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Flashcards in Critical Care Environment Deck (82):
1

first line drug for all emergency situations Giving a drug to treat a disorder brought on by hypoxemia without effectively correcting the cause of hypoxemia is ineffective - O2 sat >96%

Oxygen

2

Nitrate Dilates peripheral vessels decreasing preload and afterload, reduces blood pressure ; Also dilates coronary arteries- used for chest pain  Continuous blood pressure and heart monitoring  SE: Hypotension, headache

Nitroglycerin

3

narcotic analgesic to treat chest pain associated with MI and acute PE  Relieves pain and reduces anxiety, dilates venous vessels and reduces cardiac workload  SE: Respiratory depression, hypotension  Narcotic antagonist naloxone (Narcan)

Morphine sulfate

4

anticholinergic to treat bradycardia, heart block and asystole  Inhibits vagus nerve  Cardiac and blood pressure monitoring needed  SE: dysrhythmias, increased HR, ischemia, restlessness, anxiety, mydriasis, thirst, urinary retention

Atropine sulfate

5

Beta-adrenergic  To increase heart rate - temporary measure while waiting for transcutaneous pacemaker  Increases myocardial oxygen consumption, therefore, myocardial ischemia is a concern  Tachycardia, ventricular fibrillation may occur

Isoproterenol (Isuprel)

6

antidysrhythmic to treat paroxysmal supraventricular tachycardia (PSVT)  Slows conduction through AV node, interrupts dysrhythmia producing re-entry pathways and can restore NSR  Cardiac monitoring and vital signs  SE: hypotension, dysrhythmias, short period of asystole following injection

Adenosine (Adenocard)

7

- antidysrhythmic to treat supraventricular tachydysrhythmias (SVT)  Calcium channel blocker - (negative chronotropic & inotropic) - also used to treat angina  Monitor HR and BP  SE: headache, bradycardia, hypotension

Verapamil (Calan, Isoptin)

8

antidysrhythmic to treat PSVT, A-fib/flutter (with increased rate)  Calcium channel blocker - (negative chronotropic & inotropic) - also used to treat angina  Monitor BP and HR  SE: myocardial depression, bradycardia, can increase digoxin levels

Diltiazem (Cardizem, Dilacor XR)

9

antidysrhythmic to treat ventricular dysrhythmias  A fast sodium channel blocker, class 1B  Local anesthetic effect on heart; ↓myocardial irritability  Monitor cardiac and assess for S/S toxicity (confusion, drowsiness, hearing impairment, conduction defects, myocardial depression, muscle twitching, seizures)  Metabolized in liver

Lidocaine

10

antidysrhythmic to treat atrial, ventricular and supraventricular dysrhythmias  A fast sodium channel blocker, class 1A  SE – severe ↓BP, heart block, rhythm disturbance & cardiac arrest  Excreted via kidneys

Procainamide (Procan; Pronestyl)

11

to correct body depletions and dysrhythmias  Works with Na+-K+ ATPase pump  Physiologic effects similar to Ca++ channel blockers with neuromuscular blocking effects  If Mg++ ↓ - atrial & ventricular dysrhythmias  Uses - ↓Mg levels; refractory VT & VF & life threatening dysrhythmias associated with digoxin toxicity and tricyclic antidepressants, torsades de pointe  SE - ↓BP, mild ↓HR, flushing, sweating

Magnesium sulfate

12

sympathomimetic to treat profound ↓HR, asystole, pulseless ventricular tachycardia and ventricular fibrillation (VF & VT)  Catecholamine with alpha & beta adrenergic effects  Improves perfusion of heart and brain in cardiac arrest  Requires cardiac & hemodynamic monitoring  Do not give at same site as sodium bicarbonate

Epinephrine

13

to treat metabolic acidosis  Monitor ABGs  Do not administer epinephrine, norepinephrine, or dopamine in same site

Sodium bicarbonate

14

osmotic diuretic to treat edema of CNS and other conditions  Highly irritating to veins, use filter needle  Assess neurological status, labs, serum osmolality, I/O

Mannitol (Osmitrol)

15

- glucocorticoid to treat edema of CNS and other conditions  Stabilizes Na+/K+ pump – thus no excess H20 crosses cellular membrane  SE – transient ↑BP, ↑BS

Methylprednisolone (Solu-Medrol)

16

opiate antagonist  Competitively binds to opiate receptor sites  Shorter duration than many opiates, may need to repeat dosing  Can precipitate withdrawal symptoms  SE – Potential for pulmonary edema and cardiovascular collapse in some OD patients

Naloxone (Narcan)

17

Reversal agent for the respiratory depressant and sedative effects of benzodiazepine medications (Valium, Versed, Librium)

Flumazenil (Mazicon, Romazicon)

18

to treat poisoning  absorbs ingested toxins in GI tract & prevents absorption body

Activated charcoal

19

drugs should not be used to correct the hypotension associated with this condition → administer fluids or blood products

hypovolemic shock

20

to treat hypotension; low dose ↑urine output  Sympathomimetic  SE - ↑HR, dysrhythmias, myocardial ischemia, N/V  Assess IV site hourly for S/S of drug infiltration, extravasations causes tissue necrosis, treat extravasations with phenotolamine (Regitine) 5-10mg diluted in 10-15cc NS

Dopamine

21

to treat shock states with ↓CO (↑BP D/T ↑CO – no vasoconstriction)  Sympathomimetic with beta-1 adrenergic activities; beta-1 effects (↑force of contraction, ↑HR)  Requires cardiac & BP monitoring, assess for ischemia  Adverse effects are dose related – myocardial ischemia, ↑HR, dysrhythmias, headache, nausea, tremors

Dobutamine

22

to treat hypotension  Catecholamine with potent vasoconstrictor (alpha adrenergic) effects  Requires cardiac and BP monitoring, assess for ischemia, nursing care is similar to dopamine  Additional effects – myocardial ischemia, dysrhythmias, impaired organ function; extravasation causes tissue necrosis

Norepinephrine (Levophed)

23

to treat anaphylactic shock  Bronchodilator and maintains blood pressure due to vasoconstrictive effect, also ↑cardiac performance  SE - ↑HR, dysrhythmias, ↑BP, angina

Epinephrine

24

antihypertensive to treat hypertensive crisis  Rapid acting vasodilator, acts on the smooth muscle of the vessels  Protect from light- keep wrapped with aluminum foil, medication has a faint brown color, increases cyanide levels (measure cyanide and thiocyanate levels every 24 hours)

Sodium nitroprusside (Nipride)

25

loop diuretic  Diuretic effect  Depletes Na+ and K+ - assess electrolyte levels

Furosemide (Lasix)

26

Indications for Arterial line

1. Monitor blood pressure ( 5-15 mm Hg higher than manual ) 2. Obtain blood specimen and arterial blood gases 3. Administration of vasoactive medications

27

A-line : insertion points

Radial, brachial

28

A-line : measurements - waveforms

Q image thumb

1. Systolic (top waveform) , diastolic( bottom ) and mean arterial pressure ( min 60 - to perfuse vital organs) * Dicrotic notch - closure of aortic valve

Small, wavy , dampened - obstruction or inducer imbalance 

29

A-line : complications

1. Bleeding 2. Infection 3. Thrombosis 4. Neurovascular impairment

30

Phlebostatic axis ( R atrium level ) - Level and calibrate transducer Q8hrs , when pt bed or position is changed 

4th intercostal space on the R sternum - to the side of the pt chest midway between ant and post chest

31

PA catheter : indications

for patients with complicated fluid balance conditions

32

PA catheter : measurements

1. CVP - right atrial pressure 2. PAP - pulmonary artery pressure 3. PCWP - pulmonary capillary wedge pressure 4. CO

33

CVP

1-8 mmHg

34

PAP

15/5- 25/15 mmHg

35

PAWP

indirect measurement of left atrial pressure + left ventricular and diastolic pressure 4-12 mmHg; High - left ventricular failure , hypervolemia 

36

PA catheter insertion

jugular or subclavian veins

37

PA catheter complications

1. Infection 2. Air embolism 3. Pulmonary infarction or rupture 4. Ventricular arrhythmias

38

Cardioversion

deliver a synchronized shock during QRS wave

39

Cardioversion: indications

for unstable atrial and ventricular dysrhythmias ( pulse is present - fast rhythm) - A-fib, A-flutter, V-tach 

40

Cardioversion: sedate

IV Valium, Versed if awake ; consent 

41

Cardioversion : pad placement

1. Upper right chest, just under the clavicle, next to the sternum 2. Left lower chest, just lateral to the precordium

42

Cardioversion : monitor

1. Maintain airway 2. Monitor VS & LOC

43

Defibrilation

asynchronous electric shock

44

Defibrilation : indications

Pulseless ventricular rhythms - Vtach & Vfib

45

Defibrilation : procedure

1. Biphasic -start at 200 joules ( mono - 360) 2. Perform within 15-20 sec of the onset or arrhythmia 3. CPR - Shock 4. Two minutes of CPR between shocks

46

IABP - intra-aortic balloon pump - purpose

increased coronary perfusion - increases CO by as much as 40 % - decreases LV work and myocardial oxygen requirements

47

IABP - insertion

through the femoral artery , threaded into the descending aorta

48

IABP - diastole

Ventricles are filling - balloon inflates ( blocking the aorta ) - blood forced into coronary artery

49

IABP - systole

balloon deflates when ventricles contract - creates a vacuum affect ( reduces afterload) - improves LV ejection + CO

50

IABP - indications

1. Failure to wean from cardiopulmonary bypass 2. Cardiogenic shock 3. HF 4. MI

51

IABP - complications

1. Vascular injuries 2. Displacement of balloon 4. Peripheral nerve damage + thrombus formation 5. IABP destroys platelets - thrombocytopenia 6. Infection 7. Improper timing - can increase afterload ( decrease CO ) 8. Pt is relatively immobile - HOB less than 45 ; cant flex leg

52

VAD - ventricular assist device

TX of end stage heart failure - improve CO

53

VAD used ...

short term - bridge while waiting for a heart transplant long term - when unresponsive to medication or surgery

54

VAD for L ventricular heart failure

more common - Tube pulls blood from left ventricle into a pump - sends blood to the aorta

55

CO

4-7 L/min

56

Amount of blood pumped from the LV each minute

CO

57

Preload = CVP = Right atrial pressure

how much the myocardial fibers are stretched at the end of diastole just before the next contraction

58

Amount of blood ejected with each contraction

SV

59

Pressure or resistance the heart must overcome to eject blood through the semilunar valves during systole

Afterload

60

Locus of control

degree of control : * inner ( decisions ) & external ( fate, luck ) or combination

61

Respiratory failure

PaO2 < 60 mm Hg & PaCO2 > 50 mmHg

62

Endotracheal tube - verify placement

1. check end-tidal CO2 levels - use CO2 detector 2. listen for bilateral breath sounds 3. X-ray

63

Hemodynamic monitoring consists of

1. Catheter 2. Infusion system 3. Transducer 4. Monitor 5. Pressure bag

64

Pressure bag - A-line & PA catheter

1. NS or D5W 3-10 ml/hr - prevent back up of the blood and oclusion 2. 300 mmHg - maintains pressure

65

Allen's test

prior to insertion of A-line - 1. patency of the ulnar & radial artery 2. adequacy of collateral circulation

66

Central venous pressure cather ( CVP line ) - measures and provide 

1. RA pressure - preload - monitor pt fluid status 

2. Venous access for fluids and blood sampling 

67

CVP line inserted 

subclavian, jugular, femoral veins ; catheter tip - superior vena cava 

68

CVP readings - high & low 

High - fluid overload - decrease IV rate, IV diuretics 

Low - hypovolemia - increase IV rate 

69

PA  catheter : balloon 

1. wedged briefly 8-15 sec - get reading - remove - risk for pulmonary infarction 

70

CVAD 

1. PICC lines ( long term IV TX - vesicant ; 1 year) 

2. Non-tunneled CVAD ( few weeks )

3. Tunneled CVAD ( years )

4. Subcutaneous ports ( non - coring needle ; years )

71

CVAD complications 

1. Infection

2. Bleeding

3. Pneumothorax and hemothorax

4. PE

5. Cardiac tamponade 

72

AED

Automatic external defibrilator ; * " All clear "

73

ICP catheters - Infection !!! - strict aseptic technique 

1. Epidural ( easy, low risk )

2. Intraventricular ( most invasive, drainage + sampling of CSF )

3. Subarachnoid ( easy )

74

Quinton catheter 

double lumen dialysis catheter ; jugular or subclavian veins; for ARF or CRF ( while waiting for fistula to mature) 

75

Sengstaken-Blakemore tube 

TX bleeding esophageal varices ( last resort ); two ballons ( one -stomach; second - esophagus) ; pt is intubated on mechanical ventilator 

76

Parenteral nutrition - PPN & TPN 

1. PPN ( peripheral parenteral nutrition) - peripheral IV - lower osmolarity 

2. TPN ( total parenteral nutrition ) - central IV - higher osmolarity 

77

Paternalism 

restriction of one's freedom ( autonomy ) to protect the pt from harm (making decision for pt ) 

78

Beneficence

prevent harm

79

Nonmaleficence 

do no harm 

80

Fidelity 

keep promises 

81

Veracity 

tell the truth 

82