NR-341 Exam 1 Study Guide/ Complex Adult Health Exam 1. Critical Care Exam 1 Guide

NR-341 Exam 1 Study Guide/ Complex Adult Health Exam 1. Critical Care Exam 1 Guide. Diagnostic Tests o ABGs, Chest x-rays, CT, pulmonary function tests, end tidal CO2 monitoring, bronchoscopy.  Assessments o Lung sounds, work of breathing, use of accessory muscles, chest expansion, nasal flaring, respiratory rate, pulse ox  Interventions o Ineffective airway clearance reposition patient o ARF  Causes: pulmonary edema, atelectasis, pneumonia, COPD, asthma, ARDS, thoracic, spinal or head injuries, drug overdose, neuromuscular disorders  Type 1 - hypoxemic or oxygenation failure  PAO2 less th  an 60 MMHG o Normal PaO2 = 80 - 100  Hypoventilation o Hyperventilation causes further issues when trying to correct this  Intrapulmonary shunting o Blood did not get oxygenated and dispersed to rest of body system o Blood that is shunted from the right side of the heart to the left without oxygenation. o Based on rate ventilation and perfusion: Rate of ventilation= rate of perfusion; ratio of VQ = 1 o Based on amount of ventilation and perfusion:  Normal ventilation (V) IS 4 L/MIN  Normal perfusion (Q) IS 5L/Min  Normal V/Q Ratio IS 4/5 or 0.8  VQ scan patient must lie for 30 minutes o Tissue hypoxia anaerobic metabolism and lactic acidosis o Normal Cardiac output  600 – 1000 ML/MIN of O2  Low cardiac output decrease O2 blood to tissues anaerobic metabolism production of lactic acid metabolic acidosis  Type 2 - hypercapnic or ventilator failure  PACO2 > 50 MM HG  Increase in PaCO2 (hypercapnia) due to decrease O2 in body and CO2 can be blown off  Increase in ventilation excess CO2 blown off (hypocapnia)  VQ mismatch not 1:1  Assessment of respirator failure: most common hypoxemia restlessness  Medical management: O2, bronchodilators, corticosteroids, ventilators, transfusion, nutritional support, hemodynamic monitoring 2  HGB 12- 16  Anemic is less than 8 HGB o Respiratory failure causes  Failure to ventilate  Failure to oxygenate  Failure to protect airway Acute Respiratory Distress Syndrome (ARDS)  Noncardiogenic pulmonary edema- pulmonary edema not caused by a cardiac problem.  Diagnostic criteria o 1. PaO2/FiO2(decimal) ratio of less than 200 – PaO2 divided by Fi02 … 100 divided 21 =  Optimal Ratio 476.19  ***Decreasing PA02 levels despite increased FIO2 administration o 2. Bilateral infiltrates not explained by something else. (Normally air should be black, you will see white puffy stuff all over if you have this)  Risk Factors. 4 Factors o Sepsis #1*** o Pneumonia o Trauma o Aspiration of Gastric contents  Pathophysiology o Basic underlying patho: damage to type II pneumocyte, which produces surfactant o 4 steps  1. Injury to the lung that stimulates the inflammatory response (either direct or indirect) with stimulates inflammatory response. Inflammatory cells and their mediators damage the alveolocapillary membrane.  2. Onset of pulmonary edema (blood cell, cell debris, stuff)  3. Alveoli start to collapse. Production of surfactant stop and alveoli collapse. Lungs become less compliant.  4.Lungs become stiff and noncompliant. Lung becomes fibrotic. Severe gas exchange impairment.  Diagnostic Tests o Chest x-ray  Symptoms or ARDS: o Dyspnea and tachypnea and hypoxemia, that does not improve with supplemental oxygen therapy. o Elevated PACO2 > 50 MM of HG o Decreased PAO2 < 60 MM of HG o V/Q mismatch o O2 Satureation < 90% o Hyperventilation with normal breath sounds o Respiratory alkalosis o Increased temperature and pulse o Worsening chest x-rays that progress to “white out” o Increased PIP on ventilation o Eventual severe hypoxemia not improved with O2 therapy o Late stages -> Eventually will hypoventilate -> respiratory acidosis 3  Treatment of ARDS o Treat the cause, more supportive care o Oxygenation and ventilation**KEY to treating ARDS  Positive end-expiratory pressure (PEEP) – high amounts of PEEP 10-15cm of peep.  Possible non-traditional modes of ventilation – oscillator or nvrp  Decrease Oxygen consumption o Comfort  Sedation  Pain relief  Neuromuscular blockade o Positioning  Prone positioning  Better profusion to posterior part of the lung. Takes weight of heart off of the lungs  Protect airway! Face down.. In regular bed patient will be with head on side.  Skin integrity – different pressure points (hips, knees)  Continuous lateral rotation therapy  Complications: DIC, long term pulmonary affect, organ failure, death o Fluid and electrolyte balance o Adequate nutrition o Psychosocial support – more for family o Prevention of complications  Thrombus or embolus formation, DIC, death, Organ failure, pulmonary affects  Acute Respiratory Failure as a result of Underlying Disease o Several conditions both acute and chronic can result in Acute Respiratory Failure  COPD  Asthma Exacerbation  Pneumonia - All types  Pulmonary Embolism pulmonary angiogram is a definitive diagnosis o Treatment of ARF in Chronic Diseases (not really going to study this)  Treat the underlying cause  COPD - Bronchodilators, corticosteroids, antibiotics (infection)  Asthma - IV corticosteroids, bronchodilators  Pneumonia - Antibiotics, fluids  Pulmonary Embolism - DVT prophylaxis, thrombolytics, heparin, vena cava filter Maintain Oxygenation - Administer oxygen, ventilate if needed, minimize demands Ventilation  Indications for ventilation: To support patient’s respiratory system until the cause of the respiratory failure has been treated. This is a temporary treatment. Patients are not meant to be on ventilator forever.  Reasons to be Ventilated: o Hypoxemia - PaO2 ≤ 60 mm Hg on FiO2 > .50 o Hypercapnea - PCO2 ≥ 50 mm Hg with pH ≤ 7.25 o Norms:  PAO2: 80 – 100  SaO2 90 – 100% 4  pH 7.35 – 7.45  PaCO2 35 – 45  HCO3 – 22 - 26 o Progressive deterioration (changes in vitals, using accessory muscles)  Increasing RR  Decreasing VT  Increase WOB  Positive pressure ventilation o Opposite of how we normally breath making it somewhat uncomfortable o Air is pushed into the lungs instead of drawn in this is positive pressure. o Movement of gases into lungs through positive pressure o Normal breathing is negative pressure.  Ventilator Settings o FiO2  Fraction of inspired O2 or amount of O2 the machine gives (how much oxygen are we breathing)  Room air = 21%  Ventilator can be set to 30-100%  Sp02 – pulse ox – 02 on Hgb  Pa02: ABG – oxygen in arterial system o Tidal Volume (VT)  How much air will the patient get with each breath or How much volume am I taking in.  Normal is 350 - 550 – Taken off height and weight.  Adjusted according to peak and plateau pressure o Respiratory rate:  10 -m20 breaths initially, usually 12-14 – How many breaths am I taking in.  Cheyne stokes- cyclical with apneic periods  Bios – cluster breathing  Kussmaul – deep, regular and rapid o I: E Ratio Inspiration: Expiration ratio; normal 1:2 ( 1 sec of inhale to 2 sec of exhale). We take more time on exhalation. o Positive end-expiratory pressure (PEEP)  Instills a small amount of pressure into the patients lungs at the end of expiration.  Purpose: Helps to keep airway and keep alveoli open to improve gas exchange.  5-20 cm H2O  Can cause reduced cardiac output if high and blocks venous return. Hyperinflation of the lungs increases thoracic pressure and compresses the heart  High levels can pop alveoli and cause pneumothorax  Keep alveoli to improve gas exchange o Sensitivity  Amount of patient effort. How hard the pt has to work to get flow of O2 from the ventilator (how hard does the patient have to work to get oxygen from the ventilator.  Goal is to avoid patient-ventilator dyssynchrony (“fighting the ventilator”)  Data to Monitor During Mechanical Ventilation 5 o Exhaled tidal volume (EVT) – how much your patient is exhaling, how much is coming out of the patients lungs.  Amount exhaled should be equal to amount going in Ex: If you are getting 250 then you want 250 out. Could be air trapping.. there is something going on.  Should not be more than 50 mL different from set VT o Peak inspiratory pressure (PIP)  How hard the ventilator has to work to deliver a breath.  Should be less than 40 mm Hg  High PIP can be caused by three main reasons.  2. Mucous plug  1. Noncompliant or stiff lungs due to ARDS or pulmonary fibrosis  3. Pt is biting the tube. Usually use oral airway to prevent this used as bit block. o Total respiratory rate – What the patient is doing, we set the ventilator rate but patient can take more breaths then we set the machine at.  Count total rate, which accounts for set rate and patient effort  Ventilator Modes o Volume Assist/Control (V-A/C) – 40%, 12 Rate (3)  Ventilator does most of the work because the patient cannot  Given to wean a patient off to SIMV patient who codes goes straight to AC first  Pt can take additional breaths but they get the same tidal volume as when ventilator initiates the breath Ex: patient who just has surgery and is still sedated, brain injuries  Set a rate, set a tidal volume, Fi02, and peak  Every minute 12 breaths AC 12  RR should be 12 or higher   If patient wants to take additional breaths that is fine  When the patient initiates a breath, the ventilator will assist them to get whatever the set tidal volume, The ventilator is assisting the patient with every breath.  Tidal volume will be the same for both ventilator and pt. breath.  *Key is that when patient initiates a breathe, the ventilator will assist them to get whatever the set tidal volume is o Synchronized intermittent mandatory ventilation (SIMV) – 40% 12 Rate  Patient does most of the work ** When patient initiates breath they will get the tidal volume that they alone can take, the ventilator will not assist them.  Set a rate, set a tidal volume, Fi02, and peak  When ventilator takes a breath you are going to get a set volume but when patient takes a breath you are only going to get the tidal volume that they alone can take.  On SIMV the ventilator will synchronize the breaths. Ex: 12 min 5- V, 10 - V P – 13, 18 - V, 23 - V. It will retime itself to how you are breathing so it doesn’t give you to many breaths.  Pt can take additional breaths but they only get the volume they can take in not the amount the ventilator gives on the breaths they initiate.  Ventilator then synchronizes next breath after the pt initiated breath. If rate is every 5 seconds, then the machine schedules next breath for 5 seconds after the patient takes their own breath.  *Key is that when pt initiates a breath they will get the tidal volume that they alone can take, ventilator will not assist them. 6 o Pressure Ventilation  Patient has to be able to breathe on their own, initiate breath on their own  Ventilator set to allow air flow until preset pressure is reached  VT is variable  PIP can be better controlled  Only gets pressure during inspiration  Risk of hypoventilation and respiratory acidosis  Includes CPAP, pressure support (PSV), pressure A/C, inverse-ratio ventilation, and airway pressure release (APRV) o Pressure Support (PS) – have to be able to breathe on own, the machine will not give any breaths. Used of weaning. Will only get pressure during inspiration. 40%, Rate varies. Pressure 5-20 cm H20 on inspiration  Patient’s spontaneous effort is assisted by preset amount of positive pressure  6 to 12 cm H2O  Decreases WOB with spontaneous breaths  Also useful in weaning  Pressure support ventilation requires the patient to trigger each breath, which is then supported by pressure on inspiration  Patient may vary amount of time in inspiration, respiratory rate, and tidal volume (VT) o Advanced Modes  Pt is very sick and has non-compliant lungs(lungs are very stiff) – Usually seen with ARDS  Inverse ratio  Longer inspiration and short expiration 2:1 instead of 1:2  Pt has to be sedated to be on this mode.  APRV  Similar to inverse ratio except you set 2 levels of pressure.  More comfortable that inverse ratio – patient should be sedated.  Oscillatory Ventilation  Give very high ventilator and respiratory rates with small tidal volumes – high resp. rate with low tidal volume.  300-400 RR (breaths for minute) – usually give in the nicu. We give this for adults because we are trying to get more air to the lungs.  Noninvasive Positive-Pressure Ventilation (NPPV) – we give positive pressure vent. With a mask. o Delivery of positive-pressure ventilation (PPV) without artificial airway  Via face mask, nasal pillow  Key: Mask has to have a tight seal and has to have a intact resp. drive (has to be able to breathe on own), able to protect airway  Intact respiratory drive  Useful in patients: COPD, Heart Failure, Palliative Care o Reduces complications associated with MV o Examples  Nasal Continuous Positive Airway Pressure (CPAP)  BiLevel Continuous Airway Pressure (BiPAP) o Useful in many patients  COPD – difficult to get patients off ventilation  Heart failure, Palliative care (DNR) 7 o Requirements  Tight seal of mask  Intact respiratory drive (breathe on their own)  Able to protect airway (pts with lots of secretions or vomit) prevent aspiration o Contraindicated  Pts with dementia  Anxious patients  Claustrophobia  Pts with fragile skin  Facial trauma or burns  Sedated patient ABGs PH 7.35 (acidic) – 7.45 (basic) 7.35-7.39 acidic 7.4 neutral 7.41-7.45 basic PaCO2 45 (acidic) – 35 (basic) RR = CO2 RR = CO2 HCO3 22 (acidic) – 26 (basic) PaO2 80-100 >80 = hypoxemic  Compensations o Uncompensated or none  pH – abnormal, CO2 or HCO3 – one or the other abnormal but not both. o Partial compensation  pH/Everything is abnormal and CO2 and HCO3 are opposite o Fully compensated  pH – normal, HCO3 and CO2 are opposite o Compensation happens using either Kidneys or Lungs  Imbalanced States o Respiratory Acidosis hypoventilating, asthma, & impaired gas exchange, COPD and narcotics o Metabolic Acidosis diarrhea, DKA, low bicarb o Respiratory Alkalosis hyperventilating, fever, respiratory infection, anxiety o Metabolic Alkalosis ingestion, high bicarb, prolong vomiting, loss of stomach acid o ***Uncompensated Combined Acidosis/alkalosis (both respiratory and metabolic). When Both CO2 and HCO3 are acidic/basic Oxygen and Oxygen Delivery Purpose of Oxygen: To treat or prevent hypoxia.  21% of 02 is room air.  Humidification - To prevent dryness of mucous membranes. More than 4L of 02 you need to put on humidification. 8  High flow nasal cannula-thicker and can go up to 15 liters- 40 liters needs humidifier  Nursing Implications: monitor o2 saturations, respiratory rate, accurately documents how much oxygen patient is on, skin care – skin break down top of the ears bottom of the chin. Make sure nasal cannula is in the patients nose.  If patient does not have an order you cannot put oxygen on: It is considered a medication. Oxygen Device Amount of Oxygen Delivered Nursing Considerations Nasal Cannula 1L to 6L/min (24-44% FiO2) Humidification is added for rates greater than 4L/min. Flow rates greater than 6L are not effective. If oxygenation is not restored at 6L than another device is required. Simple Face Mask 5L-12L (30-60% FiO2) Secure fit, monitor for skin breakdown and teach the patient to wear the mask. Do not use less then 5 L Venturi Mask 24-40% FiO2 Appears as a simple face mask with an adapter. The adapter determines the FiO2 and the amount of oxygen that should be set in L/min. Given when need a SPECIFIC amount of oxygen. Partial Nonrebreather Mask 35-60% FiO2 Contains a reservoir bag to allow for more oxygen. Contains 1 one-way valve to ensure that the patient breaths in a higher concentration of oxygen. Important: The bag needs to inflate. Nonrebreather Mask 60-80% FiO2 Contains a reservoir bag to allow for more oxygen. Contains 2 one-way valves to ensure that the patient breaths in a higher concentration of oxygen. Important: The bag needs to inflate. Aerosol and Humidity Delivery Systems 10 L/min and FiO2 is adjusted Humidity face mask for patients without an artificial airway. T-Piece is used for a patient with an endotracheal tube. Trach collar is used for a patient with tracheostomy. Usually for Extubated patients/ after we have removed a breathing tube. Humidifies airway. Manual Resuscitation Bag (aka ambu bag) 15 L/min Used to manually deliver breaths to the patient who is either not breathing or is breathing ineffectively Face Tent: High humidity also, patient how has a laryngial resections, some type of nasal packing, if you cant use nasal cannula. Sits under chin. 9 Trach Collar: Someone with a tracheostomy needs O2 T Piece: Used when somebody is going be taken of artificial ventilator, use to see if patient can maintain his or her own airway safely. If patient can do the work of breathing they can be extabated. Usually used for weaning. Amub Bag When it is connected to oxygen it will provide 100% O2. Every patient in ICU should have this bed side Ventilator: Provides breathing oxygen, o Continuous Positive Airway Pressure (CPAP) – CPAP when patient is on the ventilator 40%, rate varies, pressure 5-20 cm continuously  Patient has to be able to initiate breath and breathe on their own** Ventilator will not give any breaths. Used for weaning  Used for sleep apnea or individual who is healthy  BIPAP – improves gas exchange if patient is near 90%, patient intubation  RR and Tidal volume varies bc pt is taking their own breaths  Continuous positive airway pressure throughout respiratory cycle to patient who is spontaneously breathing.  Similar to PEEP  Via ventilator or nasal or face mask  Option for patients with sleep apnea  May facilitate weaning  Can also be used to prevent re-intubation  Positive pressure at end expiration splints alveoli and supports oxygenation  Pressure does not fall to zero, indicating the level of CPAP. Continuous pressure o Bilevel positive airway pressure (BiPAP) – decrease work of breathing  Used because CO2 is too high and needs to be decreased o Propfalol used for intubating no half life o RASS scale (richmen agitation) titrate to -2 or -4 depending on sedation o 3 step process  Look and listen – 1)see bilateral chest rise 2)auscultate breath sounds  3)Should change to yellow if it is in trachea calorimetric CO2 detector  Changes yellow because CO 2 is blowing off  XRAY done immediately 10  3 cm above carinanotify PCP pulmonary specialist notified nurse charts .