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
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)
Hypoxemic Causes: VQ mismatch & shunting
Normocapnic
• 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. [Show Less]