T2 - Blueprint (Josh) Flashcards
V/Q Ratio:
Avg ventilation is —
Avg perfusion is —
Which means, normal V/Q Ratio is —
V = 4 L/min
Q = 5 L/min
V/Q = 4/5 = 0.8 (more perfusion than ventilation)
What would cause a V/Q less than 0.8?
less O2 going into the the blood in lungs
- Shunting
What would cause a V/Q more than 0.8?
less blood getting into the alveoli than normal
- PE
- Cardiogenic shock
What level of shunting is abnormal?
What level of shunting is life-threatening?
greater than 10%
greater than 30%
What is the horizontal axis of the Oxyhemoglobin curve?
Vertical axis?
PaO2 (oxygen unbound and able to get to tissue)
SaO2 (oxygen bound to Hgb)
When the Oxyhemoglobin Curve shifts right, what does this mean?
Hgb gets rid of O2 more readily
- Hypercapnia
- Acidosis
- Rise in 2,3 DPG
- Fever
When the Oxyhemoglobin Curve shifts left, what does this mean?
Hgb holds on to the O2 so it doesn’t perfuse to tissue
- Alkalosis
- Low CO2
- Low temp (CoLd)
- Low 2,3 DPG
- Increased Carb. Monoxide
What are two ways to estimate shunting?
A-a Gradient (10-20 mmHg normal)
PaO2/FiO2 Measurement (normal is 286)
What does a wide A-a gradient (greater than 20 mmHg) mean?
more O2 in alveoli than in arterial blood
indicating there is a lot of shunting going on
With V/Q Mismatch, the A-a gradient is —
With Alveolar Hypoventilation, the A-a gradient is —
wide (because the O2 in alveoli isn’t perfusing well)
normal (because the Alveoli aren’t getting O2)
Is this a health lung?
PaO2 = 95
FiO2 = 50%
95 divided by 0.5 = 190
not a healthy lung function
too much shunting
normal should be 286
ABGs:
Normal PaO2
Normal PaCO2
PaO2 = 80-100 mmHg
PaCO2 = 35-45 mmHg
ABGs:
Normal Bicarb
21-28 mEq/L
- rises when acidic to buffer
ABGs:
Normal SaO2
95-100
What is a normal PETCO2?
20-40 mmHg
- Partial Pressure of End Tidal CO2
***Measures amount of expired CO2 in exhaled air
What conditions raise PETCO2?
anything that reflects inadequate gas exchange or an increase in cellular metabolism (both of which increase production of CO2)
- Hypoventilation
- Bronchial intubation
- Partial airway obstruction
- COPD
- Fever
- Increased CO and BP
What conditions lower PETOC2?
anything that reflects poor pulmonary ventilation
- PE
- Apnea
- Hypothermia
- Sedation
- Sleep
- Cooling
- Reduced CO and BP
Bronchoscopy:
NPO how long?
8 hrs prior
***assess gag reflex before allowing to drink
Bronchoscopy:
What about a fever?
mild fever around 24 hours is not uncommon
Thoracentesis:
How much can be withdrawn daily?
1000mL
Thoracentesis:
Why do we need them to deep breath post procedure?
help expand the lungs
BNC:
Rates?
FiO2?
1-6 L/min
24-44%
Simple Mask:
Rates?
min of 5 L/min
***monitor for aspiration
***no humidity
Partial Rebreather:
Rates?
FiO2?
6-11 L/min
60-75%
***1/3 Vt with each breath
Nonrebreather:
Rates?
FiO2?
12-15 L/min
greater than 90%
Aerosol Mask
Rates?
FiO2?
never less than 8 L/min
28-100%
Aerosol Mask:
What do we nee do with FiO2 amounts greater than 50%?
high flow setup
Tracheostomy Mask/Hood:
Rates?
FiO2?
never less than 8 L/min
28-100%
What is the most accurate way to deliver O2?
Venturi Mask
***ideal for CO2 retainers
How do you determine correct placement of ETT?
End-tidal CO2 detector
Auscultate x 5
Inspect chest expansion
CXR to determine depth (3-4 cm above carina)
With ETT, what pressure should cuff be?
14-20 mmHg
When suctioning ETT, what should we NEVER use?
saline
ETT Extubation Process
Hyperoxygenate first
Suction ET and Oral cavity
Rapidly deflate cuff
Remove at PEAK INSPIRATION
Instruct client to cough
Monitor q 5 mins
Trach:
How can we prevent aspiration of food?
elevate HOB at least 30 ins after eating
Trach:
How often should we turn client?
q 1-2 hrs and support out of bed activities and early ambulation
Trach:
What kind of swabs and mouthwash?
those without ETOH
Chlohexidine
Mechanical Ventilation:
What are the Modes we talked about?
AC (Assist Control)
PRVC
Synchronized Intermittent Mandatory Ventilation (SIMV)
BiPAP
CPAP
Mechanical Ventilation:
What are the Setting we talked about?
Tidal Volume (Vt)
Mniute Ventilation
I:E Ratio
Rate
FiO2
PIP (Peak Inspiratory Pressure)
CPAP
PEEP (Positive End Expiratory Pressure)
Pressure Support
Mechanical Ventilation:
How is Minute Ventilation calculated?
MV = RR x Vt
RR = 12 and Vt = 600
Then, MV = 12 x 0.6 = 7.2 L/min
Mechanical Ventilation:
What is normal I:E ratio and what would we set it at for COPD?
normal is 1:2
set at 1:4 for COPD to prevent breath stacking
Mechanical Ventilation:
Which setting provides positive pressure at end of expiration?
Which setting provides positive pressure at beginning of inspiration?
PEEP
Pressure Support
Mechanical Ventilation
Which setting augments the patients own Vt?
Pressure Support
***assists movement of air through tubing in order to augment the client’s Vt
Mechanical Ventilation:
— is the amount of pressure it takes for ventilator to deliver Vt or breath.
Number changes from breath to breath
PIP
**if increases, look for kink, biting, or mucous plug
Describe the Cardiovascular Compromise that being on a Vent can cause?
Increases intrathoracis pressure, which leads to
decreased venous return, which leads to
decreased preload, which leads to
decreased CO and BP, which leads to
tachycardia, hepatic dysfunction, renal dysfunction and impairment of cerebral venous return (ICP)
VAP:
What are some things we can do to prevent VAP?
HOB elevated 30-45 degrees
ETT w/ dorsal lumen to allow continuous suction above cuff
Oral care
Handwashing
What are included in ventilator bundles?
VAP precautions
DVT precautions
Gastric Reflux precautions
Sedation vacations
What would CSF lead look like with a nose bleed?
positive glucose test
***halo on filter paper
What should we teach regarding a Rhinoplasty?
Avoid forceful coughing/straining
Do not sneeze with mouth closed
Avoid ASA and NSAIDs
Humidifier to prevent dry mucosa
If they have neck trauma, what kind of intubation would we use?
nasal intubation so we don’t have to bend neck
Client presents with persistent unilateral ear pain and unexplained oral bleeding?
Facial, Oral, or Neck Cancer
Asthma affects the —, not the —
airways
alveoli
Asthma:
What is criteria for Mild Intermittent?
s/s less than twice a week
Asthma:
What is criteria for Mild Persistent?
s/s more than twice a week, but not daily
Asthma:
What is criteria for Moderate Persistent?
s/s daily with exacerbations twice a week
Asthma:
What is criteria for Severe Persistent?
s/s occur continually with frequent exacerbations
What Pulmonary Function Test can diagnose the severity of Asthma symptoms?
Forced Vital Capacity (FVC)
Forced Expiratory Volume in First Second (FEV1)
Peak Expiratory Flow Rate (PEFR)
Ashtma:
What decrease in FEV1 is expected with Asthma?
15-20%
Asthma:
With bronchodilators, what change can we expect in FEV1?
increase of 12%
Which corticosteroids should be taken with food?
Prednisone
Patient education for Asthma client?
Drink plenty of fluids to promote hydration
Encourage reg exercise (may require pre-medication)
Use hot water in wash to eliminate dust mites in linens
COPD is characterized by — and —-
bronchospasm
dyspnea
Etiology of COPD
Cigs
Advanced age
AAT deficiency
Exposure to air pollution
COPD:
— is an alveolar problem
— is an airway problem
Emphysema
Chronic Bronchitis
What sweat chloride test is diagnostic for CF?
60-200
***Normal is 5-35 mEq/L
How do you deal with exacerbations of CF?
Avoid mechanical vent
Supplemental O2
Heliox (50% helium; 50% O2)
Airway clearance techniques
Meds
Chest Tube Drainage System:
Which chamber should we see continuous bubbling?
Chamber 3 (Suction)
***bubbling in chamber 2 is an air leak
Chest Tube Drainage System:
Where should we keep the water line in Chamber 2?
2 cm
Chest Tube Drainage System:
What level is common in Chamber 3?
-20cm H2O
What amount of fluid intake for pneumonia to promote thinning of secretions?
2-3 L/day
Pneumonia:
What should we remember about Cephalasporins and Penicillins?
take with food
**obtain sputum culture BEFORE antibiotic therapy
Pneumonia:
What are adverse effects of glucocorticoids?
Hypokalemia
Immunusuppression
Fluid retention (weight gain)
Hyperglycemia
Poor wound healing
Flu:
How long are adults contagious?
24 hr before symptoms until about 5 days after
TB:
When is client no longer considered infectious?
after 3 negative sputum cultures
TB Meds:
Isoniazid
Take on empty stomach
Avoid ETOH due to hepatotoxicity
TB Meds:
Rifampin
Orange pee
Hepatotixic (jaundice0
Use a condom (interferes with oral contraceptives)
TB Meds:
Pyranzinamide
Drink a glass of H2O with each dose and increase fluids throughout day
Avoid ETOH due to hepatotoxicity
TB Meds:
Ethambutol
E for Eye (Vision issues)
No for children less than 13
TB Meds:
Streptomycin Sulfate
Otoxic (report ringing in ears)
ARF:
What is the hallmark sign of Type I?
hypoxemia (PaO2 less than 60)
***oxygenation problem
ARF:
Diagnostic criteria for Type I?
Diagnostic criteria for Type II?
PaO2 less than 60
PCO2 greater than 45 and pH less than 7.35
Treatment regimen for ARF?
Treat underlying cause
Assess ABGs
Correct Acidosis
Prevent complications
Nursing care of ARF?
Unilateral – good lung down
Bilateral – HOB at east 30 degrees and turn frequently
Early on with SARS, what would we see?
What about days 2-7?
early: fever, headache, bodyache, cold symptoms
days 2-7: dry cough, SOB, hypoxia with cyanosis
ARDS:
What is mild?
PaO2/FiO2 of 201-300 with CPAP of 5 cm or greater
ARDS:
What is Moderate?
PaO2/FiO2 of 101-200 with CPAP of 5cm or greater
ARDS:
What is Severe?
PaO2/FiO2 of 100 or less with CPAP of 5 cm or greater
Difference between Pneumonia and ARDS?
pneumonia is at one site
ARDS is diffuse throughout whole lung
What will CXR look like with ARDS?
white out
What are the Phases of ARDS?
Exudate Phase
Fibroproliferative Phase
Resolution Phase
Chronic ARDS Phase
ARDS:
What is the FiO2 goal?
SaO2 of 90% with FiO2 less than 65%
ARDS:
What do you do with the I:E Ratio?
inverse it so that inspiration is longer than expiration
***requires a neuromuscular block
Which lung disease will we use the crazy rolling bed?
ARDS
ARDS:
Why would you allow some hypercapnia?
reduces atelectrauma and baratrauma
ARDS:
Which modes on Vent would be used?
AC (to give lungs a rest)
Pressure Control for worsening ARDS to reduce volutrauma)
ARDS:
Why use the PEEP mode?
What complications can this cause?
recruits collapsed alveoli to decrease pulmonary shunting
can cause barotrauma b/c increased pressure can decrease venous return
Diagnostic criteria for Type II DM?
A1c of 6.5% (normal is 4-6)
Fasting BS greater than 126
2 hr BS greater than 200
Casual BS greater than 200
Describe the Somogyi Effect and how to prevent?
tendency of body to respond to hypoglycemia by rebounding with severe hyperglycemia
usually in sleep hours
prevent by taking midnight snack before bed
To prevent kidney damage from DM, how much fluid should we encourage?
2-3 L/day
no sodas or ETOH excess
Oral Glycemics:
What should we remember about Metformin?
Farts (GI effects)
- take with food
- never crush or chew
Lactic Acidosis
Hold 48 hrs before dye procedure
Oral Glycemics:
What should we remember about Sulfoylureas (Glip, Glim, Glyb)?
Monitor for hypoglycemia
Take 30 mins before meals
Avoid ETOH (disulifram)
Oral Glycemics:
Which class of medications can mask the tachycardia caused by hypoglycemia, a side effect of oral glycemics?
Beta Blockers
Oral Glycemics:
Which med requires that you monitor the A1c every 3 months?
Repaglinide
Oral Glycemics:
Take —- 15-30 mins before meals.
Repaglinide
Oral Glycemics:
What do we do if we miss a dose with Repaglinide?
skip it
Oral Glycemics:
Which one can make you gain weight (fluid) and effect Oral Contraceptives?
Pioglitazine
Oral Glycemics:
Which one requires you to keep dextrose paste on hand in case you have a hypoglycemic episode?
Acarbose
Miglitol
Oral Glycemics:
Which one do you take with the first bite of each meal?
Ararbose
Miglitol
Oral Glycemics:
Which ones are subQ?
Exenatide (before morning/evening meals)
Pramlinitide (before major meals)
Oral Glycemics:
Hold — if A1c is greater than 9%.
Pramlinitide (subq)
How many carbs do you give with mild hypoglycemia (less than 60)?
Moderate hypo (less than 40)?
Mild = 10-15 g
Moderate = 15-30 g
What can we give that is 15 g of carbs if they are facing mild hypoglycemia?
4 oz fruit juice or soft drink (not diet)
8 oz nonfat or 1% milk
3-4 glucose tablets
8-10 hard candies
1 T of honey, sugar, or corn syrup
If they are unconcious and cannot take PO 15 g or carbs, what can we do?
25-50 mL of D50W IV push
…or…
Glucagon 1 mg IM or SQ
Rehydration protocol for DKA?
First hr: 15-20 mL/kg/hr or NS (isotonic)
Then: 1/2 NS (hypotonic) at 4-14 mL/kg/hr
Rehydration protocol for HHS?
1 L of NS until BP stable
then, 1/2 NS at 100-200 mL/hr
HHS:
What level of osmolality will we see?
greater than 320 mOsm/kg
normal is 280
Metabolic Syndrome:
What is the Abdominal Obesity criteria?
Men: greater than 40 in
Women: greater than 35 in
Metabolic Syndrome:
What is the Hyperglycemia criteria?
Fasting BS of 100 or more
…or…
on treatment for elevated glucose
…or…
Abnormal A1c (5.5-6.0)
Metabolic Syndrome:
What is the HTN criteria?
130/85 or greater
…or…
on treatment for HTN
Metabolic Syndrome:
What is Hyperlipidemia criteria?
Triglycerides greater than 150
HDL greater than 40 in men or 50 in women
