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1 216 Med Surg > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

Tachypnea, prolonged expiration, nasal flaring, intercostal muscle retraction, accessory muscle use, and SpO2 below 80% are all signs of what?

A

Hypoxemia

Late signs:

  • Paradoxic chest or abdominal wall movement with respiratory cycle.
  • Cyanosis

Restlessness, confusion, agitation, and combative behavior suggest inadequate O2 delivery to the brain and should be fully investigated.

retraction: inward movement of the intercostal spaces

accessory muscles: sternocleidomastoid, pectoralis major, etc.

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2
Q

Tachycardia, tachypnea, and mild hypertension can be early signs of what?

A

Acute respiratory failure.

Such changes can indicate an attempt by the heart and lungs to compensate for decreased O2 delivery and rising CO2 levels.

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3
Q

Morning HA, slower respiratory rate, and a decreased level of consciousness may indicate issues with CO2 removal. What may this indicate?

A

Hypercapnia

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4
Q

This is commonly defined as a PaO2 less than 60 mm Hg when the patient is receiving an inspired O2 concentration of 60% or more:

A

Hypoxemic respiratory failure.

This definition incorporates two important concepts: 1. The PaO2 level indicates inadequate O2 saturation of hemoglobin and 2. This PaO2 level exists despite giving supplemental O2 at a percentage of 60%

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5
Q

This is commonly defined as a PaCO2 greater than 45 mm Hg in combination with acidemia (arterial pH less than 7.35)

A

Hypercapnic respiratory failure.

This definition incorporates three important concepts: 1. The PaCO2 is higher than normal. 2. There is evidence of the body’s inability to compensate for this increase (acidemia). 3. The pH is at a level where a further decrease may lead to sever acid-base imbalance.

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6
Q

Upper airway obstruction (r/t edema/burns)
Apnea/respiratory distress
Risk of aspiration - can’t protect airway
Ineffective airway clearance of secretions
Serum PaO2 50 or less
Serum PCO2 50 or greater

These are also possible indications for what?

A

Endotracheal intubation (ET)

“50-50” rule

PCO2 at 50 would also indicate respiratory acidosis

We also take pH into consideration

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7
Q

When do we need to consider establishing a tracheostomy?

A

Indications:
Trauma or swelling prevents endotracheal intubation tube (ETT)

Long term artificial airway (AA)

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8
Q

When do we use nasal intubation?

Why is ET intubation preferred?

What are some complications with ETT’s?

A

Primarily with oral surgery.

This is via the nose, nasopharynx and vocal cords.

ET intubation is preferred because it’s fast and has a larger diameter tube

Complications: Chipped teeth, removal during procedure, limited space for oral care, tube occlusions (biting=bite block)

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9
Q

We need consent, unless emergent, and to teach about the risks r/t ETT’s. What are those?

What type of O2 device is used during the ET intubation procedure?

A

Risks of pain, restraints, and not being able to eat or drink.

Bag-valve-mask (BVM) with 100% O2 (hypervent B4 procedure and in between attempts)
Suction
and IV access

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10
Q

What are the RSI’s?

A
  1. SEDATION: midazolam/Versed, etomidate
  2. ANALGESIC: fentanyl
  3. PARALYTIC: succinylcholine (“sux”)
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11
Q

What type of procedure requires placement of patient in the sniffing position?

How long should each attempt take?

A

Intubation procedure
- Hyperventilate prior and between attempts

Each attempt should be less than 30 seconds
- If unsuccessful: ventilate 100% for 3-5 min B4 reattempt.

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12
Q

We auscultate the chest, check for bilateral chest rise, assess the tube location at the teeth, observe the CO2 detector (EtCO2), perform a chest xray (CXR), and monitor ABG’s…. for WHAT?

A

Confirmation of correct ETT placement. (If you go down too far, you’ll only hear breath sounds on one side, usu. the right.

This is done after the cuff of the ETT is inflated and secured in place.

  • We document the lip line.
  • Female around 21 cm
  • Men around 23 cm

Then connect to the ventilator.
EtCO2 = End Tidal, the volume of CO2 in the lungs at the end of exhalation. Norm: 35-45 mm Hg.

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13
Q

What should the cuff be inflated to in order to maintain placement?

A

20 - 25 cm H2O

This may change according to the needs of the patient, but 20-25 is standard.

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14
Q

How do we maintain tube patency?

What do we need to constantly reassess?

How do we provide good oral care and maintain skin integrity?

A

Suctioning and assessing for indications for sxning.

Reassess: oxygenation:
SpO2 stabilizing? (Sp = peripheral capillary O2 saturation)
Evaluate ABGs (Is the resp distress improving?)
*Assess for any complications

Oral care:
Chlorhexidine rinse/swabs

Skin:
Chapstick, moisten tongue and gums
Reposition tube q 24 H (from side to side)
* Confirm placement with each move and after each transport performed.

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15
Q

What complications may we encounter with intubation?

A
  • Unplanned extubation:
    Signs - lip marker not in place, O2 sat decreases, ABGs indicate decreased O2, etc
  • Prevention - soft restraints, Rx, talking to them
  • Interventions - Ambu bag until able to reinsert.
  • Aspiration:
    Sublottic sxn ETT
    Yankauer sxn (only in the mouth)
    NG/OG tube: to decompress r/t decrease risk of emesis
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16
Q

When is suctioning indicated?

A

Suction only if:

  • Visible secretions
  • Sudden respiratory distress: possible mucous plug
  • Suspected aspiration
  • Increase in peak airway pressures (liquid in lungs)
  • Increased respiratory rate or coughing
  • Decrease in SpO2
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17
Q

If an intubated patient has a peak airway pressure, what may this indicate?

What intervention can you perform?

A

Liquid in the lungs.

Suction.

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18
Q

What is the difference between open and closed suctioning?

What are some potential complications with suctioning?

What interventions need to be performed when the patient’s secretions are thick?

A

Open sxn is similar to trach sxn, needs to be sterile procedure…

Closed suctioning system is included in the ventilatory circuit, allowing to introduce the suction catheter into the airways without disconnecting the patient from the ventilator, and it remains sterile… preventing the introduction of bacteria.

Dysrhythmias, ICP, Mucus damage, Hypoxia

Thick secretions: hydration - oral/IV - mobilize secretions
** NO SALINE bullets ** These cause increased risk of infection

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19
Q

What complications may we encounter with suctioning?

A
  • Dysrhythmias: r/t vagal nerve stimulation
  • ICP: anything causing hypoxia increases ICP
  • Mucus damage
  • Hypoxia
20
Q

What does FIO2 mean?

A

Fraction of Inspired Oxygen: You need 21% or more of oxygen exchanged for CO2 in order to maintain homeostasis.

PaO2/FIO2: The ratio of partial pressure arterial oxygen and fraction of inspired oxygen is a comparison between the oxygen level in the blood and the oxygen concentration that is breathed.

0.21 being the fraction of inspired oxygen (FiO2) of room air (ambient). Room air is 21% O2.

21
Q

What does PEEP mean?

What is the purpose of PEEP?

A

Positive End Expiratory Pressure

It is the pressure in the lungs (alveolar pressure) above atmospheric pressure (the pressure outside of the body) that exists at the end of expiration.

The purpose of PEEP is to increase the volume of gas remaining in the lungs at the end of expiration in order to decrease the shunting of blood through the lungs and improve gas exchange. There is fluid in the lungs.

22
Q

FYI

Negative pressure is what we see in an “iron lung,” it’s like a vaccuum.

A

Positive pressure is what we will see in the ICU, it pushes air into the lungs.

23
Q

Different settings for Positive Pressure Ventilation (PPV):

Volume: Tidal volume of air (VT) - Volume of gas delivered during each ventilator breath. Usu 5-15 cc/kg

Pressure: Maximum amount of pressure the ventilator can use to deliver breath. 10-20 cm H2O above peak inspiratory pressure; max is 35 cm H2O.

A

Respiratory Rate (RR): Number of breaths delivered by the ventilator per minute. Usually 4-20 breaths per minute. Typically around 12.

Flow: delivers volume slowly or quickly

FIO2: amount of O2 delivered by vent to patient. 21-100%; usu set to keep PaO2 above 60 mm Hg or SaO2 above 90%.

Inspiratory:Expiratory (I:E) Ratio - Length of inspiration compared to length of expiration (you inhale faster than exhale). Usu 1:2 or 1:1.5, unless inverse ration vent is required.

24
Q

What are the 3 stages of shock?

What is going on in these phases?

What will we see?

What should we do?

A
  1. Compensatory: Increased BP, increased HR, decreased blood flow to the kidneys and GI, increased Na, increased respiratory rate (tachypneic), AandOx3-slight confusion/restlessness, skin is pale
  2. Progressive: decreased responsiveness, further decrease in perfusion, decrease in CO, decreased BP, increased HR, decreased urinary output, skin is cold and clammy, tissue hypoxia = lactic acidosis = metabolic acidosis
  3. Irreversible (refractory): unresponsive, severe hypotension, decreased HR, hypoxemia, respiratory failure, anuria, hypothermia, mottled cyanotic skin
25
Q

Why is an increased serum potassium a sign that a patient has moved out of the compensated stage of shock?

A

The increase in potassium is d/t the cellular death that is occurring which releases the K into the blood.

This will also occur in renal failure and with acidosis

26
Q

When do we intubate?

What do we tell the patient or family?

A

Indications:

  • Unable to maintain airway/ losing responsiveness
  • Apnea
  • Decreased RR
  • Airway obstruction
  • Increased risk of aspiration
  • Respiratory distress
  • Paralysis of respiratory muscles
  • Patient can’t breath on their own (too tired)
  • To clear secretions

We tell them about possible restraints, won’t be able to talk or eat like normal, patient sedated and/or paralyzed.

Need consent!

27
Q

What are the steps and medications used during an intubation procedure?

A
  • BVM 100% O2 (Ambu)
  • RSI:
    1. Sedative (midazolam/versed, etomidate)
    2. Analgesic: fentanyl
    3. Paralytic: succinylcholine
  • Sniffing position
  • Hyper ventilate between attempts
28
Q

How do we confirm placement of an ETT?

A
  • CXR
  • Auscultation of lung sounds
  • CO2 detector (EtCO2): Gold is good, yes for yellow
  • Look at the lines on the tube
  • Bilateral chest rise
  • ABGs
29
Q

What is PEEP?

What are the advantages of PEEP?

What are the disadvantages of PEEP?

A

Positive End Expiratory Pressure - pressure is applied at the end of exhalation to increase the lung volume, keeping the alveoli open longer to allow for greater air exchange (esp important when fluid present). Optimal setting is 5 cm H2O. This improves oxygenation and limits O2 toxicity.

Advantages:

  • Increases aeration of patent alveoli
  • Increases aeration of collapsed alveoli
  • Prevents the collapse of alveoli
  • Allows oxygenation at lower FiO2, limiting O2 toxicity.

Disadvantages:

  • Auto PEEP may have additional PEEP over what is set. This causes an increased work of breathing and hemodynamic instability.
  • Can decrease venous return
  • Possible barotrauma and perhaps a pneumothorax
30
Q

Why do ABG levels of PaO2 of 52, PaCO2 of 58, and a pH of 7.28 indicate acute respiratory failure in a patient with chronic lung disease?

A

The CO2 is high and the pH is low.

Respiratory acidosis.

31
Q

We determine alveolar hypoventilation is occurring in a patient on the ventilator when what occurs?

A

Auscultation reveals an air leak around the ET tube.

32
Q

What is the criteria for sepsis and SIRS?

A

Sepsis: 2 SIRS criteria as well as confirmed OR suspected infection

SIRS: 2 of the following

  • Temp greater than 100.4 or less than 96.8
  • RR greater than 20
  • HR greater than 90
  • WBCs greater than 12,000 or less than 4,000 or greater than 10% bands
  • PCO2 less than 32 mm Hg
33
Q

A patient is admitted to the hospital in a late stage of septic shock and SIRS. What is the nurse’s priority action?

A

Administer 100% oxygen by nonrebreather mask

ABCs

34
Q

You are implementing fluid resuscitation on your patient in septic shock. When do you begin to use vasopressors?

A

When the central venous pressure (CVP) is at least 8 mm Hg. This is to keep their MAP at greater than or equal to 65. How do you calculate MAP?
(2 x diastolic + systolic) divided by 3

35
Q

A septic patient with the following VS:
BP 70/42, O2 sat 90%

What would be implemented third?

A

Obtain urine and blood samples.

ABC’s in order:

  1. Titrate oxygen to keep O2 > 91%
  2. Start NS 1000 mL over 30 minutes
  3. Obtain urine and blood samples
  4. Give Vancomycin (Vancocin) 1g IV
36
Q

What mechanism of an MI can result in SIRS?

A

Ischemic or necrotic tissue.

SIRS=Systemic Inflammatory Response

  • Stage I: body mounts a localized inflammatory response-release of mediators-cytokines to the insult on body.
  • Stage II: cytokines released into systemic circulation to mount bigger response (still considered localized). The chemicals are released out in body to ask for help.
  • Stage III: significant systemic reaction-increased vascular permeability, increased fluid in alveoli, cardiac depression, vasodilation.
37
Q

What is the goal of fluid resuscitation and pharmacotherapy of shock?

A

Maintain mean arterial pressure of at least 65 mm Hg.

MAP [(2 x diastolic) + systolic] divided by 3.

NS 30 mL/kg

CVP 8-12
MAP >65
U.O. 0.5 mL/kg/hr

Normal lactate levels 0.5-1 mmol/L

38
Q

Which patient manifestation confirms the development of MODS?

A

Elevated serum bilirubin, serum creatinine of 2.9, platelet count of 15,000.

The bilirubin indicates liver failure
The creatinine indicates renal failure
The low platelets also indicate possible liver cirrhosis.

39
Q

What are some causes of SIRS?

What is the most common cause of infection leading to sepsis?

What are some ways to prevent SIRS?

A
  • Causes of SIRS (systemic inflammatory response)
  • MI
  • Trauma
  • Burns
  • Pancreatitis
  • Clots
  • Infection (bacterial, fungal, viral)
  • Bacterial infection is the most common cause of SIRS
  • Prevent SIRS by:
  • Preventing infection and treating infections quickly
  • Preventing any of the above causes
40
Q

Compare and contrast hypoxemic and hypercapnic respiratory failure:

A 
Hypoxemic: 
- Lack of O2 - PaO2 < 60
- Causes: V/Q mismatch, shunting, diffusion problems: fluid in lungs, over-sedation, and neuromuscular dz
- S/S: 
Tachypnea
Accessory muscle use
Cyanosis is a late sign
Fatigue
Low SpO2

Hypercapnic:
- PaCO2 > 45 and pH < 7.35
- Causes: CNS depression, chest wall problem - rib fracture(s), asthma/COPD, neuromuscular dz
- S/S:
Bradypnea then tachypnea, tripod, pursed lip breathing, disorientation is early sign, a.m. headache, progressive somnolence, cardiac dysrhythmia

41
Q

What interventions are used to treat ARDS?

How do we mobilize secretions?

What does the “good lung down” mean?

A 
- Tx ARDS by: 
Txing the underlying cause.
O2 therapy
Steroids
Bronchodilators
Diuretics
Antibiotics
- Mobilize secretions by:
Chest physiotherapy
Vibration
Good lung down
Prone positioning
  • “Good lung down” means positioning the patient so that postural drainage can occur from the bad lung to the good lung.
42
Q

What are the possible complications of positive pressure ventilation?

A

Complications of PPV:

  • Increased thoracic pressure. This leads to:
  • Decreased venous return. This leads to
  • Decreased cardiac output
  • Barotrauma
  • Alveolar hypoventilation - resp. acidosis
  • Alveolar hyperventilation - resp. alkalosis
  • VAP (vent associated pneumonia)
  • Water / Na retention
  • Impaired cerebral blood flow
  • GI ulcers
  • Nutrition - need enteral feedings
  • Pressure ulcers
43
Q

What signs are we looking for when considering readiness of extubation?

A

Preweaning (assessment):

  • Lungs clear
  • Respiratory muscle strength, can initiate inspiration
  • Neurologic status - awake and alert
  • Adequate oxygenation (as you’re tapering)
    • SpO2 > 90%
    • pH > 7.25
    • Hemodynamically stable

Weaning stage:

  • Reduction of vent support: PEEP <5-8
  • Spontaneous breathing trial (w/ev still in place)
  • Drugs are titrated to provide comfort but allow pt to assist.

Weaning outcome:
Deep breath and… extubate
Suction, O2, reassess

44
Q

What is “VAP”

S/S?

How do we prevent?

A

VAP means Ventilator Associated Pneumonia. It is a pneumonia that occurs 48 hours or more after ET intubation. It occurs in as many as 27% of all intubated patients, with half developing within the first 4 days.

S/S: Increased WBC level, fever, purulent or odorous sputum, crackles or wheezes on auscultation, and pulmonary infiltrates noted on chest x-ray.

We prevent with VAP bundle:

  1. Minimize sedation (sedation vacation) - daily spontaneous awakening trials and daily spontaneous breathing trials.
  2. Early exercise and mobilization
  3. Use of ET tubes with subglottic secretion drainage ports for pts likely to be intubated greater than 48-72 hours
  4. HOB elevation at a minimum of 30-45 degrees, unless contraindicated
  5. No routine changes of the pt’s ventilator circuit tubing.
  6. Oral care with chlorahexadine swabs/rinse
45
Q

What are the most common microorganisms to cause VAP?

A
  • E coli
  • Klebsiella Strep pneumonia
  • Pseudomonas
  • MRSA
46
Q

meaning of inotropic

A

Modifying the force or speed of contraction of muscles.

An inotrope is an agent that alters the force or energy of muscular contractions. Negatively inotropic agents weaken the force of muscular contractions. Positively inotropic agents increase the strength of muscular contraction.

1 216 Med Surg (5 decks)

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