Skills - Rationale Flashcards

Question

Non invasive ventilation - Benefits - Evidence needed for respiratory support - Contraindications

Answer 1

Benefits - Improved survival, fewer complications, increased comfort and decreased cost - Can be used in acute, chronic, hypoxaemic or hypercapnic conditions Evidence needed for respiratory support - Moderate to severe respiratory distress - Increased respiratory rate - Use of accessory muscles - Arterial blood gas show respiratory acidosis or PaCO2/FiO2 under 200 Contraindications - Impaired consciousness - Hemodynamic instability - Myocardial ischemia, unstable angina - Unable to protect airway - Copious respiratory secretions - Uncooperative, agitated or depressed level of consciousness - Difficulty fitting mask - Head trauma with unstable respiratory drive - Recent upper airway or GI surgery

Answer 2

Endotracheal tube or mechanical ventilation Full ventilation support - maintained effective alveolar ventilation irrespective of patient comfort Partial ventilation support - patient contributes to breathing and maintaining alveolar ventilation

Answer 3

4 phases: Change from expiration to inspiration phase - Time triggered (deliver breath after set time) - Pressure triggered (patient effort sufficient to decrease circuit pressure) - Flow triggered (patient effort sufficient to drop flow in circuit) Inspiration phase - Pressure limited - pressure rises but does not exceed set limit (poor lung compliance) - Volume limiting - max volume to deliver - Flow limiting - patient access to increase flow to accommodate increased demand Change from inspiration to expiration phase - Volume & time cycling - not influenced by changes in lung compliance but may contribute to increased airway pressure - Pressure cycling - influenced by lung compliance and volume delivered dependent on flow, length of inspiration, lung characteristics and set pressure - Flow cycling - pressure supported breath (exhalation valve open when predetermined flow rate reached) - Pressure, flow, volume or time can be variable cycling but only one cycle per individual breath Expiration phase - Passive - baseline pressure altered and usually positive - PEEP usually applied and prevents early airway closure and alveolar collapse at end of expiration

Answer 4

- Continuous mandatory ventilation - Assist control ventilation - Synchronized intermittent mandatory ventilation - Pressure support ventilation - Continuous positive airway pressure

Answer 5

Enteral - Gastrointestinal tract administration Parenteral - Any route other than GIT administration Pulmonary - Endotracheal tube in inhalation Topical - Applied to skin and mucous membrane

Answer 6

``` Endotracheal - rapid Enteral - slow Intramuscular - moderate Intranasal - rapid Intraosseous - immediate Intravenous - immediate Pulmonary - rapid Subcutaneous - slow Sublingual - rapid Topical - moderate ``` Note - quicker absorption in areas with rich blood supply and absorbent membrane

Answer 7

- Dietary factors - Cardiovascular function - Gastrointestinal function - Immunological function - Liver function - Renal function - Albumin concentration - Stress - Fever - Starvation - Behavior - Alcohol intake - Tobacco or marijuana smoking - Age - Sex - Pregnancy - Lactation - Exercise - Sunlight - Barometric pressure - Disease - Infection - Occupational exposures - Psychological status - Drugs - Circadian and seasonal variations

Answer 8

Therapeutic effect - Desired response/reason drug is prescribed Therapeutic margin - Plasma concentration of a drug between therapeutic threshold and toxic levels Peak level - Highest plasma concentration of a drug Incremental doses - Multiple smaller doses given over time (Titrate to achieve desired response) - Aim is to achieve peak plasma levels within therapeutic margin within minimum effective dose and reduce potential for toxicity as well as maintain a therapeutic drug plasma level

Answer 9

Paediatric - Baby liver and kidneys are immature - All drug doses must be related to body weight (Agex3+7) Elderly - Diminished metabolism and excretion can lead to increased drug reaction Larger doses are required to reach desired concentration in larger people

Answer 10

Sex differences - Male and female drug reaction differences due to difference in size and difference in distribution of fat and water Genetic factors - Can cause abnormal sensitivity - Difference in drug metabolism Psychological factors - Influenced by way a person feels about a drug and what they believe the drug will achieve Illness/Disease - Use consult line Environmental - Temperature can effect drug activity - Elevated temp causes peripheral blood vessels to dilate therefore intensify action of vasdilators - Cold environment can cause vasoconstriction that can inhibit the action of vasodilators - Environment can influence a persons hydration status which directly influences the peak plasma levels of drugs

Answer 11

``` Right drug Right dose Right patient Right time (and frequency) Right route of administration Right to refuse (if capable) Right date (drug expiration) Right documentation Right to aseptic drug administration ```

Answer 12

- Obtain consent from patient - Exclude risk of contamination - Check drug to be given - Re-check allergy status of patient - Check packaging is in tact - Check contents as should be - Check dose - Check drug is in date - Check route of administration - Ensure drugs identified in packaging is same as in administration device - Dispose of everything safely

Answer 13

Pain is subjective - Numerical format (0-10) - Phrases (mild, moderate, severe) - Descriptive - stabbing, throbbing, sting, sharp, tight etc.

Answer 14

- Always unethical to withhold pain relief - Never be coercive with regard to pain relief - Do not treat the pain you think the patient is experiencing, treat the pain the patient is experiencing

Answer 15

Acute - Sudden onset that usually response well to management Chronic - persistent/recurrent and requires constant pain management Referred - pain felt that does not arise from point of origin Somatic - arising from skeletal muscle, ligaments, vessels or joints Superficial - abrasions, soft tissue injuries Visceral - often described as dull and aching and difficult to localize Emotional

Answer 16

Protective pain sensations - Nococeptive pain - has a purpose as it is neurological and reflexive response as a result of damage to tissue > Can cause increased BP, tachycardia, tachypnoea as it activates SNS Non-Protective pain sensations - Neuropathic pain - chronic or persistent and caused by damage to CNS or PNS

Answer 17

- Rest and reassurance - Positioning - Heat/cold - Therapeutic drug intervention - Reduction - Pressure

Answer 18

- Intesity - Onset - Aggravating factors - Relieving factors - Quality - Location - Duration - Associated symptoms (OPQRST AS-PN)

Answer 19

- Determine presence and cause of pain - Identify exacerbating co-morbitdities - Review beliefs, attitudes and expectations regarding pain - Gather information that assists and impacts an individualized treatment plan

Answer 20

``` Fentanyl Ibuprofen Lidocaine 1% Ketamine Paracetamol Morphine Sucrose 24% ```

Answer 21

Used in opiate overdose - Can cause pupil constriction - Half life is considerable shorter than heroin therefore can have rebound

Answer 22

Antiemetic for nausea and vomiting

Answer 23

Inadequate tissue perfusion/shock

Answer 24

Hypovolaemia (relative/absolute) - Inadequate circulating volume - Fluid volume loss, hemorrhage, burn, severe diarrhea and/or vomiting - Relative hypovolaemia (anaphylaxis, septic, spinal) Cardiogenic - Inadequate cardiac pump function - Dysrhythmia (electrical/mechanical), angina/AMI, poisoning, other cardiac muscle damage Distributive - Peripheral vasodilation and maldistribution of blood flow - Usually caused by acute vasodilation without concomitant increase in intravascular volume or CO Obstructive - Extra cardiac obstruction to blood flow - Caused by obstruction in CV system that reduces CO despite normal heart function and blood volume (cardiac tamponade, embolism, thrombus, tension pneumothorax)

Answer 25

Pump - Pipes - Fluid Pump problems - Problems associated with myocardium resulting in decreased pumping efficiency Pipe problems - Difficulty relating to loss of vascular tone or capabilities Fluid problems - Loss of intravascular fluid volume due to variety of reasons

Answer 26

Class 1 - Hemorrhage - Loss of up to 750mL, usually no signs or symptoms, equivalent to donating a unit of blood - Patient presents pink and adequately perfused Class 2 - Hemorrhage - Loss of 750-1500mL blood (15-30%) - Patient presents anxious and restless, mild tachycardia, BP unchanged or mild diastolic elevation, decreased urine output, mildly pale Class 3 - hemorrhage - Loss of 1500-2000mL blood (30-40%) - Patient presents as tachycardia, tachypnoea, decreased BP, CNS status dropping, decreased urine output, pale skin, mild cyanosis Class 4 - hemorrhage - Loss of over 40% - Patient presents as tachycardia, tachypnoea, narrow pulse pressure, severely shocked appearance, CNS severely depressed, ashen grey in color and severe cyanosis

Answer 27

- Arteriole vasoconstriction, resulting in redistribution of blood from skin, skeletal muscle, kidney and splanchnic viscera - Increased HR and contractility that increases CO - Constriction of venous capacitance vessels, which augments venous return - Release of vasoactive hormones epinephrine, norepinephrine, dopamine and cortisol to increase arteriolar and venous tone - Release of antidiuretic hormone and activation of the renin-angiotensin axis to enhance water and sodium conservation to maintain intravascular volume

Answer 28

- Cerebral blood flow > Vascular tone is regulated by CO2 pressure, O2 pressure and autonomic and neurohumoral control (PCO2 has greatest effect on intra-cerebral vascular diameter and subsequent resistance) - Cerebral perfusion pressure (60-100mmHg) > CPP = MAP-ICP - Intracranial pressure (0-15mmHg) > Increased ICP the ability to maintain CPP is compromised and blood flow diminished > Body compensates by increasing MAP which elevates ICP and CSF is displaced to compensate > If unresolved brain substances can herniate > Signs and symptoms include headache, nausea, vomiting, altered level of consciousness, Cushing's triad (increase systolic pressure, decreased pulse rate and irregular respiratory pattern) > See slide 86 for flow chart of process - Mean arterial pressure (85-95mmHg) > Maintained with a systolic BP of 100-120mmHg (maintain MAP to allow blood flow but minimize cerebral edema) Cerebral vasodilation occurs by increasing ICP and decreasing CPP

Answer 29

Uncontrolled hemorrhage - Give fluid to maintain perfusion status NOT to replace blood products - Radial pulse/BP 80-90mmHg - Risks include Disrupt formation of thrombus, Raise BP, Cool blood, Increase bleeding, Decreased oxygen carrying capacity Controlled hemorrhage - Administer IV fluid - Maintain BP normal for patient - Conserve body heat

Answer 30

- Capillaries lose ability to retain fluid - Extravasation - Osmotic gradient between intravascular and extravascular space is detrimentally affected - Causes edema and accumulation of vascular fluid in tissues - Physiological issues include compromised CO, systematic vascular resistance and reduced peripheral blood flow

Answer 31

``` Septic shock results in - Persistent hypotension, organ hypoperfusion despite adequate fluid intake - Tachypnoea - Tachycardia - Febrile/Frigid - Oliguria - Altered mental status - Peripheral vasodilation -Under 2 sec capillary refill - Mottled skin Fluid therapy is indicated to maintain perfusion ```

Answer 32

Diabetic ketoacidosis - Hyperglycaemic - Diagnosed through blood glucose reading - Past history include known diabetes, polyuria/polydispsia, kussmaul's respirations, pear-drop/acetate smell off breath, acidosis, dehydration/dry mucous membranes

Answer 33

``` Heat exhaustion - Orthostatic hypotension - Core body temperature - Headache - Nausea and vomiting - Loss of water and salt - Electrolyte imbalance If left untreated can lead to heat stroke ``` Treatment - Keep patient cool - Conservative use of fluids

Answer 34

Heat stroke - Classical/exertion - Altered mental status/neurological dysfunction - Core body temperature over 41 degrees - Hot, dry skin - Organ failure - Electrolyte imbalance Treatment - Effective cooling will mitigate continuing fluid loss (remove clothing, gentle fanning, aggressive/conservative fluid therapy, oxygen therapy)

Answer 35

``` Based on - Cardiac preload - Cardiac after load - Contractility To achieve a balance between systemic oxygen delivery and oxygen demand ```

Answer 36

Need to know - drops per minute - Volume to be infused - Period of time (min) - Number of drops per millimeter Formula: Drops per minute = (Volume to be infused x drop factor) / Duration of infusion (min)

Answer 37

Cell has same concentration inside and out If it becomes unbalanced use osmosis to equal out (Osmosis - molecules move from low concentration to high concentration)

Answer 38

Compare outside and inside of cell | - Hypotonic when low solute extracellularly therefore osmosis occurs to shift fluid inside cell meaning the cell swells

Answer 39

Compare outside and inside of cell - Hypertonic when high amount of solute extracellularly therefore osmosis causes water to rush out of cell meaning the cell shrinks * Fluid use very cautiously

Answer 40

Colloids - Not used by ACP - Contains protein molecules that often too large to pass through capillary membrane - Remain in vascular compartment for longer time than crystalloid solutions Crystalloids - Quick to equilibriate between vascular and extra vascular spaces - 3mL of crystalloid solution required to replace 1mL of blood (maintain BP)

Answer 41

``` Isotonic crystalloid Electrolyte replenishes Precautions - Heart failure - Renal failure - Uncontrolled hemorrhage ```