Critical Care: Heart Blocks

**With heart blocks, the AV node is sick. Therefore the P-R INTERVAL will be abnormal.

I. FIRST DEGREE HEART BLOCK

  • HEART RATE: Variable
  • RHYTHM: Regular
  • P WAVES: Normal
  • P-R INTERVAL: consistently longer than 0.20 seconds
  • QRS WIDTH: Usually normal
  • INTERVENTIONS: Continue to monitor, IV, O2

II. SECOND DEGREE HEART BLOCK, TYPE I (WENCKEBACH, MOBITZ I)

  • HEART RATE: Variable
  • RHYTHM: Irregular
  • P WAVES: Normal; # of P’s > # of QRS
  • P-R INTERVAL: progressive lengthening on consecutive beats until you drop one QRS
  • QRS WIDTH: Usually normal, absent when blocked
  • INTERVENTIONS: Continue to monitor, IV, O2

III. SECOND DEGREE HEART BLOCK, TYPE II (MOBITZ II)

  • HEART RATE: Variable, slow
  • RHYTHM: Irregular
  • P WAVES: Normal; # of P’s > # of QRS
  • P-R INTERVAL: consistent when it happens, absent with blocked beats
  • QRS WIDTH: Usually normal, absent when blocked
  • INTERVENTIONS: transcutaneous pacemaker; *closely monitor, as it may lead to complete heart block!

IV. THIRD DEGREE (COMPLETE) HEART BLOCK

  • HEART RATE: Variable, slow
  • RHYTHM: Regular
  • P WAVES: Normal; # of P’s > # of QRS
  • P-R INTERVAL: Random
  • QRS WIDTH: Wide
  • INTERVENTIONS: transcutaneous pacemaker; may then need permanent pacemaker
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Critical Care: Atrial Rhythms

I. PREMATURE ATRIAL CONTRACTIONS (PACs)

  • HEART RATE: Variable
  • RHYHTM: Irregular
  • P WAVES: Abnormal configuration, 1:1 ratio
  • P-R INTERVAL: Variable, may be shorter
  • QRS WIDTH: Usually normal
  • INTERVENTIONS: Continue to monitor, check pulse

II. PAROXYSMAL/SUPRAVENTRICULAR TACHYCARDIA (P/SVT)

  • HEART RATE: 100-300
  • RHYTHM: Regular
  • P WAVES: Abnormal, may be hidden
  • P-R INTERVAL: Variable, may be hidden
  • QRS WIDTH: Usually normal
  • INTERVENTIONS: Continue to monitor, may use vagal maneuvers and adenosine, cardioversion if other measures are ineffective

III. ATRIAL FIBRILLATION

  • HEART RATE: Atrial – >350, Ventricular – depends on AV block
  • RHYTHM: Irregular
  • P WAVES: Fibrillatory waves, “scribble”
  • P-R INTERVAL: Absent
  • QRS WIDTH: Usually normal
  • INTERVENTIONS: Prevent clots with anticoagulants, rate control with calcium channel blockers

IV. ATRIAL FLUTTER

  • HEART RATE: Atrial – 250-300, Ventricular – depends on AV block
  • RHYTHM: Atrial – regular, Ventricular – varies with AV
  • P WAVES: “Sawtooth” flutter waves
  • P-R INTERVAL: Absent
  • QRD WIDTH: Usually normal
  • INTERVENTIONS: Prevent clots with anticoagulants, rate control with calcium channel blockers
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Critical Care: Sinus Rhythms

I. NORMAL SINUS

  • HEART RATE: 60-100
  • RHYTHM: Regular
  • P WAVES: Normal
  • P-R INTERVAL: Normal
  • QRS WIDTH: Normal
  • INTERVENTIONS: Continue to monitor, check pulse

II. SINUS BRADYCARDIA

  • HEART RATE: <60
  • RHYTHM: Regular
  • P WAVES: Normal
  • P-R INTERVAL: Normal
  • QRS WIDTH: Normal
  • INTERVENTIONS: Symptomatic? (low BP, pale, dizzy) – may need atropine; otherwise, monitor and check pulse

III. SINUS TACHYCARDIA

  • HEART RATE: >100
  • RHYTHM: Regular
  • P WAVES: Normal
  • P-R INTERVAL: Normal
  • QRS WIDTH: Normal
  • INTERVENTIONS: Determine causes (anxiety? pain?); may need beta blockers, calcium channel blockers, analgesics or antipyretics as appropriate

IV. SINUS ARRHYTHMIA

  • HEART RATE: Variable
  • RHYTHM: Irregular
  • P WAVES: Normal
  • P-R INTERVAL: Normal
  • QRS WIDTH: Normal
  • INTERVENTIONS: Continue to monitor, check pulse
Image Source: #1, #2.

Critical Care: Ventricular Rhythms, Asystole, PEA

I. PREMATURE VENTRICULAR CONTRACTIONS (PVCs)

  • HEART RATE: Variable
  • RHYTHM: Irregular
  • P WAVE: Normal
  • P-R INTERVAL: Normal
  • QRS WIDTH: Wide
  • INTERVENTIONS: Monitor; watch for sequences of PVCs which may lead to VTac

II. VENTRICULAR TACHYCARDIA (VTac)

  • HEART RATE: > 100
  • RHYTHM: Regular
  • P WAVES: None
  • P-R INTERVAL: None
  • QRS WIDTH: Wide
  • INTERVENTIONS: Check for pulse: if none, proceed to CPR & shock; otherwise, monitor; may need antidysrhythmics (Amiodarone, Procainamide)

III. VENTRICULAR FIBRILLATION (VFib)

  • HEART RATE: Variable, rapid
  • RHYTHM: Irregular
  • P WAVES: None
  • P-R INTERVAL: None
  • QRS WIDTH: Wild
  • INTERVENTIONS: EMERGENCY! Proceed to defibrillation, CPR & ACLS measures

IV. ASYSTOLE

  • NO heart rate; NO P waves, P-R intervals or QRS complexes
  • INTERVENTIONS: Check for causes*DO NOT shock!

V. PULSELESS ELECTRICAL ACTIVITY (PEA)

  • Any organized rhythm (other than VTac, VFib, asystole) with NO PULSE
  • INTERVENTIONS: First, CPR, intubation & ACLS measures; then look for causes
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Critical Care: Phases of Burn Care

PHASES OF CARE FOR THE BURN PATIENT:

  • Pre-hospital Phase
  • Emergent Phase
  • Acute Phase
  • Rehab Phase

I. PRE-HOSPITAL PHASE – primary concerns are ABC’s (airway, breathing, circulation)

  • Remove from the burn source
  • Check patency of airway and for adequate ventilation
  • Check for adequate circulation
  • Treat as needed – flush the skin for chemical injuries, remove clothing, 100% O2 for carbon monoxide poisoning
  • Prevent hypothermia – only cool for < 10 minutes

II. EMERGENT PHASE – main concerns are hypovolemic shock and edema

  • Airway management: may need intubation R/T edema or swelling of the airway, 100% humidified O2
  • Fluid resuscitation: 2 large bore IVs if 15% burn, central line if 30% burn
    Parkland (Baxter) Formula: 4 mL X kg X % Total Body Surface Area Burned (TBSAB)
    1/2 total in 1st 8 HRS
    1/4 total in 2nd 8 HRS
    1/4 total in 3rd 8 HRS
    Example: For a 70 kg patient with 50% TBSAB → 4 mL X 70 kg X 50 TBSAB = 14,000 mL in 24 hrs
    1/2 total in 1st 8 hrs = 7000 mL (875 mL/hr) ← to calculate, just divde 7000 mL/8 hrs
    1/4 total in 2nd 8 hrs = 3500 mL (437.5 mL/hr)
    1/4 total in 3rd 8 hrs = 3500 mL (437.5 mL/hr)
  • Wound care: debridement, escharatomies (an incision on the skin to relieve pressure due to edema), multiple dressing changes, room needs to be kept warm (85 degrees F), may need artificial skin
  • Pain management: analgesics, nonsystemic antimicrobial agents (Silverlon, Acticoat, Silvadene, Sulfamylon), thromboembolism prophylaxis (Lovenox), tetanus immunization
  • Nutrition: assess gastric residuals frequently, bowel sounds q8h, feedings usually started slowly at 20-40 mL/hr; may give calcium-containing supplements and milkshakes; supplemental vitamins in the emergent phase, iron in the acute phase

III. ACUTE PHASE

  • Wound care: debridement, topical antimicrobial creams (silver sulfadiazine, silver-impregnated dressings)
  • Excision and grafting: after 1-2 days, wound exicsion performed – important to maintain blood conservation and observe for circulation problems, coverage achieved with cultured epithelial autografts (grow skin from the patient’s own cells) or artificial skin
  • Pain management: 2 kinds of pain – background pain and treatment-induced pain, will need continuous IV opioids, around-the-clock management and may be even anxiolytics to potentiate pain relief, patient-controlled analgesia may also be used
  • Physical therapy: maintain joint function and prevent contractures, best times to perform active/passive range-of-motion exercises are during and after wound cleansing; patient’s with neck burns should sleep without pillows or neck dangling off the bed to hyperextend the neck

IV. REHAB PHASE

  • Range of motion exercises
  • Pressure bandages: used to keep scars flat, never worn over unhealed wounds
  • Relieve itching
  • Psychological support: patient may have permanent disfigurement due to scarring, assess for coping skills and family support
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Content derived from Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 8th Edition.

Foundations: Sequence for Removal of Personal Protective Equipment (PPE)

UNITE GOWN AT THE WAIST

REMOVE GLOVES

UNTIE GOWN AT NECK AND ALLOW TO FALL OFF SHOULDERS

DISCARD GOWN

REMOVE MASK

PERFORM HAND HYGIENE

Image Sources: #1, #2, #3#4, #5, #6.

Common Medication Suffixes

Below are common suffixes which identify a class of medications:

  • -ARTAN = angiotensin 2 receptor blockers (ARBs
  • -ASONE = corticosteroids
  • -AZOSIN = alpha blockers
  • -BICIN = antineoplastic, cytotoxic agents (cancer medications)
  • -BITAL = barbituates
  • -CAINE = local anesthetic
  • -CILLIN = Penicillin antibiotics
  • -CYCLINE = Tetracycline antibiotics
  • -DIPINE = calcium channel blockers
  • -FENAC = NSAIDs
  • -FLOXACIN = Fluroquinolone antibiotics
  • -IRAMINE = antihistamine
  • -ITIDINE = H2 antagonists
  • -LAX = laxatives
  • -NACIN = anticholinergic
  • -OLOL = beta blockers
  • -PAM = benzodiazepines
  • -PARIN = anticoagulants/antithrombotics
  • -PRAMINE = tricyclic antidepressants
  • -PRIL = ACE Inhibitors
  • -PROFEN = NSAIDs
  • -RAZOLE = proton pump inhibitors
  • -ROMYCIN = Macrolide antibiotics
  • -SARTAN = angiotensin 2 receptor blockers (ARBs)
  • -SEMIDE = loop diuretics
  • -SETRON = antiemetics, antinauseants
  • -STATIN = cholestrol medications
  • -VIR = anti-virals
  • -VUDINE = anti-virals
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Content Source: #1, #2.

Medical-Surgical: Cushing’s vs Addison’s Disease

CUSHING’S 

  • think moon face, buffalo hump, truncal obesity – a “cushy” appearance
  • HIGH in everything, EXCEPT potassium – hypernateremia, hypertension, hyperglycemia, hypokalemia

ADDISON’S 

  • think bronze skin, weight loss, decrease appetite
  • LOW in everything, EXCEPT potassium – hyponatremia, hypotension, hypoglycemia, hyperkalemia
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Maternal/Child Health (OB): Fetal Heart Tones Acronym

VEAL CHOP

Variable decelerations…..Cord compression
Early decelerations………Head compression
Accelerations…………….OK, may need Oxygen
Late decelerations……….Placental Insufficiency

INTERVENTIONS

Variable decels → reposition mother to knee-chest position to get baby’s head off the cord OR use two fingers to lift the baby’s head off the cord until further interventions required
Early decels → 
sign that baby is descending into the pelvis, monitor as needed
Accelerations → 
reassuring (normal) sign; last for 15+ seconds and peaks 15+ beats/min
Late decels →
worrisome sign; reposition mother, administer IV fluids and anticipate discontinuing/decreasing Oxytocin or administering a tocolytic to decrease contractions

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Critical Care: Hemodynamics

HEMODYNAMIC MONITORING: BASIC SETUP
Hemodynamic monitoring measures the oxygenation, flow and pressure of the cardiovascular system. Data obtained helps to assess trends over time concerning the patient’s fluid volume, response to cardiovascular medications and improvement of therapy.

PRINCIPLES
Referencing
 is the positioning of the pressure transducer so that it is at the level of the heart
Phlebostatic Axis is the landmark for referencing of the pressure transducer at the 4th intercostal space, midchest

Zeroing is the confirmation of the pressure within the system; procedure: open stopcock to off TO the patient and observe the monitor for a reading of zero. Zeroing is typically performed at the beginning of the shift, when the validity of reading is questioned or after position changes.

HEMODYNAMIC PARAMETERS [THERAPEUTIC VALUES] 
Preload:
Central Venous Pressure (CVP) or Right Atrial Pressure (RAP) [2-8 mmHg] 
Pulmonary Artery Wedge Pressure (PAWP) or Left Atrial Pressure (LAP) [6-12 mmHg]
Pulmonary Artery Pressure (PAP) [4-12/25 mmHg] 

Afterload:
Systemic Vascular Resistance (SVR) [800-1200 dynes]
Pulmonary Vascular Resistance (PVR) [<250 dynes]

Other:
Stroke Volume (SV) [60-150 mL/beat]
Cardiac Output (CO) [4-8 L/min]
Cardiac Index (CI) [2.2-4 L/min/m2]

Arterial Hemoglobin Oxygen Saturation [95-100%]
Venous Hemoglobin Oxygen Saturation [70%]

 

Image Sources: #1, #2.
Content derived from Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 8th Edition