Critical Care Exam 1

Level 1 Intensive Care

comprehensive care with extensive support. usually found in teaching hospitals.

Level 2 Intensive Care

comprehensive care for most patients, some services not offered (such as cardiac or neurosurgery)

Level 3 Intensive Care

stabilization of patients, and transfer to higher level facility.

Open ICU

the pts primary physician or a hospitalist may manage care

Closed ICU

intensivist manages care. intensivists are certified doctors in critical care, and may be specialize in internal medicine, surgery, or pulmonology.

Shock S/S

• MAP < 60

• decreased CO and tissue perfusion

• increased HR and blood sugar

• activation of RAAS → vasoconstriction and Na and H2O retention

• progresses to increased vascular permeability, release inflammatory mediators (SIRS)

• metabolic needs not met → organs ischemia

LPN limitations

can care for stable patients with chronic illnesses, never ER or ICU

• no IV push, initial assessments, education, care plans

• can do IV piggyback that isn’t the first dose

P wave

atrial depolarization

QRS

ventricular depolarization

• 1-3 boxes (0.04-0.12 seconds)

PR interval

• 3-5 boxes (0.12-0.2 seconds)

T wave

ventricular repolarization

ST segment

• 0.08-0.12 seconds

• elevation = heart muscle problems

• depression= decrease oxygen to heart muscle

QT interval

ventricular depolarization

• QT/RR=QTc (vary with heart rate)

• QTc should be 0.44 seconds or less

• QT prolong increases the risk of lethal dysrhythmias

Common medications that prolong QT interval

• amiodarone

• procainamide

• sotalol

Sinus Tachycardia

• HR > 100

• clinical associations: hypovolemia, fever, pain

• assessment findings: hypovolemic (dry mucous membranes, hypotension)

• tx: the cause if symptomatic (hypovolemia= fluids and blood)

Sinus Bradycardia

• HR < 60

• clinical associations: aging heart and meds (propranolol, amiodarone)

• assessment findings: decrease CO (pale/cyanotic skin, weak pulses, cold skin, decreased urine output, changes in LOC)

• tx: if symptomatic ! atropine and pacemaker if meds don’t work

Sinus Arrhythmia

• irregularity

• clinical association: normal for pt or stimulants (caffeine)

• assessment: asymptomatic

• tx: no tx

SVT (supra ventricular tachycardia) or atrial tachycardia

UTA PR and T wave, 1 wave form between QRS’s, very fast

• clinical associations: SNS stimulation or idiopathic

• assessment findings: decreased CO

• tx: vagal maneuver (bare down), Adenosine (push fast in most medial IV, will stop the heart so have crash cart, can be given twice 6mg per dose), cardioversion

Paroxysmal SVT

runs of SVT

Atrial Fibrillation (Afib)

always irregular, UTA P and T waves

• clinical associations: cardiac diseases

• assessment findings: symptoms mostly in rapid Afib (HR > 120): decreased CO or asymptomatic

• tx: diltiazem (Ca channel blocker, rate control; used with rapid Afib), amiodarone (antiarrhythmic; converts to normal rhythm), cardioversion if meds don’t work (must do echocardiogram first to check for clots), radiofrequency ablation (if cardioversion doesn’t work; burns cardiac tissue). All pts should be on anticoagulants because they are at increase risk for clots (Warfarin and Eliquis)

Atrial Flutter (A flutter)

UTA P and T waves; “saw tooth” wave formations between QRS

• (the following are the same as Afib)

• clinical associations: cardiac diseases

• assessment findings: decreased CO or asymptomatic

• tx: diltiazem (Ca channel blocker for rate control), amiodarone (antiarrhythmic; converts to normal rhythm), cardioversion if meds don’t work (must do echocardiogram first to check for clots). All pts should be on anticoagulants because they are at increase risk for clots (Warfarin and Eliquis)

Junctional Rhythm

P waves are absent or upside down

• (the following are the same as bradycardia)

• clinical associations: aging heart and meds (propranolol, amiodarone)

• assessment findings: decrease CO (pale/cyanotic skin, weak pulses, cold skin, decreased urine output, changes in LOC)

• tx: if symptomatic ! atropine and pacemaker if meds don’t work

Sinus Rhythm w/ PVC’s (premature ventricular contraction)

abnormal looking QRS’s that interrupt rhythm

• clinical associations: ischemia, MI’s, hypoxia, acid base imbalances, stimulants, hypokalemia

• assessment findings: asymptomatic, pt may complain of “heart skipping a beat”

• tx: tx the cause

  • unifocal: formations look the same

  • multifocal: formations look different

Ventricular Tachycardia (V tach)

look like upside down V’s

• (the following are the same as PVC’s)

• clinical associations: ischemia, MI’s, hypoxia, acid base imbalances, stimulants, hypokalemia

• assessment findings: asymptomatic

• tx: tx the cause

  • stable: pulse present; amiodarone and cardioversion

  • unstable: no pulse; CPR, defibrillate, epinephrine

Ventricular Fibrillation (V fib)

no pulse, small waves

• tx: CPR, defibrillate, and epinephrine

Asystole

straight line

• tx: CPR, epinephrine

  • DO NOT DEFIBRILLATE

Sinus Rhythm w/ PAC’s (premature atrial contraction)

P wave comes sooner and looks funky, causing it to be irregular

• (the following is the same as PCV’s)

• clinical associations: ischemia, MI’s, hypoxia, acid base imbalances, stimulants, hypokalemia

• assessment findings: asymptomatic, pt may complain of “heart skipping a beat”

• tx: tx the cause

  • unifocal: formations look the same

  • multifocal: formations look different

Sinus Rhythm w/ bundle branch block

enlarged QRS (over 0.12 seconds)

• clinical associations: cardiac

• assessment findings: asymptomatic

• tx: no tx

where do you look to identify the block?

PR interval

• 1st degree: PR interval long

• 2nd degree type i: PR interval progressively gets longer until you drop a QRS complex

• 2nd degree type ii: PR interval normal and consistent but more P’s than QRS’s

• 3rd degree: PR interval’s are all different, do not follow a pattern, and more P’s than QRS’s

Sinus Rhythm w/ 1st degree AV block

PR interval longer than normal (>0.2 seconds)

• clinical associations: anything cardiac related

• assessment findings: asymptomatic

• tx: no tx

2nd degree AV block type i

PR interval progressively gets longer until you drop a QRS complex

• clinical associations: meds, aging heart, post MI’s

• assessment findings: usually asymptomatic

• tx: is not treated at this point

2nd degree AV block type ii

PR interval normal and consistent but more P’s than QRS’s

• clinical associations: meds, aging heart, post MI’s (same as type i and 3rd degree blocks)

• assessment findings: decreased CO (cool skin, decreased capillary refill, decrease LOC)

• tx: atropine and pacemaker (same as bradycardia)

3rd degree AV block / Complete heart block

PR interval’s are all different, do not follow a pattern, and more P’s than QRS’s

• clinical associations: meds, aging heart, post MI’s (same as 2nd degree blocks)

• assessment findings: decreased CO (cool skin, decreased capillary refill, decrease LOC)

• tx: atropine and pacemaker (same as bradycardia and 2nd degree type ii)

Idioventricular Rhythm (IVR)

P wave absent, HR 20-40; “dying rhythm”

• clinical associations: cardiac related, dying

• assessment findings: decreased CO, signs of death

• tx: depends (dying? after MI?)

Torsades de Pointes

wave forms get bigger and smaller

• clinical associations: QT prolonged due to meds (amiodarone, procainamide, sotalol), and hypomagnesemia

EKG changes with hyperkalemia

peaked t waves → leads all wave forms to being widened

EKG changes with hypokalemia

presence of PVT’s, V tach, V fib, and possibly a U wave

EKG changes with hypocalcemia

vary from bradycardia to V tach and asystole

EKG changes with hypercalcemia

• bradycardia, AV blocks, bundle branch block

• shortened QT interval

EKG changes for hypomagnesemia

• similar to low potassium and calcium

• prolonged PR and QT, U waves, T wave flattening, and wide QRS

pulseless electrical activity (PEA)

often seen during codes, monitor shows sinus rhythm → check pulse !

• CPR, epinephrine, do not defibrillate !

causes of PEA (5 H’s)

• hypoxia (give O2)

• hypovolemia (give fluids)

• hypothermia (warm them up)

• H+ ions/acidosis (give sodium bicarb)

• hypokalemia or hyperkalemia

treatments of PEA (5 T’s)

• tablets (overdose): Narcan for opioids and Flumazenil for benzos

• tamponade (cardiac): pericardial centesis

• tension pneumothorax: needle decompression → chest tube

• thrombosis (coronary): fibrinolytics (TNK or TPA)

• thrombosis (pulmonary)

CPOT pain assessment

0= relaxed, neutral 1= tense 2= grimace

score for one minute at rest then observe during procedure (repositioning, suctioning, etc)

behavioral pain scale (BPS)

• scores 3-12 (higher score, higher pain)

  • score > 6 = pain that needs treatment

pharmacologic control of pain

• opioid agonists (morphine, fentanyl)

• nonopioids (used along w/ opioids; acetaminophen, NSAIDs)

• adjuvants (used along w/ above meds; steroids, muscle relaxants, etc)

acetaminophen

• injection or PO

• DO NOT exceed 4gms/day

• tx mild to mod pain

• may not be used if pt has liver failure of high alcohol consumption

nonsteroidal anti-inflammatory agents (NSAIDs)

• ketorolac: IM/IV, postop pain, less than 5 days due to increase risk of kidney failure

ketamine

• injection or PO

• does not decrease respiratory depression, but causes hallucinations

how often should you assess pain with critical patients?

at least 4 times/shift and PRN

morphine

• PO and injection form

• water soluble: slow onset of action, longer duration than fentanyl (lipid soluble)

• indicated for severe pain

• S/E: respiratory depression, vasodilation, pruritus, sedation, N/V

fentanyl

• dosed in micrograms

• injection, transdermal, lozenge

• rapid onset, shorter duration than morphine

• S/E: similar to morphine, may cause bradycardia, rigidity in chest wall if given rapidly

opioid reversal

• RR > 8-10 breaths/min

  • naloxone: repeat dosing may be needed due to duration of effect being shorter than opioids

what is the most life-threatening opioid side effect?

respiratory depression

methadone

• injection or PO

• used to tx pain and opioid dependence

• longer duration than morphine with less sedation

remifentanil and sufentanil injection

• used in pain clinics, surgery, anesthesia

• more sedation

• more potent than morphine

other pain management meds

• hydromorphone: injection or PO, more potent than morphine, not indicated in renal/liver failure

• meperidine: injection or PO, requires frequent doses

• codeine: injection or PO, metabolizes to morphine, rarely used in critical care

patient-controlled analgesia (PCA)

• pt must be alert, family cannot push the button

levels of sedation

• light/minimal

• moderate with analgesia (conscious/procedural)

• deep sedation and analgesia; cannot maintain airway → ventilator

RASS

provider sets sedation goal, nurse titrates based on assessment findings

• 4= combatice

• 3= very agitated

• 2= agitated

• 1= restless

• 0= alert and calm

• -1= drowsy

• -2= light sedation

• -3= moderate sedation

• -4= deep sedation

• -5= unarousable

sedative drips

benzodiazepines w/ anti-anxiety, anti-convulsant, amnesic and sedative properties must be weaned off slowly due to withdrawal complications

• midazolam (versed): used IVP for procedural sedation

• lorazepam (ativan): slower onset, longer duration than versed

benzodiazepines

• amnesic not analgesic

• no longer recommended for routine sedation of ventilated pts

• overdose can be reversed by flumazenil (romazicon)

• S/E: delirium, respiratory depression, hypotension

propofol

• lipid soluble, rapid onset/short half-life

• not amnesiac or analgesic

• can be IVP or continuous infusion (need ventilatory if infusion)

• complications: bradycardia, hyperlipidemia, respiratory depression

dexmedetomidine (precedex)

• short term sedative, continuous infusion

• analgesic

• complications: bradycardia and hypotension

• no respiratory depression :)

ventilatory sedation awakening trial

• turn off sedative infusion once daily (sedation vacation)

• stop/reduce analgesics per protocol

• assess RASS and LOC

• determine if ready to wean off…if not → restart at half OG dose then titrate up as needed

true or false: sedation negates any need for analgesia in mechanically intubated patients.

FALSE

delirium

disorganized thinking, inattention, and change in LOC

• increases morbity and mortality

• risk factors: older age, past alcohol or sedative use, dementia, impaired vision or heating, sepsis, disruptions in sleep

ABCDEF bundle for ventilated patients

• Awakening

• Breathing

• Coordination

• Delirium monitoring

• Exercise/Early mobility

• Family empowerment

temporary pacemakers

• transcutaneous: on skin; painful

• transvenous: through vein in atrium or ventricle (most common)

• epicardial: bypass surgery pts; loosely sutured in

pacemaker codes

• pacing: act of delivering the pulse

• sensing: pacemaker being able to sense needs of the heart

• rate control

• output dial: amount of electrical current

• sensitivity control

pacemakers on EKG

• atrial pacemaker: spike before P wave

• ventricular pacemaker: spike before QRS

failure to pace on EKG

slow HR or period of asystole (longer pause than oversensing)

• can be due to battery issue, connection issue

failure to capture on EKG

pacer spike with no waveform afterwards (heart did not respond)

• often due to displaced electrode/lead, reduced electrical output

• what to do? check connections of pacemaker

undersensing on EKG

pacer cannot sense the pt’s intrinsic rhythm; will see pacer spikes where they are not supposed to be

• usually due to sensitivity not being high enough

oversensing on EKG

pacemaker sensing wrong signal as an intrinsic beat; small pause on strip

• can be due to artifact or large P or T waves

• sensitivity setting too high

how can you temporarily stop pacemaker ?

magnet

pacemaker nursing management

• preventing pacemaker malfunction

• protecting against microshock

• preventing complications (infection at site)

  • never touch bare wires with bare hands !

demand pacemaker

set to deliver impulse when pt’s intrinsic factor doesn’t fire

constant pacemaker

constantly delivering electrical impulses

implantable cardioverter defibrillation (ICD)

pt’s with end stage HF

• monitor for dysrhythmias

• educate pt that if a shock fires, come to the ER (so we can determine what happened)

acute coronary syndrome (ACS)

ranges from angina to acute MI

• angina: symptom of CAD

  • angina symptom equivalents: more common in women; SOB, N/V, GERD like symptoms

stable angina

temporary loss of blood supply

• pain occurs at exercise/exertion (same everytime)

unstable angina

pain at rest, that doesn’t resolve

variant angina

due to coronary spasms

• pain at rest, w/ activity, and at night time

medical management for angina

• stress test, 12 lead EKG

• MONA: morphine, O2, nitrates, aspirin

• avoid Valsalva maneuvers: vomiting, coughing, straining (these decrease venous return; do not want)

ischemia on EKG

T wave inversion

ischemia and injury on EKG

inverted T wave and ST elevation 

injury, ischemia, and infarction on EKG

inverted T wave, ST elevation, and Q wave (before QRS complex; indicated nercrosis)

anterior wall infarction MI

• cause cardiogenic shock or death

• occlusion of the left anterior descending (LAD) artery

inferior wall infarction MI

• conduction issues

• end up with bundle branch blocks, bradycardia, etc. 

non-ST segment elevation MI (NSTEMI)

repolarization impaired but able to return to normal 

ST segment elevtation MI (STEMI)

cells do not fully repolarize

• permanent damage 

MI nursing management

• monitor cardiac biomarkers (troponin; will be up, we want to trend down) 

• balance myocardial O2 supply and demand (meds and monitor EKG) 

• prevention of complications

• patient education (risk factor modification, angina manifestations, when to call HCP, nitroglycerin education; take second nitro while calling ambulance) 

MI medical management

• recanalize coronary artery with fibrinolytics or cardiac cath

• anticoagulation: heparin, anti-platelets (aspirin, clopidogrel)

• dysrhythmia prevention: beta blockers, amiodarone

• prevention of ventricular remodeling: ACE or ARB

fibrinolytic therapy

dissolve clots quickly (tPA, rPA)

• eligibility criteria: must have recent onset of angina, w persistent ST elevation, BBB’s that may obscure ST segment analysis or hx suggesting acute MI, extended contact to device time

• exclusion criteria: recent procedure or blood thinners

• GOAL: receive fibrinolytics 30 min after ED arrival; outcomes → break clot, return blood flow, relieve pain (if >2hrs from PCI hospital, give fibrinolytics then can transfer)

• monitor for return of symptoms, EKG changes, bleeding (re-occlusion); dual-antiplatelet meds to prevent this (aspirin)

• meds post fibrinolytics: aspirin, Plavix

percutaneous coronary intervention (PCI)

• atherectomy: remove plaque

• percutaneous transluminal coronary angioplasty (PTCA):  balloon pushes plaque to side

• coronary stents: drug eluting stents (keeps plaque in place)

• nursing management: sheath removal; radial or femoral, monitor access site for bleeding, pulses, color.

• aspirin for life, apixaban or Eliquis for weeks to months 

coronary artery bypass surgery (CABG)

take a vein from the leg, sew it onto the heart to bypass blockage

• pt on bypass machine (oxygenate and circulates the heart), so they can stop the heart

CABG nursing management

• optimize CO; HR (pacing, meds, AFIB), preload (require fluids), afterload (resistance; BP needs, carefully rewarm), contractility (inotropic meds)

• temp regulation and prevent hypothermia (causes vasoconstriction, arrhythmias, increase bleeding risk) 

• control bleeding

• maintain mediastinal chest tube (may have order to milk tube to help drain)

• recognize cardiac tamponade (fluid around heart in pericardium)

  • Beck’s Triad: hypotension, JVD, muffled heart sounds

  • falling vitals, no chest tube output also indicate tamponade 

• promote early extubation 

• assess neurologic complications

• prevent infection: blood glucose < 180mg/dL (insulin drip)

• preserving kidney function: monitor I&O, MAP >65

valve replacement

leaflets of valve removed and replaced; via sternotomy or TAVR (less risks, used only with atrial valve)

• complications: same as CABG; hemorrhage, infection, dysrhythmias, hypo/hypertension