Critical Care Medications and Nursing Management

Mannitol

a diuretic used to decrease ICP

Beta blockers

primarily used to decrease HR but also decreases BP (decrease afterload)

Atropine

used for symptomatic bradycardia to increase the HR

Amiodarone

an antiarrhythmic used for afib, ventricular arrhythmias

Epinephrine

vasoconstrictor used to increase BP

Norepinephrine

vasopressor used to treat hypotension, usually in septic shock

Nitroprusside

vasodilator used to treat hypertensive emergency to rapidly decrease bp (decrease afterload)

Clonidine

decrease bp/hr (decrease afterload)

CUS

Concerned, Uncomfortable, Safety concern 'I am concerned about this in pt A, I am uncomfortable, and this could be a safety issue.'

Feedback

Info provided to improve individual/overall team performance

Task assistance

team members foster a climate where assistance will be actively sought/offered

Asystole

s/sx: pulseless, pt is dead; Nursing care: run CPR/ACLS. This is not a shockable rhythm.

Vtach

s/sx: chest pain, SOB, palpitations, dizziness; WITH pulse: cardiovert; WITHOUT pulse: defibrillate

1st Degree Heart Block

PR interval is longer than 0.20 seconds. Monitor- usually no tx

2nd Degree Type 1 Heart Block

PR interval gets progressively longer until a QRS is dropped (p wave is not followed by qrs). Tx: treat underlying, pace, monitor

2nd Degree Type 2 Heart Block

Some p waves are not followed by QRS. More serious than type 1. Tx: O2, pace

3rd Degree Heart Block

P waves/QRS or atria/ventricles are independently operating. P waves will be 6-10, QRS will be 2-4/wide and wacky. This is life threatening and needs CPR/ACLS and pacing

AICD

electronic device placed in chest to monitor for irregular rhythms and shock accordingly

Pacemaker failures

Sense: spike is present but heart still does whatever; Capture: no QRS at all (spike is present); Fire: no spikes at all (ekg looks like underlying rhythm)

Cardiac Tamponade

s/sx: Beck's triad: hypotension, JVD, muffled heart sounds; Tachycardia; SOB; Chest pain

Preload

Volume in the heart at the end of diastole (filling); WAYS TO MEASURE: Central Venous Pressure (CVP) 2-8: measures RIGHT side; IF CVP IS HIGH: FLUID OVERLOAD- jvd, edema; IF CVP IS LOW: FLUID DEFICIT; Wedge: 4-15: Measures LEFT VENTRICLE preload; IF WEDGE IS HIGH: FLUID OVERLOAD- crackles, DOE; IF WEDGE IS LOW: FLUID DEFICIT; Treatment to decrease preload: use diuretics

Afterload

Resistance the heart must face in order to pump blood out to the body; SVR(left side) and PVR(right side) measures; HIGH SVR: too much resistance, give vasodilators like nitro/nitroprusside, -pril. Sx seen: bounding pulses/htn; LOW SVR: too dilated. Use vasopressors. Sx: may be shock- dec LOC

Contractility

'Squeeze': strength of contraction from heart; INC contractility: harder squeeze, blood gets further- bounding pulse; DEC contractility: soft squeeze, blood does not get far- thready pulse

Hypertensive EMERGENCY

>180/120; Organ damage!!!!!

Hypertensive URGENCY

>180/120

Stroke

No organ damage present

Asymptomatic

May be asymptomatic

CM

Severe headache, chest pain, N/V

Tx for Stroke

ICU stay- IV antihypertensive- nitroprusside, nitro, nicardipine

Follow-up Treatment

Outpatient, oral antihypertensives (clonidine)

Abdominal Aneurysm

Dilation of the vessel

Abdominal Aneurysm Symptoms

Often asymptomatic, abdominal pulsation

Abdominal Dissection

Burst of vessel

Classic signs of AAA

Sudden pain in abdomen, syncope, hypotension

Abdominal Dissection Treatment

Life threatening unless there is emergent repair

cardiogenic Shock

Heart suddenly cannot pump enough blood to meet the body's needs. Most commonly caused by severe MI

Shock Diagnosis

SBP of <90 for longer than 30 min, Inc wedge of >15, Decreased Cardiac Index <2.2

Shock Confirmation

Confirm w EKG, echo, cardiac enzymes, CXR (cardiomegaly)

Shock Treatment

Drug therapy: Inotropes (dobutamine, digoxin), vasopressors (norepi), vasodilators (nitroprusside/nitroglycerin)

Invasive Monitoring Equipment

Intra-aortic balloon pump + Impella Vascular Assist Device

Shock Procedures

PCI, CABG

Sepsis Risk Factors

SIRS, infection, trauma, major surgery, acute pancreatitis, burns

Sepsis Symptoms

SIRS criteria consists of low bp, fast hr/rr, and abnormal wbc. May also present w fever/chills, sweating, altered mental status

Sepsis Treatment

FLUID RESUSCITATION using NS or LR at least 30 ml/kg

Sepsis Antibiotics Administration

Adm abx asap after identifying possible sepsis. Ideally within 1 hr

Hypovolemic Shock Symptoms

Increased hr, decreased bp dizziness, oliguria, pallor, weak pulses

Hypovolemic Shock Treatment

Stop the loss and replace volume

Neurogenic Shock Symptoms

Decreased hr/bp, hypothermia, oliguria, decreased loc, all pressures decreased

Neurogenic Shock Treatment

Treat cause, maintain c-spine, restore vascular volume using vasopressors/fluids, optimize o2 delivery

Oxygenation Curve

High CADET: face RIGHT (right releases, meaning hgb lets go of o2 easily)

Normal Hypoxemia

80-100

Mild Hypoxemia

60-75

Moderate Hypoxemia

45-59

Severe Hypoxemia

<45

Intubation Criteria

Hypercapnia/hypoxia, failure to protect airway

Nursing Care for Intubated Patients

Aseptic practices, HOB at least 30 degrees, oral care frequently, turn pt frequently to prevent pressure sores/dvt

Tension Pneumothorax Symptoms

Increased pleural pressure, lung sounds absent on affected side, chest pain, air hunger

Tension Pneumothorax Treatment

Doctor decompresses trapped air then places a chest tube

Open Chest Injury

Penetrating chest wall injury that sucks air in/out.

Flail Chest

Two rib fractures in two or more places.

Acute Respiratory Distress Syndrome (ARDS)

Life threatening with severe inflammation and fluid buildup in alveoli.

ARDS Symptoms

Dyspnea, restlessness, cyanosis, accessory muscle use, increasing hypoxemia (O2 does not work - refractory).

P/F Ratio

A ratio of <250 indicates severe hypoxemia in ARDS.

Pulmonary Artery Wedge Pressure

A value of <17 indicates complications in ARDS.

Chest X-Ray in ARDS

Shows ground glass appearance.

Shunt Calculations

PaO2 (given) / FiO2.

Normal Shunt Value

Normal is 350-450.

FiO2 Calculation

Every 1 L is 3% added to 21% (room air).

Neuro Trauma Mechanisms

Acceleration, deceleration, and coup-contrecoup injuries.

Focal Brain Injury

Localized to one area.

Diffuse Brain Injury

Affects many areas of the brain, causing widespread damage.

Basil Skull Fracture Symptoms

Battle sign, raccoon eyes, rhinorrhea/otorrhea (CSF leakage).

General Skull Fracture Symptoms

Decreased LOC, deformity of skull, unequal pupils, abnormal posturing.

Diffuse Axonal Injury Symptoms

Severe headache, decreased LOC, meningeal signs: nuchal rigidity, photophobia.

Increased ICP Treatment

Mannitol (diuretic), increase HOB, cluster care.

Cushing's Triad

Hypertension, bradycardia, irregular respirations (Cheyne-Stokes).

Spinal Cord Injury Symptoms

Loss of movement/sensation lower than point of injury.

Autonomic Dysreflexia

Occurs in patients above T6, causing extreme headache and hypertension.

Abdominal Compartment Syndrome

Occurs when intra-abdominal pressure rises to a level that impairs organ functioning.

Hepatic Failure Symptoms

INR >1.5, encephalopathy with no history of cirrhosis <26 weeks.

GI Bleed Symptoms

Occult blood, hematemesis, hematochezia, melena, anemia, decreased BP/increased HR.

Acute Pancreatitis Symptoms

Severe abdominal pain, Cullen's sign, Grey Turner's sign, SIRS, nausea/vomiting, decreased LOC.

Appendicitis Symptoms

Fever, rebound tenderness, Rovsing's sign (palpate LLQ, pain in RLQ).

Palliative Care

An interdisciplinary approach to relieve suffering/improve quality of life.

DNR

Do not resuscitate; treat but do not continue if heart stops.

Death Definition

Total irreversible failure of cardiorespiratory system/irreversible loss of all brain function.