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NUR 212 > 2.1 Respiratory Failure > Flashcards

2.1 Respiratory Failure Flashcards

1
Q

Explain the difference between hypoxia and hypoxemia

A

Hypoxia:
Arterial blood paO2 of <60 (norm 60-100)
Reduced level of tissue oxygenation
Hypoxia is a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis; this can result from inadequate oxygen delivery to the tissues either due to low blood supply or low oxygen content in the blood (hypoxemia)

Hypoxemia:
Inadequate oxygenation at the cellular (tissue) level
Low oxygen content in the blood
Decrease O2 in blood
Life threatening
Leads to cardiac dysrhythmias
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2
Q

Analyze the two types of respiratory failure and some common causes for each
RESPIRATORY INSUFFICIENCY
RESPIRATORY FAILURE

A

Respiratory Insufficiency:
Resp function not adequate to meet needs of body
Compensatory mech working to prevent harm
May be acute or chronic

Respiratory Failure:
Unable to achieve adequate gas exchange even at rest
Compensatory mech no longer working
Inadequate tissue O2
Severe acid/base disturbance
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3
Q

Identify ABG changes in each type of of acute respiratory failure

A

PaO2: <60mm HG on oxygen or room air (60-100 norm)
PaCO2: >50mm HG (35-45 norm)
Resp rate: >30 or <8/min
Vital capacity: <15ml/kg

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4
Q

Compare the goals of interventions in respiratory insufficiency and respiratory failure

A

Goal:
Restore the PaO2 (60-100 norm) and PaCO2 (35-45 norm) to previous levels
Low paO2 and high paCO2 = ventilation problem
Hypoxemia with hypercapnia (excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration)

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5
Q

Pathology of pleural effusions?

A

Excess pleural fluid between the parietal and visceral pleura

Transudative:

  • protein poor excessive fluid
  • heart failure most common
  • may also have renal failure, nephrosis, liver failure and malignancy

Exudative:

  • protein rich excessive fluid
  • seen with inflammatory process such as infection, systemic inflammation, pulmonary infarction, malignancy
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6
Q

Complications of pleural effusions

A

Lung scarring
Pneumothorax (secondary to thoracentesis)
Empyema (Infection that turns into an abscess)
Sepsis

Significant morbidity and to death

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7
Q

Treatment of of pleural effusions

A

Treatment:
Monitor: O2, no intervention if not problems

Thoracentesis: invasive procedure to remove fluid, analyze for appearance, cell count, protein, glucose

Pleurodesis: chemical or surgical. Creation of adhesions between the parietal and visceral pleura. Instilling chemical agent to produce an inflammatory response that creates scar tissue and adhesions between the layers

Nursing care:
Pre:
Consent
Patient understanding of procedure
Fasting or sedation before
Cough suppressant
Patient upright, leaning forward
Post:
Monitor pulse, color, O2, dressing on site
Position patient on unaffected side for 1 hour
Label specimen
Vital signs
Obtain chest x-ray
Diagnosis:
Auscultation
Percussion
Tactile fremitus
Chest x-ray
CT
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8
Q

Analyze methods to oxygenate/ventilate patients utilizing noninvasive techniques (NIV)

A 
High flow O2:
Must be able to vent on own
Normal inhale speed of 20-30 LPM
High flow is up to 60 LPM
Heated to body temp, 100% humidified
Washes dead space to decrease CO2, increased O2

CPAP:
Continuous positive airway pressure
Pt received set amount of pressure
Can be delivered via ETT or mask

BiPAP:
2 levels of positive pressure
Higher on inspiration
Lower on expiration

Full face (nasal interface):
Less risk for aspiration and claustrophobia
Easier secretion clearance, communication, nutrition
Easy to fit and secure

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9
Q

What assessment indicates appropriate oxygenation/ventilation

A 
Monitoring O2 
BP
Respiratory
Lung sounds
Skin color
Capillary refill
ABG within normal ranges
-pH 7.35-7.45
-PaCO2 35-45
-HCO3 22-26
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10
Q

Review assessments/interventions for patients receiving NIV (non-invasive ventilation)

A 
Nasal cannula
Face mask
CPAP
BiPAP
Assist Controlled
Synchronized Intermittent
Positive End Expiratory (PEEP)

Assess:
Correct settings per orders
O2
Proper fitting

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11
Q

Identify indications for mechanical ventilatioin

A

Apnea or progression of resp failure
Hypoxemia that is unresponsive to other methods
Increased work of breathing with progressive fatigue
Most common indicator is actual/potential resp muscle fatigue

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12
Q

What is endotracheal intubation?

A

Inserted by provider

Place between right and left lung

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13
Q

Discuss rationale for insertion of endotracheal intubation

A

Rationale for insertion:
To keep airways open
Protect the lungs
Stopped breathing or having difficulty breathing
Head injury and can’t breath on own
Sedation needed for period of time for recovery

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14
Q

Discuss procedure, equipment, assistance needed, cuff, signs of successful intubation of endotracheal intubation

A

.

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15
Q

Discuss oral endotracheal intubation complications, advantages and disadvantages

A

Endotracheal intubation

Complications:
Obstruction or displacement
Pressure necrosis of lips
Tracheoesophageal fistula

Advantages:
Easier insertion
Larger tube can be used facilitating breathing and suctioning

Disadvantages:
More difficult to secure
Can be obstructed by biting
Communication and mouth care more difficult
Increased risk of lower respiratory infection

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16
Q

Discuss endotracheal intubation extubation

A

Can be performed when patient can maintain effective respirations and ventilation
Gag, cough and swallowing reflex must be intact
After oxygenation and suctioning, cuff is deflated and tube removed
Provide humidified oxygen immediately after
Close observation of respiratory distress
Inspiratory striders w/in 24 hr indicates laryngeal edema
Sore throat, hoars voice common
Slowly reintroduce oral intake
Assess swallowing

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17
Q

Describe positive pressure ventilation

A

More commonly used
Push air into the lungs
Can be used with noninvasive and invasive ventilators

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18
Q

Compare volume-cycled and pressure cycled ventilators

A

Volume cycled: air delivery until a preset volume is delivered

Pressure cycled: cycle off when a present pressure is achieved within the airways

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19
Q

What is the controlled method of ventilating a patient

A

Ventilation controlled breaths is usually triggered by a present time intervals.
Ex: a breath is delivered every 5 seconds of a rate of 12 breaths per minute

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20
Q

What is the assist-control method of ventilating a patient

A

Used when patients at risk for respiratory arrest (head injury, OD)
Assisted breaths are triggered by inspiratory effort
If respiratory rate drops below present number, ventilator-controlled breaths are delivered
All breaths, assisted and controlled are delivered at a specific tidal volume or pressure and inspiratory flow rate

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21
Q

What is the SIMV method of ventilating a patient.

A

SIMV: synchronized Intermittent Mandatory Ventilation

Vent breaths synchronized between patient’s own (unassisted) breaths
Used with weaning

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22
Q

What is the ventilator settings for respiratory rate

A

Number of ventilator-delivered breath per minute

Usually 12-15/min for adults using ACMV (assist-controlled), may be slower with SIMV (synchronized intermittent)

23
Q

What is the ventilator settings for tidal volume

A

Amount of gas delivered with each ventilator breath
Usually 8-10 ml/kg

Tidal volume is the amount of air that moves in or out of the lungs with each respiratory cycle

24
Q

What is the ventilator settings for FiO2 (fraction of inspired oxygen)

A

For all supplemental oxygen delivery devices, the patient is not just breathing the direct oxygen, but rather is breathing a combination of room air plus the oxygen from the supplemental device
Percentage of oxygen delivered with ventilator breaths
Can be set at 21 (room air) and 100%
Meaning that the concentration of oxygen at room air is 21%

25
Q

Explain how these settings (respiratory rate, tidal volume, FiO2) are adjusted to correct abnormal ABG results

A

.

26
Q

Review CPAP

A 
CPAP:
Continuous positive airway pressure
Pt received set amount of pressure
Can be delivered mask
Must be spontaneous breather
Can be used with endotracheal intubation
Used to help maintain open airways and alveoli
Decreases work of breathing
27
Q

Review Bi-PAP

A

BiPAP:
2 levels of positive pressure
Higher on inspiration
Lower on expiration
Bilevel ventilation is mode of high PEEP and low PEEP
Three modes:
S: spontaneous breathing
T: timed mode- pressure supported breaths are delivered at a predetermined rate
S/T: spontaneous timed- ventilator switches to timed mode if spontaneous breathing falls below preset rate

28
Q

Review PEEP

A

PEEP:
Positive End Expiratory Pressure
Requires intubation
Positive pressure is maintained during exhalation and between breaths to keep alveoli open between breaths
Reduces hypoxemia
Allows lower percentages of inspired oxygen
Used to treat ARDS

29
Q

Review PSV

A

PSV: Positive supportive ventilation
Patient breaths spontaneously
Ventilator delivers present level of pressure assistance with each spontaneous breath
Used for weaning
Allows patient to strengthen pulmonary muscles without compromising oxygenation and ventilation during weaning
Deceases work of breathing
Cycle is flow limited; inspiration is terminated when inspiratory airflow rate falls below present rate

30
Q

Review high flow oxygen

A

High Flow
Must be able to vent on own
Normal inhale speed of 20-30 LPM
High flow is up to 60 LPM
Heated to body temp, 100% humidified
Washes dead space to decrease CO2, increased O2
Usually used after patient fails on nasal canula

31
Q

Identify CPAP and PEEP complications

A

Complications

Over distention of alveoli (pneumothorax)
Subcutaneous emphysema (fluid retention in face)
Ventilation-perfusion (V/Q) mismatch (either the ventilation (airflow) or perfusion (blood flow) in the lungs is impaired)
Fall in cardiac output due to decreased venous return r/t increased intrathoracic pressure (low BP)
May affect other organs: liver, kidney, brain

32
Q

List complications of mechanical ventilation

A 
Pulmonary complications
Hemodynamic alterations
Fluid retention
CNS disturbances
Infection
GI disturbances: ulcer/ileus
Psych trauma
Upper airway damage
33
Q

Nursing interventions related to the complications of mechanical ventilation

A 
Prevention of VAP
LOC assessment
Respiratory rate, depth, patterns
HR, BP, lung sounds
Skin color
O2 
ABG's
34
Q

Identify evidence based strategies for preventing ventilator associated pneumonia (VAP)

A

Good hand hygiene
HOB 30 degrees
Suction when needed
Oral care

35
Q

Identify nutritional needs of the patient on a ventilator

A

Enteral or parenteral nutrition is provided because endotracheal tube prevent eating
Nasogastric, gastrostomy, jejunostomy is placed
Mechanical ventilation promotes Na and water retention due to its effects on cardiac output

36
Q

Discuss weaning and how it is accomplished

A 
Maintaining O2 saturation at determined level
Patient request: medications, water, communicate, food
Mouth care
Resume if patient deteriorates
Assess skin
How does the patient tolerate it
Sub with nasal canula and assess
Is O2 improving
37
Q

Discuss ARDS high risk patients

A 
Shock
Infection (sepsis most common)
Trauma
Fat emboli
Aspiration
Inhaled toxins
Drug overdose
Hematological disorders
Metabolic disorders
Radiation
38
Q

Discuss ARDS pathological changes in the lungs

NON CARDIOGENIC PULMONARY EDEMA

A

ARDS is characterized as non-cardiogenic pulmonary edema caused by inflammatory damage to alveolar and capillary walls
Acute onset secondary to an underlying inflammatory process such as: sepsis, pneumonia, gastric aspiration

39
Q

Discuss ARDS pathological changes in the lungs

ATELECTASIS

A

Partial or total lung collapse and airlessness
Most common cause is obstruction of bronchus ventilating
Other causes: pneumothorax, pleural effusion, tumor, loss of pulmonary surfactant and inability to keep alveoli open
Acute or chronic

40
Q

Discuss ARDS intrapulmonary (right to left) shunt

A

Hypoxia can be aggravated by intracardiac right-to-left shunt through a patent foramen ovale
Positive pressure ventilation and PEEP may increase shunting

41
Q

Discuss ARDS signs and symptoms

A

Early: subtle, minor change in orientation, restless, change in VS, anxiety, tachypnea (abnormally rapid breathing), dyspnea (difficult or labored breathing)

Middle: hypocapnia, worsening hypoxemia, dyspnea, hyperventilation

Late: crackles tachycardia, hypertension, confusion, restless

42
Q

Discuss ARDS diagnostic tests (ABCs, x-ray)

A

Diagnosis:
Chest x-ray: white out with pulmonary infiltrates
PaO2 low in spite of O2 treatment (refractory hypoxemia)
PaCO2 low due to hyperventilation
pH high: respiratory alkalosis

43
Q

Discuss ARDS treatment and rationale

A 
Intervention:
Prevent
Correct underlying problem
O2 at lowest % to produce oxygenation
Careful admin of fluids
Prevent/control infection
Mech vent with PEEP
Chest physical therapy and C&DB
Frequent position changes
44
Q

What CVEs (cardiovascular event) indicate a need for sedation and neuromuscular blocking medications

A

.

45
Q

Discuss collaboration of the nurse with the respiratory therapist, physician and RN case manager in care of patients with acute resp failure, ARDS and pneumothorax

A

.

46
Q

Complication of mechanical ventilation

PULMONARY COMPLICATIONS

A

Barotrauma: lung injury due to overdistention of alveolar. Volume and pressure of delivered gas can contribute to Barotrauma leading to overextended alveolar rupture.
Sub-q emphysema: causing air in subcutaneous tissue causing swelling of face, neck, chest
Pneumothorax: unequal chest expansion, decreased breath sound on affected side, chest tube insertion is necessary

Alveolar hypoventilation: caused by system leads, increased secretions

Alveolar hyperventilation: may lead to respiratory alkalosis

Ventilator-associated pneumonia (VAP): loss of humidification and trapping pathogens. Oral secretions and gastric content can enter through the open epiglottis. Cough reflex inhibited/impaired

Upper airway damage: gentle insertion of ETT, firm stabilization of tube, frequent monitoring of cuff pressures (high volume/low pressure), humidification to prevent drying

Oxygen toxicity: monitor O2 saturation, decrease oxygen need by keeping pt afebrile, block care, sedation, monitor hgb, add/increase PEEP

Nursing:
monitor for crepitus
Auscultate lungs sounds bilaterally
Look for equal chest expansion
Be alert to high inspiratory pressure
Keep tidal volume low
Closed in-line technique with suctioning
47
Q

Complication of mechanical ventilation

HEMODYNAMIC ALTERATIONS

A 
Positive pressure ventilation and PEEP increase intrathoracic pressure
Decreased venous return
Restriction of ventricular filling
Restricted blood flow through the lungs
Dysrhythmias
Check weight daily
48
Q

Complication of mechanical ventilation

FLUID RETENTION

A

Na and water imbalance
Fluid retention:
Progressive fluid retention often occurs after 24-48 hours of positive pressure ventilation, especially with PEEP
Associated with decrease urine out put and Na retention

Causes:
Renin-angiotensin system activated with decrease CO2
Intrathoracic pressure changes lead to Na retention
Increased ADH with stress response
Decreased insensible fluid loss via airway

NI:
Strict I/O, daily weight, maintain IV therapy, monitor electrolytes

49
Q

Complication of mechanical ventilation

CNS DISTURBANCES

A

.

50
Q

Complication of mechanical ventilation

INFECTION

A

Causes:
Endotracheal tube bypasses normal filtering, cleansing, humidifying of nasal and oral pharynx
Suctioning and tubing are entrances for bacteria
Ventilator associate pneumonia: primary cause of hospital acquired pneumonia, 10-25% occurrence in vented pts

NI:
use humidified air
Consistent hand washing
Use in-line suctioning; sterile technique
Change tubing per protocol
51
Q

Complication of mechanical ventilation

GI DISTURBANCES

A 
GI bleeding/Ulcers/Infection
Medications to maintain gastric pH of >4
-to decrease nosocomial infection, stress ulcer, contamination of resp tract r/t reflux and aspiration
-histamine receptor blocker: famotidine
-proton pump inhibitor: omeprazole

Constipation/ileus

  • monitor bowel sounds
  • monitor tube feeding residuals
52
Q

Complication of mechanical ventilation

PSYCH TRAUMA

A

Cause:
Patient unable to speak (major cause of fear), eat, move or breath normally
Needs: knowledge, control, hope, trust

NI:
Explain all procedures
Alternate communication methods
Allow freq family interaction
Accept patients feeling, frustration
53
Q

Complication of mechanical ventilation

UPPER AIRWAY DAMAGE

A

.

54
Q

Discuss nasal endotracheal intubation complications, advantages and disadvantages

A 
Complications:
Obstruction or displacement
Pressure necrosis of nares
Obstruction of sinus drainage, sinusitis
Tracheoesophageal fistula

Advantages:
More easily secured and stabilized
More tolerated by patient
Facilitates oral care and communication

Disadvantages:
Smaller tube, infers with suctioning and oral secretions
Increased risk of lower respiratory infection

NUR 212 (22 decks)

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