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107 Cards in this Set
- Front
- Back
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What is acute respiratory distress syndrome?
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-non cardiac pulmonary edema
-progressive refractory hypoxemia: when you are putting O2 on them & O2 sats still don't go up. -complication of hospitalized pts *serious medical-surgical prob *may not be lung related *mortality remains 50-60% |
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Hallmark sign of ARDS?
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when giving O2 & they aren't getting any better. PE can mimic this but PE will usually also have chest pain.
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Pathophysiology of ARDS?
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-Injury or infl czs lung damage: will get SOB very quickly.
*alveolar capillary membrane leaks *plasma & bld cells into interstitial space *interstitial pressure incrs & fluid floods the alveoli *surfactant inactivated *coating forms over alveolar membrane |
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Etiology of ARDS?
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-no single exogenous or endogenous precipitating factor --> multiple causes. Can be internal or external insult
-exact causative mechanism is unknown -direct & indirect causes |
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5 direct lung injuries that are assoc w/ ARDS?
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-aspiration of gastric contents
-severe thoracic trauma *pulmonary contusion -diffuse pulmonary infection *bacterial: most common *viral *fungal: pneumocystis carini -toxic gas (smoke inhalation) -near drowning |
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What type of clinical disorders can cz ARDS?
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anything that is a huge insult to your body can trigger it.
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8 indirect lung injuries that may be associated w/ ARDS?
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-severe sepsis: common
-shock -acute pancreatitis -severe nonthoracic trauma -multiple long bone fractures -drug overdose -hypertransfusion (multiple transfusions) -reperfusion injury *after lung transplant *after cardiopulmonary bypass |
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3 most common indirect lung injuries that are assoc w/ ARDS?
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-severe sepsis
-shock -acute pancreatitis |
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What are the 4 phases of ARDS?
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Phase I: acute injury
Phase II: latent period Phase III: exudative phase Phase IV: fibroproliferative phase |
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How does Lidocaine suppress ventricular arrhythmias?
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-Suppresses ventricular arrhythmias by decreasing automaticity
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How may lidocaine reduce the instances of sudden cardiac death?
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-Because it decreases myocardial irritability it may reduce the instances of sudden cardiac death
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Indications for Lidocaine?
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-Used to suppress ventricular ectopy such as VT and VF as well as PVCs especially in patients with ischemic heart disease. Works well w ischemic heart dz.
-Used in VF that has converted with initial defibrillation while reasons for VF is explored |
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Precautions w/ Lidocaine?
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-Excessive dosages may cause myocardial and circulatory depression.
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Indicators of Lidocaine toxicity?
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Indicators of toxicity include: drowsiness, disorientation, decreased parenthesis and muscle twitching. Grand mal seizures are a serious sign of toxicity.
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How does Amiodarone work?
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-Works by prolonging the potential and refractory periods. (means even arrhythmia based areas of hearts can’t trigger as often. Slows EVERYTHING down which allows normal rhythm to take dominance again.)
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Amiodarone also works by inhibiting...
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It also inhibits adrenergic stimulation, slows the sinus rate, increases PR and QT intervals and decreases peripheral vascular resistance (which lowers the BP)
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Indications for Amiodarone?
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-Used for the management of life threatening ventricular arrhythmias
-May also be used for atrial fibrillation or flutter (usually use Cardizem first though) |
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How is Amiodarone given?
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-Continuous infusion (after the above 24 hour loading dose) 0.5 mg/min via an infusion pump. (ALWAYS given on a pump)
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Precautions with Amiodarone?
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-Use cautiously in patients with CHF, thyroid disease, and severe pulmonary or liver disease
-Monitor BP, HR, signs of ARDS (rales, dyspnea, tachypnea) |
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What is dopamine?
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-A catecholamine whose effects are dose related. Dosage of this drug will depend exactly on what we want it to do.
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What is a low dose of dopamine & what effects does it produce?
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-Low doses-0.5-2mcg/kg/min
-produces a vasodilating effect on the renal, mesenteric and cerebral arteries. -Urinary output increases while HR and BP stay the same. Use if no heart problems but in renal failure. Will not see this type of dose in codes. |
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What is a middle dose of dopamine & what effects does it produce?
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-Middle Doses of 2-10 mcg/kg/min
-produces beta effects which increases cardiac output due to enhanced myocardial contractility |
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What is a high dose of dopamine & what effects does it produce?
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-Higher doses-above 10-20 mcg/kg/min
-produces alpha effects which cause vasoconstriction |
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Indications for dopamine?
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-Used in hypotension in the absences of hypovolemia. Hypotension should be accompanied by poor tissue perfusion, oliguria, or changes in level of consciousness
-Should be used at the lowest dose possible. |
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Dosage of Dopamine?
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-Usually dose for hypotension is 5-10 mcg/kg/min and titrated to patient’s response
-Must be given as an infusion on a pump. Don’t want this to infiltrate. Many places will require a central line for this. -May be mixed with NS, D5W or RL |
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Precautions w/ Dopamine?
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-Should not be added to solutions containing sodium bicarbonate since dopamine is inactivated in an alkaline pH
-Frequently cause N and V -Infiltration may cause tissue necrosis -Increase myocardial oxygen demands so it should be given with caution in MI patients -Do not decrease abruptly-may cause rebound hypotension: need to wean pt off, anywhere from 1 hr to 3-4 hrs. -Titrate to the BP. Monitor BP, UO, mental status, skin color, capillary refill |
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Sodium bicarbonate may be given for?
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metabolic acidosis
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Dosage for sodium bicarbonate?
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-1mEg/kg IV bolus
-Use ABGs to guide administration -Rarely given |
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Precautions for sodium bicarbonate?
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-Monitor ABGs
-Flush IV line well before and after administration since some meds (catecholamines such as epinephrine) are inactivated by the bicarbonate. Calcium chloride will precipitate with bicarbonate -Can not be given down the ET tube |
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What is diltiazem (Cardiazem) & what is it useful for?
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-Calcium channel blocker: slows down the Ca channel blocker. Keeps Ca from going in and out of cell as fast, so slows repolarization.
-Useful for PSVT associated with atrial fibrillation or flutter |
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What is Mg used for in codes?
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-low Mg as bad for CO as potassium.
-Used for refractory v. fib -Torsades de Pointes very uniform looking. Circular in ventricle. Cycle is just going round and round. -If you know the Mg level is low |
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What is norepinephrine (Levophed) & what is it used for in codes?
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-Vasopressor: pure vasopressor, just clenches down arterials & increases systems vasodilation. Used post-code to get BP back. If infiltrates, will kill ALL the tissue.
-Very potent -Given by IV infusion |
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What is calcium chloride used for?
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-To treat an underlying problem: just know it’s used only to replace if it’s low.
-IV push |
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What is morphine used for?
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especially post-code.
-Ischemic chest pain: -Pulmonary edema -Decreases RR -Decreases preload (vasodilation) -Decreases anxiety |
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During a cardiopulmonary arrest, what is produced?
Which is compounded by? What is essential after all of the above? |
•hypoxia-induced anaerobic metabolism results in the generation of lactic acid.
•This is compounded by ventilatory failure, which results in CO2 retention & respiratory acidosis. •Prompt & effective ventilation is essential. |
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Sodium bicarbonate reacts w/ ____ to form ____ & ____ to buffer metabolic acidosis?
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HCO3 reasts w/ H+ ions to form water & CO2 to buffer metabolic acidosis.
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What is the major problem w/ the use of sodium bicarbonate?
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•that it has a high CO2 content
-The CO2 crosses rapidly into the cells causing paradoxical worsening of intracellular hypercapnia and acidosis. Bicarbonate crosses into the cells more slowly. Can actually have cells go into bigger acidosis so only use if have chronic problem or may use post-code. |
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It has been found that when a pt is in alkalosis the cells are less likely to?
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- to receive an oxygen molecule than if the patient is acidosis.
-So it is better to have a patient a little acidotic (7.25) than alkalotic (7.75) |
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Should sodium bicarbonate be given for respiratory acidosis?
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-Should not be given for respiratory acidosis. Instead the patient should be intubated and ventilated with 100% O2
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In mild to moderate metabolic acidosis, the acidosis will resolve w/?
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-will resolve w/ ventilation & volume replacement
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In severe acidosis will sodium bicarb be used?
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-the use of sodium bicarb is still controversial.
-If bicarb is used, it should be given 10 min after the arrest or according to ABGs only. Not given during codes. |
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What are the duties of the primary nurse in a code?
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needs to give the code team information
-what is code status, get chart, call primary physician (will also make call when time to end code) , interact with family: will not be bagging, compressions once the code team arrives. Need to be the one giving all the info (meds they’ve had, who pt is, why there, what happened to them) |
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What is pharmacy duty in code?
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depends on hospital if they show up. In small facility, nurse admin will run to get meds but large facility usually has pharmacist to pull any meds that aren’t on code cart.
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What happens if pt codes in chair?
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-If pt codes in chair, then put them on floor, if codes in bathroom pull them out if not enough room to work in there.
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Equipment in a crash cart?
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-Crash cart-know where it is located/make sure stocked, look over it to be familiar.
-Backboard: need for CPR bc otherwise will sink into bed as doing compressions. -Airway supplies/suction: will have ET tubes, set up airway first, then Ambu bag with mask. -Monitor/defibrillator -Medications: most are unit dose. -IV supplies: pt must have IV line so we can give them meds, even like to have 2 and like to be a big bore size but MUST HAVE at least 1. |
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What is bradycardia (EKG)?
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-Bradycardia: can be a normal finding in athletes. Pts who are hypoxic/in respiratory failure, may see sinus bradycardia.
-The SA node discharges impulses more slowly than normal and conduction continues in a normal fashion through the rest of the heart. |
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What is complete heart block (EKG)?
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P waves & QRS waves at a regular rhythm but AV node isn’t working so what is going on in atrium is not going down to ventricles so each part of heart is doing it’s own thing. Will be symptomatic. These are the pts who receive pacemakers.
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Txment for bradycardia?
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-If the patient is symptomatic (light headed, decreased BP decreased UO) if the pt is asymptomatic, will not do something about that before really checking them out bc may not need intervention. So first question is always, “Are they symptomatic?”
-Give Atropine IV -Consider transcutaneous pacing -Dopamine infusion at lowest dose possible |
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What is a premature ventricular contraction (PVC)?
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-An ectopic foci in the ventricles discharges an impulse before the SA node.
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Unifocal PVC can be a sign of?
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can be normal or can be sign that you have an irritable heart. So need to evaluate pt & see what is going on.
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What may be done for frequent PVCs?
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may be symptomatic, had a problem w/ heart. Will most likely intervene pharmacologically. First, find your normal QRS waves & circle them to help you. Rhythms that are out of order, big & wide then they’re PVC’s.
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What can several PVCs in a row mean?
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Most ppl don’t have this on regular basis. Usually means have irritable heart bc of heart problems or electrolyte problem.
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Tx for PVCs?
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-For frequent PVCs (greater than 6/min, multifocal (wide & bizarre, coming from different directions & look different means they are coming from diff parts of ventricle), runs of PVCs)
-What could be causing the PVCs (oxygen, electrolyte problems) -Amiodarone IV/Infusion (#1 drug of choice used for PVC’s). Will give 1 of these drugs if only have PVC probs. -Lidocaine IV/infusion |
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What is ventricular tachycardia?
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-An ectopic foci in the ventricles becomes the pacemaker of the heart
-Becomes so dominant that it is overriding all the normal functions of the heart. Not an efficient or well synchronized rhythm. Can even run backwards and will only run at about 1/3 of the normal force. -Has no pause, is continual & rapid. So perfusion of coronary arteries decreases. If this doesn’t resolve, pt will code. |
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Tx for VT w/ a pulse?
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-Amiodarone IV/infusion (will do this first)
-Lidocaine IV/infusion (may use this) -Synchronized Cardioversion (machine senses where are in cycle and hits at a time that won’t send them into a worse rhythm.) -If they are pulse-less, then we will treat much more like Vfib. Will be in a code now. |
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What is ventricular fibrillation?
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-Normal electrical conduction is replaced by choatic activity in the ventricle. All organized activity in heart has ceased. Think of jello moving. When someone is in V-fib, they are dying.
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What is asystole?
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-No electrical activity is happening. No pacemaker is firing. Things are very bad if get to this. Usually can’t get anything back after this rhythm. Complete heart silence.
-1st: check electrodes. Will not defibrillate bc usually won’t do anything. |
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What is pulseless electrical activity (PEA)?
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-The patient has electrical activity on the monitor but no heartbeat: Big problem. For some reason electrical system of heart is working but heart muscle cells aren’t working. Check responsiveness, call for code, start CPR while figure out what is going on. Won’t defibrillate right away.
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Tx for PEA & asystole?
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-Check for responsiveness, activate EMS (call a code), call for defibrillator
-Begin CPR -Start and IV and administer Epinephrine IVP (Epinephrine may be repeated every 3-5 minutes) -Atropine IV -Consider causes (bc need to take care of cause bc fixing cz is only way to get pt back) of PEA |
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Possible causes of PEA?
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hypovolemia(may be no volume there to pump, so need to give them vol)
-hypoxia -acidosis (can make cell walls NOT allow contraction) -potassium imblances -hypothermia (may be able to get these pts back all the way), overdose -cardiac tamponade (fluid built up around pericardial sac so unable to pump) -tension pneumothorax, acute coronary syndrome, PE |
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What is Synchronized Cardioversion?
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-use this when have a pulse w/ V-tach
-Uses electrical activity to convert a cardiac dysrhythmia to a hemodynamically stable rhythm -Patient is usually sedated: bc being electrocuted basically. |
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How does synchronized cardioversion differ from defribillation?
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Differs from defibrillation in that the electrical discharge is synchronized (at a specific time) with the R wave to avoid trigger ventricular VF from an accidental discharge during the vulnerable period. Want to make sure everything depolarizes at the same time. Special situation, need to tell defibrillator that
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What is defibrillation?
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-Uses unsynchronized electrical discharge in an attempt to convert a dysrhythmia (VF or pulseless VT) to a more stable rhythm (just a big shock, no synchronization). Only use for
-If defibrillating a patient, be sure that the synchronized button is off: bc will never find the right rhythm to shock if in VF or pulseless VT). |
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Defibrillation Safety?
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-Check to be sure that no one is touching the bed or pt. (Say “All Clear” loudly)
-Use 25 pounds of pressure -Verify the EKG: for V-fib or pulseless V-tach -Defibrillator may work on battery |
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Equipment needed for an intubation?
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-Laryngoscope blade and handle
-Suction set up -Syringe/tape -Endotracheal tube -Adult-size 8 common -Peds-the size of the peds patients little finger |
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After intubation?
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Listen for bilateral breath sounds
Check for exhaled CO2 Rescue pods |
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What are chemical buffer systems & what are the 3 types?
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-Systems that keep the pH relatively constant
-–Carbonic Acid - Bicarbonate Buffer System –Phosphate Buffer System: these 2 are not the primary systems and we don’t monitor them on a regular basis. –Protein Buffer System |
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What is the Carbonic Acid - Bicarbonate Buffer System?
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•the system that we monitor clinically: when do ABGs, bicarbonate levels
•maintains stable pH with 20 bicarbonate : 1 carbonic acid: this is what needs to stay in balance |
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Regulation of acid-base balance through respiratory control?
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–makes changes quickly: body has a very quick response time to maintain control over this. Within minutes & sometimes seconds.
–pH ⇓, more acid, rate and depth of breaths ⇑ –pH ⇑, more alkaline, rate and depth of breaths ⇓ |
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Acid-base balance through renal regulation?
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–kidneys make permanent adjustments: takes days to weeks to happen & days to weeks to reverse.
–when acidosis occurs, H+ excreted in urine –when alkalosis occurs, HCO3 (bicarbonate) excreted in urine |
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What is pH?
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-tells us the quickest, the most. Will measure this first.
•Measures the acidity (pH goes down) or alkalinity (pH goes up) of a solution •Large number of H ions = decreased pH •Small number of H ions = increased pH •Normal pH 7.35-7.45: KNOW FOR EXAM!!! More out of whack it is, the worse condition is. Ex: 7.2 = dead or dying. 7.1 = pt usually dead. Can have a normal pH that has been compensated for. Which means other ABGs will still be abnormal. If have a normal pH level then everything is either normal or body has compensated for pH. |
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What is an acid?
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•Acid - compound that gives up hydrogen
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What is a base?
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-compound that combines with acids
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What is acidosis?
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•Abnormal increase in hydrogen ion concentration as a result of an accumulation of too much acid or a loss of a base. Most common way to lose base is diarrhea.
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What is alkalosis?
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•Abnormal condition caused by excess bicarbonate or deficiency of acid
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What is an ion?
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•Electrically charged particle
H+ - hydrogen HCO3 - bicarbonate CO2 - carbon dioxide H2CO3 - carbonic acid |
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What is pCO2 or paCO2 & what does is reflect? Normal level?
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– direct measurement of the partial pressure of CO2 in the blood
–reflects the respiratory component: directly r/t to depth & rate of respirations. So if hyperventilating/holding breath CO2 will go up. –normal 35-45 mm Hg: normal CO2 |
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What is SaO2 & the normal?
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–arterial oxygen saturation, has no effect on acid-base balance.
–normal 95-100% |
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What is pO2 or paO2?
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•pO2 or paO2: doesn’t determine acid-base balance
–partial pressure of oxygen dissolved in the blood |
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What is HCO3, what does it reflect & the normal level?
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–bicarbonate ion
–reflects the metabolic component of acid-base: tells about kidney acid-base balance. –normal 22-26 mEq/L |
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⇑ HCO3 czs the kidneys to?
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–⇑HCO3 (alkaline) causes the kidney to retain H+
-this usually only happens when ppl take excessive amts of antacids. |
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⇓ HCO3 czs the kidneys to?
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–⇓ HCO3 (acidic) causes the kidneys to excrete H+
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Base excess/base deficit reflects?
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-reflects an increase or decrease in the total amount of base present: don’t use to calculate ABGs but does help you to see what is going on.
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Steps to interpreting blood gases?
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Step 1: Look at ph: ALWAYS start with this. Will be normal, compensated, acidosis or alkaline.
Step 2: Look at pCO2 Step 3: Look at HCO3 Step 4: Match up the respiratory and metabolic component that matches the pH problem, bc just need to find the prob that matches with the pH. •Choose the best interpretation based on patient data •Remember: You need only the CO2 and HCO3 along with the pH to interpret ABGs |
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Normal Arterial Blood gas interpretation?
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•when get ABG back this is all the info that will be on it.
pH: 7.35 – 7.45 PaO2: 80 – 100 mmHg O2 Sat: 95% or higher PaCO2: 35-45 mmHg HCO3: 22-26 mEq/L B.E.: -2 - +2 |
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Acidotic levels of pH, CO2, HCO3?
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–pH < 7.35
–CO2 > 45 –HCO3 < 22 |
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Compensation is occurring if?
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–pH is approaching the normal range, but
–pCO2 and/or HCO3 are out of balance |
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Lungs will compensate if?
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•Lungs will compensate if the primary imbalance is metabolic
⇑ acid ⇓base |
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Kidneys will compensate if the primary balance is?
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•Kidneys will compensate if the primary imbalance is respiratory
COPD ⇑ ICP -Whatever is working is what will be compensating for the problem. |
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What are the 4 types of acid-base disturbances?
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these 4 types can be combined.
•Respiratory Acidosis •Respiratory Alkalosis •Metabolic Acidosis •Metabolic Alkalosis |
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What is respiratory acidosis?
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•A carbonic acid excess resulting from any situation that decreases the rate of pulmonary ventilation. Anything that can cz respiration probs.
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Etiology of respiratory acidosis?
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•anything that affects respiratory function can cz resp acidosis
•Damage to the resp center (brain stem damage, too much opioids) •Obstruction to the resp. passage •Loss of lung surface for ventilation: ARDS, pneumonia, pulmonary edema, pneumonectomy. •Weakness of the resp. muscles: •Severe resp. depression oImportant to recognize patients with inadequate ventilation early so interventions can be begun |
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S/S of respiratory acidosis?
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•Decrease pH and increased PCO2: on lab work
•Visual disturbances, may even have hallucinations •Headaches •Confusion, may see anxiety •Drowsiness: •Coma |
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If have normal pulse ox on pt then chances are what else is normal?
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-If have normal pulse ox on a pt, chances are the CO2 is normal bc O2 is last thing to get into blood so won’t have too much CO2. If CO2 up then O2 level may be high.
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Intervention for respiratory acidosis?
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-Correct underlying problem to improve ventilation
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What is respiratory alkalosis?
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•A carbonic acid deficit: so much acid is gone so now have more base than we need.
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Etiology of respiratory alkalosis?
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•Caused by excessive pulmonary ventilation or any condition that increases the metabolic rate: too much CO2 getting blown off. Usually only caused by:
1. Hyperventilation [hv can be czed by brain stem injury] (have breath into bag), 2. bagging or ventilating (decrease vol. or rate going in) |
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S/S of respiratory alkalosis?
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•Increased pH and decreased PCO2
•Lightheadedness •Numbness and tingling of the fingers and toes |
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Interventions for respiratory alkalosis?
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•Treat underlying cause
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What is metabolic acidosis?
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•A bicarbonate deficit that occurs when excess acids are added or bicarbonate is lost.
-Happens when too much acids being produced or too much bicarb lost. |
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Etiology of metabolic acidosis?
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•Loss of bicarbonate-diarrhea, draining wounds
•Renal failure: #1 cause of metabolic acidosis •DKA: body trying to compensate. Sign is Kussmaul breathing. •Salicylate intoxication: Aspirin overdose. •Starvation: may see some of these s/s from ppl on Atkins diet if they aren’t drinking enough fluid. Kidneys need LOTS of fluid to flush out all those acids. •Shock: in shock or trauma pts its very common to see respiratory & metabolic acidosis simultaneously. |
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S/S of metabolic acidosis?
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•Decrease in pH and decrease in HCO3
•Headache •Mental dullness •Kussmal respirations-rapid, deep respirations |
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Interventions for metabolic alkalosis?
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•Sodium Bicarbonate: but also need to correct the core problem or it will just be lost through the urine.
•Dialysis: for renal failure pts to help equalize |
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What is metabolic alkalosis?
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-not very common.
•Bicarbonate excess that occurs when an excessive amounts of acid are lost from the body or when an increase amount of bicarbonate are added orally or IV |
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Etiology of metabolic alkalosis?
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•Loss of hydrochloric acid from the stomach: vomiting or out of NG tube.
•Loss of K ions through diarrhea, fistulas •Ingestion of large amounts of bicarbonate or other antacids •Excessive administration of bicarbonate •Diuretic therapy •Mineralocorticoids |
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S/S of metabolic alkalosis?
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•Increase in pH and increase in HCO3
•Mental confusion: any new onset confusion, acid-base balance needs to be ruled out. •Dizziness •Numbness and tingling of toes and fingers: just like respiratory alkalosis. Any type of alkalosis usually causes the same s/s. •Muscle twitching •Tetany and seizures |
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Tx of metabolic alkalosis?
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-hard to treat
•Treat the underlying problem •Diamox-which will increase excretion of bicarbonate from the kidney |
