“ “ Never let what you cannot do Never let what you cannot do interfere with what you can do” interfere with what you can do” - - John Wooden John Wooden - - CCRN REVIEW PART 1 CCRN REVIEW PART 1 Sherry L. Knowles, RN, CCRN, CRNI Sherry L. Knowles, RN, CCRN, CRNI
The CCRN Review prepares critical care nurses for the CCRN and PCCN certification exams and is an excellent review for other nurses and other health care professionals.
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““Never let what you cannot do Never let what you cannot do
interfere with what you can do”interfere with what you can do”- - John WoodenJohn Wooden - -
CCRN REVIEW PART 1CCRN REVIEW PART 1
Sherry L. Knowles, RN, CCRN, CRNISherry L. Knowles, RN, CCRN, CRNI
OBJECTIVESOBJECTIVES1.1. Understand the different types of acute coronary syndromes.Understand the different types of acute coronary syndromes.
2.2. Identify basic coronary circulation and how it relates to different types of Identify basic coronary circulation and how it relates to different types of myocardial infarctions.myocardial infarctions.
3.3. Anticipate potential complications associated with an AMI.Anticipate potential complications associated with an AMI.
4.4. Identify the standard treatment of an AMI.Identify the standard treatment of an AMI.
5.5. Distinguish between various AV blocks.Distinguish between various AV blocks.
6.6. Recognize the signs & symptoms of heart failure.Recognize the signs & symptoms of heart failure.
7.7. Identify the treatment of heart failure.Identify the treatment of heart failure.
8.8. Recognize the general definition and classifications of aortic aneurysms.Recognize the general definition and classifications of aortic aneurysms.
9.9. Understand the different types of aortic dissections.Understand the different types of aortic dissections.
10.10. Recognize the signs & symptoms of cardiomyopathy.Recognize the signs & symptoms of cardiomyopathy.
11.11. Differentiate between the different types of cardiomyopathy.Differentiate between the different types of cardiomyopathy.
12.12. Identify the treatment for the different types of cardiomyopathy.Identify the treatment for the different types of cardiomyopathy.
13.13. Understand the different stages of shock.Understand the different stages of shock.
14.14. Differentiate between different types of shock.Differentiate between different types of shock.
CCRN REVIEW PART 1CCRN REVIEW PART 1
OBJECTIVESOBJECTIVES15.15. Distinguish between arterial and venous peripheral vascular disease.Distinguish between arterial and venous peripheral vascular disease.
16.16. Identify the various treatments for peripheral vascular disease.Identify the various treatments for peripheral vascular disease.
18.18. Identify the various treatments for acute respiratory failure.Identify the various treatments for acute respiratory failure.
19.19. Recognize the signs & symptoms and causes of various respiratory Recognize the signs & symptoms and causes of various respiratory alterations.alterations.
20.20. Identify the standard treatment for various respiratory alterations.Identify the standard treatment for various respiratory alterations.
21.21. Identify the components of cardiac output and stroke volume.Identify the components of cardiac output and stroke volume.
22.22. Recognize the pulmonary artery catheter waveforms.Recognize the pulmonary artery catheter waveforms.
23.23. Recognize the basic treatments used for commonly seen hemodynamic Recognize the basic treatments used for commonly seen hemodynamic profiles.profiles.
24.24. Explain the common causes of gastrointestinal bleeding. Explain the common causes of gastrointestinal bleeding.
25.25. Describe the most commonly seen treatments for GI bleeding.Describe the most commonly seen treatments for GI bleeding.
26.26. Describe the signs & symptoms of acute pancreatitis and available Describe the signs & symptoms of acute pancreatitis and available treatments.treatments.
– Term used to cover a group of symptoms Term used to cover a group of symptoms compatible with acute myocardial ischemiacompatible with acute myocardial ischemia
– Acute myocardial ischemia is insufficient blood Acute myocardial ischemia is insufficient blood supply to the heart muscle usually resulting from supply to the heart muscle usually resulting from coronary artery disease coronary artery disease
Acute Coronary SyndromeAcute Coronary Syndrome
DEFINITIONDEFINITION
– Infarction occurs due to mechanical obstruction Infarction occurs due to mechanical obstruction
of a coronary artery (or branch) caused by a of a coronary artery (or branch) caused by a
May include crushing chest pain (which may or may May include crushing chest pain (which may or may not radiate), back, neck, jaw, teeth and/or epigastric not radiate), back, neck, jaw, teeth and/or epigastric pain, SOB, nausea/vomiting and dizzinesspain, SOB, nausea/vomiting and dizziness
ST ELEVATIONSST ELEVATIONS– Anterior Wall MIAnterior Wall MI
Leads VLeads V11-V-V44
Reciprocal changes in leads II, III, and aVFReciprocal changes in leads II, III, and aVF Area supplied by the LADArea supplied by the LAD
– Inferior Wall MIInferior Wall MI Leads II, III and aVF Leads II, III and aVF Reciprocal changes in leads I, and aVLReciprocal changes in leads I, and aVL Area usually supplied by the RCAArea usually supplied by the RCA
– MONA MONA (Morphine, O2, Nitroglycerin, Aspirin),(Morphine, O2, Nitroglycerin, Aspirin), Heparin, beta-blockers, and ace inhibitors. May also Heparin, beta-blockers, and ace inhibitors. May also include thrombolytics or Gp2b3a inhibitorsinclude thrombolytics or Gp2b3a inhibitors
– Goals: Relieve pain, limit the size of the Goals: Relieve pain, limit the size of the infarction and to prevent complications infarction and to prevent complications (primarily lethal dysrhythmias) (primarily lethal dysrhythmias)
– MONA MONA (Morphine, O2, Nitroglycerin, Aspirin)(Morphine, O2, Nitroglycerin, Aspirin), , Heparin, beta-blockers, and ace inhibitors. Heparin, beta-blockers, and ace inhibitors. May also include thrombolytics or Gp2b3a May also include thrombolytics or Gp2b3a inhibitorsinhibitors
DEFINITIONDEFINITION– A bulge or ballooning of the aorta A bulge or ballooning of the aorta
When the walls of the aneurysm include all three When the walls of the aneurysm include all three layers of the artery, they are called true aneurysmslayers of the artery, they are called true aneurysms
When the wall of the aneurysm include only the When the wall of the aneurysm include only the outer layer, it is called a pseudo-aneurysmouter layer, it is called a pseudo-aneurysm
– May be thoracic or abdominalMay be thoracic or abdominal
Aortic AneurysmsAortic Aneurysms
CAUSESCAUSES Atherosclerosis Atherosclerosis
Marfan syndrome Marfan syndrome
Hypertension Hypertension
Crack cocaine usage Crack cocaine usage
Smoking Smoking
Trauma Trauma
Aortic Aneurysms RuptureAortic Aneurysms Rupture
An aortic aneurysm, depending on its size, may An aortic aneurysm, depending on its size, may rupture, causing life-threatening internal bleedingrupture, causing life-threatening internal bleeding
The risk of an aneurysm rupturing increases as the The risk of an aneurysm rupturing increases as the aneurysm gets largeraneurysm gets larger
The risk of rupture also depends on the location of The risk of rupture also depends on the location of the aneurysmthe aneurysm
Each year, approximately 15,000 Americans die of a Each year, approximately 15,000 Americans die of a ruptured aortic aneurysm. ruptured aortic aneurysm.
Aortic AneurysmsAortic Aneurysms
CLASSIFICATIONSCLASSIFICATIONS
– Classified by shape, location along the aorta, Classified by shape, location along the aorta, and how they are formedand how they are formed
– May be symmetrical in shape (fusiform) or a May be symmetrical in shape (fusiform) or a localized weakness of the arterial wall (saccular)localized weakness of the arterial wall (saccular)
Aortic AneurysmsAortic Aneurysms
Aortic AneurysmsAortic Aneurysms
SIGNS & SYMPTOMSSIGNS & SYMPTOMS
– Often produces no symptoms Often produces no symptoms
– If an aortic aneurysm suddenly ruptures it presents If an aortic aneurysm suddenly ruptures it presents with extreme abdominal or back pain, a pulsating with extreme abdominal or back pain, a pulsating mass in the abdomen, and a drastic drop in blood mass in the abdomen, and a drastic drop in blood pressure pressure
– An increase in the size of an aneurysm means an An increase in the size of an aneurysm means an increased in the risk of rupture increased in the risk of rupture
Aortic AneurysmsAortic Aneurysms
THORACIC SIGNS & SYMPTOMSTHORACIC SIGNS & SYMPTOMS– Back, shoulder or neck pain Back, shoulder or neck pain
– Cough, due to pressure placed on the tracheaCough, due to pressure placed on the trachea
– Hoarseness Hoarseness
– Strider, dyspneaStrider, dyspnea
– Difficulty swallowing Difficulty swallowing
– Swelling in the neck or armsSwelling in the neck or arms
Aortic DissectionsAortic Dissections
DEFINITIONDEFINITION
– Tearing of the inner layer of the aortic wall, which allows blood to leak into the wall itself and causes the separation of the inner and outer layersTearing of the inner layer of the aortic wall, which allows blood to leak into the wall itself and causes the separation of the inner and outer layers
– Usually associated with severe chest pain radiating to the backUsually associated with severe chest pain radiating to the back
Aortic DissectionsAortic Dissections
A.A. Dissection Dissection beginning in the beginning in the ascending aorta ascending aorta
B.B. Whenever the Whenever the ascending aorta ascending aorta is not involved is not involved
Aortic DissectionsAortic Dissections
A.A. Dissection Dissection beginning in the beginning in the ascending aorta ascending aorta
B.B. Whenever the Whenever the ascending aorta ascending aorta is not involved is not involved
Aortic DissectionsAortic Dissections
Aortic DissectionsAortic Dissections
Aortic AneurysmsAortic Aneurysms
COMPLICATIONSCOMPLICATIONS
RuptureRupture
Peripheral Peripheral embolization embolization
InfectionInfection
Spontaneous Spontaneous occlusionocclusion of aorta of aorta
Aortic AneurysmsAortic Aneurysms
TREATMENTTREATMENT
Medical managementMedical management
– Controlled BP (within specific range)Controlled BP (within specific range)
Surgical repairSurgical repair
> 4.5 cm in Marfan patients or > 5 cm in non-> 4.5 cm in Marfan patients or > 5 cm in non-Marfan patients will require surgical Marfan patients will require surgical correction or endovascular stent placementcorrection or endovascular stent placement
CardiomyopathyCardiomyopathy
DEFINITIONDEFINITION
– Diseases of the heart muscle that Diseases of the heart muscle that cause deterioration of the function of cause deterioration of the function of the myocardiumthe myocardium
Heart disease of unknown cause, although viral Heart disease of unknown cause, although viral infection and autoimmunity are suspected causesinfection and autoimmunity are suspected causes
– Secondary (extrinsicSecondary (extrinsic)) Heart disease as a result of other systemic diseases, Heart disease as a result of other systemic diseases,
such as autoimmune diseases, CAD, valvular such as autoimmune diseases, CAD, valvular
disease, severe hypertension, or alcohol abusedisease, severe hypertension, or alcohol abuse
– Known as HOCM Known as HOCM Hypertropic Obstructive CardiomyopathyHypertropic Obstructive Cardiomyopathy
Positive inotropic drugs Should Positive inotropic drugs Should NotNot Be Used Be Used Contractility will Contractility will outflow tract obstruction outflow tract obstruction
Nitroglycerin Should Nitroglycerin Should NotNot Be Used Be Used– Dilation Will Worsen The Problem Dilation Will Worsen The Problem
SVTSVT– Supraventricular rhythm at rate 150-250 Supraventricular rhythm at rate 150-250
– P waves cannot be positively identifiedP waves cannot be positively identified
Atrial Tach = supraventricular rhythm with p wave morphology Atrial Tach = supraventricular rhythm with p wave morphology that is noticeably different from the that is noticeably different from the
sinus p wavesinus p wave
Ventricular TachycardiaVentricular Tachycardia
VTVT– Ventricular rate of 100-250/minVentricular rate of 100-250/min
– Wide QRSWide QRS
Torsades de PointesTorsades de Pointes
Polymorphic VTPolymorphic VT– VT with alternating ventricular focus VT with alternating ventricular focus
– Often associated with prolonged QT Rate < 100Often associated with prolonged QT Rate < 100
Heart Blocks (AV Blocks)Heart Blocks (AV Blocks)
Sinus Rhythm with First Degree AV BlockSinus Rhythm with First Degree AV Block
Sinus Rhythm with Second Degree AV Block, Type 2Sinus Rhythm with Second Degree AV Block, Type 2
Sinus Rhythm with Second Degree AV Block, Type 1Sinus Rhythm with Second Degree AV Block, Type 1
Third Degree AV BlockThird Degree AV Block
DEFINITIONDEFINITION
– A condition in which the heart cannot pump A condition in which the heart cannot pump sufficient blood to meet the metabolic needs of sufficient blood to meet the metabolic needs of the bodythe body
– Pulmonary (LVF) and/or systemic (RVF) Pulmonary (LVF) and/or systemic (RVF) congestion is present.congestion is present.
Fluid in the alveolus that impairs gas exchange byFluid in the alveolus that impairs gas exchange by altering the diffusion between alveolus andaltering the diffusion between alveolus and capillarycapillary
Acute left ventricular failure causes cardiogenic Acute left ventricular failure causes cardiogenic pulmonary edemapulmonary edema
Non-cardiogenic pulmonary edema is a synonym for Non-cardiogenic pulmonary edema is a synonym for Adult Respiratory Distress Syndrome (ARDS)Adult Respiratory Distress Syndrome (ARDS)
Heart FailureHeart Failure
COMPENSATORY MECHANISMSCOMPENSATORY MECHANISMS– Sympaththetic nervous system stimulationSympaththetic nervous system stimulation
TachycardiaTachycardia Vasoconstriction and increased SVRVasoconstriction and increased SVR
– Renin-angiotensin-aldosterone system Renin-angiotensin-aldosterone system activation (RAAS)activation (RAAS)
Hypo perfusion to the kidneys (renin)Hypo perfusion to the kidneys (renin) Vasoconstriction (angiotensin)Vasoconstriction (angiotensin) Sodium and water retention (kidneys)Sodium and water retention (kidneys) Ventricular dilationVentricular dilation
Are they taking ASA, Coumadin, Ticlid, Plavix, Are they taking ASA, Coumadin, Ticlid, Plavix, Oral Contraceptives, Hormones?Oral Contraceptives, Hormones?
Attempts to deliver more blood to the tissuesAttempts to deliver more blood to the tissues
–VasoconstrictionVasoconstriction Attempts to maintain adequate BP in order to Attempts to maintain adequate BP in order to
adequately perfuse the body tissuesadequately perfuse the body tissues
–Increased ADH SecretionIncreased ADH Secretion ADH makes the body hold onto water in an effort to ADH makes the body hold onto water in an effort to
maintain volume and thus enough blood pressure to maintain volume and thus enough blood pressure to perfuse the body tissuesperfuse the body tissues
Types of ShockTypes of Shock
Hypovolemic ShockHypovolemic Shock– Inadequate perfusion to the tissues due to insufficient intravascular Inadequate perfusion to the tissues due to insufficient intravascular
volumevolume
Cardiogenic ShockCardiogenic Shock– Inadequate perfusion to the tissues due to heart failureInadequate perfusion to the tissues due to heart failure
Distributive ShockDistributive Shock– Inadequate perfusion to the tissues due to blood flow out of the Inadequate perfusion to the tissues due to blood flow out of the
intravascular space causing insufficient intravascular volumeintravascular space causing insufficient intravascular volume
– Anaphylactic, Septic, and Spinal ShockAnaphylactic, Septic, and Spinal Shock Obstructive ShockObstructive Shock
– Inadequate perfusion to the tissues due to obstruction of blood flowInadequate perfusion to the tissues due to obstruction of blood flow
Hypovolemic ShockHypovolemic Shock
SIGNS & SYMPTOMSSIGNS & SYMPTOMSLow BPLow BP TachycardiaTachycardia
Cardiogenic Shock is the only shock with Cardiogenic Shock is the only shock with PAWP PAWP
Early (Hyperdynamic) Shock is the only shock with Early (Hyperdynamic) Shock is the only shock with CO and CO and SVRSVR
Neurogenic Shock is the only shock with Neurogenic Shock is the only shock with BradycardiaBradycardia
Anaphylactic Shock has the definitive characteristic of wheezing due Anaphylactic Shock has the definitive characteristic of wheezing due to bronchospasmto bronchospasm
Parameter Hypovolemic Cardiogenic Neurogenic Anaphylactic Early Septic Late Septic
CVP/RAP
PAWP or Norm
CO
BP
SVR
HR Normal
Shock ProfilesShock Profiles
SIRS Sepsis Severe Septic MODS DeathSIRS Sepsis Severe Septic MODS DeathInfection Infection Sepsis Shock Sepsis Shock
Sepsis SyndromeSepsis Syndrome
Sepsis– SIRS’ response with presumed/confirmed infectionSIRS’ response with presumed/confirmed infection
Severe Sepsis– Sepsis associated with organ dysfunction, hypoperfusion Sepsis associated with organ dysfunction, hypoperfusion
(lactic acidosis, oliguria, altered mental status etc.), or (lactic acidosis, oliguria, altered mental status etc.), or hypotension (SBP < 90 mmHg or ↓ SBP > 40 mmHg)hypotension (SBP < 90 mmHg or ↓ SBP > 40 mmHg)
Septic Shock– Sepsis with perfusion abnormalities and hypotension Sepsis with perfusion abnormalities and hypotension
EARLY STAGE (Hyperdynamic)EARLY STAGE (Hyperdynamic)Normal BPNormal BP TachycardiaTachycardiaConfusion Confusion Agitation (or listless)Agitation (or listless) Respiratory RateRespiratory Rate TemperatureTemperatureNormal ColorNormal Color Normal or Normal or UOP UOPNormal PAWPNormal PAWP CO CO SVR SVR
3.3. Improve PerfusionImprove Perfusion– Prevent organ dysfunctionPrevent organ dysfunction– Treat temp as neededTreat temp as needed
2.2. Treat The CauseTreat The Cause – Pan culture, antibiotics Pan culture, antibiotics
– Seek primary site of infectionSeek primary site of infection
– Direct therapy to primary causeDirect therapy to primary cause
1.1. Stabilize The PatientStabilize The Patient– Fluids (lots of fluids) 150ml/hr or moreFluids (lots of fluids) 150ml/hr or more
– VasoconstrictorsVasoconstrictors
Treatment for SepsisTreatment for Sepsis
HEMODYNAMICSHEMODYNAMICS
Invasive PA Catheter Invasive PA Catheter CONTRAINDICATIONSCONTRAINDICATIONS
Mechanical Tricuspid or Pulmonary Valve Mechanical Tricuspid or Pulmonary Valve
Right Heart Mass (thrombus and/or tumor)Right Heart Mass (thrombus and/or tumor)
Tricuspid or Pulmonary Valve EndocarditisTricuspid or Pulmonary Valve Endocarditis
BasicBasic ConceptsConcepts
CO = HR X SVCO = HR X SV
BP = CO x SVRBP = CO x SVR
CO and SVR are inversely relatedCO and SVR are inversely related
CO and SVR will change before BP changesCO and SVR will change before BP changes
StrokeStroke VolumeVolume
Components Stroke VolumeComponents Stroke Volume
– PreloadPreload:: the volume of blood in the the volume of blood in the ventricles at end diastole and the stretch ventricles at end diastole and the stretch placed on the muscle fibersplaced on the muscle fibers
– AfterloadAfterload:: the resistance the ventricles the resistance the ventricles must overcome to eject it’s volume of must overcome to eject it’s volume of bloodblood
– Contractility:Contractility: the force with which the the force with which the heart muscle contracts (myocardial heart muscle contracts (myocardial compliance)compliance)
PAC Insertion SequencePAC Insertion Sequence
Phlebostatic AxisPhlebostatic Axis
4th ICS Mid-chest, regardless of head elevation4th ICS Mid-chest, regardless of head elevation
RAP (CVP)RAP (CVP)
RVPRVP
PAPPAP
PAWPPAWP
SVRSVR
0-8 mmHg0-8 mmHg
15-30/0-8 mmHg15-30/0-8 mmHg
15-30/6-12 mmHg15-30/6-12 mmHg
8 - 12 mmHg8 - 12 mmHg
700-1500 700-1500 dynes/sec/cmdynes/sec/cm22
Normal Hemodynamic ValuesNormal Hemodynamic Values
Normal Hemodynamic Normal Hemodynamic ValuesValues Values normalized for body size (BSA)Values normalized for body size (BSA)
End result of O2 delivery and End result of O2 delivery and consumptionconsumption
Measured in the pulmonary arteryMeasured in the pulmonary artery An average estimate of venous saturation for An average estimate of venous saturation for
the whole body.the whole body.
Does not reflect separate tissue perfusion or Does not reflect separate tissue perfusion or oxygenationoxygenation
SVV < 10–15% = not preload responsive SVV < 10–15% = not preload responsive
Measuring PA PressuresMeasuring PA Pressures
Measure All Hemodynamic Values Measure All Hemodynamic Values at End-Expirationat End-Expiration
– ““Patient PeakPatient Peak””
– ““Vent ValleyVent Valley””
Spontaneous RespirationsSpontaneous Respirations
Measure all pressures atMeasure all pressures at end-expirationend-expiration
AtAt top curve top curve with Spontaneous Respirationwith Spontaneous Respiration
““patient-peak”patient-peak”
Intrathoracic pressure Intrathoracic pressure decreasesdecreases during during spontaneous inspirationspontaneous inspiration
– Negative deflection on waveformsNegative deflection on waveforms Intrathoracic pressure Intrathoracic pressure increasesincreases duringduring
spontaneous expirationspontaneous expiration
– Positive deflection on waveformsPositive deflection on waveforms
Measuring PA PressuresMeasuring PA Pressures
Measure all pressures atMeasure all pressures at end-expirationend-expiration AtAt bottom curvebottom curve with mechanical ventilatorwith mechanical ventilator
““Vent-Valley”Vent-Valley”
Intrathoracic pressureIntrathoracic pressure increasesincreases during during positive pressure ventilations (inspiration)positive pressure ventilations (inspiration)
– Positive deflection on waveformsPositive deflection on waveforms Intrathoracic pressureIntrathoracic pressure decreases decreases during during
– Correct location for measurement of PAWPCorrect location for measurement of PAWP Average the peak & trough of the a-waveAverage the peak & trough of the a-wave
– Begins near the end of QRS or at the QT Begins near the end of QRS or at the QT segmentsegment
Delayed ECG correlation from CVP since Delayed ECG correlation from CVP since PA catheter is further away from left atriumPA catheter is further away from left atrium
v-wavev-wave– Represents left atrial fillingRepresents left atrial filling
– Begins at about the end of the T waveBegins at about the end of the T wave
PAWP WaveformPAWP Waveform
PAWP WaveformPAWP Waveform
BREAK!BREAK!
CCRN REVIEW PART 1CCRN REVIEW PART 1
ARDSARDS
Drowning Drowning
PneumothoraxPneumothorax
Respiratory Respiratory
FailureFailure
Respiratory AlterationsRespiratory Alterations
ChronicChronic LungLung DiseaseDisease
PneumoniaPneumonia
PulmonaryPulmonary
EmbolismEmbolism
ARDSARDS
DEFINITIONSDEFINITIONS
– Severe respiratory failure associated with pulmonary Severe respiratory failure associated with pulmonary infiltrates (similar to infant hyaline membrane disease)infiltrates (similar to infant hyaline membrane disease)
– Pulmonary edema in the absence of fluid overload or Pulmonary edema in the absence of fluid overload or depressed LV function (Non-cardiogenic pulmonary edema)depressed LV function (Non-cardiogenic pulmonary edema)
– Originates from a number of insults involving damage to the Originates from a number of insults involving damage to the alveolar-capillary membranealveolar-capillary membrane
COPDCOPD– Presents with hyper-inflated lung fields Presents with hyper-inflated lung fields
Due to chronic air trappingDue to chronic air trapping
May be barrel chestedMay be barrel chested
– May lead to cor pulmonale May lead to cor pulmonale (right-sided heart failure)(right-sided heart failure)
Due to chronic high pulmonary pressuresDue to chronic high pulmonary pressures
– Often hypercarbic (high pCO2)Often hypercarbic (high pCO2) Often dependent upon hypoxic driveOften dependent upon hypoxic drive
Chronic Lung DiseaseChronic Lung Disease
COPD TREATMENTCOPD TREATMENT– Avoid overuse of oxygenAvoid overuse of oxygen (except in emergencies) (except in emergencies)
– BronchodilatorsBronchodilators
– SteroidsSteroids
– HydrationHydration
– EducationEducation
Pursed Lip BreathingPursed Lip Breathing
Leaning UprightLeaning Upright
Near DrowningNear Drowning Salt WaterSalt Water
– Causes body fluids to shift into lungsCauses body fluids to shift into lungs Osmosis: From low to high concentrationOsmosis: From low to high concentration Results in hemoconcentration & hypovolemiaResults in hemoconcentration & hypovolemia
– Results in acute pulmonary edemaResults in acute pulmonary edema Fresh WaterFresh Water
– Fluids shift into body tissuesFluids shift into body tissues Results in hemodilution & hypervolemiaResults in hemodilution & hypervolemia Can result in gross edemaCan result in gross edema
– Damaged alveoli fill with proteinaceous fluidDamaged alveoli fill with proteinaceous fluid May lead to pulmonary edemaMay lead to pulmonary edema
PneumoniaPneumonia
Lung infection (bacterial, viral, or fungal)Lung infection (bacterial, viral, or fungal)
– Most commonly caused by SMost commonly caused by Streptococcus treptococcus pneumoniaepneumoniae
Symptoms include fever, pleuretic chest Symptoms include fever, pleuretic chest pain, productive cough, and tachypneapain, productive cough, and tachypnea
– Often presents bronchial breath sounds over the Often presents bronchial breath sounds over the lung area lung area
Treatment involves giving the right antibioticTreatment involves giving the right antibiotic
PneumothoraxPneumothorax DEFINITIONSDEFINITIONS
– Simple pneumothoraxSimple pneumothorax Results from buildup of air or pressure in the pleural spaceResults from buildup of air or pressure in the pleural space
– Spontaneous pneumothoraxSpontaneous pneumothorax May be due to blebs that ruptureMay be due to blebs that rupture The 2 key risk factors are increased chest length and The 2 key risk factors are increased chest length and
cigarette smokingcigarette smoking
– Tension pneumothoraxTension pneumothorax Involves a buildup of air in the pleural space due to Involves a buildup of air in the pleural space due to
one-way movement of airone-way movement of air Progressively worsensProgressively worsens Requires immediate interventionRequires immediate intervention
PneumothoraxPneumothorax
Tension PneumothoraxTension Pneumothorax
PneumothoraxPneumothorax
CAUSESCAUSES
– BarotraumaBarotrauma
– InjuryInjury
– BlebsBlebs
PneumothoraxPneumothorax
SIGNS & SYMPTOMSSIGNS & SYMPTOMS– Standard PneumothoraxStandard Pneumothorax
Sharp "pleuritic" chest pain, worse on breathingSharp "pleuritic" chest pain, worse on breathing Sudden shortness of breathSudden shortness of breath Dry, hacking cough (may occur due to irritation Dry, hacking cough (may occur due to irritation
of the diaphragm)of the diaphragm) May cause mediastinal shift May cause mediastinal shift
– Tension pneumothoraxTension pneumothorax Signs of standard pneumothorax with signs of Signs of standard pneumothorax with signs of
cardiovascular collapse cardiovascular collapse Immediately life threateningImmediately life threatening May cause mediastinal shiftMay cause mediastinal shift
– Depends on symptoms & size of pneumothorax Depends on symptoms & size of pneumothorax
– Provide respiratory supportProvide respiratory support
– May need chest tube or needle decompression May need chest tube or needle decompression Some resolve without interventionSome resolve without intervention
Ineffective with shuntingIneffective with shunting Prolonged O2 > 40% causes O2 toxicityProlonged O2 > 40% causes O2 toxicity Must use caution with CO2 retainersMust use caution with CO2 retainers
– Chronic hypercapnia causes CO2 retainers Chronic hypercapnia causes CO2 retainers to use hypoxic driveto use hypoxic drive
– Too much O2 can depress respirationsToo much O2 can depress respirations
Gastrointestinal BleedingGastrointestinal Bleeding HematemesisHematemesis – vomiting of blood (or coffee ground – vomiting of blood (or coffee ground
material) (indicates bleeding above the duodenum )material) (indicates bleeding above the duodenum )
MelenaMelena – passage of black tarry stools > 50ml (indicates – passage of black tarry stools > 50ml (indicates degradation of blood in the bowel)degradation of blood in the bowel)
HematocheziaHematochezia – passage of red blood (rectal bleeding)– passage of red blood (rectal bleeding)
Occult BleedingOccult Bleeding – bleeding that is not apparent to the – bleeding that is not apparent to the patient and results from small amounts of bloodpatient and results from small amounts of blood
Obscure BleedingObscure Bleeding – occult or obvious but source not – occult or obvious but source not identifiedidentified
HematemesisHematemesis – – always UGI sourcealways UGI source
MelanaMelana – – indicates blood has been in GI tract indicates blood has been in GI tract for extended periods for extended periods – Mostly UGIMostly UGI– Small bowelSmall bowel– Rt colon (if bleeding relatively slow)Rt colon (if bleeding relatively slow)
HematocheziaHematochezia – Mostly colonMostly colon– Massive UGI bleeding (not enough time for degradation)Massive UGI bleeding (not enough time for degradation)
TREATMENTTREATMENT– Find the underlying causeFind the underlying cause
– Endoscopy or colonoscopyEndoscopy or colonoscopy
– Medical and /or surgical therapy Medical and /or surgical therapy SomatostatinSomatostatin IV or intra-arterial vasopressinIV or intra-arterial vasopressin SclerotherpaySclerotherpay Angiography with embolizationAngiography with embolization ElectrocoagulationElectrocoagulation Band ligationBand ligation Balloon tamponade (Sengstaken-Blackmore tube)Balloon tamponade (Sengstaken-Blackmore tube)
The Pancreas secretes digestive enzymes, The Pancreas secretes digestive enzymes, bicarbonate, water, and some electrolytes into bicarbonate, water, and some electrolytes into the duodenum via the pancreatic ductthe duodenum via the pancreatic duct
The Pancreas also produces The Pancreas also produces and secretes insulin and secretes insulin
PancreatitisPancreatitis
DEFINITIONDEFINITION– An autodigestive process resulting An autodigestive process resulting
from premature activation of from premature activation of pancreatic enzymespancreatic enzymes
PancreatitisPancreatitis
PATHOSHYSIOLOGYPATHOSHYSIOLOGY
• Inactive pancreatic enzymes are activated outside Inactive pancreatic enzymes are activated outside of the duodenumof the duodenum
• The swelling pancreas causes fluids to shift into The swelling pancreas causes fluids to shift into the retro peritoneum and bowel the retro peritoneum and bowel
• Fluid shifts can cause severe hypovolemia and Fluid shifts can cause severe hypovolemia and hypotensionhypotension
• Inflammation cause commotion around pancreasInflammation cause commotion around pancreas
Acute diabetic ketosis or oliguriaAcute diabetic ketosis or oliguria
Hemorrhagic pancreatitis may appear Hemorrhagic pancreatitis may appear
THE ENDTHE ENDPART 1PART 1
CCRN REVIEWCCRN REVIEW
THANK YOUTHANK YOU
CCRN REVIEW PART 1CCRN REVIEW PART 1
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Bridges EJ.(2006) Pulmonary artery pressure monitoring: when, how, and what else to use. AACN Adv Crit Care. 2006;17(3):286–303.
Chulay, M., Burns S. M. (2006). AACN Essentials of Critical Care Nursing. McGraw-Hill Companies, Inc., Chapter 23.
Finkelmeier, B., Marolda, D. (2004) Aortic Dissection, Journal of Cardiovascular Nursing: 15(4):15–24.
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