Exam 2 Study Guide PDF

**Exam 2 Study Guide** **PPT 1: Assessments of Patients with Respiratory Problems** AIRWAY BREATHING CIRCULATION!!! Review: - Breathing provides O2 and removes Co2 (gas exchange) - Basic life support - Humidification - Alveoli - get damaged easiest, gives issues when dealing with h...

**Exam 2 Study Guide** **PPT 1: Assessments of Patients with Respiratory Problems** AIRWAY BREATHING CIRCULATION!!! Review: - Breathing provides O2 and removes Co2 (gas exchange) - Basic life support - Humidification - Alveoli - get damaged easiest, gives issues when dealing with hospital population - air sacs in the lungs where O2 and Co2 are exchanged during breathing - primary site of gas exchange Assessment: - Smoking- cigarettes, vaping, medical marijuana - Allergies- seasonal, medication (typically induce anaphylaxis which can occlude airway), environmental - Drugs- legal or illegal drug use (can cause respiratory depression) - Travel- diseases more prevalent in other areas of the world, socioeconomic status of other areas, airplanes, pollution - Family History- COPD, underlying lung conditions, smoking in the home - Occupation- mortician (embalmment fluid), construction workers, miners, lead, black mold Physical Exam: - Establish if the pt is hemodynamically stable vital signs - Temperature is important because when altered can disturb homeostasis - General appearance - Pale - Positioning - Signs of labored beathing - Use of accessory muscles (late signs, expect pt to go into respiratory distress quickly) - Nasal flaring - Clubbing (hypoxemia) - Auscultation of breath sounds - Different adventitious lung sounds will tell you different things - Wheezing airway bronchoconstriction vasodilate - Rhonchi obstruction most likely mucous sit pt up, deep breathe, bronchodilate - Crackles fluid trapped in alveoli diuretic, determine if there is an infectious process and if so give antibiotics - Chest xray can help determine if you are treating the correct adventitious lung sounds for the right reasons - Signs of impaired gas exchange - Delayed capillary refill - Cyanotic or pale - Can become ashy in color - Circumoral cyanosis (skin around mouth becomes blue or gray) Signs and Symptoms - Objective data - General appearance and vital signs - Slight change in these and this pt becomes your priotity - Subjective Data - Cough were they coughing is there sputum, color - Chest pain determine if chest pain is respiratory or cardiac related pneumothorax, collapsed lung, hemothorax, pleural effusion, friction rub - Dyspnea (SOB) how bad, when did it start, how long has it been going on - MEWS score scale that determines patients overall physiologic state Shunt - Results when something interferes with air movement in gas exchange areas - Blood bypasses alveoli without picking up oxygen - Alveoli fills with fluid while shunting process occurs causing loss of oxygen - Main cause of hypoxemia Examples of Shunts: - Foreign body - Food bolus - Cant pass food down upper airway - EMERGENCY because airway and breathing are compromised - All it takes it one cough or swallow for it to get to an area where it cant be removed and becomes extremely dangerous - Bronchospasms - Worried about constriction and spasms its creating in airway - Typically increases RR causing more constriction than dilation - Decreases o2 - Mucous plugging - Mostly seen on pt with vent - Aggressive suctioning - Can happen in trach pt as well nasopharyngeal suctioning, chest pt, cough and deep breathe, auscultator - Cystic fibrosis pt are prime pt for this to happen to (important to catch quickly bc once these pt are ventilated its hard to get them off) - Pneumonia - Coughing and deep breathing - Chest pt - HOB up - Flutter and incentive spirometry - Pulmonary edema - Fluid filled alveolar sacs that move into bronchioles - Crackles and PINK FROTHY SPUTUM (assess ABC and get vital signs b/c this pt needs fast intervention) - First and easiest intervention IV diuretics to get fluid off if pt doesn't respond they will go back to ICU and get intubated bc the heart and lungs will simultaneously fail - Hypoventilation - Not being able to perfuse - Inadequate inhalation and exhalation - Poor RR Dead Space - Space in lungs where there is NO gas exchange - Anatomical air passages with no gas exchange, mouth, nose, trachea, bronchi - Pathological pulmonary embolus, shock (vasoconstriction) - Dead space causes 150 ml of air volume (normal is 450-700ml) - Pt cannot survive with this amount of air volume and will get put on vent \*need to know how to calculate how much lung volume pt needs\* Determining Dead Space - Chest xray - Lungs will look cloudy or whited out - Common in shock or PE\ prepare for intubation - If they don't have clear picture on Xray stat ct scan with contrast to determine if there is PE, necrosis or whatever else - Sometimes intubate before CT scan to secure airway because the pt can decompensate in the 20-30 minutes it takes to get the scan Hypoxemia blood oxygen is low Hypoxia deficiency of oxygen supply to body (clubbing) - Can be both at same time - Can be hypoxemic living daily life -- COPD, CF, emphysema, HF, cardiomyopathy - Anything with impaired gas exchange b/t heart and lungs just depends on the degree and if it alters acid base balance - Get ABG to determine if acid base balance is disrupted to determine what interventions are needed [Venous Blood Gas] can be done from normal blood draws, from vein [Arterial Blood Gas] required in radial, brachial or femoral, more accurate but more invasive, advocate for arterial line if frequent blood draws are necessary Respiratory Changes with Aging - Harder for adults to compensate - Changes in chest wall kyphosis, spinal issues, smooth muscle around lungs is less plyable, decreased expansion - Larynx and pharynx less plyable - Lung tissues atelectasis, more sedentary, not coughing and deep breathing, cant inhalate and exhalate the same decrease in tidal volume - Alveoli must take aging process into consideration when oxygenating so you don't blow their lungs up - Pulmonary vasculature more fryable, vessels more frail and flimsy - Muscular strength decreases (atrophy) Physical Assessment 1. Inspection - Watch chest rise and fall - Symmetry - Checking frequently allows you to notice small changes - Check during hourly rounding 2. Palpation - Touch chest and back to confirm what youre seeing 3. Percussion - Do not percuss 4. Auscultation - Can help indicate adventitious lung sounds - Can help indicate vasoconstriction or vasodilation Labs +-----------------------+-----------------------+-----------------------+ | CBC | BMP | ABG and VBG | | | | | | - RBC, HGB, HCT | - Electrolytes | - Check to ensure | | | | acid base balance | | - Oxygen carrying | - How well is the | is in check | | capacity | body filtering | | | | toxins | | | | | | | | - BUN, Cr | | | | | | | | - GFR | | +=======================+=======================+=======================+ | Lactate | Sputum | Troponin | | | | | | - Anaerobic | - Just because it | - Have to confirm | | respiration | has color doesn't | whether it is | | | mean its | cardiac or | | - Not enough oxygen | infection | respiratory | | reaching tissues | | | | | - Sputum culture | - Facility specific | | - Tells how much | can determine | whether or not | | oxygen is being | disease process | they will get all | | used and how much | and what is best | cardiac | | is left | course of | biomarkers but | | | treatment | all you need is | | | | troponin | | | - Can see other | | | | specimens within | | | | sputum | | +-----------------------+-----------------------+-----------------------+ Diagnostic Evaluation - Chest xray (diagnostic of pneumonia) - CT Scan - With or without contrast - Wouldn't use contrast with kidney injury - GFR should be at least 60 - Pulse ox - Looking at capillary beds - Not as efficient in pt with decreased perfusion - Emphysema, COPD (will be lower but that is their normal) - Hand flat - Also takes HR - 93-100% - Capnography - See CO2 levels - Normal 35-45 mmHG - Can be seen in overdoses if they aren't blowing off enough Co2 - If Co2 is too high can alter mental status - Used in ICU all the time - Pulmonary function tests - How well is the pt ventilating - How much o2 is being pushed in and out of lungs - What meds are needed to institute better lung function - Used to test for asthma - Not used in hospital setting usually - Can be used if trying to wean pt off oxygen and they keep desatting - Bronchoscopy - Conscious sedation - Anesthetizing drug to diminish cough and gag reflex t put scope into lungs and get closer look - Can get biopsies - Looking for areas of concern - Can indicate empyema (infectious fluid filled space in pleural space) - Can pull tissue and mucous samples out - Thoracentesis (removes fluid) - Awake sitting on edge of bed - Nurses assist in this - Gets fluid out of pleural space - Used in pleural effusions - Can be diagnostic or just to get fluid off - Pain management necessary PO or IV - Lung Biopsy - Bronchiole or lung biopsy - Typically done if youre looking for cancer - Don't take these lightly - Go from transbronchial to endobronchial with light sedation - For mediastinal they get fully sedated - V/Q Scan - Radiology test using radionucleotides - How much air can go into lungs and how much perfusion is there - Similar to CT scan but no dye so better for pt with decreased kidney function - Used in pt worried about pulmonary embolism - Safer alternative to CT scan but takes longer because radioactive substance has to travel through the lungs - Very rare and not typically used in hospital setting - MRI SVO2 Monitoring - Another monitoring device with swanz ganz catheter - Normal 60-80% - Monitors Spo2 supply and demand - How much oxygen is pt requiring and what is the demand and what is left in the tank - After MI rare that pt can compensate the increase supply vs the decreased demand - Think of what could case pt Spo2 to drop and increase demand but decrease supply (repositioning) - Pt don't have anything left in their tanks and their bodies give out - Will see significant drop in numbers the sicker they are even if they don't appear hypoxic or hypoxemic **PPT 2: Acute Respiratory Failure** **Pulmonary Embolism** - Priority patients - Can decompensate very quickly - Can be minor or large - all pt used to get admitted but only some do now - lots of meds to treat outpatient (anticoags) - when it becomes multiple in nature or multiple risk factors admitted - CAT scan done with dye to get visualization of lungs - Can do without dye (V/Q scan) but not as accurate or reliable Risk Factors - Prolonged immobility - DVT/PE treatment prophylaxis - Trauma pt - Obesity - Smoking - Birth control pills - Surgical pt - Long car rides without getting up Manifestations - Rare for pt to come in SOB - Restlessness or anxiety - Sharp chest pain upon inspiration - Can be R or L - Feel pressure as if something is sitting on your chest Lung scan - V/Q scan pr CAT scan = gold standard - Still get chest xray but doesn't show PE Prevention - Quit smoking - VTE prophylaxis - In and out surgery sent home on VTE prophylaxis - Come off birth control pillws - Nurses wear compression socks - Lose weight - Stay active - Get up and stretch during long trips Interventions - SCD/TEDS - Ambulation - Flutter valve and incentive spirometry - Cough and deep breathe - HOB 30-45 - Out of bed with every meal at least - Chest PT - Anything to increase gas exchange - Slowly increase physical activity - Extra therapy or Rehab - Anticoagulation therapy (coumadin, Eliquis, zorolto) - Thrombolytic therapy (rare because of how high risk, used as last effort) - Embolectomy (surgical removal of clot) - Inferior vena cava filters (last effort if pt is decompensating) **Acute Respiratory Failure** - Sudden deterioration in pulmonary gas exchange resulting in Co2 retention and inadequate oxygenation (ventilation and gas exchange issues) - Doesn't necessarily have t be respiratory in nature but causes respiratory effects +-----------------------------------+-----------------------------------+ | Type 1 or Hypoxemia | Type 2 or Hypercapnic | | | | | - PaO2 \45 | | | | | - Abnormal o2 transport and | - Failure to exchange or remove | | inadequate oxygen exchange | carbon dioxide | | | | | - Most common | - Decrease alveolar minute | | | ventilation | | - Good likelihood and fairly | | | easy treatment | - Seen in COPD and emphysema | | | | | - Treatment to settle down | - Administer oxygen but not in | | airways or create them to | large quantities | | open up =bronchodilators of | | | corticosteroids, nebulizer | - Albulterol, corticosteroids, | | albuterol | bronchodilators | | | | | | - Blow off Co2 pursed lip | | | breathing, BIPAP | | | | | | - If unable to do with mask or | | | nasal prongs may need | | | intubated | +===================================+===================================+ | Type 3 or Mixed hypoxemia | Type 4 Respiratory Failure or | | hypercapnic | SHOCK | | | | | - Inadequate alveolar | - Patients who are intubated | | ventilation and abnormal o2 | and ventilated in the process | | transport | of resuscitation for shock | | | | | - Can be acidodic or alkolotic | - Goal of ventilation is to | | | stabilize gas exchange and | | - Typically respiratory in | unload respiratory muscles | | nature | | | | - Pt is a mess and only way to | | - High Co2 levels | get ahold of the situation is | | | intubation and securing | | - Low bicarb levels | airway | | | | | - Hypoxemic and hypoxic | | | | | | - Typically treated with Meds, | | | Bipap and highly considered | | | intubation because it may | | | take awhile to figure out | | | whats going on | | +-----------------------------------+-----------------------------------+ Management of Acute Respiratory Failure - If pt comes in with respiratory ailment you need to triage them at high level even if they aren't because they are decompensate very quickly and you need to keep an eye on them frequently - If pt comes in and they are already decompensating intubate - Goal: Correct the cause, alleviate hypoxemia and hypercapnia - Potential causes: infection, airway obstruction, cardiac function Infection - Once it takes hold it creates an abundance of opportunities to replicate all over the body - Creates so many secondary complication - Send urine off and get culture to determine what exactly you are targeting - Using antibiotics that aren't working just puts pt at higher risk Acute Respiratory Distress Problems - Asthma - COPD - Chronic bronchitis - Emphysema - Lung cancer - Cystic fibrosis - Pneumonia - Pleural effusion - Covid **Acute Respiratory Distress Syndrome** - Condition in which fluid collects in the lungs air sacs depriving organs of oxygen - Can occur in those who are critically ill or have significant injuries - Often fatal increasing risk with age and severity of illness - Can have severe SOB and often are unable to breathe on their own without support from ventilator Prevention - Early identification and changes in pt vital signs - BP goes up until it cant then goes down - HR goes up - O2 goes down - Oxygen supply and demand decrease because there is nothing left in the tank - Tidal volume decreases - Not enough exhaled air or inhaled air - RR increase until it cant then drops apnea of respiratory arrest - Best thing to do is intubate them and mange them - Turn and reposition - Chest PT - Therapy run through mechanical ventilatory that can give extra air into lungs - HOV elevated - Suctioning - Nebulizer - Corticosteroids and bronchodilator Patho Lung injury decreased blood flow to lungs alveolar membrane damage increased permeability interstitial and alveolar edema further impaired oxygenation leaky membranes causes osmotic pressure changes pulmonary edema inflammatory changes can lead to fibrosis - Don't want to diurese these pt right away - Once you see fibrotic changes in the lungs they do less inhalation and exhalation messing with tidal volume and hyperperfusing the lungs - If this happens try to manage the best you can but eventually it cant be managed and the pt either needs a lung transport or need extubated and let them die +-----------------------------------+-----------------------------------+ | Stage 1 | Stage 2 (exudative) | | | | | - First 12 hours | - 24 hours | | | | | - Patient increase SOB on | - Hypoxemia is resistant to | | exertion | supplemental oxygen | | | | | - RR | - Mechanical ventilation | | | required | | - Few chest xray changes | | | | - BP and HR increases | | - Spo2 decreases | | | | - Spo2 decreases | | - Fatigue | | | | - Try to give oxygen but pt | | | needs more and more o2 | | | | | | - Exudative phase, try BIPAP | | | but pt will most likely end | | | up in ICU ventilated | | | | | | - Notify physician | +===================================+===================================+ | Stage 3 (proliferative) | Stage 4 (fibrotic) | | | | | - Days 2-10 | - Days \>10 | | | | | - Hemodynamically unstable | - Lung fibrosis issues | | | | | - Evidence of SIRS (systemic | - Ventilator management issues | | inflammatory response | | | syndrome) | - Once fibrosis sets it the | | | damange is irreversible | | - More evident something is | | | going on | - The lungs are no longer | | | complacent and there is | | - HTN or possibly already going | nothing else that can be done | | towards hypotensive | | | | - Once pt is extubated they | | - Hyper or hypothermic | usually pass almost | | | immediately | | - RR increase | | | | | | - Sao2 decreaing | | +-----------------------------------+-----------------------------------+ Diagnostic Criteria of ARDS - PaO2: Fio2 ratio \