M2 Gas Exchange Flashcards
Anemia
Deficiency in the number of erythrocytes (RBCs)
Poor hemoglobin
Poor hematocrit
Hemoglobin
Part of RBC responsible for O2 transfer
Hematocrit
Volume of RBCs
Anemia is caused by
Blood loss
Impaired erythrocyte production
Increased erythrocyte destruction
Anemia and gas exchange
Low hemoglobin = low O2
Leads to tissue hypoxia
This is the cause of manifestations
Common anemia causes
Decreased RBC production
Blood loss
Increased RBC destruction
Decreased RBC production and stomach
Low Iron
Low Cobalamin (b12)
Low Folic acid
Decreased RBC production and kidneys
Low Erythropoietin
Decreased RBC production and Liver
Low Iron availability
Blood loss causes
GI
Trauma
GI
Bleeding duodenal ulcers
Colorectal cancer
Liver disease
Trauma
Acute Trauma
Ruptured aortic aneurysm
Increased RBC destruction causes
Hemolysis causes
SCD
Medication
Bad blood
Classification of anemia is done via
CBC
Reticulocyte count (% of RBCs in blood)
Peripheral smear
Morphology vs etiology of blood
Morphology - cellular characteristics
Etiology - MOA of condition
Normal hemoglobin
male
female
13-17
12-15
Mild anemia Hgb values
Symptoms
10-12
exertional dyspnea
fatigue
Moderate anemia Hgb values
Symptoms
6-10
Bounding pulse
Dyspnea
“Ringing in the ears”
Fatigue
Severe anemia Hgb values
Less than 6
Severe anemia Integumentary symptoms
Pallor
Jaundice
Icteric sclera
Pruritus
Smooth tongue
Severe anemia cardiovascular symptoms
low viscosity results in
HR increase
Stroke volume increase
Systolic murmurs
then angina and MI
Severe anemia pulmonary symptoms
tachypnea
dyspnea at rest
orthopnea (breath better upright)
Long term Anemia symptoms
HF
Cardiomegaly
Pulmonary congestion
Ascites
Peripheral edema
Anemia risk factors
GI surgery - gastrectomy, small bowel resection
Disease - Chron’s, celiac, diverticulitis
Alcoholism
Meds that can cause anemia
H2 histamine receptor blockers, decrease gastric acid secretion - famotidine (pepcid), cimetidine
Proton pump inhibitors, also decrease gastric acid secretion - omeprazole, pantoprazole (prazole!)
Pernicious or megaloblastic anemia
Vit b12 deficiency
Gastric mucosa dont produce intrinsic factor due to GI illness or low hydrochloric acid in body
Intrinsic factor
Made by parietal cells of gastric mucosa
Helps absorb B12
Treatment for pernicious anemia
Good nutrition
B12 therapy
Parenteral - cyanocobalamin or hydroxocobalamin
Intranasal - Nascobal
Oral high dose supplements
Oral B12 schedule
if left untreated
1000mcg/day for 2 weeks
Then 1 a week until Hgb is normal
Then monthly for life
Death in 1-3 years
Clinical manifestation of Pernicious anemia
Severe Pallor
Slight Jaundice
Smooth beefy tongue (glossitis)
Fatigue
Weight loss
Paresthesia (tingling) of hands/feet
Gait difficulty
Folic acid and anemia
Folic acid is needed for DNA synthesis
DNA synthesis leads to RBC formation and maturation
NO FA, NO DNA synth, NO RBC
Common causes of low Folic Acid
MOST COMMON
Poor nutrition
Chronic alcohol abuse
2ND most common
Malabsorption syndromes (Crohn’s celiac etc.)
Meds - methotrexate, anticonvulsants, some contraceptives
Folic acid anemia treatment
Same as pernicious
replace orally
Aplastic anemia
(pancytopenia)
etiology
Decrease in all blood cells
Etiology - congenital, or acquired
Acquired aplastic anemia causes
toxins - insecticides, arsenic, radiation, gold
meds - antiseizure, antimetabolites, antimicrobials
infections - hepatitis parvovirus
Aplastic anemia clinical manifestation
Fatigue
Dyspnea
Neutropenia
Thrombocytopenia
Cognitive changes
Cardiovascular changes
Neutropenia can lead to
Thrombocytopenia can lead to
infection risk
bleeding - petechiae, ecchymosis (bruise), epistaxis (nose bleed)
Cardiovascular changes with aplastic anemia
Palpitation
Tachycardia
Murmurs
Angina HF MI
Palpitation vs murmur
Palpitation - strong irregular beat
murmur - irregular blood swooshing
Cognitive manifestation of aplastic anemia
Impaired thought
Irritability
Depression
HA
In aplastic anemia all lab values would be
bleeding times would be
Decreased - less cells
prolonged - less clotting factors
Values to check for Aplastic anemai
Hgb
WBC
Plt
Bleed time
Bone marrow
Aspiration
Treatment of Aplastic anemia
ID cause
Supportive care - BLOOD Transfusion
ATG
Cyclophosphamide (cyclosporine)
Bone marrow with aplastic anemia
Hypocellular = less production
Increased yellow marrow, fat content
ATG Antithymocyte globulin
Horse serum - polyconal antibodies against human T cells
gets rid of autoimmune cytotoxic T cells that target and destroy pts hematopoietic stem cells
also results in anaphylaxis and serum sickness
If Aplastic anemia pt is less than 55 treatment options
if more than 55 treatment options
Have human leukocyte antigen (HLA) match
HSCT (Hematopoietic stem cell transplant) can be used
High dose of corticosteroids may be used
HLA
HSCT
Human leukocyte antigen - protein, helps body differentiate between self and not self
Hematopoietic (immature cell) stem cell transplant
Hemolytic anemia 101
Caused by destruction of RBCs faster than production
Intrinsic and Acquired
Intrinsic hemolytic anemia
Hereditary defects in RBCs
Acquired hemolytic anemia
RBCs damaged by via secondary disease or injury
Hemolytic anemia results in excess rbc destruction which affects and enlarges what organs
SPLEEN mainly
and Liver
responsible for RBC destruction
With gradual anemic hypovolemia
treatment
H&H will not reflect for up to 48h due to body accommodation of blood loss
Blood transfusion
Fluid replacement with LACTADE RINGER LR (has the replacing components lost at hemorrhage)
3 Components of gas exchange
Ventilation
Transport
Perfusion
Ventilation
O2 and CO2 exchange at LUNGS
Transport
hemoglobin carrying o2 and co2 too and from body
Perfusion
Exchange of O2 and CO2 and capillaries
Anemia impacts what part of gas exchange
TRANSPORT
Low RBC = low hemoglobin
ARDS
Acute respiratory distress syndrome
Non-cardia pulmonary edema
Refractory hypoxemia
Severe acute resp failure
Refractory Hypoxemia
(Stubborn condition) of (Low 02 in blood)
Is ARDS a primary process
NO
ARDS results frm
Septic shock
Near drowning
O2 toxicity
Aspiration of foreign material into lungs
Multiple transfusion
Heart surgery
fibrosis
tissue becoming damaged and scarred
ARDS lungs manifestations
Dyspnea
Tachypnea
Crackles
Rhonchi
ARDS muscle manifestations
Intercostal retraction
Use of accessory muscles
ARDS other manifestation
Altered mental status
Anxiety
Cyanosis
Diagnosing ARDS
ABGs
Decrease pO2
INITIALLY resp alkalosis, THEN resp acidosis
Chest xray
Whiteout
A/B of ARDS
First resp alkalosis
Then resp acidosis
Treatment of ARDS
Correct disorder
meds
Low dose steroids
LMWH
ventilatory
PEEP with low setting oxygen
Prone position
Position for ARDS
PRONE
PEEP
Positive end expiratory pressure
pushes air at end of exhale so alveoli don’t collapse
Nursing and ARDS
Ventilator and PEEP
Hemodynamic monitoring
Lung sounds
Daily weight
Ventilator and PEEP adverse effects
Will result in decrease in cardiac output
this will lower venous return resulting in ventilation issues
First signs of PEEP/ventilator related cardiac issues
how to monitor
Urine output decrease
Decrease in level of consciousness
Do hemodynamic monitoring
Weaning off of ventilator what to monitor for
Increase in BP HR or RR
Decrease in O2 sat
Dyspnea and Cyanosis
Diaphoresis and pallor
Anxiety LOC
Accessory muscle use
Position for ventilator weaning
Reduce anxiety by
At night
High fowlers
Explaining process
Let pt rest
To wean off, decrease vent supported breaths by
avoid what
2/min
respiratory depressants
Care after extubating
KEEP intubation kit handy
Provide supplemental O2
Do pulmonary hygiene
Incentive spirometer use
sit up
10 times an hour
Vent alarm for
low pressure
low ventilation
low exhaled vol
Measured PIP less than set PIP
causes
Cuff leak
Circuit leak/disconnection
Endotracheal tube displacement
PIP
Peak inspiratory pressure
Vent alarm for
low pressure
low ventilation
low exhaled vol
Solutions
Check ett
check disconnetions
check cuff
ask pt if higher flow needed
check water traps
Vent alarm
High pressure
measured PIP greater than set PIP
Causes
Secretions
water in tube
Kink of blockage of tube
Pneumothorax
Atelectasis
Bronchospasms
Vent alarm
High pressure
measured PIP greater than set PIP
Solutions
Suction
Reposition pt
Insert bite block
Empty water traps
bronchodilators
Vent alarm high tidal volume
Causes
PT trying to take MORE air in than what is set on ventilator
Vent alarm high tidal volume
Solution
Increase tidal volume or flow rate
Pulmonary embolism
Thrombus fragments, fragment occludes lung vasculature
Types of thrombus
Clot
Fat
Air
Tumor
DVTs can result in
Pulmonary embolisms
Other causes of pulmonary embolisms
Right HF
A fib
Upper extremity thrombosis
Pelvic surgery or childbirth
Superficial thrombophlebitis
Inflammation and clot due to vein trauma
due to IV cath
DVT may dislodge due to
Mechanical forces
Don’t massage
spontaneously
S/S of DVTs
Calf tenderness
Redness
+ Homan’s sign
Homan’s sign
Firmly and abruptly dorsiflex (point toes up) the ankle
if deep calve pain = DVT
Other Pulmonary Embolism (PE) risk factors
Immobilization
Surgery
Stroke
Malignancy
Hypertension
smoking
oral contraceptives
PE triad
Chest pain
Dyspnea
Hemoptysis (spitting blood)
REPORT IMMEDIATELY
Other PE indicators to report
airway
general
PaCO2 will be
Cough
friction rub
Tachypnea
Tachycardia
anxiety
fever
LOC change
LOW
Other PE indicators to report
airway
general
PaCO2 will be
Cough
friction rub
Tachypnea
Tachycardia
anxiety
fever
LOC change
Pulmonary infarction
Complication of PE
Death of lung tissue due to lack of blood flow
Pulmonary hypertension
PE complication
Dilation and hypertrophy of the RT ventricle due to increased pressure in lung arteries
Diagnostics for Pulmonary embolisms
visual
Ventilation/Perfusion lung scan
Pulmonary angiography
Chest xray
CT
Diagnostics of pulmonary embolism
LAB
EKG
D-dimer (normal less than 250)
PaO2 LOW
ST segment and T wave changes
D dimer
protein produced during blood clot dissolving
normal is LESS than 250
Order for PE
Supplemental O2
EKG
Labs
IV Heparin, start coumadin
Bed rest
Goal of PE interventions
meds
Lyse existing emboli
Prevent new ones
heparin
coumadin
thrombolytic therapy
Thrombolytic therapy requirements
Remain on bedrest
Vitals Q2h
When on Thrombolytic therapy monitor
PT/INR - warfarINR
PTT - Heparin
Heparin
inhibits formation of other clots
WHICH COULD FORM IN PRESENCE OF EXISTING CLOT
when to start Heparin therapy
DVT diagnosis
Before it can become PE
Heparin therapy
Bolus 100u/kg
iv infusion till APTT normal is 20-30 sec
therapeutic APTT levels 1.5-2 times normal
Therapeutic APTT levels
1.5-2 times normal
40-75 sec
Heparin contraindications
S/S of bleeding
Hematuria
Blood in stool
Ecchymosis
Petechia
LOC
Heparin Antidote
How to dose
Protamine sulfate
1mg per 100u
To prevent DVTs in high risk clients can we give heparin Subcutaneously
YES
Other drugs for PE
Lovenox - low dose heparin
Dextran - Plasma expander ?
Warfarin
Aspirin
Starting pt on warfarin
10-15mg qd for 2 days
then 2.5 to 7.5 mg qd in EVENINGS
Warfarin may need to be take for up to _ after DVT
6 months
Monitoring Prothrombin/INR time with warfarin
PT/INR
normal pt is 12 seconds, therapeutic is 1.5-2 times normal so 18-25
INR is 2.0-3.0
Bleeding assessment for warfarin
Same as heparin
Antidote for warfarin
Vit K
Anticoagulant VS thrombolytic
Anticoagulants warfarin heparin
Thrombolytic tPA tissue plasminogen activator
Common tPAs
Streptokinase
Urokinase
tPA moa
dissolves clots
When on tPA interventions
Monitor for bleeding
Only essential invasive procedures
Needle gauge is ONLY 22 or 23
How long to apply pressure when pt is on anticoagulants or thrombolytics
?
How often do you check IV sites if pt on bleed precaution
q2h
Bleed precaution and rectal tissue
NO rectal temps
NO enemas
lubricate suppositories well
Avoid constipation
ADLs and bleed precaution
Use electric razor
Use soft bristle toothbrush
No nose blowing
Psych complications of Pulmonary Embolisms
Anxiety
Sense of doom
Fear
PE surgery
Pulmonary embolectomy
Inferior vena cava filter
Post DVT, PE, and bleed precaution discharge teaching
Assess bleeding
No antihistamines?
Wear elastic stockings
No laxatives - bleed
No leg crossing - dvt
Prevention of DVTs
Avoid prolonged sitting (planes, long car rides)
Increase fluids
Wear shoes at all times
Can you stop bleed meds abruptly
NO
if bleeding occurs, apply direct pressure for
extremity care
if unresolved
5 min
apply ice, elevate
Go to ER
Notify DR. if on blood thinners and this occures
Excessive menstrual bleeding
Blood in urine/stool
Easy bruising
Cystic Fibrosis 101
Defective chloride ion transport
mucus becomes viscous and dehydrated
obstruction of airway, GI, integument, reproductives
Cystic fibrosis is autosomal
gender?
race
recessive
not a factor
yes
Glands affected by Cystic Fibrosis
Exocrine
release secretions on to surface, interior or exterior
i.e. sweat, saliva, digestive juices.
CF and resp complications
Chronic infections
Air trapping
Hypoxia
Air trapping and CF
Hyperinflation
Atelectasis
Fibrosis
Destruction of lung tissue
CF hypoxia
A/B?
vascular?
Hypercapnia - resp acidosis
vasoconstriction - right side heart hypertrophy = CHF
CF GI digestive enzymes that are blocked
Amylase (starch) Lipase (fat) Trypsin (protein)
secreted by PANCREAS
Pancreas may also have CF problems with islets of langerhans which results in
T1 diabetes
GI CF thick intestinal mucus can cause bowel
obstruction
intussusception (telescoping)
CF GI inflammation results in
Crohn’s disease
Bile is produce in the
thickened bile damages those organs
Liver
Gallbladder
CF and skin
Increase in salt and chloride sweating
CF and reproduction
Seminal vesicles obstruction in men
Thickened cervical mucous in women
CF resp system S/S
Early
Late
Early
Wheezing
Dry cough
Frequent infection
Late
finger clubbing
barrel chest
nasal polyps
CF GI S/S
Meconimu ileus - bowel obstruction
bulky foul fatty stool
failure to thrive
delayed development
T1 diabetes
Test for CF
are related to S/S
Sweat test
Fecal fat test
Liver function
Fasted blood
Pulmonary function
Pulmonary treatments with CF
Bronchodilators and Chest physio therapy
Mucolytic - help with viscosity
CFTR - cystic fibrosis transmembrane regulator
Antibiotics - infection
CFTR and CF
increase chloride transport
Digestive meds for CF
H2 (histamine) blockers, Proton pump inhibitors - reduces stomach acid
Pancreatic enzymes
Vitamins
Iron
Ursodiol
vitamins and CF
Fat soluable ADEK
help with malabsorption
Iron and CF
help with malabsorption
Ursodiol and CF
Bile acid
helps prevent gallstone and liver disease
Resp interventions for CF
CPT (chest therapy) - 1/2 times before meals
Nebulizer treatment - for airflow and mucus clearance
Exercise
Antibiotics
Nutrition and CF
High calorie balanced diet
110-200% of recommended dietary calories
Moderate fat intake
pancratic enzymes
GERD meds
Vitamins
Sodium
Infection prevention and CF
Limit exposure to people with resp infections
Adequate rest
Immunizations
BiPAP
Bilevel positive airway pressure
CPAP
Continuous positive airway pressure
higher flow on inhalation
continuous flow
FiO2
Fraction of inspired oxygen
Indicates amount of oxygen the ventilator delivers
Expressed as a percentage
21% room air
40% for support
100% for severe hypoxemia
Tidal volume
Preset amount of oxygen and air delivered by ventilator
PRVS
Pressure regulated volume control
This setting adjusts volume and pressure based on lung compliance
AC
Assist control setting
Supports every breath
Used at night to help pt rest
risk for hyperventilation
SIMV
Synchronized intermittent mandatory ventilation
setting
Not all breaths are assisted
PT has to start breathing on their own
Pressure support setting with SIMV
small pressure to help on inspiration
Ventilator complications
Infection
Atelectasis
Barotrauma
O2 toxicity
Barotrauma
Alveolar rupture due to high pressure
Ventilator bundle AKA
Ventilator associated pneumonia prevention
4 components
Head of bed at 30-45 degrees
Daily assessment for extubation
Peptic ulcer prophylaxis
DVT prophylaxis
Other prevention
CLEANING the DEVICES
Preventing atelectasis with Ventilation
Repositioning - to redistribute pressure
Pulmonary hygiene, CPT
PEEP
With vents assess breath sounds how often
q4h
Barotrauma and emphysema
Subcutaneous emphysema is an early warning sign
Decreased breath and heart sounds with Ventilators could indicate
pneumothorax
Oxygen toxicity vent S/S
decrease in LOC
weakness
N/V
hypoxemia
cyanosis
To avoid Oxygen toxicity use
Lowers FiO2 setting to produce O2 sat of 90% at 60mmHg
