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NUR265 Exam 2 Review – Accurate Answers To All
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Terms in this set (115)
Acute respiratory failure: classified by blood gas abnormalities; partial
pressure of arterial oxygen (Pao2) less than 60mm
Hg, arterial saturation (Sao2) less than 90% or partial
pressure of arterial carbon dioxide (Paco2) more
than 50mm Hg occurring with acidemia (pH<7.30)
• Ventilation failure is a problem in oxygen intake (ventilation) and blood
delivery (perfusion); perfusion is normal but
ventilation is inadequate; chest pressure does not
change enough to permit air movement into and out
of the lungs, too little oxygen reaches the alveoli and
carbon dioxide is retained leading to hypoxemia
o Extrapulmonary causes of Neuromuscular disorders (Myasthenia gravis,
ventilation failure Guillian-Barre, poliomyelitis)
Spinal cord injuries affecting nerves to intercoastal
muscles
CNS dysfunction (stroke, increased ICP, Meningitis)
Chemical depression (opioids, sedatives, anesthetics)
Massive obesity
Kyphoscoliosis
Sleep apnea
External obstruction/construction
,o Intrapulmonary causes of ventilation Airway disease (COPD, asthma)
failure Ventilation-perfusion mismatch:
• PE
• Pneumothorax
• ARDS
• Amyloidosis
• Pulmonary edema
• Interstitial fibrosis
• Oxygenation failure: chest pressure changes are normal and air moves in
and out w/o difficulty but does not oxygenate the
blood sufficiently, perfusion is decreased
oxygenation failure causes Low atmospheric oxygen concentration (high
altitudes, closed spaces, smoke inhalation, carbon
monoxide poisoning)
Pneumonia
CHF with pulmonary edema
PE
ARDS
Interstitial pneumonitis-fibrosis
Abnormal Hgb
Hypovolemic shock
Hypoventilation
Complications of nitroprusside therapy (thiocyanate
toxicity, methemoglobinemia)
oxygenation failure assessment o Assess for dyspnea (difficulty breathing; hallmark
sign of respiratory failure)
o Assess for change in respiratory rate or pattern
o Changes in lung sounds
o Manifestations of hypoxemia (pallor, cyanosis,
increased HR, restlessness, confusion)
o Manifestations of hypercarbia (high arterial blood
levels of carbon dioxide)
o May have decreased Spo2
o ABG most accurate assessment of oxygenation
,oxygenation failure TX o Oxygen therapy is appropriate for any patient with
acute hypoxemia
o Use to keep Pao2 level above 60 mm Hg while
treating cause of resp failure
o Mechanical ventilation may be needed
o Position patient upright in comfortable position
that facilitates ease breathing
o Use relaxation, diversion, and guided imagery to
decrease anxiety
o Energy saving measures (limit self-care activities,
no unnecessary procedures)
o MDI may be prescribed to widen bronchioles and
decrease inflammation to promote gas exchange
o Encourage deep breathing
Acute Respiratory Distress Syndrome: exchange of oxygen for carbon dioxide in the lungs
is inadequate for oxygen consumption and carbon
dioxide production within the body cells
• Unexpected and catastrophic pulmonary
complication occurring in a person with no previous
pulmonary problems; patients are critically ill and
managed in ICU
• Major site of injury is alveolar capillary membrane
• Interstitial edema causes compression and
obliteration of the terminal airways and leads to
reduced lung volume/compliance
• ABG levels reveal respiratory acidosis and
hypoxemia that do not respond to increased % of
oxygen
characteristics of ARDS o Hypoxemia that persists when 100% O2 given
o Decreased pulmonary compliance
o Dyspnea
o Non-cardiac associated bilateral pulmonary edema
No abnormal lung sounds are present on
auscultation b/c edema of ARDS occurs 1st in the
interstitial spaces and not the airways
o Dense pulmonary infiltrates on x-ray
, causes of ARDS o Exacerbation of COPD
o PN
o TB
o Contusion/neurological injuries
o Sepsis
o Burns
o Aspiration
o Inhaled toxins
o Emboli
o Drug OD
o Fluid overload
o Shock
o trauma
o DIC (disseminated intravascular coagulation)
s/s and assessment of ARDS o Decreased breath sounds
o Tachypnea, Dyspnea, hyperpnea, crackles or rales
o Intercostal retractions
o Cyanosis, pallor
o Hypoxemia: SpO2 <50mm Hg with FiO2 >60%
o Diffuse pulmonary infiltrates on x-ray ("white out")
o Verbalized anxiety/restlessness
• Plans/nursing interventions for ARDS o Identify and treat the cause of the ARDS
o Positioning for maximum lung expansion, fowlers
o Restrict fluid intake as perscribed
o Monitor for s/s of hypoxemia and oxygen toxicity
***Suction only when secretions are present
o Monitor breath sounds for pneumothorax
o Provide emotional support to decrease anxiety and
allow ventilator to "work" the lungs
o Vitals and cardiac monitoring
o Monitor ABG's routinely
• pH 7.35-7.45
pc02 35-45 **above 45 = hypercapnia
hco3 21-28
payment. benefits now
NUR265 Exam 2 Review – Accurate Answers To All
Questions
Save Groups
Terms in this set (115)
Acute respiratory failure: classified by blood gas abnormalities; partial
pressure of arterial oxygen (Pao2) less than 60mm
Hg, arterial saturation (Sao2) less than 90% or partial
pressure of arterial carbon dioxide (Paco2) more
than 50mm Hg occurring with acidemia (pH<7.30)
• Ventilation failure is a problem in oxygen intake (ventilation) and blood
delivery (perfusion); perfusion is normal but
ventilation is inadequate; chest pressure does not
change enough to permit air movement into and out
of the lungs, too little oxygen reaches the alveoli and
carbon dioxide is retained leading to hypoxemia
o Extrapulmonary causes of Neuromuscular disorders (Myasthenia gravis,
ventilation failure Guillian-Barre, poliomyelitis)
Spinal cord injuries affecting nerves to intercoastal
muscles
CNS dysfunction (stroke, increased ICP, Meningitis)
Chemical depression (opioids, sedatives, anesthetics)
Massive obesity
Kyphoscoliosis
Sleep apnea
External obstruction/construction
,o Intrapulmonary causes of ventilation Airway disease (COPD, asthma)
failure Ventilation-perfusion mismatch:
• PE
• Pneumothorax
• ARDS
• Amyloidosis
• Pulmonary edema
• Interstitial fibrosis
• Oxygenation failure: chest pressure changes are normal and air moves in
and out w/o difficulty but does not oxygenate the
blood sufficiently, perfusion is decreased
oxygenation failure causes Low atmospheric oxygen concentration (high
altitudes, closed spaces, smoke inhalation, carbon
monoxide poisoning)
Pneumonia
CHF with pulmonary edema
PE
ARDS
Interstitial pneumonitis-fibrosis
Abnormal Hgb
Hypovolemic shock
Hypoventilation
Complications of nitroprusside therapy (thiocyanate
toxicity, methemoglobinemia)
oxygenation failure assessment o Assess for dyspnea (difficulty breathing; hallmark
sign of respiratory failure)
o Assess for change in respiratory rate or pattern
o Changes in lung sounds
o Manifestations of hypoxemia (pallor, cyanosis,
increased HR, restlessness, confusion)
o Manifestations of hypercarbia (high arterial blood
levels of carbon dioxide)
o May have decreased Spo2
o ABG most accurate assessment of oxygenation
,oxygenation failure TX o Oxygen therapy is appropriate for any patient with
acute hypoxemia
o Use to keep Pao2 level above 60 mm Hg while
treating cause of resp failure
o Mechanical ventilation may be needed
o Position patient upright in comfortable position
that facilitates ease breathing
o Use relaxation, diversion, and guided imagery to
decrease anxiety
o Energy saving measures (limit self-care activities,
no unnecessary procedures)
o MDI may be prescribed to widen bronchioles and
decrease inflammation to promote gas exchange
o Encourage deep breathing
Acute Respiratory Distress Syndrome: exchange of oxygen for carbon dioxide in the lungs
is inadequate for oxygen consumption and carbon
dioxide production within the body cells
• Unexpected and catastrophic pulmonary
complication occurring in a person with no previous
pulmonary problems; patients are critically ill and
managed in ICU
• Major site of injury is alveolar capillary membrane
• Interstitial edema causes compression and
obliteration of the terminal airways and leads to
reduced lung volume/compliance
• ABG levels reveal respiratory acidosis and
hypoxemia that do not respond to increased % of
oxygen
characteristics of ARDS o Hypoxemia that persists when 100% O2 given
o Decreased pulmonary compliance
o Dyspnea
o Non-cardiac associated bilateral pulmonary edema
No abnormal lung sounds are present on
auscultation b/c edema of ARDS occurs 1st in the
interstitial spaces and not the airways
o Dense pulmonary infiltrates on x-ray
, causes of ARDS o Exacerbation of COPD
o PN
o TB
o Contusion/neurological injuries
o Sepsis
o Burns
o Aspiration
o Inhaled toxins
o Emboli
o Drug OD
o Fluid overload
o Shock
o trauma
o DIC (disseminated intravascular coagulation)
s/s and assessment of ARDS o Decreased breath sounds
o Tachypnea, Dyspnea, hyperpnea, crackles or rales
o Intercostal retractions
o Cyanosis, pallor
o Hypoxemia: SpO2 <50mm Hg with FiO2 >60%
o Diffuse pulmonary infiltrates on x-ray ("white out")
o Verbalized anxiety/restlessness
• Plans/nursing interventions for ARDS o Identify and treat the cause of the ARDS
o Positioning for maximum lung expansion, fowlers
o Restrict fluid intake as perscribed
o Monitor for s/s of hypoxemia and oxygen toxicity
***Suction only when secretions are present
o Monitor breath sounds for pneumothorax
o Provide emotional support to decrease anxiety and
allow ventilator to "work" the lungs
o Vitals and cardiac monitoring
o Monitor ABG's routinely
• pH 7.35-7.45
pc02 35-45 **above 45 = hypercapnia
hco3 21-28
