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144 Cards in this Set

  • Front
  • Back
External respiration
aka: ventilation
mechanical part of breathing
breathing in and out
Where does diffusion occur?
Between the alveoli and blood vessels
Must pass through capillary membranes
Exchanges O2 for CO2
Transport
the process of oxygen getting to all of the tissues and organs
Must have a clear path
Internal respiration
AKA: tissue diffusion
O2 is exchanged for CO2 within the cells
Dead Space
The % of inspired volume of air that does not take place in gas exchange
Well ventilated alveoli
Poor or no blood supply
Shunting
Blockage in the alveoli
Good blood supply
airway obstruction prevents air from reaching blood supply
Causes of shunting
fluid infiltration, chronic/acute obstruction, brochial constriction, pneumonia
PaO2
partial pressure of O2 in bloodstream
BEST INDICATOR OF 02 STATUS
find via an ABG
What is the best indicator of O2 status?
PaO2
When is a pt in respiratory failure?
PaO2 less than 200
PaO2 less than 300 if other organs are failing
Patho of COPD
alveoli lose elasticity
extra air stays in alveoli
diaphragm pushed down
shallow breaths
chest expands more
intercostal muscles overworking
COPD characteristics
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
Best way to check for central cyanosis?
Mucus membranes and lips
Characteristic of COPD
Nasal Cannula O2 delivery
up to 6L
Which type of O2 delivery device is preferred for increased humidification?
Face tent
open mask that sits below the chin
gives lots of humidified air
Venturi Mask
very precise delivery of O2
used with COPD pts because we can measure exactly how much O2 they are getting
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
SpO2
peripheral O2 reading
read by clip on finger
FiO2
how much O2 we are giving our patient
What is a normal pH for COPD pts?
NORMAL pH range!
close to being acidodic (7.36ish)
pH will fall when compensatory mechanisms fail
Which causes ventricular irritability?
Alkalosis or Acidosis
Acidosis
When does a pt acquire CAP?
in the community or within 48 hrs of hospital admission
What does the CURB-65 assess?
Assesses severity of CAP
C- confusion
U- Urea/BUN
R- Respiratory rate
B- BP
The first sign of hypoxia is......
Confusion
You must give an antibiotic within ________ hours of a CAP pt walking in the door. (door to dose rule)
4 hours
Get a sputum sample
Aspiration pneumonia/pneumonitis
Aspiration is main cause
No pathogen involved
Secondary illness can occur
Benefits of NIPPV
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
Adverse effects of NIPPV
Sinus pain
Flatulence (air may get into GI tract)
Candidates for NIPPV
Severe COPD pts with exacerbation
cardiogenic pulmonary edema
pt that came off of ventilator and cannot breathe on their own
Pts to NEVER give NIPPV to
Pts needing sedation
Pts that have been vomiting
Pts that won't tolerate it
Special consideration of a Nasal Mask
Must keep mouth closed or else the air will come right back out
What must be worn with NIPPV?
Dentures
Impossible to get a good seal without them in
Who can intubate a pt?
doctor or CRNA
Nursing implications during intubation process
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
What do you do if your pt is having PVCs or low O2 sats during the intubation process?
STOP the person that is intubating and bag the pt
Assesment after post-intubation procedure
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
Gold standard for ETT placement confirmation
CHEST X RAY
What meds are given with RSI?
RSI: Rapid sequence intubation
Sedation (Versed)
AND
NMBA (paralytic)
How often do you reposition an intubated pt?
Every 24 hours
Change the position of ET tube in mouth
How often is oral care done on intubated pts?
Every 2 hours
HOB elevation for intubated pts
at least 30 degrees
Ideal cuff pressure for intubated pts
20-25 mmHg
Put 10cc into cuff then have RT check pressure
Indications for Venilator
Respitory failure
To monitor respirations during surgery
The actual volume of air pushed in by the ventilator machine with each breath is the _________________
Tidal volume
The number of times a minute the ventilator delivers a breath is the ___________________
Rate
PEEP
Positive end respiratory pressure
Generally see 5-12
0 with normal lungs
too high can cause a pneumo
PEEP on vent is used for which pts
Refractory hypoxemia
pulmonary edema
ARDS
CMV: continuous mandatory ventilation
Not used often
Will continuously cycle at the same rate
ACV: Assist control ventilation
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
SIMV: synchronized intermittant mandatory ventilation
Usually used to wean pts
Vent won't assist when pt tries to breathe.
Varying tidal volume with pt's breath
Once a pt succeeds with SIMV, they can move onto ___________
CPAP
PSV: pressure support ventilation
Gives a continuous airway pressure
Greater FLOW of O2
Helps get a better TV
Reduces the work of breathing during weaning
PC: Pressure Control
ACM is no longer adequate
The machine pushes air into the lungs until a certain pressure is met
Must sedate pt
What are potential problems with pressure control?
Pt coughing
asychronious breaths
True/False:
Pts on pressure control settings must be sedated.
TRUE: these pts must be sedated
PC-IRV: Pressure control, inverse ratio ventilation
Same as pressure control BUT
Inspiratory time is lengthened
Expiratory time is shortened

Pt needs deep sedation
Could also give a paralytic
CPAP: Continuous positive airway pressure
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
Once a pt is successful with CPAP, the pt is _____________.
Extubated
Causes of High pressure alarms include:
coughing, secretions, kinked tubing, mucus plug in tube, decreased lung compliance, worsening of tissues (esp. with ARDS)
Causes of low pressure alarms include:
something is disconnected, deflated cuff, bad seal, pt pulls tube out

decreased TV=low pressure
What did ARDS used to be called?
White lung syndrome.... because these pts have white out on their x-rays
Direct causes of ARDS include:
Smoking
Pneumonia
Drowning
Indirect causes of ARDS include:
Severe inflammatory process
Massive trauma
Sespis
Patho of ARDS
Alveoli inflamed
Edema occurs, increased pulm cap. permeability
Excess secretions
Alveoli lose elasticity and deflate
Decreased surfactant
Micro emboli form/vasoconstiction
Decreased oxygenation
Characteristics of ARDS
Refractory hypoxemia
paO2/FiO2 less than 200- NORMAL for ARDS
Stiff lungs
Higher inspiratory pressures
White out on xrays
Less lung compliance
Five P's of ARDS management
Perfusion
Positioning
Protective lung ventilation
Protocol weaning
Prevent complications
Lying in bed can lead to __________________ which is a precursor to pneumonia
Atelectasis
What position should ARDS pts be in?
PRONE
continuous lateral position bed
turn q2h
Why should ARDS pts not have a very high PEEP?
Because of r/o pneumothorax
but we need these PEEP pressures to keep the alveoli open
ARDS stands for.....
Acute Respiraotry Distress Syndrome
An asthma attack that doesn't go away and does NOT respond to treatment is called ___________
Status Astmaticus
Causes of status astmaticus:
Virus, allergens, temperature changes, smoking
Anything that causes an asthma attack
Manifestions of Status Astmaticus
brochospasm, hyperinflation, hypoxemia, anxiety
acidosis
sinus tach,
"silent chest"
exacerbations AND remission
diapragm flattening on xray
Which is more dangerous? Silent chest or wheezing
Silent chest
Because that means nothing is moving in the lungs
The pt should be mechanically ventilated
How are COPD and status astmaticus different?
Status astmaticus has exacerbation and remission. COPD does not.
Status astmatic ABGs (initial and eventual)
Initial: alkalosis and lower PaCO2
Eventual: acidosis and higher PaCO2
Status Astmatic treatment
short acting bronchodilators (albuterol, atrovent)
steroids
anti-inflammatories
mag sulfate
if these dont work: intubation, ventilation, sedation
List 2 short acting bronchodilators
albuterol- beta agonist, opens airways
atrovent
treats acute astmaticus
When can you restrain a mechanically ventilated pt?
Combative
confused
during a procedure
Are RNs allowed to initiate restraints?
yes.
How often do you assess restraints?
every hour
Antidote for benzos (Versed)
Romazicon/flumazeril
2 Common continuous sedation infusions
Versed
Propofol/diprovan
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.
Propofol/diprovan dosage range for anesthetic purposes
100-200mcg/kg/min
RNs cannot give this
What is the dosage range of propofol used for sedation?
up to 50mcg/kg/min
How is propofol packaged?
in a glass bottle of 50-100ml/bottle
Nursing implications for propofol
dedicated line
change tubing every 12 hours
strict aseptic technique
Common Neuromuscular Blocking Agents (NMBAs)
Norcuron
Pavuon
Tracrium
What is an NMBA?
Neuromuscular blocking agent
continous IV infusion
used for pt on vent to produce TOTAL paralysis of body
When you hear the vent alarm beeping of a pt on NMBA, how long do you have to stop the beeping?
IMMEDIATELY
stop what you are doing and troubleshoot the vent because the pt cannot breathe on their own since their muscles are paralyzed
Nursing implications for NMBA
make sure pt is properly ventilated
opthalmic ointment
CHECK TWITCHES Q1 HOUR
GIVE CONTINUOUS SEDATION
low pressure mattress, keep heels up, LMW heparin, ROM
4 of 4 twitches for a pt on NMBA:
<75% blocked
____ of 4 twitches is 100% blocked
0 of 4
2 of 4 twitches is _____% blocked
80% blocked
maintain the pt here
___ of 4 twitches is around 75% blocked
3 of 4 twitches
1 of 4 twitches if ____% blocked
90% blocked
How often do you assess the twitches of a pt on NMBA?
Q1 hour
SubQ emphysema/ pneumomediastinum interferes with _______________ because it presses on tissues.
Cardiac ouput
Complications of mechanical ventilation include:
barotrauma (pneumo, subQ emphysema)
VAP
immobility
inadequate nutrition
decreased CO
How do you treat a simple pneumothorax?
Don't do anything for it
An open pneumothorax can result in a ____________ pneumothorax.
Tension
Open pneumothorax treatment
Put a seal over the wound
Manifestations of a tension pneumothorax
deviated trachea
no lung sounds on one side
increased JVD
Treatment of tension pneumothorax
Put a 16g IV neele between ribs so the air will escape
Put a chest tube in the _________ part of the lung to drain fluid
lower part of lung
Put a chest tube in the _________ part of the lung to re-inflate lungs.
upper part of lung
What indicates an air leak in a chest tube?
Tidaling or air bubbles in the water seal chamber
3 parts of chest tube drainage system
Collection chamber
Water seal chamber
Suction control
Nursing implications to prevent VAP
Oral care Q2h
HOB at 30 degrees or higher
Continuous subglottal suctioning
Nursing implications during suctioning
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
Weaning is the process of:
Decreasing ventilator support
Resuming spontaneous ventilation
We know a pt is spontaneously breathing if the RR is _________ than the rate set on the ventilator.
Higher
FiO2 requirements should be ________ or less in order to start the weaning process.
0.04
this shows the pt does not require high O2 needs
Factors to assess during pre-weaning phase
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
Order of Weaning
1. AC
2. SIMV
3. SIMV at decreased rate
4. CPAP
5. Extubation
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
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
Can RNs extubate a patient?
yes
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?
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.
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
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
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
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
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
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
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
How are the results of a VQ scan given?
in probability
For a PE, an echo diagnostic test will show _________________ of the heart.
enlargement
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