Basic Patient Assessment Flashcards
The view from the door
- color
- RR
- breathing pattern
- use of accessory muscles
- chest movement
- easily audible breath sounds
- WOB
- LOC
- monitor displays
Specific doc orders or protocol
- must have a specific order for the vent or a protocol to follow
- protocols are unique for each setting
What is OVP?
a self test and required paperwork
AARC ventilator check
- recorded and are parts of the medical record
- includes patient info and observations at time of check
- record should include drs. ordered settings
- other information is imperative regarding pt-vent interface and observations
What is charting by exception?
don’t have to chart the normal stuff but do have to chart abnormal stuff
What is included in a vent check?
- modes
- sensitivity
- auto-PEEP (must be measured. may be difficult to trigger if auto-PEEP)
- accessory muscle usage - ex flow
- can increase flow to shorten IT. change mode to allow for more spontaneous breaths
- if auto-PEEP and you increase PEEP, plat/peak will not change (or if PV, VT won’t change)
What should you keep in mind during a vent check?
- IMV and demand flow. watch triggering
- VE, VT and F - measure by hand
- correcting for tubing compliance
- PB 7200/840 corrects for tubing compliance
- set volume = delivered volume
How can you tell if you have auto-PEEP?
by doing an expiratory hold or adding PEEP but nothing changes
What is the tubing compliance for most circuits?
3-4
Why do you subtract PEEP when calculating tubing compliance?
we want to figure out what the driving pressure is
First 30 mins of intubation
- breath sounds = volume and tube placement
- vital signs checked - HR, BP
- alarms set - at least high/low pressure, low VT and apnea
- ABG within 15 minutes
- chest xray
What is the first thing you should do when assessing a patient?
listen to breath sounds
What should you set the FiO2 as when first intubating unless a blood gas says otherwise?
100%
Vitals, exam of chest
- EKGs
- temp increase or decrease
- BP
- CVP
- PAP
- PE exam
What would cause an increase in temperature?
- atelectasis
- infection
- tissue necrosis
- CA Hodgkins
- leukemia hyperthyroidism
What would cause a decrease in temperature?
- met disease
- CNS disorders
- drugs
- alcohol, heroin, CO
For every degree high in temp, your metabolic rate increases by what?
10%
How do you set the trigger sensitivity?
select lowest level to cycle without auto cycling
What are the top reasons a machine will not cycle?
- sensitivity set too low
- auto-PEEP
- high bias flow
- abdominal paradox
What does “alveolar ventilation is not ventilation” mean?
just because air is going in and out doesn’t mean it’s in contact with alveolus
Normal alveolar ventilation
3.5 L
Normal CO2
40
Normal minute ventilation
5 L
Normal dead space
1.5 L
What does it mean if someone’s CO2 was 41 one day and 52 the next?
his dead space went up
What should you keep an eye on when monitoring airway pressure?
- peak inspiratory pressure
- plateau pressure
- Raw
- EEP
- MAP
- pressure limit
- low pressure alarm
- checking for leaks
What should plateau pressure always be below?
30
What is mean airway pressure?
the average pressure of an airway
What is plateau pressure?
no airflow
What is the difference between plateau and mean airway pressures?
plateau pressure is usually higher because it only includes the inspiratory phase while the mean airway pressure includes both inspiratory and expiratory phases
What is the purpose of the five-step protocol?
to minimize over inflation leading to tracheal necrosis
What is the first step of the five-step protocol?
the minimal leak technique (MLT) should be used whenever possible
What is the second step of the five-step protocol?
a reasonable MLT should be established, one in which only 50 to 100 mL of VT is lost during inspiration. for example, in vc-cmv with a 600 mL VT setting and delivery, the VTe is 500-550 mL
What is the third step of the five-step protocol?
a high-volume low-pressure cuff should not require more than 5 mL for inflation. if it does, the tube is probably too small
What is the fourth step of the five-step protocol?
if a minimal leak cannot be maintained with a cuff volume of less than 5 mL then the practitioner should make sure that the intracuff pressure is less than 25 mmHg and that the cuff-to-tracheal diameter ratio checked on chest radiograph is 1:1.5 or less
What is the fifth step of the five-step protocol?
if steps 1 through 4 cannot be achieved, follow-up evaluation of the patient for tracheal stenosis should be performed for at least 1 year after discharge
What should you keep an eye on when monitoring compliance?
- static compliance
- dynamic compliance
- airway resistance
- bedside measuring of press-volume curve
What does it mean if there are no changes in compliance and resistance when measuring the pressure-volume curves?
it’s not the lung
What does it mean when there is a decrease in compliance?
large change in pressure but no change in volume
What does compliance mean?
how much work 1 cmH2O is doing. if it is distending one at 20 and another at 30, the second lung has better compliance
What happens when there is a decrease in dynamic compliance in PCV?
pressure will not change but VT delivery will fall
What happens when there is a decrease in dynamic compliance in CMV?
VT will not change but pressure will fall
When you change static compliance, you will also change ___
dynamic compliance
What does it mean when there is no change in peak or plateau pressures?
no change in airway resistance since peak-plat = Raw
What happens when plateau stays the same but peak changes?
change in airway resistance
If plateau stays the same, there is no change in what?
static compliance
