Exam 1: Cardiovascular, ECG, Shock & Sepsis Flashcards
(205 cards)
1
Q
What is angina?
A
Reduced blood flow to the myocardium results in inadequate oxygen delivery to heart muscles causing ischemia, which then produces chest pain
2
Q
What is stable angina?
A
emporary, transient, reversible, predictable, and manageable most likely triggered by activity or exertion that usually lasts 3-5 minutes before relieved by rest or nitro. No permanent damage occurs if transient and relieved. Certain activities are the cause of this type of angina, such as walking to the mailbox. There will be no elevation in Troponin levels.
3
Q
what is unstable angina?
A
(pre-infarction) unpredictable and may occur at night or at rest.
4
Q
What is considered new onset angina?
A
First symptom that usually occurs after exertion or during periods of increased demands on the heart
5
Q
What is variant angina?
A
(Prinzmetal) caused by coronary spasm and may occur when at rest or at night. Can cause changes in ST segments
6
Q
What is preinfarction angina?
A
Chest pain that occurs in days or weeks before an MI Warning sign!!
7
Q
What does the acronym PQRST mean for angina?
A
P: Precipitating events (Exercise, exertion, stress, rest, cold temps, smoking (nicotine causes vasoconstriction), heavy meals) What were you doing at the time this started?
Q: Quality of pain (Squeezing, pressure, heaviness, burning, fullness)
R: Radiation of pain (Arm, neck, shoulder, jaw, back)
S: Severity of pain
T: Timing (When it began, what activity, how long it lasted
8
Q
What are the lab values that should be looked at for a patient experiencing angina?
A
Troponin I*
Troponin T*, CK-MB, Myoglobin
Electrolytes, Cholesterol
HDL, LDL,
C-reactive protein, homocysteine levels
9
Q
What diagnostics that can be performed for a patient experiencing angina?
A
-ECG
-Exercise tolerance test
-Thallium Scan
-Cardiac cath
-Positron emission -5tomography (PET), —-MRI
-Transesophageal Echocardiography -Halter monitor
10
Q
On an ECG what will you see for angina, MI and necrosis?
A
angina=ST depression means ischemia can be reversed.
MI=ST elevation means injury will occur and elevated Q wave=necrosis
11
Q
What are the treatment options for angina?
A
Can be managed at home, stop activity and sit/lie down. If chest pain is not resolved try nitro, and if pain is not resolved in 15 minutes call 911
-Pts should have blood pressure cuff at home and be able to check BP
12
Q
What are the common medications for Angina?
A
SL NTG
Antiplatelet agents (aspirin)
ACEI or ARB
Beta blocker
Nitrates
Calcium channel blocker
13
Q
What is the protocol for nitroglycerin?
A
Have client sit/lie down
administer 1 SL tablet or spray under tongue
Wait 5 minutes
if unrelieved administer 2nd dose and wait 5 min
if then unrelieved administer 3rd dose. Take vital signs with each dose, but if 3 doses does not resolve pain-call 911. Use acetaminophen for headache.
14
Q
What medication for angina should not be used with nitroglycerin?
A
Ibeuprofen
15
Q
What determines an emergency in regards to angina?
A
If it occurs at rest, is not responsive to nitro, and lasts longer than 5min=emergency!
16
Q
What are some risks to monitor for with nitro?
A
-Injury related to hypotension from nitro
-Syncopal events
-educate on need/reasoning for remaining seated/supine when taking nitro
-do NOT bite into nitro, ask if they have a sting-if not the nitro may have been exposed to light/heat
-appropriate technique for nitro, —–educate s/sx of MI
17
Q
What are acute coronary syndromes?
A
Conditions characterized by excessive oxygen demand and/or inadequate supply of oxygen/nutrients to heart muscle commonly associated with plaque disruption, thrombus formation, vasoconstriction
18
Q
What are the different types of acute coronary sydromes?
A
Unstable Angina
Non-ST segment elevation MI
ST Segment MI
19
Q
What is a Non-Stemi?
A
Same as unstable angina w/the exception that there is actual cell death (can tell from cardiac markers), partial occlusion of coronary artery, and length of pain/symptoms are longer than unstable angina (Partial thickness damage to heart muscle)
20
Q
What is a STEMI?
A
-Acute ST elevation MI occurs when an intracoronary plaque ruptures with thrombus formation completely occludes the vessel
-Full thickness damage to heart muscle->entire artery is blocked)
21
Q
What is the goal of treatment in a STEMI?
A
Treatment goal of re-establishing perfusion as quickly as possible. Time is muscle (door to balloon in 90-minutes)!
22
Q
What is the pathology of a myocardial infarction?
A
Area of tissue death will result in non-functional scar tissue, and understanding the coronary artery affected will indicate the location of necrosis (downstream of occlusion).
23
Q
What is a ‘widowmaker’?
A
An MI in the left main descending coronary artery
24
Q
On an ECG in regards to MIs, what is the difference between a Q-wave MI and a non Q wave MI?
A
A Q wave=entire thickness of wall is damaged
Non Q wave=Partial damage
25
Cardiac Enzymes:
What is the normal level of Troponin T
<0.1ng/mL
26
Cardiac Enzymes:
What is the onset and return to normal of Troponin T after MI?
Onset is 4-6 hours
Return to normal in 10-14 days
27
Cardiac Enzymes:
What is the normal range of Troponin I?
Normal=<0.03ng/mL
28
Cardiac Enzymes:
What is the onset and return to normal of Troponin I after MI?
Onset is 4-14 hours
Return to normal in 7-10 days
29
Cardiac Enzymes:
What are the normal levels of CK-MB (not cardiac specific)?
0% of total CK
30
Cardiac Enzymes:
What are the onset, peak and return to normal of CK-MB after MI?
Onset 3-6 hours
Peak 24 hours
Back to normal in 2-3 days
31
Cardiac Enzymes:
What are the normal levels of myoglobin (not cardiac specific)?
<90mcg/L
32
Cardiac Enzymes:
What is the onset and back to normal of myoglobin after MI?
Onset in 2 hours
Back to normal in 24 hours
33
In regards to monitoring Troponin levels, what is very important to remember?
We do not monitor for just one Troponin level, but successive troponin levels (q3) to monitor for the extent of damage.
34
What are the first-do priorities for MI?
-Initiate cardiac monitoring on 12 lead ECG (ONLY HAS 10 WIRES).
-MONA: Morphine, Oxygen, Nitroglycerin, Aspirin
-Thrombolytic Therapy: used to dissolve clots in coronary arteries that is most effective if administered under 6 hrs from symptom onset. Indicated for chest pain lasting over 30 minutes. Contraindicated in recent surgery, pregnancy, PMH of cerebral bleed, or bleeding disorders
35
What are the common medications used to treat MI?
Vasodilators (Nitro)
Analgesics (morphine)
Beta blockers
ACEI
Calcium Channel Blockers
Antiplatelets
Thrombolytic Agents (alteplace)
Anticoagulants
HMG CoA inhibitors
Antidysrhythmics
36
The ischemia from an MI leads to acidosis which leads to cardiac irritability frequently causing?
PVCs
V-tach
V-fib
Atrial Fib
37
What is a diagnostic cardiac catheterization?
Also known as a Cardiac Angiogram, it determines the blood flow in areas of coronary artery blockage by inserting a catheter into the radial, brachial or femoral artery and injecting an iodine based contrast dye that allows for visualization. Can be diagnostic or interventional.
38
What is an interventional cardiac catheterization for?
Percutaneous coronary intervention (PCI), Percutaneous transluminal coronary angioplasty (PTCA) or angioplasty
PTCA Involves balloon-tipped catheter -> balloon inflated to open stent leading to flattening of plaque and dilate artery balloon deflated and catheter removed, stent remains in place and keeps artery patent
39
After a cardiac catheterization, what are some of the important RN considerations?
Position supine with legs straight
Keep on telemetry
Maintain bed rest 2-6 hr
Assess q15 min x 1 hr
Assess 30 min x2 hr
Assess q1hr x 4hr
Assess Q4
Encourage PO fluids
Anticoag therapy
40
What are the discharge instructions for a patient post cardiac cath?
Avoid strenuous exercise/activity restrictions for prescribed period (3-12 weeks)
Report bleeding from site, chest pain, SOB, color/temp changes to extremity, changes in sensation to extremity
Restrict lifting < 10 lbs for prescribed time
40
What is a coronary artery bypass graph?
Also known as a CABG-
Procedure that restores perfusion to myocardium by creating a bypass using a vein (saphenous) or artery (mammary/radial) around the obstruction.
40
If a stent is placed, what is the anticoagulation therapy?
For drug eluting stent: 6-12 months of clopidogrel + aspirin until epithelialization
For bare metal stents: 1-3 months
41
What are the requirements to have a CABG?
For clients who do not respond to medical management of CAD and who are not candidates for PCI
Experience angina with ≥ 50% occlusion of the left main coronary artery that cannot be stented Have 2 or 3 vessel disease
Have ischemia with heart failure
Have an acute MI
Have signs of ischemia s/p PCI
Have coronary vessels unsuitable for PCI
42
A minimally invasive CABG is when?
A patient only has one area that needs to be bypassed
43
What are the RN considerations for pacing wires post CABG?
Need to be capped and protected
Pts cannot shower with pacing wires
Assess site and provide site care Q shift
Monitor for s/s of infection
Remove within 48-72 hours if possible
44
What are the sternal precautions post CABG?
6 to 10 weeks
No pushing or pulling, No lifting > 5 pounds, No lifting arms over head, No stretching arms behind back, Pace activities, Rest before and after meals, Rest before and after exercise. These patients should also be enrolled in cardiac rehab.
45
What is the discharge teaching for a CABG?
Incision care (Soap and water), Shower no tubs, monitor and report signs of infection, resume normal activities slowly, sternal precautions 6 to 10 weeks, sexual activity based on healthcare provider guidance, no driving for 6 to 8 weeks
46
What is an ART line?
A line placed in the radial (most common), brachial or femoral artery that provides continuous info about changes in BP allows withdrawal of arterial blood samples, monitors circulation in limb that has line (cap refill, temp, color but does NOT allow infusions
47
What is a pulmonary artery catheter?
Catheters that have multiple lumens, ports, and components that allow for different measurements such as blood sampling and infusions of IV fluids
48
Where is a PA catheter inserted?
Into the:
Internal jugular
Femoral
Subclavian
Brachial
then threaded through RA and RV branch of the pulmonary artery.
49
What is the proximal lumen used for in a PA catheter?
can be used to measure right arterial pressure (CVP), infuse IV fluids, and measure blood samples
50
What is the distal lumen of a PA catheter used for?
used to measure pulmonary artery pressures, but NOT used for IV admin.
51
What is the balloon inflation port of a PA catheter used for?
be intermittently used for PAWP measurements, but when not in use should be left deflated and in locked position unless you are taking pulmonary artery wedge
52
What is a central venous catheter?
Line that measures right atrial pressure and preload that is inserted into the internal jugular or subclavian vein then advanced to the superior vena cava.
53
How should the patient be positioned for a central venous catheter when taking measurements?
Requires client to be supine (or minimally elevated 15-30 degrees) during measurements
54
What are the complications of a central venous catheter?
Infection: Use transparent dressings containing chlorohexidine, sterile dressing changes (including surgical mask for RN & client)
Hemorrhage
Air Embolus: Enters through break in system or open stopcock
Position pt in Trendelenburg for insertion and removal.
Never infuse anything through a monitoring line
Occlusion
55
What is the normal electrical pathway through the heart?
SA Node->AV Node (between atrium and ventricles->L and R bundle branches (septum/ventricles)->Purkinje Fibers (ventricles)
56
What are the rates of the internal pacemakers of the heart?
***********IMPORTANT************
SA Node (natural pacemaker)-intrinsic rate=60-100bpm
AV Node-intrinsic rate=40-60bpm
57
What does the P wave represent?
Atrial depolarizaton
58
What does the PR segment represent?
The time required for the impulse to travel through the AV node, where it is delayed and through the bundle of HIS, bundle branches, and Purkinje fiber network before ventricular depolarization
59
What does the QRS complex represent?
The ventricular depolarization and is measured from the begining of the Q (or R) wave to the end of the S wave
60
What does the J point represent?
The junction where the QRS complex ends and the ST segment begins
61
What does the ST segment represent?
Early ventricular repolarization
62
What does the T wave represent?
Ventricular repolarization
63
What does the U wave represent?
Late ventricular repolarization
64
What does the QT interval represent?
The total time required for ventricular depolarization and repolarization
is measured from begining of the QRS complex to the end of the T wave
65
What is the normal range of time for the PR interval on an ECG?
0.12-0.20 seconds (3-5 small boxes)
66
What is the normal time for the QRS interval on an ECG?
0.06 to 0.12 Seconds (1.5 to 3 small boxes)
67
What is the normal time for the QT interval on an ECG?
0.34-0.43 seconds (8.5-10.75 small boxes/1.7 to 2.5 large boxes)
68
Fill in the blank:
In general, the ___________ the HR, the ______________ the QT interval, and the _____________ the HR, the __________________ the QT interval.
In general, the faster the heart rate the smaller the QT interval, the slower the heart rate the longer the QT interval.
69
ECG waveforms are measured in ___________ and ______________.
ECG waveforms are measured in amplitude (voltage) and duration (time).
70
ECG:
One large box = _____ seconds=____ms=_____mm=_____mV
One large box = 0.20 seconds=20ms=5mm=0.5mV
71
ECG:
One small box = _____ seconds=_____mm=_____mv
One small box = 0.04 seconds=1mm=0.1mv
72
A pacemaker spike would be followed by?
Immediately by a QRS complex
73
Pacing spake seen without subsequent QRS complexes imply a?
loss of capture
You would assess vital signs and level of conciousness
74
Prior to cardioversion, the nurse would turn off what?
Oxygen therapy to prevent fire
75
What would indicate significant tachycardia on a ECG?
the P wave touching the T wave
76
What is the normal time range for the PR interval?
0.12-0.20 seconds
77
What is the normal time for the QRS interval?
0.06-0.12 seconds
78
What is the normal time for the QT interval?
0.34-0.43 seconds
79
How many boxes on an ECG are in 6 seconds?
30
80
What are the causes for sinus bradycardia?
Athletes
Medications (beta blockers, calcium channel blockers, digoxin)
MI
Severe hypoxia
Increased ICP
81
What are the priority nursing interventions for sinus bradycardia?
******
Assess the client to see if symptomatic
If symptomatic:
Apply O2
Ensure PIV access
Administer Atropine 1mg IVP
Place pacer pads on client
Prepare for transcutaneous pacing
Only Purple Animals Poop Plump Plums
O(O2, P-PIV, A-Atropine, PP-Pacerpads, P-Pacing)
82
What are considered symptoms paired with sinus bradycardia?
*****
Hypotension
Altered mental status
Angina (get EKG)
S/S of HF or Shock
83
What are the potential causes of sinus tachycardia?
Fever
Meds
HF
Hypovolemia
Caffiene
Nicotine
Cocaine
Frilly Moms Have Happy Cats Never Cranky
84
How fast is the SA node firing in sinus tachycardia?
>100bpm
85
What are the priority nursing interventions for sinus tachycardia?
If symptomatic:
Apply O2
PIV access
IV fluid replacement (if hypovolemic)
Administer meds (Beta blocker, calcium channel blocker, digoxin)
Only Purple Injection Meds
86
What are considered symptoms when paired with sinus tachycardia?
The same as sinus bradycardia
Hypotension
Altered mental status
Angina (get EKG)
S/S of HF or Shock
87
What is a Premature atrial contraction?
Ectopic focus of atrial tissue fires before the next impulse is due
(The relay racer starts running before the previous racer returns)
88
What are premature atrial contractions caused by?
Stress
Fatigue
Anxiety
Inflammation
Infection
Caffeine
Nicotine
Alcohol
Drugs
COPD
Hypertension
Pregnancy
89
What will show up on an ECG for premature atrial contractions?
Normal Rate, underlying rhythm
P wave disrupted by a premature beat
PACs will always occur intermittently
90
What is atrial fibrillation?
Multiple ectopic foci discharging in the atria which leads to disorganized, chaotic electrical activity
91
In atrial fibrillation you will see no clear _______________ on an ECG
p waves
92
What are the potential causes of atrial fibrillation?
CAD
HTN
HF
Hyperthyroidism
Age
93
What are the priority nursing interventions for atrial fibrillation?
Apply O2
Administer medication (BBs, CC, amiodarone, and anticoagulants******)
Prepare for possible cardioversion
Monitor for signs of emboli, stroke and vascular occlusion
94
Which dysrhythmia shows up on a ECG as a saw-like pattern where the T-wave is covered by a fluttered pave?
Atrial flutter
95
What are the priority nursing interventions for superventricular tachycardia if the patient is stable?
Have client perform vagal maneuvers while getting Adenosine from pixis
Administer Adenosine 6mg rapid IVP
Adenosine 12mg rapid IVP for second and final dose
96
What are the priority nursing interventions for superventricular tachycardia if the patient is unstable?
Synchronized cardioversion
Administer BB, CCBs, Antidysrhythmics
Possible surgical ablation
97
What is one of the ways to identify a 1st degree heart block?
Prolonged PR interval >0.20 seconds
98
What is the saying to remember a 1st degree heart block?
If the R is far from the P, then you have a first degree
99
Which type of heart block is when there is a gradual lengthening of PR interval until one QRS does not conduct and is cyclical?
2nd degree (Wenchebach's)
100
What are the priority nursing interventions for a 2nd degree (Wenchbach's)?
Measure and monitor ECG strips
If symptoms worsen, may need pacemaker
These patients will respond to atropine!!!!
101
What does a 2nd-degree AV block (Mobitz Type II) on a ECG?
There is a constant PR interval, but one or more QRS complexes are missing
102
Which type of AV block will not always respond to atropine and which patients will NOT respond to atropine?
Mobitz Type 2 might not
3rd degree heart blocks will NOT
103
Which type of AV block has the saying "If the P's and Q's don't agree, then you have a?
3rd degree
104
What will you see on a ECG from a third degree heart block?
No relationship between the P wave and the QRS complex
105
What are the priority nursing interventions for a 3rd degree heart block?
LIFE THREATENING
Notify provider
Apply pacer pads & being pacing
Provider will insert temp. pacing wires for transvenous pacing
106
What are the different types of temporary pacemakers?
Transcutaneous
Transvenous
Epicardial
107
What is a transcutaneous pacemaker used for?
It is an external pacemaker that is noninvasive and used in emergencies for transient dysrhythmias that decrease CO
It is painful to patient
108
What is a transvenous pacemaker?
An internal invasive pacemaker that is a pacing electrode via large ventral vein to R ventricle for direct contact with endocardium
109
What is a epicardial pacemaker?
An internal and invasive pacemaker that is typically used after open heart surgery and paces through thoracic musculature to heart via lead wires
110
What are the types of permanent pacemakers?
Fixed rate
Demand
111
What is a fixed rate pacemaker?
A pacemaker that fires at a present rate regardless of pts HR
112
What is a demand pacemaker?
Senses heart's electrical activity and fires at present rate when heart's intrinsic rate is lower than set rate
113
What is the Antidysrhythmic function of a pacemaker?
Can fire over pace a tachy-dysrhythmias or deliver an electrical shock
114
A pacer spike followed by a p-wave is?
Atrial pacing
115
A pacer spike followed by a QRS complex is?
Ventricular pacing
116
What are pacemakers used for?
Symptomatic bradycardia
Complete Heart block
Chronic or current dysrhythmias from SA or AV malfunction
117
What should the RN be documenting post pacemaker insertion?
Insertion time
Model #
Settings
Rhythm strip
VS client response
118
What is the discharge teaching for a pacemaker?
Take pulse every day at the same time
Notify provider if <5 beats below set rate
Batteries last 10 years
No heavy lifting for 2 months
Will set off security alarms
Wear medical alert bracelet
Carry pacemaker ID card
119
What assessment findings would indicate pacemaker failure?
Brady/tachycardia
Drop in BP
Palpitations
SOB
Chest Pain
Dizziness
Syncope
120
What is failure to capture?
Pacing spikes without P waves or QRS
121
What is failure to sense?
Pacing spikes at intervals different than program settings
122
If a pacemaker is failing and discharges on the T wave, what can occur?
It can cause V-Fib
123
What are the priority nursing actions in pacemaker failure?
-Assess VS for decreased CO
-Assess for hypoperfusion
-Document w/attached rhythm strip
-Notify the healthcare provider of changes in amplitude up or down
-Interrogate pacemaker company
124
What type of device is indicated for patients who have experienced one or more episodes of spontaneous VT or VF not caused by MI?
Implantable Cardioverter/Defibrillator
125
What does a Implantable Cardioverter/Defibrillator do?
Monitors for life-threatening changes in cardiac rhythm and automatically delivers an electrical shock
It also has pacing capabilities
126
What are the nursing considerations for premature ventricular contractions (PVCs)?
Apply supplemental O@
Administer antidysrhythmic, BBs, CCBs
If pt has over 40, prepare for surgical ablation
127
What is the cause of a PVC?
Increased irritability of ventricular cells=premature contraction where a single impulse is seen as early ventricular complex followed by a pause
128
What are the potential causes of PVCs?
Common in healthy individuals
Acid-base imbalance
Heart disease
Scarring
Meds
Stress
EtOH
Hypoxia
Caffiene
Exercise
129
What might a patient who is experiencing PVCs feel?
Sensation of heart 'skipping a beat' or 'flip-flopping' pounding
130
What are the potiential causes of ventricular tachycardia?
CAD
HF
Mitral Valve Prolapse
Digoxin Toxicity
MI with hypoxia and acidosis
131
What is the most important thing to assess for in ventricular tachycardia?
A pulse!!!!!
The reason why this is important is because the treatment is different-but pulse V-tach will deteriorate to pulseless v-tach quickly
132
What are the priority nursing interventions for ventricular tachycardia with a pulse?
Call Rapid Response
Apply O2
Administer amioderone, lidocaine, potassium and magnesium replacement
Cardioversion
Red Orbs Aim Low Purposefully Meaningful Care
133
What are the priority nursing interventions for pulseless v-tach?
Start CPR and Call a Code
Ventilate with bag valve mask with 100% O2
Establish IV/IO
Prepare to defillibrate
ACLS med-Epinephrine 1mg IVP, amiodarone 300mg followed by 150mg IV
Cats Cradle Big Energy Differently Except Ants
134
Anything with a wide QRS complex >0.12 with an HR of 170 or higher is considered which type of dysrhythmia?
Ventricular Tachycardia until proven otherwise
135
What is Ventricular Fibrillation?
Rapid disorganized depolarization of ventricles with no organized electrical activity and no ventricular muscle contraction
Ventricles are quivering in unsynchronized manner
136
What are the potential causes of v-fib?
MI
Hypoxia
Electrocution
Electrolyte Imbalance
Med Toxicity
137
What do you assess for if you see V-fib on a ECG?
Breathing and Pulse
Pt. May be exhibiting seizure-like activity
138
What are the priority nursing interventions for V-Fib?
EMERGENCY
Follow ACLS protocol
Defibrillate ASAP
Ventilate client with BVM with 100% O2
Establish IV/IO access
ACLS meds: Epinephrine 1mg IVP, amiodarone or lidocaine
139
What are the steps in defibrillation safety?
Do not touch anything in contact with pt
Verify everyone is clear
Remove BVM and face away to prevent electrical arch
Ensure correct placement of pads
Resume CPR immediately after shock is administered
Wait 2 minutes before checking pulse and rhythm
140
What are the reversible causes of pulseless electrical activity?
H's and T's
H: Hypoxia, Hypovolemia, Hypoglycemia, Hypothermia, Hypo/Hyperkalemia, Hydrogen (Acidosis)
Ts: Toxins, Tamponade, Tension Pneumothorax, Thrombosis (PE or MI), Trauma
141
What are the potential causes of Ventricular asystole?
Hypoxia
Increase/Decrease of K+
Acidosis
Drug Overdose
Hypothermia
142
What is the rapid response criteria?
Acute changes in:
HR (<40 or >130)
Systolic BP (<90)
Respiratory Rate (<8 or >28 or threatened airway)
SpO2 (<93%)
LOC
Bleeding
O2 requirements increase >50%
New, repeated or prolonged seizures
Failure to respond
143
What are the early warning signs of cardiac arrest?
Trending decrease or increase in respirations
144
What are the late warning signs of cardiac arrest?
Coughing
Gasping
Pallor
Twitching
irregular movement
145
What is a fusiform aneurysm?
when the entire artery is affected
146
What is a saccular aneurysm?
Aneurysm appears as an outcropping
147
What are the SSAs for an abdominal aortic aneurysm?
-Gnawing pain with abdominal, flank, or back pain
-Pain is unaffected by movement
-Pain lasts for hours to days
-Pulsation in the upper abdomen to the left of the midline by the xiphoid
-Murmur on auscultation (whoosh sound)
148
What are the SSAs for a ruptured abdominal aortic aneurysm?
-Severe sudden pain in the lower back or abdomen
-Pain radiates to groin, buttocks, and legs
-Loss of pulses distal to rupture
-Massive internal hemorrhage
-Back pain
-Difficulty swallowing
149
Hypotension, diaphoresis, decreased LOC, dysrhythmias and oliguria are all signs of what?
Shock second to hypovolemia
Signs of massive internal hemorrhage
150
What are the post surgical restrictions for an abdominal aortic aneurysm repair?
No stair climbing
No lifting >15lb
No driving for 6-12 weeks
Avoid pulling, pushing or straining
Incisional care
Pts will normally go home on statins
151
2/3 of aortic aneurysms are?
Type 1 Thoracic aortic aneurysms in ascending aorta
152
1/3 of aortic aneurysms are?
Type 2 thoracic aortic aneurysms in descending aorta
153
What are the SSAs for a Aortic Dissection?
-Sharp, tearing, ripping, stabbing pain that cannot be relieved with Rx (HALLMARK SYMPTOM)
-Pain in anterior chest, back, neck, throat, jaw, teeth depending on origin
-Diaphoresis
-N/V
-Pallor
-Faintness/syncope/altered LOC
-Rapid, weak, thready pulse
-Decrease or absence of peripheral pulses
-Aortic regurge
154
What are the priority interventions for aortic dissection?
-2 large bore IV catheters
-Fluid resuscitation with NS and meds
-Indwelling cath
-IV morphine
-IV beta blocker
-Subsequent treatment depends on location
155
What are the other symptoms of infective endocarditis besides the development of right-sided heart failure and arterial embolization?
-Petechiae on trunk, extremities, mucosa
-Splinter hemorrhages on nail bed
-Osler nodes on palms or hands and feet
-Janeway lesions: Flat, reddened maculae on hands and feet
-Roth spots: round or oval hemorrhagic lesions on retina
-Cardiac Murmer
-Recurrent fever and flu-like symptoms (shaking chills-rigors)
-Positive blood cultures
156
If a patient has infective endocarditis and has sudden abdominal pain with radiation to L upper quadrant/shoulder, what could this indicate?
Embolization in the spleen
157
If a patient has infective endocarditis and has flank pain that radiates to groin, hematuria, and renal failure what could this indicate?
Embolization in the kidney
158
What is the difference between infective endocarditis and rhematic endocarditis?
Infective endocarditis is a microbial infection of the endocardium (inner most layer of the heart) caused most commonly by staph and strep associated by drug misuse
Rheumatic endocarditis is a complication of rheumatic fever (group A beta-strep infection)
159
What is the pathology of rheumatic endocarditis?
Inflammatory lesions that involve all layers of the heart and scarring of the heart valves can lead to erosion, malfunction and calcification of the valves that then impairs contractility of the myocardium and can lead to cardiomegaly and HF
160
What are the first do priority interventions of endocarditis?
Bed rest to decrease workload
IV antibiotics for 4-6 weeks if infective endocarditis
Good oral hygiene
Monitor for sepsis
Remind client to notify providers of endocarditis, esp dentist
161
What is the RX treatment of rheumatic endocarditis?
Antibiotics for 10 days + prophylactic antibiotics for life to prevent infective endocarditis
Vancomycin/genamicin
162
What are the risk factors for pericarditis?
Complication of MI
Infective organisms
Acute exacerbation of connective tissue disease
Post cardiac surgery
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What are the SSAs for pericarditis?
-Substernal precordial pain that radiates to L side of neck, shoulder or back
(Patient will be sitting up and leaning forward because of this)
-Pain is worse on inspiration, sitting supine, coughing or swallowing
-SOB
-A-fib
-Pericardial friction rub
164
On an ECG what will you see for pericarditis that you would also see during a STEMI?
ST segment elevation
HOWEVER, for pericarditis it is global ST segment elevation instead of alternating ST segment elevation like an MI
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What drugs do you want to avoid when a patient has pericarditis?
Aspirin and anticoagulants
Increases the risk of cardiac tamponade
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What are signs and symptoms of a cardiac tamponade?
-Rapid fluid accumulation in the pericardium (20-50mL)
-Sudden decrease of cardiac output
-Sudden onset of pulsus paradoxis (systolic BP decrease >10mmHg during inspiration0
-Narrowing pulse pressure (SBP-DBP<30mmHg)
-Muffled heart sounds
-JVD with clear lungs q
167
What are the priority nursing interventions for cardiac tamponade?
Contact provider immediately
Administer O2
Assess BP carefully
Fluid resuscitation
Prepare for pericardiocentesis or pericardial window
168
What is myocarditis?
Diffuse inflammation of the myocardium that is often associated with pericarditis but can be with or without fluid accumulation in the pericardial sac
169
What is the potential cause of myocarditis?
Commonly associated with viral, fungi or bacterial infections
170
What are the SSAs for myocarditis?
Murmur
Tachycardia
Dysrhythmias
Possible friction rub
Fever
Fatigue
Chest pain with deep breath
171
What is an inotropic medication and which ones are used for infective and inflammatory cardiac disorders?
Inotropic medications increase cardiac contractility
Dopamine
Dobutamine
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What are the antidysrhythmic medications for infective and inflammatory cardiac disorders?
Amiodarone
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What does amiodarone do?
blocks certain electrical signals in the heart to restore normal rhythm
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What are the antihypertensives used in infective and inflammatory cardiac disorders and what do they do?
Decrease afterload
Beta-blockers
Calcium channel blockers
ACEIs
175
When are anticoagulants used for infective and inflammatory cardiac disorders?
For mechanical valve replacement
A-fib
Severe L ventricular dysfunction
176
What do nitrates do?
Decrease both preload and afterload by vasodilation
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What are the types of shock?
Hypovolemic
Cardiogenic
Distributive
Obstructive
178
What are the stages of shock?
Initial
Compensatory
Progressive
Refractory
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What occurs in the initial stage of shock?
-Baseline MAP <10mmHg
-Compensation responses include vascular constriction and increased HR
-Can have increased RR and increased diastolic pressure
180
What occurs during the compensatory stage of shock?
-MAP decreases by 10-15mmHg
-Kidneys/hormones decrease urine output, increase thirst, increase blood vessel constriction
-Tissue hypoxia leads to restlessness/fidgety/anxious
-Falling systolic, raising diastolic
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What occurs during the progressive stage of shock?
-Sustained MAP decrease >20mmHg from baseline
-Shunting from nonvital to vital organs
-Cyanosis around mouth
-Anaerobic metabolism
-Rapid, thready pulse
-Hypotension
-Pallor
-Cool & clammy skin
-Anuria
-Sense of impending doom
-Needs to be corrected within 1 hour
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Why must conditions causing shock be corrected within 1 hour or less of progressive stage?
Clotting factors are beginning to be made due to metabolites, and will progress to full DIV if not turned around in 1 hour
183
What occurs during the refractory stage of shock?
-Widespread Cell death/damaged tissue
-MODS
-Rapid loss of consciousness
-Nonpalpable pulse
-Cold & dusky extremities
-Shallow and slow respirations
-Unmeasurable SpO2 concentrations
-Death
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What is MODS?
Multiorgan Dysfunction Syndrome
Sequence of cell damage that is caused by massive release of toxic metabolites and enzymes which causes onset of DIC
185
What is DIC?
Disseminated Intravascular Coagulation where clotting factors are being made, forming little clots everywhere, but once the clotting factors are gone, patients bleed from everywhere including IV sites
186
What are the causes of hypovolemic shock?
Anything that causes a massive loss of vascular volume such as bleeding from surgical site, chest tube output, trauma, major blood loss, severe dehydration
187
What are the SSAs for hypovolemic shock?
Hypotension
MAP <60-65mmHg
Decreased LOC
Cool and Clammy Skin
Hypoxemia without dropping SPO2
Decreased urine output to under 30mL/hr (0.5mL/kg/hr)***
188
What is the treatment for hypovolemic shock?
-Large bore IV
-Fluid rescuitation
-Blood rescuitiation
-Vasopressors (fluid & blood first)
-Supplemental O2 if SpO2<94
-Strict I&Os
-Lower HOB, elevate legs`
189
When treating hypovolemic shock and your diastolic pressure drops, what does this indicate?
Your fluid and blood resuscitation has not been successful
190
What are the lab findings for hypovolemic shock?
Decreased pH (acidosis)
Increased PaO2 (hypoxia)
Increased PaCO2(hypercap)
Increased serum lactate
Increased potassium
Increased fluid shifts
Increased dehydration
Decreased H & H if hypovolemic shock is caused by hemorrhage
191
What causes cardiogenic shock?
Loss of contractility or pump failure leads to impaired cardiac output
192
What are the early signs of cardiogenic shock?
Restlessness
Anxiety
Tachypnea
Tachycardia (>100)
Normal BP
193
What are the late signs of cardiogenic shock?
SBP <90mmHg or decreased <30mmHg from baseline
Change in LOC
Crackles in lungs
Cool and clammy skin
Thready/decrease peripheral pulses
Decreased urine output (<30mL/hr or 0.5mL/kg/hr)`
194
What is the treatment for cardiogenic shock?
Meds
Monitor fluids (to prevent overload)
Assess for overload
Supplemental O2
Strict I&O
Balloon pump to help with circulation
Trend LOC, VS, cardiac rate and rhythm, urine output, pulses
195
What is the 1 hour sepsis bundle?
-Early identification/screening tools & warning signs
-If sepsis is probable: Antibiotics within 1 hr
-If sepsis probable but no signs of shock: rapid assessment and data collection with antibiotics within 3 hours
-For hypofusion: 30mL/kg of IV crystalloid within 3 hours of rescuitation
-Vasopressor (norepi) with goal of MAP >65mmHg
-Invasive monitoring with ART line
-Insulin therapy at glucose >180mg/dL
196
What are the early SSAs for sepsis?
-Low or high-grade fever
-Tachycardia with stable or elevated BP
-Warm extremeties
-Decreased UO
-Increased RR (>22)
-Narrowing pulse pressure as shock progresses
197
What are the late SSAs for sepsis?
-Hypotension
-Poor CO/perfusion
-weak/thready pulse
-Change in LOC
-Cap refill >3 seconds
-Pallor
-Mottling
-Cool extremities
-Oliguria progressing to anuria
-Tachypnea
-Hyperglycemia
-Inappropriate clotting leading to DIC
198
What does septic shock require?
Vassopressor treatment to maintain MAP >65mmHg or have serum lactate >2mmol.L despite adequate fluid restricution
199
What are the common lab findings for septic shock?
Decreased pH
Decreased PaO2
Decreased segmented neutrophils w/increasing band levels
Decreased WBC
Increased PaCO2
Increased Serum Lactate
200
What type of shock is anaphylactic shock?
Distributive shock
201
What are the priority interventions for anaphylactic shock?
-Establish/stabilize airway
-Call RRT
-Ensure intubation/trach equip is ready
-Apply O2 with high flow non-rebreather at 100% FiO2
-Administer epinephrine
-Admin diphenhydramine, methylprednisonene
-May administer beta agonist nebulizer for bronchospasm
-Initiate IV fluids
-May administer drugs to support cardiac function
202
What is SIRS with a suspected source of infection?
Sepsis
203
What SSAs define SIRS?
Qualified by any two:
Fever or hypothermia
Heart rate greater than 90 beats/minute
Respiratory rate greater than 20 breaths/minute or paCO2 less than 32 mmHg
WBC count greater than 12000 or less than 4000
