Respiratory and Hemodynamics

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foxyt14
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282506
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Respiratory and Hemodynamics
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2014-11-21 17:27:56
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respiratory hemodynamics
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Lecture 3
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  1. What does hemodynamics tell us?
    • quantitative info about:
    • vascular capacity
    • blood volume
    • pump effectiveness
    • tissue perfusion
  2. What does central venous pressure measure?
    fluid volume status...and pressures in right atrium

    looks at blood volume and venous return
  3. What side filling pressure does central venous pressure measure?
    right
  4. What causes decreases in central venous pressure, pulmonary artery pressure and pulmonary capillary wedge pressure?
    • hypovolemia
    • venodilation
    • decreased venous return
  5. Normal central venous pressure #s
    0-8 mm/Hg
  6. What causes increase in central venous pressure?
    • Hypervolemia
    • Impedance to right atria emptying
  7. What does the pulmonary artery pressure evaluate in the heart?
    • evaluates how the left ventricle is working
    • overall cardiac fxn
  8. What does Pulmonary Capillary Wedge Pressure measure?
    left ventricle function by measuring the amount of pressure generated by the left ventricle
  9. Normal pulmonary capillary wedge pressure values?
    5-15mmHg
  10. What causes an increase in pulmonary capillary wedge pressure?
    • Hypervolemia
    • Impedence to LA emptying
  11. Preload
    the volume that fills the L ventricle at the end of diastole
  12. AFterload
    wall tension generated by the LV during systole to open the aortic valve and eject it's contents
  13. SVO2 monitoring
    reflects the balance btwn oxygen supply and demand
  14. Normal SVO2
    60-80%
  15. Systemic Vascular Resistance
    What does it measure?
    What's normal?
    • afterload
    • 800-1200
  16. What does systemic intra-arterial monitoring measure?
    arterial blood pressure and correlates it to cuff BP
  17. What increases preload?
    • fluids
    • blood products
    • volume expanders
  18. What decreases preload?
    • diuretics
    • ACE inhibitors
    • Venous dilators
  19. What increases afterload?
    • Norepinephrine
    • Epinephrine
    • Dopamine
    • Vasopressin
    • Phenylephrine
  20. What decreases afterload?
    • Calcium channel blocker-anti hypertensives
    • Nitroglycerine
    • Nitroprusside
  21. ROME in ABG's
    Respiratory opposite (pH and CO2 going in opposite directions)

    Metabolic equal (pH goes down so does HCO3...or both go up)
  22. Define respiratory failure
    inability of the cardiac and pulmonary systems to maintain an adequate exchange of oxygen and carbon dioxide in the lungs
  23. What characterizes respiratory failure?
    abnormal blood gas
  24. What is oxygenation failure?
    inadequate O2 transfer between the alveoli and the pulmonary capillary bed.
  25. Common causes of oxygenation failure/hypoxemia?
    • mismatch of ventilation and perfusion
    • hypoventilation
  26. What is ventilatory failure?
    mismatching in which the perfusion is normal, but ventilation is inadequate.

    Thoracic pressure cant be changed enough to move air in and out of the lungs
  27. What causes ventilatory failure?
    • abnormalities of the alveoli and airways
    • CNS depression
    • neuromuscular conditions
    • abnormalities of the chest wall
  28. Crucial things to assess with impaired gas exchange
    • lung sounds
    • LOC/cap refill/skin color
    • ABG
    • CBC
    • Hemodynamics
    • dysrhythmias
  29. Crucial things to assess with ineffective breathing pattern
    • RR and depth
    • changes in tidal volume and tidal capacity
    • ventilator management
  30. Crucial interventions with inability to sustain spontaneous ventilation
    • monitor weaning from vent
    • decrease use of respiratory muscle depressant meds
    • provide periods of rest and activity
  31. Interventions for ineffective airway clearance
    • assess secretions
    • hydration
    • monitor tidal volume and vital capacity
    • TCDB
    • suction
    • position
    • chest physiotherapy
  32. What makes a person be put on a vent?
    • severely inadequate gas exchange
    • hypoxemia
    • progressive alveolar hypoventilation
    • respiratory acidosis
  33. What is the goal of mechanical ventilation?
    • to maintain alveolar ventilation appropriate for the client's metabolic needs
    • to correct hypoxemia
    • maximize oxygen transport
  34. What characterizes a person is in ARDS?
    • acute onset of hypoxemia
    • bilateral chest imaging opacities
    • damaged alveolar capillary membrane causing it to become filled with fluid
  35. Interventions for a person with ARDS
    • intubation and mechanical ventilation with PEEP
    • positioning....prone
    • F&E
  36. Medications given to a person with ARDS
    • morphine
    • sedatives and paralytics
    • heparin 
    • diuretics
  37. Complications from ARDS
    • dysrhythmias
    • Infection/sepsis
    • stress ulcers
    • DIC
    • Barotrauma
    • CHF
    • VA-PNA
    • Volutrauma
  38. Why do people on a ventilator go in to renal failure?
    the renal tissue doesnt get perfused due to hypotension, hypoxemia or hypercapnia

    Also....they are given vanco a lot to prevent/treat infections
  39. Indications for a person to be put on a vent
    • apnea...or impending apnea
    • acute respiratory failure
    • severe hypoxia
    • respiratory muscle fatigue
  40. What are the goals of a person on a vent?
    • resolve hypoxemia and hypoxia
    • maximize oxygen carrying capacity of arterial blood
    • adequate cardiac output, Hgb
  41. What is the purpose of a ventilator?
    • supports patients until they recover the ability to breathe independently
    • a bridge to long term mechanical ventilation...or until a decision is made to withdraw ventilatory support
  42. How do you verify appropriate placement of an endotrachial tube?
    • End tidal CO2 detector...watch for a color change
    • Auscultate lungs for breath sounds
    • Auscultate epigastrum for the absence of air
    • X RAY!!!
  43. Details about a Pressure Regulated Volume Control Ventilator
    the ventilator monitors each breath and compares it to the tidal volume

    If the delivered volume is too low, the pressure is increased on the next breath, and vice versa
  44. Details about a Pressure Support Ventilator
    used to assist with the weaning of a patient off a vent

    patient must be able to initiate breath in this modality
  45. Name and describe 2 non invasive mechanical ventilators
    BIPAP-two different pressure levels, one for inspiration and one for expiration

    CPAP-constant pressure is delivered

    **Have to be able to breathe spontaneously on their own
  46. How does an invasive ventilator work?
    ET or trach is placed in the patient and air is pushed in to the patients lungs(inhalation) and exhalation is passive
  47. What is PEEP?
    positive pressure applied at the end of expiration to improve oxygenation by opening collapsed alveoli
  48. What is the purpose of PEEP?
    to maintain or improve oxygenation while limiting the risk  of O2 toxicity
  49. What does PEEP prevent?
    small airway collapse at the end of expiration to increase oxygenation
  50. List ongoing nursing care of a patient on a vent
    • assess position/placement of tube
    • doc tube placement in cm at teeth/lips
    • soft wrist restraints to prevent extubation
    • suction oral/tracheal secretions
    • assess respirotary status q1-2 hrs
    • reposition ET tube q24h
    • assess for skin breakdown
    • provide adequate nutrition
  51. Monitoring of cuff pressure on a vent patient
    • do q8h
    • must be below 20mmHg
    • assess for air leaks
  52. How can you tell that there is a possible air leak in a ventilated patient?
    • clients speaking
    • air hissing
    • decreasing SaO2
  53. What is a low pressure alarm signaling on a ventilated patient?
    possible disconnection or leak in the system

    • loss of airway from total/partial extubation
    • ET tube/Trach cuff leak
  54. What is a high pressure alarm signaling on a ventilated patient?
    an increase pressure from sputum, fluid condensation, coughing, pneumothorax, bronchospasm, kink in tube

    anything that will cause an increased resistance, obstruction
  55. When do you suction?  Rules of suctioning....
    coughing, coarse rhonchi, high pressure, decreased spo2

    • sterile technique
    • hyperoxygenate....120max for 15 sec
    • assess for dysrhythmias....stop
    • monitor SaO2....<85% stop
    • dont put saline down ET Tube
  56. How do you prevent VAP?
    • hand hygiene
    • suction
    • oral care with Peridex and tooth brushing
    • prophylactic antibiotics
    • positioning to prevent aspiration...HOB at 30
    • residual checks
    • prophylactic stress ulcer meds
    • dont change tubes regularly
  57. S/S of VAP
    • fever
    • increased WBC
    • purulent sputum
    • odorous sputum
    • crackles/rhonchi
    • CXR with pulmonary infiltrates
  58. ABCDE bundle to facilitate weaning from mechanical ventilation is aimed at reducing....
    • oversedation
    • immobility
    • development of delirium

    all of which harm patients
  59. ABCDE bundle
    • Awakening trial
    • Breathing trial..see if can spont. breath on own
    • Coordination....work with RT to get off vent
    • Delirium...are they delirious?
    • Early...can they get up and walk around the room while vented?
  60. RN's collaborate with RT and Critical Care MD to wean a patient from vent....what criteria needs to be met to wean them....
    • awake and alert
    • negative inspiratory pressure >-20 H2O
    • PEEP<5
    • Not on resp. depressant meds or anesthesia
    • Protective reflexes in tact
    • patent airway
    • Stable CVS....WNL
    • clear breath sounds
    • ABG WNL
  61. Most common way to wean a person from a ventilator
    CPAP
  62. Indicators that vent weaning isnt going well...
    • SBP increase/decrease by 20
    • RR increase by 10 or above 30
    • HR increase/decrease by 20 or above 120
    • arrhythmias
    • TV <300
    • Increased PaCO2
    • Increased WOB
  63. Most common sign that an older person is suffering from hypoxemia
    change in mental status
  64. Low SVO2 means....and caused by?
    persons consuming more oxygen than the body has in reserves

    • anemia
    • hemorrhage
    • hypoxemia
    • shock
  65. High SVO2 means...
    there's a maldistribution of blood related to SEPSIS

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