Seminar Exam 1 Flashcards
1
Q
vertebral nerves in respiratory system
A
C 3, 4, and 5 - keep you alive
C 6 and 7 - raise your arms to heaven
2
Q
what is the goal of cardiac catheterization post MI?
A
- establish coronary artery reperfusion
- limit damage
- time is muscle
- thrombolytic therapy if no cath lab
3
Q
status asthmaticus and CPAP/BiPAP
A
- NOT RECOMMENDED
- b/c of instability of patients and inherent difficulty in providing ventilatory support during acute face
- preventing hyperinflation, autoPEEP, barotrauma
- few studies to support its use
4
Q
obstructive shock
A
- adequate fluid but not in right places d/t obstruction
- embolus: big central PE
- blocks flow from R to L side of heart
- can’t fill ventricle (Starling’s law)
- no stretch, no squeeze, no CO
- cardiac tamponade: accumulation of fluid between pericardial sac and heart
- puts pressure on heart so ventricles can’t squeeze
- problem is not with heart, but with fluid - makes it obstructive not cardiogenic shock
5
Q
structures of respiratory system
A
- CNS (medulla)
- rate and rhythm
- peripheral nervous system (phrenic nerve)
- diaphragm
- respiratory muscles
- chest wall
- lungs
- upper airway
- bronchial tree
- alveoli
- pulmonary vasculature
6
Q
hypovolemic shock
A
- not enough volume (not necessarily due to blood loss)
- also b/c of excessive diarrhea/vomiting
- diabetes insipidus - really high renal losses
- usually pituitary defect
- primary characteristic:
- not enough volume in person’s body
7
Q
what causes a febrile seizure?
A
dramatic change (spike) in temperature
8
Q
patient intolerance of NPPV
A
- restlessness/agitation/mask removal
- dyssyncrhony
- leaks, sensitivity, autoPEEP
- hemodynamic instability
- worsening respiratory failure/acidosis
- hypoxemia, hypercarbia
- inability to manage secretions
- increasing lethargy
9
Q
muscles of respiration
A
- diaphragm
- phrenic nerve C3,4,5
- intercostals
- thoracic
- lumbar - innervate abdominal muscles (accessory)
- accessory muscles - neck and upper back
- scalenus
- trapezius
- sternocleidomastoid
10
Q
medical students
A
- 4 years after bachelor’s
- structue varies - major clinical training in second two years
- apprenticeship model - supervision by residents, fellow, and/or attending
- many med students “passing through” - externs or 4th year students may have chosen rotations
- no license to practice - must have orders co-signed
11
Q
volu/barotrauma r/t vent complications
A
- excess volumes or pressures
- floppy, overstretched lungs
- permanent fibrotic changes (balloon analogy)
12
Q
sypmtoms of BV
A
- gray, malodorous vaginal discharge
- sometimes pain, itching, burning sensation
13
Q
detecting auto PEEP
A
- occurs when expiratory time is insufficient to completely empty a delivered TV.
- portion of TV is trapped in alveoli, pressure remainsi n lung at end expiration
- consequence:
- hemodynamic compromise, increased WOB, barotrauma
14
Q
cardiogenic shock
A
- heart is not strong enough to pump volume throughout body
- not moving (adequate) volume to perfuse tissue
- causes: acute failure of heart’s pumping mechanisms
- massive heart attack
- unstable dysrhythmia (v.tach, v.fib, idioventricular rhythm)
- chest trauma
15
Q
attending
A
- physician/surgeon/dentist
- fully licensed and credentialed and authorized to admit patients to an insitution or have patients admitted to care
- member of medical/dental staff and usually member of faculty associated with agency
- ultimately responsible for medical care of patient under care
- may be episodic (based on situation)
- ultimate decision maker re: medical treatment decisions when team involves trainees or other consultants
16
Q
oropharyngeal airway
A
- measure from mouth to angel of jaw
- only for patients without gag reflex
17
Q
BiPAP
A
18
Q
causes of CPAP/BiPAP failure
A
- development of complciations
- MI, GI bleed, sepsis
- limitation of ventilator
- can’t deliver high FiO2
- varied flow capabilities could result in dyssynchrony
- patient-vent dyssynchrony
- autoPEEP
- worsening patient status
- ventilator limitations
19
Q
staff development roles
A
- orientation
- nurse residency programs
- continuing education
- relationships with schools of nursing for student placement
20
Q
initial treatment for MI
A
- MONA
- Morphine - only for chest pain if refractory to nitrates
- evidence of increased mortality
- oxygen - only for hypoxemia if indicated (pulm edema)
- titrate to SaO2 94%
- nitro - promote vasodilation in coronary vasculature
- not in BP < 90 or 30 mm below baseline
- not in RV infarct 2/2 preload dependence - caution in inferior infarct
- not if PDE inhibitor w/in 24-48 hrs
- aspirin - decreases platelet aggregation, promote blood flow around thrombus
- chew non-enteric 325 mg if no allergy or a PMH of PUD
21
Q
anemic hypoxia
A
- low hemoglobin
- hemoglobin can’t hold oxygen
- carboxyhemoglobin - exposure to carbon monoxide
- methemoglobin - topical lidocaine
22
Q
malnourishment r/t ventilation
A
- reduced response to hypoxia and hypercarbia
- muscle atrophy
- respiratory tract infections
- decreased surfactant production
- slowed healing of damaged tissues
- lower serum albumin levels
23
Q
definition of chronic respiratory failure
A
- PaO2
- PaCO2 = 45 mmHg or greater (hypercapnia)
- arterial pH - 7.36
- chronic folks decompensate quickly b/c body is already compensating
- 50-50 players - PaO2 and PaCO2 close to 50
24
Q
what does A, B, and C show?
A
- A: peaked T waves
- hyperkalemia if generalized (all 12 leads)
- myocardial injury if in isolated, contiguous leads
- B: t-wave inversion
- sign of MI
- no Q waves if initial insult is not full thickness or only several hours after initial insult
- C: ST segment elevation
25
disadvantages of AC ventilation
* all breaths have tidal volume preset, which could lead to respiratory alkalosis
* no spontaneous compensation by patient (take small breath, exhale more)
* respiratory alkalosis makes oxygen less available to dissociate to tissues
* all breaths are positive pressure breaths
* barotrauma, autoPEEP
* no normal spontaneous breathing
* patient can be dyssynchronous
* panic d/t lack of ventilatory control
* more sedation for patient tolerance
26
remote monitoring units (VISICU)
* rural areas
* specialty units
* consultations i.e. wound care
27
schematic of physiologic respiration
* pressure support modes allow for varying inspiratoryf low, whereas volume-cycled modes deliver volume
* volume-cycled are more uncomfortable b/c less physiologic and requires more sedation for patient tolerance
28
non-acute care hospital settings
* out patient clinics
* nursing facilities: skilled nursing, rehab, long term care
* highly variable structure
* often flat compared to highly bureaucratic teaching hospitals
* nurses may not be supervising nurses
29
info needed to wean off vent
* adequate PaO2, pH, PaCO2
* FiO2 is .4-.5
* low or no PEEP
* reasonable RR
* weaning individualized
30
ventilation support
* BiPAP
* mehcanical ventilation
* goals:
* PaCO2 to pre-exacerbation level
* normalize pH
31
S in SBAR
* Identify person to whom you are speaking
* Identify self, occupation, location
* Identify patient by name, age, sex, admission
* Identify what is wrong with patient
32
mask fit/intolerance and CPAP/BiPAP
* NOT RECOMMENDED WHEN:
* claustrophobia, facial deformities, absence of teeth
* different non invasive options hsould be considered if intolerance is evident
33
flow of medical work in teaching institutions
* sustdents/residents/fellows/NPs/PAs will often pre-found
* rounds with team - who is present?
* general play for day is set
* may involve nursing and other disciplines
* discharge decisions often made
* good time to clarify questions and bring entire team's attention to important issues
* be part of the team!
34
continuous positive airway pressure
* spontaneous breathing
* postiive end expiratory pressure applied
35
recruitment maneuver
* not so much now we have advanced pressure support modes
* high pressure for 5-1 min to minimize barotrauma but facilitate recruitment
* difficult to coordinate with docs, etc.
36
non-invasive ventilation indications
* impending respiratory failure
* transient respiratory distress
* acute COPD exacerbation
* cardiogenic pulmonary edema
* hypoventilation syndrome
* nocturnal sleep disorder
37
distributive shock
* loss of normal vascular response to stress and position change
* septic shock
* neurogenic/spinal shock
* anaphylactic shock
38
priority interventions for PVCs
* CXR, ABG
* treat underlying cause, monitor for R on T or increasing ventricular ectopy
39
ventilator complications
* auto PEEP
* hemodynamic instability
* positive H2O balance
* infection - VAP
* GI bleed d/t stress ulcer
* volutrauma/barotrauma
* oxygen toxicity
40
definition of acute respiratory failure
* PaO2 \< 50 mmHg (hypoxemia)
* PaCO2 \> 45 mmHg (hypercapnia)
* arterial pH \< 7.35
41
noninvasive ventilation
* to rest patients with chronic ventilatory failure
* CPAP --\> BiPAP
* nasal mask or full face mask attached to bilevel pressure generator
42
schematic of AC / CMV ventilation
43
R in SBAR
* explain what you require
* how urgent, timeframe
* suggestions of actions to take
* clarify what actions you expect to be taken
44
best treatment for febrile seizure
tylenol (for prevention) or if fever spikes beyond 101.5 (want to let normal fever burn out if possible)
45
medicine, surgery, and other specialties
* surgery refers to spcialties where surgical operations/procedures are part of patient management
* medicine and surgery co-manage many patient
* service to which patient is admitted has ultimate say
46
initial CPAP/BiPAP settings
* CPAP
* 3-5 cm H2O
* titrated to relieve dyspnea, improved oxygenation
* BiPAP
* pressure support (I-PAP)
* 5 cm H2O (10-15 cm H2O)
* PEEP (E-PEEP)
* 3-5 cm H2O
* sensitivity
* pressure trigger (-0.5 cm H2O
* flow trigger (1 Lm)
47
how can nurses prevent febrile seizures?
* education
* can happen up to 5 mo old
* some family hx as risk factor
* safety
* time the seizure
* remove objects
* put child on side in case of vomiting
48
risk factors for BV
* new/multiple sexual partners
* frequent sexual intercourse
* douching
* smoking
49
diagnostic criteria for preeclampsia
* systolic BP _\>_140, diastolic _\>_ 90 x 2 within 4 hours
* porteinuria
* 24 hr urine _\>_ 300 mg
* protein:creat ratio _\>_ 0.3 g
* persistent + 1 urine dipstick
* without proteinuria:
* thrombocytopenia
* renal insufficiency
* impaired liver function
* cerebrovascular changes
* pulm edema
50
VAP bundle overview
* some vented patients are at high risk for complications:
* VAP, VTE, GI bleed
* four elements of care to prevent these events
* when all 4 are used, dramatic reduction in VAP rates and moribidity and mortality
* in addition to insitution-specific VAP prevention protocol
51
SIMV advantages
* synchronized to patient breathing
* less breath stacking and air trapping
* exercsie respiratory muslces
* may improve CO in select patients
* potentially less respiratory alkalosis
52
reciprocal changes in EKG leads
oppositive deflection in opposing lead
53
GYN exam
* general apperaance
* lungs
* CV
* breasts - masses, nipple discharge
* abdomen
* external genitalia - appearance, odor, discharge
* cervix - apperance, diameter, discharge
* vaginal walls - appearance, discharge
* bimanual - to fingers, pressing on uterus from outside
54
treatment for preeclampsia
* magnesium sulfate - seizure ppx
* birth - induce labor via ocytocin or pitocin
55
clinical management of respiratory failure
* maintain/establish airway
* oxygenation
* ventilatory support
56
causes of inadequate ventilation (NORMAL lungs)
* brain injury
* SCI
* drug overdose
* muscle weakness (MS)
* nerve disorders (myasthenia gravis)
* structural abnormality of chest
57
adjunct ventilator therapies
* pressure support (PSV)
* positive end expiratory pressure (PEEP)
58
definition of shock
a state of hypoperfusion in which there is no or not enough oxygen and the tissues ultimately die
59
STI screening grade definitions
60
hypoxemic hypoxia
decreased arterial O2 tension
61
CCU priorities when post MI, post cath patient arrives
* oxygenation, assessment, vitals, pulse checks, groin checks, labs
* why intubation? too sick - needs airway, ventilation, oxygenation support
* 14 gauge cortiss cath with swan-ganz catheter to introduce invasive hemodynamic monitoring
* mointor flow through R side to infer info about L side
* CO, SV, ejection fraction, pulmonary artery bed pressure)
62
assess this rhythm
* stable b/c blood pressure high enough to perfuse
* interventions: antiarrhythmic to get more stable rhythm
* if BP 50/30 with a pulse: cardioversion
* pulseless? defibrillation
63
VQ mismatch - dead space
ventilation w/o perfusion (PE)
64
* Venturi
* 24-60%
65
potential exclusions for use of CPAP and BiPAP
* status asthmaticus
* hemodynamic instability
* airway and mental status
* mask fit or intolerance
* excessive secretions
* severe agitation
* high FiO2 requirements
66
normal ABGs
* pH 7.35 - 7.45
* PaCO2 - 35-45 mmHg
* PaO2 - 80-100 mm Hg
* bicarb: 22-26
* O2 Sat: 90-100%
67
volume cycled ventilation
* delivers preset tidal volume w/ each ventilator-initiated breath
* most frequently used type in adults/large children
68
organization of medical teams
* providers grouped into services
* team manages patients with similar diagnoses
* nurses call page operators to find out who is "covering" specific team at any given moment
* interns/residents rotate teams eveyr few weeks
* medicine stays with medicine, etc.
69
physician assistants
* utilized in different specialties
* ED, L&D
* orders need to be co-signed by physician
70
volume cycled ventilation modes
* Assist-Control (A/C) or Continuous Mandatory Ventilation (CMV)
* Synchronized Intermittent Mandatory Ventilation (SIMV)
71
auto-PEEP
* breath stacking / air trapping from incomplete exhalation (residual end pressure at start of next breath)
* mode that gives new breath doesn't allow patient to fully exhale last breath
* volume and pressure left in alveolar bed
* results in volu/barotrauma to lungs (pneumo if too much)
72
SBAR
* Situation
* Background
* Assessment
* Recommendation
73
B in SBAR
* give patient's presenting complaint
* give patient's relevant PMH
* briefy summary of background
* events leading up to current situation
74
diagnostic studies of respiratory failure
* ABGs
* acid/base balance
* ventilation
* oxygenation
* CXR
* CT (for PEs - CXR cannto detect)
75
ST segment depression
myocardial ischemia - reversible!
76
residents
* most hands-on work
* progressive increase in responsibility for patient management and supervision/training of more junior traineess
* often rotate through patients in a specialty - "house officers"
* interns (1st year) may be generalists in area of care and are there to laern about area and refine skills
* "senior resident" has more hands-on experience
* PGY-1 or R3 (for post grad year x or residency year x)
* "chief resident" takes on management and additional teaching responsibility within residency program
77
optimizing PEEP
* inverse relationship btwn airway resistance and volume
* highest resistance at lowest lung vol
* atelectasis occurs as # of alveoli are closed
* compliance decreases
* PEEP routinely used to overcome
* use as little PEEP as posible to affect positive lung changes (recruiting alveoli)
78
* LEFT: ST segment elevation
* myocardial infarction
* STEMI - ST elevated MI
* RIGHT: t -wave inversion
* another indication of myocardial injury, w/ possibly more damage
* NSTEMI - non ST elevated MI
* risk factors, suspicious chest pain, non-suspicious EKG, and NO STEMI
* high clinical suspicion - they need to be ruled out via lab work
79
GI bleed r/t ventilator complications
* stress ulcer formation d/t tissue hypoxemia or flow issues 2/2 pressure changes
* poor perfusion of gastric mucosa leads to loss of goblet cells that secrete protective layer
* physiologic stress literally making GI vulnerable to ulcer formation
* PPI or H2 blocker
80
determining ventilatory settings
* tidal volume (VT)
* respiratory rate
* fraction inspired oxygen (FiO2)
* PEEP
* pressure support
* I:E ratio
* based on ideal body weight (height, weight)
81
excessive secretions and CPAP/BiPAP
* NOT RECOMMENDED
* presence of secretions requires patient to effectively clear airway
* work associatd with effective clearance may quicly overwhelm patient's endurance and result in respiratory failure
82
PSV disadvantages
* TV can decrease if:
* compliance decreases (atelectasis, de-recruited alveoli)
* WOB increases
* fatigue
83
airway management
* encourage cough
* nasopharyngeal/tracheal suctioning
* endotracheal intubation/tracheostomy
* bronchodilator therapy
* mucolytics
* COPDers
* thick secretions
* dehydrated patients
* usually need hydration to work
84
main uses of noninvasive ventilation
* prevent airway obstruction during sleep
* maintain or improve oxygenation
* maintain or improve ventilation
* provide respiratory muscle rest in different categories of patients in whom invasive mechanical ventilation through an artifical airway is not desired
85
nursing responsibilities in vent weaning
* vitals
* anxiety
* support and encourage
* patient positioning (high fowlers)
* suction only when needed
* stress-free environment
* weaning individualized
86
nurse practitioner based units
* fellow with NPs
* as effective as residents in providing care
87
non-invasive ventilation contraindications
* hemodynamic instability
* inability to protect airway, aspiration risk
* impaired mental status
* uncontrolled arrhythmia
* life threatening hypoxemia (\< 60 on 100%)
* postop vertical band gastroplasty
* severe claustrophobia
* facial deformity
88
causes of acute respiratory failure
* decreased respiratory drive
* severe brain injury, sedatives, cancer
* dysfxn of chest wall
* muscular dystrophy, myasthenia gravis, ALS
* dysfxn of lung parenchyma
* pleural effusion, hemothorax, obstruction, PNA, pulmonary emboli
* post-op after major thoracic or abdominal surgery
* pain
89
hemodynamic instability r/t ventilation complications
* decreased venous return 2/2 positive pressure in intrathoracic cavity
* decreased CO, RAP/CVP, LV
* baroreceptors think patient is intravascularly depleted b/c decreased CO 2/2 vent change
* activate renin-angiotensin-aldosterone system leading to water retention
* will happen to some degree in any patient - anticipate
90
Bohr Effect
* oxyhemoglobin shift
* to the RIGHT:
* fever, acidosis
* oxygen more readily availble to dissociate to tissues
* to the LEFT:
* cold, alkalosis
* oxygen less readily available to dissociate to tissues
91
why does respiratory failure occur?
* mechanical abnormality of lungs/chest wall
* defect in respiratory controlc enter of brain (trauma, central lesion)
* impairment in respiratory muscle function - MS, ALS, SCI
* inadequate ventilation
* inadequate oxygenation
* both
92
goal of lasix in post MI
decrease pulmonary edema
93
selecting CPAP/BiPAP interface
* full mask, nasal mask, nasal pillow
* consider
* size and shape of face/nose
* deformity
* skin integrity
* presence of tubes
* patient preferences
* chin strap, harness
94
trouble-shooting vent
* guard against incorrect settings
* vent disconnect is common first problem
* check patient FIRST
95
goal for door to balloon time in a STEMI
90 min or less
96
disadvantages of SIMV
* limited capacity for patient to meet demand (increased WOB)
* fatigue, conscious sedation for bedside procedure
* IMV drive may not give enough support at that point
* respiratory acidosis if ventilatory support is insufficient (mismatch between patient and vent)
* sedation may require more support, mode switch
* may fatigue respiratory muscles
97
differential diagnoses when a child comes in with a seizure
* febrile seizure
* infection - meningitis
* head trauma
* seizure dx (more unlikely)
* brain tumor
* ingestion of med or toxin
98
nursing care of A line
* aseptic during set-up of tubing and insertion
* Allen's test to assess collateral circulation (if placed in radial artery)
* shift assessments of dressing for sterility, intactness and site for infection, infiltration
* continuous monitoring b/c of risk of bleeding if disconnected
* assess line set up for patency, pressure gauge at 300 mm, prover IV solution (NSS), proper IV voluem to avoid air embolus
* removal as directed with direct pressure to puncture site for 5-10 minutes to prevent bleeding/hematoma
99
causes of inadequate ventilation (ABNORMAL lungs)
* COPD
* asthma
* emphysema
* chronic bronchitis
* fibrotic lungs
* trauma
100
clinical signs indicating need for ventilation
* acute dyspnea
* PaO2
* a PaCO2 \> 50 mmHg
* significant respiratory acidemia pH
101
residencies
* some post-grad training
* used to stay in hospitals (i.e. residencies)
* highly structured and meet accreditation standards
* graduates become "board eligible" or qualified to sit for exam leading to national certification in specialty or subspecialty
* training programs - first in line to respond to many clinical situations
102
proceduralists
* physician does same procedure every day on as many patients as can be accomodated
* at many academic medical centers
103
Mrs. Mann, a 56-year-old retired school teacher, presented to the ED w/ 2 hr hx of chest discomfort, diaphoresis (cool and clammy) and orthopnea. Never had a hx of similar Sx, takes no medications and has no hx of HTN or CAD. She arrived at the hospital at 0100 due to severe orthopnea and difficulty sleeping.
Primary interventions?
* VS
* IV
* labs - trop, BMP, BNP, ABGs, CBC
* continuous pulse ox
* continuous cardiac monitoring - tele
* 12 lead EKG w/in 10 min of c/o chest pain
* O2 via nasal cannula
* high fowler's with pillows under arms
* promote chest expansion, take weight of chest off by elevating arms, trouble when lying flat
* facilitate respiratory effort
104
pathologic dead space
gas exchange without perfusion (i.e., a PE)
105
fellows
* completed residencies and are pursuing training in subspecialty
* "right hand" to attending
* may have teaching involvement
* may have broad or narrow role in patient management
* function as attending
106
A in SBAR
* vitals
* concerns/abnormals
* clinical impression?
* severity of patient, additional concern
107
impact of ventilation on intrathoracic cavity
* positive pressure ventilation changes pressure in intrathoracic cavity
* will impact venous return, impacting CO
* results in chain of events that we need to anticipate
108
hemodynamic instability and CPAP/BiPAP
* NOT RECOMMENDED
* patients requiring high vasopressor and/or other supportive therapies
* require full ventilatory support to assure acid-base stability and adequacy of oxygenation and ventilation
109
intensivists
* to address need for knowledge of special aspects of critical care
* embraced by hospitals in interest of patient safety and QI
* used many times in community hospitals
110
mask intolerance and leaks in CPAP/BiPAP
* careful interface selection is essential
* patient facial characteristics
* process of applying mask - gently and gradually
* if mask leaks are large:
* patient generated cycling may be adversely affected and result in dyssynchrony (time cycled modes can be helpful)
111
pressure-cycled ventilation modes
* Continuous Positive Airway Pressure (CPAP)/ Pressure Support Ventilation (PSV)
* advanced modes i.e. APRV/ Bi-Level
112
nurse practitioners
* can be unit based or service based
* orders co-signed by physician
* job descriptions depending on education and certification based on patient population
113
non-invasive ventilation clinical benefits
* decrease WOB
* dyspnea relief
* improved gas exchange
* avoid endotracheal intubation
* decrease length of ICU stay
* decrease sedation use
* decrease nosocomial infections
114
PSV overview
* usually when patients require intubation but not vent support
* or last stage of weaning in some patients
* also used as component of other vent settings: to support ventilation along with low SIMV and CPAP
115
indications for mechanical ventilation
* inability to maintain adequate ventilation
* inability to maintain adequate oxygenation
* WOB is greater than patient can maintain
* patient cannot breathe on their own
* profound distress/impending failure/failure
* inability to maintain airway
* GCS - less than 8, intubate
116
preparing for vent weaning
* describe process to patient
* vital signs before and throughout
* evaluate LOC
* review meds for drugs that could hamper weaning
* possibly correct anemia
* K, phos, mag levels adequate
* hydration
117
advantages of PSV
* pressure support overcomes resistance of tubing
* useful with weaning
* WOB decreased
* patient controls frequency and volume
* patient determines inspiratory gas flow - more physiologic
118
inter-department committees in hospitals
* recruitment and hiring
* quality management
* safety committees
* supply/equipment selection
* risk management
* infection control
* public relations/marketing
* credentialing
119
treatment options for BV
* Flagyl/metronidazole 500 mg po qd x 7 days
* high risk 250mg tid x 7 days
* Flagyl 2 g po ONCE
* Flagyl 0.075% gel intravaginally bid x 5 days
* clindamycin 2% cream, 5g intravaginally qd at bed x 7 days
* clinda 300 mg po bid x 7 days
120
causes of hypoxemia
* aerohypoxia - high altitude (not enough oxygen in air and people can't compensate immediately)
* hypoventilation - asthma (airway restriction)
* diffusion abnormalities
* VQ mismatch
121
septic shock
* type of distributive shock
* insult of infection resulting in systemic inflammatory response with:
* dilated, poorly responsive peripheral vasculature that cannot move fluid to central vasculature
* leaky capillary bed --\> third spacing of fluid
122
oxygenation goals for hypoxemia
* acute - PaO2 60-70 mmHg
* chornic - PaO2 - 50-60 mmHg
123
oxygenation
oxygen into blood and tissue cell
124
severe agitation and CPAP/BiPAP
* NOT RECOMMENDED
* agitation makes adjustment to non-invasive interface difficult
* leaks increase when interface is displaced
* ventilation unreliable and ineffective
125
ventilation
movement of air in and out of the lungs
126
potential effects of anterolateral MI
* CHF
* pulmonary edema
* hemodynamic compromise
* cardiogenic shock
* intraventricular conduction disturbances
127
SIMV overview
* patient receives present tidal volume at set ventilator rate AND
* can initiate spontaneous breaths on own (variable tidal volumes)
* more flexible support than AC, may require less sedation
* allows exercise of respiratory muscles
128
low pressure alarm on vent
* leak
* check circuit (at y site)
129
what is BV?
* bacterial vaginosis
* most common vaginal infection, often during pregnancy
* imbalance of vaginal flora with predominance of harmful bacteria
* not an STI
130
low exhaled minute ventilation / VTe
* fatigue
* sleeping
* cuff leak
* circuit leak
131
complications of CPAP/BiPAP masks
* gatsric distention and vomiting
* nasal congestion
* eye irritation from leaks
* discomfort
* claustrophobia
* nasal and facial skin breakdown
132
* for FiO2 \> 40%
* rate of flow is very drying to mucous membranes of upper airway
* can lead to dried secretions, mucus plugging
133
apnea alarm on vent
* vitals
* fatigue, sedation
* central apnea
134
immediate concern for pediatric postop patient
* emerging from anesthesia
* respiratory - supplemental oxygen?
* raise HOB
* wake patient up, stimulate them
135
the "pecking" order in medicine
high to low in years/experience:
* attending physician
* fellow
* resident
* intern
* medical student
136
neurogenic/spinal shock
* type of distributive shock
* adequate fluid but vasculature is too dilated to pump it
* d/t neurogenic/spinal injury and loss of vascular tone/response
* fluid pools in periphery (mal distributed)
137
nurse manager
* front-line manager
* 24 hours, 7 days a week
* functioning of nit
* supervises nursing staff across all shifts
* represents unit concerns of nurses and nursing care to middle/executive level management
* The Boss!
* sometimes an assistant Nurse Manager too
* blend of models - best clinical skills (pre 1980s) + administrative background (post 1980s)
138
CPAP / PSV overview
* CPAP is analogous with PEEP
* both CPAP (noninvasive) and PSV (ETT), patient breathes independently through ventilator circuit
* no tidal volume preset, no rate preset
* only FiO2 and gas pressure at end-exhalation (PEEP) are controlled
* patient always breathing spontaneously
139
dys-synchronous ventilation
* patient limited in communication, fighting vent
* positive pressure is to provide adquate alveolar ventilation
* avoid dyssyncrhony at all costs
* risk:
* valsalva / increased positive pressure
* barotrauma
* increased WOB
* impaired cardiac function
140
dobutamine for post MI
* positive inotrope
* enhances cardiac contractility
* better squeezing power to move fluid forward
141
clinical nurse specialists
* MSN degree and are certified
* orienting new staff, continuing education, and/or research
* QI
* unit, department, or hospital based
* consultant role: wound care, specialty
* assists with complex patients
142
shift/house supervisors
* middle management
* 8 or 12 hrs
* broad spectrum of responsibilities - operational to personnel
* staffing or bed issues
* multiple different names
* NCC, PCC, NAC
143
nursing measures for preeclampsia
* IV access
* foley + strict I/O
* oxygen + face mask available
* continuous fetal monitoring
* baseline labs
* monitor vitals
* family/patient support + education
* decrease external stimuli
* assess every hour
* respirations, clonus, DTR, epigastric pain, N/V, back pain
* SCD
* incentive spirometer
144
high pressure alarm on vent
* suctioning
* biting tube
* trach tube displaced
* lungs stiffer
* volu/barotrauma
* bronchconstriction
145
lab workup for a suspected MI
* troponin - most specific and sensitive for myocardial insult
* only released with myocardial injury
* CK - released with any muslce injury
* rhabdomyolysis
* CK-MB - more specific to cardiac tissue than CK
* not as sensitive
* onset 2-4hr and peak 12-24 hr for trop and CK-MB
* duration 7 day for trop, 2-3 days for CK-MB
146
pediatric fluid balance calculation
(4ml \* 10kg ) + (2ml \* 10 kg) + (1ml \* remaining kg)
expected urine output: 1-2 ml/kg/hr
147
high FiO2 requirements and CPAP/BiPAP
* most NPPV ventilators do not provide high FiO2
* patient may require invasive ventilation or NPPV with conventional ventilator to assure required FiO2
148
relationship between cardiogenic shock and renal failure
149
histotoxic hypoxia
inability to use oxygen supplied (cyanide)
150
O2 toxicity r/t vent complications
* 0.6 L for \> 48 hours w/ positive pressure
* permanent lung injury, neuro changes
* similar to nitrogen poisoning
* be aware - some may need 100% FiO2 and they will have some degree of toxicity
* be on the look out for weaning opportunities
151
100% non-rebreather
152
prognosis for BV
* excellent when treated
* if not:
* at risk for HIV, chlamydia or gonorrhea
* possibly leading ot PID
* at risk for preterm labor/birth
153
vent weaning failure
* BP pressure devation of 20 mm Hg or more
* alteration in HR of 20 bpm or more
* cardiac dysrhythmias deviating from baseline
* change in LOC
* RR elevation
154
VQ mismatch - shunting
normal alveolar interface but blood can't get in or out so it is passing by alveolar unit and can't be oxygenated
perfusion w/o ventilation - R side to L side of heart w/o oxygenation
155
CPAP - non invasive ventilation
* denotes spontaneous breathing
* to treat hypoventilation syndrome or obstructive sleep apnea
* via full face mask, nasal mask, or nasal pillows
* FiO2 variable
* same as BiPAP w/o pressure change
156
diagnosing BV
wet mount, gram stain
157
cause and effects of chronic respiratory failure
* deterioration in gas exchange over long period of time
* absence of acute Sx and presence of chronic respiratory acidosis
* patient has developed tolerance to gradual worsening hypoxemia and hypercapnia
* COPD and neuromuscular diseases
158
flagyl patient education
DO NOT DRINK - will vomit violently
159
elements of VAP bundle
1. HOB 30-45 degrees
2. daily sedation vacation and assessment of extubation readiness
3. peptic ulcer disease ppx
4. DVT ppx (unless contra)
160
PEEP
* component manipulated in almost every mode
* usually for refractory hypoxemia
* improves oxygenation via alveoli recruitment
* may decrease CO via dereasing venous return
* may increase ICP via decreasing venous return (venous congestion in head)
161
hospitalists
* physician who is employed by the hospital to care directly for patients who are admitted by another doctor
* typically internists
162
Assist-Control Ventilation / CMV overview
* patient receives a preset tidal volume w/ each breath
* if patient initiates breath, receives full preset tidal volume set on vent
* CMV = continuous mandatory breathing
* doesn't allow for spontaneous breathing
163
oxyhemoglobin dissociation curve
* PaO2 affected by core temp, serum pH, CO2
* SaO2 (% of oxygen) affected by CO2, [H+], temp, 2,3, diphophoglyycerate
164
circulatory hypoxia
* decreased blood supply
* decreased CO
* arterial occlusion
165
possible causes of PVCs
* hypoxia
* infarcted tissue
* hypokalemia (k is the electrolyte of cardiac relaxation)
* hyperkalemia
166
specimens obtained for pap and wet mount
* swab of cervix for pap
* small amount of vaginal discharge via swab
* smeared on glass slide with 1 drop saline
* another sample with one drop KOH for whiff test
* KOH breaks down epithelial cells, leaving yeast and hyphae
* assess pH
167
clinical directors
* middle management
* cover multiple units, usually same specialties
* nurse managers report to them
* relays information and concerns between exectuive level and units
* often handles broader concerns and operational concerns
168
pressure cycled ventilation
* decelerating flow patterns rather than constant, mandatory flow
* spontaneous patient breathing (syncs better w/ patient breathing)
* primarily involves manipulation of FiO2, PEEP, PSV
169
clinical examination of respiratory distress
* dyspnea
* tachypnea (\> 30-35)
* labored breathing - accessory muscles
* poor skin color
* sweating
* tachycardia
* abnormal lung sounds
170
consultants
* when team or attendant asks for help from spcialists
* make recommendations that team rolls into orders/care
* attending makes final decisions
* especially when treatment plans in conflict
* may or may not be admitting team
* infectious disease, pods, ortho
171
Chief Nursing Officer/Executive / Director of Nursing
* executive level nursing management
* sets vision and direction for nursing practice
* interfaces with executives from other areas
* handles high profile/high cost operations
* slects, supervises, develops other executives/middle line managers
* may supervise other departments such as pharmacy, rehab, patient services
172
airway and mental status and CPAP/BiPAP
* NOT RECOMMENDED WHEN:
* inadequate airway protective reflexes
* cough and swallow essential for airway protection
* absence puts patient at risk for aspiration
* encephalopathy or coma
* inability to protect airway and remove mask when neccessary increases risk of aspiration
173
* upper right - trach collar
* lower right - another way to deliver humidified air to trach
174
* Up to 6L (FiO2 = 38%)
* Aquanox: nasal cannulas with high flow, humidified nasal passages to get higher FiO2 (80-100%)
175
high RR alarm on vent
* anxiety
* fatigue
176
CPAP/BiPAP mode options
* spontaneous
* patient initiates all breaths
* spontaneous-timed
* spontaneous w/ back-up rate
* control mode
* Rate and inspiratory time set
177
nasopharyngeal airway
* not when there is an NG or facial trauma
* easiest way to brain is through nose
* can go into brain if nasal passage is compromised
178
screening recommendations for specific STIs
* chlamydia - B
* gonorrhea - B
* syphilis - A
* HIV - A
* HSV - D
* HPV - A
* Hep B - D (B for high risk)
* Hep C - I (B for high risk)
179
charge nurse / team leader
* shift-level manager on units
* care on specific unit for specific shift
* work flow and staff
* admission discharges and transfers
* resource person
* experienced nurse
* may or may not have own patient load
180
concerns for fetus with magnesium sulfate
* fetal well-being
* lethargic on mag
* desaturations
* increases risk of C-section
181
hypoxia
insufficient oxygen availability at cellular level
182
ABG progression
1. increased WOB
* PaCO2 may be low (hyperventilation)
2. patient becomes tired
* PaCO2 rises to normal
3. patient cannot maintain WOB
* PaCO2 rises above normal (hypercapnia)
183
what dysfunction are we worried about with inferior damage to heart?
* injury to LV that impairs cardiac pumping
* risk for cardiogenic shock
* heart failure due to acute process of injury to myocardium
* risk for pulmonary edema
* not moving blood forward (explains orthopnea)
* injury to electrical conduction system
* heart block (if injury to junction)
* v.tach, v.fib, PVCs
184
advantages of AC ventilation
* ventilator assumes patient's WOB
* patient gets full tidal volume when breathin above set ventilator rate
185
PVCs
* originate in ventricle - not preceded by p wave
* no atrial kick
* risk for R on T --\> V.tach, v.fib
* decreases diastolic filling time (75% normally)
* decreases coronary artery perfusion
186
FiO2 of CPAP/BiPAP
* titrated by flowmeter
* oxygen blender
* high FiO2 requiremetns may require conventional ventilator in NPPV mode
187
anaphylactic shock
* type of distributive shock
* inflammation caused by molecule in environment
* usually large, proteinacious molecules
* body sees it as threatening and mounts big inflammatory response
* loss of normal vaso tone and pooling of blood in periphery
188
physiologic dead space
space in upper airways that don't have units for gas exchange (nose, pharynx, etc.)
