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CVICU Quiz 4
Vent
55
Nursing
Graduate
02/25/2016

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Cards

Term
Order Least O2 Support to Most O2 support
Definition
1. NC: up to 6L
2. Venti mask: provides up to 50% FiO2
3. Non rebreather: provides 100% FiO2
4. BiPap: 100% FiO2 and positive pressure
5. Intubation
Term
What does IS stand for? Purpose? How often should it be done?
Definition
Incentive Spirometry helps pt to fully expand lungs in post op patients, helps prevent atelectasis. Should be done 10 X Q 1-2 hours while awake (try for every hour). Instruct the patient to suck in through the mouthpiece as hard as they can, try to meet or exceed goal tidal volume.
Term
HIgh level PEEP may cause:
Definition
Barotrauma, hypotension, and decreased CO

Pt with increased PEEP will have SBP lowered by 5-10
Term
T/F Albuterol is a beta 2 specific drug and has no HR effect
Definition
False, will increase HR
Term
Patient's ABG is:
pH: 7.3
CO2: 60
PO2: 80
HCO3: 24
SaO2: 92%
RR: 30
on NC 5L

What can you do? What orders do you expect?
Definition
Respiratory Acidosis, patient is not breathing deep enough to oxygenate well. Encourage pt to take deeper breathes. If they can't because of pain, may expect more effective pain management from MD. If not pain related, MD may order BiPap to increase time alveoli is open to increase gas exchange; bipap will give positive pressure and force deeper breathes

If patient doesn't breathe, may turn into PEA and a code
Term
ARDS is? Primary or secondary? Causes?
Definition
Acute REspiratory Distress Syndrome

Secondary

Barotrauma, inhaled toxins, pneumonia, sepsis, influenza, aspiration, trauma
Term
DIffrence between hypoxia and hypoxemia
Definition
Hypoxemia: decreased O2 in blood; widespread

Hypoxia: decreased O2 in tissue; specific to area (anoxic brain)
Term
What could cause high peak pressure alarm?
Definition
Patient biting ET tube, Kinked tubing, mucous plug, water condensation in tubing (causes high pressures; sloshing of water in tubing can trick vent into thinking the pt is trying to breathe spontaneously, will force another breath if on A/C)
Term
Can you draw ABG while inline breathing treatment is running in ETT?
Definition
No, PO2 will be falsely elevated because inline treatment is pushed in with additional L of O2
Term
Time goal for extubation
Definition
4 hours
Term
Cpaping pt to attempt Extubation, what 3 parameters are provided?
Definition
PEEP, FiO2, Pressure support
Term
Silence button on Vent lasts how long?
Definition
2 minutes
Term
THree components of SVO2
Definition
Hgb (most important), CO, SaO2
Term
O2 Protocol is what and what does it cover up to?
Definition
Do what you need to do to titrate to 94% is our standing order. May use nonrebreather, venti, but should be communicating with MD while doing so.

Can give Venti and NC at once
Term
WHere can you find venti masks and NC? Intubation box?
Definition
Venti mask and NC: by the bathroom

intubation box on crash cart, never more than 20 feet from any room
Term
Who can intubate?
Definition
MD, RT, trained NP
Term
What do you need to ask the MD for when you call to get intubation orders?
Definition
1. Vent settings (Mode, FiO2, set rate, PEEP, Inspiratory pressure, PS, Tidal volume, goal SaO2)
2. Sedative
3. Pressors
4. ABG for 30 minutes after
5. CXR
Term
Oxgenation:
Definition
No reliable clinical S/S for arterial oxygenation

Pallor/cyanosis is sign og hypoxia, not hypoxemia
Term
When does organ failure begin?
Definition
Blood O2 at 80%
Term
SpO2, aka oxygen saturation
Definition
Fraction of oxygen-sat Hgb relative to total Hgb in blood

Indirect measurement of SaO2

Low SaO2 (ABG), low SpO2 (pulse ox) - hypoxemia

Hypoxia: specific body part, clinical S/S
Term
PaO2
Definition
Partial pressure of arterial oxygen in the blood

Normal is 70-105

Supplemental O2 makes you PO2 higher! ROom air is only 21%; more will increase PO2
Term
What is the rule of 3?
Definition
Your FiO2 multiplied by three is roughly your PaO2

50% FiO2 will make your PO2 roughly 150

If not, there is an oxygenation problem, some obstacle to effective ventilation
Term
Hypoxemia
Definition
Low levels of O2 in arterial blood, can cause tissue hypoxia

measured by PaO2 nd SaO2 and indirectly by SpO2
Term
Hypoxia
Definition
Body is deprived of adequate O2 supply

Can be generalized or local

May use nitroglycerin paste to the toes
Term
Respiratory Distress
Definition
Ventilation is not adequate enough to perform needed gas exchange

Results:
increased concentration of CO2
decreased O2
leads to respiratory acidoses
Term
Ventilation formula
Definition
RR x TV = ventilation

(Rate x depth)
Term
Ventilation
Definition
Total amount of air moved ina dn out of lungs via inhalation and exhalation

Evaluation:
Tidal volume
Repiratory Rate
Chest Rise
Compliance
Term
Tidal Volume
Definition
amount of gas expired per breath
normal 4-6 ml/kg
too hight= trauma to lungs
Term
Minute Ventilation
Definition
Ventilation per minute

Normal is 5-10 /min

Inversely affects CO2 (higher ventilation - low CO2, lower ventilation - high CO2)
Term
Peak Airway Pressures
Definition
Represents total pressure needed to push a volume of gas int lungs and is composed by
1. pressured resulting from inspiratory flow resistance
2. elasticity of lungs
3. alveolar pressure present (PEEP)

PEAK pressures - inspiratory pressure + PEEP

Constrictive lung disease will have high peak airway pressures
Term
Postive End Expiratory Pressure
Definition
PEEP helps keep your alveoli from collapsing during exhalation

High PEEP can cause:
decreased CO
Hypotension
Barotrauma
Term
I:E Ratio
Definition
Inspiratory to expiratory Ratio

Normal is 1:2, 1:3, 1:4

Inspiration is active, expiration is passive, takes longer
Term
Inverse I:E ratio
Definition
Expiration is shorter than inspiration

2:1, 3:1, 8:1

Ensures recruitment, constant inflation of the lungs give gas exchange longer to occur, helpful in damaged lungs

Hypercapnia due to low expiration times (permissive hypercapnia, e allow it because it is a smaller problem than desatting)

If patient becomes disconnected from vent, all the alveoli will collapse and desat

PT must be fully sedated because this is very uncomfortable adn unnatural, will fight the vent
Term
A/C ventilation
Definition
Assist/Control: Pressure and volume

May receive controlled or assisted breaths
If pt triggers a breath, will receive the full volume and duration of the mandatory set breath

Pt can breathe if they want, but dont have to work for it

No weaning component

Causes hyperventilation as they awake and over breath the ventilator

Volume Control: rarely used in CVICU
Pressure control: set RR, Pi, PEEP, FiO2
Tidal volume is determined by the preset pressure limit
Term
What is the difference between pressure setting and volume setting?
Definition
Pressure: Pi, fills lungs until set pressure is met

Volume: Forces the same tidal volume of air in each breath

Waveforms of set breaths will appear as green on monitor
Term
SIMV
Synchronized Intermittent Mandatory Ventilation
Definition
Early Weaning Mode for weak, chronic patients (rate of 8 or more)

More comfortable for awake patients overbreathing the set ventilator RR

The patient can breathe spontaneously while also receiving mandatory breaths

RR, Inspiratory pressure or tidal volume, pressure support, PEEP, FiO2

Red Waveforms represent spontaneous breaths with no assistance, only PS. Will usually be smaller, shallower
Term
CPAP

Continuous Positive Airway Pressure
Definition
FULL weaning mode
THe patient controls all parts of the breaht except pressure limit

The patient triggers the ventilator; there are NO set RR

THe ventilator delivers a flow up to a set present pressure limit depending on the desired minute ventilation

Tidal volumes may vary

Pressure support is a method of assisting spontaneous breating in a ventilated patient

Has set PS, PEEP, FiO2
Term
CPAP TRIAL
Definition
Needs to meet the following criteria:
1. Hemodynamically stable (MAP 65, HR less than 120, minimal drips, RR 6-28
2. SpO2 greater than 94% on FiO2 50% or lower
3. Patient is awake, and follows commands

CPAP = Pressure Support 5, FiO2 50%, PEEP 5 for 30 minutes, get ABG. If satisfactory, EXTUBATE
-If patient becomes unstable, return to vent to previous settings
-Extubate to 5 LNC; let MD know, and have RT bedside (they will be the one to do it)

As pressure support is weaned down, the TV and MV will go down naturally beacuase the support is going away; pt is doing it alone
Term
BiLevel
Definition
Similar to PCV (Pressure control ventilation)

Ideal mode for APRV (Inverse I:E ratio)
-more comfortable than PC-IRV

FOr patients who have hypoxemia
-Improved PaO2 due to alveolar recruitment
-Allows for lower FiO2 due to better gas exchange in alveoli (due to longer open time)

Set RR, PS, High PEEP, Low PEEP, FiO2

This is good for patients who need higher PEEP but are overbreathing the vent; this setting keeps the alveoli open for a longer time
Term
Volutrauma vs. Barotrauma
Definition
Volutrauma: damage to the lung caused by over distension by a mechanical vent set for an excessively high tidal volume

Barotrauma: mechanism of injury is excessive pressure
-High pressures needed to ventilate non-compliant lungs (ie: cystic fibrosis, pulmonary fibrosis)
-Scar tissue forms, function is forever impaired in that particular alveoli
Term
APnea Alarm
Definition
No machine, patient, or operator trigered breath detected

ACTION: Ventilate the patient
Term
Circuit disconnect alarm
Definition
Disconnection in the circuit

ACTION: Reconnect patient. Assess patient extubated, circuit tubing disconnect, displace ETT (ie, back of throat)
Term
Severe Occlusion
Definition
Patient circuit secverely occluded

ACTION: identify and resolve source of complete circuit occlusion

Assess crimped/occluded tubing, patient biting tube, mucus plug
Term
Increased Peak Pressure
Definition
Measured peak airway pressure high limit violated

ACTION: assess patien/vent cause for impeded air flow

Assess need for sucitoning, gag/cough, bronchoconstrictin/spasm, pneumothorax, condescation in tubing, compressed circuit tubing, patient trying to talk, tube advancement, decreased lung compliance
Term
Increased total respiration rate
Definition
Machine plus patient breaths (total) limit exceeded

Action: evaluate patient and or vent for high RR

Assess: vent rate set too high, patient has anxiety, pain increased PCO2, secretions

Risk for air trapping creating auto-peep
Term
Decreased mandatory tidal volume
Definition
Low exhaled mandatory breath tidal volume

ACTION: check source of air loss in circuit

Assess: loose crcuit connection, underinflated or incompetent cuff, pnuemothorax
Term
Decreased spontatneous breath volume
Definition
Low exhaled spontaneous breath tidal volume

ACTION: assess patient's deapth and rate of respiration

Assess: patient for hypoventilation
Term
Creating a safe environment with Ventilator
Definition
Vent and humidification alarms on

Never leave a pt once alarms are in silence mode (2 minutes)

Essential equipment bedside: ambu bag, extra O2 flowmeter, reintubation/retrach supplies, trach obturator

Suction set up, in working order

Pre/post oxygenate ptient when suctioning

When in doubt, ambu bag and call RT

Implemetn oral care interventions

implement ventilator bundle order set

Have plan to effectively ventliate patient regardless of trach type
Term
Effect of PEEP
Definition
Recruits Alveoli to increase lung volume and enchance gas exchange/oxygenation

may allow for decreased FiO2 due to alveiolar recruitment

Increases intrathoracic pressure = decreased preload, decreased CO, decreased BP, Increased PA pressure, increased ICP, decreased UP, increased ADH

May aid in decreasing pulmonary edema due to further decreased preload; may rebound effect when weaning = risk for pulmonary edema

Heart tones and BS more distant

DUe to high pressures, more at risk for subQ emphysema and alveolar rupture resulting in pneumothorac or tension pneumothorax
Term
S/S tension pneumothorax
Definition
Increased peak pressures
Increased HR and RR
Decreased BP
Decreased breath sounds on affected sides
Tracheal deviation to non affected side
Sudden SOB
Chest pain
Cyanosis

Prepare for needle aspiration/CT insertion
Term
VAP prevention
Definition
HOB 3-45 degrees
Oral Care: may include chlorhexidine (toothbrushing more effective than sponge toothettes)
Suction subglottic secretions
Term
Suctioning on ventilator
Definition
Pre oxygenate 100% at least 30 seconds before, suction less than 10 seconds

Monitor rhythm, and SP02 while suctioning

Dont draw ABGS for 30 minutes after suctioning
Term
Weaning:
Definition
Daily readiness assessment
1. underlying disease improved enough
2. oxygenation is adequate
3. inspiratory effort is afequate
4. hemodynamics stable
5. patient attempts spontaneously breathing

Weaning readiness criteria
1. underlying cause resolving
2. Adequate oxygenation: PEEP 5-8, FiO2 40-50%
3. pH >7.25
4. Hemodynamically stable
5. NIF <=-20

Respiratory <=30
MV <10 L
TV > 5 L
LOC
Hgb
patient emotionally ready

Usually takes 24 hours to recover from weaning induced respiratory muscle fatigue
Term
Focal assessment of ventilated patient:
Definition
Breath sounds
Respiratory effort
Resp. intolerance
Chest movement equal
interatction with vent
suctioning effect
secretion character
s/S infection
GI bleed
pain management
Hemodynamics
Weight gains
Condition of mucosa
Term
Progress Indicators
Definition
Devloping strength plus endurance
Physiologic/hemodynamics stability

A-A gradient
pCO2
pO2
VT
NIF
MV
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