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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