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Critical Care Med Surg > Critical Care: Airway Management Notes > Flashcards

Critical Care: Airway Management Notes Flashcards

1
Q

What is the difference between a CPAP and BiPAP?

A

CPAP delivers continuous oxygen to the patient, increases work of breathing and used for OSA.
BiPAP has 2 functions: high inspiratory positive airway pressure and low expiratory positive airway pressure. It is used for COPD with HF, Acute Respiratory Failure, and sleep apnea

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2
Q

Endotracheal intubation (ET) indications

A 
Only used for short period of time
Upper Airway obstruction
Apnea
High risk of Aspiration
Ineffective secretion clearance
Respiratory distress
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3
Q

How do you set the patient up for intubation? Explain intubation process.

A

Obtain consent if not emergent
Have a self-inflated bag-valve-mask (BVM) attach to oxygen and suctioning nearby
Ensure patient has an IV access
Remove patient’s dentures or partial plates
Place patient in sniffling position - supine with head extended and neck flexed
Preoxygenate patient with BVM for 3-5 minutes or give rapid-sequence intubation (RSI) if emergent
Monitor O2 status
Intubate patient and confirm placement
Inflate the cuff
Connect ET tube to ventilator and secure it.
Obtain chest x-ray
Obtain ABGs 15-30 minutes after

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4
Q

How does a BVM or Ambu bag work?

A

The slower the bag is deflated and inflated, higher O2 concentration

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5
Q

How do you confirm ET tube placement during the intubation process?

A

EtCO2 detector - how much CO2 is expelled from the lungs. Should be consistent after 5-6 exhalations
Auscultate lungs for bilateral breath sounds and epigastrium for absence of air sounds
X-ray location is 2-6cm above carina

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6
Q

What is an Rapid-sequence intubation (RSI)?

A

Combination of sedatives and paralytic to make the patient unconscious for intubation.

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7
Q

How can you detect CO2 with end tidal CO2 (EtCO2) detector?

A

The color or number changes with more exhaled oxygen

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8
Q

What are the nursing responsibilities for patients with artificial airways?

A 
Maintain correct tube placement
Maintain proper cuff inflation 
Monitoring oxygenation and ventilation
Maintaining tube patency
Providing oral care and maintaining skin integrity
Provide comfort and communication
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9
Q

How do you maintain correct tube placement?

A

Mark where the tube is after intubation process and ensure it is in the same place. (21 cm for women, 23 cm for men)
Observe for chest wall symmetry and auscultate for bilateral lung sounds

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10
Q

What do you do if the tube was misplaced?

A

This is a MEDICAL EMERGENCY
Stay with patient and give oxygen via BVM and 100% O2
Call for help

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11
Q

How do you maintain cuff pressure?

A

20-25 cm H2O

Measure and record cuff pressure after intubation and on a routine basis (q8hrs).

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12
Q

How do you monitor for oxygenation and ventilation with ET?

A

Monitor ABGs, SpO2, ScvO2 or SVO2.
Assess for hypoxemia
Assess respiratory rate, depth, rhythm and use of accessory muscles
Monitor PaCO2 and PETCO2

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13
Q

Suctioning indications

A

When you can see secretions in the ET tube
Sudden onset of Respiratory distress
When you suspect patient is aspirating on their own secretions
Tachypnea or frequent coughing
SpO2 decreases
Peak airway pressure increases
Auscultated adventitious breath sounds

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14
Q

What is the difference between closed-suctioning technique (CST) or open-suctioning technique (OST)?

A

OST comes in a kit and requires a new single-use catheter every time.
CST is the most common choice and a catheter can be used multiple times within 24 hours. Additionally, oxygenation and ventilation are maintained during suctioning and decreases exposure to secretions.

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15
Q

What do you do when a patient can not tolerate suctioning?

A

Stop immediately

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16
Q

How do you prevent hypoxemia when suctioning?

A

Give patient a lot of oxygen before suctioning and after each suctioning pass.
Limit each pass to 10 seconds or less
Assess ECG and SpO2 before, during and after suctioning.

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17
Q

Tracheal damage signs and symptoms

A

Blood streaks or tissue shreds in secretions

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18
Q

How do you prevent tracheal damage?

A

Limit pressure to less than 120 mm Hg
Slow and adequate suctioning and catheter insertion
Assess secretions that are coming out
Notify HCP

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19
Q

How do you manage thick secretions?

A

Maintain adequate hydration and supplemental humidification
No saline instillation
Mobilize and turn patient every 2 hours
Antibiotics PRN

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20
Q

Why is oral care important?

A

The mouth is always open and dry.

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21
Q

What is RASS scale?

A

A medical scale to assess agitation and sedation in a patient.

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22
Q

Why is the RASS scale used for intubated patients?

A

They receive around the clock pain medications and you need to assess effectiveness.

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23
Q

What do you need to monitor in patients when giving sedatives?

A

Respiratory rate and oxygen saturation.

24
Q

BiPAP contraindications

A

Patients with shock, altered mental status, increased airway secretions

25
Q

What is the mechanism for negative pressure ventilation?

A

The ventilator pulls the chest wall outwards and reduces intrathoracic pressure. It allows for passive expiration.

26
Q

What is the mechanism for positive pressure ventilation (PPV)?

A

It utilizes volume ventilation (Vt) and pressure ventilation.
Ventilator pushes air into lungs during inspiration. and raises intrathoracic pressure.

27
Q

What is alarm fatigue and how do we prevent it?

A

Alarm fatigues are for the care team who got used to hearing unnecessary amount of alarms and causes them to delay their response.
Set alarms based on patient’s specific needs

28
Q

Positive End Expiratory Pressure (PEEP)

A

Positive pressure is applied during the expiration phase.
It increases lung volume, functional residual capacity (FRC) and oxygenation of the lungs.
FIO2 can be reduced
Pressure falls between 3-20 cm H2O.

29
Q

Nitric Oxide (NO)

A

Gaseous molecule that increases vasodilation.

Diagnostic tool for pulmonary HTN and to improve oxygenation during mechanical ventilation

30
Q

Prone Positioning

A

Repositioning patient onto their stomachs. face down.
Improves lung recruitment
Requires sedation
Used with severe ARDS

31
Q

Extracorporeal Membrane Oxygenation (ECMO)

A

Alternative form of pulmonary support for patient with severe respiratory failure.
Removes blood from patient, infuse O2, remove waste and put the blood back to patient
Requires systemic anticoagulation and time-limited intervention
Needs a specialists

32
Q

Cardiovascular complications of PPV (positive pressure ventilation)

A

Hypotension
Increased MAP
Negative hemodynamics
Hypovolemia and decreased venous tone

33
Q

Pulmonary complications of PPV (positive pressure ventilation)

A 
Barotrauma
Pneumothorax
Pneumomediastinum
Volutrauma
Alveolar Hypoventilation and Hyperventilation 
Ventricular-Associate Pneumonia (VAP)
34
Q

VAP clinical signs

A 
Occurs 48 hours or more after ET
Fever
High WBC
Purulent or odorous sputum
Crackles or Wheezes
Pulmonary infiltrates on xray
35
Q

Prevention of VAP

A

Hand wash before and after touching equipment
Wear gloves
Minimize sedation
Early exercise and mobilization
ET tubes with subglottic secretion drainage ports for patients likely to be intubated for more than 72 hours
HOB elevated 30-45 degrees
Oral care with chlorohexidine
No routine changes with patient’s ventricular circuit tubing.
Drain the water that collects in the ventilator tubing away from the patient as it collects.

36
Q

ABCDEF Bundle for psychosocial needs

A 
Assessment
Both SATs and SBTs are done
Choice of analgesia and sedation
Delirium prevention and management
Early mobility
Family engagement
37
Q

Before starting sedation or analgesia, what should the nurse do?

A

Identify cause of distress.

38
Q

When a neuromuscular blocking agent is administered, what are the nursing responsibilities?

A

Address patient as if they were awake and alert.
Assess Train of Four (TOF) peripheral nerve simulation
Observe for anxiety (Physiologic signs)
Ventilator synchrony

39
Q

Neurologic System Complications and how do you treat it?

A

With head injury, impaired cerebral blood flow
JVD
Increase ICP
Elevate HOB and keep head in alignment

40
Q

Sodium and Water Complications

A 
Fluid retention
Sodium retention
Decreased urine output
Decreased renal perfusion
ADH and cortisol release
41
Q

GI complications

A

Stress ulcers
GI bleeding
Gastric and bowel dilation
Constipation

42
Q

How do you prevent stress ulcers?

A

H2-receptor blockers, PPI, EN to decrease gastric acidity

PPI increases risk for C. diff infection

43
Q

Musculoskeletal complications

A

Contractures
Pressure injuries
Foot drop
Muscle wasting

44
Q

Nutritional Therapy

A

Do a nutritional assessment
Start EN within 24-48 hours of admission
Check serum proteins everyday
Limit carbohydrates

45
Q

How do you know if the patient is ready to be weaned off ventilator?

A

Patient is trying to breathe on their own
Using their respiratory muscles well
Stable O2 levels

46
Q

3 phases of weaning:

A

Preweaning
Weaning
Outcome

47
Q

Preweaning phase. How do you know if the patient is ready to be extubated?

A

Looks at patient’s ability to breathe spontaneously
Primary problem is solved
Clear lung sounds and chest xray
Assess muscle strength and endurance.
Minimal secretions in ET tube
Ability to cough and gagged
Assess neuro status, hemodynamics, fluid and electrolyte balances, nutrition, hemoglobin.

48
Q

Weaning phase

A

Assess SAT and SBT
SAT - stopping all sedatives
SBT - last 30-120 minutes, low levels of PEEP, PSV
or FIO2.
Use weaning protocol
Rest in between weaning
Comfortable sitting or semi recumbent position.
Obtain baseline v/s and respiratory parameters
Monitor for symptoms to end trial period.

49
Q

Outcome phase or Extubating process: How do you remove ET from the patient?

A

Hyperoxygenate and suction prior to extubation
Loosen ET tapes or commercial holder
Patient takes deep breath and peak inspiratory phase, deflate the ET tube cuff and remove
Encourage deep breathing and coughing
Assess vocalization
Give supplemental O2 PRN
Provide naso-oral care
Monitor v/s for one hour after extubation process.

50
Q

Norepinephrine IV

A

Vasoconstrictor that will increase heart and peripheral perfusion.
Increase SVR, HR, BP

51
Q

Interpreting ScvO2 and SvO2

A

Normal: 60-80%
High: 80-95%
Low: <60%

52
Q

What are some medications that can cause delirium?

A

sedatives (benzodiazepines)
Analgesics (opioids)
Vasopressors

53
Q

Common problems of Critical Care Problems

A 
Anxiety
Pain 
Impaired communication
Sleep
Sensory-Perceptual Problems
Nutrition
54
Q

Supporting caregivers

A

Provide information, communication and access
Recognize caregivers feelings, listen to them openly, acknowledge their decisions
Consult other team members as needed to help caregivers cope.
Prepare caregivers during their first visit
Be allowed to stay with patient undergoing treatment and procedures as long as both parties are willing.
Let them take part in patient’s care

55
Q

Alveolar Hyperventilation Causes

A

Respiratory rate or Vt is set too high or patient is hyperventilating
Spontaneous

56
Q

High Risk Factor patients for alveolar hyperventilation

A

COPD patients or those who have chronic alveolar hypoventilation and CO2 retention

57
Q

Main complication for alveolar hyperventilation

A

Respiratory alkalosis

Critical Care Med Surg (17 decks)

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