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Exam 1 Blueprint- Sole: ch. 7, Ch. 1, Ch. 3, Ch. 2, Ch. 9, Ch. 15, Ch. 8, Ch. 13, Ch. 12, Ch. 17
Typology: Lecture notes
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APPROXIMATE number of questions Lab- blood transfusion (12), chest tubes (ATI), algorithms
Dysrhythmia (7) 10 Intro to CC (1-3) 7 Oxygenation- ventilators (9), ARDS (15), PE & ABG
Perfusion & CV (13) 8 Homeostasis – Shock (12) & Hematologic (17)
Math 2
Hemodynamics Values (Chapter 8) (PA Cath, Arterial lines) ● Values in Table 8-1 (pg. 137) ○ Cardiac Output: 4- ○ Cardiac Index: 2.5- 4. ○ Central Venous Pressure (CVp or RAP): 2- ○ Pulmonary Artery Occlusion Pressure (PAOP): 8- ○ Pulmonary Artery Pressure (PAP): ■ PAS: 15- ■ PAD: 8- ○ Systemic Vascular Resistance: 770- ○ Mixed Venous Oxygen Saturation (Sv02): 60-75% ○ Mean Arterial Pressure (MAP): > ■ 1 SBP + 2 DBP / ● Phlebostatic Axis ○ 4th intercostal space, midthoracic line ○ Approximate level of Right Atrium ○ Point to identify? ■ To level; so that readings of PA catheter are accurate ○ You can level as much as you need to and anytime they change positions ○ Zero once a shift ● What is an Allen’s Test? ○ Occlude radial and ulnar pulse ○ Release ulnar first ○ Collateral circulation in extremity ○ Should come back within 7 seconds ○ Test prior to insertion of arterial line to verify collateral circulation in the extremity ● Patients who need an arterial line are those who: ○ Are on continuous drips to inc or dec their BP ● Pressure tubing: ○ Keeps line patent ○ Keeps from backflow of blood ● Patients with bowel obstruction are unpredictable and would benefit most from central venous/right atrial pressure monitoring ● PAC measurement capabilities ○ PA systolic ○ PA diastolic ○ PAOP/PCWP/PAWP ○ Cardiac output/index ● What could happen if pressure lines are not secured/connected properly? ○ Thrombosis, Embolism, Hemorrhage, Infection
Chest Drainage/Chest tubes ● Blood-Hemothorax ● Fluid- pneumothorax ● What is the purpose of a CT? ○ Remove fluid/air ○ Fluid leaks into intrapleural space- creates positive pressure that collapsed lung tissue ● What are the 3 chambers with the closed drainage system? ○ Drainage ○ Suction ○ Water Seal (prevents air from going in) ● What is the general anatomical placement of a CT for pneumothorax? ○ Anterior chest ○ 2nd intercostal space ● General anatomical placement of a CT for a hemothorax ○ Lateral/Posterior ○ 5th/6th intercostal space ● When do you clamp a CT? ○ When a doctor orders it ○ The patient is on a vent/drip ○ Assessing for air leak ○ Changing collection Unit ● Purpose of a chest tube is to drain the fluid or air ● Always have sterile saline and hemastas in the room incase the tubing becomes disconnected ● Clamp tubing but still see bubbling → air leak in the system ● Clamp tubing and see on more bubbling → air leak in the patient ● Management ○ Avoid dependable loops ○ Lift and clear tube every 15 min ○ Tailor length of tubing to the patient
Blood products and Blood transfusion, including transfusion reactions ● Blood Products ○ Whole Blood ○ Blood Components ○ Plasma-derived Product ○ Allogeneic transfusion or autotransfusion ● Blood Transfusion ○ Check against patient identification ○ Informed consent ○ 2 nurses should verify ● Reactions ○ Life-threatening reactions usually occur within the first 15 minutes ■ Remain with the patient during this time ■ Some experience a delayed reaction
Sinus Brady: How to identify and emergency drugs to treat Powerpoint ● Sinus rhythm with a rate of less than 60 beats/min ● Causes: vagal, drugs, ischemia, disease of the nodes, ICP, hypoxemia & athletes (normal) ● Produces various hemodynamic responses ● Care/Treatment (pg. 106) ○ Symptomatic-- administration of atropine ○ Atropine not effective at increasing HR then- ■ Transcutaneous pacing ■ Dopamine infusion ■ Epinephrine infusion ● Chest pain, SOB, diaphoresis, hypotension: administer atropine ● Use a stool softener ● Excessive vagal (parasympathetic) stimulation to the heart causes decreased rate ○ Calcium Channel Blockers- Diltiazem administered 1 hour ago ○ Valsalva Maneuvers- Bearing down for a bowel movement ○ Possible inferior wall MI and heart block
Sinus Tach: How to identify and emergency drugs to treat ● Powerpoint ○ Sinus rhythm with a rate of 100-150 beats/min ○ Causes: hyperthyroidism, hypovolemia, HF, anemia, exercise, use of stimulants, fever and sympathetic response to fear or pain and anxiety may cause sinus tach ○ Assess for symptoms of low cardiac output ● Treatment (pg. 105) ○ The cause is identified and treated appropriately ○ Pain medications are administered to treat pain ○ Antipyretics are given to treat fever ● Underlying Causes ○ Fever, anxiety, graves’ disease, pain, stress, pulmonary embolism ● Results from sympathetic nervous system stimulation or parasympathetic inhibition- increase heart rate to over 100 beats per minute ● Respond to findings of Sinus Tachy ○ Assess for JVD ○ Assess BP and temp ○ Ask patient is they are experiencing any chest pain or pressure
Atrial Fib: How to identify and emergency drugs to treat ● Powerpoint: ○ Erratic impulse formation in atria ○ No discernible P wave ○ Irregular ventricular rate ○ Abnormal ventricular conduction can occur ○ Results in loss of atrial kick ○ High risk for pulmonary or systemic emboli ● Alterations in blood flow- increased risk for clot formation ● Care/Treatment (pg. 113) ○ May predispose patient to clot formation ○ No contraindications- prescribed Anticoagulant ○ After 3 weeks of antithrombotic therapy, elective cardioversion can be considered followed by 4 more weeks of antithrombotic therapy ○ Amiodarone- also responsible for pharmacologic cardioversion ● Risk Factors that contribute to A-fib ○ Advancing Age ○ High blood pressure ○ Excessive alcohol use ○ Hypertension ○ Previous Stroke ○ Thromboembolic event ○ Coronary heart disease ○ Heart failure ● Avoid caffeine ● Pulmonary embolism may contribute to this dysrhythmia ○ Stagnation of blood flow resulting in the formation of thrombi in atria ○ A thrombus can be dislodged from R atrium and travel to the lung, causing PE ● Palpitations are a symptom ● Drugs: ○ Heparin, Digoxin, Warfarin, Diltiazem, Amiodarone ● The risk for thromboembolism caused by A-fib- anticoagulation therapy is necessary
Atrial Flutter: How to identify and emergency drugs to treat Powerpoint ● Ectopic foci in atria, heart disease ● “Sawtooth” pattern ● Atrial rate fast and regular (250-350 beats/min) with AV block ● Description of atrial flutter might be constant at 2:1, 3:1, 4:1, 5:1 and so forth ○ Or may be variable ● Causes: lung disease, ischemic heart disease, hyperthyroidism, hypoxemia, HF and alcoholism ● Care/Treatment (pg. 111) ○ Receive chronic antithrombotic therapy unless contraindicated ○ Elective cardioversion may be performed once the patient has been taking anticoagulants for 3-4 weeks
V-tach: How to identify and emergency drugs to treat ● Powerpoint: ○ Rapid, life-threatening dysrhythmia ○ Three or more PVCs in a row ○ Fast rate >100 beats/min ○ Initiated by ventricles ○ Wide QRS complex > 0.10 sec ○ Usually regular ○ May, or may not have a pulse ■ Treat pulseless same as V. Fib ○ Significant loss of cardiac output ○ Hypotension ● Care/Treatment (pg. 119) ○ No pulse ■ Provide emergent basic and advanced life support interventions including defibrillation ○ Pulse Present & BP stable ■ IV Amiodarone or Lidocaine ○ Cardioversion is used as an emergency measure in those who become hemodynamically ● Typically deteriorates into ventricular fibrillation ● May occur in patients with ischemic heart disease, MI, cardiomyopathy, hypokalemia, hypomagnesemia, heart failure, drug toxicity, hypotension ● Having an episode of Ventricular Tachy- ○ Administer Amiodarone
PVC’s: How to identify and emergency drugs to treat ● Powerpoint: ○ Wide & bizarre beats ○ Compensatory pause ○ Patterns: ■ Bigeminy and trigeminy ■ Couplets and triplets ○ Unifocal vs. multifocal ○ QRS > 0.10sec ○ Irregular rhythm ○ Absent P waves ● Assess & treat the cause: hypoxia, ischemia, electrolyte imbalance, hypomagnesemia, and increased catecholamine levels ● May need antidysrhythmic agents ● Which electrolyte imbalances will contribute to this dysrhythmias and should, therefore, be monitored? ○ Hypokalemia ○ Hypomagnesemia
How to count HR with a 6-second strip. Normal PR interval and QRS. ● P-wave: ● PR interval: 0.12 to 0.20 seconds ○ Beginning of P wave to beginning of QRS complex ● QRS interval: 0.06 to 0.10 seconds ● T-wave: bigger than P-wave, no greater than five small boxes high ● QT interval: 0.32 to 0.50 seconds ○ Beginning of QRS complex to end of T-wave ● Calculating heart rate: ○ 6 second strip, count the number of QRS & multiply by 10
● Cardioversion (p.218) ○ The delivery of a synchronized electrical shock to the heart, synchronized with the patient’s cardiac rhythm by an external defibrillator ○ used as an emergency measure in patients who become hemodynamically unstable but continue to have a pulse ○ The purpose is to disrupt an ectopic pacemaker that is causing a dysrhythmia and allow the SA node to take control of the rhythm ○ Used to treat pt with VT, atrial flutter, A. Fib, or SVT who have a pulse but are developing symptoms related to poor perfusion such as, hypotension and decreased LOC ○ BOX 10- ○ If pt is undergoing cardioversion on a non emergency basis, sedate the patient before the procedure ● Defibrillation (pg. 215) ○ The only effective treatment for VF and pulseless VT ○ Delivery of electrical current to the heart through the use of a defibrillator ○ “Hands off” ○ Works by completely depolarizing the heart and disrupting the impulses that are causing the dysrhythmia ○ goal of restoring spontaneous circulation ● Differentiates Cardioversion from Defibrillation? ○ Cardioversion delivers a synchronized shock from ventricular tachycardia or supraventricular tachycardia ■ Cardioversion involves the delivery of synchronized electric shock to terminate unstable ventricular or supraventricular rhythms ■ Defibrillation delivers an asynchronous countershock, depolarizing a critical mass of myocardium to stop the re-entry circuit in ventricular fibrillation or pulseless ventricular tachy, allowing sinus node to regain control of heart
