Review for RSPT 1166 clinical written final

Report
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
Call for help;
 Establish an airway and give 2 good
breathes with a bag/mask with 100% 02

Question
When you give your two breathes, you
notice that the chest doesn’t rise.
 What do you do?

answer

Manipulate the head and neck and try
again
question
While you give two breaths and the chest
rises, the second RT in the room should
be doing what?
answer

They should start chest compressions at a
rate of 100 bpm at 30:2 ratio until the
AED or the defibrillator arrives
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?
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.

End of case study
question

Identify the effect of severe hypoxemia on
the heart.
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

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

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
question
List the s/s of chronic lung disease:
 What do you hear
 What do you see
 What do you feel

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
question
Your patient has a Pa02 of 48 torr on
room air. His Sp02 is 85%
 What do you recommend?

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]
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?

pH
7.369
PaC02 HC03-
43
24
Pa02
57
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]


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?

pH
7.36
PaC02 HC03-
51
28
Pa02
43
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

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?
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

Question
The patient is on 50%
entrainment by bland
aerosol mask.
 How do we correct
this ABG?

pH
7.369
PaC02 HC03-
43
24
Pa02
188
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

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.

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%
question

Describe the effects of going too long
between checking on a heated aerosol
going to a patient with a tracheostomy
collar.
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
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.
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.


question
Identify the approximate Fi02 of a nasal
cannula at 2 lpm and at 5 lpm.
 Why is this only approximate?

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.

question

How do we add humidity to a simple
mask?
answer

We use a cool bubble humidifier
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
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

question
Your patient
has the
following
Orders: keep

Sp02
above 92%.
What Fi02
should
he be on?
Time
device
Flow
rate/Fi02
Sp02
HR/
RR
900
N/C
2 lpm/ 28% 89%
118/29
1100
N/C
3 lpm/ 32% 93%
115/22
1300
N/C
4 lpm/ 36% 94%
115/22
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

question
Your patient
has the
following
Orders: keep

Sp02
above 92%.
What Fi02
should
he be on?
Time
device
Flow
rate/Fi02
Sp02
HR/
RR
900
N/C
1 lpm/ 24% 86%
118/29
1100
N/C
2 lpm/ 28% 89%
115/28
1300
Simple
mask
6 lpm/ 44% 95%
110/27
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.

question

Explain why we cannot keep the simple
mask at 4 lpm?
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

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.
answer
1.
2.
3.
4.
5.
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]
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?

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

question

At what time
you give the
next
treatment of
Albuterol &
Atrovent if
both are
ordered Q4
hours?
time
device
Flow
rate
/Fi02
comments
830
SVN w/ 2.5 mg
Albuterol
.5 mg
ipratropium
bromide
6 lpm
HR 89/23
HR 89/22
Wheezing
unchanged.
answer

We would schedule the next treatment for
12:30 noon.
question

Describe the effect of an obstruction in
the 02 line coming from a Thorpe tube
answer
If the Thorpe tube is compensated for
backpressure, the rise in pressure
upstream from the obstruction will cause
the flow meter to read the correct flow
rate.
 If the Thorpe tube wasn’t compensated,
the rise in back pressure would result in
an erroneously lower flow than the
patient is actually getting

question

Describe the effect of an obstruction in
the 02 line on the delivered flow rate
coming from a Bourdon gauge that is
calibrated for flow rate.
answer
Bourdon gauges are not flow meters; they
read pressure only, but occasionally they
are calibrated in LPM so that a Bourdon
gauge may be used as a uncompensated
flow meter.
 When there is an obstruction downstream,
the Bourdon gauge will read the back
pressure as increased flow rate, so it will
display an erroneously high flow rate

question
Your patient is being transferred from the ER to
the ICU. He is on a NRM at 12 lpm. His Sp02
displays 90%/HR 89 bpm.
 After going through various doorways, you
notice that the NRM reservoir bag is deflated,
the Sp02 is showing: 88%/HR 115 bpm. The
flow meter on the Bourdon gauge shows a flow
rate of 15 lpm.
 The humidifier is alarming
 Is there a disconnection or is the tubing
pinched?

answer



If there was a disconnection, the bag would be deflated
due to drop in flow.
If there was a disconnection, the flow rate would be the
same.
There is no humidifier alarm for disconnection
If there was a pinched line, the bag would be deflated
due to drop in flow.
 If there was a pinched line the Bourdon gauge would
show the back pressure as increased flow rate.
 Many bubble humidifiers have excessive pressure popoff valves and these valves will alarm in the face of an
occlusion that results in high pressure.

question
Your E cylinder has 1500 and the patient’s
flow rate is 2 lpm.
 How long will a tank last if your hospital
policy is to change out a tank when there
is 15 minutes left.

answer

Your E cylinder has 1500 and the patient’s flow
rate is 2 lpm.
Duration = psig x factor/ LPM
Duration = 1500 x .28/ 2 LPM
Duration = 420 liters/ 2 LPM
Duration = 210 minutes
210-15 = 195 minutes
195minutes/60 = 3.25 hours
.25 hours x 60 = 15 minutes
So this tank will run out in 3 hours & 15 minutes
question
Your H cylinder has 1150 and the patient’s
flow rate is 5 lpm.
 How long will a tank last if your hospital
policy is to change out a tank when it
reaches 500 psig?

answer
Your H cylinder has 1150 and the patient’s flow
rate is 5 lpm.
 In this case we first subtract 500 psig so that we
start with 650 psig

Duration = 650 x 3.14/ 5 LPM
Duration = 2041/ 5 LPM
Duration =408.2 minutes
Duration = 6.8 hours
Duration = 6 hours + [.8 x 60]
Duration = 6 hours and 48 minutes
Question
Case study
You patient is 1 day post op abdominal
surgery. His Sp02 is 93% HR 92 bpm, RR
23 bpm. His respirations are shallow and
without retractions.
 You hear diminished basal BS and crackles
over the RML.
 What would you suggest for this patient?

answer
His Sp02 is good and he shows no s/s of
respiratory distress
 One day post op, his respiratory rate may
be decreased because of pain or sedation
 His BBS demonstrate the presence of
atelectasis, so we need to start him on
Incentive Spirometer

question

What would be the clinical significance of
this patient’s LOC for successful Incentive
Spirometry?
answer
He must co-operate, so while he can be sleepy
or even lethargic [this means arousal with
stimulation] he cannot be comatose or in a
vegetative state.
 If he is severely mentally retarded or have
dementia, he may not be able to follow
directions.
 If he is alert, but suffers a neuromuscular
disorder, he may lack the muscle strength or coordination to follow directions

question

If the patient in the above question is a 35
YO BM who is 5 feet 8 inches tall, what
would be a reasonable goal to start him
on with the IS?
answer
To cough effectively he needs to get 15 ml/Kg
IBW
IBW = 105 + [8 x 6]
105 + 48 = 153 pounds
To convert to kg = 153/2.2 = 69.5 kg
To cough effectively he needs to get
[69.5kg x 15ml.kg] or 1042 ml IC
 Before surgery he could easily have gotten 3 x
that, so over the next couple of days we will
work up to [1042 x 3] or 3.1 Liters

question
On his first IS, your patient gets 850 ml on
his goal.
 What would you tell him?

answer
You did a wonderful job with this but we
need to increase the goal to 1000.
 Try this again and this time hold your
breath for 5-10 seconds
 We need to do this for at least 10 breaths

question

To assess the success of this patient’s IS
treatment, you would want to recommend
what actions?
answer





I would compare HR & RR before & after IS
I would listen to BBS and should hear increased
basal breath sounds and decrease in crackles
after sucessfull deep breathing and coughing
Over the next few days:
I would monitor the temperature for infection
resolution
the X-ray for resolution of atelectasis
question

If this patient complains [c/o] pain on
deep inspiration, what can you
recommend?
answer
If he complains of pain on deep
inspiration, I would alert the nurse that he
needs pain medication.
 If it is an IV, I can try the IS in about 5-10
minutes
 If it is a shot in the arm or buttocks, I will
have to wait for 30 minutes
 If it is a pill, I will have to wait 30-45
minutes

question

How would you recognize the presence of
atelectasis in your post-op patient?
answer





On inspection, the increased WOB associated
with decreased compliance seen with significant
atelectasis would be obvious in retractions,
increased RR and HR and use of accessory
muscles
If severe decreased gas diffusion, we might start
getting decreased Sp02 & cyanosis from
hypoxemic hypoxia
On auscultation, we would hear crackles and
diminished basal breath sounds
On palpation we might have poor chest
excursion
On percussion there will be dullness
question

What would you want to recommend if
the Incentive spirometry seems to be
failing to treat the atelectasis?
answer
If this patient cannot get an IC of 10
ml/kg, we need to start IPPB at 15 ml/Kg
IBW
 If the patient can get an IC of 10 or more
but there is documented [X-ray]
worsening atelectasis, we need to start
IPPB at 15 ml/Kg IBW

End of case study
question
You charted the wrong HR after a SVN
with 2.5 mg Albuterol and 3 ml of 20%
acetylcystiene.
 How do you correct this entry?

answer
I would draw a single line through the
wrong word and put the correct HR just
above it.
 Then I would initial and date the error.

question

Why can we not use erasable ink or pencil
on charting?
answer

The chart is a legal document that can be
used in court. All entries must be legible
even the ones that have been noted as
‘errors.’
question

If your patient had a PEFR that was 300
lpm and his predicted was 600 lpm, do
you think this patient has a restrictive
defect or a obstructive defect?
Answer
If your patient had a PEFR that was 300
lpm and his predicted was 600 lpm, he
has a decreased PERF which means he
has narrowed airway and increased RAW
 So he has an obstructive defect

Case study # 2
Question
Your patient is a 45 YO WF whose IBW is
65 kg. She has X-rays w/ atelectasis in the
RML and RLL.
 She has crackles everywhere and
diminished BS over the RLL.
 Her RR is 29 bpm and HR is 103 bpm &
she has a fever of 103
 What do you recommend?

answer
Incentive spirometer and deep breathing
can prevent atelectasis, but once it is
severe enough we need to start IPPB at
15 ml/Kg IBW.
 If the patient cannot get 10 ml/Kg IBW on
IS, we need to advance to IPPB

Question
You start the IPPB at a rate of 6-8 bpm.
You see that the manometer goes back to
-2 then moves up to +12. the inspiratory
time is about 3 seconds long.
 You measure a VT of 500 ml at these
parameters.
 What do you recommend right now?

Answer
a rate of 6-8 bpm is OK for IPPB. Too fast and
we worry about air trapping and decreasing the
Cardiac Out put
 The sensitivity needs to be set so that the
patient can trigger the breath by -2 cmH20 or
less pressure. This is OK
 An inspiratory time of 3 seconds is too long;
increase the flow rate to decrease the
inspiratory time.
 a 500 ml is too low [500/65 Kg] or 7.9 ml/Kg
IBW…so we need to increase the VT by
increasing the PIP to get 15 mL /Kg [or 975 ml.]

End of review

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