RRT- Clin Sims- Lindsey Jones 100% correct answers already graded A+

General Assessment : Visual Assessment (Stage I) Any assessment that you can do quickly by just glancing at the patient, a monitor, or the patient's record should be done first. Visual assessment items include: General appearance Color Medical history Heart rate (exception to the rule) General Assessment : Bedside (Patient contact) assessment (Stage II) This includes all things that relate to the respiratory status of the patient and can be done quickly and usually without cost or too much effort from the patient. Bedside assessment items include: Breath sounds Palpation of the chest or trachea Examination of the upper airway Blood pressure Vital capacity measurement General Assessment : Laboratory assessments (Stage III) This involves any test requiring laboratory analysis and/or interpretation. Or, it may require special equipment or technicians to perform. Laboratory assessments usually have a cost associated with them. These assessment items must relate to the respiratory status of the patient. Examples of laboratory assessments include: Arterial blood gas analysis Chest X-ray CBC Urinalysis Pulmonary function screening (FEV1, pre and post bronchodilator studies) Serum electrolytes ECG Bilirubin level General Assessment : Special tests and assessments (Stage IV) Special tests are done when you suspect specific problems or diseases. They are often costly and/or require significant time for interpretation. Or, it may be a special test because it relates only to one thing. Very often, this test is used for diagnosis. Picking incorrect special assessments will usually result in significant negative points. Special tests and assessment should only be done if it relates! Examples of special tests and assessments include: CAT scan of the head, Complete pulmonary function testing (DLCO, Nitrogen washout), Tensilon test, Bronchogram, Sweat chloride test, Mantoux test, Pulmonary angiogram, Lung perfusion scan, Tracheal Palpation Amniocentesis, Acid-fast sputum stain Ventilator: Initial Adult Settings : There are five areas that must be addressed when initially placing a patient on a ventilator. In order of importance and priority, they are: Rate, Tidal Volume, Oxygen, PEEP, & Mode Ventilator: Initial Adult Settings : Rate Always between 8 and 12 Immediately weed out all options that do not have rates between 8 and 12. Consider a rate of 14 only if nothing else is offered. Ventilator: Initial Adult Settings : Tidal Volume 8 - 12 mL/kg Calculate the range of appropriate tidal volume Immediately discount every option that shows a tidal volume not in that range. Ventilator: Initial Adult Settings : Oxygen If it is an emergency, then FIO2 is 1.0 Otherwise, the patient should be put on EXACTLY what they were on previously. If there is no record of previous FIO2 then use the adult therapeutic range of 40 to 60%. Remember that oxygen is drug. So, if 40% and 55% is offered, then choose the lower. Ventilator: Initial Adult Settings : PEEP Therapeutic PEEP for an adult is 10 cm H20. That means that if PEEP is offered at 0 to 9 cm H20, then it is OK to pick. Do not worry too much about whether it is indicated or not. Remember, however, that on initial set up, less PEEP is better than more. While PEEP of zero is acceptable, some PEEP is preferable. ***ARDS Exception—if asked to put someone with ARDS on a ventilator, since PEEP therapy is considered a key care strategy, a PEEP of 10 is indicated. Ventilator: Initial Adult Settings : MODE Notice that mode is last priority because ALL MODES ARE GOOD. However, on the NBRC exam, first choose SIMV if available. Next, choose ASSIST/CONTROL. Lastly, CONTROL MODE should be used. ***ARDS Exception—if asked to put someone with ARDS on a ventilator, Pressure Control Mode may selected as an initial setting Adult Ventilator Weaning : Acceptable methods are what, and how are they done Acceptable methods: ~Cold cessation—remove from the ventilator and monitor ~IMV/SIMV—gradual decrease in rate, allowing patient to breathe spontaneously ~Pressure support ventilation—overcome dynamic compliance, gradual decrease. ~T-piece Trials Adult Ventilator Weaning : Readiness to wean: What are the parameters used to determine the readiness to wean? VT >5 mL/kg VC > 10 mL/gh MIP > - 20 cm H2O Rate 8 to 20 breaths per minute RSBI < 106 (RR / Vt(L)) Vd/Vt ratio < 60% % Shunt < 20% ABGs adequate oxygenation and ventilation (or same as before ventilator) Underlying condition needs to be resolved (if ventilatory related) Adult Ventilator Weaning : Weaning Failure: A patient fails if any of what values fall below acceptable limits? Pulse > 20 bpm from baseline (prior to weaning) BP > 20 torr from baseline PaCO2 >10 torr from baseline RR >10 from baseline OR is > 30 breaths per minute Also, weaning fails if there is a significant change in the patient's status generally (ie confusion, lethargy, unresponsiveness). Adult Ventilator Weaning : Successful Weaning: While there are no explicit expectations on what methods should be used for weaning, what are some limitations on how far you need to go.... If SIMV rate 4 is accomplished, there is no need to decrease to 2 No need to decrease FIO2 below 0.40 No need to decrease PEEP below 5 cm H2O Remember, cessation of mechanical ventilation does not mean extubation. One can stay on a ventilator on a heated aerosol and be extubated another day. Ventilator Troubleshooting : High pressure alarm : Patient vs Machine Patient = Patient coughing, need suctioning? Patient resisting inspiration , need sedation? Pneumothorax, check for signs ET tube cogged by sputum or herniated cuff? Machine = Accumulated water in the circuit? Pinched circuit? Recent change in alarm limits or settings? Ventilator Troubleshooting : Low pressure alarm : Patient vs Machine Patient Chest tube leakage Patient inadvertently partially extubated (not always obvious) Cuff is under-inflated or deflated Machine Circuit is disconnected from the patient Circuit has come apart or has a leak On some ventilators, flow rate may not be sufficient (pressure cycled machines) Infant Ventilator Setup : Ventilator Type? Infant Ventilators are usually time-cycled, pressure limited. Infant Ventilator Setup : Mode? Mode Always pick SIMV/IMV mode first (if offered) Infant Ventilator Setup : Rate and I time Rate Greater than 20 breaths per minute I-time 0.3—0.6 seconds Infant Ventilator Setup : Pressure ? Pressure Greater than 20 cm H2O Infant Ventilator Setup : FIO2? FIO2 Same as previous. If there is not previous setting, then 30 to 60% If Emergency, then 100%. Most often, you have been manually resuscitating the infant, so you will choose 100%. Infant Ventilator Setup : PEEP? PEEP 0 to 2 cm H2O. Although you may advance to higher PEEP settings, (never go more than 8 cm H2O) start at 0 to 2 cm H2O when initially beginning mechanical ventilation. Change PEEP in increments of 1 if possible. **Also, if the infant was on CPAP, put the initial PEEP level and FIO2 at the same levels of the CPAP settings. Adult Oxygen Therapy : There are only 3 levels of oxygen therapy on the simulations. What are they? COPD level- 24—28% Usually 1-2 lpm nasal cannula or a venturi mask Adult Therapeutic level- 30—60% (40-55%) is better. Usually 60% is not an option. Will more likely be 55% 30% is suitable for patient who have current pulmonary problems and have history (ie, Drug overdose, Myasthenia gravis, etc) Emergency level- 100% Any emergency for any patient, any age (including COPD) Adult Oxygen Therapy : ABOVE 60%??? In cases where 60% is not enough to maintain good color or adequate PaO2, then employ CPAP or BIPAP. Do not go higher than 60% unless it becomes an emergency. Modifying Therapy : Problem: Patient becomes short of breath when getting CPT with the head of bed down Possible actions: ??? Stop the therapy, switch to other secretion mobilizing therapy like PEP therapy or incentive spirometry. Modifying Therapy : Problem: Patient's secretions remain thick in spite of significant hydration therapy with heated aerosol Possible actions: ??? Possible actions: Give Mucomyst, try ultrasonic nebulization