N303
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Balance of Fluids & Electrolytes | Homeostasis
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is vital to neuromuscular function and acid based balance | Electrolyte balance
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Inflammation and decreased protein cause | Fluid shifts
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Fluids are drawn to | Na+ and glucose
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Decreased concentration to increased concentration (cell -> Vasc. space) | Osmosis
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Increased concentration to decreased concentration (vasc. space -> cell) | Diffusion
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Pulls fluid in | Osmotic pressure
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Push fluid out | Hydrostatic pressure
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Decreased BP, Hypovolemia, Hyponatremia, Hyperkalemia cause: | Adrenal gland to secrete aldosterone;
Kidney retains H2O & Na+, Excretes K+
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The concentration of fluid that affects the movement of water between fluid compartments | Osmolality
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The higher the osmolality the greater the pulling power of water. (_______ pressure) | Osmotic
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Drawn to H+ ions | Chloride
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Maintain acid balance | Bicarbonate
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Move fluids into diff. spaces Intravasc. -> ICF/ECF | Crystalloids
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D5 & H2O: Iso in bag, _____ in body. Body metabolizes sugar, H2O is _____. | Hypotonic
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Hypotonic solution | Cells grow
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Isotonic Solution | Volume Expansion
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Hang Blood | Hang ISO
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D5 1/2 NS ________ in bag ________ in body | Hyper
Hypo
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Hypertonic solution | Cells Shrink
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Contain proteins (ex. albumin) that remain intravascular and pull fluid from cells & interstitial space (very high osmotic pressure) | Colloid
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Interstitial edema, +2 pitting edema Swollen legs -> fluid in interstitial spaces | Second Spacing
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M: 37 - 49 F: 36 - 46 | Hematocrit (HCT)
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8 - 22 mg/dL | Blood Urea Nitrogen (BUN)
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135 - 145 mEq/L | Na+
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70 - 110 mg/dL | Glucose
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Fluid accumulates where fluid is not normally at in large amounts: anasarca | Third Spacing
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Give colloids + diuretics to get the fluid back where it belongs | Third Spacing
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98 - 106 mEq/L | Chloride (Cl-)
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8.5 - 10 mg/dL | Calcium (Ca+)
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3.5 - 5.0 mEq/L | Potassium (K+)
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1.3 - 2.1 mEq/L 1.6 - 2.6 mg | Magnesium (Mg+)
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1.7 - 2.6 mEq/L 2.5 - 4.5 mg | Phosphate (PO4-)
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275 - 295 mOsm/kg | Serum Osmolality
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M: 14 - 18 gm/dL F: 12 - 16 gm/dL | Hemoglobin (Hgb)
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First line med for V-tach | Amiodarone
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2nd line med for V-tach | Lidocaine
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Shockable??? | V-tach
V-fib
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Unstable, pulseless V-tach | Call Help
Call Code
Start CPR
D-fib
Epinephrine
Vasopressin
Amiodarone
Lidocaine
Resuscitation
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Stable V-tach w/pulse | Amiodarone
Lidocaine
Mg+, K+
Sync Cardiovert
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HR >180 Acute MI, CAD, Cardiomyopathy, Heart Failure, Valvular disease K=, Mg+ imbalance Artifact - Ck. Pt. | V-Tach
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Amiodarone Lidocaine | Antiarrhythmics
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40 - 60 bpm No P wave - No Atrial Kick Always Regular | Junctional Escape
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HR 150 - 250 bpm Always Regular May or may not see P waves Drug of choice: Adenosine | Superventricular Tachy (SVT)
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O2 IV access Heart monitor Vagal maneuvers Adenosine | Stable SVT Treatment
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ADENOSINE - Chest pain, Dropping BP, other distress Ca+ Chan Blocker Beta Block Cardiovert - LAST RESORT | Unstable SVT Treatment
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Control HR & Rhythm Diltiazem Amiodarone Digoxin | Atrial Tachy Treats
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Sinus Node Disease Meds (Beta Blocks) Hypoxia Athletes | Sinus Brady Causes
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O2 IV Access Atropine Sulfate(if symptomatic) Continuous Monitoring | Sinus Brady Treats
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Blocks PNS to Increase HR anticholinergic | Atropine Sulfate
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"Early" Atrial depolar Usually Asymptomatic Treat the cause | PAC - Premature Atrial Contraction
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Stress, anxiety, fatigue, infection, lack of sleep, meds, cafiene, Heart failure, Electrolyte imbalance, MI | PAC causes
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Chaotic firing of Atrium - No Pattern Irregularly - Irregular No meaningful P waves Loss of Atrial Kick Decrease C.O. 20 - 30% | A-Fib
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Amiodarone | A-fib
(treats arrhythmias)
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HR 100 - 150 ALWAYS has a cause: anxiety, pain, fever, activity, dehydration, Heart fail, anemia FIX CAUSE -> FIX RHYTHM | Sinus Tachy
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FIX CAUSE -> FIX RHYTHM Give O2 Beta Blocks (lopressor) Ca+ Chan Blocks (Decrease HR) | Sinus Tachy Treats
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Beta Blocker - Decreases HR | Lopressor
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HR>250 bpm - SAWTOOTH Conduction Ration P:QRS -> 4:1 | A-Flutter
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Cardioversion Ca+ Channel Blocks Beta Blocks Digoxin | A-Flutter Treats
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Ideal RASS Score | -2: Lt. Sedation - Briefly awakens w/eye contact to voice (<2 secs)
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HOB > 30* Prevent Stress Ulcer DVT Prophylaxis Sedation Vacation Oral Care q2hrs Weaning Trial | Vent Bundle
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Low Pressure Alarm | Leak in Line or disconnection
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High Pressure Alarm | Resistance in circuit:
Kinked Tube
Pt. Biting Tube
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AIR IN Amt air delivered to lungs -> 1 breath 5-12 mL | Tidal Volume
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3-5 cm H2O > 20 + Dmg can occur Keeps Alveoli inflated during expiration | PEEP
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Hyper inflated lungs take space from Heart -> Heart can't fully open and close -> Increases PEEP -> | Increased PEEP -> Decreased C.O.
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Assist Control Vent (set # of guaranteed breaths) | CPAP to wean from vent (Pt breathes on own -> alarm for Apnea)
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Coumadin Reversal | Fresh Frozen Plasma
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Left Heart Failure Manifestations? | Decreased C.O. -> Weak peripheral Pulses
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Electrical CHAOS!!! Vents wiggle -> No Squeeze -> No Pulse -> Pt. Always Unconscious #1 Cause: Acute MI D-Fib w/in 5 mins or DEAD! SHOCKABLE!!! | V-Fib
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#1 Cause of V-Fib | Acute MI
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Hypo & Hyperkalemia can cause: | V-Fib
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Hypovolemia Hypoxia Hypoglycemia Hypothermia | V-Fib Causes
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Conduction problem in the AV Node | AV Blocks
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A-V Node Conduction Delay PR >.20 Usually age, Asymptomatic & Benign | 1st* AV Block
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Mobitz I (Wenkebach) Mobitz II | 2nd* AV Block
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PR Lengthens PROGRESIVELY Less Serious Treat Symptoms AV Node can't keep up - usually temporary and fixes itself | Mobitz I (Wenkenbach)
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PR same & constant More Serious Some QRS's Drop | Mobitz II
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MI AV Node/Bundle Branch disease More serious than Type I | AV Block Type II
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Atropine Dopamine Epinephrine Temporary Pacemaker, if unstable | AV Block Type II - Treatments
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AV Node can't keep up _-> P progressively lengthens until QRS drops off -> Starts over -> Temporary, No treatment | Mobitz I (Wenkenbach)
2nd* AV Block
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P wave w/o QRS -> usually rqrs. Pacemaker (if unstable) -> Atropine, Dopamine, Epinephrine | Mobitz II
2nd* AV Block
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Complete Heart Block Decreased C.O. LOC, Syncope, can progress to Asystole SERIOUS!!! | 3rd* AV Block
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Atria <- No Communication with -> Ventricle ALWAYS more P's than QRS's | AV Block Type III
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Meds: Digitalis toxicity Degenerative Heart Disease Acute MI Myocarditis | 3rd* AV Block
Causes
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Treat symptoms Usually gets perm. pacemaker Atropine, Dopamine, Epi. - while awaiting pacemaker | 3rd* AV Block
Treats
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One of the 2 Bundle Branches is blocked Wide QRS >0.12 12 lead EKG -> determine R or L Not treated unless acute | Bundle Branch Blocks (BBB)
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Causes Acute conditions - MI or Heart Fail Increased HR | Bundle Branch Blocks (BBB)
Temporary
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Causes: Infarct of Bundle Branch Congenital Heart Disease Rheumatic Heart disease Cardiomyopathy Severe aortic stenosis Any heart disease causing scarring of conduction system | Bundle Branch Blocks (BBB)
Permanant
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Pt: HR 40, Sinus Rhythm, SOB, Chest pain, BP 87/60 | Symptomatic Bradycardia
Give Atropine 1 mg IV to increase HR
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Pt: Heart beating out of chest, diaphoretic, Tachypneic, BP 70/40 Heart Monitor: SVT Valsalva & 3 doses Adenosine - NOT working Immediate action?? | Unstable SVT
Valsalva & Adenosine Failed...
Prepare for Synchronised Cardioversion
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8 hrs. post CABG: Report what? Mediastinal drainage of 100 mL/hr T: 98.8* BP 160/80 K+ 3.8 | Increased BP -> Increased Vascular pressure may cause bleeding @ incision sites
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35 - 45 | PaCO2
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22 - 26 | HCO3-
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Necrosis of Heart Muscle do to lack of O2 Decreased O2 & Increased Demand | MI
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Peripheral Edema Jugular Vein Distension Ascites Heptomegaly Fatige | R Sided Heart Failure
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Tachycardia Dyspnea Decreased Cerebral perfusion SOB, Wt Gain, Confusion | L Sided Heart Failure
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CHEST PAIN?? M.O.N.A. | Morphine
O2
Nitro
Aspirin
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Congestive Heart Failure UNLOAD FAST | Upright
Nitrates
Lasix
O2
Ace inhibitors
Digoxin
Fluid Restrict
Afterload Decreased
Sodium restiction
Test (Dig, ABG, K+)
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Block Beta Receptors in Heart: Decrease HR, Force of contraction, Rate of AV Conduction | Beta Blockers
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Bradycardia, Lethargy, CHF, Depression, GI Disturbances, Decreased BP | Beta Blockers
S/E
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PropranOLOL (Inderal) AtenOLOL (Tenormin) MetroprOLOL (Lopressor) | Beta Blockers
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