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Advanced Acute > Midterm Study Guide: Cardiac & ABGs > Flashcards

Midterm Study Guide: Cardiac & ABGs Flashcards

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1
Q

two types of hypovolemic shock

A

Absolute and Relative

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2
Q

Absolute shock:

A

decreased preload from volume loss of circulating blood

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3
Q

Relative shock:

A

decreased preload d/t increase in the capacity of blood vessels to sequester blood volume away from the heart

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4
Q

four stages of schock

A

initial, compensatory, progressive, refractory

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5
Q

initial stage: what does this look like

A

*usually not clinically apparent
*metabolism changes at cellular level from aerobic (w/o2) to anaerobic (w/o o2) depriving the cells of oxygen
*causes lactic acid to build up and must be removed by the liver which requires o2, but o2 is unavailable d/t decreased tissue perfusion

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6
Q

Compensatory stage

A

During the compensatory stage of shock, the body tries to maintain blood pressure and organ perfusion by activating compensatory mechanisms. (increase heart rate, constricting blood vessels to redirect blood flow to vital organs)

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7
Q

Progressive (what has failed)

A

*Compensatory stage has failed
*CO decreases and BP decreases
*Anasarca (diffuse profound edema) decreasing blood flow to the pulmonary capillaries
*Hypoperfusion leads to ischemia of distal extremities
*complete deterioration of the cardiac system and thus all organ systems

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8
Q

Refractory stage

A

the body’s organs and tissues fail to receive sufficient oxygen and nutrients. Blood pressure remains critically low, and vital organs sustain irreversible damage, often leading to multi-organ failure and death

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9
Q

Hypovolemic shock def

A

inadequate intravascular vol leading to decreased tissue perfusion
*MOST COMMON FORM OF SHOCK

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10
Q

Patho of hypovolemic shock

A

loss of circulating fluid vol -> decrease in venous return -> decrease in preload -> decrease in CO and SV -> inadequate cellular o2 supply -> ineffective tissue perfusion

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11
Q

Absolute fluid loss through… (5)

A

*hemorrhage
*GI loss (v/d)
*fistula drainage
*DM
*Diuresis
(ex. trauma patients)

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12
Q

Relative fluid loss though… (3)

A

*fluid moves out of the vascular space into extravascular space
*intracativity space
*third spacing - fluid leaking from vascular space to interstitial space
(ex. burn patients)

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13
Q

Classifications of hypovolemic shock (4)

A

1: 15-20% vol loss (750mL)
2: 15-30% vol loss (750-1500mL)
3: 30-40% vol loss (1500-2000mL)
4: >40% vol loss (>2000mL)

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14
Q

S/S of hypovolemic shock (6)

A

*high HR
*norm to low BP
*Low CO (amount of blood pumped in 1 min) & CI (measure of CO per square meter of body surface)
*CVP (measure of BP in central veins)/wedge low
*SVR(resistance the arteries present to flow of blood) low
*UO low

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15
Q

RN interventions for hypovolemic shock: (8)

A

*enhance vol replacement
*minimize fluid vol loss
*maintain optimal cardiac contractility and CO
*maintain optimal o2 sats
*control body temp
*prevent injury caused by decreased perfusion
*maintain nutrition status
*maintain renal perfusion

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16
Q

RN interventions for hypovolemic shock: enhance vol replacement (2 + what type of volume)

A

*2 large bore IV caths: 18g+
*Volume!
1. crystalloids: isotonic saline 3ml for every 1ml lost
2. Hypotonic saline: when Na is high
3. warm fluids
4: colloids: albumin
5.Blood and blood product: increase o2 carrying capacity

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17
Q

RN interventions for hypovolemic shock: Minimizing vol loss (4)

A

*compression of compressible vessels
*surgery to control bleeding
*antidiarrheals
*blood transfusions

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18
Q

RN interventions for hypovolemic shock: maintain optimal cardiac contractility and CO (4)

A

*PA line readings Q1hr (best measure of pressure w/i the pulmonary artery
*Dobutamine for CO
*NaHCo3 if pH <7.0
*Hourly I&Os

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19
Q

RN interventions for hypovolemic shock: maintain optimal o2 sat (3)

A

*keep SpO2 >95% (start 5-6L/min NC)
*intubation is likely (monitor ABGs)
*Maintain bedrest and adequate rest periods

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20
Q

RN interventions for hypovolemic shock: control body temp (2 + why)

A

(why: overheating increases myocardial o2 consumption)
*tx hyperthermia w/ cooling blankets
*warm IV fluids

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21
Q

RN interventions for hypovolemic shock: Prevent injury caused by decreased perfusion (4)

A

*limit sedatives
*give meds through central line
*monitor cap refill
*monitor s/s of skin breakdown

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22
Q

RN interventions for hypovolemic shock: Maintain nutrition status (2)

A

*Enteral feeding tube
*monitor electrolytes

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23
Q

RN interventions for hypovolemic shock: maintain renal perfusion (5)

A

*insert FC and monitor I&Os
*monitor renal labs (BUN, Creat, etc)
*replace vol
*monitor urine color
*dobutamine: increases perfusion

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24
Q

What will a hypovolemic shock pt look like? (7)

A

*pale, cool skin
*weak or rapid pulse
*decreased BP
*altered LOC
*thirst
*anxiety/restlessness
*N/V

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25
sepsis
systematic inflam response to infection
26
Severe sepsis
sepsis complicated by organ dysfunction
27
Septic shock
Presence of sepsis complicated by organ dysfunction
28
Septic shock:
presence of sepsis with hypotension despite fluid resuscitation -> inadequate tissue perfusion resulting in hypoxia
29
Septic shock factors (2)
*Intrinsic factors: internal or inherent qualities or characteristics *Extrinsic factors: external influences or environmental conditions that impact an organism
30
Examples of intrinsic factors leading to septic shock (2)
*extreme age *coexisting diseases: ex. burns, cancer, substance abuse, malnutrition, etc
31
Examples of extrinsic factors leading to septic shock (6)
*invasive devices *med therapy *fluid therapy *surgical or trauma wounds *surgical or invasive diagnostic procedures *immunosuppressive therapy (chemo)
32
septic shock patho:
infection -> immune response -> inflamm -> HoTN -> decreased perfusion -> cellular damage -> impaired cellular metabolism
33
3 major patho effects of septic shock
*vasodilation *maldistribution of blood flow *myocardial dysfunction: decreased EF, ventricular dilation
34
s/s of septic shock (7)
*increased HR *HoTN *full bounding pulse *pink, warm, flushed and then cold (warm better than cold sepsis) *first increased RR then decreased RR *decreased UO *increased temp
35
What are ART lines used for and not used for? (3)
*Best continuous BP monitoring & Assessment of arterial waveforms: give info about cardiac status *Blood sampling: ABG *NOT used for giving fluids or drugs
36
Why do we measure arterial blood pressure through the ART line?
Most accurate and reliable measurement and available quickly
37
What type of patients would most likely require arterial line placement?
Critically ill patients, such as those in intensive care units (ICUs), post-operative patients, or those undergoing major surgeries, often require arterial line placement for continuous blood pressure monitoring and frequent arterial blood sampling.
38
Besides blood pressure monitoring and ABG sampling, what other information can be obtained from arterial lines?
Arterial lines provide valuable information about arterial waveforms, which can indicate changes in cardiac output, systemic vascular resistance, and arterial compliance. This helps clinicians assess the patient's cardiovascular status and response to therapy.
39
Process of the arterial blood pressure waveform
Aortic valve opens -> 75% of the SV is ejected -> systolic pressure peaks -> 25% of the SV is ejected -> aortic valve closes
40
How do we want the arterial blood pressure waveform to look?
peaked not humped (means line is failing)
41
What does a widened pulse pressure on the arterial waveform suggest?
A widened pulse pressure, seen as an increased difference between systolic and diastolic pressures, may suggest conditions such as aortic regurgitation, arteriosclerosis, or increased stroke volume.
42
What is systolic arterial pressure
max pressure with which the blood is ejected from the left ventricle
43
Diastolic arterial pressure
reflects how rapid the blood flow through the arterial system and the vessel's elasticity
44
what conditions/meds make BP higher
*HTN, epi, dopamine, levophed
45
What conditions/meds lower BP
*septic neurogenic shock, nipride
46
What is the MAP
average pressure occuring in the aorta and its major branches during cardiac cycle
47
necessary MAP to perfuse vital organs
60
48
MAP formula
SBP + (2x DBP)/ 3
49
What are pressors used for
HoTN, shock, sepsis
50
what do vasopressors do?
Increase afterload
51
Examples of vasopressors that increase afterload
*epinephrine *Norepinephrine (Levophed) *High-dose dopamine
52
STEMI: What (9)
*Cell death. Involved all 3 layers. *QRS complex = altered shape. *Q-waves = wider and deeper (giggity). *ST- segment changes. *Thrombolytics = yes *Mechanical interventions = yes *Tx protocols well tested. *Easier to dx. *Complete blockage of artery.
53
STEMI: Chest pain assessment (P-U)
P: What PROVOKES it? Where? Q: QUALITY? R: RADIATE? To what REGION? S: SEVERITY 1-10? SYMPTOMS? T: TIME pain started? TX before coming to ER? U: UNDERSTANDING situation
54
STEMI: Common s/s of pain for men (6)
Severe chest pain > 30 minutes New/different pain More intense pain Elephant on chest Vise-like Radiates down the left arm/jaw/neck/back
55
STEMI: Common s/s of pain for women (6)
Any of what the men get + Unexplained SOB Cold sweat Sudden fatigue Nausea Lightheaded
56
STEMI: VS (4)
*HR up and then down *RR up: O2 demand goes up but less is getting perfused to tissues *BP up then down *Temp goes up
57
STEMI: Clinical assessment-Skin
Assess skin temperature, color, cap refill, and other peripheral pulses: Circulation slows
58
STEMI: Clinical assessment-Heart
Auscultate heart sounds: Murmurs or new S3 and S4 (hard)
59
STEMI: clinical assessment- Lungs
*Auscultate lung sounds: Crackles and wheezes *Observe for breathlessness and pink frothy sputum: Pulmonary edema
60
STEMI tx (3 immediate)
*Stop ischemia by decreases demand and improving supply *12-lead EKG w/in 10 minutes of arrival! *MONAB: Morphine, O2, Nitro, Aspirin, Beta-Blockers
61
STEMI: Analgesia
(this is super painful!) *Morphine - 2-8 mg IV Q5-15 minutes (depends on BP b/c vasodilation) *Control the environment: Extreme anxiety, Fear, Give info
62
STEMI: Oxygen tx
*O2 at 2L to keep sats > 90% *HOB elevated (easier to breath, let gravity move diaphragm) *IV access w/2 large-bore needles (at LEAST 20 but 18 is better) 1. NS 2. Thrombolytics 3. Morphine
63
STEMI: Monitor for complications
*Reactions to meds 1. Hypotension 2. HA 3. RR 4. Bleeding 5. Continue pain
64
STEMI: Lab studies (electrolytes)
altered K, Ca, and Mg
65
STEMI: Lab studies cardiac (bio markers)
*Cardiac enzymes: Proteins released from damaged myocardial cells *Total CK: Released w/any muscle breakdown (not just cardiac muscle) *CK-MB: Represents cardiac component *CK-Index: Ratio of CK-MB to Total CK *Myoglobin and Troponin 1: More sensitive for heart
66
STEMI: Coagulation studies (we want these in case we need to go to surgery)
* PT (Prothrombin time): If you give Coumadin *PTT (Partial Prothrombin Time): If you give Heparin *Anti-Factor Xa Assay: If you give Lovenox
67
STEMI: lab studies: CBC
Check the differential d/t tissue necrosis
68
STEMI tx: Percutaneous Coronary Intervention (PCI) possibilities (4)
*Angioplasty (PTCA): Balloon catheter is passed through the stenosis (plaque) and inflated with helium. It enlarges the diameter by compressing and splitting the plaque. *Cardiac stent: Small spring device holds lining of vessel wall apart to maintain patency of the vessel *Rotational Ablation (Rotoblator): High speed diamond-tipped (giggity) device that cuts the hard plaque but not the soft vessel wall. It pulverizes material into micro-debris *CABG: Papillary muscle rupture. Acute ventricular septal defect. Left main coronary artery occlusion
69
If PCI for STEMI, what is the goal time from paramedics to balloon up in
90 minutes
70
STEMI: Fibrinolytics (what, when to give, contraindications, dx criteria)
*dissolves all clots *give w/i 30 min of arrival, w/i 12 hrs of onset of pain *Contraindications: recent surgeries, bleeding, pregnancy = result in hemorrhagic strokes *Further contraindications: facial trauma, uncontrolled HTN, or ischemic stroke w/ mon *CXR, and EKG
71
Bleeding precautions for fibrinolytics
*no razors, needle sticks, toothbrushes, or suppositories *check stool for blood *expect to see arrhythmias and elevated cardiac markers if med is still working
72
Anticoagulant/Antiplatelet Medications: Heparin
*Decreases thrombi formation, infarction rate, and DVTs *Doesn’t work on the primary clot *60 units/kg then start drip at 12 units/kg/hr *Monitor PTT Q6hrs *Keep PTT between 50-70
73
Anticoagulant/Antiplatelet Medications: Lovenox
Chromogenic anti-Xa Heparin assay
74
Anticoagulant/Antiplatelet Medications: ASA
*Decreases platelet aggregation *Prevents further thrombosis *Give as 4 low-dose ASA (May only give 2 when in combination with TNKase)
75
Anticoagulant/Antiplatelet Medications: Plavix
*Blocks platelet aggregation *300-600 mg loading dose, then 75-150 mg maintenance dose
76
Beta blockers
*Lower HR *Lower O2 consumption *Lower dysrhythmias (ventricular) *Contraindications: HF, Low CO, Heart block, Active asthma
77
Vasodilator drugs:
Nitro: spray, SL, PO, topical, IV
78
STEMI: secondary prevention meds
*ACE inhibitors *Diuretics *Antihyperlipidemics
79
STEMI: secondary prevention meds (ACE inhibitors)
*(Captopril, Vasotec, Prinivil) w/in 24 hours after STEMI *Action: Slows progression of L ventricular dysfunction *Dose: Dependent on the drug and reason
80
STEMI: secondary prevention meds (Diuretics)
if heart failure is present
81
STEMI: secondary prevention meds (Antihyperlipidemics)
if total cholesterol, LDL, triglycerides are elevated
82
STEMI: Post-cardiac syndrome
*Therapeutic Hypothermia: -Increased neurologic function -Increased survival rate -33 degrees for 12-24 hours
83
NSTEMI (8)
*Blood supply to heart is inadequate but without cell death. *Damage to part of a wall, not full-thickness. *No ST changes. *No thrombolytics. *Tx w/mechanical interventions on a less emergent basis. *Less well tested protocols. *More difficult to dx. *Partial occlusion of artery.
84
ACLS scenario: Bradycardia
P/R check BP check *Atropine Q4 minutes, max 3 mg (reflex brady) P/R check BP check H&T P/R check BP check *Atropine 1 mg BP check P/R check BP check ~ 2 minutes ~ P/R check BP check Placer pads IMMEDIATELY ROSC?
85
ACLS Scenario: Pulseless Asystole/PEA
P/R check CPR *Epi 1 mg Q2 min, no max Call RT/intubate P/R check CPR P/R check CPR *Epi 1 mg P/R check CPR H&T P/R check CPR *Epi 1 mg ROSC?
86
ACLS Scenario: Tachy w/o Pulse AND Tachy w/Pulse
P/R check Stable? Cardiovert 100 J Pulse? Rhythm change? Go to that algorithm
87
ACLS Scenario: V-Fib/Pulseless V-Tach
P/R check Defib 120 J CPR P/R check Defib 150 J CPR Epi 1 mg Call RT/Intubate P/R check Defib 200 J CPR Amiodarone 300 mg OR Lidocaine 1-1.5 mg/kg H&T P/R check Defib 200 J CPR Epi 1 mg P/R check Defib 200 J CPR Amiodarone 150 mg OR Lidocaine 0.5-0.75 mg/kg P/R check Defib 200 J CPR Epi 1 mg P/R check Defib 200 J CPR P/R check Defib 200 J CPR Epi 1 mg ROSC?
88
ACLS scenario: ROSC
*Mange airway - Start 10 breaths/min - SpO2 92-98% - PaCO2 35-45 mmHg *Manage hemodynamic parameters - Systolic BP > 90 mmHg - MAP > 65 mmHg *Obtain 12-lead EKG *Consider for emergent cardiac intervention if: - STEMI - Unstable cardiogenic shock - Mechanical circulatory support required *Follows commands? Yes: - TTM - Obtain brain CT - EEG monitoring - Other critical care management No: - Other critical care management * Evaluate and tx rapidly reversible etiologies *Involve expert consultation for continued management
89
ABG analysis: PH
*normal range: 7.35-7.45 *If pH <7.35 = acidic *if pH >7.45 = alkaline/basic *If pH is out of wack at all, it is uncompensated
90
ABG Analysis: CO2
*normal range: 35-45 *Respiratory level *Opposite of pH readings. This bitch is acidic and problematic so we don’t “read” her like the other girls who are more basic. More of her means more acidity. Less means more basic. *<35 = alkaline/basic *>45 = acidic
91
ABG analysis: HCO3
*Norm range = 22-26 *Metabolic level *Interpreted just like PH. Lower number? = more acidic

Advanced Acute (13 decks)

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