Upgrade to remove ads
N443 Exam #2
Terms in this set (246)
What are the 3 types of circulation that affect perfusion?
1. Pulmonary circulation
2. Systemic circulation
3. Coronary circulation
What is the order of blood flow in fetal to pulmonary circulation?
Placenta->Umbilical vein->Ductus venosus->Right atrium to left ventricle through the foramen ovale->Aorta->Systemic circulation->Blood returns to the placenta via the umbilical arteries
What is the Foramen Ovale?
The opening between the atria of the fetal heart
What is Systole?
It occurs when the ventricles contract and eject blood
What is Diastole?
It occurs when the atria contract and ventricles fill, perfusing the myocardium
What is Stroke Volume?
It is the difference between the End Diastolic Volume and the End Systolic Volume
What is Cardiac Output?
It is the amount of blood pumped by the ventricles in one minute
What is the equation for Cardiac Output?
HR x SV = CO
What is the Cardiac Cycle?
One complete heartbeat
-Typically around 70-80 times per minute
How is the Ejection Fraction calculated?
It is the Stroke Volume divided by the End Diastolic Volume
What is the normal range of Ejection Fraction?
What is the normal Cardiac Output for adults?
What are the ranges for reduced Ejection Fraction?
SEVERE: LESS THAN 35%
What is important to know about infant, child, and teen EF compared to adults?
It is SIMILAR!
What are the different influences on Cardiac Output?
What is Depolarization?
It occurs when the heart contracts and there is an action potential in the sinoatrial node (SA node)
What is Repolarization?
It occurs when the heart relaxes
How are myocardial cells unique?
They have a refractory period where no stimulation will cause contraction
What is an Action Potential?
It is an movement of ions across the cell membranes
What is the order of the Electrical Conduction System?
SA Node (pacemaker)->Internodal pathways->AV Node->Right bundle branch->Left bundle branch->Purkinje Fibers
What is important to know about a standard 12 lead EKG?
-It used 10 lead wires
-6 limb leads view the frontal plane
-6 precordial or chest leads view the horizontal plane
What is important to know about diagnostic pediatric EKGs?
They use 15 leads with 3 additional precordial leads on the right side of the chest
What is an EKG or ECG?
A graphic record of electrical activity in the heart
What are the 6 steps to interpret an EKG?
1. Rate: count the # of R waves in a 6 second strip
2. Regularity: measure distance between R to R
3. Assess for P waves
4. Measure PR interval
5. QRS duration
6. ST elevation
What EKG assessment & labs are done to evaluate when there is risk?
-C reactive protein
-Ankle brachial index
-Exercise EKG testing
-Electron beam CT scan
-Myocardial perfusion imaging
What EKG assessment & labs are done when there is suspected injury in cardiac markers released from necrotic heart muscle?
What are the indications for an EKG?
-Chest pain or persistent discomfort above the waist
-Chest pressure or tightness
-Heartburn or epigastric pain
-Sensations of heart racing or heart rate too slow
-Syncopal episode or severe weakness
-New onset stroke symptoms
-Recent illicit drug use
For what patient population are EKGs indicated for when there are atypical symptoms?
-Diabetics and women
What are some alterations in perfusion?
-Acute coronary syndrome
-Acute myocardial infarction
What are potential complications from alterations in perfusion?
-Structural defects (aneurysm or valve malfunction)
What is the goal in therapy to treat alterations in perfusion?
Pain relief and preservation of muscle
What occurs as a result of Bradycardia (A or V)?
Decrease in CO->leads to syncope
What occurs as a result of Tachycardia (A or V)?
Reduction in stroke volume & CO due to decreased ventricular filling time and decreased ventricular filling
What occurs with Atrial Fibrillation?
An electrical disturbance of the upper chambers that interferes with the 'atrial kick'
What occurs with Ventricular Fibrillation?
The CO drops to zero and the individual is incompatible with life
What occurs with an AV Block?
The conduction between the atria and ventricles is impaired
-It can be either 1st
-2nd degree ( Type 1 & 2)
-3rd degree (complete heart block)
What are the potential affects of Arrhythmias?
-Shortness of breath
-Low blood pressure
What are the conservative therapies for treating alterations in perfusion?
-Control of hypertension
-Control of diabetes
-Complementary and alternative therapy
What are the clinical therapies for treating alterations in perfusion?
-Intensive care after MI
-Intra aortic balloon pump
-Ventricular assist device (VAC)
What are the independent and collaborative interventions for alterations in perfusion?
-Independent: aimed at improving and promoting perfusion
-Collaborative: pharmacologic, focus on risk reduction and disease progression
What is arterial oxygen saturation? How and when is it measured?
-It is the O2 saturation of hemoglobin of arterial blood
-It is measured by pulse oximetry
-It is either continuously or intermittently monitored
What are the different interventions for when the arterial oxygen saturation is low or high?
LOW: Increase Oxygen
HIGH: If on Oxygen, start to wean off
What is venous oxygen saturation? How and when is it measured?
-It is the O2 saturation of hemoglobin in venous blood and reflects the dynamic balance between oxygenation of the arterial blood, tissue perfusion, and tissue O2 consumption
-Measured continuously via a PA catheter (SvO2)
What are the potential causes and the interventions for when the venous oxygen saturation is low or high?
Low SvO2: could be caused by decreased O2 supply or increased O2 demand
-Determine the cause and fix it (anemia, hypoxemia, cardiogenic shock, seizures)
High SvO2: could be caused by increased O2 supply or decreased O2 demand
-Determine the cause and fix it (sepsis, hypothermia)
What is important to know about Blood Pressure? How is it measured and when is it monitored?
-Blood pressure determines tissue perfusion and is evaluated based on the MAP
-It is measured by an arterial line in either the radial, femoral, or brachial artery
-It is continuously monitored
What factors contribute to blood pressure?
CO & opposing blood flow (SVR)
What is the relationship between BP and O2?
A higher BP means there is a greater O2 requirement
What does an arterial line measure?
MAP (for BP)
What do PA catheters measure?
-PA pressures (preload)
What is Preload? What influences it?
-It is the amount of cardiac muscle fiber tension, or stretch, that exists at the end of diastole, just before contraction of the ventricles
-It is influenced by volume & compliance of the ventricle
What is Frank-Starling's Law?
-The more the myocardial fiber is stretched during the filling, the more it shortens during systole and the greater the force of the contraction
-Increase in preload->increase in force of contraction->increase in SV & CO
How is Preload measured in the Left ventricle vs. the Right ventricle?
Left Ventricle: Pulmonary artery wedge pressure (PAWP) or Pulmonary artery diastolic pressure (PAD)
Right Ventricle: Central Venous Pressure (CVP)
How are PAWP values obtained?
-PA catheter is used to obtain values
-PAWP needed to 'wedge' by inflating the balloon
-Can also use the PAD to obtain approximate value of wedge
When are PA pressures monitored?
What could be the potential causes and interventions for either a high or low PAWP and PAD?
High: could be caused by heart failure and volume overload
-Treated with diuretics or vasodilators (Nitroglycerine, Nipride)
Low: could be caused by volume depletion
-Treated with fluids
How is the CVP value obtained? How often is it monitored?
-Value obtained in the right atrium or vena cava using a PA catheter, central line, or PICC
What could be the potential causes and interventions for either a high or low CVP?
High: could be caused by heart failure and volume overload
-Treated with diuretics or vasodilators (Nitroglycerine, Nipride)
Low: could be caused by volume depletion
-Treated with fluids
What is Afterload? How is it measured in the Left vs. Right ventricle?
-It is the forces opposing ventricular ejection
How is the SVR value obtained? What is important to know about it?
SVR: Systemic Vascular Resistance
-Value obtained via a PA Catheter
-Calculated with CO
-Continuously or intermittently monitored
What could be the potential causes and interventions for either a low or high SVR?
Low SVR: vasodilation
-Treated with vasoconstrictors (NE, neosynephrine, vasopressin) and fluids
High SVR: vasoconstriction
-Treated with vasodilators (Nipride, Nitroglycerine)
How is the PVR value obtained? What is important to know about it?
PVR: Pulmonary Vascular Resistance
-Value obtained with a PA Catheter
-Continuously or intermittently monitored
-Could indicate pulmonary hypertension!
-NEED TO HAVE PAWP TO CALCULATE
How is contractility measured?
-IT CAN'T BE DIRECTLY MEASURED
-If preload, heart rate, and afterload remain constant yet the CO changes, the contractility is changed!
What are the interventions for increasing or decreasing heart contractility?
Increase: POSITIVE Inotrope
-Dobutamine, Primacor, Dopamine
Decrease: NEGATIVE Inotrope
(Calcium channel blockers, Beta blockers)
-Verapamil, Diltiazem, Metoprolol
What do nurses need to know when monitoring Hemodynamics?
-What values are abnormal
-What the abnormal values mean in terms or pathophysiology
-How to treat with standing orders
What is the nursing responsibility for line insertion?
-Check labs, allergies
-Have all equipment ready
-Set up pressure bag
-Ensure physician obtained informed consent
-Ensure aseptic technique
-Monitor waveforms or for ectopy
-Obtain chest XRay
-Apply occlusive dressing
What is Peter Pronovost's Checklist for Aseptic technique?
-Use full-barrier precautions during insertion (cap, mask, sterile gloves, sterile gown, large sterile drape)
-Clean the patient's skin with chlorhexidine antiseptic
-Avoid the femoral site if possible
-Remove unnecessary catheters if possible
What are some possible arterial line complications?
-Neurovascular impairment or loss of limb
What are some possible PA catheter complications?
What is important to know when discontinuing lines?
-Monitor for ectopy
-Hold pressure (20 minutes for an arterial line)
-Frequently monitor site
What is shock? What could it lead to?
-Occurs when the cardiovascular system fails to perfuse the tissues adequately
-It leads to impaired cellular metabolism
What are the common manifestations of all types of shock?
-Increased respiratory rate
What are the 4 types of Shock?
What are the two etiologies behind Hypovolemic Shock?
What are the three etiologies behind Distributive Shock?
What occurs in Cardiogenic Shock?
The heart has impaired PUMPING ability to contract and to pump blood which results in an inadequate supply to heart and tissues
What occurs in Obstructive Shock?
Structural compression causes decreased venous return, outflow, stroke volume, cardiac output, and cellular oxygen supply->This leads to decreased tissue perfusion and impaired cellular metabolism?
What occurs in Hypovolemic Shock?
Relative or Absolute hypovolemia leads to decreased circulating volume, venous return, stroke volume, cardiac output, and cellular oxygen supply->This leads to decreased tissue perfusion and impaired cellular metabolism
What occurs in Anaphylactic Distributive Shock?
What occurs in Septic Distributive shock?
What occurs in Neurogenic Distributive shock?
An imbalance between sympathetic and parasympathetic stimulation leads to massive vasodilation, decreased vascular tone, decreased SVR, and inadequate cardiac output->This leads to decreased tissue perfusion and impaired cellular metabolism
What is important to know about Neurogenic shock?
-It is a hemodynamic phenomenon
-Can occur within 30 minutes of a spinal cord injury at the 5th T vertebra or above
-Can last up to 6 weeks
-Can also occur in response to spinal anesthesia
-Results in massive vasodilation leading to pooling of blood in vessels, tissue hypoperfusion, and ultimately impaired cellular metabolism
What are the 3 stages of shock? What is important to know about them?
Stage 1: Early, reversible, and compensatory
Stage 2: Immediate or progressive
Stage 3: Refractory or irreversible
What occurs in the Early stage of Shock?
-Baroreceptors detect drop in MAP by <10
-SNS increases HR and cardiac contractility
-SNS increases peripheral vasoconstriction->Increased SVR->rise in arterial pressure->Narrowed pulse pressure->Anaerobic metabolism maintains homeostasis->perfusion of cells, tissues, organs maintained
What occurs in the Compensatory stage of Shock?
-MAP falls 10-15 mmHg and blood volume drops by 25-35%
-Increased myocardial O2 consumption
-Compensatory mechanisms able to maintain blood pressure and tissue perfusion to vital organs
-Compensatory mechanisms short-acting
-Hypotension in children is LATE finding
What occurs in the progression to Refractory or Irreversible Shock?
-Compensatory mechanisms fail
-Decreased CO, profound hypotension, bradycardia, dysrhythmias, anuria, hypothermia, unresponsive with dilated pupils
-Hallmark features: continued decreased cellular perfusion->altered capillary permeability->leakage of fluid and protein out of vascular space into surrounding interstitial space-> decreased circulating volume->increase in systemic interstitial edema->further decreased perfusion->cellular death
What are the clinical manifestations of Shock?
-Cold, clammy skin with prolonged capillary refill
-Decreased renal perfusion-> decreased UO
-AMS, disorientation, anxiety, and confusion
What are the hemodynamic manifestations of shock?
-Hypotension defined as MAP <70
-Increased pulmonary wedge pressure
What are the biochemical manifestations of shock?
What is the VIP rule for treatment of shock?
1. V: VENTILATION
2. I: INFUSE
3. P: PUMP
What is the nursing assessment of an individual with shock?
-Sleep and rest
-Maintaining body temperature
-Movement and positioning
What are the priority nursing diagnoses for an individual with shock?
-Deficient fluid volume
-Decreased cardiac output
-Ineffective tissue perfusion
What are the priority interventions for an individual with shock?
-Oxygen, fluids, BP, HR, Urine
What are the priority interventions for children with shock?
-Fluid resuscitation at 10-20 ml/kg
-Most common anaphylaxis to food
-Prolonged capillary refill is a late sign
What are the nursing goals for a client with shock?
-Evidence of adequate tissue perfusion
-Restoration of normal or baseline BP
-Recovery of organ function
-Avoidance of complications from prolonged states of hypoperfusion
Which patient populations are at risk for shock?
-Patients who are immunocompromised
-Patients with chronic illness
-Surgery or trauma patients
What is important to know about an Implantable Cardioverter-Defibrillator (ICD)?
-Consists of a lead placement system placed through subclavian vein to the endocardium
-Battery powered pulse generator implanted subcutaneously
-Sensing system monitors HR & rhythm
-Includes anti-tachycardia and anti-bradycardia pacemakers (Overdrive pacing for tachy, backup pacing for brady)
What are the indications for the use of an ICD?
-Survival of sudden cardiac death (SCD)
-Spontaneous sustained VT
-Syncopal episode with inducible ventricular tachycardia/fibrillation during electrophysiology study
-High risk for life-threatening dysrhythmias
What are the indications for use of a pacemaker?
-Used to pace the heart when the normal conduction pathway is damaged: Bradycardia, Atrial Fibrillation, Heart Failure, Syncope
-Pace atrium and/or both ventricles
What is important to know about on-demand pacing in pacemakers?
-Fires only when the HR drops below preset rate
-Sensing device inhibits pacemaker when HR is adequate
-Pacing device triggers when no QRS complexes within set time frame
What is important to know about Antitachycardia and Overdrive pacing in pacemakers?
Antitachycardia: Delivery of a stimulus to the ventricle to terminate tachydysrhythmias
Overdrive: Pacing the atrium at rates of 200-500 impulses/minute to terminate atrial tachycardias
What are the different types of pacemakers?
-Single chamber: one lead is either at atrium or ventricle
-Dual chamber: two leads, one in atrium and one in ventricle
-Biventricular chamber: three leads, one in atrium, two in ventricles
What is important to know about Cardiac Resynchronization Therapy (CRT) in pacemakers?
-Resynchronizes the heart by pacing both ventricles to help increase LV filling time and improve the heart's efficiency
-Biventricular pacing delivers electrical impulses to both ventricles to help them contract at the same time
-Used to treat patients with heart failure
-Can be combined with ICD for maximum therapy
What are the temporary pacemakers?
Power sources outside the body:
What are the nursing implications for patients with pacemakers?
-008 once stable
-Limit arm and shoulder activity
-Monitor insertion site for bleeding and infection
-Patient teaching is important
-Symptom awareness for failure lead/device
What are the nursing implications when monitoring for device failure of pacemakers?
-ECG monitoring for malfunction
-Failure to sense: causing inappropriate firing
-Failure to capture: lack of pacing when needed leads to bradycardia or asystole
What are some complications that are looked for in patients with Pacemakers?
-Atrial or ventricular septum perforation
What are the nursing considerations and potential implications for pacemaker patients going to the OR?
-Interrogation or setting adjustments
-Role varies by setting
-Change in device function due to electromagnetic interference (most common due to electrocautery and it may causing pacing inhibition)
What is involved in the patient and caregiver teaching after insertion of a Pacemaker?
-Follow up appointments for pacemaker function checks
-Avoid direct blows
-Avoid high-output generator
-No MRIs unless pacer approved
-Microwaves are OKAY
-Avoid antitheft devices
-Travel not restricted
-Pacemaker/ICD identification card
-Medic alert ID
What is the cause of Peripheral Vascular Disease? What areas does it commonly affect?
-Results from atherosclerosis, the hardening and narrowing of arteries causing blood flow obstruction
-Often coexists with coronary artery disease, cerebrovascular disease, and kidney disease
-Manifests as a progression of symptoms
-May affect the iliac artery, femoral artery, tibial artery, or the peroneal artery
What are risk factors for the development of Peripheral Vascular Disease?
-Chronic kidney disease
What are the clinical manifestations of PVD?
-Diminished or absent pulses
-Skin color changes
-Pain at rest
What is important to know about Critical Limb Ischemia?
-Can be caused by PVD
-Chronic ischemia rest pain lasting more than 2 weeks
-Arterial leg ulcers or gangrene
-May result in amputation
What is the cause of Acute Arterial Ischemic Disorders? What are the signs and symptoms?
-Caused by sudden interruption of arterial blood supply
-5 P's: pain, pallor, pulselessness, paresthesia, and paralysis
What is the nursing management for patients with Acute Arterial Ischemic Disorders?
-Treatment goals: adequate perfusion in tissues, pain relief, increased exercise tolerance, intact healthy skin
-Education: exercise therapy
What can cause Chronic Venous Insufficiency? What are the clinical manifestations?
-May result from long-standing varicose veins
-Venous valves not functioning properly
-Causes pooling of blood
-Clinical manifestations: leathery appearance of lower leg, brownish color, edema, venous ulcers, pain while in dependent position
What is the nursing management for CVI?
-Assess nutritional status
-Monitor for infection
What are the diagnostic studies for PVD?
-Ankle brachial index (ABI)
What is the risk factor modification for PVD?
-Glycosylated hemoglobin <7% for diabetics
-Aggressive treatment for HLD
-Blood pressure management
What is the drug therapy for PVD?
-Medications for intermittent claudication: Cilostazol and Paotoxilylline
What are Primary Cardiomyopathies?
They are idiopathic
What can cause Secondary Cardiomyopathies?
They result from other processes:
-Connective tissue disorders
What is the difference between Intrinsic and Extrinsic Cardiomyopathies?
Intrinsic: abnormalities originating in the heart muscle
Extrinsic: result from diseases not unique to heart muscle cell abnormalities
What are the different classifications of Cardiomyopathies?
-Arrhymogenic Right Ventricular Dysplasia
What is important to know about Hypertrophic Cardiomyopathy?
-50% inherited by genetic predisposition
-More common in males
-Also known as: asymmetric septal hypertrophy, muscular subaortic stenosis, idiopathic hypertrophic subaortic stenosis
What are the hallmarks of Hypertrophic Cardiomyopathy?
-Disproportionate thickening of interventricular septum
-Disorganization of septal muscle cells
-Greater hypertrophy of the ventricular septum than the ventricular chambers
-Heart silhouette may appear to be normal size
What are the primary defects of Hypertrophic Cardiomyopathy?
-Left ventricular stiffness
What is the progression of Hypertrophic Cardiomyopathy?
Thickening of intraventricular septum and wall->hyperdynamic state->increased contractility->increased EF->impaired diastolic relaxation->decreased ventricular compliance
-Obstruction to aortic outflow may be present!
What is the collaborative treatment for Hypertrophic Cardiomyopathies?
-Cardiac resynchronization therapy (CRT)
What is important to know about Restrictive Cardiomyopathy?
-Restriction of the heart to stretch and fill
-Characterized by rigid ventricular walls, decreased ventricular filling that impairs filling, decreased ventricular size, elevated end diastolic pressures, and decreased CO
-Contractility is unaffected; EF is normal!!!
What does Restrictive Cardiomyopathy commonly cause?
-Causes myocardial fibrosis and infiltrative processes such as amyloidosis
-Fibrosis of myocardium and endocardium causes stiffness and rigidity of ventricles
What is the treatment for Restrictive Cardiomyopathy? What are the common signs and symptoms?
-Same treatment as for heart failure
-Dyspnea on exertion and exercise intolerance common
-Jugular venous pressure and S3 and S4 are common
What is important to know about Arrhthmogenic Right Ventricular Myopathy?
-High risk for ventricular tachyarrhythmias and sudden death
-Heart muscle becomes thickened and body replaces the muscle of the right ventricle with fatty and fibrous tissue
-Occurs in both men and women
-Accounts for up to 1/5 of sudden cardiac deaths in individuals under 35 y.o.
What is important to know about Dilated Cardiomyopathy?
-MOST COMMON TYPE
-Most common cause of heart failure
-Most common in males 20-60
-30% inherited by genetic predisposition
What is the pathophysiology of Dilated Cardiomyopathy?
-Ventricular dilation WITHOUT myocardial hypertrophy
-Grossly impaired systolic function
-Diminished myocardial contractility
What is the impact of Dilated Cardiomyopathy?
-Increased end-diastolic fractions
-Decreased ventricular stroke volume
What is the end result of Dilated Cardiomyopathy?
-Dysrhythmias with palpitations
What are the patient findings in individuals with decreased cardiac output?
-Decreased exercise tolerance
-Weak peripheral pulses
-Systemic and pulmonary emboli
-JVD and hepatomegaly
What are the signs and symptoms of Pulmonary Congestion?
-Paroxysmal noctural dyspnea
What are the signs and symptoms of dysrhythmias with palpitations?
What are the treatments of cardiomyopathies?
-Similar to CHF and pulmonary edema
-Bedrest and reduced activity
-Immunosuppressants if documented inflammatory disease
What medications are commonly used to treat Cardiomyopathies?
-Angiotensin II receptor blockers
What is important to know about fetal circulation?
-There is high pulmonary vascular resistance, which leads to constricted pulmonary vessels
-Low systemic vascular resistance
-Patent foramen ovale
-Patent ductus arteriosus
-Ventricles EQUAL in size
What is the anatomy and physiology of the pediatric heart?
-Muscle fibers of the infant heart less developed and organized
-Left ventricles two times larger than the right by 2 months of age
-Heart muscle fully developed by 5 years of age
What is important to know Oxygenation in the fetus and baby after birth?
-Relative polycythemia at birth
-Oxygen content means the hemoglobin level, hemoglobin saturation, and PO2
-Chronic hypoxemia of cyanotic congenital heart defect stimulates bone marrow to increases RBCs
What is important to know about Cardiac Functioning in the infant?
-High oxygen requirements for first 2 weeks in life
-Cardiac output relies on heart rate until heart rate developed (5 years of age)
-Response to any stressor will be tachycardia
-Death from primary cardiac event uncommon
-Hypoxemia> Bradycardia > Cardiac Arrest
What are the two potential causes of a congenital heart defect?
Either a defect in the heart or great vessels or persistence of a fetal structure after birth
What is the etiology of a congenital heart defect?
-Often occur within 8 weeks of gestation
-Result from combined or interactive effect of genetic or environmental factors: drug exposure, maternal viral infections, maternal metabolic disorders, maternal alcoholism, maternal complications of pregnancy, genetics
-MORE THAN ONE DEFECT IS COMMON
What are the current categories of congenital heart defects?
What are the two types of septal defects?
-Atrial septal defect
-Ventricular septal defect
What is important to know about an atrial septal defect?
-Occurs from patent foramen ovale, the opening in the atrial septum
-Can be small or large
-Causes left-to-right shunting
What is important to know about ASD in the first few decades of life?
-Subtle physical examination findings
-70% of ASD not detected until 5th decade of life
What are the clinical manifestations of ASD?
-Infants with large ASD may have pulmonary overcirculation and slow growth
-Older adults and children may have SOB with activity
-PULMONARY HYPERTENSION AND STROKE ARE COMPLICATIONS
What are the assessment findings of ASD?
-Soft systolic ejection murmur at pulmonic areas
-Widely split second heart sound due to increased right ventricular volume
What is important to know about Ventricular Septal Defect?
-Most common type of congenital heart defect
-May close spontaneously often within the first 2 hours of life
-Leads to increased pulmonary blood flow
-Small defects do not manifest symptoms in a neonate
-Large defects cause tachypnea, tachycardia, poor growth, CHF, and pulmonary hypertension
What are the treatment options for VSD?
-May close spontaneously
-If no signs/symptoms of CHF or poor growth, use conservative treatment
-Surgical patching during infancy only if symptomatic because of high risk to neonate
-Closure by transcatheter device during cardiac catheterization if possible
-Prophylaxis for infective endocarditis for 6 months after surgical or device closure or indefinitely with residual VSD
What are the priority nursing diagnoses for a patient with VSD?
-Decreased cardiac output
-Excess fluid volume
-Ineffective infant feeding pattern
-Risk for infection
-Interrupted family processes
-Compromised family coping
What is important to know about Eisenmenger's Syndrome?
-Right to left or bidirectional shunting at the atrial or ventricular level
What are the different obstructive defects in congenital heart defects?
-Coarctation of the aorta
-Bicuspid aortic valve
What is important to know about coarctation of the aorta?
-Obstruction of systemic outflow
-Often near the ductus arteriosus
-Often associated with bicuspid aortic valve
What is the other term for aortic stenosis?
Bicuspid aortic valve
What are the cyanotic defects in congenital heart defects?
-Transposition of the great arteries
-Tetralogy of Fallot
What is the common example of an acyanotic defect in congenital heart defects?
Patent Ductus Arteriosus (PDA)
What is important to know about Patent Ductus Arteriosus?
-Failure of the ductus arteriosus to close after birth
-Usually the higher O2 concentration constricts the ductus
-Usually closes within 10-15 hours with permanent closure 10-21 days unless SaO2 remains low
-Higher aortic pressures at birth leads to shunting of blood from the aorta to the pulmonary artery
-Increased pulmonary artery blood flow leads to CHF
What is the other term for Acute Renal Failure?
Acute Kidney Injury
What is important to know about acute renal failure?
-ABRUPT onset causing disturbance in fluid, electrolyte, and acid-base balance
-Occurs in 5-10% of hospitalized patients (60% in ICU)
-Staging depends on the decrease in UO and the increase in serum creatinine
-YOU NEED TO FIND THE CAUSE!!!
What percentage of AKI is caused by prerenal causes? What is the common prerenal cause?
What percentage of AKI is caused by intrarenal causes? What is an example and what is important to know about this?
-DAMAGE TO TISSUE
-Due to renal artery stenosis, cholesterol, embolus, malignant HTN, preeclampsia, massive hemolysis, rhabdomyolysis, DIC, infection, nephrotoxic medications
-Prolonged tissue ischemia from prerenal causes can also result in acute tubular necrosis
What percentage of AKI is caused by postrenal causes? What is an example and what is important to know about this?
-OBSTRUCTIVE causes; something that prevents urine excretion
-BPH, cancer, renal calculi
-In patients with 2 kidneys, the obstruction must be BILATERAL to cause AKI
What are the risk factors for developing AKI?
What assessments/labs/imaging are used to identify AKI?
-BUN, Creatinine (when ratio of BUN:Cr>20, indicative of prerenal cause)
-Fractional excretion of sodium and urea (FENA) (less than 1% confirms prerenal cause)
-Renal US, abdominal/pelvis CT
What are the different phases of AKI?
What is important to know about the Oliguric phase of AKI?
-Urine output <400ml/day
-Fluid volume overload
-Azotemia/uremia (trouble concentrating, seizures, lethargy, coma)
-Decreased calcium/increased phosphorus
What is important to know about the use of Continuous Renal Replacement Therapy?
-Used in ICU when patients are unable to tolerate hemodialysis
-Fluid removal is more gradual and you have to control how much fluid is removed each hour
-Another line to consider
What is important to know about the Diuretic phase of AKI?
-Gradual increase in urine output to 1-3L/day
-Labs may remain abnormal for a few days
-How does your care for the patient change?
When does the Recovery phase of AKI begin?
When the GFR increases and returns to normal
What are the outcomes of AKI?
-High death rate
-Children may have residual kidney damage
-Adults are at risk for subsequent AKI or progressive chronic kidney disease
What can be done for prevention of AKI?
-Careful assessment of nephrotoxic drugs
-Patient education about OTC drugs
-Use imaging without contrast, if possible
-Older adults are high-risk population
-What is the relationship between race and kidney injury/disease?
What is Respiratory Failure?
It is when one of both gas exchanging functions are inadequate
What is Hypoxemia?
Insufficient O2 transferred to the blood
What is Hypercapnia?
Inadequate removal of CO2 from the blood
What is ARDS and what is important to know about it?
-Acute Respiratory Distress Syndrome (ARDs)
-Also known as shock lung, posttraumatic respiratory distress syndrome, vietnam lung, etc.
-Hallmark of ARDs is PULMONARY EDEMA in the absence of cardiac failure
-Sudden progressive form of acute respiratory failure
What are the primary insults of ARDS?
What are the secondary insults of ARDS?
-Severe massive trauma
What is the pathophysiology of ARDs?
-ARDs is an alteration of membrane permeability in pulmonary capillaries and alveoli
-Changes from ARDs thought to be due to stimulation of inflammatory and immune systems
What are the 3 phases of ARDS?
1. Injury of exudative stage
2. Proliferative stage
3. Fibrotic stage
What is important to know about the Exudative stage of ARDS?
-Neutrophils adhere to pulmonary microcirculation, causing damage to vascular endothelium and increased capillary permeability
-Fluid crosses into the alveolar space
-Alveolar cells are damaged, surfactant dysfunction leads to atelectasis
-Intrapulmonary shunt develops
-Hyaline membranes line alveoli, contribute to atelectasis and fibrosis and lead to decreased gas exchange and compliance
-Lungs become less compliant and higher airway pressures must be generated
What is important to know about the Reparative or Proliferative phase of ARDS?
-Influx of neutrophils, monocytes, and lymphocytes
-Lung becomes dense and fibrous
-Lung compliance continues to decrease
-If phase persists, widespread fibrosis results
-If stopped, lesions will resolve
-ABG may start to show respiratory acidosis and hypercapnia
What is important to know about the Fibrotic or Chronic/Late phase of ARDS?
-Lung is completely remodeled by fibrous and collagenous tissues
-Decreased lung compliance
-Decreased area for gas exchange
-In some patients, changes in lungs may be irreversible and lead to higher rate of mortality
What is the clinical progression of ARDS?
-Progression varies among patients
-Survival chances are poor for those who enter the fibrotic phase (requires long-term mechanical ventilation)
-Some survive acute phase of lung injury and the pulmonary edema resolves and they make a full recovery
What are the early clinical manifestations of ARDS?
-Increased work of breathing
-Increased respiratory rate
-Decreased tidal volume (respiratory alkalosis from increase in CO2 removal, decrease in CO2 and tissue perfusion)
What are the late clinical manifestations of ARDS?
-Symptoms worsen with increased fluid accumulation and decreased lung compliance
-Pulmonary function tests reveal decreased compliance, lung volumes, and functional residual capacity (FRC)
-Tachycardia, diaphoresis, changes in mental status, cyanosis, and pallor
-Diffuse crackles and coarse crackles
-Hypoxemia despite increased FiO2
-Increased WOB despite initial findings of normal PaO2 or SaO2
What is seen on an X-Ray of an individual with ARDS?
-Chest X-ray termed 'whiteout' or 'white lung' because of consolidation and widespread infiltrates throughout lungs
-Leaves few recognizable air spaces
What are potential complications of ARDS?
-Ventilator associated pneumonia
-Barotrauma: pneumothorax or subcutaneous emphysema
-High risk for stress ulcers
What is the collaborative care for a patient with ARDS?
-Identification of an underlying cause
What is the respiratory therapy for an individual with ARDS?
-Lateral rotation therapy
-Positive pressure ventilation with PEEP
What are the diagnostic tests for ARDS?
-CBC, chemistries, blood cultures
What is included in a nursing assessment for an individual with/suspected with ARDS?
-History of lung disease
-Tobacco, alcohol, drug use
-Prior injury or trauma
-Exposure to lung toxins
-Anxiety, mental status change
-Skin, cardiac, and respiratory assessment
-Changes in pH, PaCO2, PaO2, SaO2
What are the nursing diagnoses for a patient with ARDS?
-Ineffective airway clearance
-Ineffective breathing pattern
-Risk for imbalanced fluid volume
-Impaired gas exchange
-Imbalanced nutrition: less than body requirements
What are the nursing considerations for a patient with ARDS?
-Maintain patent airway
-Promote spontaneous ventilation
-Enhance cardiac output
-Monitoring for tolerance of ventilator weaning
-Prevent skin breakdown
What is included in planning following recovery from ARDS?
-PaO2 within normal limits for age or at baseline on room air
-Resolution of precipitating factor(s) for ARDS
-Clear lungs on auscultation
What is the evaluation for a patient with ARDS?
-No abnormal breath sounds
-Effective cough and expectoration
-Normal respiratory rate, rhythm, depth
-Synchronous thoracoabdominal movement
-Appropriate use of accessory muscles
-Decreased or absent peripheral edema
-Normal PA or PA wedge pressures
-Verbalization of positive attitude towards outcome
-PaO2 and PaCO2 within normal range or at baseline
-Maintenance of weight or weight gain
-Serum albumin and protein normal range
What is important to know about the use of mechanical ventilation?
-It is the mechanical movement of air in and out of the patient's lungs
-Can be done via ETT or tracheostomy
What is important to know about the Respiratory Rate (RR) as a mechanical ventilation parameter?
-Number of breaths per minute that the ventilator delivers
-Ventilator can provide all of pt's ventilation, or patient may be able to breathe spontaneously between ventilator breaths
-May titrate rate to control CO2 levels
What is important to know about the Tidal Volume (TV) as a mechanical ventilation parameter?
-Volume of gas the ventilator will deliver to the patient with each breath
-Set TV according to Ideal Body Weight (IBW)
-TV also affects CO2 levels
What is important to know about the Positive End Expiratory Pressure (PEEP) as a mechanical ventilation parameter?
-Maintains small end-expiratory pressure
-Prevents collapse of alveoli
What is important to know about the Fraction of Inspired Oxygen (FiO2) as a mechanical ventilation parameter?
-The amount of oxygen the ventilator delivers
What is important to know about the Minute Volume as a mechanical ventilation parameter?
-Volume of gas the ventilator will deliver to the patient in one minute
What is important to know about the Peak Inspiratory Pressure as a mechanical ventilation parameter?
-Reflects airway resistance and lung compliance
-Elevated with either increased resistance or decreased compliance
What is important to know about the Plateau Pressure as a mechanical ventilation parameter?
-Pressure applied to the small airways and alveoli
How does volume controlled mode work in mechanical ventilation?
-A tidal volume (TV) is preset
-Breaths are delivered at a set rate
-Pressure will vary
-Flow is constant through the breath
How does pressure controlled mode work in mechanical ventilation?
-A pressure level is preset
-Breaths are delivered at a preset rate
-Pressure is constant throughout the delivered breath
-Tidal volume will vary
-Flow is also variable through the breath
How does dual controlled mode work in mechanical ventilation?
-Pressure Regulated Volume Control (PRVC)
-An alternative to straight pressure control and/or volume control
-In this mode we attempt to obtain best of both volume and pressure control
-PRVC regulates pressure to changing compliance of the lungs to adjust inspiratory flow and pressure to maintain a SET tidal volume
What are the severity levels of ARDS depending on the degree of Hypoxemia?
-Depends on the PaO2/FiO2 ratio
SEVERE: Less than 100
How is mechanical ventilation used in ARDS for protective ventilation?
-Use low tidal volumes (starting with 6/Kg IBW)
-Limiting plateau pressure-30cm of H20 or less
-If plateau pressures are >30, try 4/kg IBW
-Increasing PEEP to help with oxygenation
-Pressure control ventilation may be tried if high inspiratory airway pressures are required to deliver even low tidal volumes
How is prone positioning useful for treating ARDS?
Improves oxygenation through:
-recruitment of dependent lung zones
-increased functional residual capacity (FRC)
-increased diaphragmatic excursion
-improved ventilation-perfusion matching
What are the recruitment maneuvers for a patient on mechanical ventilation?
-Patient receives a high PEEP setting on the ventilator for a short time, repeated 4 times
-Helps with atelectasis due to the edema in the lungs
-Increases end expiratory lung volume
How are sedation and paralytics used for mechanically ventilated patients?
-Used to help with uncomfortableness of ventilators
-Restlessness and agitation lead to low oxygenation and high airway pressures
-Lungs need to rest
What is important to know about the use of Extracorporeal Life Support (ECLS)?
-Used for severe cases of ARDS
-A membrane oxygenator is a piece of equipment which acts as a lung to deliver oxygen into the patient's blood. The circuit acts as an artificial heart and lung for the patient.
-ECLS takes the emphasis off the mechanical ventilator and provides gas exchange so that harmful levels of support from the ventilator can be reduced
When is a tracheostomy used for mechanical ventilation in patients?
-Surgically placed artificial airway into the trachea through the neck
-Placed during prolonged ventilation of 7-14 days
-Easier to wean from ventilator
What controls the wake behavior in an individual?
-The Reticular Activating System (RAS)
What controls the sleep behavior in an individual?
-Involves a variety of neurologic structures
-Melatonin (linked to environmental light-dark cycle)
-Sleep promoting neurotransmitters
What are characteristics of the 3 stages of NREM sleep?
Stage 1: slow eye movements
Stage 2: heart rate and temperature decrease
Stage 3: deep, or slow wave sleep and delta waves
What is important to know about REM sleep?
-20 to 25% of sleep
-Occurs 3 to 4 times per night
-Period when most vivid dreaming occurs
What are the risk factors for Insomnia?
-Age of 60+
-Mental health disorder
What are the risk factors for Obstructive Sleep Apnea?
-Large neck circumference
What are the risk factors for Narcolepsy?
-Orexin (Hypocretin deficiency)
What are the risk factors for parasomnias?
What are the risk factors for night terrors in adults?
Drug or alcohol abuse
What are the risk factors for Restless Leg Syndrome?
What are the symptoms of Insomnia?
-Difficulty falling asleep
-Difficulty staying asleep
-Waking up too early
-Complaints of waking up feeling unrefreshed
What is Acute Insomnia?
Difficulty falling asleep or remaining asleep for at least 3 nights/week for less than 1 month
What is Chronic Insomnia?
-Same symptoms as acute
-Daytime symptoms that persist for 1 month or longer
What is the etiology of Chronic Insomnia?
-Often no known cause
-Stressful life event
-Psychiatric illness or medical condition
-Medications or substance abuse
-Jet lag, exercising near bedtime, nightmares
-Irregular sleep schedules
-Using alcohol to induce sleep
What is Insomnia diagnosed through?
What is the interprofessional collaboration for Insomnia?
-Complementary and alternative therapies
What are the complementary and alternative therapies for Insomnia?
-Melatonin: effective for jet lag and shift work
-Valerian: safe but clinical trials have not shown effectiveness
-Chamomile: safe but clinical trials have not shown effectivenes
-White noise and relaxation strategies
What is included in the nursing assessment of an individual with Insomnia?
-Assess diet, caffeine, and alcohol intake
-Ask about sleep aids
-Sleep diary for 2 weeks
-Medical history: factors that affect sleep
What are the nursing diagnoses for Sleep and Rest Disorders?
-Disturbed sleep pattern
-Readiness for enhanced sleep
What is the nursing implementation for individuals with sleep disorders?
-Assess primary role in teaching sleep hygiene: decrease caffeine and reduce light and noise
-Teach patient about sleep medications
What is important to know about Obstructive Sleep Apnea?
-Also called Obstructive Sleep Apnea-Hypoapnea Syndrome (OSAHS)
-Partial or complete upper airway obstruction during sleep
-Apneic period may include hypoxemia and hypercapnia
What are the clinical manifestations of Obstructive Sleep Apnea?
-Frequent arousals during sleep
-Excessive daytime sleepiness
-Witnessed apneic episodes
What can complications of Obstructive Sleep Apnea result in?
What is the nursing and collaborative management of mild sleep apnea?
-Sleeping on the side
-Avoiding sedatives and alcohol use 3-4 hours before sleep
What is the nursing and collaborative management of severe sleep apnea?
-CPAP: poor compliance
What are the gerontologic sleep considerations?
Older age is associated with overall shorter sleep time, decreased sleep efficiency, more awakenings, and insomnia symptoms
-Awakenings increase fall risk
-Medications can contribute to sleep problems
-AVOID LONG-ACTING BENZODIAZEPINES
What are the special sleep needs of nurses?
-Nurses on permanent nights or rapidly rotating shifts are at increased risk of experiencing shift work sleep disorder
-Use strategies to help reduce distress associated with shift work: on-site napping, consistent sleep-wake schedule
YOU MIGHT ALSO LIKE...
core III final
ch 37 shock
OTHER SETS BY THIS CREATOR
443 Lung Cancer
N443 Exam #1
N443 Exam One Meds and Labs to know