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Terms in this set (106)
What types of things would you document upon treatment of a patient?
Date and Time
Patient vitals pre and post
Breath sounds pre and post
Any modifications to the therapy
How you performed the therapy (ex. IS reps the patient did)
How the patient tolerated the therapy
O2 therapy the patient is on
If the patient coughed and any sputum production/characteristics
Name the 3 absolute contraindications to Postural Drainage and Percussion.
1. Pulmonary embolism
3. Flail chest
Acapella is what type of PEP therapy?
Vibratory PEP therapy
What type of patient should use the GREEN Acapella?
This is recommended for patients able to maintain an expiratory flow of 15 liters per minute or greater for 3 seconds.
What type of patient should use the BLUE Acapella?
This is recommended for patients capable of less than 15 liters per minute for 3 seconds (children).
How would you instruct a patient to take an Acapella treatment?
The patient needs to be sitting upright with their mouth tightly sealed around the mouthpiece.
Have the patient inhale a bit higher than VT and exhale normally to FRC regularly through the device.
The patient should be able to exhale for 3-4 seconds while the device vibrates. If the patient cannot maintain an exhalation for this length of time, adjust the dial CLOCKWISE.
How can you administer an Acapella treatment?
Regardless of the Acapella color, you can administered this treatment via mouthpiece, mask (ambu), or tracheostomy tube.
Name the absolute contraindications for an IPV treatment.
What's another name for the Cough Assist Device?
Name the 2 modes on the Cough Assist Device.
Manual or Automatic
What should the initial pressures be set at, on the Cough Assist machine?
What type of adjuncts can be used to administer a Cough Assist treatment?
Facemask, mouthpiece, or a tracheostomy tube.
To set the inspiratory and expiratory pressures, what mode should the machine be in?
Please explain in detail how you would administer a Cough Assist treatment.
Put the mouthpiece into the patient's mouth with a tight seal.
You'll have 4-5 cycles of changing pressures. Then you ask the patient to cough after completing their cycles.
If they cough before the cycles are over, that's okay.
This treatment is usually done until the patient is fatigued from it.
What does IPPB stand for?
Intermittent Positive Pressure Breathing
Indications for IPPB therapy?
1. To improve lung expansion. (atelectasis)
2. Aid in secretion removal of patients who can't take deep breaths. (Neuromuscular disorders, post-op abdominal or thoracic surgery)
3. To provide short-term ventilatory support.
4. To deliver aerosolized medications. (Patients with ventilatory muscle weakness or those who are unable to hold an optimal breathing pattern.)
5. To induce a sputum sample for culture and sensitivity or other diagnostic studies.
Please give an example of clinical situations in which IPPB therapy is indicated.
Patient cannot do IS therapy (cannot generate a VC greater than 10-15 mL/kg, is in a coma, a quadriplegic, neuromuscular disorders)
How can you help prevent the patient from hyperventilating when receiving an IPPB treatment?
Maintain the respiratory rate between 10-12 breaths per minute.
Name an ABSOLUTE contraindication for administering an IPPB treatment.
Tension Pneumothorax without a functioning chest tube.
What are the three main settings for IPPB machine?
Sensitivity (-1 cm H2O)
Flow (15 LPM)
Pressure (15 cm H2O)
You are giving an IPPB treatment on the Bird Mark 7 unit. To give the patient 100% oxygen, you push in the air-mix control knob. What effect does this adjustment have on the flow rate to the patient?
Increases the flow of the gas
A patient who was initially anxious about taking an IPPB treatment and needing a fast breath is now breathing in a more relaxed manner. What adjustment would you make to allow for a longer inspiratory time?
Decrease the flow
While coaching an active IPPB treatment, you notice that the needle on the pressure manometer "bounces" around as the pressure increases. To better adjust treatment to the patient's needs, you would do which of the following?
Increase the flow
During administration of an IPPB treatment, you notice the system pressure rises above the set pressure to end inspiration. What should you instruct the patient to do?
Allow the machine to give you a deep breath.
Also tell the patient to relax.
A patient is having difficulty initiating each breath with the IPPB machine. What should you adjust?
Lower the sensitivity
What control is used to increase the volume delivered by an IPPB machine?
The flow control knob.
Turning the knob to a higher number causes a greater flow into the mainstream breathing circuit and nebulizer (decreases inspiratory time).
If the flow control knob is turned to a lower number this causes less flow and increases inspiratory time.
An IPPB machine cycles on with patient effort but does not shut off. The most likely cause of this problem is?
The sensitivity is too low.
What range of pressures are used when administering CPAP therapy?
What alarm system is ESSENTIAL for monitoring patients receiving CPAP therapy?
Low pressure alarm.
This monitors the pressure at the patient's airway. If the low pressure alarm is sounding the patient is not receiving the prescribed therapy and thus not effective.
Adequate flow is important to maintain CPAP levels. How can you determine if you are giving enough flow to the patient?
The flow is adequate if pressure drops no more than 1-2 cm H2O on a deep inspiration.
If not, you'll need to increase the flow.
CPAP is used to increase?
What is purpose of an EzPAP treatment?
This is another type of therapy used for lung expansion and the treatment and prevention of atelectasis.
How would you instruct a patient to perform an EzPAP treatment?
Place mouthpiece in the patient's mouth and instruct patient to breathe easily against the pressure from the device.
Take a breath in and they will feel pressure upon exhalation. You'll look at the manometer to see what kind of pressure they're generating.
Slowly adjust flow meter (increase or decrease liter flow) until desired expiratory airway pressure is reached. Typically you want an expiratory pressure of 10-20 cm H2O.
What type of pressures should be achieved during an EzPAP treatment?
10 - 20 cmH2O
If you were to start a new patient on IS therapy, how can you determine what the IS goal should be?
10 mL/kg IBW x 2
How often should IS therapy be performed?
10 times per hour while awake
IS therapy is indicated when a patient's post-operative IC is what percentage of the pre-operative IC?
If PFT (Pulmonary Function Test) results are not available, what should the initial IS goal be set at?
Twice the tidal volume measured at the bedside.
What are some clinical causes for an increase in Tactile Fremitus?
Lung tumor or mass
What are some clinical causes for a decrease or absence in Tactile Fremitus?
Chronic Obstructive Lung Disease (Emphysema)
Muscular or Obese Chest Wall
What equipment should be at the bedside during an intubation?
Cuff: Insert 10-12 cc of air into the pilot line, apply small amount of pressure to the cuff to determine if cuff will hold pressure , then remove the 10-12 cc of air you placed into the cuff. The cuff should remain deflated during the intubation procedure.
Suction: Make sure you have a Yankauer, sterile suction catheter kit and suction canister and regulator at the bedside and in working condition prior to intubation. Set vacuum pressure according to patient population.
Manual resuscitator: Mask and ambu at bedside with a working flowmeter.
Laryngoscope, bulb and batteries: Both MacIntosh and Miller blades should be available. Ask the physician or whomever is intubating the patient which blade they want. Place the blade on the laryngoscope and test to make sure the light is working.
Explain the intubation procedure:
Explain procedure to patient.
Lubricate tube and stylet.
Place patient in "sniffing" position.
Pre-oxygenate patient with 100% oxygen if spontaneously breathing. If the patient's tongue falls back into the throat (due to sedation), insert an oral airway
Hold laryngoscope with your LEFT hand, insert into the patient's mouth (right to left), sweeping tongue to the left
Position laryngoscope blade to expose the vocal cords.
Once vocal cords are visualized insert ETT (cuff deflated) with RIGHT hand through the vocal cords
\When you see cuff go through vocal cords, insert tube an additional 2 -3 cm.
Once the ETT is in the correct position, inflate cuff immediately insert 10-12 cc of air into the pilot line.
Add EtCO2 detector to the hub of the ETT.
Immediately ventilate using the manual resuscitator and check tube placement.
Stat CXR after tube confirmation.
List pieces of equipment you would want at the bedside prior to extubating a patient?
Suction equipment, towel, syringe to deflate the cuff, oxygen source, airway box, ambu bag with PEEP valve.
Explain the extubation procedure.
Obtain an order for the extubation.
Gather your supplies (suction equipment, syringe, towel, supplies to reintubate, O2 delivery device like a cannula).
Position the patient in a Semi-Fowler's position and hyper-oxygenate them.
Suction orally and down the ETT.
Let them know what is going to happen.
Remove the hollister device from the face and deflate the cuff.
Have the patient make a big cough and pull the tube out.
Have the patient continue coughing and suction them orally.
Have the patient talk to you - ask them questions.
Place their oxygen device on them and assess their vitals (breath sounds, WOB, heart rate, SpO2)
Keep the ventilator there for a couple hours just in case reintubation is needed.
Chart this procedure (Patient _______ was extubated this date and time per Dr. Whoever, positive cuff leak noted. Document all vital signs obtained. Patient placed on 2L NC, no distress noted)
What are normal cuff pressures?
Droplets are ______________ than 5 microns and travel _____________ than 3 feet.
Larger ; Less
Healthcare worker should wear a ___________ if working with a droplet precaution patient.
Healthcare worker should wear a ___________ if working with an airborne precaution patient.
In airborne transmission, pathogens are ___________ than 5 microns.
How can you easily and quickly determine the effectiveness of ventilations and compressions delivered during CPR?
You should feel a pulse and the chest should rise and fall if it is effective.
Describe the 2 methods for opening an airway. When is each method indicated?
Head-Tilt-Chin-Lift method is the procedure of choice for opening the airway of all victims except for those with a known or suspected cervical spine injury.
Jaw-Thrust method is used for opening the airway of victims who have a known or suspected cervical spine injury.
When are flow-inflating bags used?
Mainly in anesthesia and neonatal care.
When are self-inflating bags used?
Used for pediatric and adult patients.
The self-inflating bag will be able to give you what concentration of oxygen?
Up to 100%
What else can the flow-inflating bag provide?
What's the primary disadvantage of using a flow-inflating bag?
Can only be used if a source of compressed gas is available; Without a tank the ambu won't work.
May be more difficult to use due to the pressure relief/bleed off valve.
What are some advantages of a Flow-Inflating bag?
1. 100% oxygen is guaranteed with this because it does not entrain room air.
2. Can be used to deliver CPAP or PEEP.
3. Pulmonary compliance is easier to assess.
Describe FOUR ways of achieving a high FiO2 with a self-inflating bag.
1. Increasing the flow rate will increase the delivered oxygen concentration (up to 100%)
2. Decrease the ventilation rate (10-12 RR) so that you can deliver more O2.
3. Slower bag re-inflation will increase the O2 concentration delivered.
4. Use of an oxygen reservoir. You can get close to 100% O2 with this.
When evaluating a patient for home oxygen, what does the PaO2 and SpO2 have to be less than? How long does the test have to be administered? What if the patient is bed bound, how do you administer the test?
PaO2 = 55 mmHg or less
SaO2 is 87% or less
Therapist will walk the patient for 5 mins. If the SpO2 drops while walking, therapist will place patient on O2 and walk them until 92% SpO2 is obtained.
If the patient is bed bound, have them move around in bed for 5 mins (arm circles, etc.) Use the same guidelines as above.
ABG Puncture procedure:
Obtain an order for the ABG. Scan the patient's chart for any anti-coagulant meds or bleeding disorders, if they have a dialysis shunt.
Gather your supplies, go into the room, introduce yourself and the procedure you're going to do.
Perform the Allen's test.
Wipe area carefully with alcohol swabs or Iodophor (Betadine). Make a circle and continue outward. Let it dry.
Use sterile ABG kit.
The bevel of the needle should be up.
Evacuate the air from the needle and withdraw the syringe to the 1 cc marking. Do not re-puncture the skin with a needle that has been under the skin and withdrawn.
Hold the syringe at the base like a pencil at a 45-degree angle. "Big poke".
Puncture the artery. If you don't get it, withdraw the needle almost out but not quite, and re-do.
As soon as you pull out, apply the gauze right away. Hold pressure for 3-5 minutes.
Put the safety lock back on the needle and roll it to mix the heparin in with the sample.
After you bandage the patient, take the needle off and put it in the sharps container.
Push the air out of the sample.
Run it in the iSTAT.
Please explain in detail how to perform the Modified Allen's Test.
Use pressure to simultaneously block both arteries ( ulnar and radial).
Have patient make a "hard fist" and then extend fingers three times. Release pressure on the ulnar artery only. Releasing the pressure over the ulnar artery should result in the hand flushing within 5-15 seconds.
This is a positive test result and proves that the ulnar artery has adequate circulation to the hand.If the hand does not flush within 15 seconds of the release of the ulnar artery, the circulation is inadequate, and the radial artery of that wrist must not be punctured.
Blood gas analyzers provide the DIRECT measurement of what values? And what other ABG values are CALCULATED?
DIRECT: PCO2, PO2, pH
CALCULATED: HCO3, BE, SaO2
What if the patient's temperature is HIGHER than normal, the UNCORRECTED results will reveal what changes?
12-lead EKG placement?
V1: 4th intercostal space on RIGHT sternal border
V2: 4th intercostal space on LEFT sternal border
V3: midway between V2 and V4
V4: 5th intercostal space on mid-clavicular line
V5: 5th intercostal space on anterior axillary line
V6: 5th intercostal space on mid axillary line
List some difference between a fenestrated and non-fenestrated tracheostomy tube.
Fenestrated has holes, and you can talk through the fenestrated trach. A nonfenestrated trach does not.
Fenestrated trachs are used for weaning and for less ventilator-dependent patients while nonfenestrated trachs are used for more critical patients.
Benefits of using a PMV.
Improves speech production
Improves swallowing and may reduce aspiration
Facilitates secretion management
Explain the procedure for placing the PMV:
1. Place patient on a pulse oximeter. Obtain a baseline HR, RR and O2 saturation.
2. Suction the oral airway with the tonsil-tip catheter.
3. Suction down the tracheostomy tube to ensure that the patient has a patent airway.
4. If a cuffed tracheostomy tube is in use DEFLATE the CUFF.
5. Attach the Passy-Muir Valve directly to the tracheostomy tube hub with a slight twisting motion.
6. Monitor the following parameters while on the Passy-Muir valve for adverse changes:- HR, RR, Respiratory effort, O2 saturation, effectiveness of cough & ability to clear secretions, subjective expression of comfort.
Explain the procedure for cleaning the PMV:
1. Collect valve from patient.
2. Wash the used valve with water and mild soap. Avoid hot water or brushing which may cause damage to valve.
3. Rinse completely with warm water. Note: Do not use peroxide, bleach, alcohol or autoclave.
4. Rinse thoroughly with warm water. If the valve is not rinsed completely, residue may cause the valve to stick.
5. Allow to air dry and place in storage container.
What is a tracheal button?
A short tube that extends from skin to just inside the anterior tracheal wall.
Used to maintain patency of tracheal stoma to relieve airway obstruction and facilitate secretion removal.
Placed after tracheostomy tube is removed.
What are Biot's respirations?
Irregular breathing with long periods of apnea.
What are Cheyne-Stokes respirations?
Irregular type of breathing; breaths increase and decrease in depth and rate with periods of apnea.
*near death breathing
What are Kussmaul respirations?
Deep and fast respirations.
What is apneustic breathing?
Prolonged gasping inspiration followed by extremely short, insufficient expiration.
What can cause the trachea to move towards the affected area?
Phrenic Nerve Paralysis
What can cause the trachea to move away from the affected area?
Massive Pleural Effusion
When are Flat percussion notes heard?
They are heard over areas of very HIGH density (completely airless areas).
ex. MASSIVE atelectasis, pneumonectomy (removal of the lung).
When are Dull percussion notes heard?
They are heard over areas with a decreased amount of air relative to solid material. They are less dense than flat sounds.
Ex. pneumonia (consolidation), pulmonary fibrosis, atelectasis, pleural effusion, pulmonary edema, tumors.
What is whispered pectoriloquy?
Patient whispers words, usually "one, two, three" while examiner auscultates lung periphery.
Normally the high-frequency vibrations created by whispering are filtered by normal lung tissue and are heard as muffled, low-pitched sounds.
In the presence of consolidation, high-pitched sounds are heard with increased clarity.
When are Resonant percussion notes heard?
They are heard over normal lung parenchyma.
Ex. left sided-heart failure, bronchitis, pulmonary fibrosis.
When are Hyperresonant percussion notes heard?
They are heard over areas of decreased density (increased amounts of air relative to solid material).
Ex. pneumothorax, asthma, emphysema, chronic bronchitis.
What are crackles?
An adventitious breath sound.Discontinuous, intermittent, crackling, bubbling sounds, short duration.
More common on inspiration but also heard on exhalation.
Caused by excessive secretions or fluid in the airway, or the popping open of collapsed airways during inspiration.
What is wheezing?
It is sounds produced by air passing through narrowed airways.
Can be heard on inspiration or exhalation; continuous sound.
The narrowing may be due to Bronchospasm, Mucosal edema, inflammation, Mucus, foreign body or tumor.
The greater the airway narrowing, the higher the pitch of the wheeze; this explains why the pitch of a patient's wheezing may decrease following effective bronchodilator therapy.
What is rhonchi?
This is low pitched polyphonic expiratory wheezing that is commonly associated with secretions in the airways.
Coughing or tracheal suctioning often cause these sounds to be modified or eliminated.
What is stridor?
This occurs in the presence of upper airway obstruction. It is a continuous sound heard primarily over the larynx and trachea during inspiration.Very high-pitched and loud; can often be heard without a stethoscope.
What is minute ventilation? (VE)
VE = VT x RR
The total volume of gas inhaled and exhaled after one minute.
Normal adult rate is 5-10 L/min.
What values does a Wright Spirometer measure?
VC, MV, VT
What value does a manometer measure?
What will present a false-high reading on a pulse oximeter?
Presence of carbon monoxide
Dark skin pigmentation
What will present a false-low reading on a pulse oximeter?
What condition causes no change in a pulse oximeter reading?
What will cause an unpredictable pulse oximeter reading?
Poor perfusion to the area
What is the principle of pulse oximetry?
Spectrophotometry: every substance has a unique pattern of light absorption, like a fingerprint.
How accurate is pulse oximetry?
In terms of accuracy, the pulse oximetry readings of sick patients usually fall within +/- 3-5% of those obtained with an invasive blood gas sample
Most clinicians consider pulse oximeter readings unreliable at saturations below _______%
What is JVP?
Jugular Venous Pressure
JVP reflects the volume and pressure of venous blood in the right side of the heart.
With elevated venous pressure, the neck veins may be distended as high as the angle of the jaw, even when the patient is sitting upright.
How is the flow adjusted on a Bourdon Gauge regulator?
The flow is adjusted by varying the magnitude of the pressure gradient across the fixed-size orifice.
What two things is a Bourdon regulator a combination of?
A flowmeter device that is always in combination with an adjustable pressure-reducing valve.
What does a Bourdon Gauge regulator measure?
Pressure in the chamber.
In regards to a Bourdon regulator, when the pressure gradient increases, flow __________.
When back pressure is applied to Bourdon Gauge Regulators outlet, the flow indicated is ________ than the actual flow.
What does the American Standard Safety System (ASSS) regulate?
Regulates high pressure threaded connections to large cylinder valve (larger than size E cylinders; sizes F-H/K).
What does the Pin-Indexed Safety System (PISS) regulate?
Regulates connections to small cylinders with yoke and pin type connections.
Cylinder size E or smaller.
What does the Diameter-Indexed Safety System (DISS) regulate?
Regulates threaded connections at pressure of 200 psig or less between gas pressure reducing devices and gas administering devices.
What are some uses for Heliox?
Used for upper airway obstruction: tracheal tumor, post-extubation laryngeal edema, croup.
What are the standard mixtures for Heliox?
Equation for tank duration?
Tank factors for E cylinder and H cylinder?
Duration of flow= pressure (psig) X Cylinder factor/ flow (L/min)
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