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185 Cards in this Set
- Front
- Back
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Electrode Placement 3 Lead |
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Electrode Placement 5 Lead
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snow over grass
smoke over fire white on right |
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Bedside Monitoring -EKG |
Only shows electrical activity Single lead shows: -rate & regularity -time to conduct an impulse
NOTE: it does NOT: -identify/locate an infarct -identify axis deviation or chamber enlargement -identify right to left differences in conduction -the quality or presence of pumping action |
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The conduction system: Pacemaker |
-SA Node Pacemaker back-ups -AV Node (heart beats 40-60 beats/min) -Ventricular cell (heart beats 20-40 beats/min) |
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The conduction system: Rhythm |
P wave: atria contract
QRS: ventricles contract T wave: reversal of ions |
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ECG PAPER |
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PR time interval |
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Normal Intervals |
P-R 0.12-0.20secs
QRS 0.08-0.11 (<.12) Q-T 0.33-0.42 |
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Systematic Analysis |
-regularity of rhythm -determine the heart rate -presence & appearance of P waves -measure the PR interval -measure the QRS duration -use data to interpret the rhythm |
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Regularity of rhythm |
R-R determines regularity Are they spaced out the same? Yes? The rhythm is regular. |
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Rate |
In a 6 second strip, count QRS complexes and add zero. |
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P waves |
Are P waves present? Are they similar? Are they upright? Does each P wave have a QRS complex? Is the P wave the same distance from the QRS complex in each beat? |
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PR Interval |
PR interval should be 0.12-0.20 seconds |
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QRS complex interval |
should be less than 0.12 seconds |
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Name the rhythm |
Naming the Rhythm is: Last step in systematic analysis |
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Dysrhythmias originating in the SA Node |
Sinus Bradycardia Sinus Tachycardia Sinus Dysrhythmias |
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Sinus Bradycardia: Rules of Interpretation |
Rate: <40 Rhythm: regular (R-R) pacemaker site: SA Node p waves: upright & normal PRI: Normal .12-.20 QRS: Normal <.12 |
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Sinus Tachycardia: Rules of Interpretation |
Rate: >100 rhythm: regular (R-R) pacemaker site: SA node p waves: upright & normal PRI: Normal .12-.20 QRS: Normal <.12 |
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Sinus Dysrhythmia: Rules of Interpretation |
Rate: 60-100 rhythm: Irregular (R-R) pacemaker site: SA node P waves: upright & normal PRI: Normal .12-.20 QRS: Normal <.12 |
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Causes of Sinus Bradycardia <60 HR |
-beta blockers -morphine -vomiting -athlete -sleeping NOTE: contact physician if s/s occur -syncope -SOB -decreased BP -chest pain Head of bed up and place on oxygen |
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Causes of Sinus Tachycardia HR>100 |
-pain -anemia -dehydration -fever -infection -hypothyroidism -caffeine TX: treat stressors |
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Dysrhythmias originating in the Atria |
Premature Atrial Contractions (PAC) Paroxysmal Supraventricular Tachycardia (SVT) Atrial Flutter Atrial Fibrillation |
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Premature Atrial Contractions: Rules of Interpretation |
rate: depends on underlying rhythm rhythm: usually regular except for PAC pacemaker: ectopic sites in atria p waves: occurs earlier than expected PRI: varies dependent of foci of impulse QRS: usually normal |
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Premature atrial contractions |
Does not wait for SA node to fire, irritable atrial cell. NOTE: An earlier beat than normal. More common w/women. Causes: fluid overload/fatigue |
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Paroxysmal Supraventricular Tachycardia: Rules of Interpretation (SVT) |
rate: 150-250 rhythm: regular pacemaker: atrial/outside SA node P waves: often buried in t wave PRI: usually normal (.12-.20) QRS: usually normal (<.12) |
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Paroxysmal Supraventricular Tachycardia (SVT) (sudden-------above ventricle----rapid) |
TX: Adenosine -vagal stimulation -carotid massage -pressure on eyeballs -beta blockers, diliatazem (decrease HR) -ablasion (go into heart and zap heat/cold) Causes -stress -fatigue -caffeine -alcohol -pms -fluid overload |
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Supraventricular tachycardia (SVT) |
Rapid, narrow QRS HR 150-250 TX: ADENOSINE |
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Adenosine (Adenocard) -only for SVT |
Action
-slows conduction through AV node -interrupts re-entry -will not convert aflutter or afib -give rapidly IV push, follow w/saline flush S/E -brief period of asystole -flushing, headache, lightheadedness, dizziness, nausea, SOB, rarely chest pain NOTE: rush of blood to head. STOPS then STARTS your heart again. |
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Adenosine (SVT) |
NOTE: has to be given rapidly because it is not metabolized by kidney or liver. It is broken down by RBC. Brief period of asystole. |
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Atrial Flutter: Rules of Interpretation |
rate: atrial rate 250-350, ventricular rate varies rhythm: usually regular (R-R) pacemaker: atrial (outside SA node) P waves: f waves present (no p waves) PRI: usually normal (.12-.20) QRS: usually normal (<.12) |
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Atrial Flutter |
-Impulse travels to atria over and over -atrial activity over 300 beats/min -we need to slow down electrical conductivity Causes: -heart failure/atrial stretch -alcoholism -hyperthyroidism -ischemic heart disease TX: -amiodorone -beta blockers -if no blood clot present, send electrical shock to heart |
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Atrial Fibrillation: Rules of Interpretation |
rate: atrial rate 350-750, ventricular rate varies rhythm: irregular (R-R) pacemaker: atrial (outside SA node) p waves: none discernible/f waves present PRI: None QRS: Normal (<.12) |
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Atrial Fibrillation |
-f wave quivering -precedes stroke in a lot of people -irregular HR, need more than 6 sec strip Causes: -alcoholism -hypo/hyperthyroidism |
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Treatment of AFIB & AFLUTTER Note: Afib can lead to stroke |
-rate control (decrease HR) -prevent thromboembolism (anticoagulants) -rhythm control (convert back to sinus) chemical direct current cardioversion catheter ablation |
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TX of Afib and Aflutter (Rate Control) |
Beta blocker -esmolol (Brevibloc) -metroprolol (Lopressor) -propranolol (Inderal) -carvedilol (Coreg) -atenolol (Tenormin) Calcium Channel Blockers -verapamil(Isoptan, Calan) -diltiazem (Cardizem) drip Digoxin (Lanoxin) Amiodarone (Cordarone) |
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Diltiazem (Cardizem): Action (Afib & Aflutter) |
-Inhibits movement of Ca across cardiac and arterial muscle -slows cardiac conduction -decreases contractility -dilates coronary arteries |
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Diltiazem (Cardizem) (Afib & Aflutter) |
Control rapid ventricular response Aflutter, Afib, SVT) Administration: IV infusion then oral |
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Diltiazem (Cardizem) (Afib & Aflutter) |
Interventions -Monitor VS -Cardiac monitor (hypotension) -Stop! HR < 50 Heart block (brady) acute heart failure (CHF) |
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TX of Afib and Aflutter: Prevent thromboembolism |
Vitamin K agonist: warfarin (Coumadin) -target INR 2.0-3.0 unless age >75 (1.6-2.5) -antidote: Vitamin K Heparin or enoxaparin (Lovenox) -until therapeutic warfarin or when surgical procedures -target PTT: 60-75 sec -antidote: protamine sulfate Direct thrombin inhibitor: Dabigatran(Pradaxa), rivaroxaban(Xarelto), apixaban(Eliquis) go home on these -no anticoagulation studies -NO antidote |
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TX of Afib and Aflutter: Cardioversion |
-Timed electrical shock to stop re-entry -Sedation -Emergency equipment -Anticoagulants for 3-4 week prior to and following after unless <48 hours from onset and no evidence of thrombus |
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TX of Afib and Aflutter: Catheter Ablation |
-to maintain SR in patients w/tx failure -best outcome if performed in an experienced center (perform > 50 ablations per year) -no evidence-based guidelines on procedure operator |
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Lariat Procedure: Afib |
-tie off atrial appendage, the primary source of blood clots in atrial fib -Approaches open heart cath lab -percutaneous ligation -cardiac plug |
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Complimentary or alternative therapy: Heartmath |
studying energy fields |
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Dysrythmias originating in the ventricles |
-Ventricular Escape Complexes and Rhythms -Premature Ventricular Contractions (PVC) -Ventricular tachycardia -Ventricular fibrillation -Asystole -Artificial Pacemaker Rhythm |
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Ventricular Escape Complexes and Rhythms: Rules of Interpretation |
rate: 15-40 rhythm: escape complex, irregular; escape rhythm, regular pacemaker: Ventricle P waves: None PRI: None QRS: 0.12 seconds or wider, bizarre |
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Ventricular Escape Complexes and Rhythms (no p wave, no atria action, no pr interval, wide QRS complex, rate 15-40) |
-ventricular cell is pacemaker -conduction in ventricles is abnormal -didn't come down conduction system properly so QRS is wider -need to increase HR -epinepherine -pacemaker -CPR if no pulse NOTE: No P wave, No PR interval |
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Premature ventricular contraction (PVC): Rules of Interpretation |
rate: underlying rhythm rhythm: interrupts regular underlying rhythm pacemaker: Ventricle P wave: None PRI: None QRS: >.12 seconds, bizarre |
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Premature Complexes: PVC (big fat & ugly QRS) Causes: electrolyte imbalance, ischemia |
unifocal PVC: every PVC that interrupts regular underlying rhythm is the same multifocal PVC: there is more than one kind of PVC interrupting regular underlying rhythm. bigeminy PVC: every other beat is PVC trigeminy PVC: every third beat is PVC |
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Unifocal PVC |
one area of the heart has irritability -less worriesome |
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Multifocal PVC |
-more worrisome PVC -2 areas of heart with irritability |
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Bigeminy PVC |
- every other beat PVC |
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Trigeminy PVC |
-every third beat is PVC |
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Ventricular Tachycardia (VT) |
3 or more PVC's = VT -Runs of VT are more worrisome |
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Ventricular Tachycardia: Rules of Interpretation |
rate: 100-250 rhythm: usually regular pacemaker: ventricle p waves: usually absent, if present, not associated with QRS PRI: None (no p wave) QRS: wide >.12 (ischemia) |
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Ventricular Tachycardia (VT) |
TX depends on what patient presents like.... -unstable, not feeling well, pale diaphoretic, chest pain CARDIOVERSION (stop it before gets worse) -stable, awake, asymptomatic Oxygen, 12 lead ECG, call RAPID, amiodorone, magnesium.....and so on -pulseless VT defibrillation, CPR and so on |
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Ventricular Fibrillation: Rules of Interpretation |
rate: no organized rhythm rhythm: no organized rhythm pacemaker: numerous ventricular foci p waves: usually absent PRI: None QRS: None |
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Vfib NO CARDIAC OUTPUT CODE -ventricle cells are firing whenever they want. |
LOOK AT YOUR PATIENT, ARTIFACT? -Call CODE -the definitive tx: defibrillation -epinephrine (stimulate heart/jump start) |
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Defibrillation |
-Asynchronous countershock depolarizes myocardium to allow SA node to regain control. -stops all electrical activity @ heart. -converts back to sinus rhythm -early defib increases the chance of survival Types -AED -Manual -Implanted -External vest |
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Asystole: Rules of Interpretation |
rate: no electrical activity rhythm: no electrical activity pacemaker: no electrical activity p waves: absent PRI: absent QRS: absent |
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Asystole |
TX: -CPR -epinephrine -look for other causes/fix them hypovolemia (fluids) tension pneumo(lung collapsed on vent) cardiac tamponade (fluid around pericardium) hypoxia (oxygen/good cpr) |
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Artificial Pacemaker Rhythm: Rules of Interpretation |
rate: varies w/pacemaker rhythm: regular/irregular pacemaker: depends on electrode placement p waves: may or may not be present; pacemaker spikes PRI: If present, varies QRS: >.12 seconds, bizarre (wide) |
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Artificial Pacemaker Rhythm |
-not tested for clinical setting -wide QRS -Pacemaker telling heart to contract -look for pacing spikes on strip |
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Pacemakers |
Temporary (Bridge for s/s-pace right away) -transcutaneous (skin/muscle) -external (subclavian to heart) -epicardial (wires put in @ open heart, wires outside body can be paced) Permanent -ventricular -atrial-ventricular -biventricular (both ventricles) |
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Pacemakers Precautions |
-incision care -restrict arm motion for 1-2 months (pacer to scar into place) -avoid electromagnetic fields (MRI, leaning over running car engine) -regular follow up |
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Pulseless Electrical Activity -no P waves -CPR, epinephrine, treat the causes |
-electrical activity without mechanical activity SVT on monitor but pt is dead/no pulse sinus bradycardia with no pulse -treat the cause hypovolemia tension pneumothorax cardiac tamponade hypoxia |
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Xtra credit on exam: Dysrhythmias originating within the AV Junction |
First-Degree AV Block Second-Degree Type 1 AV Block Second-Degree Type 2 AV Block Third-Degree AV Block |
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First-Degree AV Block (Partial block) |
First-Degree AV Block -Partial block -PRI longer than normal >.20 (otherwise looks normal) AV holding pulse/electrical, longer than normal NO TX for First-Degree AV Block |
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Second-Degree Type I AV Block AKA: Wenckebach -do not treat this one -if symptomatic - pacemaker |
-P waves: normal, some P waves not followed by QRS -PRI: Increases until QRS is dropped, then repeats P_R QRS, P__R QRS, P___QRS, QRS Dropped NOTE: PR interval gets longer with every beat, then QRS gets dropped and it starts all over again. |
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Second-Degree Type II AV Block tx: pacing, maybe atropine block is in bundle of his(septal) causes: anterior MI, cardiac surgery close to septum of heart |
-PRI always stays the same -some P waves not followed by QRS may be > .20 |
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Third-Degree AV Block complete block tx: pacemaker causes: inferior MI |
-SLOW HR (important clue to recognize) -Wide QRS -PRI has no pattern -AV node not working at all |
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Removes old and imperfect RBCs and WBCs |
Spleen |
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Main producer of many clotting factors |
Liver |
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Stores RBCs and platelets |
spleen |
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Produces most cells of the blood |
bone marrow |
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Breaks down hemoglobin |
spleen |
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Phagocytizes foreign material |
liver |
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Transports oxygen to cells |
RBCs |
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Defends against infection...... |
WBCs |
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Production is stimulated by erythropoetin... |
RBCs |
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Maintains hemostasis |
Platelets |
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Normal level platelets |
150,000-400,000 |
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Normal level WBCs |
5,000-10000 |
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Bone Marrow Testing |
Aspiration -cells & fluid -painful pulling sensation Biopsy -core sample of solid tissue and cells -pain with needle rotation Position -pt supine for sternum -left sideline for iliac crest NOTE: bedside/lab/office, done anywhere |
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Bone marrow testing |
pre procedure -informed consent -positioning -sedation (versed,conscious sedation) post procedure -pressure to site (if pt had right side done, pt lays on right side/same as dressing) -observe dressing for bleeding for 24h -mild analgesic and ice packs -no contact sports for 48h -no aspirin (bleeding) -Q15 for 1hr, Q30 for 1hr, Q4 Vitals (like any procedure or surgery) - |
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Anemia (lacks healthy RBC) |
A condition that develops when your blood lacks enough healthy RBCs Reduced # of cells -blood loss -decreased production (kidney disease, decreased erythropoietin, hypothyroidism) -increased destruction (chemotherapy, prosthetic valves) Unhealthy Cells: -sickle cells -vitamin or iron deficiency (folic, B12) -bone marrow problems (lead poisoning) |
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Anemia Manifestations think: brain wants more oxygen |
Integument -pale skin -cool skin -brittle nails (clubbed) Cardiovascular -tachycardia (heart cranking away to deliver) -murmur & gallop -orthostatic BP (especially after meals, fluid shifts to digestive system after meals) Respiratory -dyspnea -decreased Oxygen (many times not decreased) (unreliable indicator because hgb could be decreased with good Sa02) Neurologic -fatigue (lack of oxygen to brain) -headache |
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Sickle Cell Disease (low oxygen, sickled red cells clump together occluding small blood vessels) |
-When exposed to low oxygen levels, HbS changes RBC from round to sickle shape. -cells clump, block blood flow, cause tissue hypoxia and eventual organ damage. -If oxygen problem corrected, will return to somewhat normal shape. Note: 40% total Hgb abnormal=HbS, rounded shape when not with oxygen |
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Sickle Cell Problems |
-Sickle cell disease: person has genetic disorder -Sickle cell trait: 1 abnormal gene(under stress may exhibit symptoms of sickle cell anemia) -Sickle cell crisis: sudden onset of excessive sickling. Frequent/infrequently. -decreases Quality of life and could cause organ damage/failure Note: the disease is 2 abnormal genes |
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Sickle cell Anemia Manifestations |
-increased HR, S3, hypotension, SOB, weakness -pale, jaundice -decreased LOC, behavior changes -decreased Hgb and Hct, increased Retic & MCHC |
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Sickle Cell Obstruction Manifestations
(sickled red cells clumped together occluding small vessels, low 02) |
-Pain @ abdomen, back, legs, joints -absent or distant pulses -cyanosis, leg ulcers -firm enlarged liver & spleen -pain, degenerative changes -s/s stroke, seizures -increased WBC |
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Sickle Cell Nursing Diagnosis |
-acute pain -chronic pain -RC: Sepsis -RC: Multiple Organ Dysfunction |
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Acute Pain Interventions: Sickle Cell |
-assess pain level (where is it?, 1-10) (PCA pump) -humidified O2 (they are dehydrated) -hydration IV: D5 .45 (250ml/hour for 4h, then drop to 125ml/hour) do not use 0.9NS oral: anything/noncaffeinated -avoid cold temps/triggers sickling Enhance circulation -no restrictive clothing -positioning (no bends, lay flat, do not curl up, we do not want clumps to form in bends to occlude vessels) -temperature (72 degrees or warmer) (NO COLD-vasoconstricts) -Assess Pulses (wrist and feet) -minimize BP |
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RC: Sepsis (Sickle Cell) |
Prevention -handwashing -aseptic technique Detection -assess for s/s -Q4H temp -monitor WBCs -BP not done often (prevent clumping) Drug therapy -vaccinations (prevent infectious disease) -antibiotics Note: decreased spleen function (1st organ to be affect in sickle cell - splenectomy?) |
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RC: Multiple Organ Dysfunction (Sickle Cell) |
Interventions to prevent multiple organ dysfunction Transfusions -could result in iron overload Hydration -oral fluids (4L/day) -dehydration triggers sickling |
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Sickle Cell |
Always think: Prevent occlusions by preventing clumping and obstruction
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Thalassemia (Mediterranean Basin-Turkey, Italy, SE Asia) |
Inherited anemia Forms -minor -major fatal in 1st year if not diagnosed, need regular blood transfusions, can live full adult life(used to be up to 30 years of age), watch for iron overload w/blood transfusions |
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Thalassemia tx (Major) |
TX: Major -RBC transfusions -chelation therapy (painful, thick, awful) -CURE: BONE MARROW TRANSPLANT NOTE: defected synthesis Hgb. RBC rigid, do not bend and flow through smaller vessels that well, and premature cell destruction. |
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Hemolytic Anemias |
Glucose 6 Phosphate Dehydrogenase Deficiency -early cell breakdown -hydrate Immunohemolytic -attack self -immunosuppressive drugs |
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Deficiency Anemias (iron deficiency-common in older adults and menstruating women) |
Iron -poor diet -poor absorption -blood loss Treatment -food: red meat, whole grains, leafy greens, egg yolks, raisins -supplements |
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Deficiency Anemias (B12 deficiency) |
Causes -poor intake, poor absorption, lack of intrinsic factor in stomach, needed for B12 absorption) TX -meats, beans, leafy greens, citrus -supplements |
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Deficiency Anemia (Folic Acid deficiency) |
Cause -common in alcoholics, poor diet, anticonvulsants, Crohns disease (malabsorption disease), oral contraceptives TX -meat, leafy greens -supplement |
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Iron supplements (iron deficiency anemia) |
-taken on empty stomach is ideal but if it is not tolerated Vit C enhances absorption so take with orange juice. -causes GI upset frequently on empty stomach -stools will be dark green or black -can stain teeth and subcutaneous tissues (liquid form can stain back of mouth) -IM use Z track method to prevent permanent skin discoloration -IV can cause hypotension and flushing, first dose anaphylaxis |
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Iron supplement Examples |
Oral (upset stomach) -ferrous fumarate -ferrous gluconate -iron polysaccaride IM -iron dextran (Imferon) Z track/permanent discoloration IV (brown color) -iron dextran -iron sucrose (Venofer) -sodium ferric fluconate |
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Vitamin B12 supplements -pernicious anemia (lack of intrinsic factor) -antidote for cyanide poisoning |
Implications/precautions -intrinsic factor needed for GI absorption, usually administered IM, subcutaneously, or intranasally -lifelong replacement therapy -may turn skin and urine red for 2-5 weeks Examples: -cyanocobalamin (nascobal) -Hydroxocobalamin (cyanokit) |
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Folic Acid Deficiency (tx of megoblastic and macrocytic anemias) |
Implications/precautions -may turn urine more yellow -frequently in combination with other vitamins
Examples -folate -folvite PO, IM, IV, SubQ |
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Aplastic Anemia (RBC and platelet problem) |
-Failure of bone marrow to produce RBCs Manifestations -petechiae (platelet problem too) -ecchymosis (platelete problems too) TX -bone marrow transplant |
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Blood Loss Anemia |
Cause -nose bleeding/trauma/blood loss Manifestations -same as others (pale & cool skin, brittle nails, tachycardia, SOB, fatigue, and headache....) -decreased MVC, ferritin, and iron TX -transfusions -iron replacement |
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Polycythemia Vera |
-sustained elevation of RBCs -may also have elevated WBCs and platelets, thick, trouble flowing, thrombus formation -fatal if levels increased for too long manifestations -reddish, flushed skin -veins distended -thrombosis (abdominal pain, liver enlargement/spleen enlargement) -increased K+ and uric acid levels. Cells break down(cells trying to get through narrow vessels) -itching, tingling (body tried to dilate vessels) |
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TX: Polycythemia Vera |
-need fluids to thin blood -anticoagulants aspirin -no restrictive clothing -no extreme temps (hot/cold) -Phlebotomy (take blood out 2x week and up to 5x a week) this blood cannot be used by anyone else -fatal if levels increased for too long |
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Manifestations of anemia do not include..... |
orthostatic hypertention Note: anemia manifestations -headache & fatigue -intolerance to cold -tachycardia after meals -orthostatic hypotension |
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If one parent has sickle cell disease and the other carries the trait, their children..... |
S S S s May have the trait: Ss May have the disease: SS Note: 2 abnormal genes are needed for disease. |
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The priority nursing diagnosis for a patient in a sickle cell crisis is...... |
Acute Pain |
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A statement that requires further clarification.... |
Alcoholic beverages are a good source of folic acid. No. It is not. A good source of folic acid is MEAT and LEAFY GREENS or a supplement. |
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True statements |
-Organ meats and leafy greens will help all 3 types of deficiency anemia. -Carrots and raisins are a good source of iron. -Citrus fruits are a good source of B12. |
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Transfusions Note: 1 unit of blood = an increase of 1Hgb, if not, pt might be bleeding |
Whole blood -stabilize trauma victims faster, not used in the U.S. Packed RBCs -increased RBCs, stabilize Hgb and oxygenation -must be ABO & RH compatible -infuse over 2-4 hours -max hang time for packed cells is 4 hours Washed RBCs -patients can get allergy to proteins from receiving blood transfusions. Minor proteins have been removed. This < allergic reaction. -aren't common. -for pts with sensitivities to minor proteins Granulocytes -WBC that are used for neutropenic pts. -anytime WBCs are given, pt has some type of reaction to them and that's why they aren't given that often. Mostly given in the oncology unit, Icu, or a specialty unit. -Pts experience chills, pain in joints and abdomen -they increase WBC count when pts have hard time fighting infection in the body. -controversial because of S/E |
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Transfusions |
Platelets -restores hemostasis & stops bleeding -No compatibility testing for ABO and RH. -goes in over 15-30 minutes. -goes in quick or will clot -kept chilled and results in pt being cold too -FYI 10 units=10 different donors Fresh Frozen Plasma (FFP) -coagulation factor, provides clotting factor, helps with bleeding -replaces blood volume -FFP requires ABO compatibility, NO RH -infuses over 30 min - 1hr Cryoprecipitate -for pts with fibrinogen level of less than 100mg/dL -given IVPush within 3 minutes (QUICKLY) -best if ABO compatible -given to hemophilia pts -for specific clotting disorders Albumin (protein) -low protein states -burn victims -digestive abnormalities -pulls fluid into blood stream -5% and 25% two types -infused at 10ml/hr, could cause fluid overload -ABO not required |
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Transfusions Indications for tx |
Packed RBCs -anemia -low hgb Washed RBC -hx of allergic reaction Platelets -thrombocytopenia, platelets<20,000 -pts who are actively bleeding with platelet count of <80,000 FFP -deficient in plasma coagulation factors -Pt or PTT 1.5 times normal Cryoprecipitate -hemophilia -fibrinogen <100 WBCs -sepsis -neutropenic infection not responding to antibiotics |
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Transfusion Reactions: Hemolytic -ABO or Rh incompatibility -wrong blood given/human error -life threatening |
Manifestations
-increased HR, increased RR, decreased BP (shock) -apprehension, impending doom -pain in chest, back head TX -STOP THE BLOOD!!! Note: cells hemolyzing, cell destruction in body, plugging up vessels, urine bloody |
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Type & Screen |
-verify blood type -make sure blood bank has it |
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Type & Cross |
-pt blood mixed w/blood bank blood -reaction or no reaction? -safe to give to patient? |
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Transfusion Reaction: Allergic |
-urticaria, itching, bronchospasm -antibody reaction tx -symptomatic -benadryl |
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Transfusion Reaction: Febrile |
-chills, fever, increased HR, increased RR, decreased BP -antibody reaction -not as severe as hemolytic reaction |
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Transfusion Reaction: Bacterial |
-rapid onset of sepsis -transfusion contaminated |
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Transfusion Reactions: Circulatory Overload |
Manifestations -crackles, SOB, JVD, low Sa02, increased RR, bounding pulse, restlessness, confusion TX -diuretic Prevention -infusing slow, over 2-4 hours Note: to prevent fluid overload sometimes blood is given along with Lasix |
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Multiple Transfusions: Complications |
Acute -hyperkalemia (during transfusion cells are damaged and K+ is released from cell, this raises the pt's serum K+. The longer the blood is stored the greater cell breakdown = increased serum K+.) -hypocalcemia (citrate preservative binds with Ca+, after transfusion pt is hypocalcemic. Chronic -Iron Overload (blood transfusions leave pts with increased iron levels. This causes heart damage, heart failure, and impairs thyroid function. -Infection Red cross or whoever is blood bank is not able to screen for every infection therefore pt could potentially be left with infection. |
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National patient Safety Goals & Quality Standards for Transfusions |
1. informed consent 2. Pre-transfusion measure for specific product -hgb & hct, clotting times, platelets 3. verification process -by 2 people, or one person & bar code, one must be a qualified transfusionist (RN) 4. documentation -order to transfuse, pt identification, VS @ specific intervals -vs before transfusion -vs 15 min after start -vs @ end of transfusion 5. Pre-surgical screening (type & screen) -hysterectomy, orthopedic, cardiac surgery (increased blood loss surgeries) |
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The patient with O+ blood is in need of an emergency transfusion but the lab does not have any O+ blood. Which unit of blood could be given to the patient? |
O- |
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Which nursing task could be delegated to an unlicensed nursing assistant? |
Assist a pt who received 10 units of platelets with brushing his teeth. Note: Nothing to do with assessments |
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Shock |
-The whole body's response to poor tissue oxygenation -started by any condition where oxygen delivery to the tissues is impaired |
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Physiologic causes of shock |
1. pump failure-tissues don't get oxygen,heart attack, cardiac tamponade, dysrhythmias 2. volume loss-no blood to circulate to tissues, burns leaking proteins, vomiting, diarrhea 3. loss of vascular tone -brain injury, no regulation of vascular tone and dilation, spinal trauma (receptors aren't working) -anaphylaxis (allergies, capillaries dilated, vasodilation through entire body -sepsis vasodilation, fever Note: more than one can occur at the same time |
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Physiologic causes of shock |
pump failure volume loss loss of vascular tone Note: more than one may occur at the same time |
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Common Pathway (simplified): Shock |
Widespread impaired cellular metabolism -decreased oxygen delivery --anaerobic metabolism--depletion of ATP--impaired Na/K pump--depressed cell function -decreased glucose delivery--cells shift to glycogenolysis, lipolysis & gluconeogenesis--cells cannot repair----ammonia toxicity cell death Note: lack of oxygen---lack of glucose = cell death Cells need two things to function: oxygen and glucose. This allows cells to generate energy and do their specific job. |
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Common Symptoms: Shock (decreased oxygen and glucose to cells) |
Neurologic Respiratory -restlessness -increased RR _anxiety -shallow breaths -confusion -lethargy Metabolism -decreased temp(shock) Cardiovascular -(increased temp(sepsis) -increased HR -thirst -thready pulse -acidosis(anaerobic m) -decreased BP -decreased urine output -decreased CO Skin -pale -clammy -cool |
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General Treatment Priorities (Shock) |
Medical Emergency -911 or rapid response (home & hospital) -02: whatever needed (NC, NRM, Vent) -IV access -Monitor (cardiac monitor and Sa02) Identify the cause: -vasopressors -antibiotics |
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Mean arterial pressure (are organs getting perfused?) |
Average arterial pressure Formulas -MAP = diastolic +1/3 pulse pressure -MAP = 2diastolic + systolic/3 Normal (70-110mmHg) <60mmHg = organ ischemia >60mmHg = organs getting perfused |
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Physiologic causes of shock include: |
-pump failure -volume loss -loss of vascular tone (more than one may occur at the same time) |
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Common symptoms of shock include: |
-change in LOC -Tachycardia -rapid respirations --decreased urine output |
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A patient demonstrates common symptoms of shock. Prioritize the following actions.... |
Call rapid response Oxygen IV fluids treat dyshrythmias |
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Mean arterial pressure should be maintained about 60mmHg to prevent organ ischemia.... |
True |
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Hypovolemic |
Decreased blood volume -burning, bleeding, diarrhea, vomiting, severe dehydration Manifestations depend on the stage -initial -non-progressive or compensatory -progressive or intermediate -refractory or irreversible |
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Initial Stage of Shock |
Compensatory Response (hard to tell, not detectable) -MAP decrease from baseline (5-10mmHg) -Brain activates sympathetic nervous system -Adequate organ perfusion Manifestations -increased HR -increased RR -BP (normal/slight increase diastolic pressure) |
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Non-Progressive or Compensatory Stage Shock |
Compensatory Response -MAP decrease from baseline (10-15mmHg) -kidneys release renin (we need fluid!!!) -brain releases ADH, aldosterone, epinephrine and norepinephrine (retain fluid & vasoconstrict in hopes of increasing BP) -acidosis and hyperkalemia result due to anaerobic metabolism(low 02/lactic acid and cell destruction = hyperkalemia) Manifestations -increased HR, increased RR -decreased BP -pulse ox 90-95% (lowering) -decreased urine output (need it for BP) -decreased PH (low 02 = lactic acid) -hyperkalemia (cell destruction, K+ falls out) -pale cool skin (vasoconstricting)(help BP) Treat the cause -bring them back -IV fluids (stabilize BP) -Antibiotics (infection) Note: During this compensatory stage Brain and Heart try to preserve themselves to get the 02 they need, however, kidney and lungs do not receive the 02 they need during anaerobic metabolism. Brain and Heart come first! |
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Progressive or Intermediate Stage Shock |
Compensatory response -MAP decreased from baseline(20mmHg or more) -severe vasoconstriction -vital organs become hypoxic (brain & heart) -non vital organs are anoxic (BAD!!!) -Only one hour to fix! Manifestations -decreased BP -0 urine output (kidneys are done) -pulse ox 75-80% -confusion, lethargy, weakness |
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Progressive or Intermediate Stage summed up |
-SEVERE vasoconstriction -Vital organs are now hypoxic (heart & brain) -non vital organs are anoxic (dying) -BP is low -Kidneys shut down (zero urine) -Sa02 @ 75-80% (not good) -confusion, lethargy, weakness (brain needs more oxygen) |
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Refractory or Irreversible: Final stage shock |
Compensatory response -cell death & tissue damage -multiple organ dysfunction (MODS) -death (inevitable) Manifestations -decreased BP (BP tanked, only palpable @ systolic, no diastolic, example: 50 palpable) -pulse ox <70% -0 urine output (kidneys still dead) -unconscious patient (brain done) -0 reflexes (brain done) Note: Life support until family decides when to pull the plug |
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Hypovolemic Shock Treatment |
-oxygen (NC, NRM, vent, whatever is needed) -Restore volume crystalloids - purely volume loss, these are our IV fluids..... colloids-blood products, blood loss from burns -vasoconstrictor drugs norepinepherine (levophed, increase BP) epinephrine-IV infusion, not IV push dopamine (intropin) - IV infusion (NOTE: sometimes causes arrhythmia problems) |
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Necrosis from Extravasation (IV infusion/meds leak into the extravascular space/tissues) |
Prevention -closely monitor IV site -if subcut phentolamine (Regitine) to tissues IV cannula before removal clockwise to tissues Note: Regitine is antidote and needs to be put in IV catheter before removal and then injected clockwise into the sore to vasoconstrict. |
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Cardiogenic shock (pump failure) Note: extreme end of CHF |
causes
-pump failure MI Dysrhythmias (VT/VF) Cardiomyopathies Treatment -oxygen delivery (cpap) -decrease preload (lasix, nitro) -enhance contractility milrinone (primacor) dobutamine -dilate coronary vessels to enhance perfusion to muscle nitroglycerin nitroprusside (Nipride) |
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Obstructive (Note: not technically heart problem, but causes problems of the heart) |
causes -heart can not pump effectively due to outside conditions cardiac tamponade PE tension pneumothorax(kinked aorta,closed) tumors (lung CA, breast CA, tumors) Treatment -remove cause -supportive airway fluids (IV) drugs (vasopressors) |
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Distributive Note: tank is too big - all vessels dilated and big and brain isn't able to send out signals to vasocontrict - connection is impaired. 2. is there a leak in tank? |
Pathophysiology -loss of sympathetic tone -blood vessel dialation -vascular leakage Causes Neurologic -head/spinal injury -severe stress/anesthesia Chemically induced -anaphylaxis (allergic reaction, dilation & leakage) (benadryl) -capillary leak (severe wound, burns-severe burns cause a shift of fluid outside bloodstream) -sepsis (inflammatory response from bacteria, viruses, fungus) (dilation, clotting, leaking fluids) |
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Distributive Managment: tank too big Note: dilation or leak? |
Airway -02 -intubate Drugs -epinephrine (vasoconstrict) -benadryl (anaphylaxis) |
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A patient experiencing cardiogenic shock is receiving all of the following treatments. Which of the following statements regarding treatment are incorrect? Nitroglycerin(Tridil) decreased afterload: FALSE note: it decreases preload MOSTLY |
Treatments for cardiogenic shock -dobutamine (dobutrex) enhances contractility -furosemide (lasix) decreases preload -bipap/cpap improves oxygen delivery |
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A patient is admitted for treatment of a pulmonary embolism. The nurse should monitor the patient for what form of shock? |
Obstructive -(outside condition is causing heart to not pump effectively) -PE(blood clot in lung) |
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A patient with shock has severe generalized edema. The nurse recognizes this is most likely caused by what type of shock? |
Distributive Note: vascular leakage into interstitial space (everywhere) generalized edema This is not cardiogenic shock because the edema would be more dependent as in CHF, ankles....bla bla bla) |
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Sepsis: Infection (increased mortality) |
Normal response -dilate arteries and constrict veins to increase blood flow -local swelling dilutes microorganisms and toxins Sepsis is an over response (to infection) -uncontrolled inflammation -uncontrolled coagulation -uncontrolled fibrinolysis NOTE: bacteria is in blood stream, all over the body #1 mortality in ICU |
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SIRS Criteria (systemic inflammatory response system) (people @ risk for sepsis) |
SIRS CRITERIA -fever >38 C or < 36C (>100.4 or <96.8 F) (skin pale/flush/fever/low temp?) -HR > 90/min -RR>20/min or Pc02 <32 (fast breathing) -abnormal WBC (5000-10000 normal) |
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SEPSIS Criteria |
1. Known Infection 2. Two or more SIRS criteria and one or more of the following -hypotension -decreased urine output -positive fluid balance (a lot more going in than coming out) -decreased capillary refill -increased BS without diabetes -change in mental status -increased creatinine level (>1.2) |
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Septic shock |
-hypotension after fluid resusitation or -serum lactate >4mmol/L -urine output <30ml/hr for 2 or more hours despite fluid resusitation -procalcitonin increases in shock (marker for bacterial infections and sepsis) not on test. In major trauma if >2 it is sepsis, if >10 septic shock. |
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Code Sepsis |
Pre-hospital sepsis screening -baseline LOC -baseline VS and T -Skin color flushed (fever) mottled,pale,yellow/waxy (cold) -check blood glucose |
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Pre-Hospital Therapy |
-100% 02 -IV access -fluid bolus (500ml or 20-40ml/kg) -vasopressors norepinephrine (Levophed) dopamine 5-20mcg/kg/min |
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Hospital Resusitation Bundle: within 3 hours Sepsis |
within 3 hours (of diagnosis) -fluids to improve tissue perfusion AEB: urine output improves BP improvement MAP > 60 -serum lactate -cultures blood x2 other sites (infection?) -imaging -antibiotics (quicker is best) within 3 hours, need cultures first |
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Hospital Resusitation Bundle: within 6 hours Sepsis |
-vasopressors (if BP not improving w/fluids) GOAL: -MAP >= 65 -CVP 8-12mmHg (pressure of fluid coming back to heart, normal is 6-12, we want it to be slightly higher) -urine output >=0.5ml/kg/hr -Sv02 >=65 (@ least 35% of the oxygen pumped out by your heart is being used by body) -remeasure lactate levels |
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Additional therapies: Sepsis |
-source control within 12 hours (drain infected wound) -prevent infection -improve CO if needed -cautious use of blood products -mechanical ventilation if ARDS -HOB to decrease aspiration -minimize sedation |
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Additional Therapies: Sepsis |
-glucose control insulin for BS >180 CRRT or hemodialysis DVT prophylaxis enoxaparin (lovenox) or dlteparin (Fragmin) SCDs Stress ulcer prophylaxis (PPI - proton pump inhibitor) Nutrition oral feeding if tolerated Setting care goals prognosis plan of care note: the seriousness of disease discussed with family-the sooner discussed the better |
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Quality Indicators |
-presentation of sepsis (date, location of hospital) -resuscitation bundle completed within 3 hours serum lactate level blood cultures before abx abx started within 3 hours of ED admission or 1hr inpatient within 6 hours -fluids/vasopressors(if appropriate) for MAP >=65, CVP 8-12, urine output >=0.5ml/kg/hr or Sv02 at or above 65% -remeasure lactate levels management bundle initiated within 24 hours -prevent infection -BG control -DVT and stress ulcer prophylaxis, etc. Pam says "hours" are not on the test??? |
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Which of the following assessment findings meet SIRS criteria?
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WBC 3900 Yes, abnormal, lower T 101F Yes >100.4 HR 98 Yes >90 RR 24 Yes>20 BS 146 No, this is a part of sepsis criteria |
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The nurse is caring for a patient with a new diagnosis of suspected sepsis. In what order will the nurse implement the following collaborative interventions. |
1. Administer oxygen (stabilize pt) 2. 1000 ml 0.9 NS infusion (3 hours) 3. Obtain wound and blood cultures (3 hours before abx) 4. Hang IV antibiotic (3 hours, after culture) 5. begin norephinephrine (levophed) (within 6 hours if BP not improving w/fluids) 6 Administer insulin coverage (within 24hr) |
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Prioritization for Sepsis broken down |
Stabilize pt FIRST -oxygen within 3 hours -IV fluids -cultures -antibiotics -lactate draw -imaging within 6 hours -vasopressors -remeasure lactate within 24 hours -blood glucose control |
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Sepsis Case study Manifestations by System 1 (Heart) |
Cardiovascular -decreased CO (early stage increased CO) -increased HR, thready pulse (early stage-bounding pulse -orthostatic hypotension (all shock) -flat veins (distended in cardiogenic shock) |
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Sepsis Case Study Manifestations by System 2 (Pulmonary) |
Pulmonary -increased RR -decreased PaC02 and 02 -pallor,waxy, cyanosis Note: In Distributive shock skin could be flushed because of anaphylaxis |
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Sepsis Case Study Manifestations by System 3 (Renal) |
Renal -decreased urine output -abnormal BUN and creatinine |
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Sepsis Case Study Manifestations by System 4 (Neuromuscular) |
Early -Anxiety -restlessness Late -lethargy-coma -weakness -decreased DTR (deep tendon reflexes) |
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Sepsis Case Study Manifestations by System 5 (GI/metabolic) |
GI/metabolic -decreased motility -decreased bowel sounds -N&V -thirst (except older patients) -elevated BS (seen in sepsis) most times it's decreased BS |
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Sepsis Case Study Manifestations by System 6 (Integument) |
Integument -mottled -cool -moist, clammy -dry mouth (in all) |
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Name this rhythm..... Cause of this rhythm.... Treatment |
Sinus Rhythm with PVC (multifocal PVC) -ischemia -electrolyte imbalance antiarrhythmic and oxygen |
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Name of Rhythm Difinitive tx of rhythm Causes |
Vfib (ventricular fibrillation) LOOK AT PT!!! Unconscious pt........ Defibrillation hypoxia,electrolyte imbalance PE, cardiac tamponade |
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Name of Rhythm Potential complication Causes |
Afib (atrial fibrillation) stroke/PE, precedes stroke alcoholism, hypo/hyperthyroidism |
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Name of Rhythm Treatment of Rhythm |
VTach (ventricular tachycardia) pulseless vtach: defibillation unstable/not feeling well: cardioversion asymptomatic/stable/awake: oxygen 12 lead ECG Call rapid amiodorone magnesium |
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Name of Rhythm Cause of Rhythm Treatment |
Atrial flutter alcoholism amiodorone, beta blockers |
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Name of Rhythm Cause of Rhythm Treatment |
SVT (rapid narrow QRS complex)-no p caffeine, alcohol, cocaine Adenosine**, (cardiovert, beta blocker and calcium channel blocker to slow HR) |
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1st degree AV block
Causes Treatment |
Longer PR interval electrolyte distrubances No treatment |
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Name of Rhythm Causes TX |
Second-degree type 1 AV block medications cause: beta blockers, calcium channel blockers tx: discontinue meds/no treatment/if symptomatic pacemaker |
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Name of Rhythm Causes TX |
Second-degree type 2 AV block Causes: anterior MI tx: immediate transcutaneous pacing/pacemaker Note: PR constant, dropped QRS |
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Name of Rhythm Causes TX |
Third-Degree AV Heart Block Causes: coronoary ischemia Tx: Pacemaker |
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Don't forget to go over that long azz math problem. |
Help me! |
