Adult Respiratory

Question 1

Steps to interpreting ABGS
How to interpret if it’s compensated, partially compensated, uncompensated

Answer 1

1. Determine if the problem is acidosis or alkalosis. Look at the pH. If it is below 7.4 think acidosis, if it is higher than 7.4 think alkalosis.
2. Determine if the problem is respiratory or metabolic in origin. PCO2 (35-45 mmHg) ,an increased PCO2 indicates acidosis, and a decreased pCO2
   indicates alkalosis. HCO3 (22-26 mmHg), a decreased HCO3 indicates acidosis and an increased
   HCO3 indicate alkalosis
3. To determine partially compensated – all 3 numbers are abnormal.
4. Acute uncompensated (aka uncompensated) pH abnormal and only one parameter is
   abnormal.
5. Fully compensated-ph normal C02 and HC03 abnormal
   NOTE: Look at Oxygen First! If patient is Hypoxic – This Is The Priority!

Question 2

How to do an Allen’s test

Answer 2

1. Rest the patient’s arm on the mattress or bedside stand and support his wrist with a rolled towel. Tell him to clench his fist. Using your index and middle fingers, press on the radial and ulnar arteries. Hold this position for a few seconds.
2. Without removing your fingers from the patient’s arteries, ask him to unclench his fist and hold his hand in a relaxed position. The palm will be blanched because pressure from your fingers has impaired the normal blood flow.
3. Release pressure on the patient’s ulnar artery. If the hand becomes flushed, which indicates blood filling the vessels, you can safely proceed with the radial artery puncture. If the hand does not flush, select another site for the puncture.

Question 3

Mr. Thomas is a 65-year-old man with pneumonia. He is admitted with dyspnea, fever and chills. His blood gas is:
pH = 7.28
PaCO2 = 56
HCO3- = 25
PaO2 = 70%
What is your interpretation?

Answer 3

Mr. Thomas has uncompensated respiratory acidosis with hypoxemia as a result of his pneumonia.
This is due to inadequate ventilation and perfusion.

Question 4

What are some causes of respiratory acidosis?

Answer 4

Severe respiratory infections (e.g., pneumonia) can cause respiratory acidosis. Other causes may include CNS depression, pneumothorax, pulmonary edema, pulmonary embolus, bronchial obstruction, etc.

Question 5

Mr. Thomas is a 65-year-old man with pneumonia. He is admitted with dyspnea, fever and chills. His blood gas is:
pH = 7.28
PaCO2 = 56
HCO3- = 25
PaO2 = 70%
He is is respiratory acidosis with hypoxemia as a result of his pneumonia.This is due to inadequate ventilation and perfusion.
Treatment?

Answer 5

1. Improve ventilation and oxygenation – supplemental O2, CPAP, BiPAP, or mechanical ventilation
2. Treat underlying cause – antibiotics for infection
3. Bronchodilators
4. Removal of secretions – chest physiotherapy, suctioning

Question 6

Ms. Thompson is a 21-year-old college student. She has a history of Crohn’s Disease and is complaining of a four-day history of bloody, watery diarrhea. A blood gas is obtained to assess her acid-base balance:
pH = 7.28
Co2 = 43
P02 = 88
Hco3 = 20
Sao2 = 96%
What is your interpretation?

Answer 6

Ms. Thompson has uncompensated metabolic acidosis due to excessive bicarbonate loss from her diarrhea.
Loss of alkali secondary to severe diarrhea or intestinal malabsorption.

Question 7

What are causes of metabolic acidosis?

Answer 7

Loss of alkali secondary to severe diarrhea or intestinal malabsorption.
Other causes include those which creates an accumulation of acid including renal failure, DKA, anaerobic metabolism, starvation and salicylate intoxication.

Question 8

Ms. Thompson is a 21-year-old college student. She has a history of Crohn’s Disease and is complaining of a four-day history of bloody, watery diarrhea. A blood gas is obtained to assess her acid-base balance:
pH = 7.28
Co2 = 43
P02 = 88
Hco3 = 20
Sao2 = 96%
Ms. Thompson has uncompensated metabolic acidosis due to excessive bicarbonate loss from her diarrhea. What is the treatment?

Answer 8

1. Treatment with antidiarrheals and bowel rest.
2. IV fluids as necessary
3. Monitor potassium levels ( range 3.5 – 5.0 mEq/L) (could become hypokalemic due to diarrhea)
4. Not necessary to administer bicarbonate at this time

Question 9

Mr. Higgins is a 64-year-old man brought to the ED by his sister after a 3-week history of worsening confusion, difficulty walking, lack of food intake, and vomiting. He has a long-term history of alcohol abuse, PTSD, and GERD. She reports that his diet is comprised only of Pepsi and alcohol. He has also been taking four spoonfuls of baking soda every day to alleviate dyspepsia. A blood gas is obtained:
pH = 7.64
CO2 = 58
HCO3- = 62
PO2 = 95
SaO2 = 95%
What is your interpretation?

Answer 9

Mr. Higgins has partially compensated metabolic alkalosis due to loss of acid (excessive vomiting) and excessive bicarbonate ingestion (baking soda).
His body is compensating by retaining CO2, most likely from hypoventilation.
He has signs and symptoms which include lethargy, weakness, disorientation and nausea/vomiting.

Question 10

What are causes of metabolic alkalosis?

Answer 10

Loss of acid (excessive vomiting)
Excessive bicarbonate ingestion (baking soda)
Other causes include excessive ingestion of antacids, administration of diuretics and electrolyte imbalances (hypokalemia and hypochloremia).

Question 11

Mr. Higgins is a 64-year-old man brought to the ED by his sister after a 3-week history of worsening confusion, difficulty walking, lack of food intake, and vomiting. He has a long-term history of alcohol abuse, PTSD, and GERD. She reports that his diet is comprised only of Pepsi and alcohol. He has also been taking four spoonfuls of baking soda every day to alleviate dyspepsia. A blood gas is obtained:
pH = 7.64
CO2 = 58
HCO3- = 62
PO2 = 95
SaO2 = 95%
Mr. Higgins has partially compensated metabolic alkalosis due to loss of acid (excessive vomiting) and excessive bicarbonate ingestion (baking soda).
His body is compensating by retaining CO2, most likely from hypoventilation.
Treatment?

Answer 11

1. Treat underlying cause – stop alcohol consumption, anti-emetics, stop baking soda consumption, and administer IV fluids.
2. Monitor serum potassium and replace as necessary.
3. Medications that increase excretion of bicarbonate (acetazolamide).
4. Dialysis for pH greater than 7.55. Dysrhythmias, seizures and coma may result from alterations in depolarization of neuronal and cardiac muscle cells.

Question 12

How is alkalosis related to hypokalemia?

Answer 12

pH greater than 7.45 is the ECF = alkalosis
Potassium moves to ICF = hypokalemia

Question 13

Ms. Carr is patient who was admitted for a drug overdose. She is being mechanically ventilated, and a blood gas is obtained to assess her for weaning:
pH = 7.54
CO2 = 19
HCO3- = 16
PO2 = 100
SaO2 = 98%
What is your interpretation?

Answer 13

Ms. Carr has partially compensated respiratory alkalosis from being over-ventilated.
Hyperventilation and overventilation are common causes because it decreases serum CO2 in the lungs and blood because CO2 is eliminated because of the increased rate of respirations.

Question 14

Causes of respiratory alkalosis

Answer 14

Hyperventilation and overventilation
Other causes include fever, pain, anxiety, hypoxia and lung conditions (early pulmonary edema, pulmonary embolism, pneumonia).

Question 15

Ms. Carr is patient who was admitted for a drug overdose. She is being mechanically ventilated, and a blood gas is obtained to assess her for weaning:
pH = 7.54
CO2 = 19
HCO3- = 16
PO2 = 100
SaO2 = 98%
Ms. Carr has partially compensated respiratory alkalosis from being over-ventilated. Treatment?

Answer 15

1. She cannot be weaned yet so adjustments to the ventilator need to be made (decrease rate or TV?)
2. Treat underlying causes. CXR to determine if pneumonia or pulmonary edema is present. Spiral CT to rule out pulmonary embolus.
3. May require sedation if breathing over the set rate (pain).

Question 16

How does negative-pressure ventilation work?
Typically used for what kind of patients?

Answer 16

• During spontaneous breathing, negative pressure is created when the thoracic cavity expands, causing intrapulmonary pressure to drop and air to flow into the
  lungs.
• The negative-pressure ventilator provides a negative “pulling” pressure on the external chest wall, assisting in ventilation.
• The patient is fitted with a shell that connects to a ventilator. Through use of the ventilator, the air is removed from the area between the patient and the shell, causing negative pressure on the external chest wall.
• Typically used for patients with respiratory disorders usually associated with neuromuscular disorders that impede normal respiratory muscle function. Example: Iron Lung

Question 17

How does positive-pressure ventilation work? What are the two types?

Answer 17

• Requires the placement of an endotracheal tube (ETT) or tracheostomy tube.
• Provides positive-pressure ventilation by exerting positive pressures on the airways, pushing air into the lungs, causing the alveoli to participate in gas exchange.
• Exhalation occurs passively.
• Positive-pressure ventilation can be delivered by pressure-cycled or volume-cycled ventilators.
• Pressure- cycled ventilators deliver air into the lungs until a preset air pressure is reached.
• Volume -cycled ventilators deliver air into the lungs until a preset volume is reached.

Question 18

What is a CO2 Detector used for and how is it used?

Answer 18

Confirms ETT placement
It is attached to the end of the ETT. It contains a nontoxic chemical indicator which quickly responds to exhaled CO2 with a color change from purple to yellow.

Question 19

What is a Laryngeal Mask Airway used for?

Answer 19

If endotracheal intubation is not feasible or has failed, an alternative airway device, such as a laryngeal mask airway (LMA), may be used until a definitive airway can be placed.

Question 20

Mechanical ventilator setting
Fraction of inspired oxygen (FiO2)
Goal?

Answer 20

• The amount of oxygen received via the ventilator
• Expressed as a fraction or decimal (Example: FiO2 21% = .21)
• Vent can provide 21% - 100% O2 depending on patient needs
• The goal is to maintain a PaO2 above 60 mmHg at
  the lowest possible setting

Question 21

Mechanical ventilator setting
Respiratory rate (f)
Normal rate?

Answer 21

• The number of respirations the patient receives
  per minute via the ventilator
• Typically, 8 – 12 depending on patient need
• Gradually decreased in a patient who is
  breathing spontaneously
• When the respiratory rate is assessed, it
  includes the numbers of both the vent and
  spontaneous breaths

Question 22

Mechanical ventilator setting
Tidal volume (Vt)

Answer 22

• The amount of preset air that is delivered to the
  lungs with each breath
• Setting is based on ideal body weight
• Usual setting is 8 to 10 mL/kg (Example: 62.5 kg x
  8mL = 500 Vt)
• Adjustments may be made according to ABG results
• Lower Vt may be ordered on patients with ARDS to
  prevent barotrauma

Question 23

Mechanical ventilator setting
Positive-end expiratory pressure (PEEP)

Answer 23

• Constant pressure applied at the end of expiration to
  help prevent alveolar collapse and keep alveoli
  open.
• Improves oxygenation, allowing the FiO2 to be lowered. Prolonged high FiO2 can cause lung injury.
• Typical settings for PEEP are 5 to 20 cm H20
• Indicated in ventilator modes AC, SIMV and
  pressure control ventilation

Question 24

Mechanical ventilator setting
Pressure Support (PS)

Answer 24

• Extra push of air to help with spontaneous breath.
• The more pressure support that is applied, the larger
  the spontaneous breath with assistance.
• Typical settings are 5 to 20 cm H2O.
• Often used with spontaneous breathing trial.

Question 25

Mechanical ventilator setting Peak Inspiratory Pressure (PIP) How does it increase?

Answer 25

- Maximum pressure reached during inspiration - Typical goal is to keep PIP less than 35 cm H20. PIP > 40 cm H20 can result in lung injury. - PIP increases with increased airway resistance (secretions in the airway, bronchospasm, biting ETT) and decreased lung compliance (pulmonary edema, ARDS, infiltrates, pneumothorax). - Report PIP greater than 40 cm H20!

Question 26

Mechanical ventilator setting Minute ventilation (Ve)

Answer 26

- Amount of air delivered per minute - Measured : Ve = Vt x f - Ve is useful when controlling PCO2 on an ABG - Because our Vt is based on body weight, we can adjust our respiratory rate (f) - More Ve = more CO2 clearance; less Ve = less CO2 clearance - Goal is Ve 5-10 L/min

Question 27

Mechanical ventilator setting Assist-Control Mode Complication?

Answer 27

- Volume-controlled mode of ventilation - Preset: Vt, f, FiO2, PEEP (NO PS!) - If the patient does not initiate a breath, the vent delivers the breath at the preset rate and volume - If the patient does initiate a breath, the ventilator delivers the preset volume (assisted breath), allowing the patient to control the rate of breaths - Complication is excessive ventilation in the hyperventilating patient leading to respiratory alkalosis (causes are pain, anxiety, acid-base imbalance or other non-respiratory disorders). - A/C is often the first form of ventilation used because it allows us to take full control of Ve and work of breathing (WOB).

Question 28

Mechanical ventilator setting Synchronized intermittent mandatory ventilation (SIMV)

Answer 28

- Volume-controlled mode useful for weaning off the ventilator - Preset: Vt, f, FiO2, PEEP, PS - If the patient does not initiate a breath, the ventilator delivers the preset volume and rate per minute to the patient - SIMV allows the patient to breathe spontaneously at his/her own volume between breaths given by the ventilator - This mode “synchronizes” with patient’s effort to breathe. - Pressure support (PS) gives each spontaneous breath support. - When used for weaning, the number of breaths can be decreased so that the patient takes over and breathes spontaneously, with ventilatory assistance

Question 29

Mechanical ventilator mode Pressure-support ventilation (PS or PSV)

Answer 29

- Mode often used for weaning or during a spontaneous breathing trial - May also be used in conjunction with SIMV or CPAP - Gives a set positive pressure during spontaneous respirations - Preset: FiO2, PEEP, PS (No Vt or f) - Ve and WOB will be completely dependent on patient with assistance of PS - Typically, settings will be 10/5 or 5/5

Question 30

Complications of Mechanical Ventilation Hypotension Interventions

Answer 30

- Associated with positive pressure modalities and mechanical ventilation. - Results in increased intrathoracic pressure decreasing venous return to the right side of the heart. This may ultimately result in decreased cardiac output. - Fluids may be ordered by the health care provider to correct the hypotension; ventilator settings may also need to be adjusted (volume) - Vasopressors may also be used - It is important to note that sedatives could contribute to hypotension and may need to be adjusted to elevate the blood pressure.

Question 31

Complications of Mechanical Ventilation Infection

Answer 31

Infection is a potential complication because the normal defenses of the upper and lower respiratory systems are bypassed. The ETT can be a direct source to the lungs because both increase the risk of introduction of infectious substances.

Question 32

Complications of Mechanical Ventilation Barotrauma Intervention

Answer 32

- Complication of the mechanical ventilator due to the increased positive pressure applied to the lungs, which can cause alveolar rupture. - Overdistention of the alveoli can lead to an excessive amount of air entering into the pleural space, causing a tension pneumothorax. - This can be life threatening and the nurse must notify the health care provider immediately and prepare for chest tube insertion to allow removal of trapped air in the pleural space. - O2 sat, CXR

Question 33

Complications of Mechanical Ventilation Aspiration interventions

Answer 33

Keeping the head of the bed (HOB) elevated between 30 and 45 degrees reduces the risk of aspiration of gastric and pulmonary secretions. PPIs used to decrease acid

Question 34

Complications of Mechanical Ventilation Ventilator-Associated Pneumonia (VAP) Prevention

Answer 34

- Serious HAI resulting in high morbidity, high mortality, and high cost of treatment. - Typically develops 48 hours or more after endotracheal intubation. Results from aspiration of oral pharyngeal and/or gastric contents. - Prevention involves using ETTs with subglottic drainage ports for patients requiring greater than 48 to 72 hours of intubation, elevating HOB between 30 to 45 degrees, and changing the ventilator circuit only when visibly soiled or malfunctioning.

Question 35

Non-invasive Positive Pressure Ventilation CPAP: how does it work?

Answer 35

Continuous positive airway pressure (CPAP) - Administered via tight-fitting facemask - Maintains one continuous pressure throughout the respiratory cycle to help keep the alveoli open through inspiration and expiration - Often used in obstructive sleep apnea (OSA)

Question 36

Non-invasive Positive Pressure Ventilation BiPAP: how does it work?

Answer 36

Bilevel positive airway pressure (BiPAP) - Administered via tight-fitting face mask - Maintains a higher-pressure during inhalation to assist with opening of the alveoli - Maintains a lower pressure during exhalation which keeps the alveoli from collapsing during/at the end of exhalation but also allows ease of exhalation - Often used prior to invasive measures (ETT)

Question 37

Mechanical Ventilator High-Pressure Alarms

Answer 37

- Mucous plug or increased secretions: suction as needed - Biting on the ETT: insert an oral airway to prevent biting - Pneumothorax: assess for asymmetrical chest rise and decreased breath sounds over the site, CONTACT HCP - Anxious and/or fighting the ventilator: assess patient, provide emotional support, reevaluate sedation/analgesics if needed - Kink in the tubing: assess the tubing - Water collected in the ventilator tubing: empty water from vent tubing

Question 38

Mechanical ventilator Low-Pressure Alarms

Answer 38

- Cuff leak: assess for cuff leak, check cuff pressure, call HCP - Leak in the ventilator circuit: assess all connections and tubing - Ventilator disconnected from ETT - Extubation - Patient stops breathing in PS or SIMV modes: assess patient, notify HCP

Question 39

Criteria for weaning off the mechanical vent

Answer 39

- Reversal of the underlying cause of respiratory failure - Ability to maintain a pH greater than or equal to 7.25 during spontaneous ventilation - PEEP less than or equal to 5 – 8 cm H20 - FiO2 less than or equal to .4 - .5 (40 – 50%) - PaO2/FiO2 ratio greater than 150 – 200 - Hemodynamic stability (patients receiving low doses of vasopressors may be considered) - Ability to initiate an acceptable inspiratory effort

Question 40

PaO2/FiO2 ratio How to find it, what it means for ARDS

Answer 40

- The ratio of the partial pressure of oxygen over the fraction of inspired oxygen - To determine, divide PaO2 by FiO2 - Example : PaO2 90 mmHg /FiO2 .21 = 428 ARDS severity Mild = 200-300 Moderate = 100-200 Severe = <100

Question 41

Methods for Weaning Pressure Support

Answer 41

- Provides inspiratory support to overcome resistance to gas flow through the ventilator circuit and artificial airway - Begin at a level of PS that ensures non-labored RR and Vt - Gradual reduction in PS in 2 to 5 cm H2O increments - Discontinue when stable for two hours or longer with PS 5 cm H20

Question 42

Methods for Weaning T-piece

Answer 42

- Remove patient from ventilator and provide humidified O2 via the T-piece adapter attached to the ETT or tracheostomy - Requires high level of attention - Increase time on T-piece as tolerated with adequate rest periods ( 6 – 8 hours) on full ventilatory support - May discontinue when patient is stable on T-piece for at least two hours

Question 43

Methods for Weaning CPAP

Answer 43

- Patient performs all the WOB - CPAP of 5 cm H20 - Increase time on CPAP as tolerated with adequate rest periods (6 – 8 hours) on full ventilatory support - Discontinue when patient tolerates CPAP for at least two hours

Question 44

Mechanical Ventilator Complications with Extubation

Answer 44

- Reintubation: have an intubation tray at the bedside in case the patient becomes unstable and requires re intubation - Aspiration: The patient is suctioned before extubation, and the patient is instructed to cough as the tube is being removed to reduce the incidence of aspiration. - Signs of airway obstruction: Dyspnea, cyanosis, coughing, and stridor. Stridor is an abnormal, high pitched, crowing sound heard on inspiration that is caused by edema of the glottis or laryngospasm. Notify the health care provider immediately for reintubation. - If the patient tolerates SBT without tachycardia, hypertension, hypotension, deteriorating ABG results, or arrhythmias, they can be extubated

Question 45

Mechanical Ventilation Priority Actions and Interventions

Answer 45

- HOB elevated 30 to 45 degrees (reduces risk for aspiration) - Clear airway secretions with suctioning ETT, frequent position changes, and increasing activity - Daily “sedation vacations” and readiness to wean assessments - DVT prophylaxis (SCDs) - Daily oral care chlorhexidine - Peptic ulcer prophylaxis (PPIs)

Question 46

Mr. Jones is a 55-year-old male who presents to the ED complaining of a sudden onset of dyspnea, left-sided pleuritic chest pain and tachypnea. He appears anxious and scared. He is a computer programmer and has been working 18 hours a day for a month. Vital signs: Pulse: 128 BP: 126/72 RR: 32 Temp: 98.0 O2 Sat: 95% (room air) What are you going to ask Mr. Jones about?

Answer 46

Assess for risk factors of PE 1. Do you smoke? Smokes 1 pack/day 2. Have you been traveling on a plane recently? Denies recent air travel 3. Have you had any reduced activity? Reduced activity (sits at a desk for 18 hours/day) 4. A history of clotting disorders? Denies history of clotting disorders, DVT 5. A history of cancer? Denies history of cancer 6. A history of hypertension? History of hypertension 7. Obesity is a risk factor: Height: 5’9”, Weight: 250 lbs. (BMI:36.9) Other risk factors include advanced age, oral contraceptives, trauma/recent surgery, and a history of Afib

Question 47

Mr. Jones is a 55-year-old male who presents to the ED complaining of a sudden onset of dyspnea, left-sided pleuritic chest pain and tachypnea. He appears anxious and scared. He is a computer programmer and has been working 18 hours a day for a month. Pulse: 128 BP: 126/72 RR: 32 Temp: 98.0 O2 Sat: 95% (room air) - Smokes 1 pack/day - Reduced activity (sits at a desk for 18 hours/day) - History of hypertension - Height: 5’9”, Weight: 250 lbs. (BMI:36.9) What are the priority physical assessments? What do you think is going on?

Answer 47

Priority assessments - Tachypneic, shallow respirations - Tachycardic - Left-sided pleuritic chest pain, dyspnea - Obese - +2 pitting edema in both lower extremities - Crackles in left lower lobe upon auscultation - O2 sat 95% Pulmonary embolism: classic presentation of pleuritic chest pain, SOB, and hypoxemia Assess respiratory status: Dyspnea (increased on inspiration), Hypoxemia, Cyanosis, Tachypnea, Chest pain, Cough, Crackles, Hemoptysis, Wheezing, Shallow respirations, Edema in lower extremities Vital signs: Tachycardia, Hypotension, Low grade fever, Pulse oximetry

Question 48

Mr. Jones is a 55-year-old male who presents to the ED complaining of a sudden onset of dyspnea, left-sided pleuritic chest pain and tachypnea. He appears anxious and scared. He is a computer programmer and has been working 18 hours a day for a month. Pulse: 128 BP: 126/72 RR: 32 Temp: 98.0 O2 Sat: 95% (room air) - Smokes 1 pack/day - Reduced activity (sits at a desk for 18 hours/day) - History of hypertension - Height: 5’9”, Weight: 250 lbs. (BMI:36.9) What tests do you anticipate?

Answer 48

D-dimer - 680 ng/ml (Reference Range <500 ng/ml) - D-dimers are fibrin degradation products or fragments produced during fibrinolysis - A positive test indicates thrombus formation - This test can also be positive in other condition because D-dimer is nonspecific, it is not recommended for use in diagnosing PE CBC - Hgb 14gm/dl (Reference range 14-18gm/dl) - Hematocrit 43% (Reference Range 42-52%) - WBC 7,000 (Reference Range 5,000 – 10,000) - Platelets 167, 000 thousand/microliter (Reference 150-450) ABGs - pH 7.50 - PaCO2 30 - HCO3 22 - Pa02 78 - Tachypnea causes respiratory alkalosis; PaO2 is reduced because of increases dead-space ventilation (Onset) - Metabolic acidosis results from hypoxia and the subsequent transition to anaerobic metabolism (Late) B-type natriuretic peptide (BNP) - Because of the strain on ventricles brought on by PE, BNP may be elevated - This peptide is released by overstretched ventricles under physiological stress - 89 pg/mL (Normal <100pg/mL) EKG - The initial study for any patient presenting with chest pain to rule out myocardial infarction (MI) CXR - May reveal atelectasis similar to pneumonia and infiltrates at the area of the embolism Spiral CT scan of the Chest with Contrast - Most ordered test to diagnose PE - A large bore IV is required in an antecubital vein for contrast to be administered - BUN and creatinine levels must be checked prior to contrast administration

Question 49

Pulmonary Embolism Pathophysiology

Answer 49

- Occlusion of the pulmonary arteries by a blood clot or other particulate matter. - Results in decreased blood flow to functioning alveoli or areas of the lung so that gas exchange can take place. - The obstruction results in an impaired ventilation-to-perfusion ratio (V/Q ratio) or ventilation-perfusion mismatch (V/Q mismatch). - This V/Q mismatch prevents gas exchange at the alveolar level, leading to hypoxemia and vasoconstriction in the affected pulmonary vascular bed. - PE may result in an increase in pulmonary vascular resistance (PVR) because blood flow cannot move past the obstruction. - If the right ventricle cannot overcome this increased PVR, then the left ventricular preload (blood flow to the left ventricle) is reduced. - This leads to decreased oxygenation, decreased cardiac output (CO), and hypotension. - The increased PVR also leads to pulmonary hypertension, causing a back flow of blood into the right ventricle and eventual right heart failure.

Question 50

Mr. Jones is a 55-year-old male who presents to the ED complaining of a sudden onset of dyspnea, left-sided pleuritic chest pain and tachypnea. He appears anxious and scared. He is a computer programmer and has been working 18 hours a day for a month. He has had a D-dimer, CBC, ABGs, BNP, EKG, and CXR What other diagnostic studies can be done if the other studies are inconclusive?

Answer 50

Ventilation-perfusion scan (V/Q scan) - May be used if CT scan is not available or inconclusive Identifies areas of the lungs that are ventilated but not perfused effectively - Indicates obstruction of the of the pulmonary vasculature (PE) - The phrase “high probability” indicates a V/Q mismatch Pulmonary Angiography - Most definitive study for visualization of the pulmonary vasculature - Limited due to invasive nature and time to perform - May only be done if the patient is stable or all tests are inconclusive

Question 51

Mr. Jones is a 55-year-old male who presents to the ED complaining of a sudden onset of dyspnea, left-sided pleuritic chest pain and tachypnea. He appears anxious and scared. He is a computer programmer and has been working 18 hours a day for a month. Mr. Jones completed a spiral CT scan with contrast. The radiology report indicates a pulmonary embolus in the left pulmonary artery. What do you anticipate Mr. Jones orders will include?

Answer 51

Provide oxygen and ventilation Anticoagulant therapy IV fluids - to decrease viscosity of blood Baseline aPTT and PT/INR - for anticoagulants

Question 52

What are the priority medications for a Pulmonary embolism?

Answer 52

Oral Xa Inhibitors - Used in nonsymptomatic patients with a low-risk blood clot - Inhibits the conversion of prothrombin to thrombin - No laboratory monitoring is needed - Examples: Rivaroxaban (Xarelto), Apixaban (Eliquis), Dabigatran (Pradaxa) Lovenox (Enoxaparin) - Anticoagulant - Low-molecular weight heparin - Administered subcutaneously Heparin - Anticoagulant - IV administration in emergency settings - Monitor aPTT (normal 25-35 seconds, on heparin it is 1.5 to 2.5 times the normal) - Antidote: protamine sulfate Tissue plasminogen activator (tPA) - Thrombolytic to dissolve current thrombi/emboli - Thrombolysis occurs within 3 hours of event - Given in hemodynamically unstable patients - High risk for bleeding

Question 53

Mr. Jones is a 55-year-old male who presents to the ED complaining of a sudden onset of dyspnea, left-sided pleuritic chest pain and tachypnea. He appears anxious and scared. He is a computer programmer and has been working 18 hours a day for a month. Mr. Jones completed a spiral CT scan with contrast. The radiology report indicates a pulmonary embolus in the left pulmonary artery. What type of anticoagulant therapy do you anticipate the physician to order and why?

Answer 53

Intravenous heparin therapy Mr. Jones is symptomatic Complains of chest pain (left-sided, sudden onset) Hypoxic Tachypneic Tachycardic He needs something to be administered quickly (IV)

Question 54

Mr. Jones is a 55-year-old male who presents to the ED complaining of a sudden onset of dyspnea, left-sided pleuritic chest pain and tachypnea. He appears anxious and scared. He is a computer programmer and has been working 18 hours a day for a month. Mr. Jones completed a spiral CT scan with contrast. The radiology report indicates a pulmonary embolus in the left pulmonary artery. Mr. Jones will be started on high-dose heparin protocol. What must you consider before administering heparin?

Answer 54

aPTT 32 seconds (Reference range 30-40 seconds) On heparin, the aPTT is 1.5-2.5 times the normal Bleeding precautions - Blood in urine, stool, sputum, and gums - Unusual bruising Adequate IV access Availability of protamine sulfate

Question 55

Mr Jones is 113.6 kg. How would you calculate his initial dose and infusion rate? Heparin = 80 units/kg Maximum initial bolus = 7500 units Initial infusion rate = 18 units/kg/hr Maximum infusion rate = 2000 units/hr * Initial Bolus: _______units/kg x _______kg = ________ units heparin * Begin at ______ units/kg/hr x ________ kg / 100 units/ml = ________ ml/hr (rounded to the nearest 100ml/hr)

Answer 55

* Initial Bolus: 80 units/kg x 113.6 kg = 9100 units heparin (rounded to nearest 100 units) * Begin at 18 units/kg/hr x 113.6 kg / 100 units/ml = 20 ml/hr (rounded to the nearest 100ml/hr) Maximum initial bolus is 7500 units (we will administer that dose) Rate is 20 ml/hr (2000 units/hr)

Question 56

Mr. Jones is a 55-year-old male who presents to the ED complaining of a sudden onset of dyspnea, left-sided pleuritic chest pain and tachypnea. He appears anxious and scared. He is a computer programmer and has been working 18 hours a day for a month. Mr. Jones completed a spiral CT scan with contrast. The radiology report indicates a pulmonary embolus in the left pulmonary artery. He is started on heparin therapy. It is 24 hours later, and Mr. Jones is feeling better. HR is 92 bpm (NSR), blood pressure is 116/72, RR 20 breaths per minute, and O2 saturation is 98% on room air. His repeat lab values are as follows: ABG - pH 7.42 - PaCO2 36 - HCO3 23 - PaO2 91 aPTT - 72 seconds Now that Mr. Jones is stable what other test might be ordered and why?

Answer 56

Venous doppler ultrasound of both lower extremities - Evaluates blood flow through the vessels - Mr Jones. +2 pitting edema in both lower extremities - 40% of patients with PE also have a deep vein thrombosis (DVT) - DVT is a major risk factor for developing a PE

Question 57

What can be done for a patient to prevent recurrent PEs? Indications?

Answer 57

Inferior Vena Cava (IVC) Filter - Placed to prevent recurrent PE's - The filter allows for blood passage but is designed to trap any further emboli originating in the lower extremities Indications: - Active bleeding that disqualifies anticoagulation therapy - Recurrent PE despite anticoagulation therapy - Evidence that hemodynamic or respiratory dysfunction is severe enough that another PE could be fatal

Question 58

Mr. Jones is a 55-year-old male who presents to the ED complaining of a sudden onset of dyspnea, left-sided pleuritic chest pain and tachypnea. He appears anxious and scared. He is a computer programmer and has been working 18 hours a day for a month. Mr. Jones completed a spiral CT scan with contrast. The radiology report indicates a pulmonary embolus in the left pulmonary artery. He is started on heparin therapy. It is 24 hours later, and Mr. Jones is feeling better. HR is 92 bpm (NSR), blood pressure is 116/72, RR 20 breaths per minute, and O2 saturation is 98% on room air. After a 4-day hospitalization, the physician has elected to discharge the patient home on Coumadin therapy and Lasix. What is the priority discharge teaching for Mr. Jones?

Answer 58

Disease process / lifestyle modifications - Exercise regimen - Cardiac – prudent diet - Adequate fluid intake (eight 8-ounce glasses of water daily) - Smoking cessation Medications - Explain mechanism of action of Coumadin - Encourage regular follow-ups or coordinate home health for INR checks (therapeutic level 2.0 – 3.0) - Explain MOA of Lasix and potential signs and symptoms of hypokalemia Bleeding precautions - Encourage the use of soft toothbrushes - Use an electric razor - Avoid activities with a risk of bleeding - Fall precautions Diet - Limit foods high in vitamin K as these foods may interfere with the efficacy of Warfarin (green leafy vegetables such as kale, broccoli, spinach, cabbage and lettuce, etc.) Signs and symptoms of recurrent PE /DVT - Lower extremity edema and pain, with redness and warmth, which may be due to the presence of DVT - Pleuritic chest pain and shortness of breath may indicate a recurrent PE

Question 59

Mrs. Simmons is a 65-year-old female recently diagnosed by her primary care physician with influenza A and did not fill prescription for Tamiflu. She presents to the emergency department accompanied by her spouse with worsening shortness of breath, fever, cough with green sputum, and new onset altered mental status. She is awake and alert but acutely dyspneic with rapid, shallow breathing and is using her accessory muscles. She is unable to express herself in full sentences (pauses after each word to catch her breath). She is sitting upright in bed, restless and agitated. Her skin is hot to touch and flushed. Vital signs: BP: 186/101 Pulse: 136 RR: 36 O2 Sat: 76% (room air) Temp: 101.2 F What are your priority physical assessments?

Answer 59

Respiratory - Hypoxic (76% room air) - Tachypneic (RR 36) - Rapid shallow breaths with use of accessory muscles - Coughing green sputum - Restless and agitated (sign of hypoxia/hypoxemia) - Unable to complete full sentences - Breath sounds indicative of underlying cause of respiratory failure - Crackles (pulmonary edema), Rhonchi (pneumonia, COPD), Diminished or absent breath sounds (hypoventilation) Cardiovascular - High blood pressure (186/101) - Tachycardic (136 bpm) - Compensatory mechanism Integumentary - Skin hot to touch (Temp 101.2 F) - Skin is flushed (Hypercapnia?) - Cyanosis may be visible in the nail beds and around the mouth in initial stages of hypoxemia. - A deep pink coloration to the skin is highly indicative of increased CO2 levels Neurological - Altered mental status (Hypercapnia) (sign of impending respiratory failure) - Restless and agitated (Hypoxia) - Somnolence would be a sign of hypercapnia - Headache would be a sign of hypercapnia

Question 60

Mrs. Simmons is a 65-year-old female recently diagnosed by her primary care physician with influenza A and did not fill prescription for Tamiflu. She presents to the emergency department accompanied by her spouse with worsening shortness of breath, fever, cough with green sputum, and new onset altered mental status. She is awake and alert but acutely dyspneic with rapid, shallow breathing and is using her accessory muscles. She is unable to express herself in full sentences (pauses after each word to catch her breath). She is sitting upright in bed, restless and agitated. Her skin is hot to touch and flushed. Vital signs: BP: 186/101 Pulse: 136 RR: 36 O2 Sat: 76% (room air) Temp: 101.2 F What are your priority nursing interventions?

Answer 60

Oxygen (NRBM 100% FIO2) Cardiac monitoring - Hypoxia and increased oxygen demand due to tachycardia may lead to dysrhythmias. Immediate IV access (preferably a large bore IV) - To get meds to her quickly Raise the head of the bed

Question 61

Mrs. Simmons is a 65-year-old female recently diagnosed by her primary care physician with influenza A and did not fill prescription for Tamiflu. She presents to the emergency department accompanied by her spouse with worsening shortness of breath, fever, cough with green sputum, and new onset altered mental status. She is awake and alert but acutely dyspneic with rapid, shallow breathing and is using her accessory muscles. She is unable to express herself in full sentences (pauses after each word to catch her breath). She is sitting upright in bed, restless and agitated. Her skin is hot to touch and flushed. Vital signs: BP: 186/101 Pulse: 136 RR: 36 O2 Sat: 76% (room air) Temp: 101.2 F You put her on oxygen (NRBM 100% FIO2). What if she doesn't tolerate it?

Answer 61

BiPAP Administered via tight-fitting facemask Maintains a higher-pressure during inhalation to assist with opening of the alveoli Maintains a lower pressure during exhalation which keeps the alveoli from collapsing during/at the end of exhalation but also allows ease of exhalation Often used prior to invasive measures (ETT)

Question 62

Mrs. Simmons is a 65-year-old female recently diagnosed by her primary care physician with influenza A and did not fill prescription for Tamiflu. She presents to the emergency department accompanied by her spouse with worsening shortness of breath, fever, cough with green sputum, and new onset altered mental status. She is awake and alert but acutely dyspneic with rapid, shallow breathing and is using her accessory muscles. She is unable to express herself in full sentences (pauses after each word to catch her breath). She is sitting upright in bed, restless and agitated. Her skin is hot to touch and flushed. Vital signs: BP: 186/101 Pulse: 136 RR: 36 O2 Sat: 76% (room air) Temp: 101.2 F What diagnostic studies/lab work do you anticipate ordering?

Answer 62

1. Stat portable CXR: During the early phases of ARDS, serial chest x-rays can be used to identify the bilateral infiltrates that are the hallmark sign of this disease process. This is sometimes described as a “ground glass appearance” and is also characterized as a “snow screen effect” or “whiteout” effect (Hers show this) 2. ABGs: Excellent tool to assess the adequacy of both oxygenation and ventilation in the lungs 3. CBC: Hematocrit and hemoglobin should be analyzed to make certain that there are enough binding sites for oxygen to ensure adequate oxygen-carrying capacity. 4. Chemistry 5. EKG 6. Cardiac enzymes 7. BNP 8. Sputum for C&S: To rule out a pathogenic cause 9. Blood cultures ( x2)

Question 63

Mrs. Simmons is a 65-year-old female recently diagnosed by her primary care physician with influenza A and did not fill prescription for Tamiflu. She presents to the emergency department accompanied by her spouse with worsening shortness of breath, fever, cough with green sputum, and new onset altered mental status. She is awake and alert but acutely dyspneic with rapid, shallow breathing and is using her accessory muscles. She is unable to express herself in full sentences (pauses after each word to catch her breath). She is sitting upright in bed, restless and agitated. Her skin is hot to touch and flushed. Vital signs: BP: 186/101 Pulse: 136 RR: 36 O2 Sat: 76% (room air) Temp: 101.2 F CXR show infiltrates and labs show decreased PaO2 (59 mmHg), low H&H, high WBC, high BUN/Cr, high glucose, high BNP Mrs. Simmons has been in the emergency department for about an hour and does not appear to be improving. She remains tachypneic and becomes more confused. Her 02 saturation is 83% and respiratory rate remains 36 breaths per minute. You auscultate breath sounds and note scattered rhonchi on the right side and diminished breath sounds in the bases. The physician has elected to proceed with bilevel positive airway pressure (BiPAP) to improve oxygenation. Why?

Answer 63

- Mrs. Simmons is in acute respiratory failure secondary to pneumonia - She remains hypoxic with 100% FiO2 via nonrebreather mask - Her respiratory muscles are becoming fatigued as she continues to breathe at rapid rate - She is now displaying signs and symptoms of hypercapnia because she is becoming increasingly confused - Since her alveoli are not being ventilated, the positive pressure from BiPAP will help keep the alveoli open to increase the amount of oxygen delivered - BiPAP provides positive pressure at the end of exhalation along with higher positive airway pressure during inhalation, which allows for better oxygenation and ventilation

Question 64

Type I – Hypoxemic Respiratory Failure What are two possible causes?

Answer 64

PaO2 less than 60 mmHg despite increased inspired oxygen with normal of low CO2 Scenario I - The lungs are adequately ventilated but not perfused - High V/Q mismatch: air is entering the lungs, but blood is blocked from reaching the alveoli due to embolism, and thus no gas exchange occurs - Example : PE Scenario II - The lungs are perfused but inadequately ventilated (shunt) - Low V/Q mismatch: blood is perfusing the lungs, but air cannot get to the alveoli due to fluid or exudate in the air spaces - Example : atelectasis or pneumonia

Question 65

Mrs. Simmons has been in the emergency department for about an hour and does not appear to be improving. She remains tachypneic and becomes more confused. Her 02 saturation is 83% and respiratory rate remains 36 breaths per minute. You auscultate breath sounds and note scattered rhonchi on the right side and diminished breath sounds in the bases. The physician has elected to proceed with bilevel positive airway pressure (BiPAP) to improve oxygenation. Mrs. Simmons is in acute respiratory failure secondary to pneumonia What medications do you anticipate the physician ordering for Mrs. Simmons?

Answer 65

1. Intravenous antibiotics (Levaquin, erythromycin, etc.) - To treat suspected pneumonia 2. Bronchodilators (Beta-2 agonists – Albuterol) - Helps open the airways by stimulating beta-2 receptors within the lungs - Helps to improve airflow because of an increase in the diameter of the airways 3. Corticosteroids (Solumedrol, solucortef, etc.) - Help decrease the inflammatory response, decreasing bronchoconstriction and increasing the airway diameter. 4. Sedatives (Ativan) - Used to control agitation and anxiety that increase with the work of breathing an oxygen consumption 5. Diuretics (Lasix) - Used to decrease pulmonary congestion, especially in cases where pulmonary edema is the underlying cause of failure

Question 66

Mrs. Simmons is transferred to the ICU but continues to deteriorate despite one hour of BiPAP with multiple adjustments in settings. She is still struggling to oxygenate, and the family agrees to intubate her and place her on a mechanical ventilator. She is placed on Assist Control Mode, FiO2 70%, Vt of 500 mL, f of 12, & PEEP of 5. ABGs pH 7.25 pCO2 52 mmHg HCO3 28 mEq/L PaO2 70 mmHg What is the severity of her ARDS? (PaO2/FiO2 ratio) What is the patho of ARDS?

Answer 66

To determine, divide PaO2 by FiO2 Mrs. Simmons : PaO2 70 mmHg /FiO2 .70 = 100 Less than or equal to 100 = Severe ARDS Patho - Sudden and advanced progression of ARF - Characterized by hypoxemia, dyspnea and decreased lung compliance despite increased oxygen delivery - Inflammatory response causes increased pulmonary capillary permeability, vasoconstriction, and decreased collagen - Eventual diffuse fibrosis and scarring results in greatly impaired gas exchange and compliance

Question 67

What are some potential complications of ARDS?

Answer 67

1. Sepsis/infection - Inflammation from underlying pneumonia accompanied by hypoxemia and decreased cardiac output may lead to multisystem organ-dysfunction syndrome (MODS) 2. Dysrhythmias and decreased cardiac output - Blood pressure may be decreased due to right-side heart failure and the increased intrathoracic pressure, thus decreased venous return associated with PEEP - Inotropic and vasoactive medications may be required to augment cardiac output and support blood pressure (Dopamine, dobutamine, and norepinephrine) - Hypoxemia may lead to cardiac dysrhythmias - Monitor output closely as decreased urine output is an early sign of poor oxygen delivery to the tissues and shock 3. Ventilator-associated pneumonia (VAP) - VAP prevention to include sterile technique with suctioning, hand-washing, and oral care 4. Stress ulcers - Increased risk for skin breakdown due to immobility and hypoxia

Question 68

Mrs. Simmons is transferred to the ICU but continues to deteriorate despite one hour of BiPAP with multiple adjustments in settings. She is still struggling to oxygenate, and the family agrees to intubate her and place her on a mechanical ventilator. She is placed on Assist Control Mode, FiO2 70%, Vt of 500 mL, f of 12, & PEEP of 5. She is in severe ARDS. What are your primary nursing interventions/actions? Meds?

Answer 68

1. Monitor vital signs closely 2. Monitor SpO2/pulse oximetry closely - Pulse oximetry may be low because of V/Q mismatch or intrapulmonary shunting 3. Neurological assessments - Potential neurological compromise due to refractory hypoxemia and potential increase in PaCO2. This may result in increased intracranial pressure. - Level of consciousness and pupillary assessment every 1-2 hours 4. Respiratory assessments - Auscultate for adventitious breath sounds (crackles, rhonchi, or diminished breath sounds). - Crackles may be due to fluid buildup in the lungs secondary to increased capillary permeability. - Diminished breath sounds due atelectasis and fibrotic changes in the lungs 5. Monitor urine output - Decreased urine output is an early sign of poor oxygen delivery to the tissues and shock 6. Monitor mechanical ventilation - Increases in airway pressures may be due to the presence of secretions or worsening lung compliance - Decreases in airway pressure may indicate a leak in the system - Suctioning 7. Labs - ABGs - CBC - Serum lactate levels - Liver/Renal function tests: Abnormal renal and liver values indicate the progression of ARDS to MODS - Blood & sputum cultures 8. Meds - Antibiotics - Corticosteroids - Bronchodilators - Paralytic agents: Reduce the risk of barotrauma because of controlled patient-ventilator synchrony; the patient cannot take a breath out of sync with the ventilator - Sedatives - Analgesics - Inotropic/vasoactive agents: Dopamine, dobutamine, norepinephrine (Levophed); used to increase and maintain blood pressure/organ perfusion in critically ill patients 9. Positioning/skin care - Patients are at increased risk for skin breakdown due to immobility and hypoxemia/hypoxia - Infection preventions

Question 69

What kind of positioning can help treat ARDS? What are teaching points?

Answer 69

Proning - Allows for better oxygenation and alveolar recruitment by having the “good” side down - Increases the recruitment of collapsed posterior alveolar units and reduces the V/Q mismatch via gravity as blood flow is directed to the better-aerated anterior portion of the lungs Teaching - Provide family education and support during this critical period by educating on disease, potential course, equipment and treatments - Understanding the medications, invasive lines and mechanical ventilation may help decrease anxiety and provide some sense of control - Provide family with time for visiting to help them stay engaged and involved with patient care - Refer to spiritual and emotional support systems

Question 70

Describe ECMO as treatment for ARDS

Answer 70

Extracorporeal membrane oxygenation (ECMO) - Technique which uses a pump to circulate blood through an artificial lung outside the body (extracorporeal), where oxygenation and CO2 removal takes place. Blood is then returned to the bloodstream. - Invasive form of therapy with many risks and complications.

Question 71

Describe a tracheotomy and how a tracheostomy tube is placed

Answer 71

- The skin over the 2nd tracheal ring is identified and a vertical incision of 2-3 cm in length is made - A second incision is made entering the trachea - Once the trachea has been entered, the tracheostomy tube is placed and secured with sutures and a tracheostomy tube holder - A CXR is ordered to ensure proper placement of the tube - Trach is for when a patient requires mechanical ventilation for longer than 7 to 14 days - Provides a stable airway in patients who require long term ventilator support, allows access to the lower airway for suctioning, relieves upper airway obstructions.

Question 72

Describe the tracheostomy components - Outer Cannula - Neck Plate - Inner Cannula - Obturator - Inflated Cuff - Uncuffed Tube - Fenestrated Tracheostomy Tube

Answer 72

- Outer cannula: tube that holds the tracheostomy open - Neck plate: extends from the side of the outer cannula. There are holes in the neck plate that attach the Velcro strap around the neck. - Inner cannula: locks inside of the outer cannula. It can be removed for cleaning or may be disposable. - Obturator: used to insert a tracheostomy tube - Inflated cuff: a cuffed tracheostomy tube is used for the patient who needs continuous mechanical ventilation or a patient who is at risk for aspiration. It is recommended that cuff pressure be maintained at 20 to 30 cm H2O to decrease the risk of injury to esophageal tissue and aspiration. - Uncuffed tube: used for patients who are ready for decannulation (the process of removing the tracheostomy tube) or are not receiving mechanical ventilation. - Fenestrated tracheostomy tube: has a removable inner cannula and a plastic plug. If the inner cannula is removed, the cuff deflated, and the plastic plug in place, the patient is able to speak and breathe through the natural airways.

Question 73

Ms. Sampson is a 76-year-old female who arrives at the ICU approximately one hour after a tracheotomy. She has an 8mm tracheostomy tube in place and is attached to a mechanical ventilator. She is still drowsy from sedation but may be aroused by verbal stimulus. She has a history of lung cancer. Vital signs: - Pulse: 92 - BP: 136/84 - RR: 12 (Assist Control on the Vent) - O2 sat: 98% What Post-Op orders do you anticipate?

Answer 73

CXR - To ensure proper placement of the tracheostomy tube - Assess for pneumothorax Humidified O2 - Loosen secretions - Prevent obstruction Tracheostomy care - Each shift and as needed per facility protocol - To maintain patent airway and prevent infection - Report excessive bleeding Suctioning - Every 1-2 hours or as needed - To maintain patent airway and prevent infection Intubation tray and replacement kit at bedside - In case of decannulation - Accidental tracheostomy tube decannulation 72 hours after the procedure is a medical emergency! - Emergency: the tracheostomy is not mature, greater risk of tissue damage and unsuccessful ventilation

Question 74

What does the nurse do when decannulation occurs?

Answer 74

- Accidental tracheostomy tube decannulation within the first 72 hours of the surgical procedure is considered a medical emergency because the tracheostomy is not mature, and during reinsertion, there is greater risk for tissue damage and unsuccessful ventilation. - If accidental decannulation occurs, the nurse must stay with the patient, call for assistance from respiratory therapy and a health care provider, and provide manual ventilation using a manual resuscitation bag with 100% oxygen. - Best practices require that replacement tracheostomy tubes are maintained at the bedside; this includes a tube equal in size and a tube that is one smaller in size, along with an intubation tray.

Question 75

Describe the process of tracheostomy care

Answer 75

- Wash hands and apply personal protective equipment. - Suction the tracheostomy as needed. - Remove old dressing; place in biohazard bag along with soiled gloves; put on clean gloves. - If patient has disposable inner cannula, remove the old inner cannula and replace with a new inner cannula using aseptic technique. Secure in place. Remove soiled gloves. - Inspect the tracheostomy site for signs of infection, irritation, and skin breakdown. - Prepare sterile supplies from tracheostomy cleaning kit. - If the patient has a reusable inner cannula, remove and clean the inner cannula; use sterile saline and a small brush to remove secretions. - Rinse with sterile saline and replace inner cannula after drying with sterile 4 × 4s. - Replace inner cannula and secure in place. - Clean around the stoma site with sterile cotton-tipped applicators moistened with sterile saline. Cleanse the plate of the tracheostomy with sterile cotton-tipped applicators moistened with sterile saline. Do not allow any solution into the tracheostomy stoma. Using dry 4 × 4 gauze, dry the stoma area. - Place a new sterile tracheostomy dressing under the tube plate. - Replace the Velcro tracheostomy holder if soiled. The tracheostomy tube holder should be changed with two caregivers. - Allow room for one to two fingers’ width of space between the Velcro tube holder and the neck. - Remove gloves and wash hands. - Document procedure, how patient tolerated procedure, education that was done with patient, and assessment of the stoma site.

Question 76

Describe the process of suctioning the tracheostomy tube

Answer 76

- Wash hands and put on protective equipment. - Encourage the patient to cough to assist in removing the secretions if the patient is alert. - Place patient in a semi-Fowler’s position. - Turn on suction and set suction vacuum up to 120 mm Hg. - Open suction catheter kit and place sterile drape on bedside table. - Open sterile saline container and fill with sterile saline solution, approximately 100 mL. - Open lubricant and squeeze on sterile field. Lubricant is needed only when suctioning nasotracheal; it is not used for artificial airways. - Apply sterile gloves, pick up suction catheter with dominant hand (keep sterile), and attach the catheter to the suction tubing. Use nondominant hand when touching the suction tubing (this hand will be nonsterile). - Suction a small amount of saline to make sure the equipment is functioning correctly. Apply small amount of lubricant on catheter if performing nasotracheal suctioning. - Remove oxygen device with nondominant hand and hyperoxygenate the patient by providing 100% oxygen via an Ambu bag that is connected to 100% oxygen. Hyperoxygenate with 4–6 breaths. - Instruct the patient to take a deep breath. - Insert the catheter quickly; do not apply suction on insertion of the catheter. Insert catheter far enough to stimulate the cough reflex. - Apply suction and rotate catheter as the catheter is gently withdrawn over a maximum period of 10 seconds by placing thumb of nondominant hand over the catheter. - Encourage patient to cough. - Reoxygenate the patient again with 100% of FiO2 via the Ambu bag for 2–3 breaths. - Rinse the catheter with sterile saline solution while maintaining suction. This will allow the saline to rinse the catheter between suction attempts. - If secretions are still present, repeat procedure for a maximum of three passes of the catheter; provide a rest period of 20–30 seconds between passes of the catheter - When the procedure is complete, replace oxygen source to patient, clean area, and discard per hospital policy. - Suction patient’s mouth and, if indicated, provide mouth care to the patient. Use a separate suction line when providing mouth care. - Assess the patient’s breath sounds, vital signs, cardiac rhythm if the patient is on monitor, and SaO2 level throughout the procedure and after the procedure. - Document procedure, patient’s response, and breath sounds; include color, consistency, and amount of secretions noted and patient’s BP, pulse, respirations, and SaO2 level before, during, and after the procedure

Question 77

Complications of Tracheostomy Subcutaneous Emphysema

Answer 77

- Can occur if there is a puncture or tear in the trachea and air moves into the surrounding tissue. - The air can move into the neck area, chest, or even the face. - If this occurs, the skin becomes edematous with air and feels like a crackling sensation when palpated with the fingers and hand. - Notify the health care provider immediately if this finding is observed!

Question 78

Complications of Tracheostomy Infection

Answer 78

- Infection can occur early or late in a patient with a tracheostomy. - It is imperative to use aseptic techniques when providing tracheostomy care and when suctioning the patient. - Teach the patient and the caregiver about tracheostomy care before discharge, have the patient or family member return demonstrate the correct procedure, and ensure follow up with home care once the patient has been discharged.

Question 79

Tracheostomy Complications Tracheoesophageal fistula

Answer 79

- Develops as a result of overinflation of the tracheostomy cuff. The excessive pressure from the cuff causes a fistula (hole) to occur between the trachea and the esophagus. - Prevention includes maintaining proper cuff pressures. - Observe for pulsating tube

Question 80

Tracheostomy Complications Tracheal Stenosis

Answer 80

- Narrowing of the trachea due to scar tissue that forms from irritation of the mucosal lining of the trachea from the cuff. - Prevention includes maintaining proper cuff pressures, preventing pulling of a tracheostomy tube, and maintaining proper positioning of the tracheostomy tube

Question 81

Tracheostomy Tube Priority Nursing Interventions

Answer 81

*Suctioning per protocol - No longer than 10 seconds per pass - Document procedure, patient’s response, and breath sounds; include color, consistency, and amount of secretions noted and patient’s BP, pulse, respirations, and SaO2 level before, during, and after the procedure *Monitor vital signs and document! *Monitor and document respiratory status - SaO2 - Assess breath sounds; wheezes, crackles, or rhonchi may indicate a need for suctioning; diminished or absent breath sounds may indicate a pneumothorax - Skin color: pallor or cyanosis may indicate hypoxia - Respiratory effort *Document appearance of tracheostomy site - A small amount of bleeding from the site is expected for the first few days - Report moderate to large amounts of bleeding to the HCP immediately!

Question 82

Ms. Sampson tolerated the tracheostomy without complications. Within a couple of days, she was weaned from the ventilator and transferred to the floor. On day 7, her sutures were removed and she was discharged home on day 8 with her new tracheostomy and tube. What are you going to teach Ms. Sampson and her family upon discharge?

Answer 82

*Teach pt/family about tracheostomy care before discharge - Make sure that the pt/family return demonstrated the correct procedure and document *Teach pt/family proper suctioning - Return demonstrate and document - Advise them to report changes in secretion color, consistency, and amount *Notify HCP if there are s/s of infection *Coordinate with discharge planner to ensure home health upon discharge *Teach potential long-term tracheostomy complications - Infection - Tracheal stenosis - Tracheal fistula (prevention: proper cuff pressures at 20-30 cm) - Obstruction: encourage patient to deep breathe and cough, suctioning, and providing humidification with the oxygen source.

Question 83

Mr. Chiu, a 67-year-old male, presents to his primary care clinic with complaints of a persistent dry cough over the last two months. He does not have a fever, chest pain, dyspnea, night sweats, heartburn, sore throat, or rhinorrhea. He notes an unintentional 10-lb weight loss over the past three months, and his medical history is unremarkable. He is married and has two grown children. He recently retired from his job as a restaurant manager, has smoked a pack of cigarettes per day for 45 years, and has no history of illicit drugs. Vital signs: BP: 128/68 Pulse: 92 Temp: 98.4 RR: 20 Pulse Ox: 93% (RA) What are your priority physical assessments? What diagnostic study do you think will be ordered?

Answer 83

Oxygen saturation - Normal O2 saturation is 97%-100% - Mr. Chiu’s is 93% on room air. May need further investigation. *Temperature - Increased temperature is a sign of infection - His is normal at 98.4 *Assess breath sounds - Wheezing may indicate airway obstruction - Rhonchi may indicate increased secretions in the upper airway - Diminished breath sounds are ominous *Cough - Indicates an irritation of the tracheobronchial tree - Ask if the cough is productive. If so, amount and color. Is there blood present? - If blood is present, this indicates the rupture of small blood vessels *Weight/Nutritional status - He admits to 10-lb weight loss over the last three months - No change in appetite *Smoked a pack a day over 45 years - Major cause of lung cancer is smoking *Pain? *Lung cancer symptoms: - Persistent cough, Dyspnea, Wheezing, Hemoptysis, Chest pain, Frequent episodes of pneumonia or bronchitis *Chest X-ray

Question 84

Mr. Chiu, a 67-year-old male, presents to his primary care clinic with complaints of a persistent dry cough over the last two months. He does not have a fever, chest pain, dyspnea, night sweats, heartburn, sore throat, or rhinorrhea. He notes an unintentional 10-lb weight loss over the past three months, and his medical history is unremarkable. He is married and has two grown children. He recently retired from his job as a restaurant manager, has smoked a pack of cigarettes per day for 45 years, and has no history of illicit drugs. Mr. Chiu’s physical exam is significant for decreased breath sounds in the right lower lobe as well as scattered inspiratory wheezes. He admits to intermittent hemoptysis over the last couple of weeks. The nurse practitioner orders a CXR, which reveals a mass in the right lower lobe. What additional diagnostic tests do you anticipate the provider to order next?

Answer 84

*CT Scan - Cornerstone of imaging studies and can identify much smaller nodules than a CXR - Has limited ability to discern benign and malignant lesions *Sputum for cytology - Quick and noninvasive - Limited to certain tumor cells *Bronchoscopy - For a large number of suspected lesions, use of a flexible bronchoscopy is a common way to achieve diagnosis - Examines the larger airways, the trachea and bronchi through scope inserted in the mouth or nose - A biopsy can be done during the procedure *Bone scans and abdominal scans - Should be performed if metastases is suspected *PET scan - If an abnormal finding is seen on a CT scan or a pathologic diagnosis is confirmed, a PET scan should be ordered - Can detect areas of increased metabolic activity as occurs with rapidly dividing cancer cells

Question 85

Mr. Chiu has non-small cell lung cancer. His PET scan confirms hypermetabolic activity in the right lower lobe, and mediastinal lymph nodes as well as metastatic lesions to the left 5th rib, thoracic 5th, and lumbar 3rd vertebrae. A brain MRI is performed, which is negative for metastases. He is offered treatment with standard chemotherapy. Why is surgery not an option?

Answer 85

Surgery is the preferred treatment if there is NO metastasis. Since Mr. Chiu has metastasis, surgery is not an option.

Question 86

Mr. Chiu, a 67-year-old male, presents to his primary care clinic with complaints of a persistent dry cough over the last two months. He does not have a fever, chest pain, dyspnea, night sweats, heartburn, sore throat, or rhinorrhea. He notes an unintentional 10-lb weight loss over the past three months, and his medical history is unremarkable. He is married and has two grown children. He recently retired from his job as a restaurant manager, has smoked a pack of cigarettes per day for 45 years, and has no history of illicit drugs. Mr. Chiu’s physical exam is significant for decreased breath sounds in the right lower lobe as well as scattered inspiratory wheezes. He admits to intermittent hemoptysis over the last couple of weeks. The nurse practitioner orders a CXR, which reveals a mass in the right lower lobe. Mr. Chiu has non-small cell lung cancer. His PET scan confirms hypermetabolic activity in the right lower lobe, and mediastinal lymph nodes as well as metastatic lesions to the left 5th rib, thoracic 5th, and lumbar 3rd vertebrae. A brain MRI is performed, which is negative for metastases. He is offered treatment with standard chemotherapy. What are our priority nursing interventions/actions?

Answer 86

*Provide O2 as needed - Maintain 02 saturation > 90% *Administer medications as ordered - Nonopioid analgesic (Acetaminophen or NSAIDS) - Opioids (Hydrocodone, Oxycodone, Codeine, Morphine Fentanyl, Hydromorphone) - Pain medication needs to be administered around the clock rather than on demand to avoid peaks of pain! - Bronchodilators – bronchial smooth muscle relaxants to open airways and reduce work of breathing *Position – Semi-Fowler’s *Coordinate hospice/palliative care

Question 87

Mr. Chiu, a 67-year-old male, presents to his primary care clinic with complaints of a persistent dry cough over the last two months. He does not have a fever, chest pain, dyspnea, night sweats, heartburn, sore throat, or rhinorrhea. He notes an unintentional 10-lb weight loss over the past three months, and his medical history is unremarkable. He is married and has two grown children. He recently retired from his job as a restaurant manager, has smoked a pack of cigarettes per day for 45 years, and has no history of illicit drugs. Mr. Chiu’s physical exam is significant for decreased breath sounds in the right lower lobe as well as scattered inspiratory wheezes. He admits to intermittent hemoptysis over the last couple of weeks. The nurse practitioner orders a CXR, which reveals a mass in the right lower lobe. Mr. Chiu has non-small cell lung cancer. His PET scan confirms hypermetabolic activity in the right lower lobe, and mediastinal lymph nodes as well as metastatic lesions to the left 5th rib, thoracic 5th, and lumbar 3rd vertebrae. A brain MRI is performed, which is negative for metastases. He is offered treatment with standard chemotherapy. What are our priority teaching points?

Answer 87

*Breathing techniques - Controlled breathing techniques help to increase the clearance of sputum and reduce sense of breathlessness. - Pursed lip breathing encourages the exchange of oxygen and carbon dioxide *Pacing activities *Smoking cessation *Nutritional education – small frequent meals *Medications - Explain purpose and use of bronchodilators - Educate on potential side effects of narcotic pain medication - Remember, pain medication should be taken around the clock rather than on demand to avoid peaks of pain!

Question 88

Mr. Johnson is a 65-year-old male who presents to your clinic complaining of fatigue. He has gained 20 pounds over the last six months. He is here at the insistence of his wife and feels that he will probably be back to normal if he loses weight. She mentions that he has been more tired lately when he comes home from work and has trouble concentrating on tasks. She often finds that he has dozed off in front of the TV while waiting for dinner. He has restless sleep during the night, and she is getting tired of having her own sleep disrupted with his loud snores. He does little else but sleep during the weekend and she worries that might be a sign of depression. Vital signs: BP: 167/106 HR: 96 O2 sat: 96% Temp: 98.4 FSBS: 306 mg/dL Height: 69” Weight: 256 pounds Meds: Metformin 1000mg BID, Losartan (Cozaar) 50mg BID, Lipitor 20mg daily What should we ask him? What do we think it is and what leads us to this conclusion?

Answer 88

Medical History? - Type II Diabetes Mellitus: Metformin 1000 mg BID - Hypertension: Losartan (Cozaar) 50mg BID - Hyperlipidemia: Lipitor 20mg daily Obstructive Sleep Apnea - Loud snoring - Snorting - Witnessed apnea - Gasping during sleep - Recurrent waking during sleep - Choking during sleep He has risk factors and his s/s point to OSA - Male gender: 30% of men have OSA - Obesity: he is 256 pounds - Type II Diabetes: currently uncontrolled, 306 mg/dL - Age: 65 years old OSA risk factors: History of Atrial fibrillation, Nocturnal dysrhythmias, T2DM, Heart failure, Pulmonary hypertension, Male gender, Obesity, Cigarette smoking, Alcohol use, 40-65 years of age, Craniofacial or upper airway soft tissue abnormalities, Menopause

Question 89

Mr. Johnson is a 65-year-old male who presents to your clinic complaining of fatigue. He has gained 20 pounds over the last six months. He is here at the insistence of his wife and feels that he will probably be back to normal if he loses weight. She mentions that he has been more tired lately when he comes home from work and has trouble concentrating on tasks. She often finds that he has dozed off in front of the TV while waiting for dinner. He has restless sleep during the night, and she is getting tired of having her own sleep disrupted with his loud snores. He does little else but sleep during the weekend and she worries that might be a sign of depression. Mr. Johnson has hypertension and takes daily medication. Considering his history and current risk factors, what else should we be concerned about?

Answer 89

- OSA is recognized as a mediator of cardiovascular disease because of recurrent hypoxemia, the release of inflammatory mediators such as endothelins (proteins that constrict blood vessels), and insulin resistance. - In response to hypoxia, inflammatory mediators are released, which leads to the adherence of white blood cells to endothelium, causing endothelial damage and atherosclerosis. - The release of endothelin, a potent vasoconstrictor, results in endothelial dysfunction and damage. - Severe nocturnal hypoxemia can result in cardiac ischemia, myocardial infarction, erectile dysfunction, stroke, actual fibrillation, heart failure, and sudden cardiac death. - Having OSA puts him at higher risk for pulmonary hypertension and vice versa

Question 90

Mr. Johnson is a 65-year-old male who presents to your clinic complaining of fatigue. He has gained 20 pounds over the last six months. He is here at the insistence of his wife and feels that he will probably be back to normal if he loses weight. She mentions that he has been more tired lately when he comes home from work and has trouble concentrating on tasks. She often finds that he has dozed off in front of the TV while waiting for dinner. He has restless sleep during the night, and she is getting tired of having her own sleep disrupted with his loud snores. He does little else but sleep during the weekend and she worries that might be a sign of depression. Vital signs: BP: 167/106 HR: 96 O2 sat: 96% Temp: 98.4 FSBS: 306 mg/dL Height: 69” Weight: 256 pounds Meds: Metformin 1000mg BID, Losartan (Cozaar) 50mg BID, Lipitor 20mg daily What orders do you anticipate for for Mr. Johnson?

Answer 90

1. Polysomnography (sleep study) - Electrocardiogram - Pulse oximetry - Respiratory airflow - Eye and skeletal muscle movement - EEG - Apnea-hypopnea Index: number of apneic events each hour Other tests to consider: *Chest X-ray - Can show enlargement of the right ventricle of the heart or the pulmonary arteries, which can occur in pulmonary hypertension *12-lead EKG - Evaluate electrical patterns that may reveal right ventricular enlargement or strain *Echocardiogram - Can be used to determine the size and thickness of the right ventricle, and measures the the pressure in the pulmonary arteries *Right heart catheterization - If the echocardiogram reveals pulmonary hypertension - Allows for measurement of the pressures in the main pulmonary arteries and right ventricle of the heart

Question 91

Mr. Johnson is a 65-year-old male who presents to your clinic complaining of fatigue. He has gained 20 pounds over the last six months. He is here at the insistence of his wife and feels that he will probably be back to normal if he loses weight. She mentions that he has been more tired lately when he comes home from work and has trouble concentrating on tasks. She often finds that he has dozed off in front of the TV while waiting for dinner. He has restless sleep during the night, and she is getting tired of having her own sleep disrupted with his loud snores. He does little else but sleep during the weekend and she worries that might be a sign of depression. Vital signs: BP: 167/106 HR: 96 O2 sat: 96% Temp: 98.4 FSBS: 306 mg/dL Height: 69” Weight: 256 pounds He undergoes a sleep study, which reveals OSA. What do we anticipate his treatment will be?

Answer 91

Continuous positive airway pressure (CPAP) - Treatment of choice for OSA - CPAP prevents collapse of the upper airway using pressure delivered through the use of a nasal, oral, oronasal mask during sleep. - A CPAP machine delivers a continuous stream of positive pressure, keeping the airway open and providing an unobstructed airway. - Patients are taught about the operation, care, and maintenance of the CPAP machine. Follow-up care is conducted for problem solving and to evaluate the effectiveness of therapy.

Question 92

Mr. Johnson is a 65-year-old male who presents to your clinic complaining of fatigue. He has gained 20 pounds over the last six months. He is here at the insistence of his wife and feels that he will probably be back to normal if he loses weight. She mentions that he has been more tired lately when he comes home from work and has trouble concentrating on tasks. She often finds that he has dozed off in front of the TV while waiting for dinner. He has restless sleep during the night, and she is getting tired of having her own sleep disrupted with his loud snores. He does little else but sleep during the weekend and she worries that might be a sign of depression. Sleep study shows OSA. He is given a CPAP. What will be our priority teaching points for Mr. Johnson?

Answer 92

*Weight loss and management *Diabetes management *Disease process - OSA, risk factors, management *Medication compliance *CPAP - Instruct on the proper use and maintenance of equipment and application of the mask *Smoking cessation if patient smokes