Exam 1

Question 1

1. Describe a patient who is at high risk for imminent respiratory failure.
2. Describe the nursing management of patients who are in respiratory failure.
3. Drugs to treat ARF and why:
4. Describe the Pathophysiology and pathophysiological mechanisms of ARF

Answer 1

1. Those who have comorbidities and an acute infection. Like COPD and the flu or covid. Happens when compensatory mechanisms fail.
2. Mobilizations of secretions (give bronchodilators prior to chest PT). Remember humidification of O2, and O2 therapy (must be tolerated by patient), maintain PaO2 between 55-60 and SaO2 at 90% w/ lowest O2 concentration possible
3. Relief of bronchospasm
   Bronchodilators
   Reduction in airway inflammation
   Corticosteroids
   Reduction in pulmonary congestion
   Diuretics, nitrates if heart failure present
   Treatment of pulmonary infection
   IV antibiotics
   Reduction in severe anxiety, pain, and agitation
   Benzodiazepines
   Narcotics

Question 2

1. Hypercapnic respiratory failure is a problem of ………… and results from inadequate ….. removed from lungs. It can be caused by either the ………… and …………., or by the ……..
2. Name some illness or injury that cause Hypercapnic respiratory failure.
3. Hypoxemic respiratory failure is a problem of …………. . It results in a ……. mismatch.
4. Hypoxemic respiratory failure is caused by:
5. Describe a shunt
6. What are the consequences of hypoxemia?

Answer 2

1. ventilation, CO2, alveoli and airways, or CNS
2. Asthma
   Emphysema
   Cystic fibrosis
   Drug overdose
   Brainstem infarction
   Spinal cord injury
   Injury to chest wall (includes obesity)
   Neuromuscular conditions (Guilain Barre or MS)
3. oxygenation. Ventilation-perfusion (V/Q) mismatch.
4. COPD
   Pneumonia
   Asthma
   Atelectasis
   Pain
   Pulmonary embolus
5. a pathological alternate pathway of circulation that allows deoxygentated blood to bypass the lungs from the right side of the heart to the left side of the heart. Subsequently, oxygenation does not occur. Shunting is an example of extreme V/Q mismatching.
6. Cells shift from aerobic to anaerobic metabolism
   Lactic acid production
   Metabolic acidosis and cell death
   Decreased cardiac output
   Impaired renal function

Question 3

1. Early signs of ARF:
2. Late sign:
3. Name some specific clinical manifestations of ARF:

Answer 3

1. Tachycardia
   Tachypnea
   Mild hypertension
   Severe morning headache
   Mental status change
   restlessness
2. Cyanosis
3. Rapid, shallow breathing pattern
   Tripod position
   Dyspnea
   Pursed lip breathing
   Retractions
   Change in I:E ratio

Question 4

1. what is FIO2?
2. What is mechanical ventilation?
3. What is PEEP?
4. Who is Bipap indicated for?
5. Who is Bipap not indicated for?

Answer 4

1. The fraction of inspired oxygen (FiO2) is the concentration of oxygen in the gas mixture. The gas mixture at room air has a fraction of inspired oxygen of 21%, meaning that the concentration of oxygen at room air is 21%
2. Process by which FIO2 (21% room air or greater)and set amount of air volume is moved into and out of lungs by a mechanical ventilator. Can be either invasive or non-invasive
3. Positive end-expiratory pressure (PEEP) is the alveolar pressure above atmospheric pressure that exists at the end of expiration
4. COPD patients with heart failure and ARF and sleep apnea. Also be used after extubation to prevent reintubation.
5. shock, altered mental status, or increased airway secretions are not candidates for BiPAP due to the risk of aspiration and the inability to remove the mask.
   Must be careful when feeding. TPN might be best option

Question 5

1. Describe A/C and when we use it
2. Describe SIMV and when we use it
3. When is intubation indicated?
4. What are the 3 types of intubation and describe each:
5. What equipment would you want ready when intubating?
6. Do we always sedate with intubation?

Answer 5

1. vent mode in which the patient’s own breath triggers the ventilator to deliver a breath of a specific volume. Ideal volume is 8ml(Kg). Used on patients initially on the vent or for those who need more support
2. vent mode that doesn’t deliver the set volume when a patient triggers their own
   breaths between vent breaths. For patients who are a little stronger or weaning
3. Apnea
   Inability to breathe or protect airway
   High risk of aspiration
   Ineffective clearance of secretions
   Respiratory distress or Muscle fatigue
   Respiratory failure
4. Oral:
   Procedure of choice
   Airway can be secured rapidly
   Larger-diameter tube can be used
   Mouth care is challenge, can bite tube, tooth damage possible

Nasal:
Indicated when head and neck manipulation is risky

Tracheotomy:
Surgical procedure performed to create stoma in neck–when need for artificial airway expected to be long term

5. Ambu bag attached to O2, suction ready, IV access.
6. Depends on patient’s LOC. Not for comatose or cardiac arrest

Question 6

1. What do we do pre-intubation?
2. How do we confirm placement of ET tube?
3. What do we do after ET tube placement?
4. What is a Minimal leak technique and why?

Answer 6

1. Preoxygenate using BVM with 100% O2 for 3 to 5 minutes.
   Limit each intubation attempt to <30 seconds.
   Ventilate patient between successive attempts using BVM with 100% O2
2. auscultate lungs bilaterally, observe chest wall movement, End-tidal CO2 detector (turns yellow), and monitor SpO2
3. Connect tube to mechanical ventilator
   Secure airway
   Suction ET tube and pharynx
   Insert bite block, if needed
   Obtain chest x-ray
   2 to 6 cm above carina Continue to observe chest for symmetric chest wall movement
   Continuously monitor pulse oximetry
   Obtain ABGs in 30”-1 hour
4. auscultate trachea to hear a small air leak from cuff to ensure cuff isn’t pressing too hard on trach walls (usually 20-25cm of pressure)

Question 7

1. Should we routinely suction intubated patients? When is it indicated?
2. How do we manage thick secretions?

Answer 7

1. No. May cause trachitis.
   visible secretions, sudden onset of resp distress
2. Adequate hydration
   Supplemental humidification
   Mobilize and turn patient
   Antibiotics as needed

Question 8

1. Name some diagnostic studies for ARF
2. What is PaO2 and how it compares to SpO2?

Answer 8

1. History and physical assessment
   ABG analysis
   Chest x-ray – to rule out pneumonia, chf, pneumothorax
   CBC, sputum/blood cultures, electrolytes
   ECG
   Urinalysis
   V/Q lung scan – helps determine if clot
   Pulmonary artery catheter (severe cases)

stop on slide 27

2. SpO2 is the amount of hemoglobin in the bloodstream that has oxygen attached 95%-100% normal

PaO2 is the amount of oxygen floating around in the bloodstream without being attached to any hemoglobin 80-100 is normal.