Med Surg Exam 1 (Respiratory System) Flashcards
1
Q
“Impaired Gas Exchange”
- correlated to what condition?
- assessment finding (lung sound)
A
- correlated ot ARDS
- fine crackles on auscultation (best heard on the back)
2
Q
4 examples of impaired gas exchange diseases
A
- pneumonia
- atelectasis
- cystic fibrosis
- tuberculosis
3
Q
“Ineffective Airway Clearance”
- interventions (3)
- contraindicated intervention
A
- interventions: (1) encourage fluids, (2) suction airway, (3) coughing
- do not increase oxygen delivery
4
Q
“Inadequate Ventilation” or “Ineffective Breathing Pattern”
- correlated to what condition?
- indicated by what s/s (6)
A
- correlated to COPD (high respiratory acidosis)
- s/s: tripod position, pursed lip breathing, decreased RR, morning headache, tachycardia, muscle weakness
5
Q
“Inadequate Perfusion”
- assessment s/s (6)
- perfusion complications due to mechanical ventilation?
- interventions (2)
A
- s/s: cool, clammy, diaphoretic skin, pale extremities, decreased LOC, prolonged capillary refill time
- decreased CO
- interventions: (1) monitor, (2) give drugs and IV fluids to maintain adequate CO
6
Q
What disease process causes a patient to not adequately ventilate due to the physical inability to expand lungs?
A
COPD
7
Q
What is an EARLY assessment finding of hypoxemia? Late assessment finding?
A
- Early: Agitation / change in LOC
- Late: Cyanosis
8
Q
Prevention for “Impaired Gas Exchange” (4)
A
- deep breathing
- huff and staged coughing
- incentive spirometry
- early ambulation
9
Q
What is the optimal max O2 administration for patient?
A
PaO2 greater than 60 mmHg and SaO2 90% or more at the lowest O2 concentration
10
Q
Interventions for “Impaired Gas Exchange” (5)
A
- Patient positioning - PRONE position (requires an ICU intensivist, respiratory therapist, and 3-4 other nurses)
- Postural drainage
- Humidification
- Hydration
- Nutrition: maintain protein and calories, administer through TPN or G/J-tube
11
Q
Interventions for “Inadequate Airway Clearance” (5)
A
- Encourage fluids
- Airway suctioning
- Patient repositioning: HOB at 30 degree angle
- Chest physiotherapy
- Humidification
12
Q
When suctioning the airway, what should the nurse do? (2)
A
- Suction on the way UP the tube, do not suction on the way down
- Small amounts at a time around the mouth, through the nose (NG), throat, and top of lungs through trach)
13
Q
Normal ABG levels: pH, paO2, PaCO2, HCO3, BE
A
pH: 7.35-7.45 paO2: 80-100 paCO2: 35-45 HCO3: 22-26 BE: -2 - +2
14
Q
Base excess indications (BE)
A
> +2 means metabolic alkalosis
< -2 means metabolic acidosis
15
Q
Normal range for mean arterial blood pressure? Formula for mean arterial blood pressure (MAP)?
A
Normal range: 70-100 mmHg
Formula = [systolic + 2{diastolic)] / 3
16
Q
What is a physical assessment finding of respiratory acidosis?
A
Tachycardia
17
Q
Which arterial blood gas value is necessary to identify if a condition is compensated or uncompensated?
A
Blood pH
18
Q
A nurse is analyzing an ABG report of a client with COPD and respiratory acidosis. Which compensation mechanism is likely to occur?
A
The kidneys will retain bicarbonate
19
Q
What are the three stages of ARDS?
A
- injury or exudative phase
- reparative or proliferative stage
- fibrotic or fibroproliferative phase
20
Q
Define ARDS
A
sudden and progressive form of ARF in which an inflammatory response damages the alveoli-capillary membrane and becomes permeable to fluid
21
Q
ARDS is a condition that develops because
A
alveolar capillary membrane permeability has changed, leading to fluid collecting in the alveoli sacs
22
Q
Acute respiratory failure is not a _____, it is a ____.
A
ARF is not a condition, it is a diagnosis
23
Q
Possible causes of ARDS? (9)
A
- pneumonia
- car accident/chest trauma
- COVID
- COPD
- infections
- spinal cord injury
- pulmonary embolism
- premature infants
- exhaustion
24
Q
Examples of direct injuries that cause ARDS? (5)
A
- aspiration of gastric contents
- bacteria
- virus
- COVID
- COPD
25
Examples of indirect injuries that cause ARDS? (5)
1. chest trauma
2. pulmonary embolism
3. O2 toxicity
4. shock
5. sepsis
26
Progression of ARDS to ARF is indicated by? (3)
1. increased WOB
2. respiratory distress
3. use of accessory muscles
27
S/S of ARF (4, in order)
1. tachypnea
2. tachycardia
3. diaphoresis
4. cyanosis
28
ARDS goal?
PaO2 of 60 mmHg or less and SaO2 above 90%
29
If a patient's paO2 levels are low (lower than 60) when oxygenated (ex: 100% rebreather mask), this indicates that the patient is?
Progressing to acute respiratory distress
30
2 types of acute respiratory failure?
1. hypoxemia
| 2. hypercapnia
31
Hypoxemic RF is an _____ issue. Insufficient _____ (PaO2 less than?)
- oxygenation issue
| - insufficient OXYGEN (PaO2 less than 60 mmHG)
32
s/s of hypoxemic RF? (4)
1. change in LOC / restless (FIRST)
3. dusky skin
4. dysrhythmias / tachycardia
5. tachypnea
33
4 pathophysiological reasons for hypoxemic RF?
1. V/Q mismatch
2. shunting
3. alveolar hypotension
4. diffusion limitation
34
Hypercapnic RF is a ______ issue. Inadequate ______.
- VENTILATORY issue
| - inadequate CO2 REMOVAL
35
What are 4 general etiological factors for hypercapnic RF?
1. CNS problems
2. neuromuscular conditions
3. abnormal chest movement
4. conditions of the airway and alveoli
36
What is an EMERGENT INTERVENTION for the progression of acute hypoventilation to severe hypercapnic ARF?
Apply a bag-valve mask and assist with breathing
37
List the RESPIRATORY causes of hypoxemic RF (5)
1. ARDS
2. Hepatopulmonary syndrome (V/Q mismatch)
3. Pulmonary embolism
4. Pneumonia
5. Toxic inhalation
38
- s/s of pulmonary embolism (2).
- Why would a pulmonary embolism lead to hypoxemic RF?
- What would be used to differentiate a pulmonary embolism from an acute coronary event?
- SOB, painful to breathe
- decreased perfusion of the lungs leaves little blood to pick up oxygen from the alveoli
- ECG
39
List the CARDIAC causes of hypoxemic RF (3).
1. anatomic shunt (ventricular septal defect)
2. CARDIOGENIC SHOCK
3. high cardiac output (diffusion limitation)
40
- Describe the reason why a cardiogenic shock could lead to hypoxemic RF
- s/s of cardiogenic shock (4)
- decreased blood flow through the pulmonary vasculature --> decreased blood flow to lungs
- hypotension, cyanosis, clubbing of fingers, cool/clammy skin
41
RESPIRATORY causes of hypercapnic RF (3).
1. asthma (narrowing airways; wheezing, high-pitched sounds)
2. COPD
3. CF
42
CNS causes of hypercapnic RF (4).
1. brainstem injury or infarction
2. sedative and opioid overdose
3. spinal cord injury
4. severe head injury
43
TRAUMA causes of hypercapnic RF (3)
1. kyphoscoliosis
2. pain from severe obesity
3. thoracic trauma (flail chest)
44
NEUROMUSCULAR cause of hypercapnic RF
Guillain-Barre Syndrome
45
While caring for a patient admitted with a pulmonary embolism, the nurse notes a change in the patient's SaO2 from 94% to 88%. What should the nurse do FIRST?
Increase the amount of oxygen delivered
46
What is the most common cause of a V/Q mismatch?
increased secretion in the airways (ex: COPD, pneumonia, asthma)
47
Interventions for V/Q mismatch (2)
1. O2 therapy (reverse hypoxemia)
| 2. treat underlying cause
48
Describe the physiological mechanism of a shunt that will lead to RF.
blood exits the heart and misses gas exchange (d/t anatomical or intrapulmonary shunt) = alveoli will fill with fluid = impaired gas exchange
49
Describe adventitious lung sounds and possible reasons (3)
1. fine crackles = pulmonary edema
2. coarse crackles = fluid
3. absent or diminished = atelectasis, pneumonia, hypoventilation
50
What is the main cause of death for patients on treatment for ARDS?
Multiple organ dysfunction syndrome accompanied by SEPSIS (vital organs are affected) = decompensated heart failure leads to diminished gas exchange
51
RESPIRATORY complications of ARDS treatment (7)
1. O2 toxicity
2. VAP
3. Barotrauma
4. Abnormal lung function
5. Volutrauma
6. Alveolar hypoventilation
7. Alveolar hyperventilation
52
O2 toxicity leads to (3)
1. decreased surfactant production
2. fibrotic changes in the alveoli
3. increased pulmonary capillary permeability
53
O2 toxicity prevention
Avoid ventilation at all times to decrease the possibility of dependency and weaning complications
54
What is barotrauma?
When the ALVEOLI ARE OVERDISTENDED and rupture with excess pressure due to high mechanical ventilation and high peak pressures (PEEP)
55
Intervention for barotrauma?
Decrease the tidal volume and PEEP to 5 cm H20 if mechanically ventilated
56
Define volutrauma.
Too much volume going into patient's lungs during mechanical ventilation
57
GASTROINTESTINAL complication of ARDS treatment
STRESS ULCER (high risk related to diversion of blood from GI tract to respiratory system to meet O2 demand)
58
RENAL SYSTEM complication of ARDS treatment
Acute kidney injury (d/t decreased renal perfusion and O2 delivery to kidneys)
59
Monitor ____ and ____ for patients with AKI. Which would give a more accurate understanding of a patient's fluid status?
- I&Os and body weight
| - BODY WEIGHT would provide a more accurate indication of cardiac and respiratory health
60
CARDIAC complications of ARDS treatment (2)
1. decreased CO
| 2. dysrhythmias
61
HEMATOLOGIC complication of ARDS treatment
Venous thromboembolism
62
Intervention/prevention for venous thromboembolism, a complication related to ARDS treatment (3)
1. use of SCDs for prevention
2. early ambulation
3. anticoagulants (ex: HEPARIN/LMWH such as lovenox and unfractionated heparin)
* * lovenox can be taken home **
63
PSYCHOLOGICAL complications of ARDS treatment (4)
1. survivors may experience anxiety
2. memory and attention issues
3. nightmares
4. depression / PTSD
64
paCO2 greater than 45 mmHg and pH less than 7.35 indicates?
respiratory acidosis = hypercapnic RF
65
paCO2 of less than 60 mmHg on O2 therapy greater than 60% indicates?
hypoxemic RF
66
s/s of hypoxia (7)
1. tachypnea
2. nasal flaring
3. intercostal muscle retraction
4. SpO2 of less than 90%
5. inability to speak in complete sentences without pausing
6. Paradoxical chest or ABD wall movement with respirations (LATE)
7. cyanosis (LATE)
67
Indications of mechanical ventilation (4)
1. slow RR (respiratory muscle fatigue)
2. persistent hypoxia
3. hypoventilation
4. REFRACTORY HYPOXEMIA (paO2 remains low despite high flow O2 delivery *classic sign of ARDS*)
68
Who decides what type of mechanical ventilator the patient should be on?
RT and HCP
69
Medications during mechanical ventilation (3)
1. opioids: provide pain relief but decreases respiration
2. neuromusuclar blocking agent: provides effective synchrony with ventilator
3. IV sedation and analgesia concurrently when patient is paralyzed or in pain
70
Causes of distress/agitation/anxiety in mechanically ventilated patients (5)
1. nutritional deficits
2. pain
3. hypoxemia
4. hypercapnia
5. environmental stressors
71
Intervention for safe sedation for clearance of secretions/mucus
reduce the amount of oxygen delivery to allow patient to cough out secretions/mucus
72
monitoring VENTILATION includes? (4)
1. paCO2 levels less than 50
2. partial pressure of end-tidal CO2 (ETCO2)
3. RR and rhythm
4. use of accessory muscle use
73
What indicates EFFECTIVE ventilation?
paO2 greater than 60, SaO2 greater than 90%, good LOC, good perfusion
74
monitoring OXYGENATION includes (4)
1. ABGs
2. pulse ox
3. mixed venous O2 sat or CVO2 sat
4. lung sounds
75
List clinical signs of hypoxia from first to last (3)
(first) changes in LOC, dusky skin, dysrhythmias (last)
76
Managing thick secretions (3)
1. adequate hydration
2. humidification
3. mobilize and turn patients
77
Types of oxygen delivery systems (6)
1. BiPAP
2. CPAP
3. high-flow
4. venturi
5. partial vs complete CO2
6. non-rebreather
78
Prevention for ventilator complications (6)
1. good hand hygiene before and after suctioning
2. suction patients AS NEEDED (do NOT routinely suction)
3. keep HOB greater than 30-45
4. initiate early mobilization
5. perform daily spontaneous breathing trials (SBT)
6. perform daily oral care with chlorhexidine solution every 2-3 hours
79
Prevention for ventilation complications associated with the GI system - risk for stress ulcers and GI bleed (2)
1. stress ulcer prophylaxis: medications to decrease acidity (ex: histamine 2 or H2 receptor blocker, proton pump inhibitors/PPI)
2. proper enteral nutrition
80
Ventilator-associated pneumonia occurs ____ or more after intubation
48 hours or more
81
Risk factors for VAP (4)
1. contaminated respiratory equipment
2. INADEQUATE HAND WASHING
3. environmental factors
4. impaired cough
82
s/s of VAP (6)
1. fever
2. high WBC count
3. purulent or odorous sputum (ex: PINK, FROTHY BLOODY)
4. crackles or wheezes
5. pulmonary infiltrates
6. productive coughing
83
Prevention for VAP (6)
1. minimize sedation (PERFORM DAILY ASSESSMENT FOR READINESS FOR EXTUBATION)
2. early exercise/mobilization
3. subglottic secretion drainage port
4. elevate HOB 30-45 degrees
5. oral care with chlorhexidine
6. NO routine changes or ventilator circuit tubing
84
Psychosocial needs for VAP? (2)
1. feeling safe is overpowering
| 2. just because they are unconscious, does not mean that the patient cannot hear or feel
85
Indications for suctioning (5)
1. visible or suspected secretions
2. sudden onset of respiratory distress
3. increased RR or frequent cough
4. sudden drop in SpO2
5. adventitious lung sounds
86
Prevention of complications WHEN suctioning
hyperoxygenate before AND after, limit to 10 seconds of suctioning
87
What are the 3 phases of weaning and extubation?
1. preweaning
2. weaning (longest period for patients who have been ventilated longer)
3. outcome
88
Causes of HIGH-PRESSURE ALARMS (5)
1. secretions, coughing, gagging
2. patient fighting ventilator (ventilator asynchrony)
3. kinked or compressed tubing
4. increased resistance
5. decreased lung compliance (ex: pulmonary edema, ARDS)
89
Interventions for HIGH-PRESSURE ALARMS (5)
1. FIRST: coach patient to breathe with the vent and reasssure
2. clear secretions (using incentive spirometer)
3. unkink tubing, insert bite block
4. reposition
5. give bronchodilator or sedation
90
Causes of LOW-PRESSURE ALARMS (3)
1. total or partial ventilator disconnect or extubation
2. air leak
3. ET tube or tracheostomy CUFF LEAK (ex: patient is able to speak/grunt)
91
Interventions for LOW-PRESSURE ALARM (2)
1. check connections / patency
| 2. INFLATE CUFF (20-25 cm H2O)
92
Who is responsible for re-inflating cuff when low-pressure alarms?
The RT
93
What is the normal tidal volume for patients in terms of cuff inflation?
4-8 liters per kilo
94
Low tidal volume alarms due to?
Permissive hypercapnia
95
Define permissive hypercapnia.
low tidal volume used to prevent barotrauma can lead to an increase in paCO2 (goal to minimize paCO2)
96
A low tidal volume can prevent barotrauma, but it is contraindicated in patients with? (2)
- traumatic brain injury
| - increased ICP
97
Who is at greatest risk for barotrauma?
COPD patients
98
Purpose of PEEP (positive-end expiratory pressure)
Positive pressure applied to airway during exhalation in order to prevent alveolar collapse
99
Benefits of PEEP (3)
- increases lung vol and functional residual capacity (FRC)
- improves oxygenation
- allows a decrease in O2 (FiO2)
100
What is the optimal FiO2 level for patients on mechanical ventilation?
40-50%
101
Is it okay for a patient to be on 60% FiO2?
That is too much, but it is acceptable for a short-period of time for very hypoxic patients
102
PEEP is indicated for what patients?
ARDS patients
103
PEEP should be used with caution for patients with (3)
- increased ICP
- low CO
- hypoventilation
104
What is the optimal PEEP level?
5-10 mmHg (titrated to improve oxygenation without compromising hemodynamics)
105
COMPLICATIONS if PEEP is too high (3)
1. increased WOB
2. barotrauma (due to high inspiratory pressure and PEEP >5)
3. hemodynamic instability (blood is unable to be delivered back to the heart due to high pressure)
106
Ventilator setting changes based on ABGs
- DECREASED tv and rr
- INCREASED tv and rr
- decreased: respiratory alkalosis
| - increased: respiratory acidosis
107
Ventilator settings determine?
"how fast are we going to make the patient breathe?"
108
Ventilator settings are based on? (7)
1. patient's ventilatory status
2. WOB patient should/could perform
3. respiratory rate
4. ABGs
5. tidal volume
6. FiO2
7. PEEP
109
When should ventilator settings be turned off?
Never, all ventilator alarms should stay on
110
Ventilator modes determine?
"volume or pressure?"
111
Volume MODE is mainly for ____
critically ill patients
112
What are the 2 types of VOLUME modes for mechanical ventilation?
1. assist-control ventilation (ACV)
| 2. synchronized intermittent mandatory ventilation (SIMV)
113
Assist-control ventilation (5)
- delivers preset Vt frequency
- dependent machine doing most of the work for the patient (most beneficial for ARDS patients)
- allows some control
- patient breathes FASTER = potential for hyperventilation
- requires continuous monitoring
114
Synchronized-intermittent mandatory ventilation (SIMV) (4)
- delivers preset Vt frequency IN SYNCHRONY with patient's spontaneous breathing
- less dependent, allows more control
- improves patient/ventilator synchrony
- lower Mean Airway Pressure (less air in thoracic cavity) to prevent muscle atrophy
115
What are the 3 types of PRESSURE MODES of mechanical ventilation?
1. pressure support ventilation
2. pressure-controlled/inverse ratio ventilation (PC-IRV)
3. airway pressure release ventilation (ARPV)
116
Pressure-support ventilation (6)
1. positive pressure applied to support INSPIRATION ONLY
2. less dependent/invasive
3. patient determines inspiratory length, Vt, and respiratory rate
4. used for continuous ventilation and weaning
5. increases patient comfort, decreases WOB, O2 consumption
6. increases endurance
117
Pressure-controlled/inverse ratio ventilation (PC-IRV)
1. I/E ratio begins at 1:1 and progresses to 4:1 = change in rate
2. longer inhales, shorter exhales!
3. allows gradual expansion of collapsed alveoli without over ventilating
4. **due to change in rate, patient needs SEDATION with or without paralysis**
118
Airway pressure release ventilation (ARPV) (3)
1. preset CPAP with short-timed pressure releases
2. permits spontaneous breathing
3. **does not require sedation**
119
What are 2 forms of non-invasive mechanical ventilation?
1. CPAP
| 2. BiPAP
120
CPAP (7)
1. continuous positive airway pressure to keep airway open
2. NOT curative
3. is used to treat obstructive sleep apnea
4. administered with face mask, ET, or tracheal tube
5. should be used with caution for patients with myocardial compromise (d/t increased WOB)
6. **switch to CPAP ventilation indicates an improvement**
7. **patient MUST be able to remove mask independently (possibility of vomiting = expected!)**
121
BiPAP (5)
1. delivers oxygen and 2 levels of positive pressure support (high inspiratory and low expiratory)
2. indicated in patients who have been extubated
3. contraindicated in patients with excessive secretions
4. patient MUST be able to remove masks by themselves and breathe spontaneously on their own
5. expected to vomit!
122
Cardiac complications related to positive pressure ventilation
- decreased CO
- decreased preload
- decreased BP
123
s/s of decreased CO as a result from positive pressure ventilation (PPV) (4)
1. changes in LOC
2. decreased BP
3. decreased peripheral perfusion
4. low cap refill
124
The nurse monitors the patient with positive pressure mechanical ventilation for?
Signs of cardiovascular insufficiency because pressure in the chest impedes venous return
125
Endotracheal intubation (ET)
INVASIVE procedure via mouth, nose, and past the larynx
126
Preparation for ET intubation
consent (unless emergent) and patient teaching
127
BEFORE ET intubation (3)
- PRE-OXYGENATE using BVM with 100% O2 for 3-5 mins
- O2 therapy
- suctioning
128
Confirmation of ET placement (5)
- ETCO2 detector
- paO2
- SaO2
- auscultate lungs
- observe chest movement
129
AFTER ET intubation (3)
- connect tube to mechanical ventilator, secure airway
- MARK POSITION OF THE TUBE
- monitor ABG, SaO2, ETCO2
130
What should the nurse do in the event of ET tube displacement? (3)
1. stay with the patient and call for help
2. maintain privacy
3. support ventilation with BVM at 100%
131
What is the proper cuff pressure for an ET tube?
20-25 mm H20
132
Advantages of an ET tube? (3)
- airway can be secured rapidly
- larger diameter tube decreases WOB
- easier to remove secretions and perform bronchoscopy
133
Disadvantage of an ET tube?
Increased risk for infection
134
Tracheostomy
INVASIVE procedure, surgically inserted via stoma in the neck
135
Benefits for an early tracheostomy? (4)
1. fewer vent dependent days
2. reduced LOS
3. decreased pain
4. improved communication
136
What are general disadvantages of artificial airways? (5)
1. hard to place if patient has limited head and neck mobility
2. teeth can be chipped or removed
3. salivation INCREASES, swallowing difficulties
4. can obstruct tube by biting down
5. mouth care is a challenge
137
Disadvantages of nasal tube ventilation?
unplanned extubation and aspiration
138
A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?
Nitroprusside is a vasodilator = effective if the patient has WARM, PINK, AND DRY SKIN (sign of increased CO)
139
Does oxygenation require a HCP order?
Oxygen requires a documented order; however, it can be given immediately when needed without a written order but is required to be ordered soon after
140
What can be delegated to a UAP or care partner? (3)
1. daily oral care
2. I&O recording
3. ambulate patient or reposition every 2 hours
141
What cannot be delegated to a UAP or care partner? (2)
1. assessing patient's pain
| 2. educating/teaching patient
142
How many nurses should be involved when performing oral care for unconscious patients?
Two nurses, one for suctioning, the other for brushing
143
Epinephrine (3)
- bronchodilator
- increases HR and BP
- used for patients with asthma
144
Dopamine
- vasopressor
- contracts blood vessels = increases BP and HR
- used for patients with ARDS
