Respiratory care skills Flashcards
Role of the cardiopulmonary system
- We need full function of cardiac and pulmonary systems
- Right side of the heart pumps the blood into pulmonary circulation
- Left side of the heart pumps to rest of body (systemic circulation)
- Cardiopulmonary physiology involves the delivery of deoxygenated blood (blood high in CO2 and low in O2) to the right side of the heart and to the pulmonary circulation, and oxygenated blood from the lungs to the left side of the heart and the tissues
The 3-step process of oxygenation
1) Ventilation
2) Perfusion
3) Diffusion
- If any of these 3 are compromised then breathing is compromised
Ventilation
- Moving gases in & out of lungs
- Requires muscles, nerves, and the elastic structure of the lungs
Perfusion
- Oxygenated blood to tissues
- Deoxygenated blood to lungs
Diffusion
- Movement of molecules from high concentration to low concentration
- Exchange of the gases
Physiological factors that compromise oxygenation
- Cardiac disorders
- Anemia
- Pregnancy
- Fever
- Infection
- CNS or chest wall conditions.
Developmental factors that compromise oxygenation
- Age related changes resulting in decreased ability for the lungs to expand
Lifestyle factors that compromise oxygenation
- Smoking
- Malnourishment
- Obesity
Environmental factors that compromise oxygenation
- Smog
- Asbestos
- High altitudes; reduced about of O2 being inhaled
Goals of ventilation
- Normal arterial oxygen tension (PaO2): 80 – 100mmHg
- Normal arterial carbon dioxide tension (PaCO2): 35 - 45 mmHg
Partial pressure of oxygen
- The amount of oxygen dissolved in the plasma
- PaO2
- 80-100 mmHg
Partial pressure of carbon dioxide
- The amount of CO2 dissolved in the plasma
- PaCO2
- 35-45 mmHg
Alterations in respiration
- Hyperventilation
- Hypoventilation
- Hypoxia
Hyperventilation
- Definition: Ventilation > than required
- Decreased amount of CO2 in the body; breathing more than what is needed to rid the amount of co2 in the body
- Increased rate of respiration
- Alveoli level
- Want to treat the underlying cause
Causes:
- Anxiety
- Infections
- Fever
- Shock
- Acid-base imbalance
- Meds (e.g., ASA, amphetamines)
Hypoventilation
- Definition: Ventilation < than required
- Alveoli is inadequate to meet oxygen demands or to remove CO2
- Elevation of CO2 in the body
- Changes in mental state, dysrhythemia, potential of cardia arrest
- COPD; chronic CO2 retainers; their body has adapted to higher levels of CO2
- Want to treat the underlying causes of hypoventilation
Causes:
- Atelectasis
- Inappropriate O2 administration in patients with COPD
- COPD patients are chronic CO2 retainers - their stimulus to breathe is low O2 concentration
- If the O2 concentration is increased, their respiratory rate decreases
Hypoxia
- Definition: inadequate tissue oxygenation at the cellular level.
- Life threatening condition
Causes:
- Decreased Hgb & lowered O2 carrying capacity
- Decreased concentration of inhaled O2
- Inability of tissues to extract O2 from blood
- Decreased diffusion of O2 from alveoli to blood
- Poor tissue perfusion
- Impaired ventilation
- Trauma
Signs and symptoms of hypoxia
- Restlessness
- Apprehension / agitation
- Declining LOC
- Dizziness
- Fatigue
- Usually increased P, R & B/P (initially) but then decrease in vital signs
- Cyanosis
Manages by giving oxygen and treating the underlying cause
Pulmonary function test (PFT)
Measures lung volume and capacity
- Done by RTs
- Measure the lung volume and capacity
- Take a deep breath, forcefully exhale into the machine
- Diagnosing and managing pulmonary diseases
Arterial blood gases (ABG)
Measures the adequacy
of tissue oxygenation
pH: 7.35-7.45
PaCO2: 35-45mmHg
PaO2: 80-100mmHg
- Measures the adequacy of tissue concentration in the blood
- Arterial blood taken
- Looking at pH of blood
Pulse oximetry (SpO2)
Indirect measure of oxygen
saturation
- Measures the amount of oxygen bound to hemoglobin
- Finger probe most commonly used
- LED light inside to take measurement
- Want 95-100%
- High 80’s and low 90’s might be appropriate for some chronic conditions i.e. COPD
- 70%or below is life threatening
- Interpret with caution; many factors and influence; nail polish, artificial nails, capillary refill, and tremors
- When we get value outside or normal range want to critically think
- Patient needs normal capillary refill for accurate test
Imaging: X-rays/CT scans
Provide visualization of
lung fields
Potential nursing diagnoses for respiratory assessment
- Ineffective airway clearance
- Ineffective breathing pattern
- Impaired gas exchange
- Impaired spontaneous ventilation
- Ineffective tissue perfusion
Airway maintenance interventions
Goal is to ensure the trachea is free of obstruction and bronchi are free and open
Mobilization of pulmonary secretions
- Humidification
- Nebulization
- Chest Physiotherapy (CPT)
- percussion (cupping)
- vibration (shaking pressure applied during exhalation) - Postural Drainage
Suctioning
- Oropharyngeal & nasopharyngeal
- Orotracheal & nasotracheal
- Tracheal
Artificial airways
- Oral, nasal and endotracheal
Humidification
- Process of adding water to gas
- Keeps airways moist and helps to loosen secretions
- Needed for clients receiving O2 > 4L/min
- Intended to help keep the airways moist when delivering oxygen
- Also helps to loosen secretion when airways moist
- Also good for patients with tracheal tubes; bypassing mouth and nasal passages skips the humidification and goes straight into the body
- Humidify to infants; oxygen hood
Nebulization
- Process of adding moisture or medications to inspired air
- Improves clearance of pulmonary secretions
- Often used for bronchodilators and mucolytic agents
- Makes an aerosol mist and helps to mobilize the pulmonary secretions
- Ventiln treatment
- Also used with mucolytic medication
Chest physiotherapy (CPT)
- Good for patients who are emitting large amount of mucous or who have collapsed alveoli
- Loosen things in your chest
- Striking the chest wall with a cupped hand or using special cups
- Hitting over the areas that need to be drained to loosed the secretions
- Also vibration method to loosen secretions
- Important to note there are a lot of contraindications; bleeding disorders, fractures ribs, use of steroid medications (increase risk of fractures)
Postural drainage
- Using different positioning techniques to help draw out secretions from specific sections of the lungs
- As they flow out of the trachea and can spit them out
- Different positions for different conditions
- Usually done with a medical order
- Mindful about the positions where the head is lower
- Also mindful of duration of time; more than 5 minutes but not a hard and fast end to that
- Often used in junction with the chest physiotherapy; 20-40 minutes spent in the position
Types of suctioning
Oropharyngeal and nasopharyngeal
- Patient has effective cough but unable to clear secretions by expectorating or swallowing
Orotracheal and Nasotracheal:
- Patient unable to manage secretions and does not have an artificial airway
Tracheal Suction
- Suction via an artificial airway (endotracheal or tracheal tube)
- Want to move from clean to dirty
Suctioning devices
- Yaunkauer; suction tubes used for oropharyngeal suctioning
- All other types use flexible/soft suctions catheter
- Soft suction catheter comes in many sizes, but measured in French
- The smaller the French, the smaller the diameter of the catheter
- The large the French, the bigger the diameter of the catheter
- Peds; 6-10 French (small diameter)
- Adult; 12-16 French (14 is average)
- If they have thick secretions sometimes you need a larger catheter to get it out
Suctioning considerations
Oropharyngeal and orotracheal:
- Yankauer for oropharyngeal
- Soft catheter for orotracheal
Nasopharyngeal and Nasotracheal:
- Nasal route is preferred to prevent gag reflex stimulation
- Contraindications: nasal occlusions, nose bleed, epiglottitis, croup, some head/face/neck sx, irritable airway/bronchospasm, MI.
Tracheal Suction:
- Choose a suction catheter no bigger than 50% of airway diameter.
General suctioning technique (for all 3 methods)
- Assess pt (including SpO2)
- Semi-Fowler’s position
- No suction during insertion of catheter
- Rotate catheter and apply intermittent suction during WITHDRAWAL
- Suction pressure should be maintained between 100-150 mmHg (Adult) but check local policy
- Suctioning should not exceed 10 seconds per pass
- Administer oxygen between passes
- Wait 1-2 minutes between each pass
- Encourage patient to cough
- Don’t forget the mouth care!
Undesired effects of suctioning
- Scarring of the trachea; airway trauma
- Drying out the airway from removing all secretions
- Can cause hypoxia
- Can trigger broncho-spasms
- Can sometimes lead to cardia arrhyemthia due to vagus nerve stimulation
- Infection
- Important to have oxygen at the bedside incase something goes wrong while suctioning
Red flags while suctioning
- Keep an eye on the oxygen saturation; don’t want less than 90% unless baseline is low, them don’t want a drop more than 5%
- Mindful of HR; don’t want to see a drop of more than 20bmp or increase of more than 40bmp
Suctioning technique
Nasopharyngeal and Nasotracheal:
- Use water soluble lubricant
Insert during inhalation
- Nasopharyngeal; approx. 15-20cms (length of tip of nose to angle of mandible)
- Nasotracheal; approx. 20cms. If you hit resistance, pull back by 1-2 cm.
- Turn head to L for R bronchus and R for L bronchus
Tracheal Suction:
- Choose a suction catheter no bigger than 50% of airway diameter.
- Hyperoxygenate before starting
- Insert catheter until resistance is met (approx. 13-15cm) and pull back 1-2cm
Types of artificial airways
- Oral airway
- Nasal airway
- Tracheal airway (endotracheal and tracheal tubes)
Indications for an artificial airway
- Decreased level of consciousness
- Airway obstruction
- Help with removal of secretions
Oral airways
- Prevents the tongue from falling back into the oral cavity
- Measure from the corner of the mouth to the angle of the jaw
- Inset upside down and then flip it over as it gets to the back of the mouth or sideways
- Do not want to use if patient has an intact gag reflex
Nasal airway (nasal trumpet)
- Used to maintain an airway in the case where patient is conscious but is diminished or have an intact gag reflex
- Measured from tip of nose to the ear lobe
- Inset bevel end towards septum and them flip it down as getting back
Endotracheal tube (ETT)
- Typically used in emergencies
- Nurses typically not inserting ETT tubes, but some advanced course or rural areas you will be trained; often inserted by physician or RT
- Typically meant for short term ventilation (<14days)
- If needed for more than 14 days they will move onto the tracheal tube
- Balloon at end; inflated to keep tube in place
- Marking on tube to ensure it hasn’t moved
Tracheostomy tube (trach tube)
- Similar to ETT tube, but more permanent
- Used when patient will be on ventilator for a long period of time
- Often seen at complex continuing care
Bag valve mask (Ambu-bag)
- Used in emergency when we need to provide oxygen before tubing
- Found bedside or crash cart
- Connect it to oxygen
- Turn on high 50L/min
- Tilt head back a bit
- EC positioning for hand over bag (i.e what we have learned previously in CPR courses)
- Once mask is in place; bag in rate for 8-10 breaths/min
- Want to just squeeze enough to see chest rise and fall; don’t want to squeeze the whole bag in there
Non-invasive methods to promote lung expansion
Ambulation
- Early ambulation associated with better outcomes and faster healing time
Positioning
- Reduces pressure on lungs and helps with expansion
Cough techniques and deep breathing exercises
- Coughing and deep breathing
- Pursed-lip breathing
- Diaphragmatic breathing
- Use of incentive spirometer (IS)
- Cascade cough; slow deep breath and hold for 2 seconds, then do a series of coughing
- The huff cough; stimulates a natural cough reflex and is generally effective inly for clearing central airways. While exhaling, the patient opens the glottis by saying the word “huff”. With practice, the patient inhales more air and may be able to progress to the cascade cough.
- Quad couch; patient’s that don’t have control over abdominal muscles, as they take exhale you push up and in on diaphragm to produce a cough, DON’T DO UNLESS ORDERED
Invasive methods for promoting lung expansion
Chest tubes
- Most invasive method
- Are inserted to remove air and fluids from the pleural space
Incentive spirometer (IS)
- Different types seen in practice
- Try and turn deep breathing/coughing exercises into a game to keep them engaged
- Trying to attain a higher level
- Try and do 5-19 breaths every hour (a lot)
Maintenance and promotion of oxygenation
- Goal: To prevent or relieve hypoxia
- Flow rate = liters per minute (L/min).
- Concentration (FiO2) = mixture of room air and O2 delivered to patient (ex: 28%)
- FiO2 is fraction of inspired oxygen
- O2 therapy can deliver 22-100% supplemental oxygen.
- O2 is a drug-to be used only when indicated.
- Prescribed by MD, however RNs may initiate in an emergency (up to 2L/min)
Supply of oxygen
Wall units
- Permanent wall-piped system
Portable O2 tank
Equipment
- Flow meter/regulator
Oxygen wall units
- Flow meter attached to wall
- Use dial on right hand side
- Adjust it to ball is aligned with the amount of oxygen you want to give
- Important note: want to not mix it up with medical air; double check that it’s oxygen that you’re using
Portable oxygen tank
- Often used in hospital when patient going to testing or ambulating
- Make sure you check the level of oxygen in the tank before you take it; don’t want to run out
Methods of oxygen delivery
Low-flow devices:
- Oxygen concentration varies depending on breathing pattern
- Nasal cannula
- Simple face mask
- Non-rebreathing mask (aka reservoir mask)
- Face tent
High-flow devices:
- Provide a fixed FiO2 regardless of breathing pattern
- Venturi mask
Nasal Cannula (nasal prongs)
- Most common low flow device you will see
- Can go up to 6L/min
- In practice usually won’t see more than 4L/min
- Remember humidification; if giving 4L/min need it
- Mindful of skin breakdown behind the ear
- Dryness underneath the nose
- Drying of the nasal passages
- Don’t want to use if known mouth breather
Face mask
- Try to not use for extended periods of time; difficult to talk or eat
- Fit loosely over patient’s mouth and nose
- Concentrations of 40-60% of oxygen
- Contraindication; do not use with patients with COPD; their stimulus is level of oxygen and do not want to negate
Face mask with reservoir bag
- Oxygen flows into bag then patient inhales
- Carbon dioxide is exhaled out to side
- Set at 10L/min
- Delivers oxygen concentration between 60-80%
- There are partial breathers as well, 40-70% and patient receives more room air as opposed to oxygen
- Want to make sure bag is full; if partially deflated it means patient might be inhaling some of their exhaled COs
Face tent
- Covers whole chin and mouth
- Good for patient with broken nose
- Patient who is clostrophobic
Trach oxygen mark
- Like a simple mask but goes over trachea
Venturi mark (VM)
- Only high flow device
- Deliver more precise concentrations of oxygen
- Have special meters that help you determine amount of oxygen and specific concentrations of oxygen
- Good for COPD patients or patients who are very unstable
Safety precautions for administering oxygen
- Highly combustible
- “No smoking” enforced
- Ensure all electrical equipment is working properly
- Be familiar with fire procedures and the location of the closest fire extinguisher
- Check level of portable tanks prior to transporting patient
Adverse effects of O2 administration
- Nosocomial infection from equipment
- Skin breakdown around the mask, over ears, and nares
- Hypoventilation in patients with COPD
- Oxygen toxicity
Oxygen toxicity
- Risk factors: Receiving oxygen at concentration >50% for >24hours
- Produces free radicals that cause damage to the alveolar-capillary membrane resulting in damage to the lung and respiratory distress
- Manifestations: dyspnea, nasal congestion, cough, sore throat, chest pain with deep breathing
- Prevention: Limit use of 100% O2, use lowest concentration possible
The flow of blood through the heart
Deoxygenated blood:
Superior vena cava/inferior vena cava > right atrium > tricuspid valve > right ventricle > semilunar valve > pulmonary artery/lung
Oxygenated blood:
pulmonary vein > left atrium > mitral valve > left ventricle > aortic arch/ descending aorta > arteries throughout body
Factors that influence oxygenation
1) Physiological
2) Developmental
3) Lifestyle
4) Environmental
Safety measures the implement when administering oxygen
a) Inform the patient, visitors, roommates, and all personnel that smoking is not permitted in areas where oxygen is in use
b) Ensure that all electrical equipment in the room id functioning correctly and is properly grounded. An electrical spark in the presence of oxygen can result in a serious fire.
c) Locate the closest fire extinguisher.
d) Know the fire procedures and the evacuation route for the area.
e) Check the oxygen level of portable tanks before transporting a patient to ensure that enough oxygen in the tank exists to complete the transport
