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NURS 362 this shit confuse me > Nursing Management of Patient with Artificial Ventilation > Flashcards

Nursing Management of Patient with Artificial Ventilation Flashcards

1
Q

What are the indications of administering supplemental oxygen therapy?

A
  • Hypoxemia
  • Hypoxia
  • Dyspnea
  • Other signs and symptoms of respiratory distress
  • Dyspnea on exertion (DOE)
  • Changes in respiratory pattern
  • Abnormal Arterial Blood Gas (ABG)
  • Fatigue
  • Level of consciousness (LOC) changes
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2
Q

What are the two main complications of supplemental oxygen therapy that would indicate stopping oxygen therapy and how are they different?

A

Hypercapnia:

  • high amounts of CO2 in the blood
  • Patient Relies on hypoxia for respiratory drive
  • When PaO2 becomes too elevated, it may cause respiratory Arrest
  • Common COPD

Oxygen toxicity:

  • Occurs when adults are given long term percentages of over 50 – 60% O2
  • can cause lung damage
  • Destroys lung surfactant
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3
Q

What signs and symptoms should the nurse monitor for the development of oxygen toxicity?

A
  • Fibrotic changes (thickening of lungs)
  • Increased capillary congestion
  • Interstitial space thickening
  • Respiratory distress including Dyspnea and pulmonary edema
  • CNS effects like Paresthesia, seizures and Restlessness
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4
Q

What are the two main treatments for oxygen toxicity the nurse can expect to be ordered?

A
  • Positive End Expiratory Pressure(PEEP)

- Continuous Positive Airway Pressure(CPAP)

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5
Q

What nursing Interventions can be utilized to increase oxygenation?

A
  • Incentive Spirometer
  • Encourage coughs and deep breathing
  • Position patient to encourage drainage of secretions
  • chest percussion
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6
Q

What is included in the nursing care of a patient with an endotracheal tube?

A
  • Monitor O2
  • Cuff Management
  • Maintain patent airway (tube)
  • Oral care
  • Skin care
  • Safety and Comfort
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7
Q

How does the RN monitor the oxygenation of a patient with an endotracheal/tracheostomy tube?

A
  • Assess for signs and symptoms of hypoxemia
  • Change in mentation, anxiety, dusky skin, dysrhythmias
  • Continuous SpO2
  • arterial blood gases for more accurate assessment
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8
Q

What signs would the nurse observe in a patient with an endotracheal or tracheostomy tube that would indicate hypoxemia?

A
  • Grunting,
  • Change in level of consciousness (LOC),
  • Intercostal spaces evident,
  • Color (Cyanosis, Circumoral Pallor),
  • Seesaw chest movement,
  • Nasal flaring,
  • Retractions and Dysrhythmias,
  • Tachypnea
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9
Q

How does the nurse manage the cuff of a patient with an endotracheal or tracheostomy tube?

A
  • Inflate cuff when patient requires mechanical ventilation or is high risk for aspiration
  • Cuff pressure should be maintained at 20-25 mmHg and checked every 6-8 hrs; record routinely
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10
Q

What are 5 reasons tracheostomy tubes are used?

A
  • Bypass upper airway obstruction
  • Permit long term mechanical vent
  • Permit oral intake and speech
  • Replace an endotracheal tube
  • Remove tracheobronchial secretions
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11
Q

In an emergency situation where the patient is comatose the nurse would expect what to be utilized to maintain a patent airway in the patient?

A

Endotracheal Tube

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12
Q

In a patient requiring long term intubation greater than 3 weeks what tube will likely be utilized?

A

Tracheostomy tube

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13
Q

What methods can the nurse use to promote effective airway clearance?

A
  • Chest physiotherapy,
  • Frequent position changes,
  • Increased mobility,
  • Suctioning
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14
Q

When assessing a patient with an endotracheal or tracheostomy tube what would indicate to the nurse the patient requires suctioning?

A
  • Visible secretions in the tube
  • Sudden onset of respiratory distress
  • Suspected aspiration of secretions
  • Auscultation of adventitious breath sounds over bronchi or trachea
  • Increased respiratory rate & sustained coughing
  • Sudden or gradual decrease in SpO2
  • Changes in LOC, restlessness, tachycardia
  • Cyanosis or pallor
  • Increased peak airway pressure
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15
Q

What is the priority assessment the nurse should perform when caring for a patient with a tracheostomy or endotracheal tube?

A

Respiratory status

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16
Q

What are early complications of tracheostomy tubes or endotracheal intubation the nurse must be aware of?

A
  • Tube dislodgment
  • Accidental decannulation
  • Bleeding
  • Pneumothorax
  • Air embolism
  • Aspiration
  • Subcutaneous emphysema
  • Laryngeal nerve damage
  • Posterior tracheal wall penetration
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17
Q

What are late complications of tracheostomy tubes or endotracheal intubation the nurse must be aware of?

A
  • Airway obstruction from secretions
  • Infection(Ventilator associated pneumonia)
  • Rupture of innominate artery
  • Dysphagia
  • Tracheoesophageal fistula
  • Tracheal dilation, ischemia, or necrosis
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18
Q

What complications of endotracheal intubations must the nurse be aware of?

A
  • Tube dislodgment
  • Accidental removal
  • Laryngeal swelling, hypoxemia, bradycardia, hypotension, death
  • High cuff pressure
  • Tracheal bleeding, ischemia, or necrosis
  • Low cuff pressure
  • Risk of aspiration and hypoxia
  • Trauma to tracheal lining
  • Vocal cord paralysis
  • Ventilator associated pneumonia
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19
Q

A nurse is caring for a patient with severe hypoxia, hypoxemia and pulmonary edema requiring continuous ventilation and PEEP. The nurse observes multiple indications for suctioning. Which type of suctioning should the nurse use?

A

Inline/Closes suctioning because it allows for continuous ventilation, sustains PEEP, and has a lower risk of exacerbating patient’s hypoxia than open suctioning.

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20
Q

How can the nurse assess for correct placement of endotracheal tubes?

A
  • Auscultate lungs sounds,
  • end-tidal carbon dioxide levels,
  • chest x-ray ordered if suspicions of poor placement
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21
Q

What is included in oral care of patient with an endotracheal tube

A
  • Brush patient’s teeth, gums, tongue, and surface of the ET tube twice a day
  • Rinse patient’s mouth with 0.12% chlorhexidine gluconate oral rinse twice a day, or as ordered(NO MOUTHWASH)
  • Cleanse mouth every 2-4 hours between brushings with an oral swab
  • Post brushing teeth and oral care
  • Suction oropharyngeal secretions whenever apparent
  • Perform deep suctioning at least every 4 hours
  • Apply oral moisturizer to the oral mucosa and lips
  • Rotate tube to other side of mouth to prevent pressure injuries
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22
Q

What is included in oral care of patient with a tracheostomy tube

A
  • Brush patient’s teeth, gums, and tongue twice a day
  • Rinse patient’s mouth with 0.12% chlorhexidine gluconate oral rinse twice a day, or as ordered(NO MOUTHWASH)
  • Cleanse mouth every 2-4 hours between brushings with an oral swab
  • Post brushing teeth and oral care
  • Suction oropharyngeal secretions
  • Apply oral moisturizer to the oral mucosa and lips
  • Change or cleanse inner cannula at least every 8 hours or more frequently if needed or as ordered
  • Cleanse, assess, and dry stoma and change protective dressing at least every 8 hours or more frequent if needed or as ordered
  • Change Tracheostomy ties or tube holder per frequency as ordered or per facility policy
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23
Q

What can the nurse do to best prevent and monitor for complications in patients with endotracheal or tracheostomy tubes?

A
  • Administer warmed humidity – should see mist in tubing
  • Maintain appropriate cuff pressure
  • Suction as needed
  • Maintain skin integrity
  • Auscultate lung sounds
  • Monitor for signs and symptoms of infection (temp, WBC)
  • administer prescribed O2; monitor O2 sat
  • Monitor for cyanosis
  • Maintain adequate hydration
  • Sterile technique for suctioning and care
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24
Q

How often should the nurse assess the placement of tracheostomy and endotracheal tubes and what should nurse focus on?

A

Assess every 2-4 hours, focus on airway remaining patent and respiratory status including assessing vitals, lung sounds, skin/mucosa color, equal bilateral chest rise and fall,

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25
Q

What degree should the head of bed be at for patients with tracheostomy and endotracheal tubes and what would the nurse want by the bedside?

A
  • The HOB should be at 30-45 degrees
  • Ambu bag and suction at bedside both tubes
  • Extra Inner cannulas and spare tracheostomy tube
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26
Q

In a situation where a tube is dislodged what is the immediate action the nurse should take?

A

Manually ventilate patient and call for necessary help

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27
Q

What are the indications for mechanical ventilation?

A
  • Compromised airway
  • Severe decrease in oxygenation
  • Altered breathing pattern
  • Drug overdose
  • Inhalation injury
  • Shock
  • Multi-system Failure
  • COPD
  • Thoracic or abdominal surgery
  • Trauma or lung injury
  • Acute respiratory distress syndrome (ARDS)
  • Neuromuscular disorders
  • Brain injury or damage
  • Rest the respiratory muscles
  • Coma
  • PaO2 <50 mmHg with FiO2 >0.60 or PaO2 >50 mmHg with pH <7.25
  • Vital Capacity <2 times tidal volume
  • Negative inspiratory force <25 cm H20
  • Respiratory Rate >35/min
28
Q

What type of ventilation will a patient with chronic respiratory failure or neuromuscular conditions like poliomyelitis, MD, ALS and Myasthenia Gravis be provided to use at home and why?

A

Negative pressure ventilation because..

  • it does not require intubation,
  • it is simple and adaptable for home use.
  • It exerts negative pressure on external chest
  • decreases the intrathoracic pressure during inspiration and allows air to flow into lung simulating spontaneous respiration
29
Q

What is positive pressure ventilation and the 4 different types?

A
  • Used in acute care, operating room, or at home
  • Generally used with an ET tube or tracheostomy
  • During inspiration, the ventilator pushes air into the lungs under positive pressure
  • Intrathoracic pressure is RAISED during lung inflation (unlike normal inspiration)
  • Patient exhales passively
  • 4 types are volume cycled, pressure cycled, high frequency oscillatory support, non-invasive positive-pressure ventilation
30
Q

What are nursing Interventions for patients with mechanical ventilation via Endotracheal or Tracheostomy tube?

A
  • Assessment of settings
  • Assessment and troubleshooting of alarms
  • Maintenance of airway and patient safety
  • Suctioning of patient (see other section)
  • Restraints
  • Excess water in system
  • Timely change of disposable components
31
Q

Volume cycled ventilation

A
  • Delivers preset volume with each inspiration, Airway pressure varies based on patient’s need, Exhalation occurs passively
  • Disadvantage: possibility of barotrauma
32
Q

Pressure cycled ventilation

A
  • Delivers preset pressure of air with each inspiration, Volume of air/oxygen varies based on patient’s resistance or compliance
  • Disadvantage: inconsistent tidal volume
33
Q

High Frequency Oscillatory Support Ventilation

A
  • High respiratory rates (180-900 breaths/min)
  • Low tidal volume,
  • High airway pressure,
  • Used to open alveoli
34
Q

Non-Invasive Positive-Pressure Ventilation (NIPPV)

A
  • Eliminates need to ET tube or tracheostomy, CPAP, BiPAP,
  • Decreases risk of pneumonia,
  • Pressure controlled ventilation with pressure support
  • 3 types (PEEP, CPAP, and BiPAP)
35
Q

Positive end-expiratory pressure (PEEP):

A
  • Positive pressure during exhalation,
  • Useful in pulmonary edema
  • WATCH COPD or those with low cardiac output.
36
Q

Continuous positive airway pressure (CPAP):

A
  • Delivered continuously during spontaneous breathing

- Good for sleep apnea

37
Q

Bilevel positive airway pressure (BiPAP):

A
  • Noninvasive modality
  • Okay in COPD and heart failure, sleep apnea
  • Can help prevent re-intubation after extubation.
38
Q

What are the 4 modes of mechanical ventilation and

A

CMV, AC ventilation, IMV, SIMV

39
Q

How does controlled mechanical ventilation(CMV) work? What type of client would receive CMV and why is it the least used mode?

A
  • Ventilator delivers a set tidal volume at a set rate
  • Used for clients who cannot initiate any spontaneous respirations
  • Least used because it does not allow any client-initiated breaths
40
Q

What is the most common mode of mechanical ventilation and how does it work?

A
  • Continuous Mandatory Ventilation aka Assist Control (A/C) Ventilation
  • Ventilator delivers a set tidal volume OR pressure, and a set rate
41
Q

What is the main difference between IMV and AC Ventilation?

A
  • IMV allows the client to breath spontaneously at own rate and tidal volume between ventilator breaths
  • Any spontaneous breaths are not machine assisted or machine sensed
  • Patient could be exhaling as the machine is delivering a breath
42
Q

What two modes of mechanical ventilation can be used as both a primary mode and a weaning mode and how do they differ from each other?

A

-Intermittent Mandatory Ventilation(IMV) and Synchronized Intermittent Mandatory Ventilation(SIMV)

  • SIMV works the same as IMV but the SIMV machine senses spontaneous breaths and will not deliver a breath during exhale
  • Ventilator delivers a set tidal volume and has a set rate (only for machine assisted breaths)
43
Q

What is included in the nurse’s assessment of a client on IMV or SIMV?

A

-“Sync”: does the patient seem synchronous with vent, breathing easily?
-“Bucking”: attempting to breathe on own, not allowing ventilator to deliver breaths
Monitor:
-Respiratory rate,
-Minute volume,
- Spontaneous or machine Tidal Volume ,
-FiO2,
-ABGs

44
Q

What is Pressure Support Ventilation (PSV) and how does the nurse assess a client on it?

A
  • PSV provides constant pressure to patient own
  • Completely relies on patient’s spontaneous breaths

-Nurse should assess the rate and tidal volume of breaths and pressure

45
Q

What can occur in a patient on PSV if the nurse does not assess the pressure and change it accordingly?

A

-Can cause tachypnea and large tidal volumes

46
Q

What is Airway Pressure Release Ventilation (APRV)?

A
  • Pressure limited and time triggered mode
  • Two levels of continuous positive airway pressure: high level and low level
  • Two levels of inspiratory time: high and low
  • Time triggered mandatory breaths are delivered by the machine, but patient can take spontaneous breaths
  • Tidal volume is patient driven
47
Q

What are the types of alarms associated with mechanical ventilation and main causes of each?

A
  • High Pressure Alarm: Caused by increased airway secretions, bronchospasm, displaced or obstructed tube, water in tubes, stiff airway (ARDS), kinked tubing
  • Low Pressure Alarm: Usually a disconnection or leak in the system
  • Apnea Alarm: patient off ventilator, tubing disconnected from patient
  • Temperature Alarm: usually needs more water for humidification
48
Q

What is the first action of a nurse responding to an alarm

A

Immediately ASSESS PATIENT

49
Q

Nursing Documentation for Ventilated Patients

A
  • Mode
  • Tidal Volume
  • Rate
  • FiO² (Percent oxygen)
  • Amount of PEEP (if used)
  • Pressure Support (if used)
  • Sputum – amount, frequency, color
  • Patient tolerance to vent and to suctioning
50
Q

Risks Associated with Mechanical Ventilation

A
  • Infection: especially Ventilator Acquired Pneumonia(VAP),
  • Pneumothorax, Lung damage
  • Side effects of sedation/paralytic meds
  • Hypotension: increased positive pressure increases intrathoracic pressure, which inhibits blood return to the heart
  • Maintenance of life when not wanted
  • Sodium and water imbalance: progressive fluid retention after 48-72 hours of positive pressure ventilation (PPV), decreased UO, increased Na+
  • GI system problems like stress ulcers and GI bleeding, peptic ulcer prophylaxis and Decreased peristalsis
  • Nutritional Issues
51
Q

What are the potential nutritional issues associated with mechanical ventilation?

A
  • Hyper-metabolism associated with critical illness

- Elimination of normal route for eating causing inadequate nutrition

52
Q

What further complications can nutritional issues associated with mechanical ventilation and what nursing interventions can be used to prevent them?

A
  • Inadequate nutrition puts person at risk for -poor oxygen transport secondary to anemia -poor exercise
  • Decreased total protein, albumin
  • Can also contribute to water and sodium imbalance
  • Delayed weaning
  • Decreased response to infections

-Nurse can use enteral feeding tube and an IV to provide adequate nutrients, fluid sodium/ Saline and electrolytes.

53
Q

What complication should the nurse be aware of and monitor for after using an enteral tube to address malnutrition in a patient on mechanical ventilation?

A

-Be aware of Stress ulcer: assess for
-upper abdominal pain
-pain that varies based on food intake.
-feeling unusually full or bloated.
symptoms of anemia(pale skin and dyspnea)
-nausea or vomiting.

  • Also can cause GI distress like constipation and Diarrhea can also exacerbate fluid, sodium electrolyte and nutrient imbalances
54
Q

What are the 3 steps of the weaning process?

A
  1. Gradual removal from the ventilator
  2. Removal of ET or tracheostomy tube
  3. Removal from oxygen
55
Q

When should the weaning process be initiated and what must be true about the patient before this happens?

A

-Weaning should be initiated at the earliest time possible when safe for patient

Patient must be

  • hemodynamically and physiologically stable
  • Spontaneously breathing
  • Recovered from acute stage medical or surgical issues
  • Cause of respiratory failure is reversed
56
Q

Why should mechanical ventilation not be abruptly stopped and what are the actions of the nurse in a situation where it is?

A
  • can decrease respiratory rate
  • cause anxiety due to patient psychological dependence on ventilator
  • Respiratory Distress or cardiac compromise

Nursing action

  • Nurse can give short times off vent or with 0 rate
  • Nurse may place patient on T-piece or Briggs as means of temporarily maintaining oxygenation
  • Nurse must assess for respiratory distress or cardiac compromise
  • Should not be done at night
57
Q

What should be included in the Nurses education on the weaning process of a patient on long term mechanical ventilation?

A
  • Prepare the patient psychologically
  • Educate patient and family
  • Explain that they may feel SOB
  • explain that oxygen status, pulse ox, EKG, and respiratory pattern will be monitored
  • explain that successful weaning is supplemented with intensive pulmonary care
  • Let patient know the weaning process is a little different with each person.
58
Q

What is the main goal of the weaning process of a patient on long term mechanical ventilation and how is this accomplished?(give specific ventilators)

A
  • The main goal is to gradually decrease ventilators control over patient’s breathing
  • CMV with PEEP->
  • CMV without PEEP->
  • AC with PEEP->
  • AC without PEEP->
  • IMV with PEEP->
  • IMV without PEEP->
  • SIMV->
  • Briggs Adaptor, T piece, Trach collar/mask
59
Q

What is extubation and when can it occur?

A
  • Extubation is the removal of Endotracheal tube after intubation
  • can occur within 2-3 hours post weaning if patient was intubated for a short period of time
  • May take days to week depending on how long intubated with ET tube
60
Q

What must the patient be able to do before the tracheostomy tube can be removed?

A
  • Breathe spontaneously
  • Cough up own secretions
  • Swallow
  • Move the jaw
61
Q

What are the steps in the process of removing a tracheostomy tube and when can they be done?

A

Once pt has adequate secretion clearance

  1. move to a trial period of mouth and nose breathing
  2. Decrease tracheostomy size (completed by provider)
  3. Change to a fenestrated tube
  4. Switch to a smaller tracheostomy (stoma) button

Once pt demonstrates ability to maintain airway
-5. tube is removed and occlusive dressing is placed over stoma

62
Q

Ventilator Associated Pneumonia(VAP)

A
  • One of the most common nosocomial infections
  • Leading cause of death from nosocomial infections
  • Occurs 48 hours or more after mechanical ventilation with intubation
  • Can occur with mechanically vented patients with a tracheostomy as well (occurrence may be different)
63
Q

What risk factors of VAP should the nurse be aware of?

A
  • Poor oral hygiene
  • Contaminated respiratory equipment
  • Poor hand washing
  • Decreased ability of patient to cough and clear secretions
  • Immobilization
  • Patient’s age and co-morbidities
  • Re-intubation
  • Depressed consciousness
  • Paralysis
64
Q

What was the VAP Bundle that hospitals adopted and what guidelines did it include?

A

VAP bundle developed to include group of
interventions to provide a standardized method of care based on evidence/best practice and outcomes (prevent VAP)
-Elevate HOB 30 – 45 degrees
-Daily “sedation vacations” with assessment of readiness to extubate
-Peptic ulcer disease prevention
-Deep vein thrombosis prevention
-Oral care daily with chlorhexidine gluconate 0.12% oral rinse

65
Q

What actions can the nurse caring for a patient on mechanical ventilation take to prevent VAP in addition to what is included in the VAP Bundle?

A
  • Effective and frequent hand washing before and after suctioning, whenever ventilator equipment is touched or contact made with respiratory secretions
  • Wear gloves when in contact with the patient
  • Maintain ET tube cuff pressure
  • Prevent condensation and sub-glottic drainage that collects in the ventilator tubing by draining it frequently
  • Gastric volume monitoring

NURS 362 this shit confuse me (8 decks)

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