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Pccn Review Part 1

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Progressive Critical Care Nurse Certification Review, Part 1 of 2

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Pccn Review Part 1

  1. 1. <ul><ul><ul><li>“ Never let what you cannot do interfere with what you can do” </li></ul></ul></ul><ul><ul><ul><li> John Wooden  </li></ul></ul></ul>PCCN REVIEW PART 1 Sherry L. Knowles, RN, CCRN, CRNI
  2. 2. <ul><li>TOPICS </li></ul><ul><li>Acute Coronary Syndromes </li></ul><ul><li>Acute Myocardial Infarction </li></ul><ul><li>Heart Blocks </li></ul><ul><li>Heart Failure </li></ul><ul><li>Cardiac Alterations </li></ul><ul><li>Aortic Aneurysms </li></ul><ul><li>Cardiomyopathy </li></ul><ul><li>Shock States </li></ul><ul><li>Peripheral Vascular Disease </li></ul><ul><li>Respiratory Alterations </li></ul>PCCN REVIEW PART 1 <ul><li>ARDS </li></ul><ul><li>Chronic Lung Disease </li></ul><ul><li>Drowning </li></ul><ul><li>Pneumonia </li></ul><ul><li>Pneumothorax </li></ul><ul><li>Pulmonary Embolism </li></ul><ul><li>Respiratory Failure </li></ul><ul><li>Gastrointestinal Alterations </li></ul><ul><li>GI Bleeding </li></ul><ul><li>Pancreatitis </li></ul>
  3. 3. <ul><li>OBJECTIVES </li></ul><ul><li>Understand the different types of acute coronary syndromes. </li></ul><ul><li>Identify basic coronary circulation and how it relates to different types of myocardial infarctions. </li></ul><ul><li>Anticipate potential complications associated with an AMI. </li></ul><ul><li>Identify the standard treatment of an AMI. </li></ul><ul><li>Distinguish between various AV blocks. </li></ul><ul><li>Recognize the signs & symptoms of heart failure. </li></ul><ul><li>Identify the treatment of heart failure. </li></ul><ul><li>Recognize the general definition and classifications of aortic aneurysms. </li></ul><ul><li>Understand the different types of aortic dissections. </li></ul><ul><li>Recognize the signs & symptoms of cardiomyopathy. </li></ul><ul><li>Differentiate between the different types of cardiomyopathy. </li></ul><ul><li>Identify the treatment for the different types of cardiomyopathy. </li></ul>PCCN REVIEW PART 1
  4. 4. <ul><li>OBJECTIVES </li></ul><ul><li>Understand the different stages of shock. </li></ul><ul><li>Differentiate between different types of shock. </li></ul><ul><li>Distinguish between arterial and venous peripheral vascular disease. </li></ul><ul><li>Identify the various treatments for peripheral vascular disease. </li></ul><ul><li>Define respiratory failure. </li></ul><ul><li>Identify the various treatments for acute respiratory failure. </li></ul><ul><li>Recognize the signs & symptoms and causes of various respiratory alterations. </li></ul><ul><li>Identify the standard treatment for various respiratory alterations. </li></ul><ul><li>Explain the common causes of gastrointestinal bleeding. </li></ul><ul><li>Describe the most commonly seen treatments for GI bleeding. </li></ul><ul><li>Describe the signs & symptoms of acute pancreatitis and available treatments. </li></ul>PCCN REVIEW PART 1
  5. 5. <ul><li>Acute Coronary Syndromes </li></ul><ul><li>Acute MI </li></ul><ul><li>Aortic Aneurysms </li></ul><ul><li>Cardiac Alterations </li></ul>Cardiovascular Conditions <ul><li>Cardiomyopathy </li></ul><ul><li>Heart Blocks </li></ul><ul><li>Heart Failure </li></ul><ul><li>Shock States </li></ul>
  6. 6. <ul><li>DEFINITIONS </li></ul><ul><ul><li>Term used to cover a group of symptoms compatible with acute myocardial ischemia </li></ul></ul><ul><ul><li>Acute myocardial ischemia is insufficient blood supply to the heart muscle usually resulting from coronary artery disease </li></ul></ul>Acute Coronary Syndrome
  7. 7. <ul><li>DEFINITION </li></ul><ul><ul><li>Infarction occurs due to mechanical obstruction of a coronary artery (or branch) caused by a thrombus, plaque rupture, coronary spasm and/or dissection. </li></ul></ul><ul><ul><li>STEMI vs. NSTEMI (non-STEMI) </li></ul></ul>Acute Myocardial Infarction
  8. 8. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Complains Vary </li></ul></ul><ul><ul><ul><li>May include crushing chest pain (which may or may not radiate), back, neck, jaw, teeth and/or epigastric pain, SOB, nausea/vomiting and dizziness </li></ul></ul></ul><ul><ul><li>ST elevations on ECG </li></ul></ul><ul><ul><li>Elevated cardiac enzymes </li></ul></ul>Acute Myocardial Infarction
  9. 9. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li> PAWP,  CO,  SVR, dysrhythmias, S 4 , cardiac failure, cardiogenic shock </li></ul></ul><ul><ul><li>Diaphoresis, pallor, referred pains </li></ul></ul><ul><ul><li>Diabetics and women often present abnormal symptoms </li></ul></ul>Acute Myocardial Infarction
  10. 10. Coronary Circulation
  11. 11. I AVR V1 V4 II AVL V2 V5 III AVF V3 V6 II V 12 Lead ECG
  12. 12. <ul><li>ST ELEVATIONS </li></ul><ul><ul><li>Anterior Wall MI </li></ul></ul><ul><ul><ul><li>Leads V 1 -V 4 </li></ul></ul></ul><ul><ul><ul><li>Reciprocal changes in leads II, III, and aVF </li></ul></ul></ul><ul><ul><ul><li>Area supplied by the LAD </li></ul></ul></ul><ul><ul><li>Inferior Wall MI </li></ul></ul><ul><ul><ul><li>Leads II, III and aVF </li></ul></ul></ul><ul><ul><ul><li>Reciprocal changes in leads I, and aVL </li></ul></ul></ul><ul><ul><ul><li>Area usually supplied by the RCA </li></ul></ul></ul>Acute Myocardial Infarction
  13. 13. <ul><li>ST ELEVATIONS </li></ul><ul><ul><li>Lateral Wall MI </li></ul></ul><ul><ul><ul><li>I, aVL, V 5 and V 6 </li></ul></ul></ul><ul><ul><ul><li>Area supplied by the Circumflex artery </li></ul></ul></ul><ul><ul><li>Posterior Wall MI </li></ul></ul><ul><ul><ul><li>Reflected on the opposite walls </li></ul></ul></ul><ul><ul><ul><li>Opposite deflections </li></ul></ul></ul>Acute Myocardial Infarction
  14. 14. Coronary Arteries
  15. 15. Anterior Wall MI
  16. 16. Inferior Wall MI
  17. 17. <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Dysrhythmias, heart failure, pericarditis, ventricular aneurysms, ventricular thrombus, VSD, mitral regurgitation, papillary muscle (or chordae tendineae) rupture, pericardial effusions, pericarditis </li></ul></ul>Acute Myocardial Infarction
  18. 18. <ul><li>NURSING INTERVENTIONS </li></ul><ul><ul><li>O 2 </li></ul></ul><ul><ul><li>Bedrest </li></ul></ul><ul><ul><li>Serial ECG’s </li></ul></ul><ul><ul><li>Serial cardiac enzymes </li></ul></ul><ul><ul><li>Keep pain free (NTG. MSO 4 ) </li></ul></ul><ul><ul><li>MONA (Morphine, O2, Nitroglycerin, Aspirin), Heparin, beta-blockers, and ace inhibitors. May also include thrombolytics or Gp2a3b inhibitors </li></ul></ul><ul><ul><li>PCI, PTCA, IABP, CABG </li></ul></ul>Acute Myocardial Infarction
  19. 19. <ul><li>TREATMENT </li></ul><ul><ul><li>Time Is Heart Muscle </li></ul></ul><ul><ul><li>Prompt ECG </li></ul></ul><ul><ul><li>Goals: Relieve pain, limit the size of the infarction and to prevent complications (primarily lethal dysrhythmias) </li></ul></ul>Acute Myocardial Infarction
  20. 20. <ul><li>TREATMENT </li></ul><ul><ul><li>MONA (Morphine, O2, Nitroglycerin, Aspirin) , Heparin, beta-blockers, and ace inhibitors. May also include thrombolytics or Gp2a3b inhibitors </li></ul></ul><ul><ul><li>Cardiac Catheterization (with angioplasty, atherectomy and/or stent) </li></ul></ul><ul><ul><li>IABP, CABG, education </li></ul></ul>Acute Myocardial Infarction
  21. 21. Balloon Angioplasty
  22. 22. Vascular Stent Deployment
  23. 23. Atherectomy
  24. 24. <ul><li>SPECIFIC TREATMENTS </li></ul><ul><ul><li>Inferior Wall (IWMI) </li></ul></ul><ul><ul><ul><li>Fluids </li></ul></ul></ul><ul><ul><ul><li>Inotropics </li></ul></ul></ul><ul><ul><ul><li>Afterload reducing medications </li></ul></ul></ul><ul><ul><li>Anterior Wall (AWMI) </li></ul></ul><ul><ul><ul><li>Diuretics </li></ul></ul></ul><ul><ul><ul><li>Inotropics </li></ul></ul></ul><ul><ul><ul><li>Afterload reducing medications </li></ul></ul></ul>Acute Myocardial Infarction
  25. 25. <ul><li>DEFINITION </li></ul><ul><ul><li>A bulge or ballooning of the aorta </li></ul></ul><ul><ul><ul><li>When the walls of the aneurysm include all three layers of the artery, they are called true aneurysms </li></ul></ul></ul><ul><ul><ul><li>When the wall of the aneurysm include only the outer layer, it is called a pseudo-aneurysm </li></ul></ul></ul><ul><ul><li>May be thoracic or abdominal </li></ul></ul>Aortic Aneurysms
  26. 26. <ul><li>CAUSES </li></ul><ul><ul><ul><li>Atherosclerosis </li></ul></ul></ul><ul><ul><ul><li>Marfan syndrome </li></ul></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Crack cocaine usage </li></ul></ul></ul><ul><ul><ul><li>Smoking </li></ul></ul></ul><ul><ul><ul><li>Trauma </li></ul></ul></ul>Aortic Aneurysms
  27. 27. <ul><ul><li>An aortic aneurysm, depending on its size, may rupture, causing life-threatening internal bleeding </li></ul></ul><ul><ul><li>The risk of an aneurysm rupturing increases as the aneurysm gets larger </li></ul></ul><ul><ul><li>The risk of rupture also depends on the location of the aneurysm </li></ul></ul><ul><ul><li>Each year, approximately 15,000 Americans die of a ruptured aortic aneurysm. </li></ul></ul>Aortic Aneurysms Rupture
  28. 28. <ul><li>CLASSIFICATIONS </li></ul><ul><ul><li>Classified by shape, location along the aorta, and how they are formed </li></ul></ul><ul><ul><li>May be symmetrical in shape (fusiform) or a localized weakness of the arterial wall (saccular) </li></ul></ul>Aortic Aneurysms
  29. 29. Aortic Aneurysms
  30. 30. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Often produces no symptoms </li></ul></ul><ul><ul><li>If an aortic aneurysm suddenly ruptures it presents with extreme abdominal or back pain, a pulsating mass in the abdomen, and a drastic drop in blood pressure </li></ul></ul><ul><ul><li>An increase in the size of an aneurysm means an increased in the risk of rupture </li></ul></ul>Aortic Aneurysms
  31. 31. <ul><li>THORACIC SIGNS & SYMPTOMS </li></ul><ul><ul><li>Back, shoulder or neck pain </li></ul></ul><ul><ul><li>Cough, due to pressure placed on the trachea </li></ul></ul><ul><ul><li>Hoarseness </li></ul></ul><ul><ul><li>Strider, dyspnea </li></ul></ul><ul><ul><li>Difficulty swallowing </li></ul></ul><ul><ul><li>Swelling in the neck or arms </li></ul></ul>Aortic Aneurysms
  32. 32. <ul><li>DEFINITION </li></ul><ul><ul><li>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 layers </li></ul></ul><ul><ul><li>Usually associated with severe chest pain radiating to the back </li></ul></ul>Aortic Dissections
  33. 33. <ul><ul><li>Dissection beginning in the ascending aorta </li></ul></ul>Aortic Dissections <ul><ul><li>Whenever the ascending aorta is not involved </li></ul></ul>
  34. 34. <ul><ul><li>Dissection beginning in the ascending aorta </li></ul></ul>Aortic Dissections <ul><ul><li>Whenever the ascending aorta is not involved </li></ul></ul>
  35. 35. Aortic Dissections
  36. 36. Aortic Dissections
  37. 37. <ul><li>COMPLICATIONS </li></ul><ul><ul><ul><li>Rupture </li></ul></ul></ul><ul><ul><ul><li>Peripheral embolization </li></ul></ul></ul><ul><ul><ul><li>Infection </li></ul></ul></ul><ul><ul><ul><li>Spontaneous occlusion of aorta </li></ul></ul></ul>Aortic Aneurysms
  38. 38. <ul><li>TREATMENT </li></ul><ul><ul><ul><li>Medical management </li></ul></ul></ul><ul><ul><ul><ul><li>Controlled BP (within specific range) </li></ul></ul></ul></ul><ul><ul><ul><li>Surgical repair </li></ul></ul></ul><ul><ul><ul><li>> 4.5 cm in Marfan patients or > 5 cm in non-Marfan patients will require surgical correction or endovascular stent placement </li></ul></ul></ul>Aortic Aneurysms
  39. 39. <ul><li>DEFINITION </li></ul><ul><ul><li>Diseases of the heart muscle that cause deterioration of the function of the myocardium </li></ul></ul>Cardiomyopathy
  40. 40. <ul><li>CLASSIFICATIONS </li></ul><ul><ul><li>Primary / Idiopathic ( intrinsic ) </li></ul></ul><ul><ul><ul><li>Heart disease of unknown cause, although viral infection and autoimmunity are suspected causes </li></ul></ul></ul><ul><ul><li>Secondary ( extrinsic ) </li></ul></ul><ul><ul><ul><li>Heart disease as a result of other systemic diseases, such as autoimmune diseases, CAD, valvular disease, severe hypertension, or alcohol abuse </li></ul></ul></ul>Cardiomyopathy
  41. 41. Cardiomyopathy <ul><li>Hypertropic Cardiomyopathy </li></ul><ul><li>Restrictive Cardiomyopathy </li></ul><ul><li>Dilated Cardiomyopathy </li></ul>
  42. 42. <ul><li>Bizarre hypertrophy of the septum </li></ul><ul><ul><li>Previously called IHSS </li></ul></ul><ul><ul><ul><li>Idiopathic Hypertropic Subaortic Stenosis </li></ul></ul></ul><ul><ul><li>Known as HOCM </li></ul></ul><ul><ul><ul><li>Hypertropic Obstructive Cardiomyopathy </li></ul></ul></ul><ul><li>Positive inotropic drugs Should Not Be Used </li></ul><ul><ul><li> Contractility will  outflow tract obstruction </li></ul></ul><ul><li>Nitroglycerin Should Not Be Used </li></ul><ul><ul><li>Dilation Will Worsen The Problem </li></ul></ul>Hypertropic Cardiomyopathy
  43. 43. Harley
  44. 44. <ul><li>TREATMENT </li></ul><ul><ul><li>Relax the ventricles </li></ul></ul><ul><ul><ul><ul><li>Beta Blockers </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Calcium Channel Blockers </li></ul></ul></ul></ul><ul><ul><li>Slow the Heart Rate </li></ul></ul><ul><ul><ul><ul><li>Increase filling time </li></ul></ul></ul></ul><ul><ul><li>Use Negative Inotropes </li></ul></ul><ul><ul><ul><ul><li>Optimize diastolic filling </li></ul></ul></ul></ul><ul><ul><li>Do Not use NTG </li></ul></ul><ul><ul><ul><ul><li>Dilation will worsen the problem </li></ul></ul></ul></ul>Hypertropic Cardiomyopathy
  45. 45. <ul><li>Rigid Ventricular Wall </li></ul><ul><ul><li>Due to endomyocardial fibrosis </li></ul></ul><ul><ul><li>Obstructs ventricular filling </li></ul></ul><ul><li>Least common form </li></ul>Restrictive Cardiomyopathy
  46. 46. <ul><li>TREATMENT </li></ul><ul><ul><li>Positive Inotropics </li></ul></ul><ul><ul><li>Diuretics </li></ul></ul><ul><ul><li>Low Sodium Diet </li></ul></ul>Restrictive Cardiomyopathy
  47. 47. <ul><li>Grossly dilated ventricles without hypertrophy </li></ul><ul><ul><li>Global left ventricular dysfunction </li></ul></ul><ul><ul><li>Leads to pooling of blood and embolic episodes </li></ul></ul><ul><ul><li>Leads to refractory heart failure </li></ul></ul><ul><ul><li>Leads to papillary muscle dysfunction secondary to LV dilation </li></ul></ul>Dilated Cardiomyopathy
  48. 48. <ul><li>TREATMENT </li></ul><ul><ul><li>Positive Inotropes </li></ul></ul><ul><ul><li>Afterload Reducers </li></ul></ul><ul><ul><li>Anticoagulants with Atrial Fib </li></ul></ul>Dilated Cardiomyopathy
  49. 49. Cardiomyopathies
  50. 50. <ul><li>GENERALIZED TREATMENT </li></ul><ul><ul><li>Positive Inotropes </li></ul></ul><ul><ul><ul><li>Except with Hypertropic Cardiomyopathy </li></ul></ul></ul><ul><ul><li>Vasodilators </li></ul></ul><ul><ul><ul><li>Except with Hypertropic Cardiomyopathy </li></ul></ul></ul><ul><ul><li>Reduce Preload & Afterload </li></ul></ul><ul><ul><ul><ul><li>Diuretics </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Beta Blockers </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Calcium Channel Blockers </li></ul></ul></ul></ul><ul><ul><ul><ul><li>IABP </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vasodilators (as indicated) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fluid Restriction </li></ul></ul></ul></ul><ul><ul><li>Daily weights, prn O2, planned activities, education, and emotional support </li></ul></ul><ul><ul><ul><ul><li>Consider Heart Transplant </li></ul></ul></ul></ul>Cardiomyopathy
  51. 51. <ul><li>STABLE VS UNSTABLE </li></ul><ul><ul><li>Stable </li></ul></ul><ul><ul><ul><li>Start with medications </li></ul></ul></ul><ul><ul><li>Unstable </li></ul></ul><ul><ul><ul><li>Shock (cardioversion or defibrillation) </li></ul></ul></ul>Conduction Defects
  52. 52. Normal Sinus Rhythm Heart Rate 60 - 100 bpm Rhythm Regular P Wave Before each QRS & identical PR Interval (in seconds) 0.12 to 0.20 QRS (in seconds) < 0.12
  53. 53. <ul><li>AFib </li></ul><ul><ul><li>Multifocal atrial impulses at rate 300-600/min </li></ul></ul><ul><ul><li>Irregular conduction to ventricles </li></ul></ul>Atrial Fibrillation
  54. 54. <ul><li>AFL </li></ul><ul><ul><li>Atrial impulses at rate of 250-350/min </li></ul></ul><ul><ul><li>Regularly blocked impulses at the AV node </li></ul></ul><ul><ul><li>Saw tooth flutter waves </li></ul></ul>Atrial Flutter
  55. 55. <ul><li>WAP </li></ul><ul><ul><li>Multiple ectopic foci in the atria </li></ul></ul><ul><ul><li>Three or more p wave morphologies </li></ul></ul><ul><ul><li>Rate < 100 </li></ul></ul>Wandering Atrial Pacemaker
  56. 56. <ul><li>SVT </li></ul><ul><ul><li>Supraventricular rhythm at rate 150-250 </li></ul></ul><ul><ul><li>P waves cannot be positively identified </li></ul></ul>Supraventricular Tachycardia Atrial Tach = supraventricular rhythm with p wave morphology that is noticeably different from the sinus p wave
  57. 57. <ul><li>VT </li></ul><ul><ul><li>Ventricular rate of 100-250/min </li></ul></ul><ul><ul><li>Wide QRS </li></ul></ul>Ventricular Tachycardia
  58. 58. <ul><li>Polymorphic VT </li></ul><ul><ul><li>VT with alternating ventricular focus </li></ul></ul><ul><ul><li>Often associated with prolonged QT Rate < 100 </li></ul></ul>Torsades de Pointes
  59. 59. <ul><ul><li>Sinus Rhythm with First Degree AV Block </li></ul></ul>Heart Blocks (AV Blocks) <ul><ul><li>Sinus Rhythm with Second Degree AV Block, Type 2 </li></ul></ul><ul><ul><li>Sinus Rhythm with Second Degree AV Block, Type 1 </li></ul></ul><ul><ul><li>Third Degree AV Block </li></ul></ul>
  60. 60. <ul><li>DEFINITION </li></ul><ul><ul><li>A condition in which the heart cannot pump sufficient blood to meet the metabolic needs of the body </li></ul></ul><ul><ul><li>Pulmonary (LVF) and/or systemic (RVF) congestion is present. </li></ul></ul>Heart Failure
  61. 61. <ul><li>DEFINITION </li></ul><ul><ul><li>Pulmonary Edema </li></ul></ul><ul><ul><ul><li>Fluid in the alveolus that impairs gas exchange by altering the diffusion between alveolus and capillary </li></ul></ul></ul><ul><ul><ul><li>Acute left ventricular failure causes cardiogenic pulmonary edema </li></ul></ul></ul><ul><ul><ul><li>Non-cardiogenic pulmonary edema is a synonym for Adult Respiratory Distress Syndrome (ARDS) </li></ul></ul></ul>Heart Failure
  62. 62. <ul><li>COMPENSATORY MECHANISMS </li></ul><ul><ul><li>Sympaththetic nervous system stimulation </li></ul></ul><ul><ul><ul><li>Tachycardia </li></ul></ul></ul><ul><ul><ul><li>Vasoconstriction and increased SVR </li></ul></ul></ul><ul><ul><li>Renin-angiotensin-aldosterone system activation </li></ul></ul><ul><ul><ul><li>Hypo perfusion to the kidneys (rennin) </li></ul></ul></ul><ul><ul><ul><li>Vasoconstriction (angiotension) </li></ul></ul></ul><ul><ul><ul><li>Sodium and water retention (kidneys) </li></ul></ul></ul><ul><ul><ul><li>Ventricular dilation </li></ul></ul></ul>Heart Failure
  63. 63. <ul><li>FUNCTIONAL CLASSIFICATIONS </li></ul><ul><ul><li>Class I </li></ul></ul><ul><ul><li>Class II </li></ul></ul><ul><ul><li>Class III </li></ul></ul><ul><ul><li>Class IV </li></ul></ul>Heart Failure <ul><li> (without noticeable limitations) </li></ul><ul><li> (symptoms upon activity) </li></ul><ul><li>(severe symptoms upon activity) </li></ul><ul><li>(symptoms at rest) </li></ul>
  64. 64. <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Dysrhythmias </li></ul></ul><ul><ul><li>Respiratory Failure </li></ul></ul><ul><ul><li>Progressive Deterioration </li></ul></ul><ul><ul><li>Acute Renal Failure </li></ul></ul><ul><ul><li>Fluid & Electrolyte Imbalances </li></ul></ul>Heart Failure
  65. 65. <ul><li>TREATMENT </li></ul><ul><ul><li>Improve Oxygenation </li></ul></ul><ul><ul><li>Decrease Myocardial Oxygen Demand </li></ul></ul><ul><ul><li>Decrease Preload </li></ul></ul><ul><ul><li>Decrease Afterload </li></ul></ul><ul><ul><li>Increase Contractility </li></ul></ul><ul><ul><li>Manage Dysrhythmias </li></ul></ul>Heart Failure
  66. 66. <ul><li>DEFINITION </li></ul><ul><ul><li>Inadequate perfusion to the body tissues </li></ul></ul><ul><ul><li>Low blood pressure with impaired perfusion to the end organs </li></ul></ul><ul><ul><li>May result in multiple organ dysfunction </li></ul></ul>Shock States
  67. 67. <ul><li>TYPES OF SHOCK </li></ul><ul><ul><li>Hypovolemic Shock </li></ul></ul><ul><ul><li>Cardiogenic Shock </li></ul></ul><ul><ul><li>Distributive Shock </li></ul></ul><ul><ul><li>Obstructive Shock </li></ul></ul>Shock States
  68. 68. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><li>The body attempts to compensate for shock: </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><ul><li>Attempts to deliver more blood to the tissues </li></ul></ul></ul><ul><ul><li>Vasoconstriction </li></ul></ul><ul><ul><ul><li>Attempts to maintain adequate BP in order to adequately perfuse the body tissues </li></ul></ul></ul><ul><ul><li>Increased ADH Secretion </li></ul></ul><ul><ul><ul><li>ADH makes the body hold onto water in an effort to maintain volume and thus enough blood pressure to perfuse the body tissues </li></ul></ul></ul>Shock States
  69. 69. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Hypovolemic Shock: </li></ul></ul><ul><ul><ul><li>Low BP, tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin,  resp. rate,  UOP,  CO,  PAWP,  CVP,  SVR,  lactate levels </li></ul></ul></ul>Shock States
  70. 70. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Cardiogenic Shock: </li></ul></ul><ul><ul><ul><li>Low BP, tachycardia, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin,  resp. rate,  UOP,  CO,  PAWP (low with RVF),  CVP,  SVR, JVD, peripheral edema, ventricular gallop, dyspnea, pulmonary crackles,  lactate levels </li></ul></ul></ul>Shock States
  71. 71. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Anaphylactic Shock: </li></ul></ul><ul><ul><ul><li>Low BP, tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, warm feeling, pruritus, hives, angioedema, bronchoconstriction, wheezing, laryngoedema, dyspnea, cool, clammy skin,  UOP,  CO,  PAWP,  CVP,  SVR,  lactate levels </li></ul></ul></ul>Shock States
  72. 72. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Obstructive Shock: </li></ul></ul><ul><ul><ul><li>Low BP, tachycardia, restlessness, confusion, agitation (or listless), pallor, cool, clammy skin,  UOP,  CO </li></ul></ul></ul><ul><ul><ul><li>Symptoms related to cause </li></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>Shock States
  73. 73. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Septic Shock: </li></ul></ul><ul><ul><ul><li>Early Stage (Hyper-dynamic, Warm Phase) </li></ul></ul></ul><ul><ul><ul><ul><li>Normal BP, tachycardia, confusion, agitation (or listless),  resp. rate,  temp, normal color, normal or  UOP,  CO, normal PAWP,  CO,  SVR,  </li></ul></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>Shock States
  74. 74. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Septic Shock: </li></ul></ul><ul><ul><ul><li>Late Stage (Hypo-dynamic, Cold Phase) </li></ul></ul></ul><ul><ul><ul><ul><li>Low BP, tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin,  UOP,  CO,  PAWP,  CVP,  SVR,  lactate levels </li></ul></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>Shock States
  75. 75. <ul><li>TREATMENTS </li></ul><ul><ul><li>Hypovolemic Shock: </li></ul></ul><ul><ul><ul><li>Volume (IVF, Blood) </li></ul></ul></ul><ul><ul><li>Cardiogenic Shock: </li></ul></ul><ul><ul><ul><li> CO </li></ul></ul></ul><ul><ul><ul><li> Preload & Afterload </li></ul></ul></ul><ul><ul><ul><li> Myocardial Demand </li></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>Shock States
  76. 76. <ul><li>TREATMENTS </li></ul><ul><ul><li>Anaphylactic Shock: </li></ul></ul><ul><ul><ul><li>Epinephrine </li></ul></ul></ul><ul><ul><ul><li>IVF </li></ul></ul></ul><ul><ul><ul><li>Vasoconstrictors </li></ul></ul></ul><ul><ul><ul><li>Support/Maintain Airway </li></ul></ul></ul><ul><ul><li>Obstructive Shock: </li></ul></ul><ul><ul><ul><li>Treat the Cause </li></ul></ul></ul>Shock States
  77. 77. <ul><li>TREATMENTS </li></ul><ul><ul><li>Septic Shock: </li></ul></ul><ul><ul><ul><li>IVF (150cc/hr or wide open) </li></ul></ul></ul><ul><ul><ul><li>Treat Cause (pan culture, antibiotics) </li></ul></ul></ul><ul><ul><ul><li>Vasoconstrictors in warm phase </li></ul></ul></ul><ul><ul><ul><li>Treat temp (if needed) </li></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>Shock States
  78. 78. <ul><ul><ul><li>BREAK! </li></ul></ul></ul>PCCN REVIEW PART 1
  79. 79. <ul><ul><li>Aorto/Iliac Disease: Pre & Post PTA/Stent </li></ul></ul>Vascular Disease
  80. 80. Peripheral Vascular Disease SYMPTOMS PAIN PAIN RELIEF EDEMA PULSES INTEGUMENT CHANGES ULCERS SKIN TEMPERATURE SEXUAL ISSUES ARTERIAL Upon walking On resting, standing or dependent position of lower limbs None Decreased or absent Hair loss Skin shiny Nail thickening Pallor when elevated Red when dependent Ulcers located on toes, lateral areas or site of trauma Gangrene possible Cool Impotency Sexual dysfunction VENOUS While standing Elevation of extremities Present, edematous May be difficult to palpate Brownish pigmentation May be cyanotic when extremities are dependent Ulcers located on ankles, medial or pre-tibial areas Normal or warm Not present
  81. 81. Peripheral Vascular Disease <ul><li>TREATMENTS </li></ul><ul><ul><li>Medical </li></ul></ul><ul><ul><ul><li>Are they taking ASA, Coumadin, Ticlid, Plavix, Oral Contraceptives, Hormones? </li></ul></ul></ul><ul><ul><li>Invasive </li></ul></ul><ul><ul><ul><li>PTA, atherectomy, stents </li></ul></ul></ul><ul><ul><li>Surgical </li></ul></ul><ul><ul><ul><li>Grafts </li></ul></ul></ul>
  82. 82. <ul><ul><li>Bypass Grafts </li></ul></ul>Peripheral Vascular Disease
  83. 83. <ul><li>ARDS </li></ul><ul><li>Drowning </li></ul><ul><li>Pneumothorax </li></ul><ul><li>Respiratory Failure </li></ul>Respiratory Alterations <ul><li>Chronic Lung Disease </li></ul><ul><li>Pneumonia </li></ul><ul><li>Pulmonary Embolism </li></ul>
  84. 84. <ul><li>DEFINITIONS </li></ul><ul><ul><li>Severe respiratory failure associated with pulmonary infiltrates (similar to infant hyaline membrane disease) </li></ul></ul><ul><ul><li>Pulmonary edema in the absence of fluid overload or depressed LV function (Non-cardiogenic pulmonary edema) </li></ul></ul><ul><ul><li>Originates from a number of insults involving damage to the alveolar-capillary membrane </li></ul></ul>ARDS
  85. 85. Acute Respiratory Distress Syndrome
  86. 86. <ul><li>PATHOPHYSIOLOGY </li></ul><ul><ul><li>Inflammatory mediators are released causing extensive structural damage </li></ul></ul><ul><ul><li>Increased permeability of pulmonary microvasculature causes leakage of proteinaceous fluid across the alveolar–capillary membrane </li></ul></ul><ul><ul><li>Also causes damage to the surfactant-producing type II cells </li></ul></ul>ARDS
  87. 87. <ul><li>CXR CHARACTERISTICS </li></ul><ul><ul><li>Normal size heart </li></ul></ul><ul><ul><li>No pleural effusion </li></ul></ul><ul><ul><li>Ground Glass appearance </li></ul></ul><ul><ul><li>Often normal early in the disease but may rapidly progress to complete whiteout </li></ul></ul>ARDS
  88. 88. ARDS
  89. 89. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Symptoms develop 24 to 48 hours of injury </li></ul></ul><ul><ul><ul><li>Sudden progressive disorder </li></ul></ul></ul><ul><ul><ul><li>Pulmonary edema </li></ul></ul></ul><ul><ul><ul><li>Severe dyspnea </li></ul></ul></ul><ul><ul><ul><li>Hypoxemia REFRACTORY to O2 </li></ul></ul></ul><ul><ul><ul><li>Decreased lung compliance </li></ul></ul></ul><ul><ul><ul><li>Diffuse pulmonary infiltrates </li></ul></ul></ul><ul><ul><li>Symptoms may be minimal compared to CXR </li></ul></ul><ul><ul><li>Rales may be heard </li></ul></ul>ARDS
  90. 90. ARDS <ul><li>RISK FACTORS </li></ul><ul><li>Acute Pancreatitis </li></ul><ul><li>DIC </li></ul><ul><li>Head Injury </li></ul><ul><li>ICP </li></ul><ul><li>Fat Emboli </li></ul><ul><li>Blood Products </li></ul><ul><li>Heart/Lung Bypass </li></ul><ul><li>Tumor Lysis </li></ul><ul><li>Pulmonary Contusion </li></ul><ul><li>Narcotics </li></ul>Smoke inhalation Inhaled toxins Burns Near Drowning DKA Pregnancy Eclampsia Amniotic Fluid Embolus Drugs Sepsis Massive Trauma Shock Multiple Transfusions Pneumonia Aspiration     Infection Other Risk Factors Common Risk Factors
  91. 91. <ul><li>TREATMENT </li></ul><ul><ul><li>Respiratory Support </li></ul></ul><ul><ul><li>PEEP, CPAP </li></ul></ul>ARDS
  92. 92. <ul><li>COPD </li></ul><ul><ul><li>Presents with hyper-inflated lung fields </li></ul></ul><ul><ul><ul><li>Due to chronic air trapping </li></ul></ul></ul><ul><ul><ul><li>May be barrel chested </li></ul></ul></ul><ul><ul><li>May lead to cor pulmonale (right-sided heart failure) </li></ul></ul><ul><ul><ul><li>Due to chronic high pulmonary pressures </li></ul></ul></ul><ul><ul><li>Often hypercarbic (high pCO2) </li></ul></ul><ul><ul><ul><li>Often dependent upon hypoxic drive </li></ul></ul></ul>Chronic Lung Disease
  93. 93. <ul><li>COPD TREATMENT </li></ul><ul><ul><li>Avoid overuse of oxygen (except in emergencies) </li></ul></ul><ul><ul><li>Bronchodilators </li></ul></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Hydration </li></ul></ul><ul><ul><li>Education </li></ul></ul><ul><ul><ul><li>Pursed Lip Breathing </li></ul></ul></ul><ul><ul><ul><li>Leaning Upright </li></ul></ul></ul>Chronic Lung Disease
  94. 94. <ul><li>Salt Water </li></ul><ul><ul><li>Causes body fluids to shift into lungs </li></ul></ul><ul><ul><ul><li>Osmosis: From low to high concentration </li></ul></ul></ul><ul><ul><ul><li>Results in hemoconcentration & hypovolemia </li></ul></ul></ul><ul><ul><li>Results in acute pulmonary edema </li></ul></ul><ul><li>Fresh Water </li></ul><ul><ul><li>Fluids shift into body tissues </li></ul></ul><ul><ul><ul><li>Results in hemodilution & hypervolemia </li></ul></ul></ul><ul><ul><ul><li>Can result in gross edema </li></ul></ul></ul><ul><ul><li>Damaged alveoli fill with proteinaceous fluid </li></ul></ul><ul><ul><ul><li>May lead to pulmonary edema </li></ul></ul></ul>Near Drowning
  95. 95. <ul><li>Lung infection (bacterial, viral, or fungal) </li></ul><ul><ul><li>Most commonly caused by S treptococcus pneumoniae </li></ul></ul><ul><li>Symptoms include fever, pleuretic chest pain, productive cough, and tachypnea </li></ul><ul><ul><li>Often presents bronchial breath sounds over the lung area </li></ul></ul><ul><li>Treatment involves giving the right antibiotic </li></ul>Pneumonia
  96. 96. <ul><li>DEFINITIONS </li></ul><ul><ul><li>Simple pneumothorax </li></ul></ul><ul><ul><ul><li>Results from buildup of air or pressure in the pleural space </li></ul></ul></ul><ul><ul><li>Spontaneous pneumothorax </li></ul></ul><ul><ul><ul><li>May be due to blebs that rupture </li></ul></ul></ul><ul><ul><ul><li>The 2 key risk factors are increased chest length and cigarette smoking </li></ul></ul></ul><ul><ul><li>Tension pneumothorax </li></ul></ul><ul><ul><ul><li>Involves a buildup of air in the pleural space due to one-way movement of air </li></ul></ul></ul><ul><ul><ul><li>Progressively worsens </li></ul></ul></ul><ul><ul><ul><li>Requires immediate intervention </li></ul></ul></ul>Pneumothorax
  97. 97. Pneumothorax
  98. 98. Tension Pneumothorax
  99. 99. <ul><li>CAUSES </li></ul><ul><ul><li>Barotrauma </li></ul></ul><ul><ul><li>Injury </li></ul></ul><ul><ul><li>Blebs </li></ul></ul>Pneumothorax
  100. 100. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Standard Pneumothorax </li></ul></ul><ul><ul><ul><li>Sharp &quot;pleuritic&quot; chest pain, worse on breathing </li></ul></ul></ul><ul><ul><ul><li>Sudden shortness of breath </li></ul></ul></ul><ul><ul><ul><li>Dry, hacking cough (may occur due to irritation of the diaphragm) </li></ul></ul></ul><ul><ul><ul><li>May cause mediastinal shift </li></ul></ul></ul><ul><ul><li>Tension pneumothorax </li></ul></ul><ul><ul><ul><li>Signs of standard pneumothorax with signs of cardiovascular collapse </li></ul></ul></ul><ul><ul><ul><li>Immediately life threatening </li></ul></ul></ul><ul><ul><ul><li>May cause mediastinal shift </li></ul></ul></ul>Pneumothorax
  101. 101. <ul><li>TREATMENT </li></ul><ul><li>Spontaneous pneumothorax </li></ul><ul><ul><li>Depends on symptoms & size of pneumothorax </li></ul></ul><ul><ul><li>Provide respiratory support </li></ul></ul><ul><ul><li>May need chest tube or needle decompression </li></ul></ul><ul><ul><ul><li>Some resolve without intervention </li></ul></ul></ul><ul><li>Tension pneumothorax </li></ul><ul><ul><li>Requires immediate intervention </li></ul></ul><ul><ul><li>May cause cardiovascular collapse </li></ul></ul><ul><ul><li>May need chest tube or needle decompression </li></ul></ul><ul><ul><ul><li>2 nd intercostal space </li></ul></ul></ul>Pneumothorax
  102. 102. <ul><li>TREATMENT </li></ul><ul><ul><li>Pleurodesis </li></ul></ul>Pneumothorax <ul><ul><ul><li>Chemical or surgical adhesion of the lung to the chest wall </li></ul></ul></ul><ul><ul><ul><li>Used for multiple collapsed lungs or persistent collapse </li></ul></ul></ul>
  103. 103. Flail Chest
  104. 104. <ul><li>Definition </li></ul><ul><li>Signs & Symptoms </li></ul>Pulmonary Embolism <ul><ul><li>Arterial embolus that obstructs blood flow to the lung </li></ul></ul><ul><ul><li>Symptoms include sudden dyspnea, cough, chest pain, hemoptysis and sinus tachycardia </li></ul></ul><ul><ul><li>Blood gas shows low pO2 & low pCO2 </li></ul></ul><ul><ul><li>May present positive Homan’s Sign </li></ul></ul><ul><ul><li>May present loud S2 </li></ul></ul>
  105. 105. <ul><li>Diagnostic Tests </li></ul><ul><ul><li>CXR </li></ul></ul><ul><ul><li>VQ Scan </li></ul></ul><ul><ul><li>Pulmonary arteriogram </li></ul></ul><ul><ul><li>Venous ultrasound of the lower extremities </li></ul></ul><ul><ul><li>ABG with low pO2 & low pCO2 </li></ul></ul><ul><ul><li>D-Dimer </li></ul></ul>Pulmonary Embolism
  106. 106. <ul><li>Treatment </li></ul><ul><ul><li>Requires immediate intervention </li></ul></ul><ul><ul><li>Provide respiratory support </li></ul></ul><ul><ul><li>Treat pain & comfort </li></ul></ul><ul><ul><li>Usually includes intravenous heparin </li></ul></ul><ul><ul><ul><li>Heparin reduces risk of secondary thrombus formation while clot is reabsorbed </li></ul></ul></ul><ul><ul><li>May require embolectomy </li></ul></ul><ul><ul><li>May require thrombolysis </li></ul></ul><ul><ul><li>May need umbrella filter </li></ul></ul><ul><ul><li>May need long term anticoagulants </li></ul></ul>Pulmonary Embolism
  107. 107. <ul><li>DEFINITIONS </li></ul><ul><ul><li>Failure to maintain adequate gas exchange </li></ul></ul><ul><ul><li>Inadequate blood oxygenation or CO2 removal </li></ul></ul><ul><ul><li>PaO2 < 50 mmHg and/or PaCO2 > 50 mmHg and/or pH < 7.35 on Room Air </li></ul></ul>Respiratory Failure
  108. 108. Respiratory Failure TYPE I Hypoxemia without hypercapnia TYPE II Hypoxemia with hypercapnia
  109. 109. <ul><li>CAUSES </li></ul><ul><ul><li>V/Q Mismatching </li></ul></ul><ul><ul><li>Intrapulmonary Shunting </li></ul></ul><ul><ul><li>Alveolar Hypoventilation </li></ul></ul>Respiratory Failure
  110. 110. <ul><li>V/Q MISMATCHING </li></ul><ul><ul><li>COPD </li></ul></ul><ul><ul><li>Interstitial Lung Disease </li></ul></ul><ul><ul><li>Pulmonary Embolism </li></ul></ul>Respiratory Failure
  111. 111. <ul><li>PULMONARY SHUNTING </li></ul><ul><ul><li>AV fistulas/malformations </li></ul></ul><ul><ul><li>Alveolar collapse (atelectasis) </li></ul></ul><ul><ul><li>Alveolar consolidation (pneumonia) </li></ul></ul><ul><ul><li>Excessive mucus accumulation </li></ul></ul>Respiratory Failure
  112. 112. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Restlessness / Agitation </li></ul></ul><ul><ul><li>Confusion /  LOC </li></ul></ul><ul><ul><li>Tachycardia / Dysrhythmias </li></ul></ul><ul><ul><li>Tachypnea / Dyspnea </li></ul></ul><ul><ul><li>Cool, clammy, pale skin </li></ul></ul>Respiratory Failure
  113. 113. <ul><li>ARTERIAL BLOOD GASES </li></ul><ul><ul><li>pH 7.30 / pO2 45 / pCO2 80 </li></ul></ul><ul><ul><li>pH 7.30 / pO2 55 / pCO2 65 </li></ul></ul><ul><ul><li>pH 7.32 / pO2 50 / pCO2 50 </li></ul></ul><ul><ul><li>pH 7.55 / pO2 65 / pCO2 22 </li></ul></ul>Respiratory Failure
  114. 114. <ul><li>TREATMENT </li></ul><ul><ul><li>Ensure Adequate Ventilation </li></ul></ul><ul><ul><li> FiO2 </li></ul></ul><ul><ul><ul><li>Ineffective with shunting </li></ul></ul></ul><ul><ul><ul><li>Prolonged O2 > 40% causes O2 toxicity </li></ul></ul></ul><ul><ul><ul><li>Must use caution with CO2 retainers </li></ul></ul></ul><ul><ul><ul><ul><li>Chronic hypercapnia causes CO2 retainers to use hypoxic drive </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Too much O2 can depress respirations </li></ul></ul></ul></ul>Respiratory Failure
  115. 115. <ul><li>GI Bleed </li></ul><ul><li>Pancreatitis </li></ul>Gastrointestinal Alterations
  116. 116. <ul><li>CAUSES </li></ul><ul><ul><li>UGI Bleeding </li></ul></ul><ul><ul><ul><li>Includes the esophagus, stomach, duodenum </li></ul></ul></ul><ul><ul><ul><ul><li>Peptic Ulcer Disease (PUD), or Esophageal Varices </li></ul></ul></ul></ul><ul><ul><ul><ul><li>ASA, NSAID’s, Anticoagulants, Alcohol </li></ul></ul></ul></ul><ul><ul><ul><ul><li>H. Pylori </li></ul></ul></ul></ul><ul><ul><li>LGI Bleeding </li></ul></ul><ul><ul><ul><li>Includes the jejunum, ileum, colon, rectum </li></ul></ul></ul><ul><ul><ul><ul><li>Colorectal cancer, Polyps, Hemorrhoids, IBD </li></ul></ul></ul></ul>Gastrointestinal Bleeding
  117. 117. Gastrointestinal Bleeding
  118. 118. <ul><li>Hematemesis – vomiting of blood (or coffee ground material) (indicates bleeding above the duodenum ) </li></ul><ul><li>Melena – passage of black tarry stools > 50ml (indicates degradation of blood in the bowel) </li></ul><ul><li>Hematochezia – passage of red blood (rectal bleeding) </li></ul><ul><li>Occult Bleeding – bleeding that is not apparent to the patient and results from small amounts of blood </li></ul><ul><li>Obscure Bleeding – occult or obvious but source not identified </li></ul>Gastrointestinal Bleeding
  119. 119. <ul><li>Hematemesis – always UGI source </li></ul><ul><li>Melana – indicates blood has been in GI tract for extended periods </li></ul><ul><ul><li>Mostly UGI </li></ul></ul><ul><ul><li>Small bowel </li></ul></ul><ul><ul><li>Rt colon (if bleeding relatively slow) </li></ul></ul><ul><li>Hematochezia </li></ul><ul><ul><li>Mostly colon </li></ul></ul><ul><ul><li>Massive UGI bleeding (not enough time for degradation) </li></ul></ul>Gastrointestinal Bleeding
  120. 120. <ul><li>TREATMENT </li></ul><ul><ul><li>Find the underlying cause </li></ul></ul><ul><ul><li>Fluid volume replacement </li></ul></ul><ul><ul><li>Endoscopy or colonoscopy </li></ul></ul><ul><ul><li>Medical and /or surgical therapy </li></ul></ul><ul><ul><ul><li>Somatostatin </li></ul></ul></ul><ul><ul><ul><li>IV or intra-arterial vasopressin </li></ul></ul></ul><ul><ul><ul><li>Sclerotherpay </li></ul></ul></ul><ul><ul><ul><li>Angiography with embolization </li></ul></ul></ul><ul><ul><ul><li>Electrocoagulation </li></ul></ul></ul><ul><ul><ul><li>Band ligation </li></ul></ul></ul><ul><ul><ul><li>Balloon tamponade (Sengstaken-Blackmore tube) </li></ul></ul></ul>Gastrointestinal Bleeding
  121. 121. <ul><li>The Pancreas secretes digestive enzymes, bicarbonate, water, and some electrolytes into the duodenum via the pancreatic duct </li></ul><ul><ul><li>Lipase, Amylase, Trypsin </li></ul></ul><ul><li>The Pancreas also produces and secretes insulin </li></ul>The Pancreas
  122. 122. <ul><li>DEFINITION </li></ul><ul><ul><li>An autodigestive process resulting from premature activation of pancreatic enzymes </li></ul></ul>Pancreatitis
  123. 123. <ul><li>PATHOSHYSIOLOGY </li></ul><ul><ul><li>Inactive pancreatic enzymes are activated outside of the duodenum </li></ul></ul><ul><ul><li>The swelling pancreas causes fluids to shift into the retro peritoneum and bowel </li></ul></ul><ul><ul><li>Fluid shifts can cause severe hypovolemia and hypotension </li></ul></ul><ul><ul><li>Inflammation cause commotion around pancreas </li></ul></ul>Pancreatitis
  124. 124. <ul><li>MANY CAUSES </li></ul><ul><ul><li>Alcoholism </li></ul></ul><ul><ul><li>Biliary Disease </li></ul></ul><ul><ul><li>Gallstones </li></ul></ul><ul><ul><li>Infections </li></ul></ul><ul><ul><li>Hyperparathyroidism </li></ul></ul><ul><ul><li>Hypertriglyceridemia </li></ul></ul>Pancreatitis <ul><ul><li>Hypercalcemia </li></ul></ul><ul><ul><li>Peptic Ulcer Disease </li></ul></ul><ul><ul><li>Cystic Fibrosis </li></ul></ul><ul><ul><li>Vascular Disease </li></ul></ul><ul><ul><li>Multiple Drugs </li></ul></ul><ul><ul><li>More </li></ul></ul>
  125. 125. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Abdominal Pain </li></ul></ul><ul><ul><li>Nausea & Vomiting </li></ul></ul><ul><ul><li>Abdominal Distention </li></ul></ul><ul><ul><li>Jaundice </li></ul></ul><ul><ul><li>Malnutrition </li></ul></ul>Pancreatitis <ul><ul><li>Hematemesis </li></ul></ul><ul><ul><li>Grey Turner’s Sign </li></ul></ul><ul><ul><li>Cullen’s Sign </li></ul></ul><ul><ul><li>Elevated Amylase, Lipase, LDH, AST, WBC’s BUN, and Glucose </li></ul></ul>
  126. 126. <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Hypocalcemia </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Acute Tubular Necrosis </li></ul></ul><ul><ul><li>DIC </li></ul></ul><ul><ul><li>Obstructive Jaundice </li></ul></ul><ul><ul><li>Erosive Gastritis </li></ul></ul><ul><ul><li>Paralytic Ileus </li></ul></ul><ul><ul><li>Pseudocyst or Abscess </li></ul></ul><ul><ul><li>Bowel Infarction </li></ul></ul><ul><ul><li>Internal Bleeding </li></ul></ul><ul><ul><li>Fat Necrosis </li></ul></ul>Pancreatitis <ul><ul><li>Pleural Effusion </li></ul></ul><ul><ul><li>Pulmonary Infiltrates </li></ul></ul><ul><ul><li>Hypoxemia </li></ul></ul><ul><ul><li>Atelectasis </li></ul></ul><ul><ul><li>ARDS </li></ul></ul><ul><ul><li>Pericardial Effusion </li></ul></ul><ul><ul><li>Mediastinal Abscess </li></ul></ul><ul><ul><li>Hyperglycemia </li></ul></ul><ul><ul><li>Hypertriglyceridemia </li></ul></ul><ul><ul><li>Encephalopathy </li></ul></ul>
  127. 127. <ul><li>TREATMENT </li></ul><ul><ul><li>Stabilization </li></ul></ul><ul><ul><ul><li>Correct Fluid And Electrolyte Status </li></ul></ul></ul><ul><ul><li>Respiratory Support </li></ul></ul><ul><ul><li>Control Pain </li></ul></ul><ul><ul><ul><li>Demerol </li></ul></ul></ul><ul><ul><li>NG Tube </li></ul></ul><ul><ul><ul><li>NPO </li></ul></ul></ul><ul><ul><li>TPN </li></ul></ul><ul><ul><ul><li>Restricted Diet </li></ul></ul></ul>Pancreatitis <ul><ul><li>Monitor For Complications </li></ul></ul><ul><ul><li>Monitor Blood Sugar </li></ul></ul><ul><ul><li>Drug Therapies </li></ul></ul><ul><ul><ul><li>Somatostatin, Anticholinergics </li></ul></ul></ul><ul><ul><li>Watch For Signs Of Infection </li></ul></ul><ul><ul><li>Pray </li></ul></ul>
  128. 128. <ul><li>FULMINATING PANCREATITIS </li></ul><ul><ul><li>Overwhelming form </li></ul></ul><ul><ul><li>Necrotizing form </li></ul></ul><ul><ul><li>Extreme symptoms </li></ul></ul><ul><ul><li>Seen with ESRF patients </li></ul></ul><ul><ul><li>May lead to ARDS & DIC </li></ul></ul>Pancreatitis
  129. 129. <ul><li>FULMINATING PANCREATITIS </li></ul><ul><ul><li>Signs & Symptoms </li></ul></ul><ul><ul><ul><li>Tachycardia & low BP (may be the only sign) </li></ul></ul></ul><ul><ul><ul><li>Pulmonary & cerebral insufficiency </li></ul></ul></ul><ul><ul><ul><li>Acute diabetic ketosis or oliguria </li></ul></ul></ul><ul><ul><ul><li>Hemorrhagic pancreatitis may appear </li></ul></ul></ul>Pancreatitis
  130. 130. <ul><ul><ul><li>THE END </li></ul></ul></ul><ul><ul><ul><li>PART 1 </li></ul></ul></ul>PCCN REVIEW
  131. 131. <ul><ul><ul><li>THANK YOU </li></ul></ul></ul>PCCN REVIEW PART 1
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