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SLU NURS 440 - NUR 440 Case Study 2

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NUR 440 Case Study 2Case Study TwoMr. S., age 54, had a large anterior MI and is in the intensive care unit of a small hospital.He was not a candidate for TPA. Mr. S. has been placed on a mechanical ventilator and a PA line has been inserted. You are awaiting the cardiologist’s arrival to insert an intra-aortic balloon pump while you are stabilizing the patient for air transport to a hospital with a cardiac cath lab. You have a novice, nursing student observing you. Answer the following questions from this inquisitive student (in terms the student would understand).1. What is the primary reason an NG tube is inserted when someone is put on mechanical ventilation?Gastrointestinal disturbances may occur as a result of positive pressure ventilation, including gastric distention from air leaking around the ETT or tracheostomy cuff, NG tubes are utilized to decompress the stomach. In addition to decompression of the stomach, pharyngeal stimulation may occur from the artificial airway and result in vomiting. Should this occur, the NG tube to suction will prevent this from occurring. 2. What is a PA line and why is it used? The PA catheter is a multi-lumen catheter inserted through a vein and “floated” into the right side of the heart and into the pulmonary artery. The PA catheter is used to measure pressures in the pulmonary artery and when the balloon on the end is inflated, the occlusive pressure indirectly measures left atrial and left ventricular pressure, in the absence of mitral valve disease. The pressures in the left ventricle cannot be measured with a PA catheter. With the catheter tip in the pulmonary artery, the mitral valve is the only thing between the catheter tip and the left ventricle. This is why the PA catheter “indirectly” measures the pressures in the left ventricle. PA catheters may also be used to calculate cardiac output andother hemodynamic values. PA catheters may be used to measure hemodynamics and pulmonary pressures during hypovolemic shock, septic shock, multisystem failure, cardiogenic shock and acute respiratory distress syndrome. What information is obtained from it? PA catheters can be used to measure PA pressures, pulmonary occlusion pressure,cardiac output and mixed venous oxygenation. Stroke volume, SVR, coronary perfusion pressure, oxygen delivery and oxygen uptake can also be calculated. What is cardiac output, stroke volume, afterload, preload? Cardiac output (CO) is the volume of blood ejected from the heart in one minute. The CO is determined by the stroke volume (SV) and heart rate (HR). Multiply theSV by the HR and you will get the CO. Stroke volume is the volume of blood ejected from the heart with each beat. Afterload is the resistance or impedance to ejection of blood from the left ventricle. Afterload is also referred to as systemic vascular resistance (SVR). Preload is the volume of blood in the left ventricle at the end of diastole. This pressure created by preload is termed left venricular end-diastolic pressureNUR 440 Case Study 2(LVEDP). Starling’s Law can be related to preload. As the volume increases in theleft ventricle the contractility increases and improves CO, to a degree. If too muchvolume is added to the ventricle, contractility is decreased and therefore CO is then diminished. Figure out the patient’s cardiac output with the following information: HR=90, BP=110/70, SV=100. Patient’s cardiac output is HR X SV = CO or 90 X 100 = 900 L/min3. What is an intra-aortic balloon pump and why is it used? An intra-aortic balloon pump is a mechanical circulatory assist device. They are used in the treatment of heart failure when pharmacologic interventions have failed. The goal of the IABP is to decrease myocardial workload and maintain perfusion to the vital organs. They are generally used as a bridge option for patients awaiting transplantation or are awaiting surgical intervention. The IABP’s principles are to enhance diastolic function and reduce afterload.4. What is a cardiac catheterization? Cardiac catheterization is a diagnostic; invasive procedure used for patients with known or suspected cardiac disease. Indications for a cardiac catheterization include: coronary artery disease, AMI, unstable angina, myocardial ischemia, pulmonary hypertension, cardiac valve disease and congenital heart disease. During catheterization, a catheter is inserted into the femoral vein or artery after receiving a local anesthetic. Hemodynamic pressures are taken; a dye is injected to determine the level of blockage to the coronary arteries. Right heart catheterization can also be performed using a PA catheter. You explain to the student that the patient is in normal sinus rhythm. 5. What are the criteria for normal sinus rhythm?Rhythm must be regular, 60-100 beats/min, P waves must be normal in size, shapeand direction. P wave must precede each QRS complex. The PRI must be between0.12-0.20 seconds. QRS complex must 0.06-0.10 seconds. 6. What is the normal pacemaker of the heart? What is its rate of automaticity?The normal pacemaker of the heart is the sinoatrial node (SA). It is considered the natural pacemaker because it’s automaticity is greater. The automaticity of theSA nodes is 60-100 beats/min. As you are explaining the information about cardiac rhythm the waveform on the cardiac monitor goes erratic with no discernable P waves or QRS complex. 7. What would be your first priority?Check the patient to see if they are experiencing any symptoms. If they are not, it may be due to artifact from the patient moving or other interference. If symptomatic-- follow ACLS protocol.Shortly before transferring the patient, his rhythm converts to a symptomatic bradycardia (HR=45).NUR 440 Case Study 28. What types of symptoms would he have with bradycardia?Hypotension, dyspnea, altered mental status, chest pain, congestive heart failure. 9. What is the drug of choice for this rhythm?Atropine, 0.5 to 1.0 mg IV push, Q 3-5 minutes to a maximum dose of 0.03 mg/kg.Follow ACLS guidelines. After you have successfully treated Mr. S. for his bradycardia, the mechanical ventilator’shigh-pressure alarm is sounding.10. What might this mean and what would you do about it?There are many causes for high pressure alarms, including: airway obstruction (patient may be fighting with the ventilator), circuit collapse, kinked tubing, ETT in right main stem bronchus or against carina, cuff herniation, increased airway resistance, secretions, plugs,


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