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Unit 4 Flashcards

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1
Q

What are the 4 airway adjuncts

A

Nasal trumpet
Laryngeal mask airway—tongue in way
Oropharyngeal airway
Supraglottic airway — special training

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2
Q

What is an endotracheal tube and what are the indications of use

A

Tube passed from the mouth or nose through vocal cords into trachea, used with mechanical ventilation to support airway
Indications: inability to protect airway, respiratory/cardiac arrest, structural compromise of the airway, surgery

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3
Q

What is a tracheostomy and what are the indications of use

A

Surgically created opening/stoma in the neck used for long term artificial airway
Indications: prolonged mechanical ventilation, upper airway obstruction, facilitating pulmonary toilet (cleaning secretions, not able to cough up),

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4
Q

What are the comments of RSI (rapid sequence intubation)

A

Preparation-gather supples
Pre oxygenated
Induction—sedative meds
Paralysis—paralytics
Intubation —monitor vitals
Post intubation care
Monitoring— attempts should be limited to 30 seconds at a time

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5
Q

What are the medications used for RSI

A

Sedative— propofol, etomidate
Rapid onset opioid—fentanyl
Paralytic—rocuronium or succunylcholine

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6
Q

How do you confirm tube placement

A

Auscultate lungs, X-ray, etCO2 detector (gold=good)
Inflate cuff if present
Connect ETT to ventilator
Secure ETT and record depth (@lips or teeth)
Monitor oxygen saturations and vital signs
Record ventilator settings

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7
Q

What are the nursing priorities when it comes to ventilators

A

Maintain correct tube placement
- auscultate breath sounds—especially after repositioning
- daily chest X-ray to confirm placement
- ensure the securemnt device is secured to face and ETT
Maintain tube patency
- keep mouth clean and remove oral secretions
Maintain cuff inflation
- listen for audible leak and reinflate with RT as needed
Maintain skin integrity

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8
Q

How often do you do oral cares

A

2 hours

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9
Q

What are complications of intubation

A

Damage to teeth
Extubation
Aspiration
Damage to tissues

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10
Q

What are complications of suctioning

A

Hypoxemia
Bronchospasm
Increased ICP
Dysrhythimas
Hypo or hypertension
Tracheal mucosal damage
Pulmonary bleeding
Pain
Infection

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11
Q

What are signs of unplanned/ self extubation

A

1 sided breath sounds
Low pressure alarm on ventilation (leak, tube out of place)
Respiratory distress
Gastric distention (air in belly)

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12
Q

What is the nursing management if there is unplanned extubation

A

Remain calm
Stay w pt
If no breath sounds are heard, remove ETT and begin bagging

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13
Q

How do you prevent unplanned extubation

A

Adequate sedation
Communication during patient movement
Restraints

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14
Q

What is VAP protocol

A

Avoid intubation
Minimize sedation
Assess readiness to extubation
Early mobilization
Elevate HOB
Frequent oral cares
Change circuit when soiled
Suction prn

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15
Q

How can we prevent skin breakdown with ventilated pts

A

Reposition every 2 hours
Protect skin under and around securement device
- repositionsecuremnt device every 24 hours
Provide oral cares every 2 hours
= insert bite Block if indicated

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16
Q

When can a patient be extubated

A

Vent is weaning as blood gas results and patient condition improves.
Pt can be extubated when blood gas results are within normal limits on low oxygen and ventilator support

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17
Q

What is hypoxemic failure

A

Inadequate oxygen transfer to body
PaO2 is less than 60mmHg
—hemoglobin is not saturated with oxygen
—condition still exists despite supplemental oxygen

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18
Q

What is hypercapnic failure

A

Insufficient CO2 removal
PaCO2 is greater than 50 mmHg
—body is unable to compensate
—pH is low; further decrease leads to severe acid-base imbalance

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19
Q

What are the four physiologic mechanisms of hypoxemic failure

A

Ventilation-perfusion (V/Q) mismatch
Shunt
Diffusion limitation
Alveolar hypoventilation

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20
Q

V/Q mismatch what is the main problem, manifestations, and treatment

A

Discrepancy between ventilation and perfusion
-decreased ventilation d/t secretions, bronchospasm, or pain
-decreased perfusion d/t emboli or fluid buildup
Treat the cause, administer supplemental o2

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21
Q

Shunt of hypoxemic failure what is the main problem, manifestations, and treatment

A

Blood does not participate in gas exchange
- blood is being diverted away from the lungs due to anatomical or intrapulmonary issue
-oxygen is not effective
Mechanical ventilation with high FiO2

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22
Q

Diffusion limitation what is the main problem, manifestations, and treatment

A

Compromised gas exchange
-hypoxemia during exertion
Rest and decrease HR and O2 demands

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23
Q

Alveolar hypoventilation what is the main problem, manifestations, and treatment

A

Low rate of gas exchange in lungs; occurs in combination with other types of
-high PaCO2 levels
-low PaO2 levels
Improve ventilators effort, if possible
Specific causes=specific treatments

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24
Q

What are the four characteristics or categories of hypercapnic failure

A

Abnormalities of the airways and alveoli
Abnormalities in the CNS
Abnormalities of chest wall
Neuromuscular conditions

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25
CNS problem what is the main problem, manifestations, and treatment
Suppression of the respiratory drive -D/T: opioid overdose, brain stem infarction, TBI, spinal cord injury Treat the cause, support respiratory effort
26
Chest wall abnormalities what is the main problem, manifestations, and treatment
Physical abnormalities limit chest wall or diaphragm movement —severe obesity, flail chest, lung expansion is limited May nor may not be able to treat
27
Neuromuscular conditions what is the main problem, manifestations, and treatment
Related to muscular weakness or paralysis Guillain-Barré syndrome, toxin exposure, muscle wasting during critical illness Rest, decrease hear rate and systemic oxygen demands
28
Airway and alveoli problems what is the main problem, manifestations, and treatment
Airflow obstruction and trapping COPD, asthma, CF, fatigue, ventilators failure Maximize disease treatment, nutrition
29
What will you monitor for respiratory failure
Observe, listen, ABG, X-ray, PaO2, PaCO2
30
What are symptoms of hypoxemic failure
Accessory muscle use with breathing Dyspnea Nasal flailing Paradoxical chest or abdominal wall movement with respiratory cycle (late) Prolonged expiration Deceased SpO2 Tachypnea Cyanosis (late)
31
What are the manifestions of hypercapnic failure
Dyspnea Limited chest wall movement Pursed lips breathing Tripod position Decrease respiratory rate or rapid rate with shallow respirations Decreased tidal volume (less air per breath) Decreased minute ventilation (less volume inhaled and exhaled per minute)
32
What is Acute Respitory distress syndrome
Sudden, progressive process that causes the alveolar-capillary membrane to become permeable —fluid accumulates in the lungs, which prevents gas exchange
33
What are the three phases of Acute Respiratory Distress syndrome
Injury (exudative) phase—membrane permeable Reparative (proliferative) phase—trying to heal Fibrotic phase—scarring (no return)
34
What is the injury phase of ARDS
It is when there is interstitial edema V/Q mismatch, intrapulmonary shunt Shunt—increased cap permeability and destruction of collagen Surfactant dysfunction —-Atelectasis Junk builds up in alveoli
35
What is the reparative phase of ARDs
Inflammatory cells destroy vasculature Lung compliance decreases Dense fibrous tissue forms
36
What is the fibrotic phase of ARDs
Complete remodeling of lung occurs-scarring and fbrosis from —reduced area for gas exchange Three phases Pulmonary HTN
37
What is a normal PaO2/FiO2 ratio
Normal >400 Mild <300 Moderate <200 Severe <100
38
What are complications of ARDs
Intubation and ventilation Chronic lung disease Stress ulcers VTE Acute kidney injury Infection Deconditioning/complications of immobility Psychosocial issues
39
What drugs relieve pulmonary congestion with ARDs
Diuretics, morphine (comfort), nitroglycerin
40
What are the four classifications of Shock
Distributive Hypovolemic Cardiogenic Obstructive
41
Anaphylactic is what kind of shock
Distributive shock Problem with tone IgE release causes increase vascular permeability, vasodilation, decrease SVR
42
Neurogenic is what kind of shock
Distributive Spinal injury or spinal anesthesia Problem with tone from autonomic deregulation leading to cardiovascular instability (dec HR and Dec BP)
43
What are nursing cares for anaphylactic and neurogenic distributive shock
Anaphylactic —epinephrine IM, diphenhydramine (Benadryl), and steroids, protect the airway Neurogenic: stabilize the spinal cord, vasopressors if needed Support other two sides Volume: fluids-anaphylactic, caution with neurogenic Pump: not usually a problem, could give atropine if bradycardia persists
44
What are the three major effects of septic
Vasodilation Maldistribution of blood flow Myocardial depression
45
What are nursing cares for septic shock
Fix the problem Poor tone results from mass inflammatory response Need to restore intravascular volume to maintain organ perfusion Other two sides Volume— fluid resuscitation —if not responsive add NE and vasopressin Pump: not usually a problem
46
What is the difference between absolute and relative loss
Absolute= external loss Relative loss is internal loss (bleeding inside)
47
What are the hallmark signs of hypovolemic sock
Tachycardia Decreased cap refill Decrease cerebral perfusion Dec urine output Tachypnea —> bradypnea
48
What are hallmark signs of cardiogenic shock
Tachycardia, Dec BP, Dec SV, Dec CO, Inc CVP, Inc pulmonary artery wedge Decrease perfusion to brain and rest of body Dec urine output d’t dec renal blood flow Myocardial Tachypnea, crackles, cyanosis Pallor cold and clammy
49
What labs do you expect on cardiogenic shock
BNP inc Inc BG Inc BUN Inc toponin Chest X-ray ECG Abnormal echo
50
What nursing cares do you do for cardiogenic shock
Stop the problem causing the problem (dysrhythmias) Support with inotropic agents Support two other sides of triangle Tone: promote vasodilation Volume: diuresis Position flat Monitor renal
51
What is obstructive shock
Occurs when blood flow is block and circulation to the major organs is disrupted PE Tampoande Pericardial effusion
52
What are hallmarks of obstructive shock
Tachycardia, decreased BP, Dec preload, Dec CO Dec cerebral perfusion Hypoactive to absent bowel sounds Decreased urine output Tachypnea progressing to Bradypnea
53
What are nursing cares for obstructive shock
Fix the problem—treat the cause Monitor relevant labs
54
What is the normal range of CO2
Acidic Normal 35-45 Less=less acidic More=more acidic
55
What is the normal range of HCO3
21-28 Basic Less= more acidic More- more basic
56
What does PaCO2 tell us about
Tells us how the respiratory system is functioning
57
What does the HCO3 tell us
Tells us how the kidneys are functioning
58
What is the initial stage of shock
Not clinically apparent Little oxygen—> metabolic shifts from aerobic to anaerobic—> lactic acid buildup
59
What is the compensatory stage of shock
Compensatory stage: body activates neural, hormonal, and biochemical compensatory mechanisms to overcome increasing consequences of anaerobic metabolism
60
What are the specific of organ responses to compensatory stage of shock
SNS responses vasoconstictin and increase HR Start of pulmonary ventilation—perfusion mismatch Some mental status changes Cool clammy skin Activation of RAAS: causes vasoconstriction and water reabsorption
61
What is the progressive stage of Shock
Progressive shock begins when compensatory mechanism fails
62
What are the vitals of progressive stage
Dec CO—> Dec BP and inc HR MAP <60 (or 40 drop in BP from baseline) Dec peripheral perfusion Critical respiratory system dysfunction—ARDS Third spacing
63
What is refractory stage of shock
Organs are failing, body’s compensatory mechanisms are overwhelming, recovery is unlikely —profound hypotension and hypoxemia —easte products accumulate—lactate, urea, ammonia, CO2 Fluid and plasma products continue to leak from vessels Cerebral ischemia present (disruptive blood flow to brain) Lactate also causes vascular leakage
64
What is the systemic progression of MODS
Lungs—> kidneys (AKI)—>liver (DIC)—>gut (lactic acidosis)
65
What is the priorities in shock
Prevent and treat infection Maintain tissue oxygenation/perfusion Nutrition and metabolic support Appropriate support of individuals failing organs
66
What do you do if fluid resuscitation is unsuccessful
Consider vasopressors (NE—inc BP, MAP, CVP, SVR/Epinephrine—inc HR and contractility/ dopamine—inc contractility, decrease vascular resistance) And inotropes (dobutamine—inc contractility, decrease workload)
67
T/F fluid resuscitation is likely contraindicated in cardiogenic shock dt increased workload on the heart
T
68
Isotonic crystalloid (0.9% NaCl, LR) what type of shock is it used for and what are the nursing considerations
Initial volume replacement in all types -monitor circulatory overload -no LR in liver failure -Use LR if patient is in hyperchloremic acidosis
69
Hypertonic crystalloid (3% NaCl) what types of shock is it used for and what are the nursing considerations
Hypovolemic shock, DKA Monitor for hypernatremia Frequent neuro checks Central line is preferred
70
What are the four metabolic abnormalities of type 2 diabetes
1. Insulin resistance 2. Fatigued pancreas 3. Inappropriate glucose production by the liver 4. Altered production of hormones and cytokines
71
What are the hallmarks of DKA
Hyperglycemia Dehydration Ketosis/acidosis
72
What does DKA look like
3 Ps S/s dehydration (lethargy, weakness, sunken eyeballs, dry membranes, tachycardia, hypotension) N/V Kussmaul respirations—rapid deep breathing Fruity breath
73
What are the treatments of DKA
First ABCs, then: 1st priority—IV access and fluid resuscitation 2nd priority—insulin —baseline K —Monitor BP levels hourly —goal: reduce 50-100 mg/dl/hour to avoid cerebral edema 3rd normalize electrolytes (ECG and bicarbonate) 4th priority—determine and treat cause
74
What is HHS
Blood sugar >600 seen in type 2 diabetes Hallmarks: severe hyperglycemia, dehydration, elevate serum osmolatiy High mortality rate 60 years old or older with (UTI, pneumonia, other acute illness
75
What does HHS look like
3Ps Absent ketones in blood or urine Neurological manifestions (serizures, coma, aphasia, etc)
76
What do you do if you get hypoglycemic is a diabetic pt
Ingest 10-15 grams of simple carbs Recheck BG in 15 minutes Give IM or sub q glucagon
77
What is the CAM assessment
To assess delirium
78
What does an alcohol intoxication look like
Confusion Unresponsivness Seizures GI: N/V CV: HR decreased R: Decrease RR, irregular Decreased temp
79
What does overdose of opioids look like
Unresponsive Dyspnea Respiratory arrest Constricted pupils Choking or gurgling
80
What does overdose of benzos look like
Decrease LOC Constricted pupils Respiratory arrest Choking or gurgling
81
How do you treat alcohol withdrawal
CIWA assessment Ativan Thiamine Electrolytes
82
How do we treat opioid withdrawal
Narcan (acute) Methadone (chronic) Benzodiazepines: flumazenil (acute), Ativan (chronic)

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