BKAT Test Study Guide

BKAT Study What to do first if patient has chest pain. Rest! ECG changes in an acute MI ST elevation in 2 or more contiguous leads. Ischemia d/t full thickness loss of muscle. EMERGENCY. Inferior leads II, III, aVF. RCA occlusion. Septal leads V1 & V2. Anterior leads V1 - V4. LAD lesion. Lateral leads V5, V6, I, and aVL. Circumflex lesion. Cardiac enzymes Troponins, CK-MB, and CK Changes in CK Rise: 3-6 hours Peak: 24 hours Normal: 3-4 days Changes in CK-MB Released after myocardial necrosis. Specific for myocardial damage. Rise: 3-12 hours Peak: 24 hours Normal: 2-3 days Troponin I Protein found in cardiac muscle. High sensitivity. Rise: 3-12 hours Peak: 24 hours Normal: 5-10 days Troponin T Protein found in cardiac muscle. High sensitivity. Rise: 3-12 hours Peak: 12-48 hours Normal: 5-14 days Common conditions that cause a murmur Aortic dissection, aortic regurgitation (both acute & chronic), mitral valve regurgitation (both acute & chronic), mitral valve stenosis Drugs to decrease afterload/SVR/PVR (Arterial Dilators) Nitroprusside, nitroglycerin, amrinone, alpha (Regitine) & Ca channel blockers Drugs to increased afterload/SVR/PVR (Vasopressors) Epinepherine, norepinepherine, dopamine, neosynephrine Drugs to decrease contractility/SVI Beta blockers (atenolol, metoprolol, propranolol, labetolol, esmolol) and Ca channel blockers Drugs to increase contractility/SVI Positive inotropes, dobutamine, dopamine, milrinone, and digoxin Drugs to decrease preload/CVP/PAWP Venous Dilators - Nitroglycerin, nitroprusside, amrinone, alpha & Ca channel blockers Diuretics - Furosemide, bumex, mannitol Drugs to increase preload/CVP/PAWP Volume - Colloid, crystalloids, blood, hetastarch Dysrhythmia control - antirhythmics, pacemaker, AICD Complications when using thrombolytics Allergic reaction, bleeding/hemorrhage, stroke Failure to capture Pacer delivers a stimulus at the appropriate time but no depolarization occurs. No P or QRS wave after pacer spike. Failure to fire/pace No pacer spikes seen Failure to sense Pacemaker does not detects heart's intrinsic activity or interprets noncardiac activity as intrinsic activity. Spikes in inappropriate times. Normal PR 0.12 - 0.20 Normal QRS 0.04-0.10 Normal QT Less than 0.48. Varies by age, HR, and gender. Vasopressors Epinepherine, norepinepherine, dopamine, phenylephrine/neosynephrine, vasopressin/pitressin, milrinone/Primacor, dobutamine/Dobutrex 1/8 Indication for dopamine/Intropin Acts on SNS to increased HR and BP. Indicated for hypotension, low CO, decreased renal blood flow. Use if patient is bradycardic. Doses of dopamine Low: 0.5-2 mcg/kg/min (dopaminergic) Intermediate: 2-10 mcg/kg/min (beta receptors, increases CO) High: over 10 mcg/kg/min (alpha receptors, vasoconstrict) SE of dopamine Watch volume and starting BP. Use central line. Inactivated by sodium bicarb. Can cause acidosis. SE: ectopic beats, tachycardia, tissue necrosis d/t extravasation Treatment of dopamine extravasation Phentaolmine 5-10 mg and possibly nitropaste to vasodilate Indication for norepinepherine/Levophed Indicated for diastolic hypotension (specifically decreased SVR) and septic shock. Stimulates alpha & beta receptors. Increased contractility, HR, and vasoconstriction. Doses of norepinepherine 2-12 mcg/min. Immediate onset. SE of norepinepherine Replace volume first because it can cause GI and renal hypoperfusion. Have a central line. SE: dizziness, HA, hyperglycemia, myocardial/mesenteric/renal ischemia, tissue necrosis with extravasation. Treatment of norepinepherine, epinepherinem, dobutamine, and Neosynephrine extravasation Phentaolmine 5-10 mg. Indications for epinepherine/Adrenalin Simulates alpha and beta receptors. Used post cardiac surgery for "stunned" myocardium. ACLS protocol. Bronchial relaxation at low doses, increased contractility at high doses. Dosages of epinepherine 2-20 mcg/min. Immediate onset. Irritating to heart, so only good for emergency use. SE of epinepherine SE: myocardial/mesenteric/renal ischemia, tachycardia, hyperglycemia, HA, tissues necrosis with extravasation SE of phenylephrine/Neosynephrine Pure alpha stimulator. Used during C/P bypass, anesthesia induced hypotension, vascular failure in shock. Vasoconstricts arterioles without cardiac effect. Dosages of Neosynephrine 10-100 mcg/min. Immediate onset. SE of Neosynepherine Use central line. Wean this first! SE: Reflex bradycardia, myocardial/mesenteric/renal ischemia, tissue necrosis with extravasation. Indications for vasopressin/Pitressin Antidiuretic hormone used to vasocontric. Endogenous hormone. Vasoconstricts peripheral arterioles & vasodilates coronary, pulmonary, and CNS circulation. Effective for hypotension, shock, decreases needs of other pressors, and Cardiac surgery. Dosages of vasopressin 1-10 units/hr. Long half-life. Not titrated. SE of vasopressin SE: Skin/mesenteric ischemia, bradycardia, decrease UOP & result in hyponatremia, use with caution in neurosurgery patients Indications for dobutamine/Dobutrex Beta I stimulator. Used to increase CO for systolic heart failure, cardiogenic shock, MV regurgitation, post MI, post cardiac surgery, C/P bypass for "stunned" myocardium. Dosages for dobutamine 2-15 mcg/kg/min. SE of dobutamine Less effect on HR than dopamine. Use central line. Check compatibilities. Can be used peripherally during an emergency. SE: ectopic beats, tachycardia, arrhythmias, tissue necrosis with extravasation. Indications for nitroprusside/Nipride Causes peripheral vasodilation by acting on venous and arterial smooth muscle. Decreases BP, SVR, preload, and afterload therefore increasing CO. Used for HTN, CHF, and hypertensive emergency. Dosage of nitroprusside 0.5-0.10 mcg/kg/min. Light sensitive. Start with low dose. 2/8 SE of nitroprusside Make sure there is adequate volume and the BP is above 90. May incompatibilities (can use with nitro & heparin). Can cause thiocyanate toxicity with higher doses. Monitor for metabolic acidosis. SE: hypotension, HA, nausea, and vomiting. Indications for milrinone/Primacor Positive inotrope with vasoactive activity. Increases CO and decreases SVR. Used in CHF and to increase CO. Dosage of milrinone Bolus (50 mcg/kg over 10 minutes) and then gtt (0.375-0.75 mcg/kg/min). Precipitates with lasix. Longer half-life. Not titrated. SE of milrinone Renal excretion. SE: arrythmias, decreased BP, HA, hypokalemia Indications for nitroglycerin/Nitrostat Direct relaxation of vascular smooth muscle and vasodilation. Used for HTN, angina, CHF, and MI to decrease O2 demands. Dosage of nitroglycerin 5-200 mcg/min. Start low. Immediate response. SE of nitroglycerin Use with caution for patient dependent on preload for CO (inferior wall MI or right sided MI). May see tolerance after 24 hours. SE: Hypotension, reflux tachycardia, HA, flushing, nausea. IV antidysrhythmics Atropine = bradycardia Lidocaine = VT, ventricular irritability Amiodarone = afib, VTACH, Vfib Pronestyl = VTACH, Vfib (can cause torsades) Verapamil = CA channel block, IV push Diltiazem = Ca channel blocker, afib, make sure BP good Adenosine = SLAM IT, SVT, short half-life Indications for a pacemaker Treat sudden cardiac death, EF < 35%, sustained VT, refractory HF despite optimal medical management Problems with pacemakers Failure to capture, over sensing, and under sensing Signs and symptoms of cardiac tamponade Rise in filling pressure with decreased CO & hypotension. CVP=PAOP=PAD. Sudden drop in bleeding. Narrowing pulse pressure. Tachycardia, dysrhythmias, decreased ECG voltage. Decreased UOP. Anxiety and restlessness. Low blood pressure and weakness. Chest pain radiating to neck, shoulders, or back. Trouble breathing or taking deep breaths. Rapid breathing. Discomfort that is relieved by sitting or leaning forward. Postoperative care of chest tubes Assess q15 for first few hours to monitor drainage changes. Output to average ~100 cc/hr and should gradually decrease. Average is a total of 1L output. Chest tubes are removed when total drainage is < 100 ml for 8 hours. If output > 100 ml/hr then order PT, PTT, and platelets. Purpose of Swan (PA) catheter Measure vascular capacity, blood volume, pump effectiveness, and tissue perfusion. Visual of PA catheter waveforms Normal CVP/RAP 1-8 mm Hg Normal PAWP/LVEDP (left ventricular end diastolic pressure) 4-12 mm Hg Normal PAP Systolic: 15-25 mm Hg Diastolic: 6-12 mm Hg If PAWP is low? Hypovolemia If PAWP is elevated? Hypervolemia and indicative of left ventricular failure. Normal CO 4-8 L/min Normal SVO2 60-80% O2 into lungs 3/8 Three peaks (a, c, v waves) & Two descents (x and y) Describe CVP waveform Represents atrial contraction. Correlates to PR interval. Describe "a" wave with CVP Represents closure of tricuspid valve. Correlates to QRS complex. Describe "c" wave with CVP Represents atrial filling. Correlates to TP interval. Describe "v" wave with CVP How to measure CVP 1) Phlebostatic axis (4th intercostal space & midthoracic line) 2) Print strip. Measure at end expiration. VENTILATED = valley. Regular breathing = peak. 3) Find zpoint at end of QRS. Describe x descent of CVP Atrial relaxation. Ventricular systole. Describe y descent of CVP Tricuspid valve reopening Causes of elevated CVP RV failure, tricuspid stenosis or regurg, pericardial effusion, constrictive pericarditis, superior vena cava obstruction, fluid overload, hyperdynamic circulation, high PEEP setting Done via fast flush. Optimally dampened arterial waveform Troubleshooting over damped arterial line waveforms No dicrotic notch, waveform is smooth and curved (abnormal). Check patient first. Check for blood clots, hypotension, correct leveling, insertion sight, straighten insertion site, air bubbles, pressure bag. Troubleshooting under damped arterial waveforms. Hyperdynamic. Check position, insertion site, tubing length, loose connections, air bubbles. Normal MAP 65-105 mm Hg Normal RV Systolic: 15-28 mm Hg Diastolic: 0-8 mm Hg Direct measurement of the blood pressure in the right atrium and vena cava. It reflects ventricular preload and predicts fluid responsiveness, right ventricular infarction, right heart failure and 4/8 What does CVP measure? Why is it important? cor pulmonale, tamponade, tricuspid regurgitation or stenosis, complete heart block, and constrictive pericarditis. PEEP > 10 increases CVP due to positive inspiratory pressure exerted. What does PAWP measure? Why is it important? Occurs when balloon is wedged and reflects left ventricular pressure. Directly measure pulmonary artery pressure. If there are left ventricular dysfunctions, such as with a myocardial infarct or cardiomyopathy, a low cardiac output may exist. Situations when PAWP > LVEDP Mitral stenosis, atrial myxoma, pulmonary venous obstruction (e.g. fibrosis, vasculitis), L to R shunt, COPD Situations when PAWP < LVEDP Left ventricular failure, raised intra-thoracic pressure (high PEEP), non-compliant left ventricle (e.g. hypertensive cardiomyopathy), aortic regurgitation CLABSI prevention Hand hygiene, chlorhexidine skin prep, full-barrier precautions (mask, patient head turned away), avoid femoral vein, take out catheters as soon as possible, daily assessment of catheters Normal ABGs pH: 7.35 - 7.45 PaCO2: 35 - 45 HCO3: 22 - 26 SaO2: 95 - 100 PaCO2: 80 - 100 Normal vacuum pressure for suctioning -20 mm Hg, low intermittent suctioning best, 120-140 Biphasic settings for defibrillation 150 J Goals when responding to ventilator alarm Always check patient first. Possible causes of high pressure ventilator alarms Water in vent circuit, Coughing, Kinking or biting of endotube, Secretions in the airway, Bronchospasm, Tension pneumothorax Possible causes of low pressure ventilator alarms Indicate that either the ventilator did not reach the pressure it expected or that some of the air it delivered was not exhaled back into the tubing for measurement. Look for disconnected tubing or an air leak. The most common places for leaks are around the ET tube cuff, poorly secured connections, and drainage and access ports on the tubing. Verify ET tube placement? At the lip. Needs to be verified with a CXR. ET tube problems Check cuff pressure (20-30 cm H20) - higher can cause necrosis. RT to evaluate cuff leak. Reposition to minimize skin breakdown. Change tubing every 24 hours. DO NOT exceed 120-140 when suctioning. VAP prevention HOB > 30, sedation reduction, weaning, DVT prophyalxis, oral cares, hand hygiene Complications of chest trauma to lungs Pneumothorax, PE, pleural effusion, ARDS Complications of high cervical injury/spinal cord Respiratory dysfunction: loss of function, loss of drive. Protective measures to take for a high cervical injury Protect neck/spine, C4 innervates diaphragm - worry about breathing (probable intubation) Components of neuro exam LOC, mental status, cognitive function, cranial nerves, motor, sensory, coordination, and reflexes S/S of increased ICP Early: Change in LOC, agitation, headache, and vomiting. Late: Pupillary dilation from CN III compression and loss of reflexes. Drugs to treat increased ICP Osmotic diuresis (mannitol, 3%, 23%). Sedation/analgesia. Reduce fever. Antihypertensives. Vasodilators. (Strict management of SBP.) Normal ICP 0-15 What does Babinski reflex indicate? Up going toe indicates pyramidal tract or upper motor neuron problem. 5/8 Stroke patient care Ischemic: IV thrombolytic if within 3 hours, frequent neuro checks, manage HTN, ASA, avoid hypotonic solution, manage BG, no steroids or anticonvulsants Hemorrhagic: Cause/location of bleed, keep euvolemic, avoid hyperthermia, anticonvulsants, quiet/dim room, HOB 30-45%, treat pain, avoid valsalva, prevent vasospams, HHH therapy, Mg replace, statins Describe use of Dilantin IV form causes bradycardia. Will precipitate with ANYTHING other than NaCl. Describe Diabetes Insipidus (DI) Due to ADH deficiency resulting in massive urine output, excessive thirst, and hyperosmolality Describe SIADH Excess ADH results in highly concentrated urine with minimal output, appetite loss, nausea, vomiting, irritability, confusion, seizures. Clinical presentation of DI Polyuria, polydipsia, altered normal bowel habits, signs of dehydration Treatment of DI Fluid replacement and prevention of future episodes. Hypotonic fluids, oral fluids, vasopressin or nasal spray, I&O, weight, skin assessment, electrolytes, education Lab values of SIADH Serum Na < 120, serum osmolality < 250, urine specific gravity > 1.030, low Hgb & Hct d/t hemodilution Management of SIADH Treat underlying cause, reduce fluid intake, replace Na, possible hypertonic IV fluid administration, diuretic if needed, strict I&O, education S/S of DKA Thirst or a very dry mouth, Frequent urination, High blood glucose (blood sugar) levels, High levels of ketones in the urine, Constantly feeling tired, Dry or flushed skin, Nausea, vomiting, or abdominal pain, Fruity odor on breath, A hard time paying attention, or confusion Labs of DKA Glucose > 350, hyperkalemia, hyponatremia, elevated BUN & Cr, acidosis (pH < 7.30), HCO3 < 15 Treatment of DKA Insulin bolus & gtt, IV fluids, monitor electrolytes, strict I&O, monitor neurological status S/S of hypoglycemia Neurogenic - nervousness, sweating, intense hunger, trembling, weakness, palpitations, trouble speaking Neuroglycopenic - confusion, drowsiness, change in behavior, coma, seizure, death (BG < 45) Treatment of hypoglycemia Glucose (10-15gr x 3), Glucagon (IM), D50 (IV, potential for rebound hypoglycemia) S/S of hyperglycemia Frequent urination, Increased thirst, Blurred vision, Fatigue, Headache General info on diabetes Can be type I or type II. Type I pancreas stops producing insulin. Type II insulin resistance. Treatment of diabetes type II Diet & exercise are first treatment. Drugs: 1) Sulfonylurea - stimulate beta cells to release insulin 2) Biguanides (metformin) - improve sensitivity to insulin & decrease glucose produced by the liver 3) Thiazolidinediones - Increased cell receptors, improves muscle effectiveness, decrease glucose produced in the liver 4) Alpha glucosidase - decreases ability of intestinal tract enzymes to metabolize carbs 5) Meglintinides - stimulate beta cells to release insulin 6) Insulin What drugs cause adrenal crisis? Steroids 6/8 Lab indicators of renal function BUN and Cr Describe drug adjustments to be made for patients in renal failure Decrease the dose or increase the during between doses (not cleared as well through the kidneys) Renal diet restrictions Restrict Na, K, and protein. Normal UOP 30 ml/hr Complications with acute renal failure Increased K, increased fluid, HTN CAUTI prevention Hand washing, aseptic insertion technique, frequent pericare, no dependent loops, no kinked tubing How to verify NG tube placement CXR Assess for GI bleed Coffee ground emesis or drainage Aspiration precautions HOB > 30, frequent handwashing, assess feeding tube, assess for residuals, swallow study, ETT cuff at appropriate levels GI suction Low intermittent. 120-140 mm Hg. Describe digoxin toxicity Confusion, Irregular pulse, Loss of appetite, Nausea, vomiting, diarrhea, Palpitations, Vision changes (blind spots, blurred vision, changes in how colors look, or seeing spots), Decreased consciousness, Decreased urine output, Difficulty breathing when lying down, Excessive nighttime urination Heparin reversal agent Protamine When to use Amiodarone and dosage For VT with pulse (150 mg) or pulseless Vfib (300 mg) Drug to use for asystole Epinepherine Drug for bradycardia Atropine What to do if a transfusion reaction starts? STOP the blood What to do if a patient develops hypovolemic shock? FLUIDS first (crystalloid/collliod). Keep MAP > 60 mmHg. Then support oxygenation. Vasopressors are fluid replacement is optimal. Treatment of cardiogenic shock Vasodilators & inotrops (nitro, dobutamine, milrinone) to optimize hemodynamics. Cardizem to stop afib. Remove obstruction. Surgery/stent/bypass. Treatment of septic shock Fluids (crystalloid), antibiotics, follow lactate, get blood cultures before starting abx. Keep MAP > 65 & CVP 8-12 - can use pressors, Best vasopressors for septic shock Neorepinephrine, Epinepherine, Vasopressin 1) Vasoconsriction, increased HR/SBP, increased RR, dilated coronary arteries d/t Epi & Norepi What do we see in a patient with shock (or with activation of SNS)? 2) Increased ACTH, cortisol, and blood glucose d/t adrenals 3) Na & H2O retention with decreased urinary output d/t RAAS activation What to see with lidocaine toxicity in the heart? Ventricular irritability Complications of long bone fractures Fat emboli, air emboli (PE) Chest trauma complications Pneumothorax Initial treatment for burn patients Follow ABCs - secure an airway, intubate early if there are signs of obstruction, watch for smoke inhalation, then LOTS of fluids Nursing concerns with rewarming Watch for hyperkalemia (causing arrhythmias), hypoglycemia, and hypotension (secondary to vasodilation). Go slow! Do not allow shivering. Monitor electrolytes & glucose frequently. Normal cardiac index (CI) 2.5-4.0 Normal stroke volume (SV) 60-100 Normal stroke volume index (SVI) 33-47 Normal systemic vascular resistance 800-1200 7/8 Stress Induced Hyperglycemia in Critically Ill Patients • >200 •Endogenous process resulting from inflammatory response •Exogenous sources: corticosteroids, immunosupps, sympathomimetics, D5 infusions, parenteral and enteral nutrition. •Volume depletion Critical Illness and Insulin Resistance •Insulin resistance sustained by inflammatory mediators •Endocrine exhaustion leads to relative deficiency of insulin production Novolog (Rapid Acting Insulin) Onset: 15 min Peaks: 1 hr Duration: 2-4 hrs Humulin R/Novolin R (Regular/Short Acting Insulin) Onset: 30 min Peak: 2-3 hrs Duration: 3-6 NPH (Intermediate Insulin) Onset: 2-4 hrs Peaks: 4-12 hrs Duration: 12-20 hrs Lantus/Levemir (Long-Acting Insulin) Onset: 1-2 hrs Peaks: (minimal peak) Duration: 18-26 hrs 8/8