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Complex CR341 Adult Health Study

Guides

Normal Lab Ranges Albumin: 3.5-5. Pre- albumin: 19- ABG’s o pH 7.35-7. o paCo2 35- o HCo3 22- o paO2 80- ▪ Below 60 is severe hypoxemia

- When given a list of patients and deciding who to see first, always look at PaO2. - Need to know compensation, level of hypoxemia - ABG example - Work on ABG problems o pH 7.35 - normal (leans toward acidic side) o Pco2 68 - high o Hco3 30 - high bc its trying to fix the acid o Pao2 55 ▪ Fully compensated respiratory acidosis with mild hypoxemia - Metabolic acidosis o Causes ▪ DKA - most common ▪ CKD ▪ Shock ▪ Diarrhea o Compensation ▪ Increased respiratory rate (hyperventilation) - Metabolic alkalosis o Causes ▪ NG suctioning ▪ Diuretics (increase K and decrease HCo3) ▪ Vomiting o Compensation ▪ Decreased respiratory rate - Respiratory acidosis o Causes ▪ Hypoventilation ▪ Narcotics ▪ Hypercapnic respiratory failure ▪ Low pH and high Pco ▪ COPD- Compensated ▪ CNS Depression o Compensation ▪ Excrete H+ ions through urine - Respiratory alkalosis o Causes ▪ Hyperventilation ▪ Anxiety

- Early signs of respiratory distress o Restlessness o Agitation o Tachypnea- respiratory alkalosis 1st then will go into acidosis o Tachycardia **Critical Care

• CPOT: Critical Care Pain Observation Tool** o 1st thing- 1 minute observation!!!! ▪ You can get anywhere between 0-8 points. There are 4 categories worth 2 points each. Know how your patient presents in each category. ▪ Facial expression ▪ Patient is frowning or lowering brow- he is tense. He will get 1 point ▪ Eyes shut and orbital tension (Grimacing)- 2 points ▪ Body movements ▪ Slow cautious movements- protection - 1 point ▪ Pull on tubes, trying to get out of bed- 2 points ▪ Muscle tension ▪ No resistance with passive movement - 0 pts ▪ Resistance to passive movement - 1 pt ▪ Very tense & rigid- 2 pts ▪ Compliance with vent or vocalization ▪ Tolerates the vent- 0 pts ▪ Alarms going off but they are spontaneous - 1 pts ▪ Asynchrony (fighting the vent)- 2 pts ▪ Vocalization ▪ Sobbing and crying- 2 points - Delirium o Risk Factors ▪ Age ▪ Being on a ventilator ▪ Polypharmacy ▪ Visual and hearing deficits ▪ Make sure pt has glasses and hearing aid ▪ Sleep deprivation ▪ Ensure they get adequate rest. Cluster care to give periods of rest. ▪ History of dementia ▪ Tubes and restraints ▪ Never put restraints on patients with delirium- it will make it worse. ▪ There is a sequence of how you deal with agitation ▪ 1st: therapeutic communication ▪ Sitter ▪ Medicate ▪ Restraints ▪ Avoid benzos and narcotics

o Medication ▪ Haldol - Good drug to give

- Propofol o Used as a sedative & antiasthenic - patient must be on Vent o Given as an infusion that will need to be titrated o CANNOT IV PUSH without doctor in room giving directions o Short half life- good thing! o Turns urine green o Monitor BP every 5 minutes - causes hypotension o Cannot be used in pt’s with allergies to eggs or soy o Will increase fats - triglycerides and cholesterols. o Change tubing using aseptic technique every 12 hours - Richmond Agitation and Sedation Scale (RASS) o Use for patients with delirium o 0, +4, or - o 0 is alert and calm o +4 is combative and agitated o -5 unresponsive ▪ Nursing interventions ▪ Use propofol as a sedative ▪ May need to titrate infusion based on provider order ▪ Physician order will say “keep below -2 (slightly sedated) on RASS scale”

• CAM ICU- Confusion Assessment method o In order to do this, you must have completed a RASS scale. o 1st thing to remember- it has to be acute onset and a fluctuating course (changes in how pt presents) ▪ This means if a patient has a history of dementia and is acting like he did when he first came in it is not delirium. o 4 parts ▪ Acute onset / fluctuating course- have to have these 2 ▪ Inattention ▪ Squeeze my hand every time you hear an A in the phrase “Save A Heart” ▪ Disorganized thinking ▪ Ask questions… 1 right & 1 wrong ▪ Will a stone float on water? ▪ Are there fish in the sea? ▪ Altered level of consciousness (positive RAAS) - ABCDEF Bundle - for delirium

o A- assess and manage pain ▪ CPOT o B- both SAT (spontaneous awakening trial) ▪ Take the pt off the ventilator and see if he wakes up & if he can comprehend instructions ▪ and SBT (spontaneous breathing trial ) ▪ Everyday hes on the ventilator, we take off ventilator and propofol to see if he can breathe on his own o C-choice of sedation ▪ No benzos- will use haldol o D- delirium arbitrary (CAM ICU) ▪ Acute change or fluctuating course of mental status o E- early mobility o F- family ▪ Family is NOT TO BE USED AS SITTERS. It is important to have family around as it helps to reorient the patient. ▪ What do you do the first time the family comes in to see the patient? ▪ Walk with them to the room ▪ Explain the equipment in the room ▪ Tell them what the patient will look like ▪ It is ok to touch the patient ▪ Go into the room with the family & stay for awhile to answer questions ▪ Should not have restricted visiting hours.

• Medications for Delirium **** NO Benzo’s or Opiods for delirium - ever!** o If pt has a +3 on RAAS & has delirium they will be on haldol o Haldol or haloperidol ******* antipsychotic ▪ Can cause tardive dyskinesia ▪ Can cause hypotension ▪ Fall Risk ▪ Has anticholinergic effects - Can cause dry mouth - Urinary retention - Constipation ▪ QT prolongation o Omeprazole ▪ PPI ▪ MOA: ▪ Can cause C diff o Famotidine ▪ H2 blocker ▪ MOA ▪ Can cause altered LOC o Heparin

▪ Can give Sub-Q or IV ▪ Lab test for this med- APTT (Normal APTT: 30-40secs) ▪ Monitor aPTT, H&H & Platelet count!

• At risk for heparin induced thrombocytopenia ▪ Antidote
• Protamine sulfate ▪ If pt has a DVT or PE, he will be on heparin infusion.
• Expect to draw APTT every 4 hours bc you need to titrate heparin based on the result. ▪ Therapeutic range is ??? o Enoxaparin ▪ Low molecular weight heparin ▪ Short half life ▪ Pt with high risk for DVT’s will be on this medication ▪ How to administer
• Given Sub- Q
• Clean the skin
• Pinch the skin
• Insert on abdomen 2 inches away from the umbilicus at a 90 degree angle
• Leave the air bubble to o Decrease the bruising o And ensure they get the whole dose
• Do not massage. o Warfarin ▪ Pt with A-Fib ▪ PT/INR (therapeutic INR 2-3) (less than 1 is pt is not on warfarin) ▪ Antidote
• Vitamin K ▪ The only way given is PO! o Apixaban (Eliquis) ▪ Lab test: XAI ▪ No frequent labs needed ▪ No dietary restrictions **Nutrition
• What triggers a dietary consult? o Low albumin o Low or high BMI o .Hypermetabolic state (Burns) o Braden scale less than 17 ▪ Braden scale assess skin breakdown
• Labs o Normal albumin - 3.5- o Normal prealbumin 19-**

o Calcium and albumin bind together. If the patient has a low albumin they will also have an incorrectly low calcium o Corrected calcium equation ▪ 0.8 (normal albumin - patients albumin) +serum calcium

- Parenteral feedings - Total Parenteral Nutrition (TPN) o Less need for interruptions o Used for GI issues, GI rest, trauma, pancreatitis. o No diarrhea o Has dextrose, amino acids, electrolytes and multivitamins. Once a day we will add a bottle of lipids. May add Mg, Thiamine, K+, Ca+ or insulin. o The main source of calories in TPN is dextrose ▪ If the amount of dextrose is less than 20% it can be given peripheral IV ▪ Won't get enough calories ▪ If greater than 20% of dextrose must be given through central line o Complications ▪ Translocation due to gut not functioning ▪ Elevated blood glucose ▪ May need insulin ▪ Central line TPN complications - possible select all that apply question ▪ Thrombus ▪ Air embolism ▪ Pneumothorax ▪ ▪ ▪ Diminished or absent breath sounds ▪ Decreased O2 sats ▪ Hypoglycemia if stopped abruptly - Enteral feedings o May have interruptions in feeding o Diarrhea will occur o Can be done through NG tube, duodenal tube or J2. o Duotube - nasal duodenal ▪ Confirm placement with X ray ▪ Fewer complications ▪ Decreased morbidity and mortality ▪ Decreases length of stay ▪ Maintains gut integrity ▪ Prevents translocation of bacteria into bloodstream o Complications ▪ It the pt does not tolerate well they can have diarrhea - if feedings are too hypertonic

Neuromuscular blockade (paralytic) assessment

TOF (Train of Four) the electrode on the ulnar nerve and delivers a small

shock and you are to count the small thumb twitches.

Infection Dyspnea

(0-4+ twitches) we only want 1-2 twitches

BIS the electrode goes on the head and it measures the brain responses we

want 40-

100 awake and alert 80-60 mod sedation 40-60 deep sedation Less 40 deep hypnotic state EKG Basics

• P wave o Atrial depolarization o Nice and round
• QRS o Ventricular depolarization o Nice and narrow o P wave present before every QRS
• T wave o Ventricular repolarization o Start at baseline and should be grounded o Absolute refractory period ▪ When PVC lands on refractory period nothing will happen o Relative refractory period o R on T phenomenon ▪ Abnormal impulse like PVC occurs= R on T phenomenon= will cause repetition of impulse. Can turn into V tach, or asystole.
• Small box = 0.04 seconds
• Big box= 5 small boxes= 0.

• PR Interval o 0.12-0.20 seconds o From P to Q wave o Represents the impulse going to SA node to AV node to the purkinje fibers o Prolonged PR = 1st degree AV Block (0.28) - if it’s the first episode - notify HCP. If not, continue to monitor.
• QRS o 0.06-0. o Ventricle contracting o Measuring the time it takes the impulse to contract
• QT Interval o 0.33-0. o Ventricle contracting o If it is prolonged or greater than 0.50 the pt is at high risk for a lethal dysrhythmia ▪ Haldol/zofran/CCB’s/BB’s/amiodarone prolong the QT interval. If they already have a prolonged interval HOLD MED. - 6 second method o Count R waves o Multiply by 10 o Rate of 90 - 3 second strip o R waves x 20 - Big box method o count # of large boxes between 2 consecutive R waves o Can only use that when rhythm is regular ▪ How do you know if it's regular? ▪ The distance of the R waves is always the same Lethal Dysrhythmias
• Ventricular Tachycardia (V Tach) (100-300) o Regular rhythm o Big, wide QRS- patient has problem with ventricles o Assess to see which type o 3 types ▪ Stable - you have time - have pulse ▪ Awake, alert & talking ▪ Give amiodarone 150mg IV over 10 minutes ▪ Follow that with continuous infusion of 1 mg /min ▪ Unstable -you don't have as much time - have pulse ▪ Cardiovert

▪ Give amiodarone 150 mg over 10 mins ▪ Follow that with continuous infusion ▪ Pulseless V Tach - same tx for V FIB ▪ No pulse, Call for help ▪ ▪ ▪ ▪ Defib 2nd time ▪ Give EPI 1 mg IVP - every 3-5 mins ▪ CPR again ▪ Defib 3rd time ▪ Give amiodarone 300 mg IVP ▪ Potential question: what drug might you anticipate giving after your 3rd shock? Amiodarone

- Asystole / PEA o Pulselessness electrical activity o DON'T SHOCK - not an electrical problem ▪ Assess the patient to ensure he is connected to monitor ▪ Call for help ▪ Start CPR ▪ As quickly as you can give Epi 1mg IVP o Identify cause - Draw ABG’s (H’S & T’s ) ▪ H’ s ▪ T’ s ▪ Hypovolemia (most common reason) ▪ Give IV fluids ▪ Hypoxia ▪ Ensure he has enough O ▪ Hypothermia ▪ H+ ions (acidosis) ▪ Draw ABG’s ▪ hypo/Hyperkalemia ▪ Tablets (OD) ▪ Tamponade (Cardiac) ▪ Tension pneumothorax ▪ Thrombosis (Cardiac- MI) ▪ Thrombosis (Pulmonary - PE) - SVT (160-

o Regular o No P wave o No PR interval o Nice Narrow QRS (normal range) - problem is with the atrium not the ventricles. o Decreased ventricle filling. Decreased stroke volume. Decreased CO.

• Stable (you have time) o Vagal Maneuver o Adenosine - check if patient has hx of asthma (causes bronchospasm) Start CPR Defibrilla te CPR

▪ Causes cardiac pause then returns to sinus rhythm. ▪ Short half life ▪ Rapid IV Push - use 3 way stop cock (3 ports adenosine, flush 10- 20ml NS and IV fluid. Rapid Flush. ▪ 1st dose 6 mg.. If doesnt work 2nd dose 12 mg

• Unstable (no time) o Altered loc o Decreased BP o Chest pain o dyspnea o Cap refill longer than 3 seconds o Must Cardio vert ▪ Synchronized
• ST Sinus Tach (100-160) o Everything is normal - HR is elevated. o Decreased CO ▪ Find / Treat the cause: fear, anxiety, pain, hypovolemic, dehydration. ▪ Meds: ▪ Beta Blockers ▪ CCB’s
• Sinus Bradycardia (less than 60) o Ask yourself, are they symptomatic?? ** Check BP ** o Assess ▪ Altered LOC ▪ Pale Diaphoretic ▪ Hypotensive ▪ Delayed Cap Refill ▪ Decreased perf pulses o Treatment:
• O2 *** Pick this 1st *** - if this is an answer option on the test
• Assess
• Put Pacer Pads on.
• #1 Atropine IVP. 0.5 mg start - up to 3mg.
• #2 Epi/norepi/dopamine - IV infusion
• #3 Pacer Pads - Atropine o Increases HR o Anticholinergic - drys you up ▪ Dry mouth, urinary retention, constipation o Dilates pupils

- Epi o Increases HR and BP ▪ How to give? o Causes vasoconstriction o Increases contractility - positive inotrope o Automaticity (keeps rhythm going) If you see mg/min or mcg/kg/min = primary infusion

• PVCs Premature ventricular contractions o Abnormal (wide bizarre) QRS that happens for a long time o Can be unifocal (look the same just on top or bottom of line) or multifocal (above and below the line). o The pulse will feel irregular o Causes - possible select all that apply ▪ Electrolyte imbalances ▪ MI’s ▪ Hypoxia ▪ Stress ▪ Caffeine ▪ Drugs - stimulants o Concern ▪ R on T phenomenon ▪ 3 or more PVC’s can become a lethal dysrhythmias
• Can go into V tach, V fib or asystole o Medications ▪ Lidocaine ▪ Amiodarone
• Used for ventricular dysrhythmias
• Side Effects: o Hypotension o Bradycardia o Toxicities: liver and renal - must monitor levels o Thyroid dysfunctions hypo/hyper o Problems with eye disorders o Pulmonary fibrosis o Neurotoxic o Blue discoloration of the skin

o ** Won’t happen with just one dose but with patients that use it as maintenance med. ** o She just wants us to know these side effects. o Ex of question o Regular o Rate is 88 o PR interval is 0. o QRS is 0. o QT interval is 0. ▪ Answer: normal sinus rhythm

- DVT o If at risk, we will prophylactically put him on enoxaparin. ▪ Exonaparin given Sub Q ▪ 2 inches away from umbilicus ▪ Clean the site ▪ Pinch the skin ▪ Will not expel bubble o Once he gets a DVT we will put him on heparin ▪ aPTT ▪ Monitor H&H, PLatelets ▪ Will be on heparin infusion ▪ Titrated based on aPTT. ▪ Pt will have labs drawn every 4 hours - Pulmonary Embolism o S/S- SELECT ALL THAT APPLY QUESTION ▪ Chest pain ▪ Dyspnea ▪ Decreased O2 sats ▪ Low grade fever ▪ Hemeptysis ▪ Bloody sputum ▪ Tachypnea ▪ Tachycardia ▪ Low BP ▪ Altered LOC o Tx ▪ Heparin ▪ TPA- Clot Buster ▪ Extreme risk for bleeding. Before administration be sure all invasive procedures have been done. ▪ Embolectomy ▪ Small clot: monitor o Diagnosed by

▪ Spiral CT with contrast dye ▪ If cannot have contrast dye, will have VQ scan o Complications ▪ Can develop pulmonary HTN ▪ Right ventricular damage ▪ ECG to see if it is damaged Respiratory

- Intubating a patient o Rapid sequence intubation (RSI) ▪ Causes the least amount of trauma to the patient. ▪ Nursing responsibilities ▪ Position the patient supine at HOB ▪ We are responsible for ensuring the patient is completely sedated before administering a paralytic! ▪ We will give 3 medications ▪ opiates, sedatives, and paralytics ▪ Reoxygenate ▪ Time & monitor ▪ If it takes more then 30 seconds, we need to stop and bag the pt to hyperoxygenate before going again. o Risks/ Complications of intubation ▪ Broken teeth ▪ Check the patients teeth before intubating them as a broken tooth may occur. ▪ Aspiration ▪ If a tooth indeed does break, this puts the patient at risk for aspirating it. ▪ Trauma ▪ There is a blade used to pass down the ET tube and thst could cause trauma to oral cavity. o How to ensure placement ▪ Co2 detector: GOLD is GOOD ▪ Check for bilateral chest expansion - Auscultate ▪ Chest X ray o After confirming placement ▪ Secure the tube and mark & document the centimeters from lip to teeth. Every shift measure to confirm ET tube is still in place. - Ventilation o Indications for ventilation ▪ Apnea ▪ Unable to protect airway - pt with a stroke who lost gag/ swallow reflex with excess salivation ▪ Severe hypoxia ▪ Acute resp failure ▪ Failure of resp muscles o Nursing interventions ▪ Suctioning - NO USE OF SALINE IN ET TUBE ▪ Indications for suctioning

▪ Visible secretions from ET tube ▪ Sudden onset of respiratory distress ▪ Suspected aspiration - due to secretions ▪ Decreased Spo2 and increased RR ▪ Clearing thick secretions ▪ Hydrate the patient with IV fluids to influence humidification ▪ Use of a mucolytic ▪ Mobilization & frequent positioning o Complications of ventilators ▪ VAP ▪ Pneumothorax ▪ Trauma

- VAP (Ventilator Associated Pneumonia) Bundle o To prevent VAP ▪ Hand Hygiene ▪ Elevate HOB to at least 30 degrees unless contraindicated ▪ Oral care - chlorhexidine ▪ SAT/SBT daily ▪ DVT prophylaxis ▪ Ulcer prophylaxis o Indications that the patient is developing VAP ▪ Change in thick secretions- assess COCA ▪ yellow/ green, foul smelling sputum. ▪ Elevated WBC ▪ Fever ▪ New infiltrates on x ray ▪ Decrease in O2 sats ▪ TX: antibiotic! - If the patient is on the ventilator and scores a 4 on the RAAS scale meaning he is fighting the ventilator he is experiencing asynchrony. o Nursing interventions for asynchrony ▪ Verbal coaching- give reassurance - When we give a paralytic is it important to assess the skin as he may be more prone to skin breakdown. The eyes will dry up so ensure he has an order for eye drops is necessary. - Two tools (to measure level of sedation) o Train of 4 (on the ulnar nerve) ▪ 0-4 twitches ▪ 0 twitches- paralyzed ▪ 4 twitches- too much o Bis (Bispectral Index) monitor (on forehead/temple area) ▪ > 90 full consciousness ▪ 80-60 generally moderate sedated ▪ 40 -60 deep sedation - Extubation o Planned extubation ▪ Criteria ▪ Normal ABG’s ▪ Afebrile

▪ RAAS scale of 0 ▪ Stable vitals ▪ Decreased secretions ▪ Positive air leak ▪ To test for positive air leak - assessing for edema of airway ▪ Upon auscultation you should be able to hear the air leak meaning there is space between trachea and ET tube ▪ First 1-2 hours are biggest concern ▪ Assess airway for s/s of edema ▪ Stridor- BAD ▪ Pt will have sore throat ▪ Discourage talking to encourage vocal rest. o Unplanned extubation ▪ Pt has pulled out ET tube or in transport the ET tube comes out. ▪ Always a bad thing! ▪ 1st thing: Assess the patient's airway!!!! ▪ If showing any s/s of resp distress, immediately bag the patient. ▪ Call for help o Terminal extubation ▪ Withdrawing ventilator for a patient dying ▪ Pt must have a DNR ▪ Must ensure pt is not a donor ▪ Stop propofol or other continuous infusion ▪ When ventilator is removed ▪ Decreased O2 sats ▪ Resp distress ▪ May be agitated ▪ Know and expect these reactions! Treat them with morphine and ativan!

- Alarms o Apnea alarm ▪ When the pt is on CPAP / BIPAP. Pt is not breathing on their own and have spontaneous breaths. Apnea alarm will sound. Bag the patient o Low pressure alarm ▪ Probably due to the ET tube becoming disconnected ▪ 1st thing - CHECK ALL CONNECTIONS ▪ If you can't solve the problem.. BAG the patient o High pressure alarm ▪ Due to pt biting the ET tube ▪ Insert bite block ▪ Could be mucus bug at end of ET tube ▪ Something is obstructing. ▪ Assess for kinks ▪ If you can't solve the problem … BAG the patient Ventilator Settings - Tidal volume: 6-8 mL/kg - FiO2 - amount of O

o Around 40%

- Rep rate: 12- - Peak: 5- - I/E ratio o Inspiration to expiration ratio ▪ 1: o When pt has ARDS, we will manipulate I/E ratio. - Assist control o Problem: pt can overbreathe the machine o Resp alkalosis ▪ Resp distress ▪ Restlessness, agitation, tachypnea/ tachycardia o Bradycardia & cyanosis are LATE signs of resp distress o BIGGEST CONCERN WITH ASSIST CONTROL: RESPIRATORY ALKALOSIS Pressure control o CPAP ▪ Continuous air blowing into patients lungs ▪ Increases work of breathing o BIPAP ▪ 2 levels

• High level of pressure on inspiration
• Low level of pressure on expiration o CPAP/ BIPAP ▪ Pt has to have spontaneous respirations o BIGGEST CONCERN WITH PRESSURE CONTROL: RESPIRATORY ACIDOSIS o APRV ▪ Assist control + Pressure control ▪ We change I/E ratio from 1:2 to 2:1, 3:1, or 4: **Causes of respiratory distress
• Hypoxemic Respiratory Failure** o Low PaO2 less than 60 ▪ Pts with ARDS, PE, pneumonia, or pulmonary edema o Problem: gas exchange - Hypercapnic Respiratory Failure o pH: less than 7. o Pco2 greater than 50 ▪ Pt with ALS, & MS o Pt will be in respiratory acidosis o Cause: sedatives & opiates. Pt with a spinal cord injury- paralyzed diaphragm - poor ventilation o Problem: Ventilation - ARDS o Decreasing PaO2, increasing FiO o Problem: gas exchange

o Increased capillary permeability causes fluid to enter the capillary, alveoli gets sticky, and alveoli start to close up. o Non cardiogenic o Increased work of breathing, decreased compliance o Nursing interventions ▪ Prone the patient ▪ High risk for unplanned extubation ▪ APRV ▪ Clean the patient ▪ Increase PEEP. o Patients with ARDS can experience MODS (Multi organ dysfunction syndrome) ▪ Will see in labs ▪ Increase creatinine- kidneys fail ▪ Go from aerobic metabolism to anaerobic ▪ AST/ALT/Liver enzymes elevated ▪ Decreased platelets

• PEEP o Adds extra air at the end of expiration to keep alveoli open o Goal: to improve PaO2 and decrease Co2 retention to keep alveoli open for gas exchange o Problem: trauma to alveoli ▪ Ruptured alveoli HEMODYNAMICS
• CO=SVxHR - Normal Ranges: o CO: 4-8L/min o SV: 70-100 ml/beat o HR: 60-100 bpm o CVP: 2-8 (Central Venous Pressure) o PAOP 8-12 (Pulmonary Artery Occlusion Pressure) o CI: Cardiac index: 2.5-4.5 L/min (cardiac output based on patients size) ▪ we won't have to do the math she said. Just know that is the normal range.
• Preload : Volume of blood/venous return to the heart. o Right side - CVP (2-8) o CVP is low = hypovolemia FVD o CVP is high = hypervolemia FVE (RHF)
• Left side - PAOP (8-12)

o PAOP is low = hypovolemia o PAOP is high = hypervolemia (LHF) Afterload : Resistance - the work needed to open valves.

• Right Side - PVR pulmonary vascular resistance o PVR is high = pulm edema, increased PHTN, clot, PE, pneumonia, acidosis (She didn’t talk about low pvr - or I missed it)
• Meds that affect PVR o Sildenafil - ED meds or meds for PHTN that cause vasodilation o Morphine - causes vasodilation of pulm vessels Left Side: SVR systemic vascular resistance
• SVR is low = Low BP vasodilation
• SVR is high = High BP vasoconstriction
• Most common reason for high SVR is HTN. Increased SVR happens with fight/flight. High BP. Vasoconstriction. (catecholamines released, hypothermia, or cardiogenic shock). Decreased SVR happens with distributive shock. Low BP. Vasodilation. She said we need to have this concept down. Contractility : The squeeze
• What decreases: BB’s, CCB’s, and shock
• What increases: SNS, vasopressors, and + inotropes
• SNS Increases HR, BP, Contractility, and workload. When blocked - you decrease all. Angiotensin 2 - Vasoconstrictor - increases SVR. Promotes the release of aldosterone (retains water) SVO
• Is the O2 demand and O2 used. Measured by a PAC or Central Line. We want an SVO

60%. Low SVO2 (less than 60%)

• Caused by:
• less O2 delivered - (low hemoglobin, low o2 sats, low CO, anemia, Shock, Hypovolemia)
• Increased consumption - (increased work of breathing, fever, shivering, agitated) High SVO2 (more than 60%)
• Increased CO - Sepsis - (in warm phase - increase CO which will increase

svo2)

• Decreased consumption - (Neuromuscular blockers, anesthesia, analgesics, inotropes)

• If you stop agitation his svo2 will go up. If you give him blood products his svo2 will go up. PAC - pulmonary artery catheter (balloon tipped catheter in the PA)

• Complications o Pneumothorax o Infection o Dysrhythmias o Bleeding o clot/thrombus/embolus o Pulmonary infarction - lungs doesn’t have blood flow o Rupture of pulmonary artery PICC - Arterial Line - (perph inserted central line)
• Must do Allen’s test to confirm the ulnar artery is ok.
• This line is safer - does not cause dysrhythmias, HTN, or hypotension. Complications
• Thrombus
• ↓ perfusion to the hand
• Air embolism
• Infection
• Blood loss Leveling the transducer:
• Position stopcock same level as right atrium
• 4th intercostals space
• End of sternum - mid axillary Drugs : ** Need to go over again **
• CVP of 2 - give patient PRBC’s, NS, Albumin
• CVP of 14 - give patient diuretics, ACE Decrease preload: nitrates, ccb’s, dobutamine, morphine Increase Afterload: Epi, norepi, dopamine (vasopressors) Decrease afterload: CCB, BB, ACE, and milrinone Increase Contractility - + inotropes, epi, norepi, dopamine, dobutamine Decrease contractility - CCB, BB Nitroglycerin - causes dilation of coronary arteries and venous dilator. ?? Preload. Hydralazine - Arterial Dilator. Decreases afterload. Nitroprusside - potent dilator - dilates both arteries and veins.↑ preload and ↑ afterload. SHOCK (cellular function goes from aerobic to anaerobic metabolism - releases lactic acid)

Compensatory Phase

• ↓ BP - CO increases because epi kicks in then…
• HR increases and contract = increase in BP - HR and BP increases from epi
• Heart and brain get all the blood
• ↑ Restless, agitated, confused.
• ↑ RR
• Alkalosis
• ↓ peristalsis and ↓ bowel sounds
• Kidneys will start the RAAS
• Pale and cool
• Liver is ok at this point. Progressive Phase
• When compensatory fails. Support organs as they fail
• ↓ mental status - decreased CO
• ↓ perfusion
• Resp acidosis
• Lungs are the 1st to go.
• ATN = metabolic acidosis (so patient is in BOTH resp and metabolic acidosis)
• Jaundice
• ↑ Ammonia levels
• ↑ LA levels
• DIC (disseminated intravascular coagulation - overactive coagulation) Refractory Phase
• Irreversible
• Unresponsive
• Bradycardic
• Resp failure
• Ischemic gut
• Anuria
• Liver failure
• Skin cold and mottled SEPSIS Need to meet the criteria
• QSOFA o SBP ≤ 100 o RR ≥ 22 o GSC ≤ 14 o SIRS ▪ T > 38° ▪ HR > 90 ▪ RR > 20

Early signs

• ↑ HR
• BP is normal
• ↑ SVO2
• ↓ CVP, PAOP, SVR
• Warm and flushed
• MAP ≥ 65 Late signs
• ↓ BP
• ↓ SV
• Cool and Pale
• Anuria
• Positive Blood Cultures 1° Bundle
• Lactic Acid Level
• Blood Cultures x2 (Before and after antibiotics given)
• Broad Spec Antibiotics
• 30 ml/kg NS
• Crystalloids For LA results >4 and ↓ BP - you would add a vasopressor (norepi) after the fluids. Tx for Sepsis:
• Blood
• DVT prevention
• Positioning
• Cardio Pulm assessments
• Recheck LA levels.
• Cap refill
• O2 sat
• Urine output
• Skin
• Fluid responsiveness ANAPHYLAXIS - major vasodilation
• ABC’s o s/s: ▪ Laryngeal edema ▪ Dizziness ▪ Chest pain ▪ Angioedema ▪ Pruritus ▪ Hives ▪ ↑ HR ▪ ↑ BP

▪ Anxiety ▪ N/V/D ▪ Incontinenet Tx : (^) • O2

• Stop the antigen
• Lg bore IV fluids NS
• Epi 0.3-0.5 mg IM to vasoconstrict - then assess airway and VS.. that will tell us if we need a second epi.
• Positive inotropes
• Benadryl
• Corticosteroids Obstructive Shock
• Pericarditis leads to cardiac tamponade
• Pneumothorax
• PE
• s/ s: o ↓ BP o ↓ Preload o ↓ Urine output o Narrow BP o ↓ CO o ↑ SVR o Agitated, cool, and clammy Tx : (^) • Cardiac tamponade - cardiac paracentesis
• Tension pneumo - Needle decompression
• PE - thrombolytics Hypovolemic Shock
• s/s: o ↓ Preload, CO, SV, Cap refill, UO o Pale, cool, and clammy o ↑ RR then ↓RR o ↑ LA o ↑ Urine Spec gravity Tx : (^) • 2 lg bore IV’s
• Stop loss of volume (bleeding)
• Fluid 300ml NS for each 100ml of loss
• Blood - 1 unit FFP
• If Low H&H = blood loss - give them blood

• If High H&H = dehydrated - No blood loss - rehydrate. Cardiogenic Shock
• HR, MI, or Acute decomp HF o s/s ▪ ↓ HR ▪ ↓ CO ▪ ↑ SVR ▪ ↑ Troponin ▪ ↑ BNP ▪ ↑Glucose ▪ ↑ Bun ▪ ↑ preload Tx : (^) • Positive Inotropes
• Nitrates
• Diuretics
• Vasodilators Acute Kidney Injury
• Prerenal - o interferes with renal perfusion. o Caused by dehydration, AAA, N/V/D, hypotension, or injury.
• Intrarenal - o Direct damage to the tissue. o Caused by drugs, toxins, inflammation, infection, reduced perfusion.
• Postrenal - o Obstructed flow of urine. o More common in men. BPH, tumor, trauma, or kidney stones. - Contrast dye AKI: o Tx: give Acetylcysteine (Mucomyst) before and after scan. Use for a patient at risk for AKI.
• Phases: Oilguric, diuretic, Recovery - look at week 4 outline. **Complex Adult Health Final Study Guide
• Organ donation** o Must be determined brain dead ▪ Criteria ▪ No pupillary responses ▪ No corneal reflex

▪ No response to pain - sternal rub ▪ No ocular or vestibular reflex ▪ Cold water in ears- normal response is eyes to deviate to affected ear ▪ No oculocephalic reflex ▪ To finally determine to brain death ▪ EEG flat ▪ Cerebral angiogram - look to see the contrast is in the brain ▪ Apnea test- ultimate test ▪ Take off ventilator, put on oxygen, draw abgs, leave on oxygen for 8-10 minutes and retest ▪ No respiratory diaphragm movement= positive apnea test ▪ ABG’s will show respiratory acidosis ▪ Brain dead patients stop producing, so we may have to intervene to keep the organs vital - donor network may take over this care ▪ ADH ▪ Vasopressin or desmopressin to sub ▪ BP ▪ Give vasopressors ▪ Insulin ▪ Will be hyperglycemic- give insulin ▪ Thyroid hormone ▪ Hypothyroid- give levothyroxine ▪ Our Goal

• Maintain functionality of organs that will be transplanted o Maintain adequate CO & gas exchange ▪ If we suspect we have a donor, notify donor network
• Once determined to be a candidate they take over the care of the patient. ▪ Organ recipient
• Also needs to meet certain criteria to ensure positive survival rate ▪ What triggers a call to a donation network?
• GCS less than 5
• Communication from family or client/comfort measures in place
• Cardiac death. o Professor Stocker likes to ask questions about Kidney transplants
• Kidney Transplant o Pre-op ▪ HLA testing done ▪ Draw CBC & BMP ▪ Hemodialize the pt before the procedure ▪ Ensure he has optimal blood levels o Post op