Term
| Surgeries go in what order in terms of post-op pulmonary complications? |
|
Definition
| 1- Upper Abdominal 2-Thoracic 3-Sternal 4-Lower Abdominal 5- Head and extremity |
|
|
Term
| Upper abdominal surgeries include... |
|
Definition
| AAA, Exploratory lapartomy, gastrectomy, colectomy, cholecystectomy, nephrectomy, hepatatectomy |
|
|
Term
|
Definition
incision under inferior angle of rib cage- cardio-thoracic approach for bilateral lung transplant |
|
|
Term
|
Definition
|
|
Term
|
Definition
| CABG, Cardiac transplantation |
|
|
Term
| What types of CABG can you do? |
|
Definition
a) on-pump (conventional- use CP bypass machine) b) off-pump (no bypass machine). Dec LOS and hospital |
|
|
Term
| Where can you cut for CABG? |
|
Definition
Minimally invasive: da Vinci robot Mid-CAB: window btw 2nd and 3rd ribs parasternal Full median sternotomy |
|
|
Term
| what are the advantages of da vinci robot? |
|
Definition
| dec LOS, dec length of surgery, dec anesthesia, dec chest trauma, improved cosmesis, dec recovery time and return to prior level. |
|
|
Term
| Sternal precautions and mobility post cardiac surgery (sternotomy) |
|
Definition
| Push up w/both arms evenly (do not use UE to get OOB/chair), Log roll to sitting, NO PRONE, avoid canes, no crutches, use RW if needed, no across the chest seatbelts, no bending over to put on shoes and socks- 1 leg at a time. |
|
|
Term
|
Definition
| 2 or more ribs that are fractured in 2 or more places. See paradoxical movement |
|
|
Term
| Post-op pulmonary complications? |
|
Definition
| atelectasis/pneumothorax, pneumonia, pleural effusion |
|
|
Term
| causes of atelectasis/ppc |
|
Definition
| hypoventilation, anesthesia and post op meds, dec activity of respiratory muscles, inc abdominal girth, positioning |
|
|
Term
Complications with anesthesia |
|
Definition
| Arterial hypoxemia occurs immediately, respiratory depression (alveolar hypoventilation, reduced response to CO2, blunted ventilatory response to hypoxemia, longer the surgery the more anesthesia, more risk of PPC), slowing or stopping of mucociliary transport. |
|
|
Term
| Mechanical changes that alter gas exchange |
|
Definition
| Vital capacity reduced (40% in upper abdominal surgery), FRC reduced (70% in upper abdominal surgery), **lack of periodic max inflation |
|
|
Term
|
Definition
| incision site (upper abd highest risk, then sternal, then thoracic, then extremity), age >60, Prolonged anesthesia time (>3hrs) |
|
|
Term
| why does the incision site for upper abd carry highest risk of pulmonary complications? |
|
Definition
| the diaphragm function is impaired by local irritation, inflammation, trauma, effect of incisional pain, all resulting from shallow breathing pattern. |
|
|
Term
|
Definition
**improve functional mobility, reverse PPC, max independence to clear airway etc. |
|
|
Term
| Caution flat postures for... |
|
Definition
| heart failure, pulmonary edema, craniotomy/head trauma, esophageal or gastric surgery, feeding tubes/PEG, pregnancy, morbid obesity. |
|
|
Term
| surgical complicactions of heart/lung transplant |
|
Definition
Acute: infection chronic: rejection |
|
|
Term
|
Definition
| heart transplant, diabetes |
|
|
Term
|
Definition
|
|
Term
| PT eval pre-op heart/lung transplant |
|
Definition
| exercise tolerance (submax tests or walk test), vitals, O2 sat, RPP, rate of percieved exertion, |
|
|
Term
The SA node of the donor for an orthotopic heart surgery is __________ and will increase with ________ activity (i.e ______ and _________) |
|
Definition
| DENERVATED...SYMPATHETIC...EXERCISE....ANXIETY |
|
|
Term
| PT treatment pre-op heart/lung transplant |
|
Definition
| educate, CV endurance training, MS strength and flexibility, breathing retraining |
|
|
Term
| Which SA node responds rapidly with sympathetic stimulation? (with an orthotopic heart transplant) |
|
Definition
| THe native SA node (not the donor) |
|
|
Term
| The most common implication for lung transplant is |
|
Definition
|
|
Term
| indications for bilateral lung transplant |
|
Definition
| infectious lung disease, emphysema, primary pulmonar hypertension |
|
|
Term
| what is a negative implication of a bilateral lung transplant? |
|
Definition
No sensation of pulmonary secretions or need to cough; blunted response to ventilatory demands of exercise or anxiety (DENERVATION) |
|
|
Term
| post-op meds post heart/lung transplant |
|
Definition
| Prednisone or SOlu medrol (steroids). adverse effects: CHF, HTN, edema, euphoria, insomnia, glaucoma, cataracts, ulcers, osteoporosis, myopathy |
|
|
Term
| What do you have to watch for with a pt w/heart/lung transplant in terms of exercise? |
|
Definition
| exercise assoc HTN, m. atrophy (due to steroids), suboptimal nutritional status, deconditioning |
|
|
Term
| why do u want to avoid HTN episodes for a person with a donor heart? |
|
Definition
| reduce ischemia and loss of perfusion to a donor heart |
|
|
Term
WHat is the best indicator of response to exercise for a person w/heart transplant? |
|
Definition
| NOT HR!!! Use RPE scale or ventilatory response. and monitor BP response closely |
|
|
Term
| What happens to CO and HR for a donor heart with exercise? |
|
Definition
| CO inc slightly due to inc SV but HR does not change until after 5 min due to circulating catecholomines which will then inc CO. |
|
|
Term
| In normal heart, with exercise, ___ is the steepest inc with exercise |
|
Definition
|
|
Term
| Transplantation response to activity: Heart treatment is: |
|
Definition
60-70% exercise capacity of normals |
|
|
Term
| Heart Lung and Lung transplant response to activity |
|
Definition
| 40-60% exerccise capacity of normals. |
|
|
Term
| Lung transplant response to activity |
|
Definition
| mildly elevated RR and minute ventilation |
|
|
Term
| how do you know there is an acute rejection of heart/lung transplant? |
|
Definition
| low grade fever, inc in resting BP, hypotension w/activity, myalgias, fatigue, dec exercise tolerance, ventricular dysrhythmias |
|
|
Term
Lateral costal breathing is indicated for... |
|
Definition
patient with inc abdominal fat and/or pregnant (can't get movement anteriorly) |
|
|
Term
| What position is best for diaphragm? |
|
Definition
| Hooklying because gravity can help |
|
|
Term
| how do you progress diaphragmatic breathing? |
|
Definition
| HOB inc 45 degrees, sitting upright, standing, activity |
|
|
Term
Diaphragmatic breathing is not optimal for a patient with.... and is best for a patient with... |
|
Definition
COPD Restrictive Lung Disease |
|
|
Term
| Pursed-lip breathing is indicated for patient with.... |
|
Definition
|
|
Term
| Does segmental breathing really help? |
|
Definition
| for elderly, yes bc dec adherence of pleural membranes (atelectasis, pneumonia, splinting) |
|
|
Term
Pursed lip breathing operates on what principles? |
|
Definition
positive expiratory pressure: positive end expiratory pressure: only on airways at the end of expiration continuous positive airway pressure |
|
|
Term
| alveoli has ______ ventilation channels |
|
Definition
|
|
Term
| Do not use segmental breathing with----- |
|
Definition
|
|
Term
What position is good for strengthening diaphragm (but lots of pressure) |
|
Definition
|
|
Term
| Supine position negatively alters.... |
|
Definition
| Configuration of the chest wall (more transverse), ant-post position of hemidiaphragm (more cephaled), the intrathoracic pressure (shifting of the abdominal viscera), intraabdominal pressure (shifting of abdominal viscera), secretion pooling (so more out of position to train), inc intrathoracic blood volume (inc preload), pre-disposition to airway closure (and inc WOB) |
|
|
Term
What types of breathing can u use for atelectasis? |
|
Definition
| diaphragmatic, segmental, percussion |
|
|
Term
| What is the most important part of incentive spirometry? |
|
Definition
| HOLD at the end of inspiration |
|
|
Term
| Inspiratory muscle energy requires |
|
Definition
| WOB, respiratory m. strength and endurance, efficiency of muscles |
|
|
Term
| what is the first sign of fatigue? |
|
Definition
paradoxical breathing- upper part moves more with inspiration |
|
|
Term
which invasive lines are easily mobile? |
|
Definition
| peripheral venous line, central venous pressure line,feeding tubes, drains, chest tubes (NOT arterial lines) |
|
|
Term
| if a catheter comes out, what do you do? |
|
Definition
| apply light pressure until bleeding stops |
|
|
Term
| Heparin/saline locks are used on... |
|
Definition
| peripheral and central venous lines |
|
|
Term
| what is a low pressure system? |
|
Definition
|
|
Term
| where do you insert the central venous pressure line? |
|
Definition
| jugular or subclavian vein |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| what are the benefits of central venous pressure lines? |
|
Definition
| more direct access b/c 3 ports and more stable for longer use.... it is closer to the heart so it gets there faster. what? |
|
|
Term
| what pressure does the central venous pressure line measure? |
|
Definition
| R atrial pressure which reflects right ventricular end disastolic pressure. |
|
|
Term
| Where are arterial lines inserted? |
|
Definition
|
|
Term
| which line is life threatening if dislodged? |
|
Definition
|
|
Term
| what do arterial lines measure? |
|
Definition
| BP via electrical transducers connected to the monitor. (invasively) |
|
|
Term
| What are the precautions for a femoral arterial line? |
|
Definition
| Do not exceed 30 deg flexion at the hip |
|
|
Term
| BP is only accurately read from an arterial line if.... |
|
Definition
| the transducer is level with the heart. |
|
|
Term
| What line is as close as we can get to the L ventricle without being in it? |
|
Definition
|
|
Term
Swan-Ganz catheter is inserted into the ___ or _____, thru the ___, thru the ___, thru the ___, and sits in the _______. |
|
Definition
| jugular or subclavian vein, thru the SVC, RA, RV, pulmonary artery. |
|
|
Term
| What does the Swan Ganz catheter measure? |
|
Definition
| CO, RAP, RVP, PAP, PCWP, core temperature |
|
|
Term
| what is pulmonary capillary wedge pressure? |
|
Definition
| It reflects left ventricular end diastolic pressure... you put it thru the path to pulmonary a. and it sits there without actually being in the LV. |
|
|
Term
| which line is not ok for ambulation? |
|
Definition
|
|
Term
| what is a complication if the pulmonary a. line is pulled? |
|
Definition
| it can enter the RV and cause arrhythmias |
|
|
Term
| which tubes, drains, wires are NOT sutured? |
|
Definition
|
|
Term
| what shoould u do with jackson pratt drain prior to movement? |
|
Definition
| drain bulb, tape and secure it to the patient |
|
|
Term
| If you want to walk with chest tube, what are the steps you take |
|
Definition
| ok with MD, disconnect pleuro-vac from suction only if no air leak (no bubbling) or less than 3 on air leak meter. If more than 3, you must use portable suction apparatus. |
|
|
Term
| When should you avoid walking someone with temporary pacing wires? |
|
Definition
Need bedrest at least 1 hour after wire removal, nonambulatory with wires in a Swan or Zoll pacer. |
|
|
Term
| what are precautions for IABP? |
|
Definition
| LOG ROLL, no flexion at hip greater than 30, once removed pt is on bedrest for at least 6 hrs. |
|
|
Term
| Intra cranial pressure generally kept... |
|
Definition
|
|
Term
|
Definition
| bed mobility ok, OOB per MD, no ambulation! |
|
|
Term
| what is the difference btw low flow oxygen and High flow? |
|
Definition
low flow- variable FI02 (depends on RR and TV) high flow- fixed 02 (does NOT depend on RR and TV) |
|
|
Term
| examples of low flow oxygen |
|
Definition
| nasal cannula, simple face mask, partial rebreather face mask, non-rebreather face mask |
|
|
Term
| simple face mask is used for |
|
Definition
| short term use only. delivers approx 35-55% FIO2 at 5-10L/min, easily mobile w/portable 02, not optimum for eating or talking. |
|
|
Term
| what is the purpose of IABP? |
|
Definition
| assist in perfusion to the coronaries and systemic system, dec angina, dec work of heart |
|
|
Term
| In a Partial Rebreather face mask, pts inspire 02 from... |
|
Definition
|
|
Term
| What happens to exhaled TV with a Partial Rebreather mask? |
|
Definition
| 1/3 to bag, the remainder exits the mask (3 way valves) |
|
|
Term
which type of system gives you no room air to inhale? (one way valve) |
|
Definition
|
|
Term
Which low flow face mask delivers approx the same FI02 amount as the Venturi face mask? |
|
Definition
|
|
Term
| If desired FI02 is less than 60% and the person wants to ambulate but is wearing an aerosol mask, which face mask would be optimal? |
|
Definition
|
|
Term
| With a tracheotomy, will the patient be able to talk? |
|
Definition
| if the cuff is deflated, yes. if inflated, no. |
|
|
Term
Can a patient talk with an NG tube? |
|
Definition
| yes- doesnt block esophagus |
|
|
Term
| Most mechanical vents are based on the princciple of ... |
|
Definition
| Positive pressure: Volume-preset tidal volume |
|
|
Term
If a patient is on weaning mode, they might be on... |
|
Definition
| synchronized intermittent mandatory ventilation or Pressure support ventilation, or CPAP |
|
|
Term
| non-weaning mode, rate and TV set. This is apart of ---- type of mechanical ventilation. This is -------- pressure ventilation |
|
Definition
| Assist Control.... Positive |
|
|
Term
As you are weaning off a mechanical ventilator, what is the first machine that will respond to spontaneous respiratory rate and TV? It also augments spontaneous TV to meet desired TV. |
|
Definition
| Pressure support ventilation |
|
|
Term
| The less the pressure support ventilation, the ______ effort the patient has to initiate a breath |
|
Definition
|
|
Term
| which mechanical ventilator gives you a "boost". ie you start to take a breath and the machine finishes it? |
|
Definition
| Pressure support ventilation |
|
|
Term
| If pressure is 8cm H20, it is called ______ If it is 7 it is ____ |
|
Definition
|
|
Term
| if someone is wearing an epidural cath, what should you be sure to do? |
|
Definition
|
|
Term
| how do they decide what to set the ventilator rate at? |
|
Definition
| lowest rate to keep PaC02 btw 35-45 |
|
|
Term
Why do you want to avoid excessive PEEP? |
|
Definition
it will reduce CO and impair O2 delivery (increases intra-thoracic pressure so its harder for preload to come in). |
|
|
Term
| for a pt with COPD, what speed of inspiratory flow will be most beneficial? |
|
Definition
fast b/c it will dec inspiratory time which allows for longer expiratory time |
|
|
Term
| for a pt with pneumonia, what speed of inspiratory flow will be most beneficial? |
|
Definition
| slow bc it maximizes distribution of 02 |
|
|
Term
| What are the complications of mechanical ventilation? |
|
Definition
| oxygen toxicity, barotrauma, decreased CO, endotracheal tube, pneumonia, diaphragm atrophy (within 18 hours). |
|
|
Term
| Weaning criteria for mechanical ventilation: Mode: |
|
Definition
| spontaneously breathing with natural RR< 25 bpm and PaCO2 btw 35-45. |
|
|
Term
| weaning criteria for mechanical ventilation. FI02 |
|
Definition
| if FI02 is less than 40-50% FIO2 with a Pa02 less than 60. |
|
|
Term
| weaning criteria for PEEP |
|
Definition
|
|
Term
| Factors contributing to weaning failure |
|
Definition
| respiratory muscle weakness, meds (steroids, muscle relaxants) |
|
|
Term
| What is the best time to work with a pt on a ventilator? |
|
Definition
| stable level of weaning, NOT immed after a dec in support, coordinate PT activity w/weaning. |
|
|
Term
| what are teh signs of R heart failure? |
|
Definition
| ascites, liver engorgement, JVD |
|
|
Term
| what is the ratio of normal expiration: inspiration? |
|
Definition
|
|
Term
What is metabolic syndrome? |
|
Definition
| Precurser to CAD. Presence of 3+: abd obesity, glucose intolerance, BP of at least 130/85, high triglycerides, low HDL |
|
|
Term
|
Definition
| 3-5 cm above angle of Louis is RV problem |
|
|
Term
| after atrial systole, what valves close? |
|
Definition
|
|
Term
| Lub comes from ___ valves |
|
Definition
|
|
Term
| where do you auscultate the pulmonic valve? |
|
Definition
| L 2nd Intercostal space parasternally |
|
|
Term
| what do you auscultate at the apex of the heart? |
|
Definition
| PMI and mitral valve and S3, S4 |
|
|
Term
| which side of the heart carries oxygenated blood? |
|
Definition
|
|
Term
|
Definition
during predictable level of physical activity or emotional stress |
|
|
Term
|
Definition
| onset of exercise, relieved if you keep exercising |
|
|
Term
|
Definition
| spontaneous angina at rest, usually not provoked by exercise |
|
|
Term
|
Definition
| during or soon after eating meals |
|
|
Term
| what are determinents of RPP? |
|
Definition
|
|
Term
| what is the BIG THREE for cardiac risk predictor |
|
Definition
|
|
Term
what are the stages of HTN? |
|
Definition
| <120 normal, 120-130 preHTN, 140-159 HTN stage I, >160 HTN stage 2 |
|
|
Term
| with HTN, your risk of ______ inc |
|
Definition
|
|
Term
| what are teh ECG changes for ischemia? |
|
Definition
| <20 min, peaked T waves, inverted T waves, ST segment depression |
|
|
Term
|
Definition
| 20-40 min, ST segment elevation |
|
|
Term
| EKG changes for infarction |
|
Definition
| >1-2 hrs, abn Q waves, greater than 2mm wide or greater than 25% height of R wave in that lead |
|
|
Term
|
Definition
| bronchospasm, mucosal edema, airway secretions |
|
|
Term
| the lungs end at T-- posteriorly after expiration |
|
Definition
|
|
Term
| a person who is comfortable at rest but gets fatigue after walking up the stairs has class ___ angina on the NY scale |
|
Definition
|
|
Term
| If someone has flail chest, how will their breathing pattern be? |
|
Definition
| paradoxical.. descent of teh diaphragm dec intrathroacic pressure on inspiration, injured area caves in, on epiration it moves out. |
|
|
Term
| hyperventilation or kussmauls respiration |
|
Definition
|
|
Term
| metabolic or brain injury may have what tpe of breathing pattern? |
|
Definition
| periodic respiration- alternating hyperpnea and apnea |
|
|
Term
what are abnormal responses to work for systolic BP? |
|
Definition
| not rising with inc in workload, drop of 15-20 during activity./ |
|
|
Term
| rule of thumb for HR response to exercise? |
|
Definition
| raises 10 beats/min w/every inc MET |
|
|
Term
which abnormal sound is heard in early diastole? |
|
Definition
|
|
Term
| what pathologies might lead to LV CHF producing Pulmonary edema? |
|
Definition
| CAD, mitral valve dysfunction, outflow tract obstruction |
|
|
Term
Superficial LE test- filling time btw 10-15 seconds indicates ___ |
|
Definition
| mod to severe disease. 15-45s is severe, |
|
|
Term
| symptoms of deep circulatory inadequacy |
|
Definition
| cramps during ambulation, shin splints. |
|
|
Term
| what do you record for Deep arterial insufficiency |
|
Definition
| claudication time, absolute walking time, pain disappearance time |
|
|
Term
| Temporary pacing wires can be passed through a ____ or a ____ line in emergent cases. If the wires are NOT in place, ________ pacers, or large patches placed onto the skin (ant/post to heart) and connected to a pacer/defibrillator. This is also emergent. |
|
Definition
central line or Swan-ganz line.... Zoll |
|
|
Term
| How much 02 max does the nasal canula deliver? |
|
Definition
|
|
Term
non-rebreather delievers how much fraction of inspired oxygen? |
|
Definition
|
|
Term
| which high flow ventilator is not easily mobile bc of wide bore tubing and nebulizer? How much FI02 and when can you cahnge their mask? |
|
Definition
| Aerosol mask. It delivers 28-100% FIO2 at 4-15 L/min but you can change to Venturi mask to ambulate if FIO2 is less than 60% (venturi is 24-55% at 4-10L/min) |
|
|
Term
In pts with cancer, what is the most important clinical factor in predicting survival time? |
|
Definition
|
|
Term
| what is recommended for exercising a pt with breast cancer? |
|
Definition
-Moderate intensity -at least 3/week for 30 min per therapy session -resistance training |
|
|
Term
| CI to exercise for pt with cancer |
|
Definition
| unusual fatigue and/or weakness, irregular pulse, dec HR with work, leg pain/cramps, nausea/vomiting/diarrhea, disorientation, dizziness, dyspnea, IV chemo in past 24 hours, low platelet/WBC count (20,000/1500) |
|
|
Term
| what should you modify for a pt post-masectomy to prevent lymphedema? |
|
Definition
| don't take BP in that arm (just in case) |
|
|
Term
| what are risk factors assoc w/onset of lymphedema in post masectomy pts? |
|
Definition
| skin puncture, weight gain, BMI>26, infection, injury, radiation |
|
|
Term
| post heart/lung transplant, patient must wear _______ outside of the room. |
|
Definition
|
|
Term
| who is most at risk following sternotomy for sternal instability? |
|
Definition
| obese, COPD, NYHA IV (bad circulation) |
|
|
Term
| how do you prevent the bad side effects of anesthesia? |
|
Definition
| get them to cough and move |
|
|
Term
|
Definition
| complication of surgery... puncture heart m so the eblood accumulates ouside the chamber, inside the pericardial sac (restrictive disease) |
|
|
Term
| precautions for manual techniques |
|
Definition
| rib fractures, pneumothorax, chest tubes and lines |
|
|
Term
| what is heart-lung and lung transplant?? |
|
Definition
|
|
