Fundamentals part 1 Flashcards
(44 cards)
What is the first thing to know if a patient is on a ventilator?
First thing is to know WHY they’re on it
What will they try before a patient is put on ventilator?
Non-invasive modalities (and if they fail then you will do the vent)
like nasal cannula
bipap
“drive for breathing”
co2 levels
co2 lab range
35-45
What is the compensation method for too much co2 in a clients system?
hyperventilation bc co2 is dependant on respiratory rate
Patient asks what area of the brain regulates their breathing rate. What do you tell them?
It is their medulla
What happens to the vessels if co2 is high
What does this cause?
Common issues. but can you explain why?
Blood vessels will vasodilate
And then BP drops
fluid retention, kidney & brain problems
How often will oral care orders be for a ventilated patient?
How often will you reposition the patient?
Will you always reposition?
q2 hours
q2 hours
- not always if there is a contraindication
How are meds given when a patient is on a ventilator?
Will change the route to IV
unless it is a navel drug
major sign of co2 build up in a patient
to compensate, they’ll try to hyperventilate
what assessment tool can help assess for co2 build up in a patient
what values
glascow coma scale (due to consciousness measurement)
normal is 15
if less than 8, intubate
how do we check to see if our ventilation intervention was successful for an patient?
check abgs
what is the significance of the medulla obloganta
it sets the respiratory breathing rate
what does the pons do
Takes care of the depth and length of respirations
what part of the brain allows for altering of breathing
cerebrum
List the symptoms of patient with a high Co2.
What does the high CO2 do to BP?
What does this lead to?
fatigue, headache, confusion
If you have too much co2, your vaso will vasodilate so BP drops
Fluid retention
&
Can lead to kidney and brain issues
What happens to vessels if co2 is low?
What happens to the HR next?
the vessels vasoconstrict
HR increases to get more perfusion done
and sometimes the perfusion isn’t enough for peripheral body parts
Your ventilated patients CO2 levels are high. What nursing intervention will you consider doing before calling the doctor?
Suction secretions bc these can block the Co2 from exiting
Check their o2 sat
- remember how to power-shoot if this is off
What should the HOB be at for a ventilated patient?
When we assess the patient’s lungs, what are we assessing for?
HOB at 45 degrees
- to avoid aspiration & pneumonia
Assess for crackles
before suctioning what is a good intervention to do on the mechanical vent?
hyperventilate so they don’t de-sat
You need to reposition your vented patient. Since they’re ventilated, what should you do?
Hold the tubing in place so that it doesn’t accidentally come out.
You hear the high pressure alarm go off for the vented patient.
What does it mean if it goes off?
What do you do?
Your vented patient begins to cough. What do you do?
There is a blocked airway or occlusion.
Or something more serious like a Tension pneumothorax
You should always check and see why it is going off.
Reassure them and tell them to cough. Stay with them & talk them through it.
What does it mean when you hear a low pressure alarm go off on the ventilator?
What should you do if you hear it?
The vent didn’t reach the pressure it needed to be at or exhale wasn’t measured properly.
Check tubing and wipe away any condensation.
You hear alarm go off on the mechanical vent. What should you do in order?
What should you make sure is in the room at the start of the shift?
- Check the patient first.
- Check the tubing.
- Call RT
- Bag pt with ambu bag
Ambu-bag
