Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
297 Cards in this Set
- Front
- Back
|
7 dimensions of an illness
|
PQQRSST: Place, Quality, Quanitity, Regulating/aggrevating factors, Setting, Symptoms, Timing
|
|
|
4 aspects of physical assessment
|
Inspect, Palpate, Percuss, Ascultate
|
|
|
Patient Goals should be:
|
Ojective, Measurable, Demonstrable, Realistic, Agreeable, Patient-Centered
|
|
|
Steps to the Nursing Process
|
ADPIE: Assess, Diagnose/Analyze, Plan, Intervention, Evaluation
|
|
|
"Nursing is...doing for the patient what they would do if they had the knowledge, strength, ability...and helping them not to need your care anymore"
|
VA Henderson
|
|
|
"nursing is...giving pt whatever they need for their needs to be met...client-centered care, not disease-centered"
|
Ida Jean Orlando
|
|
|
"Nursing is...the diagnosis and treatment of human responses to actual or potential health problems...combine the art of caring with the science of health care"
|
ANA
|
|
|
"nursing is...diagnosing human responses to actual or potential health problems, under direction of physician..."
|
CT Nursing Practice Act
|
|
|
Chief Complaint (cc)
|
"in quotes in the words of the pt"
|
|
|
9 Human Response Patterns
|
Communicating, Valuing (spiritual), Relating, Knowing, Feeling, Moving, Perceiving, Choosing, Exchanging
|
|
|
Normal Temp
|
97-99 F = 37 C
|
|
|
Normal Pulse
|
60-100
|
|
|
Normal Respiration Rate
|
12-20 (24 in hospital setting)
|
|
|
Normal BP
|
120/80 (130/75 for diabetics)
|
|
|
Normal SAO2 (oxygen saturation)
|
95-100, <90% is hypoxemia
|
|
|
Normal USG
|
1.002 - 1.028 (high in dehydration, high ADH) (low with DI, low ADH, glomerulosnephritis and pyelonephritis = damage to kidney's tobules and kidney can't absorb water, Renal failure = fixed USG of 1.010)
|
|
|
surgical diuresis
|
increased urine volume a few days after surgery. In first few days, be aware of fluid retention and avoid FVE
|
|
|
brain surgery and fluid volume
|
post-surgery = no ADH, so get DI, so NEED urine retention drugs
|
|
|
1oz = x cc
|
30 cc = 1 oz
|
|
|
molecules
|
electrically neutral
|
|
|
1 liter = x cc
|
1000cc = 1 liter
|
|
|
edema is x cc of extra water
|
edema is 2500cc of extra water
|
|
|
1 lb = x cc
|
500cc = 1 lb
|
|
|
IVF = x L water
|
3.5-6
|
|
|
Equation for Cardiac Output
|
HR x SV = CO
|
|
|
Signs of shock
|
HR up, Resp Rate up, BP down
|
|
|
sequence of blood flow
|
heart -> arteries -> arterioles -> capillaries -> venules -> veins -> heart
|
|
|
Capillary action
|
diffusion of oxygen and nutrients from blood into tissues and diffusion of waste products of metabolism from tissues into blood
|
|
|
4 words to describe fluid of wound
|
serous, sanguinous, sero-sanguinous, purulent
|
|
|
Normal albumin in blood
|
3.5-5
|
|
|
Preload
|
how much blood returns to heart (measured in jugular vein)
|
|
|
CVP
|
central venous pressure = measurement of R ventricular preload
|
|
|
colloid osmotic pressure
|
pull of albumin on water and other molecules into the space where colloids are located
|
|
|
Normal serum osmolality
|
300 (when high, will be THIRSTY)
|
|
|
Liver failure and albumin
|
can't metabolize albumin, so will have VERY low levels, low venous colloid osmotic pressure, low albumin (high fatality rate)
|
|
|
Heart Failure and fluid
|
FVE (fluid backs up in system)
|
|
|
IVs for Shock
|
ALWAYS hypertonic: need to get volume into blood
|
|
|
Measuring Edema
|
<1/4"=1+, 1/4"-1/2"=2+, 1/2"-3/4"=3+, 3/4"-1"=4+
|
|
|
Formula for Mean Arterial Pressure (MAP)
|
sBP + 2(dBP)/3
|
|
|
Renin-Angio-Ald System (RAAS) effects on HEART
|
angio I and II = vasoconstriction; ald = NA and H2O resabsorption
|
|
|
SNS response to heart failure and volume loss
|
decrease in SV stimulated baroreceptors, incr SNS stim -> incr. HR and force of contraction -> peripheral vasoconstriction -> shunts blood to heart and brain -> incr. venous return
|
|
|
ADH
|
osmo of IVF high -> ADH secretion -> reabsorbs H20 in kidney tubules -> sm amt of urine with high USG
|
|
|
ANP
|
when BV or BP incr -> stretches atria -> releases ANP -> incr. vasodilation -> lowers BP, BV, and preload/afterload. ALSO release of ANP -> decr. ADH -> decr. BV, decr. BP, decr. preload/afterload. ALSO release of ANP -> incr. filt rate in kidney -> urine excretion -> decr. BV, BP, preload/afterload
|
|
|
Normal daily Urinary output
|
1,500cc/day
|
|
|
Calculated Insensible daily loss
|
1,000cc/day
|
|
|
ADH and stress
|
increase ADH output, decrease urine output
|
|
|
daily baseline fluid requirement
|
30cc/kg/day (25 for obese and elderly)
|
|
|
5% albumin solution
|
Isotonic
|
|
|
Dextran
|
albumin/blood replacement drug: for every 1cc, pulls 2cc H2O back into blood stream from ICF (great post surgery)
|
|
|
TPN
|
must be administered via central line (risks of emboli and lung collapse, hyperglycemia, infection)
|
|
|
TPN bag goes dry...
|
...replace with 10% dextrose to stabalize blood sugar
|
|
|
PPN bag goes dry...
|
...replace with 5% dextrose
|
|
|
air emboli
|
Air in IV: put pt in Left Lat position; give 100% O2, and knowthat 50cc 02 = LBP, 100 cc 02 = lethal
|
|
|
Enteral vs. Parenteral
|
Enteral: GI Parenteral: IV, subcutaneous (non-GI)
|
|
|
NG tubes
|
single lumen CANNOT be used to decompress the stomach (need double lumen) Salem Sump Tube (sst) used to decompress.
|
|
|
Responding to Aspiration
|
put head of bed <30degrees, shut off Enteral feeding; use constant infusion (no bolus); monitor and avoid G-distension; feed post pylorically
|
|
|
Responding to Diarrhea
|
reduce rate of tube feeding; treat with antibiotics; add bulking agents
|
|
|
Responding to High Gastric Residuals (not processing GI food)
|
high risk = sepsis; hyperglycemia; diabetes; trauma; MI; add prokinetic agents; feed post pylorically; check residuals every 15 minutes
|
|
|
Responding to Dehydration
|
Monitor I/O and weight; provide free water
|
|
|
Rales
|
crackles in lungs = L ventricular failure and FVE
|
|
|
SOB
|
Heart failure or FVE
|
|
|
cough
|
heart failure or FVE
|
|
|
s3 heart sound
|
heart failure or FVE
|
|
|
Jugular Vein Distension
|
Right ventricular failure, FVE, high BP
|
|
|
THIRST
|
FVD
|
|
|
Orthostatic BP
|
FVD
|
|
|
Pulse pressure
|
(diff between s and d pressure) GROSS MEASURE OF SV of <30, FVD
|
|
|
Pulse Quality
|
full, bounding = FVE
weak, thready, fast = FVD |
|
|
normal H/H
|
42-52%
|
|
|
Normal BUN
|
5-25 (elevated = FVD, renal dysfunction)
|
|
|
Normal Creatnine
|
0.1-1.2 (elevated = FVD, renal dysfunction)
|
|
|
Azotemia
|
abnormally high concentrations of urea and nitrogens in blood
|
|
|
Uremia
|
excess urea in blood; sign of renal failure
|
|
|
USG
|
<1.010 = FVE; >1.025 = FVD
|
|
|
Normal CVP
|
2-8; <2=FVD; >12=FVE
|
|
|
Normal PAWP
|
6-12; >12 = FVE; <6= FVD
|
|
|
FVE Signs/Symptoms
|
edema, moist tongue/mucosa, full Jugular veins, rales/crackles in lungs, weight up, H/H down, Serum Osm down, pulse bounding and full, BP up
|
|
|
FVD Signs/Symptoms
|
tenting of skin, tongue is red, beefy, fissured, mucosa dry, jugular veins flat, weight down, H/H high, serum osmo >310, thirsty, pulse is fast weak and thready, BP down, CONFUSION
|
|
|
Formula for Serum Osmolality
|
2(Na) + Glu/18 + BUN/2.8
|
|
|
USG < 1.010
|
overhydration, duiretics, DI, CHF
|
|
|
USG > 1.030
|
dehydration, proteinuria, preeclampsia
|
|
|
Renal Failure and urine output
|
restrict fluid to 500cc/day for 24 hours
|
|
|
FVD risk factors
|
burns, blood loss, surgery, vomiting, fever, GI suction, fistulas, Diabetes Melodus, DI, polyuria, laxatives/diuretics, sepsis, liver disease, lymphatic blockage
|
|
|
1st sign of FVD
|
anxiety
|
|
|
Normal weight loss vs. deficit
|
Normal = 250cc/day (1/2lb) If loss is 1lb, think FVD.
|
|
|
Necessary Urinary output/day
|
500cc; if <500cc, BUN and Creatnine in blood goes up, causing toxicity
|
|
|
oliguria
|
urinary output <400cc/day
|
|
|
FVE risk factors
|
Cirrhosis (hyperald.), Cushing's disease, IV fluid admin, CHF, renal failure
|
|
|
low Albumin
|
3rd spacing, water leaves blood and doesn't return (want hypertonic solution
|
|
|
complications of sepsis
|
expand capillaries, fluid leaves blood stream, edema, no albumin to hold water in blood
|
|
|
fevers and metabolism
|
every deg over 90 = 15% incr. in metabolism (causes FVD) and incre of Resp. Rate 4/min
|
|
|
Normal Urinary Output
|
60cc/hr
When <30cc/hr -> TELL PRECEPTOR |
|
|
Normal MAP
|
>70-105; when <60 releases renin, shuts down periph vasc. sys., release ald to increase BP
|
|
|
KVO
|
keep vein open (slow IV)
|
|
|
Causes of Edema (not FVE)
|
impaired lymphatics, inflammation, clots/venous congestion, liver disease, sepsis
|
|
|
Response to Cardiogenic Shock
|
PUMP WITH SALINE
|
|
|
reasons to avoid Ald release
|
heart failure, kidney failure (can't handle increased BV)
|
|
|
Signs of RV failure
|
edema, jugular vein distension, lung disease
|
|
|
Signs of LV failure
|
VERY LOW BP, pulmonary edema, shortness of breath, rales/crackles, cough
|
|
|
Hypotonic solutions
|
<250; 2/3 of H20 will leave ECS for ICS
|
|
|
D5W
|
considered isotonic, but hypotonic in body (adds H2O to body: 1/3 ECS,2/3 ICS)
Great for pts who are hypernatremic, adds H2O to blood |
|
|
1/2 Normal Saline
|
hypotonic, good for dehydration (gives a little salt and water)
problem: swelling (a lot of water leaves bloodstream) |
|
|
D5 w/1/2 Normal Saline
|
hypertonic (but Isotonic once glu is released into body) -> contains k+
This is the NORMAL IV fluid usedin hospitals, has: sugar, water, Na+, K+ |
|
|
Full Saline
|
high Na+ content -> causes hypernatremia, stays extracellular -> 250cc saline stays in bloodstream -> incr BP
GREAT FOR SHOCK Not good for elderly/weak haearts (can't handle hypernatremia) GIVE WITH DIURETIC (but then will incr. K+ level) |
|
|
blood makeup
|
45% RBCs
|
|
|
Obesity and water volume
|
lower water volume
|
|
|
D5W
|
isotonic, but hypotonic once glu absorbed, DOES NOT PRODUCE ECFV overload, raises blood sugar, too much can cause ICF edema
Problem: DON'T use with pts with cranial pressure or shock |
|
|
1/2 Normal Saline
|
hypotonic; provides free water and Na+. Treats hypertonic ECFV depleted states (good for severe dehydration)
Problem: can cause hyponatremia (sodium leaves blood) |
|
|
Normal Saline
|
ECFV replacement. Perioperative. Shock
Problem: ECFV overload in pts with CHF or renal failure. |
|
|
Ringer's Lactate
|
iso/mild hyper; provides ECFVreplacement; lactate replacement; perioperative.
GREAT for Burns contains K+ Problem: ECFV overload in pts with CHF or renal failure. |
|
|
3% NaCL
|
HYPERTONIC! treatment of severe hyponatremia
Problem: ECFV overload |
|
|
D5 1/2 normal saline
|
hypertonic. Replaces water, sodium, and some sugar (contains K+)
|
|
|
Hypotonic Solutions
|
<250
Problems: bad for dehydration (takes H2O out of bloodstream); causes edema; volume concentration of bloodstream NEVER USE WITH: cranial pressure, burns, liver disease, hypoalbuminemia |
|
|
Isotonic Solutions
|
250
Problems: expand IVF (risk for FVE) NEVER USE WITH pts with alkalosis |
|
|
Hypertonic Solutions
|
Problems: Need Anal Incontinence bag!!! Puts water into ECF/causes FVE.
ALWAYS ADMIN BY PUMP NEVER GIVE TO pt with ICF dehydration,or pts with CHF or renal failure |
|
|
Normal Cardiac Output
|
4-6 L/minute
|
|
|
Hospital Normal Output/Loss
|
30cc/hr
|
|
|
Normal BUN:cr
|
10-15:1
|
|
|
Normal CVP
|
2-8
|
|
|
pancreatic drain
|
HCO3 (bicarbonate)
|
|
|
vomiting and electrolytes
|
decrease K+ and HCl
|
|
|
Signs/Symptoms of Hypokalemia
|
weakness, cramps, decr. reflexes, paralysis of resp. muscles, paralysis of ileus, nausea, constipation, hypotension, arythmias, drowsiness, dizziness, flat T-wave, U-WAVE
REALLY TIRED |
|
|
80% of K+ excreted by...
20% of K+ excreted by... |
kidney
GI track |
|
|
Hypokalemia causes
|
K+ loss: diarrhea, ileostomy, vomiting, GI suction, NG tube, intenstinal drain
low K+ intake: anorexia, alcoholism, fasting, NPO Fluid/elect shift: ALKALOSIS, vomiting Drugs that lower K+: diuretics, kayexalate, IV glucose, insulin, steriods, licorice, aldosterone, antibiotics ALKALOSIS: need acids in blood stream, so K+ leaves blood and goes ICF. |
|
|
Administering K+
|
DILUTE! MIX WELL! SALINE FLUSH with GI admin; irrigate with Normal Saline; NEVER BOLUS; never exceed 10meq/hr (in >100cc); MAX is 20 meq/hr IV
|
|
|
Hyperkalemia causes
|
Increase intake: salt substitutes, K+-sparing meds, crushing injuries/burns, ACE inhibitors, transfusions of old blood
Decreased output: renal disease, adrenal gland failure, hypoaldosteronism Redistribution: Acidosis (want H+ out of cells, so K+ comes in) |
|
|
Signs and Symptoms of Hyperkalemia
|
bradycardia, irregular pulse, decr. CO, Cardiac arrest, PEAKED T-WAVES, PROLONGED PR, numbness of extremeties, muscle weakness, paralysis, GI cramps, diarrhea, oliguria, cell lysing, confusion
|
|
|
Treatment of Hyperkalemia
|
Dextrose/Insulin, Kayexalate, Ion exchange resin (get Na+ in, K+ out, watch for hypernatremia) , Sodiumbicarb: alkalinizes plasma (K+ into cells)
|
|
|
Calcium gluconate for Hyperkalemia
|
treats symptoms, not cause
NEVER give to pts with digitalis meds, increases arrhythmias |
|
|
shortcut formula for Serum Osmolality
|
2 x Na = approx. of serum osmolality
|
|
|
Causes of Hyponatremia
|
Dilutional: IV admin, hypotonic solutions, SIADH
Drugs: cytoxan, diabinese, SSRIs, MAO inhibitors Heart failure, liver failure: nephrosis: decreased Arterial volume and triggers ADH release (pt appears edemic/FVE) LOSS of Na relative to water: diuretics, burns, vomiting, Ald deficiency |
|
|
Signs and Symptoms of Hyponatremia
|
edemic/FVE, low Serum Osmo, USG < 1.010, nausea, abdominal cramping, CNS dysfunction (cell swelling and cerebral edema), lethargy, neuro damage, <115 = seizures, cramps, weakness (may seem FVD if on diuretics)
|
|
|
False pseudohyponatremia
|
Hyperglycemia: for every 100mg incr. in glu level, the Na level decr. by 1.4
|
|
|
Diff presentaitons of hyponatremia
|
FVD = diuretic therapy
FVE = CHF and cirrhosis euvolemia = SIADH |
|
|
Hyponatremia due to NA loss
|
urine Na<10meq/L and USG <1.010
|
|
|
Hyponatremia due to NA loss
|
urine Na<10meq/L and USG <1.010
|
|
|
Hyponatremia due to SIADH/water gain
|
urine Na >20meq/L and USG >1.012 (continues continue to excrete sodium and retain water
|
|
|
Hyponatremia and IV
|
cautiously admin. HYPERTONIC solution (3% normal saline has high osmolality)...can they accept additional water loadw/out CHF/pulmonary edema? (give with lasix)
|
|
|
treatment of hyponatremia
|
plasma Na should raise by only 12 meq in 1st 24hrs.
Problem: osmotic demylination and brain dehydration/injury |
|
|
Key manifestations of Hypernatremia
|
"thirst" and renal conc. of urine to conserve H2O
|
|
|
Causes of Hyponatremia
|
water loss: DI, low ADH, Osmotic diuresis, renal disease (can't concentrate correctly), diarrhea, excessive diaphoresis
Gain of Na+ relative to H2O: problems matching thirst/injesting, hypertonic feedings, hyperaldosteronism |
|
|
Na reduction in hypernatremia
|
don't lower Na more than 2meq/hr.
|
|
|
IV for hypernatremia
|
D5W or 1/2 saline
|
|
|
SIADH presentation
|
pts do not appear wet or dry...euvolemic! but have dilutional hyponatremia
|
|
|
Treatment of SIADH
|
fluid restriction
diuretics tetracycline/demeclocyline (increases water clearance form renal tubules seizure precautions |
|
|
Causes of SIADH
|
cancer (lung especially), chemotherapy, analgesics, antidepressants, nausea
|
|
|
SIADH lab results
|
serum sodium low
serum osmolality low urine osmolality high urine sodium high |
|
|
DI causes
|
low ADH secretion, caused by tumor of hypothalamus, kidney non-response to ADH, head trauma, cranial surgery, lithium carbonate and demeclocycline
|
|
|
Signs and symptoms of DI
|
serum osm high >300
diuresis 5-20L/day polyuria with low USG low urine osmolality FVD weight loss |
|
|
DI Interventions
|
problem is urine output >100cc/hr x 3hrs
exogenous ADH admin |
|
|
liters body water deficit formula
|
(.6(kgwt) x serum Na -140)/140
|
|
|
gauges for IVs/catheters
|
flow rates slow as length increases.
|
|
|
daily K+ intake
|
20-60mE/day
|
|
|
insulin and K+
|
when admin insulin, get hypokalemia, need to give K+ with insulin
|
|
|
Hypokalemia and digitalis
|
makes digitalis more effective and more concentrated in the body
|
|
|
K+ and renal failure
|
do not give K+ with renal failure
|
|
|
False hyponatremia
|
hyperglycemia - glu acts as imposter and pull water into bloodstream. FALSE LOW SODIUM. Dilutional.
for every incr of 100g glu = should reflect ACTUAL incre of 1.4-1.6 in Na (add glu level to Na level to get actual Na level) |
|
|
relat. between CO2 and carbonic acid
|
need to maintain a 20:1 ratio
|
|
|
major organs of pH buffering
|
kidneys (metabolic) and lungs (respiratory)
|
|
|
Kidney regulation of pH
|
slow compensation
when bicarb down, regenerate bicarb OR when bicarb up, reabsorb bicarb from renal tubules |
|
|
Metabolic Acidosis regulation
|
low pH
Kidneys excrete H+ and conserve bicarb to restore balance |
|
|
Renal failure and acid balance
|
causes metabolic acidosis
|
|
|
Response to Metabolic Alkalosis
|
pH increases
Kidneys retain H+ and excrete bicarb to restore balance |
|
|
Response to Pulmonary Acidosis
|
when CO2 in blood increases, stimulates respiration = greater elimination of CO2 to lower acid load
|
|
|
Response to Pulmonary Alkalosis
|
CO2 levels down = lowers resp. rate = increases CO2 in blood and raises acid load
|
|
|
three types of blood protein
|
fibrinogin = clotting
albumin = colloid osmotic pressure globulin = immunology |
|
|
use of normal saline
|
flush wounds/GI tubes
|
|
|
bowman's capsule
|
role in filtration of molecules into urine...this is the reason we don't pee blood (RBCs are too big)
|
|
|
skin turgor evaluation
|
use sternum/forehead in elderly, hand in young
|
|
|
Creatinine
|
normal 0.1-1.4
higher is FVD lower is FVE |
|
|
cc equivalent of swelling/edema
|
2,500cc (five pounds)
|
|
|
pericardium
|
parietal = outer
serous/visceral = inner |
|
|
role of lubricating fluid between pericardial tissue layers
|
keeping the heart tissue from becoming inflamed
|
|
|
vena cava
|
inferior/superior: large veins where blood enters heart
|
|
|
diastole
|
heart muscle relaxes (dub)
|
|
|
systole
|
heart pumps blood out, ventricular muscles contract
|
|
|
Diastole
|
most of venous blood enters the Right Atrium
|
|
|
pulmonary arteries and veins
|
arteries carry deoxygenated blood
veins carry oxygenated blood |
|
|
Left ventricular pressure vs. Right ventricular pressure
|
LV works harder, walls are thicker, must pump to entire body
|
|
|
blood supply: aorta, coronary arteries
|
aorta: head, back, and major organs of digestion
coronary arteries: supply the heart muscle |
|
|
SA node
|
pacemaker: sends signal to L & R atrium = simultaneous contraction
|
|
|
AV node
|
received message from SA node, sends to AV bundle
|
|
|
AV bundle
|
receives signal from AV node and sends to R/L bundles and purkinje fibers
|
|
|
Purkinje fibers
|
receive message from AV node to R & L ventricles, which contract
|
|
|
Factors that affect Peripheral Resistance
|
Blood Vessel Diameter (vaso contriction/dilation), length of blood vessel (longer in obese people), viscosity of blood.
|
|
|
Catalysts that increase Peripheral Resistance
|
vasoconstriction of arteries
lengthening of blood vessels higher blood viscosity |
|
|
s/s of CV dysfunction
|
Right Side: fluid retention
Left Side: dyspnea both: fatigue, pain (ischemia) (won't see in diabetics, who have less pain reception) |
|
|
physical exam for s/s of CV dysfunction
|
postural changes, distress, dyspnea, edema, cyanosis around mouth, clubbing, heaves, JVD (R-side failure), listen for S3 and S4 (ventricular failure), scites, homan's sign (Deep Vein thromboses) pulses, coldness in hands/feet
|
|
|
Tropanin
|
GOLD STANDARD:
protein that releases from injured/dead heart muscle cells normal <.5 myocardial injury .5-.8 MI acute >.8 Rises in 4-6 hours after event Peaks in 10-24 hours Stays elevated for 10-14 days Reflect INJURY, not just death, can be used to interrupt MI process |
|
|
CK-MB
|
enzyme present when there is tissue necrosis.
ONLY REFLECTS CELL DEATH returns to normal in 48 hours (missable) >6% = MI |
|
|
Lipid Profile
|
IDs risk factors and influences drug choices
LDL= 80-190 HDL= 30-60 LDL:HDL = 3:1 |
|
|
Angiography/Ateriography
|
catheter to coronary arteries.
Dye injected, areas of poor perfusion = diminished uptake |
|
|
Cardio Catheterization
|
attains injection fraction (normal: 55-65%
detects coronary blockages: where, how much, how occluded? Checks for backflow and valve function <40% flow = CARDIAC FAILURE |
|
|
Nursing care for post-radiological testing
|
check bleeding at site
avoid hematoma (bruising) monitor blood flow in peripheral arteries in limb where procedure was done antiplatelet meds vasodilation meds If dye used, increase fluids to flush dye from system |
|
|
Components of an EKG/cardioelectrical impulse
|
automaticity
excitability Conductivity Contractility |
|
|
Normal PR interval
|
.12-.20 sec
|
|
|
Normal QRS interval
|
.04-.10 sec
|
|
|
Noraml QT Interval
|
0.34-0.43 sec
|
|
|
demopressin
|
decreases urine output for pts post neuro surgery
|
|
|
QRS interval <0.12 sec
|
bundle branch block: PVC
|
|
|
QRS Interval represents
|
ventricular repolarization
|
|
|
P to P =
R to R = |
arterial rate
ventricular rate |
|
|
small boxes on EKGs represent X seconds
|
.04
|
|
|
If see a Q-wave, indicates:
|
previous MI
|
|
|
Sinus bradycardia
|
HR <60
problems in SA node all else normal, constant |
|
|
sinus trachycardia
|
SA node problem
HR >100-180 P waves encroach on preceding T waves all else normal, constant treatement: beta-blockers, calcium channel blockers |
|
|
Atrial Flutter
|
Atrial muscle problem
a rhythm regular v rhythm is reg if block reg; varies if block varies A rate is 250-350 P wave: flutter (F) waves "saw-toothed" Treatment: drugs to slow ventricular response: digoxin, calc. chan blockers, beta-blockers. anti-arrhythmics |
|
|
normal atrial HR
|
40-60
|
|
|
atrial fibrillation
|
problem with atrial muscle
atrial rhythm irregular v rhythm TOTALLY irregular NO P-WAVES BIG RISK OF THROMBOSIS WITH A-fib and A-flutter. NEED ANTI-COAGULATION after 24-48 hrs |
|
|
Premature Ventricular Contractions
|
problem with Ventricular Muscle
irregularity, followed by pause rate varies P waves inconsistent, unrelated QRS wider than 0.14 Treatment: treat cause anti-dysrhythmics we all feel these when heart "jumps" |
|
|
PVD
|
premature ventricular contraction
|
|
|
ventricular trachycardia
|
three or more PVCs in a row
can't determine atrial rate v rhythm regular P-waves not visible AV dissociation QRS: wider than 0.14 Treatment: USUALLY AN EMERGENCY: check for pulse. V-tach = ACLS! |
|
|
ventricular problems result in:
|
wide QRS compels
no p-wave |
|
|
Ventricular Fibrillation
|
electrical chaos in the ventricles.
ventricular contraction cannot occur no cardiac output RAPIDLY FATAL ACLS! |
|
|
Asystole
|
ventricular standstill
complete absence of v rhythm no QRS FULL CARDIAC ARREST ACLS! |
|
|
SA node firing on EKG is the:
|
p-wave
|
|
|
from lecture: atrial flutter characterization
|
saw-toothed waves
p-t buried together NO ATRIAL KICK! ventricles fill passively and have low CO atrial does not beat in an organized fashion atrial doesn't fill ventricle no PR interval QRS normal at <.12 A rate: 220-430 pbm V rate: <300 bpm No Uniform Regular P-wave |
|
|
from lecture: a-fib charaterization
|
no discernable regular p-wave: P-wave looks FLAT
LOSE atrial KICK of 25% of output...ventricles filling passively ONLY "a-fib of 90" means 90 is V Rate (they don't count A rate) No PR interval! A rate: 350-650 pbm V rate: slow to rapid rhythm is irregular QRS normal at <.12 |
|
|
increased risks of rapid a-fib/a-flutter
|
V rate high
now have poor CO AND high HR BP will drop Pulse becomes thready She's in worse shape because has lower cardiac output AND low BP. |
|
|
EF warning signs (what % is a red flag)
|
<40% increases risk
|
|
|
further risks of a-fib and a-flutter
|
when pts go into a-fib and a-flutter, but CLOTS! Increases risks of emobolism/stroke
give pt blood thinner: heparin |
|
|
heparin "rule of thumb"
|
if pt has NEW a-fib/a-flutter for 48 hours, hang HEPARIN!
|
|
|
from lecture: Premature Ventricular Contraction (PVCs)
|
we all have these.
irregular stim. originating in the ventricular muscle. TOTALLY irregular QRS interval: WIDE (>.14) |
|
|
from lecture: v-tach
|
ventricular tachycardia: 3 PVCs in a row. Missed heart beats BECAUSE OF CONTRACTION BEFORE VENTRICLES FULL
big risk in situations with ischemia |
|
|
from lecture:v-fib
|
ventricular fibrillation: most deadly
electrical chaos in the ventricles ventricular contraction DOES NOT OCCUR NO CARDIAC OUTPUT: rapidly fatal (3-5 minutes) pt is pulseless |
|
|
from lecture:locations of inflammation of the heart
|
endocardium (inside)
pericardium (outside) entire heart |
|
|
from lecture: causes of infective endocarditis
|
IV drug use
previous mitral valve procedures dental procedures strep staph e.coli |
|
|
from lecture: s/s infective endocarditis
|
flulike symptoms
fever/night sweats weight loss fatigue cardiac murmurs back/joint pain heart failure |
|
|
pericarditis: leading to cardiac tampynod
|
inflammation of pericardium: if sac becomes too large and swollen, will start to squish heart and diminish CO and pump action
|
|
|
s/s of pericarditis
|
friction rub (heard on L sternal border)
pain in inspiration EKG shows ST segment/T-wave inversion fever and elevated WBC count |
|
|
atherosclerosis
|
build up of plaque (intima) in arteries, leading to coronary artery disease (CAD)
causes ischemia or infarction (necrosis) |
|
|
s/s of myocardial ischemia
|
anginal pain (often reversible at rest)
INVERTED T-WAVE |
|
|
s/s of myocardial injury
|
ST elevation (double hill)
|
|
|
s/s of necrosis
|
Abnormal Q
|
|
|
progress up to MI
|
atherosclerosis -> ischemia/angina -> myocardial injury -> MI
|
|
|
DM and cardiac risk CAD
|
DM increases the rate of plaque build up
|
|
|
hypertension and CAD
|
hypertension increases workload on heart, increasing risk of disease
|
|
|
angina pectoris
|
"strangling of the chest" = ischemia of limited duration, but can -> dysrhythmias -> MI
|
|
|
UNSTABLE angina
|
preinfarction
anginal symptoms at rest |
|
|
prinzmetal's/variant angina
|
spasm of the coronary arteries
(high risk among cocaine users) |
|
|
risks of angina
|
could dislodge antherosclerotic plaque
|
|
|
treatment of angina
|
want supply to equal demand
1. Nitrates: dilate Blood vessels (up supply) 2. Beta-2 blockers: decrease HR (down demand) AND decrease contractility (down demand) 3. Calcium channel blockers: vasodilate (up supply) AND decrease contractility (down demand) 4. Antiplatelet: prevent clots |
|
|
Beta blockers
|
decrease HR (down demand) AND decrease contractility (down demand)
|
|
|
Calcium channel blockers
|
vasodilate (up supply) AND decrease contractility (down demand)
|
|
|
time to full Necrosis of the heart from onset of Ischemia
|
6 hours
|
|
|
patho changes in MI
|
hypoxia -> stimulates vasodilation of blood vessels -> acidosis (K+ imbalance) -> suppresses AV node and contractile function -> automaticity and ectopy increase (can lead to arrhythmias)
AND catecholamines released in response to pain/hypoxia -> increases HR and contraction -> increase O2 demands -> necrosis |
|
|
anterior wall MI
|
25% of all MIs w/highest mortality rate
damage to L ventricular wall L ventricular failure and L ventricular arrhythmias |
|
|
s/s of heart failure/MI
|
pain unrelieved at rest
nitro does not releive nausea diaphoresis confusion/irritability shortness of breath weakness |
|
|
s/s of left side failure
|
sleep dyspnea
high PCWP blood-tinged sputum cough orthopnea exertional dyspnea cyanosis |
|
|
Preload
|
volume coming into ventricles (end diastolic pressure)
Inreased in: hypervolemia |
|
|
Afterload
|
resistance that the left ventricle must overcome to circulate blood
Increased in: hypertension, vasoconstriction when afterload goes up, cardiac workload goes up with MI, want to decrease afterload |
|
|
treatments to decrease oxygen demand to the heart
|
nitrates: decreases afterload
beta blockers: decrease HR, decrease arrhythmias, decrease contractility calcium channel blockers: used with ANGINA. Increase myocardial perfusion and dilates coronary arteries. decreases contractility and rate and vasospasm morphine: dilates arteries to decrease myocardial demand PUT PT IN SEMI FOWLER's POSITION to reduce CHF |
|
|
treatments to improve circulation to the heart
|
antiplatelet meds (heparin)
thrombolytics/TPA: clot busters PTCA (angioplasty with balloon) CABG: coronary artery bypass nitrates: for vasodilation |
|
|
stroke volume
|
60-80 spm
|
|
|
pathophysiological changes in heart failure: compensatory mechnisms
|
increased heart rate-> too fast means cardiac output may fail and heart muscle will tire
improve stroke volume: more stretch inmyocardial fibers (high preload) means greater force of contraction, so CO rises. Too much stretch will decrease cardiac output Aterial Peripheral vasoconstriction:blood shunted to major organs. too much will cause too great an afterload, which increases 02 demand by left ventricle. This may ultimately decrease stroke volume. retention of sodium and water: RAAS activated to increase blood volume returning to Left ventricle. Myocardial hypertrophy: thickening of walls, increasing the force of contraction and increases CO. problem is that blood supply to muscle may not be good enough and will become 02 deprived |
|
|
digoxin
|
oral agent that increases contractility of the heart (positive inotropic)
|
|
|
inotropy
|
influences contractility
|
|
|
% of cardiac output used by kidneys
|
30%, so if CO is low, will see <30cc/hr of urine
|
|
|
s/s of right sided failure
|
low stroke volume
peripheral edema low urine output (no blood volume to kidneys) distended jugular veins GI distress cyanosis dependent edema |
|
|
treatment of right-sided failure
|
NEED MORE PRELOAD
NO diuretics NO nitrates give her positive inotropic (enhance contractility on Right side) give her blood volume |
|
|
increasing contracility does XXX to 02 demand?
|
INCREASES 02 demand
|
|
|
s/s of left-sided failure
|
pulmonary edema
rales/crackles in lungs low cardiac output high heart rate low stroke volume |
|
|
treatment of left-sided failure
|
NEED MORE AFTERLOAD
diuretics positive inotropics to up contractility sit head of bed up in semi-fowler's decrease afterload (vasodilate) |
|
|
starling's Law
|
the more you stretch the myocardial muscle, the greater the force of contraction, so the better to cardiac output
|
|
|
Norepinephrin
|
ANS
raises BP through vasoconstriction |
|
|
Beta 1 Receptors
|
Baroreceptors
raises BP through increasing cardiac output |
|
|
Alpha 1 Receptors
|
Baroreceptors
raises BP through vasoconstriction |
|
|
Blood vessels and BP
|
determines peripheral vascular resistance, increase to increase BP
|
|
|
Angiotestin
|
RAAS
raises BP through vasoconstriction |
|
|
Parkland's Formula
|
4cc/kg/% of burn
1/2 in 1st 8hrs 1/2 in next 16hrs |
|
|
DKA
|
FVD
hyperkalemic |
|
|
Digitalis and potassium
|
dig with low potassium means pt blacks out...bad Drug Interaction
|
|
|
P-Wave
|
A contraction
|
|
|
QRS
|
V contraction
|
|
|
lasix and potassium
|
lowers potassium, check before putting a pt on lasix
|
|
|
ringer's lactate
|
surgical pts, burns
|
|
|
hospital "normal" IV
|
D5 1/2 normal saline
|
|
|
Hyperkalemia and EKG
|
peaked T-waves
|
|
|
Hypokalemia and EKG
|
U-wave
|
|
|
Hyperkalemia and PH
|
acidosis
|
|
|
Hypokalemia and PH
|
alkalosis
|
|
|
CO2 and PH
|
higher CO2 raises ACID LEVELS, lowers PH
|
|
|
Kayexalate "dog"
|
ion exchange resin, so gets rid of K+ and BRINGS IN Na+...don't use on pt with poor heart
|
|
|
brown urine
|
hyperkalemia (cells are lysing)
|
|
|
Bicarb "dog"
|
cardiac, because increases salt load
|
|
|
NG tube irrigation
|
ISOTONIC = normal saline
|
|
|
Tube feeding and dehydration
|
water down IV with H2O
|
|
|
Ischemia and EKG
|
t-wave changes
|
|
|
how to up O2 supply
|
vasodilate:
nitrate morphine O2 |
|
|
quick formula for serum osmolality
|
Na x 2
|
|
|
s/s of A-fib
|
Dizzy/faint
weak |
|
|
A-Fib EKG
|
no p-wave
irregular r-r interval |
|
|
aortic/pulmonic valves are...
|
semi-lunar valves
|
|
|
mitral/tricuspit valves
|
AV valves
|
|
|
major organs with:
Potassium FVE Na |
K+ is heart...think kidney problem
FVE: protest the brain from swelling Na: think brain |
|
|
CVP Normal
|
2-6 mmHg
|
|
|
PCWP Normal
|
8-12 mmHg
|
