Lecture 3 MARK k Lectures

Calcium Channel Blockers

*Calcium-Channel Blockers are like Valium for your heart

• Valium -> calm’s you down; so CCB’s calm your heart down

• (ex. if tachycardic, give CCB’s but not in shock)

• THEY REST YOUR HEART (not stimulants)

Positive Inotropes, Chronotropes, Dromotropes

Cardiac Stimulants- stimulate, speed (up the heart)

Negative Inotropes, Chronotropes, Dromotropes

Cardiac Depressants: calm the heart down, (weaken & slow down)

When do you want to “depress” the heart? What do CCB’s treat?

A: anti-hypertensives: Relax heart & blood vessels to bring down BP

AA: anti-angina’s: Relax heart to use less O2 to make angina go away

/ treats angina by addressing oxygen demand

AAA: anti-atrial arrhythmia: atrial flutter, A-fib, premature atrial contractions

* Never ventricular

what about supra-ventricular tachycardia??

• Because it means ‘above the ventricles’ (which (are the atria)

What are the side effects of CCB?

****“H & H” ****

• HYPO tension (low blood pressure)

• Headache: vasodilation to the brain

• * Hint: headache is a good thing to select for (‘select all that apply’ questions.

Names of CCB’s (calcium channel blockers)

• Anything ending in ‘-dipine’

• - ex. amlodipine, nifedipine

Name of OTHER CCB’s that DONT end in -dipine’

• VERAPAMIL & CARDIZEM

Which CCB can be given on a continous IV drip??

• Cardizem

What VS needs to be assessed before giving a CCB?

BP = because of risk of hypotension (low blood pressure)

• Parameters/guidelines - hold CCB if systolic is (under 100)

• You need to monitor BP if PT is on a Cardizem (continuous drip (if it’s under 100 then you may (have to stop or change the drip rate)

Normal Sinus Rhythm

• P wave before every QRS & followed by a T wave for every single complex,

• All P wave peaks are equally distant from each (other, QRS evenly spaced)

V-Fib

• Chaotic squiggly line, no pattern

V-tach

sharp peaks, has a pattern

A-Systole

flat-line

QRS depolarization,

it’s talking about ventricular ( (so rule out anything atrial)(

P-wave

then it’s talking about atrial

The word “chaotic” is used to describe

A-fib: with “p-wave”

V-fib: with QRS

The word “bizarre” is used to describe

Atrial Tachycardia if w/ P wave

Ventricular Tachycardia if with QRS

PVC’s

(premature ventricular contractions)

• Also known periodic wide bizarre QRS (ventricular because QRS)

• Bizarre -> tachycardia (- you can call a group of PVC’s a short run of V-tach)

Do Physician’s care about PT’s having PVC’s?

NO, not a high priority = low priority

They NEVER reach top priority (highest is moderate priority)

How do you know if PVC’s should be moderate priority?

i. If there are more than 6 PVC’s in a minute

ii. If there are more than 6 PVC’s in a row

iii.If the PVC fall on the T-wave of the previous beat (R on T phenomenon)

Lethal Arrhythmia’s (HIGH PRIORITY (Will kill you in 8 mins or less)

• Asystole

• V-Fib

• BOTH HAVE NO CARDIAC OUTPUT

What is the medication for V-Tach and PVC’s

for ventricular use LIDOCAINE/****AMIODARONE***

Atrial arrhythmias use ABCD’s

A: Adenocard (Adenosine)

B: Beta blockers

C: Calcium channel blockers

D: Dig/ Lanoxin

ADENOCARD (Adenosine)

- Have to push in less than 8 seconds (FAST IV (push)

• Slam this drug, followed by a flush; use a big vein; BUT the problem w/ slamming it fast is (the risk of PT going into A-Systole for 30 seconds. THEY WILL come out of it so don’t worry …unless longer than 30 sec.

for IV pushes: when you don’t know you go slow

BETA-BLOCKERS

all end in ‘-lol’

• Are negative inotropes, chronotropes, & dromotropes like calcium-channel blockers (a.k.a. valium for your heart so they treat A, AA, AAA & (have same side-effects)

• ** generally speaking, don’t make a big difference (between Beta- & Calcium channel blockers

• CCB are better for PT’s w/ asthma ( or COPD -> Beta-B’s bronchoconstrict

Digitalis

Med: Lanoxin

• Used for patients with heart failure (to improve blood circulation)

• Control’s A-Fib (rate and rhythm)

S&S of DIG TOXICITY (lanoxin)

• Bradycardia (↓ HR) ⚠

• Dysrhythmias (irregular heart rhythms)

• Anorexia (early sign)

• Nausea, vomiting

• Fatigue, weakness

• Confusion, dizziness

• Yellow/green vision, halos

• Risk ↑ with hypokalemia

How do you trat V-Fib?

you SHOCK them!!!

How do you trat asystole??

• Use EPINEPHRINE & ATROPINE (in this order!)

*if epinephrine doesn’t work then use atropine

Chest Tubes??

Purpose is to re-establish negative pressure in the pleural space (so that the lung expands when the chest wall moves)

• Pleural space -> negative is good (negative pressure (makes things stick together)

• Ex. gunshot to the lung adds positive pressure

• Hint: when you get a chest tube question, look at the reason for which it was placed (will tell you what to expect & what not to expect

Pneumothorax

• to remove air (because air (created the positive pressure)

Hemothorax

• to remove blood

Pneumohemothorax

• to remove blood & air

Apical placement

The chest tube is way up high, thus it is ( removing air (because air rises)

ex. it’s bad if you’re apical tube is draining 200 mL or it is not bubbling

Basilar placement

At the bottom of the lungs, thus it is (removing blood/liquid (because of gravity)

ex. it’s bad if your basilar tube is bubbling or not draining any mL

How many chest tubes & where would you place them for a unilateral pneumohemothorax?

2 chest tubes (apical for pneumo, basilar for hemo)

How many chest tubes & where would you place them for a bi-lateral pneumothorax?

2 tubes (apical on left, apical on right)

How many chest tubes & where would place them for post-op chest surgery?

2 tubes (apical & basilar on the side of the surgery)

*you are to assume that chest surgery/trauma is (unilateral unless otherwise specified (they will say bilateral)

How many chest tubes would you need and where would you place them for a post-op right pneumonectomy?

NONE! because you are removing the lung so you ( don’t need to re-establish any pressure (there is not ( pleural space)!

What do you do if you knock over the plastic containers that certain tubes are attached to?

1. Set it back up & have PT take some deep breaths

2. NOT a medical emergency! (don’t call MD)

What do you do if the water seal breaks?? like the actual device breaks?

1. First = CLAMP it!!! because now positive pressure (can get in! don’t let anything get in

2. Second = CUT the tube away from the broken device

3. Third = stick that open end into sterile water (-> then unclamp it because you’ve re-established the water seal doesn’t need clamp if it’s under water)

4. *** BETTER for the tube to be under water THAN clamped! -> air can’t go in and stuff can still keep coming out (if clamped, nothing can come out, which is what the tube is for)

What is the first thing to do when the if the seal breaks?

• Clamp the tube!!

What’s the best thing to do when the seal breaks??

• Put the end of the tube under water!!

You notice the PT has V-fib on the monitor. You run to the room and they are non-responsive with no pulse. What is the first thing you do?

A. place a backboard

B. Start chest compressions

A. place a backboard

You notice the PT has V-fib on the monitor. You run to the room, and they are non-responsive with no pulse. What is the best thing to do?

A. place a backboard

B. Start chest compressions

B. Start chest compressions

What is the first thing you do if the chest tube gets pulled out?

A. Take a gloved hand and cover the hole

B. Cover the hole with vaseline gauze

A. Take a gloved hand and cover the hole

What is the best thing you do if the chest tube gets pulled out?

A. Take a gloved hand and cover the hole

B. Cover the hole with vaseline gauze

B. Cover the hole with vaseline gauze

Bubbling chest tubes, what are the two questions you ask?

A) Where is it bubbling?

B) When is it bubbling?

Intermittent bubbling in the water seal?

• It is a good sign, the water seal is supposed to be bubbling intermittently

Continuous bubbling in the water seal??

• It is a BAD sign; the water seal is NOT supposed to be continuously bubbling, means a leak in the system that you need to find and tape it until it stops leaking.

Intermittent in suction control chamber

• BAD sign, means suction is not high enough, turn it up on the (wall until bubbling is continuous)

Continuous in suction control chamber

• Good sign, the suction is supposed to be suctioning continuously.

What is a thoracentesis??

• Second alternative, that assist with reestablishing negative pressure into the pleural cavity.

• “temporary”

• A straight Cath to a foley is what a thoracentesis is to a chest tube.

• between a chest tub and a thoracentesis, a chest tube has a higher risk of infection.

How long can you clamp a chest tube for??

• 15 Seconds (MAX)

• Use rubber tipped clamps, to not puncture the tube.

Congenital Heart defects YOU NEED TO REMEBER

REMEMBER THE WORD TRouBLe

Every congenital heart defect is either TROUBLE or NO TROUBLE (ALL BAD or NO BAD)

Either causes a lot of problems or it’s no big deal (no in-between defect)

Trouble congenital heart defects

• All of the “trouble” congenital heart defects start with the letter “T”

• Surgery is required

• Growth, development and life expectancy: Slow, delayed and short

• Parents experience: Grief, financial stress, lot’s of caregiving issues.

• Going home: apnea monitor

• Hospital stay at growth: weeks

• Who follows care: Pediatrician, Cardiologist

• Shunting: R to L (tRoubLe)

• Cyanosis: Blue (trouBle)

Congential heart defects that are not trouble

• Don’t need surgery

• growth and development: normal

• life expectancy: normal

• parent’s experience: regular average person issues

• going home: no apnea monitor

• Hospital stay at birth: 24-48 hours

• Who follows care: pediatrician/ pediatric NP

• Cyanosis: Acyanotic

If the question on the NCLEX refers that you are teaching parents about a congenital heart defect that is trouble ..

Pick the answer choices that are trouble, teach the parent’s that it is going to be alot of trouble.

If the question on the NCLEX refers that you are teaching parents about a congenital heart defect that is not going to be trouble

Pick all the answer choices that are not trouble; teach the parents that it is not going to be trouble.

Kids with a Trouble or NOT trouble congenital heart defect will ALL have a ….

MURMUR

• Why? = because of the shunting of the blood regardless of direction of shunt

• All have an Echocardiogram done to find out what the defect is or why there’s a murmur.

4 Defects of Tetralogy of Fallout:

“VarieD PictureS Of A RancH”

1. VD = ventricular defect

2. PS = pulmonary stenosis

3. OA = overriding aorta

4. RH = right hypertrophy

Contact precautions

• For anything enteric = can be caught from intestine, fecal, oral.

• C-Diff,

• Hep. A

• Cholera

• Dysentery

• Staph infections

• C-Diff

• Herpes infections

• Shingles

• Zoster (varicella)

What PPE do you use for contact precautions?

NO: mask, eye/face shield (unless for universal), ( special filter mask, PT mask, neg. air flow.

YES: gloves, gown, hand-washing, special supplies & dedicated equipment (includes toys) ** disposable supply vs. dedicated equipment, thermometer cover - BP cuff that stays in room.

Private or non-private room for CONTACT precautions??

• Private room is preffered (but not required)

• This means two kids with RSV can be in the same room together

• Can one kid with RSV and one kid with SUSPECTED RSV can be roomed together?? NO NO NO we need positive cultures to CONFIRM that the child has RSV.

DROPLET precautions

• For bugs that travel 3 feet on large particles due to sneezing/coughing

• - all meningitis: cultured through lumbar puncture

• H Flu (haemophilus)

• Influenza B -> commonly causes epiglotitis( never stick something down throat because it will cause obstruction.

For DROPLET precautions is it a private or non-private room

• PRIVATE ROOM

What is the PPE for DROPLET precautions??

NO: gown, eye/face shield, special filter mask, (neg. air flow

YES: mask, gloves, hand-washing, PT worn (mask when leaving room), disposable supplies (& dedicated equipment)

Airborne precautions

• M-M-R

• TB

• Varicella (chicken pox)

Private or non-private room for Airborne precautions

• PRIVATE ROOM (repeated answer)

PPE for AIRBORNE precautions?

• NO: gown (mostly for contact), eye/face shields

• YES: mask, gloves, hand-washing, special filter (mask ONLY for TB, PT mask for leaving room (but really shouldn’t be leaving).

• Neg. Air flow disposable supplies & dedicated equipment is a good thing but not really as essential.

PPE = Personal Protective Equipment

• ALWAYS TAKE OFF IN ALPHABETICAL ORDER

• ex: gloves, goggles, gown, mask

• putting on is reverse alphabetically for the ‘g’s’ & mask comes 2nd

• ex:gown, mask, goggles, gloves