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Review for RSPT 1166 clinical written final

Review for RSPT 1166 clinical written final. By Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP. Question: Case study. You walk into a patient’s room and notice that his RR is 3 bpm and that his skin is dusky. You feel no pulse rate at the carotid artery. What is the first thing you do?. answer.

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Review for RSPT 1166 clinical written final

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  1. Review for RSPT 1166clinical written final By Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP.

  2. Question: Case study • You walk into a patient’s room and notice that his RR is 3 bpm and that his skin is dusky. You feel no pulse rate at the carotid artery. • What is the first thing you do?

  3. answer • Call for help; • Establish an airway and give 2 good breathes with a bag/mask with 100% 02

  4. Question • When you give your two breathes, you notice that the chest doesn’t rise. • What do you do?

  5. answer • Manipulate the head and neck and try again

  6. question While you give two breaths and the chest rises, the second RT in the room should be doing what?

  7. answer • They should start chest compressions at a rate of 100 bpm at 30:2 ratio until the AED or the defibrillator arrives

  8. Question • If the patient responds to the AED and has a carotid pulse of 70 bpm, but still is unconscious and apnic, what do you do?

  9. answer • with a pulse of 70 bpm, we can stop chest compressions, but because the patient is unconscious we need to ask for an artificial airway [intubation] • and because he is apnic, we rescue-breathe with bag/mask at 100% at a rate of 10-12 bpm. • Once we stop compressions, we can trust the Sp02 reading, so we can use that to monitor the success of our bagging.

  10. End of case study

  11. question • Identify the effect of severe hypoxemia on the heart.

  12. answer • any hypoxemia can cause tachycardia, even arrhythmias if the heart is already irritable • but moderate to severe hypoxemia will result in vasoconstriction of pulmonary capillaries so that right ventricular work of the heart is increased • Cor pulmonale is right heart failure secondary to long-standing lung disease

  13. Question • Your patient has a Pa02 of 65 torr, PaC02 40 mmHg on an Fi02 of 45%. Assume that the PB is 760 torr • Calculate his P(A-a) • Calculate his a/A ratio

  14. answer • To figure the P(A-a)D02 & a/A, we must first find the PA02 PA02 = [ (PB – H20) X FI02] – (PaC02/.8) PA02 = [ (713) .45] – (40/.8) PA02 = 270 mmHg P(A-a)D02 = 270 – 65 = 205 a/A ratio = Pa02/PA02 65/270 = .24

  15. question • List the s/s of chronic lung disease: • What do you hear • What do you see • What do you feel

  16. answer • You will see a person with increased AP diameter • You might see use of accessory muscles of inspiration and exhalation • You will hear wheezing, prolonged exhalation, ‘distant’ Breath sounds [this is different from ‘diminished.’] • On percussion, you will hear hyper-resonance. • On palpation of the belly, you might feel muscle tensing during forced exhalation

  17. question • Your patient has a Pa02 of 48 torr on room air. His Sp02 is 85% • What do you recommend?

  18. answer • I would give supplementary 02 to get the Sp02 above 90-92% • Because I have the Pa02 48 torr on an Fi02 of .21, I could calculate the required Fi02 to get an predicted Pa02 of 80 torr. Pa021: Fi021 as Pa022 : Fi022 48: .21 as 80: x 48x = .21 (80) X = 16.8/48 X= .35 We need to increase the Fi02 to 35% to get the Pa02 back to normal [80 torr]

  19. question • Your patient has the following ABG on 2 lpm: • How do we correct this Pa02? • Is this patient some one in whom we need to worry about 02 induced hypoventilation?

  20. answer • To correct a Pa02 of 57 on 2 lpm. • First we estimate the Fi02 is 20 + (2 x4) = .28 Pa021: Fi021 as Pa022 : Fi022 57: .28 as 80: x 57x = .28 (80) X = 22.4/57 X =.39= increase the Fi02 to 39% or 40% • This patient doesn’t have chronic hypercapnia because the PaC02 is normal [35-45]

  21. Question • Your patient’s ABG are as follows: • Is this patient a person with chronic hypercapnea? • How would we correct this patient’s Pa02 if this ABG was on 28% entrainment mask?

  22. answer • This patient’s ABG is consistent with COPD because it has a high PaC02 with a normal pH • I need to correct the Fi02 to get a Pa02 between 55 and 60 torr. Pa021: Fi021 as Pa022 : Fi022 43: .24 as 60: x 43x = .24 (60) X = 14.4/43= increase the Fi02 33% to get predicted Pa02 of 60 torr

  23. Question • In the patient situation that was just completed, why can we safely increase this patient’s to Fi02 33% when we ‘know’ 1-2 lpm or 24-28% is considered ‘safe’ for persons with chronic hypoxemia and chronic hypercapnia?

  24. answer • Once we have an ABG, we can use the actual Pa02 to figure our next step. • We use 1-2 lpm as a ‘safe place to start,’ but if we need to give our COPD patient a NRM to get the Pa02 between 55-60 torr, we do so. • only by getting the Pa02 above 65 torr can we cause 02 induced hypoventilation • So it’s not a safe Fi02 but a safe Pa02

  25. Question • The patient is on 50% entrainment by bland aerosol mask. • How do we correct this ABG?

  26. answer • Because the PaC02 is normal, we can correct to 80 mmHg • We would decrease the Fi02 Pa021: Fi021 as Pa022 : Fi022 188: .50 as 80: x 188x = .50 (80) X = 40/188= .21 While monitoring the HR, RR and Sp02, you should be able to safely discontinue the 02

  27. Question • Your patient has a RR 35 bpm with a estimated VTof 500. • If he is getting 02 via a 60% entrainment mask running at 10 LPM, is this a high flow system for him? • Explain your answer.

  28. answer • His VE = 35BPM x .500 VT = 17.5 LPM • The total flow of a 60% device at 10 LPM is 10 LPM + [10 x 1] = 20 LPM • Remember 60% is an air : 02 ratio of 1:1 • To be a true high flow system for this patient, his total flow must be equal to VE ( I + E ) • So 17.5 [1+ 1.5] = 17.5 x 2.5 =43.7 LPM. • He needs 43.7 LPM of total flow to avoid entrainment of air. He is only getting 20 LPM so there will be air entrainment so the delivered Fi02 will be less than 60%

  29. question • Describe the effects of going too long between checking on a heated aerosol going to a patient with a tracheostomy collar.

  30. answer • aerosols will rain out into the tubing and heated aerosols will rain out even faster. • The RCP must check a trach collar patient at least Q 3-4 hours & drain the hose and a heated trach collar may need to be dumped even more often [Q2-3 hours] • The extra water in the tube can obstruct the flow to the patient and it can literally drown the patient if this water tips into the unprotected airway. • Because this water is dirty compared to the lower airway, this can be a source of infection • Even if you have placed a water trap into the circuit, the weight of the water could pull the hose apart or pull the collar off the patient’s neck. • Heated hoses are helpful, but even they will need to be drained periodically

  31. question • Explain what would happen to the ability of a tracheostomy collar to deliver 02 correctly if water was to collect in the low spot [dependent] in the tubing.

  32. answer • This is kinda tricky: • The back pressure created by the obstruction down stream from the entrainment device will cause the lateral pressure to rise so that less air is entrained into the device. Fi02 • At the outlet of the aerosol generator, we will get an increased Fi02 with a decreased flow rate • As the water fills up the hose, there will be less flow rate downstream from the obstruction, so even if there is a higher Fi02, it may not get to the patient. So the patient’s delivered Fi02 is less.

  33. question • Identify the approximate Fi02 of a nasal cannula at 2 lpm and at 5 lpm. • Why is this only approximate?

  34. answer • The Fi02 of a N/C at 2 lpm is 20 + (2 x 4) or .28. • The Fi02 of a N/C at 5 lpm is 20 + (5 x 4) or .40. • These are only estimates because the nasal cannula is a low flow system & the more the patient’s VE rises, the lower the delivered Fi02.

  35. question • How do we add humidity to a simple mask?

  36. answer • We use a cool bubble humidifier

  37. question • Explain what will happen if the flow rate going to the simple mask was to exceed the ability of the bubble humidifier to allow the flow through the device

  38. answer • the soft plastic sides of the humidifier will swell and if there is a pressure pop-off, it will alarm as the pressure rises above 2 psig. • and if it is compensated, the flow meter will show the correct [lower] flow rate • The patient’s delivered Fi02 will drop and no twisting of the flow meter knob will increase the flow to the patient

  39. question • Your patient has the following Orders: keep Sp02 above 92%. What Fi02 should he be on?

  40. answer • The order says keep Sp02 above 92% so • We need to decrease the flow rate to 3 lpm where the Sp02 rose to 93%. • While there is nothing wrong with a 94% Sp02, the order only requires getting the oxygenation above 92%. • You always go with the lowest amount that can do the job

  41. question • Your patient has the following Orders: keep Sp02 above 92%. What Fi02 should he be on?

  42. answer • We need to decrease the flow rate on the simple mask to 5 LPM and recheck the Sp02. • If the patient’s Sp02 is still above 92%, then we must put the nasal cannula back on at 4 LPM because we cannot have a flow rate on the simple mask below 5 LPM.

  43. question • Explain why we cannot keep the simple mask at 4 lpm?

  44. answer • We need at least 5 lpm to blow off the exhaled C02. • As a patient re-breathes his C02, the PaC02 will rise making him to breathe faster and deeper as his CNS reacts to the increased H+ in the CSF

  45. question • Your patient has been sent home. The doctor orders an MDI of Flovent 2 puffs BID at home. List the things the patient needs to know about giving himself a MDI of Flovent.

  46. answer • The Flovent is an inhaled steroid-not a Beta II so it is not a rescue drug • He needs to use a spacer to keep medication out of his mouth & to get more into his airways • He needs to rinse his mouth to minimize oral fungal infections • He needs to take a slow deep breath with each puff followed by an inspiratory hold for 5-10 seconds • He needs to take this BID which means in the AM and in the PM [about 12 hours apart]

  47. question • Your patient is going home and he is get get MDI of Albuterol 2 puffs Q 6 hours & PRN. He will also get Atrovent MDI QID and Flovent TID. • What will you tell him about scheduling?

  48. answer • Q 6 hours means that he will take MDI of Albuterol every 6 hours • PRN means that he can take a few extra as needed • TID means that he takes the Flovent 3 x a day, basically with meals • QID means that he takes the Atrovent 4 x a day. Meal times and bedtime

  49. question • At what time you give the next treatment of Albuterol & Atrovent if both are ordered Q4 hours?

  50. answer • We would schedule the next treatment for 12:30 noon.

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