Module 1
Name the components of cardiac output
Heart rate x Stroke Volume
What does the Pulmonary Artery Catheter measure?
-Cardiac output
-SvO2 (distal port)
-L heart preload (PAOP/PAWP)
Atrial Fibrillation is characterized by:
a. Hundreds of atrial impulses from different locations in the atria firing at the same time
b. Regular ventricular activity
c. May be controlled (HR<100) or uncontrolled (HR >100)
d. Regular and fast atrial rate
e. A & C are correct
f. B &C are correct
e. A & C are correct
You work on a telemetry unit. When you walk into one of your patient's room they complain of chest pain and shortness of breath. You look at the cardiac monitor and you are alarmed that they are in vtach. What are your next actions? SATA
A. Assess and prepare to treat the cause
B. administer epinephrine
C.Prepare for cardioversion
D. Have the patient lie in the recovery position
A and C: the patient can speak so, the next actions will be for the patient in Vtach WITH a pulse. Epinephrine is appropriate for pulseless rhythms and the recovery position will not help a patient with a lethal rhythm.
One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply:
A. Temperature 104.8 ‘F
B. Heart rate 40 bpm
C. Heart rate 140 bpm
D. Anxiety, restlessness
E. Urinary output 15 mL/hr
F. Blood pressure 70/56
G. Pale, cool skin
H. Weak peripheral pulses
I. Blood pressure 220/106
C, D, E, F, G, and H. Signs and symptoms of hypovolemic shock include: tachycardia, hypotension, increased respiratory rate, cool/pale/clammy skin, anxiety, decreased urinary output (normal UOP is >30 mL/hr), weak peripheral pulses
Name the indicators of perfusion
Level of consciousness
Pulses
Skin color
Skin Temperature
Capillary refill time
Urine output
What does the Central venous line measure?
ScvO2
What ventricular rhythms are considered a medical emergency?
Ventricular Fibrillation (VF)
Ventricular Tachycardia (VT)
-Similar as VTach treatment
-Magnesium when appropriate
A 35-year-old male arrives to the emergency room with multiple long bone fractures and an internal abdominal injury. The patient is anxious. Patient’s vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 ‘F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to?
A. Collect a urine sample
B. Obtain an EKG
C. Establish 2 large-bore IV access sites
D. Place a warming blanket on the patient
C. This patient is at major risk for hypovolemic shock due to the multiple long bone fractures and an internal abdominal injury (this can lead to relative hypovolemic shock…where fluid is loss inside the body). The patient is already showing signs and symptoms of hypovolemic shock. Therefore, it should be a nursing priority to establish IV access (at least two sites should be obtained using a large-bore cannula….18 gauge or higher). Fluids and possibly blood products will need to be given to this patient along with pain medication etc.
The charge nurse is monitoring the care of several critically ill patients in the ICU. Which patient requires immediate intervention by the provider?
A.The patient with a PA catheter remaining in the wedge position
B.The patient with an SvO2 of 55%
C.The patient with an SVR of 1,300 (increased)
D.The patient with a CO of 3.2 (decreased)
Answer:A
Rationale:All of the above patient situations are slightly abnormal, requiring attention, but a pulmonary artery catheter that remains in a wedge position may indicate the possibility of pulmonary artery occlusion requiring repositioning or discontinuation of the catheter. Decreased mixed venous oxygen saturation and cardiac output may indicate the need for volume or inotropic support. The slightly increased systemic vascular resistance would need to be evaluated for cause, such as hypovolemia, and treated as necessary.
Describe the difference between contractility and ejection fraction.
Contractility=pumping action of the heart
Ejection fraction=% of blood ejected from the ventricles with each contraction
The heart’s native impulse travels from:
a. Bundle of His - bundle branches- AV node – SA - Purkinje fibers
b. AV node – SA - bundle branches - bundle of His - Purkinje fibers
c. SA - AV node - bundle of His - bundle branches - Purkinje fibers
d. Purkinje fibers - bundle of His - bundle branches - SA - AV node
c. SA - AV node - bundle of His - bundle branches - Purkinje fibers
Your patient is in asystole, what is your next action?
Initiate CPR
A patient is receiving large amounts of fluids for aggressive treatment of hypovolemic shock. The nurse makes it PRIORITY to?
A. Rapidly infuse the fluids
B. Warm the fluids
C. Change tubing in between bags
D. Keep the patient supine
The answer is B. It is very important when giving large amount of fluids that the nurse ensures the fluids are warm. WHY? To prevent the patient from developing hypothermia. If this develops, clotting enzymes can become altered along with leukopenia and thrombocytopenia. Keep the patient warm, but not too hot.
ScvO2 is the central venous oxygen saturation and is an indication of oxygen saturation of blood returning from the upper body.
A patient has a blood pressure of 220/140. The physician prescribes a vasodilator. This medication will?
B. Decrease the patient’s blood pressure and decrease cardiac afterload
a. PR interval = ?
b. QRS interval = ?
c. QT interval = ?
a. PR interval = ______________.12-.20__________ b. QRS interval = __________.04-.10______________ c. QT interval = ________<.52________________
Dfib: not synchronized, higher energy, indicated in VFIB and Vtach with out a pulse
Cardioversion: synchronized, delivered on the R wave, lower energy, indicated in afib and unstable tachyarrhythmias
You’re caring for a patient with cardiogenic shock. Which finding below suggests the patient’s condition is worsening? Select all that apply:
A. Blood pressure 95/68
B. Urinary output 20 mL/hr
C. Cardiac Index 3.2 L/min/m2
D. Pulmonary artery wedge pressure 30 mmHg
B and D. When answering this question look for values that are abnormal and that point to worsening tissue perfusion (urinary output should be 30 mL/hr or greater….if it’s lower than this it show the kidneys are not being perfused) and worsening cardiac output (the blood pressure and cardiac index are within normal limits BUT pulmonary artery wedge pressure is NOT). A pulmonary artery wedge pressure (also called pulmonary capillary wedge pressure) is the pressure reading of the filling pressure in the left atrium. A normal PAWP is 4-12 mmHg and if it’s >18 mmHg this indicates cardiogenic shock. If it reads high, that means there is back-flowing of blood into the heart and lungs (hence the left ventricle is failing to pump efficiently and increasing the pressure in the left atrium).
Which of the following assessment findings requires immediate follow up from the nurse?
A: Ox sat=96%
B: Cap refill <2 seconds
C: Urine output is 400ml yesterday
D: K+ = 4.5
C: Urine output is 400ml yesterday, normal urine output 0.5-1.5 mL/kg/hr
A patient with hypovolemic shock is given IV fluids. IV fluids will help _________ cardiac output by:*
D. increase, increasing preload
" IV fluids will increase venous return to the heart. This will increase the amount of fluid that will fill the ventricles at the end of diastole…hence increasing preload and increasing cardiac output."
You notice that your patient has a U wave on their ECG. Which order do you expect to implement?
A. An order for SQ Heparin
B. PO Morphine sulfate
C. IV potassium chloride
D. Instruct the patient to perform the vasovagal maneuver
C. IV potassium chloride:causes of the u wave include: digoxin toxicity and hypokalemia. Potassium chloride is one form of potassium replacement therapy
True or False: Atropine will decrease HR
FALSE: Atropine will increase the HR
A patient with cardiogenic shock has a blood pressure of 70/38. In addition, the patient is experiencing dyspnea with a respiratory rate of 32 breaths per minute and has an oxygen saturation of 82% on room air. On auscultation, you note crackles throughout the lung fields. You notify the physician. What order below would you ask for an order clarification?
A. Dopamine IV stat
B. Normal saline IV bolus stat
C. Furosemide IV stat
D. Place patient on CPAP (continuous positive airway pressure)
The answer is B. This patient with cardiogenic shock is experiencing a decrease in cardiac output (hence the blood pressure), so an order for Dopamine can help provide a positive inotropic effect (increase the contractility of the heart which will increase stroke volume and cardiac output). The patient is also experiencing pulmonary congestion due to the cardiogenic shock. The heart is failing to pump blood forward, so it is backing up in the lungs. This is leading to an increased respiratory rate, dyspnea, and low oxygen saturation. The order for Furosemide (which is a diuretic) will help remove the extra fluid volume from the lungs and the CPAP (continuous positive airway pressure) will help with oxygenation. The nurse would question the order for a normal saline IV bolus. This bolus would add more fluid to the lungs and further congest the fluids.