test 2 Flashcards
Assist control
resting mode. must set rate, Vt (tidal vol- amount of air inhaled and exhaled), inspiratory time, and PEEP. ventilator sensitivity is also set, and when the pt initiates a spontaneous breath, a full volume breath is delivered. All breaths are of the same preset vol (ACV)
Synchronized Intermittent Mandatory Ventilation SIMV or IMV
Must set rate, Vt (Tidal vol), inspiratory time, sensitivity and PEEP. In between “mandatory breaths”h pts spontaneously breath at their own rates and Vt. with SIMV, the ventilator synchronizes the mandatory breaths with the pt’s own respirations. during spontaneous breaths receives pre set FiO2, but self regulates rate and vol. prevents muscle atrophy as the pt takes on more of the WOB.
continuous positive airway pressure (CPAP)
delivers continuous positive pressure during spontaneous breathing and restores functional residual capacity (FRC)
guidelines on ventilator associated pneumonia (VAP) prevention
VAP prevention: HOB min 30-45
uno routine changes of circuit tubing
dorsal lumen above the cuff to allow continuous suctioning of subglottic secretions
gloves and HH
always drain water that collects in tubing away from pt
hemoglobin levels and anemia
hemoglobin: female: 12-16 (+ 1 for males) mild anemia: 10-12 moderate anemia: 6-12 severe less than 6
sxs of anemia
mild- moderate: fatigue, palpitations, dyspnea, roaring in ears
cobalamine
vit b 12, rbc maturation, red meat, liver, dairy, fish, enriched grain, eggs. deficiency usually in vegetarian diet, or dairy elimination, chronic alcoholics
folic acid
rbc maturation, green leafy vegetable, liver, meat fish legumes whole grains orange juice peanuts
iron
liver, muscle meats, eggs, dried fruit, legumes, dark green leaf veg, whole grain and enriched bread and cereal, potato. 2-6grams. 2/3 in hemoglobin and muscles, 1/3 in bone marrow, spleen, liver. if have iron def anemia need to eat 10-15mg/day
ascorbic acid
vit c, conversion of folic acid to its active form, aids in iron absorption- citrus, green leafy vegetables, strawberries, cantalope
iron deficient anemia sxs
iron def anemia sxs
mild- weak, pallor, TONGUE INFLAMMATION
other- fatigue, FISSURES in corners of mount, NAILS- thin, brittle, rigid, SPOON SHAPED
Iron administration
diet high in iron- 10-15mg/day
PO-coated, take with vit C, one hr before meal
IM/IV (only for severe) watch for allergic rxn!
IM (Iron dextran)- z track to reduce skin staining
IV (sodium ferrous gluconate) less chance allergy
troponin I (cTnl)
bedside assay, serial sampling X3, with CKMB and serial ECG, contractile protein released after MI, both I and T highly specific to cardiac tissue. neg <0.5, suspicious 0.5-2.3, positive >2.3
CK-MB
> 4-6% of total CK are indicative of MI, increase within 4-6 hrs, serial sampling with troponin
normal pr interval
0.12-.20
normal qrs time
0.04-0.12, prolonged- bundle branch prob
pvc
caused stimulant, infection trauma or hypo
fix prob, if symptoms give O2 and lidocaine. then amiodarone, eliminate stress and stimulants
PVCs have wider irreg QRS with a reg underlying rythm
A Fib
irreg R to R. reduced CO and BP. amiodarone to fix- anticoagulant. TEE to verify no clots then cardioversion
amidodarone
1dose- loading dose, slow ivp always D5W, always filter
V tach with pulse
O2 and Epi, 12 lead EKG, amiodarone, prepare for cardioversion. long term- place an ICD
torsades de pointes- low mg
atropine
for both second degree blocks- then transcutaneous pacemaker
duration of qt interval
.34-.44
ST seg
.12 second- myocardial ischemia or infarct aka acute coronary syndrome
ACE inhibitor
prils- greatly reduces incidence of adverse outcomes in pt with CAD, reduces blood pressure, reduce after load after MI, used in HF (DOC) and protect kidney, for after stem of anterior wall with HF or EF <40. baseline BP, WBC with diff. first dose hypotension- d/c diuretics 2-3 days before, start low dose, monitor BP closely for 2 hours- if necessary, give fluids. persistent dry cough, taste diminished, hyperkalemia (no sparing diuretic), angioedema, neutropenia and birth defects
ACE inhibitor
prils- prevents vasoconstriction. greatly reduces incidence of adverse outcomes in pt with CAD, reduces blood pressure, reduce after load after MI, used in HF (DOC) and protect kidney, for after stem of anterior wall with HF or EF <40. baseline BP, WBC with diff. first dose hypotension- d/c diuretics 2-3 days before, start low dose, monitor BP closely for 2 hours- if necessary, give fluids. persistent dry cough, taste diminished, hyperkalemia (no sparing diuretic), angioedema, neutropenia and birth defects
Ca channel blocker
same effect on heart as beta blocker. reduce force of contraction, slow heart rate, and suppress conduction through the AV node- lower bp and increase o2 to the heart. used to prevent angina. Very Nice Drugs Dis(pines)- more vasodilation of coronary arteries. verapamil for dysrhythmia, diltiazem for both.s/e HA, hypertension, dizzy, peripheral edema, renal/hepatic dysfncn, no beta blockers- cause HF
*caution with HF, LV impairment, AV block; call dr if HR irreg. SOB, swelling, n/v, dizzy
Ca channel blocker
same effect on heart as beta blocker. reduce force of contraction, slow heart rate, and suppress conduction through the AV node- lower bp and increase o2 to the heart. used to prevent angina. Very Nice Drugs Dis(pines)- more vasodilation of coronary arteries. verapamil for dysrhythmia, diltiazem for both.s/e HA, hypertension, dizzy, peripheral edema, renal/hepatic dysfunctional, no beta blockers- cause HF
- taper off or risk of rebound HTN
- caution with HF, LV impairment, AV block; call dr if HR irreg. SOB, swelling, n/v, dizzy
sympathomimetic drugs
dopamine and dobutamine- both- increase contractility and HR, dilates renal blood flow (more pp). both short term HF treatment, both continuous infusion, continuous monitor UO, ECG, and BP. Only dopamine increase after load, decrease CO, so dobutamine preferred. Dig only one can take PO/ long term. Both risk for tachycardia. dopamine for neurogenic shock. also NE (levophed), increase HR and BP and decrease UO
beta blocker
prevent SNS stimulation, decrease atrial ectopic stimulation, for HTN, angina, Afib, a flutter take apical pulse before and call dr <60, if asthma want B1 selective, non selective also affects lungs≥ can mess up hypoglycemic response, don’t take with verapamil
amiodarone
K channel block- prolong the action potential and refractory period of the cardiac cycle, decreases rate of depolarization, decrease contractility, PO- conversion of A fib, recurrent Vfib or Vtach. loading dose, filter, d5w
A/E pulm tox -baseline cxr and pulm fan test, baseline liver and thyroid, call with vision changes (blind), highly toxic, A/E may last for a while after d/c. no grapefruit= tox, sig increase risk of dig tox. first for AFIB, most widely used antidysrythmia drug. combo with ACEI or BB can cause bradycardia, risk of severe dysrhythmia increases with diuretic use- because of decrease in k and mg
heparin
effective aPPT 60-80 seconds (normal 30-50)
warfarin
effective PT 1.5-2 times control (normal 12-13)
INR 2-3
atropine
given for symptomatic sinus brady, and for both 2nd degree heart blocks, with o2. may do transcutaneous pacing. reverses parasympathetic slowing of the heart and increases HR
norepinephren
sympathomimetic, used for shock to increase HR and BP, long term will injure kidneys. vasoconstriction, shunts blood away from extremities. decrease kidney perfusion- decrease UO, dilate pupils, glycogenesis, bronchioles open
norepinephrine-NE-levophed
epinephrine- give when pulseless, CPR, defibrillator
lidocaine for
PVC, Vtach (with amiodarone),maybe with epi during asystole. without Vtach will convert to Vfib
tetralogy of fallot
have a ventricle septal defect, an overriding aorta, pulmonic stenosis with resulting right ventricle hypertrophy. Severity depends on severity of stenosis
coarctation of the aorta
narrowed at one point, hypertrophy of left ventricle, heart damage. HTN in upper extremities, hypotension in lower extremities. TX- balloon angioplasty, a little at a time to stretch out
PVC
ectopic beat from ventricle, QRS usually >.12 sec, unifocal- same place, multifocal- different origins (PVCs look different) give lidocaine and o2 if symptomatic. sustained- more than 30 second run. 3+ in a row= Vtach. lower stress and stop stimulants
LDH1 and 2
LDH 1 is heart and LDH 2 is serum, 2 should be larger, if 1 is larger- heart had issue
risk factors for sudden cardiac death
usually caused by acute ventricular dysrhythmias (Vtach, Vfib). strongest predictors: left ventricular dysfunctional (EF < 30%) and Vent. dysrhythmias after MI. others: hx of syncope, left ventricular outflow tract obstruction/ aortic stenosis, male gender- especially african american, and family hx of left ventricular dysrhythmias. if witnessed- therapeutic cooling. use implantable cardioverter-defibrillator to prevent reoccurrence.
post heart sx exercise
start slow- listen to body, limit isometric bc HR and BP rise quickly. do isoTONIC exercises- with movement. assess HR and keep in target limits- 80% of max or < 20 more than resting rate. If HR exceeds limit, or have chest pain or SOB, take a break. always warm up and cool down (5 min), aim for most days of week for at least 30 minutes.
Before cardiac cath/pci
assess allergies (contrast), v/s, heart and breath sounds, pulses, skin temp, color, sensation of extremities, teach procedure, kidney fxn (mucomyst/acetylcysteine protects, you will have palpitations, hot and flushed all over
post cath/pci
perform assessment again and compare with baseline. assess cath insert site for bleeding, monitor ECG for dysrhythmia, monitor for pain, monitor IV infusions of anticoagulants and anti platelet, teach about d/c meds and activity restrictions (asa, clopidegrel, nitro), assess q15min for first hour. monitor map and bp- if not correlating, something is leaking. monitor blood sugar. 5 Ps distal to puncture site. bed rest, flat, leg straight for 4-6 hrs, hold metformin next 48 hrs. notify dr if chest pain
come in with crushing substernal chest pain
oxygen, nitro, asa, morphine, ekg, health hx
carvedilol
peripheral alpha blocker for HTN, take at bedtime to avoid dizzy, orthohypo, avoid excessive exercise, prolonged standing (constricts) and heat (dilates). OD can cause profound bradycardia, hypotension, bronchospasm and carcinogenic shock. take BP standing 1 hour after amin to assess tolerance, titrate down- or may cause sweating, palpitations and HA
Risk for CAD
HTN, tobacco use, inactivity, stress, anger, anxiety, obesity, diabetes, family hx heart d/s, white middle aged men, age, elevated serum lipids: total cholesterol over 200. HDL <50, LDL >160, triglycerides >150
hemorrhagic shock
aka hypovolemic shock. tx- crystalloid fluid replacement and colloids (fluid loss, blood loss) blood loss may need plasma expanders/ blood products. sxs-dcreased cardiac output- fast thready pulse, low BP, tachycardia, dizzy, lethargic, anxious- lots of blood in spleen, femur, heart.
cardiogenic shock
pump prob. tx- pressers, inatropes, treat underlying problem, drugs to increase cardiac output. sis- tachycardia, tachypnea, pulmonary edema- not pumping, blood backing up, low UO
anaphylactic shock
sensitivity prob, bronchoconstriction, laryngospasm- all smooth muscle tighten, chest pain, third spacing, flush, sweat, swell, n/v/d. maintain airway potency, epinephrine, antihistamines, risk for decrease BP from getting leaky- IV fluids and 02
neurogenic shock
within 30 min of above t5 spinal cord injury. last up to 6 wks, lose sympathetic tone, heart rate slow, veins dilate- low bp, cold, dry skin, risk for hypothermia. lose reflexes. tx- vasopressors (dopamine), corticosteroid, may need to be paced or inatrope, may need ventilator, do need O2, maintain blood pressure and temperature (keep warm)
distributive shock
lose perfusion to peripheral veins, neurogenic, anaphylactic and septic
CO and Cardiac index
co=stroke vol X HR, CO is usually 4-8 L/min
cardiac index= CO/Body surface area (BSA). this adjusts the CO to boxy size. normal CI is 2.8 to 4.2
ventricular remodeling
to compensate for damaged heart, unaffected ventricle hypertrophies and dilates. also, affected area grows scar tissue- don’t want it too large/stiff. ACE inhibitors can prevent or reverse ventricular remodeling. if pt can’t handle ACEI- then give ARB
ventricle aneurysm
risk for 6 weeks- slowly increase activity and be mindful. sx: HF sxs, dysrhythmia, or angina. aneurysm harbor thrombi- risk of embolic stroke
V tach w/ pulse tx
lidocaine and o2 first, epi (keep perfusing), amiodarone, maybe cardioversion. no pulse- epi, cpr, defib. monomorphic- all qrs look the same, polymorphic- look different, like tornadoes de points
a fib tx
amiodarone first (if symptomatic ) anticoagulants, most common dysrhythmia, irregular rhythm
premature atrial complex pac tx
no tx- find and tx underlying cause of atria irritation- caffeine, stress, hypok, CHF, MI..
A flutter
prob from one place- ablation therapy. Atrial rate around 300, ventricle rate matters for perfusion. “controlled” if ventricle rate less than 100. no sx- no tx. regular rhythm
2 degree AVB type 1
wenkebach. progressive prolongation of PR interval, bradycardia. if sxs- atropine to increase HR
pacemakers for
symptomatic 2nd degree AVB type 2, 3rd degree AVB, Sinus brady (if atropine did not work, or suppression of persistent tachycardia. synchronous is synched with your heart- so only fires when needs to. a synchronous- has a set rate. fail to capture- regular rate, turn up. failure to sense- irregular rate of spikes- pacemaker malfunction
sinus tachycardia tx
tx reason, adenosine, beta blocker, vagal nerve stimulation, verapamil
hyperemic resp failure
paO2 <60 w/ O2 >60% normal 80-100
ARDS
sudden and progressive- alveolar capillary interface becomes damaged and more permeable. P-PaO2, F- FiO2, norm P/F ration >400. 200-300 acute lung injury. <200 = ARDS
most common early sxs- tachypnea anddyspnea
chest tube- when to call dr
tracheal deviation, sudden increase WOB,
Drained >100mL in 1 hour, Drainage stops after 24 hours (and can’t find occlusion), pulled or falls out, visible eyelet, o2 sat <90,
pneumothorax causes
trauma, PEEP, clamping chest tube, taping pneumothorax X4, emphysema,
hemoglobin- anemia
normal hgb: 12-17
mild anemia: 10-12
moderate anemia: 2-10
severe <6
