Final Flashcards
Stages of shock
Initial
Compensatory
Progressive
Refractory (mods)
Initial stage of shock
↑ hr/rr - may be only signs
↓ map - 5-10 (still normal)
Compensatory stage of shock
↑ hr/rr, ↓ map 10-15
↓ urine,↑ na+
Tissue hypoxia
Kidney mechanisms -RAS
• ↑ renin, epi, norepi
Acidosis (↓ ph ),↑ lactic,↑ k+
Progressive stage of shock
↓ map 20+
Still compensating but hypoxia to vital organs
Ischemia to less vital organs (skin, kidneys, brain)
Impending doom, confusion, ↑ thirst
↑ hr/rr, weak pulse, ↓ bp, narrow pulse pressure
Pallor, cyanosis, cool extremities, decreased cap refill
↓ urine, ↓ GFR, ↑ specific gravity. Sugar/acetone in urine
↓ bowl sounds, slowed gi mobility
Refractory (mods)
Everything crashing, no return
Massive release of toxins = microthrombi formation
→ DIC ** all platelets 1 fibrin used up
Interventions for shock
Semi fowlers, ↑ perfusion
Meds:
- vasoconstrictors: Levo (norepi), epi (adrenaline), vasopressin
- inotropic agents: dobutamine
- nitro + sodium nitroprusside =↑ myocardial perfusion
Q15 VS
Sepsis vs sepsis shock
Sepsis: mods
Sepsis shock: system inflammatory response syndrome (SIRS)
- ↓ gas exchange and perfusion occurs
What causes SIRS?
Infection + widespread inflammation
Inflammatory mediators released, body attacks itself = SIRS
SIRS s/sx?
↓ bp, ↓ UOA, ↑ rr
Temp change (based on WBC function & duration)
Inappropriate clotting, microthrombi form (DIC), ↑ lactic
Lactic levels?
Lactic: 1-2
> 2 = sepsis, 4-6= septic shock
Nursing interventions for sepsis
broad spectrum abx
Blood cultures
Innate vs compensatory response sepsis
Innate: fever, leukocytosis, left shift/bandenemia
Compensatory: ↑ hr, ↓ bp, MODS
1 change in V/s in ____ to ____ hrs =↑risk of sepsis
4-6hrs
DIC labs
↑ d dimer, FDP, pt / ptt
↓ plts, fibrinogen
s/sx of DIC
Tx?
Bleeding from everywhere
Hemorrhagic manifestations: petechia, seeeping IV, bruising
Reversal for anticoags: vit K, protamine sulfate
Hypovolemia s/sx
End stage?
↑ hr, ↓bp, ↑ rr
Orthostatic hypotension, thready pulse, ↓ LOC
= hypoxia, ↓ CVP, seizures ( ↓ Na+)
End stage: pale, clammy
Causes of hypovolemic shock
Trauma:
hemorrhage = ↓JVP
and third spacing
What is 3rd spacing
Hypovolemia → ruptured vessels → ↑ inflammatory mediators = SIRS
Nursing interventions for hemorrhage?
PRBCs
FMP/Cryo = whole blood
CVP
What does it monitor?
What are the ranges?
Monitors R atrial pressure
2-8 = good
<2 = hypovolemia
>8 = hypervolumia
How to calculate MAP?
What do we want it at?
What is cardiac output?
SBP + 2 (DBP) =____ /3 = MAP
>65
Co= hr x stroke volume
Primary assessment?
Immediate: ABCDE
A=irway/alert: APVU (alert, pain/voice arousal, unresponsiveness), cspine
B-reathing: 6L with no order, broken ribs/flail chest can do this
C-irculation: IV, pulses, transfusion
D-isability: GCS, pupils
E-xposure, remove clothing `
secondary assessment:
Everything else
SAMPLE
Symptoms
Allergies
Medications
Past hx
Last oral intake
Events
Objective vs subjective
Objective: what we see, pain scale, V/s
Subjective: what pt says
Heat exhuastion s/sx?
nursing interventions
flu like ha, N/V, weakness
rehydrate, remove tight clothing
Heat stroke
temp above 104
AMS, dehydration, cerebral edema
↑ hr, ↓bp, ↑ rr, weak pulses,
↓ Na+, ↑ trop,
Color code:
Red:
Yellow:
Green:
Black:
red = emergent
yellow= can wait short time
green = walking, unwounded
Black = dead
internal vs external disasters?
internal: fire, explosion, violence, loss of critical utilities
External: Epic shut down, viruses, natural disasters
Level 1-4
Level 1: teaching hospital, all resources, conducts research for trauma verification
Level 2: provides care to most pt
Level 3: stabalizes pt with most injuries, transfers
Level 4: rural/remote, basic trauma stabilization + ACLS, transfer immediately
Left sided heart failure s/sx:
Pulmonary congestion: ↑ RR, wheezing, crackles, blood tinged sputum, orthopnea, nocturnal/exertional dyspnea
↑ hr, weak pulse, S3 = overload
cyanosis, cool extremtiies
restles, dizzy, AMS, confusion
what is L sided HF also called?
what should we monitor?
congestive heart failure
PAP and PAWP -
*****increased PAWP
what is R sided heart failure also called
Cor pulmonale if not caused by L sided HF
s/sx of R heart failure
fatigue, ascites, edema, weight gain, enlarged spleen/liver, RUQ pain
RV heave, loud S2, increased peripheral venous pressure
anorexia, GI distress, poly/nocturia
what causes R sided HF
LHF, RV MI, Pulm HTN, and COPD
when do we give nitro to a HF patient?
if SBP is <100
systolic vs diastolic
systolic = impaired contractility
diastolic = impaired filling
Nstemi vs Stemi
Nstemi: ST depression, T wave inversion, no increased trop = ischemia
Stemi: ST elevation, trop increased = infarction/necrosis
MI s/sx
Male
Female
Male: neck, jaw, lower back, chest pain
SOB, n/v
Female: fatigue, neck, jaw, upper back pain, epigastric pain, heartburn, abd pain
What is an MI ?
occlusion of BF = injury -> ischemia -> infarction
plt aggregation, thrombi form at site, infarction begins = heart ↑ o2 demand but ↓ supply
Labs for MI
↑ K+, mag, calcium, trop, CK
what is released during an MI
catecholmines release -> ↑ HR afterload/contractions = ↑ o2 requirements -> vent rhythyms
MI nursing interventions
surgical?
MONA
Oxygen first
Nitro x3 back to back
-contraindicated with viagra/afil meds
morphine Q5-15 min
aspirin: chew for faster effect
Surgery: PCI
MI meds
MONA
Beta blockers
antiplts (ASA)
thrombolytic therapy (alteplase)
Anticoags (heparin, Lovenox)
cardiogenic shock?
caused by acute MI
s/sx: ↑ hr, rr, low bp, cool, clammy, decrease UOA, JVD, pulm edema, orthopnea, chest discomfort, syncope
Preload definition
when is it increased?
what drugs decrease in?
volume of blood in Ventricles at end of diastole
increases in hypervolemia, regurg, HF
drugs: decrease preload- diuretics, vasodilators
Define afterload
drugs to reduce after load?
resistance LV must overcome to circulate blood
drugs: ACE, ARBs, ARNI
(triple A, decrease Afterload)
drugs to ↑ contractility
digoxin, BB< CBB, aldosterone Antag
what is CAD
what does CAD lead to?
Plaque buildups in arteries
atherosclerosis -> angina (partial block) -> MI (complete block)
Types of angina?
stable: on exertion/stress, no other s/sx
Unstable: with/wo exertions - worsens, considered pre infarction (diaphoresis, SOB)
Prinzmetal (variant): occurs at complete rest, spasms (ST changes, but no trop/Ck changes)
Try performing better always
Tricuspid, pulmonary, bicuspid, aorta
Pacemakers education?
no magnets, dont place leads/lat pads on it, pacer spikes on ECG, no MRI
indications of pacemaker?
bradycardia, heart bloc, sick sinus syndrome, tachy dysrhythmia, sinus arrest
complications of pacemaker
hemo/pneumothorax
cardiac tamponade
cardioversion vs defib
cardiovert: out of abnormal rythyms, lower amount of jules
-atrial dysrhythmia, SVT, Vtach with pulse
Defib: direct shock, stop electrical activity, allows SA node to perfuse
-pusless Vtach/Vfib
what meds do we give for extreme bradycardia
Atropine, epi, dopaminewh
what meds do we give for extreme tachy?
adenosine, amniodarone, verapamil
-AFIB, SVT, VTach with pulse
when do we give lidocaine/epi?
Vtach w/o pulse
Vfib
cardiomyopathy:
dilated?
hypertrophic?
restrictive?
Dilated: decreased systolic
Hypertrophic: decreased diastolic filling
Restrictive: no diastolic filling due to fatty tissue depos
Drugs we give for cardiomyopathy?
diuretics, vasodilators, cardiac glycosides
what is pericarditis?
what are the types?
inflammation of pericardium
Acute (infection, post MI)
Chronic constrictive (thickening of pericardium)
s/sx of pericarditis?
what do we not do with this pt?
substernal precordial pain, worsens w/breathing
coughing
pericardial friction rub
Do NOT place pt supine
what can pericarditis lead to?
CARDIAC TAMPONADE= fluid accumulation in pericardium
s/sx of cardiac tamponade?
tx of this?
JVD, paradoxical pain
BECKS triad: hypotension, muffled heart sounds, bradycardia
Pericardiocentesis
what causes rheumatic carditis?
infection from group A
s/sx of rheumatic carditis?
↑ hr, cardiomegaly, murmur, friction rub, precordial pain, prolonged PR, HF
what causes ineffective carditis?
s/sx?
IV drug use
s3/s4, murmur, neuro changes, petechiae, splinter hemorrhages, osler nodes, lesions of hands/feet, roth spots, sudden abd/flank pain, renal infection
what does mitral regurg cause?
afib, palpitations, high pitched diastolic murmur
Cardiac cath care?
two sites: radial, femoral
Preop: CHG, V/s, informed consent
Post-Op: post op v/s, watch for bleed in TR band, dont move extremities
define AFIB
causes?
irregular hr, no p’s, irregular electrical signals from SA node
intrinsic: within heart
extrinsic: outside heart, age, disease`
s/sx of afib
palpitations, dyspnea, fatigue, syncope, murmur, s1 loudness
tx of afib
high risk for blood clots, anticoagulation needed
tx underlying issue
rate control:
BB - class 3
CCB - class 4
rhythym control:
amnio- class 1
sotalol - class 3
CHAD 2 score interpretation
CHAD2 score
+1: DM, HTN, obesity, age, CHF
+2: stroke
0= asa only
1= lt anticoag (warfarin, asa)
2= indefinite anticoag
AFIB RVR tx?
Atrial tachyardia?
aflutter?
Cardioversion and BB
only monitor unless symptomatic
monitor `
what is more threatening atrial or vent rhythyms?
ventricular
torsades de pointes tx?
DONT SHOCK
bolus MAG/30min
digoxin therapeutic range:
1.5
normal
PR
QRS
QT
0.12-0.20
0.04- 0.08
0.32-0.40
BPM
SA node
AV node
Bundle of His
Purkinje fibers
60-100
40-60
L/R bundle branches
20-40
define
automaticity
excitability
conductivity
contractility
spontaneous, cardiac cell, automatic
polorization/generate action potential
beating of heart, electrical impulses
performance of heart, pre/afterload
diagnostic + Pathophysiology of ARDS
diagnostic criteria: PaO2/FIo2 ration <200, PWP <18, Cxray infiltration
Release of 3 inflammatory mediators: histamine, seratonin, bradykinin
decreased surfactant, increased cap permeability = pulmonary fibrosis + multi system failure
s/sx of ARDS:
hypoxia, decreased pulmonary compliance, dyspnea, bilateral pulm edema
worst complication of ARDS?
TX for this? why?
intrapulmonary shunting: aveoli collapse = deoxy but no reoxygenate
PEEP: opens aveoli, keeps them from collapsing
Hypoxemia vs hypoxia
hyperventilation?
hypoxemia: decrease o2 in blood
hypoxia: decreased tissue perfusion
hyperventilation increases CO2, resp alkalosis then acidosis `
ventilatory failure?
physical problem with lung (trauma), defect in resp control (neuro), poor function of resp muscles
-hypercapnic: paCo2 >50
oxygenation failure?
insufficiemt o2 in aveoli, decreased lung perfusion but normal ventilation
-R-L shunting
vent/perfusion mismatch
abnormal hgb
hypoxemia: PaO2 <60%
both ventilatory and oxygenation failure
problem with lungs (asthma, emphysema, bronchitis), decreased bronchioles/aveoli
02 failure, increased work of breathing, resp muscles dont work
acute resp failure?
oxygenation/ventilatory failure
hypoxemic, hypercapnic
early s/sx of acute resp failure
late ?
Restlessness, air hunger, tachypnea, tachy, dyspnea, anxiety
late: AMS, confusion, lethargy, diaphoresis, cyanosis, decreased breath sounds, use of accessory muscles, resp arrest
PE risk factors:
TX?
prolonged immobilization, hx, obesity, age, central venous catheters, surgery, conditions
o2, continous monitor, IV access, drugs (anticoags, fibrinolytics)
what 4 major sx do PEs lead to?
hypoxemia, hypotension, hemorrhage and anxiety
s/sx of PE
resp: dyspnea, increased RR, pleuratic chest pain, dry cough, hemoptysis: hypoxemia
cardiac: tachy, JVD, syncope, cyanosis, abmromal heart sounds: hemorrhage + hypotension
Impending doom: anxiety
assist control vs SIMV
AC: breaths for pt, does all the work
SIMV: lets pt breath on own, easier to wean off, synchronizes with breath/inspiratory effect
PEEP normal level?
complications?
8
increased intravacular pressure, decreased venous return = Decreased BP/CO = need pressors
PIP level
below 40
if greater = tube dislodegemnt or pt has problem, can cause lung damage/barotrauma
Pio2 level
30-35 before extubation
at 60 for longer than 6hrs = lung damage = o2 toxicity , hypoxemia
what should PaO2/FiO2 ratio be?
300-400
less than 200 = intubation needed
pulmonary contusionn
asymptomatic at first, lethal
Tele monitor
s/sx: bloody sputum, crackles/wheezing, decreased breath sounds
Rib fracture
compromised ventilation due to pain
-IS, cough, deep breath, do NOT bind/splint
Flail chest:
intubate if true paradoxical
Tension pneumothorax:
Chest tube
MEDICAL EMERGENCY
assymetry of thorax, trach deviation, JVD, no breath sounds one side
pneumothorax:
accumulation of air in pleural cavity
hyperresonance
Hemo thorax
monitor for s/sx of hypovolemia
Tracheobronch trauma:
SURGERY - due to being hit
subq emphysema, stridor
fluid overload s/sx:
high bp, hr, rr, bounding pulses
AKI causes:
how to avoid?
occurs?
underlying condition, reduced CO or obstruction
drink 2-3L
occurs quickly- hrs to days, failure to maintain waste elimination, fluid/electrolyte balance, acid base balance
diagnostic definition of AKI
0.3 increase in 48hrs
1.5x baseline in 7 days
<0.5ml/kg/hr for 6hrs
early s/sx of AKI
Late s/sx
decreased UOA, unadequate hydration, check weight
Late: lethargy, CNS changes, seizures, muscle twitching, N/V, decreased peristalsis, itchiness, HTN, HF< edema, MI, thrombosis, anemia, bleeding
Bun/Cr
pre-renal
intrinsic renal?
pre renal: >20
intrinsic: <10
health teachings of AKI
low potassium (no tomatoes, oranges, banana)
low sodium
do not smoke
no NSAIDs
regular blood work
control BP - take meds
if SOB or no urine occurs go to ED
Pre - renal?
Causes?
reduced blood flow
hypovolemia/perfusion/tension, burns, sepsis
intra renal?
Causes?
affect renal cortex/medulla
NSAIDS, gentamicin/vanc, allergic disorders, embolism, thromobosis of renal vessels
post renal?
urine flow obstruction
calculi, tumors, urethral obstruction
what will alter kindey resultd?
abx and nsaids
4 phases of AKI
what do all phases do?
Initiation: begins w/initial result
Oliguria: increased serum concentration of substance usually excreted
Diuresis: gradual increase in UOA, GFR recovering
Recocery: sx improve, takes 3-12m
All phases increases CR
ICP range
CPP range
ICP: 7-15
CPP: 60-80
priority stroke intervention:
CT scan
cushings triad?
widened pulse pressure (SBP high), bradycardia, abnormal respirations
SCI vent needed?
C1-C3 = intubate
c4-C5: may need vent
C6+: independednt breathing
MAP for spinal cord injuries:
80-85
stroke scale:
0- no stroke
1-4: mild stroke
5-15: moderate stroke
16-20: mod-severe
21-41: severe stroke
L side stroke causes what
R sided weakness, paralysis
Aphasia
visual problems (R visual field gone)
slow performance: cautious
aware of deficits: anxious, depressed
impaired comprehension: math, language
R sided stroke causes:
Paralsyis and neglect of L side
unable to swallow
denies/minimize problems
rapid short attention span
impulsive, safety problems, bed alarm needed
impaired time, memory loss
Ischemic stroke nursing care
alteplase within 3.5-4 hrs
BP dropped gradually
ASA - antiplt therapy
hemorrhagic stroke care
manage ICP
craniotomy or ventricular drain system
BP goal of 140 (130-150)
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