Test #2

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Sarahs129
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261200
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Test #2
Updated:
2014-03-04 22:25:34
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Critical Care Test
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Description:
Alterations in Cardiac Output, Myocardial Tissue Perfusion, Invasive Cardiac Treatment Modalities, Fluid and Electrolyte balance, Acute Pulmonary disorders, Actue Renal Injury
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  1. Complications from decreased CO
    • Failure of myocardical integrity
    • Rhythm disturbances
    • Cardiac arrest
  2. Aortic semilunar valve
    Between LV and Aorta
  3. Pulmonary semilunar valve
    Between RV and Pulmonary artery
  4. Ticuspid valve
    Between RA and RV
  5. Bicuspid valve
    Between LA and LV
  6. Valve stenosis
    Leaflets fuse together and valve can not fully open.
  7. Mitral stenosis can cause...
    Increased PA pressure and pulmonary edema
  8. Aortic stenosis can cause...
    LVH and decreased CO
  9. Valve regurgitation
    Valve does not completly close allowing backflow
  10. Treatment for valve stenosis or regurgitation.
    • Valve repair
    • Valve replacement - c/b mechanical or biological
  11. Heart failure is...
    A structural or funcational disorder which decreases the ventricles ability to fill and/or eject
  12. Manifestations of HF
    • Dyspena
    • Fatigue
    • Exercise intolerance
    • Edema - peripheral and/or pulmonary
    • Orthopnea
  13. Management for HF
    • ACE/ARBs
    • BB
    • Diuretics
    • Inotropes (contractility)
  14. 3 processes of and Acute MI
    • Ischemia - reversable and temporary
    • Myocardical Injury - damaged cells, EKG changes
    • Infarction - dead cells, irreversable.
  15. Diagnosis of an MI
    • Subjective info from patient
    • EKG
    • Serum cardiac markers
    • **Suspect all chest pain to be an MI**
  16. PQRST - Chest pain assessment
    • P - Precipitating Factors
    • Q - Quality and Instensity
    • R - Region and Radiation
    • S - Signs and Symptoms
    • T - Timing and Responses to Treatment
  17. Stable Angina
    • Predictable - effort or anxiety related
    • Relieved with rest and nitro
    • Can progress to unstable
  18. Unstable angina
    • Spontaneous - no cause
    • Difficult to relieve
    • EKG changes - ST depression
  19. Prinzmetal's angina
    (Variant angina)
    • d/t spasms of the coronary artery
    • Treatment: CCB
  20. Immediate Emergency Treatment for CP
    • Vitals
    • O2 - 2-4L
    • ASA - 325mg chewed
    • Nitro
    • CP assessment
    • Start IV
    • EKG
    • Labs
    • Morphine
    • **Think MONA**
  21. Criteria for a positive diagnosis for an MI
    ST segment elevation equal or greater to 1mm in 2+ leads, next to each other.
  22. Diagnosis of an MI: Serum Markers
    • CPK and Troponins
    • d/t myocardial death, cells that should be within the heart leak out into the blood stream.
  23. Goal of Peperfusion therapy with an MI
    • Restore blood to the injured area
    • The earlier the better - best if started within 2 hours, still significant benefit within 6 hours.
  24. Perfusion therapy in an MI
    • Thrombolytic therapy
    • PCI (PTCA)
    • CABG
  25. Thrombolytic Therapy
    • TPA
    • Streptokinase
    • Reteplase
  26. Contraindications for thrombolytic therapy
    • Active bleeding or anything the can potentially bleed
    • Uncontrolled HTN
    • CVA within 2 months
    • Allergies to medications
  27. Cardiac Follow up
    • Activity - PT, Cardiac rehab
    • Work - depends on the MI
    • Driving - usually 4 weeks
    • Sexual activity -usually 4 weeks
  28. Rhythms that occus most frequently with an MI
    • Sinus Brady - decreases tissue perfusion
    • A-Fib - common after MI, can throw a clot
    • Heart Blocks
    • V-Tach
    • V-Fib
  29. VSD
    • Blood shunts from LV to RV
    • Decreases CO
    • Increases RV workload
    • Treatment: Repair
  30. Papillary muscle rupture
    • Leaflet eversion into atrium during systole
    • Sever MR
    • Severe pulmonary edema
    • Treatment: diuretics, repair
  31. Ventricular aneurysm
    • Weakened portion of the myocardium
    • CHF
    • Ventricular dysrhythmias
  32. Ventricular rupture
    • Massive bleeding into pericardial sac
    • Cardiac tamponade
    • Death within minutes
  33. When do you call a code?
    • Cardiac - Asystole, VT, VF, PEA
    • Respiratory - Apnea
    • Surgical - Exsanguination
  34. Role of a recording nurse during a code.
    • Senior or charge nurse
    • Records events of the code
    • Prompts physician in charge
    • Crowd control
  35. Role of Medication nurse in a code
    • Closest to IV access
    • Administers meds from code cart
    • Maintains IV drips
    • Confirms administration of meds
  36. Role of the MD in charge during a code
    • The most senior resident
    • Runs the code
  37. Role of surgical resident during a code
    • Responds to all codes
    • Inserts central IV access
    • Stands by for surgical intervention
  38. Role of Anesthesiolgist/CRNA during a code
    • Intubates patient
    • Manages airway
  39. Role of RT in a code
    • Ventilates patient
    • Manages airway
    • Performs and processes ABGs
  40. Amiodarone
    1st line of drug during a code for VT or VF
  41. Lidocaine
    2nd line of drug during a code for aarythmias
  42. Vasopressin
    • Used in conjunction with Amio or Lidocaine
    • Restores BP
  43. Epi
    • Most frequesntly used drug during a code
    • Will increase contratility and HR
    • Used in asystole, PEA, VT, VF
    • SIDE EFFECTS: tachycardia, HTN
  44. Dopamine
    Catecholamine to increase CO, BR and BP
  45. Complications due to dosing with Dopamine
    • Low dose - increases renal function
    • Moderate doses - used as an inotrope
    • High doses - vasoconstriction, increases BP
  46. Levophed
    Vasoconstriction, increase HR and CO
  47. Atropine Sulfate
    • Increases HR (chronotrope)
    • Uses with asystole, brady, PEA and HBlock
  48. PCI =
    Percutaneous coronary intervention
  49. Assessment prior to PCI
    • H&P
    • Consent
    • BUN & Creat.
    • ECG - CXR
    • Allergies?
    • IV access
    • Groin prep
    • NPO
  50. Medication restrictions and PCI
    • Heparin - can stop prior to or continue with depending on MD
    • Coumadin - stop 2-7 days prior
    • Metformin - hold 48 hours pre- and post-
  51. PTCA
    • Guide wire advanced across lesion
    • Balloon inflated x15-90 seconds
    • Can be repeated
  52. Stents
    • Performed after PTCA
    • To open closures
    • Prevent late stenosis
    • Repair disections
  53. Artherectomy
    (2 Types)
    • Removal of plaque from an artery
    • *Directional coronary artherectomy
    • *Rotablator
  54. Directional Coronary Atherectomy
    Plaque is shaved off and collected within the cutter for removal
  55. Rotablator
    • Sanding effect
    • Creates microparticles so they can pass in circulations without damage
  56. Immediatly post-PTCA
    • ECG
    • IV fluids
    • CP assessment
    • ACT
    • Accu-check
  57. Renal complications of PTCA
    (and treatment)
    • Contrast dye places burden on renal system
    • Treatment: increase PO intake, Diuresis, Mucomyst
  58. Sheath removal
    (complications)
    • ACT at bedside to assess coagulation
    • Femoral artery compression or Femstop
    • Complications: vasovagal syncope, bleeding
  59. Coronary artery disection
    • Tear in intimal layer of artery creating a flap obstructiing the lumen.
    • Can fix with a stent
  60. Abrupt Artery Closure
    • Thrombus formation, coronary spasm -- immediatly return to cath lab
    • Sudden onset of CP and EKG changes
  61. Restenosis
    • Narrowing of a previously dilated vessel
    • Plavix x6 mos
    • Back to cath lab
  62. Retroperitoneal bleed from PTCA
    (Signs & Symptoms)
    (Treatment)
    • Catheter manipulation in aorta causes bleed into retroperitoneal space
    • S & S: back or flank pain, hypotension, decreased H&H, restlessness
    • Treatment: d/c anticoags, blood products, IV fluids
  63. Pseudoaneurysm
    (Signs & Symptoms)
    (Treatment)
    • Contained rupture of an arterial wall
    • S/S: auscultation of bruit, palpable mass
    • Tx: stop or decrease anticoags, compession by US
  64. Arterial Thombosis/Embolization
    (Signs & Symptoms)
    (Treatment)
    • S&S: LE ischemia and pain, loss of pulses, numbness, lower motor funcation
    • Tx: initiate anticoags, may need surgery
  65. Indications for an electrophysiology study (EPS)
    • Syncope
    • Brady arrythmia
    • SVT
    • ICD/PPM
    • Ablation
  66. EPS procedure
    • Up to 5 catheters inserted to different parts of the heart
    • Stimulate heart with electricity and try to produce the abnormal rhythm.
    • Can see where it is originating from and able to correct it
  67. Intra aortic balloon pump
    Inflates and deflates in sync with the cardiac cycle.
  68. Intra aortic balloon pump during diastole
    • Aortic valve closes - balloon inflates
    • Increases coronary artey perfusion by forcing blood to coronary arteries rather than down the aorta
  69. Intra aortic balloon pump during systole
    • Balloon deflates at start of systole
    • Reduces intra-aortic volume, reducing aortic pressure
  70. Goals of intra-aortic balloon pump
    • Increase coronary artery perfusion
    • Decreases O2 demand for LV
    • Decreases myocardical workload
  71. Intra aortic balloon pump complications
    • Femoral artery obstruction
    • Blood clots
  72. LVAD
    • Diverts blood flow around the failing ventricle
    • Reduces cardiac workload
  73. Why get an LVAD?
    End stage HF to get to transplantation or improve QOL
  74. Complications of LVAD
    • Infection
    • Bleeding
    • Clots
    • CVA
    • Renal failure
  75. CABG
    • Coronary Artery Bypass Graft.
    • Provides an alternate route for blood to perfuse the an ischemic area of the heart.
    • Arteries will last longer then veins.
  76. Advantages vs. Disadvantanges
    Saphenous Vein as CABG
    • A: easily harvested, allows multiple grafts, no atomic limitations, open on endoscopic harvest.
    • D: 2 anastomosis sites, long leg inscision, leg edema, last 6-10 years.
  77. Advantages vs. Disadvantages
    Internal Mammary Artery as CABG
    • A: improved patency, remains open longer, one anastomosis.
    • D: excessive dissection, not as accessable in an emergency, anatomic limitations.
  78. Advantages vs. Disadvantages
    Radial Artery as CABG
    • A: improved patency, remains open longer, easily harvested.
    • D: requires good ulnar circulation, higher rates of spasms, 2 anastomosis sites.
  79. On-pump vs. off-pump CABG surgeries
    • On-pump: stops heart and Cardiopulmonary bypass machine (CPB) is used to pump the blood for you during surgery.
    • On-pump: surgery is done while your heart is still beating.
  80. Cardiopulmonary bypass (CPB)
    (procedure)
    • Expose the heart
    • Induce hypothermia
    • Initiate machine
    • Perform procedure
    • Stabilize rhythm and hemodynamics
    • Chest tube inserted
    • Epicardial pacing wires
  81. Effects of CPB machine
    • Intravascular fluid deficit
    • Coagulopathy - platelets can be destroyed within the machine
    • Hemolysis - can have low blood counts after surgery
    • Pulmonary dysfunction
    • Hyperglycemia
    • Hypokalemia
    • Neurologic dysfunction - can cause long term neuro change.
  82. Types of valve surgeries
    • Replacement
    • Repair and reconstruct
  83. Types of replacement valves
    • Biological or tissue - lasts 10-15 years however no need for long term anticoags
    • Mechanical - lasts longer however needs lifelong anticoagulants
  84. Most commonly repaired valve is...
    the aortic valve
  85. Commissurotomy
    Seperates fused valve leaflets
  86. Annuloplasty
    Repairs the valves annulus for better function
  87. Valvuloplasty
    Repairs valve leaflets for better function
  88. TAVR
    Valve replacement done thru a catheter.
  89. Valve post-op management
    • Hook up PA catheter, A-Line and monitor
    • EKG, BMP, Mag, CBC, Coags, ABGs
    • Assess hemodynamics and fluid status
    • Monitor for complications
  90. Most critical time following valve surgery
    1st 6-8 hours
  91. Post-Op Care after valve surgery
    • BP CONTROL - avoid hypotension as is will decrease perfusion to the coronary arteries AND avoid hypertension as the increased pressure can damage the suture lines
    • URINE OUTPUT - want to monitor kidney status
  92. If CVP is low post-op following valve surgery...
    Give albumin because it stays within the intravascular space
  93. Patient is hypotensive...
    Decreased BP
    Decreased CVP/PCWP
    Decreased CO
    • Hypovolemic
    • Give fluids
  94. Patient is hypotensive...
    Decreased BP
    Decreased CO
    Increased PCWP/CVP
    • Fluid status is good, poor contractility
    • Give inotropic agents
  95. Patient is hypotensive...
    Decreased BP
    Decreased SVR
    Adequate CO
    • Vasodialated
    • Give vasoconstrictor
  96. High BP after heart surgery
    • Can disrupt surgical sutures
    • Give CCBor Nitro
  97. Hypothermic after heart surgery
    Want to warm them up -- cold blood wont coagulate
  98. Manifestations of cardiac tamponade after heart surgery
    • Sudden decrease in CT drainage
    • JVD, muffled heart sounds
    • Go back to OR
  99. Carina
    • Y junction at the end of the trachea
    • Contains a lot of nerves and will cause coughing and bronchospasm if touched
  100. Ventilation
    Physical movement of gases in and out od the lungs
  101. Diffusion
    Movement of gases down a pressure gradient
  102. Perfusion
    Pumping of flow of blood into tissues and organs
  103. Name of the nerves that supply the diaphragm
    Phrenic nerves
  104. Lung compliance
    The ease in which the lungs are able to expand
  105. PEEP and lung compliance
    Increase PEEP with decreased lung compliance
  106. The majority of CO2 molecules are transported in the blood as:
    HCO3 (bicarbonate)
  107. V/Q ratio
    • Normal = 4:5
    • V=ventilation
    • Q=perfusion
    • The ratio between the amount of air getting to the alveoli and the amount of blood being sent to the lungs
  108. Cor Pulmonale
    Failure of the right side of the heart, brought on by long-term high blood pressure in the arteries of the lung and right ventricle of the heart (PVR)
  109. Respiratory acidosis
    • Too much CO2
    • Hypoventilation
  110. Respiratory alkalosis
    • Not enough CO2
    • Hyperventilation
  111. Metabolic alkalosis
    • Too little acid
    • Suctioning, vomiting
  112. Metabolic acidosis
    • Too much acid
    • DKA, renal failure, dehydration
  113. BE +2
    Metabolic alkalosis
  114. BE -2
    Metabolic acidosis
  115. Hypoxia vs. hypoxemia
    • Hypoxia = decreased SaO2
    • Hypoxemia = decreased PaO2
  116. Nutrition with respiratory problems
    Carbs increased CO2
  117. Breath sound associated with fluid or secretions most commonly heard on inspiration
    Crackles
  118. Breath sound that is course, bubbly sounds most commonly heard on expiration
    Rhonchi
  119. Breath sound or air passing through a constricted airway, may be heard on inspiration or expiration.
    Wheeze
  120. Capnography
    • Commonly referred to as EtCO2
    • Measures CO2 level at the end of exhalation
  121. Normal pH
    7.35-7.45
  122. Normal PCO2
    45-35
  123. Normal HCO3
    22-26
  124. pH 7.25
    PCO2 60
    HCO3 26
    Uncompensated respiratory acidosis
  125. pH 7.37
    PCO2 57
    HCO3 32
    Compensated Respiratory Acidosis
  126. pH 7.45
    PCO2 49
    HCO3 34
    Compensated metabolic alkalosis
  127. pH 7.25
    PCO2 68
    HCO3 31
    Partially compensated respiratory acidosis
  128. pH 7.28
    PCO2 34
    HCO3 16
    Partially compensated metabolic acidosis
  129. Indications for defibrillation
    • Pulseless VT
    • VF
  130. Cardioversion
    • Elective procedure used to convert an abnormal rhythm into sinus rhythm
    • Patient is sedated
    • Shock is delivered on R wave
  131. A code with a patient with an ICD
    Do not wait for the ICD to shock, defib immediately.
  132. Contraindications for Zoll
    C-spine or flail chest
  133. ICF
    • Most stable
    • Fluid within cells
    • Rich in Potassium, Phosphate, Protein
    • Regulated by Na/K pump
  134. ECF
    • Intravascular (Least stable)
    • Fluid in the plasma
    •     and
    • Interstitial
    • Fluid between cells and tissues
  135. Osmosis
    Movement of fluid in and out of cells from low to high concentration.
  136. Serum osmolality
    Concentration of particles in plasma
  137. With decreased serum osmolality
    -What is the concentration of solutes?
    -What is the fluid volume?
    -What conditions are associated with this?
    • Decreased concentration of solutes.
    • Fluid volume excess.
    • SIADH, water intoxication.
  138. With increased serum osmolality
    -What is the concentration of solutes?
    -What is the fluid volume?
    -What conditions are associated with this?
    • Increased concentration.
    • Fluid volume deficit.
    • Hyperglycemia, DMI, dehydration
  139. Starling forces
    • Maintains fluid balance between ICF and ECF
    • Diffusion and Osmosis
  140. Aldosterone and fluid balance relationship
    Where there is Aldosterone, there is Na -- H2O follows Na which will increase fluid volume.
  141. Physical assessment FVD vs. FVE
    • FVD: sunken eyes, dry oral mucosa, tongue furrows.
    • FVE: Round edematous face
  142. Urine output
    and Specific gravity
    (FVD vs. FVE)
    • FVD - low output
    • High output does not always mean FVE
    • Low SG - FVE
    • High SG - FVD
  143. Isotonic fluids
    • Cause little or no shifting of fluids
    • Cells remain unchanged
  144. Medical conditions that require isotoic solutions
    • N/V
    • Burns
    • Dehydration
    • Gastic fluid loss
    • DKA
  145. Hypotonic fluids
    -caution with..
    • Cause cells to swell as it is less osmolar then our body fluids.
    • -caution with head injury
  146. Hypertonic fluids
    Causes cells to shrink as is more osmolar than our body fluids
  147. What physiologic changes occur in the older adult that can impact their fluid balance?
    • Decreased body fluids
    • Change in thrist receptors
    • Changes in nutritional intake
    • Diminished renal function
  148. What is the principle role of Starling Forces?
    to maintain balance between fluid compartments.
  149. How do the Starling forces achieve fluid balance between compartments?
    Diffusion and osmosis
  150. Why is the blood transfusion stopped after 4 hours?
    risk of contamination
  151. What elecctrolyte imbalance can cause weakening and even paralysis of the respiratory muscles?
    • Hypokalemia
    • Hypomagnesemia
  152. What would the HR and BP probably be in FVD state?
    Tachy, hypo
  153. A central venous pressure of 1 mm/Hg is indicative of what FV state?
    FVD
  154. What is the expected albumin level in a patient with generalized edema?
    Hypoalbuminemia
  155. When isotonic IV fluids are administered where is the fluid shifted?
    NO fluid shifts
  156. Hypotonic IV fluids are contraindicated in what medical conditions?
    • Any chance of ICP: Cerebral edema, Head trauma, Post-neuro surgery, Post-CVA
    • Potential for 2nd or 3rd spacing: Liver disease, Ascites, Burns
  157. What action by the nurse should occur if PRBCs are not opened to infuse within one hour of receiving them? Why?
    Returned to the blood bank d/t risk for contamination
  158. Some reasons that FFP would be ordered for a patient?
    Reverse high INR prior to surgery to who has a GI bleed on Coumadin
  159. What does FFP have that makes it effective against a high INR?
    Clotting factors
  160. What clinical manifestation would indicate that the patient was experiencing a severe allergic reaction during a blood transfusion?
    SOB, feeling of doom, CP, circulatory collapse, cardiac arrest.
  161. What clinical manifestations would indicate an acute febrile reaction during a blood transfusion?
    Fever, chills, flushed skin, muscle aches and pains, HA, anxiety.
  162. What is that name of the fluid that is part of the ECF and lies between the cells and the tissues?
    Interstitial fluid
  163. What is the effect on FV when there is increase in the secretion of renin by the kidneys?
    A lot of dilute urine output
  164. What FV state is the patient in with a dx of DI?
    FVD
  165. In hypersonic solutions, where does the fluid shift?
    Out of the cells into interstitial and intravascular spaces.
  166. What classification of IV fluids is the goal standard for treatment for FVD?
    Isotonic IV fluids
  167. What classification of IV fluids have the greatest potential to cause damage to the veins due to the toxicity of the solution?
    Hyper
  168. What medical conditions benefit from hypertonic fluids?
    • Cerebral edema
    • Increased ICP
    • ARF (with caution)
    • Water intoxification
  169. What are possible causes of positive orthostatic tilt?
    FVD d/t dehydration, acute blood loss or diuretics
  170. Examples of transcellular fluids.
    CSF, peritoneal fluid, synovial fluid, pericardial fluid, pleural fluid
  171. What classification of ABX can cause renal dysfunction and thus alter fluid and electrolyte imbalance?
    Aminoglycosides
  172. Distended neck veins is indicative of what FV status and what alteration in hemodynamic status?
    • FVE
    • Increased CVP d/t increased RA pressure
  173. What is the name given to the measurement that measures the kidneys ability to concentrate urine?
    Specific gravity.
  174. What is the normal range for specific gravity?
    1.005-1.030
  175. A urine specific gravity of <1.005 is indicative of what FV status in most cases?
    • FVE
    • DI
  176. What is the gold standard urine measurement for determining FV status in patients?
    Urine osmolarity
  177. Where does the fluid shift when a patient receives Hypotonic IV fluids?
    Intravascular to intracellular or interstitial
  178. In what situations would isotonic solutions be contraindicated or used with caution?
    • Cardiac or renal disease
    • Hypernatremia
    • Elevated Na+ of Cl levels
  179. What are possible adverse consequences from hypertonic IV fluids?
    • Overload
    • Pulmonary edema
    • Phlibitis
  180. What blood product would be ordered for a patient with symptomatic thrombocytopenia?
    Platelets
  181. What is the rate of infusion for platelets
    As fast as the patient can tolerate
  182. When would a nurse expect to administer autonomous PRBCs?
    Postop following an elective surgery
  183. When would a nurse expect to administer albumin?
    • To improve 3rd spacing
    • With severe symptomatic hypoalbuminemia
  184. When would a nurse expect to administer cryopreciptate?
    To replace deficient clotting factors
  185. What is the primary regulator of ICF?
    NA+/K+ pump
  186. What position should the nurse place the patient when assessing for JVD?
    Supine, HOB 30 degrees
  187. A wedge pressure of 15mm.Hg ids indicative of what FV state and what physiological condition?
    FVE
  188. What classification of IV fluids is Lactated Ringers?
    Isotonic
  189. Why is D5W an incorrect choice for patients with DVD?
    It becomes Hypotonic in the body
  190. What does a low urine osmolality indicate about FV status?
    Low concentration -- dilute urine -- FVE
  191. Restrictive lung disease
    • Problem with getting air in.
    • Can be cause by external stimuli (obesity, scoliosis) or internal stimuli (pneumonia)
  192. Manifestations of Restricitve lung disease
    FINE ISPIRATORY CRACKLES
  193. Obstructive lung disease
    Hinder expiratory outflow
  194. Manifestations of Obstructive lung disease
    WHEEZES most common.
  195. Asthma
    effects of recurrent asthma?
    • EPISODIC airflow obstruction
    • Can cause thickening of the airway
  196. Goal of patient with asthma.
    KEEP SMALL AIRWAYS OPEN
  197. Status Asthmaticus
    • Severe asthma attack
    • Need to recognize quickly
    • DOES NOT RESPOND TO TYPICAL MEDS
  198. Whats the difference between an asthma attack and status asmaticus?
    Status Asthmaticus does not respond to typical asthma meds
  199. Acute vs. Chronic pulmonary disorders
    • Acute - rapid onset, episodic (ARDS)
    • Chornic - slow, insidious onset (COPD)
  200. ARF
    • Life threatening
    • Failure to ventilate and oxygenate
  201. ABG manifestations of ARF
    • Sudden or gradual onset
    • Sudden decreased in PaO2 or rapid increase of PaCO2
    • Need to recognize rapidly!!
  202. Clinical signs of ARF
    • Imdending doom
    • Tachypnea
    • Tachycardia
    • Use of accesory muscles
  203. Early and Late signs of ARF
    • Early: RAT - Restlessness, Anxiety, Tachypena/cardia
    • Late: BED - Bradycardia, Extreme restlessness, Dyspnea
  204. Drug therapy for ARF
    • Bronchodilator - relief of brochospasm
    • Coricosterioids - reduce inflammation
    • Diuretics/Nitrates - reduce pulmonary congestion
    • Antibiotics - treat infections
    • Benzos/Narcotics - reduce anxiety and pain
  205. ARDS
    • Complication of a disease process
    • Caused by direct or indirect injuries (pneumonia, near drowning, drug overdose)
    • Begins 1-2 days after insult
    • Flooding of the alveoli d/t injury
  206. Non-cardiogenic pulmonary edema
    • ARDS
    • Flooding of the lungs, not d/t the back up of blood from the heart.
  207. Diagnosis of ARDS
    • Wedge pressure of 18 or less with no evidence of heart failure
    • PaO2 / FiO2 = O2 status (Normal 300-500)
  208. Phases of ARDS
    • Exudative phase - Lasts 1-3 days, Neutrophil infiltration
    • Fibroproliferative phase - Lasts 3-7 days, lung remodeling
  209. Diagnosis of ARDS
    Failure to oxygenate no matter how much O2 is given.
  210. Drug therapy for ARDS
    • Meds not usually effective
    • Corticosteroids - reduce inflammation
    • Nitric Oxide - reduce pulmonary HTN
    • Surfactant
  211. Thromboemboli
    lower extremity thrombus
  212. Fat embolism
    d/t a fracture of a large bone
  213. Amniotic embolism
    d/t amniotic fluid accessing the mothers circulation
  214. Virchow's Triad
    • Hypercoagulability
    • Injury to vascular endothelium
    • Venous statis
  215. Best way to diagnosis a PE
    Pulmonary angiogram
  216. Acute Kidney Failure
    Cause?
    Time course?
    Prognosis?
    • Discrete cause - shock, mephrotoxic drugs
    • Hours to days
    • Reversible if treated early
  217. Chronic Kidney Failure
    cause?
    time course?
    prognosis?
    • Chronic process - DM, CHF, HTN
    • Months to years
    • Irreversible - dialysis or transplant
  218. Oliguria
    • <400 mL urine in 24 hrs
    • usually accompanies AKI
  219. Prerenal AKI
    • Hypoperfusion
    • Can be caused by decreased CO (Need at least 70mmHg), Vascular obstruction or NSAIDS
  220. Intrarenal AKI
    Damage or disease directly to the nephron
  221. Postrenal AKI
    Obstruction of the urinary tract - after the kidneys
  222. Prerenal findings
    • Hypotension
    • BUN:Creat. >20:1 (Normal 10-15:1)
    • Urine Na <20
  223. Prerenal treatment
    • Increase renal perfusion
    • Maintain BP
    • Treat underlying cause
  224. Prerenal Clinical Management
    • Protect existing renal function
    • Increase CO (GOAL)
    • Optimize fluid status
    • Increase BP
    • Relieve obstruction
    • Nephrology consult
  225. A patient has a BP of 75/42 and +3 edema. Her MD orderes Levophed at 5mcg/min to raise her BP. Do you agree?
    • No because he needs fluids 1st
    • Yes because he needs to increased BP after he has the volume
  226. What drug category can cause prerenal kidney injury?
    1. Beta Blockers
    2. Cardiac glycosides
    3. NSAIDs
    4. Statin drugs
    3. NSAIDS
  227. A mean arterial pressure is below 65 mmHg may result in what conditions?
    1. Increased renal prefusion and increase GFR
    2. Release of substances that produce local vasodilation
    3. Inadequate renal prefusion pressure
    4. Renal artery obstruction
    3. Inadepuate renal perfusion pressure
  228. A client in the ICU develps prerenal failure following surgery.
    What of the following casues should the nurse suspect?
    1. Vascular disease
    2. Urethral obstruction
    3. Hypovolemia
    4. Glomerulonephritis
    3. Hypovolemia

    • 1. intrarenal
    • 2.postrenal
    • 4.intrarenal
  229. For glomerular filtration to take place, it is important to maintain...
    1. A low hydrostatic pressure
    2. An adequate cardiac output
    3. A low renal blood volume
    4. A high renal vascular resistance
    2. A adequate cardiac output
  230. Intrarenal injury
    Disturbances within the kidney itself, glomerulus or renal tubes
  231. Most common form of intrarenal failure?
    • Acute tubular necrosis
    • Can recover if caught early
  232. Reasons for intrarenal injury
    • Nephrotoxic drugs
    • Rhabdomyolysis (release of myoglobin)
    • Tumor Lysis syndrome (release of K, Pho, uric acid)
    • Heopatrorenal syndrome (cirrhosis of liver)
  233. Rhabdomyolysis and ARF
    • d/t excessive muscle breakdown
    • Releases myoglobin which can not be filtered through kidneys in large amounts
  234. Manifestations of Rhabdo
    • Muscle weakness
    • Red/brown urine
    • CK > 100,000
  235. Treatment for Rhabdo
    • IV fluids to flush kidneys
    • Sodium bicarb
    • Dialysis
  236. Onset phase of AKI
    • 2-4 days after insult
    • BUN AND Cr INCREASE
    • save function of nephrons
  237. Oliguric phase of AKI
    • <400 ml/day
    • Can also be Non-oliguria (more at risk !! )
    • Decreased GFR
  238. Diuretic phase of AKI
    • 10 days after insult
    • Renal function begins to return
    • GFR INCREASES
    • BUN AND Cr DECREASE
  239. Recovery phase of AKI
    Can take up to 1 year
  240. Postrenal failure
    • d/t BPH, CALCULI, TUMORS
    • Can still have function of one kidney
  241. Clinical findings of postrenal failure
    • Depends on the etiology
    • IVP will show obstruction
  242. Uremia
    Ammonia is released as byproduct of uremia, can cause destruction of GI capillaries. Will cause GI bleeding d/t decreased clotting factors
  243. What type of renal failure would the nurse expect to see in a client who OD'd accidentally on Nebcin?
    1. Prerenal
    2. Postrenal
    3. Extrarenal
    4. Intrarenal
    4. Intrarenal
  244. Which of the following lab data is the most accurate indicator that a patient with ARF has met the expected outcomes?
    1. Decreasing BUN levels
    2. Decreasing serum Cr levels?
    3. Decreasing neutrophil levels?
    4. Decreasing lymphocyte levels?
    2. Decreasing serum Cr levels.
  245. Chronic kidney failure
    • Slow progression
    • Irreversible
    • CAUSED BY HTN, DM
    • Won't have any sx until 25% left
  246. Treatment for CRF
    Dialysis or transplant
  247. 5 stages of CRF
    • 1 - diminished reserve
    • 2 - renal insufficiency
    • 3 - renal failure
    • 4 - decreased GFR
    • 5 - ESRF - CRRT required
  248. Manifestations of CRF
    • Increased Na, K, Ph
    • Decreased Ca
    • Metabolic acidosis
  249. Renal replacement therapy
    • IHP - intermittent
    • CRRT - continuous
    • Peritoneal - instilled into abdomen
  250. Hemodynamic and CRF
    • MUST be hemodynamically stable to qualify for hemodialysis because so much fluid will be lost.
    • IF NOT, need CRRT
  251. Dialysis disequilibrium syndrome
    • Usually occurs after 1st couple of treatments until body acclimates.
    • c/o HA, confusion, seizures, n/v
    • STOP treatment
  252. Skin brushing in ARF is secondary to the effects of:
    1. Increased erythropoietin
    2. Decreased ammonia levels
    3. Severe hypocalcemia
    4. Excessive uremic toxins
    • 4. Excessive uremia toxins
    • 1 would be decreased, 2 would be increased
  253. Patients in renal failure are at risk for developing metabolic acidosis as a result of:
    1. Decreased excretion of K
    2. Increased excretion of H
    3. Increased excretion of K
    4. Decreased excretion of H
    4. Decreased excretion oh H
  254. A pacer spike is present but no QRS complexes?
    Failure to capture
  255. A pacing spike does not recognize the patients intrinsic rhythm?
    Failure to sense
  256. All of the following PPM leads are in direct contact with the myocardial tissue EXCEPT:
    1. Transcutaneous PPM
    2. Transvenous PPM
    3. Epicardical PPM
    4. Permanent PPM
    1. Transcutaneous PPM

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