Exam 1: oxygenation Flashcards
how many fingers should fit beneath trach ties?
1 finger
what is the approximate time someone can have an ET tube? after that time is up, what would they have placed?
~ 2 weeks –> tracheostomy
there are a ton of reasons someone might need a tracheotomy, but name some major (generalized) reasons…. (4)
- obstruction
- trauma
- paralysis
- head/neck surgery
how would you communicate with person that had impaired communication r/t tracheostomy or ventilator? (3)
yes/no questions
white board
picture board
how do we verify placement of tracheostomy tube?
chest x ray
what is focus of post op care after tracheostomy tube is inserted?
maintaining patent airway: normal rate, depth, clear sounds, O2 sat + assessing for complications
tracheostomy tube dislodgement within 72 hours of placement = ???
and what do we do?
= MEDICAL EMERGENCY!!!
= CALL CODE!!!
a tracheostomy can cause what major complication?
pneumothorax
hallmark sign of pneumothorax + describe it.
subcutaneous emphysema: sounds and feels like rice crispies
what is most likely cause of trach tube obstruction?
secretions
s+s of tube obstruction w/ trach (3)
- dyspnea
- loud breathing
- difficulty suctioning
main focus for trach tube obstruction is PREVENTION. what are some ways we can do this? (4)
- pulmonary hygiene
- change inner cannulas (BID)
- suctioning PRN
- O2
cuff pressure for trach should stay below what range? why?
<14-20 mmHg
to prevent tissue damage / pressure injuries in trachea
what type of O2 should be used w/trachs?
warm, humidified air
when suctioning a patient and starting to see hypotension and bradycardia, what should you do? what could it be?
STOP!!! - could be vagal stimulation (risk of dysrhythmias)
re: trach, suction time and passes should be limited to what?
10-15 seconds x 3
how often do ties get changed with trach?
PRN
how often should oral hygiene be performed with trach?
q2
term: excessive fluid inside the lungs / alveoli
pulmonary edema
what are the 3 populations of patients that are at great risk of pulmonary edema?
- HF
- renal failure
- elderly
acute pulmonary edema (aka “flash pulmonary edema”) =
MEDICAL EMERGENCY
s+s of pulmonary edema (5)
- pink, frothy sputum coarse crackles
- cough
- coarse crackles
- anxiety, restlessness (r/t dyspnea)
- confusion (O2 not getting to brain)
interventions for pulmonary edema (3 main, 2 others)
- increase O2
- raise HOB
- vitals (O2 sats)
others…
4. diuretic
5. morphine
term: blockage in a pulmonary vessel in the lungs (solid, liquid, air)
pulmonary emboli
PE’s are most often caused by what?
DVT
virchow’s triad components
- hypercoagulability
- damage to tissue vessel
- immobility / stasis of blood flow
what is most common assessment finding with PE? + others (5 total)
- shortness of breath
- chest pain
- restlessness/agitation
- cough
- bloody sputum (infarct of lung)
typically rapid onset
what does an elevated d-dimer indicate?
clot somewhere in the body (byproduct of fibrin breaking down)
gold standard for PE imaging
pulmonary angiography
interventions for PE
- O2 (SpO2 >95%)
- raise HOB
- get help! (rapid)
for evaluating effectiveness of anticoags for PE, what assessment would be appropriate?
respiratory
(patient going from intubated to extubated and from 10L to 2L with less dyspnea….)
if a patient has hypotension r/t PE, what type of meds would you expect to see given? (general)
positive inotropic meds (increase CO)
vasopressors (increase afterload)
what specific assessments should be done with patient on anticoagulants?
bleeding (including neuro checks)
antidote for warfarin
vitamin K
antidote for apixaban
andexanet
antidote for heparin
protamine sulfate
labs for heparin
aPTT + platelets (b/c of risk of HITT)
labs for warfarin
PT + INR
what is normal PaO2?
80-100 (arterial blood oxygen level)
term: inadequate oxygen supply to tissue
hypoxia
term: low arterial blood oxygen levels
hypoxemia
term: air movement
ventilation
term: blood flow
perfusion
term: when ventilation and perfusion do NOT match
mismatch –> respiratory failure
respiratory failure indicated by what level of PaO2?
respiratory failure indicated by what level of PaCO2?
PaO2: <80
PaCO2: >45 (hypercapnic respiratory failure)
ventilation failure leads to….
decreased O2 in alveoli and increased CO2 in alveoli
oxygenation/perfusion failure leads to….
deoxygenated blood (b/c of shunting)
s+s of acute ARF (3)
- dyspnea
- changes in respiratory pattern
- confusion
intervention for ARF (2)
- O2
- positioning
+ treat underlying cause
ARDS is a type of acute respiratory failure WITH…..
reduced compliance*
profound dyspnea
increased work of breathing
loud breathing
pulmonary edema
severe hypoxemia regardless of increased O2*
ARDS caused by what? (generalized)
another disease process with a major systemic inflammatory response or direct injury to lungs –> injury to alveoli –> fluid collects in alveoli
3 ways to diagnose ARDS
- ABG
- chest x-ray
- sputum culture
ARDS interventions (3 main)
- PEEP (positive end-expiratory pressure): to prevent alveoli from completely collapsing at end of expiration
- prone (more alveoli in posterior lungs)
- sedation (stop work of breathing)
when do we tend to use ET tubes? (r/t time frame of use)
when they need an artificial airway for less than 10-14 days
tip of ET tube should lie where?
2cm above carina
the purpose of the ET tube cuff is to __________, NOT to hold it in place.
purpose: create a seal and prevent secretions from being aspirated
when intubating patient, what are some of the RN’s role? (4)
- oxygenate patient
- raise HOB (before intubation, then lay flat)
- reduce anxiety: talk with patient, hold hand, keep calm
- admin meds
what meds do we typically want for intubation?
- sedation
- pain meds
- paralytic
how long should intubation attempts be limited to?
30 seconds (then use bag valve mask)
what things main should be monitored with intubation? (3)
- frequent BP (q5mins, but can be more often)
- continuous SpO2
- continuous telemetry
RN role immediately after intubation (3)
- auscultation (bilateral breath sounds and NO air in abdomen)
- observation (bilateral chest movement)
- assess and document where tube is (ex: “26cm at the lips/teeth”)
what is GoLd StAnDaRd for ET tube placement confirmation?
KNOW
Waveform Capnography (ETCO2)
best indicator that we’re in the trachea
what is normal range of ETCO2?
35-45
after auscultation and waveform capnography, what should also be done to confirm placement?
chest X-ray
what is mnemonic for complications of intubation?
DOPE
dislodgement
obstruction
pneumothorax
equipment failure
what is most common site of ET tube misplacement?
right side mainstem (b/c right side is larger and straighter)
what are some ventilator interventions? (9)
- suction PRN!
- oral care q2h
- keep HOB >30 degrees
- reposition q2h
- pulmonary hygiene
- mobility
- delirium prevention
- CHG bath daily from neck down
- antacids (b/c esophagus always open)
what is ultimate goal of intubation and mehanical ventilation?
GET THEM OFF THE VENT!
what are the components of the ABCDEF ventilator bundle?
KNOW
Awake (turn off sedation everyday)
Breathe (trials)
Choice of sedation/Coordination
Delirium prevention/assessment
Early mobility
Family presence
term: lung bruise
pulmonary contusion
what happens after a pulmonary contusion?
fluid accumulates in the lung –> respiratory failure
nursing interventions for pulmonary contusion (3)
- increase O2
- raise HOB (if appropriate positioning for this trauma pt)
- pain meds
main intervention for rib fracture
pain management - to allow them to take proper breaths (PCA)
deep chest injury (internal organ damage) is much more likely with which types of rib fracture?
KNOW
fracture to 1st and 2nd ribs or fracture of 7 ribs or more
higher mortality rate
term: paradoxical chest wall movement caused by fractured ribs
flail chest (ribs become free floating)
interventions for flail chest (5)
one major difference from other respiratory trauma interventions
- O2
- ABG
- telemetry
- respiratory monitoring
- good lung down (encourages V/Q matching)
DON’T PUT IN HIGH FOWLERS, CAN SEND THEM INTO SHOCK
term: air enters the pleural space
pneumothorax (pressure on lung and lung collapses)
s+s of pneumothorax (4)
- subcutaneous emphysema**
- absent or diminished breath sounds (unilateral breath sounds)
- reduced movement of chest wall
- increased O2 demand
diagnostic for pneumo
chest x ray
intervention for pneumo
chest tube (allows for re-expansion of lung and establishing negative pressure again)
term: complete lung collapse involving air entering the lung without exit
tension pneumothorax
hallmark finding of tension pneumothorax
KNOW
tracheal deviation
aside from tracheal deviation (hallmark), what are other s+s of tension pneumo? (4)
- respiratory distress
- distended neck veins (blood cannot flow into heart)
- hypotension (b/c of increased pressure, heart cannot push blood out)
- tachycardia (compensation for pressure on heart)
intervention for tension pneumo
CALL CODE
needle thoracostomy w/ large bore needle (releases air in the thoracic cavity)
term: bleeding into pleura
hemothorax
difference in chest tube placement from pneumothorax vs hemothorax
hemothorax chest tube = positioning lower (b/c of blood pooling near bottom of lungs) + larger tube
when should we notify provider with chest tube output?
output is > 60/hr
