Study Guide Flashcards
Medications to slow the heart down? Non medications that slow down the heart?
- Amiodarone, Lidocaine, digoxin, cardizem
- Vaso maneuver
What are the typical causes when PVC is frequent and sustained? Treatment
- ventricular irritability due to hypoxia
- heart disease
- drug toxicities
Progressive Stage Medical Management:
-Depends on type of shock and cause
-Based on degree of decompensation
-Some interventions are common to all:
Appropriate IV fluids
Prevent complications
Close, continuous monitoring
-Medications to restore perfusion:
Support pumping action of heart (inotropics-dobutamine)
Vasoconstrictors (dopamine, norepi)
Perfusion through dialation (Sodium nitroprusside)
Support resp system-ABGs
Hemodynamic monitoring-CVP, Art line, PCW
Examples of Thrombolytic therapy?
- TPA, Alteplase, Tenecteplase TNK,
PVC may be a warning for the impending onset of ….?
- impending onset of, or precipitate V-tach or V-fib
Treatment of Cardiac Tamponade?
-Pericardiocentesis - removes fluid
Pericardial window - involves removing a portion of the pericardium to permit excessive pericardial fluid to drain into the pleural space.
-Pericardiectomy
What is Capillary leak syndrome?
Response of capillaries to the presence of body chemicals that enlarge capillary pores and allow fluid to shift from the capillaries into the interstitial tissues.
Progressive Stage (intermediate) of SHOCK:
MAP falls more than 20 mm Hg from baseline
Compensation functioning, no longer adequate
Vital organs develop hypoxia
Less vital ischemia
Life-threatening emergency-critical rescue!
Immediate interventions are needed.
Vital organs can only tolerate so long
Survival depends on age and overall health
Treatment of stable Atrial Fibrillation vs treatment of unstable atrial fibrillation?
- Medications: Antidysrhythmics (Amiodarone, procainamide, lidocaine), beta blockers, calcium channel blockers, procainamide, digoxin)
- Cardioversion “.”
What is ANGINA PECTORIS?
- Temporary imbalance /b/ the coronary arteries ability to supply oxygen and the cardiac muscles demand for oxygen. “strangling of the chest”
Describe VARIANT Angina?
Variant - chest pain or discomfort resulting from coronary artery spasm and typically occurs after rest. EKG = ST changes but no changes in troponin or CK levels b/c no tissue has be damaged yet. * begins to block oxygen flow to the tissues
What does endocarditis/pericardit sound like?
Washing machine sound
- S3 or S4
What is the Atrial rate? and
Ventricular rate?
Atrial >300/min
Ventricular > 100/min
Signs and Symptoms of CARDIOGENIC SHOCK?
- Everything is going to decrease (perfusion, BP, CO)
Initial (early) stage of SHOCK?
- Difficult to detect!
- Baseline MAP decreased by less than 10 mm Hg
- Heart and respiratory rate increased from the baseline or a slight increase in diastolic blood pressure
- Adaptive responses of vascular constriction and increased heart rate
- Compensatory mechanisms effective
- Overall metabolism still aerobic
What is the normal EJECTION FRACTION? What does the EF measure?
- 50-70%
- Contractility
Pathophysiology of SHOCK:
-Cells forced to produce energy with anaerobic (w/o 02) metabolism This causes: Low yield of energy and ATP Produces lactic acid (why we draw lactic acids) Acidotic cell environment Membrane more permeable Electrolytes and fluid seep in and out Na-K pump fails Cell structures damaged Cell death
3 major components:
- Volume
- Pump
- Vasculature
Must respond to feedback systems: (3 compensatory responses)
- Neural (sympathetic vs parasympathetic, baroreceptors/epi/norepi)
- Chemical( RAAS and kidneys that are trying to make adjustments in order to maintain adequate blood volume and flow )
- Hormonal (aldosterone NA/water retention in order to maintain blood volume and increase blood volume to increase CO)
When one fails, the others compensate
Eventually no longer able to compensate
Tissues are then not perfused adequately
Shock occurs
How does a PVC appear on the EKG? What is the rate?
and Rhythm?
- seen as early ventricular complexes followed by a pause
- QRS wide (greater than 0.12 sec ), bizarre appearance (uniform or multiform)
Rate = variable; Rhythm= atrial regular, ventricular irregular;
What is obstructive shock?
caused by problems that impair the ability of the normal heart to pump effectively. The heart itself remains normal but conditions outside the heart prevent either adequate filling or adequate contraction of heart muscle
What is the atrial/ ventricular rhythm for a person in Atrial Fibrillation?
Irregular
Refractory (Irreversible) Stage of SHOCK:
Rapid loss of consciousness, nonpalpable pulse, cold, dusky extremities; slow, shallow respirations; unmeasurable oxygen saturation
MODS can occur here or as separate syndrome
Therapy ineffective, death imminent
What speeds up the heart? Medications? Non medications that increase heart rate?
Atropine
Epinephrine
Inotropic - Dobutamine
- Caffeine - stimulants
Medications for shock?
Insulin
Steroids
Antibiotics
Vasopressors
Manifestations of sepsis/septic shock:
Early symptoms of sepsis:
- fever usually higher than 101˚F (38˚C)
- low body temperature (hypothermia)
- fast heart rate
- rapid breathing, or more than 20 breaths per minute
Severe sepsis:
- noticeably lower amounts of urine
- acute confusion
- dizziness
- severe problems breathing
- bluish discoloration of the digits or lips (cyanosis)
Formula for Drip factor
Volume (mL)/ Time (min) x Drop Factor (gtts/mL) = Y (Flow Rate in gtts/min
Signs and Symptoms of Atrial Fibrillation?
- irregular rapid heart rate
- lower blood pressure
- ortho-hypotension
- low 02 stat
- anxious
- change in level of consciousness
What is ATRIAL FIBRILLATION? Rhythm? P waves?
Occurs when the atria beat chaotically and irregularly — out of coordination with the two lower chambers (the ventricles) of the heart
Progressive stage manifestations:
- Laboratory data: Low blood pH, rising lactic acid, hyperkalemia
- Cardiac: Rapid, weak pulse, Hypotension, Pallor, cool, moist skin, anuria
- Pulmonary: Cyanosis, Hypoxemia
- Neuro: Decreased cerebral perfusion, Mental status deteriorates, Feeling of doom
What does MAP stand for? What MAP value is necessary to maintain perfusion of major body organs, such as the kidneys and brain. What happens when the map is decreased?
- Mean Arterial Pressure
- 60 to 70 mm Hg
- When map is below 60 the heart hurts
Distributive Shock? What are the two causes of Distributive Shock? What are the difference between the two causes?
occurs when blood volume is not lost from the body but is distributed to the interstitial tissues where it cannot perfuse organs.
Causes- Loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, and increased capillary leak.
-neural-induced and chemical-induced
For pt with ENDOCARDITIS, what are some Ports of entry of Infective Agents?
- Oral cavity
- Skin rash
- Lesion/abscess
- Infection
- Surgery or invasive procedure
When do you do CARDIOVERSION (synchronized) ? What test should you do before cardioversion on a pt with AFIB, AFLUTTER?
- VTACH with pulse
- Unstable AFIB or AFLUTTER
- electively for stable tachydysrhythmias
- Trans Esophageal Echocardiogram - (TEE) - check to see if there are any clots that can be dislodged
What percent of cardiac output is Atrial Kick is responsible for? What are the manifestations when Atrial Kick is lost?
- 25 - 30% of CO
- When Atrial Kick is lost Manifestations Hypotension, shortness of breath, chest pain, increase pulse rate (to make up for cardiac output)
What populations are known for having silent MI’s? Why?
- Diabetics
- Women
- Elderly
Antidote for COUMADIN ? Antidote for Heparin?
Coumadin = vitamin K Heparin = Protamine Sulfate
Manifestations of Cardiac Tamponade?
Cardiac tamponade findings:
- JVD
- Paradoxical pulse
- Decreased CO
- Muffled heart sounds
- Circulatory collapse
- Hypotension
-
Right sided heart failure
- Characterized by insufficient force of cardiac contraction and/or inadequate filling of the heart with blood.
Symptoms:
Peripheral edema, JVD, weight gain, ascites, hepatomegaly, S3 gallop on auscultation
What is the treatment and goal time of treatment?
- cath lab in 90 mins or less
Time frame of giving thrombolytics post MI? How are they administered?
- Within first 6 hrs of cardiac event
- Given during cardiac catheterization but they can be given via IV
3 Common origins of distributive shock?
- Anaphylaxis
- Sepsis
- Capillary leak syndrom
What is the result of a NSTEMI ? EKG appearance?
- Myocardial ischemia due to coronary vasospasm, spontaneous dissection, and sluggish blood flow due to narrowing of the
- ST depression or T wave Inversion
What do the P waves look like in AFIB?
- Wavy with no prominent P wave
What does MONA stand for? What position should a pt with a potential MI sit in?
- Morphine, O2, Nitro, Aspirin
- Morphine sulfate - vasodilates coronary arteries, relaxes/decreases anxiety. ease pain, increases oxygenation, lowers BP, decreases demand of 02
- O2 - body is deprived
- Nitro - vasodilator (sublingual, spray, IV) - should bring more 02 to the heart. I
- Aspirin - antiplatelet
- Position of comfort; semi-fowlers
What valve problems sound like a washing machine?
Stenosis
what are the stages of SHOCK?
Initial stage (early shock) Nonprogressive stage (compensatory stage) Progressive stage (intermediate stage) Refractory stage (irreversible stage)
Nonprogressive (compensatory) Stage of SHOCK?
- BP stays WDL
- MAP falls 10 t0 15 mm/hg below baseline
- Kidney, baroreceptors, and hormonal adaptive mechanisms activated.
- Stimulates sympathetic NS
- Kidneys sense decreased MAP
- Renin/angiotensin system activated
- Pituitary kicks in with ADH
- Tissue hypoxia in nonvital organs.
- Acidosis and hyperkalemia.
- Stopping conditions that started shock and supportive interventions can prevent shock from progressing
- Can have no permanent damage
- Best time to intervene
Still have some clinical signs that indicate poor organ perfusion:
Anxiety, restlessness, thirst
Resp: increased resp rate, decrease in O2 sat
Cardiac: tachycardia, falling systolic pressure, rising diastolic pressure, narrow pulse pressure, cool extremities, decreased UO
Manifestations of Atrial Fibrillation?
- No P waves
- irregular rhythm
- Decreased cardiac output (loss of 25-30% CO)
When AFIB is prolonged > 48 hours the patient will be at risk for ______?
Mural Thrombi (Formation of a thrombus in contact with the endocardial lining of a cardiac chambe)
Nonprogressive (compensatory) interventions:
- ID cause: Correct underlying disorder
- Compare changes to baseline
- Support by: Help maintain BP and adequate perfusion
- Vasoconstrictors, inotropic, enhance CO
- Fluid replacement: Crystalloids, colloids, blood products
- Medication
- Oxygen
- Monitor tissue perfusion, vitals
- Patient safety
- Reduce anxiety for pt and family
_________ is lost when the SA Node is not the chief dominant pacemaker in the heart (afib, aflutter)
Atrial Kick
What are PREMATURE VENTRICULAR CONTRACTIONS?
- Results from increased irritability of ventricular cells
- lower chambers of the heart contract before they should. When this happens, your heartbeat becomes out of sync.
Disease states that affect Afterload? Drugs used to improve?
Disease states that increase resistance makes it harder for the heart to pump blood
- Hypertension
- Aortic stenosis
- Increased blood viscosity
**Antihypertensives - Beta Blockers, Vasodilators
Who is at high risk for Endocarditis?
- IV drug abusers
- Valve replacement recipients
- People who have had systemic infections
- People with structural cardiac defects
Pacemaker/ICD EDUCATION:
- Report skin irritation at pacemaker site, report fever,
- Don’t apply pressure over your generator. Avoid tight clothing
- Follow activity restrictions
- Avoid external electrical fields
- Record daily pulse (1min) at the same time every day. (or if they patient is having symptoms of P/M failure)
- Teach patient S/S of pacemaker failure
- Report hiccups, weight gain, difficulty breathing, dizziness, fainting, chest pain.
PT or INR tests for?
coumadin and warfarin
what is Hemodynamic monitoring?
Invasive system used in critical care areas to provide quantitative information about vascular capacity, blood volume, pump effectiveness, and tissue perfusion
types:
Pulmonary artery catheter
Invasive arterial catheter and monitoring
Pulmonary capillary wedge pressures
Medications for Valvular disease?
- ACE inhibitor - blood pressure
- Digoxin- decrease contractility
- Beta Blockers - protects the heart
- Antibiotics
- Anticoagulant
- Diuretics
- Vasodialators
Atrial Fibrillation is almost always associated with _____________ and _______.
- Heart disease
- COPD
What is the Ejection Fraction? What is it measuring?
- Percent of the blood ejected from the heart during systole
Treatment of PVC ?
- Treatment = antidysrhythmics if symptomatic (amiodarone, lidocaine, procainamide, B-blockers)
What drugs are aimed at decreasing preload?
Vasodilators, Diuretics
What does Digoxin do?
- increases vagal tone, slowing AV nodal conduction.
Interventions for sepsis/septic shock:
- Correct the cause!
- Use of sepsis resuscitation bundle within 6 hours
- Oxygen therapy
- IV therapy: Normal saline (NS) or Lactated Ringers (LR)
- Drug therapy: Vasoconstrictors: Dopamine, Epinepherine etc.
- Agents to enhance contractility and perfusion/CO
- Blood replacement therapy
- Identify those at risk, early detection!
Factors that influence MAP?l. For the stable patient with sustained VT, administer oxygen and confirm the rhythm via a 12-lead ECG. Amiodarone (Cordarone), lidocaine, or magnesium sulfate may be given.lo999mom
- Total blood volume
- Cardiac output
- Size o9:of the vascular bed
What is the most common cause of obstructive shock?
Cardiac tamponade
Patients with a an EF less than __% are a candidate for an Implantable cardioverter defibrillator? What must the EF be to diagnose heart failure?
- 33%
- 40%
Sepsis/septic shock lab values
lactate levels, BC before antibiotics, WBC, clotting factors with DIC
Hypovolemic Shock
pH, Lactic Acid, Hematocrit, Hemoglobin, Potassium
Cause of Mitral Valve Regurgitaion
Aging, infective endocarditis, rheumatic heart disease
What is the goal of crisis intervention
-to help survivors return to their previous lifestyle as quickly as possible.
**Crisis Intervention. The focus of the initial interview and follow-up with the client who has been sexually assaulted is on the rape incident alone. Problems identified but unassociated with the rape are not dealt with at this time.
Signs of Physical Abuse to a child:
- Has unexplained burns, bites, bruises, broken bones, or black eyes
- Has fading bruises or other marks noticeable after an absence from school
- Seems frightened of the parents and protests or cries when it is time to go home
- Shrinks at the approach of adults
- Reports injury by a parent or another adult caregiver
- Abuses animals or pets
Signs that a parent or adult caregiver are abusing a child?
- Offers conflicting, unconvincing, or no explanation for the child’s injury
- Describes the child as “evil,” or in some other very negative way
- Uses harsh physical discipline with the child
- Has a history of abuse as a child
- Has a history of abusing animals or pets
