422 Comprehensive study
What is the normal range for PAP?
25/10
Describe characteristics of second degree type I heart block
(PR) Longer, longer, longer drop, then you have a Wenkebach
Steps for ECG interpretation
1. Regular or irregular rhythm 2. Calculate HR 3. Find P waves - present/absent? 4. Measure PR interval - longer than 0.20 seconds? 5. Measure QRS interval - consistent? Wider than 0.12? 6. Observe T wave - absent? Inverted? 7. Note any ectopic beats - any extra/skipped beats? 8. Determine the organ - SA, AV, ventricles? 9. Correctly identify the rhythm
What is normal range for CVP?
2-8
In the "getting gas vs shock" analogy, what does cardiogenic shock represent?
Gas pump not working
What is SIRS?
Generalized inflammation in organs from initial insult (Infection, ischemia, infarction, injury)
How many BPM does the ventricles generate?
20-40
What is the normal range for FiO2?
21-100% as needed
What is the death rate of 2 organ failure with MODS? 3 organ failure?
2: 40-60% 3: 70-80%
What is the normal range for MPAP?
4-12
What is the normal range for CO?
4-8L/min
How many BPM does the AV node generate?
40-60
After the phlebostatic axis is measured, what angle can the patient sit at?
45 degrees (no greater that 30 for a ventilated patient)
What is the normal range for TV?
450-550 (6-8mL/kg)
Where is the phlebostatic axis?
4th intercostal space, midaxillary line
What is the normal range for PEEP?
5-15
What is the normal range for EF?
50-75%
how long is adenosine's half-life?
6 seconds
What is the normal range for PAWP?
6-12
How many BPM does the SA node generate?
60-100
What should MAP be at?
65 or >
What is the normal range for MAP?
70-105
What is the normal range for RR on a ventilator?
8-12
What is the normal range for SVR?
800-1200
What is the normal range for PVR?
<250
What would the serum lactate level be to diagnose sepsis?
>2 - sepsis; >4 - severe sepsis
The nurse is concerned that a patient is at risk for developing obstructive shock because of which assessment findings? Select all that apply. A. Age 80 B. History of A-fib C. T3 spinal cord injury D. Latex allergy E. Bacteremia
A. Age 80 B. History of A-fib Spinal cord injury would lead to neurogenic shock, Latex allergy would lead to anaphylactic shock, and bacteremia would lead to septic shock
While assessing a client with dilated cardiomyopathy, the nurse notices that the ECG rhythm no longer has any P waves, on a fine wavy line. The ventricular rhythm is irregular with a QRS duration of 0.08 seconds, the heart rate is 110 BPM. The nurse interprets this rhythm as: A. Atrial fibrillation B. Ventricular fibrillation C. Atrial flutter D. Sinus tachycardia
A. Atrial fibrillation
In the following list, identify items to be included in a teaching plan for a thrombocytopenic client requiring bleeding precautions. Select all that apply. A. Avoid intramuscular injections B. Brush teeth with a soft toothbrush C. Avoid rectal temperatures, suppositories, and examinations D. Avoid flossing your teeth E. Blow your nose gently F. Avoid fresh fruits and vegetables G. Avoid contact sports H. Use a straight razor instead of an electric shaver
A. Avoid intramuscular injections B. Brush teeth with a soft toothbrush C. Avoid rectal temperatures, suppositories, and examinations E. Blow your nose gently G. Avoid contact sports
The nurse is caring for patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock? Select all that apply. A. Bradycardia B. Hypotension C. Warm dry skin D. Abdominal cramps E. Palpitations
A. Bradycardia B. Hypotension C. Warm dry skin
A patient that is being treated for cardiogenic shock is being hemodynamically monitored. Which findings are consistent with the patient's diagnosis? Select all that apply A. Elevated PAWP B. Elevated CVP C. Elevated PVR D. Elevated MAP E. Elevated stroke volume
A. Elevated PAWP B. Elevated CVP C. Elevated PVR
A client with disseminated intravascular coagulation (DIC) will experience simultaneous alterations in normal hemostatic mechanisms and clotting processes. The nurse knows this client will most likely develop which of the following? A. Excessive thrombosis and bleeding B. Decreased platelet production C. Immediate sodium and fluid retention D. Increased thromboplastin and fibrinogen levels
A. Excessive thrombosis and bleeding
The nurse knows that a 75 year old client with severe HrTN will experience increased workload of the heart due to which of the following? A. Increased afterload B. Increased CO C. Overload of the heart D. Increased preload
A. Increased afterload
The nurse knows that a 45 year old client with severe HrTN will experience increased workload of the heart due to which of the following? A. Increased afterload B. Increased CO C. Overload of the heart D. Increased preload
A. Increased afterload - it takes more work to push out more fluid
The nurse is caring for a patient with a diagnosis of aortic stenosis. The client reports episodes of angina and passing out recent at home. The client has surgery in 2 weeks. Which of the following would be the nurse's best explanation about activity at this time? A. It is best to avoid strenuous exercise, stairs, and lifting before your surgery B. Take short walks 3 times daily to prepare for postoperative rehab. C. There are no activity restriction unless the angina reoccurs; then please call the office D. Gradually increase activity before surgery to build stamina for the postoperative period
A. It is best to avoid strenuous exercise, stairs, and lifting before your surgery
After cardiac surgery, a client's BP is 90/38 mmHg. How would the nurse interpret this client's MAP and organ perfusion status? A. Organs are in danger of ischemia and perfusion pressure is critically low B. Organs are at risk for insufficient perfusion and perfusion pressure is borderline low C. Perfusion pressure is adequate to meet organs' perfusion needs D. Perfusion pressure minimally meets the organs' perfusion needs
A. Organs are in danger of ischemia and perfusion pressure is critically low The MAP calculates to 55. Adequate tissue perfusion is 65+.
A patient with a history of alcoholism is admitted to the ICU with hemorrhage from esophageal varices. Admission VS are BP 84/58 mmHg, HR 105, RR 32. The nurse recognizes the onset of SIRS upon finding: A. Pulmonary edema B. Cardiac dysrrhythmias C. Absent bowel sounds D. Decreasing BP
A. Pulmonary edema Respiratory system is often the 1st system to show signs of SIRS --> empty space wants to fill with fluid
A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realized that this type of shock is due to: A. Reduced CO B. Increased stroke volume C. Reduced blood volume D. Blood flow blocked in the pulmonary circuation
A. Reduced CO
What criteria should the nurse use to determine NSR for a client on a cardiac monitor? Select all that apply. A. The RR intervals are relatively consistent B. One P wave precedes each QRS complex C. 4-8 complexes occur in a 6 second strip D. The ST segment is higher than the PR interval E. The QRS complex ranges from 0.12 to 0.20 seconds
A. The RR intervals are relatively consistent B. One P wave precedes each QRS complex - 4-8 complexes occur in a 6 second strip (40-80 BPM) - The ST segment is higher than the PR interval (STEMI --> MI) - The QRS complex ranges from 0.12 to 0.20 seconds (QRS <0.12 seconds; PR interval <0.20 seconds)
Which data collected by the nurse for a patient who has cardiogenic shock indicate that the patient may be developing MODS? A. The patient's serum creatinine level is elevated B. The patient complains of intermittent chest pressure C. The patient's extremities are cool and pulses are weak D. The patient has bilateral crackles throughout lung fields
A. The patient's serum creatinine level is elevated Cool extremities and weak pulses aren't specific to only MODS
A patient is experiencing an anaphylactic reaction to a medication. The nurse is concerned that the patient will develop distributive shock becasue: A. The release of histamine causes vasodilation with plasma leakage B. Sympathetic innervation is interrupted C. Microorganisms overwhelm the vascular system D. Parasympathetic innervation functions are unopposed
A. The release of histamine causes vasodilation with plasma leakage
Which preventative actions by the nurse will help limit the development of SIRS in patients admitted to the hospital? Select all that apply. A. Use aseptic technique when caring for invasive lines or devices B. Ambulate postoperative patients as soon as possible after surgery C. Remove indwelling urinary catheters as soon as possible after surgery D. Advocate for parenteral nutrition for patients who cannot take oral feedings E. Administer prescribed antibiotics within 1 hour for patients with possible sepsis
A. Use aseptic technique when caring for invasive lines or devices B. Ambulate postoperative patients as soon as possible after surgery C. Remove indwelling urinary catheters as soon as possible after surgery E. Administer prescribed antibiotics within 1 hour for patients with possible sepsis Enteral is preferred over parenteral
What are the appropriate nursing interventions for the patient with delirium in the ICU? Select all that apply. A. Use clocks and calendars to maintain orientation B. Encourage round-the-clock presence of caregivers at the bedside C. Sedate the patient with appropriate drugs to protect the patient from harmful behaviors D. Silence all alarms, reduce overhead paging, and avoid conversations around the patient E. Identify physiologic factors that may be contributing to the patient's confusion and irritability
A. Use clocks and calendars to maintain orientation C. Sedate the patient with appropriate drugs to protect the patient from harmful behaviors E. Identify physiologic factors that may be contributing to the patient's confusion and irritability
A nurse notes that a client with sinus rhythm has a PVC that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be: A. V-fib B. V-tach C. A-fib D. Asystole
A. V-fib
When caring for an immunosuppressed client, the nurse knows which of the following precautions are important? Select all that apply. A. Wash hands thoroughly before entering the room B. Wear a mask, gloves, and gown as appropriate C. Restrict visitation by people with active infections D. Discourage the client from bathing E. Instruct the client to avoid crowds F. Encourage the client to eat only fresh fruits and vegetables G. Instruct the client to cook all foods thoroughly H. Dispose of all linen in the trash after use
A. Wash hands thoroughly before entering the room B. Wear a mask, gloves, and gown as appropriate C. Restrict visitation by people with active infections E. Instruct the client to avoid crowds G. Instruct the client to cook all foods thoroughly
What is the treatment for shock?
ABCs (underlying cause), fluid resuscitation, vasopressors
What effect does lidocaine have on the heart?
Accelerate repolarization
What does frothy sputum mean?
Air and fluid are mixing together
What test is used for arterial line placement?
Allen's test
What are some examples of distributive shock?
Anaphylactic, septic, neurogenic
What area on the heart will lead V3 show and what artery?
Anterior side and LAD
What area on the heart will lead V4 show and what artery?
Anterior side and LAD
The nurse is teaching a client with hemophilia A about home management. Which strategy should the nurse include in the teaching plan? A. Increase iron-rich foods in the diet B. Avoid contact sports C. Use aspirin when severe pain occurs D. Minimize joint pain by walking and weight-bearing
B. Avoid contact sports
What would you give someone with bradycardia who is symptomatic?
Atropine
What is the MCV?
Average RBC volume or size
What does MAP measure?
Average arterial pressure during a single cardiac cycle - Tissue perfusion
What is MCH?
Average weight of Hgb per RBC (decreases with microcytic anemias, increases with macrocytic anemias)
A patient who had cardiac surgery 24 hours ago has had a urine output averaging 20mL/hr for 2 hours. The patient received a single bolus of 50 mL of IV fluids. Urine output for the subsequent hour was 25mL. Daily lab results indicate the BUN is 45. Based on these findings, the nurse would anticipate the patient at risk for which problem? A. Hypovolemia B. Acute kidney injury C. Glomerulonephritis D. UTI
B Acute kidney injury
The nurse receives a unit of packed red blood cells (PRBCS) from a blood bank and notes that the time on the clock reads 4:10 PM. By what time must the blood begin infusing? A. 1650 B. 1640 C. 1700 D. 1710
B. 1640
Your otherwise healthy post-op abdominal hysterectomy patient is noted to have an RR of 8/min while sleeping. An ABG reveals the following: pH 7.31, pCO2 55, pO2 60. Nursing actions for this patient include all of the following EXCEPT: A. Placement of O2 at 3L/min by NC per PRN order B. Administer narcotic pain medication per PRN order C. Stimulate patient and ask patient to take deep breaths D. Notify physician
B. Administer narcotic pain medication per PRN order
The nurse is caring for an ICU patient with a history of HrTN. The client is being treated with metoprolol (Lopressor), hydrochlorothiazide (HydroDiuril), and captopril (Capoten). The client has a BP of 120/80 mmHg and HR of 48. Which of the following is the best action taken by the nurse? A. Administer the metoprolol and hydrochlorothiazide, hold the captopril, and notify the physician B. Administer the captopril and the hydrochlorothiazide, hold the metoprolol and notify the physician C. Administer all the medications and notify the physician D. Withhold all the medications and notify the physician
B. Administer the captopril and the hydrochlorothiazide, hold the metoprolol and notify the physician Captopril (Capoten) causes vasodilation; Hydrochlorothiazide (HydroDiruil) decreases the BP through urination, and Metoprolol (Lopressor) decreases the HR. Because the patient's HR is already low at 48, the nurse should hold the Metoprolol.
A client arriving in the ER is receiving CPR from paramedics, who are giving ventilations through and ET tube they placed in the client's home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a HR of 55 with a palpable pulse. Which action should the nurse take first? A. Start an IV line and administer amiodorone 300mg IV over 10 minutes B. Check ET tube placement C. Obtain an ABG sample D. Administer atropine 1mg IV
B. Check ET tube placement - we HAVE to check if the tube is placed correctly via the end tidal CO2 Atropine will increase the HR but is only given for SYMPTOMATIC bradycardia. Amiodarone will decrease the heart rate.
The hemodynamic changes the nurse expects to find after successful intubation of intraaortic balloon pump therapy in a patient with cardiogenic shock include (select all that apply): A. Decreased SV B. Decreased SVR C. Decreased PAWP D. Increased diastolic BP E. Decreased myocardial O2 consumption
B. Decreased SVR C. Decreased PAWP D. Increased diastolic BP E. Decreased myocardial O2 consumption
When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of MODS? A. Increased serum albumin B. Decreased respiratory compliance C. Increased GI motility D. Decreased BUN/Creatinine ratio
B. Decreased respiratory compliance
A client has developed A-fib, with a ventricular rate of 150 BPM. A nurse assesses the client for: A. Nausea and vomiting B. HoTN and dizziness C. HrTN and headache D. Flat neck veins
B. HoTN and dizziness Decreased CO priorities: palpitations, chest pain with discomfort, decreased perfusion (pulses, CRT, skin color/temp), HoTN, pulse deficit, fatigue, dizziness/syncope, weakness, SOB
The nurse is initiating an IV infusion of LR for a client in shock and recognizes that the purpose of LR for the client is to: A. Provide dextrose and nutrients to prevent cellular death B. Increase fluid volume and urinary output C. Draw water from the cells into the blood vessels D. Replace electrolytes of NA, K, Ca, and Mg for cardiac stabilization
B. Increase fluid volume and urinary output
The nurse is caring for a patient receiving a continuous NE IV infusion. Which patient assessment finding indicated the need to titrate to a lower dose? A. HR of 64 B. MAP of 108 C. Low SVR D. Low PAWP
B. MAP of 108 - normal range for MAP is 70-102
While caring for a client who sustained an MI, the nurse noted 8 PVCs in 1 minute on the cardiac monitor. The client is receiving an IV infusion of LR and oxygen at 2L/min. The nurse's first course of action should be to: A. Increase the IV infusion rate B. Notify the physician promptly C. Increase the O2 D. Administer a prescribed analgesic
B. Notify the physician promptly PVCs of >5-6/min in post MI patients = notify HCP immediately --> V-tach --> V-fib >6 PVCs/min is serious - decrease ventricular irritability with medications such as lidocaine
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? A. Palpate extremities for bilateral pulses B. Observe the patient's respiratory effort C. Check the patient's LOC D. Examine the patient for any external bleeding
B. Observe the patient's respiratory effort
A client with bleeding problems is diagnosed with vitamin K deficiency. The nurse knows that vitamin K is essential because it assists with normal blood clotting by performing which of the following? A. Regulating Factors VIII and IX utilization B. Promoting prothrombin formation in the liver C. Stimulating platelet proliferation and differentiation D. Assisting with iron absorption
B. Promoting prothrombin formation in the liver
Which life threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? Select all that apply. A. Fluid volume overload B. Renal insufficiency C. Cerebral ischemia D. Gastric stress ulcer E. Pulmonary edema
B. Renal insufficiency C. Cerebral ischemia
What will the nurse identify as symptoms of hypovolemic shock? Select all that apply. A. Temperature of 99.6F (36.4C) B. Restlessness C. Decrease in BP of 20 mmHg when the patient sits up D. CRT greater than 3 seconds E. Sinus bradycardia of 55 BPM
B. Restlessness C. Decrease in BP of 20 mmHg when the patient sits up D. CRT greater than 3 seconds
Which assessment findings by the nurse caring for a patient with a right radial arterial line is a normal finding? Select all that apply. A. The right hand feels cooler than the left hand B. The MAP is 77mmHg C. The system is delievering 3mL of flush solution per hour D. The flush bag and tubing were last changed 2 days ago E. A waveform that corresponds with each heartbeat via auscultation
B. The MAP is 77 mmHg C. The system is delivering 3mL of flush solution per hour D. The flush bag and tubing were last changed 2 days ago - must be changed every 72-96 hours E. A waveform that corresponds with each heartbeat via auscultation
The nurse should report which of the following as a critical value for an adult? A. Total WBC 11,000/mm3 B. Total WBC 1,700/mm3 C. Hemoglobin 12.7 g/dl D. Platelet count 110,000/mm3
B. Total WBC 1,700/mm3
A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing: A. PVCs B. V-Tach C. V-fib D. Sinus tachycardia
B. V-Tach
Why can splenomegaly affect blood cell counts in a client? A. The spleen works directly with the bone marrow to produce blood cells B. When the spleen enlarges, its normal filtering capacity increases, often causing a decrease in the number of circulating blood cells C. When the spleen enlarges, its normal filtering capacity increases, often causing an increase in the number of circulating blood cells D. Anemia is primarily caused by disorders of the spleen
B. When the spleen enlarges, its normal filtering capacity increases, often causing a decrease in the number of circulating blood cells
What does increased procalcitonin indicate r/t sepsis?
Bacterial infection
What does procalcitonin indicate?
Bacterial presence
What are some ways to stimulate the vasovagal response?
Bear down/have patient strain, induce gag reflex, drink cold water
What drug class is metoprolol?
Beta blocker
What effect does diltiazem have on an ECG?
Bradycardia, prolonged PR interval, AV block
What effect does metoprolol have on an ECG?
Bradycardia, prolonged PR interval, AV block
What are some examples of hypovolemic shock?
Burns, diabetes insipidus, hemorrhage
You must assign an ICU staff nurse to care for a critical patient. Who is most appropriate? A. A temporary agency nurse, with extensive ICU experience, who has been in your ICU for 3 days B. An LPN with 10 years of experience in your ICU who is in the last semester of an RN program C. An RN who has worked in your ICU for 2.5 years after transferring from the MBU D. An RN who has 12 years of ER experience that has been floated to ICU today
C. An RN who has worked in your ICU for 2.5 years after transferring from the MBU An LPN cannot take care of an unstable patient as well as cannot assess or teach patients
The nurse recognized that which patient would be most likely to develop hypovolemic shock? A patient with: A. Decreased CO secondary to ECG changes B. Severe constipation causing watery diarrhea C. Ascites D. Syndrome of inappropriate ADH (SIADH)
C. Ascites - the fluid is not in circulation
A client is having frequent PVCs. A nurse would place priority on assessment of which of the following items? A. Sensation of palpations B. Causative factors such as caffeine C. BP and peripheral perfusion D. Precipitating factors such as infection
C. BP and peripheral perfusion
A client with a white blood cell disorder asks how such a condition develops. The nurse begins by stating that all blood cells are produced in which of the following? A. Thymus B. Central nervous system C. Bone marrow D. Spleen
C. Bone marrow
The nurse has just admitted a client to the telemetry floor with reports of acute chest pain radiating down the left arm. Which lab studies should the nurse order to evaluate myocardial damage? Select all that apply. A. Hgb and Hct B. Serum glucose C. CK-MB D. Troponin I E. Myoglobin F. BUN
C. CK-MB D. Troponin I E. Myoglobin
The nurse is caring for a 29 year old man who was admitted a week ago with multiple rib fractures, a pulmonary contusion, and a left femur fracture from a motor vehicle crash. After the attending physician tells the family that the patient has developed sepsis, the family members have many questions. Which information should the nurse include in explaining the early stage of sepsis? A. Antibiotics may not work once an infection has progressed to sepsis B. Weaning the patient off from the ventilator will be a top priority in early sepsis C. Large amounts of IV fluids are required in sepsis to fill dilated blood vessels D. The patient has recovered from sepsis if he has warm skin and ruddy cheeks
C. Large amounts of IV fluids are required in sepsis to fill dilated blood vessels Treatment for shock is 1. ABCs 2. Fluids 3. Vasopressors
SIRS is characterized by all of the following except: A. Core temperature of higher than 38c or lower than 36c B. Respiratory rate of more than 20 breaths per minute C. Lymphocytosis D. HR of more than 90 BPM
C. Lymphocytosis
The nurse is caring for a 72 year old man in cardiogenic shock after an acute MI. Which clinical manifestations would be of most concern to the nurse? A. Restlessness, HR of 124, hypoactive bowel sounds B. MAP of 54, increased jaundice, cold and clammy skin C. PaO2 38, serum lactate of 46.5 mcg/dl, and bleeding from puncture sites D. Agitation, RR 32, and serum creatinine 2.6
C. PaO2 38, serum lactate of 46.5 mcg/dl, and bleeding from puncture sites This indicated the patient is in DIC
A client has returned to the med-surg unit after a cardiac catheterization. What is the PRIORITY post-procedure nursing assessment for this client? A. Assess the patient's pain level B. Observe neuro function every 15 minutes C. Palpate the site for a possible hematoma D. Monitor skin warmth and turgor
C. Palpate the site for a possible hematoma
To establish hemodynamic monitoring for a patient, the nurse zeros the: A. CO monitoring system to the level of the left ventricle B. Pressure monitoring system to the level of the catheter tip located in the patient C. Pressure monitoring system to the level of the atrium, identified as the phlebostatic axis D. Pressure monitoring system to the level of the atrium, identified as the midclavicular line
C. Pressure monitoring system to the level of the atrium, identified as the phlebostatic axis
Which of the following clinical conditions can the nurse suspect is most likely occurring when an immunosuppressed client develops disorientation, diminished urine output, and vital signs of T 102.1, P 124, R 24, PB 92/60? A. Acute renal failure B. Pneumothorax C. Septic shock D. Compartment syndrome
C. Septic shock
The nurse monitors the patient with positive pressure mechanical ventilation for: A. Paralytic ileus because pressure on the abdominal contents affects bowel motility B. Diuresis and Na depletion because of increased release of ANP C. Signs of cardiovascular insufficiency because pressure in the chest impedes venous return D. Respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels
C. Signs of cardiovascular insufficiency because pressure in the chest impedes venous return
A client with a rapid rate a-fib asks a nurse why the physician is going to perform carotid massage. The nurse responds that this procedure may stimulate the: A. Vagus nerve to increase the heart rate, overriding the rhythm B. Diaphragmatic nerve to slow the heart rate C. Vagus nerve to slow the hear rate D. Diaphragmatic nerve to override the rhythm
C. Vagus nerve to slow the heart rate
What are common labs to get for DIC?
CBC, fibrinogen, PT/PTT/TT, FSP, D-dimer
What drug class is diltiazem?
CCB
How does phenylephrine affect CVP, PAWP, PVR, SVR?
CVP - PAWP - PVR - SVR ^
How does epinephrine (low dose) affect CVP, PAWP, PVR, SVR?
CVP - PAWP - PVR - SVR v
How does adenosine affect CVP, PAWP, PVR, SVR?
CVP - PAWP - PVR ^ SVR -
How does adrenaline affect CVP, PAWP, PVR, SVR?
CVP - PAWP - PVR ^ SVR -
How does nitric oxide affect CVP, PAWP, PVR, SVR?
CVP - PAWP - PVR v SVR -
How does nitroglycerine affect CVP, PAWP, PVR, SVR?
CVP - PAWP v PVR - SVR v
How does dopamine affect CVP, PAWP, PVR, SVR?
CVP ^ PAWP - PVR - SVR -
How does vasopressin affect CVP, PAWP, PVR, SVR?
CVP ^ PAWP - PVR v SVR -
How does epinephrine (high dose) affect CVP, PAWP, PVR, SVR?
CVP ^ PAWP ^ PVR - SVR ^
How does norepinephrine affect CVP, PAWP, PVR, SVR?
CVP ^ PAWP ^ PVR - SVR v
How does dobutamine affect CVP, PAWP, PVR, SVR?
CVP ^ PAWP v PVR - SVR v
How does sodium nitroprusside affect CVP, PAWP, PVR, SVR?
CVP v PAWP v PVR - SVR -
What are some examples of cardiogenic shock?
Cardiac dysrhythmias, valvular regurgitation or stenosis, MI
What does an increase in monocytes typically indicate and what are some examples?
Chronic infections worsening typically late during acute phase of infection and chronic infection Examples: Hodgkin's disease, multiple myeloma, some leukemias, SLE
What is DIC?
Clotting and hemorrhaging at the same time
What is more concerning in DIC, clotting or hemorrhaging?
Clotting cause it can lead to ischemia
The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing MODS? A. 22 year old patient with SLE who is admitted with a pelvic fracture after a motor vehicle accident B. 48 year old patient with lung cancer who is admitted for SIADH and hyponatremia C. 65 year old patient with CAD, dyslipidemia, and primary HrTN who is admitted for unstable angina D. 82 year old patient with type II diabetes mellitus and CKD who is admitted for peritonitis related to a peritoneal dialysis catheter infection
D. 82 year old patient with type II diabetes mellitus and CKD who is admitted for peritonitis related to a peritoneal dialysis catheter infection
A patient admitted to the hospital from a long term care facility appears to be in the late stage of shock with SIRS. Which order implemented by the nurse has the highest priority? A. Insert an indwelling urinary catheter B. Insert 2 large bore IV catheters C. Administer NS at 100mL/hr D. Administer 100% O2 by nonrebreather mask
D. Administer 100% O2 by nonrebreather mask Late stage of shock with SIRS would mean the patient's LOC is changing (most likely declining)
The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are A. Blood pressure, pulse, and respirations B. Breath sounds, blood pressure, and body temperature C. Pulse pressure, level of consciousness, and pupillary response D. Level of consciousness, urine output, and skin color and temperature
D. Level of consciousness, urine output, and skin color and temperature These three tell you the most about tissue perfusion
Which is the most important instrument used as a diagnostic and monitoring tool for determining the severity of a shock state? A. Arterial line B. Indwelling urinary catheter C. ECG monitor D. Pulmonary artery catheter
D. Pulmonary artery catheter
The vital signs of a client with cardiac disease are as follows: BP 100/78, HR 48 BPM, RR 18 breaths/min. Atropine is administered IV push. What nursing assessment indicates a therapeutic response to the medication? A. Systolic BP has increased by 20mmHg B. Pupils are dilated C. Oral secretions have decreased D. Pulse rate has increased to 70 BPM
D. Pulse rate has increase to 70 BPM
The patient is receiving IV Nitropress (sodium nitroprusside) via central line to decrease a patient's left ventricle afterload. Which hemodynamic measurement would best evaluate the effectiveness of this medication? A. MAP B. PVR C. PAWP D. SVR
D. SVR
A client with complete heart block may exhibit: A. Nausea and vertigo B. Flushing and slurred speech C. Cephalalgia and blurred vision D. Syncope and slow ventricular rate
D. Syncope and slow ventricular rate
Which finding would most likely explain a low pressure alarm for a patient who has an arterial line in the left radial artery? A. An arterial line that requires flushing B. A clot in the left hand C. A change in the patient's position requiring the need to re-zero the monitoring equipment D. V-Tach
D. V-Tach - This rhythm isn't effective in pumping blood out into the circulatory system meaning the pressure in the artery is going to be low The line needing to be flushed and a clot in the left had would indicate a high pressure alarm
What is the antidote for malignant hyperthermia?
Dantrolene
What effect does diltiazem have on the heart?
Decrease automaticity of SA node, delay AV conduction, reduce contractility - valium for the heart
What is the primary cause of shock?
Decreased SVR
What does a high PVR indicate?
Decreased pulmonary blood flow and increased pulmonary distention, pulmonary HrTN, pulmonary vascular disease, PE, hypoxic pulmonary vasoconstriction, increased respiratory pressures, contraction of smooth muscles (acidosis, medications)
What are some clinical manifestations of DIC?
Decreased tissue perfusion: -Brain: Change in LOC, focal neurologic signs, seizures -Heart: chest pain, Hypoperfusion, ECG ST elevation, arrhythmias -Lungs: Dyspnea, clinical Ix of hypoxia, chest pain -Kidney: Decreased urine output, proteinuria, electrolyte imbalances -GI: Abdominal pain, diarrhea (may be bloody) -Skin: Cyanosis (toes, fingers, lips, nose, ears) mottling, coldness, necrosis Decreased platelets: Petichiae, ecchymosis Hemorrhage -Tachycardia -HoTN -Tachypnea -Overt bleeding: *Mucosal surfaces: gingival bleeding, epistaxis *GU: Hematuria *GI: Hematemesis, melena *Pulmonary: Hemoptysis *Gynecologic: vaginal bleeding *Skin: Profound bruising and oozing from puncture points/IV sites/wounds -Occult bleeding *Swollen joints and joint pain from bleeding into joints *Abdominal distention and rebound tenderness from intraperitoneal bleeding *Back pain and leg numbness from retroperitoneal bleeding *HA, changes in LOC, papillary changed from intracerebral hemorrhage *Blurred vision, loss of visual field from retinal hemorrhage
What does BUN/Creat measure r/t sepsis
Decreased urine output --> decreased tissue perfusion
How does dobutamine affect circulation?
Decreases SVR
What effect does metoprolol have on the heart?
Decreases automaticity of SA node, slow impulse conduction of AV node, reduce atrial and ventricular contraction - calms everything down
What effect does amiodarone have on the heart?
Delay repolarization, resulting in prolonged duration of action potential and refractory period - slows impulses down
What are the 5 medications that must be given through a central line?
Dobutamine, levophed (NE), dopamine, angiotensin II, and phenylephrine
What are the 4 stages of shock?
Early, compensatory, progressive, refractory
What are some extrinsic triggers for DIC?
Extensive surgery, crush injuries, malignancies, neurologic damage, endotoxins, obstetrical conditions
What reading would the machine give if the transducer is too high?
False high reading
What could a high CVP indicate?
Fluid overload, increase venous return (vasoconstriction), cardiac tamponade
What is MCHC?
Hgb average concentration in groups of RBCs (decreased concentration = pale, increased concentration = bright red color)
What dose a low PAWP indicate?
HoVolemia
What dose a low PAP indicate?
HoVolemia, low viscosity
What does the PR interval represent?
How long the impulse takes to go from the SA node to the Perkinje fibers
What are some characteristics of a hypermetabolic state?
HrGlycemia/HoGlycemia, insulin resistance (pancreas not working), catabolic state (breakdown), liver disfunction (can't make albumin and no filtering), lactic acidosis (liver doesn't work), electrolyte imbalances, metabolic acidosis, hematologic system (DIC)
What are signs and symptoms of autonomic dysreflexia?
HrTN, pounding headache, profuse sweating, nasal congestion, bradycardia, flushed/clammy skin, goosebumps
What does an increase in basophils typically indicate?
Hypersensitivities
What could a low CVP indicate?
Hypovolemia, decreased venous return (vasodilation), shock
When giving an IV bolus for sepsis to a morbidly obese or severely underweight patient, what is the bolus dose calculated with?
Ideal body weight
Describe characteristics of third degree
If Ps and Qs don't agree, then you have a third degree
Describe characteristics of first degree heart block
If R is far from P, then you have a first degree
When is a platelet transfusion indicated?
If platelets are at or below 20,000 OR if the patient is symptomatic
Describe characteristics of second degree type II heart block
If some Ps don't get through, then you have a Mobitz II
What does a "shift to the left" mean?
Increase in number of immature neutrophil bands
How does increased SVR affect the heart?
Increase myocardial O2 demand (Diminished ventricular compliance --> reduced stroke volume --> decreased CO)
What does a low PVR indicate?
Increased pulmonary blood flow and decreased pulmonary distention, lowest at functional residual capacity, pulmonary HoTN, pulmonary vasodilation, decreased respiratory pressures, administration of O2, relaxation of smooth muscles, medications - CCB, aminophylline
How does dopamine affect circulation?
Increases MAP
What area on the heart will lead II show and what artery?
Inferior area and RCA
What area on the heart will lead III show and what artery?
Inferior area and RCA
What area on the heart will lead aVF show and what artery?
Inferior area and RCA
What does CRP measure?
Inflammatory markers
What does LFT measure r/t sepsis?
Lactate is managed by the liver; high lactate could Ix decreased liver function
What are common labs to get for a patient with suspected sepsis?
Lactate, blood culture, procalcitonin, CRP, prealbumin/albumin, CBC, LFT, BUN/Creat
What does macrocytic RBCs mean and what are some examples?
Large average size RBCs Examples: Pernicious (folate deficiency) anemia
What area on the heart will lead I show and what artery?
Lateral side and circumflex
What area on the heart will lead V5 show and what artery?
Lateral side and circumflex
What area on the heart will lead V6 show and what artery?
Lateral side and circumflex
What area on the heart will lead aVL show and what artery?
Lateral side and circumflex
Which side of the heart and which hemodynamic pressure does cardiogenic shock affect?
Left side of heart - PAWP and SVR
What does a high PAP indicate?
Left to right cardiac shunt, COPD, PE, pulmonary edema, pulmonary HrTN, left ventricular failure, right sided valve disease
What does a high PAWP indicate?
Left ventricular failure, mitral valve disease, cardiac tamponade, constrictive pericarditis
Does lidocaine affect an ECG reading?
Little to no effect
What is the #1 sign of shock?
Low MAP
Vasopressin MOA, type of shock, nursing implications
MOA: ADH, nonadrenergic vasoconstrictor, increase MAP and urine output Type of shock: Shock states (most often septic shock) refractory to other vasopressors Implications: Given with NE and in low doses, infusions are not titrated, monitor hemodynamic pressures and urine output
Sodium nitroprusside MOA, type of shock, nursing implications
MOA: Arterial and venous vasodilation, decrease preload, afterload, CVP, PAWP, BP and increase or decrease CO Type of shock: Cardiogenic shock with increased SVR Implications: Continuously monitor BP, protect solution from light, wrap infusion bottle with opaque covering, give with D5W only, monitor serum cyanide levels and for signs of cyanide toxicity (metabolic acidosis, tachycardia, altered LOC, seizures, coma, almonds smell on breath)
Epinephrine (low doses) MOA, type of shock, nursing implications
MOA: B-adrenergic agonist (cardiac stim, bronchodilation, peripheral vasodilation), increase HR, contractility, CO and decreases SVR Type of shock: Cardiogenic and anaphylactic shock and septic shock if 2nd agent needed after NE Implications: Monitor for HR >110 BPM, dyspnea, pulmonary edema, chest pain, dysrhythmias from increased MVO2, and renal failure die to ischemia
Norepinephrine MOA, type of shock, nursing implications
MOA: B1 adrenergic agonist (cardiac stim), a-adrenergic agonist (peripheral vasoconstriction), renal and splanchnic vasoconstriction; increases BP, MAP, CVP, PAWP, SVR and increase or decrease CO Type of shock: Cardiogenic shock after MI, septic shock (first drug of choice for BP unresponsive to fluid resuscitation) Implications: Give via ventral line (infiltration leads to tissue sloughing), monitor for dysrhythmias due to increased MVO2 requirements
Hydrocortisone MOA, type of shock, nursing implications
MOA: Decrease inflammation, reverses increased capillary permeability and increases BP and HR Type of shock: Septic shock (requiring vasopressor therapy despite fluid resuscitation to maintain adequate BP) and anaphylactic shock (if HoTN persists after initial therapy) Implications: Monitor for HoK, HrGlycemia, and consider use as continuous infusion
Angiotensin II (Giapreza) MOA, type of shock, nursing implications
MOA: Increase BP, MAP, SVR Type of shock: Septic and other distributive shock Implications: Give via central line, monitor for thromboembolic events, VTE prophylaxis is recommended
Dobutamine MOA, type of shock, nursing implications
MOA: Increase myocardial contractility, CO, SV, CVP, Decreases ventricular filling pressures, SVR, PAWP and can increase or decrease HR Type of shock: Cardiogenic shock with severe systolic dysfunction, septic shock to increase O2 delivery and raise ScvO2/SvO2 to 70% if Hgb >7 or Hct >30% Implications: Give via central line (infiltration leads to tissue sloughing), do not give in same line with NaHCO3, monitor HR, BP (HoTN may worsen requiring additional vasopressor), stop infusion if tachydysrhythmias develop
Dopamine MOA, type of shock, nursing implications
MOA: Positive inotropic effects - increase myocardial contractility, automaticity, atrioventricular conduction, HR, CO, BP, MAP, MVO2 and can cause progressive vasoconstriction at high doses Type of shock: Cardiogenic shock Implications: Give via central line (infiltration leads to tissue sloughing), do not give in same line with NaHCO3, monitor for tachydysrhythmias and peripheral vasoconstriction at moderate to high doses
Nitroglycerine MOA, type of shock, nursing implications
MOA: Venous dilation, dilates coronary arteries, decreases preload, MVO2, SVR, and BP Type of shock: Cardiogenic shock Implications: Continuously monitor BP and HR since reflex tachycardia may occur, glass bottle recommended for infusion
Epinephrine (high doses) MOA, type of shock, nursing implications
MOA: a-Adrenergic agonist (peripheral vasoconstriction), increase SV, SVR, systolic BP, CVP and PAWP and decreases diastolic BP and widens pulse pressure Type of shock: Cardiac arrest, pV-Tach, V-fib, asystole Implications: Monitor for HR >110 BPM, dyspnea, pulmonary edema, chest pain, dysrhythmias from increased MVO2, and renal failure die to ischemia
Phenylephrine MOA, type of shock, nursing implications
MOA: a-adrenergic agonist (peripheral vasoconstriction), renal, mesenteric, splanchnic, cutaneous, and pulmonary blood vessel constriction; increase HR, BP, SVR, and increase or decrease CO Type of shock: Neurogenic shock Implications: Monitor for reflex bradycardia, headache, restlessness, renal failure (from decreased renal blood flow); give via central line (infiltration leads to tissue sloughing)
What is the most common WBC type in an elevated WBC? Uncommon?
Most common: Neutrophils Most uncommon: Basophils
What does serum lactate measure r/t sepsis?
Muscle breakdown --> metabolic acidosis
What are the symptoms for SIRS and how many do you have to have in order to be diagnosed with SIRS?
Must have at least 2/4 symptoms to have SIRS T >100.5 (38c) or < 96.8 (36c) HR >90 RR >20 OR PaCO2 <32 WBC >12000 OR <4000 OR 10%+ band cells
What is autonomic dysreflexia caused by?
Neurogenic shock
When is synchronized cardioversion delivered?
On R wave
When should you intervene with someone with bradycardia?
Only if they're symptomatic
What are some examples of obstructive shock?
PE, cardiac tamponade, pulmonary edema
What are the 2 non-shockable rhythms?
PEA and asystole
What does an increase in eosinophils typically indicate and what are some examples?
Parasite or anaphylactic reaction Examples: Parasitic infections, allergic rhinitis, hay fever, skin rashes
If the patient is sat up more than 45 degrees, what must be done?
Phlebostatic axis remeasured
What does CBC measure r/t sepsis?
Platelet count (DIC), WBC
What is thrombocytopenia?
Platelets <150,000
What is thrombocytosis?
Platelets >450,000
What drug class is amiodarone?
Potassium channel blocker
What is the treatment for SIRS and MODS?
Prevent and treat infection -strict asepsis, assess need for invasive lines, institute interventions to control infection once suspected Maintain tissue oxygenation -decrease O2 demand, increase O2 delivery: sedation, mechanical ventilation, manage pain, rest Meet nutrition and metabolic needs - Pt uses 1.5-2 times more energy, enteral better than parenteral, goal is to preserve organ function, monitor plasma transferrin and prealbumin levels to assess liver protein synthesis Support failing organs -ARDS: O2 therapy, ventilation -DIC: Heparin, blood products -Renal failure: renal replacement or dialysis
What effect does amiodarone have on an ECG?
Prolonged PR and QT intervals, widened QRS, bradycardia
What does PAP measure?
Pulmonary artery blood pressure
What does the PAWP measure?
Pulmonary capillary pressure, reflects left ventricular preload or left ventricular end-diastolic pressure
What are examples of noninvasive hemodynamic monitoring?
Pulse rate and quality, BP, skin temperature and color, CRT, pulse oximeter, LOC/mentation, weight, 7 Ps of peripheral circulation (Polar, pallor, pulses, perfusion, paresthesia, pain, paralysis)
What is another term for crackles?
Rales
What are consequences of inflammatory response from MODS?
Release of mediators, direct damage to endothelium, HrMetabolism, increse vascular permiability, activation of coagulation cascade
What does PVR measure?
Resistance or impediment of the pulmonary vascular system to blood flow - Right ventricular afterload
What dose SVR measure?
Resistance or impediment of the systemic vascular bed to blood flow - Left ventricular afterload
What does the P wave represent?
SA node firing
What is the equation for MAP?
SBP + (2 DBP)/3
What is sepsis?
SIRS with confirmed infection which can lead to organ dysfunction
What is the equation for CO?
SV x HR = CO
What is septic shock?
Sepsis with hypotension despite fluid resuscitation (30mL/kg for fluid resuscitation)
What area on the heart will lead V1 show and what artery?
Septal and LAD
What area on the heart will lead V2 show and what artery?
Septal and LAD
What is MODS?
Septic shock with 2+ organ failure --> liver failure --> body shuts down from toxins
What is DIC a common complication of?
Shock
What can SIRS lead to?
Shock --> MODS
What does microcytic RBCs mean and what are some examples?
Small average size of RBCs Examples: Iron deficiency, thalassemia
What drug class is lidocaine?
Sodium channel blocker
What is always at the phlebostatic axis?
Stopcock
What tool is used for invasive pressure monitoring?
Swanz-ganz line
What kinds of cardioversion are there?
Synchronized (shock) and adenosine
Why is getting a blood culture important r/t sepsis?
Type and sensitivity
What are some treatments for DIC?
Treat the root problem, correct hypovolemia, stop microclotting with heparin, stop bleeding with FFP (all clotting factors), cryoprecipitate (has factors VIII and XIII and fibrinogen), platelets (maintain >50,000 but don't transfuse until <20,000), PRBC
In the "getting gas vs shock" analogy, what does obstructive shock represent?
There is a block in the gas line
In the "getting gas vs shock" analogy, what does hypovolemic shock represent?
There is no gas
In the "getting gas vs shock" analogy, what does distributive shock represent?
There's a problem with the hose
What are some triggers of SIRS?
Tissue trauma - burns, crush injuries, surgical procedures Abscess formation - intraabdominal, extremities Ischemic or necrotic tissue - pancreatitis, vascular disease, MI Microbial invasion - bacteria., virus, fungi Endotoxin release - gram negative bacteria Global perfusion deficits - post cardiac resuscitation, shock states Regional perfusion deficits - distal perfusion deficits
What are some intrinsic triggers of DIC?
Transfusion reaction, septicemia, sickle cell disease, ARDS, Malignant Hrthermia
What are the 2 shockable rhythms?
V fib and pulseless V tach
What are CCBs like for the heart?
Valium (Calms the heart down)
What does a high SVR indicate?
Vasoconstriction (HrTN, HoThermia, aorta disease, aortic valve stensosi, viscous blood, stress response, cardiogenic shock, obesity, smoking, pain, fear - anything vasoconstrictive)
What does a low SVR indicate?
Vasodilation (Morphine, nitrates, CCBs, septic/anaphylactic/neurogenic shock - anything vasodilative)
What does the CVP measure?
Venous pressure in the R atrium; R ventricular preload/R ventricular end-diastolic pressure -- Fluid status
What is the pathophysiology of DIC?
Vessels vasodilate and become leaky --> vessels sustain damage --> coagulation factors try to fix damage but can't keep up because most/all clotting factors are being used --> bleeding through holes but also coagulation increases to fix the holes
What is the best way to prevent MODS?
Vigilant assessment - ongoing and monitor for early signs
What does an increase in lymphocytes typically indicate and what are some examples?
Viral infections Examples: Mono, measles, mumps, rubella, HIV, CLL
What are signs and symptoms of septic shock?
Warm, pink skin (early)/cool and pale skin (late), ARDS --> respiratory distress, altered mental status, decreased LOC
What will the QRS look like when the ventricles initiate a beat?
Wide QRSA
How is the PAWP measured?
With a balloon inflated
What does a low MAP indicate?
decreased blood flow through the organs
What does a high MAP indicate?
increased cardiac workload
What does prealbumin/albumin measure r/t sepsis?
vasodilation --> vessels become leaky --> edema and decreased BP --> decreased tissue perfusion