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512 Cards in this Set
- Front
- Back
Ventilation
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Breathing air in and out of the lungs
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Oxygenation
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Getting Oxygen into the blood
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Circulation
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Moving the blood through the body
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Perfusion
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Getting Blood and Oxygen into the tissues
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Ventilation
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Respiratory Rate, Tidal Volume, Chest Movement Breath Sounds, PaCO2
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Oxygenation
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Heart Rate, Color, Sensorium, PaO2
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Circulation
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Pulse Heart Rate and Strength. Cardiac Output
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Perfussion
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Blood Pressure, Sensorium temperature, Urine Output hemodynamics
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When you have an emergency what comes first?
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1st is Ventilation (establish an open airway and breathe 2nd. Oxygenation (Increase FIO2) 3rd is Circulation (Chest compressions defibrillate, give heart drugs Most Common problem is Oxygenation
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What is on a Patient Evaluation?
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l) Admission Notes include: Admitting diagnosis History of Present Illness (chief complaint) and past medical history2) Signs and Symptoms things you can see Color, Pulse Edema, Blood Pressure Symptoms Patient must tell you: dyspnea, pain neasea muscle weakness Occupation or Employment History Allergies, Prior Surgeries Illness or Injury Vital Signs, RR, Pulse, BP, Temp Physical Exam of Chest inspection, palpation, purcussion and auscultation
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What is smoking history?
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Patients number of pkg per day times number of years smoked
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What is an Advance Directive?
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DNR: Do Not Resuscitate
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What is On the Respiratory Care Orders?
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Type of treatment, frequency, medication dosage and dilution Physican Signature
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What goes on a Patients Progress Notes and Lab Reports
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Respirator Notes Date, times Reactions Nursing Notes check patient status boats Reports ABG Pulmonary Function testing Image Reports Xrays Ct, MRI, PET
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What are the basic lab Assessments?
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CBC, electrolytes, urine analysis, pleural fluid Intake and Output: Normal l liter a day Sensible water loss-urine, vomiting Insensible water loss Lungs and Skin If intake exceeds output could cause: Weight gain, electrolyte imbalance Increased homodynamic pressures... Decreased Lung Compliance
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What do you check for bedside interview?
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Determine Level of Consciousness Alert and responsive is Norma) Lethargic somnolent sleepy could be COPD Overdose or Sleep Apnea stuporous confused, respond inappropriate could be Drug Overdose, Intoxication Semi Comatose responds only-to painful Stimuli Coma does not respond to painful stimuli Obtunded drowsy state may have decreased cough or gag Check Orientation to time and place and person Assess emotional State Check activities of daily living: Eating, dressing, walking, bathing
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What are some subjective symptoms?
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Orthopnea difficulty breathing upright CHF General Malaise: electrolyte imbalance Dyspnea Grade I normal dys pnea occurs. after unusual exertion Grade II breathless after going up hills or stairs Grade 111 dyspnea while walking abnormal speed Grade IV dyspnea slowly walking short distances Grade V dyspnea at rest, shaving dressing
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What is pain and some signs?
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Reaction of specific nervous tissue, BP up and HR also
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Whet are some symptoms of Nose and throat?
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Excessive nasal secretions Itching and burning of nose and throat Dysphagia difficulty swallowing and hoarseness
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What does the Respiratory Care Plan consist of?
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Case Management Plan Therapy protocols Disease management Patient and family educational needs
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What is a patents physical environment?
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Ramps, doorways. stairs
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What are open ended questions?
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Questions that ask a Patient to describe they provide more detail.
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How do you assess a patnent's learning need?
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Knowing possible barriers Language Age Education Emotional barriers
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Assessment by Inspection What Can you see?
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General Appearance age height, weight sex, nourishment Peripheral Edema Caused by CHF and Renal Failure Clubbing of fingers Chronic hypoxemia Venous distention CHF Seen during exhalation COPD Capillary refill indication of peripheral circulation noninvasive and quick Diaphoresis heavy sweating Heart failure Fever infection TB night-sweats Cachectic Muscle Wasting
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What do you look at for skin Color?
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Normal is pink,tan,brown, black Abnormal is a decrease in color anemia or blood loss Vasoconstriction will cause a change by reducing blood flow Jaundice Increase in bilirubin 17 blood tissue face and trunk Erythema Redness of skin capillary congestion and inflammation Cyanosis blue or blue gray Hypoxia from increased amount of reduced hemoglobin.
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What are the chest Configurations?
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Normal is normal A-P diameter Kyphosis is hunch back or convex spine curve Scoliosis is lateral curvature of-the Spine Kyphoscoliosis combination hunchback and lateral curvature Barrel chest result of chronic air trapping C0PD increased AP diameter
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What is the normal movement of the Chest?
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Symmetrical Both sides of chest move at same Time Abdomen moves out due to diaphram dropping chest moves outward and upward
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What is Asymmetrical ?
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Asymmetrical is an unequal movement of chest Underlying pathology could include Chronic lung disease Atelectasis Pneumotorax Flail Chest Paradoxical Intubated patient with endotacheal tube in one lung
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What are some breathing patterns?
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Eupnea Normal RR depth and rhythm Tachyphnea Increased RR > 20 Bpm Fever, Hypoxia, Pain, CNS problem Bradypnea Oliaopnea Decreased RR < 8bpm variable depth and Rhythm Apnea is cessation of breathing Cheyne-Stokes Increased and Decreased Rate and Depth with periods of Apnea Caused by increased intracranial pressure meningitis, drug overdose
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What is accessory muscle activity?
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Muscles used to increase ventilation during times of stress are Diaphragm-intercostals scalene, sternocleidomastoid and abdominal
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What is muscle Condition?
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Muscle wasting atrophy is loss of muscle tone and occurs in paralysis Increase in muscle size hypertrophy occurs in C0PD patients
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What are retractions?
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Intercostals and or sternal retractions occur when the chest moves inward during inspiratory efforts instead of outward This is due to a obstructed airway A sign of respiratory distress in infants
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What is nasal flaring?
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Flaring of the nostrils during inspiration. A sign of respiratory distress in infants Expiratory grunting and retractions occur in newborns to prevent atelectasis
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What is the character of a cough?
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Strong, moderate or weak. Productive or non productive Frequent or infrequent, tight or moist A dry or nonproductive cough may indicate a tumor in the lungs. A productive cough may indicate an infection.
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What is the pulse?
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Normal 60-100 bpm Tachycardia >100 bpm indicates hypoxemia anxiety, stress Bradycardia <60bpm indicates heart failure shock code emergency
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When is heart rate a cause for concern?
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Increased heart rate > 2Obpm is an adverse reaction, stop therapy, notify nurse and doctor Any change in rhythm is indication for further monitoring
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What is paradoxical pulses pulse paradoxus?
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Pulse blood pressure varies with respirations May indicate severe airtrapping as m status asthmatics tension pneumothorax
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What is tracheal deviatlon?
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Pulled to Abnormal side? Pulmonary Atelectasis Pulmonary Fibrosis Pnemonectomydiaphragmatic paralysis
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Whet is percussion ?
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Percussion is done by placing the middle finger between two ribs and tapping the middle fingers first joint with the middle fingertip of your opposite hand Resonance Normal filled air filled lungs\ This gives a hollow sound. Flatness heard over Sternum muscle on area of atelectasis Dullness heard over a loud filled organs such as heart or liver pleural effusion or pneumonia will give this thudding sound Tympany heard over air filled stomach) This is a dreamlike sound and when heard over the lungs indicates increased volume Hyperresonance found in areas of the lung where pnemothorax or emphysemas are present this is a booming sound
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What are breath sounds?
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Normal breath sounds vesicular Bronchial breath Sounds normal sounds heard over tracheal on bronchi Over the lung would indicate lung Consolidation
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Abnormal Breath Sounds
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Rates crackles secretion fluid
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Coarse rales rhonchi Large Airways Secretions
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Patient needs suctioning
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Medium Rales
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Middle airways secretions Patient needs chest physical therapy
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Fine Rales mass crepitate rates
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Abrader fluid Patient has cHF pulmonary edema Patient needs IPPB heart drugs diuretics and oxygen
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What is wheeze due to?
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Broncho spasm, patient needs bronchodilator Unilatenatal Wheeze indicative of a foreign body obstruction, Mucus plug
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What is stndor?
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Due to upper airway obstruction Supraglottic swelling epiglottis Subglottic swelling croup post extubation Foreign body aspiration solids or fluids
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What is Pleural Friction Rub?
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Coarse grating or crunching sound visceral and parietal pleura rubbing together
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What are normal Heart Sounds)
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SI and S2
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What are abnormal heart sounds?
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S3 and S4 heart sounds You need an Echocardiogram
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What is normal blood pressure?
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120180 mmHg using a sphygmomanometer Increased Blood Pressure indicates cardiac stress-hypoxemia Decreased blood pressure indicates poor perfusions shock<
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What is the position of the endothachial tube?
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Below the vocal cords and no closer than 2 cm or I inch above the carina
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What are some of the anatomical landmarks?
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Trachea seen as a dark area midline Costophrenic angles, Angle made by the outer curve of diaphragm and the chest wall Angles are obliterated by Pleural Effusions Diaphragm Dome Shaped normally Flattened with COPD Vascular Markings are Blood Vessels lymphatics,lung tissue
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What are the positions and projections on the chest x-ray?
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AP projection-anterior, posterior
Lateral decubitus position-Patient lying on affected side-valuable for detecting small pleural effusion |
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What is normal chest x-ray?
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Both hemidiaphragms are frounded (dome-shaped) The right hemidiaphragm is slightly higher than the left, liver pushes it up. The right hemidiaphragm is at the level of the sixth anterior rib.
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What are the position of tubes and catheters?
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Chest tubes should be located in the pleural spaace surrounding the lung. Nasogastric tubes and feeding tubes should be positioned in the stomach and small bowel below the diaphragm. Central Venous catheters are placed in the right or left subclavian or jugular vein and should rest in the vena cava or right atrium of the heart.
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What is a valuable diagnostic tool for an upper airway obstruction in children ? Croup and Epiglottitus
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Lateral neck x-ray
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What is the classic x-ray sign for croup(larynotrachebronchitis)
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Viral disorder , the xray will reveal tracheal narrowing in a classic pattern called steeple sign, pencil point , picket fence all meaning pointing
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What is Epiglottitis and what x-ray sign helps identify it?
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Epiglottitis is a potentially life-threatening inflammaaton of the supraglottic airway caused by a bacterial infection. A lateral neck x-ray shows supaglottic narrowing showing a thumb sign.
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What is Radiolucent?
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Dark pattern, air seen on X-ray normal for lungs
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What is Radiodense?
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White pattern, solid , fluid normal for bones, organs.
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What is an Infilttrate?
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Any ill-defined radiodensity as in Atelectasis.
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What is Consolidation?
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Solid white area, such as Pneumonia(inside)
Pleural effusion (outside) |
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What is hyperlucency?
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Extra pulmonary air as seen in COPD, asthma attack, pneumothorax.
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What are Vascular markings?
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Lymphatics, vessels,lung tissue
Increased with CHF Absent with Pneunmothorax |
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What is Diffuse meaning on X-ray?
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Spread throughout as in Atelectasis /Pneumonia
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What is Opaque meaning on X-ray?
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Fluid , solid as in consolidation
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What is Bilateral and what is unilateral?
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Bilateral means on both sides
Unilateral means on one side |
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What are Fluffy infiltrates?
What are Butterfly/Batwing pattern? |
Diffuse whiteness and infiltrate in shape of butterfly as seen with Pulmonary Edema
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What are patchy infiltrates and platelike infiltrates?
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Scattered densities and thin-layered densities as seen in Atelectasis
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What is Ground Glass Appearance and Honeycomb Pattern?
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Reticulogranular and Reticulonodular as seen in ARDS/IRDS
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What is an Air Bronchogram?
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Pneumonia
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What are peripheral-wedge-shaped Infiltrate?
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Pulmonary Embolus
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What are Concave superior inerface/border?
What are Basilar infiltrates with meniscus? |
Pleural effusion
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What is Bronchography?(bronchograms)
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Injection of radio-opaque contrast that outlines the airways it allows study of obstruction lesions(tumors) and bronchiectasis.
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What is a V/Q scan?
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Two scans ventilation and perfusion if the results indicate a normal ventilation scan but abnormal perfusion scan= Pulmonary Emboli
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What type of equipment do you need for a MRI?
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Manual resuscitation equipment should have detachable non-rebreathing valves made of non-ferrous(non-metallic) materials.
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What is an Electroencephalography? (EEG)
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Electrical activity of the brain. Indications for brain tumors, injuries, retardation, epilepsy, seizuries, sleep disorders.
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What is normal ICP?(intracranial pressure)
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5-10 mm Hg
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When should ICP be treated?
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If ICP> 20 mmHg
Patient should be hyperventilated until PaCo2 is 25-30 mmHg |
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What is Ultrasonography of the Heart? Echocardiogram (ECG)
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Non invasive method for monitoring cardiac performance.
More S1 or S2 |
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What is the normal RBC? red blood cell count
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Normal value
4-6 mill/cu mm |
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What is normal Hemoglobin? Hb
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Normal value
12-16 gm/dl |
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What is normal hematocrit?Hct
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Normal value
40-50% |
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What is normal White blood cell ? WBC
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Normal WBC
5,000 to 10,000 per cu mm |
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What is leukocytosis?
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Increased WBC over 10,000 is bacterial infection
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What is leukpenia?
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Decreased WBC count under 5,000 mean viral infection
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What are Electrolytes and their clinical application of imblance?
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K+, Na+, Cl-, HCO3-(CO2 content) are elements required by the body for normal metabolism.
Electroyle imbalance cause muscle weakness, soreness, nausea, mental changes such as lethargy, dizziness and drowsiness - general maliase |
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What is the normal value for K+ Potassium?
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Normal = 3.5 - 4.5 range Important for acid-base balance
CO2 + |
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What is Hypokalemia?
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Low K+ low potassium, metabolic alkalosis, excessive excretion , renal loss, vomiting
Flattened T waves on EKG |
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What is Hyperkalemia?
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High K+ potassium , kidney failure, metabolic acidous
Spiked T wave on EKG |
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What is the normal value for Na+ sodium?
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Normal Na+ Sodium is 140mEq/L (135-145 range)
CO2+ |
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What is hyponatremia?
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Low Na+ low sodium
fluid loss from diuretics, vomiting, diarrhea, fluid gain from: CHF,IV therapy |
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What is hypernatremia?
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High Na+ high sodium
Dehydration |
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What is the normal value for Cl- Chloride?
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Normal values for Cl- Chloride 90 mEq/L (80-100 range)
Pa- |
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What is hypochloremia?
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Low Cl- chloride
metabolic alkalosis |
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What is hyperchloremia?
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High Cl- chloride
metabolic acidosis |
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What is normal HCO3?
Bicarbonate (total CO2 content) |
Normal HCO3 24mEq/L
22-26 range |
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What do you look at in Sputum analysis?
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Amount of sputum teaspoons, tablespoon.
Consistency-thin,thick, tenacious Color |
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What does the color of sputum tell you?
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Clear-normal
Mucoid-White/gray, chronic brochitis Yellow presence of WBCs bacterial infection Green- stagnant sputum, gram negative bacteria (Bronchiectasis, pseudomonas) Brown/dark- old blood Bright red - hemoptysis(bleeding tumor, TB) Pink frothy- pulmonary edema |
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What does the sputum culture tell you?
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Identify the bacteria present and what antibiotics will kill the bacteria
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What is the difference between the Gram and Acid fast stain?
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Gram stain identifies whether it is gram positive or negative this is a fast test less than 1 hour.
Acid fast stain indicates tuberculosis takes longer to get result |
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What is an Oscilloscope?
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Oscilloscope is a moniter that is at the head of the bed that provides the visual image of the ECG
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What is the Electrocardiograph?
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It is the printed version of recording the electrical activity of the heart.
Always Look at Lead II |
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What is a Holter Monitor?
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Portable version of an electrocardiograph that is worn under clothes for 24-48 hours continually
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What is an Electrode?
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Electrode is a sticker placed on the skin to conduct electric current
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What is a lead?
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A positive and negative electrode that allows electrical current to flow.
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How many leads and electrodes are there in a 12 lead?
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There are 12 leads and 10 stickers (electrodes)
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What lead do you moniter?
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Moniter Lead II
Left leg positive, Right Arm Negative |
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What is distintive about the AVR lead?
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AVR is the only limb lead that produces an upside down (neg) pattern
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What leads give dimension of right heart and where are they placed ?
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V1 - 4th intercostal space on right side of sterum
V2 - 4th intercostal space on left side of sterum |
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What leads give dimension of Ventricular septum and where are they placed?
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V3- between V2 and V4 on left side
V4 - 5 th intercostal space, left mid clavicular line |
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What leads give dimension of left heart and where are they placed?
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V5- between V4 and V6 on the left side
V6-5th intercostal space, left mid-axillary ling |
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What is normal heart rate?
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60-100 bpm
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What is bradycardia?
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<60bpm
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What is tachycardia?
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>100bpm
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What is flutter?
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>200bpm
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What is fibrillation?
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Too fast to count
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How do you measure heart rate on a strip?
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You measure the distance between the two R waves and divide 300 by it.
If the two R waves are between 3 and 5 large blocks the the rate is normal 60-100 If the two R waves are closer than 3 large blocks then the rate is greater than 100-tachycardia If the two R waves are wider than 5 large blocks than the rate is less than 60 - bradycardia |
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How do you treat Sinus Rhythm?
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Normal rate, no skips, or extra beats, treat other symptoms
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How do you treat Sinus Tachycardia?
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Sinus rhythm > 100
Treat with Oxygen |
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How do you treat Sinus bradycardia?
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Sinus rhythm <60
Treat with Atropine, Oxygen |
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How do you treat PVC's?
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Premature ventricular contractions (PVC)
Absent of P wave Treat with Oxygen, Lidocaine, Suctioning |
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How do you treat V tach?
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Ventricular tachycardia
Ventricular rhythm with rate>100 Treat with Defibrillate (If No Pulse) Lidocaine and Cardiovert (If Pulse Present) Oxygen |
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How do you treat V-fib?
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Ventricular fibrillation, completely irregular ventricular rhythm
Treat-Defibrillate |
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How do you treat Multifocal PVC's?
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Premature ventricular contractions
No P wave , Large QRS Treat with Oxygen, Lidocaine (this reduces the irritibility of heart) |
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How do you treat Asystole?
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Confirm in 2 leads first, then Epinephrine, Atropine , 100% Oxygen and CPR
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What does the axis of an ECG measure?
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Axis measures the direction of all the electricity through the heart during contraction
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What do you assess for a perinatal history?
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Mother's History: History of pregnancy, age, smoking and substance abuse, nutrition, infecton , previous pregnancies/outcomes. Hypertension, toxemia diabetes ( diabetes prone to have problems with premature babies)
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What is the gestation Age of infant?
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Time since the estimated date of conception.
Term-38 to 42 weeks Preterm(premature) less than 38 wks Post- more than 42 wks |
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What are the five factors for evaluating infant and when are they done?
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APGAR routinely done at 1 and 5 minutes
A isAppearance (Color) Good is 2 completely pink Bad is 1 Body pink , extremities blue, Real Bad is 0 blue all over, pale Pulse Good(2) is >100 minute Bad(1) is <100 minute Real Bad (0) is absent no pulse Grimace(Reflex irritability) Good(2) cough or sneeze Bad(1) grimace Real Bad(0) No response Activity Good(2) Active motion Bad(1) some flexion of extremities Real Bad (0) Limp No movement Respiratory effort Good(2) Regular, strong cry Bad(1) slow, irregular weak cry Real bad(0) Absent no cry |
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What action do you take based on APGAR score?
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0-3 RESUSCITATE
4-6 SUPPORT stimulate, warm , administer O2 7-10 MONITOR routine care |
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What is a transillumination?
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Bright fiberoptic light placed against the infant's chest in a darkened room
Normally a lighted halo is seen around the point of contact A Pneumothorax or pneumomediastinum will cause the entire hemithorax to light up |
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What are the vital signs of an infant?
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Normal pulse rate 110-160bpm
Respirations normal 30-60breaths per minute(higher in preterm babies) Blood Pressure Normal term Infant 60/40mmHg Preterm 50/30 mmHg Birth Weight Normal Term>3000gm 3kg 28wks 1000gm |
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What are some signs of Respiratory Distress in Infants?
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Cyanosis bluish all over
Acrocyanosis is bluish extremities not true cyanosis Retractions intercostal sucostal substernal or supraclavicular retractions Nasal Flaring dilation of nasal openings (breathing through nose) Capillary refill How long it takes for normal color to return -longer than 3 seconds may indicate a decreased cardiac output |
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What are some methods of measuring gestional age?
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Dubowitz Method and New Ballard Score
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What are pre and post ductal blood gas studies and what do they mean/
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If the pre-ductal (right radial artery Pao2 is 15 mmHg highter than the post-ductal (umbilical artery) PaO2 , then the patient has a paten ductus arteriosus with a right to left shunt. Needs a Echocardiogram
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What are the normal Blood glucose levels in infants?
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Hypoglycemia
Term infants >30 mg/dL Preterm > 20 mg/dL |
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What is L/S ratio and what does it mean?
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Lecithin/sphingomyelin , a ratio
of 2:1 or highter is good. It measures lung maturity. A ratio less than 2:1 indicates high risk of hyaline membrane disease (HMD) or Infant respiratory distress syndrome (IDS) approaches zero |
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What is PG?
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Most reliable indicator of pulmonary maturity even with diabetes. Phosphatidylglycerol
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What is capnography and what is the normal range?
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Measuring exhaled carbon dioxide content using infrared absorption. ETCO2 normal value is 3-5%
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What does an increase in Capnograph (PECO2 or PetCO2% ) indicate?
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An increase indicates a decrease in ventilation (ventilatory failure)
Increase Tidal Volume |
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What does an decrease in the capnograph indicate?
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Decrease indicates an increase in ventilation or decreased perfusion (deadspace disease: pulmonary embolism, hypovolemia
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What does low PetCO2 reading immediately following intubation indicate?
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ET tube is in the esophagus
If patient already on ventilator and you get low or 0 reading then reconnect patient to ventilator |
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What does the PetCO2 do during CPR?
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The PetCO2 should increase during CPR
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What are the examples of color change for PCO2?
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Purple=poor
Yellow=normal False readings may occur in patients who have been without CPR for a period of time |
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What is a non-invasive method of monitoring oxygen saturation?
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Pulse oximetry measures SaO2 or SpO2 and pulse
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What effects accuracy of pulse ox?
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Perfusion, shock and hypotension, conditions that interfere with the light transmission, fingernail polish bright ambient lights, erytherma (redness of skin due to capillary dialation)
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What will make a pulse ox measure higher?
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Carbon Monoxide poisoning
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What accurately measures COHb?
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Co-oximeter/hemoximeter
Used to diagnose carbon monoxide poisoning.>20% COHb |
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What is normal COHb reading and abnormal?
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Normal COHb is 1-3%
COHB for smokers 5-10% Heavy Smokers 10-15% |
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What is an invasive and non-continuous measurement of O2Hb?
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ABG but is this is calculated and the Co-oximetry are directly measured
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What are transcutaneous PO2 and PCO2 measurement?
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Continuous non-invasive measurement by electrodes placed on the skin instead of ABG
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What improves Transcutaneous PO2 and PCO2 measurment?
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Heating the skin to 43-45C improves the capillary blood flow (perfusion) and enhances gas movement through the skin.
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How long should electrode site be changed for transcutaneous measurement?
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Every four hours. If redness or blistering every 3 hrs.
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What is hemodynamics?
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Hemodynamics is monitoring the blood pressures . circulation and perfusion
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What is the physiology of blood pressures?
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Without sufficient blood pressure the tissue will not receive the oxygen and nutrients it needs to survive.(perfussion)
High blood pressure causes strain on the heart and willeventually cause heart failure. There are three factors that control blood pressures: Heart, Blood and Vessels |
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How do changes in the heart affect blood pressure?
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Increase in the heart rate / strenght will increase the blood pressure
Decrease in the heart rate/ strength will decrease the blood pressure-contractility |
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How does the blood affect the blood pressured?
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Excessive fluids increase pressures so give diuretics
Loss of fluids decrease pressures so give fluid |
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How does the condition of the vessels change blood pressures/
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Vessel constriction increase pressures so give sodium nitro(Nipride)
Vessel dilation decrease pressures give dopamine |
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How do you calculate mean arterial pressures (MAP)?
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MAP= 1 x systolic + 2 x diastolic / 3
Normal value is 120/80mmHg Normal = 90mmHg |
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What is the normal blood pressure?
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120/80 or 90mmHg
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What is the normal value for Central Venous Pressure ?
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2-6 mmHg
4-12 cmH2O Mean right atrial pressure. If low also give fluids and drugs |
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What is the Pulmonary Artery Pressure (PAP)?
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25/8mmHg or 14mmHg
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What is the Wedge Pressure (PWP)?
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4-12mmHg
Estimates left ventricle filling (preload) Equal to left atrial pressure |
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What is the flow of blood through the body?
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Left ventricle through the aortic valve into the systemic arterial system to the capillary then the systemic veins back to right heart through right atria through the tricuspid valve to right ventricle through the pulmonic valve into the pulmonary artery through the lungs then to the pulmonary veins into the left atria through the mitral valve into the left ventricle again.
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When will CVP be increased/
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Right Heart Failure, Cor pulmonale (tricusid valve) The CVP will be up
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When will PAP be increased?
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Lung disorders, Pulmonary embolism, Pulmonary hypertension, Air Embolism , Hypoxcemia
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When will PCWP be increased?
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Left heart failure Mitral valve stenosis CHF/pulmonary edema High PEEP effects
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What happens with Hypervolemia (fluid overload)?
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Every value is up
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What happens with Hypovolemia (fluid decreased)?
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Every value is down
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What is pulse pressure and the normal?
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The difference between the systolic and diastolic pressure
The normal value is 40 mmHg |
|
What is Cardiac Output equation?
|
Fick equation =
QT=VO2/Ca-v)o2 (10) QT= heart rate x stroke volume Normal Value 4-8L/min |
|
How do you calculate Cardiac Index (Cl)?
|
Cardiac Index is the cardiac output (QT) divided by the body surface area (BSA) in meters squared(m2)
Cl= QT/BSA normal is 2.5-4L /min/m2 half of QT normal |
|
What is the Systemic Vascular Resistance( SVR)?
<20 mmHg/L/min or 1600Dynes/sec/cm-5 |
The pressure gradient across the systemic circulation divided by the cardiac output
SVR=MAP-CVP/Cardiac output x 80 for dynes/sec/cm-5 |
|
How may SVR change?
|
SVR is increased with systemic hypertension and or vasoconstriction(especially due to Alpha Type drugs) SVR may change with changes in cardiac output or index if other values remain constant
|
|
What is Pulmonary Vascular Resistance(PVR)?
Normal <2.5mmHg/L/min or 200Dynes/sec/cm-5 |
The pressure gradient across the pulmonary circulation divided by the cardiac output.
PVR=(MPAP-PCWP) / Cardiac Output x 80 |
|
How is Pulmonary Vascular Resistance increased?
|
PVR is increased with hypoxia, pulmonary hypertension and lung disease
|
|
What is the formula for calculating resistance?
|
R= Change in Pressure /Flow
|
|
What are the three sights for obtaining an arterial blood gas?
|
Radial, Brachial, Femoral
|
|
What should Not be used to monitor oxgen therapy and why?
|
Capillary gases should not be used as PO2 values do not correlate very well with actual arterial blood.
|
|
What artery is the first choice to draw a ABG and why?
|
Radial artery is first choice because of accessibility and collateral blood flow.
|
|
What test is used to assess collateral blood flow?
|
Modified Allen's Test and you release the ulnar artery to test for collateral blood flow.
|
|
What does Blood Gas Analyzers Measure?
|
PCO2 (severinghaus electrode)
PO2(Clark electrode) PH(Sanz electrode) All other values are calculated |
|
What is point of care testing?
|
Monitoring done at the bedside
|
|
What is the Alveolar Air Equation? PAO2
|
PAO2 calculates the partial pressure of oxygen in the alveoli.
PAO2= (7 x FIO2)-(PaCO2 + 10) |
|
What is the A-aDO2 or the
A-a gradient? |
A-a gradient measures the difference between alveolar and arterial PO2.
Best done after patient has been on 100% oxygen for 20 minutes. |
|
What can be evaluated by the A-a gradient (A-aDO2)?
|
Therapy to improve distribution of ventilation can be evaluated(IPPB, IS )
|
|
What are the values of the A-a gradient?
|
Normal 25-65 mmHg on 100%
V/Q mismatch 66-300mmHg Shunting >300mm Hg |
|
What is CaO2 and it's normal?
|
CaO2 is the best measurement of oxygen delivered to the tissues, or best index of oxygen transport Oxygen in RBC + Oxygen in Plasma
Normal is 17-20 vol %(mL/dL) |
|
What is the CaO2 formula?
|
CaO2= (Hb x 1.34 x SaO2)
If SaO2 above 90% then don't use it |
|
What is CvO2 and it's normal?
|
CvO2 is total amout of oxygen carried in the mixed venous blood.
Normal is 12-16vol% Blood is drawn from Pulmonary Artery by swan-ganz catheter |
|
What is the C(a-v) O2?
|
C(a-v)O2 is the arterial minus the venous oxygen content It measures oxygen consumption of the tissues
CaO2-CvO2 Normal 4-5vol% Short Cut Take SaO2-SvO2 x 2 and put in decimal |
|
What happens when QT cardiac output decreases?
|
CvO2 and SvO2 decreases and C(a-v)O2 increases
|
|
What is the PaO2/FIO2 ratio and what are the normals and what is it used for?
|
PaO2/FIO2 measures the efficiency of oxygen transfer across the lung and used in deternimation of ALI or ARDS
Normal is 380 mmHg or > Less than 300mmHg is ALI Less than 200mmHg is ARDS |
|
What does C(a-v)O2 equal?
|
C(a-v)O2 = (SaO2- SvO2) x 0.2
|
|
What is the QS/QT?
|
The portion of the cardiac output that is shunted
Normal value is 3-5% (PAO2-PaO2( first number from A-a + 1 ) x 5 |
|
What is the relationship of PaO2 to SaO2?
|
SaO2 =PaO2 + 30
|
|
What is VD /VT?
|
Dead space to Tidal Volume ratio Ventilation without Perfussion
VD/VT= PaCO2-PECO2/PaCO2 |
|
How do you calculate VD?
|
VD/VT x VT= VD
|
|
How do you determine a desired VE?
|
(VE (known) x PaCO2 (known) /Desired PaCO2
|
|
How do you determine a Desired FIO2?
|
PaO2(desired) x FIO2(known) /PaO2 (known)
|
|
How do you determine a desired rate?
|
Current rate x PaCO2(known) / Desired PaCO2
|
|
What are the normal blood gas ranges?
|
PCO2 35-45 torr
PO2 80 - 100 torr pH 7.35 - 7.45 HCO3 22 - 26 mEq/L SO2 95-100% Venus 70-75% |
|
What are the blood gas interpretations?
|
CO2 to Ventilation
35-45torr normal Above 45 Patient Not Ventilating Ventilate Pt or Increase Tidal Volume or Rate Below 35 Pt Is Ventilating too much Add Deadspace if PO2 acceptable Abnormal PCO2 with normal pH Pt COPD don't change ventilation |
|
What are the normal oxygen values and responses/
|
PaO2 FIO2 Interpretation
80 -100 on ,21 Normal <80 on .21-.59 Hypoxemia due to Poor ventilation High PCO2 INcrease ventilation V-Qmismatch normal PCO2 Increase FIO2 up to 0.60 Below 80 on .60+ Shunting, Venus Admixture Start CPAPif Pt breathing on own Start PEEP if Pt on ventilator Above 100 (hyperoxemia) if on .22-1.0 Over Oxygenation Decrease the FIO2 first if at or above .60 Once FIO2 is<60 then reduce PEEP/CPAP and decrease ventilation if lowPCO2 |
|
What are the exceptions to the rule for ABG interpertations?
|
TYPE 1 ABG looks good / Pt looks and feels bad / CO poisoning /100% oxygen treatment /Anemia Low Hb , pt maybe hypoxic PVC's , tachycardia, distress, CBC low/ give oxygen until transfusion is complete / Pulmonary Embolus (increased dead space)Sudden increased rate and depth of breathing/Anticoagulat therapy support ventilation.
COPD type 2 also could have given too high an oxygen flow |
|
What are some types of Spirometers?
|
Water -seal Collins measures volume and time and are most accurate. Pneumotachometers measure flow like the Turbine Wright respirometer, Pressure differential Fleish and can continuously measure VE.
Peak flow meters can measure at the bedside they have a resistor and moveable indicator, resistance is provided by utilizing a narrow orifice |
|
What is the plethysmograph?
|
It's the body box , it measures airway resistance difference in pressure between the mouth and the alveoli and it will more accurately measure FRC in COPD patients
|
|
What are some recording devices?
|
Kymograph is a rotating drum which maneuver is recorded on graph paper it plots volume (y-axis) against time (x-axis)
The X-Y recorder plots volume(x-axis) against flow(y-axis) Advantage over kymograph is it allows for recording of flow-volume loops |
|
How is equipment tested for accuracy?
|
Volume calibration and leak tests by using a large volume syringe , normally 3.0 liters. If a leak occurs recalibrate.
|
|
What is a gas analyzer?
|
Galvanic fuel cell that produces a current measures partial pressure , displays FIO2 as percent. Accuracy can be affected by water on the sensor, high system pressures and changes in altitude, if unable to calibrate , change fuel cell.
|
|
What is a polarographic?
|
Similar to a galvanic fuel cell except it has a battery . If unable to calibrate change the battery and check electrolyte level. Trouble shooting recalibrate analyzer and recheck equipment
|
|
What is the VC, SVC?
|
Vital Capacity pt takes maximal inspiration followed by a maximal exhalation without force.
The SVC will provide the important Volumes used to measure Restrictive Disease |
|
What are the volumes and capacities measured in pulmonary diagnostic testing?
|
VT tidal volume normal breathing
IRV inspiratory reserve volume ERV expiratory reserve volume IC inspiratory capacity (IRV+VT) VC Vital capacity (IRV+VT+ERV |
|
What is the best indicator of Restrictive lung disease?
|
Decreased Vital Capacity
|
|
What is FVC forced vital capacity?
|
The volume that can be expired as forcefully and as rapidly as possible after a maximum inspiration. It provides important flow rates to measure obstructive disease
|
|
What is the best indicator of Obstructive disease?
|
Decreased FEV1/FVC
If the FEV1 is decreased but the FER1/FVC ratio is normal then the patient is restrictive only. Most individuals can exhale all of their air in about 2 seconds |
|
What is the forced expiratory flow 200-1200?
|
FEF200-1200 is average flow during the first 1000ml after 200ml expired decreased values are associated with large airway obstruction. (begining of breathe)
|
|
What is forced expiratory flow 25-75?
|
FEF25-75 decreased values are associated with small airway obstruction. (middle of breathe)
|
|
What is PEFR?
|
Peak expiratory flow rate effort dependant sometimes used to evaluate asthmatic patients , pre and post bronchodilation.
|
|
What is MVV?
|
Maximum voluntary ventilation the largest volume and rate that can be breathed per minute by voluntary effort.12-15 seconds. Measures the muscular mechanics of breathing preOp patients.
|
|
What is pre and post bronchodilator PFT testing?
|
Used to measure the reversibility of an obstructive pattern . increase of 12% or 200mL in the FEV1 post test is considered significant
|
|
How do you measure FRC?
|
FRC (RV,TLC) is measured by either the He dilution (closed method) or N2 wash out (Open method)
|
|
What are flow volume loops?
|
Displays the volumes and flow rates of the FVC. Flow rates are measured on the vertical axis. Expiratory flows are above the base line. Inspiration is below the line.Volume is measured directly on the horizontal axis. Restrictive is a skinny and tall loop . Obstructive is short and wide loop
|
|
What is the evaluation of pulmonary function tests?
|
Values predicted on age, height, and sex
80-100% of predicted=normal 60-79%of predicted=mild disorder 40-59% of predicted=moderate <40% of predicted=severe |
|
How can PFT tell the difference between Obstructive and Restrictive disease?
|
Restrictive only decreased Volumes, VC or FVC
Obstructive only decreased flows, FEV1, FEV1/FVC Both obstructive and restrictive decreased flows and decreased volumes |
|
What is a bronchoscopy?
|
A procedure that allows the therapist to visualize the trachea and bronchi.
|
|
What are the types of bronchoscopy and what is the difference in use?
|
There is a flexable bronchoscopy used for diagnostic reasons and a ridgid bronchoscopy used for therapeutic reasons in the OR for foreign-body obstruction atelectasis.
Also used for intubation in patients with a suspected neck fracture use a flexable fiberoptic bronchoscopy |
|
What is the first procedure before inserting the bronchoscopy?
|
Topical anesthetic is administered to control the gag/cough reflex and prevent laryngospasm. Lidocaine , cetacaine, novacaine.
Patients receiving continuous ventilation need a special adaper Bodaii for introduction of the scope and Increase FIO2 and Increase high pressure alarm setting. Be sure to reset after procedure. |
|
What is partial obstruction?
|
Inspiratory stridor, cough/gurgling or unilateral wheeze
|
|
What is complete obstruction/
|
Marked inspiratory efforts without air movement inability to speak
Marked, sternal, intercostal and epigastric retractions. Marked distress and marked attempts to ventilate |
|
What is the cause of upper airway obstruction?
|
Tongue/soft tissue obstruction most common
|
|
What are the methods of establishing a patent airway and the contraindications?
|
Head-tilt / Chin -lift Opens airway and pulls tongue back
Contraindications: fractured neck Jaw Thrust / Modified Jaw Thrust Allows for establishing a patent airway in patients with suspected neck fractures |
|
When do you preform a Abdominal thrust?
|
When complete airway obstruction is indicated. Contraindications; Obese victims, Advanced pregnancy, Infants
|
|
When do you preform a chest thrust?
|
Used instead of abdominal thrust on obsese victims, infants and pregnant women
|
|
When do you use a oral pharynegal airway?
|
Unconscious patient Patient has bite block as in seizure facilitate oral suctioning
Complications: Airway to be left uncecured. |
|
When do you use a nasal pharygneal airway?
|
On a conscious patient to facilitate deep tracheal suctioning and decrease nasal trauma
Complications; Trauma to mucosa -lubricate water soluble |
|
What is the size determination and insertion techniques of oral and nasal techniques?
|
Size of oral -Lenght should be equal to distance formangle of jaw to just past corner of mouth. Insert upside down and twist into position.
Nasal- Length of airway is from tip of earlobe to center of nostrils. Inserted the way it is anatomicallly shaped with water soluble lubricant. |
|
What is the purpose of oral and nasal intubation?
|
Patent airway
Access for suctioning Means for mechanical ventilation Protect airway (aspiration, obstruction) Direct instillation of medication. |
|
What is NAVEL?
|
Narcan-Narcotic Overdose
Atropine-Bradycardia Valium-Versed-Sedative Epinephrine_Asystole Lidocaine-PVC's |
|
What are some complications of intubation?
|
Infection, fever,secretions
Cuff pressures, Larynogospasm most serious Right mainstem intubation>25cm marking deep VAP Ventilator acquired pneumonia |
|
What is cuff pressure related to?
|
Cull pressure is directly related to capillary pressures. It should be equal to or less than 20 torr or mmHg or 25cmH2O
>5mmHg is the lymphatic vessel resulting in edema >10mmHg is vein resulting in edema > 20mmHg is the artery resulting in necrosis |
|
What is the procedure for ventilation?
|
Position patients head in sniffing position. Adequately hyperoxygenate(resuscitation bag with FIO2 100% for 2 minutes) Hold laryngoscope in left hand, ET tube in right hand Insert b lade down reght side of mouth Advance blade, lift epiglottis, visualize cords (curve blade tip into vallecula, straight blade tip under epiglottis) have suction available Insert tube, inflate cuff, assess tube position, ventilate, and oxygenate
|
|
How do you assess the position of the tube?
|
Look for bilateral chest expansion during inspiration
Auscultation, breath sounds should be heard on both sides Capnography or CO2 dectectors Chest x-ray - tip of tube should be 2 cm or 1 inch above carina or at the aortic notch |
|
What do you preform for tube maintenance?
|
Suctioning maintain patency
Humidification prevent dehydration of tissue (100% Humidity @ 37 C best way to prevent obstruction Cuff pressure minimal leak minimal occluding volume use high volume/low pressure cuff (equal to or < 20 mm Hg pressure |
|
What equipment do you use for intubation?
|
Laryngoscope, Handle , Always held in left hand, holds batteries for light,
Blades, Curved MacIntosh fits into vallecula, indirectly raises epiglottis Straight Miller blade fits directly under epiglottis (preferred for infants) |
|
What do you check for troubleshooting upon intubation?
|
If light does not work
tighten bulb check handle attachment change blades check batteries |
|
What are the blade and endotracheal tube sizes used/
|
Blade sizes: Adult Size 3
Pediatric Size 2 Term Infant Size 1 Pre-term Size 0 Tube Sizes Full term Infant 3 -3.5 Adult males 8 - 9mm Adult females 7-8 mm Adult (wt in kg ? 10 = approximate size |
|
When do you use Magill forceps?
|
Only to aid nasal intubation
|
|
What are the tube markings and cuff types used in intubation?
|
Oral intubation-21-25cm mark
Nasal Intubation 26-29cm mark Cuff types: Low pressure, high volume, high compliance , floppy cuff Cuff pressure should not exceed 20mmHg or 25cmH2O |
|
What is the MOV and MLT?
|
Minimal occluding volume -stop inflating at no leak via trach or endotracheal tube
Minimal leak technique slowly inject air during inspiration until leak stops then small amount of air is removed to allow a sling leak during inspriation |
|
What is a DLT?
|
Double lumen endotracheal tube /Carlen's tube : A tube with two independent lumens of different lengths; the longer lumen is inserted into either right or left mainstem and shorten end into trachea above the carina to independent lung ventilation (two ventilators) Unilateral lung disease, used in surgery during a pneumonectomy , lobectomy, esophageal resecton and aortic aneurysm
To provide airway protection in preventing blood or secretions from entering the unaffected lung |
|
What is a LMA?
|
Laryngeal Mask Airway used fmost frequently during anesthesia Inflatable mask positioned directly over the opening into the trachea (hypopharynx) Indicated for short term intubation or facial or nasal injuries. Or and Emergency Dept , EMTs
|
|
When would an endotracheal tube be inserted into the trachea?
|
If patient was eating or had a heart attack and no time.
|
|
What is the proper extubation technique?
|
Suction the airway below then above the cuff
Deflate the cuff have patient inspire deeply Pull the tube out at peak inspiration to prevent vocal cord damage Have patient cough to clear any remaining secretions, speak Administer oxygen and humidity if as indicated Observe for any complications: Laryngeal edema - strider Respiratory obstruction |
|
What do you do for complications and management of extubation?
|
Severe respiratory distress and/or Marked inspiratory stridor--REINTUBATE the patient
Moderate distress/stridor-Oxygen, cool mist aerosol and racemic epinephrine to reduce swelling Mild distress/stridor /Sore throat--Provide humidity, oxygen and/or racemic epinephrine as necessary |
|
What are the indications and advantages of Tracheostomy?
|
Preferred method for long-term ventilation
When upper airway obstruction prevents intubation/child epigloltisis Patient is able to eat and speak with takling trach tubes |
|
When should the cuff be deflated on a trach tube?
|
The cuff should be kept deflated unless the patient is eating or on positive pressure ventilation and the tube should not be changed more than once a week .
|
|
When do you replace a trach tube?
|
When the tube is obstructed and unable to pass a suction catheter, then you must pull tube out, ventilate and insert new tube. If the tube is too small , change to larger tube .5 size larger as you will have too high cuff pressure >20mm Hg . Also change if punctured cuff , unable to seal trach
|
|
What types of trach tubes are there?
|
Standard trach tubes may have an inner cannula for easy cleaning, Often have an oberator to reduce trama during insertion.
Fenestrated tubes has opening in outer cannula above the cuff for weaning and temporary mechanical ventilation with inner cannula and can be used for phonation you must deflate cuff for this Tracheal Button used to maintain stoma, for multiple intubations. |
|
What other types of trach tubes are there?
|
Jackson trach tube , silver or metal comes with inner cannula , no cuff, not for resuscitation (you need cuff )
Lamen-Wilkinson Foam/Bivona Cuff Foam filled cuff in which air is evacuated prior to insertion, Pilot is open to the atmosphere and foam expands to seal treachea(has no pilot balloon) Do not inflate the cuff with a syringe |
|
What tracheal speaking devices are there?
|
One way valve that attaches to tracheostomy tube. Cuff should be deflated
|
|
What is a laryngectomy and larngectomy tube?
|
Surgical removal of the patient's larynx, patient will breathe through a laryngectomy tube initially , patient cannot be orally or nasally intubated it has no cuff, Laryngectomy tube will be removed after 3-6 weeks then patient will have a permanent stoma . Laryngectomy tubes are designed to maintain a patent airway after a laryngectomy has been performed
|
|
What is postural drainage and percussion(vibration) done for?
|
Purpose is for improve mobilzation of secretions , prevent accumulation of secretions and improve ventilation, the indications is accumulated or retained secretions ineffective cough examples are bronchiectasis, CF lots of secretions.
|
|
What are the body positions for postural drainage?
|
Bed is flat-Upper lobes
Head of bed down 15 degrees Middle lobes Head of bed down 30 degrees Lower Lobes If patient aspirates while in a particular body position,first suction and then place in opposite position for drainage If patient has unilateral consolidation affected side up to drain and increase perfusion to unaffected lung |
|
For how long do you percuss for and what do you do for sensitive patients?
|
Percuss for 5 minutes in every position and use mechanical percussors or percussion cups for sensitive patients
|
|
How and when do you perform vibration?
|
After every segment you put hand over hand compress and vibrate with exhalation to move secretions to larger airways
|
|
What are some alternative airway clearance techniques?
|
Positive Expiratory (PEP) Therapy The expiratory flow resistor prevents end-expiratory pressures from falling to zero
Flutter Valve Devices Combines positive expiratory pressure therapy with high-frequency oscillations at the airway. (PEP) |
|
What is Autogenic Drainage?
|
Breathing exercises utilized to improve mucus clearance, primarily in patients with cystic fibrosis and bronchiectasis. Patients are insturcted to breathe at low lung volumes to loosen secretions from the small airways. Patients then increase their volume by breathing in the normal tidal volume range , but exhaling at low range , during last stage patient breathes at high lung volumes
|
|
What are external percussive devices?
|
High frequency chest wall compression devices , oscillatory , vests
|
|
What is intrapulmonary percussive ventilation?
|
IPV is for bronchial clearance is a combination of high frewuency pulse delivery of a sub tidal volume and a dense aerosol , delivering more aerosol to the distal airways and coughing helps facilitate removal of retained secretions
|
|
Why would you modify chest physical therapy?
|
Consideration for pediatrics and neonates, size of thorax , fear and positioning , goal 5 minutes but must listen to patient. Presence of chest tubes, fractures and treatments (IPPB, IS, bronchdialator) must be scheduled and coordinated with CPT
|
|
How do you evaluate if CPT is working?
|
Assessment of bronchial hygiene is preformed by
Ascultation /improved BS Inspection/color, chest expansion Chest x-ray improved pattern |
|
When would you discontinue bronchial hygiene?
|
When you have clear breath sounds and xray , Ambulating Well, Strong cough , Afebrile 24 hrs, Hazards occur (dizziness, SOB, cyanosis
|
|
What is the purpose, indications and hazards of suctioning?
|
Purpose patent airway,specimen collection, stimullate cough
Indications accumulated secretions Obstructed airway, depressedf cough , inability to swallow Hazards Trauma to mucosa (most common) Lubricate catheter(nasal-tracheal suctioning) use gentle technique Contamination use aseptic technique Hypoxemia leading to trachcardia, arrhythmias (most severe) Bradycardia from vagal nerve stimulation |
|
What is the procedure of suctioning?
|
100% O2 pre and post suctioning is required. Oxygenation should be for at least 1-2 minutes.
|
|
What is some of the equipment used in suctioning?
|
Vacuum regulators Used to adjust vacuum pressure
Adjust with tubing occluded and a built in shut off device in the collection bottle prevents aspirated secretions from entering the regulator and vacuum system when bottle is full |
|
What are the suction pressures for patients?
|
Adult 100- 120 mm Hg
Child 80 - 100 mm Hg Infant 60 - 80 mm Hg |
|
What type of suction catheters and specimen collectors?
|
Coude tip catheter is angled to help suction the left main stem bronchus
A closed system suction catheter the Ballard (inline suction) allows the patient to receive ventilation and oxygenation during suctioning. Indicated for patients with high oxygen and or PEEP |
|
What and how are the sizes of catheters determined?
|
The ideal catheter length is 20 -22 inches.
Catheter size is listed in French Units The external diamenter of the suction catheter should be no greater than 1/2 the Inside diameter (ID) of endo or trach tube Catheter Size = ID size x 3 / 2 |
|
What is an oral suction device?
|
Yankauer , tonsil suction device , used to suction the mouth and throat, using aseptic technique
|
|
What is a suction trap?
|
Lukens trap , used to collect a sputum specimen
|
|
How do you modify suctioning?
|
Change size and type of catheter If having difficulty removing secretion , verify the appropriate catheter size for patients endotracheal tube
Change to a Coude catheter is used to suction the left mainstem bronchus Change to a closed system suction(Ballard) catheter. Alter negative pressure/ suctioning should be stopped if hazards occur reduce level of vacuum or do in less time, increase negative pressure to remove thick tenacious secretions. Instill to dilute secretions 5-10cc normal saline or Mucomyst (Acetylcysteine) Alter duration of suctioning no longer than 15 seconds If cardiac arrhythmias Stop and decrease time in airway |
|
What do you do to troubleshoot suctioning?
|
Check catheter for patency
Assure vacuum system is working Change or empty a full collection bottle Check all connections |
|
What are the hazards of aerosol therapy (continuous nebulization)?
|
Bronchospasm treat with bronchodilator
Secretion swelling and airway obstrution treat with suctioning Fluid overload ( CHF, renal failure and especially infants) treat by monitoring intake and ooutput and weight Cross contamination(especially large volume, heated aerosol devices) heated humifier to treat |
|
How do you check a bubble humidifier alarm?
|
Occluding or pinching the connecting tubing and listening for the whistling alarm
If no alarm occurs there is a leak If alarm sounds without occlusion oxygen flow is excessively high or obstruction or kinking of tubing |
|
What is a heat moisture exchanger/
|
An artificial nose humidifier, must be removed during aerosol therapy and some may not be as effective as Heated Humidifiers and may increase or thicken secretions, if this occurs change to a heated humidifier
Ideal use is for patient transport and short term ventilation |
|
What is the preferred heat humidifier?
|
The Wick is preferred , it can deliver 100 % body humidity (44mg/L) It has a low risk of cross contamination (nosocomial infection) because no particles are being produced.
|
|
What is a heated wire circuits?
|
Used in conjunction with ventilator humidification systems to minimize circuit condensation.
Condensation (rainout) is minimized |
|
What are some Aerosol Devices/
|
Pneumatic nebulizers-gas
Jet nebulizers gas also hand held small volume nebulizer (SVN) are used to nebulize small doses of medications A 1-3 second breath hold is important to enhance medication delivery |
|
What are Large volume nebulizers used for/
|
LVN are used to deliver bland aerosols to the upper airway to decrease the chances of edema or humidity deficit
For thick secretions a heating element can be added. Heated jet nebulizers have a much higher output of water vapor and aerosolized solution than non-heated nebulizers |
|
How do flow and FIO2 interact in a LVN?
|
As the FIO2 is decreased on the nebulizers , air entrainment is increased , the density of the mist decreases and the total flow or output of the mist increases
|
|
How do you trobleshoot a LVN?
|
Not enough mist: often due to clogged capillary tube , insufficient flow , a decrease in the temperature or insufficien water level
Changes in FIO2: Any increase in resistance (such as water collecting in the tubing) will cause less air to be entrained causing the FIO2 to increase The best way to verify adequate aerosol flow is to observe the aersol comming out the end of the tubing during inspiration. (turn up flow or add another neb) Flow >50% add two Nebs |
|
What is a SPAG?
|
Small particle aerosol generator nebulizer specifically designed to deliver Ribavirin (anti viral) for treating RSV (bronchiolitis) used with a scavenger evacuation system
|
|
What is a electric nebulizer?
|
Ultrasonic nebulizer has the highest output range of aqueous solution without heating
|
|
What is a DPI?
|
Dry powder inhaler medications are in powder form and do not require a propellant
Inhale through the DPI with more force than when using an MDI |
|
What is a MDI?
|
Metered dose inhaler shake canister first. Patient inhales slowly while squeezing cartridge. Hold breath briefly to allow distribution. Patient must be able to understand and cooperate
Spacers improves the efficacy of MDI and can be used to overcome coordination difficulties |
|
What is the Drug Calculation?
|
Drug % x 10 = #mg/mL
#mg/mL x dosage ordered =number of mg of drug |
|
What is Clark's Rule?
|
Clark's Rule=
wt(lb) x normal adult dose/ 150 |
|
What are Sympathomimetics Drugs?
|
Front door Bronchodilators
Alpha, beta1 and beta2 adrenergic recptor agonist |
|
What are Parasympatholytics drugs?
|
Back Door Bronchodilator
Anticholinergics drugs act by blocking cholinergic parasympathetic receptors |
|
What are Xanthine drugs?
|
Side door bronchodilators
This inhibitor indirectly increases the amount of cAMP within the smooth muscle this increased amount of cAMP causes bronchodilation |
|
What are wetting agents?
|
Substances to liquefy secretions and as diluent for medications.
|
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Name some wetting agents
|
Water given orally is the best mucolytic
Saline solution .45% hypotonic saline 0.9 Saline normal saline same as body tissue 1.8 - 15% hypertonic saline , commonly used to induce sputum specimens, and also cause bronchospasm or secretion obstruction |
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What is an asthmatic prophylactic agents?
|
Inhibit histamine release
Cromolyn Sodium (Intal) donot give during asthma attack only in prevention of bronchospasm Nedocromil(Tilade) donot give during acute asthma attack |
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What are corticosteroids?
|
Anti inflammatory,immunosuppressive agent Status asthmaticus and asthmatic bronchitis
(end in one) Predisone Methyleprednisolone(Solu-Medrol) Dexamethasone(Decadron) Beclamethasone(Vanceril/Beclovent) Triamcinolone(Asmacort) Funisolide(Aerobid) Fluticasone(Flovent) Pulmicort(budesonide) to prevent thrush rinse with water |
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What are decongestants?
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Alpha effect which causes vasoconstriction and reduces blood flood and mucosal edema
Racemic Epinephrine(vaponephrine) |
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What are Leukotriene modifiers?
|
Non steroid drugs that have been approved for use in cases of mild to moderate asthma
Montelukast(Singulair) |
|
What are anti inflammatory /long acting brochodilator combinations?
|
Combination of fluticasone(anti inflammatory) and salmeterol(long acting bronchodilator)--Advair Indicated for asthma
|
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What are some beta bronchodilators?
|
Albuterol-0.5mL normal 2.5mg/Side effect Tremors
Metaproterenol(Alupent or Metaprel) dosage 0.3mL q4 Terbutaline(Brethine or Bricanyl) 0.5mL Bitolterol(Tornalate) 1.25QID Pirbuterol(maxair)0.2mg/puffQ4-6hr Saimeterol(Serevent)21ug/puffBID Formelterol |
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What are some of the side effects of beta adrenergic bronchodilators?
|
Tachycardia
Palpitations Hypertension/hypotension Headache Tremors Paradoxical hypoxemia Nausea vomiting |
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What are some anticholinergic bronchodialators?
|
Atropine Sulfate
Ipratropium Bromide (Atrovent) Tiotropium(Spiriva) |
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What are some Adrenergic/Anticholinergic bronchodilators?
|
Combination of beta adrenergic and anticholinergic agents.
Ipratropium Bromide and Albuterol(Combivent, DuoNeb) |
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What are some Xanthine drugs?
|
Theophylline (Aminophylline)
Theophylline(Theo-Dur) Oxytriphylline(Choledyl) Caffine also |
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What are the safe blood levels of theophylline and signs of toxicity?
|
Therapeutic blood levels of theophylline are 10-20/ug/mL
Blood levels are important to monitor in asthmatic patients Signs of toxicity are tremors nausea and vomiting nervousness tachycardia and other arrhymias |
|
What is given for mucus plugs, CF?
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Acetylcysteine(mucomyst) dissolves disulfide bonds used for liquefaction of thick tenacious secretions
Always give bronchodilator first |
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What is a mucolytic agent other than mucomyst?
|
Dornase Alpha(pulmozyme)
digests extracellular DNA treat viscous secretions CF |
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What are Cardiac Glycosides and what are they used for?
|
Increases the strength of contraction
Treatment of CHF Digitalis(Crystodigin) Digoxin (Lanoxin) |
|
What are anti-arrhythmic agents?
|
Used for arrhythmias-
Atrial arrhymias Quinidine, Propranolol (Inderal) Ventricular arrhythmias Lidocaine control of PVC's, pulseless ventricular tachycardia, or ventricular fibrillation |
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What is Amiodarone used for?
|
Treatment of pulseless ventricular tachycardia and ventricular fibrillation that has not responded to defibrillation
|
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What do you treat bradycardia with?
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Atropine, Epinephrine
|
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What do you treat angia with?
|
Nitroglycerin (vasodilation)
Isordil Relief of pain (angina pectoris) is almost immediate |
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What are the vasodilator drugs and what do they treat?
|
Vasodilator drugs used to decrease BP. (Nitro)
Diuretics-Thiazides Chlorthiaside(Diuril) Hydrochlorothiazide(Hydrodiuril) Sympatholytics are Methyldopa (aldomet)blocks sympathetic neurotransmission Propranolol(Inderal) bloks over reactive sympathetic neurons Metoprolol(Lopressor) B1 blockade(slow down the rate) |
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What are direct vasodilators?
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Diazoxide(Hyperstat IV)
Sodium Nitroprusside(Nipride)light sensitive Nipride lowers blood pressure and decreases ventricular preload |
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What are vasopressers and what do they do?
|
Vasopressors are a adrenergic and raise blood pressure.
Dopamine used to maintain BP Norepinephrine(Levophed ) used in cardiogenic shock |
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What are some diuretics, what do they do and what effects do they have?
|
Loop diuretics- furosemide(lasix)
Used for pulmonary edema, liver and kidney disease, CHF Adverse effects:hyplkalemia, hypochloremia, metabolic alkalosis |
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What do you use for drug over dose?
|
Narcotic Antagonist: Naloxone(narcan) reverses narcotics.
|
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What is an antiviral agent?
|
Used to treat respiratory syncytial virus (RSV)
Delivered via a smalll particle aerosol generator SPAG Deliver Ribavirin(Virazole) |
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What are some artificial surfactants and how used and delivered/
|
Used to prevent and treat IRDS/HMD(hylan membrane disease)
Route of administration directly into trachea, immediately after birth or once RDS has been diagnosed Survanta Infasurf, Curosurf |
|
What is used to treat Central sleep apnea
|
Doxapram(Dopram)
Medroxyprogesterone(hormone) Aminophylline/Theophylline, caffine used to treat Apnea of Prematurity |
|
What is nicotine therapy and some treatments?
|
Used to help patients quit smoking
Nicotine gum(NIcorette) Patch (Nicotrod, NicoDerm) Nicotine nasal spray (Nocotrol NS) Nicotine inhaler |
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What are some antibiotics?
|
Penicillin-effective especially for gram postive organasims all the coccus (strep, diplo etc)
|
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What are good for broad spectrum therapy?
|
Carbenicillin, Amoxicillin, Ampicillin
|
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What are some penicillnase resistant drugs?
|
Methacillin. oxacillin and nafcillin
|
|
What is a broad spectrum drug?
|
Cephalosporins :effective on gram+ and gram- and can be given to patients allergic to penicillin
Cephalothin(Keflin) Cephaloridine(Loridine) Cephalexin(Keflex) Erythromycin and for mhycoplasm pneumoniae infections |
|
What are Aminoglycosides?
|
Good for gram- E. Coli, Pseudomonas
the mycins Streptomycin Gentamycin Tobramycin Vacomycin |
|
What are the antituberculin drugs?
|
Used to treat TB
Isoniazid(INH) Rifampin Streptomycin Ethambutol Combination therapy usuall will continue for 2 yrs (3 drug combination0 Chemoprophylaxis for TB - 1yr of Isoniazid (INH) if exposed and no alchol |
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What is the ideal breathing pattern?
|
Slow, deep inspriation(from resting exhalation)
Inspiratory pause/hold (1-3 seconds) |
|
What is IS and how is it preformed?
|
Indications: Prevention of atelectasis ,treatment of atelectasis. Encourage patients to take a deep breath.
IS should be performed hourly for 10 breaths Date, time and Volume (IC) should be charted Increase or decrease volume goals based upon patient's performance. Half of pre op goal Volume-oriented:Patient inspires until preset measured volume of gas in inhaled. Flow-oriented Patient's inspiratory flow rate causes a ball or float to rise |
|
How do you troubleshoot IS?
|
Patient's must be reminded to inhale not exhale into device
In flow spiromenter ,a slow inspiration may not generate sufficient flow to raise the float/ball :may need to switch to a volume type spirometer |
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What are the indications of IPPB therapy?
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Prevent or correct atelectasis in patients unable to take a Deep Breath
|
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What are the hazards of IPPB therapy/
|
Hyperventiation-dizziness, tingling of fingers (have pt slow down respirations)
Impeding venou return-results in decreased cardiac output increased intracranial pressure (keep pressure low) |
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What is pressure-cycled ventilators?
|
IPPB therapy - Bird Mark 7
Pressure cyclec : inspiration ends if you don't reach preset pressure Flow rate ; Increasing flow will increase the E-time Decreasing flow will increase the I time |
|
What are appropriate ventilators for IPPB home therapy?
|
Bennett AP-4 and AP-5 ventilators ,electrically powered
|
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What changes on IPPB will effect the FIO2/
|
Increase pressure will increase FIO2
Decrease flow (increased inspiratory time) will increase the FIO2 |
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What changes on IPPB will change the volume?
|
Increasing the pressure will increase the volume
Decreasing the flow will increase the volume (increased inspiratory time) Increasing th flow will increase turbulence and decrease volume (decreased inspiratory time) |
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What changes the effect on the I:E ratio on IPPB ?
|
Increased pressure(increase tidal volume) will increase the inspiratory time
Increased flow will decrease expiratory time |
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How do you troubleshoot IPPB?
|
Loss of pressure means leak or not enough flow
Excessive pressure means Obstruction or too much flow Failing to cycle into inspiration mean adjust sensitivity or tight seal around mouthpiece Failing to cycle off means a Leak, mouthpiece/mask seal Cuff leaking Fenestrated trach tube open Loose equipment connection If pressure does not rise normally =not enough flow |
|
What are the indications for non-invasive positive pressure ventilation NPPV?
|
To avoid intubation , in patient who is DNI
To facilitate long-term ventilation at home Assist a patient in early respiratory failure/COPD Contraindications -poorly fitting mask |
|
What is BiPAP ventilation?
|
Non invasive
Provides two levels of CPAP One during inspiration(IPAP) One during expiration(EPAP) IPAP (ventilation) should be greater than EPAP (oxygenation) An I:E ratio of 1:2 is preferred Contraindicated for patients with dysphagia (trouble swallowing) |
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What is a negative pressure ventilators , extrathoracic?
|
Negative pressure (suction) is applied to the outside of the chest.
This causes the chest to rise and expand(inspiration) Ventilation is controlled by adjusting the length of inspiration andt the amount of suction (time cycled ventilation Indicated for intermittent use , home care(central sleep apnea) and patients with neuromuscular strength |
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What do you troubleshoot for in negative pressure ventilators?
|
Chest cuirass is hissing and unable to reach pressure means check for leaks
Patient is breathing faster than the rate setting on the machine means increase the rate on the machine |
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What are some of the negative effects of positive pressure ventilation?
|
Decreased venuous return
Increased intrathoracic pressures Increased intracranial pressures Decreased cardiac output |
|
What are the types of positive pressure ventilation?
|
volume cycled-pressure is applied until a preset volume is delivered, inspiration ends
Airway pressure will increase and decrease with changes in patient's compliance or airway resistance. Pressure Cycled- ventilation is (VT) adjusted by increasing or decreasing the pressure limit Inspiration ends when preset pressure is reached. Although peak pressure will remain constant , the volume will change as lung compliance and or airway resistance change This type of ventilator is best for intermittent therapyIPPB or continuous ventilation for patients with normal lungs (Bird Mark 7, Bennett PR-2) Inspiration ends when time is reached . Also used for infant ventilation |
|
What type of ventilators are used for home/
|
Examples of negative pressure-Cuirass or shell and Body Wrap or poncho
Positive vents Intermed Bear33 Life Care PLV 100 and 102 Aequitron LP 6 and LP10 Puritan Bennett companion 2801 A backup vent should be provided for any pt who requires ventilation the majority of the time |
|
What are the qualities of a transport ventilator?
|
Should be portable and lightweight
Duration of flow must be considered when using an oxygen tank to power vent If respiratory rate or tidal volume decreases on pneumatic transport vent-check the tank pressure-may be running out of gas |
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When should you change a vent circuit and how?
|
Every seven days and manual ventilation with a resuscitation bag will be necessary while the new circuit is attached and tested by another person
|
|
What are the common alarms for a ventilator?
|
High pressure limit (set 10-15 cmH2O above peak airway pressure)
Minimum exhaled volume(set 100mL below exhaled tidal volume) Low pressure limit (set 10 cmH2O below peak airway pressure) |
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What does a low pressure alarm on the ventilator mean?
|
Consider :
Leak in the ventilator circuit Insufficient flow Endotracheal/tracheostomy tube cuff leak |
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What does a high pressure alarm on the ventilator mean?
|
Consider:
Equipment obstruction(ventilator circuit) Patient obstruction (endotracheal tube, pneumothorax, increased airway resistance , secretions etc.) |
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What does low exhaled volume alarm mean?
|
Consider;
Equipment disconnect(ventilator circuit) Low spontaneous tidal volume |
|
What are time cycled pressure limited ventilators?
|
Inspiration begins and ends according to preset inspiratory time
Maintains preset pressure limit using pressure popoff (pressure relief valve) Volume delivered demands close monitoring because it varies with EVERYTHING Pressure limit, flowrate, inspiratory time, compliance, airway resistance patient effort during spontaneous breathing, CPAP or PEEP changes |
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What are the dtime cycled pressure limited settings for infants?
|
Mode-SIMV
Peak Inspiratory Pressure(PIP)- 20-30 cmH2) Respiratory Rate 20-30 breaths Inspiratory time- 0.5-0.6 seconds Flow- 5-6 L/min FIO2 40 -60% or set at same level prior to ventilation PEEP 2-4 cmH20 Change in increments of 2 cm H2O and not above 8 cm H2O |
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What are the three phases of mechanical ventilation?
|
Phase 1 initiating mechanical ventilation (when, settings)
Phase 2 caring for the patient receiving mechanical ventilation(changes) Phase 3 weaning a patient off mechanical ventilation (when, method, monitoring) |
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What are the indications for continuous mechanical ventilation?
|
Apnea(not breathing) observation
Acute ventilatory failure not breathing enougnh (one ABG) Impending respiratory failure rising PaCO2 (serial ABGs) neuromuscular, VC, MIP Oxygenation last reason for ventilator, used to reduce work of breathing(Oxygen, CPAP) |
|
What are the clinical data for mechanical ventilation?
|
Patient Assessment
Arterial Blood Gases , PH 7.35-7.45.mmHg PCO2 35-45mmHg PO2 80-100mmHg Bedside pulmonary function Tidal Volume(VT) >5mL/kg Vital capacity(VC) >10mL/kg or 2 x Vt Respiratory rate(f) 8-20 bpm Minute ventilation(VE) <10L/min Maximun inspiratory pressure(MIP) -20 cmH2O measures muscle strength (NIF) Maximum expiratory pressure(MEP) 40cmH2O Physiological assessment/calculations A-a DO2(21%O2) 5-10mmHg A-aDO2(100%O2)25-65mmHg Acceptable66-300mmHg Qs/Qt(% shunting) <5% Acceptable <20% VD/VT(%deadspace) 20-40% Acceptable<60% Cst(static compliance)60-100mL/cmH2O Acceptable>25mLcmH2O Qs/Qt(%) |
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What is the set-up of a continuous ventilator?
|
Mode, VT, RR,FIO2, and PEEP
Mode:Control, assist/control, IMV/SIMV Tidal volume and Rate two most important controls and should be set first Tidal volume(VT) set at 10mL/kg of ideal body weight Range 8-12 set at 10 mL/kg and go 100mL up and down to get range Respiratory rate 8-12breaths FIO2 and PEEP once the ventilation has been set (VT and f ) then the next life function oxygenation should be set, Oxygenation begins with FIO2 setting if no information about prior O2/ABGs or patient on room air(21%) then Oxygen at 40-60% and no PEEP therapy Patient was on oxygen prior to ventilation then same FIO2 and or/PEEP PEEP 0-10 cmH2O |
|
What measurements are taken with patient OFF the ventilator?
|
Tidal Volume(using respirometer)
Respiratory Rate (f) Vital capacity(VC) Maximum inspiratory pressure(MIP) Maximum expiratory pressure(MEP) |
|
What are measurements are taken with patient ON the ventilator?
|
Exhaled tital volume(VT)= (VE /f)
Respiratory rate(f) Minute ventilation(VE)=(VT x f) Inspiratory flow (I:E ratio) Alveolar ventilation VA=Tidal volume -weight x 10 |
|
What is the formula for static compliance and what is the normal value?
|
Stactic Compliance = Exhaled volume/Plateau pressure -PEEP
Normal is 60 - 100 cm H2O |
|
What are some of the reasons for increasing pressures on a ventilator?
|
Increasing airway resistance(Raw) obstructive disease
Peak inspiratory pressure(PIP) increases Plauteau pressure(Ppl) REMAINS SAME - compliance Raw can be estimated;PIP-Plp Common causes are secretions in airway Bronchospasm Treatment /suction and bronchodilator Decreasing lung compliance(CL) restrictive Peak inspiratory pressure(PIP) Increases Plateau pressure (Ppl)Increases Complance down Common causes: atelectasis, pulmonary edema ARDS, pneumonia Treatment: Increase PEEP , treat underlying cause for decreased compliance |
|
What is the mean airway pressure(Paw) what controls affect it ?
|
Paw is the average pressure transmitted to the airway from the beginning of one breath to the beginning of the next.
Controls that affect Paw peak inspiratory pressure(PIP) rate(f) inspiratory time(IT) PEEP most influence on Paw inspiratory and expiratory Peak Flow Tidal Volume Inflation hold |
|
What are the typical mean airway pressure values(Paw)?
|
Patients with normal compliance and resistance 5-10 cmH2O
Obstructive patients 10-20 cm H2O ARDS patients 15-30cm H2O |
|
What does Control mode on ventilator indicated for?
|
Head trauma/surgery patients, status asthmaticus, flail chest, does not allow patient to initiate breaths. Change it
|
|
What is the assist/control mode?
|
Ventilator gives Tidal volume everytime patient inhales
Patient may hyperventilate if in pain |
|
What is the SIMV mode usually used for?
|
Spontaneously breathing patient
Ventilator provides a miniumum minute ventilation Used with COPD patients to normalize ABGs Used with tachypnea(>mo bpm) to avoid hypervention(pulmonary emboli) Used for weaning patients Used instead of assist/control to reduce barotrauma Used with PEEP to reduce barotrauma |
|
What is pressure control ventilation used for (PCV)?
|
Used when peak inspiratory pressures(PIP) are very high(>50 cm H2O
Recommended for patients requiring high FIO2's(>60%) and PEEP (>15 cm H2O) High PIP(>50 cm H2O) Low PaO2's and decreased compliance (ARDS) |
|
What do you do to normalize a high PaCO2?
|
Increase the tidal volume(8-12mL/kg)
Increase the respiratory rate Remove the deadspace |
|
What do you do to normalize a low PaCO2?
|
Decrease the tidal volume Target PaCO2 for head injury should be 25-30mm Hg
Decrease respiratory rate |
|
What do you do to increase a low PaO2?
|
First increase FIO2 by 5-10%(up to 60%)
Then Increase PEEP levels by 5cm H2O until: Acceptable oxygenation is achieved or unacceptable side-effects occure (decrease compliance, decrease cardiac output, barotrauma) |
|
What do you do to decrease a high PaO2?
|
First decrease FIO2 to less than 60%
Then decrease PEEP |
|
What is High Frequency Ventilation and when do you use it?
|
Positive pressure ventilation with breathing rates in excess of 150 bpm and low tidal volumes(<5mL/kg) 1-3mL/kg
Used for ARDS, pulmonary interstitial emphysema and infants |
|
What are the primary controls used to adjust ventilation and control gas exchange?
|
1) Rate control/frequency
2) Amplitude/drive pressure regulator(volume) 3) % inspiratory time (I:E ratio) |
|
What are the types of HFV?
|
High Frequency Positive Pressure Ventilation HFPPV
Rate150-300 Hertz 2-5 High Frequency Jet Ventilation HFJV Rate100-600 Hertz1.5-10 High Frequency Flow Interruper Ventilation HFFIV Rate 120-1320 Hertz 2-22 High Frequency Oscillator Ventilation HFOV Rate 60-3000 Hertz >50 |
|
What do you adjust in Volume control to change the I:E ratio?
|
Flow rate
Increasing the flow rate will increase the time for exhalation |
|
What do you adjust to change Inspiratory Plateau and why?
|
The inflation hold, the purpose is to increase diffusion of gases (improve distribution) and to decrease microstelectasis formation.
Not to be used with head injury patients and hypotensive patients |
|
How should the patient be positioned for mechanical ventilation?
|
Patient should initially be placed in a supine position.
If patient stable Low or semi Fowlers |
|
Why should you adjust pressure support?
|
To help patient overcome the resistance of breathing thorough the ventilator circuit
Pressure support can be adjusted above the airway resistance , PIP , Plateau |
|
What is normal PEEP/CPAP and when is it theraputic?
|
PEEP/CPAP normal is 2-10cm H2O is considered physiological
PEEP/CPAP therapy 10-30 cm H2O |
|
When is PEEP/CPAP improving patients status?
|
PO2 increases
Static Compliance increases(corrected plateau pressures decrease) Cardiac output/Cardiac Index stabel or increases Hemodynamic pressures are stable(PAP, PWP0 Increased PVO2,SVO2, stable or decreased A-aDO2 |
|
When is PEEP/CPAP too high?
|
PO2 decreases
Static Compliance decreases(corrected plateau pressures increase) Cardiac Output.cardiac index decreases Hemodynamic pressures increase(PAP, PWP) Decreased PVO2 , SVO2,stable or increased A-aDO2 For patient with head injuries, increase the FIO2 instead of increasing or adding PEEP Hypotensive pts also |
|
What is the sign volume and rate set at and why?
|
Usually in Assist Control
Used to decrease microatelectasis Sign volume set at double the VT or less (1.5 2 times VT) Rate set at 1-3 sighs every 4-15 minutes |
|
How do you calculate minimum flowrate?
|
Flowrate= (Tidal volume x Rate) x (I + E)
|
|
What does a spontaneous volume/pressure loop look like?
|
Skinny Oval
|
|
What does a assisted volume/pressure loop look like?
|
Fish tail , with tail over pressure line
|
|
What does a controlled volume/pressure loop look like?
|
Football
|
|
What does Poor compliance too low a PEEP look like on loop graph?
|
Football is flat on bottom, starts at 0 and is flat till 10 or whatever
If PEEP is optimual football starts at 10 or whatever is optimual for that PEEP |
|
What does the loop look like on the volume/pressure in overdistension of the lung?
|
Beak of duck
To improve reduce tidal volume in volume control or change to pressure control and limit PIP |
|
What does the loop look like on the volume/pressure with low compliance?
|
Lazy line, just above the pressure line slanting down
such as in ARDS, IRDS,pneumonia, pulmonary edema,) Improve with PEEP therapy, surfactant therapy |
|
What does the loop look like on the flow/volume loop with high airway resistance (decreased flow)?
|
Laying flat above and below 0 line
This can occur with bronchospasms, secretions and other forms of obstruction Therapy: Bronchodilator therapy , suctioning |
|
What does the loop look like on the flow/volume loop with leak?
|
The loop will be broken , not at 0 in both flow/volume and volume/pressure
Example of leaks: Cuff, curcuit,chest tube bubbles in water chamber 2 |
|
How do you evaluate air trapping (auto PEEP ) problems ?
|
Flow / time graph and expiratory flow does not return to th zero baseling before next breath starts. square pattern
|
|
What are the ideal drug characteristics for patients receiveing mechanical ventilation?
|
Potent respiratory depressant
Minimal cardiovascular effects Euphoric effects (makes being conscious tolerable) Analgesic effects(alleviate pain) Easily reversible |
|
What are the pharmacological agents used for mechanically ventilated patients?
|
Morphine sulfate is a narcotic analgesic and causes a decrease in respiratory rate and tidal volumes in high doses.
Valium/Versed /ativan /Conscious sedation procedure Anti-anxiety , sedative, anticonvulsant, Acts on CNS for anxietry, relieves fear Pavulon(Pancuronium Bromide)Non-depolarizing neuromuscular blocking agent Causes total muscle relaxation Takes 2-3 min , no cardiovascular effects. Reversed by anticholinesterase dreu Edrophonium Chloride(Tensilon) Curare(d-Tubocurarine)Non-depolarizing neuromuscular blocking agent, causes muscle paralysis, Reversed by Neostigmine and Atropine(Neostigmine destroys acetylcholinesterase) Check for complete reversal by asking patient to move Norcuron(Vecuronium bromide) Non-depolarizing neuromuscular blocking agent, more potent than Pancuronium Bromide, less likely to cause histamine release, onset 2.5 -3min, duration 25-40min Anectine(succinylcholine chloride) Sucostoran, given primarily for intubation, Fast acting drug last 3-10minute |
|
What do you assess for weaning from vent?
|
1) Verify that underlying disease process has been reversed
2) Aterial Blood Gases should show adequate ventilation and oxygenation(PCO2, PO2, pH) Bedside pulmonary function: VT>5mL/kg VC>10mL/kg f 8-20bpm MIP/NIF >-20cm H2O MEP>40cm H2O RSBI<100 (RR/Vt(L) rapid shallow breathing index Clinical measurements A-aDO2<300mm Hg Qs/Qt <20% VD/VT<60% Pulse and blood pressure normal |
|
What methods are used for weaning?
|
Traditional method/Trial and error/T-piece trial. Patient is taken completely off the ventilator.
IMV/SIMV decreasing the ventilator rate and allowing the patient to breathe spontaneously. Pressure Support Ventilation(PSV) IPAP to support inspiration when the patient is having difficulty with weaning. PSV can be used with IMV/SIMV Drugs that suppress ventilation should be stopped The patient should be aware of what is happening |
|
What do you assess during weaning from vent?
|
Heart and Lungs , if heart rate increases 20 beats or more from baseling, then stop weaning and resume mechanical ventilation.
If the heart rate increases less than 20 beats, continue weaning and observe closely, you may increase the FIO2 while off the ventilator BP,RR, VT,VC should be checked every 20 minutes for any problems. Sensorium: Patient should be alert and responsive . Any chance in mental status or level of consciousness would indicate the need to resume mechanical ventilation. Other assessments: ABG should be drawn after 20 -30 minutes off the ventilator to assess ventilation and oxygenation Summary of adverse conditions to Resume mechanical ventilation Increase in HR by>20 bpm Change in BP by 10-20 torr Increased PaCO2 by >10 torr RR increases by >10 or is >30 BPM |
|
What are the steps in basic life support (BLS)?
|
1) Determine unresponsiveness- tap and shout
2) Call for help-do not leave paient 3) Establish airway- position patient, elevate chin(head tilt-chin lift or modified jaw thrust) 4) Check for breathing-watch for chest movement,listenand feel air flow(no more than 10 seconds) 5) Give two breaths-(if unable to ventilate , reposition head) 6) Check for pulse, carodid artery 7) If pulseless:begin chest compressions-chech hand postion 8)Provide 100% oxygen and draw arterial blood gas 9)Even with proper CPR (30:2) can only establish about 30% of the patient's original cardiac output |
|
What are the two most common complications of basic life support?
|
Number One Complication of artificial respirations is Gastric distention.
Number One Complication of external cardiac compression is Rib fractures |
|
What are the differences in performing CPR on adult , child, infant and newborn?
|
IN establishing airway the same for Infant under 1yr to Adult use the head tilt-chin lift or Modified jaw thrust
Except in the Newborn Birth to 1 month Just Head slightly Extended Breathing Rate 8yrs to Adult:10-12breaths/min or every 5-6seconds Child and Infant under 1 to 8yrs 12 -20 breaths/min Newborn birth to 1 month 40 -60 breaths/min Compressions 8yrs to Adult Use heel of bottom hand Child 1 to 8yrs Use heel of 1 hand Infant to 1 month Use 2 or 3 fingers Birth to 1 month Use 2 fingers or thumbs Position of hands or fingers Infants to Adult -Lower half of sternum Newborn birth to 1 month Use Lower Third of Sternum Depth 8yr to Adult 1 1/2 - 2inches Child 1 to 8yrs 1 to 1 1/2inch Infant under 1 yr 1/2 to 1 inch Newborn birth to1 month 1/2 to 3/4 inch Rate 100/min except for Newborn is 90/min Compression to Ventilation Ratio 8yr - Adult 30:2 both one and two rescurer Child Under 1 to 8 yrs 15:2 two rescurer Newborn 3:1 both one and two rescuer For Under 1 to 8yr call 911 after 1 min or 20 cycles Newborn birth to 1 month Begin chest compressions if HR is < 60 despite 30 sec. of ventilation .Only newborn has pulse and you still start compressions |
|
What is Hypotension and how do you treat it?
|
Characterized by low blood pressure, poor capillary refill,weak thready pules.
Treated with fluid challege, dopamine, dobutamine |
|
What is Bradycardia and how treated?
|
Characterized by heart rate < 60 in an adult and heart rate<100 in an infant
Treated with atropine, dopamine and epinephrine for adult Epinephrine and atropine for children Also treated with external pacemaker |
|
What are Ventricular arrhythmias and how are they treated?
|
PVC:treat with Oxygen and LIdocaine
Pulseless Ventricular Tachycardia treat with defibrillation at 360 joules If defibrillation unsuccessful, start CPR and administer:Epinephrine, amiodarone or lidocaine Ventricular fibrillation treat with Defibrillation at 360 joules, if defibrillation unsuccessful, start CPR and administer Epinephrine, amiodarone or lidocaine Special considerations: if the patient has a metabolic acidosis(documented by ABG) administer sodium bicarbonate. |
|
What is asystole and how is it treated?
|
No activity , straight line
1st Confirm in two leads Treat with Epinephrine, Atropine, DO NOT DEFIBRILLATE CPR, intubate , IV pacing |
|
What is cardioversion?
|
Therapeutic procedure (non-emergency) involves low voltage (50-100Joules) current to heart to attempt to convert dysrythmia to normal sinus rhythm. The electric current is synchronized with patient's rhythm. (Shock to R wave)
Atrial fibrillation , atrial flutter and venticular tachycardia with pulse. If ventricular fibrillation occurs , check pulse first, then turn off synchronizing switch , increase to 200 joules and defibrillate Madazolam(Versed) is a strong short acting sedative given prior to cardioversion |
|
What is dibrillation and when is it used?
|
Similar to cardioversion ,except used when emergency (lethal) cardiac dysrhymias are present.
Pulseless Ventricular Tachycardia Ventricular Flutter Ventricular Fibrillation Normally 360 Joules Life threathing, unsynchronized |
|
What is the criteria for the ideal resuscition bag?
|
Self -inflating
Good mask design, will fitting, shapeable and transparent Reservoir to give 95-100% oxygen at 15 L/min with a quick attachment (not bulky) |
|
How do you troubleshoot a resuscitation bag?
|
If bag fills rapidly and collapes easily on minimal pressure then check inlet valve.
If bag becomes difficult to compress with normal patient compliance , patient valve maybe stuck open or closed. Too high flow may cause valves to jam. Use 15 L/min. If these are not the problem use another form of ventilation |
|
What are the advantages of mouth to valve mask ventilation?
|
Head tilt is applied , mask is placed on the face of patient, (an oropharyngeal airway maybe inserted if needed)
This eliminates direct contact with patient and eliminates exposure to exhaled air. Easy to preform and supplemental oxygen can be administered |
|
What equipment is needed for patient transport?
|
Intubation equipment
Portable oxygen Resuscitation device Transport vent if patient on vent Pulse oximeter Appropriate medications portable ECG monitor Stethoscope and spirometer, for tidal volume assessment |
|
What is Pulmonary Edema ?
|
Congestive Heart Failure/Left ventricular failure and lung reaction. Excessive fluids accumulate in the lungs that affect ventilation and especially oxygenation
|
|
What are the signs of Pulmonary Edema?
|
Assessment:
Orthopnea,pitting edema, distended neck veins and increased respiratory distress. Pink/frothy/watery secretions Fine crepitant audible rales ore crackles |
|
What is the treatment of Pulmonary Edema/ Congestive Heart Failure(CHF)?
|
Improve gas exchange-give 100% O2 via non-rebreather, IPPB wigh 100% o2 and ethanol, PEEP, CPAP if necessary.
Increase strength of heart contraction(Inotropy)- give digitalis Decrease venous return-give lasix(diuretic) body position(Fowlers) |
|
What is Pulmonary Emboli?
|
Deadspace disease(ventlation without perfusion) Caused by blood clots in the lungs and will affect oxygenation and circulation.
|
|
What are some of the signs of Pulmonary Emboli?
|
Assessment:
Sudden onset of dyspnea, tachypnea Patient appears to be hyperventilating but is not (ABG's show normal PaCO2) Anxious, chest pain Wedge shaped x-ray Ventilation/Perfusion (V/Q) scan-shows no perfusion with ventilation=deadspace disease |
|
What is the treatment of Pulmonary Emboli?
|
Anticoagulation therapy(heparin and coumadin)
Oxygen therapy Thrombolytic drugs/screens/surgery |
|
What is a Pneumothorax/
|
Presence of gas in the pleural space that can seriously affect ventilation
|
|
What are some of the signs of Pneumothorax?
|
Assessment:
Sudden onset of dyspnea with decreased breath sounds and tracheal shift away from the affected side Decreased vocal fremitus, percussion is hyperresonant or tympanic. X-ray shows hyperlucency without vascular markings and a flattened diaphragm. |
|
What is the treatment for Pneumothoraxx?
|
Give 100% O2 via non-rebreathing mask
Immediate chest tube/ thoracentesis, or relieve pressure with needle and tubing inserted into a glass of water |
|
What is CO poisoning?
|
The inability of hemoglobin to bind with oxygen due to the binding of carbon monoxide. This can serously arrect oxgenation.
|
|
What are the symptoms of CO poisoning?
|
Assessment:
History of present illness will be important. (fireman, smoke filled room, burning building etc.) Redness of skin Breathing labored and deep (tachypnea, hyperpnea) Tachycardia with normal ABGs Increase COHb on co-oximeter>20% Do not rely on pulse oximetry(SpO2) |
|
What is the treatment of CO poisoning?
|
100% O2 via non-rebreathing mask, CPAP mask
Hyperbaric Oxygen |
|
What is Status Asthmaticus?
|
Sustained asthma attack, unrespinsive to bronchodilator therapy. Will have marked affect on ventilation and oxygenation
|
|
What are the symptoms of Status Asthmaticus?
|
Assessment:
Diagnosis made by history Retractions and pulsus paradoxus ABG's indicating respiratory acidosis or respiratory failure(PCO2>45) |
|
What is the treatment of Status Asthmaticus?
|
100%O2 therapy via a non-rebreathing mask
Subcutaneous epinephrine x 3 Mechanical ventilation-sedate,paralyze,control if necessary Bronchodilator therapy and steriods |
|
What are some examples of trauma?
|
Head,chest, neck,burns and near drowning
|
|
How do you treat trauma?
|
Always start with airway,breathing and circulation
Administer 100% O2 Administer drugs and/or fluids based upon bedside and laboratory assessment Remainder of treatment is based upon careful patient assessment. |
|
What is a thoracentesis and the most common disorder that requires it?
|
Diagnostic and/or therapeutic procedure in which a needle is inserted into the chest to remove air/fluid from the pleural space. Most commonly used for pleural effusion
|
|
How is a thoracentesis preformed?
|
Patient is sitting up and leaning forward, 3 to 10 mL of licocaine is used to anesthetize the skin with a 25 gauge needle. A larger and longer needle is then used to anesthetize the thickness of the chest wall. The needle is inserted until the fluid level is reached. This is established when fluid can be withdrawn. 100 to 300 of pleural fluid is aspirated for diagnostic purposes with a 50 mL syringe
|
|
What does the pleural fluid appearance mean?
|
A clear fluid that has a light straw color is called a transudate (serous fluid) and is associated with Congestive Heart Failure
A cloudy or opaque fluid (more cells) is empyema and is an exudate as is infections that produce yellow or milky exudate fluid. Purulent or pus filled is an exudate also chyle containing lymphatic exudative fluid Mucopurulent is an exudate containing mucus and pus Bloody effusions (hemothorax, serasanguineous) may suggest malignancy of cancer Loculated means very thick Pleural fluid pH can be measured and a ph < 7.30 is considered significant (Exudate) |
|
What is a Polysomnography?
|
Sleep Apnea Study
|
|
What is sleep apnea and what are the 3 types?
|
Sleep apnea is a condition in which the patient has apnea during sleep for periods of 10 seconds or longer.
There are 3 types: Central:apnea due to loss of ventilation effort/chest stops moving Obstructive;apnea due to blockage of the upper airway/chest still moves Mixed:a combination of central and obstructive |
|
What does Polysomnography use to confirm the diagnosis and assess the severity of sleep apnea?
|
Chest motion detectors to measure respiratory effort
Flow dectectors to measure nasal flow Oximetry to measure oxygen desaturation(SpO2) during apneic periods If nasal flow decreases and respiratory effort decreases(chest rise) then desaturation is a result of central problem If nasal flow decreases but respiratory effort increases(chest rise) then desaturation is a result of an obstructive pattern. |
|
What are the treatments for Sleeep Apnea?
|
Weight loss
Surgery Respiratory stimulants for Central Apnea Tracheostomy Nasal mask CPAP and/or BiPAP therapy |
|
What conditions require a chest tube?
|
Pneumothorax air enters the pleural space with little or no fluid If this air that enters the pleural space is not allowed to escape it will not only collapse the lung but also affect the mediastinum by pushing it away from the effected side. This is a tension pneumothorax
Hemothorax or pleural effusion is fluid that enters the pleural cavity with no air. Immediate action should be taken to insert a large bore needle to relieve the pressure. Then insert a chest tube and apply the most appropriate chest tube drainage system. |
|
Where is the chest tube placed?
|
One , two or more chest tubes may be inserted into the pleural space. If the tube is to drain Air (A-anterior) from the pleural space it is placed in the anterior chest (second interspace in the midclavicular line)
If the tube is to drain Fluid from the pleural space 1st is placed between the fourth and fifth interspace in the midaxillary line(fluid under arm) |
|
How do water seal suction drainage systems work?
|
One collection (bottle) system bottle should be lower than pt.
Three bottle collection system 1st bottle is collection bottle from patient (blood drained) 2nd bottle is Water seal bottle with 2cm of water in it if bubbles in this the 2nd bottle patient still has a leak 3rd bottle is the suction control bottle it has 20cm of water and has gentle bubbles when system is on |
|
What are the Low Flow Devices to deliver Oxygen ?
|
1) Low flow - provide ONLY part of total inspired volume
a) Cannula: Delivered FIO2: 0.24 - 0.45 / Flow 1-6LPM To approximate FIO2 : for every 1LPM increase FIO2 increases by 4% Most appropriate initial oxygen device for COPD patients with stable respiratory rates and tidal volumes. b) Oxygen Conservation Cannulas Reservoir cannula- Designed to maintain FIO2 at lower level by using a reservoir. The flowrate may be reduced without affecting the FIO2 Used commonly in the homecare setting to reduce costs. c)Transtracheal Oxygen Catheters(TTO2) Amethod of delivering long-term low flow oxygen therapy directly into the airway by a surgically implanted catheter If the patient becomes SOB or has increased WOB ith a TTO2 device the catheter could be obstructed with secretions and you would need to flush catheter. d) Simple mask Delivered FIO2 : 0.40- 0.55 Flow 6-10LPM Flow MUST be greater than 5LPM to flush out exhaled CO2 e) Partial rebreather mask Delivered FIO2 : 0.60 - 0.65 Flow 6-10LPM/ Has NO one-way flaps |
|
What is the rule for oxygen deliervy for COPD patients?
|
COPD Patients
1 - 2 LPM = 24 to 28% FIO2 Theraputic 30 to 60% FIO2 Emergency Situation 100% FIO2 |
|
What are the high flow devices to deliver oxygen?
|
1) High Flow Devices provides patient's entire inspired volume(100%)
a) Non-rebreather mask 1) Delivered FIO2: 0.21 to 1.0 2) Used to deliver 100% O2 in an emergency (Pneumothoras, CO Poisoning, CHF,Burns,etc) He/O2, CO2/O2 mixtures 3)Ideally has THREE one-way valves 4) Troubleshooting a) Flow rates must be sufficient to keep the bag from collapsing. If bag collapes, increase the flow b) If patient inhales and bag does not contract 1)Mask is not tight, seal mask 2) Nonrebreathing valve is stuck, replace mask b)Air-Entrainment Mask/Venturimask 1) Precise FIO2 concetrations available (ideal for patients with COPD) 2)Ideal for patients with irregular tidal volumes, rates and breathing patterns c)Brigg's adapter (T-piece) 1)Delivered FIO2 : 0.21-1.0 depends upon the aerosol source 2)Turn up flow, add tubing after the patient d)Aerosol masks, trach collars(masks) and face tents 1)Delivered FIO2 : 0.21-1.0 depends upon the aerosol source and nebulizer output |
|
What is an Oxygen Hood?
|
1)Clear plastic device of various sizes that completely encloses the head of the infant for the administration of oxygen and high humidity
2)Flow range 7-14L/min to prevent CO2 buildup and allow controllled FIO2 without sealing the infants neck around the hood. 3)Monitor temperature: a) Overheating can cause dehydration and apnea b) Underheating can increase O2 consumption 4)Monitor FIO2 -Preferred method is to analyze O2 continuously near the infant's face. Oxygen may "layer" with higher FIO2 in the lower layers |
|
What environmental control devices are there for oxygen delivery?
|
1)Mist Tent, Oxygen Tent, Croupette
a)Indicated for patients requiring a controlled environment b)Environmental factors controlled: 1) Oxygen concentration 2)Temperature(less than room temperature 3)Filtered gas 4)Humidity and aerosol delivery c)Used mostly for neonatal and pediatric patients d)Run flow at 12-15L/min to wash out CO2 FIO2 variable at 0.40-0.50 and hard to control f) If FIO2 is fluctuating-make sure tent is tightly tucked in. Increase flow 2)Incubators (Isolette) a)Indications 1)Filtered gas 2)Temperature control-will maintain a neutral thermal environment Ideal for non-stressed newborns 3)Radiant warmers(Open incubator a)Ideal for code emergency and for easy access. b)Provides a neutral thermal environment but will not decrease insensible water loss in premature infants due to evaporation. 4)Troubleshooting 1) As eith most circuits, LOSS OF PRESSURE indicates a)Leak b) Insufficient flow INCREASED PRESSURES indicates a) Obstruction b)Faulty exhalation/CPAP/PEEP valve c)With excessive flow, a continuous venting of the pop-off valve will occur |
|
What is Hyperbaric Oxygen Therapy?
|
1) Means of increasing the PO2 by increasing the barometric pressure
2) Diseases/disorders frequently treated by hyperbaric O2 therapy a) CO poisoning b) Tissue transplants/grafts c) Anaerobic infections(gas gangrene) d) Decompression sickness (bends) |
|
What is Helium/Oxygen Therapy (He/O2)?
|
1)Purpose-decreases the patient's work of breathing by delivering low density gas(most important property) that can easily maneuver around obstructions. Used for patients with increased airway resistance, edema, foreign object obstruction, or partial vocal cord paralysis
2) Concentrations used:80%He/20%O2 or 70%He/30%O2 mixtures 3) Considerations a)Therapy given with non-rebreather b) Use 1.7 for both concentrations =1.7 x Liter /min |
|
What is Nitric Oxide Therapy?(NO)
|
1)The physiologic effects of nitric oxide are due to its ability to relax smooth muscle. This improves blood flow to alveoli to improve ventilation/perfusion mismatch, decreases pulmonary vascular resistance, decreases pulmonary pressures and improves oxygenation
2)Indications for nitric oxide therapy include: a) primary and chronic pulmonary hypertension b) Pulmonary fibrosis c) Pulmonary embolism d) Respiratory distress syndrome(ARDS) e) Congenital heart defects f) Persistent pulmonary hypertension of the newborn g) Chronic lung disease h) Heart and lung transplant i) Sepsis j) Sickle cell disease 3)Effective dose is in the range of 2 - 20ppm (parts per million) 4) Recommended starting dose is 20ppm. Doses up to 40 ppm can be sdministered without major side effects 5) Nitric oxide is most commonly delivered via mechanical ventilation. (I-NO delivery system) but can be delivered through a nasal cannula to spontaneously breathing patients as well 6) I - NO-Vent is a machine that is attached to vent to deliver NO Therapy 7) When nitric oxide is exposed to oxygen it can forem nitrogen dioxide(NO2) Levels of nitrogen dioxide greater than 10 ppm can result in cellular damage, pulmonary edema and death 9) Other adverse effects include: a)poor/and or paradoxical response b) methmeglobimenia/ hemoglobin ability to carry oxygen c) rebound hypoxemia and /or pulmonary hypertension d) increased left ventricular filling pressure e) platelet agglutination(cells clump together 10)Discontinuing therapy a) Must be done carefully to prevent a rebound effect b) The nitric oxide level dhould be decreased to the lowest possible dose, usually 5 ppm or less c) The patient should be able to maintain a good oxygenation level on an FIO2 of 0.4 or less d) Before withdrawing the nitric oxide always hyperoxygenate the patient |
|
What do you do to troubleshoot an oxygen cylinder?
|
Troubleshooting:
a) If tank is leaking, check and tighten all connections, check outlet for debris and check/replace washer b) If patient states that no flow is sended from the cannula, the patient should be insturcted first to verify the flow by inserting the cannula into a glass of water and checking for bubbles |
|
What is the Formula for finding the duration of flow for a tank?
|
Formula of Duration (in min)
Tank factors E cylinder= 0.3 H cylinder= 3.0 duration= tank psi x tank factor/ Liters running at |
|
What is a pulsed-dose oxygen delivery system?
|
1) Used in place of a flowmeter with low flow oxygen devices(nasal cannula, reservoir cannula and transtracheal catheters) and connected to a 50 psi gas source
2) Device senses the start of inspiration and delivers oxygen only during inspiration |
|
What is an Air-Oxygen Proportioners (Blenders)?
|
1) Purpose:
a) To control the mixing of air and oxygen to obtain a specific FIO2 2) Can be used with a non-rebreather mask to achieve a precise FIO2 |
|
What is an Air Compressor?
|
1) Used as an alternative means for providing air to patient without using an air cylinder
2) Can be used in a hospital, out-patient clinic or in the home setting 3) Can be used to power a hand-held nebulizer for a COPD patient in the home setting |
|
Why are Total Flow and Oxygen Percentage calculations used?
|
These calculations are necessary when:
a) A patient's inspiratory peak flow exceeds the output of the delivery device. (normal peak flow is approximately 40-60 L/min b) blenders are unavailable for achieving specific FIO2 |
|
What are the air-oxygen entrainment ratios?
|
Total Flow = Flowmeter setting x Factor
Factors are; FIO2 28%Ratio10:1= 11Factor FIO2 40% Ratio 3:1 = 4 Factor FIO2 60%Ratio 1:1=2 Factor |
|
What is the terminology for disinfection and sterilization techniques?
|
Terminology:
1) Disinfection-the process of destroying vegetative pathogenic organisms 2) Sterile-lack of any life organism 3) Vegetative organisms-growing microorganisms 4) Pathogenic organisms-disease producing. 5) Contaminated-the introduction of disease causing microorganisms. 6) Static-growth is inhibited 7) Cidal-microorganisms are killed. 8) Spore-a resistant form of certain species of bacteria. |
|
What is the first thing that should be done before the disinfection process?
|
All equipment should be adequately cleaned by removing organic soil and disassembled prior to the disinfection process.
|
|
What are the physical methods of disinfection and sterilization?
|
1) Steam under pressure (steam autoclave)
a) Conditions for sterilization- 121C at 15psi for 15 min. b) This method will not be used for plactics or other heat sensitive items.(rubber) c) Items must be wrapped in penetrable packaging d) All air must be evacuated and steam must be allowed to penetrate all parts of the load. e) Heat sensitive tapes and/or biological indicators are used to assure that the conditions sterilization have been met. 2) Pasteurzation -disinfection processes using moderate temperatures to kill vegetative organisms. a) Items are first washed then completely submersed in a hot water bath at 63-70C for 30minutes (plastics, rubber) b) Items must be completely dried then assembled and packaged 3) Incineration-the best method of treating contaminated disposable items and supplies. 4) Irradiation-gamma rays are used to sterilze pre-packaged equipment a) Items that have been gamma radiated should not be re-sterillzed with ethylene oxide. |
|
What are the chemical methods of disinfection and sterilization?
|
1) Ethylene oxide sterilization (ETO) sterlizes equipment by alkylation of enzymes.
a) Factors influencing the ETO process: 1) Temperature of the chamber 2) Concentration of ETO: 800-1000 mg/L 3) 50% relative humidity enhances the effectiveness of ETO 4) Exposure time 5) Aeration time 6) Can't get water out b) Biological indicators(Attest) are necessary to verify that the conditions for sterility have been met. c) Examples:Bird Mark VII, Electric Incentive Spirometry device, and a non-disposable resuscitation bag removed from a HIV patient's room d) Not recommended for sterilizing a bronchoscope |
|
What is Alkaline gluteraldehyde?
|
Cidex - disinfection or sterilization process
a) The pH of Cidex is 7.5-8.5 b) Cidex is : 1) bactericidal in 10 minutes 2)tuberculocidal in 10-20 minutes 3) sporicidal in 10 hours(to sterilize) c) Equipment must be rinsed, dried and packaged after each soaking d) Cidex once activated will be fully potent for 14 days. e) Appropriate method for resuable plastics(mouthpiece, tubing aerosols, etcl) f) Appropriate method for a bronchoscope |
|
What is Acid guteraldehyde?
|
Sonacide-disinfection/sterilization processl
a) Sonacide's pH is 2.5-3-5 Sonacide is : 1) bactericidal in 10 minutes 2) tuberculocidal in 20 minutes 3) sporicidal in 1 hour c) Equipment must be rinsed, dried and packaged after exposure to Sonacide d) Sonacide remains potent for 28 days |
|
What is the Alcohol disinfection process?
|
Alcohol disinfection process:
a) Ethyl and isopropyl alcohol are most effective in 70 - 90% solutions b) Alcohol wipes are not sporicidal although it is bactericidal and fungicidal |
|
Are soaps and detergents used as disinfects?
|
Not antimicrobial agents but will be used as cleaners
a) Agents are surfactants that will reduce surface tension |
|
What are some common respiratory pathogens?
|
Gram + Cocci-pneumonia , respiratory track infections
All the Cocci- Staphylococcus Streptococcus, Diplococus, Pneumococcus 2) Gram Negative cause pneumonia and respitatory tract infections Grow in water and found in GI tract. Spread by poor hand washing . a) Pseudomonas aeruginosa -produces green sputum (most common) b) Haemophilus influenza c) Serratria marcescens d) Escherichia coli e) Proteus f) Klebsiella 3) Acid fast bacilli a) Mycobacterium tuberculosis-TB 4) Pathogenic fungi a) Candida- Candidiasis b) Histoplasma capsulatum-Histoplasmosis c) Coccidioides immitis-Coccidiomycosis 5) Viruses commonly cause respiratory infections, flu-like symptoms and viral pneumonia a) Adenovirus b)Influenza c) Cytomegalovirus (CMV) d) Respiratory Syncytial Virus (RSV) |
|
What are nosocomial infections?
|
Dirct contact, airborne, droplet, and indirect transmission are common routes for infectious organisms to be transmitted. Hospital accwuir
|
|
What is Acid guteraldehyde?
|
Sonacide-disinfection/sterilization processl
a) Sonacide's pH is 2.5-3-5 Sonacide is : 1) bactericidal in 10 minutes 2) tuberculocidal in 20 minutes 3) sporicidal in 1 hour c) Equipment must be rinsed, dried and packaged after exposure to Sonacide d) Sonacide remains potent for 28 days |
|
What is the Alcohol disinfection process?
|
Alcohol disinfection process:
a) Ethyl and isopropyl alcohol are most effective in 70 - 90% solutions b) Alcohol wipes are not sporicidal although it is bactericidal and fungicidal |
|
Are soaps and detergents used as disinfects?
|
Not antimicrobial agents but will be used as cleaners
a) Agents are surfactants that will reduce surface tension |
|
What are some common respiratory pathogens?
|
Gram + Cocci-pneumonia , respiratory track infections
All the Cocci- Staphylococcus Streptococcus, Diplococus, Pneumococcus 2) Gram Negative cause pneumonia and respitatory tract infections Grow in water and found in GI tract. Spread by poor hand washing . a) Pseudomonas aeruginosa -produces green sputum (most common) b) Haemophilus influenza c) Serratria marcescens d) Escherichia coli e) Proteus f) Klebsiella 3) Acid fast bacilli a) Mycobacterium tuberculosis-TB 4) Pathogenic fungi a) Candida- Candidiasis b) Histoplasma capsulatum-Histoplasmosis c) Coccidioides immitis-Coccidiomycosis 5) Viruses commonly cause respiratory infections, flu-like symptoms and viral pneumonia a) Adenovirus b)Influenza c) Cytomegalovirus (CMV) d) Respiratory Syncytial Virus (RSV) |
|
What are nosocomial infections?
|
Dirct contact, airborne, droplet, and indirect transmission are common routes for infectious organisms to be transmitted. Hospital accquired
|
|
What are isolation procedures and techniques?
|
1) Once the organisms have been identified, attempts are made to isolate the microorganism and prevent its spread.
2) Type of isolation is dependent upon how organism is spread. a) Universal/Secretion precautions 1) Gloves are worn by personnedl having contact with secretions. Mask and gowns are optional 2) Used eith acquired immunosuppressed deficiency syndrome(AIDS) b) Respiratory Isolation-Airborne transmission 1) Patients must have private rooms and closed doors. 2) Masks and gloves are worn when working with the patient, gowns are not necessary. 3) Diseases requiring respiratory isolation: Measles,Rubella, Mumps, Pertussis, Meningitis and Suspected Tuberculosis patients. 4) Paatients should wear a mask when persons are in the room. c) Strict/complete isolation 1) Gloves, masks and gowns must be worn by all personnel and visitors. 2) Staphylococcus aureus and group Patients with streptococcus pneumonia must by isolated by this method. d) Protective(reverse) isolation procedures must be followed 1) Strict isolation procedures must be followed. 2) Used with burn, transplant, or cancer patients and immunosuppressed individuals. e) Enteric/Blood isolation 1) Gowns are used, gloves necessary only when having direct contact with the patient and infected blood/fecal material f) Wound and skin isolation 1) Gloves are worn by personnel having contact with infected areas. 2) Mask and gowns are optional. |
|
What does home care infection control consist of?
|
1) Flu shots/immunizations
2) Clean equipment daily a) Wash with mild detergent b) Remove all soap by rinsing well with water c) Soak in white distilled vinegar (acetic acid) solution for 20 min.--Pseudomonas d) Rinse, drain, dry without wiping e) Air dry on a clean towel |
|
What different types of home oxygen delivery systems are there and what are some of their safety measures?
|
1) Cylinders
a) Indicated for patients who use small amouts of oxygen intermittently (Prn) b) They can be stored indefinitely but Do Not store in the trunk of a car. 2) Liquid bulk oxygen systems a) Last longer than cylinders, used often in the home b) Non-electrical, portable units are easily filled for trips 3) Oxygen concentrators a) Principle of operation: 1) Run on electricity and have limited portability 2) Utilize a molecular sieve that removes nitrogen and other gases from room air to concentrate the oxygen. 3) If molecular sieve beds are not working-analyze the FIO2, check circuit breaker/fuse b) Safety: a) Instruct patients to routinely check and change filters 2) A properly grounded electrical outlet is required. 3) A backup system (tank or liquid ) must be used in case of a power failure |
|
What Is Chronic Obstructive Disease?
|
1) Description: characterized by dyspnea on exertion with significant hypercapnea
2) Terminology used commonly to describe a COPD patient -chronic ventilatory failure patient, chronic hypercapnic patient, increased compliance patient, a loss of elastic recoil patient and CO2 retainer. C-BABE- Cystic Fibrosis , Chronic Bronchitis,Asthma, Bronchiectasis, Emphysema |
|
What are the assessments for COPD?
|
Assessment COPD:
a) Expiratory wheeze, barrel chest, clubbing and cyanosis b) Percussion notes-resonant or hyper-resonant c) Hyperlucency, hyperinflaton, increased A-P diameter on chest X-ray d) Compensated respiratory acidosis wht hypoxemia and hypercapnea e) Pulmonary functions- decreased flows(FEV1) |
|
What is the treatment for COPD?
|
a) Aerosol therapy-low flow O2
b) Medications-bronchodilators, (give with compressed air) expetorants, corticosteroids and diuretics c) Rehab therapy (purse lip breathing), proper nutrition and monitor fluid intake d) If a COPD pt. comes into ER in a full arrest-resuscitate with 100% O2 |
|
What are two acute obstructive diseases?
|
Croup and Epiglottitis
|
|
What is the etiology , symptoms and treatment of Croup?
|
Croup is caused by the Parainfluenza (85%) Viral , it is an Upper Respiratory Infection , usually strikes in the Winter children less than 3 years old, the Onset is Gradual and Admission Criteria is Stridor At Rest
Treatment and Drugs: Cool mist tent, Dexamethasone (Steroid) and Racemic Epinephrine Aerosol Lateral Neck X-Rays revel : Subglottic edema, Steeple or pencil sign |
|
What is the etiology, symptoms and treatment of Epiglottitis?
|
Epiglottitis is caused by Hemophilus Influenza (Bacterial) There is no upper respiratory infection it is usually between 3-7 years old the onset is Sudden , there is fever ,drooling and retraction, and a toxic appearance
Admission Critera is Drooling Extended neck and a Suspicion of epiglottitis Treatment and drugs are Intubation, IV Antibiotics (Ampicillin) Lateral Neck X-Rays revel Supraglottic edema, Thumb or thumbprint sign and Obliterated vallecula |
|
What is a mycobacterium disease ?
|
Tuberculosis - caused by acid-fast , rod-shaped bacteria, spread by inhalation
|
|
What is the Assessment of Tuberculosis?
|
Assessment:
a) Night sweats(nocturnal diaphoresis), weight loss and weakness b) Dry couch with or without hemoptysis and pleural pain c) Two positive test are required from-TB test, bacteriological studies, sputum culture d) X-rays will show consolidation, fibrosis and cavity formation |
|
What is the treatment for Tuberculosis?
|
a) Isolate-Respiratory isolation
b) Drugs-Isoniazid(INH) , ethambutol, streptomycin, rifampin |
|
What is an infectious disease?
|
Pneumonia , infectious bacteria or virus enters the lung via inhalation or aspiration
|
|
What are some assessments of Pneumonia?
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Assessments of Pneumonia:
a) Chills, fever, cough, purulent sputum, dyspnea, cyanosis, rales and rhonchi on auscultation b) White blood cell count (WBC) increased in bacterial, decreased in viral c) Scattered patchy opacity/ consolidation on x-ray |
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What is the treatment of Pneumonia?
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Treatment of Pneumonia:
a) Oxygen therapy if needed (pulse oximetry , ABG) b) Bronchial hygiene c) Antibiotics-penicillin for gram positive infections(stap &streptococcus), streptomycin, gentamycin and tobramycin for gram negative infections(serratia, klebsiella, haemophilus, pseudomonas, E.coli, proteus) d) Mechanical ventilation if PCO2>45mmHg and PaO2<60mmHg |
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What is pleural effusion, assessment of and treatment for?
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1) Description: Fluid in the pleural space
2) Assessment: a) Dyspnea, chest pain, decreased breath sounds and dry non-productive cough b) Mediastinal shift to the unaffected area(away from the affected area) c) Lateral decubitus x-ray- obliteration of the costophrenic angle, unilateral basilar infiltrate with meniscus formation 3) Treatment: a) Thoracentesis/or chest tube drainage system b) Antibiotics |
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What is Acute Respiratory Distress Syndrome (ARDS)?
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(ARDS) is a series of reactions leading to inflammation, resulting in a decrease in lung compliance, shunting, hypoxemia
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What are the assessments of ARDS?
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Assessment for ARDS:
a) Respiratory distress with tachypnea and cyanosis b) Refractory hypoxemia, increased A-a DO2 gradient and work of breathing c) X-ray -shows diffuse alveolar infiltrates in honeycomb/ground glass pattern d) Decreased FRC, shunting and respiratory failure |
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What are the treatments for ARDS/
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Treatment for ARDS:
a) O2 therapy-adequate arterial oxygenation without high FIO2 b) CPAP/PEEP therapy- to increase FRC and to decrease work of breathing c) Titrate PEEP and FIO2 such that the FIO2 can be reduced below .60 (decrease FIO2 first then PEEP d) Use IMV/SIMV with PEEP e) Consider pressure control ventilation |
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Name two neuromuscular diseases?
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Myasthenia Gravis and Guillain Barre Syndrome
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What is the etilolgy , signs, symptoms , tests and treatment of Myasthenia Gravis?
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Etiology of Myasthenia Gravis is it is an Auto-immune response , No URI
Signs and Symptoms: Onset is slow, fatigue improves with rest Paralysis is descending(Mind to Ground) Diagnostic tests are : postive tensilon test and monitoring of VCand MIP Drugs and treatment is Neostigmine,Pyridostigmine Intubation /mech vent -short term |
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What is the etilogy ,signs, symptoms, tests and treatment of Guillain Barre Syndrome?
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Etilolgy of Guillain Barre Syndrome is a Delayed reaction to a viral infection
URI is present Signs/Symptoms are Acute , sudden weakness Paralysis is Ascending(Ground to Brain) Diagnostic Tests are spinal tap revels protein in spinal fluid and you Monitor VC/MIP Drugs/treatments are Steroids, Prophylactic Antibiotics Mech vent/trach-long term Plasmapheresis |
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What is the treatment plan for Asthma?
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Zone Green Peak Flow(80-100%) Level 1
No symptoms of an asthma episode /Able to perform usual activities/No coughing, wheezing or chest tightness Status is stable/Action plan is continue with medications in daily treatment plan /Use preventative (anti-inflammatory medicine(steroids) Yellow Peak Flow (50-80%) Level 2 Increased need for inhaled quick relief medicine Increased asthma symptoms upon awakening Awakening at night with asthma symptoms Status is increase in symptoms Action plan is Preventative(anti-inflammatory) inhaler ADD: Quick relief(short-acting bronchodilator) inhaler (Albuterol) Begin/increase treatment with oral steroids. Call doctor Return to Level 1 when symptoms improve Red/Level 3 /Peak Flow (less than 50% Or No improvement after increasing treatment according to Zone 2 ) Very short of breath Increased symptoms longer than 24 hours Limited daily activities Status : No improvement Or Increase in symptoms Action: Quick relief(bronchodilator) inhaler Begin /increase treatment with oral steroids Call Doctor Danger Signs: Status/ Difficulty walking and talking due to shortness of breath Lips or fingernails are blue Go To Hospital or Call 911 Call Doctor if: Asthma symptoms worsen while taking oral steroids Or Inhaled bronchodilator treatments are not lasting 4 hours Or Peak flow drops despite following treatment plan |
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What is the Cardiac Output equation?
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QT= heart rate x stroke volume
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What is pulse pressure?
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Pulse pressure=systolic-diastolic
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What is Stroke volume?
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Stroke volume=CO/Heart rate
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What is ejection fraction?
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Ejection fraction=Stroke volume/End Diastolic Volume
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What is QT?
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QT=VO2/C(a-v)O2 (10)
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What is VO2?
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Oxygen consumption=
VO2=QT x C(a-v)O2 x 10 |
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What is Alveolar ventilation equation?
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VA=(VT-VD)f
use ideal body weight for VD |
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What are the Hemodynamic's Values?
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CVP is 2-6 mmHg or 4-12H2O
PAP is 25/8 is 13mmHg PCWP is 4-12mmHg MAP is 120/80 or 90mmHg Cardiac Output is 4-8L/m Cardiac Index is 2-4 L/m |
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What is an easy way to remember pulmonary function?
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FVC is Restrictive <80%
FEV1 is Obstructive <80% |
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What do you do to increase ventilation on a ventilator?
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To increase ventilation:
High Jet Frequency Increase Driving Pressure Bi-Pap Increase IPAP Osculation Increase Amplitude Pressure Control Increase PIP Volume Control Increase Tidal Volume |
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What is the shortcut for Shunt Equation?
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Take the first number from the A-aDo2 add a 1 and x it by 5
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What is the number for normal Resistance?
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.6-2.4 cmh2o/l/min
PIP - Plateau Plateau -PEEP if PEEP given |