Respiratory

October 14, 2009

Once an endotracheal tube is inserted, placement must be verified before it is

secured. Which is the most accurate way to verify placement before the x-ray?
Assess end tidal CO2 level. Put a device on the end of the tube that assesses for
CO2 level.
DON’T want abdominal distension.

Mechanical ventilation—can set tidal volume, respiratory rate, occasional vs.

continuous breaths. Positive vs. expiratory effort. Or allow to breathe on own and it
kicks in if they stop.
Suctioning both in the tube and around the tube since secretions collect above the
cuff. The cuff is the little balloon that holds it in there…like a catheter. Secretions
get caught on there. Syringe to inflate the cuff.

To prevent from clamping down on your tongue or tube use an oral tube as a
protective device. Also important to warm and humidified O2 supplied to the client.

Mr. A having increasing problems. Either give him medication and make him
comfortable, or offer him bipap—external, not intubation.

Even with the BiPAP—still having difficulty breathing. Color is now dusky—gray-ish.
He is somnolent—probably means CO2 is high.
ABG’s—pH 7.28 (should be 7.35-7.45), pCO2 75, pO2 45, HCO3 18 (should be 22-
28)
Need pressure on that artery for at least 5 minutes (for people with NO bleeding
problems).

pCO2 is very high—we can see why he is somnolent.

Son wants to have a trach—but he specifically said that he does not want to be
intubated.

Could the endotracheal intubation be effective? It is possible…we don’t know. But it

is against his wishes. The law says that whether that durable power of attorney or
not…
…if durable power of attorney, definitely has the right.
The son is next of kin and when the father cannot speak for themselves anymore,
he has the right to say whatever. We try to convince the son that the father did NOT
want to be intubated, but at the end of the day, he has the bottom line.

The way that you can really determine if the endotracheal tube is in the right place
is CO2 .

NEW MR. A
Get a report from the nursing home.

The only way for us to get at secretions, only way to do anything is in laryngectomy.
No exchange of air or secretions through the mouth.
If they need long term conduit, put in a trach tube.
Can reinsert within 72 hours

Test review

Finding associated with pericarditis—chest pain that increases with a deep breath
3-11 rn nurse, dinner break. Which should be assessed first. –76 yo admitted for
substernal chest pain.
Enter the room and find patient unresponsive. –begin cpr
Newly diagnosed type 1 dm. –need to keep tight control of blood sugar levels.
50yo patient with type 2 dm. teach him to manage his disease—hba1c level,
opthamology, and podiatry
Has an ekg. Clinical manifestations that needs immediate intervention—chest pain
Most at risk for atrial fib—post surgery
Week after gi bleed. Treatment option for MI—can’t have thrombolytic. On mona.
Balloon angioplasty
Chest pain indicative of evolving MI. looking for necrosis—ST elevation on a 12 lead
EKG.
Common side effects of nitro…not shortness of breath
Taking care of a patient post card cath. Bleeding…apply direct pressure
New onset CHF related to right ventricular heart failure. Swollen ankles
Involving MI…denial—most common
Patient with MI develops left vent heart failure. Poor organ perfusion—urine output.
88 yo patient six second strip. Normal sinus, bradycardia. Not hyperkalemia
Regular insulin iv bolus. Check fingerstick.
Discharging a patient who has metformin. CT scan as an outpatient. Stop that med
for a few days before.
Symptoms if pacemaker malfunctions—SOB and dizziness.
Type 2—HHS
PR interval. .12-.20
Cardiac impairment—activity intolerance.
Blood test about MI—troponin I
Patient with DKA on insulin. HYPOKALEMIA.
At telemetry station—go to patient’s room.
Pt with a cardiac history complains of substernal chest pain. Assess for an airway
Paint candidate for thrombo. By 930
Angina.
What does ekg rep. pacemaker pacing 100 of beats.
HHS needs isotonic fluids.
What does p wave on ekg…atrial depolar
46 yo cardiac cath patient
Pr interval on patients ekg is .24. document it.
Teach patient to drink fluids. Dm
Cardiac tamponade…jvd and muffled heart
Doesn’t have diabetes yet…stress hyperglycemia.
40 yo type 1 diabetes…give insulin .