TEST 2 Flashcards
What is the neurochemical control of ventilation?
Respiratory center
Central and peripheral chemoreceptors
What are the mechanics of breathing?
Major and accessory muscles
Lung elasticity
AIrway resistance
Alveolar surface tension
Work of breathing
What is Gas Transport for breathing
Distribution of ventilation and perfusion
Oxygen transport
Carbon dioxide transport
What is control of pulmonary circulation
Distribution of pulmonary blood flow
What is negative pressure breathing
Air moves from higher pressure to lower pressure
During inspiration: Diaphram and intercostal muscles contract expanding lungs. This creates an increase in volume and a decrease in pressure causing outside air to flow in
Hypoxemia
Low levels of 02 in blood
Hypoxia
Decreased tissue oxygenation
How many liters can a nasal cannula give
2-6L
After 4 make sure it is humidified
How many liters can a simple face mask give?
6-10L
How many liters can a non-rebreather give?
10-15L
**
Difference between a partial and full non-rebreather?
Partial - No one-way valves, allows patient to rebreathe some exhaled air which mixed with fresh oxygen, typically delivers 40-70% oxygen
**Non-rebreather **- one-way valves which prevent patient from inhaling exhaled air, delivering only fresh oxygen 60-100%
What is a venturi mask?
O2 concentration ranging from?
Which allows?
Adjustable oxygen concentration - typically ranging from 24-60%
Mixes fresh 02 with room air in precise ratios allowing for accurate control of Fio2**
CPAP
Continuous Positive Airway Pressure
*primarily used for?
Provides 1 continuous pressure level into airway to keep it open during inspiration and expiration / Patient must be able to breathe independently
*Primarily used for Sleep apnea
**Goal is to prevent airway collapse and maintain regular breathing patterns
BiPap
Bilevel Positive Airway Pressure
*commonly used for?
2 levels of pressure - one for inhalation and a lower pressure for exhalation
The pressure changes between inhalation and exhalation
*Commonly used for COPD, central sleep apnea or resp failure
**Goal to assist both with inhaling more effectively and reducing effort required to exhale
Define Ventilator Modes
How many breathes are delivered to the patient.
Many different modes
A/C Assist Control or CMV Continuous mandatory ventilation
Delivers a preset tidal volume or pressure at a preset rate of respirations
Every breath is the preset volume whether initiated by patient or machine
*pts who need total assistance from vent
SIMV
Synchronized intermittent mandatory ventilation
Delivers preset tidal and # of breaths per min
Patient can also breath spontaneously with no assistance from vent
*Pt doesnt need as much assistance from ventilator
In what ways can a patient be weaned off ventilator?
CPAP
SIMV - rate slowly decreased
Tidal volume
Vents give?
Amount of air delivered with each breath
Vents 10-15Ml/kg of body weight
Fi02
Fraction of inspirated oxygen concentration / % of oxygen delivered to pt
Normal 21% / on vent close to 30%
PEEP
Positive End Expiratory Pressure
Like keeping a small amount of air in lungs to prevent them from collapsing after breathing out
Pneumothorax
What to do?
Open-
Closed-
OPEN - Cover it immediately w/ occulsive dressing go to surgery or chest tube insertion
CLOSED - CHEST TUBE!
-Chest tubes are removed when lung is expanded (2-10days) or fluid is removed (3-4 days)
Hemothorax
Blood accumulation between chest wall and lung; often associated with pneumothorax
Same treatment as pneumothorax - maybe surgery to control bleeding
Empyema?
S/S
Treatment
Pus collected in pleural space
*Fever, chest pain, cough, SOB
Chest tube, surgery, antibiotics
Steps for chest tube removal?
Tell pt to take deep breath IN and bear down slightly on inspiration. so no air enters the pleural space
Hemopneumothorax
Both blood and air in chest cavity
Open pneumothorax
wound is large enough to allow air to pass freely in and out of thoracic cavity with each attempted respiration. “Sucking chest wounds”
*Lungs collapse, heart and vessels shift toward noninjured side with each inspiration and opposite side with each expiration “mediastinal flutter or swing” causes major circulatory problems
Nursing assessment of pneumothorax
Simple - Trachea midline, expansion of chest is decreased, breath sounds diminished, percussion may reveal normal or hyperresonance
Tension - trachea is shifted away from affected side, Chest expansion increased or decreased, breath sounds diminished, percussion on affected side is hyperresonant
Small chest tube is inserted where?
Large?
Suction?
Small - 28 french, 2nd intercostal space
Large - 32 french, 4th or 5th intercostal at midaxillary line
Suction - 20mmHg
When is a thoracotomy performed?
If more than 1500 ML blood aspirated by thoracentesis or chest tube output is greater than 200mL/H
ARDS classification
MILD
MODERATE
SEVERE
Mild - Pa02/FIO2 >200mmHg but <=300nnHg
Moderate - Pa02/FIO2 - >100mmHg but <=200mmHg
Severe = Pa02/FIO2 - <=100mmHg
BNP level is helpful in distinguishing ARDS from
Cardiogenic pulmonary edema
What could be some causes of ARDS?
Trauma
Pulm infection
Prolonged cardiopulmonary bypass
Shock
Fat emboli
Sepsis
What are ABGS for ARDS
Decreased P02 increased dyspnea
*pt not getting better even with higher FIO2
If the rhythm starts with a P wave then its?
Sinus
Inappropriate sinus tachycardia?
Enhanced automaticity of SA node or excessive sympathetic tone with reduces parasympathetic tone that is out of porportion to physiologic demands
What is POTS
Postural Orthostatic Tachycardia Syndrome
Tachycardia without hypotension and by presyncopal symptoms such as palpitations, lightheadedness, weakness and blurred vision that occur with sudden postural changes
AFIB Classification
Paroxysmal
Sudden onset w/ termination that occurs spontaneously or after treatment
Last less than 7 days but may reoccur
AFIB Classification
Persistent
Long-standing persistent
Permanent
Nonvalvular
Persistent - Lasting more than 7 days
**Long-standing persistent ** - Lasting more than 12 mo
Permanent - Persistent, but decision made not to restore sinus rhythm
Nonvalvular- Absence of mod-severe mitral stenosis or mechanical heart valve
Preload
Define
Increased in:
Amount of blood remaining in ventricles at end of diastole.
*degree of stretch the heart muscle fibers at end of diastole
Increased in: hypervolemia, regurgitation of cardiac valves, heart failure
Afterload
Define
Increased in
Resistance or pressure that the heart muscle must overcome to eject blood from ventricles during systole (contraction)
*The force that the ventricles need to generate to push blood into circulation
Increased in: Hypertension, vasoconstriction
Contractility
Factors affecting?
Intrinsic ability of the heart muscle to contract, independent of preload and afterload
Factors affecting: Symoathetic nervous system, Inotropic agents, Oxygen supply
How much 02 does the myocardium need?
70-75% of what is delivered by coronary arteries
Echocardiogram
Apical 4 chamber view / front of heart
Visualizes structure, looks at valves and can get ejection fraction
ETT
More invasive than echocardiogram
Looks at back of heart
Stress test
What are they looking for?
What do they give?
CAD
Thallium - it does not enter infarcted or scared areas
CBK
Troponin
biomarker to diagnose heart damage
CPK - Elevated, suggest cardiac muscle damage. Rise 4-6hrs after & return to normal 48-72hrs
Troponin - Proteins specific to cardiac muscle. Elevate when injury or stress to heart. Rise within 3-4 hours and may remain elevated 1-2weeks
CPK can also be found in skeletal muscles and brain and troponin is highly specific to heart.
In cardioversion what wave are we trying to synchronize?
R wave
What is CABG?
Surgical procedure taking a blood vessel from another part of the body (leg or chest) and grafting it to bypass the blocked coronary artery
Colladeral circulation
as we age we develop ‘Shunts” away from the blockage in heart to continue to get blood flow
Not in younger patients
What would we ask in patients with heart issues?
P
Q
R
S
T
P - What were they doing?
Q - How does it feel?
R - Where does pain go
S - 1-10
T- How long has this been going on?
Unstable angina
The patient has clinical manifestations of coronary ischemia but ECG and biomarkers show no evidence of MI
STEMI
ECG evidence of acute MI with characteristics changes in two contiguous leads on a 12 lead ECG. There is significant damage to myocardium
NSTEMI
Elevated cardiac biomarkers but no definite ECG evidence of acute MT. May be less damage
What does it mean when ECG shows inverted T wave
ISCHEMIA
INJURY
INFARCTION
Acute inferior MI
How much Aspirin would you give if a pt comes in for MI
325mg
What is happening in the P wave? QRS? T?
P wave - atrial depolarization / Atrial contraction
QRS - Ventricle depolariztion / ventricle contraction
T - Ventricle repolarization /
Difference between synchronized cardioversion vs defibrillation?
Synchronized - hit on R wave, Done when they have a pulse
Afib, pSVT, Vtach, –less life threatening confitions
Defibrillation - Delivered immediately without syndronizing to hearts rhythm
Life threatening arrhythmias that can lead to sudden cardiac arrest
Vent fib, Pulseless vent tach, Torsades de pointes
what do hormones do?
Fluid and electrolyte balance
Host defenses
Response to injury and stress
Energy metabolism
Growth and development
Reproduction
Hormones are apart of what system
Endocrine
What is antidiuretic hormone?
Aka vasopressin
Produced by hypothalamus and released by post pit
Role: Regulating water balance / retain fluids
Maintainin blood pressure, fluid balance, blood volume
What two disorders happen from issues with ADH?
Diabetes insipidus
Syndrome of inappropriate antidiuretic hormone secretion
What is the process of SIADH to water intox?
ADH elevated
Kidneys retain water / plasma volume expands
BP rises
Body sodium diluted
Water intox!
Differences between ICP and Shock
ICP
BP -up
PULSE - down
RESP - down
SHOCK
BP -down
PULSE -up
RESP- up
What is occipital lobe responsible for?
Analyzes visual input
Helps recognize objects, faces, written
Depth perception
Stores info and helps with recognition
What is Temporal lobe responsible for?
Process sounds - speech, music, environmental noise
**Language comprehension **- Wernickes area (understanding spoken/written)
**Memory formation **-
Emotional processing
Recognition - faces, objects, scenes, visual memory
What is frontal lobe responsible for?
Decision making, problem solving, planning, reasoning, judgement
Motor control
Speech production - Broca’s area (speech production)
Personality
Attention/focus
Short term memory functions
What is parietal lobe responsible for?
sensory perception (touch, temp, pain, pressure)
Depth perception, hand-eye
Sense of body position and mvmt
Mathematical and analytical skills
Language processing
Autoregulation
brains ability to change the diameter of its blood vesssels to maintain constant cerebral blood flow during alterations in systemic blood pressure
EPIDURAL - above dura mater, between skull and dura mater
SUBDURAL - Between dura mater and brain
What does CSF do?
Acts as shock absorber to brain and spinal cord
Bathes neurons
Decreases when brain tissue or blood flow increases to compensate
What % of brain is
CSF
Intravascular blood
Brain tissue
CSF - 10%
Intravascular blood - 12%
Brain tissue - 78%
Any increase is ICP
Super ventricular
Epidural
Subdural
Super ventricular - nost accurate, highest rate of infection
Epidural - least invasive, least accurate
Subdural - Decreased accuracy at high pressures
What is formular for CPP?
Ideal number?>
No autoregulation between?
Cerebral perfusion pressure = MAP-ICP
Ideally 70-80
We dont get autoregulation when ICP falls below 50 or above 150
What is Cushings triad?
Icreased in BP
Bradycardia
irregular Respiratory
+Some add Wide pulse pressure
*this is a LATE sign
What is Decorticate posturing
Decerebrate
Pressure where?
Decorticate - pressure on cortical structures. Towards core
Decerebrate - Pressure on cerebellum. at sides
If someone has complete spinal cord damage what are symptoms?
Total loss of motor, sensory and reflex activity below area of damage
Relay activity
Signal goes up spinal cord, information is processed and impulses down decending tracts to signal movement
RESPIRATORY IMPAIRMENT in spinal injuries
Injury at or above C5 may result in instant death
Below C4 spare diaphragm but can involve impairment of intercostal and abdominal muscles
Spinal Shock
Temporary - sympathetic function impaired. Parasympathetic take over
Hypoxia, hypotension, bradycardia, temp flucations
Vasodilation, venous pooling, decreased C/o, loss of reflexes and sensation
*Could mask the extent of injury. This is caused by swelling.
Sign its over: get reflexes back
Side effects of Nitro
Headache, Flushing, dizziness
Postural hypotension, tachycardia, collapse, palpitations
Nausea, vomit,
Pallor, sweating, rash
NEVER TAKE WITH VIAGRA
GCS - What does score mean?
15
9-12
8
3
15 - Good
9-12 - Maybe hospitalization, freq orientation
8 = intubate and ventilation
3 = Severe TBI. Must be kept artificially alive
