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🧠 Part 1: Complex Health Alterations – What You Need to Know

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🧠 Part 1: Complex Health Alterations – What You Need to Know

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Definition:
When chronic illnesses worsen or become unstable, they’re considered “complex.” This includes organ failure, ICU admissions, or worsening conditions like COPD, heart failure, or liver disease.

Why It Matters:

Failure to Rescue: Up to 60% of cardiac arrests in hospitals are preventable if early signs are caught.

Nurses are the frontline in spotting subtle changes in condition (especially vital signs and behavior).

Outcomes: ICU stays often lead to ICU-acquired weakness, cognitive dysfunction, PTSD, and reduced quality of life.

Why It’s Hard for New Nurses:

Lack of pattern recognition = too many irrelevant details, missed warning signs.

Inexperience leads to “doing everything” rather than “doing the right thing fast.”

Contributing Factors:

Lack of access to care, structural racism, historical trauma, and medical mistrust all increase the likelihood that chronic illness will become complex.

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Why It’s Relevant:

Complex patients often don’t recover—EOL conversations happen during active treatment.

High ICU mortality + aggressive treatment often lead to undignified death.

End-of-Life Decision-Making:

Most decisions are made by surrogates (family), often in emotional distress.

Be aware of: cultural values, grief stages, health literacy, and mistrust.

Nurses are key to educating and supporting families through this vulnerable process.

The Dying Process:

1. Early Stage: More sleep, less appetite.

2. Middle Stage: Mental status changes, irregular vitals.

3. Late Stage: Surge of energy, “death rattle,” cool/mottled skin.

Comfort Care:

Morphine for pain and air hunger.

Scopolamine for secretions.

Benzos for anxiety.

Mouth care, spiritual and emotional support.

Post-Mortem Care:

Follow state and hospital protocols.

Offer family viewing and support.

Contact organ donation teams if applicable

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🧍‍♂️ 1. Physical Assessment: Checking for Perfusion

Perfusion = how well oxygenated blood is reaching tissues.

Key Indicators:

LOC (Level of Consciousness): Confusion = early sign of low perfusion.

Pulses: Weak = low cardiac output.

Skin: Pale or cool = potential poor circulation.

Capillary Refill: Delayed = inadequate perfusion.

Urine Output: <30 mL/hr = low kidney perfusion (kidneys get 25% of CO!).

❤️ 2. Hemodynamics: Understanding the Pump

Cardiac Output (CO) = Heart Rate x Stroke Volume

Stroke Volume is made of:

Preload: Volume of blood at end of diastole (measured with CVP or PAOP).

Afterload: Resistance the heart pumps against (SVR/PVR).

Contractility: Strength of the heart’s squeeze.

Ejection Fraction: % of blood pumped out with each beat (not the same as SV!).

Monitoring Tools:

Central Venous Line (CVP): Measures right heart preload.

Pulmonary Artery Catheter (PA line):

Measures left heart preload (PAOP)

Cardiac output

Mixed venous oxygen (SvO2)

Has 4 ports: proximal, distal, thermistor, balloon

🌬️ 3. Oxygen Evaluation: Is the Body Getting Enough O2?

O2 Delivery Depends On:

Cardiac Output

Hemoglobin

Oxygen saturation (SaO2)

PaO2 (dissolved O2 in plasma)

Venous O2 Saturation = Oxygen leftover after tissue use

ScvO2 (central) → from upper body (CVP line)

SvO2 (mixed) → from whole body (PA line)

Normal Range: ~60–75%

Low SvO2: Low supply or high tissue demand

High SvO2: Low demand or excessive supply (e.g. early sepsis)

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ECG (electrocardiogram) = electrical activity of the heart

Different from echocardiogram, which shows heart structure and movement

What ECG shows:

How the heart's electrical system fires

Clues about rate, rhythm, and possible issues like ischemia, blocks, or arrhythmias

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⏱ 3. ECG Intervals

PR interval: 0.12–0.20 sec

QRS duration: <0.10 sec

QT interval: ≤0.44 sec

QTc > 0.50 sec = DANGEROUS (risk of torsades or lethal arrhythmia)

📏 4. How to Analyze a Rhythm Strip

Use these steps every time:

1. Rate – Count QRS in 6 sec strip × 10

2. Regularity – Are R-R and P-P intervals equal?

3. Are there P waves?

4. Is there 1 P for each QRS, and 1 QRS for each P?

5. Any extra findings? (e.g., U waves, odd shapes)

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🔌 5. Pacemakers – What Nurses Should Know

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🔌 5. Pacemakers – What Nurses Should Know

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Purpose: Help manage bradycardia, heart blocks, or electrical dysfunction.

Types:

Transcutaneous (pads, emergency)

Transvenous (ICU, catheter-based)

Epicardial (post-op)

Implanted/Internal (long-term)

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1. Failure to fire: No pacer spikes when needed

2. Failure to capture: Pacer fires but no response from heart

3. Under-sensing: Pacer doesn’t detect intrinsic heart rhythm, fires inappropriately

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🧠 Common Cardiac Rhythms

🔹 Sinus Rhythms

Sinus Bradycardia (<60 bpm): Can be normal (athletes) or symptomatic (treat w/ atropine if unstable)

Sinus Tachycardia (>100 bpm): Often compensatory (fever, anemia, hypovolemia), treat underlying cause

🔹 Junctional Rhythms

Originate near the AV node

P waves: absent, inverted, or buried

Rate varies; accelerated junctional rhythm = 60–100 bpm

🔹 Atrial Arrhythmias

Atrial Fibrillation (AFib): Irregular, no distinct P waves; risk for clots → anticoagulate

Atrial Flutter: Regular "sawtooth" pattern (F-waves), similar management to AFib

SVT (Supraventricular Tachycardia): Rapid, narrow QRS, regular; treat w/ vagal maneuvers, adenosine, cardioversion if unstable

💥 Lethal Ventricular Rhythms

⚠️ Ventricular Tachycardia (VTach)

Wide QRS, fast rhythm

With a pulse: Treat w/ amiodarone, cardioversion

No pulse: Immediate CPR + defibrillation

⚠️ Torsades de Pointes

Twisting ribbon-like rhythm

Give magnesium ASAP

⚠️ Ventricular Fibrillation (VFib)

Chaotic, no pulse

Immediate CPR + defibrillation

⚠️ Pulseless Electrical Activity (PEA)

Normal rhythm but no pulse

CPR + epinephrine; identify & treat 5 H’s and T’s:

H’s: Hypoxia, Hypovolemia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia, Hypothermia

T’s: Tamponade, Tension pneumothorax, Toxins, Thrombosis (MI, PE)

⚠️ Asystole

Flatline = dead

Confirm leads → CPR + epi if full code

⚡ Cardioversion vs Defibrillation

Cardioversion: Synchronized (R wave), used in unstable AFib/flutter/SVT

Defibrillation: Unsynchronized, used in VFib or pulseless VTach

💊 Key Meds

Epinephrine: 1 mg Q4 min during CPR

Amiodarone: Antiarrhythmic for VTach, VFib

Atropine: For symptomatic bradycardia

Adenosine: For SVT (6 mg → 12 mg); crash cart required!