Final Exam - Part I Flashcards
(105 cards)
1
Q
______ is defined as an abnormally low arterial oxygen tension.
A
Hypoxemia
2
Q
_____ refers to insufficient oxygen in the tissues, and can be generalized or local. What 2 other measures should be taken to measure hypoxia?
A
hypoxia
pulse ox and blood gas analysis
3
Q
What are the 5 general mechanisms that cause hypoxia? Which ones cause hypoxia at rest? Which one is MC? Which one is NOT clinically relevant in the inpt setting?
A
hypoventilation
vent/perfusion mismatch** MC
right to left shunt
diffusion abnormalities
reduced inspired oxygen tension-> NOT relevant in the inpt setting
4
Q
What are 3 reasons for acute oxygen therapy?
A
hypoxemia (PaO2 < 60 mm Hg or oxygen saturation [SaO2] < 90%)
tachypnea with a respiratory rate >24 breaths/minute.
5
Q
What are the 2 main oxygen delivery systems? Which one has room air mixed in? What are 3 types of masks for low flow oxygen?
A
low flow and high flow oxygen
low flow: nasal cannula (NC), simple mask, and reservoir mask
6
Q
What masks do high flow oxygen therapy use?
A
venturi masks
7
Q
What are the 3 goals for breathing fractions of inspired oxygen?
A
-Increase alveolar oxygen tension
-Decreasing the ventilatory work required to maintain adequate alveolar oxygen tension (Pa02)
-Decrease myocardial work
8
Q
_____ Consistent, predictable administration of oxygen allows for the evaluation of adequacy and effectiveness of oxygen therapy through clinical assessment and ABG
A
FIO2
Fractions of Inspired Oxygen (FIO2):
9
Q
When is a non-rebreather vs rebreather used?
A
NRB typical in clinical setting-exhaled gases vented to atmosphere
-RB (expensive)-used in anesthesia
10
Q
What are the advantages of the high flow devices?
A
consistent FIO2 if properly applied despite variation in ventilation pattern. Can control temperature and humidity
11
Q
**One liter of oxygen typically increases pulse ox by ____
A
4%
12
Q
What are the 2 main causes of inadequate ventilation?
A
Inadequate respiratory effort
Airway Obstruction
13
Q
What usually causes inadequate respiratory effort?
A
Inadequate respiratory effort can result from intrinsic (intracranial hemorrhage) or extrinsic (opioid overdose) factors
14
Q
What are the 2 airway maneuvers? Which one can you use in a c-spine injury?
A
head tilt/chin lift
jaw thrust: can use if concerned about c-spine
15
Q
**When is an oropharyngeal airway used?
A
only use in a DEEPLY unresponsive patient who is unable to maintain his/her own airway
16
Q
When are NPAs used?
A
NPAs can be used if patient not tolerating OPA or difficult OPA
17
Q
What 3 things does bag mask ventilation depend on? How should you squeeze a bag mask? What is the rate?
A
Patent airway
Adequate mask seal
Proper ventilation (volume, rate, cadence
Squeeze steadily over 1 second
Rate should not exceed 10-12 breaths per minute
18
Q
What are the 2 different types of noninvasive ventilation?
A
CPAP and BiPAP
19
Q
What are the 3 indications for intubation?
A
- failure to maintain a patent airway
- failure to oxygenate or ventilate
- anticipate deterioration in clinical condition
20
Q
What are the 3 different types of emergency airway management?
A
rapid sequence intubation (RSI)
bag-valve mask ventilation (BVM)
Endotracheal intubation
21
Q
What are the 5 indications for mechanical ventilation?
A
22
Q
What are the 4 phases of mechanical ventilation?
A
23
Q
What are the 3 different types of breaths of mechanical ventilation?
A
controlled, assisted and spontaneous
24
Q
_____ are triggered by the ventilator and have limit and cycle variables set by the ventilator operator.
A
controlled breaths
25
_____ are similar to controlled breaths, in that limit and cycle variables are set by the
assisted breaths
26
_____ are triggered and cycled by the patient.
spontaneous breaths
27
What is the overarching goal of intubation and mechanical ventilation?
is to support the patient while treating or awaiting the underlying cause of respiratory failure to sufficiently improve such that the patient can resume independent breathing
28
What can shorten the time a pt spends on mechanical ventilation?
scheduled daily sedation breaks and consideration for spontaneous breathing trials (SBT) shorten the duration of mechanical ventilation
29
What is the general criteria to evaluate an intubated pt for when deciding to try a trial of spontaneous breathing?
30
What are the 4 categories that need to be assessed when weaning ventilation?
disease-> needs to be significantly improved
neurological function- > pt needs to be alert and following commands and able to initiate a breath
respiratory
cardiovascular -> hemodynamically stable and on minimal inotropic/vasopressor support
31
What are the respiratory requirements to wean ventilation?
The patient should have an oxygen requirement of Fi02
32
Who is needed at bedside to extubate a pt?
nurse
respiratory therapist
physician
33
What are the steps to extubate a pt?
pt should be sitting up and informed of the process
clear secretions in the mouth and pharynx
The ETT holder is subsequently disconnected from the ETT, the balloon deflated, and the ETT removed in a swift motion
secretions are suctioned again and the pt is encouraged to cough
34
**What are the criteria for SIRS, need ___ of the 4. What is the mortality rate?
Temperature > 38 or < 36
Heart Rate > 90 bpm
Respiratory Rate > 20
WBC > 12,000, < 4,000, or > 10% immature (band) forms
Need 2 of the 4
Carries up to an approximate10% mortality rate
35
What are the sepsis criterai?
SIRS plus culture proven or presumer presence of infection
OR
Life-threatening organ dysfunction caused by a dysregulated host response to infection
36
What is the severity of sepsis graded on?
organ dysfunction and hemodynamic compromise
37
Sepsis is the ____ MC cause of death in the US
9th
38
Define severe sepsis
is defined as Sepsis with one of more symptoms of organ dysfunction/tissue hypoperfusion-hypoxia
that must be due to sepsis NOT a pre-existing condition and symptoms must persist despite given at least 3 Liters of fluids
39
What are the 9 signs of severe sepsis?
40
Define septic shock
Sepsis with refractory hypotension with mean SBP lower than 65mmHg unresponsive to crystalloid fluid challenge of 30 cc/kg (IBW) (3 liters minimum) or Lactic acid level > 2 (or 1.6) after appropriate management of hypovolemia
41
What is the fluid of choice for septic shock?
with 0.9% NS or LR
42
What is the mortality risk of septic shock?
Mortality risk 40-60%
43
What is Multiple Organ Dysfunction Syndrome MODS?
Severe acquired dysfunction of at least 2 organ systems, lasting at least 24-48 hours in the setting of:
Sepsis
Trauma
Burns
Severe inflammatory conditions
44
What does the mortality of MODS depend on? What are the mortality rates if 1, 2, or 3 organs are involved?
Mortality = number of dysfunctional organs and duration of dysfunction
One organ lasting more than 1 day - 20% mortality
Two organs lasting more than 1 day - 40% mortality
Three organs lasting more than 3 days - 80% mortality
45
Pts with sepsis, ____ will have a positive blood culture. ___ will have no microbial cause identified from any source
less than 50%
20-30%
46
What are the MC sites of infection that lead to sepsis?
UTI and respiratory tract
47
What are the general treatment approaches to sepsis?
Empiric antibiotics while cultures are pending
Optimal fluid resuscitation
Pressors as needed
Additional therapies as needed: Drainage of abscess, Removal of lines, moderate control of hyperglycemia, and steroids if indicated.
48
What is included in the Society of Critical Care Medicines 1 hour bundle for sepsis?
49
**What are the goals for abx therapy in sepsis?
**Start antibiotic within 1 hour
approperiate abx directed against suspected organisms
50
When would you need to consider a fungal source?
Recent abdominal surgery
Patient on TPN
Chronic Steroid Use
51
What are the top 4 MC organisms that cause sepsis? What are 2 others you should consider?
Escherichia coli
Staphylococcus aureus
Klebsiella pneumoniae
Streptococcus pneumoniae
MRSA and pseudomonas
52
What are the risk factors for MRSA?
Prior history of MRSA or colonization
Recent IV antibiotics
Chronic wounds
Recurrent skin infections
Invasive devices
Hemodialysis
Recent Hospitalization
Severity of illness
IV Drug use
53
What is the abx regimen if pseudomonas is UNLIKELY?
VANC PLUS 1 of the following
cefriaxone/cefotaxime/cefepime
pip/taz or ticarcillin-clavulanate
meropenem or imipenem
54
What is the abx regimen if pseudomonas is LIKELY?
Vanc PLUS 2 of the following:
Ceftazidime/cefepime
impipenem, meropenem
pip/taz or Ticarcillin-clavulanate
cipro
gentamicin/amikacin
aztreonam
55
**_____ is the first line vasopressor used in sepsis. What should the MAP be?
**norepinephrine
target MAP of 65
56
_____ is 2nd line vasopressor used in sepsis
vasopressin is 2nd line then dobabutamine
57
What are the recommendations for steroids in septic shock?
Hydrocortisone in adult pts with septic shock when hypotension responds poorly to fluid resuscitation and vasopressors
Hydrocortisone is steroid of choice
58
What is the preferred glucose range in sepsis?
Aim for Moderate glycemic control (BG 140-180 mg/dL). Tight glycemic control can lead to worse outcomes.
59
_____ is super important to maintain and if indicated need to start _____ early
nutrition!!
start enteral feedings early (less than 48 hours)
caution with TPN because it can lead to increased infectious complications
60
When is TPN indicated in sepsis?
Only use if absolute necessary. Indicated in post-GI surgery.
61
What should the MAP be in sepsis? Urine output?
MAP ≥ 65 mmHg
Urine output ≥ 0.5 mL/kg/hr
62
What are some complications of severe sepsis/septic shock?
acute lung injury
kidneys injury: ATN-requiring short of long-term dialysis
weakness
ICU delirium
63
When is it safe to transfer a pt from the ICU to the general floor?
Hemodynamically stable-off of vasopressors
No need for invasive monitoring
Not intubated or requiring intermittent noninvasive mechanical breathing (CPAP/BiPAP)
64
What are 3 ways to lower risk of sepsis?
early removal of:
Urinary catheters
Central venous catheters
Extubation when possible
65
What is patient safety? What are errors defined as?
freedom of accidental medical injury, which is often the result of error
failures of execution or planning
66
What is the difference between near misses and adverse medical events
near miss: an event that causes no harm but had the potential to do so
adverse medical event caused the patient harm
67
What are medical errors usually the result of?
incompetence, poor preparation or lack of motivation
68
How many people a year develop infections during their hospitalization? What are the hand-hygiene rates?
nearly 2 million
30-70%
69
What patient populations are considered vulnerable for medical error?
elderly pts
ped pts
pts undergoing neuro, thoracic or vascular sx
pts admitted urgently rather than electively, especially in the ICU
70
What are the 2 major categories of medical error?
human based and system based
71
How are human performance defined based on what 3 categories? What are the 2 further subdivisions?
skills
rule-based actions
performance
errors of execution and errors of planning
72
What is the main contributor to the human performance shortfall? What are the 4 limitations to a typical human?
limitation of human performance
1. humans have a SHORT term memory
2. humans naturally cut corners and create workarounds
3. stress can cause tunnel vision and filtering
4. fatigue
73
**the impact of _____ is similar to having a BAC of ____
fatigue
0.1%
74
**error rate under _____ when dangerous activities are occurring ____
very high stress
rapidly
75
What has the systems based focus shifted to?
systems in which individuals work in order to design defenses that identify, intercept and prevent errors before they result in harm
76
**______ are the MC cause of nosocomial bloodstream infections
indwelling vascular catheters
77
What 2 pathogens cause more than 2/3rds to 90% of all CLABSI?
staph epidermidis and staph aureus
78
What are the criteria to consider it cellulitis?
must go to dermal layer
79
What are ways to prevent intravascular catheter related infections?
use a subclavian site rather than jugular or femoral site
aseptic technique
80
What is appropriate aseptic technique for short-term peripheral catheters?
standard hand hygiene before catheter insertion with proper aseptic technique while inserting and manipulating
81
What is the aseptic technique for central lines?
max sterile barrier precautions during insertion of central lines
sterile gloves, gown, cap, mask, large drape aka all the things
82
What cleaning solution should be used when cleaning the pt for a central line placement? For peripherals?
2% chlorhexidine
any skin antiseptic can be used for peripheral insertion
83
How often should you change peripheral short-term catheters? What if aseptic technique is NOT ensured?
q 72-96 hours
replace every 48 hours
84
What should you clean hubs with prior to using them?
clean hubs with 70% ethanol prior to use
85
Up to __% of elderly pts develop pressure ulcers within the first week of hospitalization. _____ may be as high as ___% for older persons with pressure ulcers in the year after hospital discharge
15% develop pressure ulcers
mortality as high as 60%
86
What are some causes and risk factors for pressure ulcers?
frictional forces between the heels and bedsheets
bedbound patients
older pt because their skin is susceptible to shear forces
moisture: think urine facilitates skin breakdown
87
What are the 5 basic components for comprehensive pressure ulcer prevention?
risk assessment
skin care
mechanical loading
support surfaces
nutritional support
88
What is the risk assessment used the most widely in the US for pressure ulcers? How is it scored? What is the cutoff score?
Braden scale for predicting pressure sore risk
6= high risk
23= low risk
18 is the cut-off score for onset of pressure ulcer risk
89
When should you assess risk for pressure ulcer?
admission
discharge
whenever the pt's clinical condition changes
90
Where should you pay close attention to when performing braden scale for pressure ulcer risk assessment?
greater trochanter, heels, sacrum and coccyx because >60% of all pressure ulcers occur at these locations
91
What is reasonable prevention with regards to repositioning for hospitalized patients to prevent pressure ulcers? What is the range?
every 2 hours
critically ill may require hourly repositioning and some in specialty beds may only need it every 4 hours
92
What are 2 different surface supports that may help prevent pressure ulcers?
heel boots and waffle mattress
93
_____ are the MC type of adverse event in acute care hospitals. How many result in injury?
falls
1/3 result in injury
94
____ of falls are thought to be preventable. What does a fall due to the length of a hospital stay?
1/3 of falls are preventable
increases length of stay by average of 6.27 days
95
What pt population age range is likely to fall? What age range are most likely to incur injury?
fall rate is higher among patients 65 years old and older
patients over the age of 85 are the most likely to incur injury because of a fall
96
Where do most falls occur in the hospital?
occur in the pt's rooms and bathrooms during transfers between the bed and a chair
OR
while using the toilet or shower
97
What are som extrinsic factors that increase risk of falls?
use of FOUR or more rx drugs
use of high risk medications
environmental challenges
98
What are some of the aspects of the universal falls prevention in a hospital setting?
nursing staff orient all pts to the hospital environment
pt's possessions and call bell are easily within pt's reach
floor is clean and dry
pt's wear nonskid socks
99
_____ accounts for 25% of all VTE dx in the community
recent hospitalization for medical illness
100
What are 4 potentially serious long-term complications from a VTE?
post-thrombotic syndrome
cardiorespiratory insufficiency
recurren VTE
bleeding associated with anticoag therapy
101
What are the 7 highlighted VTE risk factors?
acute medical illness (CHF, COPD)
Acute ischemic stroke
acute neurologic dz
IBD
Cancer
sepsis
previous VTE
102
_____ is the VTE prohpylaxis prediction tool. Who needs to be assessed for VTE prophylaxis?
padua prediction score
everyone!!!
103
What are the VTE prophylaxis therapy options? Which one is used more commonly?
LMWH** used more frequently because it is only 1 SC shot a day
unfractionated heparin
104
_____ needs to be adjusted for renally impaired pts. What is normal dose? What is renal dose?
LMWH
normal: 40mg SC qd
renal: 30mg SC qd
105
_____ is a possible condition with which VTE prophylaxis med? What type of pt? What do you need to monitor?
heparin-induced thrombocytopenia
UFH in surgical pts
monitor platelets
