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Intro To RC > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

what is IS?

A
  • Incentive Spirometry: one form of lung expansion therapy (also IS or SMI)
  • SMI: Sustained maximal inspiratory effort
  • improves pulmonary function by maximizing alveolar recruitment and optimal airway clearance
  • It works by increasing the transpulmonary pressure gradient (Ptp)
  • Ptp: is the difference between the alveolar pressure (Palv) and the pleural
    pressure (Ppl)
  • When Ptp pressure increases -> more alveoli expand
  • We do this in one of two ways:
    o Decreasing the Ppl
    o Increasing the Palv

Spontaneous deep inspiration increases the Ptp gradient by decreasing the Ppl
Other lung expansion therapies apply positive pressure, which can lead to other complications – that’s why incentive spirometry is a great option!

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2
Q

when do we use IS?

A
  • Measurable goal for IS is to have a VC of 10 mL per 1 kg of IBW
  • IS is cheap and takes little time – staff must be knowledgeable
  • Must have a normal MV  which means we need the RR to be less than 25 bpm
  • Minimal risk patients usually do well with just breathing exercises, frequent repositioning and early ambulation… but out high-risk patients need IS
  • Purpose is to coach the patient to take a Sustained Maximal Inspiratory effort
    (SMI)
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3
Q

how do we administrate IS?

A

Planning:
- Identify high risk patients
- Get doctor’s order
- Gather equipment
- Set goal
Implementation:
- Place in fowlers position
- Patient assessment (VS and BS)
- Instructions on how and how often
- Encouragement is very important
Follow Up:
- Patient reassessment (VS and BS)
- Monitor patient’s performance
Chart:
- Date and time
- Patient assessment pre and post
- Volume
- Cough and sputum
- Patient cooperation

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4
Q

what complications could Thoracic or abdominal surgery can cause?

A
  • Pneumonia
  • Acute Respiratory failure
  • Atelectasis- alveolar collapse
    **The solution to these problems is LUNG EXPANSION THERAPY…
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5
Q

what are other lung therapies?

A
  • Deep breathing/ cough
  • CPAP (continuous positive airway pressure)
  • PEP (positive expiratory pressure)
  • IPPB (intermittent positive pressure breathing)
  • Early patient mobility
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6
Q

Atelectasis is AKA as volume lost

A

seen on an x-ray as a white spot

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7
Q

what are the types of ATELECTASIS?

A
  • Gas absorption
  • Compression- something is pressing
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8
Q

what is gas absorption?

A
  • this can occur either when there is a complete interruption of ventilation to a section of the lung or when there is a significant shift in ventilation
  • Gas distal to an obstruction is absorbed by blood passing through the pulmonary capillaries
  • This causes partial collapse of the nonventilated alveoli
  • In a larger airway or bronchus, lobar atelectasis develops (a total lobe is affected)
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9
Q

what is compression atelectasis?

A
  • this occurs when the transthoracic pressure exceeds the trans alveolar pressure
  • (OUTSIDE pressure exceeds the INSIDE pressure)
  • Pressure between body surface area and the alveoli > Pressure difference between alveoli and pleural
    space
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10
Q

what can cause compression atelectasis?

A
  • General anesthesia
  • Sedatives and bed rest
  • Painful deep breaths (avoidance of deep breaths)
  • Weak diaphragm or impairment
  • Fluid overload
  • Excessive secretions with low tidal volume
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11
Q

what patients have an increased chance of Atelectasis?

A

* The closer the incision to the diaphragm, the greater the risk for atelectasis*
- Obesity
- Neuromuscular disorders
- COPD patients
- Age
- Smoking history
- Heavy sedation – too little pain meds
- Abdominal or thoracic surgery

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12
Q

what are the Clinical Signs of Atelectasis

A
  • Being aware of risk factors
  • Increased RR (the worse the atelectasis, the higher the RR) (PaO2 goes up, RR
    goes up)
  • Fine late inspiratory crackles BS (sudden opening of the distal airways)
    o The more atelectasis becomes present, the less likely this will occur
  • Bronchial BS (when patient is completely occluded -consolidated with more
    atelectasis)
  • Diminished BS (excessive secretions blocking the airway)
  • Tachycardia (hypoxemic)
  • Chest X-Rays
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13
Q

what are some other breathing exercises?

A
  • Pursed lip breathing
  • Diaphragmatic breathing
  • Segmental breathing
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14
Q

what is pursed lip breathing ?

A

Patient exhales through their lips while held in a whistling position

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15
Q

what is diaphragmatic breathing?

A
  • Patient places their hand on their chest below the xiphoid process
  • Hand lifts on inhale and lowers on exhale
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16
Q

what is segmental breathing?

A
  • Hand is placed on chest where the focus of breath is desired
  • Hand moves outward on inspiration
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17
Q

what is Electronic Medical Record (EMR) ?

A

– changed the way RTs document care
- The record for a patient’s admission or event can be found in the EMR. The sum
of all EMRs of a patient can be found in the patient’s electronic health records, or EHR.

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18
Q

what is Computerized Physician Order Entry (CPOE)?

A
  • how we receive our orders
  • prevent and eliminate medical errors.
  • improves accuracy and communication of physician’s orders.
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19
Q

what are the General Sections Found in a Patient Medical Record?

A
  • Admission data and diagnosis and admitting dr.
  • History and physical exam (also progress notes and plan of care)
  • Nurse’s notes
  • Health maintenance and immunizations
  • Allergies
  • VS flowsheet
  • Input and output sheet- patient’s fluid intake and output over time
  • Lab results
  • Consultation notes
  • Surgical or treatment consent
  • Anesthesia and surgical record
  • Specialized therapy records and progress notes (ex: respiratory care)
  • Specialized flow data- records made over time during specialized procedures
  • Advanced directives- living will, power of attorney, etc.
  • Medication record- drugs and IV given to patient
    o EMAR (Electronic Medication Administration Record)
20
Q

what are the rules for charting?

A
  • Only edit, CANNOT erase
  • Accurately summarize data
    o Subjective data (patient’s feelings)
    o Past and current data (objective info – vitals and BS)
    o Assessment data (professionals conclusion about presented data)
    o Therapy given
    o Patient’s response
    o Treatment plans
  • Analyze and Assess data
  • WHEN IN DOUBT, CHART
  • Do not leave blank lines
  • Use standard abbreviations only
  • Use proper spelling
  • Use present tense
  • Be accurate, clear and concise
  • Document all important conversations
21
Q

what is SBAR?

A

used frequently by us in the clinical setting to document everything.

22
Q

what is an aerosol?

A
  • Suspension of solid or liquid particles in gas
  • We deliver meds but smog, fog, pollen, dust, smoke etc. are also aerosols
23
Q

what is the output of aerosols?

A
  • the amount of emitted dose leaving the mouthpiece of a nebulizer
  • A large portion of this output will never reach the patient’s lungs
  • It depends on the patient’s breathing pattern and the particle size
24
Q

what are the particle sizes and how are they measured?

A

Measured by MMAD
- 5 - >50 microns (upper airway)
- (2-5 for lower airway)
- (1-3 microns (alveolar sacs)

25
Q

what is deposition?

A
  • not all aerosol particles delivered to the lungs are deposited
  • A small part may be exhaled, those that are deposited in the respiratory tract depend
    on:
  • Size
  • Shape
  • Motion of the particles
  • Physical characteristics of the airway
  • Breathing pattern
    o Inspiratory flow rate
    o Flow pattern
    o Inspiratory to expiratory flow rate
    o Tidal volume
    o RR
    o Breath hold
26
Q

what does the deposition of an aerosol depend on?

A
  • Inertial impaction
  • Gravimetric sedimentation
  • Brownian diffusion
27
Q

what is Inertial impaction?

A
  • the theory behind the larger particles
    o Suspended particles in motion collide with and are deposited on a surface
    o Main deposition for particles larger than 5 micrometers
28
Q

what is brownian diffusion?

A
  • smaller particles (less than 3 micrometers)
  • They have a very low mass, so they easily bounce around by collisions with gas molecules
  • Smaller particles (.5-1 micrometers) remain suspended and have greater retention in the lungs
29
Q

what is gravimetric sedimentation?

A
  • Main deposition for particles 1-5 micrometers (when patient is breathing normally)
  • Larger particles settle faster (due to gravity)
  • Breath holding after inhalation of an aerosol increases the residence time for the particles in the lungs and enhances distribution
  • 10 second breath hold can increase deposition by 10%
30
Q

what happens to an aerosol over time ?

A
  • particles grow, shrink, combine and fall out of suspension over time
31
Q

what are the aerosol delivery devices?

A
  • MDI
    o Pressurized metered dose inhalers (pMDI)
    o Breath actuated pressurized MDIs
  • DPI
  • Hand-bulb Atomizer
  • Nebulizers
    o Ultrasonic
    o Vibrating Mesh
    o LVN (pneumatic jet)
    o SVN (pneumatic jet)
32
Q

what is an MDI and what is its particle size?

A
  • 2-6 micrometers, initial velocity 80% deposited in the oropharynx
  • If used with a spacer or holding chamber reduce oral deposition by 90-99%
33
Q

what is a DPI and what is its particle size?

A
  • particle size of the drug is 1-3 m, but the size of the carrier substance is 20-65 m
  • This leaves 80% of the carrier deposited in the oropharynx
34
Q

what is a hand-bulb atomizer and what is its particle size?

A
  • nasal spray pump (5-40 m)
     Atrovent, Flonase, Saline Spray
35
Q

what is a ultrasonic nebulizer?

A
  • uses a piezoelectric crystal to generate an aerosol
     MMAD 2.5- 6 m
     Usually a cool mist
     Quiet, no compressed gas, no direct flow is given to the patient, continuous mist
36
Q

what is a vibrating mesh nebulizer?

A
  • dome shaped plate connected to a piezoelectric element
  • MMAD 3-4 m
  • Electric energy is applied to piezoelectric that vibrates at high frequency
  • Plate moves up and down creating a micropump
  • Plate actively pumps the liquid and breaks it into droplets
37
Q

what is an LVN?

A
  • Continuous Nebulizers (when the patient is not responding to frequent breathing treatments, and they need that longer period of time of treatment)
  • MMAD 2.2-3.5 m
  • Bland aerosol
  • HEART- high-output extended aerosol respiratory therapy neb (1-2 hours albuterol)
  • HOPE
  • SPAG (small particle aerosol generator)- delivery of Ribavirin for RSV
    o Main problem with SPAG is that caregivers are exposed to the med
38
Q

what is a SVN?

A
  • Main way to deliver respiratory meds in acute care
  • Medication is converted to an aerosol
  • MMAD 1-5 m
39
Q

what are the 4 types of SVNs?

A
  • Continuous neb with simple reservoir
  • Continuous neb with collection bag
  • Breath-enhanced neb
  • Breath-actuated neb
40
Q

how do we create an aerosol?

A
  • Powered by a high-pressure stream of gas directed through a restricted orifice
  • The gas stream leaving the jet passes by the opening of the capillary tube immersed in the medication
  • The high jet velocity draws the liquid up the capillary tube and into the gas stream and it becomes a spray
  • This spray is directed against one or more baffles and reduces the particle size
41
Q

what are the factors that effect the nebulizers performance?

A
  • Nebulizer design (what device?)
  • Flow -> the higher the flow, the smaller the particle size, the shorter the treatment
  • Gas Source
  • Density -> the lighter the gas, the greater flow needed to generate the same
    output
  • Humidity and Temp -> cool and dry (smaller particle), warm (larger and
    saturated)
  • Characteristics of the drug (Mucomyst – harder to nebulize)
42
Q

what are the indications for a SVN?

A
  • Adventitious BS
    o Stridor (Racemic epinephrine in upper airway)
    o Wheezing (albuterol in lower airway)
    o Coarse crackles (Mucolytic)
  • Increased respiratory effort (change in breathing pattern)
  • Signs of hypoxemia (increased HR, decreased SpO2)
  • Decreased peak flow rate
    WE MUST assess our patients before and after treatment:
  • HR (are they having an adverse reaction?)
  • SpO2 (is there an improvement?)
  • BS
  • Change in peak flow (20%)
  • Patient’s reaction (how do you feel after that treatment?)
43
Q

what are the hazards for a. SVN?

A
  • Most common is drug reaction
  • Infection
  • Airway reactivity – bronchospasm from cool air or Mucomyst
  • Drug concentration
  • Eye irritation (anticholinergics- Atrovent- ipratropium bromide)
  • Secondhand exposure to aerosol drugs
44
Q

what do we do if a med is asked to be given but it is not a normal drug?

A

we should avoid this. If the physician is asking you to do this, make sure you are backed by
an institutional policy that says this is okay.

45
Q

what happens during continuous nebulization?

A
  • Continuous nebulization of bronchodilators is approved for 5-20 mg/hour in adults and peds with severe asthma.
  • they need to be assessed every 30 minutes for the first 2 hours and then hourly.
  • If the patient has a positive response to this, we need to discontinue.
46
Q

what happens to the deposition when a child is crying during an aerosol treatment?

A
  • greatly reduces lower airway deposition and therefore should not be administered to a crying child.
  • Can use a mask “blow by”
    technique, but the inhaled med is greatly reduced
47
Q

what is PEFR and what are the levels?

A
  • Peak Expiratory Flow Rate
  • Coaching is important
  • Important assessment of airflow obstruction
    o Airway inflammation
    o Bronchial hyperreactivity
  • Green is >80%
  • Mild is closer to 65-80%
  • Moderate is 50-65%
  • Severe is < 50%

Intro To RC (9 decks)

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