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Postprocedure education for central lines
- No BP's on that arm
- No heavy lifting
- Cleaning once a week
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What makes a midline different?
- not central because it doesn’t go into aortic branch
- Similar to Peripheral venous access
- Into basilic to the axilla
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What cannot be done with a midline?
- pH can’t be too acidic - be careful with meds
- No blood draws
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A CVAD (central venous access device) lands where?
superior vena cava
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Why do we use CVAD?
Meds not irritating to veins because it dumps into SVC where there is a large amount of blood
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What is done right after insertion of CVAD?
Xray to determine placement
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Complications of CVAD placement?
- Infection
- Malpositioned
- Infiltration
- Thrombus formation
- Phlebitis
- Thrombophlebitis
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Where is the tunneled and non-tunneled catheter placed?
- Subclavian vein
- Internal Jugular (IJ)
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What is special about accessing Ports?
- Must be specially trained
- Use a Huber needle to access
- Porta-cath life is based on the number of punctures
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Non-tunneled cath vs. tunneled - why?
Non-tunneled – if patient just needs quick renal replacement therapy (not staying in as long)
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What are the protocols for preventing infection with a CVAD?
CLABSI (central line associated bloodstream infections)
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Why use a 10 mL syringe to flush any central line?
smaller barrels exert too much pressure which poses a risk for rupturing the catheter
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How much do we flush a CVAD?
- 10 mL NS before and after medication administration
- 20 mL NS after blood draw
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Name the precautions taken to prevent catheter-related bloodstream infections. Major components of the bundle:
- Hand hygiene
- Maximal barrier precautions upon insertion (sterile - gown, mask, gloves)
- Chlorhexidine skin antisepsis
- Optimal catheter site selection
- Post-placement care
- Daily review of line necessity
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Normal HCO3 (bicarb)
22-26
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K+ with someone in metabolic acidosis
hyperkalemia
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K+ in someone in metabolic alkalosis?
hypokalemia
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What is metabolic acidosis?
- pH <7.35
- too much acid (H ions) not enough base (HCO3)
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What are some causes of metabolic acidosis?
- Starvation diet / low carb diets
- DKA (metabolic) – extremely high glucose that can’t be used – tissues use fat
- Kidney failure (metabolic) – under elimination of H+ ions or underproduction of bicarb (also caused by pancreatitis)
- Hypoxia at tissue level (metabolic) – fever, infection
- Salicylate intoxication (ASA overdose)
- Diarrhea – over elimination of bicarbSevere dehydration
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What are some causes of Respiratory Acidosis?
- Hypoventilation (respiratory)
- Sedation
- Opioid
- Airway obstruction
- TBI
- Alcohol intoxication
- Anesthesia
- Sleep apnea
- COPD/Asthma
- ALS/MS/Muscular Dystrophy
- Guillan Burre
- Pain / Trauma – example fractured ribs
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An overproduction of hydrogen ions can result in ?
Metabolic acidosis
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An underelimination of hydrogen ions (like in kidney failure) can result in ?
metabolic acidosis
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An underproduction of bicarbonate (like in kidney failure pancreatitis, liver failure or dehydration) can result in ?
metabolic acidosis
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An overelimination of bicarbonate (like in diarrhea) can result in ?
metabolic acidosis
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An underelimination of hydrogen ions (like in respiratory depression, airway obstruction, COPD, trauma...) can result in ?
Respiratory Acidosis
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What do we want to assess first in a patient at risk for acidosis?
Cardiac system - acidosis can lead to cardiac arrest from hyperkalemia
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Cardiac manifestations (Key features) of acidosis?
- Delayed electrical conduction: (brady to heart block, tall T-waves, widened QRS, prolonged PR
- Hypotension
- Thready peripheral pulses
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CNS manifestations (Key features) of acidosis?
Depressed activity: lethargy, confusion, stupor, coma
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Neuromuscular manifestations (Key features) of acidosis?
- hyporeflexia
- skeletal muscle weakness
- flaccid paralysis
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Respiratory manifestations (Key features) of acidosis?
- Kussmaul respiration
- variable respirations
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Integumentary manifestations (Key features) of acidosis?
- warm, flushed, dry skin (metabolic acidosis)
- pale to cyanotic and dry skin (respiratory acidosis)
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What is Alkalosis?
- pH >7.45
- too much base (HCO3) and not enough acid (H ions)
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What are some causes of Metabolic Alkalosis?
- Antacids use
- Vomiting (lose acid)
- Loop Diuretics (number one cause of metabolic alkalosis in hospitals)
- NG suctioning
- Blood transfusions with citrate
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What are some causes of Respiratory Alkalosis?
- Anxiety
- Hyperventilation – must be careful with mechanical vent patients
- Anytime body not getting enough O2 to tissues – compensation is to breath more times in a minute
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An increase of base components (like ingesting antacids, blood transfusion) can cause ?
Metabolic Alkalosis
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A decrease of acid components (like in vomiting, NG suctioning, thiazide diuretics, hypercortisolism, or hyperaldosteronism) can cause ?
Metabolic Alkalosis
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An excessive loss of carbon dioxide (like in hyperventilation, fear, anxiety, mechanical vent, ASA tox, altitudes, shock, pulmonary problems) can cause ?
Respiratory Alkalosis
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CNS manifestations (Key features) of Alkalosis?
- increased activity
- anxiety, irritability, tetany, seizures
- +Chvostek's sign
- +Trousseau's sign
- Paresthesias
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Neuromuscular manifestations (Key features) of Alkalosis?
- Hyperreflexia
- muscle cramping and twitching
- skeletal muscle weakness
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Cardiovascular manifestations (Key features) of Alkalosis?
- Increased HR
- normal or low BP
- Increased digitalis toxicity
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Respiratory manifestations (Key features) of Alkalosis?
- Increased rate and depth of ventilation (in Respiratory alkalosis)
- Decreased respiratory effort associated with skeletal muscle weakness (in metabolic alkalosis)
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When assessing a patient with respiratory issues, what are some questions to ask?
- Where do you work
- Smoker
- Meds are you on
- Health problems
- Travel
- Childhood illnesses
- Cough
- Illness
- HF
- COPD
- Lung cancer
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air entrapment under the skin – crackling sensation - also called subcutaneous emphysema
Crepitus
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Breath sounds over the trachea and larynx. Inspiration < Expiration, harsh and hollow.
Bronchial
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Breath sounds heard over bronchi. Inspiration = Expiration, mixture of both sounds
Bronchovesicular
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Breath sounds heard over Left lower lung anterior and posterior. Inspiration > Expiration, periphery, alveoli.
Vesicular
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Breath sounds like popping, hair being rolled between finders, velcro sounds
- fine crackles
- fine rales
- high-pitched rales
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Breath sounds like lower-pitched course rattling sounds caused by fluid or secretions
Crackles
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Breath sounds like Continuous snoring sounds
Ronchus (rhonchi)
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Breath sounds like grating scratching sounds
pleural friction rub
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Name of elevated levels of RBC's often related to excessive production of erythropoietin in response to chronic hypoxic state (COPD, high altitude).
polycythemia
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What do we tell patients not to do before PFT's?
- No smoking 6-8 hours before
- No bronchodilators 4-6 hours before
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This PFT indicates respiratory muscle strength and ventilatory reserve
- FVC (forced vital capacity)
- reduced in obstructive and restrictive diseases
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What does forced vital capacity (FVC) test for?
the maximum amount of air that can be exhaled as quickly as possible after maximum inspiration
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This PFT is effort dependent and declines normally with age. It is reduced in certain obstructive and restrictive disorders.
FEV1 (forced expiratory volume in 1 sec)
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What does forced expiratory volume in 1 second (FEV1) test for?
maximum amount of air that can be exhaled in the first second of expiration
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This PFT indicates hyperinflation or air trapping. Often from obstructive pulmonary disease. Normal or decreased in restrictive pulmonary diseases.
Functional residual capacity (FRC)
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What does functional residual capacity (FRC) test for?
Amount of air remaining in the lungs after normal expiration
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Cyanosis unresponsive to O2 therapy, chocolate-brown-colored blood, after benzocaine topical anesthetic
- methemoglobinemia
- call RRT
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Preprocedure bronchoscopy
- consent
- medicate
- dentures out
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What are potential complications of bronchoscopy?
- methemoglobinemia
- laryngospasm
- aspiration - no eating/drinking until gag reflex returns
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Why is thoracentesis done?
- get fluid off lungs
- put meds into lungs (usually chemo)
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What are complications of thoracentesis?
- pneumothorax
- bleeding (watch for hemoptysis)
- decreased breath sounds on affected side
- tachycardia
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What must the patient do following thoracentesis?
lay on unaffected side for one hour
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What is the risk associated with lung biopsy?
pneumothorax
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Two key things to remember with O2 therapy
- Use lowest amount of O2 possible
- Length of tube does not affect how much O2 getting
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Important info for O2 via NASAL CANNULA
- Flow rate: 1-6 L
- FiO2: 24-44%
- Varies on how you breath (RR and volume)
- If more than 4 L - need moisture
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Important info for O2 via FACE MASK
- Flow rate: at least 5 L
- FiO2: 40-50%
- prevent from rebreathing exhaled air
- must flush out CO2 – remember this
- aware of vomiting
- good seal or not doing any good
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Important info for O2 via PARTIAL REBREATHER
- Flow rate: 6-11 L
- FiO2: 60-75%
- Must keep Bag 2/3 full on inspiration and expiration
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Important info for O2 via NON-REBREATHER
- Flow rate: 10-15 L
- FiO2: 90%
- Able to bring in maximum amount of O2 – not mixed with any outside air
- One way valve with flaps
- flaps close when taking in O2, must open when exhaling or will suffocate on CO2 (safety issue)
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Important info for O2 via VENTURI MASK (HI-FLOW)
- Flow rate: must be 4-10 L
- FiO2: 24-50%
- Adapters allow us to give the Precise amount of O2
- Safety issue: flow must be 4-10 or not giving liter flow enough O2 on this mask, monitor can get caught in bed linens, tubing kinks easily, make sure adapter not covered
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S/S of oxygen toxicity
- nonproductive cough
- dyspnea
- chest pain beneath sternum
- GI upset
- crackles on ausclutation
- nasal stuffiness
- sore throat
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Patients at risk for Oxygen induced hypoventilation?
- COPD
- these patients run the same PaCO2 all the time
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Education for patients and family going home with Oxygen
- No smoking
- Keep away from gas/fire/flammable liquids (acetone)
- Wear cotton
- Make sure everything grounded
- Make sure electrical is in good working order
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