Cardiac Tamponade

This has nothing to do with tampons in the heart ok! Just an FYI.

When blood or fluid accumulate in the sac which surrounds the heart it exerts pressure against the heart, making it harder for the heart to pump. As you can imagine, if the ventricles cannot fill fully or contract effectively then cardiac output decreases. Decrease cardiac output is not good news!

So how do you know if someone has this?

Well the symptoms are nothing unusual: chest pain, restlessness, quick shallow breathing, palpitations, pallor, tachycardia, weak peripheral pulses, pulsus paradoxical, distended neck veins, low BP… (do these all sound a little familiar? MI anyone?) Well causes of cardiac tamponade can be MI, Dissecting aortic aneurysm (thoracic), end-stage lung cancer, heart surgery, Pericarditis caused by bacterial or viral infections, or direct wounds to the heart.

How do we diagnose? Echocardiogram is the usual diagnostic tool, but MRI, CT, CXR or EKG can also highlight or confirm this.

Can you see the halo of fluid around the heart?

This is an emergency! The fluid must be drained to reduce damage to the myocardium and reestablish cardiac output.

Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac, the tissue that surrounds the heart. The patient will be hyperoxygenated, given fluids to maintain blood pressure. It is important to note that a pericardiocentesis may have to be repeated because cardiac tamponade can return. With fast treatment the outcome is usual good, without treatment death is immanent.

A pericardial draining tube may be placed during surgery to keep in place postop. The drainage will be measured every shift and documentation on the color, amount and consistency is very important! The tube will usually be removed slowly over the postop recovery weeks at the discretion of the cardiologist.

NCLEX Success: Remember your A-B-Cs!

Say it with me: AIRWAY, BREATHING, CIRCULATION!

If you have renewed CPR with AHA recently you’ll know that they have changed that to CAB from ABC, but for NCLEX you need to stick with the ABC.

So here comes that irritating priority question. You try to apply Maslow but all options are physiological, so there is nothing to eliminate. What do you do? You apply the ABCs.

Airway will always be the most important factor to take priority: anaphylaxis? Choking? So look for it, if it isn’t there, look for breathing, it could be simple like raising HOB to decrease dyspnea in a CHF pt – keep focused on the “B” until you can rule it out. If no luck at that point, move to circulation. Hemmorhage? Potential for bleed? Change in vitals (↑HR, ↓BP)?

Look at the big picture and apply all the ABCs and use them to lead you to the right answer! Priorities will always contain ABC/Maslow or combination! Use your question answering skills! 🙂

Nursing Skills: Reasons for Chest Tubes

So I thought I’d write about chest tubes this week because I had a patient with two chest tubes and was post removal of a pericardial tube also. Not only that, but a colleague had a young pt in his 20’s whose chest tube popped out on the same day! Needless to say I thought it would be a great topic to cover. I’ll break it into three postings

Firstly, chest tubes aren’t as scary as they appear: sure, they are stuck in someones chest but there are many different reasons for a chest tube so knowing a thorough background on your pt is very important.

The procedure for placing chest tubes is called a Thoracostomy.

Reasons for inserting a chest tube:

Pneumothorax: This is when air collects in the pleural space; can also be referred to as a “collapsed lung”. The air pressure in the pleural space does not allow the lung to reinflate.

Pneumothoraxes can occur after central line insertion, after chest surgery, after trauma to the chest, or after a traumatic airway intubation. It is very important to remember that if the air continues to collect in the chest, the pressure in that pocket can increase and push the whole mediastinum over to the other side – this is called a “tension pneumothorax”, and is  life-threatening.

 

 

 

 

 Hemothorax: This is is when blood fills/pools in the pleural space and reduces the area for lung expansion. This can happen due to trauma or surgery. There is a possibility of having a hemo-pneumothorax which means air and blood fill the cavity. Also there remains the risk for medialstinal shift “hemo-tension-thorax”, this would be an emergency.

 

 

 

 

 

Pleural Effusion: This is the accumulation of fluid in the pleural space. This can be caused by CHF, liver failure, kidney failure, peritoneal dialysis, pneumonia, lymphoma or breast cancer. Though most pleural effusions are caused by congestive heart failure, pneumonia, pulmonary embolism and malignancy.

 

 

 

 

 

 

 

 

 

 

 Empyema: This is when pus is the substance which fills the pleural space. This is clearly cause by infection, but the pressure of pus in the pleural space makes it difficult for pts to breathe freely, they will likely have fevers and chills, malaise and chest pain.

NCLEX Success: Maslow’s Hierarchy of Needs

Maslow is a great tool to narrowing down or answering NCLEX questions. Those pesky priority questions are the ones in which Maslow can lend a helping hand. Here is how you use the Maslow Strategy:

1. Look at the answer choices. Determine if the answer choices are both physiological and psychosocial, if they are – apply the Maslow strategy.
2. Now, eliminate all psychosocial answer choices.
3.  If the answer choice is physiological, don’t eliminate it. Maslow states that physiological needs must be met first. Although pain certainly has a physiological component, it is considered a psychosocial need on Nclex.

NCLEX Success: Use Free Resources!!!

Being a student of any kind, well apart from some of those really rich Harvard prodigies, you probably know all about being on a budget, or to put it plainly – poor. Due to lack of funds due to all those lab fees, uniforms, strange looking nursing gadgets, your pocket is probably lacking the big bucks required to take one of those fancy NCLEX review courses. Hence, the advice I am about to crown you with – GOOGLE MAGIC BABY!

Yes, I passed the NCLEX-RN. And no, I did not pay for Kaplan or Hurst or any other claim-to-pass program. I knew that those courses were never an option because of the cost, so I gave myself a low budget and decided to use Google to help me. When Googling away, I found a plethora of material which was amazing! None of it cost $, and all of it so easy to access. The use of torrents is a controversial topic, but if you are guilt free about it then crack on! There are apps out there, as well as Saunders interactive test bank (very helpful resource), these can be purchased or with a little digging, found for free.

Kaplan Trainers. I see these are talked about a lot on the forums and people seem to freak out about the scores they get on them. I Googled them and found them posted on scribd.com. I printed a few and worked through them as a brain exercise. My best advise is not to focus on the scores! Scores don’t matter – learning matters. It really isn’t about the questions you get right, its about learning from the rationales on the ones you got wrong. Read ALL rationales, but make notes on the ones you get wrong – see if there is a trend, any topic that you are frequently getting wrong, which shows you where you need to put in some hard graft. Focus in on those weaknesses.

Practice, practice, practice! It’s all about banging out those questions.

So get those fingers Googling, and find out what’s free. There are some great Tumblr sites out there too. Below I will post some of the most helpful and intriguing sites I found!

http://rightatrium.tumblr.com/post/43568301576

http://www.scribd.com/doc/148347851/Nclex-Kaplan-Exam-1

http://www.scribd.com/doc/148349057/NCLEX-Kaplan-Exam-6

http://www.youtube.com/watch?v=HzqOkRnXBFw

http://mp3skull.com/mp3/hurst_review.html

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NCLEX Success

For all those who are embarking on their NCLEX – I feel for you!
I remember the relentless studying, the anxiety, and the need to use the bathroom every 2 minutes while in the waiting room before taking me test! Arghhhh! It was a momentous day in the life of a student. Overnight you become an RN, like a caterpillar to a butterfly…. Ok I’ll cut the crappy metaphors, we all know the torture! But do not despair, I hope to have helpful tip posts just for you NCLEXers.

This first tip is from my personal experience. Often times on the forum I saw people asking “what books did you use?”
So here is my list:

– Kaplan Strategies, Practice and Review
– Fluids & Electrolytes Made Incredibly Easy
– Prioritization, Delegation, and Assignment: Practice Exercisers for the NCLEX Exam – LaCharity

More Tips to Come! Good Luck!