Exam 1 Flashcards

Question

Symptom Management for Palliative Care - Pain (4) - NV (2) - Fever and infection (2) - Edema (2)

Answer 1

Pain (most feared) - nonopioids then transfer to opioids (morphine; Fentanyl if delirius) as needed - May need to use rectal, transdermal, IV or SubQ route as ability to swallow is lost ( Avoid IM b-c variable distribution and painful) - Avoid unnecessary treatments - Nonpharmacological: massage (not on tissue damage or if bleeding disorder), music, therapeutic touch, imagery, aromatherapy (lavender, chamomile, sweet marjoram, dwarf pine, rosemary, ginger) N/V (Cause: intestinal obstruction, increased ICP) - Antiemetics (prochlorperazine, ondansetron, dexamethasone, metoclopramide) - Avoid decompression b-c uncomfortable Fever and Infection - Antipyretics - Continue antibiotics Edema or fluid overload - Diuretics (know kidney function) - Avoid dialysis

Answer 2

Nonpharmacological - Raise HOB - Electric fan (increases ambient air flow) - Wet cloth to face - Encourage imagery and deep breathing Pharmacological - Oxygen (give regardless of O2 sat b-c dyspnea is subjective) - Give morphine (b-c alters air hunger perception, reduces anxiety and muscle tension, and reduces pulmonary congestion via pulmonary vasodilation) - Give versed (midazolam) if unable to take opioids - If bronchospasm give bronchodilators or corticosteroids

Answer 3

CPR - Family presence is important to facilitate closure during CPR or invasive procedures - Done for everyone unless DNR - Can be painful, unsuccessful or result in worsened condition DNR or DNI - DNR does not mean stop caring for patient or stop all life sustaining treatment - DNI (do not intubate)-may still want CPR - Must be signed by HCP Withdrawal or withholding of treatment - Prepare family for what to expect - implement comfort orders prior to treatment withdrawal

Answer 4

- Early and ongoing discussions (daily rounds, family meetings) - Informed consent necessary (explain things in language family can understand) - Patient’s wishes should guide discussions about withdrawal of care - Ask about family’s emotional state and acknowledge expressions of emotion - take into account cultural and spiritual practices and respect them

Answer 5

- Removal of routine interventions (labs, imaging, cardiac monitoring) --Monitors may be kept to adjust medication amounts in symptom management or for families to verify cessation of electrical activity - Removal of respiratory support devices (need DNR prior to withdrawal and withdraw paralytics first) - turn off pacemaker and ICD (may interfere w/ death pronouncement, or cause discomfort and distress due to shocks firing) - withdrawal of artificial nutrition and hydration (family may be concerned but excess nutrition and fluids can prolong suffering) - Provide symptom management in accordance w/ symptoms

Answer 6

Vision - No eye movement, staring, dilated and fixed pupils Speech - Difficult to understand, unable to speak as LOC decreases Circulation - Cold, mottled and cyanotic extremities r/t decreased peripheral circulation, poor tissue perfusion and heat loss - HR increases, irregular, gradual decrease until stops - BP drops Respiration - Shallow, apnea, labored -> Cheyne-stokes (apnea then rapid) - Death rattle (loud, wet respirations from Mucus collection)

Answer 7

Muscle Tone - Limp body/weakness - jaw drop GI and GU - Anorexia - Urinary/Anal incontinence LOC - lethargic, unresponsive, coma) drop - Increased sleep

Answer 8

Speech - talk to pt as you normally would Circulation - apply blanket - no electric blankets or heat packs Respiration - Positioning ( Elevate HOB, turn head to side) - give anticholinergics or scopolamine to decrease secretions - oral suctioning not helpful

Answer 9

- Treat body to privacy, respect and gentleness - Close the patient’s eyes and Insert dentures if the patient wore them. - Straighten the patient and lower the bed to a flat position w/ pillow behind head - Wash the patient, comb hair, clean room - Place waterproof pads under the patient’s hips to absorb any excrement. - Allow the family or significant others to see the patient in private and to perform any religious or cultural customs they wish (e.g., prayer, eye closing, washing). - Ensure that the nurse or physician has completed and signed the death certificate prior to morgue transfer

Answer 10

- Young old (65-74) - Middle old (75-84) - Old old (85-99) - Fastest growing; described as frail (geriatric syndrome w/ unintentional weight loss; weakness and exhaustion and slowed physical activity in older adults) - Elite old (100+)

Answer 11

- Decreased adaptability - Impaired organ function - Decreased reaction time - Impaired memory of recent events - visual changes: presbyopia (farsighted r/t age), glaucoma (may need meds or surgery), cataracts (may need surgery), macular degeneration, diabetic retinopathy - impaired hearing (presbycusis)

Answer 12

- Greater risk for functional decline (Need assistance w/ 2+ ADLs prior to admission) - Loss of autonomy and increased dependence r/t mental and physical changes of aging or illness - inability to drive (increased MVA)-- can decrease independence - mobility concerns (increased sleep; need for cane or walker; increased falls)

Answer 13

- Impaired stress response - ageism (discrimination r/t age) - impaired socialization r/t loss of significant others - increased elderly individuals in prison or homeless - increased drug usage

Answer 14

- Dietary fat < 30% of calories (<10% from saturated fat) - Increase calcium to b/w 1000-1500 mg daily - Daily vitamin D supplement or 10-15 min sun exposure - Increased vitamin C and A - Reduce total calories if sedentary lifestyle - Drink 2 L of fluid a day (may need Colon cocktail: prune juice, applesauce, psyllium to prevent constipation) - 35-50 g of fiber each day

Answer 15

- Yearly physical and eye exam - vaccinations (Influenza, shingles, Pneumococcal, Tetanus (booster every 10 yr)) - Drink ETOH in moderation (<1/day) or not at all - Avoid smoking - Create a hazard-free environment (No scatter rugs, waxed floors; Grab bars in bathroom; Install smoke detectors/sprinklers in home) - Exert autonomy and control as much as possible

Answer 16

- Wear seat belts - Wear glasses and hearing aids if prescribed b-c can interfere w/ ability to see or hear hazards - take driver refresher classes - Encourage to avoid night driving and bad weather driving (icy or wet roads) - Use alternative methods of transportation if unable to drive safetly - consult HCP before driving if any physical or mental deficits (i.e presbycusis or peripheral neuropathy)

Answer 17

- Diminished sense of taste, smell (Results in loss of desire for food) - Inappropriate/unbalanced foods (fast foods) - Excess meds and OTC drugs (can decrease appetite, affect food tolerance and absorption, and lead to constipation) - Tooth decay, tooth loss, poorly fitting dentures (r/t inadequate dental care and calcium loss)- may lead to avoidance of nutritious foods - reduced income - Chronic disease/ Fatigue - Decreased ability to perform ADLs - Loneliness, depression and boredom (may lead to lack of eating and weight loss)

Answer 18

- Perform nutritional screenings on the 1st day of pt. admission (include Nutritional hx, wt., ht., and BMI) - Do an oral exam to understand why patient may only eat soft/low fiber foods - Collaborate w/ RDN about the patient's nutritional status - Collaborate w/ SLP about problems swallowing or chewing - Encourage to use herbs instead of salt and sugar b-c may overuse them - Get social work involved for food bank programs - manage symptoms that may impair nutrition (pain w/ analgesic; NV w/ antiemetic)

Answer 19

Risk factors - less body water - decreased thirst sensation - Limiting fluid intake in evening due to decreased mobility, diuretics, and urinary incontinence Care - Incontinence increases w/ dehydration b-c concentrated urine irritates bladder - Drink 2 L of water a day plus other fluids - Avoid excess caffeine and alcohol - Know s/s of dehydration (dark urine, weight loss, poor skin turgor, dry mucus membranes)

Answer 20

Causes: inadequate nutrition or hydration; drugs Impacts: pain, depression, anxiety, decreased social activities, small or large bowel obstruction

Answer 21

- Assess older adults in any setting about hx of exercise and any health concerns - Teach importance of physical activity 3-5x a week for at least 30 minutes - Encourage sedentary adults to slowly start their exercise programs - If patient is homebound, focus is performing ADLs - walking and swimming are good choices (walking is best because it is weight bearing and can help prevent osteoporosis and build bones)

Answer 22

- Increased mobility, muscle strength, and balance (so decreased falls) - Better sleep - Reduced or maintained body weight - Fewer depressive symptoms (improved well-being and self-esteem) - Improved longevity (Reduced risk of Diabetes, Dementia, CAD) - Decreased risk for constipation

Answer 23

Impact: faster aging Sources - Rapid environmental changes w/ immediate reaction - Changes in lifestyle r/t retirement or physical incapacity - Acute or chronic illness - Loss of significant other - Financial hardship (Loss of work or decreased amount of work; past due bills; houseless esp. vets)

Answer 24

s/s - Physiologic: sleep disturbance; GI distress - Emotional: withdrawal, anxiety, anger, depression Management of relocation stress - Encourage patient decision making - Assess and adhere to usual lifestyle, daily activities, food preferences - Reorient frequently - Ask fam to visit often and bring special items - Establish trusting relationship early - Avoid unnecessary relocations

Answer 25

Risk factors - Hx of falling (most important predictor of falls) - Multiple illnesses - Generalized weakness or decreased mobility - Changes in sensory perception (r/t age or drugs) - impaired body orientation r/t decreased sense of touch -> decreased reaction time - Urinary incontinence or nocturia - Communication impairment (disorientation, confusion) - Alcohol/substance abuse Assessment (fall risk assessment) - Observation of Gait (wobbly?); Footwear (closed toe? Sturdy?); assistive devices (cane? Walker? Glasses?)---Do they use them? - Past medical hx (Diabetic neuropathy?, arthritis?, peripheral neuropathy?) - Drug assessment (Drug side effects?) i.e. Antihypertensives and orthostatic hypotension; Opioids and CNS depressant effects of drowsiness and acute confusion

Answer 26

Impact of falls: fractures and fallphobia (esp if osteoporosis) Prevention - Ensure hydration b-c dehydration can cause incontinence due to bladder irritation - RN communicate hazards on their health literacy level - Safeguards (handrails, grab bars, slip proof rugs, adequate lighting) - No scatter rugs, slippery floors, clutter - Pt avoids going out on bad weather days (slippery or icy) - ask for help when needed esp. toileting - use assistive devices i.e hearing aids, glasses, walker, cane, - keep bed low and locked

Answer 27

- Intolerance to standard drug dosages (use “Start low and go slow” policy) - Opioid Use (increased due to use for acute and chronic conditions w/ persistent pain) - increased risk of adverse drug events due to polymedicine/polypharmacy

Answer 28

Metabolism (monitor liver function tests) - Decreased liver size - Decreased liver blood flow - Decreased serum liver enzyme activity Excretion (get renal function test esp. Crt clearance) - Increased BUN and Crt - Reduced renal blood flow - Reduced GFR and creatine clearance (leads to slower excretion; decreases by 6.5 mL/min per decade of life)

Answer 29

Absorption - Decreased GI motility - Decreased GI blood flow - Increased gastric pH Distribution - Smaller amount of total body water - Decreased albumin level - Increased ratio of adipose tissue to lean body mass (leads to increased storage of lipid-soluble drugs in tissue vs plasma) - Decreased cardiac output

Answer 30

- Poor communication with HCP r/t poor explanations due to educational limits, language barriers or difficulty hearing and vision - Make errors (Forget to take; Duplication (think 2 is better than 1); use wrong drugs - Take OTC drugs that interact with prescribed drugs (Ex. Clopidogrel, aspirin, warfarin for anticoagulation, ibuprofen for arthritis and garlic for hypertension = bleeding risk) - Discontinue drug therapy due to cost, fear of dependency or side effects) - use leftover drugs from previous illness - Borrow from others - Use more than one pharmacy

Answer 31

- Obtain complete drug list (OTC, prescribed, herbs, supplements) - Highlight all drugs that are part of Beers criteria ( drugs where harm > benefit for elderly (ex. Benadryl, ketorolac) - Assess for duplicate drugs (Ex. Warfarin from two pharmacies) - Give verbal and written information at appropriate knowledge level - Encourage to take drugs exactly as prescribed (do not share or borrow drugs) - Be Aware of common adverse drug events (ADEs) (Hypotension from HTN drugs; Edema; Syncope; Dehydration from diuretics)

Answer 32

- meperidine - oxycodone - cyclobenzaprine - digoxin (Should not exceed 0.125 mg daily except for a-fib) - Ticlopidine - fluoxetine - amitriptyline - diazepam - promethazine - diphenhydramine - ketorolac - short-acting nifedipine - ferrous sulfate (Should not exceed 325 mg daily) - chlorpropamide

Answer 33

- Encourage use of pill boxes or associating pills w/ daily events - Use large print on drug label for poor vision - Write drug regimen on bottle - Colored labels - Easy to open bottle caps for limited hand mobility and strength

Answer 34

-Mood disorder having cognitive, affective, physical manifestations (sleep disturbance, fatigue, increased pain; worsening of current problems; suicide risk) Primary: lack of neurotransmitters (serotonin and norepinephrine) Secondary or situational: r/t sudden change in life such as illness or loss (conditions: stroke, arthritis, cardiac disease)

Answer 35

Assessment - Geriatric Depression Scale (15 yes or no questions; > 10 = possible depression) Treatment - SSRI (takes 2-3 weeks to start working) - TCAs have anticholinergic properties and should not be used (side effects: acute confusion, severe constipation, urinary retention or incontinence) - Nonpharmacological: psychotherapy; reminiscence, music therapies

Answer 36

- Slow, progressive and chronic global impairment of intellectual function Prevention of cognitive changes in older adults - Cognitive training (learning new skill) - Physical and mental activity - Social engagement - Proper nutrition

Answer 37

- Increase risk for falls, other accidents - affects mood and cognitive ability ( may lead to Isolation, depression, delirium) - Bladder and bowel incontinence - Complications of chronic diseases (DM, HTN, GERD) - Poor nutrition r/t drinking > eating

Answer 38

- Have you ever tried to cut down on your drinking? - Have people annoyed you by criticizing your drinking? - Have you ever felt bad or guilty about your drinking? - Have you ever had a drink first thing in the morning to settle your nerves? (eye-opener)

Answer 39

SPICES or geriatric vital signs * Sleep disorders * Problems with eating or feeding * Incontinence * Confusion * Evidence of falls * Skin breakdown Risks: longer hospital stays, higher medical cost, death

Answer 40

Neglect - Failure or refusal to provide or support basic needs (feeding, clothing, shelter) - Ex. Contractures, pressure ulcers, dehydration, urine burns, malnutrition, excessive body odor, listlessness Emotional abuse - threats, humiliation, intimidation, isolation Financial abuse - misuse or management of funds, resources - more common than physical Physical or Sexual - injured, assaulted, or inappropriately restrained - Ex. Clusters or regular patterns of burn (cigs), molesting, unusual hair loss, sedation, injury in bathing suit zone (abdomen, butt, genitals, upper thighs)

Answer 41

- listen to seniors and their caregivers - intervene if elder abuse suspected (MANDATED) - educate others about how to recognize and report elder abuse

Answer 42

Contributing factors - Acute or chronic disease - ADL ability - Cognitive impairment - Environmental barriers (lack of available staff; toilet far) Care - Place the pt. on a toileting schedule or a bowel or bladder training program (may delegate to UAP)

Answer 43

Two problems - Skin breakdown (esp. pressure ulcers) - Skin tears esp. the old-old and those on chronic steroid therapy b-c increased capillary fragility) Care - Prevention of pressure ulcers ( Nutritional support (protein), turn, reposition q2h, mobility/activity plan of care, moisture barriers, good hygiene) - Use the Braden scale daily - Coordinate w/ RDN and WOCN - Assess skin q8h for reddened areas that do not blanch and report any open areas (Encourage UAP to report any reddened areas so RN can assess) - Use a gentle touch

Answer 44

- CO2 does not change with age - PaO2 decreases w/ age r/t V/Q matching changes (Expected value = 80 mm Hg minus 1 mm Hg for every year > 60) - Reduced size and function of the kidneys (Loss of nephrons; Decreased renal blood flow) - Underlying conditions that may result as one ages Ex. COPD (respiratory acidosis), DKA (metabolic acidosis)

Answer 45

- pH 7.35-7.45 - CO2 35-45 (Ventilatory failure if > 50) - HCO3- 22-26 - PaO2 80-100 mm Hg (never should be < 40)

Answer 46

- ph abnormal + one abn. value = uncompensated - ph abnormal + two abn. values = partial compensation - ph normal + two abn. values = full compensation (determine primary disorder by seeing if pH on acidic (7.35-7.4) or alkalinic side (7.4-7.45) of normal)

Answer 47

O2 sat (need to know Hgb to know if adequate) - normal: 95% or higher - Amount of oxygen bound to hemoglobin compared to maximal capability of hemoglobin for binding oxygen Oxygen content (CaO2) - Measure of total amount of oxygen in blood included PaO2 (dissolved in plasma) and amount bound to hemoglobin (SaO2) - Normal = 20 mL of oxygen per 100 mL of blood

Answer 48

- normal range -2 +/- 2; -2 to 2) - Identifies non respiratory contributors to acid-base balance - <-2 base/bicarb is deficit (metabolic acidosis) - >2 base/bicarb is excess (metabolic alkalosis)

Answer 49

- Lower the number = worse the lung function (want > 286) - Estimates intrapulmonary shunting (portion of venous blood that flows to lungs w/o being oxygenated which leads to non functioning alveoli) - PaO2: partial pressure of oxygen dissolved in arterial blood plasma 80-100 mm Hg - FiO2: fraction of inspired oxygen 21-100% (21%= room air; 100% possible via vent or ambu)

Answer 50

- slow growing squamous cell carcinoma Progression - Begins with mucosa that is chronically irritated - mucosa becomes tougher and thicker from irritation and genes for cell growth damaged - metastasis to Lymph nodes, muscles, bone i.e. nearby structural areas - fatal when metastasis to organs (lungs, liver)

Answer 51

Prognosis - dependent on location and extent of tumor - curable when treated early - fatal in 2 yrs if not treated due to airway obstruction Consequences - impaired gas exchange (inability to breath) - impaired nutrition (inability to eat) - impaired self-image (impaired facial appearance) - impaired communication (inability to speak)

Answer 52

Main: tobacco and alcohol (worse when together) Others - men more than women - > 60 yrs - poor oral hygiene - chronic laryngitis - voice abuse - chemical or dust exposure - long-term GERD - oral infection w/ HPV FAMILY HISTORY IS NOT A RISK FACTOR FOR HEAD AND NECK CANCER

Answer 53

- Pain - Lumps in mouth, throat, neck - Color changes in mouth or tongue (leukoplakia (white, patchy); Erythroplakia (red, velvety); black; gray; dark brown) - Oral lesion or sore that does not heal in 2 weeks (may have burning sensation from hot liquids or citrus juice - Persistent/unexplained oral bleeding - Numbness of mouth, lips, or face - Change in denture fit - Hoarseness or change in voice quality - Persistent, unilateral ear pain - Persistent/recurrent sore throat or difficulty swallowing - Shortness of breath - Anorexia and weight loss

Answer 54

Labs - chronic alcohol use or poor nutrition (low albumin) - metastasis to liver (increased AST, ALT) - metastasis to kidney (increased BUN, Crt) - CBC, Bleeding times, and blood chemistries - Urinalysis Diagnostics - direct and indirect laryngoscopy OR bronchoscopy under anesthesia to define extent of tumor - Biopsy to confirm diagnosis, tumor type, cell features, location, and stages - X-ray of skull, sinuses, neck, and chest - CT and MRI

Answer 55

Supraglottic partial laryngectomy ( done if nodes involved) - normal or hoarse voice - Temp tracheostomy Hemi or vertical laryngectomy - hoarse voice - Temp tracheostomy Total laryngectomy - no natural voice - Permanent laryngectomy stoma

Answer 56

- Radiation - chemo - surgery (laryngectomy-- requires trach)

Answer 57

- impaired taste - skin problems (redness or irritation or tenderness; peeling skin)-- may be for up to a year - dysphagia - dry mouth (xerostomia) - risk for cavities, oral infections, halitosis, taste problems with xerostomia - hoarseness (worsened for up to 4-6 weeks) - sore throat and swallowing problems

Answer 58

Care for xerostomia - Moisturizing sprays - Increased water intake - humidification Care for skin problems - Avoid exposing skin to sun, heat, cold, abrasive actions (shaving) - Wear protective clothing w/ soft cotton - Wash area gently daily with mild soap

Answer 59

- make sure pt aware of self-care of airway, ventilation and suctioning needs post-op - let know patient needs alt form of communication post-op (speaking device, whiteboard, pen and paper) - educate about post-op pain management, nutritional support (feeding tubes), plans for discharge

Answer 60

- Airway obstruction (priority)- s/s: restlessness - Hemorrhage (esp. if wound exposes carotid artery)-- call RRT if blood leaking and do not touch b-c can rupture carotid artery; apply continuous pressure if carotid artery ruptures - wound breakdown (Risks: poor nutrition, long smoking hx, chronic alcohol use, wound contamination, radiation therapy prior to surgery) - Tumor recurrence - nutritional deficiencies (may have taste changes)

Answer 61

- care in ICU setting - For first 24 hrs, monitor airway, VS, hemodynamics, comfort, anesthesia complications - monitor stoma (stoma should be bright pink and shiny w/o crusts; blood tinged drainage = normal for 2 days) - for pain, give IV morphine via PCA (no oral meds until oral intake tolerated)

Answer 62

- Electronic devices (picture board, smart phone, computer) - Mechanical device (sound vibrates air inside mouth and throat while patient moves lips and tongue; produces robotic sound) - esophageal speech (patient burps swallowed air to produce speech; produces monotone sound)

Answer 63

- May be on mechanical ventilation - suction PRN to remove secretions - change laryngectomy tube daily - Clean stoma w/ sterile saline to prevent crusts from obstructing airway - Increase humidity w/ saline, bedside humidifier, pans of water, or house cleaning - monitor vital signs (O2 sat) and respiratory status

Answer 64

- connect to support groups - reduce anxiety and depression w/ anxiolytics ( diazepam (Valium) - be careful b-c risk for respiratory depression; lorazepam (Ativan)- less risk for respiratory depression) - stress self care (normal activities return after 4-6 weeks) - cover stoma w/ clothing or jewelry to mask appearance - use cosmetics for disfigurements

Answer 65

- Suture line of stoma care q1-2h during first few days post-op then q4h - Surgical drain collects blood and drainage for 72 hrs post-op - Monitor and record amount and character of drainage; cap refill; and activity of major BVs in region (Secretions blood tinged for 1-2 days) - Report sudden increase or decrease of drainage to surgeon (may be clot if sudden stoppage of drainage)

Answer 66

- feeding tube usually for 7-10 days post-op and removed when swallowing is safe per Swallow study - PEG > NGT to prevent aspiration - give diet high in protein and calories - small amounts of food at a time - may need thickened liquids - collaborate w/ RDN and SLP b-c at risk for aspiration, speech, and nutritional problems

Answer 67

- surgical changes in upper respiratory tract w/ laryngectomy - NGT - Difficulty swallowing r/t tracheostomy tube fixing larynx in place and cuff interfering with passage of food via esophagus - cuff pressure < 20 on trach tube (may partially deflate for easier swallowing)

Answer 68

- tuck chin when swallowing - use supraglottic swallowing (Valsalva maneuver and swallow twice to clear food that may pool in pharynx; exaggeration of normal protective mechanisms) - observe for aspiration or aspiration pneumonia and report immediately (aspiration not possible after total laryngectomy b-c airway totally separated from esophagus) - NO oral intake until swallow study done - collab w/ SLP and RDN

Answer 69

- Avoid swimming - Lean forward and cover stoma when coughing, sneezing (may need to cover when laughing and crying as well) - Wear stoma guard or loose clothing to cover stoma to prevent water from entering airway when showering - Clean stoma with mild soap and water - Lubricate stoma with non-oil based ointment - use alt communication methods - use MedicAlert bracelet and emergency card for life-threatening situations

Answer 70

What is it? - life-threatening emergency - Obstruction or compression of SVC that prevents return of venous blood from head, neck, and upper trunk Causes - Malignancies and tumors esp. lymphomas; lung cancers; Mediastinal tumors - Scar tissue formation - Thrombosis from invasive vascular device (PICC, pacemaker) Diagnostics: chest x-ray, CT, MRI Main complication: airway obstruction

Answer 71

- Chemotherapy/radiation to decrease tumor size and relieve obstruction - surgical (Metal stent) for relief of swelling-- rare - IV Steroids (methylprednisolone) for edema and inflammation - IV Diuretics (furosemide) for edema - Comfort and pain control (HOB elevated r/t dyspnea) - If due to thrombosis from IV device, remove line and give systemic anticoagulation

Answer 72

- Dyspnea (most common) - Trunk/extremity swelling - Facial edema (periorbital) esp In morning or when supine - Epistaxis and Nasal stuffiness - cough - Neck-vein distention - CNS (Headache or head fullness; Lightheadedness; Mentation changes) - Upper body erythema

Answer 73

- Hemorrhage - Cyanosis - decreased cardiac output - hypotension - stridor = rapid progression r/t narrowing of pharynx or larynx - Death results if compression is not relieved (main goal = prevent development of late signs)

Answer 74

- Inspect insertion site( eyelets of tube should not be visible; s/s of infection (redness, purulent drainage, excess bleeding)) - Palpate Insertion Site (may have subQ emphysema if puffiness or crackling - Ensure Intact Dressing at Site - Assess/reassess Respiratory Status (breathing, pulse ox, breath sounds) - Observe Trachea (tension pneumothorax if shifted) - Assess/reassess Pain (give meds and reposition) - Encourage Cough, Deep Breathing, Incentive Spirometry

Answer 75

- Avoid kinks, Occlusions, or Loose Connections (should be straight) - Do NOT Strip/Milk Tubing - Keep Drainage System Below Level of Chest - Assess for “Tidaling” (water level rises inhalation and fall exhalation) - if not present, may be obstruction - bubbling seen on exhalation, forceful cough, position changes (EXCESS BUBBLING = air leak) - Always have at least 2 cm of water to prevent air from returning to patient in water seal chamber - Limit clamping of a chest tube b-c will increase pressure in pleural space and may cause tension pneumothorax - No need to disconnect chest tube for transport - never let drainage come in contact w/ tubes (can cause tension pneumothorax)

Answer 76

- Tracheal deviation from midline - Sudden onset or increased intensity of dyspnea - O2 sat <90% - Drainage greater than 100 mL/hr, fresh blood, sudden increase in drainage - Visible eyelets on chest tube - Chest tube falls out of the patient’s chest (cover the area with dry, sterile gauze; leave one side out so air can continue to escape chest and prevent tension pneumothorax) - Chest tube disconnects from the drainage system (put end of tube in a container of sterile water and keep below the level of the patient’s chest) - Drainage in tube stops (in the first 24 hours)

Answer 77

- Sarcopenia (age-related muscle atrophy) and weakened respiratory muscles - Decreased chest wall movement (stiffens) and size - Air trapping = increased residual volume causing thinned and enlarged alveoli - Reduced sensitivity to hypoxia and hypercarbia - Decreased pulmonary reserve - Decreased pulmonary perfusion capacity - increase Dyspnea - Difficulty coughing up secretions r/t decreased cilia beat frequency in airways - Decrease in ability to protect against environmental injury and infection (r/t decreased T-cell, nutrition, swallowing ability, and mucociliary clearance)

Answer 78

Indications (at bedside by HCP) - Diagnosis (r/t hemoptysis; post-chest trauma; chest or face burn; post-aspiration; difficult intubation; airway obstruction) - therapeutic (reverse aspiration, help w/ difficult intubation; removal of secretions or growths; atelectasis) Post procedure Care - Observe sputum for hemorrhage (Expected: slightly bloody due to trauma) - Ensure gag reflex returns and anesthesia wears off before patient eats or drinks (about 2 hr)

Answer 79

Minor complications: Laryngospasm/Bronchospasm, fever, vomiting, epistaxis Major complications - anaphylaxis - Cardiac (hypotension, arrhythmias, hemorrhage, CODING/ cardiopulmonary arrest) - respiratory (respiratory failure, hypoxemia, pneumothorax) - infection

Answer 80

Pre procedure Care - Chest x-ray - Clotting studies (PT, aPTT, Platelet) - ABGs (oxygen during procedure if hypoxemic) - No oral intake for 6-8 hrs to prevent aspiration Pre-op meds - Topical anesthetic - Benzo for sedation - Opioid for pain - Atropine to reduce vasovagal response and secretions - IM Codeine to reduce cough reflex

Answer 81

Indications - Therapeutic (Removal of fluid or air from pleural space for pleural effusion or empyema) - Diagnostic (determine etiology of pleural effusion; main use) Procedure - Patient sit on side of bed OR side lying on edge of bed - Patient should not move or cough during procedure - Local anesthetic given to minimize discomfort (by HCP)

Answer 82

Risk factors for complications - Hemodynamic instability or Coagulation defects - Mechanical ventilation - Intra-aortic balloon pumps - Uncooperative patients Complications - Pain - Pneumothorax r/t intro of air into pleural space, puncture of lung, or rupture of visceral pleura - Reexpansion pulmonary edema (s/s severe coughing, SOB))

Answer 83

Indications: Diagnosis (determine if occlusion of pulmonary artery, respiratory or perfusion problems esp. PE) Process - Ventilation: radiolabeled gas inhaled via mask into lungs - Perfusion: radioisotope injected into veins and travels to lung tissue Results - Normal= perfusion scan is normal - V/Q mismatch i.e. diminished radioactivity on perfusion scan indicates obstruction i.e pulmonary embolus Complications - Bleeding at injection site - infection at site - Allergy to injection dye (anaphylaxis)-- rare

Answer 84

Indications - Detect abnormalities when respiratory problems - Assess, track, diagnose, and monitor pulmonary diseases w/ spirometry Components - lung volumes (tidal volume and vital capacity) provide info on origin of disease - Mechanics of breathing (dynamic and static compliance) - lung compliance decreases w/ pneumothorax, bronchospasm, retained secretions - Diffusion - ABGs

Answer 85

Process - Air rapidly enters pleural space and cannot escape - Lungs collapses and mediastinum shifts to opposite side due to pressure of air - Air compresses blood vessels and heart which limits venous return and reduces cardiac output and gas exchange Cause - blunt chest trauma for accident or invasive procedure - barotrauma from vent Labs/Diagnostics - chest x-ray - ABG: hypoxemia and hypercapnia Interventions - Oxygen with PEEP (positive end expiratory pressure) needed - chest tube in pleural space to remove air or fluid, reinstate negative pressure, expand collapsed lung)

Answer 86

- Tracheal deviation (away from affected due to compression of heart) - Respiratory distress (dyspneic, cyanotic - Reduced or Absence of breath sounds on affected side (hyperresonance) - Distended neck veins - Hypotension - Hemodynamic instability (cyanotic, sudden chest pain, tachycardia)

Answer 87

Causes - Blunt or penetrating trauma - Lesser trauma if tendency to bleed (i.e. on anticoagulants) Classifications - Simple: < 1L blood loss (May not exhibit manifestations) - Massive: > 1L blood loss Interventions for massive (simple may resolve on own) - chest tube to remove blood and prevent infection - Fluids - Open thoracotomy if massive or persistent bleeding at 150-200 mL/hr over 3-4 hrs

Answer 88

- Respiratory distress (dyspnea, cyanosis, tachypnea) - Blood visible on chest x-ray - Hypovolemia - Decreased breath sounds (no extra sounds) - Shock possible (tachycardia) - Dull to percussion - Chest pain r/t hypoxia

Answer 89

- Respiratory failure (dyspnea, cyanosis,) r/t intrathoracic injury and inadequate diaphragmatic movement - Shock (decreased BP, increased HR) - Paradoxical movement of the chest (Inspiration: in; Expiration: out) leads to increased work of breathing - severe Pain and anxiety - Decreased chest expansion leads to decreased ventilation - Risk for hemothorax or pneumothorax - chest deformity and crepitation over fractured ribs

Answer 90

Description - Fractures of at least two neighboring ribs in two or more places or separation of rib from cartilage - Result of blunt chest trauma Care - Oxygen (or mechanical ventilation if respiratory failure or shock) - PEEP if severe hypoxemia and hypercarbia - Pain and anxiety management (talk slow, explain everything) - Promote lung expansion via deep breathing and positioning - Secretion clearance via coughing and tracheal suctioning - Monitor VS, ABG, f/e balance, vital capacity

Answer 91

Definition: clot or other matter lodges in pulmonary artery and disrupts blood flow to lungs Patho - Increased pulmonary vascular resistance and vasoconstriction (pulmonary HTN)) - Increased right ventricular workload -> decreased left ventricular preload, CO, BP, and shock - Increased alveolar dead space r/t V/Q mismatch - Bronchoconstriction r/t hypoxia, hypocarbia, and release of mediators which also increase airway resistance and promotes atelectasis - Compensatory shunting r/t V/Q mismatch (unaffected parts of lung perfused more)

Answer 92

- ABG’s (Respiratory alkalosis later becomes respiratory acidosis; hypoxemia r/t V/Q mismatch - D-dimer (Elevated (normal D-dimer rules out PE)) - EKG (Tachycardia, new a-fib, T-wave inversion, ST segment changeS) - V/Q scan (Ventilation present; perfusion decreased) - Doppler ultrasound lower extremities if r/t DVT - Echo

Answer 93

- Tachycardia - Tachypnea and dyspnea - Pleuritic, sharp, sudden chest pain - Cough - Crackles - Hemoptysis

Answer 94

- Obesity - Oral contraceptives - Postpartum - Cardiac problems (cardiomyopathy or a-fib) - Arterial or central venous catheters - Previous PE - Virchow triad (Hypercoagulability; Venous stasis (immobility, a-fib, decreased cardiac output); Injury to endothelium (Recent trauma or burns, atherosclerosis))

Answer 95

Optimize oxygenation - Intubate and put on ventilator or give oxygen via mask - Sedatives and analgesics to reduce work of breathing - Bronchodilators Prevent further clot formation and risk of more clots - IV continuous Heparin (preferred) (Lab: PT) - Oral warfarin (long term at least 3 months; once therapeutic then heparin discontinued) (Lab: INR) - Monitor bleeding w/ anticoagulants (ex. Hematuria, melena, bruising, bleeding gums) - Education: low vitamin K diet, Bleeding precautions (electric shaver, soft toothbrush), DVT prevention (prevent DVT (encourage mobility, SCDs, ROM exercises, hydration)

Answer 96

Dissolve clot - Thrombolytics (tPA, streptokinase) when massive PE and hemodynamic instability Remove clot (embolectomy if fibrinolytic contraindicated) Prevent further PE (filter) - Green field filter-umbrella (surgically placed in vena cava and prevents further thrombotic emboli from migrating into the lungs) - Useful if anticoagulants contraindicated, recurrent embolisms, survival of massive PE Reverse Pulmonary HTN - Fluids to increase right ventricular preload and contractility - Inotropes to increase contractility and cardiac output

Answer 97

Hypoxemia normocapnic (low PaO2) - r/t V/Q mismatch, intrapulmonary shunting (extreme V/Q mismatch r/t shunting of non oxygenated blood away from lungs) - Leads to lactic acidosis and MODS - causes (PE (V/Q mismatch); COPD; Asthma; Pneumonia; Atelectasis; Pulmonary edema Hypoxemia hypercapnic (high paCO2 and low paO2) - r/t alveolar hypoventilation - Causes: Airway and alveolar conditions (asthma, COPD); Central venous problems; Drug overdose; Spinal cord injury

Answer 98

Definition - Physiologically defined condition w/ inadequate exchange of O2 & CO2 - Body is not able to meet the need for O2 at rest - most common organ failure in ICU Labs/Diagnostics - ABG analysis– most specific indicator for evaluating effectiveness of therapy (PaO2 < 60 mm Hg; Hypercapnia (HCO2 > 45)) - Blood/sputum cultures (may be done via bronchoscopy) - Electrolytes, urinalysis, CBC - Cardiac- 12 lead EKG; Pulmonary artery catheter if severe (all hemodynamic factors) - Thoracic CT and Chest x-ray

Answer 99

CNS - Restless - Headache - Decreased LOC (confused, drowsy) - ischemic-anoxic encephalopathy Cardiac - Decreased cardiac output (hypotensive, systolic HTN) - Dysrhythmias - Chest pain - palpitations - VTE (Prevent: SCDs, heparin) Pulmonary - respiratory distress (retractions, nasal flaring) - Rapid shallow breathing and Dyspnea/SOB - Tripod position - Active abdominal movement - Cyanosis

Answer 100

GI - Decreased GI blood flow - Ascites and Abdominal distention - Anorexia - NV - Constipation - Stress ulcers (Prevent: H2 antagonists, PPIS) Renal (Impaired renal blood flow (decreased urine output) Skin (Cool, clammy)

Answer 101

- Delivery system should be tolerated by patient AND lowest FiO2 to maintain O2 sat > 90% - Use positive pressure ventilation if intrapulmonary shunting present - Noninvasive okay unless rapid deterioration - Use A/C mode

Answer 102

- Relief of bronchospasm via smooth muscle relaxation (bronchodilators) - Reduction of airway inflammation (corticosteroids) - Reduction of pulmonary congestion (diuretics) - Treatment of pulmonary infections (antibiotics) - Reduction of severe anxiety, pain, and agitation (sedatives, analgesics, neuromuscular paralysis) - Sodium bicarbonate if metabolic acidosis severe (pH < 7.2), dysrhythmias, or refractory to therapy

Answer 103

Promote clearance of secretions - Hydration and humidification oxygen - Suction PRN (hyperoxygenate prior - Chest physiotherapy and vibration - Deep breathing and incentive spirometer once extubated Nutrition - nutritional support (protein) - enteral route preferred - avoid under or overeating (undereating can decrease ventilatory drive; overeating can increase ventilatory demands due to increased CO2 production)

Answer 104

Positioning - If hypoventilation, use HOB 35-45 - If V/Q mismatch, place Least affected lung part in most dependent position (if bilateral, place right lung down b-c larger) - Change position q2h Prevent desaturation - early recognition w/ continuous pulse ox monitoring - Adequate rest and recovery b/w procedures - Minimize oxygen consumption (Sedation for anxiety)

Answer 105

Definition - sudden progressive form of acute respiratory failure - pulmonary manifestation of MODS Patho - Alveolar capillary membrane becomes damaged and more permeable to intravascular fluid - Alveoli fill with fluid and collapse causing noncardiac pulmonary edema - Lung compliance drops and they become stiff Timing: within 1 week of problem

Answer 106

- Exudative –hypovolemia and increased WOB in first 72 hrs (Injury to membrane and capillaries leads to pulmonary HTN, atelectasis, decreased cardiac output) - Fibroproliferative- alveoli become enlarged and fibrotic r/t disordered healing causing stiff lungs; more Pulmonary HTN and hypoxemia - Resolution- recovery; structural/vascular remodeling and removal of debris and fluid from alveolar

Answer 107

Direct (insult to lung epithelium) - aspiration of GI contents (common) - near drowning - respiratory infection (pneumonia (common), covid) - oxygen toxicity r/t mechanical ventilation) Indirect insult r/t injury elsewhere and mediators transmit via bloodstream to lungs - Nonthoracic Trauma (common) - Sepsis (most common) - DIC (disseminated intravascular coagulation) - Shock - fat emboli

Answer 108

- chest x-ray (whited out, bilateral infiltrates) - ABGs (low PaO2 (refractory hypoxemia even w/ O2 administration) OR low PCO2 (due to hyperventilation then increases w/ fatigue) - PaO2/FiO2 ratio: < 200 due to poor lung function

Answer 109

- respiratory distress (tachypnea, dyspnea, use of accessory muscles, suprasternal retractions - cough - restless, apprehension - scattered crackles - weight gain or loss

Answer 110

- Tachycardia to bradycardia - Hypo to hypertension - Diaphoresis - Cyanosis - Pallor - changes in sensorium with decreased mentation (somnolence, agitation) - Extracardiac sounds

Answer 111

- drugs to regulate and increase BP (norepinephrine) - PRBCs for hemodynamic support - Fluid restriction and diuretics for pulmonary HTN - Treat underlying infection and trauma (i.e. sepsis) - Sedation and analgesia that balance both comfort and desired ventilatory status

Answer 112

- suction PRN for secretion clearance - give lowest oxygen (< 0.5 to maintain sat O2 > 90%) - Low tidal volume (6 mL/kg) to limit barotrauma and volutrauma - Use PEEP (positive end expiratory pressure) – 10-15 cm H2O adequate -- risk for barotrauma

Answer 113

Uses - Improves V/Q matching - Improves oxygenation in patients with ARDS b-c Good lung down to the ground ( least damaged lung in dependent position) - Reduces aspiration risk via mobilization of secretions - Decreases intrapulmonary shunting Contraindications - increased ICP or spinal cord injury - hemodynamic instability - recent abdominal surgery

Answer 114

- tube/drain obstruction (care: move out of way) - Hemodynamic instability - Massive facial edema - Pressure injuries (care: continue to turn as needed) - Aspiration - corneal ulcerations (care: lubricate and close eyes)

Answer 115

Use - Helps with V/Q matching to improve oxygenation - Prevents further pulmonary complications r/t mechanical ventilation and bedrest Types - Kinetic therapy (> 40 degree continuous rotation)- Decreases VAP incidence - Continuous lateral rotation therapy (CLRT)-- <40 degree continuous rotation Complications - Dislodgment or obstruction of tubes/lines/drains - Pressure injuries (NURSE must still turn pt q2h) - Hemodynamic instability

Answer 116

- Hospital-acquired pneumonia Prevention: HOB elevate, hand hygiene - Barotrauma (r/t rupture of overextended alveoli from excess pressure)--s/s: subQ emphysema, sternal pain, clicking sound over heart, friction rub Prevention: smaller volumes of PEEP - Volutrauma (r/t too much volume ventilating non compliant lungs) Prevention: smaller tidal volumes - Stress ulcers r/t decreased GI blood flow Prevention: PPIs, H2 antagonists, enteral nutrition - Renal failure r/t decreased renal blood flow, hypotension, hypoxemia, hypercapnia Prevention: limit nephrotoxic antibiotics

Answer 117

Use (above glottis) - maintain airway patency via keeping tongue out of way - oropharyngeal is only used if unconscious w/ absent or diminished gag reflex Complications - Trauma to oral or nasal cavity (care: lubricate nares prior to insertion of nasopharyngeal - wrong length (If too long, blocks airway; If too short, tongue blocks it) - Laryngospasm - Gagging - Vomiting

Answer 118

Use (most common artificial airway) - short-term airway management (usually < 2 weeks) - usually oro b-c simpler and allows use of larger diameter - Naso ETT used for more patient comfort and preferred if jaw fracture Care - Daily chest x-ray to check placement - Secure tube to upper lip to prevent displacement - Know size and length of tube (extend 2 inches at lip or teeth?)

Answer 119

r/t Intubation -> Care: suction set up - Vomiting - Aspiration r/t actual tube - Oral or naso trauma, inflammation, ulceration (Ex. Laryngeal and tracheal injuries) - Sinusitis and otitis - Cardiac arrest - Pressure ulcers (Care: rotate; use high volume, low pressure cuff) - Tube obstruction and displacement

Answer 120

- Laryngeal and tracheal stenosis - Cricoid abscess - Hoarseness and vocal cord immobility - Stridor - Odynophagia, sore throat - Coughing - Pulmonary aspiration

Answer 121

Use: long term airway management ( > 7 days) Indications - Upper airway obstruction r/t trauma, burns, tumors, swelling - Airway clearance r/t spinal cord injury, neuromuscular disease, severe debilitation, inability to wean, prolonged unconsciousness Care - Never cut dressing (fold or use 4 x 4) b-c threads can be aspirated) - Cuffed tube for pts w/ mechanical ventilation - Deflate tube before decannulation b-c no airway if cuffed - always have extra tube of same size and smaller at bedside in case of displacement Patient education - Use shower shield - Wear medical alert bracelet to identify inability to speak

Answer 122

r/t procedure - Displacement of trach (emergency in first 72 hrs post-op b-c trach may close) (Care: Ambu if dislodged tube and have another nurse call RRT; 2nd nurse present when suctioning or moving pt in first 72 hrs) - Hemorrhage (small amount = expected; constant oozing is abnormal) - Laryngeal nerve injury (hoarseness) - Pneumothorax (Care: confirm bilateral breath sounds; hourly respiratory assessment) - Cardiac arrest - subQ emphysema (air in neck) After removal - Tracheal stenosis - Tracheocutaneous fistula

Answer 123

- Hemorrhage - Tracheomalacia (tracheal dilation and erosion of cartilage) - Tracheoesophageal fistula or tracheoinnominate artery fistula - Tube obstruction (S/s: difficulty breathing, noisy respirations, difficulty inserting suction catheter, thick, dry secretions, high peak pressures); care: use removable inner cannula, cough and deep breathe, suction, humidify oxygen) - Stoma infection (Prevention: sterile technique; assess q8h for s/s of infection (purulent drainage, redness, pain, swelling, change in tissue integrity)) - Displacement of tube (after 72 hrs)- Care: secure tube; replace tube immediately w/ bedside tube and obturator - Pressure ulcers (care: rotate and pad)

Answer 124

- q2h and as needed b-c increased bacteria r/t decreased saliva, poor mucosal status and dental plaque - Brush teeth and stimulate gums and tongue w/ swab - No glycerin, alcohol, hydrogen peroxide because drying effects - deep oropharyngeal suctioning for pooled secretions (painful for subglottic secretions so give pain meds or sedation) - 2% chlorhexidine q4-6h

Answer 125

- Pad pressure points if s/s of irritation - Lubricate nares, face, lip w/ nonpetroleum cream to prevent drying effect - Maintain cuff pressure (Low-pressure, high volume - Monitor cuff pressure every shift to maintain within 20-30 cm H2O (< 20 = increased risk of aspiration; > 30 = decreased blood flow to capillaries in tracheal wall (report to HCP))

Answer 126

Extubation: removal of ETT; Decannulation: removal of trach tube Care - Clear secretions above cuff prior to deflation - If accidental extubation or decannulation; place pharyngeal airway with head tilt-chin lift maneuver and ambu bag and cover stoma - Cover stoma with dry dressing after tracheostomy removal

Answer 127

- Use nonverbal (thumbs up, hand squeezes, sign language, gestures, lip reading, pointing, facial expressions, blinking) b-c tube does not allow airflow over vocal cords - Assess patient’s ability to communicate (Can speak if cuffless tube) - Provide assistive devices (hearing aids and eyeglasses; pen and paper, typewriters, computers, flash cards)

Answer 128

Humidify oxygen if > 4L w/ sterile water Purpose - Prevent drying and irritation of respiratory tract - prevent undue body water loss - Facilitate secretion removal (thick, dry secretions can occlude airway and increase risk for infection)

Answer 129

- Hypoxemia r/t disconnected oxygen Care: stop suctioning if O2 < 90% - Atelectasis r/t suction catheter > ½ diameter of ETT and excessive negative pressure or prolonged suctioning - Bronchospasms r/t stimulation of airway w/ catheter Care: Give bronchodilator - Dysrhythmias (bradycardia, heart block, v-tach) r/t vagal stimulation Care: Stop suctioning and hyperoxygenate - Increased ICP - Airway trauma r/t impact of catheter in airways and excessive negative pressure - Infection

Answer 130

- Hyperoxygenate with 100% oxygen for 30-60 sec prior to suctioning and 60 seconds after suctioning - Use < 150 mm HG of suction to reduce hypoxemia, atelectasis and airway trauma - Limit number of times patient is suctioned - Suction 10-15 secs continuously on the way out to reduce hypoxemia, airway trauma, cardiac dysrhythmias (Intermittent suction during withdrawal leads to secretion dropping) - Suction mouth or nose after suctioning artificial airway

Answer 131

- Rhonchi or wheezes (usually not for crackles) - Coughing - visible secretions in airway or indicated by dyspnea - Sawtooth pattern on flow-volume loop on ventilatory - Increased peak airway pressure on ventilator - Acute respiratory distress (increased RR (indicates hypoxia), HR; restless; decreased O2 sat)

Answer 132

- Support cardiopulmonary gas exchange (alveolar ventilation and arterial oxygenation - Increase lung volume (end expiratory lung inflation and functional residual capacity) - Decrease work of breathing - Assist with lung healing

Answer 133

- Relieve respiratory distress (hypoxemia, respiratory acidosis, muscle fatigue - Prevent or reverse atelectasis - Permit sedation and neuromuscular blockade - Reduce ICP - Decrease oxygen consumption - Stabilize chest wall - Protect airway

Answer 134

Definition: process of using an apparatus to facilitate transport of O2 and CO2 b/w atmosphere and alveoli to enhance pulmonary gas exchange Indications: Ventilation, oxygenation, airway and lung protection, secretions Types of ventilators - Positive-pressure: intubated and on machine via ETT or Trach; mechanical drive to force air into lungs - Negative-pressure: on machine but via mask; decrease atmospheric pressure around thorax to initiate inspiration

Answer 135

4 variables managed: time, flow, volume, pressure Variable mechanics - Trigger variable: initiates change from exhalation to inhalation (i.e time, pressure, flow) - Limit variable: sustains inspiration but does not end it (i.e. flow, volume, pressure) - Cycle: variable that ends inspiration (i.e any of the four variables) - Baseline: variable controlled during exhalation

Answer 136

Mode of ventilation - Assist Control (AC) - Synchronized Intermittent Mandatory Ventilation (SIMV) - Continuous Positive Airway Pressure (CPAP) Rate: respiratory rate (6-30 breaths/min) Tidal volume (VT): volume or size of the breath (6-10 mL/kg (4-8 mL/kg in ARDS) Positive-end expiratory pressure (PEEP) - amount of pressure remaining in the lung at the END of the expiratory phase; keeps alveoli from collapsing (3-5 cm H2O) - Risks of too much PEEP: barotrauma, decreased venous return FiO2 - fraction of inspired oxygen (Range: 21%-100%) - prefer <50% to maintain O2 sat > 92% and PaO2 > 60 mm Hg

Answer 137

How it works - Delivers a “machine breath” every time, whether the pt. triggers the breath or the ventilator initiates the breath (time-triggered) - patient cannot generate spontaneous volume or flow rate Indications - Volume controlled AC if weak respiratory muscles but spontaneous breathing (Risk for volutrauma) - Pressure controlled AC if decreased lung compliance, increased airway resistance or risk for Volutrauma (Risk for hypercapnia) Care - Hyperventilation risk if patient increases their respiratory rate - Sedation may be needed to limit # of spontaneous breaths

Answer 138

How it works - Delivers a pre-set number of breaths at a set volume or pressure and flow rate. - Allows the patient to generate spontaneous breaths, volumes, and flow rates between the set breaths. - Detects a patient’s spontaneous breath attempt and doesn’t initiate a ventilatory breath – prevents breath stacking (A/C does not prevent breath stacking) Indications - Volume controlled if weak respiratory muscles but spontaneous breathing - Pressure controlled if decreased lung compliance, increased airway resistance or risk for Volutrauma (Risk for hypercapnia) - used for weaning Risk - May increase work of breathing and promote respiratory muscle fatigue when used for weaning

Answer 139

How it works? - Positive pressure applied only on patient- initiated breaths on inhalation to augment efforts (similar to PEEP but only on inhalation vs. expiration) - Patient's lung mechanics and efforts controls rate, inspiratory flow, and tidal volume Use: for pt w/ stable respiratory drive to overcome mechanical resistance Risk: Hypercapnia Pros - Reduces work of breathing - increases ventilatory synchrony - Can be used with SIMV or CPAP

Answer 140

How it works? - Positive pressure applied during spontaneous breaths (no ventilator breaths in PEEP or CPAP mode) - Pt controls rate, inspiratory flow, tidal volume - Similar to pressure support but without the additional inspiratory pressure Indication - used with masks for sleep apnea (negative pressure) - used with ventilator (positive pressure) - used for weaning

Answer 141

Pro - Increase functional residual capacity - Improve oxygenation via opening collapsed alveoli at end of expiration Risks - Decreased cardiac output - Volutrauma - Increased ICP

Answer 142

- Increased secretions (care: Suction PRN) - Oxygen toxicity (Continuous oxygen > 50% for > 24-48 hrs may injure lung and reduce tissue integrity) --Care: notify HCP if PaO2 > 90 mm Hg - Respiratory muscle weakness - Ventilator-Associated Pneumonia - Ventilator induced lung injury

Answer 143

CNS - Increased ICP r/t decreased cerebral venous return GI (prevent: NGT decompression, appropriate cuff inflation) - Gastric distention r/t air leaks around ETT or trach cuff and overcomes resistance of lower esophageal sphincter - Vomiting r/t pharyngeal stimulation from artificial airway - Hypomotility and constipation r/t immobility and paralytic agents, analgesics, sedatives Cardiovascular compromise - Decreased Cardiac Output r/t decreased venous return to right side of heart Psychological complications - need for alternative communication - Patient ventilator dyssynchrony (Risks: auto-PEEP, psychological distress, decreased effectiveness) Care: ventilator accommodates patient’s spontaneous breathing pattern OR patient is sedated

Answer 144

Early s/s: dyspnea, nonproductive cough, sternal chest pain, GI upset, crackles Late s/s: decreased vital capacity and compliance; hypoxemia, pulmonary edema, hemorrhage, hyaline membrane formation and atelectasis Care: notify HCP if paO2 > 90

Answer 145

Causes - Barotrauma r/t too much PEEP - Volutrauma r/t too much tidal volume - Atelectrauma r/t shearing r/t repeated opening and closing of alveoli - biotrauma r/t inflammatory-immune response (Leads to ARDS) Care - keep pressure at 32 or below cm H2O - use PEEP - tidal volume of 6-10 ml/kg

Answer 146

Awakening Breathing Coordination Delirium monitoring Early mobility

Answer 147

- Maintain functional ambu bag at bedside - Ensure ventilator tubing free of water - Position ventilator tubing to avoid kinks - Monitor temp of inspired air (warm but not hot) - Ensure alarms audible

Answer 148

- Assess settings and do they correlate with presentation (any desynchrony?) - High pressure alarms = airway obstruction b-c patient ventilatory desynchrony, airway resistance or kinked tubing - Low pressure alarm = leak or oxygen not connected - If vent malfunctions, disconnect patient from vent and Ambu bag patient

Answer 149

Patient assessment - Listen to patient and breath sounds - Assess symptoms esp. pulmonary system (subQ emphysema, SOB, agitation, pain, work of breathing) - Assess placement and securement of ETT or trach Labs/Diagnostics - ABGs - Chest x-ray - Pulmonary function tests (Vital capacity, minute ventilation, peak inspiratory pressure, tidal volume (how much exhaled))

Answer 150

Development of pneumonia 48-72 hrs after endotracheal or other artificial airway insertion intubation b-c tube bypasses normal defense mechanisms of lung Risk factors - severe illness - increased age - presence of ARDS or malnutrition - naso intubation b-c promotes aspiration - Gastric alkalization by enteral feeds and meds b-c promotes bacterial growth

Answer 151

- Hand hygiene - Elevation of HOB (30-45 degrees) to prevent GER and aspiration - Daily “sedation vacations” and assessment of readiness to extubate - Stress ulcer prophylaxis - DVT prophylaxis - Daily oral care (teeth, gums, and tongue) with chlorhexidine q2h - Adequate endotracheal tube cuff pressure (Keep at 20cm H20-decreases aspiration)

Answer 152

Synchronized Intermittent Mandatory Ventilation - Gradual transition from ventilatory support to spontaneous breathing (slowly decrease rate until 0) - Get ABGs 30 min after trial PSV - Gradually decrease pressure support while maintain tidal volume until 5 cm H2O support achieved Spontaneous breathing trial - Remove from vent and use T-piece for spontaneous breaths OR just stop mandatory breaths on vent - Add CPAP to prevent atelectasis and improve oxygenation - Add PSV to augment inspiration - If successful, consider extubation or changing to uncuffed tube

Answer 153

Physiologic factors - Decreased gas exchange (ex. V/Q mismatch, anemia, hypoventilation, heart failure) - Increased ventilatory workload or demand (ex. Metabolic acidosis, decreased lung compliance, increased airway resistance, abdominal distention) - Decreased ventilatory drive (ex. Respiratory alkalosis or metabolic alkalosis, hypothyroidism) - Increased respiratory fatigue (ex. Malnutrition, Psychologic factors - Lack of motivation and confidence - Conditions that interfere with breathing pattern control (ex. Anxiety, fear, dyspnea) - Delirium

Answer 154

- spontaneous breathing trial - daily screening (stop sedation 1 hr prior to screening) - physiologically ready (hemodynamically stable, lungs capable of ventilation, original condition corrected) - psychologically ready (LOC stable - Decrease work of breathing via suction, HOB raised, sedatives for anxiety - interdisciplinary approach (PT for mobility)

Answer 155

Description: assistive ventilation required longer than expected given the pt’s underlying condition Levels - Simple: weaning terminated within 1 day of attempt - Difficult: completed > 1 day or < 1 week after first attempt - Prolonged: not terminated 7 days after first separation attempt

Answer 156

Initiation - start in morning - Give patient explanation on process and sensations - Closely monitor patient for any difficulties Progress: measure % of ventilatory support required or amount of time patient goes w/o vent Intolerance: show s/s of respiratory distress (dyspnea, accessory muscle use, restlessness, anxiety, change in facial expression, VS changes (HR, BP, RR) Outcome - Complete = able to spontaneously breath for 24 hrs - Incomplete = unable to wean and may go home on vent

Answer 157

Mucolytics (Liquefy secretions to help with their removal) Bronchodilators (beta 2 agonists and anticholinergics) - Relax smooth muscles when air flow limitations Steroids (Reduce airway inflammation) Sedatives - provide comfort - Decrease work of breathing and prevent ventilator fighting Neuromuscular paralysis (Nimbex-Cisatracurium besilate) - Decreases oxygen consumption: - sedate and explain all procedures to patient if giving paralytic b-c they do not inhibit pain or awareness - risk for immobility complications so prevent skin breakdown, DVT, and atelectasis

Answer 158

- Decreased VAP - Applied via mask (ex. CPAP, BiPAP) so easy application and removal - Increased comfort - Avoid danger of intubation while still keeping alveoli open

Answer 159

- Hemodynamic instability (i.e. dysrhythmias) - Apnea - Uncooperativeness/refusal/intolerance - Recent upper airway or esophageal surgery - Inability to maintain patent airway, clear secretions or properly fit mask - Emesis or copious secretions - Heavy sedation or restraints (requires mechanical ventilation b-c patient must be able to move mask if it displaces or they vomit)

Answer 160

- HOB elevation to prevent aspiration and facilitate breathing - Assess rr, accessory muscle use, oxygenation status - Ensure proper fitting mask (tight seal) - Transparent dressing over facial pressure points to prevent air leaks and facial pressure injuries - NGT for decompression as needed b-c risk for vomiting - Spend 30 min w/ patient after initiation b-c needs reassurance on how to breath on vent

Exam 1 Flashcards

(184 cards)