RCP_250_final_study_guide.pdf

RCP 250: FINAL REVIEW Chapter 4: 1. Know the most important infection control procedure for anyone with direct patient contact. Basic Infection Prevention such as proper hand hygiene–standard precautions?? 2. Know what is and is not indicated in droplet precautions (PPE, cohorting, air handling & ve...

RCP 250: FINAL REVIEW Chapter 4: 1. Know the most important infection control procedure for anyone with direct patient contact. Basic Infection Prevention such as proper hand hygiene–standard precautions?? 2. Know what is and is not indicated in droplet precautions (PPE, cohorting, air handling & ventilation procedures). (box 4.3 pg.55) Place the patient in a private room; if a private room is unavailable, cohorting is acceptable. Special air handling and ventilation are unnecessary, and the door may remain open. Perform hand hygiene and put on a surgical mask before entering the room. Remove mask before exiting the room and perform hand hygiene. Limit movement and transport of the patient from the room to essential purposes only. If transport or movement is necessary, minimize droplet transmission by having the patient wear a surgical mask. 3. Know the three major issues involved in using disposable devices when considering infection prevention and control. Pg. 63 -Cost -Quality -Reuse 4. For processing of medical equipment, know what devices fall under the “noncritical category.” Come into contact with intact skin. Noncritical patient care items or environmental surfaces. 5. Routes of infectious disease transmission: know vector borne and vehicle transmission. (pg.48-49) Vector Borne: through ticks, mites, mosquitoes, fleas Vehicle transmission: water borne or food borne Contact transmission: Contact transmission is the most common route of transmission and is divided into two subgroups: direct and indirect. Droplet transmission: Droplet transmission is a form transmission via respiratory droplets. Organisms transmitted by respiratory droplets include influenza viruses and Neisseria meningitidis. Transmission occurs when infectious droplets are propelled (usually ≤3 feet through the air) and deposited on another person's mouth or nose. 6. Be familiar with nosocomial infections. (pg.47) Develop in the hospital are called hospital onset. 7. Know what patients are at risk for acquiring health care-associated infections. Nosocomial pnemonia -chest or abdominal surgeries COPD, Smokers, Chemotherapy, advanced age, HIV Infection —--PowerPoint infection prevention 8. Know the most common types of respiratory equipment linked to HAI’s. Pg. 61 Nebulizer—--- Large volume Jet Nebulizers as they produce aerosols capable of spreading pathogenic microbes. 9. Know the importance of surveillance as it relates to infection control and prevention. Is a systematic process designed to review and analyze HAI Data on patients. This data can be used to provide outcome measurements, which may include ASSESSING the effectiveness of HAI reduction intervention, identifying clusters or outbreaks and identifying opportunities to intervene to prevent the transmission of pathogens in the healthcare environment. 10. Know the elements needed to be present for transmission of infection in the health care setting. (pg.48) Source: Humans (patients, personnel, or visitors) are the primary source of infectious agents in the health care setting, but inanimate objects (e.g., contaminated medical equipment, linen, medications) have also been implicated in transmission. Route: three major routes: contact (direct or indirect) droplet, and airborne. Host: Anyone with a compromised immune system. Chapter 16: 1. Know the terms of positional dyspnea. (pg. 321) Orthopnea: dyspnea triggered by reclining/supine position. Platypnea: dyspnea triggered by assuming the upright position Trepopnea: dyspnea that occurs when a patient with unilateral lung disease lies with the affected side (e.g., pneumonia, large pleural effusion) in the dependent (down) position. 2. Know characteristics of a cough and hemoptysis. (pg.322-323) Cough The effectiveness of a cough depends on (1) the ability to take a deep breath, (2) lung elastic recoil, (3) expiratory muscle strength, and (4) level of airway resistance. These include whether the cough is dry or loose, productive or nonproductive (of sputum), acute or chronic; occurs more frequently at particular times (i.e., day or night); and whether it is provoked by a particular position (e.g., supine). A chronic cough is one lasting 8 weeks or longer. Hemoptysis Frank hemoptysis is expectorant consisting primarily of blood. Massive hemoptysis is a medical emergency defined by coughing a variable volume of blood over a defined time period, commonly defined as more than 300 mL within 24 hours. Non-massive hemoptysis occurs in many conditions such as airway infections, pneumonia, lung cancer, tuberculosis, blunt or penetrating chest trauma, and pulmonary embolism. Hematemesis refers to blood vomited from the gastrointestinal tract that often occurs in patients with gastrointestinal disease. 3. Know abnormal breathing patterns. (Table 16.2 pg. 331) Apnea: means no respiration. Can be caused by respiratory arrest, narcotic overdose, and severe brain trauma. Agonal: Intermittent prolonged gasps. Caused by cardiac arrest. Kussmaul: It is increased rate and depth. It is caused by metabolic acidosis, diabetic ketoacidosis, and renal failure. Cheyne-stokes: respiratory rate and tidal volume increase in intensity, then decrease into apnea for several seconds. Caused by cerebral lesions, brainstem injury, severe stroke, and low cardiac input. Biot respirations: chaotic breathing with irregularity in rate and tidal volume which becomes agonal breathing. Caused by damage to medulla. Apneustic: Prolonged inspiratory pause at full inspiration that lasts 2-3 minutes. Caused by damage to lower pons. 4. Know Table 16.4: Application of Adventitious lung sounds. (pg.336) Wheeze: it is usually high pitched, and it can also be polyphonic or monophonic. This can be caused by airflow that is obstructed. Like asthma, bronchitis, and congestive heart failure. Stridor: It is high pitched, and monophonic sounds. This happens when the airflow is obstructed in the upper airway. Like croup, epiglottis, post-extubation swelling, and laryngeal edema. Course crackles: Intermittent crackling or bubbling sounds of short duration. Coarse is airflow through airway secretions. It can be caused by pneumonia and bronchitis. Fine crackles: This is heard on inspiration and depends on inspiratory effort. It can be caused by atelectasis, fibrosis, and pulmonary edema. 5. Know what pedal edema is and its characteristics. (pg.323) Pedal edema: heart failure often characterized by swelling in the lower extremities. Classic sign swollen ankles. Two subtypes of pedal edema Pitting edema: when finger pressure applied on a swollen extremity leaves an indentation mark on the skin. Weeping edema: occurs when the applied finger pressure causes a small fluid leak. 6. Know the normal breath sounds. (Table 16.3 pg.334) Vesicular:pitch is low. Intensity is soft. Located peripheral lung areas Bronchovesicular:pitch is moderate. Intensity is moderate. Located around upper part of sternum, between the scapulae Tracheal:Pitch is high. Intensity is loud. Location over the trachea 7. Know the four common heart sounds and what is happening. S1: represents closure of the AV valves S2: represents closure of the semilunar valves (aortic and pulmonary) S3: heard over the apex of the heart that, in adults, may signify CHF. S4: occurs later and may be a sign of heart disease. 8. Know the characteristics of infected or purulent sputum. (pg.322) Sputum refers to mucus expectorated from the mouth. Purulent: sputum containing pus. Suggests a bacterial infection. Purulent sputum appears thick, colored, and sticky. Fetid: sputum that is foul smelling. Mucoid: Clear, thick sputum commonly seen in patients with asthma. 9. Know the signs of abnormal sensorium. (Table16.6 pg. 326) Confused: Exhibits slight decrease of consciousness, has slow mental responses, has decreased or dulled perception, has incoherent thoughts. Delirious: Is easily agitated, is irritable, exhibits hallucinations Lethargic: Is sleepy, arouses easily, responds appropriately when aroused Obtunded: Awakens only with difficulty, responds appropriately when aroused Stuporous: Does not awaken completely, has decreased mental and physical activity, responds to pain and exhibits deep tendon reflexes, responds slowly to verbal stimuli Comatose: Is unconscious, does not respond to stimuli, does not move voluntarily, exhibits possible signs of upper motor neuron dysfunction, such as Babinski reflex or hyperreflexia, loses reflexes with deep or prolonged coma 10. Know what is associated with tripoding. (pg.325) This position gives a mechanical advantage to the accessory breathing muscles of the upper chest and neck. For example, patients with severe pulmonary hyperinflation tend to sit upright while bracing their elbows on a table. 11. Know what the presence of stridor indicates. (pg.335) Heard primarily over the larynx and trachea during inhalation. Loud, high-pitched sound associated with upper airway obstruction (i.e., larynx or trachea) and often heard without a stethoscope. It is more common in infants and children. Chapter 19: 1. Know how to interpret arterial blood gas results. PRACTICE ON ABG NINJA!! KNOW YOUR NORMAL VALUES! 2. Know the steps of the modified Allen test. (pg.371) Hold pressure on ulnar and radial arteries Have the patient pump their fist Release ulnar artery only. Hand should have color within 5-10 seconds. Return of color means positive collateral circulation No color returns mean negative and should try other hand. 3. Know the sites and angles for obtaining arterial blood gas samples. Radial at 45 degrees Dorsalis pedis at 45 degrees Brachial at 90 degrees Femoral at 90 degrees 4. Know what factors compromise the accuracy of pulse oximetry readings. Presence of HbCO Presence of high levels of metHb Presence of fetal hemoglobin Anemia (very low hematocrit, 10cm H2O, mean airway pressure greater than 20 cmH2O, and Hemodynamic instability. Frequent suctioning (more than 6 times a day) 2. Know how to correctly estimate the proper size of the suction catheter. (pg.750) To estimate quickly the proper size of suction catheter to use with a given tracheal tube, first multiply the tube's inner diameter by 2. Then use the next smallest size catheter. Example: 6mm endotracheal tube: 2x6=12 so next smallest size down is 10 F. It is always even. 3. Know where an ETT should be seen on x-ray after placement in relation to the carina. It should be 3-5 cm above the carina. 4. Know when and when not to place oropharyngeal/nasal pharyngeal airways, and proper placement. Oropharyngeal: are inserted into the mouth over the tongue. Use of oropharyngeal airways should be restricted to unconscious patients to avoid gagging and regurgitation. Nasopharyngeal: is most often placed in a patient who requires frequent nasotracheal suctioning. A nasopharyngeal airway also may be placed in a patient who was recently extubated after facial surgery. The nasopharyngeal airway helps to maintain the patency of the upper airway despite swelling. 5. Know what the Yankauer is mainly reserved for when suctioning patients. (pg.749) Secretions or fluids also can be removed from the oropharynx by using a rigid tonsillar or Yankauer suction tip. Used for upper airways (oropharynx). Clear secretions from mouth to throat. 6. Know what the LMA is, what is used for, its limitations, and when it is not indicated. (pg. 756) Laryngeal mask airway. Use of the LMA has two major limitations. 23 First, it cannot be used in a conscious or semi comatose patient because of stimulation of the gag reflex. Second, if ventilating pressures greater than 20 cm H2O are needed, gastric distension may occur. This device does not protect against aspiration should regurgitation occur. 7. Know airways are indicated for short- and long-term intubation. Pg. 755 table 37.1 Oral Intubation–short term for unconscious pts. Nasal intubation can be short and long term Tracheostomy- long term-surgically placed 8. Know what the stylet, obturator, cuff, and pilot balloons are for (ETT) and their purposes. Stylet: maintains the rigidity of the tube Obturator: maintains the rigidity of the cannula in a tracheostomy tube Cuff: inflation of the cuff seals off lower airway. Prevents aspiration or to provide positive pressure ventilation. Pilot Balloons: used to monitor cuff status and pressure. 9. Know the difference between the MacIntosh and Miller blades and how they are used in intubation. Macintosh Blade: is curved, and epiglottis is displaced indirectly. The tip of the blade is advanced into the vallecula. Miller Blade: is straight, and the epiglottis is displaced directly. The tip of the blade is advanced over its posterior surface. 10. Know the steps of endotracheal suctioning (preoxygenation, how long you should suction, when suction pressure is applied). (pg. 749-751) Two techniques for endotracheal suctioning open and closed. Open is a sterile technique and it requires you to disconnect patients from the ventilator. Often used if patient has a tracheostomy collar and not receiving mechanical ventilation. Closed uses a sterile, closed, in line suction, and does not require disconnecting from mechanical circuit. Steps of endotracheal suctioning Step1: assess patient for indications. PATIENT SHOULD NEVER BE SUCTIONED ACCORDING TO A PRESET SCHEDULE If suctioning is done without clinical indications can lead to unnecessary complications including hypoxemia, bronchospasm, mucosal irritation, and patient discomfort. Step2: assemble and check equipment. Always check suction pressure. BOX 37.1 has a list of the equipment needed. Most suction catheters for adults are 22 inches long. Diameter for adult 50% and for infants and small children diameter is 70% Step3: assess patient for hyperoxygenation. BEFORE SUCTIONING DELIVER 100% OXYGEN FOR 30 TO 60 SECONDS Step4: insert catheter. Step5: apply suction and clear catheter. Suction is applied while withdrawing the catheter. Total suction time should be kept to less than 15 seconds. If any untoward response occurs during suctioning, the catheter should be immediately removed, and the patient should be oxygenated. Step6: reoxygenate patient Step7: monitor patient and assess outcomes 11. Know steps of orotracheal intubation (how long for attempts, what hand is used, where should the ETT be for proper placement, etc.). (pg.760-765) Step1: assemble and check equipment. In general, a woman is intubated with a No. 7 or No. 7.5 orotracheal tube and a man is intubated with a No. 8.0 or No. 8.5 orotracheal tube. Step2: position patient. Place the patient in the sniff position. Step3: preoxygenate and ventilate patient. No more than 30 seconds should be devoted to any intubation attempt. If intubation fails, immediate ventilation and oxygenation of the patient for 3 to 5 minutes before the next attempt should occur. Step4: Insert Laryngoscope. Use the left hand to hold the laryngoscope and the right hand to open the mouth. The laryngoscope is inserted into the right side of the mouth and moved toward the center, displacing the tongue to the left. The tip of the blade is advanced along the curve of the tongue until the epiglottis is visualized. Step5: Visualize Glottis. Step6: Displace epiglottis Step7: Insert tube. Step8: assess tube position. Ideally, the tip of an ETT should be positioned in the trachea approximately 3 to 5 cm above the carina. To the tip of a properly positioned oral ETT in men is 21 to 23 cm. For women, this distance is approximately 2 cm less. Step9: stabilize tube and confirm placement. 12. Know how to assess tube position; where the tube should be placed, how to know when it’s not, what methods can be used to assess for correct placement. (pg.763) RT listens for equal and bilateral breath sounds as the patient is being ventilated. Air movement or gurgling sounds over the epigastrium indicate possible esophageal intubation. Chest wall should also be observed for adequate and equal chest expansion. The combination of decreased breath sounds and decreased chest wall movement on the left side may indicate right main stem intubation. 13. Know when a tracheostomy is indicated, and what to do if it is completely obstructed. (pg. 767) Tracheotomy is the preferred, primary route for overcoming upper airway obstruction or trauma and for patients with poor airway protective reflexes. Another indication for tracheotomy is the continuing need for an artificial airway after a prolonged period of oral or nasal intubation. Chapter 43: 1. Know the factors associated with causing atelectasis / the direct relationship between spontaneous respiratory rate and the degree of atelectasis present. (pg.937) Causes of atelectasis: Patients who have difficulty taking deep breaths without assistance include those with significant obesity, patients with neuromuscular disorders, patients under heavy sedation, and patients who have undergone upper abdominal or thoracic surgery. Diaphragmatic position and function are major contributors to atelectasis. 2. Know the difference between compression and gas absorption atelectasis. (pg.937) Compression atelectasis: occurs when the transthoracic pressure (the pressure difference between the body surface and the alveoli) exceeds the transalveolar pressure (PAL) (the pressure difference between the alveoli and pleural space). Common with general anesthesia or sedatives. Weakening or impairment of the diaphragm can also contribute to compression atelectasis. Gas absorption atelectasis: can occur either when there is a complete interruption of ventilation to a section of the lung or when there is a significant shift in ventilation/perfusion (V̇/Q̇). 3. Know the primary indication for lung expansion therapy. (pg.938) The goal of any lung expansion therapy should be to implement a plan that provides an effective strategy in the most efficient manner. For a patient with minimal risk of postoperative atelectasis, deep breathing exercises, frequent repositioning, and early ambulation are usually effective and can be done with minimal coaching and time from clinicians and without equipment. 5 For a patient at high risk for atelectasis (e.g., a patient undergoing upper abdominal surgery), IS is usually instituted. 4. Incentive Spirometry: hazards and complications, indications, contraindications, instructions, and monitoring. Indications: Presence of pulmonary atelectasis; upper abdominal surgery, thoracic surgery, surgery in patients w/ COPD. Presence of restrictive lung defect associated w/ quadriplegia or dysfunctional diaphragm. Ribcage injuries, patients that are on bed rest, asthma, pneumonia, cystic fibrosis. Contraindications: (box 43.2) Patient cannot be instructed or supervised to ensure appropriate use of device. Patient cooperation is absent, or patient is unable to understand or demonstrate proper use of device. Patient is unable to deep breathe effectively. Hazards and complications: (box 43.3) Acute respiratory alkalosis is the most common problem and occurs when the patient performs IS too rapidly or if the prescribed frequency of therapy is mismatched. 22 Dizziness and numbness around the mouth are the most frequently reported symptoms associated with respiratory alkalosis. Instructions and monitoring: (box43.5) Assessing the patient's performance is vital to ensuring achievement of goals. 5. Know the hazards, complications, and potential outcomes, and physiologic basis of HFNC. (pg.946) Hazards and complications: Common patient complaints when standard nasal cannulas are used at high flows are headache, drying of nasal mucosa, and nosebleeds. Nosocomial infection, Hypercarbia, Headache, drying of mouth/upper airway, impaction of secretions (associated with inadequately humidified gas mixture). Outcomes: (box43.16) Improved chest x-ray, improved breath sounds, Improved oxygenation, Improved patient comfort. Physiological basis: HFNC at elevated inspiratory flows provides a more stable FiO2. Another benefit from the enhanced flow is washing out the CO2 from the anatomic dead space. 6. Know the indications, hazards, and complications for CPAP use. (pg.944) Indications: suggested that CPAP should be used on a continuous basis until the patient recovers. Although evidence supports the use of CPAP therapy in the treating postoperative atelectasis, as with all mechanical techniques, the duration of beneficial effects appears limited. Hazards and Complications: (box 43.10) Most hazards and complications associated with CPAP are caused by either the increased pressure or the apparatus. An improperly fitted mask can also have detrimental effects on the success of CPAP. Too large a mask will increase the VD. 26 A mask that is too small would require being tightly strapped onto the patient's face. 7. Know the most common problem associated with lung expansion therapy and how to correct it. (pg.938) Staff time and equipment are the two major issues related to efficiency. The additional staff time and equipment are justified in this high-risk group. Positive pressure therapy requires significantly more staff time and equipment and is reserved for high-risk patients who cannot perform IS techniques. Chapter 44: 1. Know the four distinct phases of a normal cough and what is happening. (pg.953) Irritation: An abnormal stimulus provokes sensory fibers in the airways to send impulses to the medullary cough center in the brain. Inspiration: the cough center generates a reflex stimulation of the respiratory muscles to initiate a deep inspiration (the second phase). Compression: Reflex nerve impulses cause glottic closure and a forceful contraction of the expiratory muscles. Expulsion: The glottis opens, initiating the expulsion phase. 2. Know the complications that can arise when a patient has abnormal clearance and the diseases associated with abnormal clearance. (pg.953-954) That alters airway patency, mucociliary function, strength of the inspiratory or expiratory muscles, thickness of secretions, or effectiveness of the cough reflex can impair airway clearance leading to retention of secretions. Full obstruction: also known as mucous plugging. Can result in atelectasis which causes hypoxemia due to shunting. Partial obstruction: Restricts airflow, increasing work of breathing and possibly leading ̇ ̇ to air trapping, lung overdistension, and ventilation/perfusion (V /Q ) imbalances. Diseases associated with abnormal clearance: asthma, chronic bronchitis, and/or acute infections. Ciliary dyskinetic syndrome. Bronchiectasis. The most common conditions affecting the cough reflex are musculoskeletal and NMD, including muscular dystrophy, ALS, spinal muscular atrophy, MG, poliomyelitis, and cerebral palsy 3. Know general goals and indications for ACT. (pg.954) Primary goal assist patient to mobilize and remove retained secretions. Indications Acute: Copious secretions, inability to mobilize secretions, ineffective cough Chronic: Cystic fibrosis, Bronchiectasis, Ciliary dyskinetic syndromes, Chronic obstructive pulmonary disease patients with retained secretions. 4. Be familiar with directed cough, CPT, PEP therapy (expiratory pressures), FET, Manual assisted cough, Active cycle of breathing, autogenic drainage, Mechanical insufflation exsufflation, and high-frequency chest wall oscillation and exercise. Directed cough: (pg.960) deliberate maneuver that is taught, supervised, and monitored. It aims to assist in creating a productive cough in patients unable to clear secretions with an effective spontaneous cough. CPT: (pg.956) uses positioning, gravity, and mechanical energy to help mobilize secretions. This drainage is accomplished by simply placing the segmental bronchus to be drained in a more vertical position, permitting gravity to assist in the process. Positions generally are held for 3 to 15 minutes PEP Therapy: FET: (pg.961) consists of one or two forced expirations of middle to low lung volume without closure of the glottis, followed by a period of diaphragmatic breathing and relaxation. The technique is particularly useful in patients prone to airway collapse during normal coughing, such as patients with COPD, CF, or bronchiectasis Manual assisted cough: (pg.962) Manually assisted cough (quad—cough) is an external application of pressure to the thoracic cage or epigastric region, coordinated with a forced exhalation. Patients with neuromuscular conditions present a special challenge in cough management. These patients typically are unable to generate the forceful expulsion needed to move secretions toward the trachea. Active cycle of breathing: (pg.962) ACBT consists of repeated cycles of breathing control, thoracic expansion, and FET. ACBT is not useful with young children (