Medical Surgical: Adult III Exam 1

SA node normal rate

60-100 bpm

AV node rate as a secondary pacemaker

40-60 beats/minute

His-Purkinje system rate

20-40 beats/min

P wave represents

electrical impulse through the atrium causing atrial contraction

PR interval represents

time taken for the impulse to spread through the atria, AV node, and bundle of His

QRS complex represents time taken for depolarization (contraction) of both ventricles

time taken for depolarization (contraction) of both ventricles

ST segment represents time between ventricular depolarization and repolarization

time between ventricular depolarization and re-polarization

T wave represents

time for ventricular repolarization

QT interval represents

Time taken for entire electrical depolarization and re-polarization

Each small square on the ECG represents

0.04 seconds

Each large square represents

0.2 seconds

Stimulation of the vagus nerve does what to the SA and AV node?

Decrease rate of firing and slows impulse through AV ndoe.

What does stimulation of the sympathetic nerves do to the SA and AV node?

increases rate of firing of the SA node and increase impulse through AV node

Sinus brady is ___________ beats per minute

less than 60

What are symptoms of Sinus Bradycardia?

Fatigue, dizziness, chest pain, syncope, pale skin, hypotension, SOB, and confusion

What can cause Sinus bradycardia?

Carotid massage, valsalva maneuver, vagal stimulation
beta blockers, and calcium channel blockers

What is the treatment for Sinus Bradycardia?


Sinus tachycardia is ____________ beats per minute

101-200 beats/minute

What are symptoms of Tachycardia?

dizziness, dyspnea, hypotension, angina

What is the treatment of Sinus tachycardia?

beta blockers, adenosine, calcium channel blockers

Premature Atrial Contraction (PAC)

irregular heart rhythm characterized by atrial contractions occurring before the expected time

What causes Paroxysmal Supreventricular Tachycardia?

dysrhythmias that starts anywhere above the bundle of his. It can cause a reentrant phenomenon. Termination is sometimes followed by periods of asystole

Heart rate of Paroxysmal supraventricular tachycardia?

150-220 beats per minute

Treatment for Paroxysmal supraventricular tachycardia?

vagal stimulation, IV adenosine, beta blockers, calcium channel blockers

What is the heart rate for atrial flutter?

200-350 beats per minute

What is the treatment for Atrial Flutter?

Calcium channel blockers, beta blockers, amiodarone

What is the treatment for Atrial fibrillation?

calcium channel blockers, beta blockers, amiodarone, digoxin, cardioversion

What is the treatment for Junctional Dysrhythmias?

Atropine, Beta blockers, calcium channel blockers, amiodarone
Cardioversion should NOT be used

What is the characteristic of a First Degree block?

Prolonged PR interval. Greater than .20 seconds

What is the treatment for a First Degree Block?

Normally it is not a big deal and no treatment is needed. Most of the time it is asymptomatic

What is a Second Degree Block Type 1 called ?

Mobitz I or Wenchebach heart block

What is a characteristic of Second Degree Heart block type 1?

Gradual lengthening of the PR interval.

What is the treatment for Second Degree Heart block type 1?

If symptomatic, atropine
temporary pacemaker

What are characteristics of Second Degree Heart block type II?

P wave is nonconducted without progressive lengthening. It is more serious because certain number of impulses from the SA node are not conducted to the ventricles.

What is the treatment for Second degree heart block type II?

Transcutaneous pacing or the insertion of a permanent pacemaker. Atropine does not work with this block

What are the characteristics of a Three Degree Heart Block?

Complete block, No communication between atria and ventricles. No coordination. Each contract independently

What is the treatment for a a type 3 heart block?

Temporary transvenous pacemaker, dopamine and epinephrine is temporary measure to increase heart rate and support blood pressure until temporary pacing is started. The patient needs a permanent pacemaker as soon as possible. Atropine is not effective

VT without a pulse treatment

CPR and rapid defibrillation
followed by vasopressors

What is the treatment for Ventricular fibrillation?

CPR and ACLS with the use of defibrillation

Defibrillation is used for?

pulseless v tach and v fib

Cardioversion is used for?

Atrial fib and flutter, VT with pulse

Chest Tubes



collection of air in the pleural space

tension pneumothorax

A life-threatening collection of air within the pleural space; the volume and pressure have both collasped the involved lung and caused a shift of the mediastinal structures to the opposite side.

Pleural effusion

fluid in the pleural space


pus in the pleural cavity

What are signs and symptoms of a tension pneumothorax?

severe respiratory distress
tracheal deviation toward the unaffected side
Muffled heart sounds
cardiac arrest

What is a collection of air under the skin called?

Subcutaneous emphysema

Where is the chest tube placed if you are trying to remove air?
what if you are trying to remove fluid?

Air - second interfcostal space
Fluid- 5th or 6th intercostal space

Chest tube size for infants and young children?


Chest tube size for children and young adults


Chest tube size for adults


Chest tube size for larger adults

36FR- 40FR

When should you see air bubbling in the water seal chamber?

When the patient cough, exhales, or there is a leak

What controls the amount of suction imposed on the patient?

The amount of water in the suction control chamber
Low water- less suction
More water- more suction

What are the advantages and disadvantages of a dry system?

Advantage: safe, high suction pressure, easier set up, quiet, absence of fluid that can evaporate
Disadvantage: does not provide the same level of patient assessment information as a wet system device

What are the steps in setting up a traditional water seal system?

1. Fill water seal chamber to 2cm mark
2. Fill suction control with sterile water to water level.
3. Connect to patient
4. Apply suction. Start with low suction level and gradually increase suction until a gentle bubbling in the suction control chamber is

What type of dressing is used for chest tubes?

Occlusive dressing

A rise in water seal indicates

negative pressure is present in the pleural space (confirms healing)

When recording intrathoacic pressure in a unit on suction- what do you do?

Add the readings of suction control chamber plus the level of water seal chamber

Bubbling in the water seal indicates

air leak

What amount of drainage should be reported the provider in an hour?

over 200 in the first hour is bad and should be reported to the provider

How should you check for leaks?

starting away from the patient and going towards the patient, check all connections
Lastly change the dressing

Blood Administration


Why do you only use whole blood when absolutely needed or when individual blood products components are available?

The use of whole blood has a greater effect on fluid volume than any of the components does

What do red blood cells do?

Raise the hematocrit and hemoglobin levels without significantly increasing blood volume
This component is transfused to restore or maintain adequate organ oxygenation

What is plasma?

Liquid portion of blood. 92% water and 7% plasma proteins

What does plasma do?

maintains blood pressure, provides essention proteins, vital minerals and electrolytes.

What is plasma used for?

bleeding and coagulation disorders, replace fluid volume, replace platelet aggregating inhibitors

What is albumin used for?

maintaining blood pressure and blood volume

What is Cryoprecipitate antihemophilic factor?

component prepared by slowly thawing frozen plasma and recovering the precipitate which contains coagulation factors

T or F: O has AB antigens

False, O has neighter antigen

Who are the universal donors?

Type O

Who are universal recipients?

Type AB

T or F: AB plasma donors can give to all blood types


T or F: RH negative individuals may donate to RH positive recipients but should only receive RH negative blood to prevent formation of anti-D antibodies


What specific compatibilities are needed for whole blood transfusions?


What specific compatibilities are needed for Red blood cell and platelet transfusions?

ABO & Rh compatible

What specific compatibilites are needed for Fresh frozen plasma ?

ABO but no Rh

What size needle do you use for blood administration?

22 gauge

A person who has the D antigen is RH ____________


How long should you remain with the patient in the beginning of the transfusion?

15 mins

The rate of the infusion in the first 15 mins should be


How often should you take vitals and monitor the patient with blood administration?

Take Vitals before the transfusion
After 15 minutes
Every 30 mins up to an hour after

Infusion of blood should take no longer than _________ hours to administer


What is an Acute Hemolytic Reaction?

Your blood is incompatible. Antibodies in the recipient's plasma attach to antigens on transfused RBCs causing destruction

What are manifestations of Acute Hemolytic reaction

usually develops in first 15 minutes
Fever, chills, low back pain, abdominal chest or flank pain, flushing, tachycardia, dyspnea, tachypnea, hypotension vascular collpase, bleeding ]
Initial symptoms are pain at the IV site, elevated heart rate, chills, f

What should you do for acute hemolytic reaction?

maintain BP with IV colloid solutions
give diuretics as prescribed

What is a Febrile nonhemolytic reaction (most common)

Sensitization to donor WBC, platelets, or plasma protein

What are the manifestations of Febrile nonhemolytic reaction?

Sudden chills, rigors, fever (rise in temperature of > 1 degree celcius), headache, flushing, anxiety, vomiting, muscle pain

What is the management of Febrile nonhemolytic reaction?

Avoid aspirin in thrombocytopenic patients

What are manifestations of Circulatory overload?

cough, dyspnea, pulmonary congestion, adventitious breath sounds, headache, hypertension, tachycardia, distended neck veins

What is the management for Circulatory overload?

Place patient upright with feet in dependent position, obtain chest xray stat is ordered, administer prescribed diuretics, O2 and morphone

What are the manifestations of Sepsis?

Rapid onset of chills
High fever
Hypo-tension or shock

What is the classic sign of Sepsis?


What is Transfusion Related Acute Lung Injury?

reaction between transfused antileukocyte antibodies and recipient's leukocytes causing pulmonary inflammation and capillary leak.. Can han happen anytime and up to 6 hour after

What are manifestations of TRALI?

frothy sputum
respiratory failure
noncardiogenic pulmonary edema

What is the management of TRALI?

Draw blood for arterial blood gases and HLA
Obtain Chest x-ray STAT
Provide o2 and administer corticosteroids as ordered

When should you suspect a TRALI reaction?

patient has difficulty breathing or the onset of pulmonary edema in the absence of fluid overload or cardiac dysfunction

What should you monitor for a Massive Blood Transfusion?

RBC transfusion does not contain clotting factors, albumin or platelets. We need to monitor clotting status and electrolyte levels.

What are manifestations of Massive Blood Transfusion?

hypothermia, dysrhythmias, hypocalcemia, hyperkalemia

What are some signs of a delayed hemolytic reaction?

Fever, mild jaundice, decrease hemoglobin
occurs as early as three days or as late as several months

T or F: Delayed hemolytic reaction generally does not need treatment


What is graft vs host disease?

When T lymphocytes in the transfused component attack and react against tissue antigens in the recipient.

What are the manifestations of Graft versus host diease?

skin rash, fever, jaundice, bone marrow suppression.



When do you use a pacemaker?

Heart blocks (3rd degree or 2nd degree advanced)
Symptomatic Bradycardia,
tachycardia (less common)

What are the four types of pacemakers?

Temporary Epicardial
Temporary Endocardial (transvenous)

What are symptoms for symptomatic bradycardia that needs pacing?

Dizziness, lightheadedness, SOB, Hypotensive, diaphoretic
symptoms should go away with pacing

What is the post procedure care for someone with a permanent pacemaker?

up and moving around but limit arm and shoulder activity
arm will be in a sling

What is the post procedure care for someone with a temporary pacemaker?

we don't really want them moving a whole lot

Medications for:
Sinus Bradycardia


Medications for:
Sinus Tachycardia

Vagal Maneuver
Beta blockers (metoprolol)

Medications for:
Premature Atrial Contraction

Beta blockers (metoprolol)

Medications for:
Paroxysmal Superventricular Ventricular Tachycardia

Vagal stimulation
IV adenosine
IV beta blockers

Medications for:
Atrial Flutter

Calcium channel blockers
Beta blockers
Convert a flutter to normal sinus = ibutilide
Maintain normal sinus rhythm - amiodarone
radiofrequency ablation

Medications for:
Atrial Fibrillation

Radiofrequency ablation
Cryoblation, Dig

Medications for:
Junctional Dysrhythmia

Atropine for escape rhythm
Beta blockers
Calcium channel blockers

Medications for:
First degree heart block

No treatment

Medications for:
2 degree heart block type I

- atropine
- pacemaker
- monitor

Medications for:
2 degree heart block type II

permanent pacemaker

Medications for:
Third Degree

Trancutaneous pacemaker till temporary transvenous pacemaker then permanent
Dopamine and Epinephrine

Medications for:

Beta blockers

Medications for:
VT with pulse


Medications for:
VT without pulse

rapid defibrillation
vasopressors - epinephrine

Medications for:
Ventricular Fibrillation


Medications for: