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Concepts 3 > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Care
- Hospice (3)
- Palliative (3)

A

Hospice
- death expected within 6 months
- comfort care at end of life
- done once curative treatment stopped

Palliative Care
- offered at any point of illness starting at diagnosis through bereavement
- Includes bereavement care b-c palliative care encompasses family care
- concurrent with curative treatment

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2
Q

Goals of Palliative Care (4)

A
  • Improve quality of life (better relief of symptoms esp. Pain, Dyspnea, N/V, Fever and Infection, Edema, Anxiety, Delirium, Comfort) – does not mean pt does not want any treatments
  • Allow client to experience a “good death”– doing what patients wishes and desires are to promote peaceful and meaningful death
  • Avoiding a Bad death: not following patient’s wishes; isolation, pain; death w/o dignity
  • holistic care for all needs of patient and family
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3
Q

Common problems in Critical Care (Anxiety)

  • S/s (4)
  • Risk
  • Treatment
A

s/s: agitation/restlessness, verbal expression, BP and HR increase, dyspnea

Risk: Anxiety and agitation can complicate recovery of ICU patient

Treatment: benzos (antianxiety meds)

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4
Q

Common Problems in Critical Care (Pain)

  • Assessment Variations (3)
  • Risk
  • Treatment
A

Assessment
- may need alternate scales (Behavioral pain scale
Critical care pain observation scale)
- give elderly vertical scales and time to respond
- may need alt communication methods or utilize family

Risk
- triggers anxiety and anxiety can worsen pain

Treatment
- opioids or nonopioids (Ketorolac)

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5
Q

Common Problems in Critical Care
(Coping)

-Ineffective vs effective

A
  • ineffective: clinging to staff, on call light, anxiety, fear, denial
  • effective: express feelings
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6
Q

Opioids: What to know about the following?

  • Morphine
  • Fentanyl (2)
  • Hydromorphone
  • Meperidine
  • Codeine
  • Methadone (2)
A

Morphine (standard)

Fentanyl (synthetic opioid
- Preferred when hemodynamic instability or morphine allergy,
- Risks: bradycardia and chest wall rigidity w/ rapid admin

Hydromorphone
- Preferred with ESKD b-c inactive metabolite

Meperidine (Weakest)
- Concern: normeperidine (neurotoxic esp. if kidney failure or liver dysfunction in older adults)

Codeine (Often combined with acetaminophen)
- For mild to moderate pain

Methadone (synthetic opioid; morphine-like properties but less sedation)
- Difficult to titrate in ICU due to long half life
- Big risk: prolonged QT interval - > torsades de pointes

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7
Q

Opioids

Therapeutic effect (3)
Minor side effects (5)
High dose side effects (4)
Antidote (and tip)

A

Therapeutic effects: reduce myocardial workload; reduce anxiety, reduce severe pain

Side effects
- hypotension
- euphoria
- constipation
- NV
- urinary retention

High dose side effects
- respiratory depression (< 8-10 breaths/min; decreased Spo2 levels, elevated end tidal CO2)
- myoclonus
- hyperalgesia (increased pain response)
- allodynia (pain from stimulus that does not cause pain)

Antidote: Naloxone (risk for increased pain so give w/ nonopioid analgesic)

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8
Q

Non Opioid Analgesics (what to know?)

  • Acetaminophen
  • NSAIDS (Ketorolac)
  • Ketamine (not recommended for routine in ICU)
  • Lidocaine
  • Anticonvulsants (Ex. Carbamazepine, gabapentin, pregabalin)– 2
  • Antidepressants (Ex. TCA (amitriptyline, imipramine, desipramine) and SSRIs (paroxetine, sertraline) and SNRIs (venlafaxine))
A

Acetaminophen
- Side effects: rare if dose < 4g or < 2g if liver dysfunction, malnutrition, or excess alc use

NSAIDS (Ketorolac- most appropriate for ICU)
- Caution w/ kidney dysfunction b-c low clearance; platelet clumping/bleeding risk

Ketamine (not recommended for routine in ICU)
- Side effects r/t delirium and release of catecholamines causing dissociative state and psychosis

Lidocaine
- Anesthetic for procedural pain or neuropathic pain

Anticonvulsants (Ex. Carbamazepine, gabapentin, pregabalin)
- First line for neuropathic pain
- Used post-cardiac surgery

Antidepressants (Ex. TCA (amitriptyline, imipramine, desipramine) and SSRIs (paroxetine, sertraline) and SNRIs (venlafaxine))
- For headache, fibromyalgia, low back pain, neuropathy, central pain, cancer pain

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9
Q

Care to create Healing Environment (3)

A
  • limit lights and noise
  • hearing = last sense to go (always let know what you are doing); may need alt methods
  • have open door policy b-c family support helps w/ healing
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10
Q

Sleep Pattern Disturbance in ICU

Definition
Causes (4)
Manifestations (3)

A

Definition: insufficient duration of stages of sleep (basic human need)

Causes
- stress
- interruptions due to procedures
- physiological changes w/ ages (sleep disorders != normal part of aging)
- pain

Manifestations
- Exhaustion and altered mood (discomfort or agitation)
- delayed recovery
- ICU psychosis

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11
Q

Sleep Pattern Disturbance in ICU

Medical Management (2)
Nursing Care (4)

A

Medical Management
- hypnotic benzodiazepine (Temazepam(Restoril))- avoid if elderly
- manage any pain

Nursing Interventions
- Limit interruptions and cluster care to provide uninterrupted rest periods (use DND signs)
- Minimize awakenings and noise (limit staff conversations; do not slam doors)
- Drapes and blinds open at day; dim lights at night
- Provide earplugs and eye masks

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12
Q

Benzodiazepine (ex. diazepam (Valium), midazolam (Versed), and lorazepam (Ativan))

Side effects (3)
Risks (3)

A

Side effects
- Delirium
- dose related respiratory depression
- dose related hypotension

Risk
- Temazepam (Restoril) and other benzos have opposite effects in geriatric i.e. agitation
- Not recommended for sedation of mechanically ventilated
- abrupt withdrawal can induce seizures

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13
Q

Benzodiazepine (ex. diazepam (Valium), midazolam (Versed), and lorazepam (Ativan))

Purpose (2)
Use (2)
Antidote

A

Purpose
- Sedative-hypnotics with amnesic propertie
- no analgesic properties

Uses
- Versed/midazolam IV push for short term agitation
- Valium and Ativan for long term agitation (Ex. DT)

Antidote: Flumazenil (Romazicon)

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14
Q

Sedation in ICU (ex. benzos, propofol, dexmedetamidine)

Assessment (2)
Goal
Risks of excess sedation (4)
Risk of under sedation (2)

A

Assessment
- Do pain and anxiety assessment first
- Identify causes of agitation (anxiety, sleep deprivation)

Goal: lightest sedation for comfort in ICU

Risks of excess sedation
- depressed LOC (need to monitor monitor VS, cardiac and respiratory function closely)
- prolonged stay r/t ventilator
- psychological dependence r/t long term use
- Immobility complications (pressure ulcers, DVT, constipation, nosocomial pneumonia))

Risks for under sedation
- agitation and anxiety impairs patient’s safety i.e. prevent pulling at tubes and lines and unplanned extubation
- dysrhythmias

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15
Q

Sedation in ICU

Levels (4)

A

Light/ minimal: relief of anxiety; person alert and responds to verbal commands

Moderate/procedural: depression of consciousness for insertion of lines and tubes

Deep: depression of consciousness where pt cannot maintain open airway

General anesthesia: depression of consciousness w/ multiple meds by CRNA or anesthesiologist

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16
Q

Propofol (Diprivan)

Purpose (3)
Use (2)
Route
Composition
Contraindication (2)

A

Purpose
- Powerful sedative and respiratory depressant
- no analgesic properties
- unreliable amnesic

Use
- sedation in mechanically ventilated in ICU
- Ideal for quick awakening or spontaneous breathing trials

Route: IV continuous b-c rapid onset (30 seconds) and Short half-life (2–4-minute half life)

Composition: High lipid content (looks like milk and quickly crosses cell membranes including blood-brain barrier)

Contraindication: allergy to soy or eggs

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17
Q

Propofol (Diprivan)

Side effects (4)
Care (2)

A

Side effects:
- green urine (benign)
- Propofol-related infusion syndrome (metabolic acidosis, rhabdomyolysis, myoglobinuria, AKI, dysrhythmias) – due to use of > 5 mg/kg/hr for > 48 hrs r/t fat-emulsion
- Hyperlipidemia and hypertriglyceridemia
- Acute pancreatitis

Care
- change tubing q12h b-c high lipid = risk for bacteria growth
- look at Triglyceride level (may change to Versed/midazolam if high Triglyceride)

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18
Q

Prevention of Sedation Dependence: Daily Sedation Interruption

Process (4)

A
  • Turn off medication (propofol wears off fast; Versed/midazolam wears off slow) once a day
  • Assess LOC and neurologic function of patient after awareness attained
  • if agitated, change in VS, dysrhythmias, restart to prevent complications – MONITORING = VERY important to prevent harm during withdrawal
  • After interruption, determine next plan of care (may reduce dose to avoid dependence; may discontinue sedation if able to be off > 4 hrs
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19
Q

Prevention of Sedation Dependence: Daily Sedation Interruption

Contraindications (5)

A
  • hemodynamic instability
  • increased ICP
  • ongoing agitation or seizures
  • alcohol withdrawal
  • use of neuromuscular blocking agent
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20
Q

Causes of delirium (7)

A
  • Metabolic (f/e imbalance, hypoglycemia)
  • Intracranial (epidural or subdural hematoma, hemorrhage, meningitis, tumor, abscess, encephalitis)
  • Endocrine (thyroid, adrenal, or hyperparathyroidism)
  • Organ failure (liver, uremic, septic shock; old age)
  • Respiratory (hypoxemia, hypercarbia; mechanical ventilation)
  • Drug related (heavy metal poisoning, alcohol withdrawal)
  • Psychosocial (stress, sleep deprivation, pain)
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21
Q

Acute Confusion/Delirium

Definition
Manifestation (2)
Medical management and risk

A

Definition: Sudden onset of global Impairment in patient cognitive processes leads to inappropriate behavior, disorientation, impaired short-term memory, alt sensory perception and thought processes

Manifestation
- Hypoactive (somnolent, withdrawn, unaware, quiet, extreme fatigue)-> Loss of consciousness
- Hyperactive (picking at lines/tubes, agitation, restless, psychosis)

Medical Management
- Drug of choice: Haloperidol (Haldol)– risk for prolonged QT (> 0.44 sec) -> ventricular dysrhythmia (torsades de pointes)

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22
Q

Acute Confusion/Delirium

Nursing Care (7)

A
  • Keep patient as comfortable as possible
  • Reorient pt. to reality as much as needed (w/ fave objects or calm voice)
  • Avoid Restraints
  • Provide object for fidgeting (doll, stuffed animal)
  • Cluster care
  • Reduce environmental noise and lights
  • Daily delirium monitoring (high risk for old old or SUD)
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23
Q

Advance Directives

Components (2)
Notes (4)

A

Components
- Living will (Identifies what pt would want if near death i.e. CPR, ventilation, artificial nutrition and hydration)
- Health care power of attorney (Follows patient’s values, wishes, values; Reduces family conflict;

Notes
- HC POA does not make decisions until pt lacks capacity
- Should be updated regularly
- Pt should be asked about written advance directive upon hospital admission per Patient Self-Determination Act
- If no AD, give info on value of AD and opportunity to complete state-required forms in ED

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24
Q

Symptom Management for Palliative Care
- Anxiety/Agitation (4)
- Delirium (2)
- Comfort (3)

A

Anxiety/Agitation (r/t pain, urinary retention, constipation)
- Antianxiety meds (Ativan-lorazepam, versed- midazolam)- avoid benzos in older adults w/ agitation
- Avoid restraining
- Dim room; minimal noise
- Soothing music and aromatherapy

Delirium
- Haloperidol for psychotic symptoms
- avoid morphine if delirius

Comfort (s/s of impaired comfort: restless, moaning, grimace)
- Evaluate each procedure and medication to see if promotes comfort (Avoid unnecessary treatments or those that prolong dying process)
- Schedule meds around the clock vs PRN
- Foley to avoid exertion w/ voiding (risk for infection not big deal when near death)

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25
Q

Symptom Management for Palliative Care
- Pain (4)
- NV (2)
- Fever and infection (2)
- Edema (2)

A

Pain (most feared)
- nonopioids then transfer to opioids (morphine; Fentanyl if delirius) as needed
- May need to use rectal, transdermal, IV or SubQ route as ability to swallow is lost ( Avoid IM b-c variable distribution and painful)
- Avoid unnecessary treatments
- Nonpharmacological: massage (not on tissue damage or if bleeding disorder), music, therapeutic touch, imagery, aromatherapy (lavender, chamomile, sweet marjoram, dwarf pine, rosemary, ginger)

N/V (Cause: intestinal obstruction, increased ICP)
- Antiemetics (prochlorperazine, ondansetron, dexamethasone, metoclopramide)
- Avoid decompression b-c uncomfortable

Fever and Infection
- Antipyretics
- Continue antibiotics

Edema or fluid overload
- Diuretics (know kidney function)
- Avoid dialysis

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26
Q

Symptom Management in Palliative Care (Dyspnea)

Nonpharmacological (4)
Pharmacological (4)

A

Nonpharmacological
- Raise HOB
- Electric fan (increases ambient air flow)
- Wet cloth to face
- Encourage imagery and deep breathing

Pharmacological
- Oxygen (give regardless of O2 sat b-c dyspnea is subjective)
- Give morphine (b-c alters air hunger perception, reduces anxiety and muscle tension, and reduces pulmonary congestion via pulmonary vasodilation)
- Give versed (midazolam) if unable to take opioids
- If bronchospasm give bronchodilators or corticosteroids

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27
Q

End of life issues
- CPR (3)
- DNR or DNI (3)
- withdrawal or withholding of treatment (2)

A

CPR
- Family presence is important to facilitate closure during CPR or invasive procedures
- Done for everyone unless DNR
- Can be painful, unsuccessful or result in worsened condition

DNR or DNI
- DNR does not mean stop caring for patient or stop all life sustaining treatment
- DNI (do not intubate)-may still want CPR
- Must be signed by HCP

Withdrawal or withholding of treatment
- Prepare family for what to expect
- implement comfort orders prior to treatment withdrawal

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28
Q

End of life care: best practice for involving family in decision making (5)

A
  • Early and ongoing discussions (daily rounds, family meetings)
  • Informed consent necessary (explain things in language family can understand)
  • Patient’s wishes should guide discussions about withdrawal of care
  • Ask about family’s emotional state and acknowledge expressions of emotion
  • take into account cultural and spiritual practices and respect them
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29
Q

Stages of Withdrawal of Treatments in End of life care (5)

A
  • Removal of routine interventions (labs, imaging, cardiac monitoring) –Monitors may be kept to adjust medication amounts in symptom management or for families to verify cessation of electrical activity
  • Removal of respiratory support devices (need DNR prior to withdrawal and withdraw paralytics first)
  • turn off pacemaker and ICD (may interfere w/ death pronouncement, or cause discomfort and distress due to shocks firing)
  • withdrawal of artificial nutrition and hydration (family may be concerned but excess nutrition and fluids can prolong suffering)
  • Provide symptom management in accordance w/ symptoms
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30
Q

Signs of Approaching Death

Vision
Speech
Circulation (3)
Respirations (2)

A

Vision
- No eye movement, staring, dilated and fixed pupils

Speech
- Difficult to understand, unable to speak as LOC decreases

Circulation
- Cold, mottled and cyanotic extremities r/t decreased peripheral circulation, poor tissue perfusion and heat loss
- HR increases, irregular, gradual decrease until stops
- BP drops

Respiration
- Shallow, apnea, labored -> Cheyne-stokes (apnea then rapid)
- Death rattle (loud, wet respirations from Mucus collection)

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31
Q

Signs of Approaching Death

Muscle tone (2)
GI and GU (2)
LOC (2)

A

Muscle Tone
- Limp body/weakness
- jaw drop

GI and GU
- Anorexia
- Urinary/Anal incontinence

LOC
- lethargic, unresponsive, coma) drop
- Increased sleep

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32
Q

Care for Changes r/t Approaching Death

Speech
Circulation (2)
Respirations (3)

A

Speech
- talk to pt as you normally would

Circulation
- apply blanket
- no electric blankets or heat packs

Respiration
- Positioning ( Elevate HOB, turn head to side)
- give anticholinergics or scopolamine to decrease secretions
- oral suctioning not helpful

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33
Q

Postmortem Care (7)

A
  • Treat body to privacy, respect and gentleness
  • Close the patient’s eyes and Insert dentures if the patient wore them.
  • Straighten the patient and lower the bed to a flat position w/ pillow behind head
  • Wash the patient, comb hair, clean room
  • Place waterproof pads under the patient’s hips to absorb any excrement.
  • Allow the family or significant others to see the patient in private and to perform any religious or cultural customs they wish (e.g., prayer, eye closing, washing).
  • Ensure that the nurse or physician has completed and signed the death certificate prior to morgue transfer
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34
Q

Old categories (4)

A
  • Young old (65-74)
  • Middle old (75-84)
  • Old old (85-99) - Fastest growing; described as frail (geriatric syndrome w/ unintentional weight loss; weakness and exhaustion and slowed physical activity in older adults)
  • Elite old (100+)
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35
Q

Older Adult: Physiological Changes (6)

A
  • Decreased adaptability
  • Impaired organ function
  • Decreased reaction time
  • Impaired memory of recent events
  • visual changes: presbyopia (farsighted r/t age), glaucoma (may need meds or surgery), cataracts (may need surgery), macular degeneration, diabetic retinopathy
  • impaired hearing (presbycusis)
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36
Q

Older Adults: ADL Changes (4)

A
  • Greater risk for functional decline (Need assistance w/ 2+ ADLs prior to admission)
  • Loss of autonomy and increased dependence r/t mental and physical changes of aging or illness
  • inability to drive (increased MVA)– can decrease independence
  • mobility concerns (increased sleep; need for cane or walker; increased falls)
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37
Q

Older Adults: Psychosocial changes (5)

A
  • Impaired stress response
  • ageism (discrimination r/t age)
  • impaired socialization r/t loss of significant others
  • increased elderly individuals in prison or homeless
  • increased drug usage
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38
Q

Older Adults: Diet/ nutritional changes (7)

A
  • Dietary fat < 30% of calories (<10% from saturated fat)
  • Increase calcium to b/w 1000-1500 mg daily
  • Daily vitamin D supplement or 10-15 min sun exposure
  • Increased vitamin C and A
  • Reduce total calories if sedentary lifestyle
  • Drink 2 L of fluid a day (may need Colon cocktail: prune juice, applesauce, psyllium to prevent constipation)
  • 35-50 g of fiber each day
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39
Q

Health Protecting behavior for Older Adults (6)

A
  • Yearly physical and eye exam
  • vaccinations (Influenza, shingles, Pneumococcal, Tetanus (booster every 10 yr))
  • Drink ETOH in moderation (<1/day) or not at all
  • Avoid smoking
  • Create a hazard-free environment (No scatter rugs, waxed floors; Grab bars in bathroom; Install smoke detectors/sprinklers in home)
  • Exert autonomy and control as much as possible
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40
Q

Driving Safety for Older Adults (6)

A
  • Wear seat belts
  • Wear glasses and hearing aids if prescribed b-c can interfere w/ ability to see or hear hazards
  • take driver refresher classes
  • Encourage to avoid night driving and bad weather driving (icy or wet roads)
  • Use alternative methods of transportation if unable to drive safetly
  • consult HCP before driving if any physical or mental deficits (i.e presbycusis or peripheral neuropathy)
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41
Q

Older Adults: Inadequate or Decreased Nutrition

Contributing factors (8)

A
  • Diminished sense of taste, smell (Results in loss of desire for food)
  • Inappropriate/unbalanced foods (fast foods)
  • Excess meds and OTC drugs (can decrease appetite, affect food tolerance and absorption, and lead to constipation)
  • Tooth decay, tooth loss, poorly fitting dentures (r/t inadequate dental care and calcium loss)- may lead to avoidance of nutritious foods
  • reduced income
  • Chronic disease/ Fatigue
  • Decreased ability to perform ADLs
  • Loneliness, depression and boredom (may lead to lack of eating and weight loss)
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42
Q

Older Adults and Hospital Patients: Inadequate or Decreased Nutrition

Care for inadequate nutrition (7)

A
  • Perform nutritional screenings on the 1st day of pt. admission (include Nutritional hx, wt., ht., and BMI)
  • Do an oral exam to understand why patient may only eat soft/low fiber foods
  • Collaborate w/ RDN about the patient’s nutritional status
  • Collaborate w/ SLP about problems swallowing or chewing
  • Encourage to use herbs instead of salt and sugar b-c may overuse them
  • Get social work involved for food bank programs
  • manage symptoms that may impair nutrition (pain w/ analgesic; NV w/ antiemetic)
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43
Q

Older adults: Inadequate or Decreased Hydration

Contributing factors (3)
Care (4)

A

Risk factors
- less body water
- decreased thirst sensation
- Limiting fluid intake in evening due to decreased mobility, diuretics, and urinary incontinence

Care
- Incontinence increases w/ dehydration b-c concentrated urine irritates bladder
- Drink 2 L of water a day plus other fluids
- Avoid excess caffeine and alcohol
- Know s/s of dehydration (dark urine, weight loss, poor skin turgor, dry mucus membranes)

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44
Q

Constipation

Causes (2)
Impacts (5)

A

Causes: inadequate nutrition or hydration; drugs

Impacts: pain, depression, anxiety, decreased social activities, small or large bowel obstruction

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45
Q

Older adults: Decreased Mobility

Care (5)

A
  • Assess older adults in any setting about hx of exercise and any health concerns
  • Teach importance of physical activity 3-5x a week for at least 30 minutes
  • Encourage sedentary adults to slowly start their exercise programs
  • If patient is homebound, focus is performing ADLs
  • walking and swimming are good choices (walking is best because it is weight bearing and can help prevent osteoporosis and build bones)
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46
Q

Older adults: Benefits of Regular Exercise (6)

A
  • Increased mobility, muscle strength, and balance (so decreased falls)
  • Better sleep
  • Reduced or maintained body weight
  • Fewer depressive symptoms (improved well-being and self-esteem)
  • Improved longevity (Reduced risk of Diabetes, Dementia, CAD)
  • Decreased risk for constipation
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47
Q

Older adults: Stress and Coping

Impact of stress
Sources of stress (5)

A

Impact: faster aging

Sources
- Rapid environmental changes w/ immediate reaction
- Changes in lifestyle r/t retirement or physical incapacity
- Acute or chronic illness
- Loss of significant other
- Financial hardship (Loss of work or decreased amount of work; past due bills; houseless esp. vets)

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48
Q

Older Adults: Relocation stress syndrome

s/s (2)
Management (6)

A

s/s
- Physiologic: sleep disturbance; GI distress
- Emotional: withdrawal, anxiety, anger, depression

Management of relocation stress
- Encourage patient decision making
- Assess and adhere to usual lifestyle, daily activities, food preferences
- Reorient frequently
- Ask fam to visit often and bring special items
- Establish trusting relationship early
- Avoid unnecessary relocations

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49
Q

Accidents: Falls in Older Adults

Risk factors for falls (8)
Fall risk Assessment (3)

A

Risk factors
- Hx of falling (most important predictor of falls)
- Multiple illnesses
- Generalized weakness or decreased mobility
- Changes in sensory perception (r/t age or drugs)
- impaired body orientation r/t decreased sense of touch -> decreased reaction time
- Urinary incontinence or nocturia
- Communication impairment (disorientation, confusion)
- Alcohol/substance abuse

Assessment (fall risk assessment)
- Observation of Gait (wobbly?); Footwear (closed toe? Sturdy?); assistive devices (cane? Walker? Glasses?)—Do they use them?
- Past medical hx (Diabetic neuropathy?, arthritis?, peripheral neuropathy?)
- Drug assessment (Drug side effects?) i.e. Antihypertensives and orthostatic hypotension; Opioids and CNS depressant effects of drowsiness and acute confusion

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50
Q

Accidents: falls

Impact of falls (2)
Prevention (8)

A

Impact of falls: fractures and fallphobia (esp if osteoporosis)

Prevention
- Ensure hydration b-c dehydration can cause incontinence due to bladder irritation
- RN communicate hazards on their health literacy level
- Safeguards (handrails, grab bars, slip proof rugs, adequate lighting)
- No scatter rugs, slippery floors, clutter
- Pt avoids going out on bad weather days (slippery or icy)
- ask for help when needed esp. toileting
- use assistive devices i.e hearing aids, glasses, walker, cane,
- keep bed low and locked

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51
Q

Older Adults: Drug Use

Concerns (3)

A
  • Intolerance to standard drug dosages (use “Start low and go slow” policy)
  • Opioid Use (increased due to use for acute and chronic conditions w/ persistent pain)
  • increased risk of adverse drug events due to polymedicine/polypharmacy
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52
Q

Older adults: Age-related changes of Pharmacotherapy

  • Metabolism (3)
  • Excretion (3)
A

Metabolism (monitor liver function tests)
- Decreased liver size
- Decreased liver blood flow
- Decreased serum liver enzyme activity

Excretion (get renal function test esp. Crt clearance)
- Increased BUN and Crt
- Reduced renal blood flow
- Reduced GFR and creatine clearance (leads to slower excretion; decreases by 6.5 mL/min per decade of life)

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53
Q

Older adults: Age-related changes of Pharmacotherapy

  • Absorption (3)
  • Distribution (4)
A

Absorption
- Decreased GI motility
- Decreased GI blood flow
- Increased gastric pH

Distribution
- Smaller amount of total body water
- Decreased albumin level
- Increased ratio of adipose tissue to lean body mass (leads to increased storage of lipid-soluble drugs in tissue vs plasma)
- Decreased cardiac output

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54
Q

Older adults: Factors for improper self-administration of drugs (7)

A
  • Poor communication with HCP r/t poor explanations due to educational limits, language barriers or difficulty hearing and vision
  • Make errors (Forget to take; Duplication (think 2 is better than 1); use wrong drugs
  • Take OTC drugs that interact with prescribed drugs (Ex. Clopidogrel, aspirin, warfarin for anticoagulation, ibuprofen for arthritis and garlic for hypertension = bleeding risk)
  • Discontinue drug therapy due to cost, fear of dependency or side effects)
  • use leftover drugs from previous illness
  • Borrow from others
  • Use more than one pharmacy
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55
Q

Older adults: Medication assessment and health teaching (6)

A
  • Obtain complete drug list (OTC, prescribed, herbs, supplements)
  • Highlight all drugs that are part of Beers criteria ( drugs where harm > benefit for elderly (ex. Benadryl, ketorolac)
  • Assess for duplicate drugs (Ex. Warfarin from two pharmacies)
  • Give verbal and written information at appropriate knowledge level
  • Encourage to take drugs exactly as prescribed (do not share or borrow drugs)
  • Be Aware of common adverse drug events (ADEs) (Hypotension from HTN drugs; Edema; Syncope; Dehydration from diuretics)
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56
Q

Beer’s Criteria Drugs

A
  • meperidine
  • oxycodone
  • cyclobenzaprine
  • digoxin (Should not exceed 0.125 mg daily except for a-fib)
  • Ticlopidine
  • fluoxetine
  • amitriptyline
  • diazepam
  • promethazine
  • diphenhydramine
  • ketorolac
  • short-acting nifedipine
  • ferrous sulfate (Should not exceed 325 mg daily)
  • chlorpropamide
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57
Q

Older adults: Tips for better drug self-administration (5)

A
  • Encourage use of pill boxes or associating pills w/ daily events
  • Use large print on drug label for poor vision
  • Write drug regimen on bottle
  • Colored labels
  • Easy to open bottle caps for limited hand mobility and strength
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58
Q

Older Adults: Depression

What is it?
Primary vs Secondary

A

-Mood disorder having cognitive, affective, physical manifestations (sleep disturbance, fatigue, increased pain; worsening of current problems; suicide risk)

Primary: lack of neurotransmitters (serotonin and norepinephrine)

Secondary or situational: r/t sudden change in life such as illness or loss (conditions: stroke, arthritis, cardiac disease)

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59
Q

Older Adults: Depression

Assessment
Treatment (3)

A

Assessment
- Geriatric Depression Scale (15 yes or no questions; > 10 = possible depression)

Treatment
- SSRI (takes 2-3 weeks to start working)
- TCAs have anticholinergic properties and should not be used (side effects: acute confusion, severe constipation, urinary retention or incontinence)
- Nonpharmacological: psychotherapy; reminiscence, music therapies

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60
Q

Older Adults: Dementia

What is it?
Prevention (4)

A
  • Slow, progressive and chronic global impairment of intellectual function

Prevention of cognitive changes in older adults
- Cognitive training (learning new skill)
- Physical and mental activity
- Social engagement
- Proper nutrition

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61
Q

Older Adults: Alcohol Use

Impacts (5)

A
  • Increase risk for falls, other accidents
  • affects mood and cognitive ability ( may lead to Isolation, depression, delirium)
  • Bladder and bowel incontinence
  • Complications of chronic diseases (DM, HTN, GERD)
  • Poor nutrition r/t drinking > eating
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62
Q

Older Adults: Alcohol Use

CAGE Screening (4)

A
  • Have you ever tried to cut down on your drinking?
  • Have people annoyed you by criticizing your drinking?
  • Have you ever felt bad or guilty about your drinking?
  • Have you ever had a drink first thing in the morning to settle your nerves? (eye-opener)
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63
Q

SPICES

What does it stand for?
Risks of SPICES (3)

A

SPICES or geriatric vital signs
* Sleep disorders
* Problems with eating or feeding
* Incontinence
* Confusion
* Evidence of falls
* Skin breakdown

Risks: longer hospital stays, higher medical cost, death

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64
Q

Elder neglect and abuse: Signs and symptoms

Neglect (2)
Emotional abuse
Financial abuse (2)
Physical or sexual abuse (2)

A

Neglect
- Failure or refusal to provide or support basic needs (feeding, clothing, shelter)
- Ex. Contractures, pressure ulcers, dehydration, urine burns, malnutrition, excessive body odor, listlessness

Emotional abuse
- threats, humiliation, intimidation, isolation

Financial abuse
- misuse or management of funds, resources
- more common than physical

Physical or Sexual
- injured, assaulted, or inappropriately restrained
- Ex. Clusters or regular patterns of burn (cigs), molesting, unusual hair loss, sedation, injury in bathing suit zone (abdomen, butt, genitals, upper thighs)

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65
Q

Elder neglect and abuse: Nursing Care (3)

A
  • listen to seniors and their caregivers
  • intervene if elder abuse suspected (MANDATED)
  • educate others about how to recognize and report elder abuse
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66
Q

Older adults: Incontinence

Contributing factors (4)
Care

A

Contributing factors
- Acute or chronic disease
- ADL ability
- Cognitive impairment
- Environmental barriers (lack of available staff; toilet far)

Care
- Place the pt. on a toileting schedule or a bowel or bladder training program (may delegate to UAP)

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67
Q

Older adults: Skin breakdown

Two problems
Care (5)

A

Two problems
- Skin breakdown (esp. pressure ulcers)
- Skin tears esp. the old-old and those on chronic steroid therapy b-c increased capillary fragility)

Care
- Prevention of pressure ulcers ( Nutritional support (protein), turn, reposition q2h, mobility/activity plan of care, moisture barriers, good hygiene)
- Use the Braden scale daily
- Coordinate w/ RDN and WOCN
- Assess skin q8h for reddened areas that do not blanch and report any open areas (Encourage UAP to report any reddened areas so RN can assess)
- Use a gentle touch

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68
Q

ABGs: Age-related changes (4)

A
  • CO2 does not change with age
  • PaO2 decreases w/ age r/t V/Q matching changes (Expected value = 80 mm Hg minus 1 mm Hg for every year > 60)
  • Reduced size and function of the kidneys (Loss of nephrons; Decreased renal blood flow)
  • Underlying conditions that may result as one ages Ex. COPD (respiratory acidosis), DKA (metabolic acidosis)
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69
Q

ABGs: Normal values (4)

A
  • pH 7.35-7.45
  • CO2 35-45 (Ventilatory failure if > 50)
  • HCO3- 22-26
  • PaO2 80-100 mm Hg (never should be < 40)
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70
Q

ABGs: Compensation equations (3)

A
  • ph abnormal + one abn. value = uncompensated
  • ph abnormal + two abn. values = partial compensation
  • ph normal + two abn. values = full compensation (determine primary disorder by seeing if pH on acidic (7.35-7.4) or alkalinic side (7.4-7.45) of normal)
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71
Q

Other ABG Components

  • O2 sat– (2)
  • Oxygen content (CaO2)– (2)
A

O2 sat (need to know Hgb to know if adequate)
- normal: 95% or higher
- Amount of oxygen bound to hemoglobin compared to maximal capability of hemoglobin for binding oxygen

Oxygen content (CaO2)
- Measure of total amount of oxygen in blood included PaO2 (dissolved in plasma) and amount bound to hemoglobin (SaO2)
- Normal = 20 mL of oxygen per 100 mL of blood

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72
Q

Other ABG Components

  • Base excess/ base deficit (4)
A
  • normal range -2 +/- 2; -2 to 2)
  • Identifies non respiratory contributors to acid-base balance
  • <-2 base/bicarb is deficit (metabolic acidosis)
  • > 2 base/bicarb is excess (metabolic alkalosis)
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73
Q

Other ABG Components

  • PaO2/FiO2 ratio called P/F ratio (4)
A
  • Lower the number = worse the lung function (want > 286)
  • Estimates intrapulmonary shunting (portion of venous blood that flows to lungs w/o being oxygenated which leads to non functioning alveoli)
  • PaO2: partial pressure of oxygen dissolved in arterial blood plasma
    80-100 mm Hg
  • FiO2: fraction of inspired oxygen
    21-100% (21%= room air; 100% possible via vent or ambu)
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74
Q

Head and Neck Cancer

What is it?
Progression (4)

A
  • slow growing squamous cell carcinoma

Progression
- Begins with mucosa that is chronically irritated
- mucosa becomes tougher and thicker from irritation and genes for cell growth damaged
- metastasis to Lymph nodes, muscles, bone i.e. nearby structural areas
- fatal when metastasis to organs (lungs, liver)

75
Q

Head and Neck Cancer

  • Prognosis (3)
  • Consequences (4)
A

Prognosis
- dependent on location and extent of tumor
- curable when treated early
- fatal in 2 yrs if not treated due to airway obstruction

Consequences
- impaired gas exchange (inability to breath)
- impaired nutrition (inability to eat)
- impaired self-image (impaired facial appearance)
- impaired communication (inability to speak)

76
Q

Head and Neck Cancer: Risk Factors

Main (2)
Others (8)
What is not a risk factor?

A

Main: tobacco and alcohol (worse when together)

Others
- men more than women
- > 60 yrs
- poor oral hygiene
- chronic laryngitis
- voice abuse
- chemical or dust exposure
- long-term GERD
- oral infection w/ HPV

FAMILY HISTORY IS NOT A RISK FACTOR FOR HEAD AND NECK CANCER

77
Q

Head and Neck Cancer: warning signs (12)

A
  • Pain
  • Lumps in mouth, throat, neck
  • Color changes in mouth or tongue (leukoplakia (white, patchy); Erythroplakia (red, velvety); black; gray; dark brown)
  • Oral lesion or sore that does not heal in 2 weeks (may have burning sensation from hot liquids or citrus juice
  • Persistent/unexplained oral bleeding
  • Numbness of mouth, lips, or face
  • Change in denture fit
  • Hoarseness or change in voice quality
  • Persistent, unilateral ear pain
  • Persistent/recurrent sore throat or difficulty swallowing
  • Shortness of breath
  • Anorexia and weight loss
78
Q

Head and Neck Cancer: Diagnostics

Labs (5)
Diagnostic tests (4)

A

Labs
- chronic alcohol use or poor nutrition (low albumin)
- metastasis to liver (increased AST, ALT)
- metastasis to kidney (increased BUN, Crt)
- CBC, Bleeding times, and blood chemistries
- Urinalysis

Diagnostics
- direct and indirect laryngoscopy OR bronchoscopy under anesthesia to define extent of tumor
- Biopsy to confirm diagnosis, tumor type, cell features, location, and stages
- X-ray of skull, sinuses, neck, and chest
- CT and MRI

79
Q

3 Types of Laryngectomies (and 2 notes on after effects for each)

A

Supraglottic partial laryngectomy ( done if nodes involved)
- normal or hoarse voice
- Temp tracheostomy

Hemi or vertical laryngectomy
- hoarse voice
- Temp tracheostomy

Total laryngectomy
- no natural voice
- Permanent laryngectomy stoma

80
Q

Head and Neck Cancer: Treatments (3)

A
  • Radiation
  • chemo
  • surgery (laryngectomy– requires trach)
81
Q

Radiation: Side effects (6)

A
  • impaired taste
  • skin problems (redness or irritation or tenderness; peeling skin)– may be for up to a year
  • dysphagia
  • dry mouth (xerostomia) - risk for cavities, oral infections, halitosis, taste problems with xerostomia
  • hoarseness (worsened for up to 4-6 weeks)
  • sore throat and swallowing problems
82
Q

Care for Radiation side effects

  • xerostomia (3)
  • skin irritation (3)
A

Care for xerostomia
- Moisturizing sprays
- Increased water intake
- humidification

Care for skin problems
- Avoid exposing skin to sun, heat, cold, abrasive actions (shaving)
- Wear protective clothing w/ soft cotton
- Wash area gently daily with mild soap

83
Q

Laryngectomy: pre-op care (3)

A
  • make sure pt aware of self-care of airway, ventilation and suctioning needs post-op
  • let know patient needs alt form of communication post-op (speaking device, whiteboard, pen and paper)
  • educate about post-op pain management, nutritional support (feeding tubes), plans for discharge
84
Q

Laryngectomy: Potential complications (5)

A
  • Airway obstruction (priority)- s/s: restlessness
  • Hemorrhage (esp. if wound exposes carotid artery)– call RRT if blood leaking and do not touch b-c can rupture carotid artery; apply continuous pressure if carotid artery ruptures
  • wound breakdown (Risks: poor nutrition, long smoking hx, chronic alcohol use, wound contamination, radiation therapy prior to surgery)
  • Tumor recurrence
  • nutritional deficiencies (may have taste changes)
85
Q

Laryngectomy: General Post-op care (4)

A
  • care in ICU setting
  • For first 24 hrs, monitor airway, VS, hemodynamics, comfort, anesthesia complications
  • monitor stoma (stoma should be bright pink and shiny w/o crusts; blood tinged drainage = normal for 2 days)
  • for pain, give IV morphine via PCA (no oral meds until oral intake tolerated)
86
Q

Total Laryngectomy: Speech and Language Rehabilitation

Options for Speech (3)

A
  • Electronic devices (picture board, smart phone, computer)
  • Mechanical device (sound vibrates air inside mouth and throatwhile patient moves lips and tongue; produces robotic sound)
  • esophageal speech (patient burps swallowed air to produce speech; produces monotone sound)
87
Q

Laryngectomy Care: Maintaining a patent airway (6)

A
  • May be on mechanical ventilation
  • suction PRN to remove secretions
  • change laryngectomy tube daily
  • Clean stoma w/ sterile saline to prevent crusts from obstructing airway
  • Increase humidity w/ saline, bedside humidifier, pans of water, or house cleaning
  • monitor vital signs (O2 sat) and respiratory status
88
Q

Laryngectomy Care: Psychosocial care (5)

A
  • connect to support groups
  • reduce anxiety and depression w/ anxiolytics ( diazepam (Valium) - be careful b-c risk for respiratory depression; lorazepam (Ativan)- less risk for respiratory depression)
  • stress self care (normal activities return after 4-6 weeks)
  • cover stoma w/ clothing or jewelry to mask appearance
  • use cosmetics for disfigurements
89
Q

Laryngectomy Care: Monitoring for hemorrhage and wound breakdown (4)

A
  • Suture line of stoma care q1-2h during first few days post-op then q4h
  • Surgical drain collects blood and drainage for 72 hrs post-op
  • Monitor and record amount and character of drainage; cap refill; and activity of major BVs in region (Secretions blood tinged for 1-2 days)
  • Report sudden increase or decrease of drainage to surgeon (may be clot if sudden stoppage of drainage)
90
Q

Laryngectomy care: Promoting adequate nutrition (6)

A
  • feeding tube usually for 7-10 days post-op and removed when swallowing is safe per Swallow study
  • PEG > NGT to prevent aspiration
  • give diet high in protein and calories
  • small amounts of food at a time
  • may need thickened liquids
  • collaborate w/ RDN and SLP b-c at risk for aspiration, speech, and nutritional problems
91
Q

Aspiration: Risk factors (4)

A
  • surgical changes in upper respiratory tract w/ laryngectomy
  • NGT
  • Difficulty swallowing r/t tracheostomy tube fixing larynx in place and cuff interfering with passage of food via esophagus
  • cuff pressure < 20 on trach tube (may partially deflate for easier swallowing)
92
Q

Prevention of Aspiration

Care (5)

A
  • tuck chin when swallowing
  • use supraglottic swallowing (Valsalva maneuver and swallow twice to clear food that may pool in pharynx; exaggeration of normal protective mechanisms)
  • observe for aspiration or aspiration pneumonia and report immediately (aspiration not possible after total laryngectomy b-c airway totally separated from esophagus)
  • NO oral intake until swallow study done
  • collab w/ SLP and RDN
93
Q

Laryngectomy: Self-Management Education (7)

A
  • Avoid swimming
  • Lean forward and cover stoma when coughing, sneezing (may need to cover when laughing and crying as well)
  • Wear stoma guard or loose clothing to cover stoma to prevent water from entering airway when showering
  • Clean stoma with mild soap and water
  • Lubricate stoma with non-oil based ointment
  • use alt communication methods
  • use MedicAlert bracelet and emergency card for life-threatening situations
94
Q

Superior Vena Cava Syndrome

What is it? (2)
Causes (3)
Diagnostics (3)
Main complication

A

What is it?
- life-threatening emergency
- Obstruction or compression of SVC that prevents return of venous blood from head, neck, and upper trunk

Causes
- Malignancies and tumors esp. lymphomas; lung cancers; Mediastinal tumors
- Scar tissue formation
- Thrombosis from invasive vascular device (PICC, pacemaker)

Diagnostics: chest x-ray, CT, MRI

Main complication: airway obstruction

95
Q

Superior Vena Cava Syndrome: Management (6)

A
  • Chemotherapy/radiation to decrease tumor size and relieve obstruction
  • surgical (Metal stent) for relief of swelling– rare
  • IV Steroids (methylprednisolone) for edema and inflammation
  • IV Diuretics (furosemide) for edema
  • Comfort and pain control (HOB elevated r/t dyspnea)
  • If due to thrombosis from IV device, remove line and give systemic anticoagulation
96
Q

Superior Vena Cava Syndrome: Early manifestations (8)

A
  • Dyspnea (most common)
  • Trunk/extremity swelling
  • Facial edema (periorbital) esp In morning or when supine
  • Epistaxis and Nasal stuffiness
  • cough
  • Neck-vein distention
  • CNS (Headache or head fullness; Lightheadedness; Mentation changes)
  • Upper body erythema
97
Q

SVC syndrome: Late manifestations (6)

A
  • Hemorrhage
  • Cyanosis
  • decreased cardiac output
  • hypotension
  • stridor = rapid progression r/t narrowing of pharynx or larynx
  • Death results if compression is not relieved (main goal = prevent development of late signs)
98
Q

7 Nursing Care for patient w/ chest tube

A
  • Inspect insertion site( eyelets of tube should not be visible; s/s of infection (redness, purulent drainage, excess bleeding))
  • Palpate Insertion Site (may have subQ emphysema if puffiness or crackling
  • Ensure Intact Dressing at Site
  • Assess/reassess Respiratory Status (breathing, pulse ox, breath sounds)
  • Observe Trachea (tension pneumothorax if shifted)
  • Assess/reassess Pain (give meds and reposition)
  • Encourage Cough, Deep Breathing, Incentive Spirometry
99
Q

9 Nursing Care for chest tube system

A
  • Avoid kinks, Occlusions, or Loose Connections (should be straight)
  • Do NOT Strip/Milk Tubing
  • Keep Drainage System Below Level of Chest
  • Assess for “Tidaling” (water level rises inhalation and fall exhalation) - if not present, may be obstruction
  • bubbling seen on exhalation, forceful cough, position changes (EXCESS BUBBLING = air leak)
  • Always have at least 2 cm of water to prevent air from returning to patient in water seal chamber
  • Limit clamping of a chest tube b-c will increase pressure in pleural space and may cause tension pneumothorax
  • No need to disconnect chest tube for transport
  • never let drainage come in contact w/ tubes (can cause tension pneumothorax)
100
Q

8 emergency situations w/ chest tubes

A
  • Tracheal deviation from midline
  • Sudden onset or increased intensity of dyspnea
  • O2 sat <90%
  • Drainage greater than 100 mL/hr, fresh blood, sudden increase in drainage
  • Visible eyelets on chest tube
  • Chest tube falls out of the patient’s chest
    (cover the area with dry, sterile gauze; leave one side out so air can continue to escape chest and prevent tension pneumothorax)
  • Chest tube disconnects from the drainage system (put end of tube in a container of sterile water and keep below the level of the patient’s chest)
  • Drainage in tube stops (in the first 24 hours)
101
Q

Older Adults: Age-related changes in Gas exchange (9)

A
  • Sarcopenia (age-related muscle atrophy) and weakened respiratory muscles
  • Decreased chest wall movement (stiffens) and size
  • Air trapping = increased residual volume causing thinned and enlarged alveoli
  • Reduced sensitivity to hypoxia and hypercarbia
  • Decreased pulmonary reserve
  • Decreased pulmonary perfusion capacity
  • increase Dyspnea
  • Difficulty coughing up secretions r/t decreased cilia beat frequency in airways
  • Decrease in ability to protect against environmental injury and infection (r/t decreased T-cell, nutrition, swallowing ability, and mucociliary clearance)
102
Q

Bronchoscopy

Indication (2)
Post procedure care (2)

A

Indications (at bedside by HCP)
- Diagnosis (r/t hemoptysis; post-chest trauma; chest or face burn; post-aspiration; difficult intubation; airway obstruction)
- therapeutic (reverse aspiration, help w/ difficult intubation; removal of secretions or growths; atelectasis)

Post procedure Care
- Observe sputum for hemorrhage (Expected: slightly bloody due to trauma)
- Ensure gag reflex returns and anesthesia wears off before patient eats or drinks (about 2 hr)

103
Q

Bronchoscopy

Minor complications (4)
Major complications (4)

A

Minor complications: Laryngospasm/Bronchospasm, fever, vomiting, epistaxis

Major complications
- anaphylaxis
- Cardiac (hypotension, arrhythmias, hemorrhage, CODING/ cardiopulmonary arrest)
- respiratory (respiratory failure, hypoxemia, pneumothorax)
- infection

104
Q

Bronchoscopy

Pre procedure Care (4)
Pre procedure meds (5)

A

Pre procedure Care
- Chest x-ray
- Clotting studies (PT, aPTT, Platelet)
- ABGs (oxygen during procedure if hypoxemic)
- No oral intake for 6-8 hrs to prevent aspiration

Pre-op meds
- Topical anesthetic
- Benzo for sedation
- Opioid for pain
- Atropine to reduce vasovagal response and secretions
- IM Codeine to reduce cough reflex

105
Q

Thoracentesis

Indications (2)
Procedure (3)

A

Indications
- Therapeutic (Removal of fluid or air from pleural space for pleural effusion or empyema)
- Diagnostic (determine etiology of pleural effusion; main use)

Procedure
- Patient sit on side of bed OR side lying on edge of bed
- Patient should not move or cough during procedure
- Local anesthetic given to minimize discomfort (by HCP)

106
Q

Thoracentesis

Risk factors for complications (4)
Complications (3)

A

Risk factors for complications
- Hemodynamic instability or Coagulation defects
- Mechanical ventilation
- Intra-aortic balloon pumps
- Uncooperative patients

Complications
- Pain
- Pneumothorax r/t intro of air into pleural space, puncture of lung, or rupture of visceral pleura
- Reexpansion pulmonary edema (s/s severe coughing, SOB))

107
Q

Ventilation-perfusion (V/Q) scan

Indication
Process (2)
Results (2)
Complications (3)

A

Indications: Diagnosis (determine if occlusion of pulmonary artery, respiratory or perfusion problems esp. PE)

Process
- Ventilation: radiolabeled gas inhaled via mask into lungs
- Perfusion: radioisotope injected into veins and travels to lung tissue

Results
- Normal= perfusion scan is normal
- V/Q mismatch i.e. diminished radioactivity on perfusion scan indicates obstruction i.e pulmonary embolus

Complications
- Bleeding at injection site
- infection at site
- Allergy to injection dye (anaphylaxis)– rare

108
Q

Pulmonary function tests (PFTs)

Indications (2)
Components (4)

A

Indications
- Detect abnormalities when respiratory problems
- Assess, track, diagnose, and monitor pulmonary diseases w/ spirometry

Components
- lung volumes (tidal volume and vital capacity) provide info on origin of disease
- Mechanics of breathing (dynamic and static compliance) - lung compliance decreases w/ pneumothorax, bronchospasm, retained secretions
- Diffusion
- ABGs

109
Q

Tension Pneumothorax

Process (3)
Cause (2)
Labs/diagnostics (2)
Interventions (2)

A

Process
- Air rapidly enters pleural space and cannot escape
- Lungs collapses and mediastinum shifts to opposite side due to pressure of air
- Air compresses blood vessels and heart which limits venous return and reduces cardiac output and gas exchange

Cause
- blunt chest trauma for accident or invasive procedure
- barotrauma from vent

Labs/Diagnostics
- chest x-ray
- ABG: hypoxemia and hypercapnia

Interventions
- Oxygen with PEEP (positive end expiratory pressure) needed
- chest tube in pleural space to remove air or fluid, reinstate negative pressure, expand collapsed lung)

110
Q

Tension Pneumothorax: Clinical Manifestations (6)

A
  • Tracheal deviation (away from affected due to compression of heart)
  • Respiratory distress (dyspneic, cyanotic
  • Reduced or Absence of breath sounds on affected side (hyperresonance)
  • Distended neck veins
  • Hypotension
  • Hemodynamic instability (cyanotic, sudden chest pain, tachycardia)
111
Q

Hemothorax

  • Causes (2)
  • Classifications (2)
  • Interventions (3)
A

Causes
- Blunt or penetrating trauma
- Lesser trauma if tendency to bleed (i.e. on anticoagulants)

Classifications
- Simple: < 1L blood loss (May not exhibit manifestations)
- Massive: > 1L blood loss

Interventions for massive (simple may resolve on own)
- chest tube to remove blood and prevent infection
- Fluids
- Open thoracotomy if massive or persistent bleeding at 150-200 mL/hr over 3-4 hrs

112
Q

Hemothorax: Clinical Manifestations (7)

A
  • Respiratory distress (dyspnea, cyanosis, tachypnea)
  • Blood visible on chest x-ray
  • Hypovolemia
  • Decreased breath sounds (no extra sounds)
  • Shock possible (tachycardia)
  • Dull to percussion
  • Chest pain r/t hypoxia
113
Q

Flail Chest: Clinical manifestations (7)

A
  • Respiratory failure (dyspnea, cyanosis,) r/t intrathoracic injury and inadequate diaphragmatic movement
  • Shock (decreased BP, increased HR)
  • Paradoxical movement of the chest (Inspiration: in;
    Expiration: out) leads to increased work of breathing
  • severe Pain and anxiety
  • Decreased chest expansion leads to decreased ventilation
  • Risk for hemothorax or pneumothorax
  • chest deformity and crepitation over fractured ribs
114
Q

Flail Chest

Description (2)
Care (6)

A

Description
- Fractures of at least two neighboring ribs in two or more places or separation of rib from cartilage
- Result of blunt chest trauma

Care
- Oxygen (or mechanical ventilation if respiratory failure or shock)
- PEEP if severe hypoxemia and hypercarbia
- Pain and anxiety management (talk slow, explain everything)
- Promote lung expansion via deep breathing and positioning
- Secretion clearance via coughing and tracheal suctioning
- Monitor VS, ABG, f/e balance, vital capacity

115
Q

Pulmonary Embolism

Definition
Pathophysiology (5)

A

Definition: clot or other matter lodges in pulmonary artery and disrupts blood flow to lungs

Patho
- Increased pulmonary vascular resistance and vasoconstriction (pulmonary HTN))
- Increased right ventricular workload -> decreased left ventricular preload, CO, BP, and shock
- Increased alveolar dead space r/t V/Q mismatch
- Bronchoconstriction r/t hypoxia, hypocarbia, and release of mediators which also increase airway resistance and promotes atelectasis
- Compensatory shunting r/t V/Q mismatch (unaffected parts of lung perfused more)

116
Q

Pulmonary Embolism: Diagnosis (6)

A
  • ABG’s (Respiratory alkalosis later becomes respiratory acidosis; hypoxemia r/t V/Q mismatch
  • D-dimer (Elevated (normal D-dimer rules out PE))
  • EKG (Tachycardia, new a-fib, T-wave inversion, ST segment changeS)
  • V/Q scan (Ventilation present; perfusion decreased)
  • Doppler ultrasound lower extremities if r/t DVT
  • Echo
117
Q

Pulmonary Embolism

Clinical Manifestations (6)

A
  • Tachycardia
  • Tachypnea and dyspnea
  • Pleuritic, sharp, sudden chest pain
  • Cough
  • Crackles
  • Hemoptysis
118
Q

Pulmonary Embolism: Risk factors (7)

A
  • Obesity
  • Oral contraceptives
  • Postpartum
  • Cardiac problems (cardiomyopathy or a-fib)
  • Arterial or central venous catheters
  • Previous PE
  • Virchow triad (Hypercoagulability; Venous stasis (immobility, a-fib, decreased cardiac output); Injury to endothelium (Recent trauma or burns, atherosclerosis))
119
Q

Pulmonary Embolism: Medical Management

  • Optimize oxygenation (3)
  • Prevent further clot formation and risk of more clots (4)
A

Optimize oxygenation
- Intubate and put on ventilator or give oxygen via mask
- Sedatives and analgesics to reduce work of breathing
- Bronchodilators

Prevent further clot formation and risk of more clots
- IV continuous Heparin (preferred) (Lab: PT)
- Oral warfarin (long term at least 3 months; once therapeutic then heparin discontinued) (Lab: INR)
- Monitor bleeding w/ anticoagulants (ex. Hematuria, melena, bruising, bleeding gums)
- Education: low vitamin K diet, Bleeding precautions
(electric shaver, soft toothbrush), DVT prevention (prevent DVT (encourage mobility, SCDs, ROM exercises, hydration)

120
Q

Pulmonary Embolism: Medical Management

  • Dissolve clot
  • Removal of clot
  • Prevent further PE (2)
  • reverse Pulmonary HTN (2)
A

Dissolve clot
- Thrombolytics (tPA, streptokinase) when massive PE and hemodynamic instability

Remove clot (embolectomy if fibrinolytic contraindicated)

Prevent further PE (filter)
- Green field filter-umbrella (surgically placed in vena cava and prevents further thrombotic emboli from migrating into the lungs)
- Useful if anticoagulants contraindicated, recurrent embolisms, survival of massive PE

Reverse Pulmonary HTN
- Fluids to increase right ventricular preload and contractility
- Inotropes to increase contractility and cardiac output

121
Q

Acute Lung Failure: Types

  • Hypoxemic (3)
  • Hypercapnic (2)
A

Hypoxemia normocapnic (low PaO2)
- r/t V/Q mismatch, intrapulmonary shunting (extreme V/Q mismatch r/t shunting of non oxygenated blood away from lungs)
- Leads to lactic acidosis and MODS
- causes (PE (V/Q mismatch); COPD; Asthma; Pneumonia; Atelectasis; Pulmonary edema

Hypoxemia hypercapnic (high paCO2 and low paO2)
- r/t alveolar hypoventilation
- Causes: Airway and alveolar conditions (asthma, COPD); Central venous problems; Drug overdose; Spinal cord injury

122
Q

Acute Lung Failure

Definition (3)
Labs/Diagnostics (5)

A

Definition
- Physiologically defined condition w/ inadequate exchange of O2 & CO2
- Body is not able to meet the need for O2 at rest
- most common organ failure in ICU

Labs/Diagnostics
- ABG analysis– most specific indicator for evaluating effectiveness of therapy (PaO2 < 60 mm Hg; Hypercapnia (HCO2 > 45))
- Blood/sputum cultures (may be done via bronchoscopy)
- Electrolytes, urinalysis, CBC
- Cardiac- 12 lead EKG; Pulmonary artery catheter if severe (all hemodynamic factors)
- Thoracic CT and Chest x-ray

123
Q

Acute Lung Failure: Clinical Manifestations

  • CNS (4)
  • Cardiac (5)
  • Pulmonary (5)
A

CNS
- Restless
- Headache
- Decreased LOC (confused, drowsy)
- ischemic-anoxic encephalopathy

Cardiac
- Decreased cardiac output (hypotensive, systolic HTN)
- Dysrhythmias
- Chest pain
- palpitations
- VTE (Prevent: SCDs, heparin)

Pulmonary
- respiratory distress (retractions, nasal flaring)
- Rapid shallow breathing and Dyspnea/SOB
- Tripod position
- Active abdominal movement
- Cyanosis

124
Q

Acute Lung Failure: Clinical Manifestations

  • GI (6)
  • Renal
  • Skin
A

GI
- Decreased GI blood flow
- Ascites and Abdominal distention
- Anorexia
- NV
- Constipation
- Stress ulcers (Prevent: H2 antagonists, PPIS)

Renal (Impaired renal blood flow (decreased urine output)

Skin (Cool, clammy)

125
Q

Acute Lung Failure: Oxygen (4)

A
  • Delivery system should be tolerated by patient AND lowest FiO2 to maintain O2 sat > 90%
  • Use positive pressure ventilation if intrapulmonary shunting present
  • Noninvasive okay unless rapid deterioration
  • Use A/C mode
126
Q

Acute Lung Failure: Drug Therapy (6)

A
  • Relief of bronchospasm via smooth muscle relaxation (bronchodilators)
  • Reduction of airway inflammation (corticosteroids)
  • Reduction of pulmonary congestion (diuretics)
  • Treatment of pulmonary infections (antibiotics)
  • Reduction of severe anxiety, pain, and agitation (sedatives, analgesics, neuromuscular paralysis)
  • Sodium bicarbonate if metabolic acidosis severe (pH < 7.2), dysrhythmias, or refractory to therapy
127
Q

Acute Lung Failure: Nursing Management

  • Promote clearance of secretions (4)
  • Nutrition (3)
A

Promote clearance of secretions
- Hydration and humidification oxygen
- Suction PRN (hyperoxygenate prior
- Chest physiotherapy and vibration
- Deep breathing and incentive spirometer once extubated

Nutrition
- nutritional support (protein)
- enteral route preferred
- avoid under or overeating (undereating can decrease ventilatory drive; overeating can increase ventilatory demands due to increased CO2 production)

128
Q

Acute Lung Failure: Nursing Management

  • Positioning (3)
  • Prevent desaturation (3)
A

Positioning
- If hypoventilation, use HOB 35-45
- If V/Q mismatch, place Least affected lung part in most dependent position (if bilateral, place right lung down b-c larger)
- Change position q2h

Prevent desaturation
- early recognition w/ continuous pulse ox monitoring
- Adequate rest and recovery b/w procedures
- Minimize oxygen consumption (Sedation for anxiety)

129
Q

Acute Respiratory Distress Syndrome

Definition (2)
Pathophysiology (3)

A

Definition
- sudden progressive form of acute respiratory failure
- pulmonary manifestation of MODS

Patho
- Alveolar capillary membrane becomes damaged and more permeable to intravascular fluid
- Alveoli fill with fluid and collapse causing noncardiac pulmonary edema
- Lung compliance drops and they become stiff

Timing: within 1 week of problem

130
Q

ARDS: 3 phases

A
  • Exudative –hypovolemia and increased WOB in first 72 hrs (Injury to membrane and capillaries leads to pulmonary HTN, atelectasis, decreased cardiac output)
  • Fibroproliferative- alveoli become enlarged and fibrotic r/t disordered healing causing stiff lungs; more Pulmonary HTN and hypoxemia
  • Resolution- recovery; structural/vascular remodeling and removal of debris and fluid from alveolar
131
Q

ARDS: Causes

  • Direct (4)
  • Indirect (5)
A

Direct (insult to lung epithelium)
- aspiration of GI contents (common)
- near drowning
- respiratory infection (pneumonia (common), covid)
- oxygen toxicity r/t mechanical ventilation)

Indirect insult r/t injury elsewhere and mediators transmit via bloodstream to lungs
- Nonthoracic Trauma (common)
- Sepsis (most common)
- DIC (disseminated intravascular coagulation)
- Shock
- fat emboli

132
Q

ARDS: Diagnostics (3)

A
  • chest x-ray (whited out, bilateral infiltrates)
  • ABGs (low PaO2 (refractory hypoxemia even w/ O2 administration) OR low PCO2 (due to hyperventilation then increases w/ fatigue)
  • PaO2/FiO2 ratio: < 200 due to poor lung function
133
Q

ARDS: Early Signs (5)

A
  • respiratory distress (tachypnea, dyspnea, use of accessory muscles, suprasternal retractions
  • cough
  • restless, apprehension
  • scattered crackles
  • weight gain or loss
134
Q

ARDS: Late signs (7)

A
  • Tachycardia to bradycardia
  • Hypo to hypertension
  • Diaphoresis
  • Cyanosis
  • Pallor
  • changes in sensorium with decreased mentation (somnolence, agitation)
  • Extracardiac sounds
135
Q

ARDS: Medical Management (5)

A
  • drugs to regulate and increase BP (norepinephrine)
  • PRBCs for hemodynamic support
  • Fluid restriction and diuretics for pulmonary HTN
  • Treat underlying infection and trauma (i.e. sepsis)
  • Sedation and analgesia that balance both comfort and desired ventilatory status
136
Q

ARDS: Ventilation Management (4)

A
  • suction PRN for secretion clearance
  • give lowest oxygen (< 0.5 to maintain sat O2 > 90%)
  • Low tidal volume (6 mL/kg) to limit barotrauma and volutrauma
  • Use PEEP (positive end expiratory pressure) – 10-15 cm H2O adequate – risk for barotrauma
137
Q

ARDS: Prone Positioning

Use (4)
Contraindications (3)

A

Uses
- Improves V/Q matching
- Improves oxygenation in patients with ARDS b-c Good lung down to the ground ( least damaged lung in dependent position)
- Reduces aspiration risk via mobilization of secretions
- Decreases intrapulmonary shunting

Contraindications
- increased ICP or spinal cord injury
- hemodynamic instability
- recent abdominal surgery

138
Q

ARDS: Prone Positioning

Complications (6)

A
  • tube/drain obstruction (care: move out of way)
  • Hemodynamic instability
  • Massive facial edema
  • Pressure injuries (care: continue to turn as needed)
  • Aspiration
  • corneal ulcerations (care: lubricate and close eyes)
139
Q

ARDS: Rotation Therapy

Use (2)
Types (2)
Complications (3)

A

Use
- Helps with V/Q matching to improve oxygenation
- Prevents further pulmonary complications r/t mechanical ventilation and bedrest

Types
- Kinetic therapy (> 40 degree continuous rotation)- Decreases VAP incidence
- Continuous lateral rotation therapy (CLRT)– <40 degree continuous rotation

Complications
- Dislodgment or obstruction of tubes/lines/drains
- Pressure injuries (NURSE must still turn pt q2h)
- Hemodynamic instability

140
Q

ARDS: Treatment Complications (5 and prevention)

A
  • Hospital-acquired pneumonia
    Prevention: HOB elevate, hand hygiene
  • Barotrauma (r/t rupture of overextended alveoli from excess pressure)–s/s: subQ emphysema, sternal pain, clicking sound over heart, friction rub
    Prevention: smaller volumes of PEEP
  • Volutrauma (r/t too much volume ventilating non compliant lungs)
    Prevention: smaller tidal volumes
  • Stress ulcers r/t decreased GI blood flow
    Prevention: PPIs, H2 antagonists, enteral nutrition
  • Renal failure r/t decreased renal blood flow, hypotension, hypoxemia, hypercapnia
    Prevention: limit nephrotoxic antibiotics
141
Q

Artificial Airways: Pharyngeal

Use (2)
Complications (5)

A

Use (above glottis)
- maintain airway patency via keeping tongue out of way
- oropharyngeal is only used if unconscious w/ absent or diminished gag reflex

Complications
- Trauma to oral or nasal cavity (care: lubricate nares prior to insertion of nasopharyngeal
- wrong length (If too long, blocks airway; If too short, tongue blocks it)
- Laryngospasm
- Gagging
- Vomiting

142
Q

Artificial airway: endotracheal tube

Use (3)
Care (3)

A

Use (most common artificial airway)
- short-term airway management (usually < 2 weeks)
- usually oro b-c simpler and allows use of larger diameter
- Naso ETT used for more patient comfort and preferred if jaw fracture

Care
- Daily chest x-ray to check placement
- Secure tube to upper lip to prevent displacement
- Know size and length of tube (extend 2 inches at lip or teeth?)

143
Q

ETT: Complications

R/t intubation (2)
R/t actual tube (5)

A

r/t Intubation -> Care: suction set up
- Vomiting
- Aspiration

r/t actual tube
- Oral or naso trauma, inflammation, ulceration (Ex. Laryngeal and tracheal injuries)
- Sinusitis and otitis
- Cardiac arrest
- Pressure ulcers (Care: rotate; use high volume, low pressure cuff)
- Tube obstruction and displacement

144
Q

ETT: Complications

After removal (7)

A
  • Laryngeal and tracheal stenosis
  • Cricoid abscess
  • Hoarseness and vocal cord immobility
  • Stridor
  • Odynophagia, sore throat
  • Coughing
  • Pulmonary aspiration
145
Q

Artificial Airways: Tracheostomy

Use
Indications (2)
Care (4)
Patient Education (2)

A

Use: long term airway management ( > 7 days)

Indications
- Upper airway obstruction r/t trauma, burns, tumors, swelling
- Airway clearance r/t spinal cord injury, neuromuscular disease, severe debilitation, inability to wean, prolonged unconsciousness

Care
- Never cut dressing (fold or use 4 x 4) b-c threads can be aspirated)
- Cuffed tube for pts w/ mechanical ventilation
- Deflate tube before decannulation b-c no airway if cuffed
- always have extra tube of same size and smaller at bedside in case of displacement

Patient education
- Use shower shield
- Wear medical alert bracelet to identify inability to speak

146
Q

Trach: Complications

r/t procedure (6)
After removal (2)

A

r/t procedure
- Displacement of trach (emergency in first 72 hrs post-op b-c trach may close) (Care: Ambu if dislodged tube and have another nurse call RRT; 2nd nurse present when suctioning or moving pt in first 72 hrs)
- Hemorrhage (small amount = expected; constant oozing is abnormal)
- Laryngeal nerve injury (hoarseness)
- Pneumothorax (Care: confirm bilateral breath sounds; hourly respiratory assessment)
- Cardiac arrest
- subQ emphysema (air in neck)

After removal
- Tracheal stenosis
- Tracheocutaneous fistula

147
Q

Trach: Complications

r/t trach (7)

A
  • Hemorrhage
  • Tracheomalacia (tracheal dilation and erosion of cartilage)
  • Tracheoesophageal fistula or tracheoinnominate artery fistula
  • Tube obstruction (S/s: difficulty breathing, noisy respirations, difficulty inserting suction catheter, thick, dry secretions, high peak pressures); care: use removable inner cannula, cough and deep breathe, suction, humidify oxygen)
  • Stoma infection (Prevention: sterile technique; assess q8h for s/s of infection (purulent drainage, redness, pain, swelling, change in tissue integrity))
  • Displacement of tube (after 72 hrs)- Care: secure tube; replace tube immediately w/ bedside tube and obturator
  • Pressure ulcers (care: rotate and pad)
148
Q

Artificial Airway: Oral Care (5)

A
  • q2h and as needed b-c increased bacteria r/t decreased saliva, poor mucosal status and dental plaque
  • Brush teeth and stimulate gums and tongue w/ swab
  • No glycerin, alcohol, hydrogen peroxide because drying effects
  • deep oropharyngeal suctioning for pooled secretions (painful for subglottic secretions so give pain meds or sedation)
  • 2% chlorhexidine q4-6h
149
Q

Artificial Airway: Skin Care (4)

A
  • Pad pressure points if s/s of irritation
  • Lubricate nares, face, lip w/ nonpetroleum cream to prevent drying effect
  • Maintain cuff pressure (Low-pressure, high volume
  • Monitor cuff pressure every shift to maintain within 20-30 cm H2O (< 20 = increased risk of aspiration; > 30 = decreased blood flow to capillaries in tracheal wall (report to HCP))
150
Q

Artificial Airway: Removal

Extubation vs decannulation
Care (3)

A

Extubation: removal of ETT; Decannulation: removal of trach tube

Care
- Clear secretions above cuff prior to deflation
- If accidental extubation or decannulation; place pharyngeal airway with head tilt-chin lift maneuver and ambu bag and cover stoma
- Cover stoma with dry dressing after tracheostomy removal

151
Q

Artificial Airway: Communication (3)

A
  • Use nonverbal (thumbs up, hand squeezes, sign language, gestures, lip reading, pointing, facial expressions, blinking) b-c tube does not allow airflow over vocal cords
  • Assess patient’s ability to communicate (Can speak if cuffless tube)
  • Provide assistive devices (hearing aids and eyeglasses; pen and paper, typewriters, computers, flash cards)
152
Q

Artificial Airway: Humidification

When?
Purpose (3)

A

Humidify oxygen if > 4L w/ sterile water

Purpose
- Prevent drying and irritation of respiratory tract
- prevent undue body water loss
- Facilitate secretion removal (thick, dry secretions can occlude airway and increase risk for infection)

153
Q

Artificial Airway: Suctioning (sterile)

Complications (7)

A
  • Hypoxemia r/t disconnected oxygen
    Care: stop suctioning if O2 < 90%
  • Atelectasis r/t suction catheter > ½ diameter of ETT and excessive negative pressure or prolonged suctioning
  • Bronchospasms r/t stimulation of airway w/ catheter
    Care: Give bronchodilator
  • Dysrhythmias (bradycardia, heart block, v-tach) r/t vagal stimulation
    Care: Stop suctioning and hyperoxygenate
  • Increased ICP
  • Airway trauma r/t impact of catheter in airways and excessive negative pressure
  • Infection
154
Q

Artificial airway: suctioning

Care (5)

A
  • Hyperoxygenate with 100% oxygen for 30-60 sec prior to suctioning and 60 seconds after suctioning
  • Use < 150 mm HG of suction to reduce hypoxemia, atelectasis and airway trauma
  • Limit number of times patient is suctioned
  • Suction 10-15 secs continuously on the way out to reduce hypoxemia, airway trauma, cardiac dysrhythmias (Intermittent suction during withdrawal leads to secretion dropping)
  • Suction mouth or nose after suctioning artificial airway
155
Q

Artificial Airway: Suctioning

Indications (6)

A
  • Rhonchi or wheezes (usually not for crackles)
  • Coughing
  • visible secretions in airway or indicated by dyspnea
  • Sawtooth pattern on flow-volume loop on ventilatory
  • Increased peak airway pressure on ventilator
  • Acute respiratory distress (increased RR (indicates hypoxia), HR; restless; decreased O2 sat)
156
Q

Mechanical Ventilation: Physiological Purpose (4)

A
  • Support cardiopulmonary gas exchange (alveolar ventilation and arterial oxygenation
  • Increase lung volume (end expiratory lung inflation and functional residual capacity)
  • Decrease work of breathing
  • Assist with lung healing
157
Q

Mechanical Ventilation: Clinical Purpose (7)

A
  • Relieve respiratory distress (hypoxemia, respiratory acidosis, muscle fatigue
  • Prevent or reverse atelectasis
  • Permit sedation and neuromuscular blockade
  • Reduce ICP
  • Decrease oxygen consumption
  • Stabilize chest wall
  • Protect airway
158
Q

Mechanical Ventilation

Definition
Indications (4)
Types (2)

A

Definition: process of using an apparatus to facilitate transport of O2 and CO2 b/w atmosphere and alveoli to enhance pulmonary gas exchange

Indications: Ventilation, oxygenation, airway and lung protection, secretions

Types of ventilators
- Positive-pressure: intubated and on machine via ETT or Trach; mechanical drive to force air into lungs
- Negative-pressure: on machine but via mask; decrease atmospheric pressure around thorax to initiate inspiration

159
Q

Mechanical Ventilation

Variables (4)
Variable Mechanics (4)

A

4 variables managed: time, flow, volume, pressure

Variable mechanics
- Trigger variable: initiates change from exhalation to inhalation (i.e time, pressure, flow)
- Limit variable: sustains inspiration but does not end it (i.e. flow, volume, pressure)
- Cycle: variable that ends inspiration (i.e any of the four variables)
- Baseline: variable controlled during exhalation

160
Q

Basic Ventilator Settings

  • Modes (3)
  • Rate
  • Tidal Volume
  • PEEP (2)
  • FiO2 (2)
A

Mode of ventilation
- Assist Control (AC)
- Synchronized Intermittent Mandatory Ventilation (SIMV)
- Continuous Positive Airway Pressure (CPAP)

Rate: respiratory rate (6-30 breaths/min)

Tidal volume (VT): volume or size of the breath (6-10 mL/kg (4-8 mL/kg in ARDS)

Positive-end expiratory pressure (PEEP)
- amount of pressure remaining in the lung at the END of the expiratory phase; keeps alveoli from collapsing (3-5 cm H2O)
- Risks of too much PEEP: barotrauma, decreased venous return

FiO2
- fraction of inspired oxygen (Range: 21%-100%)
- prefer <50% to maintain O2 sat > 92% and PaO2 > 60 mm Hg

161
Q

Ventilator Modes: Assist/Control (Continuous mandatory ventilation)

  • How it works? (2)
  • Indications (2)
  • Care (2)
A

How it works
- Delivers a “machine breath” every time, whether the pt. triggers the breath or the ventilator initiates the breath (time-triggered)
- patient cannot generate spontaneous volume or flow rate

Indications
- Volume controlled AC if weak respiratory muscles but spontaneous breathing (Risk for volutrauma)
- Pressure controlled AC if decreased lung compliance, increased airway resistance or risk for Volutrauma (Risk for hypercapnia)

Care
- Hyperventilation risk if patient increases their respiratory rate
- Sedation may be needed to limit # of spontaneous breaths

162
Q

Ventilator Modes: Synchronized Intermittent Mandatory Ventilation (SIMV)

  • How it works? (3)
  • Indications (3)
  • Risk
A

How it works
- Delivers a pre-set number of breaths at a set volume or pressure and flow rate.
- Allows the patient to generate spontaneous breaths, volumes, and flow rates between the set breaths.
- Detects a patient’s spontaneous breath attempt and doesn’t initiate a ventilatory breath – prevents breath stacking (A/C does not prevent breath stacking)

Indications
- Volume controlled if weak respiratory muscles but spontaneous breathing
- Pressure controlled if decreased lung compliance, increased airway resistance or risk for Volutrauma (Risk for hypercapnia)
- used for weaning

Risk
- May increase work of breathing and promote respiratory muscle fatigue when used for weaning

163
Q

Ventilator Modes: Pressure Support

How it works? (2)
Use
Risk
Pros (3)

A

How it works?
- Positive pressure applied only on patient- initiated breaths on inhalation to augment efforts (similar to PEEP but only on inhalation vs. expiration)
- Patient’s lung mechanics and efforts controls rate, inspiratory flow, and tidal volume

Use: for pt w/ stable respiratory drive to overcome mechanical resistance

Risk: Hypercapnia

Pros
- Reduces work of breathing
- increases ventilatory synchrony
- Can be used with SIMV or CPAP

164
Q

Ventilator Modes: Continuous Positive Airway Pressure (CPAP)

How it works? (3)
Indication (3)

A

How it works?
- Positive pressure applied during spontaneous breaths (no ventilator breaths in PEEP or CPAP mode)
- Pt controls rate, inspiratory flow, tidal volume
- Similar to pressure support but without the additional inspiratory pressure

Indication
- used with masks for sleep apnea (negative pressure)
- used with ventilator (positive pressure)
- used for weaning

165
Q

Ventilator Modes: Continuous Positive Airway Pressure (CPAP)

Pro (2)
Risks (3)

A

Pro
- Increase functional residual capacity
- Improve oxygenation via opening collapsed alveoli at end of expiration

Risks
- Decreased cardiac output
- Volutrauma
- Increased ICP

166
Q

Mechanical Ventilation: Respiratory Complications (5)

A
  • Increased secretions (care: Suction PRN)
  • Oxygen toxicity (Continuous oxygen > 50% for > 24-48 hrs may injure lung and reduce tissue integrity) –Care: notify HCP if PaO2 > 90 mm Hg
  • Respiratory muscle weakness
  • Ventilator-Associated Pneumonia
  • Ventilator induced lung injury
167
Q

Mechanical Ventilation: Complications

CNS
GI (3)
Cardiac
Psychological (2)

A

CNS
- Increased ICP r/t decreased cerebral venous return

GI (prevent: NGT decompression, appropriate cuff inflation)
- Gastric distention r/t air leaks around ETT or trach cuff and overcomes resistance of lower esophageal sphincter
- Vomiting r/t pharyngeal stimulation from artificial airway
- Hypomotility and constipation r/t immobility and paralytic agents, analgesics, sedatives

Cardiovascular compromise
- Decreased Cardiac Output r/t decreased venous return to right side of heart

Psychological complications
- need for alternative communication
- Patient ventilator dyssynchrony (Risks: auto-PEEP, psychological distress, decreased effectiveness)
Care: ventilator accommodates patient’s spontaneous breathing pattern OR patient is sedated

168
Q

Mechanical Ventilation: Oxygen Toxicity

Early signs (4)
Late signs (5)
Care

A

Early s/s: dyspnea, nonproductive cough, sternal chest pain, GI upset, crackles

Late s/s: decreased vital capacity and compliance; hypoxemia, pulmonary edema, hemorrhage, hyaline membrane formation and atelectasis

Care: notify HCP if paO2 > 90

169
Q

Ventilator-induced Lung Injury

Causes (4)
Care (3)

A

Causes
- Barotrauma r/t too much PEEP
- Volutrauma r/t too much tidal volume
- Atelectrauma r/t shearing r/t repeated opening and closing of alveoli
- biotrauma r/t inflammatory-immune response (Leads to ARDS)

Care
- keep pressure at 32 or below cm H2O
- use PEEP
- tidal volume of 6-10 ml/kg

170
Q

Mechanical Ventilation: ABCDE

A

Awakening
Breathing Coordination
Delirium monitoring
Early mobility

171
Q

Mechanical Ventilation: Patient Safety (5)

A
  • Maintain functional ambu bag at bedside
  • Ensure ventilator tubing free of water
  • Position ventilator tubing to avoid kinks
  • Monitor temp of inspired air (warm but not hot)
  • Ensure alarms audible
172
Q

Ventilator Assessment (4)

A
  • Assess settings and do they correlate with presentation (any desynchrony?)
  • High pressure alarms = airway obstruction b-c patient ventilatory desynchrony, airway resistance or kinked tubing
  • Low pressure alarm = leak or oxygen not connected
  • If vent malfunctions, disconnect patient from vent and Ambu bag patient
173
Q

Mechanical Ventilation

  • Patient assessment (3)
  • Labs/diagnostics (3)
A

Patient assessment
- Listen to patient and breath sounds
- Assess symptoms esp. pulmonary system (subQ emphysema, SOB, agitation, pain, work of breathing)
- Assess placement and securement of ETT or trach

Labs/Diagnostics
- ABGs
- Chest x-ray
- Pulmonary function tests (Vital capacity, minute ventilation, peak inspiratory pressure, tidal volume (how much exhaled))

174
Q

Ventilator-Associated pneumonia

Definition
Risk factors (5)

A

Development of pneumonia 48-72 hrs after endotracheal or other artificial airway insertion intubation b-c tube bypasses normal defense mechanisms of lung

Risk factors
- severe illness
- increased age
- presence of ARDS or malnutrition
- naso intubation b-c promotes aspiration
- Gastric alkalization by enteral feeds and meds b-c promotes bacterial growth

175
Q

Prevention of VAP (7)

A
  • Hand hygiene
  • Elevation of HOB (30-45 degrees) to prevent GER and aspiration
  • Daily “sedation vacations” and assessment of readiness to extubate
  • Stress ulcer prophylaxis
  • DVT prophylaxis
  • Daily oral care (teeth, gums, and tongue) with chlorhexidine q2h
  • Adequate endotracheal tube cuff pressure (Keep at 20cm H20-decreases aspiration)
176
Q

Weaning Methods

  • SIMV (2)
  • PSV
  • spontaneous breathing trial (4)
A

Synchronized Intermittent Mandatory Ventilation
- Gradual transition from ventilatory support to spontaneous breathing (slowly decrease rate until 0)
- Get ABGs 30 min after trial

PSV
- Gradually decrease pressure support while maintain tidal volume until 5 cm H2O support achieved

Spontaneous breathing trial
- Remove from vent and use T-piece for spontaneous breaths OR just stop mandatory breaths on vent
- Add CPAP to prevent atelectasis and improve oxygenation
- Add PSV to augment inspiration
- If successful, consider extubation or changing to uncuffed tube

177
Q

Long-term Mechanical Ventilator Dependence: Factors

  • Physiological (4)
  • Psychological (3)
A

Physiologic factors
- Decreased gas exchange (ex. V/Q mismatch, anemia, hypoventilation, heart failure)
- Increased ventilatory workload or demand (ex. Metabolic acidosis, decreased lung compliance, increased airway resistance, abdominal distention)
- Decreased ventilatory drive (ex. Respiratory alkalosis or metabolic alkalosis, hypothyroidism)
- Increased respiratory fatigue (ex. Malnutrition,

Psychologic factors
- Lack of motivation and confidence
- Conditions that interfere with breathing pattern control (ex. Anxiety, fear, dyspnea)
- Delirium

178
Q

Weaning: Readiness assessment (6)

A
  • spontaneous breathing trial
  • daily screening (stop sedation 1 hr prior to screening)
  • physiologically ready (hemodynamically stable, lungs capable of ventilation, original condition corrected)
  • psychologically ready (LOC stable
  • Decrease work of breathing via suction, HOB raised, sedatives for anxiety
  • interdisciplinary approach (PT for mobility)
179
Q

Long-Term Mechanical Ventilator Dependence

Description
Classifications (3)

A

Description: assistive ventilation required longer than expected given the pt’s underlying condition

Levels
- Simple: weaning terminated within 1 day of attempt
- Difficult: completed > 1 day or < 1 week after first attempt
- Prolonged: not terminated 7 days after first separation attempt

180
Q

Weaning: Process

Initiation (3)
Progress
Intolerance
Outcome (2)

A

Initiation
- start in morning
- Give patient explanation on process and sensations
- Closely monitor patient for any difficulties

Progress: measure % of ventilatory support required or amount of time patient goes w/o vent

Intolerance: show s/s of respiratory distress (dyspnea, accessory muscle use, restlessness, anxiety, change in facial expression, VS changes (HR, BP, RR)

Outcome
- Complete = able to spontaneously breath for 24 hrs
- Incomplete = unable to wean and may go home on vent

181
Q

Mechanical Ventilation: Drug Therapy

  • mucolytics
  • bronchodilators
  • steroids
  • sedatives (2)
  • paralytics (Nimbex/cisatracurium besilate) (3)
A

Mucolytics (Liquefy secretions to help with their removal)

Bronchodilators (beta 2 agonists and anticholinergics)
- Relax smooth muscles when air flow limitations

Steroids (Reduce airway inflammation)

Sedatives
- provide comfort
- Decrease work of breathing and prevent ventilator fighting

Neuromuscular paralysis (Nimbex-Cisatracurium besilate)
- Decreases oxygen consumption:
- sedate and explain all procedures to patient if giving paralytic b-c they do not inhibit pain or awareness
- risk for immobility complications so prevent skin breakdown, DVT, and atelectasis

182
Q

Noninvasive Ventilation: Advantages (4)

A
  • Decreased VAP
  • Applied via mask (ex. CPAP, BiPAP) so easy application and removal
  • Increased comfort
  • Avoid danger of intubation while still keeping alveoli open
183
Q

Noninvasive ventilation: Contraindications (7)

A
  • Hemodynamic instability (i.e. dysrhythmias)
  • Apnea
  • Uncooperativeness/refusal/intolerance
  • Recent upper airway or esophageal surgery
  • Inability to maintain patent airway, clear secretions or properly fit mask
  • Emesis or copious secretions
  • Heavy sedation or restraints (requires mechanical ventilation b-c patient must be able to move mask if it displaces or they vomit)
184
Q

Noninvasive ventilation: nursing management (6)

A
  • HOB elevation to prevent aspiration and facilitate breathing
  • Assess rr, accessory muscle use, oxygenation status
  • Ensure proper fitting mask (tight seal)
  • Transparent dressing over facial pressure points to prevent air leaks and facial pressure injuries
  • NGT for decompression as needed b-c risk for vomiting
  • Spend 30 min w/ patient after initiation b-c needs reassurance on how to breath on vent

Concepts 3 (4 decks)

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