427 Respiratory

Question 1

Advanced Respiratory Assessment

Answer 1

• Neurological status
• Pain, procedures, conditions that affect breathing?
  * Pneumonia diagnosis, COPD exacerbation
  * Large surgery
  * Anxiety, panic
• Weakness
• Suctioning/coughing - Working? How frequently? What is the sputum?
• Medications

Question 2

Acute Respiratory Failure

Answer 2

Inability of respiratory system to provider oxygen &/OR remove carbon dioxide from the body

Question 3

Pathophysiology: Oxygenation Failure

Answer 3

• Failure of oxygenation [HYPOXEMIA]
• PaO2 less than 60 [partial pressure of arterial oxygen] - Found on ABG
• Hypoventilation, intrapulmonary shunting, ventilation-perfusion mismatching, diffusion defects, decreased barometric pressure
• Low cardiac output, low hemoglobin

Question 4

Why do you think an O2 sat isn’t the best indicator?

Answer 4

• Poor Perfusion/Circulation
• Temp
• Peripheral Artery Disease

Question 5

Pathophysiology: Ventilatory Failure

Answer 5

Ventilation failure [HYPERCAPNIA]

• PaCO2 greater than 50
• Can be related to CHRONIC respiratory failure, but NOT mutually exclusive
• Also related to hypoventilation and/or VQ mismatch
• Hypercapnia significantly increases cerebral blood flow CNS changes occur

Question 6

How do we know what is respiratory failure?

Answer 6

• Assessment findings - increased work of breathing
• Increasing O2 needs
  * Turned from 2L to 6L, no improvement? Not good
• Chest X-ray, labs [H&H, ABG]

Question 7

Treatment for Respiratory Failure

Answer 7

• Position
• Maintain PT airway
• Oxygenation with goal of PaO2 >60, O2>90%
• Minimize O2 Demand
• Treat Cause

Question 8

Acute Respiratory Distress System: ARDS Criteria

Answer 8

• Acute onset within 1 week of clinical insult
• Bilateral pulmonary opacities
• Altered PaO2/FiO2 ratio

Question 9

Direct Causes of Acute Respiratory Distress System: ARDS

Answer 9

• Aspiration of gastric contents
• Fat embolism
• Inhalation of toxic gases
• Multisystem trauma (chest and/or lung injury)
• Near-drowning
• Pneumonia

Question 10

Indirect causes of Acute Respiratory Distress System: ARDS

Answer 10

• Burns
• Cardiopulmonary bypass
• Drug overdose
• Fractures, especially of the pelvis or long bones
• Multiple transfusions
• Multisystem trauma (without chest and/or lung injury)
• Pancreatitis
• Sepsis

Question 11

Pathophysiology of ARDS

Answer 11

• Acute and diffuse injury to the lungs
• INFLAMMATORY response  cell-mediated, overly aggressive, immune response damaging the alveolar-capillary membranes
• Also, massive fluid leakage throughout the body causing edema
• Alveolar flooding  noncardiogenic pulmonary edema, shunting, V/Q mismatch, decreased compliance, hypoxemia

Question 12

Assessment Findings in ARDS

Answer 12

• Dyspnea, tachypnea, hypoxemia NOT RESPONDING to supplemental O2
• Pulse & temp may increase
• Fine crackles, restlessness, disorientation, LOC changes
• PaO2 continues to decrease dyspnea becomes severe

Question 13

ARDS Interventions

Answer 13

• Usually need mechanical ventilation
• ECMO
• Corticosteroids
• Prone positioning
• Therapeutic hypothermia

Question 14

PE Identification and Assessment Findings

Answer 14

• Classic: pleuritic chest pain, SOB, hypoxia
• Tachypnea, crackles, accentuated S2 heart sound, tachycardia, fever
• Positive D-dimer
• V/Q scan
• Spiral CT scan preferred- most accurate
• Pulmonary angiography– direct anatomical visualization, invasive, difficult

Question 15

PE Treatment

Answer 15

• Less severe - at home with blood thinners
• For severe - IV heparin & bolus immediately then transition to Lovenox
• Warfarin started immediately as well for long-term prevention and management
• Massive PEs may require surgical or catheter embolectomy
• May need an IVC filter
• Acutely - optimize oxygenation as well as you can

Question 16

Hemodynamic Monitoring in Respiratory Problems

Answer 16

• Capnography - end-tidal CO2
• Arterial line monitoring
• PA pressure monitoring
• SVO2: venous oxygen saturation, measure of oxygen content of blood returning to right side of the heart after perfusing the body - Normal 60-80%

Question 17

O2 Therapy
Principles

Answer 17

• Need an order
• Start low and progress up as needed
• Reported in percentages - lowest
  35%, highest 100%
• 2 categories of therapies: low flow,
• high flow
• Humidification: used in all methods of
  O2 therapy
• Nurse is responsible for charting levels Makes sure to chart everytime & check levels often

Question 18

Airway Management

Answer 18

Most important

• Positioning - head tilt - chin lift or jaw thrust
• Oral airway
• Nasopharyngeal airways - Nasal
  trumpet

If not working artifical Airway is needed

• Endotracheal tubes [ETT
  or ET tubes] - inserted
  through the mouth into
  the trachea
• Sized - #6-#9
• Can usually suction
  through them [if placed
  in the hospital]

Question 19

Care of the intubated
patient

Answer 19

• Verify placement every assessment
• IV placement need to be in place
• Oral care
• Verify secure
• Cuff inflated
• Tube clear? Not bitten? Switch sides of the
  mouth? Secure to the ventilator? Skin intact in
  mouth and at tape or securement device?

Question 20

Tracheostomy

Answer 20

Preferred for long term long term airway

Nursing Care

*Oral Care is need
* What for skin integrity issues
* Trach care

Question 21

Basics of Mechanical ventilation

Answer 21

• Purpose– support respiratory system
• Usually/always positive pressure ventilation– FORCE air into the lungs
  [not a passive acceptance of air]
• Main things as the nurse you are responsible for knowing:

1. Mode
2. FiO2 [percent of oxygen]
3. Tidal volumes patient intaking or what it is set on in pressure mode
4. Inspiratory pressures [again patient driven or what the setting is]
5. Rate
6. PEEP [positive end-expiratory pressure]– to POP the alveoli open

Question 22

Complications of mechanical ventilation

Answer 22

• ET tube out of position
• Unplanned extubation
• Laryngeal & tracheal injury
• Oral mucosa damage

Question 23

Pulmonary issues
r/t mechanical ventilation

Answer 23

• Barotrauma
• Oxygen toxicity
• Respiratory acidosis or alkalosis
• Infection
• Dysphagia or aspiration

Question 24

Weaning considerations

Answer 24

• Approach in a systematic fashion
• Thinking about READINESS
• Weaning trials [pressure support trials]
• Extubation– have emergency supplies ready, think about positioning
  when extubated, keep calm environment, lights on, pain managed but
  not LOC depressed
• Bedside swallow - may need speech eval