NR-341 Exam 1 Study Guide / Complex Adult Health Exam 1

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Critical Care Exam 1 Guide
Nursing Assessments

Acute respiratory failure
 Diagnostic Tests
o ABGs, Chest x-rays, CT, pulmonary function tests, end tidal CO2 monitoring, bronchoscopy.
 Assessments
o Lung sounds, work of breathing, use of accessory muscles, chest expansion, nasal flaring,
respiratory rate, pulse ox
 Interventions
o Ineffective airway clearance  reposition patient
o ARF
 Causes: pulmonary edema, atelectasis, pneumonia, COPD, asthma, ARDS, thoracic,
spinal or head injuries, drug overdose, neuromuscular disorders
 Type 1 - hypoxemic or oxygenation failure
 PAO2 less th
 an 60 MMHG
o Normal PaO2 = 80 - 100
 Hypoventilation
o Hyperventilation causes further issues when trying to correct this
 Intrapulmonary shunting
o Blood did not get oxygenated and dispersed to rest of body system
o Blood that is shunted from the right side of the heart to the left
without oxygenation.
o Based on rate ventilation and perfusion: Rate of ventilation= rate of
perfusion; ratio of VQ = 1
o Based on amount of ventilation and perfusion:
 Normal ventilation (V) IS 4 L/MIN
 Normal perfusion (Q) IS 5L/Min
 Normal V/Q Ratio IS 4/5 or 0.8
 VQ scan patient must lie for 30 minutes
o Tissue hypoxia  anaerobic metabolism and lactic acidosis
o Normal Cardiac output
 600 – 1000 ML/MIN of O2
 Low cardiac output  decrease O2 blood to tissues  anaerobic
metabolism  production of lactic acid  metabolic acidosis
 Type 2 - hypercapnic or ventilator failure
 PACO2 > 50 MM HG
 Increase in PaCO2 (hypercapnia) due to decrease O2 in body and CO2 can be
blown off
 Increase in ventilation  excess CO2 blown off (hypocapnia)
 VQ mismatch  not 1:1
 Assessment of respirator failure: most common  hypoxemia  restlessness
 Medical management: O2, bronchodilators, corticosteroids, ventilators, transfusion,
nutritional support, hemodynamic monitoring

, 2

 HGB 12- 16
 Anemic is less than 8 HGB
o Respiratory failure causes
 Failure to ventilate
 Failure to oxygenate
 Failure to protect airway

Acute Respiratory Distress Syndrome (ARDS)
 Noncardiogenic pulmonary edema- pulmonary edema not caused by a cardiac problem.
 Diagnostic criteria
o 1. PaO2/FiO2(decimal) ratio of less than 200 – PaO2 divided by Fi02 … 100 divided 21 =
 Optimal Ratio 476.19
 ***Decreasing PA02 levels despite increased FIO2 administration
o 2. Bilateral infiltrates not explained by something else. (Normally air should be black, you will
see white puffy stuff all over if you have this)
 Risk Factors. 4 Factors
o Sepsis #1***
o Pneumonia
o Trauma
o Aspiration of Gastric contents
 Pathophysiology
o Basic underlying patho: damage to type II pneumocyte, which produces surfactant
o 4 steps
 1. Injury to the lung that stimulates the inflammatory response (either direct or indirect)
with stimulates inflammatory response. Inflammatory cells and their mediators damage
the alveolocapillary membrane.
 2. Onset of pulmonary edema (blood cell, cell debris, stuff)
 3. Alveoli start to collapse. Production of surfactant stop and alveoli collapse. Lungs
become less compliant.
 4.Lungs become stiff and noncompliant. Lung becomes fibrotic. Severe gas exchange
impairment.
 Diagnostic Tests
o Chest x-ray
 Symptoms or ARDS:
o Dyspnea and tachypnea and hypoxemia, that does not improve with supplemental oxygen
therapy.
o Elevated PACO2 > 50 MM of HG
o Decreased PAO2 < 60 MM of HG
o V/Q mismatch
o O2 Satureation < 90%
o Hyperventilation with normal breath sounds
o Respiratory alkalosis
o Increased temperature and pulse
o Worsening chest x-rays that progress to “white out”
o Increased PIP on ventilation
o Eventual severe hypoxemia not improved with O2 therapy
o Late stages -> Eventually will hypoventilate -> respiratory acidosis

, 3

 Treatment of ARDS
o Treat the cause, more supportive care
o Oxygenation and ventilation**KEY to treating ARDS
 Positive end-expiratory pressure (PEEP) – high amounts of PEEP 10-15cm of peep.
 Possible non-traditional modes of ventilation – oscillator or nvrp
 Decrease Oxygen consumption
o Comfort
 Sedation
 Pain relief
 Neuromuscular blockade
o Positioning
 Prone positioning
 Better profusion to posterior part of the lung. Takes weight of heart off of the
lungs
 Protect airway! Face down.. In regular bed patient will be with head on side.
 Skin integrity – different pressure points (hips, knees)
 Continuous lateral rotation therapy
 Complications: DIC, long term pulmonary affect, organ failure, death
o Fluid and electrolyte balance
o Adequate nutrition
o Psychosocial support – more for family
o Prevention of complications
 Thrombus or embolus formation, DIC, death, Organ failure, pulmonary affects
 Acute Respiratory Failure as a result of Underlying Disease
o Several conditions both acute and chronic can result in Acute Respiratory Failure
 COPD
 Asthma Exacerbation
 Pneumonia - All types
 Pulmonary Embolism  pulmonary angiogram is a definitive diagnosis
o Treatment of ARF in Chronic Diseases (not really going to study this)
 Treat the underlying cause
 COPD - Bronchodilators, corticosteroids, antibiotics (infection)
 Asthma - IV corticosteroids, bronchodilators
 Pneumonia - Antibiotics, fluids
 Pulmonary Embolism - DVT prophylaxis, thrombolytics, heparin, vena cava filter

Maintain Oxygenation - Administer oxygen, ventilate if needed, minimize demands
Ventilation
 Indications for ventilation: To support patient’s respiratory system until the cause of the respiratory
failure has been treated. This is a temporary treatment. Patients are not meant to be on ventilator forever.
 Reasons to be Ventilated:
o Hypoxemia - PaO2 ≤ 60 mm Hg on FiO2 > .50
o Hypercapnea - PCO2 ≥ 50 mm Hg with pH ≤ 7.25
o Norms:
 PAO2: 80 – 100
 SaO2 90 – 100%