiogenic shock

A
  • MI
  • arrhythmias
  • valve defects
  • ventricular aneurysm
82
Q

What are the signs and symptoms of cardiogenic shock

A
  • S3 heart sound
  • JVD
  • decreased MAP
  • weak pulse
  • pale skin
  • cool hands and feet
  • decreased urine output
83
Q

What are the New York Heart Association functional classifications

A

During a stress test:
I - no limitations; no symptoms with normal activity
II - slight limitations; slight symptoms with normal activity
III - limitations; symptoms with less than ordinary activity
IV - symptoms at rest

84
Q

What type of treatment do we give to a patient in stage I of the NYHA functional classification during a nuclear stress test

A

Preventative treatment

85
Q

What type of treatment do we give to a patient in stage II of the NYHA functional classification during a nuclear stress test

A

Prescribe ACE inhibitors and Beta blockers

86
Q

What type of treatment do we give to a patient in stage III of the NYHA functional classification during a nuclear stress test

A

prescribe diuretics, digitalis, and dietary salt restriction

87
Q

What type of treatment do we give to a patient in stage IV of the NYHA functional classification during a nuclear stress test

A

continuous IV inotropic support

88
Q

What labs do we test for heart failure

A
  • K
  • BUN
  • Cr
  • BNP
  • Troponin
  • Digoxin levels (if on digoxin)
89
Q

What are the major drugs that we give patients for heart failure

A

Always Administer Drugs Before A Ventricle Dies
A - ACE inhibitors
A - ARBS (if can’t have ACE)
D - Diuretics
B - Beta blockers
A - Anticoagulants (some, not all)
V - Vasodilators (if can’t have ACE or ARB)
D - Digoxin

90
Q

What is digitalis

A

Digoxin
positive inotropic drug that lowers heart rate and allows more time for ventricular filling

91
Q

What does “positive inotropic” mean

A

Allows the heart to pump more blood with each beat by strengthening contraction

92
Q

What do you need to watch for when giving a patient an ACE inhibitor

A
  • K levels (increase)
  • Na levels (decrease)
  • dry cough
  • angioedema
93
Q

What can you give to a patient who had complications with an ACE inhibitor

A

Angiotensin II receptor blocker (ARBs)
- vasodilator just like ACE
- no nagging cough
- no angioedema

94
Q

What must you avoid if taking a beta blocker

A

Grapefruit juice

95
Q

Patient with Diabetes taking a beta blocker must be aware of what

A

symptoms could mask hypoglycemia

96
Q

When would you give a heart failure patient an anticoagulant

A

If they have: (blood can pool causing clots)
- a-fib
- Hx of clots (PE, DVT)
- decreased EF

97
Q

What are the signs and symptoms of digoxin toxicity

A
  • Seeing a halo around lights
  • N/V
98
Q

How do you administer digoxin

A

IVP over 5 minutes
Hold if HR < 60

99
Q

What is the antidote given when a patient is in digoxin toxicity

A

Digibon

100
Q

What is dobutamine

A

Positive inotrope like digoxin but works much faster
Digoxin works:
- oral = few days
- IVP = 24 hours

101
Q

What is CRT

A

Cardiac resynchronization therapy
used for patient with HF that have conduction issues
reduces symptoms and improves mortality

102
Q

What is Takotsubo

A

Broken heart syndrome
cardiomyopathy caused by ballooning of left ventricular apex during systole

103
Q

What are the two types of cardiomyopathy

A
  • hypertrophic
  • dilated
104
Q

What is hypertrophic cardiomyopathy

A

Genetic obstruction due to the hypertrophy of the ventricle walls. This doesn’t allow enough blood to fill the ventricles and leads to cardiogenic shock

normal EF but low volume

young, healthy athletes are dying from this

105
Q

What is dilated cardiomyopathy

A

Dilation of the ventricles allowing more blood to fill but too weak to pump it all out to the body

106
Q

What causes cardiomyopathy

A
  • genetics (hypertrophic)
  • hypertension (dilated)
  • Ischemia due to repeated MI (dilated)
  • unknown (dilated)
107
Q

What are some complications of hypertrophic cardiomyopathy

A

myocardium needs more oxygen but the ventricles pump less blood

papillary muscle rupture

108
Q

What is the physiology of the S3 heart sound

A

Extra filling after diastole (S2)
signifies an overloaded ventricle
can be physiologic in children; pathologic in adults

109
Q

When will you hear a heart murmur

A

With stenotic or insufficient valves

110
Q

How do we grade the intensity of a heart murmur

A

grade 1 - audible with good stethoscope in quiet room
grade 2 - quiet but readily audible with stethoscope
grade 3 - easily heard with stethoscope
grade 4 - loud and obvious with palpable thrill
grade 5 - very loud heard over pericardium
grade 6 - very loud, heard with stethoscope off chest

111
Q

What are the signs and symptoms of mitral valve insufficiency

A
  • may be asymptomatic for years
  • fatigue
  • dyspnea on exertion
  • palpitations
  • angina
  • S3 (with late stage HF)
  • may also have CAD
112
Q

What is the modified Duke criteria for endocarditis

A

Definitive diagnosis: 2 major criteria OR 1 major and 3 minor criteria OR 5 minor criteria

Possible Diagnosis: 1 major and 1 minor criteria OR 3 minor criteria

113
Q

What are the major criteria for the modified Duke criteria for endocarditis

A

BE

B - blood cultures (+ for bacteria >2 times 12 hours apart)
E - echocardiogram (+ for lesions on endocardium)

114
Q

What are the minor criteria for the modified Duke criteria for endocarditis

A

TIMER

T - Temperature > 38 C (fever)
I - immunological symptoms (osler nodes. janeway lesions, roth spots)
M - microbiological (+ blood cultures that don’t meet major criteria)
E - emboli (petechiae on eyelids, painless skin lesions)
R - risk factors (IV drug use, congenital heart issues)

115
Q

What causes endocarditis

A
  • bacterial infections due to surgical procedures
  • bacterial infections due to dental procedures
116
Q

What is acute respiratory distress syndrome

A

When humoral mediators attack not only the infectious agent, but the lung itself. They break down the alveoli/capillary membrane letting fluid into the alveoli and making them collapse and making it hard to breathe.

117
Q

What are the four criteria for diagnosis ARDS

A

Timing - sudden onset
X-ray - shows effect in both lungs
Heart failure ruled out
pO2 in blood:FiO2 received

118
Q

What are some common causes of ARDS

A

Direct lung injury
- pneumonia
- aspiration of gastric juices
Indirect lung injury
- sepsis
- trauma w/shock and multiple blood transfusions

119
Q

What are the three phases of ARDS

A

Exudative phase - 24 hours after initial attack
Proliferative phase - 7-10 days
Fibrotic phase - 2-3 weeks

120
Q

What is happening in the exudative phase of ARDS

A

24 hours after injury
humoral mediators damage alveolar/capillary membrane and damage surfactant cells that keep alveoli open allowing fluid to fill alveoli and collapse (atelectasis) and pulmonary edema.

INITIALLY, CXR looks clear, breathing is rapid, pO2/SpO2 normal, and ABGs indicate respiratory alkalosis

SUDDENLY, CXR shows infiltrates in both lungs, breathing slows due to exhaustion, ABGs indicate respiratory acidosis, pO2/SpO2 drops significantly, and refractory hypoxemia occurs (giving supplemental O2 doesn’t bring up SpO2)

121
Q

What is happening during the proliferative phase of ARDS

A

7-10 days after injury

body tries to repair structures
lung tissues are dense and fibrous causing stiffness in the alveoli

122
Q

What is happening during the fibrotic phase of ARDS

A

3 weeks after injury - if tissues are not repaired

dead space, fibrous lung tissue (hyaline membrane), major lung damage, poor prognosis

123
Q

What are the 8 P’s to remember for a patient on a mechanical ventilator

A
  • prevent infection (VAP)
  • PEEP (positive end expiratory pressure
  • pipes and pumps (fluid status; CVP, urine output)
  • paralysis (not all pts on a vent get this, but if they do, they also get a sedative)
  • position (tummy time)
  • protein 10 mL/hr (stimulates gut and reduces chance of ileus and stress ulcers)
  • protocol (A-F bundle)
  • Pharmacology (steroids to decrease inflammation)
124
Q

What is Cheyne-stokes respirations

A

alternating patterns of deep and shallow breathing with periods of apnea lasting 15-60 seconds

125
Q

What is Schamroth’s signs

A

clubbed fingers indicating a pulmonary issue

126
Q

A patient has a high carboxyhemoglobin level. What is wrong

A

carbon monoxide poisoning

127
Q

What is a pulmonary embolism

A

Clot in the pulmonary artery that causes blood shunting

128
Q

What is blood shunting

A

blood bypasses the right side of the heart and doesn’t become oxygenated

129
Q

What are the symptoms of a pulmonary embolism

A

sudden onset of:
- tachycardia
- tachypnea
- anxiety
- crackles
- productive cough
- DVT
- chest pain on inhale

130
Q

What are the treatments for pulmonary embolism

A
  • give O2 as needed
  • heparin
  • if patient is coding, do TPA
131
Q

What is Virchow’s triad

A

Three criteria that put someone at risk for a clot
- hypercoagulability
- venous stasis
- vessel damage

132
Q

How do you diagnose a pulmonary embolism

A
  • ventilation/perfusion (VQ) scan (gold standard
  • ABGs
  • CT scan
  • D-dimer (not conclusive, need CXR to confirm)
133
Q

What is TPA

A

Tissue plasminogen activator
- protein that breaks down clots
(heparin prevents clots, TPA destroys clots)

134
Q

What is cor pulmonale

A

Right sided heart failure without left sided heart failure

135
Q

What is emphysema

A

A type of COPD that is caused by air being trapped in the alveoli and being hyperinflated. The pressure flattens the diaphragm making it hard to breathe.

136
Q

What are the symptoms of emphysema

A
  • barrel chest
  • huffing
  • cyanosis in fingers
  • decreased breath sounds
137
Q

What are the treatments for emphysema

A
  • oxygen supplementation
  • instruct on pursed lip breathing
  • breathing treatments
138
Q

What is a bleb

A

bullous emphysema
- giant air packets sitting on the outside of the lung
- rupture of these can lead to pneumothorax

139
Q

What is a tension pneumothorax

A

buildup of air in the pleural cavity puts pressure on lungs
- vessels shift
- can be trauma related
- can be caused by mechanical ventilation with PEEP

140
Q

When doing an assessment, what signs would tell you that someone has a tension pneumothorax

A
  • tracheal deviation (not midline)
  • hyperresonant on percussion
  • decreased or absent breath sounds on auscultation
  • shortness of breath
  • hypotension
  • JVD
  • tachycardia
141
Q

What is the treatment for a tension pneumothorax

A

Needle decompression to let out the air

142
Q

What is asthma

A

chronic lung disease that causes narrowing and inflammation of the airways
- inflammation is chronic; bronchospasm occurs with a trigger (asthma attack)
- goblet cells that make mucous are overactive causing a blockage of the airways

143
Q

What are the symptoms of asthma

A
  • wheezes
  • SOB
144
Q

What is status asthmaticus

A

An asthma attack caused by a trigger
- bronchospasm (constriction of the smooth muscle on the bronchioles)
- increased mucus production
- pulsus paradoxus (pulse decreases by 10 mmHg on inhale)
- signs of impending death (absent breath sounds and paCO2 > 70)

145
Q

What meds can you give for asthma

A

Albuterol - short acting beta agonist (for emergencies)
Steroids - prednisone (oral)
Long acting beta agonists - not for emergency use

146
Q

At what point would you intubate a patient

A

Glasgow coma scale less than 8

147
Q

How long can a patient be on a vent until they need a tracheostomy

A

10 days

148
Q

What should you instruct your patient to do in regards to taking a bronchodilator

A

take last dose a few hours before bed because it can cause insomnia

149
Q

What do you teach a patient when they are taking a glucocorticoid inhaler

A

gargle with water after use

150
Q

How do you treat respiratory acidosis

A

O2 therapy

151
Q

How do you treat metabolic acidosis

A

bicarbonate

152
Q

What are some complications that can happen to a patient on a ventilator

A
  • prone to pressure ulcers
  • dysrhythmias (PVCs and PACs)
  • ischemic anoxic encephalopathy (lack of blood flow to brain)
153
Q

What is the ABCDEF bundle

A

For patients on a vent:
A - assess, prevent, manage pain
B - Spontaneous breathing/awakening trials
C - choice of sedation
D - delirium: assess (CAM-ICU scale), prevent, manage
E - early mobility
F - family engagement

154
Q

What is a major cardiac complication of being on a vent

A

Decreased cardiac output caused by positive intrathoracic pressure; can decrease blood pressure

155
Q

What side would you instruct a patient to lay on when they are post pneumonectomy or post lobectomy

A

pneumonectomy: lay on affected side so the good side can breathe better

lobectomy: lay on non affected side so that the affected side can work better and heal

156
Q

What do air bubbles in the chest tube mean

A

air leak

157
Q

What is angiogenesis

A

formation of new blood vessel in order to feed a tumor

NUR 340 (10 decks)

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