Test 2: Respiratory Flashcards
What is pneumonia?
An inflammatory process in the lungs caused by bacteria, viruses, toxins, or aspiration
Why is the color of sputum white in pneumonia?
Due to leukocytes
What is considered community-based pneumonia?
Pneumonia acquired in the community or diagnosed within 24 hours
What are the risk factors for pneumonia?
-Immobility (#1)
-Age
-Immunocompromise
-Co-morbidity/chronic conditions
-Respiratory Infections
-Conditions that increase the risk for aspiration/impaired ability to mobilize secretions
-Substance misuse
-Mechanical ventilation
-Damage to lungs
What are the SSAs for Pneumonia?
-Adventitious breath sounds: crackles, wheezes
-Decreased breath sounds/dull of percussion
-Productive cough
-Chills
-Flushed Face
-Tachypnea/SOB/difficulty breathing
-Pleuritic sharp chest pain
-Decreasing SpO2 (<92%)
What are the labs and diagnostics for pneumonia?
Increasing WBC (may be normal in elderly)
ABG: Decrease in PaO2<80mmHg
CXR: Consolidation (white areas are signs of consolidations
Check lactate and blood cultures (for signs of sepsis)
What are the first-do priorities assessments for pneumonia?
VS(increased RR, Temp and SpO2)
Lung Sounds
Periods of respiratory distress
Skin breakdown around nose & mouth from O2 delivery devices
What are the first do tasks for pneumonia?
Apply Supplemental O2
Position in high fowlers
Obtain sputum culture prior to abx
Encourage DB&C, IS
Ensure fluid intake is 2-3L
Administer IV antibiotics
Ensure adequate nutrition
Why is ensuring adequate nutrition important in patients with pneumonia?
Adequate nutrition is important to maintain the nitrogen balance because the auxiliary use of muscles for breathing increases metabolic demand
Why do patients with pneumonia need vitamin C?
Vitamin C helps the breakdown of catecholamines (norepinephrine and epinephrine)
What are the two Floroquinolones used to treat pneumonia?
Levofloxacin
Moxifoxacin
What are the nursing consideration for Floroquinolones?
-GI: N/V/D, abdominal pain
-Dizziness, insomnia, HA, CNS sx
-QT prolongation
-Black box warning: tendon rupture
What are the macrolides used to treat pneumonia?
Azithromycin
Clarthromycin
What are the nursing considerations for macrolides?
-GI: N/V/D, abdominal pain
-Take with food to decrease GI upset
What are the tetracyclines used to treat pneumonia?
Doxycycline
Minocycline
What are the nursing considerations for tetracyclines?
-GI: N/V/D, abdominal pain
-Avoid iron supplements, multivitamins, calcium or antiacids
-Photosensitivity
-Discoloration of teeth in fetuses and children
What are the nursing considerations for penicillin?
-GI: N/D, dyspepsia
-Verify all allergies & monitor for hypersensitivity
-Monitor for candidiasis infections
What are the immunizations for pneumonia?
PCV13
PPSV23
Influenza
COVID-19
Who is able to receive the immunizations for pneumonia?
Adults 65+ and those with chronic health problems
What are the expected outcomes for the treatment of pneumonia?
SpO2:
WBC:
Breathing:
Hormones:
SpO2: >94% on room air
WBC: 3.7-11K/uL
Breathing: No adventitious breath sounds without tachypnea or pleuritic chest pain
Circulation: No tachycardia
Hormones: No presence of lactate or procalcitionin
What are the possible complications of pneumonia?
Sepsis
ARDS
Bilateral Edema
Need for ventilation
Hypercarbia
What are the techniques for mobilizing chest secretions?
Ambulation
Deep breathing & coughing
Incentive spirometry
Hydration (fluid thins mucous)
What is a pulmonary embolism?
Any substance (solid, liquid, air) that enters venous circulation and lodges in the pulmonary vessels
What is the most common type of pulmonary embolism?
A PE that originates as an embolus that breaks off from a DVT and travels as an embolus into pulmonary circulation
What 3 things can occur as a result of pulmonary vascular occlusion?
Impaired gas exchange
Pulmonary tissue ischemia and infarction
Increase in pulmonary vascular resistance -> acute right heart failure
What lab values will you see for a pulmonary embolism?
ABG: decreased PaO2
Increased D-dimer
Troponin, BNP
What is one of the biggest signs of a PE?
A feeling of impending doom
What are the important risk factors for a PE?
OCPs and Estrogen tx
Prolonged immobilization
Surgery
Pregnancy
Obesity
Tobacco Use
Coagulation disorders
Anything that participates in Virchow’s triad
What is Virchow’s Triad?
Venous Stasis
Endothelial injury
Hypercoagulability
How often should you be assessing respiratory and cardiac status for a patient suspected of a PE?
Q15-30 minutes
What priority actions should you take for a pt suspected of a PE?
Administer supplemental O2
Place pt in High-fowlers position
Administer medications per order
What are the categories of medication used to treat a PE?
Anticoagulants
Direct Factor Xa Inhibitors
Thrombolytics
Pulmonary Embolism Medications:
What are some examples of anticoagulants?
Warfain
Heparin
What labs should you be checking for Warfarin?
pT
INR
What labs should you be checking for heparin?
pTT
CBC (to monitor for internal bleeding and heparin-induced thrombocytopenia)
Pulmonary Embolism Medications:
What are examples of direct factor Xa inhibitors?
Rivaroxaban
Apixaban
Pulmonary Embolism Medications:
What is the thrombolytic given and when is it contraindicated?
Alteplace
Contraindicated in pregnancy, clotting disorders and recent surgeries
What patient education should you be giving for warfarin?
Make sure the patient knows to maintain a stable vitamin K intake and the need for frequent INR monitoring
What are the indications for intubation?
Respiratory failure or insufficiency
Protection of compromised airway
Prevention of aspiration
Need to provide FiO2 >60% for long periods of time
What are some examples of respiratory failure or insufficiency that would lead to intubation?
Hypoxemic Respiratory Failure (SpO2<60)
Hypercapnic Respiratory Failure (PaCO2 >50)
What are some examples of intubation to protect a compromised airway?
Trauma, swelling, obstruction, copious secretions or inhalation of toxic substances
Would a patient with heart failure require intubation?
No, these patients are on biPAPs and do not need to be intubated to prevent aspiration
What are the steps in Rapid Sequence Intubation?
Hyperoxygenate with BVM -> induction agent (sedative) ->paralytic agent -> ETT placed after 60 seconds of paralytic
What supplies are needed for rapid sequence intubation?
ETT with stylet
10cc syringe
Laryngoscope handle and blade
ETCO2 detector (or capnography setup)
What pressure should the ETT cuff be inflated to?
Pressure of 20 to 30cm H2O
What are the RN tasks before intubation?
Ensure suction is set up and working
BVM size appropriate
Glidescope if requested (video-assisted laryngoscope)
Patient prepped with IV access, continuous monitoring and pulse oximetry
What are the RN assessments before intubation?
Allergies to anesthesia (or previous adverse rxns)
VS, Cardiac Rhythm
Lung sounds to establish baseline `
Patients cannot be weaned from a ventilator if:
They cannot establish a proper LOC
HR increases by 20bpm
RR increases by 10bpm
Systolic BP decreases 20mmHg
Pt becomes diaphoretic (indicating work of breathing is too hard)
What are the 3 methods for weaning patients off a ventilator?
T-Piece
Synchronized intermittent mandatory ventilation
Pressure support trials
On an end-tidal CO2 detector, what occurs when the purple turns to yellow?
When the purple turns to yellow, CO2 is present
What is the normal pressure of CO2 for a mechanically ventilated patient?
35-45 mmHg
What is tidal volume?
Volume of air delivered to the patient with each machine breath
What is the volume of normal tidal volume?
6-10mL/kg
The rate of the ventilator is…?
The number of breaths per minute delivered by the ventilator
What is the normal rate of a ventilator?
10-14 bpm
What is FiO2?
The amount of oxygen delivered to the patient
What is PEEP?
Positive end pressure
The positive pressure applied at the end of expiration
What can PEEP be used for?
PEEP can be used to increase functional residual capacity and improve overall oxygenation
What is ventilator sensitivity?
Sensitivity determines the amount of effort the patient must generate to trigger a breath from the ventilator
What is the I:E ratio for a ventilator?
The I:E ratio is the ratio that determines the length (or duration) of inspiration to the length of expiration
What is the flow rate of a ventilator?
How fast each breath is delivered by the ventilator
What assessments should you complete for a mechanically ventilated patient?
Ability to speak (if they can, the cuff is not properly inflated)
Placement of ET markings (cm)
Mucous membranes for color and dryness
ABGS
Capnography readings
Respiratory Status
What tasks should you be completing for a mechanically ventilated patient?
Oral care q2 hr/PRN
Suction Q2-4 and PRN
Verify alarm settings correct and on at all times
Soft wrist restraints or sitter
Reposition Q2 hours for lung expansion and drainage
Verify emergency equipment at bedside
Verify and document vent settings hourly
What should the RN be concerned about regarding nutrition for the mechanically ventilated patient?
Nitrogen balance->notify provider without nutrition for 48 hours (going to consume stores)
Raise HOB 30 degrees to prevent aspiration
Verify residuals Q4hrs
Hold tube feeding when moving
What conditions are medications going to be given prophylactically in the mechanically ventilated patient?
DVT
Peptic ulcer disease (Esp when giving anticoagulants)
What do high pressure alarms indicate?
Secretions
Bronchospasm
Pneumothorax
Displaced Tube
Blocked with water
Kinked tubing
Pt ‘fighting’ vent (normally biting)
What do low pressure alarms indicate?
Disconnection
Pt stops spontaneously breathing
Cuff leak
What does DOPE stand for>
Dislodged or displaced tube
Obstructed tube (secretions, mucous plug, kink)
Pneumothorax
Equipment failure
What is a VAP bundle?
Ventilator-Associated Pneumonia Bundle
What is included in a VAP bundle?
Elevate HOB 30-45 Degrees
Daily “sedation vacations”
Assessment of readiness to wean/extubate
Venous thromboembolism prophylaxis
Sterile Suctioning technique
Mouth Care q2/PRN (with chlorhexidine)
Meticulous hand hygiene
What assessments should you perform for ventilator safety?
Skin Breakdown/Irritation around ETT holder/tape
Depth of tube using markings at teeth or lips
Stability of tube with tube holder or tape
Cuff at the right pressure
Avoiding excess pressure while suctioning
Ensuring ventilator tubing is supported
What are some of the complications of a ventilator?
Barotrauma
Fluid retention
Oxygen Toxicity
Hemodynamic Compromise
Aspiration
VAP
What is a tracheotomy?
Surgical incision into trachea to create an airway to maintain gas exchange
What is a tracheostomy?
Opening/Stoma
What types of air can a tracheotomy be used with?
Room Air
Mechanical Ventilation
Trach collar with humidified oxygen
What does COAST stand for?
C: Another Cannula
O: Obtorator
A: Airway maintenance (bag valve mask)
S: Suction
T: Trach tube placement
What is conscious sedation?
Administration of sedatives to obtain a level of relaxation in a client so that minor procedures can be performed without discomfort but airway is maintained by patient
What type of sedation does a patient experience a decrease in LOC but can respond, is arousable, and retains their gag reflex?
Conscious sedation
What equipment should be at the bedside when a patient is under conscious sedation?
Crash cart
RSI box
Ambu bag
Suction
O2
What is the RN monitoring during conscious sedation?
Telemetry
Pulse Oximetry
Capnography
What are the common meds used for conscious sedation?
Benzodiazepines: Midazolam, lorazepam, diasepam
Opioids: Fentanyl, morphine, hydropmorphone
Anesthetics: Propofol, Ketamine
What are some of the indications for conscious sedation?
Endoscopy, lumbar puncture, cardioversion
Painful dressing changes, incision & drainage of abscesses
Burn debridement
Reduction/immobilization of fractures or dislocations
Minor surgical procedures
Removal of implanted devices and tubes
Bone marrow aspiration
What should the RN assess for prior to conscious sedation?
Allergies/prior experience with conscious sedation/anesthesia
Full baseline assessment of VS, cardiac rhythm, heart and lung sounds, LOC
How long should a patient generally be NPO before conscious sedation>
normally NPO for around 4 hours
What are the RN assessments post-procedure?
Q5 minutes during
Q15 post procedure until Aldrete Score
LOC
VS
SpO2
ETO2
Cardiac Rhythm
Lips and mucous membrane color
Ensure on supplemental O2
Ensure deep breathing and coughing
What are complications of conscious sedation?
Respiratory Depression
Cardiac Dysrhythmias
Hypotension
Aspiration
Airway Obstruction
Progression to deep sedation that requires intubation
What are the two types of respiratory failure?
Hypoxemic Normocapnia
Hypoxemic Hypercapnia
What type of failure is Hypoxemic Normocapnia?
Oxygenation failure
Normally fluid filling or collapse of alveoli
What are the ABG signs of Hypoxemic Normocapnia respiratory failure?
Decreased PaO2 and normal PaCO2
What type of failure is Hypoxemic Hypercapnia?
Ventilatory Failure caused by insufficient carbon dioxide removal that may be corrected by O2 administration
What type of CNS abnormalities can cause Hypoxemic Hypercapnia respiratory failure?
Overdose of respiratory depressant drug
High level spinal cord injuries
Traumatic brain injuries
Limited nerve supply to the respiratory muscles
What type of Chest wall abnormalities can cause Hypoxemic Hypercapnia respiratory failure?
Flail Chest
Kyphoscolosis
Severe obesity
What type of neuromuscular disorders can cause Hypoxemic Hypercapnia respiratory failure?
Guillian-Barre
Muscular dystrophy
Myasthenia Gravis
Multiple Sclerosis
What are the 4 main pathological mechanisms in respiratory failure?
V/Q mismatch
Alveolar Hypoventilation
Diffusion Limitation
Shunting/Intrapulmonary Shin
What are the SSAs of Respiratory failure indicating cerebral hypoxemia?
Restlessness
Confusion
Combative Behavior
What are the SSAs of Respiratory failure indicating hypercapnia?
Morning Headache
Slower respiratory rate
Decreased LOC
What are the SSAs of Respiratory failure indicating acidosis?
Chest pain
Cardiac Dysrhythmias
If prolonged, kidney and cerebral damage
What are the SSAs of Respiratory failure indicating Respiratory Distress?
Tachypnea (rapid breathing)
Retraction
Use of accessory muscles
Paradoxical breathing
Change from tachypnea to bradypnea
What is the pathway of ARDS?
Massive system inflammatory response-> Injury and increased permeability of the alveolar-capillary membrane->fluid movement into interstitial and alveolar spaces -> hyaline membrane formation -> decreased surfactant -> decrease pulmonary compliance->Impaired gas exchange->Acute respiratory failure t
What is a ‘stand out’ SSA for ARDS?
Refractory hypoxemia-dropping SpO2 in the presence of FiO2 100%``
ARDS:
What are the ABG findings?
PaO2
PaCO2
pH
PaO2: <60mmHg
PaCO2: >45mmHg
pHL <7.35 with SpO2 <90
What are the early manifestations of ARDS?
Dyspnea with use of accessory muscles
Tachypnea
Restlessness
Normal Breath Sounds-Fine scattered crackles
Respiratory Alkalosis
CXR normal or minimal scattered infiltrates
What are the Progressive manifestations of ARDS?
Increased WOB
Intercoastal Retractions
Tachypnea
Diaphoresis
Cyanosis/Pallor
Change in mental status
Diffuse crackles and Ronchi
CXR-extensive and dense bilateral infiltrates
Reduced lung compliance
Profound Dyspnea and refractory hypoxia
What is the treatment for refractory hypoxia?
Mechanical Ventilation
What are the first do priorities for ARDS for oxygenation?
Titrate supplemental O2 to maintain PaO2>60mmHg
Monitor H&H, promote nutrition (to maintain H&H)
Give fluids to enhance preload
Keep BP stable to maintain afterload
Monitor for tissue hypoxia
What are the first do priorities for ARDS for Alveolar ventilation improvement?
Chest percussion/positioning/suctioning/proning to mobilize secretions
Give bronchodilators to relieve bronchospasms
Conservation of fluids and administration of diuretics to improve pulmonary edema
Increase positive and expiratory pressure (PEEP) on mechanical ventilation
What is the drug therapy for ARDS?
Bronchiodilators
Mucolytics
Exogenous Surfactants
Corticosteroids, ketoconazole
Sedation then neuromuscular blockage
What are the signs of oxygen toxicity?
Stuffy nose
N/V
HA
What are the expected ABG findings for successful treatment of ARDS?
PaO2>80mmHg on RA
PaCo2>35-45mmHg
pH 7.35-7.45
SpO2 >94%
What are the respiratory complications of ARDS?
Oxygen Toxicity
Barotrauma from positive pressure ventilation
Tension Pneumothorax from high PEEP settings
Tracheomalacia
What are the cardiovascular complications of ARDS?
Dysrhythmias
Decreased CO from high intrathoracic pressure (fluid retention and poor renal perfusion)
What are the GI complications from ARDS?
Paralytic Ileus
Peptic Ulcer Formation
What are the renal complications from ARDS?
AKI
What are the hematological and immunologic complications from ARDS?
DIC
Anemia
VTE
Infections like VAP, CLABSI, CAUTI, sepsis
What are the systemic complications of ARDS?
Delirum
Deconditioning from immobilization
MODS and death
A hemothorax is?
Blood in the plural space between the parietal pleura and visceral pleura
What are the steps of a pnemothorax?
Air becomes collected between the visceral and parietal pleura->loss of negative pressure->collapsed lung
What are the steps of a tension penumothorax?
Air in pleural space that cannot escape->increase in pleural space->increased pressure in thoracic cavity-> life-threatening mediastinal shift->respiratory and cardiac compromise
A mediastinal shift of the trachea to the unaffected side indicates a?
Tension pneumothorax
What is a spontaneous pneumothorax?
a PTX with no precipitating factor, but commonly is the rupture of a small subpleural emphysematous vesicle
When does a spontaneous pneumothorax normally occur?
Many times it occurs in the middle of the night or during exercise
What is a pleural effusion?
Accumulation of exudate in the pleural space
What are the two common causes of pleural effusion?
Lupus
Cancer if it comes out of nowwhere
What is Empyema?
Purulent drainage in the pleural space from pulmonary infection, lung abscess or infected pleural effusion
What are the SSAs for percussion for a pneumothorax?
Hyperresonance (hollow sounds like a drum) on percussion of the affected side due to air in the pleural space
What are the SSAs for percussion for a hemothorax or pleural effusion?
dullness or flatness on percussion of affected side
What are te SSAs for HTX/PTX?
Tachypnea
Tachycardia
Dyspnea
Sudden, sharp pleuritic pain on the affected side
Coughing
Diminished/Absent breath sounds on affected side
Restlessness
Anxiety
Subcutaneous emphysema (rice crispy popping)
PaO2<80mmHg
White density where lung has shrunken on CXR
What are first do priority assessments for HTX/PTX?
Heart/Lung sounds
VS
SpO2
Pain levels/meds for pulmonary hygiene
Assessments for Chest tube
What amount of continuous chest tube drainage is alarming and should warrant an immediate call to a provider?
> 70mL output from chest tube
What are the first do priority tasks for HTX/PTX?
Titrate O2 to maintain SpO2>94%
Daily CXR
DB&C
Incentive Spirometry
Turning/Ambulation
Encourage fluids
What are the positional differences for HTX and PTX?
HTX: High-fowlers
PTX: Semi-fowlers
What’s the difference in chest tube placement between a HTX and PTX
For a PTX, the chest tube will be inserted higher
What is the first area of a chest tube drainage system for?
For the drainage from the patient and should be under <70mL
What is the second area of a chest tube drainage system for?
The waterseal chamber that is REQUIRED to have at least 2cm of water
What is the third area of a chest tube drainage system for
traditionally used for water suction (prescribed amount of water) and suction pressure is 20mmHg or 20cm suction
What is the amount of pressure the wall suction should be set to for a chest tube?
80mmHg
What is the amount of suction the chest tube drainage system should be set on?
20cm suction
Continuous bubbling in the water seal chamber is indicative of?
An air leak
How do you figure out where an air leak is in a chest tube drainage system?
Clamp chest tube at insertion site (if stops you know that the leak is in the insertion site or lung)
Continue clamping down to figure out where the airleak is
Never clamp down for more than a few seconds or you can cause a PTX
If an air leak has occurs, what normal function will you typically not see?
titaling
What are the indications for a chest tube?
Need for drainage of fluid, blood, or air from pleural space
Helps re-establish negative pressure in pleural space for lung (fx) and expansion
Uses a one way valve to keep air from entering pleural cavity
What are the nursing assessments for a chest tube?
Keep drainage system below the level of chest without any kinks in the tubing or dependent loops
Keep two pairs of hemostats at bedside
Assess insertion site for s/s of infection
Assess surrounding tissue for subq emphysema
Maintain occlusive dressing
Assess lung sounds for pleural friction rub and VS
Monitor for air leak
Note presence of normal titaling in the water seal chamber
Promote pulmonary hygiene
What is normal tidaling if the patient is NOT on a ventilator?
With inspiration, tidaling will go up and with expiration tidaling will go down
What is normal tidaling if the patient is on a ventilator?
Tidaling will go down when a breath is given by ventilator and up when the breath goes out
What should the RN be documenting in concerns to a chest tube?
Dressing appearance
Absence of sub-Q air
Negative for air leak (to suction or H2O seal)
Drainage color and amount
Client tolerance to pain
What are the supplies needed for a chest tube dressing change?
Sterile Gloves
Chlorhexidine sponge
Petroleum gauze
Sterile drain sponge
Sterile 4x4
Adhesive tape
Tape only 3 sides (do not remove if provider tapes 4)
What are two important things NOT to do concerning chest tubes?
Do not strip/milk tubes (this increases pressure and can cause significant damage)
Do not clamp chest tubes unless given specific orders to do so and under what condiitons
What are the expected outcomes after treatment with a chest tube?
Lung is re-expanded and negative pressure is reestablished
Resolution of drainage from pleural space
Clear breath sounds over all lung fields
SpO2>94% on RA with no accessory muscle use, tachypnea or increased work of breathing
What are the complications associated with a chest tube?
Respiratory Distress->Respiratory Failure
Infection at the insertion site
Crepitus (popping/crackling->subq emphysema)
Tension PTX
Air leak (continuous bubbling in water chamber)
Tube disconnection from chamber (place in sterile water)
Tube dislodgement from pt (place occlusive dressing w/only 3 sides taped)
What are the s/s of a tension pneumothorax in concerns to complications from a chest tube?
S/S of cardiac tamponade
S/S of decreased cardiac output
Tracheal deviation (late)
Cardiogenic shock
Respiratory and cardiovascular collapse
Recurrent PTX after chest tube removal
What are the s/s of cardiac tamponade?
muffled heart sounds
Pulsus paradoxus
Increased CVP with JVD
Absence of lung sounds on affected side
What are s/s of decreased cardiac output in regards to chest tube complications?
Weak pulse
Change of LOC
Pallor
SOB
Cap refill >2 sec
Tachycardia
What should the RN do to manage risks for a patient with a chest tube?
Emergency equipment at the bedside (padded hemotstats, gauze, bottle of sterile water, dressing)
Oxygen and suction set up and working
Ensure no kinks or obstruction with tubing
Monitor for change in output or excessive output
Monitor for decrease in breath sounds, SpO2
Monitor for increased RR, HR
Monitor for change in work of breathing
Do not delegate to UAP
What is a fail chest?
3 or more neighboring ribs on the same side of the chest sustain multiple fractures resulting in free-floating rib segments
Because there are free-floating rib segments in flail chest, what is occuring?
The ribs are not attached and are flopping around due to changes in pressure of the thorax
How does flail chest normally occur?
Normally a result of a huge impact (such as falling off a building or getting hit by a car)
Blunt chest trauma
What are you going to observe in the breathing pattern of a patient with flail chest?
Lungs below flail segments cave in on inhalation and ballon out on exhalation=Paradoxical chest movements
unequal chest expansion
tachycardia
Dyspnea
Chest pain
hypotension
How is a patient with flail chest and paradoxical chest movements normally stabilized?
Typically stabilized by positive pressure ventilation so the RN should prepare for the high possibility of intubation and mechanical ventilation
Patients with flail chest are at a high risk of developing what other respiratory condition?
ARDS
