Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

PHTH564 > Midterm exam > Flashcards

Midterm exam Flashcards

1
Q

The effect of anesthesia on respiratory function depends on? (3)

A

Depth of general anesthesia
Patient’s preoperative respiratory condition
Presence of special intra-operative and surgical conditions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the 6 effects of anesthesia on respiratory function?

A
  1. Altered breathing pattern
  2. Decreased respiratory drive
  3. Decreased FRC
  4. Decreased lung compliance and increased resistance
  5. Increased V/Q matching
  6. Depressed of abolished cough reflex, decrease mucocilary escalator
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Describe the breathing pattern change w/ anesthesia (light, deepening, deep and very deep anesthesia).

A

Light = respiration may be irregular
Deepening = regular, more than normal VT, prolonged forceful expiration
Deep = rapid, shallow breathing (panting)
Very deep = jerky, gasping, irregular

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Name 3 general characteristic of the altered breathing pattern w/ anesthesia.

A

Chest wall asynchrony
Elevation of Vd/Vt (total dead space)
Monotonous breathing = loss of sigh or yawn

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the normal sighing/yawning rate in an hour for an awake and healthy human?
What is the purpose of that normal yawning/sighing?

A

10/hour

Allow to take deep breaths = stimulates surfactant production

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What causes the chest wall asynchrony w/ anesthesia?

A

Loss of intercostal ms contribution to inspiration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What causes decreased respiratory drive w/ anesthesia? (2)

A
  1. Progressive decrease in VE as anesthesia deepens

2. Decrease central chemoreceptor sensitivity = decrease VE response to CO2 stimulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What happens when we bring lung closer to RV? (3)

A
  1. Increased airway closure
  2. Increased airway resistance
  3. Atelectasis and shunting
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the causes of decreased FRC w/ anesthesia? (5)

A
  1. Supine position during Sx = diaphragm displaced up into the chest wall by the abdo viscera
  2. Reduced rib cage ms tone = no expansion of rib cage
  3. Increased abdo ms tone = contributes to lengthening of diaphragm
  4. Additional loss of ms tone w/ ms paralysis
  5. Manipulation of the lung/diaphragm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Why decreased lung compliance is related to reduced lung volume w/ anesthesia?

A

If FRC decreases, airways become more narrow which increased airway resistance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Why mucociliary action is reduced w/ anesthesia?

A

Anesthesia, intubation, pain meds, suppl. O2 all have a drying effect on the cilia which decrease its ability to beat

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Why V/Q mismatching is increased w/ anesthesia? (3)

A
  1. Change in shape and motion of the chest wall = decreased thoracic excursion/maintained abdominal motion
  2. Inhaled anesthetics –> inhibition of hypoxic pulmonary vascoconstriction
  3. Non dependent regions (upper lung) better ventilated w/ mechanical ventilator
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are 8 the patient-related risk factors to have post-op complications?

A
  1. Pre-existing pulmonary impairment of neuromuscular illness (ASA > or = class 2)
  2. Increasing age: > 60 y.o
  3. Inactivity
  4. Active smoking (w/i last 8 weeks)
  5. Presence of skeletal deformities
  6. Malnutrition-serum albumin level < 30 g/L
  7. Noncompliant patient
  8. Obesity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

T or F

There’s an increased rate of post-op pulmonary complication in COPD.

A

T

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q 
Pt in ASA class 2 are more at risk of post-op pulmonary complications, what are risky spirometry values?
VC
FEV1
DLCO
VO2
A

VC < 50% predicted
FEV1 < 2L or 50% FVC
DLCO < 50% predicted
VO2 < 15mL/kg/min during exs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Why older pts are more at risk of post-op pulmonary complication? (2)

A
  1. Coexistent medical problems

2. Alterations in pulmonary function w/ age = increased closing capacity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Why is active smoking a patient-related risk for post-op pulmonary complications? (2)

A
  1. Reduces ciliary action

2. Irritation of airways w/ increased mucous production

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are the 2 surgery-related risk factors for post-op pulmonary complications?

A
  1. Type of Sx

2. Prolonged operative procedures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Classify the most risky cardioresp Sx to the least risky.

A

AAA > Thoracic > upper abdo > lower abdo > non abdo/non-thoracic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Diaphragm dysfunction is possible to occur during abdo/thoracic Sx:

  • What is the consequence of this?
  • What causes this?
  • Is it reversible?
A
  • Decrease FRC and ventilation in dependent (lower) lung zones
  • Splanchnic/abdo receptor stimulation during Sx = inhibition of central drive/decrease phrenic motor input OR phrenic nerve irritation during Sx
  • Yes, goes back to normal 1 week post-op
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

With duration of anesthesia, when does the risk for post-op complication becomes important?

A

Duration of anesthesia > 3 hrs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

T or F
Higher risk of post-op complication w/ epidural/spinal anesthesia and video-assisted horoscopic surgery than general anesthesia.

A

F

Lower risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Who am I?

Submammary incision extending from near midline to the 4th or 5th intercostal space at the misaxillary line.

A

Anterolateral thoracotomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What are the ms cut in anterolateral thoracotomy? (3)

A
  1. Pectoralis major
  2. Serratus anterior
  3. Internal and external intercostals
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Who am I?

Incision extending laterally from an area btw the scapula and vertebrae to the anterior axillary line of the 5th intercostal space (may also 4-6 or 7-8 for esophagus Sx).

A

Posterolateral thoracotomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What is the major problem w/ posterolateral thoracotomy?

A

Scapular instability

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What posture pts usually adopts w/ posterolateral thoracotomy?

A

Scoliosis towards operated side

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What are the ms cut in posterolateral thoracotomy? (5)

A
  1. Lower fibers of trapezius
  2. Latissimus dorsi
  3. Serratus anterior
  4. Lower fibers of rhomboids
  5. Internal and external intercostals
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What is a thocaroplasty?

A

Permanent collapse of part of a lung by removal of all or a portion of ribs 1-7

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

free card

A

free card

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What are the ms cut w/ thoracoplasty? (6)

A
  1. Trapezius
  2. Rhomboids
  3. Lat dorsi
  4. Serratus anterior
  5. Pec major
  6. Scalene
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What are the postural deformity usually observed w/ thoracoplasty? (3)

A
  1. Lack of structural support
  2. Limitation of shldr and trunk mvt = long lean of trunk on ipsilateral side so that shldr are out of alignment w/ hips
  3. Paradoxical breathing (bcs no more ribs to support lungs)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Who am I?

Vertical incision of the sternum usually used for cardiac Sx or of the mediastinum.

A

Median sternotomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What are the 2 main problems w/ median sternotomy?

A
  1. Kyphosis and splinting due to pain

2. Reduced chest expansion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Who am I?

Incision from 8th to 9th intercostal space at posterior axillary line to midline of the abdo.

A

Thoracoabdominal incision

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Thoracoabdominal incision are big incision and allow surgery of which structures? (6)

A 
diaphragm 
esophagys
biliary tract
kidney
thoracic aorta
upper abdo aorta
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What are the ms cut w/ Thoracoabdominal incision? (4)

A
  1. Lat dorsi
  2. Serratus anterior
  3. External oblique
  4. Rectus abdominus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What is a common posture observed w/ Thoracoabdominal incision?

A

Forward flexion posture = splinting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What are the 3 main problems w/ Thoracoabdominal incision?

A

Difficulty coughing
Difficulty deep breathing
Difficulty thoracic expansion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Who am I?

Resection of one or more lobes of the lungs.

A

Lobectomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Where’s the incision for lobectomy?

A

Depends on the site of the lesions and surgeon’s preference

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

What happens to the remaining lung in lobectomy?

A

expands to fill much of the remaining space

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

When are these procedures used?

  1. Simple lobectomy
  2. Lobectomy by sleeve resection
A
  1. Bronchial carcinoma

2. If neoplasm has spread to mainstem bronchus = end-to-end anastomosis of the main bronchus and remaining lobe bronchus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Who am I?

Surgical procedure that removes une segment of a lobe and used for localized lesions (abscesses, benign tumors, cysts, TB, etc)

A

Segmental resection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Who am I?

Removal of a small area of the lung.
Used for large bullae cysts, biopsies, peripheral tumors, localized fungus disease.

A

Wedge resection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Who am I?

Total excision of one lung.
Used for extensive carcinoma.

A

Pneumonectomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

During a pneumonectomy, what happens to:

  1. Parietal and visceral pleura
  2. Mainstem bronchus
  3. Pulmonary artery and vein
A
  1. Removed
  2. Stapled off
  3. Ligated and cut
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

What happens to diaphragm post-pneumonectomy?

A

Rises

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Post-pneumonectomy, mediastina and thoracic structure will shift to the operated side, what eventually prevents that from happening?

A

Effusion of serous fluid and blood forms fibrous tissue which eventually prevents the mediastinal shift

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Who am I?

Removal of the pleural sac of a segment or entire lung which makes the lung tissue adheres to the internal chest wall.

A

Pleurodectomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

For which condition pleurodectomy is usually used?

A

Recurrent spontaneous pneumothorax

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Who am I?

Stimulation of a reaction of the pleural space lining causing adhesion of the visceral and parietal pleura.

A

Pleurodesis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

For what pleurodesis is usually performed?

A

To prevent lung collapse in recurrent pneumothorax or malignant pleural effusions.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Who am I?

Removal of a restrictive membrane from the surface of the lung (i.e thickened pleura following empyema)

A

Decortication

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

What are the 4 most common types of lung biopsies?

A
  1. Percutaneous needle method
  2. Transbronchial method
  3. VATS
  4. Open lung = thoracotomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Who am I?

Removal of a portion of the emphysematous lung to reduce hyperinflation and improve lung mechanics of the remaining tissue.

A

Lung volume reduction surgery (LVRS)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

What are the consequences on respiratory function of LVRS? (6)

A
  1. Decrease dyspnea
  2. Increase FEV1
  3. Improved lung volumes
  4. Decrease CO2 retention
  5. Decrease need of suppl. O2
  6. Increase exs capacity (6MWT)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

What is the purpose of chest tubes?

A

To evacuate air, blood and other body fluid/

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

What are the possible insertion sites for chest tubes? (3)

A

Pleural
Pericardial
Mediastinal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

For what conditions chest tubes are used? (6)

A 
Pneumothorax
Pleural effusion
Hemothorax
Empyema
Pericardial effusion
Post- thoracic/cardiac surgery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

What is the purpose of the water seal bottle in chest tube?

A

To prevent drainage back into the chest cavity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

For chest tubes, how is the swing w/:

  1. quiet breathing
  2. coughing/increased respiratory effort
A
  1. Small mvt

2. Large mct

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

T or F

If attached to suction, the swing in the chest tubes is reduced.

A

T

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

How much should the fluid in the tube or the water-sealed chamber should move when pt is breathing?

A

+/- 5 cm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

In chest tube, what’s happening if there’s no swing?

A

Tubing may be occluded or lying outside the pleural space –> URGENT, report to med team

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

What does bubbling indicate in chest tubes?

A

Air leak from pleural space which is good (this is what we want the tube to do)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

How will bubbling be in chest tube if:

  1. No air leak
  2. Air leak w/ forced expiration
  3. Air leak w/ passive expiration
  4. Continous air leak
A
  1. no bubbling = we can remove the tube, air has been drained
  2. bubbling on coughing (small air leak)
  3. bubbling on expiration (moderate air leak)
  4. bubbling throughout inspiration and expiration (large air leak)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

T or F

In chest tubes, drainage can increase during pt’s mvt (transfers, exercises).

A

T

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

What does a large amount of blood draining over a short period of time may indicate in a chest tube?

A

hemorrhage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

T or F

A sudden increase of drainage volume is normal in a chest drain.

A

F

Not normal, alert the nurse/MD ASAP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

When is the chest tube usually removed by the MD?

A

When drainage is < 100 mL in 24hrs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

T or F

Patient can lie on the chest tube.

A

T

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

T or F

Chest collection device should be kept above the chest tube insertion site.

A

F

Device should be kept lower than the insertion site to avoid drainage of fluid back to patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

Which kind of exs should be encouraged for pt w/ chest tubes?

A

Shldr ROM exs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

What are the 4 main objectives of perioperative PT?

A
  1. Decrease postoperative incidence of complications
  2. Decrease hospital stay
  3. Decrease pt anxiety
  4. Increase pt self-efficacy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

What are the 5 things PT assess pre-op?

A
  1. Cognitive status
  2. Capacity to cooperate
  3. Language and communication skills
  4. Attitudes towards Sx and care
  5. Risk factors
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

On what do you educate pts pre-op? (7)

A
  1. Smoking cessation
  2. Sx procedure
  3. Effects of anesthesia
  4. Systemic effects of bed rest and immobility
  5. Monitoring and supportive device used post-op
  6. Post-op procedures (recovery room, ward, ICU)
  7. Rx rationale (prevention or reversal of post-op complications)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q

What are the primary goals of preoperative PT?(9)

A
  1. Aid lung expansion and prevent atelectasis
  2. Remove excess secretions = to decrease occurance of atelectasis and chest infection
  3. Prevent circulatory problems (DVT, PE)
  4. Maintain and restore ROM and STRG
  5. Control anxiety and modify pain
  6. Maximize chest mobility and prevent postural deformities
  7. Restore exs tolerance
  8. Maintins skin integrity
  9. Provide instruction for Rx btw Rx
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

When do we start PT post-op?

A

Day after Sx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

What is the purpose of inspiratory holds?

A

Increase lung volume

To open up atelectatic areas

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
81
Q

Post-op what specifically do you practice w/ pt for early mobilization? (3)

A
  1. Rolling
  2. Sitting (if hemodynamically stable) = in crease FRC
  3. Ambulation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
82
Q

Post-op how often should interventions be?

A

every hour (pt do them by themselves)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
83
Q

What are the pulmonary benefits of ambulation post-op? (3)

A
  1. Increase alveolar ventilation
  2. Enhances V/Q matching
  3. Optimizes DLCO by stimulating dilatation and recruitment of alveolar capillaries
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
84
Q

T or F

You can put pts head down post-op for postural drainage.

A

F

Better not. Used modified position and sidelying

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
85
Q

If unilateral lung disease, to improve PaO2 how do you position pt? Why?

A

Lying on unaffected side

Gravity dependent portion of the lung receives the greatest airflow (V/Q matching)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
86
Q

What is the main post-op complication?

When does it usually occur?

A

Atelectasis

24-48h post-op

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
87
Q

What causes atelectasis post-op? (3)

A
  1. Hypoventilation (most common)
  2. Airway obstruction by retained secretions
  3. Decreased FRC and ERV
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
88
Q

Why do pts are more likely to retain secretions post-op? (3)

A
  1. Reduced ciliary function due to anesthetic
  2. Reduced cough reflex
  3. Pain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
89
Q

What are the consequences of atelectasis post-op? (3)

A
  1. V/Q mismatch, shunt, hypoxemia
  2. Increase rate and depth of breathing
  3. Decrease PaCO2
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
90
Q

T or F

Pts breathing O2 have an increased risk of atelectasis.

A

T

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
91
Q

What are the potential factors contributing to atelectasis? (5_

A
  1. Insufficient pain management
  2. Overuse of sedation and analgesics
  3. Manual percussion, vibration and coughing w/o emphasis on thoracic expansion
  4. Improper positioning
  5. Improper use of incentive spirometry and excessive accessory ms use
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
92
Q

What is a specificity for pneumonectomy regarding positioning?

A

Lying on the operated side is recommended bcs we don’t want blood to flood the remaining lung

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
93
Q

What is the best position early post op to optimize V/Q matching for thoracotomy pts?
Why?

A 
Semi prone (1/4 towards stomach)
Bcs prone position may be difficult due to pain, lines, tubes, etc
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
94
Q

Can thoracotomy pts lie on their operated side?

A

YES

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
95
Q

What is THE intervention for thoracotomy pt?

A

Lower lateral thoracic expansion for the side of the incision

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
96
Q

What are the 2 reasons for ICU admission?

A
  1. Requires invasive hemodynamic monitoring and MV

2. Requires more intensive nursing care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
97
Q

Who am I?

I am a line inserted into a peripheral vein.
I enable administration of fluid, basic nutrition and meds.

A

Peripheral intravenous line (IV)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
98
Q

T or F

It is better not to bend the involved joint when an IV line is installed on a pt.

A

T

Its better to avoid traction and kinking of any lines.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
99
Q

What the location of an arterial line?

A

Inserted in a peripheral artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
100
Q

What are the 2 purposes of an arterial line?

A
  1. Allows arterial blood to be drawn painlessly for frequent analysis or ABGs
  2. Continuous hemodynamic monitoring of blood pressure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
101
Q

What does an dicrotic notch represent on an EKG?

A

Closure of the aortic valve and the backsplash of blood against a closed valve.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
102
Q

T or F

Diastole counts twice as much as systole because 2/3 of the cardiac cycle is spent in diastole.

A

T

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
103
Q

What’s the normal MAP range?

A

70-110 mmHg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
104
Q

What MAP is necessary for normal perfusion of organs?

A

> 60

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
105
Q

What are the 4 main possible complications for arterial line?

A
  1. Ecchymosis/hematoma
  2. Disconnection/hemorrhage
  3. Occlusion/thrombosis formation
  4. Infection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
106
Q

What’s the implication for PT with femoral line?

A

Consider risk to benefit ratio

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
107
Q

T or F

No catheter related adverse events reported for in-bed exs, standing/walking, sitting, supine ergometry have been reported in the litterature.

A

T

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
108
Q

When the femoral line is discontinued how much time should we wait for mobilizing a patient?

A

6 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
109
Q

Who am I?

Inserted thru the subclavian/internal jugular/external jugular vein and threaded into the superior vena cava OR thru the femoral vein into the common iliac vein

A

Central line

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
110
Q

What value is recorded with a central line?

A

Central venous pressure (CVP)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
111
Q

What is the normal value for CVP?

What’s the normal range?

A

5 mmHg

3-10 mmHg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
112
Q

The CVP provides info about cardiac function of which side of the heart?

A

R

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
113
Q

What are the factors that increase CVP? (6)

A
  1. Increased vascular volume = when blood is backing up into the venous circulation
  2. Decrease R ventricular function = decrease stroke volume = more blood backing up into the venous circulation
  3. Global heart failure
  4. Increase pulmonary vascular resistance
  5. Systemic vasoconstriction = increase venous return to heart
  6. PEEP > 7.5 cm HO = increase pressure in thorax, thus in the heart also
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
114
Q

What are the factors that decrease CVP? (3)

A
  1. Hypovolemia = decreased blood volume
  2. Posture, legs lowered to the floor = decrease venous return
  3. Inspiration = -ve intra-thoracic, thus cardiac, pressure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
115
Q

What are the possible complications with central venous lines? (5)

A
  1. Pneumothorax
  2. Hemothorax
  3. Cellulitis
  4. Catheter infection
  5. Sepsis = release of bacteria into the bloodstream
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
116
Q

What is the implication to PT with central venous lines?

A

Cautious ROM to jt near insertion taking care not to kink the line

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
117
Q

What is the implication for PT with PICC lines? (4)

A
  1. Caution for bending the elbow beyond 45° initially in the hospital
  2. Not carry bags on side of PICC
  3. NOT lift more than 10 lbs with arm and avoid strenuous repetitive mvt
  4. Avoid wetting = no bath or swimming (plastic wrap for shower)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
118
Q

Who am I?

I am an alternative to central venous lines and i am inserted in the periphery usually the upper arm.

A

PICC line

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
119
Q

Where the PICC line is usually inserted? Which veins and goes where?

A

Cephalic/basilic vein and slid to the distal superior vena cava

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
120
Q

What is the advantages (2) of a PICC line compared to a central venous line?

A

Decreased complication rates and lower infection rates

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
121
Q

Who am I?

Central venous device implanted subcutaneously instead of port being outside the body.

A

Port-a-cath

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
122
Q

What are the 2 main contraindications with port-a-cath?

A
  1. pt should avoid contact sports

2. manual techniques over the device is NONO

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
123
Q

T or F

Pt with a port-a-cath can resume regular activities after the pocket is healed, including swimming, sports, etc.

A

T

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
124
Q

Who am I?

I am a catheter that monitors cardiac and pulmonary status as well as maintains fluid balance.

A

Pulmonary artery catheter (aka “Swan Ganx catheter”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
125
Q

What does a pulmonary artery catheter measure?

A

Pulmonary artery pressure (PAP)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
126
Q

What is the normal values for systolic and diastolic PAP?

A

Systolic 20-30 mmHg

Diastolic = 8-15 mmHg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
127
Q

What does the PAP measure?

A

the lung milieu and what’s ahead

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
128
Q

What is a caution to keep in mind when mobilizing with pulmonary artery catheter?

A

can trigger arrhythmias

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
129
Q

Where travels a pulmonary artery catheter (where it’s inserted and where it goes)

A

Introduced into internal jugular/subvlacian antecubital vein -> R atrium -> R ventricule -> pulmonary artery -> small vessels (possibly)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
130
Q

Which factors increase PAP? (2)

A
  1. Mitral stenis and L ventricular insufficiency = back pressure directed towards the lung
  2. Increase pulmonary resistance (pulmonary HT, PE)
    * Anything that increase pressure in lung will increase PAP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
131
Q

What is the pulmonary artery wedge pressure (PAWP)?

A

Pulmonary artery catheter has a ballon at the end of it. When ballon inflates, no longer registers pressure in pulmonary capillaries; provides info on filling pressures of L side of heart (end-diastolic L ventricular pressure)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
132
Q

When in PAWP used?

A

As a Dx tool to measure how much edema (and if it’s interstitial or pulmonary)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
133
Q

Who am I?

Hydrostatic pressure in the capillaries of force pushing fluids out of the capillary into the pulmonary tissues.

A

End-diastolic L ventricular pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
134
Q

What are the values for:

  1. normal PAWP
  2. optimal filling pressure
  3. interstitial edema
  4. pulmonary (alveolar) edema
A
  1. 5-12 mmHg
  2. 12-18 mmHg
  3. 18-30 mmHg
  4. > 30 mmHg
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
135
Q

PAWP will be elevated in the presence of: (3)

A
  1. global or L cardiac insufficiency
  2. mitral valve stenosis or insufficiency = heart has to work very hard to pump blood out
  3. overhydradation (renal failure)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
136
Q

When PAWP is increased, 2 things will be observed on ABGs and auscultation, what are they?

A

Hypoxia = fluid in lung decrease gas exchange

Crackles/rhonchi on I and E = fluid in alveoli = decrease gas exchange

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
137
Q

What are the possible complications for a pulmonary artery catheter? (6)

A
  1. pneumothorax
  2. hemothorax
  3. PAC related infection
  4. ventricular arrhythmias
  5. pulmonary artery infarction, damage or rupture
  6. accidental dislodgment into the R ventricle
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
138
Q

What does literature say about PAC and PT?

What is usually done in hospital ?

A 
Litterature = no complications with participation in bed mobility, transfers, ambulation and stair climbing
Hospital = ask MD and team before doing anything with a pt that has a PAC
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
139
Q

If PAC is inserted via the femoral vein, when it is removed, pt will be flat on bedrest for how long?

A

4-6 hours usually

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
140
Q

Who am I?

My purpose is to provide nutrition and decompress/remove gastric content via suction.

A

NG tube

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
141
Q

What are the 2 main concerns with NG tube?

A
  1. Displacement

2. Aspiration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
142
Q

How pt should be positioned when feeding with NG tube?

A

During feeding, HOB elevated to 45° and maintained 30-45 min after the feeding (intermittent feeding)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
143
Q

What are the 4 low-flow systems for administration of O2?

A
  1. Nasal prongs/nasal cannula
  2. Face mask
  3. Partial rebreathing mask
  4. Non-rebreathing mask
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
144
Q

What are the 2 high-flow systems for administration of O2?

A
  1. Air entrainment devices = Venturi mask

2. High-flow nasal cannula

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
145
Q

In nasal prongs, every 1L/min increase in flow, increased FiO2 by __%.

A

4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
146
Q

In nasal prongs, flow is limited to __ L/min. Why?

A

6

To avoid excessive irritation to nasal passages.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
147
Q

In nasal prongs, the FiO2 delivered is __ to __%

A

24-44

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
148
Q

Increasing Ve ____ FiO2

A

decreases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
149
Q

The larger the Vt or the faster the RR the ___ the FiO2

A

lower

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
150
Q

T or F

Pt with deviated nose septum can have nasal prongs.

A

F, nasal passages should be patent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
151
Q

What are the PT consideration when pt has nasal prongs?

A

Ensure that have no kinks or external compress during and after a Rx session.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
152
Q

What FiO2 face masks generally deliver?

A

40-60%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
153
Q

In face masks, flow should be more than ___.

Why

A

> 5L/min

Otherwise exhaled air is accumulated in the mask reservoir and is rebreathed.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
154
Q

In face mask, the increase in FiO2 is small when flow is ___.

A

> 8L/min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
155
Q

What is the FiO2 in partial rebreathing mask?

A

> 60%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
156
Q

In partial rebreathing mask, an O2 flow of 6-10L/min provides what FiO2?

A

30-80%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
157
Q

What is the volume of the reservoir added in partial rebreathing mask?

A

500-1000mL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
158
Q

Where the air goes on expiration with a partial rebreathing mask?

A

Beginning of expiration goes to the bag (first 1/3) than additional exhaled breath escapes through exhalation ports.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
159
Q

In non-rebreathing mask, in reality with flows of 8-10L/min provide which FiO2?
Theoretically?

A

60-80%

100%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
160
Q

What is the purpose of the one-way valve in non-rebreathing mask?

A

Prevents exhalation into the bag and inhalation from the exhalation ports.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
161
Q

On the next breath in non-rebreathing mask, the bag fills with what for the next breath?

A

pure O2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
162
Q

T or F.

Venturi mask is dependent of breathing pattern.

A

F

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
163
Q

Who am I?

Pressurized O2 creates a sheering effect that causes room air to be entrained though ports.

A

Venturi mask

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
164
Q

In Venturi mask,

  1. A larger entrainment port = ___ FiO2.
  2. A smaller entrainment port = ___ FiO2
A
  1. lower

2. higher

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
165
Q

What is the range of flows and %O2 venturi masks can administer?

A

4-15L/min

24-50%

166
Q

In Venturi mask, the total flow through the mask must be over of equal to what?

A

Patient’s peak inspiratory flow rate

167
Q

What are the advantages of Venturi masks? (3)

A
  1. Consistent and predictable FiO2
  2. Patient’s pattern do not affect the FiO2
  3. Temperature and humidity of the gas may be controlled
168
Q

Which O2 administration device also provides a PEEP to improve gas exchange?

A

High-flow nasal cannula

169
Q

For High-flow nasal cannula, up to how much FiO2 and flow can be delivered?

A

100%

60L/min

170
Q

What is the purpose of humidifying the O2 in High-flow nasal cannula?

A

Increase comfort

171
Q

What is an advantage of High-flow nasal cannula compared to face mask?

A

Pt can eat, drink, talk while being on O2.

172
Q

O2 tanks last how much time usually w/ High-flow nasal cannula?

A

15 min

173
Q

What is the kind of patients that has High-flow nasal cannula? (4)

A

Pulmonary fibrosis
Severe lung disease
Infants
COVID

174
Q

What is a normal PaO2 and normal SaO2?

A

80-100mmHg

>95%

175
Q

PaO2 and SaO2 for mild hypoxemia if not shift in the HbO2 curve?

A

60-80mmHg

90-95%

176
Q

PaO2 and SaO2 for moderate hypoxemia if not shift in the HbO2 curve?

A

40-59 mmHg

60-89%

177
Q

PaO2 and SaO2 for severe hypoxemia if not shift in the HbO2 curve?

A

<40mmHg

< or = 60%

178
Q

T or F

As PaO2 decreases, SpO2 increases.

A

F

SpO2 also decreases

179
Q

When can the oxyhemoglobin dissociation curve shift to the right?

A

during exs

180
Q

When can the oxyhemoglobin dissociation curve shift to the left?

A

hypoxemia

181
Q

What happens physiologically when PaO2 < 55mmHg with decrease in PaCO2?

A

Increase minute ventilation

182
Q

In hypoxemia what happens to peripheral vascular beds, why and what dos this cause?

A

They dilate bcs organs that are working needs more O2 so they dilate –> tachycardia and increase CO to increase O2 delivery

183
Q

Pulmonary hypoxia causes what to pulmonary vessels?

A

Vasoconstriction

184
Q

In hypoxemia, what happens to erythropoietin secretion?

A

Increase

To increase RBCs and O2 carrying capacity

185
Q

What are the 4 consequences of long-term hypoxemia (“cascade of events”)?

A

Polycynthemia = increase # RBCs
Pulmonary hypertension
Cor pulmonale
Cellular changes = decrease mitochondrial function, anaerobic glycolysis

186
Q

What is the 2 scenarios where continuous O2 will be prescribed long-term?

A
  1. Resting PaO2 = 55 mmHg
  2. Resting PaO2 = 56-59mmHg OR SaO2 = 89% in the presence of any of these:
    - Cor pulmonale
    - Polycythemia (hematocrit >56%)
    - Nocturnal hypoxemia = desaturated at night
    - Pulmonary hypertension
187
Q

What is the indication for long-term discontinuous supplemental O2 during exs?

A

PaO2 = 55 mmHg OR SaO2 = 88% with a low level of exertion

188
Q

What is the indication for long-term discontinuous supplemental O2 during sleep?

A

PaO2 = 55 mmHg OR SaO2 = 88% with also complications:

  • Pulmonary hypertension
  • Daytime somnolence
  • Cardiac arrhythmias
189
Q

What are short term benefits of supplemental O2? (2)

A
  1. Decrease dyspnea with exercise in patients with COPD

2. Increase exs tolerance

190
Q

What are long term benefits of supplemental O2? (5)

A
  1. Decrease cor pulmonale
  2. Increase QoL
  3. Increase sleep
  4. Decrease exacerbations and hospital admissions
  5. Improvement or stabilization of disease progression
191
Q

PTs are allowed to administer and adjust O2 if pt has a MD prescription EXCEPT in 2 situations, which ones?

A
  1. Invasive ventilation

2. Non-invasive positive pressure ventilation

192
Q

What can happen w/ supplemental O2 in COPD pts who are CO2 retainers when their PaO2 > 60mmHg?
Why?

A

Suppression of respiratory drive

Primary ventilatory drive = chronic hypoxemia. High O2 concentration abolishes the hypoxic respiratory drive.

193
Q

What 2 complications can happen w/ supplemental O2 if FiO2>0.5 for prolonged periods?

A
  1. Absorption atelectasis

2. O2 toxicity = can cause lung and CNS damage

194
Q

A PaO2 > 80 mmHg with supplemental O2 can contribute to what?

A

Retinopathy of prematurity

195
Q

What can be done to avoid the risk of atelectasis with suppl O2?

A

O2 should be humidified to reduce the drying effects of the gas on the respiratory mucous membranes

196
Q

What does a pulse oximeter actually measure?

A

% of hemoglobin saturated with O2

197
Q

What are 4 factors that can hinder accuracy of pulse oximeter?

A
  1. Motion and WB = noise interferes with signal transmission
  2. Probe location
  3. Dirt, fingernail polish
  4. Low perfusion/dysrhythmias = weak signal in pts with poor perfusion or irregular HR
198
Q

What is the optimal location for an accurate read of the pulse oximeter?

A

3rd or 4th finger

199
Q

T or F

Pulse oximeter is a good substitute for a clinical Ax of pt’s status.

A

F

Goof quality clinical Ax is better than the pulse oximeter

200
Q

What is a caution to keep in mind with anemia and pulse oximeter?

A

In anemia, less hemoglobin carry O2 so all HB molecules may be fully sat with O2 (pulse oximeter may read 100% sat) but still body’s need in O2 are not met.
Check the PaO2 and it should be low in anemia even tho Sat is 100%.

201
Q

Who am I?

Failure of the pulmonary system to meet the demands of the body.

A

Respiratory failure

202
Q

Who am I?

Gas exchange failure manifested by hypoxemia.

A

Lung failure

203
Q

Who am I?

Ventilatory failure manifested by hypercapnia

A

Pump failure

204
Q

What are the 2 types of noninvasive positive pressure ventilation (NIPPV)?

A
  1. Mask CPAP

2. Biphasic intermittent positive airway pressure (BIPAP)

205
Q

What is the difference btw CPAP and BIPAP?

A 
CPAP = continuous
BIPAP = different pressures for inhalation and exhalation
206
Q

What are the advantages of NIPPV? (3)

A
  1. Noninvasive
  2. Prevent intubation
  3. Short term ventilation
207
Q

In which conditions NIPPV is used? (5)

A
  1. COPD exacerbation
  2. Failed intubation
  3. Pneumonia
  4. CHF
  5. Pulmonary edema
208
Q

What are possible complications for NIPPV? (8)

A
  1. Leaks
  2. Mask discomfort
  3. Eye irritaiton
  4. Sinus congestion
  5. Oronasal drying
  6. Patient-ventilator asynchrony = pt fights the MV flow
  7. Gastric insufflation
  8. Hemodynamic compromise = too much +ve pressure = decrease venous return
209
Q

What are the indications for intubation? (5)

A
  1. Airway obstruction that cannot be simply relieved
  2. Failure of noninvasive ventilation
  3. PaO2 < 60 mmHg on suppl. O2
  4. Secere head injury or pt unconscious (protection of airway)
  5. Anticipated Sx
210
Q

What are the 3 kinds of intubation?

A

Orotracheal
Nasotracheal
Trachostomy

211
Q

T or F

Cough is more effective when pt are intubated.

A

F

Cough is less effective bcs glottis cannot close.

212
Q

T or F

Pts intubates cannot speak, eat, drink.

A

T

213
Q

Where is the tube placed when intubated?

A

Midway btw carina and vocal cords OR about 5-7 cm from the carina

214
Q

What does the cuff at the end of the ET allow? (3)

A
  1. Positive pressure ventilation
  2. Airways protection (blocks aspiration or foreign materials)
  3. Removal of secretions (suctioning)
215
Q

Who am I? Nasal or oral intubation

More comfortable
Easily anchored in place
Produces less stimulation of gag reflex/vomiting 
Less risk of laryngeal ulceration
Suctioning more difficult
More difficult to insert
A

Nasal

216
Q

Who am I? Nasal or oral intubation

Less comfortable
Tends to migrate more
More risk of airway obstruction
Larger tubes which makes suctioning easier

A

Oral

217
Q

At which tracheal level a tracheostomy is usually performed?

A

2dnd or 3rd tracheal rings

218
Q

In which situation a tracheostomy is usually performed?

A

When pt cannot be extubated within 10 days

219
Q

What are the indications for tracheostomy?

A
  1. Unrelieved upper-airway obstruction
  2. Need for prolonged MV (comatose, GBS)
  3. Airway protection
  4. Need for airway access for secretion removal
220
Q

T or F

Tracheostomy can be permanent or temporary.

A

T

221
Q

What are the advantages of tracheostomy? (5)

A
  1. Increased comfort for pt
  2. Ease of mouth care
  3. Reduction of anatomical dead space
  4. Reduction of sinusitis and oral infective complications
  5. Less damage to the vocal cords (as trachea is below them)
222
Q

What are the possible complications of tracheostomy? (4)

A
  1. Stomal infections
  2. Hemorrhages
  3. Subcutaneous emphysema
  4. Pneumomediastinum = air in the mediastinum
223
Q

What are the 4 goals of invasive MV?

A
  1. Restore ABGs to normal
  2. Reduce WOB –> reduce O2 consumption
  3. Rest fatiguing respiratory ms
  4. Promote absorption of fluid in pulmonary edema
224
Q

What are the 3 major types of invasive MV?

A
  1. Pressure-controlled
  2. Time-controlled
  3. Volume-controlled
225
Q

What are the 7 modes of invasive MV seen in this class?

A
  1. Controlled (CMV)
  2. Assist-control (AC)
  3. Intermittent mandatory ventilation (IMV)
  4. Synchronized intermittent mandatory ventilation (SIMV)
  5. Pressure support ventilation (PSV)
  6. PEEP
  7. Continous positive airway pressure (CPAP)
226
Q

What happens with pressures and Respiratory ms during spontaneous breathing?

A

Respiratory ms produce airflow by lowering pleural, alveolar and airway pressure

227
Q

What happens with pressures and Respiratory ms during positive pressure ventilation?

A

Air is forced into the lungs by application of +ve pressure into the airway and alveoli
Pleural pressures increase throughout inspiration

228
Q

What kind of invasive MV am I?

Gas flows into lungs until preset pressure is reached.
Form of intermittent positive pressure ventilation.

A

Pressure-controlled MV

229
Q

In pressure-controlled ventilators, Vt varies with what (3)?

A

Airway resistance = more resistance, lung not gonna inflate as much
Lung compliance = decreased compliance (stiff), lung not gonna inflate as much
Integrity of circuit = leak, lung not gonna inflate as much

230
Q

What kind of invasive MV am I?

Gas flows to the patient until a preset inspiratory time is reached.

A

Time-controlled MV

231
Q

In Time-controlled MV, desired Vt is achieved by adjusting what (2) or (by setting what (2)).

A

Adjusting inspiratory time and flow rate

Setting Ve and RR

232
Q

What kind of invasive MV am I?

Gas flows to the patient until a preset volume is delivered even if this requires a very high pressure.

A

Volume-controlled MV

233
Q

How to prevent barotrauma in Volume-controlled MV?

A

A safety “pop-off” pressure limit is set; when the limit is reached, excess volume is vented into the atmosphere.

234
Q

T or F

Pt with increased lung resistance and with volume-controlled ventilator have more odds of reaching the pop-off pressure limit.

A

T

235
Q

In which kind of patients CMV mode is used. (3)

A

Sedation
Ms paralysis
Brain damage

236
Q

What kind of invasive ventilation mode am I?

Fully ventilatory support.
Ventilators delivers a present # of breaths/min of a predetermined volume to deliver a constant Ve.

A

CMV

237
Q

What kind of invasive ventilation mode am I?

Ventilator delivers a breath when triggered by the patient’s inspiratory effort or independently if effort does not occur within a preselected time period.

A

AC

238
Q

T or F

In AC ventilatory mode, patient’s triggering effort can exceed the preset rate.

A

T

i.e if patients breaths at 20 breaths/min, but ventilator is set at 15 breaths/min, then ventilation will follow pt and deliver 20 breaths/min

239
Q

T or F

In AC ventilatory mode, if patient’s rate drops below the “preset backup” rate, controlled ventilation is stoped and machine assist the patient on the next inspiration.

A

F

controlled ventilation is provided until the patient’s rate exceeds the backup rate

240
Q

What kind of invasive ventilation mode am I?

Patient breathes spontaneously but additionally receives periodic positive-pressure breathes at a preset volume and rate from the ventilator

A

IMV

241
Q

T or F

In IMV ventilatory mode, IMV mandatory breath is stacked upon spontaneous efforts.

A

T

242
Q

What kind of invasive ventilation mode am I?

Patient breathes spontaneously but additionally receives synchronized mandated breath.

A

SIMV

243
Q

In SIMV, if RR is 20 breaths/min and machine is set at 10 breaths/min, patient will therefore take how many spontaneous breaths?

A

10

20-10=10

244
Q

Which mode is sometimes used to wean off patients from invasive MV?

A

SIMV

245
Q

What kind of invasive ventilation mode require an intact respiratory drive?

A

PSV

246
Q

What does the patient controls in PSV? (4)

A

RR
Vt
Ve
I:E ratio

247
Q

What kind of invasive ventilation mode am I?

Respiratory effort sensed by the ventilator responds by delivering a set pressure painted as a plateau.

A

PSV

248
Q

In PSV, inspiration ends when?

A

When the flow rate drops to a given % of peak inspiratory flow

249
Q

Which kind of invasive ventilation mode can be used with all the other modes?

A

PEEP

250
Q

What are the main effects of PEEP on lungs? (5)

A
  1. Increase FRC by opening airways
  2. Recruitment of collapsed alveoli
  3. Improves V/Q
  4. Prevents atelectasis
  5. Redistribution of excess fluid within the lungs (possibly)
251
Q

What kind of invasive ventilation mode am I?

Positive pressure maintained in the airways at the end of expiration

A

PEEP

252
Q

What kind of disease PEEP is used? (2)

A

ARDS

Pulmonary edema

253
Q

What are the disadvantages of PEEP? (5)

A
  1. Decrease venous return
  2. Decrease cardiac output
  3. Hypotension
  4. Hypoxemia
  5. Barotrauma can occur
254
Q

What kind of invasive ventilation mode am I?

Airway pressure remains positive during both inspiration and expiration.

A

CPAP

255
Q

What kind of invasive ventilation mode am I?

Dual control mode within a breath.
Allow a feedback loop within a breath.
Switches within a breath from pressure control to volume control if min tidal volume has not been reached.

A

Volume-assured pressure support (VAPS)

256
Q

What are the 2 kind of invasive ventilation mode used in dual control modes breath to breath?

A

Volume support

Pressure-regulated volume control (PRVC)

257
Q

In volume support mode, what is used as feedback to adjust the pressure level to achieve the set volume?

A

Tidal volume

258
Q

T or F

In volume support mode, patient is the trigger, pressure is limited and flow is cycled.

A

T

259
Q

Volume support mode is a closed loop control of which other ventilatory mode?

A

PSV

260
Q

T or F

In PRVC, pressure is set, time is cycled and rate is limited.

A

F
Pressure is limited
Time is cycles
Rate is set

261
Q

What kind of invasive ventilation mode am I?

Ventilator delivers a target volume using the lowest possible airway pressure.
Volume feedback control for continuous adjustment of the pressure limit.

A

PRVC

262
Q

What are the 4 main possible complications with invasive MV?

A

Infections
Barotrauma
Volutrauma
Hemodynamic effects

263
Q

What is the difference btw barotrauma and volutrauma?

A 
Barotrauma = alveolar rupture from high peak inspiratory pressures 
Volutrauma = lung injury secondary to overdistention of alveoli
264
Q

What ratio is considered severe hypoxemia and with which disease it is associated to?

A

PaO2/FiO2 < 300

ALI/ARDS

265
Q

For ALI/ARDS, what is usually seen on CXR?

A

diffuse bilateral pulmonary infiltrates

266
Q

For ALI/ARDS, how is the PAP and why?

A

high, hypoxic vasoconstriction

267
Q

For ALI/ARDS, how is PAWP and hy?

A

< 18 mmHg (normal), no generalized overhydratatiohn or L heart failure

268
Q

Which disease represents the most severe form of ALI?

A

ARDS

269
Q

What is ALI?

A

non-cardiogenic pulmonary edema

270
Q

What causes a non-cardiogenic pulmonary edema?

A
  1. Accumulation of vascular fluid + proving in the interstitial spaces and alveoli
  2. Increase permeability of alveolar epithelial and capillary endothelial
271
Q

What kind of acute pulmonary condition am I?

Epithelial damage, breaks in alveolar basement membrane.
Increase lung surface tension and alveolar collapse.
Fibrinogen in fluids leaking into alveoli = pulmonary fibrosis and decrease lung compliance.

A

ARDS

272
Q

What is the clinical presentation of ALI/ARDS? (3)

A
  1. Dyspnea
  2. Severe hypoxemia: V/Q mismatch and shunting
  3. Decreased FRC
273
Q

T or F

In ALI/ARDS, pts are characteristically unresponsive to increased FiO2.

A

T

274
Q

T or F

High PEEP is often used in ALI/ARDS to help push fluid back into the interstitial space.

A

T

275
Q

What are the 3 main PT intervention for ALI/ARDS?

A
  1. Positioning as tolerated - prone
  2. Airway clearance techniques if indicated (secretion retention)
  3. Bed exs; gradual increase in mobility to pt tolerance; sitting and upright ASAP
276
Q

Who am I?

A systemic reposes to an infection that can cause tissue damage.

A

Sepsis

277
Q

What are the 5 common symptoms of sepsis?

A
  1. Fever
  2. HR > 90 beats/min
  3. Tachypnea (RR > 20 breaths/min)
  4. Leucocytosis/leucopenia
  5. Altered mental state
278
Q

What is the name of the most severe manifestation of sepsis?

A

Septic shock

279
Q

What is the pathophysiology of septic shock? (4 steps)

A
  1. Tisuue and organ hypoperfusion
  2. Decrease O2 delivery with accumulation of lactic acid
  3. Hormonal and metabolic changes: increased stress hormones and hyperglycemia
  4. Deterioration in cell and organ function
280
Q

Name 5 common causes of septic shock.

A 
Hypovolemia
Sepsis
Heart failure
Direct insult to CNS
Allergic reaction
281
Q

What are clinical features (signs) of septic shock (8)

A 
Hypotension
Decrease CO
Tachycardia
Diaphoresis, pallor
Hyperventilation
Decrease urine output
Nausea
Confusion
282
Q

Name 4 predisposing conditions associated with multiple system organ failure.

A

Systemic inflammatory response syndrome
Severe sepsis
Trauma
Tissue hypo perfusion

283
Q

Who am I?

Lipid base drug used in the ICU at low dose to sedate patients or in the OR as an anesthetic.

A

Propofol

284
Q

How is propofol usually administered? (2)

A

Bolus dose or continuous infusion

285
Q

T or F

Propofol has a long half life to it will take a lot of time to wear off.

A

F

Has a short half life so will wear off rapidly.

286
Q

Who am I?

Drug used in the ICU to back neuro-musular conduction and paralyzes patients.

A

Neuromuscular blockers

287
Q

Neuromuscular blockers must be used with what?

A

Sedative agent

288
Q

T or F

Neuromuscular blockers can be used to induce patient-ventilator synchrony during MV.

A

T

289
Q

What are the adverse effects of bed rest on the CNS? (3)

A

Decrease congnitive function, memory and concentration
Neuropathy/myopathy
Decrease standing and walking balance

290
Q

What are the adverse effects of bed rest on the respiratory functions? (6)

A 
Decrease FRC and RV
Decrease lung compliance
Retained secretions
Atelectasis
Pneumonia
Hypoxemia
291
Q

What are the adverse effects of bed rest on skeletal ms? (3)

A

Decrease ms bulk, strg, endurance
Transformation in type II fibers (a->b)
Decrease number and density of mitochondria

292
Q

What are the adverse effects of bed rest on cardiovascular function? (7)

A 
Resting tachycardia
Decrease CO, SV and increase HR during exs
Decrease VO2max
Decrease plasma and blood volume
Venous stasis
Increase risk of trombosis
Orthostatic intolerance
293
Q

What are the adverse effects of bed rest on body composition? (4)

A

Bone demineralization
Joint contractures
Protein wastage
Decrease body weight and increase in % fat

294
Q

Name 3 types of psychological adverse effects a pt in ICU can experience.

A

Depression
PTSD
Delirium

295
Q

What Rx can be used w/ pt who have psychological adverse effects in ICU? (3)

A

Awareness
Psycho support
Encouragement

296
Q

What are 3 types of ICUAW? Describe.

A 
Polyneuropathy = sensory-motor axonopathy
Myopathy = metabolic, inflammation and bioenergetic ms derangements and/or functional inactivation 
Polyneuromyopathy = combined nerve and ms involvements
297
Q

ICUAW is multifactorial. Name 10 possible factors that can cause ICUAW.

A 
Disease severity (APCHE II score)
Systemic inflammation response syndrome/sepsis
Multi-organ failure
Meds (corticosteroids, neuromuscular blocking agents)
Duration of MV
ICU length of stay
Physical inactivity, ms unloading
Hyperglycemia
Perenteral nutrition
Renal replacement therapy = dialysis
298
Q

Name 8 PT goals with critically ill patient.

A
  1. Prevent atelectasis by mobilizing and assisting removal of secretions.
  2. Assist in maintaining adequate ventilation to all areas of the lungs = maximing V/Q matching
  3. Aid venous return and prevent thrombus = ankle mpumping
  4. Maitain jt mobility at all jt= ROM exs
  5. Maintaint ms strg
  6. Prevent deformitites
  7. Assist in prevention of bed sores
  8. Psycho support
299
Q

What PT intervention for clearing of secretions in ICU?

A

Postural drainage

*Modified position for pt unable to tolerate Trendelenberg positions

300
Q

T or F

In unilateral disease and positioning the involved lung uppermost, PaO2 is not improved in the uninvolved lung lower most.

A

F

The PaO2 in lowermost lung is still improved.

301
Q

What are the 7 contraindications for prone positioning?

A 
Spinal instability
Multiple trauma
Unstable cardiac arrhythmias
Hemodynamic instability
Increased ICP
Active intra-abdo processes
Facial trauma, burns, open chest, or abdo wounds
302
Q

What are 5 benefits of prone positioning?

A 
Improves V/Q matching
Redistributes pulmonary edema
Increase FRC, increase basal lung volume
Increase respiratory system compliance
Allows heart to lay on sternum so thet its compressive force on dorsal lung regions ins eliminated
303
Q

Prone positioning is used with which types of pt usually?

A

ALI/ARDS

304
Q

Transient arrhythmias during positioning should return to normal in ___. If not, pt should be put back in its original position.

A

30 sec

305
Q

What is continuous renal replacement therapy (CRRT)?

A

Continuous dialysis

306
Q

What are 3 types of vascular access for hemodialysis?

A

Arteriovenous (AV) fistula
AV graft
Central venous catheter

307
Q

Is PT feasible when pt is on CRRT?

A

Bedside PT is feasible and appears sae

308
Q

What consideration is important w/ pt w/ flail chest?

A

Unable to lie on there # ribs

309
Q

Are intubated pt able to cough? Why?

A

No

Absence of glottic closure with ET tube

310
Q

If pt is unable to cough, what is the PT Rx? (2)

A

Assisted coughing w/ pressure on the abdo (lower costal margins)
Suctioning to stimulate a cough and remove secretions

311
Q

Which mode of MV is a contraindication for breathing exs? Why?

A

Control mode

Pt are often paralyzed/heavy sedated so unable to breath spontaneously

312
Q

What are 2 goals of breathing exs with pts able to make an independent inspiratory effort?

A
  1. Prevent/reverse atelectasis

2. Maintain/improve respiratory ms endurance, strg, coordination (esp. during weaning off MV)

313
Q

Which modes of ventilation have greater inspiratory volumes during spontaneous breaths? (2)

A

IMV and SIMV

314
Q

Which cycle of ventilation has larger volume?

A

Pressure-cycled

315
Q

Which PT Rx is appropriate to maintain chest wall compliance? (2)

A

Segmental breathing with chest-wall stretching

Inspiratory ms facilitation techniques

316
Q

What is a good exs pt can do to relieve pressure from ischial tuberosity?

A

sitting in chair, push ups

317
Q

What are 2 things not to forget concerning lines and MV when transferring a dependent pt to a chair?

A

Clamp chest tube

Temporarily disconnect from MV = prevent unnecessary trauma to the trachea

318
Q

What 3 things should be done before ambulation to reduce WOB and facilitation tolerance to ex?

A

Pulmonary hygiene
Bronchodilator therapy
Suctioning

319
Q

Name 6 benefits of PT in ICU including early mobility.

A 
Decrease complications
Decrease mortality
Increase ventilator weaning
Decrease ICU and hospital LOS
Increase physical function
Increase QoL
320
Q

When ambulating a pt, can abdo sums and drains, ECG leads, CVP lines be disconnect?

A

Yes

321
Q

What is the role of a vasopressor?

A

Increase vasoconstriction -> increase systemic vasoresistance -> increase BP

322
Q

What is the role of an inotrope?

A

Increase heart contractility

323
Q

What is the role of a chronotrope?

A

Increase HR

324
Q

What is the use of the APACHE II system?

A

Severity of illness in critical care = predicts individual survival

325
Q

The higher the score in the APACHE II, the ____ the death rate.

A

higher

326
Q

What are the standardized 5 questions?

A
  1. Open/close your eyes
  2. Look at me
  3. Open your mouth and put out your tongue.
  4. Nod your head
  5. Raise your eye brows when I have counted up to 5
327
Q

What is the cutoff to the standardized 5 questions to continue with treatment?

A

4-5/5

328
Q

What is the scale used in ICU to Ax for delirium?

Btw which score you can mobilize pt and of PT?

A

RASS

+1 and -1

329
Q

What are the 2 types of delirium? Describe.

Which one is more common?

A
  1. Hypoactive = withdrawal, flat affect, apathy, lethargy, decreased responsieness = more common
  2. Hyperactive = agitation, restlessness, attempts to remove tubes and lines
330
Q

T or F

Delirium is independently associated w/ worse outcomes.

A

T

331
Q

What are the 4 features assessed in the CAM-ICU?

A
  1. Aucune onset of mental status changes or fluctuating course
  2. Inattention
  3. Disorganized thinking
  4. Altered level of consicousness
332
Q

What are the general indications for LT candidates? (2)

A

Chronic end-stage pulmonary disease

Ineffective or unavailable other medical/surgical Rx

333
Q

What is a PT absolute contraindication for LT?

A

Limited functional status w/ poor potential for post-transplant rehab

334
Q

What are the main 5 high risk factors for LT?

A
  1. Age > 70 y.o
  2. Severe coronary disease
  3. BMI too low or too high
  4. Limited functional status w/ potential for post-transplant rehab
  5. Unreliable support system or caregiving plan
335
Q

What are 3 risk factors for LT?

A
  1. Age 65-70 y.o
  2. BMI
  3. Frailty
336
Q

What do you Ax in an intial PT Ax for LT? (7)

A
  1. QoL
  2. Respiratory S&S
  3. Use of PEP device or other (if applicable)
  4. Strg
  5. Frailty
  6. Endurance = 6MWT
  7. O2 needs
337
Q

In LT, why can comorbidities and risk factors have an impact on recovery after surgery?

A

They stimulate the metabolic response to stress

338
Q

Who am I?

Clinically recognizable state of increased vulnerability resulting from agin-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with everyday or acute stressors is compromised.

A

Frailty

339
Q

What is the main goal of pre-hab?

A

Enhancing and optimizing functional capacity

340
Q

What are 3 essential components that should be included in an effective surgical pre-hab in LT?

A

Physical
Nutritional
Psychological

341
Q

What kind of exs is included in a pre-hab LT program?

A

Aerobic training OR aerobic + resistance

342
Q

Where can pre-hab LT be delivered?

A

Outpt

Home

343
Q

Who are on the emergency list for LT?

A

Advanced disease or poor prognosis in the short term

344
Q

What are the 3 decisive factors for pt to be put of the emergency list for LT?

A

Right ventricular fct
PAP/PAH
O2 needs

345
Q

Reassessment during waiting time, à quelle frequency?

A

each 3 months

346
Q

What is the duration of a LT surgery? Single vs Double.

A 
Single = 2-4h
Double = 4-6h
347
Q

What is sequential ventilation during LT surgery?

A

Ventilate one lung while the other one is being resected

348
Q

What kind of scar for :

  1. Single LT
  2. Double LT
  3. Heart-lung
A
  1. Thoracotomy posteralateral
  2. Thoracotomy clamshell
  3. Median sternotomy
349
Q

Pt post LT usually stay in ICU how long?

A

2-5 days min

350
Q

Pt post LT are extubated when?

A

early -> less than 24h usually

351
Q

When does PT intervention start post LT?

A

ASAP -> POD 0

352
Q

What is the major cause of death 1 st year post-LT?

A

Infection

353
Q

What are the 3 PT goals in ICU post LT?

A

Ventilation
Secretion clearance
Mobility

354
Q

What kind of breathing exs you do w/ pt on MV post-LT?

A

Deep breathing

355
Q

What kind of breathing exs you do w/ pt once extubated post-LT?

A 
Incentive spirometry (5min/h)
Coughing w/ splinting
356
Q

What is the average hospital stay with LT?

A

3-4 weeks

357
Q

Is clapping/vibrations contraindicated with LT?

A

Nooo

358
Q

What you put in their HEP before D/C in LT? (3)

A
  1. Respiratory routine and stretching = daily
  2. Morderate cardio training = 30 min, daily
  3. Weight training = 3x/wk
359
Q

No driving for how many weeks with LT?

A

6

360
Q

No UE WB > 10 lbs for how long w/ LT?

A

3 months

361
Q

Protection of incision for how lung with LT?

A

3 months

362
Q

Reintegration of moderate level leisure activities after how lung with LT?

A

6 months (can be less depending on pt)

363
Q

Once D/C, LT pt must visit the out-pt PT clinic at which frequency?

A

1x/wk for 1st month

Decreasing frequency down to 2x/year

364
Q

Life expectancy w/ LT?

A

4-6 years

365
Q

After 1 year post-LT, what is the major cause of death?

A

chronic rejection

366
Q

Can you do PT when pt on ECMO?

A

Yes

367
Q

In ICU, in which conditions active mobilization (out of bed) should not occur? (20)

A
  1. O2 sat < 90%
  2. Ventilator more HFOV
  3. Prone positioning
  4. Intravenous antihypertensive therapy
  5. MAP below target range and causing sumptoms
  6. Pacemaker and aystole
  7. Bradycardia requiring pharmaco Rx
  8. Ventricular rate > 150 bpm
  9. Femoral IABP
  10. Femoral/subclavian ECMO
  11. Cardiac ischemia
  12. RASS below -2 or above +2
  13. ICP not in desired range
  14. Open lumbar drain not clamped
  15. Spinal precautions
  16. Uncontrolled seizures
  17. Unstable major # pelvic, spinal, LL long bone
  18. Large open wound chest, abdo
  19. Uncontrolled active bleeding
  20. Femoral sheaths
368
Q

In ICU, in which conditions even in-bed exs should not occur? (8)

A
  1. Prone positioning
  2. Intravenous antihypertensive therapy
  3. Bradycardia requiring pharmaco Rx
  4. RASS > +2
  5. ICP not in desired range
  6. Spinal precautions
  7. Uncontrolled seizures
  8. Uncontrolled active bleeding
369
Q

T or F

Suctioning should be carried out only when needed.

A

T

370
Q

Suction catheter can be be introduced in respiratory tract thru which orifices? (3)

A

Nose
Mouth
ET or tracheo

371
Q

The suction catheter only goes down as far as ___.

A

Carina

372
Q

Pressure for suctioning:

  1. Normal
  2. Thick secretions
  3. Indants
A
  1. 100-125
  2. 125-150
  3. 20-40
373
Q

In suctioning, which hand remains sterile?

A

Dominant

374
Q

How long should you pre-oxygenate your pt before suctioning?

A

1-2 min

375
Q

When is the suction applied when in the tube?

A

when you go back out only

376
Q

Catheter should not be in the airway longer than ___.

A

10-15 sec

377
Q

After suctioning hyperoxygenate the pt for how long and why.

A

3 min

Since suctioning causes desaturation.

378
Q

How do you nasotracheal suctioning?

A

Direct catheter upwards and posterior towards the ear
Stop when feel resistance
Roll and advance slowly
Once in pharynx ask pt to breath deeply (to open glottis)
Catheter only advance during inspiration (usually stimulates a cough)

379
Q

Possible complications for suctioning (7)

A 
Airway trauma and bleeding
Hypoxemia
Cardiac arrhythmias
Hypotension
Bacterial contamination
Bronchospasm and laryngeal spasm
Pneumothorax
380
Q

What is the goal of manual hyperinflation before suctioning?

A

Elastic recoil of lungs/chest wall enhances expiratory flow and moves secretions up towards the carina

381
Q

With manual hyperventilation, the volume delivered is __ greater than baseline Vt.

A

50%

382
Q

What are the contraindications for manual hyperinflation? (6)

A 
Subcutaneous emphysema
Pneumothorax w/o chest tube
High PEEP dependence
Hemoptysis
Bronchospasm
Raised ICP
383
Q

T or F

Hyperinflation reduces blood flow to the heart thus reduce BP.

A

T

384
Q

Normal pH

A

7.35-7.45

385
Q

Normal PaCO2

A

35-45

386
Q

Normal PaO2

A

80-100

387
Q

Normal HCO3-

A

22-26

388
Q

FEV1 mild COPD

A

> 80%

389
Q

FEV1 moderate COPD

A

50-80%

390
Q

FEV1 severe COPD

A

30-50%

391
Q

FEV1 very severe COPD

A

< 30%

392
Q

PaO2 and PaCO2 for respiratory failure

A

PaO2 < 55

PaCO2 > 45

393
Q

PaO2 for hypoxemia

A

<80

394
Q

PaO2 for hypoxemia attributed to respiratory failure

A

< 60

395
Q

Increased vocal fremitus

A

Less air = consolidation

396
Q

Decreased vocal fremitus

A

More air =

397
Q

Egophony, bronchophony, whispered pectoriloquy

A

Less air = consolidation

398
Q

Dull/flat percussion

A

less air = consolidation

399
Q

Hyperresonant

A

more air

400
Q

Lower or upper airways

  1. Crackles
  2. Stridor
  3. Wheeze
  4. Rhonchi
A
  1. Lower
  2. Upper
  3. Lower
  4. Upper
401
Q

What are the 5 tasks assessed in the FSS ICU?

A 
Rolling
Supine to sit
Sitting
Sit to stand
Walking
402
Q

In FSS ICU, which score is given if pt is fully independent?

A

7

403
Q

In FSS ICU, which score is given if pt is unable to do the task completely?

A

0

404
Q

In FSS ICU, which score is given if pt requires min assistance?

A

4

405
Q

In FSS ICU, which score is given if pt is able to do the task but with cues?

A

5

406
Q

In FSS ICU, which score is given if pt can only do a flicker of the mvt?

A

1

407
Q

In FSS ICU, which score is given if pt required max assistance?

A

2

408
Q

In FSS ICU, which score is given if pt is able to do the task by using the bedrail or an object to pull themself?

A

6

409
Q

In FSS ICU, which score is given if pt required mod assistance?

A

3

410
Q

In MRC sum score, which score is considered ICUAW?

A

48/60

411
Q

What are the 6 ms mvt tested in MRC sum score?

A 
Sh ABD
elbow flex
wrist ext
hip flex
knee ext
ankle DF
412
Q

What are the 4 test components of the PFIT?

A

Sh flexion strg
Knee ext strg
Sit to stand assistance
Step cadence

PHTH564 (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions