●
remember for shock ○
Neurogenic shock= hypotension, bradycardia, warm peripheries ○
All other types of shock= hypotension, tachycardia, cold peripheries Respiratory- 12 questions Physical Assessment --------------------------------------------------------------------------------------------------------------------------------------- ABG application & Acid base balance Arterial blood gas ●
Measures arterial o2 and co2 and ph ●
Assesses adequacy of alveolar ventilation Compensated PH: ●
PH IS NORMAL ●
but the PAo2 or HCO3 are abnormal Ph
------------7.35-7.45 Pao2---------
80-100 Paco2
---------35-45 Hco3-------
22-26 Sao2-------
95-100% ---------------------------------------------------------------------------------------------------------------------------------- Respiratory function Pulmonary edema ------------------------------------------------------------------------------------------------------------------------------ Acute Respiratory Failure (shunting, dead space) Perfusion without ventilation
(shunt) ●
Blockage that prevents oxygen from getting into the alveoli ●
There is perfusion (blood going through) but no ventilation (blood getting oxygenated) ●
result= no air exchange in that particular alveoli Ventilation without perfusion
(dead space) ●
Air is coming in and going into the alveoli (so there is ventilation) ●
There is an obstruction of
blood that is not circulating ---------------------------------------------------------------------------------------------------------------------------------- ARDS (complications) *severe form of acute lung injury with inflammation ARDS leads to: ● injury to alveolar capillary membrane ●
Severe ventilation/perfusion mismatch occurs ●
Alveolar collapse and crackles ●
Small airway constriction ●
Lung compliance decreased ●
shunting ●
Inflammation ●
Refractory hypoxemia- hypoxemia is not responding to treatment ●
Reduced lung compliance ●
Bilateral infiltrates on X Ray ●
Death from non pulmonary multi system organ failure with sepsis ●
Resembles pulmonary edema ○
Rapid onset dyspnea ○
Arterial unresponsive hypoxemia ○
ALI - fibrosing alveolitis with persistent severe hypoxemia ○
Decreased pulmonary compliance - stiff ●
Intercostal retractions -------------------------------------------------------------------------------------------------------------------------------------- Hypoventilation (patient at risk, symptoms) ------------------------------------------------------------------------------------------------------------------------------------------- Effects of PEEP ●
PEEP- (positive end expiratory pressure) improve oxygenation ○
Improves arterial oxygenation ○
Keeps a certain amount of pressure and air in lungs at the end of exhalation instead of letting it all out ■
This keeps the alveoli filled so they don’t collapse ○
May lower FIO2 ○
Goal is to get PAO2 over 60 and SPO2 over 90 ○
**can cause systemic hypotension by putting pressure on the heart ---------------------------------------------------------------------------------------------------------------------------------------------- Chest Trauma (flail chest) ■
Flail chest
(type of rib fracture where the rib is cracked in 2 or more places, creating a floating fractured piece) ●
When 2 different ribs crack in two different places ●
Results in retraction of chest on one side --------------------------------------------------------------------------------------------------------------------------------------------- Chest tubes (assessment) Airway Management ---------------------------------------------------------------------------------------------------------------------------------------------- Endotracheal intubation procedure Endotracheal tube (ETT) ●
Tube that goes into patient's mouth or nose and down the throat ○
Placement ■
Make sure the tube is going to the lungs, not the esophagus ●
Blue part is external ●
Markings on the tube mean ●
Cuff on the tube--what's the purpose? Why do we inflate it? ○
What are complications of the cuff? ●
Pilot balloon- how the cuff gets inflated (injected with 10cc syringe of air) ●
Reason for use ○
Patient is in respiratory failure ○
Surgery- this is how general anesthesia is given ------------------------------------------------------------------------------------------------------------------------------------------------------------------ Tracheostomy-----
Surgical procedure that Bypasses upper airway ●
Allows removal of secretions ●
Permits long term mechanical ventilation ●
Prevents aspiration of secretions ●
Can replace ET tube ●
Temporary or permanent ●
Secured by ties around neck ------------------------------------------------------------------------------------------------------------------------- Mechanical Ventilation (modes, assessment, management) ○
Assist control ■
Controlled mandatory ventilation ■
Provides full ventilator support ■
Preset tidal volume and RR ■
If patient initiates breath before the preset rate, the ventilator will deliver the preset volume and give an “assist breath” ○
Intermittent mandatory ventilation ■
Allows for combination of machine and regular breaths ■
Machine breaths are delivered at preset time and preset volume ■
Tidal volume is up to the patient ■
Allows patient to use their own muscles for ventilation ■
Potential increase to “buck” the ventilator ○
Synchronous ■
Machine delivers preset tidal volume and RR ■
Spontaneous breaths can occur ■
Machine senses patient breath and will not initiate machine breath ■
“Bucking the vent” is decreased ○
Constant positive airway pressure ○
Pressure support ----------------------------------------------------------------------------------------------------------------------------------------------------- Suctioning Purpose of sedative, analgesic agents Cuff assessment and management ------------------------------------------------------------------------------------------------------------------------------------- Weaning (trials, failure to wean causes) Weaning ●
Process of gradual withdrawal from dependence on vent or o2 ●
Terminal wean ○
Removal of ongoing ventilator support if the patient or family wants ○
Patient wishes ●
Cpap trial ○
Spontaneous breathing trial ○
Patient must be able to take a breath on their own -------------------------------------------------------------------------------------------------------------------------------------------- ECG Strips- 7 questions ●
Atrial flutter (saw tooth) ●
Atrial fib (uncoordinated, no P, but QRS is seen ●
V tach (tombstones) ●
V fib (uncoordinated, no P or QRS) ●
First degree (prolonged PR interval, greater than 5 tiny boxes) ●
Second degree type 1 (longer and longer PR interval followed by drop QRS) ●
Second degree type 2 (constant PR interval with drop of QRS) ●
Third degree heart block (P waves not related to QRS, QRS is wide and bizarre) ------------------------------------------------------------------------------------------------------------------------------------ Cardiac- 12 questions Symptoms of ventricular rhythms --------------------------------------------------------------------------------------------------------------------------------------------- Cardioversion ●
Used for persistent tachyarrhythmias WITH a pulse ●
Synchronized with patients HR When to do Cardio version ●
Persistent tachy
with a pulse ●
Causes hypotension, altered mental status, shock, ischemic chest pain ●
A fib ●
V tach with a pulse ●
A flutter ----------------------------------------------------------------------------------------------------------------------------------- Defibrillation ●
Used for tachydysrhythmias WITHOUT a pulse ●
Unsynchronized with patients HR When to use Defibrillation ●
No pulse ●
V fib ●
V tach without a pulse ------------------------------------------------------------------------------------------------------------------------------------ Pacemaker ●
Pacemaker is Indicated for ○
Slow pulse formation ○
AV or ventricular conduction disturbance ○
NASPE-BPEG
code for pacemaker functions ■
First letter- which chamber is being paced (V-ventricular A- atria D-duel) ■
Second letter- which chamber is being sensed by the pacemaker (V,A,D or O-off) ■
Third letter- type of response made by the pacemaker (I-inhibited, T-triggered, D-duel, O-off) ○
Complications of pacemakers ■
Infection ■
Bleeding or hematoma ■
Dislocation of lead ■
Cardiac tamponade ■
Skeletal muscle stimulation ■
Pacemaker malfunction ■
Pneumothorax or hemothorax ■
Script from irritation of electrode ○
Fixed vs Demand ■
Fixed ●
•Pacemaker is set to pace but not to sense ●
•Paces at a constant rate, independent of the patient’s intrinsic rhythm ■
Demand ●
•Pacemaker is set to to sense and respond to intrinsic activity ●
•Fires only when the patient needs it ○
Capture- ●
Term used to denote that the appropriate complex following the pacing spike -------------------------------------------------------------------------------------------------------------------------- CABG Heart failure Pulmonary edema ---------------------------------------------------------------------------------------------------------------------------------------------
remember for shock ○
Neurogenic shock= hypotension, bradycardia, warm peripheries ○
All other types of shock= hypotension, tachycardia, cold peripheries Respiratory- 12 questions Physical Assessment --------------------------------------------------------------------------------------------------------------------------------------- ABG application & Acid base balance Arterial blood gas ●
Measures arterial o2 and co2 and ph ●
Assesses adequacy of alveolar ventilation Compensated PH: ●
PH IS NORMAL ●
but the PAo2 or HCO3 are abnormal Ph
------------7.35-7.45 Pao2---------
80-100 Paco2
---------35-45 Hco3-------
22-26 Sao2-------
95-100% ---------------------------------------------------------------------------------------------------------------------------------- Respiratory function Pulmonary edema ------------------------------------------------------------------------------------------------------------------------------ Acute Respiratory Failure (shunting, dead space) Perfusion without ventilation
(shunt) ●
Blockage that prevents oxygen from getting into the alveoli ●
There is perfusion (blood going through) but no ventilation (blood getting oxygenated) ●
result= no air exchange in that particular alveoli Ventilation without perfusion
(dead space) ●
Air is coming in and going into the alveoli (so there is ventilation) ●
There is an obstruction of
blood that is not circulating ---------------------------------------------------------------------------------------------------------------------------------- ARDS (complications) *severe form of acute lung injury with inflammation ARDS leads to: ● injury to alveolar capillary membrane ●
Severe ventilation/perfusion mismatch occurs ●
Alveolar collapse and crackles ●
Small airway constriction ●
Lung compliance decreased ●
shunting ●
Inflammation ●
Refractory hypoxemia- hypoxemia is not responding to treatment ●
Reduced lung compliance ●
Bilateral infiltrates on X Ray ●
Death from non pulmonary multi system organ failure with sepsis ●
Resembles pulmonary edema ○
Rapid onset dyspnea ○
Arterial unresponsive hypoxemia ○
ALI - fibrosing alveolitis with persistent severe hypoxemia ○
Decreased pulmonary compliance - stiff ●
Intercostal retractions -------------------------------------------------------------------------------------------------------------------------------------- Hypoventilation (patient at risk, symptoms) ------------------------------------------------------------------------------------------------------------------------------------------- Effects of PEEP ●
PEEP- (positive end expiratory pressure) improve oxygenation ○
Improves arterial oxygenation ○
Keeps a certain amount of pressure and air in lungs at the end of exhalation instead of letting it all out ■
This keeps the alveoli filled so they don’t collapse ○
May lower FIO2 ○
Goal is to get PAO2 over 60 and SPO2 over 90 ○
**can cause systemic hypotension by putting pressure on the heart ---------------------------------------------------------------------------------------------------------------------------------------------- Chest Trauma (flail chest) ■
Flail chest
(type of rib fracture where the rib is cracked in 2 or more places, creating a floating fractured piece) ●
When 2 different ribs crack in two different places ●
Results in retraction of chest on one side --------------------------------------------------------------------------------------------------------------------------------------------- Chest tubes (assessment) Airway Management ---------------------------------------------------------------------------------------------------------------------------------------------- Endotracheal intubation procedure Endotracheal tube (ETT) ●
Tube that goes into patient's mouth or nose and down the throat ○
Placement ■
Make sure the tube is going to the lungs, not the esophagus ●
Blue part is external ●
Markings on the tube mean ●
Cuff on the tube--what's the purpose? Why do we inflate it? ○
What are complications of the cuff? ●
Pilot balloon- how the cuff gets inflated (injected with 10cc syringe of air) ●
Reason for use ○
Patient is in respiratory failure ○
Surgery- this is how general anesthesia is given ------------------------------------------------------------------------------------------------------------------------------------------------------------------ Tracheostomy-----
Surgical procedure that Bypasses upper airway ●
Allows removal of secretions ●
Permits long term mechanical ventilation ●
Prevents aspiration of secretions ●
Can replace ET tube ●
Temporary or permanent ●
Secured by ties around neck ------------------------------------------------------------------------------------------------------------------------- Mechanical Ventilation (modes, assessment, management) ○
Assist control ■
Controlled mandatory ventilation ■
Provides full ventilator support ■
Preset tidal volume and RR ■
If patient initiates breath before the preset rate, the ventilator will deliver the preset volume and give an “assist breath” ○
Intermittent mandatory ventilation ■
Allows for combination of machine and regular breaths ■
Machine breaths are delivered at preset time and preset volume ■
Tidal volume is up to the patient ■
Allows patient to use their own muscles for ventilation ■
Potential increase to “buck” the ventilator ○
Synchronous ■
Machine delivers preset tidal volume and RR ■
Spontaneous breaths can occur ■
Machine senses patient breath and will not initiate machine breath ■
“Bucking the vent” is decreased ○
Constant positive airway pressure ○
Pressure support ----------------------------------------------------------------------------------------------------------------------------------------------------- Suctioning Purpose of sedative, analgesic agents Cuff assessment and management ------------------------------------------------------------------------------------------------------------------------------------- Weaning (trials, failure to wean causes) Weaning ●
Process of gradual withdrawal from dependence on vent or o2 ●
Terminal wean ○
Removal of ongoing ventilator support if the patient or family wants ○
Patient wishes ●
Cpap trial ○
Spontaneous breathing trial ○
Patient must be able to take a breath on their own -------------------------------------------------------------------------------------------------------------------------------------------- ECG Strips- 7 questions ●
Atrial flutter (saw tooth) ●
Atrial fib (uncoordinated, no P, but QRS is seen ●
V tach (tombstones) ●
V fib (uncoordinated, no P or QRS) ●
First degree (prolonged PR interval, greater than 5 tiny boxes) ●
Second degree type 1 (longer and longer PR interval followed by drop QRS) ●
Second degree type 2 (constant PR interval with drop of QRS) ●
Third degree heart block (P waves not related to QRS, QRS is wide and bizarre) ------------------------------------------------------------------------------------------------------------------------------------ Cardiac- 12 questions Symptoms of ventricular rhythms --------------------------------------------------------------------------------------------------------------------------------------------- Cardioversion ●
Used for persistent tachyarrhythmias WITH a pulse ●
Synchronized with patients HR When to do Cardio version ●
Persistent tachy
with a pulse ●
Causes hypotension, altered mental status, shock, ischemic chest pain ●
A fib ●
V tach with a pulse ●
A flutter ----------------------------------------------------------------------------------------------------------------------------------- Defibrillation ●
Used for tachydysrhythmias WITHOUT a pulse ●
Unsynchronized with patients HR When to use Defibrillation ●
No pulse ●
V fib ●
V tach without a pulse ------------------------------------------------------------------------------------------------------------------------------------ Pacemaker ●
Pacemaker is Indicated for ○
Slow pulse formation ○
AV or ventricular conduction disturbance ○
NASPE-BPEG
code for pacemaker functions ■
First letter- which chamber is being paced (V-ventricular A- atria D-duel) ■
Second letter- which chamber is being sensed by the pacemaker (V,A,D or O-off) ■
Third letter- type of response made by the pacemaker (I-inhibited, T-triggered, D-duel, O-off) ○
Complications of pacemakers ■
Infection ■
Bleeding or hematoma ■
Dislocation of lead ■
Cardiac tamponade ■
Skeletal muscle stimulation ■
Pacemaker malfunction ■
Pneumothorax or hemothorax ■
Script from irritation of electrode ○
Fixed vs Demand ■
Fixed ●
•Pacemaker is set to pace but not to sense ●
•Paces at a constant rate, independent of the patient’s intrinsic rhythm ■
Demand ●
•Pacemaker is set to to sense and respond to intrinsic activity ●
•Fires only when the patient needs it ○
Capture- ●
Term used to denote that the appropriate complex following the pacing spike -------------------------------------------------------------------------------------------------------------------------- CABG Heart failure Pulmonary edema ---------------------------------------------------------------------------------------------------------------------------------------------
