Test #1 Acid Base Imbalance

Front 1

Kidneys reabsorb ____ and excrete ___

Back 1

Bicarb (HC03); H ions

Front 2

when PH <7.35 and bicarb< 22, you have ____ _____

Back 2

metabolic acidosis

Front 3

You can get metabolic acidosis from renal disease. Why?

Back 3

Failure of kidneys to excrete H+ ions or reabsorb bicarb molecule (HC03) which is made in kidneys.

Front 4

How will shock or drug intoxication cause metabolic acidosis?

Back 4

Due to excessive metabolic acids prod in body

Front 5

How does diarrhea cause metabolic acidosis?

Back 5

loss of alkaline or bicarb through diarrhea

Front 6

How can heavy exercise cause metabolic acidosis?

Back 6

body produces lactic acid

Front 7

Starvation can cause metabolic acidosis? T or F

Back 7

T

Front 8

Normal PH =

Back 8

7.35-7.45

Front 9

Normal PaCO2=

Back 9

35-45

Front 10

Normal HCO3=

Back 10

22-26

Front 11

metabolic alkalosis is usually caused by _____

Back 11

medical treatment such as massive blood transfusion, gastric suctioning, bicarb IV, and TPN

Front 12

Metabolic alkalosis is caused by increased _____ or decreased ____.

Back 12

bicarb; acid

Front 13

Vomiting & gastric suctioning cn cause metabolic alkalosis how?

Back 13

by dec acid when its removed via vomit or suction

Front 14

Using thiazide diuretics can cause metabolic ____ because___.

Back 14

acidosis; increase excretion of bicarbonate ions.

Front 15

Define compensation?

Back 15

Body trying to return its PH to normal values using the opposite system that caused condition
- so if kidneys aren't working properly, the resp system will compensate
- if initial respiratory prob, then kidneys will compensate.

Front 16

Body never overcompensates. T or F

Back 16

T

Front 17

a Correction often involves medical intervention
A.- if metabolic ____ , start bicarb drip.
B.- if _____, start HCL acid drip
C.- If ____, put pt on ventilator and inc resp rate so pt can blow off H+ ions

Back 17

A - acidotic
B - alkalosis
C.- acidotic

Front 18

Ingesting excessive antacids, can put pt in ________

Back 18

metabolic alkalosis

Front 19

Total compensation can only happen when a PH _____

Back 19

is within normal range, ie 7.35.7.45

Front 20

PaO2?

Back 20

- Partial pressure of 02 dissolved in blood plasma
- Only 3% of O2 in body is dissolved in plasma, it's waiting to attach to hemoglobin

Front 21

Normal value of Pa02?

Back 21

80-100 mmHg

Front 22

Sa02?

Back 22

-capacity for hemoglobin to carry 02.
- 97% of 02 in blood stream is bound to hemoglobin

Front 23

How does pulse oximeter measure Sa02?

Back 23

-looks at color of blood w infrared light
- nail polish effects readings, (esp dark red)

Front 24

what can effect Sa02 readings?

Back 24

warmth to extremeties, blood flow to extremeties (hands), edema

Front 25

A pt with low Hgb may get ___ Sa02 readings

Back 25

low

Front 26

If SaO2 is 97%, but Hgb is only 6, pt is ____

Back 26

not getting enough oxygenation.

Front 27

PaO2 values?
A. Normal
B. Mild hypoxemia
C. Moderate Hypoxemia
D. Severe Hypoxemia

Back 27

A. 80-100
B. 60-79
C. 40- 59
D. , 40

Front 28

Very important to look for downward or upward trends. T or F?

Back 28

T

Front 29

Pts with resp prob like COPD have a low or high PaO2 as baseline?

Back 29

low

Front 30

Age effects normal Pa02 values. how?

Back 30

Every yr over 60 your Pa02 drops by 1MM mercur

Front 31

Altitude affects oxygenation; Residents in Colorado have higher or lower Hgb values since body compensates

Back 31

higher

Front 32

To have adequate gas xchange, need 3 things to happen

Back 32

1. good ventilation - lungs
2. 02 exchange in alveoli
3. transportation of 02 via circ system

Front 33

OxyHemoglobin Dissociation Curve describes what?

Back 33

relship between avail 02 (Pa02) and the 02 att to Hgb

Front 34

Curve shows that you want pt's Pa02 to be above __ and Sa02 above __

Back 34

60; 90

Front 35

define Ventilatory Pump?

Back 35

chest wall, chest muscles (resp) and resp control ctr in brain.

Front 36

ABGs measure oxygenation of ____ not at _____

Back 36

bloodstream; tissue level;
- ABGs don't tell us if 02 is reaching tissues

Front 37

what are indicators if O2 is reaching tissues?

Back 37

- color of skin
- capilllary refill
- BP & heart rate

Front 38

Need functioning ____ and ___ systems to get blood to tissues.

Back 38

respiratory & circulatory

Front 39

Venous Oxygen (PV02) is used with critically ill pts. It measures ______.
- Normal values:
Oxygen poor: ____
Rich in C02: _____

Back 39

gas exchange at tissue (systemic) level
- 40 mm Hg
- 45 mm Hg

Front 40

If PV02 = 20 mm Hg, does this mean tissues are extracting more or less O2?

Back 40

more;

Front 41

this could be due to _____ or _____. Treatment?

Back 41

exercise; fever
- treat by giving pt more 02 and getting VS under control.

Front 42

If Pv02 = 60 mm Hg, tissues are not using 02 well due to tissue damage from _______

Back 42

DKA, shock, pt is cold (hypothermic, sepsis, durg toxicity.

Front 43

Another way for measuring oxygenation for ICU pts is called _____. This measures the % of 02 sat in blood after tissues have used 02.
- Normal values are______

Back 43

SV02 - mixed venous oxygenation
- 60-80%

Front 44

How is SV02 measured?

Back 44

insert catheter through central line to inside heart; measures gas exchange at pulmonary artery.

Front 45

What measure reflects overall utilization of 02 and adequacy of heart pumping.

Back 45

SV02; tells us how well heart is pumping and circulating 02.

Front 46

For gas exchange to occur at alveoli level, you need 3 things?

Back 46

1) healthy capillaries
2) healthy alveoli , ie thin surface, round not collapsed
3) good lung tissue, ie, can't have fluid, infection or fibrosis

Front 47

Shunting of blood?

Back 47

- if 02 doesn't pass thru from alveoli to capillaries, shunting occurs.
- if alveoli are impaired shunting of blood will occur and blood will pass into venous system w/o being oxygenated.

Front 48

Bleb?

Back 48

when alveoli collapse and form larger alveoli that are ineffective; happens with COPD and sometimes in healthy lungs

Front 49

Acute Respiratory Failure?

Back 49

when resp system has failed to oxygenate blood or eliminate C02, so body stops maintaining homeostasis and you have acidemia
- immediate, life-threatening condition

Front 50

Acute Respiratory Failure is a disease or syndrome?

Back 50

syndrome

Front 51

Acute Respiratory Failure results from
- hypoxemia
- ventilatory failure (lungs not workin)
- combo
T or F?

Back 51

T

Front 52

Acute Resp Failure is diagnosed by?

Back 52

1) Abnormal ABGs
- Pa02 <60
- Sa02 <90
- or PaC02 >50
2) with accompanying acidemia

Front 53

2 main types of Acute Resp Failure?

Back 53

- Hypoxemic Resp Failure
- Ventilatory- Based Resp Failure

Front 54

With Hypoxemic Respiratory Failure, there is a prob w oxygen getting into bloodstream due to blood not being oxygenated at the alveolar level (for some reason); usually the ____ is fine.

Back 54

ventilation

Front 55

Hypoxemic Resp Failure due to a ___ mismatch aka a ventilation/perfusion mismatch.

Back 55

VQ; one cause of that would be pulmonary emboli where blood can't reach alveoli.

Front 56

Other reasons of Hypoxemic Resp Failure?

Back 56

1) abnormal hgb
2) breathing air w low Pa02 ie low atmospheric oxygen concentration; happens to mountain climbers

Front 57

How does pneumonia cause oxygen failure?

Back 57

causes consolidation in alveoli

Front 58

How does pulmonary edema cause oxygen failure?

Back 58

excess fluid prevents 02 from being absorbed

Front 59

how does abnormal blood flow (V/Q mismatch) cause oxygen failure?

Back 59

Example = pulmonary embolism where the blood isn't passing by alveoli

Front 60

1) Pts post surgery are at risk for dev ARF. Why?

Back 60

1) Pain, immobility & dec LOC causes them not to take deep breaths which reduces their tidal vol which can cause atelectasis leading to ARF

Front 61

2) Why else are elderly pts post surgery at risk for dev ARF?

Back 61

2) due to increased age, supine pos, anesthesia lead to impaired gas xchange (sol: sit up at least 30 degrees) leading to hypexemia to ARF

Front 62

3) Why are smokers post surgery at risk for dev ARF?

Back 62

3) Hx of smoking, intubation, long hospitalization lead to altered lung defenses leading to pneumonia to ARF

Front 63

Why do we have pts post surgery use incentive spirometer, and coughing and deep breathing?

Back 63

to prevent atelectasis (collapse of alveoli) which makes pt more prone to pneumonia

Front 64

What is best way to dx ARF?

Back 64

Best way is Sa02 pulse oximeter; looking for S & S is not good way since very vague; ABGs give definitive diagnosis

Front 65

What are signs and symptoms of ARF?

Back 65

some pts are asymptomatic, cognitive deficit, tachypnea, circumoral cyanosis (late)

Front 66

Capnography (ETC02)?

Back 66

Dx tool for ARF; measures End Tidal C02 from endotracheal tube

Front 67

Bronchoscopy?

Back 67

Dx tool for ARF; direct visualization of lungs; can take biopsies

Front 68

V/Q scanning?

Back 68

Dx tool for ARF; tells us ventilation and perfusion deficits

Front 69

CT scan?

Back 69

Dx tool for ARF; look at anatomy of resp system to see fluid or infection

Front 70

Interventions for oxygenation failure?

Back 70

- give oxygen
- give bronchodilators to dilate airways
- sit in pos of comfort, ie sitting up
- C & DB- coughing and deep breathing

Front 71

Diff ways to give 02 to pt w oxygenation failure?

Back 71

- via nasal cannula up to 6L
- NRB mask - can give 100% 02
- CPAP/BPAP - delivers 100% 02 w pressure
- mech ventilator; delivers 100% 02 pt needs to be intubated

Front 72

Benefit of CPAP over mech ventilation?

Back 72

Pt doesn't have to be intubated; CPAP is not considered alternative to ventilator in severely compromised pts; used if we know ahead of time

Front 73

Benefit of ventilator w ARF?

Back 73

gives med team time to address what's causing ARF; want to intubate before pt codes

Front 74

Describe Carbon Monoxide poisoning?

Back 74

CO binds to hgb molecule 200-250x more tightly than 02
- Attached CO then prevents 02 from binding to hgb.

Front 75

CO can accum slowly over long pds of time T or F

Back 75

T

Front 76

Carbon monoxide is a gas formed by ______

Back 76

- fire combustion
- explosions release CO

Front 77

Anytime there's a fire, assume and check for CO poisoning
T or F

Back 77

T

Front 78

We see more CO poisonings in Winter or Summer?

Back 78

Winter; due to kerosene heaters, generators that are not vented properly; generator in basement killed family from CO poisoning

Front 79

CO poisoning shows normal Sa02 Sat. Why?

Back 79

infrared light sees the CO att to the hgb which is the same color so it will read normal
- blood still red; chopped meat is kept red by injecting CO into pkg

Front 80

CO poisoning shows normal Pa02. Why?

Back 80

measures 02 dissolved in plasma; could still have the 3% dissolved in plasma, so values are normal

Front 81

What's most important assessment tool for CO poisoning ?

Back 81

go by history & ask q's: how do you heat your home?

Front 82

In CO poisoning, what color are the mucus membranes and the skin (late sign)?

Back 82

cherry red

Front 83

Other S &S of CO poisoning?

Back 83

same as general hypoxia: headache, drowsiness, dizziness, malaise, nausea, altered mental state progressing to coma

Front 84

Carboxyhemaglobin level?

Back 84

measures CO level in blood; < 8% is normal
- since some pts become accustomed to low/mod levels of CO, need to rely on assessment,

Front 85

What is most important to prevent CO poisoning?

Back 85

Education:
- don't use heaters in closed rooms
- place generators outside
- chimneys cleaned yrly

Front 86

CO detectors should be placed where?

Back 86

in bedrooms; don't place near heaters

Front 87

What is treatment for CO poisoning?

Back 87

Always give 100% 02 with NRB mask to wash out C0 out of body so that eventually hgb starts attaching to 02 & releasing C0

Front 88

If pt is unconscious from
CO poisoning, do you put on NRB mask or mech ventilator?

Back 88

intubate & put on mech ventilator

Front 89

Why put pt w CO poisoning into hyperbaric chamber?

Back 89

can give 100% 02 at elevated pressure to force 02 into tissue at high pressure

Front 90

why crawl on floor to get out of burning building?

Back 90

because smoke and CO will rise

Front 91

ARDS stands for?

Back 91

Acute Respiratory Distress Syndrome aka
- shock lung
- noncardiogenic pulmonary edema in mtn climbers due to low conc of 02 in air.

Front 92

ARDS is a type of hypoxemic or ventilatory-based resp failure?

Back 92

hypoxemic resp failure

Front 93

ARDS is considered a type of ____ failure

Back 93

organ
- first identified during Vietnam War
- anytime there's massive blood loss and major trauma, pt at risk for ARDS

Front 94

There are 3 main events that precipitate ARDs?

Back 94

1) catastrophic event: MVA, near drowning, burns, inhalation of toxic gases
2) high altitude travel
3) aspiration of gastric contents; often occurs at hospital; when feeding pt, have head of bed as high as possible ( 30 -45 degrees)

Front 95

- With ARDS, you may or may not have direct injury to heart or lungs. T or F
- You can have crush injuries to lower extremeties & dev ARDS. T or F

Back 95

T
T

Front 96

How do we diagnose pt with ARDS?

Back 96

By assessing pt
- ARDS begins w dyspnea, may be crackles, pt develops cough and is restless
- After that, refractory hypoxemia occurs
- Also increased shunting of blood,ie blood not being oxygenated due to capillary going right past alveoli

Front 97

What is ARDS?

Back 97

Severe pulmonary congestion (fluid-filled alveoli) with injury to alveolar-capillary membranes which makes pulmonary gas xchange ineffective

Front 98

What is refractive hypoxemia?

Back 98

No matter how much 02 is administered, PA02 doesn't go up.

Front 99

Another sign of ARDS is "white out" found on _____

Back 99

chest xray

Front 100

What is the at-risk population for ARDS?

Back 100

ARDS occurs in young healthy men, ie young men riding motorcycles or mountain climbing; not elderly unhealthy people

Front 101

What are 2 interventions to treat ARDS?

Back 101

1) endotracheal intubation - since pulmonary gas exchange is ineffective, we must optimize 02 we're giving
2) mech ventilation w PEEP

Front 102

Why PEEP for ARDS treatment?

Back 102

PEEP= Positive End Expiratory Pressure
- pressure from ventilator at end of expiration prevents alveoli from collapsing; sometimes flattens out consolidated (fluid-filled)
alveoli
- PEEP required when pt is unresponsive to high amts of 02

Front 103

What is nursing diagnosis and outcomes for ARDS?

Back 103

Impaired gas exchange related to decreased lung compliance and interstitial edema
- Desired outcomes:
- Pt exhibits signs of effective gas exchange as evidenced by normal O2 sat or Pa02 WNL within 24 hrs
- Pt will maintain adequate tissue oxygenation as evidenced by PV02 & SV02 WNL in 24 hrs.

Front 104

Treating ARDS requires mech ventilation where pt is usually sedated and laying on stomach. Why

Back 104

Lying on stomach allows alveoli in front of body (& lungs) to be perfused better.

Front 105

Define Ventilatory Respiratory Failure?

Back 105

Perfusion is normal but ventilation is inadequate. It occurs when the thoracic pressure does not change sufficiently to permit air movement into and out of lungs. As a result, too little 02 reaches alveoli and C02 is retained resulting in hypoxemia.

Front 106

Ventilatory failure is the result of these 3 probs?

Back 106

1) mechanical abnormality of chest wall or lung from trauma, lesion , cancer
2) dec respiratory drive due to neuro (CVA) or neuromuscular ( Guillian Barre, ALS)
3) Impaired respiratory muscles due to COPD, spinal cord injury

Front 107

hypercapnia?

Back 107

elevated C02 in blood.

Front 108

S & S of Ventilatory Resp Failure?

Back 108

very vague: headache, dizziness, change in LOC
- need to do ABGs

Front 109

What are interventions for pt with Ventilatory Respiratory Failure?

Back 109

1) Open airway and provide ventilation via ambu bag if RR<12
2) treat the underlying cause.
3) mech ventilation; if C2 fracture & above, its permanent

Front 110

What is Combined Ventilatory and Oxygenation Failure?

Back 110

disease that causes oxygen failure along with inability to continue work of breathing (ventilatory failure)

Front 111

Disease caused by abnormal lungs with CAL (Abnormal Airway Limitation) due to:
- chronic bronchitis
- emphysema
- asthma
These diseases cause oxygenation failure because _______

Back 111

the bronchioles and alveoli are diseased.

Front 112

This increases the work of breathing until the respiratory muscles are unable to function effectively . T or F

Back 112

T

Front 113

Ventilatory Respiratory Failure is defined by a PaC02 level above _____

Back 113

45 mm Hg in pts who have otherwise healthy lungs

Front 114

What are 3 indications for mechanical ventilation?

Back 114

- Pa02 can't be maintained above 50 mm Hg,
- PaCO2 rises above 50 mm Hg;
- both indicate pending acute resp failure
- or to protect pt airway

Front 115

What other reason would we place pt on mech ventilation?

Back 115

When pt has spinal cord injury ro disorder that we know will impair ability to breathe.

Front 116

Goals of mechanical ventilation are to:

Back 116

- Improve oxygenation
- Improve ventilation
while keeping pt comfortable

Front 117

Define positive pressure ventilation?

Back 117

pushes air into lungs; needs to be intubated

Front 118

define negative pressure ventilation?

Back 118

mimics normal resp pattern where pt needs to be encapsulated in chamber; uses negative pressure to maximize ventilation

Front 119

what type of ventilation is used by cystic fibrosis pts to help them breathe?

Back 119

Negative pressure ventilation

Front 120

which type of ventilation was developed first and for polio epidemic in 1926?

Back 120

Negative pressure ventilation

Front 121

Positive pressure ventilation requires a ______

Back 121

ventilator; set up by resp therapist who sets the mode, rate and Fi02
- ventilator requires doctor's orders

Front 122

What else do you need in room with a ventilator?

Back 122

- suction equipment,
- 02 source,
- airway

Front 123

Name the 3 kinds of artificial airways?

Back 123

- endotracheal tube (ETT)
- nasotracheal tube (NGT)- same as ETT just inserted through nose
- tracheostomy tube

Front 124

ETT is recom'd for short term use only. Why and how long?

Back 124

- use for under 10 days since movement of tube and stress on trachea can cause erosion of trachea

Front 125

Which of the artificial airways can be used permanently or for longer periods of time?

Back 125

Tracheostomy Tube

Front 126

What are complications of long term tracheostomy tube use?

Back 126

ischemia to trachea because of ballon in trachea; balloon can cause fistulas, erosion of trachea, arteries can be damaged, permanent injury to swallowing can occur.

Front 127

When properly positioned, where does the end of the artificial airway sit?

Back 127

End of tube rests 0.8 - 1.2" above carina (pt at which trachea divides into left and right bronchi

Front 128

What are complications of trach tube?

Back 128

- bleeding
- pneumothorax
- aspiration
- damage to laryngeal nerve resulting in pt having permanent coarse voice

Front 129

How can pt speak with tracheostomy tube?

Back 129

Normally, pt won't be able to speak since not blowing air past larynx
- by inserting fenestrated tubes (tubes with holes in them) will allow pts to speak when cuff is deflated

Front 130

Can pt eat w trach tube?

Back 130

pt can swallow and eat normally with trach tube as long as pt is off ventilator

Front 131

How do we check for tube slippage past carina into L or R bronchus?

Back 131

check for equal chest expansion

Front 132

what are 4 things to do for proper tube care?

Back 132

1) assess for bilateral lung sounds to confirm placemt
2) Suction- helps remove secretions to promote adequate gas exchange
3) Secure tube - via tape or velcro fastener
4) Oral hygiene- suction mouth keep mouth clean & moist; swab mouth w antiseptic sol to prevent infection

Front 133

How do we know pt needs suctioning?

Back 133

breath sounds, wheezing, dec Sa02, coughing up lots of secretions, elevated resp rate

Front 134

Define "mode" re ventilator?

Back 134

indicates how a breathe is controlled

Front 135

Assisted Mode?

Back 135

a breath is initiated by the pt but controlled by ventilator
- allows the most control by nurse since every breath pt takes is controlled by tidal vol

Front 136

Support Mode?

Back 136

a breath is initiated and controlled by the pt and may vary by length, tidal vol and pressure

Front 137

Spontaneous Mode?

Back 137

pt can take breath whenever they want; initiated and controlled by pt without any input from ventilator

Front 138

what 4 ventilator settings sh you check and they will be on doctor's order?

Back 138

- Tidal vol- based on wt of pt
- Rate- # of breaths/min = 12-20
- Fi02 - Fraction of Inspired Oxgen: always give lowest amt of )2 that will give Sa02 > 90 or a Pa02>60.
- Mode

Front 139

What determines the kind of mode pt is on?

Back 139

Type of mode based on needs of pt, how alert they are, how much work of breathing can they perform, do they have a respiratory drive; want to make sure we're promoting gas xchange w least stress on lungs

Front 140

What are typical PEEP values written in order?

Back 140

written as pos # bet 2.5 - 10.0

Front 141

What are complications due to increased pressure from PEEP?

Back 141

- can lower cardiac output
- can lower venous return to heart, thereby dec BP
- increased pressure on lungs (esp if fragile) can incr risk of pneumothorax (greater pressure can put holes in lungs)
- Therefore, must auscultate for breath sounds q 2hrs
-

Front 142

CPAP is similar to PEEP but requires ____ but does not require _____

Back 142

- spontaneous breathing
- ventilator or artificial airway

Front 143

What is normal ratio for expiration and inspiration?

Back 143

Expiration takex 2x as long as inspiration; can chge ratio for diff therapy goals

Front 144

Fi02?

Back 144

the % of 02 in the air that is inspired

Front 145

when mechanically ventilating pt, an Fi02 >___% is considered toxic for long periods of time. ok for 1-2 days

Back 145

50%
- adding PEEP will allow Fi02 to be dec
- Ex: if pt req 100% 02, will start incr level of PEEP so that we can dec Fi02 level

Front 146

Acute Resp Failure (Hypoxemic Causes) ie blood is not being oxygenated; impaired diffusion of 02 at alveoli level
- Pneumonia
- COPD, Emphysema
- CO poisoning
- Pulmonary Edema
- Sepsis
- ARDS
- Pulmonary emboli

Back 146

Acute Resp Failure (Ventilatory Causes- chest wall or brain problem)
- Trauma: pneumothorax, car accident causing bone or muscle bruising so chest wall isn't functioning as well
- neuro - decreased respiratory drive
- spinal cord injury

Front 147

what are 3 main complications of mechanical ventilation?

Back 147

- Airway
- Infection
- Barotrauma

Front 148

Barotrauma?

Back 148

ventilator assoc lung injury rel'd to high pressure of ventilator; can blow holes in lung causing pneumothorax

Front 149

Airway complication?

Back 149

- kinked tubes an dec 02
- tubing can slip into 1 bronchi, then all tidal vol goes into 1 lung which can cause pneumothorax

Front 150

Infection from Mech Vent?

Back 150

high risk for nosocomial pneumonia aka Ventilator Associated Pneumonia (VAP)
- happens since normal barriers to infection are no longer there: open glottis, stick tubes in for suction, can no longer swallow so saliva sits in mouth producing bacteria; less teeth brushing to keep mouth clean

Front 151

The longer on a ventilator, the greater the risk of dying T or F

Back 151

T

Front 152

Therefore, goal of nursing is to get pt off ventilator ASAP; nurse can get pt off ventilator if 3 things happen: Sa02 sat increases, pt is nutritionally sound and pt is free of infection

Back 152

So True

Front 153

What are the 3 components of nursing mgmt of pt on Mech Vent?

Back 153

1) Monitor chest expansion, auscultate breath sounds
2) Note secretions
3) Turn immobile pt q 2hrs to prevent bedsores; mouth care q 4h

Front 154

Pt on MV at risk for hypotension. Why?

Back 154

caused by hi pressure that inc thoracic pressure and inhibits blood return to heart; the dec venous return dec cardiac output thus dec BP

Front 155

Everytime we suction we note what 3 things about secretions?

Back 155

1) amt: small, large
2) consistency: thick (tenacious) thin
3) color: white, green, yellow, pink froth; color may indicate type of infection

Front 156

Pink froth secretions could indicate_____

Back 156

pulmonary edema

Front 157

If pt lying flat, secretions pool on back; if lying on side, secretions pool on R or L side; suction secretions to prevent infection

Back 157

So True

Front 158

What's most common nosocomial infection?

Back 158

UTI's

Front 159

What's 2nd most common nosocomial infection?

Back 159

VAP - ventilator associated pneumonia

Front 160

Define VAP?

Back 160

Any pneumonia that occurs 48 hrs or more after intubation
- the longer on ventilator, the greater risk of VAP

Front 161

Risk factors for VAP?

Back 161

over 65, underlying illness, impaired consciousness

Front 162

Tracheostomy care is a aseptic (sterile) technique. T or F

Back 162

T

Front 163

To prevent VAP, a nurse does 4 actions:

Back 163

- handwashing
- sterility of equipment
- prevent aspiration - by elevating head of bed 30-45 degrees
- oral hygiene- by teeth brushing 1-2x/day

Front 164

Typically, give pts meds to prevent/treat stress ulcers such as Pepcid and Zantac; believe stress ulcers may be fator in VAP. T or F

Back 164

T

Front 165

what are 2 meds used with mechanical ventilation that promote sedation and paralysis?

Back 165

- Pavulon -(pancuronium bromide)
- Diprivan (propofol)
- these meds are used only after pain meds and anti-anxiety meds aren't good enough to comfort pt on MV

Front 166

____ is shorter acting

Back 166

Diprivan

Front 167

Pt on ____ is completely aware and med provides no pain relief or anxiety relief.
- Therefore also put pt anti-anxiety meds such as benzodiazopene

Back 167

Pavulon

Front 168

What are 4 signs of anxiety for pts on Mech Vent?

Back 168

1) Bucking of ventilator
2) Vital sign changes (incr BP, HR)
3) sweating,
4) moving around

Front 169

Need to make sure pts eyes stay closed (tape them shut) T or F

Back 169

True

Front 170

Sedation scales monitor?

Back 170

ability of pt to be aroused

Front 171

Weaning?

Back 171

process of removing someone from a ventilator

Front 172

When can a pt be weaned?

Back 172

once precipitating cause of ARF is resolved, and pt is stable, then we can wean pt of MV

Front 173

What are the 3 phases of weaning pt off Mech Vent?

Back 173

1) preweaning
2) weaning
3) extubation

Front 174

During preweaning phase, resp therapist measures physiological stability of pt.
What specifics does he look for?

Back 174

1) gas xchange thru ABGs
2) Sa02 sat
3) electrolytes wnl
4) measure hematocrit & hemoglobin (H&H)
5) dec use of opiates (morphine) since it depresses resp sys. So, can't give morphine boluses and expect pt will wean

Front 175

Drug Holiday?

Back 175

a disruption of meds; to get pt off ventilator, need to monitor how pt is w/o meds.

Front 176

3 methods of weaning from Mech Vent?

Back 176

1) SIMV - dec RR until all breaths are pt's own
2) Pressure support- allows pt to take all breaths on own, but assisted by pressure from vent
3) T-piece technique: remove ventilator and put pt on T-piece or CPAP delivering humidified 02.

Front 177

Nursing responsibilities while pt is being weaned?

Back 177

- monitor ABG status
- monitor VS... RR, HR, BP, Sa02
- stay w pt to comfort them
- assess breathing pattern- ie make sure pt is not fatiguing and still able to keepr RR from 12-20.

Front 178

Some pts can't be weaned. Why?

Back 178

- treatment errors are most common, ie keeping Sa02 too high or in COPD pts keep CO2 too low
- diseases
- deformities
- C-2 Fracture
- weakness of chest muscle
- some pts are afraid

Front 179

Extubate?

Back 179

Remove endotracheal tube

Front 180

Hypercarbia?

Back 180

increased C02 in blood; aka hypercapnia

Front 181

Before extubating, what should nurse do?

Back 181

1) explain procedure to pt
2) bring in equip for emergency reintubation
3) hyperoxygenate pt
4) thoroughly suction both ET tube and oral cavity.
5) then rapidly deflate balloon and remove tube at peak inspiration.
6) immediately instruct pt to cough & DB to remove secretions

Front 182

After tube removal, give ______ via face tent or mask

Back 182

humidified 02

Front 183

Sometimes nurse keeps ET tube in for ?

Back 183

suction if lots of secretions

Front 184

3 major complications of intubation found after you extubate?

Back 184

1) dysphagia
2) vocal cord paralysis
3) risk for laryngyspasm -serious prob

Front 185

When does laryngyspasm occur and what is treatment?

Back 185

- occurs within 1st 15-30 minutes following extubation
- treat by giving 100% 02 via NRB mask; open airway via jaw thrust

Front 186

After extubation, monitor pt (dont take eyes off) & assess frequently (every 10-15 min); can alternate with Resp Therapist T or F

Back 186

T

Front 187

What is most common chest wall injury?

Back 187

Rib contusion; MVA rel'd & due to blunt trauma

Front 188

2nd most common chest wall injury?

Back 188

Rib fracture - MVA rel'd & due to blunt trauma

Front 189

With ___ ___ pt can develop interstitial edema of lungs which gives less area for gas exchange

Back 189

rib contusion

Front 190

what is biggest assessment finding for rib contusion or fracture?

Back 190

pain with movement

Front 191

what are other signs for rib contusion/fracture?

Back 191

- bloody sputum (hemoptysis)
- dec breath sounds
- crackles & wheezing on effected side

Front 192

how do you def'initively dx rib contusion/fracture?

Back 192

CT scan or C Xray

Front 193

Most pts won't require treatment for either contusion or fracture. Tor F

Back 193

T
- however, pts have risk of atelectasis in future since pt may not C & DB; therefore important to give incentive spirometer

Front 194

what is collaborative care for rib contusion/fracture?

Back 194

- supplemental 02
- C & DB, incentive spirometer
- encourage activity
- pain meds so they can do C & DB

Front 195

Define pneumothorax?

Back 195

anytime air gets into pleural space and the lung collapses
- due to an interruption of the negative pressure which attracts the visceral and parietal pleura (bet lung and chest wall)
- can be caused by rib fracture

Front 196

Air enters lungs via ___ pressure

Back 196

negative

Front 197

Assessment findings for pneumothorax?

Back 197

- breath sounds are absent or uneven
- uneven chest wall movement
- hyperresonance -when you percuss, won't hear solid sounds, but rather sounds like drum since the lung collapsed and there's nothing in that space.
- Trachea deviation- only see it by looking head-on at pt; all blood vessels are moving and heart is becoming compressed
- very painful

Front 198

Another sign of pneumothorax is crepitus aka ________ which means _______

Back 198

- subcutaneous emphysema
- means air in tissues

Front 199

3 types of pneumothorax?

Back 199

- closed: no opening to outside; caused by rib fracture, asthma; pts w fragile lungs can develop blebs which make spaces in lungs and spontaneously rupture
-open: means exposed to outside air as through a penetrating wound
- Tension: when air gets trapped in the interpleural space with each inspiration and can't escape w expiration leading to complete collapse of lung

Front 200

definitive dx for pneumothorax is ___

Back 200

CXR

Front 201

Tension pneumothorax can be caused by open or closed (more common) pneumothorax T or F

Back 201

T
- medical emergency; can be quickly fatal; can cause cardiac arrest

Front 202

Common cause of tension pneumothorax is via blunt chest trauma or due to ____ ____

Back 202

ventilator injury (barotrauma)
- ventilator chest tubes can also cause by blowing holes in lung
- insertion of central line is another cause

Front 203

S & S of tension pneumothorax?

Back 203

- asymetry of thorax
- tracheal deviation
- resp distress
- unilateral absence of bowel sounds
- distended neck veins due to vessel compression
- cyanosis - heart not pumping properly

Front 204

Treatment for tension pneumothorax?

Back 204

- immediately insert large bore needle into 2nd intercostal space mid clavicular line of the affected side
- then place chest tube into the 4th intercostal space att to a water seal drainage system until lung reinflates
- water seal acts as one-way valve to let air escape

Front 205

Define hemothorax?

Back 205

loss of blood into thoracic cavity occurring after blunt chest trauma or penetrating injuries

Front 206

1) Simple hemothorax?
2) Massive hemothorax?

Back 206

1) blood loss< 1500 ml
2) blood loss > 1500 ml

Front 207

if small blood loss, pt may be asymptomatic. T or F

Back 207

T

Front 208

If large blood loss, pt will show...

Back 208

- respiratory distress
- dec breath sounds
- dull sound when percussing rather than hyperressonance since space is filled with blood

Front 209

Hemothorax is confirmed by ___

Back 209

CXR

Front 210

Thoracentesis?

Back 210

- aspirate fluid from lung by inserting needle through chest wall; lower down since fluid vs air (which rises)
- will see immediate relief of hemothorax
- pt sits on side of bed and leans over bedside table
- need needle and vaccuum bottles to withdraw fluid

Front 211

Mgmt of hemothorax?

Back 211

- replace fluids if blood is lost
- manage I & O
- check Sa02

Front 212

when is surgery required w hemothorax?

Back 212

if initial blood loss is 1500-2000 cc or if bleeding or 200 cc/hr over 3 hrs

Front 213

Flail Chest?

Back 213

-occurs with multiple fractured ribs
- where chest wall starts to separate from sternum
- causes acute resp failure since pt can no longer ventilate themselves
- pt needs mech ventilation
- paradoxical respirations
- one of the most critical injuries

Front 214

Famous pt who had flail chest?

Back 214

Gov Corzine had 11 fractured ribs (out of 15); any more than 7 fractured ribs is flail

Front 215

With flail chest, usually contusion involved causing multiple bruises on lungs and less area for 02 exchange to occur T or F

Back 215

T

Front 216

Describe paradoxic chest movement with flail chest.

Back 216

- sucking inward of loose chest area during inspiration
- puffing out during expiration

Front 217

chest tubes are not only used for pneumothorax, but also used as drains. Other uses?

Back 217

- reinflate lungs by establishing negative pressure
- drain lungs
- can inject talcum powder into pleural space which acts like abrasive and helps parietal and visceral pleura stick together.
- can inject antibiotics into lungs if lung abcess

Front 218

Heimlich valve?

Back 218

- small, 1-way valve used for chest drainage
- has flutter valve where fluid and air will come out & that prevents return of gases or fluids into pleural space
- used instead of traditional water seal drainage system
- only need chest tube, heimlich valve and drainage bag
- will see in pts with chronic pleural effusion such as cancer pts

Front 219

Critical thinking
- 54 yr woman admitted w Dx of pneumonia; RR= 50; ABGs indicate ARF; she is intubated and ventilated
- mode= A/C (assisted mode)
- Fi02= 80%; TV= 500; Rate= 10
ABGs: PH=7.30; Pa02= 75; PaC02= 58; HC03=24; 02Sat= 95%

Back 219

What can be done?
- Increase PEEP to dec Fi02
- Increase RR from 10 to dec PaC02
- resp acidosis w mild hypoxemia