Medsurg-Respiratory

Front 1

Chest tube: remove
--give pain meds half hour before the preocedure.
-- remove suture
-- ask pt. to deep breath, exhale, and bear down(valsalva maneuver) or to take a deep breath and hold it (increase intrathoracic pressure and reduces risk of air emboli) during chest tube removal.
-- airtight sterile petroleum jelly gauze dressing

Back 1

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Front 2

Complications for chest tube:
1) Air leaks:
2) accidental removal, disconnection, or system breakage.
3) Tension pneumothorax

Back 2

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Front 3

How to prevent air leaks for chest tube?
to prevent: tape all connections.
If find continuous water babbling--air leaks

Back 3

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Front 4

what to do for accidental removal, disconnection, or system breakage:

tubing seperation: ask pt. to exhale as much as possible and cough to remove as much air as possible from the pleural space. Clean up the tip and reconnect

-- drainage system breaks: immerse the end of the tube in sterile water to restore the water seal.
--chest tube accidentally removed: an occlusive dressing (taped on only three sides) should be immediately placed over the insertion site.
(only three sides taped will allow air to escape and prevent tension pneumothorax)

Back 4

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Front 5

What cause Tension pneumothorax with chest tube:
-- sucking chest wounds
--prolonged clamping or tubing.
--kinks in tubing
--obstruction of tubing.

Back 5

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Front 6

thoracentesis
-- can be done at bedside.
-- the amount of fluid removed: limited to 1 L each time. ( to prevent cardiovascular collapse)
--Recurrent pleural effusions: can be managed by instilling an irritant into the pleural space to cause scarring.
-- For continuous drainage, chest tube can be used instead of thoracentesis.

Back 6

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Front 7

Contraindication for thoracentesis:
-- severe thrombocytopenia.

Back 7

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Front 8

thoracentesis, before procedure

--consent form
-- pre-procedure X-ray to locate the site for insetion
-- Pt. position: sitting upright with arms and shoulders raised and supported on pillows and/or on an overbed table and with feet and legs well supported.

-- Tell pt: remain ABSOLUTELY STILL during the procedure. NO COUGH OR TALK.

Back 8

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Front 9

thoracentesis: during procedure

- monitor VS, respiration SaO2

Back 9

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Front 10

thoracentesis: after procedure

-- Apply a dressing over bedside
-- pt: one unaffected side for 1 hour.
-- normal activity can be resume after 1 hour if no complications.
-- encourage pt for deep breathing ( assist lung expansion)

-- if dyspnea, cough and hemoptysis, call doctor.

Back 10

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Front 11

thoracentesis: complications:

--shock
monitor for hypotension, reflex bradycardia, diaphoresis, faintness

When above S/S occurs, slow down the rate of fluid removal.
-- pneumothorax
--bleeding.
S/S: coughing and hemoptysis.
(check blood pressure)

Back 11

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Front 12

Double lumen tracheostomy has 3 parts.
1) outer cannula

2) Inner cannula
-- fits into the outer cannula and locks into place.
-- can be withdrawn and reusable , or replaced.

3) Obturator
helps for outer cannula insertion, removed right after cannula insertion, kept with the client at bedside ( will be used in case of accidental decannulation )

Back 12

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Front 13

tracheostomy :

cuffed tube -- pt can not talk
uncuffed tube -- pt. can talk.

Back 13

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Front 14

tracheostomy

pt. can eat and drink. But because laryngeal elevation, pt. may have risk for aspiration.

Back 14

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Front 15

situations which needs tracheostomy:

1) inability to oxygenate through the nasopharynx due to obstruction. AEB dyspnea, poor SaO2, poor ABG values

2) inability to wean from mechanical ventilation within 2 weeks.

3) sleep apnea not improved by CPAP.

Back 15

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Front 16

tracheostomy

different kinds of tubes. P 73. ATI book
cuffed, uncuffed, single-lumen, with cuff and pilot balloon, cuffed fenestrated, metal, talking/speaking, foam-filled

Back 16

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Front 17

tracheostomy:
care after insertion:
--monitor VS, SaO2, respiration. mucous secretions, stoma and skin surrounding stoma

-- humidification and hydration
-- suction (surgical aseptic technique)
--other method to communicate with pt.
-- for cuffed tubes, keep pressure under 20mmHg, ( prevent tracheal necrosis due to long time compression and tracheal capillaries)
-- tracheostomy care q8hr.

Back 17

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Front 18

tracheostomy care:

-- suction
-- remove old dressing and excess secretions.
-- outer cannula surface: use cotton-tipped applicators and gauze pads to clean.
-- stoma site: clean in circular motion first with hydrogen proxide, then normal saline.
-- remove and clean inner cannula
(surgical aseptic )
clean: hydrogen dioxide then normal saline.
replace the cannula if disposable.

-- place split 4X4 dressing.
-- change tie if soiled. Keep 1 or 2 finger space between the tie tape and the neck.

Back 18

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Front 19

tracheostomy:

if pt. can eat, position pt. in an upright position and tip the chin to chest to enable swallowing.

Back 19

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Front 20

Administer prescribed medications
-- anti-inflammatory drugs
--antibiotics
--aerosolized bronchodilators.
--Mucous liquefying agents (guaifenesin)

Back 20

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Front 21

tracheostomy --complications

Accidental decannulation
--keep the obturator and a spare tracheo- tube at bedside.
-- call for help.
-- if happens in 72 hours after surgery, emergency situation, call doctor.
-- if after 72 hours, the tracheo-tract is matured, nurse can immediately insert the oburator into the tracheostomy tract and insert a new tube around the obturator.

-- if unable to insert a new tube, give O2 through stoma,
-- if can not give O2 through stoma,
give O2 through mouth or nose.

Back 21

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Front 22

mechanical ventilation

-- delivers warm, 100% humidified, O2.
-- FiO2 21--100%
-- can be given through
endotracheal tube
tracheostomy tube
nasal/face (BiPAP, CPAP)

Back 22

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Front 23

mechanical ventilation
-- can be cycled on pressure, volume, time, and flow.

-- alarms: Volume, pressure, and apea

-- volume alarm (low pressure) indicates low exhale ( disconnection, cuff leak, tube displacement )

-- pressure alarm (high pressure)
indicates excess secretions, pt. biting the tube, kinks in tubing, coughing, pulmonary edema, bronchospasm, pneumothorax.

-- apnea alarm: ventilator doesnot detect spontaneous breathing in a preset period.

Back 23

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Front 24

mechanical ventilation
-- may require sedation or paralytic agents to prevent competition between extrisic and spontaneous breathing, and hyperventilation.

Back 24

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Front 25

weaning from ventilation
-- increasing period of spontaneous breathing to increase muscle strength.

-- use pressure support

Back 25

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Front 26

mechanical ventilation (maintain a patent airway)

-- document tube placement in cm. at the teeth or lips.

-- protective barriers (soft wrist restraints) according to hospital protocol to prevent self-extubation.

-- Asess respiratory status and ventilation settting Q2hr.

-- assess cuff pressure q8hr,
pressure should be < 20 mm Hg to avoid tracheal necrosis.

-- reposition the oral endotracheal tube q24 hr.

Back 26

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Front 27

medications used for mechanical ventilation
--analgesics : morphine, fentanyl

--sedatives: propofol (Diprivan), diazepam (Valium), lorazepam(Ativan), midazolam (Versed), haloperidol(Haldol)

-- Neuromuscular blocking agents: pancuronium bromide, atracurium, vecuronium

-- ulcer-preventing agents: famotidine (Pepcid), or lansoprazole (Prevacid)

-- Antibiotics for established infection.

Back 27

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Front 28

weaning intolerance from mechanical ventilation

--RR > 30/min or < 8/min
--BP and pulse change > 20% off the baseline.
--SaO2< 90%
--Dysrhythmias, raised ST seg.
-- significant decrease tidal volume
--respiratory distress: labored resp. use of accessory muscles, diaphoresis, restless, anxiety, decreased LOC.

Back 28

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Front 29

mechanical ventilation
-- suction before extubation.

Back 29

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Front 30

mechanical ventilation complications:

-- fluid retention
due to decreased cardiac output, and activation of renin-angiotensin-aldosterone system, ventilator humidification.

-- O2 toxicity
high risk if FiO2> 50%. provide minimal amount of O2
-- monitor for S/S: fatigue, restless, severe dyspnea, tachycardia, crackles, cyanosis

-- Hemodynamic compromise
risk for increased thoracic pressure (positive pressure) and resulting in decreased venous return.
monitor for tachycardia, hypotension, urine output < 30ml/hr, cool clammy extremities, decreased peripheral pulses, decreased LOC.

--risk for aspiration

-- stress ulcer (GI ulceration)
medications to prevent: Carafate, sucralfate, histamine2blockers.

Back 30

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Front 31

mechanical ventilation modes
-- AC (assist-control)
--SIMV (synchronized intermittent mandatory ventilation)
--PSV (pressure support ventilation)
-- PEEP (positive end expiratory pressure)
-- VAPSV (Volume assured pressure support ventilation)
-- ILV (Independent lung ventilation)
-- High frequency ventilation
-- (IRV) Inverse ration Ventilation

Back 31

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Front 32

mechanical ventilation AC mode:

-- preset rate and tidal volume.
-- pt. can initiate breaths, but ventilator will take over and deliver preset tidal volume.
-- Hyperventilation and alkalosis can happen
-- sedation may be needed.

Back 32

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Front 33

mechanical ventilation SIMV mode

-- preset rate and tidal volume
-- if pt. initiate breaths, tidal volume depends on the pt's effort.
-- Ventilator initiated breaths are syncrhonized to reduce competition between the pt. and ventilator.
-- SIMV can be used as regular mode and weaning mode.
--may increase the work for breathing and cause muscle fatigue.

Back 33

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Front 34

mechanical ventilation PSV mode

- pt control rate and tidal volume.
-- positive pressure during spontaneous breathing to reduce fatigue.
-- usually used as a weaning mode.
--no ventilator breathing is initiated,
-- can not guanrantee minimal minute ventilation.
-- usually combined with other modes( SIMV, AC)

Back 34

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Front 35

mechanical ventilation PEEP mode

-- must be used in conjunction with other SIMV or AC modes.
-- can not be used alone.
-- complications:
decreased cardiac output
volutrauma (trauma to lung tissue)
increased ICP

Back 35

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Front 36

mechanical ventilation VAPSV mode
-- similar to PSV mode with minimal set volume for each breath.
-- used for severe respiratory disease or those very difficult to wean

Back 36

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Front 37

high-frequent ventilation
--used often for children
-- small amount of gas at very rapid rates (60-3000 cycles/min)
-- pt. needs to be sedated and/or receiving neuromuscular blocking agents.

Back 37

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Front 38

mechanical ventilation IRV mode

-- lengthen inspiratory phase
-- IRV used for hypoxia refractory to PEEP.
-- uncomfortable for pt. Sedation / neuromusclar blocking agents. used .
-- high risk for volutrauma and decreased cardiac output. (due to air trapping)

Back 38

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Front 39

pulmonary function tests
-- FVC: forced vital volume: the volume of air exhaled from full inhalation to full exhalation.

-- FEV1: forced expiratory volume in the first second of the most forceful exhalation after the greatest full inhalation.

-- PERF: peak expiratory rate flow. the fastest airflow rate reached during exhalation.

Back 39

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Front 40

pulmonary function tests diagnostic for Asthma:

-- decreased FEV1 or PERF by 15 - 20% below the expected value (common for asthma)
--increase of FEV1 or PERF by 12% following the bronchodilators is diagnostic for asthma.

Back 40

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Front 41

Asthma (S/S)

-- mucosal edema
-- bronchoconstriction
-- excessive secretion production

Back 41

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Front 42

Asthma categories
-- mild intermittent: occur twice a week.
--mild persistent: > 2 /week
--moderate persistent: Daily
-- severe persistent: continually.

Back 42

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Front 43

Asthma treatments

--O2
--high-fowler's position
--Medications
--recognize and avoid triggers
--during status Asthmaticus, intubation.
--good nutrition
--regular excercise
--encourage pt. to get vaccine for pneumonia and influenza.

Back 43

--

Front 44

Asthma medications
--Broncodilators
*beta-2 agonist: albuterol
*cholinergic antagonist: ipratropium (Atrovent) it can cause brochodilation and decrease pulmonary secretion.
* Methylxanthines: theophylline (Theo-Dur) Needs close monitor due to narrow therapeutic range.
--anti-inflammatories
*corticosteroid: fluticasone (Flovent) and prednisone
*Leukotriene antagonists: montelukast(Singulair)
*Mast cell stablizers: cromolyn sodium (Intal)
*Monoclonal antibodies: omalizumab (Xolair)

-- Combination agents (combine bronchodilator and anti-inflammatory)
Combivent (ipratropium and albuterol
Advair ( Fluticasone and salmeterol)
-- Combination agents

Back 44

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Front 45

Asthma
When giving systemic corticosteroid, monitor for side effects:
--immunosuppression
-fluid retention,
-hyperglycemia
-hypokalemia
--poor wound healing

Back 45

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Front 46

Asthma
Two give two inhalation medications (broncodilator and anti-inflammatory agent), give broncodilator first, then give anti-inflammatory agent.

Back 46

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Front 47

Status Asthmaticus

--life-threatening episode of airway obstruction
--emergency intubation
--systemic broncodilators (e.g. epinephrine),
--systemic steroid therapy.

Back 47

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Front 48

Asthma

--beta2-agonist is used for relief of acute symptoms of asthma. (albuterol)

--old people need increase dose of beta2-agonist because they have decreased sensitivity to beta2 agonists.

Back 48

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Front 49

COPD
--includes:emphysema and chronic bronchitis
--Risk factors
smoking
alpha1-antitrypsin (AAT) deficiency
air polution

Back 49

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Front 50

COPD S/S
chronic dyspnea
cough
hypoxemia
hypercarbia
respiratory acidosis
crackles
barrel chest
hyperresonance
thin extremities and enlarged neck muscles
dependent edema (secondary to right heart failure)
pallor and cyanosis
may have polycythemia (chronic compensation)

Back 50

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Front 51

COPD
medications --same as those for Asthma

Back 51

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Front 52

COPD
--chest physiotherapy:
percussion and vibration to mobilize secretions
positioning to facilitate drainage.

Back 52

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Front 53

COPD O2 therapy
--give heated and humidified O2
--give low flow O2 (too high will cause respiratory depress)

Back 53

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Front 54

Breathing techniques for COPD pt.

-- Diaphragmatic or abd. breathing
-- Pursed-lip breathing.

Back 54

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Front 55

pneumonia

--community acquired pneumonia (CAP)

--Hospital acquired pneumonia(HAP)

Back 55

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Front 56

Medication for Pneumonia

--Same as Asthma
bronchodilators
Corticosteroids
Immunizations
(vaccine: influenza: every year
pneumonia: one time only)

--antibiotics
most commonly used: penicillin and cephalosporins

obtain any culture specimen prior to give any antibiotics.

Back 56

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Front 57

Pneumonia
Complications

--Atelectasis
--Acute Repiratory Failure
--Bacteremia (Sepsis)

Back 57

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Front 58

Pneumonia --Old people

--more susceptible for infection
--weak cough reflex and decreased muscle strength
--fever, cough, and purulent sputum are often absent.

Back 58

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Front 59

Tuberculosis (TB)
-Myobacterium tuberculosis
--Transmitted through aerolization (airbone route)
--first time infection: body encases TB bacillus with collagen and other cells--Ghon tubercle will appear.

--Small # people infected --> active form

--TB lie dormant for many years before producing disease.

Back 59

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Front 60

TB transmission

-- not contagious until S/S of the infection are present.
--transmission decreases after 2 to 3 wks antibiotic therapy

Back 60

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Front 61

TB--TB test (Mantoux Skin Test)
-- read in 48 to 72 hours
--positive within 2 - 10 wks of exposure to the infection.

--diameter > 10mm: positive
diameter > 5mm positive for immunocompromised people

--positive: exposure to TB / presence of the inactive disease
(does not confirm that the active dis. is present)

-- received BCG vaccine within 10 years : may have a false-positive resfult. --> Get X-ray to confirm.

Back 61

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Front 62

Diagnosis: confirmed by Sputum smear and culture

--positive acid-fast: active infection
TB precautions should be followed.

--first morning specimen is most accurate and preferred.

Back 62

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Front 63

TB

- before confirm diagnosis, any pt. with persistent cough, weight loss, anorexia, hemoptyiss, dyspnea, fever and chills, should consider TB.

Back 63

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Front 64

TB: S/S:

--persistent cough
--purulent sputum, possibly blood-streaked
--fatigue
--weight loss, anorexia
--Night sweats, fever

Back 64

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Front 65

TB-to prevent infection transmission

--wear N95 or HEPA respirator when caring for the TB pt.

--negative airflow room, airborne precautions
--Barrier protection
--Pt. wear mask if transportation to other departments.

Back 65

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Front 66

TB --Medications

--Isoniazid (INH)
* taken w/ empty stomach
*monitor for hepatitis and neurotoxicity
*Vitamin B6 is used to prevent the toxicity.

--Rifampin (RIF)
*urine and other secretion: orange color.
*watch for hepatotoxicity

--Pyrazinamide (PZA)
*hepatotoxicity

--Ethambutol (EMB)
*obtain baseline visual acuity test,
determine color discrimination ability.

--Streptomycin
*not widely used now due to resistance.
*ototoxicity, monitor hearing function.

--New drugs are combinations of
isoniazid or rifampin, pyrazinamide.

--Drug non-compliance is a major factor for drug resistence.

Back 66

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Front 67

TB --nutrition

--encourage fluid intake
--well balance diet
--food rich in protein, Iron, and Vit C

Back 67

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Front 68

TB pt. teaching.

-- importance of medication regimen.
incompliance will cause resistance.

-- exposted family members -->tested for TB.

--continue drug therapy for its full duration of at least 6 months.
--Continue with follow-up care for 1 full year.

--check sputum sample q2 - 4 wks.
(to monitor therapy effective)
if 3 continuous (-)--> pt. not considered infectious.
--cover mouth/nose when squeezing/coughing.
-- handwashing.
--contaminated tissue should be put in plastic bags.
--active TB pt: wear mask in public areas.

Back 68

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Front 69

TB complications
-- Miliary TB
* meningitis
*Pericarditis (accumulation of fluid in pericardial sac. )

Back 69

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Front 70

Question: a nurse is taking care of a pt. who traveled to a poor country recently. As the pt coughes, the nurse noticed blood on the tissue. Which of the following actions should the nurse take?
A) initiate universal respiratory precautions.
b) consult the primary care provider and isolate the client.
c) Give pt. a breathing treatment and a mask.
d) continue with the pt.'s physical assessment.

Back 70

B. Tracel history and blood-tinged sputum indicates possible TB. Isolation precaution should be taken until the diagnosis is confirmed. The provider should be consulted to determine further management.

Front 71

Laryngeal cancer

--risk factors: smoking and alcohol
--most common:squamous cell carcinoma (slow growing)
--treatment: laryngectomy, radiation, chemotherapy

Back 71

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Front 72

Laryngeal cancer Diagnostic procedures

--X-ray, CT, MRI
consent form, NPO
--Laryngoscopy
do tumor biopsy, confirm diagnosis
informed consent, NPO
after procedure, monitor VS, bleeding and return of Gag

--Bone scan and PET scan (positive emission Tomography)
for metastasis.
assess for allergy and renal function (ability to excrete dye)

Back 72

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Front 73

Laryngeal cancer S/S
--recurrent hoarseness or sore throat
--lump in throat/mouth/neck
--Dysphagia
--persistent, unilateral ear pain
--weight loss, anorexia

Back 73

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Front 74

Laryngeal cancer

to help swallow
--crush pills to aid in swallowing
--use thickened liquids

Back 74

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Front 75

Laryngeal cancer pt. education

-- quit smoking. nicotine replacement
--appropriate techniques for stoma care and suctioning.
--diet: high in protein and calories.

Back 75

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Front 76

Laryngeal cancer

laryngectomy

--total/partial
total: lose voice, need permanent tracheostomy

during surgery, laryngectomy tube is inserted into the stoma (prevent contractures from forming)

--if nodal neck dissection (radial neck) is done, Cranial Nerve 11 will be cut, resulting in shoulder drop following surgery.
tracheostomy is created during surgery.

-- teach pt. for alternate form of communication.
-- post-op
watch for airway patency, bleeding, and pain, speech therapy.

Back 76

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Front 77

Laryngeal cancer complication
--airway obstruction
--Aspiration
to prevent aspiration, pt. should:
* sit up to eat
* avoid liquids unless a thickener has been added
* choose foods that can be formed into a bolus. (tuna salad, turkey sandwich).

Back 77

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Front 78

if pt. coughes forcefully and aspiration is possible, what should the nurse do:
1) let the pt. sit up.
2) check SaO2
3) Suction.
4) NPO
5) Notify doctor for possible aspiration.

Back 78

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Front 79

Lung Cancer
--bronchogenic carcinoma 90% of primary lung cancer.
-- Cell types
*non-small cell lung cancer (most)
*Small cell lung cancer
fast growing, almost always associated with history of cigarette smoking.
-- Stages TNM
Tumor, Nodes, Metastasis.

--Chemotherapy: primary choice for treatment.

Back 79

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Front 80

smoking history
Pack-year history= packs/day X # years smoking.

Back 80

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Front 81

lung cancer surgeries
--pneumonectomy (cut a lung)
--lobectomy
--segmantectomy
--wedge resection

After the surgery, manage chest tube and drainage system.

Back 81

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Front 82

palliative care for lung cancer:

Pain control -- PCA pump opioid analgesics

Back 82

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Front 83

lung cancer - complications

-- Superior Vena Cava syndrome
* caused by pressure placed on vena cava by a tumor
* MEDICAL EMERGENCY!
* S/S:
early: facial edema, tightness of shirt collars, nosebleeds, peripheral edema, and dyspnea
late: LOC change, cyanosis, hemorrhage, and hypotension.

* Call doctor Immediately.
* radiation and stent placement for temporary relief.

-- metastasis
* to bone
ask pt. to ambulate carefully to avoid fracture.
* to brain

Back 83

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Front 84

Pulmonary Embolism

-- MEDICAL EMERGENCY!
--risk factors
1)long-term immobility
2)Oral contraceptive use, estrogen therapy
3)smoking
4)hypercoagulability (e.g. high platelets)
5)Obesity
6)Surgery
7)Heart failure for A. fib
8)Autoimmune hemolytic anemia such as sickle cell disease.
9)Long bone fractures
10)advanced age.
11) pregnancy

Back 84

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Front 85

Pulmonary Embolism diagnostic exams
--spiral CT
--chest X-ray
--Ventilation and perfusion Scan V/Q scan, and pulmonary angiography
--ABG analysis

--D-dimer test

Back 85

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Front 86

Pulmonary Embolism S/S
--Dyspnea, air hunger
--Pleurisy
--Tachycardia, tachypnea,
--hypotension
--Anxiety, apprehension
--Adventitious breath sounds (crackles), cough
--S3,S4
--Diaphoresis
--Decreased SaO2
--Petechiae, Cyanosis
--Pleural effusion

Back 86

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Front 87

Pulmonary Embolism interventions:
--IV
--O2
--High Fowler's position
--Pain control
--Medications
1) anticoagulants:
Lovenox, heparin, Coumadin (warfarin)
2) Fibrinolytic therapy:
alteplase, Streptokinase
--Surgical:
1)Embolectomy (remove the embolism)
2)insertion of a filter in vena cava to prevent furthur emboli from reaching the pulmonary vasculature.

Back 87

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Front 88

Pulmonary Embolism
Anticoagulant therapy:
--used to prevent clot formation (clot will not get larger and no new clots form)
--Contraindications: active bleeding, peptic ulcer, history of stroke, recent trauma
--Monitor bleeding time: PT, aPTT, INR, CBC.
--Monitor for side effects of anticoagulants(thrombocytopenia, anemia hemorrhage)

Back 88

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Front 89

Pulmonary Embolism fibrinolytic therapy

--break up clots
--contraindications: same as anticoagulants therapy

Back 89

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Front 90

Pulmonary Embolism patient education
--Avoid long period of immobility
-- Control intake of food high in VitK
(green leafy vegetables) VitK will reduce the effect of warfarin.

Back 90

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Front 91

Pulmonary Embolism complications
1) Decreased cardiac output
* monitor: EKG, BP(low or high), tachycardia, cyanosis, JVD, S3, S4
pulmonary pressure
*administer IV fluid (cystalloids) to replace vascular volume.
*administer inotropic agent: milrinone(Primacor) and dobutamine(Dobutrex) to increase myocardial contractility
* Vasodilator if pulmonary artery pressure(PAP) is too high

--Hemorrhage.
*monitor: S/S of bleeding, CBC, occult blood etc.
*prevent: Avoid intramascular injection, rectal temperature and enemas, electric shavers
*treatment: IV fluid and blood products.

Back 91

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Front 92

ARF/ARDS/SARS

--classification based on ABG values

Back 92

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Front 93

Acute respiratory failture (ARF) definition:

--PaO2 < 60 mmHg
--PaCO2 > 50 mmHg
--PH< 7.3
--SaO2< 90%

Back 93

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Front 94

ARDS (acute respiratory distress syndrome)

-- a state of ARF
--indicators for ARDS:
1) persistent hypoxemia despite administration of 100% O2
2)Decreased pulmonary compliance
3)Dyspnea
4)Bilateral pulmonary edema that is noncardiac.
5)Dense pulmonary infiltrates (ground glass on chest X-ray)

--50--60% mortality rate
--injuries to alveolar-capillary membrane, surfactant activity is reduced.

Back 94

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Front 95

SARS (severe acute respiratory syndrome)

--caused by coronavirus
--spread through air droplets
--virus doesnot spread to bloodstream because it grows at slightly lower temperature (airway) below normal body temperature.

Back 95

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Front 96

Pulmonary Embolism complications
1) Decreased cardiac output
* monitor: EKG, BP(low or high), tachycardia, cyanosis, JVD, S3, S4
pulmonary pressure
*administer IV fluid (cystalloids) to replace vascular volume.
*administer inotropic agent: milrinone(Primacor) and dobutamine(Dobutrex) to increase myocardial contractility
* Vasodilator if pulmonary artery pressure(PAP) is too high

--Hemorrhage.
*monitor: S/S of bleeding, CBC, occult blood etc.
*prevent: Avoid intramascular injection, rectal temperature and enemas, electric shavers
*treatment: IV fluid and blood products.

Back 96

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Front 97

ARF/ARDS/SARS

--classification based on ABG values

Back 97

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Front 98

Acute respiratory failture (ARF) definition:

--PaO2 < 60 mmHg
--PaCO2 > 50 mmHg
--PH< 7.3
--SaO2< 90%

Back 98

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Front 99

ARDS (acute respiratory distress syndrome)

-- a state of ARF
--indicators for ARDS:
1) persistent hypoxemia despite administration of 100% O2
2)Decreased pulmonary compliance
3)Dyspnea
4)Bilateral pulmonary edema that is noncardiac.
5)Dense pulmonary infiltrates (ground glass on chest X-ray)

--50--60% mortality rate
--injuries to alveolar-capillary membrane, surfactant activity is reduced.

Back 99

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Front 100

SARS (severe acute respiratory syndrome)

--caused by coronavirus
--spread through air droplets
--virus doesnot spread to bloodstream because it grows at slightly lower temperature (airway) below normal body temperature.

Back 100

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Front 101

Pulmonary Embolism complications
1) Decreased cardiac output
* monitor: EKG, BP(low or high), tachycardia, cyanosis, JVD, S3, S4
pulmonary pressure
*administer IV fluid (cystalloids) to replace vascular volume.
*administer inotropic agent: milrinone(Primacor) and dobutamine(Dobutrex) to increase myocardial contractility
* Vasodilator if pulmonary artery pressure(PAP) is too high

--Hemorrhage.
*monitor: S/S of bleeding, CBC, occult blood etc.
*prevent: Avoid intramascular injection, rectal temperature and enemas, electric shavers
*treatment: IV fluid and blood products.

Back 101

-

Front 102

ARF/ARDS/SARS

--classification based on ABG values

Back 102

-

Front 103

Acute respiratory failture (ARF) definition:

--PaO2 < 60 mmHg
--PaCO2 > 50 mmHg
--PH< 7.3
--SaO2< 90%

Back 103

-

Front 104

ARDS (acute respiratory distress syndrome)

-- a state of ARF
--indicators for ARDS:
1) persistent hypoxemia despite administration of 100% O2
2)Decreased pulmonary compliance
3)Dyspnea
4)Bilateral pulmonary edema that is noncardiac.
5)Dense pulmonary infiltrates (ground glass on chest X-ray)

--50--60% mortality rate
--injuries to alveolar-capillary membrane, surfactant activity is reduced.

Back 104

-

Front 105

SARS (severe acute respiratory syndrome)

--caused by coronavirus
--spread through air droplets
--virus doesnot spread to bloodstream because it grows at slightly lower temperature (airway) below normal body temperature.

Back 105

-

Front 106

Pulmonary Embolism complications
1) Decreased cardiac output
* monitor: EKG, BP(low or high), tachycardia, cyanosis, JVD, S3, S4
pulmonary pressure
*administer IV fluid (cystalloids) to replace vascular volume.
*administer inotropic agent: milrinone(Primacor) and dobutamine(Dobutrex) to increase myocardial contractility
* Vasodilator if pulmonary artery pressure(PAP) is too high

--Hemorrhage.
*monitor: S/S of bleeding, CBC, occult blood etc.
*prevent: Avoid intramascular injection, rectal temperature and enemas, electric shavers
*treatment: IV fluid and blood products.

Back 106

-

Front 107

ARF/ARDS/SARS

--classification based on ABG values

Back 107

-

Front 108

Acute respiratory failture (ARF) definition:

--PaO2 < 60 mmHg
--PaCO2 > 50 mmHg
--PH< 7.3
--SaO2< 90%

Back 108

-

Front 109

ARDS (acute respiratory distress syndrome)

-- a state of ARF
--indicators for ARDS:
1) persistent hypoxemia despite administration of 100% O2
2)Decreased pulmonary compliance
3)Dyspnea
4)Bilateral pulmonary edema that is noncardiac.
5)Dense pulmonary infiltrates (ground glass on chest X-ray)

--50--60% mortality rate
--injuries to alveolar-capillary membrane, surfactant activity is reduced.

Back 109

-

Front 110

SARS (severe acute respiratory syndrome)

--caused by coronavirus
--spread through air droplets
--virus doesnot spread to bloodstream because it grows at slightly lower temperature (airway) below normal body temperature.

Back 110

-

Front 111

ARF/ARDS/SARS treatments

--Mechanical ventilations. PEEP is often used.

--Patent airway
(suction, breath sounds, SaO2, ABG etc)

--Medications
*sedatives for anxiety
Lorazepam (Ativan)
midazolam(Versed)
Propofol(Diprivan)
*Analgesia
morphine
fentanyl(Duragesic)
*Neuromuscular blocking agents
vecuronium ( Norcuron )
Give pain, and sedate with NM blocking agent.
Pain, sedate and NM blocking agents are often used to facilitate painful ventilatory modes (inverse ratio ventilation and PEEP)
* Corticosteroids
decrease WBC migration and help to stablize the alveloar-capillary membrane during ARDS.
Cortisone, methylprednisone, dexamethasone

Back 111

-

Front 112

ARF/ARDS/SARS complications

--decrease cardiac output and fluid retention
*(PEEP) increased intrathoracic pressure and leads to a decreased blood return to the heart-->decreased CO
*hypotension
*kidney flow decrease-->fluid retention.
*Monitor I/O
*Teach pt. to avoid the valsalva maneuver.

---Barotrauma
*damage caused by ventilation to lungs

Back 112

-

Front 113

ARF/ARDS/SARS
propofol (Diprivan)
--contraindications: hyperlipidemia & egg allergies.
--monitor EKG,
--drip must be slowed down to assess neurological status.

Back 113

-

Front 114

Tension pneumothorax
--pneumothorax compress the blood vessels and limit venous return-->decreased cardiac output.

--death soon if not treated.

--Tracheal deviation to the unaffected side

--Asymmetrical chest wall movement

Back 114

-

Front 115

-pneumothorax:

Subcutaneous emphysema (air accumulation in subQ tissue)

Back 115

-

Front 116

pneumothorax treatments

--chest tube
--medications
* anxiolytics
Lorazepam (Ativan)
midazolam (Versed)

*Analgesia
morphine / fentanyl

Back 116

-

Front 117

Chest tube insertion

--insert large-bore needle into the 2nd intercoastal space may be done to alleviate pressure before chest tube insertion with tension peumothorax.

Back 117

-

Front 118

Pneumothorax complication

--Decreased cardiac output
-- respiratory failure

Back 118

-

Front 119

respiratory failure definition

-- PaO2 < 60 mmHg,
PaCO2 > 50 mmHg
PH 7.30
SaO2 < 90%
--Dyspnea
--Orthopnea
--Change in respiratory rate, pattern or working of breathing
--change in lung sounds.
--SpO2
--EtCO2
- Hemodynamic monitoring (PA and ABP)

Back 119

-

Front 120

Etiology for respiratory failure

-- oxgenation failure
(inadequate O2 transfer between the alveoli and the pulmonary capillary bed.
PaO2 60 mmHg or less.

--Ventilatory failure
Defined by a PaCO2 > 45 mmHg

Back 120

-

Front 121

nursing Dx for resrpiratory failure
-- Impaired gas exchange r/t alveolar/capillary membrane changes, respiratory center depression, respiratory muscle weakness

--ineffective breathing pattern r/t decreased lung compliance, respiratory center depression, and respiratory muscle weakness.

--Inability to sustain spontaneous ventilation r/t respiratory center depression
--Ineffective airway clearance r/t secretions and ET tube

Back 121

-

Front 122

endotracheal intubation equipment

-- Tube size 7.5-8.5
--Laryngoscope
--suction
--topical anesthetic and or IV analgesia
--Lubricant (water soluble)
--tape
--stethoscope
--Ambu bag
--Pt. position "sniffing position"
--IV, EKG, Pulse Ox. monitor
--CO2 detector "gold is good"

Procedure for intubation:
--hyperventilate before intubation
--intubate around 15 to 30 sec.
--Inflate cuff about 25 cc.
--ausculate for breath sounds
--Observe for bilateral chest expansion
--Stabilize ET tube
--Chest X-ray to double check position

Back 122

-

Front 123

Tracheostomy-- used for long term air way maintenance

Back 123

-

Front 124

Complications during intubation:

1) Airway trauma
2)Hypoxia
3) Hypotension
4)Dysrhythmias
5) Intubation of esophagus or right main stem bronchus
6)Laryngospams /bronchospasm

Back 124

-

Front 125

to prevent aspiration, the balloon of the ETT tube has been sealed very good.

Back 125

-

Front 126

Ventilator associated pneumonia (VAP) preventions:
--Hand washing
--Maintain vent circuits, suction set ups
--Oral care with Peridex (chlorhexidine) and tooth brushing
--Oral vs NG intubation and gastric feeding
--Antibiotics prophylaxis
--increased HOB to prevent aspiration
--Frequent residual checks on tube feeding
--Sedation vacations, readiness to wean extubate.
--peptic ulcer (prophylaxis)

Back 126

-

Front 127

Types of ventilators

1)Negatives --used most for neuromuscular disease
Iron lung,
cirass,
body wrap

2) Positive pressure
non-invasive: CPAP, BiPAP
Invasive:
volume cycled,
pressure cycled,
Time cycled
Microprocessor ventilators (Bear IV, puritan Bennett 7200, Sieman's servo, etc)

Back 127

-

Front 128

Modes of ventilation

-- Controlled mandatory ventilation
pt. no spontaneous breathing
Pt. receives a set tidal volume
and a set rate
--AC (assist-control)
set rate.
if spontaneious breath, deliver set volume.
the patient can control the rate.

-- SIMV synchronized intermittent mandatory ventilation
similar to AC mode: rate and tidal volume are set.
Unlike AC: pt. can breath with own rate and tidal volume between delivered breaths.

--PSV (pressure support ventilation)
pt. spontaneous breathing
no breathing delivered from machine
only pressure support 5-10 cmH2O pressure

--CPAP (continuous pressure airway support)
only pressure support
keep alveoli open

Adjuncts to mechanical ventilation

--PEEP (positive end expiratiory pressure)
invasive
complications:
barotrauma,
decreased cardiac output,
hypotension
Different from CPAP: pressure at the end of the expiration.
CPAP: pressure support throughout the entire respiratory cycle.
similar to PEEP but can not not invasive.
used to help wean clients.

Back 128

-

Front 129

Ventilator setting

--tidal volume (Vt) usually 6-7 ml/kg

--FiO2: 21 (RA)--100%

--Sign: breath with 1.5-2 times present tidal Volume (Vt)

Back 129

-

Front 130

Ventilaor
alarm set
-- low pressure: loss of pressure in the system: disconnect or leak in the system

-- High pressure: sputum, condensation fluid, coughing, pneumothorax etc.

Back 130

-

Front 131

Ventilation

--Items at bedside
Suction equipment
Ambu bag
Back up trach tube
10 cc syringe

Back 131

-

Front 132

Airway suctioning

--needs (coughing, coarse rhonchi, high pressure, low SaO2)
--sterile technique
--hyperoxygenate (100%)
pressure < 120 mmHg
Time < 15 sec.

--if dysrthythmia or SaO2<85% --->STOP!!

Back 132

-

Front 133

Weaning from ventilation:
Creteria needs to be met:
1) awake, alert
2) negative inspiratory pressure > -20 cmH2O, PEEP < 5cm

3) No respiratory depressant drugs or anesthesia

4) Protective reflexes (gag, cough) intact, patent airway.

5) stable Cardiovascular system.

6) clear Chest X-ray and breath sounds.

7) ABG within normal limits

8) rapid shallow breathing index

9)Techniques used to wean:
IMV, SIMV, PSV, CPAP.

Back 133

--

Front 134

ARDS
--alveolar capillary membrane damaged --> more permeable to intravascular fluid. --> alveolar filled with fluid-->severe dyspnea.

Back 134

-

Front 135

ARDS pathophysiology

NON-CARDIOGENIC pulmonary edema.

1) alveolar capillary membrane damage

2) Decreased production of surfactant

Back 135

-

Front 136

ARDS chest X-ray
--"White Out"

Back 136

-

Front 137

ARDS interventions

--Ventilation wit PEEP

-- Positioning (Prone position)

--Fluids and electrolytes

-- medications
morphine
sedatives / paralytics
Heparin
Diuretics

Back 137

-

Front 138

ARDS Nursing Dx:

1) Impaired gas exchange

2) Ineffective breathing pattern
r/t lung compliance

3) Activity intolerance

4) ineffective airway clearance
5) altered nutrition less than body required r/t hypoxia and fatigue

6) Fear
7) potential for infection

Back 138

-

Front 139

Anticoagulation therapy
(prevent clot formation)

*****Heparin
--Use:
initiate: 5000 --10000 units IVP
Following: 1300/24hr, continuous IV for 5-10 days.
Dose monitored and adjusted by PTT.
Keep PTT 2-2.5 times norm.
INR 2-3

Antidote: protamine sulfate.

Back 139

-

Front 140

Coumadin:

--Use: anticoagulants for Pulmonary embolism.
--Dose: 40-60 mg with maintenance dose 5-10 mg QD for 3 to 6 weeks. Effective anticoagulation will reach about 12-24 hours.

--Change from heparin to Coumadin: start coumadin 3-4 days before stop heparin.

-- Dose adjust: PT 1.5-2.0 times norm
INR: 2-3

-- Antidote: vitamin K

Back 140

-

Front 141

Thrombolytic agents

- streptokinase, tissue plasminogen activator

--complication: SKin rash, anaphylaxis, bleeding.

Back 141

-

Front 142

Expectation after ventilation:

Hoarseness

Back 142

-

Front 143

Detection of a barotraumas:

--one side of lung diminished,
--tracheal deviation.

Back 143

-

Front 144

invasive Mechanical Ventilation Rapid Sequence Intubation (RSI)

--O2
--Sedate (Versed, Etomidate)
--Neuromuscular blocking agent
--intubation

Basic protocol
--Preparation 100%
--Midazolam(Versed)
--Cricoid pressure
--Succinylcholine 1 mg/kg IVP (100mg)
--Intubate

Back 144

-

Front 145

rapid sequence intubation (RSI)

General protocol
1. Atropine
prevent vagally stimulated
bradycardia
2. control Intracranial pressure (ICP)
Lidocaine
Fentanyl

3. Sedation
*Preferred medication:
Etomidate
Midazolam (Versed)
*other drugs:
thiopental
Ketamine

4. Muscle Relaxants
Succinylcholine
Vecuronium
Pancuronium

Back 145

-

Front 146

respiratory acidosis interventions

- Aggressive chest physical therapy
--position
--coughing, deep breathing
--aerosol therapy
--suctioning

--assess: LOC, SaO2, respiratory functions.

Back 146

-

Front 147

Respiratory alkalosis interventions

--relax the patient: pain meds,
--teach pt. relax and deep, regular breath
--breath into paper bag (not common in ICU)

Back 147

-

Front 148

Metabolic acidosis interventions

--Monitor I/O and electrolyte
correct I/O and electrolytes

--prevent infection
--monitor arrhythmia
--protect from injury
--monitor ABG

Back 148

-

Front 149

metabolic alkalosis interventions

reasons: vomit (loss of gastric secretion), overuse of antaacids, K+-wasting diuretics

--monitor VS, I/O, and electrolytes.
--Protect pt. from injury.

Back 149

-

Front 150

for pt. with TB infection, to safely obtain the X-ray, the pt. can wear an isolation mask and have the X-ray done on radiology dept.

Back 150

-

Front 151

perform an Allen's test before obtain ABG.

Back 151

-

Front 152

fremitus

Back 152

-Tactile fremitus: the palpation of the chest tube while while the client repeats a syllable such as "nine-nine". Fremitus is increased over solid tissue or a tumor.

Front 153

crepitus

Back 153

-subcutaneous emphysema.

Front 154

chest tubes

-- use of one chest tube on the operative side would only be typical for penumothorax or tramatic chest injury.

-- Most thoracic surgical clients would require two chest tubes on the operative side.( upper to evacuate air, the lower one to drain blood and fluid.)

--bilateral chest tubes woule be very unusual and would only follw surgical procedures where both pleural spaces were entered.

--Pneumonectomy: remove an entire lung. No chest drainage will be necessary.

Back 154

-

Front 155

when remove chest tube, instruct the pt. to: Exhale and bear down gently:

a gentle Valsalva maneuver is recommended to maintain amount of negative pressure in the chest to prevent the air entry into the pleural space.

Back 155

-

Front 156

eosinophils increased for Asthma attack

Back 156

-

Front 157

tracheostomy care:

inner cannula: if not diaposable, must be removed, cleaned with hydrogen peroxide, and rinsed with saline

Back 157

sitz baths will help post-op care of hemorrhoids

Front 158

a pt. with laryngectomy. then the laryngectomy tube is dislodged. The nurse should teach the client to first keep calm because there is no immediate emergency. (the stoma will stay open long enough so that another tube can easitly be inserted. )

Back 158

for a pt. with incrased ICP, ismetric exercise will increase basal metabolic rate and ICP.

Front 159

-

Back 159

lidocaine

side effects: may cause tremors and seizures or convulsions. (Tremors are precursor to the major seizures and convulsions)

Front 160

crackles -- heard on inspiration and sometimes clear with a cough

Back 160

COPD:

--dyspnea
--barrel chest
--clubbed fingers and toes
--prolonged expiration

Front 161

theophylline

--therapeutic level: 10--20 mcg/ml

Back 161

asthma

-- take bronchodilator first (Serevent (salmeterol) then triamcinolone (Azmacort)
--then take corticosteroid.

Front 162

Measles -- respiratory isolation
Chickenpox -- strict isolation
impetigo -- contact isolation
cholera -- enteric isolation

Back 162

only penicillin G aqueous can be administered I.V.

Front 163

Codeine

--start to work in 30 min. (oral)

Back 163

the nursing staff is divided over withdrawing care from a competent, chronically ill pt. The nurse manager should take which step to meet the needs of her staff:

contact the institutional ethics committee

Front 164

a client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse should pulg the opening in the tube for
5 to 20 min. , then gradually lengthen this interval according to the client's respiratory status.

Back 164

theophylline toxicity:

GI disturbance (N/V/D)

Front 165

TB pt. will be on isolation for 2 weeks after starting the anti-tuberculosis therapy, after 2 wks, the pt. is NOT contagious.

Back 165

Legionnaires' disease

drug of choice

-- Erythromycin (Erythrocin)

Front 166

Acetylcysteine

-- used cautiously with asthma patient because it may induce bronchospasm.

Back 166

respiratory excursion

--to assess chest movement

Front 167

percussion:

normal lung: resonant sounds
penumothorax: hyperresonant sounds

Back 167

empyema

--accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection.

Front 168

bronchophony

-- "ninety-nine"

Back 168

a client with chronic sinusitis

Front 169

albuterol
-- may cause nervousness

Back 169

prophylactic treatment for client exposed to TB

-- daily dose of isoniazid 300 mg for 6 m to 1 year.

Front 170

for a client with advanced COPD, which nursing action beset promotes adequate gas exchange?

-- use a high-flow venturi mask to deliever O2 as prescribed.

Back 170

-

Front 171

Chest tube: Teh fluctuation in water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respiration.

air-leak meter -- not chamber---
defects leaking from the pleural space.

Collection chamber: connect chest tube from the client to the system.

Drainage from tube drains into and collects in a series of calibratedf columns in this chamber.

The suction control chamber provided the suction.

Back 171

-

Front 172

Albuterol (Proventil) may cause
: nervousness

also can cause hypokalemia ( may be used for hyperkalemia)

Back 172

Solu-Medrol
(and other steroids ) may cause GI bleeding and wound infection.

To prevent GI bleeding, antacid or H2-receoptor inhibitor (Pepcid, protonix) may be used.

Front 173

Albuterol (Proventil) may cause
: nervousness

also can cause hypokalemia ( may be used for hyperkalemia)

Back 173

Solu-Medrol
(and other steroids ) may cause GI bleeding and wound infection.

To prevent GI bleeding, antacid or H2-receoptor inhibitor (Pepcid, protonix) may be used.

Front 174

Theophylline

Toxicity:
1. GI (n/v/d/epigastric pain)
2. Neuro ( headache, irritability, restless insomnia dizziness (rare)

Back 174

-

Front 175

aminophylline (Aminophyllin)

therapeutic theophylline level is 10 to 20 mcg/ml

Back 175

-

Front 176

PE:

EKG manifest:

-- new onset RBBB
-- new onset A. fib

V/Q scan: mismatch of ventilation and perfusion.

Back 176

Oral contraceptives:

will increase risk for PE

Front 177

PE pt:
treatment:

-- Levonox
or heparin
or anti-thrombin III binder (fondaparinux)

Back 177

if pt with PE are already on Coumadin at home, INR already
maintained in therapeutic level 2.0--3.0, then no other prophylaxis is required.

Front 178

PE: S/S:

-- tachypnea,
-- tachycardia
-- hypotension
-- diaphoresis

Back 178

Exams for PE:

-- CT of chest with contrast
(Spiral CT)
Needs contrast, not good for renal failure pt.
-- V/Q scan
a good choice for renal failure pt.
-- pulmonary angiography
(gold standard)
also needs contrast.

Front 179

PE:

pt will be on anticoagulants for 3 months after discharge.

-- for recurrent episodes of PE,
(inferior vena cavae filter: IVC filter, aka: "Greenfield Filter" will be installed.

Back 179

ALI (acute lung injury)

-- PaO2 / FiO2 <= 300

Front 180

ARDS (Acute Respiratory distress syndrome)

-- PaO2/ FiO2 < = 200

Back 180

-

Front 181

Typical pathogens for community-acquired pneumonia:

-- Strep. pneumoniae
-- Haemophilus influenza
-- Moraxella catarrhalis
(previously called Branhamella)

Atypical pathogens:

-- Legionella
-- Mycoplasma
-- Chlamydia pneumonia.
-- Klebsiella pneumoniae
-- (aspiration in chronic alcoholics)
-- Staphylococcus aureus (most viral pneumoniae)
-- Pseudomonas aeruginosa

Back 181

aspiration pneumonia:

-- doctor often add clindamycin or metronidazole to the treatment to cover anaerobes.

Front 182

hospital-acquired (Nosocomial) Pneumonia (HAP)

-- develops at least 72 hours after being admitted.

Back 182

Asthma:

treatment focus:
1. Bronchodilation (albuterol)
2. control inflammation (steroids)

Front 183

How to prevent VAP (ventilator-associated Pneumonia)?

Back 183

-- Wearing gloves when in contact with respiratory secretions, when removing /moving ETT, when clearing secretions (CDC recommended)

-- Changing gloves between contact with a "dirty" body site and a "clean" body site. (CDC recommended)

--Routine Oral Care (Brush pt's teeth per shift, minimize using of saline lavage. Oral Care q4hr.

-- elevate HOB
-- Use subglottic suction when necessary.

-- Daily interruption of sedation

-- Prophylaxis for peptic ulcer disease

-- prophylaxis for deep venous thrombosis

-- Hyperoxygenation with 100% O2 before/after suction.

Front 184

Bronchophony??

Back 184

-- an increased intensity and clarity of voice sounds heard over a bronchus surrouded by consolidated lung tissue.
over noral lung tissue, the words are unintelligible, however, over areas of tissue consolidation, such as with pneumonia, the words are clear because tissue enhances the sounds.

Front 185

Egophony--?

Back 185

-- egophony : an abnormal change in tone heard when the pt speaks normally as the nurse ascultates his chest.

Front 186

Mucomyst --(acetylecysteine):

before giving to pt, check if pt has hx of
asthma.
--- Mucomyst may induce bronchospasm

Back 186

stridor -- with inspiration and expiration
may related with foreign body aspiration.

Front 187

To help prevent airway obstruction and reduce risk of aspiration, the nurse should position a client with hemiparesis on the affected side.

Back 187

--chest physiotherapy (Percussion & vibration, postural drainage)

the nurse should perform chest physiotherapy at least 2 hours after a meal to reduce the risk of vomitting and aspiration.

(preform before a meal may tire pt and impair the ability to eat. )

Front 188

Percussion and vibration may worsen bronchospasms,

-- contraindicated in pt. with bronchospasms.

Back 188

Secretions that have mobilized (especially when suction equipment isn't available) are a contraindication for postural drainage.

Front 189

Pancuronium bromide (Pavulon) , a nondeplorizing blocking agent, used for muscle relaxing and paralysis.
-- It assist ventilation by promoting intubation.

-- if pt is fighting with the ventilatior, RN can give dose IV q20 min or Q 60 min.

Back 189

-

Front 190

acetylcysteine (Mucomyst) must be used carefully for pt with asthma because it may cause broncospasm.

Back 190

--

Front 191

Sepsis:

-- has the great risk for ARDS

Back 191

-

Front 192

Intrapulmonary shunt occurs when perfusion > ventilation or normal vent. relative to increased perfusion

Back 192

-

Front 193

normal theophylline level:

10--20 mcg/ml

Back 193

-

Front 194

Theophylline:
side effects:

-- GI (N/V anorexia)
-- dysrhythmias
-- CNS (tremors, seizures)

Back 194

-

Front 195

PEEP:

- keeping alveoli open, PEEP decreases alveolar surface tension.

Back 195

-

Front 196

Positive Pressure ventilation

-- causes ADH secretion which will cause water retention.

Back 196

--

Front 197

A 48 yrs male pt admitted with Acute Respiratory Failure just extubated himself, now he has inspiratory stridor and hoarseness. Appropriate intervnetions include reassurance, humidified O2, and:

a. Bronchodilators.
b. Corticosteroids
c. Antibiotics
d. Diuretics

Back 197

answer: b.
Corticosteroids are used to reduce
mucosal swelling.

Front 198

which of the following statements is true regarding a Heimlich valve?

a. it is usually is connected to suction
b. pt. must remain in hospital when the chest tube is connected to a Hemlich valve.
c. It usually is attached to a drainage bag
d. it increases the patient's mobility

Back 198

--answer: d
Heimlich valve are used for helicopter transport, to increase physical mobility and to allow the patient to go home because they prevent the need for water -seal drainage.

Front 199

DO2:

-- O2 delivered to tissue

Back 199

-

Front 200

VO2:

-- the consumption of O2 by tissue.
( calculate by difference of SaO2 and SvO2)

Back 200

-

Front 201

Permissive hypercapnia:

-- use low tidal volumes

Back 201

-

Front 202

cromolyn sodium (intal)

--stablize epithelial mast cells, thereby reducing the

Back 202

-

Front 203

J receptors are stimulated by increase in interstitial fluid volume.

-- stimulation of J receptors may cause laryngeal constriction, hypotension, bradycardia, mucous production, and dyspnea.

Back 203

-

Front 204

Therapeutic level of digoxin:

--0.5 - 2.0 ng/ml

Back 204

-

Front 205

Chest tube:
--should not have continuous bubbling in water-seal chamber, which indicates leaking.

Back 205

-

Front 206

First line meds used for asthma:

1. beta2 agonist: -- usually the first bronchodilator used in asthma.
2. Corticosteroids: important and first line.
3. O2 also needed as first line.

Back 206

-

Front 207

The goal of successful asthma management:

-- Peek expiratory flow rate of more than 80% of personal or predicted best.

Back 207

-

Front 208

chest tube:
water in water-seal chamber falls during inspiration and rises during expiration: normal pleural pressure changes

Back 208

-

Front 209

Beta2 agonist agents: side effects:

-- Tachycardia, tremor, and hypokalemia

Back 209

-

Front 210

Public tap water contains often:

--Legionella

Back 210

-

Front 211

Pt pulled out Triple Lumen central line accidentally. possible air embolism happens, put pt in position:

-- Head DOWN and on his LEFT
(Durant's maneuver)

(this will prevent air embolus from entering the R. Ventricle outflow tract and allows time for air to be absorbed.)

Back 211

-

Front 212

the primary difference between a tracheostomy tube and a laryngectomy tube ?

Back 212

- The laryngectomy tube does not have a cuff

(a cuff is not necessary because food and fluid from the mouth can go only to the esophagus and the stomach, and air going into the laryngectomy tube can go only into lungs. The only way this patient can aspirate is if a fistula develops because the anatomy has been surgically altered by removal of the larynx.)

Front 213

Which of following ensures a specific O2 concentration?

a. NC
b. simple mask
c. Venti Mask
d. partial rebreathing mask

Back 213

answer: c.
Venturi mask is high-flow O2 delivery system that delivers a specific O2 concentration that is not affected by pt's respiratory rate and depth.

other (NC, simple mask and partial rebreath. mask) are low O2 delivery systems in which O2 concentration is affected by pt's RR and depth.

Front 214

Inhaled corticosteroid may have adverse effects: hoarseness

also can cause oral fungal infection
(always ask pt to rinse mouth after use)

Back 214

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Front 215

Prevent O2 toxicity:

-- if FiO2 = 100%, keep FiO2 100% < 1 day
-- Keep FiO2 > 60%, use no more than 2 to 3 days.

Back 215

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Front 216

External respiration:

O2 exchange in lungs (across alveolar-capillary membrane)

Back 216

internal respiration:

in Cell level ( cell uses O2 to make ATP)

Front 217

O2 supply:
NC (Nasal Cannula ) FiO2: 24-- 44%:

1 L ------ 24%
2 L -------28%
3 L ------ 32%
4 L ------ 36%
5 L ------ 40%
6 L ------- 44%
( 4 L and above must have humidifier)
Can not be higher than 6 L

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Front 218

O2 Supply
Simple Mask ( 40--60% )

-- Not accurate for Fi O2
-- 6 L ---- 10 L

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Front 219

O2 Supply:

Venti-Mask ( 24% -- 55% )

Blue Adapter: 24 --- 31%
2 L ---- 24%
3 L ---- 28%
4 L ---- 31 %
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White Adapter: 30---55 %
4L ---- 30%
6L --- 35%
8 L --- 40%
10 L ---- 45%
12 L ---- 50 %
14 L ----- 55%

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Front 220

O2 Supply:

Non-rebreather Mask: 90--100%

10 L -- 15 L

Reservior bag should be full at all times, NOT so much that it looks like it's going to burst

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Front 221

During O2 therapy:

Avoid smoking and use of any open flame

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Front 222

Ventilator Initial Setting:

-- AC
-- VT 8--10 ml/kg ( 600 ml usually starting volume)
-- Rate 12--16/min
-- Fi O2 100%, then titrate down.
-- PEEP 5
-- Inspiratory Flow: 50 L/min I:E = 1:2
-- Peak Pressure: 50 cmH2O
-- CXR: ETT ideally 5 cm above corina

Back 222

Sedation used during intubation:
Ativan
Versed
Fentanyl

If sedation is not enough, paralysis may be used:
Atracurium ( Main Paralytic)
Succinylcholine ( Short acting paralytic)

Propofol drip sedation.

Front 223

O2 toxicity: S/S
non-productive cough,
substernal pain,
nasal stuffiness,
n/v,
fatigue,
headache
sore throat
hypoventilation,
very high Sa O2

Action: Decrease O2 flow

Back 223

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Front 224

which of the following is not a likely cause of respiratory acidosis:

--pulmonary embolism

Back 224

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Front 225

BiLevel (not the same as BiPaP ) and airway pressure release ventilation allow the PEEP level to be reduced periodically to clear the AUTO-peep and CO2 accumulation.

Back 225

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Front 226

how to: pericardiocentesis?

Back 226

Procedure to relieve cardiac tamponade
Placed with torso elevated at a 45o angle
A 16 or 18 gauge needle, 6 inches long with an over the needle catheter is attached to a 60 ml syringe
The needle is inserted at a 45o angel, lateral to the left side of the xiphoid, 1 to 2 cm inferior to the xiphochondral junction
Blood is aspirated until non-clotted pericardial blood is withdrawn
Blood removed from the pericardial sac will generally not clot

Front 227

Chest Tube management:

Back 227

Chest drainage unit below the level of the chest
Clamping of chest tubes before fully re-expanded lung may cause a tension pneumothorax
Document fluctuation in the water sealed chamber, output, color, and air leak
During transport, clamping of chest tubes is contraindicated
Notify physician if initial drainage output is > 1,500 ml or if continued blood loss > 200 ml per hour
Tubing should be coiled without kinks

Front 228

Where are chest tubes placed?

Back 228

Insertion site is the 4th or 5th intercostal space at the inferior or mid axillary line

Front 229

What is the procedure for a needle thoracentesis?

Back 229

A 14-gauge needle is inserted in the 2nd intercostal space in the mid clavicular line on the effected side

Front 230

What is a tension pneumothorax?

Back 230

Air enters the plural space on inspiration
Air cannot escape on expiration
Rising intrathoracic pressure causes collapse the lung, mediastinal shift, compression of the heart, great vessels, trachea, and opposite lung
Decreased venous return, cardiac output, and hypotension
Immediate needle decompression should be performed – do not wait for tests or the physician – you have very few minutes to save the patients life

Front 231

At what level should penetrating injuries be considered as possible injuries to the diaphragm?

Back 231

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Injuries below the nipple line

Front 232

What are the signs of a ruptured diaphragm?

Back 232

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Abdominal pain
Bowel sounds in the chest
Decreased breath sounds on the injured side
Dysphagia
Dyspnea
Left shoulder pain (Kerr’s sign)
Sharp epigastric or chest pain

Front 233

Q: When is an uncuffed endotracheal tube indicated in children?

Back 233

A: Children < 8 years - because the cricoid cartilage is the narrowest portion of the trachea

Hint 233

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Front 234

Question: T/F: Children under 8 years of age rely primarily on movement of the diaphragm for breathing.

Back 234

Ans:

True
Immature intercostal muscles
Passive gastric air from crying may affect ability to ventilate adequately

Front 235

Question: T/F: A respiratory rate > 60 breaths per minute is abnormal for any child.

Back 235

Answer:

True
Neonate: 40 – 60
Infant: 30 – 60
Toddler: 24 – 40
Preschooler: 23 – 34
School age: 18 – 30
Adolescent: 12 – 16

Hint 235

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