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Kol- 410 Med Surg II > Exam 1 Review- Oxygenation part > Flashcards

Exam 1 Review- Oxygenation part Flashcards

1
Q

ARDS vs ARF - what causes it ?

A

ARDS= systematic inflammation or direct injury from aspiration or pneumonia

ARF= ventilation (physical problem like rib injury/ paralysis/drug overdose) and/or oxygenation problem (exchange- pneumonia/PE)
–> vent/oxy combined = cystic fibrosis, ARDS, asthma

ARF >ARDS

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2
Q

times you cardiovert vs times you defib?

A

cardiovert = SVT, Afib, V Tach with Pulse

defib = V tach with no pulse, V fib

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3
Q

top concerns with trachs for nurses

A

-gas exchange
-communication
-nutrition
-infection

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4
Q

top priority for post op trach?

A

maintain patent airway

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5
Q

complications from trach? top one?

A

-tube dislodgement
-pneumothorax
-bleeding
-infection
-tube obstruction**

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6
Q

____ _____ is a sign of pneumothorax realted to trach placement

A

subcutaneous emphysema

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7
Q

signs of tube obstruction

A

• Difficulty breathing
• Loud breathing
• Difficult to insert a suction catheter

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8
Q

prevention for complications re: tube obstruction?

A

• Pulmonary Hygiene: mobility! - dangling
• Inner Cannula Care - changed , 1/shift
• Suction as needed- not routinely
• Humidified Oxygen

PISH

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9
Q

how often do we suction trach?

A

as needed only!

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10
Q

how often should the inner cannula be changed/cleaned?

A

changed 1/day , 1/shift

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11
Q

what kind of oxygen do trachs need?

A

humidfied

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12
Q

how do trach patients end up with a pneumothorax?

A

◦ Occurs as a result of tracheostomy placement if the provider inadvertently enters the chest cavity
‣ need chest tube to regulate pressure to pull the lung back to inflation
◦ Subcutaneous emphysema - sign of pneumothorax
‣ sounds like rice crispies

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13
Q

You get report on your patient at the bedside from the day nurse. Your patient
has a #8 XL Shiley tracheostomy tube, which was placed two days ago. The
day nurse tells you she just did tracheostomy care about an hour ago, and other than a scant amount of serosanginous drainage, everything looks great. The CRNA had a difficult time placing the patient’s airway, so the patient has a
“Difficult Airway” sign hanging above his bed. As you scan the patient and the room, what observation would you be most concerned about:

A) The patient’s tracheostomy is only secured with ties, not sutures
B) There is a #9 XL Shiley tracheostomy tube on the bedside table with an obturator nearby.
C) There are no suction catheter kits in the room
D) The patient has audibly rhonchorous breath sounds and is coughing

A

B) There is a #9 XL Shiley tracheostomy tube on the bedside table with an obturator nearby.
◦ need one size smaller NOT bigger! + need obturator + suction set up + O2 + ambu bag

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14
Q

trach cuff pressure should be < ____ - ____mmHG

A

‣ <14-20 mm Hg

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15
Q

• Which patients with a tracheostomy need to be suctioned?
A) Everyone with a tracheostomy should be suctioned routinely
B) The patient with mucus in the artificial airway
C) The patient with noisy secretions
D) The restless patient with tachycardia and tachypnea

A

B) The patient with mucus in the artificial airway
C) The patient with noisy secretions
D) The restless patient with tachycardia and tachypnea

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16
Q

max time suctioning down the trach hole

A

10 seconds

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17
Q

sterile or clean technique for suctioning

A

sterile

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18
Q

max # times you can go down with catheter?

A

3

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19
Q

what do we do if vagal stimulation occurs when suctioning? what are the signs of vagal stimulation?

A

stop suctioning !!

◦  Bradycardia
◦  Hypotension
◦  Dysrhythmias
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20
Q

You are observing your preceptor perform tracheostomy suctioning. You become concerned when he…
A) Tells the patient that he is going to perform tracheostomy suctioning, letting the patient know that it may be painful and may cause coughing
B) Uses a sterile kit, remaining sterile through the entire process of suctioning
C) During suctioning, the patient’s heartrate drops from 89 to 53 and the nurse reassures the patient that he is almost done
D) Suctions for about 10-15 seconds, only during withdrawal of the catheter

A

C) During suctioning, the patient’s heartrate drops from 89 to 53 and the nurse reassures the patient that he is almost done

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21
Q

causes of pulmonary edema

A

• Happens a lot in older folks –> decreased heart/kidney function
◦ HF
◦ Renal failure
◦ ARDS
◦ High altitudes
◦ Brain trauma
◦ Rapidly expanding lungs
— pneunothorax –> Pulling fluid off lungs too quickly when re-expanding the lung
◦ Most common: When giving too much fluid too quickly

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22
Q

on a patho level what is causing pulmonary edema (not diseases)

A

• Increased pulmonary pressure increases, fluid leaks across pulmonary capillaries into airway and tissue

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23
Q

who is highest risk of acute pulmonary edema

A

• HF, renal, older folks
• Laboring parents on a lot of fluid can happen
◦ Results from severe fluid overload

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24
Q

acute pulmonary edema assessment findings

A

• Coarse Crackles (especially in bases)
• Cough
• SOB
• Pink, frothy sputum**
• Dyspnea
• Confusion
• Tachy/Dysrythmias
• Altered BP (low , high, or normal)
• Reduced urinary output (low cardiac output)
• Restlessness/anxiety
• Lethargy

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25
interventions for pulmonary edema
• Reassurance • HOB raised • O2 increase • Monitor SpO2, Vital signs - Meds • FIX UNDERLYING CAUSES • Ultrafiltration • Use ABC’s • O2 ◦ Face mask ◦ Noninvasive positive pressure ventilation (Bipap cpap) ◦ Intubation/Mechanical ventilation
26
which drug reduces preload (pulmonary venous return) : diuretic, antihypertensive, or dobutamine
diuretic
27
which drug provide ionotropic support (heart contraction): diuretic, antihypertensive, or dobutamine
dobutamine
28
which drug reduces the afterload (systemic vascular resistance): diuretic, antihypertensive, or dobutamine
antihypertensive
29
goals for managing pulmonary edema long term? who do you want on the team for helping to manage them?
-manage underlying diseases that cause pulmonary edema -HF core measures ◦ Discharge instructions ◦ Left ventricular systolic function ◦ ACE or ARB ◦ Smoking cessation -• Activity as tolerated / Work up to routine exercise -case management/social worker
30
Take me through the patho of what happens when you have a PE
• Reduced gas exchange • Reduced oxygenation • Pulmonary tissue hypoxia • Decreased perfusion --> increases resistance in pulmonary vasculature --> increase work of R side of heart to push blood out into the lungs --> R sided HF --> poor perfusion to rest of body • Possible death
31
Most common cause of a PE =
DVT! VTE (venous thromboembolism)
32
When the DVT dislodge and goes into your pulmonary vasculature what happens to the right side of the heart?
becomes hard to the right ventricle to push blood into the lungs
33
What puts someone at increase risk of DVT/PE
• Increased age • Hypercoagulable states • Obesity • hypercoagulable state • Prolonged immobility • Central venous catheter • IV drug use • Sepsis
34
virchow's triad =
= increase risk of developing a blood clot from 1.) damage to vessel (trauma) 2.) immobility (stasis of blood flow) 3.) hypercoagulability
35
The best way to manage a DVT is to ....
prevent it!! use anticoagulant, mobility, SCD's
36
asssesment findings for PE
• Resp compromise • Dyspnea • Chest pain – stabbing, sharp ◦ heart attack = squeezing, crushing • Restlessness • Agitation • Cough • Bloody sputum from infarcted lung (Pulmonary Edema = pink frothy) • Abnormal breath sounds • Tachypnea • Tachycardia • Diaphoresis • Fever- inflammation • Petechiae (throwing blood clots, hemorrhaging of small capillaries) • Showering clots • Increased O2 demands • Hypotension from decreased cardiac output • Abnormal heart sounds • EKG changes
37
sputum with PE vs sputum with Pulmonary edema
PE = bloody from infarcted lung Pulm Edema = pink frothy
38
heart attack chest pain vs PE chest pain
heart attack = squeezing crushing PE = stabbing, sharp
39
this lab value tells us there is clot somewhere but not specifically where
D- dimer
40
gold standard for diagnosing a PE
pulmonary angiography
41
What do you do if you suspect someone has a PE?
get some help!!
42
3 priority responses for PE management
• ABG’s with normal limits • Give O2 to maintain SpO2 > 95% • Patient maintain baseline cognitive status
43
Interventions for PE
• HOB • Increase O2 to maintain SpO2 > 95% • Call RR • Reassure your patient • Assess, assess, assess ◦ Respiratory ◦ Cardiac ◦ Skin • Imaging • Prescribed anticoagulants (monitor bleeding!!)
44
Which anticoag med works the fastest?
Heparin
45
what labs do we check with heparin ? what labs do we check with warfarin?
heparin = ptt or APTT warfarin = INR
46
how soon do we check aptt or ptt with heparin
within 6 hours check ptt or aptt
47
if your patient is going for a prcedure and they are heparin how long do you have to wait after stopping the heparin for them to go have the procedure?
stops working within 1 hour of turning off the infusion
48
antidote for heparin? antidote for warfarin?
heparin= protamine sulfate warf = vitamin k
49
how long after stopping lovenox can patient or procedure?
12 hours
50
which are the 2 acute anticoags and who is our typical extended?
acute = heparin, lovenox extended = warfarin
51
How do we know the anticoagulant meds are working to treat the PE?
clot is getting smaller = breathing better
52
what do we do to treat hypotension related to HF from a PE
-in fluids -iv drug therapy -positive inotropic meds -vasopressors -vasodilators
53
what is a pulmonary contusion?
lung bruise ! fluid accumulates and takes up space, painful , can lead to resp failure
54
Pulmonary Contusion Assessment
• Trauma to the chest • Dyspnea • Hypoxemic • Decreased breath sounds • Crackles • Wheezes • Cough • Tachypnea- compensation- tire out, can't do it for a long time --> can lead to low CO2 and dehydration • Tachycardia- compensation • Shortness of breath • Pain (especially when breathing) • Shallow breathing- atelectasis--> pneumonia !
55
how is someone with a pulmonary contusion at risk for pneumonia?
• Shallow breathing (painful to breathe deep)- atelectasis--> pneumonia !
56
how does someone with a pulmonary contusion have risk for dehydration and low CO2
Tachypnea- compensation- tire out, can't do it for a long time --> can lead to low CO2 and dehydration
57
nursing intreventions for pulm contusion
• Apply oxygen • Bed position? - sitting up can hurt, spinal precautions can't sit up, it depends! • Minimize anxiety • Rest • IV Fluids needed Monitor! can decline quickly
58
typical cause of rib fracture?
blunt force to chest
59
types of secondary injuries a rib fracture?
◦ Pneumothorax ◦ Hemothorax ◦ Pulmonary contusion
60
rib fracture assessment and management
• Pain --> pain medication, some need so much pain medication that they lose drive to breathe --> mechanically ventilate • Splinting • Shallow breathing • If injury is uncomplicated: Relieve pain to optimize deep breathing (and avoid pneumonia and atelectasis)
61
3 characteristics that define a deep chest injury from rib fracture?
• Injury to first and second ribs • Injury to more than seven ribs • Expired volume of air is <15ml/kg • high mortality rate, likely intubated
62
what is flail chest ? when does it occur?
aradoxical chest wall movement caused by fractured ribs ◦ chest seeks in when you breathe not expand like normal -occurs with toher injuries, 2 or > broken ribs that become free floating
63
flail chest interventions
• Monitor vital signs, ABG’s • Assess for worsening respiratory status/ increased O2 demand • Oxygenate • Pain Relief • Pulmonary hygiene • Aggressive Respiratory care • Reduce anxiety
64
pneumothorax vs tension pneumothorax
Pneumothorax • Air enters the pleural space • Puts pressure on the lung --> lung collapses Tension Pneumothorax = Complete lung collapse involving air entering the lung without exit • Air enters pleura during inhalation, does not exit during exhale ◦ Increased pressure in chest cavity, puts pressure on other side of chest/ other lung can collapse ◦ Decreased cardiac output, puts pressure on heart ◦ can result in complete hemodynamic collapse
65
pneumothorax assessment
• Tachypnea • Subcutaneous emphysema • Pain • Diminished/ absent breath sounds on affected side • Reduced movement of chest wall • Increased O2 demand/ Shortness of breath
66
how does a chest tube treat a pneumiothorax?
◦ Inserted through chest wall ◦ Suctions air from the pleura ◦ Creates negative pressure in pleura ◦ Lung reexpands
67
causes of tension pneumothorax
• Blunt force trauma to chest --> regular pneumo can cause it • Mechanical ventilation • Chest tubes • Central venous catheter insertion
68
tension pneumothorax assessment
• Tracheal deviation (away from affected side) = hallmark finding of tension pneumothorax ◦ call a code! ◦ moves away from the side where the pneumo is --> all the pressure is pushing on the trachea • Asymmetrical thorax • Respiratory distress/ failure • Distended neck veins • Hypotension • Tachycardia • Confusion • Decreased/absent breath sounds • fluid is backing up and pressing on the heart, fluid can't go anywhere (everything but first 2 is same as cardiac tamponade)
69
tension pneumo interventions
• Needle Thoracostomy ◦ Large bore needle pokes through the pleural space not into lung • Chest tube placed after needle YOUR ROLE? • Support patient • Call for help • Assist provider • Monitor patient • Pain relief
70
bleeding into the pleura of lung =
hemothorax
71
causes of hemothorax?
• liver failure/ renal failure/ heart failure at greatest risk for developing due to extra fluid
72
hemothorax assessment
• Vary from no changes to severe • Respiratory distress • Diminished breath sounds
73
if chest tube output is > ___ cc / hour report it to provider
>50 cc = report!
74
ventilation vs perfusion
• Ventilation (V) AIR MOVEMENT • Perfusion (Q) BLOOD FLOW
75
what happens when ventilation and perfusion are mismatched?
When they do not match in the lung (or an area of the lung )--> Respiratory failure
76
is a PE a perfusion or ventilation issue?
perfusion
77
is pneumothorax a perfusion or a ventilation issue?
ventilation
78
causes of ventilation failure
• Drug overdose • Rib Fractures • Pneumothorax • Airway obstruction • Paralysis • Brain injury • Spinal Cord injury • Physical Problems with chest and lungs • Injury or failure of the respiratory control center • Inability to control function of respiratory muscles
79
causes of perfusion failure
• Pulmonary emboli • Pneumonia • Pulmonary edema
80
causes of combined oxygen and perfusion failure?
• Leads to worse respiratory failure/ hypoxemia than ventilation or perfusion failure alone • Abnormal lungs seen with –Chronic bronchitis –Asthma –Cystic fibrosis –Emphysema –ARDS
81
assessment findings for acute resp. failure? Heart rate? pulses? breathing style? bp? mental status?
• Dyspnea • Orthopnea • Respiratory Pattern • Lung Sounds • Pulse Oximetry • ETCO2 (end tidal co2 monitoring- Co2 breathing out at end of breath, 35-45) • ABG’s • Restlessness, agitation, irritability • Confusion • Change in LOC • Hypotension • Bradycardia • Weak pulses
82
interventions for acute resp. failure?
Oxygen, Oxygen, Oxygen • Treat underlying cause • Positioning • Assist with anxiety • Energy conserving measures
83
ARDS assessment findings
• Increased work of breathing • Loud breathing- adventitious breathing sounds • Cyanosis • Use of accessory muscles for breathing • Confusion
84
ards diagnostics (4)
• ABG • Chest X-ray • Sputum culture -- bacterial component for underlying thing we could treat like pneumonia • PF ratio (PaO2, FiO2 ration) <300 = indicative ARDS
85
why do a sputum culture with ards?
test for bacterial component for underlying thing we could treat like pneumonia
86
PF Ratio < _____ = indicative of ARDS
<300
87
Why do we give ARDS patients PEEP?
◦ alveoli collapsed at end of respiration in ARDS, give a little bit of positive pressure prevents collapse of alveoli ◦ a normal person does not have collapsed alveoli at end of breath becuase we have the surfactant we need to keep them open
88
why put ARDS patients in prone position?
◦ more alveoli in posterior portion of lungs, proning allows for their expansion
89
how long can a person have an ET tube in?
<10-14 days
90
can you put an ET tube in your nose?
sure betchya
91
how far down do we want the ET tube to be?
2 inches above the carina
92
who can put in an ET tube?
◦ Anesthesiologist, Critical Care Provider, Hospitalist (and more) ◦ Respiratory Therapist ◦ Certified Nurse Anesthetist in other terms- NOT YOU. not for RN!
93
doctor says- lets intubate! what are you going to do my new nursing school grad?
• Provide oxygen • Lift head of bed • **Keep talking to your patient ** • Call for help/ Coordinate care • Gather supplies • Assess, assess, assess
94
3 meds we are giving for intubation- sedation, anaglesics, and paralytics: which one do we give first?
sedation *not everyone gets a paralytic
95
how long do we limit the intubation attempt time to?
30 seconds
96
how often do we monitor the BP during intubation?
every 5 minutes at least
97
how do we verify ET tube placemnt?
xray waveform capnography auscultation bronchoscope esophageal detector
98
priority for maintaining ET tube function after palcement
frequently check that it is in the correct place --> look at number
99
being intubated puts patients at risk for ______ later in life
delirium
100
do we put restraints on all intubated patients?
nope! only if they needs --> consider using a mitt instead
101
DOPE is an acronym for complications from intubations, what does it stand for? whats the last thing you check for?
• Dislodgement • Obstruction (sputum) • Pneumothorax • Equipment failure (last thing you should be checking for)
102
which side is more common for ET tube misplacement ?
right side- most common, bigger and straighter
103
• Your patient is intubated and is becoming agitated, moving around the bed a lot. You notice that he becomes tachypneic and tachycardic and his SpO2 falls from 94% to 87%. Upon your assessment, he has diminished breath sounds on the left. You check the ET tube placement and note that the ET tube is no longer 24 cm, as you documented this morning. It is now 27 cm at the lips. Your first action is to • Notify the provider • Notify Respiratory therapy • Order a PRN x-ray • Move the tube back to where it was on your morning assessment
• Notify the provider
104
re mechanical ventilation FiO2 % should be between
21-100
105
Vent resp rates should be
10-14
106
what is the tidal volume?
air going in or air goig out (7-10 mL/kg)
107
the higher the peep the ____ the risk of damaging the alveoli
the > the risk
108
interventions for intubated patient
• ANXIETY • Suctioning as needed, 5-10 sec, preoxygenate, <3 passes • Oral Care - every 2 hours • Head of Bed >30 degrees • Pulmonary hygiene • Mobility • Delirium prevention- assess every shift , reorient, day and night differential • Chlorhexidine bath daily from neck down (no genitals) for every ventilsted person • Anti-Acid pharmacologic agent- risk of stomach acid in lungs • Nutrition
109
head of bed for intubated patient = > __
30 degrees
110
why do we give ant acids for intubated patients?
risk of stomach acid in liungs
111
what is really important for preventing delirium in ICU?
orient to day nad night
112
ventilatior complications include....
• Hypotension • Barotrauma • Pneumothorax • Pneumomediastinum • Volutrauma • Atelectrauma • Biotrauma • Ventilator-associated lung injury • Ventilator-acquired pneumonia • Peptic Ulcer • Malnutrition • Failure to Wean • Muscle Deconditioning
113
ACDEF ventilator bundle =
• Awake(TURN OFF SEDATION) • Breathe (TRIAL) • Coordinate/ Choice of sedation (RN/RT • Delirium Prevention • Early Mobility • Family Presence
114
extubating requires what from the provider?
an order to do so
115
what do we assess for with extubation?
• Assess your patient’s ability to remain off ventilator • Assess for stridor

Kol- 410 Med Surg II (27 decks)

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