NUR 324 Review

NUR 324 review is graphics intensive, so there are 2 PowerPoint files for the review. Use this one as a PowerPoint slide show presentation, so that the questions and answers come up one at a time, not just as a print out for ECG review and others. There are website addresses imbedded that can only be clicked for direct access when in slide show view.

ECG review - slides 3- 22 ABG review - slides 23 25 Acute renal failure slides 26 31 Renal diet slide 32 Peritoneal dialysis slide 33 37 (the type of dialysis a nurse
at bedside will most likely do) site, and teach)

Contents of this PPT

HD AV Access slide 38 40 (must prepare patient, protect

Other renal slides 41 43 Hematological slides 44 58 Respiratory tracheostomy slide 59 Laryngeal slide 60-66 Intubation, mechanical ventilation slides 67 - 77 ARDS slides 78 & 79 Bioterrorism slides 80-86

Electrical basics
ECG paper moves at 25 mm/sec Small black square = _____ sec. Larger Aqua block = _____ sec.(5 little squares) Each 25 little squares = 5 bigger blocks = 1 second

3 0 0

1 5 0

1 0 0

7 5

6 0

5 0

Rate calculations based on beats/minute 1. 6 sec X 10, 2. 300/# blocks, 3. 1500/ # sq

ECG Analysis

Rhythm

Regular (normal) vs Irregular

Rate (normal 60-100)

3 ways to calculate Are they present? Shape? One for every QRS?

P-waves

P-R interval (normal .12-.20 seconds) QRS complex (normal < .12 sec.) Q-T interval (less than half the R-R interval)

Normal Sinus Rhythm

Rhythm:: Rate: P waves PR: QRS:

3 0 0

1 5 0

1 0 0

7 5

6 0

5 0

Normal Sinus Rhythm

Rhythm:: Rate: P waves PR: QRS:

PR

QT 3 0 0 1 5 0 1 0 0

Q R S

7 5
Normal rate

6 0

5 0

Look closely to see were PR, QRS, & QT are measured.

Six second ECG Simulator http://www.skillstat.com/Flash/ECGSim531.html

Good source for practice rhythms

Rate: 13 x 10 = 130 or # big blocks: >2 (150 bpm) but less than 3 (100 bpm)

Rate: between 100-150, so Sinus Tachycardia Treat the cause

Six second ECG Simulator http://www.skillstat.com/Flash/ECGSim531.html

Regular rhythm, rate: 70, P-waves before each QRS, PR: >.12, but <.20, QRS: narrow (<.12) Normal sinus rhythm

Irregular because of two beats T-wave left of arrows is bigger, Hiding p wave Sinus Rhythm with PACs (premature atrial contractions)

Atrial Flutter

Irregular rhythm Rate? 5 beats x 10 = 50 beats per minute

Atrial Fibrillation

Junctional Rhythm (will not be on exam)

Fun way to review Rhythms

The Heartbeat Dance

http://www.youtube.com/watch?v=x5oq4ErAm

Irregular because of what? Sinus Rhythm with unifocal PVCs How many PVCs per minute?

Works the same way as beats/minute 2 x 10 = 20 What treatment needed? > 6 bpm antiarrhythmic drip

Sinus rhythm with multifocal PVCs

Ventricular Tachycardia Treatment?

Defibrillation (asap) CPR & ACLS otherwise

NOTE: this wave is not flat Ventricular Fibrillation (Fine V-fib)

Treatment: Defibrillation, CPR & ACLS

This wave is considered flat

Asystole Treatment: CPR

Blocks next

Regular, P wave with every QRS, PR: >.20, QRS narrow

First degree heart block Treatment: observe if asymptomatic

Regular, P wave with every QRS, but several P waves without a QRS PR: <.20, QRS narrow

Second degree Heart Block, Type 2 Treatment: Too slow, Atropine & pacemaker

Regular P waves, not with QRS (rate: 100) Regular wide QRS (rate: ~30)

Third degree = Complete Heart Block Treatment: pacemaker (external

Regular P wave with every QRS, PR: varies (<.20, >.20, >.20, > last, drops QRS) QRS narrow, but irregular Second degree Heart Block, Type 1 (Wenkebach) Treatment: rate & symptom based, If too slow or low BP: Atropine May have temporary pacemaker

Arterial Blood Gases

pH Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis Normal Normal pCO2 HCO3 Normal Normal

This is the part you learned in NUR 222. But what about compensation? The next 2 slides will summarize the changes, but REMEMBER: if the arrows for pCO2 and HCO3 go the same direction, there is compensation happening, either partial (pH still abnormal) or full (pH back to normal).

Students may find the ABG Tic-Tac-Toe helpful http://www.youtube.com/watch?v=_OpvyEIlFj8&feature=relate

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Metabolic: Arterial Blood Gases

Respiratory (Lung buffer) (normal) slight alkalosis more alkalosis to balance resp. (normal) slight acidosis pCO2 normal (< 35) (< 35) normal (>45) (>45) pH
(< 7.35)

HCO3 (<22)
(unchanged)

Metabolic (problem area)

Uncompensated
Metabolic Acidosis

(closer to normal)

Partial Compensation
Metabolic Acidosis

(7.35-7.45)

Normal

(unchanged)

Fully Compensated
Metabolic Acidosis

Uncompensated
Metabolic Alkalosis

(>7.45)

(>26) (unchanged) (unchanged)

Partial Compensation
Metabolic Alkalosis

more acidosis to balance resp.

(7.35-7.45)

Normal

Fully Compensated
Metabolic Alkalosis

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Respiratory: Arterial Blood Gases HCO3 Respiratory pCO2 pH Metabolic

(Lung problem)
Uncompensated
Respiratory Acidosis

(kidney buffer) (< 35) (unchanged) (unchanged) (>45) (unchanged) (unchanged)

(< 7.35)

normal (>26) (>26) Normal (<22) (<22)

(normal) slight alkalosis more alkalosis to balance resp. (normal) slight acidosis more acidosis to balance resp. 2525

Partial Compensation
Respiratory Acidosis

(closer to normal)

Fully Compensated
Respiratory Acidosis

(7.35-7.45)

Normal Normal

Uncompensated
Respiratory Alkalosis

(>7.45)

Partial Compensation
Respiratory Alkalosis

Fully Compensated
Respiratory Alkalosis

(7.35-7.45)

Acute Glomerulonephritis

70% of adults recover fully Treatment:

Complications: CHF, Pul. Edema, Hypertensive encephalopathy.

Penicillin DOC (if allergic-erythromycin) Bed rest until urine clears, BP is back to normal and BUN/Cr WNL. Restriction of Na if HTN or CHF or edema is present. Cautious Intake based on Output (calculate fluid replacement carefully.) If rapid deterioration, do plasmaphereis, give steroids, antibiotics may be utilized and may require dialysis if progresses to renal failure

Acute Renal Failure

Etiology and Risk Factors (prevention is best treatment)

Prerenal (renal ischemia)

volume depletion, fluid shifts(3rd spacing) decreased CO, decreased PVR and renal vascular obstruction Acute Tubular Necrosis (ATN) 75% (drugs, dyes), Trauma(blunt), severe muscle exertion (rhabdomylosis), genetic conditions, glomerulonephritis & vascular lesions obstuctions like calculi, tumors, prostate enlargement, spinal cord injury, pelvic trauma and surgical accidents

Intrarenal

Postrenal

McCance, Table 36-11, p. 1389 (UA compared)

Acute renal failure: Phases (IV E 2)

I. Oliguric-anuric phase

last 1-8 weeks, usually 8-14 days

UOP under 400 ml/24 hours (600-700 ml/day in elderly) Fluid vol. excess edema, wt gain, HTN and CHF Elevated Urine Na+ and protein Hyperkalemia - EKG shows tall peaked T waves azotemia (uremic syndrome)

#1 symptom - decreased urine output

increase BUN/Creatinine

anemia (due to decreased hematopoiesis) weak

Acute Renal Failure

II. Diuretic Phase

mark the recovery of nephrons and their ability to excrete urine. UOP as much as 1- 2 liters /day dehydration is still azotemic (BUN decreases, Cr still high) 25% of deaths in this phase improved renal function, may last 3 months to a year. Kidneys are able to concentrate urine again.

III. Recovery Phase

Often some residual effects, but can have complete recovery.

Acute Renal Failure

Measures to lower K+ in 2-3 hours (K+ < 6): 1. Sodium Polystyrene sulfonate (Kayexalate)

administered by mouth or as a retention enema. cation exchange resin (sodium for potassium) therapy that removes 1 MEQ of K+ per gram of drug mixed in water and sorbitrol to produce osmotic diuresis (and diarrhea to remove K+ from body). daily K+ intake is limited to 40 to 60 meq

2. Dietary restrictions:

Acute Renal Failure

Measures to lower K+ in 30-60 minutes (K+ >6.5): 1. Hypertonic glucose (D50W) and insulin IV

K+ moves into the cells with the glucose in the presence of insulin (H+ ions move out of cells). to correct the underlying acidosis and cause a shift of K+ into the cells (H+ ions move out of cells). Hemodialysis can bring K+ levels to normal within 1-2 hours and correct the acidosis. Peritoneal dialysis takes 4-8 hours to achieve the same effect. generally used in advanced cardiac toxicity. Calcium antagonizes the cardiac effects of K+ to protect the heart.

2. Sodium bicarb IV

3. Dialysis

---------------------------------------------------------------------------------------------------------------------------

Calcium gluconate IV

CRF: Nutritional Considerations

Fluid: urine output plus 500ml/24 hours

very cautious and balanced I & O Protein: 1gm/kg(40-50gm/day think limited- high quality)

Calories: 35-40 Kcal/kg estimated dry weight (approx. 2000-2500KCal/day) Carbohydrates: unlimited intake of sugars and starches; bread and cereals limited due to protein limit. Need MVI, but no Iron unless low Phosphate binders with meals (Phoslo) Antihypertensive meds, adjust all meds for renal doses

Peritoneal Dialysis: Complications

Infection of exit site

staph aureus or staph epidermidis red, tender and drainage treat with antibiotics

Peritonitis

due to contamination of the solution or tubing signs include cloudy peritoneal fluid, WBC count greater than 100 cells per micro liter (cells/mL) may have diffuse abd pain, nausea and vomiting, diarrhea, abd distension and hyperactive bowel sounds. Fever or no fever. Usually staph aureus or epidermidis-treat with antibiotics. May need cath removed.

Peritoneal Dialysis: Complications

Abdominal pain

not severe but common caused by: low pH of the Dialysate. Also could be due to peritonitis, intraperitoneal irritation (usually subsides in 1-2 weeks after dialysis started) If the tip touches the bladder, bowel or peritoneum pain will occur

remedy is easy - reposition the tube.

Rapid infusion of dialysate causes referred pain to the shoulder

remedy is easy - decrease the rate of infusion.

Peritoneal Dialysis: Complications

Outflow problems

kinks may be in the tube itself, or piece of omentum, or catheter migration out of the pelvic region; after time if outflow problem-may be due to a full colonremedy is an enema! due to continued intra-abdominal pressures especially multi- parous women and elderly men. After surgical repair healing, can return to PD due to increased abdominal pressure treat with orthopedic binder

Hernias

Low back pain

Peritoneal Dialysis: Complications

Bleeding

first exchange pink or slightly bloody(due to trauma). Gross bleeding indicates injury to the abdominal wall. atelectasis, pneumonia, bronchitis due to repeated upward displacement of the diaphragm. Frequent position changes and TCDB are important. protein, amino acids and polypeptides( 9-12g/day) are lost in dialyzing fluid. With peritonitis get a 40g/day loss!

Pulmonary complications

Protein loss

Peritoneal Dialysis: Complications

Encapsulating sclerosing peritonitis and loss of ultra filtration

thick fibrous membrane surrounds and compresses bowel Small Bowel Obstruction and strangulation occur Must change to hemodialysis

Access Devices: AV Fistula

Complications of fistula: Thrombosis (may need anticoagulation or surgery to remove the clot) Infection (usually due to staph aureus) Aneurysm formation (due to repeated cannulation-may need surgical repair) Ischemia (cold fingers to gangrene-due to decreased arterial flow-occurs in very small numbers of clients)

Steal syndrome

Access Devices: AV Fistula

No BP or needle sticks in the fistula arm

Arms may be protected when CRF develops

Assess patency by palpate for a thrill or auscultation for a bruit. Avoid compression of fistula loose dressing Inspect site for infection Need to use the arm to prevent clotting, Assess movement by pt wiggling fingers immediately post op Elevate the arm on pillow until swelling is down; no slings, no ice.

Access Devices: AV Fistula

Teach

to assess patency by palpating for a thrill (or auscultation for a bruit). to avoid compression of fistula by tight clothing, or carry objects with arm bent, and not to lie on the site. to inspect site for infection To protect arm from HCP: No BP or needle sticks in the fistula arm To continue to use the arm to prevent clotting ball squeezing 5-7 days after surgery (after swelling is gone)

Renal Arterial: Surgery

RA stenosis:

Try percutaneous transluminal renal angioplasty (PTRA) & stenting

Stenosis may reoccur (antiplatlet meds given) or PTRA may be contraindicated Improvement in 2/3 of cases; home in 24-48 hrs. use autogenous vascular graft Severe HTN expected for 48 hrs must monitor and treat aggresively

Aortorenal bypass:

Obstructive Disorders: Urinary Calculi (IV C1)

Etiology and risk factors

Urinary stasis and supersaturation Calcium, oxalate, struvite, uric acid, cystine, xanthine
(see Fig. 34-4)

Pathophysiology: based on stone types

Clinical manifestations

PAIN (spasm, colic, peristalsis, radiates down) Obstruction (hydronephrosis) Tissue trauma (hemorrhage) Infection

A. Review of Diagnostic Studies & B. Critically Analyze values

Complete Blood Count (Black, Tables 74-4 & 74-5, p

2000)

RBC, Hgb, Hct WBC (blast = immature) Differential: (%) Granulocytes:

Neutrophils (Segs, Bands) Eosonophils Basophils

Monocytes Macrophage Lymphocytes (B, T, NK)

A. Review of Diagnostic Studies & B. Critically Analyze values

Platelets Regulate blood flow (can cause vasospasm) Activate & aggregate to form platelet plug Activate clotting cascade to stabilize clot Initiate repair (clot retraction & dissolution) Coagulation factors & studies (Table 74-7, p. 2002) Fibrinogen, Fibrin split products, Fibrin degradation (FDP) PT/INR & PTT Clotting factors (V, VIII, IX) Bleeding time dDimer

Leukemia: Diagnosis

CBC

decrease in RBC decreased platelets low-normal or high WBC Positive leukemic blast cells on peripheral smear key diagnostic tool. (Adults: aspirate the sternum) Painful, with slight risk of infection with this procedure. Shows: increase #s and > % blast cells types. CNS involvement

Bone marrow aspiration

Lumbar puncture (chronic disease)

Leukemia: Treatment

Major aim of initial treatment:

achieve a primary remission that lasts without relapse A remission means the absence of detectable leukemic cells in the marrow A relapse is the reappearance of leukemia cells in the marrow

If a patient has a remission but relapses, a second remission is possible, but much more difficult with each relapse, remission is shorter.

Polycythemia Vera (Unit III C3)

Relentless overproduction of erythrocytes abnormally high number of RBCs in whole blood Areas were common in WV, frequently relatives Clinical Manifestations

Hypervolemia & Hyperviscosity (poor blood flow) Hypercoagulable!! Diagnostic Tests:

Hgb 18 gm/dl or over RBC 6 mil/mm3

Polycythemia Vera

Medical/Nursing Management Assessment for:

Headache, Plethora, Dyspnea, Thrombosis, Spleenomegaly, Parasthesias, Tendency to bleed (nosebleeds, etc) Treatment: Phlebotomy to decrease volume and viscosity

May repeat weekly until levels improve (high normal)

Infectious Mononucleosis (D1)

Etiology: herpesvirus or Epstein-Barr Pathophysiology: viral, thought to be spread by the oro-pharygeal route Clinical Manifestations:

painful enlargement of lymph nodes, sore throat, fatigue, headache, malaise, myalgias, fever, pharyngitis 10-15% get a maculo-papular rash; Can get splenic enlargement if mono severe, splenic rupture due to WBC invasion of the spleen

Mononucleosis

Diagnosis:

physical assessment and physical findings; Lab: WBC 12-20,000 (50% are lymphocytes and monocytes and 10-20% are large, atypical lymphocytes. Mono spot is a blood test, detects anti-EBV antibodies

+ in 50% 1st week and 90% in the 4th week

Treatment:

Symptom based: increase fluid intake, rest, analgesics (NSAIDS) and antipyretics, gargle, Long, slow convalescence (fatigue can last 6
months)

Hemophilias (E1)

Hemophilia is a group of bleeding disorders where there is a deficiency of clotting factors. More common in men (1:10,000 in the US) About 80% inherited pattern is X recessive linked gene. Example how to deterime offspring results Xh = hemophilia gene, Xo = normal Father hemophilia, mother carrier
Father/Mother Xh Y Xh XhXh Female hemophilia XhY Male hemophilia Xo XhXo Female carrier XoY Normal male

Disseminated Intravascular Coagulation (DIC) (III F)

Complication of pathologic conditions

hypoxia, acidosis, shock, systemic disease like congenital heart, gram negative sepsis, etc.

An inappropriate systemic activation of the normal clotting mechanisms. Clinical Manifestations

onset acute, days to hours after onset of illness If it rapidly develops, usually pt will bleed from 3 unrelated areas

IV sites, a-line, surgical wounds, eyes, nose, gums, development of purpura, petechiae and hematomas

Disseminated Intravascular Coagulation (DIC) (III F)

Complication of pathologic conditions

hypoxia, acidosis, shock, systemic disease like congenital heart, gram negative sepsis, etc.

An inappropriate systemic activation of the normal clotting mechanisms. Clinical Manifestations

onset acute, days to hours after onset of illness If it rapidly develops, usually pt will bleed from 3 unrelated areas

IV sites, a-line, surgical wounds, eyes, nose, gums, development of purpura, petechiae and hematomas

DIC: diagnostic tests (Table 75-7, p. 2036)

Bleeding time > 7 min Platelets <100,000 Plasma fibrinogen less than < 195mg/dl Fibrin degradation product > 10 mcg/ml Activated Partial Thromboplastin Time (aPTT) greater than 36 sec.

Prothrombin Time (PT) prolonged (high INR) One stage factor assays (Coag. System slide 53) Factor II < 25mcg/ml; Factor V < 50%, Factor VII < 65% Factor X < 45% Factor XIII reduced

DIC: Medical & Nursing Management

ID cause and treat it Establish homeostasis

Phase I: concern is thrombosis, so give heparin IV Phase II: Replace lost blood components (platelets, FFP, Give clotting factors) Assess all body systems (vigilant) Monitor & quantify blood loss & replacement Draw & monitor labs (especially after treatments) Prevent further injury Intense emotional support to client & family

Supportive therapy

Sickle Cell Anemia: Patho

Increased sickle rates when:

Hypoxia, acute illness, dehydration and other conditions. clump up and obstruct the blood or slow blood flow ischemia and possible infarction of an organ PAIN, SWELLING AND FEVER!!

Sickle cells are rigid

Symptoms are secondary to hemolysis and Vaso-occlusive Crisis

Diagnosis occurs in childhood as discussed in Peds course

Sickle Cell Anemia

Manifestations in Adults:
See Table 75-6 in Black text (p. 2024)

Chronic hemolytic Anemia (hgb 7-10)

Patient looks jaundiced heart rate is elevated, flow murmur and enlarged heart, arrhythmias and heart failure may ensue Severe pain Hand-foot syndrome with ulcers

Vaso-occlusive crisis

Aplastic, Hemolytic or Sequestration Crisis Acute Chest Syndrome highest mortality

Emboli & infarction to lungs ARDS death

Sickle Cell Anemia: Treatment

Pain: treat aggressively!

Morphine IV q1-2 hrs or PCA pumps taper dose over 24-48 hrs NSAIDS & oral opiates at home

Prevent infection &/or Treat infections early and aggressively (broad spectrum antibiotics) Maintain hydration, electrolytes, blood

May need blood transfusion

Maintain oxygenation: avoid hypoxia Bed rest during crisis:

decreases O2 consumption

Potential Problems Associated with a Tracheostomy

Potential complications

Airway obstruction Infection Tracheal dilation Accidental decannulation Tracheal wall necrosis Subcutaneous emphysema Tracheal dilation and stenosis Tracheomalacia

Cancer of the Larynx

Benign Tumors of the Larynx: Papillomas (viral wart-like growthpolyps) Cancer of the Larynx

Clinical Manifestations Intrinsic-(hoarseness) Extrinsic (burning pain with ingestion of citrus juices & hot fluids) Late (pain that radiates to ear)

Cancer of the Larynx

Medical management

Surgical management
Laser

Radiation and chemotherapy

used for small lesions of the vocal cords leaves voice intact

Partial

takes one cord and sometimes part of the second cord removes of the larynx-preserves the voice (also called vertical partial laryngectomy) Another form of partial is the supraglottic removes the superior larynx, false cords and base of the tongue true cords are left intact so voice is preserved This procedure requires temporary trach.

Surgical Interventions

Total Laryngectomy -done with large tumors that are fixed on the cords-larynx and cords are removed-have a permanent trachno voice-must work with alternative forms of communicationteaching essential

POST-OP CARE

Continuous assessment and monitoring of patient and trach tube. Keep trach opening patent Semi fowlers is essential to facilitate ventilation, promote drainage and minimize edema Assess for complications

POST-OP CARE

Maintain a patent airway Semi fowlers (45 degrees at least) Monitor resp rate and depth Monitor pulse for increases No meds that decrease resp TCDB Suctioning and humidified O2 (trach collar) Enteral feedings and IV therapy Care of stoma, suture lines and drains (hemovac) Monitor for rupture of carotid artery

POST-OP CARE

Nutrition-usually TF for 2-3 days Clear liquids to progressive as tolerated Assess swallowing to assure safety Same measures as aspiration risk Oral care every 2 hours and prn Assess total protein and albumin Communication and speech rehab Assist pt. With alternative form of comm -yes/no ?; magic slate or flash cards,

esophageal speech and electro-larynx speech are possibilities

Rehabilitation

Essential

works with speech pathologist to affect change in alternative communication. trach care, signs of complications, nutrition and pain management like Lost Chord Club for social support. swallowing look in Black (2009)

Discharge teaching for patient and family

Refer to support groups

Client education box

Who needs intubation?

Patient unable to maintain normal gas exchange Progressive deterioration of the patients condition:

worsening of ABGs, signs of hypoxemia, changes in chest x-ray such as infiltrates, patchy whiteouts

Respiratory arrest; Respiratory insufficiency; airway obstruction; persons requiring surgery (many need).
6767

Confirming ETT placement

How do we confirm the endotracheal tube is in place???? A. Auscultation of lung sounds B. Use of the end-tidal CO2 monitor C. Chest x-ray

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MUST Secure the ET-tube Document & monitor depth of insertion Attach to mechanical ventilation circuit Note: inline suction for secretion removal
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MV: Ventilator Mechanics

Positive pressure ventilators 1. Volume cycled (controlled) *****

2. Pressure cycled ****

deliver a breath until a pre-set volume is achieved Tidal volume, rate, flow are pre-set, pressure varies (Alarm limits) deliver the breath until a pre-set pressure is reached in the patient airway Pressure limit, rate, and flow pre-set, Volume varies
Deliver small tidal volumes at very rapid rates to exchange gas in lungs with minimal distention pressures (limit damage to the lung)
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3. High Frequency Ventilation

Adjuncts

PEEP Positive end expiratory pressure applied during MV CPAP Continuous positive airway pressure is applied to a client with spontaneous respiration Pressure support (PS) Increased positive pressure applied during inspiration for intubated clients (ventilator weaning)
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Mechanical Ventilators and Analgesics

In hemo-dynamically stable patients: Analgesics (for pain relief)

Sedatives (sedation effect)

Morphine and Fentanyl (sublimaze) opioids benzodiazepines like Ativan and Versed Haldol: good sedation with minimal resp depression Propofol (Diprovan) milk of anesthesia given by constant infusion short onset of action and short acting drug cause hypotension-use with caution if unstable
7272

Neuroleptics (sedation)

Anesthetic agents (sedation)

Modes of Ventilation

Control

Preset volume delivered at a preset rate. Circuit is closed in between these mandatory breaths. Patient must be apneic or paralyzed or they fight the ventilator. Preset volume delivered for each patient inspiratory effort (of set amount). If pt fails to initiate a minimum # of bpm, the vent will initiate the breaths at the preset rate.
7373

Assist/Control

Modes of Ventilation

Synchronized intermittent mandatory ventilation (SIMV)

Preset volume delivered at preset rate. Pt may take additional breaths of any tidal volume from the open circuit between the mandatory breaths. Mandatory breaths are synchronized with pt efforts so that they dont conflict with clients own ventilatory efforts

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Modes of Ventilation

Pressure Support Ventilation

Preset positive pressure is initiated by the patients inspiratory effort TV and rate is patient controlled (minimal level alarm set) Augments or assists spontaneous breathing efforts Frequently combined with CPAP

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Alarms

Alarms set on the ventilator alert the nurse to the needs of the patient NEVER TURN OFF ALARMS! (pause, reset OK) The prudent nurse will:

Check the patient Check the circuit Check the ventilator settings Check alarm limits when the ventilator alarms.

Common causes of high pressure alarms:

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Alarms

Common causes of low alarms

*Never turn off alarms!

See Bridge to Critical Care, p 1644

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ARDS: findings

Hypoxemia unresponsive to oxygen therapy (PaCO2 of over 60, pO2 less than 50 with FiO2 higher than 50%) Diffuse bilateral alveolar infiltrates seen on chest xray without heart disease (non-cardiac pulmonary edema) Worsening crackles Eventual metabolic acidosis because of the increased work of breathing and cellular hypoxia Fluffy infiltrates, or Patchy white-outs seen on Chest x-ray If not reversed resp acidosis, further hypoxemia, hypotension, decreased cardiac output and death occurs.

Management of ARDS

Early detection and treatment interventions: treat cause (if known) to reverse process, oxygen therapy Resp support with intubation, mechanical ventilation and PEEP; may prone- Read evidence based practice, Black (2008) page 1656 -Prone positioning of adults. [Nursing history lesson: an ICU RN on nights started doing this with her patients and they got better instead of dying. She then went on to design and sell a special support that assisted in the turning process (and made lots of money) until the roto-bed came out (now KCI gets the big money and a physician has to order the bed to get insurance to pay for it, since it could be a nursing action.]

Bioterrorism

Used to intimidate a government or harm large numbers of people for political or social objectives Biological agents used during wartime are used to produce large numbers of casualties over a wide geographical area Biological weapons are any agents configured on groups of people with the intent to harm or kill. Bioterrorists use these agents for this purpose often with motives unknown

BIOLOGICAL WEAPONS

Easy to acquire and deploy Invisible and odorless Most people wouldnt know they were exposed until after they become ill Most s/s mimic the flu Mass illness and death produced by aerosolized weapons

BIOLOGICAL WEAPONS

>50 bacteria, viruses or toxins that can be used in an attack Vaccines are available for only 12 or 13 of these The 6 most likely to be used, and of greatest concern Critical Agents are smallpox, anthrax, plague, tularemia, botulinum toxin and pathogens causing viral hemorrhagic fevers (Ebola & Marburg)

ANTHRAX

Diagnosed by blood cultures, nasal swabs and chest xrays Treatment is with Cipro or Doxycycline Prophylaxis is 60 days of antibiotics Anthrax vaccine available but supplies are severely limited Mortality rate >90%

PLAGUE

Leads to shock, multiorgan failure & DIC Few labs have tests to confirm plague Treatment is with streptomycin sulfate, gentamicin, tetracycline and doxycycline A vaccine is available but probably wouldnt protect in an attack situation Mortality close to 100% if not treated within 24 hours of symptom onset

TULAREMIA

Presents as an atypical pneumonia Incubation 3 to 5 days S/S: fever, chills, rigors, myalgias, anorexia, sore throat & headache Chest xrays & serological assays diagnose Treatment is aminoglycosides x 10 days 35% mortality untreated

BOTULINUM TOXIN

S/S progress to skeletal muscle weakness then paralysis that is symmetrical, descending and progressive often leading to respiratory failure Diagnosis made on clinical circumstances Treatment is supportive care and passive immunization with an antitoxin All seven toxins have an antitoxin