Final Exam Flashcards
Care
- Hospice (3)
- Palliative (3)
Hospice
- death expected within 6 months
- comfort care at end of life
- done once curative treatment stopped
Palliative Care
- offered at any point of illness starting at diagnosis through bereavement
- Includes bereavement care b-c palliative care encompasses family care
- concurrent with curative treatment
Goals of Palliative Care (4)
- Improve quality of life (better relief of symptoms esp. Pain, Dyspnea, N/V, Fever and Infection, Edema, Anxiety, Delirium, Comfort) – does not mean pt does not want any treatments
- Allow client to experience a “good death”– doing what patients wishes and desires are to promote peaceful and meaningful death
- Avoiding a Bad death: not following patient’s wishes; isolation, pain; death w/o dignity
- holistic care for all needs of patient and family
Common problems in Critical Care (Anxiety)
- S/s (4)
- Risk
- Treatment
s/s: agitation/restlessness, verbal expression, BP and HR increase, dyspnea
Risk: Anxiety and agitation can complicate recovery of ICU patient
Treatment: benzos (antianxiety meds)
Common Problems in Critical Care (Pain)
- Assessment Variations (3)
- Risk
- Treatment
Assessment
- may need alternate scales (Behavioral pain scale
Critical care pain observation scale)
- give elderly vertical scales and time to respond
- may need alt communication methods or utilize family
Risk
- triggers anxiety and anxiety can worsen pain
Treatment
- opioids or nonopioids (Ketorolac)
Benzodiazepine (ex. diazepam (Valium), midazolam (Versed), and lorazepam (Ativan))
Side effects (3)
Risks (3)
Side effects
- Delirium
- dose related respiratory depression
- dose related hypotension
Risk
- Temazepam (Restoril) and other benzos have opposite effects in geriatric i.e. agitation
- Not recommended for sedation of mechanically ventilated
- abrupt withdrawal can induce seizures
Sleep Pattern Disturbance in ICU
Medical Management (2)
Nursing Care (4)
Medical Management
- hypnotic benzodiazepine (Temazepam(Restoril))- avoid if elderly
- manage any pain
Nursing Interventions
- Limit interruptions and cluster care to provide uninterrupted rest periods (use DND signs)
- Minimize awakenings and noise (limit staff conversations; do not slam doors)
- Drapes and blinds open at day; dim lights at night
- Provide earplugs and eye masks
Benzodiazepine (ex. diazepam (Valium), midazolam (Versed), and lorazepam (Ativan))
Purpose (2)
Use (2)
Antidote
Purpose
- Sedative-hypnotics with amnesic propertie
- no analgesic properties
Uses
- Versed/midazolam IV push for short term agitation
- Valium and Ativan for long term agitation (Ex. DT)
Antidote: Flumazenil (Romazicon)
Propofol (Diprivan)
Purpose (3)
Use (2)
Route
Composition
Contraindication (2)
Purpose
- Powerful sedative and respiratory depressant
- no analgesic properties
- unreliable amnesic
Use
- sedation in mechanically ventilated in ICU
- Ideal for quick awakening or spontaneous breathing trials
Route: IV continuous b-c rapid onset (30 seconds) and Short half-life (2–4-minute half life)
Composition: High lipid content (looks like milk and quickly crosses cell membranes including blood-brain barrier)
Contraindication: allergy to soy or eggs
Propofol (Diprivan)
Side effects (4)
Care (2)
Side effects:
- green urine (benign)
- Propofol-related infusion syndrome (metabolic acidosis, rhabdomyolysis, myoglobinuria, AKI, dysrhythmias) – due to use of > 5 mg/kg/hr for > 48 hrs r/t fat-emulsion
- Hyperlipidemia and hypertriglyceridemia
- Acute pancreatitis
Care
- change tubing q12h b-c high lipid = risk for bacteria growth
- look at Triglyceride level (may change to Versed/midazolam if high Triglyceride)
Prevention of Sedation Dependence: Daily Sedation Interruption
Process (4)
- Turn off medication (propofol wears off fast; Versed/midazolam wears off slow) once a day
- Assess LOC and neurologic function of patient after awareness attained
- if agitated, change in VS, dysrhythmias, restart to prevent complications – MONITORING = VERY important to prevent harm during withdrawal
- After interruption, determine next plan of care (may reduce dose to avoid dependence; may discontinue sedation if able to be off > 4 hrs
Acute Confusion/Delirium
Definition
Manifestation (2)
Medical management and risk
Definition: Sudden onset of global Impairment in patient cognitive processes leads to inappropriate behavior, disorientation, impaired short-term memory, alt sensory perception and thought processes
Manifestation
- Hypoactive (somnolent, withdrawn, unaware, quiet, extreme fatigue)-> Loss of consciousness
- Hyperactive (picking at lines/tubes, agitation, restless, psychosis)
Medical Management
- Drug of choice: Haloperidol (Haldol)– risk for prolonged QT (> 0.44 sec) -> ventricular dysrhythmia (torsades de pointes)
Advance Directives
Components (2)
Notes (4)
Components
- Living will (Identifies what pt would want if near death i.e. CPR, ventilation, artificial nutrition and hydration)
- Health care power of attorney (Follows patient’s values, wishes, values; Reduces family conflict;
Notes
- HC POA does not make decisions until pt lacks capacity
- Should be updated regularly
- Pt should be asked about written advance directive upon hospital admission per Patient Self-Determination Act
- If no AD, give info on value of AD and opportunity to complete state-required forms in ED
End of life issues
- CPR (3)
- DNR or DNI (3)
- withdrawal or withholding of treatment (2)
CPR
- Family presence is important to facilitate closure during CPR or invasive procedures
- Done for everyone unless DNR
- Can be painful, unsuccessful or result in worsened condition
DNR or DNI
- DNR does not mean stop caring for patient or stop all life sustaining treatment
- DNI (do not intubate)-may still want CPR
- Must be signed by HCP
Withdrawal or withholding of treatment
- Prepare family for what to expect
- implement comfort orders prior to treatment withdrawal
Care for Changes r/t Approaching Death
Speech
Circulation (2)
Respirations (3)
Speech
- talk to pt as you normally would b-c hearing is last sense to go
Circulation
- apply blanket
- no electric blankets or heat packs
Respiration
- Positioning ( Elevate HOB, turn head to side)
- give anticholinergics or scopolamine to decrease secretions
- oral suctioning not helpful
Old categories (4)
- Young old (65-74)
- Middle old (75-84)
- Old old (85-99) - Fastest growing; described as frail (geriatric syndrome w/ unintentional weight loss; weakness and exhaustion and slowed physical activity in older adults)
- Elite old (100+)
Older Adult: General Physiological Changes (6)
- Decreased adaptability
- Impaired organ function
- Decreased reaction time
- Impaired memory of recent events
- visual changes: presbyopia (farsighted r/t age), glaucoma (may need meds or surgery), cataracts (may need surgery), macular degeneration, diabetic retinopathy
- impaired hearing (presbycusis)
Older Adults: ADL Changes (4)
- Greater risk for functional decline (Need assistance w/ 2+ ADLs prior to admission)
- Loss of autonomy and increased dependence r/t mental and physical changes of aging or illness
- inability to drive (increased MVA)– can decrease independence
- mobility concerns (increased sleep; need for cane or walker; increased falls)
Older Adults: Psychosocial changes (5)
- Impaired stress response
- ageism (discrimination r/t age)
- impaired socialization r/t loss of significant others
- increased elderly individuals in prison or homeless
- increased drug usage
Older Adults: Diet/ nutritional changes (7)
- Dietary fat < 30% of calories (<10% from saturated fat)
- Increase calcium to b/w 1000-1500 mg daily
- Daily vitamin D supplement or 10-15 min sun exposure
- Increased vitamin C and A
- Reduce total calories if sedentary lifestyle
- Drink 2 L of fluid a day (may need Colon cocktail: prune juice, applesauce, psyllium to prevent constipation)
- 35-50 g of fiber each day
Health Protecting behavior for Older Adults (6)
- Yearly physical and eye exam
- vaccinations (Influenza, shingles, Pneumococcal, Tetanus (booster every 10 yr))
- Drink ETOH in moderation (<1/day) or not at all
- Avoid smoking
- Create a hazard-free environment (No scatter rugs, waxed floors; Grab bars in bathroom; Install smoke detectors/sprinklers in home)
- Exert autonomy and control as much as possible
Older Adults: Inadequate or Decreased Nutrition
Contributing factors (8)
- Diminished sense of taste, smell (Results in loss of desire for food)
- Inappropriate/unbalanced foods (fast foods)
- Excess meds and OTC drugs (can decrease appetite, affect food tolerance and absorption, and lead to constipation)
- Tooth decay, tooth loss, poorly fitting dentures (r/t inadequate dental care and calcium loss)- may lead to avoidance of nutritious foods
- reduced income
- Chronic disease/ Fatigue
- Decreased ability to perform ADLs
- Loneliness, depression and boredom (may lead to lack of eating and weight loss)
Older adults: Inadequate or Decreased Hydration
Contributing factors (3)
Care (4)
Risk factors
- less body water
- decreased thirst sensation
- Limiting fluid intake in evening due to decreased mobility, diuretics, and urinary incontinence
Care
- Incontinence increases w/ dehydration b-c concentrated urine irritates bladder
- Drink 2 L of water a day plus other fluids
- Avoid excess caffeine and alcohol
- Know s/s of dehydration (dark urine, weight loss, poor skin turgor, dry mucus membranes)
Older Adults and Hospital Patients: Inadequate or Decreased Nutrition
Care for inadequate nutrition (7)
- Perform nutritional screenings on the 1st day of pt. admission (include Nutritional hx, wt., ht., and BMI)
- Do an oral exam to understand why patient may only eat soft/low fiber foods
- Collaborate w/ RDN about the patient’s nutritional status
- Collaborate w/ SLP about problems swallowing or chewing
- Encourage to use herbs instead of salt and sugar b-c may overuse them
- Get social work involved for food bank programs
- manage symptoms that may impair nutrition (pain w/ analgesic; NV w/ antiemetic)
Older adults: Decreased Mobility
Care (5)
- Assess older adults in any setting about hx of exercise and any health concerns
- Teach importance of physical activity 3-5x a week for at least 30 minutes
- Encourage sedentary adults to slowly start their exercise programs
- If patient is homebound, focus is performing ADLs
- walking and swimming are good choices (walking is best because it is weight bearing and can help prevent osteoporosis and build bones)
Accidents: Falls in Older Adults
Risk factors for falls (8)
Fall risk Assessment (3)
Risk factors
- Hx of falling (most important predictor of falls)
- Multiple illnesses
- Generalized weakness or decreased mobility
- Changes in sensory perception (r/t age or drugs)
- impaired body orientation r/t decreased sense of touch -> decreased reaction time
- Urinary incontinence or nocturia
- Communication impairment (disorientation, confusion)
- Alcohol/substance abuse
Assessment (fall risk assessment)
- Observation of Gait (wobbly?); Footwear (closed toe? Sturdy?); assistive devices (cane? Walker? Glasses?)—Do they use them?
- Past medical hx (Diabetic neuropathy?, arthritis?, peripheral neuropathy?)
- Drug assessment (Drug side effects?) i.e. Antihypertensives and orthostatic hypotension; Opioids and CNS depressant effects of drowsiness and acute confusion
Accidents: falls
Impact of falls (2)
Prevention (8)
Impact of falls: fractures and fallphobia (esp if osteoporosis)
Prevention
- Ensure hydration b-c dehydration can cause incontinence due to bladder irritation
- RN communicate hazards on their health literacy level
- Safeguards (handrails, grab bars, slip proof rugs, adequate lighting)
- No scatter rugs, slippery floors, clutter
- Pt avoids going out on bad weather days (slippery or icy)
- ask for help when needed esp. toileting
- use assistive devices i.e hearing aids, glasses, walker, cane,
- keep bed low and locked
Older Adults: Drug Use
Concerns (3)
- Intolerance to standard drug dosages (use “Start low and go slow” policy)
- Opioid Use (increased due to use for acute and chronic conditions w/ persistent pain)
- increased risk of adverse drug events due to polymedicine/polypharmacy
Older adults: Age-related changes of Pharmacotherapy
- Metabolism (3)
- Excretion (3)
Metabolism (monitor liver function tests)
- Decreased liver size
- Decreased liver blood flow
- Decreased serum liver enzyme activity
Excretion (get renal function test esp. Crt clearance)
- Increased BUN and Crt
- Reduced renal blood flow
- Reduced GFR and creatine clearance (leads to slower excretion; decreases by 6.5 mL/min per decade of life)
Older adults: Age-related changes of Pharmacotherapy
- Absorption (3)
- Distribution (4)
Absorption
- Decreased GI motility
- Decreased GI blood flow
- Increased gastric pH
Distribution
- Smaller amount of total body water
- Decreased albumin level
- Increased ratio of adipose tissue to lean body mass (leads to increased storage of lipid-soluble drugs in tissue vs plasma)
- Decreased cardiac output
Older adults: Factors for improper self-administration of drugs (7)
- Poor communication with HCP r/t poor explanations due to educational limits, language barriers or difficulty hearing and vision
- Make errors (Forget to take; Duplication (think 2 is better than 1); use wrong drugs
- Take OTC drugs that interact with prescribed drugs (Ex. Clopidogrel, aspirin, warfarin for anticoagulation, ibuprofen for arthritis and garlic for hypertension = bleeding risk)
- Discontinue drug therapy due to cost, fear of dependency or side effects)
- use leftover drugs from previous illness
- Borrow from others
- Use more than one pharmacy
Older adults: Medication assessment and health teaching (6)
- Obtain complete drug list (OTC, prescribed, herbs, supplements)
- Highlight all drugs that are part of Beers criteria ( drugs where harm > benefit for elderly (ex. Benadryl, ketorolac)
- Assess for duplicate drugs (Ex. Warfarin from two pharmacies)
- Give verbal and written information at appropriate knowledge level
- Encourage to take drugs exactly as prescribed (do not share or borrow drugs)
- Be Aware of common adverse drug events (ADEs) (Hypotension from HTN drugs; Edema; Syncope; Dehydration from diuretics)
Beer’s Criteria Drugs
- meperidine
- oxycodone
- cyclobenzaprine
- digoxin (Should not exceed 0.125 mg daily except for a-fib)
- Ticlopidine
- fluoxetine
- amitriptyline
- diazepam
- promethazine
- diphenhydramine
- ketorolac
- short-acting nifedipine
- ferrous sulfate (Should not exceed 325 mg daily)
- chlorpropamide
Older adults: Tips for better drug self-administration (5)
- Encourage use of pill boxes or associating pills w/ daily events
- Use large print on drug label for poor vision
- Write drug regimen on bottle
- Colored labels
- Easy to open bottle caps for limited hand mobility and strength
Older Adults: Depression
Assessment
Treatment (3)
Assessment
- Geriatric Depression Scale (15 yes or no questions; > 10 = possible depression)
Treatment
- SSRI (takes 2-3 weeks to start working)
- TCAs have anticholinergic properties and should not be used (side effects: acute confusion, severe constipation, urinary retention or incontinence)
- Nonpharmacological: psychotherapy; reminiscence, music therapies
Older Adults: Dementia
What is it?
Prevention (4)
- Slow, progressive and chronic global impairment of intellectual function
Prevention of cognitive changes in older adults
- Cognitive training (learning new skill)
- Physical and mental activity
- Social engagement
- Proper nutrition
Older Adults: Alcohol Use
CAGE Screening (4)
- Have you ever tried to cut down on your drinking?
- Have people annoyed you by criticizing your drinking?
- Have you ever felt bad or guilty about your drinking?
- Have you ever had a drink first thing in the morning to settle your nerves? (eye-opener)
SPICES
What does it stand for?
Risks of SPICES (3)
SPICES or geriatric vital signs
* Sleep disorders
* Problems with eating or feeding
* Incontinence
* Confusion
* Evidence of falls
* Skin breakdown
Risks: longer hospital stays, higher medical cost, death
Older adults: Skin breakdown
Two problems
Care (5)
Two problems
- Skin breakdown (esp. pressure ulcers)
- Skin tears esp. the old-old and those on chronic steroid therapy b-c increased capillary fragility)
Care
- Prevention of pressure ulcers ( Nutritional support (protein), turn, reposition q2h, mobility/activity plan of care, moisture barriers, good hygiene)
- Use the Braden scale daily
- Coordinate w/ RDN and WOCN
- Assess skin q8h for reddened areas that do not blanch and report any open areas (Encourage UAP to report any reddened areas so RN can assess)
- Use a gentle touch
ABGs: Age-related changes (4)
- CO2 does not change with age
- PaO2 decreases w/ age r/t V/Q matching changes (Expected value = 80 mm Hg minus 1 mm Hg for every year > 60)
- Reduced size and function of the kidneys (Loss of nephrons; Decreased renal blood flow)
- Underlying conditions that may result as one ages Ex. COPD (respiratory acidosis), DKA (metabolic acidosis)
ABGs: Normal values (4)
- pH 7.35-7.45
- CO2 35-45 (Ventilatory failure if > 50)
- HCO3- 22-26
- PaO2 80-100 mm Hg (never should be < 40)
ABGs: Compensation equations (3)
- ph abnormal + one abn. value = uncompensated
- ph abnormal + two abn. values = partial compensation
- ph normal + two abn. values = full compensation (determine primary disorder by seeing if pH on acidic (7.35-7.4) or alkalinic side (7.4-7.45) of normal)
Head and Neck Cancer
What is it?
Progression (4)
- slow growing squamous cell carcinoma
Progression
- Begins with mucosa that is chronically irritated
- mucosa becomes tougher and thicker from irritation and genes for cell growth damaged
- metastasis to Lymph nodes, muscles, bone i.e. nearby structural areas
- fatal when metastasis to organs (lungs, liver)
Head and Neck Cancer
- Prognosis (3)
- Consequences (4)
Prognosis
- dependent on location and extent of tumor
- curable when treated early
- fatal in 2 yrs if not treated due to airway obstruction
Consequences
- impaired gas exchange (inability to breath)
- impaired nutrition (inability to eat)
- impaired self-image (impaired facial appearance)
- impaired communication (inability to speak)
Head and Neck Cancer: Risk Factors
Main (2)
Others (8)
What is not a risk factor?
Main: tobacco and alcohol (worse when together)
Others
- men more than women
- > 60 yrs
- poor oral hygiene
- chronic laryngitis
- voice abuse
- chemical or dust exposure
- long-term GERD
- oral infection w/ HPV
FAMILY HISTORY IS NOT A RISK FACTOR FOR HEAD AND NECK CANCER
Head and Neck Cancer: warning signs (12)
- Pain
- Lumps in mouth, throat, neck
- Color changes in mouth or tongue (leukoplakia (white, patchy); Erythroplakia (red, velvety); black; gray; dark brown)
- Oral lesion or sore that does not heal in 2 weeks (may have burning sensation from hot liquids or citrus juice
- Persistent/unexplained oral bleeding
- Numbness of mouth, lips, or face
- Change in denture fit
- Hoarseness or change in voice quality
- Persistent, unilateral ear pain
- Persistent/recurrent sore throat or difficulty swallowing
- Shortness of breath
- Anorexia and weight loss
Head and Neck Cancer: Diagnostics
Labs (5)
Diagnostic tests (4)
Labs
- chronic alcohol use or poor nutrition (low albumin)
- metastasis to liver (increased AST, ALT)
- metastasis to kidney (increased BUN, Crt)
- CBC, Bleeding times, and blood chemistries
- Urinalysis
Diagnostics
- direct and indirect laryngoscopy OR bronchoscopy under anesthesia to define extent of tumor
- Biopsy to confirm diagnosis, tumor type, cell features, location, and stages
- X-ray of skull, sinuses, neck, and chest
- CT and MRI
Head and Neck Cancer: Treatments (3)
- Radiation
- chemo
- surgery (laryngectomy– requires trach)
Laryngectomy: Potential complications (5)
- Airway obstruction (priority)- s/s: restlessness
- Hemorrhage (esp. if wound exposes carotid artery)– call RRT if blood leaking and do not touch b-c can rupture carotid artery; apply continuous pressure if carotid artery ruptures
- wound breakdown (Risks: poor nutrition, long smoking hx, chronic alcohol use, wound contamination, radiation therapy prior to surgery)
- Tumor recurrence
- nutritional deficiencies (may have taste changes)
Total Laryngectomy: Speech and Language Rehabilitation
Options for Speech (3)
- Electronic devices (picture board, smart phone, computer)
- Mechanical device (sound vibrates air inside mouth and throatwhile patient moves lips and tongue; produces robotic sound)
- esophageal speech (patient burps swallowed air to produce speech; produces monotone sound)
Laryngectomy Care: Monitoring for hemorrhage and wound breakdown (4)
- Suture line of stoma care q1-2h during first few days post-op then q4h
- Surgical drain collects blood and drainage for 72 hrs post-op
- Monitor and record amount and character of drainage; cap refill; and activity of major BVs in region (Secretions blood tinged for 1-2 days)
- Report sudden increase or decrease of drainage to surgeon (may be clot if sudden stoppage of drainage)
Laryngectomy care: Promoting adequate nutrition (6)
- feeding tube usually for 7-10 days post-op and removed when swallowing is safe per Swallow study
- PEG > NGT to prevent aspiration
- give diet high in protein and calories
- small amounts of food at a time
- may need thickened liquids
- collaborate w/ RDN and SLP b-c at risk for aspiration, speech, and nutritional problems
Prevention of Aspiration
Care (5)
- tuck chin when swallowing
- use supraglottic swallowing (Valsalva maneuver and swallow twice to clear food that may pool in pharynx; exaggeration of normal protective mechanisms)
- observe for aspiration or aspiration pneumonia and report immediately (aspiration not possible after total laryngectomy b-c airway totally separated from esophagus)
- NO oral intake until swallow study done
- collab w/ SLP and RDN
Laryngectomy: Self-Management Education (7)
- Avoid swimming
- Lean forward and cover stoma when coughing, sneezing (may need to cover when laughing and crying as well)
- Wear stoma guard or loose clothing to cover stoma to prevent water from entering airway when showering
- Clean stoma with mild soap and water
- Lubricate stoma with non-oil based ointment
- use alt communication methods
- use MedicAlert bracelet and emergency card for life-threatening situations
7 Nursing Care for patient w/ chest tube
- Inspect insertion site( eyelets of tube should not be visible; s/s of infection (redness, purulent drainage, excess bleeding))
- Palpate Insertion Site (may have subQ emphysema if puffiness or crackling
- Ensure Intact Dressing at Site
- Assess/reassess Respiratory Status (breathing, pulse ox, breath sounds)
- Observe Trachea (tension pneumothorax if shifted)
- Assess/reassess Pain (give meds and reposition)
- Encourage Cough, Deep Breathing, Incentive Spirometry
9 Nursing Care for chest tube system
- Avoid kinks, Occlusions, or Loose Connections (should be straight)
- Do NOT Strip/Milk Tubing
- Keep Drainage System Below Level of Chest
- Assess for “Tidaling” (water level rises inhalation and fall exhalation) - if not present, may be obstruction
- bubbling seen on exhalation, forceful cough, position changes (EXCESS BUBBLING = air leak)
- Always have at least 2 cm of water to prevent air from returning to patient in water seal chamber
- Limit clamping of a chest tube b-c will increase pressure in pleural space and may cause tension pneumothorax
- No need to disconnect chest tube for transport
- never let drainage come in contact w/ tubes (can cause tension pneumothorax)
8 emergency situations w/ chest tubes
- Tracheal deviation from midline
- Sudden onset or increased intensity of dyspnea
- O2 sat <90%
- Drainage greater than 100 mL/hr, fresh blood, sudden increase in drainage
- Visible eyelets on chest tube
- Chest tube falls out of the patient’s chest
(cover the area with dry, sterile gauze; leave one side out so air can continue to escape chest and prevent tension pneumothorax) - Chest tube disconnects from the drainage system (put end of tube in a container of sterile water and keep below the level of the patient’s chest)
- Drainage in tube stops (in the first 24 hours)
Older Adults: Age-related changes in Gas exchange (9)
- Sarcopenia (age-related muscle atrophy) and weakened respiratory muscles
- Decreased chest wall movement (stiffens) and size
- Air trapping = increased residual volume causing thinned and enlarged alveoli
- Reduced sensitivity to hypoxia and hypercarbia
- Decreased pulmonary reserve
- Decreased pulmonary perfusion capacity
- increase Dyspnea
- Difficulty coughing up secretions r/t decreased cilia beat frequency in airways
- Decrease in ability to protect against environmental injury and infection (r/t decreased T-cell, nutrition, swallowing ability, and mucociliary clearance)
Bronchoscopy
Minor complications (4)
Major complications (4)
Minor complications: Laryngospasm/Bronchospasm, fever, vomiting, epistaxis
Major complications
- anaphylaxis
- Cardiac (hypotension, arrhythmias, hemorrhage, CODING/ cardiopulmonary arrest)
- respiratory (respiratory failure, hypoxemia, pneumothorax)
- infection
Ventilation-perfusion (V/Q) scan
Indication
Process (2)
Results (2)
Complications (3)
Indications: Diagnosis (determine if occlusion of pulmonary artery, respiratory or perfusion problems esp. PE)
Process
- Ventilation: radiolabeled gas inhaled via mask into lungs
- Perfusion: radioisotope injected into veins and travels to lung tissue
Results
- Normal= perfusion scan is normal
- V/Q mismatch i.e. diminished radioactivity on perfusion scan indicates obstruction i.e pulmonary embolus
Complications
- Bleeding at injection site
- infection at site
- Allergy to injection dye (anaphylaxis)– rare
Bronchoscopy
Indication (2)
Post procedure care (2)
Indications (at bedside by HCP)
- Diagnosis (r/t hemoptysis; post-chest trauma; chest or face burn; post-aspiration; difficult intubation; airway obstruction)
- therapeutic (reverse aspiration, help w/ difficult intubation; removal of secretions or growths; atelectasis)
Post procedure Care
- Observe sputum for hemorrhage (Expected: slightly bloody due to trauma)
- Ensure gag reflex returns and anesthesia wears off before patient eats or drinks (about 2 hr)
Bronchoscopy
Pre procedure Care (4)
Pre procedure meds (5)
Pre procedure Care
- Chest x-ray
- Clotting studies (PT, aPTT, Platelet)
- ABGs (oxygen during procedure if hypoxemic)
- No oral intake for 6-8 hrs to prevent aspiration
Pre-op meds
- Topical anesthetic
- Benzo for sedation
- Opioid for pain
- Atropine to reduce vasovagal response and secretions
- IM Codeine to reduce cough reflex
Tension Pneumothorax: Clinical Manifestations (6)
- Tracheal deviation (away from affected due to compression of heart)
- Respiratory distress (dyspneic, cyanotic
- Reduced or Absence of breath sounds on affected side (hyperresonance)
- Distended neck veins
- Hypotension
- Hemodynamic instability (cyanotic, sudden chest pain, tachycardia)
Hemothorax
- Causes (2)
- Classifications (2)
- Interventions (3)
Causes
- Blunt or penetrating trauma
- Lesser trauma if tendency to bleed (i.e. on anticoagulants)
Classifications
- Simple: < 1L blood loss (May not exhibit manifestations)
- Massive: > 1L blood loss
Interventions for massive (simple may resolve on own)
- chest tube to remove blood and prevent infection
- Fluids
- Open thoracotomy if massive or persistent bleeding at 150-200 mL/hr over 3-4 hrs
Hemothorax: Clinical Manifestations (7)
- Respiratory distress (dyspnea, cyanosis, tachypnea)
- Blood visible on chest x-ray
- Hypovolemia
- Decreased breath sounds (no extra sounds)
- Shock possible (tachycardia)
- Dull to percussion
- Chest pain r/t hypoxia
Flail Chest: Clinical manifestations (7)
- Respiratory failure (dyspnea, cyanosis,) r/t intrathoracic injury and inadequate diaphragmatic movement
- Shock (decreased BP, increased HR)
- Paradoxical movement of the chest (Inspiration: in; Expiration: out) leads to increased work of breathing
- severe Pain and anxiety
- Decreased chest expansion leads to decreased ventilation
- Risk for hemothorax or pneumothorax
- chest deformity and crepitation over fractured ribs
Flail Chest
Description (2)
Care (6)
Description
- Fractures of at least two neighboring ribs in two or more places or separation of rib from cartilage
- Result of blunt chest trauma
Care
- Oxygen (or mechanical ventilation if respiratory failure or shock)
- PEEP if severe hypoxemia and hypercarbia
- Pain and anxiety management (talk slow, explain everything)
- Promote lung expansion via deep breathing and positioning
- Secretion clearance via coughing and tracheal suctioning
- Monitor VS, ABG, f/e balance, vital capacity
Acute Lung Failure
Definition (3)
Labs/Diagnostics (5)
Definition
- Physiologically defined condition w/ inadequate exchange of O2 & CO2
- Body is not able to meet the need for O2 at rest
- most common organ failure in ICU
Labs/Diagnostics
- ABG analysis– most specific indicator for evaluating effectiveness of therapy (PaO2 < 60 mm Hg; Hypercapnia (HCO2 > 45))
- Blood/sputum cultures (may be done via bronchoscopy)
- Electrolytes, urinalysis, CBC
- Cardiac- 12 lead EKG; Pulmonary artery catheter if severe (all hemodynamic factors)
- Thoracic CT and Chest x-ray
Acute Lung Failure: Clinical Manifestations
- CNS (4)
- Cardiac (5)
- Pulmonary (5)
CNS
- Restless
- Headache
- Decreased LOC (confused, drowsy)
- ischemic-anoxic encephalopathy
Cardiac
- Decreased cardiac output (hypotensive, systolic HTN)
- Dysrhythmias
- Chest pain
- palpitations
- VTE (Prevent: SCDs, heparin)
Pulmonary
- respiratory distress (retractions, nasal flaring)
- Rapid shallow breathing and Dyspnea/SOB
- Tripod position
- Active abdominal movement
- Cyanosis
Acute Lung Failure: Clinical Manifestations
- GI (6)
- Renal
- Skin
GI
- Decreased GI blood flow
- Ascites and Abdominal distention
- Anorexia
- NV
- Constipation
- Stress ulcers (Prevent: H2 antagonists, PPIS)
Renal (Impaired renal blood flow (decreased urine output)
Skin (Cool, clammy)
Acute Lung Failure: Oxygen (4)
- Delivery system should be tolerated by patient AND lowest FiO2 to maintain O2 sat > 90%
- Use positive pressure ventilation if intrapulmonary shunting present
- Noninvasive okay unless rapid deterioration
- Use A/C mode
Acute Lung Failure: Drug Therapy (6)
- Relief of bronchospasm via smooth muscle relaxation (bronchodilators)
- Reduction of airway inflammation (corticosteroids)
- Reduction of pulmonary congestion (diuretics)
- Treatment of pulmonary infections (antibiotics)
- Reduction of severe anxiety, pain, and agitation (sedatives, analgesics, neuromuscular paralysis)
- Sodium bicarbonate if metabolic acidosis severe (pH < 7.2), dysrhythmias, or refractory to therapy
Acute Respiratory Distress Syndrome
Definition (2)
Pathophysiology (3)
Definition
- sudden progressive form of acute respiratory failure
- pulmonary manifestation of MODS
Patho
- Alveolar capillary membrane becomes damaged and more permeable to intravascular fluid
- Alveoli fill with fluid and collapse causing noncardiac pulmonary edema
- Lung compliance drops and they become stiff
Timing: within 1 week of problem
ARDS: Diagnostics (3)
- chest x-ray (whited out, bilateral infiltrates)
- ABGs (low PaO2 (refractory hypoxemia even w/ O2 administration) OR low PCO2 (due to hyperventilation then increases w/ fatigue)
- PaO2/FiO2 ratio: < 200 due to poor lung function
ARDS: Early Signs (5)
- respiratory distress (tachypnea, dyspnea, use of accessory muscles, suprasternal retractions
- cough
- restless, apprehension
- scattered crackles
- weight gain or loss
ARDS: Late signs (7)
- Tachycardia to bradycardia
- Hypo to hypertension
- Diaphoresis
- Cyanosis
- Pallor
- changes in sensorium with decreased mentation (somnolence, agitation)
- Extracardiac sounds
ARDS: Medical Management (5)
- drugs to regulate and increase BP (norepinephrine)
- PRBCs for hemodynamic support
- Fluid restriction and diuretics for pulmonary HTN
- Treat underlying infection and trauma (i.e. sepsis)
- Sedation and analgesia that balance both comfort and desired ventilatory status
ARDS: Ventilation Management (4)
- suction PRN for secretion clearance
- give lowest oxygen (< 0.5 to maintain sat O2 > 90%)
- Low tidal volume (6 mL/kg) to limit barotrauma and volutrauma
- Use PEEP (positive end expiratory pressure) – 10-15 cm H2O adequate – risk for barotrauma
ARDS: Prone Positioning
Use (4)
Contraindications (3)
Uses
- Improves V/Q matching
- Improves oxygenation in patients with ARDS b-c Good lung down to the ground ( least damaged lung in dependent position)
- Reduces aspiration risk via mobilization of secretions
- Decreases intrapulmonary shunting
Contraindications
- increased ICP or spinal cord injury
- hemodynamic instability
- recent abdominal surgery
ARDS: Rotation Therapy
Use (2)
Types (2)
Complications (3)
Use
- Helps with V/Q matching to improve oxygenation
- Prevents further pulmonary complications r/t mechanical ventilation and bedrest
Types
- Kinetic therapy (> 40 degree continuous rotation)- Decreases VAP incidence
- Continuous lateral rotation therapy (CLRT)– <40 degree continuous rotation
Complications
- Dislodgment or obstruction of tubes/lines/drains
- Pressure injuries (NURSE must still turn pt q2h)
- Hemodynamic instability
ARDS: Prone Positioning
Complications (6)
- tube/drain obstruction (care: move out of way)
- Hemodynamic instability
- Massive facial edema
- Pressure injuries (care: continue to turn as needed)
- Aspiration
- corneal ulcerations (care: lubricate and close eyes)
ARDS: Treatment Complications (5 and prevention)
- Hospital-acquired pneumonia
Prevention: HOB elevate, hand hygiene - Barotrauma (r/t rupture of overextended alveoli from excess pressure)–s/s: subQ emphysema, sternal pain, clicking sound over heart, friction rub
Prevention: smaller volumes of PEEP - Volutrauma (r/t too much volume ventilating non compliant lungs)
Prevention: smaller tidal volumes - Stress ulcers r/t decreased GI blood flow
Prevention: PPIs, H2 antagonists, enteral nutrition - Renal failure r/t decreased renal blood flow, hypotension, hypoxemia, hypercapnia
Prevention: limit nephrotoxic antibiotics
Artificial Airway: Oral Care (5)
- q2h and as needed b-c increased bacteria r/t decreased saliva, poor mucosal status and dental plaque
- Brush teeth and stimulate gums and tongue w/ swab
- No glycerin, alcohol, hydrogen peroxide because drying effects
- deep oropharyngeal suctioning for pooled secretions (painful for subglottic secretions so give pain meds or sedation)
- 2% chlorhexidine q4-6h
Artificial Airway: Skin Care (4)
- Pad pressure points if s/s of irritation
- Lubricate nares, face, lip w/ nonpetroleum cream to prevent drying effect
- Maintain cuff pressure (Low-pressure, high volume
- Monitor cuff pressure every shift to maintain within 20-30 cm H2O (< 20 = increased risk of aspiration; > 30 = decreased blood flow to capillaries in tracheal wall (report to HCP))
Artificial Airway: Suctioning (sterile)
Complications (7)
- Hypoxemia r/t disconnected oxygen
Care: stop suctioning if O2 < 90% - Atelectasis r/t suction catheter > ½ diameter of ETT and excessive negative pressure or prolonged suctioning
- Bronchospasms r/t stimulation of airway w/ catheter
Care: Give bronchodilator - Dysrhythmias (bradycardia, heart block, v-tach) r/t vagal stimulation
Care: Stop suctioning and hyperoxygenate - Increased ICP
- Airway trauma r/t impact of catheter in airways and excessive negative pressure
- Infection
Artificial airway: suctioning
Care (5)
- Hyperoxygenate with 100% oxygen for 30-60 sec prior to suctioning and 60 seconds after suctioning
- Use < 150 mm HG of suction to reduce hypoxemia, atelectasis and airway trauma
- Limit number of times patient is suctioned
- Suction 10-15 secs continuously on the way out to reduce hypoxemia, airway trauma, cardiac dysrhythmias (Intermittent suction during withdrawal leads to secretion dropping)
- Suction mouth or nose after suctioning artificial airway
Artificial Airway: Suctioning
Indications (6)
- Rhonchi or wheezes (usually not for crackles)
- Coughing
- visible secretions in airway or indicated by dyspnea
- Sawtooth pattern on flow-volume loop on ventilatory
- Increased peak airway pressure on ventilator
- Acute respiratory distress (increased RR (indicates hypoxia), HR; restless; decreased O2 sat)
Mechanical Ventilation
Definition
Indications (4)
Types (2)
Definition: process of using an apparatus to facilitate transport of O2 and CO2 b/w atmosphere and alveoli to enhance pulmonary gas exchange
Indications: Ventilation, oxygenation, airway and lung protection, secretions
Types of ventilators
- Positive-pressure: intubated and on machine via ETT or Trach; mechanical drive to force air into lungs
- Negative-pressure: on machine but via mask; decrease atmospheric pressure around thorax to initiate inspiration
Basic Ventilator Settings
- Modes (3)
- Rate
- Tidal Volume
- PEEP (2)
- FiO2 (2)
Mode of ventilation
- Assist Control (AC)
- Synchronized Intermittent Mandatory Ventilation (SIMV)
- Continuous Positive Airway Pressure (CPAP)
Rate: respiratory rate (6-30 breaths/min)
Tidal volume (VT): volume or size of the breath (6-10 mL/kg (4-8 mL/kg in ARDS)
Positive-end expiratory pressure (PEEP)
- amount of pressure remaining in the lung at the END of the expiratory phase; keeps alveoli from collapsing (3-5 cm H2O)
- Risks of too much PEEP: barotrauma, decreased venous return
FiO2
- fraction of inspired oxygen (Range: 21%-100%)
- prefer <50% to maintain O2 sat > 92% and PaO2 > 60 mm Hg
Ventilator Modes: Assist/Control (Continuous mandatory ventilation)
- How it works? (2)
- Indications (2)
- Care (2)
How it works
- Delivers a “machine breath” every time, whether the pt. triggers the breath or the ventilator initiates the breath (time-triggered)
- patient cannot generate spontaneous volume or flow rate
Indications
- Volume controlled AC if weak respiratory muscles but spontaneous breathing (Risk for volutrauma)
- Pressure controlled AC if decreased lung compliance, increased airway resistance or risk for Volutrauma (Risk for hypercapnia)
Care
- Hyperventilation risk if patient increases their respiratory rate
- Sedation may be needed to limit # of spontaneous breaths
Ventilator Modes: Synchronized Intermittent Mandatory Ventilation (SIMV)
- How it works? (3)
- Indications (3)
- Risk
How it works
- Delivers a pre-set number of breaths at a set volume or pressure and flow rate.
- Allows the patient to generate spontaneous breaths, volumes, and flow rates between the set breaths.
- Detects a patient’s spontaneous breath attempt and doesn’t initiate a ventilatory breath – prevents breath stacking (A/C does not prevent breath stacking)
Indications
- Volume controlled if weak respiratory muscles but spontaneous breathing
- Pressure controlled if decreased lung compliance, increased airway resistance or risk for Volutrauma (Risk for hypercapnia)
- used for weaning
Risk
- May increase work of breathing and promote respiratory muscle fatigue when used for weaning
Ventilator Modes: Pressure Support
How it works? (2)
Use
Risk
Pros (3)
How it works?
- Positive pressure applied only on patient- initiated breaths on inhalation to augment efforts (similar to PEEP but only on inhalation vs. expiration)
- Patient’s lung mechanics and efforts controls rate, inspiratory flow, and tidal volume
Use: for pt w/ stable respiratory drive to overcome mechanical resistance
Risk: Hypercapnia
Pros
- Reduces work of breathing
- increases ventilatory synchrony
- Can be used with SIMV or CPAP
Ventilator Modes: Continuous Positive Airway Pressure (CPAP)
How it works? (3)
Indication (3)
How it works?
- Positive pressure applied during spontaneous breaths (no ventilator breaths in PEEP or CPAP mode)
- Pt controls rate, inspiratory flow, tidal volume
- Similar to pressure support but without the additional inspiratory pressure
Indication
- used with masks for sleep apnea (negative pressure)
- used with ventilator (positive pressure)
- used for weaning
Mechanical Ventilation: Respiratory Complications (5)
- Increased secretions (care: Suction PRN)
- Oxygen toxicity (Continuous oxygen > 50% for > 24-48 hrs may injure lung and reduce tissue integrity) –Care: notify HCP if PaO2 > 90 mm Hg
- Respiratory muscle weakness
- Ventilator-Associated Pneumonia
- Ventilator induced lung injury
Mechanical Ventilation: Complications
CNS
GI (3)
Cardiac
Psychological (2)
CNS
- Increased ICP r/t decreased cerebral venous return
GI (prevent: NGT decompression, appropriate cuff inflation)
- Gastric distention r/t air leaks around ETT or trach cuff and overcomes resistance of lower esophageal sphincter
- Vomiting r/t pharyngeal stimulation from artificial airway
- Hypomotility and constipation r/t immobility and paralytic agents, analgesics, sedatives
Cardiovascular compromise
- Decreased Cardiac Output r/t decreased venous return to right side of heart
Psychological complications
- need for alternative communication
- Patient ventilator dyssynchrony (Risks: auto-PEEP, psychological distress, decreased effectiveness)
Care: ventilator accommodates patient’s spontaneous breathing pattern OR patient is sedated
Mechanical Ventilation: Oxygen Toxicity
Early signs (4)
Late signs (5)
Care
Early s/s: dyspnea, nonproductive cough, sternal chest pain, GI upset, crackles
Late s/s: decreased vital capacity and compliance; hypoxemia, pulmonary edema, hemorrhage, hyaline membrane formation and atelectasis
Care: notify HCP if paO2 > 90
Ventilator-induced Lung Injury
Causes (4)
Care (3)
Causes
- Barotrauma r/t too much PEEP
- Volutrauma r/t too much tidal volume
- Atelectrauma r/t shearing r/t repeated opening and closing of alveoli
- biotrauma r/t inflammatory-immune response (Leads to ARDS)
Care
- keep pressure at 32 or below cm H2O
- use PEEP
- tidal volume of 6-10 ml/kg
Mechanical Ventilation: ABCDE
Awakening
Breathing Coordination
Delirium monitoring
Early mobility
Ventilator Assessment (4)
- Assess settings and do they correlate with presentation (any desynchrony?)
- High pressure alarms = airway obstruction b-c patient ventilatory desynchrony, airway resistance or kinked tubing
- Low pressure alarm = leak or oxygen not connected
- If vent malfunctions, disconnect patient from vent and Ambu bag patient
Ventilator-Associated pneumonia
Definition
Risk factors (5)
Development of pneumonia 48-72 hrs after endotracheal or other artificial airway insertion intubation b-c tube bypasses normal defense mechanisms of lung
Risk factors
- severe illness
- increased age
- presence of ARDS or malnutrition
- naso intubation b-c promotes aspiration
- Gastric alkalization by enteral feeds and meds b-c promotes bacterial growth
Prevention of VAP (7)
- Hand hygiene
- Elevation of HOB (30-45 degrees) to prevent GER and aspiration
- Daily “sedation vacations” and assessment of readiness to extubate
- Stress ulcer prophylaxis
- DVT prophylaxis
- Daily oral care (teeth, gums, and tongue) with chlorhexidine q2h
- Adequate endotracheal tube cuff pressure (Keep at 20cm H20-decreases aspiration)
Prevention of Sedation Dependence: Daily Sedation Interruption
Contraindications (5)
- hemodynamic instability
- increased ICP
- ongoing agitation or seizures
- alcohol withdrawal
- use of neuromuscular blocking agent
Mechanical Ventilation: Drug Therapy
- mucolytics
- bronchodilators
- steroids
- sedatives (2)
- paralytics (Nimbex/cisatracurium besilate) (3)
Mucolytics (Liquefy secretions to help with their removal)
Bronchodilators (beta 2 agonists and anticholinergics)
- Relax smooth muscles when air flow limitations
Steroids (Reduce airway inflammation)
Sedatives
- provide comfort
- Decrease work of breathing and prevent ventilator fighting
Neuromuscular paralysis (Nimbex-Cisatracurium besilate)
- Decreases oxygen consumption:
- sedate and explain all procedures to patient if giving paralytic b-c they do not inhibit pain or awareness
- risk for immobility complications so prevent skin breakdown, DVT, and atelectasis
Aspiration: Risk factors (4)
- surgical changes in upper respiratory tract w/ laryngectomy
- NGT
- Difficulty swallowing r/t tracheostomy tube fixing larynx in place and cuff interfering with passage of food via esophagus
- cuff pressure < 20 on trach tube (may partially deflate for easier swallowing)
QT Prolongation
Causes (5)
Risk
Treatment (4)
Causes
- electrolyte imbalance (hypokalemia, hypomagnesemia, hypocalcemia)
- bradycardia
- heart blocks
- PVC
- meds (antidysrhythmic (i.e. amiodarone), antibiotics, anesthetics, antidepressants, antiemetics, antipsychotics, opioids, sedatives)
Risk: torsades de pointes (v-tach)
Treatment: pacemaker, increase HR, stop meds, correct electrolytes
ST Segment
How many boxes is it deviated?
NSTEMI (3)
STEMI (3)
- deviated 3 small boxes up or down
Non-ST elevation MI (NSTEMI)
- No ST elevation
- T waves may be tall and symmetric
- troponin is elevated
ST elevation MI (STEMI)
- ST elevation in 2 or more consecutive leads
- T wave inversion
- troponin elevated as well
Ventricular Dysrhythmias: Characteristics (3)
- widened QRS complexes (> 0.12)
- impulses from sinus and atrial nodes fail
- lead to decreased perfusion and potential for cardiac arrest
Premature ventricular complexes (PVC)
What is it?
Causes (5)
- Early ventricular contraction/irritability (misfiring in heart outside of SA node; unable to see P wave)
Causes
- electrolytes (hypokalemia, hypomagnesemia,
- drugs (smoking, caffeine, alcohol,,
- stress (infection or invasive procedure (cardiac cath, surgery))
- respiratory problems (hypoxemia, acidosis, COPD)
- heart problems (cardiomyopathy, ventricular aneurysms, CHF, MI, sympathomimetic drugs)
Premature ventricular complexes (PVC)
Multifocal vs. unifocal
Repetitive Waves (4)
Multifocal vs. Unifocal
- Multifocal looks different and occur in different areas (more serious)
- Unifocal look the same and occurring in same place of heart
Repetitive Waves
- 2 PVCs- Couplets (two consecutive PVC)
- Bigeminy (after every normal beat)
- Trigeminy (after every two normal beats)
- 3 or more PVC’s in a row = Nonsustained run of V-tach
PVCs: Nursing care (5)
- if new or symptomatic, call HCP
- If > 3 in a row, call MRT and give amiodarone or beta blockers
- Check labs for hypokalemia or hypomagnesemia
- check perfusion (HR, BP, palpitations, decreased peripheral pulses)
- request 12-lead EKG
V-tach: Characteristics (4)
- most common ventricular dysrhythmia
- Repetitive ventricular firing greater than 140 beats/min
- no P waves
- Nonsustained V-tach = < 30 seconds (sustained can progress to v-fib)
V-Tach/v-fib: Causes (4)
- Cardiac (MI, HF, Dig toxicity,valvular dysfunction, cardiomyopathy, hypotension, SVT)
- Electrolytes (hypokalemia, hypomagnesemia)
- Meds (steroids, antidysrhythmic drugs which prolong QT)
- Drugs(cocaine)
V-tach: Care w/ carotid pulse (4)
- slow pulse with amiodarone (alt: diltiazem, digoxin, lidocaine, procainamide)
- use cardioversion (call HCP; can be elective or emergent)
- give oxygen
- Get informed consent and hold digoxin 48 hrs prior to elective cardioversion b-c increases risk of VF from shock
V-tach: Care w/o carotid pulse (4)
Note: same care for V-fib
- Implement Code Blue/ ACLS Protocol
- Defibrillate (priority after everyone clear and oxygen off)
- CPR if no defibrillation and after defibrillation
- Epinephrine q3 min if no HR and no pulse after IV established
V-fib: characteristics (4)
- Total chaos in ventricle with no discernible waves or complexes
- Ventricles quiver and no forward flow of blood which consumes oxygen
- Non-perfusing rhythm (no BP, no HR, apnea; potential for seizures and acidosis)
- fatal if not terminated in 3-5 min
Myocardial Infarction: Priority Meds (4)
- Morphine: For pain, anxiety, fear, reduces preload and afterload
- Oxygen: To maintain >90% O2 sat
- Nitroglycerin sublingual (vasodilation and increase cardiac output)–Risk for hypotension (hold if systolic <90 OR PDE5 inhibitor (sildenafil) in hx for erectile dysfunction or pulmonary HTN)
- Aspirin (ASA): Prevents clumping of platelets and reduces mortality
Myocardial Infarction: Areas from outer to inner
Area of ischemia (2)
Area of Injury (2)
Area of Infarction (3)
Ischemia
- transient and reversible due to O2 deprivation
- Seen on ECG as T-wave inversion and ST depression
Injury
- injured but potentially viable tissue if circulation adequate
- Seen on ECG as ST elevation
Infarction (irreversible)
- Area of dead muscle (necrosis) in the myocardium which becomes scar tissue
- Delayed treatment = increased damage/area of infarction
- Seen on ECG as pathologic Q waves (deeper and wider than normal)
MI: Clinical Manifestations (7)
- Angina (abrupt and not relieved by NTG); may be crushing, tightness, radiating
- systolic murmur or S3/S4 sounds (r/t papillary muscle rupture, HF, pulmonary edema)
- Pulmonary (dyspnea, tachypnea, crackles, wheezes)
- Skin (diaphoresis)
- Decreased cardiac outout) (tachycardia, hypotension, slow cap refill
- Neuro (syncope, denial)
- Muscular (weakness)
Diagnostics for MI (3)
- Cardiac monitoring (12 lead EKG within 10 min of arrival to determine where MI is in the heart)
- daily chest x-ray
- echocardiogram
Labs for MI (4)
- troponin (q6-8h b-c not elevated immediately but elevated for 7-10 days)
- Metabolic panel
- CBC
- B type natriuretic peptide (BNP) (Rule out heart failure)
MI: Other Drugs Purposes
- Beta Blocker (2)
- ACE Inhibitor and ARBs
- Anticoagulant (2)
Beta Blocker
- Decrease mortality from ventricular dysrhythmias; lower BP, prevent reinfarction
- Hold if in cardiogenic shock, heart failure, heart block (PR >0.24) or active asthma
ACE Inhibitor and ARBs
- Prevent ventricular remodeling and HF
Anticoagulant (Heparin or Enoxaparin)
- enhance perfusion
- If thrombocytopenia, give direct antithrombotic (e.g., bivalirudin, argatroban)
MI: Priority Non Pharmacological Care (4)
- place two large bore IVs
- Door-to-PCI within 120 minutes if need transfer to PCI-capable facility (90 min if PCI-capable hospital)
- Balance myocardial oxygen supply and demand (use Bed rest w/ bathroom privileges and place upright for venous return, lower preload, decrease workload)
- Prevent immobility complications (DVT, pneumonia) w/ early mobility and HOB 30 or more
Fibrinolytics (tPA (ateplase); Reteplase (rPA) or Tenecteplase (TNKase))
Eligibility (2)
Exclusion (4)
Eligibility
- Onset of STEMI within 12 hrs
- <30 min after STEMI diagnosis
Exclusion
- Uncontrolled hypertension (need antihypertensives first)
- Ischemic stroke within 3 months
- Recent surgery, facial or head trauma
- Unstable angina or NSTEMI
MI complication: Pericarditis
What is it?
S/s (4)
Care (3)
- inflammation of pericardial sac during or after MI or CABG leads to pericardium irritation
S/s
- Cardiac Friction Rub (grating, scraping, leathery scratching at sternal border)- most common initial
- Chest pain (exacerbated by deep breathing/coughing and supine)- most common
- Pericardial effusion
- ST elevation in all EKG leads
Care
- NSAIDS/Aspirin
- Rest
- Pericardiocentesis (removal of fluid)
Fibrinolytics (tPA (ateplase); Reteplase (rPA) or Tenecteplase (TNKase))
Action
Care (5)
Action: lysis of acute thrombus to reopen obstructed coronary artery and restore blood flow; short half-life
Care
- Anticoagulants(heparin) for 48 hrs after
- Antiplatelets (clopidogrel) for 14 days to 1 year after
- Continue aspirin indefinitely
- Bleeding precautions (gently handling, avoid venipunctures, apply add’l pressure)
- STOP if IC bleeding or internal bleeding and give volume expanders and coagulation factors
MI: Other Drugs Purposes
Stool Softener
Inotropic (dobutamine, dopamine, milrinone)
Diuretic
Amiodarone (antidysrhythmias)
Stool softener
- prevent straining which can slow HR via vagal stimulation
Inotropic (dobutamine, dopamine, milrinone)
- Increase CO
Diuretic
- If elevated BNP, pulmonary edema, CHF exacerbation
Amiodarone (antidysrhythmias)
- If v-tach w/ pulse or a-fib w/ RVR
PCI: Nursing Interventions r/t to risk of bleeding (4)
- Watch for S/S of bleeding (hematoma, hypotension, tachycardia; Back pain (retroperitoneal bleeding))
- Assess insertion site and apply direct pressure if bleeding
- HOB should be less than 30 degrees
- Bedrest: Instruct to keep limb straight/minimize movement for 4-6 hrs
PCI: Nursing Interventions r/t to risk for ineffective peripheral tissue perfusion (3)
- Monitor neurovascular of affected extremity (distal pulses, cap refill, color, sensation, and temperature in involved extremity)
- VS q15 for 1h, q30 for 1 hr, q1 for 4 hrs
- Monitor for graft occlusion
PCI: Nursing Interventions r/t to risk of Angina (4)
- Watch for increased chest pain r/t thrombosis or transient coronary vasospasm
- Monitor EKG for ST elevation
- Give IV NTG
- Monitor labs for hypokalemia
PCI: Nursing Interventions r/t to risk of AKI (3)
- Maintain hydration before and after (NS and/or sodium bicarb)
- Check Crt, BUN, GFR prior
- Avoid nephrotoxic drugs (NSAIDS, metformin)
MI: Signs of Reperfusion (4)
- Chest pain stops due to return of blood flow
- CK and troponin increase rapidly then decrease (a washout)
- ST elevation returns to baseline (note Failure of fibrinolytic = inability to achieve 50% resolution of ST elevation within 60-90 minutes of med admin)
- Reperfusion dysrhythmias (ex. PVCs, bradycardia, heart block, VT)- Usually self-limiting –> Care for PVCs: oxygen and correct f/e imbalance
Components of Hemodynamic Monitoring (4)
- Invasive catheter (Art-line least invasive)
- 250-300 mm Hg pressure tubing with 0.9% NS flush solution
- Transducer to convert physiologic signal into electrical energy
- Bedside monitor to display volume of electrical signal on digital scale
Care for Hemodynamic Monitoring (7)
- separate pressure bags for separate lines
- place transducer at phlebostatic axis (midaxillary 4th intercostal space) while HOB 0-60 degrees every shift
- zero transducer once a shift (open to atmospheric pressure and close to patient and flush solution)
- monitor for bleeding, infection (CLABSI), air embolus, thrombus, dislodgement
- alarms should always be audible
- do fast flush square wave test to ensure waveform not over or underdamped
- daily x-ray for placement
Art-line
What is it?
Indications (4)
Continuous measurement of three BP parameters (Systole, Diastole, Mean arterial blood pressure (MAP))
Indications
- Shock
- Hyper or hypotension
- Post-op for major surgery
- Acute lung failure b-c need frequent ABGs
Art-line: Care (3)
- perform Allen test to assess collateral circulation
- assess wave form (Systole: highest point; Dicrotic notch: closure of aortic valve and start of blood flow into arterial vasculature; Diastolic: lowest point)
- never put meds in ART
Mean Arterial Pressure
Range
Preferred values (2)
Equation
Range: 70-100 mm Hg
Preferred
- > 60 to perfuse coronary arteries
- > 65 to perfuse brain and kidneys
Equation: MAP= [(DBP(2) + SBP)/3)]
Central venous pressure (CVP)
What is it?
Indication
Placement (3)
Normal Range
- Measures right ventricular end-diastolic pressure( filling pressures of the right side of the heart) and sits in superior vena cava
Indicated for alteration in fluid volume (high = overload; low = dehydration)
Catheter Placement
- Subclavian (SC- better if > 5 days)
- Internal jugular (IJ- has best blood flow and less risk for pneumothorax)
- Femoral (if others inaccessible b-c higher risk for infection)
Range: 2-5 mm Hg
Cardiac Output
What is it?
What does Starling Law say?
Equation
Normal range
Volume of blood ejected from the left ventricle in 1 minute
Starling Law: force of ventricular blood volume ejection is related to preload (Volume of blood in the ventricle at end-diastole) and Amount of stretch (force) placed on the ventricle
Equation: HR (# of beats per minute) X SV (amount of blood ejected by ventricle w/ each heartbeat) = CO
Normal range: 4-6 L/min
Preload
What is it
Factors on left and right side (2)
When increased (2)
How to reduce (3)
- pressures resulting from volume coming into ventricles (end diastolic pressure)
Factors on left and right side
- Left side (Pulmonary artery diastolic pressure and pulmonary artery occlusion pressure)
- Right (CVP aka right atrial pressure)
- increased (hypervolemia, regurgitation of valves)
How to reduce
- diuretics
- vasodilators
- fluid restrictions
Afterload
What is it
Factors on left and right side (2)
When increased (2)
Care (2)
- resistance left ventricle must overcome to circulate blood/ overcome systolic ejection
Factors
- Left (SVR– high SVR = decreased CO)
- Right (PVR)
- increased (HTN, vasoconstriction) = increased cardiac workload
Care
- to reduce, ACEI, ARBS, vasodilators (sodium nitroprusside, NTG)
- to increase, vasopressors and IV fluids (preferably w/ art-line)
Contractility
What is it?
Relation to Afterload, Preload, Ventricle distention (3)
Drugs to improve contractility (3)
The heart’s ability to stretch and contract
Relation
- Afterload/SVR increases, contractility decreases
- Preload increases, contractility increases
- If ventricle overdistended, contractility decreases
Drugs:
- Cardiac glycoside (digoxin)
- Inotropic drugs (dobutamine, dopamine, milrinone
- Oxygen (Hypoxia = negative inotrope)
Hyperglycemia w/ absence of insulin Symptoms (11)
- Polyuria (r/t osmotic diuresis from excess glucose in urine; leads to hypokalemia)
- Polydipsia
- Polyphagia (R/t cellular starvation of glucose so need insulin vs food to push glucose into cells)
- Ketonuria and ketonemia -> metabolic acidosis -> hyperkalemia
- Kussmaul respirations (to blow off excess CO2 from anion gap) – compensatory respiratory alkalosis
- Acetone exhaled (fruity odor)
- Hemoconcentration and Hyperviscosity
- Hypovolemia (low CVP, high HR, low BP) and hypoperfusion
- Hypoxia -> lactic acid production
- Pain (headache, abdominal
- fatigue, weakness)
Diabetic Ketoacidosis (DKA): Definition (5)
- Glucose > 250 mg/dL
- Low bicarbonate level (<18 mEq/L)
- Acidosis (pH <7.30)
- Moderate or severe ketonemia and ketonuria
- Anion gap > 12
DKA: non-defining labs (6)
- Leukocytosis
- Urine: High specific gravity and osmolality
- Glucosuria (Osmotic pull of glucose increases output)
- BUN, Crt increase b-c risk for kidney impairment r/t decreased organ perfusion
- K, Na, PO4 excreted in urine (may be low)
- Serum osmolality (hyperosmolality)
DKA: Hydration (3)
- NS 1 Liter w/n first hour
- Then NS 1/2 at 250-500ml/hr
- When glucose < 200, change to D5W 1/2NS at 150-250ml/hr to prevent hypoglycemia and cerebral edema via replenishing cellular glucose
DKA: Correct Electrolytes -5
- replace sodium w/ fluids
- If hypokalemic, give K immediately before insulin
- If not hypokalemic, give 20-30 mEq of K+ within 2-3 hrs of treatments
- If hyperkalemic, insulin and volume expansion will correct
- Replace phosphate if < 1 mg/dL
DKA: Replace insulin (4)
- 0.1 unit/kg Regular Insulin IV Bolus (onset: 15 min)
followed by 0.1 unit/kg/hr via continuous IV pump - Glucose should drop 50-70 points/hr
- Switch to SubQ regular insulin 2 hours before discontinuing continuous pump
- Patient must be stable w/ consistent glucose level, no ketosis, and able to eat prior to switch to subQ
DKA/HHS: Monitoring response to therapy (5)
- Hourly glucose checks until stable (once stable, q2-4h)
- Use accuchecks unless CVP or art-line w/ blood conservation system
- rate of blood glucose change = 50—70 (More important than actual level)
- Monitor appearance, VS, I & O and Labs: BUN, Crt, K, ABGs
- NPO until glucose is stable
DKA: Markers for resolution (4)
- Blood glucose below 200 mg/dL
- Serum bicarbonate above 18 mEq
- pH greater than 7.3
- absence of ketones in urine and blood
DKA/HHS: Complications from management and key care(6)
Fluid volume overload r/t HF or kidney disease
- Care: oxygen, reduce infusion, elevate HOB, assess fluid status
Hypokalemia or Hyperkalemia
- Care: ECG monitoring, potassium chloride
Hyponatremia
- Care: NGT intermittent suctioning if NV
Cerebral edema
- Care: hourly neuro assessment esp sudden headache, confusion, pupils
Infection
- Care: oral care, repositioning, sterile technique, check venipuncture sites q4h
Hypoglycemia
- Care: stop IV insulin, give D50 or subQ glucagon q15 until glucose > 70
Hyperglycemic Hyperosmolar State (HHS): Definition (6)
- Blood glucose > 600 mg/dL
- Arterial pH > 7.3
- Serum bicarb > 18 mEq/L
- Serum osmolality > 320 mmol/kg (risk for coma if > 350)
- Absent or mild ketonuria (No ketogenesis so no fruity breath and Rapid and shallow respirations vs kussmaul)
- Severe dehydration
HHS: Management (6)
- NS 1 liter/hr for massive fluid replacement
- Once hemodynamically stable (look at CVP or PAOP) or serum Na reaches 140mEq/L change to 1/2NS.
- When plasma glucose reaches 300mg/dL, change to D5W 1/2NS 150-250 ml/hr
- 0.15 unit/kg Regular Insulin IV Bolus followed by 0.1unit/kg/hr
- subQ insulin once glucose stable and adequate food intake
- Correct electrolytes (Potassium is added based on serum level (give if < 3.3))
Older adults and glucose regulation (6)
- reduced glucose metabolism r/t increased visceral fat and decreased lean muscle mass
- reduced insulin production r/t decreased pancreatic islet function (unable to regulate and metabolize glucose concentrations)
- Type 2 DM more common in older adults
- DM in older adults = increased institutionalization and reduced functional status
- DM presents as thirst, confusion, infection, poor wound healing in older adults
- increased DM complications (ESKD, blindness, heart disease, CVA, neuropathy, depression, sexual dysfunction, periodontal disease)
Older adults: Reason for increased hypoglycemia risk (3)
- Decreased kidney function so reduced elimination of sulfonylurea and insulin
- Reduced epinephrine and glucagon release r/t hypoglycemic unawareness
- Impaired motor skills interfere w/ ability to correct glucose levels
Older adults: Endocrine system (5)
- cold intolerance (hard to distinguish from hypothyroidism) r/t decreased metabolism
- dilute urine and dehydration risk r/t decreased ADH production
- reduced thyroid hormone secretion (may not have s/s of hypothyroidism)
- hypothyroidism is most common thyroid problem in older adults
- start low and go slow w/ levothyroxine b-c risk of angina, dysrhythmias, HTN
DI: Three types
Central Diabetes Insipidus AKA neurogenic DI
- Hypofunction of the posterior pituitary gland or hypothalamus leads to ADH (vasopressin) deficiency
- no ADH = kidneys not told to concentrate urine so lose excess H2O
Nephrogenic Diabetes Insipidus
- Inability of kidney tubules to respond to circulating ADH
Dipsogenic Diabetes Insipidus
- Compulsive water drinking (> 5 L/day)
DI: labs (4)
- High Serum Na+ > 145 mEq/L
- High Serum Osmolality > 295 mOsm//L (Normal: 275-295)
- Low Urine Osmolality < 300 mOsm/L
- Low Urine specific gravity < 1.005
DI: manifestations (3)
- Dehydration (decreased skin turgor, dry mucous membrane, tachycardia, hypotension/hypovolemia, hemoconcentration, constipation, LOC change)
- large dilute urine (polyuria and nocturia ; > 3L/24 hr) w/o hyperglycemia, diuretics, or fluid challenge
- Polydipsia
DI: Medical Management
General - 3
Central DI - 2
Nephrogenic DI - 1
General
- volume resuscitation (oral or IV hypotonic)
- may need lifelong care for chronic DI w/ daily weights (ED if > 2.2 lb overnight)
- monitor for fluid balance (overload or dehydration)- need urinary catheter
Central DI
- Vasopressin (antidiuretic and vasoconstrictor): risk for HTN, angina, vasospasm (MI, CVA) so not preferred
- Desmopressin (DDAVP- strong antidiuretic w/ little effect on BP - preferred
Nephrogenic DI
- Hydrochlorothiazide (HCTZ) - reduces amount of urine via resorption of sodium and water in proximal nephron
Water deprivation Test
Purpose
Procedure
Results (2)
Purpose: measure ADH and determine type of DI
Procedure: give ADH (vasopressin)
Results
- If condition improves, there is central DI
- If condition does not improve, there is nephrogenic DI
SIADH: Labs (5)
- Hyponatremia (less than 125 mEq/L)
- Decreased Serum Osmolality – < 275 mOsm/L
- increased Urine osmolality – >100 mOsm/L
- Elevated urine sodium
- Elevated urine specific gravity (> 1.030)
SIADH: Manifestations (9)
- GI: loss of appetite, NV
- Dilutional hyponatremia (Lethargy, NV, Headache, hostility, disorientation)
- Severe Neurological Symptoms (Serum Sodium< 120 mEq/L)- > Decreased LOC, Seizures/ Coma, Apprehension
- Hypothermia r/t CNS disturbance
- Full and bounding pulse r/t increased fluid volume
- Decreased DTR’s
- Weight gain but no edema b-c water not salt is retained
- Decreased urine output
- increased thirst (polydipsia)
SIADH: Nursing Management (6)
- Meds (hypertonic NaCl, Vaptans, Diuretic(if normal Na))
- Fluid restriction (usually 500 -1000 mL/day)
- Oral care for comfort and to prevent dry mouth
- If they need any free water, use saline vs tap water
- Monitor for complications (I &O, daily weights, fluid status q2h; neuro status hourly if any changes in LOC)
- Always seizure precautions and reduce stimulation if SIADH
SIADH: Na replacement (3)
- Hypertonic saline (3%NaCl) when Na level is too low to prevent extra volume
- do not want rapid sodium increase (want gradual increase 8 mEq/L in 24 hr to prevent osmotic demyelination)
- Monitor Na+ and K+ q4h during acute phase of sodium replacement
Vaptans (Conivaptan (Vaprisol)- IV or Tolvaptan (Samsca) – PO)
Indication
Action
Risks (2)
Indication: euvolemic hyponatremia in SIADH
Action: excretes water and conserves sodium (aqua diuresis)
Risks
- For Conivaptan, hypotension (contraindicated in hypovolemia)
- For Tolvaptan, black box warning for rapid hypernatremia (risk for CNS demyelination) AND liver failure
Myxedema Coma: Manifestations (8)
- Cardiac (anemia, hypotension, bradycardia, peripheral vasoconstriction, cardiomegaly, narrow pulse pressure, prolonged QT/PR)- risk for shock and cardiac tamponade
- Pulmonary (hypoventilation)
- GI: constipation, anorexia, abdominal distention)
- cold intolerance (< 36.1)
- CNS (blank facial expression, apathy, slow speech, depression, delirium, stupor, coma)
- Skin (thick tongue w/ husky voice, brittle/thin nails and hair, nonpitting edema (weight gain), poor wound healing
- Muscle (decreased DTR, paresthesia of hands and feet r/t hyaluronic acid deposits)
- Renal (decreased GFR, specific gravity, urine osmolality and output) b-c decreased blood flow
Myxedema Coma: Labs (6)
- Low T3 and T4
- Hypoglycemia
- Increased TSH
- Hyponatremia (confusion, NV)
- metabolic acidosis/respiratory acidosis
- hypercholesterolemia (r/t incomplete metabolism)
Myxedema Coma: Medical Management (8)
- give IV levothyroxine then PO (risk for angina and dysrhythmias) - take on empty stomach
- give IV NS, glucose, steroids as needed
- mechanical ventilation for hypoventilation and respiratory acidosis
- warm blankets for hypothermia
- emollient and repositioning for skin (rough, edema, risk for breakdown)
- continuous ECG monitoring b-c risk for dysrhythmias
- communicate slowly and in written form b-c decreased comprehension
- fiber and fluids for constipation
Older Adults: GI system alterations (6)
- decreased GI blood flow and motility
- decreased Gastric emptying
- increased risk of dehydration (decreased thirst sensation)-> constipation
- More prone to GI bleeds b-c more prone to h. pylori
- Decreased absorption -> nutrient deficiency and anemias
- decreased swallowing = risk for aspiration and malnutrition
GI bleed: General Management
Prevention of Shock (3)
NGT Placement (2)
Prevent hypovolemic or hemorrhagic shock
- large bore IV for IV crystalloids, blood products (plasma, platelet, PRBCs)
- if esophageal varices, avoid frequent swallowing or activities that could rupture varices like vomiting or straining
- give Supplemental oxygen to Increase oxygen delivery and tissue perfusion
Nasogastric Tube Placement (NGT)
- Purpose: Gastric lavage to confirm bleeding via irrigation w/ NS; aspiration prevention, decompression (low suction); feeding
- Care: Do Not place if esophageal varices ; Lie on left side; Secure to gown; irrigate q4h w/ NS
