Final - Cumulative

  1. On a cardiac rhythm strip, what does the "P wave" represent?
  2. On a cardiac rhythm strip, what does the "QRS" represent?
    VENTRICULAR depolarization
  3. On a cardiac rhythm strip, what does the "T wave" represent?
    Ventricular REPOLARIZATION
  4. Steps to rhythm analysis?
    • Step 1: Determine regularity
    • Step 2: Calculate rate 
    • Step 3: Assess the P waves
    • Step 4: Determine PR interval
    • Step 5: Determine QRS duration
    • Step 6: Determine QT interval
  5. What does this represent?
    Image Upload 1
    sinus bradycardia
  6. What does this represent?
    Image Upload 2
    Sinus Tachycardia
  7. What does this represent?
    Image Upload 3
    Atrial Flutter
  8. What does this represent?
    Image Upload 4
    Ventricular tachycardia
  9. What is done for a patient in V-Tach?
    Check for a pulse

    If no pulse = CPR

    If pulse = Amiodarone --> Cardioversion
  10. What does this represent? 
    Image Upload 5
    Ventricular fibrillation (course v-fib)
  11. What is done for a patient in V-Fib?
    • Start CPR
    • Call Code
    • Defibrillation
  12. What does this represent? 
    Image Upload 6
    Atrial fibrillation

    **R-R is grossly irregular
  13. In atrial fibrillation or flutter, what happens to cardiac output?
    CO goes DOWN, can lose approx 30%
  14. What does this represent? 
    Image Upload 7
    Supraventricular tachycardia
  15. What is done for a patient in Supraventricular tachycardia (SVT)?
    Tell the pt to vagal (bear down, breath through a straw)

  16. What is done for a patient in Asystole?
    • Check the patient
    • Start CPR
    • Epinephrine

    • *not a shockable rhythm
    • ** confirm asystole on 2 leads
  17. What is the normal Cardiac Output
  18. What is the normal CVP/RAP (right arterial pressure)?
    2-6 mmHg
  19. What is the normal PCWP/PAWP (pulmonary capillary wedge pressure)?
    6-12 mmHg
  20. What is the normal SVR (systemic vascular resistance)?
    900-1400 dyne/s/cm-5
  21. What is the normal mean arterial pressure (MAP)?
    65-100 mmHg
  22. The amount of stretch on myocardial muscle fibers at end diastole? also the volume coming into the heart...
  23. What hemodynamic parameters measure the preload?
    • CVP/RAP
    • PCWP
  24. What is the ultimate goal of hemodynamics?
    make the Cardiac Output (CO) happy
  25. Name the positive Inotropes?
    • dobuatmine
    • milrinone

  26. The pressure against which the heart must work to eject blood during systole?
  27. Used to determine volume status and right ventricular function, reflects the right hearts preload?
    CVP / RAP
  28. Used to determine state of resistance in pulmonary vasculature and right ventricular function?
  29. What are the normal parameters of PAP?
    • Systolic: 15-25 mm Hg
    • Diastolic: 8-15 mm Hg
  30. Used to determine left ventricular function; reflects left hearts preload?
    PCWP (pulmonary artery wedge pressure)
  31. Describes the state of systemic vasculature; reflects the left heart's afterload
    systemic vascular resistance (SVR)
  32. If the NIBP is <90/60 what do we treat first?
    • + inotrope (dobutamine, milirinone)
    • then treat preload
    • then treat afterload
  33. If the NIBP is >90/60 what do we do first?
    treat preload and see if it positively affects afterload
  34. If preload is high what do we do?
    too much volume - stop fluids infusing then give diurectics
  35. If preload is low what do we do?
    tank is low - give fluids
  36. If afterload is high what do we do, once preload is treated?
    Give vasodilator - nitro/nipride
  37. With hemodynamics what are 4 items to initially pay attention to to treat quickly?
    • BP
    • CVP/RAP
    • PCWP
    • SVR
  38. What is the catheter used to monitor hemodynamics?
    Pulmonary artery catheter (Swan-Ganz)
  39. The amount of blood pumped by the left ventricle of the heart per minute?
    stroke volume
  40. Amount of blood ejected by the heart per minute; a product of SV x HR
    Cardiac Output (CO)
  41. Sum of all forces against which the ventricle muscle must contract to eject blood into the pulmonary and systemic circulation?
    systemic vascular resistance (SVR) - measures afterload
  42. If NIBP >90/60 and we treated preload and afterload remains elevated then do what?
    add afterload reducer (NTG)
  43. Direct arterial pressure via catheter reflects two things, what are they?
    • aortic compliance
    • cardiac function
  44. What two factors determine the Mean Arterial Pressure (MAP)?
    • cardiac output
    • peripheral resistance
  45. What is the nurses role when pulmonary artery catheter is placed?
    • make sure xray is done to ensure placement and no pneumothorax
    • dress it
    • connect it - no infusion until verified placement
  46. What are the risk factors for stroke?
    • Age
    • HTN
    • DM
    • Hyperlipidemia
    • FHX
    • Cocaine/meth
    • smoking
  47. Name the 5 warning signs of cerebral infarction (stroke)?
    • Sudden onset of weakness/numbness on one side
    • Sudden speech difficulty or confusion
    • Sudden visual difficulty (one or both eyes)
    • Sudden onset of dizziness, trouble walking or loss of balance
    • Sudden, severe headache with no known cause
  48. What does the acronym FAST mean - pertaining to stroke?
    • FACE - Smile
    • ARMS - Drift
    • SPEECH - Slurred
    • TIME – last known normal is crucial – time cutoff is 6 hours
  49. What is a contusion?
    bruise to the brain
  50. What does Coup/contre-coup mean?
    Contusions that occur at two sites in the brain
  51. A bleed in the brain between the skull and dura is what? It's the middle meningeal ARTERY. Causes rapid change in LOC
    Epidural Hematoma
  52. A bleed in the brain that is a result of VENOUS bleeding. Has a high mortality rate because it's not recognized until it's too late
    Subdural hematoma
  53. This type of bleed is deep within the brain and very difficult to remove.
    Intracerebral hemorrhage
  54. This is a very important structure of the brain that senses pressure in the brain?
    Circle of Willis
  55. Name the two major arteries in the brain that are extremely important for blood flow
    • Vertebral carotid
    • Internal carotid
  56. This is when a patient must be stimulated or talked to to keep them awake
  57. This is when a patient must have constant tactile stimulation to keep them awake
  58. This is when a patient withdraws from painful stimuli when trying to arouse them
  59. Does not respond to continuous or painful stimulation, reflexive movement only, does not make any verbal sounds?
  60. What are the stroke patient guidelines upon arrival?
    • Door to physician ≤ 10 min
    • Door to stroke team ≤ 15 min
    • Door to CT initiation ≤ 25 min
    • Door to CT interpretation ≤ 45 min
    • Door to drug ≤ 60 min
    • Door to stroke unit ≤ 3 hours
  61. When is it not safe to give TpA (fibrinolytics)?
    • BP MUST BE LESS THAN SBP <185 / DBP <110
    • Give meds to bring down then TpA (labetalol)
  62. What are the different types of traumatic brain injuries (TBI)?
    • Closed:
    • Contusion - bruising
    • Concussion
    • Diffuse axonal injury

    • Three major types of hemorrhage:
    • Epidural hematoma
    • Subdural hematoma
    • Intracerebral hemorrhage
  63. What is a diffuse axonal injury?
    Twisting and shearing of axons: nothing we can do but monitor their condition

    PT, OT, rehab can help get to a higher level of functioning

    Present in profound coma they will ultimately die
  64. What is chronic traumatic encephalopathy (CTE)?
    • Build up of TAU proteins
    • related to many head injuries, concussions from sports
  65. What is the Monro Kellie Hypothesis that relates to intracranial hypertension (ICP)?
    • Brain=80%
    • Blood=10%
    • CSF=10%
    • *An increase in one is going to necessitate a decrease in another
  66. What is the recommended Cerebral Perfusion Pressure (CPP)?
    60-70 mmHg

    CPP = MAP - ICP
  67. What is the sweet spot for MAP in a patient with ICP?
    60-150 mmHg
  68. What is important to remember with cerebral blood flow and autoregulation (pertaining to ICP)?
    • Narrow, tight window of MAP
    • compensatory mechanisms (vasodilation, vasoconstriction...)
  69. What are the causes of increased intracranial pressure?
    • Severe head injury
    • Subdural hematoma
    • Hydrocephalus
    • Brain tumor
    • Hypertensive brain hemorrhage
    • Intraventricular hemorrhage
    • Meningitis
    • Encephalitis
    • Aneurysm rupture
    • subarachnoid hemorrhage
    • Status epilepticus
    • Stroke
  70. What are S/S of increased intracranial pressure?
    • HA

  71. What is the medical management for patients with TBI's?
    ICP monitoring

    Draining off CSF – normal is 15, when 20 or greater, then will drain off 1-2mL Q2-3 minutes
  72. What is the nursing care for ventriculostomy?
    • Zeroed and leveled
    • Monitor the characteristics of drainage - At least done hourly
    • At least hourly neuro checks
    • Infection control – hand washing, aseptic technique, visitor infection control
    • Assessing the patient and S/S
  73. What is an Uncle Herniation and what can the nurse expect to see?
    • temporal side of the brain
    • pressure on 3rd cranial nerves (pupils dilated and non reactive and ptosis)
    • decreasing LOC
  74. What is a Central Herniation and what can the nurse expect to see?
    • brain herniates downward to the stem
    • change in respirations (Cheyne Stokes)
    • will = hemodynamic instability
    • pupils will be pinpoint and non reactive)
  75. What are the components of Cushings Triad?
    • Bradycardia
    • Widening pulse pressure
    • Irregular respirations
  76. What is the difference between Decorticate and Decerebrate posturing?
    • Decorticate – going to the core
    • Decerebrate rigidity – out is worse, pressing on the medulla
  77. What S/S does the nurse report to the MD in relation to TBI's?
    • Change in LOC
    • Change in Glasgow coma scale
  78. When a pt presents with respiratory compromise, what are the initial nursing interventions?
    • Sit up (high-fowler's)
    • O2 at 2L
    • Lung sounds Respirations - nasal flaring, retractions?
    • ECG
    • IV access - at least 20G in AC
    • CT of the chest - with contrast (kidney fx)
    • D-dimer, CBC, coags, cardiac markers
  79. What are the treatments for PE?
    • Anticoagulation: Heparin IV
    • Fibrinolytics
    • Embolectomy
    • Filter
  80. Ventilation failure or oxygenation failure, or both result in what?
    Acute respiratory failure (ARF)
  81. ABG's of Acute Respiratory Failure (ARF)?
    • PaO2 < 60 mmHg
    • OR
    • PaCO2 > 45 mm Hg
    • occurring with acidemia (pH < 7.35)
    • And O2 sat < 90% in both cases
  82. What causes Ventilatory failure?
    • Mechanical abnormality of the lungs or chest wall
    • Defect in the respiratory centers of the brain
    • Poor function of the respiratory muscles, especially the diaphragm Guillain-Barre spinal cord injuries chemical depression (opioids, anesthesia)
    • COPD, asthma
    • ARDS
    • PE
    • Pneumothorax
  83. How do we measure ventilation?
    Capnography (AKA end-tidal CO2 or EtCO2)
  84. When EtCO2 is <35 = hyperventilation/hypocapnia, what reasons should we consider?
    • perfusion problem
    • metabolic problem OR psychological problem
  85. When EtCO2 is >45 = hypoventilation/hypercapnia, what should we consider?
    • Think respiratory failure
    • Air NOT circulating
  86. If EtCO2 >45-50 what are the immediate nursing interventions?
    • Stimulate/arouse pt (if aroused and breathing - check Q15m x 1H)
    • Assess V/S for decompensation
    • Assess RR, quality, depth pain level, sedation reposition
    • if remains >45 call MD
  87. If EtCO2 >50 what are the immediate nursing interventions?
    • Regular interventions (stimulate, assess...)
    • If EtCO2 doesn't return to normal within 5 min - CALL RT or RRT
    • obtain ABG's
    • administer Narcan
    • may be referred to ICU
  88. Air moves in and out but does not oxygenate the blood due to perfusion problems
    V/Q mismatch
  89. What are the S/S of respiratory compromise?
    • Confusion
    • Restlessness
    • Diaphoresis
    • Dyspnea
    • Tachy
    • Cyanosis (late sign)
  90. With ARDS - what happens to the lungs?
    • damage at alveolar capillary membrane - fluid and proteins enter alveolar space
    • surfactant reduced
    • alveoli collapse
    • gas exchange is impeded
    • lungs become stiff = further hypoxemia
  91. What are the criteria for Acute Respiratory Distress Syndrome (ARDS)?
    • Hypoxemia despite 100% FiO2
    • Decreased pulmonary compliance
    • Dyspnea
    • Non-cardiac pulmonary edema
    • Dense pulmonary infiltrates on x-ray (ground glass appearance)
  92. What is the normal PaO2?
    80 - 100 mmHg
  93. What ABG's indicate that a client is in LATE ARDS?
    Respiratory acidosis because of poor perfusion As ARDS progresses we do not ventilate because of the build-up of fluids PaO2 continues to decrease
  94. What is the pathophysiology of metabolic acidosis?
    aerobic metabolism to anaerobic metabolism = metabolic acidosis
  95. What are ABG's like in early ARD's?
    Respiratory ALKALOSIS
  96. Tidal volume for ventilator controls and settings?
    7 - 10 mL/kg **(6 mL/kg in ARD's)
  97. This is the volume of air the patient receives with each breath, as measured on either inspiration or expiration.
    tidal volume
  98. Breaths per minute (BPM) for ventilator controls and settings?
  99. How is FiO2 determined and set on the ventilator?
    determined by ABG's starts at 100% and weaned according to pt needs/tolerance
  100. This is the amount of air left in the lungs after exhalation. It prevents the alveoli from collapsing because the lungs are kept partially inflated...
    Positive End Expiratory Pressure (PEEP) also prevents atelectasis
  101. This is the volume of air that can enter the lungs and is associated with pulmonary compliance
    Peak Inspiratory Pressures (PIP)
  102. What is the purpose of PEEP?
    allow for longer periods of gas exchange to occur
  103. Is it easier to breath when lung volumes are high or low?

    **Low lung volume is BAD!
  104. pressure that augments a spontaneous breath during inspiration
  105. What are the oxygenation goals (PaO2 and SaO2) for mechanical ventilation in ARDS?
    • PaO2 = 55-80 mmHg
    • OR
    • SaO2 = 88-95%
  106. What is the PEEP to use in ARDS patients to prevent barotrauma?
    5 cm H2O
  107. What is the protocol for ARDSNET? (GWTG for ARDS)
    • TV set at 6ml/kg
    • PEEP 5 cm H2O
    • FiO2 < 70% adjust to ABG’s
    • SaO2 88-95%
    • Steroids only in small doses and only for short periods of time
    • If O2 sat dropping increase PEEP
  108. A low-pressure alarm indicates what?
    disconnection or leak in ventilator circuit or patients airway cuff
  109. A high pressure alarm indicates?
    • Problem at the patient side - decreasing lung compliance
    • pneumothorax
    • water in tubing
    • secretions/mucous
    • tubing kinked
    • coughing
    • bronchospasm
  110. What are the nurses actions if the high-pressure alarms and cannot find cause?
    • take them off the ventilator
    • manually bag them
    • have someone call RT
  111. O2 saturation is 89%  what ventilator changes would you make?
    • Increase FiO2, if that doesn't work
    • Then increase PEEP

    **KNOW THIS!
  112. ABG shows pCO2 of 53- what ventilator changes need to be made?
    • Increase respirations, if that doesn’t work
    • Then increase tidal volume

    **KNOW THIS!!
  113. What is a central cord syndrome of SCI?
    can sing and dance but can't play the piano!
  114. What are the S/S of Neurogenic Shock (in SCI)?
  115. What are the S/S of Autonomic Hyperreflexia (seen in SCI)?
    • Severe hypertension
    • Bradycardia
    • Severe headache
    • Sweating
    • Flushing
    • Blurred vision
  116. What is the first thing to do in Autonomic Hyperreflexia (SCI)?
    Sit them up!
  117. According the the AHA what are the major risk factors of acute coronary syndrome ACS (aka MI)?
    • Age
    • Male
    • gender
    • heredity
  118. According the the AHA what are the modifiable risk factors of acute coronary syndrome ACS (aka MI)?
    • tobacco
    • cholesterol
    • HTN
    • physical inactivity
    • obesity
    • diabetes
  119. According the the AHA what are the contributing risk factors of acute coronary syndrome ACS (aka MI)?
    • stress
    • alcohol
    • diet/nutrition
  120. What are the S/S of the female one month before a heart attack?
    • unusual fatigue
    • sleep disturbance
    • SOB
    • indigestion
    • anxiety
    • heart racing
    • arms weak/heavy
  121. A change in leads II, III, AVF indicate MI to what part of the heart? and which artery?

    RCA (right coronary artery)
  122. A change in leads V1, V2, V3, V4 indicate MI to what part of the heart? and which artery?
    left ventricle

    LAD (left anterior descending artery)
  123. A change in leads V5/V6/AVL/I indicate MI to what part of the heart? and which artery?
    lateral (posterior)

    Circumflex artery
  124. In an inferior wall MI (II/III/AVF) what do we do?
    NO NTG give fluids!
  125. When the left ventricle is involved what happens?
    • blood isn't supplied to the rest of the body
    • low ejection fraction
  126. When the anterior of the heart is involved what happens?
    ventricles are irritable see more dysrhythmias (VT, heart blocks)
  127. What are the core measures and guidelines for treatment of MI?
    • 10 minutes for 12 lead EKG
    • 30 minutes from diagnosis to thrombolytics if no contraindication-
    • if PCI not available 90 minutes from diagnosis to cath lab
  128. What type of MI?
    Image Upload 8
    anteriolateral MI
  129. What type of MI?
    Image Upload 9
    Lateral MI
  130. What type of MI? 
    Image Upload 10
    Anteriolateral MI
  131. What initial interventions should be performed for the patient with a burn?
    • Remove patient from source of injury
    • —Remove burning & burned clothes
    • —Remove everything that can develop constriction ring
    • —Cool with water- tap water is fine
    • —Chemical burns- brush off powders, constant irrigation
  132. Assessment priorities of a burn patient
    • Airway - do they have one? can they maintain it? do they have a spinal injury?
    • Breathing - 100% O2 via NRB to help displace CO2
    • C - insert IV (ok to insert into burns, 18 or 20G to AC)
    • D - consider associate injury (CO2 poisoning, substance abuse, comorbid conditions)
    • E - remove all clothing and jewelry (maintain patient temperature & emotional support
  133. Name a way to detect partial thickness from full thickness
    look for goose pimples on skin - this indicates intact hair follicles
  134. What are the characteristics of a deep partial thickness burn?
    • Whitish
    • waxy
    • shiny appearance
  135. What is the criteria for transferring a client to the burn center?
    • Partial thickness burns >10% TBSA
    • —Full-thickness burns in patients of any age.
    • —Burns that involve the hands, feet, face, eyes, ears, perineum, and/or major joints.
    • —Electrical burns including lightening injuries
    • —Chemical burns
    • —Inhalation injury
    • trauma with risk to morbidity or mortality
    • preexisting medical d/o complicating recovery
    • burned children without qualified personnel
    • requiring special social, emotional, rehab
  136. What are IMMUNOLOGIC changes that can occur as a result of burns?
    • bone marrow suppression
    • RBC life decreased
  137. What are CARDIAC changes that can occur as a result of burns?
    Decreased cardiac output r/t hypovolemia
  138. What are the physiologic changes associated with inhalation injuries?
    • Mucosa in lungs swell and break
    • —Fluid leaks into alveolar space
    • —Cilia is damaged
    • —Mucus builds up
    • —Airway is plugged
    • Oxygen exchange is reduced
  139. What are the vascular changes resulting from burn injuries?
    • —Initial vasoconstriction to limit damage 
    • —Vasodilation
    • Fluid shift - third spacing (capillary leak
    • Profound imbalance of fluid, electrolyte, and acid-base
    • Hemoconcentrated
    • 48-72H the patient will go into a diuretic stage
  140. What is the Parkland formula most commonly used- burns >20% TBSA
    2-4ml x kg x TBSA
  141. How do we know if a burn patient is getting enough fluid? or ANY patient?
    monitor urine output

    0.5 -1ml per kg per Hour OR 30 mL/H
  142. What is important to know regarding nutrition for burn patient?
    high calories, protein for wound healing
  143. What are the four necessary steps to treat a wound?
    • Cleanse
    • Debride
    • Topical antimicrobial agent
    • Dressing
  144. Name the clinical manifestations (S/S) of Hepatitis
    • Anorexia, N/V
    • fever
    • fatigue
    • RUQ pain
    • dark urine / light stool
    • joint pain
    • jaundice
  145. What are manifestations (S/S) of hepatic encephalopathy?
    • Difficulty sleeping or not sleeping
    • Mental confusion
    • Asterixis – flapping of hands
    • decreased DTR's
    • Fetor hepaticus
    • Posturing
    • Seizures
  146. What is the treatment for Portal hypertension?
    Beta blockers to decrease pressure and BP
  147. What is the treatment for Ascites?
    • Paracentesis (p. 1199) – make sure albumin given before so that fluid stays in vascular space.
    • Spironolactone: to keep K+ (low K+ worsens encephalitis)
    • Lasix
  148. What is the treatment for Hepatic Encephalopathy?
    • Oral or rectal lactulose to pull ammonia out
    • Rifaximin – antibiotic to decrease bacteria that produces the ammonia
    • Fecal transplant
  149. What are KEY S/S in a NAFLD/NASH patient?
    • ACANTHOSIS NIGRICANS (dark neck, axillae)
    • Palmar erythema
    • Spider Naevi
    • Ascites
  150. What does albumin do?
    A protein that helps maintain oncotic pressure
  151. What does the MELD Score determine?
    • Prognosis
    • Prioritizing patients for liver transplant
  152. What is the Child-Pugh Classification for liver disease?
    Classifies the severity and risk of the disease
  153. S/S of Acute Pancreatitis?
    • RUQ PAIN
    • N/V

  154. What is the diagnostic criteria for Acute pancreatitis?
    Diagnosis of 2 of the 3:

    • Acute onset persistent, severe, RUQ/epigastric pain
    • Elevation in serum lipase or amylase to 3 times or greater upper limit of normal
    • Characteristic findings of pancreatitis on imaging (CT, MRI, US)
  155. What are S/S of CHRONIC pancreatitis?
    • Intense Abd pain with tenderness
    • Ascites
    • Respiratory compromise
    • Fat in Poop
    • Jaundice
    • Dark urine
    • polyuria, polydipsia, polyphagia (DM)
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Final - Cumulative
Final Cumulative