NUR 453 Role Transition Exam 3 Study Guide. Latest 2021.Respiratory
Ventilator emergencies
Should NEVER be turned off.
Don’t know what is
... [Show More] causing the alarm? What action is next?
o Manually bag the patient
o Can still mechanically ventilate when breathing on their own – bag WITH the pt
Three Types of ventilator Alarms
o Volume (low pressure) alarms - pt disconnected, low volume
o Pressure (high pressure) alarms - biting tube, secretions/fluid in tubing, pneumo
o Apnea alarms – not breathing
WHAT CAUSES THE ALARM?
Positive End Expiratory Pressure PEEP
o > 15 is high PEEP – can cause peumo, damage to lung tissue/barotrauma
Positive pressure decreases CO2 and compresses venous return
Assessment findings emphysema
Loss of lung elasticity leading to air trapping
Barrel shaped chest
Dyspnea – tachypnea, use of accessory muscles, pursed lip breathing
Pink puffers (high CO2)
Diminished breath sounds
Tripod position
Signs/symptoms of hypoxia
o Acute – hyperventilation, H/A, AMS (restlessness, anxious, irritability), diaphoresis
Tx: Oxygen administration, morphine sulfate to control breathing
o Chronic - clubbing, cyanosis, diminished oxygenation to vital organs
POSTOP care priorities
Oxygen administration devices - COPD patients
Nasal cannula
o Approximately 24-40% O2, 1-4Là meant for someone that is stable
If you give more than 4 L, you need to use humidifier
o SOB—start with nasal cannula
Masks: Simple; Partial rebreathing; Non-rebreathing
o Simple Mask: Can deliver ~40-60% O2; Flow meter- 5-8 L
Pro-more stable and higher concentration
Con—claustrophobic; assess for skin breakdown
Rearrange frequently and oral hygiene
o Partial Rebreathing: 60-75%, turn flow meter to minimum of 6 L
O2 in the bag (reservoir of O2)
Valves disallow re-inhalation of CO2
o Non-rebreather: Give close to 100% O2
Unstable patient or patient just recovering from anesthesia - ALL the way to 15 L
Must have airway and breathing on their own
Anticipate: 1. start to get better quickly 2. get advanced airway (intubated)
Assess frequently
Types of High Flow Devices
Venturi-Mask:
o Ex) 24% must find right adapter and set to the ordered # of L
o VERY accurate—Negative: uses a lot of O2, runs through tank quickly
T-piece: trying to wean pt of ventilatory support
o Can give up to 100% O2 via advanced airway
o Slowly wean concentration of O2, if tolerated can extubate
Noninvasive Positive-Pressure Ventilation- technique uses positive pressure to keep alveoli open and improve gas exchange
without airway intubation
o BiPAP—mechanical delivery of set positive inspiratory pressure each time the patient begins to inspire; as the
patient begins to exhale, the machine delivers a lower set end-expiratory pressure, together improving tidal
volume.
HCP can order two separate pressures—less on exhalation (allows fuller exhalation of CO2) Good for COPD
pt
o CPAP—continuous positive airway pressure sleep apnea
Same amount for inhalation and exhalation, may be harder to exhale CO2
Care of the pneumonia patient
Oxygen and bronchodilators as prescribed
Semi Fowlers
Incentive spirometer
REST—don’t ambulate
Hydration—up to 3L/day to break up secretions
High calorie & protein diet w/ small frequent meals
Cardiac
Defibrillation vs. Cardioversion vs. Pacing indications
Defibrillate: stops the heart
Cardiovert: slows the heart
Pacing: speeds up the heart
o 2
nd degree Type II Heart Block
o 3
rd degree Heart Block
TACHY
o Slow
NARROW (SVT)
o Stable – Vagal stimulation, Adenosine (6 mg take BP, follow by 12 mg), Amiodarone 150 mg IVPG, or CCB/Cardizem,
or Beta-Blocker
o Unstable – cardiovert (50 Joules)
IRREGULAR (A-FIB or FLUTTER)
o Stable – Adenosine, Amiodarone, or CCB/Cardizem, or Beta-Blocker
o Unstable – cardiovert 150 Joules
o
WIDE (V-TACH)
o Stable – Adenosine (6 mg take BP, follow by 12 mg), Amiodarone 150 mg IVPG, or CCB/Cardizem, or Beta-Blocker
o Unstable w/ pulse – cardiovert (100-120 Joules)
o Unstable no pulse – defibrillate 150, 250, 360 Joules
V-Fib
o Check patient (unresponsive) Rapid Response/911/have someone bring AED check pulse < 10 seconds
o Start compressions (30 compressions for every 2 breaths at least 100 comp/min) and Ambu Bag
o RR arrives w/ AED (continue compressions and place AED)
o Defibrillate 150, 250, 360 J
CPR order
Shock Drug CPR
Epinephrine IV 1 mg (1:10,000) x2
Amiodarone 1st dose 300 mg, 2nd dose 150 mg
30 compressions for every 2 breaths at least 100 comp/min
Defibrillate 150, 250, 360 J
Heart Failure Risk Factors
Atherosclerosis/CAD, HTN, smoking, high cholesterol, DM, family history, valvular disease, dysrhythmias, severe lung
disease, sleep apnea, hyperthyroidism
Left sided heart failure more common
Right sided heart failure (Cor Pulmonale) – caused by LHF
DVT Prevention/Interventions
Pharmacological Prophylaxis – anticoagulant therapy – Enoxaparin (Lovenox), Heparin, Coumadin
Mechanical Prophylaxis – SCD’s, hydration, avoid crossing legs, avoid tight/constrictive clothing, early ambulation/exercise
Central Line complications - Air embolus
During tubing changes instruct pt to perform valsava maneuver, head down and turned to opposite direction of IV (increases
intrathoracic venous pressure)
If suspected – place patient in LEFT side-lying position with HOB lower than feet (Trendelenburg), notify HCP, give O2
S/S: respiratory distress, chest pain, dyspnea, hypotension, rapid and weak pulse, heart murmur
Differentiate Shock States
Initial/Early Stage of Shock
Baseline MAP decreased by less than 10 mm Hg
Heart and respiratory rate increased from the baseline or a slight increase in diastolic blood pressure
Adaptive responses of vascular constriction and increased heart rate
Such a slight change, hard to catch
Non-progressive (Compensated)
MAP decreases by 10 to 15 mm Hg.
Kidney and hormonal adaptive mechanisms activated
o Renin, ADH, Aldosterone, Epi, Norepinephrine
o Sodium and water are retained
Tissue hypoxia in non-vital organs.
Build-up of metabolites:
o Acidosis- Increased RR, panting
o Hyperkalemia
Signs & Symptoms:
o Thirst and anxiety
o Restlessness
o Tachycardia, increased respiratory rate
o Decreased urine output
o Dropping SBP and rising DBP
o Narrowing pulse pressure
o Cool extremities
o 2% to 5% decrease in oxygen saturation
o Decreased bowel sounds, possible nausea vomiting
Stopping conditions that started shock and supportive interventions can prevent shock from progressing.
Progressive (Decompensated)
Sustained decrease in MAP of more than 20 mm Hg from baseline.
Vital organs develop hypoxia.
Less vital organs become ischemic
Poor perfusion and a buildup of metabolites, some tissues die
Life-threatening emergency
Immediate interventions are needed.
Conditions causing shock need to be corrected within 1 hour of the onset of the progressive stage death
Laboratory Findings [Show Less]