MED SURGE EXAM 2

MED SURGE EXAM 2 1. What are some reasons you would have an increased heart rate? Pg 693 2. What lab result would tell you your patient is in heart failure? Pg 675 3. What medication would you use for peripheral vascular disease? Pg 837 4. What are the signs and symptoms for pericarditis? Pg 791 5. After a stress test what would you further assess your patient for? 5. Define murmur • Sounds created by abnormal, turbulent flow of blood in heart Intensity A grading system is used to describe the intensity or loudness of a murmur. Grade 1: Very faint and difficult for the inexperienced clinician to hear Grade 2: Quiet but readily perceived by the experienced clinician Grade 3: Moderately loud Grade 4: Loud and may be associated with a thrill Grade 5: Very loud; heard when stethoscope is partially off the chest; associated with a thrill Grade 6: Extremely loud; detected with the stethoscope off the chest; associated with a thrill 6. Patient teaching before, during, and after, cardiac catheterization. Nursing responsibilities before cardiac catheterization include: • Instructing the patient to fast, usually for 8 to 12 hours, before the procedure • Informing patient that if catheterization is to be performed as an outpatient procedure, a friend, family member, or other responsible person must transport the patient home • Informing the patient about the expected duration of the procedure and advising that it will involve lying on a hard table for less than 2 hours • Reassuring the patient that IV medications are given to maintain comfort • Informing the patient about sensations that will be experienced during the catheterization. Knowing what to expect can help the patient cope with the experience. The nurse explains that an occasional pounding sensation (palpitation) may be felt in the chest because of extra heartbeats that almost always occur, particularly when the catheter tip touches the endocardium. The patient may be asked to cough and to breathe deeply, especially after the injection of contrast agent. Coughing may help disrupt a dysrhythmia and clear the contrast agent from the arteries. Breathing deeply and holding the breath help lower the diaphragm for better visualization of heart structures. The injection of a contrast agent into either side of the heart may produce a flushed feeling throughout the body and a sensation similar to the need to void, which subsides in 1 minute or less. • Encouraging the patient to express fears and anxieties. The nurse provides education and reassurance to reduce apprehension. Nursing responsibilities after cardiac catheterization are dictated by hospital policy and primary provider preferences and may include: • Observing the catheter access site for bleeding or hematoma formation and assessing peripheral pulses in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 4 hours or until discharge. BP and heart rate are also assessed during these same time intervals. However, a recent study did not find an association between changes in these vital signs and bleeding complications (Mert, Intepeler, Bengu, et al., 2012). These results suggest that the best method for discovering bleeding is through frequent nursing assessments of the catheter access site (Chart 25-5). • Evaluating temperature, color, and capillary refill of the affected extremity during these same time intervals. The patient is assessed for affected extremity pain, numbness, or tingling sensations that may indicate arterial insufficiency. The best technique to use is to compare the examination findings between the affected and unaffected extremities. Any changes are reported promptly. • Screening carefully for dysrhythmias by observing the cardiac monitor or by assessing the apical and peripheral pulses for changes in rate and rhythm. A vasovagal reaction, consisting of bradycardia, hypotension, and nausea, can be precipitated by a distended bladder or by discomfort from manual pressure that is applied during removal of an arterial or venous catheter. The vasovagal response is reversed by promptly elevating the lower extremities above the level of the heart, infusing a bolus of IV fluid, and administering IV atropine to treat the bradycardia. • Maintaining bed rest for 2 to 6 hours after the procedure. If manual pressure or a mechanical device was used during a femoral artery approach, the patient remains on bed rest for up to 6 hours with the affected leg straight and the head of the bed elevated no greater than 30 degrees (Weigand, 2011). For comfort, the patient may be turned from side to side with the affected extremity straight. If a percutaneous vascular closure device or patch was deployed, the nurse checks local nursing care standards and anticipates that the patient will have fewer activity restrictions. The patient may be permitted to ambulate within 2 hours (Hammel, 2009). If the radial artery was accessed, the patient remains on bed rest for 2 to 3 hours or until the effects of sedation have dissipated. The patient may sit up in bed. A hemostasis band or pressure dressing may be applied over the catheter access site. Analgesic medication is administered as prescribed for discomfort. Patients are instructed to avoid repetitive movement of the affected extremity for 24 to 48 hours (Durham, 2012). Patients are instructed to avoid sleeping on the affected arm for 24 hours. • Instructing the patient to report chest pain and bleeding or sudden discomfort from the catheter insertion sites promptly • Monitoring the patient for contrast agent–induced nephropathy by observing for elevations in serum creatinine levels. Oral and IV hydration is used to increase urinary output and flush the contrast agent from the urinary tract; accurate oral and IV intake and urinary output are recorded. • Ensuring patient safety by instructing the patient to ask for help when getting out of bed the first time after the procedure. The patient is monitored for bleeding from the catheter access site and for orthostatic hypotension, indicated by complaints of dizziness or lightheadedness (Wiegand, 2011;Woods et al., 200 7. Know about the electric conductivity of the heart. (pg.691) 8. Patient teaching about coagulotherapy. Pg 851 • Avoid procedures/activities that can increase intracranial pressure (coughing, straining) • Avoid meds that interfere with coagulation therapy (aspirin, NSAIDs, beta-lactam antibiotics) • Avoid rectal probes, rectal meds • Avoid IM injections • Monitor amount of external bleeding • Oral hygiene carefully (soft toothbrush) • Take the anticoagulant at the same time every day and notify doctor if any signs of bleeding ( reddish or brownish urine, epistaxis, tarry stools) • Ambulation, sequential compression devices and anti-embolism stockings promote venous return • Use electric razor • Use a soft toothbrush • Don't sit more than 2 hours at a time • Avoid garlic 9. How would you treat hypervolemia? 10. Know about thiazide diuretic. (pg 867) 11. What are the risk factors for hypertension? • Obesity, smoking, sedentary lifestyle, high sodium diet • Initial drug therapy for HTN: HCT2 (thiazide diuretic) 12. How long would you continue CPR? (page 816) 15. When would you use defibrillation? (pg 716) 16. What diagnostic testing would you use to diagnose cardiomyopathy? Pg 779 17. Know the therapeutic range for an INR • Normal range for INR 2-3.5 18. Adverse effect for lidocaine administration. (Pg 909 Abrams book) 19. What are the warning signs for peripheral vascular disease? (pg 823) 20. Know teachings to discontinue beta blockers. 21. What are the nursing interventions post cardiac catheterization? (pg 684) 22. Know the difference between diastole and systole (pg 654) • Systole refers to the events in the heart during contraction of the atria and the ventricles. Unlike diastole, atrial and ventricular systole are not simultaneous events. Atrial systole occurs first, just at the end of diastole, followed by ventricular systole. This synchronization allows the ventricles to completely fill prior to ejection of blood from their chambers. 23. Know the teaching for TEE. (pg 681) (Know what would be the wrong answer) 24. Know the difference for the P QRS T waves (pg 692) 25. Know what to look for and what to do when a patient complains of chest pain. (pg 663) 26. When would a patient call nine-one-one when taking Nitro? • After the third dose (take q 5 min up to 3 doses) 27. In the cardiac catheter lab what would you do and when? See question 7 28. How would you evaluate that a patient with pericarditis treatment is getting better? Page 791 o b. Temperature returns to normal range o c. Exhibits no pericardial friction rub • 2. Absence of complications o a. Sustains blood pressure in normal range o b. Heart sounds strong and can be auscultated o c. Absence of jugular vein distention 29. Know the s/s for right HF vs. left HF. (pgs. 799, 800) 31. When doing cardioversion what is the priority assessment? Pg 716 32. What reasons would you use a 12-lead ECG? Pg 677 33. Signs and symptoms that would cause a decreased cardiac output. 34. Know the difference between angina, MI, and ACS Pg 736 35. What causes an elevated cholesterol level? (pg 675) 36. Know the DASH diet (pg. 866) To lower BP, ↓ sodium, grains 37. Life modifications to reduce hypertension. • Lifestyle modification that would cause the biggest change in BP- WEIGHT LOSS 38. What would be the goal for dysrhythmias? 39. What is pulse pressure? (pg 667) • The difference between the systolic and diastolic pressures is called pulse pressure 40. What would an elevated ST wave vs a depressed ST wave mean? 41. What are the causes for aortic regurgitation? (pg 773) Aortic regurgitation is flow of blood back into the left ventricle from the aorta during diastole. It may be caused by inflammatory lesions that deform aortic valve leaflets or dilation of the aorta, preventing complete closure of the aortic valve. This valvular defect also may result from infective or rheumatic endocarditis, congenital abnormalities, diseases such as syphilis, a dissecting aneurysm that causes dilation or tearing of the ascending aorta, blunt chest trauma, or deterioration of a surgically replaced aortic valve Aortic regurgitation causes what? (pg. 773) stroke volume and ejection fraction will be decrease 42. Know the difference between hypertensive emergency and hypertensive urgency (pg 873) 43. Know the difference between preload and afterload (pg 654) Preload refers to the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. Afterload, or resistance to ejection of blood from the ventricle, is the second determinant of stroke volume. 44. What are some bad things that can happen with uncontrolled hypertension? Pg 871 45. What is the action of beta blockers? (pg 868) Beta-blockers such as metoprolol (Lopressor, Toprol) reduce myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is a reduction in HR, slowed conduction of impulses through the conduction system, decreased BP, and reduced myocardial contractility (force of contraction). 46. When someone is on a ventilator how does that prevent them from getting atelectasis? Atelectasis: ventilator keeps alveoli open 47. What are three risk factors for Venous Thrombosis? (pg 846) • Obesity, pregnancy, cancer, surgery, immobilization, oral contraceptive use, age 65 yrs 48. What lab are you going to watch for with digoxin toxicity? (pg 802) 49. What is the action of Lasix? 50. What is Virchow's Triad? (pg 824) 51. What is Beck's Triad? What is it associated with? Acute cardiac tamponade 52. What are some other things you would assess for with chest pain? C Characteristics – describe the symptoms O Onset – when did it start L Location – where is it, does it radiate, occur anywhere else D Duration – how long does the pain last S Severity – pain (scale of 1 to 10) P Pattern – what makes it better or worse) A Associated Factors – what else is going on 53. There will be approximately 4 questions about a cardene drip, such as goals, dosage, how to calculate, and assessment. Abrams book 54. There will be approximately four to five ECG strips, know the different types of rhythms. See below question 55 55. There will be a couple of questions about ECG rhythms and what medications are given for that particular rhythm. Sinus Bradycardia Sinus bradycardia occurs when the SA node creates an impulse at a slower-than- normal rate. Treatment not necessary if patient is stable. Unstable: Atropine 0.5 mg IV or Percutaneous pacemaker Transcutaneous pacing- slow rhythms Sinus Tachycardia Sinus arrhythmia occurs when the sinus node creates an impulse at an irregular rhythm; the rate usually increases with inspiration and decreases with expiration. Consider cause and treat if symptomatic Some causes: Exercise, fever, dehydration, hypovolemia, anxiety, pain, etc. Medical treatment: Adenosine, Beta blockers and calcium channel blockers. Atrial Flutter Atrial flutter occurs because of a conduction defect in the atrium and causes a rapid, regular atrial rate, usually between 250 and 400 bpm. Atrial flutter is caused by a reentrant rhythm in either the right or left atrium. Typically initiated by a premature electrical impulse arising in the atria. Atrial flutter may break down into atrial fibrillation and it usually is associated with a tachycardia. Treatment is three fold: 1 st: control the rate 2 nd: give anticoagulants to prevent clots in the atria 3rd:cardioversion using either a calcium channel blocker or the use of a cardioverter in synchronous mode. A flutter: adenosine Ventricular Tachycardia VT is defined as three or more PVCs in a row, occurring at a rate exceeding 100 bpm. The causes are similar to those of PVC. Defibrillate the patient. Monomorphic+amiodarone polymorphic-magnesium Ventricular Fibrillation The most common dysrhythmia in patients with cardiac arrest is ventricular fibrillation, which is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. Treatment is immediate defibrillation, if this fails CPR is performed. V- fib: epinephrine Defibrillate- pulseless v-tach Idioventricular Rhythm Idioventricular rhythm, also called ventricular escape rhythm, occurs when the impulse starts in the conduction system below the AV node. Ventricular Asystole Commonly called flatline, ventricular asystole is characterized by absent QRS complexes confirmed in two different leads, although P waves may be apparent for a short duration. There is no heartbeat, no palpable pulse, and no respiration. Without immediate treatment, ventricular asystole is fatal. Treatment is full ACLS procedures but primarily CPR. Atrial Fibrillation To control the heart rate in persistent atrial fibrillation, a beta-blocker (propranolol [Inderal], atenolol [Tenormin], metoprolol [Lopressor], or esmolol [Brevibloc]) or a nondihydropyridine calcium channel blocker (diltiazem or verapamil) is recommended Atrial fibrillation is an uncoordinated atrial electrical activation that causes a rapid, disorganized, and uncoordinated twitching of atrial musculature. A-fib: cardizem Cardioversion- fast rhythms Premature Ventricular Complex A PVC is an impulse that starts in a ventricle and is conducted through the ventricles before the next normal sinus impulse. Medical Management. PVCs usually are not serious. PVCs that are frequent and persistent may be treated with amiodarone or sotalol, but long-term pharmacotherapy for only PVCs is not usually indicated. 56. Know how to place the electrodes for ECG monitoring (pg 678) 57. What does 3 PVCs in a row on an ECG strip mean? (pg 708) • Ventricular tachycardia (VT) is defined as 3 or more PVCs in a row on an ECG 58. What would cause it and what would you watch for? (pg 708) • Causes: • What would you watch for? • Signs & symptoms: o shortness of breath 59. BP stages Classification of Blood Pressure for Adults BP Classification* Systolic BP (mm Hg) Diastolic BP (mm Hg) Normal 120 an d 80 Prehypertension 120–139 or 80–89 Stage 1 hypertension Stage 2 hypertension 140–159 or 90–99 ≥160 or ≥100 60. Assess pulse Scales are also used to rate the strength of the pulse. The following is an example of a 0-to- 4 scale: 0: Not palpable or absent +1: Diminished—weak, thready pulse; difficult to palpate; obliterated with pressure +2: Normal—cannot be obliterated +3: Moderately increased—easy to palpate, full pulse; cannot be obliterated 61. Difference between arterial and venous insufficiency (pg 823- chart) 62. Heart sounds, abnormal hearts sounds that you would hear with certain conditions (pg. 672) • Normal heart sounds. The first heart sound (S1) is produced by closure of the mitral and tricuspid valves (“lub”). The second heart sound (S2) is produced by closure of the aortic and pulmonic valves (“dub”). Abnormal heart sounds. • Friction rub- a harsh, grating sound that can be heard in both systole and diastole (it is caused by abrasion of the inflamed pericardial surfaces from pericarditis) • S3—Third Heart Sound. An S3 (“DUB”) is heard early in diastole during the period of rapid ventricular filling as blood flows from the atrium into a non- compliant ventricle. It is heard immediately after S2. “Lub-dub-DUB” is used to imitate the abnormal sound of a beating heart when an S3 is present. It represents a normal finding in children and adults up to 35 or 40 years of age. In these cases, it is referred to as a physiologic S3. In older adults, an S3 is a significant finding, suggesting HF. It is best heard with the bell of the stethoscope. • S4—Fourth Heart Sound. S4 (“LUB”) occurs late in diastole. S4 heard just before S1 is generated during atrial contraction as blood forcefully enters a non- compliant ventricle. This resistance to blood flow is due to ventricular hypertrophy caused by hypertension, CAD, cardiomyopathies, aortic stenosis, and numerous other conditions. “LUB lub-dub” is the mnemonic used to imitate this gallop sound. S4, produced in the left ventricle, is auscultated using the bell of the stethoscope over the apical area with the patient in the left lateral position. There are times when both S3 and S4 are present, creating a quadruple rhythm, which sounds like “LUB lub-dub DUB.” During tachycardia, all four sounds combine into a loud sound, referred to as a summation gallop. • Opening Snaps and Systolic Clicks. Normally, no sound is produced when valves open. However, diseased valve leaflets create abnormal sounds as they open during diastole or systole. Opening snaps are abnormal diastolic sounds heard during opening of an AV valve. For example, mitral stenosis can cause an opening snap, which is an unusually high pitched sound very early in diastole. This sound is caused by high pressure in the left atrium that abruptly displaces or “snaps” open a rigid valve leaflet. Timing helps to distinguish an opening snap from the other gallop sounds. It occurs too long after S2 to be mistaken for a split S2 and too early in diastole to be mistaken for an S3. The high-pitched, snapping quality of the sound is another way to differentiate an opening snap from an S3. Hearing a murmur or the sound of turbulent blood flow is expected following the opening snap. In a similar manner, stenosis of one of the semilunar valves creates a short, high-pitched sound in early systole, immediately after S1. This sound, called a systolic click, is the result of the opening of a rigid and calcified aortic or pulmonic valve during ventricular contraction. Mid to late systolic clicks may be heard in patients with mitral or tricuspid valve prolapse as the malfunctioning valve leaflet is displaced into the atrium during ventricular systole. Murmurs are expected to be heard following these abnormal systolic sounds. These sounds are the loudest in the areas directly over the malfunctioning valve. 63. Causes of cardiomyopathy (there are 4) Pg 780 64. Drug treatment for dysrhythmias See dysrhythmias strips ↑,meds are with each one Adenosine- D for down Atropine- T for tachycardia 65. Difference between emergency drugs vs. maintenance drugs 66. What procedure is done to open a valve? (pg 775) The most common valvuloplasty procedure is commissurotomy. Each valve has leaflets; the site where the leaflets meet is called the commissure. Leaflets may adhere to one another and close the commissure (i.e., stenosis). Less commonly, leaflets fuse in such a way that in addition to stenosis, the leaflets also are prevented from closing completely, resulting in backward flow of blood (i.e., regurgitation). A commissurotomy is the procedure performed to separate the fused leaflets. 67. Cardiac bypass 68. Lidocaine administration for heart complications pg 908 Abrams 69. Symptoms of aneurysm rupture (pg. 842) 70. Pink tinged sputum is usually accompanied by: Crackles 71. Pulseless electrical activity- Rhythm can be seen but not strong enough to cause a pulse- continue CPR until perfused o