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1

V/Q Ratio:

Avg ventilation is ---

Avg perfusion is ---

Which means, normal V/Q Ratio is ---

V = 4 L/min

Q = 5 L/min

V/Q = 4/5 = 0.8 (more perfusion than ventilation)

2

What would cause a V/Q less than 0.8?

less O2 going into the the blood in lungs

- Shunting

3

What would cause a V/Q more than 0.8?

less blood getting into the alveoli than normal

- PE
- Cardiogenic shock

4

What level of shunting is abnormal?

What level of shunting is life-threatening?

greater than 10%

greater than 30%

5

What is the horizontal axis of the Oxyhemoglobin curve?

Vertical axis?

PaO2 (oxygen unbound and able to get to tissue)

SaO2 (oxygen bound to Hgb)

6

When the Oxyhemoglobin Curve shifts right, what does this mean?

Hgb gets rid of O2 more readily

- Hypercapnia
- Acidosis
- Rise in 2,3 DPG
- Fever

7

When the Oxyhemoglobin Curve shifts left, what does this mean?

Hgb holds on to the O2 so it doesn't perfuse to tissue

- Alkalosis
- Low CO2
- Low temp (CoLd)
- Low 2,3 DPG
- Increased Carb. Monoxide

8

What are two ways to estimate shunting?

A-a Gradient (10-20 mmHg normal)

PaO2/FiO2 Measurement (normal is 286)

9

What does a wide A-a gradient (greater than 20 mmHg) mean?

more O2 in alveoli than in arterial blood

indicating there is a lot of shunting going on

10

With V/Q Mismatch, the A-a gradient is ---

With Alveolar Hypoventilation, the A-a gradient is ---

wide (because the O2 in alveoli isn't perfusing well)

normal (because the Alveoli aren't getting O2)

11

Is this a health lung?

PaO2 = 95

FiO2 = 50%

95 divided by 0.5 = 190

not a healthy lung function

too much shunting

normal should be 286

12

ABGs:

Normal PaO2

Normal PaCO2

PaO2 = 80-100 mmHg

PaCO2 = 35-45 mmHg

13

ABGs:

Normal Bicarb

21-28 mEq/L

- rises when acidic to buffer

14

ABGs:

Normal SaO2

95-100

15

What is a normal PETCO2?

20-40 mmHg

- Partial Pressure of End Tidal CO2

***Measures amount of expired CO2 in exhaled air

16

What conditions raise PETCO2?

anything that reflects inadequate gas exchange or an increase in cellular metabolism (both of which increase production of CO2)

- Hypoventilation
- Bronchial intubation
- Partial airway obstruction
- COPD
- Fever
- Increased CO and BP

17

What conditions lower PETOC2?

anything that reflects poor pulmonary ventilation

- PE
- Apnea
- Hypothermia
- Sedation
- Sleep
- Cooling
- Reduced CO and BP

18

Bronchoscopy:

NPO how long?

8 hrs prior

***assess gag reflex before allowing to drink

19

Bronchoscopy:

What about a fever?

mild fever around 24 hours is not uncommon

20

Thoracentesis:

How much can be withdrawn daily?

1000mL

21

Thoracentesis:

Why do we need them to deep breath post procedure?

help expand the lungs

22

BNC:

Rates?

FiO2?

1-6 L/min

24-44%

23

Simple Mask:

Rates?

min of 5 L/min

***monitor for aspiration

***no humidity

24

Partial Rebreather:

Rates?

FiO2?

6-11 L/min

60-75%

***1/3 Vt with each breath

25

Nonrebreather:

Rates?

FiO2?

12-15 L/min

greater than 90%

26

Aerosol Mask

Rates?

FiO2?

never less than 8 L/min

28-100%

27

Aerosol Mask:

What do we nee do with FiO2 amounts greater than 50%?

high flow setup

28

Tracheostomy Mask/Hood:

Rates?

FiO2?

never less than 8 L/min

28-100%

29

What is the most accurate way to deliver O2?

Venturi Mask

***ideal for CO2 retainers

30

How do you determine correct placement of ETT?

End-tidal CO2 detector

Auscultate x 5

Inspect chest expansion

CXR to determine depth (3-4 cm above carina)

31

With ETT, what pressure should cuff be?

14-20 mmHg

32

When suctioning ETT, what should we NEVER use?

saline

33

ETT Extubation Process

Hyperoxygenate first

Suction ET and Oral cavity

Rapidly deflate cuff

Remove at PEAK INSPIRATION

Instruct client to cough

Monitor q 5 mins

34

Trach:

How can we prevent aspiration of food?

elevate HOB at least 30 ins after eating

35

Trach:

How often should we turn client?

q 1-2 hrs and support out of bed activities and early ambulation

36

Trach:

What kind of swabs and mouthwash?

those without ETOH

Chlohexidine

37

Mechanical Ventilation:

What are the Modes we talked about?

AC (Assist Control)

PRVC

Synchronized Intermittent Mandatory Ventilation (SIMV)

BiPAP

CPAP

38

Mechanical Ventilation:

What are the Setting we talked about?

Tidal Volume (Vt)

Mniute Ventilation

I:E Ratio

Rate

FiO2

PIP (Peak Inspiratory Pressure)

CPAP

PEEP (Positive End Expiratory Pressure)

Pressure Support

39

Mechanical Ventilation:

How is Minute Ventilation calculated?

MV = RR x Vt

RR = 12 and Vt = 600

Then, MV = 12 x 0.6 = 7.2 L/min

40

Mechanical Ventilation:

What is normal I:E ratio and what would we set it at for COPD?

normal is 1:2

set at 1:4 for COPD to prevent breath stacking

41

Mechanical Ventilation:

Which setting provides positive pressure at end of expiration?

Which setting provides positive pressure at beginning of inspiration?

PEEP

Pressure Support

42

Mechanical Ventilation

Which setting augments the patients own Vt?

Pressure Support

***assists movement of air through tubing in order to augment the client's Vt

43

Mechanical Ventilation:

--- is the amount of pressure it takes for ventilator to deliver Vt or breath.

Number changes from breath to breath

PIP

**if increases, look for kink, biting, or mucous plug

44

Describe the Cardiovascular Compromise that being on a Vent can cause?

Increases intrathoracis pressure, which leads to

decreased venous return, which leads to

decreased preload, which leads to

decreased CO and BP, which leads to

tachycardia, hepatic dysfunction, renal dysfunction and impairment of cerebral venous return (ICP)

45

VAP:

What are some things we can do to prevent VAP?

HOB elevated 30-45 degrees

ETT w/ dorsal lumen to allow continuous suction above cuff

Oral care

Handwashing

46

What are included in ventilator bundles?

VAP precautions

DVT precautions

Gastric Reflux precautions

Sedation vacations

47

What would CSF lead look like with a nose bleed?

positive glucose test

***halo on filter paper

48

What should we teach regarding a Rhinoplasty?

Avoid forceful coughing/straining

Do not sneeze with mouth closed

Avoid ASA and NSAIDs

Humidifier to prevent dry mucosa

49

If they have neck trauma, what kind of intubation would we use?

nasal intubation so we don't have to bend neck

50

Client presents with persistent unilateral ear pain and unexplained oral bleeding?

Facial, Oral, or Neck Cancer

51

Asthma affects the ---, not the ---

airways

alveoli

52

Asthma:

What is criteria for Mild Intermittent?

s/s less than twice a week

53

Asthma:

What is criteria for Mild Persistent?

s/s more than twice a week, but not daily

54

Asthma:

What is criteria for Moderate Persistent?

s/s daily with exacerbations twice a week

55

Asthma:

What is criteria for Severe Persistent?

s/s occur continually with frequent exacerbations

56

What Pulmonary Function Test can diagnose the severity of Asthma symptoms?

Forced Vital Capacity (FVC)

Forced Expiratory Volume in First Second (FEV1)

Peak Expiratory Flow Rate (PEFR)

57

Ashtma:

What decrease in FEV1 is expected with Asthma?

15-20%

58

Asthma:

With bronchodilators, what change can we expect in FEV1?

increase of 12%

59

Which corticosteroids should be taken with food?

Prednisone

60

Patient education for Asthma client?

Drink plenty of fluids to promote hydration

Encourage reg exercise (may require pre-medication)

Use hot water in wash to eliminate dust mites in linens

61

COPD is characterized by --- and ----

bronchospasm

dyspnea

62

Etiology of COPD

Cigs

Advanced age

AAT deficiency

Exposure to air pollution

63

COPD:

--- is an alveolar problem

--- is an airway problem

Emphysema

Chronic Bronchitis

64

What sweat chloride test is diagnostic for CF?

60-200

***Normal is 5-35 mEq/L

65

How do you deal with exacerbations of CF?

Avoid mechanical vent

Supplemental O2

Heliox (50% helium; 50% O2)

Airway clearance techniques

Meds

66

Chest Tube Drainage System:

Which chamber should we see continuous bubbling?

Chamber 3 (Suction)

***bubbling in chamber 2 is an air leak

67

Chest Tube Drainage System:

Where should we keep the water line in Chamber 2?

2 cm

68

Chest Tube Drainage System:

What level is common in Chamber 3?

-20cm H2O

69

What amount of fluid intake for pneumonia to promote thinning of secretions?

2-3 L/day

70

Pneumonia:

What should we remember about Cephalasporins and Penicillins?

take with food

**obtain sputum culture BEFORE antibiotic therapy

71

Pneumonia:

What are adverse effects of glucocorticoids?

Hypokalemia

Immunusuppression

Fluid retention (weight gain)

Hyperglycemia

Poor wound healing

72

Flu:

How long are adults contagious?

24 hr before symptoms until about 5 days after

73

TB:

When is client no longer considered infectious?

after 3 negative sputum cultures

74

TB Meds:

Isoniazid

Take on empty stomach

Avoid ETOH due to hepatotoxicity

75

TB Meds:

Rifampin

Orange pee

Hepatotixic (jaundice0

Use a condom (interferes with oral contraceptives)

76

TB Meds:

Pyranzinamide

Drink a glass of H2O with each dose and increase fluids throughout day

Avoid ETOH due to hepatotoxicity

77

TB Meds:

Ethambutol

E for Eye (Vision issues)

No for children less than 13

78

TB Meds:

Streptomycin Sulfate

Otoxic (report ringing in ears)

79

ARF:

What is the hallmark sign of Type I?

hypoxemia (PaO2 less than 60)

***oxygenation problem

80

ARF:

Diagnostic criteria for Type I?

Diagnostic criteria for Type II?

PaO2 less than 60

PCO2 greater than 45 and pH less than 7.35

81

Treatment regimen for ARF?

Treat underlying cause

Assess ABGs

Correct Acidosis

Prevent complications

82

Nursing care of ARF?

Unilateral -- good lung down

Bilateral -- HOB at east 30 degrees and turn frequently

83

Early on with SARS, what would we see?

What about days 2-7?

early: fever, headache, bodyache, cold symptoms

days 2-7: dry cough, SOB, hypoxia with cyanosis

84

ARDS:

What is mild?

PaO2/FiO2 of 201-300 with CPAP of 5 cm or greater

85

ARDS:

What is Moderate?

PaO2/FiO2 of 101-200 with CPAP of 5cm or greater

86

ARDS:

What is Severe?

PaO2/FiO2 of 100 or less with CPAP of 5 cm or greater

87

Difference between Pneumonia and ARDS?

pneumonia is at one site

ARDS is diffuse throughout whole lung

88

What will CXR look like with ARDS?

white out

89

What are the Phases of ARDS?

Exudate Phase

Fibroproliferative Phase

Resolution Phase

Chronic ARDS Phase

90

ARDS:

What is the FiO2 goal?

SaO2 of 90% with FiO2 less than 65%

91

ARDS:

What do you do with the I:E Ratio?

inverse it so that inspiration is longer than expiration

***requires a neuromuscular block

92

Which lung disease will we use the crazy rolling bed?

ARDS

93

ARDS:

Why would you allow some hypercapnia?

reduces atelectrauma and baratrauma

94

ARDS:

Which modes on Vent would be used?

AC (to give lungs a rest)

Pressure Control for worsening ARDS to reduce volutrauma)

95

ARDS:

Why use the PEEP mode?

What complications can this cause?

recruits collapsed alveoli to decrease pulmonary shunting


can cause barotrauma b/c increased pressure can decrease venous return

96

Diagnostic criteria for Type II DM?

A1c of 6.5% (normal is 4-6)

Fasting BS greater than 126

2 hr BS greater than 200

Casual BS greater than 200

97

Describe the Somogyi Effect and how to prevent?

tendency of body to respond to hypoglycemia by rebounding with severe hyperglycemia

usually in sleep hours

prevent by taking midnight snack before bed

98

To prevent kidney damage from DM, how much fluid should we encourage?

2-3 L/day

no sodas or ETOH excess

99

Oral Glycemics:

What should we remember about Metformin?

Farts (GI effects)
- take with food
- never crush or chew

Lactic Acidosis

Hold 48 hrs before dye procedure

100

Oral Glycemics:

What should we remember about Sulfoylureas (Glip, Glim, Glyb)?

Monitor for hypoglycemia

Take 30 mins before meals

Avoid ETOH (disulifram)

101

Oral Glycemics:

Which class of medications can mask the tachycardia caused by hypoglycemia, a side effect of oral glycemics?

Beta Blockers

102

Oral Glycemics:

Which med requires that you monitor the A1c every 3 months?

Repaglinide

103

Oral Glycemics:

Take ---- 15-30 mins before meals.

Repaglinide

104

Oral Glycemics:

What do we do if we miss a dose with Repaglinide?

skip it

105

Oral Glycemics:

Which one can make you gain weight (fluid) and effect Oral Contraceptives?

Pioglitazine

106

Oral Glycemics:

Which one requires you to keep dextrose paste on hand in case you have a hypoglycemic episode?

Acarbose

Miglitol

107

Oral Glycemics:

Which one do you take with the first bite of each meal?

Ararbose

Miglitol

108

Oral Glycemics:

Which ones are subQ?

Exenatide (before morning/evening meals)

Pramlinitide (before major meals)

109

Oral Glycemics:

Hold --- if A1c is greater than 9%.

Pramlinitide (subq)

110

How many carbs do you give with mild hypoglycemia (less than 60)?

Moderate hypo (less than 40)?

Mild = 10-15 g

Moderate = 15-30 g

111

What can we give that is 15 g of carbs if they are facing mild hypoglycemia?

4 oz fruit juice or soft drink (not diet)

8 oz nonfat or 1% milk

3-4 glucose tablets

8-10 hard candies

1 T of honey, sugar, or corn syrup

112

If they are unconcious and cannot take PO 15 g or carbs, what can we do?

25-50 mL of D50W IV push

...or...

Glucagon 1 mg IM or SQ

113

Rehydration protocol for DKA?

First hr: 15-20 mL/kg/hr or NS (isotonic)

Then: 1/2 NS (hypotonic) at 4-14 mL/kg/hr

114

Rehydration protocol for HHS?

1 L of NS until BP stable

then, 1/2 NS at 100-200 mL/hr

115

HHS:

What level of osmolality will we see?

greater than 320 mOsm/kg

(normal is 280)

116

Metabolic Syndrome:

What is the Abdominal Obesity criteria?

Men: greater than 40 in

Women: greater than 35 in

117

Metabolic Syndrome:

What is the Hyperglycemia criteria?

Fasting BS of 100 or more

...or...

on treatment for elevated glucose

...or...

Abnormal A1c (5.5-6.0)

118

Metabolic Syndrome:

What is the HTN criteria?

130/85 or greater

...or...

on treatment for HTN

119

Metabolic Syndrome:

What is Hyperlipidemia criteria?

Triglycerides greater than 150

HDL greater than 40 in men or 50 in women