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NR 340 Critical Care Exam 1 StudyGuide (Version 3), NR 340 Critical Care Nursing
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NR 340 Critical Care Exam 1 StudyGuide (Version 3), NR 340 Critical Care Nursing
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Critical Care Exam 1 Guideursing Assessments
● History and Physical
o Smoking (how long, how much, second hand exposure)
o Hx: family, asthma, COPD, Pneumonia, intubations (why and how long), medications, allergies, work exposure
● 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
ABGs
7.35-7.39 acidic
PH 7.35 (acidic) – 7.45 (basic) 7.4 neutral
7.41-7.45 basic
RR ↑ = CO2↓
PaCO2 45 (acidic) – 35 (basic)
RR ↓ = CO2↑
HCO3 22 (acidic) – 26 (basic)
PaO2 80-100 >80 = hypoxemic
● Compensations
o Uncompensated or none
▪ pH – abnormal, CO2 or HCO3 – one or the other abnormal but not both.
o Partial compensation
▪ pH/Everything is abnormal and CO2 and HCO3 are opposite
o Fully compensated
▪ pH – normal, HCO3 and CO2 are opposite
o Compensation happens using either Kidneys or Lungs
● Imbalanced States
o Respiratory Acidosis, Metabolic Acidosis, Respiratory Alkalosis, Metabolic Alkalosis,
o ***Uncompensated Combined Acidosis/alkalosis (both respiratory and metabolic). When Both CO2 and HCO3 are
acidic/basic
xygen and Oxygen Delivery
Purpose of Oxygen: To treat or prevent hypoxia.
● 21% of 02 is room air.
● Humidification- To prevent dryness of mucous membranes. More than 4L of 02 you need to put on
humidification.
● High flow nasal cannula-thicker and can go up to 15 liters- 40 liters needs humidifier
● Nursing Implications: monitor o2 saturations, respiratory rate, accurately documents how much oxygen patient
is on, skin care – skin break down top of the ears bottom of the chin. Make sure nasal cannula is in the patients
nose.
● If patient does not have an order you cannot put oxygen on: It is considered a medication.
Oxygen Device Amount of Oxygen Delivered Nursing Considerations
, Nasal Cannula 1L to 6L/min (24-44% FiO2) Humidification is added for rates greater than 4L/min. Flow rates
greater than 6L are not effective. If oxygenation is not restored at 6L
than another device is required.
Simple Face Mask 5L-12L (30-60% FiO2) Secure fit, monitor for skin breakdown and teach the patient to wear
the mask. Do not use less then 5 L
Venturi Mask 24-40% FiO2 Appears as a simple face mask with an adapter. The adapter determines
the FiO2 and the amount of oxygen that should be set in L/min. Given
when need a SPECIFIC amount of oxygen.
Partial Nonrebreather Mask 35-60% FiO2 Contains a reservoir bag to allow for more oxygen. Contains 1 one-way
valve to ensure that the patient breaths in a higher concentration of
oxygen. Important: The bag needs to inflate.
Nonrebreather Mask 60-80% FiO2 Contains a reservoir bag to allow for more oxygen. Contains 2 one-way
valves to ensure that the patient breaths in a higher concentration of
oxygen. Important: The bag needs to inflate.
Aerosol and Humidity Delivery Systems 10 L/min and FiO2 is adjusted Humidity face mask for patients without an artificial airway. T-Piece is
used for a patient with an endotracheal tube. Trach collar is used for a
patient with tracheostomy. Usually for Extubated patients/ after we
have removed a breathing tube. Humidifies airway.
Manual Resuscitation Bag (aka ambu 15 L/min Used to manually deliver breaths to the patient who is either not
bag) breathing or is breathing ineffectively
Face Tent: High humidity also, patient how has a laryngial resections, some type of
nasal packing, if you cant use nasal cannula. Sits under chin.
Trach Collar: Someone with a tracheostomy needs O2
T Piece: Used when somebody is going be taken of artificial ventilator, use to see
if patient can maintain his or her own airway safely. If patient can do the
work of breathing they can be extabated. Usually used for weaning.
Amub Bag When it is connected to oxygen it will provide 100% O2. Every patient in
ICU should have this bed side
Ventilator: Provides breathing oxygen,
irway Management
● Positioning
o Maintain proper head and neck alignment
o High fowlers or tripod position in order to allow proper chest expansion
● Devices
o Oral Airway or Oropharyngeal.
▪ Purpose: Prevents tongue from dropping back and occluding pharynx.
▪ Not for patients who are awake, causes gag reflex and is very uncomfortable. Used for patients who are
unconscious or semi conscious because they are very comfortable and can trigger gag reflex.
, ▪ Can also be called bite block and can be used for people who have endotracheal tubes.
o Nasopharyngeal Airway also called nasal trumpets.
▪ Inserted through the nose
▪ Used when oral airway is contraindicated
▪ Used in awake patients because it is better tolerated better
o Endotracheal Intubation
▪ Usually ETT inserted through the mouth due to infections reasons if inserted in the nose – mouth or nose
but usually in mouth.
▪ Has a cuff near base of tube to keep it in place
▪ Some have suction ports in order to suction secretions and prevent Ventilator Acquired Pneumonia (VAPs)
▪ Tube has CM markings to monitor for proper placement
▪ Functions: Maintain an airway, Remove secretions, Prevent aspiration, Provide mechanical ventilation
▪ Sucks out secretion balloon of endotracheal tube.
▪ Aspiration of oropharyngeal secretions is one of the leading causes of a VAP (Ventilator associated
pneumonia)
ntubation
● Placement is done by physicians, can be done by paramedics and nurse anesthetist. Not done by nurses. Some respiratory
therapists are trained.
● Intubation is official term for putting an endotracheal tube in a patient
● Nurses responsibility
o #1 Need to know what equipment is used and where to find it
o How to assemble the equipment
o Call respiratory therapist for ventilator
o Make sure suction equipment works and is at bedside.
o Position the patient. Usually intubation is done from the HOB (as close to the head of the bed as possible) –
sometimes might need to remove the head board.
o Remove anything that may cause aspiration (dentures, tongue rings, etc.) Anything in the patients mouth that could
be dislodged.
o Insert or maintain function IV for medication administration (Most common drugs used: profolol, verstatin/versed) –
Important to sedate patient.
o Assist the position
● Verifying tube placement
o End tidal CO2 detector - changes color as CO2 reaches the tube so you know it is in the lung.
o Auscultation – clear breath sounds in both lungs. If in esophagus you might hear gurgling, you wont hear breath
sounds. If you hear breath sounds on the right and not the left it has gone down to far. Bilateral Breath Sounds.
o Esophageal detector device
o Chest x-ray – best method to verify placement. Tip or end of tube should be placed 3-4cm above the carina (where
trachea splits/bifurcates) this is important so we are oxygenated both lungs. If it is too low pull it out.
● Strategies for Securing ETT
o Tape or securement device – it just depends on what the resp. prefers.
o Usually done by respiratory therapist.
o Problem with securement device is skin integrity!
● Document important information
o That patient was intubated
o Important: Document centimeters marking where the lips meet the tube to monitor for proper placement. – In case
the tube moves. Ex: you document at 13cm… you come back later and it is at 15cm.. Call the doctor you need to get
an xray to see where the tube is.
o Post intubation assessment
o Inform physician if patient needs chest x-ray
racheostomy
● Indications: Either Long-term ventilator support airway support - For someone who cant get off the ventilator or someone
who can’t protect there away. Usually about 10- 14 days. But no set time depends on the patient.
● Can be done in the OR or at the bedside
● Important have at bed side: Always have extra trach tube in case one falls out.
● Also have obturator (used to keep airway open) at bedside in case patient removes trach if confused. You need to put this in
when patient takes it out so the hole doesn’t close.
ndotracheal Suctioning
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