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For SIRS, a patient will be diagnosed if they meet at least 2 of the following criteria:
For SIRS, a patient will be diagnosed if they meet at least 2 of the following criteria:
• Temp >38 OR <36
• HR >90
• RR >20 OR PaCO2 <32
• WBC >12,000 OR <4,000
What is the normal range for PEEP? What can high PEEP cause?
The normal range for PEEP is between 3-7.
This can be changed to a higher setting depending on the patient's needs; however, high PEEP can cause barotrauma. PEEP is used to prevent alveolar from collapsing. Too much PEEP can stretch open the lungs causing lung damage.
A patient was admitted to the ER for DKA.
What criteria could the nurse use to assess for DKA?
And what is the priority nursing action?
What electrolyte should the nurse pay extra attention to?
The nurse should assess the patient's blood sugar above 250, low LOC, fruity breath, and kussmaul breathing.
The nurse should FIRST administer fluids, then electrolyte therapy, then insulin last!
The nurse should keep track of the potassium!
On the 3rd day of intubation, the patient was found restless and starting to shake. The patient appears scared and is trying to take out the ETT. What should the nurse's priority action be?
Difference between high V/Q mismatch vs low V/Q mismatch?
High V/Q mismatch is adequate ventilation with poor perfusion.
Low V/Q mismatch is inadequate ventilation with good perfusion.
A patient came to the ER for an anxiety attack about losing their house. This patient has been not able to catch their breath for hours.
This patient is at risk for what kind of acid-base imbalance?
What is the priority nursing intervention?
This patient is most likely to develop respiratory alkalosis due to the loss of Co2.
The nurse should implement breathing techniques to help calm the patient down. Give the patient a paper bag or cup their hands to breathe into. This helps the patient preserve Co2 so they can fix the respiratory alkalosis.
The criteria for extubation:
Respiratory weaning is a gradual process– Pt must demonstrate:
(1) Evidence that the underlying cause of respiratory failure has been reversed or treated
(2) Ability to breathe spontaneously
(3) Support adequate oxygenation
(4) Maintain hemodynamic stability
What is the KEY diagnostic tool for ARDS?
The THREE expected medications used for intubation?
1) Sedative (FIRST)
2) Pain medications
3) Muscle paralyzers (ALWAYS LAST)
Indications for supplemental oxygen?
PaO2 < 60 mmHg
SaO2 < 90%
Conditions that increases need for oxygen
Fever
Infection
Anxiety
Anemia
A patient was admitted to the ICU 8 days ago for septic shock. This patient was intubated (NG) on their first day due to inability to breath on their own. The nurse should anticipate what happening next?
The nurse should anticipate the patient be scheduled for a tracheostomy due to the ETT being placed over a week ago.
Following extubation, the nurse assess a high pitch sound in the lung of the patient. What should the nurse's priority action be?
A patient was admitted to the ER for severe left upper quadrant pain. This pain started 4 days ago followed by yellow colored stool. The physician put an order in for a low-protein diet. The patient was placed in semi-fowlers. Was given insulin before breakfast. They were also given calcium supplements.
What should the nurse question?
This patient is experiencing acute pancreatitis. This client should NOT be receiving foods as this will further upset the digestive tract. They will be placed on NPO.
Patients w/ acute pancreatitis should be placed in semi-fowlers (not flat), given insulin due to increase blood sugar from pancreatitis, and be given calcium supplements due to hypocalcemia.
What is included in the VAP bundle?
- Exercise or repositioning
- Suctioning
- Replace circuit
- Administer sterile water
- Spontaneous breathing trials
- Minimize sedation
- Oral care
- PUD and DVT prophylaxis
This supplemental oxygen device is used primarily in transporting patients. Has a flow rate of 5-10 L/min.
This is an example of a simple face mask.
The nurse should immediately notify the provider as snoring is a sign of a cuff leak. This would be an example of a low pressure alarm.
This patient was admitted to the ER for an overdose of Ativan. What acid-base imbalance is this patient at most risk for? What is the priority nursing action?
Ativan is a benzodiazepine. An overdose can cause respiratory acidosis as this is a CNS depressant. The nurse should administer flumazenil immediately.
What mechanical ventilation setting am I?
The patient was recently admitted to the ICU following intubation. The respiration rates and tidal volume are both preset.
This setting allows the patient to initiate a breathe and helps them achieve a full breath.
This setting also initiates a breath if the patient does not.
I am assist control ventilation.
A patient was admitted to the ER for self induced vomiting. What acid-base imbalance is this patient at most risk for? What is the nurse's priority action?
This patient is at most risk fro metabolic alkalosis for the loss of gastric acid.
The nurse should administer lactated ringers NEVER normal saline for fluid replacement, due to a decrease risk for hyperchloremic acidosis
How often should vitals be assessed following extubation?
Also assess the gag reflex, signs of respiratory distress, and for signs of low O2.
The patient is on a mechanical ventilator. They're currently exhaling when they should be taking in a breath.
This is known as? And is found in what kind of mechanical ventilator setting?
This is an example of "bucking the vent" where the patient exhales instead of taking in a preset breath. This is only found in Intermittent Mandatory Ventilation (IMV)
The most commonly used supplemental oxygen device?
What should the nurse assess for?
A Complication?
The nasal cannula is the most used supplemental oxygen device used for low flow.
The nurse should assess for skin breakdown behind the ears.
Drying out the mucous membranes causing nose bleeds is the biggest complication.
The nursing student asks the nurse what are examples as to why the high-pressure alarm might go off for a patient on a mechanical ventilator. The nurse replies with?
- the patient is biting down on the ETT
- a clog or drainage stuck in the ETT
- pneumothorax or pulmonary edema
- patient is fighting the vent due to anxiety
- a kink in the vent
- water in the vent
- patient is coughing
This patient was recently admitted to the ER for metabolic alkalosis? What nursing intervention is contraindicated for this kind of patient?
NG suction is contraindicated for patients in metabolic alkalosis as this will further decrease gastric acid.
Nasal cannula and venturi masks are not helpful for what condition?
Nasal cannula and venturi masks are not helpful for patients experiencing acute respiratory failure.