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Assessment of Breath sounds

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ZAHRA ALNASSER

on 5 May 2014

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Transcript of Assessment of Breath sounds

Patient Position
Posterior Exam



Anterior Exam



Rales/Crackles
Rhonchi
Rhonchi are continuous low pitched, coarse rattling or gurgling lung sounds that often resemble snoring.
Wheezing
Wheezing is a continuous lung sound with a musical quality.
Fine, short, interrupted crackling sounds.

Assessment of Breath Sounds

Amal Alqahtani __Zahra Alnasser

What two priority actions should you take? Provide your rationale.

Look at cardiac monitor & implement cardiac protocols if necessary (code) to detect arrhythmia and correct it.
Vital signs to detect current patient status.


Contact the pharmacist
Contact the doctor
If necessary, contact the charge nurse
Go up the chain of command

You realize that it is illegal to take medication dispensed by a pharmacist for one patient and use it for another patient. What should you do?


Given that KCL and CaCL are compatible, would you mix them in the same bag of D5W? State your rationale.


The physician prescribes the following: Draw STAT Mg level; if below 1.4 mg/dl, give MgSO4 3Grams in 100 ml D5W over 4 hours, administer KCL 40 mEq in 100 ml D5W IVPB over 1 hour; and give CaCl2 grams in 100 ml D5W IVPB over 3 hrs. The laboratory is called to draw a STAT Mg. level. 

It is time to administer 40 mg of furosemide IVP.
-Why is this medication indicated?
-What are the nursing considerations for giving this drug IVP?
- What effect if any will furosemide have on the clinical presentation of G.S.?


The nurse from the previous shift charted the following statement, “Crackles and rhonchi clear with vigorous coughing.” Based on your knowledge of pathophysiology, determine the accuracy of this statement.


Identify the following adventitious lung sounds:

Stridor – high-pitched, monophonic, inspiratory, crowing sound, louder in neck than over the chest wall.
Pleural friction rub – a very superficial sound that is coarse and low pitched; has a grating quality as if two pieces of leather are being rubbed together.

Rhonchi – low-pitched wheezing or snoring sound associated with partial airway obstruction.
Wheeze (sonorous) low-pitched, monophonic single note, musical snoring, moaning sound heard throughout the resp. cycle.
Wheeze (sibilant) – high-pitched, musical squeaking sounds, polyphonic and heard predominantly in expiration.

The nurse completes his/her assessment of G.S. The nurse notes dyspnea, crackles throughout all lung fields posteriorly and in both lower lobes anteriorly, and rhonchi over the large airways.

What is the significance of these assessment findings in G.S.’s case?

Provide an example of your transfer report note. - Handout

What additional information should you require during this report?
Resp: lung sounds, depth pattern,
GI: feeding type, rate
GU: foley output,
pain level


http://www.youtube.com/watch?v=MzTcy6M3poM
http://www.easyauscultation.com/lung-sounds-reference-guide.aspx
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682858.html
http://www.nlm.nih.gov/medlineplus/respiratoryfailure.html
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097557/
http://www.nlm.nih.gov/medlineplus/ency/article/000187.htm
http://www.meddean.luc.edu/lumen/MedEd/medicine/skills/ekg/les2prnt.htm
Nursing Central, (2014).





Websites

Anderson, M., Arnold, E., Bishop, S., Boyd, M., Britt, R., Cassem, M…Yoho, M. (2011). HESI Comprehensive Review for the NCLEX-RN examination (4th edition). St. Louis:Elsevier.
Anne, Y., Brenda, H., Laura, E.(2010). ICU Nurses’ Experiences in Providing Terminal Care. Critical Care Nurse Quarterly, 33(3), 273-281
ATI Nursing Education. (2010). RN Adult Medical Surgical Nursing Edition 8.0 . ATI Nursing Education.

References

What’s the difference between hospice and palliative care?
All hospice care (care at the end of life) is palliative care, but not all palliative care (care to make the patient comfortable), is hospice

Questions

Vacation,
Grieving with the family
limit OT, realize the nurses in role in end of life care.
Find activities to do outside of work,
crying relieves stress,
group counseling, therapy.
Talking with others co-workers
Designing and helping to implement policies and procedures, education reform


How can nurses avoid suffering from moral distress and burnout?

Ineffective coping strategy:

- crusty nurse attitude.

coping

Abandonment and powerless


Conflict with meds administration



internal conflict


Lack of involvement in the plan of care
Differences between the medical and nursing practice models
Unrealistic expectation of the family
Lack of education

barrier to optimal care


According to Laura Epsinosa, Three factors contribute to the moral distress
1 barrier to optimal care
2 internal conflict
3 coping

Define Moral distress and explain its association with patient care in critical care settings?

Taking it as a valuable experience,
nursing education reform, guidelines for providing terminal care
More training on how to communication with families.
Experiences can make nurses realize that not everyone can be saved.
Death is a part of life.

How can nurses use the experience of caring for a dying patient for personal and professional growth?

Give them time off,
Provide a place of privacy for grieving
grieving process with the family, counseling, grief counseling,
Help facilitate steps necessary for the family to carry out the desired arrangements
nurse must go through the grieving process as well.



What steps can be taken for the nurses of dying patients?

G.S.’s arrhythmias respond to your treatment. Unfortunately, 1 week later, she puts the call light on and complains of difficulty breathing. As you enter the room you find the following: G.S. has no pulse and is not breathing.

Case study

Family-grief counseling,
offering clergy,
staff counseling,
pain control, comfort measures,
encourage the family to communication with patient.



Give examples of end-of-life care requiring the intervention of skilled critical care nurses for G.S. at this point in her care.




Determine the patients ability to receive support.
Increase consistent communication between doc and family,
advocate for the pt.
Be there/ present and support the family (listen).

What is the nurse’s role in supporting that patient’s needs in this situation?

Involve social work to evaluate the seriousness of the situation,
discuss options: need to identify the chances of her surviving in either setting.
Family meeting, explaining the necessity of the transfer, risks of staying in the ICU.
May calm the family, determine family needs.



Nursing action


Even if death is imminent, a transfer from the ICU could be disruptive to the patient, family and staff members. What nursing action(s) can or will you take to respond to this situation?


Question

Patient
Advance directives
Assess mental status first; may need psych eval.
Ethics committee if needed



Who is responsible for the decision-making in this case?


Coronary Care Unit (Cardiac); Cardiac Intensive Care Unit.
Need to discuss advance directives and health care proxy
(remember there is an article that goes with this)


Discuss what type of ICU care is appropriate for G.S. and her family?


Based on the recent turn of events the team of physicians recommend that a family meeting should be conducted to determine G.S.’s wishes should her condition worsen and her heart and lungs stop functioning.

Case study

CPR
Electrical defibrillation or cardioversion (electric shock)
Anti-arrhythmic medications (such as lidocaine, procainamide, sotalol, or amiodarone) given through a vein
Correcting the underlying cause, correct electrolyte levels, administer meds, continue cardiac monitoring.



What treatment is indicated for G.S.’s arrhythmias?


You notice that G.S. looks frightened and is lying stiff as a board.

How would you respond to this situation?
Support the patient. Explain to the patient what is happening to ease the anxiety.
Non-pharmacological relaxation techniques.
Social worker.


Case study

If the heart rate during a ventricular tachycardia episode is very fast or lasts longer than a few seconds. There may be symptoms such as:
Chest discomfort (angina)
Fainting (syncope)
Light-headedness or dizziness
Sensation of feeling the heart beat (palpitations)
Shortness of breath


What factors have contributed to these clinical findings?


CPR
Electrical defibrillation or cardioversion (electric shock)
Anti-arrhythmic medications (such as lidocaine, procainamide, sotalol, or amiodarone) given through a vein
Call a code.


What is your next priority action?


Single irritable focus in Ventricles
Ventricular rate 150-250 bpm
Wide QRS complexes
No P wave
RR intervals approximately equal
A run of three or more VPB's in a row @ rate greater than 100/min
AV dissociation may be present
Atrial capture beats may be present
Ventricular fusion beats may be present
Retrograde concealed conduction
VPB's with the same shape QRS


Ventricular Tachycardia


G.S.’s pulse is irregular. Her BP is 92/70 and her respirations are 28. She admits to being “a little lightheaded” but denies having pain or nausea. Your co-worker connects G.S. to the code cart monitor for a “quick look”. You are able to distinguish normal P-QRS-T complexes but you also note approximately 22 very wide complexes per minute. The wide complexes come early and are not preceded by a P wave.

What is your impression of these findings?

Case Study

While you administer the furosemide and hang the intravenous medication, G.S. tells you, “ This is so strange, a couple of times this morning, I felt like my heart flipped upside down in my chest, but now I feel like there’s a bird flopping around in there.”


Case Study

You open G.S.’s medication drawer to draw the furosemide into the syringe. You find one 20 mg. ampule. The pharmacist tells you that it will be at least another hour before he can send the drug to you.


Case study

hyperkalemia s/s, hypercalcemia s/s disrythmias, slow irregular heartbeat, fluid overload, hyperglycemia.

What clinical implications may be anticipated based on these current laboratory findings?

Chem 7

What additional bloodwork should be ordered?

BP, allergies, current lab values, baseline/trend values, Bp and pulse noting irregularities, PT output must be recorded.
Should be on telemetry under constant cardiac monitoring.


What additional nursing action is necessary?

monitor vitals, allergies, lab values, frequent monitoring, I/O ratio WNL

Discuss safe administration of IV KCL and CaCL.

Low Potassium, low sodium, low calcium, low chloride, high glucose. Most concerning is the potassium because it may cause arrhythmias.
Monitor renal function as the BUN and creatinine increases.


Keeping in mind that you are about to administer furosemide, which laboratory values concern you and why?


values concern you and why? Low Potassium, low sodium, low chloride, high

glucose most concerning is the potassium because it may cause arrhythmias. By

RESPIRATORY ACIDOSIS WITH COMPENSATION

Na: 135-145 mEq/L
K: 3.6-5.1 mEq/L
Cl: 98-110
Ca:
BUN: 6-24mg/dl
Creatinine: 0.64-1.27
Glucose: 67-99 mg/dl
HCO3 :
ABGs
pH: 7.35–7.45
Paco2 : 35–45 mmHg
Pao2 : 80–95 mmHg
HCO3 : 22-26
BE :
Sao2 : 95–99%

Normal Lab Values

Na - 129 mmol/L
K - 2.8mmol/L,
Cl - 92 mmol/L
Ca - 7.1 mg/dl
BUN - 37 mg/dl
Creatinine - 2 mg/dl
Glucose - 128 mg/dl
HCO3 26 mmol/ L
ABGs on 6L O2 /NC:
pH - 7.38
Paco2 - 49 mmHg
Pao2 - 82 mmHg
HCO3 - 36 mmol/L
BE - 2.2
Sao2 - 91%

The 0500 laboratory values are as follows:

5 Rights + allergy
Assess intake and output, lung sounds, BP and pulse, BUN and creatinine levels, electrolytes.
Administer slowly for 2 minutes. 4mg/min recommended IV rate.





Nursing Considerations

Dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis.
Hypotension, ↑ BUN, excessive urination, constipation, diarrhea, dry mouth, tinnitus, hearing loss.
ERYTHEMA MULTIFORME, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, APLASTIC ANEMIA, AGRANULOCYTOSIS.

Possible Adverse Reactions

-loop diuretic
-Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule.
-Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium.
-Diuresis and subsequent mobilization of excess fluids (edema, pleural effusions).
-IV dose for adults: 0.1 mg/kg/hr max 0.4 mg/kg/hr

What is furosemide (Lasix)?

Crackles (fine) – discontinuous, high-pitched sound, short popping sounds during inspiration that are not cleared by coughing.
Crackles (coarse) – Loud, low-pitched, bubbling and gurgling sounds that start in early inspiration and may be present in expiration; may decrease by coughing but will reappear shortly.

Adventitious Lung Sounds

Monitor the client for signs of respiratory distress, or airway obstruction, such as ineffective cough, dyspnea or stridor.
Heliox- Heliox generates less airway resistance than air and thereby requires less mechanical energy to ventilate the lungs.

Extubation

Palpation con't
Tenderness
Tactile fremitus

Dullness.
Hyper-resonance.

Auscultation
Assessing Breath Sounds



Normal Breath Sounds
On auscultaion, you found the client to have this breath sounds. Identify the correct interpretion from the following:


1. Crackles
2. Bronchail
3. Wheezes
4. Vesicular

Landmarks con't
Lungs Anatomy
Physical Assessment
Inspection
Palpation
Percussion
Auscultation



Respiratory Assessment
Landmarks
Landmarks con't
Rate
Rhythm
Depth
Quality & effort.
Nails and mucus membranes.



Tracheal deviation.
Deformity or asymmetry in chest expansion.
Retraction of interspaces.
Impaired respiratory movement on one or both sides.


Chest Expansion
Palpation
What to Assess?
Outlines
Introduction.
Overview of physical assessment of respiratory system.
Assessment of Breath sounds.
Tips of easy learning of breath sound.

Chief Complaint
History of Present Illness
Past history
Family history
Personal and social history
Physical exam

Percussion
1. Vesicular
Inspiratory longer than expiratory
Soft, low pitched, heard throughout most of the lung field



3. Bronchovesicular
Inspiration is equal to expiration
2. Bronchail
Expiration is longer than inspiration
Louder, high pitched, heard over manubrium
intermediate pitch and intensity
Anteriorly 1st, 2nd interspaces
Posteriorly between scapulae
G.S. has been in the ICU for 6 weeks, and her ARDS is nearly resolved. She is transferred out of the ICU and is admitted to your unit You receive the following report:
Neuro: AAO to person and place, she can move both arms and wiggle her toes on both feet:
CV heart tones are clear, VS are 138/90, 88, 26, 99.2°F, bilateral radial pulse 3+, foot pulses by Doppler only,
Skin: incisions and dressings are dry and intact;
GI: duodenal feeding tube in place;
GU (genitourinary): Foley catheter to gravity drain.

The physician has decided that he would like to wean the patient from the ventilator. What signs and symptoms of improvement should the nurse watch for, that would indicate that the patient is ready to be weaned from the ventilator?

The physician has decided that he would like to wean the patient from the ventilator. What signs and symptoms of improvement should the nurse watch for, that would indicate that the patient is ready to be weaned from the ventilator?

The nurse hears the alarm go off on a mechanical ventilator that signals the ventilator is not able to give the patient a breath. What are the possible reasons that would make this alarm go off?


What are the characteristics of a mechanical ventilator that is pressure-cycled?

The ICU has been working on improving quality and safety outcomes each quarter. One nurse sensitive indicator that they have been tracking is the incidence of VAP. The nurse know that in the care of a patient on a mechanical ventilator, what action by the nurse will contribute to the prevention of ventilator assisted pneumonia?

Check tube placement
Absence of appropriate pressure would allow her to make sounds.
Assess for an air leak around the cuff/inadequate cuff pressure.


While the nurse is caring for this patient on a mechanical ventilator, the nurse hears G.S. making sounds that sound like she is talking. What does the nurse need to check?


The nurse hears in report that the patient has been agitated and pulling on the ET. Restraints have been recently ordered and placed on the patient, but she continues to move her head and chew at the tube. What does the nurse do to ensure proper placement of the ET tube?

What are the nursing considerations related to emergent transfusion of this patient?


What were the legal implications of consent when the patient was brought in to the hospital requiring immediate OR care?


Acute onset of
- dyspnea
- tachypnea
- crackles/wheezes on auscultation
- bilateral lung infiltrates on CXR
- restlessness/agitation
- continually decreasing PaO2

Clinical presentation


Describe her clinical presentation and diagnostic evidence of ARDS?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097557/

Hemodynamic, cerebral, and metabolic stability.
Temp <38 C
Ability to maintain patent airway and initiate inspiratory effort
Evidence of partial or full resolution of underlying disease process that prompted intubation.
Physician determination of readiness.

Weaning criteria

Volume (low pressure)
Pressure (high pressure)
Apnea

Ventilator Alarms

Volume-cycled- inspiratory flow halts once the target volume is delivered.
Pressure-cycled- inspiratory flow ceases once a peak inspiratory pressure is reached.
Flow-cycled- inhalation is programmed to cease when it senses a drop in the peak flow rate, and expiratory phase begins.
Time-cycled- a timed inhalation limit is set and exhalation will begin when that limit is reached


Types of Cycling

Airway management
NPPV
Timely ET tube removal/ 1 time placement
CASS tube
Gastric reflux prevention
-Patient positioning
Equiptment maintenance
-ventilator circuit (tubing, exhalation valve/humidifier
Cross-contamination
-standard/contact precautions

VAP Prevention

The patient may also need a sitter or to be put on constant observation.
Family member
Patient teaching
Moderate sedation.

ET tube placement

Define Emergency situation
-If immediate treatment is required in order to prevent death or other serious harm to a patient, that treatment may be provided without informed consent.

Implication of Consent

Rule out basis
Consists of
Acute onset
Bilateral infiltrates
PCWP <18 mmhg w/o L atrial HTN
PaO2/FiO2 ratio <200

ARDS Diagnostic Criteria

Dyspnea, hypoxemia, and tachypnea are assessment findings considered early sign of ARDS.

8. What additional assessment findings may be found in ARDS?
Additional assessment findings include:
· Pulmonary HTN
· Multiple organ system failure
· Hypotension
· Cyanosis of skin, lips, nail beds
· Delayed capillary refill
· Confusion/disorientation
· Adventitious lung sounds

9. What factors contributed to this diagnosis?
The factors that contributed to this diagnosis are trauma the patient suffered from the car accident and also the amount of transfusions received during emergency resuscitation.



7. What assessment finding is considered an early sign of ARDS?

Acute respiratory distress syndrome is characterized by the development of acute dyspnea and hypoxemia within hours to days of an inciting event, such as trauma, sepsis, drug overdose, massive transfusion, acute pancreatitis, or aspiration. Increased capillary permeability is distinctive. Damage of the capillary endothelium and alveolar epithelium in correlation to impaired fluid removal from the alveolar space results in accumulation of protein-rich fluid inside the alveoli, thereby producing diffuse alveolar damage, with release of pro-inflammatory cytokines. Neutrophils are recruited to the lungs by cytokines, become activated and release toxic mediators. Extensive free radical production overwhelms endogenous anti-oxidants and causes oxidative cell damage. If the fluids, proteins, and blood cells accumulate too rapidly for the lymphatic system to remove, the consequences is noncardiogenic pulmonary edema (http://emedicine.medscape.com/article/165139-clinical).
In addition, the lungs experience an increase in hyaline membrane formation, development of fibroblasts, and an increased number of alveolar type II cells, as well as the inactivation of pulmonary surfactant. Interstitial fibrosis may also develop. together, these factors worsen gas exchange. decrease lung compliance, and produce areas of atelectasis (York & Kane, 2012).


6. Pathophysiology of ARDS?

Delegatable tasks include:
· Specimen/sputum collection
· Bed bath, mouth care
· I&O
· ROM


5. While you are caring for G.S. on a ventilator, you may delegate what actions to an experienced nursing assistant?

1. Assess for bilateral breath sounds and symmetrical chest movement.
2. Auscultation over the stomach to rule out esophageal intubation.
3. Marking the tube 1 cm from where it touches the incisor tooth or nares
4. Ordering chest radiography to verify that the tube placement is correct.


4. You are the preceptor for an RN who is undergoing orientation to the ICU. The RN is providing care for G.S. who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you perform immediately?

The nurse should first verify if there is an DNI (Do Not Intubate) order in place to verify if intubation is appropriate.
· Preparing the patient
The nurse should tell the patient what is about to happen, then pre-oxygenate. Intubation should be preceded by ventilation with a high concentration of oxygen, ideally at least 85%, for a minimum of 15 seconds. The aim is to maximize the patient’s PaO2 as the patient will be unable to maintain any respiratory effort (http://www.nursingtimes.net/nursing-practice/clinical-zones/critical-care/endotracheal-intubation/199630.article).
The nurse should gather the necessary equipment for intubation. The following essentials must be present prior to the procedure, using the mnemonic SALT:
-Suction: crucial to clear the airway and allow visualization of the vocal chords
-Airway: the oral airway can make it easier to mask ventilate a patient and oxygen must always be available
-Laryngoscope: for inserting the tube
-Tube: an ET tube for intubation.
The bed head should be lowered and the patient’s position flat, with their face at the level of the xiphoid cartilage of the standing person performing the procedure. A small pad/pillow should be placed under the occiput. Extend the head at the atlanto-occipital joint, which aligns the oral, pharyngeal, and laryngeal axis so that the passage from the lips to the glottic opening is a straight line (http://www.nursingtimes.net/nursing-practice/clinical-zones/critical-care/endotracheal-intubation/199630.article)
· The process of intubation
As the procedure continues, the nurse will administer the patient a combination of medications. The nurse will monitor and describe the vital signs status of the patient regularly and be prepared to pass the ET tube and other equipment to the person intubating.
Once the tube is inserted, the cuff should be inflated and checked for pressure with a manometer. The patient’s chest should be observed for equal expansion and auscultation performed at the mid-axillary line. The tube should be secured, the patient attached to an appropriate ventilator and a check X-ray ordered. A high concentration of oxygen should continue and arterial blood gases should be taken. Appropriate humidification is required (http://www.nursingtimes.net/nursing-practice/clinical-zones/critical-care/endotracheal-intubation/199630.article).

3. What should the nurse do to prepare for intubation of this patient?


2. As the nurse responsible for the care of this patient, what would you anticipate a physician to order to respond to the acute respiratory needs of this patient?

Diagnosis is reached by ruling out other diseases and disorders through specific diagnostic procedures:
· Imaging
o CXR - to reveal which parts of the lungs have fluids and enlargement of heart.
o CT scan – can provide detailed information about structures within heart and lungs.
· Lab Tests
o CBC/Chem 7 – assess for other abnormalities and bodily functions.
§ Hematologic - Von Willebrand factor (VWF) may be elevated in patients at risk for ARDS and may be a marker of endothelial injury.
§ Renal - Acute tubular necrosis (ATN) often ensues in the course of ARDS, probably from ischemia to the kidneys. Renal function should be closely monitored.
§ Hepatic - Liver function abnormalities may be noted in either a pattern of hepatocellular injury or cholestasis.
o ABGs - often initially show a respiratory alkalosis. However, in ARDS occurring in the context of sepsis, a metabolic acidosis with or without respiratory compensation may be present. As the condition progresses and the work of breathing increases, the partial pressure of carbon dioxide (PCO2) begins to rise and respiratory alkalosis gives way to respiratory acidosis.
o Sputum Cx – r/o infection
o BNP – An BNP level of less than 100 pg/mL in a patient with bilateral infiltrates and hypoxemia favors the diagnosis of ARDS/acute lung injury rather than cardiogenic pulmonary edema.
· Cardio
o EKG
o ECG - provides information about left ventricular ejection fraction, wall motion, and valvular abnormalities.
· Bronchoscopy - Bronchoscopy may be considered to evaluate the possibility of infection, alveolar hemorrhage, or acute eosinophilic pneumonia in patients acutely ill with bilateral pulmonary infiltrates.
· Hemodynamic monitoring - hemodynamic monitoring with a pulmonary artery (Swan-Ganz) catheter may be helpful in selected cases for distinguishing cardiogenic from noncardiogenic pulmonary edema.
(http://emedicine.medscape.com/article/165139-clinical)

1. What diagnostic procedures should be done to determine the cause of this acute
respiratory compromise?

End-tidal carbon dioxide detection is the most accurate technology to evaluate endotracheal tube position.
Capnograph

Reconfirmation of endotracheal tube position should be undertaken immediately at any time there is concern regarding proper location of the endotracheal tube.


ET tube placement

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097557/

setting does not allow for pretransfusion/compatibility testing.
-In extreme emergencies, when there is no time to obtain and test a sample, group ‘O’ Rh-negative packed red cells can be released.
-clinician must sign a release authorizing and accepting responsibility for the use of incompletely tested products as a life-saving measure.



Emergent Transfusion

Joanna Alicea, Abiba Arouna, Bethany Chhim, Jake Miller, & Nick Peret

Respiratory Disorder

Acute Respiratory Distress Syndrome

Student Led Case Study

· Fluid management - diurectics, strict I&O
· Noninvasive ventilation – non-rebreather mask (already in placed)
· Mechanical ventilation - to maintain oxygenation while avoiding
oxygen toxicity and the complications of mechanical ventilation. Generally, involves
maintaining oxygen saturation in the range of 85-90%, with the aim of reducing the fraction of
inspired oxygen (FIO2) to less than 65% within the first 24-48 hours. Achieving this aim almost
always necessitates the use of moderate-to-high levels of positive end-expiratory pressure (PEEP).
· Nutritional support – NPO, Enteral nutrition via a feeding tube.
· Activity restriction – Bed rest. Frequent position changes, passive and, if possible, active range of
motion activities of all muscle groups. Elevation of the head of the bed to a 45° angle is recommended to
diminish the development of VAP. Prone positioning.
(http://emedicine.medscape.com/article/165139-clinical)


SPIN

8

7

6

5

4

3

2

1

Spin
Timing
: best heard on expiration
Causes
: air passing through narrowed airways
Timing
: more obvious during inspiration
Causes
: air passing through fluid or mucus in airways
Timing
: more obvious during expiration
Causes
: airway narrowed by bronchospasm or secretions
SPIN

8

7

6

5

4

3

1

2

You are assessing a client came to ER with respiratory distress (coungh, cynosis, low O2). Upon ascultation, you find the client breath sounds to be this. What is you correct interpretation?

1. Crackles
2. Rhonchi
3. Wheezes
4. Vesicular

Introduction

Lungs and thorax assessment is a critical part of physical assessment particularly for clients with respiratory distress.


By the end of this lecture, the student will be able to:

Understand the importance of lung physical assessment.
Describe the general principles of lung physical assessment
Differentiate between normal and abnormal breath sounds.
Identify resources for easy auscultation.



Objectives

Signs of respiratory difficulty:
cyanosis
lip pursing,
nasal flaring,
sternal retraction, or wheezing.


Inspection

G.S. has been in the ICU for 6 weeks, and her ARDS is nearly resolved. She is transferred out of the ICU and is admitted to your unit You receive the following report:
Neuro: AAO to person and place, she can move both arms and wiggle her toes on both feet:
CV heart tones are clear, VS are 138/90, 88, 26, 99.2°F, bilateral radial pulse 3+, foot pulses by Doppler only,
Skin: incisions and dressings are dry and intact;
GI: duodenal feeding tube in place;
GU (genitourinary): Foley catheter to gravity drain.

The physician has decided that he would like to wean the patient from the ventilator. What signs and symptoms of improvement should the nurse watch for, that would indicate that the patient is ready to be weaned from the ventilator?

The physician has decided that he would like to wean the patient from the ventilator. What signs and symptoms of improvement should the nurse watch for, that would indicate that the patient is ready to be weaned from the ventilator?

The nurse hears the alarm go off on a mechanical ventilator that signals the ventilator is not able to give the patient a breath. What are the possible reasons that would make this alarm go off?


What are the characteristics of a mechanical ventilator that is pressure-cycled?

The ICU has been working on improving quality and safety outcomes each quarter. One nurse sensitive indicator that they have been tracking is the incidence of VAP. The nurse know that in the care of a patient on a mechanical ventilator, what action by the nurse will contribute to the prevention of ventilator assisted pneumonia?

Check tube placement
Absence of appropriate pressure would allow her to make sounds.
Assess for an air leak around the cuff/inadequate cuff pressure.


While the nurse is caring for this patient on a mechanical ventilator, the nurse hears G.S. making sounds that sound like she is talking. What does the nurse need to check?


The nurse hears in report that the patient has been agitated and pulling on the ET. Restraints have been recently ordered and placed on the patient, but she continues to move her head and chew at the tube. What does the nurse do to ensure proper placement of the ET tube?

What are the nursing considerations related to emergent transfusion of this patient?


What were the legal implications of consent when the patient was brought in to the hospital requiring immediate OR care?


Acute onset of
- dyspnea
- tachypnea
- crackles/wheezes on auscultation
- bilateral lung infiltrates on CXR
- restlessness/agitation
- continually decreasing PaO2

Clinical presentation


Describe her clinical presentation and diagnostic evidence of ARDS?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097557/

Hemodynamic, cerebral, and metabolic stability.
Temp <38 C
Ability to maintain patent airway and initiate inspiratory effort
Evidence of partial or full resolution of underlying disease process that prompted intubation.
Physician determination of readiness.

Weaning criteria

Volume (low pressure)
Pressure (high pressure)
Apnea

Ventilator Alarms

Volume-cycled- inspiratory flow halts once the target volume is delivered.
Pressure-cycled- inspiratory flow ceases once a peak inspiratory pressure is reached.
Flow-cycled- inhalation is programmed to cease when it senses a drop in the peak flow rate, and expiratory phase begins.
Time-cycled- a timed inhalation limit is set and exhalation will begin when that limit is reached


Types of Cycling

Airway management
NPPV
Timely ET tube removal/ 1 time placement
CASS tube
Gastric reflux prevention
-Patient positioning
Equiptment maintenance
-ventilator circuit (tubing, exhalation valve/humidifier
Cross-contamination
-standard/contact precautions

VAP Prevention

The patient may also need a sitter or to be put on constant observation.
Family member
Patient teaching
Moderate sedation.

ET tube placement

Define Emergency situation
-If immediate treatment is required in order to prevent death or other serious harm to a patient, that treatment may be provided without informed consent.

Implication of Consent

Rule out basis
Consists of
Acute onset
Bilateral infiltrates
PCWP <18 mmhg w/o L atrial HTN
PaO2/FiO2 ratio <200

ARDS Diagnostic Criteria

Dyspnea, hypoxemia, and tachypnea are assessment findings considered early sign of ARDS.

8. What additional assessment findings may be found in ARDS?
Additional assessment findings include:
· Pulmonary HTN
· Multiple organ system failure
· Hypotension
· Cyanosis of skin, lips, nail beds
· Delayed capillary refill
· Confusion/disorientation
· Adventitious lung sounds

9. What factors contributed to this diagnosis?
The factors that contributed to this diagnosis are trauma the patient suffered from the car accident and also the amount of transfusions received during emergency resuscitation.



7. What assessment finding is considered an early sign of ARDS?

Acute respiratory distress syndrome is characterized by the development of acute dyspnea and hypoxemia within hours to days of an inciting event, such as trauma, sepsis, drug overdose, massive transfusion, acute pancreatitis, or aspiration. Increased capillary permeability is distinctive. Damage of the capillary endothelium and alveolar epithelium in correlation to impaired fluid removal from the alveolar space results in accumulation of protein-rich fluid inside the alveoli, thereby producing diffuse alveolar damage, with release of pro-inflammatory cytokines. Neutrophils are recruited to the lungs by cytokines, become activated and release toxic mediators. Extensive free radical production overwhelms endogenous anti-oxidants and causes oxidative cell damage. If the fluids, proteins, and blood cells accumulate too rapidly for the lymphatic system to remove, the consequences is noncardiogenic pulmonary edema (http://emedicine.medscape.com/article/165139-clinical).
In addition, the lungs experience an increase in hyaline membrane formation, development of fibroblasts, and an increased number of alveolar type II cells, as well as the inactivation of pulmonary surfactant. Interstitial fibrosis may also develop. together, these factors worsen gas exchange. decrease lung compliance, and produce areas of atelectasis (York & Kane, 2012).


6. Pathophysiology of ARDS?

Delegatable tasks include:
· Specimen/sputum collection
· Bed bath, mouth care
· I&O
· ROM


5. While you are caring for G.S. on a ventilator, you may delegate what actions to an experienced nursing assistant?

1. Assess for bilateral breath sounds and symmetrical chest movement.
2. Auscultation over the stomach to rule out esophageal intubation.
3. Marking the tube 1 cm from where it touches the incisor tooth or nares
4. Ordering chest radiography to verify that the tube placement is correct.


4. You are the preceptor for an RN who is undergoing orientation to the ICU. The RN is providing care for G.S. who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you perform immediately?

The nurse should first verify if there is an DNI (Do Not Intubate) order in place to verify if intubation is appropriate.
· Preparing the patient
The nurse should tell the patient what is about to happen, then pre-oxygenate. Intubation should be preceded by ventilation with a high concentration of oxygen, ideally at least 85%, for a minimum of 15 seconds. The aim is to maximize the patient’s PaO2 as the patient will be unable to maintain any respiratory effort (http://www.nursingtimes.net/nursing-practice/clinical-zones/critical-care/endotracheal-intubation/199630.article).
The nurse should gather the necessary equipment for intubation. The following essentials must be present prior to the procedure, using the mnemonic SALT:
-Suction: crucial to clear the airway and allow visualization of the vocal chords
-Airway: the oral airway can make it easier to mask ventilate a patient and oxygen must always be available
-Laryngoscope: for inserting the tube
-Tube: an ET tube for intubation.
The bed head should be lowered and the patient’s position flat, with their face at the level of the xiphoid cartilage of the standing person performing the procedure. A small pad/pillow should be placed under the occiput. Extend the head at the atlanto-occipital joint, which aligns the oral, pharyngeal, and laryngeal axis so that the passage from the lips to the glottic opening is a straight line (http://www.nursingtimes.net/nursing-practice/clinical-zones/critical-care/endotracheal-intubation/199630.article)
· The process of intubation
As the procedure continues, the nurse will administer the patient a combination of medications. The nurse will monitor and describe the vital signs status of the patient regularly and be prepared to pass the ET tube and other equipment to the person intubating.
Once the tube is inserted, the cuff should be inflated and checked for pressure with a manometer. The patient’s chest should be observed for equal expansion and auscultation performed at the mid-axillary line. The tube should be secured, the patient attached to an appropriate ventilator and a check X-ray ordered. A high concentration of oxygen should continue and arterial blood gases should be taken. Appropriate humidification is required (http://www.nursingtimes.net/nursing-practice/clinical-zones/critical-care/endotracheal-intubation/199630.article).

3. What should the nurse do to prepare for intubation of this patient?


2. As the nurse responsible for the care of this patient, what would you anticipate a physician to order to respond to the acute respiratory needs of this patient?

Diagnosis is reached by ruling out other diseases and disorders through specific diagnostic procedures:
· Imaging
o CXR - to reveal which parts of the lungs have fluids and enlargement of heart.
o CT scan – can provide detailed information about structures within heart and lungs.
· Lab Tests
o CBC/Chem 7 – assess for other abnormalities and bodily functions.
§ Hematologic - Von Willebrand factor (VWF) may be elevated in patients at risk for ARDS and may be a marker of endothelial injury.
§ Renal - Acute tubular necrosis (ATN) often ensues in the course of ARDS, probably from ischemia to the kidneys. Renal function should be closely monitored.
§ Hepatic - Liver function abnormalities may be noted in either a pattern of hepatocellular injury or cholestasis.
o ABGs - often initially show a respiratory alkalosis. However, in ARDS occurring in the context of sepsis, a metabolic acidosis with or without respiratory compensation may be present. As the condition progresses and the work of breathing increases, the partial pressure of carbon dioxide (PCO2) begins to rise and respiratory alkalosis gives way to respiratory acidosis.
o Sputum Cx – r/o infection
o BNP – An BNP level of less than 100 pg/mL in a patient with bilateral infiltrates and hypoxemia favors the diagnosis of ARDS/acute lung injury rather than cardiogenic pulmonary edema.
· Cardio
o EKG
o ECG - provides information about left ventricular ejection fraction, wall motion, and valvular abnormalities.
· Bronchoscopy - Bronchoscopy may be considered to evaluate the possibility of infection, alveolar hemorrhage, or acute eosinophilic pneumonia in patients acutely ill with bilateral pulmonary infiltrates.
· Hemodynamic monitoring - hemodynamic monitoring with a pulmonary artery (Swan-Ganz) catheter may be helpful in selected cases for distinguishing cardiogenic from noncardiogenic pulmonary edema.
(http://emedicine.medscape.com/article/165139-clinical)

1. What diagnostic procedures should be done to determine the cause of this acute
respiratory compromise?

End-tidal carbon dioxide detection is the most accurate technology to evaluate endotracheal tube position.
Capnograph

Reconfirmation of endotracheal tube position should be undertaken immediately at any time there is concern regarding proper location of the endotracheal tube.


ET tube placement

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097557/

setting does not allow for pretransfusion/compatibility testing.
-In extreme emergencies, when there is no time to obtain and test a sample, group ‘O’ Rh-negative packed red cells can be released.
-clinician must sign a release authorizing and accepting responsibility for the use of incompletely tested products as a life-saving measure.



Emergent Transfusion

Joanna Alicea, Abiba Arouna, Bethany Chhim, Jake Miller, & Nick Peret

Respiratory Disorder

Acute Respiratory Distress Syndrome

Student Led Case Study

· Fluid management - diurectics, strict I&O
· Noninvasive ventilation – non-rebreather mask (already in placed)
· Mechanical ventilation - to maintain oxygenation while avoiding
oxygen toxicity and the complications of mechanical ventilation. Generally, involves
maintaining oxygen saturation in the range of 85-90%, with the aim of reducing the fraction of
inspired oxygen (FIO2) to less than 65% within the first 24-48 hours. Achieving this aim almost
always necessitates the use of moderate-to-high levels of positive end-expiratory pressure (PEEP).
· Nutritional support – NPO, Enteral nutrition via a feeding tube.
· Activity restriction – Bed rest. Frequent position changes, passive and, if possible, active range of
motion activities of all muscle groups. Elevation of the head of the bed to a 45° angle is recommended to
diminish the development of VAP. Prone positioning.
(http://emedicine.medscape.com/article/165139-clinical)


Time to Play
SPIN

8

7

6

5

4

3

2

1

Spin
You are the nurse assessing the respiratory system of a client with airway problem. Select all that apply to Vesicular breath sounds
1. Low pitch
2. High pitch
3. Auscultated over most lung fields
4. Auscultated over main bronchus area
5. Auscultated over upper right posterior
lung fields
6. Short on exhalation, long inhalation
7. Exhalation equals inspiration

Useful Resources

http://www.easyauscultation.com/lung-sounds.aspx


http://www.practicalclinicalskills.com/lung-sounds.aspx
References

Bickley, Lynn, S. (2012). Bates Guide to Physical Examination and History Taking (11th Ed). Philadelphia: Lippencott.


http://www.easyauscultation.com/lungsounds.aspx

Thank You

Normal Breath Sounds
1. Vesicular
Inspiratory longer than expiratory
Soft, low pitched, heard throughout most of the lung field



Tips to Easy Auscultation

Watch, listen, practice, and learn
Multimedia
Apps
Simulation


Respiratory rate, rhythm, and effort of breathing.
Oxygen saturation, and oxygen supplement.
Any symmetry, configuration, or deformities of the thorax.
Pain or tenderness over the thorax.
Percussion findings and chest expansion.
Breath sounds description, timing and location.
Amount, color, consistency, and odor of any sputum.
Documentation
What two priority actions should you take? Provide your rationale.

Look at cardiac monitor & implement cardiac protocols if necessary (code) to detect arrhythmia and correct it.
Vital signs to detect current patient status.


Contact the pharmacist
Contact the doctor
If necessary, contact the charge nurse
Go up the chain of command

You realize that it is illegal to take medication dispensed by a pharmacist for one patient and use it for another patient. What should you do?


Given that KCL and CaCL are compatible, would you mix them in the same bag of D5W? State your rationale.


The physician prescribes the following: Draw STAT Mg level; if below 1.4 mg/dl, give MgSO4 3Grams in 100 ml D5W over 4 hours, administer KCL 40 mEq in 100 ml D5W IVPB over 1 hour; and give CaCl2 grams in 100 ml D5W IVPB over 3 hrs. The laboratory is called to draw a STAT Mg. level. 

It is time to administer 40 mg of furosemide IVP.
-Why is this medication indicated?
-What are the nursing considerations for giving this drug IVP?
- What effect if any will furosemide have on the clinical presentation of G.S.?


The nurse from the previous shift charted the following statement, “Crackles and rhonchi clear with vigorous coughing.” Based on your knowledge of pathophysiology, determine the accuracy of this statement.


Identify the following adventitious lung sounds:

Stridor – high-pitched, monophonic, inspiratory, crowing sound, louder in neck than over the chest wall.
Pleural friction rub – a very superficial sound that is coarse and low pitched; has a grating quality as if two pieces of leather are being rubbed together.

Rhonchi – low-pitched wheezing or snoring sound associated with partial airway obstruction.
Wheeze (sonorous) low-pitched, monophonic single note, musical snoring, moaning sound heard throughout the resp. cycle.
Wheeze (sibilant) – high-pitched, musical squeaking sounds, polyphonic and heard predominantly in expiration.

The nurse completes his/her assessment of G.S. The nurse notes dyspnea, crackles throughout all lung fields posteriorly and in both lower lobes anteriorly, and rhonchi over the large airways.

What is the significance of these assessment findings in G.S.’s case?

Provide an example of your transfer report note. - Handout

What additional information should you require during this report?
Resp: lung sounds, depth pattern,
GI: feeding type, rate
GU: foley output,
pain level


http://www.youtube.com/watch?v=MzTcy6M3poM
http://www.easyauscultation.com/lung-sounds-reference-guide.aspx
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682858.html
http://www.nlm.nih.gov/medlineplus/respiratoryfailure.html
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097557/
http://www.nlm.nih.gov/medlineplus/ency/article/000187.htm
http://www.meddean.luc.edu/lumen/MedEd/medicine/skills/ekg/les2prnt.htm
Nursing Central, (2014).





Websites

Anderson, M., Arnold, E., Bishop, S., Boyd, M., Britt, R., Cassem, M…Yoho, M. (2011). HESI Comprehensive Review for the NCLEX-RN examination (4th edition). St. Louis:Elsevier.
Anne, Y., Brenda, H., Laura, E.(2010). ICU Nurses’ Experiences in Providing Terminal Care. Critical Care Nurse Quarterly, 33(3), 273-281
ATI Nursing Education. (2010). RN Adult Medical Surgical Nursing Edition 8.0 . ATI Nursing Education.

References

What’s the difference between hospice and palliative care?
All hospice care (care at the end of life) is palliative care, but not all palliative care (care to make the patient comfortable), is hospice

Questions

Vacation,
Grieving with the family
limit OT, realize the nurses in role in end of life care.
Find activities to do outside of work,
crying relieves stress,
group counseling, therapy.
Talking with others co-workers
Designing and helping to implement policies and procedures, education reform


How can nurses avoid suffering from moral distress and burnout?

Ineffective coping strategy:

- crusty nurse attitude.

coping

Abandonment and powerless


Conflict with meds administration



internal conflict


Lack of involvement in the plan of care
Differences between the medical and nursing practice models
Unrealistic expectation of the family
Lack of education

barrier to optimal care


According to Laura Epsinosa, Three factors contribute to the moral distress
1 barrier to optimal care
2 internal conflict
3 coping

Define Moral distress and explain its association with patient care in critical care settings?

Taking it as a valuable experience,
nursing education reform, guidelines for providing terminal care
More training on how to communication with families.
Experiences can make nurses realize that not everyone can be saved.
Death is a part of life.

How can nurses use the experience of caring for a dying patient for personal and professional growth?

Give them time off,
Provide a place of privacy for grieving
grieving process with the family, counseling, grief counseling,
Help facilitate steps necessary for the family to carry out the desired arrangements
nurse must go through the grieving process as well.



What steps can be taken for the nurses of dying patients?

G.S.’s arrhythmias respond to your treatment. Unfortunately, 1 week later, she puts the call light on and complains of difficulty breathing. As you enter the room you find the following: G.S. has no pulse and is not breathing.

Case study

Family-grief counseling,
offering clergy,
staff counseling,
pain control, comfort measures,
encourage the family to communication with patient.



Give examples of end-of-life care requiring the intervention of skilled critical care nurses for G.S. at this point in her care.




Determine the patients ability to receive support.
Increase consistent communication between doc and family,
advocate for the pt.
Be there/ present and support the family (listen).

What is the nurse’s role in supporting that patient’s needs in this situation?

Involve social work to evaluate the seriousness of the situation,
discuss options: need to identify the chances of her surviving in either setting.
Family meeting, explaining the necessity of the transfer, risks of staying in the ICU.
May calm the family, determine family needs.



Nursing action


Even if death is imminent, a transfer from the ICU could be disruptive to the patient, family and staff members. What nursing action(s) can or will you take to respond to this situation?


Question

Patient
Advance directives
Assess mental status first; may need psych eval.
Ethics committee if needed



Who is responsible for the decision-making in this case?


Coronary Care Unit (Cardiac); Cardiac Intensive Care Unit.
Need to discuss advance directives and health care proxy
(remember there is an article that goes with this)


Discuss what type of ICU care is appropriate for G.S. and her family?


Based on the recent turn of events the team of physicians recommend that a family meeting should be conducted to determine G.S.’s wishes should her condition worsen and her heart and lungs stop functioning.

Case study

CPR
Electrical defibrillation or cardioversion (electric shock)
Anti-arrhythmic medications (such as lidocaine, procainamide, sotalol, or amiodarone) given through a vein
Correcting the underlying cause, correct electrolyte levels, administer meds, continue cardiac monitoring.



What treatment is indicated for G.S.’s arrhythmias?


You notice that G.S. looks frightened and is lying stiff as a board.

How would you respond to this situation?
Support the patient. Explain to the patient what is happening to ease the anxiety.
Non-pharmacological relaxation techniques.
Social worker.


Case study

If the heart rate during a ventricular tachycardia episode is very fast or lasts longer than a few seconds. There may be symptoms such as:
Chest discomfort (angina)
Fainting (syncope)
Light-headedness or dizziness
Sensation of feeling the heart beat (palpitations)
Shortness of breath


What factors have contributed to these clinical findings?


CPR
Electrical defibrillation or cardioversion (electric shock)
Anti-arrhythmic medications (such as lidocaine, procainamide, sotalol, or amiodarone) given through a vein
Call a code.


What is your next priority action?


Single irritable focus in Ventricles
Ventricular rate 150-250 bpm
Wide QRS complexes
No P wave
RR intervals approximately equal
A run of three or more VPB's in a row @ rate greater than 100/min
AV dissociation may be present
Atrial capture beats may be present
Ventricular fusion beats may be present
Retrograde concealed conduction
VPB's with the same shape QRS


Ventricular Tachycardia


G.S.’s pulse is irregular. Her BP is 92/70 and her respirations are 28. She admits to being “a little lightheaded” but denies having pain or nausea. Your co-worker connects G.S. to the code cart monitor for a “quick look”. You are able to distinguish normal P-QRS-T complexes but you also note approximately 22 very wide complexes per minute. The wide complexes come early and are not preceded by a P wave.

What is your impression of these findings?

Case Study

While you administer the furosemide and hang the intravenous medication, G.S. tells you, “ This is so strange, a couple of times this morning, I felt like my heart flipped upside down in my chest, but now I feel like there’s a bird flopping around in there.”


Case Study

You open G.S.’s medication drawer to draw the furosemide into the syringe. You find one 20 mg. ampule. The pharmacist tells you that it will be at least another hour before he can send the drug to you.


Case study

hyperkalemia s/s, hypercalcemia s/s disrythmias, slow irregular heartbeat, fluid overload, hyperglycemia.

What clinical implications may be anticipated based on these current laboratory findings?

Chem 7

What additional bloodwork should be ordered?

BP, allergies, current lab values, baseline/trend values, Bp and pulse noting irregularities, PT output must be recorded.
Should be on telemetry under constant cardiac monitoring.


What additional nursing action is necessary?

monitor vitals, allergies, lab values, frequent monitoring, I/O ratio WNL

Discuss safe administration of IV KCL and CaCL.

Low Potassium, low sodium, low calcium, low chloride, high glucose. Most concerning is the potassium because it may cause arrhythmias.
Monitor renal function as the BUN and creatinine increases.


Keeping in mind that you are about to administer furosemide, which laboratory values concern you and why?


values concern you and why? Low Potassium, low sodium, low chloride, high

glucose most concerning is the potassium because it may cause arrhythmias. By

RESPIRATORY ACIDOSIS WITH COMPENSATION

Na: 135-145 mEq/L
K: 3.6-5.1 mEq/L
Cl: 98-110
Ca:
BUN: 6-24mg/dl
Creatinine: 0.64-1.27
Glucose: 67-99 mg/dl
HCO3 :
ABGs
pH: 7.35–7.45
Paco2 : 35–45 mmHg
Pao2 : 80–95 mmHg
HCO3 : 22-26
BE :
Sao2 : 95–99%

Normal Lab Values

Na - 129 mmol/L
K - 2.8mmol/L,
Cl - 92 mmol/L
Ca - 7.1 mg/dl
BUN - 37 mg/dl
Creatinine - 2 mg/dl
Glucose - 128 mg/dl
HCO3 26 mmol/ L
ABGs on 6L O2 /NC:
pH - 7.38
Paco2 - 49 mmHg
Pao2 - 82 mmHg
HCO3 - 36 mmol/L
BE - 2.2
Sao2 - 91%

The 0500 laboratory values are as follows:

5 Rights + allergy
Assess intake and output, lung sounds, BP and pulse, BUN and creatinine levels, electrolytes.
Administer slowly for 2 minutes. 4mg/min recommended IV rate.





Nursing Considerations

Dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis.
Hypotension, ↑ BUN, excessive urination, constipation, diarrhea, dry mouth, tinnitus, hearing loss.
ERYTHEMA MULTIFORME, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, APLASTIC ANEMIA, AGRANULOCYTOSIS.

Possible Adverse Reactions

-loop diuretic
-Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule.
-Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium.
-Diuresis and subsequent mobilization of excess fluids (edema, pleural effusions).
-IV dose for adults: 0.1 mg/kg/hr max 0.4 mg/kg/hr

What is furosemide (Lasix)?

Crackles (fine) – discontinuous, high-pitched sound, short popping sounds during inspiration that are not cleared by coughing.
Crackles (coarse) – Loud, low-pitched, bubbling and gurgling sounds that start in early inspiration and may be present in expiration; may decrease by coughing but will reappear shortly.

Adventitious Lung Sounds

Monitor the client for signs of respiratory distress, or airway obstruction, such as ineffective cough, dyspnea or stridor.
Heliox- Heliox generates less airway resistance than air and thereby requires less mechanical energy to ventilate the lungs.

Extubation

3. Bronchovesicular
Inspiration is equal to expiration
intermediate pitch and intensity
Anteriorly 1st, 2nd interspaces
Posteriorly between scapulae
2. Bronchail
Expiration is longer than inspiration
Louder, high pitched, heard over manubrium
Wheezing
Conclusion
Overview of physical assessment of respiratory system.
Assessment of Breath sounds.
Tips of easy learning of breath sound.
Full transcript