Role Transition Exam 3 Study Guide
Respiratory
Ventilator emergencies
Should NEVER be turned off.
Don’t know what is causing the alarm? What action is next?
oManually bag the patient
oCan still mechanically ventilate when breathing on their own – bag WITH the pt
Three Types of ventilator Alarms
oV olume (low pressure) alarms - pt disconnected, low volume
oPressure (high pressure) alarms - biting tube, secretions/fluid in tubing, pneumo
oApnea alarms – not breathing
WHAT CAUSES THE ALARM?
Positive End Expiratory Pressure PEEP
o> 15 is high PEEP – can cause peumo, damage to lung tissue/barotrauma
Positive pressure decreases CO2 and compresses venous return
Assessment findings emphysema
Loss of lung elasticity leading to air trapping
Barrel shaped chest
Dyspnea – tachypnea, use of accessory muscles, pursed lip breathing
Pink puffers (high CO2)
Diminished breath sounds Tripod position Signs/symptoms of hypoxia
oAcute – hyperventilation, H/A, AMS (restlessness, anxious, irritability), diaphoresis
Tx: Oxygen administration, morphine sulfate to control breathing
oChronic - clubbing, cyanosis, diminished oxygenation to vital organs
POSTOP care priorities
Oxygen administration devices - COPD patients
Nasal cannula
oApproximately 24-40% O2, 1-4L à meant for someone that is stable
If you give more than 4 L, you need to use humidifier
oSOB—start with nasal cannula
Masks: Simple; Partial rebreathing; Non-rebreathing
oSimple Mask: Can deliver ~40-60% O2; Flow meter- 5-8 L
Pro-more stable and higher concentration
Con—claustrophobic; assess for skin breakdown
Rearrange frequently and oral hygiene
oPartial Rebreathing: 60-75%, turn flow meter to minimum of 6 L
O2 in the bag (reservoir of O2)
Valves disallow re-inhalation of CO2
oNon-rebreather: Give close to 100% O2
Unstable patient or patient just recovering from anesthesia - ALL the way to 15 L Must have airway and breathing on their own
Anticipate: 1. start to get better quickly 2. get advanced airway (intubated)
Assess frequently
Types of High Flow Devices Venturi-Mask: oEx) 24% must find right adapter and set to the ordered # of L
oVERY accurate—Negative: uses a lot of O2, runs through tank quickly
T-piece: trying to wean pt of ventilatory support
oCan give up to 100% O2 via advanced airway
oSlowly wean concentration of O2, if tolerated can extubate
Noninvasive Positive-Pressure Ventilation - technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation
oBiPAP—mechanical delivery of set positive inspiratory pressure each time the patient begins to inspire; as the patient begins to exhale, the machine delivers a lower set end-expiratory pressure, together improving tidal volume.
HCP can order two separate pressures—less on exhalation (allows fuller exhalation of CO2) Good for COPD pt
oCPAP—continuous positive airway pressure sleep apnea
Same amount for inhalation and exhalation, may be harder to exhale CO2
Care of the pneumonia patient
Oxygen and bronchodilators as prescribed
Semi Fowlers
Incentive spirometer
REST—don’t ambulate
Hydration—up to 3L/day to break up secretions
High calorie & protein diet w/ small frequent meals
Cardiac
Defibrillation vs. Cardioversion vs. Pacing indications
Defibrillate: stops the heart
Cardiovert: slows the heart
Pacing: speeds up the heart
o2nd degree Type II Heart Block
o3rd degree Heart Block
TACHY
oSlow
NARROW (SVT)
oStable – Vagal stimulation, Adenosine (6 mg take BP , follow by 12 mg), Amiodarone 150 mg IVPG, or CCB/Cardizem, or Beta-Blocker
oUnstable – cardiovert (50 Joules)
IRREGULAR (A-FIB or FLUTTER)
oStable – Adenosine, Amiodarone, or CCB/Cardizem, or Beta-Blocker
oUnstable – cardiovert 150 Joules
o WIDE (V-TACH)
oStable – Adenosine (6 mg take BP , follow by 12 mg), Amiodarone 150 mg IVPG, or CCB/Cardizem, or Beta-Blocker
oUnstable w/ pulse – cardiovert (100-120 Joules)
oUnstable no pulse – defibrillate 150, 250, 360 Joules V-Fib
oCheck patient (unresponsive) Rapid Response/911/have someone bring AED check pulse < 10 seconds
oStart compressions (30 compressions for every 2 breaths at least 100 comp/min) and Ambu Bag
oRR arrives w/ AED (continue compressions and place AED)
oDefibrillate 150, 250, 360 J CPR order
Shock Drug CPR
Epinephrine IV 1 mg (1:10,000) x2
Amiodarone 1st dose 300 mg, 2nd dose 150 mg
30 compressions for every 2 breaths at least 100 comp/min
Defibrillate 150, 250, 360 J
Heart Failure Risk Factors
Atherosclerosis/CAD, HTN, smoking, high cholesterol, DM, family history, valvular disease, dysrhythmias, severe lung disease, sleep apnea, hyperthyroidism Left sided heart failure more common
Right sided heart failure (Cor Pulmonale) – caused by LHF
DVT Prevention/Interventions
Pharmacological Prophylaxis – anticoagulant therapy – Enoxaparin (Lovenox), Heparin, Coumadin
Mechanical Prophylaxis – SCD’s, hydration, avoid crossing legs, avoid tight/constrictive clothing, early ambulation/exercise
Central Line complications - Air embolus
During tubing changes instruct pt to perform valsava maneuver, head down and turned to opposite direction of IV (increases intrathoracic venous pressure)
If suspected – place patient in LEFT side-lying position with HOB lower than feet ( Trendelenburg), notify HCP, give O2
S/S: respiratory distress, chest pain, dyspnea, hypotension, rapid and weak pulse, heart murmur
Differentiate Shock States
Initial/Early Stage of Shock
Baseline MAP decreased by less than 10 mm Hg
Heart and respiratory rate increased from the baseline or a slight increase in diastolic blood pressure
Adaptive responses of vascular constriction and increased heart rate
Such a slight change, hard to catch
Non-progressive (Compensated) MAP decreases by 10 to 15 mm Hg.
Kidney and hormonal adaptive mechanisms activated
oRenin, ADH, Aldosterone, Epi, Norepinephrine
oSodium and water are retained
Tissue hypoxia in non-vital organs.
Build-up of metabolites:
oAcidosis- Increased RR, panting
oHyperkalemia
Signs & Symptoms:
oThirst and anxiety oRestlessness
oTachycardia, increased respiratory rate
oDecreased urine output
oDropping SBP and rising DBP
oNarrowing pulse pressure
oCool extremities
o2% to 5% decrease in oxygen saturation
oDecreased bowel sounds, possible nausea vomiting
Stopping conditions that started shock and supportive interventions can prevent shock from progressing. Progressive (Decompensated) Sustained decrease in MAP of more than 20 mm Hg from baseline.
Vital organs develop hypoxia.
Less vital organs become ischemic
Poor perfusion and a buildup of metabolites, some tissues die Life-threatening emergency
Immediate interventions are needed.
Conditions causing shock need to be corrected within 1 hour of the onset of the progressive stage death
Laboratory Findings:
oLow Blood pH
oElevated Lactic Acid (byproduct of anaerobic) Normal 0.5-1 mmol/L
>1 =Bad
<2 : can reverse; 3-4 ICU
oElevated Potassium levels
Signs and Symptoms:
oImpending Doom
oConfused and thirsty
oRapid, weak pulse and low blood pressure
oPallor to cyanosis of oral mucosa and nail beds
oCool and moist skin with one exception
oAnuria
o5% to 20% decrease in oxygen saturation oMay have micro-emboli- must check CMS
Refractory (Irreversible) Too little oxygen reaches tissues; cell death and tissue damage result
Body cannot respond effectively to interventions; shock continues
Rapid loss of consciousness, nonpalpable pulse, cold, dusky extremities; slow, shallow respirations; unmeasurable oxygen saturation
Can’t measure ox sat on finger b/c no perfusion to extremities
MODS
Sequence of cell damage caused by the massive release of toxic metabolites and enzymes. Microthrombi form and manifest in fingers and toes MODS occurs first in the liver, heart, brain, and kidney.
Die w/in 1-2 hours when in MODS
Gastrointestinal
Constipation-Interventions
Assess bowel sounds
Encourage fluid intake up to 3L/day
Encourage early ambulation
High reside/high fiber diet
Privacy and adequate time for bowel elimination
Stools softeners and laxatives as prescribed
Diarrhea-Interventions
Instruct proper hand washing technique
Monitor skin integrity, I/O’s, electrolyte levels and s/s of dehydration
Mild to moderate dehydration – oral rehydration therapy (avoid carbonated bevs and fluids w/ sugar [ex: apple juice])
Respiratory
Ventilator emergencies
Should NEVER be turned off.
Don’t know what is causing the alarm? What action is next?
oManually bag the patient
oCan still mechanically ventilate when breathing on their own – bag WITH the pt
Three Types of ventilator Alarms
oV olume (low pressure) alarms - pt disconnected, low volume
oPressure (high pressure) alarms - biting tube, secretions/fluid in tubing, pneumo
oApnea alarms – not breathing
WHAT CAUSES THE ALARM?
Positive End Expiratory Pressure PEEP
o> 15 is high PEEP – can cause peumo, damage to lung tissue/barotrauma
Positive pressure decreases CO2 and compresses venous return
Assessment findings emphysema
Loss of lung elasticity leading to air trapping
Barrel shaped chest
Dyspnea – tachypnea, use of accessory muscles, pursed lip breathing
Pink puffers (high CO2)
Diminished breath sounds Tripod position Signs/symptoms of hypoxia
oAcute – hyperventilation, H/A, AMS (restlessness, anxious, irritability), diaphoresis
Tx: Oxygen administration, morphine sulfate to control breathing
oChronic - clubbing, cyanosis, diminished oxygenation to vital organs
POSTOP care priorities
Oxygen administration devices - COPD patients
Nasal cannula
oApproximately 24-40% O2, 1-4L à meant for someone that is stable
If you give more than 4 L, you need to use humidifier
oSOB—start with nasal cannula
Masks: Simple; Partial rebreathing; Non-rebreathing
oSimple Mask: Can deliver ~40-60% O2; Flow meter- 5-8 L
Pro-more stable and higher concentration
Con—claustrophobic; assess for skin breakdown
Rearrange frequently and oral hygiene
oPartial Rebreathing: 60-75%, turn flow meter to minimum of 6 L
O2 in the bag (reservoir of O2)
Valves disallow re-inhalation of CO2
oNon-rebreather: Give close to 100% O2
Unstable patient or patient just recovering from anesthesia - ALL the way to 15 L Must have airway and breathing on their own
Anticipate: 1. start to get better quickly 2. get advanced airway (intubated)
Assess frequently
Types of High Flow Devices Venturi-Mask: oEx) 24% must find right adapter and set to the ordered # of L
oVERY accurate—Negative: uses a lot of O2, runs through tank quickly
T-piece: trying to wean pt of ventilatory support
oCan give up to 100% O2 via advanced airway
oSlowly wean concentration of O2, if tolerated can extubate
Noninvasive Positive-Pressure Ventilation - technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation
oBiPAP—mechanical delivery of set positive inspiratory pressure each time the patient begins to inspire; as the patient begins to exhale, the machine delivers a lower set end-expiratory pressure, together improving tidal volume.
HCP can order two separate pressures—less on exhalation (allows fuller exhalation of CO2) Good for COPD pt
oCPAP—continuous positive airway pressure sleep apnea
Same amount for inhalation and exhalation, may be harder to exhale CO2
Care of the pneumonia patient
Oxygen and bronchodilators as prescribed
Semi Fowlers
Incentive spirometer
REST—don’t ambulate
Hydration—up to 3L/day to break up secretions
High calorie & protein diet w/ small frequent meals
Cardiac
Defibrillation vs. Cardioversion vs. Pacing indications
Defibrillate: stops the heart
Cardiovert: slows the heart
Pacing: speeds up the heart
o2nd degree Type II Heart Block
o3rd degree Heart Block
TACHY
oSlow
NARROW (SVT)
oStable – Vagal stimulation, Adenosine (6 mg take BP , follow by 12 mg), Amiodarone 150 mg IVPG, or CCB/Cardizem, or Beta-Blocker
oUnstable – cardiovert (50 Joules)
IRREGULAR (A-FIB or FLUTTER)
oStable – Adenosine, Amiodarone, or CCB/Cardizem, or Beta-Blocker
oUnstable – cardiovert 150 Joules
o WIDE (V-TACH)
oStable – Adenosine (6 mg take BP , follow by 12 mg), Amiodarone 150 mg IVPG, or CCB/Cardizem, or Beta-Blocker
oUnstable w/ pulse – cardiovert (100-120 Joules)
oUnstable no pulse – defibrillate 150, 250, 360 Joules V-Fib
oCheck patient (unresponsive) Rapid Response/911/have someone bring AED check pulse < 10 seconds
oStart compressions (30 compressions for every 2 breaths at least 100 comp/min) and Ambu Bag
oRR arrives w/ AED (continue compressions and place AED)
oDefibrillate 150, 250, 360 J CPR order
Shock Drug CPR
Epinephrine IV 1 mg (1:10,000) x2
Amiodarone 1st dose 300 mg, 2nd dose 150 mg
30 compressions for every 2 breaths at least 100 comp/min
Defibrillate 150, 250, 360 J
Heart Failure Risk Factors
Atherosclerosis/CAD, HTN, smoking, high cholesterol, DM, family history, valvular disease, dysrhythmias, severe lung disease, sleep apnea, hyperthyroidism Left sided heart failure more common
Right sided heart failure (Cor Pulmonale) – caused by LHF
DVT Prevention/Interventions
Pharmacological Prophylaxis – anticoagulant therapy – Enoxaparin (Lovenox), Heparin, Coumadin
Mechanical Prophylaxis – SCD’s, hydration, avoid crossing legs, avoid tight/constrictive clothing, early ambulation/exercise
Central Line complications - Air embolus
During tubing changes instruct pt to perform valsava maneuver, head down and turned to opposite direction of IV (increases intrathoracic venous pressure)
If suspected – place patient in LEFT side-lying position with HOB lower than feet ( Trendelenburg), notify HCP, give O2
S/S: respiratory distress, chest pain, dyspnea, hypotension, rapid and weak pulse, heart murmur
Differentiate Shock States
Initial/Early Stage of Shock
Baseline MAP decreased by less than 10 mm Hg
Heart and respiratory rate increased from the baseline or a slight increase in diastolic blood pressure
Adaptive responses of vascular constriction and increased heart rate
Such a slight change, hard to catch
Non-progressive (Compensated) MAP decreases by 10 to 15 mm Hg.
Kidney and hormonal adaptive mechanisms activated
oRenin, ADH, Aldosterone, Epi, Norepinephrine
oSodium and water are retained
Tissue hypoxia in non-vital organs.
Build-up of metabolites:
oAcidosis- Increased RR, panting
oHyperkalemia
Signs & Symptoms:
oThirst and anxiety oRestlessness
oTachycardia, increased respiratory rate
oDecreased urine output
oDropping SBP and rising DBP
oNarrowing pulse pressure
oCool extremities
o2% to 5% decrease in oxygen saturation
oDecreased bowel sounds, possible nausea vomiting
Stopping conditions that started shock and supportive interventions can prevent shock from progressing. Progressive (Decompensated) Sustained decrease in MAP of more than 20 mm Hg from baseline.
Vital organs develop hypoxia.
Less vital organs become ischemic
Poor perfusion and a buildup of metabolites, some tissues die Life-threatening emergency
Immediate interventions are needed.
Conditions causing shock need to be corrected within 1 hour of the onset of the progressive stage death
Laboratory Findings:
oLow Blood pH
oElevated Lactic Acid (byproduct of anaerobic) Normal 0.5-1 mmol/L
>1 =Bad
<2 : can reverse; 3-4 ICU
oElevated Potassium levels
Signs and Symptoms:
oImpending Doom
oConfused and thirsty
oRapid, weak pulse and low blood pressure
oPallor to cyanosis of oral mucosa and nail beds
oCool and moist skin with one exception
oAnuria
o5% to 20% decrease in oxygen saturation oMay have micro-emboli- must check CMS
Refractory (Irreversible) Too little oxygen reaches tissues; cell death and tissue damage result
Body cannot respond effectively to interventions; shock continues
Rapid loss of consciousness, nonpalpable pulse, cold, dusky extremities; slow, shallow respirations; unmeasurable oxygen saturation
Can’t measure ox sat on finger b/c no perfusion to extremities
MODS
Sequence of cell damage caused by the massive release of toxic metabolites and enzymes. Microthrombi form and manifest in fingers and toes MODS occurs first in the liver, heart, brain, and kidney.
Die w/in 1-2 hours when in MODS
Gastrointestinal
Constipation-Interventions
Assess bowel sounds
Encourage fluid intake up to 3L/day
Encourage early ambulation
High reside/high fiber diet
Privacy and adequate time for bowel elimination
Stools softeners and laxatives as prescribed
Diarrhea-Interventions
Instruct proper hand washing technique
Monitor skin integrity, I/O’s, electrolyte levels and s/s of dehydration
Mild to moderate dehydration – oral rehydration therapy (avoid carbonated bevs and fluids w/ sugar [ex: apple juice])
