Understand When To Call A Rapid Response

When studying, ask yourself how you will prioritize care for patients with these conditions and how you might appropriately delegate. Review assessment findings including; important labs, medication management, nursing interventions, and evaluations. Cardiac Rhythms & Rapid Response • Understand when to call a Rapid Response • Hear rate <40 or >140 • Respiratory rate <8 or >28 • Alteration in mental status • Systolic blood pressure <90 or >180 mmHg • SaO2 <90% despite O2 supplementation • UOP <50 cc over 4 hours • Chest pain unrelieved by nitroglycerin • Threatened airway • Seizure • Uncontrolled pain • Know how to rapidly estimate heart rate • Count for 15 seconds multiply by 4 • Count for 10 seconds multiply by 6 • Know normal/expected heart rates depending on where impulse was generated (SA node, AV node, or Ventricles) • SA node: 60-100 bpm • AV node: 40-60 bpm • Ventricles: 20-40 bpm • Know how to identify cardiac rhythms from reading a description of the rhythm. • Be able to differentiate between, know appropriate treatment for, and know reasons the following rhythms might occur: Supra-ventricular tachycardia, Atrial Fibrillation, Atrial Flutter, Ventricular Tachycardia (and PVCs), Ventricular Fibrillation, First, Second, and Third degree heart blocks, and asystole. • Supra Ventricular Tachycardia • Originate in the bundle of His • Overexertion, emotional stress, stimulants, digitalis toxicity, CAD • Treatment • Vagal stimulation • Adenosine • Cardioversion • Radiofrequency catheter ablation • Atrial Fibrillation • No effective atrial contraction • Underlying heart disease, cardiomyopathy, CHF, Pericarditis, thyrotoxicosis, alcohol intoxication, caffeine use, electrolyte disturbance, cardiac surgery • Treatment • Coumadin • Decrease ventricular response • Digoxin, B adrenergic blocker, calcium channel blocker • Antiarrhythmics drugs • Cardioversion • Atrial Flutter • Slower ventricular response • CAD, mitral valve disorders, pulmonary embolus, chronic lung disease, cardiomyopathy • Treatment • Coumadin used >48h • Increase AV block • Electrical cardioversion • Diltiazem, digoxin, B adrenergic blockers • Radiofrequency catheter ablation • Ventricular Tachycardiac • • • • • PVC • • • Run of three or more PVCs Acute MI, significant Electrolyte imbalance, mitral valve prolapse, coronary reperfusion after thrombolytic therapy, CNS disorders Treatment • Monomorphic • Procainamide, amiodarone, lidocaine • Synchronized cardioversion • Polymorphic • Magnesium infusion, overdrive pacing, B-adrenergic blocker • Unsynchronized cardioversion • No pulse • Rapid defibrillation Originate in the ventricles, premature of QRS Simulants, hypokalemia, exercise, MI, mitral valve prolapse Treatment • B- adrenergic blockers, procainamide, amiodarone, lidocaine Ventricular fibrillation • Irregular undulation of varying contour and amplitude • Acute Mi, myocardial ischemia, chronic disease such as CAD, electrical shock, hyperkalemia, drug toxicity • Treatment • CPR and ACLs • Defibrillation • First degree heart block • Impulse conducted to ventricles, but duration of AV conduction is prolonged • No treatment • Second degree heart block • Type 1 • Gradual lengthening of PR interval occur in bundle of hi • Treatment • Symptomatic • Atropine • Asymptomatic • Rhythm closely observed • Transcutaneous pacemaker on standby • Type 2 • P wave not conducted, bundle block • Treatment • Pacemaker • Temporary drugs to increase HR • Third degree heart block • No impulses from atria are conducted to ventricles • Treatment • Temp pacemaker • • Drugs used temp to increase HR and support blood pressure Asystole • No mechanical activity • Hypovolemia, drug overdose, MI, hyper or hypokalemia, pulmonary embolus • Treatment • CPR • Intubation • Epinephrine • Correct underlying cause by Unknown Author is licensed under • You will need to choose the correct treatment/management/medications for the identified rhythm (Review ACLS and algorithms on PowerPoint slides). • Remember to identify a rhythm you need to understand and evaluate: • Is the rhythm fast or slow? • Regular or irregular? • Is there an identifiable P-wave? • Is there a P-wave before every QRS complex? • Is the QRS complex wide or narrow? • Know/Understand what the PR interval, QRS complex, and T wave indicate. • P wave: atrial contraction • QRS complex: atrial contraction • T wave: ventricular repolarization • PR interval: measures the time it takes between atrial contraction and ventricular contraction AKA SA node to AV node  Know normal/abnormals for PR interval, QRS complex & T waves and what the abnormal indicate. o Pwave: 0.06-0.12 seconds or 1.5-3 blocks o QRS complex: 0.12 second or 3 boxes o T wave: 0.16 seconds or 3 blocks o PR interval: 0.12-0.20 seconds or 3-5 blocks      Review Cardiopulmonary Resuscitation (CPR) o Push hard and fast (100/min) o Ensure full chest recoil o One cycle of CPR: 30 compressions then 2 breaths Know ACLS medications o Epinephrine  >5 mcg/min, alpha 1 and 2, Beta 1& 2 (VF/VT) o Amiodarone  Class III antiarrhythmia, A-fib, SVT, Aflutter o Vasopressin  Used in codes for pulseless VT/VF, asystole and PEA o Atropine  Anticholinergic to treat brady and heart block, asystole, PEA o Adenosine  Give FAST IVP to see the underlying rhythm when its fast rate and restores NSR by interrupting re-entry pathways in the AV node o Magnesium  Treats Torsade depoints understand when/why to use ablation, cardioversion, defibrillation, o Ablation  Arrhythmia o Cardioversion  Hemodynamically unstable ventricular or supraventricular tachyarrhythmias  Delivers countershock during QRS complex o Defibrillation  Terminates ventricular fibrillation  Performed within 15-20 sec of onset of arrhythmia when to synchronize, reperfusion therapy and necessary preparation for each of these procedures. o Synchronize  Persistent tachyarrhythmia causing: hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, acute heart failure  Consider sedation, if regular narrow complex consider adenosine o Reperfusion therapy  STEMI or high suspicion of AMI will require immediate medical intervension to open the arteries Also understand what to expect/nursing management following these procedures. o Post cardiac arrest  Optimizing vital organ perfusion  Titration of FiO2 to maintain O2 sat >94% and <100%  Transport to comprehensive post arrest system of care  Emergent coronary reperfusion for stemi or high suspicion of AMI  Temperature control  Anticipation, treatment and prevention of multiple organ dysfunction Problems with Immune Response • Understand and be able to compare and contrast the inflammatory bowel diseases of ulcerative colitis and Crohn’s disease, including  Pathophysiology  Colitis o Diffuse inflammation beginning in the rectum and spreading up the colon in continuous pattern o Occur in mucosa and submucosa  Crohn’s disease o Inflammation, skin lesions, ulcerations, narrowing of the lumen, microscopic leaks, abscesses or fistulas  Clinical manifestations  Colitis o Diarrhea, bloody o Weight loss o Abdominal pain o Fever o Fatigue  Cronhn’s disease o Diarrhea, cramping o Weight loss o Abdominal pain o Fever o Fatigue o Some rectal bleeding  Complications  Hemorrhage  Strictures  Perforation  Abscesses  Fistulas  C-diff  Colonic dilation  High risk colorectal cancer  Gallstone  Kidney stone  Liver disease  Thromboembolism  Collaborative care  Nursing management  Rest the bowel  Control inflammation  Combat infection •  Correct malnutrition  Alleviate stress  Relieve symptoms  Improve quality of life  Teaching points  Disease and management  Importance of rest and diet management  Perianal care  Drug actions and side effects  Symptoms or recurrence  When to seek medical care  Stress reduction strategies  Psychotherapy and behavioral therapy  Types of stomas, care, clinical expectations  Pertinent labs, medications  Drug therapy o Amino salicylates o Antimicrobials o Corticosteroids o Immunosuppressants o Biologic and targeted therapy o Hematinic and vitamins Understand and know HIV and AIDS including:  Ways the human immunodeficiency virus (HIV) is transmitted and the factors that affect transmission.  For HIV infection you need to Know:  Pathophysiology o Viral DNA enters cell nucleus and splices itself into genome permanently  Clinical manifestations o Acute infection  Flu like symptoms o Early chronic infection  Generally asymptomatic o Intermediate chronic  CD4 T cells drop to 200-500 cells o Late chronic or AIDs  Immune system severely compromised  Complications o Common opportunistic disease  Collaborative care  Nursing management o Keep viral load low o Maintain immune function o Improve quality of life o Prevent opportunistic disease and new infections • o Reduce disability o Prevent new infection o Mental health counselling  Teaching points o Disease process o Home management strategies o Physical therapy o Occupational therapy o Balanced nutrition is important o ART therapy side effects  Rash  Xerostomia  Liver failure  GI effects  Neuropathy  Fatigue  Hyperglycemia  Hyperlipidemia  Pertinent labs, medications o Drug therapy  Nucleoside, non-nucleoside, and nucleotide reverse transcriptase inhibitors  Inhibit ability of HIV to make a DNA copy early in replication  Protease inhibitors  Interfere with activity of enzyme protease  Fusion inhibitors  Interfere with HIV CD4 receptor site binding and entry into cells  Combination antiretroviral therapy  Know and understand diagnosis criteria for acquired immunodeficiency syndrome (AIDS)  One or more: o CD4 count below 200 cells/mcl o Development of opportunistic infection or malignancy o Wasting syndrome o Dementia  Progression o Monitored by CD4T cell counts and viral load o Abnormal blood tests common  Neutropenia, thrombocytopenia, anemia  Altered liver function test Understand and know Rheumatoid Arthritis including:  Pathophysiology  Antigen triggers formation of abnormal immunoglobulin  Antibodies develop against the abnormal IgG   Clinical manifestations  Fatigue  Anorexia  Weight loss  Generalized stiffness  Limited motion  Signs of inflammation  Collaborative care  Disease activity  Joint function  Age  Sex  Family and social roles  Response to previous treatment  Nursing management  Satisfactory pain management  Minimal loss of functional ability  Participate in therapeutic regimen  Maintain positive self image  Perform self care  Teaching points  Disease process  Home management  Drugs  Rest and activity modification  Cold and heat therapy  Exercise  Pertinent labs, medications  Diagnostic studies o CBC o ESR and CRP: active inflammation o RF (positive in 80% of adults) o Anti-CCP: antibody specific to RA o ANA: autoimmune reaction  Medications o Disease modifying antirheumatic drugs  Methotrexate, sulfasalazine, leflunomide o Biologic response modifiers  Enbrel, remicade, humira o Corticosteroids o NSAIDS and salicylates Understand and know Leukemia including:  Pathophysiology  Cancer of the white blood cells causing them to become non functional  Clinical manifestations  Bone pain   Joint swelling  Enlarged liver and spleen  Weight loss  Fever  Poor wound healing  Signs of anemia  Signs of bleeding  Lymphomas present with enlarged lymph nodes  Collaborative care  Bone marrow biopsy  Lymph node biopsy  Bone marrow transplant  Nursing management  High risk for infection (neutropenic precaution)  Promote adequate sleep  Asses pt energy level  Teaching points  Diligence in disease management  Need for follow up care  When to seek medical attention  Pertinent labs, medications & chemo management  Labs o WBC count  20,000- 100,000/ mm2 prior to treatment  H&H PLTs also decreased  Bleeding times increased  Chemo management o Chemotherapy to eradicate disease marrow o Neutropenic precaution Understand and know Systemic Lupus Erythematosus including:  Pathophysiology  Abnormal immune response  Clinical manifestations  Fever  Weight loss  Joint pain  Excessive fatigue precede worsening disease activity  Dermatologic problems  Musculoskeletal problems  Cardiopulmonary  Hematologic problems  Renal problems  Nervous system problems  Collaborative care  Nursing management  No live vaccines if treated with corticosteroids or cytotoxic drugs  High risk for infection    Pain management  Positive self image Teaching points  Explain nature of disease, treatment, and diagnostic procedures  Drug therapy  Emphasize importance of patient involvement for successful home management  Reduce exposure to precipitating factors  Psychosocial issues  Able to have child with remediated lupus not during active lupus Pertinent labs, medications & chemo management  Labs o Antibodies: ANA present o CBC o Serum complement o Urinalysis o X rays o ECG  Drug therapy o Mild joint pain  NSAIDS o Fatigue, skin and joint problems; reduce flares  Antimalarial drugs o Severe cutaneous SLE  Corticosteroids o Suppress immune system and decrease end organ damage  Immunosuppressive drugs o Serious skin condition  Topical immunomodulators Problems of Ingestion, Digestion, Absorption, Elimination • Understand and know diverticulitis, cirrhosis of the liver and Hepatitis o Diverticulitis  Etiology  Common in left colon  Developed at weak points such as blood vessels  Pathophysiology  Saccular dilation of outpouching of the mucosa in the colon  Clinical manifestations  Abdominal pain, changes in bowel habits, bleeding  Complications  Perforation  Fistula  Abscess  Bleeding  Collaborative care  Surgeon  GI nurses  Nursing management  Let the bowel rest by: o Clear liquids, bed rest, analgesia  If severe symptoms: o NPO, NGT, bed rest, IV fluid and antibiotics  Teaching points  Explain condition and prescribed regimen  High fiber diet  Fluids: at least 2 L a day  Avoid increased intraabdominal pressure  Prevention  High fiber diet  Decreased fat and red meat  Physical activity  Pertinent labs, medications  Occult blood  CBC  Urinalysis  Blood cultures  Paracentesis care, prep  Hepatic Encephalopathy  Esophageal varices  Liver transplant care, rejection, infections, teaching o Cirrhosis of liver  Etiology  Pathophysiology  Clinical manifestations  Complications  Collaborative care  Nursing management  Teaching points  Prevention  Pertinent labs, medications  Paracentesis care, prep  Hepatic Encephalopathy  Esophageal varices  Liver transplant care, rejection, infections, teaching o Hepatitis  Etiology  Pathophysiology  Clinical manifestations  Complications  Collaborative care  Nursing management        Teaching points Prevention Pertinent labs, medications Paracentesis care, prep Hepatic Encephalopathy Esophageal varices Liver transplant care, rejection, infections, teaching