Gas Exchange: ARDS Flashcards
How to determine proper placement of tracheostomy tube
Chest X-ray
Immediate post-op care for tracheostomy
Ensure airway,
Confirm bilateral breath sounds,
Resp assessment Q 2hr,
Assess for complications
Complications after tracheostomy
Tube obstruction, Dislodgement and accidental decannulation, Pneumothorax, Subcutaneous emphysema, Bleeding, Infection
S/S of Tracheostomy tube obstruction
Difficulty breathing, Noisy respirations, Difficulty inserting suction catheter, Thick, dry secretions, Unexplained peak pressures (w/ mech. Vent.)
Prevention of tracheostomy tube obstruction
Assess at least hourly for patency, Prevent obstruction by having pt cough & deep breathe, Provide inner cannula care, Humidify O2 source, Suction as needed
How to prevent trach tube dislodgement and decannulation
Secure tube in place
(If happens in 1st 72 hrs is emergency),
Trach tube replacement of same size or one size smaller should be at bedside along with trach insertion tray
Assess for subcutaneous emphysema in pt with Tracheostomy
Inspect and palpate for air under the skin (crepitus)
Assess for bleeding in pt with new tracheostomy
Small amounts are normal; constant oozing is not,
Wrap gauze around tube and pack into the wound to apply pressure to bleeding sites
Infection prevention for tracheostomy tubes
Use sterile technique during suctioning and trach care,
Assess stoma for s/s of infection,
Use stoma dressings to keep clean & dry,
General careful wound care
Tissue damage prevention for tracheostomy pt
Keep cuff pressure between 14-20 mm Hg or 20-30 cm H2O,
Check pressure once per shift
Other issues for potential tissue damage in pt with trach
Malnourished, Dehydrated, Hypoxia, Older, Receiving corticosteroids, Tube friction and movement
Reduce tracheostomy tissue damage
Maintain proper cuff pressure, Stabilize tube, Suction only PRN, Prevent and treat malnutrition, dehydration, and hypoxia, Humidify the air
Practices for suctioning pts with artificial airway
Assess need, Check suction source; pressure should be between 80-120 mm Hg, Set up sterile field, Preoxygenate pt for 30 sec-3 min, Insert catheter until resistance, Withdraw over 10-15 sec with int suction, Hyper oxygenate 1-5 min to pt baseline, Repeat PRN up to 3 times, Suction mouth and provide mouth care, Document secretions and pt response
When to suction tracheostomy pt
Secretions are audible or noisy, Crackles or wheezes are heard on auscultation, Increased pulse or resp rates, Mucus in artificial airway, Pt request, Increase in peak airway pressure
Prevent hypoxia when suctioning tracheostomy pt
Hyperoxygenate pt with 100% O2
Prevent tissue trauma from frequent suctioning of trach pt
Suction only as needed, Lubricate catheter, Apply suction only during withdrawal, Use twirling motion during withdrawal, Use intermittent suction for 10-15 sec only, Use sterile technique, Suction mouth AFTER airway
Tracheostomy care
Wash hands; don PPE,
Suction if needed,
Remove old dressings and excess secretions,
Set up sterile field,
Remove and clean inner cannula or replace it,
Clean stoma site,
Change trach ties (secure new in place before removing old),
Document secretions, stoma, surrounding skin, pt response, and teaching/learning
Oral hygiene
Use sponge tooth cleaner or Soft bristled toothbrush moistened in water, Help pt rinse with NS Q4 while awake, Examine mouth for sores or dental probs, Apply lip-balm
Prevent aspiration in pt with trach
Avoid meals when pt fatigued,
Provide smaller more frequent meals,
Don’t hurry the pt,
Provide close supervision if pt is self-feeding,
Keep emergency suction equip nearby and ready,
Avoid thin liquids; thicken liquids,
Position pt as upright as possible,
Partially or completely deflate cuff during meals as tol,
Suction after cuff deflation to clear airway,
Encourage to eat slowly and dry swallow,
Avoid consecutive swallows of liquids,
Teach to tuck chin and move forehead forward while swallowing,
Pt controls next bite,
Monitor resp status,
HOB elevated for >30 min
Promote communication for trach pt
Writing tablet, Magic slate, Communication board, Flash cards, Hand signals, Computer, "Yes" or "no" questions
Promote psychosocial needs of pt with trach
Allow time for communication,
Set realistic goals,
Promote self-care,
Provide encouragement & positive reinforcement,
Provide acceptance & caring behaviors,
Assess for need for counseling
Discharge needs/teaching for trach pt
Care for trach tube,
Clean suction technique,
Use shower shield over trach tube when bathing,
Cover airway lightly with cotton cloth to protect during the day,
Increase humidity in the home,
Use communication method that began in hosp,
Wear Med Alert bracelet identifying inability to speak,
Provide outside referrals as needed
Priority problems for pt’s requiring tracheostomy
Reduced oxygenation, Inadequate communication, Inadequate nutrition, Potential for infection, Damaged oral mucosa
How to prevent VAP
“Ventilator Bundle”:
Hand hygiene,
Oral care,
HOB elevation
ARDS is acute respiratory failure with:
Hypoxemia persisting with 100% O2, Decreased pulmonary compliance, Dyspnea, Noncardiac associated bilat pulmonary edema, Dense pulmonary infiltrates on XR
What is associated with ARDS?
Occurs after acute lung injury such as: Sepsis, Pulmonary embolism, Shock, Aspiration, Inhalation injury, History of hyper-inflammatory response, Severe neurological damage, Fluid leads to alveolar collapse, Unresponsive to oxygenation
Direct lung injury causes of ARDS
Aspiration of acidic gastric contents, Lung radiation, Submersion in water with aspiration, Inhalation of toxic gases, Trauma, Sepsis, Drowning, Burns, DIC
Prevention of ARDS
Early recognition of pts at high risk for the syndrome,
Monitor those at risk for aspiration,
Follow meticulous infection control
Diagnostic of ARDS
ABG that shows lowered partial pressure of arterial O2,
Diffuse haziness of lung on X-RAY,
Hemodynamic monitoring with pulmonary artery catheter,
Respiratory acidosis
Interventions for ARDS
Intubation, Conventional mechanical ventilation with PEEP, Sedation and paralysis may be needed, Corticosteroids, Antibiotics, Conservative fluid therapy, Enteral or parenteral nutrition
Tension pneumothorax
Can be side effect of PEEP, Can occur from trauma, Absence of breath sounds on one side, Asymmetry of thorax, Tracheal movement away from midline, Distended neck veins, Hypotension, Hypertympanic sound to percussion, Assess lung sounds hourly, Suction PRN
ARDS phase 1
Dyspnea & tachypnea,
Support the pt and provide O2
ARDS phase 2
Increasing pulmonary edema,
Use mechanical ventilation and prevention of complications
ARDS phase 3
Days 2-10: Pt has increasing hypoxemia, Deliver adequate O2, Prevent complications, Support lungs
ARDS phase 4
Pulmonary fibrosis with progression, Irreversible, Permanent lung damage, Prevent sepsis, pneumonia, and multi-organ dysfunction syndrome (MODS), Wean pt from vent
Mechanical ventilation
Temporary life-support technique,
May be life-long,
Most often used for hypoxemia and progressive alveolar hypo ventilation with resp acidosis,
Pts who need vent support after surgery,
Pts who expend too much energy with breathing,
Pts who have general anesthesia or heavy sedation
Endotracheal intubation
Artificial airway,
Short term basis,
Passed through nose or mouth into trachea,
Tip of tube rests 2 cm above the carina,
Usually performed as emergency,
Pt cannot talk due to inflated cuff at distal end
Purpose of intubation
Maintain patent airway,
Provide means to remove secretions,
Provide ventilation and oxygen
Nurse actions during intubation
Coordinates response,
Monitors for changes in VS,
Monitors for signs of hypoxemia, aspiration, and dysrhythmias,
Ensures no attempt lasts longer than 30 sec,
Provides oxygen between attempts,
Suctions PRN
Verification of E-tube placement
End-tidal CO2 levels, Chest X-ray, Assess breath sounds, Assess symmetrical chest movement, Assess air moving out of ET tube, If abdomen is distended, tube is in esophagus
Nursing care for ET tube
Tube placement, Cuff leak, Chest wall movement, Prevent dislodgment, Respiratory status, pulse ox, ABGs, Check vent settings Q8, Check alarms, Observe PEEP setting, Empty vent tubing, Check delivered air temp (humidity), Suction PRN, Assess mouth PRN perform care Q2, Change tape PRN, Assess for GI distress, Monitor I&O, Turn pt Q2, Schedule care for rest intervals, Monitor progress, Monitor for adverse effects, Monitor readiness to wean, Provide method of communication
Types of ventilators
Pressure-cycled,
Time-cycled,
Volume-cycled,
Microprocessor
Modes of ventilators:
Assist-control (AC)
Used as a resting mode;
Vent takes over as needed;
Responds to inspiratory effort and delivers tidal volume while pt allows rate
Modes of ventilators:
Synchronized intermittent mandatory ventilation (SIMV)
Allows spontaneous breathing at the pts rate and tidal volume between breaths
Ventilator modes:
Bi-level positive airway pressure (BiPAP)
Noninvasive pressure support ventilation by nasal mask or face mask
Modes of ventilators:
Peak airway pressure (PIP)
Pressure used by the ventilator to deliver a set tidal volume at a given lung compliance
Modes of ventilators:
Continuous positive airway pressure (CPAP)
Applies positive airway pressure throughout resp cycle for spontaneously breathing pts
Modes of ventilators:
Positive end expiratory pressure (PEEP)
Indicates severe gas exchange problem
Prevents alveoli from collapsing because it keeps the lungs partially inflated
Nursing management
Address concerns of pt and family;
Explain the purpose of vent;
Encourage pt and family to express concerns;
“ICU psychosis” pt needs frequent repeated explanations and reassurance;
Be concerned with pt first and vent second;
Understand any chronic health problems
Monitor pt response
Assess vs; Listen to breath sounds every 30-60 min; Monitor resp parameters; Check ABGs; Assess breathing pattern and breath sound r/t vent cycle; Determine need for suctioning; Assess area around ET tube Q4; Pace activities; coordinate with physician; Provide communication tools; If pt goes into resp distress, remove vent, bag/mask ventilate, call for help
Manage ventilator
Perform and document vent checks; Respond promptly to alarms; Compare prescribed setting with actual setting; Check water level and temp; Remove condensation in tubing
Potential complications with vent pt
Hypotension-avoid valsalva maneuver;
Fluid retention-monitor I&O;
Lung problems;
Stress ulcers-antacids, sucralfate, histamine blockers, or proton-pump inhibitors may be prescribed;
Paralytic ileus-parenteral support;
Malnutrition-ensure balanced nutrition via diet, enteral feedings, or parenteral feedings;
Infection-infection control adherence, oral care Q2, pulmonary hygiene;
Muscle deconditioning-get pt out of bed;
Vent dependence-attempt occasional weaning
Extubation
Hyper oxygenate pt; Suction pt; Rapidly deflate cuff; Remove tube at peak inspiration; Instruct pt to cough; Monitor VS Q5 min; Assess for resp distress; Teach pt: Semi-fowlers position; Deep breaths Q30 min; IS Q2; Limit speaking; Normal to be hoarse and have sore throat
Pulmonary contusion
Occurs most often with rapid deceleration after car crashes;
Resp failure develops over time;
Pt becomes hypoxemic and dyspneic;
May be asymptomatic then develop resp failure;
Often leads to ARDS
S/S of pulmonary contusion
Bloody sputum; Decreased breath sounds; Crackles; Wheezes; X-ray may show no abnormalities until after several days
Pulmonary contusion management
Maintenance of ventilation;
Oxygenation;
Monitor central venous pressure;
Restrict fluid intake as needed
Flail chest
Inward movement of thorax during; inspiration with outward movement on expiration;
Often involves one side of the chest;
Results from multiple rib fractures;
Can result during CPR
Flail chest S/S
Impaired gas exchange, coughing, and clearance of secretions; Paradoxic chest movement; Dyspnea; Cyanosis; Tachycardia; Hypotension; Anxious, SOB, in pain
Interventions for flail chest
Humidified O2;
Pain management;
Promotion of lung expansion through deep breathing;
Secretion clearance by coughing and tracheal aspiration;
Mechanical ventilation;
monitor ABGs;
Stabilized by PEEP;
Monitor VS and fluid & electrolyte balance;
IV fluids;
Analgesics;
Psychosocial support
Patient management with chest tube
Dressing around tube tight and intact;
Assess for difficulty breathing;
Assess pulse ox;
Listen to breath sounds bilat;
Assess skin at insertion site;
Check to see if tube eyelets are visible;
Assess for pain (note location and intensity);
Assist pt to deep breathe, cough, perform maximal sustained inhalations, and IS;
Reposition pt who reports burning in chest
Drainage system management of chest tubes
Do not strip the tube;
Keep drainage system lower than pt chest;
Keep tubing as straight as possible; avoid dependent loops;
Ensure connections are secure;
Bubbling in water seal chamber should only occur on expiration, coughing, and position change;
Assess for tidaling;
Check water levels and maintain;
Clamp tube only for short periods;
Assess and document fluid in collection chamber;
Change system before drainage fills chamber;
Draw specimen from tube after cleansing with 20 gauge needle/syringe
Emergency with chest tube
Tracheal deviation;
Sudden onset or increased intensity of dyspnea;
O2 sat70 mL/hr;
Visible eyelets on chest tube;
Chest tube falls out (first cover area with sterile gauze);
Drainage in tube stops within first 24 hrs
Focused assessment for ARDS
Chest rise (symmetric?);
Lung sounds;
Dyspnea;
Pain with breathing
Ventilatory failure
Chest pressure does not change enough to permit air movement (mechanics of breathing);
Perfusion is normal, ventilation is inadequate;
Caused by trauma, weak muscles, high spine injury, opioids…
Oxygenation failure
Air movement and oxygen intake are normal, but lung flow is decreased;
Ventilation is normal, perfusion is inadequate
Tidal volume
Amount of air delivered with each breath
Rate
The set respiratory rate of the pt or machine
Mode
Method the machine uses to deliver breaths:
Assist Control (AC);
Synchronized Intermittent Mandatory Ventilation (SIMD);
Maximum Mandatory Ventilation (MMV)
FiO2
Percentage of oxygen delivered by machine
PEEP
Positive End-Expiratory Pressure
When to suction?
PRN, not scheduled; High pressure alarm; Secretions; Coughing; Wheezing, rhonchi; Decreased O2 sat
How to suction
Sterile; Hyper oxygenate before and after; No more than 10-15 seconds per suction; No lavage before; Intermittent suction with withdrawal
