Test 2 Study Guide Complex Care

  1.   What measurements are used for ECG interpretation? Do you know the normal measurements ?  How do these measurements correlate with what is going on in the heart?
  • The waveform is made up of peaks and valleys that are designated as the letters P through U. Each letter corresponds to a specific part of the Waveform.
  • P wave – Atrial depolarization, rounded and shorter than the QRS complex
  • PR interval – Measurement from the beginning of the p wave to the beginning of the QRS
    • Normal is 0.12-0.2 seconds
    • This is the time is takes for the impulse to travel from the SA node through the AV node and into the ventricles.
  • QRS – ventricular depol, less than or equal to 0.12 seconds
  • ST segment – end of V Depol to the beginning of V Repol
    • Elevation correlates with myocardial infarction
    • Depression correlates with ischemia
  • T – ventricular repolarization
  • QT interval – total duration of depol and repol
  1.   What do these measurements mean to you as a nurse caring for a patient with dysrhythmias?
  • The normal measurements indicate the normal amount of time that it should take for an electrical impulse to do its specific task. Such as Atrial or ventricular depolarization. If the time the impulse takes is increased there may be decreased CO, or increased work of the heart and lungs.
  1.   What are the nursing responsibilities for a patient with a specific dysrhythmia (you will be responsible for only the dysrhythmias we discussed in class).
    • Be able to Identify the rhythm and dysrhythmia
    • See if the patient is tolerating the rhythm ie. Has pulses, awake, oriented, vital signs and breathing normally.
    • When to defibrillate a patient
    • When to use Electro Synchronized cardioversion on a patient.
      • There need to be R peaks in a QRS complex.
      • The shock is automatically delivered on an R peak.
      • There needs to be a pulse
    • what to do with a specific rhythm
      • Sinus Brady that is not tolerated: All Trained Dogs Eat: Atropine, Transcutaneous pacing, Dopamine, Epinephrine
      • Sinus Tach: Beta blockers to reduce rate, If the rate if still uncontrolled Adenosine can be given FAST 4 second push. Adenosine will stop the heart and hopefully restart in a better rhythm.
      • Atrial flutter – saw tooth
        • One ectopic foci that is discharging an impulse at 250-400 times per minute
        • F waves no P waves
        • Saw tooth f waves
        • Need to be on anticoagulants to prevent clots forming in the turbulence of the atria.
        • Controlled is a HR less than 100 uncontrolled is over 100

 

  • Unstable will need Synchronized Electrocardioversion, beta blockers, Vagal maneuver

 

      • Atrial Fibrillation
        • Multiple ectopic foci that are discharging at 250-40 times per minute
        • Most common clinically significant dysrhythmia

 

  • Most common cause of an ischemic stroke.

 

        • Need to be on anticoagulants to prevent clots forming in the turbulence of the atria.
        • Controlled is a HR less than 100 uncontrolled is over 100

 

  • Unstable will need Synchronized Electrocardioversion, beta blockers, Vagal maneuver

 

    • Heart blocks
      • 1st degree
        • Consistent Long PR interval over 0.20
        • Do not treat usually do to lack of signs and symptoms
      • Second degree type one, or wenckebach, or Mobitz 1
        • AV node conduction issue
        • Progressively increasing PR interval until a QRS is missed and the arrhythmia start over
        • Usually asymptomatic
      • Second degree type II, or Mobitz II
        • Normal PR interval with a dropped QRS every so often
        • Monitor for a third degree heart block
      • Third degree heart block
        • No communication between the atria and ventricles
        • Need a pacemaker, from the cath lab
    • Ventricular dysrhythmias
      • PVC – Premature ventricular contraction
        • Can be normal and untreated
        • Bigeminy – on pvc for one normal
        • Trigeminy – two PVC for every normal PQRST
        • Causes – hypoxia
        • Amiodarone is the drug of choice
      • V Tach –
        • Can cardiovert
        • Can easily turn into V fib
        • Pulseless we will defibrillate
        • Large sharp “QRS” complexes one immediately after another with no breaks
      • V Fib
        • Defibrillate to hope the SA node takes over
        • Smooth rapid continuous electrical activity with no breaks
        • Cannot cardiovert
        • AICD is an internal defibrillation device
      • PEA
        • Pulseless electrical activity
        • Give fluids and epi
      • Asystole
        • Straight line on the ECG

 

  1.   How do you know if a patient is hemodynamically compromised with a cardiac dysrhythmia?  Would you know what to do ?
  • Blood pressure changes, Heart rate changes, LOC decrease, pulselessness, reporting symptoms of chest pain or classic MI symptoms.
  • Yes, treat the problem if the patient is showing symptoms, and sometimes even if there are not.
  1.   How does defibrillation differ from cardioversion?  What is the nurse’s role in each?
  • Synchronized cardioversion – synchronized shock on the R wave
    • Need an R wave
    • Can convert them out of A flutter, fib, or V Tachycardia with a pulse.
    • May keep them in sinus for 3-6 months
    • Amiodarone Is used to prolong the time in sinus
    • May throw a clot that was in the atrium once the rhythm converts back to sinus.
    • Get a transesophageal echocardiogram to look for clots.
  • Defibrillation
    • An electric shock that is delivered and does not have to be synchronized
    • Rhythms to shock: Pulseless V Tach, V Fib
  • Cannot shock or cardiovert: PEA, Asystole

 

  1.   When is the use of an ICD warranted?  What is the patient education associated with ICD?
  • Implantable Cardioverter-defibrillator
  • when it senses a specific arrhythmia the device charges and delivers a shock.
  • A patient that can have an ICD is someone that has survived VT/VF, or at high risk for VT/VF after a surgery and cannot tolerate the medication or ablation.
  1.   Be able to identify the ECG dysrhythmias we discussed in class by their defining characteristics.  Identify treatment of specific dysrhythmias.
  2.   Pacemakers:
  • Review the patient and family teaching guidelines
  • What are the nursing interventions after a pacemaker is inserted?
  • What are the indications for a pacemaker (permanent and temporary)?

 

Endocrine

 

  1. What S/S are involved in DKA?  HHS?  What is the pathophysiology behind these S/S?
    • DKA
      • Ketones in the urine and blood
      • More common in DM1 but possible in DM2
      • s/s dry mucous membranes, tachycardia, hypotension, Kussmaul respirations, glucose over 250, dehydrated Altered LOC.
      • HypoKAlemia, HypoNatremia,
      • The cells cannot take in glucose so they must metabolize fats, which causes a waste product of Ketone acid.
      • Give Insulin and monitor electrolytes and replace any that are out of normal, Give bicarb
    • HHNS
      • No Ketones present
      • Common in DM2 or infections
      • s/s: NO ketones production, GLU > 600, Dehydration, hypotension, serum osmolarity >320 mOsm/L

 

  • FIRST THING TO GIVE: FLUIDS!!!!!, then insulin

 

    • Not giving BiCarb
  1. How does DKA differ from HHS?
  • DKA – production of ketones, blood sugar levels > 250, Usually DMI, pH<7.3, CO2 and HCO3 low, osmolality <320
  • HHNS – no ketones, blood sugar > 600, usually DMII, pH>7.3, CO2 and HCO3 levels normal, osmolality >320
  1. How is DKA treated?  HHS?  What are potential complications of DKA and HHS?
  • DKA – give Fluids, insulin, potassium(electrolytes), then bicarb if needed
  • HHNS give Fluids while keeping electrolytes in balance, then insulin.
  1. Differentiate between SIADH and DI.
  • SIADH is too much ADH
  • DI is not enough ADH

How do S/S of SIADH and DI differ in terms of serum osmolarity, serum and urine sodium, and urine osmolarity.  

  • SIADH: high urine osm, Urine sodium, and low serum osm
  • DI: low urine osm, Urine sodium, and high serum osm

What is the pathophysiology behind these differences? Describe the treatment for SIADH and DI.  What are potential complications of SIADH and DI?

  • complications for SIADH are: low serum electrolytes and overhydration
  • complications for DI are: High serum electrolytes and dehydration
  1. The most common cause of Cushing Syndrome is increased levels of _______.  What are the clinical manifestations of increased cortisol levels?  What pt teaching needs to occur around Cushing Syndrome related to exogenous glucocorticoid therapy?
  • ACTH levels are high and the hormone is produced in the pituitary.
  • At risk for everything associated with glucocorticoids
  • Buffalo hump, mustache, hair loss, thin arms, large abdomen, Moon face, weight gain, insomnia, thin skin.
  • Alternate s/s: depression, changes in appetite, Fatigue, decreased concentration and libido.
  1. What are the potential complications of glucocorticoid therapy?  
  • Immunosuppression, cannot stop the medication abruptly.

 

Oncology

General understanding of cancer, risk factors, basic treatment concepts, studies to determine hematologic malignancies, metastasizes, basic function/purpose of chemotherapy and bone marrow transplant, radiation therapy indications and concerns for patient care/side effects, general knowledge related to categories or types of hematologic cancers

 

Risk factors for cancer

 

    • leukemia, acute and chronic – Proliferation of leukemia cells in the bone marrow the eventually move into blood circulation. The cells that are produced takeaway from the body’s ability to make blood cells so levels are decreased of RBC and platelets. WBC are decreased in the beginning, then can be increased in later stages of the disease when the Leukemia cells are moving from the bone into blood circulation (Healthy mature WBCs will always be decreased). This causes the signs and symptoms of fatigue, immune suppression, and clotting issues.
      • Acute Lymphoblastic leukemia ALL

 

  • Most common form of childhood leukemia

 

        • Increased incidence with age
        • HSCT for recurrence
        • Aplastic anemia.
        • Effects more immature blood cells and grows fast
      • Acute Myeloid Leukemia AML
        • bleeding and infections are an initial sign
        • bruising and fatigue
        • Splenomegaly
      • Chronic Lymphocytic Leukemia CLL

 

  • most common leukemia in adults
  • Lymphadenopathy is a hallmark (enlargement of one or multiple lymph nodes)

 

        • 10% have B symptoms (Fever, Night sweats, >10% weight loss in 6 months.)
        • treatment is deferred in early stages
        • doesn’t often show symptoms at diagnosis
        • Effects more mature blood cells and slow progression to s/s (years)
      • Chronic Myeloid leukemia
        • stable for many years without treatment

 

  • Philadelphia chromosome in 90% of patients

 

      • Splenomegaly
  • lymphoma, Hodgkin’s and non Hodgkin’s lymphoma characteristics
    • Hodgkin’s Lymphoma
      • Reed-Sternberg cells are in the biopsied lymph nodes
      • Pertussis is common
      • Lymph Node enlargement is the the first presenting symptom
      • Epstein Barr virus is is associated with this
      • Radiation treatment is a part of the high cure rate.
    • Non Hodgkin’s
      • Chromosomal translocation can often correlate with the cause of this
      • CHOP Chemo is used
      • Autoimmune diseases are a risk factor for this
      • No Reed-Sternberg cells
  • Multiple myeloma
    • Cancer of plasma Cells
    • Proliferation of Plasma cells affecting the bone marrow and destroy bone
    • Increased production of a random Ig (antibody) also called monoclonal production
    • Treatable but not often curable.
    • First s/s is BONE PAIN, Pathologic fractures are common
    • Diagnosis with Monoclonal antibody production, X-ray, increased bone marrow plasma cells, Beta 2-microglobulin and albumin
    • Tired, thirsty, fatigue, pallor, dull low back pain, GI issues, common in the elderly
    • Signs and symptoms – Babs the CRAB: HyperCalcemia, Renal failure, Anemia thrombocytopenia, and Bone pain
    • Hypercalcemia is due to high bone turnover causing pathological fractures
    • Renal failure is due to Monoclonal production of Ig
    • Anemia is due to the resources going to make cancerous plasma cells instead of regular RBCs and thrombocytes.
    • Bone pain is due to increased bone turnover
  • what are the main nursing concerns in administration of chemo; complications and nursing care concerns related to decreases in WBC, platelets, H/H
    • PPE
    • WBC – risk for infection
    • Platelets – risk for bleeds
    • H/H – risk for anemia
  • what are the concerns with radiation (internal and external)
    • topical and deep burns
    • adjacent body features and organs that can have side effects of radiation.
  • how are cell counts influenced by cancer and cancer therapy
  • cell counts can decrease if there is a leukemia, myeloma, myeloid cancer taking up the resources to make healthy cells
  • in cancer therapy there can be a decreased number of natural healthy cells and then the low levels will be replaced with healthy stem cells.
  • Chemo induced anemia
  • concepts of targeted therapy, stem cells, and bone marrow transplants; graft vs host disease
    • targeted therapies are biologic therapies
    • BMT is done after chemo kills the cancerous cells then they are replaced through a central line into the bloodstream
  • side effects and symptom management strategies
    • fatigue, pallor, anemias of all types, pain, thirst
    • Manage the symptoms and treat the cause of the disease.
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Session 6: Oncology

Oncology

 

Review:

  • uncontrolled proliferation of cells in the body
  • Grade is the size of the tumor
  • Stage is the process for no metastasis to fully metastasized
  • Treatments: chemo, Radiation, biological (targeted), and surgery
  • Late vs. long term effects

 

  • be empathetic
  • When giving chemo, watch closely for extravasation.
    • If the medications given outside of the vessel the medication can cause major damage to the tissues.
    • If the med is given through a central line make sure the catheter is advanced the correct amount and not slid out at any point.
  • Radiation can cause burns to the skin and structures inside the body nearby the cancer location
    • Maintain skin integrity
    • Radiation can be external or implanted “seeds” for prostate cancer.
  • Biological targeted therapy
    • This type of therapy is often used first due to the higher specificity to the patient’s cancer and also tends to have fewer side effect.
  • ANC absolute neutrophil count
    • Important to keep a close eye on this during chemo because the level can drop rapidly.
    • Graded 1-4. 4 being the worst.
  • Oncologic emergencies
    • Sepsis
      • Temp above 100.4 degrees F
      • WBCs above 12000 or less than 4000
    • DIC
      • Monitor platelets, a drop indicated potential for DIC
    • SIADH
      • The tumor can produce ADH which causes retention of water.
      • Tumors can produce other hormones as well, but ADH is common and causes immediate issues.
      • These patients need to be on a water restriction.
      • Demecolcine can decrease the action of the ADH to help the patient urinate, and balance out their I’s and O’s
    • Spinal cord compression
      • Monitor for back pain which could be caused by a tumor pressing on the spinal cord
      • Treat immediately and this could cause paralysis
    • Hypercalcemia
      • A hormone similar to PTH can be secreted by cancer cells causing increased CA levels
    • Superior vena cava syndrome
      • The SVC is compressed be a tumor and the tumor must be removed to restore normal flow.
    • Tumor lysis syndrome
      • HyperK Ca phos, and uricemia
      • From the breakdown of a large number of tumor cells
  • Leukemia
    • Cancer of the blood cells usually white blood cells, and blood forming structures
    • This includes bone marrow, which will proliferate immature WBC’s
  • Lymphoma
    • Cancer of lymphocytes that also originate in the bone marrow.
    • Hodgkin’s disease – Reed-Sternberg cells
      • Most curable cancer
      • Lymph Nodes most commonly inflamed first, are around the neck and clavicles.
      • B symptoms indicate the progression of the disease from local to systemic.
        • The symptoms are: Fever, night sweats and more than 10% weight loss in less than six months.
    • Non Hodgkin’s Lymphoma –
      • Classifies all other lymphoid cancers without Reed-Sternberg cells.
      • Hallmark is painless enlarged node.
      • Full remission is uncommon.
      • B symptoms indicate the progression of the disease from local to systemic.
        • The symptoms are: Fever, night sweats and more than 10% weight loss in less than six months.
  • Multiple Myeloma
    • Proliferation of Plasma cells affecting the bone marrow and destroy bone
    • Treatable but not often curable.
    • First s/s is BONE PAIN, Pathologic fractures are common
    • Diagnosis with Monoclonal antibody, X-ray, increased bone marrow plasma cells, Beta 2-microglobulin and albumin.
    • Signs and symptoms – Babs the CRAB: HyperCalcemia, Renal failure, Anemia thrombocytopenia, and Bone pain
    • Hypercalcemia is due to high bone turnover causing pathological fractures
    • Renal failure is due to Monoclonal production of Ig
    • Anemia is due to the resources going to make cancerous plasma cells instead of regular RBCs and thrombocytes.
    • Bone pain is due to increased bone turnover

 

  • HACT
    • Replacing stem cells in a patient
    • Autologous Transplant is where the patient’s own bone marrow stem cells are collected, the patient goes through chemo and/or radiation, then the stem cells are put back so that they can start making blood cells again.
    • Allogeneic transplant is where a donor provides the bone marrow Stem cells for the patient.  
    • Prepare with immune protective measures
    • Bone marrow is stripped then replaced with healthy stem cells
    • The donor cell can be auto which means the donor is the patient previously, or
  • AML
  • Case 3 multiple myeloma
    • Leaking kidneys
    • Thirst
    • Creatinine

Multiple myeloma specific findings: high calcium levels and hence-jones protein in the urine

  • high priority – maintain high fluid intake to dilute calcium of 3-4L per day
  • Limiting movement will increase risk for pathological fractures

 

GM-CSF

  • can stimulate the production and function of neutrophils and monocytes

Leukemia patients are susceptible to infection even when they have a high white count because there is a left shift in the white cells and they are immature

 

Chemo induced anemia can cause activity intolerance due to hypoxia.

 

Stomatitis should be treated with a soft non irritating toothbrush and mouthwash to prevent further breakdown of the mouth.

 

Leukemia and bone marrow stem cells are eliminated in chemo and radiation for AML then a donor replaces the bone marrow stem cells through a transfusion

 

Session 5: Endocrine

Session 5: Endocrine

 

Diabetic Ketoacidosis

  • More common in DM1 but possible in DM2
  • s/s dry mucous membranes, tachycardia, hypotension, Kussmaul respirations, glucose over 250, dehydrated Altered LOC.
  • HypoKAlemia, HypoNatremia,
  • The cells cannot take in glucose so they must metabolize fats, which causes a waste product of Ketone acid.
  • Give Insulin and monitor electrolytes and replace any that are out of normal, Give bicarb

 

HHNS – Hyperosmolar Hyperglycemic nonketotic Syndrome

    • Common in DM2
    • s/s: NO ketones production, GLU > 600,

 

  • FIRST THING TO GIVE: FLUIDS!!!!!, then insulin

 

  • Not giving BiCarb

 

SIADH – Retaining water, not urinating

  • Too much ADH
  • Low electrolytes
  • Do not replace Na too quick due to cerebral swelling.
  • 8-12 MeQ per day Na replacement.
  • These people may need to be on a fluid restriction, with no free water.
  • Demeclocycline – reduces the action of ADH

DI – always urinating

  • Not enough ADH
  • Dehydration
  • Tachycardia, hypotension, thirsty, dehydration…
  • DDAVP – reduces the urine output
    • This will not work with nephrogenic DI because the issue is with the nephron not ADH.

 

Cushing’s disease

  • Increased production of the “stress” hormone ACTH from the pituitary tumor
    • This is usually caused by a pituitary tumor
  • At risk for everything associated with glucocorticoids
  • Buffalo hump, mustache, hair loss, thin arms, large abdomen, Moon face, weight gain, insomnia, thin skin.
  • Alternate s/s: depression, changes in appetite, Fatigue, decreased concentration and libido.
  • These people will need to be on exogenous corticosteroids to counteract the glucocorticoid ACTH
    • Do not abruptly stop the medication.

Session 4: ECG

Session 4: ECG Electrocardiogram

 

Properties of cardiac tissue

  • Automaticity – tissue that can initiate an impulse without an outside force acting on it.
  • Contractility – the ability to respond to an impulse through a mechanical force
  • Conductivity – transmit an impulse
  • Excitability – the ability to be stimulated by the electric impulse.

 

  • Polarized is the resting state of the heart
    • Na out and K in the cell
  • Depolarized is the working of contraction phase of the heart
    • Na inside and K moves outside
    • If depolarization does not happen in a synchronized way then the chamber will not be able to contract effectively
  • Repolarization – the recovery phase moving from depolarization to polarized
  • Absolute refractory phase – the muscle cannot be depolarized under any physiologic stimuli. This occurs after the start of depolarization, during repolarization.
    • From the beginning of the QRS to the peak of the T
  • Relative refractory phase – after the absolute refractory phase where the muscle will respond to strong stimulus.
    • A vulnerable phase during the t wave, where we do not want to shock.
  • Nodes
    • SA node –  located in the right atrium and automatically fires 60-100 times per minute.
    • AV node – on the right side of the heart between the right atria and the right ventricle, this can fire at 40-60 beats per minute if needed,
    • Bundle of His – central heart in between all of the chambers.
    • Right and left bundle branches –  in between the ventricles
    • Purkinje fibers – in the bottom sides of the heart. This can fire at 15-40  

Getting an ECG

  • Electrodes are placed on the chest and the electrical activity reflects the activity in the heart.
  • The electrodes are placed at specific locations.
  • Common forms of ECGs are 3, 5, and 12 lead. The more leads the better “picture” of the heart we can get.

Interpreting the graph

  • Horizontal lines represent voltage (up and down)
  • Vertical lines represent time (left to right)
  • One small box represents 0.04 second from left to right, and 0.1mV up and down
  • One large box represents 0.2 seconds from left to right, and 0.5mV up and down
    • One large box is 5×5 small boxes.

Waveform

  • The waveform is made up of peaks and valleys that are designated as the letters P through U. Each letter corresponds to a specific part of the Waveform.
  • P wave – Atrial depolarization, rounded and shorter than the QRS complex
  • PR interval – Measurement from the beginning of the p wave to the beginning of the QRS
    • Normal is 0.12-0.2 seconds
    • This is the time is takes for the impulse to travel from the SA node through the AV node and into the ventricles.
  • QRS – ventricular depol, less than or equal to 0.12 seconds
  • ST segment – end of V Depol to the beginning of V Repol
    • Elevation correlates with myocardial infarction
    • Depression correlates with ischemia
  • T – ventricular repolarization
  • QT interval – total duration of depol and repol

ECG interpretation

  1. Determine regularity
    1. Regular? Regularly irregular? Irregularly irregular?
  2. Calculate the heart rate
    1. Count the R waves on a 6 second strip and multiply by ten
    2. Do the atrial and ventricular waves match?
  3. Assess the P waves
    1. Are they present?
    2. Are the a consistent shape
    3. Is the ratio of P:QRS 1:1?
  4. Measure the PR interval
    1. Is is consistent? Is it normal?
    2. Can it be measured?
  5. Measure the QRS
    1. Do the complexes look the same?
    2. Is the measurement normal?

Rhythms

  • sinus tach – BPM over 100
    • Beta blockers will reduce rate
    • Adenosine given in a FAST 4 second push will slow or stop the heart to restart in a better rhythm
  • Sinus Brady – normal rhythm less than 60 bps
    • All Trained Dogs Eat
    • Atropine
    • Transcutaneous pulsing
    • Dopamine
    • Epinephrine
  • Atrial dysrhythmias
      • Likely to form a clot in the atrial these people need to be on anticoagulants for life.
      • AV node controls the  number of impulses that pass and then depolarize the ventricles. Needs a good AV node to control rate.
      • Controlled is a HR less than 100 uncontrolled is over 100
      • Unstable will need Synchronized Electrocardioversion, beta blockers, Vagal maneuver
      • Decreased CO and increased chance for clots.
    • Atrial flutter – saw tooth
      • One ectopic foci that is discharging an impulse at 250-400 times per minute
      • F waves no P waves
    • Atrial Fibrillation
      • Multiple ectopic foci that are discharging at 250-40 times per minute
      • Most common clinically significant dysrhythmia
      • Most common cause of a ischemic stroke.
  • Synchronized cardioversion – synchronized shock on the R wave
    • Need an R wave
    • Can convert them out of A flutter or fib
    • May keep them in sinus for 3-6 months
    • Amiodarone Is used to prolong the time in sinus
    • May throw a clot that was in the atrium once the rhythm converts back to sinus.
    • Get a transesophageal echocardiogram to look for clots.
  • Heart blocks
    • 1st degree
      • Consistent Long PR interval over 0.20
      • Do not treat usually do to lack of signs and symptoms
    • Second degree type one, or wenckebach, or Mobitz 1
      • AV node conduction issue
      • Progressively increasing PR interval until a QRS is missed and the arrhythmia start over
      • Usually asymptomatic
    • Second degree type II, or Mobitz II
      • Normal PR interval with a dropped QRS every so often
      • Monitor for a third degree heart block
    • Third degree heart block
      • No communication between the atria and ventricles
      • Need a pacemaker, from the cathlab
  • Ventricular dysrhythmias
    • PVC – Premature ventricular contraction
      • Can be normal and untreated
      • Bigeminy – on pvc for one normal
      • Trigeminy – two PVC for every normal PQRST
      • Causes – hypoxia
      • Amiodarone is the drug of choice
    • V Tach –
      • Can cardiovert
      • Can easily turn into V fib
      • Pulseless we will defibrillate
      • Large sharp “QRS” complexes one immediately after another with no breaks
    • V Fib
      • Defibrillate to hope the SA node takes over
      • Smooth rapid continuous electrical activity with no breaks
      • Cannot cardiovert
      • AICD is an internal defibrillation device
  • PEA
    • Pulseless electrical activity
    • Give fluids and epi
  • Asystole
    • Straight line on the ECG

Session 3: Coagulation and GI Issues

Session 3 Coagulation and GI Issues 

 

Prothrombin time PT

    • Monitor Warfarin therapy

 

  • Normal: 11-13
  • INR: 1-3

 

    • INR is the ratio between PT and PTT
  • Extrinsic system
  • Warfarin’s antidote is vitamin K, so have the patient on a diet that has consistent Vit K levels.

Activated Partial Thromboplastin time

  • Monitor Heparin therapy
  • Intrinsic system
  • 21-38 seconds

Platelet count

  • 150,000 – 350,000
  • Thrombocytopenia
    • Low platelet count
    • Around 50,000 is where s/s tend to arise
    • s/s: LOC, SOB, fatigue, Bloody stools, skin color changes

 

Immune Thrombocytopenic Purpura

  • ITP
  • Autoimmune
  • Platelets are seen as foreign by the spleen and are destroyed. The spleen are recognizing the antibodies on the platelet.
  • Treatment: corticosteroids, splenectomy, transfuse platelets

 

TTP

  • Schistocytes – abnormal blood cell
  • Normal PT and aPTT
  • Treatment: immunosuppression, Splenectomy, DO NOT GIVE PLATELETS, plasmapheresis

 

HIT

    • Heparin induced Thrombocytopenia
    • No heparin once this develops
    • Use a Direct thrombin inhibitor instead of Heparin (argatroban)

 

  • Table 31-16 on page 654

 

 

Hemophilia – genetic X linked recessive disorder where the person makes low amounts of a clotting factor.  

  • Person cannot make enough clotting factor
  • Type A – low in factor VIII, most common
  • Type B – low in factor IX
  • Tend to bleed in joints.
    • Rest the joint once there is bleeding, RICE, Passive range of motion ONCE BLEEDING STOPS.
  • Administer clotting factor
  • Education of when to come in: joint swelling, bruise getting worse/bigger, after trauma, confusion,
  • No contact sports for these patients.
  • Wear a med bracelet

 

DIC

  • Disseminated intravascular Coagulation
  • Thrombotic phase – fibrin and platelets in the microvasculature
  • Anticoagulant phase – Bleeding
  • Replacement of blood products when bleeding
    • Treat symptoms and chase labs to get to a therapeutic level.

 

Acute Gastrointestinal Diseases

 

  • Upper GI bleed
    • Bright red vomit
    • Coffee stools
  • Lower GI bleed
    • Bright red stool or tarry
    • Vomit may have dark red/black blood
  • Acute bleed
    • H/H may drop with in 4 hours of bleed
    • Give fluids
  • Giving blood
    • Need a type and screen sample within 72 hours
    • Co Sign with another nurse
    • MRN, name, expiration date.
    • Chills (shivering), Back pain, fever, flushed skin, are a sign of a Hemolytic transfusion reaction
      • Temperature and Blood pressure changes.

 

  • Functions of the liver
    • Metabolize fats/ steroids, Make bile, Detoxification, storage of glycogen, and vitamins.
    • Cirrhosis
      • Caused by, Hep C, Alcohol intake, Right sided Heart failure, Non alcoholic fatty liver disease.
      • Diagnostic levels – increased ALT, AST, and ammonia, Decreased Proteins, Increased PT and PTT
      • Hepatic encephalopathy – ammonia levels increased and can cause changes in LOC
      • Decreased protein diet (this may change in the future)
      • These people should not have alcohol
      • These people tend to be hypokalemia, Potassium replacement is necessary to avoid Arrhythmias.

 

  • Acute liver failure
    • Usually due to overdose of tylenol
    • Severe liver impairment correlated with hepatic encephalopathy
    • Can last 8 – 26 weeks after s/s onset
    • 40% morbidity rate.

 

  • Pancrease
    • Secretes enzymes, 90% proteolytic, Amylolytic, or Lipolytic
    • Secretin –  stimulates bicarb and water to control pH in the intestines
    • Acute Pancreatitis – pancreatitis inflammation
      • Caused by – Gallbladder disease, trauma, biliary sludge, surgery
      • Results from premature enzyme activation causing digestion of the pancreas and surrounding organs.
      • s/s: Left upper quadrant pain that is piercing, continuous and gets worse with eating, reduced bowel sounds, Shock, hypovolemia
      • Diagnosis – increase amylase and lipase, liver enzymes, bilirubin, and decrease calcium
      • Treatment plan: relieve pain, prevent shock, reduce pancreatic secretions, correct fluid and electrolyte imbalances, antibiotic prophylaxis, remove the cause if possible.
      • Prevention – stop smoking, drinking, restrict fats, don’t binge, may have permanent damage.

Session 2: Neuro

 

Session 2: Neuro

 

Spinal cord injury

 

  • Spinal cord injury patients can have lower BP’s such as 80/52
  • The issue of BP changes is when there is a large change from baseline.
  • S2,3,4 can have issues with bowel and bladder sphincter contractility
    • These are reflexes controlled in the spinal cord.
  • Spinal shock is not neurogenic shock
    • Spinal shock = spinal loss of reflexes, motor, and sensory at and below the level of injury.
      • Spinal shock is inflammation from the injury or lesion and goes away
      • Exists in the acute phase
      • No peristalsis, no voiding, need foley catheter
  • T6 and above can have autonomic dysreflexia
  • Cervical spine and above are tetraplegic and below are paraplegic
  • Injury at T12 and below is flaccid bladder
  • Injury above T12 and above is spastic bladder
  • Autonomic dysreflexia – an over reaction to something below the level of injury such as bladder distension, or a stubbed toe.
    • Above LOI vasodilation, HA, Flushed skin,  
    • Below LOI vasoconstriction, cold clammy, goose bumps, pale.

 

Stroke

 

  • Ischemic stroke – caused by loss of blood flow due to clot
    • Give TPa if within 4.5 hours of symptom onset
    • Neet CT scan to confirm Ischemic stroke
    • Excluded from TPa administration if: Head trauma or stroke in the last three months, aneurysm, active bleed, platelet count under 100,000,  INR >1.7, PT > 15 seconds. Taking warfarin, taking heparin in the last 48 hours with a high aPTT vessel

 

Epidural hemorrhage – usually ARTERIAL, FAST

Subdural hemorrhage – usually VENUS, SLOW

 

Pituitary Tumors

  • s/s – vision changes, increased ICP, DI or SIADH may be present.
  • Avoid cough, sneeze, sucking.
  • Watch for CSF leak, test leak for glucose and Halo test.
  • Surgery for this to be removed is through the nose.
  • Monitor for headache after surgery. This points toward a CSF leak.

Rosenbaum Pocket eye exam

  • An eye test on a notecard that tests each eye at an arm’s length. Make sure that the room is lit well for this test, and they have their glasses if they need them.

 

  • ICPs
    • Normal 0-10 mmhg
    • Increased is at 15 mmhg
    • Look for changes in LOC, pupils, Cushing’s triad Widening pulse pressure, bradycardia that is irregular, and irregular respiratory rate.
    • Causes – hypercapnia, hypoxemia, vasodilation

 

  • Cerebral perfusion pressure
    • The pressure that we need to perfuse the brain by overcoming the ICP.
    • >60 is normal.
    • The higher the CPP the higher the perfusion to the brain. (to a point)

 

  • Hemicraniectomy – removing a portion of the skull to allow for ICP to go down.
    • This person NEEDS a helmet when out of bed.
  • Raccoon eyes – indicative of a csf leak. Dark to black or reddish swelling under the eyes.
    • Keep HOB raised to allow the swelling to go down.