Respiratory Part 2 (Mech Vent) Flashcards
f/RR
Frequency/Respiratory rate
f/RR normal range
12-20 bpm
FiO2
Fraction/percent of inspired oxygen
- 30-100%
- RA 21%
I:E Ratio
Inspiration time compared to expiratory time
I:E Ratio normal
1:2
PEEP
positive exit-expiratory pressure
PEEP normal
5-10 cm H2O
Ve
minute ventilation/volume
(Vt x RR)
Ve normal
6-8L/min
PIP
peak inspiratory pressure
PIP normal
15-20 cm H2O
Vt
tidal volume
- amount of air delivered in 1 minute
Vt normal for ideal body wt
6-8mL/kg
Vt normal for very sick lungs
4-6 mL/kg
Why would someone need artifical airway?
Apnea, airway protection
Acute respiratory failure
Severe hypoxia
Respiratory muscle fatigue
Upper airway obstruction
ETT is used for
emergent/planned
- short duration (10-14 days)
- if planned for a temporary time longer than 2 weeks in a long-term facility
Tracheostomy (Trach)
planned
surgical procedure
(bedside or OR)
Both Artificial Airways
emergent/planned
assist with ventilation
**connected to BVM to assist with breaths
ventilator
O2 by trach collar or T piece for ETT
O2 Delivery Systems include
Nasal cannula – 1-6L
High Flow nasal cannula
Simple face mask
Venturi mask
Partial rebreather mask
Nonrebreather mask
Tracheostomy collar or T piece
CPAP
BIPAP
AVAPS
Noninvasive O2 delivery
High-flow nasal cannula
BIPAP
CPAP
AVAPS
Invasive O2 delivery
Endotracheal tube (ETT)
Tracheostomy (Trach)
Which type of ventilation is used for patients needing assistance?
noninvasive
- short time before weaning or D/C
If non-invasive ventilation is unsuccessfully tolerated, what should be expected to happen next?
the patient needs more support and may be intubated
ETT cuff is used to
prevent aspiration
ensure delivery of tidal volume with mech ventilation
The inflated cuff of an ETT prevents
air for passing to the vocal cords, nose, and mouth
What are the different types intubation?
Orotracheal
Nasotracheal
What should the nurse ensure every time they provide care to the patient or enter the room of an ETT patient?
The size and tube length of the ETT
# at the teeth
# at the lips
know if it moves or not
The goal of care for mechanical ventilation
support pt until underlying condition is corrected
- Maintain and correct hypoxia/ventilation
- provide supplemental O2
- prevent complications and maintain pt safety
- Provide EBP
- Holistic family centered care
- integrate human caring
ETT Intubation Procedure for the nurse
- Order if not emergent
- Supplies and assist provider
After intubation, what does the nurse do after the ETT is inserted to confirm placement?
- Assess End-tidal CO2 detector
-Auscultate lungs bilaterally
-Auscultate epigastric
-Observe chest wall movement (SYMMETRICAL)
-Monitor SpO2 and cardiac rhythm (stable or improved) - Purple to Yellow means CO2
CO2 detector needs to be what color to ensure in the lungs?
yellow
What tells the nurse the patient need to be intubated?
GCS<8
color change
ABGs
cardiac and pulmonic VS
low LOC
Intubation needs what medications
Paralytic (succinylcholine and rocuronium)
- paralysis the muscles
Sedative (Propofol, midazolam, versed, fentanyl)
- sleepy and drowsy
The initial assessment of ETT placement is
Capnometer YELLOW for CO2
The chest x-ray for placement of the ETT tube where?
3-4cm above the Corina
ETT cuff pressure should be
<25 cm H2O
- minimal leak technique
- verify by RT and physician
If the ETT cuff is greater than 25 cm, what could occur?
tracheal necrosis
If the ETT cuff is too low and the patient is able to talk to you, then what could occur?
unplanned extubation
aspiration
Is it okay for the patient to cough while you are suctioning them?
No, that means you have hit the Corina
ETT comes out
lace the obturator placed immediately in the hole
- call a CODE
In the event of accidental dislodgement of the trachea and the tube cannot be replaced because of tract immaturity (less than 1 week old) or other circumstances, immediately place
pt in semi-fowler’s position to decrease dyspnea
- cover with a sterile dressing and ventilate with the BVM over the nose and mouth
If the nurse sees the patient is not getting enough oxygenation and they suspect the trach has clotted off, what should the nurse do?
replace the inner cannula and check the flanges
What equipment do you need at the bedside?
Obturator (clean sterile bag)
Trach of the same size or smaller
BMV
Suction
Tracheostomy Care
obturator at bedside for emergencies
clean face plate/flange
clean stoma q shift and PRN
change inner cannula q shift and PRN
Reassess pt after procedure
Clean the trach stoma with
sterile saline and dry
change the dressing
change securement ties if soiled (unless new then leave for orders)
Nursing Care for Artificial airways
Oral care Q4 hours
In-line suctioning Q shift and PRN – need a reason, O2 down, tachypnea, tachycardic, cough, flem,
Reposition & provide passive ROM
Bathe patient Q24 hours
Change pulse oximeter and ECG patches Q24 hours
Patient/family teaching as needed
Talk to the patient and family
They can hear you! – only sedated and paralyzed
Restraints for safety; restraint release Q2 hours & skin assessment (typically)
Provide time for sleep and rest
Limit suctioning to no more than
10 secs
-HESI 10-15 secs
Mechanical Vent pharmacology
Paralytics
Sedatives
Opioids
Vasopressors/fluids/volume expanders
Bronchodilators
LEAN
LEAN drugs
Lidocaine,
Epinephrine,
Atropine,
Narcan
Loading doses of drugs can cause
BP to drop
- give vasopressors
Patient Safety for ETT
Ensure tube is secured**
- Tube is marked, auscultate, cuff pressure <25
Keep tube patent
- Suctioning, listening, alarm customized to pt
Verify/maintain placement
Monitor respiratory status
Bag valve mask (BVM) in room (obturator at bedside)
Keep scissors airway from external balloon
What should the nurse assess for when a pt is on ETT?
tolerance, color, breathing extent, cardiac monitor = PVCs, RR, environment, no clutter
When should restraints be used on an ETT pt
only when they are a danger to themselves
ETT patients HOB degree if not contraindicated
30
In-line suctioning maximum
10 seconds
When in-line suctioning, gently insert the catheter until
resistance is met
When do you apply in-line suctioning
while withdrawing the catheter
- validate completely out of the ETT by black line visual
- monitor ECG and SpO2 throughout procedure
The wall suction should be on
continuous
- tap before attempt
preoxygenate
anchor the hand and pull with the other
suction pulling out
fully out at the black line
Inline suction helps prevent infection by
closed system and protect the patient and staff from bacteria
- prevent loss of PEEP and O2
Potential complications of suctioning
Hypoxemia, bronchospasm
Increased intracranial pressure
Dysrhythmias – PVCs (Teresita pt)
↑ or ↓ BP
Mucosal damage
Pulmonary bleeding, pain, infection
After suctioning, the nurse should ensure
- Assess for adverse effects during suctioning, such as dysrhythmias.
- Evaluate the patient’s respiratory status after suctioning.
- Maintain appropriate cuff inflation pressure at 20 to 25 cm H2O or use minimal leak technique to maintain cuff pressure.
- Assess tracheostomy site at least once per shift for any signs of inflammation or infection.
- Provide tracheostomy care using sterile technique
- Notify the CN of any changes in the patient’s respiratory status
PaO2
amount of oxygen dissolved in plasma – seen on ABG
SaO2
pulse ox and is only an estimate
O2 Toxicity
uncontrollable coughing
dyspnea for a long period of time
- leads to fibrosis
PEEP is constant
pressure to keep alveoli from collapsing at the end of expirations
PIP
peak inspiratory pressure
PIP normal
15-20 H2O
PIP is the
maximum pressure of inspiration, mucous plugs will increase PIP
In order to stop retaining CO2, the ventilator settings could change to
increase RR
increase Vt
- VOLUME OF THE BREATH
If the PaO2 is too low, the nurse with order could change the settings to
increase PaO2
increase FiO2
increase PEEP
- keep alveoli open, give more O2
Non-invasive High-flow NC delivers
O2 from 21-100%
60L/min
humidification
HFNC functions
Clears physiological dead space of expired air
Keeps alveoli open at end of expiration
HFNC limits
limit pt mobility
- need good ft
HFNC requires
adequate spontaneous RR
- able to breathe on their own
Dead space in Oxygenation
volume of ventilated air that does not participate in gas exchange
Noninvasive- CPAP
present pressure provided throughout
inspiratory and expiratory breaths
Goal of CPAP
Goal- keeps alveoli from collapsing, resulting in better oxygenation and less work of breathing
CPAP can be used for what patients
face mask non-intubated
ventilator intubated or trached pt
With CPAP the patient must be able to
breath spontaneously
- PT DOES ALL THE WORK
CPAP only provides
airway pressure
CPAP mode on the ventilator can be used to evaluate what
pt’s readiness for extubation
BIPAP used to
ventilate non-intubated pts help prevent intubation
BIPAP pts must be able to
spontaneously breathe and cooperate with the tx
IPAP assists with
ventilation
EPAP assists with
oxygenation
BIPAP is especially used for
COPD pts unable to exhale against higher airway pressures to help resolve CO2 problems
- HEART FAILURE
- ACUTE RESPIRATORY FAILURE
What pts can not use BIPAP due to the increase risk of aspiration and inability to remove the mask?
shock
AMS
increased airway secretions
What is the difference between CPAP and BIPAP?
BIPAP has inspiratory pressure in addition to expiratory pressure of CPAP
Noninvasive expected outcomes
Tolerate tx till exacerbation or tx is complete
ABG
CXr
Color
Auscultation
Gas exchange
LOC
Awake for breathe
Bilateral
does not Need to work or labor to breathe
not Exhausted
Mech Vent Volume Mode
Assist Control AC
Synchronized Intermittent Mandatory Ventilation (SIMV)
Mech Vent Pressure Mode
Pressure Support Ventilation (PSV)
Positive End Expiratory Pressure (PEEP)
Positive Pressure Ventilation
inflates the lungs by introducing positive pressure and/or volume
What does the nurse need to do for positive pressure ventilation?
Verify settings/order
Assess patient
Ensure patient safety (medications turns, oral care)
Troubleshoot as needed
Monitor ABG’s
Assist control volume mode
full support mode; Controls the work of breathing
- fixed tidal Volume (Vt) that theventilatorwill deliver at set intervals of time or when the patient initiates a breath
Assist control Vt
remain the same for patient-initiated breath or ventilator breath
Which ventilator mode requires the least amount of patient effort?
Assist control
- very sick pt
How do you know if the pt is taking spontaneous breaths on assist control?
If the ventilator setting is set at a certain bpm but the ventilator shows pt receiving a higher number
Pressure Support (PS/PSV)
set airway pressure to assist the patient with spontaneous breaths
- Decreases work of breathing by giving the patient a little boost on the breaths they initiate on their own
Pressure support decreases as the pt
improves
- overcomes resistance
-trials with spontaneous breaths
- positive pressure only during inspirations and with spontaneous breaths
- must be able to initiate breath by themselves
PEEP
apply positive pressure during exhalation
3-20 cm
- improves O2 by restoring lung vol
What can be reduced when PEEP is used?
FiO2
PEEP is used with caution by what type of pts
increased ICP
low CO = hypotension
hypovolemia
Potential Complications in Vent Pts
Aspiration/abdominal distension, ileus
Oxygen Toxicity
Barotrauma
PEEP-related
Anxiety
Stress Ulcers
Infections
Muscular deconditioning
Malnutrition
Ventilator dependence - not able to wean off
VAP
Vent Complication Tx
Aspiration
Insert NG/OG to decompress the stomach – stop aspiration of acid and feed them
Vent Complication
O2 Toxicity if
FIO2 >50% for more than 24 – 48 hours
Vent Complication S/S
O2 Toxicity
restlessness, dyspnea, chest discomfort, fatigue, atelectasis
Vent Complication MINIMIZE RISK of
Barotrauma
a smaller VT (e.g., 4 to 8 mL/kg) and varying amounts of PEEP minimizes the risk for barotrauma
Vent Complication associated with
PEEP-related issues
decreased urinary output and increased sodium retention
- lowers CO and renal perfusion
- RAAS stim = retaining Na and water
Vent Complication
Barotrauma
increased airway pressure distends the lungs and possibly ruptures fragile alveoli or emphysematous blebs
- lead to pulmonary interstitial emphysema, pneumothorax, subcutaneous emphysema, pneumopericardium, and tension pneumothorax
Vent Complication
PEEP-related issues
hypotension, H2O retention : INTRATHORASIC PRESSURE
-48-72 hours after
Vent Complication Tx
Anxiety
CONFUSED AND RESTRAINED – TEACH PT AND HAVE FAMILY COME IN, MEDS
Vent Complication Tx
Stress Ulcer
Vent Complication Tx
Infections
WBCs, oral care, turning
Vent Complication Tx
Muscular deconditioning
ROM
Vent Complication Tx
Malnutrition
OG,NG tubes, rest the belly
VAP occurs within
48+ hours after intubation
Risks of VAP
Contaminated respiratory equipment
Inadequate hand washing
Environmental factors – no suctioning or oral care, no moisture
Impaired cough
Colonization of oropharynx
Guidelines Prevent VAP
Minimize sedation and sedation vacation
Provide early exercise and mobilization – ROM, ambulation, turning
Conduct subglottic secretion removal
Elevate HOB 30- 45 degrees unless contraindicated
Routine oral care with Chlorohexidine
Strict hand washing, wear gloves
Vent Patient Psychosocial Needs
feel safe
know (information)
regain control
hope
trust
Involve patients and caregivers in decision making
Nursing Mgmt for Mech Vent pt
Assess respiratory status & vital signs Q 1-2 hours
Monitor labs
Review chest x-ray/results
Turn as tolerated/Assess skin for breakdown
Prevent Ventilator Acquired Pneumonia (VAPS)
DVT prophylaxis**
Provide adequate Nutrition
NGT, OGT, Peg
Environment Safety for Mechanical Ventilation
BVM
Suction set up and ready
Are the alarms pulled in and functioning properly, set within parameters
Are restraints secured properly
Are lines and tubes secured
Can the caregiver adequately monitor the patient and monitor
Nursing Safety for Mech Vent
Wash hand and don appropriate PPE for universal precautions
Maintain closed circuit of ventilator
Be mindful of stance and actions with suctioning with trach
Perform patient positioning (prone or supine) with proper ergonomics and patient handling equipment
Have adequate staff to reposition patient/airway
Monitor restraint use as needed/ordered
Have a plan for agitation/restlessness: trend with settings
How often should the nurse assess level of sedation on a sedative pt?
every hour with appropriate scale
How to communicate the needs of a mechanical vent pt?
Use variety of methods to communicate
IV Sedatives as needed
If on IV sedation - Assess level of sedation q hour using appropriate scale as ordered (RASS, delirium scale, music therapy
Relaxation therapy
Provide a calm and relaxing environment
Mobility- bedrest, passive range of motion, active range of motion
Prone positioning is used in patients having
severe oxygenation issues
Goal of prone positioning
- Improve oxygenation by decreasing the pressure on the lungs from the abdominal contents, the heart and supporting structures, and the added weight of the lungs
- improve gas exchnage
Prone positioning contraindications
Shock
Multiple fractures or trauma
Pregnancy
Raised ICP
Tracheal surgery or sternotomy within two weeks
Pronation can last for how long
12-20 hours if showing improvement and hemodynamically stable
When can a pt be weaned off of the mechanical vent?
breathing spontaneously?
supporting adequate oxygenation?
maintaining normal hemodynamics?
Has original reason for intubation resolved?
good tolerance
Signs of weaning intolerance
↑ or ↓ RR, ↑ HR, ↓SaO2 sustained <90%, Respiratory distress, LOC change, arrhythmias, agitation or anxiety, low tidal volumes <5mL/kg
- hypertension or hypotension
diaphoresis
Extubation for nurses
Have towel, BVM, and suction ready. Monitor for respiratory difficulty.
Semi-fowlers
inhales and deflate at peak inspiration
Cough and deep breath
apply NC or face mask
What is normal after extubation?
sore throat
hoarseness
Accidental Extubation
Assess patient quickly. How is patient’s respiratory effort and O2 sat? Possibly able to breath on their own, gasping move to next step
Call for help!
If patient needs ventilation assistance, ensure the bag valve mask (BVM) is attached to the O2 flowmeter and O2 is on!
Attach the face mask to the BVM bag and after ensuring a good seal on the patient’s face, supply the patient with ventilation
Low-pressure alarms mean
leaks
Cuff leak
Leak in the ventilator circuit
Patient stops breathing in the pressure support modes of SIMV
Unintentional extubation
Tube disconnected from circuit
Barotrauma
High pressure alarms mean
blockage
Mucous plug or increased secretions
Patient bites ETT
Pneumothorax
Patient anxious and fighting the ventilator
Kink in the tubing
Water collected in the ventilator tubing
Patient is coughing
Bronchospasm
Pulmonary Edema
Decreased lung compliance
Low-pressure alarm
cuff leak interventions
Assess for cuff leak, check cuff pressure, call RT and physician
Low-pressure alarm
Leak in the ventilator circuit interventions
Assess all connections and tubing; call RT and physician, a new ventilator may be needed
Low-pressure alarm
Patient stops breathing in the pressure support modes of SIMV interventions
Assess the patient; notify RT and physician; may need to provide manual breathes via BVM
Low-pressure alarm
Unintentional extubation interventions
Assess patient for need to be reintubated; apply oxygen; may need to give manual breathes via BVM
Low-pressure alarm
Tube disconnected from circuit interventions
Reconnect tubing to circuit; assess patient
Low-pressure alarm
Barotrauma interventions
Assess subcutaneous emphysema - notify RT and physician if present
Barotrauma means
injury to your body (ears or lungs) because of changes in barometric (air) or water pressure in this case caused by the ventilator. Increased alveolar pressure during mechanical ventilation can cause barotrauma or pneumothorax
High-pressure alarm
Mucous plug or increased secretions interventions
Suction as needed
High-pressure alarm
Patient bites ETT interventions
Insert an oral airway to prevent biting (bite block)
High-pressure alarm
Pneumothorax interventions
Assess for asymmetrical chest rise, decreased breath sounds over pneumothorax site; notify physician
High-pressure alarm
Patient anxious and fighting the ventilator interventions
Assess the patient, provide emotional support, re-evaluate sedation/analgesic need
High-pressure alarm
Kink in the tubing interventions
Assess the tubing from ventilator to patient to ensure no kinking of the tube is present
High-pressure alarm
Water collected in the ventilator tubing interventions
Empty the water from the tubing
High-pressure alarm
Patient is coughing interventions
Continue to monitor
High-pressure alarm
Bronchospasm interventions
Assess for non-productive consistent coughing; give a breathing treatment
High-pressure alarm
Pulmonary Edema interventions
Assess lung sounds and ETT for fluid; suction needed, may need to be placed prone and given diuretics
High-pressure alarm
Decreased lung compliance interventions
Assess lung sounds, RR, BP and SaO2; notify RT and physician, ventilator mode may need to be changed
Arterial line and monitoring
Placed for continuous vital sign monitoring
and frequent blood draws especially ABG’s
- Usual Location: Radial or femoral artery
- continuous slow 3mL/hr flushing and mechanism for fast flushing of lines
Arterial Line/Monitoring Safety
0.9% NS used as fluid for pressurized system
NO meds given per arterial line
- Blood glucose and ABGs testing and no wasting and give back when done
Monitor extremity circulation
Pressure system 300 mmHg
Transducer level at phlebostatic axis
No circumferential dressing/tape and look visibly healthy
closed system
phlebostatic axis
reference point for zeroing the hemodynamic monitoring device (transducer)
4th intercostal space at the sternum
- correlates with right atrium
S/S of difficulty breathing
Retracting, how labored
VS – RR, O2Sat, HR
Color oral muscosa
Chest mvmt
Auscultating sounds
Airway patency
GCS = less than 8 intubate
Perfusion
ABG
Chest Xray
If the pt is tired and ecompensating, then what should the nurse do
Intubation
Gather supplies, support pt and family, prep meds (sedative/hypnotic/paralytic)
Listen over epigastric and lungs
On one side = pull up not out
CO2 detector should be yellow
Care Plan of Intubated pt
Oral care (prevent VAP, WBC high, C&S, timing, fever)
Turn q 2 hours prevent skin breakdown
Passive ROM
Nutrition – OG/NG
Give belly a rest = TPN
Decompress stomach
Suction
As needed /q shift = increase RR
Prevent stress ulcers
Prevent anxiety
RAS score and doctor parameters for tolerance and ABGs going to normal (get CO2 off increase tidal)
Proning if declining
Artery Line
4th intercostal line
300 pressure
Continuous
No meds
Should be the same for normal BP
Skin and extremity assessments
High alarm – blockage assessment, personal or tidal volume
