Cardiopulm Unit 7 Pulmonary Diagnostics, O2 Delivery systems and interventions Flashcards

Question

What may cause Metabolic Acidosis?

Answer 1

- Diabetes Ketoacidosis - Severe diarrhea - Renal failure - Shock

Answer 2

- Headache - Hyperkalemia - Nausea, vomiting, diarrhea - Changes in LOC (confusion, increased drowsiness) - Kussmaul respirations (compensatory hyperventilations)

Answer 3

- pH BELOW normal ranges of 7.34-7.45 - PaCO2 is normal in acute stages or decreased in chronic/compensated stages (Respiratory alkalosis) - **HCO3 level less than 22 mEg/L** (Primary problem)

Answer 4

- Treat the cause of the Acid accumulation or HCO3 loss - Give bicarbonate - Give insuline - Dialysis

Answer 5

- Severe vomiting - Excessive GI suctioning - Diuretics - Excessive NaHCO3

Answer 6

- Dysrhythmias (Tachycardia) - Compensatory Hypoventilation - Confusion (decreased LOC, dizzy, irriatble) - Tremors, Muscle cramps, tingling of fingers and toes - Hypokalemia

Answer 7

- pH ABOVE normal ranges of 7.34-7.45 - PaCO2 is normal in acute stages or increased in chronic/compensated stages (Respiratory acidosis) - **HCO3 level above than 26 mEg/L** (Primary problem)

Answer 8

- Replace fluid loss - Give K+ or Cl- as needed - Stop suctioning - GIve acid substance (HCL, NH4Cl)

Answer 9

- If pH is abnormal (ie., outside of 7.35-7.45), then verify which CO2 or HCO3 is consistent with the pH acidity or alkalinity (THIS IS THE PRIMARY PROBLEM) - Then assess the other system (respiratory or metabolic) to verify if it is actively compensating for the primary problem or not -If the other system is in its WNL range, then there is no apparent compensation happening -If the other system is outside its WNL range and at a level that appears to compensate for the problem, then the we can say that the system is partially compensated. - If pH is WNL but either CO2 and/or HCO3 are abnormal, then that suggests that the system is compensated. At this point, assess which side of 7.4 is it on. --Under 7.4 is on the acidic side --Over 7.4 is on the basic side ## Footnote Match the CO2 or HCO3 whichever side pH is on and that will tell you, as above, what the primary problem is.

Answer 10

Aim is to improve quality of life and functional activity for those who experience oxygen desaturation during activity or exercise

Answer 11

When the partial pressure of oxygen in arterial blood (PaO2) falls below ~55-60 mmHG - A subsequent increase in minute ventilation occurs as well as a decrease in partial pressure of Carbon Dioxide (PaCO2). This results in a compensatory rise in HR/CO to increase O2 delivery to tissues

Answer 12

- Impaired judgement - Progressive loss of cognitive and motor functions as the hypoxemia progresses - Decreased exercise tolerance - Loss of consciousness develops with severe hypoxemia - Other S/S include headache, breathlessness, or severe dyspnea, palpitations, angina, restlessness and tremors

Answer 13

When there is alveolar hypoxia resulting in redistribution of blood in the lungs

Answer 14

Pulmonary Hypertension, **Increasing the work on the Right Side of the heart**, leading to Right Heart dysfunction and subsequently failure (cor pulmonale)

Answer 15

- **Improve breathlessness**, in individuals with decreased PaO2 and SpO2 at rest or exercise - **Improve Exercise Tolerance**, in those with mild, moderate or even severe hypoxemia during exercise - **Decrease Minute Ventilation**, in individuals who were breathless and hypoxemic both during rest and activity - **Improve ventilatory muscle function**, in individuals who are hypoxemic - **Alleviate hypoxic pulmonary vasoconstriction**, in individuals who are hypoxemic ## Footnote **If none of these happen, the patient did not have an O2 problem**

Answer 16

- PaO2 < 55 mmHG or SaO2/SpO2 < 88% on room air or - PaO2 56-59 or SaO2/SpO2 89-90% with one or more: -Pulmonary Hypertension -Cor Pulmonary or Edema due to heart failure -Hematocrit >56%

Answer 17

Monitor and continue plan of care

Answer 18

Decrease/Stop activity, Position change, deep breathing, pursed-lips breathing, coughing

Answer 19

Monitor and continue plan of care

Answer 20

1. Adjust the flow as needed 2. Change O2 delivery method

Answer 21

If the Consult MD for revised order was denied, decrease activity level - If the SpO2 IS ≥ 90%, monitor and continue plan of care - If the SpO2 IS NOT ≥ 90%, stop activity and discuss with MD

Answer 22

- In the event that the O2 prescription is not written as “Keep SpO2> ----%" the **clinician should contact the referring practitioner to attempt to obtain a standing order** - **Baseline vital signs including oxygen saturation must be measured before any activity** - Assess for patient stability and determine any changes that may be occurring in clinical status since the previous therapy session - Monitor closely with activity during mobilization and interventions - At the end of any physical therapy intervention, the supplemental oxygen must be returned to the delivery device and flow rate used prior to the intervention as oxygen is specifically prescribed at rest based upon resting arterial blood gases ## Footnote In the event a patient is experiencing signs or symptoms of hypoxemia and cannot maintain adequate oxygen saturation at the amount of supplemental oxygen prescribed at rest, the prescribing health care provider should be contacted immediately

Answer 23

- Motion and weight bearing can interfere with signal transmitted to sensor - Placing probe on 3rd or 4th finger has been shown to be more accurate than index (Finger is more accurate than earlobe; however forehead probe may be the most accurate) - Dirt, nailpolish, blood can interfere with sensor light path - If the emitter and detector sensors are not in proper alignment, fasley low readings of oxygen saturation can occur - weak signal strength can occur in patients with poor perfusion and with dysrhythmias (like a fib) therefore inaccurate reading may occur

Answer 24

This is Fraction of Inspired air, this represents the percentage of oxygen in atmospheric air - FiO2 = (Flow Rate x 0.04) + 0.20

Answer 25

- Delivers flows from 0.25 to 6 L/min - Generally recommended low flow NCs **NOT** used for flows > 6 L/min due to patient discomfort

Answer 26

O2 Tank Flow - Approx FiO2 1 L/min - 0.24 2 L/min - 0.28 3 L/min - 0.32 4 L/min - 0.36 5 L/min - 0.40 6 L/min - 0.44 ## Footnote FiO2 goes up by 0.04; Maxes at 0.44

Answer 27

- Best for patients needing > 6 L/min - More comfortable, can eat/drink/talk easier than with mask

Answer 28

Highest % O2 is up to 0.75 FiO2 at 15 L/min

Answer 29

Covers mouth and nose, useful for patients unable to breath through nose

Answer 30

O2 Tank Flow - Approx FiO2 6 - 10 L/min - 0.35-0.50 (can vary)

Answer 31

- O2 system providing more specific O2 concentration than other devices - Easy system for mobilizing patients - Can provide O2 via face mask or tracheostomy tube

Answer 32

O2 Tank Flow - Turn dial and provide O2 as stated on dial for need FiO2 Approx FiO2 - 0.24 - 0.50

Answer 33

- Mask with O2 reservoir (bag) providing higher FiO2 - Advantage: Requires a lower flow of FiO2 from the tank for the FiO2 needed

Answer 34

O2 Tak Flow - Approx FiO2 6 L/min - 0.60 7 L/min - 0.70 8-10 L/min - 0.80+

Answer 35

- Can be used to manually ventilate patients during ambulation when a portable ventilator is not available, give supplemental O2 for suctioning etc. - For mobility, atracheostomy swivel connector with expandable tubing should be used to prevent extubation

Answer 36

Up to 1.00 FiO2

Answer 37

*The premis: The Position of Optial Physiologic function is Upright and moving* 1. Mobilizaton and Exercise 2. Body Positioning 3. Breathing control maneuvers 4. Coughing maneuvers 5. Relaxation and energy Interventions 6. ROM exercises (Cardiopulmonary indications) 7. Postural drainage positioning 8. Manual Techniques 9. Suctioning

Answer 38

To elicit an exercise stimulus that addresses one of the three effects on the various steps in the oxygen transport pathway or some combination ## Footnote Mobilizations and exercise, reduces stress on the pulmonary system during mobility and exercise

Answer 39

- Dyspnea on exertion – Use Dyspnea Scale with target of 4-6/10 rating during activity - Use pulse oximetry and monitor for signs of hypoxemia / respiratory distress - Consider physician orders for titrating supplemental oxygen to maintain SpO2 above > X% - Consider bronchodilator therapies before exercise training - Resistance training emphasis on function and musculature that support anti-gravity function and ADLs - Balance training due to common observation of falls in some populations with chronic pulmonary diseases (COPD, for example)

Answer 40

To elicit a gravitational stimulus that stimulates being upright and moving as much as possible: Active, active-assist, passive

Answer 41

- V/Q Matching - When **standing**, gravity pulls the mediastinal and abdominal structures down, creating more space in the thoracic cavity, which allows further expansion of the lungs and greater lung volumes. This, along with the decrease in compression on the lung bases, allows for greater alveolar recruitment. - **Sitting** often leads to the somewhat reduced lung volumes compared with standing due to abdominal organs being higher, interfering with diaphragmatic motion. Second, the abdominal muscles are in a less optimal point in the length-tension curve, since the combination of hip flexion and higher position of the abdominal contents exert upward pressure. Third, the back of the chair may limit thoracic expansion. - **Supine** position negatively affects diaphragmatic strength and an increase in blood volume within the thoracic cavity can lead to congestion of the pulmonary vasculature, which reduces lung compliance. This makes the lungs stiffer and harder to expand during inspiration

Answer 42

To augment alveolar ventilation, to facilitate mucociliary transport, and to stimulate coughing

Answer 43

- Pursed-Lip Breathing - Paced Breathing (Controlled exhalation during effortful movement) - Diaphragmatic Breathing - Lateral Costal Breathing - Inspiratory Hold Technique

Answer 44

Dyspnea at rest and/or with exertion, wheezing

Answer 45

Low Endurance, Dyspnea on exertion, tachypnea, fatigue, anxiety

Answer 46

Dyspnea, impaired lower lung expansion, hypoxemia, tachypnea, atelectasis, anxiety, excess pulmonary secretions. - Note: individuals with severe hyperinflation and flattened diaphragms will most likely not benefit from this technique because the muscle length tension relationship is abnormal and will not result in an appropriate movement of the diaphragm

Answer 47

Asymmetric Lateral chest wall expansion, localized lung consolidation or secretions

Answer 48

Hypoventilation, Atelectasis, Ineffective cough

Answer 49

- Initially we can start the patient in supine, although this requires the patient to breath against increased visceral organ resistance. Consider the sidelying position as better alternative for some - When the pt has mastered the breathing pattern in supine or sidelying progress to sitting, then standing then walking and finally stairs

Answer 50

- This may improve the flow of air into poorly ventilated regions of the lungs - The patient is instructed to hold thier breath (without using valsalva maneuver) at the height of inspiration for 2 or 3 seconds followed by a relaxed exhalation

Answer 51

To facilitate mucociliary clearance with the least effort on dynamic airway compression and the fewest adverse cardiovascular effects

Answer 52

To minimize the work of breathing and of the heart and to minimize undue oxygen demand

Answer 53

To stimulate alveolar ventilation and altre its distrubution

Answer 54

To facilitate airway clearance using gravitational effects

Answer 55

To facilitate airway clearance in conjunction with specific body positioning

Answer 56

To facilitate the removal of airway secretions collected centrally

Answer 57

- Cough Facilitation - Active Cycle Breathing - Postural Drainage with/without Percussion and Vibration

Answer 58

Impaired mucociliary transport, excessive pulmonary secretions, ineffective or absent cough

Answer 59

Optimize airway patency, increase ventilation and perfusion matching (V/Q), promote alveolar expansion and ventilation and increased gas exchange

Answer 60

- Pain Management - Inhaled Bronchodilaters ~30 minutes prior - Meal Timing: Before or at least 30 min after end of meal or tube feeding

Answer 61

- Simplest form is **deep breathing and applying techniques to improve coughing function** - These techniques should be used with **ALL** patients in inpatient care (e.g., acute care, skilled nursing facilites) to improve airway clearance or prevent pulmonary dysfunction. -However, **IF** an individual has retained secretions or has an ineffective cough, **THEN** alternatative airway clearance techniques should be used to mobilize the secretions and expel them from the airways to prevent futher pulmonary dysfunction ## Footnote Mobility (e.g. ambulation) is an additional airway clearance technique that should be used early

Answer 62

Indicated with any suspicion of real or potential retained secretions - Productive vs. Non-productive - If Productive: -Timing (e.g., Paroxysmal vs Persistent) -Appearance (e.g., color, presence of blood, frothy)

Answer 63

- Adequate Inspiration (greater than tidal volume) - Glottic Closure -Otherwise, its called a **huff** - Building up of intrathoracic pressure and intraabdominal pressure -Facilitated by abdominal and intercostal muscle contraction - Glottic opening and expulsion

Answer 64

- Consider cueing for upward gaze, scapular retraction, UE elevation as needed - "Take a deep breath in...in...in...in...in... and now hold it"

Answer 65

- Consider cueing for downward gaze, scapular protraction, UE depression and squeezing chest as needed

Answer 66

ACVT is an airway clearance technique that emphasizes the patient's control over a sequential combination of breathing strategies to accomplish the goals of mobilizing and evacuating bronchial secretions

Answer 67

**Breathing Control (BC)**: - Relaxed, diaphragmatic breathing, normal tidal volume, 15-30 seconds **Thoracic Expansion Exercises (TEE)**: - Deep, slow breathing in the vital capacity range *This cycle alternates until the patient feels prepared to expectorate the accumulated secretions, then*: **Forced Expiratory Techniques (FET)**: - 1 or 2 **Huffs** - *Huffs may be better for airways prine to collapsing*

Answer 68

This is performed **at rest** and can be combined with breathing strategies (e.g., inspiratory hold) and/or performed in a postural drainage position with or without an application of percussion/vibration

Answer 69

- Segmental bronchi positioned perpendicular to the floor - If used exclusively, each affected segment position should be maintained 5-10 minutes -Prioritize most affected segment Note some general trends: - The more caudal the lung segment to be drained, the lower the head of bed is to be positioned - The lung segment to be drained is often positioned superiorly so it can drain toward to proximal airways at the midline

Answer 70

- Pulmonary Edema - Hemoptysis - Massive Obesity - Large Pleural Effusion - Massive Atelectasis

Answer 71

- Increased ICP - Unstable hemodynamics - Recent esophageal anastomosis - Recent spinal fusion or injury - Recent head trauma - Diaphragmatic hernia - Recent eye surgery

Answer 72

- Lumbrical hand positioning with firm hands and loose wrists - 2-5 minutes per segment followed by vibration (**exhalation only**) and coughing/huffing

Answer 73

- Marked increase in RR or BP - Decrease in SpO2 - Dyspnea or increased work of breathing - Mental status change - Cyanosis

Answer 74

- Meal Timing: before or way after eating - Nebulizer treatment may assist - Can coordinate with nursing /RT in the event that is needed for suctioning is anticipated ## Footnote RT = Respiratory therapist

Answer 75

- Uncontrolled bronchospasm - Osteoporosis - Rib fx - Metastatic CA to ribs - Tumor obstruction to airway - Anxiety - Coagulopathy - Convulsive or seizure disorder - Recent PM placement - Chest tube

Answer 76

- Hemoptysis - Untreated Tension Pneumothorax - Platelet count < 50,000 - Unstable hemodynamic status - Open wounds, burns in the thoracic area - PE - Subcutaneous Emphysema - Recent Skin grafts or flaps on thorax

Answer 77

This is intended to improve on impaired strength and/or endurance of the respiratory muscles S/S of those impairments include: - Decreased (chest expansion, breath sounds, tidal volumes) - Dyspnea - Uncoordinated breathing The Concepts of IMT are the same as muscles, we incorporate the concepts of **overload, specificity and reversibility** ## Footnote WIth IMTs, a major discrepancy may exist in the diagnosis for which this treatment is applied

Answer 78

A comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, **exercise training, education, and behavior change**, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long- term adherence of health enhancing behaviors

Answer 79

- Patient assessment and goal-setting - Exercise and functional training - Self-mangement education - Nutritional Intervention - Psychosocial management *A PT may participate in any or all of these pulmonary rehabilitation program components, but makes the greatest contributions in the areas of evaluation, outcome measurement, exercise and functional training, airway clearance and education*