Mark Klimek NCLEX Review: Cardiac Medication, Calcium Channel Blockers, Cardiac Arrhythmias, Chest Tube
Mark Klimek NCLEX Review: Cardiac Medication, Calcium Channel Blockers, Cardiac Arrhythmias, Chest Tube, Congenital Heart Defects, Infectious Disease, PPE
Calcium Channel Blockers
CCBs (Calcium channel blockers) are like Valium for the heart
- They relax and slows down the heart
- In other words, CCBs have negative inotropic, chronotropic, dromotropic effects on the heart
(+) Inotropy, Chronotropy, Dromotropy
Positive inotropy
Increase cardiac contractile force à
Ventricles empty more completely à
Cardiac output improved
Positive chronotropy
Increase rate of impulse formation at
SA node à Accelerate heart rate
Positive dromotropy
Increase speed that impulses from SA
node travel to AV node (increase
conduction velocity)
When do you want to relax and slows down the heart? … To treat “A, AA, AAA”
- Antihypertensive
- AntiAnginal drugs (decreasing oxygen demand)
- AntiAtrialArrhythmia
Side Effects
Headache and hypotension
Name: ends in “dipine” … Not “pine”
- Also, verapamil, Cardizem (diltiazem)
- Cardizem (diltiazem) is given continuous IV drip
What are the parameters to assess before putting a pt on CCBs?
- Assess for BP - Hold if SBP <100
Cardiac arrhythmias
- How to interpret rhythm.
(–) Inotropy, Chronotropy, Dromotropy
Negative inotropy
Weaken/decrease the force of myocardial
contraction
Negative chronotropy
Decrease rate of impulse formation at the
SA node à decelerate heart rate
Negative dromotropy
Decrease speed that impulses from SA
node travel to AV node (decrease
conduction velocity)
Normal Sinus Rhythm
- There is a P wave, followed by a QRS, followed be a T wave for every complex
- Peaks of the P wave is equally distant to the QRS, and fall within 5 small boxes
Ventricular Fibrillation
- No pattern
Ventricular Tachycardia
- Sharp peaks with a pattern
Asystole
- A flat line
If the question mentions
- QRS depolarization = Ventricular
- P wave = Atrial
The 6 rhythms most tested on the NCLEX
1. A lack of QRS complexes is asystole—a flat line
2. P waves (atrial) in the form of saw tooth wave = atrial flutter
3. Chaotic P wave patterns = atrial fibrillation (a-fib) (Chaotic: word used to describe fibrillation)
4. Chaotic QRS complexes = ventricular fibrillation (v-fib)
5. Bizarre QRS complexes = ventricular tachycardia (v-tach) (Bizarre: word used to describe tachycardia)
6. Periodic wide bizarre QRS complexes = PVCs (Salvos of PVCs = A short runs of v-tach)
PVCs (premature ventricular contractions) are usually low priority
• However, elevate them to moderate priority if under the following 3 circumstances
- There are 6 or more PVCs in a minute
- More than 6 PVCs in a row
- R on T phenomenon (a PVC falls on a T wave)
• PVCs after an MI is common and is a low priority
Lethal arrhythmias are high priority and will kill a patient in 8 minutes or less. They are:
• Asystole and V-fib (ventricular fibrillation)
• Both rhythms produce low or no cardiac output (CO), without which there is inadequate or no brain perfusion. This may lead to confusion and death
Potentially Lethal Cardiac Arrhythmia
V-tach (ventricular tachycardia) is a potentially lethal cardiac rhythm, but it has a CO
How would a patient with or without CO presents?
- CO is absent = there is no pulse
- CO is present = there is a pulse
Treatment of PVCs and V-tach
- Ventricular = Lidocaine
- Both are ventricular rhythms
- Treat with Lidocaine
- Amiodarone is eventually the NCLEX board will want as answer
Supraventricular arrhythmias are Atrial arrhythmias (supra = above) Treatments are “ABCDs”
- Adenocard (Adenosine) … Fast IV push (push in less than 8 seconds and 20 mL NS flush right after) … These pts will go into asystole for about 30 seconds and out of it
- Beta-blockers (end in -olol)
- CCBs
- Digitalis (digoxin), Lanoxin (another digitalis analog)
Beta-blockers have negative inotropic, chronotropic,
dromotropic effects on the heart. They treat “A, AA, AAA”
- Antihypertensive
- AntiAnginal drugs (decreasing oxygen demand)
- AntiAtrialArythmia
- Side Effects = Headache and hypotension
Treatment of V-fib and Asystole
- Defib for V-fib (Defib = defibrillate = Shock em!)
- Epinephrine and Atropine for Asystole
Tx: Atrial arrhythmias
- Adena
- Beta
- Calcium
- Dig
Tx: Ventricular arrhythmias
- Lidocaine
- Amiodarone
Chest Tubes
Purpose: to reestablish negative pressure in the pleural space … Negative pressure in the pleural space makes thing stick so that the lung expands when the chest wall expands
- Pleural space is the space between the lung (visceral pleura) and the chest wall (parietal pleura)
- In a pneumothorax, chest tube removes air
- In a hemothorax, chest tube removes blood
- In a hemopneumothorax, chest tube removes air and blood
Question
A chest tube is placed in a pt for a hemothorax (blood). What would you (the LPN) report to the nurse? Or, what would you (the RN) report physician?
a. Chest tube is not bubbling
b. Chest tube drains 800 mL in the first 10 hours
c. Chest tube is not draining
d. Chest tube is intermittently bubbling
What is the chest tube not supposed to do? The chest tube is supposed to drain instead of bubbling
Therefore answer (c) is the right answer.
Question
A chest tube is placed in a pt for a pneumothorax (air). What would you (the LPN) report to the nurse? Or, what would you (the RN) report physician?
a. Chest tube is not bubbling
b. Chest tube drains 800 mL in the first 10 hours
c. Chest tube is not draining
d. Chest tube is intermittently bubbling
With a pneumothorax, bubbling is expected
Therefore, (a) is a good answer choice
- Since this is a pneumothorax, not too much blood is expected
- Consequently, 800 mL of blood over 10 hours (80 mL per hour) is too much blood and needs to be reported to the nurse or the physician
Also, pay attention to the location the tube is placed
- Apical (top) or Basilar (base)
- Apical chest tube removes Air
- Basilar chest tube removes Blood or fluid (due to gravity)
Examples
- An apical chest tube is draining 300 mL the first hour is bad … Bubbling (air) is expected
- A basilar chest tube is draining 200 mL the first hour is expected
- An apical chest tube is not bubbling … This is a bad sign because bubbling (air) is expected
- A basilar chest tube is not bubbling … This is a good sign because bubbling (air) is not expected
Example
Patient presents with a unilateral hemopneumothorax. How to care for this patient?
Place an apical chest tube for the pneumothorax and a basilar for the hemothorax
Bilateral pneumothorax needs apical chest tube one on the right and one on the left
Air tube = Apical = Top, on both sides
Post-trauma or postsurgical patient needs
- Patient presents with a unilateral hemopneumothorax. How to care for this patient? … Place an apical and a basilar chest tube on the side of the problem … Always assume trauma and surgery is unilateral unless otherwise specified
Trick question
Where would you place a chest tube for a postop right pneumonectomy?
- Postop right pneumonectomy does not need a chest tube … Since the right lung was removed, there is no need for a chest tube
- Chest tube will however be used for lobectomy (removal of a lobe of the lung), or wedge resection
Closed chest drainage devices
Types: Jackson-Pratt, Emisson, pneumovac, hemovac, etc.
What happens if one of those drainage devices is knocked over?
- Ask patient to take a deep breath and set the device back up
- Not a medical emergency … No need to call the physician
*Knock someone or something over: to push or strike someone or something, causing the person or the thing to fall.
If the water seal of the chest tube breaks
Clamp
- Clamping, unclamping, and placing the tube under water must be done in 15 seconds or less
Cut the tube away
Submerge (stick) the end of the tube under sterile water
- The most important step
Unclamp the tube if it was initially clamped, (clamping the tube prevent air to get into the chest but does not allow anything from the chest to get out)
Note
If for whatever reason the chest tube breaks, clamp, unclamping to placing the tube under water must be done in 15 seconds or less
Question
The water seal chamber of the chest tube in a patient with a pneumothorax/hemothorax breaks. What is the first course of action for the nurse?
a. Clamp the tube
b. Cut the tube away
c. Submerge (or stick) the end of the tube under sterile water
d. Unclamp the tube if it was initially clamped
- In this case, the first course of action is the clamp the tube
Question
The water seal chamber of the chest tube in a patient with a pneumothorax/hemothorax breaks. What is the priority (best) action of the nurse?
a. Clamp the tube
b. Cut the tube away
c. Submerge (or stick) the end of the tube under sterile water
d. Unclamp the tube if it was initially clamped
- In this question, the priory action for the nurse is to submerge the end of the tube under sterile water because doing so prevents air from getting into the chest. At the same time, this allows air or blood from the chest to get out
(This solves the problem by reestablishing the water seal)
Note
Clamping, unclamping, and placing the tube under water must be done in 15 seconds or less
Question
You notice on the monitor that a patient has v-fib. Pt is unresponsive and there is no pulse. What is the first step in the management of this patient?
a. Place a backboard under patient’s back while patient is supine
b. Start chest compression
“Best” is about what is the priority. Chest compression is the priority action.
If a chest tube gets pulled out …
1. Take a gloved hand and cover the opening (first step)
2. Take a sterile Vaseline gauze and tape 3 sides (best step)
Chest tube is bubbling … Ask (1) where it is bubbling, and (2) when it is bubbling?
Ask the following 2 questions
• Bubbling … Where? In the water seal chamber
- If it is intermittent, it is good (document it)
- If it is continuous, it is bad and indicates a break/leak in the system (find it and tape it)
• Bubbling … Where? In the suction control chamber
- If it is intermittent, suction pressure is too low (increase it at the wall until it is continuous)
- If it is continuous, it is good (document it)
Analogies
• A straight catheter is to a Foley catheter, as a thoracentesis is to a chest tube.
- A straight catheter goes in and out … A Foley goes in, secure it, and continuous drainage
- Thoracocentesis = go in and out … Chest tubes = go in, secure it, and leave it in place
• A Foley has a higher risk of infection than a straight Cath
• A chest tube has a higher risk of infection than thoracocentesis
Rules for clamping tubes
- Do not clamp a tube for more than 15 seconds without a physician’s order
- Use rubber tooth (will not puncture tubing), double clamps
- Therefore, when the water seal breaks, the nurse has no more than 15 seconds to clamp, cut the tube, submerge it under sterile water, and then unclamp it
Congenital Heart Defects
It is either they cause a lot of trouble or no trouble
- But nothing in between
• Memorize one word: “TRouBLe” with the lower-case vowels because congenital heart defects are either:
“TRouBLe” or Nothing to worry about
A pediatric patient with “TRouBLe” as congenital heart defect
- Needs surgery now/soon to live
- Has slowed/delayed growth and development (failure to thrive)
- Has a shortened life expectancy
- Parents will experience a lot of grief, financial and emotional stress
- Patient is likely to be discharge home on a cardiac monitor
- After, birth, patient will be in the hospital for weeks
- Pediatrician or pediatric nurse will likely refer patient to a pediatric cardiologist
Question
The nurse is teaching the parent of an infant born with Tetralogy of Fallot. Which of the following should the nurse talked to the parents about in the teaching session?
- The nurse should teach the newborn’s parents all of the choices listed above
A “TRouBLe” congenital heart defect
• “TRouBLe” shunts blood Right to Left
• “TRouBLe” is Blue (cyanotic)
• All “TRouBLe” starts with the letter “T”
- Tetralogy of Fallot
- Truncus arteriosus
- Transposition of the great vessels
- Tricuspid atresia
- Totally anomalous of pulmonary vasculature (TAPV)
- Except, Left ventricular hypoplastic syndrome
These are examples if No TRouBLe congenital heart defects
- Ventricular septal defect (VSD)
- Patent ductus arteriosus (PDA)
- Patent foramen ovale
- Atrial septal defect
- Pulmonic stenosis
All children with a congenital heart defect, whether TRouBle defect or No TRouBle defect, have
- A Murmur
- An echocardiogram need to be done to find out the cause of the murmur
4 defects of Tetralogy of Fallot — “PROVe”
- Pulmonary artery stenosis
- RVH (right ventricular hypertrophy)
- Overriding aorta
- VSD (ventricular septal defect)
No need to know what they are … Just need to spot them as answer choices on the board
Infectious Disease and Transmission-Based Precautions
There are 4 transmission-based precautions
- Standard or universal
- Contact
- Droplet
- Airborne precaution
Contact precautions
• Anything enteric (GI, or fecal/oral)
- C. diff., Hepatitis A, E. coli, cholera, dysentery
• Staph
• RSV (droplets fall onto object then patient touches object or put it in mouth)
- Do not cohort 2 RSV patients unless culture and symptoms say that have the same disease
• Herpes
PPE (personal protective equipment) for contact precaution
- Private room is preferred
- Can be in the same room if cohort based on culture and not symptoms
- Hand washing à Gown à Gloves
- Disposable supply (gloves, paper plates, plastic utensils)
- Dedicated equipment (stethoscope, BP cuff) and toys stay in the room
Droplet precautions
- For bugs travelling on large particles through Coughing, Sneezing to less than 3 feet
- Meningitis
- H. influenza b [Example: epiglottitis (nothing in the throat)]
PPE (Personal Protective Equipment)
- Private room is preferred
- Can be in the same room if cohort based on culture and symptoms
- Hand washing à Mask à Goggle or Face shield à Gloves
- Disposable supply
- Dedicated equipment
Airborne precautions “Air MTV”
- MMR
- TB
- Varicella (chickenpox)
PPE
- Private room is preferred
- Can be in the same room if cohort based on culture and symptoms
- Hand washing à Goggle or Face shield à Gloves
- Wear mask when living the room
- Keep door closed
- Disposable supply (not essential)
- Dedicated equipment (not essential)
- Negative airflow
PPE (Personal Protective Equipment)
• Order to put in on:
- Gown
- Mask
- Goggle
- Gloves
• Order to take it off … Do so in alphabetical order
- Gloves
- Goggle
- Gown
- Mask
Math Problems
Dosage calculation
IV drip rates = Volume × Drop factor / Time
- Micro/Mini drip = 60 drops per mL
- Macro drip = 10 drops per mL
Pediatric dose (2.2 lbs = 1 kg)