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Normal range for SVR (systemic vascular resistance) afterload of the left side of the heart.

800-1200

What is the normal range for SVR (systemic vascular resistance)? **afterload of the L side of the heart

800-1200

When talking about readiness for weaning in a patient on the ventilator, their RR need to be > _____ and < ______.

8; 35

PCI is a general term to mean we are doing some type of intervention in the coronary arteries through the skin (no surgical incision). The physician inserts a catheter through an artery and/or a vein (typically use the groin or the right radial artery or vein). The "door to balloon" time for PCI is < _____ minutes. **management of MI

When giving Nitroglycerin for treatment of an MI, we ***titrate IV to effect (Chest pain; start low, go slow)**** We increase until chest pain is relieved and decreased if chest pain is relieved and their BP is low. WE also monitor their BP closely with frequent VS monitoring. We want to keep the SBP > _____. If it goes below _____, will either have to cut back on the nitroglycerin or have to give them a little volume so they will tolerate the nitroglycerin a little better § Limit drop BP to 30 mm Hg below the baseline in hypertensive patients (do not want to drop them too low because you might decrease tissue perfusion). - watch BP.

The following are different noises in the ICU (the longer you are exposed to this noises, the more you are at risk for hearing damage): telephone ringing, raising/lowering side rails, O2 chest tube bubbling/ventilator, ventilator alarm, cardiac monitor alarms, and call bells. What is the noise, in dB, when raising/lowering side rails?

90 dB

normal SpO2?

95-100%

What is a desirable triglycerides level? · Anything higher is considered a risk factor

< 150 Normal

Normal range for PVR (pulmonary vascular resistance) ● afterload of the right side of the heart.

< 250

What is the normal range for PVR (pulmonary vascular resistance)? **afterload of the right side of the heart.

< 250

What is a desirable VLDL cholesterol level? **another bad cholesterol; subcategory of LDL

< 30 mg/dL

What is a desirable HDL cholesterol level in MEN? o (good cholesterol—want these to be high—considered protective and preventive of cardiovascular disease) § #1 way for pt. to increase HDL levels is to exercise (high HDL levels are desired)

< 40 Low (men)—increased risk for disease development

What is a desirable HDL cholesterol level in WOMEN? o (good cholesterol—want these to be high—considered protective and preventive of cardiovascular disease) § #1 way for pt. to increase HDL levels is to exercise (high HDL levels are desired)

< 50 Low (women)—increased risk for disease development

What is the goal HbA1C in diabetics? § People who have a chronically elevated blood sugar are at high risk because those elevated serum glucose levels damage the artery wall (remember that damaged intimal layer is what sets them up for plaque and fatty acids to adhere to that wall) **modifiable risk factor for CV disease

< 7%

What is a desirable total cholesterol level? o takes into account your LDL, VLDL, and HDL cholesterols

<200 mg/dL

What is a desirable HDL cholesterol level?

> 60 High—desirable for HDL cholesterol Remember: § < 40 Low (men)—increased risk for disease development § < 50 Low (women)—increased risk for disease development

One main indicator for the readiness for weaning a patient off of the ventilator is adequate oxygenation. What does the patient's SpO2 need to be more than? (>)

> 90%

One main indicator for the readiness for weaning a patient off of the ventilator is adequate oxygenation. What does the patient's PaO2/FiO2 need to be more than? (>)

>150-400

The following are different types of _____s: o 3 Augmented Unipolar Limb _____s + § Called augmented because the machine augments it by 50% so it will show up bigger on the machine o 3 Bipolar Limb ______s + § Limb _____s are frontal plane leads or vertical ______s o 6 Precordial (Chest) ______s = § Chest ______s are horizontal plane ______s o 12 Total _____s (or Views) of the Heart from a 12 _______ EKG § However when performing a 12-______ EKG, only 10 ______s (physical patches you place on the patient) are needed to obtain all of the 12 views

lead

The word "_______" is used interchangeably to mean "VIEW" or to mean the physical "______" you place on the patient's chest to obtain the view.

lead

If you have a patient who has inferior wall ischemia or inferior wall infarction you are going to see changes in what 3 leads with 12 Lead ECG? o The right coronary artery is usually the coronary artery that supplies the inferior wall §***** So, if you see indicative changes in these leads, it is probably the right coronary artery that has the lesion and it's the inferior wall of the heart***** **localization of infarction **ACS

leads II, III and aVF

An angiogram is when they inject dye into some vessels to do x-ray photos and that dye shows up as contrast in the x-rays to evaluate vessels. We can do angiograms of any kind of vessels but if it is angiogram of the heart that is called a coronary angiogram, heart catheterization, or heart cath for short. We have a left "heart Cath" and a right "heart Cath". Which of these is described below: o used to visualize blockages and/or do a ______ ventriculogram. Arterial approach (insert the catheters into the arteries—mostly used the femoral artery or the radial artery depending on the sizes of the catheters they need to place (radial is smaller)—historically femoral is all they used but because of the prolonged bed rest that occurs after the femoral approach, more physicians are doing radial approaches whenever they can) § Ventriculogram—a study that evaluates the EF § ______ cath - accessed through femoral or radial artery & fed through vessels until it reaches the aorta; die is then injected § ________ ventriculogram - provides information about the EF

left

Pulmonary wedge pressure- Indicative of pressures on ______ side of heart ● High wedge pressure= heart failure **pulmonary artery catheters

left

The following is PCI for ______ main disease: · Both US and European guidelines emphasize the need for a Heart Team approach for deciding revascularization strategies for LMCA disease. o If all the patient has is a ______ main lesion, you would hate to send them to major surgery of that one lesion—this is when they might consider doing a PCI for that particular lesion § Side note: cardiologist does PCI—cardiovascular surgeon does bypass surgeries (two different professionals)—both need to get together as a team to decide what the best option is for that particular patient

left

The following is PCI for ______ main disease: · The ______ main is that little portion of the coronary artery before it branches off into the LAD and the circumflex coronary arteries · Used to be taboo—not indicated unless the patient had a previous bypass, and they had some other method of profusing their myocardium because if you occlude the ______ main then you occlude both the LAD and the circumflex o When that balloon is inflated, the vessel is occluded and that is very high risk, and the patient will likely have lethal arrhythmias · Now, in some cases it is acceptable o Non-complex lesion near the ostium or on shaft of LM artery. § Syntax score - an angiographic grading tool to determine the complexity of coronary artery disease. · Both US and European guidelines emphasize the need for a Heart Team approach for deciding revascularization strategies for LMCA disease. o If all the patient has is a ______ main lesion, you would hate to send them to major surgery of that one lesion—this is when they might consider doing a PCI for that particular lesion § Side note: cardiologist does PCI—cardiovascular surgeon does bypass surgeries (two different professionals)—both need to get together as a team to decide what the best option is for that particular patient

left

Look at image 34 on phone. What is going on? o Depressed ST indicates ischemia. o Elevated ST segment indicates injury (acute infarction)

o Lateral, anteroseptal infarct

The following is trigger criteria that may require a rapid response team for a ______ issue: ○ ACUTE AND NEW ■ ________ rate of <8 or >28 ■ 02 Sat < 90 ■ Threatened airway ■ **do not necessarily have to have all 3, just have to have 1 ○ Just as hospitals create their RRT teams, they also create trigger criteria which is what will trigger someone to activate the RRT

respiratory

What risk of analgesics is described below: ○ be careful about the dosing and always monitor and evaluate them (esp narcotics; increased risk for aspiration) ■ Could cause respiratory acidosis if their respirations are suppressed too much

respiratory depression

What indication for mechanical ventilation is described below: (apnea or impending inability to breathe, ventilatory failure, severe hypoxia, respiratory muscle fatigue, and RR > 35 or < 8-10) ○ Neuromuscular problems such as ALS, Guillain-Barre ○ Stridor, tripod position while sitting ○ May have pneumonia on top of COPD ○ Do not have strength to breathe in fast and deep enough to maintain needs

respiratory muscle fatigue

What ventilator setting is described below: (TV, RR, FiO2, PEEP, PS) ● this is the rate the vent is actually set at

respiratory rate (RR)

An angiogram is when they inject dye into some vessels to do x-ray photos and that dye shows up as contrast in the x-rays to evaluate vessels. We can do angiograms of any kind of vessels but if it is angiogram of the heart that is called a coronary angiogram, heart catheterization, or heart cath for short. We have a left "heart Cath" and a right "heart Cath". Which of these is described below: o insert pulmonary artery catheter to measure pressures on the _______ side of the heart and the PAP and PAWP. Venous approach. § When they do this, they are putting in a PA catheter and getting the measurements (CVP, right atrial pressure, PAP, PAWG or left ventricular end diastolic pressure) and then they take the catheter out § Insert the catheter in a vein either through the femoral artery or the subclavian (they don't typically do this through a radial approach) § ________ cath - venous access through inferior vena cava into the RA to insert PA catheter to obtain pressures

right

One complication of ET intubation is displacement of the tube which is why nurses need to regularly monitor lip placement and have an ambu bag ready. The tube can be pushed in further and if so it will probably go down into ______ main stem of the bronchus (straighter than the L) which is the path of least resistance. ■ This is why we do frequent assessments listening to breath sounds, bilateral air exchange, bilateral chest rises ■ If only hearing breathe sounds on _____ side, changes are the tube is in _____ main stem and needs to be pulled back ○ Can be displaced or pulled up and sitting in back of throat

right

PDA—if they are _____ dominant then that is the vessel that feeds the back or posterior wall of the heart ○ If patient has occlusion of the ______ coronary artery—we would see loss of P wave, bradycardia (because the main conduction (SA) is disrupted). ○ Would rather have ______ MI - smaller muscle and just has to supply the left side of heart - easier to fix with pacemaker ○ Left would be worse because it has to supply rest of body

right

The heart is a 2-sided pump. Which side of the heart is a LOW pressure pump? ○ ______ ventricle pumps against pressure in the pulmonary system ○ Pulmonary artery pressures ○ The _____ ventricle pumps blood from the ______ ventricle to the pulmonary system. ○ The pressures in the pulmonary system are much lower than the systemic pressures.

right

When talking about coronary circulation in the heart, which coronary artery (R or L) supplies the INFERIOR wall of the heart and brings blood to the R atrium, R ventricle, SA node, AV bundle, and posterior L ventricle? § If you have a patient that comes in with an inferior MI, then you know it's probably the ______ coronary artery (this patient is high risk for developing heart blocks due to the blood supply to the SA node and the AV bundle)

right

When talking about there ports of a pulmonary artery catheter, which port (R atrial port, proximal infusion port/R ventricular port, pulmonary artery distal port, thermistor port) is described below: ■ We have the ____ ___ ____ which is usually blue (also known as the proximal port since it is closes to the ports). This port sits in the R atrium. If we connected pressure tubing to the ____ ____ _____ it would be measuring pressures in the R atrium giving us the central venous pressure (CVP).

right atrial port

The following are ______ of analgesics for pain management: ○ GI motility reduction—they are at high risk for constipation (slows down gut) ■ These patients are often simultaneously on stool softeners to try and prevent this complication ■ Assess bowel function daily ■ Constipation, impaction, ileus ○ Additive sedation—if you give them too much

risks

One recommendation for Statins (drugs to treat hyperlipidemia) is: people without cardiovascular disease who are 40 to 75 years old with ___ or more CVD risk factors and a CVD event risk of 10% or greater.

What step (1-5) of the Surviving Sepsis Campaign is described below: Measure lactate level→ tissues do not have enough oxygen and tissues will go into lactic acidosis; sepsis causes massive vasodilation→ decrease BP → decreased tissue perfusion

Nurses cannot push ________, so if that's what they want to use for the procedural sedation, then anesthesia needs to do it (RNs can only give _______ in the ICU setting for an intubated patient and it is given as a drip, not a push)

Propofol

Post cardiac surgery, the nurse needs to control bleeding complications. If we have more than ___1__ cc/hr for a couple of hours, that requires intervention. We need to check their coagulation studies because the patient may need _______ factors/coagulation factors (FFP, platelets). If their PTT is prolonged (because they have to heparinize the blood when they run it through the bypass pump—so sometimes there is some residual anticoagulation from that heparin that they put in the pump—may need to give some __3___ ___3__ § They need __3__ __3___ if their PTT (partial thromboplastin time) is prolonged—it is the reversal agent for heparin

1. 150 2. clotting 3. Protamine sulfate

If you have a basic catheter with no fancy ports: to get a CO with this system you have to inject __1___ CCs of cool fluids (normally saline) and you inject it within the ___2____ port (or injectate port) very quickly within ___3____ seconds and at the same time you hit the button the monitor that says "cardiac output". Based on the amount of time it takes the cool saline to get to the thermometer on the tip of the catheter, it is able to calculate a cardiac output ○ You have to get 3 readings and average those 3 to get an average cardiac output **measuring cardiac output

1. 10 2. proximal 3. 4

Think of a ____-lead EKG as a camera taking pictures of the heart on a pedestal at different angles. Whichever way the camera is angled at the heart will be which wall of the heart is looking at. If you understand where the ___2_____ electrode is placed on the body, it makes more sense and helps you to remember which lead looks at which wall of the heart. When looking at infarct localization, which is the focus of this intro class, it is to be able to recognize where ST changes are, which wall of the heart the lead or where those ST changes are is looking at, and which ____3____ vessel is probably the culprit vessel.

1. 12 2. positive 3. coronary

_____1_____ describes disease of the blood vessels, anywhere in any vascular bed; whereas ____2______ is referring specifically to atherosclerosis of the coronary arteries (those arteries that lay on the surface of the myocardium and bring blood supply, oxygen, and nutrients to the myocardial tissues)

1. ASCVD 2. CAD

___1____ is really a subcategory of ____2____ o ___2____ is disease in any vascular bed o ____1_____ is disease in the coronary arteries (those arteries that lie on the surface of the heart that bring blood supply to the heart muscle) · ____1_____: A progressive atherosclerotic disorder of the coronary arteries. o The leading cause of death in the US.—decreased by 31.9% § When someone has a heart attack, their highest risk for death is within the first hour

1. CAD 2. ASCVD

What are the 7 modes of ventilation?

1. Controlled Mandatory Ventilation (CMV) - volume 2. Assist-control Mechanical Ventilation (AC) - volume 3. Synchronized Intermittent Mandatory Ventilation (SIMV) - volume Most common one used 4.Airway Pressure Release Ventilation (APRV) Used more common in patients with ARDS and stiff lungs 5. Pressure Support Ventilation (PS) - pressure 6. Positive End Expiratory Pressure (PEEP) 7. Continuous positive airway pressure (CPAP) **goes from most controlled to least controlled **

With lead II, the negative electrode is on the right ____1____ and positive electrode is on the left leg with the left arm lead being the ground. § The vector of this lead is from the right ____1_____ to the right leg § ******The positive electrode is on the left leg so it is looking up ___2____ly at the heart so it is looking at the ____2_____ wall of the heart******* *bipolar limb leads

1. shoulder 2. inferior

When talking about the diagnosis of an acute myocardial infarction (AMI), we look at serial cardiac enzyme values (those enzymes that get released with tissue death). We look at __1____ ( not specific to cardiac muscle—any muscle that is injured or dies releases ___1____), ___2_ ___2__ (very specific to cardiac muscle), and ___3__ levels (very specific to cardiac muscle). **ACS

1. Myoglobin 2. CK MB 3. Troponin

What are the 4 treatments for an MI? **management of MI

1. PCI (percutaneous intervention) 2. Thrombolytic therapy 3. CABG 4. medical management

1. Partial occlusion of coronary artery—which will cause them to have an UA or NSTEMI 2. Total occlusion of coronary artery—which will cause them to have a STEMI

You need a special monitoring system or also known as a special monitoring kit. This is special IV tubing with a transducer on it that you get off the supply cart. The IV tubing that goes from the transducer up to the bag of fluid is just like any other IV tubing: ____1___ and compressible. The IV tubing from the transducer to the patient is ____2___. If you squeeze it between your finger you cannot compress it. the reason for this is that you do not want to have distention of the tubing because if the tubing was distendable you would lose some of that pressure and have false low readings. That is what is special about the monitoring kit: it has ____2_____ tubing from the transducer to the patient

1. soft 2. hard

T or F. Once the pulmonary artery catheter is put in we always get an x-ray to verify placement. It is either going to go into the R or L PA depending on which way it floats (no control)

After insertion of an arterial line (ART line), nurses will be checking color, temperature, sensation, movement, presence of pain, assess distal pulse, bleeding at site, capillary refill (this is all done to prevent neuromuscular impairment), bleeding at site ● Neurovascular checks minimum of every ____ hours

When talking about 12 Lead placement, __1___ is midaxillary 5th intercostal space. do ____1____ before ___2____ because you can place ____2____ between V4 and ____1____.

1. V6 2. V5

Post cardiac surgery, the nurse needs to manage the patient's preload, afterload, and contractility. What are the 2 main ways to manage preload in a patient?

1. administer volume as needed for low PAWP/CVP (crystalloids, colloids such as albumin, and PRBCs) 2. diuretics as needed

What type of critical care nurse has the following abbreviation: 1. ACLS 2. PALS

1. adult critical care nurse 2. pediatric critical care nurses

___1_____ is characterized by apprehension and autonomic arousal; an internal feeling (hyper-aroused state - CNS) ○ Most ICU patients have problems with ___1____!!! _____2____ is characterized by increased motor activity by patient (physical display) ○ The patient cannot get still or comfortable; they are restless and irritable ○ ****Restlessness, increased motor activity, patient cannot sit still***** __3______ is a state of temporary but acute mental confusion; reversible global impairment of cognitive processes—disorientation, impaired short-term memory, altered sensory perception, and inappropriate behavior ○ Problem that is significant in ICU patients; somewhere around 50-60% of patients in the ICU have at least 1 episode of ___3___ during their stay ○ If not managed or taken care of, it can result in poor outcomes. Both anxiety can cause ___3____ and agitation is often a component of ___3____

1. anxiety 2. agitation 3. delirium

With lead III, the negative electrode is on the left __1____ and the positive electrode is on the left leg and the ground is the right _____1_____ § ******Positive electrode on the left leg and looking up _____2____ly at the heart so it is looking at the ____2_____ wall of the heart**** *bipolar limb leads

1. arm 2. inferior

With lead 1, the negative electrode is on the right ___1___ and the positive electrode is on the left ___1____. Also uses the right leg electrode as a ground § The vector of that lead is from the right shoulder to the left shoulder § *****The positive electrode is on the left ___1___ so it is looking at the ___2___ wall of the heart*** *bipolar limb leads

1. arm 2. lateral

Most adult endotracheal tubes will be ___1___ and that means that they have a balloon on them and that balloon helps to secure that tube in the trachea. The tubing to the port is how you inflate the balloon. You inject air in through this port and the balloon inflates and this is called a ___2_____ balloon because the more pressure you have in this balloon you will be able to feel it to estimate how much pressure is in that balloon (compress between fingers). This is one of the assessments you will make if taking care of a patient with an ET tube. If the balloon is inflated too much and there is too much pressure on the trachea, that can cause tissue necrosis, tissue erosion, and a TE fistula if it really erodes away the trachea. So, you always want to have the right amount of pressure in the cuff. _3__-_3___ mmHg of Mercury is what is recommended. Respiratory therapy usually comes around at least once a shift to put manometer on ___2_____ balloon to test how much pressure is in there. NEED TO KNOW ALL OF THIS.

1. cuffed 2. pilot 3. 20-25

the following is the difference between _____1 __ and ____2_____: ● ____1_____ - fluctuations in mental status, inattention, disorganized thinking ○ (Worsen clinical outcomes and increased LOS) ○ Quick onset; did not have a problem prior to being admitted ○ This is an ACUTE PROBLEM. It is not a problem that the patient has had for years; it is something that occurs due to the acute health problem that this patient is having ● ____2_____ - slow, progressive, irreversible loss of intellectual or cognitive abilities like abstract thinking, reasoning, pathological (higher risk for _____1_____ when in critical care) ○ Ask the family about thought processes and reasoning BEFORE they were in the hospital ● Patients can have both and they can occur concurrently BUT the difference between ___2____ and ____1____, _____2_____ is a chronic problem whereas ___1____ is an acute problem. A ___2_____ patient can have ___1____ on top of that.

1. delirium 2. dementia

When looking at ST segment monitoring, we need to know what is significant. o what is significant- § ST _____1____ >0.5mm in 2 or more contiguous leads (2 leads looking at the same wall of the heart) § ST _____2______ >1mm in the limb leads (lead I, II, III, aVR, aVL, aVF-called this because positive electrodes are on the limbs) and >2mm in the precordial leads in 2 or more contiguous leads § With the precordial leads, it is significant if you see it in 2 consecutive changes. Doesn't have to be just contiguous. If 2 leads are side by side whether it is V2 and V3 because they are consecutive, that is significant

1. depression 2. elevation

In the fibrous plaque (second stage of plaque development in ASCVD), this is the beginning of progressive changes in the __1___ of vessel. __2___ (bad cholesterol) and growth factors from platelets stimulate smooth muscle proliferation and _____3 of the arterial wall (as the wall becomes thickened, the lumen of the vessel is narrowed, and the flow of blood is restricted). _____4______ transport cholesterol and other lipids into the arterial intima and this stage can occur as early as age 30. It usually repairs itself—but in pts. with CAD ___2____ and platelet growth proliferates and thicken the vessel wall.

1. endothelium 2. LDL 3. thickening 4. lipoproteins

What stage of plaque development in ASCVD is described below (fatty streak, fibrous plaque, complicated lesion): ○ lipid filled smooth muscle cells of the vessel wall ■ Usually develops a yellow tinged appearance in the vessel ■ Can occur as early as age 20

1. fatty streak

What are the 3 stages of the development of plaque in ASCVD?

1. fatty streak 2. fibrous plaque 3. complicated lesion

When talking about localization of infarction, the __1____ the lesion is in any of the vessels, the more tissue that will be involved. If your lesion is very __2____ then it may be a very small area of the myocardium that is affected. **ACS

1. higher 2. distal

The coronary artery dives into the myocardium and you typically have your area of _____1__ (myocardial tissue death) and then you have an area of injury where it is suffering and dying but still have potential to save it and then you have an area of ischemia. Whenever someone has ____2_____, time is muscle. Very time sensitive. The sooner you can get their coronary artery back open, the more tissue you can save. Once tissue is ___1____ed, it is lost and gone and can't get it back. Still have the potential to save injured and ischemic tissue. § **More time the patient went with ischemia or injury with ST elevation, the more tissue you lose** **ischemia, injury, ____1___

1. infarct 2. ACS

The following is a quick review on A&P of coronary arteries: o Right coronary artery comes off of the right side of the aorta and feeds the right side of the heart and the inferior wall. In most people, the right coronary artery feeds the __1__ wall and also has a branch (PDA) that wraps around to the back side of the heart and may feed the ___2___ wall of the heart o The left coronary artery comes off the left side of the aorta and then it branches off into the left ___3_____ descending and the left ___5____ arteries. The left ____3____ descending artery feeds the ___4____ and ____3_____ wall of the heart or brings blood supply to those heart muscle tissues o The lateral coronary artery feeds the lateral wall of the heart and in some people feeds the ___2_____ wall of the heart so whether the person is considered right sided dominant or left sided dominant would determine which vessel the PDA off of the RCA or the ___5______ feeds the major part of the ___2____ wall. If they are right dominant then the PDA is the major vessel that feeds the ___2____ wall. If left sided dominant then the ___5_____ feeds the majority of the ___2_____ wall

1. inferior 2. posterior 3. anterior 4. septal 5. circumflex

The following is a quick review on A&P of coronary arteries: o The ___1___ coronary artery feeds the ___1____ wall of the heart and in some people feeds the ___2____ wall of the heart so whether the person is considered right sided dominant or left sided dominant would determine which vessel the PDA off of the RCA or the circumflex feeds the major part of the ____2___ wall. If they are right dominant then the PDA is the major vessel that feeds the ___2___ wall. If left sided dominant then the circumflex feeds the majority of the ___2____ wall.

1. lateral 2. posterior

If you have a patient who has a lesion in the ___1____ main area of the ___1____ coronary artery than that is going to occlude both the LAD and the circumflex and that is going to encompass oxygen supply to the majority of the __1___ ventricle and that patient is at extremely high risk for sudden cardiac ___2____ (that is why they call it the widow maker) o The __1____ coronary branches off at the aorta and there is a piece that then branches off into the __1____ anterior descending artery then the ___1____ circumflex artery **localization of infarction **ACS

1. left 2. death

LOOK AT IMAGE NUMBER 18 ON PHONE. · There is a branch above where the LAD and circumflex branch off and that is called the __1____ main and it is the little piece that comes off the aorta right before it branches off to the LAD and circumflex o *******If someone has an occlusion of that __1____ main artery, it will occlude both the LAD and the circumflex and that is the __1____ ventricle, anterior, lateral, and the septal walls. Most people who have a ____1___ main occlusion do not survive because it will knock out the whole left ventricle and they are going to go into cardiac shock and probably have a lethal arrythmia and pass away. That is why a ___1___ main lesion is called the ___2_ ___2__ because those patients don't usually survive. **********

1. left 2. widow maker

Name the 5 steps for the Surviving Sepsis Campaign. ● - in the ICU they are immunocompromised and introduced to new bacteria; if you suspect sepsis in a patient, complete these steps ***within 1 hour within being admitted*****

1. measure lactate level 2. obtain blood cultures prior to administration of antibiotics 3. administer broad spectrum antibiotics 4. fluid resuscitation 4. apply vasopressors to maintain a MAP of 65 mmHg

What common problem of critical care patients (nutrition, anxiety, pain and sedation, impaired communication, sensory-perceptual problems, sleep problems) is described below: ○ 70% of ICU pt have moderate to severe ___1____ and is often linked to agitation and anxiety ○ Unrelieved ___1____ can lead to poor outcomes ○ Address ____1____ adequately ○ Intubated patients may be on continuous ____2___s ■ "____2___ holidays" are important to assess neurological level ● This is important to wake them up periodically to assess their neurological level ● Once a day at least ● Patient could have a stroke and we would not know unless checking neurological status ○ Could be because patient is post-operative with surgical wounds, trauma patients with wounds from traumatic injury, or just uncomfortable with monitoring equipment

1. pain 2. sedation

All leads have a negative and positive ____1__. Might not always have a negative and positive sticker but always have a positive and negative __1____. If the current of flow in the myocardium is going ____2____ the positive electrode then the reflection you will see on the EKG is a positive one. Most of the electrical activity will be above the baseline. If the electrical flow is going ___3____ from the positive electrode then you will see a negative complex on the EKG. Most of the electrical activity will be below the baseline or that is how it will look on the EKG. If the electrical flow is going ___4____ to the positive electrode then you may have a biphasic wave form. Some of the complexes are above the baselines and some below the baseline. That is why the QRS complex looks different in different leads; may be okay in some leads for it to be totally negative or totally positive. **positive electrode and current flow

1. pole 2. towards 3. away 4. perpendicular

It is much better to have ___1___ sided MI than a ____2___ sided MI. Blockage in the __2____ main artery commonly called the "widow maker"--> most people do not survive this because it feeds a lot of muscle

1. right 2. left

The heart is a 2-sided pump. The ____1____ side is a LOW pressure pump and the ____2____ side of the heart is a HIGH pressure pump.

1. right 2. left

The following is a quick review on A&P of coronary arteries: o ____1___ coronary artery comes off of the ___1____ side of the aorta and feeds the ___1___ side of the heart and the inferior wall. In most people, the ____1__ coronary artery feeds the inferior wall and also has a branch (PDA) that wraps around to the back side of the heart and may feed the posterior wall of the heart. o The __2____ coronary artery comes off the ___2___ side of the aorta and then it branches off into the ___2____ anterior descending and the ___2____ circumflex arteries. The ___2___ anterior descending artery feeds the septal and anterior wall of the heart or brings blood supply to those heart muscle tissues

1. right 2. left

What invasive line is described below: ● Insertion Procedure ■ *LOOK AT IMAGE TO THE RIGHT WITH THE 4 HEARTS: The ____1___ atrium is a thin wall chamber and is a ____2____ pressure chamber so not a lot of pressure there. The waveform looks like this squiggly line so when the physician gets it in the subclavian this is the waveform you are going to get. Normal CVP pressures or ___1____ atrial pressures is somewhere between 2 and 10 mmHg ● As that catheter progresses and floats past the tricuspid valve and gets into the ___1____ ventricle you will see the pressures popped up. The ___1____ ventricle has thicker walls, it has to squeeze blood out, so there is more pressure in the ___1____ ventricle. You will see a higher _____5____ and low ___4____ pressure. ****That is how you know you passed the tricuspid valve into the ___1___ ventricle.*** Another sign that may tell you physician is in the __1___ ventricle is that you will start to see ____3____ on the ECG monitor because the ___1____ ventricle is very irritable and if the catheter starts to hit the wall of the __1___ ventricle it will cause some ____3____ or even some short runs of V tach. ● Once the tip passes the pulmonic valve and into the pulmonary artery you will start to see the ___4_____ number pop up somewhere around 10-15 mmHg. ___5____ number will stay the same and ___4____ will be around 10-15 mmHg. That is how you know the physician moved from the ___1____ ventricle to the pulmonary artery. Once the catheter is in that is where the tip will stay most of the time. While the physician is putting it in, as long as the balloon is inflated it will continue to float until it gets stuck in a capillary and gets "____6____" in there. That is why it is called "pulmonary artery ____6_____ pressure (PAWP)" ● When it gets ___6____ in a pulmonary artery the sensors on the tip, now this balloon is occluding everything behind it, all the pressures behind it. The only thing it is sensing is what is ___7____ of it. What is ___7____ on the other side of it is the ___8____ side of the heart and that is why we say a ___6____ pressure are pressures indicative of the ___8____ side of the heart. Once that balloon gets ___6_____, you will see the waveform change again. It will look a little more like the CVP waveform because we are looking at pressures on the ___8____ side of the heart or pressures indicative of pressures on the ___8____ side of the heart; will be higher than CVP but waveform will look like CVP pressure ● We do NOT want the catheter to stay ___6_____ because it can cause pressure, tissue necrosis from pressure areas and pulmonary hemorrhage. You want to get an intermittent wedge pressure meaning you get your reading, record it, and deflate the balloon and it should tuck back and sit in the pulmonary artery. **You usually only wedge it for 10-15 seconds.*** ■ Once the line is put in we always get an x-ray to verify placement. It is either going to go into the __1___ or ___8____ PA depending on which way it floats (no control)

1. right 2. low 3. PVCs 4. diastolic 5. systolic 6. wedged 7. forward 8. left

In the complicated lesion stage (final stage of plaque development in CV disease), plaque grows and can cause lesion instability, ulceration, and ___1___. When it ___1___s, that is what causes the patients symptoms and a cascade of events that occur (if its in the coronary artery, that is when the patient has ACS) Side note: ____2____ is chronic, and ACS is an acute problem or manifestation of that disease. When the plaque ___1____s, the lipid core is exposed to the ____3_____. This causes an activation of platelet, and those exposed platelets cause expression of ___4_____ IIb,IIIa (2b and 3a) receptors that bind ___5____ (___5____ is the basis of clots)—this is when a ___6____ starts to form ■ Can also cause further platelet aggregation and adhesions

1. rupture 2. CAD 3. blood 4. glycoprotein 5. fibrin 6. thrombus

108 dB

A standard electrocardiogram consists of ____ leads (angles/eyes looking at the wall of the heart).

From a ______ lead EKG one can determine: § heart rate § heart rhythm § *****myocardial ischemia or infarction (focus for this lecture): identify this by looking at ST changes and knowing which lead and wall of the heart that ST change is identified on and figure out which vessel is the culprit****** § hypertrophy: enlarged myocardium § axis deviation § electrical effects of medications and electrolytes

LOOK AT IMAGE NUMBER 16 ON PHONE. The chart is a range in how the _____ lead EKG is arranged § The ______ lead EKG gives you 3 seconds snips of the person's rhythm § So leads I, II, & III on your ______ lead will be all the way to the left § aVR, aVL, and aVF are the second column on the EKG § V1, V2, V3 are on the third column § V4, V5, V6 are on the fourth column

The following is a quick review of ____ lead EKG: o 10 Total electrodes (on the body) § 4 on limbs - RA, LA, RL, LL § 6 V leads on chest

What type of CV tool is described below: · A standard ___ ____ ____ provides views of the heart in both the frontal and horizontal planes and views the surfaces of the left ventricle from 12 different angles o Really looking at the left ventricle, which is the workhorse (which is the side we worry about most with infarctions) o Frontal plane is your limb leads (lead I, II, III, aVR, aVL, aVF) o Your chest leads are looking form your horizontal plane (v-leads or your precordial chest leads) **ACS

12 Lead ECG

After insertion of an arterial line (ART line), we assess the patient's circulation every _____ hours--> referred to as CMS checks (circulation, movement, sensation) ● Minimum of ____ hours ■ Will also be checking for signs of infection

12 Lead ECG

LOOK AT PICTURE NUMBER 5 ON PHONE: ■ **for the picture on the right: we use a special syringe that only pulls back ______ mL because we do not want put so much air into that balloon to where we pop that balloon and cause an air embolus. You cause see there is also a lock right below where the syringe is inserted. If you slide it over it will lock it so you cannot inject air in. ● The port right next to the syringe (yellow port) is the distal port that sits in the pulmonary artery ● The blue port is the proximal port or the infusion port. It opens in the R atrium. If they have another infusion port, that would be the white one which opens in the R ventricle and then the last yellow port (all the way to the left) is the thermistor. There is a cable that will connect to it and connect to a monitor to relay information

1.5

When talking about readiness for weaning in a patient on the ventilator, their TV needs to be greater than or equal to ____ LmL/kg.

When talking about pulmonary artery placement, we do NOT want the catheter to stay wedged because it can cause pressure, tissue necrosis from pressure areas and pulmonary hemorrhage. You want to get an intermittent wedge pressure meaning you get your reading, record it, and deflate the balloon and it should tuck back and sit in the pulmonary artery. You usually only wedge it for___-____ seconds.

10-15

When talking about readiness for weaning in a patient on the ventilator, the rapid shallow breathing index (RSBI) is the patient's RR and average tidal volume over one minute. ■ Indication of whether or not the pt. is ready for weaning ■ Normal RSBI: 60-105/L ● Respiratory rate divided by the average tidal volume over one minute (<105) ■ Indices for Weaning: <_______/L ■ If less than ______, they are ready for weaning.

105

What type of CV tool is described below: · Central to initial risk and treatment stratification. · Patients presenting to the ER with chest pain should have a ____ ___ ____ performed and read by a physician within 10 minutes · Elevated enzymes are not necessary for a decision to administer fibrinolytics or perform PCI on patients with a STEMI. · Principle: Ischemic/necrotic tissue does not conduct electrical impulses normally (which is why we see that ST elevation or depression on the ___ ___ _____) · A standard ___ ____ ____ provides views of the heart in both the frontal and horizontal planes and views the surfaces of the left ventricle from 12 different angles o Really looking at the left ventricle, which is the workhorse (which is the side we worry about most with infarctions) o Frontal plane is your limb leads (lead I, II, III, aVR, aVL, aVF) o Your chest leads are looking form your horizontal plane (v-leads or your precordial chest leads) **ACS

12 Lead ECG

120 dB (loudest one; silence when suctioning)

When maintaining tube patency for artificial airways, tracheal mucosal damage is likely with pressures >_______ mmHg, overly vigorous catheter insertion & characteristics of the suction catheter itself ■ Blood streaks or tissue shreds in secretions may indicate mucosal damage ○ Assessments are normally every 2 hours listening to their lungs

120 mmHg

normal arterial BP?

120-80

A ______ PCI is when: · Stretches vessel wall, fractures plaque, and enlarges the vessel lumen · Reduces stenosis to less than 50% of the vessel lumen diameter 90% of the time

successful

what is the nurse to patient ratio post-op for a patient who had a CAB? · these patients can be very busy for the first few hours after surgery · The nurse will receive report from either the nurse anesthetist, the surgery nurse, or sometimes even the anesthesiologist

1:1

Dexemedetomidine (Precedex) is a centrally acting alpha ___ agonist so it stimulates alpha ___ receptors. It inhibits sympathetic activity (decreases BP and HR). ● Stimulating alpha ____ receptors causes vasodilation (side note: stimulating alpha 1 receptors causes vasoconstriction) ○ So, watch their BP and adequately hydrate the patient

Every EKG lead has ____ poles but some of them use information from the other leads as the negative pole § Augmented unipolar limb leads actually use information from all of the leads as the negative or center of the heart as the negative pole as well as the precordial chest leads § Bipolar limb leads are the only leads that have _____ specific patches

In the critical care unit, you do your assessments every _____ hours (focus assessment, I&O, V/S a minimum of every _____ hours but sometimes more frequently such as if you are titrating drips to maintain BP or bring down BP you may be doing VS every 15 minutes) ○ More frequent assessments in ICU than on med surg floors **critical care specialty units

The difference between an ET tube and a tracheostomy tube is that an ET tube is a temporary measure and may stay in a week, maybe ______ weeks at the max. This tube is placed into the trachea via the mouth or nose past the larynx (mouth to trachea). A tracheostomy is a surgical procedure performed if the patient needs ventilation for more than _______ weeks. The tube is placed through a stoma that is **surgically** created in the neck.

What step (1-5) of the Surviving Sepsis Campaign is described below: Obtain blood cultures prior to administration of antibiotics (will need 2 sets from 2 sites or 15 minutes apart)

What 4 leads in a 12 lead EKG look at the lateral part of the heart ?

Lead I, aVL, V5, V6

What 3 leads in a 12 lead EKG look at the inferior part of the heart?

Leads II and III, aVF

Normal range for CVP/RAP (central venous pressure/right atrial pressure) ■ Pre-load for the right side of the heart. ■ Reflects pressure in the right side of the heart OR pressure in the superior vena cava ■ Reflects ability of the right side of the heart to manage fluids ■ Serves as a guide to fluid volume deficit or fluid volume overload ■ Changes occur much later than pulmonary artery pressure changes (may see changes in PA pressure before CVP pressure)

2-8mmHg or 4-10 cm H20

What is the normal range for RAP/CVP? ■ Remember right atrium is a low pressure chamber with thin walls

2-8mmHg or 4-10 cm H20

What stage of plaque development in ASCVD is described below (fatty streak, fibrous plaque, complicated lesion): ○ beginning of progressive changes in the endothelium of vessel ■ LDL (bad cholesterol) and growth factors from platelets stimulate smooth muscle proliferation and thickening of the arterial wall (as the wall becomes thickened, the lumen of the vessel is narrowed, and the flow of blood is restricted) ■ Lipoproteins transport cholesterol and other lipids into the arterial intima ■ Can occur as early as age 30 ■ Usually repairs itself—but in pts. with CAD LDL and platelet growth proliferates and thicken the vessel wall

2. fibrous plaque

Normal range for CI (cardiac index)? ● Cardiac Index is the cardiac output adjusted for body size (more precise measurement of the efficiency of the pumping action of the heart***) ● Someone who is really large and has a lot of mass will need a higher CI than a small 90 pound lady who barely has any mass

2.4 - 4.0 L/min/m2

What is the normal range for cardiac index? BOLD AND RED. NEED TO KNOW.

2.4-4.0 L/min/m2

The 12-lead ECG only provides a _____-second view of each lead. When first introduced to the 12-lead ECG, these ______ seconds may seem prohibitively short. However, when looking for evidence of infarction, most of the information is obtained from analyzing a single, representative complex in each lead. It is assumed that ______ seconds is long enough to capture at least one representative complex. A ______-second view is not long enough to properly assess rate and rhythm, so at least one continuous rhythm strip is usually included at the bottom of the tracing. o Point out isoelectric line, normal ST segments, R wave progression.

2.5

If the balloon is inflated too much and there is too much pressure on the trachea, that can cause tissue necrosis, tissue erosion, and a TE fistula if it really erodes away the trachea. So, you always want to have the right amount of pressure in the cuff. ____ - ______ mmHg of Mercury is what is recommended. Respiratory therapy usually comes around at least once a shift to put manometer on pilot balloon to test how much pressure is in there. NEED TO KNOW ALL OF THIS.

20-25 mmHg

What is the normal arterial blood gas value (ABGs) for HCO3?

22-26

When talking about post-operative care of a patient with CAB, the patient is in the ICU for how many hours? o They try to get them up and moving out as soon as possible—sooner they get moving the better they will do

24-36

In critical care nursing, the nurse to patient ratio is much smaller in critical care units. Typically on average, in an ICU the nurse to patient ratio is ___:____ so ____ patients to ____ nurse. Whereas, on a medical surgical floor, you could be caring anywhere from 4 to 8 patients depending on which shift you are working.

2:1

In addition to a special monitoring kit, you need a bag of fluid which is normally 500 cc of saline and a pressure bag o the fluid has to be under pressure because that helps the system to work. It is designed to deliver _____ cc's an hour but it has to be under 300 mm of Mercury. This maintains the system, prevents blood from backing up into the system, and delivers _____ cc's an hour to keep the line open **hemodynamic monitoring

What step (1-5) of the Surviving Sepsis Campaign is described below: Administer broad spectrum antibiotics (always start on broad AB first; when C/S comes back always check to see if pt. is on the right AB that the organism is most sensitive to)

What NON-benzodiazepine drug given as sedatives for critically ill patients is described below (Propofol (Diprivan) and Dexamedetomidine (Precedex)) ○ needs airway support so pt. HAS to be intubated ■ Also known as Milk of Amnesia

Propofol

what are the 12 leads in an ECG?

3 augmented unipolar limb leads (aVR, aVL, aVF), 3 bipolar limb leads (Leads I, II, and III), and 6 precordial/chest leads (V1, V2, V3, V4, V5, and V6)

Post cardiac surgery we want to preserve renal function. We can do this by: · kidney injury (AKI) or acute renal failure (ARF) caused by decreased renal perfusion if they don't have enough preload or enough volume (volume depleted—decrease blood supply to the kidney then that is going to increase risk for AKI—this is why it is very important to maintain adequate preload and cardiac output during that post-op period to make sure that the kidneys are perfused adequately) o Vigilant monitoring of urine output - report if less than ______ cc/hour o Vigilant monitoring of electrolytes, BUN, creatinine o Maintain adequate hydration and preload § Want to maintain that perfusion pressure o Diuretics as needed § If they are overloaded

What stage of plaque development in ASCVD is described below (fatty streak, fibrous plaque, complicated lesion): ○ final stage, most dangerous, continued inflammation ■ Plaque grows—lesion instability, ulceration, and rupture ● When it ruptures, that is what causes the patients symptoms and a cascade of events that occur (if its in the coronary artery, that is when the patient has ACS) ○ Side note: CAD is chronic, and ACS is an acute problem or manifestation of that disease ● When the plaque ruptures, the lipid core is exposed to the blood ○ This causes an activation of platelet, and those exposed platelets cause expression of glycoprotein IIb,IIIa receptors that bind fibrin (fibrin is the basis of clots)—this is when a thrombus starts to form ■ Can also cause further platelet aggregation and adhesions

3. complicated lesion

What stage of plaque development in ASCVD is described below (fatty streak, fibrous plaque, complicated lesion): ○ final stage, most dangerous, continued inflammation ■ Plaque grows—lesion instability, ulceration, and rupture ● When the plaque ruptures, the lipid core is exposed to the blood ○ This causes an activation of platelet, and those exposed platelets cause expression of glycoprotein IIb,IIIa receptors that bind fibrin (fibrin is the basis of clots)—this is when a thrombus starts to form ■ Can also cause further platelet aggregation and adhesions

3. complicated lesion

One modifiable risk factor for CV disease is obesity. ANYONE with a BMI of > _____ kg/m2 (height and weight) are at increased risk for CV disease.

LOOK AT PICTURE ON PHONE OF MAN IN BED WITH BAG OF FLUID HANGING. **here you have your bag of fluid (saline) on a pressure bag and the pressure bag should be pumped up to ________ mg of Mercury. You have your drip chamber, roller clamp, goes down to the transducer. The transducer will sit on the IV pole in a transducer holder. A transducer holder is a holder that clamps onto the pole with a C clamp and the transducer fits right in there. The stopcock is usually right on top of it. that is what needs to be level with the phlebostatic axis or 4th ICS midchest. The tubing from the transducer to the patient is the hard tubing.

300

in additional to a special monitoring kit, you need a bag of fluid which is normally 500 cc of saline and a pressure bag o the fluid has to be under pressure because that helps the system to work. It is designed to deliver 3 cc's an hour but it has to be under _______ mm of Mercury. This maintains the system, prevents blood from backing up into the system, and delivers 3 cc's an hour to keep the line open. **hemodynamic monitoring

300

What is the normal arterial blood gas value (ABGs) for PCO2?

35-45

T or F. PAP is considered to reflect both right & left heart pressures (taking data from both sides of heart). PA Diastolic & PAWP are sensitive indicators of cardiac function & fluid volume status. Monitoring PA pressures permits precise manipulation of preload

T or F. PCI is preferred for STEMI and NSTEMI, especially if there is any doubt that it is actually STEMI. **management of MI

What step (1-5) of the Surviving Sepsis Campaign is described below: Fluid Resuscitation-- Administer 30ml/kg crystalloid for hypotension or lactate 4mmol/L ○ Crystalloids include NS, LR, D5½; Colloids include things like albumin (volume expanders) ○ Remeasure lactate if lactate level was elevated

ACE or ARBs

Normal Range for CO (cardiac output)? ● CO is the volume of blood pumped by the heart in L/min from the ventricles ○ Change in preload, heart rate, and contractility can affect CO ○ **measured in Liters/minute

4 - 8 L/min

What is the normal range of cardiac output? NEED TO KNOW THIS.

4-8 L/min

T or F. PEEP- you are keeping increase intrathoracic pressure→ decrease venous return and CO -- which decreases flow to the kidneys (may see a drop in BP). *****Patients with head injury or stroke you NEVER want to use PEEP (even if it is 5)*******

One main indicator for the readiness for weaning a patient off of the ventilator is adequate oxygenation. What does the patient's PEEP need to be less than or equal to? (<)

5-8 cm H2O

One main indicator for the readiness for weaning a patient off of the ventilator is adequate oxygenation. What does the patient's FiO2 need to be less than or equal to? (<)

40-50%

One modifiable risk factor for CV disease is obesity, abdominal obesity specifically. A waist circumference of > 102 cm (> ____ inches) in MEN is considered to be abdominal obesity. A waist circumference of > 88 cm (_____ inches) in WOMEN is considered abdominal obesity.

40; 35

Ketorolac (Toradol) is given no longer than ____ days due to increased bleeding and increased renal indices (BUN and creatinine). ■ In presence of renal insufficiency, dose is usually decreased to 15mg ■ Change dosages based on renal function (can cause increased creatinine; caution in OA)

Physiological PEEP is ______ cm of H20 ○ Patients who have ARDS or need extra help, we may go up to 10-15 cm ● PEEP higher than _____ cm result in decreased cardiac output

There are ____ different levels of Scheduled Narcotics (based on level of addiction). (dont need to know all of the drugs under each category for test)

What step (1-5) of the Surviving Sepsis Campaign is described below: Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a meal arterial pressure (MAP) 65 mm Hg

50-80 dB

Normal range for PAWP (pulmonary artery wedge pressure) ○ Indirect measure of left ventricular end-diastolic preload - this is the ability to actually fill ○ Note: readings are done at the end of expiration ○ A HIGH pulmonary artery wedge pressure is almost always indicative of L-sided heart failure

6-12 mmHg

What is the normal range for PAWP?

6-12 mmHg

normal HR?

60-100 bpm

60-75 dB

Normal range for SVO2 ● Fiber optic sensor on distal tip of PA catheter.(Cadillac catheter with SVO2 monitor) ● Oxygen saturation of the blood in the pulmonary artery that has already saturated the body ● Called mixed because blood from all parts of the body returning to the right heart.

60-80% oxygen

One main indicator for the readiness for weaning a patient off of the ventilator is adequate oxygenation. What does the patient's pH need to be more than or equal to? (>)

7.25

What is the normal arterial blood gas value (ABGs) for pH?

7.35-7.45

70 dB

Normal range for MAP (mean arterial pressure)? non-invasive BP) ● *Measuring end-organ tissue perfusion (lungs, liver, kidneys, etc.) ● MAP= perfusion pressure ● Systolic BP + 2 (Diastolic BP) / 3 ***

70-105 mmHg

what is the normal range for MAP? **BOLD AND RED IN NOTES. NEED TO KNOW. ○ When you get outside of this range, you start to worry about tissue perfusion. That is why the mean arterial pressure is a good number for us to evaluate tissue perfusion

70-105 mmHg

How long does a Fentanyl patch last?

72 hours

What is the normal arterial blood gas value (ABGs) for PO2?

80-100

T or F. PS is NOT used as the sole ventilator support during acute respiratory failure because of risk for hypoventilation

ACEI or ARB (one or the other)

What ICU bundle is described below: ● - awaken, breathe, choose medication/coordinate care, delirium, early ambulation (specific to ICU; typically for patient on ventilator) ○ Awakening trials for ventilated patients ■ Check neurological status ○ Breathing trials (spontaneous breathing trials) ■ If on ventilator we want to see if they can breathe on their own and take their own breathes ○ Choose medications/coordinate care ■ Coordinated effort between the registered nurse and respiratory therapist to perform the spontaneous breathing trial when the patient is awakened by reducing or stopping the patient's sedation. The combination of sedation and analgesics being used are reviewed, and changes or reductions in the doses are considered. ■ Make sure they are on adequate medications, eliminate any medications they do not need ○ Delirium prevention ■ A standardized delirium assessment program, including treatment and prevention options. ■ Daily delirium assessment; if do have delirium, institute measures to resolve and treat ○ Early mobilization and ambulation of critical care patients ■ Getting them out of bed and moving them ASAP **A bundle is nursing care that should be provided for a patient based on either the disease process they have or a treatment that they have

ABCDE bundle

When monitoring oxygenation and ventilation of artificial airways, we do frequent _______ to monitor them because we are in control of their RR and tidal volume; so we need to make sure we are giving enough and not too much ■ Daily _______ usually on patient on vent or even more often ■ Anytime you make a ventilator change you need to get some _______ to see how they are tolerating it

ABGs

○ The organization that credentializes advanced practice nurses ● "this organization" puts out these certifications

ANCC- American Nursing Credentialing Center

T or F. Patients are admitted to the ICU for 1 of 3 reasons: physiologically unstable, high-risk for serious complications, or intensive support requiring IV medications and/or advanced technology

T or F. Patients may have acute and chronic pain→ it is important to know this because those with chronic pain may have a high tolerance to pain medication

T or F. Patients with high SVR--> hard for L ventricle to eject blood and increases workload of the heart and can contribute to HF (one of the manifestations of HF)

ASA (aspirin)

The purpose of "the grading system" is simply to assess the degree of a patient's "sickness" or "physical state" prior to selecting the anesthetic or prior to performing surgery. **The American Society of Anesthesiologists Physical status classification

ASA Classification

The following is all of the info for ____ _____: ● ASA Physical Status 1 - A normal healthy patient * ● ASA Physical Status 2 - A patient with mild systemic disease* ● ASA Physical Status 3 - A patient with severe systemic disease* ● ASA Physical Status 4 - A patient with severe systemic disease that is a constant threat to life ● ASA Physical Status 5 - A moribund patient who is not expected to survive without the operation ("spiraling the drain") ● ASA Physical Status 6 - A declared brain-dead patient whose organs are being removed for donor purposes. ○ RNs who work for LOPA do a lot of things that physicians would normally do with these patients who have been declared brain dead ● Based on assessment physician makes and charts ○ Doctor will also look into patients mouth to anticipate if they will be difficult to intubate. If so, anesthesiologist will be needed

ASA classification

The following is all of the info for ____ _____: ● The American Society of Anesthesiologists Physical status classification ● The purpose of the grading system is simply to assess the degree of a patient's "sickness" or "physical state" prior to selecting the anesthetic or prior to performing surgery. ● ASA Physical Status 1 - A normal healthy patient * ● ASA Physical Status 2 - A patient with mild systemic disease* ● ASA Physical Status 3 - A patient with severe systemic disease* ● ASA Physical Status 4 - A patient with severe systemic disease that is a constant threat to life ● ASA Physical Status 5 - A moribund patient who is not expected to survive without the operation ("spiraling the drain") ● ASA Physical Status 6 - A declared brain-dead patient whose organs are being removed for donor purposes. ○ RNs who work for LOPA do a lot of things that physicians would normally do with these patients who have been declared brain dead

ASA classification

What assessment test do we perform BEFORE ART line insertion? ■ Apply pressure to both the radial & ulnar arteries then release ulnar pressure - should be visible & brisk blood return (3-5 seconds) ■ If it pinks up again, you have good ulnar flow ■ If blood return is not witnessed, the ART line will NOT be placed (indicates absence of patency in ulnar artery); will NOT be placed if pt. has carotid stenosis to that side as well ■ Test to test ulnar blood flow

Allen's Test

What does AACN stand for? This organization was founded in 1969 as the American Association of Cardiovascular Nurses; the name changed to AACN in 1971 because it better represented the population of nurses they were representing. It wasn't just cardiovascular nurses, it was nurses who cared for patients with all kinds of problems in the critical care unit

American Association of Critical Care Nurses

What organization for critical care is described below: ○ Offers Certification - CCRN (adult, pediatric, and neonatal) ○ Represents critical care nurses

American Association of Critical Care Nurses (AACN)

Post PCI, nurses have to manage the vascular access site and the patient can have various different closure devices. Sometimes physicians will use these special devices that seal the artery. Angio-seal, Perclose, and Starclose are different closure devices. Which of these is described below: § collagen plug that plugs the hole in the vessel

Angio-seal

Look at image 35 on phone. What is going on? o Depressed ST indicates ischemia. o Elevated ST segment indicates injury (acute infarction) **remember Lead I, aVL, V5, V6--> ____ part of heart

Anterolateral infarct

Antidysrhythmic drugs

Antiplatelets

What indication for mechanical ventilation is described below: (apnea or impending inability to breathe, ventilatory failure, severe hypoxia, respiratory muscle fatigue, and RR > 35 or < 8-10) ○ Who would be apneic? Stroke pt. cardiac arrest, high cervical spine injury ○ Pt. might exhibit signs & symptoms such as: hypoxia, restlessness, decreased LOC, confusion, immobility, accessory muscles use, difficulty speaking ○ Impending inability means pt. respirations are labored & they appear cyanotic - inevitable

Apnea or Impending Inability to Breathe

What does ASCVD stand for? ● General term to describe disease of the vessels and blockage in the arteries

Atherosclerotic cardiovascular disease

What CV disease is caused by focal deposit of cholesterol and lipids in the intimal wall of the artery? ● Other causes of injury to the intimal lumen of artery include: ○ DM- high blood sugars damage artery walls; a lot of microvascular damage ○ Tobacco use (smoking), hypertension, diabetes, some infectious processes ○ There are theories that the inflammatory process injuries the vessel wall so anything that causes a systemic inflammatory process can increase risk for the development of cardiovascular disease and often times infectious processes can cause a systemic inflammatory response

Atherosclerotic cardiovascular disease (ASCVD)

What CV disease is caused by focal deposit of cholesterol and lipids in the intimal wall of the artery? ○ As those lipids and cholesterol build up in the artery, the lumen of the artery narrows and then blood flow is restricted ○ There is theory that a variety of things can cause injury to the vessel wall and that injury to the vessel wall is what sets it up for plaque and fatty acids to stick to those walls

Atherosclerotic cardiovascular disease (ASCVD)

What CV disease is described below: ● General term to describe disease of the vessels and blockage in the arteries ● Type of blood vessel disorder that is included in general category of atherosclerosis (can be with any artery - anything with an arterial lumen has the potential to develop atherosclerosis) ● ________ describes disease of the blood vessels, anywhere in any vascular bed ○ Whereas coronary artery disease (CAD) is referring specifically to atherosclerosis of the coronary arteries (those arteries that lay on the surface of the myocardium and bring blood supply, oxygen, and nutrients to the myocardial tissues) ● Atherosclerosis is the major cause of CAD ○ Most of the deaths related to CAD are due to MI, HF, pericarditis ○ The development of plaque and fatty acid over time

Atherosclerotic cardiovascular disease (ASCVD)

What cardiovascular disease describes disease of the blood vessels, anywhere in any vascular bed; whereas coronary artery disease (CAD) is referring specifically to atherosclerosis of the coronary arteries (those arteries that lay on the surface of the myocardium and bring blood supply, oxygen, and nutrients to the myocardial tissues)?

Atherosclerotic cardiovascular disease (ASCVD)

What cardiovascular disease is a general term to describe disease of the vessels and blockage in the arteries and is a type of blood vessel disorder that is included in general category of atherosclerosis (can be with any artery - anything with an arterial lumen has the potential to develop atherosclerosis)?

Atherosclerotic cardiovascular disease (ASCVD)

What are some examples of *potentially* life-threatening problems?

Attempted suicide, DVT, hypoglycemia, major surgical procedures (colorectal)

What modifiable risk factor for CV disease is described below: § Controlling ______ reduces SVR which reduces the workload on the heart § HTN JAMA Guidelines 2017: § High risk patients (>10% risk [CAD, DM, CKD]) target BP of 130/80 § Low risk patients (<10% risk) target _____ of 140/90 · Sodium intake, diet, exercise & mediation compliance

Why are blood specimens taken from the pulmonary artery called mixed venous?

Because it is blood returning to the R side of the heart from all over the body where it is "mixed" before returning to the pulmonary system to get reoxygenated. · If you drew blood from tip of the PA catheter or distal port, that sample would be a mixed venous sample

Why are blood specimens taken from the pulmonary artery called mixed venous?

Because it is blood returning to the right side of the heart from all over the body where it is "mixed" before returning to the pulmonary system to get re-oxygenated.

What method of non-invasive positive pressure ventilation (NIPPV) is described below (CPAP or BiPAP): ■ Similar to pressure support ventilation because the pt. must be able to spontaneously breath & cooperate with treatment ■ Indicated for acute respiratory failure in pt. with COPD, HF & sleep apnea (NOT for shock, altered mental status, or increased airway secretions) ■ Use 2 levels of pressure: a higher inspiratory pressure and lower expiratory pressure ■ More for the sicker patients, chronic lung patients, patients who are more fragile

BiPAP

What method of non-invasive positive pressure ventilation (NIPPV) is described below (CPAP or BiPAP): ■ Stands for Bilevel positive airway pressure ■ Delivers two different levels of positive airway pressure - ● Inspiratory pressure (IPAP) ● Expiratory pressure (EPAP) ● **makes easier for someone to exhale against; patients who have air trapping may do better on a BiPAP as compared to a CPAP ■ Similar to pressure support ventilation because the pt. must be able to spontaneously breath & cooperate with treatment ■ Indicated for acute respiratory failure in pt. with COPD, HF & sleep apnea (NOT for shock, altered mental status, or increased airway secretions) ■ Use 2 levels of pressure: a higher inspiratory pressure and lower expiratory pressure ■ More for the sicker patients, chronic lung patients, patients who are more fragile

BiPAP

What non-invasive cardiac output technology is described below: ○ Cheetah® ○ New and exciting technology! ○ Much more accurate! Not typically used for continuous cardiac monitoring like in ICU but valuable for intermittent data on patient ○ This is Non-invasive !

Bioreactance technology

What could cause a high-pressure alarm to go off?

Biting the tube, kinked tubing, secretions (mucus plugs), and bronchospasm or pneumothorax; may need to be suctioned

In medical management of CAD, PCI and CABG are treatment options. Which of these 2 treatments is described below: o if they have diffuse disease/disease all throughout the vessels, bypassing them won't do a whole lot of good—could also be due to their general state of health: ______ surgery is a major surgery with lots of risks and the patient may not be in good enough condition to go through this surgery

CABG

The following are indications for a ______: · 1. Failed medical management · 2. Left main coronary artery or 3-vessel disease · 3. Not candidates for PCI—vessel too long or are of blockage is difficult to access · 4. Failed PCI and continued chest pain

CABG

There are 4 treatments for an MI: PCI, thrombolytic therapy, CABG, and medical management. Which of these 4 treatments is described below: § a surgical procedure where the surgeon creates bypasses (reroutes the blood by taking grafts either from the leg or possibly even the radial artery then tying it onto the aorta and then tying it onto the coronary artery distal to where the occlusion is) · Not typically a favored treatment in the acute phase when they present to the ER but in some cases that is the only option · Bypass vessels w/ veins from legs to reroute blood supply; not 1st line; maybe if come in with left line lesion. · Goal: salvage as much of the myocardial tissue as possible. **management of MI

CABG

What critical care specialty unit is described below: ○ may stand for coronary care unit which is a unit that cares for patients with coronary problems so coronary arteries (arteries that bring blood supply to the heart muscle) patients who have acute coronary syndrome, MI, chest pain

CCU

What cardiac marker seen with an acute myocardial infarction (AMI) is described below: (CK MB, Troponin, Myoglobulin) o____ ____ rise at 6 hours, peak 18 hours (somewhere between 15-20), back to normal by 24-36 hours § ___ _____ specific for myocardial *ACS

CK MB

What method of non-invasive positive pressure ventilation (NIPPV) is described below (CPAP or BiPAP): ■ Caution pt. with myocardial compromise because this increase the workload of breathing - pt. have to breathe against the continuous pressure ■ Use 1 level of pressure ■ More commonly used for obstructive sleep apnea

CPAP

What method of non-invasive positive pressure ventilation (NIPPV) is described below (CPAP or BiPAP): ■ Stands for continuous positive airway pressure ■ Continuous positive pressure to maintain continuous level of positive pressure- constant flow (usually in obstructive sleep apnea) one level of pressure ■ Similar to PEEP in that they both keep alveoli opened but it is applied continuously ● PEEP is positive end expiratory pressure; PEEP is only on exhalation and ________ is continuous ■ Caution pt. with myocardial compromise because this increase the workload of breathing - pt. have to breathe against the continuous pressure ■ Use 1 level of pressure ■ More commonly used for obstructive sleep apnea

CPAP

Name the 2 main non-invasive POSITIVE pressure ventilation methods.

CPAP and BiPAP

What critical care specialty unit is described below: ● cardiovascular ICU ○ Patients with CV problems

CVICU

The following is the steps in obtaining ______ readings in a patient: ○ Zero (calibrate equipment) ■ Keep transducer at phlebostatic axis (level of right atrium): 4th intercostal space at mid-chest. Obtain readings and determine any needed interventions ○ Measure at end expiration ■ Anytime you are getting PA pressures or ______ pressures, you want to measure at end expiration. You want to look at the monitor, monitor patient's respiratory status because if they are working hard to breathe that changes the intrathoracic pressure with deep breathes giving false high and false low readings

CVP

What type of pressure (PAWP, CVP/RAP) is described below: ○ Monitored by attaching pressure tubing (transducer) to the proximal port of PA catheter - transducer then converts the pressure in the catheter into a waveform & digital readout ■ The port is where the pressure is measured ○ Can also be monitored with the use of a central venous catheter (this method is more common) ○ What is the normal? 2-8 mmHg ■ Remember right atrium is a low pressure chamber with thin walls ○ Normal range for _______: 2-8mmHg or 4-10 cm H20

CVP

What type of pressure (PAWP, PAP, CVP/RAP) is described below: ○ If _______ readings are elevated & pt. is in true volume overload, you may see some JVD ○ Changes occur much later with _______ than pulmonary artery pressure changes ○ You might also hear people talking about RAP/_______ as right sided filling pressures because your RAP is the preload of the R side of the heart. This gives us an idea of the patient's volume status (dehydrated, overhydrated, normal). ■ if volume overloaded, you will see high _______ pressures. ● Possibly R-sided heart failure ■ If they are dehydrated or volume depleted you will see low _______ pressures

CVP

What type of pressure (PAWP, PAP, CVP/RAP) is described below: ○ Normal range for CVP: 2-8mmHg or 4-10 cm H20 ■ Elevated _______ indicates right ventricular HF or volume overload; decreased _______ indicates hypovolemia ■ Pre-load for the right side of the heart. ■ Right side filling pressures. ■ Mean reading ■ ________ stands for central venous pressure and is also known as RAP (right atrial pressure) ■ Sometimes the changes that occur with volume changes are delayed because we have a lot of compensatory measures

CVP

What type of pressure (PAWP, PAP, CVP/RAP) is described below: ○ What does "this type of pressure" tell you? ■ Reflects pressure in the right side of the heart OR pressure in the superior vena cava ■ Reflects ability of the right side of the heart to manage fluids ■ Serves as a guide to fluid volume deficit or fluid volume overload ■ Changes occur much later than pulmonary artery pressure changes (may see changes in PA pressure before ______ pressure)

CVP

______ is basically a measure of preload, which is usually affected primarily by fluid volume status (can determine if pt. is in fluid volume overload or deficit using _______) ○ Can get _______ with just central line ○ **remember _______ is measured as a MEAN value which is why it is in parentheses. The R atrium is a LOW PRESSURE chamber. **proximal port of PA catheter

CVP

Calcium Channel Blockers

What code for acute issues in the critical care setting (Code STEMI, Code Trauma, Code FAST) is described below: ○ Facial drooping ○ Arm weakness ○ Speech difficulties ○ Time ○ **for patient having a stroke and this could be an ER code or patient in the hospital (can have stroke even tho in hospital for something different)

Code FAST

What code for acute issues in the critical care setting (Code STEMI, Code Trauma, Code FAST) is described below: ● (ST elevation MI - pt. will go straight to cath lab; pt is having a heart attack) ○ Someone who is having an acute MI who needs rapid treatment ○ Usually time sensitive processes that need to be addressed quickly ○ Often called in the ER but can be called for a patient in the hospital because someone who is in the hospital for another problem could still have a heart attack while they are in there

Code STEMI

What are 3 codes for acute issues in the critical care setting?

Code STEMI Code Trauma Code FAST

What code for acute issues in the critical care setting (Code STEMI, Code Trauma, Code FAST) is described below: ○ Usually ER code; if you have patient and ambulance is bringing in a traumatic patient they will call this code

Code Trauma

What pain scale is more focused on critical care patients who may be sedated or unable to verbally report their pain? **looks at facial expression, body movements, muscle tension (evaluation of passive flexion and extension of upper extremities), compliance with the ventilator (intubated patients) OR vocalization (extubated patients)

Critical Care Pain Observation Tool

How often should you zero a monitoring system?

You should 0 when you put the system in, every 4 hours, and anytime you have a questionable reading. Anytime something looks different or does not make sense, rezero it.

What NON-benzodiazepine drug given as sedatives for critically ill patients is described below (Propofol (Diprivan) and Dexamedetomidine (Precedex)) ● Selective Alpha-2 Receptor Agonist ■ Stimulates the alpha 2 receptors (not alpha 1) ● Blocks part of the stress response that you get (anxiety, vasoconstriction, etc.)

Dexamedetomidine

What is a common hemodynamic complication of positive pressure ventilation?

Decreased venous return and decreased CO

Dexamedetomidine

What NON-benzodiazepine drug given as sedatives for critically ill patients is described below (Propofol (Diprivan) and Dexamedetomidine (Precedex)) ● Centrally acting alpha-2 agonist ○ It stimulates alpha 2 receptors ● Inhibits sympathetic activity (decreases BP & HR) ● ***Still address them as a pt. who is awake/alert because they will remember what they hear ● Indicated for short term sedative for mechanically ventilated patients. (only for 24 hours—this is what is approved by the FDA) ● Decreases norepinephrine levels and Reduces brain noradrenergic activity ○ So, it blocks that stress response and decreases anxiety in that way ○ Does not cause a lot of sedation—the patient can be totally awake with it but its just calms them down ● Sometimes it needs to be used in conjunction with pain medications but it just kind of takes the edge off ○ If the patient is super anxious, then it may not be enough for them; sometimes used as an adjunct ● Stimulating alpha 2 receptors causes vasodilation (side note: stimulating alpha 1 receptors causes vasoconstriction) ○ So, watch their BP and adequately hydrate the patient ● Decreases blood pressure and heart rate ○ Decreased HR because it decreases that norepinephrine level ● Reduces need for add-on morphine/opioids ● Little amnesic effect so the patient will probably remember what is happening so be cognizant of that ● Caution in diabetes because they tend to have a more pronounced hypotension and decreased sympathetic response (may have Bradycardia problem) ● Usually only indicated for patients who are in a critical care setting or maybe PACU where they have very close monitoring ● Given IV drip—not IV push

Dexamedetomidine

What NON-benzodiazepine drug given as sedatives for critically ill patients is described below (Propofol (Diprivan) and Dexamedetomidine (Precedex)) ● Decreases norepinephrine levels and Reduces brain noradrenergic activity ○ So, it blocks that stress response and decreases anxiety in that way ○ Does not cause a lot of sedation—the patient can be totally awake with it but its just calms them down ● Sometimes it needs to be used in conjunction with pain medications but it just kind of takes the edge off ○ If the patient is super anxious, then it may not be enough for them; sometimes used as an adjunct

Dexamedetomidine

What NON-benzodiazepine drug given as sedatives for critically ill patients is described below (Propofol (Diprivan) and Dexamedetomidine (Precedex)) ● Reduces need for add-on morphine/opioids ● Little amnesic effect so the patient will probably remember what is happening so be cognizant of that ● Caution in diabetes because they tend to have a more pronounced hypotension and decreased sympathetic response (may have Bradycardia problem) ● Usually only indicated for patients who are in a critical care setting or maybe PACU where they have very close monitoring ● Given IV drip—not IV push

Dexamedetomidine

What NON-benzodiazepine drug given as sedatives for critically ill patients is described below (Propofol (Diprivan) and Dexamedetomidine (Precedex)) ● Stimulating alpha 2 receptors causes vasodilation (side note: stimulating alpha 1 receptors causes vasoconstriction) ○ So, watch their BP and adequately hydrate the patient ● Decreases blood pressure and heart rate ○ Decreased HR because it decreases that norepinephrine level

Dexamedetomidine

What type of drug therapy for treatment of delirium in ICU patients is described below (Dexmedetomidine in the ICU setting, Low-dose antipsychotics haloperidol, risperidone, olanzapine & quetiapine (controversial), Short-acting benzodiazepines (e.g., lorazepam)): ○ An IV drug, alpha blocker that blocks the stress response and kind of causes a little bit of sedation ○ Patient needs to preferably need to be on ventilator and if not, need to be monitored closely

Dexmedetomidine in the ICU setting

What Benz used as a sedative for critically ill patients is described below (Midazolam, Diazepam, Lorazepam): ○ Valium) ■ (- typically used for seizure pt. & status epilepticus) ■ Longer acting

Diazepam

What do you do after the death of a trauma patient?

Don't remove any lines or anything - this is a coroner's case; ALWAYS call LOPA & coroner (these two people are called for any death)

The following are complications of _______ intubation: ● Displacement of tube (regularly monitor lip placement; have ambu bag ready) ○ Can be pushed in further and if so it will probably go down into R main stem of the bronchus (straighter than the L) which is the path of least resistance ■ This is why we do frequent asses\sments listening to breath sounds, bilateral air exchange, bilateral chest rises ■ If only hearing breathe sounds on R side, changes are the tube is in R main stem and needs to be pulled back ○ Can be displaced or pulled up and sitting in back of throat

Complications of MIs include dysrhythmias, cardiogenic shock, papillary muscle dysfunction, ventricular aneurysm, pericarditis, Dressler Syndrome. Which of these complications is described below: · fever, pleural effusion, joint pain. o Can occur after an MI o Usually, self-limiting § Takes a while for it to resolve

Dressler syndrome

What piece of technology in the ICU is described below: (ECG monitoring, positive pressure ventilation, hemodynamic monitoring, intracranial pressure monitoring, ventricular assist devices, continuous renal replacement therapy) · ALL PATIENTS in the ICU get _____ ________ o The nurse has to have knowledge of how to interpret those rhythms and how to monitor them

ECG monitoring

The following are complications of _______ intubation: ● Obstruction of tube (thick secretions, mucus plug - this will trigger high-pressure alarm) ○ High pressure alarms on vents check tubing for kinks and suctioning ● Tracheoesophageal Fistula (overinflated cuff) ○ Caused by long-term cuffed tubes in place with high pressures ■ This is why you need to check the pilot balloons and respiratory needs to check pressures in the balloon with manometer (best method to verify pressure)

The following are complications of _______ intubation: ● Pain/discomfort ● Anxiety ● Infection (VAP) ● Aspiration (elevate HOB, suction as needed bc oral intubation increases salivation) ● Displacement of tube (regularly monitor lip placement; have ambu bag ready) ● Obstruction of tube (thick secretions, mucus plug - this will trigger high-pressure alarm) ● Tracheoesophageal Fistula (overinflated cuff) ● Self-Extubation (signs include pt. vocalization, diminished breath sounds, respiratory distress, or distention) ● Pressure Sore (due to immobility and can occur on lips due to tube placement)

The following are complications of _______ intubation: ● Pressure Sore (due to immobility and can occur on lips due to tube placement) ○ Both in usual pressure risk areas such as sacrum and bony prominences along with lip where tube is sitting on ● Pain/discomfort ● Anxiety ● Infection (VAP) ● Aspiration (elevate HOB, suction as needed bc oral intubation increases salivation)

The following are complications of _______ intubation: ● Self-Extubation (signs include pt. vocalization, diminished breath sounds, respiratory distress, or distention) ○ Nurse is to stay with the pt., call for help, support the airway (Ambu bag) & secure the appropriate assistance to immediately re-intubate the pt. ○ Patients are at risk for pulling out their tubes and if they are vent-dependent they are at risk for respiratory arrest or insufficiency so you need to have am ambu bag ready and call someone to come re-intubate them ○ Close monitoring! If ICU allows, it is helpful to have someone in the room to watch them. If they are at really high risk of pulling out their tube they may need to be sedated or restraints ■ We try to not use restraints at all possible

How do you monitor a patient's ventilation? o Oxygenation is oxygen crossing that pulmonary capillary membrane and having adequate amount of oxygen in blood. The PAO2, SPO2, and SVO2 tell you about oxygenation. o Your ABG tells you about oxygenation and ventilation. o Remember that SPO2 does not tell you anything about their CO2.

ETCO2, PCO2 on ABG

What critical care specialty unit is described below: ○ Newer and evolving ○ This is providing specialized care using technology. In rural areas where they may not have some of the physicians of specialties such as cardiologist, nephrologist, neurologist, etc those physicians can visit the patient remotely using vidoe and special telemedicine equipment and provide recommendations and orders via technology ○ May not be at bedside but providing expertise using technology

Electronic/tele ICU

What method of pain management is described below: ● Term used when you are trying to transition someone from IV to PO ● To provide equal analgesic effect with new agents ○ Trying to switch someone over from IV analgesia to PO analgesia—just know there are some conversion charts out there or even some apps ● Conversion Equivalence conversion (how do you change from PO to IV & get same pain relief?) ● Several apps: Opioids Conversion

Equianalgesic

What pain scale is often used with pediatric patients but can also be used with adult patients?

Faces Pain scale (Wong Baker's scale)

Fentanyl

What analgesic for pain management is described below: (opioid) (Sublimaze, Duragesic) ● Rapid onset in acute distress ○ If your patient is in severe acute distress and you need something to work quickly then ______ is a good option ● Hemodynamic stability (causes NO direct vasodilation thus you CAN give to pt. who is unstable) ○ So, its safer to use in a patient who is hemodynamically unstable or a patient who has low BP ■ Keep in mind that if you have a patient with a fairly low BP and they are very anxious and uptight, that may be what is keeping the BP up and if you give the _______, even though it doesn't cause vasodilation, just by decreasing that stress response and relaxing the patient it may still lower their BP ● Short duration with intermittent doses ○ Not the best option if you need pain management that is going to last a while ○ Used a lot in short procedures, such as Cath lab, or doing TEs at the bedside, intubating a patient (something that you don't need it to last a long time) ● 100-fold analgestic potency of morphine ● 1/100 dose of Morphine ● 600 x greater strength (potency) than Morphine r/t lipid soluble (usually give 1/100th Morphine dose) ● No renal dosing (***CAN give it to dialysis pt. or pt. with renal insufficiency****); won't cause prolonged effect ○ it doesn't have an active metabolite, so you don't need to reduce the dose in patients with renal insufficient or renal failure ○ Because morphine is not very lipid-soluble, it takes a long time to cross the blood-brain barrier both going into and out of the brain. This produces what one might call a "slow-in, slow-out" drug. Indeed, when compared with lipid-soluble drugs, morphine is noted to be slower in onset. ______, on the other hand, is lipophilic and crosses the blood-brain barrier rapidly in both directions; it is a "fast-in, fast-out" drug. Therefore, ______ acts quickly and has a short duration of action because of its lipid solubility. ● _______ Patches (Duragesic) ○ Transdermal delivery of the medication ○ Provides low constant dose (change patch q72h, rotate sites) ■ Lasts about 72 hours ○ Questionable absorption with edema or diaphoresis (swelling & third-spacing might slow absorption) ■ May not be absorbed at a steady state and may not work very well at all ■ If the patient has a lot of generalized edema, we do not know how well its absorbed—questionable absorption with edema ○ Used in weaning pt. off of pain medications ■ Used in weaning and trying to transition the patient into a lower level of analgesia ○ Often used with cancer pt. along with MS Contin ○ Putting heat on top of the patch can cause vasodilation and increase the absorption of the ______ and overdose the patient (could cause respiratory arrest and kill the patient) ○ If you have a patient that you are having problems with and they have a _______ patch, then you might want to take the patch off

Fentanyl

What analgesic for pain management is described below: (opioid) ● No renal dosing (***CAN give it to dialysis pt. or pt. with renal insufficiency****); won't cause prolonged effect ○ it doesn't have an active metabolite, so you don't need to reduce the dose in patients with renal insufficient or renal failure ○ Because morphine is not very lipid-soluble, it takes a long time to cross the blood-brain barrier both going into and out of the brain. This produces what one might call a "slow-in, slow-out" drug. Indeed, when compared with lipid-soluble drugs, morphine is noted to be slower in onset. ______, on the other hand, is lipophilic and crosses the blood-brain barrier rapidly in both directions; it is a "fast-in, fast-out" drug. Therefore, ______ acts quickly and has a short duration of action because of its lipid solubility.

Fentanyl

What analgesic for pain management is described below: (opioid) ● Short duration with intermittent doses ○ Not the best option if you need pain management that is going to last a while ○ Used a lot in short procedures, such as Cath lab, or doing TEs at the bedside, intubating a patient (something that you don't need it to last a long time) ● 100-fold analgestic potency of morphine ● 1/100 dose of Morphine ● 600 x greater strength (potency) than Morphine r/t lipid soluble (usually give 1/100th Morphine dose)

Fentanyl

What analgesic for pain management is described below: (opioid) ● _______ Patches (Duragesic) ○ Transdermal delivery of the medication ○ Provides low constant dose (change patch q72h, rotate sites) ■ Lasts about 72 hours ○ Questionable absorption with edema or diaphoresis (swelling & third-spacing might slow absorption) ■ May not be absorbed at a steady state and may not work very well at all ■ If the patient has a lot of generalized edema, we do not know how well its absorbed—questionable absorption with edema ○ Used in weaning pt. off of pain medications ■ Used in weaning and trying to transition the patient into a lower level of analgesia ○ Often used with cancer pt. along with MS Contin ○ Putting heat on top of the patch can cause vasodilation and increase the absorption of the ______ and overdose the patient (could cause respiratory arrest and kill the patient) ○ If you have a patient that you are having problems with and they have a _______ patch, then you might want to take the patch off

Fentanyl

When talking about analgesics for acutely ill patients, the following are opioids analgesics available for patients: Morphine (IV, Duramorph, MS Contin, Roxanol), Fentanyl (Sublimaze IV or Duragesic patch), Hydromorphone (Dilaudid), and Meperidine (Demerol). Which of these drugs is described below: ○ (Sublimaze IV or Duragesic patch) ■ Good to use for weaning the pt. & chronic pain ■ Typically given during recovery or short procedures ■ Sublimaze IV or Duragesic patch) ● More potent than morphine

Fentanyl

What 2 opioids do NOT cause vasodilation and do NOT contain active metabolites? -- so it is better for patients who are hemodynamically unstable -- good for renal insufficiency or pt. with low BP (safe when pt. is hemodynamically unstable)

Fentanyl and Hydromorphone

What vent setting is described below: ● lowest % to achieve PaO2 at least 60% ○ How much oxygen you want to give the patient ○ You always want to use the lowest percent to achieve a PAO2 of at least 60%. Remember, oxygen can be toxic at high levels. Anytime you are getting an FiO2 of 60% or above, you start worrying about oxygen toxicity. ○ If PAO2 is 90% and you are on 60%, you want to cut back on that FiO2 because oxygen can cause toxicity

FiO2

When talking about settings and mode for vents, settings are based on patient status including things such as ABGs, body weight, LOC, muscle strength, etc. settings includes rate, depth, alarms, inspiratory time, and FiO2. Which of these settings is described below: ○ (goal is to achieve optimal oxygenation with lowest _______ possible) ■ Fracture of inspired oxygen ■ which percentage of oxygen are you delivering to the patient ■ On the ventilator, we have a "blender" and you dial in the percent of oxygen you want the patient to have. The ventilator uses piped in oxygen and piped in compressed air to blend it to get that precise percentage of oxygen

FiO2

______ ________ described the advantages of placing pt. recovering from surgery in separate areas (1800s). ○ She recognized that separating surgical patients from patients with medical problems especially infectious type problems benefited those patients. You were having less nosocomial infections or infections spread from patient to patient ○ In the 1800s, they started recognizing the benefits of cohorting patients ● John Hopkins opened a 3 bed post-op neurosurgical ICU in the early 1900s. ○ One of the earliest official ICU units ● WWII & Korean wars influence the development of specialty units. ● Technological advances (in diagnostics and treatments) have had great influence on the development of specialty units. ○ Highly technical skills are needed for ICU nurses **history of critical care nursing

Florence Nightingale

What reversal agent drug (Naloxone/Narcan and Flumazenil/Romazicon) is described below: · Adult dose: (do not need to memorize doses; need to know what drug is used for) o Partial antagonism (for sedation reversal): 0.1-0.2 mg IV infused over 15 sec; may repeat after 45 sec and then every min; not to exceed total cumulative dose of 1 mg o Complete antagonism (for overdose): 0.2 mg IV infused over 30 sec; may repeat with additional doses of 0.5 mg over 30 sec at 1-min intervals; not to exceed a total cumulative dose of 3 mg · Pediatric Dose: o 0.01 mg/kg/dose IV infused over 15 sec; not to exceed 0.2 mg/dose; may repeat every min; not to exceed total cumulative dose of 0.05 mg/kg or 1 mg (whichever is lower)

Flumazenil (Romazicon®)

What reversal agent drug (Naloxone/Narcan and Flumazenil/Romazicon) is described below: · Rebound sedation may occur; if used in patient with chronic BZP use, will precipitate acute withdrawal; may precipitate seizures unresponsive to BZPs · Reverses benzodiazapines o Midazolam (Versed), Diazepam (Valium), or Lorazepam (Ativan)—reverses these · Just like with Narcan, may need to give repeated doses · If you give it to people with chronic benzodiazepine use, it could precipitate an acute withdrawal which could precipitate seizures that would be unresponsive to benzodiazepines

Flumazenil (Romazicon®)

What modifiable risk factor for CV disease is described below: § Includes smokeless & regular tobacco in addition to second-hand smoke

tobacco use

What reversal agent drug (Naloxone/Narcan and Flumazenil/Romazicon) is described below: · Reverses benzodiazapines o Midazolam (Versed), Diazepam (Valium), or Lorazepam (Ativan)—reverses these · Just like with Narcan, may need to give repeated doses · If you give it to people with chronic benzodiazepine use, it could precipitate an acute withdrawal which could precipitate seizures that would be unresponsive to benzodiazepines · Adult dose: (do not need to memorize doses; need to know what drug is used for) o Partial antagonism (for sedation reversal): 0.1-0.2 mg IV infused over 15 sec; may repeat after 45 sec and then every min; not to exceed total cumulative dose of 1 mg o Complete antagonism (for overdose): 0.2 mg IV infused over 30 sec; may repeat with additional doses of 0.5 mg over 30 sec at 1-min intervals; not to exceed a total cumulative dose of 3 mg · Pediatric Dose: o 0.01 mg/kg/dose IV infused over 15 sec; not to exceed 0.2 mg/dose; may repeat every min; not to exceed total cumulative dose of 0.05 mg/kg or 1 mg (whichever is lower) · Rebound sedation may occur; if used in patient with chronic BZP use, will precipitate acute withdrawal; may precipitate seizures unresponsive to BZPs

Flumazenil (Romazicon®)

Which drug would you use to reverse the effects of a benzodiazepine?

Flumazenil (Romazicon®)

What is the antidote for benzodiazepines? do NOT give to patient with history of abuse

Flumozenil (ROMAZICONE)

What risk of analgesics is described below: ○ they are at high risk for constipation (slows down gut) ■ These patients are often simultaneously on stool softeners to try and prevent this complication ■ Assess bowel function daily ■ Constipation, impaction, ileus

GI motility reduction

What complication of positive pressure ventilation is described below: ● use of peptic-ulcer prophylaxis is recommended (H2 blocker/PPIs--Zantac, enteral nutrition) ○ Will always be NPO so will probably have an NG tube in ○ Patients are not able to eat while on ventilator ○ High risk for peptic ulcers

GI system

Glycoprotein IIb/IIIa Inhibitors

What are some objective signs a patient is in pain?

Grimacing, guarding, restlessness, tense

What are some examples of *actual* life-threatening problems? **critical care nursing

Gun-shot wound, acute MI, overdose, MVA

What part of a lipid protein is described below: o (good cholesterol—want these to be high—considered protective and preventive of cardiovascular disease) § < 40 Low (men)—increased risk for disease development § < 50 Low (women)—increased risk for disease development § > 60 High—desirable for HDL cholesterol § #1 way for pt. to increase HDL levels is to exercise (high HDL levels are desired)

HDL

What health problem is described below: ● The development of thrombocytopenia r/t administration of heparin or related anticoagulants such as Lovenox (be sure to check pt. platelet count before giving Lovenox) ● Caused by abnormal antibodies that attack platelets ● Predisposes pt. to thrombosis r/t excessive use of platelets (risk of DVT, PE, MI r/t clot) ● Determined when pt. experiences 50% reduction in platelets from baseline after use ● Signs & Symptoms: fever, chills, tachypnea, tachycardia, SOB (due to thrombus formation) ● Should not see heparin in pressure bags anymore

HIT (heparin-induced thrombocytopenia)

What medication for the treatment of delirium in a patient is described below: · IM, IV · 10-20 min onset, lasts for hours · SE: o Extrapyramidal symptoms (EPS)- risk of this occurring increases with concurrent use of a Benzodiazepine o Neuroleptic malignant Syndrome/ Torsades de pointes § This drug prolongs the QT interval which increases your risk for Torsades de pointes which is a ventricular tachycardia that is life threatening · So if the patient already has a prolonged QT interval or are on other drugs that prolong the QT interval you really need to monitor their QT interval on a regular basis and if it starts prolonging then they probably need to be taken off of one or more of those drugs that are prolonging the QT interval · Avoid with Parkinson's Pt

Haldol

Heparin

When maintaining tube patency for artificial airways, when do you perform closed suctioning? ○ Closed suctioning: oxygenation & ventilation are maintained - minimal exposure to secretions ○ Assessments are normally every 2 hours listening to their lungs

High PEEP, bloody/infectious secretions, frequent suctioning

What analgesic for pain management is described below: (opioid) (Dilaudid) ● No direct vasodilation—so it is better for patients who are hemodynamically unstable ○ Keep in mind that if you have someone with a low BP then you need to be very careful with any of these medications that you are giving—but if you have to give something then _______ is better than morphine since it doesn't cause vasodilation ● Longer duration of analgesia compared to Fentanyl ○ So better choice over fentanyl if you need it to last longer ● Lack of active metabolite - good for renal insufficiency or pt. with low BP (safe when pt. is hemodynamically unstable) ● Stronger than morphine

Hydromorphone

When talking about analgesics for acutely ill patients, the following are opioids analgesics available for patients: Morphine (IV, Duramorph, MS Contin, Roxanol), Fentanyl (Sublimaze IV or Duragesic patch), Hydromorphone (Dilaudid), and Meperidine (Demerol). Which of these drugs is described below: ○ (Dilaudid) ■ Used for pt. who are hemodynamically unstable ■ Given if the pt. is allergic to Morphine ■ Smaller dosing compared to Morphine

Hydromorphone

What bipolar limb lead (I, II, III) is described below: RA (-), LA (+), and RL ground R arm, L arm, R leg

What bipolar limb lead (Leads I, II, III) is described below: o With lead ____, the negative electrode is on the right arm and the positive electrode is on the left arm. Also uses the right leg electrode as a ground § The vector of that lead is from the right shoulder to the left shoulder § The positive electrode is on the left arm so it is looking at the lateral wall of the heart

What lead of a 12 Lead EKG is described below: § Lead ____: the negative electrode is the right shoulder and the positive electrode is the left shoulder so it is looking at the lateral wall of the heart so it is a lateral wall lead and generally it is the circumflex artery that feeds that left wall so ******if someone has some ST changes in lead _____, then you would look to see if there are ST changes in any of the other lateral wall leads that would suggest that person is having ischemia or infarct********

What are the 3 bipolar limb leads? o Called bipolar because it uses 2 stickies/patches to make the lead

I, II, and III

Post cardiac surgery, the nurse needs to manage the patient's preload, afterload, and contractility. When managing contractility, we can use an ________ and ______. These are used if inotropes are not working and you have optimized all your medication therapy o Mechanical left ventricular assist device o Used strictly for acute care in the ICU setting o A temporary bridge until we can get the patient doing better

IABP (Intra-aortic balloon pump) and Impella®

Some other reasons that patients are admitted to the _____ includes: ● Require IV polypharmacy (sedation, thrombolytic, drugs that require titration) ● Despite the emphasis placed on caring for individuals expected to survive, the incidence of death is higher in _____ pt. than non-______ patients. In general, non-survivors are typically: ● Older, have co-morbidities & experience longer ______ stays ● Patients that need to be monitored closely ● One-on-one patient may include one with a fresh open heart or on a balloon pump

ICU

The following is an ______ room setup/equipment: ○ Suction catheters ○ Bag-valve mask (Ambu) - if a pt. is on a vent & has trouble breathing, the FIRST thing you do is bag them ○ O2 flow meters, tubing, oxygen delivery ○ IV poles, pumps with multiple chambers ○ Bedside supplies (alcohol swabs, gloves, syringes, chux, etc.) ○ Admission kit (basin, general hygiene supplies)

ICU

The following is an ______ room setup/equipment: ○ ECG Bedside/Invasive pressure cables ○ BP cuff (individual use) ○ Pulse oximetry ○ Suction gauges/canisters (3-4 maybe) ■ NG tubes, chest tube, medial-sinus tube ○ Suction catheters ○ Bag-valve mask (Ambu) - if a pt. is on a vent & has trouble breathing, the FIRST thing you do is bag them ○ O2 flow meters, tubing, oxygen delivery ○ IV poles, pumps with multiple chambers ○ Bedside supplies (alcohol swabs, gloves, syringes, chux, etc.) ○ Admission kit (basin, general hygiene supplies)

ICU

_______ is an uncomfortable place; may be on the vent and sedated ○ It is the NURSE who is in charge or making sure the patient is comfortable; collaborate with the physician to make sure the patient is receiving the correct dose, medicine, etc to make them comfortable

ICU

"This tool kit" provides validated, evidence-based clinical knowledge, resources and guidelines for implementing the ABCDE Bundle to prevent the unintended consequences of critical illness such as delirium, prolonged ventilation and excessive muscular deterioration — a timely clinical topic applicable to any critical care, progressive care or step-down unit. ● A bundle is nursing care that should be provided for a patient based on either the disease process they have or a treatment that they have ● examples: CAUTI, Ventilator bundles, ABCDE Bundle, Central Line bundle, etc. -- CAUTI- catheter associated urinary tract infection ○ For patients with a foley catheter

ICU bundles

What bipolar limb lead (I, II, III) is described below: RA (-), LL (+), LA ground R arm, L leg, L arm

What bipolar limb lead (Leads I, II, III) is described below: o With lead _____, the negative electrode is on the right shoulder and positive electrode is on the left leg with the left arm lead being the ground § The vector of this lead is from the right shoulder to the right leg § The positive electrode is on the left leg so it is looking up inferiorly at the heart so it is looking at the inferior wall of the heart

What lead of a 12 Lead EKG is described below: (**2 leads**) § Leads ____ and _____: L Ø negative electrode on the left arm and positive electrode on the left leg Ø looking up at the heart at the inferior wall Ø generally the RCA that feeds the inferior wall Ø *****if someone has ST changes in these leads then you would be concerned about the inferior wall and the right coronary artery (RCA)******

II and III

What bipolar limb lead (I, II, III) is described below: LA (-), LL (+), RA ground L arm, L leg, R arm

III

What bipolar limb lead (Leads I, II, III) is described below: o With lead _____, the negative electrode is on the left arm and the positive electrode is on the left leg and the ground is the right arm § Positive electrode on the left leg and looking up inferiorly at the heart so it is looking at the inferior wall of the heart

III

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) Function: Ventilates each lung separately; requires two ventilators and sedation/paralysis Clinical Use: Used for patients with unilateral lung disease or different disease process in each lung

Independent Lung Ventilation (ILV)

Look at image number 22 on phone. What type of MI is this? · What leads show ST elevation or depression? o ST elevation in leads II, III, and aVF · What leads show ST elevation or depression? o Tombstones in lead I and aVL o Q waves in V1 o Loss of R wave progression o 2 consecutive leads have ST elevation

Inferior wall MI, probably RCA

What Benz used as a sedative for critically ill patients is described below (Midazolam, Diazepam, Lorazepam): ○ (Ativan)*** ■ (- used for long-term sedation - used for seizures, agitation, etc.) ■ Recommended for long term sedation (24-48 hours or several days of sedation) ■ PRN, IV drip

Lorazepam

What additional essential of AACN/CCRN (Interpretation and mgmt cardiac rhythms, Hemodynamic monitoring, Circulatory assist devices, Airway and ventilator management, Pharmacology, Pain, Sedation) is described below: ● will learn how to interpret & how to respond; rule of thumb - anytime pt. has any type of cardiac monitoring you always treat the pt. and not the monitoring) ○ What are the only two rhythms we immediately defibrillate? V-Fib & Pulseless V-Tach

Interpretation & Management of Cardiac Rhythms

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) Function: I:E ratio is reversed to allow longer inspiration; requires sedation/ paralysis Clinical Use: Improves oxygenation in patients who are still hypoxic even with PEEP; keeps alveoli from collapsing

Inverse Ratio Ventilation (IRV)

When looking at ST segment monitoring, we need to know where to look. § Look for ST change 0.06 seconds from the ___ point § "_____" point identified as point where "S" begins to return to isoelectric line § Where it transitions to the ST segment is the ______ point. Move over 0.06 seconds which is 1.5 little blocks and that is where you measure how much deviation from baseline. Each little block upward is 1mm

J point

When measuring cardiac output, _____ is a drug that affects contractility and cardiac output; may be titrating while monitoring

Milrinone

What analgesic for pain management is described below: (non-opioid/NSAIDS) ○ Con: ■ Decreases renal blood flow—so don't use in patients with decreased renal function, renal insufficiency, or elevated BUN and creatinine ● So can cause renal insufficiency in some patients due to the decreased renal blood flow ■ Change dose r/t renal function, age ● Some HCP don't think you should use these in the elderly population (anyone >70 years old) because they probably have some renal problems just because of their age ○ No longer 5 days r/t ↑ bleeding, ↑ renal indices (BUN and creatinine)

Ketorolac (Toradol)

What analgesic for pain management is described below: (non-opioid/NSAIDS) ○ Non-sedative/non-respiratory effect (patient is more likely to be cooperative in care) ■ 350 x stronger than aspirin ■ PO, IV, IM, Gtt ■ 30 mg = 10-12mg Morphine ■ Opioid sparing - using Toradol allows you to give 25-50% less morphine (synergistic effect) ● When given in conjunction with opioids you can use less opioid ■ Change dosages based on renal function (can cause increased creatinine; caution in OA) ■ In presence of renal insufficiency, dose is usually decreased to 15mg ■ Given no longer than 5 days due to increased bleeding & increased renal indices ○ Con: ■ Decreases renal blood flow—so don't use in patients with decreased renal function, renal insufficiency, or elevated BUN and creatinine ● So can cause renal insufficiency in some patients due to the decreased renal blood flow ■ Change dose r/t renal function, age ● Some HCP don't think you should use these in the elderly population (anyone >70 years old) because they probably have some renal problems just because of their age ○ No longer 5 days r/t ↑ bleeding, ↑ renal indices (BUN and creatinine)

Ketorolac (Toradol)

What part of a lipid protein is described below: § Ideal < 130 § 150-199 Borderline high § 200-499 High § > 500 Very high § primary target of therapy whether with diet or medications

LDL

Which cholesterol is the BAD cholesterol?

LDL

What type of drug therapy for treatment of delirium in ICU patients is described below (Dexmedetomidine in the ICU setting, Low-dose antipsychotics haloperidol, risperidone, olanzapine & quetiapine (controversial), Short-acting benzodiazepines (e.g., lorazepam)): ○ Controversial because antipsychotics have a lot of side effects on their own

Low-dose antipsychotics haloperidol, risperidone, olanzapine & quetiapine (controversial).

(non-invasive BP) ● *Measuring end-organ tissue perfusion (lungs, liver, kidneys, etc.) ● ________= perfusion pressure ● Systolic BP + 2 (Diastolic BP) / 3 *** ● Normal range for ________: 70-105 mmHg (generally just want it >70) ○ Too low= decreased tissue perfusion→ tissue will get cyanotic, anaerobic metabolism→ inefficient & produces lactic acid as byproduct ○ When you get outside of this range, you start to worry about tissue perfusion. That is why the mean arterial pressure is a good number for us to evaluate tissue perfusion

MAP (mean arterial pressure)

If the ______ is too low, that would mean decreased tissue perfusion→ tissue will get cyanotic, anaerobic metabolism→ inefficient & produces lactic acid as byproduct.

MAP (mean arterial pressure)

What is a good measurement to evaluate tissue perfusion in a patient? Normal Range: 70-105 mmHg (generally just want it > 70 mmHg) ○ Too low= decreased tissue perfusion→ tissue will get cyanotic, anaerobic metabolism→ inefficient & produces lactic acid as byproduct ○ When you get outside of this range, you start to worry about tissue perfusion. That is why the ________ is a good number for us to evaluate tissue perfusion.

MAP (mean arterial pressure)

What complication of positive pressure ventilation is described below: ● most deaths from disconnections occur when the alarm was turned off - ALWAYS leave the alarms on ○ Anytime you have a patient on Life Support and the ventilator is considered Life Support, you want to make sure that the plug is plugged into the Red plug in the wall. The Red plugs are plugs running on the emergency generation. That way if you have a power surge or lose power, the emergency generator will kick on in seconds and it will continue to power the ventilator. ○ As a general rule, anytime you have a power surge you should always go check any patients you have on Life Support to make sure those Life Support systems have restarted and functioning appropriately

Machine Disconnection/Malfunction

How is ET cuff pressure verified?

Measuring with a manometer o We do palpate balloon but not a reliable method

Meperidine

What analgesic for pain management is described below: (opioid) (Demerol) ● Still available but it has fallen of favor due to the active metabolite ○ Big problem with this drug is that active metabolite ● Avoid repeated dosing ○ Active metabolite (Normeperidine): accumulates in renal insufficiency - neurotoxic ○ CNS Stimulant: ■ Tremors, agitation, psychosis, seizures (typically do not give to OA pt.) ● Sometimes used for GI distress bc ______ relaxes the sphincter of Odi better than other medications ● Probably should not use with patients that have renal insufficiency ● Contraindicated: pt. with acute pain lasting more than 2 days or requiring large doses ● Explanation as to why you should not use certain medications with decrease renal function: An active metabolite results when a drug is metabolized by the body into a modified form which continues to produce effects in the body. Usually these effects are similar to those of the parent drug but weaker, although they can still be significant (see e.g. 11-hydroxy-THC, morphine-6-glucuronide). Certain drugs such as codeine and tramadol have metabolites that are stronger than the parent drug (morphine and O-desmethyltramadol respectively)[1][2][3] and in these cases the metabolite may be responsible for much of the therapeutic action of the parent drug. Sometimes, however, metabolites may produce toxic effects and patients must be monitored carefully to ensure they do not build up in the body. This is an issue with some well known drugs such as pethidine (meperidine) and dextropropoxyphene.[3][4]

Meperidine

What analgesic for pain management is described below: (opioid) ● Sometimes used for GI distress bc ______ relaxes the sphincter of Odi better than other medications ● Probably should not use with patients that have renal insufficiency ● Contraindicated: pt. with acute pain lasting more than 2 days or requiring large doses

Meperidine

What Benz used as a sedative for critically ill patients is described below (Midazolam, Diazepam, Lorazepam): ○ Versed) ■ (- used for conscious sedation - pre-op, cath lab; causes amnesia) ■ Short acting—used more for procedural sedation because we want something that is not going to last a long time

Midazolam

What type of hemodynamic monitoring is described below: ● Also known as arterial-based cardiac output (APCO) - Edwards® FloTrac Sensor ● Uses arterial line to determine cardiac output and stroke volume variation (SVV). ○ If you have a beat to beat variation with stroke volume you will have a high SVV ○ Means the patient is "dry" and will need some hydration ○ Based on data from arterial line, it is able to determine CO and calculate a SV variation; it is calculating how much variation there is in SV from beat to beat ● Patient has to be on vent with controlled ventilations

Minimally Invasive Hemodynamic Monitoring

What type of hemodynamic monitoring is described below: ● Helps determine fluid responsiveness ● Newer technology not quite invasive like PA catheter ● Patients who are healthy, have good CO, and undergoes cardiac bypass surgery, sometimes they will put the FlowTrac Sensor in rather a PA catheter because those patients will be on vent post-op

Minimally Invasive Hemodynamic Monitoring

What type of hemodynamic monitoring is described below: ● Hypovolemia = increased stroke volume variation (SVV). ○ Patients who are hypovolemic will have a lot of variation in SV from beat to beat. When we breathe and we have changes in intrathoracic pressure, it deceases venous return. From beat to beat you will have a change in venous return and if someone is dehydrated it will be pronounced ○ They need fluids!!!!

Minimally Invasive Hemodynamic Monitoring

What type of hemodynamic monitoring is described below: ●*** Use limited to control-ventilated patients.**** ○ Only valid in patients with positive pressure ventilation (positive controlled ventilation). When someone has positive pressure ventilation and we are blowing air into that lung, that increases intrathoracic pressure and decreases venous return. ○ The device may not be sensitive enough in patients not mechanically ventilated.

Minimally Invasive Hemodynamic Monitoring

According to the Society of Critical Care Medicine, _______ is the gold standard (causes vasodilation - may also cause sedation, hypotension, etc.); may not be the best option for those with low blood pressure ○ But there may instances where other drugs may be more appropriate for certain patients ■ Ex: _______ is a vasodilator and if the patient has poor cardiac output or low BP you may not want to use morphine

Morphine

Because _______ is not very lipid-soluble, it takes a long time to cross the blood-brain barrier both going into and out of the brain. This produces what one might call a "slow-in, slow-out" drug. Indeed, when compared with lipid-soluble drugs, _______ is noted to be slower in onset. Fentanyl, on the other hand, is lipophilic and crosses the blood-brain barrier rapidly in both directions; it is a "fast-in, fast-out" drug. Therefore, fentanyl acts quickly and has a short duration of action because of its lipid solubility.

Morphine

What analgesic for pain management is described below: (opioid) (Duramorph, MS Contin, Roxanol) ● Longer interval of action than fentanyl ● Easy to titrate ○ Can give 1-2 mg at a time and reassess the patient; if it doesn't relieve them then give another couple mg until they are comfortable ● Available in various routes (PO, IV, IM, patch) ○ Duramorph is typically used in surgery; MS Contin is long-acting morphine; Roxanol is given sublingually & is very potent, used for cancer or hospice pt. ● Has active metabolite that can accumulate with renal insufficiency (high Creatinine and/or dialysis pt.) & lead to prolonged sedation ○ Decrease dose or decrease frequency of administration ○ Cirrhosis, elevated LFTs, renal failure etc. give less of a dose and/or less frequently ○ So be careful in patients who have renal insufficiency or renal failure—they will probably need reduced dosing ● Causes direct vasodilation (hypotension) - NOT good for pt. who is hemodynamically unstable ○ This effect makes it a useful drug for pt. with pulmonary difficulty (dilates bronchioles) & for pt. with coronary pain (given if nitro doesn't relieve pain) ○ Can be a pro or a con depending on the patient ■ Pro ● If the patient is hypertensive maybe because they are very anxious that vasodilation will probably be helpful ● Or patients who have pulmonary edema (it also causes vasodilation in the pulmonary vasculature so that can help relieve some of the patients distress when they have pulmonary edema) ■ Con ● If the patient has a mean arterial pressure (MAP) of 65, so if someone is hypotensive or they are hemodynamically unstable then morphine may not be the best drug for you to use ● Roxanol - liquid that can be placed sublingually; very very potent so make sure you check doses several times before administration

Morphine

What analgesic for pain management is described below: (opioid) ● Causes direct vasodilation (hypotension) - NOT good for pt. who is hemodynamically unstable ○ This effect makes it a useful drug for pt. with pulmonary difficulty (dilates bronchioles) & for pt. with coronary pain (given if nitro doesn't relieve pain) ○ Can be a pro or a con depending on the patient ■ Pro ● If the patient is hypertensive maybe because they are very anxious that vasodilation will probably be helpful ● Or patients who have pulmonary edema (it also causes vasodilation in the pulmonary vasculature so that can help relieve some of the patients distress when they have pulmonary edema) ■ Con ● If the patient has a mean arterial pressure (MAP) of 65, so if someone is hypotensive or they are hemodynamically unstable then morphine may not be the best drug for you to use

Morphine

What analgesic for pain management is described below: (opioid) ● Has active metabolite that can accumulate with renal insufficiency (high Creatinine and/or dialysis pt.) & lead to prolonged sedation ○ Decrease dose or decrease frequency of administration ○ Cirrhosis, elevated LFTs, renal failure etc. give less of a dose and/or less frequently ○ So be careful in patients who have renal insufficiency or renal failure—they will probably need reduced dosing (Duramorph, MS Contin, Roxanol)

Morphine

When talking about analgesics for acutely ill patients, the following are opioids analgesics available for patients: Morphine (IV, Duramorph, MS Contin, Roxanol), Fentanyl (Sublimaze IV or Duragesic patch), Hydromorphone (Dilaudid), and Meperidine (Demerol). Which of these drugs is described below: (IV, Duramorph, MS Contin, Roxanol) ■ This is the gold standard for analgesia ■ Causes direct vasodilation ■ (IV, Duramorph (epidural), MS Contin (oral), Roxanol (liquid—very concentrated—be careful with dosage calculation because can cause respiratory depression or even respiratory arrest))

Morphine

Morphine Sulfate

What 2 opioids have active metabolites that can accumulate with renal insufficiency (high Creatinine and/or dialysis pt.) & lead to prolonged sedation?? ○ Decrease dose or decrease frequency of administration ○ Cirrhosis, elevated LFTs, renal failure etc. give less of a dose and/or less frequently ○ So be careful in patients who have renal insufficiency or renal failure—they will probably need reduced dosing

Morphine and Meperidine

What Sedation measurement scale (Sedation-Agitation Scale/SAS or Motor Activity Assessment Scale) is described below: 0: unresponsive; Does not move w/ noxious stimuli 1: responds only to noxious stimuli; Opens eyes OR raises eyebrows OR turns head toward stimuli OR moves limbs 2: responsive to touch or name; As above 3: calm and cooperative; No external stimuli is needed to elicit response, and pt. is adjusting sheets/clothes purposefully 4: restlessness and cooperative; No external stimuli is needed to elicit response, and pt. is picking sheets/tubes, uncovering self. Follows commands. 5: agitated; No external stimulus is required to elicit movement AND sitting up OR moves limbs out of bed AND does not consistently follow commands 6: dangerously agitated; No external stimulus required, pulling tubes OR thrashing OR trying to climb out of bed and does not calm down when asked

Motor Activity Assessment Scale

Nitroglycerin

Pharmacology treatment for MIs/ACS includes beta blockers, Morphine Sulfate, CCBs (calcium channel blockers), Nitroglycerin, ACEI or ARB (one or the other), ASA (aspirin), Heparin, Glycoprotein IIb/IIIa Inhibitors, Antidysrhythmic drugs, Lipid Lowering medication, stool softeners, and antiplatelets. Which of these medications is described below: · ↓ angina - USUALLY GIVE FIRST then try morphine if it doesn't work. · Used to decrease preload and afterload while increasing myocardial oxygen supply. · Can be administered in many different way · *****Titrate IV to effect (chest pain) (start low, go slow)******* o Increase until chest pain is relieved and decreased if chest pain is relieved and their BP is low o Monitor BP closely—frequent VS monitoring § Keep SBP > 90. If it goes below 90, will either have to cut back on the _______ or have to give them a little volume so they will tolerate the _________ a little better § Limit drop BP to 30 mm Hg below the baseline in hypertensive patients (do not want to drop them too low because you might decrease tissue perfusion). - watch BP. o Side effects: hypotension, headache! - treat with aspirin. o Brand name: Tridil · Short Acting- spray, tablets put under the tongue o Sublingual - sit down because vasodilator/low BP, take 1 wait 5 mins, if it doesn't work take a 2nd one and wait 5 mins, if still not relieved take 3rd one and call ambulance. o Quick acting o When sending patients home on this, remember to give given education on where to store it and instructions for use § Light sensitive (come in a dark brown bottle) and do expire and lose their potency § It is light sensitive, comes in brown bottle, keep in this bottle and away from sunlight, keep it with them, replace every 6 months because loses its potency. · Long Acting - Imdur (isosorbide mononitrate), Isordil (isosorbide dinitrate)--for D/c. o Extended-release tablets · Ointment- paste (change q 6 h). o Put on chest or arm—delivered transdermal · Transdermal patches- lasts 24 hours o Usually used if they are going to use it trans dermally once discharged o Sometimes patients do develop a tolerance to them, so they don't work as well § May have to give them some "Holiday Time" where the patch is off for a while - 12 hours on/12 off- prevents NTG induced vasodilation tolerance. · If someone has an inferior MI, there is a high risk for right ventricular infarct -- they need adequate volume! Careful with decreasing their filling volume by giving them nitroglycerin.

Nitroglycerin

What cardiac marker seen with an acute myocardial infarction (AMI) is described below: (CK MB, Troponin, Myoglobulin) § Rise 2 hours, peaks 3-15 hours, normal 24 hours § The earliest to rise but not specific to cardiac muscle · But if a patient comes in with chest pain and has other symptoms (diaphoresis, SOB, lots of risk factors) and has EKG changes then that ______ could be of some value—if they don't have EKG changes and their symptoms are unequivocable with not a lot of risk factors then that _______ may not be so important *ACS

Myoglobulin

Does an electrocardiogram provide information about the squeezing of the heart/mechanical (contractile) condition of the myocardium?

Should you be able to hear vocal sounds from a ventilated patient?

What analgesic for pain management is described below: (non-opioid) ● Can be helpful as standalone pain management or in conjunction with analgesics ● Ex: Advil, Aleve, Ketorolac (Toradol)

NSAIDS

When talking about the pathophysiology of an acute myocardial infarction (AMI), the infarcted area CANNOT conduct electrical impulses and CANNOT contract. A intramural infarction is found in an area in the middle of the myocardium and would probably also result in a _______. **ACS

NSTEMI

In acute coronary syndrome, you have: Deterioration of a once stable plaque --> that plaque ruptures --> platelet aggregation to the site where that lipid core is exposed to the blood --> thrombus formation. This can result in 1 of 2 things: 1. Partial occlusion of coronary artery—which will cause them to have an UA or NSTEMi OR 2. Total occlusion of coronary artery—which will cause them to have a STEMI. When talking about Partial occlusion of coronary artery-- which will cause them to have a UA or NSTEMI, which is described below: UA or NSTEMI? · patients who have a partial occlusion of a coronary artery so they may have some ST depression on their 12-lead EKG, but they don't have STEMI, but their cardiac biomarkers are positive (anytime you have tissue death that releases those cardiac enzymes when you draw their serums for the lab they will have an elevation in their cardiac biomarkers, which could include troponin and CKMB)

NSTEMI (non-ST elevation MI)

What drug would you use to reverse the effects narcotics?

Naloxone (Narcan®)

What reversal agent drug (Naloxone/Narcan and Flumazenil/Romazicon) is described below: · Dose: (do not need to memorize dose) o Adult: § Postanesthetic or opioid dependent: 0.1-0.2 mg/kg IV; may repeat q2-3min prn § Opioid overdose: 0.4-2 mg IV; may repeat q2-3min prn o Pediatric: § Postanesthetic reversal: 0.005-0.01 mg/kg IV/IM; may repeat q2-3min prn § Opiate intoxication: 0.01-0.1 mg/kg dose IV/IM; may repeat every min; not to exceed 2 mg/dose · Onset of action for IV is 1-3 min vs 10-15 min for IM; rebound sedation may occur; if used in patient with chronic opioid use, will precipitate acute withdrawal and abrupt sympathetic discharge possibly leading to acute pulmonary edema

Naloxone (Narcan®)

What reversal agent drug (Naloxone/Narcan and Flumazenil/Romazicon) is described below: · Reverses opioid agonists · Can give this if you oversedate a patient—or if you gave procedural sedation and you want to send the patient home · Vial comes in 0.4 mg vials · Sometimes the half-life of the opioid you gave might be longer than the half-life of ______ o So, the _______ may wear off before the drug does (because it does not eliminate the drug in the system, it just binds with it to make it inactive—so you may have to redose them · If you are giving it to someone that uses opioids chronically, it could precipitate a withdrawal and abrupt sympathetic discharge if you give it to them which could lead to pulmonary edema · Important things to remember: o The ______ may not outlast the drug that the patient has on board. You may have to repeat dosing. · Works very well and very quickly · Dose: (do not need to memorize dose) o Adult: § Postanesthetic or opioid dependent: 0.1-0.2 mg/kg IV; may repeat q2-3min prn § Opioid overdose: 0.4-2 mg IV; may repeat q2-3min prn o Pediatric: § Postanesthetic reversal: 0.005-0.01 mg/kg IV/IM; may repeat q2-3min prn § Opiate intoxication: 0.01-0.1 mg/kg dose IV/IM; may repeat every min; not to exceed 2 mg/dose · Onset of action for IV is 1-3 min vs 10-15 min for IM; rebound sedation may occur; if used in patient with chronic opioid use, will precipitate acute withdrawal and abrupt sympathetic discharge possibly leading to acute pulmonary edema

Naloxone (Narcan®)

What syndrome can occur with the overuse of Haldol for delirium? § This drug prolongs the QT interval which increases your risk for _____ ____ ______which is a ventricular tachycardia that is life threatening · So if the patient already has a prolonged QT interval or are on other drugs that prolong the QT interval you really need to monitor their QT interval on a regular basis and if it starts prolonging then they probably need to be taken off of one or more of those drugs that are prolonging the QT interval

Neuroleptic malignant Syndrome/ Torsades de pointes

Nitroglycerin

What alternate pain control option is described below: · A drug delivery device that delivers anesthetic (lidocaine)—something that is going to numb the area · Usually used in a surgical patient (thoracic and orthopedic) · Slowly delivers a baseline dose of anesthetic—there is no rates to set it at · Benefits: o Better pain relief and less need for narcotics o Patient feels better faster o Quicker return to normal body function o Less chance of grogginess because you don't need to use as much opioid with it (because you are numbing the area) o Greater mobility o Potential for earlier hospital release

ON-Q

What analgesic for pain management is described below: (non-opioid/NSAIDS) (acetaminophen) injection 1000mg/100ml ● This is acetaminophen IVPB ● Works quite well ● Much more available than oral acetaminophen if you give it IV ● Indications - management of: ○ Mild to moderate pain adult and ped. >age 2 ○ Moderate to severe pain w/ opioid in adult & ped. >2 ○ Reduction of fever in adult and pediatric patients. ● Dosage - ○ Adult - 1000mg over 15 min. q 6 hours X 24 h ■ Comes in 100 ccs so set pump at 400 ccs an hour to give it over 15 minutes ○ Adult and adolescents <50kg and pediatrics - 15mg/kg q 6 hours ● Used sometimes for the first 24 hours postop to help with pain management in conjunction with opioids ● Not always routinely ordered because its expensive and they don't always have good reimbursement for it ○ But keep this in mind if you have a patient who is having difficulty getting pain control especially if you cant use the NSAIDS because of their renal insufficiency this is another option—call the physician and ask them

Ofirmev

What analgesic for pain management is described below: (non-opioid/NSAIDS) ● Indications - management of: ○ Mild to moderate pain adult and ped. >age 2 ○ Moderate to severe pain w/ opioid in adult & ped. >2 ○ Reduction of fever in adult and pediatric patients. ● Dosage - ○ Adult - 1000mg over 15 min. q 6 hours X 24 h ■ Comes in 100 ccs so set pump at 400 ccs an hour to give it over 15 minutes ○ Adult and adolescents <50kg and pediatrics - 15mg/kg q 6 hours

Ofirmev

What analgesic for pain management is described below: (non-opioid/NSAIDS) ● Used sometimes for the first 24 hours postop to help with pain management in conjunction with opioids ● Not always routinely ordered because its expensive and they don't always have good reimbursement for it ○ But keep this in mind if you have a patient who is having difficulty getting pain control especially if you cant use the NSAIDS because of their renal insufficiency this is another option—call the physician and ask them

Ofirmev

practice of treating pain with minimal drug use **under treatment of pain

Oligoanalgesia

What type of pressure (PAWP, PAP, CVP/RAP) is described below: ■ _______ is considered to reflect both right & left heart pressures (taking data from both sides of heart) ■ PA Diastolic & PAWP are sensitive indicators of cardiac function & fluid volume status ■ Monitoring PA pressures permits precise manipulation of preload

PAP

What type of pressure (PAWP, PAP, CVP/RAP) is described below: ○ If the patient does not have pulmonary HTN then the pulmonary artery diastolic pressure is usually pretty equal to the pulmonary artery wedge pressure (PAWP). In the absence of pulmonary HNT, remember wedge PA pressure takes into account both R and L side of the heart, your PA diastolic will be very close to your PAWP. Sometimes they do not do wedge pressure if pretty equal; will just use PA diastolic to monitor pressures.

PAP

What type of pressure (PAWP, PAP, CVP/RAP) is described below: ○ Obtained from the distal port of the PA catheter - the ______ is read as a systolic & diastolic pressure (always lower than arterial BP in extremities) ■ ****Normal range for PA Systolic: 15-30mmHg***** ■ *****Normal range for PA Diastolic: 4-12 mmHg****** **pulmonary artery pressure

PAP

What type of pressure (PAWP, PAP, CVP/RAP) is described below: ○ If the wedge/balloon is overinflated, pt. will present with sort of like a tombstone on the waveform ○ Also known as: ■ PAOP = pulmonary artery occlusive pressure ■ LVED = left ventricular end diastolic pressure ■ PCWP = pulmonary capillary wedge pressure Wedge pressure

PAWP

What type of pressure (PAWP, PAP, CVP/RAP) is described below: ○ Indirect measure of left ventricular end-diastolic preload - this is the ability to actually fill ○ Note: readings are done at the end of expiration ● Normal range for _______: 6 - 12 mmHg

PAWP

LOOK AT IMAGE NUMBER 15 ON PHONE. · The image shows the differences with dosing between ______, fixed scheduled, and PRN o ______ (yellow line)—slow, steady background dose of medication being delivered to the patient § No peaks and valleys—just slow steady pain control o PRN (blue line)—high peaks and low valleys o Fixed scheduled (red dotted line)—such as ordering medication every 6 hours around the clock § Have some peaks and valleys but they are not as high of peaks or low of valleys as you would get with PRN scheduling (this is one of the problems with the titration method—patient can experience episodes of very severe pain or you may overdo it when trying to get their pain under control)

PCA

What pain management method is described below: ●____ _____ have a time interval between each possible dose - max of ____ ml/hr ○ If the pt. pushes the pump before the next time interval, it will not administer a dose ● Educate the pt. about how the pump works ● Can have a ____ ____ with just a basal, just a bolus dose, or both ○ Basal is set so the pt. will get a predetermined dose every hour like 1mg/hr; the bolus dose is set up so if the pain control is not good enough the pt. can get extra medication by pressing the button & bolus will have max) ● Another type is the epidural PCA - these do NOT provide bolus, typically basal rate (usually have some equivalent pain med like Brevocain that acts as a nerve block)

PCA pumps

Angiogram or PCI? o An intervention that is done to treat their disease (ex: angioplasty—the balloon, atherectomy, angioplasty with a stent, etc.) **therapeutic

PCI

In medical management of CAD, PCI and CABG are treatment options. Which of these 2 treatments is described below: o because they have disease throughout the vessel—won't do a whole lot of good to go put a stent in one area or the vessel is too small or the area where the blockage is is at a bifurcation and if they dilate and stent that area, they would risk occluding two vessels

PCI

In medical management of CAD, PCI and CABG are treatment options. Which of these 2 treatments is described below: · Performed in catherization lab using conscious sedation o General anesthesia is not used—the patient is not put to sleep o Just given something to relax them · Less invasive and less recovery time than CABG surgery o Patient can get back to their routine much quicker with PCI · Balloon angioplasty/stent placement/ atherectomy · _______ is NOT a surgical procedure · Types of ______: o Balloon angioplasty (high pressure balloon opens up vessel - coronary artery) o Stent placement (not done unless blockage is 60-70% or greater) o Atherectomy (sucks plaque out of vessel)

PCI

The following are things the patient needs to watch for after a ______ treatment: · Chest pain or shortness of breath—could suggest that they have a re-occlusion of the artery · Bleeding or swelling at insertion site o Lay flat, hold pressure, call 911 and get to the nearest ED · Pain at insertion site o Possible hematoma o Let them know that they may have a little discomfort but it really shouldn't be painful—and they might have a little tiny knot there but the rest of the area should be soft

PCI

The following are things the patient needs to watch for after a ______ treatment: · Feeling faint or weak—call physician or come to the ED o Blood loss may be the cause (possible internal bleeding) · Signs of infection o Redness, Drainage, Fever o Notify physician

PCI

There are 4 treatments for an MI: PCI, thrombolytic therapy, CABG, and medical management. Which of these 4 treatments is described below: § (percutaneous intervention) - door to balloon time = 90 minutes · The preferred method for managing STEMI and NSTEMI in the ED acute phase **management of MI

PCI

There are 4 treatments for an MI: PCI, thrombolytic therapy, CABG, and medical management. Which of these 4 treatments is described below: · General term to mean we are doing some type of intervention in the coronary arteries through the skin (no surgical incision) o Physician inserts a catheter through an artery and/or a vein (typically use the groin or the right radial artery or vein) § Either do: · PTCA (percutaneous translumenal coronary angioplasty)—go in and thread a catheter into the coronary arteries and thread it over the area of occlusion or narrowing in the lumen and there is a balloon on the catheter, and they inflate that balloon and mush the plaque up against the wall to open up the vessel (also have a stent in there while they are doing that) · Preferred if onset of symptoms > 3 hours (efficient processes need to be in place) o Go to option if available—preferred over thrombolytics · Must have a skilled _____ facility with surgical back-up in case things don't go well · "Door to balloon" time for ______ is < 90 minutes · ______ is preferred for STEMI and NSTEMI, especially if there is any doubt that it is actually STEMI **management of MI

PCI

There are 4 treatments for an MI: PCI, thrombolytic therapy, CABG, and medical management. Which of these 4 treatments is described below: · Preferred if onset of symptoms > 3 hours (efficient processes need to be in place) o Go to option if available—preferred over thrombolytics · Must have a skilled _____ facility with surgical back-up in case things don't go well · "Door to balloon" time for ______ is < 90 minutes · ______ is preferred for STEMI and NSTEMI, especially if there is any doubt that it is actually STEMI **management of MI

PCI

There are 4 treatments for an MI: PCI, thrombolytic therapy, CABG, and medical management. Which of these 4 treatments is described below: · The preferred method for managing STEMI and NSTEMI in the ED acute phase **management of MI

PCI

What is the number 1 management intervention for ACS?

PCI

The following are examples of patients that can be found in the ______: ● Scheduled for interventional cardiac procedures (stent placement) ● Awaiting heart transplant ● Receiving stable doses of vasoactive IV drugs (Cardizem) ● Being weaned from prolonged mechanical ventilation ○ Pt. will move from specialty ICU when still critical but IS hemodynamically stable; however, pt. still can't be extubated so may move to an intubation unit ○ Some pt. may move from ICU to LTAC - transition of where pt. go once out of critical condition (based on condition, diagnosis, acuity level, and also insurance)

PCU

What syndrome can be caused by Propofol? · Rare adverse effect · Generally associated with high doses and prolonged use. (which is how it is often used in the ICU—sometimes these patients are sedated for days) o The longer the patient is on it, the more risk they have for developing adverse reactions that can occur Characteristics include: · ****Acute refractory bradycardia (patient becomes bradycardic for no other explanation)**** · Severe metabolic acidosis · Cardiovascular collapse · Rhabdomyolysis (muscle breakdown) · Hyperlipidemia (because it is fat based) · Renal failure · Hepatomegaly

PRIS (Propofol Infusion Syndrome)

What ABG is the best indicator of alveolar hyperventilation/hypoventilation? **monitoring oxygenation and ventilation in artificial airways

PaCO2

There are 5 different levels of Scheduled Narcotics (based on level of addiction). Which schedule is described below: ● drugs with no currently accepted medical use & high potential for abuse. Highly addictive/most dangerous. ○ heroine, cocaine, meth, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4-methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote

Schedule 1

In acute coronary syndrome, you have: Deterioration of a once stable plaque --> that plaque ruptures --> platelet aggregation to the site where that lipid core is exposed to the blood --> thrombus formation. This can result in 1 of 2 things: 1. Partial occlusion of coronary artery—which will cause them to have an UA or NSTEMi OR 2. Total occlusion of coronary artery—which will cause them to have a STEMI. Which of these 2 results is described below? · UA—having chest pain and symptoms but do not have elevated cardiac biomarkers or cardiac enzymes · NSTEMI—patients who have a partial occlusion of a coronary artery so they may have some ST depression on their 12-lead EKG, but they don't have STEMI, but their cardiac biomarkers are positive (anytime you have tissue death that releases those cardiac enzymes when you draw their serums for the lab they will have an elevation in their cardiac biomarkers, which could include troponin and CKMB)

Partial occlusion of coronary artery—which will cause them to have an UA or NSTEMI

Which patient is doing better based off of the following values: Patient A: Height 6 ft Weight 216 lb BSA 2.22 m2 CO 4.0 L/min CI 1.89 L/min/m2 Patient B: Height 5 ft Weight 118 lb BSA 1.50 m2 CO 4.0 L/min CI 2.4 L/min/m2

Patient B (remember normal range for CI is 2.4-4.0 L/min/m2)

Perclose

A mode of ventilation which delivers a set tidal volume at preset intervals?

Pressure support ventilation (PSV)

What NON-benzodiazepine drug given as sedatives for critically ill patients is described below (Propofol (Diprivan) and Dexamedetomidine (Precedex)) ● High lipid content (delivers 1.1 kcal/mL as fat) - all tubing & solution must be changed q12h (tubing is harder & has a more yellowish color than normal tubing) ○ It is fat based ■ We have to change the tubing every 12 hours (twice a day) ○ Provides the patient with calories—if they are taking a considerable amount of this then dietitian needs to take this into account ○ Comes in a 100 mL bottle for IV drip so it doesn't usually last more than 12 hours ■ Every 12 hours, tubing has to be changed

Propofol

What NON-benzodiazepine drug given as sedatives for critically ill patients is described below (Propofol (Diprivan) and Dexamedetomidine (Precedex)) ● In low doses, _______ induces a state of deep sedation ● For an ICU nurse to give ______, the patient has to be on the ventilator and intubated because it does depress respirations and the patient will not breathe (so we need to be able to control their airway) ○ Also has to be given IV drip on a controlled volumetric pump ■ Nurses cannot push it (Nurse anesthetists can but not regular nurses) ● Short half-life, pt. can be fully conscious within 30 minutes after stopping infusion ○ Patient can be fully conscious w/in 30 minutes after turning it off ■ So, you can assess their neurological status—can give them a sedation vacation to see if their neuro status has changed and if they are able to follow commands ● Slows cerebral metabolism & decreases an IICP (sedative of choice w/ closed-head injury or bleed) ○ So, patient with head injuries the have increased ICP that we need to sedate, we can use _______ for that (to calm them down and lower all their pressures and helps with their ICP) ● Not very reliable in terms of amnesic effect ○ Even though they look sedated—they may still hear you ○ Do not say anything that you would not want the patient to hear ● High lipid content (delivers 1.1 kcal/mL as fat) - all tubing & solution must be changed q12h (tubing is harder & has a more yellowish color than normal tubing) ○ It is fat based ■ We have to change the tubing every 12 hours (twice a day) ○ Provides the patient with calories—if they are taking a considerable amount of this then dietitian needs to take this into account ○ Comes in a 100 mL bottle for IV drip so it doesn't usually last more than 12 hours ■ Every 12 hours, tubing has to be changed ● Pt. must be intubated if ______ is going to be used as a drip ● _______ is used IVP in Cardioversion (spontaneous respiration still occurs if given IVP) ● Contraindications: allergy to eggs, egg products & soy ● _______ syndrome- bradycardia and AV block→ need to stop, the patient cannot tolerate it ● Be care if patient is hemodynamically unstable because it may drop their BP

Propofol

What NON-benzodiazepine drug given as sedatives for critically ill patients is described below (Propofol (Diprivan) and Dexamedetomidine (Precedex)) ● Pt. must be intubated if ______ is going to be used as a drip ● _______ is used IVP in Cardioversion (spontaneous respiration still occurs if given IVP) ● Contraindications: allergy to eggs, egg products & soy ● _______ syndrome- bradycardia and AV block→ need to stop, the patient cannot tolerate it ● Be care if patient is hemodynamically unstable because it may drop their BP

Propofol

What NON-benzodiazepine drug given as sedatives for critically ill patients is described below (Propofol (Diprivan) and Dexamedetomidine (Precedex)) ● Short half-life, pt. can be fully conscious within 30 minutes after stopping infusion ○ Patient can be fully conscious w/in 30 minutes after turning it off ■ So, you can assess their neurological status—can give them a sedation vacation to see if their neuro status has changed and if they are able to follow commands

Propofol

What NON-benzodiazepine drug given as sedatives for critically ill patients is described below (Propofol (Diprivan) and Dexamedetomidine (Precedex)) ● Slows cerebral metabolism & decreases an IICP (sedative of choice w/ closed-head injury or bleed) ○ So, patient with head injuries the have increased ICP that we need to sedate, we can use _______ for that (to calm them down and lower all their pressures and helps with their ICP) ● Not very reliable in terms of amnesic effect ○ Even though they look sedated—they may still hear you ○ Do not say anything that you would not want the patient to hear

Propofol

What are 2 NON-benzodiazepines drugs given as sedatives for critically ill patients?

Propofol (Diprivan) and Dexamedetomidine (Precedex)

What part of a QRS complex is described below: o small, sharp NEGATIVE deflection after the P wave that preceeds the R wave

Q wave

What part of the QRS complex in an EKG is described below: o A ___ wave >.04 and deeper than 25% of the height of the R wave is abnormal and indicates infarction § As someone has an MI and it evolves and the tissue dies, it is no longer electrically active and that is represented on EKG has a pathological ____ wave § If just have a little tiny ____ wave that is not very wide, that is probably physiological and normal

Q wave

What part of the QRS complex in an EKG is described below: o Someone having an acute MI there ____ wave may not show up until they have completed their MI so may initially see the ST segment elevation but has things evolve, that person will develop a pathological _____ wave. That pathological _____ wave will stay with them for their lifetime. That is why a physician can look at a 12 lead EKG and know if someone has had an old infarct because they will have a pathological _____ wave § If they have pathological ______ waves in leads II, III, and aVF then more than likely they had an old inferior infarction

Q wave

If someone has had previous MI and now have necrotic tissue in the heart and when someone has necrotic tissue, electrical activity is not flowing through that necrotic tissue so it changes the look of the _____ ____. **morphology

QRS complex

What part of a QRS complex is described below: sharp NEGATIVE deflection that follows the R wave

S wave

What critical care specialty unit is described below: ○ surgical intensive care unit ■ Unit dedicated to surgical patients

SICU

In the V leads, should see that ____ wave progression where it starts little and then gets bigger and bigger and kind of equals out § If don't have this, then you have loss of _____ wave progression, which usually means that someone has had an anterior or lateral wall MI.

The _____ wave progression is normal to see in the precordial leads and is what you should see on the EKG lead. § On your precordial leads in V1, should see a little ____ wave but the rest of the complex is mostly negative and that is from the left to right depolarization of the septum § V2: should have a little more of the _____ wave and a big negative deflection § V3: little more _____ wave, more of a biphasic lead § V4: much taller ____ wave and much less negative because most of the flow is going toward the electrode § V5 and V6 almost all positive. Have a little bit of Q wave there from septal depolarization

The _____ wave progression is normal to see in the precordial leads and is what you should see on the EKG lead. When the myocardium depolarizes, it depolarizes from endocardium to epicardium (from the middle to the outer wall) so the flow of current is going towards the outer wall. If the positive electrode is looking at the heart and that current is flowing toward it, it should be positive.

What part of a QRS complex is described below: 1st POSITIVE deflection (above the baseline) that follows the P wave

R wave

In medical management of CAD, patients who are not candidates for PCI or CABG will be managed with medications to minimize their symptoms. Medications includes Aspirin, anti platelets, beta blockers, short and long acting nitrates (nitroglycerin), lipid lowering agents, ACE or ARBs, and Ranolazine. Which of these medications is described below: · type of antianginal that seems to help patient that have refractory disease (so maybe they are on all of their other meds, but they are still having chest pain and still having trouble managing their chest pain, but they are not a candidate for any other intervention) o Can be helpful in patients who have microvascular disease that you can't really bypass or put a stent in

Ranolazine

Patients are admitted to the ICU for 1 of 3 reasons: physiologically unstable, high-risk for serious complications, or intensive support requiring IV medications and/or advanced technology. Which of these 3 reasons is described below: ● (PA catheter, LVAD, CRRT) ○ Patients who have low BP or high BP and need continous IV medications to manage that BP or any high risk medications that need specialized monitoring ○ Pulmonary catheters

Require intensive, complicated nursing support and advanced technology

What mode of ventilation is described below: -Like AC, ______ delivers a minimum number of fully assisted breaths per minute that are synchronized with the patient's respiratory effort. These breaths are patient- or time-triggered, flow-limited, and volume-cycled. -However, any breaths taken between volume-cycled breaths are not assisted; the volumes of these breaths are determined by the patient's strength, effort, and lung mechanics. -A key concept is that ventilator-assisted breaths are different than spontaneous breaths. High respiratory rate setting on _______ allows little time for spontaneous breathing (a strategy very similar to AC), whereas low respiratory rates allow more time for spontaneous breathing.

SIMV

ST segment depression or elevation? o Pt experiencing acute interior MI o Most 12 lead EKGs are going to have at least one rhythm strip, which means it is a continuous tracing of one lead, which is how this one is. § Some 12 lead EKGs have 2 rhythm strips (one of lead I and one of lead II). § The reason for this is because normally you only have 3 second snipits of each lead and if trying to interpret a rhythm, it is hard to do with only a 3 second snipit so that's why there is an extra rhythm strip. o This patient probably has an occlusion of his LAD and it is pretty high up because it also has that septal branch so will see septal wall changes § The depression in the inferior wall leads may be that the patient has ischemia, problem with RCA, or reciprocal changes (the leads on the opposite wall from where the ST _______ is reflects with an opposite problem)

ST elevation

What does STEMI stand for? **acute coronary syndrome

ST elevation MI ST segment has tombstone appearance

What leads show ST elevation or depression?

ST elevation in leads II, III, and aVF

The following is all the info for ____ ____ monitoring: o Watching ____ _____ because have a patient who is high risk for ACS or they presented with chest pain o Know what is significant- § ST depression >0.5mm in 2 or more contiguous leads (2 leads looking at the same wall of the heart) § ST elevation >1mm in the limb leads (lead I, II, III, aVR, aVL, aVF-called this because positive electrodes are on the limbs) and >2mm in the precordial leads in 2 or more contiguous leads § With the precordial leads, it is significant if you see it in 2 consecutive changes. Doesn't have to be just contiguous. If 2 leads are side by side whether it is V2 and V3 because they are consecutive, that is significant o Know where to look § Look for ST change 0.06 seconds from the J point § "J" point identified as point where "S" begins to return to isoelectric line § Where it transitions to the ____ _____ is the J point. Move over 0.06 seconds which is 1.5 little blocks and that is where you measure how much deviation from baseline. Each little block upward is 1mm

ST segment

What part of an EKG is described below: o ****Use this to look for ischemia or infarction***** o Usually isoelectric (it should stay at the baseline) o Visualized as the segment from the end of the S wave to the beginning of the T wave o Represents that time during which the ventricle begins to repolarize. § When myocardial tissue is either ischemic or infarcting, it changes the way the heart depolarizes so we see changes on the ____ _____ o *****Depressed ST indicates ischemia.***** o ******Elevated ____ _____ indicates injury (acute infarction)*****

ST segment

What part of an EKG is used to look for ischemia or infarction in the heart? o *****Depressed ST indicates ischemia.***** o ******Elevated ____ _____ indicates injury (acute infarction)*****

ST segment

ST segment depression or elevation? o Generally think the person is having ischemia unless he has ST _______ plus positive cardiac enzymes then that means they have some tissue necrosis or injury (this would mean the person is having a non-STEMI non ST elevation MI) o Pt experiencing angina pectoris

ST segment depression

An acute myocardial infarction (AMI) is tissue ischemia resulting in the death of myocardial tissue. a ______ is ST elevation MI ( ST elevation on 12-lead EKG). A non-______ is non ST elevation MI (non-ST elevation and positive cardiac enzymes). · If you have ST depression and cardiac enzymes are negative, then that is considered unstable angina **ACS

STEMI

The following is evolution of ______: o If someone is infarcting, it is an evolution and takes some time, usually a few hours o Initially might have ST elevation that gets worse and then start to develop a Q wave and it gets deeper and invert the T wave and then once the tissue infarcting, it is infarcting but the ST segment elevation or depression will resolve and the Q wave will stay forever. Inverted T wave may stay awhile but eventually it will go back up but the Q wave is going to stay. Sometimes it takes anywhere from 6-12 hours before a Q wave to show up during the evolution of ST segment MI · When you have intact myocardium and don't have necrotic tissue, the flow of activity is generally going toward lead II so should have mostly upright complex in lead II but once you have infarction and tissue is no longer viable and the electrical activity is not flowing through that tissue, that is when the pathological Q wave is going to develop

STEMI

When talking about the pathophysiology of an acute myocardial infarction (AMI), the infarcted area CANNOT conduct electrical impulses and CANNOT contract. A transmural infarction means the area of infarction transverses the entire thickness of the myocardium o ****This will definitely result in a _______**** **ACS

STEMI

If you have a _______ reading of 50%, either the patient does not have enough oxygen to begin with. If they started out with a low ________ and used 25% of that or more than that from being sick then you will end up with a low ________. The other time is if demand is really high. Their arterial saturation is normal, ________ is normal but for some reason they are using up a lot of oxygen such as fever. This would result in a low _______ from using up oxygen available. **mixed venous oxygen saturations

SVO2

What mixed venous oxygen saturation measure is described below: ● Fiber optic sensor on distal tip of PA catheter.(Cadillac catheter with SVO2 monitor) ● Oxygen saturation of the blood in the pulmonary artery that has already saturated the body ● Called mixed because blood from all parts of the body returning to the right heart. ● Normal 60-80% oxygen (at rest) will be returned to the heart at rest (20-30% will be used) ● Gives us an idea of oxygen demand.

SVO2

What mixed venous oxygen saturation measure is described below: ● May need supplemental oxygen but the problem may be with hemoglobin ● Need to be checking peripheral O2 and H&H because they could be having a normal O2 sat ● Normally, a healthy person at rest uses only about 25% of their oxygen. That is why normal is 60-80%.

SVO2

There are 5 different levels of Scheduled Narcotics (based on level of addiction). Which schedule is described below: ● high potential for abuse, severe psychological & physical dependence ○ Hydrocodone, Adderall, Morphine, Fentanyl, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), Dexedrine, and Ritalin

Schedule 2

There are 5 different levels of Scheduled Narcotics (based on level of addiction). Which schedule is described below: ● moderate-low potential for physical and psychological dependence ○ Tylenol + codeine, testosterone, anabolic steroids, ketamine

Schedule 3

There are 5 different levels of Scheduled Narcotics (based on level of addiction). Which schedule is described below: ● low potential for abuse & low risk of dependence ○ Xanax, Valium, Benzos, Ativan, Ambien, Soma, Darvon, Darvocet, Talwin, tramadol

Schedule 4

There are 5 different levels of Scheduled Narcotics (based on level of addiction). Which schedule is described below: ● lower potential for abuse than Schedule IV & consists of preparations containing limited quantities of certain narcotics ○ Lyrica, muscle relaxer, robitussin AC, Lomotil, Motofen, Parepectolin, Soma

Schedule 5

What Sedation measurement scale (Sedation-Agitation Scale/SAS or Motor Activity Assessment Scale) is described below: 1: unarousable; has minimal or no response to noxious stimuli, does not communicate or follow commands 2. very sedated: Arouses to physical stimuli but does not communicate or follow commands 3. sedated: Is difficult to arouse, awakens to verbal stimulation, follows only simple commands 4. calm and cooperative: Calm, awakens easily, follows commands 5. agitated: Anxious or mildly agitated, attempts to sit up, calms down in response to verbal warnings 6. very agitated: Does not calm despite verbal reassurance, requires physical restraint, bites ET 7. dangerously agitated: Pulls at ET and other tubes, climbs out of bed **goes from 7 to 1 (down) in notes; opposite of this

Sedation-Agitation Scale (SAS)

Short and long-acting nitrates (nitroglycerin)

What type of drug therapy for treatment of delirium in ICU patients is described below (Dexmedetomidine in the ICU setting, Low-dose antipsychotics haloperidol, risperidone, olanzapine & quetiapine (controversial), Short-acting benzodiazepines (e.g., lorazepam)): ○ delirium associated with alcohol and sedative withdrawal ○ used in conjunction with antipsychotics to reduce extrapyramidal SE. ○ Want to stick with these short acting if you can

Short-acting benzodiazepines (e.g., lorazepam)

The following are _____ Recommendations for pain management: ● Scheduled analgesia recommended (ATC -avoids breakthrough pain & gets consistent serum level) ○ But we do use quite a bit of titrated medicine ● Continuous infusions when control is difficult with scheduled doses (consider PCA pumps) ● Use of slow-release medications recommended for de-intensifying therapy & providing baseline analgesia ○ If patient is starting to recover and we do not think they need as much pain medicine—helpful because we don't have to give it as often ● Use multiple approaches ○ Not only pharmacological or opioids (there are other medications you can use) ■ Other things you can do for comfort care other than pharmacologic methods

Society of Critical Care Medicine (SCCM)

The following are ______ clinical practice guidelines: ● If IV analgesia is required, Fentanyl, Dilaudid & Morphine are the recommended agents ○ **Notice no Demerol on this list** ● Fentanyl is preferred for rapid onset of analgesia in acutely distressed pt. ● Fentanyl or hydromorphone is best for hemodynamic unstable pt. or pt. with renal insufficiency ● Morphine & hydromorphone are preferred for intermittent therapy bc of longer duration of action

Society of Critical Care Medicine (SCCM)

T or F. Neuromuscular blocking agents do NOT provide sedation or analgesia → will need additional sedation ■ Anytime you paralyze somebody, it does NOT provide sedation. The patient can be paralyzed and totally awake.

What organization for the multidisciplinary document on pain and sedation is described below: ● Drugs are not always the answer (pre-op teaching will help; pain r/t chest tubes will be relieved with ambulation & removal; music, pet therapy, repositioning) ○ Alternative medicines, may just need to talk it out and be able to express their anxieties ● Assessing Pain: Precipitating/alleviating factors - Quality - Radiation - Severity - Timing

Society of Critical Care Medicine (SCCM)

What organization for the multidisciplinary document on pain and sedation is described below: ● Use of standardized scales necessary ○ Allows for good communication between HCPs ● Treat pain first, then anxiety ● Morphine is the gold standard (causes vasodilation - may also cause sedation, hypotension, etc.); may not be the best option for those with low blood pressure ○ But there may instances where other drugs may be more appropriate for certain patients ■ Ex: morphine is a vasodilator and if the patient has poor cardiac output or low BP you may not want to use morphine ● Drugs are not always the answer (pre-op teaching will help; pain r/t chest tubes will be relieved with ambulation & removal; music, pet therapy, repositioning) ○ Alternative medicines, may just need to talk it out and be able to express their anxieties ● Assessing Pain: Precipitating/alleviating factors - Quality - Radiation - Severity - Timing

Society of Critical Care Medicine (SCCM)

What organization for critical care is described below: ○ Puts out a lot of guidelines for critical care; more medical but nurses still use ○ Organization that is a medical society that puts out a lot of guidelines and best practices for critical care patients ○ One campaign they put out is the Surviving Sepsis Campaign

Society of Critical Care Medicine (SCCM) - for physicians

What complication of positive pressure ventilation is described below: ● progressive fluid retention 48-72 hours after PPV, esp. PEEP ○ If the positive pressure causes decreased CO, then it will stimulate the RAAS system, causing retention of sodium and water

Sodium & Water Imbalance R/T Renin system

T or F. Nurses cannot push Propofol, so if that's what they want to use for the procedural sedation, then anesthesia needs to do it (RNs can only give Propofol in the ICU setting for an intubated patient and it is given as a drip, not a push) NEED TO KNOW.

Starclose

The following are recommendations for _____ (class of drugs): · ________ are a common drug used to treat hypercholesterolemia (or hyperlipidemia) · People without cardiovascular disease who are 40 to 75 years old with 1 or more CVD risk factors and a CVD event risk of 10% or greater. · People with a history of heart attack, stroke, stable or unstable angina, peripheral artery disease, transient ischemic attack, or coronary or other arterial revascularization. · People 21 and older who have a very high level of LDL cholesterol. o 190 mg/dL or higher · People with Type 1 or Type 2 diabetes who are 40 to 75 years old.

Statins

What class of drugs are common drugs used to treat hypercholesterolemia (or hyperlipidemia)?

Statins

T or F. Nurses who work in ICU typically have advanced education whether it is with degrees or continuing education after graduating as a nurse generalist. They need extra skills and knowledge beyond what you get in your undergrad education

What critical care campaign is described below: ● - in the ICU they are immunocompromised and introduced to new bacteria; if you suspect sepsis in a patient, complete these steps within 1 hour within being admitted 1.) Measure lactate level→ tissues do not have enough oxygen and tissues will go into lactic acidosis; sepsis causes massive vasodilation→ decrease BP → decreased tissue perfusion 2.) Obtain blood cultures prior to administration of antibiotics (will need 2 sets from 2 sites or 15 minutes apart) 3.) Administer broad spectrum antibiotics (always start on broad AB first; when C/S comes back always check to see if pt. is on the right AB that the organism is most sensitive to) 4.) Fluid Resuscitation-- Administer 30ml/kg crystalloid for hypotension or lactate 4mmol/L ○ Crystalloids include NS, LR, D5½; Colloids include things like albumin (volume expanders) ○ Remeasure lactate if lactate level was elevated 5.) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a meal arterial pressure (MAP) 65 mm Hg

Surviving Sepsis Campaign

What is the 1 critical care campaign discussed in lecture? ● We have guidelines for a lot of things that pt. may acquire in the hospital (UTI, hospital-acquired pneumonia, etc.)

Surviving Sepsis Campaign

-A key concept in the AC mode is that the tidal volume (VT) of each delivered breath is the same, regardless of whether it was triggered by the patient or the ventilator. -If the patient does not initiate a breath before a requisite period of time determined by the set respiratory rate (RR), the ventilator will deliver the set VT. -However, if the patient initiates a breath, the ventilator in AC mode will deliver the set VT; these breaths are patient-triggered rather than time-triggered.

T or F. ● Critical Care Nursing as a "specialty" is less than 50 years old ● Critical Care Units opened across the country in the 60s ● About a decade after that, is when the critical care specialties started to evolve

T or F. ******* So, with APRV one of the main concerns is that _________ which can cause a decreased venous return.***********

T or F. *******When someone has an endotracheal tube or tracheostomy tube with a cuff inflated they should NOT be taking anything by mouth (NPO).*********

T or F. ****Nurses must accurately assess the problem - treating anxiety when pain is the problem (vice versa) can lead to the escalation of both issues.**** ○ *****IF THEY HAVE BOTH, ALWAYS TREAT PAIN FIRST→ treat then reassess→ if they are still having anxiety without pain then you may give them something for anxiety ● IMPORTANT: assess pain & anxiety continuously and independently***** BOLD, RED, AND HIGHLIGHTED IN NOTES.

T or F. ***Critical Alert ● Pt. has ET tube & condition changes (tachycardia/pnea, decreased LOC, etc.) CHECK THE TUBE!!! RED AND HIGHLIGHTED IN NOTES.

T or F. ***IV IM PO Transdermal - these are the routes of administration from fastest onset to slowest

T or F. ***If pt. says "I can't feel my hand", you need to call the MD bc the ART line is not perfusing the pt. hand

T or F. ***as an ICU nurse, work with your patients and their families within the constraints of the policy of the unit to come up with an acceptable visiting schedule** RED AND BOLD IN NOTES.

T or F. **CMV, AC, SIMV, and APRV are the major modes that will be picked upon. Your pressure support (PS), PEEP, and CPAP are add-ons that go on top of these settings. ** 1. Controlled Mandatory Ventilation (CMV) - volume 2. Assist-control Mechanical Ventilation (AC) - volume 3. Synchronized Intermittent Mandatory Ventilation (SIMV) - volume Most common one used 4.Airway Pressure Release Ventilation (APRV)

T or F. **all endotracheal tubes have the same type of connector (universal connector) and they connect to the ambu bag. o If you take the mask off the ambu bag, that area where the mask connects to the ambu, that piece will fit right on top of the endotracheal tube. It will also fit on the tracheostomy tube.

T or F. **we rarely ever use PEEP on a head injury patient or patient who has increased intracranial pressure (ICP)****

T or F. 70% of ICU pt have moderate to severe pain and is often linked to agitation and anxiety **common problem (pain) among critical care patients

T or F. A HIGH pulmonary artery wedge pressure is almost always indicative of L-sided heart failure. BOLD AND HIGHLIGHTED IN NOTES.

T or F. A high PAP is caused by fluid volume overload, HF, MI, pulmonary HTN. A low PAP suggests hypovolemia (low CVP & low CO).

T or F. A patient can be weaned to a rate of 0 to where you have no rate and machine is no longer giving the patient a tidal volume. The patient is taking all the breaths on their own and if you add PEEP, pressure support, to make it easier for them to breathe (overcome resistance of tube). You can also keep the PEEP on to prevent the alveoli from collapsing and this sort of makes a BiPAP but with the mechanical ventilator for some reason they do not cal it BiPAP they call it CPAP. That is the terminology they use when you wean someone down to a rate of 0 and you keep the pressure support on and PEEP on, they call that CPAP but it is really like BiPAP because you have bilevel pressure.

T or F. A patient should NOT have chest pain after a PCI procedure.

T or F. A patient's family member can activate the rapid response team if they feel the family member is not being properly taken care and they notice drastic changes in the patients status

T or F. ACS is a very time sensitive process that we need to be ready to treat quickly (need to have processes in place to that things happen for these patients in an efficient manner). Goal of treatment: time is muscle - the sooner you restore perfusion to the coronary tissues, the less damage you have to the muscle. **ACS

T or F. Another time when someone would have a low venous oxygen saturation is someone who is anemic where they do not have enough Hemoglobin to carry oxygen resulting in not enough oxygen to start with. The body extracts at least 25% so you end up with a low venous oxygen saturation. **mixed venous oxygen saturations

T or F. Anti-rhythmic drugs, thyroid drugs, stimulants—ADHD medications all affect the heart in some way. ***Any medication that is used to control HR can cause dysrhythmias.

T or F. Anyone who is having acute coronary syndrome (ACS) especially patients who are having an acute MI are at high risk for sudden cardiac death (usually secondary to a lethal arrhythmia)

T or F. Because air does not go around the tube then no air goes over the vocal chords. If air is passing over the vocal chords that makes vocal sounds and so when patients have ET tubes or tracheostomy tubes with a cuff on them they should ****NOT**** be able to make vocal sounds and not be able to talk to you. If they are talking to you either your tube got dislodged and is not where it should be or your cuff was deflated/not enough air in it, or the cuff exploded/popped. Patients with an ET tube should *****NOT*** be making noises. BOLD AND HIGHLIGHTED IN NOTES.

T or F. CAD is chronic, and ACS is an acute problem or manifestation of that disease.

T or F. Comfort and pain are very different. ○ Rest (cluster care, give them adequate resting time) ○ Positioning (prevents ischemia which causes pt. to feel pain) ■ Pillows for positioning ○ Loss of control, issues of trust, feelings of helplessness ○ Isolation of social support (pediatric families will stay with them) ■ Visiting hours could be a problem ○ Could have anxiety or could have pain, make sure you get a good assessment to see what is making them uncomfortable

T or F. Critical Alert: ● ***********Pt. has ET tube & condition changes (tachycardia/pnea, decreased LOC, etc.) CHECK THE TUBE!!!******** ● If vent is malfunctioning, use ambu-bag & bag them at FiO2 100% ● Make sure the tube is connected to the ventilator, ventilator working, check to see if they need suctioning, check pilot balloon, check the placement (first thing you should check to make sure it is not dislodged) ● Remember this is your airway (ABCs). This will come first!! ● Condition change, alarm going off, check your patient.

T or F. Decreased PaCO2, increased pH indicates alkalosis. Increased PaCO2, decreased pH indicates acidosis. **monitoring oxygenation and ventilation in artificial airways

T or F. Do NOT increase PEEP for pt. with COPD or atelectasis

T or F. Epidural hematoma is an emergency - can happen sometimes when pt. is on Lovenox & have increased bleeding time & they puncture the epidural space for procedure. ○ Important that they not be on any anticoagulants ■ No Lovenox (Enoxaparin) or anything that will thin their blood due to the risk of epidural hematoma ALL IMPORTANT; BOLD AND RED IN NOTES.

T or F. For an ICU nurse to give Propofol, the patient has to be on the ventilator and intubated because it does depress respirations and the patient will not breathe (so we need to be able to control their airway) ○ Also has to be given IV drip on a controlled volumetric pump ■ Nurses cannot push it (Nurse anesthetists can but not regular nurses) NEED TO KNOW THIS.

T or F. For anxiety management in a critically ill patient, it is most desirable to have ***PRN orders****--> treat as needed, not around the clock like we do for pain. ○ With anxiety and sedation management, The Society of Critical Care Medicine recommends for this type of management, PRN orders. Remember the Society of Critical Care Management for pain management really recommended around the clock pain management although that is something we do not always do.

T or F. For hemodynamic monitoring, the transducer needs to be re-leveled with each position change. **at the phlebostatic axis

T or F. IN the treatment of delirium we need to correct the **cause**. ○ Calm environment, look at medication list, reorient constantly ○ Try to manage it non-pharmacologically because a lot of times it is the drugs that cause the delirium

T or F. If CVP readings are elevated & pt. is in true volume overload, you may see some JVD. Changes occur much later with CVP than pulmonary artery pressure changes

T or F. If HR is normal, contractility is decent, and preload is decent, maybe there is a problem with afterload. You need to look at all components to figure out what is causing the problem and how to fix

T or F. If SV decreases, the HR will compensate by increasing so initially the CO remains the same. If HR increases, the SV will stay the same, but eventually it will decrease bc there is not enough time for the ventricles to fill.

T or F. If preload is normal, contractility is normal, and afterload is normal than maybe it is a problem with your HR.

T or F. If someone has an inferior MI, there is a high risk for right ventricular infarct -- they need adequate volume! Careful with decreasing their filling volume by giving them nitroglycerin.

T or F. If systemic blood pressure is really high, it will be hard for ventricle to generate enoguh pressure to push aortic valve open and eject that blood into the periphery

T or F. If the pulmonary artery pressures are too high, it will strain the R side of the heart of the R ventricle. The pressure that the ventricle must generate to empty its contents is called vascular resistance. Afterload of the L side of the heart is SVR (Systemic vascular resistance) and afterload of the R side of the heart is PVR or pulmonary vascular resistance

T or F. If you have ST depression and cardiac enzymes are negative, then that is considered unstable angina **ACS

T or F. If you have a patient that comes in with an inferior MI, then you know it's probably the **right coronary artery** (this patient is high risk for developing heart blocks due to the blood supply to the SA node and the AV bundle) *coronary circulation

T or F. In a 12 lead EKG, if you want to get a better view of the right ventricle, can take all the V leads that are on the left side of the chest and put them on the right side of the chest to give a better idea of what is happening in the right ventricle. Sometimes patients who come in with an inferior wall MI, might go ahead and do a right sided EKG to look at the right ventricle because those patients are at high risk for infracting that right ventricle.

T or F. In a 12 lead EKG, lead I and aVL are lateral leads. Leads II, III, and aVF are inferior wall leads. NEED TO KNOW.

T or F. In a 12 lead EKG, we DO NOT have any electrodes looking at the posterior side of the heart. All on the front of the chest. Can do an 18 lead EKG where you add electrodes to the back at the level of the 5th intercostal space and that will give you an angle looking at the posterior side of the heart. § Can also take all of the V leads and put them on the back to do a posterior EKG

T or F. In medical management of CAD, patients who are not candidates for PCI or CABG will be managed with medications to minimize their symptoms. Medications includes Aspirin, anti platelets, beta blockers, short and long acting nitrates (nitroglycerin), lipid lowering agents, ACE or ARBs, and Ranolazine.

T or F. Lecture notes: when we normally breathe we breathe with negative pressure. When you take a breath, your chest cage expands and diaphragm drops causing a negative pressure in the lungs.

T or F. Pharmacology treatment for MIs/ACS includes beta blockers, Morphine Sulfate, CCBs (calcium channel blockers), Nitroglycerin, ACEI or ARB (one or the other), ASA (aspirin), Heparin, Glycoprotein IIb/IIIa Inhibitors, Antidysrhythmic drugs, Lipid Lowering medication, stool softeners, and antiplatelets.

T or F. Positive pressure ventilation decreases venous return which can decrease intracranial pressure which is something we do not want for patients with head injuries.

T or F. Pt. must be intubated if Propofol/Diprivan is going to be used as a drip ● Diprivan is used IVP in Cardioversion (spontaneous respiration still occurs if given IVP) ● Contraindications: allergy to eggs, egg products & soy

T or F. Remember the nurse is the person who is with the patient 24/7. We need to be able to recognize a problem and relay that information to the HCP in a timely manner. NEVER underestimate the value of you as a nurse and what you can contribute to the care of your patients

T or F. The AHA estimates that 1.1 million Americans will have an MI each year and about ¼ of these die in the ED or before reaching the hospital.

T or F. The critical care nurse requires an in-depth knowledge of A&P, pathophysiology, pharmacology, and advanced assessment skills.

T or F. The major goal in patients with ACS is to reduce the amount of myocardial necrosis that occurs in patients who present with MI. The secondary goal is to prevent Major Adverse Cardiac Events (MACE) which includes heart failure, cardiogenic shock, papillary muscle rupture, left ventricular aneurism, lethal dysrhythmias, and ventricular septal wall rupture. · Goal: salvage as much of the myocardial tissue as possible. **collaborative management/goals

T or F. The major purpose of PEEP: maintain or improve oxygenation while limiting risk of O2 toxicity

T or F. The problem with CMV (controlled mandatory ventilation) is the nurse is in total control of that patient's ventilation. ■ If the patient is awake at all and they are trying to breathe, they can start a breathe while the ventilator is trying to give them a breathe and it can cause high pressure (called bucking where the patient is not breathing with the vent). ■ It is uncomfortable for the patient, therefore, rarely used anymore

T or F. The pt. self-report is the most reliable indicator of the existence & intensity of adult pain. **pain assessment

T or F. The use of minimally invasive hemodynamic monitoring is limited to control-ventilated patients. ○ Only valid in patients with positive pressure ventilation (positive controlled ventilation). When someone has positive pressure ventilation and we are blowing air into that lung, that increases intrathoracic pressure and decreases venous return. ○ The device may not be sensitive enough in patients not mechanically ventilated.

T or F. To put someone on the ventilator, we have to put in an artificial airway and the 2 airways we have are the endotracheal tube and the tracheostomy tube (positive pressure ventilation).

T or F. Typically, CI is ½ of CO so if the CO range is 4-8, the CI range is 2.4 - 4 (about half of cardiac output)

T or F. Vital capacity + residual volume = total lung capacity

T or F. When ECG changes of myocardial infarction occur, they are not found in every lead of the ECG. In fact, they are only present in the leads "looking" directly at the infarct site (indicative changes). o Indicative changes are significant when they are seen in two anatomically contiguous leads o Two leads are contiguous if: § They look at the same area of the heart § Or they are numerically consecutive chest leads

T or F. When talking about assessment for arterial lines, if someone is putting it in the radial artery, they HAVE to first check circulation to the hand. We want to make sure the ulnar circulation is good enough because when you are putting a catheter in the radial artery or any artery you are taking up some space and increasing risk for tissue ischemia to distal areas. Before ART line insertion we perform the Allen's test.

T or F. When talking about pulmonary artery catheters, the balloon is ONLY inflated upon insertion and when a PAWP is required***

T or F. When talking about ventilator associated pneumonia prevention bundles (VAP) , one criteria includes: HOB elevation >30 degrees ****reduces***** frequency & risk for nosocomial pneumonia compared to supine position ● The ventilator bundle is a bundle of nursing care that we do with patients to try to prevent the complication that can occur from a patient being on the ventilator.

T or F. Why are blood specimens taken from the pulmonary artery called mixed venous? Because it is blood returning to the right side of the heart from all over the body where it is "mixed" before returning to the pulmonary system to get re-oxygenated.

T or F. With INVASIVE positive pressure ventilation the main two concepts is volume ventilation and pressure ventilation.

T or F. With agonist-antagonist agents for pain management, nurses need to BE CAREFUL: May precipitate withdrawal in chronic opioid users if you suddenly take it away ○ Use extreme caution due to potential to precipitate withdrawal in chronic opioid users

T or F. With precordial leads NOTE: that neither the right ventricular wall (X) nor the posterior wall of the left ventricle (Y) is well visualized by any of the usual six chest leads.

T or F. With synchronized intermittent mandatory ventilation (SIMV), if the pt. is not initiating enough spontaneous breaths & the vent is set too low, the pt. O2 status may decline resulting in inadequate support & oxygenation of the pt.

T or F. You CANNOT use PS on a patient with assist control or CMV. This CAN be used on a patient with SIMV.

T or F> With invasive pressure monitoring, **to get accurate readings, you need to make sure you have enough pressure on your bag (300 mm Mercury), enough fluid in bag, no air bubbles in tubing, make sure system is zeroed and level with phlebostatic axis, and make sure catheter is not kinked from bending of arm

· Cheat Sheet o Remember, we don't have any leads looking at the posterior wall of the heart so look for reciprocal changes in V1 and V2 so instead of a Q wave if someone has a posterior wall infarction, they will have a tall R wave in V1 and V2 and a tall upright T wave in V1 and V2 with ST depression o Can have anterior lateral wall meaning its involvement of both the anterior and lateral wall. Can have inferior lateral especially if RCA and circumflex wraps around and covers 2 areas. If someone has pericarditis (inflammation of pericardial sac), will have diffuse ST elevation in all the leads o Sub-endocardial is now known as a n-STEMI or non-STEMI so that is someone who has ST depression and have symptoms as well as positive cardiac enzymes and don't have ST elevation. That means that just part of the endocardium is infarcted, not the full thickness. Those patients will never develop a Q wave because it doesn't infarct the whole thickness of the myocardium.

● If preload is normal, contractility is normal, and afterload is normal than maybe it is a problem with your HR. ● If HR is normal, contractility is decent, and preload is decent, maybe there is a problem with afterload. Yodu need to look at all components to figure out what is causing the problem and how to fix ● If systemic blood pressure is really high, it will be hard for ventricle to generate enoguh pressure to push aortic valve open and eject that blood into the periphery ● If the pulmonary artery pressures are too high, it will strain the R side of the heart of the R ventricle ● The pressure that the ventricle must generate to empty its contents is called vascular resistance. ● Afterload of the L side of the heart is SVR (Systemic vascular resistance) and afterload of the R side of the heart is PVR or pulmonary vascular resistance

What part of an EKG is described below: o Represents ventricular repolarization. o Usually upright and rounded in lead II. o ____ ______ inversion and patient with symptoms indicate ischemia. o Tall, peaked ___ ____s indicate hyperkalemia. o Hyperacute _____ ______ (really tall ____ ___s) in MI

T wave

What type of nutrition can be given in central lines because it is thicker and more osmotic? ■ Will need glucose checks because it is high concentration of glucose ■ Increase RF infection

TPN

Who owns comfort to the patient? ICU is an uncomfortable place! HIGHLIGHTED AND RED IN NOTES.

The nurse!!! The Nurse! THE NURSE!!! ○ You are the one with the patient 24/7

What cardiac marker seen with an acute myocardial infarction (AMI) is described below: (CK MB, Troponin, Myoglobulin) o myocardial muscle protein § Rise 4-6 hours, peaks 10-24, normal by 10-14 days § Cardiac specific § Elevated ______ could've been from another event (important for patients who return with chest pain) *ACS

Troponin

How do we zero a monitoring system? (4 steps)

To ensure accuracy we need to periodically zero the system: o Open the stopcock to air o Press the zero button on the monitor o Wait for the waveform to flatten and register zero. o Every 4 hours and any time a reading is questioned.

Total occlusion of coronary artery—which will cause them to have a STEMI

UA (unstable angina)

What sign/symptom of ACS requires more frequent NTG (nitroglycerin) therapy- vasodilator used for immediate vasodilation of coronary arteries? **1 of the 3 syndromes of ACS

UA (unstable angina)

What sign/symptom of acute coronary syndrome (ACS) is described below: o Diabetics may also have atypical symptoms o Pain is more severe than stable angina o Pain may occur at rest o Requires more frequent NTG (nitroglycerin) therapy- vasodilator used for immediate vasodilation of coronary arteries

UA (unstable angina)

What sign/symptom of acute coronary syndrome (ACS) is described below: o ECG may show ST segment depression during acute attack § When the patient is not having symptoms or not having pain then their 12-lead EKG may look perfectly fine § ST segment may return to normal (once the patient rests and myocardial oxygen demand decreases) or may progress to AMI (if we don't intervene and the occlusion gets worse)

UA (unstable angina)

What sign/symptom of acute coronary syndrome (ACS) is described below: o Often times we will send patients home who have coronary disease if they have stable angina with nitroglycerin § Nitroglycerin is a coronary vasodilator—patients are instructed that when they have chest pain to stop what they are doing, sit down, and take a nitroglycerin · If their chest pain is relieved with rest and nitroglycerin and they can predict when they are going to have chest pain (ex: when they cut the grass or jog) then that is stable angina o When chest pain starts occurring at rest and it becomes unpredictable and it is increased in frequency and severity and maybe not responding to the nitroglycerin like it should, that is when it is considered to be unstable

UA (unstable angina)

What sign/symptom of acute coronary syndrome (ACS) is described below: o Rarely sharp or stabbing, no change with position or breathing- not reproducible (could be reproducible if they know that if they increase their activity level or increases myocardial oxygen demand) o Most common pathophysiology for ____ ______ is thrombus resulting from disruption of atherosclerotic plaque

UA (unstable angina)

What sign/symptom of acute coronary syndrome (ACS) is described below: o Some blood continues to flow through affected artery, however, blood flow is severely diminished. § Supply of oxygen to the myocardial tissue is reduced and that is what causes the patient to have that chest pain or their symptoms (whatever their symptom may be) o Pt. generally seeks medical attention, frequently fearful of MI. (fear of impending doom) o Women present differently than men vs. diabetics (may just say they aren't feeling right)

UA (unstable angina)

What sign/symptom of acute coronary syndrome (ACS) is described below: · (Chest pain that is caused from a cardiac origin is considered angina) · chest pain that is not predictable, often occurring at rest and increasing in frequency and severity. o CAD is a chronic disease that we have to manage—there is no cure for it, so we manage it with PCIs, coronary artery bypass surgery, or with medications o When chest pain starts occurring at rest and it becomes unpredictable and it is increased in frequency and severity and maybe not responding to the nitroglycerin like it should, that is when it is considered to be unstable

UA (unstable angina)

What sign/symptom of acute coronary syndrome (ACS) is described below: · chest pain that is not predictable, often occurring at rest and increasing in frequency and severity. o CAD is a chronic disease that we have to manage—there is no cure for it, so we manage it with PCIs, coronary artery bypass surgery, or with medications o Often times we will send patients home who have coronary disease if they have stable angina with nitroglycerin § Nitroglycerin is a coronary vasodilator—patients are instructed that when they have chest pain to stop what they are doing, sit down, and take a nitroglycerin · If their chest pain is relieved with rest and nitroglycerin and they can predict when they are going to have chest pain (ex: when they cut the grass or jog) then that is stable angina o When chest pain starts occurring at rest and it becomes unpredictable and it is increased in frequency and severity and maybe not responding to the nitroglycerin like it should, that is when it is considered to be unstable o Rarely sharp or stabbing, no change with position or breathing- not reproducible (could be reproducible if they know that if they increase their activity level or increases myocardial oxygen demand) o Most common pathophysiology for ___ _____ is thrombus resulting from disruption of atherosclerotic plaque o Some blood continues to flow through affected artery, however, blood flow is severely diminished. § Supply of oxygen to the myocardial tissue is reduced and that is what causes the patient to have that chest pain or their symptoms (whatever their symptom may be) o Pt. generally seeks medical attention, frequently fearful of MI. (fear of impending doom) o Women present differently than men vs. diabetics (may just say they aren't feeling right) o Diabetics may also have atypical symptoms o Pain is more severe than stable angina o Pain may occur at rest o Requires more frequent NTG (nitroglycerin) therapy- vasodilator used for immediate vasodilation of coronary arteries o ECG may show ST segment depression during acute attack § When the patient is not having symptoms or not having pain then their 12-lead EKG may look perfectly fine § ST segment may return to normal (once the patient rests and myocardial oxygen demand decreases) or may progress to AMI (if we don't intervene and the occlusion gets worse)

UA (unstable angina)

What 2 leads look at the septal part of the heart?

V1 and V2

What lead of a 12 Lead EKG is described below: (**2 leads**) § looking at the septal wall of left ventricle. Usually a septal branch of the left anterior descending that feeds that septal wall **2 precordial chest leads

V1 and V2

What precordial or chest leads are described below: § Looking at the septum (wall between the left and right ventricle) § Considered septal leads NEED TO KNOW THESE.

V1 and V2

When talking about 12 Lead ECG, what 2 leads are **septal leads**; so if you see indicative changes (ST elevation or depression) in these then the culprit vessel is probably the **LAD or a branch off the LAD called the septal branch**? **localization of infarction **ACS

V1 and V2

What are the 6 precordial or chest leads?

V1, V2, V3, V4, V5, V6

What 2 leads look at the anterior part of the heart?

V3 and V4

What lead of a 12 Lead EKG is described below: (**2 leads**) are anterior leads. Looks at anterior wall of left ventricle **2 precordial chest leads

V3 and V4

What precordial or chest leads are described below: § Looking at the anterior wall of the heart § Considered anterior wall leads NEED TO KNOW THESE.

V3 and V4

When talking about 12 Lead ECG, what 2 leads are **anterior wall leads**; indicative changes in these leads means it the culprit lesion is in the **left anterior descending (the coronary artery that feeds the anterior wall of the heart)*** **localization of infarction **ACS

V3 and V4

What lead of a 12 Lead EKG is described below: (**2 leads**) are lateral leads **2 precordial chest leads

V5 and V6

What precordial or chest leads are described below: § Looking at the lateral wall of the heart § Considered lateral precordial/wall leads NEED TO KNOW THESE.

V5 and V6

What part of a lipid protein is described below: o another bad cholesterol) § Desirable < 30 § Subcategory under LDL (Very low)

VLDL

What could cause a low-pressure alarm to go off?

Vent becomes detached, pt. Self-extubates; cuff deflated or leaking; displaced

How do you monitor for correct ET tube placement?

When monitoring, you need to listen to breath sounds every 2 hours at a minimum. Once the tube is confirmed, the marking of where the tube is laying on the lips should be passed on in every report to make sure it does not move.

What augmented unipolar limb lead (aVR, aVL, aVF) is described below: § the center of the heart is the negative pole and the left leg is where the electrode is for the positive pole § the positive electrode is looking inferior up at the heart so looking at the inferior wall of the heart

aVF

What lead of a 12 Lead EKG is described below: (**2 leads**) § positive electrode is on the left foot and negative pole is at the center of the heart so it is looking up at the heart inferiorly so looking at the inferior wall. The RCA usually feeds the inferior wall of the heart

aVF

What augmented unipolar limb lead (aVR, aVL, aVF) is described below: § the negative pole is in the center of the heart and the positive pole is on the left arm the positive electrode is looking at the left lateral wall of the heart

aVL

What lead of a 12 Lead EKG is described below: (**2 leads**) positive electrode is on the left shoulder, negative pole is the center of the heart so looking at the lateral wall (circumflex artery feeds the lateral wall)

aVL

What augmented unipolar limb lead (aVR, aVL, aVF) is described below: § The negative electrode in this lead is the center of the heart and the positive electrode is on the right arm § The positive electrode is looking at the right atrium

aVR

What lead of a 12 Lead EKG is described below: (**2 leads**) § doesn't give a lot of information Ø positive electrode is on the right arm and the negative pole is the center of the heart so that lead is looking down at the right atrium. The right atrium is a thin wall chamber and people don't typically have MI or ischemia of the anterior wall Ø not a lot of use for this lead Ø complex ______ is completely normal to be totally negative (below the baseline) because the positive electrode is on the right shoulder and the flow of electricity is going away from that electrode

aVR

what are the 3 augmented unipolar limb leads? o Called augmented because the machine augments it by 50% to increase the size on the EKG paper

aVR (augmented vector R) aVL (augmented vector L) aVF (augmented vector foot)

"these units" are designed to care for patients who need a higher level of care. Higher level of care means more nursing care or advanced technology ● Patients who need more intensive care need to be in a setting that can accommodate advanced nursing care

critical care specialty units

Anyone with 3 or more risk factors (abdominal obesity (waist circumference), elevated triglycerides, low HDL cholesterol, elevated BP, and elevated fasting glucose) is considered to have metabolic syndrome. Which of these 5 risk factors is described below: § Waist circumference** · Men: >102 cm (>40 in) considered to have abdominal obesity · Women: >88 cm (>35 in) considered to have abdominal obesity

abdominal obesity

Anyone with 3 or more of what 5 criteria is considered to have metabolic syndrome? **cluster of risk factors · People with metabolic syndrome are at increased risk for developing heart disease or cardiovascular disease · Higher risk for atherosclerotic vascular disease (includes anyone with 3 or more of the following risk factors)

abdominal obesity (waist circumference), elevated triglycerides, low LDL cholesterol, elevated BP, and elevated fasting glucose

Flattened/Dampened (________) waveforms may indicate several problems such as: ○ Hypotension ○ Vasospasm ○ Clot occluding the catheter ○ Poor catheter placement/position (usually catheter is kinked from bending arm forward; have to put arm in arm board to prevent) ○ Bubbles in tubing ○ Positional- in radial and patient is holding wrist a certain way that kinks the catheter **invasive pressure monitoring

abnormal

Flattened/Dampened (________) waveforms may indicate several problems such as: ○ If the waveform does not look right, that is a clue that you have a problem with your system. If you do not have that sharp upstroke and you cannot see the dicrotic notch or you cannot clearly see where diastole ends, then you probable have a flattened or dampened waveform ■ Dampened means you are not seeing the sharp curves (could be patient problem such as low BP and decreased CO) **invasive pressure monitoring

abnormal

_________ rhythms that can result in an increased/decreased HR include: ● PSVT, SVT, runs of V-Tach, AV Blocks, V-Fib, A-Fib ○ With tachycardia, this will increase CO by a point. Then when it starts to get too fast, you decease ventricular filling time. There is not enough time in diastole to fill with blood. If there is not much blood in the ventricles, there is not much to eject ○ HR too fast can decrease CO and HR too slow can decrease CO

abnormal

With fibrinolytic treatment for MI/ACS, we have absolute and relative contraindications. Which of these contraindications is described below: o ICH (intracerebral hemorrhage), IC neoplasm, CHI (closed head injury) w/in 3 months, active internal bleed, suspected aortic dissection **management of MI

absolute

What modifiable risk factor for CV disease is described below: o People who are sedentary are at increased risk (sedentary lifestyle is considered a risk factor) o Recommend 30 minutes of aerobic exercise five or more times a week § Will get your HR up (swimming, jogging, walking, biking) § Not just muscle building but more CV activity (3-5 times a week for 30-40 & get HR 25% above baseline)

activity

Acute or chronic pain? ○ Onset is sudden & duration is short-term (<3 months) ○ May be brief, acute pain or acute persistent pain ○ Accompanied by a high level of autonomic arousal (increase HR, RR, BP, anxiety, confusion) ■ Those with chronic pain as well may not have this "autonomic arousal" and may not look like they are in pain because this is their norm ■ Don't see this degree of autonomic arousal with chronic pain because these people have learned to live with their pain—doesn't mean they're not having pain ○ Associated with tissue pathology, injury, or surgery ○ Patients may have ______ and chronic pain→ it is important to know this because those with chronic pain may have a high tolerance to pain medication

acute

Aspirin can be used in the treatment of an MI (162-325 mg crush/chew). In the _____ setting we have a higher dose of 162-325 mg, ***crush/chew to work quick***; do not want extended release. § Usually use the higher dose (325 mg) in the ED

acute

The following are the 4 steps in nursing management of _____ pain: 1. Selecting the appropriate analgesic ○ May have several meds to choose from on the MAR 2. Evaluating when to administer the analgesic (give pain meds 30-45 mins before PT; ATC) ○ Thorough assessments ○ Address pain early rather than later so it doesn't get severe and become harder to get under control ○ Be proactive especially in surgical or trauma patients ■ If you know you are about to get them up to walk or bathe them or turn them, then go in and assess pain and offer them pain medicine ○ May be prescribed on a PRN basis but still important to assess and ask and anticipate when they will need pain medicine 3. Evaluating how much to administer ○ Pain history, hemodynamic status, and patients' size will help you determine this ○ If they are opioid naïve (never taken opioids or had very few experiences with opioids) then that patient may need a much lower dose as opposed to someone who has chronic pain and takes opioids on a daily basis who will probably need a much bigger dose ○ Also assess how they tolerate what you give them 4. Obtaining a change in prescription when needed ○ Don't underestimate your power as a nurse—call the physician and collaborate with them if things aren't working and recommend a change in prescription if needed

acute

The following are the 4 steps in nursing management of _____ pain: 1. selecting the **appropriate** analgesic 2. Evaluating **when** to administer the analgesic 3. Evaluating **how much** to adminster 4. Obtaining a change in prescription when needed

acute

The following are the 4 steps in nursing management of _____ pain: 3. Evaluating how much to administer ○ Pain history, hemodynamic status, and patients' size will help you determine this ○ If they are opioid naïve (never taken opioids or had very few experiences with opioids) then that patient may need a much lower dose as opposed to someone who has chronic pain and takes opioids on a daily basis who will probably need a much bigger dose ○ Also assess how they tolerate what you give them 4. Obtaining a change in prescription when needed ○ Don't underestimate your power as a nurse—call the physician and collaborate with them if things aren't working and recommend a change in prescription if needed

acute

________ care is when a patient who is seeking care in an _______ care setting which may be a hospital or a long-term ________ care center

acute

Developed as a result of the recognition that patients with acute, life-threatening illness/injury could be managed more effectively if they were placed on specifically designated units. **critical care nursing

critical care specialty units

****Indicative Changes need to be investigated especially if the patient presents with chest pain, SOB, diaphoresis, or any of those symptoms that would suggest ________****** o Indicative changes are significant when they are seen in ***two anatomically contiguous leads**** o Two leads are contiguous if: § They look at the same area of the heart § Or they are numerically consecutive chest leads

acute coronary syndrome (ACS)

The following are ECG Changes associated with ______ (stable angina--> acute MI) o Inverted T wave could mean ischemia or even non-STEMI if they have positive enzymes o When start getting ST elevation, that represents injury or infarction (myocardium evolving through infarction) o The wide ST segment elevation is sometimes called tombstones because you can write RIP in there because it is a pretty ominous sign

acute coronary syndrome (ACS)

The following are ECG changes associated with ________: · Columns are all set up the same o P wave - atrial conduction o PR interval - SA to AV to ventricles before it contracts o Q wave - Some people have them and some do not (first negative deflection after isoelectric line) § Pathological Q waves - Greater than 25% of R wave § If patient has Q wave that is not greater than 25%, it may be from previous MI. o R wave - First positive deflection o ST Segment - Starts at the "J Point" § J Point - Where the QRS comes back to baseline before ST segment § When looking at ST segment elevation, find J point. o T wave - Ventricular repolarization § Repolarization of the atria is during the QRS § May have ischemia · Most will have at least one rhythm strip at the bottom that gives you a good nine seconds of a rhythm o Because each of these strips are three second snippets · You can see an ST elevation with T wave inversion in V2 and V3, V4 and V5 and you also have the loss of R wave progression o Normally you should have a little r-wave in V1, a bigger r-wave in V2, a bigger r-wave in V3, and then they start to equal out o Still have ST elevation so this is an acute anural lateral MI with some septal involvement

acute coronary syndrome (ACS)

The following are ECG changes associated with ________: · You can see an ST elevation with T wave inversion in V2 and V3, V4 and V5 and you also have the loss of R wave progression o Normally you should have a little r-wave in V1, a bigger r-wave in V2, a bigger r-wave in V3, and then they start to equal out o Still have ST elevation so this is an acute anural lateral MI with some septal involvement

acute coronary syndrome (ACS)

The following are the 4 treatments for management of ______: · 1. PCI--#1 management intervention · 2. (Thrombolytic therapy)—in parentheses because its usually reserved for cases where PCI is not available or not amenable · 3. CABG · 4. Medical Management

acute coronary syndrome (ACS)

The major goal in patients with _____ is to reduce the amount of myocardial necrosis that occurs in patients who present with MI. o Acute MI or NSTEMI, reperfusion ASAP! (the sooner we re-perfuse that myocardium the less damage the patient will have—the less damage the patient has, the less likely they are to have some of those major adverse cardiac events that can occur) o Time is muscle

acute coronary syndrome (ACS)

The secondary goal in patients with _____ is to prevent Major Adverse Cardiac Events (MACE). o **Heart failure** risk if enough of the myocardium is damaged (especially the left ventricle—it won't squeeze well and the patient could end up having acute and/or chronic HF) (lose enough muscle mass, heart blocks & need pacemaker, pericarditis). o **Cardiogenic shock**—extreme heart failure, so serve that they cannot generate a decent perfusion pressure (so their MAP will be below 70) **collaborative management/goals

acute coronary syndrome (ACS)

The secondary goal in patients with _____ is to prevent Major Adverse Cardiac Events (MACE). o **Left ventricular aneurism**—the ventricle becomes weakened due to the damaged area and it bulges out and then it doesn't squeeze well and of course the patient is likely to have heart failure and also dysrhythmias o **Ventricular septal wall rupture**—the ventricular septum actually ruptures § A life-threatening event—for the patient to survive, they would have to have emergency surgery and repair **collaborative management/goals

acute coronary syndrome (ACS)

The secondary goal in patients with _____ is to prevent Major Adverse Cardiac Events (MACE). o **Papillary muscle rupture**—where the muscles that pull down the valves (atrioventricular valve, mitral valve, tricuspid valve) rupture and then the valve becomes incompetent and they develop severe valvular regurgitation § This is an emergency and if they are not taken to surgery and then valve is not repaired within a timely fashion then they probably won't survive **collaborative management/goals

acute coronary syndrome (ACS)

The secondary goal in patients with _____ is to prevent Major Adverse Cardiac Events (MACE). o If MI, at risk for **lethal dysrhythmias** (V-tach, v-fib after 1st few hours of infarction), and for sudden cardiac death from v-tach or v-fib. § Within the first few hours of infarction, they are at highest risk—so we need to intervene o This is why it is important that ambulance brings them to hospital (shock, CPR). **collaborative management/goals

acute coronary syndrome (ACS)

The secondary goal in patients with _____ is to prevent Major Adverse Cardiac Events (MACE). MACE includes heart failure, cardiogenic shock, papillary muscle rupture, left ventricular aneurism, lethal dysrhythmias, and ventricular septal wall rupture ***Treat acute, life threatening complications (HF, arrhythmias - V-tach, v-fib).**** **collaborative management/goals

acute coronary syndrome (ACS)

What CV disease is described below: Etiology and Pathophysiology: · Deterioration of a once stable plaque --> that plaque ruptures --> platelet aggregation to the site where that lipid core is exposed to the blood --> thrombus formation o Result § Partial occlusion of coronary artery—which will cause them to have an UA or NSTEMI OR § Total occlusion of coronary artery—which will cause them to have a STEMI · STEMI—patient will have ST elevation on the 12-lead EKG and they will have positive cardiac biomarkers

acute coronary syndrome (ACS)

afterload

What CV disease is described below: Other symptoms of ____: o Diabetics—its thought that this is because they probably have neuropathies secondary to their diabetes § They are at high risk for having silent MIs or just having atypical symptoms § Women & DM do not present with the classical presentation as other pt. do - women may complain of scapula pain · Can be described as an uncomfortable pressure, fullness, squeezing · Chest pain will NOT be reproducible by palpation ("If I touch it does it hurt?") · Women may present with- Fatigue, malaise, shortness or breath, anxiety · Diabetics think they are having neuropathy and may not have the chest pain o Women—often just complain of SOB or maybe some fatigue/malaise and its not really easy to pinpoint § Not easy to recognize

acute coronary syndrome (ACS)

What CV disease is described below: Other symptoms of ____: · SOB - DOE (dyspnea on exertion) · Severe weakness · Lightheadedness · Diaphoresis · N & V · Palpitations · Moderate to severe anxiety (especially if they have that feeling of impending doom) · Fatigue · Ask pt. to take a big deep breath to rule out whether or not it's actually pleuritic chest pain

acute coronary syndrome (ACS)

· A term used to describe a spectrum of clinical syndromes (in patients with coronary atherosclerosis) representing varying degrees of coronary artery occlusion. When you see _______, it is either a bunch of syndromes or they are trying to rule out · The spectrum of syndromes includes: o ST elevation MI (STEMI)—ST segment has tombstone appearance o Non-ST elevation MI (NSTEMI) o Unstable angina (UA)

acute coronary syndrome (ACS)

acute myocardial infarction (AMI)

In unstable angina, ST segment may return to normal (once the patient rests and myocardial oxygen demand decreases) or may progress to ______ ____ ____ (if we don't intervene and the occlusion gets worse). ___ ___ ____ is tissue ischemia resulting in the death of myocardial tissue (myocardial tissue does not regenerate - you can limit the amount of damage to the myocardium & limit progression of the infarct). This is caused by occlusion of coronary artery or one of its branches. The higher the lesion or the more proximal the lesion to the aorta or the closer the lesion is to the aorta the more tissue that is probably going to be involved and the larger the MI o If it's a very distal occlusion at the end of a coronary artery, then the area of injury may be very small

acute myocardial infarction (AMI)

The following are cardiac markers for _______: · Time Review o CK MB rise at 6 hours, peak 18 hours (somewhere between 15-20), back to normal by 24-36 hours § CK MB specific for myocardial o Troponin- myocardial muscle protein § Rise 4-6 hours, peaks 10-24, normal by 10-14 days § Cardiac specific § Elevated troponin could've been from another event (important for patients who return with chest pain) o Myoglobin § Rise 2 hours, peaks 3-15 hours, normal 24 hours § The earliest to rise but not specific to cardiac muscle · But if a patient comes in with chest pain and has other symptoms (diaphoresis, SOB, lots of risk factors) and has EKG changes then that myoglobin could be of some value—if they don't have EKG changes and their symptoms are unequivocable with not a lot of risk factors then that myoglobin may not be so important *ACS

acute myocardial infarction (AMI)

The following is all of the information about the diagnosis of an ______: · ECG changes o ST elevation (> 1 mm in limb leads (lead I, II, III, aVR, aVL, aVF) or 2mm in chest leads (v-leads v1-6)) in 2 or more contiguous leads (contiguous leads are either 2 leads looking at the same wall of the heart or 2 consecutive leads if it's the v-leads) § STEMI o ST depression (> 0.5- 1 mm)—suspicious especially in patient who presents with symptoms § If with positive cardiac enzymes=NSTEMI · If someone presents with chest pain, we typically do serial EKGs until we get a positive one or until we rule out that the patient is not having a cardiac event · Serial cardiac enzyme values (those enzymes that get released with tissue death) o Myoglobin (not specific to cardiac muscle—any muscle that is injured or dies releases myoglobin) o CK MB (very specific to cardiac muscle) o Troponin levels (very specific to cardiac muscle) · Signs and symptoms · High level of suspicion for anyone over 35 who presents with chest pain longer than 20 minutes and has a history/presence of multiple risk factors. o Don't have to wait on cardiac enzymes if have high level of suspicion and ST elevation **ACS

acute myocardial infarction (AMI)

The following is info about the diagnosis of an ______: · If someone presents with chest pain, we typically do serial EKGs until we get a positive one or until we rule out that the patient is not having a cardiac event · Serial cardiac enzyme values (those enzymes that get released with tissue death) o Myoglobin (not specific to cardiac muscle—any muscle that is injured or dies releases myoglobin) o CK MB (very specific to cardiac muscle) o Troponin levels (very specific to cardiac muscle) **ACS

acute myocardial infarction (AMI)

The following is info about the diagnosis of an ______: · Signs and symptoms · High level of suspicion for anyone over 35 who presents with chest pain longer than 20 minutes and has a history/presence of multiple risk factors. o Don't have to wait on cardiac enzymes if have high level of suspicion and ST elevation **ACS

acute myocardial infarction (AMI)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ DESCRIPTION ■ Two levels of pressure: high (P-high) and low (P-low) ■ Patient breathes spontaneously during P-high and P-low ■ Time in P-high (T-high) is longer than P-low (T-low) to maintain recruitment (85-95%) to keep alveoli open

airway pressure release ventilation (APRV)

The following is the pathophysiology of an _______: · Infarcted area cannot conduct electrical impulses · Infarcted area cannot contract · This bigger the MI, the more muscle that is involved and the more myocardial dysfunction that you will have · Subendocardial dysfunction means it's just the inner part of the myocardium that is infarcted—still have some viable tissue closer to the outer part (now called a NSTEMI) · Transmural infarction means the area of infarction transverses the entire thickness of the myocardium o This will definitely result in a STEMI · Intramural infarction—an area in the middle of the myocardium—would probably also result in a NSTEMI · Subepicardial infarction—will also probably result in a NSTEMI o Because you still have some viable tissue that is transmitting electrical activity, or electrical activity is going through that tissue then you will still have that electrical activity on the EKG—which is why you get a NSTEMI rather than a STEMI **ACS

acute myocardial infarction (AMI)

The following is the pathophysiology of an _______: · Subendocardial dysfunction means it's just the inner part of the myocardium that is infarcted—still have some viable tissue closer to the outer part (now called a NSTEMI) · Transmural infarction means the area of infarction transverses the entire thickness of the myocardium o This will definitely result in a STEMI · Intramural infarction—an area in the middle of the myocardium—would probably also result in a NSTEMI **ACS

acute myocardial infarction (AMI)

The following is the pathophysiology of an _______: · Subepicardial infarction—will also probably result in a NSTEMI o Because you still have some viable tissue that is transmitting electrical activity, or electrical activity is going through that tissue then you will still have that electrical activity on the EKG—which is why you get a NSTEMI rather than a STEMI **ACS

acute myocardial infarction (AMI)

an ___ ____ ___ results from prolonged ischemia which evolves over time. Myocardial tissue can be salvaged for up to 12 hours from onset of symptoms. The sooner we treat them, the sooner we reestablish blood flow through those vessels or re-perfuse the myocardium the more tissue we are going to save. First thing you ask when patient comes in with chest pain—"When did the symptoms first start?" **ACS

acute myocardial infarction (AMI)

an ___ ____ ___ results from prolonged ischemia which evolves over time. When someone has occlusion of a coronary artery, you have an area of infarct (this is tissue that has died that we will not be able to get back—this is lost tissue). We have areas of injury and we have areas of ischemia—those are the areas that we can potentially save by intervening in a timely manner (time is muscle) o Infarcted area cannot conduct electrical impulses or contract** **ACS

acute myocardial infarction (AMI)

● Tissue ischemia resulting in the death of myocardial tissue (myocardial tissue does not regenerate - you can limit the amount of damage to the myocardium & limit progression of the infarct) ○ Electrical conduction of the heart will not be the same bc of the necrotic tissues leaving the pt. at risk for dysrhythmias · Caused by occlusion of coronary artery or one of its branches · The higher the lesion or the more proximal the lesion to the aorta or the closer the lesion is to the aorta the more tissue that is probably going to be involved and the larger the MI o If it's a very distal occlusion at the end of a coronary artery, then the area of injury may be very small **ECG may show ST segment depression during acute attack. ST segment may return to normal (once the patient rests and myocardial oxygen demand decreases) or may progress to ______ (if we don't intervene and the occlusion gets worse) **ACS

acute myocardial infarction (AMI)

● Drug that has a primary indication other than pain (i.e., anticonvulsant, antidepressant, muscle relaxant) but an analgesic for some conditions. ○ Ex: Neurontin—an anticonvulsant used a lot for neuropathic pain ○ Muscle relaxants especially if pain is caused by muscle spasms ● Gabapentin-- anticonvulsant that is also used as a muscle relaxant and for neuropathic pain

adjuvant therapy

When talking about culturally competent care, _____ ______ are viewed as a way to prepare for death and dying in certain cultures. Some ____ _____ are seen as a way to deny care. ■ Some people view ___ ______ as a way to prepare for end of life whereas others view it as a way to deny care ■ Please be aware that an_______ _____ does NOT mean do not treat; it gives you an idea of what the patient's wishes are if they cannot make decisions for themselves ■ **Just because someone is a DNR, does not mean that they are a "do not treat"**

advance directives

Post cardiac surgery, the nurse needs to manage the patient's preload, afterload, and contractility. The following are methods for controlling which of these 3 heart functions? ·**** Increased SVR (systemic vascular resistance) and hypertension common after surgery (due to vasoconstrictive effect of hypothermia)****** o Can exacerbate bleeding and increase LV workload (makes it harder for the heart to work) o During surgery they usually cool the patient's down to lower their metabolic rate § Hypothermia causes severe vasoconstriction, and it can interfere with the clotting studies · So, this can be part of the problem with their high SVR and it could also be part of the problem if they are having a lot of bleeding o Puts stress on graft suture lines. · We want to get their ______ to normal limits o Can use vasodilators for this § Control hypertension (Nipride, NTG, anti-hypertensive)

afterload

What main factor affecting stroke volume (preload, afterload, contractility) is described below: ○ Another component is HR. So if the HR is too fast, you do not have enough ventricular filling time. If you do not have enough volume in the ventricles there will not be enough to pump out so you have a decreased CO. if your HR is too slow, then you are not pumping fast enough to make a decent CO. ○ Increased _______ usually results in decreased CO (can bring down the pt. _______ using vasodilator therapy) ○ What are those ventricles pumping against? What do those ventricles have to overcome? How much pressure do those ventricles have to overcome to open those valves and pump the blood out?

afterload

What main factor affecting stroke volume (preload, afterload, contractility) is described below: ○ The ________ on the R side of the heart are the pressures in the pulmonary vascular system or pulmonary vascular resistance. If you have really high PA pressures, it is going to be really hard for the R ventricle to pump blood out into the pulmonary vasculature ○ The ________ of the L side of the heart is your systemic pressures. Remember the L side of the heart has to open the aortic valve and pump blood through this valve into the aorta and into systemic circulation. If you have high BP, it is going to be hard for the L ventricle to pump blood out the aortic valve resulting in HF.

afterload

What main factor affecting stroke volume (preload, afterload, contractility) is described below: ● (vascular resistance) ○ ________ is the pressure that the ventricle must generate to empty its contents (refers to the forces opposing ventricular ejection - includes systemic arterial pressure + mass & density of blood) ○ Typically indicated by systemic vascular resistance (SVR) ○ Increased _______ usually results in decreased CO (can bring down the pt. _______ using vasodilator therapy) ○ What are those ventricles pumping against? What do those ventricles have to overcome? How much pressure do those ventricles have to overcome to open those valves and pump the blood out? ○ The ________ on the R side of the heart are the pressures in the pulmonary vascular system or pulmonary vascular resistance. If you have really high PA pressures, it is going to be really hard for the R ventricle to pump blood out into the pulmonary vasculature ○ The ________ of the L side of the heart is your systemic pressures. Remember the L side of the heart has to open the aortic valve and pump blood through this valve into the aorta and into systemic circulation. If you have high BP, it is going to be hard for the L ventricle to pump blood out the aortic valve resulting in HF. ○ Another component is HR. So if the HR is too fast, you do not have enough ventricular filling time. If you do not have enough volume in the ventricles there will not be enough to pump out so you have a decreased CO. if your HR is too slow, then you are not pumping fast enough to make a decent CO.

afterload

preload or afterload? the pressure that the heart is pumping against to profuse the body ○ If _______ is high, the heart will have to work harder **vascular resistance

afterload

_________ is characterized by increased motor activity by patient (physical display) ○ The patient cannot get still or comfortable; they are restless and irritable ○ ****Restlessness, increased motor activity, patient cannot sit still*****

agitation

What analgesic class of drugs for pain management is described below: ● Work on different pain receptors that opioids work on; will decrease the effect of the opioids but will still treat the pain by working on a different receptor ○ These work on the mu receptor and another pain receptor ●**** BE CAREFUL: May precipitate withdrawal in chronic opioid users if you suddenly take it away ○ Use extreme caution due to potential to precipitate withdrawal in chronic opioid users***** ● (1) Nubain (relieve itching, sedates pt.), (2) Buprenex, (3) Stadol (anesthesia adjunct) ○ Nubain is the drug that helps with itching if they are having itching with Morphine Causes less respiratory depression, but more dysphoria & agitation

agonist-antagonist agents

LOOK AT IMAGE NUMBER 11 ON PHONE: **if you wedge balloon and get something like this means you probably have too much ______ in the balloon and the balloon is wrapping over the tip of the catheter and this is considered an over-wedged balloon. You need to let some _____ out. When injecting ______ watch waveform and once you see change you do not need to inject anymore ______. The balloon is getting wrapped around the tip of the catheter.

air

What complication of PA catheters (Swan Ganz) is described below: ● (always close the line to the pt. by clamping at stopcock anytime line is disconnected) ○ If significant amount of air enters bloodstream

air emboli

airway and ventilator management

airway pressure release ventilation (APRV)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ■ Inverse ratio (inspiration will be longer than expiration) ■ Pressure controlled intermittent mandatory ventilation (IMV) ■ Unrestricted spontaneous breathing ● Patient can breathe over the vent throughout the cycle, does not matter ■ Used for patients with very stiff, noncompliant lungs or ARDS ○ Rescue therapy for ARDS ■ Alveolar recruitment ● When you hear alveolar recruitment, what they are talking about is they are trying to pop open those adolectic alveoli and keep them open. We are using pressure to keep those alveoli open. The more alveoli you have open, the more surface area you have for gases to exchange over the capillary membrane ■ Lung protective strategies ● You are using reverse I:E ratio giving more time for gas exchange to occur and use lower pressures ■ Mostly used for rescue therapy for ARDS. Patients with stiff lungs and having trouble oxygenating and on full support (100% FiO2), and high pressures and still not getting good oxygenation would consider ________. ○ DESCRIPTION ■ Two levels of pressure: high (P-high) and low (P-low) ■ Patient breathes spontaneously during P-high and P-low ■ Time in P-high (T-high) is longer than P-low (T-low) to maintain recruitment (85-95%) to keep alveoli open ■ Results in a degree of autoPEEP due to the short release time (T-low) ● If patients are not exhaling all the way, they begin to "stack the breaths" (autoPEEP) which can cause barotrauma ● Have to be careful because it can result in some autoPEEP due to the short time in low pressure. ○ It is called pressure release ventilation because you have high pressure for a little while, then a quick release of pressure (low pressure), then pressure comes back up (high pressure), quick release, then comes back up. ● autoPEEP is when you start stacking the breathes. If the patient does not or is not allowed to exhale fully before another breathe is coming in then that is called autoPEEP. The problem with PEEP, in general, is that it causes decreased venous return. ○ In general positive pressure ventilation decreases venous return because of increased thoracic pressure. normally when we breathe, we breathe using negative pressure ○ With positive pressure ventilation, we are driving air in with positive pressure and that increases thoracic pressure and therefore with this increased thoracic pressure you have decreased venous return to the R side of the heart. Patients who are volume depleted or poor L ventricular function often times do NOT tolerate PEEP. Patients who are well-hydrated, have a decent ventricle, will usually tolerate PEEP quite well ● So, with ________ one of the main concerns is that autoPEEP which can cause a decreased venous return. ■ With this mode of ventilation, the physician will order 2 levels of pressure: peak high and peak low. The peak high will be longer than the peak low giving you the inverse ratio. The patient can breathe spontaneously anytime during that cycle. it is like BiPAP where you have bilevel of pressure.

airway pressure release ventilation (APRV)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ■ Results in a degree of autoPEEP due to the short release time (T-low) ● If patients are not exhaling all the way, they begin to "stack the breaths" (autoPEEP) which can cause barotrauma ● Have to be careful because it can result in some autoPEEP due to the short time in low pressure. ○ It is called pressure release ventilation because you have high pressure for a little while, then a quick release of pressure (low pressure), then pressure comes back up (high pressure), quick release, then comes back up.

airway pressure release ventilation (APRV)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ Rescue therapy for ARDS ■ Alveolar recruitment ● When you hear alveolar recruitment, what they are talking about is they are trying to pop open those adolectic alveoli and keep them open. We are using pressure to keep those alveoli open. The more alveoli you have open, the more surface area you have for gases to exchange over the capillary membrane ■ Lung protective strategies ● You are using reverse I:E ratio giving more time for gas exchange to occur and use lower pressures ■ Mostly used for rescue therapy for ARDS. Patients with stiff lungs and having trouble oxygenating and on full support (100% FiO2), and high pressures and still not getting good oxygenation would consider ________.

airway pressure release ventilation (APRV)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ● autoPEEP is when you start stacking the breathes. If the patient does not or is not allowed to exhale fully before another breathe is coming in then that is called autoPEEP. The problem with PEEP, in general, is that it causes decreased venous return. ○ In general positive pressure ventilation decreases venous return because of increased thoracic pressure. normally when we breathe, we breathe using negative pressure ○ With positive pressure ventilation, we are driving air in with positive pressure and that increases thoracic pressure and therefore with this increased thoracic pressure you have decreased venous return to the R side of the heart. Patients who are volume depleted or poor L ventricular function often times do NOT tolerate PEEP. Patients who are well-hydrated, have a decent ventricle, will usually tolerate PEEP quite well ● So, with ________ one of the main concerns is that autoPEEP which can cause a decreased venous return.

airway pressure release ventilation (APRV)

What mode of ventilation is used for patients with very stiff, noncompliant lungs or ARDS? **also rescue therapy for ARDS

airway pressure release ventilation (APRV)

When talking about settings and mode for vents, settings are based on patient status including things such as ABGs, body weight, LOC, muscle strength, etc. settings includes rate, depth, alarms, inspiratory time, and FiO2. Which of these settings is described below: ○ (ensure they are always on) ■ Set _______ for the vent to alert you if there is a problem ■ Ex: rate ______ where the vent will ______ if the patient's RR gets too fast or too slow ■ Pressure ________: if there is too much pressure or not enough pressure in the circuit the vent will _______

alarms

Decreased PaCO2, increased pH indicates ________. Increased PaCO2, decreased pH indicates _______. **monitoring oxygenation and ventilation in artificial airways

alkalosis; acidosis

The following are some ______/_______ therapies available to patients in the ICU: ● music, pastoral care, massage, pet therapy, therapeutic touch, distraction, tv ○ Patient requests these; can be very helpful to these patients

alternative/complementary

What complication of positive pressure ventilation is described below: ○ too much or too low rate ■ Measure with ABGs ■ If you are in control of all the patient's ventilation and rate is too low, the patient will hypoventilate and develop a respiratory acidosis cause you are not blowing off enough CO2. ■ If a patient is given a rate that is too fast or the patient is too anxious and breathing a lot over the ventilator, that can cause hyperventilation which causes the patient to blow off too much CO2 causing respiratory alkalosis. *pulmonary system

alveolar hypoventilation/hyperventilation

The following are precipitating factors of ______ (things that increase workload and oxygen demand; if you have enough blockage in the arteries, you will not have the supply): · Circadian Rhythm Pattern o Early in the morning when we are first awakening, and our cortisol level is up—patients tend to have more heart attacks early in the morning because of that circadian rhythm pattern o Cortisol (stress hormone) levels rise in the morning; therefore, the present with MI in the early morning.

angina pectoris (chest pain)

The following are precipitating factors of ______ (things that increase workload and oxygen demand; if you have enough blockage in the arteries, you will not have the supply): · Patients who have disease in their coronary vessels can sometimes precipitate chest pain when they increase their activity level or some of the other things on this list · physical exertion, temperature extremes, strong emotions, consumption of heavy meals, tobacco use, sexual activity, stimulants (drugs), and circadian rhythm patterns · Anything that increases myocardial oxygen demand can precipitate chest pain in someone who already has underlying coronary disease

angina pectoris (chest pain)

The following are precipitating factors of ______ (things that increase workload and oxygen demand; if you have enough blockage in the arteries, you will not have the supply): · Physical Exertion o When you increase your physical activity, you increase your myocardial oxygen demand and if you have blockage in the vessels to where you have reduced flow, your supply may not be good enough for your demand (could result in someone having chest pain) o Can be running and collapse

angina pectoris (chest pain)

The following are precipitating factors of ______ (things that increase workload and oxygen demand; if you have enough blockage in the arteries, you will not have the supply): · Stimulants - Drug o Energy drinks, cocaine (anything that increase HR) § People who take cocaine or those drugs that increase the HR and BP and cause vasoconstriction of the vessels can have a heart attack without having underlying coronary disease o May not have any type of CAD, but because of the drug—they have an MI o Cocaine o Anything that is a vasoconstrictor

angina pectoris (chest pain)

The following are precipitating factors of ______ (things that increase workload and oxygen demand; if you have enough blockage in the arteries, you will not have the supply): · Strong Emotions · Consumption of heavy meals o Blood is diverted from the coronary artery system to the GI o After a MI—advise patient to eat small frequent meals (increases circulation to the heart) o Post MI or post procedure - clear liquid · Tobacco Use o Causes vasoconstriction and increased HR (increases myocardial oxygen demand) o Damages endothelial lining · Sexual Activity

angina pectoris (chest pain)

The following are precipitating factors of ______ (things that increase workload and oxygen demand; if you have enough blockage in the arteries, you will not have the supply): · Temperature extremes o Really high temperatures (especially fevers) make someone hyperdynamic and increases HR and BP and that increases the workload of the heart (disease in the vessels=reduced supply) o Cold causes vasoconstriction and if they already have narrow vessels and now they are vasoconstricted that would reduce flow even more § Usually very cold temperatures § Hunters early in the morning in the cold

angina pectoris (chest pain)

What sign/symptom of acute coronary syndrome (ACS) is described below: Locations include: upper chest, substernal radiating to neck and jaw, substernal radiating down L arm, epigastric, epigastric radiating to neck, jaw, and arms, neck and jaw, left shoulder and down both arms, and intrascapular

angina pectoris (chest pain)

What sign/symptom of acute coronary syndrome (ACS) is described below: Possible Location: · If someone presents with chest pain, you are going to look at their chest pain, other symptoms, their risk factors to try and triangulate if this is chest pain coming from the heart or some other etiology o Always rule out if its heart pain before we attribute it to any other kind of pain because of the high level of risk § Patients who are having ACS are at high risk for acute sudden death from lethal arrhythmias

angina pectoris (chest pain)

What sign/symptom of acute coronary syndrome (ACS) is described below: Possible Location: · Upper chest · A lot of times it will radiate to the jaw or down to the left arm o Anytime you have chest pain radiating to the chest or left arm or the neck you should be highly suspicious that it is angina § Some people describe it as indigestion and are in denial and do not think its their heart and they just attribute it to epigastric pain · Epigastric pain—radiating to the neck, jaw, and arms · Could just be neck and jaw pain, could be left shoulder pain, could be pain down both arms, or it could be in the back (intrascapular) · If someone presents with chest pain, you are going to look at their chest pain, other symptoms, their risk factors to try and triangulate if this is chest pain coming from the heart or some other etiology o Always rule out if its heart pain before we attribute it to any other kind of pain because of the high level of risk § Patients who are having ACS are at high risk for acute sudden death from lethal arrhythmias

angina pectoris (chest pain)

What sign/symptom of acute coronary syndrome (ACS) is described below: o Angina - term given to chest pain caused by coronary problems o Severe, immobilizing chest pain usually described as crushing, unrelieved by rest, nitroglycerin, or position changes. (elephant on my chest) o Can be described as an uncomfortable pressure, fullness, squeezing .... § Say it feels like a vice grip or an elephant sitting on their chest o A lot of times they have a feeling of impending doom o The most common symptoms of ACS that patients will have · There are also patients who present with atypical symptoms

angina pectoris (chest pain)

What sign/symptom of acute coronary syndrome (ACS) is described below: o Can be described as an uncomfortable pressure, fullness, squeezing .... § Say it feels like a vice grip or an elephant sitting on their chest o A lot of times they have a feeling of impending doom o The most common symptoms of ACS that patients will have · There are also patients who present with atypical symptoms

angina pectoris (chest pain)

angiogram

The following are ______ of analgesics for pain management: ○ Reduced stress response symptoms, improves pt. comfort (HR hopefully goes down) ○ Increased participation in care (ambulation, toileting, etc.) ○ Reduce pain ○ Reduce anxiety if the pain is causing anxiety ○ Reduce stress response, improves pt. comfort

benefits

Angiogram or PCI? o Left "heart cath" - used to visualize blockages and/or do a left ventriculogram. Arterial approach (insert the catheters into the arteries—mostly used the femoral artery or the radial artery depending on the sizes of the catheters they need to place (radial is smaller)—historically femoral is all they used but because of the prolonged bed rest that occurs after the femoral approach, more physicians are doing radial approaches whenever they can) § Ventriculogram—a study that evaluates the EF § Left cath - accessed through femoral or radial artery & fed through vessels until it reaches the aorta; die is then injected § Left ventriculogram - provides information about the EF o Right "heart cath" - insert pulmonary artery catheter to measure pressures on the right side of the heart and the PAP and PAWP. Venous approach. § When they do this, they are putting in a PA catheter and getting the measurements (CVP, right atrial pressure, PAP, PAWG or left ventricular end diastolic pressure) and then they take the catheter out § Insert the catheter in a vein either through the femoral artery or the subclavian (they don't typically do this through a radial approach) § Right cath - venous access through inferior vena cava into the RA to insert PA catheter to obtain pressures

angiogram

Angiogram or PCI? o Right "heart cath" - insert pulmonary artery catheter to measure pressures on the right side of the heart and the PAP and PAWP. Venous approach. § When they do this, they are putting in a PA catheter and getting the measurements (CVP, right atrial pressure, PAP, PAWG or left ventricular end diastolic pressure) and then they take the catheter out § Insert the catheter in a vein either through the femoral artery or the subclavian (they don't typically do this through a radial approach) § Right cath - venous access through inferior vena cava into the RA to insert PA catheter to obtain pressures

angiogram

Angiogram or PCI? o They inject dye into some vessels to do x-ray photos and that dye shows up as contrast in the x-rays to evaluate vessels o Can do ______s of any kind of vessels but if it is _______ of the heart that is called a coronary ________, heart catheterization, or heart cath for short **diagnostic

angiogram

Angiogram or PCI? o To obtain an EF%, both right & left heart cath will need to be performed o Radial stick (easier pt. recovery) o Brachial approach is also an option o Most common approach is through the femoral artery · Contrast Dye (will feel warm sensation; pt. allergy to shellfish requires notification of MD) o Contrast dye is nephrotoxic so if pt. has renal insufficiency ensure pt. is well hydrated & limit the use of dye as much as possible (typically give 1-2L of NS after procedure) o Use Mucomyst to prevent reactions Assessment (same as PCI) - pedal pulses, V/S, BP, HR, monitoring of puncture site

angiogram

An ______ is DIAGNOSTIC and ______ is therapeutic. They are both similar in that they both have a percutaneous approach.

angiogram; PCI

A difficult dilemma is that pain and _______ are interrelated meaning on exacerbates the other (physiological response are very similar). _______ contributes to pain by activating pain pathways. o ______ alters perception of pain (usually increased) (usually increases the persons' perceptive of pain—they think it's much worse than it is) ○ Increases aversion to pain & decreases tolerance of pain ○ May increase the reporting pain ○ Always treat the pain first & hopefully the anxiety will subside ○ So, the usual recommendation is that you treat the pain first and if it relieves the pain then the ______ then you have solved both your problems with just one intervention ■ But if the _______ doesn't go away then you would treat the ______

anxiety

A difficult dilemma is that pain and _______ are interrelated meaning on exacerbates the other (physiological response are very similar). The other and the physiological responses to each are similar so sometimes it's kind of hard to figure out whether the patients is just anxious or having pain or if pain is causing ______. _______ contributes to pain by activating pain pathways. o ______ alters perception of pain (usually increased) (usually increases the persons' perceptive of pain—they think it's much worse than it is) ○ Increases aversion to pain & decreases tolerance of pain ○ May increase the reporting pain ○ Always treat the pain first & hopefully the anxiety will subside ○ So, the usual recommendation is that you treat the pain first and if it relieves the pain then the ______ then you have solved both your problems with just one intervention ■ But if the _______ doesn't go away then you would treat the ______

anxiety

For ______ management in a critically ill patient, it is most desirable to have PRN orders--> treat as needed, not around the clock like we do for pain. ○ With _______ and sedation management, The Society of Critical Care Medicine recommends for this type of management, PRN orders. Remember the Society of Critical Care Management for pain management really recommended around the clock pain management although that is something we do not always do.

anxiety

Sometimes we use sedation for _______ management. Rule out other causes for the anxious behaviors - some other causes include: ○ Hypoxia (SOB so it's difficult to breathe), hypoglycemia, sensory overload (lots of stimuli and noise—HCP in and out of rooms, ventilator noise), drug interaction, sleep deprivation (uncomfortable beds, many interruptions), pain (always treat pain first), fear (mortality is uncertain) ○ Want to try to treat these causes first ○ Before going straight to drugs ● Once other causes have been ruled out move to medications with a plan

anxiety

The following is assessments nurses perform after _____ ____ insertion: ■ Assess pt. circulation q4h - referred to as CMS checks (Circulation, Mvmt, Sensation) ● Minimum of 4 hours ■ Will also be checking for signs of infection ■ Nurse will be checking color, temperature, sensation, movement, presence of pain, assess distal pulse, bleeding at site, capillary refill (this is all done to prevent neuromuscular impairment), bleeding at site ● Neurovascular checks minimum of every 4 hours ■ Will typically see pt. with _____ _____ in place that has an arm board so that the pt. can't bend their wrist which will cause erroneously high pressures ■ ***If pt. says "I can't feel my hand", you need to call the MD bc the ______ ______ is not perfusing the pt. hand

arterial line (ART line)

The following is all of the information for _____ management (SCCM) in patients: ● Sometimes we use sedation for ______ management ● Rule out other causes for the anxious behaviors - some other causes include: ○ Hypoxia (SOB so it's difficult to breathe), hypoglycemia, sensory overload (lots of stimuli and noise—HCP in and out of rooms, ventilator noise), drug interaction, sleep deprivation (uncomfortable beds, many interruptions), pain (always treat pain first), fear (mortality is uncertain) ○ Want to try to treat these causes first ○ Before going straight to drugs ● Once other causes have been ruled out move to medications with a plan ● Most desirable to have PRN orders ○ Most desirable to have PRN orders for ______ management—treat as needed, not around the clock like we do for pain ○ With _______ and sedation management, The Society of Critical Care Medicine recommends for this type of management, PRN orders. Remember the Society of Critical Care Management for pain management really recommended around the clock pain management although that is something we do not always do.

anxiety

What common problem of critical care patients (nutrition, anxiety, pain and sedation, impaired communication, sensory-perceptual problems, sleep problems) is described below: ○ _______ management ■ have patients and families express concerns so that you are aware of them and how they are doing ■ good communication—explain and educate, include patient and family in all conversations ● you want to explain and educate on an ongoing basis ● you want to include the patient and family in all conversations. If they have a better understanding of what is going on and comfortable with oyu, that can help manage the ______ better ■ structure environment—have family bring pictures and personal items ● pillow they like, rosary or prayer blanket ■ anti-_______ drugs and relaxation techniques ● Ativan, Xanax ● Music therapy, massage ■ As a critical care nurse, you definitely will be dealing with patients and their families who have _______

anxiety

What common problem of critical care patients (nutrition, anxiety, pain and sedation, impaired communication, sensory-perceptual problems, sleep problems) is described below: ○ _______ management ■ structure environment—have family bring pictures and personal items ● pillow they like, rosary or prayer blanket ■ anti-_______ drugs and relaxation techniques ● Ativan, Xanax ● Music therapy, massage ■ As a critical care nurse, you definitely will be dealing with patients and their families who have _______

anxiety

What common problem of critical care patients (nutrition, anxiety, pain and sedation, impaired communication, sensory-perceptual problems, sleep problems) is described below: ● treat pain before anxiety) ○ What things can increase ______ in ICU pt.? Pain, impaired communication, sleeplessness, immobilization & loss of control ○ r/t uncomfortable , increase Noise, etc.. , impaired communication, sleeplessness, immobilization, loss of control ○ often caused by perceived or expected threat to: ■ health or life ● they are in the ICU probably because they are hemodynamically unstable and are at high risk of death ■ loss of control of body functions ● (either from disease process or treatments being given) ■ foreign environment ● (not in home in comfy bed, may or may not have family) ○ other contributing factors: ■ complex equipment, high noise and light levels, and intense pace of activity ● a lot happening in the ICU and is an intense environment and have a lot going on

anxiety

________ is characterized by apprehension and autonomic arousal; an internal feeling (hyper-aroused state - CNS) ○ Most ICU patients have problems with _______!!!

anxiety

Another assessment nurses will do with ____ ____ in patients is to check the equipment for proper set up. ■ IV fluid (0.9% NS) with pressure bag & tubing to catheter; connection to transducer & to monitor; check that alarms are on at all times; ensure dressing is occlusive; avoid heparin r/t HIT ● Years ago we used to put heparin in the bag of saline to keep the line open but now we know that a lot of people have Heparin Induced Thrombocytopenia (HIT) and for this reason we have taken Heparin out of maintenance bags ■ Check to make sure you have fluid in your bag, pressure bag in place pumped to 300 mm of Mercury, the bag is connected to tubing, no bubbles in tubing, catheter is not kinked, alarms are on and appropriate to that particular patient

arterial line (ART line)

The following are complications of ______ _____s: ○ Infection ○ Impaired circulation ■ Catheter takes space up in artery ○ Hemorrhage (#1 is bleeding) ■ BIG ONE. ■ If the catheter comes out the person can bleed very fast since it is an arterial bleed ■ You need to monitor closely and look at lines often and if you see a flattened waveform on the monitor, go check it as quick as you can. If alarms go off go check to make sure catheter has not come out ○ Thrombus formation ○ Neurovascular impairment ■ The radial nerve runs right along the radial artery and catheter can irritate it ■ If patient begins to complain of hand numbness, hand pain, etc you need to notify HCP because line may need to be taken out

arterial line (ART line)

What invasive line is described below: · you have a catheter in the artery, most of the time in the radial artery but can go into brachial or femoral arteries · One problem you can have with an _____ ______ is if the patient bends his hand forward (if catheter is in radial artery), it can kink it and if you kink the little catheter then you will get bad readings. Sometimes they will put the patient's arm on an arm board and roll up a rag to keep the hand back so it does not bend forward. We call this "positional"; when the kink is real easy we say the _____ _____ is "positional" and you want to keep their arm in a neutral position

arterial line (ART line)

What invasive line is described below: ● Indications for continuous arterial BP monitoring ○ Acute Hypertension/Hypotension (pt. that require a titrated drip to control BP) ■ Especially if titrating drugs ○ Shock ○ Coronary interventional procedures (CABG, MVR, AVR) in CATH lab ○ Head injury ○ Multiple trauma ○ Vasoactive drugs ○ Respiratory failure who are getting a lot of ABGs ○ Frequent ABG sampling

arterial line (ART line)

What invasive line is described below: ● Most commonly anesthesiologist and nurse anesthetist insert "these lines" ○ Some pulmonologists will put them on; some facilities have a policy that says respiratory therapy can put them in ○ Nurses do not typically put in but it is not against the Nurse Practice Act if you have a competency and policy that allows nurses to do this.

arterial line (ART line)

What invasive line is described below: ● To obtain arterial blood gas and serum lab samples ○ Do not have to stick patient every time for CBGs (example) ○ Anytime you draw blood from any line (central, arterial), some of the blood will be mixed with saline in the system an then specimen will be diluted. You do not want to send a dilute specimen for a lab or CBG because result will be inaccurate. Normally, you have to discard the first 5-10 CCs that you draw back. Then, you get another sample. ○ If you have a reservoir you do not have to discard (conserving blood and decreasing risk for infection)

arterial line (ART line)

What invasive line is described below: ● Use of ____ _____ involves placement of a catheter into the radial, brachial, or femoral artery (most commonly placed in the radial artery) ● For continuous arterial blood pressure monitoring ○ Very helpful if titrating drips to keep a BP up/down or any kind of vasoactive information ○ If you are doing BP every 15 minutes or more often, that can become traumatic for the arm

arterial line (ART line)

What invasive line is described below: ● Use of _____ ______s involves placement of a catheter into the radial, brachial, or femoral artery (most commonly placed in the radial artery) ● For continuous arterial blood pressure monitoring ○ Very helpful if titrating drips to keep a BP up/down or any kind of vasoactive information ○ If you are doing BP every 15 minutes or more often, that can become traumatic for the arm ● To obtain arterial blood gas and serum lab samples ○ Do not have to stick patient every time for CBGs (example) ○ Anytime you draw blood from any line (central, arterial), some of the blood will be mixed with saline in the system an then specimen will be diluted. You do not want to send a dilute specimen for a lab or CBG because result will be inaccurate. Normally, you have to discard the first 5-10 CCs that you draw back. Then, you get another sample. ○ If you have a reservoir you do not have to discard (conserving blood and decreasing risk for infection) ● Most commonly anesthesiologist and nurse anesthetist insert arterial lines ○ Some pulmonologists will put them on; some facilities have a policy that says respiratory therapy can put them in ○ Nurses do not typically put in but it is not against the Nurse Practice Act if you have a competency and policy that allows nurses to do this. ● _____ _____ can be used for many purposes, including: ○ Continuous arterial BP monitoring ○ Obtain ABG samples ○ Serum lab samples ● Consists of a 3-way stopcock for flushing the line or for getting ABG samples ● Pressure bag normally applies 300mmHg & is set to 10-12 drips/min ● Indications for continuous arterial BP monitoring ○ Acute Hypertension/Hypotension (pt. that require a titrated drip to control BP) ■ Especially if titrating drugs ○ Shock ○ Coronary interventional procedures (CABG, MVR, AVR) in CATH lab ○ Head injury ○ Multiple trauma ○ Vasoactive drugs ○ Respiratory failure who are getting a lot of ABGs ○ Frequent ABG sampling

arterial line (ART line)

What invasive line is described below: ● _____ _____ can be used for many purposes, including: ○ Continuous arterial BP monitoring ○ Obtain ABG samples ○ Serum lab samples ● Consists of a 3-way stopcock for flushing the line or for getting ABG samples ● Pressure bag normally applies 300mmHg & is set to 10-12 drips/min

arterial line (ART line)

The following falls under nursing management of ______ airways: ● Maintaining Correct Tube Placement ● Maintaining Proper Cuff Inflation ● Monitoring Oxygenation & Ventilation ● Maintaining Tube Patency ● Providing Oral Care & Maintaining Skin Integrity ● Fostering Comfort & Communication

artificial

What essential of AACN/CCRN (assessment, diagnosis, outcome identification, planning, implementation, interventions, education and emotional support, and evaluation) is described below: ○ higher skill _____ level, advanced technology, _____ of EKG, rate/rhythm, heart murmurs, etc.

assessment

What mode of ventilation is used if the patient has neuromuscular weakness, pulmonary edema or acute respiratory failure (pt. who are breathing but not taking in enough volume)? ○ Disadvantage: if it is too difficult for pt. to initiate breath, the WOB is increased & the pt. may tired & develop ventilatory asynchrony ("fighting the vent")

assist control ventilation (AC)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) Function: Delivers breath in response to patient effort and if patient fails to do so within preset amount of time Clinical Use: Usually used for spontaneously breathing patients with weakened respiratory muscles

assist-control ventilation (AC)

The following is information about _______ unipolar limb leads: o Called ________ because the machine augments it by 50% to increase the size on the EKG paper § If it didn't augment it, you'd have little tiny complexes § That is because with unipolar limb leads, the center of the heart is considered the negative pole so it uses information from all 3 leads to make the center of the heart the negative pole. Because it is a short distance from the center of the heart to the lead, it would be small on the EKG and that is why the machine augments it by 50%

augmented

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ■ A little more comfortable for the patient because the patient can take some breathes on their own but the problem is it can cause a respiratory alkalosis if the patient is taking a lot of breathes on their own and is delivering that full tidal volume with every breathe. If the patient is very anxious and they are breathing fast, every time they initiate a breathe it will deliver that full tidal volume. The major problem with that: if the patient is awake and breathing on their own, is that they can develop respiratory alkalosis (breathing fast with high tidal volumes and blowing off all of their CO2). A lot of times patients on ______ need to be sedated as well because it is a little uncomfortable. It is commonly used with pressure ventilation.

assist-control ventilation (AC)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ Delivers preset volume or pressure when spontaneous breath initiated by pt. (pt. & vent share WOB) ■ Will set a rate and tidal volume and the ventilator will deliver that tidal volume at the same set rate (if rate is 10 times per minute , will deliver tidal volume every 6 seconds; very similar to CMV) ■ What is different with _______: if the patient initiates a breathe in between those set breathes it will trigger the ventilator to deliver another breathe at that set tidal volume ● Delivers preset pressure or volume when initiated by the patient ● The vent senses when the patient tries to take a breath in because they sense that negative pressure. When it senses that pressure it is going to deliver that full tidal volume that has been set. ■ A little more comfortable for the patient because the patient can take some breathes on their own but the problem is it can cause a respiratory alkalosis if the patient is taking a lot of breathes on their own and is delivering that full tidal volume with every breathe. If the patient is very anxious and they are breathing fast, every time they initiate a breathe it will deliver that full tidal volume. The major problem with that: if the patient is awake and breathing on their own, is that they can develop respiratory alkalosis (breathing fast with high tidal volumes and blowing off all of their CO2). A lot of times patients on ______ need to be sedated as well because it is a little uncomfortable. It is commonly used with pressure ventilation. ○ Preset rate ensures adequate ventilation ○ Pt. can breathe faster than the preset rate but cannot breather slower than the rate ○ Breath can be triggered by the pt. or can be time-triggered ○ Used if pt. has: neuromuscular weakness, pulmonary edema or acute respiratory failure (pt. who are breathing but not taking in enough volume) ○ May cause respiratory alkalosis in pt. with high RR or respiratory acidosis in pt. with low RR ○ Disadvantage: if it is too difficult for pt. to initiate breath, the WOB is increased & the pt. may tired & develop ventilatory asynchrony ("fighting the vent") ○ Patient can initiate breath and will get 700cc but the machine will deliver 10 breaths/min no matter what

assist-control ventilation (AC)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ May cause respiratory alkalosis in pt. with high RR or respiratory acidosis in pt. with low RR ○ Disadvantage: if it is too difficult for pt. to initiate breath, the WOB is increased & the pt. may tired & develop ventilatory asynchrony ("fighting the vent") ○ Patient can initiate breath and will get 700cc but the machine will deliver 10 breaths/min no matter what

assist-control ventilation (AC)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ Preset rate ensures adequate ventilation ○ Pt. can breathe faster than the preset rate but cannot breather slower than the rate ○ Breath can be triggered by the pt. or can be time-triggered ○ Used if pt. has: neuromuscular weakness, pulmonary edema or acute respiratory failure (pt. who are breathing but not taking in enough volume)

assist-control ventilation (AC)

Patients are admitted to the ICU for 1 of 3 reasons: physiologically unstable, high-risk for serious complications, or intensive support requiring IV medications and/or advanced technology. Which of these 3 reasons is described below: ● complications (from sx, trauma, closed head injury - we need to monitor them) ○ Someone who had a craniotomy for tumor removal, patients with coronary bypass graphing or open heart surgery

at risk for serious complications

There are 3 types of PCIs: balloon angioplasty, stent placement, and atherectomy. Which of these 3 is described below: · Another type of intervention that can be performed in the Cath lab · ***Removal of plaque by excision**** o Uses a catheter that has cutting blades on it o Uses a rotational blade to shave plaque off · Also have suction on them to try and suck out all of the debris that they get form the blades from cutting the plaque · There is some risk that they can dislodge some plaque and it flows downstream and causes an infarction ·*** Less incidence of abrupt closure when compared to PCI***** · ******Limited to select location(s) of lesion in the artery******** o Not all lesions are amenable to ________ (vessel too small, at a bifurcation or some spot where they can't get to)

atherectomy

An acute myocardial infarction (AMI) is tissue ischemia resulting in the death of myocardial tissue. This is mostly secondary to _____ (95%) OR coronary artery disease (CAD). Other causes of AMIs includes: § Coronary artery spasm (Prinzmetal disease—can cause infarction if the spasm happens for long enough) § Coronary embolism (clot form some other area that becomes dislodged, travels to the heart, and becomes lodged in the coronary artery) § Blunt trauma (can cause tissue injury and death) § Cocaine use **ACS

atherosclerosis

What is the major cause of CAD? ○ Most of the deaths related to CAD are due to MI, HF, pericarditis ○ The development of plaque and fatty acid over time

atherosclerosis

With airway pressure release ventilation (APRV), this mode results in a degree of ______ due to the short release time (T-low). IF patients are not exhaling all the way, they begin to "stack the breaths" (_______) which can cause barotrauma. We have to be careful because it can result in some ______ due to the short time in low pressure. It is called pressure release ventilation because you have high pressure for a little while, then a quick release of pressure (low pressure), then pressure comes back up (high pressure), quick release, then comes back up. ________ is when you start stacking the breathes. If the patient does not or is not allowed to exhale fully before another breathe is coming in then that is called ________. The problem with PEEP, in general, is that it causes decreased venous return. ○ In general positive pressure ventilation decreases venous return because of increased thoracic pressure. normally when we breathe, we breathe using negative pressure ○ With positive pressure ventilation, we are driving air in with positive pressure and that increases thoracic pressure and therefore with this increased thoracic pressure you have decreased venous return to the R side of the heart. Patients who are volume depleted or poor L ventricular function often times do NOT tolerate PEEP. Patients who are well-hydrated, have a decent ventricle, will usually tolerate PEEP quite well ●******* So, with APRV one of the main concerns is that _________ which can cause a decreased venous return.***********

autoPEEP

What two body systems are factors affecting heart rate?

autonomic nervous system: parasympathetic (PNS) and sympathetic (SNS)

What does ABCDE stand for in the ABCDE bundle? (specific to ICU; typically for patient on ventilator)

awaken, breathe, choose medication/coordinate care, delirium, early ambulation

One way you can tell someone has delirium is a reduced ______ of the environment. This may result in: o An inability to stay focused on a topic or to change topics o Wandering attention o Getting stuck on an idea rather than responding to questions or conversation o Being easily distracted by unimportant things o Being withdrawn, with little or no activity or little response to the environment § Their arousal level can vary depending on the patient

awareness

The following are complications of an ________: · Dissection of dilated artery—catheter could tear the coronary artery o Can lead to cardiac tamponade, ischemia, and infarct · Plaque embolus—because they dislodged some of that plaque o Can lead to MI · Coronary spasm—secondary to catheter irritation o Coronary artery spasms down, tightens up, and you do not have good flow through it o A patient could have a heart attack secondary to coronary spasm o (prevented through injection of intra-coronary Nitroglycerin to dilate the artery) · Spontaneous restenosis o Small percentage of patients have this within hours after the procedure—for some reason that vessel closes off again § An emergency—usually have to go back to the Cath lab and repeat the procedure o There is also chronic restenosis · Emergent CABG required for 3-4% of PCI patients o PCI facilities should have surgery capabilities (but its not required) § Incidence has decreased a lot so now its not as strict of a requirement to have surgeries capabilities on standby

balloon angioplasty

The following are complications of an ________: · Spontaneous restenosis o Small percentage of patients have this within hours after the procedure—for some reason that vessel closes off again § An emergency—usually have to go back to the Cath lab and repeat the procedure o There is also chronic restenosis · Emergent CABG required for 3-4% of PCI patients o PCI facilities should have surgery capabilities (but its not required) § Incidence has decreased a lot so now its not as strict of a requirement to have surgeries capabilities on standby

balloon angioplasty

There are 3 types of PCIs: balloon angioplasty, stent placement, and atherectomy. Which of these 3 is described below: · Right femoral approach most common · Sometimes patients do have chest pain while the balloon is inflated because they have occluded flow o Usually relieves once they collapse the balloon · Could also use the right radial and the brachial if necessary o Then the patient doesn't have to be on bed rest as long § If they have a femoral stick then they have several hours of bed rest where they have to lay flat because we don't want them bleeding from an arterial site

balloon angioplasty

What port of a pulmonary artery catheter is described below: ○ Allows for the inflation of the balloon ○ One of the ports that comes off of the catheter; this is what makes it float

balloon inflation port

What are the 2 types of coronary stents?

bare metal (metal stents) and drug-eluding stents (coated with some drugs to try and help prevent that hyperplasia that occurs)

What complication of positive pressure ventilation is described below: ○ (excessive pressure) ■ Worry about overexpanding alveoli causing blebs and risk of popping *pulmonary system

barotrauma

The following are ______ of analgesics for pain management: ○ Increased participation in care (to a point—if we overdose them then it may make them sedated and unable or unwilling to participate in care—so need to find that sweet spot) ■ You want them comfortable enough to where they are willing enough to get out of bed, cough deep breathe, turn; do all the things we need them to do to progress but not so sedated to where they want to sleep all the time ■ Finding the right medication, right dose, right timing to get them comfortable enough to where they will participate in care. That is the goal and best option.

benefits

In medical management of CAD, patients who are not candidates for PCI or CABG will be managed with medications to minimize their symptoms. Medications includes Aspirin, anti platelets, beta blockers, short and long acting nitrates (nitroglycerin), lipid lowering agents, ACE or ARBs, and Ranolazine. Which of these medications is described below: · decrease HR and decrease myocardial oxygen demand so it could be helpful for patients who have recurring chest pain anytime they do any activity o Unless there is something that contraindicates it like hypotension, bradycardia, or heart block

beta blockers

With ET intubation, you want to use the _______ size tube that the patient's trachea can accommodate. If the tube is really small it will be hard to ventilate them because it is like blowing air or breathing through a straw. o The bigger the tube, the easier to ventilate. o Usually the rule of thumb is about the size of the patient's pinky. o Adult sizes are usually around 7-10; females take 7-7 ½ and males take 7 ½ - 8 and if tall maybe even 9 or 10. o Whoever is intubating will tell you what size they want but need to use biggest tube patient can accommodate.

biggest

What non-invasive cardiac output technology is described below: ○ Bio Z® ○ Not accurate in patients with fluid overload ■ Who do we need to monitor cardiac output in? those patients with HF and fluid overload so the value of the Bio Z was not good or useful

bioimpedance technology

The following is all the information about ______ limb leads: o Called ______ because it uses 2 stickies/patches to make the lead o With lead 1, the negative electrode is on the right arm and the positive electrode is on the left arm. Also uses the right leg electrode as a ground § The vector of that lead is from the right shoulder to the left shoulder § The positive electrode is on the left arm so it is looking at the lateral wall of the heart o With lead II, the negative electrode is on the right shoulder and positive electrode is on the left leg with the left arm lead being the ground § The vector of this lead is from the right shoulder to the right leg § The positive electrode is on the left leg so it is looking up inferiorly at the heart so it is looking at the inferior wall of the heart o With lead III, the negative electrode is on the left arm and the positive electrode is on the left leg and the ground is the right arm § Positive electrode on the left leg and looking up inferiorly at the heart so it is looking at the inferior wall of the heart

bipolar

Post cardiac surgery, the nurse needs to control _______ complications. Ways to do this includes: · ***More than 150 cc/hour for a couple of hours requires intervention***** o Check coagulation studies—may need some Clotting factors/coagulation factors (FFP, platelets) o If their PTT is prolonged (because they have to heparinize the blood when they run it through the bypass pump—so sometimes there is some residual anticoagulation from that heparin that they put in the pump—may need to give some **Protamine sulfate** § They need protamine if their PTT (partial thromboplastin time) is prolonged—it is the reversal agent for heparin o **Blood replacement based on amount of volume they lost and hematocrit*** § But don't use just the hematocrit because that lags behind

bleeding

Post cardiac surgery, the nurse needs to control _______ complications. Ways to do this includes: · **Assess for cardiac tamponade*** o Low BP, JVD (blood from the head can't drain into the ventricle because the ventricles are collapsed), muffled heart tones because there is so much stuff in the chest (Beck's triad), sudden cessation of chest tube drainage (blood clotted in the tube so it's not draining), PEA (pulseless electrical activity—they have electrical tracing on the EKG but they have no effective cardiac output) o Happens when there is a lot of fluid and blood in the chest putting pressure on the heart § Too much pressure on the heart collapses the ventricles, then the ventricles cannot fill with blood, if there is no blood in the ventricle then there is not going to be any cardiac output

bleeding

Post cardiac surgery, the nurse needs to control _______ complications. Ways to do this includes: · **Assess for cardiac tamponade*** o Requires emergency sternotomy (or I should say an emergency re-sternotomy—they need to reopen the chest) § Hopefully, you can get them back to surgery quick enough but sometimes they have to open the chest in the room § Once they open the chest and relieve that pressure usually the tamponade resolves but you need to control whatever was bleeding that caused the tamponade · If it is a clip or suture line that came off, then that needs to be repaired by the surgeon

bleeding

Post cardiac surgery, the nurse needs to control _______ complications. Ways to do this includes: · Monitor ______ closely and control ______ complications o They always have some ______, and we don't want that _______ to stay in the chest (that's why we put the tubes in to drain it to those drainage systems—monitor those closely, at least every hour)

bleeding

The 2 main complications of fibrinolytics is reperfusion arrhythmias and bleeding. Which of these 2 complications is described below: o biggest issue! § Dissolve clots anywhere in body § Weak vessel in head or aneurysm - big stroke/die because can't clot · High risk for having intracranial hemorrhage—not a whole lot we can do for this § Also worry about them ______ in areas where it's a non-compressible vessel (GI or something where you can't hold pressure to stop the _______) § Effects last about 4 hours so need to be monitored. **management of MI

bleeding

the following is all of the info about ____ ___: ● ____ ______ = Cardiac Output (CO) x Systemic Vascular Resistance (SVR) ● SVR is the amount of opposition to blood flow by the arterioles ● If you have change in either CO or SVR you will have a change in ____ _____ ● Higher ____ _____ = higher peripheral vascular resistance ● Sustained HTN = heart muscle hypertrophies*

blood pressure

The following is additional information for ICU _______: ● Multidisciplinary Rounds (goal is to identify anything that would prevent the pt. from progressing as normal) ● Goal Sheet (what you want the pt. to do on post-op days) ● Glucose Control (CBG is >110 morning of bypass, pt. will be put on insulin drip - whether pt. diabetic or not) ● Sedation/Analgesia

bundles

The following are types of ______ surgery: · Traditional sternotomy approach with cardiopulmonary ________ o Been around since the 60s—the old standard · Because of the complications that can occur with the bypass pump, there have been efforts to develop ways of doing these procedures off pump or not as invasively o MIDCAB - Minimally invasive direct coronary artery _______ o OPCAB - Off pump CAB - full or partial sternotomy on a beating heart. o TECAB - totally endoscopic coronary artery ________. · Transmyocardial Laser Revascularization o Not ______ but they can try to do it when there aren't many options

bypass

_____ _______ = Stroke Volume (SV) x Heart Rate (HR) ○ If HR is too slow, ___ ____ will drop and if HR is too high, ____ ______ will drop ○ Example: SV (70ml) X HR (80) = 5,600 ml = 5.6 L/min ○ **remember contractility, preload, and afterload all go into stroke volume (all components) ● 5,600 mL = SV (70mL) x HR (80 bpm)

cardiac output

The following is trigger criteria that may require a rapid response team for a ______ issue: ○ ACUTE AND NEW ■ Acute change in systolic BP to <90 ■ Acute sustained increase in diastolic BP> 110 ■ Acute change in heart rate to <50 or >120 ■ Onset of chest pain (cardiac chest pain cannot be reproduced by touching or breathing in deep; if hurts to breath in deep or if you touch then it's pleuritic pain) ■ Acutely cold, pulseless, or cyanotic extremity

cardiovascular

There are 3 main complications of cardiopulmonary bypass: post perfusion syndrome ("pump head"), hemolysis of the RBCs, and capillary leak syndrome. Which of these 3 is described below: o Secondary to inflammatory response (bypass causes inflammatory response) o With that inflammatory response you get vasodilation and capillary leak, so the patients tend to third space a lot § A lot of times they will come back post op and be fluid overloaded, but their fluid won't be in the intravascular space · Will be intravascularly dry, but they really have a lot of fluid in the tissues (the third space)

capillary leak syndrome

The following is nursing management post _______ surgery: o Monitor for dysrhythmias o Watch for atrial fib (occurs in 20-40% of patients who have bypass surgery go into atrial fibrillation)—because the heart is irritable, and the surgeon has been working on the heart so it's a common complication of bypass surgery § The sooner you treat atrial fib the more likely you are to get them converted to a sinus rhythm § Can happen in the immediate post-op period or 2-3 days later

cardiac

The following is nursing management post _______ surgery: · *******One of the goals: Normalize cardiac output****** o *****Do this by optimizing the heart rate**** § Patient has to have a fast enough HR to generate a decent cardiac output but not too fast because remember if its too fast then you decrease ventricular filling time and you decrease cardiac output § Temporary pacing—if having problems with heart block or bradycardia § Drug therapy—if having trouble with tachyarrhythmias or ventricular arrhythmias then they can be put on antiarrhythmics o Monitor for dysrhythmias o Watch for atrial fib (occurs in 20-40% of patients who have bypass surgery go into atrial fibrillation)—because the heart is irritable, and the surgeon has been working on the heart so it's a common complication of bypass surgery § The sooner you treat atrial fib the more likely you are to get them converted to a sinus rhythm § Can happen in the immediate post-op period or 2-3 days later

cardiac

Look on the monitor picture on phone for this question. What does "CI" stand for> · taking into account their weight and height

cardiac index

_______ _______ is the cardiac output adjusted for body size (more precise measurement of the efficiency of the pumping action of the heart***) ● Someone who is really large and has a lot of mass will need a higher _____ ______ than a small 90 pound lady who barely has any mass ● The ____ ____ takes into consideration the height and weight of the person ● ***The lower the body surface area (BSA), the higher the _____ ______

cardiac index

If SVR is way too low, the patient will have high ____ ______ since it is easy for heart to eject but sometimes can get too low causing a low BP. How can we increase the SVR and make it higher and tighten the vessels? vasoconstrictors (IV Dopamine, Lefafed)

cardiac output

PEEP higher than 5 cm results in decreased _____ ______. Because it decreases venous return. Remember if you do not have enough blood in the ventricle to eject out, you will have a decreased ___ _____. if you have decreased venous return, you will have decreased preload and decreased ___ ______. Patients who are hypovolemic or have poor L ventricle sometimes may not tolerate higher levels of PEEP. If patient does have poor L ventricle, they may only be able to tolerate 5 cm of PEEP. Because it decreases venous return, it decreases return of flow from the head. Patients who have increased intracranial pressure, PEEP can make that ICP worse because you are decreasing the venous return of blood flow form the head. It is not returning and draining from the head like it normally should; theoretically that will increase the pressure in the head. ○ **we rarely ever use PEEP on a head injury patient or patient who has increased intracranial pressure (ICP)*****

cardiac output

The following is all of the info about non-invasive _____ _____: ● Bioimpedance technology ○ Bio Z® ○ Not accurate in patients with fluid overload ■ Who do we need to monitor cardiac output in? those patients with HF and fluid overload so the value of the Bio Z was not good or useful ● Bioreactance technology ○ Cheetah® ○ New and exciting technology! ○ Much more accurate! Not typically used for continuous cardiac monitoring like in ICU but valuable for intermittent data on patient ○ This is Non-invasive !

cardiac output

The following is info about measuring _____ ____: ● If you have a basic catheter with no fancy ports: to get a ____ _____ with this system you have to inject 10 CCs of cool fluids (normally saline) and you inject it within the proximal port (or injectate port) very quickly within 4 seconds and at the same time you hit the button the monitor that says "cardiac output". Based on the amount of time it takes the cool saline to get to the thermometer on the tip of the catheter, it is able to calculate a _____ _____ ○ You have to get 3 readings and average those 3 to get an average ____ ______ ● If you have a "Cadillac version" of the pulmonary artery catheter (continuous cardiac output capabilities), it uses different technology to calculate the _____ ______. with these catheters, they actually have a longer thermoster or thermometer on he end of the catheter and it actually emits a pulse signal which warms the blood. From the time it takes the warm blood to cross that long thermoster it is about to calculate the ___ _____. the computer measures it and gives a ____ ____ reading for you.

cardiac output

When measuring ____ _____, this is obtained by injecting a 10 mL bolus of cool fluid into the proximal injectate port within 4 seconds. Time & temperature levels are evaluated & reading is obtained (thermodilution cardiac output - TCO).

cardiac output

____ _____ is the volume of blood pumped by the heart in L/min from the ventricles ○ Change in preload, heart rate, and contractility can affect ____ _____ ○ **measured in Liters/minute ● *******Normal range of ____ ____: 4 - 8 L/mi******

cardiac output

Complications of MIs include dysrhythmias, cardiogenic shock, papillary muscle dysfunction, ventricular aneurysm, pericarditis, Dressler Syndrome. Which of these complications is described below: · HF to the extreme; LV not pumping enough, can't keep BP or MAP up, high risk death → hypotension, cold/clammy, pulmonary edema, neurologic changes → stop infarct if possible (PCI, balloon pump).

cardiogenic shock

The following are complications of _________ bypass: · Clotting of blood in the circuit · Air embolism o If air gets into the circuit · ARDS (1.5% of patients) o Adult respiratory distress syndrome o Caused by that inflammatory response which injures the lung o An acute lung injury (ALI)

cardiopulmonary bypass (CPB)

The following are complications of _________ bypass: · One theory of why they have these complications is because it doesn't have pulsatile flow o When our heart beats, we have a systolic pressure and a diastolic pressure and that's the pulsatile flow o But on bypass pump it is just a slow, steady pump

cardiopulmonary bypass (CPB)

The following are complications of _________ bypass: · Postperfusion syndrome ("pump head") o Neurological problems—problems with their though processes · Hemolysis of the RBCs o The cells get beat up going through the mechanical pump and the hemolyze o The perfusionist has to heparinize the blood to try and prevent this—so they are also at risk for bleeding § Also do this to prevent the blood from clotting in those tubing or that circuit · Capillary leak syndrome o Secondary to inflammatory response (bypass causes inflammatory response) o With that inflammatory response you get vasodilation and capillary leak, so the patients tend to third space a lot § A lot of times they will come back post op and be fluid overloaded, but their fluid won't be in the intravascular space · Will be intravascularly dry, but they really have a lot of fluid in the tissues (the third space)

cardiopulmonary bypass (CPB)

The following are complications of _________ bypass: · The longer the patient is on bypass, the more potential problems they are going to have from the bypass pump o Want the surgeon to get in there do the surgery and get out o Should get this in report when receiving a patient from surgery (what was their pump time) § So, you can anticipate any problems that may have if they had a long pump time o 40 minutes is great (2-3 hours then expect some problems)

cardiopulmonary bypass (CPB)

What type of bypass surgery is described below: **traditional CABG** · Ex: saphenous vein graft sutured onto the aorta and then distally to the right coronary artery, making a bypass of the RCA o The other option (the better option) is to use the left internal mammary artery (its branch off of the subclavian that feeds the mammary tissue)—a surgeon can excise the distal end of the artery, leave it connected to the subclavian like it normally is and use that artery for the bypass (re-suture the distal end if the artery onto the coronary artery)

cardiopulmonary bypass (CPB)

What type of bypass surgery is described below: **traditional CABG** · The process of putting the patient's blood through this pump where it oxygenates it and returns it to the patient · While the patient's heart is in arrest, this machine is oxygenating the patient's blood · They usually put a canula in the femoral artery and again back in the aorta where the pull the blood from the femoral or even sometimes the right atrium and then they return it to the aorta · A pump tech (perfusionist) is the one who runs the pump o Special school that perfusionists go to—lost of respiratory therapists will go to perfusion school to be able to run the pump · Ex: saphenous vein graft sutured onto the aorta and then distally to the right coronary artery, making a bypass of the RCA o The other option (the better option) is to use the left internal mammary artery (its branch off of the subclavian that feeds the mammary tissue)—a surgeon can excise the distal end of the artery, leave it connected to the subclavian like it normally is and use that artery for the bypass (re-suture the distal end if the artery onto the coronary artery)

cardiopulmonary bypass (CPB)

What ICU bundle is described below: ● (protocol for changing dressings every so often, aseptic technique, accessing it, swabbing it, antiseptic to clean it) ○ May also be known as the CLABSI bundle (central line associated bloodstream infection) ○ Things to prevent infections secondary to a central line **A bundle is nursing care that should be provided for a patient based on either the disease process they have or a treatment that they have

central line bundle

The following are different _______ for advanced practice registered nurses: ○ CNS (mainly educates new nurses) ■ Clinical nurse specialist ○ NP, CNS, CRNA, CNM ■ Nurse practitioner or CNS with doctoral degree ○ DNP- doctor of nursing practice ○ Based more on medical models ● Usually getting a _______, requires that you take a test to demonstrate that you have knowledge above and beyond what a nurse generalist has. Some certifications may require you to do some psychomotor component.

certifications

When talking about nursing roles of ACLS and PALS nurses, the following are different ______ that nurses can get after you graduate/continuing education: ○ CCRN- critical care ■ For nurse who wants certification in critical care ○ PCCN- progressive care nurses ■ For nurse working in step down care units ○ CMC- Cardiac medicine/ CSC cardiac surgery (these are further add ons to CCRN and PCCN) ■ Add on certification to PCCN ■ You have to either have CCRN or PCCN and then can get further specialized in CMC or CSC ○ Based more on nursing models ● Usually getting a _______, requires that you take a test to demonstrate that you have knowledge above and beyond what a nurse generalist has. Some certifications may require you to do some psychomotor component.

certifications

Other causes of non-cardiac ____ ___(differential diagnosis) includes: · Maybe the patient presented with ___ _____ but its determine that it is not ACS—have to think about what other things can cause these symptoms · Pulmonary o Pneumonia, Pleuritis (inflammation of the lining of the lung), Pneumothorax, Pulmonary embolus, Pulmonary HTN · GI Causes o Gastroesophageal reflux, esophageal spasm, PUD (peptic ulcer disease), pancreatitis · Muscular skeletal and Miscellaneous o Costochondritis (inflammation of the spaces or areas between the ribs), herpes zoster, anxiety (anxiety attacks—often present with SOB or chest pain) o Costochondritis is an inflammation of the junctions where the upper ribs join with the cartilage that holds them to the breastbone, or sternum · Remember, heart problems can be lethal, so always try to rule out that it's not ACS before moving on to a differential diagnosis

chest pain

Other causes of non-cardiac ____ ___(differential diagnosis) includes: · Muscular skeletal and Miscellaneous o Costochondritis (inflammation of the spaces or areas between the ribs), herpes zoster, anxiety (anxiety attacks—often present with SOB or chest pain) o Costochondritis is an inflammation of the junctions where the upper ribs join with the cartilage that holds them to the breastbone, or sternum · Remember, heart problems can be lethal, so always try to rule out that it's not ACS before moving on to a differential diagnosis

chest pain

When assessing ____ _____ we use the acronym LOCATE. LOCATE stands for: ○ L- location/ radiation ○ O- onset/ duration ○ C- character ○ A- associated symptomes ○ T- treatments that they used at home ○ E- eliminated/ aggravates **collaborative management/goals

chest pain

What is the gold standard for confirming placement of an ET tube in a patient? o The tip of the tube should sit about 2 sonometers above the carina which is where the bronchi meet or divide from the trachea. o You do not want the tube hitting the carina because that will cause the patient to cough (where cough reflex is) and you will not be able to ventilate them.

chest x-ray

Patients can have both and they can occur concurrently BUT the difference between dementia and delirium, dementia is a _______ problem whereas delirium is an acute problem. A dementia patient can have delirium on top of that

chronic

circulatory Assistive Devices

When talking about coronary circulation in the heart, the LEFT coronary artery supplies the SEPTAL and the ANTERIOR wall of the heart and brings blood supply to the anterior 2/3 of intraventricular septum, anterior L ventricle, Lateral L ventricle along with the ______ (feeds the LATERLA wall of the heart) and the _______ then brings blood supply to the L atrium, posterior L ventricle, and Lateral L ventricle? o Much better to have right-sided MI than ______ o Blockage in the _______ main artery commonly called the "widow maker"--> most people do not survive this because it feeds a lot of muscle

circumflex

When fostering comfort and ______ with artificial airways, another big problem is _______. If they have a cuffed tube or tracheostomy tubes, they cannot make vocal sounds and cannot talk to you. Nurses caring for patients on the ventilator, get good at figuring out what patients need. Most of the time, you want water but they cannot have since they are NPO and the best you can do is swab mouth with moist swab or lemon swab. ■ Most ICUS have ________ boards ■ If patient is awake enough they can write notes

communication

The following are _____ of an MI: · Cardiogenic Shock - HF to the extreme; LV not pumping enough, can't keep BP or MAP up, high risk death →hypotension, cold/clammy, pulmonary edema, neurologic changes → stop infarct if possible (PCI, balloon pump). · Papillary muscle dysfunction - muscle that holds down valves ruptures then valves become incompetent and can decompensate quickly (severe valve regurgitation); need surgery, monitor for murmur.

complications

The following are _____ of an MI: · Dysrhythmias—80%; esp. in 1st few hours, but can have problems after -- biggest risk! · Heart failure—depends on how much muscle damage/how big the MI was. o Some patients can have acute heart failure that is caused by the heart being stunned (stunned myocardium)—its from the ischemia—will typically improve as the patient improves and as we intervene and reestablish their coronary flow o Patient who have significant infarction, especially in the left ventricle, are at high risk for heart failure and cardiogenic shock

complications

The following are _____ of an MI: · Ventricular Aneurysm - bulges out because of infarct, heart doesn't contract well, surgically resect this. · Pericarditis - inflammation of pericardial sac, treat with steroids & time, persistent chest pain, feel bad, ST elevation in ALL of the leads→ use NSAIDS to treat/manage. o Can occur after an MI · Dressler Syndrome—fever, pleural effusion, joint pain. o Can occur after an MI o Usually, self-limiting § Takes a while for it to resolve

complications

The following are ______ of an MI: dysrhythmias, cardiogenic shock, papillary muscle dysfunction, ventricular aneurysm, pericarditis, Dressler Syndrome

complications

In the cardiac _____ system, the myocardium depolarizes from endocardium to epicardium. Think of a 12-lead EKG as a camera taking pictures of the heart on a pedestal at different angles. Whichever way the camera is angled at the heart will be which wall of the heart is looking at. If you understand where the positive electrode is placed on the body, it makes more sense and helps you to remember which lead looks at which wall of the heart. o When looking at infarct localization, which is the focus of this intro class, it is to be able to recognize where ST changes are, which wall of the heart the lead or where those ST changes are is looking at, and which coronary vessel is probably the culprit vessel

conduction

The following is post-operative care for ______: **Nurse should receive report to include:** o EVH - endovascular vein harvest § If they used vein grafts, you want to know where they got them from and what method they used § If they used an EVH then where are the incisions and which leg

coronary artery bypass (CAB)

What type of sedation is described below: ● Minimize anxiety and discomfort while reducing undesirable autonomic responses to painful stimuli or to help a patient through a procedure that requires that they remain still for an extended period of time. ● Ex: endoscopy, colonoscopy, elective cardioversion, transesophageal echocardiogram) ○ These procedures are often done at the bedside or done outpatient ● Typically will administer versed

conscious sedation/ procedural sedation

Who can administer ________ sedation? ● Adult patients classified as Status I, II or III and pediatric patients classified as Status I or II are appropriate for administration of mild to moderate sedation by a qualified Registered Nurse. ● Adult patients classified as ASA status IV or V and Pediatric Patients classified as status III, IV, or V are not appropriate for administration of mild to moderate sedation agents by an RN and should have anesthesia provider responsible for care.

conscious sedation/ procedural sedation

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) Function: Similar to PEEP but used only with spontaneously breathing patients Clinical Use: Maintains constant positive pressure in airways so resistance is decreased

constant positive airway pressure (CPAP)

When measuring cardiac output, we have _______ Cardiac Output (CCO) which uses a catheter which emits a pulsed signal - a computer then measures a wave form (this is what is used currently) ○ If patient is in the ICU and will need monitoring for a while, they will place a CCO

continuous

What piece of technology in the ICU is described below: (ECG monitoring, positive pressure ventilation, hemodynamic monitoring, intracranial pressure monitoring, ventricular assist devices, continuous renal replacement therapy) o Is slow dialysis; patients who are hemodynamically unstable typically do not tolerate routine or regular hemodialysis so they need to be dialized more slowly which is called ____ ____ _____ _____ o Nurses in ICU need to know how to run this equipment and actually manage the patient who is receiving this therapy

continuous renal replacement therapy

Post cardiac surgery, the nurse needs to manage the patient's preload, afterload, and contractility. The following are methods for controlling which of these 3 heart functions? · Sometimes they have problems with ______ o If the cardiac index is low after you have optimized their HR, SVR and preload (you have done everything you can to make it easier for the heart to pump) and you are still having problems with their cardiac index then you might need to add a positive inotrope § Positive inotropes (dopamine, dobutamine, primacor)—IV drugs that we use to increase the ________ · IABP (Intra-aortic balloon pump) and Impella®--used if inotropes are not working and you have optimized all your medication therapy o Mechanical left ventricular assist device o Used strictly for acute care in the ICU setting o A temporary bridge until we can get the patient doing better

contractility

What main factor affecting stroke volume (preload, afterload, contractility) is described below: (ejection fraction) ○ Force of Contraction (FOC) ○ How well do the ventricles squeeze? You have R and L _______. Patients who have systolic Left-sided heart failure have poor _______ of the L ventricle. Patients who have Right-sided heart failure have poor _______ of the R ventricle. You have to have muscle that can squeeze. If it does not squeeze good, you will not move blood forward good having a decreased cardiac output. ○ _______ refers to the force/strength of contraction resulting in ejection of blood from the ventricles ○ Normal range for EF: 60-80% ○ EF warranting medical management is typically 40% or less ○ Increased ______ occurs when preload remains unchanged but the heart contracts more forcefully (can be achieved with drugs called positive inotropes - Epinephrine, Dopamine, Dobutamine, etc.) ○ Results in increased SV & myocardial O2 requirements ○ Decreased ________ can occur with the use of negative inotropes (alcohol, Ca Channel Blockers, Beta-blockers) & some clinical conditions (acidosis) ○ ***If preload, HR & afterload remain constant yet CO continues to change, _______ is most likely the cause (for example, it is reduced in HR) ○ _______ will be affected by heart failure, drugs (beta blockers, dopamine, epi), acidosis

contractility

What main factor affecting stroke volume (preload, afterload, contractility) is described below: ○ ***If preload, HR & afterload remain constant yet CO continues to change, _______ is most likely the cause (for example, it is reduced in HR) ○ _______ will be affected by heart failure, drugs (beta blockers, dopamine, epi), acidosis

contractility

What main factor affecting stroke volume (preload, afterload, contractility) is described below: ○ Increased ______ occurs when preload remains unchanged but the heart contracts more forcefully (can be achieved with drugs called positive inotropes - Epinephrine, Dopamine, Dobutamine, etc.) ○ Results in increased SV & myocardial O2 requirements ○ Decreased ________ can occur with the use of negative inotropes (alcohol, Ca Channel Blockers, Beta-blockers) & some clinical conditions (acidosis)

contractility

What main factor affecting stroke volume (preload, afterload, contractility) is described below: ○ _______ refers to the force/strength of contraction resulting in ejection of blood from the ventricles ○ Normal range for EF: 60-80% ○ EF warranting medical management is typically 40% or less

contractility

Nurse must have very good assessment skills for assessing pain and anticipating when the patient may need pain meds and evaluating how they responded to the pain med given or how effective it was o If you let a patient's pain get out of _____ then it could be difficult to get it back under _______—so be proactive and offer pain meds before doing activities that could trigger pain and assess for pain frequently o Proactive, good assessment, good evaluation

control

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) Function: Delivers preset volume or pressure regardless of patient's own inspiratory efforts Clinical Use: Usually used for patients who are apneic

controlled mandatory ventilation (CMV)

What does CABG stand for?

coronary artery bypass graft

controlled mandatory ventilation (CMV)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ Delivers preset volume at regular interval regardless of pt. inspiratory effort (set rate & tidal volume) ■ The physician will order a rate and a tidal volume and the ventilator is going to deliver that breathe or tidal volume at that set rate ■ If the rate is at 10, the ventilator will deliver a set tidal volume at every 6 seconds like a clock (boom boom boom). ○ The problem with _______ is the nurse is in total control of that patient's ventilation. ■ If the patient is awake at all and they are trying to breathe, they can start a breathe while the ventilator is trying to give them a breathe and it can cause high pressure (called bucking where the patient is not breathing with the vent). ■ It is uncomfortable for the patient, therefore, rarely used anymore ○ Used in pt. with no respiratory effort or unable to breathe spontaneously - includes pt. such as: ■ High c-spine injuries (cannot breathe anyway and no competing breathes) ■ End-stage degenerative neuro disease (no respiratory effort) ■ Chemical paralysis aka anesthesia (drugs given to paralyze patient) ● Use this because they are bucking the vent or ventilator desynchonzie ○ Used less often than Assist/Control ○ Typically causes the pt. to panic & fight if they have any spontaneous respiratory effort bc they're trying to breathe with the ventilator ■ Rarely used if patient is awake because it can cause them to panic since it is not a natural process ○ Rarely used unless patient is under anesthesia ○ Machine does all the breathing, pt cannot initiate a breath

controlled mandatory ventilation (CMV)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ Used in pt. with no respiratory effort or unable to breathe spontaneously - includes pt. such as: ■ High c-spine injuries (cannot breathe anyway and no competing breathes) ■ End-stage degenerative neuro disease (no respiratory effort) ■ Chemical paralysis aka anesthesia (drugs given to paralyze patient) ● Use this because they are bucking the vent or ventilator desynchonzie

controlled mandatory ventilation (CMV)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ Used less often than Assist/Control ○ Typically causes the pt. to panic & fight if they have any spontaneous respiratory effort bc they're trying to breathe with the ventilator ■ Rarely used if patient is awake because it can cause them to panic since it is not a natural process ○ Rarely used unless patient is under anesthesia ○ Machine does all the breathing, pt cannot initiate a breath

controlled mandatory ventilation (CMV)

LOOK AT PICTURE NUMBER 8 ON PHONE: **the physician puts in the _____ ______ just like a central line and on the end of it there is a one-way valve (can use this to give IV fluids as well since big catheter in a central line). In that one-way valve, the physician inserts that catheter through there. Once he passed through the catheter, he inflates the balloon and this balloon, when inflated, will float with the flow of blood. It will follow the path of the blood till it gets up into the pulmonary artery. That is why it is called a flow directed catheter because that balloon floats with the flow of the blood till it gets into position

cordis introducer

What part of a pulmonary artery catheter is described below: big bore IV, single lumen IV that the physician puts in and usually when putting a PA catheter in they will either put in the internal jugular vain or subclavian or even femoral vein (only if no other option).

cordis introducer

Since myocardial infarction is the result of an occluded _______ artery, it is worthwhile to develop a familiarity with the _______ arteries that supply the heart. Once the infarction has been recognized and localized, an understanding of _______ artery anatomy makes it possible to predict which _______ artery is occluded. **Localization of infarction **ACS

coronary

The following is all of the information for ______ circulation: · Aorta o Right ______ Artery (supplies the inferior wall of the heart)—brings blood supply to the: § Right atrium § Right ventricle § SA node § AV bundle § Posterior LV § If you have a patient that comes in with an inferior MI, then you know it's probably the right ______ artery (this patient is high risk for developing heart blocks due to the blood supply to the SA node and the AV bundle) o Left _______ Artery—brings blood supply to the: § Left anterior descending (feeds the septal and the anterior wall of the heart)—brings blood supply to the: · Anterior 2/3 of intraventricular septum · Anterior LV · Lateral LV § Circumflex (feeds the lateral wall of the heart)—brings blood supply to the: · LA · Posterior LV · Lateral LV o Much better to have right-sided MI than left o Blockage in the left main artery commonly called the "widow maker"--> most people do not survive this because it feeds a lot of muscle

coronary

The following is post-operative care for ______: **Nurse should receive report to include:** o "Pump time" § Post perfusion syndrome—the longer the patient is on the bypass pump, the higher the risk for neurological complications § The shorter the better § If you know the patient had an abnormally long pump time, then you know you need to be monitoring them closely for those neurological complications

coronary artery bypass (CAB)

The following is post-operative care for ______: **Nurse should receive report to include:** o Blood products o Baseline hemodynamics § The anesthesiologists usually put the monitoring lines in before surgery (usually in surgery holding) § Want to know what the patient's hemodynamics were like before they took them to surgery § Most of these patients don't have normal hemodynamics—they are having bypass surgery because they have something wrong with them and they have problems with their heart · But need to know what their normal are—because you may be setting unrealistic goals if you don't know what their baseline is

coronary artery bypass (CAB)

The following is post-operative care for ______: **Nurse should receive report to include:** o IVs running § What kind of IV lines do they have § If the have a Swan-Ganz catheter, triple lumens, any peripherals, then you want to know where it is § What is running through those lines—often times they are on vasopressor drips or vasodilator drips or even some positive inotropes · At a minimum they will be on some crystalloids o Recent lab values including ABGs § They will typically run some labs right before they bring them to the ICU

coronary artery bypass (CAB)

The following is post-operative care for ______: **Nurse should receive report to include:** o Summary of surgery performed (what arteries were bypassed) o "Pump time" o IVs running o Recent lab values including ABGs o Tubes and drains o Blood products o Baseline hemodynamics o EVH - endovascular vein harvest NEED TO KNOW THIS

coronary artery bypass (CAB)

The following is post-operative care for ______: **Nurse should receive report to include:** o Summary of surgery performed (what arteries were bypassed) § LIMA (left internal mammary artery)LAD (left anterior descending artery) · The LIMA was used to bypass the LAD § SVG (saphenous vein graft—taken from the leg) --> RCA (right coronary artery) § RIMA (right internal mammary artery) DF --> PDA (posterior descending artery—a branch off of the right coronary artery) § Need to know this so that if you have problems after then you will know which leads you should be monitoring—look for ST changes on the EKG

coronary artery bypass (CAB)

The following is post-operative care for ______: **Nurse should receive report to include:** o Tubes and drains § Usually, they will have at a minimum at least a mediastinal drain (tube that sits in the mediastinal space that drains fluid and bleeding from the surgery site because you don't want all of that to stay in the chest) · If all that blood and fluid stays in the chest it will put pressure on the heart and cause a cardiac tamponade § Usually, will have an NG tube § If they used the RIMA or the LIMA, they will have pleural chest tubes as well because to access the internal mammary arteries you have to deflate/collapse the lungs and then they have to re-expand them with a chest tube § Foley catheter and an arterial line

coronary artery bypass (CAB)

The following is post-operative care for ______: · Hemodynamic monitoring · PA line/arterial based cardiac output o Monitor their right atrial pressure, PAP, PAWP, SVR, PVR if they have a PA line in o Monitor their stroke volume variation if they have an arterial based cardiac output monitor · Arterial line—to monitor their BP · Pacer wires—epicardial pacer wires put in during surgery just in case the patient has rhythm problems after surgery o If the patient has rhythm problems, the nurse can quickly get an external temporary pacemaker generator and hook them up and pace them · Multiple IVs · Nasogastric Tube · Chest drainage o Mediastinal (for sure) o Pleural (possibly—could have one or two)

coronary artery bypass (CAB)

The following is post-operative care for ______: · The actual bypass surgery will take a few hours depending on how many grafts they are doing o The more arteries they are bypassing with grafts, the longer it will take—but typically anywhere from 2-4 hours · Once the surgery is finished, the patient is weaned off the bypass pump, and the heart is restarted

coronary artery bypass (CAB)

The following is post-operative care for ______: · The patient is in ICU 24 -36 hours o They try to get them up and moving out as soon as possible—sooner they get moving the better they will do · Patient is initially intubated when they get up to ICU (because the patient goes straight to ICU and not to recovery) o Anesthesia is not reversed—they slowly let it where off and let the patient wake up o Goal is to extubate as early as possible—average is in 4-6 hours § Patient has to be able to take good deep breaths and maintain oxygenation and ventilation status, can lift their head and cough then they can be extubated § Extubation is a collaborative process between the nurse and the respiratory therapist

coronary artery bypass (CAB)

The following is post-operative care for ______: · Usually taken directly to ICU—the ICU nurse recovers the patient (they bypass PACU) o The nurse lets the patient slowly wake up and lets the anesthesia wear off—when they are awake and alert, coughing and deep breathing, and maintaining good ABGs they are able to extubate them · 1:1 nurse patient ratio—these patients can be very busy for the first few hours after surgery · The nurse will receive report from either the nurse anesthetist, the surgery nurse, or sometimes even the anesthesiologist

coronary artery bypass (CAB)

The following is the nursing assessment of. patient post ______: · Chest tube drainage (mediastinal and pleural tubes are there to drain all that fluid from the chest because we don't want the fluid staying in the chest and causing problems) o Typically gets drained into a chest tube drainage system o Q 1 hour monitoring—because if they are bleeding at the surgical site that where you are going to see it § They always have some bleeding but if its excessive they may need some intervention like either some fresh frozen plasma because their coagulation studies are prolonged, or they might need some blood replacement or some platelets

coronary artery bypass (CAB)

The following is the nursing assessment of. patient post ______: · Urine output · Neurologic complications o Could be caused from Postcardiotomy delirium o Could have an Intraoperative CVA, MI · Hemodynamic Status—frequent monitoring of this o Adjusting medications and drips based on those numbers · 02 sat, ABGs, Ventilator settings · Electrolytes, CBC, coagulation studies

coronary artery bypass (CAB)

The following is the nursing assessment of. patient post ______: · Vital Signs (frequent) o May initially be every 5 minutes for a while until the patient stabilizes then it will move to every 15 minutes, then every 30, then every hour § Once very stable it will move to q 2 hours · Hemodynamic Status—frequent monitoring of this o Adjusting medications and drips based on those numbers · 02 sat, ABGs, Ventilator settings · Electrolytes, CBC, coagulation studies · Chest tube drainage (mediastinal and pleural tubes are there to drain all that fluid from the chest because we don't want the fluid staying in the chest and causing problems) o Typically gets drained into a chest tube drainage system o Q 1 hour monitoring—because if they are bleeding at the surgical site that where you are going to see it § They always have some bleeding but if its excessive they may need some intervention like either some fresh frozen plasma because their coagulation studies are prolonged, or they might need some blood replacement or some platelets · Urine output · Neurologic complications o Could be caused from Postcardiotomy delirium o Could have an Intraoperative CVA, MI

coronary artery bypass (CAB)

The following is medical management of _____: o Still do medical management even if the patient has PCI and or CABG—may not be as much or may be a little different · Aspirin—unless there is a contraindication · Antiplatelets—oral, like clopidogrel and Berlenta · Betablockers—decrease HR and decrease myocardial oxygen demand so it could be helpful for patients who have recurring chest pain anytime they do any activity o Unless there is something that contraindicates it like hypotension, bradycardia, or heart block

coronary artery disease (CAD)

The following is medical management of _____: · ACE or ARB—especially if they have a decreased ejection fraction · Ranolazine—type of antianginal that seems to help patient that have refractory disease (so maybe they are on all of their other meds, but they are still having chest pain and still having trouble managing their chest pain, but they are not a candidate for any other intervention) o Can be helpful in patients who have microvascular disease that you can't really bypass or put a stent in

coronary artery disease (CAD)

The following is medical management of _____: · Often times done in conjunction with other interventions such as PCI or CABG · ******Patients who are not candidates for PCI or CABG will be managed with medications to minimize their symptoms***** o PCI: because they have disease throughout the vessel—won't do a whole lot of good to go put a stent in one area or the vessel is too small or the area where the blockage is is at a bifurcation and if they dilate and stent that area, they would risk occluding two vessels o CABG: if they have diffuse disease/disease all throughout the vessels, bypassing them won't do a whole lot of good—could also be due to their general state of health: CABG surgery is a major surgery with lots of risks and the patient may not be in good enough condition to go through this surgery o *****Still do medical management even if the patient has PCI and or CABG****—may not be as much or may be a little different

coronary artery disease (CAD)

The following is medical management of _____: · Short and long-acting nitrates (nitroglycerin) o Long acting—to get baseline coverage or baseline vasodilatation o Sublingual spray or rescue—for when the have episode of chest pain · Lipid lowering agents—if the have hyperlipidemia (trying to modify those risk factors and minimize the chances of progression of the disease)

coronary artery disease (CAD)

There are 3 types of PCIs: balloon angioplasty, stent placement, and atherectomy. Which of these 3 is described below: · A stent is a mesh, cage-like thing that can be put in during a PCI o Angioplasty with a stent (can also have one without a stent) · Placement during PCI · Reduces restenosis rate of PCI—helps hold the vessel open

coronary stents

There are 3 types of PCIs: balloon angioplasty, stent placement, and atherectomy. Which of these 3 is described below: · Stents are put in place during a PCI. There are self-expanding stents and stents that are balloon-expandable. · Stents are inserted to treat abrupt or possible abrupt closure. · Stents are thrombogenic. Left alone after placement, they would collect platelets and new tissue would form that would reclog the artery. So, it is placement of either drug-eluding stents - ones that elude a drug to block cell proliferation, or bare metal stents with the use of oral antiplatelet agents - usually Plavix.

coronary stents

There are 3 types of PCIs: balloon angioplasty, stent placement, and atherectomy. Which of these 3 is described below: · Two type of stents o Bare Metal—metal stents o Drug-eluding—coated with some drugs to try and help prevent that hyperplasia that occurs § (chemotherapy type agent proven to prevent re-stenosis - pt. usually on anti-plaelets for 6 months-1 year) § Normally, when they put a stent in, the body tends to grow tissue over that stent because it is a foreign body · Some patients have overgrowth of that tissue which causes that restenosis so this stent will slow that process, so they do not have hyperplasia (or that overgrowth) § Problem: patients have to be on dual antiplatelet therapy for longer because it takes longer for that normal tissue to grow over that stent

coronary stents

The _______ care environment is highly complex and highly technical (swan used to do hemodynamic monitoring) ○ As a _______ care nurse, you have to understand all of this equipment, how to use it, how to troubleshoot it, and how it works

critical

The following are organizations for _____ care: ● American Association of ______ Care Nurses (AACN) ○ Offers Certification - CCRN (adult, pediatric, and neonatal) ○ Represents critical care nurses ● Society of ______ Care Medicine (SCCM) - for physicians ○ Puts out a lot of guidelines for critical care; more medical but nurses still use ○ Organization that is a medical society that puts out a lot of guidelines and best practices for critical care patients ○ One campaign they put out is the Surviving Sepsis Campaign

critical

The following is the summary of ______ care nursing: ● ICU nurses have specialized knowledge and skills ○ This is knowledge and skills beyond what you get in undergrad education ● They care for patients who are often on the verge of death ○ Need to be prepared to deal with mortality; if you work in ICU you will more than likely work on patients at the end of life ● They work collaboratively with other healthcare disciplines (pharmacist, respiratory therapist, physicians, pharmacist, nutritional therapist, case workers, etc) ○ It takes a village to take care of a critical care patient!!

critical

The scope and standards for Acute and _____ Care Nursing Practice describe and measure the expected level of practice and professional performance for acute and ______ care registered nurses and articulates the contributions of acute and ______ care nursing to a patient and family-centered healthcare system.

critical

When talking about older adults in ______ care, symptoms may be **atypical** meaning: ○ May not sense pain as well ○ Confusion may be a sign of infection; look at white count and wounds ■ May be the first sign of a problem ■ May be only symptom they present with ○ Depression is often misdiagnosed as dementia ○ Most common atypical illness presentations are "delirium" or "acute change in mental status", caregiver may say the patient is "acting differently" or no longer participating in self-care activities ○ May have multiple co-morbidities, diagnosed and undiagnosed. ○ Care can be complex and challenging requiring skilled assessment and creative nursing interventions

critical

What type of nursing was developed as a result of the recognition that patients with acute, life-threatening illness/injury could be managed more effectively if they were placed on specifically designated units?

critical care nursing

What mental health disorder/problem is described below: ● Acute onset, usually seen a lot with ICU pt. (CAM: Cognitive Assessment Measurement in ICU - ongoing assessment to ID earlier those pt. moving to _____ stage) ● It is a temporary cognitive problem where the patient does not have normal cognition (an acute problem—different from dementia which is chronic/long term)

delirium

The following are some cultural beliefs about _____ and dying in the ICU: ○ Open window to let spirit out (after patient dies) ○ Final bath for deceased (before going to funeral home or morgue) ● What do you do after the death of a trauma pt.? Don't remove any lines or anything - this is a coroner's case; ALWAYS call LOPA & coroner (these two people are called for any death)

death

Heart rate ________ by medications such as: ● Beta-blockers--> slows HR and _______ contractility ● Digoxin ● Ca Channel Blockers ● Conduction Defects--> patients with PVCs (these do not generate good BP so that will decrease CO)

decreased

If SV ________, the HR will compensate by increasing so initially the CO remains the same. If HR increases, the SV will stay the same, but eventually it will _______ bc there is not enough time for the ventricles to fill.

decreases

In low doses, Propofol/Diprivan induces a state of _____ sedation.

deep

What level of sedation (light, moderate, deep, general anesthesia) is described below: Responsiveness: Purposeful response after repeated or painful stimulation Airway: Intervention maybe required Spontaneous Ventilation: Maybe inadequate CV Function: Usually maintained

deep sedation

What level of sedation (light, moderate, deep, general anesthesia) is described below: ○ Depression of consciousness during which patient cannot be easily aroused but may respond purposefully after repeated or painful stimulation ■ Very obtunded—must really stimulate them to get them to respond at all ○ Require assistance in maintaining a patent airway; spontaneous ventilations may be inadequate ■ A lot of times, this is what we are aiming at if the patient is on a vent and we want them to sleep and be comfortable ○ Cardiovascular function is usually maintained (but this is very individualized—if patient is dehydrated then you may have issues with low BP when you relax them) ■ Frequent monitoring of BP and vital signs are needed anytime you are sedating somebody

deep sedation

Delirium or dementia? ● Affects as many as 50% of people older than 65 and as many as 80% of ICU patients ● Associated with poorer outcomes ● Preventable and/or reversible in many cases

delirium

Drug therapy for management of _______ is reserved for patients with severe agitation and nonpharmacologic intervention failure. Drug therapy includes: ● Dexmedetomidine in the ICU setting ○ An IV drug, alpha blocker that blocks the stress response and kind of causes a little bit of sedation ○ Patient needs to preferably need to be on ventilator and if not, need to be monitored closely ● Low-dose antipsychotics haloperidol, risperidone, olanzapine & quetiapine (controversial). ○ Controversial because antipsychotics have a lot of side effects on their own ● Short-acting benzodiazepines (e.g., lorazepam) ○ ______ associated with alcohol and sedative withdrawal ○ used in conjunction with antipsychotics to reduce extrapyramidal SE. ○ Want to stick with these short acting if you can

delirium

Drug therapy for management of _______ is reserved for patients with severe agitation and nonpharmacologic intervention failure. We try to not use drug therapy for ______ because a lot of times it is the drugs that contribute or even cause it but if you have patients with severe agitation or _____ and your non-pharmacological methods failed then you may need to resolve to drugs.

delirium

Management of ______ includes the following: ● Familiar objects and family ○ Family member can stay with them and may help ● Frequent reorientation ○ Constantly letting them know where they are and why ● Reduce environmental stimuli ○ Adequate sleep, manage pain and anxiety

delirium

Management of ______ includes the following: ● Try to ID and eliminate possible causes ○ Polypharmacy, pain, nutritional status and feed as appropriate ● *****Goal with ______ is early recognition and treatment***** ● Protect from harm because they can cause harm to themselves when in this delirious state ● Create a calm and safe environment ○ Modify environment as much as you can to ensure patient does not injury themselves ● Familiar objects and family ○ Family member can stay with them and may help ● Frequent reorientation ○ Constantly letting them know where they are and why ● Reduce environmental stimuli ○ Adequate sleep, manage pain and anxiety

delirium

Manifestations of ______ vary and can include: ○ Hypo to hyperactivity or both ○ Most cases symptoms develop in 2-3 days ○ Inability to concentrate, disorganized thinking, irritability, insomnia, loss of appetite, restless and confusion ○ Later manifestations may include agitation, misperception, misinterpretation and hallucinations.

delirium

The following are causes of ________: ● Dementia, dehydration ● Electrolyte imbalances, emotional stress ● Lung, liver, heart, brain, kidney dysfunction ● Infection, intensive care unit ● Rx drugs (polypharmacy) ● Injury, immobility ● Untreated pain, unfamiliar environment ● Metabolic disorders ● Lack of sleep ● Oxygenation (brain is very sensitive to hypoxemia so if pt. very confused check O2 sat) ● Electrolyte imbalance (especially Na) ● Drugs (narcotics, psychotropic) ● Hypoglycemia (act almost like a stroke pt.) ● Fever, Infection (especially in Geriatrics - OA with UTI is common example)

delirium

The following are causes of ________: ● Lack of sleep ● Oxygenation (brain is very sensitive to hypoxemia so if pt. very confused check O2 sat) ● Electrolyte imbalance (especially Na) ● Drugs (narcotics, psychotropic) ● Hypoglycemia (act almost like a stroke pt.) ● Fever, Infection (especially in Geriatrics - OA with UTI is common example)

delirium

The following are some causes of _______: ● Neurological (TIA, meningitis, encephalitis, brain abscess) ● MI ● Infection (sepsis, fever) ● Respiratory hypoxia, PE ● Alcohol withdrawal ● Glucose (hyperglycemia/hypoglycemia) ● Metabolic Issues (esp. Na) ○ Metabolic: electrolyte imbalances, particularly sodium (high or low sodium—often times have neurological symptoms)

delirium

The following is how _______ is diagnosed: ● History and physical ● Medication review (try to minimize the amount of medications they get) ○ See if there is anything we can get rid of; the more meds they are in, the more risk for med interactions, side effects, adverse reactions that cause contribute to delirium ● Confusion Assessment Method (CAM) or CAM-ICU - reliable tool for assessing ______ (table 59-18) ○ Most common _______ assessment tools

delirium

The following is treatment of ______: ● Correct the cause first if this is possible by identification of true cause ● *****Correct the cause if identified****** ○ Calm environment, look at medication list, reorient constantly ○ Try to manage it non-pharmacologically because a lot of times it is the drugs that cause the delirium ● If you cannot resolve the _______ in a reasonable time frame or the patient is at risk to himself then you may need to intervene with pharmacological measures: ● Neuroleptic ○ Haloperidol (Haldol) ● Antipsychotic ○ Olanzapine (Zyprexa)

delirium

What is the most common **atypical** illness in older adults in critical care? ○ Most common atypical illness presentations are "_______" or "acute change in mental status", caregiver may say the patient is "acting differently" or no longer participating in self-care activities ○ May have multiple co-morbidities, diagnosed and undiagnosed. ○ Care can be complex and challenging requiring skilled assessment and creative nursing interventions

delirium

What mental health disorder/problem is described below: ● Occurs in up to 87% of mechanically ventilated patients in the ICU—so it's a big problem in the ICU setting ● Associated with increased mortality, ICU stay, and health care costs. ○ So, it is important to recognize and intervene ● 98% of nurses routinely assess sedation level whereas only 47% assess for the presence of _______. ○ So, ______ should really be a part of your routine assessment in the acute care setting especially in the ICU setting or if they are on a vent, very ill, etc.

delirium

When assessing for signs and symptoms of _____, nurses should assess: ● Behavior changes: ○ Seeing things that don't exist (Hallucinations)- lots of times see family members that are not living ■ See things crawling on the wall ○ Restlessness, agitation, irritability or combative behavior- might think that they are in their house and you are breaking in trying to steal something; or that you're trying to restrain them -highly aroused ○ Disturbed sleep habits ○ Extreme emotions, such as fear, anxiety, anger or depression

delirium

When assessing for signs and symptoms of _____, nurses should assess: ● Poor thinking skills (cognitive impairment); this may appear as: ○ Poor memory, particularly of recent events ■ So, they may have good long-term memory but very poor short term memory ○ Disorientation, or not knowing where one is, who one is, or what time of day it is, may not recognize people they should be recognizing ○ Difficulty speaking or recalling words ○ Rambling or nonsense speech ○ Difficulty understanding speech ○ Difficulty reading/writing

delirium

When assessing for signs and symptoms of _____, nurses should assess: ● Reduced awareness of the environment may result in : ○ Inability to stay focused on a topic, still smart in the beginning stage (don't ask specific date maybe ask what day of the week, month, year) ○ Wandering attention (esp. OA at night) ○ Getting stuck on an idea rather than responding to questions or conversation ○ Being easily distracted by unimportant things ○ Being withdrawn, with little or no activity or little response to the environment

delirium

________ is fluctuations in mental status, inattention, disorganized thinking ○ (Worsen clinical outcomes and increased LOS) ○ Quick onset; did not have a problem prior to being admitted ○ This is an **ACUTE PROBLEM**. It is not a problem that the patient has had for years; it is something that occurs due to the acute health problem that this patient is having

delirium

_________ is a state of temporary but acute mental confusion; reversible global impairment of cognitive processes—disorientation, impaired short-term memory, altered sensory perception, and inappropriate behavior ○ Problem that is significant in ICU patients; somewhere around 50-60% of patients in the ICU have at least 1 episode of ______ during their stay ○ If not managed or taken care of, it can result in poor outcomes. Both anxiety can cause _______ and agitation is often a component of _______

delirium

______ is a slow, progressive, irreversible loss of intellectual or cognitive abilities like abstract thinking, reasoning, pathological (higher risk for delirium when in critical care) ○ Ask the family about thought processes and reasoning BEFORE they were in the hospital

dementia

The following are causes of ST _______: § Ischemia § Hypothermia § Hypokalemia § Tachycardia § Subendocardial infarct § Reciprocal ST elevation § Ventricular hypertrophy § Bundle branch block § Digitalis

depression

When talking about the diagnosis of an acute myocardial infarction (AMI), we look at ECG changes. We diagnose a patient with an AMI if we see an ST ______ (> 0.5- 1 mm)—suspicious especially in patient who presents with symptoms § If with positive cardiac enzymes=NSTEMI **ACS

depression

When talking about settings and mode for vents, settings are based on patient status including things such as ABGs, body weight, LOC, muscle strength, etc. settings includes rate, depth, alarms, inspiratory time, and FiO2. Which of these settings is described below: ○ how much tidal volume do we want them to pull in?) ■ Tidal volume- volume ventilation ● If volume ventilating someone you will have a tidal volume and that will be based off of the patient's height, weight, and underlying medical condition ● Usually between 500-700 ● Physiicans have formula to figure it out ■ Pressure- pressure ventilation ● If doing pressure ventilation instead of tidal volume setting, you will have a pressure setting and it will be somewhere around lower twenties, upper teens

depth

What modifiable risk factor for CV disease is described below: o Goal: HbA1C level < 7% § People who have a chronically elevated blood sugar are at high risk because those elevated serum glucose levels damage the artery wall (remember that damaged intimal layer is what sets them up for plaque and fatty acids to adhere to that wall)

diabetes

What essential of AACN/CCRN (assessment, diagnosis, outcome identification, planning, implementation, interventions, education and emotional support, and evaluation) is described below: ○ assisting w/medical dx & nursing dx (ex: pt. on a ventilator has Dx of ineffective airway clearance, ineffective gas exchange - work w/respiratory therapist, interpret ABG's)

diagnosis

What stage of the cardiac cycle is described below: ○ During atrial _______, blood from the superior and inferior vena cavae and the coronary sinus enters the right atrium. The right atrium fills and distends, pushing the tricuspid valve open, and the right ventricle fills. The same sequence occurs a split second earlier in the left heart. The left atrium receives blood from the four pulmonary veins (two from the right lung and two from the left lung). The leaflets of the mitral valve open as the left atrium fills and blood flows into the left ventricle. ○ Ventricular systole occurs as atrial _______ begins. As the ventricles contract, blood is propelled through the systemic and pulmonary circulation and toward the atria. The semilunar valves close, the heart then begins a period of ventricular _______ during which the ventricles begin to passively fill with blood and both the atria and ventricles are relaxed. The cardiac cycle begins again with atrial systole and the completion of ventricular filling.

diastole

elevated BP

diastole

What stage of the cardiac cycle is described below: ○ In a resting adult, each cardiac cycle lasts approximately 0.8 sec (800 msec). Atrial systole requires about 0.1 sec, and ventricular systole about 0.3 sec. Atrial ______ lasts about 0.7 sec and ventricular ________ about 0.5 sec during each cardiac cycle. ○ During the cardiac cycle, the pressure within each chamber of the heart rises in systole and falls in _______. The heart's valves ensure that blood flows in the proper direction. Blood flows from one heart chamber to another if the pressure in the chamber is more than that in the next. These pressure relationships depend on the careful timing of contractions. The heart's conduction system provides the necessary timing of events between atrial and ventricular systole. ○ During atrial _______, blood from the superior and inferior vena cavae and the coronary sinus enters the right atrium. The right atrium fills and distends, pushing the tricuspid valve open, and the right ventricle fills. The same sequence occurs a split second earlier in the left heart. The left atrium receives blood from the four pulmonary veins (two from the right lung and two from the left lung). The leaflets of the mitral valve open as the left atrium fills and blood flows into the left ventricle. ○ Ventricular systole occurs as atrial _______ begins. As the ventricles contract, blood is propelled through the systemic and pulmonary circulation and toward the atria. The semilunar valves close, the heart then begins a period of ventricular _______ during which the ventricles begin to passively fill with blood and both the atria and ventricles are relaxed. The cardiac cycle begins again with atrial systole and the completion of ventricular filling.

diastole

What stage of the cardiac cycle is described below: ● period of relaxation during which the ventricles are filling; isoelectric line on EKG

diastole

Components of a good wave form includes: ■ Rapid upstroke & clear _____ ______ - clear end diastole point; shows arterial closure ● _____ ______ is where we have closure of the aortic valve ● Remember arterial pressures are systolic, diastolic, and what is in parentheses is a mean arterial pressure ○ Change in pressure will come a little bit after the QRS but should have one with each QRS ■ Upstroke will be right after the QRS

dicrotic notch

The following are ______ instructions for a PCI intervention: · Activity o No lifting over 5 lbs. o Activity is limited for a week § i.e. No cutting the grass § Take it easy—if an artery bleeds, it can bleed very fast and the patient can bleed out · They need to know if they develop a hematoma or if they start bleeding, then they need to go to the ED as soon as possible

discharge

The following are ______ instructions for a PCI intervention: · Keep incision site clean and dry o No ointments, powders or peroxide o Dressing is not usually necessary—usually keep the dressing on for 24 hours after the procedure and then remove it and let it stay open to air § If their underwear is irritating the incision then they can put a Band-Aid on it · Activity o No lifting over 5 lbs. o Activity is limited for a week § i.e. No cutting the grass § Take it easy—if an artery bleeds, it can bleed very fast and the patient can bleed out · They need to know if they develop a hematoma or if they start bleeding, then they need to go to the ED as soon as possible · Medications o Dual anti-platelet therapy (DAPT) § Aspirin plus a P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor) § Anti-platelet - Plavix, ASA daily o Beta Blockers o Ca+ Channel blockers—if they cannot handle the beta blockers § Ca+ to reduce workload on heart o Nitrates—to keep those vessels open § Reduce incidence of anginal attacks, nitro for re-occlusion

discharge

The following are ______ instructions for a PCI intervention: · Medications o Dual anti-platelet therapy (DAPT) § Aspirin plus a P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor) § Anti-platelet - Plavix, ASA daily o Beta Blockers o Ca+ Channel blockers—if they cannot handle the beta blockers § Ca+ to reduce workload on heart o Nitrates—to keep those vessels open § Reduce incidence of anginal attacks, nitro for re-occlusion

discharge

The following are ______ instructions for a patient post op cardiac surgery: · Activity o Continue walking 4 times a day and gradually increase their activity every day o Allow rest periods in between because they will get tired · TED hose o Prescribe in the hospital—usually recommend that they continue to use that until they get back to their normal activities o Also, should probably use there IS for a couple of weeks after they go home until their activity is back to normal

discharge

The following are ______ instructions for a patient post op cardiac surgery: · Expectations o Peaks and valleys—not uncommon for them to have a little depression postoperatively o 6-8-week recovery (probably even longer than that—let them know this) · Wound care teaching o If they are not draining anything then leave it open to air, clean and dry o Wash with soap and water (don't use peroxide unless they have a wound infection) · No driving o Their reaction time isn't good o If they have a sternotomy and they get into a wreck and hit their chest on the steering wheel that is not good)

discharge

The following are ______ instructions for a patient post op cardiac surgery: · Follow-up appointments o With their CB surgeon and with their cardiologist · Cardiac Rehab o A program that brings them back in 3 times a week to do monitored exercise § They are put on a cardiac monitor while they exercise and they work with an exercise physiologist to get their activity level back up

discharge

elevated fasting glucose

The following are ______ instructions for a patient post op cardiac surgery: · Medications (make sure they have the adequate prescriptions for what they should be on) o Aspirin (definitely) o Beta blockers (probably—especially if they went into a-fib) o ACE inhibitors (possibly) o Statins (if they have hyperlipidemia, they may need to be on these) o Pain medication (will need these—make sure the physician actually orders these before the patient goes home) · Expectations o Peaks and valleys—not uncommon for them to have a little depression postoperatively o 6-8-week recovery (probably even longer than that—let them know this) · Wound care teaching o If they are not draining anything then leave it open to air, clean and dry o Wash with soap and water (don't use peroxide unless they have a wound infection) · No driving o Their reaction time isn't good o If they have a sternotomy and they get into a wreck and hit their chest on the steering wheel that is not good) · Activity o Continue walking 4 times a day and gradually increase their activity every day o Allow rest periods in between because they will get tired · TED hose o Prescribe in the hospital—usually recommend that they continue to use that until they get back to their normal activities o Also, should probably use there IS for a couple of weeks after they go home until their activity is back to normal · Follow-up appointments o With their CB surgeon and with their cardiologist · Cardiac Rehab o A program that brings them back in 3 times a week to do monitored exercise § They are put on a cardiac monitor while they exercise and they work with an exercise physiologist to get their activity level back up

discharge

The following are sources of pain and ______: ○ Physical illness (myalgia pain), trauma (wound), surgery ○ Monitoring devices (tight BP cuff) ○ ET tubes, tracheostomy tubes, mechanical ventilation ○ Routine nursing care (suctioning, dressing changes, position changes, ambulation) ○ Prolonged immobility → muscle atrophy, stiffness, aching, hurts to move, etc.

discomfort

The following is a summary of PA catheters: ● Proximal Port → Right Atrium → RAP, CVP ○ RAP is preload of the R side of the heart ● ______ Port→ Pulmonary Artery→ PAP and PAWP (with the balloon inflated) ○ The PAWP is the preload of the L side of the heart NEED TO KNOW ALL OF THIS.

distal

What port of a pulmonary artery catheter is described below: ○ _________ port terminates in the PA - this allows for continuous monitoring of PAP & obtaining mixed venous/arterial blood samples for ABGs ○ Tells pressure in pulmonary vasculature. Normal is between 15-30 systolic and 4-12 diastolic. ■ Systolic and diastolic number ■ If someone has pulmonary HTN or L-sided heart failure you will see a really high pulmonary artery pressure ○ Also used to measure PAWP (requires balloon inflation - NEVER leave it inflated >15 seconds) ■ Inflate balloon until you see change in waveform ○ The ________ port is used to measure PAWP ○ Preload of the L side of the heart ○ Patients who have HF and do not eject well and do not have good forward flow of blood because of L ventricle, fluid backs up into the L heart because it is not ejecting well and backs up into the pulmonary artery. The pressures in the L side of the heart will be HIGH. ■ If the pulmonary artery wedge pressure is very low, the patient is probably volume depleted. ○ ******A HIGH pulmonary artery wedge pressure is almost always indicative of L-sided heart failure****** ○ *****Normal PAWP- 6-12 mm Hg****** ○ Wedge is preload of the left side of the heart ■ CVP is preload of RIGHT side of the heart

distal

What port of a pulmonary artery catheter is described below: ○ Also used to measure PAWP (requires balloon inflation - NEVER leave it inflated >15 seconds) ■ Inflate balloon until you see change in waveform ○ The ________ port is used to measure PAWP ○ Preload of the L side of the heart

distal port

What port of a pulmonary artery catheter is described below: ○ Patients who have HF and do not eject well and do not have good forward flow of blood because of L ventricle, fluid backs up into the L heart because it is not ejecting well and backs up into the pulmonary artery. The pressures in the L side of the heart will be HIGH. ■ If the pulmonary artery wedge pressure is very low, the patient is probably volume depleted. ○ ******A HIGH pulmonary artery wedge pressure is almost always indicative of L-sided heart failure****** ○ *****Normal PAWP- 6-12 mm Hg****** ○ Wedge is preload of the left side of the heart ■ CVP is preload of RIGHT side of the heart

distal port

Which port of the pulmonary artery catheter is used to measure PAWP? ○ A HIGH pulmonary artery wedge pressure is almost always indicative of L-sided heart failure ○ Normal PAWP- 6-12 mm Hg ALL VERY IMPORTANT. BOLD RED AND HIGHLIGHTED IN NOTES.

distal port

One main part of the nursing assessment for a patient post-CAB is to check the chest tube _______. · (mediastinal and pleural tubes are there to drain all that fluid from the chest because we don't want the fluid staying in the chest and causing problems) o Typically gets drained into a chest tube ________ system o Q 1 hour monitoring—because if they are bleeding at the surgical site that where you are going to see it § They always have some bleeding but if its excessive they may need some intervention like either some fresh frozen plasma because their coagulation studies are prolonged, or they might need some blood replacement or some platelets

drainage

Dexemedetomidine (Precedex) is given IV _____ NOT IV _____.

drip; push

dysrhythmias

education and emotional support

Calcium channel blockers and beta blockers are medications that affect primarily _____ _____ in the heart.

electrical conduction

o EKG/ECG o A graphic representation of the heart's electrical activity. § Gives us an idea of what is happening electrically within the heart o Does not provide information about the squeezing of the heart/mechanical (contractile) condition of the myocardium o Illustrated on a graph o A standard electrocardiogram consists of 12 Leads (angles/eyes looking at the wall of the heart)

electrocardiogram

elevated triglycerides

The following are causes of ST ______: § Infarction § Vasospastic angina § Pericarditis § Early repolarization (athletes)

elevation

When talking about the diagnosis of an acute myocardial infarction (AMI), we look at ECG changes. We diagnose a patient with an AMI if we see an ST ______ (> 1 mm in limb leads (lead I, II, III, aVR, aVL, aVF) or 2mm in chest leads (v-leads v1-6)) in 2 or more contiguous leads (contiguous leads are either 2 leads looking at the same wall of the heart or 2 consecutive leads if it's the v-leads) § STEMI **ACS

elevation

When maintaining correct tube placement with artificial airways, improper position of an ET tube is considered a medical _______ and we need to bag patient immediately with FiO2 100%. We ALWAYS pass off tube placement in report (where it is taped, whether the landmark is the lips or teeth). ○ If the patient starts talking to you, more than likely either the tube got dislodged , cuff got blown, or vocal sounds are being made **nursing management of artificial airways

emergency

A continuous ____ ___ ____ monitoring is a monitor that detects amount of CO2 inhaled and gives idea of how well the patient is ventilating. *monitoring oxygenation and ventilation **nursing management of artificial airways

end tidal CO2

What is the gold standard advanced airway for mechanical ventilation?

endotracheal tube

What artificial airway for mechanical ventilation is described below: o Respiratory therapy usually comes around at least once a shift to put manometer on pilot balloon to test how much pressure is in there. o Because that tube is in the trachea, it helps to secure it there but it also prevents air from seeping around it. § When you mechanically ventilating somebody and blowing air in, you want it to expand the lungs and then you want to passively as the patient exhales, you want the air to go back out through the tube.

endotracheal tube (ET tube)

What artificial airway for mechanical ventilation is described below: o You do not want a whole lot of leakage of air around here during inspiration (talking about cuff/balloon). § This cuff helps prevent loss of pressure. oBecause air does not go around the tube then no air goes over the vocal chords §***** if air is passing over the vocal chords that makes vocal sounds and so when patients have ________ tubes or tracheostomy tubes with a cuff on them they should NOT be able to make vocal sounds and not be able to talk to you.**** o****** If they are talking to you either your tube got dislodged and is not where it should be or your cuff was deflated/not enough air in it, or the cuff exploded/popped. Patients with an ET tube should NOT be making noises.*********

endotracheal tube (ET tube)

What artificial airway for mechanical ventilation is described below: · **all _________ tubes have the same type of connector (universal connector) and they connect to the ambu bag. o If you take the mask off the ambu bag, that area where the mask connects to the ambu, that piece will fit right on top of the _________ tube. It will also fit on the tracheostomy tube.

endotracheal tube (ET tube)

What artificial airway for mechanical ventilation is described below: · **there are markings on the tube and once the tube is in place you will verify placement by listening to breathe sounds and stomach for gurgling (if hear gurgling, probably in esophagus and needs to be done again). o You listen to the base and apex of the lung, air exchange, should be bilateral and equal.

endotracheal tube (ET tube)

What artificial airway for mechanical ventilation is described below: · Most adult ________ tubes will be cuffed and that means that they have a balloon on them and that balloon helps to secure that tube in the trachea. o The tubing to the port is how you inflate the balloon. o You inject air in through this port and the balloon inflates and this is called a pilot balloon because the more pressure you have in this balloon you will be able to feel it to estimate how much pressure is in that balloon (compress between fingers). o This is one of the assessments you will make if taking care of a patient with an ________ tube. o If the balloon is inflated too much and there is too much pressure on the trachea, that can cause tissue necrosis, tissue erosion, and a TE fistula if it really erodes away the trachea. o So, you always want to have the right amount of pressure in the cuff. ***20-25 mmHg of Mercury is what is recommended.******

endotracheal tube (ET tube)

What artificial airway for mechanical ventilation is described below: · Once you verify placement, you want to document where, using the measurements on the tube, you tape the tube at the lip or teeth. o It is usually in sonometers and somewhere between 20-24 sonometers. o The taller the patient, the deeper the tube will go in. · document and pass on in report where that tube is secured whether at lip or teeth.

endotracheal tube (ET tube)

What artificial airway for mechanical ventilation is described below: · You want to use the biggest size tube that the patient's trachea can accommodate. If the tube is really small it will be hard to ventilate them because it is like blowing air or breathing through a straw. o The bigger the tube, the easier to ventilate. o Usually the rule of thumb is about the size of the patient's pinky. o Adult sizes are usually around 7-10; females take 7-7 ½ and males take 7 ½ - 8 and if tall maybe even 9 or 10. o Whoever is intubating will tell you what size they want but need to use biggest tube patient can accommodate. · Make sure you document where it is secured, pass on in report, and monitor that closely along with the pressure in the cuff.

endotracheal tube (ET tube)

What artificial airway for mechanical ventilation is described below: · You will then get a chest x-ray which is the gold standard for confirming placement. o The tip of the tube should sit about 2 sonometers above the carina which is where the bronchi meet or divide from the trachea. o You do not want the tube hitting the carina because that will cause the patient to cough (where cough reflex is) and you will not be able to ventilate them. · Once you verify placement, you want to document where, using the measurements on the tube, you tape the tube at the lip or teeth. o It is usually in sonometers and somewhere between 20-24 sonometers. o The taller the patient, the deeper the tube will go in.

endotracheal tube (ET tube)

What artificial airway for mechanical ventilation is described below: ○ If the patient is making noise, this means there is not enough pressure (air is escaping around the tube and passing through the vocal cords) ○ ET intubation is more common in the ICU setting than tracheostomy ■ Intubation can occur quickly & safely at the bedside

endotracheal tube (ET tube)

What artificial airway for mechanical ventilation is described below: ○ Indications for ET intubation include: ■ (1) Upper airway obstruction, (2) apnea, (3) high risk of aspiration, (4) ineffective clearance of secretions, (5) respiratory distress ■ Only indicated for pt. expected to require less than 2 weeks on the ventilator ○ Assisting with Intubation: ■ Ambu bag available & attached to O2, suctioning equipment ready at the bedside & IV access ■ Prepare for rapid-sequence intubation (RSI)

endotracheal tube (ET tube)

What artificial airway for mechanical ventilation is described below: ○ Mark the tube with tape after insertion to make sure it does not move in and out ○ Administration of both a sedative & paralytic agent during emergency airway management (done to decreases risk of aspiration & injury) ○ Sedative-hypnotic-amnesic such as Versed is used to induce unconsciousness ○ Rapid-onset opioid is given to blunt the pain of intubation (Fentanyl)

endotracheal tube (ET tube)

What artificial airway for mechanical ventilation is described below: ○ Paralytic drug such as succinylcholine is given to produce skeletal muscle paralysis ■ Position pt. appropriately to allow visualization of the vocal cords (sniffing position) ■ Pre-oxygenate pt. using ambu bag & 100% O2 for 3-5 minutes (hyperoxygenate) ■ Confirm proper placement using an end-tidal CO2 detector (look for color or number change) ■ Auscultate lungs for bilateral breath sounds & the epigastrium for the absence of air sounds ■ Observe chest for symmetric chest wall movement ■ Obtain ABG lab values within 25mins after intubation is confirmed to determine pt. baseline oxygenation & ventilation status (continuous pulse-ox & end-tidal CO2 monitoring gives info about arterial status)

endotracheal tube (ET tube)

What artificial airway for mechanical ventilation is described below: ○ Temporary measure; may stay in a week maybe 2 weeks at the max ○ Tube is placed into the trachea via the mouth or nose past the larynx (mouth to trachea) ○ Do not want too much pressure because the balloon can cause tissue necrosis of the trachea

endotracheal tube (ET tube)

What are the 2 artificial airways talked about in mechanical ventilation?

endotracheal tube and tracheostomy tube

What type of bypass surgery is described below: **traditional CABG** · Nowadays, they more often do an endoscopic vessel harvesting · They use endoscopy to make minimal incision o Usually make 2 or 3 depending on how much of the vein they need o Clip the vein in two places and pull it out · Patients have had much less problems with the leg incision since moving to the ____ ____ ____

endovascular vein harvest (EVH)

What type of nutrition is preferred for ICU patients? ○ Preserves the structure and function of the gut mucosa and prevents bacterial translocation ○ Associated with fewer complications and shorter hospital stays ○ Whenever possible, ______ is always preferred over parenteral! ○ Oral, _______, and last resort is parenteral

enteral

An ______ is usually used for thoracic/abdominal surgery (colon resection, lobectomy) ○ Fentanyl/Bupivacaine (increased respiratory sedation, CMS, epidural hematoma) ○ ________ hematoma is an emergency - can happen sometimes when pt. is on Lovenox & have increased bleeding time & they puncture the epidural space for procedure

epidural

The goal of ______ pain control treatment is to provide pain management without increasing the risk of respiratory depression—so it is thought that if you give it via _______ then whatever level of the spinal column you inject it in it will anesthetize the spinal column below that area and if it is inserted below the diaphragm then theoretically you shouldn't have a lot of respiratory depression ■ But sometimes it can migrate upward, especially if the patient is laying recumbent—so it can cause some respiratory sedation (don't assume that it won't) ● Need to assess for this in patients with a PCA, either epidural or IV

epidural

Additional ______ of AACN/CCRN includes: -- Interpretation and mgmt cardiac rhythms -- Hemodynamic monitoring -- Circulatory assist devices -- Airway and ventilator management -- Pharmacology -- Pain -- Sedation

essentials

The ______ of AACN/CCRN presents core information that new clinicians must understand to provide safe, competent nursing care to all critically ill patients, regardless of their underlying medical diagnoses. These ______ include: assessment, diagnosis, outcome identification, planning, implementation, interventions, education and emotional support, and evaluation.

essentials

What essential of AACN/CCRN (assessment, diagnosis, outcome identification, planning, implementation, interventions, education and emotional support, and evaluation) is described below: are we meeting our goals, if not we need to re-plan, ongoing ○ A LOT OF Collaboration/potential complications/risk for(s)/PC/Risk

evaluation

How often does the tubing for propofol need to be changed? ● High lipid content (delivers 1.1 kcal/mL as fat) - all tubing & solution must be changed q____h (tubing is harder & has a more yellowish color than normal tubing) ○ It is fat based ■ We have to change the tubing every _____ hours (twice a day) ○ Provides the patient with calories—if they are taking a considerable amount of this then dietitian needs to take this into account ○ Comes in a 100 mL bottle for IV drip so it doesn't usually last more than _____ hours ■ Every ______ hours, tubing has to be changed

every 12 hours

How often should the nurse assess cuff pressure in artificial airways? **Nursing management of artificial airways (maintaining proper cuff inflation)

every 8 hours

If someone is infarcting, it is an ______ and takes some time, usually a few hours o Initially might have ST elevation that gets worse and then start to develop a Q wave and it gets deeper and invert the T wave and then once the tissue infarcting, it is infarcting but the ST segment elevation or depression will resolve and the Q wave will stay forever. Inverted T wave may stay awhile but eventually it will go back up but the Q wave is going to stay. Sometimes it takes anywhere from 6-12 hours before a Q wave to show up during the _______ of ST segment MI

evolution

One of the main side effects of Haldol is ______ symptoms (EPS). Risk of this occurring increases with concurrent use of a Benzodiazepine.

extrapyramidal

The following is outcomes for patients post cardiac surgery AFTER being _______: · Ambulate 3-4 times a day · IS (incentive spirometer) q 1 hour while awake · Nutrition o It is not uncommon for them to have a little nausea or a lack of appetite or they may not want to eat the food the hospital has o Usually for the first month we don't worry so much about the heart healthy diet because we just want them to get enough calories § Let them eat what they want to eat just to give them enough calories and nutrition o After a month, they need to get on that heart healthy diet to prevent progression of the disease

extubated

The following is outcomes for patients post cardiac surgery AFTER being _______: · Chair for meals · Arm limitations o For patients who had a sternotomy, it takes 6-8 weeks for bone to heal (their bone was sawed open and wired back together)—its very important that they do not shift that sternum for 6-8 weeks § We don't want them using their arms to push themselves up to a sitting position § Have to help them and teach them to use their quadricep muscle to push themselves up § Every time they use their arms, it shifts the sternum, so it doesn't heal as well and that increases their risk for sternal wound infections · Ambulate 3-4 times a day · IS (incentive spirometer) q 1 hour while awake · Nutrition o It is not uncommon for them to have a little nausea or a lack of appetite or they may not want to eat the food the hospital has o Usually for the first month we don't worry so much about the heart healthy diet because we just want them to get enough calories § Let them eat what they want to eat just to give them enough calories and nutrition o After a month, they need to get on that heart healthy diet to prevent progression of the disease · Wean oxygen prn (if patients stats are good and they aren't out of breath then you want to start weaning them off) o Want them off as soon as possible · Shower after chest tubes are out o Sponge baths prior to chest tube being taken out

extubated

The following is outcomes for patients post cardiac surgery AFTER being _______: · Wean oxygen prn (if patients stats are good and they aren't out of breath then you want to start weaning them off) o Want them off as soon as possible · Shower after chest tubes are out o Sponge baths prior to chest tube being taken out

extubated

What are 2 things that increase the demand for oxygen?

fever and exercise

What type of thrombolytic drugs for MI treatment is described below: COMPLICATIONS: o Bleeding - biggest issue! § Dissolve clots anywhere in body § Weak vessel in head or aneurysm - big stroke/die because can't clot · High risk for having intracranial hemorrhage—not a whole lot we can do for this § Also worry about them bleeding in areas where it's a non-compressible vessel (GI or something where you can't hold pressure to stop the bleeding) § Effects last about 4 hours so need to be monitored. **management of MI

fibrinolytics

What type of thrombolytic drugs for MI treatment is described below: COMPLICATIONS: o Reperfusion arrhythmias - heart can be irritable, usually self-limiting, most common is accelerated idioventricular rhythm but can have v-tach or v-fib, need monitored environment with telemetry § Arrhythmias that occur when that clot is dissolved and all of a sudden, the flow is restored to the myocardium so you have an ischemic, irritable myocardium that now has flow and it just becomes very irritable so they are high risk for vtac, vfib, idioventricular rhythms, heart blocks, etc. · So, they need to be in a monitored setting where we can intervene should they have any arrhythmias § Can usually be managed so its not the worst thing **management of MI

fibrinolytics

What type of thrombolytic drugs for MI treatment is described below: CONTRAINDICATIONS: o Absolute- ICH (intracerebral hemorrhage), IC neoplasm, CHI (closed head injury) w/in 3 months, active internal bleed, suspected aortic dissection o Relative- uncontrolled HTN (SBP>180/DBP>110), ischemic CVA < 3 months, Prolonged CPR > 10min, rectal bleed, pregnancy, use of anticoagulants § If high BP, try to get it down first before giving thrombolytics (also make sure you can even give it at all) · AHA has guidelines to use some Betablockers · If you can get it down in a reasonable timeframe then you can go ahead and give the thrombolytic after physician and patient/family consent § CVA= high risk cerebral bleed · This checklist can be started by paramedics to help expedite the processes **management of MI

fibrinolytics

What type of thrombolytic drugs for MI treatment is described below: · In cases where PCI is not available maybe due to being in a rural area and it would take more than 120 minutes to get them over to a facility that can do PCI then this may be an option as a bridge until we can get them over to a tertiary care center · Note: the most reliable marker that reperfusion has occurred is ST segment back to baseline **management of MI

fibrinolytics

What type of thrombolytic drugs for MI treatment is described below: · Increased risk (more risk than with PCI) with it because thrombolytics are not specific to clot in the coronary artery—it is going to dissolve clot anywhere o So it increases risk for the patient if they have any cuts, bruises, weakened vessels in the brain (if the patient bleeds in the brain there is only so much space in that brain and more than likely they won't do well if they end up with an intracerebral hemorrhage secondary to ________) **management of MI

fibrinolytics

What type of thrombolytic drugs for MI treatment is described below: · Not the favored option o Its just a bridge (just dissolves that thrombus that is in there—doesn't do anything for the plaque)—a temporary measure o Reestablishes flow but still need to follow up with some other type of intervention (PCI, CABG, medical management) **management of MI

fibrinolytics

What type of thrombolytic drugs for MI treatment is described below: · Types/brands/generics: o Streptokinase—1st one, rarely used o Anistreplase - Eminase o Alteplase- Activase o Reteplase - Retavase o Tenecteplase - TNK—most recent one, common for MI right now **management of MI

fibrinolytics

What type of thrombolytic drugs for MI treatment is described below: · Used only in ST elevation MI (not NSTEMI) · "Door to Needle" -- <30 minutes (efficient processes need to be in place) · Preferable to administer within 3 hours of symptoms but can be administered up to 12 hours of symptom onset. · Types/brands/generics: o Streptokinase—1st one, rarely used o Anistreplase - Eminase o Alteplase- Activase o Reteplase - Retavase o Tenecteplase - TNK—most recent one, common for MI right now · Not the favored option o Its just a bridge (just dissolves that thrombus that is in there—doesn't do anything for the plaque)—a temporary measure o Reestablishes flow but still need to follow up with some other type of intervention (PCI, CABG, medical management) · Increased risk (more risk than with PCI) with it because thrombolytics are not specific to clot in the coronary artery—it is going to dissolve clot anywhere o So it increases risk for the patient if they have any cuts, bruises, weakened vessels in the brain (if the patient bleeds in the brain there is only so much space in that brain and more than likely they won't do well if they end up with an intracerebral hemorrhage secondary to ________) · In cases where PCI is not available maybe due to being in a rural area and it would take more than 120 minutes to get them over to a facility that can do PCI then this may be an option as a bridge until we can get them over to a tertiary care center · Note: the most reliable marker that reperfusion has occurred is ST segment back to baseline **management of MI

fibrinolytics

LOOK AT IMAGE NUMBER 9 ON PHONE: **when it is wedged into a little capillary, all the pressures behind it are occluded. The tip is only sensing what is ______ of the balloon and what is _______ of the balloon is the L side of the heart. So all of the pressures on the L side of the heart; when the valve is open (if during systole, the valve would be closed but we are looking at end diastolic pressures), pressures get transmitted back to the tip of the balloon. The tip of the catheter is not on the L side of the heart, that is why we say it is indicative of pressures on the L side of the heart. **PAWP

forward

What level of sedation (light, moderate, deep, general anesthesia) is described below: ○ Positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. ■ Because the drug will suppress their respirations ■ We have to breathe for them ○ Cardiovascular function may be impaired. ■ When you sedate somebody and give them analgesics and anti-anxiety medicines, often times they become so relaxed that they have vasoplegia which is when even their blood vessels relax and then they become vasodilated and they get low BP ● May have to give the Ephedrine to vasoconstrict those vessels or put them on epinephrine/norepinephrine drips

general anesthesia

What intervention of nursing management of artificial airways is described below: ○ Use writing or blinking as a way to communicate (reduces anxiety r/t inability to communicate) ○ Physical discomfort often requires sedation (Morphine, Ativan, Propofol) ○ It is not comfortable to have an ET tube in. It causes a lot of anxiety and pain. You will probably be doing some pain and comfort measures, maybe even sedation. ○ Other big problem is communication. If they have a cuffed tube or tracheostomy tubes, they cannot make vocal sounds and cannot talk to you. Nurses caring for patients on the ventilator, get good at figuring out what patients need. Most of the time, you want water but they cannot have since they are NPO and the best you can do is swab mouth with moist swab or lemon swab. ■ Most ICUS have communication boards ■ If patient is awake enough they can write notes

fostering comfort and communication

What key term of mechanical ventilation is described below: Concentration of oxygen delivered to the pt. (in percentages, how much oxygen are we giving so 20%, 30%, 40%) ○ Typically someone who is getting extra oxygen will be more than 20% ○ Room air is 21%

fraction of inspired oxygen (FiO2)

What key term of mechanical ventilation is described below: ○ Nasal Cannula ○ 1L = 24% ○ 2L = 28% ○ 3L = 32% ○ 4L = 36% ○ 5L = 40% ○ 6L = 44% ○ Invasive ventilation (ET tube) ○ Total lung capacity includes both vital capacity & residual

fraction of inspired oxygen (FiO2)

What does FiO2 stand for? ■ which percentage of oxygen are you delivering to the patient ■ On the ventilator, we have a "blender" and you dial in the percent of oxygen you want the patient to have. The ventilator uses piped in oxygen and piped in compressed air to blend it to get that precise percentage of oxygen (goal is to achieve optimal oxygenation with lowest FiO2 possible) **settings for ventilators

fracture of inspired oxygen

What ventilator setting is described below: (TV, RR, FiO2, PEEP, PS) ● lowest % to achieve PaO2 of at least 60%

fracture of inspired oxygen (FiO2)

What key term of mechanical ventilation is described below: the volume of air remaining in the lungs after maximal exhalation ○ This is what is used to direct treatment with PIP & CPAP (treatment increases amount of residual air allowing for a longer time for air exchange) ○ There is some air always in the lungs

functional residual capacity

What critical care specialty unit is described below: ○ Hemodynamically unstable or need a high level of care

general ICU

What level of sedation (light, moderate, deep, general anesthesia) is described below: (highest level of sedation; total loss of consciousness) ○ Usually give you a sedative before they put you under general anesthesia ○ A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. ■ We do not want any responses from them ○ Used when a patient is going into surgery ■ Administered by an anesthesiologist or a nurse anesthetist under the guidance of an anesthesiologist

general anesthesia

What level of sedation (light, moderate, deep, general anesthesia) is described below: Responsiveness: Unarousable, even w/painful stimulus Airway: Intervention often required Spontaneous Ventilation: Frequently inadequate CV Function: May be impaired

general anesthesia

What level of sedation (light, moderate, deep, general anesthesia) is described below: ○ The ability to independently maintain ventilatory function is often impaired. ○ Patients often require assistance in maintaining a patent airway. (will be intubated or ambu) ■ Tend to be intubated and ventilated because they cannot breathe

general anesthesia

A high wedge pressure could mean? **pulmonary artery catheters

heart failure

Complications of MIs include dysrhythmias, cardiogenic shock, papillary muscle dysfunction, ventricular aneurysm, pericarditis, Dressler Syndrome. Which of these complications is described below: · depends on how much muscle damage/how big the MI was. o Some patients can have acute ____ ______ that is caused by the heart being stunned (stunned myocardium)—its from the ischemia—will typically improve as the patient improves and as we intervene and reestablish their coronary flow o Patient who have significant infarction, especially in the left ventricle, are at high risk for ____ _____ and cardiogenic shock

heart failure

The secondary goal in patients with ACS is to prevent Major Adverse Cardiac Events (MACE). MACE includes heart failure, cardiogenic shock, papillary muscle rupture, left ventricular aneurism, lethal dysrhythmias, and ventricular septal wall rupture. Which of these MACE is described below: o ____ _____ risk if enough of the myocardium is damaged (especially the left ventricle—it won't squeeze well and the patient could end up having acute and/or chronic ___ ____) (lose enough muscle mass, heart blocks & need pacemaker, pericarditis). **collaborative management/goals

heart failure

Post cardiac surgery, the nurse needs to control bleeding complications. If we have more than 150 cc/hr for a couple of hours, that requires intervention. Blood replacement based on amount of volume they lost and _______ § But don't use just the ______ because that lags behind

hematocrit

· If one happens during the acute setting, usually the patient is going to start bleeding or if they bleed under the skin it is going to look like they have a big grapefruit laying on their femoral area o If this happens, then you need to hold direct pressure over that femoral artery

hematoma from PCI

The following is all of the information about monitoring tubing for _______ monitoring: · You need a special monitoring system or also known as a special monitoring kit. This is special IV tubing with a transducer on it that you get off the supply cart. All ICU units will have these on the supply cart and they have monitoring kits that can monitor one line at a time (like below picture) or there are systems that can monitor 3 lines at a time o the IV tubing that goes from the transducer up to the bag of fluid is just like any other IV tubing: soft and compressible o the IV tubing from the transducer to the patient is hard. If you squeeze it between your finger you cannot compress it. the reason for this is that you do not want to have distention of the tubing because if the tubing was distendable you would lose some of that pressure and have false low readings. That is what is special about the monitoring kit: it has hard tubing from the transducer to the patient o the transducer is the device that receives the information transmitted from the tip of the catheter which also has a cable on it that goes to the patient's bedside monitor that brings the date from the transducer to the bedside monitor. The bedside monitor translate it into a digital reading that we can understand

hemodynamic

The following are indications for _____ _____: ● Used to monitor acutely ill individuals or those with cardiac disease undergoing surgery ● Examples: multiple trauma victims, MI, shock (changes in BP, CO, CI), prophylactically for extensive surgery, multiple organ dysfunction syndrome (MODS) which is complication of shock ○ PA cath for pts with heart surgery ○ Arterial line for a lot of ABGs or blood draws ● Healthcare providers are using more invasive monitoring devices less and less because of the risk (catheter associated infections). Definitely patients who are severely ill will probably get a pulmonary artery catheter put in

hemodynamic monitoring

There are different levels of _____ ______. The simplest level includes monitoring heart rate and rhythm and BP & end organ perfusion (MAP) >>> central venous pressure (CVP) and intra-arterial blood pressure ○ End organ perfusion of kidneys- urinalysis, BNP ■ Is the patient making urine? If they are making urine, you know they are perfusing their kidneys. If not perfusing their kidneys, they have a decreased cardiac output. ○ End organ of Liver- liver enzymes, ammonia levels, prolong PT, edema ○ CVP measured with catheters within the heart

hemodynamic monitoring

There are different levels of _____ ______. The simplest level includes monitoring heart rate and rhythm and BP & end organ perfusion (MAP) >>> central venous pressure (CVP) and intra-arterial blood pressure. For more sophisticated monitoring a pulmonary artery flow directed catheter (Swan-Ganz) might be used or stroke volume variation monitor may be used ○ The devices we mainly talk about is the Swan-Ganz AKA pulmonary artery catheter and arterial line

hemodynamic monitoring

What additional essential of AACN/CCRN (Interpretation and mgmt cardiac rhythms, Hemodynamic monitoring, Circulatory assist devices, Airway and ventilator management, Pharmacology, Pain, Sedation) is described below: ● will learn the norms & gauge your interventions based on pt. levels to the norms; will learn what to do, what's typically done, what doctor may order) ○ Non-invasive: BP, HR, Resp ○ Invasive: Swan ganz catheter

hemodynamic monitoring

What piece of technology in the ICU is described below: (ECG monitoring, positive pressure ventilation, hemodynamic monitoring, intracranial pressure monitoring, ventricular assist devices, continuous renal replacement therapy) o This is having specialized lines in place either in pulmonary artery or radial artery to monitor pressure such as pulmonary artery pressure or continuous monitoring of BP

hemodynamic monitoring

_____ _____ is used to assess (1) heart function, (2) fluid balance, (3) effects of fluids & drugs on CO. Using non-invasive tools, invasive catheters & highly technical monitoring systems the nurse can evaluate a pt. (1) cardiac function, (2) circulating blood volume, (3) physiologic response to treatment. ○ When we take BP, we are evaluating their hemodynamic status ● If the MAP is low in the kidneys, the kidneys are affected & you might see decreased BUN & creatinine & urinary output (normal MAP is usually > 70mmHg)

hemodynamic monitoring

_______ _________ is a general term referring to the determination of the functional status of the cardiovascular system - it is a measurement of pressure, flow & oxygenation within the system. ○ How is the CV system functioning? Is it meeting the needs of the body? ● It is used to assess (1) heart function, (2) fluid balance, (3) effects of fluids & drugs on CO

hemodynamic monitoring

● Indicated for anyone who is hemodynamically unstable (MI, septic shock, multi-organ failure, requiring aggressive drug therapy that needs more invasive monitoring **bedside monitoring

hemodynamic monitoring

Purposes of _________ includes to: 1. Aid in the diagnosis of various disorders (includes what you can gather from non-invasive monitoring such as BP, O2 sat, capillary refill, etc.) 2. Assist in guiding therapies to minimize or correct dysfunction (use of Swan-Ganz to see how therapy is working; use of ART lines to see how BP medication are affecting pt.) 3. Evaluate the pt. response to therapy (watch for rise in CVP if giving pt. fluids)

hemodynamics

Purposes of _________ includes to: 1. Aid in the diagnosis of various disorders (includes what you can gather from non-invasive monitoring such as BP, O2 sat, capillary refill, etc.) a. One frequent use is to try to differentiate between a cardiogenic pulmonary edema and respiratory pulmonary edema (fluid in lungs caused by HF, ARDS) i. ARDS—adult respiratory distress syndrome. You have damage to the alveoli capillary membrane causing capillary leak resulting in pulmonary edema ii. Can put pulmonary artery catheter in to determine whether cardiogenic pulmonary edema or respiratory pulmonary edema

hemodynamics

Purposes of _________ includes to: 1. Assist in guiding therapies to minimize or correct dysfunction (use of Swan-Ganz to see how therapy is working; use of ART lines to see how BP medication are affecting pt.) a. If we are titrating drugs such as vasopressors or positive ionotropes, we can use the number or feedback we get from the pulmonary line or pulmonary artery catheter to know how drugs are working

hemodynamics

Purposes of _________ includes to: 1. Evaluate the pt. response to therapy (watch for rise in CVP if giving pt. fluids) a. We give patients in HF Lasix. If we give Lasix, they diurese, they should get some volume off and their pulmonary and Left ventricular pressure should come down

hemodynamics

_________ is the study of forces involved in circulating blood - pump, pipes, fluid & electrical conduction (this includes everything that controls homeostasis such as HR, BP, blood volume, etc.) ○ Is the blood moving forward like it should? ○ Arterial lines and pulmonary artery

hemodynamics

There are 3 main complications of cardiopulmonary bypass: post perfusion syndrome ("pump head"), hemolysis of the RBCs, and capillary leak syndrome. Which of these 3 is described below: o The cells get beat up going through the mechanical pump and the hemolyze o The perfusionist has to heparinize the blood to try and prevent this—so they are also at risk for bleeding § Also do this to prevent the blood from clotting in those tubing or that circuit

hemolysis of the RBCs

A ____ PAP is caused by fluid volume overload, HF, MI, pulmonary HTN.

high

As mentioned earlier, the ventilator is designed to monitor many aspects of the patient's respiratory status, and there are many different alarms that can be set to warn healthcare providers that the patient isn't tolerating the mode or settings. The following are common ventilator alarms and their most frequent causes: ____ respiratory rate: -- Patient anxiety or pain -- Secretions in ETT/airway -- Hypoxia -- Hypercapnia

high

As mentioned earlier, the ventilator is designed to monitor many aspects of the patient's respiratory status, and there are many different alarms that can be set to warn healthcare providers that the patient isn't tolerating the mode or settings. The following are common ventilator alarms and their most frequent causes: ______ pressure limit: -- Secretions in ETT/airway or condensation in tubing -- Kink in vent tubing -- Patient biting on ETT -- Patient coughing, gagging, or trying to talk -- Increased airway pressure from bronchospasm or pneumothorax

high

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) Function: Delivers small amounts of gas at a rapid rate (60-100 breaths/minute); requires sedation/paralysis Clinical Use: Used for hemodynamic instability, during short-term procedures, or if patient is at risk for pneumothorax

high frequency ventilation (HFV)

When performing a pain assessment on a patient, we want to get their pain ______ because this will affect what type/dose of pain medication you will be giving. The pain _____ includes: ○ Prior acute pain experiences - Ever had this pain before? What treated it? (OA typically do well with just Tylenol for pain relief due to higher pain threshold; opioids typically alter LOC) ○ Chronic pain ○ Usual relief measures (heat, cold, rest, stretching, NSAIDs, walking, etc.) ○ May need to get orders to increase dose; may need adjunct therapy; may need anxiety medication to help reduce pain ○ Tend to have a higher tolerance for pain medications and it may take a lot more medicine to get their pain under control (chronic pain) ■ Normally titrate pain meds in the ICU—give a little at a time, reassess, see how patient is doing, give more ■ Knowing their pain ______ may help you to better estimate where to start and what to expect from the patient's response to their pain management Usual relief measures

history

When securing the artificial airway/tube: · The tube should be secured using a manufacture tube ______ o This is a ________ designed for ET tubes o Respiratory therapy normally changes this at least once a shift depending on what type of _______ they have o The tube needs to be moved to a different part of the lip periodically to prevent pressure sores · You can make a tube _______ out of trach-tape which is a temporary measure but most facilities now purchase tape or ______s specific for holding these tubes

holder

Aspirin can be used in the treatment of an MI (162-325 mg crush/chew). When the patient is going ______ they can take a maintenance dose, extended release if needed, don't need to crush/chew. 81 mg will be sufficient going _______. § They may also use the half dose (162 mg)

home

When maintaining tube patency for artificial airways, thick secretions can be limited by ensuring _______ & humidification ■ Do NOT instill NS into the ET tube (decreases SvO2) ■ Postural drainage, percussion & turning pt. q2h can help move secretions ○ Assessments are normally every 2 hours listening to their lungs

hydration

Prior to suctioning consider the need to: o We do not want to hyperventilate because we could blow off all CO2 making them alkaline o When suctioning, we are pulling out the patient's oxygen o Do not want to suction any more than 10-15 seconds

hyperoxygenate the patient

Morphine causes direct vasodilation (hypotension) which is NOT good for patients who are hemodynamically unstable. This effect makes it a useful drug for pt. with pulmonary difficulty (dilates bronchioles) & for pt. with coronary pain (given if nitro doesn't relieve pain). This can be a pro or a con depending on the patient. It would be a pro if the patient is ______ maybe because they are very anxious that vasodilation will probably be helpful OR patients who have ____ ______ (it also causes vasodilation in the pulmonary vasculature so that can help relieve some of the patients distress when they have ____ ______)

hypertensive; pulmonary edema

After completing the first 5 steps of the Surviving Sepsis campaign, in the event of persistent arterial _______ despite volume resuscitation (septic shock) or initial lactate 4 mmol/L (36mg/dl): ○ Measure central venous pressure (CVP) ○ Measure central venous oxygen saturation (ScvO2) ○ Bedside CV ultrasound ○ Dynamic assessment of fluid responsiveness with passive leg raise ● Re-measure lactate if initial lactate was elevated

hypotension

What are the 2 side effects of Nitroglycerin? o Brand name: Tridil

hypotension, headache! - treat with aspirin.

What is a desirable LDL cholesterol level? *bad cholesterol; primary target of therapy whether with diet or medications

ideal < 130 mg.dL

What common problem of critical care patients (nutrition, anxiety, pain and sedation, impaired communication, sensory-perceptual problems, sleep problems) is described below: ■ Sometimes when patients are really sick and need mechanical ventilation and they have a lot of anxiety and we are having trouble ventilating them because of anxiety level, we may need to paralyze them. We give them drugs that causes neuromuscular blockade, paralyzing them so we can ventilate them like we need to ■ Anytime you paralyze someone, you also need to sedate them because the paralytic does NOT sedate them ■ We may paralyze if they have status epilepticus and we need to stop their seizures

impaired communication

What common problem of critical care patients (nutrition, anxiety, pain and sedation, impaired communication, sensory-perceptual problems, sleep problems) is described below: ○ Management strategies for ____ _____: ■ Explain everything ● "hearing last to go" ○ Research has shown that hearing is the last thing to go. Even if you are not sure if the patient can hear you, you should still talk to them and let them know what is going on ■ Look directly at patient and use hand gestures as appropriate ● For patient is hard of hearing or on vent or has any recessive communication problems ■ Communication boards or note pads ● If on ventilator and cannot communicate ■ Nonverbal communications ■ Therapeutic touch

impaired communication

What common problem of critical care patients (nutrition, anxiety, pain and sedation, impaired communication, sensory-perceptual problems, sleep problems) is described below: ● have to establish some non-verbal way to communicate w/ pt.) ○ non-verbal is important. Use of picture boards, notepads, magic slates, computer keyboards ○ Can be a result of intubation, sedation/paralytics, or neurological impairment ■ Sometimes when patients are really sick and need mechanical ventilation and they have a lot of anxiety and we are having trouble ventilating them because of anxiety level, we may need to paralyze them. We give them drugs that causes neuromuscular blockade, paralyzing them so we can ventilate them like we need to ■ Anytime you paralyze someone, you also need to sedate them because the paralytic does NOT sedate them ■ We may paralyze if they have status epilepticus and we need to stop their seizures

impaired communication

Heart rate ________ by medications such as: ● Albuterol, Adderall Cocaine ● Epinephrine, Dopamine, Atropine

increased

● Hypovolemia = ________ stroke volume variation (SVV). ○ Patients who are hypovolemic will have a lot of variation in SV from beat to beat. When we breathe and we have changes in intrathoracic pressure, it deceases venous return. From beat to beat you will have a change in venous return and if someone is dehydrated it will be pronounced ○ They need fluids!!!! ***Minimally Invasive Hemodynamic Monitoring

increased

An _______ CVP indicates right ventricular HF or volume overload; ________ CVP indicates hypovolemia ■ Pre-load for the right side of the heart. ■ Right side filling pressures. ■ Mean reading ■ CVP stands for central venous pressure and is also known as RAP (right atrial pressure) ■ Sometimes the changes that occur with volume changes are delayed because we have a lot of compensatory measures

increased; decreased

Look on the monitor picture on phone for this question. What does the red number (78/48) mean? · if the patient has an arterial line, arterial pressuring line in the artery somewhere then you would get continuous reading of BP o The number beneath is (58) is the mean arterial pressure. With hemodynamic monitoring, anytime you see any numbers in parentheses, that is a mean pressure

indicates arterial BP

Look on the monitor picture on phone for this question. What does the pink line/number (0) stand for? o Typically is NOT 0; if someone's _____ is 0 usually means that they are very dehydrated and dry or they maybe equipment is not set right, maybe transducer is too high giving a false low reading

indicates central venous pressure AKA R atrial pressure or pressure in the R atrium of the heart

Look on the monitor picture on phone for this question. What does the yellow number (19/8) mean? · if the patient has a pulmonary artery catheter in place where the tip sits in the pulmonary artery, it would give you a continous reading of pulmonary artery pressures

indicates pulmonary artery pressure

Look on the monitor picture on phone for this question. What does the yellow number (99) mean? **second line from top underneath the green line

indicates the SpO2 or the oxygen saturation monitor

Post cardiac surgery we want to prevent _______. We can do this by doing the following: · Line _____s · Infective endocarditis o Could happen if they get a sternal wound infection · Pneumonia o Due to surgery, not taking deep breaths, not moving as much · UTI o Due to foley catheter (typically, try to get the foley out the next day)

infection

Post cardiac surgery we want to prevent _______. We can do this by doing the following: · Maintaining a normal glucose level is important to help prevent _____s o It has been shown that post-op patients with elevated blood sugars are at higher risk for developing _____s o If diabetic or have consistently high blood sugars, then they will probably be on a heparin drip

infection

Post cardiac surgery we want to prevent _______. We can do this by doing the following: · Operative wound ______ o Particularly difficult in patients who have had sternotomies because if they get a sternal wound ______ that is osteomyelitis (a bone infection) it is very difficult to treat o Be meticulous with your care—keep the wound clean o Leave the wounds open to air after the patient is off the vent (keep it clean and dry) · Line _____s · Infective endocarditis o Could happen if they get a sternal wound infection · Pneumonia o Due to surgery, not taking deep breaths, not moving as much · UTI o Due to foley catheter (typically, try to get the foley out the next day) · Maintaining a normal glucose level is important to help prevent _____s o It has been shown that post-op patients with elevated blood sugars are at higher risk for developing _____s o If diabetic or have consistently high blood sugars, then they will probably be on a heparin drip

infection

Name 5 complications of arterial lines.

infection, impaired circulation, hemorrhage, thrombus formation, and neuromuscular impairment

inspiratory time

internal mammary artery graft

What type of bypass surgery is described below: **cardiopulmonary bypass** · Advantages of using the mammary artery: it's an artery not a vein and veins have valves in them and its though that veins are more likely to become re-occluded more quickly than an artery would because arteries don't have those valves in them · Left or right internal mammary · Disadvantages: the mammary arteries have all of these little branches of vessel that branch off so the surgeon has to take care to clip all of those little branches or else the patient will bleed internally o One of the complications post-op is bleeding that is sometimes caused by one of these little clips coming off § If those clips come off then they can bleed and bleed very fast § A medical emergency · Can see a pacer wirer in the other picture (epicardial pacemaker threaded through the chest wall so if the patient has heart block or arrhythmia problems after surgery the nurse can quickly conner that pacer wirer up to an external pacemaker generator) o Will especially put these on high-risk patients o Temporary—until the patient recovers or is doing better

internal mammary artery graft

What type of bypass surgery is described below: **cardiopulmonary bypass** · Can see a pacer wirer in the other picture (epicardial pacemaker threaded through the chest wall so if the patient has heart block or arrhythmia problems after surgery the nurse can quickly conner that pacer wirer up to an external pacemaker generator) o Will especially put these on high-risk patients o Temporary—until the patient recovers or is doing better

internal mammary artery graft

intracranial pressure monitoring

intramural

When talking about post-operative care of a patient with CAB, the patient is initially ______ when they up to ICU because the patient goes straight to ICU and not to recovery. o Anesthesia is not reversed—they slowly let it where off and let the patient wake up o Goal is to extubate as early as possible—average is in 4-6 hours § Patient has to be able to take good deep breaths and maintain oxygenation and ventilation status, can lift their head and cough then they can be extubated § Extubation is a collaborative process between the nurse and the respiratory therapist

intubated

The following are nursing considerations for ___ pressure monitoring: ○ Position Pt- supine, flat or < 45 degrees ○ Zero reference point - stopcock nearest transducer ■ Will level transducer to where it is open to air with the phlebostatic axis ○ If transducer higher than axis = false low reading ○ If transducer lower than axis = false high reading **to get accurate readings, you need to make sure you have enough pressure on your bag (300 mm Mercury), enough fluid in bag, no air bubbles in tubing, make sure system is zeroed and level with phlebostatic axis, and make sure catheter is not kinked from bending of arm

invasive

_______ positive pressure ventilation: pressure ventilation and volume ventilation ○ Where you put either an endotracheal tube in or a tracheostomoy tube in and you blow air into the lungs. ○ Pressure and volume ventilation has more to do with how air is delivered Non-_______ positive pressure ventilation (NIPPV): CPAP and BiPAP **invasive or non-invasive

invasive

________ lines are used in the ICU to measure systemic & pulmonary BPs - equipment includes the catheter, pressure tubing, flush system & transducer **principles of ______ pressure monitoring (hemodynamics)

invasive

Invasive or Non-invasive POSITIVE pressure ventilation? ● Pressure Ventilation: ○ Ventilator delivers air until preset inspiratory airway pressure is present ■ Inverse I: E ratio (normal is 1:2) ■ Disadvantage of pressure ventilation is that the tidal volume varies according to pt. pulmonary system (how stiff patients lungs are) ● Hypoventilation & respiratory acidosis may occur in pt. with increased resistance to flow or decreased compliance (ARDS) ○ Not getting as much tidal volume in if pressure is set too low and patients lungs are really stiff ● With pressure ventilator, nurse MUST watch closely to ensure adequate tidal volume ○ Better distribution of air flow throughout alveoli ○ Physician orders a pressure and the respiratory therapist is usually the one who sets it up on the vent and dials up the pressure. The tidal volume is driven into the lungs until you reach that set pressure. The tidal volume will vary depending on how compliant or how stiff the patient's lungs are. ○ With volume ventilation, the pressure varies; with pressure ventilation the tidal volume varies. ○ Usually pressure ventilation is reserved for those patients with non-compliant lungs and the most common situation with that is patients with ARDS (adult respiratory distress syndrome). ○ The other thing you can do with pressure ventilation is reverse the I:E ratio: he inspiration to expiration ratio. Normally when we breathe, inspiration is about half the time of expiration so the normal I:E ratio is 1:2. With inverse ratio, they either make it 1:1 where inspiration is equal to expiration or maybe inspiration is twice that of expiration (2:1). The whole purpose of doing that is to give more time for the gases to cross the capillary membrane. Again, patients with ARDS have acute lung injury and the membrane gets thickened and stiffened and so it is harder for those gases to cross that capillary basement membrane. So by reversing the I:E ratio, it gives it more time for those gases to exchange.

invasive positive pressure ventilation

Invasive or Non-invasive POSITIVE pressure ventilation? ● Primarily used in acute care settings - requires artificial airway such as ET tube or tracheostomy tubes ○ Commonly ICU, anesthesia, ED ○ ET tube: short-term; tracheostomy: long-term ● Breaths are delivered until pre-set volume or pressure is reached (passive exhale); exhalation is passive ○ Air is driven into lungs and then exhalation occurs passively once delivery of breaths stops

invasive positive pressure ventilation

Invasive or Non-invasive POSITIVE pressure ventilation? ● Volume Ventilation: ○ Ventilator is controlled by pre-set volume (500mL of air is pushed in - intrathoracic pressure is raised during lung inflation rather than lowered) ○ It will deliver the pre-set volume regardless of changes in lung compliance or resistance ○ Exhalation occurs when inflow stops - passively ○ Volume is consistent with each breath, but airway pressures will vary ○ Referring to how that breathe is delivered, how that tidal volume is delivered ■ The physician is going to order some settings and one of those will be the tidal volume and the tidal volume will either be delivered until a set volume is reached or until a set pressure is reached. With volume ventilation, you set the tidal volume (amount of air in cc/mL that you want driven into that patient's lungs). With volume ventilation, it will deliver that tidal volume regardless of much pressure it takes to get that air in (regardless of lung resistance). ■ Patients who have very compliant lungs, it takes less pressure to drive to drive the air in. patients who have very stiff lungs, it takes more pressure to drive that air in. with volume ventilation, it does not matter how much pressure it takes it is still going to drive that air in. in patients with stiff lungs it can cause some barrel trauma or volume trauma and that can result in some weakened areas in the alveoli (blebs) which can pop or crack/fracture some alveoli. Again, with volume ventilation and pressure ventilation exhalation occurs when inflow stops and it occurs passively

invasive positive pressure ventilation

With INVASIVE positive pressure ventilation the main two concepts is volume ventilation and pressure ventilation. With pressure ventilation we have an ______ I:E ratio (normal is 1:2). With _______ ratio, they either make it 1:1 where inspiration is equal to expiration or maybe inspiration is twice that of expiration (2:1). The whole purpose of doing that is to give more time for the gases to cross the capillary membrane.

inverse

**this is an "_____ ______". The patient would lay in the _____ ______ with head coming out. It causes negative pressure around the patient's thoracic cage and pulls up the rib cage causing negative pressure and pulls air into the lungs. The good thing is, it does not have complications or adverse effects you have with positive pressure ventilation. The problem is it is more like an adjunct and may not be enough for a patient with respiratory failure, especially acute respiratory failure **NEGATIVE PRESSURE VENTILATION

iron lung

Name 4 examples of non-invasive NEGATIVE pressure ventilation.

iron lung, chest vest, body wrap, and body suits

An acute myocardial infarction (AMI) is tissue ischemia resulting in the death of myocardial tissue. ______ ____ ____ is something that can occur due to an AMI. o Once that tissue is dead you can't get it back—which is why our goals are very time sensitive o ACS is a very time sensitive process that we need to be ready to treat quickly (need to have processes in place to that things happen for these patients in an efficient manner) o (goal of treatment: time is muscle - the sooner you restore perfusion to the coronary tissues, the less damage you have to the muscle) **ACS

irreversible myocardial necrosis

The heart is a 2-sided pump. Which side of the heart is a HIGH pressure pump? ○ ______ ventricle pumps against the systemic vascular pressure. ○ The ______ side of the heart (____ ventricle and ______ atrium) pump to the ______ aorta to the systemic system and is pumping against your high pressures such as blood pressures (120/80 or above). Whereas the pulmonary artery pressure is normally between 15-30/5-15 so much lower pressures on the R side of the heart than the _____ side. This is the reason why the _____ ventricle has so much more muscle mass than the R ventricle because it is having to generate enough pressure to open up the aortic valve and squeeze blood through the valve into the systemic system.

left

When talking about coronary circulation in the heart, which coronary artery (R or L) supplies the SEPTAL and the ANTERIOR wall of the heart and brings blood supply to the anterior 2/3 of intraventricular septum, anterior L ventricle, Lateral L ventricle along with the circumflex (feeds the lateral wall of the heart) and the circumflex then brings blood supply to the L atrium, posterior L ventricle, and Lateral L ventricle? o Much better to have right-sided MI than ______ o Blockage in the _______ main artery commonly called the "widow maker"--> most people do not survive this because it feeds a lot of muscle

left

if someone had an SVR of 1800, then that is a really high pressure and that means the ______ ventricle has to generate even more force of contraction to open aortic valve and eject that blood.

left

if someone had an SVR of 400, then there is very little pressure on the other side of the aortic valve (afterload is very low) so it is easy for ______ ventricle to squeeze and eject blood out through aortic valve.

left

The secondary goal in patients with ACS is to prevent Major Adverse Cardiac Events (MACE). MACE includes heart failure, cardiogenic shock, papillary muscle rupture, left ventricular aneurism, lethal dysrhythmias, and ventricular septal wall rupture. Which of these MACE is described below: o ____ _____ _____—the ventricle becomes weakened due to the damaged area and it bulges out and then it doesn't squeeze well and of course the patient is likely to have heart failure and also dysrhythmias **collaborative management/goals

left ventricular aneurism

Systemic Vascular Resistance (SVR)- afterload of the ______ side of the heart. Pulmonary vascular resistance (PVR) - afterload of the ______ side of the heart.

left; right

The secondary goal in patients with ACS is to prevent Major Adverse Cardiac Events (MACE). MACE includes heart failure, cardiogenic shock, papillary muscle rupture, left ventricular aneurism, lethal dysrhythmias, and ventricular septal wall rupture. Which of these MACE is described below: o If MI, at risk for ____ _____ (V-tach, v-fib after 1st few hours of infarction), and for sudden cardiac death from v-tach or v-fib. § Within the first few hours of infarction, they are at highest risk—so we need to intervene **collaborative management/goals

lethal dysrhythmias

The American Association of Critical Care Nurses (AACN) defines critical care nursing as the specialty dealing with human responses to _____-_____ _______ (or potentially _____-_____ ________) ○ These patients are patients who are at risk fo dying because of _____-_____ _______

life-threatening problems

What level of sedation (light, moderate, deep, general anesthesia) is described below: Responsiveness: Normal response to verbal stimuli Airway: Unaffected Spontaneous Ventilation: Unaffected CV Function: Unaffected

light sedation

What level of sedation (light, moderate, deep, general anesthesia) is described below: ● (minimal sedation; relief of some anxiety) ○ ***Ex: Pt. who has an anxiolytic such as Xanax ○ Trying to relieve some of the patient's anxiety ○ Patient follows commands ○ Cognitive functions and motor coordination may be impaired (but they should be able to response to you—if you ask them to do something, they should be able to do it) ○ Ventilation and cardiovascular function are unaffected (able to maintain their airway and breathe adequately; they are not having any low BP or bradycardia)

light sedation

Propofol has a high _____ content (delivers 1.1 kcal/mL as fat) - all tubing & solution must be changed q12h (tubing is harder & has a more yellowish color than normal tubing) ○ It is fat based ■ We have to change the tubing every 12 hours (twice a day) ○ Provides the patient with calories—if they are taking a considerable amount of this then dietitian needs to take this into account ○ Comes in a 100 mL bottle for IV drip so it doesn't usually last more than 12 hours ■ Every 12 hours, tubing has to be changed

lipid

lipid lowering agents

lipid lowering medication

The following is all of the information under ______ of infarction: · If you have a patient who has inferior wall ischemia or inferior wall infarction you are going to see changes in leads II, III and aVF o The right coronary artery is usually the coronary artery that supplies the inferior wall § So, if you see indicative changes in these leads, it is probably the right coronary artery that has the lesion and it's the inferior wall of the heart · V1 and V2 are septal leads so if you see indicative changes (ST elevation or depression) in these then the culprit vessel is probably the LAD or a branch off the LAD called the septal branch · V3 and V4 are anterior wall leads—indicative changes in these leads means it the culprit lesion is in the left anterior descending (the coronary artery that feeds the anterior wall of the heart) · The lateral wall of the heart is typically supplied by the left circumflex artery o V5 and V6 o Lead I and aVL · If you have a patient who has a lesion in the left main area of the left coronary artery than that is going to occlude both the LAD and the circumflex and that is going to encompass oxygen supply to the majority of the left ventricle and that patient is at extremely high risk for sudden cardiac death (that is why they call it the widow maker) o The left coronary branches off at the aorta and there is a piece that then branches off into the left anterior descending artery then the left circumflex artery · The higher the lesion is in any of the vessels, the more tissue that will be involved o If your lesion is very distal then it may be a very small area of the myocardium that is affected · Since myocardial infarction is the result of an occluded coronary artery, it is worthwhile to develop a familiarity with the coronary arteries that supply the heart. Once the infarction has been recognized and localized, an understanding of coronary artery anatomy makes it possible to predict which coronary artery is occluded. **ACS

localization

Nitroglycerin has different forms including short acting, long acting, ointment, and transdermal patches (treats MIs). Which of these forms is described below: · Imdur (isosorbide mononitrate), Isordil (isosorbide dinitrate)--for D/c. Extended-release tablets

long acting

A ____ PAP suggests hypovolemia (low CVP & low CO)

low

As mentioned earlier, the ventilator is designed to monitor many aspects of the patient's respiratory status, and there are many different alarms that can be set to warn healthcare providers that the patient isn't tolerating the mode or settings. The following are common ventilator alarms and their most frequent causes: ____ exhaled volume: -- Vent tubing not connected -- Leak in cuff or inadequate cuff seal -- Occurrence of another alarm preventing full delivery of breath

low

As mentioned earlier, the ventilator is designed to monitor many aspects of the patient's respiratory status, and there are many different alarms that can be set to warn healthcare providers that the patient isn't tolerating the mode or settings. The following are common ventilator alarms and their most frequent causes: ______ pressure limit: -- Vent tubing not connected -- Displaced ETT or trach tube

low

Anyone with 3 or more risk factors (abdominal obesity (waist circumference), elevated triglycerides, low HDL cholesterol, elevated BP, and elevated fasting glucose) is considered to have metabolic syndrome. Which of these 5 risk factors is described below: Men: <40 mg/dl Women: <50 mg/dl o (good cholesterol—want these to be high—considered protective and preventive of cardiovascular disease) § > 60 High—desirable for ______ cholesterol

low HDL cholesterol

When positing the transducer on the phlebostatic axis for hemodynamic monitoring, if the transducer is HIGHER than the axis, it will rust in a false ______ reading. If the transducer is LOWER than the axis, it will result in a false ______ reading. OPPOSITES HINT HINT.

low; high

What intervention of nursing management of artificial airways is described below: ○ Place a mark on the tube where tube is placed r/t pt. lips or teeth q2h ○ Confirm that the exit mark of the tube remains constant ○ Continuously monitor for symmetrical chest movement & bilateral breath sounds ○ Always pass off placement in report ○ Improper position of ET tube is considered a medical emergency - bag pt. immediately with FiO2 100% ○ Document and pass on in report where it is taped, whether the landmark is the lips or teeth, it needs to be consistent ○ If the patient starts talking to you, more than likely either the tube got dislodged , cuff got blown, or vocal sounds are being made

maintaining correct tube placement

What intervention of nursing management of artificial airways is described below: ○ High-volume, low-pressure cuff stabilizes & seals the ET tube within the trachea & prevents escape of ventilating gas ○ Assess by listening for vocal sounds ○ Overinflated cuff can result in tissue erosion & a tracheal-esophageal fistula over time ○ Cuff pressure is maintained at 20 - 25mmHg (assess & document cuff pressure q8h) ○ Patient should not be making any vocal sounds; feel the pilot balloon to make sure there is pressure in it. periodically it should be checked with a manometer to verify we do not have too much pressure in the balloon (RT)

maintaining proper cuff inflation

mechanical ventilation

maintaining tube patency

What intervention of nursing management of artificial airways is described below: ○ Tracheal mucosal damage is likely with pressures >120mmHg, overly vigorous catheter insertion & characteristics of the suction catheter itself ■ Blood streaks or tissue shreds in secretions may indicate mucosal damage ○ Thick secretions can be limited by ensuring hydration & humidification ■ Do NOT instill NS into the ET tube (decreases SvO2) ■ Postural drainage, percussion & turning pt. q2h can help move secretions

maintaining tube patency

What intervention of nursing management of artificial airways is described below: ○ Assess the need for suctioning by checking patency - indicators of suctioning include: ■ Visible secretions, sudden respiratory distress, suspected aspiration, abnormal breath sounds, increased RR or sustained coughing, any changes in PaO2 or SpO2, rhonchi in the chest ○ Closed suctioning: oxygenation & ventilation are maintained - minimal exposure to secretions ■ When do you perform this? - High PEEP, bloody/infectious secretions, frequent suctioning ■ Complications of suctioning include things such as: hypoxemia, bronchospasm, increased ICP, HTN, hypotension, dysrhythmias ○ Tracheal mucosal damage is likely with pressures >120mmHg, overly vigorous catheter insertion & characteristics of the suction catheter itself ■ Blood streaks or tissue shreds in secretions may indicate mucosal damage ○ Thick secretions can be limited by ensuring hydration & humidification ■ Do NOT instill NS into the ET tube (decreases SvO2) ■ Postural drainage, percussion & turning pt. q2h can help move secretions ○ Patients often need a lot of suctioning especially if they have a lot of secretions, pneumonia, or pulmonary edema ■ May be doing frequent suctioning ○ Secretions can get thick clogging up tubes. If tubes become clogged with secretions, you will not be able to ventilate and oxygenate them well and you may also start to see a lot of high pressures on the ventilator. That means it is taking a lot of pressure to get the air in. You need to check to see if they need to be suctioned ○ Assessments are normally every 2 hours listening to their lungs

maintaining tube patency

What intervention of nursing management of artificial airways is described below: ○ Patients often need a lot of suctioning especially if they have a lot of secretions, pneumonia, or pulmonary edema ■ May be doing frequent suctioning ○ Secretions can get thick clogging up tubes. If tubes become clogged with secretions, you will not be able to ventilate and oxygenate them well and you may also start to see a lot of high pressures on the ventilator. That means it is taking a lot of pressure to get the air in. You need to check to see if they need to be suctioned ○ Assessments are normally every 2 hours listening to their lungs

maintaining tube patency

Look on the monitor picture on phone for this question. The number beneath the red number, (78/48), is what? (talking about the (58)) With hemodynamic monitoring, anytime you see any numbers in parentheses, that is a mean pressure

mean arterial pressure

The following are indications for _____ _____: Ventilatory failure (use ABGs to determine if pt. experiencing respiratory failure) ○ pH <7.35 & PaCO2 >50mmHg (increased pH & decreased CO2, increased rate - pneumonia & COPD) ○ PaO2 = PaCO2 --> means you have ventilatory failure ○ When someone is not able to move the gases like exhale the CO2, inhale the O2, exhale CO2

mechanical ventilation

The following are indications for _____ _____: ● Apnea or Impending Inability to Breathe ● Ventilatory Failure: (use ABGs to determine if pt. experiencing respiratory failure) ● Severe Hypoxia: ● Respiratory Muscle Fatigue: ● Respiratory Rate >35 or <8-10

mechanical ventilation

The following are indications for _____ _____: ● Apnea or Impending Inability to Breathe: ○ Who would be apneic? Stroke pt. cardiac arrest, high cervical spine injury ○ Pt. might exhibit signs & symptoms such as: hypoxia, restlessness, decreased LOC, confusion, immobility, accessory muscles use, difficulty speaking ○ Impending inability means pt. respirations are labored & they appear cyanotic - inevitable

mechanical ventilation

The following are indications for _____ _____: ● Respiratory Muscle Fatigue: ○ Neuromuscular problems such as ALS, Guillain-Barre ○ Stridor, tripod position while sitting ○ May have pneumonia on top of COPD ○ Do not have strength to breathe in fast and deep enough to maintain needs ● Respiratory Rate >35 or <8-10

mechanical ventilation

The following are indications for _____ _____: ● Severe Hypoxia: ○ Requires FiO2 >50% to maintain adequate oxygenation ○ PaO2 <60mmHg on oxygen therapy ■ Giving supplemental oxygen and the best we can do is a PaO2 of less than 60 mmHg ○ Hypoxemia: low O2 in the blood/tissues (determined with ABGs)

mechanical ventilation

The following are special considerations for nursing care with ______ ______: ● Neuromuscular Blocking Agents ○ Used to provide more effective synchrony with the ventilator thus increasing oxygenation ○ Note: this does NOT provide sedation or analgesia → will need additional sedation ■ Anytime you paralyze somebody, it does NOT provide sedation. The patient can be paralyzed and totally awake. ○ Prone positioning→ redistributes the secretions in the lungs and helps them breathe better ■ Will need a physician's order ■ If you have a patient that you are having difficulty ventilation, oxygenating, and still having trouble getting PAO2 up, then we would consider prone positioning. This is when you put the patient on their belly for several hours (8-16 hrs/day). This changes the secretions, areas of lungs that are better ventilated.

mechanical ventilation

When talking about readiness for weaning in a patient on the ventilator, the _____ ___ ____ (> -20) is how strong the patient can pull in a breathe, how much negative force can they generate. Respiratory therapy has a device to measure this (put device on end of ET tube). ***This needs to be greater than -20. ****

negative inspiratory force (NIF)

The following are special considerations for nursing care with ______ ______: ● Sedation (pt. with some cognitive ability needs to be sedated) ○ Use a lot of propofol→ will cause respiratory depression but is very fast acting ■ Allows for "sedation vacation" ○ It is uncomfortable and anxiety producing ○ If the patient is ill, and having a lot trouble ventilating them and they are bucking the vent, we may also need to paralyze them with chemical drugs. We can better ventilate them and it also decreases their O2 demand and metabolic rate ● Neuromuscular Blocking Agents ○ Used to provide more effective synchrony with the ventilator thus increasing oxygenation ○ Note: this does NOT provide sedation or analgesia → will need additional sedation ■ Anytime you paralyze somebody, it does NOT provide sedation. The patient can be paralyzed and totally awake. ○ Prone positioning→ redistributes the secretions in the lungs and helps them breathe better ■ Will need a physician's order ■ If you have a patient that you are having difficulty ventilation, oxygenating, and still having trouble getting PAO2 up, then we would consider prone positioning. This is when you put the patient on their belly for several hours (8-16 hrs/day). This changes the secretions, areas of lungs that are better ventilated.

mechanical ventilation

definition of ____ ____ is the process by which oxygen is moved in & out of the lungs by a mechanical ventilator. The most basic form of a mechanical ventilator is a device used to blow air into a patient's lung, usually patients with respiratory failure or cannot meet their respiratory needs. These assist the patient to breathe.

mechanical ventilation

There are 4 treatments for an MI: PCI, thrombolytic therapy, CABG, and medical management. Which of these 4 treatments is described below: § where they just use medications if they are not candidates for any of the other 3 options · Lesion in spot that can't be dilated, if at bifurcation, etc. or not a candidate for angioplasty or thrombolytics (too old, too high risk) - aspirin, nitroglycerin, beta blocker, statins. · Goal: salvage as much of the myocardial tissue as possible. **management of MI

medical management

The following is all of the information about ________ affecting HR: *anti-rhythmic drugs, thyroid drugs, stimulants—ADHD medications ● Digoxin, Primacore, Dobutrex affect the pump ● Ca Channel Blockers & Beta-Blockers affect primarily electrical conduction ● Pressors, ACE Inhibitors & ARBs affect the pipes ● ***Any ________ that is used to control HR can cause dysrhythmias HR increased by _______ such as: ● Albuterol, Adderall Cocaine ● Epinephrine, Dopamine, Atropine HR decreased by _______ such as: ● Beta-blockers slows HR and decreases contractility ● Digoxin ● Ca Channel Blockers ● Conduction Defects patients with PVCs (these do not generate good BP so that will decrease CO) Abnormal rhythms that can result in an increased/decreased HR include: ● PSVT, SVT, runs of V-Tach, AV Blocks, V-Fib, A-Fib ○ With tachycardia, this will increase CO by a point. Then when it starts to get too fast, you decease ventricular filling time. There is not enough time in diastole to fill with blood. If there is not much blood in the ventricles, there is not much to eject ○ HR too fast can decrease CO and HR too slow can decrease CO

medications

What syndrome is a cluster of risk factors for CV disease? · *****Anyone with 3 or more of the below is considered to have _______ syndrome******* --abdominal obesity (waist circumference), elevated triglycerides, low LDL cholesterol, elevated BP, and elevated fasting glucose · People with ________ syndrome are at increased risk for developing heart disease or cardiovascular disease · Higher risk for atherosclerotic vascular disease (includes anyone with 3 or more of the following risk factors)

metabolic syndrome

What syndrome is a cluster of risk factors for CV disease? · *****Anyone with 3 or more of the below is considered to have _______ syndrome******* 1. abdominal obesity: Waist circumference** · Men: >102 cm (>40 in) considered to have abdominal obesity · Women: >88 cm (>35 in) considered to have abdominal obesity 2. elevated triglycerides: > 150 mg/dL (more than) 3. low HDL cholesterol: Men: <40 mg/dl Women: <50 mg/dl 4. elevated BP: 130/ 85 mmHg or higher 5. elevated fasting glucose: 110 mg/dL ( or more)

metabolic syndrome

What does MIDCAB stand for? **type of bypass surgery

minimally invasive direct coronary artery bypass

What type of CABG is described below: Mini-thoracotomy—they make a thoracotomy style incision and retract the ribs · Surgery is performed on a beating heart o Need a skilled surgeon to be able to suture those vessels onto a moving heart · Usually use Beta blockers or calcium channel blockers to slow HR so that the heart is easier to work on · Most of the time they are going to use one of the internal mammary arteries (IMA) --> and they will bypass either the LAD or RCA with that IMA So not all patients are candidates for this bypass

minimally invasive direct coronary artery bypass (MIDCAB)

What type of CABG is described below: · Done usually just for LAD or RCA o Can't hardly get to the backside of the heart or some of those most difficult vessels, like the circumflex, because they are not doing a sternotomy and fully opening the chest § They are actually going between the ribs · No sternotomy · No CPB (cardiopulmonary bypass) o So, they don't have the problems that come along with it—one of the pros · Mini-thoracotomy—they make a thoracotomy style incision and retract the ribs · Surgery is performed on a beating heart o Need a skilled surgeon to be able to suture those vessels onto a moving heart · Usually use Beta blockers or calcium channel blockers to slow HR so that the heart is easier to work on · Most of the time they are going to use one of the internal mammary arteries (IMA) --> and they will bypass either the LAD or RCA with that IMA So not all patients are candidates for this bypass

minimally invasive direct coronary artery bypass (MIDCAB)

the following is all of the info under _____ venous oxygen saturations: ● SVO2 ● Fiber optic sensor on distal tip of PA catheter.(Cadillac catheter with SVO2 monitor) ● Oxygen saturation of the blood in the pulmonary artery that has already saturated the body ● Called ______ because blood from all parts of the body returning to the right heart. ● Normal 60-80% oxygen (at rest) will be returned to the heart at rest (20-30% will be used) ● Gives us an idea of oxygen demand. ● Things that increase demand: fever, exercise ○ How much oxygen is that patient using? ○ If you have a SVO2 reading of 50%, either the patient does not have enough oxygen to begin with. If they started out with a low SVO2 and used 25% of that or more than that from being sick then you will end up with a low SVO2. The other time is if demand is really high. Their arterial saturation is normal, SVO2 is normal but for some reason they are using up a lot of oxygen such as fever. This would result in a low SVO2 from using up oxygen available. ○ Another time when someone would have a low venous oxygen saturation is someone who is anemic where they do not have enough Hemoglobin to carry oxygen resulting in not enough oxygen to start with. The body extracts at least 25% so you end up with a low venous oxygen saturation. ● May need supplemental oxygen but the problem may be with hemoglobin ● Need to be checking peripheral O2 and H&H because they could be having a normal O2 sat ● Normally, a healthy person at rest uses only about 25% of their oxygen. That is why normal is 60-80%.

mixed

________s of ventilation are determined by ventilatory status, respiratory drive, WOB & ABGs. The ______ of ventilation refers to how the vent works with the pt. own respiratory drive; how you deliver the breath. Another way in which how the breaths are delivered; more specific. The following are the different _____s of delivery: 1. Controlled Mandatory Ventilation (CMV) - volume 2. Assist-control Mechanical Ventilation (AC) - volume 3. Synchronized Intermittent Mandatory Ventilation (SIMV) - volume Most common one used 4.Airway Pressure Release Ventilation (APRV) Used more common in patients with ARDS and stiff lungs 5. Pressure Support Ventilation (PS) - pressure 6. Positive End Expiratory Pressure (PEEP) 7. Continuous positive airway pressure (CPAP) **goes from most controlled to least controlled **

mode

What level of sedation (light, moderate, deep, general anesthesia) is described below: ****conscious sedation, procedural sedation**** ○ CV function usually unaffected, however respiratory IS affected (HR and BP okay) ○ Typically used for someone having their wisdom teeth pulled, cardioversion, colonoscopy ○ This is what you are aiming for with procedural sedation ○ Nurses can do conscious sedation if you are ACLS certified ○ Aiming for moderate sedation but we also want to provide them some pain management

moderate sedation

What level of sedation (light, moderate, deep, general anesthesia) is described below: ****conscious sedation, procedural sedation**** ○ Conscious sedation requires nurse to be certified ○ Depression of consciousness during which pt. respond purposefully to verbal commands & when shaken (if you stimulate them, they should respond) ■ Patient falls asleep unless you stimulate them. If you pinch them on their finger hard enough, they probably will pull away their arm. They fall back asleep if not being stimulated. ○ Pt. maintains his own airway

moderate sedation

What level of sedation (light, moderate, deep, general anesthesia) is described below: ****conscious sedation, procedural sedation**** ○ Not knocking the patient out but you want them sedated enough to do a procedure (but you don't have to be doing a procedure to use this type of sedation) ○ Have emergency equipment available and ambu available just in case you overshoot it when titrating the drug. There is no set amount to give to all patients. everyone responds differently to different amounts

moderate sedation

What level of sedation (light, moderate, deep, general anesthesia) is described below: Responsiveness: Purposeful response to verbal or tactile stimulation Airway: No intervention required Spontaneous Ventilation: Adequate CV Function: Usually maintained

moderate sedation

There are both non-modifiable (cannot do anything about it) and modifiable (there is something we can do to manage it) risks for ASCVD. Which of these types of risks is described below: · Blood Pressure - HTN JAMA Guidelines 2017 o High risk patients (>10% risk [CAD, DM, CKD]) target BP of 130/80 or lower o Low risk patients (<10% risk) target BP of 140/90 or lower

modifiable

There are both non-modifiable (cannot do anything about it) and modifiable (there is something we can do to manage it) risks for ASCVD. Which of these types of risks is described below: · LDL Cholesterol (bad cholesterol) - Primary Target of Therapy o LDL<100 Optimal - If previously diagnosed ASCVD in any vascular bed than goal is LDL< 70 o 100-129 Near Optimal/Above Optimal o 130-159 Borderline High o 160-189 High 190 Very high

modifiable

There are both non-modifiable (cannot do anything about it) and modifiable (there is something we can do to manage it) risks for ASCVD. Which of these types of risks is described below: ○ Lipids (or cholesterols) ○ Obesity ○ Blood pressure ○ Diabetes ○ Tobacco use ○ Metabolic syndrome ○ Activity ○ Elevated homocysteine ○ Psychological states ○ Substance abuse ○ Some of these can be managed through meds (hyperlipidemia, HTN), exercise and diet (obesity, diabetes), quit smoking, mental health care (people with type A personalities who are very driven have an increased risk for heart disease) ■ But may not be able to eliminate

modifiable

The following is trigger criteria that may require a rapid response team for a ______ issue: ○ ACUTE AND NEW ■ Confusion, agitation, delirium ■ Unexplained difficulty to arouse ■ Difficulty speaking or swallowing ■ Changes in pupillary responses ■ Seizure

neurologic

What complication of positive pressure ventilation is described below: ● PPV esp. with PEEP can impair cerebral blood flow; may also have increased ICP with JVD ○ With PEEP you want to be careful if they have any type of head injury

neurologic system

What intervention of nursing management of artificial airways is described below: ○ Assess clinical findings related to oxygenation: ABGs, SpO2 & SvO2/ScvO2 ■ Assess for signs of hypoxemia: mental status changes, anxiety, dusky skin & dysrhythmias ■ PA or CVP catheters provide an indirect measurement of the pt. oxygenation status ■ Continuous SpO2 monitoring helps to get an idea on oxygenation ■ Continuous end tidal CO2 monitoring: monitor that detects amount of CO2 inhaled and gives idea of how well the patient is ventilating ○ We do frequent ABGs to monitor them because we are in control of their RR and tidal volume; so we need to make sure we are giving enough and not too much ■ Daily ABGs usually on patient on vent or even more often ■ Anytime you make a ventilator change you need to get some ABGs to see how they are tolerating it ○ Indicators of adequate ventilation include: respiratory assessment findings & ABGs ■ Assess pt. respirations for rate, rhythm & accessory muscles (hyperventilated pt. will breathe rapidly & deeply with some numbness or tingling; hypoventilated pt. will breathe shallowly & slowly with dusky appearance) ■ PaCO2 is the best indicator of alveolar hyperventilation/hypoventilation ■ Usually will monitor ABGs every morning of every time they get a tube change ○ Decreased PaCO2, increased pH indicates alkalosis ○ Increased PaCO2, decreased pH indicates acidosis

monitoring oxygenation and ventilation

What intervention of nursing management of artificial airways is described below: ○ Indicators of adequate ventilation include: respiratory assessment findings & ABGs ■ Assess pt. respirations for rate, rhythm & accessory muscles (hyperventilated pt. will breathe rapidly & deeply with some numbness or tingling; hypoventilated pt. will breathe shallowly & slowly with dusky appearance) ■ PaCO2 is the best indicator of alveolar hyperventilation/hypoventilation ■ Usually will monitor ABGs every morning of every time they get a tube change ○ Decreased PaCO2, increased pH indicates alkalosis ○ Increased PaCO2, decreased pH indicates acidosis

monitoring oxygenation and ventilation

What intervention of nursing management of artificial airways is described below: ○ We do frequent ABGs to monitor them because we are in control of their RR and tidal volume; so we need to make sure we are giving enough and not too much ■ Daily ABGs usually on patient on vent or even more often ■ Anytime you make a ventilator change you need to get some ABGs to see how they are tolerating it ○ Assess clinical findings related to oxygenation: ABGs, SpO2 & SvO2/ScvO2 ■ Assess for signs of hypoxemia: mental status changes, anxiety, dusky skin & dysrhythmias ■ PA or CVP catheters provide an indirect measurement of the pt. oxygenation status ■ Continuous SpO2 monitoring helps to get an idea on oxygenation ■ Continuous end tidal CO2 monitoring: monitor that detects amount of CO2 inhaled and gives idea of how well the patient is ventilating

monitoring oxygenation and ventilation

When talking about management of ______ in patients, ***TIME IS _____****. The shorter the time to reperfusion the greater the benefit. A 47% reduction in mortality was noted when fibrinolytic therapy was provided within the first hour. § Everyone on the team should know what needs to happen for that patient—needs to be an efficient process · Goal: salvage as much of the myocardial tissue as possible. **management of MI

muscle

What complication of positive pressure ventilation is described below: ● early progressive ambulation is one of the most important things to prevent immobility associated problems ○ Atrophy because they will not be using their muscles→ passive ROM ○ Typically immobile, on bedrest; at risk for all problems with immobility (pressure areas, contractures)

musculoskeletal system

What artificial airway for mechanical ventilation is described below: *not ET or tracheostomy intubation ● placed blindly through the nose - used with pt. in which head & neck manipulation/movement would be risky ○ Contraindicated in pt. with facial fractures, suspected fractures of the base of the skulls & post-op cranial surgeries (these pt. are more susceptible to kinky of the tube) ○ Patient may develop aspiration pneumonia→ suction around cuff to prevent

nasopharyngeal intubation

What special consideration for nursing care for mechanical ventilation is described below: ○ Used to provide more effective synchrony with the ventilator thus increasing oxygenation ○ Note: this does NOT provide sedation or analgesia → will need additional sedation ■ Anytime you paralyze somebody, it does NOT provide sedation. The patient can be paralyzed and totally awake. ○ Prone positioning→ redistributes the secretions in the lungs and helps them breathe better ■ Will need a physician's order ■ If you have a patient that you are having difficulty ventilation, oxygenating, and still having trouble getting PAO2 up, then we would consider prone positioning. This is when you put the patient on their belly for several hours (8-16 hrs/day). This changes the secretions, areas of lungs that are better ventilated.

neuromuscular blocking agents

Unstable angina is chest pain that is not predictable, often occurring at rest and increasing in frequency and severity. Often times we will send patients home who have coronary disease if they have stable angina with _____. _______ is a coronary vasodilator—patients are instructed that when they have chest pain to stop what they are doing, sit down, and take a ________ If their chest pain is relieved with rest and _______ and they can predict when they are going to have chest pain (ex: when they cut the grass or jog) then that is stable angina. o When chest pain starts occurring at rest and it becomes unpredictable and it is increased in frequency and severity and maybe not responding to the _______ like it should, that is when it is considered to be unstable

nitroglycerin

Does Fentanyl cause direct vasodilation?

Does Hydromorphone cause direct vasodilation?

**talking about ET tube intubation & pressure in pilot balloon** Because that tube is in the trachea, it helps to secure it there but it also prevents air from seeping around it.. When you mechanically ventilating somebody and blowing air in, you want it to expand the lungs and then you want to passively as the patient exhales, you want the air to go back out through the tube. You do not want a whole lot of leakage of air around here during inspiration (talking about cuff/balloon). This cuff helps prevent loss of pressure. Because air does not go around the tube then no air goes over the vocal chords. If air is passing over the vocal chords that makes vocal sounds and so when patients have ET tubes or tracheostomy tubes with a cuff on them they should ****NOT**** be able to make vocal sounds and not be able to talk to you. If they are talking to you either your tube got dislodged and is not where it should be or your cuff was deflated/not enough air in it, or the cuff exploded/popped. Patients with an ET tube should *****NOT*** be making ________.

noises

The following are different ______ in the ICU (the longer you are exposed to this _____, the more you are at risk for hearing damage): telephone ringing, raising/lowering side rails, O2 chest tube bubbling/ventilator, ventilator alarm, cardiac monitor alarms, and call bells.

noises

Non-invasive NEGATIVE pressure ventilation or Non-invasive POSITIVE pressure ventilation (NIPPV)? ● Delivered as non-invasive ventilation & does NOT require artificial airway ● Used for pt. with chronic respiratory failure who require assisted ventilation for short periods of time (spinal cord injuries, Guillain-Barre, ALS) ○ Not great for long-term ventilation ○ Patients with spinal cord injuries who may have compromised respiratory status that need help once in a while ○ Guillain-Barre and ALS--> patients with muscle disease and weakness that need assistance ■ Both diseases (if severe enough) may need positive pressure ventilation ● Increases & decreases pressure around the chest - causes changes in intrathoracic pressure ○ _______ pressure pulls chest outward forcing air to flow inward until machine cycles off & passive expiration takes place (decreased intrathoracic pressure causes air to rush in) ● Examples: iron lung, chest vest, body wrap & body suits ● ________ pressure ventilation (iron lung) ● Non-invasive positive pressure ventilation NIPPV (CPAP and BiPAP) ● Lecture notes: when we normally breathe we breathe with ______ pressure. When you take a breath, your chest cage expands and diaphragm drops causing a _______ pressure in the lungs.

non-invasive negative pressure ventilation

Non-invasive NEGATIVE pressure ventilation or Non-invasive POSITIVE pressure ventilation (NIPPV)? ■ Similar to pressure support ventilation because the pt. must be able to spontaneously breath & cooperate with treatment ■ Indicated for acute respiratory failure in pt. with COPD, HF & sleep apnea (NOT for shock, altered mental status, or increased airway secretions) ■ Use 2 levels of pressure: a higher inspiratory pressure and lower expiratory pressure ■ More for the sicker patients, chronic lung patients, patients who are more fragile

non-invasive positive pressure ventilation (NIPPV)

Non-invasive NEGATIVE pressure ventilation or Non-invasive POSITIVE pressure ventilation (NIPPV)? ○ BIPAP: ■ Stands for Bilevel ______ airway pressure ■ Delivers two different levels of _______ airway pressure - ● Inspiratory pressure (IPAP) ● Expiratory pressure (EPAP) ● **makes easier for someone to exhale against; patients who have air trapping may do better on a BiPAP as compared to a CPAP

non-invasive positive pressure ventilation (NIPPV)

Non-invasive NEGATIVE pressure ventilation or Non-invasive POSITIVE pressure ventilation (NIPPV)? ○ CPAP: ■ Stands for continuous _____ airway pressure ■ Continuous _______ pressure to maintain continuous level of _______ pressure- constant flow (usually in obstructive sleep apnea) one level of pressure ■ Similar to PEEP in that they both keep alveoli opened but it is applied continuously ● PEEP is ______ end expiratory pressure; PEEP is only on exhalation and CPAP is continuous ■ Caution pt. with myocardial compromise because this increase the workload of breathing - pt. have to breathe against the continuous pressure ■ Use 1 level of pressure ■ More commonly used for obstructive sleep apnea

non-invasive positive pressure ventilation (NIPPV)

Non-invasive NEGATIVE pressure ventilation or Non-invasive POSITIVE pressure ventilation (NIPPV)? ○ Requires face mask, nasal pillows, or can be applied via ventilator & artificial airway (both CPAP and BiPAP) ■ There are some CPAP and BiPAP settings that can be given via ventilator ○ Used short-term in weaning, after extubation or in acute respiratory insufficiency that is expected to resolve quickly - may also be used to prevent intubation ■ Example: patient who comes in with HF and they are in fluid overload, we give Lasix, they diurese, and within a few hours feel better. Sometimes we will use as a bridge to get volume off so we do not have to intubate them ■ If we are weaning them or extubate somebody from the ventilator and they are struggling, they may try to put them on CPAP or BiPAP and avoid re-intubating them. ■ Usually something for temporary measure although we will use it on patients with end-stage chronic lung disease and do not want to put on vent because we may never get them off ○ Used long-term in management of sleep apnea (CPAP) ○ Patients who have obstructive apnea: when they go to sleep all of their muscles relax and tongue falls back over the oropharynx and occludes their airway. They have periods of apnea while they sleep and they drop their saturation. If you put them on CPAP, you have this ______ pressure blowing into their airways and it helps to splent those airways open to prevent the relaxed muscles from falling over the oropharynx ○ CPAP: ■ Stands for continuous _____ airway pressure ■ Continuous _______ pressure to maintain continuous level of _______ pressure- constant flow (usually in obstructive sleep apnea) one level of pressure ■ Similar to PEEP in that they both keep alveoli opened but it is applied continuously ● PEEP is ______ end expiratory pressure; PEEP is only on exhalation and CPAP is continuous ■ Caution pt. with myocardial compromise because this increase the workload of breathing - pt. have to breathe against the continuous pressure ■ Use 1 level of pressure ■ More commonly used for obstructive sleep apnea ○ BIPAP: ■ Stands for Bilevel ______ airway pressure ■ Delivers two different levels of _______ airway pressure - ● Inspiratory pressure (IPAP) ● Expiratory pressure (EPAP) ● **makes easier for someone to exhale against; patients who have air trapping may do better on a BiPAP as compared to a CPAP ■ Similar to pressure support ventilation because the pt. must be able to spontaneously breath & cooperate with treatment ■ Indicated for acute respiratory failure in pt. with COPD, HF & sleep apnea (NOT for shock, altered mental status, or increased airway secretions) ■ Use 2 levels of pressure: a higher inspiratory pressure and lower expiratory pressure ■ More for the sicker patients, chronic lung patients, patients who are more fragile

non-invasive positive pressure ventilation (NIPPV)

Non-invasive NEGATIVE pressure ventilation or Non-invasive POSITIVE pressure ventilation (NIPPV)? ○ Used long-term in management of sleep apnea (CPAP) ○ Patients who have obstructive apnea: when they go to sleep all of their muscles relax and tongue falls back over the oropharynx and occludes their airway. They have periods of apnea while they sleep and they drop their saturation. If you put them on CPAP, you have this ______ pressure blowing into their airways and it helps to splent those airways open to prevent the relaxed muscles from falling over the oropharynx

non-invasive positive pressure ventilation (NIPPV)

Non-invasive NEGATIVE pressure ventilation or Non-invasive POSITIVE pressure ventilation (NIPPV)? ○ Used short-term in weaning, after extubation or in acute respiratory insufficiency that is expected to resolve quickly - may also be used to prevent intubation ■ Example: patient who comes in with HF and they are in fluid overload, we give Lasix, they diurese, and within a few hours feel better. Sometimes we will use as a bridge to get volume off so we do not have to intubate them ■ If we are weaning them or extubate somebody from the ventilator and they are struggling, they may try to put them on CPAP or BiPAP and avoid re-intubating them. ■ Usually something for temporary measure although we will use it on patients with end-stage chronic lung disease and do not want to put on vent because we may never get them off

non-invasive positive pressure ventilation (NIPPV)

There are both non-modifiable (cannot do anything about it) and modifiable (there is something we can do to manage it) risks for ASCVD. Which of these types of risks is described below: ○ Age (white, middle-aged men) ■ Risk increases as age increases ○ Gender (men - differs in presentation & symptoms; men until menopause then the incidence is equal between men and women) ■ Males are at higher risk than females up until females reach menopause (after menopause that risk kind of equals out)—there is thought that premenopausal women have some protection against development of cardiovascular disease

non-modifiable

There are both non-modifiable (cannot do anything about it) and modifiable (there is something we can do to manage it) risks for ASCVD. Which of these types of risks is described below: ○ Ethnicity (AA males have a higher tendency to have HTN at a younger age) ■ Some ethnic groups higher risk than others ○ Family history (even with NO other risk factors, this automatically puts you at risk) ○ Genetic inheritance ■ There is a small population of patients that have a very aggressive form of coronary disease (may develop quickly over 10 years instead of 20-30 years)—thought to be a genetic trait that gets passed down through generations (family history) ● Nonaggressive forms also sometimes tend to run in families

non-modifiable

When talking about analgesics for acutely ill patients, the following are ____-_____ analgesic: ○ NSAIDS ○ Acetaminophen- Ibuprofen ○ Ketorolac (Toradol)

non-narcotic

What pain scale is good for patients who are awake, alert, and can self-report their pain?

numeric pain rating scale (0-10)

What common problem of critical care patients (nutrition, anxiety, pain and sedation, impaired communication, sensory-perceptual problems, sleep problems) is described below: ○ *******Inadequate _____ increase risk poor outcomes. Goal for ______: prevent or correct nutritional deficiencies. ******** ○ Feed the gut if able unless ileus, peritonitis, intestinal obstruction, pancreatitis, GI ischemia, abd trauma, sx or severe diarrhea ○****** Inadequate ______ increases mortality and morbidity rates******

nutrition

What common problem of critical care patients (nutrition, anxiety, pain and sedation, impaired communication, sensory-perceptual problems, sleep problems) is described below: ● (enteral/parenteral ______; keep gut functioning if already working; enteral is best) ○ Enteral feeding includes NG tubes, OG tubes, Dobhoff tubes (preserves the structure & function of gut mucosa; stops the movement of bacteria across intestinal wall which will lead to edema) ○ Parental feeding includes PPN (peripheral line w/ mostly proteins) & TPN (central line with essential elements, insulin, etc.) ○ TPN - high risk for infection ○ hypermetabolic state burns sepsis or catabolic cute kidney injury or several malnourished with HF, Liver disease or pulmonary disease. ○ *******Inadequate _____ increase risk poor outcomes. Goal for ______: prevent or correct nutritional deficiencies. ******** ○ Feed the gut if able unless ileus, peritonitis, intestinal obstruction, pancreatitis, GI ischemia, abd trauma, sx or severe diarrhea ○****** Inadequate ______ increases mortality and morbidity rates****** ○ ICU patients often have hypermetabolic states, catabolic states, and severely malnourished states (chronic heart, lung, or liver disease) ■ In a hypermetabolic state they are using up a lot of calories and energy

nutrition

Name the 6 common problems of critical care patients. ● The pt. admitted to the ICU is at risk for numerous complications & special problems. Critically ill pt. are usually immobile placing them at high risk for skin problems & venous thromboembolism. The use of multiple, invasive devices predisposes the pt. to HC associated infections.

nutrition, anxiety, pain and sedation, impaired communication, sensory-perceptual problems, sleep problems

________ therapy for ICU patients includes: ● Enteral nutrition (EN) preferred ○ Preserves the structure and function of the gut mucosa and prevents bacterial translocation ○ Associated with fewer complications and shorter hospital stays ○ Whenever possible, enteral is always preferred over parenteral! ○ Oral, enteral, and last resort is parenteral ● Parenteral nutrition if the EN cannot provide enough nutrition or is contraindicated (paralytic ileus) ○ There is a lot of risks with PN such as hyperglycemia or hypoglycemia, line infections, etc. ○ Whenever possible, oral or enteral nutrition!!

nutritional

________ therapy for ICU patients includes: ● Institute early ● Monitor intake and output, daily weights ● Labs to monitor nutritional status ○ Serum protein, total albumin, prealbumin (prealbumin is best lab measure for protein levels) ○ BUN ○ Glucose ○ Electrolytes ● You want to collaborate with the HCP and dietitian ○ The dietitian can be a wonderful resource to find the most appropriate diet

nutritional

________ therapy for ICU patients includes: ● Want a lot of calories!! ● Want to feed early and start with the most natural methods; if they cant eat oral, try PPN or TPN ○ TPN- can give in central line because it is thicker and more osmotic ■ Will need glucose checks because it is high concentration of glucose Increase RF infection

nutritional

the following is all of the information for _______ therapy for ICU patients: ● Institute early ● Monitor intake and output, daily weights ● Labs to monitor nutritional status ○ Serum protein, total albumin, prealbumin (prealbumin is best lab measure for protein levels) ○ BUN ○ Glucose ○ Electrolytes ● You want to collaborate with the HCP and dietitian ○ The dietitian can be a wonderful resource to find the most appropriate diet ● Enteral nutrition (EN) preferred ○ Preserves the structure and function of the gut mucosa and prevents bacterial translocation ○ Associated with fewer complications and shorter hospital stays ○ Whenever possible, enteral is always preferred over parenteral! ○ Oral, enteral, and last resort is parenteral ● Parenteral nutrition if the EN cannot provide enough nutrition or is contraindicated (paralytic ileus) ○ There is a lot of risks with PN such as hyperglycemia or hypoglycemia, line infections, etc. ○ Whenever possible, oral or enteral nutrition!! ● Want a lot of calories!! ● Want to feed early and start with the most natural methods; if they cant eat oral, try PPN or TPN ○ TPN- can give in central line because it is thicker and more osmotic ■ Will need glucose checks because it is high concentration of glucose ■ Increase RF infection

nutritional

Look at image 33 on phone. What is going on? o Depressed ST indicates ischemia. o Elevated ST segment indicates injury (acute infarction)

o ANT-Lateral Ischemia o Inverted T waves

Look at image number 23 on phone. What type of MI is this? o Depressed ST indicates ischemia. o Elevated ST segment indicates injury (acute infarction)

o Anterior septal lateral MI o Probably LAD and branch feeding lateral wall and maybe some circumflex involvement

What are the 3 types of PCIs? **PCI is NOT a surgical procedure

o Balloon angioplasty (high pressure balloon opens up vessel - coronary artery) o Stent placement (not done unless blockage is 60-70% or greater) o Atherectomy (sucks plaque out of vessel)

· You are caring for a patient who is day 3 post CABG. The physician's assistant made rounds at 6AM and removed his left pleural chest tube. When you assess him at 8:00 AM you note subcutaneous emphysema on his left upper chest and neck. · What is likely happening? · What should you do?

o Call the physician, the chest tube was probably removed too early. He will need a chest Xray and possibly replacement of his chest tube.

Look at image number 24 and 25 on phone. o Look for the J point and ST elevation in the above 12 lead o Look for reciprocal changes o Which lead groups are involved? o What area of the heart is involved? o Which coronary artery feeds this area of the heart? o Depressed ST indicates ischemia. o Elevated ST segment indicates injury (acute infarction)

o Leads II, III, aVF all have ST elevation, these are contiguous inferior leads o Leads I, aVL, V2, V3 and V4 all have ST depression signifying reciprocal changes o These changes are consistent with an acute inferior MI o In 90% of the population the inferior aspect of the heart blood supply is via the right coronary artery

What are the 4 levels of sedation?

o Light sedation o Moderate sedation (AKA: conscious sedation or procedural sedation) o Deep sedation and analgesia General anesthesia

The high pressure alarm on the ventilator sounds. What are some potential causes?

o Needs to be suctioned, clogged tubes, kinked tube, patient bucking vent, coughing while vent is trying to deliver breathe

Acute Coronary Syndrome (ACS) is a term used to describe a spectrum of clinical syndromes (in patients with coronary atherosclerosis) representing varying degrees of coronary artery occlusion. When you see ACS, it is either a bunch of syndromes or they are trying to rule out. There are 3 disorders/diseases that fall under the spectrum of the syndrome. What are they called?

o ST elevation MI (STEMI)—ST segment has tombstone appearance o Non-ST elevation MI (NSTEMI) o Unstable angina (UA)

Look at image number 26 and 27 on phone. o Look for the J point and ST elevation in the above 12 lead o Look for reciprocal changes o Which lead groups are involved? o What area of the heart is involved? o Which coronary artery feeds this area of the heart? o Depressed ST indicates ischemia. o Elevated ST segment indicates injury (acute infarction)

o ST elevation in Leads I, aVL, V2, V3, V4, V5 o Lead II and III show reciprocal changes as well as evidence of an old MI (in the form of a pathological Q wave) o Lateral leads (I, aVL and V5) as well as Anterior and septal lead groups (V2, V3 and V4) o Anterior and Lateral are the main areas of the heart involved o Left anterior descending and the left circumflex arteries supply this area of the heart

Look at image number 21 on phone. Look at each lead. What do you see? § This patient needs quick care. Needs to go to cath lab, get vessel opened back up so that we can reperfuse that inferior wall and hopefully save some tissue

o ST elevation in lead II, III, and aVF (inferior wall leads) so this patient is probably having inferior wall infarction (STEMI)

Look at image number 30 on phone. o Look for the J point and ST elevation in the above 12 lead o Look for reciprocal changes o Which lead groups are involved? o What area of the heart is involved? o Which coronary artery feeds this area of the heart? o Depressed ST indicates ischemia. o Elevated ST segment indicates injury (acute infarction)

o ST elevation in leads I, V2, V3, V4, V5, V6 and aVL o Reciprocal changes shown in leads III and aVF o V3 and V4 are anterior leads, I, aVL, V5 and V6 are lateral leads o This is an acute anteriolateral MI o Left anterior descending and left circumflex arteries supply these areas of the heart

Look at image number 28 and 29 on phone. o Look for the J point and ST elevation in the above 12 lead o Look for reciprocal changes o Which lead groups are involved? o What area of the heart is involved? o Which coronary artery feeds this area of the heart? o Depressed ST indicates ischemia. o Elevated ST segment indicates injury (acute infarction)

o ST elevation in leads II, III and aVF o Reciprocal changes in leads I, aVL, V2 and V3 o Leads II, III and aVF are contiguous inferior leads o This is an acute inferior MI o This area of the heart is supplied by the right coronary artery in 90% of the population

Look at image 31 on phone. o Look for the J point and ST elevation in the above 12 lead o Look for reciprocal changes o Which lead groups are involved? o What area of the heart is involved? o Which coronary artery feeds this area of the heart? o Depressed ST indicates ischemia. o Elevated ST segment indicates injury (acute infarction)

o ST elevation in leads II, III, aVF and V6 o Reciprocal changes in leads V2, V3 and V4 o II, III and aVF are inferior leads, V6 is a lateral lead and ST elevation must be present in at least 2 leads that view the same area of the heart o This is an acute inferior MI o The inferior area of the heart is supplied by the right coronary artery in 90% of the population

Look at image 32 on phone. o Look for the J point and ST elevation in the above 12 lead o Look for reciprocal changes o Which lead groups are involved? o What area of the heart is involved? o Which coronary artery feeds this area of the heart? o Depressed ST indicates ischemia. o Elevated ST segment indicates injury (acute infarction)

o ST elevation in leads V1, V2, V3 and V4 o There are no obvious reciprocal changes o V1 and V2 are septal leads, V3 and V4 are anterior leads o This is an acute anterioseptal MI o The left anterior descending artery supplies this area of the heart

The low pressure alarm on the ventilator sounds. What are some potential causes?

o The balloon is deflated and air is seeping around it, ventilator circuit pops off from coughing or movement, patient is disconnected

Your patient is on CPAP and the apnea alarm keeps going off. What is the problem?

o The patient is not ready; taking too long between breathes. He either needs to go back on the vent or increase their rate.

When talking about 12 Lead ECG, what 4 leads are described below: · The lateral wall of the heart is typically supplied by the left circumflex artery **ACS

o V5 and V6 o Lead I and aVL

The low minute ventilation alarm sounds on the vent. The patient's settings are SIMV with a TV of 650, rate of 4, PS (pressure support) of 10. What could be the potential problem and how would you intervene? o Minute ventilation is how much air they are getting over a minute

o You would increase the rate of breathes. Maybe patient was being weaned and it was not enough or not ready

What is the difference between volume ventilation and pressure ventilation?

o volume ventilation delivers a certain volume no matter what the pressure is and pressure ventilation will stop when it reaches a certain pressure I believe

Higher levels of PEEP can result in ______. ○ It is positive pressure staying in those lungs, keeping the alveoli open. But, if you start getting to really high levels of PEEP, that is when you start worrying about blebs exploding causing ________.

pneumothorax

What modifiable risk factor for CV disease is described below: o Abdominal ______ specifically* § Waist circumference** · Men o >102 cm (>40 in) considered to have abdominal ______ · Women o >88 cm (>35 in) considered to have abdominal ______ o BMI > 30 kg/m2 (height and weight) are at increased risk · BMI (height & weight) · BMI: >30kg/m2

obesity

What principle of invasive pressure monitoring (hemodynamics) is described below: ● when using an invasive line the readings from a printed pressure tracing are most accurate at the end of expiration (position the pt. supine for initial readings) ● Connect to pressure bag of fluid (saline)→ when system is under pressure it constantly gives ***3cc/ hr*** ○ will prevent blood from backing up into the line and to keep the line open

obtaining BP measurements

What does OPCAB stand for? **type of bypass surgery

off pump coronary artery bypass

What type of CABG is described below: · Sternotomy approach · Performed on a beating heart · Beta or calcium channel blockers to slow HR · Pros: Less blood loss, less renal dysfunction, less postoperative atrial fibrillation, and fewer neurological complications (because no postperfusion syndrome) · Primarily used for patients with multiple co-morbidities who should avoid CPB because they are too high-risk

off pump coronary artery bypass

Nitroglycerin has different forms including short acting, long acting, ointment, and transdermal patches (treats MIs). Which of these forms is described below: · paste (change q 6 h). o*** Put on chest or arm***—delivered transdermal

ointment

There are four common misconceptions regarding ______ use that contribute to inadequate treatment of pain - these include: ○ Fear of addiction (opiophobia) ○ Fear of physical dependence ○ Fear of tolerance ○ Fear of respiratory depression

opioid

When talking about analgesics for acutely ill patients, the following are _____ analgesics available for patients: ○ Morphine (IV, Duramorph, MS Contin, Roxanol) ○ Fentanyl (Sublimaze IV or Duragesic patch) ○ Hydromorphone (Dilaudid) ○ Meperidine (Demerol)

opioid

What artificial airway for mechanical ventilation is described below: *not ET or tracheostomy intubation ● passed through the mouth & vocal cords then into the trachea - this is the procedure of choice in emergencies ○ Large bore tube is used which reduces the work of breathing bc there is less airway resistance

oral intubation

What does PICS-F stand for? ○ Symptoms of depression and anxiety ○ 1/3 of family members have PTSD symptoms ● PTSD from being in the ICU ● Can be prevented by talking to the patient and trying to make them comfortable; help them understand what is happening and that we are there to help them

post-intensive care syndrome-family

The following is trigger criteria that may require a rapid response team for a ______ issue: ○ ACUTE AND NEW ■ Uncontrolled, out of proportion pain ■ Acute change in urine output (standard for post-op p.t is 30mL/hr) ■ Acute bleeding ■ Acutely elevated temp

other

THe following are some appropriate ______ for a patient post cardiac surgery: · Extubation ASAP · PA catheter is usually removed on post-op day 1 · Out of bed and to a chair on post-op day 1 o They need to be in the chair for all meals and then once they hit post-op day 2, they should be walking in the hallways 4 times a day (barring any complications—need to be extubated and drips off and lines out) o If they aren't walking by post-op day one, then we really want them to walk post op day 2 · Out of ICU on post-op day 1-2 · Home in 4-5 days if uncomplicated (average stay is 5-7 days)

outcomes

Over-sedation or too little sedation? ● State of unintended pt. unresponsiveness in which the pt. resides in a state of suspended animation that resembles general anesthesia ○ Patient may need to be intubated and ventilated ○ Could have cardiovascular side effects (vasodilation, tachycardia, or bradycardia) ○ Unless you were aiming for general anesthesia and the patient is oversedated and unresponsive, then that is over-sedation basically. We would have to protect their airway, maybe breathe for them, intubate them, and then they may have some of those CV side effects (vasodilation, tachycardia, bradycardia) ● Narcan is given for narcotics/opioids; Romazicon is given for benzos ● Run into trouble in those with renal impairment, COPD with O2 at home, etc. (use caution)

over sedation

State of unintended pt. unresponsiveness in which the pt. resides in a state of suspended animation that resembles general anesthesia

over sedation

When maintaining proper cuff inflation for artificial airways, an _____ cuff can result in tissue erosion & a tracheal-esophageal fistula over time. Cuff pressure is maintaining at 20-25 mmHg (assess and document cuff pressure q8hrs).

overinflated

oxygen

When talking about post-operative care of a patient with CAB, the nurse needs to monitor _____ ____ which is epicardial pacer wires put in during surgery just in case the patient has rhythm problems after surgery o If the patient has rhythm problems, the nurse can quickly get an external temporary pacemaker generator and hook them up and pace them · Multiple IVs

pacer wires

Nurses must accurately assess the problem - treating anxiety when pain is the problem (vice versa) can lead to the escalation of both issues. IF THEY HAVE BOTH, ALWAYS TREAT ______ FIRST→ treat then reassess→ if they are still having anxiety without ______ then you may give them something for anxiety ● IMPORTANT: assess ______ & anxiety continuously and independently BOLD, RED, AND HIGHLIGHTED IN NOTES.

pain

The International Association for the Study of Pain (IASP) defines ______ as: "an unpleasant sensory & emotional experience associate with actual or potential tissue damage" (tissue damage may result from more than things such as trauma or wounds; can occur with IV sticks, invasive lines, etc.)

pain

The following are other non-pharmacological _____ management methods: ● Family ● Music ● Massage, lighting ● Positioning ● Temperature ● Sleep ● Spirituality ● Pet Therapy—controversial, especially in the critical care setting

pain

What leads of a 12 lead EKG (augmented unipolar, bipolar, precordial/chest leads) is described below: o These leads are right next to each other so there is some overlap there § So if had changes in V2 &V3, might consider it to be an anterior wall injury § The ______ leads are consecutive so considered significant if have changes in 2 consecutive leads

precordial

The following is alternate _____ control options: ● Epidural: usually used for thoracic/abdominal surgery (colon resection, lobectomy) ○ Fentanyl/Bupivacaine (increased respiratory sedation, CMS, epidural hematoma) ○ Epidural hematoma is an emergency - can happen sometimes when pt. is on Lovenox & have increased bleeding time & they puncture the epidural space for procedure ○ The goal is to provide pain management without increasing the risk of respiratory depression—so it is thought that if you give it via epidural then whatever level of the spinal column you inject it in it will anesthetize the spinal column below that area and if it is inserted below the diaphragm then theoretically you shouldn't have a lot of respiratory depression ■ But sometimes it can migrate upward, especially if the patient is laying recumbent—so it can cause some respiratory sedation (don't assume that it won't) ● Need to assess for this in patients with a PCA, either epidural or IV ○ Also, important to check their circulation and movement and sensation below the level (CNS assessments—legs, feet, toes) ○ At risk for developing and epidural hematoma due to the catheter being in that space which is why we are so careful with those CNS assessments below the level ○ *****Important that they not be on any anticoagulants ■ No Lovenox (Enoxaparin) or anything that will thin their blood due to the risk of epidural hematoma******* ○ Fentanyl/ bupivacaine ■ Increase resp sedation ■ CMS ■ Epidural Hematoma

pain

The following is alternate _____ control options: ● On Q Ball: squishy ball they fill with medication attached to a tube inserted into the site of surgery - when pt. is in pain they squeeze the ball which puts medication internally into the area (used a lot for thoracic or abdominal surgeries) ○ Better pain relief and less need for narcotics ○ Feel better faster ○ Quicker return to normal body function ○ Less chance of grogginess ○ Greater mobility ○ Potential for earlier hospital release

pain

The following is alternate _____ control options: ● PCA: IV/epidural (also Dilaudid, Morphine) ● Epidural: usually used for thoracic/abdominal surgery (colon resection, lobectomy) ● Also PCA Morphine, hydromorphone ● Will need to be assess respirations, level of pain, adverse effects, if epidural do distal site assessment (hematomas and paralysis)

pain

The following is the info for The Who ______ ladder: 1.Use a non-opioid (NSAID, Acetaminophen) or an adjuvant (Xanax) or both 2.If pain persists or increases, use an opioid for mild-moderate pain (Codeine, Tramadol) & non-opioid or adjuvant 3.Opioid for moderate-severe pain (Morphine, Dilaudid) & non-opioid and adjuvant 4.Cancer pt. - you want true pain relief bc their pain is not going to go away; typically see them on patches, Roxanol, Xanax, analytic, etc.

pain

What additional essential of AACN/CCRN (Interpretation and mgmt cardiac rhythms, Hemodynamic monitoring, Circulatory assist devices, Airway and ventilator management, Pharmacology, Pain, Sedation) is described below: ● ______ post-op or trauma is really acute _____ but some could have chronic on top of acute _______ - learn how to recognize this) ○ Uncomfortable to be in the ICU, may have a tube down their throat

pain

_______ is whatever the patient says it is, existing whenever the experiencing person says it does. Do NOT impose your beliefs-- be respectful of people's perceptions of their _____.

pain

_______ management and sedation is a win-win strategy. It provides humane and compassionate care for the paint. _____ and discomfort elicit physiologic responses that are maladaptive. ○ Repositioning- they are in a lot of _____ and don't want to move (may develop pneumonia and pressure sores) ○ Increased HR, BP, RR; cortisol release; anxiety; ○ can they participate in their own care? ○ TCDB, etc. ○ May make healing processes slow or may impede it

pain

_______ management and sedation is a win-win strategy. _____ limits the pt. ability to cooperate w/ pulmonary hygiene, weaning, mobilization & other aspects of care. Pain, agitation & delirium are associated with poor outcomes (discharge criteria: have to be eating, have to be back at baseline in terms of functioning).

pain

_______ management and sedation is a win-win strategy. ______ can limit patients ability to cooperate with pulmonary hygiene, weaning, mobilization and other aspects of care. ○ So, we need to find the sweet spot when managing ______, anxiety, and discomfort to where they are comfortable/awake enough to not illicit these physiologic responses that are maladaptive but awake enough to cooperate in what we need them to cooperate with ○ Unless we are trying to knock them out bc sometimes with patients on full support on the vent may need to be put into an induced coma or have them very sedated

pain

Complications of MIs include dysrhythmias, cardiogenic shock, papillary muscle dysfunction, ventricular aneurysm, pericarditis, Dressler Syndrome. Which of these complications is described below: · - muscle that holds down valves ruptures then valves become incompetent and can decompensate quickly (severe valve regurgitation); need surgery, monitor for murmur.

papillary muscle dysfunction

The secondary goal in patients with ACS is to prevent Major Adverse Cardiac Events (MACE). MACE includes heart failure, cardiogenic shock, papillary muscle rupture, left ventricular aneurism, lethal dysrhythmias, and ventricular septal wall rupture. Which of these MACE is described below: o ____ ____ _____—where the muscles that pull down the valves (atrioventricular valve, mitral valve, tricuspid valve) rupture and then the valve becomes incompetent and they develop severe valvular regurgitation § This is an emergency and if they are not taken to surgery and then valve is not repaired within a timely fashion then they probably won't survive **collaborative management/goals

papillary muscle rupture

Which autonomic nervous system is described below: ○ Rest & digest which decreases HR ○ Decease HR bradycardia at night with rest- fluctuations with sleep pattern Valsalva maneuver, vagal nerve stimulation **factor affecting HR

parasympathetic nervous system

Look on the monitor picture on phone for this question. What does the green number at the top (110) mean? · To the left where it says "HR 130/50" is what the alarm limits meaning if the patient's HR goes above 130 or drops below 50, the alarm will go off.

patient's HR

What principle of invasive pressure monitoring (hemodynamics) is described below: done every 8-12 hours & when the system is opened to air or measurement accuracy questioned (involves activating the fast flush & checking that equipment reproduces a distortion-free signal)

perform a dynamic response test

Complications of MIs include dysrhythmias, cardiogenic shock, papillary muscle dysfunction, ventricular aneurysm, pericarditis, Dressler Syndrome. Which of these complications is described below: · - inflammation of pericardial sac, treat with steroids & time, persistent chest pain, feel bad, ST elevation in ALL of the leads→ use NSAIDS to treat/manage. o Can occur after an MI

pericarditis

What additional essential of AACN/CCRN (Interpretation and mgmt cardiac rhythms, Hemodynamic monitoring, Circulatory assist devices, Airway and ventilator management, Pharmacology, Pain, Sedation) is described below: ○ Some drips are allowed on regular floors (dopamine up to 5, insulin) ○ Learn what's used, not used, titrated, drips

pharmacology

What anatomical location do we level the transducer with? o **Because we are monitoring CV pressures we have to level the transducer, where it opens to air, with a CV landmark, basically the R atrium

phlebostatic axis

What anatomical location do we level the transducer with? ○ Closest to the level of right atrium ○ Axis should be level with transducer (adequate measure of ART line or CVP) ○ Will use this axis for ART lines & Swan-Ganz ○ Position the pt. supine, flat or <45 degrees ○ Zero out the reference point (stopcock nearest the transducer) - zeroing out usually done once a shift or more if readings or not consistent ○ If the transducer is higher than the axis, it will result in a false law reading ○ If transducer lower than axis = false high reading

phlebostatic axis

What anatomical location do we level the transducer with? ● reference point): ○ Mid-axillary line, 4th ICS (right below the nipple line) midchest ■ When leveling transducer, you want the transducer to be level with the 4th ICS mid chest which is about the area of the R atrium ■ Since we are monitoring CV pressures, we want our transducer level with the CV system or R atrium

phlebostatic axis

Nurses often assume that the pt. who is extremely ill, weak or confused cannot self-report pain → may need to use other methods to assess their pain. Just because they cannot report it doesn't mean they are not in pain and we need to use other signs to assess their pain besides self-report such as their _______ responses. **Pain assessment

physiological

The following are some ________ responses to pain and anxiety: ● Tachycardia ● Tachypnea ● Hypertension ● Increased cardiac output (only initially) ● Pallor and/or flushing ● Cool extremities ● Mydriasis (pupillary dilation) ● Diaphoresis ● Increased glucose production- increase stress response which stimulates the liver to produce more glucose (gluconeogenesis) ● Nausea ● Urinary retention ● Constipation ● Sleep disturbances ● Atelectasis in bases of lungs from breathing shallow

physiological

We have ________ PEEP. Normally when we breathe, at the end of expiration our epiglottis closes and it is thought that we always have around 5 sonometers of PEEP. Well, when a patient is on a ventilator and they have an ET tube in place, their epiglottis never closes. We do not maintain that PEEP so it is very common for most patients on the ventilator to have at least 5 sonometers of PEEP and this is considered ________ PEEP. Higher levels of PEEP can be used and that helps to drive those gases across the membrane, recruit more alveoli, and allows use of less FiO2 because it is helping to drive gases across the membranes. If yu are having trouble oxygenating a patient and you keep going up on the FiO2, then they may try adding more PEEP instead and you may begin to get more improvement in your PA02 just because you recruited more alveoli. ______ PEEP is 5 cm of H20. ○ Patients who have ARDS or need extra help, we may go up to 10-15 cm

physiological

Patients are admitted to the ICU for 1 of 3 reasons: physiologically unstable, high-risk for serious complications, or intensive support requiring IV medications and/or advanced technology. Which of these 3 reasons is described below: ● typically either BP/cardiac, resp., neurological, or GI that is unstable) Ex: BP maintained by pressors, if too high and need continuous drip to lower it; bradycardia, V-Tach, rigid/distended abdomen, paralytic ileus, etc. ○ Other term used is hemodynamically unstable such as high or low BP ○ Respiratory failure, head injury, etc.

physiologically unstable

Patients are admitted to the ICU for 1 of 3 reasons. What are they?

physiologically unstable, high-risk for serious complications, or intensive support requiring IV medications and/or advanced technology

Pressors, ACE inhibitors, and ARBs are medications that affect the ______ of the heart.

pipes

The following is information about 12 Lead ________: R and L arm leads should be placed outwardly on the shoulders (preferentially over bone rather than muscle) (RA) The R leg lead (ground lead) should be placed below the umbilicus (RL) The L leg lead should be just below the umbilicus. (LL)

placement

The following is information about 12 Lead ________: V4 should be placed in the 5th intercostal space on the mid-clavicular line. V1 and V2 are positioned in the 4th intercostal space. V3 lies halfway between V2 and V4. V4, V5, and V6 should be placed along a horizontal line--this line does NOT necessarily follow the intercostal space

placement

The following is information about 12 Lead ________: o Have landmarks to identify where to put each of the leads o Really important when you do a 12 lead EKG that you put them in the right place because often times doing serial EKGs so need to be able to compare the EKGs and if the leads are not placed in the same place then you aren't comparing apples to apples and may miss some of the information you need o Not actually on the arms and legs because there is a lot of movement in those extremities so acceptable to put the arm leads on the shoulders and leg leads on the lower torso o V6 is midaxillary 5th intercostal space. Do V6 before V5 because you can place V5 between V4 and V6 o Really important that electrodes are placed in the same place all the time

placement

The following is information about 12 Lead ________: o V6 is midaxillary 5th intercostal space. Do V6 before V5 because you can place V5 between V4 and V6 o Really important that electrodes are placed in the same place all the time

placement

What essential of AACN/CCRN (assessment, diagnosis, outcome identification, planning, implementation, interventions, education and emotional support, and evaluation) is described below: ○ plan for post-op day 1 - what does pt. need to do, are they meeting outcomes; if not what do we need to change/modify

planning

The development of ______ occurs over many years-- it is a slow progressive disease. Most people don't show symptoms until they get to their 4th, 5th, or even 6th or later decade of life ■ There is evidence of some people having some degree of disease as early as age 20

plaque

For hemodynamic monitoring, the transducer needs to be re-leveled with each _____ _______. Anytime you change the patient's position (head up, head down, bed up, bed down) that could change the level of the transducer so you need to relevel the transducer with the phlebostatic axis. We use a carpenter level just like every dad has in their shop. You level it, put one end next to the transducer where it is open to air and the other at the 4th ICS. If it is NOT level and the transducer is too high and above the phlebostatic axis, it will give you false low readings. If the transducer is too low and below the phlebostatic axis, it will give you false high readings. Whenever you are doing hemodynamic monitoring, it is very important to have accurate data. You do not want to treat a patient based on false information. You want to pay attention to trends. If something is out of what has been trending and change, always check your system to make sure it is not a system problem.

position change

The following are complications of _______ pressure ventilation: ○ Alveolar hypoventilation/hyperventilation- too much or too low rate ■ Measure with ABGs ■ If you are in control of all the patient's ventilation and rate is too low, the patient will hypoventilate and develop a respiratory acidosis cause you are not blowing off enough CO2. ■ If a patient is given a rate that is too fast or the patient is too anxious and breathing a lot over the ventilator, that can cause hyperventilation which causes the patient to blow off too much CO2 causing respiratory alkalosis. ○ Ventilator-associated pneumonia (VAP) ■ Pneumonia occurring because patient is on the ventilator ■ Hospital acquired problem

positive

The following are complications of _______ pressure ventilation: ● Machine Disconnection/Malfunction: most deaths from disconnections occur when the alarm was turned off - ALWAYS leave the alarms on ○ Anytime you have a patient on Life Support and the ventilator is considered Life Support, you want to make sure that the plug is plugged into the Red plug in the wall. The Red plugs are plugs running on the emergency generation. That way if you have a power surge or lose power, the emergency generator will kick on in seconds and it will continue to power the ventilator. ○ As a general rule, anytime you have a power surge you should always go check any patients you have on Life Support to make sure those Life Support systems have restarted and functioning appropriately

positive

The following are complications of _______ pressure ventilation: ● Musculoskeletal System: early progressive ambulation is one of the most important things to prevent immobility associated problems ○ Atrophy because they will not be using their muscles→ passive ROM ○ Typically immobile, on bedrest; at risk for all problems with immobility (pressure areas, contractures) ● Psychosocial Needs: pt. have an overwhelming need to feel safe - inform them, help them gain control, help to give them hope ○ Anxiety-producing situation for patient and family; need a lot of communication and support

positive

The following are complications of _______ pressure ventilation: ● Neurologic System: PPV esp. with PEEP can impair cerebral blood flow; may also have increased ICP with JVD ○ With PEEP you want to be careful if they have any type of head injury ● Gastrointestinal System: use of peptic-ulcer prophylaxis is recommended (H2 blocker/PPIs--Zantac, enteral nutrition) ○ Will always be NPO so will probably have an NG tube in ○ Patients are not able to eat while on ventilator ○ High risk for peptic ulcers

positive

The following are complications of _______ pressure ventilation: ● Pulmonary System: ○ Barotrauma (excessive pressure) ■ Worry about overexpanding alveoli causing blebs and risk of popping ○ Volutrauma (excessive volume, will cause fractures in alveoli) ● Sodium & Water Imbalance R/T Renin system: progressive fluid retention 48-72 hours after PPV, esp. PEEP ○ If the ______ pressure causes decreased CO, then it will stimulate the RAAS system, causing retention of sodium and water

positive

When talking about electrical axis of the heart, we are talking about the general flow of electrical activity in the heart. Electrical activity starts in the right atrium, depolarizes the right and left ventricle, passes down through the AV node and then depolarizes the right and left ventricle together § Starts at the top of the heart and flows down to the apex § If the axis of the lead is parallel to the axis of the heart, then you should see a mostly _______ complex on the EKG. So the axis of the inferior wall leads are very similar to the axis of the heart so those should be mostly ______ on the EKG.

positive

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) Function: Positive pressure applied at the end of expiration Clinical Use: Used with CV, A/C, and SIMV to improve oxygenation by opening collapsed alveoli

positive end expiratory pressure (PEEP)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ During _______, lung volume during expiration & between breaths is greater than normal ○ Major purpose of _______: maintain or improve oxygenation while limiting risk of O2 toxicity ○ Increases functional residual capacity (FRC) ○ ______- you are keeping increase intrathoracic pressure→ decrease venous return and CO -- which decreases flow to the kidneys (may see a drop in BP) ○ Patients with head injury or stroke you NEVER want to use _______ (even if it is 5) **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

positive end expiratory pressure (PEEP)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ Facilitates oxygenation by increasing surface area for gas exchange & preventing airway collapse ■ With alveoli recruitment, we are trying to keep all the alveoli popped open. The more alveoli available for air exchange, the better the gas exchange will be. ■ It is pressure that is applied at the end of expiration. It keeps it in there even though the patient has expired ○ Maximizes number of alveoli available for O2 exchange ○ Allows adequate oxygenation with less FiO2 ○ Alveolar recruitment- maximizes the amount of alveoli available for oxygen exchange ○ Ventilator maneuver in which positive pressure is supplied during exhalation (pt. exhale remains passive, but the pressure falls to a level greater than 0 - usually 3-20cm H2O) ○ During _______, lung volume during expiration & between breaths is greater than normal ○ Major purpose of _______: maintain or improve oxygenation while limiting risk of O2 toxicity ○ Increases functional residual capacity (FRC) ○ ______- you are keeping increase intrathoracic pressure→ decrease venous return and CO -- which decreases flow to the kidneys (may see a drop in BP) ○ Patients with head injury or stroke you NEVER want to use _______ (even if it is 5) **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

positive end expiratory pressure (PEEP)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ Maximizes number of alveoli available for O2 exchange ○ Allows adequate oxygenation with less FiO2 ○ Alveolar recruitment- maximizes the amount of alveoli available for oxygen exchange ○ Ventilator maneuver in which positive pressure is supplied during exhalation (pt. exhale remains passive, but the pressure falls to a level greater than 0 - usually 3-20cm H2O) **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

positive end expiratory pressure (PEEP)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ● Complications: ○ Decreased cardiac output (decreased venous return because of increased intrathoracic pressure) ○ Increased ICP related to decreased venous return (decrease venous return - elevate HOB) ○ Alveolar barotrauma & pneumothorax (from all of the pressure) ○ May stimulate RAAS (renin-angiotension) release & later decrease renal function (decreased renal flow) ■ If it decreases CO, then that will decrease flow to the kidneys, that will trigger the RAAS system and if lasts long enough, can cause renal insufficiency and acute kidney injury ○ A patient can be weaned to a rate of 0 to where you have no rate and machine is no longer giving the patient a tidal volume. The patient is taking all the breaths on their own and if you add ______, pressure support, to make it easier for them to breathe (overcome resistance of tube). You can also keep the _______ on to prevent the alveoli from collapsing and this sort of makes a BiPAP but with the mechanical ventilator for some reason they do not cal it BiPAP they call it CPAP. That is the terminology they use when you wean someone down to a rate of 0 and you keep the pressure support on and _______ on, they call that CPAP but it is really like BiPAP because you have bilevel pressure. **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

positive end expiratory pressure (PEEP)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ● Contraindications ○ Highly compliant lungs (COPD) ○ Unilateral or non-uniform disease (atelectasis) ○ Hypovolemia ○ Low cardiac output ○ Physiological _______ - 5cm H20 ○ >5cm can result in decreased cardiac output ○ Do NOT increase _____ for pt. with COPD or atelectasis **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

positive end expiratory pressure (PEEP)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ● Higher levels of _______ can result in pneumothorax ○ It is positive pressure staying in those lungs, keeping the alveoli open. But, if you start getting to really high levels of _______, that is when you start worrying about blebs exploding causing pneumothorax ○ *******we rarely ever use _______ on a head injury patient or patient who has increased intracranial pressure (ICP)****** **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

positive end expiratory pressure (PEEP)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ● Indications ○ Classic indication is ARDS (lungs are non-compliant & airway pressures not sent to heart) Lungs with diffuse disease ○ Severe hypoxemia unresponsive to FiO2 >50% ○ Loss of compliance or stiffness ○ Pulmonary edema **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

positive end expiratory pressure (PEEP)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ● Physiological ______: ○ We have physiological _______. Normally when we breathe, at the end of expiration our epiglottis closes and it is thought that we always have around 5 sonometers of ______. Well, when a patient is on a ventilator and they have an ET tube in place, their epiglottis never closes. We do not maintain that _______ so it is very common for most patients on the ventilator to have at least 5 sonometers of ______ and this is considered physiological _______. ○ Higher levels of ______ can be used and that helps to drive those gases across the membrane, recruit more alveoli, and allows use of less FiO2 because it is helping to drive gases across the membranes. If yu are having trouble oxygenating a patient and you keep going up on the FiO2, then they may try adding more _______ instead and you may begin to get more improvement in your PA02 just because you recruited more alveoli. **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

positive end expiratory pressure (PEEP)

The following is nursing management ______ PCI: · ***Managing the Vascular Access Site** o*** HOB flat when sheath is still in place*** § Sometimes when they give anticoagulants during the procedure, they need to leave the actual catheter introduced in place for two hours until that anticoagulant wears off o ***Once anticoagulants wear of, the cardiovascular nurse will pull that sheath and apply direct pressure for 10-15 minutes**** § Will have to be trained to do this if you work on a cardiovascular floor that cares for PCI patients

post

The following is nursing management ______ PCI: · A vasodilator drip may be hanging and may need to be titrated per cp or blood pressure. · Plavix is usually given in Cath Lab. A loading dose is administered, and the amount is based upon whether a pt was already on Plavix when admitted. · ASA is started within 24 hours.

post

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ● Physiological _______ is 5 cm of H20 ○ Patients who have ARDS or need extra help, we may go up to 10-15 cm ● ________ higher than 5 cm result in decreased cardiac output ○ Because it decreases venous return. Remember if you do not have enough blood in the ventricle to eject out, you will have a decreased CO. if you have decreased venous return, you will have decreased preload and decreased CO. ○ Patients who are hypovolemic or have poor L ventricle sometimes may not tolerate higher levels of _______ ■ If patient does have poor L ventricle, they may only be able to tolerate 5 cm of _______ ○ Because it decreases venous return, it decreases return of flow from the head. Patients who have increased intracranial pressure, _______ can make that ICP worse because you are decreasing the venous return of blood flow form the head. It is not returning and draining from the head like it normally should; theoretically that will increase the pressure in the head ○ *******we rarely ever use _______ on a head injury patient or patient who has increased intracranial pressure (ICP)****** **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

positive end expiratory pressure (PEEP)

What ventilator setting is described below: (TV, RR, FiO2, PEEP, PS) ● usually 5-10 (avoid greater settings to avoid barotrauma & decreased CO)

positive end expiratory pressure (PEEP)

Negative or postive pressure ventilation? ● During inspiration the ventilator pushes air into the lungs under _______ pressure (intrathoracic pressure is raised during lung inflation rather than lowered - expiration still occurs passively) ● _______ pressure means instead of using negative pressure to pull air into the lungs, you are using a blowing or blowing air into the lungs. ○ Have both non-invasive and invasive _______ pressure ventilation ● Non-invasive _______ pressure ventilation (NIPPV)--> CPAP and BiPAP ● Invasive _______ pressure ventilation: pressure ventilation and volume ventilation ○ Where you put either an endotracheal tube in or a tracheostomoy tube in and you blow air into the lungs. ○ Pressure and volume ventilation has more to do with how air is delivered

positive pressure ventilation

What piece of technology in the ICU is described below: (ECG monitoring, positive pressure ventilation, hemodynamic monitoring, intracranial pressure monitoring, ventricular assist devices, continuous renal replacement therapy) o Patients who have respiratory failure may need to be put on the ventilator (technology used to breathe for patients)

positive pressure ventilation

In acute care, we use more _______ pressure ventilation whether it is non-invasive or invasive. ________ pressure ventilation is not typically seen in acute care setting.

positive; negative

The following is nursing management ______ PCI: · ******Hold metformin for 48 hours after the procedure***** o There is an interaction between the metformin and the dye, and it can cause some metabolic acidosis o Sometimes physician forget to do this

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The following is nursing management ______ PCI: · *****Monitor anticoagulant or antiplatelet drips- if on IIb/IIIa then monitor for bleeding/hematoma******* o Eptifibatide (Integrillin®) - IV antiplatelet o Tirofiban (Aggrastat®) - IV antiplatelet o Bivalirudin (Angiomax) - IV anticoagulant o Also monitor if they are on nitroglycerin

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The following is nursing management ______ PCI: · *****Monitor vital signs—just like ______-op****** o Every 15 minutes x 4, every 30 minutes x 2, and then every hour x 4 o Also look at their puncture wound site because if they punctured an artery, they are at high risk for hematoma o And check their circulation distally to the puncture site § If femoral approach—check the pedal pulses and the CMS to the feet and toes § Radial stick—check CMS to the hands and fingers

post

The following is nursing management ______ PCI: · ****Monitor for chest pain and ST changes***** o If the patient has an acute occlusion, remember there is a small incidence of patients who shut down their vessel hours after the procedure and they will typically present with chest pain and possibly some ST segment changes o Possible signs of acute closure o Patients should not be complaining of severe chest pain § May occasionally complain of some achiness but pretty much the chest pain that they were having before should be relived because we opened up their vessel

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The following is nursing management ______ PCI: · ****Monitor for chest pain and ST changes***** o Stat 12 lead for complaints of chest pain § On the _______-PCI order set § Look at your ST segments to see if there are any signs of ST segment elevation or ST segment depression · This is where it is helpful to know which vessel was dilated and/or stented because then you will know which leads to look at o Also, when you put them on telemetry, you want to put them on a lead overlooking that area of the heart o Ex: if the had an LAD angioplasty then the patient probably needs to be in a V2 or V3 lead (V3 probably better) o Ex: if they had angioplasty of the RCA then a lead 2 would be the best lead

post

The following is nursing management ______ PCI: · ****Monitor vasodilator drips***** o Nitroglycerine (Tridil®) § Veno and artereo vasodilator—so watch their BP (it can drop) · ******Administer antiplatelet medication******—usually loaded with one of the antiplatelets during the Cath lab and then they are going to be on daily doses (oral)—DAPT (dual antiplatelet therapy—an antiplatelet and aspirin) o Clopidogrel (Plavix®) o Prasugrel (Effient®) o Ticagrelor (Brilinta®) o Aspirin

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The following is nursing management ______ PCI: · ***Managing the Vascular Access Site** o ***Monitor for bleeding*** o ****Check distal pulses**** o ***Instruct patient to keep leg straight and head down***** § If it is a femoral approach, they usually order 4-6 hours of bed rest, unless they use a closure device · With their head no higher than 20-30 degrees · If it is a radial approach then the 4-6 hours of the bed rest does not apply—the whole purpose of the bed rest is to prevent bending at the femoral site where the stick was

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The following is nursing management ______ PCI: · ***Managing the Vascular Access Site** o Closure devices—sometimes physicians will use these special devices that seal the artery § Angio-seal—collagen plug that plugs the hole in the vessel § Perclose—a suture that they tie § Starclose—a clip that they use § If a closure device is used, then usually their bed rest is reduced to 2 hours instead of the 4-6 hours · So, the patient can get up quicker or go home sooner § Expensive § Still need to frequently monitor them because they sometimes do fail (look at the puncture site for bleeding/hematoma)

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The following is nursing management ______ PCI: · After pulling sheath, pressure is held 10-15 minutes unless more time is needed. · A Closure pad or DSTAT pad is applied. These pads have properties that help coagulation at the site. · A boomerang is another device applied by the doctor, but closed by the nurse. · A closure device is applied by the doctor in cath lab. Angio-seal is a plug of collagen that occludes the artery. Perclose is where the artery is sutured. · Still need bleeding assessment for closure devices. These devices mean early ambulation.

post

The following is nursing management ______ PCI: · After the procedure, monitor patient for cp and st changes...this could be an indication of abrupt closure of the artery. CP could also be an indication of vasospasm after a PCI. · Monitor VS. A sudden drop in BP can mean the patient is vagaling or that the patient is bleeding from the femoral artery. · The patient can come back from procedure with 1 or more drips hanging. Anticoagulant or antiplatelet drips need to be monitored. The physician will order the time to hang these drips . Pt has risk of bleeding.

post

The following is nursing management ______ PCI: · Monitor for bleeding. Ask patient if there is any pain. Note any back pain - possible bleeding. Palpating the access site for hematoma. Will feel a hard knot. Check site when patient is returned from cath lab. Check opposite leg for comparison. Note and mark any drainage on the bandage to compare over next few hours. · Check distal pulse. If you had the patient before they went to cath lab, you have a good comparison. · Keep leg straight and head down...vagal response if not if sheath is in. If sheath is pulled already, can put pressure and cause site to bleed.

post

The following is nursing management ______ PCI: · Monitor for chest pain and ST changes · Monitor vital signs—just like post-op · Monitor anticoagulant or antiplatelet drips- if on IIb/IIIa then monitor for bleeding/hematoma Hold metformin for 48 hours after the procedure · Monitor vasodilator drips Administer antiplatelet medication · Managing the Vascular Access Site o Monitor for bleeding o Check distal pulses o Instruct patient to keep leg straight and head down o HOB flat when sheath is still in place o Once anticoagulants wear of, the cardiovascular nurse will pull that sheath and apply direct pressure for 10-15 minutes Closure devices

post

The following is nursing management ______ PCI: · When patients come in for STEMI or NSTEMI, often times PCI is an urgent intervention o There is also a large population of patients who come in electively for a PCI § So, this may not be an urgent situation, but they are still having a PCI, and post op management is the same § In most cases those patients will be admitted into the hospital for an overnight stay and they usually go to the medsurg floor usually a telemetry floor because you do want to have those patients on a cardiac monitor

post

The following is nursing management ______ PCI: · _______-PCI—patient comes back to the floor and you want to do the routine post-op monitoring, just like you would do if you had a surgery patient o VS every 15 minutes o Monitor for bleeding o Monitor for problem with circulation distal to wherever they stuck o Assess for any complications or chest pain

post

_____ procedure monitoring includes: · An Aldrete score of 9 or greater is suggested for discharge. In general, patients should be able to tolerate some oral intake and have sufficient return of motor skills to walk and dress themselves prior to discharge. · When patient reaches pre-procedural base line (or -1-2) - ready for discharge or cessation of special monitoring. If patient does not reach baseline score consult physician regarding discharge.

post

_____ procedure monitoring includes: · Do the pre reading and then the _____ reading o If the patient has a lower pre-score to begin with then it could explain a lower post score (maybe they have an amputation or neurological problems before) o If _____ score is within 1-2 of their pre-score, then generally they are considered acceptable to move to the next level of care · Another validated tool often used for ______ procedural monitoring

post

_____ procedure monitoring includes: · Often used to evaluate if a patient is awake enough after sedation to promote them to the next level of care—or if you are doing an outpatient procedure, to discharge them · Often used by PACU unit (recovery units) to determine whether or not its safe to move the patient back up to their room—or for outpatient procedures, whether or not they have recovered adequately enough to be sent home

post

______ PCI, nurses have to manage the vascular access site and the patient can have various different closure devices. Sometimes physicians will use these special devices that seal the artery. Angio-seal, Perclose, and Starclose are different closure devices. If a closure device is used, then usually their bed rest is reduced to 2 hours instead of the 4-6 hours. So, the patient can get up quicker or go home sooner. § Expensive § Still need to frequently monitor them because they sometimes do fail (look at the puncture site for bleeding/hematoma)

post

post perfusion syndrome ("pump head")

What are the 3 main complications of cardiopulmonary bypass?

post perfusion syndrome ("pump head"), hemolysis of the RBCs, and capillary leak syndrome

What does PICS stand for? ○ Approximately 1/3 of patients ○ Physical, cognitive and mental health problems because of their stay in ICU ○ Some ICU patients have PICS and this is kind of like PTSD for an ICU patient. Military people who are in wars or in combat have PTSD because of their experiences. There is evidence that some patients have PICS. ○ Do all you can to make them comfortable and keep them oriented. Bring in that humanistic side to your nursing care to help prevent that PICS syndrome

post-intensive care syndrome (PICS)

What syndrome that ICU patients can experience is described below: ○ Approximately 1/3 of patients ○ Physical, cognitive and mental health problems because of their stay in ICU ○ Some ICU patients have PICS and this is kind of like PTSD for an ICU patient. Military people who are in wars or in combat have PTSD because of their experiences. There is evidence that some patients have PICS. ○ Do all you can to make them comfortable and keep them oriented. Bring in that humanistic side to your nursing care to help prevent that PICS syndrome

post-intensive care syndrome (PICS)

What leads of a 12 lead EKG (augmented unipolar, bipolar, precordial/chest leads) is described below: o This is a schematic view of the areas of the heart visualized by the chest leads. o Leads V1, V2, and V3 are contiguous. o Leads V3, V4, and V5 are contiguous, as well as V4, V5, and V6. o Note that neither the right ventricular wall (X) nor the posterior wall of the left ventricle (Y) is well visualized by any of the usual six chest leads.

precordial

What leads of a 12 lead EKG (augmented unipolar, bipolar, precordial/chest leads) is described below: o V1 & V2 § Looking at the septum (wall between the left and right ventricle) § Considered septal leads o V3 &V4 § Looking at the anterior wall of the heart § Considered anterior wall leads o V5 & V6 § Looking at the lateral wall of the heart § Considered lateral precordial/wall leads

precordial

What leads of a 12 lead EKG (augmented unipolar, bipolar, precordial/chest leads) is described below: o ________ chest leads are the V leads § The leads look at the heart in a cross-section manner § Looking directly at the left ventricle, which is the thickest muscle/chamber that squeezes and eject blood out to the periphery against those high pressures so have a thick wall of the left ventricle § V leads are designed to look directly at the left ventricle

precordial

Post cardiac surgery, the nurse needs to manage the patient's preload, afterload, and contractility. The following are methods for controlling which of these 3 heart functions? · Administer volume as needed for low PAWP/CVP (crystalloids, colloids [albumin], PRBCs) o Patient will probably come back with some crystalloids in progress o One of the problems with bypass surgery is that the patients have an inflammatory response and that causes some capillary leak so they tend to third space a lot (may have a lot of fluid on board but not in their vascular space—a lot of it is in the tissues) § To manage that we use some crystalloids and albumin (a colloid)—helps pull that fluid from the third space back into the intravascular space o If the volume problem is because they have bled too much, then we need to replace with packed red cells · Diuretics as needed o Not common that you have to give diuretics on the same day as surgery but its very common that you need to give diuretics post-op day one or two · Almost all of these patients gain 10 pounds overnight due to all that volume (because you are giving them all those colloids and fluids trying to fix the third spacing) o The surgeon will probably order 40 of Lasix IV if you weigh them the next morning and they have gained 10 pounds

preload

Post cardiac surgery, the nurse needs to manage the patient's preload, afterload, and contractility. The following are methods for controlling which of these 3 heart functions? · Diuretics as needed o Not common that you have to give diuretics on the same day as surgery but its very common that you need to give diuretics post-op day one or two · Almost all of these patients gain 10 pounds overnight due to all that volume (because you are giving them all those colloids and fluids trying to fix the third spacing) o The surgeon will probably order 40 of Lasix IV if you weigh them the next morning and they have gained 10 pounds

preload

What main factor affecting stroke volume (preload, afterload, contractility) is described below: ○ ________ of the R side of the heart is the pressure or volume in the L ventricle right before systole and there is a number we can get with the Swan Ganz catheter called a pulmonary artery wedge pressure and that is the ________ of the L side of the heart ○ On the R side of the heart, the CVP or the right atrial pressure is the ________ of the R side of the heart

preload

What main factor affecting stroke volume (preload, afterload, contractility) is described below: ● (venous return) ○ ________ is the amount of blood in the ventricles at the end of diastole ○ PAWP (Pulmonary artery wedge pressure) reflects left ventricular end-diastolic pressure; CVP (central venous pressure) reflects right ventricular preload ○ As ________ increases, forces generated in contraction also increase, thus SV & CO increase ○ Decreased by - acute blood loss, dehydration, diuresis, vasodilation, etc. ○ Increased by - elevating pt. legs, exercising, administration of fluids ○ If not enough volume in the ventricle, before systole, there will not be much to eject out decreasing stroke volume. You have to have enough volume to circulate blood ○ ________ of the R side of the heart is the pressure or volume in the L ventricle right before systole and there is a number we can get with the Swan Ganz catheter called a pulmonary artery wedge pressure and that is the ________ of the L side of the heart ○ On the R side of the heart, the CVP or the right atrial pressure is the ________ of the R side of the heart

preload

You might also hear people talking about RAP/CVP as right sided filling pressures because your RAP is the _______ of the R side of the heart. This gives us an idea of the patient's volume status (dehydrated, overhydrated, normal). ■ if volume overloaded, you will see high CVP pressures. ● Possibly R-sided heart failure ■ If they are dehydrated or volume depleted you will see low CVP pressures

preload

preload or afterload? volume of blood in the ventricles right before systole **venous return

preload

preload or afterload? ● volume of blood in the ventricles right before systole ○ you have ______ on the R side of the heart and on the L side of the heart ○ you have to have volume to pump out; if you do not have volume in there you will not have a good CO. ○ if you have too much _____, it can strain the heart and it cannot pump effectively

preload

what are the 3 main factors affecting stroke volume (SV)?

preload, afterload, contractility

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) Function: Preset pressure that augments the patient's inspiratory effort and decreases the work of breathing Clinical Use: Often used with SIMV during weaning

pressure support (PS)

What ventilator setting is described below: (TV, RR, FiO2, PEEP, PS) ● usually 5-10 (support needed to get through the tubing)

pressure support (PS)

What are the 2 add-n mode of ventilations that can be added on to some of the previous modes discussed (CMV, AC, SIMV, APRV)

pressure support (PS) and positive end expiratory pressure (PEEP)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ Can be used with other SIMV or as a stand alone in weaning ■ If you get the patient down to a rate of 0 and you leave the ______ on, it makes it easier (if the patient is still intubated) for the patient to pull those breathes in ○ What are some advantages of _______ ventilation? ■ Increased pt. comfort, decreased WOB, decreased O2 consumption, increased endurance conditioning (pt. exercises own respiratory muscles) ○ **NOT used as the sole ventilator support during acute respiratory failure because of risk for hypoventilation **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

pressure support ventilation (PS)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ Present amount of pressure is delivered for a set time (duration of spontaneous breath) (5-15, can be up to 20) ■ Only during inspiration on a patient who takes a spontaneous breath ■ Cannot use _____ on a patient with assist control or CMV ■ This can be used on a patient with SIMV ○ Pt. must be able to initiate breaths - pt. determines inspiratory length, tidal volume & respiratory rate --- makes it easier for pt to initiate a breath ○ Augments pt. spontaneous respiration & decreases work of breathing (decreases workload of pt. to pull oxygen in & actually initiate a breath) ○ Volume & pressure levels are affected by the pt. lung compliance ○ Can be used with other SIMV or as a stand alone in weaning ■ If you get the patient down to a rate of 0 and you leave the ______ on, it makes it easier (if the patient is still intubated) for the patient to pull those breathes in ○ What are some advantages of _______ ventilation? ■ Increased pt. comfort, decreased WOB, decreased O2 consumption, increased endurance conditioning (pt. exercises own respiratory muscles) ○ **NOT used as the sole ventilator support during acute respiratory failure because of risk for hypoventilation ○ This is a little extra pressure during inspiration, normally somewhere around 5-20 sonometers with 10 sonometers being a common number used. This creates a little bit of pressure in the system (positive pressure) that makes it easier for the patient to pull the air in. that is during a spontaneous breathe where the patient is using negative pressure to pull the air in. it makes it easier; especially for a patient with an ET tube and they are trying to breathe in through a straw and it is harder to pull air in since there is resistance to the air. With the ________, it helps overcome the resistance of the tube. **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

pressure support ventilation (PS)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ Pt. must be able to initiate breaths - pt. determines inspiratory length, tidal volume & respiratory rate --- makes it easier for pt to initiate a breath ○ Augments pt. spontaneous respiration & decreases work of breathing (decreases workload of pt. to pull oxygen in & actually initiate a breath) ○ Volume & pressure levels are affected by the pt. lung compliance **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

pressure support ventilation (PS)

What mode of ventilation is described below: (CMV, AC, SIMV, APRV, PS, PEEP, CPAP) ○ This is a little extra pressure during inspiration, normally somewhere around 5-20 sonometers with 10 sonometers being a common number used. This creates a little bit of pressure in the system (positive pressure) that makes it easier for the patient to pull the air in. that is during a spontaneous breathe where the patient is using negative pressure to pull the air in. it makes it easier; especially for a patient with an ET tube and they are trying to breathe in through a straw and it is harder to pull air in since there is resistance to the air. With the ________, it helps overcome the resistance of the tube. **The following are add-ons that you can add on to some of the previous modes discussed (CMV, APRV, SIMV, AC)

pressure support ventilation (PS)

With INVASIVE positive pressure ventilation the main two concepts is volume ventilation and pressure ventilation. Which of these 2 is described below: ○ Better distribution of air flow throughout alveoli ○ Physician orders a pressure and the respiratory therapist is usually the one who sets it up on the vent and dials up the pressure. The tidal volume is driven into the lungs until you reach that set pressure. The tidal volume will vary depending on how compliant or how stiff the patient's lungs are. ○ With volume ventilation, the pressure varies; with ____ _______ the tidal volume varies. ○ Usually _____ ______ is reserved for those patients with non-compliant lungs and the most common situation with that is patients with ARDS (adult respiratory distress syndrome).

pressure ventilation

With INVASIVE positive pressure ventilation the main two concepts is volume ventilation and pressure ventilation. Which of these 2 is described below: ○ The other thing you can do with ____ _____ is reverse the I:E ratio: he inspiration to expiration ratio. Normally when we breathe, inspiration is about half the time of expiration so the normal I:E ratio is 1:2. With inverse ratio, they either make it 1:1 where inspiration is equal to expiration or maybe inspiration is twice that of expiration (2:1). The whole purpose of doing that is to give more time for the gases to cross the capillary membrane. Again, patients with ARDS have acute lung injury and the membrane gets thickened and stiffened and so it is harder for those gases to cross that capillary basement membrane. So by reversing the I:E ratio, it gives it more time for those gases to exchange.

pressure ventilation

With INVASIVE positive pressure ventilation the main two concepts is volume ventilation and pressure ventilation. Which of these 2 is described below: ○ Ventilator delivers air until preset inspiratory airway pressure is present ■ Inverse I: E ratio (normal is 1:2) ■ Disadvantage of ____ ______ is that the tidal volume varies according to pt. pulmonary system (how stiff patients lungs are) ● Hypoventilation & respiratory acidosis may occur in pt. with increased resistance to flow or decreased compliance (ARDS) ○ Not getting as much tidal volume in if pressure is set too low and patients lungs are really stiff ● With pressure ventilator, nurse MUST watch closely to ensure adequate tidal volume

pressure ventilation

Long-term goals for patients with ACS is ________ which is aimed at modifiable risk factors/management/prevent from progressing. (coronary disease or all vascular disease is a chronic condition that has to be managed)—all of the things we do just mange it, not cure it (it can progress and continue to be a problem for the patients) o Lifestyle changes - exercise, heart healthy diet, weight loss. o Lipid lowering medications (hyperlipidemia). o Aspirin - 81 mg antiplatelet. (to prevent platelet aggregation) o Smoking cessation. o Hypertension and diabetes management. **collaborative management/goals

prevention

There are 2 approaches to pain management: preventive and titration approach. Which of these 2 approaches is described below: ○ Analgesics are given before the pt. complains of pain - given ATC not PRN ■ Maybe using a PCA with continuous basal dosing ○ Teach pt. not to wait until pain becomes a 10 before asking for medication ○ Using meds around the clock

preventive approach

What are the 2 approaches to pain management?

preventive approach and titration approach

The following are ______ rated as moderately-severely painful in ICU patients: ● ABG/Arterial line insertion ● Central line insertion ● ET suctioning ● ET tube in place ● Indwelling urinary catheter (especially if having bladder spasms) ● Mechanical ventilation (especially if the patient is awake; may start breathing against the vent) ● Moving from bed to chair ● NG tube insertion ● IV insertion ● Turning in bed

procedures

What critical care specialty unit is described below: ● (PCU pt. at risk for serious complications, but risk is lower than ICU pt.) ○ AKA stepdown units ○ These are units in between med surg and ICU; is a step down from ICU. patients who need a higher level of care but maybe not hemodynamically unstable, may not need a 2:1 nurse ratio but usually 3:1 ratio instead ○ The nurse to patient ratio is usually 3 to 1 or 4 to 1 (nurse: patient) ● Use of PCUs provides critical care nursing for an at-risk pt. population in a more cost-effect environment

progressive/intermediate care units

What critical care specialty unit is described below: ● Use of PCUs provides critical care nursing for an at-risk pt. population in a more cost-effect environment

progressive/intermediate care units

The following are ______ to cardiopulmonary bypass: · The physician can arrest the heart, so they are not having to do surgery on a beating heart · And they can open the chest nice and wide and get the exposure to the heart

pros

What is the reversal agent for heparin?

protamine sulfate

What intervention of nursing management of artificial airways is described below: ○ Lips, tongue & mouth should be moistened with saline/water swabs to prevent drying ○ Oral care includes: brushing teeth BID, suctioning q2-4h as needed, reposition & re tape ET tube q24h ○ Trying to prevent ventilator associated pneumonia with oral care ○ If the tube sits on lip on the same spot all the time, that can cause a pressure sore on their lip

providing oral care and maintaining skin integrity

The following is a summary of PA catheters: ● ________ Port → Right Atrium → RAP, CVP ○ RAP is preload of the R side of the heart ● Distal Port→ Pulmonary Artery→ PAP and PAWP (with the balloon inflated) ○ The PAWP is the preload of the L side of the heart NEED TO KNOW ALL OF THIS.

proximal

When talking about there ports of a pulmonary artery catheter, which port (R atrial port, proximal infusion port/R ventricular port, pulmonary artery distal port, thermistor port) is described below: ■ The ____ _____ _____, or R ventricular port, is an opening that sits in the R ventricle. This is used as an infusion port to give IV fluids and medications. You can also use this port to give IV fluids and medications if not doing continuous monitoring through it. those are 2 possible ports you can use for IV fluids and medications. Not all pulmonary catheters have that infusion port, some only have the R atrial port which may be labeled as the infusion port.

proximal infusion port

What port of a pulmonary artery catheter is described below: ○ _________ port terminates in the RA - it is used to measure RAP/CVP & to administer injectate for measuring cardiac output ○ Gives idea of patients volume levels ■ too low, may be dehydrated ○ Low pressure pump so the readings will be low (2-10) ■ Many times you will not get "normal" numbers with this patients because they are not doing well so look at trends ○ CVP is basically a measure of preload, which is usually affected primarily by fluid volume status (can determine if pt. is in fluid volume overload or deficit using CVP) ○ Can get CVP with just central line ○ **remember CVP is measured as a MEAN value which is why it is in parentheses. The R atrium is a LOW PRESSURE chamber.

proximal port

Which port of the pulmonary artery catheter is used to measure RAP/CVP and to administer inject ate for measuring cardiac output? ○ Gives idea of patients volume levels ■ too low, may be dehydrated

proximal port

What complication of positive pressure ventilation is described below: ● pt. have an overwhelming need to feel safe - inform them, help them gain control, help to give them hope ○ Anxiety-producing situation for patient and family; need a lot of communication and support

psychosocial needs

Look on the monitor picture on phone for this question. Over to the right you see "SVO2". This is oxygen saturation of the blood in the _______ artery. o It is lower than your SPO2 because this is blood returning back to the heart after oxygenating or deoxygenating tissue in the body which is normally low o Normal: 60-80

pulmonary

Look on the monitor picture on phone for this question. Your _______ artery pressure, CVP, SVO2, CI, and SVR--> you get all of these numbers if the patient has a ______ artery catheter in place · Your arterial line would be a separate line which would give you the arterial pressure

pulmonary

The following are complications of ____ ____ catheters (Swan-Ganz): ● Infection (invasive device, hole) ● Air emboli (always close the line to the pt. by clamping at stopcock anytime line is disconnected) ○ If significant amount of air enters bloodstream ● Pneumothorax ● Thromboembolism ● Fluid overload (if given too much volume with IV) ● Hemorrhage (especially with arterial line if it comes out) ● Pulmonary infarct (if balloon stays wedged) / tissue necrosis