Critical Care Exam Questions and Correct Answers.

Critical Care Exam Questions and Correct Answers AACN - Correct Answers: certify nurses; protect consumer by establishing high standards of professional practice CCRN - Correct Answers: certification for nurses who provide care in critically ill adult, pediatric, or neonatal populations PCCN - Correct Answers: certification for nurses who provide acute care in progressive care, telemetry, and similar units CNML - Correct Answers: certification for critical care managers and leaders CCNS - Correct Answers: certification for acute and critical care clinical nurse specialists Level A (Scale for Rating Research Evidence) - Correct Answers: meta-analysis or metasynthesis studies; results consistently support specific action, intervention, or treatment Level B (Scale for Rating Research Evidence) - Correct Answers: randomized and nonrandomized controlled studies; results consistently support specific action, intervention, or treatment Level C (Scale for Rating Research Evidence) - Correct Answers: qualitative, descriptive, or correlational studies, reviews, or trials with inconsistent results Level D (Scale for Rating Research Evidence) - Correct Answers: Peer-reviewed with clinical studies to support recommendations Level E (Scale for Rating Research Evidence) - Correct Answers: theory-based evidence from expert opinions Level M (Scale for Rating Research Evidence) - Correct Answers: Manufacturer's recommendation only Ask-Tell-Ask (Communication) - Correct Answers: Communication technique that assesses concerns before providing info Situational Awareness (Communication) - Correct Answers: being aware of one's surroundings Calgary Family Assessment - Correct Answers: Assessment that involves structural, developmental, and functional assessments Family Bundle - Correct Answers: Provide structure for planning and carrying out family care; based on 5 concepts: evaluate, plan; involve; communicate; support (EPICS) Principlism - Correct Answers: widely applied ethical approach based of 4 fundamental moral principles to contemporary ethical dilemmas; respect for autonomy; beneficence; nonmaleficence; justice Beneficence - Correct Answers: the duty to provide benefits to others when in a position to do so, to help balance harms and benefits; the benefits of an action should outweigh the burdens Futility - Correct Answers: states that care should not be given if it is futile in terms of improving comfort or the medical outcome Veracity - Correct Answers: states that persons are obligated to tell the truth in their communication with others Fidelity - Correct Answers: requires that one has a moral duty to be faithful to the commitments made to others Elements of Informed Consent - Correct Answers: competence (capacity); voluntariness; disclosure of information Living Will - Correct Answers: a witnessed written document or oral statement voluntarily executed by a person that expresses the person's instructions concerning life-prolonging procedure; not legally binding in some states Proxy - Correct Answers: a competent adult, not designated to make health care decisions for an incapacitated person, but is authorized by state statute to make healthcare decisions for the person Surrogate - Correct Answers: a competent adult designated by a person to make health care decisions should that person become incapacitated Patient Self-Determination act (End-of-life issue) - Correct Answers: requires that all healthcare facilities that receive medicare or medicaid funding inform their patients about their right to initiate an advance directive and the right to consent to or refuse medical treatment Withholding, Limiting, or Withdrawing Therapy - Correct Answers: Priority should be anticipating patient symptoms; assessment of patient response; titration of therapy to relieve emotional and physical distress; common meds used are analgesics (ie. Morphine) and anxiolytics (ie. benzodiazepines) Ventilator WIthdrawal - Correct Answers: Known as "terminal weaning"; consist of titration of ventilator support to minimal levels, removal of ventilator, but not artificial airway, or complete extubation; titrate pain meds and sedation as needed to relieve symptoms of respiratory distress Commonly withheld therapy - Correct Answers: vasopressors; antibiotics; done when goal of treatment shift to palliation instead of cure; address these before withdrawing or withholding ventilation Ethical Principles for withholding and withdrawing life-sustaining treatment - Correct Answers: life-sustaining treatment should not be withdrawn while patient is receiving paralytic agents. When paralytic drugs are discontinued, patient must demonstrate sufficient motor activity to allow thorough clinical assessment before withdrawal of support Hemodynamic Assessment - Correct Answers: Used to titrate therapies to a specific end point; detect inadequate tissue perfusion; quantify severity of disease; and guide therapy normal cardiac output (CO) (hemodynamic values) - Correct Answers: 4 to 8 L/minute normal central venous pressure (CVP) and Right atrial pressure (RAP) (hemodynamic values) - Correct Answers: 2 to 6 mm Hg Normal stroke volume (SV) (hemodynamic values) - Correct Answers: 60 to 130 mL/beat normal mixed venous O2 sat (SvO2) (hemodynamic values) - Correct Answers: 60% to 75% Normal central venous O2 sat (ScvO2) - Correct Answers: 65% to 85% what affects BP reading - Correct Answers: presence of cardiac dysrhythmias; respiratory variation; shivering; external cuff compression; decreased peripheral perfusion Jugular Venous Pressure - Correct Answers: Provides an estimate of intravascular volume; an indirect measure of central venous pressure (CVP); Normal is 7 to 9 cm jugular venous distention - Correct Answers: occurs when CVP is elevated due to fluid overload, RV dysfunction, superior vena cava obstruction, right HF Assessment of jugular venous pressure - Correct Answers: look for highest point of pulsation; measure the vertical distance between this pulsation and the angle of Louis in cm; add 5 cm to this number for an estimation of CVP Lactate - Correct Answers: normal levels is 0.5 to 1.6 mEq/L; determine tissue hypoperfusion in circulatory shock, establish adequacy of resuscitation; assist in diagnosis of patients who have metabolic acidosis Indication of Arterial Line - Correct Answers: hemodynamic instability; assess efficacy of vasoactive medication; frequent ABG analysis Indication of Central Venous Catheter - Correct Answers: measure right heart filling pressures; estimate fluid status; guide volume resuscitation; assess central venous O2 sat (ScvO2); administer large-volume fluid resuscitation or irritant medications; access to place transvenous pacemaker Indication of Pulmonary Artery Catheter - Correct Answers: identify and treat cause of hemodynamic instability; assess pulmonary artery pressures; assess mixed venous O2 sat (SvO2); directly measure cardiac output (CO) Invasive Hemodynamic monitoring nursing dx - Correct Answers: ineffective tissue perfusion; decreased cardiac output (CO); fluid volume excess or deficit Complication of Invasive hemodynamic monitoring - Correct Answers: thrombosis; pneumothorax; hemothorax; cardiac dysrhythmias; pericardial tamponade components for validating accuracy of invasive hemodynamic monitoring - Correct Answers: patient positioning (up to 45 degrees); zeroing the transducer; leveling the air-fluid interface (zeroing stopcock) to the phlebostatic axis; assessing dynamic responsiveness (do the square wave test) Reason why zeroing stopcock must be positioned at phlebostatic axis - Correct Answers: If below, will result in false elevation; if above, will result in false low reading Accurate hemodynamic data - Correct Answers: It can be obtained when patient is supine, HOB up to 45 degrees, or lateral positions from 30 to 90 degrees Assessing dynamic responsiveness (doing the square wave test) - Correct Answers: activate the fast flush valve/actuator on the pressure tubing system for at least 1 second; should be done after catheter insertion; once per shift; and after opening the system Overdamped dynamic responsiveness (square wave test) - Correct Answers: square wave test results no oscillations, upstroke is slurred, or undershoot is not produced Underdamped dynamic responsiveness (square wave test) - Correct Answers: square wave test results in excessive oscillations Causes of overdamped dynamic responsiveness (square wave test) - Correct Answers: blood clots, blood left in catheter after getting a blood sample, air bubbles, compliant tubing, loose connections, kinks, PIP will drop suddenly Causes of underdamped dynamic responsiveness (square wave test) - Correct Answers: excessive tubing length (48 inches); small bore tubing; sometimes unknown Arterial Pressure Monitoring - Correct Answers: For patients at risk for compromised tissue perfusion and volume status; need frequent lab work; has hypo or hypertension; and takes vasoactive agents (ie. Dopamine); Radial artery is site of choice, also femoral and brachial. Most accurate method of getting systemic BP; pressure should be @ 300 mm Hg; gives beat-by-beat info; NIBP should be lower than invasive Causes of higher NIBP compared to invasive - Correct Answers: air bubbles in catheter; failure to zero the transducer air-fluid interface; blood in catheter; blood clot at catheter tip; kinking; catheter tip lodged against arterial wall; soft, compliant tubing; long tubing; too many stopcocks; improper cuff size and placement RAP/CVP Monitoring - Correct Answers: estimate central venous blood volume and right heart function; pressure is obtained from right atrial port of PAC; assess preload of right side of heart; subclavian and internal jugular veins are common insertion site; CVCs contain multiple lumens; assess and guide fluid resuscitation; must be measured @ end expiration and end of ventricular diastole Methods for Determining Accurate RAP - Correct Answers: Pre-e method (method of choice); mean of the a Wave; z-point method Complications of RAP/CVP monitoring - Correct Answers: carotid puncture; pneumothorax; hemothorax; perforation of RA or RV; cardiac dysrhythmias Clinical Considerations of RAP/CVP Monitoring - Correct Answers: If both RAP and stroke index (SI) are low, hypovolemia is the cause; If RAP is high and SI is low, RV dysfunction is the cause; If RAP is low, cause is upright position; if RAP is high, cause is decrease in RV's ability to eject blood, hypervolemia, severe vasoconstriction, mechanical ventilation, pulmonary HTN, right-sided HF Causes of Abnormalities in RAP/CVP Monitoring - Correct Answers: alterations in venous tone, blood volume, or RV contractility Pulmonary Artery Pressure Monitoring (PAC) - Correct Answers: measure pressure in left side of heart, continuous CO, RV end diastolic volume, RV ejection fraction, and mixed venous O2 sat; used to administer fluids and electrolytes; obtain intermittent thermodilution CO measurements; measures PAP and PAOP; enable transvenous pacing and CCO capabilites; for ease of insertion of catheter, place patient in Trendelenburg position Hemodynamic Parameters Monitored via the PA Catheter - Correct Answers: LV filling pressure; RAP; PA systolic (PAS); PA diastolic (PAD); PA mean pressure (PAPm); PAOP; pulmonary and systemic vascular resistance (PVR and SVR); cardiac output (CO) Normal PAP - Correct Answers: 25/10 mm Hg normal PAPm - Correct Answers: 15 mm Hg normal PAOP; Normal left atrial pressure (LAP) (hemodynamic values) - Correct Answers: 8 to 12 mm Hg How is PAOP obtained - Correct Answers: Inflate balloon no more than 1.5 mL of air for no longer than 8 to 10 seconds What does increase in PAOP indicates - Correct Answers: indicates increase in LV blood volume to be ejected with next systole; fluid volume excess; LV failure; MI what does decrease in PAOP indicates - Correct Answers: indicates reduction in LV blood volume to be ejected with next systole; fluid volume deficit Nursing implications for PAC - Correct Answers: Make periodic comparisons of PAD and PAOP to assess accuracy of PAOP measurement Venous O2 sat - Correct Answers: the percent of hgb saturation in central venous circulation; provides an assessment of amount of O2 extracted by tissues Factors that affect venous O2 sat - Correct Answers: CO; hgb; arterial O2 sat; tissue metabolism what calculates oxygen delivery and consumption - Correct Answers: Venous O2 sat (SvO2); central venous O2 sat (ScvO2) Normal Venous O2 Sat (SvO2) - Correct Answers: 60% to 75% Causes of low SvO2 - Correct Answers: decreased in O2 delivery; cardiogenic shock; CHF; MI; increased in O2 consumption; septic shock; seizures; shivering Causes of high SvO2 - Correct Answers: increase in O2 delivery; increase in FiO2; decreased in O2 consumption; hypothermia; anesthesia; hypothyroidism; if over 80%, it may be due to technical error Mean Arterial Pressure (MAP) - Correct Answers: systolic BP x (2 x DBP) divided by 3; normal is 70 to 105 mm Hg Indications for Esophageal Doppler Monitoring (EDM) - Correct Answers: evaluate descending aortic blood flow; hypoperfusion; hypovolemia; hemorrhagic shock; septic shock; diagnose and mgmt. of HF, cardiogenic shock, valvular dysfunction, ventricular septal rupture, cardiac rupture with tamponade Pain - Correct Answers: classified as malignant/nonmalignant; nociceptive/neuropathic; acute/chronic Pain responses - Correct Answers: increased CO; pallor/flushing; cool extremities; mydriasis (pupillary dilation); diaphoresis; increased glucose production; nausea; urinary retention; constipation; sleep disturbance Nociceptive Pain - Correct Answers: either somatic or visceral; Somatic is from irritation or damage to nervous system; Visceral is diffuse, poorly localized, and referred; activated by mechanical, chemical, and thermal stimuli Anxiety - Correct Answers: linked to reward and punishment centers of brain; marked by agitation, apprehension, and autonomic arousal Negative Effects of Pain and Anxiety - Correct Answers: increases catecholamine (epinephrine; norepinephrine) levels; associated with cardiac events and increased mortality in patient with cardiac disease; hemodynamic instability; immunosuppression; tissue catabolism; isolation; loneliness Characteristics of Pain - Correct Answers: precipitating cause; severity; location; duration; alleviating or aggravating factors PQRST Method (Pain Measurement Tool) - Correct Answers: for chest pain; P is provocation or position (what precipitated it and location); Q is quality; R is radiation; S is severity or symptoms associated with pain; T is timing or triggers for pain Behavioral Pain Scale (Pain Measurement Tool for nonverbal patient) - Correct Answers: scale of 1 to 4; looks at facial expression (relaxed; partially tightened; fully tightened; grimacing); looks at upper limbs (no movement; partially bent; fully bent; permanent retracted); looks at compliance with ventilation (tolerating movement; coughing; fighting ventilators; unable to control) Critical-Care Pain Observation Tool (Pain Measurement Tool for nonverbal patient) - Correct Answers: for patient with or without endotracheal tube; looks at facial expression, body movement, muscle tension in upper extremities, compliance with ventilator, nonventilator vocalization Sedatives - Correct Answers: Too much increases rates of ventilator-associated pneumonia; not enough increases risk of myocardial ischemia; promote synchronous breathing with ventilator Anxiety and Sedation Measurement tools - Correct Answers: Richmond agitation-sedation scale (RASS); the Ramsay Sedation Scale (evaluate postop patients; include 3 levels of wakefulness and 3 levels of sedation); the Sedation-Agitation Scale (1 is unarousable, 7 is dangerously agitated) Electroencephalogram (EEG) - Correct Answers: continuous monitoring of sedation; records spontaneous brain activity by placing electrodes on patient's head; takes up to 60 minutes to place electrodes; 90 indicates full consciousness; 40 to 60 indicates deep sedation; 0 indicates complete suppression Hyperactive Delirium Clinical Findings - Correct Answers: agitation; restlessness; attempts to remove catheters/tubes; hitting; biting; emotional lability; combative and disoriented; place self or others at risk for injury; hallucinations; delusions; paranoia may be seen Hypoactive Delirium Clinical Findings - Correct Answers: withdrawal; flat affect; apathy; lethargy; decreased responsiveness; goes unnoticed and the most prevalent Risk Factors of Developing Delirium - Correct Answers: history of depression; dementia; stroke; substance abuse; hypothermia; fever; renal failure; liver disease; cardiogenic or septic shock; HIV infection; rectal or bladder catheters; tube feedings; presence of physical restraints; visual or hearing impairment; anticholinergic medications; benzodiazepines; opioids Management of Delirium - Correct Answers: splints/binders to restrict movements; Haloperidol IV (cause mild sedation without hypotension); awakening and breathing coordination, delirium monitoring and management, and early mobility (ABCDE) bundle Indications of Neuromuscular Blockade (NMB) - Correct Answers: used to control increases in ICP (rapid-acting); improve chest wall compliance; reduce peak airway pressures; prevent ventilator dyssynchrony Nursing Implementation for NMB - Correct Answers: sedate patient before administering; monitor patient for respiratory problems, skin breakdown, corneal abrasions, and development of venous thrombi; perform train-of-four (TOF) response testing; lubricate eyes to prevent corneal abrasions; ensure prophylaxis for DVT; reposition patient Q2H; provide oral hygiene; maintain mechanical ventilation; monitor breath sounds; suction airway; provide passive ROM; place indwelling urinary catheter to monitor urine output; monitor bowel sounds and for abdominal distention; monitor for physiological changes of pain or anxiety Examples of NMB - Correct Answers: succinylcholine (not for hyperkalemia); pancuronium (long acting; not for renal or liver failure); atracurium and cisatracurium (few side effects; hypotension, tachycardia, rash) Benefits of Epidural Analgesia ("CAINEs") - Correct Answers: increased vital capacity and functional residual capacity of lungs; improve airway resistance; coronary artery vasodilation; decreased BP and HR; less N&V; faster return of GI function; decreased total opioid requirement; decreased sedation; earlier extubation, mobilization; decreased length of stay Contraindications of Epidural Analgesia ("CAINEs") - Correct Answers: coagulopathies; CV instability; sepsis; ETOH or drug intoxication; obesity Side Effects of Epidural Analgesia if administered with local anesthetics - Correct Answers: sympathetic blockade (HTN; venous pooling); motor weakness; sensory block; urinary retention NSAIDS - Correct Answers: side effects include renal insufficiency; GI ulcers; tinnitus; thrombocytopenia; example is ketorolac (toradol) Benzodiazepines - Correct Answers: examples are midazolam; versed; Ativan; sedative and a hypnotic; caution with patients who are hemodynamically unstable as it can cause hypotension; can be given with acute seizures; promote amnesia, but associated with delirium Propofol (Diprivan) - Correct Answers: IV general anesthetic; side effects are hypotension; bradycardia; high triglyceride levels and metabolic acidosis if long-term or high-dose; need tiny IV catheter for continuous infusion and should not hang more than 12 hours Dexmedetomidine (Precedex) - Correct Answers: short term sedative (24 hours) in patients receiving mechanical ventilation; produces anxiolytic affects; bradycardia and hypotension may develop Opioid Withdrawal Symptoms - Correct Answers: pupillary dilation; sweating; rhinorrhea; tachycardia; HTN; tachypnea; vomiting; diarrhea; increased sensitivity to pain; restlessness; anxiety Benzodiazepine Withdrawal Symptoms - Correct Answers: Tremor; HA; nausea; sweating; fatigue; anxiety; agitation; increased sensitivity to light and sound; muscle cramps; sleep disturbances; seizures Substance Abuse (Pain and comfort challenges) - Correct Answers: increases risk of developing pneumonia and sepsis and challenges management of pain and comfort Symptoms of alcohol withdrawal syndrome (AWS) - Correct Answers: agitation; tachycardia; paranoid-like behavior; death; can be prevented by continuous infusion of ethanol and thiamine. Flunitrazepam; IV clonidine; IV haloperidol lower incident of pneumonia and shorter ICU stay and less days of mechanical ventilation Chyme - Correct Answers: breakdown proteins to help with digestion amylase - Correct Answers: breaks down carbohydrates Lipase - Correct Answers: breaks down fats Stomach - Correct Answers: secretes fluid high in sodium, potassium, and other electrolytes Small Intestine - Correct Answers: Where chloride; sulfate; iron; calcium; and magnesium are absorbed; contains the Brunner glands that produce an alkaline compound (mucus) Jejunum - Correct Answers: where monosaccharides (sugars), glucose, galactose, and fructose, water-soluble vitamins (thiamine, folic acid, vitamin C), riboflavin, and pyridoxine are absorbed Ileum - Correct Answers: where the fat-soluble vitamins (A,D,E,K), fat, cholesterol, bile salts, and vitamin B12 are absorbed Colon - Correct Answers: where sodium and potassium, vitamin K, and some B vitamins are absorbed. Also absorb water and fatty acids Pancreas - Correct Answers: Has exocrine and endocrine function; secretes bicarb and enzymes; digestive enzymes like trypsinogen prevent autodigestion; produces insulin, glucagon, and somastatin Bile being produced by the body each day (gallbladder) - Correct Answers: 400 to 800 mL; helps emulsify and absorb fats: provides route for breakdown and elimination of cholesterol Liver - Correct Answers: secretes bile; produces urea that is released into blood; produce lymph; metabolize lipids and vitamin A; synthesis of clotting factors, and synthesis of proteins and albumin Malabsorptive Syndrome that can impair patient's ability to utilize nutrients - Correct Answers: short bowel syndrome; history of radiation to bowel; history of bariatric surgery; presence of an ileus; intestinal pseudo-obstruction; Crohn's disease; diverticulosis; gastroparesis Normal BMI - Correct Answers: 18.5 to 24.9 BMI overweight BMI - Correct Answers: 24 to 29.9 BMI Obese BMI - Correct Answers: 30 to 39.9 BMI Extremely Obese BMI - Correct Answers: 40 or more BMI Types of Tubes used for Enteral Nutrition - Correct Answers: Large-bore NG tubes and flexible small-bore (5 to 12 Fr); Small-bore is used for patient who does not tolerate gastric feeding tube placement and reduces the risk of nasal tissue necrosis; Small-bore is not used for more than 6 weeks (short-term) Percutaneous Endoscopic Gastrostomy (PEG) - Correct Answers: Feeding tube that does not require anesthesia and allows feedings to begin soon after placement; for long-term Jejunostomy Tube - Correct Answers: feeding tube than can only be placed during a laparotomy Enteral Nutrition (EN) - Correct Answers: Type of nutrition for patients with neuromuscular impairment, those who are hypercatabolic, those with hypoperfusion states Nursing Management of Enteral Nutrition - Correct Answers: flush feeding tubes Q4H with 30 mL of water if continuous EN; flush feeding tubes before and after feedings and medication administration with 30 mL of water if intermittent EN; check gastric residual volume (GRV) Q4H if feeding via PEG; If GRV is 200 to 250, give promotility agent; if GRV is more than 500 mL, hold feedings; patient require 30 mL/kg of total fluid intake daily Complications of Enteral Nutrition Feedings - Correct Answers: tube obstruction; improper tube placement; aspiration; diarrhea; dumping syndrome; hyperglycemia; electrolyte imbalance interventions for feeding tube obstruction - Correct Answers: administer medication in elixir diluted with water; irrigate tube with warm water or pancreatic enzymes to relieve obstruction Interventions for improper tube placement - Correct Answers: identify patient who are obtunded (not alert); heavily sedated; those receiving NMB Interventions for aspiration - Correct Answers: assess placement Q4H; do not use blue dye in enteral formulas to assess for aspiration as it may cause death and it is unreliable; monitor abdominal girth measurement for distention Interventions for Diarrhea - Correct Answers: administer fiber-enriched formula or bulking agents; use full-strength, ready to use formula; rinse delivery sets with warm (soapy preferred) water after feedings; change administration sets Q24H; limit hanging time of formulas at room temp to 8 hours; administer feedings at room or body temp; limit bolus feedings to less than 300 mL Interventions for Dumping Syndrome - Correct Answers: slow rate and frequency of feeding bolus Interventions for Hyperglycemia - Correct Answers: Monitor fluid status closely Parenteral Nutrition - Correct Answers: uses central IV access catheter (central line) that is placed in superior vena cava or RA, PICC line, external tunneled catheter, or subcutaneous port; two options are PPN and TPN; PPN is isotonic; TPN is hypertonic and can only be given centrally due to risk of phlebitis and vascular damage; good for patients who have prolonged NPO (1 week) Nursing Management of Parenteral Nutrition - Correct Answers: inspect PN formula for gross particulate contamination, discoloration, particular formation, and phase separation at time of compounding; change all tubing Q24H; NO IVP or infusion medication given on TPN and PPN line except lipid infusions; monitor for fluid and electrolyte imbalance, chem panel, triglycerides, and glucose levels; blood glucose monitoring Q6H; administer insulin Immune-Enhancing Formulas - Correct Answers: for burns (30% of body); head and neck cancer; trauma; GI surgery; mechanical ventilation w/o sepsis; components of the formula are arginine; glutamine; omega-3 fatty acids; branched-chain amino acids; nucleotides; vitamin A, C, and E Drug-Nutrient Interactions - Correct Answers: If patient require fluid restriction, use 15 mL for flush; If administering phenytoin, stop EN feeding for 1 to 2 hours before and after dosing or monitor and adjust phenytoin dosage based on serum drug levels Gas Exchange - Correct Answers: ventilation moves gases in/out of alveoli; diffusion @ pulmonary capillaries moves gas from alveoli to capillaries; perfusion (transportation) is when oxygenated blood is perfused and transported to tissue; diffusion to cells is when oxygen goes into cells and carbon dioxide leaves Respiratory center of the Medulla and Pons - Correct Answers: controls the rate, depth, and rhythm of ventilation Work of Breathing (WOB) - Correct Answers: the amount of effort required for maintenance of a given level of ventilation; if increased, it requires more oxygen and glucose and can lead to respiratory failure and use of mechanical ventilators Compliance - Correct Answers: It is a measure of distensibility/stretchability of lung and chest wall; the change in lung volume per unit of pressure change; best measured under static conditions (no air flow) with 2-second inspiratory hold maneuver with mechanical vent; normal ranges from 50 to 170 mL/cm H20 Causes of decreased compliance - Correct Answers: pulmonary fibrosis; acute respiratory distress syndrome (ARDS); pulmonary edema; obesity Causes of increased compliance - Correct Answers: emphysema (lung can collapse during expiration) Dynamic Compliance - Correct Answers: measure while gases are flowing during breathing; measures lung compliance and airway resistance to gas flow; normal ranges from 50 to 80 mL/cm H2O Resistance - Correct Answers: It is the opposition to the flow of gases in the airways; it is affected by airway length; airway diameter; flow rate of gases; increases when airway lengthens or narrows (mucus, edema, spasm), when gas flow increases Normal tidal volume (volume of normal breath) - Correct Answers: 500 mL Normal total lung capacity - Correct Answers: 6000 mL Eupnea - Correct Answers: normal breathing pattern that is regular and even with occasional sigh Tachypnea (20 bpm) - Correct Answers: may occur with anemia, low PaO2, and elevated PaCO2 Bradypnea (10 bpm) - Correct Answers: may occur with CNS disorders; depressants; ETOH; severe metabolic alkalosis; fatigue Cheyne-Stokes respirations - Correct Answers: deep, swallow respiration followed by period of apnea that last about 20 seconds; occurs in CNS disorders and CHF Biot's respirations - Correct Answers: also known as cluster breathing; vary in depth and have varying periods of apnea; seen with brainstem injury Kussmaul's respiration - Correct Answers: deep, regular, rapid (20 bpm) breathing apneustic respiration - Correct Answers: gasping inspirations followed by short, ineffective expirations; associated with lesions to pons Dullness - Correct Answers: lung sounds during percussion when tissue is more dense than normal Flatness - Correct Answers: lung sounds during percussion when there is no air or the lungs are collapse hyperresonance - Correct Answers: lung sounds during percussion when amount of air increased and in emphysema Tympany - Correct Answers: lung sounds during percussion when large amount of air is present and pneumothorax Crackles - Correct Answers: adventitious sounds; discontinuous, explosive, bubbling sounds of short duration; due to atelectasis; pulmonary edema; bronchitis; pneumonia; interstitial fibrosis; either fine, coarse, wet/dry Rhonchi - Correct Answers: adventitious sounds; coarse, continuous, low-pitched, sonorous, or rattling sound; due to pneumonia, bronchitis, excess fluid; occurs in inspiratory and/or expiratory Wheezes - Correct Answers: adventitious sounds; high- or low-pitched whistling, musical sound heard during inspiration and/or expiration (common); due to bronchospasm (asthma), airway obstruction, inflammation, stenosis Stridor - Correct Answers: adventitious sounds; high-pitched, continuous sound heard over upper airway; a crowing sound; due to partial obstruction of upper airway (laryngeal edema), epiglottitis; life threatening Pleural Friction Rub - Correct Answers: adventitious sounds; coarse, grating, squeaking, or scratching sound; due to pleural inflammation seen in pneumonia, TB, chest tube insertion Partial Pressure of Arterial Oxygen (PaO2) - Correct Answers: normal is 80 to 100 mm Hg Arterial Oxygen Saturation of Hgb (SaO2) - Correct Answers: normal is 92% to 99%; represents the way oxygen is transported to tissues; measured from arterial blood sample or pulse ox; will drop also if PaO2 drops Signs and symptoms of Hypoxemia - Correct Answers: pallor, cool, dry skin; diaphoresis (late); tachycardia; dysrhythmias; chest pain; HTN early, followed by hypotension; increased HR early, followed by decreased HR; restlessness; confusion; combativeness/agitation; coma Conditions that causes respiratory acidosis - Correct Answers: CNS depression; respiratory neuromuscular disorders; trauma of spine, brain, chest wall; restrictive lung diseases; COPD (cannot get CO2 out); acute airway obstruction Conditions that causes respiratory alkalosis - Correct Answers: hypoxemia;stimulants; CNS irritation; excessive ventilator support; fever; Causes of Metabolic Acidosis - Correct Answers: DKA; renal failure; drug overdose; diarrhea; pancreatic or small bowel fluid loss Causes of Metabolic Alkalosis - Correct Answers: citrate in blood transfusions; vomiting; NG suctioning; low potassium and/or chloride; diuretics ABG Critical Values - Correct Answers: PaO2 of 60 mm Hg; PaCO2 of 50 mm Hg; pH of 7.25 or 7.60 Fraction of Inspired oxygen (FiO2) (ventilator setting) - Correct Answers: the amount of oxygen being administered to patient; set from 0.21 to 1.00 (100% oxygen); should be set to maintain PaO2 between 60 and 100 mm Hg and/or SpO2 of at least 90%; average is 2300 mL Low-Flow Oxygen Delivery Devices - Correct Answers: nasal cannula; simple face mask; partial-rebreather mask; non-rebreather mask; delivers oxygen @ flow rates less than patient's inpiratory demand for gas; total demands are not met; requires patient to draw in (entrain) room air with oxygen High-Flow Oxygen Delivery Devices - Correct Answers: air-entrainment or Venturi mask, high-flow cannula; flow of oxygen is sufficient for patient's total inspiratory demand; FiO2 remains constant Humidification - Correct Answers: recommended when oxygen flow is 4 liters/min to prevent mucous membranes from drying Nasal Cannula (Low-flow) - Correct Answers: Provide O2 concentrations between 24% and 44%; each 1 liter/min increase oxygen by 4%; High Flow Nasal Cannula - Correct Answers: Delivers oxygen @ 15 to 40 liter/min; provide high concentration of oxygen ranging from 60% to 90% Simple Face Mask - Correct Answers: Flow rate should be set to at least 5 liter/min to prevent rebreathing CO2; delivers flow rate @ 5 to 12 liters/min; provide concentration of 30% to 60% Face Mask with Reservoirs - Correct Answers: Provide concentration of 35% to 60% (partial) or 60% to 80% (non-rebreather); may be used in patient with severe hypoxemia; non-rebreather has one way valve Oral Airways (airway management) - Correct Answers: Prevents tongue from falling back and obstructing pharynx; for patient with depressed LOC; make ventilation of ambu bag easier; prevent unconscious patient from biting and occluding ETT Nasopharyngeal Airways (airway management) - Correct Answers: Also known as nasal airway or nasal trumpet; not recommended for extended use as it can cause sinusitis or otitis; Endotracheal Intubation (ETT) - Correct Answers: can be inserted through mouth and nose; decrease ventilator-associated pneumonia; used to establish airway, assist in secretion removal, provide mechanical ventilation; protects airway from aspiration if patient have depressed cough/gag reflex Procedure for Oral ETT - Correct Answers: choose proper ETT size, usually between 7.5 to 9.0; tube is inserted about 5 to 6 cm and cuff is inflated Procedure for Naso ETT - Correct Answers: done 2 ways: blind or direct visualization; naris is prepared with vasocontricting agent to reduce bleeding and an anesthetic agent; position patient semi-Fowler, high Fowler, or supine; Blind can only be done in patient who can spontaneously breath; correct placement is 28 cm (males) & 26 cm (females) Verification of ETT Placement - Correct Answers: auscultate epigastrium and lung fields and observe for bilateral chest expansion; use a disposable ETCO2 detector, or a bulb aspiration device (ETCO2 will change from purple to yellow); pulse oximetry (should not fall); portable chest radiograph; Tip of TT should be about 3 to 4 cm above the carina Indications for Tracheostomy - Correct Answers: long-term mechanical ventilation; long-term secretion management; protecting airway from aspiration when cough/gag reflexes are impaired; bypassing upper airway obstruction that prevents placement of ETT; reducing WOB associated with ETT Advantages of Tracheostomy - Correct Answers: shorter than ETT; airflow resistance is less than ETT; better tolerated than ETT; requires less sedation or restraint use than ETT; allows patient to talk; makes oral hygiene easier; permits oral intake Percutaneous Dilatational Tracheostomy (PDT) - Correct Answers: can be done @ bedside; ensure IV access line are accessible for sedatives and analgesics; monitor physiological parameter Q15 minutes; complication is accidental decannulation due to unsecured trachea and reinsertion may cause difficulty; oral intubation may be required Endotracheal Suctioning - Correct Answers: Prevents complications such as hypoxemia, airway trauma, infection, and ICP; stimulates cough reflex and promotes mobilization; indicated in presence of rhonchi; O2 desat; change in VS; dyspnea; restlessness; increased PIP; high-pressure vent alarms; hyperoxygenate for 30 seconds; Positive-Pressure Ventilation (Mechanical Ventilation) - Correct Answers: forces air into lungs via artificial airway; enlarges thoracic cavity; increases negative chest pressure, which results in flow of air into lungs Tidal Volume (Vt) (ventilator setting) - Correct Answers: amount of air delivered with each preset breath; ensure that excessive stretch and pressure on lung tissue is avoided; set at 6 to 8 mL/kg of ideal body weight and lower for obstructive airway disease; PIP should be below 40 cm H2O and Pplat should be below 30 cm H2O; goal is to achieve lowest Pplat while maintaining gas exchange RR (ventilator setting) - Correct Answers: frequency of breath (f); set to rates 14 to 20 bpm; when it is decreased or mode of ventilation is changed, patient becomes capable of participating in ventilator work Inspiratory-to-Expiratory Ratio (I:E) (ventilator setting) - Correct Answers: set at 1:2 (33% inspiration; 66% expiration); ratio of 1:3 or 1:4 may be needed in COPD patients to promote more complete exhalation and reduce air trapping; reserve with noncompliant lungs (ie. ARDS) Positive End-Expiratory Pressure (PEEP) - Correct Answers: set at 5 to 20 cm H2O; allows airway to be held open and improve oxygenation; mechanically vented patients receive 3 to 5 cm H2O; used to decrease high FiO2; when applied, pressure reading does not return to zero at end of breath; adverse effects is ICP and decrease in CO (decrease venous return, volutrauma, or barotrauma) Nursing Management of PEEP - Correct Answers: when level is increased, evaluate patient's hemodynamic response; If client experienced decreased CO, ensure patient has adequate intravascular volume (preload) and administer fluids. if that does not work, administer dobutamine (inotropic agent) Auto-PEEP - Correct Answers: the spontaneous development of PEEP due to gas trapping in lung from insufficient expiratory time and incomplete exhalation, rapid RR, high VE demand, airflow obstruction, inverse I:E ratio ventilation. Peak Inspiratory Pressure (PIP) - Correct Answers: the max pressure that occurs during inspiration; should never be allowed to rise above 40 cm H2O, as it can cause ventilator-induced lung injury; monitor @ least Q4H and with changes in patient's condition Volume Ventilation - Correct Answers: Tidal volume is constant for every breath delivered by ventilator; set to allow airflow into lungs until preset volume has been reached; PIP varies in this mode; has two types: assist/control (A/C) and synchronized intermittent mandatory ventilation (SIMV) Assist/Control (A/C) Ventilation (volume ventilation) - Correct Answers: for patient who can breathe spontaneously; delivers preset number of breaths of a preset tidal volume; when patient initiates a breath, ventilator delivers one as well; indicated it patient whose respiratory muscles are too weak or unable to perform WOB; Disadvantage of Assist/Control (A/C) Ventilation (volume ventilation) - Correct Answers: respiratory alkalosis may develop; treated or prevented by providing sedation or analgesia prn or changing to SIMV; patient may rely on this instead of attempting to initiate spontaneous breathing. Nursing Management of Assist/Control (A/C) Ventilation (volume ventilation) - Correct Answers: monitor total RR, EVt, PIP; monitor synchronization with the ventilator, and acid-base status Synchronized Intermittent Mandatory Ventilation (SIMV) (volume ventilation) - Correct Answers: delivers a set of number of breaths of a set tidal volume; tidal volume is variable and depends on patient's effort; helps prevent respiratory muscle weakness because patient helps with WOB; Indicated when patient is allowed to breathe at their RR, hyperventilation during A/C mode, and to wean patients from mechanical ventilation Nursing management of SIMV - Correct Answers: monitor total RR to see if patient initiates spontaneous breaths; adequate spontaneous Vt is 5 to 7 mL/kg of ideal body weight; rising total RR means that patients is getting tired (can lead to atelectasis); monitor EVt to ensure Vt is being delivered; assess PIP and ABGs Pressure Ventilation - Correct Answers: Set to allow air to flow into lungs until present inspiratory pressure (PIP) has been reached; tidal volume is variable; can be reliably controlled for each breath the ventilator delivers; May cause hypoventilation and respiratory acidosis; monitor EVt Continuous Positive Airway Pressure (CPAP) (pressure ventilation) - Correct Answers: applied throughout respiratory cycle to spontaneously breathing patient; no mandatory breaths or other ventilatory assistance given; patient perform all WOB; provides pressure @ end expiratory; used as mode of weaning; same as PEEP; monitor EVt; set alarm to detect low EVt and apnea; administered via nasal or face mask; Pressure Support (PS) (pressure ventilation) - Correct Answers: changes patient's spontaneous respiratory activity by the delivery of a preset amount of inspiratory positive pressure; used as a stand-alone or in combination with other modes; changes patient's spontaneous tidal volume and decrease WOB associated with artificial airway; typical levels are 6 to 12 cm H2O; monitor EVt (if inadequate, increase PS); promotes conditioning of respiratory muscles; used for COPD Pressure Assist/Control (P-A/C) (pressure ventilation) - Correct Answers: RR is set; every breath is changed by a set amount of inspiratory pressure; if patient triggers additional breaths beyond mandatory breaths, they are augmented by set amount of inspiratory pressure; typical pressure ranges from 15 to 25 cm H2O; for ARDS or with high PIP; reduces risk of barotrauma; monitor total RR to see if patient is initiating spontaneous breaths; monitor EVt for adequacy of volume Pressure-controlled inverse-ratio ventilation (PC-IRV) (pressure ventilation) - Correct Answers: set to provide longer inspiratory times; increase MAP, open and stabilize alveoli; for noncompliant lungs (ARDS) and when oxygenation is not adequate even with high FiO2, PEEP, or positioning; patient must be sedated and may be paralyzed to prevent dysynchrony & oxygen desaturation Airway Pressure-Release Ventilation (APRV) - Correct Answers: provides two levels of CPAP, one during inspiration and one during expiration; Allow unrestricted spontaneous breathing; starts at elevated pressure (P-high), followed by low pressure (P-low); lowers PIP: alternatives to V-A/C or P-A/C What to do When Mechanical Ventilator Alarm Sounds - Correct Answers: check if patient is disconnected from vent; if not, assess patient for distress, adequate ventilation and oxygenation; assess LOC, HR, color, etc; If patient is in acute distress, disconnect the patient from ventilator and manually ventilate with ambu bag while another RN figure out the problem High Peak Pressure Causes and Intervention - Correct Answers: vent is set 10 cm H2O above average PIP and pressure increases in circuit can cause it; assess for kinks, anxiety and level of sedation, patient biting/gagging on tube; observe for coughing; auscultate lung sounds if suctioning or bronchodilator is needed; empty water from water traps if needed; assess for pulmonary pathology getting worse; call MD/RT Low Pressure; Low PEEP/CPAP Causes and Interventions - Correct Answers: vent is set 10 cm H2O below average PIP, set 3 to 5 cm H2O below set PEEP/CPAP, and pressure decreases in circuit can cause it; assess for leaks or disconnection; if malfunction, ventilate patient manually and notify RT/MD Low Exhaled Tidal Volume or Low Minute Ventilation (VE) Causes and Interventions - Correct Answers: vent is set 10% below set tidal volume and patient's average minute ventilation (VE) is the cause; assess for disconnection, leak in cuff; measure cuff pressure (inflate as needed); assess for air leak in chest drain system; assess for changes in lung compliance, increase in airway resistance, or patient fatigue; call MD if patient related High Exhaled Tidal Volume or High Minute Ventilation (VE) Causes and Interventions - Correct Answers: vent is set 10% above set tidal volume and patient's average minute ventilation (VE); assess cause for increased RR or tidal volume (ie. anxiety, pain, hypoxemia, metabolic acidosis) and treat; assess for excess water in tubing and drain Apnea Alarm Causes and Intervention - Correct Answers: Vent is set for 20 seconds and no exhalation detected is the cause; assess for cause of lack of spontaneous respiratory effect; physically stimulate patient; encourage patient to take a deep breath, reverse sedatives or narcotics; manually ventilate patients; notify RT/MD to modify vent settings Ventilator Bundle - Correct Answers: interrupt sedation each day to assess readiness to wean from ventilator; administer medication for peptic ulcer disease and DVT prophylaxis; daily oral care with chlorhexidine or antiseptics; Maintain HOB @ 30 to 45 degrees ETT out of position intervention (Complication of Mechanical Ventilation) - Correct Answers: If patient cannot be ventilated and tubes not displaced, attempt to pass suction catheter through airway to determine if it is obstructed Unplanned Extubation Intervention (Complication of Mechanical Ventilation) - Correct Answers: Cut end of endotracheal tube to 2 inches beyond the fixation point; provide support for ventilator tubing and close suction systems and keep them out of patient's reach; use 2 staff members when repositioning an endotracheal tube Laryngeal and Tracheal Injury Causes and Prevention (Complication of Mechanical Ventilation) - Correct Answers: due to excess pressure exerted by distal cuff; do routine cuff pressure monitoring; pressure should not exceed 25 to 30 cm H2O Damage to Oral or Nasal Mucosa Causes and Prevention (Complication of Mechanical Ventilation) - Correct Answers: due to tape or devices that secure the ETT; assess skin; provide skin care; reposition ETT daily to prevent necrosis Barotrauma (Pressure Trauma) (Complication of Mechanical Ventilation) - Correct Answers: alveolar tear or rupture due to excessive peak inflating volume; may occur with PEEP, high tidal volume; may cause subcut. emphysema; life-threatening complication is tension pneumothorax, which causes lung collapse, tachycardia, and hypotension; Sign and symptoms of Barotrauma (Complication of Mechanical Ventilation) - Correct Answers: high PIP and MAP; decreased breath sounds; tracheal shift; subcut. crepitus; air leak in chest drainage system, symptoms associated with hypoxia Treatment of Barotrauma (Complication of Mechanical Ventilation) - Correct Answers: immediate insertion of chest tube or needle thoracostomy; remove patient off ventilator and ventilate with bag-valve device Volutrauma (Volume Trauma) (Complication of Mechanical Ventilation) - Correct Answers: Causes increased permeability of alveolar-capillary membrane, pulmonary edema, accumulation of WBCs and protein in alveolar spaces and reduces surfactant production; prevent by keeping PIP below 40 cm H2O and/or Pplat 30 cm H2O Oxygen Toxicity (Complication of Mechanical Ventilation) - Correct Answers: causes tracheobronchitis; lead to changes in lung that mimic ARDS; may cause absorption atelectasis and alveolar collapse if FiO2 is 1.0 from lack of nitrogen; prevent by lowering FiO2 to 0.60 because nitrogen is needed to prevent collapse of alveoli Respiratory Alkalosis (Complication of Mechanical Ventilation) - Correct Answers: If A/C ventilation set at 10 bpm but patient's RR is 28 bpm, It can cause this Respiratory Acidosis (Complication of Mechanical Ventilation) - Correct Answers: If ventilator is set at a low RR (ie. 2 to 6 bpm) and patient does not have an adequate drive to initiate additional breaths, it can cause this Factors that Contribute to Ventilator-Associated Pneumonia (VAP) (Complication of Mechanical Ventilation) - Correct Answers: Inadequate humidification or systemic hydration; decreased ability to produce an effective cough Strategies to Reduce Ventilator-Associated Pneumonia (VAP) (Complication of Mechanical Ventilation) - Correct Answers: Prevent drainage of ventilator circuit condensate into patient's airway; discard and never drain it back into humidifier; Use ETT with lumen for aspirating subglottic secretions; Use noninvasive mechanical ventilation when possible Indicators of Worsening Oxygenation - Correct Answers: Need to increase FiO2 by 0.20 or higher for 2 or more days; Need to increase PEEP by 3 cm H2O for 2 or more days Complication of Mechanical Ventilation in the Cardiovascular System - Correct Answers: hypotension and decreased cardiac output due to increased intrathoracic pressure (administer volume to ensure adequate preload, followed by inotropic agents as needed); Patient with high PIP who receive PEEP of 10 cm H2O may need hemodynamic monitor to assess volume status and CO Complication of Mechanical Ventilation in the GI System - Correct Answers: stress ulcers and GI bleeding; initiate EN ASAP; monitor patient for gross and occult blood in gastric aspirate and stools; Neuromuscular Blockade (NMB) - Correct Answers: Medication for those who have acute lung injury or increased ICP and those who require nontraditional modes of mechanical ventilator Insufficient Sedation (Nursing Care for Mechanical Ventilation) - Correct Answers: May precipitate ventilator dyssynchrony and alterations in thoracic pressures and gas exchange Oversedation and Prolonged Sedation (Nursing Care for Mechanical Ventilation) - Correct Answers: Increases risk of VAP, lung injury, delay weaning; associated with longer duration of mechanical ventilation and lengths of stay in ICU and hospital High Potential for Successful Weaning of Mechanical Ventilation - Correct Answers: Evidence of reversal of underlying cause of respiratory failure; adequate oxygenation; able to initiate an inspiratory effort; Patient can tolerate spontaneous breathing trial (SBT) of 30 to 120 minutes; Readiness to Wean from Mechanical Ventilation - Correct Answers: negative inspiratory pressure or force that exceeds -20 cm H2O; spontaneous tidal volume of 5 mL/kg; vital capacity of 10 to 15 mL/kg; minute ventilation of 5 to 10 L/min; rapid shallow breathing index 105; PaO2;FiO2 of 150 to 200; PEEP of 5 to 8 cm H2O Factors that Impair Weaning - Correct Answers: Anemia; fever; infection; sleep deprivation; pain; abdominal distention; bowel abnormalities; Types of Weaning Methods - Correct Answers: Pressure Support (PS); T-piece; CPAP; SIMV Criteria for Discontinuing Weaning - Correct Answers: Spontaneous tidal volume is 5 mL/kg; O2 Sat 90%; HR changes 20% from baseline; BP changes 20%; Hypoxemic or Oxygenation Failure (Acute Respiratory Failure) - Correct Answers: Type of ARF with PaO2 of 60 mm Hg and PACO2 that is normal or low Hypercapnic or Ventilatory Failure (Acute Respiratory Failure) - Correct Answers: Type of ARF with PaCO2 of 50 mm Hg and pH of 7.30 Mechanism that Reduce PaO2 and Cause Hypoxemia (Patho of Oxygenation Failure) - Correct Answers: Hypoventilation; Intrapulmonary shunting; ventilation-perfusion (V/Q) mismatching; Diffusion defects; low CO; low hgb level; tissue hypoxia; decreased barometric pressure Causes of Hypoventilation (Mechanism that Reduce PaO2 and Cause Hypoxemia) - Correct Answers: alveolar ventilation is reduced; drug overdose (CNS depression); neurological disorders that decreases the rate and depth of respiration; abdominal or thoracic surgery Intrapulmonary Shunting (Mechanism that Reduce PaO2 and Cause Hypoxemia) - Correct Answers: Blood returns to left side of heart without doing any gas exchange; part of lung are inadequately ventilated, but adequate perfused, so blood is shunted past lung and return unoxygenated to left side of heart; due to septal heart defects; atelectasis; pneumonia; pulmonary edema; Treat by opening the alveoli Ventilation-Perfusion (V/Q) Mismatching (Mechanism that Reduce PaO2 and Cause Hypoxemia) - Correct Answers: Rate of ventilation is equal the rate of perfusion; due to hypoxemia and corrected by increasing FiO2; occurs in pneumonia and pulmonary edema; If ventilation exceeds blood flow, V/Q ration is 1.0; If ventilation is less, V/Q ratio is 1.0 Low Cardiac Output (CO) (Mechanism that Reduce PaO2 and Cause Hypoxemia) - Correct Answers: Normally, it delivers 600 to 1000 mL/min of O2; When O2 is low, cell converts to anaerobic metabolism which causes lactic acid production that depresses the function of myocardium and lowers CO Low Hemoglobin (HGB) level (Mechanism that Reduce PaO2 and Cause Hypoxemia) - Correct Answers: normal is 95%; if low, O2 supply to tissues are impaired and tissue hypoxia can occur; may be due to carbon monoxide poisoning or SCD Tissue Hypoxia (Mechanism that Reduce PaO2 and Cause Hypoxemia) - Correct Answers: Causes cellular death and organ failure; could be due to cyanide poisoning Hypercapnia (Cause of Ventilation Failure) - Correct Answers: Increases cerebral blood flow; patient appears restless and anxious, demonstrate slurred speech, and decreased LOC Dead Space and Ventilation-Perfusion (V/Q) Mismatch - Correct Answers: Volume of inspired gas that fills upper and lower airways; normal is 25% to 30%; when increased, PaO2 increase; Increase is due to reduced perfusion of lung and it no longer participate in gas exchange Hypoxia and Hypercapnia - Correct Answers: Begins with anxiety, restlessness, and confusion which later progresses to lethargy, severe somnolence, and coma Acute Respiratory Failure (ARF) - Correct Answers: increases tidal volume when compensating; causes tachycardia and increased BP, which leads to dysrhythmias, angina, bradycardia, hypotension, cardiac arrest Goals of Treating Patients with Acute Respiratory Failure (ARF) - Correct Answers: maintain patent airway with NPPV, intubation, and mechanical ventilation; Optimize O2 delivery; in unilateral lung disease position patient on their side with better functioning lung down; Minimize O2 demand; treat the cause; prevent complications Clinical Findings of Acute Respiratory Distress Syndrome (ARDS) - Correct Answers: dyspnea; tachypnea; decreased lung compliance; diffuse alveolar infiltrates on chest x-ray; lung insult; increase in HR and temp; PaCO2 decreases; respiratory alkalosis; crackles; rhonchi; bronchial breath sounds; decrease lung volume; increased in PIP Criteria of ARDS - Correct Answers: PaO2/FiO2 ratio 200; PAOP 18 mm Hg; PEEP or CPAP requirements of or equal to 5 cm H2O; pulmonary capillary wedge pressure 18 mm Hg Causes of ARDS - Correct Answers: diffuse pneumonia; fat embolism; neurogenic pulmonary edema; oxygen toxicity; pulmonary contusion; multisystem trauma; radiation Pathophysiology of ARDS - Correct Answers: inflammatory reaction that damages alveolar-capillary membrane, which allows blood into alveoli causing pulmonary edema; Pulmonary HTN occurs; production of surfactant stops; lungs eventually becomes fibrotic Interventions for ARDS - Correct Answers: Intubation and mechanical ventilation with low tidal volume of 6 mL/kg, low end-inspiratory plateau pressure of 30 cm H2O, FiO2 @ 0.60, ventilator RR of 33 bpm, and PaCO2 of 50 to 70 mm Hg; PEEP; NMB; sedation; prone positioning, which alters V/Q ratio and it is the last option with complications of peripheral nerve injury, pressure ulcers, corneal ulceration. Turn off gastric tube feeding for 1 hour before turning patient; fluids and electrolytes (colloids); nutrition; Pharmacological Treatment of ARDS - Correct Answers: Furosemide with albumin if protein level is low; corticosteroids if severe and before day 14; inhaled nitric oxide for severe refractory hypoxemia; Cisatracurium (NMB) if severe during the first 48 hours Clinical Findings of COPD (Type of ARDS) - Correct Answers: sputum production; increase in lung capacity; reduction in forced expiratory volume (FEV); pursed-lip breathing; wheezing; crackles; hypercapnia; metabolic alkalosis; tachypnea; malaise; fever; normal pH, low PaO2 of 60 to 65, elevated PaCO2 of 50 to 60; Interventions of COPD (Type of ARDS) - Correct Answers: oxygen; SABA; LABA; anticholinergics, such as ipratropium bromide (used if SABA and LABA did not work); methylxanthines, such as theophylline (causes HA, restlessness, seizures); Corticosteroids for 7 to 10 days (causes hyperglycemia); antibiotics to fight influenza, pneumonia, and catarrhalis; ventilatory assistance, such as NPPV, ETT, tracheostomy Adverse Effects of Bronchodilators - Correct Answers: Tachycardia; dysrhythmias; tremors; hypokalemia; anxiety; bronchospasm; dyspnea Pathophysiology of COPD (Type of ARDS) - Correct Answers: progressive, chronic; characterized by emphysema; inflammation that leads to scarring, narrowing, increase mucus production; increase in goblet cells, while decrease in cilia; causes ARF Pathophysiology of Asthma (Type of ARDS) - Correct Answers: chronic inflammatory disorder; air trappings, prolonged exhalation, and V/Q mismatching with increased intrapulmonary shunt occur Clinical Findings of Asthma (Type of ARDS) - Correct Answers: chest tightness; cough especially at night; hyperventilation; respiratory alkalosis; peak expiratory flow readings 50% of patient's normal values; tachypnea; tachycardia; pulsus paradoxus 15 mm Hg; Status Asthmaticus - Correct Answers: occurs when bronchodilators does not work; sign and symptoms are fatigue, hypercapnia, hypoxia, respiratory acidosis Signs of ARF in Patient with Asthma - Correct Answers: breathlessness at rest and need to sit upright; speaking in single words and not sentences; lethargy; confusion; paradoxical thoracoabdominal movement; absence of wheezing; bradycardia; respiratory acidosis and hypoxemia with PaCO2 50 and PaO2 60 Interventions of Asthma (Type of ARDS) - Correct Answers: O2 therapy (helium and O2); intubation and mechanical ventilation; patient are at risk for auto-PEEP, barotrauma, and hemodynamic compromise. Virchow Triad - Correct Answers: Favor the development of VTE; consist of venous stasis (reduction in blood flow), altered coagulability of blood, and damage to vessel walls Pathophysiology of Pulmonary Embolism (PE) - Correct Answers: causes lack of perfusion to ventilated alveoli, increase in dead space, V/Q mismatch, decrease CO2 tension; gas exchange cannot occur, inflammation occurs; atelectasis and shunting occurs; lead to pulmonary HTN; RV increases in size causing leftward shift of septum Clinical Findings of Pulmonary Embolism (PE) - Correct Answers: sudden onset dyspnea; hemoptysis; chest pain that worsens by deep inspiration; unexplained cardiorespiratory complaints; syncope; chest wall tenderness; tachypnea; decreased SpO2; tachycardia; cough; crackles; wheezing; fever Diagnosis of Pulmonary Embolism (PE) - Correct Answers: Positive D-dimer; dead space detected with V/Q Scan; Prevention of Pulmonary Embolism (PE) - Correct Answers: monitor for low-grade fever; administer IV fluids as prescribed; I&Os; avoid adjusting knee section of bed or using pillows under knees Treatment of Pulmonary Embolism (PE) - Correct Answers: streptokinase or alterplase; argatroban; lepirudin; vena cava filters placed in inferior vena cava; supplemental O2; analgesics; inotropic or vasopressor support if hemodynamically unstable Cystic Fibrosis (CF) - Correct Answers: defect in chloride transport that causes formation of thick, sticky mucus with little water that obstruct organs; lead to chronic lower respiratory tract bacterial infection, chronic bronchitis, dilatation of bronchioles; complications include pneumothorax, arterial erosion, hemorrhage, respiratory failure Interventions of Cystic Fibrosis (CF) - Correct Answers: lung transplant; antibiotic therapy to prevent infections; mucolytic agents, such as Pulmozyme; bronchodilators; EN with pancreatic enzyme supplements; noninvasive mechanical ventilation (first line); ETT with mechanical ventilation (second line)