NCMB418 LECTURE: Exam Week

12
BSN 4TH YEAR 1ST SEMESTER MIDTERM 2023
Bachelor of Science in Nursing 4Y1
Professor: Michael Joseph Diño, PhD, MAN, RN, LPT
Midterm Topics: • Orientation to other people (May bf ka na?)
• Neurologic and Fluids and Electrolytes • Orientation to time (Sa ganda mong ‘yan, kailan pa
• Respiratory Function in Critical Care wala?)
• Megacode and Post-Cardiac Arrest • Orientation to place (Wait, saan ka now?)
• Memory (How young are you?)
NEUROLOGIC AND FLUIDS AND ELECTROLYTES • Remote memory
Types of Data • Recent memory (Kumain ka na ba?)
Objective Subjective • General knowledge (Who is the current president?)
Observed Subject • Attention span and calculation skills (What is 4x3?)
Verified Patient Cranial
Explicit (shown) Implicit (covered that you - CODE: Oh! Oh! Oh! To Touch And Feel A Girl’s Vagina So
need to uncover) Heavenly! Try It!
Signs Symptoms - The nurses instructed the patient to do some tests using
- Objective data can be used for unconscious while instruments to determine if the cranial nerves are
- Subjective data can be used for conscious. functional.
- Objective data is empirical = measurable
- Implicit (covered that you need to uncover) You will
uncover this by asking the patient a questions.
Types of Assessment
OPPA assessment
• Observe/ inspect – less intrusive
• Palpate
• Percuss
• Auscultate – most intrusive

Body Systems – Critical Care

Coordination (Neurologic)
- “You feed all my senses and being”
- It is essential to know how to properly assess the client
neurologically.
- Checking the sensorium, the intact of the nerve impulses,
movements, and reflexes.
- MCSMR:
• Mental
• Cranial
• Sensory
• Motor
• Reflexes
Mental
- Mental Assessment:
• Alert = Patient follows commands and responds
completely and appropriately to stimuli.
• Lethargic = Patient is drowsy, has delayed but
appropriate responses to verbal stimuli, and may drift
off to sleep during the examination.
• Stuporous = Patient requires vigorous stimulation for a
response. Responses vary in appropriateness.
• Comatose = Patient doesn’t respond appropriately to
verbal or painful stimuli and can’t follow commands or
communicate verbally.
- Functional screening:
• Orientation to person (What is your name?)
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 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER MIDTERM 2023

Sensory
- It is being assessed together with the motor assessments.
• Pain
• Touch
• Position
• Vibration
Motor
• Tandem Walking/ Heel To Toe – Drug or alcohol intoxication,
motor neuron weakness or muscle weakness
• Romberg’s Test – Coordination and balance: posterior
columns of the spinal cord
• Fingers-To-Nose Test – Cerebellar disease: beyond the tip
of the nose; Pass-point test
• Rapid Alternating Movement – Upper motor neuron
weakness, Finger-to-finger test
• Heel-To-Shin – Disease of the posterior spinal tract
Reflexes
- For adults, nurses are using the deep tendon reflexes
- We are assessing using the hammer.
- We are recording the grading scale of it.
- It is being done when the client has a specific neurologic
condition.

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Breathing (Respiration) • Vesicular – heard over the thorax, lower pitched and softer
- “You are the air that I breathe” than bronchial breathing.
- Ask about a history of breathing problems, disease, • Crackles – parang nasa tubig ung tunog
lifestyle, and current issues. • Wheezes – horning sound
- Most important to report to the doctor is the lung/ breath
sounds.
- In assessing and asking the past history of the client,
obtain the subjective and objective cues. Also, used the
O.P.P.A mnemonics. It is being done to conscious clients.
If the client is unconscious, refer these details to the
relative of the client.

Circulation (Fluid and Electrolytes)

- “You are the force that nourish”

• H2O = It always follow Na

• Na = Mental Function (Neuro)
• K = Pumping of the heart (elicits excites the heart)
• Ca = Bones
• Mg = Muscles
• PO4 = Inversed relationship with Ca.
Ex: Decreased Calcium = Increased Phosphate (Vice
Versa)

• Bronchial – heard over the trachea has a higher pitch,

louder, inspiration and expiration are equal and there is a
pause between inspiration and expiration.
• Bronchovesicular – softer than bronchial sounds, but
have a tubular quality.
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 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER MIDTERM 2023

RESPIRATORY FUNCTION IN CRITICAL CARE
Respiratory Process
- Three external respiration processes are needed to
maintain adequate oxygenation and acid-base balance.
1) Ventilation
- Gas distribution into and out of the pulmonary
airways
- From the body, outside the environment
- MACRO – between the body and the environment.
Taking in oxygen and taking out of carbon dioxide.
2) Pulmonary Perfusion
- Blood flow from the right side of the heart is being
oxygenated through the pulmonary circulation, and
into the left side of the heart. Then, it will be pump
all throughout the body
- MESO – middle or average
3) Diffusion
- Gas movement from an area of greater to lesser
concentration through a semipermeable membrane
- MICRO occurs at the level of cellular.
- Exchange of oxygen and carbon dioxide in and out of
the cell of human body.
- Ex: The blood products are having an exchange with
the atoms and compounds of oxygen, water, and
carbon dioxide.
- Buffer System is the mechanism that occurs in the body
just to maintain the right amount of everything
(homeostasis). It prevents sudden change in the body by
balancing it.
- When the CO2 is being absorbed in exchange of O2,
plasma is made up majority of water. When the CO2 and
H2O binds, it may form H2CO3 (Acidic).
- If the H2CO3 breaks down (meaning the one H is being
separated), it will form HCO3 (Alkaline/ Basic). It is the
process of maintaining the acid-base balance.
Breathing Mechanism
- Mechanical forces, such as movement of the diaphragm
and intercostal muscles, drive the breathing process.
These muscles contract when the patient inhales and relax
when the patient exhales.
- In critical care, there’s a lot of factors that can affect in the
respiration of the patient.
- Ex: If the client experienced vehicular accident, some of
the anatomical features of the respiratory system might
introduce challenges to the patient.

Respiratory Patterns
Pattern Description Possible Cause
- Once, unoxygenated blood/ oxygenated at the pulmonary Respiratory rate Restrictive lung
circulation. This oxygenated blood will be pump throughout greater than 20 disease, pain,
the body by the left side of the heart. Tachypnea breaths per minute sepsis, obesity,
- The oxygenated blood can either be dissolve in plasma or anxiety, and
binds with the RBC. fever
• The oxygenated blood is dissolves in the plasma of respiratory rate CNS depression
blood to the liquid component. The values of oxygen in below 10 breaths and increase
plasma are known as PaO2. Bradypnea per minute intra-cranial
• When the oxygenated blood and RBC are binding with pressure
each other, it will travel all throughout circulation
wherein habang nagtatravel yan, nagkakaroon ng Absence of
Apnea
cellular diffusion between the RBC and the cells of the breathing
human body. Deep breathing exercise, fever,
Hyperpnea
- At the micro perspective, there’s a release of oxygen then hypoxia
there’s an absorption of carbon dioxide for excretion. Rapid and deep diabetic
Kussmaul
(parang exchange, mag rerelease ng oxygen, ididistribute ketoacidosis
ang oxygen and after that ipapalit with carbon dioxide that Regular cycle of heart failure, kidney
are considered as waste produtcs) change in the failure, or
- If there’s an exchange between the O2 and CO2, the CO2 rate and depth of CNS damage
Cheyne-
is now present in the blood. breathing (normal during
Strokes
- When the CO2 is present in the blood, its either it will form (shallow - deep - sleep among
a carbonic acid (H2CO3) or bicarbonate (HCO3). It is shallow - apnea elderly)
called as “buffer system” of 20-60 seconds)
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Rapid deep breaths severe CNS damage • SaO2 (Arterial Oxygen Saturation)
that alternate Modified Allen’s Test
Biots
with abrupt periods - When the doctor ordered for ABG, as a nurse, you need to
of apnea confirm it. Then, performed modified Allen’s test. It is being
done because you need to check first the perfusion of the
Chest Inspection blood on that particular area.
- performed to check the preserved patency between the
radial and ulnar artery before puncturing one of these
arteries.
- Ex: During cannulation or sampling.
- To conduct the test:
1) The examiner compresses both arteries till the skin of
the patient appears blanch. This can be accelerated by
elevating the hand and having the patient repeatedly
open and clench the fist.
2) The ulnar artery is then released while the compression
of the radial artery is maintained which result in flushing
of the hand due to hyperemia within 5-15 seconds. (The
test is positive) To prevent false negatives, the hand
should not be hyperextended.
• Barrel – round and bulging 3) If the hand remains blanch longer than 15 seconds, it
• Pigeon – with a sternum that protrudes beyond the front of indicates that the collateral circulation is inadequate or
the abdomen non-existing between the arteries and the test is
negative.
• Funnel – funnel-shaped depression on all of or part of the
- A faster version of the test can be conducted by
sternum
compressing one of these arteries and having the patient
• Kyphoscoliosis – spine curves to one side and the
clench its fist for several seconds. A lack of flushing after
vertebrae are rotated
opening the hand suggest an insufficient or absent
collateral flow from the artery that has not been
Arterial Blood Gas Monitoring
compressed.
- Routinary procedure in a patient with problem in
- It is usually performed by the doctors or the medical
respiration.
technologist.
- Ordered by the doctor when the client is hooked in chest
Obtaining Arterial Blood Sample
tubes, undergone in a mechanical ventilation, post-cardiac
- Arterial blood is required for an ABG. In most critical care
arrest (main root of cause: respiratory system)
units, a doctor, respiratory therapist, or specially trained
- Frequently performed in critically ill clients to access acid-
critical care nurse draws ABG samples through an [a]
base balance, ventilation, and oxygenation.
arterial line or [b] percutaneous puncture (radial, brachial
- An arterial blood sample is analyzed for oxygen tension
or femoral artery). In percutaneous puncture, an Allen’s
(PaO2), bicarbonate (HCO3) and pH using a blood gas
test must be performed.
analyzer.
- Code: SIDE
per hydrogen; an indication of the
Choice is radial artery of non-
pH blood’s acidity or alkalinity 7.35-7.45 Site selection
dominant wrist; clean site
Sterile and non-sterile gloves,
carbon dioxide tension; reflects
35-45 Site gauze pad, googles, ABG kit
PaCO2 adequacy of lung ventilation Materials
mmHg (Heparinized syringe), cup of
Preparation
ice NOTE: Heparinized Syringe
carbon dioxide tension; reflects
22-26 is to prevent blood clotting.
HCO3 the activity of the kidneys in
mEg/L Insert Needle Insertion 30-60 angle
retaining or excreting bicarbonates
Automatic syringe fill and
oxygen tension; reflects the body’s
80-100 Draw 2 ml of blood place container in ice; apply
PaO2 ability to pick up oxygen from the
mmHg pressure after for 5 minutes
lungs
ABG Analysis should be done
oxygen saturation; percentage of
Ensure Test and monitor within 10 minutes; monitor
SaO2 hemoglobin saturated with oxygen 95-100%
patient for nerve damage
at the time of measurement
• pH (Potential of Hydrogen)
• PaCO2 (Partial Pressure of CO2) “Respiratory Parameter”
• HCO3 (Bicarbonate) “Metabolic Parameter”
• PaO2 (Partial Pressure of Oxygen)
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Arterial Blood Sampling

1) Wash hands
2) Don apron
3) Don gloves
4) Gather a clean equipment tray
5) Gather the equipment (Sharps Disposal Container, Alcohol ABG Analysis
Swabs, Gauze pad, Syringe, Needle) - CODE: I will go to ROME with 3 friends. Will eat breakfast at
6) Introduce yourself around 7:35-7:45. Budget is 6.6 dollars split into 3.
7) Confirm the patient details - BREAKFAST THAT WE WILL ORDER:
8) Explain the procedure • Pinoy Breakfast (pH)
9) Gain Consent • English Breakfast = Pancake, Chocolate Syrup, and
10) Check for any contraindications (Medication such as Orange Juice (PaCO2)
Warfarin or Aspirin, problems with clotting in the blood, • American Breakfast = Ham, Cheese, and Omelet
problems with liver) (HCO3)
11) Allen’s Test - For the value of pH, get the indicated time in the code.
- Ask patient to make a tight fist - For the value of PaCO2, get the 35-45 in the indicated time.
- Apply pressure over the radial and ulnar artery - For the value of HCO3, split the 6 into 3 (6/3)= 2. Therefore,
- Wait approximately 30 seconds the value of HCO3 is 22-26.
- NOTE: Pallor should be noted - If below the pH normal value, it is acidic while if above the
- Remove pressure from the ulnar artery. pH normal value, it is basic.
- NOTE: Color should return within 7 seconds with - MEANING OF ROME: Respiratory Opposite, Metabolic
adequate ulnar artery supply. Equal
12) Expel the heparin from the ABG syringe - Since HCO3 is metabolic, the interpretation is same with
13) Withdraw the plunger slightly. pH. If it is below the HCO3 normal value, it is acidic while if
14) Attach the needle above the HCO3 normal value is basic.
15) Palpate location of radial artery. NOTE: The wrist should - Since PaCO2 is a respiratory parameter, the interpretation
be positioned in extension. is opposite. Therefore, if the PaCO2 is below the normal
16) Clean the puncture site for 30 seconds value, it is basic while if the PaCO2 is above the normal
17) 0.1-0.2 m/s of local anesthetic (Lidocaine 1%) should be value, it is acidic.
slowly injected subcutaneously over the planned
puncture site, at least 60 seconds prior to ABG sampling
(in non-emergency settings) NOTE: Ensure to always
aspirate prior to injection of local anesthetic.
18) Warn the patient of a sharp scratch
19) Insert the needle at 30-45 angle
20) Aim towards the maximum point of pulsation
21) Observe for flashback
22) Hold the needle still whilst the syringe fills
23) Remove the needle. NOTE: Ensuring to apply firm
pressure immediately. Continue to apply pressure for at
least 5 minutes
24) Insert needle into rubber block
25) Dispose needle into appropriate sharps container
26) Attach cap to syringe
27) Thank patient
28) Dispose of used equipment appropriately.
29) Wash hands
Interpreting ABG Values
STEP 1: Know the normal values

STEP 2: Check the characteristics of ph, paco2, hco3 check

which value matches with pH
STEP 3: Identify compensation

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Respiratory Bedside Procedures

Pulse Oximetry [SpO2; SaO2]

- This is used to monitor arterial oxygen saturation non-
invasively.
- It’s performed either intermittently or continuously. In
pulse oximetry, arterial oxygen saturation values are
usually denoted with the symbol SpO2. Arterial oxygen
saturation values, which are measured invasively via ABG
analysis, are denoted by the symbol SaO2.
• SITES: Finger, Earlobe, Nose, Toe
• NORMAL: 95-100% (within 2% of ABG)
• CARE: Protect sensor to light exposure

- Two diodes send red and infrared light through a pulsating

arterial vascular bed such as the one in the fingertip. A
photodetector slipped over the finger measures the
transmitted light as it passes through the vascular bed,
detects the relative amount of color absorbed by arterial
blood, and calculates the saturation without interference
from the venous blood, skin, or connective tissue.
- Nursing Considerations:
• Nurses Place the sensor over the finger or other site,
such as the toe, bridge of the nose, or earlobe, so that
the light beams and sensors are opposite each other.
• Protect the sensor from exposure to strong light, such
as fluorescent lighting, because it interferes with results.
• Check if pulse rate on the oximeter corresponds to the
patient’s actual pulse. If not, reposition the sensor.
• Rotate the sensor every 4 hours.
• Normal reading is 95-100%; oxygen saturation readings
are usually within 2% of ABG values.
• Pulse oximetry isn’t used when carbon monoxide
poisoning is suspected because the oximeter doesn’t
differentiate between oxygen and carbon monoxide
bound to hemoglobin. An ABG analysis should be
performed in such cases.
Venous O2 Sat (SvO2)
- Reflects the oxygen saturation level of venous blood.
- Can be determined by measuring the amount of oxygen
extracted and used or consumed by the body’s tissues.
- When CO poisoning occurs, it is being used to assess the
oxygen saturation in the central lines.
- It is being measured using the central catheters.
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- It is being placed either the brachial vein or at the chest
part near the heart and pulmonary area.
- It is being attached on the sensor that gives the SvO2
number.
- SvO2 sample is obtained from the most distal port of the
pulmonary artery (PA) catheter, which contains the ideal
mix of all venous blood in the heart. Samples may be
drawn from a central catheter if a PA catheter isn’t
available. Continuous SvO2 monitoring is done using the
SvO2 or oximetric PA catheter.
these data to a carbon dioxide value and a
corresponding waveform, or capnogram.
2) Summarily, monitoring ETCO2 falls under three major
categories:
a) colorimetric - use of pH sensitive strips
b) capnometric - numerical display
c) capnographic - wave display
- Nursing Considerations:
• ETCO2 values are usually 2 to 5 mm Hg lower than the
PaCO2 value. Normal PaCO2 is 35-45 mmHg. Normal
ETCO2 is 30-43 mmHg.

- Nursing Considerations:
• During catheter insertion, monitor the patient’s vital • Notify the practitioner of a 10% increase or decrease in
signs, heart rhythm and ventilatory function. readings.
• Apply a sterile dressing or sterile transparent dressing
over the catheter insertion site.
• Closely monitor the patient’s hemodynamic status.
Troubleshoot the catheter for problems that can
interfere with accurate testing, such as loose
connections, balloon rupture, or clot formation on the
tip of the catheter.
End Tidal CO2 (ETCO2)
- Carbon dioxide concentration at end expiration
- A photodetector measures the amount of infrared light
absorbed by the airway during inspiration and expiration.
- Capnogram is a CO2 waveform at hemodynamic monitor.
It can be either high tech (attached at cardiac monitor) or
Mechanical Ventilation
not high tech (with litmus paper alike)
- Mechanical ventilation involves the use of a machine to
- Indications:
move air into a patient’s lungs. Mechanical ventilators use
• Monitor airway patency
either positive or negative pressure to ventilate patients.
• Early detection of CO2 elimination Negative-pressure ventilators work by creating negative
• Assess intervention effectiveness pressure, which pulls the thorax outward and allows air to
flow into the lungs.

- Procedure:
1) In ETCO2 monitoring, a
photodetector
measures the amount
of infrared light
absorbed by the airway
during inspiration and - Indications of mechanical ventilator include:
expiration. An ETCO2 1) Acute respiratory failure
monitor may be a 2) Respiratory center depression
separate monitor or part of the patient’s bedside 3) Neuromuscular disturbances
hemodynamic monitoring system. The monitor converts

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- Modes of Ventilatory Control: Ventilator Settings

• Volume-cycled - delivers a preset volume of air each Setting Description Range
time, regardless of the amount of lung resistance; most amount of oxygen 5-10 mL/kg
common Vt delivered to patient with
• Pressure-cycled - generates flow until the machine each ventilation
reaches a preset pressure, regardless of the volume Determines how fast Vt Low (decrease
delivered or the time required to achieve the pressure will be delivered during pressure);
Flow rate
• Time-cycled - generates flow for a preset amount of inspiration High (increase
time. pressure)
- Nursing Considerations Percentage of oxygen 21-100%
• Provide emotional support to the patient during all FiO2 delivered with each
phases of mechanical ventilation to reduce anxiety and ventilation
promote successful treatment. Even if the patient is respiratory rate; breaths 4-20
unresponsive, continue to explain all procedures and RR per minutes that ventilator
treatments. is set to deliver
• Turn on the ventilator alarms at all times to alert you to amount of effort that the Low; High
potentially hazardous conditions and changes in the patient must generate
Sensitivity
patient’s status. If an alarm sounds and the problem before ventilator will give a
can’t be easily identified, disconnect the patient from breath
the ventilator and use a handheld resuscitation bag
• Assess cardiopulmonary status frequently, at least Ventilator Alarms
every 2 to 4 hours or more often, if indicated. Assess Alarm Possible Cause Intervention
vital signs and auscultate breath sounds. Monitor pulse Disconnected ET tube Reconnect
Low
oximetry or ETCO2 levels and hemodynamic Displaced tubes Check placement
Pressure
parameters as ordered. Defect (malfunction) Ventilate manually
• Be alert for the development of complications Secretions in airway Suctioning
High
associated with mechanical ventilation. These Coughing, gagging Order sedative
Pressure
complications include decreased cardiac output, Patient biting ET tube Insert bite block
trauma, pneumothorax, oxygen toxicity, stress ulcers,
and ventilator-associated pneumonia (VAP). Weaning
- The patient’s body quickly comes to depend on artificial
ventilation and must gradually be reintroduced to normal
breathing. Successful weaning depends on a strong
spontaneous respiratory effort, arterial blood gas levels
within normal limits, a stable cardiovascular system, and
sufficient respiratory muscle strength and LOC to sustain
spontaneous breathing. Criteria must be individualized.
- Several weaning methods are used:
• Intermittent Mandatory Ventilation (IMV) – the number
of breaths produced by the ventilator is gradually
reduced, allowing the patient to breathe independently.
• Pressure Support Ventilation (PSV) – may be used alone
or as an adjunct to IMV in the weaning process. In this
procedure, a set burst of pressure is applied during
inspiration with the patient’s normal breathing pattern,
- Common Mechanical Ventilation Complications: allowing the patient to build respiratory muscle strength
• Barotrauma - high airway pressure in the alveoli. • Spontaneous Breathing Trials – placing the patient on
• Volutrauma - overdistention of the alveoli minimum pressure support, using continuous positive
• Atelectrauma - tissue trauma in the alveoli caused by airway pressure
inadequate pressure within alveolar units
• Hypotension - decreased venous return due to
increased intra-thoracic pressure
• Gastrointestinal problems - peptic ulcers, bleeding,
inadequate nutrition, paralytic ileus

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MEGACODE AND POST CARDIAC ARREST • 3-Lead ECG System

Cardiac Monitoring
- provides continuous observation of the patient’s heart rate
and rhythm and is a routine nursing procedure in critical
care patients.
- It is common in (a) emergency units, post-anesthesia
recovery units and operating rooms.
- Cardiac Monitor – A device that shows the electrical and
pressure waveforms of the cardiovascular system for
measurement and treatment. Parameters specific to
respiratory function can also be measured.
- Attaching 3 electrodes on the patient’s chest.
- “White on the Right, Smoke over Fire”
• 5-Lead ECG System
- Attaching 5 electrodes on the patient’s chest
- “Snow over Grass, Melt Chocolate”
- Add the green and brown electrodes for 5-lead
electrodes.

Electrocardiograph (ECG)
- a graphic record or representation of the electrical activity
of the heart muscles.

• V1 Fourth intercostal space at the right sternal edge

• V2 Fourth intercostal space at the left sternal edge
• V3 Midway between V2 and V4
• V4 Fifth intercostal space in the mid-clavicular line
• V5 Left anterior axillary line at same horizontal level as V4
Electrode Placement • V6 Left mid-axillary line at same horizontal level as V4 & V5
- Electrodes detect the tiny electrical changes on the skin
that arise from the heart muscle depolarizing during each Normal Sinus Rhythm
heartbeat. - It is imperative for critical care nurses to recognize the
- Electrodes are optimally placed directly on dry skin. normal sinus rhythm to ascertain deviations and
- To prevent unclear ECG tracing, the following preparations abnormalities.
are suggested: Normal Sinus Rhythm (NSR)
a) Shaving the skin if necessary, Characteristics Description
b) Removing dead skin cells by rubbing the area with a Rate 60-100 bpm
rough paper or cloth, Rhythm regular
c) Removing oil, grease and dirt using alcohol, and P-wave precede QRS, consistent shape
d) Using electrodes from airtight packages. PR Interval 0.12 to 0.20 second
- In emergency situation, healthcare providers use 3 or 5 QRS Complex 0.04 to 0.10 second
leads of electrodes because they have no plenty time to Conduction normal flow
attach those electrodes.
Limb Leads Bipolar I, II, III
Augmented aVR, aVL, aVF
Chest Leads Precordial V1, V2, V3, V4, V5, V6
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Rhythms Originating in the Atria

Rhythms Originating in the Sinus Node

• Atrial Flutter - caused by fixed re-entry circuit in the right

atrium on patients with health concerns (e.g. rheumatic
heart disease, atherosclerotic heart disease, heart failure,
myocardial infraction)

• Sinus Bradycardia - can be normal findings in athletes

during sleep; may be a response to vagal simulation and
certain medications (digitalis, beta-blockers, calcium
• Atrial Fibrillation - an extremely rapid and disorganised
channel blockers); seen in patients with increased ICP,
pattern of depolarisation; most commonly seen in adults
uremia, myxedema and obstructive jaundice.
post cardiac surgery and with conditions such as
rheumatic heart disease, pulmonary disease , MI, and
congenital heart disease

• Sinus Tachycardia - a normal response to exercise and

emotion; and can be caused by some medications (e.g.
ephinephrine, dopamine, caffein)

Rhythms Originating in the Ventricles

[NOTE: ventricular arrhythmias are considered to be more
dangerous than other arrhythmias due to their potential to
decrease cardiac output]
• Sinus Arrhythmia - occurs when sinus node discharges
irregularly, and is a normal phenomenon during respiration;
may be caused by digitalis toxicity.

• Sinus Arrest - occurs when impulses from the sinus node

are not formed as expected (p-wave absent at some point);
also known as sinus pause; causes include vagal
simulation and drugs (digitalis, beta-blockers, calcium
channel blockers)

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• Ventricular Asystole - absence of any ventricular rhythm.

• Ventricular Fibrillation - rapid, ineffective quivering of the 15 ECG Readings

ventricles; no cardiac output or palpable pulse (fatal
without immediate treatment)
• Supraventricular Tachycardia - rapid rhythm of the heart
that begins in the upper chambers.
• Ventricular Tachycardia - rapid ventricular rhythm;
commonly caused by coronary artery diseases.
4 - Sinus – Normal BUT… (Complete PQRST)
• Sinus Bradycardia – Hear rate is less than 60
• Sinus Arrhythmia – irregular
• Sinus Arrest – with pauses
• Sinus Tachycardia – heart rate is more than 100
2 – Atria – Piercing (Pins)
• Atrial FLUtter – piercing Up
• Atrial FIBrillation – piercing up/down
4 – Ventricles – The Grass (No Negative Deflection)
• Ventricular Asystole – no “grass”
• Ventricular Fibrillation – budding “grass”
• Supra Ventricular Tachycardia – Medium “grass”
• Ventricular Tachycardia – Wide “grass”
4 – AV Blocks – With Defects (Deficient PQRST)
Managements in ACLS

AV BLOCKS
• First Degree AV Block - prolonged AV conduction to the
ventricles; due to coronary artery disease, rheumatic heart
disease and administration of some drugs (e.g. digitalis,
beta- blockers or calcium channel blockers).

• Second Degree AV Block (Type 1) - occurs when one Slow Rhythm (Bradycardia)
atrial impulse at a time fails to be conducted to the - Below the normal limits (< 60 bpm)
ventricles (occurs at AV node) - Examples: Sinus Bradycardia, AV Blocks
- Effective sya kapag bumibilis na ang heart rate
- Pharmacological intervention – ano ang dose, gaano ka
frequent binibigay.
- Managements: A. T. D. E
• Atropine Sulfate
• Second Degree AV Block (Type 2) - occurs when one - Pharmacological intervention
atrial impulse at a time fails to be conducted to the - Dose: 0.5 mg
ventricles (occurs below AV node) - Max: 3 mg
- Total: 6 doses
- Interval: 3-5 mins
• Transcutaneous Pacing
- Procedure
- Delivery of small electrical current to temporarily
• Third Degree AV Block - complete failure of conduction of restore electrical activity of the heart.
all atrial impulses to the ventricles. o Demand TCP – delivers electrical stimulus only
when needed.
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o Fixed Rate TCP – delivers electrical stimuli at a Roles in ACLS

selected rate regardless of patient’s intrinsic
cardiac activity.
- Device used is same with the defibrillator but small
dosage only.
• Dopamine Infusion
- Pharmacological intervention
- Renal Dose = 2 mcg/kg/min
- Cardiac Dose = 5 mcg/kg/min
- Vasopressin Dose = 10 mcg/kg/min
• Epinephrine Infusion
- Pharmacological intervention
- Titrate to response (depende un dosage nya, doon
sa response ng client)
- Initial: 2 mcg/ min
- Max: 10 mcg/min
- It can increase up to 4 mcg/min if the client does not
response to the medication. Stop if there’s a
response.
Fast Rhythm (Tachycardia)
- Above the normal limits (>100 bpm)\
- Management:
1) Stable
• Physiologic (Natural) 1) Team Leader
- Vagal maneuver (massaging the carotid) Allow - Every resuscitation team must have a defined leader
the client to cough - Assign roles to team members
• Pharmacologic - Makes treatment decisions
- Adenosine: Min = 6 mg; Max = 12 mg - Provides feedback to the rest of the team as needed
2) Unstable - Assume responsibilities for roles not defined
• Sedate - If you are a team leader, you should know when to ask
- Diazepam = 5 mg others to prepare the medications, know how to read
- Medazolam = 5 mg ECG readings, know what would be the intervention for
• Synchronized Cardioversion (this is painful the next scenario
procedure that’s why we need to sedate the pt first) 2) Compressor
- SVT = 50 J - Assesses the patient
- AF = 120 J - Performs compressions according to the local
protocols
Megacode - Rotates every 2 minutes or earlier if fatigued
- Tandem with monitor defibrillator or CPR Coach. They
are interchanging their roles every now and then. (Kasi
nakakapagod mag compress all the time, palitan sila)
3) Monitor Defibrillator
- Brings and operates the AED monitor/defibrillator and
acts as the CPR Coach if designated.
- If the monitor is present, places it in position where it
can be seen by the team leader (and most of the team)
- Partner of compressor
- He or she is the one who checks the cardiac monitor
and provides shock if necessary.
4) Airway
- Opens the airway
- Provides bag-mask ventilation
- Inserts airway adjuncts as appropriate
5) IV/ IO/ Medications
- An ACLS provider role
- Initiates IV/IO access
- Prepares and administers the medications

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6) Timer/ Recorder
- Records the time of interventions and medications (and
announces when these are next due)
- Records the frequency and duration of interruptions in
compressions
- Communicates these to the team leader (and the rest
of the team)
- Documents all the procedures
American Heart Association Guidelines
- ACLS providers functioning within a high-performance
team can choose the optimal approach for minimizing
interruptions in chest compressions.
- There are different protocols to maximize chest
compression fraction and high-quality CPR.
High-performance teams
- High-performance teams are essential to successful
resuscitation attempts and can translate to improved
survival for patients in cardiac arrest.
- Effectively incorporate timing, quality, coordination, and
administration of the appropriate procedures during a
cardiac arrest. In addition, these teams clearly identify
their overall purpose and goals.
- They are aware of the skills each member possesses and
not only understand each team member's motivation, they
know their strengths and weaknesses.
- High-performance teams also incorporate effective
conflict resolution and communication skills.
- High performance teams continually measure their
performance, evaluate the data, look for ways to improve
performance, and then implement those learnings.
- One of the measures of a high performance team is the
ability to achieve specific performance metrics and a high
chest compression fraction, or CCF.
Chest Compression Fraction (CCF)
- CCF is the amount of time spent doing high quality chest
compressions during a cardiac arrest event.
- You can only achieve a high CCF by eliminating pauses
during high-quality CPR.
- The Resuscitation Outcomes Consortium, or ROC trials,
showed that a 10 % increase in CCF is roughly equal to an
11 % increase in survival.
- Pauses typically occur during:
• Intubation
• Rhythm analysis
• Pulse checks
• Compressor switches
• Defibrillation.
- We'll address some best practices for eliminating pauses
in some of these areas, but you'll also need to measure
high-quality CPR metrics at your own place of practice to
identify other areas where pauses exist. You can't improve
what you don't measure.
1) Hover
- Whenever compressions are paused, compressors
should hover over the chest and be prepared to resume
compressions.
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2) Pulse Check/ Precharge Defibrillator
- 15 seconds before pausing compressions at the end of
each two-minute cycle:
• Check for a pulse as a placeholder
• Pre-charge the defibrillator
• Prepared to deliver a shock in 10 seconds or less.
3) Switch Compressors
- For seamless transitions, switching between cycles
every 2 minutes is best. However, if a compressor
needs to switch because of fatigue, coordinate the
switch to happen as fluidly as possible.
4) Feedback Devices
- It's a best practice to use real-time feedback devices
during CPR. However, if a feedback device isn't
available, a metronome can help establish the proper
rate. If your AED or defibrillator doesn't have a
metronome, you can download a metronome app to
your mobile device before the conclusion of this course.
5) High performance team Roles and dynamics
- Successful high-performance teams also practice good
communication skills and adhere to the key elements of
effective team dynamics. These elements help teams
work together in the most efficient way possible.
- The American Heart Association has grouped the
elements of team dynamics into three categories:
a) Roles
- Clear roles and responsibilities should be
immediately established by the team leader or
the first rescuer on the scene. When all team
members know their roles and responsibilities
during a resuscitation attempt, the team
functions smoothly.
- Every member of the team should know his or her
limitations. Team members should ask for
assistance and advice early, not when the
situation deteriorates.
- Sometimes a team member or team leader may
need to correct actions that are incorrect or
inappropriate. It's important to be tactful,
especially if you need to correct a colleague
before they make a mistake.
b) What to communicate
- Knowledge sharing and summarizing information
are critical components of effective team
performance. Team leaders should review what's
happened and ask for ideas and observations
from team members.
c) How to communicate
- Closed-loop communication is the process of
verifying that the message sent was received as
intended. It also verifies that any assigned tasks
have been completed.
- In addition to using closed-loop communication,
teams should use clear messaging. Concise,
clear language helps prevent misunderstandings.
Teams that work together frequently can create
terms or phrases that have specific meaning for
them to ensure clarity among members.
 CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER MIDTERM 2023

- Teams need to communicate with respect. Speak to each

other in a professional manner, regardless of scope of
practice or expertise. Resuscitation events are stressful
and emotions can run high.
- Understand that this is the nature of CPR and remember
the life you're trying to save. Not only is it important to
know what to do during a cardiac arrest, but it's just as
important to know how to work together as a team during
an event.
Debriefing
- as a team is an important component of every
resuscitation attempt. Such debriefing during and after an
attempt helps individual team members perform better,
and it may also bring system strengths and deficiencies to
light.
- Implementation of debriefing programs may even improve
patient survival after cardiac arrest. It's not enough to know
what to do or even how to do it. To obtain the best results,
your team must perform both the what and the how
flawlessly.
- That requires practice, and effective practice requires
measurement. But measurement is only effective if you're
trying to brief the team, set goals to improve, and practice
more.
- Remember, you cannot improve what you do not measure.
For more information on how your team can implement
this type of program, please ask your instructor for more
information.
Return of Spontaneous Circulation (ROSC)
- The return of spontaneous circulation or ROSC is not the
end of the cardiac arrest protocol. The high performance
team should continue to maintain an acute sense of
urgency.
- Patients are still in a toxic state, and the possibility of
another arrest is extremely likely. One of the key actions to
take is targeted temperature management. It is the only
intervention that has been shown to improve neurologic
recovery after cardiac arrest and ROSC.
- The resuscitation team should consider inducing targeted
temperature management for any patient who remains
comatose after ROSC.
- The AHA recommends cooling to a target temperature of
32 to 36 degrees Celsius for at least 24 hours.

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Waveform Capnography [Ventilation]

- Waveform capnography represents the amount of carbon
dioxide (CO2) in exhaled air, which assesses ventilation. It
consists of a number and a graph. The number is
capnometry, which is the partial pressure of CO2 detected
at the end of exhalation. This is end-tidal CO2 (ETCO2)
which is normally 35-45 mm Hg.

WHO WILL PASS THE BOARD EXAM??

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AHA Update: Post-Cardiac Arrest Care

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