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Acute care > Week 9 > Flashcards

Week 9 Flashcards

1
Q

What is a common code red emergency code?

A

Fire

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2
Q

What is a common code gray emergency code?

A

Severe weather

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3
Q

What is a common code pink emergency code?

A

Abducted child or baby

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4
Q

What is a common code silver emergency code?

A

Active shooter

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5
Q

What is a common code black emergency code?

A

External emergency

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6
Q

What are some codes that require the action of a PT?

A
  • Code Blue
  • Rapid Response
  • Sepsis Alert
  • Stroke Alert
  • NSTEMI Alert
  • Trauma Alert
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7
Q

What the therapist role inn the codes that require their action?

A

Recognizing the need for the

activation, initiating action, or assisting the teams as needed

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8
Q

What are the codes not traditionally initiated by therapy team?

A

Sepsis, NSTEMI, trauma

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9
Q

What are the codes that can be initiated by therapy team?

A
  • Code Blue
  • Rapid Response
  • Stroke Alert
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10
Q

What is the goal of a code blue?

A

Perform resuscitation efforts after a person has stopped breathing or after the heart has stopped beating

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11
Q

Who initiates a code blue?

A

Anyone with CPR certification or who can verify that a person has stopped breathing or has no pulse

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12
Q

When is a code blue initiated?

A
  • Person has stopped breathing
  • Person has no pulse
  • Unable to determine if the person has a pulse or breathing, and person unresponsive
  • Unsure of what to do and have dire concern for the life of the person
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13
Q

Who are the team members involved in a code blue?

A
  • Critical care MD
  • Hospitalist
  • Primary RN
  • Nursing supervisor
  • RT, PCT/CNA
  • Recorder
  • Runner
  • Security
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14
Q

What are the characteristics of a code blue as it relates to a PT?

A

It is possible that you as the therapist, after calling code,
may have to initiate CPR until team arrives!

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15
Q

What is the goal of a rapid response?

A

Intervene before the onset of injury, respiratory arrest, or cardiac arrest

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16
Q

Who initiates a rapid response?

A

Anyone, including family, hospital staff, nursing staff, physicians, visitors

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17
Q

When is a rapid response called?

A 
• HR>140 or <40
• RR>28 or <8
• Systolic BP>180 or <90
• Urine output <50 cc over 4 hrs
• Staff, family, or visitor has significant concern about the
pt’s condition
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18
Q

Who are the team members involved in a rapid response?

A
  • Critical care MD
  • Hospitalist
  • Primary RN
  • Critical care RN
  • Nursing supervisor
  • RT
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19
Q

What are the similarities between a code blue and a rapid response?

A
  • Alert team of highly trained clinicians to respond to a medical emergency
  • May be called by therapy staff
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20
Q

What is the main difference between a code blue and a rapid response?

A
  • Rapid response = Goal is prevention of decline

* Code blue = Goal is resuscitation

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21
Q

What is the goal of a stroke alert?

A

Quickly notify the appropriate team of providers about an acute stroke and dedicate hospital resources to the immediate diagnosis and treatment of these patients
• Timely CT scan
• Neuro eval
• Determining need to administer tPA and/or surgical intervention

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22
Q

Who initiates a stroke alert?

A

EMS in route to hospital, ER team upon arrival in hospital, anyone on medical floor noting
stroke symptoms

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23
Q

When is a stroke alert initiated?

A

Patient exhibits signs of acute stroke: FAST

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24
Q

Who are the team members involved in a stroke alert?

A
  • Neurologist
  • Hospitalist/ER physician
  • ICU nurse
  • RT
  • Radiologist
  • Radiology tech
  • Neurosurgeon (if needed)
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25
Q

What does the FAST acronym stand for when used to exhibit signs of an acute stroke?

A
  • Face. Look for an uneven smile
  • Arm: (check if one arm is weak)
  • Speech (listen for slurred speech)
  • Time (call 911 right away)

Anyone could mean a stroke

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26
Q

What is an advanced directive?

A

Legal documents that specify decisions about end-of-life care

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27
Q

What does an advanced directive: Living will do?

A

Outlines what treatments a patient wants in the event of life threatening conditions and/or the inability to express those desires him/herself; also may contain information regarding organ or tissue donation

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28
Q

What does an advanced directive: Durable power of attorney for health care do?

A

Document that names a trusted

health care proxy to make health care decisions when the patient is unable to do so

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29
Q

What are the characteristics of an advanced directive?

A
  • Part of the routine questions asked of hospitalized patients on admission
  • Not always available in emergency situations, though
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30
Q

What is a DNR?

A

Order indicating patient’s wishes to not perform CPR or other life saving measures in the even of a cardiopulmonary arrest

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31
Q

When is a DNR applicable?

A

Unless an out-of-hospital DNR exists, usually only applicable in the hospital situation
• In both cases, in/out of hospital, look for special patient identifiers

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32
Q

What are some other terminologies used to address a DNR?

A
  • Allow Natural Death (AND)

* AND-I (allows specified interventions that can be performed)

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33
Q

What does a DNI result from?

A

Resulted from separating wishes of no CPR from no mechanical ventilation (MV)
• Pulmonary compromise CAN occur in setting of no cardiac compromise
• Pulmonary compromise, when left untreated, can lead to need for CPR
• What are pt’s wishes when this is the case?

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34
Q

What are the characteristics of a DNI?

A
  • At times, a trial of MV appropriate (i.e., pt. w/pneumonia where trial of MV could make a difference in quality of life and ultimately result in full recovery)
  • Up to physician to thoroughly explain these scenarios to get a full understanding/consent from patient
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35
Q

What are the safety precautions of a NPO(no food or drink) in place for?

A

• Minimize risk of aspiration from stomach contents or vomiting during or
immediately following a procedure
• Protect a patient from dangerous swallowing conditions
• Enforce bowel rest in the case of an obstruction or dysfunction in the GI system

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36
Q

In what situation will a patient have a NPO?

A
  • Awaiting surgery
  • Bowel blockages
  • Severe diarrhea or vomiting
  • Swallowing/aspiration precautions
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37
Q

What kind of conditions require a 1 on 1 care for the patient?

A

Medical, mental health, or behavioral conditions necessitate 1-on-1 care for the
patient
• Delirium and extreme confusion
• Suicide risk
• Situational (i.e., during meals due to aspiration precautions)
• Medical conditions that may impair judgement or create an unsafe circumstance
• Extreme fall risk
• Patient is a danger to others or is in danger FROM others (may involve law enforcement or
hospital security)

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38
Q

What are the restrictions put in place for a patient on 1 on 1 supervision?

A

NEVER leave the patient alone
• Family members sometimes asked to be the supervision, otherwise, may need a sitter
• As a PT, you may be the appropriate 1-on-1 supervision while performing treatment
• In cases where you feel uncomfortable being alone with the patient, certainly appropriate to request additional person in the room

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39
Q

How is a personal protective equipment (PPE) selected?

A

Based on what the provider is doing for the patient, or based on what type of transmission based precaution the patient is in

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40
Q

What are the items needed for a PPE?

A
  • Gown
  • Face mask or respirator
  • Goggles or face shield
  • Gloves
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41
Q

What does a gown do as a PPE?

A

Helps protect clothing from any type of splashes of fluid

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42
Q

What are some key points to keep in mind when donning and doffing a PPE?

A
  • Put on PPE before entering the patient’s room
  • Keep hands away from face, and don’t touch PPE
  • Avoid touching areas in the patient’s room
  • Remove PPE at patient’s doorway or outside of the room, and perform hand hygiene immediately
  • Remove the respirator outside of room after closing the patient’s door
  • If hands become contaminated during PPE removal, stop and perform hand hygiene and then proceed with PPE removal
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43
Q

What is the sequence of donning a PPE?

A
  • Hand hygiene
  • Gown
  • Mask/respirator
  • Goggles/ face shield
  • Gloves
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44
Q

What are some tips for when wearing a respirator?

A
  • Always follow the manufacturer’s instructions
  • Perform an annual “mask fit test” with your employer
  • After donning your mask, perform a seal check to ensure a proper seal and fit
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45
Q

How do you perform a seal check with a respirator?

A

Place hand over the mask, and gently inhale and exhale feeling for any leakage

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46
Q

What is the order for doffing the PPE?

A
  • Gloves
  • Goggles or face shield
  • Gown
  • Mask or respirator
  • Perform hand hygiene
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47
Q

What are the contaminated areas of the PPE?

A
  • Outside of gloves
  • Front of the gown
  • Gown’s sleeves
  • Front of face shield/ goggles
  • Front of mask or respirator
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48
Q

What are the clean areas of the PPE?

A
  • Inside of gloves
  • Back of the gown
  • Gown’s ties
  • Straps of face shield/ goggles
  • Straps of mask or respirator
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49
Q

What are the risk factors of a health care- associated infection?

A 
• Age 
• Immunodeficiency 
• Immunosuppression 
• Misuse of antibiotics 
• Use of invasive diagnostic
or therapeutic procedures
• Agitation 
• Surgery 
• Burns 
• Length of hospitalization
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50
Q

____ is the single most effective way to prevent the spread of infection

A

Hand Hygiene is the single most effective way to prevent the spread of infection

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51
Q

When should hand hygiene be done?

A

• Before and after eating
• Before and after caring for patients
• Before and after treating a cut or wound
• After using the toilet
• After blowing your nose, coughing, or sneezing
• After touching garbage, soiled linens, or other dirty
objects

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52
Q

What are the guidelines for hand hygiene with soap?

A

• Wet hands with warm or cold clean, running water
and apply soap
• Lather hands by rubbing them together w/soap. Make sure to get the backs of hands, between fingers, and under nails
• Scrub hands for at least 20 sec (“Happy Birthday” song x 2)
• Rinse hands under running water
• Dry hands w/towel and turn off water with towel

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53
Q

What are the guidelines for hand hygiene without soap?

A

• If running water and soap not accessible, use alcoholbased hand sanitizer containing at least 60% alcohol
• Although acceptable in the health care environment,
sanitizers DO NOT eliminate all types of germs, remove
harmful chemicals, nor are as effective when hands are
visibly dirty.

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54
Q

What is the techniques for the application of hand sanitizer?

A

• Apply gel or foam into palm of one hand
• Rub hands together
• Rub product over all surfaces of hands and fingers
until hands are dry

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55
Q

What are the good

cough and sneeze etiquette?

A

• Cover your mouth and nose when your cough or
sneeze with a tissue or by suppressing in your
antecubital space of elbow
• Wear a mask if you have a cough or cold that does not
preclude you from being at work
• HAND HYGIENE!!
• Instruct your patients to do this as well

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56
Q

What is the standard precaution for preventing a health care- associated infection?

A

Treat all patient situations as if they are potentially
infectious
• Wash hands before and after each and every patient contact
• Wear different sets of gloves with each patient
• Use personal protective equipment (PPE) such as a mask, face shield, gown, if contact w/body fluids possible (blood, urine, feces, emesis, wound exudate, etc)
• Follow respiratory hygiene and cough etiquette
• Use aseptic technique

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57
Q

What are the characteristics of the standard precaution for preventing a health care- associated infection?

A

• Terminology should be STANDARD precautions– mistake to use “Universal
Precautions” terminology
• ALWAYS FOLLOW THESE PRECAUTIONS NO MATTER WHAT OTHER PRECAUTIONS IN PLACE!

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58
Q

What is an airborne infection?

A

Contagious pathogens transmitted by airborne droplet
nuclei that have ability to remain suspended in the air for extended time:
• Measles, varicella (until lesions
dry/crusted), TB

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59
Q

What are the precautions to avoiding an airborne infection?

A
  • Standard precautions plus
  • Wear fitted N95 respirator mask or positive air purifying respirator (PAPR)(if N95 mask not available or does not fit properly)
  • Eye protection if splash/spray to eyes likely
  • Airborne infection isolation room required = negative pressure airflow
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60
Q

What is a droplet infection?

A

Transmission involves contact of the conjunctiva or mucous membranes in nose or mouth w/large-particle droplets (>5µm) generated from coughing, sneezing, talking, or suctioning.
• Influenza, meningitis, mumps, rubella, certain types of pneumonia

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61
Q

What are the precautions to avoiding a droplet infection?

A
  • Standard precautions plus

* Mask with or w/o face shield depending on proximity to patient

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62
Q

When do contact precautions occur?

A
  • Direct physical contact w/infected/colonized person
  • Indirect contact with an object or reservoir
  • Examples: MRSA, Shingles (herpes zoster), VRE, c-diff
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63
Q

What are the precautions to avoiding a contact infection?

A
  • Standard precautions plus
  • Gown and gloves required
  • In the case of c-diff, MUST use soap and water for hand hygiene as alcoholbased sanitizers do not kill the bacteria
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64
Q

What are the characteristics of a neutropenic precaution?

A
  • For patients with low # neutrophils (severe = < 500 cells/cubic mm)
  • Wash hands before/after entering pt room
  • Wear gloves and possibly a mask
  • Care providers with illness symptoms not allowed
  • No fresh fruits/vegetables or flowers allowed in room
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65
Q

What are the characteristics of a radiation precaution?

A

• Similar to neutropenic
• Items brought into room must remain in room for duration of pt’s stay
• May have time limits for visitors and caregivers d/t radiation exposure
• Likely shoe covers, gown, gloves, surgical mask– all of which must be disposed of
prior to leaving room

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66
Q

What is the normal range for PaO2?

A

75-100

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67
Q

What happens to the normal range for PaO2 with age?

A

Decreases after 70, it decreases each decade by ten

68
Q

What is the normal range for PaCO2?

A

35-45

69
Q

What is the normal range for pH?

A

7.35-7.4-7.45

70
Q

What are the functions of arterial blood gases?

A
  • Measures the acidity and the levels of oxygen, carbon dioxide, and bicarbonate within the blood
  • Quantifies the magnitude of gas exchange abnormalities
  • Identify type of respiratory failure
71
Q

What is the sequence in which arterial blood gases are written?

A

pH/PaCO2/PaO2/HCO3-/SaO

72
Q

What is acidemia?

A

pH < 7.35

73
Q

What is alkalemia?

A

pH > 7.45

74
Q

What is the abg in the presence of respiratory acidosis?

A

pH: decreased
PaCO2: increased
HCO3: normal

75
Q

What is the abg in the presence of respiratory alkalosis?

A

pH: increased
PaCO2: decreased
HCO3: normal

76
Q

What is the abg in the presence of metabolic acidosis?

A

pH: decreased
PaCO2: normal
HCO3: decreased

77
Q

What is the abg in the presence of metabolic alkalosis?

A

pH: increased
PaCO2: normal
HCO3: increased

78
Q

What are the characteristics of PaO2?

A

Normal: 80-100 mmHg
• Hypoxemic states are due to a variety of disorders (e.g. shunt,
hypoventilation, ventilation-perfusion mismatch)

79
Q

What are the characteristics of SaO2?

A

Called SaO2 (88% or greater) when measured with an ABG, SpO2 when measured with a pulse oximeter.

80
Q

What is normal PaCO2?

A

Normal: 35-45 mmHg

81
Q

What are the characteristics of pH?

A

Normal: 7.35-7.45
• Compensated states
• Uncompensated states

82
Q

What is normal bicarbonate HCO3?

A

Normal: 22-26 mEq/L)

83
Q

What is metabolic acidosis?

A

Increased H+ due to a drop in HCO3-

84
Q

What is metabolic alkalosis?

A

Decreased H+ due to increased renal absorption of HCO3

85
Q

What is respiratory acidosis?

A

Increased H+ due to excessive CO2 and decreased alveolar ventilation

86
Q

What is respiratory alkalosis?

A

Decreased H + due to a decrease in CO2 when too

much is blown off

87
Q

What are the indications for mechanical ventilation?

A

• RespiratoryFailure
• Cardiopulmonary arrest
• Trauma (especially head, neck, and chest)
• Cardiovascular impairment (strokes, tumors, infection, emboli, trauma)
• Neurological impairment (drugs, poisons, myasthenia gravis)
• Pulmonary impairment (infections, tumors, pneumothorax, COPD, trauma,
pneumonia, poisons)

88
Q

What is type 1 (acute) respiratory failure?

A

Hypoxemic

• Failure of oxygen exchange at alveoli/capillary interface

89
Q

What is type 2 (acute) respiratory failure?

A

Hypercapnic

• Failure to exchange or remove carbon dioxide (may also have hypoxemia)

90
Q

What is type 3 respiratory failure?

A

Perioperative

• Atelectasis, Often results in type I or type II respiratory failure (after procedure)

91
Q

What is type 4 respiratory failure?

A

Shock

92
Q

What are the characteristics of type 1 (acute) respiratory failure?

A
  • Low PaO2 (<55mmHg)

- Normal PCO2 (35-45mmHg)

93
Q

What are the characteristics of type 2 (acute) respiratory failure?

A
  • Low PaO2 (< 55 mmHg)
  • High PCO2 (> 45mmHg)
  • Low pH (< 7.3)
94
Q

___ is contraindicated during acute respiratory failure

A

Inspiratory muscle training is contraindicated during acute respiratory failure

95
Q

What is indicated during acute respiratory failure?

A

Resting respiratory muscles, to reduce the work of breathing

96
Q

What are the causes of acute respiratory failure?

A
  • Pulmonary embolism
  • Pneumonia
  • Restrictive lung disease
  • Obstructive lung disease
  • Neuromuscular disease
  • Congestive heart failure
  • Unstable arrhythmia
  • Pulmonary edema
  • CVA
  • Overdose
97
Q

What is the treatment method for an acute respiratory failure?

A

Respiratory support

98
Q

What are the goals of respiratory support?

A
  • Correct hypoxia and hypercapnia

- Rest respiratory muscles

99
Q

What are the methods of respiratory support?

A

• Non invasive pressure ventilation
- CPAP:continuous positive airway pressure
- BiPAP: bi-level positive airway pressure
• Invasive: mechanical ventilation

100
Q

What are the settings and terms of mechanical ventilation?

A
  • Tidal Volume usually set at 400-1200cc, dependent on body mass
  • Ventilator rate: breaths/min, set at lowest rate to keep PaCO2 between 35-45 mmHg
  • Fraction of inspired oxygen (FiO2): lowest value to meet satisfactory paO2
  • Positive end-expiratory pressure (PEEP)
101
Q

What are the characteristics of Controlled Mandatory Ventilation (CMV)?

A
  • Ventilator has total control of FiO2, tidal volume, flow rate
  • Patients likely sedated/pharmacologically paralyzed
  • No respiratory effort by patient
  • Critical cases
  • Machine take control
102
Q

What are the characteristics of Assist Control Ventilation (ACV)?

A
  • Rate and tidal volume set by RRT
  • Patient controls respiratory rate but ventilator assists every breath
  • Once patient initiates breath, preset volume or pressure of flow rate is delivered by ventilator
  • Can be set so that machine will initiate breath if patient initiated respiratory rate is too low to meet rate set by therapist
  • Machine does 90-100% of work
  • Risk for hyperventilation and barotrauma (it doesn’t perceive breath)
103
Q

What are the characteristics of Synchronous Intermittent Mandatory Ventilation (SIMV)?

A

• Rate and tidal volume set by RRT
• Ventilator assists patient with breath if needed
• Patient can breathe spontaneously on their between ventilator breaths
• Used as weaning mode
- SIMV of 2: patient almost breathing independently
- SIMV of 15: mostly relying on ventilator

104
Q

What are the characteristics of Pressure Support Ventilation (PSV)?

A

• Patient initiated breaths are augmented by ventilator to maintain a certain inspiratory pressure and tidal volume
• The greater the PSV the less effort by the patient
- Usual range 5-25cmH20
• Used as a weaning mode
- Can reduce pressure support volume
- Can increase time spent with this reduced assistance to address impaired endurance

105
Q

What are the characteristics of Continuous Positive Airway Pressure (CPAP)?

A
  • Weaning mode
  • Completely spontaneous
  • Positive pressure maintained to prevent alveolar collapse
  • Usually 5-7cm H20
106
Q

What are the characteristics of weaning criterias?

A

• Mode: spontaneous breathing with natural respiratory rate
- <25breaths/min on
• PaCO2 35-45mmHg
FiO2: at less than 40-50% with a PaO2 >60mmHg
• PEEP < 5-7cmH2O
• MIP of at least -20 (diaphragmatic strength)

107
Q

When does oxygen toxicity occur?

A

Occurs when the partial pressure of alveolar O (P O ) remains elevated above 2A2
normal levels prolonged period of time (>24 hours)

108
Q

___ concentrations of O2 can cause a state of hyperoxia

A

Supraphysiologic concentrations of O2 can cause a state of hyperoxia

109
Q

What are the characteristics of hyperoxia?

A

• Development of reactive O2 species (ROS)
- Damage to cells and tissues
- Inflammation with diffuse alveolar damage
• Absorption Atelectasis

110
Q

What does prolonged controlled mechanical ventilation (CMV) result in?

A

A rapid diaphragmatic atrophy.

Ventilator-Induced Diaphragmatic Dysfunction (VIDD)

111
Q

What are the characteristics of rapid diaphragmatic atrophy?

A

• In as few as 12-18 hrs of CMV; significant fiber atrophy in
• Significant atrophy in both both slow and fast muscle fibers of the diaphragm (12 hours)
• Occurs before atrophy in peripheral skeletal muscles
- It would take approximately 96 hrs to achieve the same level of atrophy in unloaded locomotor skeletal muscles as observed in the diaphragm after 12 hrs of CMV.
• CMV-induced atrophy exceeds the rate reported for the diaphragm after denervation.

112
Q

Key contractile proteins, such as ___ and __, are oxidized in the diaphragm during prolonged CMV.

A

Key contractile proteins, such as actin and myosin, are oxidized in the diaphragm during prolonged CMV

113
Q

Redox disturbance; CMV leads to increased levels of ___ production

A

Redox disturbance; CMV leads to increased levels of reactive oxygen species (ROS) production

114
Q

What are the characteristics of diaphragm recovery from VIDD?

A

Muscle fiber size and contractile properties, returns to near normal levels within 24 hours after returning to spontaneous breathing

115
Q

When does (VIDD) muscle atrophy of diaphragm occur?

A

Within 18-24 hours on mechanical ventilation

116
Q

What are the characteristics of Ventilator-Induced Diaphragmatic Dysfunction (VIDD)?

A
  • Most rapid loss of muscle strength occurs over first week, in particular ankle dorsiflexors and knee extensors, within 96hrs
  • Loss of lean body mass estimated as 1% per day in patients with critical illness
  • Muscle dysfunction can be seen on EMG within a few days of bedrest
  • Those with ICU acquired weakness report strength deficits, fatigue, and cognitive changes 6 months to a year after hospital discharge
117
Q

What is the relationship between supplemental oxygen and FiO2 of room/ambient air?

A

FiO2 of Room/Ambient Air 20.9% (78% Nitrogen ;1% CO2)
• Each liter of increase with supplemental O2, increases FiO2 by approx 4% (if you have someone on 1L, it increases FiO2= 24%, 2L+ 28%…)

118
Q

What are the characteristics of low flow delivery of supplemental oxygen?

A

FiO2 is approximation and varies with RR and TV (how much they breathe and the amount)

119
Q

What are the characteristics of high flow delivery of supplemental oxygen?

A

Precise O2 delivery, does not vary with RR and TV

120
Q

What is the maximum amount of supplemental oxygen used for vents to avoid O2 toxicity?

A

60%. Can go up to 80%, but it is rare

121
Q

What are the methods of low flow oxygen delivery?

A
  • Nasal Cannula
  • Simple face mask
  • Partial rebreather
  • Non breather
122
Q

What are the characteristics of a nasal cannula?

A 
• Easily portable
• Can only really deliver 22- 44% FiO2
  - Thus don’t use above >6L
• Can dry out nasal passages.
  - Often humidified when >3L given (keep nasal moist)
• Most common
123
Q

What are the characteristics of a simple face mask?

A
  • Delivers approx. 35-55% FiO2 at 5-10/min Flow
  • Easily mobile with portable O2
  • Makes talking and eating difficult (often have to be used while exercising and a cannula during the day)
  • Directly over face
124
Q

What are the characteristics of a partial rebreather?

A
  • Delivers 40-60% FiO2 at 10- 15L/min flow
  • Patients inspire from resevoir bag attached to mask (can breathe more of a consistent amount)
  • Air entering bad from trachea and primary bronchi, where no gas exchange occurs, the patient rebreathes O2 “just expired”
  • Easily mobile
125
Q

What are the characteristics of a non-rebreather?

A
  • Delivers 80-90% FiO2 at 10- 15L/min flow.
  • Works similar to partial rebreather, however has one way valve that exhalation into reservoir bag, which results in a higher concentration in the bag.
  • Only used in seriously ill patients, and possibly during exercise in patients with ESLD
  • Always breathing 80-90, but it can vary with RR and TV
126
Q

What are the types of high flow oxygen delivery?

A
  • Venturi mask

- Transtracheal catheters “trach masks”

127
Q

What are the characteristics of a venturi mask?

A
  • A Venturi mask mixes oxygen with room air, creating high-flow enriched oxygen of a settable concentration.
  • Delivered at a higher pressure, uses a wider tube.
  • It provides an accurate and constant FI,O2. Flow is set by gauges in the tube-mask manifold
  • Typical FI,O2 delivery settings are 24, 28, 31, 35 and 40% oxygen.
  • The Venturi mask is often employed when there is concern about CO2 retention. (not moving air effectively)
  • Usually around 40%
128
Q

What are the characteristics of a transtracheal catheters “trach masks”?

A

• Trandeliver oxygen directly into the trachea.
- Basically the same thing as the Venturi mask but it is delivered directly into the tracheostomy.
• High-flow transtracheal catheters may reduce the work of breathing and augment CO2 removal.
• Patients who have been extubated and taken of ventiliators may benefit from an interim of high-flow transtracheal oxygen to better ensure weaning success

129
Q

What is the PVC limit to stop exercise and have the patient sit and if worsens return to bed?

A

6

130
Q

What should be done if a patient’s rhythm deteriorates into an arrhythmia?

A

Return to the room

131
Q

What is orthostatic intolerance?

A

Hypotension associated with a change in position, typically when moving from supine to standing (take vital sign gradually)

132
Q

What are the symptoms of orthostatic intolerance?

A

Dizziness, change in mentation, postural instability, and possibly loss of consciousness
- Post-operative, bedrest, cardiogenic insufficiency, medications (anti-hypertensives, antidepressants, and drugs used to treat Parkinson’s disease and erectile dysfunction), the elderly
(before stand up move legs in bed)

133
Q

What are the causes of orthostatic intolerance?

A
  • Depletion of blood volume

* Impairment of baroreflex- mediated vasoconstriction (laying supine)

134
Q

Who is usually the 1st to identify orthostatic intolerance in patients?

A

Physical therapy. Alert the medical team

135
Q

What will reduce the risk of orthostatic intolerance?

A

Early mobility

136
Q

What is the response of HR in the presence of orthostatic intolerance?

A

Increase of greater than or equal to 20 beats/min

137
Q

What is the response of systolic BP in the presence of orthostatic intolerance?

A

Decrease of 20 mmHg or greater with associated onset of symptoms

138
Q

What are the PT indications for ICU rehab?

A
  • Getting patient moving, prevents de-conditioning, reduces risk of atelectasis>consolidation>pneumonia, reduces risk of bed sores and DVT
  • Goal to determine stability for ambulation, transfers, stairs, ADLs, assistive device needs, tolerance to activity, PLOF
  • D/C planning (always ask ptdo they live alone/family, floors in home, steps to needs, can ptestablish self of 1stfloor bathroom) may need to talk to family if pton vent)
139
Q

What are the outcomes associated with team based ICU care?

A
  • Lower mortality (Wheelan, et al -2003)
  • Reduced nosocomial infection, adverse events and costs (Jain, 2006)
  • Rating of team function is correlated with Ventilator Associated Pneumonia and Incidence of Pressure Ulcers (Manojlovichet al –2009)
  • Improved interprofessional communication related to identifying risk factors early, increasing referrals, clear understanding of patient and family input
140
Q

What are the characteristics of the mobilization of a mechanically ventilated patient?

A

• Approximately a quarter of the total inpatient cost for hospital stay*
• 1 ICU day = 3-6 non-ICU days depending on treatment provided
- For recovery
- Longer someone is in there, the longer the recovery

141
Q

What are the implications of mechanical ventilation for over 48 hours?

A

After 1 year…
• 69% limitations in their ADL’s
• 50% had returned to work
• Other sequelae include depression, post-traumatic stress syndrome, and anxiety\
• Pulmonary function tests normal to near normal
• Decreased quality of life scores compared to normative values
• 48% of patients had returned to work 1 year after hospitalization, 65% two years afterward

142
Q

What are the contraindications to mobilization of a patient in the ICU?

A

•Patients who require significant doses of vasoactives for hemodynamic stability
- (maintain MAP> 60)
• Mechanically ventilated patients who require FiO2 80% and/or PEEP >12, or have acutely worsening respiratory failure (want them at 60%)
• Patients maintained on neuromuscular paralytics
• Neurologic instability or acute event (<24 hours)
• Patients who are unresponsive/ unable to reduce sedation
• Patients with unstable spine or extremity fractures
• Patients transitioning to comfort care
• Patients with rigid femoral catheters
• Patients with open abdomen, at risk for dehiscence
• Patients with recent autograft or flap placement (plastic surgery)

143
Q

What is the typical series of assessments to determine progression of mobility of an ICU patient?

A

• Awake, participatory, initiation, following commands
• Moving limbs against gravity
->resistive exercises
• HOB elevated/ LE’s dependent/ chair position
• Sitting EOB
• Standing to chair
• Marching ->Walking

144
Q

What kind of patient is an incentive spirometer useful for?

A

Patients who can’t move around 1st

145
Q

What does an incentive spirometer do for patients?

A

It helps to facilitate surfactant production to keep the alveoli from collapsing

146
Q

How is an incentive spirometer used?

A
  • Breathe out (exhale) normally.
  • Breathe in (inhale) SLOWLY.
  • Goal is to get this marker to rise as high as possible.
  • Make sure this ball stays in the middle of the chamber while you breathe in.
  • Hold your breath for a 3 to 5 seconds.
  • Then slowly exhale.
  • 10 to 15 breaths spirometer every 1 to 2 hours.
  • Good for preventing atelectasis (alveolar collapse) and mobilizing secretions
147
Q

What is the typical progression of an ICU patient?

A

• Post op day 0 pt transfers to chair with RN in AM then B2B
• Post op day 1 pt transfers from sit to stand, get to doorway, pre gait
- Afternoon ambulation
• Post op day 2-3 chest tubes d/c, cardiac pacer d/c (pt must be supine for either and remain still for 1hr with pacer d/c)
- Stairs assessment
- Independent ambulation assessment
• Consider using a standardized assessment, six clicks PAC, POMA/Tinetti, 5mGS, DGI, 6MWT

148
Q

What are the usual discharge times for common cardiopulmonary procedures?

A
  • CABG: 4-5days
  • Valve Replacement: 2-3 days
  • PCI: 1-2days
  • VATS lobectomy 4-5days possibly earlier
  • Thoracotomy: 4-5days
  • Heart Transplant: 1week
149
Q

What are algorithms used for in cardiopulmonary procedures?

A

Can be used as a basic screening tool, especially with initiation of hospital mobility program

150
Q

What are the other considerations to take for ICU patients?

A
  • Symptoms
  • Vitals
  • Critical Lab values
  • Change in medical status
  • Hospital policy
  • Individual comfort level in ICU
  • Risk/Benefit
151
Q

What is the role of a RN in an ICU?

A

Always check in, make a schedule, nurses can transfer patients and ambulate once PT determines safety

152
Q

What is the role of a MD/DO in an ICU?

A

Must establish good communication for referrals and d/c plan

153
Q

What is the role of a RRT: (respiratory therapist) in an ICU?

A

Manages mechanical vent, and other supplemental O2 device.

154
Q

What is the role of a CSW (Social Worker) in an ICU?

A

D/C planning

155
Q

What is Post-intensive Care Syndrome (PICS)?

A

A collection of health problems that remain after critical illness which can involve the patient’s body, thoughts, feelings, or mind and may affect the family.
• ICU-acquired weakness
• Cognitive or brain dysfunction
• Other mental health problems

156
Q

What is ICU -acquired weakness (ICUAW)?

A

Muscle weakness that develops during an ICU stay. Other terms include critical illness myopathy
/polyneuropathy
• 33% of all patients on ventilators
• 50% of all patients admitted with severe infection (sepsis)
• Up to 50% of patients who stay in ICU for at least one week
May take more than a year to recover fully, making ADL’s difficult and increasing burden of care

157
Q

What is cognitive dysfunction?

A

Problems connecting with remembering, paying attention, solving problems, and
organizing and working on complex tasks.
• 30-80% of ICU patients
• In some cases this may be permanent
May affect whether the patient can return to work, balance a
checkbook, or perform other tasks that involve organization
and concentration.

158
Q

What are other mental health problems associated with an ICU?

A 
Critically ill patients may develop
• Problems staying asleep/falling asleep
• Nightmares or unwanted memories
• Anxiety/depression
• Can be similar to PTSD
159
Q

What are some ways to help manage mental problems following an ICU discharge?

A

May benefit from psychotherapy and/or psychiatry following ICU discharge
• Speech therapy can also assist with strategies to deal with impaired memory and attention

160
Q

What is the impact of Post-intensive Care Syndrome (PICS) on family and caregivers?

A

• Change in social role within the family and in society
• Change in ability to hold a job
– financial implications
• Change in ability to control and convey emotions
• Shame and fear regarding cognitive and mental health changes
• Neglect own self care

161
Q

What are the some strategies to minimize Post-intensive Care Syndrome (PICS): family?

A
  • Talk about familiar things, people and events
  • Talk about the day, date, and time
  • Bring in pictures and favorite items for home
  • Read aloud at bedside
  • ICU diaries
  • Involved in care – EXERCISES
  • Take care of themselves
  • Seek out resources/ support groups
162
Q

What is delirium?

A

A disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time
• Up to 80% of mechanically ventilated ICU patient

163
Q

What are the types of delirium?

A
  1. Hyperactive (ICU pychosis)
  2. Hypoactive
  3. Mixed
164
Q

____ was an independent predictor of higher 6-month mortality and longer hospital stay

A

Delirium was an independent predictor of higher 6-month mortality and longer hospital stay

165
Q

What do efforts to prevent or treat ICU delirium do?

A

Have the potential to improve patient outcomes and reduce cost of care

Acute care (9 decks)

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