Exam 1
6:ekg
4:abg
A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate
way for the nurse to evaluate fluid balance?
a. Skin turgor
b. Daily weight
c. Urine output
d. Edema presence
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important
for the nurse to monitor while the patient is receiving this infusion?
a. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema
Following a thyroidectomy, a patient reports “a tingling feeling around my mouth.” Which assessment
should the nurse complete first?
a. Verify the serum potassium level.
b. Test for presence of Chvostek’s sign.
c. Observe for blood on the neck dressing.
d. Confirm a prescription for thyroid replacement.
The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place.
If the patient is unsuccessful in coughing up secretions, what action should the nurse take?
a. Encourage increased incentive spirometer use.
b. Encourage the patient to increase oral fluid intake.
c. Put on sterile gloves and use a sterile catheter to suction.
d. Preoxygenate the patient for 3 minutes before suctioning.
Which action should the nurse take first when a patient develops epistaxis?
a. Pack the affected nare tightly with an epistaxis balloon.
b. Apply squeezing pressure to the nostrils for 10 minutes.
c. Obtain silver nitrate that may be needed for cauterization.
d. Instill a vasoconstrictor medication into the affected nare.
A patient arrives in the emergency department with a possible nasal fracture after being hit by a
baseball. Which finding by the nurse is most important to report to the health care provider?
a. Clear nasal drainage
b. Report of nasal pain
c. Bilateral nose swelling and bruising
d. Inability to breathe through the nose
When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a
temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse
anticipate taking?
a. Teach the patient about the use of expectorants.
b. Use a swab to obtain a sample for a rapid strep antigen test.
c. Discuss the need to rinse the mouth out after using any inhalers.
d. Teach the patient to avoid nonsteroidal anti-inflammatory drugs (NSAIDs).
A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2)
of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?
a. Administration of 100% O2 by non-rebreather mask
b. Endotracheal intubation and positive pressure ventilation
c. Insertion of a mini-tracheostomy with frequent suctioning
The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has
wheezes and a weak cough effort. Which action should the nurse take?
a. Position the patient on the left side.
b. Assist the patient with staged coughing.
c. Place a humidifier in the patient’s room.
d. Schedule a 4-hour rest period for the patient.
A nurse is caring for a patient with right lower lobe pneumonia who is obese. Which position will provide
the best gas exchange?
a. On the left side
b. On the right side
c. In the tripod position
d. In the high-Fowler’s position
A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease
the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?
a. Elevate head of bed to 30 to 45 degrees.
b. Give enteral feedings at no more than 10 mL/hr.
c. Suction the endotracheal tube every 2 to 4 hours.
d. Limit the use of positive end-expiratory pressure.
A patient admitted with acute respiratory failure has ineffective airway clearance from thick secretions.
Which nursing intervention would specifically address this patient problem?
a. Encourage use of the incentive spirometer.
b. Offer the patient fluids at frequent intervals.
c. Teach the patient the importance of ambulation.
d. Titrate oxygen level to keep O2 saturation above 93%.
The nurse observes a new onset of agitation and confusion in a patient with chronic obstructive
pulmonary disease (COPD). Which action should the nurse take first?
a. Observe for facial symmetry.
b. Notify the health care provider.
c. Attempt to calm and reorient the patient.
d. Assess oxygenation using pulse oximetry.
The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is
from an acute myocardial infarction?
a. The pain increases with deep breathing.
b. The pain has lasted longer than 30 minutes.
c. The pain is relieved after the patient takes nitroglycerin.
d. The pain is reproducible when the patient raises the arms.
Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable
angina?
a. “The pain wakes me up at night.”
b. “The pain is level 3 to 5 (0 to 10 scale).”
c. “The pain has gotten worse over the last week.”
d. “The pain goes away after a nitroglycerin tablet.”
Which patient statement indicates that the nurse’s teaching about sublingual nitroglycerin (Nitrostat) has
been effective?
a. “I can expect nausea as a side effect of nitroglycerin.”
b. “I should only take nitroglycerin when I have chest pain.”
c. “Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart.”
d. “I will call an ambulance if I have pain after taking 3 nitroglycerin 5 minutes apart.”
A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute
myocardial infarction (AMI). Which laboratory test is most specific for the nurse to monitor in
determining whether the patient has had an AMI?
a. Myoglobin
b. Homocysteine
c. C-reactive protein
d. Cardiac-specific troponin
Heparin is ordered for a patient with a non–ST-segment-elevation myocardial infarction (NSTEMI). How
should the nurse explain the purpose of the heparin to the patient?
a. “Heparin enhances platelet aggregation at the plaque site.”
b. “Heparin decreases the size of the coronary artery plaque.”
c. “Heparin prevents the development of new clots in the coronary arteries.”
d. “Heparin dissolves clots that are blocking blood flow in the coronary arteries.”
Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with a
myocardial infarction (MI)?
a. Monitor heart rate.
b. Ask about chest pain.
c. Check blood pressure.
d. Observe for dysrhythmias.
Diltiazem (Cardizem) is prescribed for a patient with newly diagnosed Prinzmetal’s (variant) angina.
Which action of diltiazem is accurate for the nurse to include in the teaching plan?
a. Reduces heart palpitations.
b. Prevents coronary artery plaque.
c. Decreases coronary artery spasms.
d. Increases contractile force of the heart.
A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when
taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused
follow-up on this symptom?
a. Assess both feet for pedal edema.
b. Palpate the radial pulses bilaterally.
c. Auscultate for a pericardial friction rub.
d. Check the heart monitor for dysrhythmias.
A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about safely
resuming sexual intercourse. Which response by the nurse is best?
a. “Most patients are able to enjoy intercourse without any complications.”
b. “Sexual activity uses about as much energy as climbing two flights of stairs.”
c. “The doctor will provide sexual guidelines when your heart is strong enough.”
d. “Holding and cuddling are good ways to maintain intimacy after a heart attack.”
A patient who has recently started taking pravastatin (Pravachol) and niacin reports several symptoms to
the nurse. Which information is most important to communicate to the health care provider?
a. Generalized muscle aches and pains
b. Dizziness with rapid position changes
c. Nausea when taking the drugs before meals
d. Flushing and pruritus after taking the drugs
A patient had a non–ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing
intervention is appropriate for the registered nurse (RN) to delegate to an experienced licensed
practical/vocational nurse (LPN/VN)?
a. Reinforcement of teaching about the prescribed medications
b. Evaluation of the patient’s response to walking in the hallway
c. Completion of the referral form for a home health nurse follow-up
d. Education of the patient about the pathophysiology of heart disease
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of
acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best
indicator that the treatment has been effective?
a. Weight loss of 2 lb in 24 hours
b. Hourly urine output greater than 60 mL
c. Reduced dyspnea with the head of bed at 30 degrees
d. Patient denies experiencing chest pain or chest pressure
A patient who has chronic heart failure tells the nurse, “I was fine when I went to bed, but I woke up in
the middle of the night feeling like I was suffocating!” How should the nurse document this finding?
a. Orthopnea
b. Pulsus alternans
c. Paroxysmal nocturnal dyspnea
d. Acute bilateral pleural effusion
Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with
acute shortness of breath has heart failure?
a. Serum troponin
b. Arterial blood gases
c. B-type natriuretic peptide
d. 12-lead electrocardiogram
A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea
and a dry, hacking cough. Which action should the nurse take first?
a. Auscultate the abdomen.
b. Check the capillary refill.
c. Auscultate the breath sounds.
d. Ask about the patient’s allergies.
A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE)
inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-lb weight gain in the
past 3 days. What is the nurse’s priority action?
a. Teach the patient about restricting dietary sodium.
b. Assess the patient for manifestations of acute heart failure.
c. Ask the patient about the use of the prescribed medications.
d. Have the patient recall the dietary intake for the past 3 days.
After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient
should the nurse assess first?
a. A patient who reported dizziness after receiving the first dose of captopril.
b. A patient who has new-onset confusion and restlessness and cool, clammy skin.
c. A patient who is receiving oxygen and has crackles bilaterally in the lung bases.
d. A patient who is receiving IV nesiritide (Natrecor), with a blood pressure of 100/62.
What should the nurse measure to determine whether there is a delay in impulse conduction through
the patient’s ventricles?
a. P wave
b. Q wave
c. PR interval
d. QRS complex
The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which
method will be fastest to use?
a. Count the number of large squares in the R-R interval and divide by 300.
b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes.
c. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.
d. Calculate the number of small squares between one QRS complex and the next and divide into 1500.
A patient has a junctional escape rhythm on the monitor. What heart rate should the nurse expect the
patient to have?
a. 15 to 20
b. 20 to 40
c. 40 to 60
d. 60 to 100
A patient has a sinus rhythm and a heart rate of 72 beats/min. The nurse determines that the PR interval
is 0.24 seconds. What action should the nurse take?
a. Notify the health care provider immediately.
b. Document the finding and monitor the patient.
c. Give atropine per agency dysrhythmia protocol.
d. Prepare the patient for temporary pacemaker insertion.
A patient who was admitted with a myocardial infarction has a 45-second episode of ventricular
tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the
nurse take next?
a. Immediately notify the health care provider.
b. Document the rhythm and continue to monitor the patient.
c. Prepare for synchronized cardioversion per agency protocol.
d. Prepare to give IV amiodarone per agency dysrhythmia protocol.
After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular
(AV) block, which finding indicates that the drug has been effective?
a. Increase in the patient’s heart rate
b. Increase in strength of peripheral pulses
c. Decrease in premature atrial contractions
d. Decrease in premature ventricular contractions
A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to
drug therapy for several days. What topic should the nurse plan to include in patient teaching?
a. Anticoagulant therapy
b. Permanent pacemakers
c. Emergency cardioversion
A patient on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain.
Which action that is included in the agency dysrhythmia protocol should the nurse do first?
a. Obtain a 12-lead electrocardiogram (ECG).
b. Notify the health care provider of the change in rhythm.
c. Give supplemental O2 at 2 to 3 L/min via nasal cannula.
d. Assess the patient’s blood pressure and discomfort level.
A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132.
What action should the nurse take next?
a. Perform synchronized cardioversion.
b. Start cardiopulmonary resuscitation (CPR).
c. Give atropine per agency dysrhythmia protocol.
d. Apply supplemental O2 via non-rebreather mask.
Which action will the nurse include in the plan of care for a patient who was admitted with syncopal
episodes of unknown origin?
a. Explain the association between dysrhythmias and syncope.
b. Instruct the patient to call for assistance before getting out of bed.
c. Teach the patient about the need to avoid caffeine and other stimulants.
d. Tell the patient about the benefits of implantable cardioverter-defibrillators.
nr 341 syllabus
nr 341 exam 1 chamberlain
nr 341 proctored exam
nr 341 quiz 5
nr 341 exam 1 study guide
nr 341 exam 2
chamberlain complex exam 2
nr 341 quiz 4
– prevents code
– s/s of septic shock
– have before admission
– NO SLOW CODES
– right to say no
– based on the needs of the patient
– hospital will never restrict visitation
perfusion and oxygenation until organ transplant
– decreased pH
– increased CO2
– decreased PaO2
– sedate
– paralyze
– auscultate
– chest xray
– fall and rise bilateral
– CO2 detector – gold is good
– prone (maintain airway)
– elevate HOB 30-45 degrees
What should you do after 7 days on a Ventilator?
– DNR
– take them off ventilator to die
– COMFORT IS KEY, NO PAIN (benzos, pain meds)
American Association of Critical Care Nurses: Focus of the Group
– assists NURSES to attain knowledge and influence
– healthy work environment initiative
Highest setting you can put a Nasal Cannula?
Patient is on 90% Fi02 (10L), Respiratory Distress…What do I do?
– respiratory depression
– respiratory acidosis
– hypoventilation
– respiratory alkalosis
– hyperventilation
– tingling, numbness in fingers (decreased perfusion)
What is a sign of decreased Perfusion?
– PaO2 >60 and FiO2 <.4
– PEEP <5-8 cm
– PaO2/FiO2 should be 150-200
Vented patient is Asystole, don’t know if he has DNR?
– biting the tube
– mucus plug
– kinked tube
if you can’t figure it out, bag patient and call an RT
Prepare you patient for weaning
tell patient breathing will be hard
– RR increases
– HR increases
– O2 decreases
– low hemoglobins will not be successful
Patient is Tachy (150), hypotensive, signs of shock, heart failure…
– vagel maneuver first
– synchronized cardioversion
Patient is brady (35), hypotensive, diaphoresis, dizzy and SOB
– agitation and sedation
– tells you if you need a neuro block
– 4 needs a neuro block
– 2 is typical
– restless and irritable (WHY)
– typically not adequately oxygenated
– only when indicated
– hyperoxygenate before
What is common to see with weaning?
– tachy
– agitated
– using accessory muscles
Patient w/ tachypnea, restlessness, getting worse, hypoxia…
What is the first thing to do when patient alarms go off?
100 compressions – 2 minutes – check pulse
– start meds
– epi (1:10,000, 1 mg)
Heparin: preventive/ Therapeutic/ use
Enoxaparin: preventive/ therapeutic/ use
Preventive:
-SC 30 to 40 mg/ daily
Therapeutic:
-SC
-mg/Kg
-1.5 mg/ Kg/ daily or 1 mg BID
Use:
-PPI
-H2 blockers
*PPI increase RF for C-diff*
-regional anesthesia/ nonopioid adjuncts
-analgesia-based sedation tech. w/ fentanyl
-Daily linked SAT/ SBT
-multidisciplinary coordination of care
-faster liberation from mech. vent.
D: Delirium monitoring & management
F: family engagement & empowerment
-psychotropic
-benzo
-opioids
also caused by inadequate pain control
-anti-cholinergic
-dry eyes
-dry mucus membranes
-EPS (Cogentin)
-drowsiness
Familiarization
-person/ place/ time
-current events
-items
-less environmental noise (TV/ machines)
-CAM
– (-)1 to (-) 2
-usually titration orders
-NO benzo’s
-Admin Haldol (anti-cholinergic)
dry mouth
increase QT
EPS: admin cogentin
Last result for 4+ RASS (last resort)
Paralytics
-vecuronium
-succinycholine
sedation/ analgesia/ amnesia
Continuous sedation monitored by:
During paralytic use analgesics for pain monitored by:
-no monitor
-constant sedation and pain meds admin
RSI (Rapid Sequence Intubation)
Sedative
-Ketamine 1-2mg/kg
-Propofol 2mg/kg
–Etomidate 0.3mg/kg
-Midazolam 1mg SIVP
Neuromuscular Blocker(paralytic)
-Vocuronium (ROC) 1mg/kg Adult – 100mg (Give before sedative)
-Succinylcholine 1mg/kg Adult 100mg (Give after sedative)
Nursing responsibilites:
-no more than 30 secs during attempt
-ventilate for 3-5 mins before reattempt
-Equip gather
-hyper O2
-sedate (etomidate or precedex)
-paralytic
-tube placement & check w/ chest expansion bilateral and auscultation
-CO2 detector- Gold is good
-Chest x-ray is still the GOLD standard
checklist for chemical paralysis
class: general anesthetic
Indication: anesthesia, induction, sedation
Action: hypnotic, produces amnesia
Nursing Considerations:
– use cautiously with CVD, lipid disorder, increased ICP
– can cause apnea, bradycardia, *hypotension*
– burning and pain at insertion site
– *can turn urine green*
– assess respiratory status and hemodynamics
– maintain patent airway
– assess level of sedation
-5 to 10 mcg/kg/min
-use when ventilated or qualified MD or nurse anesthetist
-*do not use if allergic to egg/soybean*
-anti-cholinergic
-MOA
-decrease cerebral cortex function
A/E:
-*extend QT wave*
*ADD MORE*
critical care pain observation tool
-scale of 0 thru 8 used to quantify non-verbal pain
-observe minimum of :01
-greater than 3 indicates pain.
1. Facial: Grimacing-2
2. Body movements: restelessness/ agitation-2
3a. Ventilator compliance (intubated):fighting vent-2
3b. Vocalization (extubated):cyring out/sobbing-2
4. Muscle tension:very tense/ rigid-2
advanced directive (living will)
Two weeks max, then tracheostomy
-ease
-swelling
-less infection
-no gag reflex
-protein requirements increase
-admin w/in 24 hours of admittance
-area is reddened
-increase WBC
cannot infiltrate on central line
-if stopped, hang D-10 (dextrose)
-flora
-peristalsis
-mucous layer
If Pt does not have working gut for enteral nutrition
-can cause breakdown and secondary infections
-decrease immunity of Pt
-30 degrees or higher for aspiration
*if hypotensive 10 degrees or less*
How to test for nutrition efficiency
pH 7.35-7.45
PaCO2 35-45
HCO3 22-26
PaO2 80-100
measure the R-R interval, count the number of big boxes between & divide into 300
count number of small boxes between a R-R and divide into 1500 (one min =1500 small boxes).
Count the number of QRS complexes in a 6 second strip and multiply by 10
atrial depolarization (contraction)
-Sinus rhythm
-not present= not sinus
extended PR interval
-1st degree block
K+ (potassium)
-increased T-wave = increase of K+
-calm/ cooperative
-pH > 7.3
-FiO2 < 0.60
-hemodynamically stable
Termination SBT/ not tolerating
PVC (Premature Ventricular Contraction)
-every other beat PVC
-feel radial pulse and compare to apical pulse to check perfusion
-every two beats, then PVC
-same as bigeminy
-PVCs land on T wave
-can send Pt into Vtach/ torsade’s de point/ v-fib
-muscle cell is depolarized so cannot respond to another stimulus
PR interval >0.20
e/t rheumatic feer, digoxin, beta blocker, inferior MI, Increase vagal tone
V-fib/ unstable- pulseless V-tach algorithm/ pulseless torsades
Loos like VT but twists around baseline (changes axis and amp)
-deflect up and downwards
Torsades des pointes associations
-wide and bizarre
– > 0.12 secs
-MI
-untreated VT
-HF
-electric shock
Tx: ACLS
Vfib= Dfib
rapid, random, ineffective contractions of the atrium
-pulseless
-electrical activity on ECG
-poor prognosis
-clinically dead
H & T’s
-no electrical or mechanical activity
-no CO
-no BP
-no Pulse
-“flat line”
Tx: no D-fib
-CPR and EPI/ vaso
-turn Pt
-mucolytic
-resp. therapy vest
-correct antibiotic administration
–no use of saline bullets
-trauma
-decreased O2 stats => d.rythmias=> PVC
-secondary infection
-> 48 hours on vent
-sputum
-new infltrates on x-ray
-new fever
Early signs of respiratory distress
-restless
-agitation
-increase RR (tachypnea)
-increase HR (tachycardia)
Acid base relationship with Resp. distress
-starts as Resp. alk
-ends with Resp. acidosis
-cyanosis
-mottling
-bradypnea (decreased RR)
-low PaO2
-high CO2
-can’t ventilate themselves (breathe on own)
-PaO2 < or = 60mmHg on FiO2 > 50%
-PaCO2 > or = 50mmHg w/ pH of 7.25 or less
Ventilator Alarms
-Low Pressure
-High Pressure
-apnea
If you can’t fix ventilator alarm & problem quickly, what do you do?
-BVM/ AMBU-bag
-breathes for them, call for help
-cannot leave room until fixed
Tx of hyperventilation on AC mode of ventilation
APRV (airway pressure release ventilation)
provides 2 levels of CPAP (inspiration/ expiration)
*mode of ventilation along with spontaneous ventilation to promote lung recruitment of collapsed & poorly ventilated alveoli
*CPAP is released periodically for a brief period
*short realease along with spontaneous breathing promote CO2 elimination
*release time is short to prevent peak exp flow from returning to a zero baseline
-ARDS Pt
-best of AC/PC
ARDS (acute respiratory distress syndrome)
-clot formed and thrown to lung => pulmonary HTN in R. vent.
-hemoptosis
-agitation
-sob
-increased HR
-decreased BP (or unaffected)
examples of lipid tubing and how long are they good for before changing out?
-0.5 mg IV q 3-5 min
-max dose 3 mg
-symptomatic bradycardia
-asystole
-pupils
-may not work if the QRS is wide (ventricle)
-asystole
-vtach(pulseless)
-v.fib
-PEA
-symptomatic bradycardia (IV infusion)
-decreased excitability
-prolongs action potential to terminate VT or VF
-dead v.tach
-v.fib
-fast v.tach
-a.fib
-a.flutter
Amiodarone nursing implications
-central line
-in-line filter
-long half-life
-cytochrome p450 enzyme
-monitor liver function
-lung toxicity
-neuro toxicity
-thyroid toxicity
-wear sunscreen/ sunglasses
-MOA: slows conduction of AV node and interrupts AV nodal reentry circuits
-Admin: A/C IV site, 6 mg pushed rapidly followed by 20 mL NS, can repeat with 12mg
-Tx: fast atrial rhythms, slow down, may convert
-nursing implications: Pt may asystole for 15 seconds, educate Pt, chest pain, headache, if asthma: may complain of chest tightness/ bronchospasm
-hypotension
-symptomatic bradycardia
-occasionally for CO (not 1st line drug)
-tachycardia
-increased dysrhythmias
-admin central line: extravasation => necrosis
-pulse: yes
-asymptomatic no Sx
150-100mg IVBolus/ 10 mins, then infusion of amiodorone
Cardiac dysrhythmias: unstable manifestations
-hypotension
-pale/ cool skin
-weakness
-angina
-dizziness/ syncope
-confusion/ disorientation
-SOB
Rapid response team call criteria
RRT
-CCRN
-RT
-physician (critical or hospitalist)
the amount of energy needed to breath.
compliance lungs
define?
decrease this?
things that block the flow of gas like bronchoconstriction, edema, mucous build up
poisition for airway control:
normal way?
neck injury?
OPA: prevents tongue from falling and blocking airway
NPO: you can suction through this
for patients with decrease LOC and need an airway
patient has nasal obstruction or epistaxis
how to confirm placement ETT, OPA, NPO?
indication for ventilation:
hypoxemia?
hypercapnia?
progressive deterioration?
amount of air inhaled or exhaled with each breath under resting conditions
endotracheal intubation
define/preffered route?
used to do what?
patient needs artifical airway for longer than 10-14 days than they need what?
tracheostomy may be created to avoid mucosal and vocal cord damage due to ETT placement to long.
what must be by patient bed side at all times when they have ETT or tacheostomy?
reduce leak for ETT regarding the cuff?
is a patient able to talk with ETT?
no due to it goes into vocal cords and a proper seal would make it so they cant talk
ETT how much to inflate balloon?
nursing care for making sure ETT secure each shift?
A procedure performed under sterile conditions.
what to avoid when doing endotracheal suction?
Avoid normal saline installation into the tube
normal respiratory pressure?
positive pressure?
FiO2
define?
normal in air we breath?
tidal volume:
define?
normal amount?
on ventilator adjust it to what?
ventilator setting four big ones?
-Fio2
-Tidal Volume
-Resp Rate
-I:E Ration
-PEEP
ETCO2 monitoring
-monitors what?
normal?
used when?
-alveolar CO2 as assess trends in patients ventilation status
30-43mm HG
-ETT, PCA, brain injury
Ventilator alarms:
KEY POINT WITH ALARMS?
three types?
complications of mechanical ventilation: ETT malposition
define?
s/s?
how to check for this?
complications of mechanical ventilation: unplanned Extubation
risk factors for this?
agitated, improper use of restraints
complications of mechanical ventilation: laryngeal and tracheal injury:
how does this occur?
complications of mechanical ventilation: mucosal damage:
occurs when?
tx?
tight tape, ETT pressing down on lip or tongue
-resposition tube and tape q24hours, assess skin
complications of mechanical ventilation: barotrauma:
what occurs during this?
s/s
tx?
complications of mechanical ventilation: oxygen toxicity
occurs when?
s/s?
ventilator associated infections:
big problem?
causes?
prevention?
complications of mechanical ventilation: stress ulcers/GI bleed
prevention?
-start tube feeding ASAP
-use H2 receptor blockers or PPI
-position changes
core ventilator bundle for prevention
questions to ask when determining if ready to wean off ventilator?
after ventilator wean off to what?
when to stop the weaning process from a ventilator ?
-increase HR
-hypoxic
-unstable VS
-Restless
-Anxious
how to wean off ventilator for end of life care:
remove ETT and stop machine, provide comfort care
-Stridor
-Hoarseness
-Change in Vital signs
-Low oxygen satuation
noninvasive positive pressure ventilation this would be like CPAP or BIPAP
patient needs to do what after extubation?
cough, deep breath to clear secretion and use incentive spirometer
what can you use extubation period to prevent doing another ETT?
NPPV: noninvasive positive pressure ventilation this would be like CPAP or BIPAP
after extubation what most be done before having food?
swallow study before food or drinks
Noninvasive Positive-Pressure Ventilation (NPPV)
Positive pressure ventilation PPV without artificial airway: includes?
ØTight seal
ØIntact respiratory drive
ØAble to protect airway
-skin assessment around the mask
-FIO2 and pressure setting proper setting
tracheostomy:
indication?
types?
how much air to go in pilate balloon?
-Fistula formation
-Trachea necrosis
-aspiration
-airway obstruction
-bleeding
-trachea stenosis
can anything besides air go into tracheostomy?
NO and to prevent this cover if needed in public but not to tight due to breathing through this
goes in after hole is made to maintain size, than insert tube and remove this once tube is placed.
tracheostomy initial trach tie?
don’t remove for 24 hour due to is could close up
chest tube:
define?
three chambers in the chest tube machine?
Noncardiogenic pulmonary edema
tx in ARDS prevent what complications?
-Ventilation pneumonia
-DVT
-stress ulcers
-nutrition issues
-tube placement confirm when moving
Status asthmaticus:
define?
nursing actions?
full disclosure to patient or legal resp. possible risk and benefits of tx. On the doctor.
has the written wishes for the patients. Along with organ donations information should be in here.
Withholding life sustaining treatment: ?
withholding stopping the ventilator use, comfort measures are still done for the patient
client and family has right to when they want it or not. AMA support family from stopping CPR.
pt makes their own decisions. If impaired by sedation than find next of Kin
end of life care decisions must be made by who?
next of kin or power of attorney
behavioral pain scale:
used when?
includes what?
scoring?
regional anesthesia:
two types?
epidural anesthesia:
how its given?
-catheter is left in place so more doses can be given PRN
regional anesthesia:
desired effects?
vasodilation, analgesia, better surgical outcomes
spinal vs epidural anesthesia:
which one more rapid?
duration?
regional anesthesia: spinal and epidural:
complication?
regional anesthesia: spinal and epidural:
how do you know if dose to high?
patient may feeling tingling in arms and hands along with inadequate breathing and apnea
General anesthesia drugs:
Barbiturates: Methohexital
advantage:?
adverse effects?
nursing action?
-short outpatient procedures because rapid onset and metabolic clearance. but also used for induction and maintenance of anesthesia
lipid base so gives it creamy white color
-low HR, dysrhythmias, low BP, apnea, transient phlebitis, hypertriglyceridemia “hyperlipidemia”
-monitor for HR, BP, triglyceride q24hours when sedated >24hours
-RR depression, low BP, myocardial depression, seizure
Isoflurane and Desflurane
sevoflurane
General anesthesia drugs:
inhalation agents: gaseous agents like nitrous oxide:
MOA?
used when?
with o2 to prevent hypoxemia
-avoid patient with strong hx of N/V and bone marrow depression
analgesic and amnesic “loss of memory”
-hallucinations and nightmare, ICP, IOP, increase HR/BP
benzo
adjuncts to general anesthesia:
opioids: fentanyl, morphine, methadone
MOA?
side effects?
adjuncts to general anesthesia:
nondepolarizing agents: Pancuronium, rocuronium
reverse of these drug?
anticholinesterase- neostigmin, pyridostigmine
adjuncts to general anesthesia: antiemetics
examples?
side effects?
adjuncts to general anesthesia: Dexmedetomidine:
used when?
side effects?
adjuncts to general anesthesia: dexamethasone:
used when?
counteracts emetic effects of inhalation agents and opioids
hospice define?
main goal?
includes?
final phase of patients illness when death is imminent
noisy wet sounding RR
caused by mouth breathing and build up of mucous in airway
alternative periods of apnea and deap rapid breathing
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
resp center location?
regulated by what?
compliance:
define?
decrease when?
increased when?
resistance in Resp system:
define?
increase when?
how can compliance and resistance be measured?
compensation occurs rapidly.
a few days to occur
PaCO2:
considered what?
connection to patient?
an acid so if it is elevated that means body has more acid. If lower than body has less acid.
reflection of how well the patient is ventilating.
hyperventilation- PaCo2 is low due to breathing fast greater amount of co2 leaving the body
hypoventilation: paCo2 is high due to patient not breathing off co2 and holding more inside
a base so if elevated body has more base and if lower it has less of a base
pH: 7.35-7.45
PaCO2: 35-45
Hco3: 22-26
PaO2: 80-100
Ph: 7.30
PaCO2: 50
HCO3: 27
PaO2: 60
?
Ph: 7.36
PaCO2: 31
HCO3: 18
PaO2: 85
?
The answer is fully compensated metabolic acidosis. The pH is 7.36 which is normal but leans towards the acidotic side. The PaCO2 is low. A low PaCO2 is alkalosis which does not match the pH. The PaO2 is normal which indicates that it is not a respiratory problem. The HCO3 is low which is acidotic. Therefore it is a metabolic acidosis.
hypoxia:?
hypoxemia?
early signs of poor oxygenation?
late signs?
oxygen
ventilation
prevention of complication
nasal cannula:
amount of oxygen?
nurse considerations?
1L to 6L/min (24-44% FiO2)
-use water soluble gel to prevent dry nares
-humidification for 4L or more
simple face mask:
amount of oxygen?
nursing consideration?
venturi mask:
amount of o2?
nursing consideration?
partial non rebreathing mask:
amount of oxygen?
nursing consideration
non rebreather mask
amount of o2?
nursing consideration
Aerosol and Humidity Delivery Systems
oxygen amount?
for what type of patients?
Aerosol and Humidity Delivery Systems
type for trach patient?
type for ETT patient?
key point?
Trach collar
T- piece
-dont cover the T piece, and make sure nothing pulling it
Manual Resuscitation Bag (aka ambu bag)
amount of o2?
oxygen toxicity:
define?
s/s?
nursing action?
results from high concentration of oxygen (above 50%), long duration of oxygen therapy (24-48hours) and the degree of lung disease
-nonproductive cough
-subternal pain
-nasal stuffiness
-N/V, fatigue, H/A
-lower o2 amount to maintain normal spo2, ABG monitor. use CPAP or biPAP to help decrease amount of oxygen needed, PEEP if on mechanical ventilator to decrease need of oxygen
acute respiratory failure:
define?
hypercapnic respiratory failure
hypoxemic respiratory failure
define?
causes?
respiratory failure:
classifed by what?
levels for each one?
four causes for hypoxemia and hypoxemia resp failure?
two most common?
V/Q mismatch
define?
increased examples?
Alveolar hypoventilation
define?
examples
when amount of o2 in arterial blood is low
when Pao2 falls and can lead to hypoxemia