Advanced Respiratory Flashcards
Pulmonary embolus is most commonly caused by ________.
a DVT that breaks off and lodges in the pulmonary artery
In pulmonary embolus ventilation is _______ than perfusion so _________ results.
greater; hypoxemia
low arterial blood oxygen level
hypoxemia
The pulmonary artery is the only artery that carries ____________ blood
de-oxygenated
_______ embolism is almost always deadly
Saddle
What can cause a PE?
air, tumor cells, amniotic fluid, foreign objects, injected particles, infected clots, exudate, fat emboli, or oil (diagnostic procedure)
What are the risk factors for PE?
pregnancy, immobility, obesity, central line, pacemaker, trauma, medications (oral contraceptives, hormone replacement)
Syndrome consisting of Venous stasis, Hypercoagulability, and Vessel wall inflammation
Trousseau’s Syndrome
What are the signs of DVT?
Redness, Warmth, Pain, Edema
What is the most common predisposing factor for the development of DVT?
immobility
What are the respiratory manisfestations of PE?
dyspnea, pleuritic chest pain, tachypnea, crackles, dry cough, hemoptysis, and decreased O2 saturation
What are the cardiac manifestations of PE?
tachycardia, distended neck veins, syncope, cyanosis, hypotension, abnormal heart sounds (S3 S4), abnormal electrocardiogram findings, shock, and dizziness
pain on inspiration
pleuritic chest pain
What are late and uncommon signs of PE?
low-grade fever, petechiae, symptoms of flu, N/V
What are the classic symptoms of PE?
feeling of impending doom, dyspnea, sharp chest pain, apprehension, restlessness, cough, hemoptysis
What are the gold standard diagnostic tests for PE?
VQ scan, spiral CT w/ contrast, and angiogram
What are other tests for PE?
ABGs, EKG, CXR, D-dimer blood test, Echo
In the initial stage of PE, the PaO2 is _____ and the PaCO2 is _____, which means respiratory _________.
low; low; alkalosis
In the middle stage of PE, the PaO2 is _____ and the PaCO2 is _____, which means respiratory _________.
low; risking; acidosis
In the late stage of PE, Tissue hypoxia develops and _______ builds up , which means metabolic _________.
lactic acid; acidosis
stage of PE in which the patient hyperventilates causing hypoxia and pain
initial stage
stage of PE in which blood begins to shunt leading to PaO2 being low, PaCO2 rising causing respiratory acidosis
middle stage
stage of PE in which tissue hypoxia occurs with build up of lactic acid causing metabolic acidosis (pH
late stage
What kind of diet helps prevent PE?
low fat, high fiber
What is the most common symptom of PE?
pleuritic chest pain
What are the priority problems for a patient with PE?
hypoxemia, hypotension, potential for bleeding, and anxiety
Hypoxemia in a PE is related to a mismatch of __________ and ___________.
lung perfusion and ventilation (V/Q mismatch)
Hypotension in a PE is related to _________________.
inadequate circulation to the left ventricle (decreased cardiac output)
What does the nurse do first for a patient with PE?
apply oxygen
What is the priority nursing intervention for a patient with a PE?
promotion of gas exchange and tissue perfusion
What position should the nurse put the patient with a PE?
High Fowler’s
How often should the nurse re-assess respiratory status in the patient with a PE?
q 30 minutes
What drug is given initially to PE patient?
Heparin
How long is heparin given to PE patient?
for the first 5-10 days
What day is coumadin started for a PE patient?
Day 3
What drug is given for a massive PE?
tPA or activase
What additional drug will a patient need while on tPA to raise the BP?
vasopressin to raise the BP
PT/INR Therapeutic Level with Coumadin
2.5-3.0
PTT Therapeutic Level with heparin
40-75 seconds
surgical removal of the clot that caused a PE
emoblectomy
umbrella that is put in the inferior vena cava that keeps clot from moving up from the legs
inferior vena cava interruption
What kind of IV fluid will be given to a PE patient?
crystalloids
PE patient will be on continuous __________ and _________ monitoring.
EKG and respiratory
impairment of the lung’s ability to maintain adequate oxygen and carbon dioxide homeostasis occuring over minutes to hours that results in a rapid change in respirations resulting in hypoxemia, hypercapnia or both
Acute Respiratory Failure
Acute Respiratory Failure is based on ABG value of PaO2 50 with a pH
60; 90%; 50
Use ______ for Acute Respiratory Failure patients.
bi-pap
Whatever the underlying problem, the patient in acute respiratory failure is always _________.
hypoxemic
type of respiratory failure in which the patient is unable to move air adequately out of the alveoli, allowing buildup of CO2
ventilatory failure
What causes extrapulmonary ventilatory respiratory failure?
neuromuscular disorders, spinal cord injury, CNS dysfunction (stroke), chemical depression (overdose), kyphoscoliosis, massive obesity, sleep apnea, and external obstruction or constriction
What causes intrapulmonary ventilatory respiratory failure?
airway disease (COPD, asthma), V/Q mismatch (PE, pneumothorax, ARDS, amyloidosis, pulmonary edema, and interstitial fibrosis
In ventilatory respiratory failure, perfusion is __________ but ventilation is ____________.
normal; inadequate
In oxygenation respiratory failure, perfusion is __________ but ventilation is ____________.
decreased; normal
type of respiratory failure in which thoracic pressure changes are normal, and air moves in and out without difficulty (Ventilation) but does not oxygenate the pulmonary blood sufficiently (perfusion)
Oxygenation Failure
decreased oxygen supply in the tissues
hypoxia
A combination of ventilatory and oxygenation failure involving both hypoventilation and profound hypoxemia which often occurs in patients who have abnormal lungs such as those with chronic bronchitis or emphysema or during asthma attacks
Combined Ventilatory and Oxygenation Failure
Combined Ventilatory and Oxygenation Failure usually involves _________ failure along with ____________ failure.
cardiac; respiratory
What are the clinical manifestations of Acute Respiratory Failure?
hypoxemia, hypercapnia, and respiratory acidosis
What are the symptoms of Acute Respiratory Failure?
Dyspnea, Orthopnea (sleep on 2-3 pillows, tripod position), Alterations in respirations and breath sounds, Tachypenia, Irritability/restlessness. Confusion, Headache, Increasing somnolence, coma, Cardiac dysrhythmias ( PVC), and Tachycardia
In Acute Respiratory Failure, increased work of breathing causes ___________.
exhaustion
If a ventilated patient is picking at the bed sheets, what does the nurse assess first?
adequate oxygenation
Besides mechanical ventilation, what is the only other therapy that blows off CO2?
bi-pap
How is Acute Respiratory Failure diagnosed?
ABGs, CXR, Pulmonary Spirometry, sputum culture, CT or CBC
Elevating the HOB, lowers the ___________.
diaphragm
Hypoxia that persists even when oxygen is administered at 100% in which the lungs cannot expand or contract and dense pulmonary infiltrates are seen on CXR
Acute Respiratory Distress Syndrome (ARDS)
ARDS acronym
Assault to pulmonary system, Respiratory distress, Decreased lung compliance (lung tissue becomes fibrotic – irreversible), Severe respiratory failure
Direct Lung Injury (Primary Insults) Risk Factors for ARDS
Aspiration of gastric contents, Severe thoracic trauma
including pulmonary contusions, Diffuse pulmonary infections (pneumonia), bacterial, viral, or fungal infections, Toxic gas inhalation including smoke, nitrous oxide, ammonia, and chlorine, Near-drowning, and TRALI-Transfusion related acute lung injury (Hemorrhagic)
Indirect Lung Injury (Secondary Insults) Risk Factors for ARDS
severe sepsis, anaphylaxis, acute pancreatitis, severe non-thoracic trauma, multiple long bone fractures (fat emboli), hypovolemic shock, drug overdose, Multiple transfusions (TRALI), reperfusion therapy (following transplant and bypass surgeries)
Transfusion Related Acute Lung Injury causing indirect lung injury due to inflammatory response to multiple transfusions
TRALI
phase of ARDS lasting up to a week that is associated with damage to the alveolar capillary cells and alveolar cells as well as proteinaceous fluid flooding the alveoli which compromises normal gas exchange and triggers diffuse alveolar collapse
Acute exudative phase
The diffuse alveolar collapse in ARDS inactivates __________.
surfactant
What is the result of surfactant inactivating?
worsening hypoxemia that doesn’t respond to oxygen administration
phase of ARDS marked by resolution of the acute phase and initial repair of the lung. A patient who reaches this phase may recover fully, or move on to the third phase.
Proliferative phase
phase of ARDS in which fibrotic tissue replaces the normal lung structure, generally causing progressive vascular occlusion, pulmonary hypertension, and eventually decreased lung compliance
Fibrotic phase
What is the hallmark sign of ARDS?
accessory muscle use including intercostal and suprasternal retractions
The symptoms of ARDS
dyspnea, tachypnea, pallor, diaphoresis, wheezes and crackles, decreased breath sounds in all fields, restlessness, apprehension, decreased level of consciousness, motor dysfunction, and tachycardia
How is ARDS diagnosed?
ABGs, CBC, CXR, CT, Echo, PFTs
Initially in ARDS, the PaO2 is ______, the PaCO2 is ________ or _______, and the pH is ___________.
low; normal or low; elevated
Initially in ARDS, the patient is in respiratory ___________.
alkalosis
As ARDS worsens, the pH __________ and lactic acid ________.
decreases; increases
As ARDS worsens, the patient is in repiratory _________.
acidosis
APRV
Airway Pressure-Release Ventilation
Normal I/E ratio
1:2 or 1:4
In APRV, the I/E ratio is ______.
2:1 (breathing in more than they breathe out)
In APRV, the tidal volume is ____ mL/kg.
6
ARDS patients will have a PEEP of _______.
10-15
For ARDS patient when supine, HOB needs to be _____ degrees.
30-45
It is very important to ______ an ARDS patient.
TURN
What are the signs of a tension pneumothorax?
absent breath sounds, high ventilation pressure, and hypotension
What drugs are given to ARDS patients?
sedatives, surfactant, corticosteroids, antibiotics, fluids, and diuretics
Short acting prostaglandin drug that can improve blood flow and oxygenation in the lungs and reduce inflammation
Prostacyclin
drug for ARDS patients that improve soxygenation and reduces pulmonary vascular resistance
inhaled nitric oxide
What are the common complications associated with ARDS?
Pulmonary hypertension, Myocardial dysfunction, Dysrhythmias (V.fib or V. tach), MODS, Barotrauma, and volutrauma, Ventilator Associated Pneumonia, Stress Ulcers (Cushing’s and Curling’s), Skin Breakdown, Nutrition problems
What is the most common indirect predisposing disorder of ARDS?
sepsis
Pulmonary edema associated with ARDS is caused by ________.
alveolar injury
The blunt, nonpenetrating chest traumas are _______, ________, and _________.
fractured ribs, flail chest, and tension pneumothorax
The penetrating chest traumas are _______, ________, and _________.
Open pneumothorax, Hemothorax, and Tracheobronchial injury
What causes blunt, nonpenetrating chest trauma?
direct impact, compression, or rapid deceleration/ acceleration
The most common chest injury seen in the US in which a blow to the chest causes Interstitial hemorrhage associated with intra-alveolar hemorrhage, resulting in decreased pulmonary compliance and respiratory failure develops over time
Pulmonary Contusions
Pulmonary Contusions are diagnosed by _______ or ______.
CT or CXR
What is the hallmark sign of a Pulmonary Contusion?
increased bronchial secretions
Pulmonary Contusions symptoms include?
Hemoptysis, Hypoxemia, Increased bronchial secretions, Restlessness, Dyspnea, Decreased breath sounds, Crackles and wheezes
For a patient Pulmonary Contusion, the HOB should be ______ degrees.
45-60 Fowler’s
Pulmonary Contusion patient will _________ over time since injury.
worsen
Pulmonary Contusion patients need pain control so they can ___________.
take a deep breath
What is the hallmark sign of severe trauma?
Fracture of ribs 1 and 2
What is the most common type of blunt chest trauma?
fractured ribs
With fractured ribs, patient will be in respiratory _________.
acidosis
With fractured ribs, hypoxia and respiratory acidosis results from _____________.
shallow respirations due to pain
What position should the patient be placed with fractured ribs?
Fowler’s
If the pain is severe with fractured ribs, the patient will receive an ___________.
intercostal nerve block
A thoracic injury resulting in paradoxical motion of chest wall segments that is often the result of direct impact, high-speed injury
flail chest
paradoxical motion of the chest
Chest will puff up when exhaling and will sink in when inhaling
What is the hallmark sign of fail chest?
paradoxical motion of the chest
What are the symptoms of flail chest?
Severe chest pain, Dyspnea, Cyanosis, Tachycardia, Hypotension, Tachypnea, shallow respirations, and Diminished breath sounds
In flail chest, hypoxia and respiratory acidosis results from ___________.
shallow respirations due to pain
What position should the flail chest patient be placed in?
Fowler’s
All respiratory patients are in Fowler’s position except for _______ patients who are prone.
ARDS
injury that occurs when an opening through the chest wall allows the entrance of positive atmospheric air pressure into the pleural space
open pneumothorax
Spontaneous pneumothorax occurs with ____________.
rupture of a pulmonary bleb
injury that occurs from a blunt chest injury or from mechanical ventilation (volutrauma or barotrauma)
closed or tension pneumothorax
ABG of pneumothorax patient will show respiratory ________ and _______.
alkalosis; hypoxia
pneumothorax symptoms
Absent breath sounds on affected side, Cyanosis, Decrease chest expansion unilaterally, Dyspnea, Hypotension, Sharp chest pain, Subcutaneous emphysema as evidence by crepitus on palpation, Sucking sound with open chest wound, Tachycardia, Tachypnea
Tension pneumothorax can cause ____________ which is a medical emergency.
tracheal deviation
With tracheal deviation, immediate treatment is _________.
insertion of a chest tube
Right lung tension pneumothorax will cause contents of the chest to move _______.
left
Left lung tension pneumothorax will cause contents of the chest to move _______.
right
hemothorax that causes less than 1500 mL blood loss
simple
hemothorax that causes more than 1500 mL blood loss
massive
Percussion during pneumothorax is ___________.
hyper resonant
Percussion during hemothorax is __________.
dull
Hemothorax can be caused by what?
CVL insertion, Lung contusions or lacerations, Chest trauma, Cancer (leaking blood)
Which assessment finding alerts the nurse to a possible pulmonary contusion?
increased bronchial secretions
What are the treatments for hemothorax?
chest tube, thoracentesis, or thoracotomy
