問題一覧
1
What is the treatment for Afib & Aflutter? + note
1. Rate control, 2. Prevent thromboembolism, 3. Rhythm control: -Chemical -Direct current cardioversion -Catheter ablation, Note: we care about atrium & ventricle b/c of remodeling and fibrosis
2
What are the Rate Controlers?
1. Beta blockers -Esmolol (Brevibloc), metoprolol (Lopressor), propranolol (Inderal), carvedilol (Coreg), atenolol (Tenormin) -control ventricles, 2. Calcium channel blockers -Verapamil (Isoptan, Calan), diltiazem (Cardizem) -we like to try to save these for exacerbation use, 3. Digoxin (Lanoxin) -not as commonly used anymore, 4. Amiodarone (Cordarone) -can cause H2O retention
3
What is the most common Beta Blocker used for Rate control?
Metoprolol Tartrate: -Taken twice a day -Short acting, good for 10 to 12 hours -More effective but less compliance, Metoprolol Succinate: -Taken once a day -Long acting -Decent control and good compliance, -Patient is often started on Tartrate at hospital due to effectiveness -Patient is converted to Succinate once discharged due to better compliance at home
4
What is the Action & Use for Diltiazem (Cardizem)?
Inhibits movement of Ca across cardiac and arterial muscle, Slows cardiac conduction (hope to follow only one impulse), Decreases contractility, Dilates coronary arteries, Used to control RVR (rapid ventricular response), aflutter, afib, SVT
5
What are the Administration and Interventions for Diltiazem (Cardizem)?
Give IV infusion then oral, Monitor VS, Cardiac monitor, STOP use if experiencing: -hypotension -bradycardia -have acute congestive heart failure
6
Who the Hell is Chad2 and his friend Chads2 Vasc2!? & Why does it matter?!
A clinical prediction tool/rule for estimating the risk of stroke in people with non-rheumatic atrial fibrillation, Chads2 Vasc2, This is a refinement of the tool for the risk of stroke in patients with A-fib, IT MATTERS BC YOU NEED TO CHART IT AS A NURSE!!!!!!
7
Prevent Thromboembolism: Vitamin K agonist: Warfarin (Coumadin) + note
Target INR: -2.0 to 3.0 (unless over 75 y.o. then 1.6 to 2.5) -If artificial valve: 2.5 to 3.5, Antidote: Vitamin K, Note: -Only drug we had until 7 yrs ago -Has a lot of interactions -Patients come into ER with profuse bleeding -Requires weekly blood draws -Harder to clot & increases bleeding problems
8
Prevent Thromboembolism: Heparin or Enoxaparin (Lovenox): + note
Unitl therapeutic warfarin OR when surgical procedures, Target PTT: -low intensity: 60 to 80 -high intensity: 60 to 100, Antidote: Protamine Sulfate, Note: -Remember aptt goes with Heparin, double tt’s look like H
9
Prevent Thromboembolism: Direct thrombin inhibitor: Dabigatran (Pradexa), Rivaroxaban (Xarelto), Apixaban (Eliquis) + note
No anticoagulation studies, FDA recently approved antidotes (Praxabind & Andexxa), Note: -no blood draws needed -works by Factor 10A -pradaxa was the first to challenge warfarin, it was the game changer -can be costly -stopped a day or 2 before surgery
10
What are the Chemical Rhythm Controllers?
Flecanide (Tambocar), dofetilide (Tikosyn), propafenone (Rhythmol), ibutilide (Corvert) -Serial EKG (tik) -Started in hospital, keep 4-3 days in hospital (tik) -Look at Q-T (tik), Amiodarone (Cordarone), dronedarone (Multaq) -Swelling (am) -Worst pulmonary risks (am) -costly (mul) -game changer (mul) -bid (mul), Digoxin (Lanoxin) & sotalol (Sirine) only if dc cardioversion -Last resort (dig), These control ventricle rate & keep atrium & SA under control
11
What is Cardioversion? + note
Timed electrical shock to stop re-entry, Sedation, Emergency equipment, Anticoagulants for 3-4 week prior to and following after unless < 48 hours from onset and no evidence of thrombus, Note: -Home on warfarin for 4-6 weeks first -Esophageal Echo is done to check for Left atrial appendage -Cardiversion resets whole cycle -Crash cart is near by during it
12
What is Catheter Ablation? + note
To maintain Sinus Rhythm in patients with treatment failure, Best outcome if performed in an experienced center (perform > 50 ablations per year), No evidence-based guidelines on procedure operator, Note: -May take 2 to 3 ablations for afib -May have tried cardioversion once first before receiving ablation -They look at pulmonary vein closely -Works great for aflutter -70 to 75 percent effective
13
What is Atrial appendage closure?
Close atrial appendage, the primary source of blood clots in afib, Approaches: -Open heart -Cath lab -Percutaneous ligation -Cardiac plug, Use a watchman device, umbrella shaped, filters out blood clots, sometimes done if pt can’t take blood thinners ex. parkinsons, or fall risks
14
Dysrhythmias Orginating in the Ventricles: What are rules of interpretation for Ventricular Escape Complexes and Rhythms?
Rate: 15-40, Rhythm: escape complex, irregular; Escape rhythm, regular, Pacemaker site: Ventricle, P waves: none, PRI: none, QRS: 0.12 seconds (3 boxes) or wider; bizarre
15
Dysrhythmias Orginating in the Ventricles: What are the rules of interpretation for Premature Ventricular Contractions?
Rate: underlying rhythm, Rhythm: Interrupts regular underlying rhythm, Pacemaker site: Ventricle, P waves: none, PRI: none, QRS: >0.12 seconds (> 3 boxes), bizarre, Causes: caffeine, alcohol, dehydration, nicotine, low K, low magnesium, Note: -No T wave is evidence of a old heart attack, Treatment: -Give O2 -BMP -K & Magnesium check
16
Premature Complexes: Picture is an example of what?
Multi-focal
17
Premature Complexes: Picture is an example of what?
Premature Atrial Contraction
18
Premature Complexes: Picture is an example of what?
Unifocal
19
Premature Complexes: Picture is an example of what?
Multi-focal
20
Premature Complexes: Picture is an example of what?
Runs w/ PVCs ———> leads to v tach
21
Dysrhythmias Orginating in the Ventricles: What are the rules of interpretation for Ventricular Tachycardia?
Rate: 100-250, Rhythm: Usually regular, Pacemaker site: Ventricle, P waves: Usually absent, if present, not associated with QRS, PRI: None, QRS: >0.12 seconds (> 3 boxes), bizarre, Treament if stable: -O2 -EKG -Cardioversion, Treatment if unstable: -O2 -Cardioversion, Treatment if pulseless: -defibrillator
22
Dysrhythmias Orginating in the Ventricles: What are the rules of interpretation for Ventricular Fibrillation? + note
Rate: No organized rate, Rhythm: No organized rhythm, Pacemaker site: Numerous ventricular foci, P waves: Usually absent, PRI: None, QRS: None, Note: -No real rhythm -Quivering, not contracting -Chaotic, not pumping, Treatment: -CPR (to get blood flowing and ox moving) -Defibrillator
23
What is a Defibrillator?
Asynchronuous countershock depolarizes myocardium to allow SA node to regain control, Early defib increases the chance of survival 73%, Types: -AED -Manuel -Implanted -External vest, Know: -Mono-phasic not used anymore -Bi-phasic sends electrical impulses in both directions
24
Dysrhythmias Orginating in the Ventricles: What are the rules of interpretation for Asystole?
Rate, Rhythm, & Pacemaker site: No electrical Activity, P waves, PRI, & QRS: Absent, THEY’RE FUCKING DEAD, Do CPR until they get a pulse
25
Dysrhythmias Orginating in the Ventricles: What are the rules of interpretation for Artifical Pacemaker Rhythm? + note
Rate: Varies with pacemaker, Rhythm: May be regular or irregular, Pacemaker site: Depends upon electrode placement, P waves: May or may not be present; pacemaker spike, PRI: If present, varies, QRS: > 0.12 seconds (> 3 boxes), bizarre, Note: -Used for permanent afib, if meds didn’t work, & failed cardioversion
26
What are the Types of Pacemakers?
Temporary: -Transcutaneous -External -Epicardial, Permanent: -Ventricular -Atrial - ventricular -Biventricular -S-ICD
27
What are Precautions for Pacemakers? + note
Incision care, Restrict arm motion for 1-2 months, Avoid electromagnetic fields, Regular follow up, Note: -Pacemakers make heart muscles squeeze -Avoid reaching over head or outward -Can pace atrium or ventricles or biventricular(if major heart attack) -If underlying rhythm of 40 bpm pace is used to get up to 60 bpm -Will put in pacemaker if ablation is not a good option -Not for if afib comes and goes
28
What is PEA?????
PULSELESS ELECTRICAL ACTIVITY, Electrical activity without mechanical activity (no squeeze)
29
What is the treatment for PEA?
1. Check pulse, 2. CPR, 3. Fluids (lost volume), 4. Epi , 5. Fix cause
30
What are the causes of PEA? 5 H’s
Hypovolemia (#1 cause), Hypoxia, Hydrogen ions (acidosis), Hypo/ Hyperkalemia , Hypothermia
31
What are the causes of PEA? 5 T’s
Toxins, Tamponade (cardiac), Tension pneumothorax, Thrombosis (coronary or pulmonary), Trauma, Also: -Massive MI -Overdose of tricyclic antidepressants
32
What are signs and symptoms of PEA?
Pulselessness, Loss of consciousness, No palpable BP
33
Name that rhythm, treatment and causes:
Aflutter, Treatment: -Cardioversion -Beta blocker -Cardizem -Amiodarone, Causes: -Hyper/hypoparathyroidism -Heart failure -MI -Valve disease
34
Name that rhythm, Treatment, and concern:
Afib, Treatment: -Cardizem bolus & drip -Beta blocker -Rhythm controler -send home on Eliquis or Xarelto, Conern: -Stroke
35
Name that rhythm & treatment:
Asystole, Treatment: -CPR until get pulse -then defibrillator
36
Name that rhythm, causes, & treatment:
Mulitfocal PVC, Causes: -Prveious MI -Hypoxia -CHF, Treatment: -Oxygen -Amiodarone -Mag if low -K if low -Ecterolyte panel & Thyroid panel needs to be done, BMP
37
Name the rhythm and concern:
V-Tach, Conern: -Low volume -Low oxygen -Not enough blood pump -Organ failure, brain damage, death
38
Name the rhythm, concern, & treatment:
V-fib, Conern: -Quivering, no pattern -Low oxygen -Low volume -Bleeding out, Treatment: -CPR -Defibrillator
39
Name the rhythm and note:
Ventricular Paced Maker, Note: -100% paced -Pacer spike between each QRS (picture-ventricular) -If pacer spike before p wave & before QRS, it’s pacing both atrium and ventricle, Example: Can happen if MI causes HF which causes atrial damage which means we’re only worried about pacing the ventricles
40
A 33 y.o. women with a history of tachycardia comes to the hospital clinic stating that she doesn’t feel well. The nurse connects the client to a cardiac monitor and observes a rate of SVT varying between 160 and 180 bpm. She reports shortness of breath, palpitations, and weakness. She appears very anxious. The BP reading is 88/56 mm Hg. What is the nurses initial action?
Oxygen at 2L (work way up), IV access (to support BP)
41
Later, the client is still in SVT, and reports feeling much better other than “having some palpitations.” The heart rate is 150 bpm. Which action does the nurse anticipate will be ordered by the health care provider?
Administration of adenosine followed by a saline bolus
42
The SVT resolves immediately after IV adenosine is administered. Because the client has experienced repeated episodes of symptomatic SVT, a cardiologist has been consulted and treatment options discussed. What is the preferred treatment for recurrent SVT?
Radiofrequency Cather ablation
43
When working in a clinical setting, which dysrhythmia does the nurse identify as most common?
Atrial Fibrillation
44
The nurse is caring for a client with episodes of spontaneous sustained ventricular tachycardia (VT) who is to have an implantable cardioverter/defibrillator placed. What is the priority nursing action?
Assess client for ability to cope with discomfort and fear
45
A client admitted to a telemetry unit with a new diagnosis of atrial fibrillation (AF) tells the nurse, “I feel fine, there’s nothing wrong with me.” Which nursing response is appropriate?
“AF can cause clots to form from irregular blood flow in the heart.”