Exam IV review
Respiratory alkalosis partially compensated
pH PCO2 HCO-3
↑7.45 ↓35 ↓22
Metabolic acidosis partially compensated
pH PCO2 HCO-3
↓7.35 ↓35 ↓22
* All three trend downward (↓)
Respiratory alkalosis fully compensated
pH PCO2 HCO-3
(norm) ↓35 ↓22
Metabolic alkalosis fully compensated
pH PCO2 HCO-3
7.40-7.45 ↑45 ↑26
pH is at the high end of normal!
Ventilator setting that affects nursing and our patient is ______
Positive End Expiratory Pressure
PEEP: What is it,
Pressure in the lungs that keeps alveoli open at the end of expiration; prevents complete alveoli collapse & can improve hypoxemia or reduce vent associated lung injury.
To (↑) increase the volume of gas remaining in the lungs at the end of expiration in order to (↓)decrease the shunting of blood through the lungs & improve gas exchange.
PEEP: High setting- what system does that affect?
The cardiovascular system.
↑ PEEP creates intra-thoracic pressure and ↓ venous return causing DECREASED CARDIAC OUTPUT causing ↓perfusion and ↓ oxygen delivery (and etc.,)
Mechanically ventilated patient PEEP setting should be__ to __ cm H20
3 / 5
VAP bundle: (5)
- HOB 30°
- Waken daily & assess readiness to wean
- Stress ulcer prophylaxis
- DVT prophylaxis
- Oral care (chlorhexidine in some bundles)
Prevention of VAP: (13)
- Hand washing & standard precautions
- Ventilator bundle (see above or previous card)
- Prevent transmission
- Sterile water in circuit
- Drain condensate AWAY from patient
- *Avoid NS during suctioning (never let RT put NS down your pt's throat for suctioning- can cause pneumonia)
- Prevent infection & aspiration
- Avoid re-intubation (don't allow pt. to pull out tube)
- Oral intubation ( preferred)
- ETT w/continuous aspiration of subglottic secretions - will cause pneumonia
- Sedation & weaning protocols
- Aseptic suctioning of endotracheal tube (ET)
ET tube placement: Where should it be located?
2-3 cm above the carina
Checking ET tube placement:
- Check for bilateral breath sounds (immediate after intubation)
- For confirmation: Xray or end tidal CO2
How do we know if a patient has been intubated properly?
- Bilateral breath sounds
- Symmetrical chest expansion
- Verified by Xray & ETCO2 detector (very reliable)
* Secure tube when placement is verified & record cm @ lipline for reference*
How can you tell if ET tube is in Rt. mainstem bronchus?
No breath sounds on left side & really loud breath sounds on right side.
* Unilateral breath sounds- to right side!
Do we load up COPD patients w/oxygen?
No, it will knock out their respiratory drive!
*They get their drive from hypoxia
Initial sign of hypoxemia
CNS signs of hypoxemia:
Restlessness, anxiety, confusion, fatigue, agitation & coma
Hypertension followed by hypotension
↑ Heart rate
Cool & dry
--- Late signs---
Use of accessory muscles
What do you do if you are in a room and a vent alarm goes off?
Assess for one minute, if you cannot figure out what is going on, bag pt. until RT arrives.
High risk DVT patients: Intervention for them if going home & cannot use an antcoagulant
Vena cava filter
AKA- IVC or greenfield filter
Other options (non invasive):
SCD's, ted hose, walking
Can you use heparin to dissolve a Pulmonary embolism (PE)
NO! Heparin is an anticoagulant not a thrombolytic.
Thrombolytics dissolve clots & PE's
- Assess pt frequentily for VTE
- Compression stocking or intermittent pneumatic compression device
↓ unfractionated heparin
Low-molecular weight Heparin (lovenox, fragmin, Innohep)
Most common cause of AKI in critically ill pt
Most common type of intra-renal injury
Acute tubulor necrosis (most common prerenal)
Acute tubulor necrosis ATN (most common prerenal)
Usually caused by a lack of oxygen to the kidney tissues (ischemia of the kidneys). It may also occur if the kidney cells are damaged by a poison or harmful substance.
The internal structures of the kidney, particularly the tissues of the kidney tubule, become damaged or destroyed. ATN is one of the most common structural changes that can lead to acute renal failure.
ATN is one of the most common causes of kidney failure in hospitalized patients.
Effective against gram negative basili bacteria
Serum creatinine level ratio: 0.6 what should the BUN be
Ratio is 10:1 or 20:1 (anything over 20:1 is NOT metabolic)
* Hint, hint- take your creatinine and multiple by 10 & your BUN and multiply it by 20
Severe flank pain, blood in urine, what renal injury is expected?
* after urine
Normal urine output
Example: Your patient had an output of 250 mLs in 6hrs and weighs 77kg. Is that an adequate amount of urine output for that time frame?
0.5-1mL/kg/hr---> is normal output
Example: 250/6hr=41.666/77kg = 0.54
1kg weight gain ___ mL
1 pound weight gain ____ mL
When giving a patient fluid for kidney injury, frequently assess ____ _____ to be sure we are not fluid overloading them
Listening for adventitious lung sounds (crackles, etc.,)
* If you hear crackles, fluid is not properly dispersed and expelled
What is best used for removal of K+ from the body
Given orally or by enema
CRRT- Continous renal replacement therapy
For unstable patients not suitable for HD or PD.
* More gradual
Benefit- staff nurse @ bedside, minimal heparin, flexible fluid administration, more gradual solute removed.
Percutaneous catheter: What to be aware of
Infection- because these catheters stay in longer that the average
How long do you have to wait prior to using newly placed fistula?
AV fistula assessment
* If any of those are absent, notify the physician
If your patient is on HD and dialysizing and they start to complain of headache, nausea, show signs of disorientation, what could those be a sign of? What do you do?
* Treat symptoms then stop dialysis and notify the physician
* Seizure is another symptom of disequilibrium- be prepared to administer an anticonvulsant.*
The nurse assesses for which electrolyte disorder in the client w/metabolic alkalosis?
The nurse monitors for which acid-base imbalance in the client who has received 6 units of packed RBCs in the past 6hrs secondary to blood loss in surgery?
The nurse determines which client as at greatest risk for acidosis?
The adult client w/pneumonia
What do you do if your patient becomes hyptensive during dialysis?
- Slow dialysis
- Return fluid
- Give albumin
Slow, continuous, ultra filtration (SCUF):
Only takes fluid off
Only for volume overload patients
Remove water & solutes using dialysate
CRRT does not use _________.
Peritoneal dialysis: Patient has fever, chills- what do we assess?
Return fluid (effluent) for cloudiness.
*Cloudyness indicates infection -Peritonitis
Main goals for treating cystic fibrosis (CF)
- Antibiotic therapy- pneumonia (P.aeruginosa is the most common)
- Air way clearance- mucolytic agents (Recumbinant human Dnase- Pulmozyme **drug of choice)
- Nutrional support- enteral w/pancreatic enzymes (tube feeding)`
Step to follow when a pt. ventilator alarms : High pressure
- Assess for kinks, in tube or vent circuit
- Assess anxiety & sedate pt biting or gagging on tube (use airway secure device
- Observe coughing, ausculte lung sounds for need of suction or bronchodilator
- Use communication device if pt is trying to talk
- Empty water from the traps
- Assess for worsening pulmonary patho resulting in ↓ in lung compliance
- Call RT if alram persists
Step to follow when a pt. ventilator alarms : Low pressure
- Asess for leaks in vent circuit or disconnection of vent circuit from airway; reconnect if so!
- Manually vent pt w/bag mask device if malfunction noted
- Notify RT to troubleshoot alarm
High pressure / Low pressure- which alarm is harder to find the problem?
Low pressure alarms are HARDER find the problem!!!
High pressure alarm is ____ to find the source of alarm
The client has the following arterial blood results: pH 7.12; HCO3- 22; PCO2 65; PO2 56mm Hg. The nurse correlates these values to which clinical situation?
A) Diabetic ketoacidosis in a person w/emphysema
B) Complete tracheal obstruction related to aspiration of a hot dog
Complete tracheal obstruction related to aspiration of a hot dog
The client has just experienced a 90 second grand mal seizure & has the arterial blood gas values shown below. How should the nurse be prepared to intervene?
pH 6.88; HCO3- 22; PCO2 60, PO2 50
Applying oxygen by mask or nasal cannula
*The client has experienced a combination of metabolic & acute respiratory acidosis through heavy skeletal muscle contractions & not gas exchange. When the seizures have stopped & the client can breathe again, the fastest way to return to acid-base balance is to administer oxygen.
The nurse recognizes which client as at greatest risk for alkalosis?
An adult client with a critical illness receiving total parenteral nurtrition
* TPN is lactated which rapildly converted in the body to bicarbonate
The postanesthesia care unit nurse is caring for a client who has just undergone an open whipple procedure. The client has multiple tubes & drains in place after the surgery. Which will the nurse assess first?
Endotracheal tube w/40% FiO2
* Airwy & oxygenation status should always be assessed first, with other assessments completed afterward
A nurse caring for four clients knows that which client is most at risk for the development of acute respiratory acidosis?
38YO male who had abdominal surgery & has a respiratory rate of 8/min
* respirations @ 8/min places this patient at highest risk for acidosis from the retention of CO2
The nurse correlates which condition to the following arterial blood gas values: ph 7.48; HCO3- 22; PCO2 28; PO2 98
Hyperventilation after receiving news of family member's death
A nurse is caring for 4 patients on the medical surgical floor. Which patient is at highest risk for metabolic alkalosis?
A pt. on high doses of lasix (furesomide) for fluid overload
PEEP: Normal range
5 cm H20
*Will be 10-12 if pt has more/worse respiratory problems
In assessing the pt 6hrs after a radical nephrectomy for renal cell carcinoma, the nurse notes that the client's blood pressure has decreased from 134/90 to 100/56mm Hg & the urine output is 20ml for this past hour. Which is the nurse's best action?
Notify the health care provider
A client w/suspected diminished renal functioning has come to the outpatient clinic for an appt. What lab test would be most accurate in assess this client's renal reserve?
24hr urine for creatinine clearance
What assessment would help the nurse determine the patency of a client's AV fistula for dialysis?
The presence of a thrill & bruit
A nurse is caring for a client who is undergoing peritoneal dialysis. The nurse notes the color of the effluent to appear cloudy yellow. What is the nurse's best action?
Notify the health care provider
When providing care for a client receiving peritoneal dialysis, the nurse notices that the effluent is cloudy. Which intervention is the most important for the nurse to carry on?
Sending a specimen of the effluent for culture & sensitivity
The pt reports the regular use of the following medications. Which one alerts the nurse to the possiblity of renal impairment when used consistently?
b) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Nonsteroidal anti-inflammatory drugs (NSAIDs)
* NSAIDs inhibit prostaglandin production & decrease blood flow to the nephrons. They can cause interstitial nephritis & renal impairment
The client w/CKD is prescribed drugs to be given @ 0900, digoxin & epoetin alfa (Epogen). He is complaining of nausea & vomiting. Which action will the nurse take first?
Holds the dose of digoxin
* Signs of dig toxicity are N/V. Digoxin is exreted by the kidneys, careful with CKD patients*
The nurse is caring for a client who is receiving peritoneal dialysis (PD). Which nursing intervention has the greatest priority when performing a dialysis exchange?
Use sterile technique when hooking up dialysate bags
During HD, a pt. w/CKD develops headache, nausea, vomiting, and restlessness. After notifiying the physician, which action by the nurse is most appropriate?
Preparing to administer an anticonvulsant
* HA, N/V & restlessness may be signs of dialysis disequilibrium syndrome. * Rapid ↓ in fluid & the BUN level can cause cerebral edema & ↑ICP.
* Early recognition & treatment of this syndrome are essential for preventing a life-threatening situation
A client w/mildly diminished renal reserve asks how to prevent further damage to the kidneys. What is the nurse's best response?
"Ask if any newly prescribed meds, foods, or diagnostic test pose a risk to your kidney function."
A client w/ARF has begun treatment w/ continuous arteriovenous hemofiltration (CAVH). For what complication of this treatment should the nurse monitor this client?
* The greatest risk for clients undergoing CAVH is bleeding resulting from the anticoagulants used to prevent membrane clotting
In planning care for the client w/renal cell carcinoma, the nurse monitors for which electrolyte imbalance?
Which of the following clients is most at risk for developing postrenal failure
Client diagnosed w/renal calculi
* Postrenal failure includes disorders that OBSTRUCT THE FLOW OF URINE, such as renal calculi
Can a patient with CRF who is on HD and a sodium-and potassium restricted diet eat/use salt substitutes?
Salt substitutes contain potassium & therefore should not be used
* Patients are taught to avoid salt substitutes because most contain potassium. In CRF, hyperkalemia is a danger because it can lead to caridac dysrhythmias.