Taylor final exam part 3

what do you do with a patient who shows to have a sinus rhythm on the ECG tracing, but no palpable pulse?

DO NOT DEFIBRILLATE

describe transcutaneous pacing

-an emergency treatment to stabilize a patient until a more permanent solution can be applied and it works by causing the heart to contract

describe CvO2

-oxygen content of mixed venous blood

-(Hb x 1.34 x SvO2) + (PvO2 x 0.003)

what is the normal for CvO2

15%

describe CcO2

-oxygen content of pulmonary capillary blood

-(Hb x 1.34) + (PAO2 x 0.003)

what is the normal for CcO2

no set normal

describe PAO2

-ideal alveolar gas equation

-(Pb - PH2O)FiO2 - (PaCO2 x 1.25)

what is the normal for PAO2

100

what increases P[A-a]O2

-oxygen diffusion disorders

-V/Q mismatching (normal 4:5 or 0.8)

-right-to-left intracardiac shunting

-age

what decreases PaO2/FiO2

ventilation-perfusion mismatching, pulmonary shunting, and diffusion defects

what is the equation for DO2

DO2 = Qt x (CaO2 x 10)

what increases DO2

-increased oxygenation saturation

-increased hemoglobin concentration

-increased cardiac output

what decreases DO2

-decreased oxygen saturation

-decreased hemoglobin concentration

-decreased cardiac output

what is the equation for C[a-v]O2

CaO2 - CvO2

what is the normal for C[a-v]O2

5 vol%

what increases C[a-v]O2

-decreased cardiac output

-exercise

-seizures

-hyperthermia

what decreases C[a-v]O2

-increased cardiac output

-skeletal relation (induced by drugs)

-peripheral shunting (sepsis)

-certain poisons (cyanide)

-hypothermia

what is the equation for VO2

VO2 = Qt [C(a-v)O2] x 10

what increases VO2

-seizures

-exercise

-hyperthermia

-increased body size

what is the equation of Qs/Qt

CcO2 - CaO2 / CcO2 - CvO2

explain why a Hb can only be 97% saturated

-some goes to hemoglobin and some goes to plasma

-certain amount that bind to plasma ALWAYS

-.03ml is always dissolved in plasma

what are some other names for Cor pulmonale

-right hypertrophy

-increased right ventricular work

-right ventricular failure

what is needed for a shunt scenario

-barometric pressure

-PaO2, SaO2

-PvO2, SvO2

-Hb concentration

-PAO2 (partial pressure of alveolar oxygen)

-FiO2

what are the calculations needed for a shunt scenario

-PAO2

-CcO2

-CaO2

-CvO2

-Qs/Qt

describe diffusion limited

anything lung or capillary membrane

describe perfusion limited

anything blood

what factors make a/A ratio most reliable

-ratio < .55

-FiO2 >30%

-PaO2 < 100

what all factors go along with head and face assessment

-examine facial expression

-nasal flaring

-pursed-lip breathing on exhalation

-cyanosis

-diaphoresis

describe examine facial expression

determine whether the patient is in acute distress or is experiencing physical pain

describe nasal flaring

external nares flare outward during inhalation

describe cyanosis

-detected around the lips and oral mucosa

-when respiratory disease results in reduced oxygenation of the arterial blood

-indication on hypoxia

describe diaphoresis

-cold and wet

-excessive sweating

-common finding in patients in acute respiratory distress, patients with infection, and those having severe pain

-common in patients experiencing a myocardial infarction

what goes along with eyes during assessment

-pupillary reflexes

-pupils should be equal, round, reactive to light, and accommodation (PERRLA)

-Ptosis (drooping eyelid)

-Nystagmus (eyeballs shake back and forth rapidly)

what factors go along with neck during assessment

-assess for JVD (most often in result of right-sided heart failure)

-assess for tracheal position

-palpate for lymphadenopathy

-contraction of the sternocleidomastoid muscle

-carotid pulses

what factors go along with breathing pattern and effort during assessment

-normal breathing (12-18)

-accessory muscles (inhalation = chest and neck/ exhalation = intercostal muscles, chest)

-approximate I:E ratio

-retractions (requiring more negative pressure)

-bulging (no chest wall movement)

-abdominal paradox (diaphragm fatigue)

-respiratory alternans (belly breathing and accessory muscle alternating)

-Hoover sign (retractions on lower lateral chest)

what factors go along with inspection for central cyanosis during assessment

-present when the patient's trunk or oral mucosa is cyanotic

-lungs are not oxygenating the blood adequately

-indication that tissue oxygenation may not be adequate

-cyanosis apparent when deoxygenated hemoglobin is present

-patients with severe anemia (Hb of 4-5g or less)

what factors go along with palpation during assessment

-evaluate vocal fremitus, estimate thoracic expansion, assess skin and subcutaneous tissues of chest

-vocal fremitus

-rhonchial fremitus

what increases vocal fremitus

-pneumonia

-lung tumor or mass

-atelectasis

what decreases vocal fremitus

-unilateral: bronchial obstruction, pneumothorax, and pleural effusion

-diffuse: COPD with hyperinflation, muscular, or obese chest wall

describe Rhonchial fremitus

-contaminated with thick secretions may produce palpable vibrations

-often identified during inhalation and exhalation may clear if patient produces an effective cough

-associated with coarse, low-pitched sound that is audible without a stethoscope

what factors go along with skin conditions during assessment

-general temperature (rule out sepsis)

-condition of the skin (dry/diaphoretic/pull back feature/ wafting)

-subcutaneous emphysema (feels like rice crispies)(fresh trach patients)

what factors go along with percussion during assessment

-assess resonance (dull percussion note/high pitch note)

-done during examination to assess resonance of the underlying tissue

-percussion over lung fields (hyperresonant = loud, low pitch booming sound)

what factors go along with auscultation during assessment

-performed with a stethoscope

-diaphragm is most often used to auscultate lung sounds

-bell is most often used to auscultate heart sounds

what factors go along with examination of the extremities

-clubbing

-cyanosis

-pedal edema

-capillary refill time (2-5sec)

-skin temperature

-skin turgor

describe tracheal breath sounds

-loud, high-pitch breath sound heard directly over the trachea with an equal inspiratory and expiratory component

describe normal (vesicular) breath sounds

-soft, low-pitched sound heard over normal lung parenchyma; have a minimal expiratory component

describe Harsh breath sound

-a louder version of the normal breath sound

-occur with decreased attenuation

describe Bronchial breath sound

-a louder version of the normal breath sound with an equal inspiratory and expiratory component

-occur with decreased attenuation

-suggest an increase in lung density as occurs with pneumonia

describe diminished breath sound

-softer version of the normal breath sound

-occur with shallow breathing or increased attenuation (density of the lungs)

-shallow breathing or hyperinflation of the lungs as with emphysema

describe absent breath sound

no sound heard

describe crackles

-discontinuous ALS heard most often on inspiration

-course vs. fine (rales)

describe wheezes

continuous ALS heard most often on exhalation

describe stridor

monophonic, high-pitched wheeze heard over the upper airway in patients with croup or epiglottis

describe pleural friction rub

creaking or grating type of sound that occurs when the inflamed pleural membranes (pleurisy) rub together

describe tachypnea

-rapid rate of breathing

-cause: loss of lung volume, arterial hypoxemia, metabolic acidosis

describe apnea

-no breathing

-cause: cardiac arrest

describe Biot

-irregular breathing with long periods of apnea

-cause: increased intracranial pressure

describe Cheynes-Stokes

-irregular type of breathing; breaths increase and decrease in depth and rate with periods of apnea

-cause: diseases of central nervous system, congestive heart failure

describe Kussmaul

-deep and fast

-cause: metabolic acidosis

describe apneustic

-prolonged inhalation

-cause: brain damage

describe paradoxical

-injured portion of chest wall area moves in the opposite direction to the rest of the chest

-cause: chest trauma

describe andominal paradox

-contraction of accessory muscles to aid inspiratory effort; diaphragm is pulled upward and abdomen sinks inward during inspiration

-cause: fatigue of the diaphragm, paralysis

describe afferent

central to peripheral

-"act of doing it" "to"

describe efferent

peripheral to central

-"from the source" "F that"

what is the brain stem responsible for?

-consists of midbrain, pons, and medulla oblongata (contains medullary respiratory centers)

-most cranial nerves originate in brain stem

what is the cerebellum responsible for?

-posterior part of the brain

-responsible for equilibrium, muscle tone, and coordination

-cerebellar lesions cause: loss of coordination (ataxia), tremors, disturbances in gait and balance (Parkinson's)

describe Glasgow coma scale (GCS)

-most widely used instrument to quantify neurologic impairment

-score given for (motor response/verbal response/eye opening/not reliable for patients with impaired verbal response)

describe Richmond agitation sedation scale (RASS)

-zero for an alert and calm patient and goes as high as +4 for a combative and violent patient

-a low of -5 for an unarousable patient

describe confusion assessment method for the ICU (CAM-ICU)

-evaluates delirium

-an acute change or fluctuation in mental status plus inattention and either disorganized thinking or an altered state of consciousness at the time of assessment

describe full consciousness

patient is alert and attentive, follows commands, response promptly to external stimulation if asleep, and once awake remains attentive

describe lethargy

patient is drowsy but partially awakens to stimulation; the patient will answer questions and follow commands but will do so slowly and inattentively

describe obtundation

patient is difficult to arouse and needs constant stimulation to follow a simple command

-although there may be verbal response with one or two words, the patient will drift back to sleep between stimuli

describe stupor

patient arouses to vigorous and continuous stimulation; typically a painful stimulus is required

-only response may be an attempt to withdraw from or remove the painful stimulus

describe coma

patient does not respond to continuous or painful stimulation

-there are no verbal sounds and no movement, except possibly by reflex

what is a decrease in Qt

decrease due to a decrease in volume of oxygenated blood being brought to the tissues (decreased circulatory blood volume)

what are the calculations for Qt and MAP

- Qt = HR x SV (normal = 60-130)

-MAP = Qt x SVR

-MAP = HR x SV x SVR

-MAP = systolic + (diastolic x 2) / 3

what causes an increase in preload

increased circulatory volume (venous return)

what causes a decrease in afterload

-decreased SVR

-decreased PVR

-increased SV

-hypotension

describe cardiac glycosides

-diuretics

-digitalis family (digoxin/digitoxin)

-increase the force of cardiac contraction

-commonly given orally at home use

what cant cardiac glycosides be used for?

Cor pulmonale

describe CHF

-left sided heart failure

-afterload = increased left ventricular

-preload = increased left ventricular

-PVR = increased

- SVR = increased

describe Cor pulmonale

-right sided heart failure

-afterload = increased right ventricular

-preload = increased right ventricular

-PVR = increased

-SVR = normal

define rate

number of ventricular contractions in 1 minute

define systemic vascular resistance

-resistance that the blood pumps against coming out of the left ventricle

-measurement of the afterload of the left heart

-affected by: radius of vessel/viscosity of the blood

define mean arterial pressure

typical measure of blood pressure as it related to perfusion

define vascular tone

radius of the vessels

define contractility

strength at which the heart contracts

explain the cliniclal indication for vasopressors

-lower BP by direct relaxation of vascular smooth muscle

-used in treatment of shock

-support BP until underlying cause of shock can be reversed

what 3 medications used for vasopressors

-Norepinephrine

-Dopamine

-Dobutamine

cardiac output and SVR directly affect what?

MAP

BP

know uses for diuretics

-increase in sodium loss

-lower vascular resistance by reducing plasma volume

-not maintained with chronic diuretic therapy

what medications are used for diuretics

-potassium sparing

-amiloride

-triamterene

-thiazide

-chlorothiazide

what causes an increase in SvO2

-increased CO

-inotropic drugs, IABP support, afterload reducing agent increases contractility

-increase SaO2

-increase Hb (polycythemia)

-blood transfusion

-decreased O2 demand

-decreased VO2

-hypothermia, paralysis, anesthesia, cytotoxicity

-ethanol toxicity, cyanide poisoning, sepsis

what causes a decrease in SvO2

-decreased CO

-heart failure, increased PEEP, arrythmias

-decreased SaO2

-hypoxia suctioning, disconnect from vent

-decreased Hb

-anemia, hemorrhage

-increased O2 demand

-increased VO2 (fever, shivering, agitation, seizures)

describe low compliance extension tubing for a fluid filled monitoring system

-fluid filled semi-rigis catheter placed in the body compartment to be monitored

-end of catheter connected to fluid-filled semi-rigid connecting tubing

-the enclosed fluid transfers the pressures from the in-situ catheter tip of the pressure transducer

describe pressure tranducer for fluid filled monitoring system

-electromechanical device that converts applied pressure into an electrical signal

-has a pressure sensitive diaphragm enclosed by a fluid-filled dome

-as the patient's pressure pulses, it is transmitted by the fluid, and strikes te diaphragm

-mechanical movement of the diaphragm is converted into an electrical signal that processed by the amplifier

describe amplifier

-take very small electrical signal generated by transducer and increase it to an amplitude that is clinically useful

-filter out unwanted signals and produce the waveform on oscilloscope

-amplifies it to 10x its original signal

describe automatic flush device and pressure bag

-when monitoring cardiovascular pressures

-bag of NS (with or without Heparin) connected to monitoring catheter via stopcocks and noncompliant extension tubing

-prevent clotting or backflow

-provides a way to flush the system

-allows for "square wave" testing

explain the importance of zeroing a fluid-filled monitoring system

-called balancing

-eliminates the effect of atmospheric and hydrostatic pressure

-gives transducer set point at 0mmHg

-

what port of a PAC can medications be infused?

proximal port