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Critical Care > Respiratory Case Studies > Flashcards

Respiratory Case Studies Flashcards

1
Q

Pulmonary Embolism s/s

A

dyspnea
hypoxemia
cyanosis
tachypnea
chest pain
cough
crackles
hemoptysis
wheezing
shallow respirations
edema in lower extremities

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2
Q

pulmonary embolism onset s/s

A

pleuritic chest pain
SOB
hypoxemia

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3
Q

Pulmonary embolism vitals

A

tachycardia
hypotension
low grade fever
pulse oximetry low

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4
Q

Pulmonary Embolism tests

A
  1. EKG
  2. Coagulation studies : PT / PTT and INR
  3. CXR
  4. Spiral Chest CT
  5. V/Q mismatch
  6. pulmonary angiography
  7. Duplex Ultrasonography
  8. D-dimer
  9. BNP
  10. ABG
  11. CBC
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5
Q

PE spiral chest CT

A

need large IV for contrast
BUN and Creatinine levels need to be assessed before contrast is given

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6
Q

V / Q scan

A

identifies areas of lungs that are ventilation but not perfused efficiently

-low / medium / high probability

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7
Q

d-dimer

A

fibrin degradation products or fragments produced during fibrinolysis

+ test = thrombus formation

***NOT recommended in dx PE because is nonspecific

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8
Q

BNP test

A

measures overstretching of the ventricles , peptide is released

> 100 is indicative of HF

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9
Q

Pulmonary Embolism Risk Factors

A
  1. advanced age
  2. smoking
  3. reduced activity
  4. clotting disorder
  5. air travel
  6. obesity
  7. hx of a-fib
  8. oral contraceptives
  9. hx of DVT
  10. cancer
  11. trauma or recent surgery
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10
Q

Pulmonary Embolism Meds

A
  1. Lovenox
  2. Heparin
  3. Warfarin
  4. tPA
  5. Oral Xa inhibitors
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11
Q

what labs to monitor on Heparin

A

aPTT

normal is 25-35 seconds
heparin = 1.5 - 2.5 times that

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12
Q

heparin antidote

A

protamine sulfate

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13
Q

what labs to monitor on warfarin (coumadin)

A

INR
range = 2-3 or 2.5 - 3.5

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14
Q

antidote for warfarin

A

vitamin K

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15
Q

Pulmonary Embolism teaching

A

exercise : strengthen patients heart
cardiac diet
adequate fluid intake : 8oz glasses / day
med education : FOLLOW UP LABS
bleeding precautions
limit vit K intake on Warfarin

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16
Q

Acute Respiratory Failure

A

one or both gas exchange functions of lungs are compromised

-leads to hypercapnia and hypoxemia
-not a disease but condition CAUSED by another disease

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17
Q

Respiratory Failure level

A

PaO2 < 60 mmHg despite increased oxygen with normal PaCO2

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18
Q

hypercapnia s/s

A

headache
confusion
decreased LOC
tachycardia
tachypnea
dizziness
flushed / pink skin

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19
Q

hypoxemia s/s

A

tachycardia
tachypnea
elevated BP
decreased cerebral perfusion

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20
Q

decreased cerebral perfusion s/s

A

restlessness
confusion
anxiety
cyanosis
–> eventual coma

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21
Q

Acute Respiratory Failure Tests

A

ABG
Venous Oxygenation
CBC
CXR
Sputum Culture

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22
Q

type 1 ARF , ABG

A

initial respiratory alkalosis –> eventual respiratory acidosis

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23
Q

type 2 ARF , ABG

A

pH < 7.35 and PaCO2 > 45 mmHg

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24
Q

venous oxygen saturation ARF

A

amount of oxygenated blood returning to heart

normal = 60-80%

decreased = inadequate cardiac output

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25
Q

CBC , ARF

A

Hct. and Hgb should be analyzed to ensure enough oxygen binding sites

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26
Q

CXR, ARF

A

reveal underlying patho

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27
Q

sputum culture , ARF

A

rule out pathogenic cause of failure

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28
Q

ARF management

A
  1. high flow O2 with non-rebreather
  2. non-invasive positive pressure ventilation
  3. endotracheal intubation, tracheostomy, mechanical vent with PEEP
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29
Q

non-invasive positive pressure vent , ARF

A

used in severe V/Q mismatch

  1. BiPAP
  2. CPAP
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30
Q

ARF medications

A

-bronchodilators
-inhaled steroids
-diuretics
-sedatives
-antibiotics

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31
Q

ARF bronchodilators

A

opens airway by stimulating beta-2 receptors

ex: albuterol, levalbuterol, salmeterol

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32
Q

ARF inhaled steroids

A

decrease inflammatory response , combination of bronchodilators and steroids provide more therapeutic response

ex: flovent, pulmicort, aerobid, qvar

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33
Q

ARF IV steroids

A

solu-medrol and solu-cortef

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34
Q

ARF diuretics

A

used to decrease pulmonary congestion , esp. when pulmonary edema is underlying cause

ex : lasix

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35
Q

ARF sedatives

A

used to control agitation and anxiety that increase work of breathing , esp with mechanical ventilation

ex: propofol and versed

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36
Q

ARF antibiotics

A

treat suspected pneumonia , initially broad spectrum and adjusted

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37
Q

ARF priority actions

A
  1. patent airway
  2. vitals and O2 Sat.
  3. cardiac monitoring
  4. neuro assessment
  5. med administration
  6. breath sounds
  7. skin color
  8. elevate HOB
  9. administer IV fluids
  10. nutrition
  11. prepare for invasive or noninvasive vent support
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38
Q

ARF vitals

A

BP / pulse / RR increased to attempt to increase oxygenation

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39
Q

ARF O2 goals

A

maintain SpO2 > 94%

PaO2 of 80mmHg

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40
Q

ARF cardiac monitor

A

hypoxia and increased oxygen demand due to tachycardia –> dysrhythmias

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41
Q

ARF neuro assessment

A

early indication of impending respiratory failure

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42
Q

ARF breath sounds

A

crackles : pulmonary edema
rhonchi : pneumonia , COPD
diminished breath sounds : hypoventilation

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43
Q

ARF skin color

A

cyanosis in nailbeds and around mouth

deep pink color indicates HIGH CO2 levels

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44
Q

ARF education

A
  1. disease process
  2. medication administration
  3. infection prevention : HAND WASHING
  4. smoking cessation
  5. diet and hydration
  6. breathing technique
  7. energy conservation
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45
Q

ARF breathing techniques

A

pursed lip breathing, diaphragmatic breathing allowing for better alveolar ventilation

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46
Q

ARF energy conservation

A

determine priorities and daily living, aerobic exercise improves respiratory status

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47
Q

Acute Respiratory Distress Syndrome

A

sudden / advanced progression of acute respiratory failure

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48
Q

ARDS s/s

A

hypoxemia
dyspnea
decreased lung compliance

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49
Q

ARDS treatment

A
  1. mechanical ventilation
  2. ECMO
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50
Q

ARDS mechanical vent

A

primary tx of refractory hypoxemia

-lung compliance decreases
-work of breathing increases
-oxygenation continues to be refractory

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51
Q

ARDS ventilation setting

A

reduced tidal volume and PEEP

-lower tidal volumes
-high PEEP

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52
Q

ARDS ECHMO

A

uses a pump to circulate blood through an artificial lung outside of the body

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53
Q

PEEP

A

keeps alveoli from collapsing

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54
Q

using lower tidal volumes

A

volume of air moved with one breath , helps improve oxygenation while also reducing occurrence of ventilator induced lung injury

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55
Q

ARDS assessments

A
  1. vital signs
  2. neuro assessment
  3. respiratory assessment
  4. monitor UO
  5. monitor mechanical ventilation
  6. monitor EKG
  7. skin assessment
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56
Q

ARDS vitals

A

increased HR
increased RR
decreased BP
low O2
decreased CVP
decreased PA pressure

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57
Q

ARDS neuro assessment

A

LOC and pupillary assessment every 1-2 hours
neuro compromise d/t refractory hypoxemia and PaCO2 increase

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58
Q

ARDS respiratory assessment

A

crackles r/t fluid buildup
later stage : diminished lung sounds r/t atelectasis and fibrotic changes

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59
Q

ARDS urine output

A

decreased UO is early sign of poor oxygen delivery

60
Q

ARDS mechanical ventilation

A

increase airway pressure (PIP) could mean secretions
decrease in airway pressure could mean a leak

61
Q

ARDS priority test

A
  1. CXR
  2. ABG
  3. CBC w/ diff
  4. sputum / blood culture
  5. serum lactate level
  6. liver and renal function
62
Q

ARDS chest x-ray

A

done to monitor improvement and progression, identify the bilateral infiltrates

-ground glass appearance, snow screen effect, whiteout effect

63
Q

ARDS ABGs

A

initially sho hypoxemia / hypocapnia
later = respiratory acidosis
metabolic acidosis b/c of hypoxemia

64
Q

ARDS CBC w/ diff

A

determine cause of ARDS is an infection
> 10,000 is infection

65
Q

ARDS sputum culture

A

early = cause of ARDS
later = complication

66
Q

ARDS serum lactate

A

elevated confirms anaerobic metabolism

67
Q

ARDS liver fxn

A

abnormal test indicates progression of ARDS to MODS

68
Q

ARDS medications

A
  1. Antibiotics
  2. Corticosteroids
  3. Furosemide (Lasix)
  4. Neuromuscular blocking agents
  5. Dopamine / dobutamine / norepinephrine
69
Q

ARDS antibiotics

A

used for if cause of ARDS is infection
-broad then narrow after pathogen identified

70
Q

ARDS corticosteroids

A

used to decrease inflammatory response
-controversial use

71
Q

ARDS lasix

A

to decrease pulmonary hypertension and edema

72
Q

ARDS neuromuscular blocking agents

A

reduce risk of barotrauma
-vecuronium
-used with severe ARDS

73
Q

ARDS dopamine / dobutamine / norepinephrine

A

increase and maintain BP / organ perfusion

74
Q

ARDS action

A
  1. suctioning
  2. positioning
  3. administer medications
  4. infection prevention
75
Q

ARDS suctioning

A

presence of secretions in ETT , secretions bring infection

76
Q

ARDS positioning

A

PRONING allows for better oxygenation
elevate HOB

77
Q

ARDS infection prevention

A

hand washing
monitor care of central line
foley cath care
increase risk for ventilator assisted pneumonia

78
Q

ARDS teaching

A

-provide family education and support
-understand medications, lines, vent
-provide family with visiting hours
-spiritual needs

79
Q

Tracheostomy

A

used when pt has been on mechanical ventilation for 7-14 days

-provide long term vent support, access for lower airway suctioning, relieve upper airway obstuction

80
Q

what is ordered after trach placement to ensure proper placement ?

A

CXR

81
Q

outer cannula

A

tube that holds tracheostomy open

82
Q

neck plate

A

extends from sides of outer cannula

83
Q

inner cannula

A

can be removed for cleaning and disposable

84
Q

obturator

A

used to insert a trach tube

**KEEP AT BEDSIDE

85
Q

inflated cuff

A

used for pt with continuous mechanical ventilation or pt at aspiration risk

86
Q

trach cuff pressure setting

A

20-30 cm H2O to decrease injury to esophageal tissue and aspiration

87
Q

uncuffed tube

A

used for patients who are ready for decannulation or are not getting mechanical vent

88
Q

fenestrated trach tube

A

has removable inner cannula and plastic plug , pt is able to speak through natural airway

89
Q

trach care

A

provided each shift : once every 12 hours and as needed

-provide patent airway and prevent infection

90
Q

trach suctioning

A

1-2 hours or less
assess breath sounds : wheezing , crackles, rhonchi
coughing, audible secretions, increase in pulse or RR or restlessness

91
Q

trach complications

A
  1. decannulation !!
  2. obstruction
  3. bleeding
  4. pneumothorax
  5. subcutaneous emphysema
  6. infection
  7. tracheoesophageal fistula
  8. tracheal stenosis
92
Q

decannulation

A

within first 72 hours is considered MEDICAL EMERGENCY
-greater risk for tissue damage and unsuccessful ventilation

93
Q

Decannulation actions

A

stay with the patient and call for assistance , provide manual ventilation using a manual resuscitation bag w/ 100% oxygen

94
Q

what needs to be at the bedside for trachs ?

A

OBTURATOR
tube in equal size and one smaller
intubation tray

95
Q

Trach obstruction

A

caused by secretions
encourage deep breathing / coughing , suctioning, humidification
air needs humidification

96
Q

Trach bleeding

A

small about expected first few days
report moderate to large amounts of bleeding, continuous oozing

97
Q

trach pneumothorax

A

collection of air in pleural cavity, occur during trach procedure if lung is pierced

chest X-ray always ordered after the procedure

98
Q

trach subcutaneous emphysema

A

occur if puncture or tear in the trachea
-moves to neck, chest, face area
**FEELS LIKE CRACKLING (rice krispies)
notify provider immediately

99
Q

trach infection

A

use aseptic technique , teach patient and caregiver

100
Q

trach tracheoesophageal fistula

A

overinflation of tracheostomy cuff causes a hole to occur between trachea and esophagus

MAINTAIN CUFF PRESSURE

101
Q

trach tracheal stenosis

A

narrowing of trachea due to scar tissue

MAINTAIN CUFF PRESSURE , prevent pulling of trach tube

102
Q

obstructive sleep apnea

A

caused by upper airway obstruction , narrowing of upper airway leading to intermittent breathing pattern

-collapsing of upper airway

103
Q

OSA risk factors

A

a-fib
nocturnal dysrhythmias
type II DM
HF
pulmonary HTN
male
obesity
smoking
hyperlipidemia
menopause

104
Q

OSA s/s

A

loud snoring
snorting
witnessed apnea
gasping during sleep
choking during sleep
recurrent waking up
daytime sleepiness
taking intentional naps

105
Q

OSA dx

A

15 or more obstructive sleep events / hour
POLYSOMNOGRAPHY

106
Q

polysomnography

A

EKG
pulse ox
respiratory airflow
eye / skeletal muscle movement
electroencephalogram

**key is apnea-hypopnea index value

107
Q

OSA tx

A

CPAP : delivers continuous positive pressure keeping airway open and provide unobstructed airway

108
Q

OSA surgery

A

remove excessive tissue in airway interfering with adequate airflow

-bariatric surgery
-tonsillectomy
-adenoidectomy
-uvulopalatopharyngoplasty
-nasal polypectomy
-tongue reduction
-epiglottoplasty

109
Q

OSA complications

A
  1. cardiovascular disease : recurrent hypoxemia
  2. endothelial damage / atherosclerosis : release of inflammatory mediators
  3. cardiac ischemia : nocturnal hypoxemia
110
Q

OSA assessment

A
  1. Vitals : HTN , dysrhythmias
  2. height and weight
  3. sleep , rest , activity hx
111
Q

OSA action

A
  1. administer meds
  2. dx testing : polysomnography
112
Q

OSA teaching

A
  1. disease process
  2. medication use
  3. no smoking
  4. CPAP instructions
  5. weight reduction
113
Q

small cell lung cancer

A

grows quickly and metastasizes to other organs in body, poor prognosis

114
Q

lung cancer tests

A
  1. CXR
  2. CT of chest
  3. sputum for cytology
  4. bronchoscopy
  5. mediastinoscopy
  6. bone scans , abd CT
  7. PET scan
115
Q

lung cancer bronchoscopy

A

tells number of lesions, assesses trachea and bronchi
-biopsy may be performed

116
Q

lung cancer mediastinoscopy

A

surgical procedure allowing direct visualization of mediastinum

-scope inserted through incision in chest to visualize lesions

117
Q

lung cancer tests when concerned for spreading

A

PET and CT scans

118
Q

lung cancer surgery

A

used when there is no metastasis of cancer
used for non-small cell tumors
-chemo can be used before and after surgery

119
Q

lobectomy

A

removal of entire lobe of lung

120
Q

pneumonectomy

A

removal of entire lung

121
Q

wedge resection

A

removal of small section from lobe of lung

122
Q

lung cancer non-surgical

A

chemotherapy and radiation

123
Q

chemotherapy

A

may be used in conjunction with surgery
-primary tx option for more advanced cancers or if pt cannot undergo surgery

124
Q

radiation

A

versatility, used in situations where surgery is not an option
-used palliatively for pain management

125
Q

lung cancer s/s

A

persistent cough
dyspnea
wheezing
hemoptysis : bloody cough
chest pain
episodes of pneumonia / bronchitis

126
Q

lung cancer assessments

A
  1. oxygen sat. : SpO2 < 90% indicates poor gas exchange
  2. temperature : elevated = infection
  3. breath sounds : wheezing, rhonchi
  4. coughing : bloody?
  5. pain
  6. appetite / weight : appetite can be decreased , SE of chemo
127
Q

lung cancer actions

A
  1. provide O2
  2. pain / anxiety meds
  3. small frequent meals
  4. semi-folwers positition
128
Q

lung cancer pain meds

A

NSAIDS
opioids : oxycodone, hydrocodone, morphine, codeine

129
Q

lung cancer bronchodilators

A

open airway to decrease WOB
-albuterol, theophylline, ipratropium bromide

130
Q

lung cancer teaching

A

breathing technique : PURSED LIP BREATHING !!
pacing activity to conserve energy
no smoking
nutrition
pain medications around the clock : keeps pain controlled instead of unbearable

131
Q

pulmonary hypertension

A
  1. Primary Pulmonary HTN : rare and rapid progressive form
  2. Secondary Pulmonary HTN : forms overtime , increase in pulmonary pressure
132
Q

pulmonary HTN s/s

A

dyspnea on exertion
SOB
fatigue
exertional chest pain
dizziness
exertional syncope

133
Q

pulmonary HTN complications

A
  1. R sided heart enlargement and HF
  2. PE
  3. arrhythmia
  4. OSA
134
Q

HTN R sided heart enlargement and HF

A

heart tries to compensate by thickening walls and expanding chamber to increase amount of blood it can hold but actually increases strain on heart

135
Q

HTN PE

A

increases likely to develop clots in small arteries in lungs

136
Q

HTN arrhythmias

A

cause irregular heartbeats leading to pounding heartbeats , dizziness and fainting

137
Q

pulmonary HTN dx

A
  1. CBC for polycythemia
  2. CXR
  3. EKG
  4. CT scan
  5. echocardiogram
  6. R heart cath
  7. ABG for hypoxemia
  8. Pulmonary function test
138
Q

HTN CXR

A

can show enlargement of R ventricles

139
Q

HTN CT scan

A

show heart size, blood clots, look for lung disease (COPD and pulmonary fibrosis)

140
Q

HTN R heart cath

A

directly measure pressure in main pulmonary arteries and R ventricle

*** > 25 mmHg at rest and > 30 with exercise = HTN !!!!

141
Q

HTN medications

A
  1. CCB : Diltiazem
  2. Sildenafil
  3. Prostacyclins
  4. Bosetan
  5. Digoxin
142
Q

diltiazem

A

should not be used with R sided HF

-vasodilates to reduce pressure in PA

143
Q

sildenafil

A

do not take with nitroglycerin = HYPOTENSION

144
Q

bosetan

A

monitor liver function

145
Q

HTN education

A

medications
portable oxygen
diet, activity, lifestyle

Critical Care (15 decks)

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