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Med Surg- lecture 2

Terms in this set (22)

arterial line
-keeping track of BP
-can draw blood from it (labs, ABGs)
-can't give meds through them!!
What to monitor with arterial line?
-cap refill
-sensation
-temperature
-numbness tingling
-if these things are seen: check pulse, get doppler, take catheter OUT
nursing management with A-line
-make sure pressure bag is set at 300mmHg, keeps the line open so it doesn't clot off
-make sure transducer is at phlebostatic axis (mid axillary line, 4th intercostal space)
-make sure it is ZERO'd to the atmosphere
Central Venous Catheter
-used to give blood products and fluids
-sites at internal jugular, subclavian, femoral (can't get heart pressures in femoral)
-don't draw blood from these lines to prevent infection
Normal CVP
2-8mmHg
*if low= hypovolemic (give fluids d/t dehydration)
*if high= overload (give diuretics)
signs of hypovolemia
tachycardia (heart compensating)
confusion
low urine output
Swans
-still a central line, measure pulmonary artery pressure (left side of heart), CO of patient (how well heart is pumping blood out to body)
-pulmonary arterial wedge pressure
-gives you LEFT ventricular volume (fluid status of pt)
-normal wedge pressure is 6-15mmHg
*if low wedge levels= they need more fluid
*if high wedge levels= overloaded
Acute Coronary Syndrome (ACS)
-myocardial infarction (MI)
-PCI is an intervention for treatment of patients with confirmed STEMI
-a small percent of patients may need emergent CABG surgery
Coronary Surgical Revascularization
-coronary artery bypass graft (CABG)
-requires sternotomy and cardiopulmonary bypass (CPB)
-uses radial arteries or veins for grafts
-minimally invasive direct coronary artery bypass (MIDCAB)
-off pump coronary artery bypass (OPCAB)
-robotic coronary artery bypass
Why a CABG?
-coronary surgical revascularization
-relief of angina with coronary artery stenosis (70% despite guideline-directed medical therapy
-relief of symptoms and decreased need for reintervention are superior with CABG
contraindications to CABG
-small, narrow vessels
-diffuse disease
-lack of conduit suitable for bypass grafts
-severe aortic sclerosis
-severe LV dysfunction
Pre-Op CABG considerations
-patient evaluation
-medical history
-physical exam
-lab data
-diagnostic studies
-pre-op blood conservation
-autologous donation
-erythropoietin
-intra-aortic balloon pump (IABP) and emergency surgery for ischemia, arrhythmia, pulmonary edema or shock
-medical optimization
-increased creatinine after contrast
-delay after ST-elevation MI (STEMI)
-glycemic control
intra-operative CABG management
-standard operation
-CPB via median sternotomy
-aortic cross-clamp
-techniques to protect the heart from ischemia during aortic cross clamping
-cardiac arrest with cardioplegia
-combo approach to protect the heart
-moderate systemic hypothermia
-profound myocardial hypothermia
-medications
cardiopulmonary bypass
-oxygenates and pumps blood
-removes venous blood
-returns oxygenated blood on arterial side
-requires anticoagulation
-associated sequelee
physiologic effects of CPB
-last acutely for several hours and up to 2-3 days postoperatively
-blood encounters plastic and metal surfaces of CPB machine
-whole body inflammatory response
-unique bleeding complications
-hormonal stress response and massive defense reaction
-fluid retention and fluid shifts
-organ dysfunction
post-op CABG management
-hemodynamic-hypotension, low CO/CI, bleeding (chest tubes) and physical assessment
-glucose management
-signs of shock
-dysrhythmias
-monitor ABG
-fluid and electrolyte status
-wean ventilatory support
-vascular access and IV med management
-pain management
Immediately post op CABG
-IV fluids
-vasopressors and positive inotropes
-vasodilators
-IV meds for BP control
-beta blockers
-calcium channel blockers
-nitrates
-rate control and anti-dysrhythmics
-amiodorone, adenosine, digoxin
-bleeding reversal agents
-aspirin, plavix
-lipid blocking therapy
-prophylactic antibiotics
CABG post-op patient education
-cough and deep breathing with chest splinting
-incentive spirometry
-optimizing comorbidities
-smoking cessation
-sternal precautions
-sternum reinforced with special wires
-lift no more than 5-8 pounds
-no pushing or pulling with their arms
-no reaching behind their back, both arms out to the side or overhead
-early mobility
-OOB within 6 hours post extubation
atrioventricular valves
-tricuspid valve
-R side of heart bw atrium and ventricle
-mitral valve (bicuspid)
-L side of heart bw atrium and ventricle
semilunar valves
-aortic valve
-L side of heart bw LV and aorta
-pulmonic valve (bicuspid)
-R side of heart bw RV and pulmonary artery
valvular heart disease
Any disease process involving the heart valves
mitral valve stenosis
-majority of adult cases result from rheumatic valvulitis or endocarditis
-scarring of valve leaflets and chordae tendineae
-contractures develop with adhesions bw commissures of the leaflets ("glued together")
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