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401 > Unit 1 > Flashcards

Unit 1 Flashcards

1
Q

Establishing priorities

A

Maslow’s, A.B.C.D., Trends before Isolated events, Actual before Potential, Systemic before Local, Least stable before Most stable, Acute before Chronic. Also take into account Time management and infection control.

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2
Q

pH high, CO2 normal, HCO3 high

A

Metabolic Alkalosis

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3
Q

pH high, CO2 low, HCO3 normal

A

Respiratory Alkalosis

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4
Q

pH low, CO2 normal, HCO3 low

A

Metabolic Acidosis

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5
Q

pH low CO2 high, HCO3 normal

A

Respiratory Acidosis

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6
Q

ABG: Compensation

A
  • Respiratory system can compensate in minutes, metabolic system takes hours/days.
  • If all three numbers are abnormal, you have partial compensation.
  • If pH is normal, but CO2 and HCO3 are abnormal, you have full compensation.
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7
Q

ABG: Hypoxemia scale

A

Normal 80-100, Mild hypoxemia 70-79, Moderate hypoxemia 60-69, anything less is severe.

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8
Q

Mechanical Ventilation: AC/ACV

A
  • Assist Control Ventilation
  • Most common
  • Preset RR and Vt
  • Pt “triggers” breath and vent takes over (no work of breathing)
  • *If pt suddenly declines, they may have aspirated or vomited
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9
Q

Mechanical Ventilation: Synchronized Intermittent Mechanical Ventilation (SIMV)

A
  • Synchronized Intermittent Mechanical Ventilation
  • Preset RR and Vt
  • Pt must do some of the work of breathing (more than with AC)
  • Pt may spontaneously breathe
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10
Q

Mechanical Ventilation: CPAP

A
  • Continuous Positive Airway Pressure
  • Prevent alveolar collapse
  • Pt does all the work of breathing
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11
Q

Mechanical Ventilation: BiPAP

A
  • Bi-level Positive Airway Pressure
  • Two levels for pts who unable to exhale against the higher pressure.
  • Example setting: 12/5, 12 is the IPAP (inspiratory) and 5 is the EPAP (expiratory)
  • If pt declines from here, prepare for intubation
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12
Q

Mechanical Ventilation: Pressure Regulated Volume Control (PRVC)

A
  • Pressure Regulated Volume Control
  • Used on pts w/ ARDS
  • Delivers pre-set Vt at the lowest possible pressure.
  • Used when lungs are stiff
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13
Q

Mechanical Ventilation: Airway Pressure Release Ventilation (APRV)

A
  • Airway Pressure Release Ventilation
  • Used for pts w/ O2 issues, not ventilation issues
  • Pt must spontaneously breathe
  • Do not want pt heavily sedated.
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14
Q

PaO2:FiO2 Ratio: PaO2 is 90, FiO2 is 21%

A

Answer: 90 / 0.21 = 429

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15
Q

Ventilator Pt Care

A
  • Ambu-bag at bedside
  • Oral care Q 4 hrs
  • Frequent turning/positioning
  • *Nutrition
  • Sedation Vacation
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16
Q

High Pressure (Pressure) Alarms

A

Line is occluded in some way: kink, pt “bucking” vent, coughing, pulmonary edema, or Pneumothorax.

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17
Q

Low Pressure (Volume) Alarms

A

Lack of good seal somewhere in line: accidental extubation, cuff leak, or circuit leak.

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18
Q

Acute Respiratory Failure

A

Failure of pulmonary system to maintain adequate gas exchange

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19
Q

Acute Respiratory Failure: Hallmark Signs

A
  • Hypoxemia, due to different lung disorders that interfere w/ transfer of O2 to the blood
  • Hypercapnia, due to insufficient O2 removal, drug OD (cocaine), Neuromuscular diseases, CNS trauma, Respiratory Acidosis *(Pt will have inability to compensate and must be put on vent)
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20
Q

Good lung up or down?

A

DOWN!!!

If disease is bilateral, place Rt lung down

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21
Q

ARF: management

A
    • 1st promote adequate gas exchange: NC/PEEP/Vent, keep O2 >90 (also helps prevent ischemic-anoxic encephalopathy [brain damage] )
  • Give NAHCO3 for if needed to reverse Acidosis
  • Nutritional support must be started w/in 1-3 days of Vent depending on nutritional state pre-vent.
  • Promote secretion clearance
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22
Q

ARF: Meds

A
  • Give NAHCO3 to reverse Acidosis

- Give Bronchodilator, Steroid, and Mucolytics in that order

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23
Q

ARF: Positioning

A
  • Good lung down if unilateral, Rt lung down if bilat

- Non-recumbent positioning for pt w/ alveolar hypoventilation

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24
Q

PE: Diagnostic Procedures

A
  • *Spiral CT
  • V/Q scan: will show difference in Ventilation and Perfusion
  • Pulmonary Angiogram: can give a better view of where the embolus may be
  • D-Dimer: asses thrombin and plasmin activity
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25
Q

PE: S/S

A
  • *Impending Doom
  • Acute onset dyspnea, pleuritic chest pain, hemoptysis, tachycardia
  • ABG shows low O2, and low-early/high-late CO2
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26
Q

PE: Meds

A
  • O2 for vasoconstriction (keeps clot from going deeper)
  • Dobutamine: Pulmonary vasodilator (to avoid infarction)
  • Morphine/Sedatives: relieve anxiety and improve tolerance of ETT
  • TPA: clot-buster (if uncontrolled bleeding occurs give FFP)
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27
Q

ARDS: Hallmark S/S

A
  • *Pulmonary Edema in the absence of cardiac failure
  • *Characterized by acute lung inflammation due to direct/indirect injury
  • If chronic, heart will be hypertrophied
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28
Q

ARDS: Exudative phase

A
  • Chemical mediators increase capillary permeability
  • Fluid leaks into pulmonary interstitium
  • Fluid forced from interstitial space into alveoli (alveolar edema)
  • Damaged to type 1 alveolar cells and decreased surfactant
  • Collapse of alveoli and decreased lung compliance
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29
Q

ARDS: Exudative phase S/S

A
  • Restlessness, apprehension, progressive dyspnea and tachypnea, moderate use of accessory muscles
  • Breath sounds usually clear
  • ABG: mild Resp. Alk.
30
Q

ARDS: Proliferative phase

A
  • Starts 7-10 days after exudative phase
  • Decreased surfactant, causes collapse of alveoli and decreased compliance
  • Compression, collapse, and edema of alveoli and small airways, pulm. shunting
  • Hypoxemia
  • Increased airway resistance, decreased compliance, increased work of breathing, pt fatigues which leads to hypoventilation
  • Hypoventilation and increased dead space worsen hypoxemia
  • Pulm. HTN, increased RV, decreased CO
31
Q

ARDS: Proliferative phase S/S

A
  • Agitation, increased resp. distress and accessory muscle use, fatigue
  • Breath sounds: fine crackles
  • ABG: Resp. Acid.
  • CXR shows “white out”
32
Q

ARDS: Fibrotic phase

A
  • Cellular granulation, membrane pulm. fibrosis
  • Structural/vascular remodeling
  • Further stiffening of lungs, increasing pulm. HTN, worsening hypoxemia, MODS, decreased LOC and urine output
  • Recovery: resolution of fibrosis and restoration of alveolo-capillary membrane
33
Q

ARDS: Survival

A
  • Directly related to presence of MODS/Sepsis

- Recovery lasts from weeks-months

34
Q

ARDS: Management

A
  • Treat underlying cause
  • AC ventilation (*repeated opening/closing of alveoli releases chemical mediators and worsens ARDS)
  • PEEP, low Vt, or PCV (PEEP should not be used until healing has begun)
  • Maintain SaO2 >90 using lowest level of FiO2
  • Encourage fluids to help circulation
  • Nutritional support
35
Q

ARDS: Pt Care

A
  • *Turn pt
  • Good lung down
  • Monitor Hgb
  • Vent care
36
Q

Pulmonary Contusion: S/S

A
  • Interstitial/alveolar hemorrhage, alveolar edema, atelectasis
  • Breath sounds initially clear, crackles later
  • Hypoxia
  • ABG: Resp. Acid. and hypoxemia
  • CXR: initially clear for first 1-2 days, later shows infiltrates
37
Q

Pulmonary Contusion: Management

A
  • Adequate O2, vent, secretion removal
  • Antimicrobial Rx
  • Avoid hypervolemia
38
Q

Tension Pneumothorax: S/S

A
  • Mediastinum shifts to UNaffected side
  • Low PaO2, high PaCO2
  • Breath sounds diminished on affected side
  • Percussion is hyperresonant
  • CXR shows “dead space”
39
Q

Tension Pneumothorax: Management

A

-Emergency: insert tube/needle into 2nd intercostal space at mid-clavicular line to release trapped air, insert chest tube in 4th or 5th intercostal space and mid-axillary line to release hemothorax.

40
Q

PaO2:FiO2 Lung Injury Scale

A
  • Normal Lung: 300-500
  • Acute Lung Injury: 200-300
  • ARDS:
41
Q

H and H

A
  • 1 unit PRBC increases Hb by 1 gm
  • 1 unit PRBC increases Hct by 3-4%
  • Typically a late sign (6-12 hours), and actual H and H may be worse than results as bleeding may still be going
42
Q

External v. Internal Hemorrhage

A
  • External: Fe stores are depleted

- Internal: Fe is recovered

43
Q

Acute Viral Infections: Lab Findings

A
  • ESR :elevated
  • Albumin: decreases
  • C-Reactive Protein: Increases
44
Q

Bacterial Infection: Lab Findings

A
  • Acute infection: WBCs increased (Segs and Bands up)
  • Sepsis: WBCs decreased (your body has nothing left to fight with. (Segs down, Bands up)
  • Pt is considered to be in recovery when lab values begin to trend towards normal (Segs up, Bands down)
45
Q

Degenerative Shift to the Left

A
  • Increase in Bands with no leukocytosis (no bone marrow response)
  • Poor Prognosis
46
Q

Regenerative Shift to the Left

A
  • Increased Bands with Leukocytosis (shows bone marrow response)
  • Good prognosis
47
Q

Shift to the Right

A
  • Decrease in Band cells and an increase in Segs

- Body is recovering

48
Q

SIRS Criteria

A
  • Temp: 100.4
  • HR: > 90
  • RR: >20 or Pa CO2 12,000 (or >10% bands)
  • 2 of these plus current or recent infection = SEPSIS
49
Q

Sepsis: Labs

A
  • CBC and WBC: high, then drop
  • Culture: should be positivie
  • ABG: Met. Acid./Hypoxemia
  • Normal Lactate: 0.5 - 2 (tx elevated numbers with fluids)
  • Glucose: should be closely monitored (pt may be put on an insulin drip)
50
Q

Thrombocytosis

A
  • Increased risk of clotting

- Risk factors: Renal failure, splenectomy, CA

51
Q

Thrombocytopenia

A
  • Increased risk of bleeding

- Risk factors: CA, massive blood transfusion, bypass machine

52
Q

Heparin Induced Thrombocytopenia (HIT)

A

Pt develops antibodies to Heparin (Heparin-PF4) which cause to kick off the clotting cascade whenever Heparin is introduced to the system.

53
Q

HIT: Tx

A
  • Avoid use of Heparin or any derivatives
  • Monitor plt counts
  • Monitor for thrombosis
54
Q

Prothrombin Time: Coumadin effectiveness

A
  • If effective, PT should be 2-2.5 times the normal range
  • If prolonged, decrease meds
  • If shortened, Increase meds
55
Q

Fibrinogen

A
  • Important coagulation protein
  • Normal: 200-400
  • Decrease could indicate: liver disease, DIC, or CA
  • If 700 risk for MI/CVA
56
Q

D-Dimer

A
  • Very general test

- Normal:

57
Q

Fibrin Degradation Products (FDP)

A
  • Fibrin is split by plasmin and creates FDPs
  • Normal: 0-10
  • Critical if > 40
  • Increased value could indicate: DVT, cardiac/thoracic surgery, liver disease, CA, or MI
58
Q

Protein C

A
  • Anticoagulant produced by liver
  • Prevents thrombosis/enhances fibrinolysis
  • Decreases w/ age, DIC, liver disease, and ARDS
59
Q

DIC: S/S

A
  • Bleeding: *Petichiae, bleeding/oozing from various sites, hematuria,
  • Clotting: *Altered LOC, thrombosis, gangrene, PE, bowel ischemia/infarction, ARF
60
Q

DIC Labs: Plt count, Fibrinogen, PT, Protein C, FDPs, D-Dimer, Serum Bilirubin, BUN

A
  • Plt count: down
  • Fibrinogen: down
  • PT: prolonged
  • Protein C: down
  • FDPs: up
  • D-Dimer: up
  • Serum Bilirubin: up (RBCs are breaking down)
  • BUN: up (RBC fragments [schistocytes] clog kidneys)
61
Q

DIC: Tx

A
  • Treat underlying cause
  • Correct Imbalances: O2, replace fluids/electrolytes, give vasopressors
  • Severe Bleeding: Cryoprecipitate, FFP, plt transfusion
62
Q

Albumin

A
  • Indicator of nutritional status
  • Normal: 3.4-5
  • If low, pt has been malnourished for awhile and there will be more problems as well
63
Q

Calculating Osmolality

A
  • Normal Serum Osmolality: 280-303
  • Normal Urine Osmolality: 300-900
  • Calculated: 2Na + BUN/3 + Glucose/18
64
Q

Albuterol (Proventil)

A
  • Class: Beta2-Andrenergic Agonist
  • AE: Tachycardia, palpitations, tremors
  • Teaching:Take Beta2’s before inhaled glucocorticoids
65
Q

Terbutaline (Brethine)

A

Class: Long-acting Beta2-Andrenergic Agonist (*Oral)

-AE:tachycardia, palpitations, tremors

66
Q

Midazolam (Versed)

A
  • Class: Benzodiazepine
  • AE: CNS depression, Respiratory depression
  • D/D interactions: Any CNS depressant
67
Q

Diphenhydramine (Benadryl)

A
  • Class: H 1 Blocker (antihistamine)
  • AE: Sedation, Anticholinergic Effects, GI discomfort, Hallucination
  • Contraindicated in 3rd trimester
  • Caution in children/older adults, asthma, urinary retention, HTN, open-angle glaucoma
68
Q

Insulin: Rapid Acting

A
  • Humalog or Novalog

- Onset

69
Q

Insulin: Short Acting

A
  • Regular Insulin, Humulin-R, or Novolin-R
  • Onset: 30 min.-1 hr
  • Peak: 2-3 hr
  • Duration: 5-7 hr
  • *Always draw short acting first
  • *Don’t admin if cloudy
70
Q

Insulin: Intermediate Acting

A
  • NPH, Humulin-N, or Novolin-N
  • Onset: 1-2 hr
  • Peak: 4-12 hr
  • Duration: 18-24 hr
71
Q

Insulin: Long Acting

A
  • Glargine (Lantus)
  • Onset: 1 hr
  • Peak: none
  • Duration: 10-24 hr
  • *Do not mix with any other insulin

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