Critical Care Final Exam

What is rheumatoid arthritis?

chronic, systemic autoimmune disease that causes inflammation in the joints,

leading to pain, stiffness, swelling, and potential joint deformity

S/S of Rheumatoid Arthritis

• Symmetrical joint involvement (hands, wrists, knees)

• Morning stiffness lasting more than 30 minutes

• Fatigue, low-grade fever

•Pain improves with activity

Priority concern of RA

Sudden joint redness, warmth, and limited motion (may suggest joint infection or septic arthritis)

First line medications to slow RA

• DMARDs (Disease-Modifying Antirheumatic Drugs) - first-line to slow disease progression (e.g., methotrexate)

Meds to reduce pain for RA

• NSAIDs - for pain and inflammation

Meds to use during RA flare ups

• Corticosteroids - used short-term during flare-ups

Patient education for using methotrexate

• Start early to prevent joint damage

• Takes 4-6 weeks for full therapeutic effect

• Must monitor for liver toxicity and immunosuppression

Labs to monitor for RA

C-reactive protein (CRP) - used to track inflammation and response to treatment like prednisone

• CBC, liver function, renal panel (for med side effects)

What is Systemic Lupus Erythematosus?

SLE is a chronic autoimmune disease that can affect multiple organs including skin, joints, kidneys, and the nervous system

SLE S/S

• Fatigue

• Joint pain (nonerosive)

• Butterfly (malar) rash over cheeks and nose

• Photosensitivity

• Hair loss

Concerning symptoms for SLE

• New-onset edema (especially periorbital or in the lower extremities) may indicatelupus nephritis

• Shortness of breath, chest pain, or neuro changes may signal organ involvement

Common labs for SLE

• ANA (Antinuclear Antibody) - primary screening test for SLE

• CBC - monitor for anemia, leukopenia, thrombocytopenia

• Urinalysis - assess for proteinuria or hematuria in lupus nephritis

Complications to monitor for SLE

• Lupus Nephritis - inflammation of the kidneys; may cause leg swelling, protein in urine

• Increased risk for infections and blood clots

SLE Medications

NSAID

corticosteroids

immunosuppressants

antimalarial

Immunosuppressive therapy side effects

-Infection risk

-Bone marrow suppression

-GI effects

-Renal and Liver toxicity

Immunosuppressive therapy patient education

-HH

-Avoid crowds

-Monitor temp

-Med adherence

A-fib

No p wave

Irregular

A flutter

Regular

Sawtooth

premature ventricular contraction (PVC)

Wide QRS interruption

Premature Atrial Contraction (PAC)

Elongation between t and p

Early pop in of p wave

Regular

V tach

Emergency-shockable rhythm

Looks like uniform points

V fib

squiggly line

Code blue-shockable rhytm

1 degree AV block

Long PR interval

Regular

2nd degree AV block type 1

Longer PR intervals until absent beat

Regular

2nd degree AV block type 2

Everything regular till sudden drop

3rd degree AV block

atria and ventricles beat independently of each other

(P waves have no relation to QRS waves)

Regular

A-fib: stable patient, treatment?

Metoprolol

Digoxin

Diltiazem

a fib unstable tx

cardiovert

long term a fib management

Beta blocker

Amiodarone, flecanaide, ablation

Anticoagulant

PSVT

Tachycardia over 150bpm

Normal PR Interval

0.12-0.20 seconds(3-5 small boxes)

Normal QRS durration

0.06-0.10(<3 small boxes)

Normal QT interval

Men <0.44 and Women <0.46

PR interval

delay of AV node to allow filling of ventricles(time between atria and ventricles)

QRS

ventricular depolarization

QT interval

ventricular depolarization and repolarization

How many seconds and mV is 1 ekg box

0.04 secs

0.1 mV

When is Sinus Bradycardia dangerous?

Dizziness

Hypotension

SOB

AMS

Symptomatic Sinus Bradycardia Tx

Atropine IVP(repeat every 3-5 mins. max 3mg)

Bradycardia with hypotension or shock tx

Transcutaneous pacing or dopamine/epi infusion

Medication induced bradycardia tx

hold or adjust beta blocker, CCB, or digoxin

When do you never cardiovert a fib

when it is older than 48 hours without anticoagulation

A fib patient education

Stop smoking

Reduce stress

limit caffiene

Stable a flutter tx

Rate control- beta blocker and CCB

Rhythm control- amiodarone, cardioversion

Anticoagulant-prevent stroke

Unstable a flutter tx

Synchronized cardioversion

Anticoagulant before cardioversion if older than 48 hours

tx underlying cause

SVT tx and interventions

1.Vagal maneuver

2.Adenosine

3. Synchronized Cardioversion

When are PVC dangerous

->6 per minute

-QRS looks different each time

-Bigeminy and Trigeminy

-Couplets or Runs

-PVC occuring on top of T wave

Stable V tach tx

Amiodarone

Lidocaine or procainamide

K+ or Mag if low

Unstable V tach tx

Synchronized cardioversion, IV amiodarone if conscious and correct electrolytes

Pulseless v tach tx

CPR and defibrillation, epi, amiodarone

V fib tx

Defibrillation and CPR

Epi

Amio

First degree Heart block tx

no tx required

Second degree heart block type 1 tx

fix the cause

asymptomatic: no treatment required

symptomatic: pacing

Second degree heart block type 2 tx

pacemaker

Third degree heart block tx

pacemaker

How to treat asystole

CPR

initiate advanced cardiac life support

give epinephrine and/or vasopressin

place an airway

Labs related to cardiac rhythms

-electrolytes

-troponin

-BNP

Who may need a pacemaker

-Symptomatic bradycardia

-Third degree block

-Second degree type 2

-Sick Sinus syndrome

-Slow Afib

-Post cardiac surgery or post MI

Cirrhosis lab values

1) Elevated AST & ALT

2) Low platelet count

3) low albumin

4) Increased total bilirubin (more conjugated)

5) elevated PT/INR

6) Elevated Creatine

7) elevated ammonia

Cirrhosis s/s

Jaundice

Peripheral edema

Esophageal varices

Spider angiomas

Hepatic encephalopathy

itching

fatigue

dark urine

ascites

Cirrhosis medications

Lactulose and Rifaximin(lower ammonia)

Diuretics(fluid overload)

non selective beta blocker(reduce portal htn)

Vit k(correct coagulapathy)

Albumin IV(volume expansion)

Antibiotics(for spontaneous peritonitis)

Esophageal Varices s/s

hematemesis,

melena,

Hypotension

Tachycardia

light headedness

shock

low hgb and hct

Esophageal varices medications

-nonselective beta-blockers

-octreotide

-FFP

Hepatic encephalopathy s/s

-astrixis

-twitching of extremities

-confusion

-inappropriate behavior

-seizures

DUE TO INCREASE AMMONIA LEVELS

Hepatic encephalopathy lab values

High ammonia

Signs of Liver failure

- jaundice

- confusion

- anorexia/nausea, vomiting

- bleeding and bruising

- ascites

- fatigue and weakness

- spider vein

- palmar erythema

- RUQ pain

- dark urine and pale stools

Critical Acute liver failure s/s

Hepatic encephalopathy

Esophageal Varices

Sepsis

Spontaneous peritonitis

Mutli-organ dysfunction

How do you tx sinus tachycardia

Treat the underlying cause

If it's symptomatic sinus tach, you can try vagal maneuver, beta blocker, and CCBs

2 complications of A fib

Clots(MI and stroke)

Heart failure(Decreased CO)

What could frequent PACs turn into?

A fib

How do you treat torsades De Point

Mag sulfate

Anticoagulant usually partnered with A fib

Warfarin

ABGs for early and late stage asthma

early: Respiratory Alkalosis

Late: Respiratory Acidosis

80-100% peak flow reading

Green- your medication is working, resume normal activity

50-80% peak flow reading

Yellow-use caution in activities. Refer to your treatment plan for actions. Relax

Less than 50% peak flow reading

Red-Medical alert, seek medical attention

Silent chest

no air movement indicating respiratory failure

What should you do if you can not visualize the trachea

suction

Preventative measures of VAP

-Head of bed 30-45

-Sedation vacation

-Oral care with Chlorhexidine

-DVT and ulcer prophylaxis

-Suction

-Hand hygiene

Sedation vacation

Daily pausing of sedation to assess readiness

s/s of VAP

-fever

-elevated WBC

-Positive sputum or tracheal culture

-tachycardia

-secretion(yellow/green, poor smell)

-crackles or rhonci

-decreased O2 level

High pressure vent alarm

obstruction

kink

biting

Low pressure vent alarm

Disconnection

leak

What is the first thing you do when a vent alarm is going off?

Check the patient

COPD education

-quit smoking

-O2 maintenence

-Purse lip breathing

-Frequent check ups

What level should you keep a patients Oxygen at for COPD

88-92%

What is the diagnosis of COPD

FEV1/FVC ratio of less than 70%

Interventions for COPD patient

-high calorie food

-Small frequent meals

-Tripod positioning

-Hydration

-Encourage activity

Medications for COPD

SABA, LABA and ICS

Oral or IV steroids for copd exacerbation

ABx for bacterial triggers

When should you intubate a COPD patient?

If CO2 rises and LOC drops despite support

COPD exacerbation s/s

productive cough

increase O2 needs

Lower activity intolerance

risk respiratory failure

COPD ABG

respiratory acidosis

What confirms a COPD diagnosis

spirometry

Hypoxic drive

A "backup system" to control respiration; senses drops in the oxygen level in the blood.

Why does hypoxic drive play a role in COPD

giving too much o2 can reduce COPD patient's drive to breath leading to respiratory depression and CO2 retention

Normal ABG levels

pH: 7.35-7.45

PCO2: 35-45

HCO3: 22-26

Common causes of each ABG imbalance

Metabolic Acidosis- diarrhea

Metabolic alkalosis- throwing up

Respiratory acidosis-hypovent

Respiratory alkalosis-hypervent

Left sided HF s/s

SOB

Crackles

Orthopnea

Pulmonary Edema

Right sided HF s/s

JVD

Edema

Ascites

Systolic HFrEF

Can't pump

-low bp