LAB Arterial testing and pulse oxymetry Senarios

DuoNeb

A combination of ipratropium bromide (Atrovent) and albuterol sulfate for aerosol drug administration.

Aerosol

A suspension of solid or liquid particles in a gas, used for inhaling medications.

High Dose Albuterol

Typically used to treat hyperkalemia by facilitating the uptake of potassium into cells.

Mucolytics

Medications used to loosen and thin mucus in excessive secretions.

Corticosteroids

Anti-inflammatory drugs used in aerosol therapy to decrease airway inflammation.

Bronchodilators

Medications used to relax and open the airways in cases of bronchoconstriction.

Tachycardia

A condition characterized by a heart rate over 100 bpm.

Tachypnea

An elevated respiratory rate; typically defined as over 20 breaths per minute.

Nebulizer Liter Flow

The appropriate flow for a small volume nebulizer is generally set between 6-8 L/min, with a maximum of 10 L/min.

Peak Flow Meter

A device used to measure the peak expiratory flow rate in patients with asthma.

SpO₂

Peripheral capillary oxygen saturation, a measure of how much oxygen is in the blood.

DPI (Dry Powder Inhaler)

A device that delivers medication in a dry powder form, predominantly used for chronic maintenance therapy.

QD

Once daily, a dosing schedule indicating a medication should be taken one time per day.

BID

Twice daily, a dosing schedule indicating a medication should be taken two times per day.

Functional Residual Capacity (FRC)

The volume of air remaining in the lungs after a normal expiration, important for effective inhalation.

Thrush

A fungal infection that can occur in the mouth, often prevented by rinsing after using steroid inhalers.

Green Zone

Peak flow above 80%, indicating asthma is controlled.

Yellow Zone

Peak flow between 50%-80%, indicating the need for a short-acting inhaled beta₂ agonist.

Red Zone

Peak flow below 50%, indicating a medical alert and the need for immediate medical attention.

Pulse Oximetry

A non-invasive method to monitor the oxygen saturation of a patient's blood.

Alarm Limits in Pulse Oximetry

Lower SpO₂ alarm for COPD set at 85% and for a normal patient at 88%.

Albuterol

A short-acting bronchodilator used for relief of bronchoconstriction.

Hyperkalemia

An elevated level of potassium in the blood, treatable with high-dose albuterol.

You get paged to attend to a 65-year-old female presenting to the emergency department with acute onset shortness of breath. 
The doctor has ordered Mrs. Cobbert to receive a DuoNeb.”
What two medications make up DuoNeb? 

ipratropium bromide(brand name Areovent) and albuterol sulfate

“Her(Mrs. Cobbert) symptoms began approximately one day ago.” 

Show me what you would do first when you arrive in the emergency department. 

Check chart then do Hand hygene

Why is it important to verify the physician’s order? 

To verify the appropriate medication, dosage, & frequency 

What is the main purpose for using this small volume nebulizer? 

To administer aerosolized medications for inhalatoin

Identify four specific indications for aerosol therapy?

a. An aerosol in a suspension of solid or liquid particles in gas

b. Shortness of breath (SOB)

c. INcreased WOB(signs of respiratory distree)

d. Bronchoconstriction (Bronchodilators)

e. Inflanation (Corticosteroids)

f. Excessive secretions (mucolytics)

g. Patient falls into Yellow or Red Flow Zone

h. High Doce albuterol treatment are used to treat Hyperkalemia

Whay type of medication would you use for excessive secretions?

Mycolytics (help loose/thin secretions)

What about Inflamation? What medication woul you use?

Corticosteroids (decrease airway inflammation)

What if your patient has bronchocostriction’s

Give Bronchodilators

What does high-dose albuterol help treat?

Hyperkalemia

What assessments will you perform before administering the small volume nebulizer? 

a. Measure pulse, respiraoty rate and saturation

b. Asseses color and level of dyspnea

c. Assesses breath sould and note adventitios counds by lobe and segment

d. Astablishes base line peak flow or FEV1 if delivering a brochodilator agent.

What device do you use before brochodilator treatment

Peak Flow Metter

Temperature 97.7

Normal

Heat Rate (HR) 108 bpm

Tachycardia

Respiratoty Rate (RR) 26/min

Tachypnea

Blood Pressure (BP) 114/64 mm/Hg

Normal

SpO2 94% on 3L nasal cannula

Normal

“Demonstrate how you would set up your small volume nebulizer and tell me what the appropriate liter flow would be.” 

• Nebulizer cup

• MOuthpiece

• Nebulizer T-piece

• Corrugated Tubing

• Aerosol mask

• Tubing

• Baffle

What liter flow are you supposed to have it on? (SVN)

6-8L/min

And you can go as high as what? (SVN)

10 L/min

Patient positioning / mouthpiece vs mask 

sitting up because medication can settle in the nebulizer if the patient is lying flat.

If the patient is sleepy, unable to follow commands, or unable to coordinate using the mouthpiece

use a mask instead

how you know the treatment is nearing completion

The nebulizer begins to sputter. 

How do you know the nebulizer is working? 

you can see aerosol/mist being produced

Differentiate particle sizes targeted for the upper vs the lower airway. 

1. Upper - 5-10 microns 

2. Lower - 2-5 microns 

Identify some follow-up assessments you would perform after administering a SVN. 

a. Measure pulse, respiration rate and saturation

b. Assesses color and level of dyspnea

c. Assesses breath sounds

d. Instruct patient to cough

e. NOtes changes in Peal Flow or FEV1(force expiratory volume)

She then says Mrs. Cobbert’s breathing treatments are continuing, but the patient develops an adverse reaction. What would you recommend? 

1. Stop treatment Immediaterly

2. Notify the nurse

3. Notify the Physician

4. Contenie monitoring

   1. Consider reducing albuterol to the lowest dose, with Xoponex/Lavalbuterol as an alternative if needed.

At 1300, you are paged to assist Mr. Mali on the fifth floor with his new DPI.” 

How old does the patient have to be to use a DPI? 

Greater than 5 y.o.

What are some indications/advantages and types of medications used for DPI therapy? 

The pt does not have to worry about coordination to inhale with inspiration

What peak/inspiratory flow does the patient need to achieve? 

60 L/min or greater

Are DPIs short-acting/quick-relief medications or maintenance medications? 

Maintenance medication

“DPI should never be used as quick relief. They’re always considered long-term maintenance.” 

What are some Diskus DPIs?

Advair, Flovent, Serevent

What about DPIs with a gelatin capsule?

Foradil Aerolizer, Spririva Handihaler

What about breath-actuated DPIs?

Asmanex Twisthaler, Azmacort, Pulmicort, Symbicort

DPI demonstration

Then she says:

“I want you guys to go ahead and demonstrate how to assemble the DPI and load the medication properly.”

She demonstrates the devices and then has the student teach the patient.

The main instructions she gives are:

Hold the DPI upright when loading it.

Tell the patient to exhale first.

She specifically describes exhaling to:

FRC — Functional Residual Capacity

Do not exhale into the DPI.

Put lips tightly around the mouthpiece.

Then Take a forceful, deep inspiration.

demonstrates it with a strong inhalation.

What should the patient do after taking a steroid DPI?

a.       Rinse the mouth.

Why do we rince the mouth?

Prevent Thrush, dysphonia/voice changes

To make sure the DPI is effective Mr. Mali needs to reach a peak flow of what value?

60 L/min

How often are DPIs usually taken

QD or BID

What limitations are associated with using DPIs?

children under 5 y.o., inaquate inspiratory flow, high humidity (because medication can clump)

“The doctor has now ordered overnight pulse oximetry since Mr. Mali experienced several de-sats last night.” Identify three indications for pulse oximetry.

a.       The need to monitor the adequacy of arterial oxyhemoglobin saturation

b.       The need to quantitate the response of arterial oxyhemoglobin saturation to therapeutic intervention or to a diagnostic procedure (ex: bronchoscopy)

c.       The need to comply with mandated regulations or recommendations by authoritative groups

d.       Documented hypoxemia

e.       Overnight Pulse Oximetry

f.         Vital Signs Assessment

“Show me how you would demonstrate how to properly set the alarm limits.”

low SpO₂ alarm for COPD.

85%

“Show me how you would demonstrate how to properly set the alarm limits.”

low SpO₂ alarm for Normal Patient

88%

“Let's say they were an athlete and their resting heart rate was 50. What would you set the low heart-rate alarm to?”

“What's the rule?”

10 bpm below the athlete's baseline.

“If they're not an athlete and their resting heart rate is 75, what would you set the low heart-rate alarm to?”

55 bpm

If they're non-athletes, it's always ____ no matter what

55 bpm

High HR alarm “If their heart rate was 80, what would you set their high alarm to?”

120 bpm (bc HR is 60-100)

If baseline HR is over 100 → high alarm = baseline + 20 bpm

HR 115 → alarm _____ bpm

135 bpm

Identify at least four causes of inaccurate/erroneous SpO₂ readings.

a.       motion artifact

b.       abnormal hemoglobins (COHb and metHb)

c.       intravascular dyes

d.       low perfusion states

e.       dark skin pigmentation

f.         cold extremities

g.        dark nail polish (black, blue, purple, green)

h.       SpO2 readings are not always reliable below 80% depending on the pulse ox!

“You guys have been called about Mr. Walsh. You're assisting the nurse to discharge him home. He's 48 years old. He has asthma”.

“The doctor has prescribed an MDI and a peak flow meter for him to take home.”

What are two indications for using a peak flow meter?

Measures how well the patient's asthma is controlled, and Helps identify airway narrowing/onset of an asthma attack

“Now instruct Mr. Walsh on the proper way to use a peak flow meter.”

“Hi, Mr. Walsh. I'm ____ from Respiratory. We're going to measure how well your asthma is doing and see if you need to take any extra medication today.”

Demonstrates:

1. Set marker to zero

2. Patient takes a deep/maximal breath in

3. Forms a tight seal around the mouthpiece

4. Blows as hard and fast as possible

5. Record the result

6. Reset the meter

7. Repeat until you have three valid trials

8. Record the best of the three

Current peak flow ÷ Personal best peak flow × 100 = percent of personal best

Example: personal best = 500 L/min, today's best effort = 300 L/min.

300 ÷ 500 × 100 = 60%

Green Zone

above 80% (asthma is controlled; continue usual asthma medications).

Yellow Zone

50%–80% (use a short-acting inhaled beta₂ agonist and consider whether daily therapy needs adjustment).

Red Zone: below 50%

medical alert (take a short-acting beta₂ agonist and contact the doctor/go to the ER as directed).

“Mr. Walsh's normal baseline peak flow is 500 L/min. Today his best reading is 300 L/min. What percentage of his normal baseline is he at, what zone is he in, and what would you recommend?”

300 ÷ 500 × 100 = 60%. He is in the Yellow Zone. I would recommend a short-acting inhaled beta₂ agonist and notify/follow up with his physician regarding his asthma control.