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NR-341 Exam 1 Study Guide / Complex Adult Health Exam 1 (100%)
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NR-341 Exam 1 Study Guide / Complex Adult Health Exam 1
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1Critical 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%
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