Critical Care Exam 2

Front 1

Defining characteristics of ARF?

Back 1

PaO2 <80 (hypoxemic)
PaCO2 >45 + acidosis (hypercapnic)
COPD w/severe ABG deterioration & clinical deterioration

Front 2

What is Alveolar hypoventilation? And causes?

Back 2

deficient movement of air into & out of the alveoli (usually from obstruction)
other causes- restrictive lung diseases, CNS disease/depression, chest wall dysfunction (pneumothorax), acute asthma, neuromuscular disease

Front 3

What is V/Q mismatch (hypoxemia)?

Back 3

ventilation/perfusion mismatch
decreases ventilation w/normal blood flow (increased secretions in airways/alveoli, bronchospasm, atelectasis, pain)
OR
normal ventilation w/decreased blood flow (PE)

Front 4

Tx of V/Q mismatch?

Back 4

tx underlying cause

Front 5

Consequences of untx ARF in each system?

Back 5

Resp- Increased rate at 1st, decreased w/worsening & muscle fatigue
Cardio- tachycardia, decreased CO
CNS- permanent brain damage
Renal- Acute tubular necrosis
GI- ischemia, bacterial translocation

Front 6

2 major consequences of untx of ARF?

Back 6

hypoxemia - tissue hypoxia - anaerobic metabolism & lactic acidosis = need NaHCO3 to buffer
renal hypoxia - release of erythropoietin from renal cells - bone marrow increases RBC to attempt to increase the blood's O2 carrying capacity- may lead to ATN

Front 7

Early S&S of ARF? And tx?

Back 7

dyspnea, restlessness, anxiety, H/A, fatigue, cool & dry skin, HTN, tachycardia
tx- elevate HOB, O2

Front 8

Intermediate S&S of ARF? And tx?

Back 8

confusion, lethargy, tachypnea, hypotension, dysrhythmias, ischemia
tx- Elevate HOB, O2 NC, may need to intubate

Front 9

Late S&S of ARF? And tx?

Back 9

cyanosis, diaphoresis, coma, resp arrest
tx- intubate, call code

Front 10

What is a PE?

Back 10

obstruction of the pulmonary arterial bed by a dislodged thrombus, fat or air embolus, heart valve growths or a foreign substance

Front 11

What is the patho of PE?

Back 11

vascular wall damage, venostasis, & hypercoagulability of blood cause thrombus formation, thrombus loosens from trauma, clot dissolution, muscle spasm, intravascular pressure change, or peripheral blood flow change, embolus travels to the R side of the heart, enters the lung through the pulmonary artery, embolus dissolves, fragments or grows

Front 12

What happens with an untx PE?

Back 12

alveoli are prevented from producing enough surfactant to maintain alveolar integrity, alveoli collapse = atelectasis
large enough embolus will clog pulmonary vessels = death

Front 13

Complications of PE?

Back 13

pulmonary infarction
pulmonary HTN

Front 14

S&S of PE?

Back 14

sudden unexplained dyspnea- hallmark sign
angina, pleuritic chest pain, tachycardia, air hunger, impending doom, productive cough that may be blood tinged

Front 15

Less common S&S of PE?

Back 15

low grade fever, pleural effusion, massive hemoptysis, chest splinting, lower extremity edema, cyanosis, syncope, distended neck veins, pleural friction rub, circulatory collapse, hypoxia

Front 16

Risk factors of PE?

Back 16

long car trips, long plane trips, cancer, pregnancy, hypercoagulability, birth control, previous DVT or PE

Front 17

Dx of PE?

Back 17

CXR, V/Q scan, pulmonary angiography, EKG, hemodynamics, ABGs, D-Dimer

Front 18

What do you see on a CXR for a PE?

Back 18

may see PE or other pulmonary conditions

Front 19

What do you see on a V/Q scan?

Back 19

reveals perfusion defects beyond occluded vessels
injection of radio-isotope, inhalation of radioactive gas
can't do on an intubated pt

Front 20

Pulmonary angiography for PE?

Back 20

most definitive test
insert cath through antecubital or femoral vein to pulmonary artery where contrast is injected
most beneficial when anticoagulation (heparin) is contraindicated

Front 21

EKG for PE?

Back 21

used to distinguish PE from MI

Front 22

Expected hemodynamics for PE?

Back 22

elevated pulmonary systolic pressure, 20-30
diastolic pressure, 8-15
mean pressure, 10-20
& wedge pressure 6-12
if no wedge pressure ordered go off of diastolic pressure

Front 23

Early ABG results from PE?

Back 23

hypoxemia
hypocapnia
resp alkalosis
(CO2- <35, pH > 7.45)

Front 24

ABG if embolus is large?

Back 24

hypoxia, hypercapnia, resp acidosis

Front 25

How to tx Shunting?

Back 25

intubate, increase O2, increase peep

Front 26

What is SaO2?

Back 26

% of O2 on Hgb
90-100

Front 27

What is PaO2?

Back 27

O2 dissolved in arterial blood
80-100

Front 28

D-Dimer for PE?

Back 28

measures amount of cross-linked fibrin fragments after clotting event ( DVT, acute MI, angina, acute CVA)
not specific or sensitive to PE or clot anywhere

Front 29

When do you use an IVC filter?

Back 29

when you can't use anticoagulants

Front 30

Best tx for PE?

Back 30

1st admin O2 then give heparin 60-70
if levels high, stop for 1 hr
decrease rate

Front 31

Other tx for PE?

Back 31

O2 prn, Heparin, SCDs, fibrinolytics, surgery

Front 32

What is Pulmonary edema?

Back 32

accumulation of fluid in extravascular spaces of the lungs
extravascular spaces = interstitium & alveoli

Front 33

What are the causes of Pulmonary edema?

Back 33

L sided heart failure d/t arteriosclerosis, cardiomyopathy, HTN, valvular heart disease

Front 34

Patho of Pulmonary edema?

Back 34

changes in pulmonary capillary hydostatic pressure, capillary oncotic pressure, capillary permeability, & lymphatic drainage
prevents fluid infiltration into the lungs because the fluid leaks into the interstitial space & alveoli causing impaired gas exchange & edema

Front 35

What are the Early S&S of Acute pulmonary edema? And tx?

Back 35

S3 audible- hallmark
exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, cough, mild tachypnea, HTN, basilar crackles, tachycardia
O2, elevate HOB, Lasix

Front 36

What are the Late S&S of APE & tx?

Back 36

labored, rapid resps, diffuse crackles, blood tinged frothy sputum, increasing tachycardia, arrhythmias, cold clammy skin, diaphoresis, cyanosis, hypotension, weak pulses
Pt is drowning r/t forced fluid in alveoli

Front 37

Dx for APE?

Back 37

ABGs, CXR, Pox, Swan, EKG

Front 38

ABGs will show what for an APE?

Back 38

hypoxemia, & variable PaCO2
PaCO2- dependent on pt's level of fatigue, increased fatigue = increased CO2

Front 39

CXR of APE will show what?

Back 39

diffuse haziness (whited out) of lung fields, cardiomegaly r/t increased pumping, pleural effusion

Front 40

Normal Cardiac output & cardiac index?

Back 40

4-8L
2-4 (pt specific)

Front 41

Pulse Ox will show what w/APE?

Back 41

decreasing SaO2

Front 42

Swan will show what for APE?

Back 42

shows L sided heart failure & can be used to r/o ARDS
decreased CO & CI

Front 43

EKG for an APE?

Back 43

previous or current MI

Front 44

Tx for APE?

Back 44

elevate HOB, high concentrate O2 usually by NC (pt can't tolerate face mask, feels like they're suffocating more), meds
if can't tx soon enough intubate & mechanical vent

Front 45

Meds for APE?

Back 45

diuretics (Lasix), positive isotropes, vasopressors (Levofed), antiarrhythmics (Cardizem), arterial vasodilators (Tridil, nitropreside), Morphine, Natrecol, venous dilator (nitroglycerin IV)

Front 46

Preload affects what?

Back 46

fluid

Front 47

Afterload affects what?

Back 47

pressure

Front 48

What is ARDS?

Back 48

pulmonary edema in the absence of cardiac failure
NO L SIDED HEART FAILURE- NOT CAUSED BY L VENT FAILURE

Front 49

What is primary pulmonary insult?

Back 49

directly affects lung tissue/alveolar membranes
aspiration, near drowning, toxic inhalation, pulmonary contusion, pneumonia, thoracic trauma, O2 toxicity

Front 50

What is secondary pulmonary insult?

Back 50

Anywhere but the lungs
sepsis, non-thoracic trauma (immobility), excessive blood transfusions, pancreatitis, shock, PE, DIC, opioid overdose

Front 51

What is the patho of exudative phase?

Back 51

pulmonary capillary wall damage, fluid leaks into interstitial space, impaired gas exchange r/t widening of gap between alveoli & pulmonary capillaries, increased fluid volume that increases pressure exerted on alveoli causing atelectasis w/decreased lung volume

Front 52

R-L shunt in Exudative phase?

Back 52

blood passes from R to L w/o being oxygenated causing hypoxemia, hypoxia, multi system organ faliure

Front 53

S&S of exudative phase in ARDS?

Back 53

restless, apprehensive/afraid, progressive dyspnea & tachycardia, moderate use of accessory muscles, clear breath sounds, ABG of resp alkalosis & normal PaO2

Front 54

Patho of Proliferative phase?

Back 54

decreased lung compliance, decreased surfactant production, & refractory hypoxemia

Front 55

Proliferative phase S&S of ARDS?

Back 55

increased resp distress, increased tachypnea, increased accesory muscle use, fine crackles, mental status changes/agitation, resp acidosis

Front 56

Patho of Fibrotic phase of ARDS?

Back 56

irreversible, diffuse interstitial & alveolar fibrosis, increased dead space vent, increased hypoxemia & hypoxia, multiple organ dysfunction syndrome

Front 57

Fibrotic S&S of ARDS?

Back 57

increased tachycardia, hypotension, cool mottled ischemic skin, renal & liver failure, severe agitation, hallucinations, coma, death

Front 58

Long-term effects in recovery phase of ARDS?

Back 58

permanent loss of lung tissue, fibrotic = can't change
mild-moderate diminished vital capacity
impaired gas exchange
difficulty exercising, socializing & completing ADLs

Front 59

Dx of ARDS?

Back 59

decreased PaO2 despite increased FIO2- hallmark
CXR- diffuse, bilateral infiltrates
NO CHF

Front 60

Tx of ARDS?

Back 60

mechanical vent
goal- normal PaCo2
PEEP

Front 61

Good causes of PEEP in ARDS?

Back 61

decreases alveolar collapse, increases Functional Residual Capacity, increased lung compliance, decreased R-L shunt, increased clearing of lung fields

Front 62

Risks of PEEP in ARDS?

Back 62

increased alveolar distention causing weakness of alveolar walls causing rupture & decreased CO

Front 63

Other tx of ARDS?

Back 63

coughing, hyperoxygenate prior to in-line suctioning, turn, prone, specialty tube feedings, infection control techniques
DON'T INTERRUPT PEEP

Front 64

Meds for ARDS?

Back 64

antibiotics, corticosteroids, vasodilators, bronchodilators, mucolytics, diuretics, colloids, opioids/sedatives/neuromuscular block (Nimbex)

Front 65

Cause of SARS?

Back 65

coronavirus

Front 66

How is SARS transmitted?

Back 66

person-person contact
droplet precautions

Front 67

DX of SARS?

Back 67

pt hx (travel to area w/SARS, close contact w/other person w/SARS)
CXR- hazy opacities/ground glass appearance, progression to bilateral consolidation in 24-48hrs, culture from blood, stool, nasophary or orophary

Front 68

Tx of SARS?

Back 68

antipyretics, O2, vent support, IV fluids, antibiotics, antiviral, corticosteroids

Front 69

Isolation precautions for SARS?

Back 69

negative pressure
full barrier- gloves, gown, resp mask, eye shield
put hands together after leaving room to go wash hands

Front 70

What is a Pneumonectomy?

Back 70

removal of entire lung
empty space fills w/fluid
usually w/thoracoplasty

Front 71

What do I do for a pneumonectomy & chest tube?

Back 71

NO CHEST TUBE
Lay pt good lung up

Front 72

What is a Lobectomy?

Back 72

removal of lobe/lobes
lung over expands filling entire cavity

Front 73

What do I do after lobectomy?

Back 73

turn pt onto both sides
2 CHEST TUBES

Front 74

What is an open lung biopsy?

Back 74

resection of a small portion of lung for biopsy
CHEST TUBE

Front 75

What is Decortication?

Back 75

removal of visceral pleura
CHEST TUBE

Front 76

What is a thoracotomy?

Back 76

incision in thorax

Front 77

What is VATS?

Back 77

dx procedure
scope w/camera & video projector
biopsy specimen
CHEST TUBE

Front 78

What are the benefits of VATS?

Back 78

decrease blood loss, less invasive, decrease post-op rehab

Front 79

2 types of thoracotomy & what are they?

Back 79

median sternotomy- smaller tubes, split sternum; used for heart pts
posterolateral- anterior axillary line in 4, 5, 6 intercostal
anterolateral- sternal border to mid axillary line used for trauma pts

Front 80

What to teach pt Pre-op for thoracotomy?

Back 80

cough & deep breath techs, incentive spirometry, pain/comfort, stop smoking

Front 81

What to teach pt post-op for thoracotomy?

Back 81

pain, chest tube, arm movement, frequent assessment of breathing

Front 82

What is a thoracentesis?

Back 82

drains fluid from pleural spaces, test fluids for dx, if pneumothorax may need chest tube, monitor for pneumothorax

Front 83

Post op care for lung surgeries?

Back 83

assessment, auscultate, S&S hypoxemia/hypoxia, RR, ABG, oxygenation & ventilation, incentive spirometry, no suction unless absolute necessary, pain measurement using CPOT or WILDA, prevent atelectasis w/pt getting OOB, coughing & deep breathing, pain control, hydration

Front 84

Post-op complications?

Back 84

ARF, bronchopleural fistula, hemorrhage, subcutaneous emphysema, cardiovascular disturbances, pulmonary edema

Front 85

Stages of bubbling?

Back 85

initial bubbling-ok
intermittent bubbling
continuous bubbling- persistent air leak
fluctuations = tidaling

Front 86

Nursing care w/chest tubes?

Back 86

mark drainage levels, keep system below chest, monitor drainage amounts, check dressings, monitor crepitus, tubing, assess lungs sounds & PaO2, suction @ -20

Front 87

Emergency equipment for chest tubes?

Back 87

vasoline gauze, sterile water, clamps

Front 88

Complications of chest tubes?

Back 88

no drainage= malpositioning, kinks, suction, tubing, no milking or stripping
can gently manipulate

Front 89

D/C of chest tubes when?

Back 89

< 5% pneumo, no air leak, drainage, CXR

Front 90

Procedure for D/C chest tubes?

Back 90

explain procedure, medicate, position, MD removes, occlusive dressing, CXR

Front 91

What to monitor for after chest tube removal?

Back 91

bleeding, fluid leak, air leak, resp distress

Front 92

Fx rib sites & areas affected at each site?

Back 92

1 & 2- great vessels & brachial plexus
middle ribs- lung injuries
lower ribs- abd injuries
R sided 8th & below ribs- liver
L sided 8th & below- spleen

Front 93

Dx of rib fx?

Back 93

CXR

Front 94

Complications of rib fx?

Back 94

atelectasis, puncture/pneumothorax, spleen & liver injuries, flail chest, hemothorax, pneumonia

Front 95

What is flail chest?

Back 95

loss of stability r/t multiple rib fxs on 2 or more places fx on 1 rib
paradoxical resp- hallmark sign
possible contusion or hemopneumothorax

Front 96

Tx for Flail chest?

Back 96

stablize chest segment- no surgery/external fixation, mechanical vent, lie on affected side, IV fluids, pain control

Front 97

What is a closed pneumothorax?

Back 97

rupture in visceral or parietal pleural & chest wall
air source inside chest that separates 2 pleura & lung recoils by collapsing

Front 98

What is a spontaneous pneumothorax & S&S?

Back 98

unexpected air leak into visceral pleural space that can cause tension pneumothorax (life threatening)
sudden SOB at rest w/o exertion- hallmark
decreased breath sounds or absent

Front 99

Tx for pneumothorax?

Back 99

Chest tube
pleurodesis/mechanical abrasion, partial pleurectomy

Front 100

What is an open pneumothorax?

Back 100

air enters parietal pleural space through opening in chest wall causing barometric pressure in pleural space

Front 101

What is a tension pneumothorax?

Back 101

rapid accumulation of air in pleural space w/tension on heart & great vessels
one way valve effect, air trapping occurs
TRUE EMERGENCY

Front 102

Tension pneumothorax can cause?

Back 102

mediastinal shift or tracheal deviation

Front 103

Tx for pneumothorax & hemothorax?

Back 103

CHEST TUBE

Front 104

Tx for tension pneumothorax?

Back 104

medical emergency
needle decompression- 14G stick in chest to let air out