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131 Cards in this Set

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  • Back
Heart sounds
S4 S1 S2 S3

S1 is start of systole (tri and bi shutting)
S2 is start of diastole (aortic and pulmonic shutting)
CO =
SV x HR

Normal is 4-8L/min
Baroreceptors
in aortic arch and carotid sinus, stretch and pressure

- stimulation inhibits sympathetic NS --> decreased HR and peripheral vasodilation

Decrease in BP --> increased HR
Chemoreceptors
respond to changes in Co2 and O2 an plasma pH

when stimulated they increase cardiac activity
Coronary angiography
- flushed sensation with dye
Complications of cath
- bleeding, hematome, tompanade
- allergic reaction
- thrombus formation
- aortic dissection
- dysrhythmias
- MI
- stroke
- looping, kinking
- puncture of ventricles or cardiac septum or lung
- breaking off catheter
- infection
- death
Informed consent includes
- full disclosure
- understanding and comprehension
- voluntary

- nurse can only witness, not give informed consent
don't forget to apply the _____ pre op
GROUND!! don't want pt to get electrocuted!!
Anesthesia barbituates
Pentothal, Brevital
- less than 5 min, caution cause may not be intubated yet

- hangover
Non-barbituate anesthesi
amidate and propofol

- caution with propofol in high triglyc pts (its lipids)
Inhalation agents
halothan, enflurane, desflurane

**big deep breaths after in PACU
** pain will come as soon as anesthesia out so monitor for this!!
Complications of inhales anesthesia
- coughing
- laryngospasm
- increased secretions
- respiratory depression (especially when combined with narcotics)
Opioids with anesthesi
- fentanyl
- Sufentanil
- Morphine
- Dilauded
Antagonist for opiods
NARCAN (naloxone)
Benzos with anesthesi
Versed, Valium, Ativan

- some have a paradoxical reaction (hyperactive)
Antagonist for Benzos
Romazicon (flumazeril)
Neuromuscular (paralytic) agents
Suzzinycholine (SUCCS)
- good for laryngospasms with ventilator also
*** must also be sedated!!!!!!
- make sure pt is able to expand chest post op as the reversal can wear off quickly!!!
- monitor reflexes and airway patency! if not good may beed ventilator!!
Neuromuscular/paralytic agent antagonist
- antocholinergics

NEOSTIGMINE
Anti nausea meds
Zofran, anapsine, scopalamine
Dissociative anesesthesia
KETAMINE
- used for quick anesthesia (like popping joint into place)
- may cause agitation and hallucinations
Treatment for malignant hyperthermia
DANTROLENE (DANTRIUM)
- warming it speeds the process up
- should have 36 vials in OR and PACU

- need glucose, insulin, and calcium to treat the hyperkalemia caused from the muscle breakdown also! and bicarb to treat metabolic acidosis
S/S of malignant hyperthermia
- hyperthermia (late)
- rigidity of muscles (EARLY!)
- the muscle breaks down and can affect kidneys, and is deadly
#1 cause of airway obstruction
tongue
1 liter of water =
i kg (2.2 lbs)
Hypothermia
less than 95 degrees
Med for post op shivers
Demoral (ONLY used for this)
Record temp every....
q 4h for 48 hours after surgery
signs of bowel ischemia (in AAA)
- no bowel sounds
- fever
- abdominal distention
- diarrhea
- bloody stools
**REPORT immediately
For AAA, notify MD id extremities...
-cool, pale, mottled, decreas ed or absent pulses
Gomerulonephritis
- antibody reaction
- strep, ebstein barr
- Proteinuria, hematuria, increased BUN and creatinine, urine excretion os RBCs, WBCS, casts

** monitor pt with recent sore throat
Acute Post streptococcal Glomerulonephritis (APSGN)
- 5-21 days after group A beta hemolytic strep
- Generalized body edema and periorbital is first sign then ascites and body (including crackles, congestions, etc.)
- HTN (HTN emergency), hematuria, oliguria, proteinuria, abdominal pain/flank pain or asymptomatic

- rest, antihypertensives, restricted protein intake, antibiotics for strep

- takes over 1-2 years for everything to fully resolve (proteinuria)
Good pasture syndrome
- pulmonary hemorrhage
- glomerulonephritis
- p anti-glomerular basements membrante antibodies present

- tx with immunosupression, plasmapharesis, corticosteroids, renal transplant, dialysis
Rapidly progressive glomerulonephritus (RPGN)
associated with ARF within weeks
Chronic glomerulonephritis
acute that didn't resolve

- may may not recall hx of renal problems
Nephrotic syndrome
- lots of proteinuria --> low labumin --> whole body edema (swollen toad)

- do a 24 hour urine protein, give ACE inh.
- will also get hyperlipidemia and low calcium storage
- loss of clotting factors
- thromboembolism, flank pain
IVP, intravenous pyelogram caution
allergy to shellfish
Hematuria is common after
Extracorporeal shock wave lithotripsy (ESWL)
what size stone can pass
less than 4mm
NEver give ACEs or ARBS when...
pt has renal artery stenosis
Renal artery stenosis
may present with rapid HTN
Polycystic kidney disease
- adult form is autosomal dominant
- treatment is like end stage renal disease
Recording ureter catheter output
should be recorded seperately from other caths

- pt on bedrest while in place, avoid tension and pressure on it
NEVER do this to a ureter catheter
never clamp it, notify MD if there is a decrease in output!
suprapubic catheters
- coil extra tubing
- milk catheter
- have pt turn side to side
Nephrostomy tube
- temporary
- irrigate with no more than 5ml sterile saline
Most common cause if intra renal failure
acute tubular necrosis
Degree of renal failure correspons in post renal..
with the degree of obstruction
BUN and creatinine ratio in ARF
- fixed (they both increase at the same time and rate)

- when BUN increases faster than creatinine the problem is usually volume depletion, muscle breakdown, or increased intake of protein
Urine specific gravity in pre renal oliguria
> 1.025 with low Na concentration (because RAA has been activated to keeping Na)
Oliguris =
< 400mL/day
Oliguria specific gravity in acute renal failure (inrtarenal)
fixed at 1.010 (normal because tubules are no longer responding)

high urine in sodium (can no longer conserve sodium)

- if cause is ATN, then urine would also have RBCs, WBCs, casts
Electrolyte/issues in ARF
can't secrete H or reabsorb bicarb --> metabolic acidosis --> Kussmaul respirations
--> kyperkalemia (make sure on cardiac monitor!!)
--> can't activate Vitamin D
--> hyponatremia (tubules can't conserve Na)
--> low calcium
--> increased phosphate
--> impaired RBC production/anemia--> infection risk
When is hyperkalemia treated
when K > 6 mEq

or if have dysrhythmias
ECG changes with hyperkalemia
- peaked T
- widening QRS
- ST depression
- V-fib
Before giving Kayexalate make sure...
they have bowel sounds and not paralytic ileus or necrotic bowels
Intake of K limitations
40 mEq
2 most common causes of death in ARF
- infection and cardiorespiratory complications
Asterixis
hand flap, indicative of encephalopathy
Diuretic phase =
urine output 1-3L per day (some may reach 5L)
- nephron still not fully functioning but can excrete wastes but can't concentrate urine
Electrolytes/issued in diuretic phase
- hypovolemia
- hypotension
- hyponatremia
- hypokalemia
Recovery phase
- when GFR, BUN, creatinine start to stabalize
- can last up to 12 months
#1 and other dtx for prerenal
#1- Fluid challenge

- diuretics (can't give thiazides when creatinine too low)
- dopamine to increase kidney perfussion
Intrarenal tx
- Calcium channel blockers
- Nutrition (calories, TPN if needed)
- Protein restriction .6G/kg or 40G/day) for non dialysis and 1-1.5G/kg for dialysis pts)
- Na restricted to 60-90 mEq
- Fluid restricted (urine output + 600mL)
Chronic renal failure GFR
< 60 ml/min for 3 months (normal is 125 ml/min)- urine creatinine clearance measurement reflects this also
End stage renal disease GFR
< 15 ml>mind
- require renal replacement therapy
Labs/issues/electrolytes for CRF
- urine specific gravity 1.010
- increase BUN
- Increased serum creatinine and decreased creatinine clearance (most accurate indicators)
- hyperlipidemia
- hyperkalemia
- metabolic acidosis (can't produce bicarb)
- anemia (lack of erythropoeitin)
- infections
- HTN (RAA)
- CNS depression
- renal osteodystrophy (deactivation of Vitamin D)--> increased risk for fractures
- integumentary changes (dry, scaly, yellow-gray, pallor, pruritis)
- uremic halitosis
- hypercalcemia
- hypophosphatemia
- proteinuria
- albumin/creatinine ratio >300
- fixed BUN/creatinine ratio
- hyperparathryoidism (goes with calcium and phosphate)
First intervetion before anything if CRF pt comes
**put them on a cardiac monitor because of hyperkalemia!!! fatal arryhtmias, most serious electrolyte disorder
to treat hyperkalemia
- restrict K foods
- acute tx:
-- iv glucose and insulin
--calcium gluconate
-- kayexalate (causes diarrhea)
-- Sodium bicarb (K into cells, corrects acidosis)
- Dialysis
CKD HTN goal
130/80

- sodium and fluid restrictions
- diuretics (no thiazides)
- Beta blockers, CCB, ACE in EARLY stages (pril)
* caution with used of ACE in FULL renal failure cause of hyperkalemia (debatable)
Diet
- sodium resitrcition
- potassium restriction
- phosphorus resitrction (1000 mg/day)
--milk, whole grains, dried beans, peas, and lentils, organ meats, nuts and seeds (BP), chocolate, cola
- iron (if ferritin < 100) and folic acid, maybe B12 supplements
- protein restriction
- fluid restrictions (UOP + 600 mL)
Phosphate biders
WITH each meal
may causes constipation
Procrit
stop giving, or only occassional with H/H normalized
Drugs to be cautious with with CRF (toxicities)
- Digoxin
- Antibiotis (vanco,gent)
- analgesics (demoral, NSAIDs)
- adjust diabetic agents
Weight gain between dialysis goal
- no more than 1-3 kg between dialysis txs, KNOW dry weight and includes anything liquid at room temp, ice cream, jello, etc.
GFR when dialysis started
< 15 ml/min
AV fistula
- may take up to 3-4 months for fistula to "mature" and to be bale to use for dialysis
-best

- fill thrill, hear bruit
AV grafts
- thrombogenic
- easily infected
external shunt
- temporary
- infections, thrombosis
Complications of hemodialysis vascular access devices
- thrombosis/stenosis (thrill and bruit should be there)
- Infection
- Aneurysm (ischemia distal to site)
- high output HF
DO NOT do this in arm with acess
- blood pressure
- IV insertion
- venipuncture
Dialysis disequilibrium syndrome
- rapid shift in fluids
- cerebral edema--> neuro complications (N/V, confusion, HA, seizures)
periotneal dialysis
- client choice
- less hazardous, but carries risk for peritonitis
- no vascular access needed, but does need catheter access device
Peritoneal solution must be...
warmed to body temperature
Three phases of peritoneal dialysis
- inflow (fill)
- dwell (equilibrium)
- drain

-may take client 2 weeks to tolerate full volume
Peritonitis
- cloudy return (indicates infection in peritoneum)
- fever
- rebound tenderness
- abdominal pain
- malaise
- nausea

- send outflow for specimen
Tunnel infection
PD
- difficult to treat
- can lead to peritonitis or abscess
- may require cath removal
Insufficient flow of dialysate
- major cause is constipation
- check for kinks, position, signs of migration or clots
- make sure drainage bag is lower than pt
- try milking tube
- xray if migration suspected
Most common cause of death in elderly with ESRD is...
MI and stroke

- followed by withdrawal of dialysis (make sure pt not depressed and is compitent when deciding, psych eval before)
ventilation and perfusion of lungs
Lungs should be better perfused than ventilated
Low V/Q
ventilation is lower, perfusion is good still
High V/Q
ventilation is good but perfusion is not
Normal V/Q=
0.8
Respiratory failure =
PaO2 <60 while on 60% or more oxygen

AND/OR

PaCo2 > 48 and pH < 7.35
Cardinal signs of respiratory insufficiency
restlessness and agitation
The nest evaluation of current state of respiration and perfusion
ABGs
Hyperkalemis in resp failure
- pt could be trying to get risk of hydrogen so holding potassium
tests for Pulmonary embolism
- ventilation perfusion scan
- pulmonary angiogram (most conclusive)
- spiral CT (less invasive, seeing more)
Normal I:E ratio
1:2

- increased 1:3 and 1:4 in COPD, etc.
Goal of treatment for acute resp failure
PaO2 > 60%
SaO2 > 90%

**verify CODE status!!
O2 toxicity
high O2 greater than 60% of O2 for longer than 48 hours (intubated pts)
NIPPV
not a vent so can use if...
CO2 restricted enteral formula
- low carb, high lipids
- Pulmo cal
- don't want carbs cause glucose breaks into Co2
Best dx for determining pulm HTN
- Right sided heart cath to measure pressures
Virchow's triad
perfect storm for pulmonary embolism

- venous stasis
- altered coagulability
- damage to vessel wall
D-dimer
- normal level indicates Pulm embolism unlikely, elevated is possibility (not for sure, not diagnostic)
Asthma
- reversible
- bronchospasm
- bronchial wall edema
- increased mucus
- overinflated lungs/hyperventilation and stuff
Status asthmaticus
- respiratory fatigue --> acute respiratory failure
--> hypercapnia, hypoxia, resp acidosis, decreased CO, circulatory collapse, cardiac arrest

* can't stop with intubation cause spasms are way down in bronchioles
Bad signs in asthma
can't speak sentences
lethargy and confusion
silent chest
bradycardia
resp acidosis and hypocemia (Co2 >45 and O2 <60)
Emphysema
- wall destruction of alveoli
- loss of recoil/collapse
- retained secretions
- gas trapping
- pulmonary artery constriction
COPD pts and first sign of infection
put on antibiotics and flu shots!!

- especially chronic bronchitis pts

- pts must call MD if changes in sputum
Chronic bronchitis
- increased number of mucus-secreting glands
- swelling and inflammation
- hypertrophy of mucosa of bronchial tree
- thick tenacious mucus
- destruction of cilia
Early signs of COPD problems
Dyspnea and hyperventilation
pneumothorax
complete or partial collapse of lung

- aire in intrapleural space
Types of pneumothorax
- hemothorax- blood in intrapleural space
- Closed- no external wound (spontaneous pneumothorax with rupture of small blebs)
- Open-
- Tension
Open Pneumothorax tx
- cover with vented dressing secured on 3 out of 4 sides
- medical emergency!
Tension pneumothorax
- from open or closed pneumothorax
- could be caused by vented dressing not venting or clamped or blocked chest tube
- emergency!
Subcu emphysema
one of the signs of pneumothorax
- feels like bubble wrap under skin, sounds like rice crispies
Normal intrapleural pressures
below atmospheric pressure
inspiration- -8 to -10
expiration- -4 to -5 cm H2O
Empyma
purulent pleural fluid (associated with lung abscess or pneumonia)
Thoracotomy position
sitting on edge of bed with arms on edge of table for thorocentesis

can also lay down with affected side up
3 compartments of chest tube drainage system
- Collection chamber (receives fluid and air from chest cavity)
- water seal chamber (one way air valve, always want water in the chamber)
- Suction control chamber
Suction control chamber
- to apply suction if needed
- typically 20 cm of water
- amount of suction is regulated by the amount of water in the chamber, not the amount of suction applied to system
- suction is usually ordered to -20 cm H2O (can go up to -40 too)

- If it is a dry suction control chamber there is no water. To increase suction you have to turn the dial on drainage system, vacuum source will not increase the pressure
Water seal chamber
- 2 cm water
- initially brisk bubbles of aire in chamber as pneumpthorax is evacuated
- during normal use there will be intermittedn bubbling during exhalation, coughing, or xneezing
- want normal fluctuation (tidling) of water during I and E. Rises with inspiration and falls with expiration (opposite with mechanical ventilation).
- If bubbling increases there could be an air leak
- if it ceases or tidling ceases then lungs could be reexpanded or blocked also
Care of tubing, etc.
- no milking or stripping of chest tube without Dr order
- stat chest xray after insertion
- Never clamp with a dr's order (unless quickly checking for air leaks)
- auscultate lungs and check for subcu emphysema around site
- keep clamp by bedside for emergencies of massive airleak, etc.
If chest tube dislodges
- apply 3 sided gauze, 1 side vented
- notify MD and stat chest x-ray
- assess resp status
- monitor vital signs

- if it just came off the drainage system, quickly recommect and have pt cough and exhale to stabilize negative pressure, reestablish water seal
Chest tube removal
- medicate pt before!!
- gravity drained for 24 hours before removal
- cut sutures, check if will need vaseline gauze
- valsalva as it is being removed
- airtight dressing and assess for drainage
- post chest x-ray with "wet" reading (quick reading)
- ausc. lungs and assess resp status
- vitals
most commonly fractured ribs
- 5-10 (4-9)
#1 worry with rib fractures
atelectasis (hurts to breath), #1 sign is pain
Empyma s/s
- s/s of pleural effusion
- fever
- night sweats
- weight loss
- cough

(sounds like TB)
lung abscesses are frequently caused by
aspiration
Stop tracheal suctioning if
- arrhythmias
- HR drops 20 bmp
- HR increases 40 bpm
- SpO2 drops < 90%