Week 2 - Respiratory, ABGs

Question 1

Acute Respiratory Failure Overview

Occurs when oxygenation, ventilation, or both are ___________

• Insufficient O2 transferred to blood
• ___________
• Decreased PaO2 and SaO2
• Inadequate CO2 removal
• ___________
• Increased PaCO2
• ABGs assess pH, PaO2, PaCO2, bicarbonate, SaO2
• Pulse oximetry assesses arterial O2 saturation(SpO2)

Answer 1

Occurs when oxygenation, ventilation, or both are inadequate

• Insufficient O2 transferred to blood
• Hypoxemia
• Decreased PaO2 and SaO2
• Inadequate CO2 removal
• Hypercapnia
• Increased PaCO2
• ABGs assess pH, PaO2, PaCO2, bicarbonate, SaO2
• Pulse oximetry assesses arterial O2 saturation(SpO2)

Question 2

Hypoxemic (Oxygenation) or Hypercapnic (Ventilatory)

Answer 2

Hypoxemic
PaO2 is less than or equal to 60 mm Hg on 60% or more oxygen

Hypercapnic
PaCO2 is over 50 mm hg and pH is under 7.35

Question 3

Common Causes of ARF

Hypoxemic:
* ARDS
* Asthma
* Chronic Bronchitis
* Pulmonary Edema
* Emphysema
* Pneumonia
* PE
* Pneumothorax

Hypercapnic:
* ARDS
* Asthma
* Chronic Bronchitis
* Pulmonary Edema
* Emphysema
* COPD
* Cystic Fibrosis
* Hypoventilation syndrome
* Brainstem injury
* Guillain-Barre Syndrome
* Muscular dystrophy

Answer 3

Hypoxemic:
* ARDS
* Asthma
* Chronic Bronchitis
* Pulmonary Edema
* Emphysema
* Pneumonia
* PE
* Pneumothorax

Hypercapnic:
* ARDS
* Asthma
* Chronic Bronchitis
* Pulmonary Edema
* Emphysema
* COPD
* Cystic Fibrosis
* Hypoventilation syndrome
* Brainstem injury
* Guillain-Barre Syndrome
* Muscular dystrophy

Question 4

Hypoxemic Resp. Failure

1. Mismatch between Ventilation (V) and perfusion (Q)
   —. V/Q mismatch
2. Shunt
3. Diffusion limitation
4. Alveolar hypoventilation

Answer 4

1. Mismatch between Ventilation (V) and perfusion (Q)
   —. V/Q mismatch
2. Shunt
3. Diffusion limitation
4. Alveolar hypoventilation

Question 5

pH – the measure of ________ balance found in arterial blood

______ - _______

Answer 5

pH – the measure of acid/base balance found in arterial blood

7.35 – 7.45

Question 6

PaO2 – the partial pressure of O2 found in _______________

_____ - _______ mmHg

Answer 6

PaO2 – the partial pressure of O2 found in arterial blood

80 – 100 mmHg

Question 7

PaCO2 – the partial pressure of CO2 found in arterial blood

_____ - _____ mmHg

Answer 7

PaCO2 – the partial pressure of CO2 found in arterial blood

35 – 45 mmHg

Question 8

HCO3 – the measure of __________ found in arterial blood (buffer that helps balance pH)

_____ - _____ MeQ/L

Answer 8

HCO3 – the measure of bicarbonate found in arterial blood (buffer that helps balance pH)

22-26 MeQ/L

Question 9

SaO2 – O2 saturation in the arterial blood _______ %

Answer 9

95-100

Question 10

SpO2 – O2 saturation in the peripheral capillaries; estimate of the amount of O2 that is bound to Hbg in the blood versus the total amount of Hbg _______%

Answer 10

95-100

Question 11

Hypoxemic Respiratory Failure
Etiology and Pathophysiology

Diffusion Impairment
* Gas exchange across alveolarcapillary membrane is compromised by a process that destroys the alveolar membrane or affects blood flow through the pulmonary capillaries

Alveolar-capillary membrane is thicker (fibrotic) and slows gas exchange

Pulmonary fibrosis, interstitial lung disease, ARDS

Pulmonary edema – accumulation of fluid, WBCs or protein in alveoli

Answer 11

Diffusion Impairment
* Gas exchange across alveolarcapillary membrane is compromised by a process that destroys the alveolar membrane or affects blood flow through the pulmonary capillaries

Alveolar-capillary membrane is thicker (fibrotic) and slows gas exchange

Pulmonary fibrosis, interstitial lung disease, ARDS

Pulmonary edema – accumulation of fluid, WBCs or protein in alveoli

Question 12

Clinical Manifestations of Hypoxemia and Hypercapnia

Signs of respiratory failure are related to
A sudden decrease in PaO2 or rapid increase in PaCO 2 implies a serious condition or lifethreatening emergency
Signs of respiratory failure are related to Extent of changes in PaO2 or PaCO2
Speed of change (acute versus chronic)
Ability for compensation to occur

Failure of compensatory mechanisms leads to resp. failure

Answer 12

Signs of respiratory failure are related to
A sudden decrease in PaO2 or rapid increase in PaCO 2 implies a serious condition or lifethreatening emergency
Signs of respiratory failure are related to Extent of changes in PaO2 or PaCO2
Speed of change (acute versus chronic)
Ability for compensation to occur

Failure of compensatory mechanisms leads to resp. failure

Question 13

Clinical Manifestations of Hypoxemia & Hypercapnia cont.

Lack of O2 affects all body systems
* Manifestations may be specific or nonspecific
* First sign of hypoxemic ARF is a change in ________________

Decreased O2
_________, _________, agitation

Increased CO2
morning headache, decreased RR, decreased LOC

• Early signs of ARF – tachycardia, tachypnea, pallor, mild increase in work of breathing (WOB)
  Heart and lung compensation for decreased O2 and rising CO2
• Cyanosis is an unreliable indicator of hypoxemia

Answer 13

Clinical Manifestations of Hypoxemia & Hypercapnia cont.

Lack of O2 affects all body systems
* Manifestations may be specific or nonspecific
* First sign of hypoxemic ARF is a change in mental status

Decreased O2
restlessness, confusion, agitation

Increased CO2
morning headache, decreased RR, decreased LOC

• Early signs of ARF – tachycardia, tachypnea, pallor, mild increase in work of breathing (WOB)
  Heart and lung compensation for decreased O2 and rising CO2
• Cyanosis is an unreliable indicator of hypoxemia

Question 14

Hypoxemia and Hypercapnia

Observe
* Position: lie down, sit upright, or tripod
* Work of breathing (WOB); effort needed by respiratory muscles to inhale air into the
lungs

• Breathing patterns
  _______, shallow (hypoxemia); monitor for fatigue
  _____ RR (hypercapnia)

Change from rapid to slow RR indicating severe muscle fatigue and leading to respiratory arrest

Answer 14

Observe
* Position: lie down, sit upright, or tripod
* Work of breathing (WOB); effort needed by respiratory muscles to inhale air into the
lungs

• Breathing patterns
  Rapid, shallow (hypoxemia); monitor for fatigue
  Slow RR (hypercapnia)

Change from rapid to slow RR indicating severe muscle fatigue and leading to respiratory arrest

Question 15

Hypoxemia and Hypercapnia

Observe
* Ability to speak
2 to 3 word _______
* _________ breathing
Increased expiratory time; prevents small bronchial collapse
* _________ of intercostal spaces or supraclavicular area; use of accessory muscles
* Paradoxical breathing
Abdomen and chest move outward with exhalation and inward with inhalation (opposite of normal)
May be diaphoretic from increased WOB

Answer 15

Observe
* Ability to speak
2 to 3 word dyspnea
* Pursed-lip breathing
Increased expiratory time; prevents small bronchial collapse
* Retraction of intercostal spaces or supraclavicular area; use of accessory muscles
* Paradoxical breathing
Abdomen and chest move outward with exhalation and inward with inhalation (opposite of normal)
May be diaphoretic from increased WOB

Question 16

Hypoxemia and Hypercapnia S&S

Auscultate breath sounds
* Fine crackles: ________ edema
* Coarse crackles: ______ in airways
* Absent or diminished: atelectasis, pneumonia, or hypoventilation
* Bronchial: consolidation
* Pleural friction rub: ____________ involving pleura

Answer 16

Auscultate breath sounds
* Fine crackles: pulmonary edema
* Coarse crackles: fluid in airways
* Absent or diminished: atelectasis, pneumonia, or hypoventilation
* Bronchial: consolidation
* Pleural friction rub: pneumonia involving pleura

Question 17

Manifestations of Hypoxemia - Specific

• Respiratory: ________, tachypnea, prolonged expiration, nasal flaring, intercostal muscle retraction, use of accessory muscles, decreased SpO2 (less than 80%), paradoxic chest or abdominal wall movement with respiratory cycle (late), cyanosis (late)

Answer 17

• Respiratory: dyspnea, tachypnea, prolonged expiration, nasal flaring, intercostal muscle retraction, use of accessory muscles, decreased SpO2 (less than 80%), paradoxic chest or abdominal wall movement with respiratory cycle (late), cyanosis (late)

Question 18

Manifestations of Hypoxemia - Nonspecific

• CNS: agitation; _________; disorientation; restless, combative behavior; delirium; decreased level of consciousness; coma (late)
• Cardiovascular: ___________; hypertension; skin cool, clammy, and diaphoretic; dysrhythmias (late); hypotension (late)
• Other: ________, inability to speak in complete sentences without pausing to breathe

Answer 18

• CNS: agitation; confusion; disorientation; restless, combative behavior; delirium; decreased level of consciousness; coma (late)
• Cardiovascular: tachycardia; hypertension; skin cool, clammy, and diaphoretic; dysrhythmias (late); hypotension (late)
• Other: fatigue, inability to speak in complete sentences without pausing to breathe

Question 19

Manifestations of Hypercapnia - Specific

• Respiratory: ________, ________ position, pursed-lip breathing, __________ RR or rapid rate with shallow respirations, decreased tidal volume, decreased minute ventilation

Answer 19

• Respiratory: dyspnea, tripod position, pursed-lip breathing, decreased RR or rapid rate with shallow respirations, decreased tidal volume, decreased minute ventilation

Question 20

Manifestations of Hypercapnia - Nonspecific

• CNS: morning __________, disorientation, confusion, progressive somnolence, increased intracranial pressure, coma (late)
• Cardiovascular: __________, HTN, dysrhythmias, bounding pulse
• Neuromuscular: muscle _________, decreased deep tendon reflexes, Tremors, seizures (late)

Answer 20

• CNS: morning headache, disorientation, confusion, progressive somnolence, increased intracranial pressure, coma (late)
• Cardiovascular: tachycardia, HTN, dysrhythmias, bounding pulse
• Neuromuscular: muscle weakness, decreased deep tendon reflexes, Tremors, seizures (late)

Question 21

Nursing and Interprofessional Management: ARF

Management and care will vary; factors to consider:
Age
Severity of onset
Underlying comorbidities
Suspected or most likely cause

Acute care requires collaboration between nursing, physicians, respiratory therapists,
pharmacists, and others is essential

Answer 21

Management and care will vary; factors to consider:
Age
Severity of onset
Underlying comorbidities
Suspected or most likely cause

Acute care requires collaboration between nursing, physicians, respiratory therapists,
pharmacists, and others is essential

Question 22

Mild to moderate ARF
* __________ O2
* Non-invasive ventilation (Bi-PAP) for patients who are awake, alert, able to maintain a patent airway, able to clear own secretions

Answer 22

Mild to moderate ARF
* High-flow O2
* Non-invasive ventilation (Bi-PAP) for patients who are awake, alert, able to maintain a patent airway, able to clear own secretions

Question 23

Severe ARF - ICU care

_________ ventilation
Continuous pulse oximetry
_________ blood pressure (ABP) monitoring
Frequent ABGs
______________________ (CVP) monitoring
Advanced hemodynamic monitoring

Answer 23

Mechanical ventilation
Continuous pulse oximetry
Arterial blood pressure (ABP) monitoring
Frequent ABGs
Central venous pressure (CVP) monitoring
Advanced hemodynamic monitoring

Question 24

Clinical Problems (ARF)

Impaired ___________ system function
Inadequate tissue _________
__________ imbalance

Answer 24

Impaired respiratory system function
Inadequate tissue perfusion
Acid-base imbalance

Question 25

ARF - Overall goals * Independently maintain a patent _______ * Absence of _______ or recovery to baseline breathing patterns * Effectively _____ and able to clear secretions * Normal ____ values or values within patient's baseline * _______ sounds within patient's baseline

Answer 25

* Independently maintain a patent airway * Absence of dyspnea or recovery to baseline breathing patterns * Effectively cough and able to clear secretions * Normal ABG values or values within patient's baseline * Breath sounds within patient's baseline

Question 26

ARF Prevention * Thorough history and physical assessment to identify at-risk patients and initiate early ____________ Special attention to patients with neuromuscular, cardiac or respiratory problems Deep __________ and coughing, incentive spirometry, early _________ * Frequent assessment of __________ patients Prevent: atelectasis, pneumonia, complications of immobility, and optimize hydration and nutrition

Answer 26

* Thorough history and physical assessment to identify at-risk patients and initiate early interventions Special attention to patients with neuromuscular, cardiac or respiratory problems Deep breathing and coughing, incentive spirometry, early ambulation * Frequent assessment of high-risk patients Prevent: atelectasis, pneumonia, complications of immobility, and optimize hydration and nutrition

Question 27

ARF - Implementation: Acute Care Identify and treat ________ ______ of ARF Continuous monitoring of patient response to therapy: changes in _________ status, trends in ABG, signs of clinical improvement Modifications may be indicated for patients with V/Q mismatch, shunting, diffusion impairment

Answer 27

Identify and treat underlying cause of ARF Continuous monitoring of patient response to therapy: changes in respiratory status, trends in ABG, signs of clinical improvement Modifications may be indicated for patients with V/Q mismatch, shunting, diffusion impairment

Question 28

ARF - Respiratory therapy * Goals Maintain adequate oxygenation and ________ Correct ________ imbalance * Interventions ____ therapy Mobilizing _____________ Positive pressure ventilation (PPV)

Answer 28

* Goals Maintain adequate oxygenation and ventilation Correct acid-base imbalance * Interventions O2 therapy Mobilizing secretions Positive pressure ventilation (PPV)

Question 29

Oxygen Therapy Goal: correct _________ Apply O2 at ________ possible FiO2 to keep SpO2, PaO2 and SaO2 within patient-specific goals Never withhold ________ from a hypoxic patient Observe response and monitor for changes in ________ status, RR, and ABGs

Answer 29

Goal: correct hypoxemia Apply O2 at lowest possible FiO2 to keep SpO2, PaO2 and SaO2 within patient-specific goals Never withhold oxygen from a hypoxic patient Observe response and monitor for changes in mental status, RR, and ABGs

Question 30

Oxygen Therapy cont. Delivery system * Selected on patient’s overall condition, degree of respiratory failure, ability to maintain patent ________, amount of FIO2 the device delivers, patient’s ability to _______ spontaneously * Maintain PaO2 at 60 mm Hg or more and SaO2 at ____% or higher at lowest O2 concentration possible Patient with hypoxemia is often agitated, disoriented, restless; ________ can worsen the problem * Adjust approach, use of face mask accordingly

Answer 30

Delivery system * Selected on patient’s overall condition, degree of respiratory failure, ability to maintain patent airway, amount of FIO2 the device delivers, patient’s ability to breathe spontaneously * Maintain PaO2 at 60 mm Hg or more and SaO2 at 90% or higher at lowest O2 concentration possible Patient with hypoxemia is often agitated, disoriented, restless; anxiety can worsen the problem * Adjust approach, use of face mask accordingly

Question 31

Oxygen Therapy cont. High FiO2 for prolonged periods can lead to adverse effects * Oxygen ________ (greater than ____% O2 for longer than 48 hours); inflammation and cell death by disrupting the alveolar capillary membrane * Absorption atelectasis; lack of nitrogen to help maintain size and shape of alveoli * Increased pulmonary capillary permeability * Decreased surfactant production or inactivation * Fibrotic changes in the alveoli

Answer 31

High FiO2 for prolonged periods can lead to adverse effects * Oxygen toxicity (greater than 60% O2 for longer than 48 hours); inflammation and cell death by disrupting the alveolarcapillary membrane * Absorption atelectasis; lack of nitrogen to help maintain size and shape of alveoli * Increased pulmonary capillary permeability * Decreased surfactant production or inactivation * Fibrotic changes in the alveoli

Question 32

Oxygen Therapy cont. Patients with chronic hypercapnia, (COPD) * Blunts response of chemoreceptors to high CO2 levels as respiratory stimulant * Provide O2 at ____ flow (nasal cannula at 1 to 2 L/min or Venturi mask at 24% to 28%) * Consider __________ ventilation with higher FIO2 for inadequate response

Answer 32

Patients with chronic hypercapnia, (COPD) * Blunts response of chemoreceptors to high CO2 levels as respiratory stimulant * Provide O2 at low flow (nasal cannula at 1 to 2 L/min or Venturi mask at 24% to 28%) * Consider mechanical ventilation with higher FIO2 for inadequate response

Question 33

Secretions can block or limit the exchange of _______, causing or worsening ARF Secretions can be mobilized by Proper _________ Effective _________ Chest physiotherapy _________ Humidification Hydration Early _________ when possible

Answer 33

Secretions can block or limit the exchange of gases, causing or worsening ARF Secretions can be mobilized by Proper positioning Effective coughing Chest physiotherapy Suctioning Humidification Hydration Early ambulation when possible

Question 34

Position patient upright; HOB should be raised to at least ___ degrees; reclining chair or chair bed ---Increases respiratory expansion, decreases dyspnea, and mobilizes secretions Risk of aspiration: use side-lying position Unilateral lung disorders --Lateral or side-lying position; “_____ lung down” to improve V/Q matching by draining secretions to remove with suctioning Bilateral lung disorders -- Reposition at regular intervals on __________

Answer 34

Position patient upright; HOB should be raised to at least 30 degrees; reclining chair or chair bed ---Increases respiratory expansion, decreases dyspnea, and mobilizes secretions Risk of aspiration: use side-lying position Unilateral lung disorders --Lateral or side-lying position; “good lung down” to improve V/Q matching by draining secretions to remove with suctioning Bilateral lung disorders -- Reposition at regular intervals on both sides

Question 35

Effective Coughing Encourage patients to cough to clear ________ Augmented coughing (quad coughing) * Used when patient unable to cough productively (weak) * Place one or both hands at anterolateral base of lungs; have patient take a deep breath and move hands forcefully ___ as expiration begins * Increased abdominal pressure and helps patient cough * Increases expiratory flow and promotes secretion clearance

Answer 35

Encourage patients to cough to clear secretions Augmented coughing (quad coughing) * Used when patient unable to cough productively (weak) * Place one or both hands at anterolateral base of lungs; have patient take a deep breath and move hands forcefully up as expiration begins * Increased abdominal pressure and helps patient cough * Increases expiratory flow and promotes secretion clearance

Question 36

Chest Physiotherapy For all patients who are producing sputum, have severe atelectasis or pulmonary infiltrates (on CXR) _______ drainage __________ __________ --Helps move secretions to larger airways for more effective coughing or suctioning Contraindicated in TBI with ICP, unstable orthopedic injuries, and recent hemoptysis

Answer 36

For all patients who are producing sputum, have severe atelectasis or pulmonary infiltrates (on CXR) Postural drainage Percussion Vibration --Helps move secretions to larger airways for more effective coughing or suctioning Contraindicated in TBI with ICP, unstable orthopedic injuries, and recent hemoptysis

Question 37

Suctioning If patient unable to expectorate secretions Done in an _______, non-intubated patient using a soft-tip suction catheter through a nasopharyngeal tube Proceed with caution to avoid stimulating the ____ reflex (vomiting) Suctioning through an artificial airway is only done as ________

Answer 37

If patient unable to expectorate secretions Done in an awake, non-intubated patient using a soft-tip suction catheter through a nasopharyngeal tube Proceed with caution to avoid stimulating the gag reflex (vomiting) Suctioning through an artificial airway is only done as needed

Question 38

Humidification and Hydration Adjunct in secretion management Thin secretions * Aerosols of sterile normal saline or mucolytic drugs via nebulizer * O2 via aerosol mask * Monitor for bronchospasm and severe coughing Hydration * Oral intake ______ L/day (unless contraindicated) * IV ______ * Monitor for fluid overload – crackles, dyspnea, increased weight or CVP

Answer 38

Thin secretions * Aerosols of sterile normal saline or mucolytic drugs via nebulizer * O2 via aerosol mask * Monitor for bronchospasm and severe coughing Hydration * Oral intake 2 to 3 L/day (unless contraindicated) * IV fluids * Monitor for fluid overload – crackles, dyspnea, increased weight or CVP

Question 39

Positive Pressure Ventilation (PPV) Noninvasive positive pressure ventilation (NIPPV) * Provides O2 and decreases WOB with spontaneous breathing; must be awake, alert, and VS stable * Contraindicated for decreased LOC, high O2 requirements, facial trauma, hemodynamic instability, or excess Two forms * _______ —continuous positive airway pressure * Constant pressure during inspiration and expiration * ________—bilevel positive airway pressure (more common) * Uses 2 different levels of positive pressure – one with ________ & _____________

Answer 39

Noninvasive positive pressure ventilation (NIPPV) * Provides O2 and decreases WOB with spontaneous breathing; must be awake, alert, and VS stable * Contraindicated for decreased LOC, high O2 requirements, facial trauma, hemodynamic instability, or excess Two forms * CPAP—continuous positive airway pressure * Constant pressure during inspiration and expiration * BiPAP—bilevel positive airway pressure (more common) * Uses 2 different levels of positive pressure – one with inspiration; another with expiration

Question 40

Drug Therapy Consider: comorbidities & presence of infection Goals of drug tx: Reduce airway __________ and therapy bronchospasm Relieve pulmonary _________ Treat infection Reduce anxiety, pain, and restlessness

Answer 40

Reduce airway inflammation and therapy bronchospasm Relieve pulmonary congestion Treat infection Reduce anxiety, pain, and restlessness

Question 41

Drug Therapy cont. Reduce airway inflammation and _________ * Acute bronchospasm Short-acting __________ repeated every 15-30 minutes until a response is achieved using hand-held nebulizer or metered-dose inhaler with a spacer Monitor VS and _____ changes for signs of dysrhythmias or cardiac ischemia * ____________ help with inflammation Effects may take hours when given IV; 4-5 days when inhaled See: Drug Alert – hypokalemia, adrenal insufficiency, hyperglycemia

Answer 41

Reduce airway inflammation and bronchospasm * Acute bronchospasm Short-acting bronchodilators repeated every 15-30 minutes until a response is achieved using hand-held nebulizer or metered-dose inhaler with a spacer Monitor VS and ECG changes for signs of dysrhythmias or cardiac ischemia * Corticosteroids help with inflammation Effects may take hours when given IV; 4-5 days when inhaled See: Drug Alert – hypokalemia, adrenal insufficiency, hyperglycemia

Question 42

Drug Therapy cont. Relieve pulmonary congestion Injury to alveolar capillary membrane from HF or fluid overload can cause interstitial fluid accumulation in lungs Decrease pulmonary congestion caused by HF * IV _______ * Morphine * Nitroglycerine ** Use w/ caution – can cause changes in HR & rhythm & significant decreases in BP

Answer 42

Relieve pulmonary congestion Injury to alveolar capillary membrane from HF or fluid overload can cause interstitial fluid accumulation in lungs Decrease pulmonary congestion caused by HF * IV diuretics * Morphine * Nitroglycerine ** Use w/ caution – can cause changes in HR & rhythm & significant decreases in BP

Question 43

Drug Therapy cont. Treat infections * Cause excessive mucus production; fever; increased O2 consumption; inflamed, fluidfilled and/or collapsed alveoli * Cause or worsen ARF * Diagnosed with CXR and sputum cultures * Treated with IV ________ Reduce anxiety, pain, and restlessness * Address ______; do not depend solely on use of medications * Benzodiazepines and Opioids – use _______ dose possible (RR) * See Safety Alert

Answer 43

Treat infections * Cause excessive mucus production; fever; increased O2 consumption; inflamed, fluidfilled and/or collapsed alveoli * Cause or worsen ARF * Diagnosed with CXR and sputum cultures * Treated with IV antibiotics Reduce anxiety, pain, and restlessness * Address cause; do not depend solely on use of medications * Benzodiazepines and Opioids – use lowest dose possible * See Safety Alert

Question 44

Nutrition Therapy Collaborate with _______ Maintain _______ and _______ stores Critically ill: hypermetabolic state Start enteral nutrition within ______ hours to avoid depletion and delayed recovery

Answer 44

Collaborate with dietician Maintain protein and energy stores Critically ill: hypermetabolic state Start enteral nutrition within 24 to 48 hours to avoid depletion and delayed recovery

Question 45

Expected outcomes * Independently maintain a patent _______ * Maintain adequate __________ * Have normal __________ stability * Achieve a return to baseline respiratory system function

Answer 45

* Independently maintain a patent airway * Maintain adequate oxygenation * Have normal hemodynamic stability * Achieve a return to baseline respiratory system function

Question 46

Acute Respiratory Distress Syndrome (ARDS) Sudden _________ form of acute respiratory failure ________ capillary membrane becomes damaged and more _________ to intravascular fluid

Answer 46

Sudden progressive form of acute respiratory failure Alveolar capillary membrane becomes damaged and more permeable to intravascular fluid

Question 47

Acute Respiratory Distress Syndrome (ARDS) * One of most common conditions seen in the adult ICU (___% of all ICU admissions) * More than 200,000 cases per year in United States * Mortality rate about ___%

Answer 47

* One of most common conditions seen in the adult ICU (10% of all ICU admissions) * More than 200,000 cases per year in United States * Mortality rate about 35%

Question 48

ARDS: Etiology - Predisposing factors * Most common: _______ Other: multiple organ dysfunction syndrome (MODS) Multiple risk factors means 3 to 4 times likely to develop ARDS * Direct lung ______ Common: pathogen in lungs; aspiration, virus, bacteria, or sepsis * ________ lung injury Common: problem (e.g., sepsis or massive trauma) from elsewhere in the body move toward favorable lung environment and proliferate > acute lung injury > ARF > ARDS

Answer 48

* Most common: sepsis Other: multiple organ dysfunction syndrome (MODS) Multiple risk factors means 3 to 4 times likely to develop ARDS * Direct lung injury Common: pathogen in lungs; aspiration, virus, bacteria, or sepsis * Indirect lung injury Common: problem (e.g., sepsis or massive trauma) from elsewhere in the body move toward favorable lung environment and proliferate > acute lung injury > ARF > ARDS

Question 49

ARDS Pathophysiology Pathophysiologic changes divided into 3 phases * _______ or exudative phase * Reparative or __________ phase * ________ or fibroproliferative phase

Answer 49

* Injury or exudative phase * Reparative or proliferative phase * Fibrotic or fibroproliferative phase

Question 50

ARDS Injury or exudative phase * Begins 24 to 72 hours after initial lung injury (direct or indirect); lasts _____days Interstitial edema occurs from engorgement of peribronchial and perivascular interstitial space Fluid surrounding alveoli crosses membrane and enters alveolar space; capillary blood cannot be oxygenated resulting in V/Q mismatch and intrapulmonary shunt

Answer 50

7 – 10

Question 51

ARDS Injury or exudative phase cont. * Exact cause of damage to alveolar-capillary membrane unknown; may be stimulation of ___________ and immune systems Stimulation attracts neutrophils to pulmonary interstitium which release biochemical, humoral, and cellular mediators leading to increased pulmonary capillary permeability, destruction of collagen, formation of pulmonary microemboli, and pulmonary artery vasoconstriction

Answer 51

inflammatory

Question 52

ARDS Injury or exudative phase cont. * Hypoxemia and stimulation of juxtacapillary receptors in stiff lung parenchyma (J reflex) leading to increased RR and decreased tidal volume (VT), causing increased CO2 removal, resulting in respiratory alkalosis * Increased cardiac output (CO)—compensatory mechanism to increase pulmonary blood flow * As pulmonary edema and pulmonary shunt increase, compensation fails, causing hypoventilation, decreasing CO, and decreasing tissue O2 perfusion

Answer 52

* Hypoxemia and stimulation of juxtacapillary receptors in stiff lung parenchyma (J reflex) leading to increased RR and decreased tidal volume (VT), causing increased CO2 removal, resulting in respiratory alkalosis * Increased cardiac output (CO)—compensatory mechanism to increase pulmonary blood flow * As pulmonary edema and pulmonary shunt increase, compensation fails, causing hypoventilation, decreasing CO, and decreasing tissue O2 perfusion

Question 53

ARDS Injury or exudative phase cont. * Alveolar cells type I and II are damaged Surfactant dysfunction leading to atelectasis Widespread _________ causing decreased compliance, compromised gas exchange, and increased hypoxemia * Necrotic cells, protein, and fibrin form thick hyaline membranes that line alveoli Contribute to fibrosis and atelectasis, resulting in decreased gas exchange capability and lung compliance

Answer 53

atelectasis

Question 54

ARDS Injury or exudative phase cont. * Refractory hypoxemia Severe V/Q mismatch and shunting of pulmonary capillary blood Classic sign of ARDS Unresponsive to increasing O2 concentrations * Diffusion Impairment worsens _________ * Lungs become less compliant Higher airway pressures must be generated to inflate “stiff” lungs, increasing WOB requiring mechanical ventilation

Answer 54

hypoxemia

Question 55

ARDS Reparative or proliferative phase * 1 to 2 weeks after initial lung injury * Influx of neutrophils, monocytes, lymphocytes, and fibroblasts continues leading to increased pulmonary vascular resistance and pulmonary HTN as pulmonary vasculature is destroyed * Lung compliance continues to ________

Answer 55

decline

Question 56

ARDS Reparative or proliferative phase cont. * Hypoxemia worsens due to thickened alveolar membrane causes V/Q mismatch, diffusion impairment, and shunting * Airway resistance severely increased * Proliferative phase complete when diseased lung replaced by dense, fibrous tissue * If reparative phase persists, widespread fibrosis results * If reparative phase is stopp

Answer 56

* Hypoxemia worsens due to thickened alveolar membrane causes V/Q mismatch, diffusion impairment, and shunting * Airway resistance severely increased * Proliferative phase complete when diseased lung replaced by dense, fibrous tissue * If reparative phase persists, widespread fibrosis results * If reparative phase is stopp

Question 57

ARDS Fibrotic or fibroproliferative phase * Patients with ARDS may not enter this stage * Poorer prognosis for those who do * Chronic or late phase * 2 to 3 weeks after initial lung injury * For those that don’t fully recover, the lung is completely __________ by collagenous and fibrous tissues

Answer 57

remodeled

Question 58

ARDS Fibrotic or fibroproliferative phase cont. * Diffuse scarring and fibrosis cause Decreased lung compliance Decreased area for ____________ * Hypoxemia continues Pulmonary hypertension * Results from pulmonary vascular destruction and fibrosis

Answer 58

gas exchange

Question 59

ARDS Clinical Progression Some patients survive acute phase of lung injury; pulmonary edema resolves * Complete recovery within _______ Survival chances are poor for those who enter _______ phase * Require long-term mechanical ventilation Factors determining recovery versus progression * Nature of initial injury, comorbidities, how quickly patient received care, pulmonary complications, genetic predisposition

Answer 59

Some patients survive acute phase of lung injury; pulmonary edema resolves * Complete recovery within a week or so Survival chances are poor for those who enter fibrotic phase * Require long-term mechanical ventilation Factors determining recovery versus progression * Nature of initial injury, comorbidities, how quickly patient received care, pulmonary complications, genetic predisposition

Question 60

Complications of ARDS Ventilator-associated _________ (VAP) * Implement ventilation bundle protocol reduces the incidence of VAP in mechanically ventilated patients * Strategies for prevention of VAP Good _______ hygiene Elevate HOB _______ degrees Daily _____ care with chlorhexidine (0.12%) solution Daily assessment for readiness for __________ Stress ulcer prophylaxis Venous thromboembolism prophylaxis

Answer 60

Ventilator-associated pneumonia (VAP) * Implement ventilation bundle protocol reduces the incidence of VAP in mechanically ventilated patients * Strategies for prevention of VAP Good hand hygiene Elevate HOB 30 to 45 degrees Daily oral care with chlorhexidine (0.12%) solution Daily assessment for readiness for extubation Stress ulcer prophylaxis Venous thromboembolism prophylaxis

Question 61

Complications of ARDS Venous ___________ (VTE) * Immobility and venous stasis leading to increased risk of deep vein thrombosis (DVT) and pulmonary emboli * Prophylactic management Intermittent pneumatic ________ stockings ______________ Early ambulation, if possible

Answer 61

Venous Thromboembolism (VTE) * Immobility and venous stasis leading to increased risk of deep vein thrombosis (DVT) and pulmonary emboli * Prophylactic management Intermittent pneumatic compression stockings Anticoagulants Early ambulation, if possible

Question 62

Complications of ARDS Acute _______ injury (AKI) * Occurs from decreased renal __________ and subsequent decreased delivery of O2 to kidneys From hypotension in septic shock, hypoxemia, or nephrotoxic drugs used to treat ARDS-related infections * Management Monitor input and output Daily weight Daily BUN and creatinine Dialysis or continuous renal replacement therapy (CRRT)

Answer 62

Acute kidney injury (AKI) * Occurs from decreased renal perfusion and subsequent decreased delivery of O2 to kidneys From hypotension in septic shock, hypoxemia, or nephrotoxic drugs used to treat ARDS-related infections * Management Monitor input and output Daily weight Daily BUN and creatinine Dialysis or continuous renal replacement therapy (CRRT)

Question 63

Survivors of ARDS may have Anxiety Memory and attention issues Inability to focus Nightmares Depression PTSD (up to 5 years later)

Answer 63

Anxiety Memory and attention issues Inability to focus Nightmares Depression PTSD (up to 5 years later)

Question 64

Because _____ is the most severe form of ARF, the subjective and objective data you need for both is the same

Answer 64

ARDS

Question 65

ARDS planning With appropriate therapy, goals include: * PaO2 of __ mmHg or higher and adequate lung ventilation to help correct any acid-base imbalance Longer term goals for ARDS * PaO2 within normal limits for age or at baseline on room air * SaO2 >90% * Resolution of the cause(s) * Clear lungs on auscultation

Answer 65

60

Question 66

ICU care for patients with moderate to severe ARDS > Complex and _________ clinical course > Need _________ ventilation until resolution of inflammation and fluid accumulation begins _________ HR RR BP SpO2 monitoring EtCO2 monitoring

Answer 66

> Complex and unpredictable clinical course > Need mechanical ventilation until resolution of inflammation and fluid accumulation begins Continuous HR RR BP SpO2 monitoring EtCO2 monitoring

Question 67

ARDS Best practices (ARDSNet protocol) * ____ administration * ___________ ventilation * Low tidal volume (VT) ventilation * Permissive hypercapnia * Positive end expiratory pressure (PEEP) * _____ positioning * Extracorporeal membrane oxygenation (ECMO)

Answer 67

* O2 administration * Mechanical ventilation * Low tidal volume (VT) ventilation * Permissive hypercapnia * Positive end expiratory pressure (PEEP) * Prone positioning * Extracorporeal membrane oxygenation (ECMO)

Question 68

ARDS Respiratory Therapy Oxygen administration * Primary goal is to correct _________ * Initially high-flow systems (BiPAP) that deliver high O2 concentrations to maximize O2 delivery Usually temporary Unable to keep PaO2 within acceptable ranges * SpO2 continuously monitored * Mechanical ventilation with FiO2 (70% or higher) to keep PaO2 at least 60 mmHg

Answer 68

hypoxemia

Question 69

ARDS Respiratory Therapy cont. Mechanical ventilation * Pressure-control type of ventilation Keeps inspiratory and plateau pressures from becoming too high Prevents alveolar overdistention and __________ Reducing pressure going into stiff, noncompliant lungs helps to revent further lung injury

Answer 69

rupture

Question 70

ARDS Respiratory Therapy cont. Low tidal volume (Vt) ventilation * Low tidal volume 4 to 8 mL/kg Avoids volutrauma and barotrauma leading to lower mortality Volutrauma causes alveolar fracture and movement of fluids and protein into alveolar spaces

Answer 70

Low tidal volume (Vt) ventilation * Low tidal volume 4 to 8 mL/kg Avoids volutrauma and barotrauma leading to lower mortality Volutrauma causes alveolar fracture and movement of fluids and protein into alveolar spaces

Question 71

ARDS Respiratory Therapy cont. __________ hypercapnia * Low tidal volumes leads to slow increase in PaCO2 * PaCO2 up to 60 mmHg is acceptable in early phase ARDS * Brain and systemic circulation compensate with gradual increase Contraindicated with TBI or  ICP * Requires frequent ABGs; keep pH 7.30 to 7.45 * Patient usually has continuous IV analgesia and sedation

Answer 71

Permissive

Question 72

ARDS Respiratory Therapy cont. _________________ pressure (PEEP) * During PPV, apply PEEP at 5 cm H2O to compensate for loss of glottic function with an ET * PEEP  functional residual capacity and helps to open up collapsed alveoli * Apply PEEP at 3 to 5 cm H2O increments until oxygenation is adequate with FiO2 less than or equal to 60% Higher levels may be needed but no identified optimal level of PEEP

Answer 72

Positive end expiratory

Question 73

ARDS Respiratory Therapy cont. Positive end expiratory pressure (PEEP) * Complications Increased intrathoracic and intrapulmonic pressures generated in the lungs and to the surrounding structures at end expiration can compromise venous return leading to _________ preload, CO, and BP High PEEP or excess inspiratory pressures can lead to barotrauma and volutrauma

Answer 73

decreased

Question 74

ARDS Respiratory Therapy cont. _______ positioning * In early ARDS, fluid moves freely in lungs and pools in gravity-dependent regions * When in supine position, mediastinal contents and heart place more pressure on lungs and predispose to atelectasis * Prone positioning is an option for refractory hypoxemia when other strategies fail to increase PaO2

Answer 74

Prone

Question 75

ARDS Respiratory Therapy cont. ______ positioning * Perfusion may be better matched to ventilation Air-filled alveoli in anterior lung become dependent; posterior alveoli may reexpand leading to increased oxygenation May be able to reduce FiO2 or PEEP Monitor for dysrhythmias or hypotension from fluid shifts Suctioning may be required more often

Answer 75

Prone

Question 76

ARDS Respiratory Therapy cont. Prone positioning * Best practice: position prone in early ARDS * Up to ___ hours per day * Positioning requires an ICU intensivist, respiratory therapist, and 3 to 4 nurses * Be attentive to securing the airway * Once prone, position in a side-lying position

Answer 76

16

Question 77

ARDS Respiratory Therapy cont. ___________ membrane oxygenation (ECMO) * Large blood vessel cannulated and catheter inserted; catheter connected to a device that allows blood to exit the patient and pass across a gas-exchanging membrane outside the body to the ECMO unit ; O2 is delivered and CO2 is removed; oxygenated blood is returned to the patient * Extracorporeal CO2 removal (ECCO2R): used to enhance oxygenation; blood flow rate is lower

Answer 77

Extracorporeal

Question 78

Alternatives to Prone Position Continuous lateral _________ therapy (CLRT) * Continuous, slow, side-to-side turning of bed frame less than 40 degrees; 18 of every 24 hours * Simulates postural drainage and mobilizes secretions; may also have vibrator pack for CPT Kinetic therapy * Patient rotated side-to-side at 40 degrees or greater Monitor pulmonary status and patient

Answer 78

rotation

Question 79

ARDS Supportive Therapy Analgesia and sedation * Given direct IV or continuous IV * Decrease discomfort from ET tube, reduces WOB, and prevents ventilator dyssynchrony * Asynchronous ventilation considerations Adjust inspiratory flow rates or other setting Consider neuromuscular blocking agent Always give simultaneous analgesia and sedation and monitor levels of sedation

Answer 79

Analgesia and sedation * Given direct IV or continuous IV * Decrease discomfort from ET tube, reduces WOB, and prevents ventilator dyssynchrony * Asynchronous ventilation considerations Adjust inspiratory flow rates or other setting Consider neuromuscular blocking agent Always give simultaneous analgesia and sedation and monitor levels of sedation

Question 80

ARDS Supportive Therapy cont. Promoting tissue __________ * Risk for hemodynamic compromise * Hemodynamic monitoring via a central venous or pulmonary artery catheter See trends, detect changes, and adjust therapy Monitor MAP and BP to determine adequate CO * Inadequate: give IV fluids, drugs, or both Monitor tissue perfusion (SaO2 , mixed venous oxygen saturation)

Answer 80

perfusion

Question 81

ARDS Supportive Therapy cont. Maintaining fluid balance and __________ * Challenges: pulmonary edema and intravascular depletion * Monitor hemodynamic parameters, daily weights, hourly I & O * Maintain protein and energy stores to avoid loss of muscle mass and delayed recovery * Start enteral or parenteral nutrition in 24 to 48 hours

Answer 81

nutrition

Question 82

ARDS Evaluation Expected outcomes (similar for patients with ARF) * Maintain and sustain adequate ___________ & ____________ with decreasing amounts of O2 * Be hemodynamically stable * Be free of complications

Answer 82

oxygenation and ventilation

Question 83

ARF is not a _________ , it is a symptom of insufficient lung function

Answer 83

disease

Question 84

Indications for ABG’s - Evaluate adequacy of ________ - Evaluate the _________ status - Evaluate _________ balance

Answer 84

- Evaluate adequacy of ventilation - Evaluate the oxygenation status - Evaluate acid-base balance

Question 85

Obtaining an Arterial Blood Sample 1. Arterial puncture is made at the radial, brachial or ______ artery 2. May be drawn from an _________ 3. Samples drawn by RN or RCP - check with your facility for policy 4. Collateral circulation must be assessed before doing a puncture by using the ___________

Answer 85

1. Arterial puncture is made at the radial, brachial or femoral artery 2. May be drawn from an arterial line 3. Samples drawn by RN or RCP - check with your facility for policy 4. Collateral circulation must be assessed before doing a puncture by using the Allen’s test

Question 86

Allen’s Test - Patient forms tight ______ forcing blood from the hand causing blanching -Pressure is applied to ____________ arteries to obstruct blood flow to the hand -Pressure to ulnar artery is released, patient opens hand...if palm turns pink within __ seconds, collateral flow is adequate

Answer 86

- Patient forms tight fist forcing blood from the hand causing blanching -Pressure is applied to radial and ulnar arteries to obstruct blood flow to the hand -Pressure to ulnar artery is released, patient opens hand...if palm turns pink within 6 seconds, collateral flow is adequate

Question 87

Normal ABG Values pH: CO2: HCO3: BE [base excess]: PaO2: SpO2:

Answer 87

pH: 7.35-7.45 CO2: 35-45 HCO3: 22-26 BE [base excess]: -2 to +2 PaO2: 80-100 SpO2: 94-100%

Question 88

How the pH is Balanced Lungs regulate>CO2 = ACID Kidneys regulate>HCO3 = BASE

Answer 88

Lungs regulate>CO2 = ACID Kidneys regulate>HCO3 = BASE

Question 89

Analysis of ABG’s - Six Step Process Step #1: Analyze the ___ Step #2: Analyze the ___ Step #3: Analyze the ___ Step #4: Match either the PaCO2 or the HCO3 with the pH Step #5: Assess for Compensation Step #6: Analyze the PaO2 and SaO2 for Hypoxemia

Answer 89

Step #1: Analyze the pH Step #2: Analyze the PaCO2 Step #3: Analyze the HCO3 Step #4: Match either the PaCO2 or the HCO3 with the pH Step #5: Assess for Compensation Step #6: Analyze the PaO2 and SaO2 for Hypoxemia

Question 90

If the pH is low and the PaCO2 is high, the HCO3 is normal, the patient has __________________ If the pH is high and the PaCO2 is low, the HCO3 is normal, the patient has __________________ If the pH and HCO3 are low and the PaCO2 is normal, the patient has __________________ If the pH and HCO3 are high but the PaCO2 is normal, the patient __________________

Answer 90

If the pH is low and the PaCO2 is high, the HCO3 is normal, the patient has respiratory acidosis If the pH is high and the PaCO2 is low, the HCO3 is normal, the patient has respiratory alkalosis If the pH and HCO3 are low and the PaCO2 is normal, the patient has metabolic acidosis If the pH and HCO3 are high but the PaCO2 is normal, the patient has metabolic alkalosis

Question 91

Step #5 ABG analysis: Assess for Compensation * Determine whether the PaCO2 or the HCO3 go in the opposite direction of the pH * If so, then the patient has __________ * Example: when the respiratory system (CO2) becomes acidotic, the metabolic system (HCO3) will become alkalotic in an attempt to bring the pH back to normal

Answer 91

compensation

Question 92

Step #5: Compensation Continued -Fully Compensated: pH _________ -Partially Compensated: pH is ABNORMAL and both the CO2 or HCO3 are ABNORMAL -Non-Compensated: pH is ABNORMAL and either the CO2 or HCO3 are the problem

Answer 92

normal

Question 93

Step #6: Analyze the PaO2 and SaO2 for Hypoxemia * If the PaO2 is less than ___, the patient has hypoxemia * If the SpO2 is less than ____%, the patient has hypoxemia * A patient on supplemental oxygen may have a PaO2 of more than 100 mmHg

Answer 93

* If the PaO2 is less than 80, the patient has hypoxemia * If the SpO2 is less than 90%, the patient has hypoxemia * A patient on supplemental oxygen may have a PaO2 of more than 100 mmHg

Question 94

low VS high pH

Answer 94

High pH - alkalosis Low pH- acidosis

Question 95

[Cheat sheet]

Answer 95

Question 96

Respiratory acidosis

Answer 96

Question 97

Respiratory alkalosis

Answer 97

Question 98

Metabolic acidosis

Answer 98

Question 99

Metabolic alkalosis

Answer 99

Question 100

Case study 1 - Mr. Blue, a 67 year old man with a history of chronic obstructive pulmonary disease, arrives to the ED complaining of shortness of breath. He is barrel-chested, has cyanotic nail beds, with distant breath sounds and crackles on inspiration. He sits on the edge of the chair, learning forward, with both hands on his knees. ABG: pH 7.25 PaO2 52 (room air) PaCO2 54 HCO3- 30 =

Answer 100

respiratory acidosis

Question 101

Case Study #2: Mr. Money, a 32 year old international banker returns from a vacation in Guatemala. He complains of severe vomiting for five days. He is very fatigued, has sunken eyes, dry mucus membranes, HR 110 and BP is 85/50. On standing his pressure falls and his heart rate increases to 125. ABG: pH 7.50 PaCO2 47 PaO2 80 HCO3- 38 O2 sat 94% =

Answer 101

metabolic alkalosis

Question 102

Case Study #3: Mr. Bad-Luck, a 32 y.o. man, was injured in a bicycle accident suffering multiple fractures having been hit by a bus. Surgery has been delayed due to coagulopathy. He is intubated and placed on the ventilator due to aspiration pneumonia, compromised airway, and increasing confusion. FIO2 50%. ABG: pH 7.39 PaCO2 37 PaO2 58 HCO3- 22 O2 sat 91% =

Answer 102

hypoxemia (apply oxygen)

Question 103

Upper Airway Functions: -Filtration -Humidification -Heat Supply *These are __________ when a patient is on a ventilator

Answer 103

-Filtration -Humidification -Heat Supply *These are bypassed when a patient is on a ventilator

Question 104

OXYGENATION is reflected in the PaO2 (dissolved/free oxygen) *Normal range PaO2= ________ mmHg

Answer 104

OXYGENATION is reflected in the PaO2 (dissolved/free oxygen) *Normal range PaO2= 80-100 mmHg

Question 105

VENTILATION is reflected by PaCO2 levels *HYPO- ventilation usually causes ______ PaCO2 > retaining/not blowing it off *HYPER- ventilation usually causes ______ PaCO2 > blowing too much off *Normal range PaCO2 = 34-45 mmHg

Answer 105

*HYPO- ventilation usually causes HIGH PaCO2 > retaining/not blowing it off *HYPER- ventilation usually causes LOW PaCO2 > blowing too much off *Normal range PaCO2 = 34-45 mmHg

Question 106

Oxygen Transport Oxygen is carried into the blood two ways: 1. (SaO2) = % of oxygen bound to ___________________ (i.e. 98%) 2. (PaO2) = dissolved/free oxygen molecules in _______

Answer 106

Oxygen is carried into the blood two ways: 1. (SaO2) = % of oxygen bound to hemoglobin in erythrocyte (i.e. 98%) 2. (PaO2) = dissolved/free oxygen molecules in plasma

Question 107

Oxyhemoglobin Dissociation Curve 1. Shows relationship between _______________________ 2. Describes ability of hemoglobin to _____ O2

Answer 107

1. Shows relationship between O2 saturation and PaO2 2. Describes ability of hemoglobin to bind O2

Question 108

PaO2 versus SaO2 PaO2 is the amount of free form dissolved ______________ -Determined using blood gases (ABG’s) -Normal range is 80-100 mmHg -No benefit if greater than 100 > can actually be harmful (can lead to ______ ) -If greater than 100 > turn down the FiO2 on ventilator or oxygen device

Answer 108

oxygen particles in the blood - toxicity

Question 109

PaO2 Versus SaO2 Continued SaO2 is the % of _______________ -Determined using a pulse oximeter -Reading is affected by various conditions

Answer 109

oxygen BOUND to HEMOGLOBIN

Question 110

General Indications for Mechanical Ventilation - Failure to adequately __________ - Failure to adequately __________ - To facilitate diagnostic, surgical, and therapeutic procedures - Failure to protect the airway

Answer 110

- Failure to adequately oxygenate - Failure to adequately ventilate - To facilitate diagnostic, surgical, and therapeutic procedures - Failure to protect the airway

Question 111

Specific Indications for Mechanical Ventilation -Acute Respiratory Failure (Inability of a pt to maintain adequate PaO2, PaCO2 and potentially acidic pH) - Impending Respiratory Failure (Pt is barely maintaining normal blood gases at the expense of significant WOB) - Prophylactic Ventilatory Support (to decrease WOB, minimize O2 consumption and hypoxemia, reduce cardiopulmonary stress, &/or control airway with sedation) - Hyperventilation Therapy (Acute head injury)

Answer 111

-Acute Respiratory Failure (Inability of a pt to maintain adequate PaO2, PaCO2 and potentially acidic pH) - Impending Respiratory Failure (Pt is barely maintaining normal blood gases at the expense of significant WOB) - Prophylactic Ventilatory Support (to decrease WOB, minimize O2 consumption and hypoxemia, reduce cardiopulmonary stress, &/or control airway with sedation) - Hyperventilation Therapy (Acute head injury)

Question 112

CONTRAINDICATIONS TO INVASIVE VENTILATORY SUPPORT Absolute - Untreated tension __________ - Patient’s informed ________ Relative - Medical futility - Patient pain and suffering

Answer 112

Absolute - Untreated tension pneumothorax - Patient’s informed refusal Relative - Medical futility - Patient pain and suffering

Question 113

Mechanical Ventilation - __________ tube (ETT) -Oral or nasal -Passes through the vocal cords into the trachea -Patients cannot ______ ETT Cuff inflated to protect airway -20-25 cm H2O; check once a shift _________ to verify placement of tip -Should be at least 2 cm – 6 cm above carina -Quick method is to use ETCO2 -Check placement at teeth level; 21 cm for women and 23 cm for men -Consider sedation and pain meds

Answer 113

Mechanical Ventilation - Endotracheal tube (ETT) -Oral or nasal -Passes through the vocal cords into the trachea -Patients cannot talk ETT Cuff inflated to protect airway -20-25 cm H2O; check once a shift Chest x-ray to verify placement of tip -Should be at least 2 cm – 6 cm above carina -Quick method is to use ETCO2 -Check placement at teeth level; 21 cm for women and 23 cm for men -Consider sedation and pain meds

Question 114

Tidal volume (VT) - The volume of air moved into and out of the lungs during each ventilation cycle - _____ mL/kg

Answer 114

8-10

Question 115

Positive End Expiratory Pressure (PEEP) - The positive pressure that will remain in the airways at the ___________ that is greater than the atmospheric pressure in mechanically ventilated patients - 5 cmH20

Answer 115

end of exhalation

Question 116

Fraction of Inspired O2 (Fi02) - Fraction of oxygen in the inhaled gas - 0.30-1.00

Answer 116

- Fraction of oxygen in the inhaled gas - 0.30-1.00

Question 117

Respiratory Rate - _____

Answer 117

12-20

Question 118

Peak Inspiratory Pressure (PIP) - Highest level of pressure applied to the lungs during ________ - Keep it below 40 cmH20

Answer 118

inhalation

Question 119

End-tidal Carbon Dioxide (ETCO2) - A noninvasive technique which measures the partial pressure or maximal concentration of carbon dioxide (CO2) at the ____________ - ______ mmHg

Answer 119

end of an exhaled breath 35-45

Question 120

Ventilator Alarms High Pressure -Increased or thicker _______ -Bronchospasm -Fighting the vent -_______in the ventilator circuit -Tubing _______ -Decreased lung compliance Low Pressure -Leak in the ETT or Removal of the ETT tube Alarm Fatigue

Answer 120

High Pressure -Increased or thicker secretions -Bronchospasm -Fighting the vent -Water in the ventilator circuit -Tubing kinked -Decreased lung compliance Low Pressure -Leak in the ETT or Removal of the ETT tube Alarm Fatigue

Question 121

Vent Modes ________ Control -Pressure Regulated Volume Control (PRVC) -A mode of ventilation in which the ventilator attempts to achieve a set tidal volume at the lowest possible airway pressure _______ - Pressure Support (PS) - A level of support pressure is set to assist every spontaneous effort. The patient determines the tidal volume, respiratory rate, and flow rate

Answer 121

Assist Control -Pressure Regulated Volume Control (PRVC) -A mode of ventilation in which the ventilator attempts to achieve a set tidal volume at the lowest possible airway pressure Wean - Pressure Support (PS) - A level of support pressure is set to assist every spontaneous effort. The patient determines the tidal volume, respiratory rate, and flow rate

Question 122

Assessment of Ventilated Patients - Breath sounds - Spontaneous respiratory rate, volume, and pattern -Placement/level of ETT at teeth measured in cm - ETT cuff pressure and apparent stability of the tube - Chest motion - Skin color - Level of consciousness (LOC) - Secretions > Suction as needed, document color, consistency, amount & frequency of suctioning > this prevents ventilator acquired pneumonias (VAP)

Answer 122

- Breath sounds - Spontaneous respiratory rate, volume, and pattern -Placement/level of ETT at teeth measured in cm - ETT cuff pressure and apparent stability of the tube - Chest motion - Skin color - Level of consciousness (LOC) - Secretions > Suction as needed, document color, consistency, amount & frequency of suctioning > this prevents ventilator acquired pneumonias (VAP)

Question 123

More Assessments - Prevent untoward effects of disconnection from ventilator during bedside procedures (restraints?) - Documentation of oxygenation and ventilation status (e.g., arterial blood gas results, exhaled PCO2 measurements) - Documentation of patient-ventilator synchrony during assisted or supported breaths

Answer 123

- Prevent untoward effects of disconnection from ventilator during bedside procedures (restraints?) - Documentation of oxygenation and ventilation status (e.g., arterial blood gas results, exhaled PCO2 measurements) - Documentation of patient-ventilator synchrony during assisted or supported breaths

Question 124

Ventilator - Safety Concerns - How can you tell if ETT is in correct position? - What are s/s that ETT is NOT in correct position? - If patient pulls out ETT what should you do? - If ETT is pushed in by several centimeters what should you do? - Ventilated patients are at high risk for aspiration. How is this prevented? - How does your facility prevent ventilator acquired pneumonias (VAP)?

Answer 124

- How can you tell if ETT is in correct position? - What are s/s that ETT is NOT in correct position? - If patient pulls out ETT what should you do? - If ETT is pushed in by several centimeters what should you do? - Ventilated patients are at high risk for aspiration. How is this prevented? - How does your facility prevent ventilator acquired pneumonias (VAP)?

Question 125

Liberation from Mechanical Ventilation (aka: Weaning) - Daily Screening Pt. must meet these criteria: -No vent discontinuation/______ within past 24 hrs -No active cardiac ischemia or __________ (hemodynamically stable) -No neuromuscular blocking agents -Adequate ____ (limited or no sedation) -Limited/no restlessness or anxiety -Adequate respiratory drive, cough, & ability to mobilize secretions

Answer 125

-No vent discontinuation/failure within past 24 hrs -No active cardiac ischemia or arrhythmyias (hemodynamically stable) -No neuromuscular blocking agents -Adequate LOC (limited or no sedation) -Limited/no restlessness or anxiety -Adequate respiratory drive, cough, & ability to mobilize secretions

Question 126

Assessments During Weaning -Monitor for Failure: - Tachypnea - Dyspnea - Agitation/anxiety/restlessness - Tachycardia - Dysrhythmias - SpO2 less than 90% - Hyper or hypotension - Changes in LOC

Answer 126

-Monitor for Failure: - Tachypnea - Dyspnea - Agitation/anxiety/restlessness - Tachycardia - Dysrhythmias - SpO2 less than 90% - Hyper or hypotension - Changes in LOC

Question 127

Pleural Space -Lies between the parietal pleura (membrane lining the chest cavity) and the visceral pleura (surrounds the lungs) - Holds about 50 ml of lubricating fluid - Creates a negative pressure that keeps ___________ - Excess fluid or air accumulation in the pleural space limits lung expansion and leads to respiratory distress

Answer 127

the lungs expanded

Question 128

Why Do We Need Chest Tubes ____________: Air in the pleural space caused by trauma, lung disease, invasive pulmonary procedure, forceful coughing, surgical complication, or may occur spontaneously –To drain air, the chest tube is placed in anterior chest at the second or third intercostal space ____________: Blood in the pleural space caused by blunt/penetrating trauma or a complication of chest surgery –To drain fluid, the chest tube is placed at lung base ____________: Excessive fluid in the pleural space caused by pneumonia, left ventricular heart failure, pulmonary embolism, cancer, or complication of surgery

Answer 128

Pneumothorax: Air in the pleural space caused by trauma, lung disease, invasive pulmonary procedure, forceful coughing, surgical complication, or may occur spontaneously –To drain air, the chest tube is placed in anterior chest at the second or third intercostal space Hemothorax: Blood in the pleural space caused by blunt/penetrating trauma or a complication of chest surgery –To drain fluid, the chest tube is placed at lung base Pleural effusion: Excessive fluid in the pleural space caused by pneumonia, left ventricular heart failure, pulmonary embolism, cancer, or complication of surgery

Question 129

Why Do We Need Chest Tubes (other reasons) _________: Pus from an infection, such as pneumonia; must always be drained no matter how small the amount Other considerations: Preventively after cardiac/pulmonary surgery to drain blood postoperatively and prevent cardiac tamponade

Answer 129

Empyema

Question 130

Chest Tube Insertion -Done in patient’s room, ED, interventional radiology, or OR - Aseptic (sterile) procedure -Position patient for comfort depending on site to be inserted -Tube will be anchored with sutures -Insertion site will have an occlusive dressing applied –e.g. Petroleum gauze -Connections securely taped (closure device) -Chest X-ray to confirm position

Answer 130

-Done in patient’s room, ED, interventional radiology, or OR - Aseptic (sterile) procedure -Position patient for comfort depending on site to be inserted -Tube will be anchored with sutures -Insertion site will have an occlusive dressing applied –e.g. Petroleum gauze -Connections securely taped (closure device) -Chest X-ray to confirm position

Question 131

Chest Tube Insertion - Pain medication -Heimlich/Flutter Valve - _________ System: Wet versus Dry System –-- Have this set up and ready before insertion

Answer 131

- Pain medication -Heimlich/Flutter Valve - Drainage System: Wet versus Dry System –-- Have this set up and ready before insertion

Question 132

Drainage Collection Chamber -Receives fluid and air from the pleural space -The drained fluid stays in this chamber while expelled air vents to the water seal chamber -Drainage chamber is not emptied – RN to mark amount every shift on the chamber -When this chamber is full, change out the closed chest drainage system with a new one

Answer 132

-Receives fluid and air from the pleural space -The drained fluid stays in this chamber while expelled air vents to the water seal chamber -Drainage chamber is not emptied – RN to mark amount every shift on the chamber -When this chamber is full, change out the closed chest drainage system with a new one

Question 133

Water Seal Chamber - Contains 2 cm of water, which acts as a one-way valve: – Brisk bubbling of air in this chamber = pneumothorax – Intermittent bubbling during exhalation, coughing, or sneezing = there is still some air in the pleural space – No bubbling = air leak resolved, lung expanded __________: This up and down movement of water in concert with respiration reflects intrapleural pressure changes during inspiration and expiration – If tidaling stops suddenly - assess the chest tube for occlusion – If tidaling gradually slows then eventually stops – means the lung has re-expanded

Answer 133

Water Seal Chamber - Contains 2 cm of water, which acts as a one-way valve: – Brisk bubbling of air in this chamber = pneumothorax – Intermittent bubbling during exhalation, coughing, or sneezing = there is still some air in the pleural space – No bubbling = air leak resolved, lung expanded Tidaling: This up and down movement of water in concert with respiration reflects intrapleural pressure changes during inspiration and expiration – If tidaling stops suddenly - assess the chest tube for occlusion – If tidaling gradually slows then eventually stops – means the lung has re-expanded

Question 134

Water Suction Control Chamber - The water suction control chamber uses a column of water to control the amount of suction from the wall regulator - The chamber is typically filled with 20 cm of water --– The suction pressure is usually ordered to be - 20 cm H2O - To start suction, _________ the vacuum source until gentle bubbling is present in the this chamber - Excessive bubbling does not increase the amount of suction but does increase the rate of evaporation of the water and the amount of noise made by the device

Answer 134

Water Suction Control Chamber - The water suction control chamber uses a column of water to control the amount of suction from the wall regulator - The chamber is typically filled with 20 cm of water --– The suction pressure is usually ordered to be - 20 cm H2O - To start suction, increase the vacuum source until gentle bubbling is present in the this chamber - Excessive bubbling does not increase the amount of suction but does increase the rate of evaporation of the water and the amount of noise made by the device

Question 135

Dry Suction Control Chamber - Dry suction chest drainage systems do not contain water. - They often have a visual alert that shows if the suction is working. - It uses a regulator to dial the desired negative pressure; this is internal in the chest drainage system. - To increase the suction pressures, turn the dial on the drainage system. - Increasing the vacuum source does not increase the pressure. When decreasing suction, depress the manual vent to reduce excess vacuum to the lower prescribed level.

Answer 135

Dry Suction Control Chamber - Dry suction chest drainage systems do not contain water. - They often have a visual alert that shows if the suction is working. - It uses a regulator to dial the desired negative pressure; this is internal in the chest drainage system. - To increase the suction pressures, turn the dial on the drainage system. - Increasing the vacuum source does not increase the pressure. When decreasing suction, depress the manual vent to reduce excess vacuum to the lower prescribed level.

Question 136

[chest tubes] Complications -________: Usually minor, but may require surgery if extensive - ________: Likelihood increases the longer the chest tube is in place - Subcutaneous ________: Characterized by swelling in face, neck, and chest; crackles on palpation

Answer 136

-Bleeding: Usually minor, but may require surgery if extensive - Infection: Likelihood increases the longer the chest tube is in place - Subcutaneous emphysema: Characterized by swelling in face, neck, and chest; crackles on palpation

Question 137

Nursing Considerations [chest tubes] -Monitor vital signs - Assess breath sounds bilaterally (check for SQ emphysema, crepitus) - Assess the insertion site - Encourage the patient to TCDB -Make sure connections are taped securely -Keep collection apparatus below level of pt chest; don’t allow tubing to touch floor

Answer 137

-Monitor vital signs - Assess breath sounds bilaterally (check for SQ emphysema, crepitus) - Assess the insertion site - Encourage the patient to TCDB -Make sure connections are taped securely -Keep collection apparatus below level of pt chest; don’t allow tubing to touch floor

Question 138

Nursing Considerations cont. for chest tubes -Check suction control and water seal chambers frequently -Assess drainage for color, amount - Measure drainage every 8 hours or more often depending on patient’s condition -Document assessment - Report: drainage greater than 200 mL in the first hour, development of subcutaneous emphysema, or any signs and symptoms of respiratory distress

Answer 138

-Check suction control and water seal chambers frequently -Assess drainage for color, amount - Measure drainage every 8 hours or more often depending on patient’s condition -Document assessment - Report: drainage greater than 200 mL in the first hour, development of subcutaneous emphysema, or any signs and symptoms of respiratory distress

Question 139

more Nursing Considerations for chest tubes -At the bedside: Always keep 2 Kelly clamps- may be needed if the chest tubes accidentally become dislodged/disconnected from the tubing -Tubing: Avoid aggressive manipulation such as “stripping” -Patency: To maintain patency, try “gentle” hand-over-hand squeezing of tubing and release -Clamping: Avoid except when replacing chest drainage unit, locating air leak, or assessing when tube will be removed

Answer 139

-At the bedside: Always keep 2 Kelly clamps- may be needed if the chest tubes accidentally become dislodged/disconnected from the tubing -Tubing: Avoid aggressive manipulation such as “stripping” -Patency: To maintain patency, try “gentle” hand-over-hand squeezing of tubing and release -Clamping: Avoid except when replacing chest drainage unit, locating air leak, or assessing when tube will be removed

Question 140

more Nursing Considerations for chest tubes If client must be transported: suction is usually off and air is vented out – Tubing is not _______ for transport! - If a tube accidentally pulls out – quickly place a tight occlusive dressing over the insertion site on the chest to prevent air from re-entering - If chest tube becomes detached from the drainage system – quickly place the end of the chest tube into a bottle of sterile water

Answer 140

If client must be transported: suction is usually off and air is vented out – Tubing is not clamped for transport! - If a tube accidentally pulls out – quickly place a tight occlusive dressing over the insertion site on the chest to prevent air from re-entering - If chest tube becomes detached from the drainage system – quickly place the end of the chest tube into a bottle of sterile water

Question 141

Chest Tube Removal - Can remove chest tube when: –There’s little to no ________ –Air leak is gone –Patient is ________ normally without respiratory distress –Fluctuations in water seal chamber stopped –Chest X-ray shows lung re-expansion with no residual air or fluid

Answer 141

–There’s little to no drainage –Air leak is gone –Patient is breathing normally without respiratory distress –Fluctuations in water seal chamber stopped –Chest X-ray shows lung re-expansion with no residual air or fluid

Question 142

Chest Tube Removal -Gather supplies and explain procedure to patient -Pain meds 30 - 60 minutes prior -During peak exhalation, the clinician will remove the chest tube in one quick movement (Valsalva maneuver) - Immediately apply a sterile gauze dressing containing petroleum to prevent air from entering pleural space - Monitor patient’s respiratory status - Arrange for chest X-ray to confirm lung re-expansion - Monitor patient’s respiratory status and SpO2 for 1-2 hours after removal

Answer 142

-Gather supplies and explain procedure to patient -Pain meds 30 - 60 minutes prior -During peak exhalation, the clinician will remove the chest tube in one quick movement (Valsalva maneuver) - Immediately apply a sterile gauze dressing containing petroleum to prevent air from entering pleural space - Monitor patient’s respiratory status - Arrange for chest X-ray to confirm lung re-expansion - Monitor patient’s respiratory status and SpO2 for 1-2 hours after removal

Question 143

Acute respiratory failure is when one or both happen: - Oxygen unable to pass from lungs to _____, causing blood oxygen level to drop (hypoxemia). -Loss of blood oxygen means tissues and ______ may not function appropriately. - Carbon Dioxide (CO2) unable to pass from blood into _______. - Body unable to get rid of CO2 (___________). - Buildup of CO2 can cause damange to tissues and organs. - Can be classified as two main types based on underlying mechanism

Answer 143

- Oxygen unable to pass from lungs to blood, causing blood oxygen level to drop (hypoxemia). -Loss of blood oxygen means tissues and organs may not function appropriately. - Carbon Dioxide (CO2) unable to pass from blood into lungs. - Body unable to get rid of CO2 (hypercapnia). - Buildup of CO2 can cause damange to tissues and organs. - Can be classified as two main types based on underlying mechanism

Question 144

Type I vs II Respiratory Failure

Answer 144

Hypoxemic Respiratory Failure (Type I) Hypercapnic Respiratory Failure (Type II)

Question 145

Hypoxemic Respiratory Failure (Type __) Known as: Lung Failure, Oxygenation Failure, Respiratory Insufficiency. Definition: Failure of lungs to provide adequate ___ to meet metabolic needs. O2 ____, CO2 normal or slightly↓ Causes: Pneumonia, Acute Respiratory Distress Syndrome (ARDS), Pulmonary Edema, Pulmonary Embolism, trauma to lungs, heart attack, sepsis.

Answer 145

Hypoxemic Respiratory Failure (Type I) Known as: Lung Failure, Oxygenation Failure, Respiratory Insufficiency. Definition: Failure of lungs to provide adequate O2 to meet metabolic needs. O2 ↓↓, CO2 normal or slightly↓ Causes: Pneumonia, Acute Respiratory Distress Syndrome (ARDS), Pulmonary Edema, Pulmonary Embolism, trauma to lungs, heart attack, sepsis.

Question 146

Hypercapnic Respiratory Failure (Type __) Known as: Pump Failure, __________ Failure. Definition: Failure of the lungs to _________ adequate CO2. Low O2 levels. O2 ↓, CO2 ____ Causes: COPD, Muscular Dystrophy, Amyotrophic Lateral Sclerosis (ALS), Drug Overdose (opioids or sedatives), stroke, sepsis.

Answer 146

Hypercapnic Respiratory Failure (Type II) Known as: Pump Failure, Ventilatory Failure. Definition: Failure of the lungs to eliminate adequate CO2. Low O2 levels. O2 ↓, CO2 ↑↑ Causes: COPD, Muscular Dystrophy, Amyotrophic Lateral Sclerosis (ALS), Drug Overdose (opioids or sedatives), stroke, sepsis.

Question 147

Signs and Symptoms of Acute Respiratory Failure __________ Tachypnea Sweating Cyanosis Use of ____________ Restlessness __________ Agitation

Answer 147

Dyspnea Tachypnea Sweating Cyanosis Use of accessory muscles Restlessness Confusion Agitation

Question 148

ARDs - Life threatening condition - Type of ____.

Answer 148

ARDs - Life threatening condition - Type of ARF.

Question 149

ARDS vs ARF

Answer 149

Question 150

ARF/ARDS Interventions _______ therapy - Supplemental oxygen - Bilevel positive airway pressure (BIPAP). Mechanical ___________ - - Long-term ventilator therapy may result in tracheostomy placement. Medications - ___________ -Corticosteroids -Antibiotics Close monitoring - Continuous monitoring of oxygen levels - Arterial Blood Gas (ABG) - Respiratory rate - Vital signs

Answer 150

Oxygen therapy - Supplemental oxygen - Bilevel positive airway pressure (BIPAP). Mechanical ventilation - Ventilator - Long-term ventilator therapy may result in tracheostomy placement. Medications - Bronchodilators -Corticosteroids -Antibiotics Close monitoring - Continuous monitoring of oxygen levels - Arterial Blood Gas (ABG) - Respiratory rate - Vital signs

Question 151

Mechanical Ventilation * Usually initiated as pressure-regulated volume control (______). * Delivers set tidal volume and rate with lowest possible pressure. * Patients may require for: * Low _____ (75-100 mmHg) levels * High ______ (35-45 mmHg) * Abnormal ____ (7.35-7.45) * Always check the patient before the equipment.

Answer 151

* Usually initiated as pressure-regulated volume control (PRVC). * Delivers set tidal volume and rate with lowest possible pressure. * Patients may require for: * Low PaO2 (75-100 mmHg) levels * High PaCo2 (35-45 mmHg) * Abnormal pH (7.35-7.45) * Always check the patient before the equipment.

Question 152

Interventions for Vented Patients Mobilizing _________ - Assessing need for suctioning. - Always preoxygenate before suctioning, review patients SpO2, and document amount, color, and consistency of secretions after suctioning. - Patients with thick secretions on mechanical ventilation. -Hydration and nutrition important. _____ Hygiene -Compliance with VAP bundle - Prevention of ventilator association pneumonia - Wash your hands. - Turn and Reposition patient q__h - Keep HOB 30degrees and higher - Administer sedatives if not tolerating ventilator. - Always assess hemodynamic status prior to extubation. - Communicate with patients, give simple, clear directions and explanations.

Answer 152

Mobilizing secretions - Assessing need for suctioning. - Always preoxygenate before suctioning, review patients SpO2, and document amount, color, and consistency of secretions after suctioning. - Patients with thick secretions on mechanical ventilation. -Hydration and nutrition important. Oral Hygiene -Compliance with VAP bundle - Prevention of ventilator association pneumonia - Wash your hands. - Turn and Reposition patient q2h - Keep HOB 30degrees and higher - Administer sedatives if not tolerating ventilator. - Always assess hemodynamic status prior to extubation. - Communicate with patients, give simple, clear directions and explanations.

Question 153

Mnemonic - indications for chest tube PEACH

Answer 153

Pneumothorax Effusion (plueral) Abscess Cancer (lung) Hemothorax

Question 154

Normal VS Abnormal (Ventilation) _______ is normal and expected __________ bubbling is normal (associated with breathing / coughing) __________ bubbling is NOT normal (may indicate air leak)

Answer 154

Tidaling is normal and expected Intermittent bubbling is normal (associated with breathing / coughing) Continuous bubbling is NOT normal (may indicate air leak)

Question 155

Nursing Considerations for Patients with Chest Tubes * With new chest tube monitor patients' vital signs, oxygen saturation, breath sounds, and insertion site every 15 minutes for first 2 hours, and then every shift. * Ensure an occlusive dressing is at bedside such as (sterile 4X4 gauze or petroleum gauze) * Used in the event of accidental removal or when chest tube is dc’d. * Monitor chest tube drainage. * If tube disconnects from drainage system accidentally: * Immerse tube in sterile water

Answer 155

* With new chest tube monitor patients' vital signs, oxygen saturation, breath sounds, and insertion site every 15 minutes for first 2 hours, and then every shift. * Ensure an occlusive dressing is at bedside such as (sterile 4X4 gauze or petroleum gauze) * Used in the event of accidental removal or when chest tube is dc’d. * Monitor chest tube drainage. * If tube disconnects from drainage system accidentally: * Immerse tube in sterile water

Question 156

Hypoxemic: _________ failure * Oxygen is not reaching the tissues even if ventilation is normal * PaO2 ≤ 60 mmHg on FiO2 ≥ 60% oxygen Hypercapnic: _________ failure * Imbalance between supply and demand of gas exchange * Inadequate ventilation even if perfusion is functioning unimpaired * PaCO2 > 45 mmHg and pH < 7.35 * PaCO2 is ACIDIC above 45 * PH is ACIDIC below 7.35 * ABG interpretation: Respiratory Acidosis

Answer 156

Hypoxemic: Oxygenation failure * Oxygen is not reaching the tissues even if ventilation is normal * PaO2 ≤ 60 mmHg on FiO2 ≥ 60% oxygen Hypercapnic: Ventilatory failure * Imbalance between supply and demand of gas exchange * Inadequate ventilation even if perfusion is functioning unimpaired * PaCO2 > 45 mmHg and pH < 7.35 * PaCO2 is ACIDIC above 45 * PH is ACIDIC below 7.35 * ABG interpretation: Respiratory Acidosis