Exam 1

Causes of High pressure alarm

Causes - coughing, biting the ET tube, kink in tube, increased secretions, increased water in tubes, pneumothorax, pneumonia, ARDS

A client with a recent MI asks the nurse why he has to have his blood drawn so many times each day. Which nursing response is indicated?

"We are evaluating the damage to and recovery of your heart muscle."

post PCI Education

- bedrest for 4-6 hours following sheath removal -Keep extremities straigh - HOB no higher than 30 degrees - report any chest pain or numbness in extremities - begin home going teaching

evidence of reperfusing in MI pts

- cessation of chest pain - elevated ST segments return to baseline - reperfusion dysrhythmias (shouldnt last more than 30 minutes_ , early and marked peaking of CKMB and troponin

Unstable Angina

- new onset angina with usual activity, abrupt increase in frequency, severity or duration of pre-existing stable angina, or angina at rest or that is difficult to control with drugs -Requires immediate treatment! Patient is at risk for AMI, dysrhythmias or SCD

What to do for heart complications in vent pts

-Need adequate fluid to increase preload -Inotropics to improve contractility

Cardiac Tamponade

-pulsus paradoxus- SBP decreases during inspiration - narrowed pulse pressure - becks triad- hypotension, distended neck veins, muffled heart sounds

Normal QRS duration

0.04-0.12 (1-3 boxes)

Normal PR interval

0.12-0.20 (3-5 boxes)

ECG: one large box is how many seconds

0.20

ECG: one small box is how many seconds

0.4

ECG: one large box vertically is

0.5

2. A patient's ventilator is at 10 cm H2O of PEEP. Which assessment findings would the nurse evaluate as indicating a possible negative consequence to this ventilator setting? (Select all that apply.) 1. Pneumothorax 2. Increased sedation 3. Decrease in blood pressure 4. Lower respiratory rate 5. Temperature elevation

1, 3 Rationale: 1. PEEP increases the pressure and volume within the alveoli, both of which can cause alveoli to burst. 2. Sedation is a consequence unrelated to elevated PEEP. 3. The use of PEEP can result in hemodynamic changes. Lower blood pressure can be an effect of increased pressure in the chest and decreased return to the heart as a result of higher levels of PEEP. 4. Lower respiratory rate does not have a direct relationship to PEEP. 5. Temperature alterations do not have a direct relationship to PEEP.

The heart pumps how many times in 24 hours

100,000

pericardial cavity contains how many ml of fluid ?

15-50 ml

CVP

2-5 Ride sided preload

6 seconds is how many boxes

30 boxes

Cardiac Output is how many L/min

4-8

How many liters per minutes does the heart pump

5-20 L

Low exhaled volume should be set at:

50-100 ml less than tidal volume

A 70 kg client is intubated and placed on mechanical ventilation. The nurse can expect which initial tidal volume?

560 mL

PAOP

6-12 Left sided preload

Stroke volume is usually how much

60-100 ml/beat

Hypoxemic is 02 less than what percent

90

normal troponin levels

<0.5

BNP

> 100 is diagnostic for heart failure - the more stretch you have, the more BNP is going to be released (the more the brain and body needs oxygenated blood, the more bnp will be released)

If someone is having an MI you are going to look at key things:

AMPLE: Allergies Meds Previous med/surg/fam hx Last Meal Events

Cause of HF

Acute MI, Uncontrolled HTN, valvular dysfunction, infection, cardiomyopathy

Nipride is used primarily for ?

Afterload.. its a mixed venous and arterial dilator (for hypertensive crisis and CHF)

A nurse is providing discharge instruction to a client whose abdominal aortic aneurysm will be treated medically. Which topics should the nurse include in this instruction? 1. Importance of smoking cessation 2. Importance of keeping blood pressure in the hypotensive range 3. How to palpate for changes in the diameter of the vessel 4. How to monitor for blood in the urine

Answer: 1 Rationale: 1. Smoking is a major contributing factor to the development of AAA. Smoking cessation is essential. 2. Blood pressure should be controlled, but the pressure must be high enough to perfuse organs. Hypotensive range is not generally necessary. 3. Palpation of the aneurysm for size is not accurate and is contraindicated for the client. 4. Blood in the urine is not a finding associated with dissection or rupture of AAA.

A client with an MI is receiving continuous ST segment monitoring. The nurse notes a 2 mm ST segment depression from baseline. What initial action should the nurse take? 1. Assess the client and collaborate with the health care provider. 2. Continue to monitor the client; this is a normal finding. 3. Administer nitroglycerin as ordered. 4. Adjust the sensitivity of the alarms.

Answer: 1 Rationale: 1. Changes in the ST segment are the most sensitive electrographic indicators of ischemia and injury to the myocardium. The nurse should assess the client and take action based upon that assessment, including collaborating with the health care provider. 2. ST depression is not normal. It indicates myocardial ischemia. 3. The nurse would administer nitroglycerin if the client complained of chest pain. 4. ST depression of new onset is serious. Adjusting the alarms is not indicated.

A patient is being evaluated after accidentally overdosing on antihypertensive medication. Which clinical finding would the nurse anticipate? 1. Low urine output 2. Jugular vein distension 3. Warm extremities 4. Bounding pulses

Answer: 1 Rationales: 1. Low BP would trigger the RAAS. Renin is released and triggers the release of angiotension I, which then converts to angiotension II. Angiotensin II stimulates the release of aldosterone and water is conserved. In addition, as kidney perfusion drops, GFR diminishes, resulting in decreased urine production. 2. Hypotension would cause partial collapse of the jugular veins, not distension. 3. Extremities would more likely be cool and pale or mottled due to peripheral vasoconstriction. 4. Pulses would more likely be weak and thready due to low circulating pressures.

A client who has atherosclerosis is placed on the HMG Co-A enzyme inhibitor atorvastatin (Lipitor). Which outcome indicates to the nurse that the drug is having the desired effect? (Select all that apply.) 1. Reduction in LDL levels 2. Increase in HDL levels 3. Reduced CRP levels 4. Normalization of serum glucose levels 5. Increase in triglyceride levels

Answer: 1, 2 Rationale: 1. HMG Co-A enzyme inhibitors such as Lipitor act to reduce LDL levels. 2. HMG Co-A enzyme inhibitors such as Lipitor may increase HDL levels. 3. CRP levels are not affected by HMG-Co-A enzyme inhibitors. 4. Glucose levels are not affected by HMG-Co-A enzyme inhibitors. 5. HMG Co-A enzyme inhibitors such as Lipitor act to reduce triglyceride levels.

A client has been diagnosed with hypertensive emergency. Which interventions would the emergency department nurse anticipate delivering? (Select all that apply.) 1. Admitting the client to the hospital 2. Titrating IV medications to control the blood pressure 3. Interventions to slowly decrease the blood pressure 4. Administration of oral medications 5. Managing the client on an outpatient basis

Answer: 1, 2 Rationale: 1. In a hypertensive emergency the client is admitted to the ICU for rapid reduction of blood pressure. 2. IV medications are used in hypertensive emergency. 3. In hypertensive emergency, the blood pressure is treated aggressively with attempts to lower it as quickly as possible. 4. IV medications are given in hypertensive emergency. 5. The client is admitted to ICU for treatment of hypertensive emergency.

A patient has decreased cardiac output from decreased myocardial contractility. The nurse would anticipate which treatment? (Select all that apply.) 1. Digoxin 2. Oxygen 3. Calcium 4. Dobutamine 5. Furosemide

Answer: 1, 2, 3, 4 Rationales: 1. Digoxin is a positive inotropic agent and would increase myocardial contractility. 2. Contractility decreases with hypoxemia; therefore oxygen therapy is indicated. 3. Cardiac muscle contraction depends on adequate calcium intake. Low serum calcium can impair myocardial contractility. 4. Dobutamine is a positive inotropic agent and would increase myocardial contractility. 5. Furosemide is not administered to increase myocardial contractility.

Which food choices would the nurse interpret as indicating that the client understands dietary instruction for the management of hypertension? (Select all that apply.) 1. Low fat milk at lunch 2. Wine with the evening meal 3. Potassium-bearing fruits such as bananas for breakfast 4. Vitamin B enriched cereal for breakfast 5. Pretzels as an afternoon snack

Answer: 1, 3 Rationale: 1. The diet should include calcium rich foods. Low-fat dairy is a good choice. 2. The client should be advised to avoid alcohol consumption. 2. The diet should be rich in potassium. 4. While vitamin B enriched cereal is a good general choice for breakfast, it is not specifically indicated for management of hypertension. 5. The diet should be low in sodium. Pretzels are high-sodium snacks.

A nurse is preparing to administer the client's daily dose of carvedilol (Coreg). What findings would indicate need to collaborate with the prescriber before administration? (Select all that apply.) 1. Heart rate of 48 bpm 2. Respiratory rate of 14 breaths/min 3. Second degree AV block 4. Presence of a dry cough 5. Shortness of breath at rest

Answer: 1, 3, 5 Rationale: 1. Carvedilol is a beta-blocker. Heart rate below 50 bpm should be reported to the primary care provider before medication is administered. 2. As long as the respiratory pattern is not labored and the client is oxygenating well, there is no reason to report a respiratory rate of 14. This rate is not an effect of the carvedilol. 3. Carvedilol is a beta-blocker. Beta-blocking agents are contraindicated in clients with 2nd or 3rd degree heart block. 4. Presence of a dry cough is associated more with ACE inhibitors and would not be a reason to hold the carvedilol. 5. Carvedilol is a beta-blocker, which should not be given to clients in decompensated heart failure. Shortness of breath at rest can be an indicator of this type of failure.

A client with history of an abdominal aortic aneurysm has been admitted for treatment of pneumonia. Which assessment finding would require the nurse to contact the client's primary health care provider immediately? (Select all that apply.) 1. The client becomes suddenly hypotensive. 2. The client reports a headache. 3. The client's urine is cloudy. 4. The client reports hip pain. 5. There is new absence of pedal pulses in the left foot

Answer: 1, 4, 5 Rationale: 1. Sudden hypotension is an indicator of possible rupture of the AAA. 2. Headache is not associated with complications from the AAA. It should be treated, but it is not necessary to immediately contact the provider. 3. Cloudy urine most often indicates infection or dehydration. It should be treated, but it is not necessary to immediately contact the provider. 4. Abdominal pain, including hip pain, can indicate that the AAA is dissecting or rupturing. This finding should be immediately conveyed to the provider. 5. Absence of pedal pulses indicates a problem with circulation that could be dissection or rupture of the AAA.

A client's blood pressure has measured 139/85 mm Hg and 136/88 mm Hg at the last two monthly appointments. What should the nurse tell the client about these blood pressure measurements? 1. "Your blood pressure is normal." 2. "Your blood pressure measurements fall in the prehypertension range." 3. "You now have stage I hypertension." 4. "Since you have stage II hypertension, medications will be necessary."

Answer: 2 Rationale: 1. Normal blood pressure is less than 120 mm Hg systolic and less than 80 mm Hg diastolic. 2. Prehypertension is from 120-139 mm Hg systolic or 80-89 mm Hg diastolic. 3. Stage I hypertension is 140-159 mm Hg systolic or 90-99 mm Hg diastolic. 4. Stage II hypertension is 160 or greater mm Hg systolic or 100 or greater mm Hg diastolic.

The nurse is providing pre-procedure education to a client scheduled for an exercise stress test (EST) at 0800. Which instruction should the nurse provide? 1. "Take your beta blocker medication at 0700 the morning of your exam." 2. "Do not smoke for 8 hours before your test." 3. "You may have one cup of regular coffee without cream or sugar the morning of the procedure." 4. "You should not eat or drink anything for at least 24 hours before the procedure."

Answer: 2 Rationale: 1. Beta blockers are often held for 24 hours before EST. 2. The client should not smoke for several hours before the EST. 3. The client should not drink beverages containing caffeine for several hours before the procedure. 4. The client should not eat or drink anything for several hours before the procedure, but 24 hours is excessive.

A 35-year-old patient who is 6 feet tall and weighs 435 pounds is receiving inotropic medications to improve cardiac output. The patient's heart rate at the beginning of the treatment was 62 bpm, and his temperature was 37.4 C. Which outcome measure would be the best to evaluate the efficacy of the medications? 1. Cardiac output (CO) 2. Cardiac index (CI) 3. Stroke volume (SV) 4. Heart rate (HR)

Answer: 2 Rationales: 1. The extreme value of this patient's body surface area requires an outcome measure other than CO. 2. CI is CO corrected for body size, which is very important for this patient. 3. SV is the volume of blood pumped by the heart with each beat. Changes in stroke volume alter CO, but this is not the most important parameter in this scenario. 4. Increased HR can be a side effect of some inotropic medications, but it is not the primary outcome measure.

A client with coronary artery disease experiences fatigue, shortness of breath, and heartburn after walking his dog. Which medication should the client take when he returns home? 1. Lovastatin (Mevacor) 2. Acetylsalicylic acid (ASA) 3. Calcium carbonate (Tums) 4. Theophylline (Theo-Dur)

Answer: 2 Rationale: 1. Lovastatin can reduce serum cholesterol levels, but this is not a high priority in this case. 2. This client is exhibiting symptoms of myocardial ischemia. Acetylsalicylic acid (ASA) provides an anticoagulant effect that can reduce the severity of the ischemic event. 3. Calcium carbonate can relieve heartburn; however, the extreme fatigue and shortness of breath coupled with chest discomfort suggests a coronary event in need of treatment. 4. Theophylline is used for respiratory symptoms and might address the shortness of breath; however, the fatigue and heartburn together with the SOB indicate a potential cardiac problem.

A client walks up to the triage nurse's desk in the emergency department and says, "My chest is really hurting." What should be the nurse's first action? 1. Ask the client when the pain started. 2. Have the client sit down. 3. Send the client's spouse to admit the client. 4. Ask the client if there is a history of cardiac problems.

Answer: 2 Rationale: 1. Questions about the pain are important, but are not the first priority in this scenario. 2. The nurse should immediately make attempts to reduce the metabolic load on the client's heart. Sitting down or lying down with the head elevated is one way to accomplish this. 3. This is not the priority in this scenario. 4. Historical questions are important, but are not the priority in this scenario.

The nurse would monitor a client with which lesion most closely for the development of acute myocardial infarction? 1. Stable plaque 2. Unstable plaque 3. Normal plaque 4. Advanced plaque

Answer: 2 Rationale: 1. Stable plaque impedes blood flow to myocardial tissues and is associated with the development of stable angina, a predictable and less threatening type of cardiac ischemia. 2. Unstable plaque is has a greater tendency toward rupture, platelet aggregation, fibrin attraction, and thrombus formation in the coronary arteries. This activity can precipitate an acute myocardial infarction. 3. Plaque is not normal. The normal situation is no plaque development. 4. There is not a category of plaque development termed "advanced plaque."

A client has been diagnosed with heart failure. How should the nurse explain this disorder to the client? 1. "The fluid accumulated in your ankles makes it too difficult for your heart to pump blood effectively. 2. "The two bottom pumping chambers of your heart are not working correctly." 3. "The valves between the chambers of your heart are weak." 4. "The large vessel leading from your heart is blocked."

Answer: 2 Rationale: 1. The fluid that accumulates in the ankles is generally a result of heart failure, not the reason it develops. 2. Heart failure is a clinical syndrome that results from any structural or functional cardiac disorder that decreases the ability of the ventricles to fill or eject. 3. Heart failure can be a long-term result of valvular disorder, but this is not the best explanation of the client's status. 4. Blockage of the aorta would eventually cause heart failure, but this is not the best explanation of the client's status.

A patient is admitted to the unit with multiple trauma resulting in significant blood loss. During assessment, the nurse notes low blood pressure and signs of low cardiac output. Based on these two findings, the nurse would expect which effect on the patient's peripheral resistance (PR)? 1. PR will decrease 2. PR will increase 3. PR will remain the same 4. PR will fluctuate

Answer: 2 Rationales: 1. If the body responded with a decreased PR, the blood pressure would drop further. 2. PR represents afterload. The body will react to increased blood pressure to perfuse vital organs by increasing arteriole vasoconstriction. This results in greater PR. 3. The PR will change when blood pressure and volume drop. 4. The PR will not fluctuate, but will change.

The nurse is caring for a patient who has increased afterload. Which findings is the patient most likely to exhibit? (Select all that apply.) 1. Normal heart rate 2. Decreased stroke volume 3. Hypertension 4. Hypotension 5. Heart rate decreases

Answer: 2, 3 Rationale: 1. Changes in afterload cause changes in heart rate. 2. If afterload increases, stroke volume decreases because the ventricle is meeting increased resistance and cannot effectively pump out its volume. 3. When arterial vessels are constricted (hypertension), afterload to the left ventricle increases. 4. Decreased blood pressure is associated with decreased afterload. 5. As afterload increases, heart rate increases.

Atherosclerosis is an inflammatory disorder caused by chronic injury or inflammation to the endothelium. During client education the nurse explains that which conditions are sources of that injury? (Select all that apply.) 1. Hypotension 2. Tobacco smoke 3. Hypercholesterolemia 4. Hypoglycemia

Answer: 2, 3 Rationale: 1. Hypotension is not injurious to the endothelium. Hypertension is a contributing factor. 2. Components of tobacco smoke cause injury to the endothelium. 3. Hypercholesterolemia contributes to the development of atherosclerotic plaques in the lining of the arteries. 4. Hypoglycemia does not lead to atherosclerosis. Hyperglycemia is a contributing factor. 5. There is no evidence that low triglycerides are related to endothelial injury.

A 60-year-old female was just diagnosed with stable angina. Which information is important for the nurse to provide to this client? (Select all that apply.) 1. Rest will not relieve your symptoms. 2. You may not experience crushing chest pain. 3. Your cardiac symptoms may include fatigue, upper arm weakness, or heartburn. 4. Your cardiac symptoms may include dizziness or inability to think clearly. 5. You should immediately contact your healthcare provider if you need to take nitroglycerin to control your chest pain.

Answer: 2, 3, 4 Rationale: 1. Stable angina should be relieved with rest and/or nitroglycerin. 2. Older persons and women may not experience crushing chest pain as a cardiac symptom. 3. Fatigue, upper arm weakness, and heartburn are also cardiac symptoms reported by women. 4. Older persons may report dizziness and mental status changes as cardiac symptoms. 5. If the client is diagnosed with stable angina, there is no reason to immediately notify the health care provider if nitroglycerin relieves the symptoms. The client would report the symptoms at the next visit.

The patient with cirrhosis of the liver has significant ascites. The patient is cold, clammy, and confused. The nurse interprets these findings as indicating which physiological condition?. 1. Increased preload from increased venous return to the heart 2. Decreased afterload from peripheral vasodilation 3. Decreased preload from a relative volume depletion 4. Increased afterload from ankle edema

Answer: 3 Rationales: 1. The patient's condition would not result in increased venous return to the heart. 2. The patient's condition would not result in peripheral vasodilation. 3. Ascites results in third-spacing of fluid derived from the circulating blood volume. This is relative volume depletion, as the volume is still within the body but no longer in the circulating volume. Decreased preload results in decreased cardiac output with resultant cold clammy skin and decreased mentation. 4. The patient may have ankle edema, but this finding is not as significant as another.

A client has a history of stable angina. How would the nurse expect this client to describe episodes of chest pain? 1. "I have chest pain when I am resting. It's not related to physical activity." 2. "My chest pain usually occurs with minimal activity." 3. "I usually have chest pain when I am physically active, but resting makes it go away." 4. "I've tried taking nitroglycerin tablets, but they don't help my chest pain."

Answer: 3 Rationale: 1. Prinzmetal's angina (variant angina) is associated with chest pain that occurs at rest and is not related to activity or heart rate. 2. Unstable angina is not predictable. It occurs at rest or with minimal activity. 3. Stable angina is chest pain that is predictable with physical activity. Stable angina is relieved by rest or nitroglycerin. 4. With stable angina, chest pain is relieved by rest or nitroglycerin. Chest pain not relieved by nitroglycerin is associated with unstable angina.

A patient with a history of palpitations reports feeling that her heart is skipping beats. Which assessment data warrants immediate intervention by the nurse? 1. Heart rate of 60 bpm with regular rhythm 2. S1 and S2 heart sounds present 3. Patient report of feeling light-headed 4. S3 heart sound present

Answer: 3 Rationales: 1. Palpitations are associated with irregular heart rhythms. 2. S1 and S2 are normal heart sounds. 3. Palpitations are related to the occurrence of premature beats. The patient is at risk for decreased cardiac output and decreased cerebral perfusion, as manifested by light-headedness. 4. S3 is a diastolic filling sound caused by decreased ventricular compliance.

A patient returns to the high-acuity unit after a cardiac catheterization. It is important for the nurse to question which order by the health care provider? 1. Assess left groin insertion site for bleeding or hematomas. 2. Assess bilateral pedal pulses. 3. Ambulate as desired. 4. Keep the patient's left leg straight for 1 hour.

Answer: 3 Rationale: 1. The nurse should assess for complications such as hematoma and bleeding from the insertion site. 2. Pedal pulses should be assessed to identify peripheral artery thrombosis or embolus. 3. Bed rest must be maintained for 4-6 hours to promote healing of the arterial puncture site. 4. The patient should keep the procedural leg straight to reduce stress on the procedure site.

A client is admitted to the emergency department in a hypertensive crisis. Which finding would indicate to the nurse that this is actually a hypertensive emergency? 1. Client's systolic B/P is 188 mm Hg 2. Client complains of a headache 3. Client's diastolic B/P is 118 mm Hg 4. Client complains of chest pain

Answer: 4 Rationale: 1. The range of systolic B/P is the same for both hypertensive urgency and hypertensive emergency. 2. Headache is a common complaint with both hypertensive urgency and hypertensive emergency. 3. The range of diastolic B/P is the same for both hypertensive urgency and hypertensive emergency. 4. Chest pain indicates target organ damage which indicates that the hypertensive crisis is hypertensive emergency.

Which laboratory result would the nurse interpret as indicating that the client is at greatest risk for developing atherosclerosis? 1. Total cholesterol 180 mg/dL; LDL 80 mg/dL 2. Total cholesterol 170 mg/dL; LDL 120 mg/dL 3. Total cholesterol 210 mg/dL; LDL 140 mg/dL 4. Total cholesterol 250 mg/dL; LDL 170 mg/dL

Answer: 4 Rationale: 1. Total cholesterol of 180 mg/dL and LDL of 80 mg/dL places the client in the optimal category for cardiac health. 2. Total cholesterol of 170 mg/dL and LDL of 120 mg/dL places the client in a desirable category for these two measures. 3. Total cholesterol of 210 mg/dL and LDL of 140 mg/dL places the client in the borderline high risk category for the development of atherosclerosis. 4. Total cholesterol of 250 mg/dL and LDL or 170 mg/dL places the client in the high risk category for the development of atherosclerosis.

A patient is admitted with unstable angina. Which information about this patient requires the most immediate action by the nurse? 1. Elevation of the BNP 2. S3 heart sounds 3. Auscultation of a carotid bruit 4. Elevation of serum troponin levels

Answer: 4 Rationales: 1. Elevation of BNP is associated with increased preload. However, several other factors can elevate BNP levels, so this is not the most critical finding. 2. S3 is a ventricular filling sound and can be a sign of early heart failure, but it is not the most critical finding. 3. Auscultation of a carotid bruit can indicate turbulent flow in the carotid artery. However, this is generally a chronic finding and is not the most critical finding. 4. Elevated troponin has a high sensitivity and specificity for myocardial injury.

A client has been diagnosed with infective endocarditis. Which teaching information should the nurse provide to this client? (Select all that apply.) 1. "You will probably be on antibiotic therapy for at least two weeks." 2. "Infective endocarditis usually affects the muscle in the wall of your heart." . 3. "Most people who develop infective endocarditis are smokers." 4. "It is very important that you take your antibiotics on time and according to the directions provided." 5. "You will have several blood tests done to determine which antibiotic is necessary."

Answer: 4, 5 Rationale: 1. Antibiotic therapy for infective endocarditis generally lasts at least six weeks if not longer. 2. Infective endocarditis affects the valves of the heart. 3. Infective endocarditis is most often associated with preexisting heart disease and physiological states that decrease the immune status. Examples are extremes of age, surgery, and IV drug use. 4. Timely administration according to an exact schedule is necessary to achieve and maintain adequate blood levels of antibiotics. 5. Generally blood cultures from at least three different venipuncture sites are used to determine the correct antibiotic.

Match the hemodynamic measurements with their corresponding component of CO: 1. PAWP A. preload RV 2. CVP B. afterload LV 3. SVR C. ventricular stroke work index 4. PVR D. preload LV 5. contractility E. afterload

Answers 1) D 2) A 3) B 4) E 5) C

The client with an MI is receiving continuous ST segment monitoring. The nurse notes a 2 mm ST segment depression from baseline. What initial action should the nurse take?

Assess the client and collaborate with the health care provider.

A ventilaton mode where it wants to make sure every single breath has the right tidal volume .. ventilator will sense when pt is attempting to breath and will then deliver a specific volume. Ventilator will deliver breath if the patient's rate is less than the set rate. There is a potential or hyperventilation if RR is too high

Assist Controlled (AC) Remember: "Control Freak"

A client has been intubated and placed on a volume-cycled mechanical ventilator. The nurse carefully assesses the client for findings associated with a risk associated with this type of ventilator. What is that risk?

Barotrauma

What is the primary nursing intervention indicated for a symptomatic client with a PAWP of 3 mm Hg?

Begin volume replacement.

what drug classification reduces myocardial o2 consumption and myocardial workload in MIs ?

Beta Blocker - decreased dromotropic, chronotropic, and inotropic action of the heart - No direct/ immediate effect on preload

Causes of atelectasis

Blocked airway, too low of tidal volume

chronic heart failure

Blood is backing up and putting stretch on the ventricle and increasing preload in the right side if the right side ventricle is damaged Right ventricle isn't working, it cant push blood forward so it will go backwards into the body (JVD, edema), increased right sided preload will occur (CVP) Left side preload would be elevated when left ventricle is damaged... backs up into the pulmonary system (SOB, crackes, difficulty breathing,,, increased left preload (WEDGE pressure)

A client has developed a cardiac rhythm abnormality in which the atria are no longer contracting effectively. The nurse will observe this client for which effect on cardiac output (CO)?

CO will decrease.

a variation of PEEP. Pressure is applied throughout the cycle not just end-expiration. Applied to spontaneous breaths and can be used as the primary mode of ventilation

CPAP (Continuous positive airway pressure)

Treatment of Barotrauma

CT remove from vent and bag

What should the nurse do in order to assess the afterload status of a client's left ventricle?

Calculate the systemic vascular resistance, Determine the client's cardiac index, Determine the client's mean arterial pressure

A PA catheter has just been inserted. What is the nurse's primary intervention?

Call for a chest x-ray.

Stroke Volume=

Cardiac Output/ HR

Cardiac muscle structure differs from skeletal muscle in which of these ways? Select all that apply.

Cardiac muscle has more mitochondria, Cardiac muscle is highly interconnected in a latticework structure.

Cardiac Index=

Cardiac output/ body surface area

Causes of PVC

Causes: Acute ischemia (MI) Medication (Digitalis toxic) Electrolyte imbalance < Magnesium, <Potassium Hypoxia Caffeine ETOH Acidosis Stress Cardiomyopathy Invasive procedures (PA)

The low tidal volume alarm on a client's ventilator keeps sounding. What is the nurse's first action?

Check ventilator connections.

S/S of pt with barotrauma

Chest pain, dyspnea, increase peak inspiratory pressure, decreased lung sounds on affect side

Atelectasis :What is it?

Collapse of alveoli- alveoli are underinflated

A nurse is concerned because the client's cardiac output is low. The nurse would implement interventions affecting which parameters?

Contractility,Heart rate, Preload, Afterload

A ventilation mode that breaths are completely provided by the vent with preset volume and rate. Pt's inspiratory efforts are not considered. Circuit is closed between mandatory breaths. If pts are not apnic or paralyzed they will fight the vent

Controlled

What are the three modes of ventilation and what so the modes determine?

Controlled (C), Assist Controlled (AC) and Synchronized Intermittent Mandatory Ventilation (SIMV) Modes determine how much the patient will participate.

vfib tx

DFIB>>>>VFIB Lidocaine- makes the cells harder to depolarize (not used as much because it has some toxic side effects)

What intervention is most important to include in the nursing care plan of a client who is started on a diuretic?

Daily weights, Monitor I & O

What do CCB do

Decrease HR, Contractility, afterload

A client is admitted to the high-acuity unit with dehydration. The nurse provides care by observing the client for signs of which disorder?

Decreased CO

A client has just been admitted to the ICU after CABG surgery. Which nursing diagnosis has priority in the initial hours after surgery?

Decreased Cardiac Output

The nurse is caring for a client with hypertension. Based on this diagnosis, the nurse identifies that the client is at risk to develop which change?

Decreased cardiac output

stemi goals for 10- 30- 90 mind

Door to EKG in 10 min Door to cath lab in 30 min door to reprofusion in 90 min

A client has just been intubated for placement on a mechanical ventilator. What is the first assessment of the tube placement?

End tidal CO2 monitoring

Inotropes with sympathomimetic properties

Epinephrine, Dobutamine, Dopamine, Norepinephrine, Phenylephrine

An 85-year-old male with a medical history of coronary artery disease presents to the Emergency Department with dehydration. He is given 5 liters of IV fluid. The nurse understands that this client is at greatest risk for which problems?

Excess preload

SVT causes

Excessive use of alcohol, caffeine, tobacco and other (street drug) stimulants Electrolyte imbalances, hypoxia Seen in the elderly and generally associated with acute cardiorespiratory illness and COPD

A client is being discharged from the hospital after a non-ST elevation myocardial infarction. The nurse is discussing appropriate home care during the last half-hour of the client's hospital stay. Which client education topic should be addressed by the nurse during this small window of time before client discharge?

Explaining proper use of nitroglycerin

fraction of inspired oxygen which means the percentage of O2 concentration the patient is getting. Use the lowest to acheive the best Pa O2

FIO2 (room air is 21%) *FIO2 more than 50 will start damaging the lung)

Criteria for weaning off vent support

FIO2 < .50 PEEP < 5cm RR < 30 TV > 5 ml/kg

S/S of a pt with gastric stress ulcer, ileus, gastric distention

GI bleed, abd distention, decreased BS

Nurse management after PCI

HTTA, prevent/ minimize complications of catheter procedures: angina, renal protection, femoral site care, bleeding; monitor for reperfusion dysrhythmias, pt/ fam education

complex clinical syndrome that results from any structural or functional impairement of ventricular filling or ejection of blood

Heart Failure

What does PEEP do and what is its setting usually at

Helps to keep alveoli open longer and opens collapsed alveoli. (Applies pressure during expiratory breath) 5-12 cm H20

need to know when afib started because

If you do not know what time the afib started you aren't going to try to put the person back into NSR because if you get the heart contracting strongly again it could spew the clots all through the body

Treatment of atelectasis

Increase PEEP if intubated (can also increase tidal volume but not as likely as PEEP) - If not intubated:* incentive spirometry*

A client is placed on dobutamine, a positive inotropic agent. The nurse determines that the desired outcome for administering this drug has been reached when which response is assessed?

Increased cardiac output

A client's ventilator settings were changed as follows: tidal volume increased from 450 mL to 500 mL and rate increased from 14 breaths to 16 breaths per minute. What ABG change would the nurse anticipate?

Increasing pH

What is a danger of wedging balloon in pulmonary artery?

It could get stuck or perforate pulmonary artery

STABLE ANGINA`

It is predictable (Has a pattern), is associated with such things as physical activity or exposure to cold Usually lasts for 1-5 minutes and is relieved by rest May result in transient ST depression but will disappear with pain relief Doesn't mean you don't have a problem

Renin Angiotensin System

Kidney blood flow decreased > renin released>(first med:beta blockers- can stop renin release which prevents angiotensinogen from becoming angiotensin 1) >angiotensinogen converts to angiotensin 1>(second med: ACEI to prevent from converting angiotensin 1 to angiotensin 2)> angiotensin 2 > (ARB- angiotensin 1 is converted to angiotensin 2 but the receptors are all blocked so that the angiotensin 2 cannot hook up to any of the receptors and then becomes ineffective and blocks the cascade)> vaso constriction and release of aldosterone (sodium and water retention)> (aldosterone blockers- stop the aldosterone from hooking up to receptors for water and sodium retention... will still have the vasoconstriction)> increase in BP

SVR

Left sided afterload

PSVT TX

Lower the HR* First: try Valsalva Maneuver (Bare down) Next: try Carotid Massage (discouraged in the elderly) MD's Only! Adenosine: stops all electrical activity of the heart (normal conduction pathway resumes) Amiodarone (chemical converter)- for afib or flutter, Calcium Channel Blockers, Beta-Blockers If all else fails: Electrical Cardioversion (usually 100 jules or less) (difference between this defibrillation and this- less energy is used for cardioversion.. Defib is usually up to 300 jules)

Initial tx for MI

MONA Morphine Oxygen Nitro (dilator, decreases preload and afterload, enhanced coronary artery perfusion) Aspirin

Why could Mechanical Ventilation cause heart problems?

MV causes increased intrathoracic pressures Decreased venous return to R side of heart Increased RV afterload (can affect cardiac output)

asystole tx

Medication: Epinephrine, Atropine CPR Administer Oxygen Consider ETT Placement

PEA TX

Medication: Epinephrine, Atropine CPR Administer Oxygen Fix underlying Cause

A client says, "My doctor says I have something called variant angina." What pattern would the nurse expect this client to report?

More pain at night

PEA

No Pulse * EKG shows a weak, low amplitude, slow rate signal with regular rhythm. No characteristic waveform shape, but the shape is consistent in each lead.

Underlying rhythm is usually sinus NSR is interrupted by an early, abnormally-shaped atrial P-wave.. may be inverted p wave

PAC premature atrial contractions

Assessment for MI

PQRSTAAA Position of the pain Quality of the pain Radiation.. does the pain move anywhere Severity: scale 0-10 Timing: when pain started Aggravating factors: what makes it worse Alleviating factors: what makes it better Associated symptoms: ie n/v

amount of time it takes for the atria to depolarize

PR interval

A Single ectopic impulse originating in the ventricles There is an absent of P-Wave for this beat. Temporary shortening of the R-R Interval. Wide QRS Complex (shape of QRS and T depends on location of ectopic focus)

PVC premature ventricular contractions

A client admitted with severe dyspnea and diaphoresis is diagnosed with acute respiratory failure. The nurse would expect which result from the client's ABG analysis?

PaCO2 greater than 50 mm Hg

The flow of tidal volume (TV) is called? Range:

Peak Flow 40-80 L/min *Slower flow is better distribution of gases; faster - better for COPD*

A client with ACS says, "My chest is hurting even though I've been resting for about 30 minutes. It seems like I'm having more and more chest pain that lasts longer and longer." What nursing interventions are indicated? Select all that apply.

Perform a rapid physical assessment. Obtain an ECG according to protocol. Check the client's venous access device for patency.

The fibrous layer that lines the heart and great vessels Fluid filled sac around the heart

Pericardium

anticoagulants given IV in the cathlab

Plavix - clopidogrel Effient- Plasugrel Brillinta- Ticagrelor

PEEP of 5 cm H2O

Positive end expiratory pressure (PEEP) applies pressure to the airway during the EXPIRATORY breathing phase, which forces alveoli to remain open throughout the breathing cycle.

What to monitor with patients on ventilators?

Pulse ox, vitals, Peek inspiratory pressure

I:E

Ration of determining time of inspiration to expiration *usually 1:2*

FIO2 of 0.30:

Refers to the fraction of inspired oxygen or oxygenation concentration expressed as a decimal. Often in an emergency, the initial FIO2 setting is much higher; however, her intubation is nonemergent and her oxygenation status had not yet been compromised (although it was beginning to deteriorate).

s/s of heart complications with vent pts

S/S - increased HR, Decreased BP and UO. Cool clammy skin

MAP =

SBP+ 2 DBP/ 3

High pressure alarm

Set @ 10 - 20 cm above peak inspiratory pressure

allows periodic larger than normal TV - a substitute for the normal sighing reflex.

Sighs 10-15/hr (Infrequently used if pt is on a high tidal or PEEP)P

What does Adenosine do ?

Stops the heart and helps it to get into normal rhythm (would use first for medication of SVT... even if it doesn't completely fix the problem, it will hopefully slow the heart down enough to identify if it is afib or what not to treat with other medications then)

Amount of blood ejected from the ventricle with each beat

Stroke Volume

a preset volume of gas is delivered at a preset rate. Pt may take a spontaneous breath between machine. Machine breaths are set not to occur during pt breaths. Better muscle conditioning but may be more work because pt breaths are not assisted. Does not decrease CO as much as other modes and is used for weaning

Synchronized Intermittent Mandatory Ventilation (SIMV)

The client is on CPAP for weaning from a mechanical ventilator. Assessment reveals a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles. What should the nurse anticipate will occur?

The client will be placed back on full ventilatory support.

A client's cardiac index is figured to be 3.2L/min/m2. How should the nurse interpret this data?

The client's CI is within the normal range.

Asystole

There is no electrical activity (No ECG signal) No Mechanical Activity (No Pulse) Electrical Shock Therapy is ineffective to restore any EKG rhythm Medication Therapy may restore EKG rhythm.

Volume cycling

This cycling system delivers a preset volume of gas to the lungs regardless of the pressure required to deliver the volume. Volume is constant while pressure varies. Since too much pressure results in barotrauma, maximum pressure limits are set to protect the lungs.

Assist/control mode

This mode is sensitive to the inspiratory effort of the patient, allowing the patient to initiate a ventilator breath at the prescribed settings (assist). The control part of the mode is a timed breath backup should the patient cease to trigger a breath at the prescribed rate. A/C mode is considered a "resting mode" because it rests the respiratory muscles.

Positive pressure ventilator

This type of ventilator drives gases into the lungs through ventilator circuitry attached to an artificial airway.

volume of gas delivered to the patient during a ventilator breath 5-15 ml/kg (usually around 750 but depends on pt size)

Tidal Volume (TV)

Other Complications with vents

Tracheal damage Skin damage Communication Anxiety Aspiration

A client is suspected of having an atrial septal defect that has been undiagnosed for 30 years. Which primary diagnostic testing would the nurse anticipate preparing this client to undergo?

Transesophageal echocardiogram

what are reasons for non ischemic elevations?

Trauma, CHF, HTN, Pulmoary embolism, sepsis

present within 3 hours after onset of symptoms; remains elevated 1-2 weeks after acute MI

Troponin

Nitroglycerin

Used for acute MI, unstable angina, CHF SE: HEADACHE, hypotension, flushing Nursing: contraindicated with Sildenefil (viagra)

A client who has been on a mechanical ventilator for three days develops a fever of 101.0°F, green sputum, and right lower lobe crackles. The nurse contacts the physician regarding possible development of which complication?

Ventilator-associated pneumonia

If preload is low give...

Volume

Localized dilation of a portion of the aorta > 1.5 times its normal diameter usually at a weakened area of the aortic wall

abdominal aortic aneurism (AAA)

Deviation from NSR No organized atrial depolarization, so no normal P waves (impulses are not originating from the sinus node). Atrial activity is chaotic (resulting in an irregularly irregular rate). Common, affects 2-4%, up to 5-10% if > 80 years old

afib

fire continuously due to a looping re-entrant circuit

aflutter

TX for a gastric stress ulcer, ileus, or gastric distention

antacids, prevent GI bleed (Give PPI, H2 blockers, etc. to prevent)

is like the layers ripping apart. Which makes the layers week and blood gets in there gets trapped ,BP rises, more pressure is put on the vessel, and it can rupture/ lead to death

aortic disection

Pwave is

atrial depolarization

if rate/ rhythm is high give...

beta blockers, calcium channel blockers

Cause of unstable angina

blood clots that block an artery partially or totally - occurs at rest and usually lasting more than 20 minutes

sarcoplasmic reticulum store

calcium

The amount of blood ejected from the heart each minute

cardiac output

s/s of pericarditis

chest pain: sharp, constant, alleviated by leaning forward Friction Rub Ecg Changes from the fluid change

Appears 4-8 hours after onset of injury and peaks at 15-24 hr

ckmb

angina pectoris is a symptom of

coronary artery disease (CAD)

what do beta blockers do

decrease HR, Contractility, BP

arterial vasodilators?

decrease afterload

venous vasodilators do what

decrease preload

Pt s/s with atelectasis

decreased or abset lung sounds, crackles

If preload is high give...

diuretics, vasodilators

inner surface of heart lines the chambers and valves.

endocardium

SA node problems

fire too slow- sinus brady dire too fast- sinus tachy

QRS is the time it takes for what

for the impulse to travel through the bundle of branches and purkinje fibers

if rate/ rhythm is low...

give atropine, isuprel, pacemaker

Prevention of pulmonary infection in vents

hand washing, sterile technique, prevent aspiration, change tubing as directed (24 hours), good oral care... DO NOT drain secretions back into humidifier

cardiac output =

heart rate X stroke volume

the pericardial fluid helps to do what

helps to reduce friction and acts as a lubricant

TX OF AFIB

heparin/ coumadin therapy to avoid occurance of stroke due to loss of atrial kick

AFIB TX

if symptomatic, may require immediate cardioversion - 48 hour window for new onset - TEE - Anticoag - amiodarone drip - Maze procedure atrial pacemaker and defib

Causes of pulmonary infection w/ vents

immunocompromised, bypassing normal defense mechanisms, exposed to staph and strep

sympathomimetics do what

increase HR, increase afterload, increase contractility

S/S of pulmonary infection w/ vents

increased HR, RR, temp; crackles, rhonchi, wheezes, decreased sats, change in sputum color

usually use PADP (pulmonary artery diastolic pressure) to guestimate?

left sided preload

Barotrauma: (Volutrauma) What is it and may cause Can Cause.....

lung injury or alveolar rupture/ alveolar distention... It is basically air that is expelled from the lung through damaged alveoli and into surrounding area May cause is high PEEP but can also be from increased TV, and intubate R mainstem bronchus Can cause pneumothorax (life threatening, air becomes trapped in thorax and displaces organs to unaffected side), pneumomediastinum, pneumopericardium, etc.

Acute MI treatment goals

maintain cardiac output, minimize cardiac workload, prevent complications associated with AMI, pt/fam education

what gender is most likely to have substernal chest pain

male; females might not have pain but feel tired

Acute coronary syndrom is an umbrella term for the clinical signs and symptoms of

myocardial infarction

muscular wall of heart

myocardium

high contractility give...

negative inotropes

treat low BP

norepinepherine

tx OF PVC

not all require tx, beta blockers, amiodorone, treat underlying condition, o2

bb and ccb blockers will do what for afib

nothing for converting back to nsr, only help control rate

Low contractility give...

optimizing preload inotropes, assist devices

if after load is high give....

oxygen, vasodilators, CCB, IABP, Surgery

s/s of AAA

palpable, pulsatile mass in the umbilical area of the abdomen, abdominal pain and lower back pain with an acute rupture: severe abdominal pain and hypotension with abrupt loss of consciousness

antidote to heparin

protamine sulfate

the basic protein units responsible for contraction

sarcomeres (many sarcomeres make up myofibrils)

ACE INHIBITORS do what ?

they block the vasoconstricive effects of angiotensive II (assist in preload reduction by blocking the effects of aldosterone release)

sinus brady tx

treat underlying prob, atropine, prolonged pacemaker

If afterload is low give...

vasopressors

qrs is

ventricular depolarization

t wave

ventricular repolarization

Causes of low pressure alarm

when you have a disconnect, cuff leak, or leak in circuitry

when map is less than 60 it means what?

you stop profusing to the kidneys and see decrease in urine output