[Exam 3] Chapter 21 - Respiratory Care Modalities Flashcards
At sea level, concentration of O2 in RA is ?
21%
What is the goal of oxygen therapy?
To provide adequate transport of oxygen in the blood by decreasing the work of breathing and decreasing stress of myocardium
What factors affect oxygen transport?
- CO, how effective can heart deliver blood to body
- Arterial Oxygenation, how well are tissues recieivng blood
- Concentration of Hemoglobin.
What is Hypoxemia?
Decreased PaO2 , arterial oxygenation
What is Hypoxia?
Decrease O2 to tissue cells.
First symptom of Hypoxia?
Change in patients respiratory rate or pattern, as well as change in mental status.
What is Hypoxemic Hypoxia?
Decrease of O2 in the blood, which equals decreased O2 in the tissue.
What is circulatory Hypoxia?
Deals with heart. Inadequate circulation which leads to decreased CO, Shock, Arrest.
What is Anemic Hypoxia?
Decreased hemoglobin. Are not getting enough blood in the patients body.
What is Histotoxic Hypoxia?
Result of exposure to toxic substances which interferes with tissues ability to use available O2. Like Cyanide poisoning.
What is FiO2?
Fraction of inspired oxygen?
FiO2 at RA?
21%
Concentration of oxygen delivered when low?
> 35% Oxygen
Concentration of oxygen delivered when moderate?
35 - 60%
Concentration of oxygen delivered when high?
> 60%
If a patient is on 1L NC, how much total oxygen are they receiving?
24% oxygen
If a patient is on 2L NC, how much total oxygen are they receiving?
28% oxyen
What is the rule when adding oxygen from a NC?
Add 3% for first L, then 4% for any additional L.
How do BiPap or Mechanical Ventilators show how much oxygen someone is receiving?
In percentage of oxygen
What should you always remember about O2?
That it is a medication and you will always need an order
What type of devices use FiO2?
Mechanical Ventilator, Bipap, Oxymask O2 Setting
To be on a mechanical ventilator, what do you need to have
Endotracheal tube
Endotracheal Tube: This is usually inserted why?
Because the patient has respiratory failure
Endotracheal Tube: What is respiratory failure?
Sudden life-threatening deterioration of gas exchange , where patient loses appropriate function of lungs and they cannot provide oxygenated blood to meet needs of body.
Endotracheal Tube: What is respiratory failure defined as?
PaO2 < 50% (Hypoxemia)
CO2 > 50
Ph < 7.35
This is respiratory acidosis
Endotracheal Tube: You will see respiratory acidosis in what type of patient?
COPD patient, muscular disorders, patients who are hypoventilating due to overdose or CVA,
Endotracheal Tube: What are these also called?
ET, ETT,
Endotracheal Tube: What do these treat?
Respiratory failure , and provide a patient airway for patient that cannot protect themselves.
Endotracheal Tube: Where is this placed?
Goes through mouth, down through trachea and vocal cords, and sits above where bronchi split off.
Endotracheal Tube: What is the balloon that is located above the end of the tube?
It is called the cuff. Help secure the ET tube in place and helps prevent any secretions from going past it and into lungs.
Endotracheal Tube: How will this usually be placed?
With a laryngoscope. Helps visualize the vocal cords and gets the ET tube in place.
Endotracheal Tube: What should we check for in patient immediately after intubation?
Check symmetry of chest expansion. Monitor for signs of aspiration Secure tube to patients face with tape. Use sterile suction technique to prevent infection Reposition every 2 hours
Endotracheal Tube: What to do for patient when extubation? (removal of endotracheal tube)
Explain procedure.
Have self-inflating bag ready
Suction the tree, remove tape, then deflate cuff.
Give 100% oxygen for few breaths, then isnert new sterile catheter inside .
Have patient inhale. At peak inspiration, remove tube and suction airway through tube as its pulled out.
Endotracheal Tube: What care can be done to patient following extubation?
Give heated humidifity and oxygen by facemask
Monitor respiratory rate
Monitor patients oxygen level
Keep patient NPO.
Education on performing coughing and deep-breathing exercises.
Endotracheal Tube: What is the suctioning that patients require called?
In-Line suctioning, and will be hooked straight to ET tube.
Endotracheal Tube: What is In-Line suctioning connected to?
ET Tube that connects to suction canister.
Endotracheal Tube - Complications: Complications from a high cuff pressure?
Tracheal bleeding Ischemia Pressure Necrosis Vocal Cord Paralysis Harder to get patient exbutated because they breathe through tube.
Endotracheal Tube - Complications: How long can ET tubes be used for?
14-21 days because of irritation and trauma that can be caused to trachea.
Endotracheal Tube - Complications: Complications from low cuff pressure?
Aspiration Pneumonia, because fluid is getting into lungs.
Endotracheal Tube - Complications: What is usually done to prevent patients from pulling out tube?
Making sure that they are sedated and restrained.
Endotracheal Tube - Complications: What should be done when they are restrained?
Education to family member as to why they are restrained.
Tracheostomy Tube: What is given once the patients get to the 14-21 day mark?
They are switched to a tracheostomy tube.
Tracheostomy Tube: what is this?
An opening made into the trachea and these tubes can be placed permanently or temporarily. Gives patient more time to try to get off of ventilator.
Tracheostomy Tube: What are the two different types?
Fenestrated Tube: Have one piece coming off and allows patient to talk
Double-Cuffed Tube - inflating two cuffs alternately help prevent tracheal damage
Tracheostomy Tube: Main difference between this and ET tube?
How much shorter the canula is
Tracheostomy Tube: Patients who have this long-term will be more likely to get which type?
The double-cuffed tube. To prevent long-term tracheal damage.
Tracheostomy Tube: Who would get this?
A patient who needs to be on a ventilator long-term, paralyzed and breathing affected.
Tracheostomy Tube: Biggest complication?
Mucous plugs. So you want to make sure they are suctioned properly. Pay attention and listen for adventitious sounds.
Tracheostomy Tube: What other problems can occur?
Tracheal-Esophageal Fistula. You get an opening between the different layers of the trachea that are not supposed to be there
Tracheostomy Tube - Nursing Management: How to prevent complications?
Administer adequte warmed humidifty.
Maintain cuff pressure at approrpaite level
suction as needed.
Ausculate lung sounds.
Monitor for cyanosis
Maintain adequate hydration
Use sterile technique when suctioning
Tracheostomy Tube - Nursing Management: When will trachea ties need to be changed?
When they are soiled
Tracheostomy Tube - Nursing Management: When are gauze changed?
When they are soiled or per unit policy, such as once per shift
Tracheostomy Tube - Nursing Management: What is used to clean the trachea area?
You use sterile water, sterile saline.
Tracheostomy Tube - Nursing Management: What specific nursing assessments will need to be done?
Checking for lung sounds, chest-xray, make sure patient positioned in semi-fowlers.
Tracheostomy Tube - Nursing Management: If suctioning not connected to in-line, what needs to be done?
Maintaining sterile technique when suctioning. Useful to have extra trachea at bedside to help replace it.
Nursing Diagnosis - Pts with ET Intubation or Tracheostomy: What to do for communication?
You want to have a pen and paper available
Nursing Diagnosis - Pts with ET Intubation or Tracheostomy: Which patient will have more communication issues?
Patients that are trached.
Nursing Diagnosis - Pts with ET Intubation or Tracheostomy: What are Passy Mirror valves?
Help trache patients with speech and decreases aspiration, helps with swallowing,
Nursing Diagnosis - Pts with ET Intubation or Tracheostomy: What must you make sure you do if Passy Mirror valve is used?
Make sure that the cuff has been deflated. This can issues with not getting adequate oxygen
Nursing Diagnosis - Pts with ET Intubation or Tracheostomy: What Diagnosis may we use?
Anxiety, Knowledge Deficit, and Ineffective Airway Clearance.
Nursing Diagnosis - Pts with ET Intubation or Tracheostomy: When is ineffective airway clearance a problem?
When proper airway suctioning is not done.
Nursing Diagnosis - Pts with ET Intubation or Tracheostomy: How to prevent VAP (Ventilated Associated Pneumonia)
Oral care every 2 hours, suction patient when you hear adventitious sounds, and keep HOB elevated
Nursing Diagnosis - Pts with ET Intubation or Tracheostomy: How to prevent infections with trach care?
Make sure you suction trachea, provide oral care and make sure its not dry, and make sure trach site is clean.
Mechanical Ventilation: What is this?
Positive or negative pressure breathing device to maintain ventilation or oxygenation
Mechanical Ventilation: Why would this be used?
For compromised airway or something thats caused acute respiratory failure
Mechanical Ventilation: Example of negative pressure device?
Iron lung
Ventilators: Which ones should we know about?
BiPap/CPap.
Ventilators: How do positive pressure ventilators work?
During inspiration, push air in that will inflate lungs. Expiration happens passively.
Ventilator Modes: What are these modes used to describe?
How the breaths are being delivered to the patients.
Ventilator Modes - Continuous Mandatory Ventilation (CMV): What is this?
This is full ventilator support. Giving a pre-set determine volume of air, respiration’s are set, ventilator is doing all breathing for patient.
Ventilator Modes: Assist Control (A/C) is similar to what?
Continuous Mandatory Ventilaiton (CMV)
Ventilator Modes: How does A/C differ from CMV?
Patient is able to initiate their own breath. Depending on how big patient can take breath, ventilator may give an assist.
Ventilator Modes: What is Synchronized Intermittent Mandatory Ventilation (SIMV)?
This is a combo of assisted breath and spontaneous breaths.
Ventilator Modes: When would SIMV be initiated?
When the physician orders to back off the ventilator support.
Ventilator Modes: What is Pressure Support Volume (PSV)?
Patient is doing a lot of work of breathing by themselves, but ventilator is providing some pressure to keep alveoli open.
Ventilator Settings - Ventilator Mode: What is this usually set to
Unless patient is starting to be weaned, this will be CMV, or Assist Control
Ventilator Settings - Ventilator Mode: You want to see if this is doing what for patient?
All the work for the patient or if they are starting to be weaned off of it
Ventilator Settings - Tidal Volume: What is this?
How much of volume is the vent putting into the lungs
Ventilator Settings - Tidal Volume: How is this calculated?
By weight. 10-15 mils x kg of the patient
Ventilator Settings - Tidal Volume: How much is given if patient is 70 kg?
70 x 10-15 = 700 for the tidal volume.
Ventilator Settings - Respiratory Rate: THis is set depending on what
What is going on with patient. If acidosis , will be set on higher ventilator rate
Ventilator Settings - Peep: What is this
Positive End Expiratory Pressure, helps increase functional residual capacity. Helps open up alveoli and prevent collapse of aveoli.
Ventilator Settings - Peep: Why is keeping the alveoli open important?
Helps improve gas exchange and improve O2 and getting CO2 levels within appropriate level
Ventilator Settings - Peep: What is the problem with PEEP?
As PEEP goes up, it increases pressure within thoracic cavity. Heart can have more pressure pushing against it. Will result in decreased blood pressure.
Ventilator Settings - FiO2: What is this
How much oxygen the patient is getting. The percentage of oxygen.
Ventilator Settings - Peep: What is the lowest PEEP we will see on a ventilator?
5
Ventilator Settings - Peep: This is usually in what range?
5-15
Ventilator Settings - Peep: What happesn when you get above 15
You see issues with baro trauma within lungs. So much pressure can be caused that can cause them to have a pneumothorax and collapse part of lung.
Noninvasive Positive-Pressure Ventilation: What does this usually include?
Continuous Positive Airway Pressure (CPAP) or Bi-Level Positive Airway Pressure (bi-PAP)
Noninvasive Positive-Pressure Ventilation: Definition for these types of ventilators?
Use of a mask or other device to maintain a seal and permit ventilation
Noninvasive Positive-Pressure Ventilation: CPAP is usually for who
Sleep Apnea,
Noninvasive Positive-Pressure Ventilation: How does a bi-PAP work?
Instead of airway being open by continuous air, gives a certain pressure on inspiration and another pressure on expiration.
Noninvasive Positive-Pressure Ventilation: What type of patient would use Bi-PAP?
Those with COPD, usually at night. Sometimes those with HF, as it eases breathing and enhances gas exchange. Pulmonary Edema too.
Noninvasive Positive-Pressure Ventilation: How does bi-PAP help with pulmonary edema?
Helps open the alveoli and push the fluid out of there. Lasix may also be prescribed.
Noninvasive Positive-Pressure Ventilation: What must you be careful of with bi-PAP?
Putting a patient on bi-PAP if they have AMS. They may start retaining CO2 because they don’t accept t`he inflow of air.
Nursing Process - Care of Patients Who Are Mechanically Ventilated, Assessment: What will we want to assess?
Lung sounds, check on patient’s mental status, see if they can squeeze fingers, check pupils, spontaneous breathing trials where it may be paused,
Nursing Process - Care of Patients Who Are Mechanically Ventilated, Assessment: Path of a nasogastric tube?
Goes through the nose and into the stomahc
Nursing Process - Care of Patients Who Are Mechanically Ventilated, Assessment: Path of endotracheal tube?
Goes through mouth and into windpipe
Nursing Process - Care of Patients Who Are Mechanically Ventilated, Assessment: How does mechanical ventilator work?
Blows air or air with increased oxygen, through tubes into patients airways
Nursing Process - Care of Patients Who Are Mechanically Ventilated, Assessment: What does air flowing to patient pass through?
Humidifier that warms, moistens air
Nursing Process - Care of Patients Who Are Mechanically Ventilated, Diagnosis: Biggest ones?
Impaired Gas Exchange, because they have respiratory failure.
Ineffective Airway Clearance
RF Trauma R/T ET Tube
Impaired Verbal Communication
Impaired Physical Mobility
Nursing Process - Care of Patients Who Are Mechanically Ventilated, Interventions: What should we do?
Make sure you do respiratory assessment, HOB > 30 , ABGs, and must be in constant communication with respiratory therapist, suction tube
Nursing Process - Care of Patients Who Are Mechanically Ventilated, Interventions: Why must you be in contact communication with respiratory therapist?
Nurses care for patient, but RT is the person who actually managed the ventilator.
Nursing Process - Care of Patients Who Are Mechanically Ventilated, Interventions: What is Bucking the Vent?
When the patient starts to fight the ventilator, like coughing
Nursing Process - Care of Patients Who Are Mechanically Ventilated, Interventions: What should be done when patient is Bucking the Ventilator?
We should get the Ambu-Bag to properly oxygenate them and make sure they are getting the oxygen they need.
Nursing Process - Care of Patients Who Are Mechanically Ventilated, Interventions: What complications should be prevented?
Prevent infections, prevent BAP, Prevent pressure ulcers.
Nursing Process - Care of Patients Who Are Mechanically Ventilated, Interventions: What is the main goal for the patient?
Making sure that they have optimal gas exchange, improving comfort, and making sure they have no infections
Care of Patients Who Are Mechanically Ventilated, Collaborative Problems: What happens with alterations in cardiac function?
You have decreased CO R/T increased PEEP.
Care of Patients Who Are Mechanically Ventilated, Collaborative Problems: Why is Barotrauma seen?
Because of the increased PEEP, which can cause a pneumothorax.
Care of Patients Who Are Mechanically Ventilated, Collaborative Problems: Why is keeping the PEEP working properly importnt?
Because you want to ensure that the alveoli are kept open and that they are receiving the proper O2 and gas exchange
Care of Patients Who Are Mechanically Ventilated, Collaborative Problems: What to know for pulmonary infection?
This is a Ventilated Assocaited Pneumonia (VAP). Want to do oral care, suctioning, HOB > 30.
Care of Patients Who Are Mechanically Ventilated, Collaborative Problems: What to know for sepsis?
Related to VAP, Want to make sure we prevent all types of infection.
Weaning: What will the goal always be for these types of patients?
Getting them off of the ventilator.
Weaning: What is weaning?
A three step process. Remove vent, remove ET tube and trach, and then eventually remove the O2
Weaning: What steps will be taken when attempting to Wean?
Start with CMV Mode, and then SIMV pressure support so patient can take breaths on their own and are capable of doing so.
Weaning: What is the second step in the process?
Removing the ET Tube and Trach. Once removed, patient is usually placed on NC or Oxy-Mask.
Weaning: What is the third step in the process?
Eventually taking the patient off of oxygen so that they are able to breathe on RA.
Weaning: WHo is involved in this collaborative process?
Primary Physician like Pulmonologist or Critical Care DOc, RT, and RN.
Weaning: What should you make sure of when patient is being weaned?
Check their HR and is sitting at acceptable level. Don’t want tachy. Don’t want dysrhythmias.
Monitor O2 sat, don’t want it to drop. > 90%.
Respiration > 8 but < 20 .
Weaning: How long will you stick with this patient?
For 20-30 minutes to ensure that they are okay. Then check on them every 5-10 minutes.
What Lab Values indicate Mechanical Ventillation is necessary?
PaO2 < 55
PaCO2 > 50 and pH < 7. 32
Clinical manifesations showing a need for mechanical ventilation?
Apnea or BRadypnea
Respiratory Distress with Confusion
Confusion with need for airway protection
Weaning: Lab values necessary for weaning patient off?
VC MIP TV Minute Ventilation Rapid/Shallow Breathing Index
Vital Capacity: 10-15 mL/kg MIP : At least -20 cm TV: 7-9 mL/kg Minute Ventilation: 6L/min Rapid/Shallow BreathingIndex: Below 100 breaths/min
Weaning - Patient Preparation: What must be done for patient?
They must be stable, and make sure they have enough strength before they are weaned.
Weaning - Methods of Weaning?:
Pressure of Port Trials, the Daily Spontaneous Breathing Trial, Sedation Vacation,
Weaning - Methods of Weaning?: What to know for ABG levels?
They should always be within normal limits before we try to exubate a patient.
