Exam 2 Flashcards
1
Q
What are the 5A’s for treating smoking use and dependence?
A
- Ask about tobacco use: Identify and document tobacco use status for every pt at every visit
- Advise to quit: in a clear, strong, and personalized manner, urge every tobacco user to quit
- Assess willingness to make attempt to quit: Is the user willing to make an attempt at quitting?
- Assist in attempt at quitting: offer medication and provide counseling or referral for additional Rx
- Arrange follow-up: for pt willing to attempt to quit, arrange F/U contacts beginning with 1st week after quit date
2
Q
What are examples of pulmonary tests that can be performed?
A
Pulmonary function test
CT Scan (PE Protocol)
VQ Scan/MRI
CXRay
Bronchoscopy
Thoracentesis
Sputum cultures
3
Q
What is the gold standard to rule our a PE?
A
CT scan
4
Q
If someone is hypoventilating, their end total CO2 will be…
A
High
5
Q
If someone is hyperventilating, their end tidal CO2 will be…
A
Low
5
Q
A capnography lower than 40 indicates hypo/hyperventilation.
A
hypoventilation
6
Q
What is normal pH levels?
A
7.35-7.45
7
Q
What is the normal range for PaCO2?
A
35-45mmHg
8
Q
What is the normal range for HCO3?
A
22-26 mEq/L
9
Q
What is the normal range for PaO2?
A
80-100mmHg
10
Q
What medications might be used in a patient in respiratory distress?
A
Bronchodilators: B2-adrenergic agonists, anticholinergic agents
Anti-inflammatory: corticosteroids
Mucolytics: guaifensin, N-acetylcysteine neb
Antibiotics: broad spectrum until C&S back
11
Q
What important medication might you see with a patient experiencing pulmonary edema?
A
Diuretics
12
Q
Where does arterial blood gas sampling occur?
A
radial, brachial, or femoral arteries (no tourniquet needed)
13
Q
What needs to be done before a radial stick occurs?
A
Allen’s test
14
Q
Why do ABGs need to go on ice?
A
Reduce oxygen metabolism, get more accurate reading of PaO2
15
Q
What does a positive Allen’s test mean?
A
Ulnar is patent
16
Q
Why would your PaCO2 go up?
A
Hypoventilation
17
Q
What is the indication for chest tubes?
A
To drain fluid or air from the thoracic cavity, in the pleural space
- Hemothorax
- Pneumothorax
- Tension pneumothorax
- Pleural effusion
18
Q
What happens in a tension pnemothroax?
A
Air in the pleural space increasing and unable to escape. Pushes EVERYTHING to the unaffected side
19
Q
What is the treatment for a tension pnemothroax?
A
Needle decompression
20
Q
What is happening during pleural effusion?
A
fluid between pleural space
21
Q
If pleural effusion is spontaneous, what is that an indication of?
A
Cancer
22
Q
What are the three parts of a chest drain system?
A
Collection Chamber
Water Seal Chamber
Collection Apparatus
23
Q
What does an air leak in a chest drain system mean?***
A
Bubbling on inspiration and expiration (abnormal finding but expected)
In the underwater seal
24
What is tidaling?***
Normal finding. Rise and fall of water in water seal chamber.
Should rise with inspiration and fall with expiration (opposite when someone is mechanically ventilated)
25
What should be assessed and managed with pts with chest tubes?
-VS and CV/Pulm assessment q2
-Check tubes for patency
-Monitor and mark drainage q1, q4,q8
-Assess for airleaks and that connections are sealed
-Assess patient for pain
-Assess CT insertion site
-Change dressing per unit policy/procedure
26
How does having a chest tube system lead to atelectasis?
Pain from chest tubes
More shallow breaths
Days of shallow breaths lead to atelectasis
Need to offer pain meds***
27
What is being monitored with a chest tube system?
Water seal
Drainage
Positioning
Complications
28
What do you do during a chest tube dislodgment/accidental removal?
Grab petroleum gauge and cover hole
29
What are the goals of intubation?
-Maintain alveolar ventilation appropriate for pt's respiratory and metabolic needs
-Correct hypoxemia and maximize oxygen transport
-Protect the airway
-Alleviate respiratory distress
-Prevent or reverse atelectasis
-Acid/base balance
30
What equipment is needed to intubate someone?
-Laryngoscopes
-Blade
-Working lightbulb
-ET tube (Fr 7, 7.5, 8 in size)
-Stylet
-Stethoscope
-Syringe (10mL) to inflate cuff
-Tape (holds tube in place)
-O2 source and ambu bag
-Capnography + Pulse Ox
-Medications for sedation and paralytic
31
What are examples of neuromuscular blockers?
Vecuronium
Succinylcholine
Rocuronium
Pancuronium
32
What are examples of sedative medications?
Etomidate
Propofol
Midazolam
33
How do you confirm placement of the ET tube?
Bilateral breath sounds
Colormetric CO2 detector
"Misting" in the tube
CXR
Capnography Waveform
34
What is the most common mode of ventilation?
PRVC - Pressure Regulated Volume Control
35
What determines alveolar ventilation?
Minute ventilation (MV = RR x TV)
36
What is the starting RR for intubated patients?
10-12 breaths per minute
37
What is the starting TV for intubated patients?
6-8 mL/kg (no more than 10)
38
What must be done whenever settings are changed on the ventilation?
Draw ABGs within 20-30minutes
39
What can cause the "high pressure" alarm to set off?***
-Increased airway resistance (coughing, agitated pt biting the tube, secretions, broncospasms, kinks in circuit)
-Decrease lung compliance (pulmonary edema, pneumonia, ateletisis, pneumothorax)
40
What can cause the "low pressure" alarm to set off?***
Disconnection in tubing/system
Electrical failure
41
What are examples of ET Tube complications?
Oral vs Nasal
Lip, tongue, teeth, tracheal damage
Mucous plugs***
Pt bites tube
Sinusitis
Fistula
Granulomas
Infection
Cuff ulcerations
42
What is VAP?
Ventilator Associated Pneumonia
43
What is included in the VAP bundle?
Oral care
HOB 30-45 degrees
GI prophylaxis
DVT prophylaxis
OOB
44
What are the numbers of oxygenation under the Berlin definition?***
Mild: 200 < PaO2/FiO2 <= 300mmHg
Moderate: 100 < PaO2/FiO2 <= 200mmHg
Severe: PaO2/FiO2 <= 100mmHg
45
What is the timing of ARDS under the Berlin definition?
Within 1 week of a known clinical insult or new or worsening respiratory symptoms
46
What is the level of normal PaO2/FiO2 ratio?
Greater than 300 is normal
47
What are the four criteria for SIRS?
fever >38.0°C or hypothermia <36.0°C,
tachycardia >90 beats/minute,
tachypnea >20 breaths/minute,
leucocytosis >12*109/l or leucopoenia <4*109/l
48
What are the stages of ARDS?***
Stage one: first 24 hours
Stage two: 24-48 hours
Stage three: 2-10th day
Stage four: after 10 days
49
What are the symptoms of the different stages of ARDS?***
Stage one: first 24 hours (tachypnea)
Stage two: 24-48 hours (further tachypnea, dyspnea, tachycardia, clear breath sounds)
Stage three: 2-10th day (need intubation to maintain O2, high FiO2 %, diffuse crackles, high PEEP, tachycardic, hypotension, vasopressors)
Stage four: after 10 days
50
What are the three criteria of ARF?***
PaO2 < 55-60mmHg (hypoxemia)
PaCO2 > 50mmHg (hypercapnia)
pH < 7.35 (respiratory acidosis)
51
What is the pH imbalance of ARF?
Respiratory acidosis
52
Which each cardiac cycle, how much blood of cardiac output is pumped to the kidneys?
21% of cardiac output
53
What are the functions of the kidneys?
-filtration and excretion
-fluid, electrolyte and acid/base balance
-blood pressure regulation
-stimulation of RBC production
-regulates calcium reabsorption in the bone
54
How many nephrons are in each kidney?
1 million in each kidney, 2 million total
55
What are examples of nephrotoxins?****
-Contrast dye
-ACEs/ARBs
-Loop/thiazide diuretics
56
Define ventilation.
movement of air btw atmosphere and the alveoli-by inhalation/exhalation, higher to lower pressure
57
Define alveolar ventilation
volume of fresh gas entering respiratory zone available for gas exchange per minute
Inversely proportional to PaCO2 (if rapid breathing, alveolar vent is increased and CO2 decreases; if slow breathing, alveolar vent is decreased, and PaCo2 levels increase
58
Is work of breathing a passive or active process?
Expiration is a passive process caused by elastic recoil of the lung. During inspiration, WOB takes place
59
Define diffusion
exchange of O2 ad CO2 btw pulmonary capillaries and alveoli
60
What factors affect diffusion?
-surface area available for diffusion
-thickness of alveolar-cap membrane,
-partial pressure of gas across the membrane
-solubility and molecular characteristics of the gas
61
Define perfusion
flow of blood through the pulmonary capillary bed
62
How does body position affect perfusion?
Sitting upright: the bases of the lungs are better perfused than the apexes
Supine: apex to base are perfused evenly, but posterior better perfused than anterior/reverse for prone b/c of gravity
63
What are other functions of the lungs?
-Acid base balance (CO2)
-Metabolism of certain compounds (inhaled corticosteroids)
-Filtration/Warming
64
What are the nurse's role pre-intubation?
Place patient on the monitor
Know patient’s history and allergies
Prepare the equipment
Manage the airway
Oxygenate/ventilate the patient
Prepare the medications
Suction PRN
65
What are the nurse's role during intubation?
Watch the monitor (SpO2)
Auscultate breath sounds BILATERALLY!!! And over abdomen
Inflate cuff
Secure tube
Bag until vent arrives
Order chest xray
Note the tube placement.
66
What is a severe adverse effect of succinylcholine?
Malignant hyperthermia (causes high temps and can lead to rhabdo and death)
67
What is the role of the nurse post-intubation?
Adjusting the vent setting/parameters per protocol
Responding to alarms
Recognizing and managing complications
Nursing management of tube:
Humidification
Cuff management
Suctioning
Communication
Oral hygiene
68
What is the importance of humidification of the ETT or trach?
Add water to the inhaled gas to:
PREVENT drying and irritation of resp tract
PREVENT undo loss of body water
FACILITATE secretion removal
69
What are characteristics of cuff management for ETTs or trachs?
-Use only low pressure, high volume cuffs.
-Need to monitor cuff inflation pressures AT LEAST once a shift (20-25 mmHg)
70
Is suctioning a sterile or clean procedure?
Sterile.
71
What are the complications of suctioning ETTs or Trachs?
-Hypoxia
-Too large a suction catheter puts too much negative pressure and cause collapse of airways = atelectasis
-Bronchospasm from stimulation of airways
-Bradycardia due to vagal stimulation
-Trauma
72
What are the rules for length and duration of suctioning?
-Provide 3 hyperoxygenation breaths before and after each pass of catheter
-No more than 15 seconds of suction
-No more than 3 passes
-We DO NOT instill saline prior
73
Why is oral hygiene important for ventilators?
Oropharyngeal secretions pool at cuff; increased risk of seeping below cuff and into airways, setting up VAP
74
The iron lung is an example of (negative/positive) pressure.
Negative pressure - used in the polio epidemic in the 1930s/40s
75
What ventilator controls are most important for nurses?
Mode, FiO2, resp rate, tidal volume or pressure, PEEP
76
What ventilator mode is used for weaning?
Pressure support/CPAP
77
An FiO2 > 60% for more than 24 hours puts patients for great risk of...
oxygen toxicity
78
What should FiO2 be when suctioning a patient?
100%
79
How does oxygen toxicity occur?
-Starts to occur in patients who have been receiving > 60% FiO2 for longer than 24 hours
-Damage occurs at the alveolar level with capillary leaking
-May lead to pulmonary edema and acute lung injury if FiO2 is left high for several days
-Damage can be reversed if O2 levels are decreased
80
What is the definition of TV?
number of MLs of air to be delivered with each breath
81
What is the definition of RR?
number of breaths the vent delivers
82
How does inadvertent hyperventilation occur?
will result in resp alkolosis-associated with serum electrolyte shifts and arrhythmias
83
What is part of "lung protective ventilation?"
-Low TV***
-Permissive hypercapnia
-Relative hypoxemia
-Low plateau pressure
84
What does PEEP stand for?
Positive End Expiratory Pressure
85
What is PEEP?
Positive pressure delivered at end of expiration to keep alveoli open
86
When are low and high PEEPs used?
-Low pressures (2-5cm H2O) adequate to maintain SaO2 or PaO2 in most patients
-Higher pressures (8-10cm H2O) in patients with refractory hypoxemia (ARDS)
87
In a patient with more critical issues of oxygenation, their PEEP requirement is (higher/lower).
Higher
88
What are the drawbacks of a higher PEEP?
Impedes venous return, causes decreased cardiac workload, bc of decreased circulatory flow, but can cause hypotension; heart then needs to compensate for decreased BP, ends up working harder
89
Why should you avoid nasal intubations as much as possible?
more infections from sinusitis
90
Why should you move an ET tube side to side each few days?
To prevent pressure injuries (HAPI)
91
What ET tube complication can occur with long term use intubation?
Laryngeal granulomas (inflammation and ulceration); after 2 weeks, insert trach
92
Aspiration can increase the risk of what respiratory illnesses?
VAP or ARDs
93
What is an appropriate cuff pressure?
20-25 mmHg
94
What can be done to minimize the risk of aspiration?
Always put NG tube down
Suction mouth, pharynx prior to turning
HOB > 30 degrees if possible
95
What is a barotrauma?
rupture of alveoli due to ventilation/PEEP that can lead to tension pneumothorax
96
What are s/s of barotrauma?
Pain, dyspnea, decreased breath sounds on affected side, increased peak inspiratory pressures
This all leads to hypotension, bradycardia, and cardiac arrest.
97
During a needle decompression for a tension pneumothorax, where is the needle inserted?
IC space 2
98
What is ventilator associated pneumonia (VAP)?
-Hospital acquired nosocomial pneumonia in a pt who has been intubated for at least 48 hours
-Second most common HAI
-Intubated pts have 10 fold incidence
99
What are the risk factors for VAP?
Orophar and gastric colonization; aspiration, compromised lung defenses, mech ventilation, re-intubation, self-extubation, supine position
100
What are nursing measures to prevent VAP?
-Meticulous hand washing
-Wearing gloves when suctioning ETT
101
What is included in oral care for VAP?
Teeth brushing, antiseptic solutions and alcohol free mouthwash, apply water soluble moisturizer, frequent oral suctioning
102
What are some causes of hemodynamic instability?
-Decrease of CO and hypotension
Leading to...
-Lack of sympathetic tone
-Decreased venous return
-Secondary to the effects of positive pressure ventilation and increase intrathoracic pressures
103
What is the nursing intervention for fluid imbalance?
Need to give IV fluid resuscitation to increase circulating volume
104
What complications can come from immobility of intubated patients?
Muscle wasting, weakness and contractures, loss of skin integrity, pneumonia, DVT with PE, constipation and ileus
105
What complications can come from GI problems of intubated patients?
Distention, hypomotility, ileus (bc of immobility and narcotics), vomiting, breakdown of intestinal mucosa leading to bacteremia, stress ulcers
106
What complications can come from muscle weakness of intubated patients?
-Deconditioning and atrophy
-Respiratory muscles need re-training
107
What are the nurse's responsibility in weaning trials?
-Monitor VS
-Monitor level of anxiety
-Support and encourage the patient emotionally
-Patient positioning – reverse trendelenberg and/or semi- to high-Fowler’s position may improve respiratory movements
-Suction when needed
-Provide a stress free environment – no baths, diagnostic tests, or unwanted visitations
108
What are the components of the readiness criteria for weaning trials?
-Hemodynamically stable
-Core temp > 36, < 39
-Cxray-no abnormal findings, treat pathology prior
-SaO2 > 90% on FiO2 of < 40% and PEEP of 5 or less
-ABG and major electrolytes WNL or baseline for patient
-No residual paralytics
-Hematocrit > 25%
-Adequate pain/anxiety/agitation management
109
What is needed to fully evaluate weaning failure?
ABGs
110
What does weaning failure look like?
Decrease in LOC
SBP increase/decrease by 20 mmHg
DBP > 100 mmHg
HR increase by 20 bpm
PVCs, runs of VT
ST elevations
RR > 30, < 10
RR increase by 10 bpm
Spont TV < 250 ml
PaCO2 increase by 5-8 mmHg, or pH < 7.30
O2 sat < 90%
Diaphoresis
Severe agitation/anxiety unrelieved by reassurance
Paradoxical chest wall motion
111
What are the expected outcomes of post-extubation?
-Patent airway is maintained
-No signs of respiratory distress
-No increased WOB
-Lungs are clear to auscultation/baseline for patient
-Pt is without evidence of atelectasis
-Peak, mean and plateau pressures are WNL
-ABGs are WNL
112
What complications should be observed post-extubation?
Laryngospasm
Aspiration
Laryngeal and tracheal edema
Tracheal stenosis
Vocal cord paralysis
Laryngeal ulceration
Hoarseness and sore throat
113
What are the nursing steps for extubation?
Have the intubation cart/ intubation kit handy!
Educate the patient
Pre-oxygenate the patient
Suction ET tube and mouth
Deflate cuff
Pull tube
Supplemental oxygen – generally a face mask
Observe response – ABG + observe RR, quality of Resp, O2 Sat, Breath sounds
Close monitoring of VS and all hemodynamic parameters
Good pulmonary toilet
114
Which acute respiratory disorder is an inflammatory lung injury resulting in hypoxemia?
ARDS
115
What are examples of direct injury to the lungs that causes ARDS?
Gastric Aspiration
Near Drowning
Toxic Inhalation
Diffuse Pneumonia
Pul contusion
Pulm vasculitis
116
What are examples of indirect injury to the lungs that causes ARDS?
Non pulm Sepsis
Severe Pancreatitis
Multiple Trauma
Burns
Shock
Multiple Transfusions
Neurogenic States
Anaphylaxis
Eclampsia
Tissue Necrosis
DIC
Transfusion-related acute lung injury (TRALI)
Drug overdose
117
What is the most common cause of ARDS?
Sepsis
118
ARDS is considered a complex syndrome rather than one specific disease. What were the common symptoms associated with ARDS?
1) acute tachypnea
2) decreased lung compliance
3) diffuse pulmonary infiltrates
4) hypoxemia, despite supplemental O2
119
What are the components of the Berlin definition and explain their criteria?
Timing: symptoms being within one week of clinical insult or new/worsening respiratory symptoms
Chest imaging: bilateral opacities not fully explained by sirseffusions, lobar/lung collapse, or nodules
Origin of edema: resp failure CANNOT be explained by cardiac failure or fluid overload alone
Oxygenation (moderate to severe impairment of O2)
120
What are the simple components of the Berlin definition?
Timing
Chest imaging
Origin of edema
Oxygenation
121
What is the definition of ARDS oxygenation severity according to the PaO2:FiO2 ratio?***
> 300 Normal
200-300 Mild
100 -200 Moderate
= or < 100 Severe
122
What disease processes cause physiological shunts to occur?***
PNA, atelectasis, tumor or mucous plug
123
What is physiologically happening with a low V/Q ratio?***
the alveoli with no ventilation but normal perfusion
PHYSIOLOGICAL SHUNT: blood passes by alveoli without gas exchange occurring
124
What is physiologically happen with a high V/Q ratio?***
alveoli with normal V but no Q
ALVEOLAR DEAD SPACE: alveolus has inadequate perfusion available, and gas exchange cannot occur
125
What disease processes cause alveolar dead space to occur?***
PE, cardiogenic shock, anatomic shunt, and mechanical ventilation with high tidal volumes
126
What is a silent unit?***
Alveoli with no V and no Q
Both ventilation and perfusion are decreased
Seen in pneumothorax or severe ARDS
127
What are the 4 criteria of SIRS?
fever >38.0°C or hypothermia <36.0°C,
tachycardia >90 beats/minute,
tachypnea >20 breaths/minute,
leucocytosis >12*109/l or leucopoenia <4*109/l
128
What is SIRS?
Systemic Inflammatory Response Syndrome
129
Between ARDS and SIRS, which is an inflammatory response that affects the whole body?
SIRS, an lead to multisystem organ dysfunction with the respiratory system usually being the first affected
You have an overly aggressive host defense - response to insult or tissue damage in the body. Caused by macrophages, with granulocytes as the targeted tissues
130
What are the 3 pathophys hallmarks of ARDS?***
Change in lung vascular tissue
Increased lung edema
Impaired gas exchange
131
What are the mediators responsible for the cascade of organ damage in ARDS?
-Inflammation (bradykinin, histamine. tumor necrosis factor)
-Coagulation (microthrombi & fibrin deposition)
-Activation of hypothalamic-pituitary-adrenal axis during stress (release of catecholamines, termination of host defense response)
132
What are the s/s of Stage 1 of ARDS?
First 24 hours
Early: May see restlessness, increased resp rate; dyspnea and tachypnea. Moderate to extensive use of accessory muscles
No changes on xray yet
ABG may show resp alkalosis
133
What are the s/s of Stage 2 of ARDS?
24 hours - 48 hours
Severe dyspnea, tachypnea, cyanosis and tachycardia, increased agitation and restlessness
Coarse bilateral crackles
Decreased air entry into dependent lung fields
CXR: patchy bilateral infiltrates
ABG decreased SaO2 despite supplemental O2
134
What are the s/s of Stage 3 of ARDS?
2 to 10 days
Decreased air entry bilaterally
Impaired responsiveness, Decreased gut motility, generalized edema
CXR: decreased lung volumes
ABG: worsening hypoxemia
135
What are the s/s of Stage 4 of ARDS?
Symptoms of MODS (decreased urine output, poor gastric motility and symptoms of impaired coagulation) or you can have single –system involvement (respiratory) with improvement over time
CXR: Pneumothoraces pneumos
Surfactant damaged causing alveolar collapse
ABG Worsening hypoxemia and hypercapnia (more shunting now)
136
What is the nursing care if the cause of ARDS was sepsis?
Fluid support, perhaps pressors, abx
137
What are the goals of ARDS care?***
Patent airway will be maintained
PaO2:FiO2 ratio of 200-300 or more maintained
Lung-protective strategies used (low VT, avoid maintaining high oxygen)
Oxygenation maintained (PaO2 of 55-88 mmHG with SaO2 88-95%)***
138
What complications can come from oxygen toxicity?
collapsing of alveoli, seizures, and disorientation
139
What are secondary complications of ARDS?
-Ventilator assisted/induced lung injury (VALI/VILI; barotrauma/volutrauma)
-SIRS
-Multisystem organ dysfunction (MODS) due to hypoxemia
-PE, DVT, atelectasis, and nosocomial infections due to immobility
140
What is characterized by sudden and life-threatening deterioration of gas exchange, resulting in CO2 retention (hypercapnia) & inadequate oxygenation (hypoxemia)?
Acute respiratory failure
141
Is ARDS a type of respiratory failure?
Yes. Every patient in ARDS is in respiratory failure, but not every respiratory failure patient is in ARDS
142
What do the ABGs of a patient in acute respiratory failure look like?***
PaO2 < 55-60 mmHg Hypoxemia
PaCO2 > 50mmHg Hypercapnia
pH < 7.35 Severe acidosis
143
What are the two classifications of acute respiratory failure?
Acute Hypoxemic Respiratory Failure
Acute Hypercapnic Respiratory Failure
144
What are the qualifications for acute hypoxemic respiratory failure?
Defect in oxygenation
PaO2 of < 55-60mmHg
145
What are the qualifications for acute hypercapnic respiratory failure?
Defect in ventilation
CO2 > 50mmHg
146
What are characteristics of acute respiratory failure?
Decreased ventilatory drive (narcotics, ETOH, brainstem lesion)
Resp muscle fatigue or failure (ALS, Guillian-Barre)
Increased WOB (COPD, asthma, rib Fx)
147
What pt signs and symptoms would warrant immediate intubation?
Coma, change in MS, low or agonal breathing rate, obvious muscle fatigue, cyanosis, or impending cardiac arrest
148
What are signs of hypoxemia?
Dyspnea
Cyanosis
Restlessness
Confusion
Anxiety
Delirium
Tachypnea
Tachycardia
HTN
Arrhythmias
149
What are s/s of hypercapnemia?
Dyspnea
Headache
Peripheral/conjunctival hyperemia
HTN
Tachycardia
tachypnea
Impaired LOC
Asterixis
Use of accessory muscles
Intercostal/supraclavicular retraction, paradoxical abdominal movements
150
What do you do if supplemental oxygen is not enough and you need to move to mechanical help?
Intubate
151
What are s/s of acute respiratory failure?
Flaring nostrils
Strap muscles of neck
Cephalad sternal vector
Abdominal paradox
Pulsus paradoxus
Notch retraction
Intercostal retraction
152
What is the nursing management for acute respiratory failure?
Airway: intubate and ventilate
O2: restore and maintain oxygenation
Correct Acid-Base disturbance
Restore Fluid/electrolyte balance
Optimize cardiac output
Treat underlying cause
153
What are the goals of in acute respiratory failure management?
Patent airway will be maintained
Oxygenation will be maintained (PaO2 of 80-100 mmHg with SaO2 > 90%)
ABGs will be within normal limits
154
What are the functions of the kidneys?
Filtration and excretion
Fluid, electrolyte and acid/base balance
Blood pressure regulation
Stimulation of RBC production
Regulates calcium reabsorption in the bone
155
Where does acetazolamide work on the nephron?
Proximal convoluted tubule
156
Where do osmotic diuretics (mannitol) work on the nephron?
Proximal convoluted tubule
157
Where do loop diuretics (furosemide) work on the nephron?
Prevent reabsorption of Na and K in ascending loop of Henle
158
Where do thiazides (HCTZ) work on the nephron?
Prevents Na reabsorption in distal convoluted tubule
159
Where do potassium-sparing diuretics (spironolactone) work on the nephron?***
Works in distal convoluted tubule to prevent reabsorption of Na
160
What is the MOA of ARBs?
Blocks receptors thereby promoting vasodilation, Na and H2O excretion
161
What is the MOA of ACE inhibitors?
-Prevents conversion of Angiotensin 1 to angiotensin 2
-Stops Na secretion, stops ADH production, stops arteriolar vasoconstriction
162
Describe how renal blood flows.
Kidneys receive blood from renal artery which branches into AFFERENT arteriole, then into capillaries called GLOMERULUS where filtering takes place. Leaving the Glomerulus is the EFFERENT ARTERIOLE
163
How is GFR measured?
-GFR measured by creatinine bc it is never secreted or reabsorbed
-GFR is relatively stable over a wide range of BP because of auto-regulation.
164
What is normal GFR?
> 60
165
What are the two most important risk factors for kidney disease?
DM, HTN
166
What Review of Systems questions are important to ask regarding renal function?
Urine output
Back pain
Abdominal pain/N/V
Rashes/itching
Leg swelling
Shortness of breath
Fever
167
What physical assessment data is relevant to renal function?
Urine
CVA tenderness
Abdominal tenderness
Skin
Edema
Lung sounds
Vital signs
168
How do you assess volume status?
VS, JVD, crackles, wheezes, S3 or S4, tongue and mucous membranes, check for ascites and the fluid wave, edema, weight gain
169
What skin assessments are relevant to renal function?
color, bruising, bleeding, skin turgor, dry, itchy, “Uremic Frost”
170
What does CVA tenderness indicate?
may indicate an infection, check temp. Ask about freq, hesitancy, urgency, burning, blood, incontinence, lower back pain
171
What are the nursing interventions when a patient has a AVF?***
listen for bruit. It will be continuous; feel for the thrill. It will be a vibrating purr. If these have changed: MEDICAL EMERGENCY and Call MD
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What does a positive Chvostek’s sign indicate?
hypocalcemia
173
What does a positive Trousseau sign indicate?
hypocalcemiaa, hypomagnesimia, and metabolic alkalosis
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What is azotemia?
When BUN/Creatinine is elevated
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How can dehydration affect Na+ levels?
hypernatremia
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What should not be present in urine?
There should be no protein, ketones, glucose, casts (sign of renal disease with inflammation), WBC, blood
If + WBC, bacteria, nitrite, leuk esterase: + infection and we can EMPIRICALLY start AntiBx
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What is a KUB xray?
kidney-ureter-bladder
Can see stones, size of kidneys and hydronephrosis
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What is a Renal US or Renal Artery US?
looks for renal artery stenosis—hard to control BP if have RAS, can stent
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Post biospy of the kidneys, what should be done?
assess for internal bleeding
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What are the radiology tests for kidney function?
KUB X-ray
CT abdomen/pelvis
MRI
Pyelogram
Renal US/Renal Artery US
Kidney biopsy
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What are the stages of Chronic Kidney Disease?
< 60 – starts mild kidney injury
< 30 – moderate
<15 - ESRD
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Prerenal, intrarenal, or postrenal:
Due to damage to the glomeruli, tubules, or interstitium (damage to the renal parenchyma)***
Intrarenal
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Prerenal, intrarenal, or postrenal:
Due to damage/obstruction along the urinary tract system***
Postrenal
184
Prerenal, intrarenal, or postrenal:
Due to true volume loss or decreased effective arterial blood volume***
Prerenal
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What are the causes of prerenal injuries?
Hypovolemia
Shock states
Decreased cardiac output
Excessive diuresis (meds or hyperglycemia)
186
What are the treatments for prerenal injuries?
Often reversible with early intervention
Treat underlying cause (IVF, pressers, inotropes)
187
What are the causes of intrarenal injuries?
Prolonged hypoperfusion***
Nephrotoxic drugs
IV contrast
Diabetes
Hypertension
Rhabdomyolysis
Acute tubular necrosis-most common cause
Think about CT scans and cath; usually wont do if cr > 1.3; can also cause cr to rise peaking at 48 hours post contrast dye load
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What are the treatments for intrarenal injuries?
Stop nephrotoxic meds, hydrate, treat underlying chronic diseases
189
What is the most common cause of renal failure?
Acute Tubular Necrosis (ATN)
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What can cause ATN?
Nephrotoxic drugs (Damage to epithelial layer):
Antibiotics
Contrast media
Heavy Metals
Environmental chemicals
Ischemic origin (Basement membrane damage):
Hypovolemia
Decreased cardiac output
Systemic vasodilation
DIC
Renal vasoconstriction
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What are the causes of postrenal injuries?
Prostate disease-prostatitis, BPH
Cancer
Large kidney stones (calcium, uric acid, struvite, cystine)
192
What are the treatments for postrenal injuries?
Remove obstruction; foley insertion to empty bladder when have uropathy
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What are the risk factors for chronic kidney disease (glomerulosclerosis)?
The dysfunction occurs because of the fibrotic changes to tissue over time
age, DM, HTN, AKI, high cholesterol
194
What are the treatments for chronic kidney disease?
Monitor labs
Avoid nephrotoxic drugs
Encourage PO hydration
ACE and ARB is renal protective in early disease
Manage comorbid conditions
195
What are the indications for RRT?
196
What are nephrotoxic drugs?
197
Why is an ACE inhibitor renal toxic and protective at the same time?
198
What are the origins of ATN?
Nephrotoxic drugs and ischemia
199
Complications of CRRT?
Hypotension and hypothermia
200
How is dialysis accessed?
Graft or Fistula
201
What patient teaching is needed for diaylsis?
Cannot miss a dialysis
202
What patient teaching is necessary for a patient who undergoes dialysis?***
Signs of infection
Hemorrhage from dialysis access
Aneurysm or pseudoaneurysm of access
Hypotension/hypertension from fluid imbalance
Thrombosis of dialysis access
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What are the signs of peritonitis?
Low grade temp
Abdominal pain
Cloudy drainage
204
How do you treat periotitis?
Treated with broad spectrum antibiotic
205
What are the nursing interventions for the retained dialysate in peritoneal dialysis?
-Should drain equal or more than put in to dwell
-Check tubing, reposition patient, lower the drainage bag, assess for s/s of fluid overload, fullness, or discomfort
206
Why would a patient get CRRT rather than normal HD?***
-reserved for very sick, hemodynamically unstable
-ICU patients who cant handle the large fluid shifts of hemodialysis
207
What are the four cardinal symptoms of respiratory dysfunction?
Dyspnea
Chest pain
Sputum production
Cough
208
What diseases/illnesses are associated with friction rub?
pleural effusion, pneumothorax
crackling, grating sound heard more often with inspiration
209
What diseases/illnesses are associated with rhonchi?
bronchitis, pneumonia
deep, low-pitched rumbling noises that are sometimes referred to as sonorous wheezes or gurgles
210
How do you distinguish between a pericardial rub and pleural rub?
ask to hold breath, if don’t hear it, it is friction rub. If hear it with heart beat, it is pericardial rub
211
What diseases/illnesses are associated with stridor?
Croup, after extubation indicating edema
harsh, high-pitched inspiratory sounds often described as crowing as air passes through constricted trachea
212
What are the 5 A's of tobacco?
Ask about tobacco use
Advise to quit
Assess willingness to make attempt to quit
Assist in attempt at quitting
Arrange follow-up
213
Between pulse ox and capnography, which would you see changes in first?
See changes in the capnography before you’ll see changes in the O2 sat
214
What is the difference between pulse oz and capnography?
Pulse ox:
Oxygen Saturation
Reflects Oxygenation
SpO2 changes lag when patient is hypoventilating or apneic
Should be used with Capnography
Capnography:
Carbon Dioxide
Reflects Ventilation
Hypoventilation/Apnea detected immediately
Should be used with pulse Oximetry
215
What does D dimer measure?
D dimer is a fibrin degradation product (or FDP), a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis.
216
In addition to oxygen, what medications might be used in a patient in respiratory distress?
Bronchodilators
Anti-inflammatory (corticosteroids)
Mucolytics
Antibiotics
217
What important medication might you see with a CHF or Pulmonary Edema patient in respiratory distress?
Diuretics
218
What sites can an arterial blood gas sampling be done?
radial, brachial, femoral
219
What type of syringe is used for an arterial blood gas sampling?
heparinized syringe
220
What must be done after drawing an arterial blood gas sample?
place on ice
221
What are the etiologies of respiratory acidosis?
CNS depression, decreased ventilation and pulm edema
222
What are the etiologies of respiratory alkalosis?
anxiety, fear, hypoxia, pain, head injury, and mechanical ventilation
223
What are the etiologies of metabolic acidosis?
Diarrhea and GI losses due to the excessive loss of bicarb
Aspirin overdose
Renal failure
Lactic acidosis (sepsis or rhabdo)
Ketoacidosis
224
What are the etiologies of metabolic alkalosis?
vomiting from loss of gastric acid, diuretics from excessive K, high NG output, antacids
225
What are the clinical signs of a hemothorax?
reduced breath sounds on the affected side and a rapid heart rate
226
What are the clinical signs of a pneumothorax?
sudden chest pain and SOB
227
What are the most common causes of pleural effusion?
Leaking from other organs
Cancer
Infections (pneumonia or TB)
228
What are the clinical signs of a pleural effusion?
Shortness of breath
Chest pain, especially when breathing in deeply (This is called pleurisy or pleuritic pain.)
Fever
Cough
229
What are classic symptoms of a tension pneumothorax?
hypotension and hypoxia
230
How do you treat hyperkalemia?
Potassium-restricted diet
Kayexalate (Usually causes diarrhea)
Hyper QT wave:
IV insulin (regular insulin)
IV D50
Calcium Gluconate (stablize)
231
What are the 4 settings would you change in an intubated patient?
FiO2 (want the lowest rate possible)
RR (too fast RR-->resp alkalosis)
TV (barotrauma, volutrauma; 6-8 mL/kg)
PEEP
232
What is the best way to increase perfusion?
IV fluids
