UNIT 1-CARE OF A RESPIRATORY PATIENT 1 Flashcards
(107 cards)
1
Q
What is acid base balance?
A
The process of regulating the PH, bicarbonate concentration and partial pressure of carbon dioxide of the body fluids
Regulated through respiratory and renal function
2
Q
What is gas exchange?
A
THe process by which oxygen is transported to the cells and carbon dioxide is tranported from the cells
3
Q
What is perfusion?
A
The flow of blood through the arteries and capillaries delivering nutrients and oxygen to the cells and removing cellular wastes
4
Q
What are 3 important parts of perfusion
A
- Vessels
- Blood
- Closed system
5
Q
What structures are part the upper respiratory tract?
A
- Nasopharynx
- Oropharynx
- Laryngopharynx
4
6
Q
What structures are part of the lower respiratory tract?
A
- Broncholes
- Right & left lung
- Aleolar ducts
- Alveoli
7
Q
What are different types of respiratory obstruction?
A
- Pulmonary Edema
- Cardiogenic pulmonary edema is caused by back up fluid that the heart cannot clear
- Non-cardiogenic is due to inflammation from injury and/or infection
- Acute respiratory distress syndrome
- Pneumothorax/Hemothorax
- Pneumo: collapsed lung caused by trauma that damages the lung tissue (either too much PEEP or a hol ein the chest and air leaks into the pleural space
- Hemo: collapsed lung caused by a collection of air or blood outside the lung but within the pleural cavity.
- Pulmonary Embolism
- Occurs when there is a blood clot that is loged in a blood vessel in the lungs blocking blood flow to part of the lung.
8
Q
What are types of airway obstructions?
A
- Pulmonary edema
- Non-cardiogenic due to inflammation (ARDS)
- Collapsed Lung
- Atelectasis
- Pneumothorax or hemothorax
9
Q
What are types of perfusion obstructions
A
Vessel obstruction- pulmonary embolism
10
Q
what is tidal volume?
A
Volume of air exchanged with each breath usually around 400-500ml
11
Q
How much air is exchanged with each breath?
A
400-500mL
12
Q
What is fi02?
A
% of oxygen
13
Q
What is the % of oxygen in room air
A
21%
14
Q
What is fi02 of a nasal cannula at 4-6L of oxygen?
A
37-45% 02
15
Q
High flow oxygen at 60L/min is how much fi02?
A
100%
16
Q
What is MAP?
A
Mean arterial pressure. This is how much perfusion that is getting to the organs
17
Q
MAP should be greater than ___1__ but less than __2__
A
- 65 preferably 70
- Less than 100
18
Q
How do you figure your MAP?
A
SBP + 2(DBP) /3
19
Q
What is the purpose of ABGs?
A
Maintain homeostasis
20
Q
What is the normal pH level
A
7.35-7.45
21
Q
What is the normal PaO2 level?
find out what Pa02 level
A
80-100 mmHg
22
Q
What is a normal Sa02 value?
A
more>95%
23
Q
What is the normal PaCO2 level?
A
35-45mmHg
24
Q
What is the normal HCO3?
A
22-26mEq/l
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CO2 is the ____ component o our blood and the lungs regulate the co2 levels within mins
ACID
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To compensate for acidosis the RR and depth will do what
Increase to blow of co2
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To compensate for alkalosis the RR and depth will do what
Decrease to retain CO2
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The Pa02 and FiO2 ratio is used to determine....
lung injury
Normal lung ratio: 300-500
Acute lung injury Ratio: 200-300
ARDS: Less than 200 is very significant
ARDS: Less 100 is severe with high mortality
Acute lung injury (is like ARDS but has less of a shunt resulting in hypoemia)
As lungs become injured, they require higher concentrations of oxygen to maintain the Pa02
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What is the ventilation/perfusion ratio (V/Q)
V/Q is the ventilation to perfusion ratio
1. (v) air moving in and out
2. (q) blood circulating to areas of the lung (perfusion)
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V/Q causes changes in....
Pa02 and PaCo2
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How do we treat ventilation/perfusion imbalances like hypoemia?
Give oxygen and identify and treat underlying problem.
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What is hypoxemia?
It is a reduction of arterial oxygen tension or partial pressure of oxygen Pa02. Patients will experience hypoxia first which will show as hypoxemia later
Decreased o2 gas exchage r/t ventilation and or perfusion failure.
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What are early and late Pa02 levels in hypoexmia?
Early: Pa02 <80mmHG
Late: Pa02 <60mmhg
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What are some disease processes that block the alveolar causing hypoxemia in patinets?
Pulmonary Edema
Pneumonia
ARDS
Cystic Fibrosis
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What are can cause a perfusion blockage that can cause hypoxemia in patients?
Pulmonary Embolism
36
What types of airway obstructions can cause hypoxemia?
1. Asthma
2. COPD
3. Anaphalaxis
4. Atelectasis
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Respiratory depression caused by opiod overdose can cause what?
Hypoxemia
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What are symptoms of hypoxemia?
1. Dyspnea
2. Tachypnea & tachycardia
3. Coughing
4. Wheezing
5. COnfusion
Cyanosis (bluish/purpleish)color in skin, fingernails and lips
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What is Hypercapnia?
Inadequate alveolar ventilation causing hypoventalation and retention of Co2.
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What are early levels of Paco2 in a hypercapnic patient
more than 45mmHg
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What are late levels of Paco2 in hypercapnic patient
more than 50mmHg
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What CNS conditions can cause hypercapnia?
1. Spinal cord injury
2. Opiod overdose
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What neruomuscular conditions can cause hypercapnia
1. Multiple sclorosis
2. ALS
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What chest wall abnormalities can cause hypercapnia
1. Barrel chest
2. Kyphosis
3. Trauma-open thorax wound
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What are some airway or alveolar blockages that can cause hypercapnia?
COPD
Cystic fibrosis
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What are symptoms of hypercapnia?
1. Hypoventilation (dyspnea)-unable to remove the co2 from the body
2. Tachycardia
3. Diaphoresis
4. Headache
5. Restlessness
6. Change in consciousness-co2 sedates-so very lethargic
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What are the consequences of hypercapnia?
1. Body can tolerate high co2 levels better than low o2 levels
2. Slow changes in co2 allow for compensation
3. Need to treat the primary cause before patient deteriortes
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When co2 levels cannot be maintained within normal limits by the respiratory system, one of two primary problems exists....
1. Increase in co2 production or
2. Decrease in alveolar ventilation
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What is happening in either hypoxemia and/or hypercapnia?
1. Shunt- blood exits the heart without taking part in gas exchange as this is a perfusion issues (cardiac like septal defect, cardiogenic pulmonary edema)
2. DIffusion limitation- occurs when gas exchange across the alveolar- capillary membrane is compromised by either the destruction of the alveoli or blockage within the pulmonary capillaries so either PERFUSION and or VENT issues (ards, pulmonary edema)
3. Alveolar hypoventilation-- decrease in ventilation that causes hypercapnia and hypoxemia which is typically caused by vent issues (cns conditions, acute asthma, chest wall dysfunction)
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What are early signs of respiratory failure?
1. Mental status changes
2. Breathing pattern changes
- Dyspnea, Tachypnea
3. Heart rate and rhythm changes
- Tachycardia, Hypertenion
4. Refusal to take oral fluids
5. Decreased urine
6. Wheezing or persistent cough
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What are late signs of respriatory failure?
1. Bradycadia
2. Bradypnea occur
3. Lethargic unreponsive
4. Increased co2 which leads to monring HA, decreased RR, and Decreased LOC
5. Cyanosis is a late sign when Pa02 is less than 45mmHg
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What is acute respiratry distress syndrome (ARDS)
Pulmonary Edema due to trauma or infection.
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What are some causes of ARDS?
1. Aspiration of gastric contents
2. Near drowning
3. MVC
4. Chemical inhalation (paints)
5. Sepsis
6. Covid-19
7. **viral pneumonia, fat emboli, decreased surfactant production, fluid overload and shock**
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What are s/s of ARDS?
1. Profound dyspnea
2. Hypoxemia
3. INcreased WOB
4. Resp distress leading to endotracheal intubation
5. Severe hypoexmia
6. Hypercapnia
7. Metabolic acidosis
8. Organ dysfunciton
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What might a patient with ARDS xray look like?
"white out" and pleural effusions
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How do you calculate the severity of hypoemia?
Pa02/Fio2 ratio (P/F ratio) of ards
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What happens during th eexudative phase of ARDS?
1. Cell injury and inflammation
2. Alveolar edema decreases ventilation > hypovenilation occurs
- Low Pa02 and elevated Paco2
- White out on chest xray
3. Resp failure- classic sign > refactory hypoxemia
4. Assesed ventilation needed
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What happens in the proliferative phase in ARDS.
1. Edema fluid resorption
2. Recovery phase
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what happens during the Fibrotic phase (rare) of ARDS
1. Fibrosis of lungs
2. Ventilator dependent breathing
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What are our nursing actions for a patient with ARDS?
1. Assess respiratory rate, depth, and vitals
2. Administer oxygen
3. Fowler's position
4. Restrict fluid intake
5. Breathing treatment
6. Administer diuretics and/or gluccprtocpod steriods
7. Prepare for intubationand mechanical ventilation if the patient declines
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A collapsed lung is...
A condition that occurs when air or blood leaks into the space between the lungs and chest wall
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What is and what can cause a pnumothroax?
1. Open/closed wound causing air to enter the chest wall
2. A blunt or penetrating chest injury, certain medical procedures (high tidal volumes on mechanical vents) or lung disease can cause
3. A pneumomothorax can be spontaneous caused by exisiting lung disease or by trauma
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What is a hemothorax?
Blood in the plueral space causing collapsed lung
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What are some causes of either pneumothorax or hemothroax?
Trauma--MVC, gunshot wound
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What can cause a pneumothorax?
VALI- Ventilator induced lung injury caused by high PEEP levels and or tidal volume too high on the vent.
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What are nursing actions for care of a patient with a pnumothorax or hemothroax
1. Assess lung sounds, resp rate/depth, vitals
2. Monitor skin around chest tube insertion site
3. Mobility-- ROM, TCDB, turn frequently
4. Care of a chest tube
- Disloged from patinet apply sterile dressing over site taped on 3 SIDES and call the physcian immediately
- System breaks- insert tube into sterile water or saline
- milking, stripping or clamping- NOT RECOMMEDED
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What is the purpose of a chest tube?
Placed to release either air or blood to return negative pressure to the intrapleural space
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When assessing a patient with a chest tube what are we assessing?
1. Assess lung sounds, resp rate, depth, vitals
- Listening for absent breath sounds on affected side
- looking for cyanosis
- dyspnea
- decreased chest expansion unilaterally
- Hypotension
- Sharp chest pain
- Subcutaneous emphysema- Co2 or air leaking into the skin causig crepitus (crackling) feeling in skin
- Tracheal deviation to the UNAFFECTED side with a tension pnumo
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What do we need to know about tension pneumos?
Seen with closed pneumos from closed chest wounds or mehanical ventilation
Creates a one way valve which allows air out of the lung but not out of the pleural space creating a tracheal devation
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What should we know about closed drainage systems?
1. Pnurmos should have bubbling in the water seal during EXPIRATION but NOT continous bubbling.
2. Water evaporates from the suction control and will need to be monitored and add water if it is low
3. Bubbling in the suction chamber is expected
4. Drainage chamber is marked each shift for output
5. If drainage chamber is full, will need to change out systems with a new one
6. Clamping and milking are NOOOOT recommended it could increase the chance of a pneumo or the pressure
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Continous bubbling in a closed drainage system indicates....
a leak in the system
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What do you do if the chest tube becomes disloged?
1. Cover the site with a sterile dressing, and tape on three sides (this allows air to escape and prevent tension pnumothorax) notify MD
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What happens if a chest tube system breaks?
Insert the tube 1 inch into a bottle of sterile water or sterile normal saline and obtain a new system
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I can you identify crepitus in a patient with a chest tube?
Palpate around chest tube insertion
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What is a pulmonary embolism?
It is a embolus loged within the pumonary system causing a perfusion issue
76
What are some causes of a PE
1. DVT (common), cancer, fat emboli
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What are s/s of a PE?
1. Severe dyspnea, Tachypnea
2. Hypoexmia unresponsive to oxygen therapy
3. Chest pain
4. Tachycaria, diaphoresis
5. Changes in mental status
6. Syncope
7. Cyanosis
8. Pallor
78
What are some diagnostic tests to diagnosis PEs?
1. D Dimer lab- Elevated levels from protiens that break down blood clots
2. CT scan
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What are some nursing actions for patients who have a PE?
1. Assess respiratory rate, depth, vitals
2. Elevate head of bed to increase oxygen perfusion
3. Oxygen
4. Heparin therapy
5. Mobility
6. Nutrition
7. Teaching about anticogulant therpay
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What should should patients be limited with patients taking coumadin
vitamin K- leafy veggies
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Are nursing assessment & eval include of respritaroy system.
1. Vital signs are vital- are there any trending or abnormal
2. Assessment
- Working of breathing
- Rate,depth of breaths
- lung sounds
82
What are good positions for resp. patients
1. Generally, fowlers or semi fowlers-HOB raised to at leart 30 degree
2. Risk of aspiration: Side-lying position
3. Unilateral lung disorders- "good lung down" to improve v/q
4. Bilateral lung disorders- side to side respositioning
5. Prone to ventilated patients to move secretions
83
What do we want our saO2 to be
95%
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Why should we be mindful of COPD patients that rely on the hypoxic drive to breathe?
Their chemoreceptors that recognize Co2 are less sensitive to Co2. It is the lack of oxygen that causes them to breath. So, if you give them too much oxygen, they might become severly hypoxic because their drive to breathe is high Co2 and not high o2. but remember never withhold oxygen from a hypoxic patient
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What should we keep in mind about resp patients and nutritional therapy.
1. Start feeding enteral (OGT, NGT, oral) within 48 hours- the sooner the better
2. How many calories are they getting through there feeding tube
3. verify placement of OGT and NGT prior to using the tube
4. High protien promotes healing, unless contrindicated
5. Parenteral is always through a central line
6. Fluid restriction ARDS
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What do we need to know about mobility and resp patients?
1. Active or passive range of motion every shift
2. Turning every 2 hours or more, if the patient can tolerate it
3. If not vented, encourage ambulation, if possible and do it early
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What patient education should we provide resp patients
1.Labs and what they mean – understand what they are for so you can pass this along to your patients and their families
2.Oral care for vented patients
3.Medications – what are they for? What side effects?
4.Mobility – Incentive spirometer, ambulation
Sleep – importance of rest
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What are our BAM drugs?
Bronchodilators
B- Beta 2 Agonist (ALBUTEROL)
- Dilate bronchioles
- Immediate action
- Expect- wheezing to diminish and hear clear breath sounds
A- Anticholinergics (IPRATROPIUM)
- Dry up fluid
- Expect- dry mucous membranes, tachycardia, hot/dry skin
M- Methlxanthines (Theophylline)
- Bronchodilator and stimulatory effects
- Long term control of asthma (example-- caffeine)
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What is our 1st and 2nd line drug fro asthma?
1. Albuterol
2. Ipatropium
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Always take bronchodilator before.....
inhaled steriod inhalers
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How do you know if a nebulizer bronchodilator is effective?
1. After 3 doses if not working, call HCP
2. Effective decrease in RR and o2 sats increased above 90%
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What are side effects of nebulizer bronchodilator...
expected.... are tachycardia, tremors, and insomnia (feel like adrenaline rush)
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What are our SLM drugs?
Anti-i nflammatory agents
S- Steriods (beclomethasone)
- Slow onset so not used as first line for asthma attack
- Inhaled- need to rinse mouth or perform oral care- DO NOT SWALLOW WATER as these can cause thrush
L- Leukotriene Inhibitor (montelukast)
- Slow onset (1-2 weeks) but opens airway
- Long term managment for prevention NOT a rescuse drug
- Expect a cough, sore throught, fatigue, headache
M- Mast Cell stabilizers (Cromolyn)
- Stops inflammation
- Acts fast but not a rescue inhaler
- takes about 15 mins before exercise to reduce exercise induced asthma
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Salmeterol and fluticasone should not be used for...
Asthma attacks.... these meds are for long term inflammatory control of the bronchioles
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What are some diuretics that a resp. patient might take?
1. Furosemide, hydroclorothiazie, bumetanide
- Nutrition education- encourage high potassium foods, bananas, oranges, green leafy vegetables, liver, avacado
- ECG- hypokalemia > flat T waves, prolonged QT, ST depression, U waves
- Want to maintain potassium 4.0-5.0 for ICU patients
2. Spironolactone (K+ sparing)
- Nutiriton education- avoid high potassium foods
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What are some anti-coagulant therapry a resp patient may take?
Anticoagulant
1. Injection: Heparin, Enoxiparin
2. Oral: Warfarin, Apixaban, Rivroxaban
3.
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What are anti-coagulants?
Decrease the bodies ability to clot and prevents clots forming allow the body time to reabsorb and break down clots in the body already. They do no break down clots
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What do we need to monitor on a patient taking Heparin injcections?
1. monitor platelet levels- do not give if less than 100k
2. Labs: Heparin gtt- monitor partial thromboplastin time (PTT) normal levels 46-70
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What is the antidote for heparin therapy?
Protamine sulfate
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What are our actions if PTT is greater than 30 or there is signs of bleeding while on heparin
1. Stop the heparin gtt and notify provider
2. Prepare antidote
3. Reassess labs in 1 hour
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What should we monitor with a patient taking warfarin (oral)
1. Labs: monitor INR levels for warfarin- theraputic levels 2-3
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What is the antidote for warfarin
Vitamin K
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What are our actions if INR is greater than 4 in a patient taking oral warfarin
1. Assess for bleeding
2. Prepare vitamin K
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What are our actions for the INR is less than 2 on a patient taking oral warfarin?
1. Give warfarin to increase INR to 2.5
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Is heparin fast or slow acting? what about Warfarin
Fast acting
Warfarin is slower acting- taking 5 days to reach theraputic level
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What are some anti-inflammatory drugs a resp patient may take?
1. Corticoid steriods or glucocorticoids- steriod hormones used to suppress immune responses like inflammation... slow onset .
2. Oral: prednisone-- oral only
3. Oral or injection: methlprednisolone, dexa methasone, betmethasone
4. Inhaled: beclomethsone, fluticasone
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