Pulmonary Flashcards
(119 cards)
1
Q
Parietal Pleura
A
- lines chest wall
- slides back and fourth with breath
2
Q
Visceral pleura
A
- lines the lung parenchyma
- protective layer
3
Q
How much vacuum pressure prevents lungs from collapsing?
A
-5cm h2o
4
Q
Alveoli
type II cells
A
- produce surfactant
- decrease surface tension
Makes it easier to inflate during inspir
Prevents collapse during expiration
5
Q
Ventilation
A
air in and out of lungs
6
Q
Perfusion
A
movement of blood
7
Q
Diffusion
A
gas exchange
1. high concentration to low concentration
8
Q
Alveolar diffusion is affected by
(4)
A
- Surface area
- Thickness of alveolar capillary membrane
- Partial pressure of gasses
- Solubility of the gas (co2 diffuses 20x faster than o2)
9
Q
VQ
Normal Unit
A
things are working correctly
10
Q
VQ
Shunt Unit
A
- Perfusion over ventilation
- Blood passes without gas exchange
pneumonia, atelectasis, tumor, mucous plug
11
Q
VQ
Deadspace unit
A
- Ventilation over perfusion
- Does not participate in gas exhcange
- pulmonary embolism, pulmonary infarction
12
Q
Oxygenation
A
- (Sa02) bound to hemoglobin saturation of arterial blood
- (Pa02) dissolved in plasma
13
Q
Clinical manifestations of hypoxemia
A
- Tachypnea
- Hyperventilation
- Dyspnea
- Abd breathing
- C’s (cool, clammy, cyanosis)
- Tachycardia, HTN, palp, angina, dysrhythmia
14
Q
PaCO2 tells us about what status?
A
Ventilation
15
Q
PaCO2 High vs Low
A
- High = hypoventilation
- Low = hyperventilation
16
Q
Clinical manifestions of hypercapnia (High PaCO2)
A
- Drowsiness (difficult to arose)
- Flushed
- Headache
very similar to hypoxysemia becuase HIGH PaCO2 means HYPOventilation
17
Q
pH normal values
A
7.4 absolute
7.35-7.45
18
Q
PaO2 normal values
A
80-100mm Hg
hypoxemia
19
Q
SaO2 normal values
A
93-99%
hypoxia
20
Q
PaCO2 normal values
A
35-45 mm Hg
this is an ACID
respiratory parameter of the lungs
21
Q
HCO3 normal values
A
22-26 mEq/L
Metabolic parameter regulated by the kidneys (SLOWER)
this is a BASE
22
Q
Compensation of pH
A
other system changes to bring pH back to normal
Ex: respiratory is acidic = pH acidic, kidneys will become more basic to correct
23
Q
Partial vs Full compensation
A
Partial = pH unchanged
Full = pH is now normal
24
Q
Alkalosis
A
too much HCO3
too little CO2
25
Acidosis
too much CO2
too little HCO3
26
Mixed Disorder
All BASIC or ALL ACIDODIC
27
Goal of oxygen therapy
Deliever the LEAST amount necessary
28
Nasal canula
1. 1-6L/min
2. 21-44% FiO2
29
High - flow nasal canula
1. 1-60L/min
2. 21-100% FiO2
30
Acute Respiratory Failure
| Etiology
Inadquate gas exchange
secondary to disorder
problem with oxygenation or CO2 elimination
ABGs --> hypoexmia/ hypercapnia
31
Acute Respiratory Failure
| Causes
Intrapulmonary
1. Lower airways
2. alveoli, capillary membrane, pulmonary embolism
Extrapulmonary
1. Upper airway
2. CNS injury, neuromuscular disorders, thorax, pleura
32
Acute Respiratory Failure
| Treatment
* Improve oxygenation/ventilation
* Non-invasive or intubation
* Treat cause
33
Non-invasive Ventilation
uses a mask to fit over nose and mouth
**PAPs**
34
BiPAP
Positive pressure on inspiration and experiation
IPAP (bumps inspiration --> in deep= out deep)
EPAP (maintain pressure/recruit more)
35
CPAP
Continuous positive airway pressure
Inspir/Expir is the same
36
Acute Respiratory Failure
| **Nursing interventions**
* airway protection (prevent aspiration) (note emesis)!
* nutrition/hydration
* oral/skin care
* communication --> write
37
Intubation
| Placement (verification), color?, coughing presence?
* Placed in trachea 2-3cm above carina
* CXRAY for verification
* ETCO2 goes from purple to yellow
* Coughing indicated suctioning / inproper placement
38
Intubation
| **Nursing Interventions**
* Prep equipment
* Monitor time, pulse ox/BP
* Sedative then paralytic
* Secure/note placement
39
Goals of Mechanical Ventilation
1. Improve ventilation
2. Decrease work of breathing
3. Correct inadequate breathing patterns
4. Improve oxygenation
40
Ventilation (PaCO2) components
* Rate
* Tidal Volume
* Pressure support
41
# [](http://)
Oxygenation (PA02/SaO2) components
FiO2
PEEP
42
Tidal volume
Size of each breath
(larger breath in, larger breath out)
43
Rate
number of breaths per minute
(easiest to change)
44
Tidal volume (Vt) and Rate (f) affect (1) and indirectly affect (2).
1. PaCO2
2. pH
45
Assist Control (A/C)
| Ventilation modes
Ventilation delievers tidal volume at preset rate
Patient will never get fewer but can get more
Patient can trigger aditional breath **THEN vent will kick in and delivers full tidal volume**
46
Synchronized Intermittent Mandatory Ventilation (SIMV/IMV)
| Ventilation modes
Preset volume at preset rate
Patient can breath spontaneously with pressure support (may not be a good quality tidal volume)
47
Advantages of SIMV
* Respiratory muscles are active/coordinated
* Can be used as weaning mod
* If pt stops breathing, they will still recieve preset volume
48
Pressure Support
| Ventilation modes
used for breathing trial/weaning
vent gives a a boost to trig spontaenous volume making inspiration easier
overcomes increased airway resistance afford by ETT (less work to initiate breath)
49
Fraction of Inspired Oxygen
| Fi02
percentage of oxygen delivered via the ventilator
**30-100%**
50
Positive End Expiratory Pressure
| PEEP
Positive pressure applied t the end of expiration
Increases oxygenation and prevents collapse of alveoli (recruits more)
Set at 5cm H20
If 100% FiO2,
peep will increase
cause better gas exchange
potentially lower o2
51
Complications of PEEP
hemodynamic compromise d/t decreased venous return
**Volutrauma/Barotrauma**
damage alveoli/decrease venous return --> hypotension
52
Elevated PaCO2 on ABG means on vent you need to
increase rate
53
Low PaCO2 on ABG means on vent you need to
increase Fi02
54
Complications of Mechanical Ventilation
* Aspiration
* Barotrauma
* Pneumonia
* Decrease CO
* Decrease fluid balance
55
ABCDEF bundle
breaks cycle of over sedation
**a**ssess pain
**b**oth spontaneous awakenoing trials wakening trials
**c**hoice of pain meds/sedation
**d**elirium
**e**arly mobility
**f**amily engagement
| decrease vent time
56
ICU delirium nonpharm intervention
Monitor/manage pain (FACE, FLACC, CPOT)
Ortient --> axo, whiteboards
Sensory aids
Sleep --> encourage as much as possible
57
Ventilation Pharmacologic management
Analgesics with short half-lives to be able to tirtate to orientation
**Fentanyl most popular**
58
Propofol (diprivan)
Anesthetic agent (short-acting)
**CNS depression/hypotension warning**
tubing/bottle change q12h
59
Propofol Contraindication
egg, soybean, peanut allergy
60
Propofol complication
pancreatits
infusion syndrome
61
Dexmedetomidine (Precedex)
Sedative (alpha 2 agonist)
continuous iv
**Bradycardia/hypotension**
DOES NOT cause respiratory depression
Can maintain when extubated d/t no withdrawal
**Titrate no frequent than q30min**
62
Benzodiazepines
Anxiolytics
Alc abuse or unable to use precedex/propofol
**LONG ACTING, RESPIRATORY DEPRESSION**
**precipitate delirium, prolong ventilation**
63
Benzodiazepine reversal agent
Flumazenil
Romazicon
64
RASS assessment
sedation scale
65
Neuromuscular blocking agents (NMBA)
Cisatracurium, Ro**curonium**,
**PARALYTIC!! NEED SEDATION FIRST**
decreases oxygen demand
**post op, therapeutic hypothermia**
BIS/train of four
66
Bispectral Index Monitoring
measures sedation level
0-100
**40-60 general anesthesia goal
80 is light/mod sedation**
67
Peripheral Nerve Stimulator -- Train of Four
check before NMBA
68
Nursing considerations for NMBA
SAFETY: airway in place, ambu bag at bedside
infuse only after sedated
eye/skin care
once d/c, continue til TOF is 4/4
69
Ventilator-Associated Pneumonia
| Etiology
Risk when on mech vent for over 48 hours, bacteria enters through aspiration/leakage around ET cuff
70
Aspiration prevention
maintain ETT cuff pressure of 20-25 mmHG
70
Oral care VAP
brush teeth/gums/tongue twice a day using soft toothbrush
71
VAP oropharyngeal suctioning
suction before deflating cuff
with each oral care/turn
72
Removal of subglottic secretions
-10 to -20cm continous suction through dorsal lumen above cuff
73
VAP aspiration prevention
HOB 30-45 degrees
use sedation sparingly
verify TF placement
swallow eval after prolonged intubation
74
Suction ETT
no greater than 120mmHg
limit passes to 10-15sec 3 sets
watch vs, hyperoxygen, no lavage
75
Vent considerations
Ulcer prophylaxis
DVT prophylaxis
Communication
Psychological care
Fam
Nutrition
76
Troubleshooting vent alarms
High vs Low
High --> obstruction
Low --> leak
77
Guidelines for weaning from short-term ventilation
1. Hemodynamically stable
2. **Sa02 >90 on Fi02 less than 50 and peep less than 8**
3. ABG WNL
4. Adequate pain management
5. No neuromuscular blockade
78
Spontaneous Breathing Trials
"CPAP"
pressure support, peep/fi02
no tidal volume
enteral feeds hold
minimize sedation
monitor patient response
79
Criteria for stopping SBT
RR > 35
SaO2 < 90%
Decreased tidal volumes
Increased work of breathing
Increased anxiety and/or diaphoresis
HR > 140
SBP > 180 or < 90
80
Extubation Criteria
ABGs WNL for the patient
Respiratory rate < 30
NIF > -20 cm water
Negative Inspiratory Force
(-30 is better, -10 is worse)
Patient alert/following commands
Adequate cough/gag reflex to protect airway
Occlusion test (if concerned for tracheal swelling) -- gurgling test if deflate cuff
81
Extubation Procedure
| 8 steps
1. Elevate HOB and instruct pt
2. Suction ETT/oropharynx
3. Deflate cuff and remove
4. Cough
5. Suction
6. Oxygen administration
7. Assess edema/ability to talk
8. Monitor VS
82
Which setting provides patient with a tidal volume?
AC
(rate/tidal volume)
83
Which setting augument spontaneous breath by decreasing resistance?
Pressure support (bump!)
84
# *
Which vent setting increases to improve oxygenation?
PEEP
85
Tracheostomy tubes
| Uses
Long-term intubation
**trauma, tumors, spinal cord injury**
86
Terminal vent weaning/withdrawal
| Reasons
poor prognosis, requests, interventions are now futile
87
Terminal vent weaning/withdrawal
| Nursing interventions
Establish a time, expectations and goals
NMBA should be discontinued and cleared
Opioids and sedatives (morphine and benzodiazepines)
Create a calm environment
After comfort achieved, vent settings are reduced
88
Acute Lung Injury
| Etiology
* Pulmonary manifestation of MODS
* Non-cardio pulm edema
* Disruption of alveolar-capillary membrane
* ARDS
89
Acute Respiratory Distress
| Direct causes
* Aspiration
* Infection pneumonnia
* Lung contusions
* Toxic inhalations
90
Acute Respiratory Distress
| Indirect causes
* Sepsis
* Burns
* Trauma
* Blood transfusion
91
ARDS
| Pathophysiology
* reduce blood flow to lungs
* platelet aggregation
* increases permeability
* fluid to interstitial space
alveoli collapse decreasing gas exchange and lung compliance (lungs are now stiff)
**Refractory hypoxemia is end resul correct with high Fi02/PEEP**
92
Clinical Manifestations of ARDS
* Tachypnea/tachycardia
* Clear then crackles
* restless, agitated, lethargic
* accessory muscles
* Hypoxemia non respondent to treatment
93
Pa02:Fi02 ratio
normal = >350
ALI < 300
ARDS < 200
94
What would refractory hypoxemia look on an xray?
diffuse "white out"
95
Management of ARDS
* Prevention/detection
* High Fi02/PEEP
* Pressure-controlled ventilation
* NMBA's
* Antibiotics/steroids
* Continuous lateral rotation
* Pronation
96
Pneumothorax
air in pleual space with lung collapse
97
Open/closed pneumothorax
| Assessment
* Short of breath
* Hyperresonance
* Pain
* Subq emphysema
* Respiratory distress
98
Open chest trauma
| Management
1. Chest tube
2. Cover site with 3 sided occulsive dressing
99
Tension Pneumothorax
| Etiology
one-way pneumo (air can enter but cannot escape)
100
Tension Pneumothorax
| Clinical manifestations
* displacement of mediastinum and trachea to **uneffected side**
* PMI displaced
* Neck vein distention
101
Tension Pneumo
| Treatment
1. needle aspiration
2. chest tube
102
Hemothorax
| Etiology
blood in pleural space with collapse of lung
103
Hemothorax
| Assessment findings
* Hypotension
* Hypovolemic shock
*** Dullness**
104
Hemothorax
| Causes
* chest trauma
* rib fracture
* CVC placement
* anticoagulation therapy
105
Flail Chest
| Etiology
multiple rib fractures causing unstable wall
106
Flail chest
| Clinical manifestations
* Paradoxical chest expansion
* decreased negative pressure
* decreased tidal volume
* pain
107
Flail chest
| Treatment
* oxygenation/vent
* pain control
108
109
Chest tubes
inserted in pleual space
remove fluid or air
restore negative intrapleural pressure
RE-expand lung
110
Chest tube
| Nursing interventions
* Monitor amount and drainage
* Assess for air leak/subq emphysema
* Patency
* Suction (-27cm)
111
How would a nurse assess for air leaks?
1. If lung chamber is bubbling
2. Clamp tube
2. If stops --> tube
3. If doesnt stop its a leak
112
Pulmonary Embolus
| Etiology
VTE in pulmonary vasculature
90-95% DVT
113
Pulmonary Embolus
| Assessment
* Tachypnea/cardia
* Apprehension
* Chest pain
* Hemoptysis
* Syncope
* Crackles
*** DVT evidence **
114
Pulmonary Embolus
| Risk factor
POST OP!!!
no prophylaxis
birth control/pregnancy
smoking
115
PE diagnostics
* d-dimer
* **CTA (CT angiography)**
116
When a DVT more concerning
Above the knee!
117
Pulmonary Embolus
| Pathophysiology
* Deadspace = bronchoconstriction
* hypoxemia
* 40% < occulded is MASSIVE
118
Pulmonary Embolus treatment
* Anticoagulation (acute/longterm)
* Thrombolytic therapy
* Hemodynamic support (+ inotropic agents)
* Embolectomy
* ICV filter
