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Module 7 (Critical Care) > Respiratory Part 2 (Mech Vent) > Flashcards

Respiratory Part 2 (Mech Vent) Flashcards

1
Q

f/RR

A

Frequency/Respiratory rate

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2
Q

f/RR normal range

A

12-20 bpm

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3
Q

FiO2

A

Fraction/percent of inspired oxygen
- 30-100%
- RA 21%

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4
Q

I:E Ratio

A

Inspiration time compared to expiratory time

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5
Q

I:E Ratio normal

A

1:2

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6
Q

PEEP

A

positive exit-expiratory pressure

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7
Q

PEEP normal

A

5-10 cm H2O

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8
Q

Ve

A

minute ventilation/volume
(Vt x RR)

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9
Q

Ve normal

A

6-8L/min

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10
Q

PIP

A

peak inspiratory pressure

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11
Q

PIP normal

A

15-20 cm H2O

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12
Q

Vt

A

tidal volume
- amount of air delivered in 1 minute

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13
Q

Vt normal for ideal body wt

A

6-8mL/kg

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14
Q

Vt normal for very sick lungs

A

4-6 mL/kg

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15
Q

Why would someone need artifical airway?

A

Apnea, airway protection
Acute respiratory failure
Severe hypoxia
Respiratory muscle fatigue
Upper airway obstruction

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16
Q

ETT is used for

A

emergent/planned
- short duration (10-14 days)
- if planned for a temporary time longer than 2 weeks in a long-term facility

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17
Q

Tracheostomy (Trach)

A

planned
surgical procedure
(bedside or OR)

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18
Q

Both Artificial Airways

A

emergent/planned
assist with ventilation
**connected to BVM to assist with breaths
ventilator
O2 by trach collar or T piece for ETT

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19
Q

O2 Delivery Systems include

A

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

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20
Q

Noninvasive O2 delivery

A

High-flow nasal cannula
BIPAP
CPAP
AVAPS

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21
Q

Invasive O2 delivery

A

Endotracheal tube (ETT)
Tracheostomy (Trach)

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22
Q

Which type of ventilation is used for patients needing assistance?

A

noninvasive
- short time before weaning or D/C

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23
Q

If non-invasive ventilation is unsuccessfully tolerated, what should be expected to happen next?

A

the patient needs more support and may be intubated

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24
Q

ETT cuff is used to

A

prevent aspiration
ensure delivery of tidal volume with mech ventilation

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25
Q

The inflated cuff of an ETT prevents

A

air for passing to the vocal cords, nose, and mouth

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26
Q

What are the different types intubation?

A

Orotracheal
Nasotracheal

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27
Q

What should the nurse ensure every time they provide care to the patient or enter the room of an ETT patient?

A

The size and tube length of the ETT
# at the teeth
# at the lips

know if it moves or not

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28
Q

The goal of care for mechanical ventilation

A

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

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29
Q

ETT Intubation Procedure for the nurse

A
  • Order if not emergent
  • Supplies and assist provider
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30
Q

After intubation, what does the nurse do after the ETT is inserted to confirm placement?

A
  • 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
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31
Q

CO2 detector needs to be what color to ensure in the lungs?

A

yellow

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32
Q

What tells the nurse the patient need to be intubated?

A

GCS<8
color change
ABGs
cardiac and pulmonic VS
low LOC

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33
Q

Intubation needs what medications

A

Paralytic (succinylcholine and rocuronium)
- paralysis the muscles
Sedative (Propofol, midazolam, versed, fentanyl)
- sleepy and drowsy

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34
Q

The initial assessment of ETT placement is

A

Capnometer YELLOW for CO2

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35
Q

The chest x-ray for placement of the ETT tube where?

A

3-4cm above the Corina

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36
Q

ETT cuff pressure should be

A

<25 cm H2O
- minimal leak technique
- verify by RT and physician

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37
Q

If the ETT cuff is greater than 25 cm, what could occur?

A

tracheal necrosis

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38
Q

If the ETT cuff is too low and the patient is able to talk to you, then what could occur?

A

unplanned extubation
aspiration

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39
Q

Is it okay for the patient to cough while you are suctioning them?

A

No, that means you have hit the Corina

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40
Q

ETT comes out

A

lace the obturator placed immediately in the hole
- call a CODE

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41
Q

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

A

pt in semi-fowler’s position to decrease dyspnea
- cover with a sterile dressing and ventilate with the BVM over the nose and mouth

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42
Q

If the nurse sees the patient is not getting enough oxygenation and they suspect the trach has clotted off, what should the nurse do?

A

replace the inner cannula and check the flanges

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43
Q

What equipment do you need at the bedside?

A

Obturator (clean sterile bag)
Trach of the same size or smaller
BMV
Suction

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44
Q

Tracheostomy Care

A

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

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45
Q

Clean the trach stoma with

A

sterile saline and dry
change the dressing
change securement ties if soiled (unless new then leave for orders)

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46
Q

Nursing Care for Artificial airways

A

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

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47
Q

Limit suctioning to no more than

A

10 secs
-HESI 10-15 secs

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48
Q

Mechanical Vent pharmacology

A

Paralytics
Sedatives
Opioids
Vasopressors/fluids/volume expanders
Bronchodilators
LEAN

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49
Q

LEAN drugs

A

Lidocaine,
Epinephrine,
Atropine,
Narcan

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50
Q

Loading doses of drugs can cause

A

BP to drop
- give vasopressors

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51
Q

Patient Safety for ETT

A

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

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52
Q

What should the nurse assess for when a pt is on ETT?

A

tolerance, color, breathing extent, cardiac monitor = PVCs, RR, environment, no clutter

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53
Q

When should restraints be used on an ETT pt

A

only when they are a danger to themselves

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54
Q

ETT patients HOB degree if not contraindicated

A

30

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55
Q

In-line suctioning maximum

A

10 seconds

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56
Q

When in-line suctioning, gently insert the catheter until

A

resistance is met

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57
Q

When do you apply in-line suctioning

A

while withdrawing the catheter
- validate completely out of the ETT by black line visual
- monitor ECG and SpO2 throughout procedure

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58
Q

The wall suction should be on

A

continuous
- tap before attempt
preoxygenate
anchor the hand and pull with the other
suction pulling out
fully out at the black line

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59
Q

Inline suction helps prevent infection by

A

closed system and protect the patient and staff from bacteria
- prevent loss of PEEP and O2

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60
Q

Potential complications of suctioning

A

Hypoxemia, bronchospasm
Increased intracranial pressure
Dysrhythmias – PVCs (Teresita pt)
↑ or ↓ BP
Mucosal damage
Pulmonary bleeding, pain, infection

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61
Q

After suctioning, the nurse should ensure

A
  • 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
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62
Q

PaO2

A

amount of oxygen dissolved in plasma – seen on ABG

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63
Q

SaO2

A

pulse ox and is only an estimate

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64
Q

O2 Toxicity

A

uncontrollable coughing
dyspnea for a long period of time
- leads to fibrosis

65
Q

PEEP is constant

A

pressure to keep alveoli from collapsing at the end of expirations

66
Q

PIP

A

peak inspiratory pressure

67
Q

PIP normal

A

15-20 H2O

68
Q

PIP is the

A

maximum pressure of inspiration, mucous plugs will increase PIP

69
Q

In order to stop retaining CO2, the ventilator settings could change to

A

increase RR
increase Vt
- VOLUME OF THE BREATH

70
Q

If the PaO2 is too low, the nurse with order could change the settings to

A

increase PaO2
increase FiO2
increase PEEP
- keep alveoli open, give more O2

71
Q

Non-invasive High-flow NC delivers

A

O2 from 21-100%
60L/min
humidification

72
Q

HFNC functions

A

Clears physiological dead space of expired air
Keeps alveoli open at end of expiration

73
Q

HFNC limits

A

limit pt mobility
- need good ft

74
Q

HFNC requires

A

adequate spontaneous RR
- able to breathe on their own

75
Q

Dead space in Oxygenation

A

volume of ventilated air that does not participate in gas exchange

76
Q

Noninvasive- CPAP

A

present pressure provided throughout
inspiratory and expiratory breaths

77
Q

Goal of CPAP

A

Goal- keeps alveoli from collapsing, resulting in better oxygenation and less work of breathing

78
Q

CPAP can be used for what patients

A

face mask non-intubated
ventilator intubated or trached pt

79
Q

With CPAP the patient must be able to

A

breath spontaneously
- PT DOES ALL THE WORK

80
Q

CPAP only provides

A

airway pressure

81
Q

CPAP mode on the ventilator can be used to evaluate what

A

pt’s readiness for extubation

82
Q

BIPAP used to

A

ventilate non-intubated pts help prevent intubation

83
Q

BIPAP pts must be able to

A

spontaneously breathe and cooperate with the tx

84
Q

IPAP assists with

A

ventilation

85
Q

EPAP assists with

A

oxygenation

86
Q

BIPAP is especially used for

A

COPD pts unable to exhale against higher airway pressures to help resolve CO2 problems
- HEART FAILURE
- ACUTE RESPIRATORY FAILURE

87
Q

What pts can not use BIPAP due to the increase risk of aspiration and inability to remove the mask?

A

shock
AMS
increased airway secretions

88
Q

What is the difference between CPAP and BIPAP?

A

BIPAP has inspiratory pressure in addition to expiratory pressure of CPAP

89
Q

Noninvasive expected outcomes

A

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

90
Q

Mech Vent Volume Mode

A

Assist Control AC
Synchronized Intermittent Mandatory Ventilation (SIMV)

91
Q

Mech Vent Pressure Mode

A

Pressure Support Ventilation (PSV)
Positive End Expiratory Pressure (PEEP)

92
Q

Positive Pressure Ventilation

A

inflates the lungs by introducing positive pressure and/or volume

93
Q

What does the nurse need to do for positive pressure ventilation?

A

Verify settings/order
Assess patient
Ensure patient safety (medications turns, oral care)
Troubleshoot as needed
Monitor ABG’s

94
Q

Assist control volume mode

A

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

95
Q

Assist control Vt

A

remain the same for patient-initiated breath or ventilator breath

96
Q

Which ventilator mode requires the least amount of patient effort?

A

Assist control
- very sick pt

97
Q

How do you know if the pt is taking spontaneous breaths on assist control?

A

If the ventilator setting is set at a certain bpm but the ventilator shows pt receiving a higher number

98
Q

Pressure Support (PS/PSV)

A

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

99
Q

Pressure support decreases as the pt

A

improves
- overcomes resistance
-trials with spontaneous breaths
- positive pressure only during inspirations and with spontaneous breaths
- must be able to initiate breath by themselves

100
Q

PEEP

A

apply positive pressure during exhalation
3-20 cm
- improves O2 by restoring lung vol

101
Q

What can be reduced when PEEP is used?

A

FiO2

102
Q

PEEP is used with caution by what type of pts

A

increased ICP
low CO = hypotension
hypovolemia

103
Q

Potential Complications in Vent Pts

A

Aspiration/abdominal distension, ileus
Oxygen Toxicity
Barotrauma
PEEP-related
Anxiety
Stress Ulcers
Infections
Muscular deconditioning
Malnutrition
Ventilator dependence - not able to wean off
VAP

104
Q

Vent Complication Tx
Aspiration

A

Insert NG/OG to decompress the stomach – stop aspiration of acid and feed them

105
Q

Vent Complication
O2 Toxicity if

A

FIO2 >50% for more than 24 – 48 hours

106
Q

Vent Complication S/S
O2 Toxicity

A

restlessness, dyspnea, chest discomfort, fatigue, atelectasis

107
Q

Vent Complication MINIMIZE RISK of
Barotrauma

A

a smaller VT (e.g., 4 to 8 mL/kg) and varying amounts of PEEP minimizes the risk for barotrauma

108
Q

Vent Complication associated with
PEEP-related issues

A

decreased urinary output and increased sodium retention
- lowers CO and renal perfusion
- RAAS stim = retaining Na and water

109
Q

Vent Complication
Barotrauma

A

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

110
Q

Vent Complication
PEEP-related issues

A

hypotension, H2O retention : INTRATHORASIC PRESSURE
-48-72 hours after

111
Q

Vent Complication Tx
Anxiety

A

CONFUSED AND RESTRAINED – TEACH PT AND HAVE FAMILY COME IN, MEDS

112
Q

Vent Complication Tx
Stress Ulcer

A
113
Q

Vent Complication Tx
Infections

A

WBCs, oral care, turning

114
Q

Vent Complication Tx
Muscular deconditioning

A

ROM

115
Q

Vent Complication Tx
Malnutrition

A

OG,NG tubes, rest the belly

116
Q

VAP occurs within

A

48+ hours after intubation

117
Q

Risks of VAP

A

Contaminated respiratory equipment
Inadequate hand washing
Environmental factors – no suctioning or oral care, no moisture
Impaired cough
Colonization of oropharynx

118
Q

Guidelines Prevent VAP

A

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

119
Q

Vent Patient Psychosocial Needs

A

feel safe
know (information)
regain control
hope
trust
Involve patients and caregivers in decision making

120
Q

Nursing Mgmt for Mech Vent pt

A

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

121
Q

Environment Safety for Mechanical Ventilation

A

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

122
Q

Nursing Safety for Mech Vent

A

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

123
Q

How often should the nurse assess level of sedation on a sedative pt?

A

every hour with appropriate scale

124
Q

How to communicate the needs of a mechanical vent pt?

A

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

125
Q

Prone positioning is used in patients having

A

severe oxygenation issues

126
Q

Goal of prone positioning

A
  • 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
127
Q

Prone positioning contraindications

A

Shock
Multiple fractures or trauma
Pregnancy
Raised ICP
Tracheal surgery or sternotomy within two weeks

128
Q

Pronation can last for how long

A

12-20 hours if showing improvement and hemodynamically stable

129
Q

When can a pt be weaned off of the mechanical vent?

A

breathing spontaneously?
supporting adequate oxygenation?
maintaining normal hemodynamics?

Has original reason for intubation resolved?

good tolerance

130
Q

Signs of weaning intolerance

A

↑ or ↓ RR, ↑ HR, ↓SaO2 sustained <90%, Respiratory distress, LOC change, arrhythmias, agitation or anxiety, low tidal volumes <5mL/kg
- hypertension or hypotension
diaphoresis

131
Q

Extubation for nurses

A

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

132
Q

What is normal after extubation?

A

sore throat
hoarseness

133
Q

Accidental Extubation

A

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

134
Q

Low-pressure alarms mean

A

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

135
Q

High pressure alarms mean

A

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

136
Q

Low-pressure alarm
cuff leak interventions

A

Assess for cuff leak, check cuff pressure, call RT and physician

137
Q

Low-pressure alarm
Leak in the ventilator circuit interventions

A

Assess all connections and tubing; call RT and physician, a new ventilator may be needed

138
Q

Low-pressure alarm
Patient stops breathing in the pressure support modes of SIMV interventions

A

Assess the patient; notify RT and physician; may need to provide manual breathes via BVM

139
Q

Low-pressure alarm
Unintentional extubation interventions

A

Assess patient for need to be reintubated; apply oxygen; may need to give manual breathes via BVM

140
Q

Low-pressure alarm
Tube disconnected from circuit interventions

A

Reconnect tubing to circuit; assess patient

141
Q

Low-pressure alarm
Barotrauma interventions

A

Assess subcutaneous emphysema - notify RT and physician if present

142
Q

Barotrauma means

A

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

143
Q

High-pressure alarm
Mucous plug or increased secretions interventions

A

Suction as needed

144
Q

High-pressure alarm
Patient bites ETT interventions

A

Insert an oral airway to prevent biting (bite block)

145
Q

High-pressure alarm
Pneumothorax interventions

A

Assess for asymmetrical chest rise, decreased breath sounds over pneumothorax site; notify physician

146
Q

High-pressure alarm
Patient anxious and fighting the ventilator interventions

A

Assess the patient, provide emotional support, re-evaluate sedation/analgesic need

147
Q

High-pressure alarm
Kink in the tubing interventions

A

Assess the tubing from ventilator to patient to ensure no kinking of the tube is present

148
Q

High-pressure alarm
Water collected in the ventilator tubing interventions

A

Empty the water from the tubing

149
Q

High-pressure alarm
Patient is coughing interventions

A

Continue to monitor

150
Q

High-pressure alarm
Bronchospasm interventions

A

Assess for non-productive consistent coughing; give a breathing treatment

151
Q

High-pressure alarm
Pulmonary Edema interventions

A

Assess lung sounds and ETT for fluid; suction needed, may need to be placed prone and given diuretics

152
Q

High-pressure alarm
Decreased lung compliance interventions

A

Assess lung sounds, RR, BP and SaO2; notify RT and physician, ventilator mode may need to be changed

153
Q

Arterial line and monitoring

A

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

154
Q

Arterial Line/Monitoring Safety

A

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

155
Q

phlebostatic axis

A

reference point for zeroing the hemodynamic monitoring device (transducer)
4th intercostal space at the sternum
- correlates with right atrium

156
Q

S/S of difficulty breathing

A

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

157
Q

If the pt is tired and ecompensating, then what should the nurse do

A

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

158
Q

Care Plan of Intubated pt

A

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

Module 7 (Critical Care) (22 decks)

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