RT 2 final

What are the indications for ABG puncture

The need to evaluate the adequacy of acid-base (pH), ventilation (PaCO2), oxygenation (PaO2, SaO2), oxygen carrying capacity of blood (PaO2, HbO2, Hbtotal, and dyshemoglobins).

The need to quantitate the patient’s response to therapeutic intervention and/or diagnostic evaluation

The need to monitor severity and progression of a documented disease process

What are the sites used for ABG puncture

Radial, femoral, brachial and dorsalis pedis arteries.

What are the benefits of radial site ABG puncture

There is normally good collateral circulation and easy access. It is easily compressed and superficial.

What are some reasons you may need to use a different puncture site for an ABG

What supplies are needed for ABG puncture

What are potential complications for ABG punctures

Hematoma, arteriospasm, air or clotted-blood emboli, anaphylaxis from local anesthetic, introduction of contagion at sampling site and consequent infection in patient, introduction of contagion to sampler by inadvertent needle stick, hemorrhage, trauma to vessel, arterial occlusion, vasovagal response, pain.

What are some conditions that may require longer artery compression in regard to ABG

Anticoagulation patient’s,

What needs to be monitored in regard to arterial puncture and ABG samples

What is the post ABG puncture care

What is the post ABG puncture monitoring

Handling and troubleshooting difficulties with ABG procedure or things that could go wrong

What is the purpose, time, what are you looking for, and what do you do if you do not like the result of an Allens test

The purpose of the test is to determine collateral circulation. You are looking for the hand to “Pink-Up” after the pressure is released from the ulnar artery. The hand should pink up within 10-15 seconds, if it does than it’s positive (There is adequate collateral circulation). If the hand does not pink up within 10-15 seconds, the test is negative and an ABG puncture should not be done on that hand. If the test is negative, perform the Allens test on the other arm.

What might happen specifically to a ABG sample if left without ice (CO2)

What might happen if air bubble is present in ABG sample (CO2, PO2).

The PaO2 levels could increase, while the PCO2 levels would decrease.

If a patient arrives for a sleep study late and they need a baseline ABG, but the patient just ran up multiple flights of stairs, what should the clinical consider? How could it effect the ABG

Normal pH range for arterial blood

7.35-7.45

Ranges of hypoxemia and normal when given PaO2 values.

100-80 normal

60-79 mild

40-59 moderate

<40 severe

Respiratory acidosis versus respiratory alkalosis?

Respiratory acidosis-The lungs cannot remove enough CO2, leading to an accumulation of CO2 and a decrease in blood pH (making it more acidic)

Respiratory alkalosis-Excessive elimination of CO2 through hyperventilation, resulting in a higher blood pH (making it more alkaline)

Metabolic acidosis versus metabolic alkalosis

Metabolic acidosis-Low pH, HCO3. Caused by excess acid production like in ketoacidosis or lactis acidosis. Means there is too much acid (hydrogen ions) or too little bicarbonate in the body

Metabolic alkalosis- Occurs when there is too much bicarbonate or too little hydrogen ions. pH and bicarbonate (HCO3) are high. Caused by a loss of acid (Vomiting, diuretic use, excessive antacid intake.

PaCO2 versus HCO3

PaCO2 reflects the respiratory component of acid-base balance. PaCO2 measures the amount of carbon dioxide dissolved in arterial blood and indicates how effectively the lungs are eliminating CO2 while HCO3 reflects the metabolic component, it acts as a buffer to maintain pH.

How does the body compensate for respiratory acidosis?

Buffering by blood proteins and phosphate systems, these buffers temporarily neutralize excess hydrogen ions, slightly raising pH. Typically, bicarbonate increased by about 1 mEq/L for every 10 mmHg rise in CO2 which is insufficient to fully normalize pH. The body attempts hyperventilation to expel excess CO2. Therefore, the body compensates for respiratory acidosis primarily through renal retention of bicarbonate and increased acid excretion, along with acute buffering and respiratory adjustments.

How does the body compensate for metabolic acidosis

Increased breathing rate and depth (Hyperventilation) to expel more carbon dioxide which helps to raise blood pH. The kidneys attempt to retain bicarbonate (HCO3) and excrete hydrogen ions (H+) to help correct the acid-base imbalance.

Interpretation of ABG’s

IBW calculations

Female: 105+5(height in inches-60)

Male: 106+6 (height in inches-60)

BODY WEIGHT IS ALWAYS MEASURED IN KILOGRAMS.

Example: 5 ft 7 in female: 105+5 (67-60=140

To convert pounds to kilograms, divide by 2.2, so 140/2.2=63.63 kg.

IBW goals and what to do if not meeting the goal.

Kg IBW 10= Tidal volume 2= minimal goal for IS

Hazards of hyperinflation

Hyperventilation, fatigue, discomfort (Must access for patient pain), pneumothorax, exacerbation of bronchospasm, hypoxia (monitor patient SpO2.)

What types of patients would benefit or be considered for IPPB

Need for delivery of medications to a patient who cannot take a deep breath (<10 mL/kg ideal body weight.)

Atelectasis, especially in sedated postoperative patients and patients recovering from chest or abdomen surgery who are reluctant to breathe deeply or cannot take deep breaths on their own.

What happens to alveoli and pressure gradients during IPPB

IPPB troubleshooting-if it won’t cycle off, what does that mean.

If the machine won’t cycle off- there could be leaks, tighten all tubing, ensure there are no leaks around the mouthpiece, mask, or nose, check the circuits expiratory valve function.

Initial IPPB settings-sensitivity, pressure, etc.

Sensitivity-adjust so the patient has to draw no more than -2 cm H2O

In regard to IPPB, how does pressure and volume relate

IPPB contraindications

Untreated pneumothorax, it will only worsen the problem. Pulmonary hemorrhage, if IPPB is administered with this air may enter a blood vessel and result in an air embolism.

Goals of airway clearance therapy

To prevent the accumulation of pulmonary secretions. To improve the mobilization of retained secretions, to improve the distribution of ventilation, and to decrease airway resistance.

Which types of patients would be the most likely and least likely to benefit from CPT

Who would benefit-Bronchiectasis, CF, acute respiratory failure with retained pulmonary secretions, acute atelectasis, ventilation and perfusion abnormalities resulting from retained pulmonary secretions, inefficient breathing patterns in patients with COPD. Prevention of postoperative respiratory complications.

Who does not-Recent spinal surgery. head/neck injuries that aren’t stabilized. Large pleural effusions. Rib fractures. Tube feeding or recent meals. Lung contusion. Empyema.

Disease states and which BHT/CPT might be the most ideal

CF-Autogenic drainage (Mobilizes secretions in a way comparable to postural drainage and percussion but without the degree of O2 desaturation).

Postural drainage-CF, bronchiectasis, chronic bronchitis or pneumonia.

Signs of retained secretions

Crackles heard on auscultation. Diminished or absent breath sounds.

Describe and define intrapulmonary percussive ventilation

An airway clearance technique that uses a pneumatic ventilator to deliver a series of small tidal volumes at high frequency (110 to 225 cycles/min). 15-20 minute treatment.

Describe and define postural drainage

Involves positioning a person with the assistance of gravity to aid the normal airway clearance mechanism. Positioning varies based on specific segments of the lungs with a large number of secretions. The effect of gravity can help move secretions to the central airways, to where they can be removed by a cough or mechanical aspiration. Positions should generally be held for 3-15 minutes.

Describe and define mechanical insufflation-exsufflation

This device delivers positive pressures of 30 to 50 cm H2O over a 1-3 second period and then the airway pressure is suddenly reversed to a negative pressure of -30 to -50 cm H2O. This helps patients with neuromuscular disease generate expiratory flow rates to mobilize secretions.

Describe and define CPT

Chest physical therapy-Is a variety of techniques aimed at the mobilization of pulmonary secretions and promotion of greater use of the respiratory muscles, which should result in an increase in the distribution of ventilation. Includes- postural drainage, chest percussion, chest vibration, cough techniques, and breathing exercises

Describe and define forced expiratory technique

The FET or Huff cough is a modification of the directed cough. It consists of one or two forced expirations of middle to low lung volumes. These expiratory maneuvers are performed with an open glottis, followed by diaphragmatic breathing and relaxation.

Define and describe PEP

Positive expiratory pressure is a bronchial hygiene therapy used in the management of airway secretions and postoperative atelectasis. It is an alternative to CPT and incentive spirometry, especially in pediatric patients with CF and bronchiectasis. It’s effective in preventing postoperative atelectasis by opening airways and improving gas exchange. PEP is achieved by having the patient exhale through a mask or mouthpiece with a resistance valve. The valve creates back pressure into the patient’s airway. Generally, PEP levels of 10-20 cm H2O are used.

Describe and define HFCWO

Is a technique to improve sputum clearance from the airways. An inflatable vest is wrapped around the patient’s chest and is attached to an air pulse generator which intermittently injects small volumes of air into the vent and then ejects them out at a high rate. Thie creates oscillatory movement that helps mobilize secretions. Duration is typically 30 minutes with an oscillation frequency of between 5-25 Hz.

Anterior upper segment

For both upper lobes

Posterior apical segment

Upper lobe

Anterior segments

Right posterior segment

left posterior segment

Right middle lobe

left lingular

Anterior segments (Lower lobes)

Right lateral segments

How does a flutter valve work

The angle at which this device is held will determine the PEP. The more upright the flutter is held, the higher the PEP generated back down the airway. Exhaling reasonably fast but not too forcefully causes the stainless-steel ball in the device to be pushed up into the angled portion of the device to produce PEP. The angle causes the ball to oscillate or “flutter”, up and down.

Environmental factor considers for hospital discharge to home care

Home safety (assess for hazards like poor lighting, very dirty, clutter), social support, living situation (assess for concerns of abuse.)

CMS requirements for home O2 prescription

-Qualifying diagnosis: chronic lung disease or condition causing hypoxemia

-Documented hypoxema-PaO2 < or equal to 55 mmHg or SpO2 less than or equal to 88%

-Physician order: Must include flow, frequency, duration, and diagnosis

-Objective testing: ABG or pulse ox, must reflect patient in stable state

-Medical necessity: O2 must improve patient condition

ECG electrode placement

What supplies could you use or what might you need to do to get the electrodes to stick properly

Clean the skin with alcohol based prep pads, shave the hair,

Causes of artifact when obtaining an EKG

Circumstance when you should consider placing the limb electrodes on the torso instead of the extremities.

When they are an amputee