Labs
Normal
pTT
INR
CO
CVP
pTT: 30-40
INR: 0.7-1.8
CO: 4-8
CVP: 2-6
General Assessment of Shock
ABG
SvO2
Neuro
cool, decreased CVP, tachycardia, restlessness, confusion, clammy, hypoactive bowels
Late: lethargy, hypotension, metabolic/respiratory acidosis
1. JVD
2. Muffled heart sounds
3. hypotension
Pulmonary Embolism Specific test and Treatment
Plasma D-Dimer
ABG
Anticoagulants nad IV heparin, Warfarin, throbolytic therapy, catheter directed thrombolysis
Explain Chest tube drainage system
Allows for expulsion of air and/or fluid while allowing lung to re-expand
Collection chamber: allows for accumulation of blood and fluid
Water seal: one-way valve, allowing for removal of air/blood without introduction of air back into pleural space
Suction: Assists in the re-expansion of lung, discontinued as the lung re-expands
Why does CVP increase and why does it decrease?
Increased:
•Right sided heart failure
•Volume overload
Decreased:
•Reducing circulating blood volume
Hypovolemic shock
•Assessment
•Neuro status, vitals, hemodynamic readings (CVP), I&O, skin color and temperature
•Labs
•ABG, SvO2, Hemoglobin and hematocrit, metabolic profile, lactate/base deficit
•Interventions
•Apply oxygen and/or prepare to intubate
•Insert two large bore IVs, administer fluid and/or blood replacement as ordered
Medication Treatment for Aortic Aneurysm
•Antihypertensives (ACE inhibitors, angiotensin II receptor blockers (ARBs), and/or beta blockers
•Macrolides and tetracyclines may inhibit secondary infections implicated in aneurysm development
•Statins to reduce progression of atherosclerosis
•Regular ultrasounds or CT to monitor growth of aneurysm over time
Lay pt flat
2 large bore IV
decrease stress
Oxygen Treatment for ARDS
and Positioning
High flow nasal cannula and ECMO with prone positioning
What happens if the chest tube comes out
Submerge end into sterile water to preserve water seal
Apply Vaseline gauze, notify physician, and prepare for new insertion
greater than or equal to 4
Cardiogenic shock and medications
•As it progresses: shortness of breath, crackles, decreased peripheral pulses, cool pale skin, decreased bowel sounds, decreased urine output, restlessness, and confusion
•Tachycardia with initiation of compensatory mechanisms
•Increased SVR, increased left-ventricular end-diastolic volume (wedge pressure), and decreased mixed venous oxygen level
•Metabolic acidosis with increased serum lactate level in arterial blood gas
•Inotropic Medications
•Dobutamine hydrochloride (Dobutamine) and Epinephrine can improve cardiac output
•Vasopressor Support
•Dopamine hydrochloride, norepinephrine (Levophed), or phenylephrine (Neo-Synephrine) to support blood pressure and maintain a proper mean arterial pressure (MAP)
•Nitroglycerin
•Decreases preload with venous dilation and afterload through arterial dilation. Monitor for hypotension.
Meds:
•Nitroprusside
•Can use to decrease afterload, but used with caution
•Diuretics
•Use with caution to decrease filling volumes
•Morphine Sulfate
•Relieve pain due to MI and decrease venous return and preload through venous dilation
Treatment for Cardiomyopathy
Open Heart surgery
Pacemaker
•ACE –improve hearts pumping capacity. Reduce afterload.
•ARB -like ACE-given to patients who do not tolerate ACE
•Beta Blockers – Decrease sympathetic nervous system response. Decreases the workload of the heart.
•Diuretics- Reduce fluid accumulation in lungs. Spironolactone may help prevent further scarring of heart tissue.
Nursing interventions for ARDS
•Airway Suctioning
•Keep endotracheal tube clear of secretions to facilitate delivery of ventilatory volume
•Increased secretions required increased positive pressure and could be a source of infection
• Medication Administration
•Paralytics, analgesics, and sedatives
•Inotropic/Vasoactive
•Antibiotics
• Patient Positioning / Activity
•Prone positioning, elevate head of bed, frequent position changes, range of motion
• Infection Protection / Prevention
•Hand washing, central line care, mouth care, and foley catheter care
• Educate Patient
•On disease processes, medications, plan of care
Explain PEEP and the normal values involved
Positive End-Expiratory Pressure (PEEP)
Pressure applied at end of expiration to prevent alveolar collapse, improve oxygenation, and allow FiO2 to be lowered
Peep often between 2-5 cm H2O to minimize alveolar collapse and based on patient’s underlying pathophysiology
Normal SvO2
60-75%
Septic shock manifestations
Early Stages (Hyperdynamic or warm sepsis):
•Tachycardia with bounding pulses, warm flushed skin, febrile, normal blood pressure d/t compensatory responses, confusion, and decreased urine output
•Temporary increase in CO and mixed venous oxygen levels, but low filling pressures and systemic vascular resistance with compensatory mechanisms
•
Late Stages (Hypodynamic or cold shock)
•Cool, pale skin, weak and thready pulses, hypothermia
•Tachycardia, hypotension, lethargy or coma, anuria,
•Decreased cardiac output, variable filling pressures depending on resuscitation, systemic vascular resistance remains low, decreased mixed venous oxygen levels
General Assessment of Heart Stuff
CV: CP not relieved by NTG, S3, new onset of murmur. JVD (45 degrees) due to heart failure. BP might be elevated(sympathetic stimulation) or decreased (decreased contractility). Irregular pulse-Afib. ST changes tachy brady or another dysrhythmia
Respiratory: SOB, Dyspnea, Tachy Crackles –Pulmonary edema
GI Nausea, vomiting, indigestion
GU decreased urine output indicates cardiogenic shock
Skin: cool, diaphoretic, pale (cardiogenic shock)
Neuro: anxiety restless lightheadedness (decreased contractility- decreased cerebral oxygenation-cardiogenic shock)
Psychosocial-Impending doom
TB Assessment: initial, progressive and late
•Initial: Fatigue, unexplained weight loss, night sweats, fever, and chills
•Progressing: Productive cough with rusty or blood-streaked sputum
•Late: Dyspnea, orthopnea, rales
Who needs an arterial hemodynamic monitor and who does not?
Who needs it:
•Patients who need frequent blood pressure measurements.
•Patients receiving doses of vasoactive drugs requiring titration.
•Patient requiring frequent blood samples.
Who does not:
•Peripheral vascular disease
•Hemorrhagic disorders
•Patients receiving anticoagulants or thrombolytic therapy
•Sites of vascular surgery.
ABG reading
pH: 7.56
PaCO2: 20
HCO3: 20
respiratory alkalosis, partially compensated
Sepsis Bundle
1. lactate levels
2. culture
3. broad spectrum antibiotic
4. specific disease antibiotic and fluids
5. give vasopressor if fluid does not work
Meds for ACS
–Oxygen
–Aspirin (162 or 325 chew)
–P2Y12 Platelet inhibitors Clopidogrel (Plavix) ticagrelor (Brilinta)
–Nitroglycerin
•Types
•Interventions
–Morphine
–Glycoprotein IIb/IIIa inhibitors Abciximab-(Reapro), Eftifibatide-(Integrilin)
–Beta blockers (not given if patient has signs heart failure)
–ACE inhibitors/ARBs (within 24 hours)
•Decreases oxygen demand, prevents remodeling
–Calcium channel blockers (only for variant or Prinzmetal angina)
Manifestations of Hypercapnia in Respiratory failure
•Headache, confusion, decreased level of consciousness (LOC) or increased somnolence
•Tachycardia, tachypnea, dizzy, flushed, pink coloring to skin
Complications of Invasive lines like hemodynamic monitoring
•Hemorrhage
•Air emboli
•Infection
•Altered skin integrity
•Impaired circulation
•Pulmonary infarction
•Thrombus/embolus
•Ventricular dysrhythmia