N.C.M.

106 PRELIMINARY EXAMS REVIEWER

Nyjil Patrick B. Columbres

JULY 14, 2013

UNIVERSITY OF LUZON Dagupan City

N. C. M. 106
Implantable Cardioverter Defibrillator placed in patient with recurrent ventricular arrhythmia. A device that is controlled by microcomputer, inside pulse generator is implanted in left front shoulder with 2 leads for atria and ventricle to deliver high energy shock. Automatic External Defibrillator a computerized defibrillator that analyses heart rhythm and tells the operator when to perform defibrillation. Common is public places such as airports, parks, and malls. Hemodynamic Monitor: 1. Monitor records appropriate waveform 2. Transducer attached to tubing to measure flow, pressure, temp, and sound which change electrical sign. 3. Amplifier interpret electrical signals with more accuracy. Equipment: Pressure bag Fluid flush system with Heparin Tubing Measurement of Hemodynamic Parameters: 1. Intra-arterial Monitoring continuous display of Blood Pressure, obtain blood samples, used to patient with dopaminiperide, ABG Analysis. Measures MAP-SBP + (2x diastolic BP) divided by 3. Complications include Thrombosis, Embolism and Hematoma. 2. Pulmonary Artery Pressure monitors left ventricular function and fluid volume status. It also measures Right Arterial Pressure (CVP = 0-8mmHg), Right Ventricular Pressure (12-25mmHg/0-8mmHg), Pulmonary Artery Pressure (15-25mmHg/6-12mmHg), and Pulmonary Wedge Pressure (4-12 mmHg) a port attached syringe to inflate the balloon located on the distal lumen. Used for indirect measurement of Left Ventricular Function. 3. Systemic Vascular Resistance (770-1500 dynes/sec/cm-5) it measures afterload (The pressure the left ventricles need to exceed to eject its volume it is increased in hypothermia and shock. 4. Pulmonary Vascular Resistance (20-120 dynes/sec/cm-5) it measures afterload affecting right ventricle. It is increased in pulmonary hypertension, hypoxemia, pulmonary embolism, and academia.

5. Cardiac Output using thermistor located on the distal part. It is used to determine how effective the heart is meeting the demands of their body. Technique is to inject 5-10 mL of D5IV or NS to Pulmonary Catheter. Intracranial Pressure Monitoring is used to patients who are at risk of developing increased ICP.

Criteria of in monitoring ICP: Risk for increased ICP. Comatose patients having below 8 GCS Abnormal CT Scan Methods of ICP Insertion: Epidural Sensor transducer is placed between skull and the Dura. It is less invasive so less accurate. Drainage of CSF cant be done. Subdural sensor is placed post craniotomy for post-operative monitoring. Subarachnoid screw/bolt inserted into the subarachnoid space, this system is unreliable; it can be obstructed. Intraventricular catheter is placed via burr hole into the lateral ventricle. Most accurate and CSF can be drained. Acetazolamide Drug used to inhibit CSF Secretion. Endotracheal Intubation it is the passage of tube into the trachea either mouth or nares to maintain airway of patient. Criteria: On Gas Anesthesia Removal of Copious Secretions Respiratory arrest and other respiratory compromise Contents of tray: Laryngeal Scope (Curved or straight) ET Tube Stylet Oral Airway Magill Forceps Syringe

Steps in Endotracheal Intubation: 1. Place patient in sniffing position, Give anxiolytics and paralytic Agent 2. Hyperoxygenate patient to 100% 3. Insert Laryngoscope to view vocal cord 4. Suction excess secretions in the oropharynx 5. Lubricate ETT with KY Jelly and place stylet on the center of the ETT. 6. Insert ETT thru the vocal cords just 2-3cm above the carina 7. Inflate cuff with Syringe. 8. Once done, let RT auscultate bilateral lung air entry. 9. Chest X-Ray to verify proper alignment. 10. Secure ETT by tape and document cm marking for the depth at the patient lip. Positive Pressure Ventilation common type of ventilator support use in ICU. Air is forced into the lungs via ETT and deliver air according to preset volume/pressure by mode.

a. CMV deliver a minimum preset RR to the patient. Example: If the order is 12 breaths/min, the ventilator will deliver 12 breaths. Use to patients with chronic respiratory problems. b. SIMV ventilator will deliver a preset Tidal Volume or pressure for every breath. Breath is delivered according to the timing of patient own respiratory effort. When patient inspires independently, the ventilator does not deliver pressure/volume which may result to respiratory muscle fatigue. This is used for weaning. c. Pressure Control Ventilation delivers breaths at a preset target pressure. Inspiration decreases as the alveolar pressure nears the pressure on the airways. d. Volume Control Ventilation solves this volume gas exchange roblem. There is always a risk that the inspiration pressure will climb high. Different Ventilator Settings: a. FIO2 (Fraction of Inspired Oxygen) this is the preset. FIO2 maybe set to 21-100%. This is titrated according to patient pulse oximeter. b. Tidal Volume amount of air exchanged or delivered with each inspiration and expiration. This determined by patient weight range from 4-12 ml/kg c. PEEP (Positive End Expiratory Pressure) it adds pressure at the end of expiration on ventilation breaths. Helps to keep alveoli open to participate in gas exchange. Give PEEP 5cm H2O routine to keep functional residual capacity. d. CPAP (Continuous Positive Airway Pressure) adds to FRC in patient with spontaneous breathing given by mask or ventilator. Used to patient with sleep apnea. Use to augment spontaneous breath during weaning process.

e. Pressure Support Ventilation used to support patient breath and help increase Tidal Volume. Provides positive pressure as patient is taking breath that ultimately helps to reduce work of breathing. Used as Weaning. f. Inverse Ration Ventilation Delivered as pressure controlled. Comparison of the inspiration and expiratory time. Patient requires sedation or paralysis because patient feels uncomfortable. g. Airway Pressure Release Ventilation unites two levels of CPAP (P high help patient increase lung volume during spontaneous breath) and P low allows reduction of airway pressure. h. Mandatory Minute Ventilation this monitors the minute ventilation and deliver additional breaths when patient falls below the minimum. i. Proportional Assist Ventilation this allows the ventilator to act in response to the patient work of breathing on breath by breath basis. The ventilator adjust the support it provides depending on patient effort. Nursing Management: 1. Secure artificial airway and monitor tube movement. 2. Auscultate lung every 4hours. 3. Suction as needed, Hyperoxygenate before, during and after procedure. 4. Position patent semi-fowlers if possible. 5. Monitor patient volume status. Give bronchodilators. 6. Turn patient every 2hours. 7. Monitor set and titrate FIO2 8. Monitor ABG and adjust ventilator setting. 9. Apply soft restraint if needed. 10. If orally intubated secure tube alternating sides of mouth daily. 11. Monitor ETT pressure once per shift. 12. Provide oral care every 2 hours. 13. Review and respond to ventilator alarms promptly. 14. Monitor ETT and ventilator circuits turning and repositioning patient. 15. Wash hands before and after procedures. Acute Myocardial Infarction totally occluded of a coronary artery which leads to shock or death. Healing Process: Inflammatory process formed 4 hours. Necrotic zone 4-10 days it is well defined. Scar tissue Forms within 10-14 days. Signs and Symptoms: Chest pain last 30 minutes. Anxiety because of impending doom
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 Nausea and vomiting Syncope Blood pressure maybe Low or High

Acute Care Management: Improve myocardial oxygen supply by giving oxygen Decrease myocardial oxygen demand by bed rest, N. P. O., mechanical devices. Decrease preload and after-load by drugs (Morphine Sulfate, nitroglycerin (oral, patch, iv) and calcium channel blockers) Increase heart contractility (dopamine) Maintain electrophysiological activity Maintain hemodynamic stability. Detect/prevent complications. Nursing management: Assess pain and skin Continue monitoring 12 lead ECG Check Vital Signs, Level of Consciousness, Intake and Output. Obtain Central Venous Pressure, Pulmonary Artery Wedge Pressure, Cardiac output. Maintain Oxygen Therapy. Give drugs like nitroglycerin, aspirin, Morphine Sulfate, Beta-Blockers, and Calcium Channel blockers. Monitor infections signs.

Surgical Management: Intra-aortic Balloon Pump is a counter-pulsation device. Insertion of balloon tipped catheter permits inflation and deflation during diastole and systole triggered from the ECG. It is inserted via femoral artery and advanced through aorta confirmed by chest X-ray. It increases coronary artery perfusion and decrease myocardial consumption. Percutaneous Trans-luminal coronary angioplasty - a catheter with balloon is inserted thru a guide wire during coronary angiogram via femoral artery. Balloon is inflated to compress atherosclerotic plaque to increase lumen diameter. Anticoagulant is required before the procedure. Metal stent - stainless steel slotted wire device designed to mechanically support coronary artery to prevent acute restenosis after P. T. C. A. Stent is placed in lesion site, expanded by balloon which improve lumen diameter. Maintain anticoagulant because of secondary thrombus formation may occur.
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Drug-Elutent stent It is inserted to reduce in-stent restenosis. These are impregnated with antiproliferative agents (Rapamycin, Paclitaxel). Patient will receive Aspirin or Clopidogrel for 3-6 months to prevent Endothelization of stent surfaces. Heart failure - inability of the heart to pump/maintain adequate amount cardiac output into the systemic circulation to meet tissue metabolic and oxygen demands. Risk factors: Myocardial infarction. Ischemic Heart Disease. Valvular disease. Cardiomyopathies. Coronary Heart Disease. Fluid Overload.

Right Side Heart Failure Signs and Symptoms: Jugular vein distention Weight Gain Ascites Hepatomegaly Anasarca Nausea and vomiting Bloating Low urine output High Central Venous Pressure Nocturia Electrolyte Imbalance Dyspnea

Left Side Heart Failure Signs and Symptoms: Cardiomegaly Extra Heart Sounds Adventitious Breath Sounds (Crackles and Wheezing) Decreased Systolic Blood Pressure Orthopnoea Nocturia Night productive cough Irritability Dusky skin and nail beds Tachycardia Restlessness Ventricular ectopic beats
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 Decreased cardiac output, Increased Pulmonary Artery Wedge Pressure, Paroxysmal nocturnal Dyspnea

Diagnostic tests: ECG Findings: Left or right ventricle hypertrophy and ischemia Chest X-Ray Findings: Cardiomegaly Pleural effusion Pulmonary venous congestion Acute care management: Improved myocardial function Reduce circular volume Reduce myocardial work Detect/prevent complications

Nursing management: Analyze ECG and Echocardiogram results Check Vital Signs Monitor Central Venous Pressure, Pulmonary Artery Wedge Pressure, and Cardiac Output. Assess skin Review Blood Urea Nitrogen and Creatinine level, echocardiogram results, and Arterial blood Gas. Pulmonary Edema It is an abdominal accumulation of fluid both in interstitial and alveolar spaces. A life threatening situation that needs immediate treatment Risk factors: Hypertension Ischemic Heart Disease Myocardial Infarction Valvular disease Cardiomyopathies Congestive Heart Failure Over-hydration Acute septal defects

Diagnostic tests: Arterial Blood Gas: Respiratory Acidosis with Hypoxemia Increased Brain Natriuretic Peptide Chest X-Ray Signs and Symptoms: Sudden onset of Dyspnea and Orthopnoea. Severe anxiety, restlessness, irritability, Fatigue Cool moist skin Tachycardia and Tachypnea Moist cough with pink blood tinged frothy sputum. Chest discomfort Palpitations Fatigue severe coughing Jugular vein distention

Acute care management: Reduce preload and after-load Improve heart contractility Give high concentration Oxygen Mechanical ventilation

Nursing management: Care of Ventilated patient on Continuous Positive Airway Pressure with PEEP. Give drugs as prescribed Pulmonary/oral hygiene Obtain Central Venous Pressure, Pulmonary Artery Wedge Pressure, Cardiac Output, Systemic Vascular Resistance, Pulmonary Vascular Resistance Monitor Vital Signs, ECG strips, BUN, and Brain Natriuretic Peptide Assess skin, heart and lung function Review echocardiogram results Stroke It is the sudden loss of brain function resulting from disruption of blood supply to an area of brain resulting in tissue necrosis. Stroke is characterized by symptoms more than 24 hours with permanent neurologic deficit. Main types of stroke: Ischemic stroke - damage to brain due to clogged artery, caused by: a. Thrombus which affected blood flow and cause platelet aggregation thus forming a clot. b. Emboli Rheumatic Heart disease Mitral Stenosis, Atrial Fibrillation.
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 Haemorrhagic stroke - when blood vessel burst leaking blood into the surrounding spaces or brain tissue. Brain tissue most common site of hematoma is the basal ganglia

Transient Ischemic Attack - Brief episode of Neurologic deficits that resolve less than 24 hours. It does not cause infarction but a warning sign of impeding stroke. Diagnostic tests: CT scan - visualize areas of ischemia or infarction 3 hours after vascular occlusion. Cerebral angiogram - identifies areas of ulceration, stenosis, thrombus, occlusion, arteriovenous malformations, and displaced arteries.

Signs and symptoms: Depends on the area of the infarct. A. Internal carotid artery Contralateral paresthesia, hemiparesis of face, arms, and legs contralateral hemiplegia, hemianesthesia visual blurring or hemianopsia, blindness Dysphasia in dominant hemisphere involvement. B. Anterior cerebral artery mental impairment contralateral hemiparesis sensory loss of toes ataxia incontinence C. Middle cerebral artery level of consciousness varies from confusion to coma contralateral hemiparesis to hemiplegia greater to arms and face than leg aphasia Dysphasia homonymous hemianopsia inability of turn eyes toward the paralyzed side

D. Posterior cerebral artery contralateral hemiplegia with sensory loss confusion, memory involvement homonymous hemianopsia
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E. Vertebrobasilar artery Dizziness, Vertigo and Nausea Ataxia Syncope Blindness or diplopia visual disturbances Nystagmus Numbness paresis of the face, tongue, mouth dysphagia and dysarthria Physical assessment: Blood Pressure maybe normal or high mild tachycardia cheyne-stokes respiration afebrile/febrile Peripheral pulses maybe diminished.

Acute care patient management: Thrombolytics Prevent additional thrombotic events - anticoagulants, anti-platelets Prevent hyperglycaemia/hypernatremia Prevent further haemorrhagic events. Reduce increased ICP - drain CSF, corticosteroids, osmotic diuretics, loop diuretics Prevent complications - seizures, herniation.

Dexamethasone (dexadron) prevents cerebral Edema. Phenytoin (Dilantin) - to prevent seizure

Nursing management: Monitor GCS, VS, ECG, Oxygen Saturation, CVP, I&O, PT, PTT, Electrolytes, ABG, and Glucose. Assess factors increasing ICP Elevate height of bed Give drugs as ordered.

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