N4551 Critical Care Nursing: Module #1 Review
1. The nurse is evaluating the respiratory status of pt diagnosed with respiratory distress. Please match
... [Show More] which
assessment data would help the nurse evaluate each diagnosis (one diagnosis per assessment finding).
Ability to verbalize __1___ 1. Altered Airway Clearance
Skin color __3___ 2. Impaired Breathing Pattern
Respiratory depth __2___ 3. Impaired Gas Exchange
Level of consciousness __3___
Respiratory rate __2___
Breath sounds __2___
Secretions __1___
Accessory muscle use __2___
Tongue obstruction __1___
2. Define the two types of respiratory failure and the potential causes for each?
Respiratory Type I
Hypoxemic
Normocapnic
Definition: PaO2 < 60 mmHg; Supplemental O2 > 60%; cannot be on nasal cannula because those
only go up to 44%; low O2 below 60 , but CO2 is normal (normal level 35-45)
Causes: VQ mismatch & shunting
• VQ mismatching (ventilation-perfusion mismatch; supposed to be 1:1 ratio; normal circulation
of blood out of heart is 4-5 L; so if there is not enough blood, or not enough O2 in blood,
results in mismatch)
• Caused by: increase secretions, alveolar collapse, bronchio-constriction, pulmonary
embolism, atelectesis (water in alveoli)
• Shunting: blood going from one side to the other without being oxygenated
• Anatomic shunt caused by:
Ventricular septal defect (blood goes through without any O2 due to the hole
between the ventricles) TX: surgical
Patent Ductus Arteriosus (lack of connection between the pulmonary artery n the
pulmonary vein with no O2) * becomes a ligament TX: surgical
Tetrology of Fallot: (1) ventricular septal defect, aorta shifted causing an obstruction
of blood from R ventricle to the lungs causing (2)pulmonary stenosis,(3)R ventricle
develops hypertrophy which narrows the pulmonary vein; O2 poor blood goes to body
Transposition of the Great Vessels: completely unoxygenated blood is going to the
body, pulmonary artery comes off the L ventricle, cannot survive without being fixed
• Intrapulmonary shunt caused by: *the body closes gate to keep from circulating blood
to certain part of lung that you’re not going to oxygenate.
Atelectasis: water in alveoli decrease compliance of lungs
Pulmonary Edema
Pulmonary Fibrosis
ARDS: acute respiratory distress syndrome
Respiratory Type II
In order for CO2 increases- you have to under ventilate the alveoli. No perfusion problems.
Hypoxemic
Hypercapnia
Definition: Increased PaCO2 levels; low o2, elevated Co2
Causes: alveolar hypoventilation (under ventilating the alveoli)
• caused by: chest trauma, CNS injury- overdose with pills or drugs, massive obesity
3. Inspiratory Capacity: TV + IRV
•Tidal Volume: how much air you move in & out with one breath; adults usually about 1 L
• Inspiratory Reserve Volume: the maximum amount of air you can inhale above the normal tidal volume.
4. Functional Residual Capacity: Dead space + ERV
•Expiratory Reserve Volume: the maximum air you can force out above the normal tidal volume.
•Residual Volume: the amount of air left in the alveoli after you force the normal amount out of the lungs. Can
never get rid of it unless in space or a vacuum, this keeps the alveoli from collapsing on themselves. (Dead
space)
5. Vital Capacity: IRV, TV, ERV; the dead space is not included in this amount NO dead space
6. Total Lung Capacity: Sum of all lung volumes, all four of the above are included.
7. Pt weighs 188 pounds. What tidal volume range would the nurse recommend?
Weight in kg times 5 and 10 to get the range. 188/2.2= 85.4545 kg x 5 = 427.27
10 x 85.4545 kg = 854.54 Range: 427.3 - 854.5
Normal range is 500-1000 ml per breath. So this range is just below the normal at the lowest part.
8. Oxygenation: the exchange of the air into the hemoglobin at the alveolar area; PaO2; SaO2; gas exchange at the
alveoli level (pulmonary edema, pneumonia)
9. Ventilation: the movement of air, breathing; getting the air into the lungs like alteration in breathing patterns
(symmetry of chest expansion, retractions, accessory muscle use, nasal flaring, tripod position, pursed lip breathing,
RR, inspiratory/expiratory ratio 1:2, exhale twice as long as we inhale), alteration in airway clearance, tongue
obstruction, swelling, vomit, excess of secretions. V (ventilation) à alveoli
10. Perfusion: the exchange of gas to the capillaries & out to the tissues; PaCO2; pH: how much hydrogen is out there;
HCO3: how much metabolic bicarb in the kidneys; (perfusion of blood to be perfused at the capillary bed can be
effected by blood loss; listen to breath sounds, rales, crackles, absent, also with skin color, cold, clammy). Q à
capillaries (perfusion, blood flow to the capillaries)
•For every ml of blood going in there is ml of air going to the capillaries. If not 1:1 ratio than VQ mismatch.
11. Hypoxemia: an inadequate level of O2 in the blood, the consequence of respiratory failure, when the lungs no longer
are able to perform their chief function of gas exchange. Decreased O2 in the blood eventually leads to hypoxia.
• S/S: cyanosis, restlessness, stupor, coma, Cheyne-Stokes respiration, apnea, increased BP, tachycardia, an initial
increase in cardiac output that later falls, producing hypotension and ventricular fibrillation or asystole
• Resistant to O2 therapy
• PaO2 below 60 and on supplemental O2 greater than 60%
Rationale for determining O2 amount to treat hypoxemia: The most reliable method for measuring the degree of
hypoxemia is ABGs to determine the partial pressure of oxygen in the arterial blood (PaO2: norm 95-100).
12. Chest Trauma: rib fractures, pneumothorax, hemothorax, diaphragmatic rupture, aortic tear, cardiac tamponade
A. Mechanism of Injury
• Direct force: penetrating wounds including iatrogenic
• Indirect force: blunt, non-penetrating, acceleration-deceleration, crush e.g. falls, steering wheel,
blows
• Spontaneous: rupture of a pleural bleb
B. Assessment: ABCs, respiratory pattern, chest wall movement, tenderness, crepitus of chest wall, breath
sounds, heart sounds, adventitious sounds; Neurological assessment, vital signs; Hypovolemia, relative
hypovolemia: JVD, urine output; Hypoxia: ABG, pulse ox, pulses, cap refill; Lab: Hgb, Hct, chemistries, type &
cross match, CXR, abdomen x-ray; Assess abdomen
C. Treatment: ABC and C-spine precautions; Supplemental O2, ventilatory support; vital signs; Two large bore
IV’s; Assess & treat life threatening conditions first (Tension pneumothorax, flail chest, cardiac tamponade,
massive hemothorax, open pneumothorax, or aortic tear); History of injury, other history; Chest tube, foley cath,
hourly I&O; EKG, cardiac monitor; Early surgical repair when indicated
D. Nursing Process:
• Alteration in tissue oxygenation RT altered gas exchange secondary to lung collapse, etc.
• Alteration in tissue perfusion RT decreased cardiac output secondary to hemorrhage, cardiac
tamponade, tension pneumothorax, etc. Anxiety/fear/diminished coping RT fear of unknown & pain
• High risk for infection RT diminished tissue integrity secondary to wounds, invasive devices &/or
surgery
• Complications of chest trauma: hemorrhage, hypoxia, ARDS, hazards of immobility
13. Pulmonary Embolism: Blockage of pulmonary blood flow by a clot, air, or mechanical means; can be single or
multiple. Most commonly dislodged clot in vein, return to RV, pumped to lung, lodges in lung capillary bed. Best
thing for this is to prevent it with SCDs, movement, ambulation, elastic hose, TurnCoughDeepBreathe (TCDB),
avoid tight clothes, crossing legs, sitting or standing for long periods of time.
• Risk Factors: Virchow’s Triad [Show Less]