NUR 455 Midterm Exam

Type I Respiratory Failure Hypoxia defined as - -O2 less than 50 Type I Respiratory Failure Hypoxia Assessment Findings - -increased pulse (try to circulate RBC), increased respiratory rate, restless, anxious, diaphoresis, agitated (decreased O2 to brain) late: cyanosis, mental status changes Type I Respiratory Failure Hypoxia is found in - -pneumonia, ARDS, pneumothorax, PE, pulmonary edema, drowning, bleeding, tumor, trauma Type II Respiratory Failure Hypercarbia is defined as - -CO2 more than 50 Type II Respiratory Failure Hypercarbia assessment findings - -lethargic, decreased respiratory rate, difficulty focusing, tired, less responsive, decreased respiratory drive (neuro symptoms of increased CO2) Type II Respiratory Failure Hypercarbia found in - -CNS depression, drug overdose, asthma, COPD, chest wall abnormalities/trauma, neuromuscular disease (Myasthenia Gravis, Guilian-Barre) normal pH level - -7.35-7.45 normal PaO2 level - -80-100 normal spO2 - -over 92% normal paCO2 - -35-45 normal HCO3 - -22-26 respiratory acidosis is defined as - -carbon dioxide excess; pH under 7.35 and pCO2 over 45 respiratory acidosis found in - -COPD, pneumonia, ARDS respiratory acidosis nursing interventions - -- Treat underlying cause (PE, aspiration, atelectasis, pneumothorax, overdose of sedatives) - Improving ventilation - Adequate hydration to help secrete mucus - Semi fowlers position - Raise PaCO2 slowly or else the kidneys will not be able to get rid of the bicarb in time so now the patient will be in alkalosis and have a seizure - Meds NUR 455 NUR 455 -- Bronchodilators reduce bronchospasm -- Antibiotics for respiratory infections -- Thrombolytics or anticoagulants for PEing respiratory acidosis clinical manifestations - -headache, decreased LOC, hypoventilation (cause of problem), cardiac dysrhythmias, if severe: hypotension respiratory alkalosis is defined as - -carbon dioxide deficit; pH over 7.45 and CO2 under 35 respiratory alkalosis nursing interventions - -- Treat underlying cause - If anxiety instruct patient to breathe slowly or into a bag, it will help accumulate CO2, antianxiety if extreme - If wrong vent setting, decrease respiration rate respiratory alkalosis found in - -extreme anxiety, hypoxemia, early phase of salicylate intoxication, gram-negative bacteria, wrong vent settings respiratory alkalosis clinical manifestations - -- headache, tingling, dizziness - hyperventilation (cause of problem), Excitation and belligerence, lightheadedness, unusual behaviors, followed by decreased LOC if severe, Periorbital and digital paresthesia, carpopedal spasm, tetany, Diaphoresis, Cardiac dysrhythmias metabolic acidosis is defined as - -base deficit; pH under 7.35 and HCO3 over 22 metabolic acidosis nursing interventions - -- Treat underlying cause -- If high chloride the aim is to eliminate the source - Bicarbonate is given unless in cardiac arrest since it can cause paradoxical intracellular acidosis - Monitor potassium closely because patients could go from hyperkalemia to hypokalemia with treatment metabolic acidosis found in - -DKA, lactic acidosis, renal failure metabolic acidosis clinical manifestations - -decreased LOC, hyperventilation (compensatory mechanism), abdominal pain, nausea and vomiting, cardiac dysrhythmia metabolic alkalosis is defined as - -base excess; pH over7.45 and HCO3 under 26 metabolic alkalosis nursing interventions - -- Monitor I and O cause fluid depletion - Might need to give sodium chloride -- Kidneys need sodium and chloride to allow excretion of bicarb - H2 receptor antagonist cimetidine (Tagament) reduces production of gastric HCl if cause is gastric suction - Carbonic anhydrase inhibitors for people who cannot tolerate rapid fluid volume expansion (heart failure) NUR 455 NUR 455 metabolic alkalosis found in - -excessive vomiting, hypovolemia, diuretic use, hypokalemia metabolic alkalosis clinical manifestations - -excitation followed by decreased LOC if severe, hyperventilation (compensatory mechanism), signs of volume depletion and hypokalemia if present, Periorbital and digital paresthesia, carpopedal spasm lab findings in acid base imbalance with compensation - -normal pH but abnormal HCO3 or CO2 Indications for mechanical ventilation - -Respiratory failure: the respiratory system is unable to supply oxygen necessary to maintain metabolism or cannot eliminate sufficient carbon dioxide OR They are at high risk for developing respiratory failure: they are unresponsive/unable to protect their airway or so fatigued they cannot protect the airway Nursing Care of the Ventilated Patient - -- Mouth care - frequent extubating trials -Respiratory assessment -Size, location, security of tube -Documentation of ventilator settings -Management of ventilator alarms -Sedation/analgesia -Emergency equipment -Suctioning (not routine) -Oral care -Mobility, skin care -Communication assistance -Support to patient/family -Assess for anxiety/pain Prevention of VAP - -- minimize ventilator exposure - provide excellent oral hygiene care (chlorhexidine gluconate washes) - coordinate care for subglottic suctioning - maintain optimal positioning and encourage mobility - ensure adequate staffing - sedation vacation and weaning assessment S/s of VAP - -fever, tachycardia, fluid coming up, crackles/rhonchi, increased WBC ARDS symptoms - -- Respiratory retractions - Increased work of breathing - Musculature effort - Rales or crackles NUR 455 NUR 455 - Decreased O2 causing increased respiratory rate - Pulmonary edema - All hypoxemia s/s (restlessness, agitation, mental status change) ARDS assessment - -hypoxemia, dyspnea, tachypnea, crackles, increased WOB, early respiratory alkalosis, late respiratory acidosis, pleural effusion, decreased CO, cyanosis ARDS findings - -Chest x-ray is "white-out" - It shows consolidation (becomes solid) so decreased breath sounds in those areas ARDS treatment - -- Remove causative factors - Administration of 100% oxygen - Mechanical ventilation - antibiotics if sepsis ARDS causes - -SPARTAS - capillary permiability increses S= sepsis P=pneumonia, Pancreatitis A= Aspiration R= uRemia T=Trauma, Toxic chemicals inhalation A= Amnionic fluid emboli S= Shock *also think about increase Conc of O2, Heroine overdose PE risk factors - -- A fib (incomplete contractility of SA node) always irregular pulse rate (stagnate blood increase risk of - Chronic dehydration - Immobile - Orthopedic injury - DVT - Venous stasis - Lone bone injury (fat embolism) - Traveling - Venous congestion - Sub INR levels - Basically, blood is staying stagnant or is too thick PE assessment - -Increased work of breathing Increased respiration rate Decreased O2 Hypoxemia s/s (restlessness, anxiety, mental status change)