Ms2 - Exam 2 - Critical Care, Shock, Mods

Front 1

2 most common causitive organisms of infective endocardititis

Back 1

Staphylococcus aureus and Streptococcus viridans

Front 2

What causes sudden death from infective endocarditis?

Back 2

Vegetation breaks off and forms an embolism

Front 3

Symptoms of endocarditis

Back 3

New heart murmur.

Splinter hemorrhages (black longitudinal streaks in the nail beds)

Petechiae in the eyes and mouth.

Osler's nodes (painful red/purple pea size lesions on fingers and toes)

Janeway's lesions (painless, flat, small red spots on palms and soles)

Roth's spots (retinal lesions)

SIGNS OF MICRO/MACRO EMBOLISM ALL OVER THE BODY AND SIGNS OF INFLAMMATION (fever, chills, anorexia, etc)

Front 4

What is Osler's nodes?

Back 4

painful, tender, red/purple, pea-size lesion on fingers/toes with endocarditis

Front 5

What are Janeway's lesions?

Back 5

flat, painless, small red spots on the palms and soles with endocarditis

Front 6

What are Roth's spots?

Back 6

retinal hemorrhages with endocarditis

Front 7

What is the most important part of the health history for an endocarditis pt?

Back 7

Have you had recent dental, urologic, surgical, or gynecologic procedures? Heart disease, recent cardiac cath/surgery, intravascular device placement? Renal dialysis? Infections?

Front 8

How is endocarditis diagnosed?

Back 8

2 blood cultures 30 min apart from 2 different sites

Front 9

What are the risk factors for endocarditis?

Back 9

Prior endocarditis, prosthetic valves, acquired valvular disease, cardiac lesions

Front 10

Treatment of endocarditis

Back 10

Identify individuals at risk
Prophylactic treatment
Long-term IV antibiotics
Repeat Blood cultures
Valve replacement
Fever reducers, fluids, rest

Front 11

Nursing Dx for endocarditis

Back 11

Decreased cardiac output r/t altered rhythm, valvular insufficiency, and fluid overload

Activity intolerance r/t generalized weakness, arthralgia, and alteration in O2 transport secondary to valvular dysfunction

Hyperthermia r/t infection of cardiac tissue

Front 12

Teaching for endocarditis pt

Back 12

Prophylactic antiobiotics before dental procedures, avoid those with URI's, planned rest periods, good oral hygiene, report fever b/c it is an early sign antibiotics aren't working

Front 13

What causes pericarditis?

Back 13

Infection, MI, cardiac sx, TB, cancer, radiation to the chest/trauma, viruses, idiopathic

Front 14

What is Dressler syndrome?

Back 14

Pericarditis that occurs 4-6 weeks after cardiac sx or MI due to the antigen/antibody reaction to the necrotic myocardium. Pain, fever, friction rub

Front 15

What is the hallmark of pericarditis?

Back 15

Friction rub in time with the pulse, not the respirations. PAIN.

Front 16

What is the difference in symptoms of endocarditis and pericarditis?

Back 16

Endocarditis - embolism, petechaie

Pericarditis - pain and friction rub

Front 17

How do you determine pulsus paradoxis?

Back 17

Put pt in semirecumbant position.

1. Meaure systolic BP.
2. Inflate BP cuff at least 20mm above systolic BP.
3. Deflate slowly until systolic sounds on expiration are heard and note the pressure.
4. Deflate until systolic sounds are heard throughout the respiratry cycle, and note the pressure.
5. Determine the difference b/w the two readings.

Difference should be <10mm Hg. If not, cardiac temponade may be present.

Front 18

Symptoms of cardiac temponade

Back 18

Altered mental status, pulsus paradoxus, JVD, tachypnea, tachycardia, decreased CO

Front 19

Labs in pericarditis look like...

Back 19

Elevated C-reactive protein, ESR, Troponin, WBC

Front 20

Tx of pericariditis includes...

Back 20

Identify & treat underlying cause
NSAIDs
Steroids
Pericardiocentesis

Front 21

Difference b/w angina pain and pericarditis pain...

Back 21

Pericarditis pain radiates up to the trapezius muscle

Front 22

Difference b/w MI and pericarditis on ECG

Back 22

Pericarditis - diffuse ST elevations that don't change

MI - localized ST elevations that evolve over time

Front 23

Care for the pericarditis pt includes....

Back 23

Bedrest
HOB up 45 degrees and pt leans on overbed table
Antiinflamatory rx's
Anxiety reduction
Monitor for cardiac temponade

Front 24

What is a pericardial knock?

Back 24

Loud, early diastolic sound heard along left sternal bordor in chronic constrictive pericarditis

Front 25

What are the symptoms of chronic constrictive pericarditis, and what is it?

Back 25

Loss of elasticity of the pericardial sac from fibrin deposits/calcification of pericardial sac.

Mimics HF. JVD, no pulsus paradoxus. Pericardial knock.

Tx: pericardiectomy

Front 26

What is myocarditis?

Back 26

Focal or diffuse inflammation of the myocardium that leads to dilated cardiomyopathy

Front 27

What are the symptoms of myocarditis?

Back 27

Early signs are fever, malaise, etc

Late signs are to do with heart failure, dilated cardiomyopathy, conduction disturbances

Front 28

What does C-reactive protein indicate?

Back 28

Inflammatory process

>20mg/dL is positive or >1.2titer

Restrict food/fluids 8-12hrs before the test

Front 29

Tx for myocarditis

Back 29

Beta blockers and ACE's for HF

Nitropress, inamrinone, and milrinone for reducing the afterload

Anticoagulants b/c of blood stasis and embolism possibility

Be careful with Digoxin b/c myocarditis predisposes pts to drug-related dysrhythmias and toxicity

Bed rest
O2

Front 30

What causes rheumatic fever?

Back 30

Abnormal immune response to Strep A pharingytis (usually happens 2-3 weeks after the infection)

Front 31

What is rheumatic fever? What are the signs/symptoms?

Back 31

Affects many of the body’s connective tissues - skin, heart, CNS, joints

Valvular degeneration causes erosion of valves & regurgitation

S/S: fever, arthralgias, Chorea, skin rashes (ERHYTHEMA MARGINATUM - BRIGHT PINK, MAPLIKE MACULAR LESIONS ON TRUNK exacerbated by heat), sq nodules

HF AND POLYARTHRTITIS MOST COMMON SYMPTOMS

Front 32

What are Aschoff's bodies?

Back 32

Associated with rheumatic fever.

Nodules formed by inflammation/swelling/destruction of collegen fibers.

Front 33

Tx for rheumatic fever

Back 33

Bed rest, antibiotics for 5 years without carditis and 10 years with carditis, NSAIDS, ASA, corticosteroids, heat to painful joints

Front 34

Nursing Dx for rheumatic fever/rheumatic heart disease

Back 34

Decreased cardiac output r/t valve dysfunction or HF.

Activity intolerance r/t arthraligia/arthritis secondary to joint pain, pain from pericarditis, and HF.

Ineffective self-health management r/t lack of knowledge concerning the need for long-term prophylactic antibiotic therapy and possible disease sequelae.

Front 35

What is the most common cause of mitral valve stenosis?

Back 35

Rheumatic heart disease b/c it causes scarring and fibrosis of the valve leaflets.

Mitral valve stenosis looks like a fish mouth.

Front 36

Symptoms of mitral valve stenosis

Back 36

Accenuated S1 (trying to push blood through the valve)

Hemoptysis (due to pulmonary HTN)

Emboli (from blood stasis)

Front 37

Symptoms of mitral valve regurgitation

Back 37

Acute - Systolic murmur

Chronic - S3 sound

Front 38

What should the teaching include for mitral valve prolapse?

Back 38

Contact EMS if it's symptomatic.

Prophylactic antibiotics before dental procedures.

Take beta-blockers and avoid caffiene.

Front 39

Symptoms of aortic stenosis

Back 39

angina, syncope, exertional dyspnea

Soft S1/S2, prominent S4

Front 40

Rx for aortic stenosis

Back 40

Nitro, but be careful b/c BP may drop significantly and worsen chest pain

Front 41

Symptoms of aortic regurgitation

Back 41

Pulmonary HTN, Austin Flint murmur (low pitched diastolic murmur), and water-hammer pulse (strong quick beatthat collapses immediately)

Front 42

What should pts with mechanical valve replacements know?

Back 42

They should be on lifelong anti-coagulant therapy.

Front 43

Nursing dx for valvular disorders

Back 43

Decreased cardiac output r/t valvular incompetence

Excess fluid volume r/t fluid retention secondary to valvular-induced heart failure

Activity intolerance r/t insufficient oxygenation secondary to decreased cardiac output and pulmonary congestion

Front 44

What is the antidote to heparin and enoxaparin?

Back 44

protamine sulfate

Front 45

What is the antidote to warfarin?

Back 45

Vit. K

Front 46

What kind of fluids do we use for shock?

Back 46

Crystalloids and colloids (3ml replaced for every 1ml blood lost)

Front 47

What do we want the central venous pressure to be?

Back 47

15

Front 48

What do we want the PAWP to be?

Back 48

10-12mmHg

Front 49

Rx specific to septic shock

Back 49

Xigris

MONITOR APTT FOR BLEEDING!!!!!!!

Front 50

What should the aPTT be?

Back 50

20-35sec

Front 51

What should the PTT be?

Back 51

60-70sec

Front 52

Tx for neurogenic shock

Back 52

atropine for the bradycardia
vasopressors
no fluid resuscitation

Front 53

Tx for anaphalactic shock

Back 53

Epinephrine drug of choice
Diphenhydramine (Benadryl)
Maintain patent airway
Nebulizers
Fluid resuscitation

Front 54

Acute care for shock

Back 54

Neuro – Q1Hr neuro checks
Cardio – hemodynamic monitoring q15min. EKG
Resp – continuous pulse oximetry, intubation & ventilation
Renal – urine output q1h
Skin/Temp – monitor Q4Hr, keep warm
GI – monitor Q4Hr
Hygiene – check for skin breakdown
Emotional support – treat anxiety/fear/pain

Front 55

What is neurogenic shock?

Back 55

Injury above T5 causes SNS disfunction, so there is massive vasodilation

Low BP, bradycardia, hypothermia due to unopposed parasympathetic nervous system

Front 56

What are the stages of shock?

Back 56

1. Compensatory stage - fall in BP, epinephrine and norepinephrine release, blood diverted to heart and brain (away from kidneys, GI, and lungs) so increase in rate and depth of respiration, decreased urine output

2. Progressive - dysrhythmias and MI from decreased cardiac perfusion as compensatory mechanisms fail...crackles, tachypnea, jaundice, GI bleeding, DIC risk

3. Irreversible stage - cerebral ischemia

Front 57

How do you calulate the absolute neutrophil count?

Back 57

ANC = 10 * WBCs in 1000s * (%segs+ %bands)

Neutropenia is ANC<1500

Mild neutropenia is 1000-1499
Moderate neutropenia is 500-999
Severe neutropenia is <500

Enter WBC as 9.2 not 9200