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Complex Care Exam 1

Terms in this set (114)

what is the most common reason for inserting a chest tube
pneumothorax
in what position should you place your pt for chest tube insertion
semi fowlers
try to widen intercostal space by raising arm
at what level is suction control generally set
-20 cm water pressure
what does bubbling in the water seal chamber represent
air leak somewhere
tidaling with inspiration and expiration
describe the desired pattern of bubbling in the suction control chamber
gentle bubble
bubbling good in suction control chamber
how can you locate the source of an air leak in a chest drainage system
assess from pt and follow tube to drainage system looking for leak
milking or stripping the chest tube will cause the intrathoracic pressure to increase or decrease
increase
when is it appropriate to milk the chest tube
to remove a clot
milking is NEVER first intervention
if a pt receiving mechanical ventilation has an air leak from the lung, during which part of the respiratory cycle would bubbling be evident
inhalation/inspiration
the rhythmic movement of the water level in the water seal chamber that follows pressure changes in the chest with respirations is known as
tidaling
fluctuations
what should you do if the chest tube becomes disconnected from the chest drainage unit of if the plastic unit breaks
liquid seal with sterile water
submerge end into 1 inch of sterile water
clamp as close to insertion site as you can
what should you do if the chest tube becomes dislodged
cover site with Vaseline gauze/ dry dressing
contact physician
if air leak, cover 3 sides with tape
why can blood drained from the chest through a chest tube be used for autotransfusion
blood that comes in contact with pericardium/pleural will not clot
it is DEFIBRINOGENATED blood
what determines when the chest tube can be removed
clear breath sounds
X ray shows re expansion
drainage over 24 hours is less than 100 mL
serous drainage
stats are normal
what should you tell the pt to do as the chest tube is removed
take a deep breath and hold it
what is hypoxia
inadequate TISSUE oxygen level
what is hypoxemia
inadequate arterial BLOOD oxygen level (<90%)
identify 4 types of hypoxemia
hypoxemic (most common)
anemic
ischemic
histoxic
what is hypoxemic hypoxemia
most common type of hypoxemia
not enough available oxygen or inhalation of oxygen
what is anemic hypoxemia
not enough hemoglobin to carry oxygen to tissues
what is ischemic hypoxemia
not enough delivery of oxygen to tissues
what is histoxic hypoxemia
localized tissue effect
rare
occurs secondary to acute and severe localized inflammatory response
what are the primary purposes of oxygen therapy
to reserve side effects of hypoxemia
to maintain consistent PO2 level of at least 50-60
performed before, during, and after tracheal suctioning
what is a low-flow oxygen system
does not provide the total inspired gas as client is still breathing some room air
only adequate if tidal volume is adequate
respers not too rapid
respiration pattern is steady/stable
O2 concentration is 21% to 90%
what are some examples of low-flow oxygen systems
NC
simple mask
rebreather
non rebreather
transtracheal catheter
what is the rational for giving low-flow oxygen to a pt with COPD or Chronic CO2 retention
do not want to knock out their "natural low-flow" drive to breathe
chemoreceptors no longer sensitive to increase in PaCO2 levels
drop in O2 is what keeps pt breathing
what is considered low flow O2
2-4 L
what is normal PCO2 level
80-100
what is a high-flow oxygen system
high pressures of oxygen delivered
some can do breathing for pt
what are some examples of high-flow oxygen systems
venturi mask
aerosol
trach collar
T piece
hyperbaric chamber
which type of oxygen device has the capability of delivering between 80% to 90% FiO2
non rebreather mask
give an example of a pt condition when a non rebreather mask would be needed
often used for end of life pt to prevent struggle/air hunger
used for severe hypoxemic hypoxia pts who will later need intubation
side effect of O2 therapy in CO2 retainers
respiratory depression
what is microatelectasis
collapse of small alveoli and capillaries within lung tissue due to increases intrathoracic pressure (barotrauma)
what can cause microatelectasis
pt on mechanical ventilator
what can help pt with microatelectasis
pursed lip breathing helps keep alveoli open
why may microatelectasis be a side effect of oxygen therapy
occurs secondary to conditions necessitating high FiO2 levels (over 50%) delivered under high pressure
what is retrolental fibroplasia
abnormal proliferation of fibrous tissue immediately behind the lens of the eye, leading to blindness
it affected many premature babies in the 1950s, owing to the excessive administration of oxygen.
how does oxygen therapy lead to retrolental fibroplasia in newborns
oxygen is a potent vasoconstrictor
in newborns, high levels of O2 can cause retinal vessels to severely constrict such that O2 cannot be adequately delivered to the retinas, resulting in blindness
first identified in the 1950s with onset of incubators and delivery of 100% O2 to premature newborns
O2 toxicity effects on central
seizures
O2 toxicity effects on muscular
twitching
O2 toxicity effects on respiratory
jerky breathing
irritation
coughing
pain
SOB
tracheobronchitis
ARDS
hazards of O2
infection
fire
what is Maslow's hierarchy of pt needs
physical
security
social
ego
self actualization
Maslow's hierarchy of needs
physical
(ABCs)
air
water
food
exercise
rest
freedom from disease and disabilities
Maslow's hierarchy of needs
security
safety
shelter
stability
Maslow's hierarchy of needs
social
being loved
feelings of belonging
inclusion
Maslow's hierarchy of needs
ego
self esteem
power
recognition
prestige
met through achievement, recognition, promotions and bonuses
Maslow's hierarchy of needs
self actualization
development
creativity
met though autonomy and achievement
physiologic needs consist of
airway
cardiovascular
general
mobility
skin integrity
nutrition
effects of malnutrition
problems with wound healing and prevention of infection
low albumin 3.5-5 (need albumin lab when on tube feeding)
decreased immune responses
low BUN 10-20 (blood urea nitrogen)
negative nitrogen balance
at risk for multiple organ failure
assessment of altered nutrition
less than body requirements
height and weight (fluid volume)
s/s of nutritional alterations (poor skin turgor/sunken eyes)
lab data (altered CBC, decreased albumin, increased BUN/creatinine)
types of administration of nutritional support
oral supplementation
enteral tube feedings
total parenteral nutrition
oral supplementation
high calorie supplements
enteral tube feedings
through gut
NG, PEG, J tube
pts unable to eat orally but still have functional GI tract
total parenteral nutrition (TPN)
through central vein
highly concentrated glucose solution delivered vie central or peripheral IV route
non functioning GI tract
nursing responsibilities with TPN
monitoring serum/urine glucose
monitoring I&Os
monitoring site for infection
change bag and tubing every 24 hours
maintaining correct solution and rate of infusion
complications of TPN
hyperglycemia/hypoglycemia
infection (local or systemic)
pneumothorax
air emboli
goals of nutritional support
replenish depleted protein store
promote wound healing
restore client to baseline
special needs/issues for ICU
family-focused care
pain management/issues
manage/prevent sleep disturbances
prevent infection
safety
(nursing interventions for client receiving O2 therapy)
maintain PaO2 of at least ____ to ____ to maintain adequate SaO2 of at least ___% to ___%
maintain PaO2 of at least 50 to 60 to maintain adequate SaO2 of at least 88% to 90%
(nursing interventions for client receiving O2 therapy)
how often do you measure exact concentration of inspired O2 with O2 analyzer
every 8 hours
(nursing interventions for client receiving O2 therapy)
how often do you change a NC
every 24 hours
what is the #1 medical diagnosis in the ICU
acute respiratory failure
what is acute respiratory failure
failure of:
delivery of O2 into arterial blood
removal of CO2 from mixed venous blood
acute respiratory failure
type 1
hypoxemia WITHOUT hypercapnia
actue respiratory failure
type 2
hypoxemia WITH hypercapnia
what is the cause of acute respiratory failure
any disease/condition resulting in insufficient gas exchange
clinical manifestations of acute respiratory failure
dyspnea
s/s of hypoxemia
increased work of breathing with use of accessory muscles
decreased breath sounds
adventitious breath sounds (crackles, gurgles, wheezes)
possible pleural friction rub
medical interventions for acute respiratory failure
supplemental O2
TCBD
turning
suctioning
semi fowlers
consider prone position
medication intervention for acute respiratory failure
bronchodilators (aminophylline, theodur, alupent)
steroids (solu-medrol)
antibiotics
purpose of thoracic surgery
biopsy/remove tumor
rest abscesses or emphysemas
pleurodesis for repeated pneumothorax
types of thoracic surgery
lobectomy
pneumonectomy
what is a lobectomy
entire lobe removed
performed when tumor is isolated to one love and lummox nodes are free from metastasis
what is a pneumonectomy
entire ling removed
performed when tumor involves lobar and hilar lymph nodes or when lobectomy would not remove all of tumor
post op nursing care for thoracic surgery
support ventilation and gas exchange
prevention of atelectasis (proper pt positioning, IS & TCDB, early ambulation)
pain management
monitor for complications (acute respiratory distress, hemorrhage)
what is thoracic trauma
trauma to chest and or lungs resulting in interference of ventilation and gas exchange
presence of air and or blood in pleural cavity, especially under pressure, results in impaired ventilation, obstructed venous return, and decreased cardiac output
physical assessment of thoracic trauma
inspection
permission
palpation
auscultation
diagnostic procedures of thoracic trauma
X rays
labs
on going assessment of thoracic trauma
airway
respiratory effort
ABGs
urinary output
what kind of O2 supplementation will be provided with pt with thoracic trauma
high FiO2 with non-rebreather (high level of O2)
what to anticipate with the heart of pt with thoracic trauma
myocardial compromise (look for dysrhythmias)
shock (cardiogenic or hypovolemic)
what is the best way for nurse to ascertain improvement or stabilization versus deterioration
auscultate frequently!
normal arterial pO2
pO2
80 to 100 mmHg
normal arterial pH
pH
7.35 to 7.45
normal arterial pCO2 (acid)
pCO2
35 to 45 mmHg
normal arterial HCO3 (base)
HCO3
22 to 26 mEq/L
normal arterial SO2%
SO2%
95% or higher
normal VENOUS values for:
pO2
pH
pCO2 (acid)
HCO3 (base)
SO2%
normal VENOUS values for:
pO2- 35 to 40
pH- 7.31 to 7.41
pCO2 (acid)- 40 to 50
HCO3 (base)- 22 to 26
SO2%- 70% to 75%
define hypoxemia
inadequate blood O2
three types of hypoxemia
mild (PaO2 60-79)
moderate (PaO2 40-59)
severe (PaO2 <40)
respiratory acidosis definition
a decrease in blood pH
due to an increase in CO2
and hydrogen ion concentration
cause of respiratory acidosis
HYPOVENTILATION
related to lung disease (COPD)
s/s of respiratory acidosis
hyperpnea
visual disturbances
confusion
drowsiness
coma
metabolic acidosis definition
state of excess acid or reduced base bicarbonate in the body
causes of metabolic acidosis
DKA
diarrhea
draining intestinal fistulas
lactic acidosis
salicylate poisoning
starvation
surgical anesthesia
conditions that increase metabolic needs (fever)
shock
convulsions
s/s of metabolic acidosis
HA
mental dullness
hyperpnea with deep respiratory effort (Kussmaul)
N/V
abd pain
fluid deficit
HYPERKALEMIA
respiratory alkalosis definition
a rise in blood pH due to loss of CO2 and carbonic acid
cause of respiratory alkalosis
HYPERVENTILATION
related to anxiety
early phase of COPD
early salicylate toxicity
high altitudes
mechanical ventilation
s/s of respiratory alkalosis
lightheadedness
numbness and tingling of fingers and toes
hyperreflexia
tetany
convulsions and coma
metabolic alkalosis definition
a rise in blood pH
due to excess base bicarbonate ion
or reduced hydrogen ion (acid) concentration
caused by excessive loss of nonvolatile acid (lactate)
results in loss of K+ in the kidney
HYPOKALEMIA
causes of metabolic alkalosis
excessive administrations of alkalis
persistent or excessive vomiting
prolonged GI suction
diuretic therapy (K+ wasting)
s/s of metabolic alkalosis
slow shallow respirations
alkaline urine
mental confusion
dizziness
numbness and tingling of extremities
muscle twitching
late tetany and convulsions
s/s of hypokalemia
define compensatory mechanisms: buffer systems
boys attempts to return pH into normal range
bicarbonate buffer systems
lungs
regulate carbon dioxide (acid)
lungs cannot completely compensate; blowing of CO2
bicarbonate buffer system
kidneys
metabolic (base)
can completely compensate
can the lungs fully compensate for a metabolic imbalance
no, even though they act fast
respiratory disturbances result in ____________ ____________, which may take several days to become maximal, but compensation is ________________
respiratory disturbances result in KIDNEY COMPENSATION, which may take several days to become maximal, but compensation is COMPLETE
what do the kidneys do for compensation for respiratory acidosis
kidneys excrete more acid
kidneys increase bicarbonate (base) reabsorption
what do the kidneys do for compensation for respiratory alkalosis
kidneys excrete bicarbonate
metabolic disturbances result in ____________ ____________, which acts quickly, but compensation is ________________
metabolic disturbances result in PULMONARY COMPENSATION, which acts quickly, but compensation is INCOMPLETE
what type of compensation occurs for metabolic acidosis
hyperventilation to decrease PaCO2
compensation is rapid (minutes to hours)
what type of compensation occurs for metabolic alkalosis
hypoventilation to increase PaCO2 (limited by fall in PaCO2)
compensation is rapid (minutes to hours)
what is sodium bicarbonate IV push and/or drip often used for
to treat metabolic acidosis
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