Exam 2 Study Guide PDF

Respiratory I. Respiratory Mechanics & Assessment: Stimulus for Breathing: Normally, CO2 levels trigger breathing. ○ In COPD patients, O2 levels become the primary stimulus due to chronic CO2 retention. Normal Respiration Rates: ○ Adults: 12-20 breaths/minute...

Respiratory I. Respiratory Mechanics & Assessment: Stimulus for Breathing: Normally, CO2 levels trigger breathing. ○ In COPD patients, O2 levels become the primary stimulus due to chronic CO2 retention. Normal Respiration Rates: ○ Adults: 12-20 breaths/minute ○ Infants: 30-60 breaths/minute. Eupnea: Normal breathing. Bradypnea: Slow respiratory rate. Inspiratory/Expiratory Ratio ○ A 1:2 ratio (inspiration shorter than expiration) is normal. Body Position: Upright posture promotes ease of lung expansion. Environmental Factors: Pollution, allergens, and humidity can affect respiration. Lifestyle Habits: Smoking, drugs, and alcohol negatively impact respiratory function. Work of Breathing (WOB): The effort required to breathe. Increased WOB is a key indicator of respiratory distress. Conditions Increasing WOB ○ Restrictive lung movement (e.g., idiopathic pulmonary fibrosis) ○ Airway obstruction (e.g., asthma, COPD) II. Restrictive Lung Diseases: Characteristics: Difficulty filling the lungs with air during inhalation, leading to shortness of breath. Key Features: ○ Decreased total lung volume and capacity ○ Decreased elasticity of the lungs ○ decreased chest wall expansion during inhalation ○ stiffening of the lungs (as seen in idiopathic pulmonary fibrosis). Pneumonia: Accumulation of pus or fluid in the alveoli due to inflammation (consolidation). Atelectasis: Partial or complete collapse of a lung or lobe. III. Obstructive Lung Diseases:  Characteristics: Obstruction in the air passages, making exhaling difficult and increasing residual air volume. The diameter of the airway decreases and the resistance increases. Asthma: ○ bronchoconstriction ○ Inflammation ○ mucus production ○ airway obstruction COPD (Chronic Obstructive Pulmonary Disease): ○ chronic bronchitis and emphysema ○ Airways become inflamed and thickened ○ the tissue where oxygen exchange occurs is damaged ○ Symptoms include: shortness of breath (SOB) cough with mucus Fatigue frequent lung infections IV. Advanced Respiratory Concepts & Interventions: Accessory Muscle Use: Using muscles other than the diaphragm and intercostal muscles to breathe, indicating respiratory distress. ○ Accessory muscles include: the sternocleidomastoid pectoralis major Trapezius Intercostal muscles abdominal muscles. The tripod position is often adopted to facilitate breathing Signs & Symptoms of Altered Respiratory Function: ○ Cough ○ SOB/dyspnea ○ sputum production ○ bradypnea/tachypnea/Cheyne-Stokes breathing ○ chest pain ○ use of accessory muscles ○ adventitious breath sounds Cheyne-Stokes Breathing: Alternating periods of increased rate and depth of respirations followed by apnea (cyclic pattern)  Stridor: High-pitched sound heard on inspiration, indicating upper airway obstruction or edema. Cyanosis: Bluish discoloration of the skin, lips, mucous membranes, or nail beds due to low oxygen levels. Clubbing: Enlargement and rounding of the fingertips, associated with chronic hypoxia in cardiac or respiratory diseases. Pulse Oximetry: Normal readings are 95-100%, but COPD patients may have lower readings. A baseline is crucial for monitoring. Oxyhemoglobin curve ○ Left shift - LOVING, higher binding affinity of O2 ○ Right shift - lesser binding affinity of O2 Interventions to Improve Respiratory Function: Hydration, positioning (upright), ambulation, deep breathing, pursed-lip breathing, stacked/huff cough, incentive spirometry. Peak flow meter - measures the peak expiratory volume with forces exhalation. BEFORE AND AFTER TREATMENT Spacer - ensures patient recieves all medication from inhaler Acapella - uses positive expiratory pressure to force air behind the sputum and move it forward Nebulizer treatment - delivers aerosolized medication directly to the lungs Metered dose inhaler - measures delivery of respiratory medication to the lungs Oxygen Therapy: ○ Three principles: lowest concentration shortest duration continuous monitoring of ABGs and O2 saturation. Oxygen Delivery Systems: ○ Low-flow: These systems do not meet all the patient's ventilatory demands and mix with room air. 1. Nasal cannula 1-6 L = 24-60% 2. simple face mask 5-10L = 40-60% 3. partial rebreather mask 10-15L = 30-60% 4. non-rebreather mask 10-15L = 55-90% ○ High-flow: These systems provide a precise FiO2 and meet all the patient's ventilatory demands. 1. High-flow nasal cannula 60l/min  a. Increases low of O2, premixed air, heated and humitified 2. venturi mask colored valves 24-60% a. Meets demands of COPD patients b. Requires humidification, precise and accurate 3. tracheostomy collar 28-98% a. High humidity 4. oxygen hood/tent GREATER THAN 60% a. High humidity V. Clinical Scenarios & Case Studies: Consider the following when reviewing cases and clinical scenarios: Patient Assessment: ○ Identify the key signs and symptoms, respiratory rates, oxygen saturation levels, and other relevant data. Oxygen Delivery System Selection: ○ Choose the appropriate low-flow or high-flow oxygen delivery system based on the patient's condition and needs. Weaning from Oxygen: ○ The process should be incremental, with close monitoring of the patient's response. Tracheal Suctioning: ○ This procedure aims to clear secretions and maintain a patent airway. VI. Tracheal Suctioning: Purpose: Remove secretions through a tracheostomy tube or other airway access device. Assessment for Need: ○ Listen for adventitious breath sounds (like gurgling or wheezing) ○ monitor oxygen saturation and respiratory rate ○ assess for signs of respiratory distress such as increased work of breathing, retractions, or cyanosis Procedure: 1. Suction only on the way out of the airway 2. Suction to the end of the tracheostomy tube, max 1 cm below 3. use intermittent suction 4. rotate the catheter  5. Do not suction longer than 10-15 seconds 6. Hyperoxygenate the patient before and between passes 7. Limit to 3 passes per session 8. monitor for complications Complications: Edema, obstruction, hypoxia/bronchospasms, expulsion of the tracheostomy tube, infection, hemorrhage, and skin breakdown. I. Enteral Nutrition Enteral Nutrition Definition: ○ Nutrition delivered through the GI system. NPO Diet: Nothing by mouth (Nil per os). Clear Liquid Diet: Tea, soda, light-colored Jell-O, clear broth. Full Liquid Diet: Tea, soda, Jell-O, broth, ice cream, sherbet, anything that becomes liquid at room temperature. Soft Diet: Pureed foods, foods not requiring chewing (e.g., soft pasta, pudding, applesauce, yogurt, eggs). Suitable for patients with poor dentition or difficulty swallowing. "As Tolerated" Diet: Determined by the patient's individual tolerance. Restrictive Diets: Limit certain food items. Examples include: ○ Cardiac Diet: Low sodium, low fat. ○ Diabetic Diet: Low sugar, consistent carbohydrates (e.g., 60 grams/meal). ○ Obese Patient Diet: Restricted calories. ○ Renal Diet: Low protein, low sodium, low potassium, fluid restriction. Nasogastric Tube (NGT): A tube inserted through the nose into the stomach. Uses include gastric decompression, gastric lavage, and gastric feeding. Placement must be confirmed by X-ray and a "ready to use" order. Auscultation with air insertion is no longer used to check placement. NGT Confirmation (Post-X-Ray): Assess aspirate characteristics, observe for respiratory distress, and confirm exit site markings. NGT Insertion: Can be performed by a provider, nurse, or nursing student. Checking Residual: Use a syringe to withdraw gastric contents to determine if the patient is absorbing the tube feeding. Return any residual to the stomach. Salem Sump: ○ An NGT used for suctioning. The pigtail is an air filter preventing the tube from adhering to the stomach mucosa. Short-term use. Levine Tube:  ○ An NGT used for tube feeding. Percutaneous Endoscopic Gastrostomy (PEG) Tube: ○ A surgically placed tube for long-term tube feeding, accessed through the abdomen. Gastrojejunostomy Tube: ○ Similar to a PEG tube but has three lumens (compared to PEG's two), allowing for tube feeding through the jejunal port while connecting the gastric port to suction. Long-term use. Kangaroo (Patrol) Pump: Controls the amount and rate of tube feed administration. Use only 8 hours' worth of tube feed in a bag with this pump. Medication in Tube Feeding Bags: Never add medication to a tube feeding bag. Tube Feed Bag Changes: Every 24 hours. Patient Positioning (Tube Feeding): ○ Minimally semi-Fowler's (30-45 degrees). Holding Tube Feedings: ○ Hold if residual is 1.5-2 times the rate. Hypertonic Feeding Solutions: Can cause diarrhea due to osmotic gradient drawing fluid from the body into the GI tract. Adjust feeding as needed. Stopcock (Lopez Valve): Allows access to NGT/PEG/GJ tubes without disconnecting the system. Bolus Tube Feeding: ○ A specific amount of tube feed administered at once, rather than continuously via a pump. Hold if residual is 250-500 cc. II. Parenteral Nutrition Parenteral Nutrition Definition: Intravenous delivery of fluids. Examples of Parenteral Fluids: IV fluids, electrolytes, nutrition, medication, blood products. Isotonic Solutions: Same osmolarity as cells (e.g., 0.9% sodium chloride, Lactated Ringer's). Used for hypovolemia. Hypotonic Solutions: ○ Lower osmolarity than cells (e.g., 0.45% sodium chloride). ○ Fluid shifts into cells; use cautiously to prevent fluid depletion and cardiovascular collapse. Hypertonic Solutions: ○ Higher osmolarity than cells (e.g., 3%, 5% sodium chloride). ○ Requires strict monitoring in ICU due to risks of circulatory overload, hypertension, and pulmonary/cerebral edema.  ○ Fluid is pulled from cells into the intravascular space. Angiocath: Device used for venous access (peripheral IV). IV Tubing Preparation: Prime the tubing before use to remove air. Gravity Infusion Rate: Fill the drip chamber halfway; count drips for one minute (or 30 seconds x 2) to determine the drip rate. IV Complications: ○ Infiltration: IV fluid leaks into surrounding tissue; may present with pain, burning, soft swelling. Apply heat or cold, elevate extremity. ○ Phlebitis: Inflammation of a vein; causes redness, warmth, and hardness at the IV site. May be caused by catheter size, infusion duration, irritating fluids, or poor vein selection. Can lead to thrombophlebitis (blood clot formation). ○ Infection: Redness, pain, warmth, pus at the IV site. ○ Fluid Overload: Too much fluid infused or infused too quickly; symptoms include hypertension, edema, dyspnea, and heart issues. ○ Air Embolism: Air entering the cardiovascular system, often due to insufficiently primed IV tubing or during central line placement. IV Orders: ○ Maintenance Fluid: Fluid administered at a prescribed rate to maintain homeostatic fluid status. ○ Bolus: A large amount of fluid given in a short time (sometimes called a fluid challenge). ○ KVO (Keep Vein Open): 10-20 cc per hour, preventing IV clotting. Banana Bag/Osler Bag: Yellow in color; contains vitamins and minerals in an isotonic solution. Infusion Pump: Regulates IV fluid infusion. Pump Occlusion (Fluid Side): Problem above the pump. Pump Occlusion (Patient Side): Problem below the pump. Piggyback Tubing (Secondary Tubing): Connects a secondary fluid bag to the primary line. IV Push: Administering medication directly into a PIV or primary line via a syringe. Always flush with normal saline before and after an IV push. IV Push Chart Importance: Details how much of what medication can be pushed, if dilution is needed, and possible adverse effects. Triple Lumen Central Line: A short-term central line allowing infusion of three incompatible fluids simultaneously. External Jugular IV: A peripheral line, not a central line. Hickman and Groshong Catheters: Long-term tunneled central catheters; Groshong does not require heparin flushes to keep the line patent.  Central Line Placement Confirmation: X-ray. Dacron Sheath: A cuff anchoring the central line and acting as a barrier against microorganisms. PICC (Peripherally Inserted Central Catheter): ○ A long-term central catheter inserted into the arm and threaded into the superior vena cava. A specially trained nurse can place this bedside, and placement is verified by X-ray. TPN/CPN (Total Parenteral Nutrition/Complete Parenteral Nutrition): ○ Contains >10% dextrose and/or >5% protein. Infused through a central line. Complications include infection, fluid overload, and hyperglycemia. Use D10W if TPN/CPN needs to be stopped abruptly. Patients receive finger sticks to monitor for hyperglycemia. PPN (Peripheral Parenteral Nutrition/Partial Parenteral Nutrition): ○ Contains