Medsurg Exam 1

Antidysrhythmic Medication

used for prevention and treatment of a cardiac dysrhythmia

Automaticity

ability of the heart to generate an electrical impulse

Bradydysrhythmia

dysrhythmia of <60bpm

Chronotropic

rate of impulse formation

Conductivity

ability of cardiac tissue to transmit electrical impulses

Dysrhythmia

abnormality in formation or conduction (or both) of electrical impulse in the heart affecting heart rate and/or rhythm

Ectopic

when an electrical impulse arises from an abnormal focus, anywhere other than the SA node

Excitability

ability of a cardiac muscle cell to respond to an electrical stimulus

Paroxysmal Superventricular Tachycardia

episodic burst of a rapid HR that originates in part of the heart above the ventricles

Sinus Rhythm

electrical activity of the heart initated by the SA node

Tachydysrhythmia

dysrhythmia > 100

SA Node Rate of Impulse

60-100 bpm

AV Node Rate of Impulse

40-60 bom

Ventricle Rate of Impulse

20-40 bpm

P Wave

atrial depolarization (contraction)

PR interval

AV conduction time

QRS complex

ventricular depolarization (contraction)

ST segment

follows ventricular depolarization and occurs prior to the start of ventricular repolarization

T Wave

ventricular repolarization (resting state)

QT Interval

the time for ventricular repolarization to complete

MAP Calculation

(diastolic x 2 ) + systolic / 3

Bradycardia Clinical Presentation

• lightheadedness or dizziness

• easily fatigured

• syncope/near syncome

• dyspnea

• chest pain

• discomfort

• confusion

• SOB

• mental changes

Sinus Bradycardia Lab Concerns

• electrolytes

• thyroid panel

• troponin

• blood/urine

Sinus Bradycardia - Nurses Role

• fall precautions

• identify cause

• monitor VS

• monitor ECG

• saline lock

• prepare for pacemaker

Sinus Bradycardia Treatment

• IV atropine 1 mg every 3-5 mins, no more than 3mg total

• monitor HR

• temp pacemaker if still unstable/symptomatic

Tachycardia Risk Factors

• family history

• HTN

• blood electrolyte imbalance

• hyperthyroidism

• history of heart disease

• obesity

• uncontrolled diabetes

• old age

• excessive alcohol or caffeine consumption

Tachycardia Triggers

• stress and anxiety

• electrolyte imbalances

• meds/side effects

• caffine/stimulants

• dehydration

• alcohol consumption

• high fever

• illness

• intense physical acrtivity

Tachycardia Clinical Presentation

• fatigue

• SOB

• sustained rapid heartbeat

• chest pain

• pressure

• tightness

• fluttering sensation

Tachycardia - Nurses Role:

• fall precautions

• client education

• decrease intensity of activity

• assess vitals

• teach vasovagal maneuvers

• ECG

• hemodynamic instability

Tachycardia Treatment

• identify underlying cause

• betablockers (metoprolol) (-lol)

• catheter ablation

Catheter Ablation

performed to destroy the abnormally excited cardiac cells responsible for increased HR

MAP range

70-100

A-Fib Risk Factors

• old age

• HN

• heart disease

• rheumatic heart disease

• pericarditis

• hyperthyroidism

• obesity

• diabetes

• metabolic disease

• lung or kidney disease

• sleep apnea

• family history

A-Fib Clinical Presentation

• fatigue

• SOB

• chest pain

• lightheadedness

• dizziness

• palpitations

Echocardiogram

measures the size of the atria and ventricles

Transesophogeal Echocardiogram (TEE)

deects the development of blood clots in the left atrium

A-Fib Blood Tests

• TSH

• Thyroxine

• CBC

• Creatinine

• Glucose

• INR

A-Fib Testing

• echo

• TEE

• blood tests

A-Fib ECG Appearance

• irregular rhythm

• p waves —> atrial activities between QRS complexes

• ventricular rate can be normal (60 to 100) or increased (100 to 200)

• rapid HR greater than 100/min is referred to as rapid ventricular response

A-Fib - Nurses Role

• bleeding precautions

• fall precautions

• avoid herbal supplements and stimulants

A-fib Treatments

• electrocardioversion

• catheter ablation

• anticoagulants

• diet modification

Cardioversion

• used for patients with a pulse and unstable tachydysrhythmias

• resets the hearts electrical activity in an organized rhythm

• used for a fib, a flutter, SVT and wide complex tachycardia

• syncronized timing

• sedation

Defibrilation

• used for patients without a pulse in shockable rhythms

• stops chaotic electrical activity in a disorganized rhythm

• used for v-fib and pVT

• timing not relevant

• no sedation

Atrial Flutter Risk Factors

• HTN

• previous cardiac surgery

• thyroid disorders

• valve issues

• advanced age

• chronic lung disease

• diabetes

Atrial Flutter Clinical Presentation

• lightheadedness

• palpations

• SOB

• hypotension

• dizziness

Atrial Flutter Treatment

• anticoagulant

• digoxin

• rate control

• cardioversion

SVT Clinical Presentation

• sudden symptoms

• dizziness

• lightheadedness

• syncope

• hypotension

• SOB

• palpitations

• increased risk of falls

SVT Treatment

• vagal manuevers

• IV adenosine 6mg IV over 1 to 3 seconds, then flush with 20mL NS

• Repeat with 12mg followed by 20ml NS

• have defibrilator on hand

• IV diltiazem

• IV esmolol

• IV metoprolol

• adenosine, betablockers, CCBs, dive, electrical cardioversion

Shock

Inadequate tissue perfusion

• decreased O2 delivery

• removal of metabolites

• failure of circulatory system to maintain adequate perfusion of vital organs resulting in cellular edema, hydrolysis of cellular membranes and cellular death

• causing metabolic lactic acidosis

Tissue Perfusion Determinants

Cardiac Output (CO) = HR x SV

Stroke Volume

function of preload, afterload and contractility

Shock: Renin-Angiotensin Axis

• water and sodium conservation and vasoconstriction

• increase in blood vol and blood pressure

• SNS releases: norepinephrine, epinephrine, dopamine and cortisol

Pre-Shock Stage

MAP: 65ish

HR: 100+ bpm

RR: 20+ bpm

Skin: cold and clammy

Urine Output: mildly decreased

Mentation: confusion

Acid-Base Balance: respiratory alkalosis

Shock Stage

BP: systolic <80-90mmHg

HR: 100-150 bpm

RR: rapid, shallow respirations, crackles

Skin: mottled, petechaie

Urine Output: severely decreased

Mentation: lethargic

Acid-Base Balance: metabolic acidosis

End Organ Dysfunction

BP: requires mechanical or pharmacologic support

HR: erratic or asystole

RR: requires ventilation

Skin: jaundice

Urinary Output: anuric, requires dialysis

Mentation: unresponsive

Acid-Base Balance: profound acidosis

Distributive Shock

decreased SVR and perfusion (abnormal vasodilation, leaky capillaries, etc) (pipes)

Hypovolemic Shock

loss of 25-30% circulating volume (not enough fluid) (tank)

Cardiogenic Shock

systemic hypoperfusion as a result of decreased cardiac output (heart not pumping well) (pump)

Obstructive Shock

blockage of blood flow, disrupting circulation to major arteries (block)

Septic Shock

occurs as a result of the release of inflammatory cytokines which damage the internal layers of blood vessels and initiate clotting mechanisms

3 Types of Distributive Shock

• septic

• anaphylactic

• neurogenic

Anaphylactic Shock

occurs in response to severe hypersensitivity to an allergen, mediated by IgE increasing vascular permeability, vasodilation and decreasing SVR

Neurogenic Shock

occurs due to autonomic dysregulation caused by a spinal cord injury above the level of T6

Sepsis

massive infection - a group of symptoms in response to an infection that can include organ dysfunction relatd to the infection
steps: sirs, sepsis, severe sepsis, septic shock

Early S/Sx of Septic Shock

• tachycardia

• bounding pulses

• blood pressure may be normal

• warm/flushed skin

• febrile

• confused

• decreased urine output

Late S/Sx of Septic Shock

• tachycardia

• weak, thready pulses

• hypotension

• cool, pale skin

• hypothermia

• lethargy or come

• anuria

• bleeding

Treatments in Sepsis Bundle

• fluid resuscitation

• vasopressors (if fluid resuscitation did not achieve MAP of 65) - norepinephrine first line

• bloodwork - serum lactate and two sets of blood cultures (CBC, BMP, LFT, ABG)

• antibiotics - antibiotics administered within 1 hour of sepsis (cultures before antibiotics)

Sepsis Assessments

• neuro status

• VS

• hypodynamic monitoring (CO)

• respiratory monitoring: lung sounds, effort, rate, SAT

• urinary output

• skin color and temp

• cap refill

• signs of bleeding

Sepsis Actions

• asepsis

• mouth care q4 hrs

• O2 as ordered

• fluid replacement as ordered

• monitor lactic acid (higher = worse)

• 2 blood cultures (different sites)

• ABX after cultures are drawn

• vasodrips as ordered (norepinephrine)

• supportive care (nutrition, turning, etc)

Sepsis/Shock Complications

• stress ulcers

• disseminated intravascular coagulopathy

• multiple organ dysfunction syndrome

Stress Ulcers

• proton pump inhibitors - pantoprazole

• H2 blockers - famotadine

• mucosal protectants - sucralfate

Disseminated Intravascular Coagulopathy

2 phases: clotting or thrombosis —> bleeding

Multiple Organ Dysfunction Syndrome (MODS)

result of excessive inflammation

• poor perfusion —> impaired cell functions, metabolic acidosis and organ failure

• compromised lungs —> ARDS

• renal system, hepatic system, GI system shutdown

Anaphylaxis

low cardiac output and SVR

• severe allergic reaction

• occurs after sensitization

• affects multiple body systems

  • massive vasodilation

    • histamine release / blood vessel permeability / hypotension

    • flushing / rash / edema / urticaria

    • nausea / vomiting / diarhea

    • dizziness / confusion / headache / fainting

• shock —> CV and respiratory failure

Anaphylaxis Triggers

• insect stings

• food

• meds

• substances

• exercise

Risk Factors for Anaphylaxis

• asthma

• chronic lung disease

• medications

  • beta blockers

  • alpha adrenergic blockers

• mastocytosis

Anaphylaxis Initial Presentation

• rash/urticaria

• shortness of breath / wheezing

• stomach pain / nausea

• facial swelling

• fainting

Anaphylactic Shock if Untreated

• hypotension

• hypoxia

Anaphylaxis Medical management

• remove trigger

• IM epi - 2-3x if needed

• IV epi if IM is inneffective

• 100% nonrebreather or intubation

• IV fluid - circulatory support

• antihistamines, corticosteroids, inhaled bronchodilators

Anaphylaxis Assessments

• VS

• hemodynamic monitoring

• respiratory lung sounds, effort, rate, SAT

• skin

• peripheral perfusion

Neurogenic Shock

• decreased CO with decreased venous + arterial vasodilation

• phenomenon that occurs after spinal cord injury to T6 or higher

• vascular tone is significantly decreased - can’t vasoconstrict - relaxed/dilated vessels

• pooling of blood —> decreased return to the heart + decreased CO

• unable to compensate via tachycardia —> severe brady

Neurogenic Shock S/Sx

• warm, dry skin

• flushing

• hypotension

• bradycardia

Medical Management of Neurogenic Shock

• CV support

• fluid resuscitation

• vasoactive IV

• bradycardia

• pacing

• intubation

• mechanical ventilation

• VTE prophylaxis

• SCDs

• heparin

Neurogenic Shock Assessment

• VS

• hemodynamic monitoring (CO)

• repiratory

Hypovolemic Shock

intravascular volume is decreased by 25-35% resulting in poor CO

Hemorrhagic Shock

caused by insufficient perfusion of blood and oxygen to the body tissues resulting in an imbalance of oxygen supply and demand

Causes of Hypovolemic + Hemorrhagic Shock

blood loss

• trauma

• internal bleeding

• aneursyms

fluid loss

• vomiting

• diarrhea

• excessive urination

• burns

third spacing

Hypovolemic Shock Compensatory S/Sx

• normal B/P

• tachy

• restless

• confused

• decreased urine

• cold, clammy skin

• weak pulse

• slow cap refill

• hyperventilation

• hypoactive bowels

Hypoivolemic Shock Progressive S/Sx

• lethargy

• hypotension

• anuria

• cold, cyanotic skin

• weak or absent pulse

• dysrhythmias

Hypovolemic Shock Refractory S/Sx

• coma

• severe hypotension

• ischemic/necrotic cold extremities

• renal/hepatic failure

Hypovolemic Shock Medical Management

• assessment + stabilization of airway

• rapid fluid resuscitation

  • nonhem: warm crystaloids (NS or LR)

  • hem: packed RBC or FFP or platelets

• prep for intubation

• 100% nonrebreather

• insert large-bore IV

Hypovolemic Shock Assessments

• neuro

• VS

• hemodynamic monitoring

• respiratory lung sounds, effort, rate, SAT

• urine output

• skin color/temp