Exam 4 Flashcards
what is IS?
- Incentive Spirometry: one form of lung expansion therapy (also IS or SMI)
- SMI: Sustained maximal inspiratory effort
- improves pulmonary function by maximizing alveolar recruitment and optimal airway clearance
- It works by increasing the transpulmonary pressure gradient (Ptp)
- Ptp: is the difference between the alveolar pressure (Palv) and the pleural
pressure (Ppl) - When Ptp pressure increases -> more alveoli expand
- We do this in one of two ways:
o Decreasing the Ppl
o Increasing the Palv
Spontaneous deep inspiration increases the Ptp gradient by decreasing the Ppl
Other lung expansion therapies apply positive pressure, which can lead to other complications – that’s why incentive spirometry is a great option!
when do we use IS?
- Measurable goal for IS is to have a VC of 10 mL per 1 kg of IBW
- IS is cheap and takes little time – staff must be knowledgeable
- Must have a normal MV which means we need the RR to be less than 25 bpm
- Minimal risk patients usually do well with just breathing exercises, frequent repositioning and early ambulation… but out high-risk patients need IS
- Purpose is to coach the patient to take a Sustained Maximal Inspiratory effort
(SMI)
how do we administrate IS?
Planning:
- Identify high risk patients
- Get doctor’s order
- Gather equipment
- Set goal
Implementation:
- Place in fowlers position
- Patient assessment (VS and BS)
- Instructions on how and how often
- Encouragement is very important
Follow Up:
- Patient reassessment (VS and BS)
- Monitor patient’s performance
Chart:
- Date and time
- Patient assessment pre and post
- Volume
- Cough and sputum
- Patient cooperation
what complications could Thoracic or abdominal surgery can cause?
- Pneumonia
- Acute Respiratory failure
- Atelectasis- alveolar collapse
**The solution to these problems is LUNG EXPANSION THERAPY…
what are other lung therapies?
- Deep breathing/ cough
- CPAP (continuous positive airway pressure)
- PEP (positive expiratory pressure)
- IPPB (intermittent positive pressure breathing)
- Early patient mobility
Atelectasis is AKA as volume lost
seen on an x-ray as a white spot
what are the types of ATELECTASIS?
- Gas absorption
- Compression- something is pressing
what is gas absorption?
- this can occur either when there is a complete interruption of ventilation to a section of the lung or when there is a significant shift in ventilation
- Gas distal to an obstruction is absorbed by blood passing through the pulmonary capillaries
- This causes partial collapse of the nonventilated alveoli
- In a larger airway or bronchus, lobar atelectasis develops (a total lobe is affected)
what is compression atelectasis?
- this occurs when the transthoracic pressure exceeds the trans alveolar pressure
- (OUTSIDE pressure exceeds the INSIDE pressure)
- Pressure between body surface area and the alveoli > Pressure difference between alveoli and pleural
space
what can cause compression atelectasis?
- General anesthesia
- Sedatives and bed rest
- Painful deep breaths (avoidance of deep breaths)
- Weak diaphragm or impairment
- Fluid overload
- Excessive secretions with low tidal volume
what patients have an increased chance of Atelectasis?
* The closer the incision to the diaphragm, the greater the risk for atelectasis*
- Obesity
- Neuromuscular disorders
- COPD patients
- Age
- Smoking history
- Heavy sedation – too little pain meds
- Abdominal or thoracic surgery
what are the Clinical Signs of Atelectasis
- Being aware of risk factors
- Increased RR (the worse the atelectasis, the higher the RR) (PaO2 goes up, RR
goes up) - Fine late inspiratory crackles BS (sudden opening of the distal airways)
o The more atelectasis becomes present, the less likely this will occur - Bronchial BS (when patient is completely occluded -consolidated with more
atelectasis) - Diminished BS (excessive secretions blocking the airway)
- Tachycardia (hypoxemic)
- Chest X-Rays
what are some other breathing exercises?
- Pursed lip breathing
- Diaphragmatic breathing
- Segmental breathing
what is pursed lip breathing ?
Patient exhales through their lips while held in a whistling position
what is diaphragmatic breathing?
- Patient places their hand on their chest below the xiphoid process
- Hand lifts on inhale and lowers on exhale
what is segmental breathing?
- Hand is placed on chest where the focus of breath is desired
- Hand moves outward on inspiration
what is Electronic Medical Record (EMR) ?
– changed the way RTs document care
- The record for a patient’s admission or event can be found in the EMR. The sum
of all EMRs of a patient can be found in the patient’s electronic health records, or EHR.
what is Computerized Physician Order Entry (CPOE)?
- how we receive our orders
- prevent and eliminate medical errors.
- improves accuracy and communication of physician’s orders.
what are the General Sections Found in a Patient Medical Record?
- Admission data and diagnosis and admitting dr.
- History and physical exam (also progress notes and plan of care)
- Nurse’s notes
- Health maintenance and immunizations
- Allergies
- VS flowsheet
- Input and output sheet- patient’s fluid intake and output over time
- Lab results
- Consultation notes
- Surgical or treatment consent
- Anesthesia and surgical record
- Specialized therapy records and progress notes (ex: respiratory care)
- Specialized flow data- records made over time during specialized procedures
- Advanced directives- living will, power of attorney, etc.
- Medication record- drugs and IV given to patient
o EMAR (Electronic Medication Administration Record)
what are the rules for charting?
- Only edit, CANNOT erase
- Accurately summarize data
o Subjective data (patient’s feelings)
o Past and current data (objective info – vitals and BS)
o Assessment data (professionals conclusion about presented data)
o Therapy given
o Patient’s response
o Treatment plans - Analyze and Assess data
- WHEN IN DOUBT, CHART
- Do not leave blank lines
- Use standard abbreviations only
- Use proper spelling
- Use present tense
- Be accurate, clear and concise
- Document all important conversations
what is SBAR?
used frequently by us in the clinical setting to document everything.
what is an aerosol?
- Suspension of solid or liquid particles in gas
- We deliver meds but smog, fog, pollen, dust, smoke etc. are also aerosols
what is the output of aerosols?
- the amount of emitted dose leaving the mouthpiece of a nebulizer
- A large portion of this output will never reach the patient’s lungs
- It depends on the patient’s breathing pattern and the particle size
what are the particle sizes and how are they measured?
Measured by MMAD
- 5 - >50 microns (upper airway)
- (2-5 for lower airway)
- (1-3 microns (alveolar sacs)
what is deposition?
- not all aerosol particles delivered to the lungs are deposited
- A small part may be exhaled, those that are deposited in the respiratory tract depend
on: - Size
- Shape
- Motion of the particles
- Physical characteristics of the airway
- Breathing pattern
o Inspiratory flow rate
o Flow pattern
o Inspiratory to expiratory flow rate
o Tidal volume
o RR
o Breath hold
what does the deposition of an aerosol depend on?
- Inertial impaction
- Gravimetric sedimentation
- Brownian diffusion
what is Inertial impaction?
- the theory behind the larger particles
o Suspended particles in motion collide with and are deposited on a surface
o Main deposition for particles larger than 5 micrometers
what is brownian diffusion?
- smaller particles (less than 3 micrometers)
- They have a very low mass, so they easily bounce around by collisions with gas molecules
- Smaller particles (.5-1 micrometers) remain suspended and have greater retention in the lungs
what is gravimetric sedimentation?
- Main deposition for particles 1-5 micrometers (when patient is breathing normally)
- Larger particles settle faster (due to gravity)
- Breath holding after inhalation of an aerosol increases the residence time for the particles in the lungs and enhances distribution
- 10 second breath hold can increase deposition by 10%
what happens to an aerosol over time ?
- particles grow, shrink, combine and fall out of suspension over time
what are the aerosol delivery devices?
- MDI
o Pressurized metered dose inhalers (pMDI)
o Breath actuated pressurized MDIs - DPI
- Hand-bulb Atomizer
- Nebulizers
o Ultrasonic
o Vibrating Mesh
o LVN (pneumatic jet)
o SVN (pneumatic jet)
what is an MDI and what is its particle size?
- 2-6 micrometers, initial velocity 80% deposited in the oropharynx
- If used with a spacer or holding chamber reduce oral deposition by 90-99%
what is a DPI and what is its particle size?
- particle size of the drug is 1-3 m, but the size of the carrier substance is 20-65 m
- This leaves 80% of the carrier deposited in the oropharynx
what is a hand-bulb atomizer and what is its particle size?
- nasal spray pump (5-40 m)
Atrovent, Flonase, Saline Spray
what is a ultrasonic nebulizer?
- uses a piezoelectric crystal to generate an aerosol
MMAD 2.5- 6 m
Usually a cool mist
Quiet, no compressed gas, no direct flow is given to the patient, continuous mist
what is a vibrating mesh nebulizer?
- dome shaped plate connected to a piezoelectric element
- MMAD 3-4 m
- Electric energy is applied to piezoelectric that vibrates at high frequency
- Plate moves up and down creating a micropump
- Plate actively pumps the liquid and breaks it into droplets
what is an LVN?
- Continuous Nebulizers (when the patient is not responding to frequent breathing treatments, and they need that longer period of time of treatment)
- MMAD 2.2-3.5 m
- Bland aerosol
- HEART- high-output extended aerosol respiratory therapy neb (1-2 hours albuterol)
- HOPE
- SPAG (small particle aerosol generator)- delivery of Ribavirin for RSV
o Main problem with SPAG is that caregivers are exposed to the med
what is a SVN?
- Main way to deliver respiratory meds in acute care
- Medication is converted to an aerosol
- MMAD 1-5 m
what are the 4 types of SVNs?
- Continuous neb with simple reservoir
- Continuous neb with collection bag
- Breath-enhanced neb
- Breath-actuated neb
how do we create an aerosol?
- Powered by a high-pressure stream of gas directed through a restricted orifice
- The gas stream leaving the jet passes by the opening of the capillary tube immersed in the medication
- The high jet velocity draws the liquid up the capillary tube and into the gas stream and it becomes a spray
- This spray is directed against one or more baffles and reduces the particle size
what are the factors that effect the nebulizers performance?
- Nebulizer design (what device?)
- Flow -> the higher the flow, the smaller the particle size, the shorter the treatment
- Gas Source
- Density -> the lighter the gas, the greater flow needed to generate the same
output - Humidity and Temp -> cool and dry (smaller particle), warm (larger and
saturated) - Characteristics of the drug (Mucomyst – harder to nebulize)
what are the indications for a SVN?
- Adventitious BS
o Stridor (Racemic epinephrine in upper airway)
o Wheezing (albuterol in lower airway)
o Coarse crackles (Mucolytic) - Increased respiratory effort (change in breathing pattern)
- Signs of hypoxemia (increased HR, decreased SpO2)
- Decreased peak flow rate
WE MUST assess our patients before and after treatment: - HR (are they having an adverse reaction?)
- SpO2 (is there an improvement?)
- BS
- Change in peak flow (20%)
- Patient’s reaction (how do you feel after that treatment?)
what are the hazards for a. SVN?
- Most common is drug reaction
- Infection
- Airway reactivity – bronchospasm from cool air or Mucomyst
- Drug concentration
- Eye irritation (anticholinergics- Atrovent- ipratropium bromide)
- Secondhand exposure to aerosol drugs
what do we do if a med is asked to be given but it is not a normal drug?
we should avoid this. If the physician is asking you to do this, make sure you are backed by
an institutional policy that says this is okay.
what happens during continuous nebulization?
- Continuous nebulization of bronchodilators is approved for 5-20 mg/hour in adults and peds with severe asthma.
- they need to be assessed every 30 minutes for the first 2 hours and then hourly.
- If the patient has a positive response to this, we need to discontinue.
what happens to the deposition when a child is crying during an aerosol treatment?
- greatly reduces lower airway deposition and therefore should not be administered to a crying child.
- Can use a mask “blow by”
technique, but the inhaled med is greatly reduced
what is PEFR and what are the levels?
- Peak Expiratory Flow Rate
- Coaching is important
- Important assessment of airflow obstruction
o Airway inflammation
o Bronchial hyperreactivity - Green is >80%
- Mild is closer to 65-80%
- Moderate is 50-65%
- Severe is < 50%
