Flashcards
Critical Care Respiratory
Cards in this deck (55)
- 1Negative pressurePressure exerted around the thorax, allows the chest wall to expand which draws air into the lungs in the same manner as normal breathing
- 2Positive pressureForces air into the lungs. The opposite of normal breathing
- 3HypoxemiaPaO2 ≤ 60 mm Hg on FiO2 > .50
- 4HypercapneaPCO2 ≥ 50 mm Hg with pH ≤ 7.25
- 5Progressive deteriorationIncreasing Respiratory Rate
Decreasing tidal volume (Vt)
Increase work of breathing (WOB) - 6Endotracheal Intubation Used to:Maintain an airway
Remove secretions
Provide mechanical ventilation - 77.5 tend to be females. 7.5 to 9 are males. Balloon wont let air leak out around tube. Patients can still aspirate on tube. You don’t want balloon too firm because then you will get tracheal erosion. Position is 3-4 cm above the carina. Make sure you mark lip line measurement so you know if it is coming out or going down. You can be nasally intubated or nasally intubted.Only keep intubated for 14 days. Prefer oral intubation. To verify placement chest xray is most conclusive verification. Watch for chest movement bilatteraly and breath sounds.
- 8Verify PlacementAuscultate epigastric area
Auscultate bilateral breath sounds
ETCO2 detector
Chest x-ray—3 to 4 cm above carina
Record cm at the lip line for reference - 9Ventilator SettingsFiO2: Fraction of Inspired Oxygen
Tidal Volume (VT)
8 to 10 mL/kg to low of 4 to 8 mL/kg
Respiratory rate
I:E ratio; normal 1:2 - 10Ventilator Setting: Sensitivityamount of patient effort; possible mucous plug? Something blocking the airway? Pressure alarm may sound.
- 11Ventilator Setting: Sighis an additional breath. Can be used during suctioning.
- 12Modes of ventilation: Assist/Control Ventilation (A/C)Preset number of breaths at preset VT
Patient may trigger additional breaths
VT does not vary
Ventilator performs most of the WOB
Useful in normal respiratory drive but weak or unable to exert WOB
Risk of hyperventilation and respiratory alkalosis - 13Assist/Control meansthat the patient initiates a breath on their own, the ventilator will assist patient to get full tidal volume. Tidal volume will be consistent during all tidal breaths even if the patient doesn’t breath. It tries to rest respiratory muscles.
- 14Modes of Ventilation: Synchronized Intermittent Mandatory Ventilation (SIMV)Preset VT at a preset respiratory rate
In between “mandatory” (preset) breaths, the patient may initiate spontaneous breaths
VT of spontaneous breaths varies
Helps to prevent respiratory muscle weakness because patient contributes more WOB
Risk of hypoventilation - 15“weening mode”trying to figure out if patient can breath on their own so ventilator will not help. The ventilator will give breaths but if the patient takes a spontaneous breath the vent. Will not help.
Risk of hypoventilation: 10 breaths only with no help from patient. Normal respirs are 12-20 - 16In volume ventilation, a preset volume of oxygen is delivered to the patient.Tidal volume consistent
- 17In pressure ventilation, the volume is delivered until a preset pressure.Tidal volume varies
- 18Positive End Expiratory Pressure (PEEP)Positive airway pressure to mechanically assisted breaths: help with oxygen
Keeps airways open at end of expiration and increases functional residual capacity
Use to decrease amount of FiO2 needed
Risk for barotrauma and decreased cardiac output - 19CPAPContinuous positive airway pressure throughout respiratory cycle to patient who is spontaneously breathing
Similar to PEEP
Via ventilator or nasal or face mask
Option for patients with sleep apnea - 20CPAP 2Same thing as PEEP but patient is spontaneously breathing individual. You can have hypotension with that as well. Not as much but can still have it.
- 21Pressure Support (PSV)Patient’s spontaneous effort is assisted by preset amount of positive pressure
6 to 12 cm H2O
Decreases WOB with spontaneous breaths
Also useful in weaning - 22Physiological Changes -Cardiovascular SystemHypotension
Decreased cardiac output as a result of decreased venous return (decreased preload), especially with PEEP - 23Physiological changes -GI System, complicationsStress ulcers
GI bleeding - 24Physiological changes -GI System, InterventionsStress ulcer prophylaxis
Provide nutritional support
Assess swallowing prior to initiating oral feedings - 25Physiological changes - Psychosocial ComplicationsStress
Anxiety
Dyssynchrony
Noise
Altered sleep-wake patterns
Dependence - 26Interventions – Auscultate Lung SoundsLung sounds should be auscultated every 4 hours.
Assessment should be completed before and after suctioning - 27Interventions - MobilityEach institution has protocols for restraints to prevent accidental extubation.
Patient should be turned and repositioned every 2 hours if the condition warrants - 28Interventions- ABG’sABG’s should be analyzed and reported to the ordering physician.
ABG’s are analyzed to assess the effectiveness of the treatment - 29Interventions – Means of CommunicationInability to communicate is one of the voiced frustrations of patients in the acute care unit.
A means of communication needs to be established.
Example: blink your eyes once for yes and twice for no. Squeeze hands, wiggle toes.
Communication boards, charts. - 30Interventions- EnvironmentMaintain a calm environment.
Protect the patient from his environment.
Communicate with the family- explain what the purpose and goals of mechanical ventilation are.
Explain the equipment in the room to the family. - 31Interventions – Vital SignsAgency protocols and patient’s condition dictate the frequency of vital sign assessment.
Blood pressure can be affected by medications prescribed, mechanical ventilation and pathophysiology. - 32Interventions -Endotracheal SuctioningSuction as indicated by assessment
Visible secretions
Coughing
Rhonchi
High inspiratory pressure on ventilator
Ventilator alarm
Conventional versus closed suction
Hyperoxygenate throughout procedure
Avoid normal saline instillation - 33Interventions - infectionNormal protective mechanisms bypassed by ETT tube
Ventilator-associated pneumonia (VAP)
Aspiration of bacteria from oropharynx or gastrointestinal tract
Many potential causes
Controversies about best way to diagnose—no “gold standard” - 34Research-Based VAP PreventionElevate head of bed 30 to 45 degrees
Prevent drainage of condensate back to patient
Hand hygiene
ETT with subglottic suction capability
Aspirate secretions from above ETT
Oral hygiene program
Non-invasive ventilation as possible
Prophylaxis for DVT
Peptic ulcer disease prevention - 35Treatment of VAPWashing hands before and after patient contact.
Bacteria-specific antibiotic therapy. - 36Interventions - NutritionThe preferred route of providing nutrition is enteral nutrition.
Pulmocare tube feedings are low in carbohydrates because the by product of carbohydrate metabolism is carbon dioxide production.
Nurses role: prevention of aspiration, monitor tolerance of feedings, proper positioning (HOB elevated 30°) - 37TroubleshootingNever shut alarms off; silence only
Manually ventilate if uncertain of problem - 38Types of AlarmsIncreased tidal volume, minute ventilation, or respiratory rate
Decreased tidal volume, minute ventilation, or respiratory rate
High and low inspiratory pressure alarms (PIP)
High and low PEEP or CPAP alarms
Special mode activation alarms (e.g., I:E ratio activation), apnea alarm
Loss of power or loss of gas pressure alarms - 39Low-Volume/pressure AlarmPatient does not receive preset VT
Causes
Inadequate spontaneous VT
Disconnection of circuit from ETT or other break in the circuit
Leak in cuff of ETT
Tube out of position
Fix the cause - 40Low volume alarm or low pressure alarm indicates that the patient is not receiving the preset tidal volume ordered or the pressure is to easy to delver the breath.Disconnection somewhere
Loose tubing
Leaky or broken cuff … you will hear air passing by listening at mouth or feeling it by the mouth - 41High Pressure AlarmHigh pressure alarm will sound if preset pressure limit is exceeded
Causes
Secretions and mucus plugs
Kinks in ETT tube or tubing
Talking
Dysynchrony
Barotrauma - 42High Pressure Alarm … gasses or volume is not able to be pushed into lungsNo gas is exchanging
Suction needed … lots of secretions
The patient could be biting on the endotrachealtube or the tube is kinked
Occlusion … mucus plug forming
Malposition … endotube down too far
Spontaneous pneumothorax … air accumulating into the pleural space … if suspected auscultate (you will hear very diminished or no sounds) … watch for decreased O2 sats - 43ETT Malposition/Extubation: How do you access for presence of this conditionTo assess for malposition is the same as the previous slide-make sure you check the lip line level of the ET tube with each assessment.
- 44ETT Malposition/Extubation interventionsThe interventions will vary on the problem of malposition. So base your actions on the cause. Is the tube down too far or is the tube out to far. In either case, make sure that you assess the oxygenation status of your patient.
- 45Weaning Patients from VentilatorThe process in which the support from the mechanical ventilator is reduced which causes the work of breathing to be increased by the patient.
Individualized decisions
Collaborative team effort - 46Readiness to WeanUnderlying cause for mechanical ventilation resolved
Hemodynamic stability; adequate cardiac output
Adequate respiratory muscle strength
Adequate oxygenation without a high FiO2 and/or high PEEP
Absence of factors that impair weaning
Mental readiness
Minimal need for medicines that cause respiratory depression - 47Readiness to Wean 2level of consciousness
physiologic and hemodynamic stability
adequacy of oxygenation and ventilation
spontaneous breathing capability
respiratory rate and pattern
adequate nutritional status due to the increased metabolic demands
Look at H&H levels, need to have adequate oxygen carrying capacity. - 48These are methods that can be utilized to wean the patient from mechanical ventilation. All of these can be utilized with the ET tube in place.Vital capacity
Respiratory rate
Monitor vital signs
Maintain a patent airway
Monitor pulse ox levels
Suction as needed. - 49Monitor response of the patient and terminate the weaning process if:Heart rate increases by 20 beats/minute
Systolic blood pressure increase of 20 mm HG
Decrease in oxygen saturation to less than 90%
Respiratory rate less than 8 or greater than 20/minute
Arrhythmias
Fatigue
Respiratory distress
Cyanosis
Panic
Erratic or labored breathing
Change in level of consciousness - 50Stop the Weaning ProcessRespiratory rate > 30 or < 8 breaths/min
Low spontaneous VT
Labored respirations
Use of accessory muscles
Low oxygen saturation
HR or BP changes > 20% from baseline
Dysrhythmias (e.g., PVCs)
ST-segment elevation
Decreased level of consciousness
Anxiety - 51Weaning DifficultiesDraw ABGs
Place patient back on the ventilator
Identify cause of weaning difficulty - 52ExtubationDetermine need for secretion management
Assess
Stridor
Hoarseness
Change in VS
Low oxygen saturation - 53Sedation management – propofol and nursing interventionsPropofol commonly used medication (page 32 of text).
Very short acting sedative.
Nursing interventions:
Monitor vital signs (especially monitor for hypotension)
Daily sedation vacations
Monitor lipid levels
IV tubing changed every 12 hours - 54Sedation Management- Other medicationsAnalgesics: morphine
Sedatives: benzodiazepines, neuroleptics, and propofol
Neuromuscular blocking agents (NMBAs): paralytic agents - 55Sedation management – nursing condsiderationsMonitor vital signs
Neurological assessment
Assess for need
Administer at lowest levels possible
If using a sedative, analgesics are still required for pain management
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- Flashcards on Critical Care Respiratory , created by Heather Wagar on 27/09/2013.
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- Heather Wagar
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