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144 Cards in this Set
- Front
- Back
External respiration
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aka: ventilation
mechanical part of breathing breathing in and out |
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Where does diffusion occur?
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Between the alveoli and blood vessels
Must pass through capillary membranes Exchanges O2 for CO2 |
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Transport
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the process of oxygen getting to all of the tissues and organs
Must have a clear path |
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Internal respiration
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AKA: tissue diffusion
O2 is exchanged for CO2 within the cells |
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Dead Space
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The % of inspired volume of air that does not take place in gas exchange
Well ventilated alveoli Poor or no blood supply |
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Shunting
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Blockage in the alveoli
Good blood supply airway obstruction prevents air from reaching blood supply |
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Causes of shunting
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fluid infiltration, chronic/acute obstruction, brochial constriction, pneumonia
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PaO2
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partial pressure of O2 in bloodstream
BEST INDICATOR OF 02 STATUS find via an ABG |
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What is the best indicator of O2 status?
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PaO2
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When is a pt in respiratory failure?
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PaO2 less than 200
PaO2 less than 300 if other organs are failing |
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Patho of COPD
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alveoli lose elasticity
extra air stays in alveoli diaphragm pushed down shallow breaths chest expands more intercostal muscles overworking |
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COPD characteristics
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Barrel chest
chronic hypoxia CO2 retention LOW PaO2- normal HIGH PCO2- normal Increased RBC=viscous blood=risk for blood clots central cyanosis right ventricular hypertrophy weight loss tripod position |
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Best way to check for central cyanosis?
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Mucus membranes and lips
Characteristic of COPD |
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Nasal Cannula O2 delivery
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up to 6L
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Which type of O2 delivery device is preferred for increased humidification?
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Face tent
open mask that sits below the chin gives lots of humidified air |
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Venturi Mask
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very precise delivery of O2
used with COPD pts because we can measure exactly how much O2 they are getting |
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True/False
When giving ABG results, you should only report abnormal results. |
FALSE
Always report ALL values Must report how much O2 the pt is on |
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SpO2
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peripheral O2 reading
read by clip on finger |
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FiO2
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how much O2 we are giving our patient
|
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What is a normal pH for COPD pts?
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NORMAL pH range!
close to being acidodic (7.36ish) pH will fall when compensatory mechanisms fail |
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Which causes ventricular irritability?
Alkalosis or Acidosis |
Acidosis
|
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When does a pt acquire CAP?
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in the community or within 48 hrs of hospital admission
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What does the CURB-65 assess?
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Assesses severity of CAP
C- confusion U- Urea/BUN R- Respiratory rate B- BP |
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The first sign of hypoxia is......
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Confusion
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You must give an antibiotic within ________ hours of a CAP pt walking in the door. (door to dose rule)
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4 hours
Get a sputum sample |
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Aspiration pneumonia/pneumonitis
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Aspiration is main cause
No pathogen involved Secondary illness can occur |
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Benefits of NIPPV
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Pt can still eat and talk
Can be used intermittantly Can be used for DNI pts Reduced complications No need for sedation Reduces work load of breathing Promotes CO2 removal Non-invasive |
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Adverse effects of NIPPV
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Sinus pain
Flatulence (air may get into GI tract) |
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Candidates for NIPPV
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Severe COPD pts with exacerbation
cardiogenic pulmonary edema pt that came off of ventilator and cannot breathe on their own |
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Pts to NEVER give NIPPV to
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Pts needing sedation
Pts that have been vomiting Pts that won't tolerate it |
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Special consideration of a Nasal Mask
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Must keep mouth closed or else the air will come right back out
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What must be worn with NIPPV?
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Dentures
Impossible to get a good seal without them in |
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Who can intubate a pt?
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doctor or CRNA
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Nursing implications during intubation process
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Oxygenate with ambu bag before procedure
Suction Obtain and check equipment Blow up cuff on ET tube Hyperextend pt's head- nose to the ceiling Take headboard off Monitor O2 and EKG Apply cricoid pressure |
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What do you do if your pt is having PVCs or low O2 sats during the intubation process?
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STOP the person that is intubating and bag the pt
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Assesment after post-intubation procedure
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Auscultate- blow up cuff, bag pt, listen
Look at chest/stomach to see what is rising Placement with CO2 detector- purple means in the lungs Secure if placement confirmed Get a chest xray |
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Gold standard for ETT placement confirmation
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CHEST X RAY
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What meds are given with RSI?
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RSI: Rapid sequence intubation
Sedation (Versed) AND NMBA (paralytic) |
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How often do you reposition an intubated pt?
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Every 24 hours
Change the position of ET tube in mouth |
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How often is oral care done on intubated pts?
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Every 2 hours
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HOB elevation for intubated pts
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at least 30 degrees
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Ideal cuff pressure for intubated pts
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20-25 mmHg
Put 10cc into cuff then have RT check pressure |
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Indications for Venilator
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Respitory failure
To monitor respirations during surgery |
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The actual volume of air pushed in by the ventilator machine with each breath is the _________________
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Tidal volume
|
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The number of times a minute the ventilator delivers a breath is the ___________________
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Rate
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PEEP
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Positive end respiratory pressure
Generally see 5-12 0 with normal lungs too high can cause a pneumo |
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PEEP on vent is used for which pts
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Refractory hypoxemia
pulmonary edema ARDS |
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CMV: continuous mandatory ventilation
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Not used often
Will continuously cycle at the same rate |
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ACV: Assist control ventilation
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VERY common
used for pts not spontaneously breathing Set rate and tidal volume- control vent senses when pt tries to take a breath so the vent will kick in a full TV breath- assist |
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SIMV: synchronized intermittant mandatory ventilation
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Usually used to wean pts
Vent won't assist when pt tries to breathe. Varying tidal volume with pt's breath |
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Once a pt succeeds with SIMV, they can move onto ___________
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CPAP
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PSV: pressure support ventilation
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Gives a continuous airway pressure
Greater FLOW of O2 Helps get a better TV Reduces the work of breathing during weaning |
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PC: Pressure Control
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ACM is no longer adequate
The machine pushes air into the lungs until a certain pressure is met Must sedate pt |
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What are potential problems with pressure control?
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Pt coughing
asychronious breaths |
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True/False:
Pts on pressure control settings must be sedated. |
TRUE: these pts must be sedated
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PC-IRV: Pressure control, inverse ratio ventilation
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Same as pressure control BUT
Inspiratory time is lengthened Expiratory time is shortened Pt needs deep sedation Could also give a paralytic |
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CPAP: Continuous positive airway pressure
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Increased airflow
Pt is initiating every breath on their own Can be extubated if pt is successful on this Pt pulls in their own tidal volume |
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Once a pt is successful with CPAP, the pt is _____________.
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Extubated
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Causes of High pressure alarms include:
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coughing, secretions, kinked tubing, mucus plug in tube, decreased lung compliance, worsening of tissues (esp. with ARDS)
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Causes of low pressure alarms include:
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something is disconnected, deflated cuff, bad seal, pt pulls tube out
decreased TV=low pressure |
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What did ARDS used to be called?
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White lung syndrome.... because these pts have white out on their x-rays
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Direct causes of ARDS include:
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Smoking
Pneumonia Drowning |
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Indirect causes of ARDS include:
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Severe inflammatory process
Massive trauma Sespis |
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Patho of ARDS
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Alveoli inflamed
Edema occurs, increased pulm cap. permeability Excess secretions Alveoli lose elasticity and deflate Decreased surfactant Micro emboli form/vasoconstiction Decreased oxygenation |
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Characteristics of ARDS
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Refractory hypoxemia
paO2/FiO2 less than 200- NORMAL for ARDS Stiff lungs Higher inspiratory pressures White out on xrays Less lung compliance |
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Five P's of ARDS management
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Perfusion
Positioning Protective lung ventilation Protocol weaning Prevent complications |
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Lying in bed can lead to __________________ which is a precursor to pneumonia
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Atelectasis
|
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What position should ARDS pts be in?
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PRONE
continuous lateral position bed turn q2h |
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Why should ARDS pts not have a very high PEEP?
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Because of r/o pneumothorax
but we need these PEEP pressures to keep the alveoli open |
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ARDS stands for.....
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Acute Respiraotry Distress Syndrome
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An asthma attack that doesn't go away and does NOT respond to treatment is called ___________
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Status Astmaticus
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Causes of status astmaticus:
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Virus, allergens, temperature changes, smoking
Anything that causes an asthma attack |
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Manifestions of Status Astmaticus
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brochospasm, hyperinflation, hypoxemia, anxiety
acidosis sinus tach, "silent chest" exacerbations AND remission diapragm flattening on xray |
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Which is more dangerous? Silent chest or wheezing
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Silent chest
Because that means nothing is moving in the lungs The pt should be mechanically ventilated |
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How are COPD and status astmaticus different?
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Status astmaticus has exacerbation and remission. COPD does not.
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Status astmatic ABGs (initial and eventual)
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Initial: alkalosis and lower PaCO2
Eventual: acidosis and higher PaCO2 |
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Status Astmatic treatment
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short acting bronchodilators (albuterol, atrovent)
steroids anti-inflammatories mag sulfate if these dont work: intubation, ventilation, sedation |
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List 2 short acting bronchodilators
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albuterol- beta agonist, opens airways
atrovent treats acute astmaticus |
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When can you restrain a mechanically ventilated pt?
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Combative
confused during a procedure |
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Are RNs allowed to initiate restraints?
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yes.
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How often do you assess restraints?
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every hour
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Antidote for benzos (Versed)
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Romazicon/flumazeril
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2 Common continuous sedation infusions
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Versed
Propofol/diprovan |
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True/False?
RNs are able to administer high doses of propofol/diprovan. |
False.
RNs are only able to administer low doses for sedation (up to 50mcg/kg/min) can ONLY start drips. RNs cannot give bolus. |
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Propofol/diprovan dosage range for anesthetic purposes
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100-200mcg/kg/min
RNs cannot give this |
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What is the dosage range of propofol used for sedation?
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up to 50mcg/kg/min
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How is propofol packaged?
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in a glass bottle of 50-100ml/bottle
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Nursing implications for propofol
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dedicated line
change tubing every 12 hours strict aseptic technique |
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Common Neuromuscular Blocking Agents (NMBAs)
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Norcuron
Pavuon Tracrium |
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What is an NMBA?
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Neuromuscular blocking agent
continous IV infusion used for pt on vent to produce TOTAL paralysis of body |
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When you hear the vent alarm beeping of a pt on NMBA, how long do you have to stop the beeping?
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IMMEDIATELY
stop what you are doing and troubleshoot the vent because the pt cannot breathe on their own since their muscles are paralyzed |
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Nursing implications for NMBA
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make sure pt is properly ventilated
opthalmic ointment CHECK TWITCHES Q1 HOUR GIVE CONTINUOUS SEDATION low pressure mattress, keep heels up, LMW heparin, ROM |
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4 of 4 twitches for a pt on NMBA:
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<75% blocked
|
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____ of 4 twitches is 100% blocked
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0 of 4
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2 of 4 twitches is _____% blocked
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80% blocked
maintain the pt here |
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___ of 4 twitches is around 75% blocked
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3 of 4 twitches
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1 of 4 twitches if ____% blocked
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90% blocked
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How often do you assess the twitches of a pt on NMBA?
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Q1 hour
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SubQ emphysema/ pneumomediastinum interferes with _______________ because it presses on tissues.
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Cardiac ouput
|
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Complications of mechanical ventilation include:
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barotrauma (pneumo, subQ emphysema)
VAP immobility inadequate nutrition decreased CO |
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How do you treat a simple pneumothorax?
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Don't do anything for it
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An open pneumothorax can result in a ____________ pneumothorax.
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Tension
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Open pneumothorax treatment
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Put a seal over the wound
|
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Manifestations of a tension pneumothorax
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deviated trachea
no lung sounds on one side increased JVD |
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Treatment of tension pneumothorax
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Put a 16g IV neele between ribs so the air will escape
|
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Put a chest tube in the _________ part of the lung to drain fluid
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lower part of lung
|
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Put a chest tube in the _________ part of the lung to re-inflate lungs.
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upper part of lung
|
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What indicates an air leak in a chest tube?
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Tidaling or air bubbles in the water seal chamber
|
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3 parts of chest tube drainage system
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Collection chamber
Water seal chamber Suction control |
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Nursing implications to prevent VAP
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Oral care Q2h
HOB at 30 degrees or higher Continuous subglottal suctioning |
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Nursing implications during suctioning
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Pre-oxygenate at 100% for 1 minute
Do not exceed 10 secongs Repeat as needed Monitor O2 sats and EKGs for dysrhythmias NO NORMAL SALINE IN ETT |
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Weaning is the process of:
|
Decreasing ventilator support
Resuming spontaneous ventilation |
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We know a pt is spontaneously breathing if the RR is _________ than the rate set on the ventilator.
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Higher
|
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FiO2 requirements should be ________ or less in order to start the weaning process.
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0.04
this shows the pt does not require high O2 needs |
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Factors to assess during pre-weaning phase
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If the cause is resolved, spontaenously breathing, muscle strength, chest xray, auscultation, hemodynamic stability, ABGs, FiO2 requirements, neuro status, fluid and electrolytle balance, mag levels, hemoglobin, sedation/analgesic
|
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Order of Weaning
|
1. AC
2. SIMV 3. SIMV at decreased rate 4. CPAP 5. Extubation |
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During the weaning phase, how long should a pt be on CPAP?
|
AT LEAST 24 HOURS
If they do well and have good ABGs, then we may be able to extubate them |
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We know a pt is now tolerating the weaning process if....
|
If RR is increasing
If O2 sats are decreasing So we should get an ABG before intervening If PaO2 is decreasing, call the doctor |
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Can RNs extubate a patient?
|
yes
|
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Extubation procedure
|
tonsil tip suction, high fowlers position, untie ties, suction the pt before, deflate the balloon, have pt take a deep breath, pull out the tube when pt exhales, put pt on nasal cannula, monitor
|
|
Will a pt be NPO after being extubated?
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Only if they were intubated for 3 or more days.
Needs a swallow study before being able to eat. Ice chips is okay for sore throat. |
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Signs of failure to wean
|
high RR
high pressure alarms from asychronious breathing decreased O2 sats high BP agitated, anxious change in LOC Call the doctor and get ABG |
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Advantages of Trach VS ETT
|
better control of airway, better communication, more comfortable, can come on and off the vent, can put O2 right to trach, can wean faster and better
|
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Indications for terminal extubation
|
irreversible pt condition
ETT in place for maximum time and weaning has failed COPD failure to wean terminal stage of disease and family is against trach |
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Terminal extubation procedure
|
set up a time for it to take palce, family agrees upon DNR order, continue comfort measures, provide privacy for family
pt will get hypoxic and hypercapnic and will lose consciousness |
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Pulmonary embolus patho
|
fragment travels up right side of into lungs
blocks blood flow causes dead space |
|
PE manifestations
|
increased pressure in right side of heart
brand new murmur from tricuspid regurg increased JVD hypoxia hypotension syncope anxiety dyspnea |
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What is the most commmon cause of a PE?
|
Blood clot in lower extremity or pelvis
aka venous thrombus |
|
s/sx of a blood clot
|
warmth, swelling, pain
|
|
tests to diagnose a blood clot
|
definitive: doppler
d dimer elevation homans |
|
List types of emboli
|
air, fat, amniotic fluid, blood clot
|
|
Risk factors for PE
|
dehydration
older than 40 recent surgery lasting more than 30 mins cancer immobility female taking contraceptives pregnancy polycythemia sickle cell obesity trauma burns CVD smoking previous episode/hx |
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Signs and symptoms of PE
|
acute onset dyspnea
high RR high HR low BP syncope new murmur from tricuspid regurg increase in CVP JVD decreased O2 sats |
|
What is the most reliable non-invasive diagnostic test for a PE?
|
Helical/spiral CT
pt has to hold breath for 30 secs cannot do if pt has lost LOC |
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How are the results of a VQ scan given?
|
in probability
|
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For a PE, an echo diagnostic test will show _________________ of the heart.
|
enlargement
|
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What is the absolute most diagnostic test for a PE?
|
Angiography
this is invasive so risks are involved |
|
Will ABGs diagnose a blood clot?
|
No
|
|
List anticoagulants
|
heparin
warfarin low molecular weight heparin- lovenox |
|
Heparin info
|
anticoagulant
weight based initially bolus, then a drip monitor PTT, get baseline labs |
|
What is the normal range for PTT?
|
60-80
Monitor this with heparin |
|
Warfarin info
|
Anticoagulant
will go home on this Monitor INR will be started on this while on heparin protein bound diet safety measures drug interactions: antibiotics, oral hypoglycemic meds |
|
If repeated PEs, they will put in a ______________________
|
Vena cava filter
big enough to let blood run through but small enough to catch clots is put into the inferior vena cava |
|
PE Prevention
|
Compression stockings
hydration early ambulation assess for DVT prophylactic LMWH: monitor platelets |