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)
2
Q
In what conditions would we see an increase in preload
A
- hypervolemia
- valve regurgitation
- heart failure
3
Q
What is afterload
A
The resistance that the left ventricle must overcome in order to pump blood to the body
4
Q
In what conditions would we see an increase in afterload (broad)
A
- hypertension
- vasoconstriction
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
6
Q
What is this
A
Ventricular paced rhythm
7
Q
What is Intrinsic rate
A
The patient’s own heartbeat
8
Q
What is extrinsic rate
A
A rate that is set by an artificial source
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
10
Q
What is sense
A
The ability of the pacer to “see” the intrinsic activity of the heart
11
Q
What is a trigger
A
An intrinsic event causes a stimulus to be delivered (ex. long AV delay)
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)
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.
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)
15
Q
What are the three different modes when it comes to pacemakers
A
- Atrial pacing
- ventricular pacing
- Atrial/Ventricular pacing
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
17
Q
What is ventricular pacing
A
Stimulates the ventricles to contract when there is a loss of “atrial kick”
this sustains cardiac output
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
19
Q
What is atrial/ventricular pacing
A
Stimulates both the atria and ventricles to contract
- more like intrinsic pacing
- synchronizes atria and ventricles
20
Q
what is this
A
atrioventricular pacing
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
22
Q
What are the three types of temporary pacing routes
A
- transcutaneous
- epicardial
- transvenous
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
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
25
What is transvenous pacing
An external pacemaker attached to the heart through the femoral artery
emergency; used as a bridge
26
What do the three letters indicate in pacemaker codes
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
27
What are some common pacemaker codes
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)
28
What is failure to pace
The voltage isn't high enough on the pacemaker to incite a response by the myocardium
no pacer spikes seen on EKG
29
What is failure to sense
The pacer isn't sensing intrinsic beats from the heart which leads to overpacing
only relevant in synchronous pacing
30
what is failure to capture
When the pacer fires but doesn't elicit a response from the myocardium
pacer spikes are seen on the EKG
31
What needs to be avoided by patients with a pacemaker
High voltage electrical equipment/generators
32
what is this
failure to pace
increase mV
33
what is this
failure to capture
increase mV
34
what is this
failure to sense
decrease mV
35
what is this
Normal atrial pacing; failure to sense for v pacing
decrease mV
36
what is this
failure to capture
increase mV
37
what is this
V paced; oversensing (tachycardia)
increase mV
38
What is an ICD
Implantable cardioverter defibrillator
39
How does an ICD work
- 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)
40
What are the two types of valvular disease
- stenosis
- insufficiency
41
What is valvular stenosis
When the aortic or mitral valve become stiff and hard to open or close
42
What is valvular insufficiency
When the aortic or mitral valve don't close all the way which leads to regurgitation
43
What causes valvular stenosis
- rheumatic heart disease/fever (aortic and mitral)
- calcification with age (aortic)
44
What causes valvular insufficiency
- rheumatic heart disease/fever (both)
- left ventricle dilation (mitral)
- aneurysm of ascending aorta (aortic)
45
What is cardiopulmonary bypass
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
46
What is a carotid endarterectomy
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
47
What are some post operative measures we take as nurses for a patient who underwent a carotid endarterectomy
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)
48
What is an intraaortic balloon pump
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
49
What is stroke volume
The volume of blood the heart is pumping with each beat
50
How do you calculate stroke volume
end diastolic volume - end systolic volume
51
What are some ways to increase preload
- give fluids
- increase bp (vasoconstrictors)
52
what are some ways to decrease preload
- diuretics
- vasodilators
53
What are the levels of bedside hemodynamic monitoring from least invasive to most invasive
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
54
What is intraarterial BP monitoring
catheter is inserted in the radial artery (or femoral artery) and is used to monitor blood pressure
55
How do you set up an arterial line for BP monitoring
- 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
56
What is the phlebostatic axis
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
57
What test must be done before inserting an arterial line
Modified Allen's test
- have patient make a fist
- occlude both radial and ulnar artery
- release ulnar artery and see if hand reperfuses
57
What is the phlebostatic axis
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
57
What is central venous pressure monitoring
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
58
How do you set up CVP monitoring
Make sure dressing is clean and intact and zero is at the phlebostatic axis
be sure you have a good waveform
59
What is the range for a normal CVP reading
2-5 mmHg
<2 = hypovolemia
>5 = hypervolemia
60
What are some complications that can arise with CVP monitoring
- infection
- air embolism
61
What is pulmonary artery pressure monitoring
Using a Swan Ganz catheter, insert into the pulmonary artery from the right ventricle to measure pulmonary capillary wedge pressure (PAWP/PAOP)
62
When would you use pulmonary artery pressure monitoring
for patients with:
- cardiac output issues
- shock (hypovolemic, cardiogenic, or septic)
- multisystem failure
- Acute respiratory distress syndrome
63
How do you know when the Swan Ganz catheter is in the pulmonary artery
When the waveform measures tall, even peaks between 10-25 mmHg
64
What are some non-invasive ways to monitor cardiac output
- Echocardiogram
- Transesophageal echocardiogram (TEE)
- Passive leg raises
65
What are the signs and symptoms of increased afterload
- crackles
- pulmonary congestion
- dyspnea
- Low O2 saturation
- mental status changes
66
What is an LVAD
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
What is ejection fraction
How much blood is being pumped from the left ventricle to the body
68
How do you calculate EF
stroke volume / end diastolic volume
69
What does EF<40% mean
Heart failure or cardiomyopathy
70
What is systolic heart failure
heart failure with a reduced EF
HFrEF (<50%)
71
What is diastolic heart failure
heart failure with a preserved EF
HFpEF (50-70%)
72
What does it mean if someone has an EF > 70%
Left ventricle stenosis
73
What are some things that can cause heart failure
- faulty valves
- arrhythmias
- MI/CAD
- genetics
- uncontrolled HTN
- recreational drugs
- infections
74
What are the symptoms of left sided heart failure
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
What are some common causes of right sided heart failure
- left sided heart failure
- COPD
- Pulmonary HTN
76
What are the symptoms of Right sided heart failure
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
What is the major sign of pulmonary edema
pink, frothy sputum
78
What is pulmonary edema
Capillary fluid moves into alveoli caused by damage to the left ventricle (L sided HF)
79
How do we treat pulmonary edema
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
What is cardiogenic shock
When the heart fails to pump enough blood to the body
81
what are the most common causes of cardiogenic shock
- MI
- arrhythmias
- valve defects
- ventricular aneurysm
82
What are the signs and symptoms of cardiogenic shock
- S3 heart sound
- JVD
- decreased MAP
- weak pulse
- pale skin
- cool hands and feet
- decreased urine output
83
What are the New York Heart Association functional classifications
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
What type of treatment do we give to a patient in stage I of the NYHA functional classification during a nuclear stress test
Preventative treatment
85
What type of treatment do we give to a patient in stage II of the NYHA functional classification during a nuclear stress test
Prescribe ACE inhibitors and Beta blockers
86
What type of treatment do we give to a patient in stage III of the NYHA functional classification during a nuclear stress test
prescribe diuretics, digitalis, and dietary salt restriction
87
What type of treatment do we give to a patient in stage IV of the NYHA functional classification during a nuclear stress test
continuous IV inotropic support
88
What labs do we test for heart failure
- K
- BUN
- Cr
- BNP
- Troponin
- Digoxin levels (if on digoxin)
89
What are the major drugs that we give patients for heart failure
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
What is digitalis
Digoxin
positive inotropic drug that lowers heart rate and allows more time for ventricular filling
91
What does "positive inotropic" mean
Allows the heart to pump more blood with each beat by strengthening contraction
92
What do you need to watch for when giving a patient an ACE inhibitor
- K levels (increase)
- Na levels (decrease)
- dry cough
- angioedema
93
What can you give to a patient who had complications with an ACE inhibitor
Angiotensin II receptor blocker (ARBs)
- vasodilator just like ACE
- no nagging cough
- no angioedema
94
What must you avoid if taking a beta blocker
Grapefruit juice
95
Patient with Diabetes taking a beta blocker must be aware of what
symptoms could mask hypoglycemia
96
When would you give a heart failure patient an anticoagulant
If they have: (blood can pool causing clots)
- a-fib
- Hx of clots (PE, DVT)
- decreased EF
97
What are the signs and symptoms of digoxin toxicity
- Seeing a halo around lights
- N/V
98
How do you administer digoxin
IVP over 5 minutes
Hold if HR < 60
99
What is the antidote given when a patient is in digoxin toxicity
Digibon
100
What is dobutamine
Positive inotrope like digoxin but works much faster
Digoxin works:
- oral = few days
- IVP = 24 hours
101
What is CRT
Cardiac resynchronization therapy
used for patient with HF that have conduction issues
reduces symptoms and improves mortality
102
What is Takotsubo
Broken heart syndrome
cardiomyopathy caused by ballooning of left ventricular apex during systole
103
What are the two types of cardiomyopathy
- hypertrophic
- dilated
104
What is hypertrophic cardiomyopathy
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
What is dilated cardiomyopathy
Dilation of the ventricles allowing more blood to fill but too weak to pump it all out to the body
106
What causes cardiomyopathy
- genetics (hypertrophic)
- hypertension (dilated)
- Ischemia due to repeated MI (dilated)
- unknown (dilated)
107
What are some complications of hypertrophic cardiomyopathy
myocardium needs more oxygen but the ventricles pump less blood
papillary muscle rupture
108
What is the physiology of the S3 heart sound
Extra filling after diastole (S2)
signifies an overloaded ventricle
can be physiologic in children; pathologic in adults
109
When will you hear a heart murmur
With stenotic or insufficient valves
110
How do we grade the intensity of a heart murmur
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
What are the signs and symptoms of mitral valve insufficiency
- may be asymptomatic for years
- fatigue
- dyspnea on exertion
- palpitations
- angina
- S3 (with late stage HF)
- may also have CAD
112
What is the modified Duke criteria for endocarditis
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
What are the major criteria for the modified Duke criteria for endocarditis
BE
B - blood cultures (+ for bacteria >2 times 12 hours apart)
E - echocardiogram (+ for lesions on endocardium)
114
What are the minor criteria for the modified Duke criteria for endocarditis
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
What causes endocarditis
- bacterial infections due to surgical procedures
- bacterial infections due to dental procedures
116
What is acute respiratory distress syndrome
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
What are the four criteria for diagnosis ARDS
Timing - sudden onset
X-ray - shows effect in both lungs
Heart failure ruled out
pO2 in blood:FiO2 received
118
What are some common causes of ARDS
Direct lung injury
- pneumonia
- aspiration of gastric juices
Indirect lung injury
- sepsis
- trauma w/shock and multiple blood transfusions
119
What are the three phases of ARDS
Exudative phase - 24 hours after initial attack
Proliferative phase - 7-10 days
Fibrotic phase - 2-3 weeks
120
What is happening in the exudative phase of ARDS
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
What is happening during the proliferative phase of ARDS
7-10 days after injury
body tries to repair structures
lung tissues are dense and fibrous causing stiffness in the alveoli
122
What is happening during the fibrotic phase of ARDS
3 weeks after injury - if tissues are not repaired
dead space, fibrous lung tissue (hyaline membrane), major lung damage, poor prognosis
123
What are the 8 P's to remember for a patient on a mechanical ventilator
- 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
What is Cheyne-stokes respirations
alternating patterns of deep and shallow breathing with periods of apnea lasting 15-60 seconds
125
What is Schamroth's signs
clubbed fingers indicating a pulmonary issue
126
A patient has a high carboxyhemoglobin level. What is wrong
carbon monoxide poisoning
127
What is a pulmonary embolism
Clot in the pulmonary artery that causes blood shunting
128
What is blood shunting
blood bypasses the right side of the heart and doesn't become oxygenated
129
What are the symptoms of a pulmonary embolism
sudden onset of:
- tachycardia
- tachypnea
- anxiety
- crackles
- productive cough
- DVT
- chest pain on inhale
130
What are the treatments for pulmonary embolism
- give O2 as needed
- heparin
- if patient is coding, do TPA
131
What is Virchow's triad
Three criteria that put someone at risk for a clot
- hypercoagulability
- venous stasis
- vessel damage
132
How do you diagnose a pulmonary embolism
- ventilation/perfusion (VQ) scan (gold standard
- ABGs
- CT scan
- D-dimer (not conclusive, need CXR to confirm)
133
What is TPA
Tissue plasminogen activator
- protein that breaks down clots
(heparin prevents clots, TPA destroys clots)
134
What is cor pulmonale
Right sided heart failure without left sided heart failure
135
What is emphysema
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
What are the symptoms of emphysema
- barrel chest
- huffing
- cyanosis in fingers
- decreased breath sounds
137
What are the treatments for emphysema
- oxygen supplementation
- instruct on pursed lip breathing
- breathing treatments
138
What is a bleb
bullous emphysema
- giant air packets sitting on the outside of the lung
- rupture of these can lead to pneumothorax
139
What is a tension pneumothorax
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
When doing an assessment, what signs would tell you that someone has a tension pneumothorax
- tracheal deviation (not midline)
- hyperresonant on percussion
- decreased or absent breath sounds on auscultation
- shortness of breath
- hypotension
- JVD
- tachycardia
141
What is the treatment for a tension pneumothorax
Needle decompression to let out the air
142
What is asthma
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
What are the symptoms of asthma
- wheezes
- SOB
144
What is status asthmaticus
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
What meds can you give for asthma
Albuterol - short acting beta agonist (for emergencies)
Steroids - prednisone (oral)
Long acting beta agonists - not for emergency use
146
At what point would you intubate a patient
Glasgow coma scale less than 8
147
How long can a patient be on a vent until they need a tracheostomy
10 days
148
What should you instruct your patient to do in regards to taking a bronchodilator
take last dose a few hours before bed because it can cause insomnia
149
What do you teach a patient when they are taking a glucocorticoid inhaler
gargle with water after use
150
How do you treat respiratory acidosis
O2 therapy
151
How do you treat metabolic acidosis
bicarbonate
152
What are some complications that can happen to a patient on a ventilator
- prone to pressure ulcers
- dysrhythmias (PVCs and PACs)
- ischemic anoxic encephalopathy (lack of blood flow to brain)
153
What is the ABCDEF bundle
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
What is a major cardiac complication of being on a vent
Decreased cardiac output caused by positive intrathoracic pressure; can decrease blood pressure
155
What side would you instruct a patient to lay on when they are post pneumonectomy or post lobectomy
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
What do air bubbles in the chest tube mean
air leak
157
What is angiogenesis
formation of new blood vessel in order to feed a tumor
