Airway ALL CARDS Flashcards
What does end tidal Co2 measure
Normal range?
It is the amount of exhaled carbon dioxide.
35-45 mmhg
T/F
End tidal Co2 is a good indication of late respiratory distress
False.
It is an EARLY sign of respiratory distress. If it is outside the 35-45 range, we can tell something is wrong early on.
Three methods to monitor Co2
Colorimetric
Capnometric
Capnographic
Colorimetric definition
Colorimetric is monitoring co2 based off the color changes of a paper
Capnometric defintion
A numeric reading of co2 amount
Capnographic defintion
Gives a numeric value and a visual waveform to monitor co2
What is a Filter line?
What else can it do?
It is the filter on a nosepiece that collects the co2 sample after exhaling
Filterline can deliver 5 Liters of O2
How can you tell there is a filterline occlusion?
What do you do if theres an occlusion?
Sat drops
Co2 levels are off
Feel it
- make sure you check this before you call doctor if there is a problem
You replace the Filterline
Three examples of reasons to monitor ETCO2?
Sleep apnea
PCA Pumps
Sedation
Who are common candidates for end tidal co2 monitoring due to sleep apnea?
Males
Obsese patients
Thick neck
Post surgery pts
Why would we use ETCO2 monitoring for a pca pump?
Narcotic medications are used with these pumps and it can affect respiratory drive
Why would a sedated patient need to have their ETCO2 monitored?
Due to sedation meds they won’t be able to notify us if they are having breathing issues so the filter can help us make sure they are
- they too can cause resp depression
- colonoscopy, tee, etc
Your patient has a ETCO2 reading is 34. Their RR is 13. What do you do?
You would need to continue to monitor them and check the trends. The range is 35-45. It being 34 is not too concerning right now.
- you can ask them if they are feeling ok
What happens to a patients ETCO2 reading levels if you ventilate them too quickly?
Not enough Co2 will be able to build up in the alveoli - which causes a LOWER ETCO2 reading.
What happens to a patients ETCO2 reading levels if you ventilate a patient too slowly?
Sort of odd but by ventilating too slowly extra amount of Co2 will be able to build up in the alveoli which will cause HIGHER ETCO2 reading.
Can you get an O2 sat reading on a patient that is coding?
What about end tidal Co2?
No, you can’t. They’re not perfusing.
Yes the end tidal CO2 can be read and it can help you see if you’re doing good compressions.
What do you consider if you are consistently getting low Co2 readings?
How can a pulmonary embolism cause a low ETCO2 reading?
Is this perfusion, metabolic, or a psych problem?
Think about the perfusion, metabolic, psych problems causing it
A blocked pulmonary artery will cause less Co2 rich blood to return to the lungs and so you can’t breath co2 out
A perfusion issue
How can DKA cause a low ETCO2 reading?
What type of breathing occurs in DKA?
DKA involves the body being in an acidosis state. CO = acid. In order to get read of the acid, the body will start to breath rapidly to breath off more Co2 to compensate…… which then turns more slow and labored ultimately leads to LOW ETCo2 levels.
In order to compensate the hyperventilation going on is called Kussmauls = rapid, shallow breathing (like a sigh). The worse the acidosis from dka gets the slower and more labored the kussmauls become due to air hunger.
Clinical presentations of a pulmonary embolism that would cause a low etco2?
SOB
D-dimer labs
What is the likely reason someone’s ETCO2 would be high?
Respiratory failure of some sort due to not being able to breath off the normal of co2 at first. And it accumulates - so eventually your end tidal volume rises
If someone is going into respiratory arrest which is the best early indicator and why : O2 sat or ETCO2?
ETCO2.
You can inhale enough oxygen and still go into arrest due to just being fatigued. The CO2 however doesn’t lie.
What is a later sign of respiratory arrest?
LOC changes
- but you should be able to identify these before they become HUGE issues
What is the RR and ETCO2 gonna be like if a patient is hyperventilating?
High RR and ETCO2 will be low
- pt is blowing off co2 at quicker rates leading to less ETco2
What is arterial co2?
what happen to arterial co2if the etco2 is low from hyperventilation
co2 level drawn with abg
it will drop as well
what happens to ph if we try to drop co2 levels in the body?
what is treatment like for a pt hyperventilation?
raise the ph
We find out why and treat it
what happens to etco2 if the patient is hypo-ventilating?
what happens to arterial co2?
what state does this lead to?
common states that cause this?
Treatment goal?
RR breathing is slow so the co2 can not clear out in the lungs so the end product is too much co2 in the alveoli
arterial co2 levels rise too
metabolic acidosis
head injuries and opioids OD
Increase depth and rate of RR to help them blow off all the CO2.
Tool used to place ET intubation tube to see the vocal cords for placement
Where is ET intubation placed
What determines the size?
Miller
Placed through trachea (mouth)
- Can sometimes do it through the nose if there is too much trauma in mouth
7.8-8 French ET tube is common in adults but depends on the the patient size
Main reasons we would use an ET tube?
Airway patency for perfusion
Can also be used for support for breathing for an apnea patient who can’t breath on their own so their lungs can heal
Can bypass an obstruction
Can protect from airway aspiration
Can give meds
Acronym for meds that can be given down an Endotracheal tube (ET)?
Navel
Narcan - opioid displacement drug for OD , quick acting (protect yourself)
atropine - increase HR , symptomatic bradycardia
Vasopressin - constricts vessels to increase hr and bp
Epinephrine - constricts vessels to increase hr and bp as well
Lidocaine - rate control and cardiac support
List 5 equipment pieces or factor for ET intubation
Bag-valve-mask and make sure it is attached to 100% o2 before you give it
Suctioning equipment
Patent IV access (for meds)
EKG monitor
Pre-medication (happens just seconds before the intubation by the anesthesia team)
Three Factors that go into deciding whether to give premedication when intubating a patient with an ET tube?
LOC - are they conscious/coding/etc? If so, don’t use the meds.
Nature of procedure
Non-emergent - you won’t need meds during a code.
Best way to prepare for intubation?
Know the signs of respiratory distress and ACT!!!
What is an RSI?
What nature of issue would we use this?
Rapid sequence intubation where you can give PARALYTIC agent to deploy airway
- used for emergencies because it allows for a quick intubation
Reasons to use RSI?
It is quick intubation
Helps with perfusion
Decreases aspiration, combativeness, and injury to us actually paralyzing them
Reasons we won’t give an RSI to specific?
Comatose patients
Cardiac arrest patients
Bc the patient is asleep or the needs is irrelevant
Why do we use paralytic agents?
Likely candidates we use this?
What meds do we give NEED to give with these?
Intubation success and ease
Post code, hypothermia, severe trauma since body needs to heal
- all to prevent hardship when intubating a patient
Sedative agent such as midazolam (versed) to keep the pt calm and sedated
- remember a paralytic only paralyzes a patient . It doesn’t knock them out
How do we ensure the patient is at the right level of paralyticc?
Use of the train of four (TOF)
Metal prongs emit electricity and place them on radial artery - and observe for twitches of the thumb.
How many train of four twitches do we want when measuring the paralytic effectiveness
What is our back up measurement if we don’t get anything on the radial artery?
What if we get a zero?
We want 2/4 twitches when holding medal at the radial site
Move to temporal site and check for 2/4 twitches of the eye
Call physician and then you will decrease the amount the paralytic drip is running
List the neuromuscular blocking drugs/PARALYTICS in alphabetical order
Curare Mivacurium Pancuronium Rocuronium Succincylcholine
You’ll be needing these if your patient is wide awake for a intubation. Just know these aren’t for sedation in intubation
What do we do before intubation?
How long should intubation attempts take? What if it takes too long?
Pre-O2 the BVM mask at 100% for 3-5 minutes
Less than 30 seconds
- you will need to remind the crna about this and watch o2 levels
- You need to bag the patient with 100% o2 and ventilate them in between
What happens after intubation?
How do we check where it is?
Cuff is inflated by resp therapy and confirm placement of the ET tube
- all while pt is being manually ventilated btw
Check with xray
- and also check the ETco2 levels
After intubation how do you measure the end tidal co2 to confirm placement?
Purple meaning?
yellow?
Deliver 6 breaths and then measure
Purple means no exhaled co2 detected = bad
yellow co2 is detected = successful
Can you detect CO2 during cardiac arrest or other code situations?
Not exactly because there’s no perfusion. BUT you can if you are doing compressions
T/F
ETCO2 can detect right main stem intubation
False. it cannot.
a very common misplacement actually
- instead, check for bilateral lung sounds.if they aren’t equal then the may be a stem placement. then get xray
You use a colorimetric detector to check to see for proper trachea tube placement. You get a positive result . Should you immediately think there is proper placement
No- you can get a false positive due to acidity from stomach and acidic drugs like epinephrine. Put all the pieces together to check - auscultate - colorimetric/other co2 - xray
T/F
Incorrect tube placement on a patient is not emergent
false. It is an emergency
Main goal when there is an incorrect tube placement ?
What do you need to support?
Stay with patient and maintain the airway with BVM and 100% oxygen
support ventilation
When there is an incorrect tube placement , what should you prepare for?
What do you try to monitor?
Prepare for re-intubation
Vitals, ekg, and pulse ox
How will you as a nurse be maintaining correct tube placement?
How often should you monitor the et tube?
You will need to know the proper tube size and french placement always. (22@ the lip)
2-4 hours
What if you notice the et tube is slipping?
How do we prevent the pt from pulling et tube out?
Let RT know so they will tape it for you if it is slipping
- best with 2 people so you may have to assist
Use of soft limb restraints can keep the patient from pulling the tube out
T/F
Tubing always stays in place if a patient is moving
False.
You need to check and support the tubing if the pt is moving because it can come out.
Common injuries that occur due to ET tube placement?
Lips, teeth, orapharynx, and vocal cords
- so assess for these
What is a possible risk due to the gag reflex in intubated patients?
Vomiting and aspiration
What nerve can be triggered by intubation?
Vagus nerve which leads to bradycardia
- watch vitals the entire time
Common misplaced intubation locations?
Esophageal and right main stem intubations
- if this is the case, the lung sounds won’t be equal
When you xray for intubation placement where should the tube be
3-5 cm above the carina
Why do you need to check the cuff when dealing with an ET tube?
Check for proper cuff inflation because there could be leaks or sounds the patient makes
check o2 and if it is trending down, call RT to check the cuff inflation.
What do you need to check for when it comes to stabilization of the Et tube?
Make sure it is taped properly around the mouth so no gas escapes!
What do we need to check for skin integrity wise due to the et cuff?
how do we prevent this?
It can cause pressure and skin injuries
Cuff pressure is measured and recorder on routine basis
utilize RT if you think there might be a leak
How do we maintaining tube patency?
What are indications to suction?
Assess need for suctioning because we do not suction routinely - bc we don’t do this routinely. Can cause coughing and affect abgs
- Decrease in o2 sats and secretions to indicate the need to suction
- Sudden onset of resp distress
Listen for lung sounds of fluid or crackles - An increased respiratory rate and so they cough - which can lead to monitor going off.
Open suction technique
Using oral suction to get around the tube
close suction technique
suctioning that is inside the et tube where you push the button and draw out the suction tubing
- enclosed in plastic
- the one you did at capstone first day
- safer for you since there is less exposure of secretions
What should you do before suctioning?
How long should suctioning last?
Vital to watch?
Hyper-oxygenate before hand
- but if their o2 sats are high and good then you don’t always need to
Less than 10 seconds
Watch 02 levels
What should suction pressures be limited to?
What should you avoid while suctioning?
less than 12o mmhg
Avoid overly vigorous catheter insertion
Reasons why secretions could be thick
How to fix this?
Not getting enough liquid
Call for IV fluids
Supplemental humidification
Postural drainage
Turning patient every 2 hours
Percussion to break everything up
Potential complications that may occur while suctioning
Hypoxia because it blocks their airway
Bronchospasm
Increased ICP
Dysrhythmias (pvc)
BP changes (up or down)
Trauma to airway (bleeding - call if acute!)
Infection!!! (Due to sores or breakdown)
Practice Q:
What are indication for suctioning patient?
Bucking the vent
Their o2 goes down
Secretions
Resp distress all of a sudden
How often should you provide oral care to your ventilated patients?
Oral care is done every 2 hours. Always!
Do it more often if needed
Why would a ventilated patient need to be on DVT prophylaxis?
What med can we use?
Nonmed intervention?
This patient is lying in bed 24/7. We need to make sure they don’t throw a clot.
Heparin drip
SQ Lovenox
SCD
We need to prevent stress ulcers in ventilated patients. How would you do this?
The patient will be ventilated and be laying down. So we turn them q2hrs.
How do we usually feed ventilated patients?
Gut feedings w protein (if diet allows). And it is super important bc it helps them heal.
What should the bed angle be at for a ventilated patient ?
What about for tube feedings?
Elevate HOB between 30-45 degrees
30-45 for tube feedings too
What are navel drugs again?
Is there a golden rule set dose for NAVEL drugs? Route difference?
Drugs that can be given with ET tube that are lipid soluble
Nope no set amount but the the dose is 2-2.5x higher than IV/IO
Since NAVEL drugs are liquid soluble, how much do we mix them with?
What do we do once we are done giving the NAVEL meds>
5-10 mLs of NS
Do 1-2 ventilations
List the NAVEL drugs again that are ok with an ET tube/vent
Narcan Atropine Vasopressin Epinephrine Lidocaine
T/F
It is okay to not talk to your ventilated patient
FALSE
You need to always explain everything with patient and family
They will both have a lot of anxiety.
Main meds used to address discomfort with a patient who already has been intubated?
Fentanyl - analgesic
Propofol - sedation
Alternative therapies to address discomfort in family?
Meditation
Music
TV noise
Main nursing preventions meeded?
Aspiration - do suctioning, oral care, keep hob raised
Improper cuff inflation - do your assessment , call RT if you suspect
Patient positioning - 30-45 degrees
Suction oral cavity as needed
Low intermittent suctioning for those doing tube feeding with OG and NG tube
Nasal cannula limit for L/minute
Simple face mask limit
1-6 L/min
6-10 L/min
Nonbreather mask limit L/minute
10-15 L/min
