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Complex > Exam 2 > Flashcards

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
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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

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3
Q

What is the gold standard to rule our a PE?

A

CT scan

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4
Q

If someone is hypoventilating, their end total CO2 will be…

A

High

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5
Q

If someone is hyperventilating, their end tidal CO2 will be…

A

Low

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5
Q

A capnography lower than 40 indicates hypo/hyperventilation.

A

hypoventilation

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6
Q

What is normal pH levels?

A

7.35-7.45

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7
Q

What is the normal range for PaCO2?

A

35-45mmHg

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8
Q

What is the normal range for HCO3?

A

22-26 mEq/L

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9
Q

What is the normal range for PaO2?

A

80-100mmHg

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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

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11
Q

What important medication might you see with a patient experiencing pulmonary edema?

A

Diuretics

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12
Q

Where does arterial blood gas sampling occur?

A

radial, brachial, or femoral arteries (no tourniquet needed)

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13
Q

What needs to be done before a radial stick occurs?

A

Allen’s test

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14
Q

Why do ABGs need to go on ice?

A

Reduce oxygen metabolism, get more accurate reading of PaO2

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15
Q

What does a positive Allen’s test mean?

A

Ulnar is patent

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16
Q

Why would your PaCO2 go up?

A

Hypoventilation

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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
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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

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19
Q

What is the treatment for a tension pnemothroax?

A

Needle decompression

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20
Q

What is happening during pleural effusion?

A

fluid between pleural space

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21
Q

If pleural effusion is spontaneous, what is that an indication of?

A

Cancer

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22
Q

What are the three parts of a chest drain system?

A

Collection Chamber
Water Seal Chamber
Collection Apparatus

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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

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24
Q

What is tidaling?***

A

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)

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25
Q

What should be assessed and managed with pts with chest tubes?

A

-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

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26
Q

How does having a chest tube system lead to atelectasis?

A

Pain from chest tubes
More shallow breaths
Days of shallow breaths lead to atelectasis

Need to offer pain meds***

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27
Q

What is being monitored with a chest tube system?

A

Water seal
Drainage
Positioning
Complications

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28
Q

What do you do during a chest tube dislodgment/accidental removal?

A

Grab petroleum gauge and cover hole

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29
Q

What are the goals of intubation?

A

-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

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30
Q

What equipment is needed to intubate someone?

A

-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

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31
Q

What are examples of neuromuscular blockers?

A

Vecuronium
Succinylcholine
Rocuronium
Pancuronium

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32
Q

What are examples of sedative medications?

A

Etomidate
Propofol
Midazolam

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33
Q

How do you confirm placement of the ET tube?

A

Bilateral breath sounds
Colormetric CO2 detector
“Misting” in the tube
CXR
Capnography Waveform

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34
Q

What is the most common mode of ventilation?

A

PRVC - Pressure Regulated Volume Control

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35
Q

What determines alveolar ventilation?

A

Minute ventilation (MV = RR x TV)

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36
Q

What is the starting RR for intubated patients?

A

10-12 breaths per minute

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37
Q

What is the starting TV for intubated patients?

A

6-8 mL/kg (no more than 10)

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38
Q

What must be done whenever settings are changed on the ventilation?

A

Draw ABGs within 20-30minutes

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39
Q

What can cause the “high pressure” alarm to set off?***

A

-Increased airway resistance (coughing, agitated pt biting the tube, secretions, broncospasms, kinks in circuit)
-Decrease lung compliance (pulmonary edema, pneumonia, ateletisis, pneumothorax)

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40
Q

What can cause the “low pressure” alarm to set off?***

A

Disconnection in tubing/system
Electrical failure

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41
Q

What are examples of ET Tube complications?

A

Oral vs Nasal
Lip, tongue, teeth, tracheal damage
Mucous plugs***
Pt bites tube
Sinusitis
Fistula
Granulomas
Infection
Cuff ulcerations

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42
Q

What is VAP?

A

Ventilator Associated Pneumonia

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43
Q

What is included in the VAP bundle?

A

Oral care
HOB 30-45 degrees
GI prophylaxis
DVT prophylaxis
OOB

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44
Q

What are the numbers of oxygenation under the Berlin definition?***

A

Mild: 200 < PaO2/FiO2 <= 300mmHg
Moderate: 100 < PaO2/FiO2 <= 200mmHg
Severe: PaO2/FiO2 <= 100mmHg

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45
Q

What is the timing of ARDS under the Berlin definition?

A

Within 1 week of a known clinical insult or new or worsening respiratory symptoms

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46
Q

What is the level of normal PaO2/FiO2 ratio?

A

Greater than 300 is normal

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47
Q

What are the four criteria for SIRS?

A

fever >38.0°C or hypothermia <36.0°C,

tachycardia >90 beats/minute,

tachypnea >20 breaths/minute,

leucocytosis >12109/l or leucopoenia <4109/l

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48
Q

What are the stages of ARDS?***

A

Stage one: first 24 hours
Stage two: 24-48 hours
Stage three: 2-10th day
Stage four: after 10 days

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49
Q

What are the symptoms of the different stages of ARDS?***

A

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

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50
Q

What are the three criteria of ARF?***

A

PaO2 < 55-60mmHg (hypoxemia)
PaCO2 > 50mmHg (hypercapnia)
pH < 7.35 (respiratory acidosis)

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51
Q

What is the pH imbalance of ARF?

A

Respiratory acidosis

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52
Q

Which each cardiac cycle, how much blood of cardiac output is pumped to the kidneys?

A

21% of cardiac output

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53
Q

What are the functions of the kidneys?

A

-filtration and excretion
-fluid, electrolyte and acid/base balance
-blood pressure regulation
-stimulation of RBC production
-regulates calcium reabsorption in the bone

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54
Q

How many nephrons are in each kidney?

A

1 million in each kidney, 2 million total

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55
Q

What are examples of nephrotoxins?**

A

-Contrast dye
-ACEs/ARBs
-Loop/thiazide diuretics

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56
Q

Define ventilation.

A

movement of air btw atmosphere and the alveoli-by inhalation/exhalation, higher to lower pressure

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57
Q

Define alveolar ventilation

A

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

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58
Q

Is work of breathing a passive or active process?

A

Expiration is a passive process caused by elastic recoil of the lung. During inspiration, WOB takes place

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59
Q

Define diffusion

A

exchange of O2 ad CO2 btw pulmonary capillaries and alveoli

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60
Q

What factors affect diffusion?

A

-surface area available for diffusion
-thickness of alveolar-cap membrane,
-partial pressure of gas across the membrane
-solubility and molecular characteristics of the gas

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61
Q

Define perfusion

A

flow of blood through the pulmonary capillary bed

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62
Q

How does body position affect perfusion?

A

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

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63
Q

What are other functions of the lungs?

A

-Acid base balance (CO2)
-Metabolism of certain compounds (inhaled corticosteroids)
-Filtration/Warming

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64
Q

What are the nurse’s role pre-intubation?

A

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

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65
Q

What are the nurse’s role during intubation?

A

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.

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66
Q

What is a severe adverse effect of succinylcholine?

A

Malignant hyperthermia (causes high temps and can lead to rhabdo and death)

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67
Q

What is the role of the nurse post-intubation?

A

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

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68
Q

What is the importance of humidification of the ETT or trach?

A

Add water to the inhaled gas to:
PREVENT drying and irritation of resp tract
PREVENT undo loss of body water
FACILITATE secretion removal

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69
Q

What are characteristics of cuff management for ETTs or trachs?

A

-Use only low pressure, high volume cuffs.
-Need to monitor cuff inflation pressures AT LEAST once a shift (20-25 mmHg)

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70
Q

Is suctioning a sterile or clean procedure?

A

Sterile.

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71
Q

What are the complications of suctioning ETTs or Trachs?

A

-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

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72
Q

What are the rules for length and duration of suctioning?

A

-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

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73
Q

Why is oral hygiene important for ventilators?

A

Oropharyngeal secretions pool at cuff; increased risk of seeping below cuff and into airways, setting up VAP

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74
Q

The iron lung is an example of (negative/positive) pressure.

A

Negative pressure - used in the polio epidemic in the 1930s/40s

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75
Q

What ventilator controls are most important for nurses?

A

Mode, FiO2, resp rate, tidal volume or pressure, PEEP

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76
Q

What ventilator mode is used for weaning?

A

Pressure support/CPAP

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77
Q

An FiO2 > 60% for more than 24 hours puts patients for great risk of…

A

oxygen toxicity

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78
Q

What should FiO2 be when suctioning a patient?

A

100%

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79
Q

How does oxygen toxicity occur?

A

-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

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80
Q

What is the definition of TV?

A

number of MLs of air to be delivered with each breath

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81
Q

What is the definition of RR?

A

number of breaths the vent delivers

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82
Q

How does inadvertent hyperventilation occur?

A

will result in resp alkolosis-associated with serum electrolyte shifts and arrhythmias

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83
Q

What is part of “lung protective ventilation?”

A

-Low TV***
-Permissive hypercapnia
-Relative hypoxemia
-Low plateau pressure

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84
Q

What does PEEP stand for?

A

Positive End Expiratory Pressure

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85
Q

What is PEEP?

A

Positive pressure delivered at end of expiration to keep alveoli open

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86
Q

When are low and high PEEPs used?

A

-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)

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87
Q

In a patient with more critical issues of oxygenation, their PEEP requirement is (higher/lower).

A

Higher

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88
Q

What are the drawbacks of a higher PEEP?

A

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

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89
Q

Why should you avoid nasal intubations as much as possible?

A

more infections from sinusitis

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90
Q

Why should you move an ET tube side to side each few days?

A

To prevent pressure injuries (HAPI)

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91
Q

What ET tube complication can occur with long term use intubation?

A

Laryngeal granulomas (inflammation and ulceration); after 2 weeks, insert trach

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92
Q

Aspiration can increase the risk of what respiratory illnesses?

A

VAP or ARDs

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93
Q

What is an appropriate cuff pressure?

A

20-25 mmHg

94
Q

What can be done to minimize the risk of aspiration?

A

Always put NG tube down
Suction mouth, pharynx prior to turning
HOB > 30 degrees if possible

95
Q

What is a barotrauma?

A

rupture of alveoli due to ventilation/PEEP that can lead to tension pneumothorax

96
Q

What are s/s of barotrauma?

A

Pain, dyspnea, decreased breath sounds on affected side, increased peak inspiratory pressures

This all leads to hypotension, bradycardia, and cardiac arrest.

97
Q

During a needle decompression for a tension pneumothorax, where is the needle inserted?

A

IC space 2

98
Q

What is ventilator associated pneumonia (VAP)?

A

-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
Q

What are the risk factors for VAP?

A

Orophar and gastric colonization; aspiration, compromised lung defenses, mech ventilation, re-intubation, self-extubation, supine position

100
Q

What are nursing measures to prevent VAP?

A

-Meticulous hand washing
-Wearing gloves when suctioning ETT

101
Q

What is included in oral care for VAP?

A

Teeth brushing, antiseptic solutions and alcohol free mouthwash, apply water soluble moisturizer, frequent oral suctioning

102
Q

What are some causes of hemodynamic instability?

A

-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
Q

What is the nursing intervention for fluid imbalance?

A

Need to give IV fluid resuscitation to increase circulating volume

104
Q

What complications can come from immobility of intubated patients?

A

Muscle wasting, weakness and contractures, loss of skin integrity, pneumonia, DVT with PE, constipation and ileus

105
Q

What complications can come from GI problems of intubated patients?

A

Distention, hypomotility, ileus (bc of immobility and narcotics), vomiting, breakdown of intestinal mucosa leading to bacteremia, stress ulcers

106
Q

What complications can come from muscle weakness of intubated patients?

A

-Deconditioning and atrophy
-Respiratory muscles need re-training

107
Q

What are the nurse’s responsibility in weaning trials?

A

-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
Q

What are the components of the readiness criteria for weaning trials?

A

-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
Q

What is needed to fully evaluate weaning failure?

A

ABGs

110
Q

What does weaning failure look like?

A

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
Q

What are the expected outcomes of post-extubation?

A

-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
Q

What complications should be observed post-extubation?

A

Laryngospasm
Aspiration
Laryngeal and tracheal edema
Tracheal stenosis
Vocal cord paralysis
Laryngeal ulceration
Hoarseness and sore throat

113
Q

What are the nursing steps for extubation?

A

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
Q

Which acute respiratory disorder is an inflammatory lung injury resulting in hypoxemia?

A

ARDS

115
Q

What are examples of direct injury to the lungs that causes ARDS?

A

Gastric Aspiration
Near Drowning
Toxic Inhalation
Diffuse Pneumonia
Pul contusion
Pulm vasculitis

116
Q

What are examples of indirect injury to the lungs that causes ARDS?

A

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
Q

What is the most common cause of ARDS?

A

Sepsis

118
Q

ARDS is considered a complex syndrome rather than one specific disease. What were the common symptoms associated with ARDS?

A

1) acute tachypnea
2) decreased lung compliance
3) diffuse pulmonary infiltrates
4) hypoxemia, despite supplemental O2

119
Q

What are the components of the Berlin definition and explain their criteria?

A

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
Q

What are the simple components of the Berlin definition?

A

Timing
Chest imaging
Origin of edema
Oxygenation

121
Q

What is the definition of ARDS oxygenation severity according to the PaO2:FiO2 ratio?***

A

> 300 Normal
200-300 Mild
100 -200 Moderate
= or < 100 Severe

122
Q

What disease processes cause physiological shunts to occur?***

A

PNA, atelectasis, tumor or mucous plug

123
Q

What is physiologically happening with a low V/Q ratio?***

A

the alveoli with no ventilation but normal perfusion

PHYSIOLOGICAL SHUNT: blood passes by alveoli without gas exchange occurring

124
Q

What is physiologically happen with a high V/Q ratio?***

A

alveoli with normal V but no Q

ALVEOLAR DEAD SPACE: alveolus has inadequate perfusion available, and gas exchange cannot occur

125
Q

What disease processes cause alveolar dead space to occur?***

A

PE, cardiogenic shock, anatomic shunt, and mechanical ventilation with high tidal volumes

126
Q

What is a silent unit?***

A

Alveoli with no V and no Q
Both ventilation and perfusion are decreased
Seen in pneumothorax or severe ARDS

127
Q

What are the 4 criteria of SIRS?

A

fever >38.0°C or hypothermia <36.0°C,

tachycardia >90 beats/minute,

tachypnea >20 breaths/minute,

leucocytosis >12109/l or leucopoenia <4109/l

128
Q

What is SIRS?

A

Systemic Inflammatory Response Syndrome

129
Q

Between ARDS and SIRS, which is an inflammatory response that affects the whole body?

A

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
Q

What are the 3 pathophys hallmarks of ARDS?***

A

Change in lung vascular tissue
Increased lung edema
Impaired gas exchange

131
Q

What are the mediators responsible for the cascade of organ damage in ARDS?

A

-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
Q

What are the s/s of Stage 1 of ARDS?

A

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
Q

What are the s/s of Stage 2 of ARDS?

A

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
Q

What are the s/s of Stage 3 of ARDS?

A

2 to 10 days
Decreased air entry bilaterally
Impaired responsiveness, Decreased gut motility, generalized edema

CXR: decreased lung volumes
ABG: worsening hypoxemia

135
Q

What are the s/s of Stage 4 of ARDS?

A

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
Q

What is the nursing care if the cause of ARDS was sepsis?

A

Fluid support, perhaps pressors, abx

137
Q

What are the goals of ARDS care?***

A

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
Q

What complications can come from oxygen toxicity?

A

collapsing of alveoli, seizures, and disorientation

139
Q

What are secondary complications of ARDS?

A

-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
Q

What is characterized by sudden and life-threatening deterioration of gas exchange, resulting in CO2 retention (hypercapnia) & inadequate oxygenation (hypoxemia)?

A

Acute respiratory failure

141
Q

Is ARDS a type of respiratory failure?

A

Yes. Every patient in ARDS is in respiratory failure, but not every respiratory failure patient is in ARDS

142
Q

What do the ABGs of a patient in acute respiratory failure look like?***

A

PaO2 < 55-60 mmHg Hypoxemia
PaCO2 > 50mmHg Hypercapnia
pH < 7.35 Severe acidosis

143
Q

What are the two classifications of acute respiratory failure?

A

Acute Hypoxemic Respiratory Failure
Acute Hypercapnic Respiratory Failure

144
Q

What are the qualifications for acute hypoxemic respiratory failure?

A

Defect in oxygenation
PaO2 of < 55-60mmHg

145
Q

What are the qualifications for acute hypercapnic respiratory failure?

A

Defect in ventilation
CO2 > 50mmHg

146
Q

What are characteristics of acute respiratory failure?

A

Decreased ventilatory drive (narcotics, ETOH, brainstem lesion)
Resp muscle fatigue or failure (ALS, Guillian-Barre)
Increased WOB (COPD, asthma, rib Fx)

147
Q

What pt signs and symptoms would warrant immediate intubation?

A

Coma, change in MS, low or agonal breathing rate, obvious muscle fatigue, cyanosis, or impending cardiac arrest

148
Q

What are signs of hypoxemia?

A

Dyspnea
Cyanosis
Restlessness
Confusion
Anxiety
Delirium
Tachypnea
Tachycardia
HTN
Arrhythmias

149
Q

What are s/s of hypercapnemia?

A

Dyspnea
Headache
Peripheral/conjunctival hyperemia
HTN
Tachycardia
tachypnea
Impaired LOC
Asterixis
Use of accessory muscles
Intercostal/supraclavicular retraction, paradoxical abdominal movements

150
Q

What do you do if supplemental oxygen is not enough and you need to move to mechanical help?

A

Intubate

151
Q

What are s/s of acute respiratory failure?

A

Flaring nostrils
Strap muscles of neck
Cephalad sternal vector
Abdominal paradox
Pulsus paradoxus
Notch retraction
Intercostal retraction

152
Q

What is the nursing management for acute respiratory failure?

A

Airway: intubate and ventilate
O2: restore and maintain oxygenation
Correct Acid-Base disturbance
Restore Fluid/electrolyte balance
Optimize cardiac output
Treat underlying cause

153
Q

What are the goals of in acute respiratory failure management?

A

Patent airway will be maintained
Oxygenation will be maintained (PaO2 of 80-100 mmHg with SaO2 > 90%)
ABGs will be within normal limits

154
Q

What are the functions of the kidneys?

A

Filtration and excretion

Fluid, electrolyte and acid/base balance

Blood pressure regulation

Stimulation of RBC production

Regulates calcium reabsorption in the bone

155
Q

Where does acetazolamide work on the nephron?

A

Proximal convoluted tubule

156
Q

Where do osmotic diuretics (mannitol) work on the nephron?

A

Proximal convoluted tubule

157
Q

Where do loop diuretics (furosemide) work on the nephron?

A

Prevent reabsorption of Na and K in ascending loop of Henle

158
Q

Where do thiazides (HCTZ) work on the nephron?

A

Prevents Na reabsorption in distal convoluted tubule

159
Q

Where do potassium-sparing diuretics (spironolactone) work on the nephron?***

A

Works in distal convoluted tubule to prevent reabsorption of Na

160
Q

What is the MOA of ARBs?

A

Blocks receptors thereby promoting vasodilation, Na and H2O excretion

161
Q

What is the MOA of ACE inhibitors?

A

-Prevents conversion of Angiotensin 1 to angiotensin 2
-Stops Na secretion, stops ADH production, stops arteriolar vasoconstriction

162
Q

Describe how renal blood flows.

A

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
Q

How is GFR measured?

A

-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
Q

What is normal GFR?

A

> 60

165
Q

What are the two most important risk factors for kidney disease?

A

DM, HTN

166
Q

What Review of Systems questions are important to ask regarding renal function?

A

Urine output
Back pain
Abdominal pain/N/V
Rashes/itching
Leg swelling
Shortness of breath
Fever

167
Q

What physical assessment data is relevant to renal function?

A

Urine
CVA tenderness
Abdominal tenderness
Skin
Edema
Lung sounds
Vital signs

168
Q

How do you assess volume status?

A

VS, JVD, crackles, wheezes, S3 or S4, tongue and mucous membranes, check for ascites and the fluid wave, edema, weight gain

169
Q

What skin assessments are relevant to renal function?

A

color, bruising, bleeding, skin turgor, dry, itchy, “Uremic Frost”

170
Q

What does CVA tenderness indicate?

A

may indicate an infection, check temp. Ask about freq, hesitancy, urgency, burning, blood, incontinence, lower back pain

171
Q

What are the nursing interventions when a patient has a AVF?***

A

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

172
Q

What does a positive Chvostek’s sign indicate?

A

hypocalcemia

173
Q

What does a positive Trousseau sign indicate?

A

hypocalcemiaa, hypomagnesimia, and metabolic alkalosis

174
Q

What is azotemia?

A

When BUN/Creatinine is elevated

175
Q

How can dehydration affect Na+ levels?

A

hypernatremia

176
Q

What should not be present in urine?

A

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

177
Q

What is a KUB xray?

A

kidney-ureter-bladder
Can see stones, size of kidneys and hydronephrosis

178
Q

What is a Renal US or Renal Artery US?

A

looks for renal artery stenosis—hard to control BP if have RAS, can stent

179
Q

Post biospy of the kidneys, what should be done?

A

assess for internal bleeding

180
Q

What are the radiology tests for kidney function?

A

KUB X-ray

CT abdomen/pelvis

MRI

Pyelogram

Renal US/Renal Artery US

Kidney biopsy

181
Q

What are the stages of Chronic Kidney Disease?

A

< 60 – starts mild kidney injury
< 30 – moderate
<15 - ESRD

182
Q

Prerenal, intrarenal, or postrenal:
Due to damage to the glomeruli, tubules, or interstitium (damage to the renal parenchyma)***

A

Intrarenal

183
Q

Prerenal, intrarenal, or postrenal:
Due to damage/obstruction along the urinary tract system***

A

Postrenal

184
Q

Prerenal, intrarenal, or postrenal:
Due to true volume loss or decreased effective arterial blood volume***

A

Prerenal

185
Q

What are the causes of prerenal injuries?

A

Hypovolemia
Shock states
Decreased cardiac output
Excessive diuresis (meds or hyperglycemia)

186
Q

What are the treatments for prerenal injuries?

A

Often reversible with early intervention
Treat underlying cause (IVF, pressers, inotropes)

187
Q

What are the causes of intrarenal injuries?

A

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

188
Q

What are the treatments for intrarenal injuries?

A

Stop nephrotoxic meds, hydrate, treat underlying chronic diseases

189
Q

What is the most common cause of renal failure?

A

Acute Tubular Necrosis (ATN)

190
Q

What can cause ATN?

A

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

191
Q

What are the causes of postrenal injuries?

A

Prostate disease-prostatitis, BPH
Cancer
Large kidney stones (calcium, uric acid, struvite, cystine)

192
Q

What are the treatments for postrenal injuries?

A

Remove obstruction; foley insertion to empty bladder when have uropathy

193
Q

What are the risk factors for chronic kidney disease (glomerulosclerosis)?

A

The dysfunction occurs because of the fibrotic changes to tissue over time

age, DM, HTN, AKI, high cholesterol

194
Q

What are the treatments for chronic kidney disease?

A

Monitor labs
Avoid nephrotoxic drugs
Encourage PO hydration
ACE and ARB is renal protective in early disease
Manage comorbid conditions

195
Q

What are the indications for RRT?

A
196
Q

What are nephrotoxic drugs?

A
197
Q

Why is an ACE inhibitor renal toxic and protective at the same time?

A
198
Q

What are the origins of ATN?

A

Nephrotoxic drugs and ischemia

199
Q

Complications of CRRT?

A

Hypotension and hypothermia

200
Q

How is dialysis accessed?

A

Graft or Fistula

201
Q

What patient teaching is needed for diaylsis?

A

Cannot miss a dialysis

202
Q

What patient teaching is necessary for a patient who undergoes dialysis?***

A

Signs of infection

Hemorrhage from dialysis access

Aneurysm or pseudoaneurysm of access

Hypotension/hypertension from fluid imbalance

Thrombosis of dialysis access

203
Q

What are the signs of peritonitis?

A

Low grade temp
Abdominal pain
Cloudy drainage

204
Q

How do you treat periotitis?

A

Treated with broad spectrum antibiotic

205
Q

What are the nursing interventions for the retained dialysate in peritoneal dialysis?

A

-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
Q

Why would a patient get CRRT rather than normal HD?***

A

-reserved for very sick, hemodynamically unstable
-ICU patients who cant handle the large fluid shifts of hemodialysis

207
Q

What are the four cardinal symptoms of respiratory dysfunction?

A

Dyspnea
Chest pain
Sputum production
Cough

208
Q

What diseases/illnesses are associated with friction rub?

A

pleural effusion, pneumothorax

crackling, grating sound heard more often with inspiration

209
Q

What diseases/illnesses are associated with rhonchi?

A

bronchitis, pneumonia

deep, low-pitched rumbling noises that are sometimes referred to as sonorous wheezes or gurgles

210
Q

How do you distinguish between a pericardial rub and pleural rub?

A

ask to hold breath, if don’t hear it, it is friction rub. If hear it with heart beat, it is pericardial rub

211
Q

What diseases/illnesses are associated with stridor?

A

Croup, after extubation indicating edema

harsh, high-pitched inspiratory sounds often described as crowing as air passes through constricted trachea

212
Q

What are the 5 A’s of tobacco?

A

Ask about tobacco use
Advise to quit
Assess willingness to make attempt to quit
Assist in attempt at quitting
Arrange follow-up

213
Q

Between pulse ox and capnography, which would you see changes in first?

A

See changes in the capnography before you’ll see changes in the O2 sat

214
Q

What is the difference between pulse oz and capnography?

A

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
Q

What does D dimer measure?

A

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
Q

In addition to oxygen, what medications might be used in a patient in respiratory distress?

A

Bronchodilators
Anti-inflammatory (corticosteroids)
Mucolytics
Antibiotics

217
Q

What important medication might you see with a CHF or Pulmonary Edema patient in respiratory distress?

A

Diuretics

218
Q

What sites can an arterial blood gas sampling be done?

A

radial, brachial, femoral

219
Q

What type of syringe is used for an arterial blood gas sampling?

A

heparinized syringe

220
Q

What must be done after drawing an arterial blood gas sample?

A

place on ice

221
Q

What are the etiologies of respiratory acidosis?

A

CNS depression, decreased ventilation and pulm edema

222
Q

What are the etiologies of respiratory alkalosis?

A

anxiety, fear, hypoxia, pain, head injury, and mechanical ventilation

223
Q

What are the etiologies of metabolic acidosis?

A

Diarrhea and GI losses due to the excessive loss of bicarb
Aspirin overdose
Renal failure
Lactic acidosis (sepsis or rhabdo)
Ketoacidosis

224
Q

What are the etiologies of metabolic alkalosis?

A

vomiting from loss of gastric acid, diuretics from excessive K, high NG output, antacids

225
Q

What are the clinical signs of a hemothorax?

A

reduced breath sounds on the affected side and a rapid heart rate

226
Q

What are the clinical signs of a pneumothorax?

A

sudden chest pain and SOB

227
Q

What are the most common causes of pleural effusion?

A

Leaking from other organs
Cancer
Infections (pneumonia or TB)

228
Q

What are the clinical signs of a pleural effusion?

A

Shortness of breath
Chest pain, especially when breathing in deeply (This is called pleurisy or pleuritic pain.)
Fever
Cough

229
Q

What are classic symptoms of a tension pneumothorax?

A

hypotension and hypoxia

230
Q

How do you treat hyperkalemia?

A

Potassium-restricted diet
Kayexalate (Usually causes diarrhea)

Hyper QT wave:
IV insulin (regular insulin)
IV D50
Calcium Gluconate (stablize)

231
Q

What are the 4 settings would you change in an intubated patient?

A

FiO2 (want the lowest rate possible)
RR (too fast RR–>resp alkalosis)
TV (barotrauma, volutrauma; 6-8 mL/kg)
PEEP

232
Q

What is the best way to increase perfusion?

A

IV fluids

Complex (2 decks)

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