NURS 444 week 3 Flashcards
Respiratory Failure and classification
when all compensatory mechanisms fail
hypoxemic- resp. failure. Insufficient O2 transferred to blood
hypercapnic- resp. failure. Inadequate CO2 removed from the lungs
Hypoxemic Respiratory Failure
Oxygenation issue
Causes
- ventilation-perfusion (v/q) mismatch
- COPD
- pneumonia
- asthma
- atelectasis
- pain
- pulmonary embolus
Hypercapnic Respiratory Failure
ventilation issues
causes:
- Airways and alveoli:
asthma, emphysema, cystic fibrosis
- CNS;
drug overdose, brainstem infarction, spinal cord injury - chest wall:
flail chest (gunshot wound), kyphoscoliosis, morbid obesity, fracture, mechanical restriction, muscle spasms - neuromuscular conditions
muscular dystrophy, guillain-barre syndrome, MS
V/Q scans
help diagnose a PE
if low –> increased circulation but low ventilation
if high –> decreased circulation but good ventilation
Consequences of hypoxemia and hypoxia
*** cells shift from aerobic to anaerobic
- lactic acid production
- metabolic acidosis and cell death
- decreased cardiac output
- impaired renal function
Sudden or Gradual onset of Respiratory Failure
Sudden: life-threatening
> greater risk if coexisting with cardiac problems or anemia
> ex. asthma exacerbation
Gradual: compensation occurs
< ex. COPD with URI. may recover faster than sudden
Resp. Failure clinical manifestations
Early SIgns: irritable/ restless
- tachycardia
- tachypnea
- mild htn
Severe morning headache
Late sign: cyanosis
- rapid, shallow breathing pattern
- tripod position
- dyspnea
- pursed lip breathing
- retractions
- change in I:E ratio
Resp. Failure Diagnostic studies
- H&P assessment
- ABG analysis
- CXR
- CBC, sputum/ blood cultures, electrolytes
- ECG
- urinalysis
- V/Q lung scan
- pulmonary artery catheter (rare and only in extreme cases)
Resp. Failure management
Oxygen Therapy
- maintain PaO2 55 to 60 mm Hg or more and SaO2 at 90% or more at the lowest O2 concentration possible
Resp. Failure meds.
- Bronchodilators
relieve of bronchospasms - Corticosteroids
reduction in airway inflammation - Diuretics, nitrates if HF present
reduction of pulm. congestion
nitrates to reduce workload of heart - IV antibiotics
Tx of pulm. infections - Benzos, narcotics
reduction of severe anxiety, pain, and agitation
Mechanical ventilation
process by which FiO2 (fraction of inspired oxygen)- 21% RA or greater, and a set amount of air volume is moved in and out
Positive pressure ventilation (PPV)- pushing pressure in
Non-invasive PPV: Bi-PAP, CPAP
BIPAP
positive pressure on inspiration
indicated for; COPD with HF or RF and sleep apnea
contraindicated for; shock, altered mental status, ^ airway secretions
indications for intubation
-apnea
-inability to breathe or protect airway
-resp. distress or muscle fatigue
-resp. failure
ET intubation prep
self-inflating bag valve mask connected to oxygen
suctioning
IV access
premedication depends on patient’s LOC and nature of procedure
Immediate actions during intubation
- Inflate cuff
- Manually ventilate patient with BVM
- Confirm placement of ET tube:
End-tidal CO2 detector
Auscultate lungs bilaterally
Ausculate epigastrium
Observe chest wall movement
Monitor Sp02
We need an x-ray to confirm placement
After ET placement
- connect to mechanical vent.
- secure ET tube (mark at lip and do before x-ray)
- suction ET tube and pharynx
- insert bite block if needed
- obtain cxr
*** 2- 6 cm above carina and observe chest wall for symmetric movement - continuously monitor pulse ox
- obtain ABGs in 30 min - 1 hr
Ventilator machine settings
AC
SIMV
FiO2
PEEP- positive end-expiratory pressure- allows pressure on exhalation. Keep alveoli open
Rate
VT
Nursing management: after ET placement
-maintain correct placement
- maintain proper cuff inflation
cuff pressure: 20-25 mm Hg (usual)
stabilizes and seals ET tube within trachea
excess volume can cause tracheal damage
cuff pressure 20-25 cm H2O
measure and record on routine basis: minimal occluding volume (MOV) technique and minimal leak technique (MLT)
what does increased airway pressure mean
there is pressure in the airway
can be an occlusion.
changes in expiratory flow would be an early sign before peak airway pressure increase
Complications associated with suctioning ET
! hypoxemia
! branchospasm
! increased intracranial pressure
! dysrhytmias
! hyper/ hypotension
! mucosal damage/ bleeding
! pain
! infection
** hyperoxygenate before and after, no more than 120 pressure of suction, limit each pass to 10 seconds or less
Continued ET nursing management
- monitor oxygenation and ventilation
- Oral care: prevent vent. acquired pneumonia
- maintain skin integrity
- foster comfort and communication
- physical and emotional stress
unable to speak, eat, move, breathe normally
pain, fear, and anxiety r/t tubes/ machines
VAP
occurs 48 + hours after intubation
Manifestations: fever, high WBC, purulent or odorous sputum, crackles/ wheezes, pulm. infiltrates
VAP prevention guidelines
minimize sedation
early exercise and mobilization
subglottic secretion drainage port
elevate HOB 30-45
oral care with chlorhexidine
no routine changes of ventilator circuit tubing
wake patient up occasionally to assess
What we base mode off of in vent. settings
vent. status
resp. drive
ABGs
Most often used modes in weaning
CPAP
PS: pressure support ventilation delivers pressure during inspiration and spontaneuous breath
weaning and extubation:
Phase One: Preweaning or assessment
- Assess muscle strength
- Assess endurance
- Auscultate lungs
- Assess chest x-ray
- Non-respiratory factors
Phase 2: Weaning
- spontaneous breathing trial (30-120) min.
- monitor for:
tachycardia (dysrhythmias)
tachypnea (dyspnea)
sustained desaturation (SpO2 <90)
hypertension/ hypotension
agitation/ anxiety/ mental status change
diaphoresis
sustained V1 < 5 mL/kg
Phase 3: Weaning Outcome
weaning stops and patient is extubated
or
weaning stops because no progress is made
extubation:
-hyperoxygenate and suction
- loosen ET tapes or holder
- deflate cuff and remove tube at peak of deep inspiration
- have patient deep breath and cough
- supplemental O2
- careful monitoring after extubation
ARDS
sudden progressive form of acute resp. failure
alveoli fill with fluid
results in:
- severe dyspnea
- hypoxia
- decreased lung compliance
- diffuse pulmonary inflitrates
ARDS pathophysiology
from different indirect lung injuries
- most common cause is sepsis or aspiration pneumonia.
Early Clinical Manifestations of ARDS
- dyspnea, cough, tachypnea, restlessness
- chest auscultation may be normal or have fine scattered crackles
- ABG: mild hypoxemia and resp. alkalosis caused by heperventilation
- cxr may be normal or show some scattered infiltrates
Late clinical manifestations of ARDS
! progression of fluid accumulation
! decreased lung compliance
! PFT show decreased lung compliance and volume
! evident discomfort and increased work of breathing
! suprasternal retractions
! tachycardia, diaphoresis
! changes in sensorium with decreased mentation, cyanosis and palor
! hypoxemia and a PaO2/ FiO2 ratio <200 despite increased FiO2
! cxr shows diffuse and extensive bilateral interstitial infiltrates
Oxygen therapy in ARDS
O2 therapy to maintain PaO2 60 or greate
may need intubation
may need higher levels of PEEP
ARDS complication
- vent. associated pneumonia
- Barotrauma- rupture of overdistended alveoli during vent.
- Volutrauma- when large tidal volumes used to vent. non-compliant lungs
- high risk stress ulcers
*** Renaul failure
Interventions for ARDS
Maintenance of cardiac output and perfusion
maintenance of fluid balance
minimize hypotension and decreased CO2 from mechanical ventilation and high levels of PEEP
Tension Pneumothorax: diagnosis
- CXR
- displaced trachea
- displaced heart sounds
*** can be fatal
Tension Pneumothorax S&S
severe dyspnea
tachycardia
tracheal deviation (late sign)
decreased or absent breath sounds on affected side
neck vein distention
cyanosis
diaphoresis
** fatal if pressure in pleural space not relieved
Hemothorax
hemorrhage from chest wall, lung, or mediastinum
common after surgery
often with pneumothorax
Things to know about chest tube collecting chamber
Collection drainage chamber- should not see more than 200 mL/ hr. If no collection, think of a clot
Ambulatory care of chest tubes
disconnect but NEVER clamp. clamping only if chest tubes are being changes
if chamber breaks, remove chamber from tube and place tube in sterile water
Possible chest tube complications
- clots in tubing
- tubing disconnection
- accidental removal
- subcutaneous emphysema (ex. picture of woman with swollen face)
Chest tube discontinuation
when drainage has decreased,
pneumo is resolved (CXR)
breath sounds and VS are stable
Chest tube removal
done by physician
give meds. before removal
valsuva maneuver
obtain materials
> suture removal kit
> petroleum gauze
> 4x4s
> foam tape
> sterile gloves
> follow-up CXR
> monitor for resp. distress
