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Med Surg 3 (theory class) > NURS 444 week 3 > Flashcards

NURS 444 week 3 Flashcards

1
Q

Respiratory Failure and classification

A

when all compensatory mechanisms fail

hypoxemic- resp. failure. Insufficient O2 transferred to blood

hypercapnic- resp. failure. Inadequate CO2 removed from the lungs

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2
Q

Hypoxemic Respiratory Failure

A

Oxygenation issue
Causes
- ventilation-perfusion (v/q) mismatch
- COPD
- pneumonia
- asthma
- atelectasis
- pain
- pulmonary embolus

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3
Q

Hypercapnic Respiratory Failure

A

ventilation issues

causes:
- Airways and alveoli:
asthma, emphysema, cystic fibrosis

  • CNS;
    drug overdose, brainstem infarction, spinal cord injury
  • chest wall:
    flail chest (gunshot wound), kyphoscoliosis, morbid obesity, fracture, mechanical restriction, muscle spasms
  • neuromuscular conditions
    muscular dystrophy, guillain-barre syndrome, MS
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4
Q

V/Q scans

A

help diagnose a PE

if low –> increased circulation but low ventilation
if high –> decreased circulation but good ventilation

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5
Q

Consequences of hypoxemia and hypoxia

A

*** cells shift from aerobic to anaerobic
- lactic acid production
- metabolic acidosis and cell death
- decreased cardiac output
- impaired renal function

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6
Q

Sudden or Gradual onset of Respiratory Failure

A

Sudden: life-threatening
> greater risk if coexisting with cardiac problems or anemia
> ex. asthma exacerbation

Gradual: compensation occurs
< ex. COPD with URI. may recover faster than sudden

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7
Q

Resp. Failure clinical manifestations

A

Early SIgns: irritable/ restless
- tachycardia
- tachypnea
- mild htn

Severe morning headache

Late sign: cyanosis
- rapid, shallow breathing pattern
- tripod position
- dyspnea
- pursed lip breathing
- retractions
- change in I:E ratio

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8
Q

Resp. Failure Diagnostic studies

A
  • H&P assessment
  • ABG analysis
  • CXR
  • CBC, sputum/ blood cultures, electrolytes
  • ECG
  • urinalysis
  • V/Q lung scan
  • pulmonary artery catheter (rare and only in extreme cases)
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9
Q

Resp. Failure management

A

Oxygen Therapy
- maintain PaO2 55 to 60 mm Hg or more and SaO2 at 90% or more at the lowest O2 concentration possible

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10
Q

Resp. Failure meds.

A
  • Bronchodilators
    relieve of bronchospasms
  • Corticosteroids
    reduction in airway inflammation
  • Diuretics, nitrates if HF present
    reduction of pulm. congestion
    nitrates to reduce workload of heart
  • IV antibiotics
    Tx of pulm. infections
  • Benzos, narcotics
    reduction of severe anxiety, pain, and agitation
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11
Q

Mechanical ventilation

A

process by which FiO2 (fraction of inspired oxygen)- 21% RA or greater, and a set amount of air volume is moved in and out

Positive pressure ventilation (PPV)- pushing pressure in

Non-invasive PPV: Bi-PAP, CPAP

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12
Q

BIPAP

A

positive pressure on inspiration

indicated for; COPD with HF or RF and sleep apnea

contraindicated for; shock, altered mental status, ^ airway secretions

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13
Q

indications for intubation

A

-apnea
-inability to breathe or protect airway
-resp. distress or muscle fatigue
-resp. failure

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14
Q

ET intubation prep

A

self-inflating bag valve mask connected to oxygen
suctioning
IV access

premedication depends on patient’s LOC and nature of procedure

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15
Q

Immediate actions during intubation

A
  • Inflate cuff
  • Manually ventilate patient with BVM
  • Confirm placement of ET tube:
    End-tidal CO2 detector
    Auscultate lungs bilaterally
    Ausculate epigastrium
    Observe chest wall movement
    Monitor Sp02

We need an x-ray to confirm placement

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16
Q

After ET placement

A
  1. connect to mechanical vent.
  2. secure ET tube (mark at lip and do before x-ray)
  3. suction ET tube and pharynx
  4. insert bite block if needed
  5. obtain cxr
    *** 2- 6 cm above carina and observe chest wall for symmetric movement
  6. continuously monitor pulse ox
  7. obtain ABGs in 30 min - 1 hr
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17
Q

Ventilator machine settings

A

AC
SIMV

FiO2

PEEP- positive end-expiratory pressure- allows pressure on exhalation. Keep alveoli open

Rate

VT

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18
Q

Nursing management: after ET placement

A

-maintain correct placement

  • maintain proper cuff inflation
    cuff pressure: 20-25 mm Hg (usual)
    stabilizes and seals ET tube within trachea
    excess volume can cause tracheal damage
    cuff pressure 20-25 cm H2O
    measure and record on routine basis: minimal occluding volume (MOV) technique and minimal leak technique (MLT)
19
Q

what does increased airway pressure mean

A

there is pressure in the airway
can be an occlusion.

changes in expiratory flow would be an early sign before peak airway pressure increase

20
Q

Complications associated with suctioning ET

A

! hypoxemia
! branchospasm
! increased intracranial pressure
! dysrhytmias
! hyper/ hypotension
! mucosal damage/ bleeding
! pain
! infection

** hyperoxygenate before and after, no more than 120 pressure of suction, limit each pass to 10 seconds or less

21
Q

Continued ET nursing management

A
  • monitor oxygenation and ventilation
  • Oral care: prevent vent. acquired pneumonia
  • maintain skin integrity
  • foster comfort and communication
  • physical and emotional stress
    unable to speak, eat, move, breathe normally
    pain, fear, and anxiety r/t tubes/ machines
22
Q

VAP

A

occurs 48 + hours after intubation

Manifestations: fever, high WBC, purulent or odorous sputum, crackles/ wheezes, pulm. infiltrates

23
Q

VAP prevention guidelines

A

minimize sedation
early exercise and mobilization
subglottic secretion drainage port
elevate HOB 30-45
oral care with chlorhexidine
no routine changes of ventilator circuit tubing

wake patient up occasionally to assess

24
Q

What we base mode off of in vent. settings

A

vent. status
resp. drive
ABGs

25
Q

Most often used modes in weaning

A

CPAP
PS: pressure support ventilation delivers pressure during inspiration and spontaneuous breath

26
Q

weaning and extubation:
Phase One: Preweaning or assessment

A
  • Assess muscle strength
  • Assess endurance
  • Auscultate lungs
  • Assess chest x-ray
  • Non-respiratory factors
27
Q

Phase 2: Weaning

A
  • spontaneous breathing trial (30-120) min.
  • monitor for:
    tachycardia (dysrhythmias)
    tachypnea (dyspnea)
    sustained desaturation (SpO2 <90)
    hypertension/ hypotension
    agitation/ anxiety/ mental status change
    diaphoresis
    sustained V1 < 5 mL/kg
28
Q

Phase 3: Weaning Outcome

A

weaning stops and patient is extubated
or
weaning stops because no progress is made

extubation:
-hyperoxygenate and suction
- loosen ET tapes or holder
- deflate cuff and remove tube at peak of deep inspiration
- have patient deep breath and cough
- supplemental O2
- careful monitoring after extubation

29
Q

ARDS

A

sudden progressive form of acute resp. failure
alveoli fill with fluid

results in:
- severe dyspnea
- hypoxia
- decreased lung compliance
- diffuse pulmonary inflitrates

30
Q

ARDS pathophysiology

A

from different indirect lung injuries
- most common cause is sepsis or aspiration pneumonia.

31
Q

Early Clinical Manifestations of ARDS

A
  • dyspnea, cough, tachypnea, restlessness
  • chest auscultation may be normal or have fine scattered crackles
  • ABG: mild hypoxemia and resp. alkalosis caused by heperventilation
  • cxr may be normal or show some scattered infiltrates
32
Q

Late clinical manifestations of ARDS

A

! progression of fluid accumulation
! decreased lung compliance
! PFT show decreased lung compliance and volume
! evident discomfort and increased work of breathing
! suprasternal retractions
! tachycardia, diaphoresis
! changes in sensorium with decreased mentation, cyanosis and palor
! hypoxemia and a PaO2/ FiO2 ratio <200 despite increased FiO2
! cxr shows diffuse and extensive bilateral interstitial infiltrates

33
Q

Oxygen therapy in ARDS

A

O2 therapy to maintain PaO2 60 or greate

may need intubation

may need higher levels of PEEP

34
Q

ARDS complication

A
  • vent. associated pneumonia
  • Barotrauma- rupture of overdistended alveoli during vent.
  • Volutrauma- when large tidal volumes used to vent. non-compliant lungs
  • high risk stress ulcers

*** Renaul failure

35
Q

Interventions for ARDS

A

Maintenance of cardiac output and perfusion

maintenance of fluid balance

minimize hypotension and decreased CO2 from mechanical ventilation and high levels of PEEP

36
Q

Tension Pneumothorax: diagnosis

A
  • CXR
  • displaced trachea
  • displaced heart sounds

*** can be fatal

37
Q

Tension Pneumothorax S&S

A

severe dyspnea
tachycardia
tracheal deviation (late sign)
decreased or absent breath sounds on affected side
neck vein distention
cyanosis
diaphoresis

** fatal if pressure in pleural space not relieved

38
Q

Hemothorax

A

hemorrhage from chest wall, lung, or mediastinum

common after surgery

often with pneumothorax

39
Q

Things to know about chest tube collecting chamber

A

Collection drainage chamber- should not see more than 200 mL/ hr. If no collection, think of a clot

40
Q

Ambulatory care of chest tubes

A

disconnect but NEVER clamp. clamping only if chest tubes are being changes

if chamber breaks, remove chamber from tube and place tube in sterile water

41
Q

Possible chest tube complications

A
  • clots in tubing
  • tubing disconnection
  • accidental removal
  • subcutaneous emphysema (ex. picture of woman with swollen face)
42
Q

Chest tube discontinuation

A

when drainage has decreased,
pneumo is resolved (CXR)
breath sounds and VS are stable

43
Q

Chest tube removal

A

done by physician
give meds. before removal
valsuva maneuver
obtain materials
> suture removal kit
> petroleum gauze
> 4x4s
> foam tape
> sterile gloves
> follow-up CXR
> monitor for resp. distress

Med Surg 3 (theory class) (13 decks)

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