NUR 425 Complex Care Exam 2 Blueprint, Exams of Nursing

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Complex Care Exam 2

Blueprint

NUR 425 Complex Care Exam 2 Blueprint Exam 2 will cover course content from Week 5 (ABGs) through Week 7 (Intracranial Pressure Monitoring) To guide your studying, review the learning outcomes for each module listed at the bottom of this document Questions will include 47 multiple choice and three select all that apply questions. You should know the normal values for (Use your Lewis text for reference):  Normal vital signs in adults o BP: 120/ o HR: 60- o RR: 12- o Temp: 97.8-99.1 F  Normal MAP in adults o 70-90 mmHg  Normal PEEP setting o 5cmH  ICP (and be able to define increased ICP) o 5-15 mmHg o Increased: 20 mmHg or more persisting for 5+ minutes  CPP (be able to calculate CPP) o MAP-ICP=CPP o CPP: 60-100mmHg  PaO2/FiO2 ratio o < 200 mmHg=ARDS  SaO o > 95%  ABG values o PaO2 80-100 mmHg o PaCO2 35-45 mmHg o PaHCO3 22-26mEq/L o pH 7.35-7.

Understand the significance of the following: Not required to memorize actual normal ranges  Tidal volume o Normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied o 8-10mL/kg ideal body weight Be able to identify/describe the following select breathing patterns and what they could signify:  Apnea o Lack of breathing o Prolonged respiratory phase or pauses alternating with expiratory pauses o Volume of lungs remained unchanged  Ataxic breathing o Irregular breathing o No pattern  Cheyne stokes  Kussmaul breathing The following medications could be tested on this exam. You should know the medication’s indications, major side effects, and nursing considerations when administering these:  Corticosteroids (the general drug category & their use for respiratory issues)  Norepinephrine  Mannitol  3% NaCl  0.45% NaCl ("1/2 normal saline")  Fentanyl  Pancuronium  Metoprolol  Midazolam Distribution of Questions Week 5: Wednesday (Arterial Blood Gases): 13 questions Four additional questions will incorporate your ABG knowledge and respiratory failure, ARDS, and/or mechanical ventilation content  LO 1 (2 question), LO 2 (1 question) LO 2,3&4: (4 questions) LO 2 & 3 (4 questions), LO 4 (2 questions)

Week 6: Monday (Respiratory Failure and ARDS): 13 questions  LO 1 (1 question), LO 1& 2 (2 questions), LO 2 (1 question), LO 2& 3 (1 question) LO 3 (3 questions), LO 4&5 (3 question), LO 5 (2 questions) Week 6: Wednesday (Mechanical Ventilation): 13 questions  LO 1 (1 question) LO 1,2,&4 (1 question) LO 2&3 (1 questions), LO 2,3,&4 (1 question) LO 3 (2 questions) LO 4 (2 questions) LO 5 (2 questions) ; LO 2&6 (2 questions) ; LO 7 (1 question) Week 7: Monday (Intracranial Pressure Monitoring) 11 questions  LO 1,2,3&5 (1 question) LO 1,2&3 (2 questions) LO 1,2&4 (1 question) LO 1,4&5 (1 question) LO 1&5 (1 question) LO 4 (2 question) LO 5& (2questions) LO 7 (1 question) Associated Learning Outcomes for Each Module Week 5: Monday (Arterial Blood Gases):

1. Relate the pathophysiology of acid-base imbalances to the compensatory mechanisms. 1. Buffer System 1. First line to maintain homeostasis 2. Fast, immediate but low threshold (does not last very long) 3. Cannot maintain pH without resp and renal systems 2. Respiratory System 1. Twice as effective as buffer system 2. Works moderately quickly, effects within minutes, max effect in 24 hours 3. More sustainable compared to buffer system, but not long term 4. Noted by changes in PaCO 5. Compensation: 1. Normal: 35-45 mmHg 2. Metabolic Acidosis Problem: low pH 1. Triggers hyperventilation: increase RR, decrease CO2, increase pH 3. Metabolic Alkalosis Problem: high pH 1. Triggers hypoventilation: decrease RR, increase CO2, decrease pH 3. Renal System 1. Works the slowest, begins in 24 hours, can take 2-3 days to have max effect 2. Most sustainable, lasts longer 3. Noted by changes in H+ and HCO3- 4. Compensation:

1. Normal: 22-26 mmHg
2. Respiratory Acidosis Problem: low pH
   1. Kidneys reabsorb HCO3+excrete H=increased HCO3 in blood=increased pH
3. Respiratory Alkalosis Problem: high pH
   1. Kidneys excrete HCO3+retain H=decreased HCO3 in blood=decreased pH
4. Interpret the components of an arterial blood gas and the normal values for each component.
5. Steps of Interpreting ABGs STEP 1: Look at each number and label STEP 2: Evaluate oxygenation STEP 3 : Determine acid-base status Evaluate the pH STEP 4: Determine the primary cause of the acid base status (respiratory or metabolic) same direction as pH-(MATCHES pH) STEP 5: Determine compensation
6. Normal ABG Values
7. pH: 7.35-7.
8. PaO2: 80-100 mmHg
9. PaCO2: 35-45 mmHg
10. HCO3: 22-26 mEq/L
11. SaO2: > 95%
12. Evaluate arterial blood gases results for mixed, uncompensated, partially compensated, and fully compensated acid base imbalances.
13. Uncompensated (ROME)
14. Respiratory Acidosis
15. pH: low
16. PaCO2: high
17. HCO3: normal
18. Respiratory Alkalosis
19. pH: high
20. paCO2: low
21. HCO3: normal
22. Metabolic Acidosis
23. pH: low

2. PaCO2: normal
3. HCO3: low
4. Metabolic Alkalosis
5. pH: high
6. PaCO2: normal
7. HCO3: high
8. Mixed/Combined
9. Mixed Acidosis
10. pH < 7.35: low
11. PaCO2 > 45: high
12. HCO3: low
13. Mixed Alkalosis
14. pH > 7.45: high
15. PaCO2 < 35: low
16. HCO3 > 26: high
17. Partially Compensated
18. All abnormal values
19. Find which abnormal value matches the pH
20. PC Resp Acidosis
21. pH: low -> acid
22. PaCO2: high -> acid
23. HCO3: high -> base
24. PC Resp Alkalosis
25. pH: high -> base
26. PaCO2: low -> base
27. HCO3: low-> acid
28. PC Metabolic Acidosis
29. pH: low -> acid
30. PaCO2: low -> base
31. HCO3: low -> acid
32. PC Metabolic Alkalosis
33. pH: high -> base
34. PaCO2: high -> acid
35. HCO3: high -> base
36. Full Compensated
37. One system is causing disturbance, one is compensating, it is working
38. pH is now normal, looking to see if slightly acidic or slightly basic
39. Between 7.35-7.4->normal but on acidic side
40. Between 7.4-7.45->normal but on basic side
41. C Resp Acidosis
42. pH: between 7.35-7.4 -> acid
43. PaCO2: high -> acid
44. HCO3: high -> base
45. C Resp Alkalosis
46. pH: between 7.4-7.45 -> base

2. PaCO2: low -> base
3. HCO3: low-> acid
4. C Metabolic Acidosis
5. pH: between 7.35-7.4 -> acid
6. PaCO2: low -> base
7. HCO3: low -> acid
8. C Metabolic Alkalosis
9. pH: between 7.4-7.45 -> base
10. PaCO2: high -> acid
11. HCO3: high -> base
12. Compare the clinical manifestations, causes, and treatments for respiratory acidosis and alkalosis, metabolic acidosis and alkalosis, and mixed states.
13. Respiratory Acidosis
14. Cause:
15. HYPOventilation (CO2 retained in lungs):
16. CNS Depression: drugs, alcohol, brainstem injury
17. Pulmonary Disease: COPD, PE, PNA, Pulmonary Edema
18. Resp Muscle Weakness: paralysis, fatigue
19. Treatments:
20. Increase RR and depth
21. CNS Depression: narcan, reduce sedation
22. Intubate or change existing vent setting
23. Suctioning, bronchodilators
24. Treat PNA, pneumothorax
25. Respiratory Alkalosis
26. Cause:
27. Hyperventilation (Excessive CO2 removed by lungs):
28. Hypoxia
29. Fever
30. Pregnancy/Labor
31. High Altitude
32. Anxiety
33. Initial PE
34. Treatments:
35. Decrease RR and depth
36. Decrease CNS Stimulation: anxiety, pain, fever, may need to stop or reverse drugs
37. Need to retain CO2 – breathe into paper bag
38. Change existing vent settings
39. Metabolic Acidosis
40. Cause:
41. Buildup of acid:
42. Shock: lactic acid
43. Renal failure: uric acid
44. DKA: ketoacids

4. Intoxication: ASA overdose
5. Bicarb deficit/loss:
6. Diarrhea
7. Treatments:
8. Excrete acid/retain bicarb
9. Admin NaHCO
10. Encourage Kussmaul respirations, may do this with vent
11. Diarrhea: Antidiarrheal
12. Renal Failure: dialysis
13. DKA: insulin
14. Metabolic Alkalosis
15. Cause:
16. Loss of acid:
17. Stomach acid: NGT suctioning, vomiting
18. Drugs causing hypokalemia
19. Bicarb excess:
20. Antacid overdose
21. Over-admin of NaHCO
22. Treatments:
23. Need to excrete bicarb/retain acids
24. D/C drugs causing imbalance (antacids, thiazide diuretics)
25. D/C NGT suction
26. Antiemetics
27. Acetazolamine (Diamox) Week 6: Wednesday (Respiratory Failure and ARDS):
28. Compare the pathophysiological mechanisms of VQ mismatch including shunt, diffusion limitation, and hypoventilation
29. Hypoventilation
30. Increased PaCO2 and decreased PaO
31. Not breathing enough -> not getting enough O2 to begin with
32. Lead to resp acidosis
33. V/Q mismatch
34. Ventilation is effective and alveoli are moving well, but we can’t get blood to the alveolus
35. Typically caused by pulmonary embolus
36. Clot is making it impossible to get O2 out of alveolus
37. Intrapulmonary Shunting
38. Large amount of blood returning to left side of heart that has not engaged in gas exchange causes low PaO2 and leads to alveolus collapse
39. Caused by atrial or ventricular defects, atelectasis, PNA, pulmonary edema
40. Higher levels of O2 are not helpful b/c blood is being shunted away from lungs

3. Diffusion defect
   1. Gas movement from area of high concentration to low
   2. O2 needs to move across a membrane, if membrane is too thick or full of fluid, O2 exchange is more difficult or “defective”
   3. Typically due to increased interstitial fluid
   4. Hypercapnia is late sign
4. Describe the pathophysiology and clinical manifestations of respiratory failure [recognize early and late signs as well as failure to ventilate vs failure to oxygenate]
5. Occurs due to a disease state – resp failure is not a disease
6. Based upon ABG’s
7. Failure of Ventilation
8. PaCO2 > 45 in combination w/ acidemia
9. Causes:
10. Airflow obstruction: asthma, COPD, CF
11. Chest wall abnormalities: trauma, severe obesity
12. Resp Depression: CNS depression, head injury
13. Muscle Weakness/paralysis: SCI, MS, myasthenia gravis, muscle atrophy
14. Failure of Oxygenation
15. PaO2 < 60 mmHg when receiving inspired O2 concentration > 60%
16. Causes:
17. Difficulty getting blood into alveolus: PE, shock, hypotension
18. Difficulty getting enough O2 to cross the space between alveolus and capillary: alveolar injury, PNA, toxic inhalation, ARDS, diffusion limitation
19. Early Signs:
20. Change in mental status, fatigue, restlessness
21. Anxiety (SNS response): tachycardia, tachypnea, mild HTN
22. Morning headache
23. Later Signs:
24. Rapid, shallow breathing pattern - hyperventilation
25. Tripod position
26. Pursed-lip breathing
27. Dyspnea
28. Retractions
29. Paradoxic breathing
30. Diaphoresis
31. Prolonged hypoxemia: Aerobic metabolismà lactic acidosis
32. Abnormal breath sounds
33. Describe appropriate nursing and collaborative interventions for the patient with respiratory failure
34. Goals:
35. Maintain patent airway
36. Optimize O2 delivery: be precise

3. Minimize O2 demand: pain med, rest, reducing fever, stress
4. Treat cause
5. Prevent complications: tissue breakdown, infection
6. Treating:
7. CXR, ABG, CBC, ECG
8. Sputum and blood culture
9. O2 delivery and ventilator support
10. Tolerated by pt
11. Maintain PaO2 over 55, SaO2 over 90, still use lowest concentration possible
12. Oxygen delivery devices
13. Noninvasive: NC, simple mask, venti mask, NRM, CPAP, BIPAP
14. Invasive: ETT, tracheostomy
15. Ventilatory Support – helping move air
16. Positive pressure ventilation
17. CPAP, BIPAP
18. Invasive mechanical ventilation
19. Suctioning, positioning, hydration, effective coughing
20. Drug Therapy:
21. Bronchodilators – Albuterol: relief of bronchospasm
22. Corticosteroids: reduce airway inflammation
23. Diuretics/nitrates (if HF present): reduce pulmonary congestion
24. IV antiobiotics: treatment of pulmonary infections
25. Benzos, opioids: reduce anxiety, pain, agitation (watch for resp depression)
26. Identify the basic pathophysiology and clinical manifestations of Acute Respiratory Distress Syndrome (ARDS)
27. Pathophysiology:
28. Damage to alveolar-capillary membrane causes increased capillary permeability leading to pulmonary edema
29. Decreased lung compliance – stiff lungs
30. Clinical Manifestations:
31. Severe refractory hypoxemia
32. Low PaO2 and SaO2 despite increasing O2 admin
33. White out CXR
34. Reps fluid in lungs
35. Abnormalities related to mechanical ventilation
36. Increasing use of PEEP
37. Increasing PIP: how much resistance the ventilator is encountering when it tries to deliver breaths
38. Prioritize appropriate nursing and collaborative management strategies for the patient with ARDS.
39. Maintain Airway:
40. ETT
41. Optimize O2 delivery:

1. Oscillatory ventilation
   1. Delivers low tidal volume at very fast rate (300-420 bpm)
   2. Used in pts w/ non compliant lungs who remain hypoxic despite conventional and advanced ventilation
2. High PEEP
3. Rot-a-prone bed
4. Minimize O2 demand:
5. Reduce metabolic demand
6. Treat the cause:
7. Sputum cultures/antibiotics, sepsis, multiple organ dysfunction
8. Prevent complications:
9. VAP, hypoxia, decubitius ulcers Week 6: Monday (Mechanical Ventilation):
10. Discuss the indications for mechanical ventilation. (includes nursing roles related to intubation)
11. Discuss collaborative care and nursing management of clients requiring mechanical ventilatory support.
12. Treating Ventilator Associated Pneumonia
13. Occurs 48 hours or more after ETT intubation
14. Happens b/c ETT bypasses normal airway defenses (warmth, humidification, filtration)
15. Characterized by:
16. Purulent sputum
17. Elevated WBC’s
18. Crackles or rhonchi
19. CXR
20. Treatment:
21. Hand washing
22. Elevate head of bed 30-45 degrees
23. Interrupt sedation each day to assess readiness to wean from ventilator
24. Prophylaxis for DVT, PUD
25. Meticulous oral care q2h
26. Data to Monitor
27. Total Respiratory Rate
28. How many breaths did pt take on their own
29. PIP
30. Max pressure that occurs during inspiration
31. Increases with airway resistance
32. Tidal Volume
33. Is the full Vt getting in?
34. How big of a breath can pt take on their own?
35. How big of a breath did that amount of pressure create?
36. O2 sat

5. ABG’s
6. Look at your pt!
7. Describe the modes of mechanical ventilation: CPAP, PS, AC, SIMV
8. CPAP (Pressure):
9. Used on a pt that is spontaneously breathing
10. Can be invasive or noninvasive
11. FiO2 and PEEP ONLY
12. Only mode that can use both mask or tube
13. PS – Pressure Support
14. Setting:
15. Can be added onto SIMV
16. Provides help with spontaneous breaths
17. Mode:
18. Ventilator is support breaths that pt takes on their own
19. PS (ex. 10 cmH20), FiO2, PEEP ONLY
20. AC – Assist Control (Volume)
21. Preset number of breaths
22. Vt of spontaneous does not vary
23. Ventilator supports all breaths
24. Useful in normal respiratory drive but weak or unable to exert WOB
25. Risk of hyperventilation and resp alkalosis
26. VT, RR, FIO2, PEEP
27. SIMV – Synchronized Intermittent Mandatory Ventilation (Volume)
28. Volume of spontaneous breath varies
29. Does not support spontaneous breaths
30. Helps to prevent resp muscle weakness bc pt contributes more WOB
31. Risk of hypoventilation
32. VT, RR, FIO2, PEEP
33. Recognize the risks associated with positive pressure mechanical ventilation and intubation.
34. Mechanical Ventilation Complications:

35. 3 days is considered long term – increased complications and poor outcomes

36. Right mainstem bronchus intubation
37. Unplanned extubation
38. Laryngeal/tracheal injury – damage to oral/nasal mucosa
39. Oxygen toxicity
40. Acid-base disturbances
41. Psychosocial concerns: stress, anxiety, depression
42. Peptic Ulcer Disease
43. Hemodynamic compromise; PEEP causing decreased CO/BP
44. ETT Suctioning Complications:
45. Endotracheal suctioning
46. In-line – closed

2. Sterile – open
3. Indications for suctioning
4. Increased inspiratory pressure
5. Adventitious lung sounds
6. Coughing
7. Decreased O2 saturations
8. Copious secretions
9. Suctioning Complications
10. Decrease PaO2 and O2 sats
11. May cause ECG arrhythmias (PVCs)
12. Increased ABP, ICP
13. Bronchospasm
14. Can lead to tracheal hemorrhage, wall damage
15. Predisposed to nosocomial PNA
16. Identify indicators of readiness to wean as well as successful and unsuccessful weaning
17. Readiness to Wean
18. Underlying cause for mechanical ventilation is resolved/resolving
19. Hemodynamically stable; adequate cardiac output to provide tissue perfusion
20. Adequate respiratory muscle strength RR < 30
21. PaO2 > or = 80mmHg
22. Minimal secretions
23. Acceptable vital signs
24. Alert/awake and spontaneously breathing
25. Acceptable chest x-ray and ABGs
26. Adequate oxygenation without a HIGH FiO2 (> 50% ) and/or HIGH PEEP (> 8 cm H2O)
27. Absence of any factors that impair weaning-infection, anemia, fever, sleep deprivation, pain, abdominal distention
28. Mental readiness
29. Minimal need for medications that cause respiratory depression
30. Short Term Weaning Trials
31. Short duration-usually 30 minutes to 2 hours with periods of rest
32. Change the mode and settings so that the patient does more work!
33. SIMV vs. AC (both can be weaning modes if the RR is lowered)
34. Pressure Support (now the patient has to trigger all breaths, but they get some support with each breath)
35. CPAP (now the patient has to trigger every breath- and they don’t get any extra support with each breath)
36. T-Piece trials strengthens respiratory muscles (no pressure, just humidified FiO2 and a secure airway!)
37. Failure to Wean
38. Respiratory rate > 35 or < 8 breaths per minute

2. Low spontaneous tidal volumes < 5 mL/kg
3. Labored respirations and use of accessory muscles
4. Poor ABGs or sats (< 90%) during weaning process
5. Tachycardia and HTN
6. Dysrhythmias: PVCs
7. ST-segment elevation not present prior to weaning
8. Decreased LOC
9. Increased WOB to point of exhaustion
10. Agitation, Anxiety
11. Diaphoresis
12. Apply knowledge of mechanical ventilation and respiratory physiology to acid base balance
13. Recognize appropriate use of paralytics in the mechanically ventilated patient
14. Analgesic – Morphine and Fentanyl
15. Always address pain first
16. Sedative – Midazolam and Propofol
17. Fine line between too much sedation and too little
18. Neuromuscular blocking agents – Pancuronium, etc.
19. Cause chemical paralysis
20. Lets the ventilator do all the work
21. Remember there are no sedative or analgesic properties associated with neuromuscular blocking agents
22. Train of Four – measuring paralysis
23. Delivers electrical impulse to nerves and see what muscular response we get
24. Place along ulnar nerve, sometimes done on temporal nerve
25. Start low around 10mA, then hit TOF button
26. Device delivers 4 quick impulses
27. Watch hand by thumb for subtle muscular response (twitch)
28. Not enough:
29. Will see four twitches at 10 mA
30. Too much:
31. No twitches even when turning up mA
32. Happy medium – appropriately paralyzed:
33. Not all four twitches but not zero either
34. Looking for about two twitches Week 7: Wednesday (Intracranial Pressure Monitoring)
35. Define Intracranial Pressure and Increased Intracranial Pressure
36. Intracranial Pressure:
37. Pressure exerted by brain tissue, blood, and CSF against the inside of the skull (inexpandable vault)
38. Normal: 5-15 mmHg
39. Increased Intracranial Pressure:

1. Pressure in skull is 20 mmHg or higher persisting for 5 minutes or longer
2. Calculate Cerebral Perfusion Pressure (CPP)
3. MAP – ICP = CPP
4. CPP: pressure required to perfuse the brain
5. Normal: 60-100 mmHg
6. Identify appropriate nursing interventions to address reduced CPP
7. Identify clinical manifestations of increased ICP
8. Change in LOC, vision, reflexed, and VS
9. Pupils:
10. One bigger than other, sluggish reaction to light – pressure on parasympathetic, compressed CNIII
11. Pinpoint – OD on opioids, think of more drug induced
12. ICP > 15 mmHg (elevated, early sign that ICP is starting to go up)
13. Increasing and persistent headache
14. Vomiting
15. Cushing’s Triad (late sign of IICP):
16. Systolic HTN (>120) w/ widening pulse pressure (>60)
17. Bradycardia
18. Irregular respiratory pattern
19. Cheyne Stokes
20. Alternating periods of rapid breathing and apnea
21. CNS Hyperventilation (Kussmaul)
22. Sustained regular, rapid, deep breathing
23. Apneustic
24. Cluster
25. Ataxic
26. No pattern
27. Determine appropriate nursing interventions for increased ICP
28. Positioning:
29. HOB to facilitate outflow but promote CPP
30. Prevent neck flexion
31. Skin Care
32. Watch for pressure ulcers
33. Prevention of infection and/or hemorrhage
34. Psychosocial issues
35. Allowing family as appropriate
36. Decrease environmental stimuli
37. Reduce Causes:
38. Metabolic demand – fever, seizures, shivering
39. Stress
40. Suctioning < 10 sec at a time
41. Abd distention
42. Assess neuro status frequently
43. Safety considerations:
44. Seizure precautions

2. Restraints?
3. Keep normotensive, hydrated, and nutritionally adequate
4. Maintain ICP, CBF, CPP
5. Watch for secondary brain injury
6. Medications:
7. Osmotic Diuretics - Mannitol
8. Causes diuresis by increasing osmolarity within the nephron
9. Decreases cerebral edema
10. Hypertonic Saline – 3% NaCl
11. Pulls fluid out of interstitial space and into intravascular space
12. Decreases cerebral edema
13. Must infuse slowly and through central line @ about 30 mL/hr
14. Monitor Na levels
15. Antiseizure drugs – Phenytoin, Dilantin
16. Seizures increase metabolic demand
17. Prophylactic for those at risk for having seizures
18. Corticosteriods – Dexamethasone
19. Reduce swelling by working on inflammatory process
20. Identify the purpose of an external ventricular drain
21. Drain CSF and trend ICP waveform
22. Describe basic nursing and collaborative care of the patient with an external ventricular drain
23. Reduce risk of/monitor signs of infection
24. Assess brain perfusion: CPP, neuro assess, IICP, reduce risk for IICP
25. Physician orders: closed, intermittent, continuous, height
26. Evaluate CSF drainage: color, characteristics, amount
27. Potential Complications:
28. Risk for rapid outflow of CSF
29. Infection, subdural hematoma
30. Inaccurate readings -> inappropriate interventions -> pt complications