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module 1 Flashcards

1
Q

work of breathing

A

amount of effort required for maintenance

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2
Q

signs of difficulty breathing

A

tripod positioning, accessory muscle use

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3
Q

what happens with increased work of breathing?

A
  • increased energy expenditure and body uses more glucose
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4
Q

compliance

A

elasticity and expandability of the lungs and thoracic structures

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5
Q

ventilation

A
  • diffusion at pulmonary capillaries
  • perfusion
  • diffusion to cells
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6
Q

inspiration

A
  • active
  • diaphragm lowers and contracts
  • intercostal muscles contract
  • thoracic cavity expands
  • intrapleural and intra-alveolar pressures become negative = air flows into lungs
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7
Q

expiration

A
  • passive
  • diaphragm relaxes
  • intercostal muscles relax
  • thoracic cavity reduces
  • lungs recoiling generates positive intra-alveolar pressure w. air flowing out of lungs
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8
Q

O2 in the blood vs alveoli

A
  • O2 in blood within capillaries of lungs is lower than in the alveoli; O2 diffuses from the alveoli to the blood
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9
Q

CO2 concentration in blood vs alveoli

A
  • CO2 has higher concentration in blood than in alveoli - CO2 diffuses from the blood into the alveoli
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10
Q

transportation of oxygenated blood

A
  • oxygenated blood in pulmonary capillaries is transported via the pulmonary vein to the left side of the heart
  • it is then perfused and transported to tissues
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11
Q

transportation of CO2

A
  • transported via the vena cava to the right side of the heart and into pulmonary capillaries
  • diffuses into alveoli and is eliminated through expiration
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12
Q

what do the pons and medulla control?

A

rate, depth, and rhythm of ventilation

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13
Q

what stimulates respirations (increases rate/depth to blow it out)

A

hypoxia or increased partial pressure of CO2

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14
Q

what diminishes respirations

A

too much ventilation, decreased partial pressure of CO2

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15
Q

factors that determine compliance

A
  • surface tension of alveoli, connective tissue and water content of lungs + compliance of the thoracic cavity
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16
Q

increased compliance

A

lungs have lost their elastic recoil and become over-distended = emphysema
- more distended lungs requires lower pressures during ventilation; can collapse during expiration

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17
Q

decreased compliance

A

lungs and thorax are stiff
causes = morbid obesity, pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, + ARDS
- requires greater-than-normal energy expenditure to create negative pressure to inflate lungs

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18
Q

resistance

A
  • opposition to flow of gasses in the airways
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19
Q

reasons for resistance

A
  • Contraction of bronchial smooth muscle (asthma)
  • thickening of bronchial mucosa (chronic bronchitis)
  • obstruction of the airway by mucus, a tumor, or foreign body
  • loss of lung elasticity
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20
Q

tidal volume (symbol, normal value, significance)

A
  • VT or TV
  • 500 mL
  • may not vary, even with severe disease
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21
Q

tidal volume description

A

volume of air inhaled and exhaled with each breath

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22
Q

inspiratory reserve volume (symbol, normal value)

A
  • IRV
  • 3000 mL
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23
Q

inspiratory reserve volume description

A

maximum volume of air that can be inhaled after a normal inhalation

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24
Q

expiratory reserve volume (symbol, normal value, significance)

A
  • ERV
  • 1100 mL
  • decreased with restrictive conditions (obesity, ascites, pregnancy)
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25
Q

expiratory reserve volume description

A
  • maximum volume of air that can be exhaled forcible after a normal exhalation
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26
Q

residual volume (symbol, normal value, significance)

A
  • RV
  • 1200 mL
  • may be increased with obstructive disease
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27
Q

residual volume description

A

volume of air remaining in lungs after maximum exhalation

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28
Q

vital capacity (symbol, normal value, significance)

A
  • VC
  • 4600 mL
  • decreased in neuromuscular disease, generalized fatigue, atelectasis, pulmonary edema, COPD, obesity
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29
Q

vital capacity description

A

maximum volume of air exhaled from the point of maximum inspiration
VC = TV + IRV + ERV

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30
Q

inspiratory capacity (symbol, normal value, significance)

A
  • IC
  • 3500 mL
  • decrease may indicate restrictive disease; obesity
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31
Q

inspiratory capacity description

A

maximum volume of air inhaled after normal expiration
IC = TV + IRV

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32
Q

functional residual capacity (symbol, normal value, significance)

A
  • FRC
  • 2300 mL
  • may be increased with COPD; may be decreased in ARDS and obesity
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33
Q

functional residual capacity description

A
  • volume of air remarking in lungs after normal expiration
    FRC = ERV + RV
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34
Q

total lung capacity (symbol, normal value, significance)

A
  • TLC
  • 5800 mL
  • decreased with restrictive disease (atelectasis and pneumonia); increased in COPD
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35
Q

total lung capacity description

A

volume of air in lungs after maximum inspiration
TLC = TV + IRV + ERV + RV

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36
Q

hypoxemic respiratory failure

A
  • oxygenation failure
  • PaO2 less than/equal to 60 mmHg on more than/equal to 60% oxygen
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37
Q

hypercapnic respiratory failure

A
  • ventilatory failure
  • PACO2 greater than 45 mmHg and pH <7.35
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38
Q

fine crackles description

A

high pitched, crackling sounds (fire crackling, or velcro coming apart)

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39
Q

fine crackles causes

A

previously deflated airways that are popping back open

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40
Q

fine crackles example

A

pulmonary edema, asthma, obstructive diseases, atelectasis

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41
Q

coarse crackles description

A

low pitched, wet bubbling sound

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42
Q

coarse crackles causes

A

inhaled air collides with secretion in the trachea or large bronchi

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43
Q

coarse crackles example

A

pulmonary edema, pneumonia, depressed cough reflex

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44
Q

pleural friction rub decription

A

low-pitched, harsh/grating sounds

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45
Q

pleural friction rub causes

A

pleura is inflamed and loses its lubricant fluid

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46
Q

pleural friction rub example

A

pleuritis, pneumonia, TB

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47
Q

wheezes description

A

high-pitched musical instrument with more than one type of sound quality (polyphonic)

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48
Q

wheezes causes

A

air moving through a narrow airway

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49
Q

wheezes examples

A

asthma, bronchitis, chronic emphysema

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50
Q

stridor description and what does it require

A

high pitched whistling or gasping with harsh sound quality
- requires medical attention!!!

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51
Q

stridor causes

A

disturbed airflow in larynx or trachea

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52
Q

stridor example

A

croup, epiglottis, any airway obstruction

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53
Q

geriatric considerations

A
  • decreased chest wall dispensability
  • decreased alveolar surface area
  • decreased alveolar elasticity
  • decreased lung volume
  • decreased physiologic compensatory mechanism for hypercapnia and hypoxia
  • weaker respiratory muscles
  • decreased cough and gag reflex
  • kyphosis
  • barrel chest
  • lower PaO2 levels on ABGs
  • increased risk for secretion retention, pneumonia, poor gas exchange, mental status changes, aspiration, respiratory distress and failure
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54
Q

respiratory acidosis

A

pH low, PaCO2 high

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55
Q

causes for respiratory acidosis

A

hypoventilation, anesthesia/sedatives, overdoses, neuromuscular disorder, spine/brain/chest wall trauma, restrictive lung disease (COPD), later phase of acute airway obstruction

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56
Q

treatment for respiratory acidosis

A

increase RR

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57
Q

respiratory alkalosis

A

pH high, PaCO2 low

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58
Q

respiratory alkalosis causes

A

hypoxemia, anxiety, fear, pain, fevers, stimulants, CNS irritation (CNS hyperventilation), excessive ventilatory support (vent with a rate that is way too high or bagging them too fast with a bag valve mask)

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59
Q

respiratory alkalosis treatment

A

decrease RR, administer sedatives, rebreather mask

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60
Q

critical values, pt cannot tolerate, ADDRESS IMMEDIATELY

A
  • PaO2 <60
  • PaCO2 > 50
  • pH <7.25 or > 7.6
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61
Q

stop and address the pt when oxygen evaluated by ….

A

PaO2 <30 or SaO2 <90 (pulse ox)

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62
Q

compensation

A

regulation of CO2 in lungs and bicarbonate in kidneys

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63
Q

uncompensated

A

if pH is out of range + CO2 or HCO3 is in range

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64
Q

partially compensated

A

if CO2 + HCO3 are BOTH out of range and pH is out of range

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65
Q

fully compensated

A

if pH is in range

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66
Q

respiratory alkalosis symptoms

A
  • seizures
  • deep, rapid breathing
  • hyperventilation
  • tachycardia
  • low or normal BP
  • numbness & tingling of extremities
  • lethargy
  • light headedness
  • nausea, vomiting
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67
Q

respiratory acidosis symptoms

A
  • hypoventilation leads to hypoxia
  • rapid, shallow respirations
  • low BP
  • headache
  • hyperkalemia
  • dysrhythmias (high K+)
  • drowsiness, dizziness, disorientation
  • muscle weakness, hyperreflexia
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68
Q

CO2 in respiratory alkalosis

A

increase loss of CO2 from lungs

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69
Q

CO2 in respiratory acidosis

A

retention of CO2 by lungs

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70
Q

respiratory problem - alkalosis

A

ph High, CO2 low

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71
Q

respiratory problem - acidosis

A

pH low, CO2 high

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72
Q

respiratory problem remember

A

respiratory opposite

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73
Q

metabolic problem - alkalosis

A

pH high, HCO3 high

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74
Q

metabolic problem - acidosis

A

pH low, HCO3 low

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75
Q

metabolic problem remember

A

metabolic equal

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76
Q

making adjustments to ventilator settings according to ABG results: Low PaO2

A

increase FiO2 or PEEP

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77
Q

Making Adjustments to Ventilator Settings According to ABG Results: high PaCO2 and low pH

A

increase tidal volume, respiratory rate, PIP

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78
Q

A 74 kg male patient is intubated and receiving volume-controlled A/C ventilation with the following settings: FiO2 of 50%, set rate of 15 breaths/min, and a set tidal volume of 550 mL. The patient’s total respiratory rate is 29 breaths/min and the following ABG results were obtained: pH 7.53, PaCO2 27, HCO3 23 mEq/L, BE -2, PaO2 82, SaO2 97%.
Which of the following would you recommend?
A. Increase the FiO2
B. Increase the set rate
C. Increase the set tidal volume
D. Add mechanical dead space

A

answer: D

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79
Q

rationale for D. Add mechanical dead space

A
  • pH is increased, PaCO2 is decreased → respiratory alkalosis
  • PaO2 and SaO2 values are normal → do not make adjustments to FiO2
  • Pt’s spontaneous breathing rate is already too high → do not increase rate
  • 50 mL/74 kg = 7.4 mL/kg → falls within normal range of 5-10 mL/kg for tidal volume → confirms that tidal volume setting is appropriate
  • Adding mechanical dead space to the circuit is a method for treating hyperventilation. The pt will essentially rebreath the gas from their anatomic dead space, which will increase the PaCO2 level.
  • Can also decrease the minute ventilation by decreasing the rate or decreasing the tidal volume
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80
Q

52 kg female patient is receiving volume control A/C mechanical ventilation with a tidal volume of 400 mL, a set rate of 10/min, and an FiO2 of 35%. Her blood gas results are as follows: pH 7.31, PaCO2 49, HCO3 24 mEq/L, BE -2 mEq/L, PaO2 84, SpO2 95%
Based on the given information, which of the following changes is appropriate at this time?
A. Increase the FiO2
B. Increase the tidal volume
C. Increase the set rate
D. Maintain the current settings

A

answer : C

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81
Q

Rationale: C. Increase the set rate

A

pH is decreased, PaCO2 is increased → respiratory acidosis
PaO2 and SaO2 values are normal → do not make adjustments to FiO2
Need to decrease the PaCO2 by blowing off some of that CO2 and increasing the minute ventilation (by increasing the rate or the tidal volume)
400 mL/52 kg = 8 mL/kg → falls within appropriate tidal volume range (set correctly)

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82
Q

oxygen therapy administration of O2 greater than…..

A
  • 21% to provide adequate transport of oxygen in the blood, decrease the work of breathing, and reduce stress on the myocardium
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83
Q

what does oxygen transport to tissue depend on ?

A

cardiac output, arterial oxygen content, concentration of hemoglobin, and metabolic requirements

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84
Q

indications for oxygen therapy and s/s = hypoxemia

A
  • decrease in arterial oxygen tension in the blood
  • s/s = mental status changes (agitation, disorientation, confusion lethargy and coma), dyspnea, increase in BP, changes in HR, dysrhythmias, diaphoresis, cool extremities
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85
Q

indications for oxygen therapy= hypoxia

A

decrease in oxygen supply to the tissues and cells. can be caused by problems outside the respiratory system - ruptured hematoma in leg

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86
Q

oxygen therapy: high flow

A
  • humidified with a special flow system up to 40 L/min
  • pt is more comfortable and can get up 60%-90% O2 concentration (higher (O2) than non-rebreather)
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87
Q

high flow: venturi mask

A

each orifice will give a specific FiO2 corresponding to the numbers
- FiO2 = fraction of inspired oxygen; the concentration of oxygen in the gas mixture

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88
Q

oxygen toxicity

A

too high a concentrated of O2 (>50%) is administered for an extended period (longer than 48 hrs)

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89
Q

oxygen toxicity if untreated

A

free radicals severely damage cells - respiratory failure, pulmonary edema, cell death

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90
Q

s/s of oxygen toxicity

A

substernal discomfort, paresthesia, dyspnea, restlessness, fatiguem malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, alveolar infiltrates evident on chest x-rays

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91
Q

prevention of oxygen toxicity

A
  • use lowest effective concentrations of O2
  • PEEP or CPAP prevent/reverse atelectasis + lower oxygen percentages to be used
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92
Q

low flow systems

A
  • cannula
  • nasal catheter
  • mask, simple
  • mask, partial rebreathing
  • mask nonrebreathing
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93
Q

cannula suggested flow rate (L/min)

A

1-2
3-5
6

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94
Q

nasal catheter suggested flow rate (L/min)

A

1-6

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95
Q

mask simple suggested flow rate (L/min)

A

5-8

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96
Q

mask, partial rebreathing suggested flow rate (L/min)

A

8-11

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97
Q

mask, nonrebreathing suggested flow rate (L/min)

A

10-15

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98
Q

cannula O2 percentage setting

A

24-28
32-40
44

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99
Q

transtracheal catheter suggested flow rate (L/min)

A

1/4 - 4

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100
Q

mask, venturi suggested flow rate (L/min)

A

4-6
6-8

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101
Q

mask, aerosol suggested flow rate (L/min)

A

8-10

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102
Q

tracheostomy collar suggested flow rate (L/min)

A

8-10

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103
Q

t-piece suggested flow rate (L/min)

A

8-10

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104
Q

face tent suggested flow rate (L/min)

A

8-10

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105
Q

pulse dose suggested flow rate (mL/breath)

A

10-40

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106
Q

nasal catheter O2 percentage setting

A

22-44

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107
Q

mask, simple O2 percentage setting

A

40-60

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108
Q

mask, partial rebreathing O2 percentage setting

A

50-75

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109
Q

mask, nonrebreathing O2 percentage setting

A

80-95

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110
Q

high flow systems

A
  • transtracheal catheter
  • mask, venturi
  • mask, aerosol
  • tracheostomy collar
  • t-piece
  • face tent
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111
Q

oxygen conserving devices

A

pulse dose (or demand)

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112
Q

transtracheal catheter O2 percentage setting

A

60-100

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113
Q

mask, venturi O2 percentage setting

A

24, 26, 28
30, 35, 40

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114
Q

mask, aerosol O2 percentage setting

A

30-100

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115
Q

tracheostomy collar O2 percentage setting

A

30-100

116
Q

t-piece O2 percentage setting

A

30-100

117
Q

face tent O2 percentage setting

A

30-100

118
Q

cannula advantages

A

lightweight, comfortable, inexpensive, continuous use with meals and activity

119
Q

nasal catheter advantages

A

inexpensive, does not require a tracheostomy

120
Q

mask, simple advantages

A

simple to use, inexpensive

121
Q

mask, partial rebreathing advantages

A

moderate O2 concentration

122
Q

mask, nonrebreathing advantages

A

high O2 concentration

123
Q

transtracheal catheter advantages

A

more comfortable, concealed by clothing, less oxygen liters per minute needed than nasal cannula

124
Q

mask, venturi advantages

A

provides low levels of supplemental O2
precise FiO2, additional humidity available

125
Q

mask, aerosol advantages

A

good humidity, accurate FiO2

126
Q

tracheostomy collar advantages

A

good humidity, comfortable, fairly accurate FiO2

127
Q

t-piece advantages

A

same as tracheostomy; good humidity, comfortable, fairly accurate FiO2

128
Q

face tent advantages

A

good humidity, fairly accurate FiO2

129
Q

pulse dose (or demand) advantages

A

deliver O2 only on inspiration, conserve 50-75% of O2 used

130
Q

cannula disadvantages

A

easily dislodged, from nares, skin breakdown over ears or nares, nasal mucosal drying, variable FiO2

131
Q

nasal catheter disadvantages

A

nasal mucosa irritation; catheter should be changed frequently to alternate nostril

132
Q

mask, simple disadvantages

A

poor fitting, variable FiO2, must remove to eat

133
Q

mask, partial rebreathing disadvantages

A

warm, poorly fitting, must remove to eat

134
Q

mask nonrebreathing disadvantages

A

poorly fitting, must remove to eat

135
Q

transtracheal catheter disadvantages

A

requires frequent and regular cleaning, requires surgical intervention, with associated risk for surgical complications

136
Q

mask, venturi disadvantages

A

must remove to eat

137
Q

mask, aerosol disadvantages

A

uncomfortable for some

138
Q

t-piece disadvantages

A

heavy with tubing

139
Q

face tent disadvantages

A

bulky and cumbersome

140
Q

pulse dose (or demand) disadvantages

A

must carefully evaluate function individually

141
Q

attempt to open the airway

A
  • head-tilt/chin lift maneuver= pulls tongue away from back of pharynx
142
Q

attempt to clear the airway

A
  • observe chest + listen/feel for movement of air
  • use a cross-finger technique to open the mouth and observe for obvious obstructions
  • if no passage of air is detected = CPR
143
Q

bag and mask resuscitation

A
  • apply mask to pt’s face and create a seal by pressing thumb of the non dominant hand on bridge of the nose and index finger on chin
  • using rest of the fingers on the hand, pull on the chin and the angle of the mandible to maintain the head in extension
  • use dominant hand to inflate the lungs by squeezing the bag to its full volume
144
Q

endotracheal intubation

A
  • placement of tube (with the aid of a laryngoscope) through the nose or mouth into the trachea
  • oral route is preferred: less trauma and infections
  • secure tube to prevent accidental extubation
145
Q

sniffing position

A
  • head even with shoulders, instead of with bed, using a folded blanket
  • will help facilitate endotracheal intubation
146
Q

purpose of endotracheal intubation

A
  • provide patent airway for mechanical ventilation, removal of secretions, pts w/ upper airway obstruction
147
Q

equipment needed for endotracheal intubation

A
  • stylet, endotracheal tube, 10 mL syringe for cuff inflation, laryngoscope (curved or straight blade depending on pt’s anatomy), lubricant, CO2 detector (capnography), tape to secure, yankauer, forceps to help with movement/guiding, chlorhexidine to clear out airway
148
Q

lecture note about intubation

A

you will know if you intubate the right mainstream bronchus because you will not have chest rise on the left side

149
Q

how to prevent air leaking and minimize aspiration (endotracheal tube) ?

A

tube cuff inflated to prevent air from leaking around the outer parts of the tube to minimize the possibility of aspiration + secure the tube

150
Q

verify positioning of endotracheal tube

A
  • checking end-tidal carbon dioxide levels + confirmed with chest x-ray
151
Q

pressure that cuff pressures should be maintained at

A

20-25 mmHg

152
Q

complication of high cuff pressure

A

tracheal bleeding, ischemia, and pressure necrosis

153
Q

complication of low cuff pressure

A

increases the risk of aspiration pneumonia

154
Q

what should always be introduced through the endotracheal tube

A

warm, humidified oxygen

155
Q

max of how long it can be used for

A

no longer than 14-21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), + to decrease the work of breathing

156
Q

disadvantages of endotracheal intubation

A
  • depressed cough reflex, thicker secretions, depressed swallow reflexes, increased risk of aspiration and ventilator-associated pneumonia, ulcerations/stricture of the larynx/trachea, inability of pt to communicate needs
157
Q

to improve pts tolerance of tube

A

comfort measures, opioid analgesia and sedation

158
Q

what can inadvertent removal of the tube cause

A

laryngeal swelling, hypoxemia, bradycardia, hypotension, and even death

159
Q

PEEP

A

not a specific mode, but it is an adjunct to any of the vent modes
- the amount of pressure remaining in the lung at the END of the expiratory phase
- utilized to keep otherwise collapsing lung units open while improving oxygenation

160
Q

collaborative practice interventions to prevent ventilator-associated pneumonia (5 key elements)

A

1) elevation of HOB (30-45 degrees
2) daily “sedation vacations” + assessment of readiness to extubate
3) peptic ulcer disease prophylaxis
4) DVT prophylaxis
5) daily oral care w/ chlorhexidine (0.12% oral rinses)

161
Q

care of the patient with an endotracheal tube: immediate after intubation

A

1) check symmetry of chest expansion
2) auscultate breath sounds of anterior and lateral chest bilaterally
3) obtain capnography or end-tidal CO2 as indicated
4) ensure chest x-ray obtained to verify proper tube placement
5) check cuff pressure every 6-8 hrs
6) monitor for signs and symptoms of aspiration
7) ensure high humidity; a visible mist should appear in the T-piece or ventilator tubing
8) administer oxygen concentration as prescribed by the primary provider
9) secure the tube to the patient’s face with tape, and mark the proximal end for position maintenance
9a) cut proximal end of tube if its longer than 7.5 cm (3 in) to prevent kinking
9b) insert an oral airway or mouth device of orally intubated to prevent atelectasis and to optimize lung expansion
10) use sterile suction technique and airway care to prevent iatrogenic contamination and infection
11) continue to reposition patient every 2 hours and as needed to prevent atelectasis and to optimize lung expansion
12) provide oral hygiene and suction the oropharynx whenever necessary

162
Q

care of the patient with an endotracheal tube: extubation (removal of endotracheal tube)

A

1) explain the procedure
2) half self-inflating bag and mask ready in case ventilatory assistance is required immediately after extubation
3) suction the tracheobronchial tree and oropharynx, remove tape, and then deflate the cuff
4) give 100% oxygen for a few breaths, then insert a new, sterile suction catheter inside tube
5) have the patient inhale. At peak inspiration, remove the tube, suctioning the airway through the tube as it is pulled out

163
Q

care of the patient with an endotracheal tube: care of the patient following extubation

A

1) give heated humidity and oxygen by facemask and maintain the patient in a sitting or high fowler’s position
2) monitor respiratory rate and quality of chest excursions. Note stridor, color change, and change in mental alertness or behavior
3) monitor the patient’s oxygen level using a pulse oximeter
4) keep patient NPO, or only give ice chips for the next few hours
5) provide mouth care
6) educate the patient about how ti perform coughing and deep-breathing exercises

164
Q

care of the patient with an endotracheal tube: preventing complications associated with endotracheal tubes

A
  • administer adequate warmed humidity
  • maintain cuff pressure at appropriate levels
  • suction as needed per assessment findings
  • maintain skin integrity. change tape and dressing as needed or per protocol
  • auscultate lung sounds
  • monitor for s/s of infection, including temperature and WBC
  • administer prescribed oxygen and monitor oxygen saturation
  • monitor for cyanosis
  • maintain adequate hydration of the patient
  • use sterile techniques when suctioning and performing tracheostomy care
165
Q

tracheostomy

A
  • surgical procedures in which an opening is made in the trachea btw the 2nd and 3rd tracheal rings
  • bypasses the upper airway to bypass of an obstruction, allows removal of secretions, permits long-term mechanical ventilation, prevents aspirations of secretions, or replaces an endotracheal tube
166
Q

cuffed tracheostomy tube of an appropriate size is inserted

A
  • an inflatable attachment to the tracheostomy tube that is designed to occlude the space between the tracheal walls and the tube, to permit mechanical ventilation, and to minimize the risk of aspiration
167
Q

complications of tracheostomy

A

bleeding, pneumothorax, aspiration, subcutaneous/mediastinal emphysema, laryngeal nerve damage, posterior tracheal wall penetration

168
Q

long term complications of tracheostomy

A

airway obstruction, infection, rupture of the innominate artery, dysphagia, tracheoesophageal fistula formation tracheal dilatation, tracheal ischemia and necrosis

169
Q

fenestrated t-tube

A

allows pt to talk

170
Q

double cuffed tube

A

inflating the two cuffs alternately can help prevent tracheal damage

171
Q

nursing management for tracheostomy

A
  • continuous monitoring
  • when VS are stable place pt in semi-fowler’s position to facilitate ventilation, promote drainage, minimize edema, and prevent strain on the suture lines
  • suction PRN; when adventitious breath sounds are detected or whenever secretions are obviously present
  • maintain cuff pressure at appropriate level
  • auscultate lung sounds
  • maintain skin integrity - change tape and dressing PRN or per protocol
  • maintain adequate hydration of the pt
  • monitor for cyanosis
  • administer prescribed oxygen and monitor oxygen saturation
  • use sterile technique when performing tracheostomy care
  • analgesia and sedative agents must be given w/ caution b/c of risk of suppressing the cough reflex
172
Q

what can unnecessary suctioning do

A

initiate bronchospasm + cause mechanical trauma to tracheal mucosa

173
Q

how often should cuff pressure be monitored by

A

at least q8h

174
Q

mechanical ventilation

A

positive or negative pressure breathing device to maintain ventilation or oxygenation for a prolonged period

175
Q

spontaneous respiration

A

negative inspiratory force - air enters the lungs

176
Q

mechanical respiration

A

positive inspiratory pressure - air pushed into the lungs

177
Q

indications for mechanical ventilation

A
  • PaO2 <55 mmHg - continuous decreases in O2
  • PaCO2 > 50 mmHg and pH <7.32 - persistent acidosis
  • vital capacity <10 mL/kg
  • negative inspiratory force <25 cm H2O
  • FEV1 <10 mL/kg
  • thoracic/abdominal surgery, drug overdose , neuromuscular disorders, inhalation injury, COPD, multiple trauma, shock, multiple trauma, shock, multisystem failure, and coma
178
Q

negative-pressure ventilators

A

“iron lung”, chest cuirass, rarely used today

179
Q

positive-pressure ventilators

A

inflate lungs by exerting positive pressure on airway, pushing air in, and forcing the alveoli to expand during inspiration; expiration occurs passively; intubation or tracheostomy is usually necessary

180
Q

pressure-cycled

A

delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs

181
Q

pressure-cycled limitation

A

volume of air or oxygen can vary as the pt’s airway resistance or compliance changes - tidal volume delivered may be inconsistent

182
Q

high-frequency oscillatory support ventilators

A
  • deliver very high respiratory rates (180 to 900 breaths/min) that are accompanied by very low tidal volumes and high airway pressures through small pulses of oxygen enriched air
  • used to open alveoli in situations and high airways (atelectasis + ARDS) and to protect the lungs from pressure injury
183
Q

RTZ

A

delivers very small tidal volumes at extremely fast rate which minimizes changes of a lung injury; ventilation increased by increasing amplitude or decreasing frequency; oxygenation increased by increasing the MAP or increasing the FiO2; indicated for neonates (pulmonary hypoplasia)

184
Q

volume-cycled

A

deliver a preset, relatively constant volume of air with each inspiration

185
Q

disadvantage of volume cycled

A

pts may experience barotrauma because of the pressures required to deliver the breaths may be excessive; causes damage to alveolar capillary membrane and air to leak into the surrounding tissues

186
Q

noninvasive positive pressure ventilation

A
  • use of facemask or other device to maintain a seal + permit ventilation
  • eliminates need for endotracheal intubation/tracheostomy + decreases risk of nosocomial infections
  • most comfortable mode for the pt = pressure-controlled ventilation with pressure support
  • eases the work of breathing and enhances gas exchange
187
Q

indications for noninvasive positive pressure ventilation

A

acute or chronic respiratory failure, acute pulmonary edema, COPD, chronic heart failure, or a sleep-related breathing disorder

188
Q

contraindications for noninvasive positive pressure ventilation

A

respiratory arrest, serious dysrhythmias, cognitive impairment, or head/facial trauma

189
Q

CPAP ; continuous positive airway pressure

A
  • provides positive pressure to the airways throughout the respiratory cycle; can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli or used with a leak-proof mask to keep alveoli open to prevent respiratory failure
190
Q

what is CPAP effective for

A

OSA, positive pressure acts as splint, keeping upper airway+ trachea open during sleep

191
Q

patient needs to be_______ for CPAP

A

breathing independently/spontaneously - no mandatory breaths are given

192
Q

RTZ for CPAP

A

continuous pressure that is above atmospheric pressure is delivered and maintained throughout entire breathing cycle; useful mode for weaning

193
Q

Bi-level positive pressure airway pressure

A

(BiPAP) delivers two levels of positive airway pressure provided via a nasal/oral mask, nasal pillow, or mouthpiece with a tight seal and a portable ventilator each inspiration can be initiated either by the pt or by the machine if it is programmed with a backup rate (ensures the pt receives a set number of breaths per minute)

194
Q

controlled mechanical ventilation mode

A
  • provides full ventilator support by delivering preset tidal volume + respiratory rate
  • indicated for pts who are apneic
195
Q

continuous mandatory ventilation (CMV)/ assist control ventilation (A/C) modes

A
  • delivers a preset tidal volume or pressure at a preset rate of respirations, regardless of whether the breath is initiated by the pt or the ventilator
  • Pt triggers additional spontaneous breaths in btw whatever the ventilator is set at; when they initiate the breath by exerting the negative inspiratory pressure, vent is going to deliver volume of assisted breath constantly (whether they do or don’t take a breath) - not good for pts w/ COPD because they have a longer expiratory phase so we would be giving them a breath as they are trying to breathe out
196
Q

CMV and A/V disadvantages

A

in pts w/ respiratory alkalosis: pt hyperventilates due to anxiety/pain; treated w/ sedation/anti-anxiety med or changing it to SIMV

197
Q

CMV and A/C RTZ

A

minimum number of breaths delivered by the ventilator but the ventilator the pt can also trigger assisted breaths; pt makes effort to breathe and ventilator assists in delivering the breath, breaths are NOT spontaneous (pt triggered but still delivered by ventilator); sensitivity control can be adjusted to make it easier or harder for the pt to initiate a breath; indicated when mechanical ventilation is first initiated; provides full ventilatory support; major complication = hyperventilation - respiratory alkalosis (result of too many breaths being given to pt)

198
Q

intermittent mandatory ventilation (IMV) mode

A
  • combination of mechanically assisted breaths + spontaneous breaths
  • mechanical breaths delivered at preset intervals + preselected tidal volume, regardless of the it’s effort
  • allows pts to use their own muscles for ventilation to prevent atrophy
  • spontaneous breaths are limited to the tidal volume generated by pt
  • lowers mean airway pressure
  • “fighting the ventilator” may be increased - trying to exhale when ventilator is delivering a breath
  • set # of breaths from ventilator + btw those, pt can spontaneously breathe
  • IMV does not recognize spontaneous breaths (allows pt to be breathing at the same time as the vent) - DO NOT use on it who breathes spontaneously
199
Q

synchronized intermittent mandatory ventilation (SIMV) mode

A
  • delivers preset tidal volume + number of breaths per minute
  • senses pt breathing efforts and does not initiate a breath in opposition to pt’s efforts - fighting the ventilator is reduced + prevent stacking breaths (machine will not breathe on top of the pt)
  • when pt’s ability to breathe spontaneously increases, preset number of ventilator breaths is decreased + the pt does more work of breathing
200
Q

RTZ SIMV

A
  • delivers preset mandatory number of breaths but also allows the pt to initiate spontaneous breaths in between the mandatory breaths; allows operator to set with a controlled pressure or controlled volume; primary indication is partial ventilatory support; used for weaning; helps maintain pt’s respiratory strength; distributes tidal volumes evenly throughout lung fields reducing the V/Q mismatching; helps to decrease pt’s mean airway pressure
201
Q

pressure support ventilation (PSV) mode

A
  • pt is triggered, pressure limited, and flow cycled
  • applies a pressure plateau to the airway throughout the pt-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing
  • pressure support is reduced gradually as the pt’s strength increases
  • may need to adjust the pressure support to avoid tachypnea or large tidal volumes
  • backup rate may be given (adding SIMV)
202
Q

PSV RTZ

A

pt’s spontaneous breaths are sup[ported by the ventilator during the inspiratory phase of breathing; as the pt trigger a breath, the ventilator assists by adding pressure to make breathing easier; level of pressure is preset by operator so have control over how much support you give the pt; the higher the level of pressure support that is set - the easier it will be for the pt to take a breath; breaths are time-cycled and pressured-limited; often used to help the pt overcome the airway resistance that is caused by the endotracheal tube (if tube is too small)

203
Q

pressure regulated/volume controlled (PRVC) mode

A
  • preset tidal volume at a set rate with lowest possible pressure
  • similar to assist control
  • breaths can be vent initiated (controlled) or patient initiated (assisted)
  • vent makes adjustments breath to breath
204
Q

PRVC RTZ

A
  • provides volume controlled breaths with the lowest pressure possible by altering the flow and inspiratory time, used to keep peak airway pressure at the lowest possible level; volume-cycled; can be pt triggered or time triggered
205
Q

airway pressure release ventilation (APRV) mode

A
  • time triggered, pressure-limited mode of mechanical ventilation that allows unrestricted, spontaneous breathing throughout the ventilatory cycle
  • allows alveolar gas to be expelled through the lungs’ natural recoil
  • associated with less ventilator-induced lung injury, fewer adverse effects on cardiocirculatory function, and lower need for sedation/neuromuscular blockade
206
Q

APRV RTZ

A

two levels of CPAP are applied with an intermittent release phase for spontaneous breaths; set high pressure/low pressure/high time/low time; recommended to improve oxygenation and treat refractory hypoxemia; good for pts with ARDS, acute lung injury, atelectasis

207
Q

proportional assits ventilation (PAV) mode

A
  • provides partial ventilatory support in which the ventilator generates pressure in proportion to the pt’s inspiratory efforts
  • the more inspiratory pressure the pt generates, the more pressure the ventilator generates
208
Q

PAV RTZ

A

machine uses variable pressure to provide pressure support for a pt’s spontaneous breaths; level of pressure support is adjusted depending on the pt’s work of breathing; wither pressure triggered or flow-triggered and breathing cycle ends once the pt’s volume or flow demands are met; if pt’s lungs show rapid improvement - over distention or barotrauma could occur because too much pressure would be delivered

209
Q

PEEP

A

positive pressure applied at end of expiration to keep alveoli open and avoid hypoxemia
- set from 5-20 cm H2O

210
Q

high PEEP

A
  • common in its with long term vents and ARDS
  • increases intrathoracic pressure
  • can result in decreased CO d/t decreased venous return + increased ICP
  • caution for barotrauma
  • have a chest tube on hand
211
Q

adjusting the ventilator purpose

A
  • pt is comfortable and breaths synchronously with the machine
  • if the volume ventilator is adjusted appropriately, the pt’s ABG values will be satisfactory and there will be little or no cardiovascular compromise
212
Q

monitoring the equipment

A
  • controlling mode (A/C ventilation and SIMV)
  • tidal volume and rate settings (tidal volume is usually set at 6-10 mL/kg [ideal body weight[ or 4-8mL/kg for the patient with ARDS [ideal body weight]; rate is usually set at 12-16 breaths per minute
  • FiO2 setting may be set btw 21-100% to maintain optimal PaO2 (>60 mmHg) or SpO2 level >92%
  • peak inspiratory pressure (PIP) (Normal is 15-20 cm H2O; increases w/ increased airway resistance or decreased compliance
  • sensitivity (A 2-cm H2O inspiratory force should trigger the ventilator)
  • inspiratory-to-expiratory ratio (usually 1:2 [1 sec of inspiration to 2 sec of expiration] unless inverse ratio is ordered)
  • sigh settings (usually set at 1.5x the tidal volume and raging from 1-3/hr), if applicable
  • water in the tubing, disconnection or kinking of the tubing
  • humidification (humidifier filled with water) and temperature
  • alarms (turned on and functioning properly at all times per the Joint Commission Alarm Safety Goal)
  • PEEP and pressure support level if applicable
213
Q

ventilator problems

A
  • increase in peak airway pressure or decrease in pressure or loss of volume
214
Q

alterations in cardiac function

A
  • position intrathoracic pressure during inspiration compresses the heart and great vessels which reduces venous return, cardiac output, tissue perfusion, and oxygenation
  • assess for s/s of hypoxia
  • assess cardiac output, cardiac index, hemodynamic values if pulmonary artery catheter is in place
215
Q

barotrauma

A

trauma to the trachea or alveoli secondary to positive pressure

216
Q

pulmonary infection and sepsis

A
  • report fever or change in color/odor of sputum
  • subglottic secretions may increase the pts’ risk for the development of VAP
217
Q

GI complications from ventilators

A
  • stress ulcers and GI bleeding
  • start enteral feeding as soon as possible + give ulcer prophylaxis
  • monitor for occult blood + aspirate from GI system
218
Q

alveolar injury or rupture as a result of…

A

excessive pressure: subcutaneous emphysema or pneumomediastinum
- s/s = high peak inspiratory pressure, decreased breath sounds, tracheal deviation to unaffected side, crepitus, air leak in chest drainage systems, signs of hypoxemia

219
Q

troubleshooting problems with mechanical ventilation

A
  • high pressure - high blockage
  • low pressure - loss of connection, leak
220
Q

ventilator problems

A
  • increase in peak airway pressure
  • decrease in pressure or loss of volume
221
Q

cause of increase in peak airway pressure

A
  • coughing or plugged airway tube
  • patient “fighting” ventilator
  • decreasing lung compliance
  • tubing kinked
  • pneumothorax
  • atelectasis or bronchospasm
222
Q

cause of decrease in pressure or loss of volume

A
  • increase in compliance
  • leak in ventilator or tubing; cuff on tube/humidifier not tight
223
Q

patient problems

A
  • cardiovascular compromise
  • barotrauma/pneumothorax
  • pulmonary infection
224
Q

cardiovascular compromise cause

A

decrease in venous return due to application of positive pressure to lungs

225
Q

barotrauma/pneumothorax cause

A

application of positive pressure to lungs; high mean airway pressures lead to alveolar rupture

226
Q

pulmonary infection cause

A

bypass of normal defense mechanisms, frequent breaks in ventilator circuit; decreased mobility; impaired cough reflex

227
Q

the ABCDE bundle

A

the awakening and breathing, coordination, delirium monitoring and management, early mobility bundle

228
Q

awakening and spontaneous breathing trials

A
  • the nurse determines if it safe to stop sedation
  • if determined safe, the nurse will determine if patient tolerated the sedation interruption
  • if the patient tolerated the interruption, the respiratory therapist will determine if the patient is a candidate for a breathing trial
229
Q

monitoring and management of delirium

A

the patient will be assessed at least every 2-4 hrs using a sedation assessment scale (e.g. the CAM-ICU)

230
Q

early mobility

A
  • the patient is able to respond to verbal stimuli
  • the patient is receiving less than 60% FiO2 and less than 10 cm of PEEP
  • the patient has no circulatory or central catheters or injuries that may contraindicate mobility
231
Q

nursing interventions: enhancing gas exchange

A
  • monitor ABGs and other indicators of hypoxia - not trends
  • auscultate lung sounds frequently
  • judicious use of analgesics to relieve pain w/o suppressing the respiratory drive
  • monitor fluid balance: I&O + daily weights
  • frequent repositioning to diminish the pulmonary effects of immobility
232
Q

nursing interventions: promoting effective airway clearance

A
  • assess lung sounds + presence of secretions at least every 2-4 hrs
  • measures to clear airway: suctioning, CPT, position changes, promote mobility
  • periodic sighs to prevent atelectasis
  • at least 1-3 sighs per hour at 1.5 x the tidal volume if the pt is receiving A/C ventilation
  • in SIMV mode, mandatory ventilations act as sighs b/c they are greater volume than the pt’s spontaneous breaths
  • humidification of airway to liquefy secretions so that they are more easily removed
233
Q

medications to promote effective airway clearance

A
  • adrenergic bronchodilators
  • anticholinergic bronchodialtors
  • mucolytic agents (acetylcysteine)
234
Q

adrenergic bronchodilators

A

most inhaled + work by stimulating the beta-receptor sites to mimix the effects of epinephrine - result in smooth muscle relaxation + dilation of constricted bronchial tubes

235
Q

anticholinergic bronchodilators

A

produce airway relaxation by blocking cholinergic-induced bronchoconstricton
- monitor for dizziness, nausea, decreased oxygen saturation, hypokalemia, increased HR, + urine retention

236
Q

mucolytic agents

A
  • acetylcysteine
  • liquefy secretions so that they are more easily mobilized
  • monitor for adequate cough reflex, sputum characteristics nausea, vomiting, bronchospasm, stomatitis, urticaria, + rhinorrhea
237
Q

preventing trauma and infection

A
  • infection control measures
  • tube care: position the tubing so that there is minimal pulling or distortion of the tube in the trachea. replace ventilator circuit tubing and in-line suction tubing periodically
  • tracheostomy care performed q8h or more frequently
  • cuff pressure monitored q8h
  • oral care - oral cavity is a primary source of contamination of the lungs
  • elevation for increased temp or increased WBC count
  • pallor and increased pulse may indicate internal hemorrhage
238
Q

criteria for successful home ventilator care: patient criteria

A
  • the pt has a chronic underlying pulmonary or neuromuscular disorder
  • the pt clinical pulmonary status is stable
  • the pt is willing to go home on mechanical ventilation
239
Q

criteria for successful home ventilator care: home criteria

A
  • the home environment is conducive to care of the pt
  • the electrical facilities are adequate to operate all equipment safely
  • the home environment is controlled, without drafts in cold weather and with proper ventilation in warm weather
  • space is available for cleaning and storing ventilator equipment
240
Q

criteria for successful home ventilator care: family criteria

A
  • family members are competent, dependable, and willing to spend the time required for proper training as primary caregivers
  • family members understand the diagnosis and prognosis
  • family has sufficient financial and supportive resources and can obtain professional support if necessary
241
Q

three stages of weaning

A
  • pt is gradually removed from the ventilator
  • pt is removed from the endotracheal/tracheostomy tube
  • pt is removed from oxygen
242
Q

criteria for initiation of weaning

A

physiologically and hemodynamically stable, demonstrates spontaneous breathing capability, recovering from acute stage of medical/surgical problems, + when cause of respiratory failure is sufficiently reversed

243
Q

pt preparation for weaning

A

psychological preparation + assessing factors that impair the delivery of oxygen, increase oxygen demand (sepsis, seizures, and thyroid imbalances), or decreased the pt’s strength (inadequate nutrition and neuromuscular disease)

244
Q

methods of weaning

A
  • CPAP
  • SIMV
  • T-piece trials
245
Q

CPAP methods of weaning

A

allows pt to breathe spontaneously while applying positive pressure throughout the respiratory cycle to keep the alveoli open and promote oxygenation

246
Q

SIMV methods of weaning

A

rate is slowly decreased by 1-3 breaths per minute until pt is fully breathing on their own

247
Q

T-piece trials methods of weaning

A

normally conducted with pt disconnected from ventilator, receiving humidified oxygen only, and performing all work of breathing - pts do not have to overcome the resistance of the ventilator
- if pt appears to be tolerating T-piece/tracheostomy mask trial, a second set of ABGs is drawn 20 minutes after pt has been on spontaneous ventilation at a constant FiO2 PSV
- alveolar-arterial equilibrium takes 15-20 minutes to occur

248
Q

when is pt placed back on the ventilator

A
  • each time signs of fatigue or deterioration develops
  • signs of exhaustion and hypoxia correlated with deterioration in the blood gas measurements indicate the need for ventilatory support
249
Q

if clinically stable, pt usually extubated within ……

A

2-3 hrs after weaning and allowed spontaneous ventilation by means of a mask with humidified oxygen

250
Q

pts who have hd prolonged ventilatory assistance usually require more gradual weaning…

A

may take days or even weeks, primarily weaned during the day and placed back on the ventilator at night

251
Q

successful weaning supplemented by intensive pulmonary care

A

oxygen therapy, ABG evaluation, pulse oximetry, bronchodilator therapy, CPT, adequate nutrition/hydration, adequate humidification, BP measurements, + incentive spirometry

252
Q

sedation vacation

A

if pt receiving IV sedatives (propofol and midazolam), current guidelines recommend that pt’s sedative dose be decreased by 25-50% prior to weaning

253
Q

removal of tracheostomy tube considered when…

A

pt can breathe spontaneously, maintain adequate airway by effectively coughing up secretion, swallow, + move the jaw

254
Q

trial period of mouth breathing or nose breathing

A
  • once pt can clear secretions adequately
255
Q

methods of trial period of mouth breathing or nose breathing

A

changing to a smaller size tube to increase the resistance to airflow or plugging the tracheostomy tube, changing to a fenestrated tube, switching to a smaller tracheostomy/stoma button that helps keep the windpipe open after the larger tracheostomy tube has been removed
- when tube is removed, occlusive dressing is placed over stoma, which heals in several days-weeks

256
Q

successful weaning requires…

A

early and aggressive nutritional support due to respiratory muscle atrophy
- compensation for inadequate nutrition must be undertaken with care- excessive intake can increase the production of carbon dioxide and the demand for oxygen and lead to prolonged ventilator dependence and difficulty weaning
- adequate protein intake

257
Q

adequate protein intake

A

25% or total daily kilocalories, or 1.2 to 1.5 g/kg/day

258
Q

pulmonary artery catheter (PAC)

A

procedure in which an intravascular catheter is inserted through a central vein (femoral, jugular, antecubital, brachial) to connect the right side of the heart and advance towards the pulmonary artery

259
Q

what is PAC utilized for

A

access right sided chamber filling pressures, estimation of cardiac output, intracardiac shunt evaluation, valvular studies, and valvular resistance

260
Q

what is PAC an excellent tool for

A

assessment if pts with pulmonary hypertension, cardiogenic shock, and unexplained dyspnea

261
Q

indications for PAC

A
  • evaluation or diagnosis of pulmonary hypertension
  • distinguishing etiology of shock based on mixed venous oxygen saturation (SvO2) measurement such as septic or cardiogenic shock
  • assessment of volume status in severe shock
  • evaluation of pericardial illness such as cardiac tamponade or constrictive pericarditis
  • assessment of right sided valvular disease, congenital heart disease, cardiac shunts - when surgical repair is planned
  • ATI - critical illness, HF, post CABG, ARDS, AKI, burn injury, trauma injury
262
Q

contraindications to PAC

A
  • insertion of the catheter through a site where there is an active infection
  • presence of a right sided ventricular assist device
263
Q

placement of PAC

A
  • insertion of catheter from one of main central veins - superior or inferior vena cava - right atrium- tricuspid valve- right ventricle- pulmonary valve- pulmonary artery
  • tip of catheter lies in main pulmonary artery where balloon measures pressure
  • inflation can measure pulmonary capillary wedge (occlusive pressure = indirect assessment of left sided filling pressure
  • pressure waveform can be seen on monitor b/c of transducer in catheter
  • each section of heart has distinct pattern that helps determine where tip of catheter is
  • done under fluoroscopy (most common) or at the bedside w/ use of US and echocardiography
264
Q

swan-ganz/right heart catheter

A
  • quadruple lumen catheter w/ theromodilution sensor that is attached to a pressure transducer outside of body (60-110 cm in length; 4F-8F in caliber)
265
Q

blue lumen

A
  • CVP port; right atrial lumen
  • 30 cm from tip and rests within right atrium
  • proximal port used for infusion
  • can assess CVP and RA pressure
266
Q

white/clear lumen

A
  • terminates close to prior lumen
  • rests within the right atrium
  • used for infusion
267
Q

yellow lumen

A
  • PA distal; pulmonary artery lumen
  • distal port
  • measure PAP
  • can be used for mixed venous draws
268
Q

red/white connector

A
  • (thermistor)
  • temperature sensitive wire that terminated 4 cm proximal to tip of catheter
  • rests in a ain pulmonary artery
  • connection of thermistor port to CO monitor allows determination of CO using thermodilution
269
Q

red lumen

A
  • balloon port
  • helps place the tip of catheter in the pulmonary artery
270
Q

complications of PAC

A
  • infection of insertion site
  • pneumothorax when placed in subclavian vein
  • air embolism: entrapment of air from infusion ports
  • atrial.ventricular arrhythmias due to irritation of contact of catheter w/ cardiac walls
  • calve rupture or cardiac wall perforation
  • vessel rupture at moment of balloon inflation
  • pulmonary infarction can occur when balloon is inflated for long period/migration of catheter to distal branches
  • thromboembolism secondary to inflammation or infection
271
Q

PAWP - pulmonary artery wedge pressure

A
  • measurement obtained during momentary balloon inflation of a pulmonary catheter
  • reflective of left ventricular end-diastolic pressure
  • normally ranges between 4-12 mmHg
272
Q

decreased PAWP

A

hypovolemia or afterload reduction

273
Q

increased PAWP

A

hypervolemia, left ventricular failure, mitral regurgitation, intracardiac shunt

274
Q

arterial lines

A
  • needed for continuous BP monitoring + blood specimens for ABGs
  • common insertion sites: radial artery (most common), brachial artery, femoral artery
275
Q

alien’s test

A
  • performed to verify patent radial and ulnar circulation
  • pt[’s hand is elevated + pt makes a fist for 30 seconds
  • nurse compresses the radial and ulnar arteries simultaneously, causing the hand to blanch
  • pt opens fist and nurse releases the pressure on the ulnar artery
  • if blood flow is restored (hand turns pink) in 6 seconds, circulation to hand may be adequate enough to tolerate placement of radial artery catheter
276
Q

assessing - arterial waveforms ; overdamped

A

complaint tubing; loose connections, blot clot in cannula tip kinked cannula

277
Q

assessing - arterial waveforms ; underdamped

A

long stiff tubing, too many stop cocks, defective transducer

278
Q

assessing blood pressure accuracy of arterial lines

A

compare arterial line reading with NIBP reading

279
Q

neurovascular assessment 5 p’s

A

pain, pulses, paresthesia, pallor, paralysis

280
Q

setting up arterial lines; equipment

A

sterile gloves, ART-line kit, pressure tubing, 500 cc NS, pressure bag, IV pole, chloraprep, A-line needle, dressing/tape, transducer kit, cable to connect transducer to monitor

281
Q

prevent nerve damage from arterial lines

A
  • pt should have arm board on hand to prevent nerve damage if the wrist is bent + pressure on radial nerve from the catheter
282
Q

zero calibrate line

A

tells transducer to ignore pressure from atmosphere
- every 4 hrs, after blood is taken, + as needed

283
Q

arterial lines - pt should be…

A

flat

284
Q

phlebostatic axis

A
  • place transducer at level of right atrium
  • alter level of transducer when pt changes position
285
Q

how to get baseline data for arterial lines

A

square wave test

286
Q

when removing arterial line….

A

hold pressure on site for 10 minutes and applying dressing to site
- do not apply BP cuffs to arm + do not infuse any IV fluids via arterial line

287
Q

complications for arterial lines

A
  • rapid extreme blood loss
  • flat waveform or extremely low pressure reading - check STAT
  • phlebitis + infection
  • if a-line does not flush, do not force the flush b/c pt could have a thrombosis

471 (4 decks)

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