Chapter 21 Respiratory Care (Continued)

Question 1

Describe a tracheostomy.

Answer 1

Tracheotomy is a surgical procedure in which an opening is made into the trachea (tracheostomy). An indwelling tube is inserted into the trachea (tracheostomy tube). This may be permanent or temporary.

Uses: bypass of upper airway obstruction, removal of tracheobronchial secretions, permit long-term use of mechanical ventilation, prevent aspiration of oral or gastric secretions in unconscious or paralyzed patient (closing off trachea from esophagus), and to replace an ET tube.

Question 2

Describe nursing care for a patient with a tracheostomy.

Answer 2

Continuous monitoring and assessment.

Proper suctioning needs to be conducted to ensure patency of the opening.

After vitals become stable, place patient in semi-fowler position (facilitates ventilation, drainage, minimizes edema, prevents strain on suture lines)

Analgesia and sedatives may be administered with caution because of the suppression of cough reflex.

Alleviation of apprehension and providing effective means of communication is important (paper and pencil, magic slate, call light within reach at all times).

REVIEW CHART 21-9 P. 507

Question 3

What are some complications of a tracheostomy?

Answer 3

Early: bleeding, pneumothorax, air embolism, aspiration, sub-Q or mediastinal emphysema, laryngeal nerve damage, posterior trachial wall penetration.

Long-term - airway obstruction (secretion accumulation and protrusion of cuff over tube opening), infection, rupture of inominate artery, dysphagia, tracheoesophageal fistula, tracheal dilation, tracheal ischemia, trachial necrosis.

After removal - tracheal stenosis

CHART 21-8 for prevention of complications (ET and trach) (P.507)

Question 4

What are ways to prevent complications associated with et tubes and tracheostomies?

Answer 4

Adequate warmed humidity

Appropriate level of cuff pressure

Suction as needed (assessment findings)

Maintain skin integrity by changing tape and dressing per protocol.

Auscultate lung sounds

S/S of infection, including temp and WBC

Administer prescribed O2 and monitor saturation

Cyanosis

Adequate hydration

Sterile technique for suctioning and tracheostomy care

Question 5

Describe the process and considerations for suctioning of an ET tube or trach.

Answer 5

When to do it: when adventitious breath sounds are detected or secretions are obviously present. DO NOT SUCTION IF NOT NECESSARY. This can cause bronchospasm and mechanical trauma to mucosa.

This is a sterile procedure.

Patients on mechanical ventilation may have a in-line suction catheter (closed suction) that may be used. This allows for suction without being disconnected from the ventilator circuit,decreases hypoxemia, sustains PEEP, decreases anxiety related to suctioning, and minimizes cross-contamination of airborne pathogens.

REVIEW CHART 21-10 P.509 FOR PROCEDURE

Question 6

How is the cuff of an ET tube or trache managed?

Answer 6

The pressure of the cuff needs to be adequate enough to prevent aspiration as well as deliver sufficient tidal volume.

The best pressure is between 15-20 mmHg

Cuff pressure should be checked every 8 hours

With long-term intubation higher pressures may be needed to maintain an adequate seal.

Question 7

Describe the assessment of a patient on a ventilator.

Answer 7

Systematic full-body assessment with focus on respiratory: rate, pattern, sounds, spontaneous ventilatory effort, signs of hypoxia, setting and function of ventilator, adventitious breath sounds may indicate need for suction. look at neurological status and how well the patient is coping to assisted ventilation. Check the comfort level of the patient and their ability to communicate. GI and nutritional status is important for future and present weaning.

Read p. 514 in book

Question 8

What is the purpose of mechanical ventilation?

What isa mechanical ventilator?

Answer 8

There are a few purposes: to control the patients respirations during surgery or treatment, oxygenate blood when patients ventilatory efforts are not adequate, and to rest the respiratory muscles

A mechanical ventilator is a positive or negative pressure device that can maintain ventilation and oxygen delivery for a prolonged period.

Question 9

Explain some of the ventilator modes.

Answer 9

A/C - preset volume AND rate, if patient initiates own breath inbetween machines the machine will deliver preset volume

SIMV - preset volume AND rate, however, if the patient breaths between machines breaths the machine senses it and allows the patient to take that breath themself with no assist. This allows the ventilator settings to be changed as the patients ability to spontaneously breath increases.

Question 10

Describe the nursing process in regards to patients on mechanical ventilator: Assessment, Diagnosis, Planning and Goals, Interventions, Evaluation.

Answer 10

Read P.514 in book.

Question 11

What are some troubleshoots for mechanical ventilation?

Answer 11

Increase in peak airway pressure

- Coughing or plugged tube -- suction airway, empty condensation fluid from circuit
- Patient "fighting" ventilator -- adjust sensitivity
- decrease in lung compliance -- manually ventilate, assess for hypoxia or bronchospasm, check ABG values, sedate only if necessary
- Tubing kinked -- check tubing, reposition patient, insert oral airway if needed.
- pneumothorax -- manually ventilate, notify primary provider
- atelectasis or bronchospasm -- clear secretions

Decrease in pressure or loss of volume

- increase in compliance -- none
- Leak in ventilator or tubing; cuff on tube/humidifier not tight --- check entire ventilator circuit for patency and correct leak.

Cardiovascular compromise
- decrease in venous return due to application of positive pressure to lungs — assess for adequate volume status by assessing HR, BP, CVP, pulmonary capillary wedge pressure, and urine output… notify care provider if values are abnormal

barotrauma/pneumothorax
- Application of positive pressure to lungs; high mean airway pressures lead to alveolar rupture —- Notify primary provider, prepare patient for chest tube insertion, avoid high pressure settings for patients with COPD, ARDS, history of pneumothorax

Pulmonary Infection
- Bypass of normal defense mechanisms; frequent breaks in ventilator circuit; decreased mobility; impaired cough reflex — use meticulous aseptic technique, frequent mouth care (Q1), optimize nutritional status

Question 12

Discuss use and indications for CPAP and BIPAP.

Answer 12

CPAP - provides positive pressure to the airways through the respiratory cycle, can be used with cuffed ET tube or trache to open alveoli and is also used with leak-proof mask to keep alveoli open which prevents respiratory failure.
- Indications: OSA is the most common (keeps upper airway and trache open during sleep (splint)) PATIENT MUST BE BREATHING INDEPENDENTLY

BIPAP - offers control of inspiratory and expiratory pressure settings while providing PSV (pressure support ventilation), can be delivered through nose or mouth as long as there is a tight seal and has a portable generator. Respirations can be initiated by the patient or by the generator if it is programmed with a backup rate ensuring a minimum number of breaths per minute.
- Indications: ventilatory assistance needed at night, such as COPD or sleep apnea, patients usually need to be highly motivated in order to tolerate

Question 13

What are some general indications and contraindications for NIPPV?

What are the advantages of NIPPV?

Answer 13

Acute or chronic respiratory failure, acute pulmonary edema, COPD, chronic heart failure, sleep-related breathing disorder, improve oxygenation and relax respiratory muscles at home while patient sleep at night, end of life care, patients who done want ET tube but will need short or long-term ventilatory support

Contraindications: those who have experienced respiratory arrest, serious dysrhythmias, cognitive impairment, head or facial trauma.

Advantages: elimation of the need for ET tube or tracheostomy, decreases risk for nosocomial infections like pneumonia, can be set up with backup vent rate for patients with periods of apnea.

Question 14

What are some indications for mechanical ventilation?

Answer 14

Labs:
PaO2 < 55 mmHg
PaCO2 > 50mmHg andpH <7.32
vital capacity < 10ml/kg
negative inspiratory force <25cm H2O
FEV1 < 10 ml/kg

Clinical manifestations:
Apnea or bradycardia
Respiratory distress with confusion
Increased work of breathing not relieved byother interventions
confusion with need for airway protection
circulatory shock

Question 15

What is the physiiologic basic for cardiovascular complications due to positive pressure mechanical ventilation?

Answer 15

The positive thoracic pressure caused by inhalation compresses the heart and great vessels, thereby reducing venous return and cardiac output. Usually exhalation relieves the positive pressure.

Question 16

What are two specific nursing interventions that are common throughout most facilities with mechanical ventilation?`

Answer 16

Pulmonary auscultation and ABG measurements.

LOOK UP MORE INTERVENTIONS IN BOOK

Question 17

Explain the process of weaning.

Answer 17

Three stages:

1. remove patient from ventilator
2. remove from ET tube or tracheostomy
3. remove form oxygen

This process should be done at the earliest time consistent with patient safety.

The decision is made based on a physiologic, not mehanical viewpoint.

Patient needs to be hemodynamically stable, recovering from acute medical or surgical problems, or have reversal of cause of respiratory failure.

Collaboration for weaning involves primary provider, respiratory therapist, and the nurse.

Question 18

Describe some criteria and care involved in weaning a patient from mechanical ventilation.

Answer 18

• Assess patient for weaning criteria:

a. Vital capacity: 10–15 mL/kg
b. Maximum inspiratory pressure (MIP) at least –20 cm H2O
c. Tidal volume: 7–9 mL/kg
d. Minute ventilation: 6 L/min
e. Rapid/shallow breathing index: Below 100 breaths/minute/L; PaO2 >60 mm Hg with FiO2 <40%

• Monitor activity level, assess dietary intake, and monitor results of laboratory tests of nutritional status. Reestablishing independent spontaneous ventilation can be physically exhausting. It is crucial that the patient have enough energy reserves to succeed.
• Assess the patient’s and family’s understanding of the weaning process, and address any concerns about the process. Explain that the patient may feel short of breath initially and provide encouragement as needed. Reassure the patient that he or she will be attended closely and that if the weaning attempt is not successful, it can be tried again later.
• Implement the weaning method as prescribed (e.g., continuous positive airway pressure [CPAP], T-piece).
• Monitor vital signs, pulse oximetry, electrocardiogram, and respiratory pattern constantly for the first 20–30 minutes and every 5 minutes after that until weaning is complete. Monitoring the patient closely provides ongoing indications of success or failure.
• Maintain a patent airway; monitor arterial blood gas levels and pulmonary function tests. Suction the airway as needed.
• In collaboration with the primary provider, terminate the weaning process if adverse reactions occur. These include a heart rate increase of 20 bpm, systolic blood pressure increase of 20 mm Hg, a decrease in oxygen saturation to <90%, respiratory rate <8 or >20 breaths/min, ventricular dysrhythmias, fatigue, panic, cyanosis, erratic or labored breathing, paradoxical chest movement.
• If the weaning process continues, measure tidal volume and minute ventilation every 20–30 minutes; compare with the patient’s desired values, which have been determined in collaboration with the primary provider.
• Assess for psychological dependence if the physiologic parameters indicate that weaning is feasible and the patient still resists. Possible causes of psychological dependence include fear of dying and depression from chronic illness. It is important to address this issue before the next weaning attempt.

Question 19

What are some different methods of weaning?

Answer 19

CPAP - will allow the patient to breath spontaneously with positive pressure keeping alveoli open to promote oxygenation. May reduce patient anxiety because the machine is keeping track of the patients breathing. CPAP is often used in conjunction with PSV.

T-piece (ET tube) or tracheostomy mask (trach tube) - The patient is taken off of the ventilator and is only receiving humidified oxygen, the patient has to do all of the work of breathing. The patient may find it more comfortable since there is no positive pressure to overcome, or they may become anxious because they have no support from the ventilator. Oxygen content may be the same or higher than when on mechanical ventilation. use when the patient is awake and alert, breathing without difficulty, and has good gag or cough reflexes. Monitor the patient closely and provide encouragement. If the patient tolerates the mask/t-piece trial, after 20 minutes while spontaneously ventilating at a constant FiO2 PSV an ABG should be drawn (Alveolar-arterial equilibrium occurs after 15-20 minutes). A deteriorating ABG indicates theneed for mechanical ventilation.

THESE TRIALS MAYBE DONE DAILY

Some patients may still need vigorous supportive therapy for ADLs, or may still have borderline pulmonary function after being weaned.

Others: oxygen therapy, ABG evaluation, pulse oximetry, bronchodilatortherapy, CPT, adequate nutrition, hydration, humidification, BP assessment, IS.

Question 20

What is you are trying to wean a patient who is on sedatives (propofol, mdazolam)?

Answer 20

The recommendation is a “sedative vacation”, which is a decrease in sedative dose by 25%-50% before weaning. For patients who cant tolerate the withdrawal of sedation, dexmedetomidine (Precedex) may be initiated for spontaneous breathing trials without causing significant respiratory depresion.

Question 21

What are some things that the nurse should look for while attempting to wean the patient off of the ventilator?

Answer 21

Tachypnea (>35 BPM), tachycardia, reduced tidal volumes, decreased oxygen saturations, increased CO2 levels, use of accessory muscles, PVCs with tachycardia, paradoxical chest movement (contraction during inspiration and expansion during expiration), fatigue, late sign is bradypnea.

Question 22

Tid bits for weaningfrom oxygen?

Answer 22

want the patients PaO2 to be70-100 mm HG on RA, less than 70mmHg is recommended oxygen.

To be eligible for reimbursement from CMS (centers for medicare and medicaid services) for in-home oxygen, the patient must have a PaO2 of less than 55 mmHg while awake and at rest.

Question 23

Nutrition and weaning?

Answer 23

After only a few days of mechanical ventilation the respiratory muscles become weak or atrophied, if the patient doesnt have adequate nutrition those muscles may be catabolized for energy.

Excessive intake can increase the production of CO2 and demand for oxygen.

adequate PROTEIN is important in increasing respiratory muscle strength. should equal 25% of daily kilocalories, or 1.2-1.5 g/kg/day

Question 24

Describe the importance of the preoperative nursing assessment for a patient undergoing thoracic surgery.

Answer 24

The nurse should auscultate all breath sounds in all regions of the lungs. Note if the sounds are normal which indicate free flow of air in and out of lungs. In some patients (like those with emphysema) the breath sounds may be absent or decreased.

Note any crackles, wheezes, hyperressonance, or decreased diaphragmatic movement.

Unilateral diminished breath sounds and rhonchi can indicate occlusion by mucus plugs.

Asking the patient to cough during auscultation can help assess for retained secretions.

IT IS IMPORTANT TO NOTE ANY RHONCHI OR WHEEZES

assessment of cardiovascular status and pulmonary reserve is important. Pulmonary function studies are conducted to see if enough functioning lung tissue will be left after a proposed lung resection. ABGs are also assessed to see functionality of lungs. exercise tolerance tests are important in determining the ability of the patient to handle removal of one lung in a pneumonectomy.

These preoperative studies also provide a baseline for the postoperative period.

more studies include bronchoscopic examination, chest x-ray, MRI, ECG (conduction defects, CAD), nutritional assessment, BUN/CK (renal function, BG levels or glucose tolerance levels (check for diabetes), electrolyte and protein levels, blood volume, CBC.

Question 25

What are some preoperative methods of improving airway clearance before thoracic surgery?

Answer 25

Often this is associated with increased respiratory secretions. Secretions are cleared preop in order to reduce the risk for atelectasis and infection postop.

Strategies - humidification, postural drainage, chest percussion (after bronchodilators if prescribed)

Estimation of volume of large amounts of sputum can help in the determination of whether and when the amount of secretions has decreased.

Preop antibiotics are prescribed for infections, which can also cause excessive secretions.

Question 26

What are some preop education highlights that should be described for a patient undergoing thoracic surgery?

Answer 26

More often now patients are admitted the day of their surgery, which leaves little time for assessment and education.

Anaesthesia, thoracotomy, chest tubes and drainage systems (postop), oxygen and possible use of ventilator (postop), frequent turning to promote drainage of lung secretions, IS use before surgery to familiarize patient with correct use early, diaphragmatic and pursed-lip breathing practice and education.

Explain the need for a coughing routine, that it may be uncomfortable, and educate on how to splint the incision with hands, pillow, or folded towel.

Teach the patient FET (forced expiratory technique) if they have diminished expiratory flow rates or if they refuse to cough. inhale deep diaphragmatic and exhale in distinct pant or huff against hand. Practice with small huffs then advance to one strong huff.

Blood and other fluids may be administered, oxygen will be admnistered, vitals will be checked often, chest tube education, may be admitted to ICU for 1-23 days after surgery, pain in incision site, medication will be available to relieve pain and discomfort.

Question 27

What are some risk factors for surgery related atelectasis and pneumonia?

Answer 27

Preoperative Risk Factors
• Increased age • Obesity • Poor nutritional status • Smoking history • Abnormal pulmonary function tests • Preexisting lung disease • Emergency surgery • History of aspiration • Comorbid states • Preexisting disability

Intraoperative Risk Factors
• Thoracic incision • Prolonged anesthesia

Postoperative Risk Factors
• Immobilization • Supine position • Decreased level of consciousness • Inadequate pain management • Prolonged intubation/mechanical ventilation • Presence of nasogastric tube • Inadequate preoperative education

Question 28

What are some techniques for relieving anxiety related to the thoracic procedure?

Answer 28

Listened to patient and evaluate feelings about illness and treatment

Determine motivation to recover

Help address patient fears and coping with stress of procedure: corrrect misconceptions, support patients decision to go with surgery, reassure that incision will “hold”, be honest about questions about pain and discomfort, education on PCA or PCEA if used, tell about possible non-opioid use initially to decrease dosing of opioid agents and help facilitate return to normal respiratory function.

Question 29

What is the purpose of chest drainage?

Answer 29

Chest drainage systems are used to re-expand lungs and remove excess air, fluid, and blood. Also used to treat spontaneous and traumatic pneumothorax.

Question 30

Where may a chest tube be placed?

Answer 30

right or left pleural space or mediastinum.

Question 31

How much fluid is normally in the pleural space? (space between visceral and parietal plerua)

Answer 31

20 ml of fluid to help lubricate

Question 32

What does surgical incision of the chest wall do to the pleural space?

Answer 32

causes some degree of pneumo or hemothorax (serous fluid or blood) which collect in the pleural space restricting lung expansion and reducinmg gs exchange. The tube in the space restores the negative intrathoracic pressure needed for re-expansion of lungs.

Question 33

Define ARF (acute respiratory failure).

Answer 33

Failure to adequately ventilate and/or oxygenate.

Ventilatory: mechanical malfunction of lungs or chest wall, impaired muscle function, malfunction in respiratory control center of brain.

Oxygenation: lack of perfusion to pulmonary capillary bed, condition that alters gas exchange medium (pulmonary edema, pneumonia).

Combined leads to more profound hypoxemia than either one separately.

Criteria is based on ABG results

Question 34

Define ARDS (acute respiratory distress syndrome).

Answer 34

a state of acute respiratory failure that has a mortality rate of about 60%

• systemic inflammatory response that injures the alveolar-capillary membrane, which then makes it permeable to large molecules and the lung space is filled with fluid
• A reduction in surfactant weakens the alveoli which causes collapse or filling of fluid, leading to worsening edema.

Question 35

Define severe acute respiratory syndrome (SARS).

Answer 35

Result of viral infection from a mutated strain of coronaviruses, which is a group of viruses that also cause the common cold.

• virus invades pulmonary tissue, leading to inflammation
• spreads through droplets from sneezing, coughing or talking
• virus does not spread through bloodstream because it only thrives in temperatures that are slightly below our core body temperature.

Question 36

Where should you read more about respiratory failure RIGHT NOW?

Answer 36

Pages 153-155 in the ATI book.

Question 37

Whats the difference between a water seal and a dry suction chest tube system?

Answer 37

Both: have three chambers - collection chamber, water seal (middle) chamber, and a wet suction control chamber.

Dry suction is quieter than traditional water seal, in wet suction intermittent bubbling means system is functioning properly.

Dry suction has an indicator that signifies suction pressure is good.

Tidaling is the increase in water level on inspiration and a decrease to baseline on expiration in a water seal system.

WATER NEEDS TO BE AT 2cm height!

Question 38

What the difference between an atrium ocean and oasis chest tube system?

Answer 38

Atrium ocean = water seal system, suction control is determined by height of water column in the chamber.

Atrium Oasis = dry suction water seal, mechanical regulator controls suction.

LOOK AT P. 527!!!!

Question 39

What about a disposable chest tube?

Answer 39

?

Question 40

Describe the setup and management of patients with a chest tube.

Answer 40

LOOK AT CHART 21-20 AND 21-21 starting on P. 524!!!

Question 41

What are some issues that can occur with a chest tube and how do you manage those complications?

Answer 41

Respiratory distress - treat underlying cause, always give oxygen, if respiratory failure intubate and mechanically ventilate if necessary.

Dysrhythmias - cause by hypoxia during procedure, antiarrhythmic medications.

Pulmonary infection or effusion -

Pneumothorax - air leak from surgical site, failure of chest tube, may also be a hemothorax… maintain the chest drainage system and monitor for signs… SOA, tachycardia, tachypneic, increasing respiratory distress.

Bronchopleural fistula - RARE, prevents return of negative intrathoracic pressure and inhibits lung re-expansion…. treated with closed chest drainage, mechanical ventilation, and possibly pleurodesis

Hemmorrhage or shock - treat underlying cause, whether it be by reoperation or blood products or fluids, overinfusion of fluids may cause pulmonary edema. look for symptoms early ones include: dyspnea, crackles, tachycardia, pink and frothy sputum. REPORT AND TREAT IMMEDIATELY.