Summary CCRN review Exam ( guarantee of a pass in your exam)

CCRN: Test Prep © 2004 Ed4Nurses, Inc. 1 w w w . 1 0 0 K -C e rt ifi e d-N u r s e s . c o m Presented by: David W. Woodruff, MSN, RN, CNS Checklist for Success We will guarantee your success on the CCRN certification exam! -- If you study the right things in the right ways -- Success Checklist: □ Attend the entire CCRN: Test Prep program (or use the entire A/V package). □Study 5 hours per week for 90 days using the handout, pocket study guide, and flash cards. □ Listen to all of the audio CDs or watch all of the video-enhanced CDROMs. □Identify areas of weakness that need additional study. □ Review the audio CDs (or CDROMs) of the topics you identified as requiring additional study. □Participate in the Nurses’ Success Network on-line study groups and post at least one comment or question per week. Login at: www.Nurses-Success-N User: ccrn Password: excellence □ Achieve a passing grade of at least 80% on the “Challenge Exam” on-line at the Nurses’ Success Network. □ Use the on-line resources recommended in the “Challenge Exam” results. The CCRN: Test Prep is a 90-day program to guarantee your success on the certification exam. You must use this program and take the exam within 90 days of registering for the guarantee for us to assure your success. Register for the guarantee on-line at :www.Nurses-Success-N CCRN: Test Prep © 2004 Ed4Nurses, Inc. 2 CCRN: Test Prep Description: This unique two-day program presents the content of the CCRN exam in a question and answer format. By the conclusion of the program the participant will have answered 150 questions in the format and distribution of the actual exam. In-depth explanations will be presented for rationale behind correct and incorrect answers, along with the theoretical underpinnings of essential concepts. This unique, informative and fun seminar is perfect for CCRN preparation, or a comprehensive critical care review. Objectives: 1. Examine strategies for successful completion of the CCRN exam. 2. Describe common hematologic and immunologic dysfunction in the critical care patient. 3. Describe the process of coagulopathy in DIC. 4. Compare and contrast common GI disorders. 5. Plan care for the patient suffering from abdominal trauma. 6. Compare and contrast septic, hypovolemic, and cardiogenic shock. 7. Describe hemodynamic changes that occur with shock. 8. Plan care for patients with cardiopulmonary disorders. 9. Compare and contrast acute and chronic renal failure. 10. Describe clinical symptoms of electrolyte disturbances. 11. Plan care for patients with electrolyte and water emergencies. 12. Explain the benefits of several treatment options for acute respiratory failure. 13. Plan care for patients with respiratory disorders. 14. Describe a simple assessment plan for patients with increased intracranial pressure. 15. Evaluate nursing interventions for increased intracranial pressure. 16. Describe common endocrine dysfunctions in the critical care patient. 17. Compare and contrast diabetic ketoacidosis and hyperosmolar, hyperglycemic syndrome. 18. Define professional and ethical nursing care using AACN definitions. All content in CCRN: Test Prep is ©2004 by Ed4Nurses, Inc. and all rights are reserved. Copying or distribution in any form is strictly prohibited by US copyright law. CCRN: Test Prep © 2004 Ed4Nurses, Inc. 3 DAY 1 8:00 Introduction and Test Overview 8:30 Hematologic / Immunologic (3%) A&P Blood Products & Plasma Organ Transplantation Life-threatening coagulopathies Immunosuppression-Acquired Sickle Cell Crisis 9:45 Break 10:00 Gastrointestinal (6%) GI Bleed Hepatic Failure Acute Pancreatitis Bowel infarction/obstruction/perforation Abdominal Trauma 11:30 Multisystem (8%) Sepsis / Septic Shock / MODS Toxic Ingestions Toxic Exposures 12:00 Lunch 1:00 Multisystem (con’t) 1:30 Cardiovascular (32%) Acute Coronary Syndromes Cardiac Inflammatory Disease Conduction System Defects Acute Heart Failure & Pulmonary Edema Aortic Aneurysm Pericarditis 2:15 Break 2:30 Cardiovascular (continued) Cardiac Trauma Hypertensive Crisis Shock 4:30 Adjourn CCRN: Test Prep © 2004 Ed4Nurses, Inc. 4 DAY 2 8:00 Renal (5%) Acute & Chronic Renal Failure Renal Trauma Electrolyte Imbalances 9:00 Pulmonary (17%) Acute Respiratory Failure Pulmonary Pharmacology 9:45 Break 10:00 Pulmonary (con’t) ARDS Pneumonia Pulmonary Embolus, Fat Embolus Asthma / COPD Chronic Lung Disease Thoracic Trauma / Thoracic Surgery 12:00 Lunch 1:00 Neurologic (5%) Aneurysm Encephalopathy Stroke (ischemic, hemorrhagic) Intracranial Hemorrhage Seizures Head Trauma Neurosurgery / ICP Monitoring 2:00 Break 2:15 Endocrine (4%) Diabetes Insipidus Diabetes Ketoacidosis & Hyperosmolar Coma Acute Hypoglycemia Hormones and Endocrine A&P 3:00 Professional Caring and Ethical Practice (20%) Advocacy Collaboration Caring Practice 4:00 Adjourn CCRN: Test Prep © 2004 Ed4Nurses, Inc. 5 Today’s speaker: David W. Woodruff, MSN, RN, CNS David began his healthcare career as a paramedic. After years of treating patients “in the field”, David obtained his nursing degree. His extensive experience includes trauma nursing at a level-I trauma center, and staff positions in Neurological, Coronary, Medical and Surgical Intensive Care Units. David holds a Master’s degree in Adult Health nursing and is a Clinical Nurse Specialist in Critical Care Nursing. He is a member of AACN, The Society of Critical Care Medicine, and Sigma Theta Tau. He has served as an Instructor of Nursing, Unit Manager, Nursing Expert Witness, and President of a private nursing consulting firm. David presents seminars throughout the country on a variety of topics including critical care and medical-surgical nursing, and has published articles in Nursing, RN, and Image. He is widely regarded as a knowledgeable and thorough instructor who can make even the most difficult content material understandable. I would be happy to hear from you and answer any additional questions you may have. Feel free to contact me at: Phone: (330) 467-2629 e-mail: web: CCRN: Test Prep © 2004 Ed4Nurses, Inc. 6 Introduction and Test Overview 1. Why Become Certified? A study conducted by the Nursing Credentialing Research Coalition found that certification has a profound impact on the personal, professional and practice outcomes of certified nurses. Overall, nurses in the study stated that certification enabled them to experience fewer adverse events and errors in patient care than before they were certified. Additional results revealed that certified nurses: • expressed more confidence in detecting early signs of complications; • reported more personal growth and job satisfaction; • believed they were viewed as credible providers; • received high patient satisfaction ratings; • reported more effective communication and collaboration with other health care providers; and • experienced fewer disciplinary events and work-related injuries. 2. What is “CCRN”? a. Registered service mark of AACN. b. Credential for certified critical care nurses. 3. What to Expect from “The Test” AACN – Certification Corporation Fees: $300 non-member $220 member of AACN Test dates: Year-round Requirements: RN license 1750 hours of clinical experience with acute and critical care patients within the previous 2 years (875 within the past year). Exam is computer-based, 150 questions, with a 3-hour time limit Paper-based testing is offered at the NTI Certification is for 3 years. Recertification can be by CERPs or re-testing. Cost of recertification is: $250 non-member, $170 member If you join AACN ($78 fee) at the time you register, you pay $298 and get member benefits. CCRN: Test Prep © 2004 Ed4Nurses, Inc. 7 4. Testing Dates, Places and Times AACN Certification Corporation 101 Columbia Aliso Viejo,CA Phone: (800) 899-2226 E-mail: Web: Applied Measurement Professionals Inc. (AMP) 8310 Nieman Road Lenexa, KS Phone: (800) 345-6559 Fax: (913) 541-0156 Business Hours: 8:30 am - 5:00 pm CST Monday-Friday E-mail: Web: Over 100 testing centers nationwide 5. What to bring with you: a. Photo ID i. Driver’s license ii. State ID card iii. Military ID card b. Second ID without photo c. Do not bring any personal items with you d. Please Note: This is a focused 90-day program designed to assure your success on the ANCC MedSurg certification exam. You must register for the guarantee and complete the “Certification Checklist” within 90 days to be eligible for the guarantee. You can do this! 9 If you are qualified 9 And you study the right stuff in the right way 9 You will pass! I guarantee it! CCRN: Test Prep © 2004 Ed4Nurses, Inc. 8 Hematologic / Immunologic (3%) 4 questions 1. The nurse is caring for a 32-year-old experiencing organ rejection after a kidney transplant. Which of the following signs will the patient exhibit? a. Decreased BUN/Creatinine b. Increased transaminase level c. Increased urine output d. Increased BUN/Creatinine 2. A primary chemical mediator in anaphylactic reaction is? a. Myocardial Depressant Factor b. Histamine c. Complement d. Interferon 3. Which of the following laboratory diagnostic findings will most likely be seen in DIC? a. PT and PTT prolonged b. Fibrinogen increased c. Platelet count increased d. D-dimer normal 4. The beneficial effects of heparin in DIC are thought to be due to its: a. Stimulating effect on platelet manufacture b. Neutralizing of free-circulating thrombin c. Antifibrinolysin activity d. Inhibition of platelet factor XII release CCRN: Test Prep © 2004 Ed4Nurses, Inc. 9 Hematology 1. Functions: a. Medium for transport of O2 and CO2 and nutritients b. Maintains hemostatsis c. Maintains internal environment d. Immune e. Inflammation f. Stress Response i. Impaired skin barrier or irritated mucous membrane ii. Impaired gag, cough or swallow iii. Increased gastric pH, colonization = aspiration iv. Acute Stress Reactions 1. Catabolism 2. Decreased healing 3. Inhibit immune response 4. Inflammatory Response g. Hemostasis i. Termination of bleeding ii. Vascular response iii. Platelet response iv. Coagulation 1. Platelets 2. Thrombocytopenia 3. HITT response Disseminated Intravascular Coagulation (DIC) 1. Definition 2. Factors Triggering DIC 3. Etiology: a. Bleeding b. Trauma c. Sepsis d. Abrupto Placenta CCRN: Test Prep © 2004 Ed4Nurses, Inc. 10 4. Clinical Presentation a. Bleeding b. Signs of Thrombosis c. Clinical Presentation i. Petechiae ii. Ecchymosis iii. Purpura d. Labs in DIC i. Platelets ii. PTT iii. PT iv. Fibrinogen v. FDP/FSP vi. D-dimer vii. Antithrombin III 5. Medical Management a. Maintain ABC’s b. Careful or oral and mucosal bleeding c. Treat stimuli d. Correct hypovolemia, hypotension, hypoxia, and acidosis e. Stop microclotting to maintain perfusion f. Stop Bleeding g. Stop Thrombosis h. Administer IV Heparin i. Plasmapheresis j. Nursing Management k. Nursing Care of the Bleeding Patient l. Blood Products i. Risks of transfusion ii. PRBC’s iii. Platelets iv. FFP v. Cryoprecipitate vi. Adverse Reactions 6. Complications of DIC a. Mortality b. Hypovolemic Shock c. Acute Renal Failure d. Infection e. Acute Respiratory Distress Syndrome f. Stroke g. GI dysfunction CCRN: Test Prep © 2004 Ed4Nurses, Inc. 11 7. Nursing a. Administer Vitamin K and Folic Acid b. Treat Ischemic Pain c. Maintain skin integrity Acquired Immunodeficiency Syndrome (AIDS) 1. Etiology a. HIV, CD4 retrovirus b. High-risk groups i. High-risk sexual behavior ii. Infected sex partners iii. IV drug users iv. Recipients of blood products before 1985 c. Pathophysiology i. Invasion and destruction of T4 (helper) cells ii. Incubation 6 months to 10 years iii. Decreased immune response iv. Opportunistic infection 2. General principles for management a. Universal precautions b. Protect from infection c. Inflammatory response will be muted Transplantation Criteria for organ transplantation 1. Recipient criteria a. End-stage organ disease b. Absence of: i. Infection ii. Malignancy iii. Other failing organs iv. Substance abuse 1. Donor criteria a. Free of sepsis, cancer, prolonged hypotension b. Free of communicable disease CCRN: Test Prep © 2004 Ed4Nurses, Inc. 12 Anti-rejection medications Drug Major Effects Side Effects Corticosteriods ↓ Inflammation ↑ Risk of infection GI bleed Hyperglycemia Adrenal suppression Cyclosporine ↓ Immune and inflammatory responses Potentiates other immunosuppressives Hepatotoxicity Nephrotoxicity Hyperkalemia Hypomagnesemia ATgam (antithymocyteglobulin) Reduces T-cell production ↑ Risk of infection Thrombocytopenia Imuran (azathioprine) ↓ Immune response ↑ Risk of infection Oral and gastric erosion Hepatotoxicity OKT3 (muromonab-CD3) Alters T-cell recognition of antigens ↑ Risk of infection Symptoms of infection ↓ WBC, platelet levels Prograf (tacrolimus) ↓ Inflammatory response GI distress HTN, chest pain Hyperkalemia Hypomagnesemia Nephrotoxicity Hepatotoxicity CellCept (mycophenolate) ↓ Immune response GI distress ↓ WBC, platelet levels Hypertension Hypokalemia 1. General patient care a. Support transplanted organ i. Heart Transplant ii. Lung iii. Liver iv. Pancreas v. Kidney b. Watch for signs of infection i. May be ↓ due to ↓ immune response CCRN: Test Prep © 2004 Ed4Nurses, Inc. 13 Leukemia’s Acute Incidence Characteristics Acute Lymphocytic (ALL) Acute Myelogenous (AML) Age 2-4 Age 12-20 Anemia, Bleeding, Infection, ↓ RBC, H&H, ↑ WBC, Joint and bone pain Chronic Incidence Characteristics Chronic Lymphocytic (CLL) Chronic Myelogenous (CML) Age 50-70 Age 30-50 ↑ WBC, ↓ RBC, Enlarged spleen, Hepatomegaly, Swollen glands a. Diagnostics i. Bone marrow aspiration b. Treatment ii. Chemotherapy iii. Stem cell transplant iv. Transfusion 3. Multiple Myeloma a. Plasma cells invade bone marrow, and lymph system b. Bones become weak and painful c. Diagnostics i. X-rays ii. Bone marrow aspiration iii. Hypercalcemia d. Treatment i. Chemotherapy ii. Interferon iii. Bone marrow transplantation iv. Plasmapheresis v. Management of Hypercalcemia 4. Non-Hodgkin’s Lymphoma a. Malignant neoplasm of the lymphatic system b. Results in overgrowth of premature and ineffective cells c. Diagnostics i. Fever, swollen glands, night sweats, weight loss d. Treatment i. Chemotherapy ii. Radiation therapy iii. Stem cell transplant CCRN: Test Prep © 2004 Ed4Nurses, Inc. 14 Sickle-Cell Crisis 1. Etiology a. More common in black males b. Presence of Hemoglobin S 2. Precipitating factors a. Dehydration b. Stress or strenuous exercise c. Infection d. Fever e. Bleeding f. Acidosis g. Hypoxia (smoking) h. Cold weather i. Pregnancy 3. Presentation a. Bone crisis i. Long bone pain b. Acute chest syndrome i. Chest pain ii. Dyspnea iii. Tachycardia iv. Bloody sputum v. Pulmonary fibrosis c. Abdominal crisis i. Sudden, constant abdominal pain ii. Not usually associated with N/V/D d. Joint crisis i. Stiff, painful joints e. Jaundice, bruising, blood in urine may occur with any 4. Management a. Oxygen b. Fluids c. Folic acid d. Hydroxyurea (Hydrea) e. Pain control i. Mild: Tylenol or NSAIDs ii. Moderate: Codeine, Oxycodone iii. Severe: Morphine, Dilaudid f. Transfusion 5. Complications a. Renal dysfunction b. Stroke c. Blindness d. Infection (spleen becomes clogged) CCRN: Test Prep © 2004 Ed4Nurses, Inc. 15 Gastrointestinal (6%) 9 questions 1. Nursing interventions for the patient with hepatic failure include: a. Restrict protein in diet b. Avoid use of narcotics, sedatives and tranquilizers c. Administer lactulose and neomycin d. All the above 2. The most common cause of upper GI bleeding is: a. Peptic ulcer disease b. Esophageal varices c. AV malformation d. Gastric tumor 3. Octreotide is often used to control bleeding from esophageal varices. The primary action of Octreotide is to: a. Increase platelet aggregation b. Increase clotting factors c. Decrease venous return d. Decrease blood flow 4. The administration of vasopressin should be most carefully monitored in patients who have: a. Diabetes Insipidus b. Coronary artery disease c. Hypotension secondary to GI bleed d. Diabetes Mellitus 5. The inability of the liver to conjugate what substance is the primary contributor to hepatic coma? a. Ammonia b. Urea c. Fatty Acids d. Bilirubin 6. Ecchymosis around the umbilicus indicative of peritoneal bleeding is called a. Chvostek’s sign b. Grey Turner’s sign c. Cullen’s sign d. Trousseau’s sign CCRN: Test Prep © 2004 Ed4Nurses, Inc. 16 7. Pulmonary complications of acute pancreatitis may include: a. Adult Respiratory Distress Syndrome b. Elevation of the diaphragm and bilateral basilar rales c. Atelectasis, especially of the left base d. All of the above 8. Which of the following laboratory findings is most specific for pancreatitis? a. Leukocytosis b. Elevated serum and urinary amylase c. Hyperglycemia and hypokalemia d. Decreased serum albumin and total protein 9. Another diagnostic finding seen in the patient with pancreatitis would include: a. Increased Hct b. Hypocalcemia c. Hyperalbuminemia d. Decreased potassium CCRN: Test Prep © 2004 Ed4Nurses, Inc. 17 GI Bleed Etiology: 1. Peptic Ulcer Disease (55%) 2. Esophageal varices (14%) 3. Arteriovenous malformations (6%) 4. Mallory-Weiss tears (5%) 5. Tumors & erosions (4% each) 6. Other (12%) Drug Mechanism of injury Caffeine ↑ acid production Vasopressors ↓ mucosal blood flow ASA, alcohol, indomethacin, steroids H+ back diffusion Corticosteroids ↓ mucous secretion Chemotherapy, steroids ↓ cell renewal Prevention: 1. Helicobacter pylori a. Pathogenesis i. Transmitted by fecal-oral route ii. Renders mucosa vulnerable to acid damage iii. Inflammatory response b. Treatment (80-90% eradication rate) i. Antibiotics ii. Antisecretory agent 2. NSAIDS a. Affects local and systemic prostaglandin inhibition b. Majority are uncomplicated and asymptomatic 3. Stress a. Common cause of UGI bleeding (1.5% of all ICU pts.) b. Higher mortality than pts. admitted with 1° dx. Of UGI bleeding c. Independent risk factors: i. Respiratory failure ii. Coagulopathy H. Pylori infection or NSAID use is responsible for 98% of upper GI bleeds. CCRN: Test Prep © 2004 Ed4Nurses, Inc. 18 4. Esophageal varices a. Secondary to portal hypertension b. Bleeding stops spontaneously in 50% of cases c. Mortality 70-80% in those who continue bleeding d. Treatment i. Blood pressure management 1. Propanolol, nadolol ii. Vasopressin, NTG iii. Octreotide 1. ↓ gastrin production 2. Local vasoconstriction iv. Esophageal balloon tamponade (Blakemore / Linton tubes) v. Injection sclerotherapy vi. Variceal band ligation (↓ rebleeding rate, mortality) vii. Transjugular intrahepatic portosystemic shunt (TIPS) 1. ↓ portal pressure 2. Complications: a. ↑ encephalopathy b. Shunt occlusion and rebleeding c. Shunt migration 5. GI prophylaxis a. H2 receptor antagonists i. Block gastric acid output by blocking histamine receptors b. Sucralfate i. Inhibits pepsin secretion c. Proton pump inhibitors i. Inhibits Hydrogen ion formation regardless of source of stimulation d. ↑ risk of pneumonia in mechanically ventilated patients (??? ↑ risk of aspiration) Early Detection 1. Bloody nasogastric aspirate (10-15% false negative) 2. Hemoglobin / Hematocrit 3. Melena / occult blood monitoring 4. Nausea / vomiting / hyperactive bowel sounds 5. Coagulation abnormalities 6. Shock 7. Risk scoring for intervention: a. Hemoglobin b. Systolic B/P c. Syncope / melana d. Tachycardia e. Cardiac disease f. Hepatic disease CCRN: Test Prep © 2004 Ed4Nurses, Inc. 19 Management of Acute Crises 1. ICU admission a. Aspiration is a major risk with active bleeding 2. Management of coagulopathies 3. Blood product replacement (most transfusion physicians recommend only component therapy) a. PRBCs (to HCT of 30) b. FFP c. Platelets 4. Hemodynamic support a. Fluids b. Vasopressors c. Monitoring 5. Gastric acid reduction a. H2 blockers b. Proton pump inhibitors 6. Endoscopy a. Diagnostic intervention of choice b. Allows treatment 7. Angiography a. Cauterization 8. Surgery a. Gastric resection b. Shunt surgery c. Liver transplantation References: Cook, D.J., Reeve, B.K., Guyatt, G.H., Heyland, D.K., Griffith, L.E., Buckingham, L., Tryba, M. (1996). Stress Ulcer Prophylaxis in critically ill patients: Resolving discordant meta-analyses. JAMA, 275, (4), 308-314. Internet sites: American Gastroenterological Association: American College of Gastroenterology: Society of Gastroenterology Nurses and Associates: CCRN: Test Prep © 2004 Ed4Nurses, Inc. 20 Hepatic Failure 1. Etiology a. Viral hepatitis b. Acetaminophen overdose i. Chronic alcohol use increases susceptibility c. Alpha1-antitrypsin deficiency d. Autoimmune disease 2. Diagnostic testing a. CBC b. PT c. AST / ALT d. Bilirubin e. Ammonia f. Glucose g. Lactate 3. Symptoms a. Jaundice b. ↓ level of consciousness c. Ascites d. Hypotension & tachycardia (SIRS) 4. Management a. Supportive: i. ↑ ICP: mannitol ii. Renal failure: dialysis iii. Coagulopathy: platelets, FFP b. Liver transplant Acute Pancreatitis 1. Etiology a. Alcoholism b. Biliary tract disease c. Drugs i. Thiazides ii. Acetaminophen iii. Tetracycline iv. Oral contraceptives d. Infection e. Hyperlipidemia, hypertriclyceridemia f. Structural abnormalities of bile or pancreatic ducts 2. Pathogenesis a. Edema b. Necrosis CCRN: Test Prep © 2004 Ed4Nurses, Inc. 21 c. Hemorrhage d. Pancreatic enzyme release e. Inflammation i. Enzymes and toxins enter the peritoneum ii. ↑ permeability of blood vessels, third spacing iii. Enzymes enter systemic circulation ↑ capillary permeability iv. Shock from ↓ circulating volume 3. Symptoms a. Abdominal pain i. ↑ after eating or alcohol ingestion ii. Severe, persistent, penetrating iii. Radiates to back or neck b. Fever c. Nausea / Vomiting without ↓ pain d. Sweating 4. Physical exam a. Appears acutely ill b. Tachycardia, tachypnea, hypotension c. ↑ temperature d. LUQ abdominal tenderness with guarding e. ↓ or absent bowel sounds f. Signs of dehydration g. Signs of necrosis (50% mortality) i. Grey Turner’s sign ii. Cullen’s sign 5. Hemodynamics a. ↓ preload (CVP, PAOP) b. ↓ CO c. ↓ afterload (SVR) 6. Diagnostic tests a. Labs i. ↑ Serum and urine amylase ii. ↑ Lipase iii. Amylase:creatinine clearance ratio iv. ↑ Glucose v. ↓ Calcium 2° to ↓ albumin CCRN: Test Prep © 2004 Ed4Nurses, Inc. 22 Ranson’s Criteria On Admission During 1st 24 hours ƒ Age 55 ƒ WBC 16 ƒ Glucose 200 ƒ LDH 350 ƒ SGOT 250 ƒ HCT ↓ 10% ƒ BUN ↑ 5mg/dl ƒ Ca++ 8 ƒ pO2 60 mmHg ƒ Base deficit ↑ 4 ƒ Fluid sequestration 6L 3 criteria require supportive care 7 are critically ill with close to 100% mortality 7. Treatment a. NPO b. NG drainage i. Does not decrease pancreatic enzyme secretion ii. Helpful in managing: 1. Vomiting 2. Gastric distension 3. Ileus 4. Aspiration from ↓ mental status c. IV fluids d. Hemodynamic support e. Pain relief i. Demoral or Dilaudid ii. Morphine may cause biliary colic or spasms of the sphincter of Oddi f. Antibiotics for necrotizing pancreatitis i. Imipenem ii. Ciprofloxin iii. Cefotaxime g. TPN nutrition (low lipids) 8. Complications a. Death from cardiovascular instability b. Infection c. Pseudocyst i. Collection of blood, necrotic tissue, inflammatory debris encapsulated in fibrotic tissue d. Hypovolemic shock e. Respiratory failure / ARDS f. Pleural effusion g. Renal failure 2° to hypovolemia CCRN: Test Prep © 2004 Ed4Nurses, Inc. 23 Bowel infarction 1. Pathogenesis a. Acute mesenteric ischemia (AMI) b. Insufficient blood flow due to: i. Arterial occlusion ii. Venous occlusion iii. Non-occlusive processes 2. Symptoms a. Pain b. N/V c. Bloody diarrhea d. Hypovolemia e. Metabolic acidosis 3. Diagnostic tests a. Labs: i. ↑ H/H ii. ↑ Amylase iii. ↑ WBC b. KUB c. CT or MRI d. Ultrasound e. Guaiac stools 4. Treatment a. Medical i. Volume replacement ii. Correct underlying condition iii. Improve mesenteric blood flow iv. NG tube v. ATB b. Surgical i. Bowel resection ii. Embolectomy iii. Revascularization 5. Complications a. Perforation b. Strictures c. Infection CCRN: Test Prep © 2004 Ed4Nurses, Inc. 24 Abdominal Trauma 1. Esophagus a. Penetrating injury more common than blunt b. Early diagnosis is important, gastric acid erodes tissues, and contaminates the wound c. Mortality is as high as 27%, mostly due to infection d. Areas at risk for injury i. At the cricoid cartilage ii. At the arch of the aorta iii. As it passes through the diaphragm e. Manifestations i. Look for abrasions, contusions, lacerations ii. Pain iii. Fever iv. Dysphagia v. Bloody emesis vi. Mediastinal crepitus f. Diagnosis i. CXR, KUB ii. Esophagogram g. Treatment i. NG decompression ii. Surgical repair h. Leaks are common 2. Diaphragm a. Fairly well protected b. Most often injured by penetrating trauma of the lower chest c. 15% of patients with stab wounds d. 46% of patients with GSW e. Manifestations i. Have a high degree of suspicion in pts. with trauma to the abdomen or as high as T4 ii. Chest pain iii. Dyspnea iv. Peristalsis heard in the chest v. Difficulty passing an NG tube vi. Persistent air leak from a chest tube f. CXR g. Evidence on exploratory lap h. Treatment i. Herniation can occur weeks to years later ii. Therefore, surgical repair is necessary i. Complications i. Intra-abdominal hypertension increases risk of herniation CCRN: Test Prep © 2004 Ed4Nurses, Inc. 25 3. Stomach a. Most is penetrating b. Accounts for about 19% of abdominal injuries c. Can result from CPR d. Good prognosis with prompt recognition and treatment e. Manifestations i. Epigastric pain and tenderness ii. Peritonitis iii. Bloody drainage from NG iv. Abdominal free air f. Treatment i. NG tube ii. Surgical resection iii. H2-blockers g. Complications i. Peritonitis ii. Intra-abdominal abscess iii. Gastric fistula iv. Prolonged healing or breakdown of the repair may result in contamination or hemorrhage 4. Liver: size and location make it vulnerable to injury a. Most common abdominal organ to be injured b. Highest mortality with direct blunt trauma (about 70%) and shotgun injuries: (10-15% from hemorrhage) Liver Injury Scale Grade Injury I Hematoma I Laceration Subcapsular, nonexpanding, 10% surface area Capsular tear, non-bleeding, 1 cm depth II Hematoma Subcapsular, nonexpanding, 10-50% surface area c. Manifestations i. Have a high degree of suspicion with patients with persistent unexplained hypotension ii. Evidence of peritonitis with bile leakage iii. RUQ pain or tenderness d. CXR e. Diagnostic peritoneal lavage may be helpful f. CT is preferred, if stable g. Treatment i. If bleeding is small, serial CT scans ii. Liver resection is indicated if: 1. Bleeding is extensive, or on-going 2. Signs of sepsis CCRN: Test Prep © 2004 Ed4Nurses, Inc. 26 3. Deterioration of liver function tests h. Complications i. Uncontrolled hemorrhage ii. Sepsis iii. Decreased albumin iv. Hypoglycemia v. Drug toxicity vi. Bleeding from loss of clotting factors i. Post-operative follow-up i. Labs: 1. Coagulation profile 2. Ammonia level 3. Liver profile 4. Serum protein and glucose 5. Replace blood products as needed ii. Major complications secondary to liver damage 1. Blood loss 2. PRBCs, platelets, FFP 3. Assess for DIC 4. Pulmonary insufficiency 5. Atelectasis, pleural effusion, pneumonia are common a. Related to position of the liver, pleural irritation, and pain 6. Infection 7. Tissue debris, necrosis, bile 8. Abscess or sepsis 9. Assess for signs of infection 10. CT for abscess formation 5. Spleen: most commonly injured organ in blunt trauma a. Isolated splenic injury occurs in about 20% of all cases and is associated with a very low mortality b. Overall mortality 11%, with associated injury 25% c. Assessment i. LUQ injury ii. Pain or tenderness iii. Ballance’s sign: dullness to percussion that disappears with position change d. Manifestations i. Graded from I to V depending on injury severity ii. KUB may show changes in splenic outline iii. CT scan iv. Fractures of ribs 8-10 associated with a 20% chance of injury v. ↑ WBC, ↓ H/H vi. Hypovolemia, shock CCRN: Test Prep © 2004 Ed4Nurses, Inc. 27 e. Treatment i. Localized bleeding control to preserve spleen, if damage is superficial and localized ii. Partial splenectomy, when wound is deep iii. Splenectomy, when blood supply is interrupted, spleen is destroyed, or hemorrhage cannot be stopped f. Complications i. OPSI: Overwhelming Postsplenectomy Infection: due to loss of immune actions of the spleen ii. Hemorrhage iii. Infection, abscess 6. Pancreas: mostly from penetrating wounds a. Associated with multi-organ injury b. Pancreatic enzymes may not elevate due to inactivation during injury c. Manifestations i. Mechanism of injury ii. Epigastric pain & tenderness iii. ↑ amylase, lipase iv. Nausea, vomiting d. Treatment i. Drainage of enzymes ii. Surgical repair iii. Wound drainage e. Complications (due to inadequate drainage during surgery) i. Pseudocyst ii. Abscess 7. Bowel a. Penetrating, blunt or shearing trauma b. Duodenal and Ileum Injuries c. Rarely single organ injuries d. Alkalinity of contents produces immediate irritation e. Often difficult to diagnose since contents are sterile, peritonitis does not occur immediately f. Fever, jaundice, bowel obstruction, abdominal pain, edema g. Graded I-V by severity h. Octreotide to decrease secretions i. Complications i. Sepsis with MODS and duodenal fistula can be lethal The American Gastroenterological Association: CCRN: Test Prep © 2004 Ed4Nurses, Inc. 28 8. Small Bowel a. Look for contusions, wounds over abdomen b. Abdominal pain and tenderness c. ↓ bowel sounds d. Hypovolemia e. Delayed rupture is possible f. CT scan, KUB for free air g. Treatment is surgical intervention h. Fluid / nutrition deficiency common post-op i. Fistula formation is possible post-op 9. Abdominal assessment a. History i. Prior surgeries ii. Nutritional deficits iii. Absorption problems b. Inspection c. Auscultation d. Percussion e. Palpation f. Diagnostic studies i. X-rays ii. CT iii. Arteriography iv. Diagnostic Peritoneal Lavage 10. Intra-abdominal Hypertension a. Caused by fluid volume resuscitation b. Results in renal dysfunction and respiratory compromise c. Measured in bladder with T-piece catheter d. Hypertension is defined as 18 mmHg e. Temporary abdominal closure reduces abdominal pressure and improves lung dynamics, but does not improve renal function or oxygenation. CCRN: Test Prep © 2004 Ed4Nurses, Inc. 29 GI Surgeries: 1. Whipple (Pancreaticoduodenectomy) a. Used for: i. Resectable pancreatic cancer ii. Pancreatic cancer iii. Chronic pancreatitis b. Removal of: i. Head of the pancreas ii. Duodenum iii. Part of the common bile duct iv. Gallbladder v. Sometimes a portion of the stomach c. Complications: i. Peritonitis ii. Sepsis, SIRS, MODS iii. Pancreatic fistula iv. Uncontrolled blood sugar in diabetics 2. Esophago-gastrectomy a. Used for: i. Esophageal cancer b. Removal of: i. Part of the esophagus ii. Part of the stomach iii. Anastomose with intestine c. Complications: i. Anastomotic leak ii. Stricture formation iii. Diarrhea 3. Gastric bypass (Roux-en-Y) a. Used for: i. Surgical treatment of obesity b. Bypass of: i. Part of the stomach ii. Duodenum c. Complications: i. Dumping syndrome ii. Peritonitis iii. Gallstones iv. Nutritional deficiency Resources: Brolin RE (2002). Bariatric surgery and long-term control of morbid obesity. JAMA, 288(22): 2793–2796. CCRN: Test Prep © 2004 Ed4Nurses, Inc. 30 Multisystem (8%) 12 questions 1. As a result of multisystem trauma, edema can occur in the peritoneal and retroperitoneal areas and cause intra-abdominal pressure to increase. Intraabdominal pressure is measured using a urinary catheter and is hypertensive if the pressure exceeds: a. 10 mmHg b. 50 mmHg c. 100 mmHg d. 150 mmHg 2. Initial treatment for hypovolemic shock includes: a. Vasopressors b. Volume resuscitation c. Stopping the loss d. Antibiotics 3. Death from multisystem trauma that occurs within minutes is usually caused by: a. Great vessel laceration b. Head injury c. Pelvic fracture d. Multisystem organ failure 4. The primary purpose of obtaining blood cultures in the septic patient is: a. To diagnose sepsis b. To guide therapy c. To evaluate the level of response d. To determine a source 5. A defining characteristic of septic shock that differentiate it from other types of shock is: a. Low blood pressure b. Wide pulse pressure c. Decreased urine output d. Tachycardia 6. Corticosteroids are often used in septic shock for: a. Inflammation b. Adrenal replacement c. Immunosuppression d. Bronchodilation CCRN: Test Prep © 2004 Ed4Nurses, Inc. 31 7. Septic shock with ARDS and acute renal failure may be treated with activated protein C (Xigris). A major complication of Xigris is: a. Hypoxia b. Hyperglycemia c. Bleeding d. Acidosis 8. The systemic inflammatory response syndrome (SIRS) can cause multiorgan dysfunction. The first organ to be involved is: a. The heart b. The lungs c. The brain d. The liver 9. Using vasopressors in shock may cause: a. Increased splanic perfusion b. Decreased cardiac output c. Decreased pulmonary perfusion d. Increased peripheral perfusion 10. Mr. Jones took 100 tablets of Percocet in a suicide attempt. As his nurse, you should know that treatment of ingested poisoning includes: a. Managing the ABCs and administering activated charcoal b. Administering ipecac c. Hyperbaric oxygen d. Prompt transport to a poison control center 11. Ms. Lett is admitted for burns suffered in a house fire. Since she is complaining of shortness of breath, an ABG is drawn. Due to the etiology of the burns, the nurse should be especially concerned about: a. pO2 of 83 b. pCO2 of 50 c. COHb of 18 d. pH of 7.32 12. In the initial resuscitation of burns, which treatment is the priority? a. Fluid volume replacement b. Administration of antibiotics c. Management of the airway d. All of the above CCRN: Test Prep © 2004 Ed4Nurses, Inc. 32 Multisystem Trauma 1. Decreased intravascular volume a. Hemorrhage b. Dehydration c. Burns d. Third spacing 2. Decreased blood pressure a. ↓ preload, ↓ SV, ↓ CO 3. Compensatory mechanisms activated r/t ↓ CO 4. Treatment goal is to replace lost volume a. RBCs b. Colloids i. Albumin, Dextran, Hetastarch ii. May decrease risk of pulmonary edema iii. Osmotic “pull” increases intravascular volume c. Crystalloids i. NS, Lactated Ringers ii. Proven efficacy in traumatic hypovolemia iii. Only 20% remains in the blood stream at 1 hour iv. Can result in significant hemodilution and ↓ DO2 d. Hemoglobin substitutes i. PolyHeme® ii. Oxygent Fluid Vol. Expansion Advantages Disadvantages NS, LR 1 hour Proven efficacy May contribute to edema Colloids 24 hours Less edema Volume limit Blood products Remains Great colloid, replacement ↑ inflammation. ↑ mortality Hb substitutes Varies Immediate oxygen delivery Multiple side effects Not proven effective Volume loss Stage Symptoms 10% 1 ↑ HR, normal B/P 20% 2 ↓ B/P, ↓ CO, ↑ HR 25% 3 Compensation begins to fail CCRN: Test Prep © 2004 Ed4Nurses, Inc. 33 Hemodynamics in Hypovolemic Shock General Principles for Managing Multisystem Trauma 1. Primary Survey a. Airway, Breathing, Circulation, Disability, Exposure 2. Trimodal Distribution of Death a. First Peak i. Within minutes ii. Due to lacerations of large vessels or of essential organs b. Second Peak i. Minutes to several hours ii. Due to: iii. Subdural / epidural hematoma iv. Hemothorax v. Pelvic fractures vi. Ruptured spleen vii. Significant blood loss c. Third Peak i. Several days to weeks ii. Due to sepsis or multisystem organ failure CCRN: Test Prep © 2004 Ed4Nurses, Inc. 34 Sepsis / Septic Shock / MODS 1. Maldistribution of blood volume (massive vasodilation) a. Sepsis (most common) b. Anaphylactic c. Neurogenic d. Spinal 2. Hyperdynamic stage: a. Tachycardia, ↑ CO b. ↓ afterload c. Flushing d. Fever e. ↑ blood glucose 3. Shock stage a. ↑ HR, ↑ RR b. ↑ afterload c. Hypothermia d. ↓ organ perfusion 4. Sepsis stimulates the Systemic Inflammatory Response Syndrome (SIRS) CCRN: Test Prep © 2004 Ed4Nurses, Inc. 35 5. Compensatory mechanisms activated r/t ↓ B/P 6. Treatment goals: a. “Fill” vascular space b. Prevent secondary organ damage i. Vasopressors 1. Dopamine 2. Levophed 3. Neosynphrine 4. Vasopressin ii. IV fluids iii. Colloids iv. Blood products v. Xigris Hemodynamics in Sepsis CCRN: Test Prep © 2004 Ed4Nurses, Inc. 36 Poisoning Ingested 1. Emesis a. Serious aspiration risk 2. Gastric lavage a. 500-3000cc 3. Activated charcoal a. 50-100 grams 4. Specific antidotes a. Narcan for opiates b. Atropine for organophosphates c. Methylene blue for methemoglobinemia d. Acetylcystine for acetaminophen 5. Support a. Cardiovascular b. Pulmonary c. Valium or Phenobarbital for seizures d. Mannitol and dexamethasone for ↑ ICP Carbon Monoxide 1. Emitted from gas, charcoal, oil, wood 2. Brain and heart most affected 3. Symptoms: a. Low-level exposure i. Shortness of breath ii. Mild nausea iii. Mild headache b. Moderate-level exposure i. Headache ii. Nausea iii. Light-headedness iv. Dizziness c. High-level exposure i. Death within minutes 4. Treatment a. Oxygen (reduces COHb half-life from 4-5 hours to 1 hour) b. Hyperbaric oxygen therapy (↓ half-life to 30 minutes) CCRN: Test Prep © 2004 Ed4Nurses, Inc. 37 Burns 1. Types: a. Thermal b. Electrical c. Chemical d. Radiation 2. Zone of injury 3. Assessment a. Rule of nines b. Classification i. First degree ii. Second degree iii. Third degree 4. Complications a. Intra-abdominal hypertension b. Pulmonary injury a. Smoke inhalation b. CO intoxication c. Airway burns c. Fluid volume deficit i. First 24 hours (1) 4 ml LR / %TBSA / kg (2) ½ volume in 1st eight hours (3) ¼ volume next eight hours (4) ¼ volume last eight hours ii. Second 24 hours (1) D5W with 40 mEq KCl to maintain normal electrolyte balance (2) Plasma or albumin to maintain hemodynamic balance d. Infection i. Burn dressing ii. Antibiotics e. Electrolyte imbalances 5. Pain Control CCRN: Test Prep © 2004 Ed4Nurses, Inc. 38 Cardiovascular (32%) 48 questions 1. Which of the following variables affects cardiac output directly? a. Preload b. Stroke volume c. Afterload d. Resistance 2. Coronary artery perfusion is dependent upon: a. Diastolic pressure b. Systolic pressure c. Afterload d. SVR 3. Mixed venous oxygen saturation (SvO2) assesses: a. Preload b. Afterload c. Oxygen delivery d. Oxygen consumption 4. Chest pain that is not relieved by rest and nitroglycerine is called: a. Variant angina b. Stable angina c. Unstable angina d. Prinzmetal’s angina 5. The nurse administering t-PA for acute myocardial infarction must monitor the patient for all of the following except: a. Peripheral thrombosis b. Myocardial reperfusion c. Bleeding complications d. Coronary reocclusion 6. Which finding would not indicate coronary reperfusion during t-PA infusion? a. Drop in arterial blood pressure b. Resolution of ST segment elevation c. Ventricular tachycardia d. Dramatic reduction in chest pain 7. Which of the following is not an indication for thrombolytic therapy? a. An occluded arteriovenous fistula b. Non-Q Wave Myocardial Infarction c. Peripheral arterial occlusion d. Acute Myocardial Infarction CCRN: Test Prep © 2004 Ed4Nurses, Inc. 39 8. The pathologic changes found on 12 Lead ECG to indicate myocardial ischemia are: a. ST elevation b. ST segment depression and T wave elevation c. Q wave formation d. ST segment depression and T wave inversion 9. Failure to capture is a complication of pacemakers that may be caused by: a. Lead maturation b. Lead displacement c. Dead battery d. Open circuit 10. Automatic implantable cardio-defibrillators (AICDs) may be initiated in the treatment of: a. Frequent PVCs b. Atrial fibrillation c. Narrow-complex SVT d. Symptomatic VT 11. The nurse auscultates an S4 gallop during her assessment. The appearance of an S4 gallop during an anginal episode may signify: a. Congestive heart failure b. Decreased compliance of the ischemic myocardium c. Aortic stenosis d. Increased left ventricular filling volume 12. Heart failure caused by the inability to fully relax is called: a. Systolic b. Diastolic c. Biventricular d. Complete 13. The primary function of drug therapy with beta-blockers in heart failure is to: a. Increase blood pressure b. Block compensatory mechanisms c. Increase urine output d. Decrease arrhythmias 14. Early symptoms of fluid overload and pulmonary edema are: a. Rales and hypoxia b. S3 heart sound and tachycardia c. Increased respiratory rate and subjective dyspnea d. ST-segment elevation in the chest leads CCRN: Test Prep © 2004 Ed4Nurses, Inc. 40 15. Mechanical ventilation may be helpful to your patient with CHF because it: a. Decreases preload b. Increases alveolar pressure c. Increases oxygenation d. All of the above 16. An Intraaortic Balloon Pump (IABP) has the following hemodynamic effects: a. Increases left ventricular pressure b. Increases wedge pressure c. Increases coronary artery perfusion d. Increases afterload 17. The IABP is: a. Deflated during systole b. Inflated during systole c. Deflated during diastole d. None of the above 18. IABP therapy is contraindicated for which of the following disorders? a. Papillary muscle rupture b. Incompetent aortic valve c. Left ventricular failure d. Unstable angina refractory to medical regimen 19. Which coronary artery supplies the atrioventricular (AV) node? a. Right coronary artery b. Coronary sinus artery c. Left anterior descending artery d. Nodal artery 20. Coronary perfusion occurs during: a. Systole b. Diastole c. Equally during diastole and systole d. Continuously 21. The forth heart sound (S4) occurs: a. After ventricular contraction b. Is best heard with the diaphragm of the stethoscope c. Is a normal finding in children d. During atrial contraction CCRN: Test Prep © 2004 Ed4Nurses, Inc. 41 22. Flotation of a pulmonary artery catheter into a wedge position increases the risk of: a. Dysrhythmias b. Infection c. Pneumothorax d. Pulmonary infarction 23. Which of the following pulmonary artery pressures are within normal limits? a. PAP 34/24, wedge = 12 b. PAP 30/20, wedge = 10 c. PAP 28/18, wedge = 20 d. PAP 24/14, wedge = 12 24. Which of the following results in an elevated pulmonary artery pressure and a normal wedge pressure? a. Cardiac tamponade b. Left ventricular failure c. Myocardial infarction d. Pulmonary embolism 25. Which of the following is the least accurate in diagnosing an acute myocardial infarction? a. Patient’s history b. Physical examination c. Enzyme studies d. Serial EKG’s 26. The inferior wall myocardial infarction will show changes in which EKG leads? a. V1 to V4 b. V1, AVL c. V5 and V6 d. II, III, AVF 27. The most common complication of an acute myocardial infarction is: a. Dysrhythmia b. Congestive heart failure c. Cardiogenic shock d. Pulmonary embolism 28. Which of the following hemodynamic parameters would indicate left ventricular failure in a patient with COPD? a. PAP 25/22, wedge = 14 b. PAP 48/26, wedge = 16 c. PAP 22/12, wedge = 16 d. PAP 48/26, wedge = 20 CCRN: Test Prep © 2004 Ed4Nurses, Inc. 42 29. Which of the following medications would be most effective in the acute myocardial infarction patient to decrease preload and afterload? a. Dopamine b. Nitroglycerine c. Dobutamine d. Digoxin 30. Positive inotropic agents are used to: a. Improve tissue perfusion b. Decrease water loss through the kidney c. Increase heart rate d. Vasodilate vessels 31. Which condition would stimulate renin production? a. Increased blood supply to the renal tubules b. Decreased blood pressure c. Decreased sympathetic output d. Increased sodium concentration 32. Acute rejection in cardiac transplantation is diagnosed by: a. ECG b. Chest X-ray c. Echocardiography d. Endomyocardial biopsy 33. After cardiac transplantation, the patient is placed on cyclosporine (Sandimmune). In assessing for complications related to this drug therapy, the nurse should monitor: a. Blood glucose b. Serum creatinine c. Serum amylase d. Serum magnesium 34. You are caring for a patient recently admitted with and IWMI. Which of the following 12 Lead ECG findings would you anticipate? a. T-wave inversion I, and AVL b. Q wave formation and ST-segment elevation in II, III, and AVF c. QRS duration greater than 0.01 in all leads d. R-wave taller in V6 35. Your patient with an IWMI also has a RV infarction. He soon develops RV failure. Which of the following data would you expect to see? a. PAP 23/8 PAOP 19 CVP 20 b. PAP 54/28 PAOP 14 CVP 14 c. PAP 54/18 PAOP 24 CVP 5 d. PAP 28/10 PAOP 10 CVP 20 CCRN: Test Prep © 2004 Ed4Nurses, Inc. 43 36. A sign of a peripheral arterial occlusion is: a. Pallor b. Swelling c. Redness d. Dyspnea 37. Your patient has just come to the unit after a Carotid Endarterectomy (CEA). As her nurse, you will assess for all of the following except: a. Hypertension b. Changes in mental status c. Bleeding d. Seizures 38. A thoracic aortic aneurysm causes chest pain that: a. Radiates to the left arm b. Bores through to the back c. Is sharp and worse while reclining d. Is associated with diminished breath sounds 39. A patient who presents with stabbing chest pain that is worse in the supine position, with fever and chills is probably suffering from: a. Myocardial infarction b. Pulmonary embolism c. Pericarditis d. Pneumothorax 40. Primary patient care management of pericarditis includes all of the following except: a. Monitoring for signs of cardiac tamponade b. Evaluating the effectiveness of pain relief strategies c. Maintaining the patient’s bowel regimen d. Providing emotional support 41. Subacute bacterial endocarditis (SBE) is usually caused by; a. Dental procedures b. Normal valves c. IV drug abuse d. Prosthetic valves 42. The valve most often affected by infective endocarditis is: a. Mitral b. Aortic c. Tricuspid d. Pulmonary CCRN: Test Prep © 2004 Ed4Nurses, Inc. 44 43. Following a motor-vehicle accident, pericardial tamponade is suspected. Which of the following findings is consistent with traumatic tamponade? a. Muffled heart sounds b. Pericardiocentesis of 50 cc of blood c. ST-segment depression in the limb leads d. Rales on auscultation 44. The classic triad (Beck’s triad) of symptoms of cardiac tamponade are: a. Tachycardia, hypotension, narrow pulse pressure b. Rales, muffled heart sounds, bradycardia c. Widened pulse pressure, atrial arrhythmias d. Hypertension, flushing, pulses paradoxus 45. Mr. Ford comes to the emergency department (ED) after a motor-vehicle accident. He is complaining of chest pain, dyspnea, and has ST-segment elevation on the anterior leads. Mr. Ford is most likely suffering from: a. Pneumothorax b. Flail chest c. Cardiac contusion d. Pulmonary embolism 46. In Cardiogenic shock the initial goal is to: a. Increase cardiac output b. Increase oxygen supply c. Decrease oxygen consumption d. Decrease contractility 47. The medication that increases oxygen supply to the heart during Cardiogenic shock is: a. Dopamine b. Nitroglycerine c. Nitroprusside d. Dobutamine 48. Calcium-channel blockers have which of the following functions? a. Increase vascular tone b. Increase velocity of AV conduction c. Decrease cardiac oxygen consumption d. Increase cerebral oxygenation CCRN: Test Prep © 2004 Ed4Nurses, Inc. 45 Cardiovascular 1. Coronary Perfusion a. Cardiac cycle b. Aortic pressure c. Coronary Artery Perfusion Pressure i. CAPP = Diastolic BP – PAOP ii. Normal 60-80mmHg 2. Determinants of Ventricular Function a. Cardiac Output i. Heart Rate X Stroke Volume ii. Stroke Volume 1. Preload 2. Afterload 3. Contractility iii. Supply and Demand 1. Supply a. Coronary artery patency b. Diastolic time c. Diastolic pressure d. O2 extraction e. Hemoglobin f. SaO2 2. Demand a. HR b. Preload c. Afterload d. Contractility CCRN: Test Prep © 2004 Ed4Nurses, Inc. 46 Flow and Assessment 3. Hemodynamic Monitoring a. Uses i. Measure hemodynamic waveforms ii. Blood samples iii. Central venous access iv. Perform intracardiac pacing b. Indications c. Complications Electrocardiogram (ECG) 1. General Info 2. Electrolyte imbalances a. Hypokalemia: ventricular irritability i. Flat T wave with prominent U wave ii. T-wave + U wave same amplitude iii. ST-segment flattening iv. Prolonged QT interval v. ST-segment depression vi. Treatment: 1. PO or IV replacement b. Hyperkalemia: ventricular depression i. Tall, narrow peaked T waves ii. Widened QRS iii. P wave widens iv. P-wave barely visible v. Treatment c. Hypo-hyper-calcemia d. Hypo-hyper-magnesemia CCRN: Test Prep © 2004 Ed4Nurses, Inc. 47 RA 3-5 mmHg RV 25/3-5 mmHg PA 25/8-12 mmHg PAOP 8-12 mmHg LA 4-12 mmHg LV 120/4-12 mmHg Ao 120/80 mmHg CCRN: Test Prep © 2004 Ed4Nurses, Inc. 48 Mixed-Venous Oxygen Saturation (SVO2) 1. CO/CI 2. H+H 3. Oxygenation 4. Metabolic Demand Precapillary Pressure 30 mmHg Postcapillary Pressure 10 mmHg CO 4-8 liter/min CI 2.4-4.2 liter/min/m2 PVR 37-250 dynes/sec/cm2 SVR 800-1200 dynes/sec/cm 2 CCRN: Test Prep © 2004 Ed4Nurses, Inc. 49 Coronary Artery Disease 1. Definition a. Pathophysiology b. Etiology c. Risk Factors 2. Clinical Manifestations Stable Angina 1. Clinical presentation a. ECG 3. Treatment a. Rest b. Anticoagulants c. Vasodilators d. Beta Blocker e. ACE I Unstable Angina 1. Clinical Presentation 2. Pathophysiology 3. New Terminology 4. Biochemical Markers 5. Treatment management a. ASA b. Beta Blockers c. Calcium Channel Blockers ??? d. Heparin e. NTG f. Morphine g. GP IIb-IIIa drugs h. Assistance for the ventricle i. IABP 1. Increase coronary perfusion 2. Decrease afterload 3. Absolute contraindication: Aortic insufficiency 4. Monitor a. Vascular Exam b. Timing ii. Interventional 1. Pre-procedure 2. Post-procedure 3. 6 P’s CCRN: Test Prep © 2004 Ed4Nurses, Inc. 50 Acute Myocardial Infarction 1. Etiology 2. Pathophysiology 3. Classifications 4. Clinical Presentation a. ECG Changes i. Anterior Wall ii. Inferior Wall b. Enzymes c. Diagnosis 5. Manage and Monitor a. Reduce Size of Infarction b. Door to Diagnosis and Treatment c. Diagnosis d. Treatment Paradigm i. Oxygen, pain management ii. Reperfusion therapies 1. Cath lab (PCI) 2. Thrombolytics (tPA) 3. CABG iii. Increase Myocardial Oxygen Supply iv. Decrease Myocardial Oxygen Demand e. ACC/AHA guidelines i. Reperfusion Therapy ii. ASA iii. ACE I iv. Beta Blocker v. Lipids: Statins vi. Smoking Cessation Information f. RV Infarction i. Assess for clinical signs of RVMI: 1. Classic triad: a. Jugular vein distension b. Clear lungs c. Hypotension ii. Maintain adequate filling pressures iii. Avoid diuretics and NTG (highly sensitive) iv. Hemodynamics 1. CVP 10 mmHg 2. CVP within 5 mm Hg of PAOP v. Complications → Plug in the Pump! ← CCRN: Test Prep © 2004 Ed4Nurses, Inc. 51 Heart Failure Systolic Dysfunction 1. Dysfunction of contractility 2. Weak contraction → ↓ SV → ↓ CO → ↑ EDP/EDV → hypertrophy 3. Etiology: a) Ischemic heart disease b) Cardiomyopathies c) Hypertension d) Valvular disease e) Pericardial disease f) Chronic tachycardia g) Connective tissue disease h) Neurogenic i) Pulmonary disease 4. Primary symptoms a) Dyspnea / orthopnea b) Exercise intolerance c) Edema d) Mental status changes e) S3, S4 f) Tachycardia g) Rales h) Hepatomegaly i) JVD Diastolic Dysfunction 1. Dysfunction of relaxation 2. Incomplete relaxation → restricted filling → ↓ SV → ↓ CO → ↑ EDP (EDV is normal) 3. Etiology: a. LV hypertrophy b. Ischemic states 4. Primary symptoms a. Dyspnea, fatigue Compensation 1. Renin-Angiotensin-Aldosterone 2. Clinical Presentation LVF a. Tachypnea, Dyspnea, orthopnea, PND b. Pulsus alternans 3. Clinical Presentation RVF a. JVD, HJR, edema, ascites, CVP elevation b. Abnormal liver functions CCRN: Test Prep © 2004 Ed4Nurses, Inc. 52 Management 1. Beta-adrenergic agonists a. Dopamine (Intropin), Dobutamine (Dobutrex), Norepinephrine (Levophed) b. Short-term exacerbation treatment c. Long-term use in HF clinics d. ↑ cardiac output (↑ contractility), ↑ VO2 2. Phosphodiesterase inhibitors a. Amrinone, (Inocor), Milrinone (Primacor) b. Short-term exacerbation treatment c. Long-term use in HF clinics d. ↑ cardiac output (contractility), vasodilation (↓ afterload), ↑ VO2 3. Diuretics a. ↑ cardiac output by ↓ preload b. Watch for electrolyte disturbances 4. Vasodilators a. Nitrates i. ↓ preload, ↑ contractility, ↓ afterload b. Ca+ channel blockers i. ↑ contractility, ↓ afterload c. Natrecor i. ↓ preload, ↓ afterload 5. Angiotension-converting enzymes (ACE) inhibitors (ie. Enalapril) a. Block the RAS activation that causes vasoconstriction and remodeling b. Decrease afterload (vasodilation) c. Favorable affects on mortality and morbidity d. ACE inhibitors continue to be preferred over Angiotensin II (AT) blockers 6. Beta-blockers (ie. Metaprolol, Carvedilol) a. Blocks sympathetic NS compensation that leads to decompensation & remodeling b. Improves mortality and morbidity 7. Anticoagulation and antiplatelet drugs a. Atrial fibrillation b. Venous stasis from ↓ CO 8. Amiodarone a. Currently not recommended for primary prevention of death in CHF 9. Automatic Implantable Cardiac Defibrillator (AICD) a. Recommended for patients with “sudden cardiac death” syndrome CCRN: Test Prep © 2004 Ed4Nurses, Inc. 53 10. Aldosterone Antagonists (spironolactone) a. Blocks aldosterone action on the sympathetic NS 11. Mechanics of positive pressure ventilation (CPAP, BiPAP, MV) a. Positive pressure ventilation b. Effects: i. Pulmonary pressures i. Airflow ii. Hemodynamics 12. Goals of therapy a. Prevent further myocardial remodeling / damage b. Prevent reoccurrence of failure c. Increase activity tolerance d. Relieve symptoms e. Improve prognosis 13. Novel Treatments a. A-V sequential pacemaker b. Biventricular pacing c. Ventricular assist devices d. Cardiomyoplasty e. Enhanced external counterpulsation f. Transplant CCRN: Test Prep © 2004 Ed4Nurses, Inc. 54 Infective Endocarditis Infection of the endocardium (inner lining) of the heart that covers the valves and contains the purkinje fibers. 1. Incidence a. Males 3X females b. 50 years c. Mitral valve prolapse (30% in younger patients) d. Rheumatic heart disease (20%) e. Calcific aortic stenosis (50% in older patients) 2. Etiology: a. Subacute bacterial endocarditis (SBE) i. Dental procedures ii. GU or GI tract iii. Abnormal valves b. Acute bacterial endocarditis i. Normal valves c. Prosthetic valvular endocarditis i. Within 1 year of valve replacement ii. After pacemaker or AICD placement d. Right-sided endocarditis i. IV drug abuse ii. Catheter-related infections (CVC, PA cath) 3. Clinical presentation a. Develops on: i. Mitral (most common) ii. Aortic iii. Tricuspid iv. Pulmonary (rare) b. Fever c. Fatigue, night sweats, anorexia d. Weight loss e. Back pain f. Embolism i. MI ii. CVA 4. Diagnosis a. Blood cultures i. 5% will not have positive cultures ii. May take 4 days to grow some organisms b. Murmur i. Aortic insufficiency murmur (most common) c. Widened pulse pressure d. Transesophageal echocardiography (TEE) i. Detects 90% of vegetations CCRN: Test Prep © 2004 Ed4Nurses, Inc. 55 5. Management a. Untreated endocarditis is always fatal b. Antibiotics c. Valvular repair if heart failure present 6. Complications a. Heart failure b. Emboli c. Sepsis Trauma 1. Blunt: myocardial contusion a. RV Primary site b. Labs c. Treat pain d. Ventricular rupture, tamponade, CA thrombosis, valve dysfunction, conduction defects, HF, shock, emboli 2. Penetrating a. Puncture of heart, or BOX, with sharp object b. Etiology: violence, industrial accident, sports, explosion, crush injury c. Pathophysiology: loss of blood, tamponade d. Presentation: visible wound, bleeding, hypotension, tamponade e. Management: i. Control hemorrhage ii. OR iii. Monitor for complications 1. Hemorrhagic shock 2. Tamponade 3. Hemothorax 4. Pneumothorax f. Diagnosis i. H & H, ECG, CXR, Aortogram, CT scan g. Overall Management i. Control bleeding ii. Control BP iii. Prepare for exploratory thoracotomy iv. Monitor for complications 1. Hemorrhage shock 2. Cardiac tamponade 3. Hemothorax 4. False aneurysm CCRN: Test Prep © 2004 Ed4Nurses, Inc. 56 3. Tamponade a. Etiology i. Post-cardiotomy ii. Post MI iii. Iatrogenic causes iv. Post CPR v. Anticoagulation vi. Rupture of great vessels vii. Aortic aneurysms viii. Infection b. Pathophysiology i. Accumulation of fluid ii. Decreased contractility iii. ↓ stroke volume, cardiac output, LV function, RV function, shock c. Presentation i. BECK’s TRIAD a. Tachycardia, Hypotension, Narrowed PP ii. Hemodynamics d. Diagnosis i. CXR ii. ECG iii. Echo and/or TEE iv. CT Fluoroscopy e. Management i. ABC’s ii. Circulating blood volume iii. Inotropes iv. Pericardiocentesis v. Pericardial window vi. Emergency thoracotomy CCRN: Test Prep © 2004 Ed4Nurses, Inc. 57 Hypertensive Crisis Diastolic blood pressure 120 mmHg 1. Etiology a. Pre-existing hypertension (most common) b. Renal disease c. Scleroderma d. Illicit drugs e. Pre-eclampsia, eclampsia f. Head injury g. Autonomic dysreflexia h. Tumors 2. Symptoms a. Chest pain b. Headache c. Decreased mental status d. Diuresis 3. Diagnostics a. CBC b. Electrolytes c. Urine i. Blood ii. Casts d. EKG e. Chest x-ray 4. Treatment a. Sodium nitroprusside b. Apresoline c. Vasotec d. Brevibloc e. Labetalol 5. Complications a. MI, CHF b. Stroke, cerebral bleed c. Aortic dissection CCRN: Test Prep © 2004 Ed4Nurses, Inc. 58 CARDIAC PEARLS a. ABC’s b. CO/CI – preservation of function c. PERFUSION d. Maintaining HR X SV i. PRELOAD ii. AFTERLOAD iii. CONTRACTILITY e. ST segment depression = ischemia f. ST segment elevation = current of injury g. IABP= increase coronary perfusion, decrease afterload: SO, it increases myocardial oxygen supply and decreases demand h. Murmurs: systolic = AS, MR i. Most common systolic murmur in recent MI is mitral insufficiency j. ST segment elevation in II, III, AVF = inferior infarction k. ST segment elevation in I, AVL, V leads = anterior infarction CCRN: Test Prep © 2004 Ed4Nurses, Inc. 59 Renal (5%) 8 questions 1. Acute renal failure differs from chronic renal failure in that it: a. Results in higher BUN levels b. Has a higher mortality rate c. Requires peritoneal dialysis d. Is associated with diabetes 2. The best dialysis schedule for the patient with acute renal failure is: a. Every other day b. Weekly c. Daily d. Bi-weekly 3. The primary etiology of hyperphophatemia is: a. Over-replacement b. Hypercalcemia c. Renal failure d. Hypoalbuminemia 4. Bradycardia, tremors and twitching muscles are associated with which electrolyte disorder? a. Hypokalemia b. Hyperkalemia c. Hypophosphatemia d. Hyperphosphatemia 5. Treatment for hypercalcemia includes: a. Fluids and diuretics b. Amphogel c. Kayexelate d. Dialysis 6. Hyponatremia is usually associated with: a. Fluid overload b. Dehydration c. Diuresis d. Over-administration of normal saline 7. Mr. Smith was involved in a motor-vehicle accident and is experiencing hematuria. The best diagnostic test to evaluate renal trauma is: a. Ultrasound b. Computed tomography (CT) c. Intravenous pyelogram (IVP) d. Angiography CCRN: Test Prep © 2004 Ed4Nurses, Inc. 60 8. Which of the following is not an etiology of acute renal failure (ARF)? a. Sepsis b. Shock c. Bladder tumor d. Hypertension Acute & Chronic Renal Failure 1. Acute Renal Failure: Sudden loss of renal function a. Etiology: i. Pre-renal 1. Most common outside the ICU 2. Etiology a. Low cardiac output b. Shock c. Renal artery stenosis 3. ↓ blood flow to kidneys, ↓ pressure in renal artery, ↓ forces favoring filtration, ↓ GFR 4. Kidney’s response is vasoconstriction 5. End result is ischemic damage to kidney ii. Intra-renal 1. Most common in the ICU 2. Causes a. Glomerulonephritis b. Antibiotics c. Myoglobinemia d. SLE, Diabetes 3. Direct damage to glomerulus CCRN: Test Prep © 2004 Ed4Nurses, Inc. 61 iii. Post-renal 1. Rare 2. Causes a. Urethral calculi b. BPH c. Urethral stricture d. Bladder cancer e. Neurogenic bladder 3. Partial obstruction = ↑ forces opposing filtration = ↓ GFR 4. Total obstruction = compression and necrosis b. Phases: i. Oliguria 1. Sudden onset of oliguria 2. Symptoms resemble CRF a. Nausea & Vomiting b. Drowsiness, confusion, coma c. GI bleeding d. Asterixis e. ↑ K+, ↓Na+, acidosis f. Cardiac arrhythmias g. Kussmal’s respirations h. Hypervolemia i. Edema j. HTN 3. Treatment: a. Dialysis b. Renal diet c. Fluid restriction ii. Diuretic (10-15 days) 1. Indicates that nephrons are healing 2. UO ↑ to 4-5 liters/day 3. Unable to concentrate urine or filter wastes 4. Can have excessive excretion of K+ and Na+ 5. Manifestations a. Hypovolemia b. Hypotension c. Electrolyte imbalances Acute Renal Failure is a secondary disease. Therefore mortality is about 40% CCRN: Test Prep © 2004 Ed4Nurses, Inc. 62 iii. Recovery (lasts 4-6 months) 1. BUN, Cr slowly return to normal iv. Treatment: 1. Hemodialysis 2. Continuous renal replacement therapy a. CAVHD b. CVVHD 3. Renal diet 4. Fluid restriction 2. Chronic Renal Failure: Progressive loss of renal function a. Etiology: i. Diabetes ii. Hypertension iii. Glomerulonephritis b. Stages: i. Decreased renal reserve 1. ↓ number of functional nephrons ii. Renal insufficiency 1. Asymptomatic ↑ in BUN / Cr. iii. Renal failure 1. Symptomatic ↑ in BUN / Cr. iv. End-stage renal disease 1. Severe ↑ BUN / Cr. 2. Chronic dialysis is needed c. Bricker hypothesis i. Intact nephrons hypertrophy to compensate for diseased nephrons d. Signs and symptoms of oliguria e. Treatment: i. Hemodialysis ii. Peritoneal dialysis iii. Renal diet iv. Fluid restriction v. Medications BUN/Cr Oliguria Diuresis CCRN: Test Prep © 2004 Ed4Nurses, Inc. 63 Renal Trauma 1. Renal injuries a. Blunt trauma i. Coup, contracoup ii. Shearing of renal artery, ureters iii. Direct kidney damage is most often accompanied by other abdominal injury b. Penetrating c. Manifestations i. Flank pain ii. Gray-Turner’s sign (flank ecchymosis 76%) iii. Hematuria d. KUB e. IVP f. Urethrogram g. Cystogram h. Ultrasound i. CT scan j. MRI 2. Kidney laceration 3. Treatment a. Partial / total nephrectomy CCRN: Test Prep © 2004 Ed4Nurses, Inc. 64 Electrolyte Abnormalities Potassium (3.5-5 mEq/L) 1. Acquired in diet, excreted in urine, must be replaced daily 2. Major intracellular cation 3. Functions: a. Maintains osmotic pressure inside cells b. Maintains electrical potential c. Maintains acid/base balance d. Participates in metabolism 4. Hyperkalemia a. Common causes: i. Renal failure ii. Over-replacement iii. Cell damage / shift out of cells 1. Acidosis 2. Hemolysis 3. Sepsis 4. Chemotherapy iv. Spironolactone administration b. Manifestations i. Bradycardia ii. Tremors, twitching iii. Nausea / vomiting iv. EKG changes: (↑ K+ suppresses the