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4th semester pharm

test 2 cardiac, resp, and pharm.

QuestionAnswer
ejection fraction (EF) Fraction of blood ejected by the ventricle relative to its end-diastolic volume EF = (SV / EDV) · 100     Normal, 55%-70%
Drugs that increase blood pressure (BP) Dopamine Norepinephrine Epinephrine Phenylephrine Vasopressin
Dopamine Doses less than 5 mcg/kg/min Stimulate dopaminergic receptors Dilates renal vasculature Primarily a beta stimulator Increases myocardial contraction rate and force Promotes smooth muscle relaxation
Dopamine Doses of 10-20 mcg/kg/min Alpha stimulator Promotes vasoconstriction Increases systemic vascular resistance (SVR) Monitor HR and urine output Usually restricted to critical care areas
Norepinephrine Stimulates alpha1 receptors to a greater degree than dopamine Stimulates beta receptors to a lesser degree than epinephrine Increases SVR Causes vasoconstriction Increases glomerular filtration rate and renal blood flow
Epinephrine Alpha1, beta1, and beta2 agonist Increases BP by increasing HR CO SVR
Phenylephrine Selective alpha1 agonist Increases SVR without raising HR Better option than norepinephrine, epinephrine, or dopamine if patient already is tachycardic
Vasopressin (antidiuretic hormone) Refractory hypotension ACLS guidelines for cardiac arrest Causes vasoconstriction and increases BP
Drugs that decrease BP Vasodilators Nitroglycerine Nitroprusside Nicardipine
Nitroglycerine Dilates coronary arteries Decreases myocardial oxygen consumption Decreases venous return to heart Decreases afterload (at higher doses) Usually doesn’t significantly lower BP
Nitroprusside Drug of choice for hypertensive emergencies Dilates peripheral arteries More profound effect on: BP Afterload reduction
Nicardipine Slow-acting calcium channel blocker Causes vasodilation Decreases SVR Short half-life Can treat hypertensive emergencies Option in ACLS ischemic stroke algorithm
Drugs affecting contractility Positive inotropes Improve myocardial contractility Digoxin Dobutamine Dopamine Negative inotropes Reduce myocardial contractility Beta-blockers Calcium channel blockers
Beta receptors Beta1 receptors Located in one organ: the heart Beta2 receptors Located in: two kidneys and blood vessels: vasodilation two lungs: bronchodilation
Beta-blockers Cardioselective Predominately block beta1 receptors in heart May slightly affect beta2 receptors
Beta-blockers Nonselective (e.g., propranolol) Block beta1 and beta2 receptors Bronchoconstriction Decreased HR and contractility contraindicated in pulmonary disease
Beta1 agonists Stimulate beta1 receptors in heart Increase HR Contractility Automaticity Conduction velocity Examples Dobutamine Dopamine (at 5-10 mcg/kg/min)
Dobutamine Predominately a beta1 agonist that increases contractility and CO
Milrinone Phosphodiesterase inhibitor Relaxes smooth muscles (vasodilator) Increases contractility Decreases afterload Used in dilated cardiomyopathy (CMP) when dobutamine is ineffective
Drugs to decrease HR Tachydysrhythmias decrease CO: By shortening diastolic filling time Especially detrimental in heart failure (HF) patients Metoprolol Alpha-beta blockers Labetalol Carvedilol Diltiazem
Metoprolol Cardioselective beta1 blocker Decreases HR and results in reduced myocardial oxygen consumption Monitor patient for bradydysrhythmias Contraindicated in patients with second- or third-degree atrioventricular (AV) block without a pacemaker
Alpha-beta blockers Labetalol - Used to treat hypertension Carvedilol - Used to treat HF Decreases HR and contractility (beta1 receptors) Causes vasodilation and reduces afterload (alpha receptors) Contraindications:patients with second- or 3rd-degree AV block w/o pacema
Diltiazem Calcium channel blocker Decreases HR Slow conduction through AV node Commonly used for supraventricular tachycardia (e.g., atrial fibrillation) Contraindicated in patients with second- or third-degree AV block without a pacemaker
Elevated afterload in dilated CMP or HF Angiotensin-converting enzymes (ACE) inhibitors Enalapril Angiotensin II receptor blockers (ARBs) Candasartan Positive inotropes Dobutamine Dopamine Milrinone
HF and volume overload Loop diuretics Interfere with sodium and water reabsorption in loop of Henle Furosemide or bumetadine Aldosterone antagonists Inhibit sodium and water retention Potassium sparing Caution with potassium-sparing ACE inhibitors Spironolactone
ARBs and ACE inhibitors Inhibit renin-angiotensin-aldosterone system Promote vasodilation and sodium and water loss May cause symptomatic hypotension, as well as diuretics Especially in the first hour of administration Monitor vital signs
Nesiritide Newest drug for treating acute decompensated HF Recombinant B-type natriuretic peptide Promotes diuresis and natriuresis Results in sodium and water loss Vasodilator Decreases SVR Decreases systolic blood pressure Increases CO without increasing H
Mission of board of nursing Protect welfare of the people of Texas
position statements provide more information on topics that may confuse nurses
Why a license is required to ensure the competency of practice
continuing educations requirements 20 contact hours within 2 years
Duty to patient cannot be superseded by hosp or doctor
Board fulfills it mission through Regulation of Nursing Practice Approval of nursing education programs
Texas Legislature Changes or amends bills that impact the Nursing Practice Act
Board of Nursing Responsible to public Validates nurse’s skills, knowledge, abilities No jurisdiction in facility policy Prohibited from lobbying legislature
Board Members Appointed by the Governor Confirmed by Senate Represent Nursing Practice Nursing Education Consumers
RN and LVN Insignia Nurses required to wear an insignia with name and title
Change of Name or Address Nurse must notify BON of name or address change Has 10 days Must send copy of the document changing the name Rule 217.7
Nursing Licensure Compact A legal agreement between states who are members Bill to enter Texas into Compact signed into law in 1999
Ethical Conduct in Nursing Influenced by Nurse’s Power Knowledge (licensure) Access to personal and financial information Physically/emotionally exposed Control client’s actions and environment
Ethical Conduct in Nursing Influenced by Client’s Vulnerability Illness/sedation Knowledge deficit Age Disability Fear retribution
Good Professional Character Important because behavior indicates individual is able to consistently conform with generally accepted standards of nursing practice
Factors that may indicate Good Professional Character Ability to practice nursing in autonomous role Ability to recognize and honor interpersonal boundaries Ability to self-disclose facts, circumstances, events or errors to enhance health status of clients
Professional Boundaries The space “between the nurse’s power and the client’s vulnerability”
Unprofessional Conduct Failure of clinical nursing instructor to adequately supervise student experiences Falsifying reports, client documentation and agency records Threatening or violent behavior in the workplace Failure of the nurse to consistently arrive at work on time
Supervision vs. Delegation Defined as the active process of directing, guiding, and influencing the outcome of a person’s performance of a task Mere act of supervision does not infer RN delegation Teaching client’s family is not delegation LVNs assign; do not delegate
RN Delegation Use Nursing Process Do not delegate tasks that require independent nursing judgment Delegate to Unlicensed Assistive Personnel “UAP” RNs do not delegate but assign to LVNs
Prohibited from Delegation Nursing assessments Plan of care Professional judgment and intervention Responsibility and accountability for teaching
Tasks Most Commonly Delegated Non-invasive and non-sterile treatments Collecting, reporting, and documentation of data Ambulation, positioning, turning Transportation within a facility Personal hygiene and elimination, Feeding, or placing of meal trays Activities of Daily livin
Discretionary Tasks Sterile procedures involving a wound or anatomical site which could potentially become infected Non-sterile procedures such as dressing or cleansing penetrating wounds or deep burns Invasive procedures – inserting tubes in a body cavity
Tasks Not Within Scope Nursing Judgment to Delegate Physical, psychological, social assessment Formulation of nursing care plan and evaluation tasks That required professional nursing judgment or intervention Responsibility and accountability of client health teaching meds except med aides
RN May Not Delegate Calculation of medication doses Administration of initial dose of medication not previously administered to client medications by injectable route except for insulin receiving verbal or telephone orders ordering client’s medication from pharmacy
Delegation FAQ’s Paramedics/EMTs are unlicensed personnel in ER/Acute care setting Student nurses or foreign-trained nurses not yet licensed in Texas cannot perform prohibited tasks (ex: nursing assessment, care planning) in any setting
Nasal cannula 1/4 to 8 liters per min 22 - 45% FIO2 stable pt. with known needs
Simple Mask 5 - 12 lpm 35 - 50 FIO2 pt who can't use or tolerate nasal cannula. Emergency use short term therapy
partial re-breathing mask 6 - 10 lpm 35 - 60 FIO2 Emergency use requiring moderate to high FIO2
Non re-breathing mask 10-15 lpm 55 - 70 FIO2 Emergencies requiring high FIO2
Vent setting typical resp rate 6- 20 breaths per minute
typical tidal volume vent setting 10-12 ml/kg
typical oxygen concentration vent setting FIO2 May be set between 21% and 100%adjusted to maintain Pao2 level greater than 60 mm Hg or Spo2 level greater than 90%
Positive End Expiratory Pressure (PEEP) 3-5 CM/H2O
Pressure Support 5-10 cm/h2o
respiratory flow rate and time 40-80 liters per min
Inspiration/expiration ratio 1:2
High pressure vent alarm probably an obstruction
Low pressure vent alarm check for leaks
ARDS - Acute Respiratory Distress Syndrome Acute in onset Ratio of partial pressure of oxygen to fraction of inspired oxygen less than or equal to 200 mm Hg Bilateral infiltrates Pulmonary artery occlusion pressure (PAOP) less than or equal to 18 mm Hg
ARDS - Medications Bronchodialators, steroids, sedatives, analgesics
ARDS - Complications Encephalopathy, cardiac disrhythmias, GI bleeding, venous thrombosis
Acute lung injury vs ARDS The only difference in definition is that ARDS has 200 mm/hg pao2 to fio2 ratio and ACL has 300 mm/hg
Purpose of PEEP improve oxygenation while reducing FIO2 to less toxic levels open closed alveoli stabilizing flooded alveoli Increasing FRC
Why PEEP can be neg decrease cardiac output because of increased intrathoracic pressure barotrauma
Noninvasive respiratory device bipap cpap
SIMV - synchronous intermittent mandatory ventilation delivers gas at a preset tidal volume or pressure and rate while allowing the patient to breathe spontaneously. Ventilator breaths are synchronized to the pt's respiratory effort.
Assist Control The vent delivers a fixed volume but the pt initiates the breath.
Control The vent pushes in a breath not influenced by the patient.
Pressure cycled modes deliver a fixed pressure at variable volume (neonates)
Volume cycled modes deliver a fixed volume at variable pressure (adults)
Pressure Cycled modes - triggered by pt. own breath pressure support ventilation pressure control ventilation cpap bipap
Volume cycled modes - SIMV - Synchronous intermittent mandatory ventilation Control- not influenced by pt Assist control - pt starts to breath and gets whole tidal volume
Vent setting to improve oxygenation PEEP - increases the functional residual capacity. Prevents progressive atelectasis and intrapulmonary shunting. Prevents repetitive opening and closing injuries. Improve VQ matching
pulmonary shunting blood moves past alveoli but doesn't get any oxygen because of alveolar collapse.
Conditions that result in pulmonary shunting infection, fluid buildup, CHF, or anything that cause fluid to be in the alveoli instead of air.
Ventrui mask precise % of O2
What happens with too much O2 oxygen toxicity - overabundance of oxygen free radicals damage alvelor capillary membrane. Can initiate acute lung injury. Carbon Dioxide retention in pts with COPD, Absorption atalectasis washes out the nitrogen that holds the alveoli open.
PAO2/FIO2 ratio Greater than 300 lower value the worse the lung function.
VT - Tidal volume - the volume of air moved in and out of the lungs with each normal breath typical 7 ml/kg
Functional residual capacity the volume of air remaining in the lungs at the end of a normal expiration - normal 2000ml
VE minute ventilation - volume of air expired per min 5-10 liters
VD - Dead space the amount of air contained in the bronchial s and throat that is not used for ventilation typical 33% of min ventilation.
Weaning from Mechanical Ventilation disease process is resolving Hemodynamically stable Adequate level of consciousness to assist Minimal need for sedatives of other medications that may cause respiratory depression Nutritionally sound with adequate total protein and albumin levels
Oxygen risks fire, trauma to face, drying of mucus membranes
FIO2 Fraction of inspired oxygen
PIP Peak respiratory pressure normal value 40 -80
Relationship between PaO2 and SaO2 Critical zone PaO2 decreases to less than 60 mm Hg
Steps for Weaning Procedure explained to patient Adequately rested and positioned for comfort Baseline parameters obtained Monitored for tolerance Terminal weaning – withdrawn from terminally ill patient
Virchow's Triad hypercoaguability injury to vascular endothelium venous stasis
Where are the bubbles in a chest tube drainage system suction control portion
Parasympathetic nervous system Releases acetylcholine via stimulation of vagus nerve Causes decrease in sinus node discharge and slows conduction through AV node
Coronary Circulation Right coronary artery Left coronary artery Splits into two branches Left anterior descending - (The Widdow Maker) Left circumflex Blood flow occurs during diastole
S1 caused by closure of mitral and tricuspid valves Heard best at apex (5th intercostal space, left midclavicular line)
S2 caused by closure of aortic and pulmonic valves Heard best at second intercostal space at R or L sternal border
Orthotopic Heart Transplants Replacement of the heart in the native position
Heart transplant what is left All of recipient’s heart is removed except posterior walls of the atria that contain the orifices of the pulmonary veins and vena cava
Heart transplant post operative concerns Cardiac tamponade Fresh plasma or fresh frozen plasma may benefit patients who have had chronic right ventricular failure, subsequent liver enlargement, abnormal coagulation studies Rejection Complication of Biopsy Infection CMV
Complication of Left sided heart faiure pulmonary edema
Complication of Right sided heart failure peripheral edema jugular vein distention hepatomegaly
Class I agents Sodium Channel blockers slow rate of depolarization of pacemaker cells
Class II Beta adrenergic blockers inhibit dysrhythmias ex metoprolol propranolol
Class III Slow rate of phase 3 repolizeration amiodarone
Class IV Calcium Channel blockers - inhibits influx of calcium during plateu phase ex verapamil diltiazem (slow rate increase contractility)
Parasympathetic nervous system Releases acetylcholine via stimulation of vagus nerve Causes decrease in sinus node discharge and slows conduction through AV node
Coronary Circulation Right coronary artery Left coronary artery Splits into two branches Left anterior descending - (The Widdow Maker) Left circumflex Blood flow occurs during diastole
S1 caused by closure of mitral and tricuspid valves Heard best at apex (5th intercostal space, left midclavicular line)
S2 caused by closure of aortic and pulmonic valves Heard best at second intercostal space at R or L sternal border
Orthotopic Heart Transplants Replacement of the heart in the native position
Heart transplant what is left All of recipient’s heart is removed except posterior walls of the atria that contain the orifices of the pulmonary veins and vena cava
Heart transplant post operative concerns Cardiac tamponade Fresh plasma or fresh frozen plasma may benefit patients who have had chronic right ventricular failure, subsequent liver enlargement, abnormal coagulation studies Rejection Complication of Biopsy Infection CMV
Complication of Left sided heart faiure pulmonary edema
Complication of Right sided heart failure peripheral edema jugular vein distention hepatomegaly
Class I agents Sodium Channel blockers slow rate of depolarization of pacemaker cells
Class II Beta adrenergic blockers inhibit dysrhythmias ex metoprolol propranolol
Class III Slow rate of phase 3 repolizeration amiodarone
Class IV Calcium Channel blockers - inhibits influx of calcium during plateu phase ex verapamil diltiazem (slow rate increase contractility)
Typical Systolic BP 90 -140
typical diastolic 60-90
typical MAP 70-100
Cardiac output 4-8 l/min
Central venous pressure (right atrial pressure ) 2-6 mg/hg
Pulmonary artery pressure PAS - 20 -30 pulmonary artery systolic PAD - 8-12 pulmonary artery diastolic PAM 25 pulmonary artery mean
Pulmonary capillary wedge pressure 4-12 mm/hg
Pulmonary vascular resistance 37 - 250 dynes/sec/cmto the 5th
Stroke volume 50 - 100 ml
Electrical conduction of the heart SA node to the AV node Bundle of HIS to purkenje fibers.
Created by: kcorkinsnctc