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Complex Care Exam 2

Terms in this set (100)

normal tidal volume for mech vent
500mL
indications for mech vent
respiratory failure
apnea
anticipated respiratory failure
correlation between intrathoracic pressure and cardiac output on mech vent
pressure exerted within the intrathoracic cavity slows blood return to right side of heart, which decreases cardiac output
modes of ventilation
A/C
IMV
APRV
CPAP
A/C
assist control
most common (same as CMV)
tidal volume and resp set so pt is not doing any of their own work, but pt can do more on their own, in which case machine will assist
IMV
intermediate mechanical vent
dose not give pt tidal volume
weaning mode
pt has to do own work, but guaranteed help from set RR
APRV
airway pressure release vent
most common for a pt with sever resp failure, usually ARDS
pt breathes spontaneously without restrictions
tidal volume varies bc inspiration is spontaneous and pressure limited
used with problems with gas exchange
CPAP
continuous positive airway pressure
weaning and trailing
if weaning, place at 0
if trailing, monitor toleration
pt does all work
for sleep apnea, may or may use FiO2
what will you see if pt is not tolerating CPAP
higher RR (tachypnea)
increase RR will cause increase BP/arrhythmias
PEEP
positive end expiratory pressure
keeps alveoli open at the end of expiratory
better for gas exchange
complications with PEEP
barotrauma
hypoTN
what is barotrauma
could result in atelectasis
decrease BP, increase HR, decrease venous return>increase intrathoracic pressure>decrease O2, vessel compression
IRV
inverse ration vent
last ditch effort for a pt maybe with ARDS
longer insp than exp
reverse I:E ratio
what do you do with a pt with IRV
sedate, bc very uncomfortable
each breath delivered with set pressure, no set vent
complications with mech vent
infection
bartrauma
stress ulcers
cardiac compromise
asynchronous respers
gastric complications
P/F ratio
tells about resp, especially oxygenation
normal 300-500
<300 acute lung injury
<200 ARDS
FiO2 and O2 for mech vent
FiO2 50-60
O2 90-92
3 purposes of mech vent
decrease work
oxygenation
ventilation
ET tube cuffs
prevents air leaks
not to keep in place
normal <200
when do you inflate ET tube cuff
mech vent
oral care
feeding
when do you deflate ET tube cuff
weaning
when to take of mech vent
good ABGs
40% FiO2
CPAP tolerated at lowest PEEP
managing own secretions/swallowing
what is high frequency vent
alternative or addition to vent (ARDS)
small tidal volume with high RR
liquid vent
uses fluorocarbons
great at carrying O2 (ARDS)
settings for mech vent
Rate
Mode- how insp is controlled
FiO2
Tidal vol
Other- PEEP, PSV, etc
suctioning with mech vent
PRN!!
listent o breath sounds before and after
hyperoxygenate
STERILE
signs of readiness for weaning
tidal volume and negative pressure
ABGs within normal parameters
stable VS
sign of NOT tolerating the weaning process
increase RR, BP
agitated
bad ABGs
alt LOC
arrhythmias
low O2
what is capnography
amount of exhaled CO2 that measures ventilation
oxygenation- how we get O2 to the tissue
ventilation- movement of air, how we get rid of CO2
capnography vs pulse ox
cap-
immediate
immediate apnea
measures CO2 in airway, breath vent status, O2 sats
pulse ox-
delayed
high sat for several minutes
when is the highest CO2 concentration
at the end of expiration; end-tidal CO2
Value of Capnography
assist with intubation, continuous monitor ET, ventilation/perfusion monitor
purpose of hemodynamic monitoring
measures pressure of cardiac output and circulatory system with early detection
normal MAP
70-90
SPB + 2(DBP) / 3
normal CVP
4-10
right heart filling (arterial) pressure and correlate with right arterial pressure
what is CVP
central venous pressure tells about fluid status
what does CVP monitor
fluid volume status and approximates PRELOAD
what increased CVP
think too much fluid
hypervolemia, vasoconstriction, cardiac tamponade
increase venous return
R heart failure/pulm HTN
regurgitation
AFTERLOAD needs decreased
what decreased CVP
think not enough fluid
dehydration, shock, hypovolemia
PRELOAD need increased
complications of CVP
air emboli
thrombus
infection
nursing care with CVP
give fluids if low
give diuretics if high
pt positioning
PAP
pulmonary artery pressure
Allows for eval of left ventricular and overall cardiac function
Tells about resistance, blood flow, PA pressure, CO, R artrail/ventricular pressures, LV pressures
what do you use to eval PAP
swann gannz
normal PAP
25/10
what does decreased PAP mean
hypovolemia
shock
what does increased PAP mean
pulm HTN
L heart failure
PAWP
pulmonary artery wedge pressure
Reflects preload of Left Ventricular, equal to pulm A diastolic if there are no pulm probs
normal PAWP
8-12
what does increased PAWP mean
LV failure
mitral valve problems
hypervolemia
pericardial tamponade
what does decreased PAWP mean
hypovolemia
shock
cardiac output
Amt of blood heart pumps in 1 min
Use PA cath w/separate lumen to thermodilute
Norm- 4-8 L per minute
CO= HR x SV
SV= preload, afterload, contractility
cardiac index
Calculation of CO per sq meter of body surface area
Normal- 2.8-4.2 L/min/m2
You want a CI of at least 2
what do CO and CI tell us
if body is keeping up with O2 demand
ejection fraction (EF)
Normal = 55-70
Percent of blood pumped out of LV w/ each heart beat
<25% is a concern
acute coronary syndrome (Acute MI)
STEMI and NSTEMI
Irreversible necrosis of heart muscle from inadequate blood supply from coronary artery
Risk factors of acute coronary syndrome
age
gender
hyperlipidemia
HTN
DM
obesity
smoking
NSTEMI
Non ST - segment elevation MI, non-Q wave infarction
White platelet rich deposits
Partial occlusion
Unstable thrombus
Micro thrombi
STEMI
transmural infarction, ST - segment elevation MI
Red fibrin rich deposits
Full occlusion
Stable thrombus
Sequencing of the events as follows:
•Atherosclerotic lesion
•Intiminal lesion with fissuring and hemorrhage
•Thrombus formation and spams leading to
•Obstruction of the flow of the blood leading to
•Necrosis of the heart muscle
order of injury
ischemia
injury
infarction/necrosis
ischemia
reversible
interruption of blood flow
EKG-T wave inversion
injury
reversible
surrounds the zone of infarction in affected myocardium
cales do not fully repolarize due to deficient blood supply
EKG- abnormal Q wave sometimes develops
infarctions/necrosis
irreversible
death of tissue from prolonged impairment of blood flow
EKG- ST elevation
associated labs
troponin- MI has occurred
myoglobin- chest pain has occurred
CKMB- necrosis has occurred
associated EKG readings
ischemia- T wave inversion
injury- ST elevation
infarction- pathologic Q waves
MONA
•Morphine - relieving pain, easing anxiety, decreases myocardial O2 consumption; helps decrease venous return to right heart > decrease workload of heart
•Oxygen - 2 to 3 L/min NC > supplemental O2 max myocardial O2 supply
•Nitro - q 5 min for total of 3 labs > promotes coronary vasodilation
•Aspirin - 325 mg PO > acts as anti-platelet agent to reduce clot formation
Digoxin
contraindicated because it increased contractility of the heart and the cardiac workload (afterload) too aggressively if already damaged
Asynchronous pulse generator
fixed rate, independent of heart activity
delivers a pacing stimulus at a set rate regardless
Synchronous pulse generator
Demand, paces only when HR falls below what it should be, sense's heart activity
Sensing - the hearts electrical activity
Firing - pulse generator puts out electrical charge
Capture - effectively stimulate the heart by current from the pulse generator
purpose of temporary pacing
postop open heart, bradycardia - drug induced, symptomatic 2nd degree AV block, inferior MI w/heart block
initiates heartbeat
purpose of permanent pacing
complete heart block, sick sinus syndrome, Stokes Adam, overdrive pacing, symptomatic sinus brady, long QT
use when the condition persists even w/adequate therapy
complications of pacing
-penetration of the heart by the transvenous lead
-infection
-lead system becomes dislodged from the heart
fracture of the lead system - kids when they're growing
-arrhythmias
-electrical stimulation of the diaphragm either by the transvenous lead that has perforated the heart or when the output on the pacemaker is turned too high
nursing care of pace makers
keep arm at side for at least 24 hours
things that will affect pacemakers- dentist, MRI, radiation, welding equipment
determining MA: threshold or output - amount of electrical energy required to stimulate the heart
CT scan
computerized tomography
Reconstruction of thin slices of brain that shows an actual pic of the brain
Radiation-
white= high, black= low
CT scan normal colors
Bone= white
Blood= off white
Brain tiss= shaded grey
CSF= off black
Air= black
Purposes to CT
tumors
hemorrhages
hematomas
cerebral atrophy
hydrocephalus
pt prep for CT
NPO 4-6 hours prior
lumbar puncture
hallow needle in subarachnoid space
L4/L5
purpose of LP
diagnostic
CSF draw
therapeutic (decrease ICP)
post LP
monitor for changes in LOC
lie flat 1-6 hrs
increase fluid intake to prevent HA
if a HA does occur use ice pack/meds
CSF values
normal volume 135-150
normal pressure 75-100
CSF color/odor
should be colorless and odorless
Blood= yellow/orange/brown- RBC breakdown and bilirubin release
Cloudy/turbid- increase WBC w/meningitis, increase prtn w/brain tumor
normal #s with CSF
No RBC
WBC- 0-5
Protein- 15-45 (elevated w/ tumors, infections and hemorrhages
Glucose- 60-80 (decreased level may indicate bacteria in CSF)
cerebral angiogram
injection of dye into intra/extracranial vasculature by carotid/vertebral A by subclav/brach/fem/axillary A (coronary arteries)
purpose of cerebral angiogram
aneurysm
occlusion
hematoma
diagnostic
pt pre repp with cerebral angiogram
teach burning w/dye injected 20-30 sec, assess baseline VS, allergies to dye, hydration so dye will dilute
post care with cerebral angiogram
bedrest up to 12 hrs, 15 min-hr VS checks, monitor puncture site, increase fluids to flush dye
EEG
electroencephalogram
recording of electrical impulses/brain waves from brain that has electrodes on scalp to amplify the waves
purpose of EEG
detect and localize abnormalities- seizures/ injury/infarction (slowing)/irritable (spikes), brain death
pre prep with EEG
make sure hair/scalp clean, no sedatives/anticonvulsants/etc b/c it can cause false results
neuro assessment
LOC
Alert>lethargic>obtunded>stuporous>Comatose
Arousal - "wakefulness"; purely a function of brainstem and has nothing to do w/ thinking
Awareness - cerebral cortex, or thinking part of brain, in functioning
alterations in GCS
Glasgow Coma Scale
• Highest= 15
• Lowest= 3
• Anything under 8= intubate
• 7 or less usually= coma
• Eyes open, verbal response, motor response
• Intoxication is an invalid measure for a pt w/ Glasgow
Posturing
• Decorticate- flex, fine tremors/stiff, arms held tight to sides of body
• Decerebrate- extend - most serious progonosis, arms fully extended
motor reflex responses
gag reflexes
probably most important because they're at risk for aspiration if impaired
• IX- glossopharyngeal
• X- vagus
motor reflex responses
corneal reflex
blink
• V- trigeminal
• VII- facial
motor reflex responses
pupillary reflex
• II- optic (sees)
• III- oculomotor (constricts) - size of pupils
eye/pupil responses
Oculocephalic reflex (dOll's eye)
• Eyes move to the Opposite side your head is facing
• Seen in comatose pts, norm if brainstem intact
Oculovestibular reflex (cold caloric test)
• Pt's head raised to 30, 20-100 mL of ice water injected into auditory canal
• Norm eye mvmt= slow tonic nystagmus toward irrigated ear for 30-120 seconds
• Abnorm eye mvmt= disconjugate eye mvmt= brainstem lesion, no mvmt= no fxn
Oval pupil is indicative of intracranial HTN (IICP)
vital sign changes with neuro assessment
common CM on intracranial injury= systemic HTN
Cushing's triad
• widened pulse pressure
• brady
• abnormal resp pattern
ICP
intracranial pressure
pressure w/in the cranium, composed of CSF, cerebral blood & brain tissue
• Norm- 0-15 mmHg
• Elevated- 15-19 (increased blood, CSF, swelling)
• Moderately elevated- 20-39
• Severely elevated- >40
• >20mmHg, you need to intervene
• Acute intracranial HTN = 20-25 mmHg or greater
CPP
cerebral perfusion pressure
amt of press needed to assure adequate cerebral perfusion (oxygenation of brain tissue), represents balance b/t ICP and systemic BP
• Norm- 70-100
• <70- inadequate brain perfusion
• >100- increased cerebral bf= IICP
• If there's increased CPP then control it w/IVF and vasopressors
• MAP - ICP = CPP
• To increase MAP - IV fluids, vasopressors
• To decrease ICP - HOB 35-45, Mannitol
• Goal of treatment for pt w/ IICP to main CPP at 70 - use of volume therapy (IV fluids) and vasopressors (vasopressin)
go back and review the ICP and CPP stuff
...and acute brain injury
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