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  1. Normal ABG values
    • pH             7.35 - 7.45
    • PaCo2        35 - 45
    • HCO3-        22 - 26
  2. what is pH all about
    • pH of blood indicates concentration of hydrogen ions (H+) it contains
    • Normal levels: 7.35 - 7.45
  3. What happens when pH is less than 7.35
    • indicates ACIDOSIS, a condition resulting in HIGH concentration of H+
    • Either an excessive amount of acid or decrease in alkaline substances is cause
  4. What happens when pH is more than 7.45
    • Indicates ALKALOSIS, which results from LOW concentration of H+
    • Can be caused by either too many alkaline substances or not enough acid substances
  5. CO2
    • Carbon dioxide, one of the principal substances affecting pH
    • is the respiratory parameter
    • Because CO2 will combine with water to form carbonic acid, is considered an acid
  6. Acid-base parameters for pH levels
    • < 7.35 is acidic
    • > 7.45 is alkaline
    • (B for Base, is Bigger)
  7. PaCO2
    • Partial pressure of carbon dioxide
    • Normal blood ranges from 35 - 45
    • if PaCO2 are abnormally high - as with a COPD pt - pH can drop and respiratory acidosis results
    • If PaCo2 is decreased - triggered by hyperventilation for ex - causes pH to rise and leads to repspiratory alkalosis
  8. What are acid-base parameters for PaCO2
    • Greater than 45 is acidic
    • Less than 35 is alkaline
    • *Opposite of other two
  9. What is principle alkaline substance in extracellular fluid
    • HCO3 - bicarbonate 
    • is the metabolic parameter
    • Normal serum concentration ranges 22-26
    • HCO3 slowly binds with free H+ to reduce concentration
  10. High HCO3
    • When HCO3 increases, pH rises and metabolic alkalosis develops
    • Prolonged periods of vomiting or use of diuretics, as well as hyperaldosteronism and Cushing's syndrome, can lead to metabolic alkalosis
  11. Decrease in HCO3
    • Can be caused from diarrhea or renal disease
    • causes pH to drop and leads to metabolic acidosis
  12. Acid-base parameters for HCO3
    • Less than 22 is Acidic
    • More than 26 is alkaline
  13. 3 questions to ask when determining AGB's
    • Does pH indicate acidosis or alkalosis?
    • Is the cause of pH imbalance respiratory or metabolic?
    • Is there compensation for acid-base imbalance?
  14. Tic-Tac-Toe for ABG
    • Set up tic tac toe board, in top 3 boxes, list acidosis, normal, and alkaline
    • Put in pH, HCO3, and PaCo2 in boxes below, depending on their value
    • The column where the pH is tells you whether pt has acidosis or alkalosis
    • The relative positions of pH, HCO3, and PaCO2 reveal origin of imbalance
    • *If pH and PaCO2 fall in same column, other than normal, prob is respiratory
    • *If pH and HCO3 fall in same column, other than normal, prob is metabolic
  15. Tic-Tac-Toe for ABG: how to tell if there is compensation going on
    • Example: pH and HCO3 each fall in acid column. PaCO2 is in normal column.  This indicates no compensation and dx would be acute metabolic acidosis. 
    • *IF the PaCO2 had been in the alkaline column, that would mean there is compensation
    • Therefore, if there are no normal values, and the loner value is on other side (whether alkaline or acidic) compensation is present
  16. What if pH is within normal range, but other parameters are not?
    • Your looking at complete compensation
    • To dx origin of imbalance, you have one more step (will involve another pH value on grid)
    • First, record the pH in the normal range as pH1
    • Then recalculate pH using exact midpoint for normal (7.40)
    • Thus, pH of less than 7.4 would indicate acidosis
    • pH greater than 7.4 would indicate alkalosis
    • Ex dx: respiratory acidosis with complete compensation
  17. Causes of metabolic acidosis
    • Diabetic ketoacidosis (A serious diabetes complication where the body produces excess blood acids (ketones).
    • Diarrhea
    • Renal failure
    • shock
    • sepsis
  18. Causes of respiratory acidosis
    • Hypoventilation, may be related to:
    • drug od
    • chest trauma
    • pulmonary edema
    • airway obstruction
    • COPD
    • Neuromuscular disease
  19. Causes of metabolic alkalosis
    • Loss of gastric secretions
    • Overuse of antacids
    • potassium-wasting diuretics
  20. Causes of respiratory alkalosis
    • Hyperventilation, may be related to:
    • Anxiety
    • High altitude
    • prego
    • fever
    • hypoxia
    • excessive tidal volume in ventilated pt
    • initial stage of PE
  21. Define ARDS
    • Acute Respiratory Distress Syndrome
    • form of pulmonary edema characterized by severe hypoxemia that can rapidly lead to acute respiratory failure
    • Occurs as result of direct or indirect lung injury
    • Difficult to DX and can be fatal within 48 hrs if not dx & tx
  22. Direct lung injuries
    • Gastric aspiration
    • pneumonia
    • pulmonary contusion
    • near downing
    • prolonged inhalation of high concentrations of oxygen, smoke, or toxic subs.
  23. Indirect lung injuires
    • Sepsis
    • Drug OD
    • Prolonged hypotension
    • Cardio bypass
    • pancreatitis
    • shock
    • fat embolism
    • non thoracic trauma
    • head injury
    • hematologic disorders
  24. 3 phases of ARDS
    • Exudative phase 
    • Proliferative phase
    • Fibrotic phase
  25. Exudative phase of ARDS
    • injury to lungs occur, whether direct or indirect
    • leads to an acute inflammatory response
    • lasting up to 1 week
  26. Proliferative phase of ARDS
    • The inflammatory process in lungs occurs systemically throughout tissues, leading to increased capillary permeability and movement of fluid out of vascular space and into tissue (serious edema in alveoli)
    • Can last up to one week 
    • IF YOU SURVIVE THIS... you move to fibrotic phase
  27. Fibrotic phase of ARDS
    • sometimes called resolution or recovery phase
    • lungs begin to recover
    • lung function may continue to improve over period of 6 - 12 months
  28. ARDS s/s
    • Marked by rapid onset of dyspnea, usually 12 - 48 hr after initial injury
    • Rapid-shallow breathing
    • retractions
    • rhonich
    • tacycardia
    • cynosis
    • hypotension
    • altered mental status
  29. Treatment of ARDS
    • Primarily supportive:
    • Provide O2
    • drug therapy
    • nutritional support
    • prone positioning
    • permissive hypercapnia
    • *almost always includes ET and vent
  30. Aspiration risk
    • *aspiration can lead to pneumonia
    • pts at greatest risk:
    • acutely ill
    • tube-fed
    • lowered LOC
    • Trach or ET
    • impaired swallowing
    • GI tubes
    • depressed cough & gag reflexes

    Seizure, lying supine, stroke, brain injury, sedation, cardiac arrest
  31. Atelectasis
    • Collapse or closure of alveoli due to decreased ventilation from:
    • Pleural effusion (fluid)
    • Pneumothorax (air)
    • Hemothorax (blood)
  32. Atelectasis - risk
    • Risks: immobility, impaired swallowing, shallow breathing
    • S/s: dyspnea, cough, sputum, resp distress
    • Goal: improve ventilation and remove secretions
  33. Atelectasis prevention
    • Frequent turning
    • mobilization
    • managing secretions
    • deep breathing exercises (use incentive spirometry post-op)
  34. COPD
    includes emphysema & chronic bronchitis
  35. Emphysema
    • Elastin is destroyed and alveoli are destroyed
    • Alveoli doesn't stretch on inhalation, no recoil so air doesn't come out well
    • As air starts to come out, top of alveoli closes off. (like when front door is open, and back door is opened, front door slams shut)
    • Air gets trapped
    • Get barrel chest - from yrs of overexpanding lungs
    • "pink puffers"
    • Pursed lip breathing slosw breathing and helps prevent alveoli collapes
  36. Chronic bronchitis
    • inflammation of bronchi, plugged by mucus production or mucus plug
    • Blue Bloaters... wide chest, cyanosis in lips & nail beds, clubbed fingers
  37. Dx for chronic bronchitis
    Productive cough for at least 3 months for 2 consecutive yrs
  38. Coumadin teaching
    • Used to prevent blood clots
    • Take same time every day, dosage based on INR
    • testing goal is 2.5 
    • Avoid sudden increase or decrease in intake of foods high in vit K
    • Teratogen
    • check for s/s of bleeding or bruising
  39. Dyspnea nursing care
    • Find underlying cause: obstruction or restrictive airway, cardiac, anxiety.. etc
    • Position pt orthopneic, o2 therapy, stay with pt
  40. Ficks law
    An observed law stating rate of diffusion across a membrane is directly proportional to the concentration gradient of substance of 2 sides of membrane and reversely related to thickness of membrane
  41. Troy's theory of Ficks law
    • Four things that affect diffusion:
    • Surface area
    • diffusion properties
    • pressure gradient
    • thickness
    • If you have a prob with any of these, will have problem with diffusion of O2
  42. INR therapeutic range
    • Normal is 1
    • pts on coumadin (warfarin) is 2-3 (2.5)
  43. Lung compliance
    • measure of ease of expansion of lungs and thorax, determined by pulmonary volume and elasticity
    • High degree of compliance indicates over inflation... loss of elastic recoil in lungs, as in old age or emphysema
    • Decreased compliance means stiff lungs.. , as in atelectasis, edema, fibrosis, pneumonia, or absence of surfactant
    • Normal compliance, lungs easily stretch and distend
  44. Main sign of diminished lung compliance
    Dyspnea on exertion
  45. Orthopnea
    SOB that occurs when laying flat, causes people to sleep in chair
  46. According to Troy, what is the role of Hgb
    • Protein attached to blood cells,
    • transports oxygen - 4 O2 total
    • Is the "robin hood"... steals O2 rich (lungs) and takes to O2 poor (tissues)
  47. oxygen-hemoglobin dissociation curve
    • Refers to PaO2 (partial pressure of O2) in correlation to O2 saturation
    • *There are factors that affect how much oxygen Hbg (robin hood) can take from rich (lungs) and give to poor (tissues)
    • Think of axis, with O2 pressure on Y axis, O2 saturation on X axis
    • Normal should be S curve... as you go up in partial pressure, O2 sats will increase, to were you reach a point where can't saturate anymore
  48. Oxygen-hemoglobin dissociation curve - right shift
    • Takes more O2 to hit desired O2 sat - meaning you need more PaO2 to get to 90% sat
    • Hgb less likely to pick up O2 - it's harder for O2 to bind to Hgb
    • Not taking as much O2, but easier to release O2

    this means you can be hypoxic, but not necessarily have a respiratory prob.
  49. causes of right shift
    • low pH - high H+ 
    • high CO2 
    • low O2 
    • high temp
  50. Oxygen-hemoglobin dissociation curve: left shift
    • Takes less O2 to get to desired O2 sat
    • Easier for Hgb to bind O2, but harder to release at tissues
    • You need less PaO2 to get to desired O2 sat
  51. left shift causes
    • high pH
    • low CO2
    • high O2
    • decreased temp
  52. tactile fremitus
    vibration in chest wall when speaking that is palpable on physical examination
  53. PE prevention
    • Prevent DVT's ... duh
    • SCD's while in bed
    • anticoagulant (warfarin)
    • mobility
    • dont smoke
  54. Pneumothorax assessment
    • decreased to absent tactile fremitus
    • Hyper resonant percussion, absent breath sounds, possible friction rub
  55. Pneumothorax: s/s
    • PAIN
    • tachypnea
    • increased us of accessory muscles
    • central cyanosis
    • agitation
    • hypertensive
    • air hunger
    • diaphoresis
    • tachycardia
    • **Look for tracheal alignment, breath sounds, and expansion of chest wall
  56. Pulmonary edema assessment
    Should have normal tactile fremitus, resonant percussion, crackles and possible wheezing
  57. Pulmonary edema s/s
    • restlessness & anxious
    • SOB
    • sense of suffocation
    • tachypnea
    • low O2 sat
    • noisy breath sounds
    • cyanosis
    • JVD
    • cough (pink, foamy sputum)
  58. Chest tube assessment
    • Dressings
    • Air leaks (will see more bubbling than normal)
    • drainage
    • **Pain**
  59. If pt wants to ambulate with chest tube
    • Keep drainage system lower than thoracic cavity
    • Unhook pt FROM SUCTION ON WALL
  60. CPAP benefits
    Positive pressure applied throughout respiratory cycle to spontaneously breathing pt to promote alveolar and airway stability
  61. Suctioning of ET tube
    • Performed when adventitious breath sounds are detected or whenever secretions are present
    • Suction before oral care
    • Repeat suction until airway is clear and reassess lung sounds
  62. oxygen modality decisions
    • Choice of modality is based on the oxygenation disorder and whether there is a problem with gas ventilation, diffusion, or both
    • Simple and noninvasive: oxygen & nebulizer therapy, chest physiotherapy, breathing retaining
    • Complex, invasive tx: intubation, mechanical ventilation, surgery
  63. CPT
    • chest physiotherapy
    • treatments generally performed by Physical therapists and Respiratory therapists
    • breathing is improved by the indirect removal of mucus from the breathing passages of a patient
  64. Trach nursing care
    • Alleviate pt apprehension and provide means of communication
    • Nurse keeps paper and pencil or magic slate and call light within pt reach at all times to ensure a means of communication
  65. CABG procedure
    • Coronary artery bypass grafting
    • Type of surgery that improves blood flow to heart
    • Used to tx people who have severe coronary heart disease
    • Healthy artery or vein from body is connected, or grafted, to blocked coronary artery
    • Grafted artery/vein bypasses the blocked portion of coronary artery
  66. Complications of CABG
    Bleeding, blood clots, infection, failed graft, arrhythmias, death
  67. cardiomyopathy
    • Heart muscle disease -classified according to the structural and functional abnormalities of the heart muscle
    • 3 types:
    • Dilated cardiomyopathy
    • Restrictive cardiomyopathy
    • HCM (Hypertrophic cardiomyopathy)
  68. Dilated cardiomyopathy
    • DCM
    • Pump failure - it's not working so well, pumping half of what it should.
    • so decreased outflow
    • Heart gets overstretched, can no longer "snap back" or contract as well
  69. Tx for dilated cardiomyopathy & backup problems
    • Decrease sodium
    • Diuretic
    • Ace inhibitor (helps heart beat more efficiently)
  70. Tx for dilated cardiomyopathy & pump failure
    • Beta Blockers (decrease O2 demand)
    • Calcium channel blockers
    • Digoxin (increase contractility)
    • Pacemaker
    • Transplant
  71. Tx for dilated cardiomyopathy & decreased outflow prob
    • Ace inhibitor
    • ARB (works same way as Ace, just in different ways.)
    • Both increase diameter of arteries
  72. cardiomyopathy dx:
    • may have diastolic murmurs in DM
    • echocardiogram is most helpful
    • chest xray
    • biopsy to assess heart cells

    ECG demonstrates dysrhythmias (atrial fibrillation, ventricular dysrhythmias) and changes consistent with left ventricular hypertrophy (left axis deviation, wide QRS, ST changes, inverted T waves).
  73. Restrictive cardiomyopathy
    • RCM
    • small pump - smaller & narrower in size
    • Walls are thicker, and more rigid, so unable to pump efficiently
    • *can try available trx but may not work, depends on pt
  74. Tx for RCM and backup problems
    • Decrease sodium
    • Diuretics
    • Ace inhibitor
  75. Tx for RCM and pump failure
    Pacemaker or transplant
  76. TX for RCM and decreased outflow prob
    Ace inhibitor or ARB
  77. Hypertrophic cardiomyopathy
    • HCM
    • Blockage - outgoing blocked
    • Center septum thickens in heart, restricts flow into aorta
  78. Tx for HCM
    • Beta blocker
    • Calcium channel blocker
    • Transplant
    • Septal ablation - inject alcohol, kills cells

    No other options.
  79. Endocarditis: prevention
    • Most often caused by rheumatic heart disease (bacteria hide in valve lesions)
    • Always see doc & get abx for strep throat
    • Avoid tooth picks, nail biting, minimize acne, avoid piercing, branding or tattooing.
    • Brush teeth with soft toothbrush
  80. Endocarditis risk factors
    • Must have antibiotics before any dental work for high risk pt
    • Prosthetic valves, cardiac devices, cardiac defects
    • Elderly
    • Iv drug users
    • indwelling caths
    • immunosuppressed
    • poor hygiene
  81. HR assessment
    • EKG, X-ray, and echocardiogram
    • Cardiac markers in blood work... CK-MB is only one specific to heart
    • Congestion
    • Poor perfusion and low CO
  82. HF care
    • Goal is to relieve pt of symptoms
    • Change lifestyle - reduce sodium, encourage exercise
    • Meds: 
    • Beta blockers - ↓ workload of heart, slows down

    • Ace inhibitor
    • Digoxin - helps w contractions
  83. HF complications
    • Edema
    • Pulmonary congestion
    • Poor perfusion 
    • Can progress - once heart fails, everything else starts going downhill
  84. HF diet and education
    • Lifestyle change is best
    • Quit smoking and/or drinking
    • Low sodium (no more than 2 g daily)
    • exercise 
    • restrict fluids
  85. Pericarditis - s/s
    • anything that causes inflammation of pericardium - Infection
    • Will have L side chest pain
    • pericardium rub (sounds like 2 pieces of leather)
    • Will have EKG changes
  86. Complications with pericarditis
    • Frequent of prolonged episodes can lead to thickening and decreased elasticity of pericardium
    • Scarring may fus visceral and parietal pericardium, which leads to less blood being pumped
    • Will start seeing s/s of HF- edema and hepatic failure
  87. PTCA
    • Percutaneous transluminal coronary angioplasty
    • Use of balloon-tipped catheter to enlarge a narrowed coronary artery
    • Minimally invasive - balloon inserted through sheath usually through femoral artery. Balloon is inflated at blockage sight to compress blockage against artery wall and allow blood to flow again
    • Stent may also be placed to permanently open vessel
    • Used as intervention for ACS (acute coronary syndrome) or angina
  88. PTCA education
    • Inform pt on what is happening
    • Instruct to watch for bleeding or a hard mass at sight (hematoma)
  89. PTCA - Assessment
    • watch for:
    • bleeding at sheath sight
    • changes in EKG such as dysrhythmias or MI
    • Assess for hematoma
  90. RHD
    • Prevent fever w abx
    • always treat strep
  91. Right sided HF s/s
    • Ascites (fluid in abd) and hepatomegaly first, followed by peripheral edema
    • Also will have JVD, RUQ pain and hepatojugular reflex
    • Most commonly caused by Left sided heart failure, if not caused by COPD, MI or emphysema
  92. Stent medications
    • antiplatelet medications, usually aspirin and clopidogrel
    • Sirolimus and Paclitaxel both on the actual stents and prevent clots
    • IV heparin or a thrombin inhibitor (e.g., bivalirudin [Angiomax]
  93. Tamponade s/s
    • Accumulation of pericardial fluid under pressure, causing all chambers to be compressed
    • S/S: dyspnea, tachycardia, tachypenea, cold/clammy extremities, chest pain
  94. Triad of cardiac tamponade
    • Becks Triad:
    • JVD
    • hypotension
    • diminished heart sounds
  95. Valvuloplasty complications
    • Some degree of mitral regurgitation after procedure
    • Bleeding from catheter insertion sites
    • Emboli resulting in complications such as strokes and, rarely, left to right atrial shunts through atrial septal defect created during porcedure
  96. Valvuloplasty long term teaching
    • Pts need to be educated on how to minimize risk for developing infective endocarditis. Includes abx prophylaxis before dentist or before any invasive procedures involving respir tract 
    • Echocardiograms are repeated every 1-2 yrs to monitor effects and results
  97. MI : stemi vs nonstemi
    • St elevated means already have cell death occurring
    • Non-ST elevated means there is likely no or very little cell death, but can progress to STEMI
  98. Atropine
    • Given to pt with bradycardia
    • blocks parasympathetic action; increases SA node automaticity and AV conduction
    • Give rapidly as 0.5 mg IV push, may repeat to 3 mg
  99. Mitral stenosis
    • narrowing of the mitral valve of the heart
    • Main cause is rheumatic fever and scars mitral valve
  100. Calcium channel blockers
    • Reduce conduction and force of contraction, dilates arteries
    • Dilation reduces blood pressure and thereby effort the heart must exert to pump
    • Can help DCM and HCM
  101. ACE Inhibitors
    • Slows activity of enzyme ACE, which decreases production of angiotensin II
    • Causes blood vessels to dilate, BP is reduced
    • Makes it easier for heart to pump blood and can improve function of a failing heart
    • (med endings -pril, Ex: Lisinopril, enalapril)
    • Can help DCM and RCM by helping with edema and outflow
  102. Mitral Valve prolapse
    • Mitral valve doesn't close properly
    • Most people are asymptomatic & doesn't need tx or lifestyle changes
    • For those people that have symptoms, typically due to regurgitation and can include: dizziness, arrhythmias, SOB, orthopnea, fatigue and chest pain
  103. ACS
    • Acute coronary syndrome - umbrella term for blocked blood supply to heart
    • Emergent situation with acute onset of myocardial ischemia
  104. ACS s/s
    Chest pain, SOB, dizziness, sweating, pain in arm or jaw, (symptoms of MI)
  105. ACS DX
    • blood tests for cardiac markers
    • EKG
  106. ACS Tx & nursing care
    • MONA
    • Elevate HOB, reduce anxiety, monitor I/O's, VS, rest
  107. Digoxin
    • increases contractility of the heart
    • Can help DCM and HCM
  108. Troponin I
    • Diagnostic for MI
    • Only troponin found in cardiac muscle
  109. Diuretics
    • Can help with DCM and RCM by helping edema
    • Help with high bp by decreasing fluids

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jskunz
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324431
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CD 2
Updated:
2016-10-12 01:10:03
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