FINAL EXAM

o Metabolic acidosis § HCO3____ pH___ § Causes · Increased acids o Renal failure o Ketoacidosis o Anaerobic metabolism o Starvation · Loss of base o Diarrhea o Intestinal fistulas § Sx · HA · Confusion · Restlessness · Lethargy · Weakness · Stupor/coma · Kussmaul respiration · n/v · dysrhythmias · warm, flushed skin

<22, >7.35

- Normal ABG o PaO2: o SaO2: o pH: o HCO3: o PaCO2:

- Normal ABG o PaO2: 80-100 o SaO2: 93%-99% o pH:7.35 - 7.45 o HCO3: 22-26 o PaCO2: 35-45

o Respiratory alkalosis § PaCO2 ___, pH___ § Causes · Anxiety & nervousness · Fear · Pain · Hyperventilation · Fever · Thyrotoxicosis · Palpitations · Salicylates · Gram negative septicemia · Pregnancy § Sx · Light headedness · Confusion · Dec concentration · Paresthesia · Tetanic spasms · Cardia dysrhythmias · CNS lesions · Sweating · Dry mouth · Blurred vision

<35 >7.45

Ø Parkland Formula o 2-4 cc Ringers Lactate x Kg body weight x percent burned o Give the first half over the first 8 hours and the remainder over the next 16 hours § __ cc - thermal burns § __cc- radiation burns § __cc for electrical burns o Titrate fluids to maintain urine output of 0.5 ml/kg/hr or __-__ ml/hr in adults § Give until they pee · ___ __ is the single best indicator of fluid resuscitation in patients with previously normal renal function · First 24 hours: LR solution (4 ml/kg/% TBSA); half given over first 8 hours, remaind given over 16 hours · Second 24 hours: dextrose in water, plus K+ -- and colloid containg fluid (0.3-0.5 ml/kg/%TBSA)

2,2, 4 30-50 Urine output

TBI Management o Preventing and treating seizures o Antiseizure medication in the first __ ___ after TBI o Seizures that occur in the intial first 7 days are correlated to more ___ TBI o ___ is one of the most common drugs used in the acute period. § Monitored closely for hypotension, bradycardia, rashes and IV infiltration § The drug should be discontinued at the appearance of rash. o ____ can be administered rapidly without the infusion site reactions associated with phenytoin. o New drug - levetiracetam Managing nutrition and maintaining glycemic control o ____ ___ is useful in determing resting energy expenditure o ___ or ___ nutrition o Detrimental effect of ____ on morbidity and mortality o Hyperglycemia (blood glucose exceeding ___ mg/dL) and ___ should be avoided in patients with TBI.

7 days severe Phenytoin Fosphenytoin Indirect calorimetry Enteral or parenteral hyperglycemia 200 hypoglycemia

Arterial Pressure Monitoring - The system is maintained by a pressure of ____ mm Hg and a continuous flush of about __-__ ml/hr to prevent backflow of blood into the tubing - 2 ways to test the accuracy of the systems o ___ ___ __ § Rapidly pulling and releasing the flush piggy tail on the transducer § An overdamped wave form - pressure may appear too low § An underdamped wave form - pressure may appear too high o ___ & ___ § level the transducer at the phlebostatic axis (4th ICS, midaxillary line) § turn all stopcocks ___ (turns the system off) § remove the nonvented cap and press the zero option § higher then the axis - pressure appears too _____, lower then the axis - pressure appears too ___ § always ___ the transducer when repositioning the patient! § You may accidentally treat a false low/high blood pressure - Steps to trouble shooting a sketchy BP o Ensure the pressure is at ___ mm Hg o Make sure there is ___ in the bag o Make sure the stopcocks are turned in the appropriate direction o Check patency of the tubing by manually flushing o If these are all accurate ... then measure the ____ ___

300 3-5 Square wave test zeroing and leveling upward low high relevel 300 fluid noninvasive pressure

o Prevent shivering § Shivering often occurs between __ - ___minutes. § Increases metabolic rate, oxygen consumption, CO2 production, and myocardial workload · _______ (med) § If left ventricle is compromised, shivering can be managed with a ___ ___ in combo with simultaneous ____ § After rewarming, patients may experience an ____ in body temp · Narcotics and anesthetics administered during surgery may ___ hypothalamic regulatory center, altering peripheral blood flow and feedback. § ___ ___ regulation is important in preventing bleeding to aid in the return of normal coagulation function.

90 and 180 Meperidine (Demerol) neuromuscular blocker sedation overshoot reset Core temperature

tPa o Inclusion criteria § Symptom onset of less than __hours § Dx of ____ __ with measurable deficit on the NIHSS § Older than ___ § CT criteria: no evidence of ____ __ (high hypodensity over one third hemisphere) or ___ ___ o Exclusion criteria § ___ or ___ within past 3 months § Systolic BP___ or diastolic BP __ that is refractory to IV meds § Conditions that could precipitate or suggest ____ ___ (subarachnoid and intracerebral hemorrhage, recent I, seizures at onset, GI or urinary tract hemorrhage within previous 21 days and arterial puncture of a noncompressible site or LP within previous 7 days) § Glucose ___; INR __; PLT ____ § Recent tx with IV or SQ ___ within 48 hours and elevated PTT § Women of childbearing age who have a positive pregnancy test, major surgery or serious trauma within past 14 days, seizures at onset with postictal neurologic impairments, acute __ within 3 mo, rapidly improving stroke symptoms or only minor symptoms

4.5 ischemic stroke 18 multilobar infarction intracerebral hemorrhage) Stroke or serious head trauma >185, >110 parenchymal bleeding <50 >1.7 <100,000 heparin MI

Ø Infection o What is the main function of the skin? § Leading to compromise in the immune system o Most common cause of death in burn patients after the first __ days o Loss of mechanical barrier between the human body and the environment is the first step in the weakening of defenses o All catheters invading the body must be handled with ___ __ o Colonization of abx resistant pathogens is a great threat! o Hand washing is imperative- ensure compliance with hand hygiene protocols by ALL health care team members! § Before/after handling patient, pt bed, or equipment § When dressings are removed and wounds are exposed - ___ ___! o Diagnosed by appearance of ____ in the urine; blood glucose levels are normal o Patients who are septic have trouble regulating their ___ ___ levels o Manifestations of multisystem organ dysfunction: § Hypotension, hypoxia, dec pulmonary compliance, renal failure or hepatic dysfunction ** ____ __ § Burn sepsis is likely if the colony count is >105

7 clean technique~ sterile gloves glucose blood sugar septic shock

monitor for postop bleeding o Causes of platelet dysfunction and postop bleeding § Aspirin § Bypass machine § IABP § Heparin induced thrombocytopenia o Elevated PT (___sec) may indicate that bleeding is due to lack of factors such as ____ - can be replacd with ___ 4-6 units/infusion o Is bleeding due to coagulopathy or surgery? o Chest tube bleeding ____ml/h is surgical bleeding and mandates surgical reexploration!

>15 fibrinogen FFP >500

o metabolic alkalosis o HCO3 ___, pH___ o Causes § Gain of base · Excess ingestion of antacids · Excess use of bicarb · Lactate administration in dialysis § Loss of acid · Vomiting · Nasogastric suctioning · Hypokalemia · Hypochloremia · Administration of diuretics · Inc. levels of aldosterone o Sx § Muscle twitching with cramps § Tetany § Dixxiness § Lethargy § Weakness § Disorientation § Convulsions § Coma § n/v dec respirations

>26 >7.45

o Respiratory Acidosis § PaCO2 __, pH___ § Possible cause · Head trauma · Over sedation · Hypoventilation · Bronchial obstruction and atelectasis · Severe pulmonary infections · Heart failure & pulmonary edema · Massive PE · Myasthenia gravis · MS · CNS depression · Anesthesia · High cord injury · pneumothorax § Sx · Dyspnea · Restlessness · HA · Tachycardia · Confusion · Lethargy · Dysrhythmias · Respiratory distress · Drowsiness · Dec responsiveness

>45 <7.35

Poison/overdose Absorbents o Solid substance that has the ability to attract and hold another substance to its surface o ____ __ - effective nonsepecific adsorbent § absorbs the drug or toxin to its large surface area and prevents absorption from the GI tract. § Given as a slurry with water, orally/nasogastric/orogastric tube asap after ingestion § Usual dose is one __ g bottle § More than one dose is controversial but may be given to overdoses of large quantities of aspirin, valproic acid, and theophylline § Used cautiously with ____ bowel sounds and is contraindicated in patients with ____ ___.

Activated charcoal 50 diminished bowel obstructions

___ ___ ___ o Rapid onset of inadequate gas exchange - ____ in which PaO2 is less than 50 mm Hg, or ____ in which PaCO2 is 50 or greater, or pH of 7.25 or less. o Causes: injury to chest wall, lungs, and airways, or as a result of pulmonary disease o Complication to ____ § atelectasis, pulmonary edema, pneumonia, and pulmonary emboli Ø Pathophysiology o paO2 of ___ mmHg or less, a paCO2 greater than ___ mm Hg and an arterial pH less than ___ o in chronic hypoxemia or hypercapnia ~ acute deterioration of blood gases relative to their previous levels o may result from malfunction of the respiratory center, abnormal respiratory neuromuscular system, chest wall diseases, airway obstruction or parenchymal lung disorders o positive feedback mechanisms of continued hypoxemia and hypercapnia o hypoxemia affects every organ and tissue and hypercapnia impairs cellular functions o in acute hypercapnia, arterial blood pH is decreased ~ ____ ___ o patients with advanced COPD and chronic hypercapnia may exhibit an acute rise of ___ to a high level, a decrease of ___ ___, and a significant inc in ____ ___ during the onset of acute respiratory failure.

Acute Respiratory Failure hypoxemia, hypercapnia surgery 55, 50, 7.35 respiratory acidosis PaCO2 blood pH serum bicarbonate

Endocarditis o Management § Rapid dx, appropriate treatment and early identification of complications! § ___ ___ is based on culture results and the clinical setting § Begin treatment as soon as blood cultures are drawn § Immediate ___ ____ is indicated in the presence of native or prosthetic valve dysfunction or dehiscence, severe congestive HF secondary to valve dysfunction and uncontrolled infections § Cure of IE is difficult - requires complete eradication of the bacterial colony from the vegetation. · Involves ___ ___ therapy.

Antibiotic therapy surgical intervention prolonged abx

o ____ ____ § Prevent! § Cardiac decompensation or cerebrovascular accidents are major risks § Develops in up to ___ of patients who have undergone open heart procedures, which has led to prophylactic treatments with beta blockers before and after surgery § New onset a fib · Goal: conversion to sinus rhythm using antiarrhythmics (_____) · Control of ventricular response is a goal that can be achieved with _____. · IV beta blockers (_____) are used and administered in small boluses. § If afib lasts longer then ___hours, cardioversion is NOT a goal due to the risk for atrial ____ and possible ____ § If emergent cardioversion is required in the immediate postop period and ____ is not an option, ____ ____ may be performed to check for thrombus formation in the left atrium

Atrial fibrillation 40% amiodarone diltiazem metroprolol 48 thrombus, embolization anticoagulation transesophageal echocardiography

Signs of trauma or infection ___ ___ (bruising over the mastoid areas) suggests a basilar skull fracture. ___ ___ (periorbital edema and bruising) suggests a frontobasilar fracture. _____ (drainage of CSF from the nose) suggests fracture of the cribriform plate with herniation of a fragment of the dura and arachnoid through the fracture. ___ ___ (drainage of CSF from the ear) is usually associated with fracture of the petrous portion of the temporal bone. Signs of ___ ___ include nuchal rigidity (ie, pain and resistance to neck flexion), fever, headache, and photophobia. Signs of increased intracranial pressure Establish baseline neurologic assessment Increased ICP: Decreased LOC, restlessness, confusion, combativeness Lethargy, obtundation, coma Sluggish pupils to fixed and dilated, unequal pupils Changes in motor function Changes in ___ are a late finding. Cushing triad: 3

Battle sign Raccoon eye Rhinorrhea CSF otorrhea meningeal irritation VS increased systolic pressure, bradycardia, decreased irregular respirations

§ Intensive and Intermediate Care Management o Goal: maximizing ___ while carefully minimizing ____ __ § Frequently take VS and continues on cardiac monitor with ST segment monitoring o For the first __ hours of hospitalization, patients who are hemodynamically stable and free of ischemic type chest discomfort remain on ___ __with bedside commode privileges o Maximal pain relief - ___ is NOT an appropriate substitute for analgesics o Oxgen for patients hypoxic (<90) o Often ___ until PAIN FREE o When pain free § ___ __ and progressed to a heart healthy diet as tolerated o Record 2 o Stool softeners to avoid ___ __ § Forced expiration against closed glottis causes sudden and significant changes in systolic BP and HR § Risk for ____ ___

CO cardiac workload 12 bed rest nitroglycerin NPO Clear liquid daily weights and IO Valsalva maneuver ventricular dysrhythmias

· Indications for Use § Provides assessment of RV function, pulmonary vascular status, left ventricular function, right atrial, right ventricular, and pulmonary artery pressures, and pulmonary artery occlusion pressure as well. § Pulmonary artery pressures with thermistor have the ability to obtain the ___ & ___ § Allows clinicians to calculate parameters and determine diagnosis of cardiovascular and cardiopulmonary dysfunction, determine the therapy needed, and evaluate the effectiveness of interventions. § Pulmonary hypertension, cardiogenic shock, mixed shock states, cardiac tamponade, mechanical complications associated with STEMI

CO and the temperature

o ____ ____ is a serious complication of postop bleeding that occurs when excessive fluid or blood accumulates in the pericardial space ~ increasing pressures on the right atrium and ventricle that can lead to ____ of those structures § Collapse of the lower pressure chambers of the right heart as a result of the increasing of the ___, ____ ___ ___ and the ____. § This increase and equalization of the three values is classic evidence of cardiac tamponade § An ___ ___ __ with significant respiratory variation is another warning sign § Definitive diagnosis is made with an ____ § Interventions to prevent: · ____ & ____ chest tubes when blood begins to clot · Infusion of ____ even with ____ ___ to keep structures from collapsing.

Cardiac tamponade collapse CVP pulmonary artery diastolic pressure PAOP arterial line waveform echocardiogram Stripping and milking volume increased pressure

MSK injuries o ____ ___ § The pressure within the fascia enclosed muscle compartment is increased, causing blood flow to the muscles and nerves in the compartment to become compromised. Results in cellular anoxia; it is compromised. Ischemia ~ ___ __, which compromises nerve and muscle function. Prolonged elevation of compartmental pressure ~ death of the muscles and nerves involved. § Normal compartment pressure is __-__ mm Hg § Capillary blood flow is believed to become compromised at __ mm Hg, pain develops at a pressure between __-__ mm Hg, and ischemia occurs at pressures greater than __ mm Hg § ____ is recommended when the compartment pressure approaches 20 mm Hg below the diastolic pressure § ____ trauma patients may experience significant muscle ischemia at lower compartment pressures § Increased pain in affected area --- "..." to the injury § Typically with long bone fractures in the lower leg or forearm § s/sx: · Most reliable early sign is ____ ___ · Paresthesia · ___ & ___ (late signs - loss of extremity is threatened!) § DO NOT ____ THE EXTREMITY - decrease arterial inflow and exacerbate ischemia DVT injuries § Danger of progressing into ____ ___ § Low dose heparin or low molecular weight heparin and the use of intermittent pneumatic compression devices § Virchows triad · ___ __ from decreased blood flow, decreased muscular activity and external pressure on the deep veins · ___ ___ or concomitant pathologic state · ____

Compartment syndrome tissue damage 0-8 20 20-30 30 Fasciotomy Hypotensive out of proportion DECREASED SENSATION Pallor and pulselessness ELEVATE pulmonary embolus Venous stasis Vascular damage Hypercoagulability

Ø ... o is the term used when PEEP is supplied during spontaneous breathing o PEEP - ... § Positive pressure exerted at the end of exhalation o Assists spontaneous breathing to improve their oxygenation by ____ the end expiratory pressure in the lungs throughout the respiratory cycle. o It is common to use __ __ (2-5 cm H2O) in the intubated patient. o PEEP is increased in __-__ cm H20 increments when FiO2 levels are greater than ___% o PEEP is most often necessary in patients with ___ __ o Used to keep alveoli stented ___ o This end expiratory pressure increases the functional residual capacity by ____ of collapsed alveoli, maintains the alveoli in an ___ ___ and improves ____ ___ § Dec shunt and improves oxygenation. o In the patient who does not have adequate circulating blood volume, institution of PEEP decreases 3 o If hypotension or dec co results from PEEP application, restoring circling intravascular volume with administration of ___ ___ may correct the hypotension o Another serious complication is ___ § Most common when ___ ___ of PEEP are used (10-20 cm) in lungs with ___ ___ __ and ___ ___ and in patients with obstructive airway disease o Development of barotrauma is an ____ and usually requires is an emergency and usually requires placement of a ___ __ in the event of pneumothorax

Continuous positive airway pressure/ Positive end-expiratory pressure. positive end expiratory pressure with positive pressure breaths elevating low levels 2-5, 50 refractory hypoxemia (ARDS) open reinflation open position lung compliance venous return to the heart, dec CO and dec oxygen delivery to the tissues IV fluids barotrauma high levels high ventilating pressures low compliance emergency chest tube

inotropes § ____ o Most widely used o Given for conditions that cause hypotension, decreased CO and oliguria o Directly stimulates dopaminergic, B adrenergic, and a adrenergic receptors and promotes release of norepinephrine from sympathetic nerve terminals o Given as continuous __ infusion o Increased myocardial contractility results from dosages of 3-10 mcg/kg/min o Given through a ___ ___ to enhance distribution and avoid extravasation o AE: tachycardia, palpitations, dysrhythmias, angina, headache, nausea, vomiting, and HTN § ______ o Acts on B1 receptors and increases myocardial contractility o Also stimulates B2 receptors and A1 receptors ~ slight ___ o Used after cardia surgery, during some dardiac diagnostic stress procedures and for patients with HF, shock, or other conditions that cause poor cardiac contractility or low cardiac output o Dosage: 2-20 mcg/kg/min by continuous IV infusion o AE: tachycardia, dysrhythmias, blood pressure fluctuations, headache, nausea

Dopamine IV central line Dobutamine vasodilation

poison/overdose Continuous patient monitoring o ____ -- Evidence of drugs causing dysrhythmias or conduction delays o ___ -- May substances can be visualized during a contrast enhanced CT scam. - Chest radiographs provides evidence of aspiration and pulm edema o Electrolytes, ABGs and other labs - Imbalance in electrolyte levels - Sx of inadequate ventilation or oxygenation - evaluate by ___ ___ & ____ o ____ ___ § Uses common serum measurements to help evaluate the poisoned patient for certain drugs or toxins § Represents the difference between unmeasured anions and cations in the blood § Normal value for anion gap __-___ mEq/L § An anion gap that exceeds the upper normal value can indicate ___ ___ § Iron, INH, lithium, lactate, carbon monoxide, cyanide, toluene, methanol, metformin, ethanol, ethylene glycol, salicylates, hydrogen sulfide, strychnine, DKA, uremia, seizures, and starvation --> ____ anion gap o ____ ___ § The difference between the measured osmolality and the calculated osmolality. § Evaluating the poisoned pt for certain drugs or toxins § Osmolal gap__ is abnormal § Ethanol, ethylene glycol, and methanol --> ___ osmolal gap o _____ ___ § Laboratory analysis of a body fluid or tissue to identify drugs or toxins § Blood and urine samples are more frequently analyzed § Test sample must be collected while the drug or toxin is in the body fluid or tissue used for testing § Negative does not necessarily mean that no drug or toxin is present, but rather, that none of the drugs or toxins for which a patient has been screened is patient

Electrocardiography Radiology pulse ox and ABGs Anion gap 8-16 metabolic acidosis elevated Osmolal gap >10 elevated Toxicology screens

§ ______ - An infection of the endocardial surface of the heart, including the valves, caused by bacterial, viral, or fungal agents. o Assessment § Symptoms usually occur within __ ____ of the precipitating event and are related to four underlying processes: bacteremia or fungi, valvulitis, immunologic response, and peripheral emboli. § _____ complaints, such as general malaise, anorexia, fatigue, weight loss and ___ ____ are common. § Because symptoms are nonspecific, a careful history focusing on risk factors for IE and a physical examination are needed if endocarditis is suspected. § ** 2 are present in almost all patients § 20% of patients have a presenting symptom of ____ from septic emboli from infected heart valves in endocarditis § Definitive diagnosis of IE includes · Persistent ____ and evidence of myocardial involvement, such as echocardiographic visualization of a ____ or new or worsening ____.

Endocarditis 2 weeks Nonspecific night sweats fever and a new or changed heart murmur stroke bacteremia vegetation murmur

Ø Nutritional support o ___ ___ feedings § Mediators stimulate release of proteolytic enzymes that stimulate protein catabolism from skeletal muscle § Persistent ___ ___ is compounded by interstitial loss through capillary leak and downregulation of messenger RNA production of intravascular proteins (albumin) § Use of enteral feeding has shown reduction in ___ in the critically ill § Diet with a balanced caloric, protein, carb, and fat intake is calculated based on metabolic needs ~ emphasis on specific 3 intake § Pts with ARDS or SIRS usually require ___-___ kcal/kg/d § Avoid high ___ solutions to prevent excess CO2 production

Enteral tube protein loss mortality amino acids, lipid, and carb 25-45 carb

Use of Mechanical Ventilators Ø ... o Changes in FiO2 are based on ABG values and the SaO2. o Usually the FiO2 is adjusted to maintain an SaO2 of greater than ___% (equivalent to PaO2 of greater than 60) o ___ ___ is a concern when an FiO2 of greater than 60% is required for more than 24 hours - ... Ø ___ ___ o In the volume ventilator, the number of ml of air to be delivered with each breath is set by the clinician o Traditional, __-__ ml/kg of body weight were used o Lower tidal volume targets (5-8 ml/kg) are recommended to avoid __ or ___ caused by the large tidal volumes Ø ___ ___ o The velocity of gas flow per unit of time and is expressed as liters per min o If auto-PEEP is present, peak flow is inc to shorten inspiratory time so that the patient may exhale completely. o Inc peak flows inc ____ ~ inc ___ ___

Fraction of inspired oxygen (FiO2) 90 Oxygen toxicity strategies to allow for maintain an FiO2 of 60% or less. Tidal volume 10-15 VILI or VALI Peak flow turbulence arway pressures

Intracranial Pressure Monitoring Indications ___ ___ for at risk or increased ICP Potential ___ information ____ patient Severe traumatic ____ injury Abnormal __ findings (ie, hematoma, contusion, compressed basal cisterns) Poor clinical ___ status (ie, posturing) Reducing ICP through __ __ ICP monitoring helps improve patient outcome by providing information about the likelihood of ___ __ and facilitating calculation of ___. Helpful in guiding the use of ___ treatments (hyperventilation, mannitol and barbiturates) Brain injury, stroke, brain tumors, cardiac arrest, and surgery. Appropriate for comatose patients or patients with severe brain injury with or without abnormalities on a CT scan of the heard _____ CT scan and two or more of the following: age greater than ___ years, any motor posturing, or systolic BP ___ Monitoring is helpful in -limiting indiscriminate use of therapies with potentially harmful consequences -reducing ICP through CSF drainage ~ improve ___ -assisting in determining a prognosis -possible improving outcomes Nontraumatic neurologic disorders that may benefit -subarachnoid hemorrhage, intracerebral hemorrhage, large territory ischemic infarction, infection, hydrocephalus, and brain tumors CONTRAINDICATIONS: 3

Guide therapy diagnostic Comatose brain CT neurologic CSF drainage cerebral herniation CPP harmful Normal 40 <90 CPP coagulopathy, systemic infection, CNS infection and infection at the site of device insertion

o ____ ___ ___ § Occur in patients with valve surgery secondary to the edema at the surgical site § Resolution of this rhythm is usually attained ___-___ hours after surgery once the edema decreases. § ____ ____ & ___ also cause heart blocks § Use of epicardial ____ ___ allows better control of ventricular response compared with the use of drugs such as atroping and isoproterenol § ___ ___ is preferred if the AV node is intact because it allows optimal hemodynamics with an atrial contraction § ____ __ is the last choice § If pacing is required for more then 72 hours, ___ ___ should be considered

Heart block dysrhythmias 48-72 Myocardial ischemia and infarction pacing wires Atrial pacing Ventricular pacing permanent pacemakers

PE Management o ___ & ___ agents o Begin anticoagulant therapy immediately o SQ low molecular weight heparin (LMWH), unfractioned IV heparin (UFH), SQ fondaparinuz and adjusted dose heparin o __ ____ should only be used in unstable patients, obese patients with concern of absorption, and inc risk of bleeding o Tx with heparin or LMWH should be continued for at least __ days o ___ ___ should be started the same day the intial IV/SQ treatment is initiated and continued until INR is normal o Oral anticoag 2 o Therapy with warfarin should be continued for __-___ mo o First episode of unprovoked DVT should be treated for at least __ __ o ___ ___ for patients with acute massive PE who are hemodynamically unstable and not prone to bleeding o Contraindications: intracranial disease, recent intracranial or spinal surgery, trauma, hx of hemorrhagic stroke, and hemorrhagic disease o Heparin therapy is ___ administered concurrently with thrombolytics; however, thrombolytic therapy is followed by administration of ____, then ___ ___ o ___ ___ __ filter to prevent PE in patients with contraindications to heparin therapy Prevention o Prevention decreases the ___ & ___ associated with pulmonary embolism o Based on specific risk factors o Early and frequent ambulation o Compression devices o Elastic stockings

Heparin and thrombolytic IV UFH 5 Oral anticoag § Vitamin k antagonist (warfarin) § Factor x a/lla (thrombin) inhibitors 3-6 3 mo Thrombolytic therapy not heparin oral anticoagulation Inferior vena cava morbidity and mortality

ARDS Ø Oxygen delivery (DaO2) o Determined by 3 o The amount of oxygen delivered to the tissues every minute o Adequate DaO2 (...ml/min) is essential to meet tissue requirements for oxygen o Critically ill patients with ARDS have high demands for oxygen to maintain organ function o Transfusion requirements of values about 8 g/dl are sufficient for critically ill patients, except those with cardiac disease. o __ may be altered in ARDS due to SIRS, the effect of hypoxemia on the myocardium and the decrease in venous return induced by mechanical ventilation o Therapies to optimize CO are directed toward enhancing ____ & ____ and normalizing ____ o ____ ___ ___ ___ to assess oxygen delivery and consumption for patients with ARDS ~ rare, but may be used to ensure that appropriate interventions are instituted o ___ ___ to maintain edema and decompensation associated with ARDS o At onset, early goal directed ____ ____ is recommended. o ____ and reduced fluid administration have been studied to reduce lung edema. o Conservative fluid management with ____, plus ____ for hypoproteinemic patients ~ modest improvement in oxygenation o Positive ___ ___ are used to enhance contractility and inc cardiac output ~ may cause systemic ___ worsening hypotension §_______ may be added to counteract the vasodilation induced by SIRS

Hgb, arterial oxygenation, and cardiac output. > 800 CO preload and contractility, afterload Thermodilution pulmonary artery catheter Fluid management fluid resuscitation Diuretics diuresis albumin inotropic agents (dopamine or milirinone) vasodilation Vasoconstrictors (norepinephrine)

o Medical management of complications o ___ § Imbalance between production production and absorption of CSF § With blood in the subarachnoid space, the RBC clots and possible brain edema can occlude the very small channels leading from one ventricle to another. § Patient may require a shunt § ____ ___, tip of the catheter is is placed in a lateral ventricle and distal tip is placed in the peritoneum § The shunt drains CSF into the peritoneal cavity - prevents dangerous ICP elevations o Seizures § Anticonvulsants o Rebleeding § Risk for rebleading increases during the ___ ___ after the initial hemorrhage o _____ § usually a result of cerebral salt wasting, managed with sodium replacement and euvolemia. o Cerebral edema o Vasospasm § Angiographic vasospasm is seen ___ § Sx: changes in LOC, HA, language impairment, hemiparesis, and seizures. § Occurs __-___ days after an SAH; peak incidence between postbleed days __-___. § Can cause the development of a large area of ischemia or infarcted brain, with severe deficits § Decreases CBF, depriving brain tissue of oxygen and promiting accumulation of ___ ___. § Dx: ____ ___ - measures velocity of blood flow through segments of the arterial vessels § ___ · Some success after an SAH to improve patient outcomes. · Recommended to be used from onset through day 21 · Reduces the contraction of smooth and cardiac muscles without affecting skeletal muscle § If conventional therapy fails, manage through ___ ___ · Allows direct widening of the stenotic segment · Intra arterial administration of verapamil or nicardipine to selectively treat cerebral vasospasm o *.... § Standard for preventing and tx vasospasm · ____ ____ o Volume expansion through IV coilloid and crystalloid solutions o Inc intravascular volume and decrease blood viscosity o Cerebral vessels dilate and the MAP increases, thereby improving CPP o Monitor for pulmonary edema and heart failure · ____ o Administration of IV fluids to decrease blood viscosity, increase regional CBF, and may decreases infarction size and increase oxygen transport o Goal: decrease blood viscosity in order to improve cerebral blood flow · ____ ____ o Vasopressors o Goal: maintain systolic BP greater than 20 over normal o Raise the patients BP and brain perfusion to the point where neurologic deficits improves

Hydrocephalus Ventriculoperitoneal shunt first year Hyponatremia early 3-12 7-10 metabolic waste TCD imaging Nimodipine balloon angioplasty Triple H Therapy + nimodipine Hypervolemic expansion Hemodilution Induced hypertension

o Nursing management o Assessment § NIHSS to rate severity of the stroke and determine if they are a candidate for tPa § Nurse plays a critical role in administering thrombolytic therapy, optimize acute patient care, and move the patient to rehab quickly to maximize opportunity for an improved outcome § Nurse is in a position to identify problems § Monitor for infection, changes in temp, and changes in glucose level ____ in acute stroke patients increases cerebral infarction size and worsens neurologic outcomes -- strict glycemic control o Plan § Prevent ____ associated with immobility, hemiparesis, or any neurologic deficit § UTI, aspiration, pressure ulcers, contractures, and thrombophlebitis § Risk for ____ (mechanical prophylaxis - ROM, antiembolism stockings, and pneumatic compression devices) § Heparin or warfarin o Emotional and behavioral modification § Emotions may be ____ without explanation or control § May show frustration or agitation with the nursing staff or their fmily § Nurses role to help family ___ these changes § Modify behavior by controlling stimuli, providing rest periods, and provide repetition when patient is learning a new skill o Communication § ____ can involve motor abilities, sensory function or both § If injured near the left broca area, the memory of motor patterns of speech is affected ~ .... § Injury to left Wernicke area ~ ... § Both expressive and receptive dysphasia ~ ___ ___ § Having dysphasia does not mean the person is intellectually impaired § Communicate through writing, picture boards or gestures o Pt education and discharge § Recognize s/sx of stroke § Lifestyle modifications ot manage BP § Teachings about glucose control, weight management, and exercise programs § Compliance with meds

Hyperglycemia complications DVT labile understand Dysphasia expressive or nonfluent dysphasia (patient understands but cant express) receptive or fluent dysphasia (patient is unable to understand) global dysphasia

§ ___ drugs · Exogenous drugs that dissolve clots · ___ __ dissolves the clot and permits reperfusion of the brain tissue -- initiated as quickly as possible from symptom onset · max time window is __ hours or less from the onset of s/sx · No other ___ therapy should be given for the next 24 hours. A major risk of this therapy is ____ ___· ___ ____ § Can be given up to 6 hours after the onset of symptoms § Must be admitted to a specialty center § ___ __ remains in place for 24 hours § Advantage: medication can be delivered directly to its target § Mechanical devices · Can be used for up to __ hours after stroke onset to remove blood clots from vessels · Used if ____ for IV t PA § Anticoagulation · Secondary treatment for stroke include anticoagulation with antithrombotic and antiplatelet drugs · Antiplatelet drugs: dipyridamole - ER, ticlopidine, clopidogrel and aspirin § Deter platelets from adhering to the wall of an injured blood vessel or other platelets are given to prevent a future thrombotic or embolic event § ___ is the most common § Control of HTN and intracranial pressure · Patients with HTN are not typically treated ____. If their BP decreases after the brain becomes accustomed to the HTN needed for ____ ____, the brains perfusion pressure falls along with the BP. · Controlling ICP: ____ -- only short term, ___ restrictions, ___ elevation, avoidance of 2 , and the use of ___ ___ to decrease cerebral edema.

IV t PA 4.5 antithrombotic intracerebral hemorrhage Intra-arterial t Pa Femoral sheath 8 ineligible Aspirin accurately adequate perfusion hyperventilation fluid head neck flexion or severe head rotation osmotic diuretics

APM o ... § Common due to the placement of the catheter in the artery! § Assess for pulse, color, sensation, temperatures, and movement § If a ____ develops, then changes in color will appear distal to the catheter site (fingers if in the radial artery) § ___ must be monitored frequently § Initial baseline assessment of 4 of the extremity is made after insertion of the arterial catheter. ANY sign of impaired circulation is a basis o ___ __ § Immobilize the extremity with a brace type immobilizer

Impaired circulation to extremity thrombus Circulation color, sensation, temp and movement Catheter dislodgement

APM · Complications o ____ § Proper sterile technique, care of the insertion site, and blood sampling § Always assess the insertion site for signs of infection; redness, drainage § Use sterile technique when changing a dressing, tubing and flushing the system § Maintenance of the ___ of the system § ___ ___ sampling helps reduce the potential for open stopcock infections § Apply a ___ or ___ caps to help eliminate contamination to the pressure system · Nonvented because we don't want to introduce __ into the system!!

Infections integrity Closed system nonvented or deadender air

Concomitant Problems o ____ ___ is the leading cause of death in the first 24 hours after a burn injury § Acute pulmonary insufficiency occurs in the first ___ hours after injury § Pulmonary edema occurs between __-__ hours after injury § Bronchopneumonia occurs ___ -__ days after injury o Decrease in ___ __ & __ ___ o Transient pulmonary hypertension o Tracheobronchial and parenchymal lung injuries are usually a result of incomplete combustion of chemicals or noxious gases, which results in a chemical pneumonitis o Pathophysiological changes associated with lower lung injuries include impaired ciliary activity, hypersecretion, edema, inflammation, and bronchospasm o Inflammatory changes in the trachea and alveoli occur within __ hours of injury o Alveoli may collapse ~ dec compliance which leads to ____ o Assess § Serial ABGs § Chest film may initially appear normal - changes are reflected in___ ___ § Sputum specimen § *____ & ___ determines the presence of extra mucosal carbonaceous material (most reliable sign of inhalation inury) and the state of mucosa § ____ ____ - more specific confirmation of inhalation

Inhalation injury 36 6- 72 3-10 oxygen tension and lung compliance 24 atelectasis 24-48 hours laryngoscopy and bronchoscopy Fiberoptic bronchoscopy

§ _____ o The myocardium and peripheral blood vessels are innervated by adrenergic sympathetic fibers and respond to stimulation by inotropic agents o Used to increase the force of __ o Sympathomimetics §6 o Given to patients with impaired 2 o Enhanced ventricular contraction increases stroke volume, cardiac output, blood pressure, and coronary artery perfusion o Ventricles empty more completely, ventricular filling pressures, preload, and pulmonary congestion are decreased o BUT with an increase in contractility and HR, myocardial oxygen demand increased ~ ____ if supply-demand mismatch develops Monitor the patient for evidence of 3

Inotropes k Dopamine, dobutamine, epinephrine, isoproterenol, and norepinephrine and the phosphodiesterase inhibitor milrinone myocardial contractility or cardiogenic shock ischemia ischemia, angina and onset of dysrhythmias

..... - Designed to increase coronary artery perfusion pressure and blood flow during the diastolic phase of the cardiac cycle by inflation of a balloon in the thoracic aorta. - Inflation and deflation _____ each heartbeat - Goals: increasing ____ supply to the myocardium, decreasing ___ ___, and improving ____ ___ - Recommended for o _____ in patients with a STEMI who do not respond to other interventions o ___ ___ __ in patients with STEMI o ____ ___ that has not been quickly reversed with pharmacologic agents with patients with STEMI - Patients with STEMI and recurrent ischemic type chest discomfort with signs of hemodynamic instability, poor LV function, or a large area of myocardium at risk - Can help the failing heart by increasing ____ ___ ___ during ____ through inflation of the balloon ~ this increases the perfusion pressure of the ___ ___ - A person in acute LV failure has increased volume in the ventricle at end diastole as a result of the hearts inability to pump effectively. The increases ___ and increases the ___ the heart. IABP helps decrease excessive preload by decreasing impedance to ejection. With decreased impedance, there is more effective ___ ___ of blood and more efficient _____ of the left ventricle

Intra-Aortic Balloon Pump Counterpulsation counterpulse oxygen LV work cardiac output Hypotension Low output state Cardiogenic shock aortic root pressure diastole coronary arteries preload, workload forward flow emptying

Devices ____ ___ Accurate, low cost and reliable ICP monitoring, and are widely used Catheter is tubular instrument that is placed inside fluid filled cavities in the ventricles allow for simultaneous ____ & ____ of ICP by intermittently draining CSF Can be recalibrated in situ ____ ___ monitor ICP Tip of probe has a ____ which is inserted into brain parenchyma, the ventricles it surrounds, or the subdural space Same benefits as IVC but at a higher ___ _____ ___ Less accurate and less frequently used Placed into epidural space between the inner surface of the skull and the dura mater to monitor ICP External ventricular drainage system ICP device should have pressure range capability of __ -___ mm Hg, accuracy within the ICP range of 0-20 + 2and a maximal error of 10% in the range of 20-100 Type of monitor depends on the patients presenting symptoms, clinical factors, and the type of neurologic process

Intraventricular catheters monitoring and treatment Fiberoptic devices transducer cost Epidural monitors 0-100

APM o Accidental blood loss · ALL connections in the system should use a ___ __ type connector, need a nonvented cap · The extremity in which the catheter is should be ____ If a patient self-protective device is used it should NOT be placed over the ___ ___. ___ ___to the insertion site and connections is imperative

Leur-Lok immobilized insertion site Easy access

§ Hemodynamic Complications o Recurrent __ or recurrent ___ § Hard to dx if it occurs within the first 24 hours § Goal: lower myocardial ___ demand to relieve ___ § Emergent ___ ___ may be considered o ____ ___ § Most serious complication § Caused by the loss of contractile forces in the heart, resulting in left ventricular dysfunction § Loss of contractile forces can result from mechanical complications such as papillary muscle rupture, ventricular septal rupture, free wall rupture with tamponade and right ventricular infarction § s/sx · rapid, ___ pulse; ___ pulse pressure, dyspnea, tachypnea, inspiratory ___, ____ neck veins, ____ pain, cool, ___ skin, oliguria and decreased mentation § ABGs - decreased 2 § Hemodynamic findings - SBP ___, a mean BP ___, a cardiac index ___ L, and a PAOP ___ § Cardiac enzymes may show an additional rise or delay in reaching peak values § Goal: minimize myocardial ____ and maximize myocardial ____ ___ § IMMEDIATE actions to improve tissue perfusion and preserve viable myocardium § Supplemental oxygen § Restore BP - d/c ____ drugs and drugs with ____ ___ effects § Tx may require ____ - improve coronary artery perfusion and decrease left ventricular afterload · Left ventricular assist device may be considered

MI ischemia oxygen, pain surgical revascularization Cardiogenic shock thready narrow crackles distended chest moist PaO2 and respiratory alkalosis <85 <65 <2.2 >18 workload oxygen delivery vasodilator negative inotropic IABP

Prevention of Complications · Most serious complications is the development of ___ due to hypoxemia, hypoxia, and the persistent inflammatory response · Introduction of ___ ___ into critical care has been shown effective in reducing length of stay and reducing ventilator days · Mech vent with high PEEP, high tidal vol, and volume-controlled modes ~ ___ -- May present as ____, pneumomediastinum, or SQ/interstitial emphysema -- Prompt ___ ___insertion -- **Prevent by maintaining __ possible airway pressures, PEEP and tidal vol through the use of pressure limiting modes of mechanical vent. · Prevention/reduction in the incidence of VAP can be accomplished by using ___ ___ suction catheters * --- Use of ___ ___ to remove pooled subglottic secretions --- Monitor for ___ ___ and ensure that devices such as nasotracheal or feeding tubes are ____ from the nose when these occur -- *___ __!! Dec amount of organisms in the mouth that may migrate to the lungs -- HOB ____ and feeding with postpyloric feeding tube to reduce microaspiration and VAP · ____ has multisystem effects o Nosocomial pneumonia develops from accumulated secretions in the airway and atelectasis secondary to immbolizations o Frequent ____ & ____ ___ o ___ and subsequent ___ may be life threatening complications o DVT prophylaxis within __hours of admission § Low dose __, graded ___ ___, external pneumoatic ____ devices, frequent __ & ___

MODS care bundles volutrauma pneumothorax chest tube lowest in-line endotracheal tubes nasal secretions removed oral care 30 Immobility repositioning and chest physiotherapy DVT, PE DVT 48 heparin elastic stockings compression mobilization and ambulation

Management of Increased Intracranial Pressure - ____ ___ o Increases serum osmolality o Lowers cerebral 3 o Monitor serum osmolality every ___-___ hours and target less than ___ mOsm o (extra notes) § Hypertonic crystalloid solution that decreases cerebral edema § Bolus IV infusion over __-___ minutes in doses ranging from 0.25 - 2 § Excreted in the urine given in large doses, there is risk of acute tubular necrosis and renal failure § *monitor every 6-8 hours to a target of less than 320 mOsm § **___ must be inserted when mannitol is administered. § When mannitol is used during the early resuscitation phase in hypovolemic patients with brain injuries, ___ ___ are infused simultaneously to correct hypovelmia. § Be cautious when using mannitol and furosemide because there is a risk of ___ ___, depletion of ___ volume and ___ __. § - CO2 management o Normocapnia is the goal. o ____ (vasoconstriction) causes hypoxia. o _____ (vasodilation) causes increased ICP. o ___ is a temporary strategy for the treatment of malignant ICP. It decreases the arterial CO2 tension and results in cerebral vasoconstriction. - ____ therapy o Induced hypernatremia has been shown to increase CPP and decrease intracerebral pressure o 250 ml bolus of 3% hypertonic saline can be expected to raise serum sodium by nearly __ mEq/L -

Mannitol administration blood volume, edema, and ICP 6 to 8 320 10-30 foley crystalloid solutions over-diuresis intravascular electrolyte imbalance Hypocapnia Hypercapnia Hyperventilation Hyperosmolar 5

____ ___ - Prolonged ischemia caused by an imbalance between oxygen supply and oxygen demand - Prolonged ischemia causes irreversible cell damage and muscle death - The presence of a ___ ___ ___ characterizes most MIs § Anterior Left Ventricle o Result from occlusion of the __ § Leads .... o The LAD supplies oxygenated blood to the anterior wall of the LV, the interventricular septum and the ventricular conducting tissue o ___ ___ MIs are the most frequent type of infarction ~ may cause a significant amount of left ventricular dysfunction -- High risk for ___ failure, ____ edema, ___ shock, and death because of an inadequate pump --Associated with increased risk for intraventricular conduction disturbances, such as 2 Inferior Left Ventricle o Leads ... o Infarctions result from occlusion of the ___ ___ __ o RCA supplies oxygenated blood to the 2 o Source of blood supply to the __ __ in about 50% of the population and the ___ __ in about 90% of the pop o Potential impact on left ventricular function usually is __ for a patient with an inferior wall MI than an anteroseptal wall infarction o Because the RCA supplies oxygenated blood to much of the conducting tissue, patients are at frequent risk for _____ related to altered function of the SA node and AV nodes.

Myocardial Infarction coronary artery thrombosis LAD 1, 2, 3, 4 Anteroseptal wall heart, pulmonary, cardiogenic bundle branch blocks and fascicular blocks 2, 3, AVF right coronary artery inferior wall and the right ventricle SA node AV node less dysrhythmias

MI Pharmacological Therapy o Prophylactic antidysrhythmic during the first 24 hours of hospitalization are ___ recommended. o Easy ___ to atropine, lidocaine, amiodarone, transcutaneous pacing patches, transvenous pacing wires, a defibrillator and epinephrine to manage dysrhythmias o Daily ____ continued indefinitely. o ____ is added to the aspirin regimen for patients with a STEMI and is continued for __ days o 2 are initiated in the first 24 hours o __ are continued during and after hospitalization o First several days post STEMI ~ normalize patient's blood glucose levels (___) § Insulin infusion may be necessary

NOT ACCESS aspirin Clopidogrel, 14 B blockers and ACE inhibitors BB <180

Pulmonary Embolism Ø Assessment o ____ signs and symptoms - "the great masquerader" o Common to rule out other diagnosis (pneumonia or HF) o Suspected with new onset dyspnea, tachycardia, or sustained hypotension without other explanations o Chest pain, coughing with or without hemoptysis, clinical signs of ___ & ___ o .... is recommended for confirming the dx § CTPA contrast dye may be contraindicated in acute kidney dz or with allergies o Ventilation perfusion (VQ) scan will be used in such patients ^^ to help with dx o ____ ___ to determine if there is associated cardiac dysfunction related to a PE o DVT is often associated - assess for sx or ..... o Dx of DVT - 2 § Positive may not indicate DVT/PE § Always follow up with an ____ of lower extremities if positive

Nonspecific DVT and syncope Computed pulmonary angiography (CTPA) Transthoracic echocardiogram unilateral leg swelling and tenderness d dimer blood test and ultrasonography ultrasound

Physical Examination Mental status Level of consciousness and arousal ____ to the environment ___ content ___ is the most critical parameter to assess neurological status. This indicates the functioning of the cerebral hemispheres as well as that of the reticular activating system-- which is responsible for ___. GCS -- assess 3 . The ___ the score, the more ___. o Grading responsiveness o alert: normal o ____: may sleep more than usual or be somewhat confused on first awakening, but fully oriented when aroused o ___: drowsy but follows simple commands when stimulated o ___: arousable with stimulation; responds verbally with a word or two; follows simple commands; otherwise drowsy o ___: very hard to arouse; inconsistently may follow simple commands or speak single words or short phrases; limited spontaneous movement o ___: movements are purposeful when stimulated; does not follow commands or speak coherently o ___: may respond with reflexive posturing when stimulated or may have no response to any stimulus Pupillary changes Examine size (in millimeters) and shape Briskness of pupillary constriction - Direct and consensual response Accommodation PERRLA = Pupils Equal, Round, Reactive to Light, and Accommodation Pinpoint pupils: 3 Dilated pupils: 5

Orientation Thought LOC, arousal EYE OPENING, VERBAL RESPONSE, MOTOR RESPONSE lower impaired awake lethargic obtunded stuporous semicomatose comatose drugs, drops, damage in the pons fear, seizures, cocaine, crack, phencyclidine

Evaluation of Oxygen Delivery and Demand - Oxygen consumption = oxygen delivery - ____ ___: the amount of oxygen used by the cells every minute - ___ ___: amount of arterial oxygen that is transported to the tissues o Depends on CO, hemoglobin, and arterial oxygen saturation - if O2 delivery is inadequate, the O2 consumption is ____ to meet the demands! - If O2 consumption is met, then a further inc in O2 delivery does ___ ___ consumption - Oxygen consumption is ____ when the amount of O2 is met - Draw a ___ ___ __ from the distal lumen to determine the adequacy of O2 o Normal value is ___ ___ ___%

Oxygen consumption Oxygen delivery increased not increase independent mixed venous blood 60-80

PAP · Complications o _____ § Can occur from inserting a central line into the subclavian vein § Confirm placement with a __ __ and assess for presence of pneumo! § Complication from vessel access through the subclavian vein. The needle of the transducer sheath may pass through the vessel wall and puncture the lung during insertion causing apical pneumothorax. This can be due to varying anatomy. Signs and symptoms as well as routine postinsertion radiograph can diagnose this complication o ___ § Assess for signs of central venous catheter associated infection - fever, elevated WBC, erythema § Perform routine dressing changes and IV tubing changes § Clean with sterile technique § Sterile technique should always be used whenever manipulating the line- during insertion and dressing changes help prevent infections. o _____ § If you notice a loss of hemodynamic waveform or the inability to flush or infuse fluid, this may indicate a large thrombus - DO NOT FLUSH THE LINE ___, notify ____!

Pneumothorax chest xray Infection Thrombus FORCEFULLY physician

Use of mech. Vent Ø ...... o adjusts the pressure that is maintained in the lungs at the end of expiration. o PEEP reduction is considered if the patient has a paO2 of __-___ or an FiO2 of __% or less, is hemodynamically stable and has stabilization or improvement of the underlying illness o Monitor ABG values, SaO2, compliance and hemodynamic pressures o PEEP is usually inc in increments of __ - __ cm H2O o AE: ____ & ___ ~ reduce PEEP! o If higher PEEP is tolerated, the pt is stabilized on the new PEEP settings for about ___ mins o Hemodynamic measures are taken at end expiration o Avoid ____ the patient from the ventilator when using high levels of PEEP § O2 can deteriorate and be slow to ____ because It takes a significant amount of time for the effects of PEEP to be reestablished · If pt is oxygenated with an MRB, it must be equipped with a valve that allows levels of PEEP to be ___ ___ · ___ __ ___ apparatus can prevent breaking the PEEP circuit to suction the patient o Sensitivity § Sensitivity fxn controls the amount of ___ ___ needed to initiate an inspiration, as measured by ____ inspiratory effort § Inc sensitivity (requires less negative force) dec ___ __ __ the patient must do to initiate a ventilator breath

Positive end-expiratory pressure 80-100 50 2-5 hypotension and dysrhythmias 15 removing rebound dialed in In line suction pt effort negative amount of work

dx test infarction o Last stage - development of __ ___, the initial downward deflection of the QRS complex § Q waves represent the flow of ___ ___ toward the septum. § Q waves compatible with an MI are usually ___ seconds or more in width or __-__ the height of the R wave. § Q waves indicative of ___ usually develop within several hours of the onset of the infarction · Some may not appear until 24-48 hours after the infarction § Persistent elevation of the ST segment may indiciate the presence of a ___ ___ § __ ___may remain inverted for several weeks ~ areas of ischemia near the infarcted region. § Q waves never disappear - always provide ECG evidence of a ___ ___ § Not apart of QRS on normal EKG ~ abnormal and may indicate a history of a ___ § Presence of Q wave AND ST elevation indicates they HAD an MI and are CURRENTLY having one. § ECG can reveal the anatomical region of the heart where the abnormality has occurred. § ECG leads V1 through V4 - ___ __ of the LV § ___ ___ - leads 2, 3 and aVF § Additional leads are needed to view the right ventricle or the posterior wall of the left ventricle. § To detect posterior wall abnormalities, three of the precordial electrodes are placed posteriorly over the heart, a view known as V7, V8, and V9. V7 is positioned at the posterior ___ line; V8 at the posterior ___ line and V9 at the left border of the ___ § When an infarction in the posterior wall is suspected, the leads anatomically opposite the posterior wall are examined (principle of ____ change)

Q waves electrical forces 0.04 ¼ to 1/3 infarction ventricular aneurysm. T waves previous MI , STEMI anteroseptal wall Inferior wall reciprocal axillary scapular spine

Cardiac Surgery § Prevention of Hypothermia o Manage hypothermia § Core temperature monitoring § _____ · Patients core temperature is returned to ___ F · As warmed blood begins to circulate to the periphery, heat transfer to the surrounding tissues again causes the core temp to _____. · Pts typically enter the ICU with a temp of __-___ F

Rewarming, 98.6 decline 95-96.8

§ Monitoring for Dysrhythmias o Major issue post CABG o __ ___ is common § Sympathomimetic drugs, SIRS, hypovolemia, fever and pain § Pronlonged tachycardia may be harmed because of decreased ___ ___ filling time o ____ ___ __ § Usually electrolyte disturbances, ischemia, infarction or hypoperfusion § Frequent PACs may be a precursor to ___ · Occur commonly, especially in patients with a previous history of pulmonary or valve disease · Tx: repletion of ____ & ___· Maintaining these can minimize PAC

Sinus tachycardia coronary artery Premature atrial contractions Afibb potassium and magnesium

§ Clinical Features of Endocarditis o Fever o Heart ____ o Splenomegaly o Petechiae § ____ hemorrhages § ___ nodes (small, raised, tender nodules that occur on fingers or toes) § ____ lesions (small erythematous or hemorrhagic lesions on the palms or soles) o ___ complaints o Systemic or pulmonary ____ o Neurologic manifestations 2

murmurs Splinter Osler Janeway MSK emboli § HA § Mycotic aneurysms

PAP Complications o ______ ____ § May occur during the insertion- as the catheter passes through the right atrium dysthymias can occur because of ____ of the endocardium. Dysrhythmias typically resolve whenever the catheter reaches the __. § The patient could also experience a dysrhythmia if the catheter ___ __ of the PA into the right ventricle and the pressure waveform on the monitor will reflect that of the right ventricle- whenever the patient has this happen typically the catheter is ____ because there can be contamination at the insertion site or occasionally inflating the balloon will allow the catheter to float back into the PA. § ____ ___ should always be available at the bedside whenever a patient has a swan § Remove the PAC and treat the rhythm - even if you have to do chest compressions on an open heart! o ____ ____ ___ § Rare but potentially fatal condition of insertion. Proper advancing of the catheter with the balloon inflated will help reduce the potential of this complication. § Only inflate the balloon with the prescribed amount of air- ___ ml of air. § The catheter should become wedged when __-__mL of air is inflated into the balloon. If less air is required to obtain PAOP waveform, the catheter has migrated out of position

Ventricular dysrhythmias irritation PA slips out withdrawn Emergency equipment Pulmonary artery perforation 1.5 1.25-1.5

- Lumens o RED lumen - ____ ____ lumen o YELLOW lumen - ... - DO NOT INFUSE ___ or ___ -Systolic pressure (___-___) -diastolic pressure (__-___) >>indirect reflection of the left ventricular end diastolic pressure >info regarding CO, intravascular and intracardiac pressures ·>Inc PAP: o Systolic pressures: 2 o Diastolic pressure: 1 o BOTH: 4 · HIGH PAP - too much ___ (tx with ___) · LOW PAP - tx with ___!! o Reflects reduction in the circulating blood volume o Obtain ___ ___ bood (SvO2 - distal lumen)' o BLUE lumen - .... § Administer fluids and meds here!! § Info about cardiac output § In the ____ ___ or the SVC § Reflects BP in the right atrium and provides info about intravascular blood volume, right ventricular end diastolic pressure and right ventricular volume § Proximal infusion port resides in the right atrium § When infusing bolus, be careful not to ____ the CVP measurement § Mean pressure b/w __-__mm Hg = ____ ___ __ § Inc CVP - right sided heart failure, volume overload, cardiac tamponade, and pulmonary HTN § Low CVP - hypovolemic state, diuretic therapy, and vasodilation o ____ ___ § Measures the patients core temperature and resides at the tip of the pulmonary artery

balloon inflation distal lumen in the pulmonary artery FLUIDS OR MEDS 20-30 8-15 left sided heart failure, left or right oxygen shunting pulmonary embolism pulmonary HTN, volume overload, mitral stenosis, hypoxia volume meds volume mixed venous central venous pressure, proximal lumen right atrium misinterpret 2-6 right atrial pressure (RAP) Thermistor lumen

· Arterial Line Insertion § The most common sites for line insertion are the 3 arteries- axillary and dorsalis pedis arteries can be done as well. § Factors that are considered whenever you insert the line are · ____ of the artery in relation to the catheter- the artery should be large enough to accommodate the catheter · ____ of the site- the site should be easily accessible and free from contamination by body secretions · ____ ___ to the limb distal to the insertion site- there should be enough flow to the limb in the case that the artery becomes occluded · The ____ ___ meets the criteria and is the most used vessel- it is easy to palpate, and cannulation poses the least amount of limitation on the patients' movements. · ____ ___ can be performed before to determine if the ulnar artery provides adequate flow to the hand without the radial. · Sterile technique is used · Monitoring is assembled and flushed, and transducer is leveled (at the ____ ____) and zeroed before the catheter is placed.

brachial, radial, and femoral Size Accessibility Blood flow radial artery Allen's test phlebostatic axis

§ Indications for Intra-Aortic Balloon Pump Counterpulsation o ___ ___ after MI o __ ___ ___ post cardiac surgery o ___ ___ during PCI placement o __ ___ in the postop cardiac surgery patient o Postinfarction ___ ___ __ or mitral ___ o Short term bridge to __ ___

cardiogenic shock low cardiac output unstable angina LV failure ventricular septal defect regurgitation cardiac transplantation

§ Monitoring for Postoperative Bleeding o If the patient has received _____, it should be stopped __ - __ days before surgery o Vigilant monitoring of ____ ___ __! Hourly! o Normal chest tube drainage can range from___ - ___, with periods of increased drainage due to a change in position or temperature o If ____ml/h, intervene! o ____ is given at 1 mg every 100 units of heparin to reverse effects § Additional protamine is necessary if the patient is hypothermic, because ___ ___ may occur o ____ is commonly used to monitor the intrinsic pathway of coagulation cascade (heparin) o Aggressive _____ is important in patients with increased bleeding § As temperature ___, heparin is ____, causing increased bleeding o PLT infusion can cause a blood product reaction because each infusion may be from ____ donors

clopidogrel 5-7 chest tube drainage 100 ml - 200 ml/hr >200 Protamine rebound phenomen PTT rewarming rises reactivated multiple

§ Contraindications to IABP Counterpulsation o NEED a ____ aortic valve § May be worsened with IABP if they have aortic insufficiency o Severe ___ ___ ___ disease § Insertion would be difficult and could interrupt blood flow to the distal extremity or cause dislodgement of plage formation along the vessel wall ~ __ § If absolutely necessary, insertion can be done through the ____ ___ to bypass peripheral vessles § Previous ____ or ____ bypass graft contraindicates femoral artery insertion o Presence of an ___ ___ § May predispose the patient to dislodgement of aneurysm or RUPTURE the aneurym

competent peripheral vascular occlusive emobli thoracic aorta aortofemoral or aortoiliac aortic aneurysm

use of mech vent Ø Responding to alarms o Low pressure alarms warn of _____ of the patient from the ventilator or circuit ____ o High pressure alarms warn of ___ pressures o ___ __ alarms are necessary for all vents o Ventilator malfunction § Nursing or RT perform vent checks every __-__ hours and recurrent alarms may alert the clinican to the possibility of an equipment related issue § If problem cannot be promptly corrected by vent adjustment, a different machine is procured

disconnection leaks rising Electrical failure 2-4

Ø Stages of ARDS o Stage I § Increased ___ & ____ initially § ___ radiographic changes § Rapid progress of severity symptoms (within ___ hours) -- Cyanosis, coarse bilateral __ -- Patchy ___ on CXR § Dry ___ or chest pain may be present § Dx is difficult because of subtle signs § ____ are sequestering; no evidence of cellular damage o Stage II § ____ ____ disruption of vascular bed § Increased interstitial and alveolar ___ § Increasingly ___ to proteins -- "____ stage" § Hypoxia-____ supplemental oxygen § ____ ____ is required for worsening ratio of arterial oxygen to fraction of inspired oxygen (PaO2:FiO2 ratio). § Worsening ____:____ ratio o Stage III § "_____" stage § Develops ___- ____day after injury § ____ instability, generalized ____, hypoxemia, nosocomial ____ § Decreased lung ___ § Diffuse interstitial ____ o Stage IV § "____" stage § Develops after __ days § Increases ___ § ____ involvement, SIRS § Progressive lung ___ ·--____ management difficulties -- Increased ___ pressures --- ____

dyspnea and tachypnea Few 24 crackles, infiltrates cough Neutrophils Mediator-induced edema permeable Exudative resistant Mechanical ventilation PaO2:FiO2 Proliferative 2nd to 10th Hemodynamic edema infections volumes markings Fibrotic 10 PaCO2 Multiorgan fibrosis Ventilation airway Pneumothoraces

o Tachyarrhythmias § May lead to ____ situations § If hemodynamically unstable in a fast rhythm - ____ § Ventricular dysrhythmias develop ~ ____ or ___ interventions are necessary § Torsades - iv ____ § ____ for patients who are unresponsive to CPR, defibrillation and IV epi

emergent cardioversion electrical or pharmacological magnesium Amiodarone

Ø Severity- calculate % of body burned o Determined by the extend and the depth of the burn and the causative agent, time and circumstances surround the burn injury. o Several factors to consider: § Percentage of body surface area burned § Depth of burn § Anatomical location § Age § Med hx § Presence of concomitant injury § Presence of inhalation injury o Location of the injury § Burns to the 6 are best treated at a burn center · ~ 125 burn centers in the US · Involve functional areas and require special interventions · Higher morbidity from impaired function and altered appearance § ____ ___· Skin's elasticity is compromised leading to impaired respiratory effort o ... § More accurate determination of the extent of the burn injury · Accurate calculation of injury is important when estimating fluid resuscitation § Correlates body surface area with age-related proportions § Used most frequently at burn centers o ___ __ ___ § Quickest method to initially calculate the % TBSA § Sum all areas of partial- and full- thickness burns · Superficial burns are NOT included · Measurement varies between adults and pediatrics (kids have a proportionally larger head size than adults) § If there are scattered or small areas of burns that are noted, the size of the patient's palm, including fingers, is used for measurement- represents ___ TBSA § Head and Arm = __ § Torso, Back, Leg = __ § Perineum = __ § **Neck = __

face, hands, feet, genitalia, major joints, and perineum Circumferential burns Lund and Browder Chart Rule of nines 1% 9% 18% 1% 1%

monitoring postop bleeding o Intraoperative measures to prevent bleeding § Minimizing ____, minimizing ____ ___ and optimizing ___ ___ with full ____ § Blood loss requires replacement § Transfusion of RBC may inc exposure to ____ diseases, inc ____ and microcirculatory complications

hemodilution autologous loses coagulation status rewarming infectious immunosuppression

Ø Interpreting arterial blood gas results o Consider: oxygen status, acid base status, and degree of compensation o Evaluating oxygenation § PaO2 < pt norm, ___ exists § SaO2 <93%, inadequate amounts of ___ are bound to Hgb o Determining compensation § If the buffer systems in the body are unable to maintain normal pH, then the renal or respiratory systems attempt to compensate § If the problem is renal -> ___ try to correct it and vice versa · may take __-__ mins for the lungs to recognize and up to __ day for kidneys to correct respiratory problem § Respiratory response to metabolic pH imbalances · Metabolic acidosis:... · Metabolic alkalosis: .. § Renal response to respiratory pH imbalances · Respiratory acidosis: inc in ____ __ and ___ ___ · Respiratory alkalosis: ... § Determining level of compensation p.445 · First determine whether the pH is not within normal range - acidotic or alkalotic · If abnormal, determine which side it lies (7.38 is tending toward acidosis, whereas, 7.41 is tending toward alkalosis) · Next, see whether CO2 or HCO3 has changed to account for the acidosis or alkalosis

hypoxemia oxygen lungs 5-15 1 increase in RR and depth decrease in RR and depth hydrogen secretion bicarbonate reabsorption dec in hydrogen secretion and bicarbonate reabsorption

device Complications 5 1st Determine whether the reading is accurate. If it is accurate, determine the reason. IVCs carry the risk for catheter misplacement, obstruction, infection and hemorrhage. Due to the small holes for CSF to drain, it is easy for catheters to become obstructed; might see poor drainage of the system or change in the patients neurologic status

inaccurate readings Misplacement Obstruction of catheter Infection Hemorrhage

stroke o Clinical manifestations 6 o If symptoms resolve in less than 24 hours, the event is classified as a ____ ___ ___ -- neurologic deficit lasting less than 24 hours o Clinical management § 4 goals · Restoration of ___ (reperfusion may be accomplished by the use of ____ ___) · Prevention of recurrent ____ · ____protection · _____ care § Save as much ___ area as possible § Three necessary ingredients · 3 § Two emergency treatments for the management of stroke · IV ____ and ____ removal by use of mechanical device

o Weakness o Numbness o Visual changes o Dysarthria o Dysphagia o Aphasia transient ischemic attack CBF, IV t-PA thrombosis, Neuro, Supportive ischemic Oxygen, glucose and adequate blood flow IV t PA and embolus

thoracic trauama Pleural space injuries o Caused by disruption of an ___ structure, which allows air or blood to build up in the pleural layers, thereby leading to a decrease in negative intrathoracic pressure. o Air and blood may continue to build up in the pleural cavity, causing increased tension, which leads to a 2 o Patient may present with respiratory distress, altered ventilation and impaired gas exchange. § Restlessness, anxiety, tachypnea, decreased oxygenation, poor color and diaphorese o ____ ___ for dx, may not be seen if pneumothorax is less than 20% of the chest cavity o Tx: airway, ventilation and oxygenation. Large bore __ ___ to reexpand the lungs and drain the air or blood. Tube inserted in the fourth or fifth intercostal space at the midaxillary line. o Monitor blood in the chest tube: drainage of more than ___ ml/h for __ consecutive hours may indicate a missed injury or the need for further exploration, and should be reported. o A massive hemothorax is defined as ___ -___ L of intrathoracic blood loss and constitutes a life threatening injury. § Require immediate ____ to control bleeding o Hypovolemic shock - .... o ___ ___ hemothorax is more common than a right one and is often associated with aortic rupture. o Bleeding stops only when the pressure in the pleural cavity is .... than the pressure in the damaged vessel. o Placement of a chest tube in a patient with massive hemothorax could lead to ____ by eliminating the tamponade caused by a closed chest injury. o ___ ___ is a life threatening condition - caused by air entering the pleural space and becoming trapped without an exit. A one way valve closed system is formed ~ compression of one or more of the intrathoracic structures and prohibits them from functioning § Difficult to diagnose because of other injuries § Chest ____, ___ shift, neck vein ___, decreased ___ __ on affected side, and evidence of decreased ___ ___ § Tx: immediate ____ of the trapped air · 14-16 gauge into pleural space, usually between the second to fourth anterior intercostal space. An immediate rush of air could escape and the patients ventilation should improve. · Supplemental ____ before decompression · Needles are changed to chest tubes to allow the lungs to reexpand and to prevent reoccurence

intrathoracic tension pneumothorax or a tension hemothorax. Chest radiography chest tube 250, 2 1.5-4 thoracotomy two large bore IV lines Left massive equal to or greater exsanguination Tension pneumothorax asymmetry, tracheal, distention, breath sounds, cardiac output decompression oxygen

Thoracic Trauma Bony thorax fractures o Rib fractures, sternal fractures, and flail chest are common in trauma patients § Clinically significant as markers of serious ___ & ___ injuries, sources of pain, and predictors of pulmonary deterioration o Rib fractures are associated with: § 4 o ___ ___ involves multiple rib fractures § Respiratory movement is altered § As the patient's pulmonary status worsens the ___ ___ of the flail segment increases · Manage airway, pain, oxygen, and position o Greatest concern is __, ineffective ___ & ___ control o Ribs 1 & 2 are protected by the clavicle, scapula, humerus - so if injured than it is a ___ ___ trauma o Ribs 4-10: ___ ___, usually underlying lung injuries o Ribs 8-12: associated with ___ or ____ o ___ __: an injury that involves multiple rib fractures. Stability of thorax is disrupted, and the rib cage no longer moves in unision. Creates free floating segment of rib or sternum § The injured area does not respond to the action of the respiratory muscles; it moves in accordance with the changes in ___ pressure § Paradoxical breathing § Causes a decrease in the normal negative pressure of the chest ~ decreasing ___ and causing some degree of ___. § Follows pleural pressure instead of respiratory muscle. As the pulmonary status worsesn, that paradoxical movement of the flail segment increases. § ___ ___ may mask the injury until the patient becomes fatigued § May require ___ & ___ § Tx: turning the patient with the ___ ___ down to improve oxygenation · ___ ___, accomplished by placing the intubated patient on positive pressure ventilation o Airway management, pain management, and oxygen therapy

intrathoracic and abdominal Pneumothorax, hemothorax, and pulmonary contusion with injury to the liver and spleen Flail chest paradoxical movement pain ventilation and secretion high impact blunt trauma liver or abdominal structures. Flail chest intrapleural ventilation hypoxia Muscular splitting intubation and mechanical ventilation injured side Internal splinting

Chest Tubes Ø Assessment and Management o Maintain patency and proper functioning of the chest tube drainage system o Drain the ___ __ frequently into the collection container. o Coil the latex tubing loosely on the bed to prevent ___ and pooling of blood or drainage in a ___ ___ hanging on the floor o Never raise the chest tube drainage system above the chest - ..... o Frequently check ____, suction level and ___ ___ integrity o Secure system to the ___ of the patients bed or tape it to the floor to avoid ___ ___ o To check for chest tube patency and respiratory cycle fluctions - momentarily _____ the suction (system placed only to ____ - not clamped) § Assess cardiopulmonary status and VS every ___ ___ and as needed § Check and maintain ___ ___ every 2 hours § Monitor ___ & ___ of drainage § ___ amount of drainage on collection chamber in hourly or shift increments and document output § Prevent ___ __ from forming in tubing - make sure pt is not ___ on tubing § Refill water system with ___ __ to the water seal level and prescribed suction level § Assess for "____" in the water seal chamber with respiration or mechanical ventilation breaths § Assess for the location of __ __ (constant bubling in the water seal chamber). · ___ __ the suction. Begin at the insertion site; occlude the chest tube or drainage tube below each connection point until the ___ ___ is reached § Check that all tubing connections are securely ___ & ___ § Assess pain and give meds as needed § Assess actual chest tube insertion for sx of ____ and SQ emphysema with dressing changes § Change the dressing ___ ___ or per unit guideline

latex tubing kinks dependent loop drainage will back up into the chest. drainage water seal foot accidental overturning disconnect, water seal 2 hours tube patency type and amount Mark dependent loops, lying sterile water tidaling air leaks Turn off drainage unit sealed and taped infection twice daily

Vasodilators - Decrease ___ & ___ § _____ o Cause peripheral vasodilation, which in turn decreases venous return to the heart and reduces preload o Promote coronary artery vasodilation, improve ____ blood flow, reduce platelet aggregation, enhance perfusion to ischemic myocardium and decrease myocardial infarct size o Reduce blood pressure and previously elevated pulmonary vascular resistance, SVR, and central venous and pulmonary artery occlusion wedge pressures o At high doses, nitrates reduce afterload by ___ ____ effects o Indicated for unstable angina; larger anterior AMI; AMI associated with acute and chronic HF, acute pulmonary edema, or HTN; angina unresponsive to other therapies and prophylaxis of effort angina o Nitro has been shown to raise the ____ _ ____* in the setting of AMI o Contra to IV nitrates §___tension, uncorrected ____, hypertrophic obstructive ____, and pericardial _____ o When a ___ ___ AMI is suspected, nitrates are used with ____ ___ bc they require an adequate venous return to maintain cardiac output and BP o Patients should not receive for __ hours after sildenafil, vardenafil, or tadalafil ~....?? o Dosage forms § IV, sublingual, or topical § IV drip is initiated at ___-__mcg/min and increased every 5-15 mins, up to ___ mcg/min, to achieve the desired effects § When used to tx or prevent angina, a __-__ mg tablet is placed under the patients tongue and may be repeated twice at 5 mins intervals § Usual dose for ointment is __-__ in every 8 hrs - often initiated as ___ inch and increased gradually o AE: headache, hypotension, syncope and tachycardia o ____ may develop -- *dosing regiments that allow for...... may prevent this occurence

preload and afterload Nitrates collateral arterial vasodilator threshold for VF Hypo hypovolemia cardiomyopathy tamponade right ventricular EXTREME caution 24 life threatening hypotension! 5-20 , 200 0.3 -0.6 1-2 0.5 Tolerance nitrate free intervals for at least 12 hours

Patient care considerations Seizure _____, hypothermia, ___ craniectomy, minimizing environmental stimuli Positioning Positioning HOB (__-__degrees) elevated and neck __ position --Promote venous return and decrease ICP ___ or ___ posturing may inc ICP Flexion of hips greater than __ degrees is avoided Turn patient every __ hours, instructing patient to exhale with turn ___ ROM Avoid ___ pf patient activities (give time to rest! )

prophylaxis, decompressive 15-30 neutral Decerebrate or decorticate 90 2 Passive clustering

Pulmonary Artery Pressure Monitoring - Measure intravascular pressures, intracardiac pressures and cardiac output - The catheter sits in the ____ ___! - Inserted into the right atrium, the balloon is inflated, passess through the tricuspid valve into the right ventricle, through the pulmonic valve and into the pulmonary artery - Placement is confirmed by the ____ ___—once placed, DEFLATE _____!! (if you pull back, there is a risk of rupturing the balloon) - ____ ___ ___ ___ measures the left atrial pressure and left ventricular diastolic pressure - o Increase in PAOP:... o Measurements are most accurate at the end of ____! Point of balloon inflation differs in ventilated patients and nonventilated!

pulmonary artery wave form PASSIVELY Pulmonary artery occlusion pressure (PAOP) left ventricle failure due to reduced contractility and forward blood flow diastole

§ Early Management o Rapid diagnosis and initial management of a patient with possible MI o Benefit of ___ therapy is greatest if therapy is initiated quickly o Initial evaluation of the patient should occur within the first ___ mins after arrival. o Pt 2 are the primary methods used to determine initially the diagnosis of MI o ECG is examined for the presence of ___ ___ __of __ mm or greater in contiguous leads ---Evidence of ___ ___ __occlusion

reperfusion 10 hx and 12 lead ECG ST segment elevations 1 thrombotic coronary arterial

NIHSS o Figure 35-6 (recognize the different test used to evaluate the patient) (p. 695) o Level of consciousness o LOC question o LOC commands o Best gaze o Visual o Facial palsy o Motor arms o Motor leg o Limb ataxia o Sensory o Best language o Dysarthria o Extinction and inattention o Greater than 35 is ___ o The ___ the score the better read in book

severe, lower

cardiac surgery prevention of hypothermia § Rewarming should occur ___ to prevent hemodynamic instability due to rapid vasodilation § Assess temp using a ___ ___ or ___ ___ for more accurate temps § ___ room temperature and using radiant heat, blankets or a warming blanket. § OPCABG surgery causes hypothermia because of heat loss secondary to prolonged exposure to cool operating room temps § Hypothermia causes peripheral ____ and a shift of the oxygen - hemoglobin dissociation curve to the left, which means that ___ oxygen is released from the hemoglobin to the tissues § Hypothermia can also impair coagulation - ____

slowly pulmonary artery or tympanic membrane temperature Inc vasoconstriction less bleeding

§ Diagnostic tests ü Infarction (only) o MI - persistent myocardial injury o Hyperacute phase § Earliest stage of MI § T waves becomes ___ or __· --Hyperacute or peaked T waves § Within a few hours, hyperacute T waves ___ o Next, ST segments ___. Lasts several hours to several days --Leads facing away from the injured area may show ST segment depression ~ ___ ST segment changes. · Most likely to be seen on the onset of ____ · May simply be a mirror image of the ST segment elevation or may reflect ____ due to narrowing of another coronary artery in other areas of the heart

tall and narrow invert elevate reciprocal infarction ischemia