FINAL STUDY GUIDE

what is the response to VIFB & pulseless VTACH?

DEFIBRILLATE

what is atrial fibrillation at risk for?

risk for clot formation & embolism

what is the nursing priority in an acute cardiovascular event?

1. rapid assessment & monitoring

• cardiac monitor & obtain12 lead ECG within 10 mins

• assess vitals, pain, LOC

2. initiate MONA-H (as appropriate)

3. establish IV access

• large bore IV access for emergency meds & fluids

4. prepare for reperfusion therapy

• goal: reopen blocked artery ASAP

• PCI (angioplasty/stent) → preferred → performed within 90 mins of contact

• thrombolytic therapy → PCI unavailable, should be started within 30 mins of arrival

5. labs & baseline testing

• draw cardiac biomarkers (troponin, CK-MB, myoglobin)

• baseline: CBC, electrolytes, coagulation profile, kidney function (important before contrast or meds)

what are the s/sx of pulmonary edema?

• severe dyspnea

• orthopnea

• crackles/rales

• pink, frothy sputum

• tachypnea

• hypoxia (low O2)

• cough

• anxiety/restlessness

what are the early signs of pulmonary embolism?

• apprehension (anxiety), restlessness

• feeling of impending doom → body knows something is wrong

• sudden onset, unexplained dyspnea

• chest pain (pleuritic chest pain- pain on breathing)

• diaphoresis

what are the defining features of pulmonary embolism? (s/sx, vitals, breath sounds, abgs)

• acute dyspnea, SOB @ rest (cyanosis is a late sign)

• fearful, anxious, diaphoretic

• ↑ HR & RR, ↓ O2 sats & BP

• ↓ breath sounds, wheezes, crackles

• petechiae on chest/arms → fat embolism

• pleuritic/substernal chest pain (pain while breathing), non productive cough

• ABGs: early alkalosis, late ↓ PAO2 & acidosis

  • ↑ RR → ↑ O2 intake & CO2 exhalation → respiratory alkalosis

  • resp system becomes fatigued → respiratory acidosis

what is the nursing priority in a thromboembolic (pulmonary embolism) event? what position for air embolism & if not?

• keep pt in high fowler’s (for those not an air embolism)

• apply O2 & stay w/ pt

• assess & monitor hemodynamics (HR, BP, perfusion, dysrhythmias)

• summon MD STAT

• IV access & 12 lead ECG (r/o MI, unmanaged AFIB)

• STAT baseline labs (ABG, CBC, coags)

• prepare: IV heparin (bolus & drip), possible thrombolytic/fibrinolytic therapy (clot buster)

• surgical embolectomy if destabilizes (or if clot is too big)

• teach clients long term anticoagulant therapy

  • wafarin → PT/INR

  • rivaroxban, apixaban

• left lateral trendelenburg position to trap the air/clot in the right ventricle

how to prevent deep vein thrombosis (DVT)?

• early ambulation/mobility

• sequential compression devices (SCDs)

• TED hose (compression socks)

• anticoagulation (pharmacological)

• change positions & perform exercises (ankle circles, foot pumps)

• avoid crossing legs in bed or placing pillows behind the knees

how to prevent orthostatic hypotension?

• drink fluids to maintain blood volume (avoid dehydration)

• slowly assist patients from lying to sitting position to prevent syncope/fainting

• avoid standing for long periods

• improve circulation by wearing compression stockings

• implement fall precautions if at risk & also assist w/ ambulations

what is hypovolemia shock? what does it result in & s/sx? what is the nursing focus?

• hypovolemia shock is rapid blood loss → decreasing circulating volume & CO

• results in inadequate perfusion of vital organs → hypotension, tachycardia, cool clammy skin, altered ALOC

• nursing focus: rapid IV fluid/blood replacement, monitor vital signs, maintain airway & oxygenation stop bleeding

what is burn shock? what are the s/sx? what is the nursing focus?

• fluid loss & massive capillary leak shifting vascular fluid into interstitial spaces (third spacing) → severe edema, decreased circulating volume

• s/sx: tachycardia, hypotension, cool clammy skin, decreased urine output, ALOC

• nursing focus: airway & oxygen, rapid fluid resuscitation (NS or lactated ringer’s), stop bleeding, cover burn wounds, monitor urine output

what is febrile (non-hemolytic) transfusion reaction? onset? cause? s/sx?

• temperature rise of 1C during infusion

• onset: immediately to 1-2 hrs after initiation

• cause: antibodies for leukocytes or platelets that remain in blood

• s/sx: fever, chills, headache, malaise

what is acute hemolytic transfusion reaction? onset? cause? s/sx?

• most dangerous & life threatening, incompatible RBCs

• onset: usually immediate

• cause: infusion of ABO incompatible blood, donor blood is incompatible w/ recipient

• s/sx:

  • burning in vein, flank/back/chest pain

  • fever, chills, shock (incr. HR & decr. BP)

  • dyspnea, cyanosis

  • oozing blood IV site (disseminated intravascular coagulation → DIC)

    • blood clotting everywhere

what is transfusion associated circulatory overload (TACO) aka cause? what pt is it usually seen in & why? onset? s/sx?

• cause: rapid infusion of blood products → hypervolemia, circulatory fluid overload

  • rapid rate or large volume

• usually seen in heart failure pts b/c hard time pumping & incorporating new blood into the system

• onset: during or within 6-12 hours

• s/sx:

  • cough

  • pulmonary edema: dyspnea, orthopnea, crackles (rales), tachypnea

    • overall hard time breathing

  • hypoxemia (low O2 in blood)

  • peripheral edema

  • distended neck veins (JVD), bounding pulses

  • hypertension & tachycardia

what is the interventions for transfusion associated circulatory overload (TACO)

1. stop the transfusion immediately & maintain IV access

2. place pt in high fowler & feet in dependent position

3. administer oxygen

4. verify blood product match

5. consult physician for diuretic therapy (furosemide)

what is septic (bacterial) activation syndrome aka what is the cause? onset? s/sx? how is this treated?

• severe systemic inflammatory response d/t bacterial contamination of blood

• onset: 1-2 hrs after infusion (can happen after infusion is complete or several hours later)

• s/sx:

  • fever, chills hypotension (may not occur until transfusion is complete or several hours later)

• tx w/ fluids & antibiotics

how does hyperkalemia look on an ECG? what are the s/sx? what are the medications that causes this?

1. hyperkalemia

• ECG: peaked, narrow tall T waves, wide QRS complexes

• s/sx: MURDER: muscle weakness, urine output low, respiratory failure (d/t muscle failure), decrease cardiac contractility, early muscle twitches/cramps, rhythm changes

• medication impacts: ACE inhibitors (ends in opril), ARBS (sartan), spironolactone

how does hypocalcemia look on an ECG? what are the s/sx? what are the medication that causes this?

1. hypocalemia

• ECG: prolonged QT interval

• s/sx: tetany, Chvostek & Trousseau sign, seizures

• medication impacts: loop & thiazide diuretics

what are the common risk factors for proggresion to advanced kidney disease?

• diabetes mellitus, hypertension, proteinuria, autoimmune disorders, polycystic kidney disease, age

• modifiable factors: smoking, obesity, diet, medications (NSAIDs, nephrotoxic drugs, contrast dye)

what are neutropenia precautions? what is it for? when is this used (lab value)?

• for infection protection d/t decreased WBCs

• used when ANC (absolute neutrophil count) <1000 (moderate risk) or <500 (severe risk)

• precautions:

  • strict hand hygiene

  • mask on pt & visitor

  • avoid crowds

  • avoid raw foods, undercooked meats, unpasteurized foods, yogurt w/ live cultures, humidifiers, standing water, plants, flowers

what are the thrombocytopenia bleeding precautions/nursing care?

• avoid IM injections, rectal temps, or invasive procedures

• monitor for bleeding signs (gums, urine, stool, bruising)

• use soft toothbrush & electric razor

• administer platelet infusion if ordered

what is mucositis? what are they at risk for? what is the nursing care?

• chemotherapy or radiation damaging oral mucosa

• mouth sores → increased risk for infection

• nursing care

  • encourage frequent oral care w/ saline rinses

  • avoid alcohol based mouthwashes & spicy foods

  • provide topical anesthetics (lidocaine rinses) for pain relief

  • promote hydration, soft, bland diet to reduce irritation

what is brachytherapy? what is required?

• implanting radioactive material directly inside or very close to the tumor

• requires radiation safety precautions

what are the radiation implant safety precautions? what is the goal?

• goal: protect pt, staff, & visitors from unnecessary exposure using the three principles of time, distance, and shielding

1. private room & radiation precaution sign on door

• place pt in a private room w/ a private bath (NO SHARED ROOMS)

2. minimize staff exposure

• cluster care by organizing tasks to minimize exposure to radiation source

• rotate nursing assignments should be rotated to prevent cumulative exposure

• nurses should never care for more than 1 client w/ an radiation implantation at 1 time

• limit time to no more than 30 mins per shift per caregiver

• wear a dosimeter film badge to measure radiation exposure

• use lead shields or aprons when providing direct close care to pt (reduces radiation exposure)

3. staff & visitor restrictions

• only essential staff should enter room

• do not allow pregnant nurse to care for pt

• do not allow children younger than 16 yo or pregnant woman to visit pt

• visitors should be 6 ft away from source & limited to 30 mins per day

4. handing linens & equipment

• do not remove bed linens & dressings until after implant is removed (avoid disturbing radioactive source)

• after removal of implant, linens & dressings can be disposed normally

• other non-contaminated equipment can be removed from the room anytime

what if sealed radiation implant dislodges, how do we approach this?

1. Encourage pt to lie still to prevent further displacement

2. Use long handled forcepts to retrieve source (never use bare hands)

3. Deposit radioactive source in a lead container (limits radiation exposure)

4. Contact the radiation oncologist 

5. Document the occurence & actions taken

what is chemotherapy? what are the side effects of it?

• chemo- a systemic treatment that destroys rapidly dividing cancer cells, which also damages healthy cells (in the hair follicles, Gi tract, skin, mucous membranes)

• side effects: hair loss (alopecia), mucositis, nausea, vomitting, diarrhea, impaired immunity (neutropenia)

what are the systemic toxicities in chemotherapy? (briefly explain what it is & what we should monitor for)

• common: N/V, diarrhea

• pancytopenia (low all cell count) → d/t bone marrow suppression

  • low WBC (neutropenia) → incr. risk of infection

  • low RBC (anemia) → fatigue or pallor

  • low platelets (thrombocytopenia) → increased bleeding risk

• hepatoxicity

  • some causes liver damage

  • monitor liver function tests (AST, ALT, bilirubin)

  • assess for jaundice, dark urine, RUQ pain

• nephrotoxicity

  • some can damage renal tubules

  • assess for BUN/creatinine, urine output, encourage hydration before & after tx

• extravasation risk

  • vesicant fluid leaks into surrounding tissue

  • monitor for pain, redness, swelling, burning

what are the early warning signs for infection?

fever, sore throat, cough, urinary symptoms, redness, swelling, or drainage @ IV site

what is tumor lysis syndrome? what are the lab abnormalities & briefly explain what it can cause?

• when chemotherapy or radiation destroys tumor cells & they release potassium, phosphate, and nucleic acids into circulation

• hyperkalemia → can cause arrhythmia

• hyperphosphatemia → can form into calcium phosphate crystals & damage kidneys

• hyperuricemia → uric acid can cause AKI

• hypocalcemia → decreased b/c it binds to phosphorus (cramps, tetany, seizures, LOC changes)

what is the treatment for tumor lysis syndrome (think about elevated potassium, uric acid, phosphate & decreased calcium)?

1. hyperkalemia

• IV insulin & dextrose → drivers K+ back into cell

• calcium gluconate → stabilizes cardiac membranes & prevents arrhythmias

• sodium polystrene sulfonate (kayexalate) → remove K+ through GI tract

• IV fluids & loop diuretics

2. hyperuricemia

• allopurinol (prevents uric acid formation)

• rasburicase (convers existing uric acid into allantonin → more soluble to excrete)

• agressive IV hydration

3. hypocalcemia

• tx only if symptomatic → IV calcium gluconate slowly

• tx underlying hyperphosphatemia

TX FOCUSES ON HYDRATION, FIX ELECTROLYTES, AND RENAL PROTECTION

what to do if there is extravasation?

• stop infusion ASAP, discontinue IV, aspirate residual drug, administer antidote, notify provider

what are some complications in chemotherapy that requires urgent escalation?

• fever → infection risk d/t low WBCs

• signs of tumor lysis syndrome

  • electrolyte imbalances → arrhythmias, renal failure, neuro complications

• severe bleeding → d/t low platelets

• IV site damage → extravasation

what are the goals of care in progressive or advanced chronic illness? (define palliative vs hospice & primary focus in this situation)

1. palliative: symptom control (pain, SOB) + curative tx

2. hospice: focuses on comfort instead of curative tx, used when <= 6 months prognosis

3. primary focus

• shift from curative to improving quality of life (symptom control)

  • support decision making in pts, family

  • provide support (emotion, psychosocial, spiritual)

  • respect advance directives

  • honoring the pt’s wishes

what are some strategies to assess emotional or psychological distress? what about delirium (to differentiate)

1. observe for signs

• anxiety, depression, fear, restlessness, agitation, confusion

• signs of non-verbal: restlessness, grimacing, moaning

• withdrawal or decreases communication

2. assess for contributing factors

• pain or physical discomfort

• spiritual distress

• social isolation

• assess for distressing symptoms by obtaining info about the pt’s diagnosis & medical hx

3. communication strategies

• open ended questions, active listening, encourage expressions of sadness, loss, forgiveness, allow for silence (normal w/ overwhelming emotions)

4. delirium specific assessment

• delirium is acute & reversible, but common in EOL

• characterized by disorientation, confusion, fear, restlessness, hallucinations, anxiety

• identify causes (meds, infection, environment)

5. spiritual assessment (HOPE)

• sources of hope

• organized religion( what organization are you part of)

• personal beliefs

• effect on care decisions

what are the comfort focused interventions across disease states: pain, respiratory, GI, dysphagia, urinary, dehydration, skin, neurologic/delirium?

1. pain

• scheduled analgesics (do not delay)

• non-pharm: massage, relaxation techniques, guided imagery, distraction, therapeutic massage, listening to music

• assess emotion/spiritual contributes that can worsen pain

• administer meds for pain, nausea, anxiety, constipation; limiting medical testing, ensure spiritual & emotional counseling

2. respiratory

• dyspnea & secretions → EOL pts have irregular breathing patterns

• elevated HOB, side lying, cool air (fan), pursed lip breathing, meds: anticholinergics (reduce secretions), antiussives, expectorants, mucolytics for cough

3. GI

• constipation d/t immobility, opioids, dehydration, or lack of fiber

• constipated → stool softener, laxative, enemas

• diarrhea → antidiarrheals

• no appetite → give small portions of favorite food EVEN if they are on a prescribed cardiac diet

4. dysphagia

• inability to swallow or having drooling → risk of aspiration

• have speech pathologist do swallow study, provide small meals w/ assistance, alternative routes for med (not everything is PO), elevate HOB during & after meals

5. urinary

• incontinence d/t perineal muscles relax

• absorbent pads & barrier cream → prevent skin irritation OR use catheter if pt alrdy has skin breakdown

6. dehydration

• feelings of hunger & thirst decrease during EOL

• oral care → ice chips/small sips of fluid to moisturize the mouth, use moist cloths/swabs for unconscious pts, do not force client to each or drink, lip lubricant

7. skin

• skin becomes wax like, cool, mottled, cyanotics

• apply lotion to reduce dry skin, blankets to warm skin, reposition to avoid ulcers, pressure relieving support surfaces, protect bony prominences

8. neurologic/delirium

• acute, reversible, common toward EOL

• quiet well lit room, reorientation, provide reassurance in a soft calm voice, avoid physical constraints, provide emotional support to family, stay w/ client if fearful

how is interdisciplinary communication like in EOL? (who does it involve, what is everyone’s role)

• involves nurses, providers, social workers, chaplains, family, dietitians

• communicating w/ team to ensure clear & honest communication & compassionate care

• regular family conferences to prepare family for end of life process

• ensure alignment w/ advance directives & code status (DNR/DNI)

• nurses advocate for pt’s wishes & goal of care

  • works w/ team to increase pt’s comfort & families’ understanding & adaption of dying process

• support families & loves ones through difficulty decisions & stopping tx

• nursing care continues even when withdrawing & withholding medical txs

what are the chronic renal failure stages? (description & GFR)

1. stage 1

• kidney damage w/ normal or high GFR, >= 90

2. stage 2

• mild decrease in GFR

• 60-89

3. Stage 3a-3b

• moderate decrease

• 45-59/30-44

4. stage 4

• severe decrease

• 15-29

5. stage 5

• ESRD- kidneys can’t sustain life w/o dialysis or transplant

• < 15

s/sx of hypervolemia vs hypovolemia (just hypervolemia is on the exam)

1. hypervolemia

• SBP, HR, MAP, CVP increases

• bounding peripheral pulses, JVD, S3

• increase RR, crackles, frothy sputum (pulmonary edema)

• orthopnea, dyspnea on exertion or at rest

• peripheral edema, ascites

• weight gain (1kg = 1L)

• hemodilution (hematocrit, sodium, BUN decreased)

• decreased O2 saturation

2. hypovolemia

• increased HR & RR

• decreased BP

• urine output <30 mL/hr, poor skin turgor, dry mucous membranes, weight loss

• narrow pulse pressure & orthostatic BP changes (SBP decr. 20, 20 HR incr)

phlebitis at insertion site: what is it, mechanical/ chemical/ bacterial causes, which cause is the least common, recognition (s&s), prevention (what to use for hypertonic solutions & long term therapy, what type of filters, when to rotate sites), response

1. what is it

• inflammation of vein; looks like a reddened streak up the arm

2. mechanical cause

• insertion technique

• cannula size too large for vein

• prolonged catheter placement

3. chemical cause

• irritating med or solution

• improper dilution, too rapid delivery

• allergy to catheter material

4. bacterial causes (least common)

• poor aseptic technique

5. recognition (s/s)

• site redness, warm to touch, local swelling, palpable cord along vein, sluggish infusion rate

5. prevention

• use larger veins/ CVC for hypertonic solutions & long term therapy; stabilize catheter

• rotate sites Q72 hrs

• use 0.22 micron filters (air, bacteria, particulates)

6. recognition

• remove IV, stop infusion

• apply cold first 45 min then warm compress

• notify physician & document

IV infiltration: what is it, causes, recognition, prevention, response

1. what is it

• inadvertent administration of non-vesicant solution into surrounding tissues

2. causes

• vein damage during insertion

• vein damage my mechanical friction of catheter

• poorly secured catheter w/ dislodgment

• high delivery rate of IV fluid

3. recognition (compare opposite arm for assessment)

• site cool to touch, skin taut, dependent edema

• lack of blood backflow or pinkish blood return

• infusing rate slows but continues to flow

4. prevention

• assessment Q hour during therapy

• stabilize catheter, caution during turning in bed

• select IV catheter appropriate to task (incr rates → incr size)

  • using larger veins for higher flow rate

5. response

• REMOVE IV & RESTART ON OTHER EXTREMITY

• elevate per pt’s comfort

• application of cold or warmth per fluid/med

embolism (air): recognitions & prevention

• recognition:

  • SOB, tachypnea, chest pain, anxiety, changes in LOC, hypotension, reduced O2 saturation

• prevention:

  • prime IV tubing completely so no air bubbles, ensure connections are tight, use air filters if needed, monitor central lines

explain the valve disorders: stenosis, regurgitation, mitral valve prolapse

1. stenosis

• narrow valve does not open fully → obstructs blood flow → increases pressure behind the valve → hypertrophy of chamber

2. regurgitation

• valve does not close completely → blood leaks backwards → volume overload & dilation of chamber

3. prolapse (specific to mitral valve)

• valve bulges backward into left atrium during systole (does not close properly) → can lead to regurgitation

what is a murmur? explain diastolic vs systolic.

• turbulent blood flow through the valves

• diastolic

  • occurs during diastole (ventricular relaxation as ventricles fill w/ blood)

• systolic

  • occurs during systole (ventricular contraction → blood is being ejected from ventricles to pulmonary artery & aorta)

what are the systolic murmurs?

• mitral regurgitation

• mitral valve prolapse

• aortic stenosis

• pulmonic stenosis

• atrial septal defect

• ventricular spetal defect

what is mitral regurgitation? how does it sound?

• incomplete closure of mitral valve during systole

• high pitched systolic murmur (holosystolic murmur) → apex & axilla

what is mitral valve prolapse? how does it sound?

• mitral valve leaflets protrude into left atrium during systole → does not remain closed during systole → mitral regurgitation

• mid-systolic click & late systolic murmur

what is aortic stenosis? how does it sound?

• thick & narrow aortic valve opening

  • blood can’t flow from left ventricle to aorta → to the rest of the body

• loud, harsh systolic murmur (crescendo-decrescendo murmur) on R 2nd ICS radiates to carotids)

  • starts soft & gets louder & fades away

what is pulmonic stenosis? how does it sound?

• narrowing of pulmonary valve → restricts blood flow from right ventricle into pulmonary artery

• harsh, systolic murmur & ejection click

• thrill auscultated at upper left sternal border

what is the septal defects: atrial vs ventricular? how does it sound?

1. during septal defects (a hole) → blood flows from higher pressure to lower pressure (left to right) → left to right shunt

2. atrial

• abnormal opening between the right & left atria → second heart sound is split into 2 sounds instead of 1, systolic murmur

3. ventricular

• abnormal opening between right & left ventricles → loud, high pitched systolic murmur (holosytolic)

what are the diastolic murmur?

• mitral stenosis

• aortic regurgitation

what is mitral stenosis? what does it sound?

• thick & narrow opening of mitral valve

  • blood unable to flow from left atrium to left ventricle

• low pitched, rumbling, diastolic murmur on the apex

what is aortic regurgitation? how does it sound?

• incomplete closure of aortic valve during diastole

  • back flow of blood from the aorta into left ventricle

• high pitched blowing, diastolic murmur on the left sternal border

the steps to initiating & completing transfusion

1. receive blood from blood bank → initiate within 30mins of blood out of lab fridge (max hang time is 4 hours)

2. after 2 RN check

3. spike bag to NS & close NS

4. open blood product

5. initiate infusion at 50 mL/hr

6. stay with pt for 15 mins to assess for reactions, changes in vitals

7. clear life with NS

8. repeat assessments for vitals & reactions

9. document

10. dispose blood bag per policy

transfusion reactions & interventions

• transfusion reactions

  • chills, fevers, itching/rash, SOB, chest tightness

• interventions

  • immediately stop the transfusion

  • disconnect tubing from IV site→ do not flush prior to disconnecting

  • infuse NS w/ a NEW set of tubing

  • stay w/ pt & monitor vitals every 5 minutes

    • monitor breath sounds, lung sounds, skin, etc

  • administer emergency meds as prescribed → EPI for anaphylactic reactions

  • collect urine & blood specimens → to see reactions in the body

  • notify & return all transfusion material to blood bank

  • document incident, action taken, pt’s response