CRITICAL CARE EXAM 2

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bminch0121
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265038
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CRITICAL CARE EXAM 2
Updated:
2014-03-04 14:13:57
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Critical Care nursing
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Critical Care Nursing
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Critical Care Nursing
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  1. Defibrillation
    • Used for pulseless VT and VF
    • High Energy stim - depolarizes all cardiac cells
  2. Cardioversion
    • Elective or semi elective procedure used to convert an abnormal rhythm into a sinus rhythm
    • patient is usually sedated (propofol)
    • Impulse is synchronized on the R wave
  3. AED
    Automated External Defib
    • Used for cardiac arrest or suspected cardiac arrest
    • pads are placed in the same location as a defib
  4. ICD
    Internal Cardioverter Defib
    Fully implantable, battery-operate system designed to recognize and terminate ventricular tachyarrhythmia's that can cause SCD
  5. ICD Procedure
    • Leads introduced thru the subclavian or cephalic vein
    • Positioned inside the heart and superior vena cava
  6. ICD Tiered Therapy
    • 1. Pacing - Patient does not usually feel this
    • 2. Cardioversion - low level shock to myocardium
    • 3. High energy defib - max current to the heart
  7. Antibradycardia function
    ICD
    ICD can function as a pacer for a slow rhythm
  8. Spike
    Electrical artifact representing the discharge of electrical energy
  9. Capture
    Myocardial depolarization in response to a pacemaker spike
  10. Failure to capture
    May be from not enough current or bad lead
  11. Sensing
    The ability of the pacer to recognize intrinsic beats (natural beats)
  12. Rate Control
    Ability to set number of beats per minute
  13. Output
    Ability to set amount of current delivered to the myocardium
  14. sensitivity
    • set system to recognize intrinsic beats
    • "demand pacing"
  15. External Pacers
    Advantages
    • Noninvasive
    • implemented fast
    • low cost
    • no additional training to apply
    • can be done pre hospital setting or hospital
  16. External Pacer
    Disadvantages
    • Painful impulse for the patient
    • Not for c spine injury or flail chest
    • poor efficacy
  17. Transvenous Pacers
    • Temporary pacing lead
    • Tip of the lead in contact with RV endocardium
    • connected to a pulse generator
  18. Transvenous Pacer
    Advantages
    • minimal discomfort for the patient
    • longer time window
    • most reliable emergency pacer
    • small amount of current delivered
  19. Transvenous Pacer
    Disadvantages
    • Skill required to place
    • Fluoro required
    • can not be placed during CPR
    • Can be easily dislodged
  20. Epicardial Pacing
    • Inserted during open heart surgery
    • thin wires into epicardial muscle
    • ventricular leads - left chest wall
    • atrial lead - right chest wall
    • attached to conventional pulse generator
  21. Permanent Pacers
    Used for sinus node dysfunction, A-fib and a-flutter with low ventricular response and 3rd degree/high grade 2nd degree AV block
  22. Permanent Pacer
    Advantages
    • Physiologic AV synchrony
    • No active patient participation
    • Perm solution
  23. Permanent Pacer
    Disadvantages
    • Surgical procedure
    • battery replacements
    • some environmental hazards
  24. ICD pacer codes
    • I - Chamber paced
    • II - Chamber sensed
    • III - Response to setting
    • IV - Programmability functions
    • V - Antitachyarrhythmia functions
  25. Stenosis
    Leaflets fuse together and valves cannot fully open
  26. Mitral Stenosis
    Increased PA pressure and Pulmonary edema
  27. Aortic Stenosis
    LVH and decreased cardiac output
  28. Heart failure
    • Structural or functional disorder which decreased ventricles ability to fill and/or eject
    • Dyspnea, fatigue, fluid retention and orthopnea
  29. Classic Angina
    Chest Pain
    • Dull, sub-sternal discomfort
    • associated with SOB, palpitation, sweating, NV
    • Variants - Toothache, indigestion, jaw pain and back pain
  30. Angina Equivalent
    • No specific chest pain or discomfort
    • Silent Ischemia
    • Women
    • Diabetes
    • Elderly
    • Sudden or decompensated ventricular failure
    • suddenly fluid overloaded and can not breathe
  31. Stable Angina
    • Caused by plaque build up
    • effort or anxiety related
    • relieved by rest or nitro
    • can progress to unstable
  32. Unstable Angina
    • Spontaneous
    • Difficult to relieve - may require admission
    • ECG - ST depression
  33. Prinzmetals Angina
    • AKA Varient
    • caused by spasms of the coronary artery
    • Tx - calcium channel blockers
    • rare occurrence
    • vasoconstrictive event
  34. **Acute MI Time Course**
    • Cardiac Ischemia instantaneous
    • Injury within 20 mins
    • cell necrosis within 30 mins
    • 50% wall thickness within 2 hours
    • Infarct 90% complete within 6 hours
  35. Sinus Brady
    • HR < 60 bpm
    • Typically anterior wall MI
    • Reduces tissue perfusion
    • Involved vessel - LAD
  36. Atrial Fib
    • Irregularly irregular
    • chaotic firing of the heart cells in the atrium
    • loss of atrial kick
    • Thrombus formation may = CVA
  37. Complete 3rd degree AV Block
    • Most serious heart block
    • AV node infarcted - no longer conducts impulse
    • common in inferior wall MI
    • May require emergency pacing
  38. V Tach
    • Irritable ectopic focus in ventricle firing rapidly
    • potentially fatal
    • Awake - Amiodarone, elective cardiovert
    • Pulseless - Immediate defib, ACLS
  39. V Fib
    • Chaotic firing of individual heart cells in ventricle
    • always fatal unless corrected
  40. Ventricular Septal Defect
    • Necrosis of septum
    • Rupture of septal wall
    • Tx - Sx
  41. Papillary Muscle Rupture
    • Usually with anterior wall MI and mitral valve
    • Necrotic rupture of papillary muscle
    • server mitral regurg and pulm edema
    • produces sudden and severe heart failure
    • Tx- diuretics and Sx
  42. Ventricular Aneurysm
    • Weakened portion of myocardium
    • Balloons outward during systole
  43. Ventricular Rupture
    • Thin,necrotic wall ruptures
    • massive bleeding into the pericardial sac
    • cardiac tamponade
    • death within minutes
  44. Amiodarone
    • Used for VF and VT
    • Drug of choice
  45. Lidocaine
    • Antiarrhythmic
    • metabolized in the lover
    • Toxicity - confusion and paralysis
  46. Vasopressin
    • Helps restore BP
    • VF and VT
    • Potent vasoconstrictor
  47. Epinephrine
    • Positive inotrope and chronotrope
    • Beta 2 Stimulant
    • restores sinus rhythm
    • Used in PEA / asystole
  48. Dopamine
    • Catecholamine - stimulates adrenergic receptors in the heart and blood vessels
    • increased CO, HR and BP
    • Low dose - enhances renal function , used to increase output
    • Mod Dose - acts like inotrope - increases contractility
    • High Dose - acts as a vasoconstrictor = increased BP
  49. Levophed
    • Catecholamine
    • vasoconstriction = increases HR and CO
    • mild inotrope
    • Usually used in septic shock
    • **Fill the tank first** Give fluid
  50. Atropine
    • Primarily for symptomatic brady
    • Increases HR (chronotrope)
  51. NSS
    • Normal Saline Solution
    • Used to restore circulating volume
    • Used to increase BP
  52. PTCA
    • Balloon dilation
    • guide wire advanced across lesion
    • balloon inflated 15-90 seconds then deflated
  53. Stent
    • Performed after PTCA
    • Placed to keep open
  54. Atherectomy
    Physical removal of plaque from artery
  55. Coronary Artery Dissection
    • Tear in intimal layer of artery creates a flap which obstructs lumen
    • immediate CP
    • Mimics MI
    • Tx - Stent
  56. Abrupt Artery Closure
    • Major post op complication
    • Thrombus formation
    • Sudden CP, ST segment elevation
    • **Immediate return Cath Lab
  57. Restenosis
    • Narrowing of previously dilated vessel
    • Occurs 30% within the first 6 months
  58. Hematoma
    • Localized SubQ bleeding
    • Direct pressure to squish and break up hematoma
  59. Retroperitoneal Bleed
    • Catheter manipulation in aorta creates bleeding into retroperitoneal space
    • back pain / flank pain
    • decreased BP, Increased HR, Decreased H&H, Restlessness
  60. Pseudoaneurysm
    • Contained rupture of an arterial wall
    • Bruit and pulsatile mass
    • Tx - Stop or decrease anticoagulation
    • compression by ultrasound guidance
  61. Arterial Thrombosis/embolization
    • Presents with vascular problems
    • Tx - anticoagulant , may need surgery
  62. Electrophysiology
    "ERS"
    Invasive cardiac diagnostic procedure to investigate the hearts electrical system and responses to electrical stimuli and certain drugs
  63. Intra-aortic Balloon Pump
    • Post cardiac surgery or PCI or cardiogenic shock
    • Inserted via femoral artery
    • **placement is essential**
    • Diastole - aortic valve is close , balloon rapidly inflates, elevates aortic pressure,increases coronary artery perfusion, forces more blood through coronary artery
    • Systole - Balloon deflates at start of systole , intra aortic volume is lowered, reducing aortic pressure, decreased myocardial workload and O2 consumption and increases coronary artery perfusion
  64. Ventricular Assist Device
    • Does the work of the LV
    • Flow assistance for failing heart
    • Diverts blood flow around failing ventricle
    • Decreases heart workload and maintains circulation
  65. Coronary Artery Bypass Graft
    CABG
    Increased O2 delivery to the myocardium by providing an alternate route for blood to perfuse an ischemic area of the heart
  66. Gas exchange is at the ...
    Alveoli
  67. Ventilation
    Physical movement of gases in and out
  68. Diffusion
    Movement of gases down pressure gradient
  69. Perfusion
    • Pumping or flow of blood into tissues and organs
    • Adequate blood supply and CV functioning are needed
    • amount of blood going to body and lungs
  70. Phrenic Nerve
    Supplies the diaphragm
  71. 5 Factors affecting diffusion through alveolar capillaries
    • 1. Gas pressure and gradients
    • 2. Surface area
    • 3. Thickness
    • 4. Length of exposure
    • 5. Oxyhemoglobin dissociation curve
  72. Pressure Gradient
    • Difference between the partial pressure of gases in the alveoli and pulmonary capillary blood
    • CO2 comes out into the alveoli --> into the lungs to be expelled
  73. The majority of CO2 molecules are transported In the blood as...
    Bicarb
  74. Pulmonary Vascular Resistance
    PVR
    • Measures the resistance that blood encounters as it enters the pulmonary vascular system
    • represents RV afterload
  75. **Cor Pulmonale**
    • RV hypertrophy and dilation
    • complication of increased PVR
    • too difficult for the RV to push blood into the lungs during systole
    • Major cause of death in right heart failure due to congestion in its chamber
  76. Acid
    Substance that can give up ions
  77. Base
    Substance that can accept ions
  78. Buffer
    Substance that reacts with acids and bases to maintain a neutral pH
  79. pH
    • Represents the free hydrogen ion concentration
    • Reflection of balance between carbonic acid and bicarb
    • increased hydrogen ion = decreased pH
    • decreased hydrogen ion = increased pH
  80. Respiratory System Buffers
    • Decreased pH = Increased RR/ depth to blow off CO2
    • Increased pH = Decreased RR/ depth to retain CO2
  81. Renal System Buffers
    • Decreased pH = kidney holds bicarb
    • Increased pH = kidney excretes bicarb
  82. Status Asthmaticus
    Acute Severe Asthma
    • Key is rapid recognition of occurrence
    • Medical emergency
    • **Doesn't respond to typical asthma tx**
    • Tx - O2/mechanical vent, IV steroids, Heliox
  83. Acute Respiratory Failure
    ARF
    • Life threatening
    • Cardiopulmonary system is unable to make demand
  84. Hypoxemia
    • Failure of oxygenation
    • Tachycardia
    • Tachypnea
    • Possible dysrhythmias
    • Confusion/change in mental status
  85. Hypercapnia
    • Failure of ventilation
    • inadequate CO2 removal
    • Tremors
    • any neurologic event
    • lethargic
    • headache
    • flushed skin
    • increased CO2 = vasodilation
  86. Acute Respiratory Distress Syndrome
    ARDS
    • Complication of a disease process
    • caused by indirect or direct pulmonary injury
    • sepsis is most common cause
  87. Pathogenesis of ARDS
    *Injury to alveoli epithelium - allows fluid to flood into alveoli due to injury
  88. Pathologic Sequelae
    ARDS
    • Diffuse epithelial injury with inc'd permeability of the alveolar-capillary membrane
    • Permeability permits fluid, protein and blood cells to enter alveoli of the lung
    • Accumulation of fluids to alveolar cell damage, surfactant inactivation and formation of a hyaline membrane that inhibits gas exchange
    • Results = non-cardiogenic pulmonary edema (alveolar flooding)
  89. Diagnosis of ARDS
    • **PaO2/FIO2
    • Normal 300-500
    • Mild 200-300
    • Moderate 100-200
    • Severe < 100
  90. 2 Phases for ARDS
    • 1. Exudative Phase - commencing within 24H
    • Type 1 pneumocytes destroyed (responsible for gas exchange)
    • Diffuse alveolar damage
    • Diffuse microvascular damage
    • Neutrophil infiltration
    • 2. Fibroproliferative Phase - for 3-7 days
    • lung repair period varies
    • type 2 pneumocytes hyperplasia (responsible for surfactant )
    • Lung remodeling
  91. Drugs for ARDS
    • Not very effective
    • Corticosteroids - Reduce the inflammation
    • Nitric Oxide - increased vasodilation = improved perfusion, ventilation and oxygenation
    • surfactant
  92. Pulmonary Embolism
    • Blockage in pulmonary arterial system
    • Disrupts blood flow to an area in the lungs
    • can be thrombotic or nonthrombotic

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