Respiratory (oxygenation LECTURE)

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Respiratory (oxygenation LECTURE)
2014-10-14 22:39:07

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  1. 6 Ps of Dyspnea
    • Pulmonary Bronchial Constriction
    • Possible Foreign Body
    • Pulmonary Embolus
    • Pneumothorax
    • Pump Failure
    • Pneumonia
    • (like traffic, if road is blocked back roads are taken)
  2. Primary Purpose of the Resp System
    Exchange gases between the atmosphere and blood
  3. Two parts of the respiratory system
    • Upper= Nose-oral cavity-pharynx-larynx-trachea
    • Lower= Bronchi-lung-alveoli- heart- ribs
  4. When people are intubated, they have:
    Chest xray to confirm placement (it is easy to slip into the right side)
  5. When you are evaluating and listening to someone on ventilator, it is important to:
    Listen to hear breath sounds on BOTH sides in all quadrants
  6. Landmark used for the carina (separation of sternum)
    Angle of Louis
  7. The ____ is highly sensitive and touching it leads to extreme coughing
  8. The thoracic cavity ends at the _____
  9. The Angle of Louis is also called:
    Manubriosternal juntion
  10. When suctioning airway, remember to put the tube:
    2 cm above carina
  11. Why do the lungs stay inflated?
    Pressure surrounding them (in the intrapleural space) is always less than the pressure inside the lung
  12. Pressure surrounding lungs in the intrapleural space is always ____ pressure than inside the lung
    • LESS
    • (Remember this for chest tube!)
  13. When there is positive pressure, the chest tube removes:
    Air, Fluid, or Blood

    ***We want negative pressure
  14. Respiratory pattern associated with DKA and fruity acetone breath:
  15. Respiratory Pattern associated with "near death"
  16. Fast Respiratory Pattern
  17. Slow Respiratory Pattern
  18. Irregular respiratory pattern (fast and slow)
  19. Norm Resp Rate
  20. Thin membrane outside of the lungs but inside chest wall:
  21. There are ____ (#) pleura that are separated by the pleural space which contains ____
    2, lubricating fluid
  22. ___ liters moves across pleural space each day:
    1-2 liters

    ***NO more than 20-25cc at one time
  23. The trachea starts at the ____ and ends at the ____
    Cricoid cartilage, Carina
  24. Which bronchi is straighter?
    Right-- complications of aspiration
  25. How many alveoli are there
  26. Characteristics/Function of alveoli
    • Gas Exchange
    • Extremely susceptible to injury
    • Secrete surfactant
  27. ___ surround the alveoli making them highly efficient and crucial as a vehicle to gas exchange:
    Blood Vessels
  28. How are alveoli damaged?
    Lack of surfactant (CPAP, BIPAP, SMOKING)
  29. Air movement in and out of the lung
  30. Actual gas exchange that occurs with breathing:
  31. No exchange of oxygen takes place during respiration until:
    air enters the respiratory bronchioles
  32. Space above the bronchioles:
    • Anatomic dead space 
    • (no exchange of oxygen takes place until air enters the respiratory bronchioles)
  33. Goal of ox sat:
    95-100% (adults can't normally get to 100 because of the anatomical dead space we have in our systems)
  34. 4 primary factors that affect the relationship between ventilation and perfusion:
    Thickness of alveolar-capillary membrane (from pulmonary fibrosis or pulmonary edema)

    Surface area of membrane (ie: removed lung/lobe)

    Driving pressure of gases (ie: this pressure is lower at high altitudes)

    Diffusion coefficient (ie: CO2) diffuses more rapidly than O2
  35. How can we determine if our pt is SOB due to how they are breathing versus gas exchange
    We review examples of V/Q (ventilation/quotion scan)
  36. Measures the amount of air we take in (should be = to the amount of oxygen blood is picking up)
    Ventilation/Quotion Scan
  37. If pt SOB is due to perfusion prob, it is likely from a:
    Pulmonary Embolism
  38. Number 1 complication of orthopedic surgery
    Pulmonary Embolism
  39. Pt are always given ____ or ____, and required to where ____ to prevent clots after orthopedic surgery
    Heparin, Lovenox, SCDs
  40. If pt develops dyspnea after a surgery, run a:
    V/Q scan!!!
  41. Alveoli have a natural tendency to ____
    collapse (atelactasis)

    (surfactant is a lipoprotein that helps to prevent this from ocurring)
  42. Lipoprotein that helps to prevent the collapse of alveoli
  43. Rales and Crackles are heard on:
    END expiration on lower sides of lungs (always listen until end of breath)
  44. Dx tests for Respiratory System
    • Hgb- delivers O2 to tissues
    • Hct- % of total blood volume consisting of RBC
    • RBC- important in transport of O2 and CO2
    • Pulse Ox
    • Chest X-Ray
    • CT scan
    • MRI
    • Pulmonary Function Tests
  45. Function of Hgb
    deliverys o2 to tissues
  46. Function of RBC
    transport of O2 and CO2
  47. Normal Hgb:
    • Male= 13-18
    • Female= 12-16
  48. Normal Hct values for men and women
    • M= 40-54%
    • F= 38-47%
  49. "Averaged norms" for Hgb
  50. "averaged norm" for HCt
  51. Used to monitor saturation of O2 with HGB
    Pulse Ox (does NOT replace arterial blood gas)
  52. An Ox sat of _____ warrants further assessment:
    • <90%
    • (typically we want it greater than 95%)
  53. Often chemo pts can have a drop in:
    • Hgb 
    • (but we don't transfuse them unless the stat gets really low...ox is just a small piece of a big puzzle)
  54. Contrast medium makes O2 _____
    Rise! (increased)
  55. Factors that can cause false good signs of Ox sat:
    • Contrast medium (increases)
    • Circulation
    • Nail Polish
  56. Used to screen, dx, and evaluate changes in respiratory system (PA and/or lateral)
    Chest X-ray
  57. Dx test that takes cross section images of tissues, using contrast media
    CT scan
  58. What is important to assess and do in pt prior to CT scan:
    Check Kidney function, Allergy to shellfish, and Hydration Status and Output (contrast media may be used!)

    (Load pt up on steroids if allergic to shellfish)
  59. Things to be aware of for pt undergoing MRI:

    *Metal Implants (may shift: ie: hips, dental fillings, credit cards, pacers, etc)

    *Give Pt panic Button
  60. Norm BUN
  61. Norm Cr (much better indicator of kidney function)
    .7- 1.3
  62. Norm BS
  63. The ____ the range for lab values, the more relevant the change in values is:
  64. Things to evaluate if pt is receiving contrast media:
    Allergies to Shellfish (may receive steroids/histamines prior)

    Renal Function (do they have normal BUN/Cr?)

    Hydration! (gingerale)

    Monitro Output! (acute renal failure can occur in 48-72 hours)
  65. Acute renal failure can occur in:
    48-72 hours (esp in diabetics)
  66. Flexible tube is inserted into respiratory system to assess or lavage
  67. Prep for Bronchoscopy:
    • NPO 6-12 hours
    • Consent
    • Sedative (if needed)
  68. Post-procedural concerns for Bronchoscopy:
    NPO until gag relex returns

    Monitor for Edema

    • Blood tinged sputum is expected
    • *always check for hemorrhage though

    • Hydration to get contrast out (AFTER gag reflex comes back)
    • *Use IVs until gag reflex comes back
  69. Used to determine benign vs malignant lesions in respiratory system (injects isotope with short half life):
    Positron Emission Tomography (PET)
  70. Encourage ____ after PET scan
    Fluids post procedure
  71. Procedure done to remove pleural fluids:
  72. A _____ must be completed before a thoracentesis is performed
  73. A pt undergoing a thoracentesis must sit:
    • upright and lean forward
    • *Tell patient NOT to cough
  74. Tell Pt not to ____ during a thoracentesis
    Cough or move
  75. Post- Thoracentesis, the nurse must:
    Monitor: S/S of pneumothorax (hypoxia, diminished breath sounds)

    *Send the specimen to the lab

    *perform chest xray bc of pneumothorax complications
  76. How is the needle of a thoracentesis inserted:
    between the ribs, in the space around the lungs (pleural space-- not into the lung)
  77. Oxygen delivery methods:
    • Room Air
    • Nasal Cannula
    • Face Mask
    • Partial Rebreathing Mask
    • Non-Rebreathing Mask
  78. Percentage of Oxygen in Room Air
  79. If patient in need of oxygen is about to eat, how should you delivery oxygen?
    Nasal Cannula (so they don't have to take it off their face to eat)
  80. Maximum percentage of Oxygen able to be delivered by Nasal Cannula
  81. Flow rates of Nasal Cannula:
  82. Flow rates of Simple Face Mask
  83. Maximum percentage of oxygen able to be administered with simple face mask:
  84. Flow rates for venturi mask:
  85. Maximum percentage able to be delivered by venturi mask
  86. Flow rates of Non-Rebreathing mask
  87. Maximum percentage of oxygen able to be delivered by a non-rebreathing mask:
  88. Oxygen Devices used for Low Flow O2
    • Cannula
    • Simple Mask
    • Partial Rebreathing Mask
    • Non-rebreathing Mask
  89. Oxygen devices used to administer High Flow O2
    • Transtracheal Cath
    • Venturi Mask
    • Aerosol Mask
    • Tracheostomy collar
    • T-Piece
    • Face Tent
  90. What test needs to be performed before any Arterial Blood Gas test
    Allen's Test
  91. how do you perform the Allen's Test:
    Hold both arteries on pt wrist, then release one side to ensure patent blood flow to hand (in case other artery is occluded)
  92. Purpse of O2 Arterial Blood Gas
    Measures the O2 level in the arterial system with relationship to amount of O2 a patient is receiving (normal for adults = 80-100)

    Compares respiratory status to acid/base balance

    Acid/Base balance of pt
  93. Normal level of ABG in adult: (dependent on altitude)
  94. What do you review to determine ABG status:
    • pH value (7.35-7.45)
    • pCO2 (35-45)
    • HCO3 (22-26)
    • Base excess/deficit (-2 to +2)
    • O2 Saturation (>94%)
  95. "Blanks" to fill in for every ABG
    Comensated, Uncompensated, Normal

    Respiratory or Metabolic

    Acidosis or Alkalosis
  96. If the pH of ABG is acidotic, then we must determine:
    what is causing the acidosis
  97. In respiratory acidosis the pt is probably breathing:
  98. CO2 is a ____ substance
    • Acid
    • (respiratory system)
  99. HCO3 is a ____ susbtance
    • alkaline (base) component
    • (governed by metabolic system)
  100. What causes respiratory acidosis:
    Severe lung disease; obstructed airway

    Depression of resp. system (ie: overmedicating with narcotics)

    Hypoventilation from in general/obesity (pickwickian syndrome)

    Conditions like Guillain-Barre
  101. What would decrease someone's acid state to cause alkalosis:
    • NGT suctioning
    • Too much IV Ringer's lactate
    • Steroids
    • Soidum Bicarb Administration (orally or IV)
  102. Causes of Uncompensated Respiratory Alkalosis
    • High Fever
    • Exposure to High Temps
    • Early Salicylate intoxication
    • Intracranial symptoms from brain tumor, meningitis, encephalitis
  103. If pt has uncompensated respiratory alkalosis, they will be breathing:
    FAST (treat the cause of breathing fast)
  104. Causes of Uncompensated Metabolic Acidosis
    • Diabetic Ketoacidosis (DKA)
    • Trauma
    • Renal Failure
    • Cardiac Arrest
    • Excessive ingestion of acetylsalicylic acid (aspirin)
    • Severe Diarrhea
  105. When body is in uncompensated state, it will try to:
  106. Serial ABGs will indicate a trend in one system to ____ for the other
  107. If pt is in uncompensated respiratory acidosis, we should:
    wake them up to stimulate them to breath faster and blow out CO2 (pt will be breathing slowly because of his state)
  108. If the body compensates for an uncompensated state, you will end up with a ___ pH
  109. When the pH of an ABG is normal but everything else is off, it is likely a _____ state
  110. What will happen to O2 and CO2 levels during acute respiratory failure:
    • Hypoxemia (low O2... <95)
    • Hypercapnea (increased CO2...>45)
  111. A COPD patient has a higher baseline of ____

    (we evaluate pt according to history of their lung disease)
  112. Why don't we put COPD patients on ventilators
    They are almost impossible to get off (they have never breathed so easily)
  113. Criteria for Acute Respiratory Failure (must meet two of the four)
    1)  Acute dyspnea (RR of 30s or 40s)

    2)  PaO2 < 50 (despite giving O2 at percentage 3x room air)

    3) PaCO2 > 50 mmHg

    4) Severe Acidosis
  114. S/S of Hypoxia
    • Impaired Motor Function
    • Impaired Judgment
    • Unconsciousness
    • Increased BP, then Decreased BP
    • Vasodilation
    • Use of Accessory Muscles
    • Cyanosis (late oral mucous membranes)
  115. S/S of Hypercapnia (high CO2)
    • Lethargy
    • Confusion
    • Asterixis (tremor, seizures)
    • Miosis (severe pupil constriction)
    • Sweating
    • Pursed lip breathing
  116. A sudden change in CO2 or O2 should be a ____
  117. PaO2 < 50 could be caused by:
    • Pneumonia
    • Pulmonary Edema
    • Pulmonary Emboli
    • Alveolar Damage
  118. PCO2 >50 could be caused by
    • Drug overdose
    • CNS depression
    • Neuromuscular diseases
    • Acute Asthma
    • Cardiac
  119. What should you do for a pt on tube feedings to prevent them from going into metabolic acidosis
    Give feedings back!
  120. Asthma leads to ______ (low oxygen that won't/can't come back up despite amount of oxygen being given)
    Refractory Hypoxemia
  121. Asthma patients are generally given:
    Albuterol or theopholine (bronchodilators IV)
  122. ICU/Treatment management of Status Asthmaticus patient
    • Correct hypoxemia *goal
    • Pulmonary Hygiene (mobilize secretions to be suctioned out easier...patting on back)

    Possible Intubation (have control over airway)

    May lead to mechanical ventilation (positive pressure vent)
  123. Positive pressure maintained by a ventilator to INCREASE the functional residual capacity
  124. Function of PEEP (positive end expiratory pressure)
    • Keeps alveoli open for exchange
    • Prevents alveolar collapse with each exhale
    • Improves oxygenation
  125. Non-invasive positive pressure ventilation...can use facemask device
    NIPPV (CPAP-- sleep apnea)
  126. "ventilation" where the positive pressure is applied during the spontaneous breaths
    CPAP (continuous positive airway pressure)
  127. Potential complications that can occur when patients have PEEP or CPAP
    • Decreased CO
    • Barotrauma (decompression of vessels)
    • Increased intracranial pressure
  128. If neuromuscular blocking agents are used, remember:
    • They can still hear...communicate with them!
    • Tape eyes shut bc they have no control over motor movements
  129. Types of neuromuscular blocking agents:
    –Norcuron, Pavulon, Tracrium, Nimbex
  130. Acute Respiratory Distress Syndrome is characterized by:
    Sudden and aggressive acute respiratory failure (50-90% mortality)
  131. ARDS is usually caused by:
    Sepsis from alveolar capillary damage;

    Systemic Inflammatory Response Syndrome (widespread inflammation which could be from a variety of causes)
  132. Progression of ARDS
    Something happens to lining of alveolar capillary membrane

    Increased permeability of endothelium

    Leakage of fluid into interstitial space

    Pulmonary Edema and Decreased FRC and RV

    Stiff/Non-Compliant lungs (airways closed)

    Alveolar Collapse; Surfactant decreased

    Ineffective breathing patterns
  133. Causes of ARDS:
    Aspiration #1 cause

    • Pneumonia
    • Trauma
    • Drowning
    • Radiation to chest
    • Anaphylaxis
    • Drug overdose
    • Shock
  134. ***The major cause of ARDS is:
    Non-Pulmonary (SEPSIS)

  135. Dx findings of ARDS:
    Refractory hypoxemia- administer O2 higher and higher without improvement

    Massive infiltrates (rales)

    Lungs become stiff (due to loss of surfactant)

    Fluid leaks

    Decreased Residual Volume or FRC

    Alveoli Collapse

    ***Stop the train !
  136. When you can't give blood to pt, give ____ to maintain blood pressure
  137. Blood can only be hung for ____ hours
  138. Management of ARDs
    • O2
    • Ventilator (with PEEP)
    • Fluid (enough to keep hydrated)
    • Check Hgb
    • Fever Control
    • Nutrition (NGT vs HAL/TPN)
    • Steroids (prednisone)
    • Suction
    • Abx (antibiotics)
    • CPT (chest phsyiotherapy, position changes, nutrition, pulse ox)
    • Positioning Strategies (supine to prone)
  139. General Mechanical Ventilation Management
    Understand the endotracheal tube (becomes pt airway! )

    Baseline ABGs

    • There are usually clinical indicators for when to intubate for ventilation:
    • Increased RR, unless apnea
    • PaCO2 >50, Ph <7.25
    • PaO2 <55
    • *sometimes placed on vent to allow rest/pain management
  140. When you place a trach, always make sure:
    chest is rising and falling
  141. Post Intubation Priorities for Nurse:
    • Assess how pt looks
    • Check breath sounds
    • Check CXR for placement
    • Check ABGs
    • Check Psychosocial needs (sedation- propofol)
  142. If there is a pool of water in the pt tubing, it means:
    Condensation - they aren't getting all of their oxygen (discard water!)
  143. Type of ventilator: uses preset tidal volume, often used if patient is apneic
    CV (controlled ventilation)
  144. Type of ventilator: preset tidal volume that will be delivered when pt takes breath, pt will breath at own pace, but it will allow for big deep breaths
    Assist Control Ventilation (ACV)
  145. Type of ventilator: allows pt to breathe at own rate and depth but also deliver mandatory breaths with pre-set tidal volume ((most common)
    Intermittent Mandatory Ventilation (IMV)
  146. When receiving report for pt on ventilator:
    • Note the: 
    • -fraction of inspired oxygen (FiO2)
    • -tidal volume
    • -mode (IMV, SIMS)
    • -PEEP or not (if PEEP, how much???)
    •   *the higher the PEEP the greater the risk of complications; 20 is high!
  147. Physiologic complications from using ventilator
    • GI distention
    • Baratrauma (vessels enlarge)
    • VAP (ventilator assisted pneumonia)
    • Safety 
    • -evaluate cuff inflation
    • -evaluate subq emphysema (crepitus under skin)
    • -evaluate correct ventilator settings
    • ***Do not turn off alarms
  148. Safety measures for pt on ventilator:
    Evaluate cuff inflation

    Evaluate for SubQ emphysema (air has gone into tissue, crepitus under skin)

    Evaluate correct ventilator settings

  149. Common Chest wall injuries from ventilator:
    • Fractured ribs
    • Pneumothorax
    • Hemothorax (air in blood)
    • Tension pneumothorax (everything is shifted)
  150. Most serious injuries result if fractured ribs are over:
    a major vessel
  151. S/S of fractured rib:
    sharp knife-like pain (worse on inspiration)

    Hemoptysis indicates lung injury

    Guarding, surface bruising, bone crepitus

    Unequal chest wall expansion

    Ribs 5-10 are the least protected and more often fractured during a trauma
  152. Treatment for fractured rib:
    • ABCs
    • Rest and Ice
    • Use of opoids to decrease pain
    • If it causes hemo/pneumothorax, consider chest tube!
  153. Multiple Rib Breaks, 2 or more ribs in 2 or more separate locations
    Flail Chest
  154. What kind of movement is made with Flail Chest (multiple rib frac)
    Paradoxical movement (easily seen if pt unconscious)
  155. Management of Flail Chest
    Airway maintainence

    Supplemental O2

    IV with pain control

    May place on ventilator
  156. Things to know about chest tubes:
    • Consent required (if there is time)
    • May remove AIR or FLUID
    • Position pt laying on unaffected side 
    • *sedation/local anesthetic
    • *tubes inserted
    • *tubes sutured
    • *airtight dressing applied with petroleum gauze
    • *connect tube to drainage cath
  157. Pt must have ox < ____% or ____ to have a chest tube put in
    20%, bleeding
  158. Safety measures for Chest Tubes
    • Check breath sounds
    • Check air leaks
    • Keep collection device BELOW insertion site
    • Don't let tubes dangle
    • Maintain suction
    • Prevent kinking
    • Promote position changes (pt may lay on affected side to promote draining)
    • Check subq air emphysema
  159. If you see ANY bubbling in the pts chest tube:
    Check patient for diconnection at their site

    IF everything is connected, call the physician
  160. Removal of Chest Tube
    • Ask pt to exhale
    • 4x4 petroleum gauze over site
    • Tape
    • Evaluate pt status
    • CXR
  161. Findings from Closed Pneumothorax
    • SOB
    • Chest Tightness
    • Increased HR and RR
    • Anxiety, Restless, Chest Pain
    • Breath Sounds are distant or Absent
    • Potential Shift of Mediastinum
  162. Sucking Chest Wound
    Open pneumothorax (gunshot wound or surgery)
  163. Why do we NOT cover an open pneumothorax with 4 gauze?
    to allow air to get out (otherwise it will move trachea)
  164. Hemothorax (blood in intrapleural space) can be caused from:
    • Chest Trauma
    • Malignancy
    • Embolus
    • Adhesions
  165. pulmonary emboli most arise from clot from the ____
  166. Risk factors for DVT
    • Immobility
    • Surgery in last 3 months
    • Stroke
    • Malignancy
  167. S/S of pulmonary emboli
    • Dyspnea (MAIN SIGN!!!)
    • Diaphoresis and panicked look
    • Chest pain-- middle of the chest
    • Hemoptysis- coughing up blood!
  168. First thing to think when you see Hemoptysis:
    Pulmonary embolism
  169. Coughing up blood
  170. Dx tests for Pulmonary Embolism
    • VQ scan
    • D-Dimer
    • Pulmonary Angiography
    • CT
  171. Scoring to assess pt to see if they are at risk for pulmonary embolism
    Geneva Score
  172. A Fib patients are at huge risk for:
    pulmonary embolism
  173. 0-3 points on geneva score:
    low probability (8%) of pulmonary embolism
  174. 4-10 geneva score indicates:
    intermediate prob (28%) of pulmonary embolism
  175. 11 > points on geneva scale:
    indicates high prob (74%) of pulmonary embolism
  176. Drug therapy of Pulmonary Embolism
    • Lovenox (Enoxaparin)
    • Coumadin (Warfarin) -- initiated in 24hr, activate dosage according to aPTT if using heparin, INR if using Coumadin
  177. Actively dissolve clots
    Thrombolytics (can cause immediate bleeding, reserve for hemodynamically unstable)
  178. Filter that may help prevent clot from entering lung in a case with pulmonary embolism
    Inferior vena cava filter (IVF)
  179. Ways to prevent Pulmonary Embolism
    • Adequate hydration
    • Early removal of unnecessary lines
    • External pneumatic compression (EPC) stockings and SCDs
  180. Neither ____ or ____"lyse" existing clots (they are prevention only)
    heparin, coumadin
  181. Antidote for Heparin
    Protamine Sulfate
  182. Antidote for Coumadin
    Vit K
  183. Goal anticoagulant therapy is to achieve ____ IRN for a range of 3-6 months
    2 - 2.5
  184. Coumadin precautions:
    • be careful using knives/scissors
    • use electric razor
    • use soft toothbrush
    • use waxed dental floss
    • do not use toothpicks
    • wear shoes or non-skid slippers in house
    • take care trimming toenails
    • do not trim corns/calluses 
    • be careful with sharp tools
    • avoid activities that can easily hurt you
    • wear gardening gloves when doing yard work
    • stay active
  185. High amounts of ____ will interfere with coumadin/warfarin
    • Vitamin K
    • *keep diet the same though
  186. Foods with Vit K
    Vegetables- broccoli, cabbage, brussel sprouts, green onions, lettuce, spinach, turnips, collard greens, parsley and kale

    Meats- beef liver, pork liver

    Mayonnaise, margarine, canola oil, soybean oil


    Consider HERBS (dried basil, sage, thyme)

    *The highest = >100mcg/serving
  187. Difference between systolic and diastolic pressure:
    • Pulse Pressure
    • *40 is normal
  188. A pulse pressure > 50 usually is due to
    • A still aorta
    • (may be strong indicator of heart problems... >60 is RF for cardiovascular disease)
  189. A higher pulse pressure could be due to:
    fever, hot weather, exercise, anxiety, anemia, pregnancy, neuro disorders, Intracranial pressure
  190. a low pulse pressure may mean:
    poor heart function (<40)