Respiratory Monitoring Flashcards
after how long of breathing with what oxygen concentration can lead to oxygen toxicity?
50% for longer than 24 hours
what should fiO2 be titrated based upon to prevent oxygen toxicity?
minimal amount possible to keep PaO2 above 60mmhg or sats above 90-92%
What is a physiological shunt? What does the ventilation perfusion ratio look like? What processes is this seen in?
Blood is passing by alveoli without gas exchange occurring, low ventilation.
There is a low ventilation to perfusion ratio, possibly zero.
pneumonia, atelectasis, tumor, mucous plug
What is alveolar dead space? What does the ventilation perfusion ratio look like? What processes is this seen in?
The alveoli arent being perfused enough to allow for adequate gas exchange.
High ventilation to perfusion ratio.
Pulmonary embolus, pulmonary infarction, cardiogenic shock, mechanical ventilation with high tidal volumes.
What is a silent unit? What does the ventilation perfusion ratio look like? Where can this be seen?
This is where the alveoli arent being ventilated or perfused.
Both ventilation and perfusion are low in the ratio in this case.
This can be seen with a pneumothorax, hemothorax, or SEVERE ARDS or severe asthma.
What is positive cooperativity in relation to hemoglobin molecules?
This is the fact that as each of the 4 heme groups receives an oxygen molecule within a hemoglobin molecule, its affinity for oxygen to bind to it increases.
At 40mmHg, how saturated are hemoglobin molecules?
They are still about 70-75% saturated. This is enough of a reserve to provide oxygen to tissues in an emergency or strenuous exercise.
What are some things that effect hemoglobins ability to bind with oxygen?
pH, carbon dioxide concentration, temperature, and 2-3 DPG (diphosphoglycerate)
What are some things that increase the affinity of hemoglobin binding to oxygen? What shift does this correlate to on the oxyhemoglobin dissociation curve?
Increase pH
Decreased CO2 (Increases pH in most instances)
Decreased body temperature
Decreased 2,3 - DPG
THIS RESULTS IN A SHIFT TO THE LEFT, HEMOGLOBIN MORE READILY BINDS TO OXYGEN, THEREFORE LESS OXYGEN IS AVAILABLE FOR THE TISSUES
What is 2,3-DPG and what is its role in effecting hemoglobins ability to bind to oxygen?
2,3-DPG is a phosphate (inorganic) that is produced by RBCs, it is also an acid. It binds to hemoglobin (specifically the beta-chain) which decreases the affinity of hemoglobin to bind to oxygen, leaving oxygen more readily available for the tissues (right shift).
What are some things that decrease the affinity of hemoglobin to bind to oxygen? What shift would this correlate to on the oxyhemoglobin dissociation curve?
Decreased pH
increaseed CO2
Increased temperature
increased 2,3-DPG
This causes a shift to the right of the oxyhemoglobin dissociation curve, which means that there is a decreased affinity for hemoglobin to bind to oxygen, causing an increased availability of oxygen tot he tissues.
What is the percentage of oxygen that is dissolved in the plasma (PaO2)? Where is the other 97% of oxygen?
3% (normal PaO2 is 80-100mmHg)
The other 97% is bound to hemoglobin (SaO2 93-99%)
What is the difference between PaO2 and SaO2? What are the normal values?
PaO2 is the pressure/amount of dissolved oxygen in the plasma (80-100 mmHg)
SaO2 is the amount of oxygen bound to hemoglobin (93-99%)
What is the normal range for ABG values? (PaO2, PaCO2, HCO3, pH)
PaO2 - 80-100 mmHg
PaCO2 - 35-45 mmHg
HCO3 - 22-26
pH - 7.35-7.45
How long does it approximately take the lungs to start to compensate for pH?
Lungs - 5-15 minutes
Kidneys - 24 hours
Can either the metabolic or respiratory system overcompensate?
NO NO NO
What does FiO2 mean?
This means the fraction f inspired oxygen, when oxygen flow-rates are slower than the patients inspiratory volume (1-10l/min)
Do you give oropharyngeal airways to any patient that is conscious?
NO NO NO
Is oral suctioning a sterile process? What type of suctioning catheter would you use? What do you do after you finish suctioning EVERY TIME? What do you do before gently removing an oropharyngeal catheter?
NO, normal a yaunker is used. Rinse the tubing with tap water after suctioning. PERFORM SUCTIONING BEFORE REMOVAL.
When would you want to use caution in using a nasopharyngeal airway?
patients with craniofacial injuries.
What is the max amount of time suctioning can be performed?
15 seconds
When is an ETT necessary?
When the patient needs to be ventilated or if the airway needs to be protected.
What ways can an ET tube be inserted?
Orally or nasally
What are the advantages to an orally inserted ETT? Any disadvantages?
Pros: Less trauma, larger tube can be used, less infections
Cons: they are uncomfortable
What are the advantages of a nasally inserted ETT? Any disadvantages?
Pros: they are more comfortable
Cons: Higher rates of infection (sinus/pneumonia) and trauma to the nasal mucosa
How do you want the head of the bed when performing suctioning?
> 30 degrees
When do you ALWAYS intubate?
GCS < 8
What equipment is needed to perform and ET intubation?
laryngoscope w/ curved and straight blades (ensure light is working)
suctioning with yaunker tip
ETT with stylet
10ml syringe for inflation of cuff
Something to hold tube in place (commercial holder, tape)
Magill forceps (used in nasal intubation)
PulseOx
Oxygen source
MRB with mask
ETCO2 monitor or disposable detector
sedative and paralytic
What is the usual size of an adult for ETT, with no extra small patient, no complicated intubation?
8.0mm
What is the smallest size tube that allows bronchoscopy?
7.0MM
What is the nurses role when it comes to intubation?
Explain rationale for procedure to patient and family
position patient on back with pillow or blanket under shoulder blades to hyperextend neck and open airway
Inflate cuff before insertion to make sure its integrity
assess patient
monitor vs
monitor pulseox
gather and monitor intubation and suction equipment
collaborate with support staff as needed
What should be done with suction equipment before intubation is started?
make sure that shit works!
During intubation, when would you want to withhold the attempt and reoxygenate the patient? why?
when SaO2 falls below 90%
tachycardia, bradycardia, dysrhythmias, hypotension, cardiac arrest, ect… can occur
Where should the ETT be positioned in the trachea?
2-3 cm above the carina
What are some complications that can occur with ETT?
Laryngospasm/brochspasm
hypoxemia/hypercapnia
laryngeal edema (stridor)
trauma/bleeding to nasal, oral, esophageal tracheal, or laryngeal sites
fractured teeth
nosocomial infection (sinusitis, pneumonia, abscess)
displacement of tube (right main bronchus, esophageal)
aspiration of oral and gastric contents
tracheal stenosis/tracheomalacia
laryngeal damage, paralysis, necrosis
dysrhythmias, HTN, hypotension
failure of ventilator
disconnection
tube obstruction
tracheoesophageal fistula
What can be done to ensure gastric intubation has not occured? How is placement and positioning confirmed?
Listen to the abdominal region if breath sounds arent present.
placement is confirmed by listening for bilateral breath sounds, positioning is confirmed via CXR
What kind of tape is used to secure ETT?
waterproof tape is used
If a patient is confused and tries to self-extubate, what should be done first?
attempt to orient the patient as to why the tube is necessary and assure that you will help to make more comfortable.
What does the nurse do between each intubation attempt
suction (if needed) and hyperventilate with 100% O2.
what are the main sedatives we need to know for ETT?
Versed (midazolam)
Diprivan (propofol)
Etomidate (amidate)
Ketamine (ketalar)
What are the main paralytics that we need to know for ETT?
Succinylcholine (anectine)
Rocuronium (zemuron)
Vecuronium (norcuron)
What do you ALWAYS give first, sedative or paralytic?
SEDATIVE
What can be modified when using volume ventilators (most common)?
ventilation
RR
tidal volume
inspiratory time
What can be modified with pressure support ventilation?
pressure ventilation delievers a specific gas pressure to the airway in order to meet the inspiratory flow demand of that airway, it then holds this pressure throughout ventilation to allow less effort for the patient to breath.
Is anything else controlled with PSV? Are there other pressure modes that can control more things?
NO, just the pressure is given when the client takes a breath.
Yes, some can control the rate and inspiratory time
Describe high-frequency ventilators. What is their usual rate?
This is a mode where small frequent tidal volumes are given at a fast rate. Rate is greater than 100 bpm
What is the use for high frequency ventilation? Any complicaitons?
to prevent barotrauma and improve V/P ratio by changing delivery characteristics, helps lower ventilatory pressure while ensuring good oxygenation
Complications: necrotizing tracheobronchitis if air isnt properly humidified… also gas trapping
What is the primary thing to monitor with a patient on pressure ventilation?
VOLUME in the form of exhaled tidal volume
What is to be monitored during volume ventilation?
peak pressures
What must be done to the patient in order to perform high-frequency ventilation?
the patient must be paralyzed
Start with the broad category of positive pressure ventilators and break down into the smaller categories and their sub-categories.
Positive pressure ventilators can be either:
Volume which includes: A/C (CMV) or SIMV
Pressure which includes: PSV or PCV
High frequency
Describe A/C ventilation, what is another name for this?
This is a mode where volume and rate are preset, the preset volume at the set rate as well as for other spontaneous breaths.
Another name for this is Continuous mandatory ventilation
Describe SIMV, what is this mode commonly used for?
There is still a set rate and tidal volume, however, when a client spontaneously takes a breath above the set rate the ventilator gives no support.
This is a great way to start weaning the client from the ventilator because it allows the client to take more responsibility with their own breathing.
Why is PSV thought to be a great tool for weaning?
It is thought to increase the endurance of the respiratory muscles by decreasing the physical work and oxygen demands.
Describe pressure controlled ventilation.
Can set inspiratory pressure level, rate. and I:E ratio.
What is PCV primarily used for, like in what situation?
When the client has persistent oxygenation problems despite having high FiO2 and PEEP.
do pressure modes decrease the risk of barotrauma in low compliance lungs?
YES
Would you use a sedative or paralytic medications during some pressure ventilation modes (especially inverse ratio)?
YES YES YES
What is the process of suctioning?
BOX 25-7 P.516
What is the difference between CPAP and PEEP?
CPAP is used in clients that are spontaneously breathing and provides positive pressure throughout the respiratory cycle.
PEEP is positive-pressure given at the end of exhalation in patients receiving positive pressure breaths.
What is the point in using PEEP? What does all of this do for gas exchange?
It keeps alveoli stent open, and may recruit other alveoli that are totally or partially collapsed, all of this helps improve lung compliance.
This decreases the shunting that occurs and improves oxygenation.
If a patient is on high levels of PEEP, what is the procedure for interrupting it, in other words, should it be done? Why?
NOT often, it may take several hours to recruit alveoli again to restore FRC (functional residual capacity).
If a client has low circulating volume, should the use of PEEP be monitored closely? What can be done to correct any issues that may occur?
YES, PEEP can reduce the venous return to the heart.
If hypotension occurs or signs of decreased CO IV fluids may be administered to correct this.
Other than decreased venous return to heart, and ultimately decreased CO, what else can PEEP cause?
What levels does this usually occur at?
barotrauma, especially in lungs with high ventilating pressures and low compliance - may cause a pneumothorax
Can occur at higher levels of peep (10-20) especially in patients described in above portion of flashcard.
What is the normal range of PEEP that is used?
usually 5-20
Describe CPAP, what is it good for?
CPAP is like a mixture of PSV and PEEP, it exerts positive pressure throughout the respiratory cycle, however, the patient must have their own spontaneous rate and tidal volume.
THIS MAKES IT GOOD FOR WEANING from the vent
How do you figure out the tidal volume range for ventilated patient?
5-8 ml/kg
What is the normal PEEP range except for more difficult cases?
5-10
What is the relationship between tidal volume and CO2?
the larger the tidal volume the more CO2 that is released.
What do you do when there is an alarm on the vent and you cant figure out what the problem is?
When in doubt, bag the patient!
What may be the cause of a low pressure alarm when is comes to the patient on a ventilator?
Patient is disconnected from the ventilator
Loss of delivered tidal
Decrease in patient-initiated breaths
Increase in compliance
Where are the main areas to see if the patient is disconnected from ventilator?
Check and connect STAT, auscultate around the neck to see if there is a leak around the ETT cuff.
How can you check to see if there is a decrease in tidal volume with a patient on the ventilator? What if the patient has a chest tube?
Review CXR to ensure placement If the tube is too high
Check for loss of tidal volume through the chest tube.
What do you do when a patient on the ventilator has a decrease in spontaneous breaths?
Check the patient for the cause: Assess RR, ABGs, and the last time the patient was sedated.
What are some things that can cause an increase in compliance?
Anything that makes the airways larger. Suchs as the clearing of secretions or the relief of bronchospasm.
What are some ventilator related things that can set off the low-pressure alarm?
A leak in the ventilator system.
What are some things that can cause a leak in the ventilator system, setting off the low-pressure alarm?
Loss of connection wih tubing (start at the patient and work towards humidifier when checking.
Check for a change in the ventilator settings
What are some patient related causes of the high-pressure alarm going off?
Decreased compliance/Increase in dynamic pressures
Increased static pressures
What are some ventilator related causes of the high-pressure alarm going off on the ventilator?
Kinked tubing
Tubing filled with water
Patient & ventilator asynchrony
What are some actions that can be done for a decrease in compliance/increase in dynamic pressures?
Suctioning
beta-agonis
Check CXR for placement in right mainstem bronchus,
If patient is bucking the vent or biting tube sedate them
What are some things that can be done to check for an increase in static pressure while on the ventilator?
Check ABG for hypoxia
check for fluid overload
check CXR for atelectasis
Auscultate breath sounds
If the ventilator tubing is filled with water, how do you dispose of the water?
empty the water into a receptacle: DO NOT DRAIN BACK INTO HUMIDIFIER
What do you do if there seems to be patient and ventilator asynchrony?
recheck sensitivity and peak flow settings
Provide sedation/paralysis if indicated
If there is a sudden increase in dynamic pressures, what can be the cause?
pneumothorax
How often do you do a respiratory assessment on a vented patient?
every 2-4 hours
What is the ideal pressure of the ET cuff? How often should the cuff pressure be assessed?
20-25 mmHg
every 6-8 hours or when a leak is noted
If the ET cuff is at the ideal pressure but a leak is present, what is the first thing the nurse should do?
A slight reposition of the tube within the airway may correct the issue.
If repositioning the et tube with a leak doesn’t solve the issue, what are some of the next steps to take?
A larger or longer ET tube may need to be inserted.
Is suctioning of ett a scheduled therapy?
NO, only suction as needed.
What is the process of suctioning?
Hyperoxygenate with 100% O2 for at least 2 minutes with BVM or ventilator
Insert as far as possible into artificial airway without suction, usually until cough or resistance is met
apply intermittent suction while rotating and removing catheter, no more than 80-120 mmHg and for no longer than 10-15 seconds
What does CHOOSE NO VAP stand for?
Cuff pressure
HOB to 45
oral care 2-3 times a day
enteral feeding
suction out oral secretions
special ETT for suction
No lavage
oral intubation is best
Change ventilation circuit only when needed (tubing)
A new ambu bag with each patient
Wash hands
How long after intubation is a tracheostomy tube recommended?
72 hours (3-7 days on the ventilator)
Why is early tracheostomy a good idea?
facilitates earlier weaning, especially if the patient has multiple comorbidities including trauma and neurological diagnoses associated with a prolonged need for an artificial airway
Other than prologned intubation which can cause tracheal stenosis, vocal cord paralysis, ect… what are some other indications for a tracheostomy tube?
upper airway obstruction
airway edema from anaphylaxis
failed intubation
multiple intubations
abscence of protective reflexes
home care
facial trauma, cervical fractures (ETT not possible with these)
desire for improved comfort
Other than making the weaning process easier because of decreased dead space, what are some other advantages to a tracheostomy tube?
enhanced patient comfort
enhanced communication
possibility of oral feeding
What are the complications of a tracheostomy tube?
acute hemorrhage at the site of insertion
air embolism
aspiration
tracheal stenosis
erosion into innominate artery with exsanguiation
failure of tracheostomy cuff
laryngeal nerve damage
obstruction of tube
pneumothorax
subcutaneous and mediastinal emphysema
swallowing dysfunction
tracheoesophageal fistula
infection
accidental decannulation with loss of airway
false placement of cannula (not in trachea)
weak voice/ hoarseness
When the tracheostomy tube is initially inserted, how long do you wait until changing the ties and dressing to allow for hemostasis?
24-48 hours
How often do you clean the tracheostomy site?
every 8-12 hours
How often is the inner cannula of the tracheostomy tube changed?
every day
When does tracheostomy care change from being every 8-12 hours for ties and dressing and inner cannula every day to daily or as needed care?
generally after 7-10 days and after secretions and drainage are minimal.
Is tracheostomy care done as sterile or clean procedure?
STERILE
READ ABOUT TRACHEOSTOMY CARE AND WEANING FROM THE VENTILATOR, LOOK AT PPT!
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