Unit 4 Flashcards
True/False: Research shows that patients with ARDS who receive conservative fluid therapy have improved lung function and a shorter duration of mechanical ventilation and ICU length.
True
True/False: A patient on bleeding precautions can take up 10 1000 mg of aspirin a day.
False; aspirin or salicylates should be avoided.
As a result of decreased surfactant, what occurs?
The alveoli become unstable and tend to collapse unless they are filled with fluid.
How often should the incentive spirometer be used?
Every hour that the patient is awake.
Ventilator alarms and Interventions:
There is increased PIP associated with deliverance of a sigh.
High pressure; Empty water from the vent tubing and remove any kinks. Coordinate with respiratory therapist to adjust pressure alarm.
How is a tension pneumothorax treated?
With a needle thoracostomy.
True/False: Patients should be taught to not cross their legs in order to prevent pulmonary embolism.
True
With how much drainage in an hour would you notify the surgeon?
If there was 100 mL/ hr of drainage.
What labs are monitored for heparin?
PTT
What labs are monitored for the patient on warfarin?
INR
Describe the second chamber of a chest tube.
It is the water seal chamber that prevents air from moving back up the tubing system and into the chest.
What is the most common cause of a pulmonary embolism?
A blood clot, but it is important to remember that any substance can cause a PE.
Which acid base imbalance is associated with acute respiratory distress syndrome?
Respiratory acidosis
When is an open thoractomy needed for a patient with a hemothorax?
When the initial blood loss is at least 1000 mLs or there is persistent bleeding at the rate of 150 - 200 mL/ hr for over 3 or 4 hours.
Why is it important to keep that collection device of a chest tube below the chest?
Because it allows gravity to drain the pleural space.
How should a patient sit after extubation?
In semi-fowlers.
How often is respiratory status assessed for the patient with a pulmonary embolism?
Every 30 minutes.
What should be avoided when a patient is taking heparin?
Salicylates Puncturing the skin Use of firm tooth burshes Use of razors Rectal manipulation
Prevention of pulmonary embolism: How high should the affected limb be elevated to promote venous return
20 degrees or more above the level of the heart.
Why is the thorax examined for a patient with a pulmonary embolism?
To look for the presence of petechiae.
What is known as a rapidly developing and life threatening complication of blunt force trauma?
Tension pneumothorax.
When can you clamp the chest tube?
When changing drainage system of checking for air leaks.
How often do you promote pulmonary hygiene to the patient who is receiving mechanical ventilation?
Every 2 hours.
What type of clothing and shoes should be avoided for the patient on bleeding precautions?
Clothing or shoes that are tight and rub.
Describe ventilatory failure in regards to acute respiratory failure.
A problem with oxygen intake and blood flow that causes a ventilation-perfusion mismatch in which blood flow is normal but air flow is inadequate.
Ventilator alarms and Interventions:
The artificial airway is displaced.
High pressure; Asses the chest for unequal breath sounds and chest excursion, obtain chest x-ray, secure tube in place.
Explain DOPE for the intubated patient that shows manifestations of decreased oxygenation.
D-displaced tube
O-obstructed tube
P-pneumothorax
E-equiptment problems
What signs would a nurse observe if a patient were to have a pulmonary embolism?
Tachypnea Crackles Pleural friction rub Tachycardia S3 or S4 heart sound Diaphoretic Low grade fever Petechiae over chest and axillae Decreased SaO2
When is it important to suction a patient who is on mechanical ventilation?
When secretions, increased PIP, rhonchi and decreased breath sounds are present.
How is a hemothorax diagnosed?
With a chest x-ray and then confirmed with a thoracentesis.
Which acid base imbalance is associated with acute respiratory failure?
Respiratory acidosis
After notifying the rapid response team, what other interventions can you do for the patient with a pulmonary embolism?
Raise head of the bed
Prepare for oxygen therapy and blood gas analysis
Reassure the patient
Continue to monitor and assess for other changes
What non invasive intervention may be done to promote gas exchange?
Positioning and manually turning the patient every two hours.
What position is best for the patient with a pulmonary embolism?
High fowlers.
What is the priority nursing action when caring for an intubated patient?
Maintaining patent airway.
What can a patient on bleeding precautions use instead of razor?
An electric razor
How is VAP prevented?
With the ventilator bundle:
- Keeping HOB elevated at least 30 degrees.
- Perform oral care by brushing teeth every 8 hours and anitmicrobial rinse with chlorhexidine every 2 hours.
- Ulcer prophylaxis
- Preventing aspiration
- Pulmonary hygiene including chest physiotherapy, postural drainage, and turning and positioning.
What can occur if tension pneumothorax is not quickly detected and treated?
It can be fatal.
What occurs in a pulmonary contusion?
Hemorrhage and edema occur in and between the alveoli, reducing both lung movement and the area available for gas exchange.
What do you do a patient develops ARDS during mechanical ventilation?
Removed the ventilator and provide ventilation with a bag valve mask device.
How often should a patient that was just extubated take deep breaths and use the incentive spirometer?
They should take deep breaths ever half hour and use incentive spirometer every two hours. They should also limit speaking.
What causes a patient with a pulmonary embolism to feel a sense of impending doom and seem restless?
Hypoxemia
If the flow is set too low for the patient who is on mechanical ventilation, what should interventions can be done?
Increasing the flow rate should be tried first, before using any chemical restraints.
What is the antidote for heparin?
Protamine sulfate
What activity is reduced in acute respiratory distress syndrome?
Surfactant
True/ False: CPR can cause flail chest.
True.
Describe the third chamber of a chest tube.
This chamber is the suction regulator when suction is applied.
What are the steps that need to be done before and during extubation?
Hyperoxygenate the patient and thoroughly suction for the ET tube and the oral cavity. Rapidly deflate the cuff of the ET tube and remove the tube at peak inspiration.
What can occur in the water seal chamber when a patient sneezes, coughs or exhales?
Bubbling.
What are ten common causes of oxygenation failure?
- Low atmospheric oxygenation concentration like high altitudes.
- Pneumonia
- CHF with pulmonary edema
- Pulmonary embolism
- Acute respiratory distress syndrome
- Interstitial pneumonitis-fibrosis
- Abnormal hemoglobin
- Hypovolemic shock
- Hypoventilation
- Complications of nitroprusside therapy
What nursing care is needed for the patient with a tension pneumothorax?
Pain control and pulmonary hygiene.
If a patient is suspected of having a pulmonary embolism what is the nurse’s priority?
Call rapid response team
What foods need to be avoided for the patient taking warfarin?
Green leafy vegetables Herbs Spring onions Brussel sprouts Broccoli Cabbage Asparagus
Why is a stool softener given to patient on bleeding precautions?
To prevent straining during a bowel movement.
What are the 3 nursing priorities when caring for a patient during mechanical ventilation?
- Monitoring and evaluating patient responses.
- Managing the ventilator system safely.
- Preventing complications.
Ventilator alarms and Interventions:
Obstruction occurs because there is a kink in the tubing or the patient is lying on the tube.
High pressure; Assess the system starting with the artificial airway and moving toward the ventilator.
When is the normal amount of PEEP used?
5-15
How is ARDS diagnosed?
Its established by a low PaO2 and determined by ABGs
What are the usual causes of ventilatory failure?
A physical problem of the lungs or chest wall.
A defect in respiratory control center in the brain.
Poor function of respiratory muscles, especially the diaphragm.
What is an example of a closed pneumothorax?
A patient with COPD who has a pneumothorax.
What is at risk for a patient with a rib fracture?
A deep chest injury
What is the cardinal feature of acute respiratory distress syndrome?
Refractory hypoxemia (hypoxemia that persists when 100% oxygen is given)
What are the normal levels of CPAP?
5-15
What are 14 major risk factors for DVT that lead to PE?
Prolonged immobility Central venous catheters Surgery Obesity Advancing age Conditions that increase blood clotting History of thromboembolism Smoking Pregnancy Estrogen therapy Heart failure Stroke Cancer (especially lung and prostate) Trauma
True/False: A patient on bleeding precautions should not floss.
True. And they should use a soft bristled toothbrush.
When is synchronized intermittent mandatory ventilation used?
Usually when the patient is weening off of the vent.
What do you do if there is continuous bubbling in the water seal chamber?
Notify the health care provider.
How does a patient with a rib fracture appear?
They have pain on movement and splints the chest defensively.
What illnesses and complications can you hear a pleural friction rub?
Pleurisy Tuberculosis Pulmonary infarction Pneumonia Lung Cancer
What is the nursing priority in the prevention of ARDS?
Early recognition of patients at high risk for the syndrome.
How is a pneumothorax treated?
Chest tube (so air can escape and lung can re-inflate)
Pain control
Pulmonary hygiene
Continued assessment fopr respiratory failure.
True/False: Enteral or parenteral nutrition is started as soon as possible for patients that are intubated.
True
True/ False: No drainage in the chest tube of a patient with a hemothorax is okay at first.
False, it is NOT okay.
What does the patient need to do immediately after the ET tube is removed?
Instruct the patient to cough.
What is the first emergency approach to all chest injuries?
Airway, breathing, circulation.
Ventilator alarms and Interventions:
The patient stops spontaneous breathing in the SIMV or CPAP mode or on pressure support ventilation.
Low pressure; Evaluate the patient’s tolerance of the mode.
Describe the first chamber of a chest tube.
It is connected to the tubes that are connected to the patient and it is the drainage collection container.
Other than refractory hypoxemia, what are the other manifestations of acute respiratory distress syndrome?
Decreased pulmonary compliance
Dyspnea
Noncardiac-associated bilateral pulmonary edema
Dense pulmonary infiltrates on x-ray
True/False: A patient on bleeding precautions should not blow their nose.
True; if they absolutely need to, they can only without blocking either nasal passage.
What causes a tension pneumothorax?
Blunt chest trauma
Mechanical ventilation with PEEP
Chest tubes
Insertion of central venous access
The patient in acute respiratory failure is always…?
Hypoxemic
What is PEEP?
Positive pressure exerted during expiration.
If you are unable to determine the cause of the alarm on the vent, what is the best action?
Ventilate the patient manually until the problem is corrected by another health care provider.
Why is it important that the fluid in chamber one cannot fill to the point where it comes in contact with any tubes?
If the tubing from the patient enters the fluid, drainage stops and can lead to a tension pneumothorax.
True/False: A patient on bleeding precautions cannot participate in sports.
False; they should just avoid contact sports.
Describe a simple hemothorax.
A blood loss of less than 1000 mL into chest cavity.
When is “milking” the chest tube appropriate?
What is important to remember when “milking” the chest tube?
To move clots and prevent obstruction.
It needs to be done very gently.
Why is it important to have at least 2 cm of water in the water seal chamber?
Because it prevents air from flowing backward into the patient.
How does continuous positive airway pressure (CPAP) work?
It applies positive airway pressure throughout the entire respiratory cycle for spontaneously breathing patients.
What are signs of a pulmonary contusion?
Decreased breath sounds Crackles or wheezes over affected area Bruising over the injury Dry cough Tachycardia Tachypnea Dullness to percussion
Why is it important to keep sterile gauze at bedside of a patient with a chest tube?
To cover the insertion site ASAP if the tubing becomes dislodged.
What are the 3 critical values associated with acute respiratory failure?
PaO2 less than 60 mm Hg OR Paco2 more than 45 mm Hg with acidemia AND Sao2 less than 90 % in both cases.
Describe a flail chest.
The result of fractures of at least two neighboring ribs in two or more places causing paradoxical chest wall movement.
Ventilator alarms and Interventions:
Airway size decreases related to wheezing tor bronchospasm.
High pressure; Auscultate breath sounds and consult with respiratory to provide prescribed bronchodilators.
Ventilator alarms and Interventions:
Increased amount of secretions or a mucus plug in the airways.
High pressure; suction as needed.
What drugs are systemically given to patients in acute respiratory failure?
Metered dose inhaler
Corticosteroids
Analgesics (pain)
What is tidal volume?
It is the volume of air the patient receives with each breath, as measured on either inspiration or expiration.
When stridor or other manifestations of obstruction occur after the extubation, what do you do?
Call rapid response team.
How often do you perform mouth care for a patient who is receiving mechanical ventilation?
Every 2 hours.
Ventilator alarms and Interventions:
Decreased compliance of the lungs is noted; a trend of gradually increasing PIP is noted over several hours or a day.
High pressure; Evaluates the reasons for the decreased compliance of the lungs. Increased PIP occurs in ARDS, pneumonia, or any worsening of pulmonary disease.
What are the two classifications of acute respiratory failure?
Ventilatory failure
Oxygenation (gas exchange) failure
What causes the manifestations of acute respiratory distress syndrome?
An inflammatory response
What is a pulmonary embolism?
A collection of particulate matter that enters venous circulation and lodges in the pulmonary vessels.
Where are abnormal lung sounds heard in the patient with ARDS?
They are not heard because the edema occurs first in the interstitial spaces and not in the airways.
How do you position the patient to facilitate ventilation-perfusion?
With good lung down.
What are the interventions associated with flail chest?
Humidified oxygen
Pain management
Promotion of lung expansion through deep breathing and positioning
Secretion clearance by coughing and tracheal suction
True/False: A patient on bleeding precautions should avoid hard and hot foods.
True because they are want to avoid any foods that would scrape or burn the inside of their mouths.
How often is the drainage in the first chamber of a chest tube measured during the first 24 hours?
Every hour.
How do you prevent bacterial contamination in mechanical ventilation equiptment?
Do not allow moisture and water in the ventilator tubing to enter the humidifier.
Where is the ET tube placed for a patient who suffered a tracheobronchial trauma?
It is placed distal to the injury.
As the nurse, how would you implement energy conserving measures for the patient in acute respiratory failure?
Have the patient do minimal self care and no unnecessary procedures.
Ventilator alarms and Interventions:
Pneumothorax occurs.
High pressure; Call rapid response team and auscultate breath sounds.
When is assist control ventilation used?
It is used most often as a resting mode. The ventilator takes over the work of breathing for the patient.
What should be monitored for the patient with a hemothorax?
Vitals, blood loss and intake and output.
What does VAP stand for?
Ventilated associated pneumonia.
What can a pulmonary contusion lead to?
ARDS.
What do you do is the chest tube falls out of the patients chest?
Cover the area with dry, sterile gauze and then call health care provider/ rapid response team.
What are the 14 common causes of acute lung injuries?
- Shock
- Trauma
- Serious nervous system injury
- Fat and amniotic fluid emboli
- Pulmonary infections
- Sepsis
- Inhalation of toxic gases
- Pulmonary aspiration
- Drug ingestion
- Hemolytic disorders
- Multiple blood transfusions
- Cardiopulmonary bypass
- Drowning
- Pancreatitis
Why are tube fed patients high risk for ARDS?
Because the tube keeps the gastric sphincter open.
How are fat emboli from fracture of a long bone dangerous?
Because the injure blood vessels and cause acute respiratory distress syndrome.
How is a pulmonary contusion managed?
With maintenance of ventilation and oxygen therapy.
What type of precaution should be implemented for the patient with a pulmonary embolism?
Bleeding precautions.
What are important factors when considering positioning for a patient with pulmonary contusion?
Should be in a moderate-fowler’s position or if side lying, the good lung should be down.
Why is it important to lower the FiO2 delivered whenever possible?
Because prolonged use of a high FiO2 can damage lungs from the toxic effects of oxygen.
Which acid base imbalance is associated with pulmonary embolism?
Respiratory alkalosis.
When should the patient on bleeding precautions contact their health care provider?
When they are injured and persistent bleeding occurs.
When they have excessive menstrual bleeding.
When they see blood in their urine or bowel movements.
Describe the sound heard with a pleural friction rub.
Loud, rough, grating, scratching sounds.
How should the dressing be on the chest around the tube for a patient with a chest tube?
It should be tight and intact
What does the chest x-ray look like for a patient with ARDS?
It will show diffuse haziness or a white out appearance of the lung.
Ventilator alarms and Interventions:
A leak in the vent circuit prevents breath from being delivered.
Low pressure; Assess all connections and all vent tubing for disconnection.
Why do you give stool softeners to prevent pulmonary embolism?
To prevent episodes of the valsalva maneuver.
What can a pulmonary contusion cause for the patient?
Tire easily, have reduced gas exchange and become more fatigued and hypoxemic.
If the patient develops refractory hypoxemia, what often occurs next?
The patient will need intubation and mechanical ventilation.
What are the common assessment findings of a patient with pneumothorax?
Reduced breath sounds on auscultation Hyperresonance on percussion Prominence of the involved side of the chest, which moves poorly with respirations Pleuritic pain Tachypnea Subcutaneous emphysema
How is ET tube placement verified?
Checking end-tidal carbon dioxide levels and with chest x-ray.
True/ False: It is uncommon for the patient to have a sore throat and a horse voice after extubation?
False; it is common for the first few days after extubation.
What is the fraction of inspired oxygen (FiO2)?
The oxygen level delivered to the patient.
How is pneumothorax diagnosed?
With a chest x-ray.
What manifestations does the patient with a pulmonary embolism show?
Sudden onset of dyspnea Sharp, stabbing chest pain Apprehension Restlessness Feeling of impending doom Cough Hemoptysis
How is oxygenation monitored for the patient with a pulmonary embolism?
Pulse oximetry.
How does PEEP improve oxygenation?
Enhances gas exchange and prevents atelectasis.
What is the antidote for warfarin?
Vitamin K
If a patient is on bleeding precautions and they are bumped, how long should they ice the affected area?
At least an hour.
Describe a massive hemothorax.
A blood loss of more than 1000 mL.
What does continuous bubbling in the water seal chamber indicate?
An air leak.
What labs are performed for a patient suspected of having a pulmonary embolism?
Metabolic panel
BNP
Troponins
D-dimer
What is the gold standard diagnostic test for pulmonary embolism?
Pulmonary angiography
When does bubbling in the water seal chamber occur and when does it stop?
Bubbling occurs when air passes through the water seal chamber and it stops when all of the air has been evacuated from the pleural space.
What does the patient need to be assessed for when taking altepase?
Internal and external bleeding
When do you re position a patient with a chest tube?
When the patient reports a a burning pain in the chest.
What are the cardiac manifestations associated with pulmonary embolism?
Tachycardia Distended neck veins Syncope Cyanosis Hypotension
What are the 8 reasons for notifying the physician or rapid response team for a patient with a chest tube?
- Tracheal deviation
- Dyspnea
- O2 sat less than 90 %
- Drainage greater than 70 mL/hr
- Visible eyelets on chest tube
- Chest tube disconnects from drainage system
- Chest tube falls out of patient’s chest
- Drainage in tube stops in the first 24 hours.
Which acid base imbalance is associated with pneumothorax?
Respiratory alkalosis
What will happen to the water seal chamber if the tubing is blocked or kinked?
The bubbling will stop.
True/False: A pillow should be placed under the knee in order to prevent pulmonary embolism.
False. Pressure under the popliteal space should be prevented.
What labs are monitored for a patient on enoxaparin?
Platelets
What causes ARDS?
Acute lung injuries.
What do you do if chest tube disconnects from the drainage system?
Put end of tube in sterile water and keep is below the patient’s chest and then call health care provider/ rapid response team.
Ventilator alarms and Interventions:
The patient coughs, gags, or bites on the oral ET tube.
High pressure; use bite block.
How are fractured ribs treated?
They aren’t. Ribs will heal spontaneously. The main focus is to decrease pain so that adequate ventilation is maintained.
Why is pulmonary hygiene done for the patient who is receiving mechanical ventilation?
To prevent complications of immobility.
What are the 8 assessment findings associated with tension pneumothorax?
- Asymmetry of the thorax
- Tracheal deviation from midline toward the unaffected side
- Extreme respiratory distress
- Absence of breath sounds on one side
- Distended neck veins
6 .Cyanosis - Hypertympanic sound on percussion over the affected side
- Hemodynamic instability
What can occur to a patient with a large hemothorax?
The patient may have respiratory distress and breath sounds reduced on auscultation.
Ventilator alarms and Interventions:
A cuff lek occurs in the ET or tracheostomy tube.
Low pressure; Evaluate the patient for a cuff leak. A cuff leak is suspected when the patient can talk or the pilot balloon on the artificial airway is flat.
Why are lung sounds assessed hourly for the patient that is intubated and on mechanical ventilation?
Because often they need PEEP and tension pneumothorax is a side effect of PEEP.
What are the 11 manifestations associated with acute respiratory failure?
Dyspnea Orthopnea (trouble breathing when laying down) Restlessness Irritability; agitation Confusion Tachycardia Decreased LOC Headache Lethargy Drowsiness Seizures
How is oxygen applied for the patient with a pulmonary embolism?
By nasal cannula or by mask.
How does SIMV mode work?
It has set tidal volume and ventilatory rate set but allows the patient to breathe on their own. If the patient does not take a breath on their own, this mode will deliver a breath to them.
Where can you hear a pleural friction rub when auscultating?
In lateral lung fields
What type of clothing should be avoided to prevent pulmonary embolism?
Tight garters
Girdles
Constrictive clothing
Describe an open pneumothorax.
When the pleural cavity is exposed to outside air as through an open wound in the chest wall.
Ventilator alarms and Interventions:
The patient is anxious or fights with the ventilator.
High pressure; Provide emotion support, explain all procedures to patient, increase flow rate, provide sedation per MD orders.
Describe oxygenation failure in regards to acute respiratory failure?
Chest pressure changes are normal and air moves in and out without difficulty but does not oxygenate the pulmonary blood sufficiently.
When is PEEP used?
To treat persistent hypoxemia that does not improve with an acceptable oxygen delivery level.
