unit 2 Flashcards
1
Q
pulmonary embolism
A
collection of matter that enters venous circulation and lodges in the pulmonary vessel
2
Q
large emboli obstruct pulmonary blood flow
A
reduced gas exchange reduced oxygenation pulmonary tissue hypoxia decreased perfusion potential death
3
Q
cause of pulmonary embolism
A
inappropriate blood clotting forms a DVT in vein in legs or pelvis
4
Q
risk factors for pulmonary embolism
A
prolonged immobility central venous catheters surgery obesity advancing age conditions that increase blood clotting history of thromboembolism pregnancy estrogen therapy cancer trauma smoking
5
Q
Pulmonary embolism prevention
A
passive and active ROM turn cough and deep breath Ted hose prevent compression in popliteal space avoid constricting clothing asses appropriateness of anticoagulant therapy frequent physical assessment of circulation patient and family teaching encourage smoking cessation
6
Q
manifestations of pulmonary embolism
A
dyspnea pleuritic chest pain on inspiration crackles or clear wheezes or rub dry or productive cough; hemoptysis tachycardia low grade fever JVD syncope cyanotic diaphoresis hypotension abnormal heart sounds shock and death
7
Q
psychosocial assessment for pulmonary embolism
A
anxiety restlessness fear "impending doom" change LOC
8
Q
lab assessment for pulmonary embolism
A
respiratory alkalosis low PaCO2 followed by metabolic acidosis Low SaO2 Metabolic panel troponin BNP d-Dimer
9
Q
Imagining assessment pulmonary assessment
A
pulmonary angiography
C1-PA
Chest x-ray
10
Q
Nursing diagnosis related to pulmonary embolism
A
Hypoxemia r/t mismatch of lunch perfusion and alveolar gas exchange
Hypotension r/t inadequate circulation to left ventricle
Potential for inadequate clotting and bleeding r/t anticoagulants therapy
Anxiety r/t hypoxemia and life threatening life
11
Q
interventions for pulmonary embolism
A
elevate HOB apply oxygen call Rapid response reassurance telemetry continuous pulse oximeter Maintain adequate venous access assess respiratory and cardiac every 30 minutes Administer prescribed anticoagulants: heparin, lovenox, fibrinolytics, warfin, Revesing agents
12
Q
aPTT, PTT
A
measure heparin therapy
common range: 20-30 seconds
therapeutic range: 1.5-2.5 times normal value
13
Q
PT (prothrombin time)
A
measures effectiveness’s of Coumadin
NR: 11-12.5 seconds
TR: 1.5-2.0 times normal value
14
Q
INR
A
CR: 0.8-11
TR for PE: 2.5-3.0
TR: for recurrent PE: 3.0-4.5
15
Q
Managing hypotension
A
IV fluid therapy ( crystalloid solution)
ECG and hemodynamic monitor
Monitor effectiveness of IF therapy( I&O, skin turgor)
DRug therapy and vassopressors; dopamine; levophed; dobutamine; nitroprusside
VS
16
Q
Minimize bleeding
A
assess for evidence of bleeding every 2 hours check emesis, stool, urine for blood asses IV every 4 hours Avoid IM injections apply ice to sites of trauma use electrical razors use soft bristled toothbrush avoid nose blowing supportive shoes hold pressure on IV site for 10 minutes after removing monitor labs
17
Q
Home management of pulmonary embolism
A
self-assessment of respiratory status self-assessment of cardiac assessment of lower extremities bleeding precautions change in LOC assess family to assume care
18
Q
thoracic trauma
A
first emergency approach to all chest injuries in BAC (breathing, airway, circulation)
rapid assessment and treatment of life threatening conditions
19
Q
pulmonary contusion
A
car crashes life threatening respiratory occur hemorrhage and edema in alveoli hypoxia and dyspnea
20
Q
Notes to take on pulmonary contusion
A
bruising over chest cough tachycardia tachypnea decreased breath sounds wheezes or crackles
21
Q
Pulmonary contusion x-ray
A
may be normal at first then develop over several days
22
Q
Rib fractures
A
blunt force
pain on movement and splints the affected side
23
Q
1st and 2nd ribs flail chest
A
poor prognosis
24
Q
Focus of treatment with rib fractures
A
analgesics to reduce pain so they can deep breath
25
flail chest
blunt chest trauma
high speed car crashes
CPR
26
Flail chest
fractures of at least 2 neighboring ribs in 2 or more places
causes paradoxical chest wall movement
27
Asses for paradoxical chest movement
```
dyspnea
cyanotic
tachycardia
increased work of breathing
hypotension
```
28
flail chest interventions
```
humidified oxygen
pain management
deep breathing with positioning
deep breathing and coughing
tracheal suctioning
Mechanical ventilation
ABG's
Monitor VS, fluid and electrolyte balances SaO2
```
29
pneumothorax
```
any injury that allows air to enter the pleural space
increases chest pressure
reduces vital capacity
blunt chest trauma or medical procedure
can be opened or closed
```
30
pneumothorax assessment findings
```
reduced breath sounds
hyperresonance on percussion
lack of chest wall movement
deviation of trachea away from side of injury
pleuritic pain
tachypnea
subcutaneous emphysema
```
31
pneumothorax interventions
```
chest x-ray
chest tube
pain control
pulmonary hygiene
continuous assessment for impending respiratory failure
```
32
tension pneumothorax
air leak in the lung or chest wall
causes collapse of affected lung
air entering pleural cavity on inspiration
air does not leave on expiration
air under pressure collapses blood vessels and decreases blood return
33
causes of tension pneumothorax
blunt chest trauma
mechanical ventilation
chest tubes
insertion of central venous access devices
34
assessment findings of tension pneumothorax
```
asymmetry of thorax
tracheal movement from midline toward the unaffected side
extreme respiratory distress
absence of breath sounds
distended neck veins
cyanosis
hyper tympanic sound on percussion
hemodynamic instability
ABG's reveal hypoxia and respiratory alkalosis
chest x-ray
```
35
tension pneumothorax emergency management
```
needle thoracotomy with large bore needle inserted in 2nd intercostal space midclavicular
chest tube in fourth intercostal space
pain control
pulmonary hygiene
psychosocial interventions
```
36
hemothorax
penetrating injuries
bleeding from injury to lung tissue or fractured ribs or sternum
bleeding from trauma to heart, great vessels, or intercostal arteries
37
assessment findings of hemothorax
decreased breath sounds
percussion on affected side is dull
chest x-ray
38
hemothorax interventions
```
remove blood
chest tubes
serial chest x-rays
aggressive pain management
frequent VS
accurate I&O
fluid replacement
surgical management
open thoracotomy
mechanical ventilation
```
39
chest tubes
drain air, blood or fluid from pleural space
placed in pleural space to allow re expansion and prevents air and fluid from re-entering
has water seal compartment to ensure that air does not enter the patient
40
Chest tubes are used for
after thoracic surgery
pneumothorax
hemothorax
palliative treatment of lung cancer or HF
41
chest tubes placement and care
tip of tube placed near front lung apex
tip of tube is placed on side near base of lung
insertion sites are protected with airtight dressing
approx. 6 feet into patients chest
42
3 parts of the drainage system on chest tubes
water seal chamber
collection chamber
suction regulator
43
chest tube chamber #1
collects fluid draining from patient and is checked hourly x24 hours
44
chest tube chamber #2
water seal that prevents air from reentering the patients pleural space
causes gently bubbling
keep filled with 2 cm of water
bubbling will stop once chest tube removed
blocked or kinked can cause bubbling to stop
excessive bubbling means an air leak
45
Chest tube chamber #3
suction control
46
Management of chest tubes drainage system
```
maintain patency
sterility of drainage system
keep manipulation of tubing
frequent respiratory assessment
pain management
```
47
Acute Coronary Syndrome
```
Unstable angina
Last longer than 15 minutes
May not be relieved by rest of NTG
ST elevation but not troponin or CK-MB changes
Untreated may lead to MI
```
48
Unstable angina
Chest pain
Discomfort that occurs at rest or with exception
Causes severe activity limitation
49
Acute myocardial infarction
Ischemia lead to injury and necrosis of myocardial tissue
| 80-90% occluded
50
Myocardial infarction
Myocardial tissue abruptly
| Severely deprived of oxygen
51
NSTEMI (Non ST Elevation)
ST segment and T wave changes on 12 lead indicating myocardial ischemia
Enzyme elevate over 3-12 hours
52
STEMI (ST elevation MI)
ST elevation in 2 contiguous leads on 12 lead ECG
Cause by plaque rupture
Complete occlusion of coronary artery
53
Acute MI
Evolves over several hours
Hypoxemia from ischemia
Increased oxygen demand may cause life-threatening ventricular dysrhythmias
54
Acute MI Extent of infarction depends on
Collateral circulation
Metabolism
Workload demands
55
Acute MI timeframe
At 6 hours tissue blue and swollen
48 hours infarction area gray and yellow striped
8-10 days granulation tissue develops
3 months thin, firm scar formation causes ventricular remodeling
56
LAD. Acute MI
Left. Anterior or septal MI
Highest mortality rate
Ventricular dysrhymaias
57
Circumflex Acute MI
Left lateral ventricle
Possible posterior wall
SA node and AV node
Sinus dysrhythmias
58
RCA Acute MI
SA and AV nodes
Right ventricle and inferior portion of LV
Right sided MI
59
Atherosclerosis nonmodification risk factors
Age
Gender
Family history
Ethnic background
60
Atherosclerosis modifiable risk factors
```
Elevated serum lipid levels
Smoking/tobacco use
Limited physical activity
Hypertension
Diabetes mellitus
Obesity
Excessive alcohol
Excessive stress/ poor coping skills
```
61
Hypoxemia from ischemia
Acidosis and electrolyte imbalances
62
Metabolic Syndrome (Syndrome X) Indicators of Risk Factors
Additional risk factor for CVD
Hypertension: either BP of 130/85 or higher or taking HTN meds
Decreased HDL; high LDL: either HDL,45 (men) or than 160 (men) or 135 (women) or taking antichlosterol meds
Elevated FBS: either 100 or higher or taking anti diabetic drugs
Large waist size: 40 inches or greater (men) or 35 inches for women; excessive abdominal fat causing central obesity
63
Patient Centered Collaborative Care
History: presenting symptoms
Physical assessment: assessment, VS, pain, symptoms
Psychosocial: denial, fear, anxiety, anger, depression,
Laboratory: troponins, CK-MB, chemistries
Radiology: chest X-Ray
12 lead ECG within 10 minutes
64
Immediate assessment
Labs
ECG
Patients wait before presenting so loss of 4-6 hours window
"Time is tissue"
65
Managing ACute pain
MONA
(morphine, oxygen, NTG, aspirin)
IV access X2
66
Improving cardiopulmonary tissue perfusion
Adequate cardiac output
Normal sinus rhythm and VS within normal limits
90 minutes from door to intervention
67
Monitoring for and Managing heart failure
Decreased CO due to ventricular dysfunction
| Rupture of the intraventricular septum
68
Killip Classification of heart failure
Class I: absent crackles and S3
ClassII: crackles in lower half of lung and possible S3
Class III: crackles more than halfway up the lung and frequent pulmonary edema
Class IV: cardio genie shock!!!!
69
Drug therapy for ACS
ASpirin: recommended; chewing 4 baby aspirins; or chew 325 mg tab X1
Glycoproteins inhibitors: IV; decreased dosage with fibrolytics
Beta-adrenergic blocking agents: Metoprolol; decrease size of infarction;
ACEI's and ARBS: given within 48 hours of ACS; prevent ventricular remodeling
CCB: promotes vasodilation and myocardial perfusion; NOT indicated after AMI; helps with angina
Thrombolytic therapy: dissolves thrombi in coronary arteries ; restore myocardial blood flow
Tissue plasminogen activator: IV (activase)
Reteplase: IV (retavase)
Tenecteplasae: IV push (TNK)
70
Thrombolytics
Most effective within 6 hours of coronary event
Indicated for CP > 30 minutes duration unrelieved by NTG indications of STEMI by ECG
Start within 30 minutes of Ed admission
71
Absolute contraindications to Thrombolytic therapy
```
Prior intracranial hemorrhage
Cerebral vascular lesion
Malignant intracranial neoplasm
Ischemic stroke within last 3 months
Suspected aortic dissection
Active bleeding
Significant CHT or facial trauma in last 3 months
```
72
Relative contraindications to Thrombolytic therapy
```
History of HTN
History of ischemic stroke, dementia
Traumatic CPR or major surgery writhing last 3 weeks
No compressible vascular punctures
Prior allergic reaction to strepto
Pregnancy
Active peptic ulcer
Current use of INR
```
73
Percutaneous coronary intervention
Reopen clotted coronary artery
| Restore perfusion writhin 2-3 hours of onset
74
Indications that artery has re-perfused
Abrupt cessation of pain
Sudden onset of ventricular dysrhythmias
Resolution of ST segment depression/ elevation or T wave inversion
A peak at 12 hours of markers of MI damage
75
Post thrombolytics
Heparin infusion for 3-5 days
APTT usually 1.5-2.5
Enoxaparin IV
76
Coronary Artery Bypass Graft
Open heart surgical procedure
| Replace occluded artery
77
Arterectomy or stent placement
Angiography to remove plaque
| Maintain potency of coronary artery
78
Hemodynamic Monitoring
Swan Ganz catheters
CVP
PAWP
RAP
79
Treatment of cardiogenic shock
Assessment
Fluids
Drug
Oxygen
80
Troponin values
81
CPK-MB values
3-5%
82
Troponin values
Book
83
CPK-MB values
Book
84
Improving gas exchange
```
Ventilation assistance
Monitor respiratory rate q 1-4 hours
Auscultate breath sounds q 4-8 hours
Position in high fowlers
Maintain oxygen saturation of 90%
```
85
Drugs to reduce afterload
ACE inhibitors
ARB
Human BNP
86
Interventions that reduce preload
Diuretics
| Venous vasodilators
87
Drugs that enhance contractility
Digoxin
| Beta blockers
88
Managing pulmonary edema
```
Early signs: crackles, dyspnea at rest, disorietnation, confusion
High fowlers position
Oxygen therapy
Nitro
Rapid-acting diuretics
IV morphine sulfate
Continual assessment
```
89
Assessment for valvular heart disease
```
Sudden illness
Ask about attacks of rheumatic fever, infective endocarditis, ask about possibility of IV drug abuse
Chest x-ray
ECG
Stress test
```
90
Nonsurgical managment of valvular heart disease
```
Rest
Drug therapy:
Diuretics
Beta blockers
Dig
Oxygen
Nitrates
Vasodilators
Anticoagulants
```
91
Surgical management of valvular heart disease
```
Reparative procedures
Balloon valvuloplasty
Open commissurotomy
Mitral valve annuloplasty
Replacement procedures
```
92
Infective endocarditis risk factors
IV drug abusers
Valve replacement recipients
Systemic infections
Structural cardiac defects
93
Manifestations of endocarditis
```
Murmur
Heart failure
Arterial embolization
Splenic infarction
Neurologic changes
Petechiae
Splinter hemorrhages
```
94
nonsurgical Management of endocarditis
Antimicrobials
| Activites balanced with adequate rest
95
Surgical management of endocarditis
Removal of infected valve
Repair or removal of congenital shunts
Repair of injured valves and chordae tendineae
Draining of abscesses in heart or elsewhere
96
Assessment of pericarditis
Substernal precordial pain
Radiating to left side of neck, shoulder, or back
Grating, oppressive pain, aggravated by breathing, coughing, swallowing
Pain worsened by supine position
Relieved by sitting up and leaning forward
Pericardial friction rub
97
Interventions for pericarditis
NSAIDs
Antibiotics for bacterial form
Pericardiectomy
98
Pericardial effusion
```
Puts patient at risk for cardiac tamponade
Cardiac tamponade findings:
JVD
Paradoxical pulse
Decreased CO
Muffled heart sounds
Circulatory collapse
```
99
Rheumatic carditis
From upper respiratory tract infection with group A beta hemolytic streptococci
Inflammation in all layers of heart
Ashoff bodies
100
Clinial manifestations of rheumatic carditis
```
Tachycardia
Cardimegaly
New or changed murmur
Pericardial friction rub
Precordial pain
Changed in ECG
Indications of heart failure
Existing streptococcal infeection
```
101
Cardiomyopathy
Chronic disease of caridac muscle
102
Cardiomyopathy nonsurgical management
```
Diuretics
Vasodilation agents
Cariac glycosides
Toxin exposure avoidance
Alcohol avoidance
```
103
To decrease high potassium (hyperkalemia) do what
Insulin and dextrose
104
Right MI do not give
A nitro drip
105
Automaticity
Cardiac cells to generate an electrical impulse spontaneously and repetitively
106
Excitability
Non-pacemaker cells to respond to an electrical impulse
| Depolarize
107
Conductivity
Ability to send an electrical stimulus from cell membrane to cell membrane
108
Contractility
Atrial and ventricular muscle cells to shorten their fiber length
Mechanical
109
SA node
Electrical impulses 60-100 bpm
Primary pacemaker
P wave on ECG
110
(Atrioventricular) AV node
PR segment on ECG
| Contraction known as atrial kick
111
Bundle of His
Right and left bundle branch system
| QRS on the ECG
112
Purkinje cells
Responsible for rapid conduction of electrical impulses throughout ventricles
Leading to ventricular depolarization
Ventricular muscle contraction
113
Depolarization
Negatively charged cells
| And develop a positive charge
114
P wave
Atrial depolarization
115
PR segment
Impulse to travel through AV node
116
Pr interval
Atrial depolarization
117
QRS complex
Ventricular depolarization
118
QRS duration
Depolarization of both ventricles
119
ST segment
Ventricular repolarization
120
T wave
Ventricular repolarization
121
QT interval
Total time
122
ECG rhythm analysis
Heart rate (slow, normal, fast)
Heart rhythm (regular, irregular)
Analyze P waves (present before each QRS)
Measure PR interval (0.12-0.20 Sec)
Measure QRS (after each P wave, less than or equal to 0.12 sec)
Q-T interval (less than or equal to 0.40 sec)
Interpret rhythm
123
First degree atrioventricular block
All sinus impulses eventually reach ventricles
124
Sinus bradycardia
HR less than 60 bpm
125
Patient centered care for sinus bradycardia
Maintain perfusion and CO
Assess LOC and patient tolerance
Atropine
Pacemaker
126
Atropine
```
IV bolus
Repeated every 3-5 minutes
Assess urinary retention
Dry mouth
Glaucoma
```
127
Sinus tachycardia
HR greater than 100 bpm
| SNS stimulation or PSN inhibition
128
Patient collaborative care for sinus tachycardia
```
Maintain perfusion and CO
Assess dehydration
Hypovolemia
Infection
HF
MI
Urinary output
Assess emotional status , medications
```
129
Supraventricular tachycardia
HR 100-280bpm
170 for adults
Terminated suddenly with or without intervention
130
Interventions for supraventricular tachycardia
Vagal maneuvers: strain like having a BM
Carotid massage: only doctors can do those
Adenosine: push this medication fast alongwith flushing fast
If does not work can do two more times
Put arm over arm
131
Atrial fibrillation
```
Atrial fibrosis
Loss of muscle mass
Cardiac decreases 20-30%
350-450bpm
No clear P waves
```
132
Atrial fibrillation is common in
Hypertension
Heart failure
Coronary artery disease
COPD
133
Atrial fibrillation patient centered care
```
Risk for PE, VTE
Antidysrhythmic drugs
Cardioversion
Percutaneous radiofrequency catheter ablation
Biventricular pacing
Maze procedure
All on anticoagulant
```
134
Atrial flutter
220-350bpm
Saw tooth appearance
One-half of atrial beats are blocked at AV junction
Calcium channel blockers
135
Cardioversion
Synchronized countershock
136
Cardioversion used for
Emergencies for unstable patients
Ventricular
Supraventricular tachydysrhythmias
Stable tachydysrhythmias resistant to medical therapies
137
Ventricular dysrhythmias
Life-threatening
| Do not get oxygenated blood to vital organs
138
Premature ventricular complexes
Early ventricular complexes followed by a pause
| Unifocal or multifocal
139
Common causes of premature ventricular complexes
```
MI
Age
CHF
COPD
Anemia or hypoxia
Stress
Caffeine
Nicotine
Infection
Hypokalemia
Hypomagnesium
```
140
Ventricular tachycardia
Repetitive firing of irritable ventricular ectopic focus
140-180 bpm
May last longer than 15-30 seconds
141
Causes of ventricular tachycardia
```
Muscle ischemia
MI
Valvular disease
HF
Drug toxicity
Hypomagnesium
Hypokalemia
```
142
Ventricular fibrillation
Electrical chaos in ventricles
Lethal dysrhythmias
Shock them
CPR
143
Ventricular asystole
Complete absence of any ventricular rhythm
Dead
Not shockable
CPR
144
CPR manegment
Maintain airway
Ventilate with mouth-to-mask device
Start chest compressions
145
Defibrillation
Depolarizes critical mass of myocardium simultaneously
| Stops and allows sinus node to regain control of heart
