unit 1&2 Flashcards
4 signs after extubation that are not good
Stridor
Hoarseness
Change in vital signs
Low oxygen saturation
4 ventilator settings
FiO2 (usually starting around 50%)
Tidal Volume (VT)
- 6 to 8 mL/kg (ideal weight)
- Adjusted according to peak and plateau pressures
Respiratory rate
-12-20 breaths initially
I:E ratio; normal 1:2
Treatment of ARDS
Positioning
Prone positioning/Continuous lateral rotation therapy
Weight of heart off of the lungs
Informed consent, refusal of consent, or withdrawal of consent for health care, unless stated in the advance directive.
Health care decision
Actions intended to benefit the patients or others
Beneficence
type of ventillator alarm that patients biting on tube, secretions blocking tube
High pressure alarm-
spontaneous breathing with ventilator on ‘flow by’ and PS=0 with PEEP=0
weaning trial
Delivery of positive-pressure ventilation (PPV) without artificial airway
- Nasal Continuous Positive Airway Pressure (CPAP)
- Bi-level Continuous Airway Pressure (BiPAP)
what is used for the reversal of opioids
naloxone
ROME=
respiratory opposite metabolic equal
deliver oxygen at 1L to 6L/min (24-44% FiO2)
Nasal Cannula
pH- 7.39 =
PaCO2- 50 ↑
PaO2- 60 ↓
HCO3- 30 ↑
is an example of ________ that is _____ compensated
respiratory acidosis that is fully compensated
normal pH but more toward the acidic side
Being fair or just to the wider community in terms of the consequences of an action. In health care, justice is described as the fair allocation or distribution of health care resources
Justice
normal pH value
7.35-7.45
if the HCO3 is ______, that means the body has more base
elevated
4 ways to verify placement of endotrachial tube placement
symmetrical chest rising
listen for bilateral lung sounds
end tidal co2 decector (change of color)
chest xray
A competent adult who has not been expressly designated to make health care decisions for an incapacitated person, but is authorized by state statute to make health care decisions for the person.
Proxy
room air is ____%
21 %
3 main adverse effects of benzodiazipines
respiratory depresion lower bp (ortho hypo) paradoxal agitation
With hyperventilation, the PaCO2 is ___ and a greater amount of___ is leaving the body
low
CO2
7 Symptoms of ARDS
Dyspnea and tachypnea
Hyperventilation with normal breath sounds
Respiratory alkalosis
Increased temperature and pulse
Worsening chest x-rays that progress to “white out”
Increased PIP on ventilation
Eventual severe hypoxemia
type of ventillator alarm that patients not breathing
Apnea alarm
An alternate term with less-negative connotations, but essentially meaning DNR.
Allow natural death
With hypoventilation, the PaCO2 is____
—the patient is not breathing adequately ( the respiratory rate may be fast but the depth of the respirations may be shallow, the respiratory rate may be slow which means not as much ventilation)
high
A ________ blood gas will have an abnormal pH and will have abnormal values for both the PaCO2 and the HCO3
partially compensated
7 most common reasons for Acute Respiratory Distress Syndrome (ARDS)
Sepsis Aspiration Trauma Near drowning Drug overdose Oxygen toxicity Fat embolism
Actions intended not to harm or bring harm to others
Nonmaleficence
3 main types of opioids
fentanyl
mopphine
hydromorphone
8 Late signs of hypoxia
confusion stupor bradypnea bradycardia (an ominous sign) hypotension cyanotic skin respiratory acidosis. dysrthymias
Movement of gases into lungs through positive pressure
Positive Pressure Ventilation
4 things Endotracheal intubation are used to do
Maintain an airway
Remove secretions
Prevent aspiration
Provide mechanical ventilation
3 things needed at the bedside when you have a patient with a Tracheostomy
Suction, size down cannula, obturator needed at the bedside
Provide humidification flow for rates greater than __L/min
4
A ______ bood gas will have an abnormal pH and one of the values (either the PaCO2 or the HCO3) will be abnormal and the other will be normal depending on the acid/base imbalance.
uncompensated
for ventilator settings how do you set tidal volume
Take 6-8 ml and multiply by the weight in kg (start at 6)
Intervention with the intent of preserving life, restoring health, or reversing clinical death.
Resuscitation
pH = 7.49 PaCO2 = 28 PaO2 = 70 HCO3 = 24 mEq/L
is an example of ________ that is _____ compensated
respiratory alkalosis
uncompensated
Be aware of the hepatotoxic effects of acetaminophen. Clients who have a healthy liver should take no more than _ g/day.
Make sure clients are aware of opioids that contain acetaminophen, such as hydrocodone bitartrate 5 mg/acetaminophen 500 mg.
4
5 things in the Ventilator bundle
Head of bed 30 degrees (prevent aspiration)
Awaken daily and assess readiness to wean
Stress ulcer prophylaxis
DVT prophylaxis
Oral care (chlorhexidine in some bundles)
A medical order that prohibits the use of cardiopulmonary resuscitation and emergency cardiac care to reverse signs of clinical death. The DNR order may or may not be specified in patients’ advance directives.
Do not resuscitate (DNR) order
Insertion of an endotracheal tube (ETT) through the mouth or nose
Endotracheal intubation
normal paC02 value
35-45
if properly placed an endotrachial tube will end up 3-4 cm above the ______
corina
4 signs that a pateint can be weaned off vent
Follow Simple commands
Hemodynamic stable
No cardiac dysthymias
Adequate muscle strength
The obligation to tell the truth
Veracity
Head and neck cancer, cant be taken off of endotracheal tube ventilator within 10-14 days
are common reasons for
Tracheostomy
refers to not enough oxygen in the blood
hypoxemia
2 types of Neuromuscular blockade needed for Treatment of ARDS
Pancuronium
Vecuronium
Treatment of ARDS
3 Comfort measures
Sedation
Pain relief
Neuromuscular blockade (paralytic need to be intubated)
– end of life situation where patient decided they do not want to be intubated anymore and code status turns to DNR and extra opioids are given but not reintubated
Terminal weaning
deliver oxygen at 4-10 L/min (24-50% FiO2)
Venturi Mask
pH- 7.30 ↓
PaCO2- 50 ↑
PaO2-60 ↓
HCO3- 27 ↑
is an example of ________ that is _____ compensated
respiratory acidosis that is partialy compensated
The moral duty to be faithful to the commitments that one makes to others
Fidelity
A permanent, irreversible unconsciousness condition that demonstrates an absence of voluntary action or cognitive behavior, or an inability to communicate or interact purposefully with the environment.
Persistent vegetative state
Patient is physically or mentally unable to communicate a willful and knowing health care.
Incapacity or incompetent decision
soft flexable plastic inserted into nares helps facilitate suctioning and protect tissue
used for potential stroke patient
Nasopharyngeal airway
Complete and irreversible cessation of brain function.
Brain death
Witnessed written document or oral statement in which instructions are given by a person to express desires related to health care decisions. The directive may include, but is not limited to, the designation of a health care surrogate, a living will, or an anatomic gift.
Advance directive
pH = 7.39 PaO2 = 60 mmHg HCO3 = 30 mEq/L PaCO2 = 51 mmHg
is an example of ________ that is _____ compensated
respiratory acidosis
every liter is __% more of FIO2
4%
should check gastric residual every __ hours
4
with a Tracheostomy No more than _____ seconds for suctioning
10-15
A ________ blood gas will have a pH within the normal range and will have abnormal values for both the PaCO2 and the HCO3
fully compensated
Respect for the individual and the ability of individuals to make decisions with regard to their own health and future (the basis for the practice of informed consent)
Autonomy
for ventilator settings I:E ratio
1:2
- Noise reduction (quiet periods)
- Calming music
- Private areas for communication with family
- Providing unrestricted visitation
- Opening the curtains
are all Interventions to reduce ________
Interventions to reduce sensory overload
A condition in which there is no reasonable medical probability of recovery and can be expected to cause death without treatment.
Terminal condition
Treatment of ARDS
3 Oxygenation and ventilation
- Positive end-expiratory pressure (PEEP)
- Possible non-traditional modes of ventilation
- Decrease Oxygen consumption
A witnessed written document or oral statement voluntarily executed by a person that expresses the person’s instructions concerning life-prolonging procedures.
Living will
complications with vents where Extended times of intubation alveoli capillary membrane is damaged and allows fluid to go into alveoli
Volutrauma
deliver oxygen at 10-15l/min (80-95% FiO2)
Nonrebreather Mask
suctiong a Tracheostomy is a _______ technique in the hospital but not in the home
sterile
pH= 7.31 PaCO2 = 32 mmHg PaO2 = 89 mmHg HCO3 = 20 mEq/L
is an example of ________ that is _____ compensated
metabolic acidosis
partially compensated
Life-threatening episode of airway obstruction that may be unresponsive to common treatment.
Status Asthmaticus
3 Indications for Ventilation
Hypoxemia
-PaO2 ≤ 60 mm Hg on FiO2 > .50
Hypercapnia
-PCO2 ≥ 50 mm Hg with pH ≤ 7.25
Progressive deterioration
- Increasing RR
- Decreasing VT (tidal volume)
- Increase Work of breath
6 nursing actions for Status Asthmaticus
oxygen
bronchodilators
Prepare for emergency intubation
IV fluids
epinephrine.
systemic steroid therapy
Irreversible cessation of spontaneous ventilation and circulation.
Clinical death or cardiac death
5 main adverse effects of opioids
resp. depression constipation n&V urinanry retnetion lower bp (orthostatic hypotension)
The POLST form is a medical order indicating a patient’s wishes regarding treatments that are commonly used in a medical crisis. The POLST complements the advance directive; it is not intended to replace it.
Physician Orders for Life-Sustaining Treatment (POLST)
Monitors alveolar CO2-assesses trends in patient’s ventilation status
Exhalation at peak
May be used with any patient with a tracheostomy or ETT; patients with PCA; brain injured patients. (Or any patient where ventilation is a concern).
ETCO2 Monitoring
how to measure a oral airway
corner of lip and angle of jaw
Consent voluntarily given after a sufficient explanation and disclosure of information.
Informed consent
if you inflate PEEP too high what can happen
Can cause reduced cardiac output if high and impedes venous return
normal HCO3 value
22-26
Normal ETCO2 values: _____mm HG
30-43
deliver oxygen at 5L-12L (40-60% FiO2)
Simple Face Mask
if the PaCO2 is elevated, that means the body has more ____
acid
top 4 interventions for respiratory distress
raise head of bed
supplemental oxygen
suction
pain/ anxiety
A competent adult designated by a person to make health care decisions should that person become incapacitated.
Surrogate
Delivers the most precise flow of oxygen and is most commonly used for copd patients
venturi mask
type of ventillator alarm that goes off if low exhaled volume (tube got disconnected)
Low pressure alarm
deliver oxygen at 6-11 (40-75% FiO2)
mixture of oxyen and co2
Partial Nonrebreather Mask
two meds that are used to prevent stress ulcers with vents
famotidine or pantoprazole (prevention)
8 Early signs of poor oxygenation
poor oxygenation restlessness pale skin elevated blood pressure tachycardia tachypnea respiratory alkalosis symptoms of respiratory distress (use of accessory muscles, nasal flaring, adventitious lung sounds )
normal O2 value
80-100
Positive end-expiratory pressure (PEEP) settings
5-20 cm H2O
Hard Plastic device to keep the tongue down and prevent occlusion of the airway
only used for patients with decreased LOC
Oral airway
Oxygen toxicity can result from high concentration of oxygen (typically above ___%),
long duration of oxygen therapy (typically more than __ to __ hr)
50%
24-48
Any medical procedure or treatment, including sustenance and hydration, that sustains, restores, or supplants a spontaneous vital function. Does not include the administration of medication or treatments deemed necessary to provide comfort care or to alleviate pain.
Life-prolonging procedure
Hypoxemia
-PaO2 ≤ __ mm Hg on FiO2 > ___
60
.50
Hypercapnia
-PCO2 ≥ __ mm Hg with pH ≤ ___
50
7.25
Progressive deterioration includes what 3 things
- Increasing RR
- Decreasing VT (tidal volume)
- Increase Work of breath
