Nursing(IV((((Monday(Lecture(Notes( Medical(Surgical(Unit .

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eRespiratoryFailure1. O2 50mm(normal35- ‐45),andapHlessthan7.35a. cessorymuscles2. Apneanotreadilyreversible3. Nursingmanagementa. AcuteRespiratoryDistressSyndrome1. Severeformofacutelunginjury2. (increasingbilateralinfiltratesonchestx- ‐ray),3. Hypoxiaunresponsivetooxygen,regardlessofpeep.4. Occursasaresultofdiffusealveolardamage.5. a,increasedalveolardeadspace.6. Clinicalmanifestationsa. ARDSisanacuteeventi. Developsin4to48hoursb. Closelyresemblesseverehemodynamicpulmonaryedema.c. Acutephasemarkedbyrapidonsetofseveredyspnea12- ‐48hoursaftertheinitiatingevent.d. Increasedalveolardeadspace,“stifflungs”7. Assessmenta. Plasmabrainnatriureticpeptide(BNP)levelsi. ThisishelpfultodistinguishARDSfromacardiaceventb. (thedefinitivetest)8. Nutritiona. ARDSpatientsrequire35- ‐45kcal/kg/day9. Nursingmanagement1 P a g e

a. n,tracheostomy,suctioning,bronchoscopyb. position10. Ventilatorconsiderationsa. ri. n)b. Paralyticsi. Pancuronium,vecuronium,atracurium,rocuronium11. entilationBrunner655- ‐6601. Indications:PaO2 50mmHgwithFiO2 0.60a. PaO2 50mmHgwithpH 7.25b. Vitalcapacity 2timestidalvolumec. Respiratoryrate 35/min(Adult)2. Classificationofventilatorsa. NegativePressure(ironlung)b. PositivePressure(mostcommon)c. CPAP–continuospositivepressured. BiPAP–maskornasale. ETtubeupto2Weeks,Trachafterthat.f. Lingoi. RR RespiratoryRateVT Tidalvolume10- :whenairenterslungii. InspiratoryPressurelimitO2 %ofoxygendeliveredwitheachbreathiii. FiO2 fractionalmeasureofinspiredO2 70%,FiO2 70iv. PEEP Positiveend- ‐expiratorypressure(veryimportant)v. BPM- ‐BreathperminuteSetrate mandatoryratedeliveredbyventvi. TotalRate spontaneousANDsetbreaths.3. Volumecycledventilator:mostcommonlyused4. VentilatorModes(breathinitiation)a. AssistcontrolVentilation[A/C]i. ceofbucking)b. Intermittentmandatoryventilation[IMV]i. waypressuretodecreasebarotrauma.c. 2 P a g e

5.6.7.8.9.i. spontaneously,itprovidesnoassistance.d. Pressuresupportventilation[PSV]i. ent’sstrengthisincreased.e. AirwayPressurereleaseventilation[APRV]i. torycycle.f. Proportionalassistventilation[PAV]i. ”withthemachine.Initialsettinga. Tidalvolume10to15ml/kgb. Recordpeakinspiratorypressurec. Recordminutevolume.d. Sensitivity–2- ctioning:10- a. Cancausesinusbradycardia(atropine)NursingProcessa. Evaluatethepatient’spsychologicalstatusi. Howaretheycoping,howisthefamilycopingb. Indepthfocusontherespiratorysystemi. ,patternii. Potentialevidenceofhypoxiac. Twomajorinterventions:i. Pulmonaryauscultationii. Interpretationofarterialbloodgassesd. Potentialcomplicationsi. Barotraumaii. Pulmonaryinfectioniii. Sepsise. Goals:achievementofoptimalgasexchangef. RiskforDVT,PE,skinbreakdowni. aningProcessa. Patientassessmentb. Trialbydecreasingsupportc. IfHR by20,theygobackontheventd. IfBPsystolic by20,theygobackonthevente. Cardiacdysrhythmia,theygobackonthevent3 P a g e

10. ComprehensiveNursingCarePlana. Promotinggasexchangei. elii. Turnandrepositionpatientevery2hoursb. Promotingeffectiveairwayclearancei. Suctionthepatientasneededc. Preventingtraumaandinfectioni. Enforcestrictaseptictechniqueandhandhygieneii. Monitorandrecordcuffpressured. Promotingoptimallevelofmobilityi. Patientinchaire. Promotingoptimalcommunicationi. Usenonverbal,boardf. Promotingcopingabilityi. Maintainsedationlevelii. Education:explainproceduresandstatusofpatientiii. Educatefamilymembers11. ComplicationsofVentsa. Cardiaci. atientatgreaterriskforcardiacdysrhythmiasb. Barotrauma/pneumothoraxi. plications)1. ockers(Pepcid)c. PulmonaryInfection:similartobarotrauma.12. howlong.a. pH7.35- ‐7.45b. PaCO235- ‐45mmHGc. HCO3- ‐22- ‐26mEq/Ld. PaO280- ‐100mmHge. SaO2greaterthan95%(pulseox)f. BE(baseexcess)- ‐3.0- ‐ 3.013. Compensationa. WhenboththePaCO2andHCO3- herreflectsacompensatoryresponse.b. heprimaryabnormality.c. Non- ‐compensation:analterationofeitherpCO2orHCO3- ‐.d. - ‐.4 P a g e

e. andHCO3- ‐,butthepHisnormal:phof7.35- ‐7.40acidosisand7.40- ‐7.45alkalosis.Medications1. Fentanyl2. Versed3. Diprivana. Usedalotinsurgerywithgeneralanesthesiab. Drugofchoiceforventedpatients4. Ativan5. t)a. Usedwithadultpopulationb. Usedtotitratemedicationsc. ition)d. Neurocheckse. MonitorarterialbloodgassesSHOCK- arfunction.(DecreasedTissuePerfusion) MAP(meanarterialpressure) cardiacoutputxperipheralresistance.Normal 65o TocalculateapproxMAP:(PulsePressure/3) diastolicpressureo (2xdiastolic systolic)/3Pathophysiologyo robic)o e(glucogenesis)o .o ydepleteStagesofshock1. Compensatory(Charton315Brunner)a. SNScausesvasoconstrictionb. BPwithinnormallimitsc. Clinicalsigns:HR 100,Resp ,respiratoryalkalosis(compensatory)i. ndcatecholaminerelease)ii. Pulsepressurewithinnormallimits(30- ‐40mmHg)5 P a g e

d. orystageBEFOREtheBPdrops.2. Progressivea. allsbelownormali. BP 90ordecreaseof40systolicbelowpatient’snorm.ii. Vasoconstrictioncontinuesb. pidandshallowc. nshockstatesd. emaintained,changesinrenalfunctionoccur.i. IncreaseinBUNandserumcreatininelevelse. levelselevatedf. DICmayoccurasacauseorcomplicationofshock3. IrreversibleStagea. sprogressiveb. urvive.ShockManagement1. reattheunderlyingcausea. y.2. Supporttherespiratorysystema. Oxygenationisfirstlinetreatment3. Fluidreplacementtorestoreintravascularvolumea. atedringersi. ccurswithshockb. idintotheintravascularspace.i. k.c. t’soxygenationneedsd. :thenursemustmonitorthepatientclosely.i. Crackles,JVD,elevatedBP)ii. hermiafromcoldfluids)4. centralline(brunnerp321)5. Nutritionalsupport(3000calperdayneeded)6 P a g e

a. Administrationofglutamineb. H2blockersorprotonpumpinhibitors.6. mea. Occurswith15%- ‐30%reductioninintravascularvolume(about750- ‐1500mlofbloodina70kgperson)b. Elderlypatient:dehydrationmaybethecausec. Treatmenti. Restoreintravascularvolumeii. Insulinifdehydrationsecondarytohyperglycemiaiii. ModifiedTrendelenburgiv. t7. CardiogenicShock:a. Coronarycardiogenicshockismorecommonthannon- ftventricle.(pumpisimpaired)b. Non- as.c. Treatment:i. Oxygenfirstlineii. Paincontrol1. Morphine:drugofchoicea. xiety.iii. drhythm.1. UsedwhenfluidtherapydoesnotmaintainMAP2. Giventhroughacentralline.3. onitoringthroughaninvasivecatheter)4. Mostcommon:dobutamine,nitroglycerin,anddopamine.5. trokevolume,andcardiacoutput6. Epinephrine:increasecontractility,rate7. cesafterload.8. doses(10mcg/kg/min)usedtoincreasecardiacoutput)7 P a g e

a. ve.9. Vasopressors(neo- onofbloodvessels.(P322)10. Antiarrhythmicsa. Atropineb. Amiotarone.d. NursingManagementi. Monitorhemodynamicandcardiacstatus.ii. ythmandotherabnormalassessmentfindings.iii. ndnitroiv. ytictherapy.v. equentlywhenpatientisonintra- ‐aorticballooncounterpulsation.8. ssels.[decreasedvenousreturn]a. Variedmechanismcanleadtothreesub- ‐typesi. on1. Reducedbyusingstrictinfectioncontrolpractices2. ybehypotensive,butresponsivetofluids3. andinsulinresistance.4. imizeoutcome.5. Confusionmaybethefirstsigninelderlypatients6. Identifythesourceofsepsis7. nsourceii. Neurogenicshock1. ffected.(FractureaboveT- ‐6)2. Restoresympathetictoneiii. Anaphylacticshock1. antigens9. Multipleorgandysfunctionsyndrome(MODS)a. shockb. Insidiousonset8 P a g e

c. Organfailureusuallybeginswiththelung.d. .e. Managementi. PreventionisthetoppriorityinmanagingMODSii. Supportingthepatientiii. Motoringorganperfusioniv. Providinginformationtothepatientv. Supportthefamily1. mmunication,end- ‐of- larCoagulation- ybelifethreatening1. a. b. resultofexcessiveclottingisbleeding.c. eDICwithischemicthrombosisandfrankhemorrhage.i. nipuncturesites,andtheGIandurinarytracts.d. Treatunderlyingcausee. Treatischemiaf. Replacefluids,correctelectrolyteimbalancesg. Xigrisfor96hours(thrombolyticenzyme)h. owistheheartfunctioning1. Determinescardiovascularassessment2. ion,identification,andtreatmentoflife- ‐threateningconditions,suchasheartfailure.a. Canalsobeusedtomonitorcertainmeds3. Typesa. CVP:centralvenouspressure(2- ‐6mmHg)i. i. Ifgreaterthan6mmHg heartfailureiii. Iflessthan2mmHg hypovolemia9 P a g e

b. Pulmonaryarterypressurei. tremityc. Intra- ‐arterialBPmonitoring4. Complicationsofinvasivepressuremonitoringa. Pneumothoraxb. Infectioni. Temp, HR, breathing,diaphoretic,shocksignsc. Airembolism5. CVPinsertedundersteriletechniquea. Throughantecubitalvein,intovenacava,rightatriumb. NeedpressurebagonanIVbagat300i. Willinstill3- ‐5mlofsalineintothecatheter.Stop- .(zeropoint)Cardiacdysrhythmias- noftheelectricalimpulsesintheheart Thesedisorderscancausedisturbancesof Rate10 P a g e

box1500littleboxesperminute,300R–R ventricularrhythmP–P atrialrhythmImpulsevsConductivity1. Alterationoftheimpulsesa. TachorBrady2. Conductiona. HeartblocksA. Atrialflutter–usuallyaregularratea. rb. Treatedwithadenosine:thenrapidflushthenraisearmc. . Ischemia,shockB. AtrialFibrillationa. Increasedchanceofbloodclotsb. Unstablehemodynamicallyc. )i. Electrocution,burns(causeelectrolyteimbalance)d. Treatmenti. Cardioconversion–synchronizedii. . ndconductsthroughtheventriclea. DigToxicity,acidosis,sleepapneaaremoreaptforPVCs11 P a g e

D.E.F.G.H.I.J.K.L.M.b. AmiodaroneVentricularTachycardiaa. Treatthecauseb. Amiodaroneisthedrugofchoice.c. Fasterthan100BPMVentricularFibrillationa. Mostcommondysrhythmiaforcardiacarrestb. Rapid,disorganized,ventricularrhythmc. CPRuntildefibrillatorisavailableAsystolea. CPR,Intubate,IVAccessb. greeAVBlocka. ConductionslowedthroughtheAVnodeb. NotreatmentifnotsymptomaticSecondDegreeAVBlocka. AVBlocka. NoimpulsesmakeitthroughtheAVnodeb. Atropinec. iaa. Assessmenti. thsoundsii. CheckforJVDiii. BrunnerP728formedicationlist1. nsvenouspacemakera. ECGon- ‐demandpacingb. Complicationsi. ardiactamponade,malfunctionii. Painatpacemakersite&increasedWBCsDefibrillationa. racranialPressureP1587,1864- ‐1869,1923- ‐1924,1977- ‐19781. ds,orsolidsintheintracranialvault12 P a g e

2.3.4.5.a. Increase80%brain,10%blood,10%csfi. Brain,Blood,CSFii. MaintainSAO2at93%andhigherb. stocompensate.c. Normalpressure0- ‐10mmHg,topnormal15mmHgEtiologya. BrainTraumab. Braintumorc. nesshasneurologicalsignificance)a. Restlessnessb. Irritabilityc. DecreaseinLOCd. Hyperventilatione. PupilChangesf. Latesignsi. Posturing1. d,armsadducted2. . . Tempincreaseg. ignificantlydecreased.i. Wideningofpulsepressureii. Slowingoftheheartiii. IncreaseinsystolicBPiv. CUSHINGSTRIAD:Bradycardia,Hypertension,Bradypneah. tichormoneICPMonitoringa. onitoring(somemeds)i. Canremovefluidii. Insertedintothelateralventricle.iii. Biggestcomplication:infectioniv. Cancollapseventricleb. Subarachnoidbolt–lessinvasivei. menta. Mannitol:osmoticdiuretici. Pullswaterout,reducespressureii. Crossesblood/brainbarriereasily13 P a g e

b. HypertonicSalinec. Glucocorticoids:Decreasesinflammation(Solu- ‐Medrol,Decadron(meningitis))d. en26and30e. Barbiturates:sedation- ‐f. Therapeutichypothermiag. DecompressiveCraniectomyh. RemovalofCSF6. NursingDiagnosisa. ctivereflexesb. ysfunctionc. ofincreasedICPd. Deficientfluidvolumerelatedtofluidrestrictione. RiskforinfectionrelatedtoICPmonitoringsystem7. Interventionsa. Suctionairwaysecretionsi. Coughingisdiscouraged!b. sensation.1. Partial:Beginononepartofthebraina. Beginononesideofcerebralcortexb. Typesi. Simplepartialseizuresii. Complexpartialseizures2. Generalizeda. Bothhemispheresinvolvedb. Convuls

1" Page" l(Unit(Acute(Respiratory(Failure(1. a),PaCO2 50mm%(normal .

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