Nursing Advanced Concepts and Skills Class 1, 2 and 3

DKA, EKG, Virtual Monitoring, Hemodynamics

DKA

Occurs when there is no insulin available. Usually an infection triggers the insulin insufficiency

DKA Symptoms

Polyuria

Ketonuria

Hypovolemia (low BP, high heart rate)

Dehydration

Polydipsia

Nausea & vomiting

Kussmaul's respirations

Fruity breath

Anticipated Lab Values

• hyperglycemia (bg >13)

• H+ increases

• pH decreases

• CO2 increases

• K+

  • initially hyperkalemia due to lack of insulin

  • more potassium out of cells

  • after insulin infusion starts, potassium moves into cells

  • patient can become hypokalemic (order for potassium)

• Ketones increase

• Creatinine and BUN increase due to poor kidney function

• possible detection of UTI (cause for infection)

DKA Treatment

• Treat BP first (Hypertonic infusion)

• Insulin infusion runs in tandem with infusion (ratios depend on orders)

• Possible potassium infusion after insulin

• May switch infusion to Dextrose to prevent hypoglycemia (insulin overdose)

Monitoring

• Vital signs

  • HR increases

  • BP decreases

  • RR increases

  • O2 saturation decreases

• blood glucose

• EKG - potassium imbalance

• Urinalysis - ketones/kidney function/infection

• input and output

DKA prevention

• regular blood sugars

• education

• advocacy

EKG Interpretation: 8 Step Approach

1. Heart rhythm (regular or irregular)

2. Heart rate

3. Presence of P wave

4. Calculate PR interval

5. Width of QRS complex

6. ST segment

7. QT interval

8. T wave

Calculate PR interval

• atrial depolarization

• beginning of P to start of QRS

• 0.12 - 0.20 seconds

• 3 to 5 boxes

Width of the QRS complex

• ventricle depolarization (Lead II)

• 0.08 - 0.12 seconds

• 1½ to 3 boxes

ST segment

• if below isoelectric line = myocardial ischemia

• if elevated = myocardial infraction

QT interval

• time required for depolarization and repolarization of ventricles

• 0.34 - 0.42

• 8½ to 10½ boxes

• prolonged in some disease states or medications

T wave

• ventricular repolarization or relaxation

• Peaked T wave = hyperkalemia

Normal Sinus Rhythm

Sinus Bradycardia

Sinus Tachycardia

Atrial Flutter

Atrial Fibrillation

SVT (supraventricular tachycardia)

Ventricular Arrhythmias

• PVC (premature ventricular contractions)

• VT (ventricular tachycardia)

• VF (ventricular fibrillation)

Premature Ventricular Contractions

Ventricular Tachycardia (monomorphic)

Ventricular Tachycardia (polymorphic)

Ventricular Fibrillation

heart blocks

Third degree heart block

• regular P waves

• regular QRS complex

• more P waves than QRS complex

• each beating to the beat of their own drum

• no correlation between P waves and QRS complex

Ventricular pacemaker rhythm (single chamber)

Narrow Complex Tachycardias

• A Fib

• A Flutter

• SVT

Atrioventricular pacemaker rhythm (Dual chamber)

Adenosine

• Sinus Tachycardia

• SVT

Amiodarone

• A Fib

• V Fib

• V Tach

Atropine

• Sinus Brady

• 3rd Degree Heart Block

• Asystole

Beta Blockers

• Sinus Tachy

• A Flutter

• A Fib

Digoxin

• A Fib

• A Flutter

• Heart Failure

Diltiazem

• Sinus Tach

Dopamine

• Sinus Brady

Epinephrine

• Sinus Brady

• V Tach

• Asystole

• V Fib

Lidocaine

• V Tach

• V Fib

• PVC

Metoprolol

Narrow Complex Tachycardia

• A Fib

• A Flutter

• SVT

Norepinephrine

• Acute Hypotension

• Cardiac Arrest

Types of Remote Patient Monitoring

• wearable devices

• pacemakers + cardioverter defib

• inhaler sensor

• non-invasive ventilation

• BP monitors

Nursing Care and Services of Remote Patient Monitoring

• Assessment, initiation, and evaluation of the treatment plan

• Education

• Counselling

• Health Care Monitoring

Benefits of Remote Patient Monitoring for HCP

• Reduced operational costs

• Improved management of patients with chronic illness

• Improved patient outcomes

• Can monitor continuously between clinic visits, sometimes unreported symptoms are caught

• Identify deterioration earlier and provide prompt care

• Reduce “White Coat Syndrome”

Benefits of Remote Patient Monitoring for Patients

• Can serve rural and remote areas

• Emergency consultation with specialists

• Reduced travel

• Can stay at home – reduce unnecessary clinic/ER visits

• Early symptom management and connection between patients and clinicians

• Timely assurance about symptoms

• Personalized health care and data management

• Ability to make self care decisions – better compliance

• Allows for habit changes by seeing data – better control over their disease

• Can show condition is improving

Risks of Remote Patient Monitoring

• Digital health literacy

• Accuracy of wearable devices

• High cost of devices

• Complexity of data analysis

• Lack of integration with electronic medical record

• Increased stress over changes in symptoms –increases patient anxiety

• Increased practitioner workload

• Hard to determine what is valuable vs extraneous data

• Data is maintained by a third party....Apple?

• Privacy concerns

• Data accuracy

• Lack of trust in technology

• May postpone contact or required visits

Virtual Nursing Practice

• appropriate technology

• appropriate duty of care

  • level of assessment required vs reality level completed virtually

  • correct use of tools

• appropriate employment support

Preload

degree of ventricular stretch before next contraction

afterload

the amount of resistance the ventricles overcome to deliver the stroke volume

contractility

strength of contraction

Stroke Volume

determined by preload, afterload and contractility

affects CO and BP

Arterial Line

• Invasive hemodynamic monitoring of BP

• monitors systolic, diastolic and MAP

MAP

• Mean Arterial Pressure

• MAP → 70 - 105 mmHg

• MAP = (systolic + 2(diastolic)) ÷ 3

indications for an Arterial line

• Evaluate unstable pts

  • acute hyper or hypotension

  • shock

• monitor vasoactive drugs

• frequent blood samples for ABG

Arterial line sites

• radial

• brachial

• femoral

Central Venous Pressure (CVP)

• aka Right Arterial Pressure (RAP)

• Normal value is 2-8 mmHg

• Measures right ventricular preload

• Often used to trend fluid status

• Elevated CVP - right ventricular failure or volume overload

• Low CVP – hypovolemia

Why Central Venous Pressure Monitoring

• Measure right heart filling pressures

• Estimate fluid status

• Guide volume resuscitation

• Assess central venous oxygen saturation

• Administer large-volume fluid resuscitation or medications

• Administration of vesicant medications

• Access to place transvenous pacemake

Central Venous Pressure sites

• Subclavian vein

• Internal Jugular

• Femoral Vein

Pulmonary Artery Pressure Monitoring

• PA catheter aka Swan-Ganz catheter

• Most invasive technology for hemodynamic measurement

• Not used as frequently anymore

• Assess left heart function

• Identify and treat cause of hemodynamic instability

• Assess pulmonary artery pressures

• Assess mixed venous oxygen saturation

• Directly measures cardiac output

PAP Monitoring sites

• large vein

  • Subclavian vein

  • Internal Jugular

PA Catherter lumens

• 5 lumens

• distal lumen port is in the PA – measures pulmonary artery pressure

• Proximal lumen ports are in the right atrium and the right ventricle – measure central venous pressure

• The balloon inflation valve is used to inflate the balloon with air to allow reading of the PA wedge pressure.

• A thermistor located near the distal tip senses PA temperature and is used to measure thermodilution cardiac output when the solution is cooler than body tempreture is injected into proximal port

Complications of PA Insertion

• Hemothorax

• Pneumothorax

• Perforation of vena cava, cardiac chamber, or pulmonary artery

• Cardiac dysrhythmia - especially when passing through right ventricle

Pulmonary Artery Wedge Pressure (PAWP)

• Aka Left Atrial Pressure (LAP)

• Used to estimate left ventricular preload

• 6-12 mmHg

• The PAWP is obtained when the balloon of the PAC is inflated to wedge the catheter from the PA into a small capillary. The resulting pressure reflects the left atrial pressure and left ventricular end-diastolic pressure (LVEDP) or ventricular filling pressures when the mitral valve is open. When properly assessed, the PAWP is a reliable indicator of left ventricular function.

Pulmonary Artery Wedge Pressure

• Increased PAWP - increase in left ventricular blood volume

  • Fluid volume excess (IV fluids, renal dysfunction)

  • Impending left ventricular failure (MI)

• Decreased PAWP – decrease in left ventricular blood volume

  • Fluid volume deficit (dehydration, diuretics, hemorrhage)

Venous Oxygen Saturation (SvO2)

• 60 - 80%

• CVP and PA can include sensor to measure SvO2

• compare with arterial O2

• decreased SvO2

  • decreased arterial O2

  • low hemoglobin

  • increased O2 consumption

• increased SvO2

  • increased O2 supply

  • Decreased O2 demand

When is Invasive Hemodynamic Monitoring used?

• Septic Shock

• Heart Failure

• Surgery and Perioperative Care

• Trauma and Hypovolemic Shock

Why is invasive hemodynamic monitoring important?

• Guides fluid and drug therapy

• Monitors response to therapy

• Assesses cardiovascular function

• Early detection of deterioration

• Evaluates tissue perfusion and oxygenation