Critical Care Exam 2
What is the most common & preferred treatment for MI current or previous?
Percutaneous Transluminal Coronary Angioplasty (PTCA)
What level do you keep the arterial access at?
Phlebostatic axis - 4th ICS MAL
What are some complications of arterial line insertion?
Pneumothorax, heart perforation, dysrhythmias, infection
What is the best action by the nurse to level and zero a hemodynamic monitoring system transducer?
Position the air-fluid interface of the zeroing transducer at the phlebostatic axis (fourth intercostal space, midaxillary line).
What is the best action by the nurse to accurately record a thermodilution cardiac output (CO)?
Position the patient supine, obtain three values within 10% of each other, and calculate the average cardiac output.
What are the major determinants of cardiac output?
Preload, Afterload, Contractility, HR
Preoperative teaching for aortic aneurysm surgery
Preop teaching includes a brief explanation of the disease process the planned surgical procedures, preoperative routines, what to expect immediately after surgery (recovery rooms, tubes, and drains), and usual postop timelines
What are the goals of management of heart failure?
Prevention of progression and exacerbation relief of symptoms decreased mortality increased quality of life increased functional ability *Talk to the patient about their goals as well*
What is the difference between regurgitation and stenosis?
Stenosis--Valve will not open all the way Regurgitation-- valve will not close all the way
What is the best position for the nurse to place the patient in to obtain a right atrial pressure measurement?
Supine, either flat or with the head of the bed no more than 60 degrees
Pulmonary Artery Catheter
Swan Ganz, balloon tipped flow directed catheter that is inserted at the patient bedside; indirectly measures left heart pressures (it is in the pulmonary aorta) - can also measure cardiac output
What are some compensatory mechanisms for heart failure?
Sympathetic nervous system, renin-angiotensin mechanism, Atrial/B type natriuretic hormones, tissue necrosis factor, myocardial hypertrophy, and ventricular dilation.
What are some nursing diagnosis for heart failure?
Impaired gas exchange rt pul edema Decreased cardiac output rt dysfunction of valves, enlarged chambers Fluid vol excess rt pul edema Activity intolerance Sleep pattern disturbance Deficient Knowledge Anxiety
A 45-year-old male is visiting the wellness clinic and has been newly diagnosed as a stage I hypertensive patient. His blood pressure assessment over the past 6 months has consistently been 145/92 mm Hg. The patient asks, "What is blood pressure?" What is the best response by the nurse?
"A measurement that takes into consideration the amount of blood your heart is pumping and the size of the vessel diameter the heart must pump against."
The nurse explains to the new RN that angiotensin-converting enzyme inhibitors (ACE inhibitors) should be started within 24 hours of acute myocardial infarction (AMI). Which statement by the new RN indicates that teaching has been effective?
"ACE inhibitors are started within 24 hours to prevent myocardial remodeling."
When checking a patient's pulmonary artery occlusion pressure, the nurse inflates the balloon as ordered, not inflating the balloon for more than 8 to 10 seconds. The patient asks the rationale behind the nurse's actions. Which statement should the nurse make?
"Prolonged inflation can obstruct blood flow, resulting in ischemia."
The nurse is orienting a new RN to the ICU. The nurse begins to review orders recently entered by the cardiologist and to explain their rationale to the new RN. Medication orders include dobutamine (Dobutrex) 400 mg in 250 mL 5% dextrose in water titrated to keep cardiac index >2 L/min/m2. Which statement by the new RN indicates that teaching has been effective?
"The cardiac index is the measurement specific to the patient's size or body area."
Angina v. MI Discomfort:
-Angina: lasts <15 min, precipitated by activity, relieved by rest & NTG, few associated symptoms -MI: lasts >20min, occurs w/o cause in AM, relieved by opioids, frequent associated symptoms
What are common types of hemodynamic monitoring?
-Arterial pressure monitoring (A line) -Pulmonary artery pressure monitoring (Swan Ganz) -Right atrial pressure monitoring (RAP)
Nursing care of post cardiac surgery patient:
-Care of chest tubes -Monitor BP for hypotension -Monitor for hypovolemia -Monitor hemodynamic pressures & treat per protocol -Monitor & treat fluids & electrolytes -Provide pain relief -Wean from vent per protocol -Assess wounds/dressings
What is the action of Morphine Sulfate?
-Decrease pain of ischemia -Decrease anxiety -Decreases extension of ischemia by lowering O2 demands
What are the actions of Nitroglycerin?
-Decrease pain of ischemia -Increase venous dilation -Decrease venous blood return to heart -Decrease preload & cardiac O2 consumption -Dilates coronary arteries -Increase cardiac collateral flow
What does Fibrinolysis require?
-EKG w/significant ST segment elevation -Ongoing chest discomfort (>20 & <12hrs) -Oriented, can cooperate -Age >35 years (>40yrs female) -BP <180/110 **This is the biggest factor
What are precautions when giving Nitroglycerin?
-Hypotension -Extreme caution in RV infarction (inferior ST changes) -Headache, syncope, tachycardia -Make sure the pt. is sitting/lying during administration
What are the nursing responsibilities specific to Morphine
-IVP over 5 min, monitor RR - if <10, report, have Narcan available, monitor BP - if SBP< 90mmHg, elevate FOB, notify MD, teach pt to report any pain - goal is 0; re-evaluate pain using 0-10 scale every 5 min, advocate for anti-eme
How much blood should be withdrawn from the a-line as discard?
3-10mL - some systems allow blood to go back into the patient through a closed system
With Morphine you push over no less than how many minutes?
5 mins (2-4mg q 5-10min)
What is the most optimal timing for PTCA?
90 mins door to PCI
what is cardiogenic pulmonary edema ?
A complication of LVF. Blood volume is increased to the point where the LV can no longer handle the load--> Blood backs up into the lungs--> Hydrostatic pressure forces fluid out into pulmonary interstitial and alveolar spaces
What is the most common and life threatening complication for lytics?
A brain bleed
Goal of AFib and Aflutter therapy
Control Ventricular response-get rate below 100 (use diltiazem, then a beta blocker)
What is one drug given indefinitely post MI?
ACE inhibitors
What are some complications of an arterial line?
Air embolus is a major complication, hemorrhage is next worst, thrombosis, & infection (most preventable)
What other etiologies or precipitating factors are associated with heart failure?
Acute MI Coronary Heart Disease Valvular heart disease Cardiomyopathies System hypertension Pulmonary hypertension
List and prioritize the pertinent nursing diagnoses in this patient with acute inferior MI?
Acute pain, Decreased CO, activity intolerance, fear, denial, anxiety, knowledge deficit
What is the best understanding of mixed venous oxygen saturation by the nurse?
An overall picture of oxygen delivery and oxygen consumption.
What does the Left Anterior Descending artery supply?
Anterior LV, Anterior inter ventricular septum, Bundle branches, Apex of LV
What are the actions of Aspirin
Antiplatelet effect to prevent clot. Everyone gets it with ischemic chest pain unless you have an allergy
What causes heart failure?
Anything that decreases supply or increases demand of oxygen
If a patient had aortic stenosis where would you hear a murmur?
Aortic area (2nd intercostal space)
What is the etiology for an aneurysm?
Atherosclerosis
What is the most common risk factor for MI?
Atherosclerosis
What happens during systole?
Atrial Contraction, Ventricular contraction, Ejection Fraction
Atrial Flutter Salient Features
Atrial Rate-251-400/min, Regular P-P interval, R-R interval can be regular or irregular, Sawtooth baseline, QTI-UTC, PRI-UTC
What is the biggest worry with monitoring arterial pressure?
Bleeding
Why do the connections in the arterial line need to be tight?
Because it could lead to an air embolism
What should a patient with a history of CVD receive before the aortic aneurysm surgery?
Beta Blocker (Metoprolol, Lopressor)
Why are the Brachial and Femoral arteries not optimal for access?
Brachial can have issues with position and Femoral can lead to catheter related blood stream infections
What are some risk factors for heart failure?
CHD (heart disease), Valve disease, cardiomyopathy, HTN, and diabetes
Right Atrial Pressure "aka"
CVP - looks at right ventricular preload (volume)
What are diagnostic studies used for heart failure?
CXR-allows us to see fluid in the lungs EKG Labs: BNP--elevated levels indicate HF (the higher the levels the more severe the heart failure) Echocardiogram-Ultrasound of the heart that allows us to see the size of chambers and tells us the EF.
What are some ways to manage unstable angina?
Calcium channel blockers help to reduce symptoms. Early revascularization (e.g., angioplasty) may be helpful. It is best treated with rest and nitroglycerin.
What are some adjunctive therapies for heart failure?
Cardiac rehab--Effective for HF and must be ordered by a physician for insurance purposes Behavioral interventions--Control BP, diabetes
Why is MI the most common cause of LV failure?
Causes necrotic tissue, stiff non-compliant ventricle, decreased ventricular wall function, ventricular wall remodeling, and cardiomyopathy
What are the nursing responsibilities to control infection risk with an arterial line?
Change the dressing, bag, and tubing per protocol, document dates for insertion and dressing changes, assess for S&S of infection q4h, limit disconnection the system/sterile caps
What are the characteristics of cardiomyopathy?
Dilated/Congested chambers (overload of fluid) or Hypertrophy (thicker heart muscle, doesn't fill enough) - enlarged heart due to pathological process
What is the most common potential complication for MI?
Dysrhythmias (PVCs, Blocks, Bradycardia, etc.) - followed by Heart Failure because the bigger a MI the greater the likelihood of this
Name 2 primary diagnostic tools used for diagnosing CHF and when/why each is used
Echocardiogram: use for initial diagnosis; detects valve dysfunction and ventricular wall motion or lack of BNP: used to verify an episode of HF; indicative of Volume Overload
If a patient is unstable and in Atrial Fibrillation or Atrial Flutter what is the treatment?
Electricity - synchronized cardioversion
What is the goal of Morphine Sulfate?
Eliminate pain (0) - you don't want any pain because it it triggers the SNS = increased work of heart
What is the significance of dilated/congested chambers in cardiomyopathy?
Enlarged chambers occurs as a result of constant fluid overload (Diastolic issue)
What can cause severe respiratory distress and what are the interventions?
Flash pulmonary edema can cause severe respiratory distress (QUICKLY). The interventions are intubation, ventilation, and diuretics
What are the nursing responsibilities for maintaining patency of an arterial line system?
Flush after each use, Maintain pressure of 300mmHg on the bag, and ensure adequate amount of flush solution
Cardiac Output Formula
Heart Rate x Stroke Volume -Normal: 4-8L/min
What are some surgical interventions for heart failure?
Heart transplant, Valve repair/replacement, CABG, Implanted Cardioverter defibrilltor (ICD), Partial left ventrculectomy, Biventricular pacing (CRT), and heart jacket.
Definition of Heart Failure
Heart's inability to meet the oxygenation needs of the body as a result of decreased pumping ability or decreased filling ability or both
How does pulmonary hypertension cause right ventricular failure?
Increased pulmonary artery pressures causes an increase in right ventricular workload. Increases afterload in RV. *Measure wedge pressure - will be high
What is the mechanism of action for Heparin?
Indirect Thrombin inhibitor -thins blood
MI Description
Infarct = death of tissue, blood flow has to be significantly decreased to cause an MI. -Myocardium abruptly & severely deprived of O2 -Blood flow lowered by 80-90% —> ischemia —> necrosis if flow not restored -Types: full thickness and partial thickness
Complications of Pulmonary Artery Catheter?
Infection, dysrhythmias, air embolus, thromboembolism, PA rupture, pulmonary infarction
Is Intraarterial BP or Peripheral Cuff monitoring more accurate?
Intraarterial BP - it should be higher
Infarct at lateral affects what?
L circumflex
Infarct at posterior affects what?
L circumflex
S&S of Left Sided Heart Failure:
L=Lungs -Shortness of breath/dyspnea -Fatigue -Cough -Frothy Sputum -Tachypnea -S3 -Tachycardia -Pulsus Alternans (weak beat, strong beat alternating) -Crackles -Orthopnea -Increased PCWP -Dysrythmia-AFib most common -Pulmonary edema-most serious complication
What does the Left Circumflex artery supply?
LA, Lateral LV, Posterior LV, Posterior inter ventricular septum
Infarct at anterior LV affects what?
LAD
Infarct at septal affects what?
LAD
What is the most common cause of right sided heart failure?
Left sided heart failure
What are some causes of right ventricular heart failure?
Left ventricular heart failure, Pulmonary hypertension, and Right ventricular infacrtion.
What are the reliable measures for hemodynamic monitoring?
Level, Balance, Calibration, and Square wave test
Where would you hear a murmur in mitral stenosis?
Mitral point (5th intercostal space)
What is the treatment for an aneurysm?
Monitor growth, control HTN (B/P), Surgery if 5.5cm or more (AAA repair)
During insertion of a Pulmonary Artery Catheter (Swan Ganz) what are nursing responsibilities?
Monitor pressures in each chamber, record values, Assess for complications (dysrhythmias, pneumothorax)
Name the nursing responsibilities for hemodynamic monitoring?
Monitor the waveform, compare the value against the cuff (at least 1x per 8hr. shift), check connections in the system to make sure they are tight, check the site and check pulses for circulation, set alarms, hold pressure for at least 5mins. when DC'd, maintain patency, and control infection risks
What are the cardiac enzymes?
Myoglobin, CK-MB, Troponin I, Troponin T
What are the most common signs and symptoms of a MI?
N/V, SOB and S4 Gallop "blub dub" (S1 has 2 sounds)
Do cardiac enzymes elevate with NSTEMI or with Angina?
NSTEMI
How does right ventricular infarction cause Right ventricular failure? *Inferior MI of right ventricle
Necrotic tissue that leads to decreased wall motion, decreased stroke volume and decreased cardiac output.
A patient is complaining of midsternal chest discomfort radiating down the right arm. The discomfort has been present for about 5 minutes. The patient is also asthmatic and allergic to calcium channel blockers. The nurse anticipates an order from the health care provider for which medication?
Nitroglycerin sublingual -These are symptoms of angina. Administration of nitrates is indicated as a first-line treatment.
What pharmacologic agents are used to improve cardiac performance in the patient with congestive heart failure?
Nitroglycerin, Nitroprusside, Catopril, Positive Inotropes (Dopamine), and Digoxin
The actions of Aspirin reduce what?
Overall Mortality from AMI, nonfatal reinfarction, nonfatal stroke
semilunar valves
Pulmonic and Aortic
What does the right coronary artery supply?
RA, RV, Posterior interventricular septum, SA node & tracts, AV node, Inferior LV
Infarct at RV affects what?
RCA
Infarct at inferior affects what?
RCA
What is the preferred site for intraarterial pressure monitoring?
Radial - Must do the Allen Test for circulation before starting this line. You need a patent ulnar artery for this.
What are the sites of intraarterial pressure monitoring?
Radial, Brachial, and Femoral
What medications manage hypertensive crisis?
Rapid acting IV antihypertensive meds -Nipride & Labetalol
What are some complications of hypertensive crisis?
Renal failure, left ventricular failure, stroke
What is the main concern for aneurysm?
Rupture
How do you recognize a MI in a 12 lead EKG?
ST elevation >1 mm Must occur in more than 1 buddy lead
What is the indication of Beta Blockers?
STEMI or NSTEMI once stable but NOT in early management
What is the indication for Fibrinolytic Therapy?
STEMI when PCI (stent or balloon) is not available -Time of onset >20min but less than 12hr -Door to drug time 30mins
What is the significance of hypertrophic tissue in cardiomyopathy?
The heart muscle is enlarged due to increased afterload making the heart work harder. (Systolic issue) The walls of the heart are thicker and the chambers are small.
You give morphine until when?
The pain is relieved, hypotensive, or bradypnea
The nurse is educating a new RN on preparing a patient for assessment of cardiac output using an esophageal monitor. Which statement by the new RN indicates that teaching was effective?
The procedure involves a thin probe inserted into the esophagus.
When are surgical interventions for heart failure necessary?
They are used when medical interventions were not effective.
Initial Assessment during an MI includes:
VS, ECG, Cardiac Enzymes (troponin), Electrolytes, Coag studies, CBC, H&P —all within 10mins, Chest X-ray- 30mins
What are some things the nurse should be looking for and intervene to?
Watch for and intervene to limit and treat cardiac ischemia, dysrhythmias, Infections, VTE, and neurological complications.
What are some precautions to take when administering Morphine Sulfate?
Watch for drop in BP (if it falls raise foot of bed 20-30 degrees & lower head of bed, IV fluid bolus), depression of ventilation, N/V (ask for antiemetic if not ordered because you want to prevent vomiting), bradycardia
How do you measure Left Heart Preload?
Wedge Pressure *Norm-6-12mmHg
When does O2 help a patient with acute coronary syndrome?
When the SPO2 is less than 94% or other indications show hypoxemia
How do you balance an arterial line?
Zero balance it (this negates atmosphere pressure)
Where do 75% of aneurysms occur?
abdominal aorta
What is an aneurysm?
an excessive localized enlargement of an artery caused by a weakening of the artery wall.
How is contractility measured?
as Ejection Fraction (SV/ EDV), 60-70% is normal
When is an aneurysm detectable?
at 5cm or more
what does mitral regurgitation lead to?
decreased LV output, regurgitation into LA, LA dilation, Pulmonary congestion, RV failure. The stroke volume is divided
What does mitral valve stenosis lead to?
decreased LV preload, decreased stroke volume and decreased cardiac output. LA gets full and backs up to the lungs
Who is most likely to have atypical presentation?
diabetics, women, the elderly (> 80)
What is the significance of Left ventricular failure as it relates to right ventricular failure?
incresed LV volume and pressures that leads to increased LA volume and pressures, which leads to increased pulmonary volume and pressures, and causes increased right ventricular workload. Remember everything form the left side is backing up into the right side.
ST depression indicates what?
ischemia
What are Nursing Care interventions for Hypertensive Crisis: Potential for for decreased cardiac output r/t LV dysfunction?
monitor VS, I&O, BP & cardiac rhythm
The patient presents to the emergency department with severe substernal chest discomfort. Cardiac enzymes are elevated, and his ECG shows ST-segment depression in V2 and V3. The nurse anticipates a diagnosis of:
non-Q-wave myocardial infarction (MI). -The non-Q-wave MI usually results from a partially occluded coronary vessel, and it is associated with ST-segment depression in two or more leads, along with elevated cardiac enzymes.
Hemodynamics
physical principles of blood flow based on pressure and resistance
What are Nursing Care interventions for Hypertensive Crisis: Potential decreased cerebral tissue perfusion r/t increased ICP secondary to CVA and cerebral edema?
rest & monitor pt. , BP monitor
To Increase Cardiac Output what needs to increase?
stroke volume, heart rate, or both
Ventricles
the two lower chambers of the heart-pumping chambers separated by inter ventricular septum
Atria
the two upper chambers of the heart-collection chambers or reservoirs separated by intertribal septum
PTCA indications
treatment of choice for STEMI if can be done in < 90 min of admission, also used w/NSTEMI, UA. lower mortality than with lytics, primary success > 90% of the time.
AV Valves
tricuspid and mitral
Atypical MI presentation:
-Pain that is: vague ache poorly localized or absent -Others: sleep disturbance (women), N/V, diaphoresis, SOB (women, elderly), Fatigue (women), back pain, syncope (elderly)
What does aortic regurgitation lead to?
It doesn't close (leaky/incompetent-blood reflux back from aorta) thus - Increased left ventricular preload and decreased cardiac output. because the valve wont close all the way the blood will back up and eventually lead to wet lungs.
Why does hypertension lead to left ventricular heart failure?
It increases after load -->systemic vasoconstriction & aortic stenosis
What does aortic stenosis lead to?
It is narrowed & won't open all the way thus - increased left ventricular afterload and work, decreased cardiac output, incomplete atrial emptying, pulmonary congestion, and right ventricle strain.
Nursing Implications for PTCA:
-Preprocedure: informed consent, shave prep, IV, teaching, get allergies -Postprocedure: check site for bleeding, VS every 15mins, check for reocclusion (look for any ST elevation), dye reaction, cardiac rhythm, encourage fluids (dye can cause acute kidney injury), & circ. checks
What are the indications for Morphine Sulfate?
-STEMI -Consider in NSTE-ACS -Evidence of Acute Pulmonary Edema -Systolic BP>90 -No hypovolemia
What is the difference in an open sternotomy vs. minimally invasive-mid CABG?
-open sternotomy = chest opened completely and heart is stopped and put on bypass -min invasive = minor cut over area & doesn't require coronary bypass
Plavix is given for how long is someone has had STEMI
1 year (given with or without lyrics for first 14days)
What are the goals of treatment for a MI?
1) Limit Infarct size 2) Reprofuse ischemia/injured area 3) Prevent/treat complications 4) Provide emotional support & education
What are some post op goals following aortic aneurysm surgery?
1. Maintain adequate respiratory function 2. Fluid and electrolyte blance 3. Pain control 4. Graft patency (Adequate BP is needed to maintain patency, prolonged low BP can lead to graft thrombosis) 5.Renal Perfusion
What is the indication for GPIIBIIIA inhibitors?
ACS with NO ST elevation -unstable angina -ua undergoing PCI
What is the only NSAID recommended for cardiac patients?
Aspirin - decrease all others because they have higher mortality, incidence of reinfarction, incidence of HPTN, and increased incidence of CHF
What is the only compensatory mechanism that is effective? why?
Atrial/ B type natriuretic hormone are the only effective compensatory mechanism because they encourage the body to excrete 5-10x normal amounts.
What is a CABG?
Coronary Artery Bypass Grafting - surgical procedure in which the ischemic area of the myocardium are revascularized by implantation of a graft
What are manifestations of pulmonary edema?
Crackles SOB Disorientation Anxiety Tachycardia Cold, Clammy skin Cyanosis
As the fluid fills lungs in Pulmonary edema, what sound would we hear upon auscultation? Where would we hear it?
Crackles will be heard upon auscultation. They will be heard low and move up and the edema progresses.
What is the primary nursing diagnosis for decompensated Heart Failure?
Impaired Gas Exchange (they are hypoxic)
What are medical interventions for heart failure?
Intra-aortic balloon pump, Balancing oxygenation & activity (LVAD/RVAD), Fluid and electrolyte balance (sodium & fluid restriction, daily weight, monitor potassium levels, strict I&O), Phramacological therapy
What is the action of Fibrinolytic Therapy?
It breaks up fibrin network that binds clots
Why does coronary artery disease lead to left ventricular heart failure?
It decreases the blood supply to the myocardium thus increasing the workload of the left ventricle
What are some causes of left ventricular heart failure?
Myocardial infarction-most common, Coronary artery disease (aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, & cardiomyopathy), and hypertension
What are the indications for Heparin?
PTCA or CABG -With fibrin-specific lytics x 48hrs (if longer use Lovenox) -STEMI w/without repercussion up to 8 days
Priority nursing diagnosis for a patient suffering from a MI?
Pain R/T myocardial infarction, ischemia, or reduced coronary artery blood flow
What is included in the postop care for a client following aortic aneurysm surgery?
Patient will be in an ICU for 24-48hrs follwong surgery for close monitoring, the patient may have ET tube, Foley catheter, NG tube, and a CVP, PA cath or an A-line. The patient will need continuous EKG and pulse ox monitoring. Pain meds are given via epidural catheter or PCA.
What are some preoperative routines for an aortic aneurysm surgery?
This varies by agency and surgeon. In general, there is bowel prep (laxatives, enema) and skin cleansing with an antimicrobial agent the day before. NPO after midnight the day of surgery, and IV antibiotics immediately before the incision is made.
What are the manifestations of an aneurysm?
back pain, flank pain, abdominal pain, abdominal bruit
What are the indications for continuous ST Segment Monitoring?
-Early phase: STEMI, NSTE-ACS, UA, R/O MI -Pts. in ED with chest pain -Pts. who had PCI with suboptimal results -Pts. with variant angina (vasospasm)
Discuss the indication, actions, and side effects of intravenous fibrinolytic administration
-Elevated ST segment of greater than or equal to 1mm in at least two buddy leads; IV route; bleeding, arrhythmia, ICH (intra cranial hemorrhage
High right atrial pressure (CVP)
-Generally high volume=high pressure -Hypervolemia - give diuretics -Vasoconstriction - give vasodilators (nitroglycerin/nitroprusside) -Right CHF -Pulmonary Hypertension
Low right atrial pressure (CVP)
-Generally low volume = low pressure -Hypovolemia - give a fluid bolus -Vasodilation - give a vasopressor (norepinephrine, dopamine) - only treat with this when you know there is adequate volume on board
Describe the typical pathophysiological process of CHF and pulmonary edema:
-Heart failure is the inability of the heart to pump sufficient blood to meet the body's demands. -Failure may begin with the left or right ventricle or occur simultaneously inboth ventricles, depending upon etiology. -A common presentation is left ventricular failure leading to pulmonary edema and subsequent right ventricular failure. -Left ventricular stroke volume falls due to disease or injury. The right ventricle continues to pump blood into the pulmonary circulation as left ventricular volumes and pressure rise. Rising pressures soon occur in left atrium and pulmonary circulation causing dyspnea. Pulmonary edema begins as pulmonary capillary oncotic pressure is exceeded and fluid extravasates into the interstitial spaces, generally causing cough and sputum production
S&S of Right Sided Heart Failure:
-JVD -Peripheral edema -Weight gain-earliest indicator (2lbs in 24hrs) -Increased right atrial pressure -Hepatomegaly -Anorexia -Nausea -Vomiting -Splenomegaly -Ascities
Typical Presentation of an MI
-P-preciptating factors (w/out cause, early in morning) -Q-quality (crushing, tightness, burning, vice-like, heavy *not sharp) -R-Region/radiation (substernal, jaw, neck, back ears, LA -S-Severity (scale) -T-Timing/treatment (lasts > 20min, relieved by opioids)
List priority nsg dx and give 1 expected outcome and 4 specific msg interventions:
-Pain r/t ineffective cardiac tissue perfusion secondary to MI AEB: verbal c/o pain -Outcome: ---Pain of "0" -Interventions: NTG - monitor BP q5min; hold NTG if SBP<90, elevate FOB & notify MD, MSO4 2-5 mg q5 Min until pain is relieved (see previous interventions specific to MSO4) assess pain q5 min using 0-10 scale, assess quality of pain, teach pt to report anypain, provide calm, quiet, restful environment
The nurse needs to obtain a cardiac output measurement from a patient who has just had a pulmonary artery catheter inserted. What are important interventions for ensuring accurate pressure and cardiac output measurements?
1. Zero reference the transducer system at the phlebostatic axis. This is a priority action. 2. Ensure rapid injection of fluid through the injectate port. Rapid injection of the appropriate solution will ensure more accurate readings.
A Fibrillation Salient Features
Atrial Rate-UTC, Ventricular Rate-Irregular, No P wave, PRI-UTC
What happens during diastole?
Atrial relaxation, Ventricular relaxation
The nurse is caring for a patient who is being monitored with a central venous catheter. In preparing to record a right atrial pressure reading, what is most important for the nurse to keep in mind when recording an accurate value?
Record the pressure at the end of expiration.
What are indications for intraarterial monitoring?
Continuous BP monitoring, Blood drawing, & Vasopressor Infusions
Other S&S of an MI include:
Diaphoresis, dizziness, weakness, palpitations, denial, feeling of doom, ST with PVBs, elevated temp, elevated BP, Cool ext w/ decreased pulses
What is malignant hypertension?
Malignant Hypertension is rapidly progressive, uncontrollable and causes a rapid onset of complications *SBP>200 DBP>130
Why are hemodynamics important in critical care?
Monitoring is used extensively in patient assessment and decision making - improves outcomes and points to appropriate interventions
What are some clinical manifestations of hypertensive crisis?
Morning headaches, blurred vision, dyspnea, Increased ICP (indocranial pressure)
To treat pain in an MI what drug is the drug of choice?
Morphine sulfate
What is the procedure for cardiac output monitoring using and esophageal monitor?
The procedure involves insertion of a thin silicone probe into the distal esophagus. The probe is easily placed similarly to an orogastric or nasograstric tube, so patients require little to no sedation. The procedure provides an immediate assessment of left ventricular performance. There are several contraindications to the procedure, including esophageal stricture and esophageal varices.
Fibrinolysis aka
Thrombolytic (clot busters)
What is the most important cardiac enzyme?
Troponin (I&T) <-- greater sensitivity and specificity than CK-MB
The patient, who is being treated for hypercholesterolemia, complains of hot flashes and a metallic taste in the mouth. The nurse educates the patient that this is a side effect of:
nicotinic acid -Common side effects of nicotinic acid include metallic taste in mouth, flushing, and increased feelings of warmth.
