321 - Cardiovascular System P. 28-38

Front 1

What is the shock position?

Back 1

on back with legs elevated (20 degrees) to avoid affecting gas exchange on the lungs (NOT TRENDELENBURG)
--gravity helps blood return to the heart without compromising brain circulation

Front 2

Hypovolemic shock is caused by:

examples:

Back 2

- loss of blood or body fluid (in all fluid compartments)
-hemorrhage (trauma, surgery, GI ulcers)
-dehydration (NPO status, severe diarrhea, vomiting, diabetes insipidus, dieresis,
laxatives)
-fracture of an organ or long bone

Front 3

-What shock:

basic problem occurs because of a loss of blood volume from the vascular space and loss of oxygen carry capacity from the loss of RBCs.

Back 3

Hypovolemic shock

Front 4

what is the earliest CM of shock?

Back 4

-increased HR

(when shock is suspected, the RN should obtain the VS… not LPN or CNA)

Front 5

Hypovolemic shock

-what happens to the RR?

Back 5

-RR increases during hypovolemic shock to ensure oxygen intake is increased so that it can be delivered to critical tissues.

Front 6

what is a sensitive indicator of early shock

Back 6

-a decrease in urine output

Front 7

-skin: an early compensatory mechanism for hypovolemic shock is blood vessel constriction in the skin, which reduces skin perfusion. this allows what?

Back 7

more blood to circulate to the vital organs

Front 8

-central nervous system changes with shock often first manifest as

Back 8

thirst. this sensation is caused by stimulation of the thirst centers in the brain in response to decreased blood volume

Front 9

Hypovolemic Shock

-ABGs show?

Back 9

Metabolic acidosis

Front 10

H&H are (increased or decraesed) when shock is caused by dehydration

Back 10

increased

Front 11

H&H are (increased or decraesed) when shock is caused by hemorrhage?

Back 11

decreased

Front 12

Hypovolemic Shock
-BP?

Back 12

-decreased BP and CVP

Front 13

Hypovolemic Shock
-what does the pulse feel like?

Back 13

-weak thread pulse

Front 14

Hypovolemic Shock

(increased or decraesed) urine specific gravity

Back 14

-increased urine specific gravity because of the decrease UO (less than 25mL/hr)

Front 15

Hypovolemic Shock

hyperkalemia or hypokalemia

Back 15

-hyperkalemia

Front 16

Intervention for hypovolemic shock!!!

-what are you trying to do?

Back 16

-restore fluid volume to the normal range
-increased the rate of IV fluid delivery

Front 17

Intervention for hypovolemic shock!!!

oxygen?

Back 17

-administer O2 (makes more o2 available to the RBCs that are left after blood loss so they can distribute it to the tissues)

Front 18

Intervention for hypovolemic shock!!!

-what position should you put them in?

Back 18

-elevate the pts feet, keeping his or her head flat or elevated to a 30 degree angle

Front 19

Intervention for hypovolemic shock!!!

IV fluids: what should you use?

Back 19

---Crystalloid fluid is given to help maintain an adequate fluid and electrolyte balance. Two common solutions are normal saline and ringer’s lactate.

Front 20

Intervention for hypovolemic shock!!!

IV fluid, what is the fluid of choice:

why?

Back 20

-Normal saline (0.9% sodium chloride in water) is the fluid replacement solution of choice used to increase plasma volume and can be infused with any blood product (it will not shrink the cell or expand the cells)

Front 21

Intervention for hypovolemic shock!!!

-vasoconstrictors such as:

why are they used?

Back 21

(dopamine, norepinephrine, Phenylephrine)

to improve blood flow by increasing peripheral resistance, increasing venous return to the heart, and improving myocardial contractility

Front 22

Intervention for hypovolemic shock!!!

How many IVs should you have ready?

Back 22

-Have 2 IVs ready with blood tubing (large bore needles for blood)

Front 23

Intervention for hypovolemic shock!!!

-S/S of early shock and glucose.. what is happening?

Back 23

-glucose is increased (in early shock breakdown of liver glycogen to glucose in response to SNS stimulation)

Front 24

Hematocrit looks at what??

Back 24

-hematocrit looks at the % of blood volume that is occupied by RBC. it is the volume of erythrocytes in the serum

Front 25

Hemoconcentration is what

Back 25

(decrease of the fluid content of the blood, with increased concentration of formed elements.

Front 26

Hemoglobin (Hb) is what?

Back 26

the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues.

Front 27

Hypovolemia and H/H- why would H/H not be decreased?

Back 27

-when someone is hypovolemic, the volume that the erythrocytes are in is less so it would be like a big glass of water vs a little glass of water and we have 100 erythrocytes in the little glass of water takes up a lot more space, higher hematocrit, then 100 erythrocytes in the big glass of water because there is more volume for them to flow around in.

Front 28

-BUN:
-what does it indicate?
-what is urea nitrogen?
-what 3 things can cause an elevated BUN?

Back 28

it indicates kidney function.
-urea nitrogen is a waste product of cellular metabolism so it is a by product of protein breakdown.
-you can see an elevated BUN with dehydration, trauma ( from muscle protein breakdown), fever.

Front 29

Hypovolemic Shock

-RBC: bleeding. when the people lose blood, there is vasoconstriction, blood is being pooled to where it needs to go (constriction causes an increase in ______________________)

Back 29

hemoconcentration

Front 30

-BUN or creatinine, which is a better indicator of kidney function?

Back 30

Creatinine is a better indicator of kidney function. it is not influenced by temp, dehydration, and trauma.
-Creatinine is a by product of protein breakdown but it doesn’t rise so easily.

Front 31

-PEDs: whatis the best indicator for shock?

Back 31

heart rate

Front 32

I & O weight diaper
24g = _____mL
(1 g = 1 mL of fluid )
( 1 kg = 1 L of fluid)

Back 32

24

Front 33

Septic Shock
-Sepsis: begins as a bacterial or fungal infection and progresses to a dangerous condition over a few days

-triggered when?

Back 33

-triggered when an infection escapes local control

Front 34

Septic Shock
--the inflammatory response produces many pro-inflammatory cytokines and as a result, there is widespread

Back 34

vasodilation and pooling of blood in some tissues

Front 35

Septic Shock
--microthrombi form within the capillaries of some organs causing hypoxia and reducing organ function

CM:

Back 35

-CM: fever, elevated WBC, mild hypotension, urine output that is lower than expected for fluid intake, and increased RR

Front 36

What shock:

multiple organ failure is evident and uncontrolled bleeding occurs, inability of blood to clot because the platelets and clotting factors were used earlier

Back 36

Septic Shock:

Front 37

Septic Shock: Lab

-hallmark of sepsis is:

Back 37

increasing serum lactate level

Front 38

Septic Shock:

Labs:
WBC?
Segs?
Bands?

Back 38

-normal or low total WBC count
-decreased segs
-increased bands (immature)

Front 39

Septic Shock:

-what happens to cardiac output and blood pressure in the early stage of sepsis and septic shock?

Back 39

CO and BP are low

Front 40

Septic Shock:

what makes pts susceptible to hemorrhage?

Back 40

-the huge number of small clots uses clotting factors and fibrinogen faster than they can be produced by the liver.

Front 41

CM septic shock

VS?

Back 41

-hypovolemia, CO, BP, and HR decrease

Front 42

Septic shock

different 3 other shocks – why?

Back 42

hyperdynamic state reaction to infection

Front 43

Cardiogenic shock
-occurs when ?


-most common cause?

Back 43

when the actual heart muscle is unhealthy and pumping is directly impaired
-MI is the most common cause of direct pump failure

Front 44

Cardiogenic shock

-fluid volume is decreased
(true or false)

Back 44

false
-fluid volume is not affected

Front 45

Cardiogenic shock causes:

Back 45

-cardiac arrest
-mypoathies
-dysrhythmias
-obstruction (tension pneumothoroax)

Front 46

Cardiogenic shock
CM:

-HR?
-RR?

Back 46

-tachycardia
-tachypnea

Front 47

Cardiogenic shock

-BP?
-UO?
-acid baes balance?

Back 47

decreased systolic BP (less than 80)
-decrease UO (less than 20)
-metabolic acidosis

Front 48

if a patient is experience an MI, what position do you put them in and what else do you do first?

Back 48

-put in semi fowlers position and give oxygen 1st

Front 49

stable angina OR unstable angina

-which one has predictable pain? (chest pain after climbing a flight of stairs)?

Back 49

-Stable angina - predictable

Front 50

MI – S/S
-women and men have different presentations of a heart attack
-where do women experience more pain?

Back 50

-women have more GI and jaw symptoms
(indigestion, epigastric pain)

(vagus nerve becomes irritated which can cause N/V)

Front 51

MI – S/S of pain that men often present with?

Back 51

-shoulder and arm pain

Front 52

MI – S/S

pain is due to what?

Back 52

to ischemia (lactic acid builds up – metabolic acidosis)

Front 53

MI – S/S

-N/V due to the reflex stimulation of the vomiting center due to severe pain (the _______ nerve runs

Back 53

vagus nerve

Front 54

MI – S/S

-Dyspnea/SOB: why?

Back 54

(you are breathing faster as a means to compensate)

Front 55

MI – S/S

skin?

Back 55

–-Diaphoresis
-cool, clammy, ashen skin (blood is being shunted to the core – vasoconstriction and SNS stimulation)

Front 56

MI S/S

-Anxiety, restlessness, confusion resulting from?

-Sense of impending doom (“I think I am going to die”) – believe them

Back 56

(lack of oxygen getting to the brain)

Front 57

MI S/S

heart sounds?

Back 57

-S3 gallop heard

Front 58

MI S/S

BP and HR initially?

Back 58

- BP and HR elevated initially and continue to rise as a result of compensation NOT cardiac output…compensatory mechanism at first..you will see elevated BP and HR initially) but after awhile the body can’t compensate anymore because the heart can’t get oxygen

Front 59

-people with an MI describe s/s of pressure, not really pain. (pressure feels like an elephant sitting on their chest, can’t get deep breathe in).

true or false

Back 59

true

Front 60

MI
-why is a 12 lead EKG useful?

Back 60

to see the conduction of the heart – SA node to the AV node to purkinje fibers)
-you can see the abnormalities which will tell you where the heart attack is occurring

Front 61

MI – Diagnostic Tests

12 lead EKG
-angina and ichemia causes what to happen to the T wave

Back 61

T wave inversion

Front 62

MI – Diagnostic Tests

with an MI, what do you see happen to the T wave?

Back 62

T wave elevation..

ST segment elevation is indicative of infarcted tissue

Front 63

MI – Diagnostic Tests

hyperkalemia causes what to happen to the T waves?

Back 63

hyper = peaked T waves.

flattened T waves = hypokalemia

Front 64

MI – Cardiac Markers

what is the most specific marker for an MI

Back 64

Creatine Kinase (CK-MB)

Front 65

MI – Creatine Kinase

-rise:
-peak:
-WNL:

Back 65

rise 4 - 6 hrs
peak 18 hours
WNL 2 – 4 days

Front 66

MI – Creatine Kinase

-CK MM
-CK BB
-CK MB
-which one is cardiac specific?

Back 66

–CK MM –in skeletal muscle
–CK BB –in the brain
–CK MB –found in myocardial muscle *cardiac specific* isoenzyme
CK (it is an enzyme this is released when there is muscle damage…is also released w/ any muscle damage so we specifically look at CK MB:

Front 67

Cardiac Markers for an MI
-Troponin I and T

What are they?

Back 67

specifically I
-(myocardial muscle protein released into the blood stream with injury to heart muscle) these are not found in healthy patients.. is not an enzyme.. it is only released in the heart.. it is heart specific (it’s the second cardiac marker that is being done)
-cardiac specific

Front 68

Cardiac Markers for an MI
-Troponin I and T

what is the advantage of using this cardiac marker? (3)

Back 68

–More cardiac specific
–Usually normal in non-cardiac muscle disease
–Elevated sooner and longer
Rises in 4-6 hrs and is WNL in 7-10 days

Front 69

Cardiac Markers for an MI
-Myoglobin: ferrous globin complex in striated muscle
-early marker of MI
-found in cardiac and skeletal muscle

when is it elevated? when does it decline?

Back 69

elevates 2 hours after MI (50-120 μ/mL)

declines after 7 hours

Front 70

Cardiac Markers for an MI
-Myoglobin

what does it do to the muscles?

Back 70

-gives muscle red color

Front 71

-Myoglobin
if doubles in 1-2 hrs may indicate what?

Back 71

MI

Front 72

-Elevation of the D-dimer is seen with an MI
-what is it?

Back 72

(it is the end product of a thrombus formation)

Front 73

Coronary Artery Bypass Graft

-what is it?

Back 73

-the occluded coronary arteries are bypassed with the patients own venous or arterial blood vessels

you have a blockage, and they take a vessel, attach it from the aorta to below the blockage. they redirect blood flow

Front 74

Coronary Artery Bypass Graft

-what kind of pts is this used in?

Back 74

-used in pts who do not respond to medical management of CAD or when disease progression is evident

Front 75

CABG –preprocedure teaching:

-teach about what tubes they will come back with, such as:

Back 75

-breathing tube may be in, you will be in critical care, chest tubes, closely monitored. they will probably be going home in 4-7 days depending upon how they do

Front 76

CABG – Nursing Care / Post procedure
•Monitoring rhythm closely for what:

Back 76

afib common /(a fib where the atria is quivering, there are no P waves. the problem is that u can have an uncontrolled atria, and the ventricular rate is high and irregular (QRS is high) and it decrease cardiac output. if the atria are quivering you won’t have filling of the ventricles. blood can pool in the chambers and that can cause clot formation and those clots can break off and go to the brain and cause CVAs.

Front 77

CABG complication is Afib
-what is the drug of choice to be used?

Back 77

–Digoxin
(slows down the conduction and allows more filling of the ventricles)

Front 78

–PVCs: premature ventricular contractions.

what does the QRS complex look like?
-what about the pulse?

Back 78

they are the wide and bizarre QRS..

if you feel a pulse and feel a skipped beat

Front 79

PVCs
-–once someone has PVCs that look different (pointing up and pointing down) means what?

Back 79

that they are coming from different parts of the heart (several parts of the ventricles are irritable

Front 80

Prevent hypothermia (warm blankets, lights) hypothermia is a big risk for the pt after CABG surgery because it promotes ___________ & ___________ prevent shivering because an increase in metabolism makes the heart work harder

Back 80

vasoconstriction and hypertension.

Front 81

CABG
-chest tubes (should have less than how many mL/hr?

Back 81

Chest tube < 200 ml/Hr

(that is cumulatively less than 200. they have 2-3 CT)

Front 82

What type of shock?

-ineffective forward motion of blood
-impaired cellular metabolism

Back 82

Cardiogenic (pump problem)

Front 83

What type of shock?

-selective vasoconstriction, increase capillary permeability, mal-distribution

Back 83

Septic shock (organism)

Front 84

What type of shock?

-venous and arterial dilation --> pooling

Back 84

Nuerogenic shock

Front 85

What type of shock?

-vasomotor center depression

Back 85

neurogenic shock

Front 86

Compensation, Progressive or Irreversible Phase of shock?

restless, irritable
apprehension
A&Ox3

Back 86

Compensation

Front 87

Compensation, Progressive or Irreversible Phase of shock?

agitation
slow to respond
possible orientation

Back 87

Progressive

Front 88

Compensation, Progressive or Irreversible Phase of shock?

unconsciousness
absent reflexes

Back 88

Irreversible

Front 89

Compensation, Progressive or Irreversible Phase of shock?

HR > 20 baseline

Back 89

Compensation

Front 90

Compensation, Progressive or Irreversible Phase of shock?

bounding (septic shock) or thready pulses

Back 90

Compensation

Front 91

Compensation, Progressive or Irreversible Phase of shock?

tachycardia
weak, thready pulses

Back 91

progressive

Front 92

Compensation, Progressive or Irreversible Phase of shock?

slow and irregular HR

Back 92

irreversible

Front 93

Compensation, Progressive or Irreversible Phase of shock?

systolic BP is normal or slightly decreased

Back 93

compensation

Front 94

Compensation, Progressive or Irreversible Phase of shock?

diastolic blood pressure is normal or slightly increased

Back 94

compensation

Front 95

Compensation, Progressive or Irreversible Phase of shock?

hypotension (less than 90)

Back 95

progressive

Front 96

Compensation, Progressive or Irreversible Phase of shock?

BP is falling to not present

Back 96

irreversible

Front 97

Compensation, Progressive or Irreversible Phase of shock?

RR: rate is increased and deeper

Back 97

compensation

Front 98

Compensation, Progressive or Irreversible Phase of shock?

RR: rate is increased and shallow

Back 98

progressive

Front 99

Compensation, Progressive or Irreversible Phase of shock?

RR: slow, shallow, cheyne-stokes

Back 99

irreversible

Front 100

Compensation, Progressive or Irreversible Phase of shock?

UO: WNL with slight increase

Back 100

compensation

Front 101

Compensation, Progressive or Irreversible Phase of shock?

oliguria

Back 101

progressive

<0.5mL/kg

Front 102

Compensation, Progressive or Irreversible Phase of shock?

Skin: pale, cool

Back 102

compensation

Front 103

Compensation, Progressive or Irreversible Phase of shock?

anuria with proteinuria

Back 103

irreversible (less than or = to 18mL/hr)

Front 104

Compensation, Progressive or Irreversible Phase of shock?

Skin: warm and flushed

Back 104

compensation in septic shock

Front 105

Compensation, Progressive or Irreversible Phase of shock?

Skin: cold and clammy, possible cyanosis

Back 105

progressive

Front 106

Compensation, Progressive or Irreversible Phase of shock?

Skin: cold, clammy, mottled, cyanotic

Back 106

irreversible

Front 107

Compensation, Progressive or Irreversible Phase of shock?

Temp: decreased

Back 107

irreversible

Front 108

Compensation, Progressive or Irreversible Phase of shock?

Thirst: normal or increased

Back 108

compensatory

Front 109

Compensation, Progressive or Irreversible Phase of shock?

Thirst: marked increase

Back 109

progressive

Front 110

Compensation, Progressive or Irreversible Phase of shock?

Thirst: severely increased if conscious

Back 110

irreversible

Front 111

Compensation, Progressive or Irreversible Phase of shock?

bowel sounds are normal or hypoactive

Back 111

compensatory

Front 112

Compensation, Progressive or Irreversible Phase of shock?

bowel sounds are hypoactive or absent

Back 112

progressive

Front 113

Compensation, Progressive or Irreversible Phase of shock?

bowel sounds are absent

Back 113

irreversible

Front 114

MI - patho?

Back 114

-thrombus--> obstructing blood flow --> ischemia --> 20-40 minutes cellular death

Front 115

MI - patho

-what chemicals are released because hypoxia

Back 115

norepinephrine and epinephrine

Front 116

MI - angina

-Angina –is what?

Back 116

a temporary decrease in blood flow to the heart/it is a supply and demand problem

Front 117

(MI is complete or nearly complete occlusion of the vessel to the point where there is no or the tiniest amount of blood flow to the heart that is usually caused by a clot. blood flow is not restored and it is cut off. ischemia is occurring (lactic acid build up – where pain comes from) most MI occur where?

Back 117

occur in the left ventricle of the heart

Front 118

Angina can be either stable or unstable
-stable is what?

Back 118

predictable (characterized by exertion or stress, running, walking, cleaning)

Front 119

Angina can be either stable or unstable

-how is stable relieved?

Back 119

rest

Front 120

Angina can be either stable or unstable

-doesn’t increase in frequency or severity over time

Back 120

stable

Front 121

Angina can be either stable or unstable

-treated with rest and nitrates


what drugs are given for prevention for angina

Back 121

stable



beta blockers

Front 122

Angina can be either stable or unstable

-this angina is not predictable

Back 122

-unstable (variant)

Front 123

Angina can be either stable or unstable

-resting discomfort which can cause the pt to awaken at night

Back 123

-unstable (variant)

Front 124

Angina can be either stable or unstable

you wake up in the middle of the night, and you have chest pain. you are not doing anything to increase the demand. occurring without physical activity.

Back 124

unstable

Front 125

Angina can be either stable or unstable

usually pre-heart attack

Back 125

unstable

Front 126

Angina or MI S/S

-relieved by nitro or rest

Back 126

Angina

Front 127

Angina or MI S/S

-lpain asts less than 15 minutes

Back 127

Angina

Front 128

Angina or MI S/S

-chest discomfort radiating to the left arm

Back 128

Angina

Front 129

Angina or MI S/S

-pain is only relieved by opioids (morphine)

Back 129

MI

Front 130

Angina or MI S/S

-pain lasts longer than 30 minutes

Back 130

MI

Front 131

Angina or MI S/S

Best question to ask when determining if they are having an MI or angina is what?

Back 131

-“Did anything make the pressure go away?”
-with a MI, the pain is not going to go away. with angina, pain will go away because you either stopped the activity or went away because of the time factory. angina is a temporary decrease in blood flow.

Front 132

-How does an AMI affect cardiac output?

Back 132

decreasing CO due to damaged tissue having diminished pumping capability