T2 - Blueprint (Josh) Flashcards
1
Q
V/Q Ratio:
Avg ventilation is —
Avg perfusion is —
Which means, normal V/Q Ratio is —
A
V = 4 L/min
Q = 5 L/min
V/Q = 4/5 = 0.8 (more perfusion than ventilation)
2
Q
What would cause a V/Q less than 0.8?
A
less O2 going into the the blood in lungs
- Shunting
3
Q
What would cause a V/Q more than 0.8?
A
less blood getting into the alveoli than normal
- PE
- Cardiogenic shock
4
Q
What level of shunting is abnormal?
What level of shunting is life-threatening?
A
greater than 10%
greater than 30%
5
Q
What is the horizontal axis of the Oxyhemoglobin curve?
Vertical axis?
A
PaO2 (oxygen unbound and able to get to tissue)
SaO2 (oxygen bound to Hgb)
6
Q
When the Oxyhemoglobin Curve shifts right, what does this mean?
A
Hgb gets rid of O2 more readily
- Hypercapnia
- Acidosis
- Rise in 2,3 DPG
- Fever
7
Q
When the Oxyhemoglobin Curve shifts left, what does this mean?
A
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
Q
What are two ways to estimate shunting?
A
A-a Gradient (10-20 mmHg normal)
PaO2/FiO2 Measurement (normal is 286)
9
Q
What does a wide A-a gradient (greater than 20 mmHg) mean?
A
more O2 in alveoli than in arterial blood
indicating there is a lot of shunting going on
10
Q
With V/Q Mismatch, the A-a gradient is —
With Alveolar Hypoventilation, the A-a gradient is —
A
wide (because the O2 in alveoli isn’t perfusing well)
normal (because the Alveoli aren’t getting O2)
11
Q
Is this a health lung?
PaO2 = 95
FiO2 = 50%
A
95 divided by 0.5 = 190
not a healthy lung function
too much shunting
normal should be 286
12
Q
ABGs:
Normal PaO2
Normal PaCO2
A
PaO2 = 80-100 mmHg
PaCO2 = 35-45 mmHg
13
Q
ABGs:
Normal Bicarb
A
21-28 mEq/L
- rises when acidic to buffer
14
Q
ABGs:
Normal SaO2
A
95-100
15
Q
What is a normal PETCO2?
A
20-40 mmHg
- Partial Pressure of End Tidal CO2
***Measures amount of expired CO2 in exhaled air
16
Q
What conditions raise PETCO2?
A
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
Q
What conditions lower PETOC2?
A
anything that reflects poor pulmonary ventilation
- PE
- Apnea
- Hypothermia
- Sedation
- Sleep
- Cooling
- Reduced CO and BP
18
Q
Bronchoscopy:
NPO how long?
A
8 hrs prior
***assess gag reflex before allowing to drink
19
Q
Bronchoscopy:
What about a fever?
A
mild fever around 24 hours is not uncommon
20
Q
Thoracentesis:
How much can be withdrawn daily?
A
1000mL
21
Q
Thoracentesis:
Why do we need them to deep breath post procedure?
A
help expand the lungs
22
Q
BNC:
Rates?
FiO2?
A
1-6 L/min
24-44%
23
Q
Simple Mask:
Rates?
A
min of 5 L/min
***monitor for aspiration
***no humidity
24
Q
Partial Rebreather:
Rates?
FiO2?
A
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
