Archer 3

Order and FiO2 range of low flow respiratory support

nasal cannula - 24-40%

simple face mask - 35-55%

non-rebreather - 100%

Venturi mask

Delivers controlled/precise oxygen percentages; color indicates flow/percentage; used for hypercapnic patients (too much CO2)

High flow nasal cannula

4-40L oxygen

BiPAP is used for…

Central sleep apnea, CHF, COPD, Parkinson's, ALS

Suction Control Chamber - chest tube

No tidaling; gentle bubbling; monitor output, replace sterile water as needed

Water Seal Chamber - chest tube

Tidaling present; intermittent bubbling; vigorous/excessive bubbling = LEAK

Drainage Collection Chamber - chest tube

No tidaling; normal drainage = serosanguinous (pink); no bubbling

What is tidaling?

Up and down movement of water in water seal chamber

Absence of tidaling in chest tube indicates?

Obstruction in chest tube OR lung has fully re-expanded

What to monitor in chest tube drainage?

Color, odor (should be NONE), consistency, amount

Critical drainage amount - chest tubes

>100 mL/hr → notify provider immediately

What to do when chest tube comes out of a pt?

1	Cover site with sterile dressing
2	Tape on 3 sides (allows air escape; taping 4 sides could cause tension pneumothorax)
3	Call provider
4	STAY WITH PATIENT

What to do when chest tube become disconnected from collection chamber?

Place end of chest tube in bottle of sterile water

What to keep at bedside for any pt with a chest tube?

Bottle of sterile water for any patient with chest tube

What should pts do prior to using an inhaler?

shake it prior to use

Emphysema

Destruction of alveoli from chronic inflammation → decreased surface area for gas exchange

Chronic bronchitis

Chronic inflammation with productive cough and excessive sputum

What is asthma?

Respiratory condition with bronchial spasms; chronic inflammation of bronchi/bronchioles + excess mucus

Signs of asthma

Prolonged expiration, wheeze, increased work of breathing, unable to speak

Treatments (6) for asthma

Albuterol (adrenergic agonist), steroids (dexamethasone), theophylline (bronchodilator), IV fluids, oxygen mask, anticholinergics (-pium)

Status Asthmaticus (describe it + tx)

Asthma attack refractory to treatment → severe respiratory failure → death; treat with magnesium sulfate, nebulizers

Signs of COPD and asthma in general

Barrel chest	Hyperinflated lungs
Accessory muscle use	Retractions, nasal flaring, tracheal tug
Lung sounds	Diminished, crackles, wheezing
Acidosis	Respiratory acidosis
Hypercarbia	High CO2
Hypoxia	Low O2

TX for COPD

Be careful with oxygen administration	COPD patients may rely on hypoxic drive
Bronchodilators	Albuterol, terbutaline
Increased fluid intake	Thin secretions
Pursed lip breathing	Helps expire completely
Small frequent meals	Prevents stomach overdistention (impedes diaphragm)

What is pneumonia?

Inflammation of lung affecting alveoli

Diagnosis (2) criteria for PNA

Chest x-ray (patchy infiltrates), sputum culture (identify bacterial source)

S/s (6) of PNA

High fever, cough, crackles, tachypnea, chest pain, work of breathing

TX for PNA

ABCs, treat infection, antipyretics, analgesia, cough suppressant, expectorants

What is ARDS?

Trigger causes lung inflammation → fluid leaks into alveoli → prevents gas exchange

Causes (6) of ARDS

Sepsis, trauma, burns, aspiration PNA, overdose, near drowning

Possible Complications from ARDS

Respiratory acidosis, irreversible lung damage

Chest x-ray finding in pt with ARDS

Diffuse bilateral infiltrates ("whited-out")

S/s of ARDS

Hypoxemia (pale, cool, dusky, mottled, low SpO2)

TX for ARDS

Intubation + mechanical ventilation, prone positioning, prevent infection (VAP)

What is pneumothorax?

Air and fluid collect in pleural space

S/s (6) of pneumothorax

SOB, chest pain, desaturation, hypotension, tachycardia, diminished breath sounds on ONE side

Critical assessment for pneumothorax

Assess if trachea is midline; if NOT → tension pneumothorax

TX for pneumothorax

Needle decompression, chest tube

What is PE?

Blood clot in the lungs

S/s (8) of PE

Anxiety, restless, dyspnea, hypoxemia, chest pain, rales, diaphoresis, hemoptysis

Treatment (4) for PE

Oxygen, high-Fowler's positioning, anticoagulants, thrombolytics

Name 4 uses of NG tube

Enteral nutrition, decompression, medication administration, removal of stomach contents after overdose

NGT insertion steps

1	Hand hygiene
2	Explain procedure to patient
3	Measure earlobe → nose → xiphoid process (insertion depth)
4	Mark depth on tube
5	Lubricate tip
6	Insert to nasopharynx; ask patient to swallow and tuck chin to chest
7	Continue advancing to predetermined depth
8	Secure tube
9	Verify placement with X-RAY

What is a Blakemore tube?

Tube with balloons that inflate to stop bleeding esophageal varices

What must be kept at bedside for pts with blakemore tubes? why?

Pair of scissors (in case of emergency)

Tube can become displaced, compressing trachea → respiratory arrest

What are esophageal varices?

Dilated veins in esophagus (life-threatening; risk of bursting/bleeding)

Causes of esophageal varices

Liver disease, alcoholism

What is GERD?

Acid refluxes from stomach into esophagus

Treatment (3) for GERD

Sit upright after eating, small frequent meals, H2 blockers, PPIs

What is gastritis?

Inflammatory disorder of gastric mucosa

S/s (2) of gastritis

Vague abdominal discomfort, epigastric tenderness (hurts when pressing down), bleeding

What to avoid in pts with gastritis?

NO more NSAIDs!

Treatment (4) in pts with gastritis

H2 blockers, PPIs, antibiotics (if H. pylori), supportive care

Pain typically occurs for gastric ulcers when?

1-2 hours after meal (worse with eating)

Pain typically occurs for duodenal ulcers when?

2-4 hours after meal (better with eating)

Gastric ulcer vs duodenal ulcer (weight, bleeding complication, causes)

Weight	Weight loss	Weight gain
Bleeding complication	Hematemesis (vomiting blood)	Melena (black, tarry stool)
Common causes	H. pylori, NSAIDs	H. pylori, NSAIDs

TX for gastric and duodenal ulcers

Antibiotics, H2 blockers, PPIs

Signs of inflammatory bowel diseases

Rebound tenderness, cramping, V/D, dehydration, weight loss, rectal bleeding, bloody stools, anemia, fever

TX for Irritable Bowel Disease

Low fiber diet (too much motility), avoid cold/hot foods, antidiarrheals, antibiotics, steroids, surgery (ileostomy, colostomy)

Crohn’s Disease vs UC (location + type)

Feature	Crohn's Disease	Ulcerative Colitis
Location	Ileum + anywhere throughout small/large intestines	Large intestines only
Type	Idiopathic inflammatory disorder	Inflammation of large intestines

Causes of diverticular disease

Decreased dietary fiber, abnormal neuromuscular function, altered motility, age >60

Sudden relief of pain of pt with appendicitis may indicate?

Appendix rupture → peritonitis

What to avoid in pts with appendicitis?

NO heat (can cause rupture)

Positioning for pt with appendicitis?

Right side, low Fowler's for comfort

#1 cause of pancreatitis

Alcoholism

Pain symptom in pt with pancreatitis

Increases with eating (due to increased enzymes)

Cullen's sign

C-shaped bruising above umbilicus

Grey Turner's sign

Bruising along the flank

Signs of pancreatitis

pain increasing with eating

c-shaped bruising above umbilicus

bruising along the flank

Key lab finding in pts with pancreatitis

Increased serum lipase (pancreatic enzyme)

TX for pts with pancreatitis

Pain control (fentanyl, hydromorphone, morphine), NPO/NGT suction, TPN (rest pancreas), calcium replacement (hypocalcemia), fluids/electrolytes, antibiotics (if fever), steroids

Signs of Cholelithiasis aka gallstones

sudden, sharp RUQ pain that radiates to back, between shoulder blades, or right shoulder

pain worsening at night or after a fatty meal

Cholelithiasis otherwise known as…

gallstones

Signs of cholecystitis

Fever, leukocytosis, rebound tenderness, abdominal muscle guarding

TX for cholecystitis

Pain control, fasting, antibiotics, fluids/electrolytes, immediate cholecystectomy if perforated

How is Hep A transmitted?

Contaminated food/water

How is Hep B transmitted?

Infected body fluids (blood, semen, vaginal fluids)

How is Hep C transmitted?

Infected body fluids (IV drug use, non-sterile equipment)

How is Hep D transmitted?

Infected body fluids (only if already have HBV)

How is Hep E transmitted?

Contaminated food/water

How to prevent Hep A?

Vaccine, hygiene/sanitation

How to prevent Hep B?

Vaccine, blood screening, hygiene

How to prevent Hep C?

Blood screening, sterile equipment, sanitary environment

How to prevent Hep D?

HBV vaccine (protects against HDV), blood screening, sterile needles

How to prevent Hep E?

Improved hygiene/sanitation

What causes hepatic encephalopathy?

Liver cannot break down ammonia → increased ammonia levels → neurotoxic

S/s (4) of hepatic encephalopathy

Changes in LOC (confusion, stupor), asterixis (hand tremor), fetor (musty/sweet breath odor), sleep/mood/speech problems

Medications to decrease ammonia (2) in hepatic encephalopathy

Lactulose OR antibiotics (neomycin, rifaximin)

Diet change for pts with hepatic encephalopathy

Decrease protein

What should the nurse monitor in pt with hepatic encephalopathy?

Serum ammonia

Fluid retention treatment for pt with hepatic encephalopathy

Potassium-sparing diuretics (spironolactone)

What is cirrhosis?

Chronic liver disease with degeneration of cells, inflammation, fibrous thickening of tissue

Causes (3) of cirrhosis

Alcoholism, hepatitis (B+C), diet

Complication for pts with cirrhosis

Portal HTN → esophageal varices

S/s (8) of cirrhosis

Palpable firm liver, ascites/edema, abdominal pain/bloating, spider angiomas, jaundice, decreased albumin, increased liver enzymes, increased bleeding risk/anemia

Treatment (6) of cirrhosis

Antacids, vitamins, diuretics, paracentesis, low protein/low sodium diet, strict I&Os, daily weights, bleeding precautions, skin care, careful with drug doses

Name 3 things you should NOT do - therapeutic communication

Ask why, give false reassurance, make assumptions

What is therapeutic silence effective for?

Patients in acute phase of severe depression

What is false reassurance?

Promises you can't always keep

Therapeutic statements should be...

Open-ended

Do NOT ______________ the care to someone else

pass off