ABGs, CVADs, O2, ACS

Question 1

Your patient is receiving chemo treatment via PICC line; his 02 sat reads 88%, his heart rate is increasing and he’s grabbing his chest. What could be happening? Interventions?

Answer 1

Embolism.

Administer O2, Clamp Catheter, Notify Physician

If it’s an air embolism, lay your patient on their left side with head down.

Question 2

You’re assessing your patient’s CVAD and they tell you they aren’t feeling well. You assess their vitals; T-37.9, BP 91/64, HR 113, RESP 19. What do you do?

Answer 2

Systemic Infection

Blood cultures/notify physician.
Antibiotics
Antipyretics
Catheter removal if ordered

Question 3

What might you find if the PICC line migrated from it’s original site?

Answer 3

Slow infusion
Edema in chest or neck
Pt. hears a gurglin sound in ear
Dysrhythmias

Question 4

Why would you use a 10 mL syringe or higher when flushing a port? Why would you use heparin?

Answer 4

To avoid excess pressure on the catheter; to avoid clotting or thrombus formation

Question 5

What are the three artery’s used for arterial catheter insertion?

Answer 5

Radial, Femoral, Brachial

Question 6

Explain the Allen’s Test

Answer 6

We are assessing for circulation.

Ask the patient to hold a fist for 30s
When they release the hand should be blanched.
By occluding the ulnar and radial artery, we can determine if there is sufficient circulation.

Question 7

What are the four components to bedside hemodynamic monitoring?

Answer 7

Invasive catheter- high pressure tubing
Transducer- Gives us something readable/measureable
Flush System
Bedside Monitor- Readouts

Question 8

Where would you “level the transducer?”

Answer 8

Phlebostatic Axis- 4th/5th intercostal space to the sternum, to the midaxillary line.

You want to align the transducer with the left atrium so that corrections can be made when the hydrostatic pressure changes in blood vessels, above and below the heart.

Question 9

What parameter is used to measure aterial perfusion?

Answer 9

MAP- Mean Arterial Pressure
**diastole times 2 plus systole is divided by 3

> 60 mm Hg is necessary to perfuse CAs
70-90 mm Hg is ideal to decrease LV workload

Question 10

What are the 5 p’s and what are they used to assess? How often do you assess?

Answer 10

Pain, pulse, pallour, parethesia, paralyisis

Neurovascular status Q4h

Question 11

How much pressure is around the pressure bag of the Pulmonary Arterial Catheter?

Answer 11

300 mm Hg

Question 12

What are the insertion sites for Pulmonary Artery Catheter?

Answer 12

Internal Jugular Vein
Subclavian Vein
Antecuboidal Vein
Femoral Vein

Question 13

What would you assess for after a PAC insertion?

Answer 13

Suture in place
Verify Position
Apply Plastic Sleeve

Question 14

Why are PACs used? Are they beneficial?

Answer 14

They’re used to measure perfusion to adequately treat certain organ dysfunctions.
This isn’t a preferred method as it interferes with certain kinds of ventilators and requires the patient to limit their movement. There are other methods used and they are easier for patients to use.

Question 15

What is PAOP? Why is it important?

Answer 15

Pulmonary Artery Occulsion Pressure, aka Wedge Pressure.

It is the pressure measured by wedging a pulmonary catheter with an inflated balloon into a small pulmonary arterial branch. Because of the large compliance of the pulmonary circulation, it provides an indirect measure of the left atrial pressure.

Question 16

What are some complications from PACs?

Answer 16

Ventricular Dysrhythmias
Endocarditis
Valvular Damage
Cardiac Rupture; Taponade 
PA thrombosis, embolism, hemorrhage 
Lung infarction

Question 17

PEEP?

Answer 17

Positive End-Expiratory Pressure- Abbreviation for positive end-expiratory pressure. A method of ventilation in which airway pressure is maintained above atmospheric pressure at the end of exhalation by means of a mechanical impedance, usually a valve, within the circuit.

Question 18

What is a high pH? What can happen?

Answer 18

> 7.45 Alkalosis
Interferes with tissue oxygenation
Interferes with neuro fxn
Interferes with muscular fxn

Question 19

What is a low pH? What can happen?

Answer 19

> 7.35 Acidosis
Decreased foce of cardiac contractions
Decrease in vascular response to catecholamines
Diminished response to effects of medications

Question 20

Name the two buffer responses. Briefly explain.

Answer 20

Respiratory Buffer System:
Excess CO2 binds with H2O = carbonic acid
Levels of Carbonic Acid determine whether the lungs increase or decrease in depth and rate
Happens within 1-3 minutes

Renal Buffer System:
Kidneys exrete or retaine bicarb
Blood pH decreases- kidneys retain HCO3
As pH rises- kideneys exrete HCO3 through urine
Takes hours to days to activate

Question 21

A 6 ft, thin, 23 year old woman comes into the ER, she’s not sure where she is or her name. She’s SOB, taking shallow breaths. You’re assessing vitals; HR is 145, RESP 8, T 35.4, BP 110/65. What is happening to her? What could her underlying condition be? What would her blood pH be?

Answer 21

Respiratory Acidosis- Increase in CO2
pH >7.35
Possible pneumothorax

Question 22

You’re calmly trying to finish your microbiology exam, when the person beside you is sweating, fidgeting, squinting and spasming. It’s freaking you out but you quickly realize what might be happening. You hand them a paper bag because….

Answer 22

Respiratory Alkalosis (>7.45)
Giving them a paper bag will help them retain CO2 and decrease the amount of Bicarb in the blood.

Question 23

A boy playing soccer comes up to you and is taking big deep breaths, normal right? Except his breath smells fruity, he’s complaining of an upset stomach, he just drank all the gatorade and is looking pretty pale. All of a sudden his LOC diminishes, now what?

Answer 23

Metabolic Acidosis (decreased bicarb, decreased pH)

The boy is ketoacidotic. Get him to the hospital stat.
He needs IV fluids NS to reduce sugar levels, (lytes: Na, K, Cl) and a steady flow of insulin.

Question 24

Your patient is hypertensive and the team has had a hard time reducing their BP, the doctor keeps increasing the amount of diuretic they are to receive. Your patient hates bananas. What is your patient at risk for?

Answer 24

Metabolic Acidosis (Increased bicarb, increased pH)

Diuretics can cause K wasting. Think potassium sparing drugs: Aldactone/Spironolactone

Question 25

Other causes for Respiratory Acidosis

Answer 25

``` Airway obstruction Severe pneumonia Chest trauma Narcotics/sedatives CNS injury neuromuscular blockade ```

Question 26

George Kent is a 54 year old widower with a history of chronic obstructive pulmonary disease and was rushed to the emergency department with increasing shortness of breath, pyrexia, and a productive cough with yellow-green sputum. He has difficulty in communicating because of his inability to complete a sentence. One of his sons, Jacob, says he has been unwell for three days. Upon examination, crackles and wheezes can be heard in the lower lobes; he has a tachycardia and a bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60 mm Hg. ``` How would you interpret this? A Respiratory Acidosis, Uncompensated B Respiratory Acidosis, Partially Compensated C Metabolic Alkalosis, Uncompensated D Metabolic Acidosis, Partially, Compensated ```

Answer 26

B. The patient has respiratory acidosis (raised carbon dioxide) resulting from an acute exacerbation of chronic obstructive pulmonary disease, with partial compensation.

Question 27

Carl, an elementary student, was rushed to the hospital due to vomiting and a decreased level of consciousness. The patient displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. He appears to be dehydrated—his eyes are sunken and mucous membranes are dry—and he has a two week history of polydipsia, polyuria, and weight loss. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm Hg, and HCO3 12 mmol/L; other results are Na+ 126 mmol/L, K+ 5 mmol/L, and Cl- 95 mmol/L. What is your assessment?

Answer 27

Metabolic Acidosis, Partially Compensated. The student was diagnosed having diabetes mellitus. The results show that he has metabolic acidosis (low HCO3 -) with respiratory compensation (low CO2).

Question 28

A cigarette vendor was brought to the emergency department of a hospital after she fell into the ground and hurt her left leg. She is noted to be tachycardic and tachypneic. Painkillers were carried out to lessen her pain. Suddenly, she started complaining that she is still in pain and now experiencing muscle cramps, tingling, and paraesthesia. Measurement of arterial blood gas reveals pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm Hg, and HCO3 25 mmol/L. What does this mean?

Answer 28

Respiratory Alkalosis, Uncompensated The primary disorder is acute respiratory alkalosis (low CO2) due to the pain and anxiety causing her to hyperventilate. There has not been time for metabolic compensation.

Question 29

Ricky’s grandmother is suffering from persistent vomiting for two days now. She appears to be lethargic and weak and has myalgia. She is noted to have dry mucus membranes and her capillary refill takes >4 seconds. She is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base disorder is shown?

Answer 29

The primary disorder is uncompensated metabolic alkalosis (high HCO3 -). As CO2 is the strongest driver of respiration, it generally will not allow hypoventilation as compensation for metabolic alkalosis.

Question 30

Mrs. Johansson, who had undergone surgery in the post-anesthesia care unit (PACU), is difficult to arouse two hours following surgery. Nurse Florence in the PACU has been administering Morphine Sulfate intravenously to the client for complaints of post-surgical pain. The client’s respiratory rate is 7 per minute and demonstrates shallow breathing. The patient does not respond to any stimuli! The nurse assesses the ABCs (remember Airway, Breathing, Circulation!) and obtains ABGs STAT! Measurement of arterial blood gas shows pH 7.10, PaCO2 70 mm Hg and HCO3 24 mEq/L. What does this mean?

Answer 30

Respiratory Acidosis, Uncompensated The results show that Mrs. Johansson has respiratory acidosis because of decreased pH and increased PaCO2 which mean acidic in nature. Meanwhile, it is uncompensated because HCO3 is within the normal range.

Question 31

Baby Angela was rushed to the Emergency Room following her mother’s complaint that the infant has been irritable, difficult to breastfeed and has had diarrhea for the past 3 days. The infant’s respiratory rate is elevated and the fontanels are sunken. The Emergency Room physician orders ABGs after assessing the ABCs. The results from the ABG results show pH 7.39, PaCO2 27 mmHg and HCO3 19 mEq/L. What does this mean?

Answer 31

Metabolic Acidosis, fully compensated Baby Angela has metabolic acidosis due to decreased HCO3 and slightly acidic pH. Her pH value is within the normal range which made the result fully compensated.

Question 32

Mr. Wales, who underwent post-abdominal surgery, has a nasogastric tube. The nurse on duty notes that the nasogastric tube (NGT) is draining a large amount (900 cc in 2 hours) of coffee ground secretions. The client is not oriented to person, place, or time. The nurse contacts the attending physician and STAT ABGs are ordered. The results from the ABGs show pH 7.57, PaCO2 37 mmHg and HCO3 30 mEq/L. What is your assessment?

Answer 32

Metabolic Acidosis, Uncompensated. The postoperative client’s ABG results show that he has metabolic alkalosis because of an increased pH and HCO3. It is uncompensated due to the normal PaCO2 which is within 35 to 45 mmHg.

Question 33

Client Z is admitted to the hospital and is to undergo brain surgery. The client is very anxious and scared of the upcoming surgery. He begins to hyperventilate and becomes very dizzy. The client loses consciousness and the STAT ABGs reveal pH 7.61, PaCO2 22 mmHg and HCO3 25 mEq/L. What is the ABG interpretation based on the findings?

Answer 33

Respiratory Alkalosis, Uncompensated The results show that client Z has respiratory alkalosis since there is an increase in the pH value and a decrease in PaCO2 which are both basic. It is uncompensated due to the normal HCO3 which is within 22-26 mEq/L.

Question 34

Three-year-old Adrian is admitted to the hospital with a diagnosis of asthma and respiratory distress syndrome. The mother of the child reports to the nurse on duty that she has witnessed slight tremors and behavioral changes in her child over the past four days. The attending physician orders routine ABGs following an assessment of the ABCs. The ABG results are pH 7.35, PaCO2 72 mmHg and HCO3 38 mEq/L. What acid-base disorder is shown?

Answer 34

Respiratory Acidosis, Fully Compensated The patient has respiratory acidosis (raised carbon dioxide) resulting from asthma and respiratory distress syndrome, with compensation having normal pH value within 7.35to 7.45, increased PaCO2 which is acidic and increased HCO3 which is basic.