1
Q
Shock Symptoms
A
Restlessness & Anxiety
Pulse weak & rapid
*Skin cold & clammy
*Diaphoresis
*Respirations *ShallowLaboredRapid
*Thirst, *Oliguria
2
Q
What is shock?
A
physiologic condition in
which there is inadequate
blood flow to tissues and cells of the body
3
Q
Causes of shock?
A
*Failure of blood vessels
*Failure of the pump
*Loss of volume
4
Q
Types/ Stages of Shock?
A
Early, Compensatory, Progressive and Irreversible
5
Q
Early Shock
A
-Physiologic Triggers
* Baroreceptors detect MAP decrease
of 10 mmHg or less
* Decrease in circulating blood
volume (less than 500 ml)
-Physiologic response (ANS)
* Increased HR
* Increased force of contraction
* Peripheral vasoconstriction
-Assessment findings
* Change in mental status
6
Q
Compensatory Shock
A
-Physiologic Triggers
* Baroreceptors detect MAP decrease
of 10-15 mmHg
* Decrease in circulating blood
volume (1000ml or more)
-Physiologic response (ANS)
* Increased HR
* Increased force of contraction
* Peripheral vasoconstriction
* Increased venous return
* Water and Na conservation
-Assessment findings
* Restlessness, anxiety,
irritability, apprehension
* Slightly increased heart rate
* Normal or slightly increased
blood pressure
* Pale, cool skin
* Slightly increased respiratory
rate
7
Q
Progressive Shock
A
- Triggers
- Compensatory mechanisms have failed Causing change from aerobic to
anaerobic metabolism - Organ function deteriorates
- Physiologic Changes
- Ischemia
- Respiratory acidosis
- GI/Liver
- Neuro
- Renal
- Skin & Temperature
- Assessment findings
- Tachycardia
- Signs of poor perfusion
8
Q
Irreversible Shock
A
-Physiologic Triggers
* Tissue and cellular death is
widespread that treatment
CANNOT reverse damage!
-Physiologic changes
* Multi-system organ failure
* Kidneys
* Lungs
* Liver
* Brain
* Heart
9
Q
What will there be an absence of with an LVAD?
A
Absence of palpable pulse and blood pressure
10
Q
What is the only anticoag medication approved from someone with a mechanical valve replacement?
A
coumadin
11
Q
Treatment for hypovolemic shock
A
restore intravascular volume with WARM FLUIDS, packed RBC’s, plasma & platelets, reverse events leading to poor perfusion and correct underlying cause of volume loss ASAP
12
Q
Treatment for a STEMI
A
to go to the cath lab to remove the blockage
13
Q
STEMI/NSTEMI medication management
A
*Analgesics(nitro & morphine)
*Antidysrhythmic(amio & lidocaine)
*Beta-Blockers
*Dopamine
*Fibrinolytics(breaks up clots)
14
Q
Does placenta previa cause DIC?
A
No, it is caused by placental abruption
15
Q
Causes of DIC?
A
NOT A DISEASE* Tissue damage
* Trauma
* Frostbite
* Burns
* GSW
* Head injury
* OB complications
* Septic abortion
* Abruptio placenta
* Amniotic fluid embolus
* Infection
* Sepsis
* Bacterial
* Parasitic
* Rickettsial
* Vessel damage
* Aortic aneurysm
* Acute glomerulonephritis
16
Q
How do you diagnose DIC?
A
- CBC
- Platelet count
- PT, PTT
- Fibrinogen level
- Fibrin degradation
products
17
Q
Symptoms of DIC?
A
- Bleeding (From IV sites, Mucus membranes, GI, GU)
- Petechia
- Joint pain
- Signs and Symptoms of shock
- Prolonged PT, PTT, Thrombin times
- Elevated D-Dimer
- Thrombocytopenia
18
Q
Treatment of DIC
A
- Treat underlying cause
- Replace volume
- Clotting factors
- Cryoprecipitate- Fibrinogen, Factor V and Factor VII
- Fresh Frozen Plasma- other factors
- Platelets
- Electrolytes
- Fluid
- Prevent secondary tissue ischemia
- Heparin
- LMWH
19
Q
Cardiomyopathy Symptoms
A
- Range from none to symptoms
of HF - Shortness of breath on exertion
- Fatigue
- Cough/ orthopnea
- Fluid retention/ peripheral
edema - Angina
- Palpitations
- JVD
20
Q
Cardiomyopathy Treatment
A
- Medical management
- Treat cause
- Medications
- Diet/ fluid restriction/ Exercise
- Temporary management
- Intra-aortic balloon pump
- LV assist device- or long term
- Surgical management
- Pacemaker
- ICD
- Heart transplant
21
Q
Ischemic Cardiomyopathy
A
- Caused by CAD
- Ventricular remodeling
post MI - Decreased LV size with
thickened intraventricular
septum - Betablocker therapy post
STEMI prevents remodeling
22
Q
Dilated Cardiomyopathy
A
- Most common
- Dilation of ventricles
- Thin myocardium
- Cause-
- > 75% medical condition/ disease
-Genetic
-Idiopathic
23
Q
What do all cardiomyopathies result in?
A
Impaired cardiac output
24
Q
What are the two classifications of cardiomyopathy?
A
Structural abnormalities and ischemic cardiomyopathy
25
What does cardiomyopathy lead to?
* Increased workload
* Severe heart failure
* Lethal dysrhythmias
* Death
26
What are the two types of valvular heart disease?
stenosis and insufficiency
27
What is stenosis?
narrow opening- impedes blood moving forward and creates a straining or squeak
28
What is insufficiency? (r/t valvular heart disease)
improper closure- causes blood to flow backwards (regurgitation) and creates a swishing sound
29
What are causes of valvular heart disease?
Congenital- malformation or connective tissue disorders (ex. Ehler's Danlos or Marfan syndrome)
Acquired- rheumatic heart disease, infective endocarditis, degenerative (from HTN)
30
S/S of valvular heart disease?
May start suddenly or develop over time
Shortness of breath
Weakness
Lightheadedness
Chest discomfort
Edema of lower extremities
Palpitations
Rapid weight gain
31
What other assessment findings might you see with valvular disease?
murmur, orthopnea, dyspnea on exertion, paroxysmal nocturnal dyspnea
32
meds for tx of valvular heart disease?
diuretics, ACE inhibitors, inotropic agents, anticoagulants, prophylactic antibiotics
NO NITRO for aortic stenosis - decreased CO, makes pt dizzy
33
surgical intervention for tx of valvular heart disease?
percutaneous transluminal balloon valvuloplasty (repairs valve for aortic or mitral stenosis), valve replacement, annuloplasty (ring insertion), TAVR
34
What is acute coronary syndrome?
any condition resulting in reduced blood flow to the heart
ex. angina (stable and unstable), MI (NSTEMI and STEMI)
35
acute tx for ACS (angina)?
nitro sublingual
35
tx for chronic ACS (angina)
long acting nitrate patches and ointment, long-acting nitrate (isosorbide), beta blockers (decrease afterload), calcium channel blockers (increase myocardial blood and O2 supply which decreases O2 demand), aspirin (reduces risk of platelet aggregation in narrowing arteries
36
What is the electrical circuit of the heart?
SA node - AV node - Bundle of His - Right and Left Bundle Branches - Purkinje fibers
37
What is the electrical action of the heart?
A. SA node impulse causes atrial depolarization -P Wave results in atrial contraction (once all cells depolarized) pushes blood into ventricles
B. AV node receives the impulse and slows it, results in PR interval
C. Impulse sent to Bundle of His beginning ventricular depolarization- R wave upstroke
C. Impulse continues to Right and Left Bundle branches causing depolarization of ventricles -R wave down stroke & S wave
C. Impulse enters Purkinje Fibers results in ventricular contraction- ST segment, pushes blood to lungs &body
D. Ventricle repolarization seen by T wave
38
what is polarization?
when the inside of a cell is more negative than the outside
39
What is depolarization?
the movement of charged particles across a cell membrane causing the inside of the cell to become positive
40
what is repolarization?
Resting phase; movement of charged particles in which the inside of the cell is restored to its negative charge
41
what is the refractory period?
the cells will not respond to further stimulation: cells cannot contract (Onset of QRS)
42
causes of sinus bradycardia?
Hypoglycemia
Hypothermia
Hypothyroidism
Previous cardiac history
Medication
Toxic exposure
Inferior wall MI
43
s/s of sinus bradycardia?
Syncope
Dizziness
Chest pain
Shortness of breath
Exercise intolerance
Cool, clammy skin
beta blockers
44
tx of sinus bradycardia?
stable- atropine
unstable- pacing (transcutaneous or temporary pacemaker)
45
causes of sinus tachycardia?
Damage to heart due to heart disease
Hypertension
Fever
Stress
Drugs
Alcohol
Caffeine
Nicotine
Recreational drugs such as cocaine
Medication side effect
Pain response
Imbalance of electrolytes
Hyperthyroidism
46
s/s of sinus tachycardia
Dizziness, Lightheadedness
Syncope,
Shortness of breath
Rapid pulse rate
Heart palpitations
Chest pain
albuterol, synthroid, epi
47
tx for sinus tachycardia?
identify and treat cause
48
symptoms of SVT?
May be asymptomatic
Palpitations (Most common)
Dizziness (Most common)
Shortness of breath
Syncope
Chest pain
Fatigue
Diaphoresis
Nausea
49
patients at risk for SVT?
Previous MI
Mitral valve prolapse
Rheumatic heart disease
Pericarditis
Pneumonia
Chronic Lung disease
Acute alcohol intoxication
50
tx for SVT?
tx depends on stable vs unstable
Short term
-Vagal Maneuvers
-Adenosine
-Cardioversion
Long Term
-Rate control
-Ablation
Adenosine: 6mg RAPID IVP followed with 20 cc Nacl bolus; repeat with 12 in 2 minutes - for unstable
51
risk factors for Afib?
Nonmodifiable
Age- 55+
Genetics- 40% increase with familial history
Ethnicity- European descent
Gender- higher prevalence in men
Modifiable
Obesity
Hypertension
Obstructive Sleep Apnea
Diabetes
Smoking
Alcohol consumption
Caffeine intake
Surgery- 20-50% post cardiac surgery
52
causes of afib?
Hypoxia
Hypertension
Congestive heart failure
Coronary artery disease
Sinus node dysfunction
Mitral valve disorders
Rheumatic heart disease
Pericarditis
Hyperthyroidism
Excessive alcohol or caffeine consumption
53
s/s of afib?
Heart palpitations
Irregular pulse rapid, slow, racing, pounding or fluttering
Dizziness or light-headedness
Fainting, confusion
Fatigue
Trouble breathing
Difficulty breathing lying down
Sensation of chest tightness
54
tx for afib?
Medical Treatment-
Rate control (slow ventricular rate to 80-100 beats/minute)
Antiarrhythmic medications
Digoxin
Beta-adrenergic blockers
Calcium channel blockers
Clot prevention
Anticoagulant therapy
Surgical Treatment-
Chemical or electrical cardioversion
Watchman procedure
55
what happens in 3rd degree heart block?
Atria and ventricles are completely dissociated
Total block at AV node
None of the impulses are conducted
Pathology is at the AV node
NEEDS INTERVENTION- medical emergency
56
s/s of ventricular tachycardia?
Chest discomfort (angina)
Syncope ,Light-headedness or dizziness
Palpitations
Shortness of breath
Absent or rapid pulse
Loss of consciousness
Hypotension
57
tx for v tach?
stable (has pulse) - meds (amiodarone)
unstable (no pulse, just electrical activity) - defibrillation
58
s/s of v fib?
Loss of consciousness
Absent pulse
Death
59
causes of v fib?
Acute Myocardial Infarction
Untreated VT
Electrolyte imbalance
Hypothermia
Myocardial ischemia
Drug toxicity or overdose
Trauma
60
tx for v fib?
defibrillation
61
what is agonal rhythm?
Idioventricular rhythm is 20 bpm or less
Often the last-ordered heart rhythm seen when resuscitation efforts are unsuccessful
62
s/s of agonal rhythm?
Loss of consciousness
No palpable pulse
No measurable BP
Management-
Continue resuscitation efforts
Confirm death with lack of cardiac muscle activity
63
causes of PEA (pulseless electrical activity)?
H’s and T’s
Hypovolemia #1 cause
Hypoxia
Hydrogen ions (acidosis)
Hypo / Hyperkalemia
Hypothermia
Toxins
Tamponade (cardiac)
Tension pneumothorax
Thrombosis (coronary or pulmonary)
Trauma
Massive MI
Overdose of tricyclic antidepressant
64
s/s of PEA?
Pulselessness
Loss of consciousness
No palpable BP
65
tx of PEA?
Determine cause & treat
CPR
Initiate ACLS protocol
66
s/s of asystole?
No palpable pulse
▪No measurable BP
▪Loss of consciousness
67
what does cardiac output measure?
CO measures amount of blood pumped out of left ventricle in 60 seconds
normal CO is 4-8 L/min
68
CO equation?
CO= SV*HR
69
what is stroke volume?
MLs of blood pumped out LV per contraction
Normal 60-130 ml/beat
SV= end diastolic volume - end systolic blood volume
70
what is ejection fraction?
% of end-diastolic volume ejected from LV
Normal EF 50-70%
EF= SV/end diastolic volume
71
pulse pressure equation
Pulse pressure = Systolic blood pressure – Diastolic blood pressure
72
mean arterial pressure equation
MAP = 1/3(systolic blood pressure + 2/3(diastolic blood pressure)
73
What is preload?
Ventricular filling
Influenced by venous return
Influenced by ventricular contractility
74
What is afterload?
Pressure of the arterial system ahead of the ventricle
Pressure LV overcomes to eject blood volume -ex. pressure in ventricle has to be higher than aorta to open the aortic valve
75
Tort: Negligence
(unintentional)
*Carelessness or failure to act as an ordinary prudent person
*Action contrary to what reasonable person would do
*Neglected to use education as would be expected by peers
*Injury must come from the breach of duty
*Gross negligence is the intentional omission of proper care
*When it involves a nurse or MD it is considered malpractice
76
Tort: Malpractice
(unintentional)
Failure of a medical professional to follow accepted standards of practice for profession
*Resulting in harm patient
*Requires expert testimony
*More specific than negligence
77
What is the nursing scope of practice based on?
The states nurse practice act
78
proximal cause
needs to be directly related- "a leads to b which lead to c"
79
Abandonment
When a nurse accepts an assignment and terminates it without an appropriate cause, don't hand off your patients, leave without notifying your supervisor,
80
what happens to the pH and PCO2 with respiratory acidosis
decreased pH and increased PCO2
81
what happens to the pH and HCO3 with metabolic acidosis
decreased pH and decreased HCO3
82
what happens to the pH and PCO2 with respiratory alkalosis
increased pH decreased PCO2
83
what happens to the pH and HCO3 with metabolic alkalosis
increased pH and increased HCO3
84
how does someone with hypoglycemia present
headache
hungry
rapid onset of altered mental status
tachycardia
cool moist skin
anxious/restless
seizure
combative behavior
85
management of mild to moderate hypoglycemia
15g of rapid acting sugar(OJ glucose tabs honey marshmallows)
15/15 rule
86
severe hypoglycemia management
know facilities policy
iv glucose(D10 iv drip or D50 IVP 10 ml over 1 min)
87
onset and action time of glucagon for severe hypoglycemia management
onset 8-10 min
action 12-27 min
may repeat in 15 min
88
how does hyperglycemia present
polyphagia
polyuria
polydipsia
headache
difficulty concentrating
blurred vision
weak and feeling tired
89
treatment for hyperglycemia
diet
exercise
medication (metformin)
rehydration
determine cause & correct/prevent
90
DKA presentation
tachycardic
hypotension
tachypnea
fever(if infection)
polydipsia
polyuria
polyohagia
ill appearing
dry skin
labored respirations
acetone breath
dry mucus membranes
N/V
decreased skin turgor
91
HHS presentation
tachycardia
orthostatis
hypotension
tachypnea
hyperthermia (if infection)
ill appearing
Altered mental status
Lethargy (Yes you can use it)
Dry mucus membranes
Sunken eyes
Decreased skin turgor
Decreased urine output
Increased cap refill time
Weak thready pulse
Anhidrosis
Coma
92
main differences between DKA and HHS
DKA-Type I diabetes
Blood glucose > 300mg/dL
Develops fast (days)
Moderate dehydration
Serum and urine ketones present
Acidosis present
Kussmaul’s respirations
Abdominal pain
HHS-Type II diabetes
Blood glucose > 600mg/dL
Develops over time (days to weeks)
Profound dehydration
Minimal to no ketones present
Normal blood pH
Normal respirations
Lethargy/ confusion
93
signs and symptoms of DKA & HHS
Hyperglycemia
Flushed, warm dry skin
Increased thirst
Decreased blood pressure
Increased pulse
Nausea & Vomiting
Decreasing LOC
Weakness
Abnormal electrolytes(K, Na)
Increased urine glucose
Stupor or coma
94
DKA & HHS management
rehydration
restore electrolytes
insulin administration
determination and treatment of underlying cause
95
why do we use insulin for DKA
stop ketosis
96
why do we use insulin for HHS
reduce blood sugar
97
H&H ranges
12-17 and 36-50
98
WBC range
4,500-11,000
99
Platelet range
150-450
100
PCO2 range
35-45
101
HCO3 range
22-28
NURSING 220
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