oxygen therapy Flashcards
whats the goal of oxygen therapy
deliver the least amount necessary
name some low flow devices
Nasal Cannula
Face mask
Venturi mask
Nonrebreather
describe acute respiratory failure
Inadequate gas exchange
Usually occurs secondary to another disorder
Problem with oxygenation or CO2 elimination or both
ABGs reveal hypoxemia and/or hypercapnia
causes of respiratory failure
Intrapulmonary
Lower airways, alveoli, pulmonary circulation, alveolar-capillary membrane
Extrapulmonary
CNS injury, neuromuscular disorders, thorax, pleura, upper airway disorder
treatment of respiratory failure
Improve oxygenation &/or ventilation
Non-invasively if possible (CPAP/BiPAP/NIV mask)
Intubation if necessary
Treat cause
describe non-invasive ventilation and give examples
Uses a mask that fits tightly over the mouth and nose, or just the nose
BiPAP – Positive pressure on both inspiration AND expiration; inspiratory and expiratory pressures are different. IPAP & EPAP
CPAP – Continuous Positive Airway Pressure; inspiratory pressure and expiratory pressure is the same
nursing considerations for NIV
Airway protection
Nutrition & Hydration
Oral care
Skin care
Communication
describe intubation
Tube is placed in trachea - between vocal cords – can not speak
Tube is placed 2-3 cm above carina
ETCO2 monitor– color change (purple to yellow) assures correct placement ETCO2
Breath sounds heard equally bilaterally
Chest x-ray for placement
Coughing - indicates need for suctioning or inappropriate tube placement
intubation nursing interventions
Ensure equipment is ready (intubation tray, ambu bag, suction)
Ensure pulse oximeter is in place, BP cuff
Administer medications (sedative, paralytic) as directed
Monitor time during each attempt–Each attempt should be limited to 30 seconds
Monitor vital signs!
Secure and note placement
what are some goals of mechanical ventilation
Improve ventilation
Decrease work of breathing
Correct inadequate breathing patterns
Improve oxygenation
what ventilator setting affect the amount of air being moved in and out of the lungs (ventilation) and what ABG values are affected
tidal volume: size of each breath
rate: number of breaths per minute
affect PaCO2 and indirectly pH
name some ventilation modes
Assist Control (AC)
Synchronized Intermittent Mandatory Ventilation (SIMV) or (IMV)
Pressure Support Ventilation (PSV)
describe assist control (A/C)
Ventilator delivers a preset tidal volume at a preset rate. The patient will never get fewer breaths than the preset rate. The patient CAN trigger an additional breath and then the ventilator kicks in and delivers the full preset tidal volume
describe Synchronized Intermittent Mandatory Ventilation (SIMV/IMV)
Ventilator delivers a preset volume at a preset rate. In between mandatory breaths, the patient can breathe spontaneously, with a pressure-supported breath. However, the tidal volume of the patient-initiated breaths will only be as large as the patient is strong enough to inspire.
advantages of SIMV
Helps keep respiratory muscles active and coordinated
Can be used as a weaning mode. As the patient improves, the preset rate is decreased, and the patient assumes greater responsibility for breathing on his/her own.
If the patient stops breathing for any reason, he/she will still receive the preset volume at the preset rate.
describe pressure support
when on IMV or Spontaneous breathing trial, this “boost” from the ventilator increases spontaneous breath volume and makes it easier for the patient to inspire.
It is meant to overcome the increased airway resistance afforded by the ETT, so the patient does not have to work as hard to initiate a breath. This facilitates weaning, and the amount of support is gradually reduced as the patient is weaned.
Positive pressure to augment patient’s inspiratory efforts
May be used with SIMV or during breathing trial
May be used as the primary mode of ventilation
Weaning modality
what vent settings affect oxygenation
FiO2 (Fraction of Inspired Oxygen)
PEEP (Positive End Expiratory Pressure)
what is FiO2
Fraction of Inspired Oxygen
The percentage of oxygen delivered via the ventilator
30-100%
what is PEEP
Positive pressure applied at the end of expiration of ventilator breaths
Increases oxygenation by preventing collapse of alveoli
Maximizes the number of alveoli available for gas exchange
Typically set at 5 cm H2O, can be increased as necessary
what are some complications of PEEP
Hemodynamic compromise d/t decreased venous return
Volutrauma or barotrauma
If a patient’s ABG results indicate an elevated PaCO2, what changes on the ventilator may be ordered to correct this?
Increase FiO2
Increase PEEP
Decrease TV
Increase rate
Increase rate
If a patient’s ABG results indicate a low PaO2, what changes on the ventilator may be ordered to correct this?
Increase FiO2
Decrease PEEP
Decrease TV
Increase rate
Increase FiO2
potential complications of mechanical ventilation
Aspiration
Barotrauma and Pneumothorax
Ventilator-associated pneumonia
Decreased cardiac output
Decreased fluid balance
Immobility
GI problems
Muscle weakness
Self-extubation
Ventilator dependence
whats the ABCDEF bundle
Assess, prevent and manage pain
Both spontaneous awakening trials and spontaneous breathing trials daily
Choice of analgesia & sedation
Delirium: Assess, prevent & manage
Early mobility and exercise
Family engagement and empowerment
ABCDEF bundle benefits
Decreased ventilator time
Decreased ICU length of stay
Improved return to normal brain function
Increased independent functional status
Improved patient and family satisfaction
Increased survival
ICU Delirium Nonpharmacologic Interventions
Pain:
Monitor and manage pain using an objective scale (e.g., FACES FLACC, CPOT, etc.)
ICU Delirium Nonpharmacologic Interventions
Orientation:
Convey the day, date, place, and reason for hospitalization
Update the whiteboards with caregiver names
Request placement of a clock and calendar in room
Discuss current events
ICU DeliriumNonpharmacologic Interventions
Sensory:
Determine need for hearing aids and/or eye glasses
Provide these for patient when appropriate
ICU DeliriumNonpharmacologic Interventions
Sleep:
Noise reduction strategies (e.g. minimize noise outside the room,
offer white noise or earplugs)
Normal day-night variation in illumination
Use “time out” strategy to minimize interruptions in sleep
Promote comfort and relaxation (e.g., back care, oral care, washing face/hands, and daytime bath, massage)
VAP prevention
aspiration prevention techniques
Maintain adequate ETT cuff pressure
Check pressure q shift with a manometer
HOB 30-45 degrees
Use sedation as sparingly as possible
Verify correct feeding tube placement
Consider swallowing evaluation after prolonged intubation
VAP prevention
oral care
Brush teeth, gums and tongue at least twice a day using a soft toothbrush
Provide oral care to oral mucosa and lips every 4 hours or PRN
Daily use of chlorhexidine
VAP prevention
oropharyngeal suctioning
Suction oropharynx with each mouth care and before turning patient or lying flat
Suction before deflating cuff
continuous removal of subglottic secretions
Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation (CASS tube)
-10 to -20 cm of continuous suction
VAP prevention
hand washing
Wash hands or use an alcohol-based waterless antiseptic agent before and after:
suctioning
touching ventilator equipment
coming into contact with respiratory secretions.
other considerations for mechanical ventilation
Stress Ulcer Prophylaxis
DVT Prophylaxis
Communication
Psychological care
Caring for the family
Nutrition
troubleshooting alarms with mechanical ventilation
Always check connection to ETT or trach FIRST
Check alarm indicators
High pressure = possible obstruction
Low pressure = possible leak
Safety: Ensure ambu bag available
guidelines for weaning from short-term ventilation
Hemodynamically stable
SaO2 > 90% on FiO2 50% or less, PEEP 8 cm H20 or less
ABGs within normal range (for patient)
Adequate pain/anxiety/agitation management
No residual neuromuscular blockade
describe spontaneous breathing trials
AKA: CPAP Trials
Pressure support, PEEP & FiO2 only
No tidal volume given by machine
Place enteral feedings on hold
Minimize sedation
Instruct patient/provide support/failures may occur
Monitor patient response (SaO2, BP, HR, respiratory rate and pattern)
criteria for stopping a SBT
RR > 35
SaO2 < 90%
Decreased tidal volumes
Increased work of breathing
Increased anxiety and/or diaphoresis
HR > 140
SBP > 180 or < 90
extubation criteria
ABGs WNL for the patient
Respiratory rate < 30
NIF > -20 cm water Negative Inspiratory Force
(-30 is better, -10 is worse)
Patient alert/following commands
Adequate cough/gag reflex to protect airway
Occlusion test (if concerned for tracheal swelling)
extubation procedure
Elevate HOB & Instruct patient on procedure
Suction ETT & Suction oropharynx
Deflate cuff and remove
Encourage coughing to remove sputum
Suction as needed
Apply oxygen
Assess for laryngeal edema
Assess ability to talk and swallow
Monitor vital signs
Which setting provides the patient with a tidal volume?
PEEP
CPAP
AC
Pressure support
AC
Which ventilator setting will augment spontaneous breaths by decreasing resistance upon inspiration ?
AC
SIMV
PEEP
Pressure support
Pressure support
Which ventilator setting can be increased to help improve oxygenation?
AC
SIMV
PEEP
Pressure Support
PEEP
If a patient has an elevated PaCO2 and a normal PaO2 what vent change may be made?
Increase PEEP
Decrease FiO2
Increase rate
Decrease TV
Increase rate
